EDITORIAL - DOS TIMES 2003.pdf · remarkable survival of cor-neal transplants can be ... Rajesh...

1July, 2003 DOS Times - Vol.9, No.1


Dear friends,As thep r e m o n s o o nshowers offer us awelcome changefrom the hot andscorchy climate ofthe capital, mynew team mem-

bers of DOS Times are ready to inviteyou to another new innings of the mostpopular ophthalmology bulletins ofrecent times.

DOS had a very good beginningearly this year when all the officebearers were chosen unanimously.I hope this healthy trend continuesin future too. Our society is a scien-tific society, it is not a political fo-rum. Why can’t we choose or selecta member who is suitable and iswilling to accept the responsibility.Accepted, that it is always better tohave healthy competition and ifthere is more than one member suit-able for a given post than solutionshould be found with mutual under-standing.

A lot of effort has been made inthe past few years to improve DOSTimes. My predecessors have car-ried out a lot of innovations and Ishall strive to continue for the same.It will be my endeavour to involveas may people as possible in DOSactivities, for which I look forwardfor your support, especially for or-ganizing DOS conferences, our

EDITORIALmonthly meetings and also DOSTimes. I think it is the duty of eachand every one of us to contributeas much as possible to our societyand I am confident of your support.DOS Times will have a multis-peciality approach with major em-phasis on practical management as-pects, which will be supported byleading Ophthalmologist of ourcountry, if possible some interna-tional faculty. Some of the articleswill also be based on review of lit-erature. I take this opportunity toinvite suggestions, advice, and let-ters to the editor from all our mem-bers so that we improve on our ef-fort to maintain the standards ofDOS Times.

We are going to include new sec-tions on institutional profiles, whichwill reveal the contributions of in-stitutions to eyecare, informationregarding facilities and training pro-grams for young ophthalmologists.The very popular DOS quiz will bepresented in a new format.

I shall also make efforts to de-velop good and healthy relationshipamong DOS Members. Our societyhas taken initiative in various fo-rums to disseminate knowledge andeducate ophthalmologists aboutvarious aspects of clinical practiceand newer advancement. I think wehave been very successful in Phaco,SICS, and LASIK. We must continueto progress, we must be careful not

to confuse our patients or our col-league as we strive for what weenvision as ultimate goals. We mustbe careful not to raise expectationsbeyond realistic outcomes. Mostimportantly we must carefully con-sider proper guidelines and assessall safety issues before the clinicalapplication of new technology toavoid undue controversies.

A new trend has been observedin recent years where many oph-thalmic companies are promotingindividual sponsorship rather thansupporting academic activities of thesociety. This trend is observed notonly for DOS but it is true for otherstate societies as well as for AIOS.Ireally don’t know where this trendis going to lead us. There should bean effort to increase participation oftraders not only for conferencesponsorship and putting up stalls butalso support for other scientific ac-tivities of society like publication ofjournals, proceedings and commu-nity programmes. The symbiotic re-lationship should be increased sothat both flourish.

We require good wishes and sup-port from each and everyone tocarry out DOS Times to a new hori-zon so that our society continues toremain at the forefront of all oph-thalmological societies in India.

– Dr. Jeewan S. TitiyalSecretary, DOS

!!Attention DOS Members!!

The registration fees for life membership ofDelhi Ophthalmological Society

is now being increased to Rs. 3,100 from1st August 2003 – Secretary DOS


Corneal transplantationis currently the most frequentand successful type of tissuetransplantation performedworldwide. With the adventof operating microscopes,better suture material and theuse of improved techniques,the failure of corneal trans-plant on a technical basis hasbecome less common. Theremarkable survival of cor-neal transplants can belargely attributed to theirunique avascular structure.This feature allows the graftto remain somewhat isolatedfrom the immune system andeffectively gives it an immu-nologically privileged status.However, the survival of cor-neal graft still remains lessthan desired. Although thereare various causes for poorgraft survival, immune me-diated rejection remains theforemost cause.

Upto 30% of penetratingkeratoplasty patients have atleast one episode of rejection,with 5% to 7% of all graftseventually failing because ofrejection. Several host factorshave been shown to increasethe risk of immune-mediatedrejection. The most importantfactors appear to be the de-gree of corneal neovascu-larization. In vascularizedcorneas, the recipient’s im-mune system can recognizeand attack the donor tissue

High Risk Penetrating KeratoplastyRajesh Sinha MD, Jeewan S Titiyal MD, Namrata Sharma MD,

Rasik B. Vajpayee MBBS, MS

much more readily thus lead-ing to a higher rate of rejec-tion and a higher failure rate.

The ‘Collaborative Cor-neal Transplantation Stud-ies’ has defined ‘High Risk’as presence of two or morequadrants of corneal stromalvascularization (Figure 1),extending at least 2mm intothe cornea, or a previousgraft rejection in the affectedeye (Regraft – Figure 2). Thedegree of vascularizationwas defined as the numberof quadrants of vasculariza-tion rather than the totalnumber of vessels, thereforea cornea is high risk whenonly two vessels are present,provided they are in differ-ent quadrants. In high riskcorneas, the incidence of re-jection is reported to be 50%to 70%. Hill has recently pro-posed a new classification ofhigh- risk corneas, based onthe degree of vasculariza-tion. In this classificationlow, medium and high riskcorneas correspond to avas-cular, 1-2 quadrants, and 3or more quadrants of vascu-larization, respectively.

Apart from these fac-tors, there are additionalrisk factors which makethe corneal graft highrisk for failure (Table 1).Corneal grafting is con-sidered as high risk forfailure in healed herpessimplex keratitis (Figure2) not only because ofhigh chance of recur-rence of the disease butalso because of the high

risk of graft rejection due tostromal vascularization thatis associated with it. At onetime, corneal transplantationin children was considereddoomed to failure and evencontraindicated. More re-cently, some success hasbeen reported, however prog-nosis for pediatric kerato-plasty is clearly not as goodas that for an adult. It issuspected that some ofthese failures mighthave been attributableto immunologic graftrejection that was un-recognized because ofdifficulty in examina-tion and communicat-ing with these patients.Therefore, all paediatrickeratoplasty should beconsidered as “HighRisk”.

The management ofhigh-risk keratoplastyand prevention of rejec-tion continues to be asignificant challenge.To prevent immune me-diated rejection in high-risk corneal transplan-tation, following meth-

ods have been advocated:1. Making the donor tis-

sue less antigenic.2. Suppressing the host

immune response.

Reducing Donor AntigenicityThe use of a central cor-

neal graft is perhaps the mostcommon strategy for reduc-ing donor antigenicity.Langerhans’ cells that ex-press class II antigens areprimarily located in the pe-ripheral cornea, and thusexcluding the peripheral cor-nea from the donor tissuecan significantly prolonggraft survival. Removal of thedonor epithelium was alsobelieved to decrease the riskof rejection because the epi-thelium is a source of class Iand class II antigens. Cor-neal grafts exposed to ultra-violet light in vitro wereshown to have a lower inci-dence of rejection presum-ably because of selectivedepletion of Langerhans’cells. Likewise, pretreatment

Cornea & Refractive SurgeryServices, Dr. Rajendra PrasadCentre for Ophthalmic Sciences,AIIMS, New Delhi.

CURRENT PRACTICE

Figure 1

Figure 2

Figure 3


of the graft with hy-perbaric oxygen orheterologous anti-bodies were found toprolong its survivalin experimental cor-neal transplantation.Corneas stored in or-gan culture have alsobeen shown to have areduced number ofLangerhans’ cells.However, none ofthese techniqueshave been shown tobe clinically signifi-cant and thus havenot been adopted asa management strat-egy for high-riskkeratoplasty.

Tissue matchinghas been studied ex-tensively as anotherstrategy for reducingdonor antigenicity inhigh-risk cornealtransplantation. Althoughsome reports have suggestedthat HLA and ABO match-ing could reduce the inci-dence of rejection, most tri-als have found no significantbenefit from histocompatibil-ity matching in high-risk pa-tients.

Suppressing the host's Im-mune Response

Currently, suppression ofthe host immune responseusing pharmacologic agentsremains the mainstay of pre-venting corneal allograft re-jection. Although corticoster-oids continue to be the goldstandard of ocular immuno-suppressants, promisingnewer agents may soon pro-vide a safe and effective ad-junct for immunosuppres-sive therapy in high-risk cor-neal transplantation.

CorticosteroidsCorticosteriods are the

drugs of choice for both theprevention and treatment ofcorneal graft rejection. Theyhave been shown to block thesynthesis of prostaglandinby inhibiting phospholipaseA2, decreasing cellular andfibrinous exudation, inhibit-ing chemotaxis and phago-cytosis, restoring capillarypermeability, stabilizing thelysozomal membranes ofpolymorphonuclear leuko-cytes, and inhibiting graftvascularization. On sys-temic administration, ste-roids also reduce the num-ber of circulating T cells andinhibit their proliferation.

Corticosteriodsare most commonly admin-istrated by topical applica-tion, which provides goodocular penetration and effec-tive immunosuppression. In

high-risk patients,topical steroids arestarted early in thepreoperative periodand applied fre-quently.Intensive Postopera-tive Corticosteroid re-gime in high riskkeratoplasty: 2 hourly x 3 days: 4 hourly upto Day15: QID upto 2 months: TDS for 2 moremonths: BD for 3 moremonths: OD for 4 moremonths

Cyclosporin ACyclosporin A repre-sents a new generationof specific immuno-suppressive agentsthat selectively inter-

feres with immunocompetentcells without causing gener-alized cytotoxic effects.Structurally, cyclosporin is ahydrophobic, cyclicdecapeptide derived from thefungus Tolypocladiuminflatum gans. It is animmunomodulator andworks mainly on T cells bybinding to an intracellularpeptide known ascyclophilin. Cyclophilin is atype of regulatory proteinknown as immunophilinthat seems to control the syn-thesis of proteins involved inT cell activation. By inhibit-ing cyclophilin activity,cyclosporin blocks the tran-scription and production ofIL-2, thus limiting the activa-tion of CD4+ and CD8+ Tcells. In addition, cyclos-porin blockers the produc-tion of other lymphokinessuch as interferon-g and in-

hibits the expression of high-affinity IL-2 receptors.

Topical cyclosporin ATopical cyclosporin A

when used alone can be ef-fective both for the preven-tion and the treatment of cor-neal graft rejection. It is pre-scribed 4 - 5 times a day inhigh risk keratoplasty alongwith other postoperativetreatment. A randomizedtrial found that 2% cyclos-porin A drops applied fivetimes a day in patient’s re-ceiving 1% dexamethasonefour times a day significantlyprolonged graft survivalcompared with 1% dexam-ethasone alone (88% cleargrafts at 12 months versus35%). It is prepared either inolive/ castor oil as 2% solu-tion or in artificial tears as1% solution.

It has been found thatwhole blood cyclosporin Alevel after topical therapy isundetectable or well belowsystemic therapeutic levels.Based on these results, itdoes not seem necessary tomonitor blood cyclosporin Alevels in patients receivingtopical cyclosporin A; how-ever, to be on safer side, therenal and liver functionshould be monitored beforeand during instituting topi-cal therapy and randomsamples should be sent todetect blood cyclosporin Alevels.

Systemic CyclosporinAlthough systemic cyclos-

porin has profound effect onthe success of many solid or-gan transplants, its applica-tion to corneal transplanta-tion is limited because of itssignificant associated sideeffects. The use of systemic

Table 1: High risk factors for Pen-etrating Keratoplasty————————————————High Risk Factors (CCTS)

Ø Deep Stromal Vascularization > 2quadrants

Ø Regrafts

Additional Risk FactorsØ Young recipient

Ø Limbal position of the transplant

Ø Eccentric, large grafts

Ø Dry Eye syndrome

Ø Lid Abnormalities

Ø Intractable lagophthalmos

Ø Defective blink-reflex

Ø Limbal stem cell deficiency

Ø Herpetic Corneal Scar

Ø Uncontrolled Glaucoma

Ø Poor Socioeconomic Status

Ø Pediatric Keratoplasty

Ø One eyed patient

CURRENT PRACTICE


CURRENT PRACTICE

S-1669Sapovadia Vasantbhai V.302, Rameshwar AppartmentsUniversity Road, Jalaram-1Rajkot-360005

N-1023Narayanan R.A-3/1, M.S. Flats, Sector-13,R.K. Puram, New Delhi-110066

L-1681Lal SanjivKanpur Retina Centre112/2(I), Benajhabar RoadKanpur-208002

S-1682Srivastava Krishna KumarD-8a, Defence ColonyJajmau, Kanpur

A-1026Agrawal AnshumanDepartment of OphthalmologySir Ganga Ram HospitalOld Rajinder NagarNew Delhi-110060

K-1027Kumar NarendraC/O Shri Mahavir Singh BerwalA-78, Kewal Park Extn.Azadpur Road, Subzi MandiDelhi-110033

K-1683Kumar AjayS/O Shri Balbir SinghHouse No.222, TibriB.H.E.L., Ranipur(Hardwar)

K-1684Kumar Rajesh RanjanC/O Sri Durga Pd. BhagatP.P. Path, West Of HospitalRajendra Nagar, Patna-16

J-1670Jhaveri Pravesh7, West View1st Pasta Lane, Colaba,Mumbai-400005

G-1024Garg PankajHouse No.1190Sector 43-BChandigarh

M-1671Mehta Gaurav Jayendrabhai“Gauravdeep”12, Saurashtra Bank SocietyVasna Barrage Road, PaldiAhmedabad-380007

B-1672Bhojwani KrishnaSahai Hospital & Research CentreSp-15, Bhabha MargMoti Dungri, Jaipur

G-1673Goyal SanjivStreet No.1Bhan Singh ColonyFaridkot-151203

B-1674Bhagat Dinesh KumarBungalow No.T-7/BSahebpara, Katihar

S-1675Swarup PradeepSwarup Eye Centre145, Dwarkapuri ColonyHyderabad-500082

A-1676Arora Sehdev KumarGagan Hospital, ADWA Road,Shahabad-MarkandaDist. Kurukshetra

New DOS Members

Continued in Page 30

Monthly Meetings CalendarFor teh Year 2003-2004

27th July, 2003 (Sunday)Army Hospital

30th August, 2003 (Saturday)Sir Ganga Ram Hospital

27th September, 2003 (Saturday)New Institute/Hospital

19 October, 2003 (Sunday)DOS Midterm Conference

2nd November, 2003 (Saturday)R.P. Centre for Ophthalmic Sciences

29th November, 2003 (Saturday)Dr. Shroff’s Charity Eye Hospital

27th December, 2003 (Saturday)New Institute/Hospital

31st January, 2004 (Saturday)Safdarjung Hospital

28th February, 2004 (Saturday)M.A.M.C. (GNEC)

28th March, 2004 (Saturday)Mohan Eye Institute

3-4th April, 2004 (Saturday & Sunday)Annual DOS Conference

cyclosporin A (dose: 4 mg/kg/ day) has been associatedwith a number of complica-tions including nephrotoxic-ity, hepatotoxicity and hy-pertension. To minimize theserious side effects, bloodcyclosporin A level shouldbe monitored carefully andkept at the lower end of thetherapeutic range. A targetlevel is between 130ng/mland 170ng/ml using wholeblood method (monoclonalantibody). But in corneal

transplant blood level ashigh as 200ng/ml is re-quired. Patients need peri-odic monitoring of their bloodpressure, serum creatinine,liver enzymes and bloodcounts while taking oralcyclosporin. Hence systemiccyclosporin has not found aplace in routine managementof high risk keratoplasty.

Oral acyclovir in a dose of400 mg twice daily is pre-scribed for 6 months to 1 yearfor prophylaxis against re-

currence of herpes simplexkeratitis in corneal graft. Thisnot only reduces the chanceof graft infection but also de-creases the risk of initiationof rejection episode.

Inspite of all the precau-tions and prophylactictherapy, development ofgraft rejection cannot be to-tally prevented. Hence thepatient and the treating phy-sician should be well awareof the early symptoms andsigns of graft rejection. A sin-

cere and regular follow upshould be done in all thesecases and patient should beencouraged for good compli-ance to achieve a good struc-tural and functional out-come of corneal grafting inhigh risk cases.

Suggested Reading1. Corneal Surgery: Theory, Tech-

nique & Tissue. Brightbill FS;Mosby, St Louis.

2. Corneal Transplantation.Vajpayee RB; JAYPEE Broth-ers.


Whenever cataract sur-gery is performed in patientswith age related cataract, thesurgeon is usually certain ofachieving a good visual out-come. This certainty regard-ing the visual prognosis is of-ten lacking when a patientwith uveitis is taken up forcataract surgery. Althoughthe visual results are betterthan about two decades agothis is not consistently so.

The visual outcome in pa-tients with uveitis followingcataract surgery depends onthree important factors,namely, preoperative, intra-operative and postoperativevariables. A thorough preop-erative evaluation is a mustfor proper planning of thesurgical approach and its ex-ecution. The postoperativeoutcome in turn is dependenton both the preoperative andintraoperative variables.

At the very beginning it isprudent to understand thatnot all cataracts in a patientwith uveitis is related per seto the inflammation alone.Uveitis associated cataractsmay be of three categories:inflammation induced, ste-roid induced and age relatedand the prognosis is better inthe latter two categories thanin inflammation inducedcataracts.

Important preoperativeconsiderations would in-clude patient age, type ofuveitis, type of cataract (seelater), treatment history andthe presence of related com-plications such as glaucoma,macular edema, vitreousopacification and bandshaped keratopathy. The ageof the patient undergoingcataract surgery would de-

Cataract Surgery in Uveitis PatientsPradeep Venketash, MD

Dr. R.P.Centre for OphthalmicSciences, AIIMS,New Delhi.

cide whether lensectomy isfeasible or not and also thepossibility of just an age re-lated cataract occurring con-currently in an eye with ahistory of uveitis in the past.Treatment history would actas an indirect indicator to-wards the type, severity andduration of uveitis; suggestthe possibility of a steroidinduced cataract and alsoreveal whether the inflam-mation has been inactive forthe preceding three monthsatleast.

Ocular examination mustpay attention to determinevisual acuity of the eye (in-cluding projection of rays);clarity of the cornea (if bandshaped keratopathy is foundto be significant it should betreated before cataract sur-gery) including its endothe-lial status; contents of theanterior chamber (shouldhave no cells but may havepersisting mild degree offlare); severity of disorgani-zation of the pupil (studydetails of pupillary fibrosis,synechiae, membrane forma-tion and the response to maxi-mal efforts at achieving dila-tion); look for iris neovascula-rization and the severity ofiris bombe’ (determine theperipheral iridocorneal rela-tionship superiorly by thevan Harrick method of grad-ing peripheral anteriorchamber depth; this is impor-tant to know while makingthe incision and formation ofthe anterior chamber duringsurgery); determine charac-teristics of the angle by go-nioscopy, evaluate density ofcataract if possible and makeall efforts to visualize at least

the posterior pole of the fun-dus (for disc pallor, cupping,macular degeneration, macu-lar edema, scarring). It is alsoof utmost importance to mea-sure the intraocular pressureand evaluate for glaucomaas well as excessive hy-potony.

Since it is very often diffi-cult to visualize structuresbehind the pupillary planeas well as the posterior seg-ment in an eye with uveitisone may have to assess theseregions using specializedmodalities like laser interfer-ometry, conventional ultra-sonography, and ultrasoundbiomicroscopy. The useful-ness of these diagnostic toolsis discussed in the section onclinical investigations inuveitis patients.

Having assessed the vi-sual potential of the eye, thesurgeon must define the ob-jectives of performing cata-ract surgery. These objectivesusually revolve around thefollowing: visual rehabilita-tion, visualization of the pos-terior segment and to alter thedeleterious course of a dis-ease (e.g. to decrease the riskof phthisis by lensectomy,anterior vitrectomy and re-moval of any cyclitic mem-brane causing traction on theciliary body). These objec-tives and the visual progno-sis have to be discussed withthe patient and an informedconsent has to be obtained.The immediate, early andlate visual outcome as indi-cated earlier is quite variablein uveitic patients undergo-ing cataract extraction. Casesin which the prognosis is re-ported to be good are steroid

induced cataract, cataract inpatients with intermediateuveitis and Fuch’s hetero-chromic iridocyclitis. Pooroutcome is seen in patientswith juvenile rheumatoid ar-thritis and rubella cataract.Well established (prerequi-sites for cataract surgery ) inuveitic eyes are:l inflammation must be un-

der control (with no orminimal medication) foratleast the preceding threemonths (cells must be ab-sent from the anteriorchamber)

l perioperative steroidcover is a must (oral andtopical corticosteroids foratleast three to four daysbefore surgery and for 7-10 days after)

l obtain the best pupillarydilation before surgery asthis would help in decreas-ing trauma to the iris duringsurgery and hence in mini-mizing postoperative inflam-mation.

The surgical options forcataract extraction in uveiticeyes remains phacoemulsifi-cation, conventional extra-capsular extraction andlensectomy. Intracapsularcataract surgery has no rolebecause it is difficult to un-dertake in eyes with a com-promised iris architectureand is also associated withgreater tissue trauma. It how-ever may be useful in someeyes with lens associateduveitis. Issues that need to beaddressed are, whether anIOL would be tolerated wellby the eye and if an anteriorvitrectomy is likely to im-prove the visual outcome.Poor candidates for IOL im-

CURRENT PRACTICE


plantation are said to thosewith cataract in associationwith juvenile rheumatoidarthritis, VKH syndrome,sympathetic ophthalmia,recurrent granulomatousuveitis of any cause and si-derosis bulbi.

Lensectomy may be con-sidered in children andyoung adults (particularlywith extensive anterior syn-echiae) and also in thosewith concurrent lesions likevitreous membranes / vit-reous opacification orcyclitic membrane.Lensectomy may have theadvantages of less damageto the corneal endotheliumand trabecular meshwork,decreased risk of after cata-ract formation and enablingmanagement of posteriorsegment lesions. Disadvan-tages of this procedure in-cludes loss of compartmen-talization with increasedpossibility of macularedema, inability to insert anIOL and a risk of retinal de-tachment (when the parsp-lana route is used).

The surgical principles ofextreme importance whileundertaking cataract sur-gery in patients with uvei-tis are, endothelial protec-

tion (emphasis onviscosurgery as much aspossible), minimizingtrauma to the iris (by avoid-ing blunt dissection ofdensely adherent synechiaeand achieving maximal pu-pillary dilation before sur-gery), complete cortical re-moval, placement of IOLwithin the capsular bag andnot disturbing the vitreouswhenever this is not indi-cated. In addition, anteriorchamber implants and im-plants with polypropyelenehaptics are strongly con-traindicated. The useful-ness of heparin in the irri-gation fluid and the role ofheparin surface modifiedIOLs is controversial.

During the surgery itself,the surgeon may encounterthe following difficulties.There may be excessivebleeding from the conjunc-tiva; entry into the anteriorchamber may be difficult(due to iris bombe’/periph-eral synechiae) increasingthe risk of detachment ofthe descemet’s membrane,iridodialysis and iris holeformation; there may bebleeding from the iris; itmay be difficult to distin-guish anterior capsule from

a pupillary membrane mak-ing it difficult to achieve aproper capsulotomy andthere may be associatedzonular weakness. To ob-tain an adequate pupillaryaperture one may resort tothe following proceduresduring surgery: iris retrac-tors, multiple sphincteroto-mies, complete iridectomy(resutured at the end of sur-gery), synechiolysis andviscodilation or by ‘sphinc-terectomy’.

Despite all precautions auveitic eye in which cata-ract extraction has been un-dertaking is at an increasedrisk of developing severalearly and late postoperativecomplications. Early com-plications include unusu-ally severe anterior cham-ber inflammation, increasein intraocular pressure, cor-neal edema, hyphema, pig-ment dispersion on the IOL,macular edema and pupil-lary capture. Late complica-tions encountered withgreater frequency are, for-mation of iridolenticularsynechiae with pupillarydistortion, displacement ofthe IOL, early and severeafter cataract formation,glaucoma and decompen-sation of the cornea andmacula. Usually, the sever-ity of inflammation duringthe early postoperativecourse acts as a predictor

for assessing the risk of de-veloping later complica-tions and the visual progno-sis.

Important postoperativenecessities in all patients un-dergoing cataract surgerywith associated uveitis is tocontinue topical steroids fora more prolonged period (3-6months) despite a relativelyquite eye, use oral steroids (infull doses) for the first 7-10days after surgery and to havea more thorough and closerfollowup. In patients whodevelop significant pigmentdispersion on the IOL,iridolenticular synechiae andafter cataract one could con-sider laser procedures suchas YAG sweeping, synech-iolysis and YAG capsulo-tomy once the eye is quite.After these procedures it isagain important to treat sucheyes with an intensive andextended course of topical ste-roids and prevent elevationof the intraocular pressure.

The greatest challengesfor a surgeon involved in op-erating cataracts in an eyewith uveitis continue to be anability to achieve an ad-equate atraumatic dilation ofthe pupil, minimizing post-operative inflammation andits sequelae, decreasing therisk of after cataract forma-tion and restoring a clear vi-sual axis.

CURRENT PRACTICE

anterior chamber implants and im-plants with polypropyelene haptics are

strongly contraindicated


It is the technique inwhich the examiner isguided by the patients re-sponse to the changes in theappearance of observed tar-gets as the power of the lensesbefore the patients eye is al-tered.

Since the conclusion de-pends on the subject, the re-sultant power may not be al-ways the pure refractive sta-tus of the eye under test. Somepatients may be sensitive tosmall changes of even 0.12 Dand some may not respondto even 1D change.

Subjective refraction maybe performed by use of trialframe or by use of phoropters.

To establish a starting pointeither or all may be useful guide:

1. Auto refraction find-ing – good AR helps a lot tohave an idea about the refrac-tive status.

2. Retinoscopy – there isno substitute of this and theobjective findings can bematched with the subjectiveresponse.

3. Previous power ofglasses – The visual acuitymeasured with presentglasses will help in estimat-ing the variation in the powerfrom the previous prescrip-tion. The old cylinder axis isalso important. It also helpsin judging the adjustmentsneeded based on previouscomplaints.

4. Keratometry – thismay be useful in approximat-

Subjective RefractionMs. Monica Chaudhry, Jeewan S. Titiyal MD

ing cylinder amount andaxis wherever the cornea isthe main refracting media ,like in aphakia andpsedophakia.

Relationship between vi-sual acuity and refractiveerror

Clue to estimate correction– Divide the visual acuity by

18 that gives the sphericalvalue or divide visual acuityby 9 for cylinder amount .

Suppose the visual acuityis 6/18.then the spherical is6/18 divided by 18 = 1D orthe cylinder is 18 divided by9 = 2Diopters.

The first stepControlling accommodation

– The fogging techniqueThe objective is to relax ac-

commodation which causesacceptance of over minus orfalse cylinder amounts.Fogging technique:

1. Achieve the spherical

power2. Modify the spherical

correction by adding + 1.0 Dsphere or higher lens whichreduces the visual acuityfrom 6/6 to 6/18 or less.

3. Plus power is reducedand minus power is addedin 0.25 steps till the patientcan just read 6/6, or the bestcorrected visual acuity isachieved.

The second step;Astigmatic component of re-

fractive error cylindricalpower and axis is deter-mined uniocularly by twomethods

Dr. R.P.Centre for OphthalmicSciences, AIIMS,New Delhi.

ART OF REFRACTION

Diagram 1 : A The clock dial - Astigmatic FAN, B Sunburst dial - Lancaster Regan astigmatic fan

11

12

1

23

4

5

6

7

89

10

0

330

300

270

240

210

180

150

120

9060

30

A B

A B

PO SITIO N FD JCC TO V ERIF Y AX IS

AXCAXC

PO SITIO N O F JCC TO V ERIF Y PO W ER

Diagram 2: AXC - axis of the cylinder in the trial frame, Black dot - indicate minus cylinderWhite dot - indicate plus cylinder


1. Jackson cross cylinder2. Astigmatic fan

Astigmatic fanTesting is done under fog-

ging and it always results inneutralization of cylindricalerror with cylinder lens ofminus power.

Fixed Astigmatic dialshave lines spaced angles 10to 30 Degrees from eachother, hence called the clockdials also.

1. the patient is fogged2. Unfog gradually and

ask to compare the sharp-ness and darkness of variouslines in various directions.

3. Discontinue unfo-gging at the point of greatestcontrast.

4. Localize the axis of mi-nus cylinder

5. simply multiply thelesser hour of the mostprominent line by 30

6. eg – if the set of 2 and 8O’ clock is clear multiply 2by 30 so the axis of the mi-nus cylinder is 60 Degrees.

7. Final power of the cyl-inder is determined by in-creasing its power until themost prominent set of lineand the set of line perpen-dicular to it are equally clear.

Jackson cross Cylinder –technique for astigmatismwithout fog.

JCC is a combination ofplus sphere combined withminus cylinder where cylin-der is twice the spherical, re-sulting in a lens which hasone meridian of convexpower and the other merid-ian perpendicular to it withconcave power. By conven-

tion the red dots indicate mi-nus cylinder power and thewhite dots indicate the pluscylindrical power. Thepower and the axis can beaccurately determined by thisas it uses the principle ofsturms conoid.

Procedure1. The retinoscopy find-

ing or the autorefraction canbe used as the starting point.

2. Target patient at oneline above which it can read.

Verify axisl Place the handle of the

cross cylinder as showncoinciding with the axismarking of the cylinder

l In case of minus cylinderin the trial frame look atthe red marks.

l Flip over the JCC once po-sition 1 , red dot to right ofthe axis and then position2 with red dot to left of theaxis.( diagram no - )

l Patient is asked to differ-entiate between the twopositions an indicatewhich position is better toread.

l Rotate the axis by 10 de-

grees to the side preferred.l Repeat this till on flipping

over both the positions areequally clear or blurred.

Verify cylinder powerl Place the axis of the cylin-

der and the JCC axis coin-ciding with each other.

l Ask patient again by flip-ping over position 1. oncethe red coinciding ( meansincreasing the minus cyl-inder value) position 2.the white dot coinciding(means the minus poweris now reduced)

l Keep on increasing or de-creasing till the patient in-dicates no difference inboth positions or reversesback.The next step after power

and axis finalization is fog-ging repeated again.

JCC is very useful andfaster than astigmatic dialsas it does not require accom-modation to be kept inactive.The dial is likely to success-ful in patients with amblyo-pia or corneal opacity wherethe retinoscopic findings arenot possible.

So summarizing the steps forJCCl Achieve sharp acuityl Determine axisl Determine the power

l Again unfog and deter-mine the sphere.

Monocular spherical endpoint

The rule is to prescribe themaximum plus and the leastminus power that permits themaximum acuity possible.

Several techniques areused but the most commonand practical is the Duoch-rome test

Duochrome or the bich-rome Method

It is the most usedand tra-ditional method to determinethe final spherical power.Itutilizes the principle of thechromatic aberration asshown in the figure.

1. Patient reds the chartwith letters on red and greenbackground.

2. The eye to be tested idslightly fogged.

3. On fogging the alpha-bets on the red backgroundwill be clearer to read.

4. Unfog in 0.25 steps tillboth the colours have equallydistinct colours.

5. So if the patient readsthe red background lettersclearer that means it requiresplus to be reduced or minusto be increased.

This method may havesome reliability problems ifthe coloured filters used arenot standardized or room il-lumination is inadequate orthe patient has colour visiondefect.

Binocular equalizationThis has to be done after

the best corrected lens is veri-fied uniocularly. The binocu-lar status of accommodationthen needs to be balanced.

The two common meth-ods used are

ART OF REFRACTIONA XC A XC

C C A FTE R C C A FTE R

Diagram 3 : To Verify Power Flip over JCC, once white dotcorresponding with axis of cyl, then red dot corresponding henceadding plus or minus alternately

Retinoscopy – there is no substitute ofthis and the objective findings can bematched with the subjective response


1. Alternate cover2. Borish Technique

Equalization by Alternateocclusion

1. Alternate occlude theeyes while the patient looksat the acuity chart

2. Compare the clarityand sharpness of each eye byrapidly occluding and alsogiving enough time to the pa-tient to pick up the difference.

3. Adjust the sphere tillboth the charts are equallysharp by increasing or de-creasing sphere.

Borish techniqueThis technique is more re-

liable than the above as ac-commodation can still be er-ratic on alternate occlusion

1. Base In prisms are putin the trial frame to dissoci-ate each eye.

2. The patient now sees2 vision drums.

3. Isolate 6/12 visualacuity line and compare thesharpness of the two charts.

4. Reduce or increasepower to make both chartsequally clear.

Near additionAfter finalizing the dis-

tance power the near addi-tion is given over the distanceto prebyopic patients. The

details of giving near correc-tion will follow in next issue.

Binocular Vision statusAfter finalizing the power

it is mandatory to check thebinocular visual status andrule out phorias , tropiasdiplopia or suppression.

Frame and face measure-ments

Before finally prescribingnote down the following:1. IPD , or monocular PD’S2. Back vertex distance of

trial frame.3. Segment height for bifo-

cals

To summarisel Starting point – objective

tests like retinoscopyl Accomodation control by

foggingl Uniocularly determine the

astigmatism

l Determine the spherel Binocularly equalizel Check binocular visual

statusl Give near addition if re-

quired.Patient Complaints and

the possible subjective teststo be done if the problem isassociated with incorrectsubjective refraction.

Blurred distance visionl Determine the final

sphere by foggingl Duochrome test to rule out

under or over correction ofmyopia

l Unequal accommodationin two eyes – Use boorishtechnique

l Verify axis and power ofthe cylinder – by JCC

Asthenopial Verify correctionl Rule out fusional and ver-

g y r

Douchrone Test

Diagram 4 : Diagram of chromatic aberration of the eye. The yellow wavelength focuss on the retina.

gence problems

Dizzinessl If strong cylinder is pre-

scribed for the first timel Cylinder axis is changedl Change in cylinder

amount in large step.

Near blurred visionl Check distance powerl Amplitude of accommo-

dationl Do duochrome for near to

rule out over or under cor-rection for near.

l Vergence problems.Subjective test is totally

patient dependant and ma-lingerers or slow responsesor poor observers can mis-lead in estimating the refrac-tive status. So there lies theimportance of objective testswhich should be correlatedwith the subjective tests.

High Lights for August Issue of DOS TimesØ Sutureless Vitrectomy : Dr. S. Natarajan

Ø Surgical Management of Pediatric Cataract : Dr. Abhay Vasavada

Ø Surgical Approach for Orbitotomy : Prof. S.M. Betheria

Ø Visual Rehabilitation After Keratoplasty : Dr. J.S. Titiyal

Ø Glaucoma Surgery with Fugo Blade : Dr. Daljeet Singh

Ø Eye Banking in India : Dr. Ramani

Ø Transpupillary Thermo Therapy : Dr. Lalit Verma


The IOL Master is : A com-bined biometry instrument. Itmeasures parameters of thehuman eye needed for in-traocular lens calculation. It measures quickly and pre-cisely1. Axial length2. Corneal curvature.3. Anterior chamber depth4. "White-To-White" (op-tionalØ non-contact optical deviceØ measures distance from

cornea to RPEPrinciple : based on partial

coherence interferometrywithin ±0.02 mm or better (A-scan ultrasonography 0.10-0.12mm)

AdvantagesØ Learned very quickly

(User Friendly)Ø Extensive integrated

safety featuresØ The LC display functions

both in patient eye align-ment as well as resultsand calculating interface.

Ø Non-contact measure-ments.(Patient comfort)

Ø Five formulae are inte-grated.Data of the desired lenses

must be entered into the da-tabase.

On the basis of postopera-tive refraction results, the lensconstants that are entered inthe calculation formulas maybe individually optimized(personalized) for every user.The axial length measure-

IOL MasterBalasubramanya R. MD, Jeewan S. Titiyal MD,

Rasik B. Vajpayee, MBBS, MS

Cataract & Refractive SurgeryService, Dr. R.P. Centre forOphthalmic Sciences,AIIMS, New Delhi - 29

ment is based on a patentedinterference optical methodknown as Partial CoherenceInterferometry (PCI). Thistechnique relies on a laserDoppler technique to mea-sure the echo delay and in-tensity of infrared light re-flected back from tissue in-terfaces-cornea and RetinalPigment Epithelium.

At least four of the mea-surements should be within0.02 mm of one another, andshould exhibit the character-istics of an Ideal Display. Anideal axial length display ismore important than a highsignal-to-noise ratio (SNR).Ø IOL master accurately de-

termines the axial lengthof eyes ranging from 14.0mm to 40.0 mm.This technique is espe-

cially useful for eyeswithØ small corneal scarsØ anterior cortical

spokesØ posterior subcapsu-

lar plaquesØ other localized me-

dia opacities.l Instruct patient

to look directly at thesmall red fixation light.l gives refractive

axial length, ratherthan the anatomic axiallength.l In high refractive

error (more than ±6.00D), measurement to betaken with the patient'sglasses in place to en-sure adequate fixation.l For eyes with

high to extreme myo-

pia, with a type 1 peripapil-lary posterior staphyloma,being able to measure to thefovea is an enormous advan-tage over conventional A-scan ultrasonography.

Valid Signal CurvesØVery good signals (signal-to-

noise ratio > 10)Ø Several secondary maxima

visible (system-specific)Ø Clear media, correctly fix-

ating patientØ Weak ametropiaØ Clear signal (SNR >2.0)Ø Secondary maxima visibleØ Relatively clear media

Non Valid Signal CurvesØ Low signal (signal-to-noise

ratio < 1.6)Ø Error message is displayed.Ø The measuring signal can-

not be clearly distin-guished from the noise.

Possible reasonsØ Unsteady (non fixating)

patient

Ø Strong ametropiaØ Dense media opacity along

the visual axisØ Repeat the measurement

and ask the patient to fix-ate steadily.l To measure aphakic

eyes, Pseudophakic Eyes, oreyes filled with Silicone Oil,select the correspondingmode from the ALSettingsmenu.l The instrument will

automatically be reset to the"phakic" mode by changingthe side (moving to othereye), or by measuring a newpatient.

OPHTHALMIC APPLIANCES


you choose the "onemeasure" option,only one measure-ment result will bedisplayed (the resultof five internal singlemeasurements)Ø If on the Options- Setup / ProgramSettings you choosethe "list of measures"option, three mea-surements resultswill be displayed, ob-tained each throughfive internal single

measurements.Ø If the results ofthe last three measurementsdiffer by an average value ofgreater than 0.5 D, or 0.08mm to 0.1 mm (depending onn) has been exceeded, the dis-play shows the message"Evaluation", which indi-cates that you need to checkfor accuracyØ check the pre-corneal tear

film of the eye to be exam-ined

Ø If needed, add artificialtears, have the patientblink, open their eyeswide, and then repeat themeasurement.

symmetrical,Ø The central point usually

not focused and not ana-lyzed

Ø all six peripheral pointsshould be visible, and lo-cated in the field betweenthe two auxiliary circleson the display.The measuring points

should be circular, or ellip-soid .Ø Five measurements within

a period of 0.5 seconds, av-erage value displayed

Ø The completion of the mea-surement indicated by ashort acoustic signal

Ø The corneal curvature (inmm, or diopters) of theprincipal meridians dis-played with the corre-sponding axis.

Ø If the cornea isspherical, only one radius, orone refractive power valuewill be displayed.Ø If several mea-surements of the corneal cur-vature are in "one measure"mode, the previously mea-sured values will be over-written in the display.Ø Simply pressshortcut key CTRL +ZØ If on the Options- Setup / Program Settings

Ø Any erroneous measure-ments should be deleted.The anterior chamber

depth is determined as thedistance between the opticalsections of the crystalline lensand the cornea produced bylateral slit illumination.Ø automatically activate the

lateral slit illuminationØ the lateral slit illumina-

tion bright and mentionedprior to measuring theACD.

Ø patient to look straightahead and directly at thesmall, yellow fixationlight and not into the lat-eral slit which is flicker-ing during the measure-ment

Ø Fine-align the instrument sothat:The image of the fixation

point appears to be opti-mally sharp within thesquare on the display,

The image of the cornea isnot disturbed by reflections,The anterior crystalline lensis optimally visible.Ø As a rule, the image of the

fixation point lies betweenthe images of the corneaand the crystalline lens. It


l Measurements thro-ugh contact lenses will leadto measurement errorsand therefore should not beperformed.l Measurements of eyes

with retinal detachment willlead to measurement errorsand therefore should not beperformed.

The corneal curvature isdetermined by measuring thedistance between reflectedlight images as in conven-tional keratometry.

ProcedureØ a drop of artificial tears is

instilled in each eye,Ø have the patient blink sev-

eral times,Ø all measurements with both

eyes open as WIDE as pos-sible.

Ø blink between each mea-surement.

Ø as many measurements asneeded

Ø good automated kerato-metry measurements willall be within 0.25 D ineach meridian.

Ø Tell the patient to fixate onthe yellow light.

Ø Align the instrument sothat the six peripheralmeasuring points are


should be near (but notwithin) the optical sectionof the crystalline lens.

AdvantageØ Non-contact measure-

ments.(Patient comfort)Ø No risk of cross infectionØ Single instrument per-

forming AL,Km &ACDØ Learned very quickly.

(User Friendly)Ø Observer independent re-

liabilityØ More accurate than con-

ventional A-scan(approxfive times)

LimitationsØ Dense media opacity

along the visual axisØ Unsteady (non fixating)

patientØ Strong ametropiaØ Patients with nystagmusØ Retinal detachment

Literature ReviewA recent study by Connors

IOLMaster is more accurate and repro-ducible than contact ultrasound in pro-

viding accurate AL measurements


and coauthors comparescontact ultrasonographyand partial coherence inter-ferometry using theIOLMaster (Zeiss Humph-rey Systems) in 111 eyes. Thelaser interferometer providedsignificantly better results,with a decreased mean ab-solute refractive error postop-eratively and an increase inthe percentage of eyes within±0.5 diopters (D) (61.2% ver-sus 42.3%) and ±1.0 D (87.4%versus 77.5%) of the pre-dicted refraction. The au-thors conclude that theIOLMaster is more accurateand reproducible than con-tact ultrasound in providingaccurate AL measurements.

Connors R. Boseman P,

Olson RJ. Accuracy and re-producibility of biometry us-ing partial coherence inter-ferometry.

J Cataract Refract SurgFeb2002; 28:235-8

A study by Packer et al.compares partial coherenceinterferometry and immer-sion ultrasound in 50 eyes.The AL measurements with

the 2 techniques were highlycorrelated.

Packer M. Fine IH.Hoffman RS. Immersion A-scan compared with partialcoherence interferometry:outcomes analysis. J CataractRefract Surg 2002; 28:239-242

In our own experience of>150 eyes at present the IOLMaster measurement weresuccessful in more than 85%of cases with respect to AL(axiallength), anterior cham-ber depth (ACD), andkeratometry measurement.

Where is my copy of DOS Times?Dear DOS members, anyone who could not receiveDOS Times from the month of July, 2003 onwards.

Please Contact:

MR. SUPROTIK BANERJIM/s. Syntho Pharmaceuticals Pvt. Ltd.

31/16, 2nd Floor, Old Rajinder Nagar, New Delhi-60E-mail: [email protected]


The prevalence of glau-coma and cataract both in-crease with each decade oflife and thus often coexist.The decision for manage-ment of such cases dependsupon the visual disabilitycaused by the cataract, thelevel of IOP control and theextent of glaucomatous dam-age. The ophthalmologist isfaced with following optionswhen dealing with a casewith coexistent cataract andglaucoma: -1. Cataract surgery alone2. Laser trabeculoplasty fol-

lowed by cataract extrac-tion

3. Filtering procedure fol-lowed by cataract extrac-tion at a later date

4. Simultaneous cataractand glaucoma surgery –Combined extraction

Cataract extraction aloneIndications : Visually signifi-cant cataract, early glaucoma-tous damage, IOP well con-trolled on single topical medi-cation

It is the treatment of choicein patients who are well con-trolled on a single drug medi-cal regimen and with little orno glaucomatous optic nervedamage. However there is apossibility of a postoperativeIOP spike which is danger-ous in patients with moder-ate/advanced glaucomatousvisual field damage becauseeven a slight post-operative

Management of Cataract inGlaucoma PatientsTanuj Dada MD, Harminder K Rai MD, Harinder S Sethi MD

Dr. Rajendra Prasad Centre forOphthalmic Sciences, New Delhi

rise of IOP can threaten theremaining field of vision.

On the other hand cataractextraction in a patient ofchronic angle closure glau-coma may be curative for theglaucomatous process andresult in a lowering of IOP.This may allow the ophthal-mologist to withdraw eventhe single anti glaucomadrug.

With the current tech-nique of phacoemusificationand the use of chondroitinsulfate and sodium hyalur-onate as viscosurgical de-vices it is important to com-pletely aspirate the vis-coelastic at the end of sur-gery as any residual vis-coelastic can lead to a verylarge IOP spike. One shoulddigitally measure the IOP af-ter sealing the main woundand the side ports to ensurethat an excessively high IOPis not obtained. Post opera-tively tab acetazolamide 250mg should be given to thepatients.

Glaucoma patients whoundergo cataract surgeryalone should be followed upregularly they may developpoor control of glaucoma anytime, requiring modificationof therapy or surgery.

Laser trabeculoplasty fol-lowed by cataract extrac-tionIndications : cataract not vi-sually disabling, mild/moder-ate glaucomatous damage, IOPwell controlled on two/moretopical medications

Argon laser/Diode laser/NdYAG laser trabeculo-plasty followed 3 monthslater by cataract extraction isanother alternative in eyeswith primary open angleglaucoma, pseudoexfolia-tion syndrome and pigmen-tary glaucoma. It decreasesthe risk of immediate eleva-tion of IOP in the postopera-tive period. This may also re-duce the requirement of antiglaucoma medications bothprior to and following cata-

ract surgery. Complicationsfollowing ALT include hem-orrhage from trabecularmeshwork during treatment,formation of peripheral an-terior synechiae, uveitis andelevation of IOP. Lasertrabeculoplasty tends to re-duce IOP by about 20% andthere is a loss of the effect overtime. Thus one has to moni-tor these patients over a pro-longed period of time.

Filtering surgery with sub-sequent cataract extrac-tionIndications: Severe uncon-trolled glaucoma, advancedglaucomatous visual field de-fects requiring IOP in “lowteens”, presence of risk factorsfor filtration failure

When IOP is uncontrolleddespite of maximal tolerablemedical therapy and lasertrabeculoplasty, a trabeculec-tomy should be performedalone. This is also the case ineyes with advanced glau-coma that require a very lowtarget pressure. Doing atrabeculectomy alone pro-vides a better IOP controlthen a combined procedure.Eyes with conjunctival scar-ring, neovascularization,healed uveitis, and youngpatients who are at a higherrisk of filtration failureshould always be subjectedto a two staged procedure.In patients who are on pilo-carpine therapy, eliminatingthe need to use miotictherapy may improve visionenough to delay cataract sur-gery.

Cataract extraction can beperformed through a tempo-ral clear corneal incision at alater date ( preferably after 3months of the trabeculec-tomy).

MANAGEMENT PEARLS


The inherent disadvan-tages of this approach arethat it requires two hospitaladmissions with two surger-ies and their associated com-plications, there is a longercumulative recovery periodand there is always a possi-bility of failure of the filtra-tion bleb after the cataractsurgery.

Simultaneous cataractand glaucoma surgery -Combined ExtractionIndicationsØ IOP not well controlled on

single topical medicationin a patient with mild/moderate glaucoma.

Ø Intolerable drug inducedside effects

Ø When the patient is notcompliant

Ø Medical disability not al-lowing patient to instilleye drops

Ø Non availability of medi-cation in patients nativearea

Ø Uncontrolled glaucoma,but an urgent need to re-store vision or when twoseparate surgeries are notfeasible (eg patient notlikely to come for followup).

Ø In eyes with phacomor-phic glaucoma who have

a delayed presentation af-ter 72 hours, a combinedextraction should be doneafter controlling the in-flammation.When combining glau-

coma surgery with cataractextraction, the surgery be-comes technically more dif-ficult than either surgeryalone, there is more post op-erative inflammation, thebleb formation is less reliableand the lowering of IOP maynot be adequate to theamount of glaucomatousdamage (i.e may not achievetarget pressure).

There are two choiceswith the phaco surgeon:1. Single site phaco trabe-culectomy.2. Two site phaco trab-eculectomy (superior trab &temporal phaco).

Single site surgery takesless time, induces against therule astigmatism, may pro-vide difficulty in cutting thetrabecular block if a punchis not available, likely to in-duce more inflammation andfibrosis and is usually donewith a fornix based flap withmore chances of postopera-tive wound leak (especiallyif Mitomycin C is used). Twosite surgery offers the benefitsof a standard trabeculectomy

surgery without any modifi-cation, a limbus based flapis used which gives a goodpostoperative bleb with adecreased chance of blebleaks and against the ruleastigmatism which may beinduced by the superior trabis neutralized by the tempo-ral phaco incision. The onlydisadvantage is that it takesa longer time to do. Variousstudies have been conductedon the efficacy of these twotechniques and there is nosignificant difference in thefinal outcome although inour experience the chancesof bleb failure are much morein a single site surgery.

The surgery of choice is atwo site phaco trabeculec-tomy with a superior trabe-culectomy and a temporalphacoemulsification.

The preponderance of evi-dence from the literature sug-gests a small (2-4 mm of Hg)benefit from the use of mito-mycin-C (MMC), but not 5-fluorouracil (5-FU), in com-bined cataract and glaucomasurgery. Two-site surgeryprovides slightly lower (1-3mm of Hg) intraocular pres-sure (IOP) than one-site sur-gery although there are con-flicting reports in literature.IOP is lowered more (1-3 mmof Hg) by phacoemulsi-fication than by conven-tional extracapsular cataractextraction in combined pro-cedures. Trabeculectomyalone produces a muchlower IOP as compared to acombined phacotrabecule-ctomy. The type of conjuncti-val flap in a 2-site phacotra-beculectomy did not seem toinfluence the final outcome.The main advantage of thefornix-based conjunctivalflap is the shorter surgical

time and the relatively fasterimprovement in vision post-operatively. The main disad-vantage is bleb leakage.

Phacoemulsification in thePresence of a FilteringBleb

Eyes which have under-gone a trabeculectomy andhave a filtering bleb needspecial consideration in ref-erence to the location of theincision, poor pupillary di-latation, low corneal endot-helial counts and the preop-erative hypotony. There isalso a risk of post operativebleb failure due to the inflam-mation produced by the sec-ond surgery. The surgeonshould keep the followingpoints in mind when operat-ing on eyes which have un-dergone a previous filteringsurgery.

1. The time interval be-tween the trabeculectomyand the second stage cata-ract surgery should be atleast3 months and preferably 6months.

2. Superpinky should beavoided as it can result in agross hypotony with shallo-wing of the anterior chamber.

3. Since the site of the fil-tering bleb is usually supe-rior, a 3 mm temporal clearcorneal incision should bemade for performingphacoemulsification.

4. The corneal endothe-lium should be coated witha dispersive viscoelasticsuch as chondroitin sulfateto provide maximal protec-tion..

5. The pupil should bedilated by use of iris hooksor other mechanical means.

6. These eyes tend tohave a shallow chamber andthe height of the infusion


Surgical approach Drop in IOP 1-4

Trabeculectomy alone 48%

Combined Phacoemulsi- 31%fication and trabeculectomy

Using MMC Additional 2-4 mm ofHg drop

Combined Phacoemulsi- 1-3 mm of Hg less than

fication and ECCE PhacoemulsificationTwo site surgery 1-3 mm of Hg more drop

than single site


OPHTHALMIC APPLIANCESbottle should be increased toprevent collapse of the ante-rior chamber. The vacuumsettings should also be kepton the lower side.

7. If there is a tendencyfor bleb failure and one needsto give postoperative mas-sage, atleast one sutureshould be applied even to a3 mm incision.

8. Early postoperativeintraocular pressure spikesare frequently observed aftercataract surgery in glauco-matous eyes, and consider-able fluctuations in pressurecan occur during the firstpostoperative month. There-fore one should keep a closewatch on the IOP and giveantiglaucoma medications inthe post operative period.Vigorous use of topical ste-roids is also indicated to de-crease post operative inflam-mation which may subse-quently lead to bleb failure.Subconjunctival injection of5-FU or mitomycin dropsmay be considered if there isa tendency for bleb failure.

References1. Jampel HD, Friedman DS,

Lubomski LH, Kempen JH,Quigley H, Congdon N,Levkovitch-Verbin H,Robinson KA, Bass EB Effectof technique on intraocularpressure after combinedcataract and glaucoma sur-gery: An evidence-based re-view Ophthalmology. 2002Dec;109(12): 2215-24.

2. Friedman DS, Jampel HD,Lubomski LH, Kempen JH,Quigley H, Congdon N,Levkovitch-Verbin H,Robinson KA, Bass EB. Sur-gical strategies for coexistingglaucoma and cataract: anevidence-based update.Ophthalmology. 2002Oct;109(10):1902-13.

3. Samuelson TW. Manage-ment of coincident glaucomaand cataract. Curr OpinOphthalmol. 1999 Feb;10(1):66-72.

4. Hsu CH, ObstbaumSATechnique and outcomeof combined phacoemulsi-fication & trabeculectomy.Curr Opin Ophthalmol. 1998Apr;9(2):9-14.

Attention DOS Members!

Contents of our websitewww.dosonline.org

w Important noticesw Monthly Clinical Meetingw Mid Term Conferencew Annual Conferencew List of Executives with Addressw List of Editorial Boardw Life Membership Formw Constitutionw Forthcoming Events

ANNUAL GENERAL BODY MEETINGThe Annual General Body Meeting of DelhiOphthalmological Society will be held onSunday the 27th July 2003 at 9.00 A.M. atAyurvigyan Auditorium, Army Hospital(Research & Referral), Near Dhaula Kuan (onNH-8) Delhi Cantt – 110010.All members are kindly requested to make itconvenient to attend.

Dr. Jeewan S. TitiyalSecretary, DOS

N O T I C E


Any breach in the conti-nuity of the posterior capsu-lar is defined as posteriorcapsular tear (PCT)1. It hasvarious nomenclatures, suchas posterior capsular rent orposterior capsular rupture.Posterior capsular tear is apotentially serious intraop-erative complication of cata-ract surgery. It may be asso-ciated with vitreous loss, cys-toid macular edema, uveitis,glaucoma, retinal detach-ment, vitreous touch syn-drome, vitreous wick syn-drome, and expulsive haem-orrhage. It is a common com-plication that occurs duringcataract surgery. The differ-ent types of posterior capsu-lar tear are intrasurgical, pre-existing (congenital or trau-matic) and spontaneous 2, 3, 4.(1) intrasurgical PCT- are themost common and can beaccidental or planned, as inprimary posterior capsulor-hexis (2) pre existing PCT areusually detected at the timeof the surgery in cases of con-genital or traumatic cataracts(3) spontaneous PCT-arerare and are associated withhypermaturity, posterior len-ticonus intra ocular tumorsand posterior polar cataractThe incidence of PCT follow-ing extracapsular cataractextraction varies from 0.2%to 10.3%5, 6 while that duringphacoemulsification rangesfrom 0.7% to 16%7, 8. Occur-rence of PCT is not only de-pendent upon surgical skill

Posterior Capsular TearTishu Saxena MS, Rasik B. Vajpayee MBBS, MS,

Namrata Sharma MD, Jeewan S. Titiyal MD,

of the surgeon or the surgi-cal technique employed.There are various types ofcataract which have higherassociation with PCT withvitreous loss. Pseudoexfo-liation, posterior polar cata-ract, traumatic cataracts,posterior lenticonus, dia-betic cataracts, cataractswith persistent primary hy-perplastic vitreous and cata-racts following vitroretinalsurgery have increased inci-dence of posterior capsulartear.

Factors, Etiology andFeatures.

Predisposing factors for aposterior capsular tear are.1. Poor visibility due to sec-ondary problems.Ø Unstable Hand position,

fluid pooling.2. Poor visibility secondaryto pathology.Ø Arcus senilis.Ø Pterygium.Ø Band shaped kerato-

pathyØ Corneal scars.Ø Dense asteroid hylosis

3. Hypermature cataracts.4. Posterior polar

cataracts.5. Pseudoexfolia-

tion.6. Black cataracts7. Traumatic cata-

racts.8. Long and short

axial length9. Cataracts follow-

ing previousvitreo retinal sur-gery.

10. Small pupil11. Demented, dis-

oriented, anxious patient.12. Inexperienced surgeon.13. Deep set eyes14. Short and obese stature,

thick neck patient15. History of vitreous loss

in other eyeIntrasurgical posterior

capsular tears are the mostcommon type of PCT. DuringECCE it can occur due tosmall incision, trauma dur-ing capsulotomy, injury toposterior capsule, irrigation-aspiration, small pupil in thecourse of cortex aspirationand high pressure from theposterior chamber 9. 10. ThesePCT are irregular in shapeand may be located any-where and have the ten-dency to enlarge rapidly. Theclinical signs of occurrenceof intrasurgical PCT are sud-den deepening of anteriorchamber and shift of the lensiris diaphragm back wards,dyscoria and incarcerationof vitreous strands in the suc-tion port of the cannula. Pos-terior capsular tear can oc-cur during any stage ofphacoemulsification surgerylike hydrodissection, nuclearemulsification, capsulor-hexis, cortical removal, irri-gation aspiration, posteriorcapsular polishing and IOLimplantation. Intra –opera-tive posterior capsular tearduring hydrodissection is

common in eyes with poste-rior polar cataract as in thesecases the posterior capsulemay either be abnormallythin and fragile or there maybe a pre existing central open-ing. The first tell–tale sign ofPCT occurring duringhydrodissection is “Pupilsnap sign”. PCT occurringduring nuclear manipula-tion is often not very obvious.The following signs shouldalert the surgeon that a prob-lem is likely to exist –deep-ening of anterior chamber,loss of lens followability andlens tilt or deepening of pos-terior chamber. If a PCT oc-curs during irrigation andaspiration, posterior capsu-lar vacuuming or duringIOL implantation, the dis-covery is quick and evidentand it can be managed im-mediately. Four cardinalsigns of torn posterior cap-sular during Phacoemulsi-fication are (1) sudden deep-ening of anterior chamber (2)momentary papillary dilata-tion (3) nuclear does not fol-lowed towards the Phaco-emulsification tip (4) nucleusfalls away from the phaco tip.

ManagementThe rupture of the poste-

rior capsule with its attend-ing complication is one ofthe most feared complica-

tions of cataract sur-gery. The manage-ment PCT is depen-dent on its immedi-ate recognition, sizeof the tear, whetherthe hyloid face is in-tact, the stage atwhich the surgicalprocedure hasreached and thecomplication whichhave ensued prior torecognition of thePCT. Timely recogni-

Dr. Rajendra Prasad Centre forOphthalmic Sciences,New Delhi

MANAGEMENT PEARLS


tion and planned manage-ment is required to ensure anoptimal visual outcome.Once a problem is suspected,a surgeon must have the dis-cipline to immediately stopworking. This however doesnot mean abrupt removal ofinstrument from the eyes.

Intra surgical posteriorcapsular tear

If PCT is identified duringearly stages of ECCE-itshould be plugged with vis-coelastic substance followedby dry aspiration of the re-maining cortical lens matter.Meticulous control of infu-sion, establishment of semiclosed system and avoidanceof over hydration preventsenlargement of tear and an-terior displacement of vitre-ous. If the PCT > 6mm, orthere is failure to visualizemargins of PCT, or there areextensive vitreous distur-bance, a partial anterior vit-rectomy followed by implan-tation of AC IOL is advo-cated.

If PCT occurs during earlystages of Phacoemulsifi-cation i.e. during capsulo-rhexis or early sculpting,then the procedure should beconverted to an ECCE. In thelate stages of Phacoemu-lsification PCT can occurwith or without intact hyloidface with or without the lux-ation of nuclear material.

PCT with intact hyloid facewith nuclear material present:-In cases of small nuclear ma-terial viscoelastic is injectedto plug the PCT and nuclearmaterial is moved into theanterior chamber withspatula and emulsified withshort bursts. In case of largenuclear material – high vis-cosity viscoelastic is injectedabove and below the nuclearmaterial. The incision is ex-

tended larger than the frag-ment and the nuclear frag-ment is extracted out with theusing Sheet’s glide or loop.

Post capsular tear with rup-tured hyloid face without lux-ation of nuclear material intovitreous. In case of small re-sidual nuclear material: highviscosity viscoelastic is in-jected under the nuclear ma-terial and dry anterior vitrec-tomy is performed followedby phacoemulsification us-ing high vacuum.

In case of large residualnuclear material: it is advis-able to convert to routineECCE.

Post capsular tear with rup-tured hyloid face with luxationof nuclear material into vitre-ous – it is a serious complica-tion and ranges from 0-18%in various reports11 . The nu-clei can get dislocated intothe vitreous during grooving(33%), cracking (33%), emul-sification (23.8%) andHydrodissection (2%). Ananterior segment surgeonwith no training in vitreo-retinal surgery should not tryto retrieve the lost nuclearfragment as it may lead toserious posterior segmentcomplications. In such casesgood anterior vitrectomyshould be done, woundshould be properly closedand the patient should berefered early to a vitreoretinalsurgeon.

Intraocular lens implanta-tion in PCT

The desired location, ori-entation, type and size of theIOL depends upon the sizeof the PCT, visibility of re-maining capsular marginand capsulo-zonular anat-omy. If PCT <6mm / marginsare clearly visible with novitreous prolapse – PCIOLimplantation in the capsular

bag may be performed.If PCT >6mm / margins

are not clearly visible–ACIOL should be implanted.In the presence of PCT, anIOL may be placed in the sul-cus if the capsular rim(anterior or posterior) isavailable or the bag if the tearis small.

Visual outcome in eyeswith PCT

PCT is a common and sig-nificant complication of cata-ract surgery that can affectvisual outcome12. When PCTis without vitreous loss anda PCIOL is implanted in thebag or ciliary sulcus, there isstill an increased risk ofCME, vitreous prolapse inthe anterior chamber andpseudophakic retinal de-tachment. Vitreous loss ap-pears to be the crucial factorinfluencing visual outcome.Once vitreous is lost, thepost-operative course is com-plicated in 30% of patientsdue to retained cortex, cor-neal edema, hyphema,blurred vision, vitreousstrands and secondary glau-coma. Long term retinal prob-lems include chronic CME,macular holes and retinaldetachment.

ConclusionRecognition and appro-

priate adjustment of the sur-gical plan in the presence ofpredisposing factors for aPCT help to decrease the in-cidence of this problem.Prompt recognition andtreatment of PCT and vitre-ous loss, methodical analy-sis and nuclear and corticalremoval, preservation of asmuch posterior capsule andappropriate IOL selectionand insertion help to preventsurgical complications andimprove usual outcome.

References1. Vajpayee RB, Sharma N, Dada

T, et al: Management of poste-rior capsular tears. Surveyophthalmol 45: 473-488, 2001

2. Angra SK, Vajpayee RB,Titiyal JS, et al: Types of pos-terior capsular breaks and theirsurgical implications. Oph-thalmic surg 22: 388-391, 1991

3. Vajpayee RB, Angra SK,Honavar SG, et al: Pre-exist-ing posterior capsule breaksfrom perforating ocular inju-ries. J cataract refract surg 20:291-294, 1994

4. Vajpayee RB, Sandramouli S:bilateral congenital posteriorcapsular defects: A case report.Ophthalmic surg 23: 295-296,1992

5. Chambless WS: Incidence ofanterior and posterior segmentcomplications in over 3000cases of extracapsular cataractextraction; intact and opencapsules. J Am Intraocul Im-plant Soc 11: 146-148, 1985

6. Courtney P: The National cata-ract surgery survey: I. Meth-ods and descriptive features.Eye 6: 487-492, 1992

7. Allinson RW, Metrikin DC,Fante RG: Incidence of vitre-ous loss among third year resi-dents performing phacoemuls-ification. Ophthalmology 99:726-730, 1992

8. Corey RP, Olson RJ: Surgicaloutcomes of cataract extrac-tion performed by residentsusing phacoemulsification. JCataract refract surg 24: 66-72, 1998

9. Gao Y, Chen T, Zhao S: Ananalysis of posterior capsularrupture in cataract surgery.Chung Hua Yen Ko tsa Chih32: 200-202, 1996

10.Hao YS, Hui YN, Li JG: Pri-mary implantation of poste-rior chamber intraocular lenseseyes with defective posteriorcapsule. Chung Hua Yen Kotsa Chih 30: 25-27, 1994

11.De Groot V, JonckheereP,Tassignon Mj : Centration ofintraocular lenses with circu-lar haptics. J Cataract RefractSurg 23: 1247-1253, 1997

12.Osher RH, Cionni RJ.The tornposterior capsule : its intraop-erative behaviour, surgicalmanagement, and long termconsequences: J Cataract Re-fract Surg !6: 490-494, 1990

MANAGEMENT PEARLS


There are 1.5 million blindchildren (corrected visualacuity <20/400 in the bettereye) in the world1-3 and onemillion of these live in Asia.The prevalence of childhoodcataract has been reported tobe 1 to 15 cases in 10,000 chil-dren. It is estimated that thereare 200,000 children blindfrom bilateral cataract glo-bally.3 (Figure 1).

EtiologyThe main causes of infan-

tile cataract are genetic, meta-bolic, prematurity and in-trauterine infections.4-6 Othercauses of childhood cataractinclude trauma, drug-in-duced cataract, radiationtherapy and cryo-applica-tion or laser therapy for ret-inopathy of prematurity.Trauma is one of the com-monest cause of unilateralcataract in the developingcountries.5,6 Bilateral cata-racts occur commonly due tothe long-term use of topicalor systemic steroid therapy.In industrialized countries,in approximately 50% of bi-lateral cases and virtually allof the unilateral cases, theunderlying cause can not bedetermined.1,3

MorphologyThe morphologic types of

childhood cataracts arebroadly classified as:a) Zonular cataract: In clinical

practice we find zonular

Pediatric CataractJagat Ram & Sushmita Kaushik

Department of Ophthalmology,Postgraduate Institute of MedicalEducation & Research,Chandigarh

cataract as one the mostcommon type. Commontypes of zonular cataractseen are nuclear, lamellar,sutural or capsular (Fig-ure 2, 3).

b) Total or diffuse cataract:These are usually bilat-eral. Most of the childrenfrom rural areas maypresent with total diffusecataract.

c) Polar cataract: This type ofcataract usually occurs inthe anterior or posteriorpolar region. Posteriorlentiglobus is also a typeof posterior polar cataract.

d) Membranous cataract: Thistype is usually associatedwith congenital anoma-lies such as microphthal-mos or congenital rubellasyndrome. Membranouscataracts may occur in as-sociation with mi-crophthalmos, congenitalrubella, Lowe syndromeand Hallermann-Streiff-Francois syndrome.

Pre-operative evaluationA thorough history from

the parents isuseful to under-stand whetherthe cataract iscongenital, de-velopmental ortraumatic in ori-gin. One mustascertain ifthere is any his-tory of maternaldrug use, infec-tion or exposureduring preg-nancy. Eachchild should be examined bya pediatrician for thoroughsystemic work up to rule outsystemic associations,anomalies or congenital ru-bella.

Ocular examinationA thorough ocular exami-

nation is a must in everychild. All children must un-dergo complete ocular evalu-ation and wherever neces-sary, examination under an-esthesia.

a. Visual acuity: Lightfixation should be recordedin each child. It is importantto note whether fixation iscentral steady and main-tained or not. Pupillary re-actions are carefully noted.

b. Corneal clarity: The cor-neal clarity is of importance

both for surgery and for as-sessment of possible raisedintraocular pressure. Condi-tions like Peter's anomaly,juvenile rheumatoid arthri-tis, or post-traumatic cornealscars may compromise thequality of cataract surgery inthese children.

c. Laterality and type ofcataract: We should docu-ment whether the cataract isunilateral or bilateral. Weshould carry out biomicro-scopic examination in coop-erative children after dilata-tion of pupil with topicalcyclopentolate 1% and phe-nyl ephrine 2.5% to evaluatethe size, density and locationof cataract to plan the surgi-cal procedure. Any sublux-ation of cataract is to be re-corded.

d.Fundus ex-a m i n a t i o nmust be car-ried out afterpupillary dila-tation. In chil-dren withdense or dif-fuse cataract,B-scan ultra-sonographyshould bedone to ruleout retinal pa-

REVIEW

Fig. 1. Bilateral total infantile cataract. An earlysurgical intervention and prompt visual reha-bilitation is mandatory to prevent irreversibleamblyopia.

Fig. 2. Zonular cataract is the most com-mon type of infantile or developmental cata-ract.

Fig. 3. This is sutural (Y- Suture) cata-ract, which may increase in density andmay require surgical intervention.


thology i.e retinal detach-ment or vitreous hemorrhage.

e. Intraocular pressureshould be recorded with ap-planation tonometry in co-operative children. In others,it should ideally be recordedunder anesthesia at the timeof surgery.

f. We should also notepresence of associated ocu-lar pathology such as mi-crophthalmos, associatedstrabismus and nystagmus.Presence of any of these fac-tors is likely to adversely af-fect the prognosis and theparents ought to be coun-seled appropriately.

g. A-scan biometry is de-sirable to measure the axiallength for calculating IOLpower and monitoring theglobe elongation postopera-tively. Wherever possible,keratometry should be doneand the IOL power calcu-lated using the SRK-II for-mula. In younger/uncoop-erative children, globe lengthcan be assessed using B-scanultrasonography.

In younger and non-coop-erative children detailedocular examination after pu-pillary dilatation is done todocument type of cataract,IOP and fundus evaluation,axial length, keratometry un-der general anesthesia.

Laboratory Work-upIt is not a must to carry out

all the laboratory investiga-tions in each case. The tai-lored approach keeping inmind the specific case is amore appropriate strategy.

The basic idea of thelaboratory work-up isto detect associatedmedical problems inaddition to the cata-ract, which may needspecialized treatment.

Cataract types thatneed no workup: Uni-lateral, posterior len-ticonus, traumatic, fa-milial.

Cataract types thatneed to be worked up: In-flammatory, oil drop-let, sporadic com-plete, associatedphysical abnormal-ity.

IOL Power CalculationIntraocular lens power

calculation for the growingpediatric eye poses severalproblems. Most reports haverecommended under-correc-tion of the IOL power for pe-diatric cataract, anticipatingthe myopic shift followingIOL implantation. The axiallength and keratometry read-ings should be measured forIOL power calculation inchildren. Dahan, et al8 sug-gested a very practical ap-proach for younger children.He stated that IOL power cal-culations may be performedusing axial length in chil-dren under one years of ageand keratometry readingsare not as crucial since thesereadings change rapidlyfrom 52.00 ±4.00D to44.00±4.0D in the first 6months of life. The K-read-ings in the newborn are ig-nored and replaced by the

average adult K-reading thatis 44.00D. Dahan, et al8 havesuggested to aim for under-correction in children be-tween two to 8 years performbiometry and under-correctby 10%. For children youngerthan 2 years, perform biom-etry and under-correct by20% or use the axial lengthonly. IOL power suggestedfor 21mm is (22.00D), 20mm(24.00D), 19mm (26.00D),18mm (27.00D) and for 17mmaxial length 28.00D. BenEzrasuggested implanting 21.0Dof adult IOLs in all pediatriccases.9 This may be accept-able for most of the childrenover 2 years but will not besuitable for eyes with mi-crophthalmos and infantilecataract.

Indications for cataract sur-gery for pediatric cataract

Indications for surgery inpediatric cataract include:l Child with visually sig-

nificant cataract. Cata-ract, which occupy visualaxis and occupy 3mm ormore of the pupil is an in-dication for cataract sur-gery.

lUnilateral partial orcomplete cataractneeds early surgery toprevent amblyopia.lPoor retinoscopic re-flex:. If during retinos-copy through dilatedpupil reflex is poordue to cataract, it is anindication for surgery.lCongenital or devel-opmental cataractwith strabismuslCongenital or devel-opmental cataractwith nystagmus / un-steady fixationlChildren with bilat-eral cataract where

one eye has been operatedsecond eye with cataractshould be operated pref-erably with in one to twoweeks to prevent amblyo-pia

When to operate pediatriccataract?

Timings of cataract sur-gery depend on the indica-tions and factors influencingvisual outcome. Once indi-cated, the child may be oper-ated as early as 2 weeks ofage considering the safety ofgeneral anesthesia. Unilat-eral cataract needs early sur-gery and in bilateral cataract,after operating first eye, sec-ond eye may be operatedwith in a week or two to pre-vent amblyopia.

Why early surgery foryounger children with cata-ract?

Early surgery is indicatedfor visually significant infan-tile cataract to prevent am-blyopia, as this is a criticalperiod of visual develop-ment. Simultaneous macularperception and fusion de-velop in the first 3months af-

CURRENT PRACTICE

Detailed ocular examination is done todocument type of cataract, IOP fundus

evaluation, axial length andkeratometry

Fig. 4. Anterior lenticonus associated with highmyopia. Cataract gradually develops which furtherimpair vision.


ter birth and stereopsis in thefirst six-months of life. Earlycataract surgery in the veryyoung children is recom-mended to ensure adequatevisual input in this criticalperiod of development.

PrognosticationVarious factors affect the

ultimate visual outcome in achild with cataract. Visuallysignificant cataracts not onlyproduce blurred images onthe retina but also affect thedevelopment of visual path-ways. In the 1970s, it wascustomary to defer infantilecataract surgery until at least6 months of age. In sharpcontrast, presently more andmore surgeons recommendthat visually significant cata-ract should be removed at theearliest possible time to pre-vent sensory deprivation asthe first few months of life iscritical. Unilateral cataractsare by far more dangerousfrom the point of view of de-velopment of dense amblyo-pia. Unilateral cataractshould be operated with infirst few weeks to months oflife to prevent developmentof sensory deprivation am-blyopia.10,11

The fixation grade shouldbe noted, and unsteady fixa-tion after surgery usually in-dicates a poorer prognosis.Similarly, children with cata-racts associated with strabis-mus may have a more com-pound problem than in thosein which the ocular align-ment is maintained. Associ-ated ocular diseases such ascorneal opacities, glaucoma,intraocular inflammation,microphthalmos, aniridia,etc. are also associated witha poorer visual prognosis af-ter surgery.

Choosing the correct op-tion in visual rehabilitationwill also affect the final out-come. The rehabilitation ofpediatric aphakia is a mustto prevent further amblyopiaand changes in the visualpathways. The options inmanagement of pediatricaphakia include aphakicglasses, contact lenses andintraocular lens implanta-tion. Aphakic glasses are un-

satisfactory for rehabilitationbecause of several problemsassociated with their usesuch as induced magnifica-tion, visual field restrictionand prismatic effect besidepoor compliance.4,10 How-ever, the use of aphakicglasses is a viable option inseveral developing countriesfor the management bilateralaphakia. However, the use ofaphakic spectacles for uni-

CURRENT PRACTICE

Table 1: Tailored approach for laboratory work-up in children with cataract*

Cataract type Associated medical Workupproblem

Nuclear (sporadic) Rubella Varicella TORCH, IgM & IgG in baby andmother

Lamellar (sporadic) Neonatal tetany Ca, phosphorus, PTH

Oil droplet Galactosemia Urine reducing substance +, urineglucose -

G-1-P uridyl trans def. Galactose-1-phosphate transferaseGalactokinase def. RBC galactokinase

Complete (sporadic) Rubella CMV TORCH, IgM & IgG in baby andmother Urine culture for CMV

PSC Diabetes Blood glucose, HgA1CCorticosteroid useRadiationJRA ANA, RF, HLA B27Refsum disease Phytanic acidMannosidasedeficiency

Subluxed Marfan Examine relatives;Echocardiography

Homocystinuria Plasma homocystine, urinenitroprusside

Sulfite oxidase Test urine sulfocysteine & thiosulfateHyperlysinemia Plasma lysineWeill Marchesani None

Anterior subcapsular Conradi syndrome X-ray of long bones(stippled epiphyses)

Spoke-like Fabry disease Alpha-galactosidase A in fibroblasts

Multicolored flecks Myotonic dystrophy Serum CPK

Punctate Down syndrome Physical exam, chromosomeanalysis if needed

Sunflower Wilson disease Serum Cu, ceruloplasmin, 24-hoururine Cu

* Albert Biglan7

lateral aphakia is of no use,since the anisokenia wouldpreclude fusion of the tworetinal images, and the largerimage in the spectacle-cor-rected aphakic eye would besuppressed anyway.

The major goal of visualrehabilitation is to bypass theuse of spectacles and strivefor an effective means of cor-rection - the intraocular lens(IOL). Although contact


is better option than parttime occlusion at least in theinitial phase of treatmentand its compliance is utmostimportant for better visualoutcome.

Preoperative Counseling1. Preoperative counselingis most important. Parentsmust understand that sur-gery is only the first step ofmanagement. The childneeds follow up for a longperiod for repeated correctionof residual and changing re-fractive error and occlusiontherapy. Possibility of post-operative complications andneed of secondary interven-tion must be emphasized. InSummary:l Pediatric cataract is a

common cause of child-hood blindness

l Early surgery is indicatedfor visually significantcataract to prevent am-blyopia.

l Only a trained and expe-rienced ophthalmologistin this field should per-form pediatric cataractsurgery.

l Choosing an appropriatemodality of visual reha-bilitation of pediatric aph-akia is important.

l Preoperative counselingof parents is most impor-tant as the surgery is onlythe first step in manage-ment and child needslong-term follow up forrepeated correction of re-sidual/changing refrac-tive error and occlusiontherapy is required.

References1. Foster A, Gilbert C, Rahi J:

Epidemiology of cataract inchildhood. A global perspec-tive. J Cataract Refract Surg

CURRENT PRACTICECURRENT PRACTICElenses offer several advan-tages over aphakic spec-tacles, such as full visualfield and stereopsis, there areseveral problems associatedwith their use such as risk ofinfection, loss of the contactlens, higher cost and diffi-culty with compliance. Re-peated insertion and re-moval of a contact lens mayalso be psychologically trau-matic to the child.11,12

Epikeratophakia for surgicalrehabilitation of pediatricaphakia has been aban-doned at present. Presently,refined microsurgical tech-niques have made lens im-plantation one of the mostsuccessful surgical tech-niques for management of pe-diatric cataract. There is aswing towards implantationof IOLs over contact lensesfor management of cataractsamong children.12-21 Youngerchildren under 8 years of ageare undercorrected with re-spect to their IOL power, andthey require additionalglasses following surgery.Spectacles may be prescribedas soon as the initial inflam-mation has subsided and themedia has cleared. The childis initially prescribed nearcorrection in the preverbalage. As the child grows olderand starts going to school,shift to bifocals or two pairsof spectacles-one for distanceand one for near. The powerof spectacles needs to bechecked on every follow upvisit and any change of 0.5Dor more needs to be incorpo-rated. The parents should betold that the spectacle powerwould gradually decreasewith the growth of the eye.Amblyopia needs to be rec-ognized early and treatedcarefully. Full time occlusion

1997;23:601-6042. Thylefors B: A global initia-

tive for the elimination ofavoidable blindness Am JOphthalmol 1998;125:90-93

3. World Health Organization.Global Initiative for theElimination of AvoidableBlindness (WHO/PBL/97.61), 1997

4. Lambert SR, Drack AV: In-fantile cataracts. SurvOphthalmol 1996;40:427-458

5. Jain IS, Bansal SL, Dhir SP,et.al: Prognosis in traumaticcataract surgery. J PediatrOphthalmol Strabismus1979;16:301-305

6. Jain IS, Pillai P, Gangwar DN,et al: Congenital cataract: Eti-ology and morphology. JPediatr Ophthalmol Strabis-mus 1983;20:238-242

7. Biglan AW, Cheng KP, DavisJS, Gerontis CC. Secondaryintraocular lens implanta-tion after cataract surgery inchildren. Am J Ophthalmol.1997; 123 :224-34.

8. Dahan E, Drusedau MU:Choice of lens and dioptricpower in pediatric pseudo-phakia. J Cataract RefractSurg 1997; 23 (Suppl): 618-623

9. BenEzra D. Cataract surgeryand intraocular lens implan-tation in children, intraocu-lar lens implantation in chil-dren. Am J Ophthalmol1996;121: 224-226

10.Birch EE, Stager DR: The criti-cal period for surgical treat-ment of dense congenitalunilateral cataract. InvestOphthalmol Vis Sci 1996;37:1532-38

11.Birch EE, Swanson WH,Stager DR, et al: Outcomeafter very early treatment ofdense congenital unilateralcataract. Invest OphthalmolVis Sci 1993; 34:3687-99

12.Kaufman HE: The correctionof aphakia. XXXVI EdwardJackson Memorial Lecture.Am J Ophthalmol 1980; 89:110

13.Levin AV, Edmonds SA,

Nelson LB, et al: Extended-wear contact lenses for thetreatment of pediatric aph-akia. Ophthalmology 1988;95: 1107-13

14.BenEzra D, Cohen E, Rose L:Traumatic cataract in chil-dren. Correction of aphakiaby contact lens or intraocu-lar lens. Am J Ophthalmol1997;123: 773-82,

15.Apple DJ, Ram J, Foster A,Peng Q. Elimination of cata-ract blindness: A global per-spective entering new Mil-lennium. SurveyOphthalmol (A specialSuppl) 2000; 45 (1): 1-196

16.Pandey S, Ram J, Werner L,Brar GS, Jain A, Gupta A,Apple DJ. Visual results andpostoperative complica-tions of capsular bag andciliary sulcus fixation of pos-terior chamber intraocularlenses in children with trau-matic cataract. J CataractRefract Surg 1999; 25:1576-84

17.Brar GS, Ram J, Pandav SS,Reddy GS, Singh U, Gupta A.Postoperative complica-tions and visual results inuniocular traumatic cata-ract. Ophthalmic Surg Laser2001;32: 233-38

18.Rosenbaum AL, Masket S:Cataract surgery and in-traocular lens implantationin children, intraocular lens.Am J Ophthalmol 1996; 121:225-26

19.Sinskey RM, Amin PA, Lin-gua R: Cataract extractionand intraocular lens implan-tation in an infant with amonocular cataract. J Cata-ract Refract Surg 1994;20:647-51

20.Vasavada A, Chauhan H: In-traocular lens implantationin infants with congenitalcataract. J Cataract RefractSurg 1994;20:592-98

21.Wilson ME, Bluestein EC,Wang XH: Current trends inthe use of intraocular lensesin children. J Cataract Re-fract Surg 1994;20:579-83


Eales’ disease is an inter-esting clinical entity, classi-cally presenting with re-peated vitreous hemorrhagesin a young adult male. How-ever, many cases may be di-agnosed on the basis of otherclassical features of the dis-ease, but no hemorrhages into the vitreous. The underly-ing pathology is retinal phlebi-tis1,2,3, typically involving theperipheral retinal veins. Theclinical manifestations are es-sentially that of inflammatorybranch retinal vein occlusions(BRVO), usually multipleand bilateral. Some timesthere may be inflammatorycentral vein occlusion(CRVO) also. Phlebitis mayor may not be associated withchoroiditis, iridocyclitis, ar-teritis or papillitis.These as-sociated features are only in-cidental and not relevant tothe clinical features of Ealesdisease. The only pathologyrelevant to the developmentof the clinical features ofEales’ disease is phlebitis.The nature of phlebitis canbe extremely variable. It maybe very acute with massivevitreous hemorrhage or verymild so as to go unnoticed.These extreme variations inthe presentation and thecourse of the disease prob-ably indicate, that it is a con-dition of multiple etiologiesand etiopathological pro-cesses. One of these is tuber-culosis. Once the pathophysi-ology of Eales disease is un-derstood, the management ofthe condition becomes bothrational and highly satisfac-tory.

Eales’ Disease or Retinal PhlebitisBijayananda Patnaik, Rajinder Kalsi

Retina Associates Eye Institute,E-584, Greater Kailash, IINew Delhi -110048www:patnaikb.com

The New ConceptThere is considerable con-

fusion, even today, in thewestern literature on the un-derstanding of the disease.This is to an extent under-standable, for these authorshave little experience ofstudying Eales 'disease inrecent years, with modernmeans, for the disease is nowa rarity in their own coun-tries. For instance, a recent(2001)4 definition of EalesDisease is “an idiopathicobliterative vasculopathy..” istotally inconsistent with theavailable contemporary kno-wledge on the subject. On theother hand, since our de-scription of the pathophysi-ology of the disease in 19791

the concept is now univer-sally accepted by all thosewho have among them-selves, had the occasion tostudy several hundred of thecases of Eales disease in thiscountry2 .The proper defini-tion would be : It is “an idio-pathic inflammatory venousocclusion..”2 Since it is nowclear that the only relevantpathology in Eales disease is

phlebitis, the use of the term‘vasculitis’ for phlebitis isboth improper and imprecise.Retinal vein inflammationcan be, on one hand very se-vere with massive infiltrationor nodule formation withcomplete obliteration of thelumen and on the other, mildcuffing of a vein segment. Todescribe both these as ‘pe-riphlebitis’ would be inap-propriate. Without blunder-ing in the realm of pathology,it would be proper to simplydescribe these as cases of‘phlebitis’.

The disease was de-scribed and was apparentlycommon in Europe in late19th and early 20th century.With affluence and improvedstandard of living, all infec-tious diseases, including tu-berculosis have disappeared.So also Eales’ disease. It isnow seen in Indian subcon-tinent, Afganistan, Turkeyand Greece that Eales dis-ease is being reported today.

Pathophysiology of ClinicalPresentations

The classical presenting

feature of Eales’ disease is re-peated vitreous hemorrhagesin a young adult male. Thepatient would complain ofsudden blurring of the vi-sion, or appearance of float-ing spots or cobwebs or sim-ply cloudy vision – all thesesymptoms are that of vitre-ous hemorrhage. The visionsome times may get com-pletely lost. Very often, withrest and time vision may tendto improve. There could berepeated such episodes. Onexamination the anterior seg-ment may show some signsof inflammation in somecases. Fundus examinationof the same eye, if the mediais clear or some times the fel-low eye would show manyof the following abnormali-ties:

1. During the stage of ac-tive phlebitis one may findyellowish white infiltrationof vein segments. The inten-sity of infiltration vary. Soalso the degree of venous in-sufficiency or occlusion.There may be massive infil-tration, nodule formation ormay be mild cuffing. The site

Fig. 1 Fig. 2

REVIEW


of inflammation is the site ofvenous occlusion. The retinalvein peripheral to the site ofinflammation would be en-gorged, tortuous. The bloodcolumn may be dark blue be-cause of stagnation. Theacuteness of the venous clo-sure also vary. In cases withvery acute closure, there maybe subhyaloid or even vitre-ous hemorrhages (Fig1). Insubacute cases the retinalterritory distal to the site ofthe inflammation wouldshow signs of venous insuf-ficiency or occlusion and ofretinal circulatory decom-pensation (Fig2). Therewould be flame shaped reti-nal hemorrhages, retinal (in-cluding macular) edema.The capillary system may beengorged and some time leakblood, causing repeated vit-reous hemorrhage (RVH).There may be areas of capil-lary closure, indicating per-sistent retinal ischaemia. Insome cases with mild phle-bitis, one may find segmen-tal inflammations with someengorgement and tortuosityof the distal veins but no ob-vious evidence of retinal cir-culatory decompensation(Fig 3). These may be de-scribed as nonacute variety(Fig 4). Fluorescein angiog-raphy would show the de-gree of insufficiency in

venous circulation. The in-flamed segments of the veinsstain and even leak the dye(Fig 5), indicating breakdown of the blood retinalbarrier of the retinal bloodvessels, caused by inflamma-tion.

2. Sooner or later, with orwithout treatment, thevenous inflammation sub-sides. The site of segmentalinflammation of the veinsmay be seen narrowed orkinked and may show par-allel sheathing. On FA thedye no longer stains or leaks.Very often, there may be a lo-calized patch of healed chor-oiditis under the vein seg-ment which was inflamed.We feel, the choroiditis is sec-ondary to phlebitis, for clas-sically these leasions areseen only along the veinsand under the inflamed seg-ments. Occasion-ally, the inflamma-tion causes perma-nent closure or de-struction of veinsegments (Fig 3).The process of cir-culatory stabiliza-tion (compensation)gets going. To startwith, there is al-ways an attempt atopening up of thenarrowed or ob-structed venous lu-

men. A serial Fluoresceinstudy would demonstratethis process. The process ishelped by effective anti in-flammatory treatment. Thesecond process of circulatorycompensation is the develop-ment of veno-venous capil-lary shunts. The blood fromthe territory of affected veinis shunted through the cap-illary bed to the adjoining ter-ritory. These lesions are seentypically in the retinal pe-riphery or temporal to themacula across the horizon-tal raphe, as dilated tortuousblood vessels (Fig.6). Rarely,one may find larger vascualrshunts(Fig 9). However, vari-able degree of state of decom-pensation could persist, spe-cially in acute and subacutecases.

3. Persistent state of dec-ompensation and retinal is-

chaemia, would lead to reti-nal neovscularisation – theproliferative retinopathy.Themost dramatic demonstrablesign of retinal ischaemia areareas of retinal capillary clo-sures (Fig 7). The ischamicretina is believed to release avaso-proliferative substance,which stimulates neovas-cular growth from surround-ing vascular system withgood circulation. When onebranch retinal vein is in-volved, the new vesselswould be seen growing fromthe frontier blood vessels ofthe area with good circula-tion proximal to the affectedterritory in the state of is-chaemia (NVE). The newvessels may grow flat on thesurface of the retina or growin the vitreous gel. Whenthere are involvement of mul-tiple retinal veins, with wide

spread peripheral is-chaemia, one would ex-pect neovascularisationof the disc (NVD) also,besides the NVEs. ThusNVD indicates widespread retinal is-chaemia. When retinalischaemia is even moresevere and persistent,there may be in addi-tion, anterior segmentneovascularization (e.g.rubiosis iridis), sometimes leading up to the

Figure 3

Fig. 4

REVIEW


dreaded neovascular glau-coma. The new vessels withfragile walls are prone to re-peated vitreous hemorrhages(RVH), accounting for theseevents in the majority ofcases.

4. With time theischaemic retina dies. Alter-natively, the ischaemicretina is selectively de-stroyed by either scatter pho-tocoagulation or cryopexy.Once the ischaemic retinadies, the stimulus for vascu-lar growth disappear and thenew formed blood vessels re-gress. The regressing newvessels are replaced withglial (scar) tissue. The glialtissue on contraction maycause several sight threaten-ing complications: 1) theremay be traction retinal de-tachment (TRD). When andif the macula is detached,there is a catastrophic loss ofcentral vision (Fig 8). 2) theremay be a traction tear, usu-ally at the point where thevein draining the new vesselgrown in to the vitreous,touches the flat retina. Thiswould lead to traction initi-ated rhegmatogenous RD(Fig.9). 3) there may be a thickscar tissue covering themacula causing serious vi-sual loss.

Thus the understandingof the pathophysiology

would explain all the (fol-lowing) features of Eales Dis-ease:

1. Segmental infiltrationof various types and severityin and around venousbranches, indicating activeretinal phlebitis, the basicPathology of Eales Disease.

2. Engorged tortuousveins distal to the site ofvenous inflammation andocclusion

3. Retinal, sub hyaloidand vitreous hemorrhage,the direct result of BRVO.

4. Retinal and macularedema as signs of venous in-sufficiency

5. Dilated tortuousblood vessels, the venovenous capillary shunts

6. Sheathing, kinking ofveins at the old site of seg-mental vein inflammation,the result of post inflamma-tory gliosis

7. Patches of choroiditisunder and along the affectedveins, secondary to phlebitis

8. New blood vessels inthe retinal periphery (NVE)and on the disc (NVD)

9. Gliosis of proliferativeretinopathy with traction RDor traction related Rheg.RD

10. Anterior segmentneovascularization (iris,angle) and neovascular glau-coma

11. Occasionally associ-

ated uveitis, arteritis or papil-litis.

EtiologyIt is not clear what causes

the retinal phlebitis. Consid-ering the wide variation inthe nature and severity of thephlebitis, it may be logical toassume that there are prob-ably multiple etiological fac-tors involved. Even therecould be multiple etiopa-thological or immunopatho-logical processes involved.

Suspicion of tuberculosisbeing a etiological factor hasexisted for decades. Ealesdisease was common in Eu-rope at a time when tubercu-losis was rampant there.With dramatic improvementof standard of living in theseindustrialized countries, tu-berculosis has all but disap-peared. So also, Eales dis-ease. The disease is now seenin countries like ours wheretuberculosis is a major pub-lic health problem. RecentPCR studies for tubercularDNA in aquous and vitreoussamples from Eales diseasecases have provided strongevidence of the actual in-volvement of tubercle bacilliin this disease. It is now be-lieved that at least some casesof retinal phlebitis showingmassive infiltration, nodularformations and complete

obliteration of venous seg-ments are probably due toactual tubercular infestationand do well with ATT. Theremay be many more, wherethe phlebitis is because ofimmune reaction to tubercu-lar proteins.

ManagementOnce the pathophysiol-

ogy of the disease is under-stood, the management be-comes both rational and ef-fective. In fact, the modernmanagement of Eales diseaseis highly satisfactory. Sincerecurrence of phlebitis is veryrare and macular circulationis usually not affected, thelong term visual results canbe surprisingly good.

Stage of Active PhlebitisDuring the state of active

phlebitis, the treatment isbases on energetic anti in-flammatory drugs. The mostcommonly used drug is oralcorticosteroids (Prednisolon,1mg/kg body weight orequivalent). Sub tenons in-jection of depo steroids havebeen used. We doubt whetherthis method of administra-tion is at all helpful. In casesshowing ocular hyperten-sive response, one may haveto use non steroidal anti in-flammatory drugs, as an al-ternative.

Figure 5 Figure 6

REVIEW


Where phlebitis is sus-pected or established to betubercular (by PCR) westrongly recommend 3 drugcombination of drugs for tu-berculosis, over and aboveoral steroids. Our favouritesare : Rifampicin, Isoniazideand Pyrazinamide.

The Stage of Persistent Is-chaemia

Once the venous inflam-mation has subsided, leavingan ischaemic retina, the dan-ger is one of vascular prolif-eration – proliferative retin-opathy. Such cases must beregularly followed up withserial Fluorescein Angiogra-phy. Evidence of persistentstate of de compensationwould include: areas of cap-illary closures, increasedpermeability of the capillarysystem in the affected area orgrowth of new vessels. Thestandard treatment for pro-liferative retinopathies is ‘se-lective retinal ablation’ of theischaemic retina, by scatterphotocoagulation and ifneeded peripheral cryo.

It is better to prevent sig-nificant neovascular growththan to regress them, oncethese have developed. Weprefer relatively early photo-coagulation and deliver thetreatment in an incrementalfashion. The treatment has to

be confined only to the terri-tory of the affected vein.

The Stage of Vascular Pro-liferation

Once there is significantneovascular proliferations,indiscriminate retinal abla-sion with photocoagulationor cryo may lead to many ofthe complications associatedwith the contractioning glio-sis that replaces the new ves-sels. Such complications canbe prevented by a techniquewe have described as ‘An-choring Photocoagulation’(Fig). The vital (macula) andvulnerable (root of the venuledraining a neovascular le-sion imbeded in the vitreousgel) areas are first sur-rounded by strong burns ofphotocoagulation. After 3 –4weeks scatter photocoagula-tion is done to regress thenew vessels. In the presenceof marked neovasculargrowth around the posteriorpole, unless the retina at theposterior pole is ‘anchored’with sufficient photocoagu-lation, peripheral ablation ei-ther by scatter photocoagu-lation or peripheral cryowould be dangerous. Therisk of macular detachmentcaused by contracting glialtissue around the posteriorpole is too great.

Peripheral cryo has some

special indications. 1) Whenpupil is small and undila-ting. Laser can not reach theperiphery 2) When vitreoushemorrhage has settled overthe lower periphery and la-ser treatment can not be com-pleted 3) When in spite of re-peated laser new vessels donot regress 4) When repeatedvitreous hemorrhages do notlet media to clear enough forsuccessful photocoagulationand vitreous surgery facili-ties are not available. In allthese situations, cryo helpsin facilitating or concludingthe treatment. Cryo alone isdangerous. Cryo can only beused as a supplement to in-complete photocoagulationwhen sufficient photocoagu-lation has been put in placearound the posterior pole.

The Stage of ComplicationsIn advanced cases with ei-

ther non absorbing vitreoushemorrhage or traction re-lated retinal complicationsthe only way to help mattersis Vitreo retinal surgery. Thevisual results are usuallygood, for the state of macularcirculation is generally goodin cases of Eales diaease.

SummaryØ Eales’ Disease is a mani-

festation of inflammatoryBRVO

Ø The basic pathology isPhlebitis

Ø It has multiple etiologiesand pathological pro-cesses.

Ø Tuberculosis is one ofthem

Ø Management is very sat-isfactory when appropri-ate treatment is applied atappropriate stages, with aproper understanding ofthe pathophysiology

Ø Anti inflammatory with orwithout ATT during thestage of active Phlebitis

Ø Selective retinal ablasionby photocoagulation dur-ing the stage of retinal is-chaemia, to prevent or re-gress new vessels

Ø Vitreous surgery in ad-vanced cases

Ø When managed properlygenerally the visual re-sults are good

References1. Kalsi R, Patnaik B. The de-

veloping features of phlebi-tis retinae (A vertical study)Indian J Ophthalmol1979;27:87

2. Das TP, Biswas J, Kumar A,Nagpal PN, Namperuma-lsamy P, Patnaik B & TewariHK. Eales Disease. Indian JOphthalmol. 1994;42:3-18

3. Gieser SC & Murphy RP.Eales’ Disease. In Ryan SJ ed.Retina. Vol, St Louis:Mosby;2001: 1505-08

Figure 7 Figure 8 Figure 9

REVIEW


The syndrome of macularchanges and poor visualacuity, following cataractsurgery was first describedby Irvine in 1953 and wassubsequently detailed byGass and Norton in 1966 ascystoid macular edema(CME). The syndrome ofCME following cataract sur-gery has therefore beentermed as ‘Irvine-Gass Syn-drome’.

Cystoid Macular Edema(CME) is one of the most com-mon causes of unexpectedpoor visual acuity followingcataract surgery. CME hasbeen classified as Angio-graphic Macular Edemaand Clinically SignificantMacular Edema. In Angio-graphic Macular Edema,there are leakages in Fluores-cein Angiography but thereis no decrease in vision,whereas Clinically Signifi-cant Macular Edema alsohas corresponding decreasein visual acuity.

With the earlier tech-niques of cataract surgeryand earlier designs of In-traocular Lens (IOL) the in-cidence of CME was reportedto be very high. Now withbetter technique of Phacoe-mulsification and better PCIOL designs, the incidence ofclinically significant CMEhas decreased to approxi-

Cystoid Macular Edema (CME)Following Cataract SurgeryVinay Garodia MD, R.P. Singh, MD

Visitech Eye HospitalAdvanced Centre for Vitreo Retinaand Lasers, Delhi.

mately 1% in uncomplicatedcases. Complicated cataractextractions like vitreous loss,iris or vitreous incarcerationin wound, retained lens mat-ter, unstable IOL etc. are as-sociated with increased riskof clinically significant CME,with reported incidences ashigh as 20%. Nd-YAGcapsulotomy in the post-op-erative period can also leadto CME in approximately1.5% of patients. Fortunatelythe majority of patients havespontaneous resolution oftheir CME with recovery ofgood visual acuity. However,chronic CME (more than 6months duration) with per-manent visual loss occurs inapproximately 1% of pa-tients undergoing ECCE.

The patient with CMEmay present with no symp-toms at all in case ofAngiographic CME. TheClinically Significant CMEusually occurs 4 to 12 weeksafter cataract surgery, andthe patient presents withpoor recovery of vision fol-lowing cataract surgery.There may also be low-gradeeye irritability with mild red-ness and photophobia. Slitlamp biomicroscopy using acontact lens or a 90/78 Dlens, is the best means tovisualise CME. There is aloss of foveal depression; themacula appears thickenedwith translucent intraretinalcystoid spaces. Epiretinalmembranes may be seen in

some of the cases. In caseswith chronic CME, theintraretinal cystoid spacesmay coalesce, producing afoveal cyst. Unroofing of thisfoveal cyst may result in for-mation of inner lamellarmacular hole. This usuallyresults in permanent loss ofvisual acuity.

There is also some degreeof optic nerve head swellingwith slight congestion anddecrease in the cup size.These changes are best ap-preciated by comparing thedisc with that of the other eye.There may also be signs oflow-grade inflammation likeciliary injection, cells andflare in the anterior chamber.Concomitant abnormalitiesfrom the complications of thecataract surgery such as irisor vitreous incarceration inwound, posterior capsularrupture, improperly place orfixated IOL, retained lensmatter etc. may also be vis-ible.

Differential DiagnosisBesides post-operative

cases, Cystoid MacularEdema may be secondary toother ocular pathologies like

Diabetes, Vascular Occlu-sions, Hypertensive Retin-opathy, Epiretinal Mem-brane, Intraocular tumours(melanoma, hemangioma),Intraocular inflammation(like Pars Planitis), RetinitisPigmentosa, Drugs (Epi-nephrine in aphakia), Radia-tion retinopathy etc. There-fore, a detailed history andexamination to rule out theseother ocular pathologiesmust be carried out beforeattributing the CME to post-operative category. The diag-nosis of CME may sometimesbe confused with othercauses of macular edema likeBranch Retinal Vein Occlu-sion (BRVO), Diabetic Macu-lar Edema, ChoroidalNeovascularisation (CNV),Photic Maculopathy, andImpending Macular Hole.Looking for other associatedsigns of the particular dis-ease does the differentiationand the diagnosis is con-firmed by performing Fluo-rescein Angiography.

Fluorescein Angiography(FA) is very useful in confirm-ing the diagnosis of CME. Inthe early frames, the capil-lary dilatation and leakageare visible in the perifovealarea. Later, pooling into theouter plexiform layer(Henle’s layer) gives rise toclassical petaloid stainingpattern, due to radial ar-rangement of the fusiformspaces, in the perifoveal re-gion (Fig. 1). There is also

MANAGEMENT PEARLS

Complicated cataract extractions likevitreous loss, iris or vitreous

incarceration in wound, retainedlens matter, unstable IOL etc. areassociated with increased risk of

clinically significant CME


leakage from capillaries inthe optic nerve head causinga late staining of the opticnerve head, which is almostalways present in cases withCME. The amount of dyeleakage on FA does not cor-relate very well with the de-gree of visual loss. This ispossibly because the visualloss is probably more depen-dant on the amount of thick-ening than the amount of dyeleakage. The macular thick-ening can be better studiedby newer technique of Opti-cal Coherence Tomography(OCT).

Before discussing the pre-vention and treatment of thiscondition, it is prudent to dis-cuss the pathogenesis ofCME. Various theories havebeen proposed implicatingvitreous traction at themacula, vitreous incarcera-tion in the wound, vitreous-uveal traction, inflammation,prostaglandins and otherinflammatory mediators.Most treatment strategies arebased on either vitreous trac-tion or inflammation as theprimary etiology, and in-clude topical, subtenon andsystemic corticosteroids,Non Steroidal Anti-Inflam-matory Drugs (NSAIDs), Nd-YAG vitreolysis, and ante-rior and posterior vitrectomy.Other additional treatmentslike systemic Acetazolamide(Diamox) have been pro-posed to reduce edema with-out directly treating thecause of edema formation.All of these proposed meth-ods of treatment have beenreported to be beneficial. Thelack of randomized thera-peutic trials limit the objec-tive information available tobase definitive recommenda-tions for the treatment of

CME. Therefore we have torely on the information fromthe past therapeutic studiesand considerations of thepathophysiology of CME.

The newer techniques ofcataract surgery and betterIOL materials have alreadyhelped in preventing CME ina long way. A good manage-ment of complications of cata-ract surgery like vitreous loss

to ensure that there is no vit-reous or iris incarcerated inthe wound also helps in re-ducing the incidence of CME.Besides a good surgical tech-nique, routine topical corti-costeroid for first 3-4 weeksand topical NSAID for 2-3months may also probablyhelp. Since Nd-YAGcapsulotomy is known to bea risk factor for CME, it is pru-

dent that this procedure beperformed only when defi-nitely indicated, and if re-quired, must be performed atleast 6 months following thecataract surgery and to useminimal power necessary todecrease the risk of CME.

We recommend astepwise therapeutic ap-proach (Table 1) to CME. Thebest course for a patient withCME for only a few monthsafter cataract surgery is towait, as most of these pa-tients will spontaneously re-solve. During this period ofwaiting, topical NSAIDs,preferably the one blockingboth cyclo-oxygenase andlipo-oxygenase pathways(e.g., diclofenac eye drops),may be used. Each of theseabove mentioned stepsshould be tried for 4-6 weeksperiod before changing thetreatment. In case of no re-sponse, add on the treatmentfrom the next step, while con-tinuing to use the previoustreatments.

When starting the patienton topical steroids, one hasto monitor the intra-ocularpressure (IOP) closely to lookfor steroid responders, i.e.,raised IOP in response totopical steroids. In cases thatdo not improve on topical ste-roids may be given the op-tion of sub-tenon steroid in-jection. Sub-tenon steroid in-jection has an advantage ofdelivering a high dose to themacula, without the systemicside effects of oral steroids.However, one has to be care-ful about raised intraocularpressure. If during the courseof topical steroids, the patientis found to be a steroid re-sponder, sub-tenon steroidmay be contraindicated.

If all the above treatment

Fig 1. Fluorescein angiogram of an eye with CME. Fluoresceinleakage from the capillaries and a classical petalloid appearance ofmacula.

Table 1: Stepwise Approach for Treating CME

Step 1 Wait and watchTopical NSAIDs

Step 2 Topical Corticosteroids

Step 3 Sub-tenon steroid injection

Step 4 Oral Acetazolamide (Diamox)Oral Corticosteroid

Step 5 Laser Nd-YAG vitreolysisVitrectomy

MANAGEMENT PEARLS

Slit lamp biomicroscopy using a contactlens or a 90/78 D lens, is the best means

to visualise CME


options fail, then oral aceta-zolamide and oral steroidmay be tried. However, onehas to be careful about thehigher incidence of systemicside effects due to these medi-cines, especially in the eld-erly population. If everythingelse fails, surgical manage-ment may be tried. Nd-YAGvitreolysis, though describedin literature, is not thatsimple a procedure to do andit may take more than one sit-ting to completely cut the vit-reous adhesions in the ante-rior chamber. Moreover, it isnot a very safe procedure andmay have complications inform of bleeding from the iris,increased inflammation oreven retinal detachment. Vit-rectomy, either through theanterior or posterior ap-

proach, has the potential fora better repair of vitreous ad-hesions to the wound or theiris, especially in the morechronic cases. Iris incarcera-tion can also be repaired dur-ing the same procedure. Inaddition, pars plana vitrec-tomy also offers the theoreti-cal advantage of removingthe vitreo-macular traction,removing the inflammatorymediators in the vitreousand allowing better access oftopical steroids to the poste-rior segment. Though therehas been no randomizedclinical trial to prove this,various series have yieldedencouraging results for vit-rectomy. With greater exper-tise and better results of vit-rectomy, this may be a usefulmode of treatment especially

in cases of chronic macularedema.

To sum up, improved sur-gical technique has alreadydecreased the incidence ofCME following cataract sur-gery, and further refinementswill undoubtedly continuethis trend. To further de-crease the incidence of CME,it is mandatory that everycataract surgeon shouldhave a basic functioning au-tomated vitrectomy unit tomanage the cases of vitreousloss properly and to mini-mize the chances of vitreousincarceration in the wound.Moreover, Nd-YAG capsulo-tomy whenever required forposterior capsular opacifica-tion must use minimal powernecessary, and should bedelayed till at least 6 months

following cataract surgeryand must be performed un-der cover of topical steroidsand topical NSAIDs. Evenafter taking these precau-tions, CME is bound to oc-cur, though in lesser numberof cases. This is a disappoint-ment for both patient and theophthalmologist alike. Theeffective prevention andtreatment of CME requiresone to understand the pro-posed pathogenesis of thedisease and to follow astepwise approach for treat-ment, as described above. Aproper management of thisentity gives a good visual re-sult most of the times and re-sults in a happy and satis-fied patient and a relievedophthalmologist.

Programme for DOS Monthly Clinical Meeting for July 2003

Venue: Army Hospital (Research & Referral), Near Dhaula Kuan, (on NH-8), Delhi Cantt-110010Date & Time : 27th July, 2003 (Sunday) at 10.00 A.M.

Case Presentation

1. Two unusual Cases of Eales' Disease ................................................ Dr. Lt. Col. A Banarji

2. Unusual Presentation in Two Case of Glaucoma ........................... Dr. Lt. Col. (Mrs.)M. Bhadauria

Clinical Talk

l Dealing with the Problems in Pediatric Cataract ........................... Col. D.P. Vats,S.M., VSM

Mini Symposium: Ocular Trauma

Chairmen: Dr. Col. D.P. Vats

Convenor: Dr. Lt. Col. A. Banarji

1. Overview of Ocular Trauma & .......................................................... Col. D.P. VatsAnterior Segment Reconstruction S.M., VSM

2. Dealing with Lens and Uveal Injuries .............................................. Lt. Col.(Mrs.) M. Bhaduaria

3. Dealing with RIOFB ............................................................................. Lt. Col. V.S. Gurunadh

Panel Discussions : 20 min.

MANAGEMENT PEARLS


S-1690Soni AnjuC/O Mr. M.C. Soni4/4, Amaltas ComplexShahpura, Bhopal

N-1691Negi ArunA-42, Sector-27, Noida

K-1697Kumar MithileshKarpuri ChowkMadhepura-852113

Y-1698Yadav HemlataA-3, ChetakpuriGwalior

M-1699Moorthy Ramesh2, SanketSankalp Society47/3, Paud RoadPune-411038

R-1704Ramesh R.P-34, Gnanam ColonyVth Main RoadRamalinga NagarTrichy-620003

K-1705Meenakumari R.P-34, Gnanam ColonyVth Main RoadRamalinga NagarTrichy-620003

S-1706Sethia K.L.C/O Gour Medical Store2nd Mile, Sevoke RoadSiliguri-734401

G-1700Gupta Bharat BhushanHouse No.332, Sector-2Ambala RoadPehowa (Dist.Kurukshetra)

G-1701Gawri AnandGawri Nursing HomeBathinda RoadMuktsar-152026

S-1702Singh Suresh PrasadApollo Eye Hospital39, Patel Basu RoadBhagalpur-812001

K-1703Shivakumar V.7, New Agraharam FortNamakkal-637001

M-1715Mithal CharuRoom No.103Female Doctor’s HostelG.M.C.H., Sector-32Chandigarh

S-1707Singh ShyamR-15, Yamuna ColonyDehradun

S-1029Sahay PallaviMohan Eye Institute11-B, Ganga Ram Hospital Marg,Old Rajinder NagarNew Delhi-110060

D-1708Devendra JayaA-194, Indira NagarLucknow-226016

S-1710Soni AmbarishHead, Dept. of Ophthalmology,Maharaja Agrasen Institute ofMedical Research & EducationAgroha (Hisar)

G-1709Goyal SanjayDistrict HospitalJashpurJashpur Nagar-496331

V-1717Verma Jag RamR.P. Netra Chikitsa KendraNormal School CompoundSultanpur

G-1721Gupta Rakesh Kumar“Anandam”Near Radha Rani ComplexSaradapally, Court MoreAsansol-713304

U-1719Upadhyaya SwatiRegional Instt. ofOphthalmologyBhopal

K-1720Khuraijam NoornikaRegional Instt. of Ophthalmology,Hamidia HospitalBhopal

J-1030Jain Neeti601-A, Puja ApartmentsI.P. Extension, PatparganjDelhi-110092

V-1031Vajpeyi Abhishek

Bhagwan Kaur Venu Eye InstituteSadatnagar, Kosli,Rewari

P-1711Punia Gurpreet#1505, Sector 33-DChandigarh

G-1712Gupta SunilRoom No.43, P.G. BlockMedical Hostel, BoysM.G.M. Medical College, Indore

A-1713Agrawal YogeshC/O Shri Girish Chand AgrawalB-26, Mahavidhya Colony2nd PhaseMathura-281001

P-1718Purwar SanjayJeewan Jyoti Nursing HomeNear Laxmi Talkies,Railway Road, Farrukhabad

U-1716Upadhyay KalpanaDepartment of OphthalmologyG.S.V.M. Medical College,Kanpur

T-1032Tuteja (Mrs.)Sonia202, State Bank NagarPaschim ViharNew Delhi-110063

R-1033Rana VishwasS-2/A/121Shalimar Garden Extension-2Dist. Ghaziabad,Sahibabad

C-1034Chaudhary NeerajC-3/42, Ashok Vihar,Phase-II, Delhi-110052

M-1035Mongia Tripti19-A, Pocket-AVikas Puri ExtensionNew Delhi

K-1036Kashfi Angabeen167, Zakir BaghOkhla RoadNew Delhi-110025

S-1037Sinha (Major) RajneeshBf-72, JanakpuriNew Delhi-110058

REVIEW

New DOS Members Continued from Page 5

Congratulations!Dr. V. Menon, Dr. S.M. Betharia, Dr. S.P. Garg and Dr. Rashmi Madan for beingappointed as Professor at Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, New Delhi.

Dr. Alkesh Chaudhary for receiving ‘Dr. Prem Chander’ Best Paper Award and bestvideo presentation at ‘North Zone Ophthalmic Conference’, October 2002.

Dr. Rakesh Ahuja for joining Galucoma Fellowship at Vancuver, Canada.

Prof. Harish Agarwal for joinig a Head of Glaucoma Services at Max Eye Care aftersucessfully completing his tenure at Dr. R.P. Centre for Ophthalmic Sciences, AIIMS,New Delhi, DOS wishes him all the best for his future assignments.

Dr. Lalit Verma and Dr. Dinesh Talwar, Senior Vitreo Retina Consultants, haveentered a new phase in their lives and have joined Centre for Sight, Green Park andApollo Hospital, New Delhi. We wish them good luck in their new endeavour.


DOS QUIZ

Rules:l Among the above intermingled alphabets, ophthalmic terms are hidden.

l No abbreviations are used. Let us see who can find the most number of words. Good luck.

l Please send your entries to the DOS office latest by 25th August, 2003.

l Prize Rs.500/- Courtesy: Syntho Pharmaceuticals

l Quiz Trophy will be given to the member who answers maximum number quizes in a yearduring the Annual GBM of DOS.

Jugglery

1. E E O O R T M N ___ ___ ___ ___ ___ ___ ___ ___

2. R V E D P N E E I ___ ___ ___ ___ ___ ___ ___ ___ ___

3. R T P T R B M A S O ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

4. S S P P T A O O I ___ ___ ___ ___ ___ ___ ___ ___ ___

5. C I R E R N I F E B G E N ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

6. A M M G K A R Y C ___ ___ ___ ___ ___ ___ ___ ___

7. D I I A A R N ___ ___ ___ ___ ___ ___ ___

8. U P T L A A E ___ ___ ___ ___ ___ ___ ___

9. UITNSOVONACERSALU ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

10. O E D T N P F L L S E U O O X ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

DOS QUIZ NO. 11. Eclipse sign is seen in …………………………..............................................................................................

2. Normal foveal thickness by OCT is …………………………..............................………………………….......

3. Concentration of Bimatoprost is …………………………..............................………………………….......

4. Most common systemic association of Retinitis Pigmentosa is ………………………………………............

5. Most common organism causing Acute painful dacryoadenitis …………………………............................

6. Treatment of choice of Tolosa Hunt syndrome …………………………....................................................

7. Most common cause of secondary lipid keratopathy is…………..…………………………........................

8. Essential blepharospasm is due to dysfunction of ………………..………………………….........................

9. Chrysiasis is due to deposition of ……………..…………………………........................................................

10. Most common lacrimal gland carcinoma is …………..…………………………..........................................


Surgical management of postoperativeendophthalmitis: comparison of 2techniquesKaynak S, Oner FH, Kocak N, Cingil G. J Cataract RefractSurg. 2003 May;29(5):966-9.

The aim of the study was to evaluate the results of 2 surgicaltechniques in eyes with postoperative endophthalmitis.Twenty-four eyes with endophthalmitis after cataract sur-gery had vitrectomy as an initial procedure according to theEndophthalmitis Vitrectomy Study (EVS) criteria (Group 1,n = 24). These eyes were compared with 28 eyes that hadtotal pars plana vitrectomy with an encircling band, sili-cone tamponade, and endolaser (Group 2, n = 28). The vi-sual and anatomical outcomes and the need for additionalprocedures (repeat vitrectomy) were evaluated in the 2groups. The study found that in Group 1, 6 eyes (25.0%) hadan additional procedure, 3 eyes (12.5%) had phthisis, and21 eyes (87.5%) had successful surgery. In Group 2, no eyehad an additional procedure, 1 eye (3.5%) had phthisis, and27 eyes (96.4%) had successful surgery. The number of addi-tional procedures was significantly less and the rate of sur-gical success was significantly higher in Group 2 than inGroup 1 (P<.01). The author concludes that despite the poorvisual prognosis of endophthalmitis surgery, more radicalintervention can increase the chance of surgical success anddecrease the number of additional procedures in eyes withpostoperative endophthalmitis.

Visual performance after interfacehaemorrhage during laser in situkeratomileusisVajpayee RB, Balasubramanya R, Rani A, Sharma N,Titiyal JS, Pandey RM. Br J Ophthalmol. 2003Jun;87(6):717-9.

The study aimed to report the visual performance in eyeswith interface haemorrhage during laser assisted in situkeratomileusis (LASIK). Authors evaluated the case recordsof 20 patients, who had bleeding from the limbal vessels inone eye during LASIK (group 1) and uncomplicated surgeryin the fellow eye (group 2) were studied. The parametersevaluated were uncorrected visual acuity (UCVA) best cor-rected visual acuity (BCVA), spherical equivalent of refrac-tion (SEQ), contrast sensitivity, and glare acuity preopera-tively and at 1, 3, and 6 months postoperatively. The studyfounds that the mean preoperative SEQ in group 1 and 2eyes was -5.79 (2.3) D and -5.27 (1.68) D, respectively. Themean decimal UCVA at 6 months after LASIK in group 1and 2 eyes were 0.6 (0.2) and 1.0 respectively (p<0.001). Themean decimal BCVA at 1 week after LASIK in group 1 and 2eyes were 0.89 (0.04) and 1.0 respectively (p<0.05). How-ever, all eyes had a BCVA of 6/6 at 1, 3, and 6 months after

LASIK. The mean contrast sensitivity values preoperativelyin group 1 and 2 eyes were 161.3 (8.7) and 172 (68.2) respec-tively. There was a significant decrease in-group 1 at 6months (102(60.5) (p<0.01)) compared to group 2. The deci-mal glare acuity preoperatively in group 1 and 2 eyes was0.95 (0.11) and 0.89 (0.12), respectively. It decreased signifi-cantly in-group 1 (0.7) (0.1 (p<0.01)) compared to group 2 atthe 6-month follow up. The authors concludes that occur-rence of intraoperative interface hemorrhage may affect thevisual performance following LASIK surgery.

Keratoplasty for keratomalacia inpreschool childrenVajpayee RB, Vanathi M, Tandon R, Sharma N, Titiyal JS.Br J Ophthalmol. 2003 May;87(5):538-42.

This paper describes the results of surgical management ofkeratomalacia in children. In this study clinical case seriesof all children with keratomalacia, admitted to an IndianCenter during the period from June 2000 to June 2001 ispresented. The parameters evaluated were demographic data,systemic associations, and results of medical and surgicalintervention. The study founds that 29 children withkeratomalacia ranging from 2 months to 5 years of age (mean1.8 (SD 1.4) years) were included in the study. All childrenbelonged to families of lower socioeconomic status. 27 pa-tients (93.1%) had not been immunized at all. The systemicdiseases precipitating the onset of keratomalacia includedmeasles (41.37%), pneumonia (31.03%), and acute diarrhoea(37.93%). 36 eyes (66.7%) had total corneal melting and 11(20.3%) eyes had paracentral corneal melting. In 15 eyes(27.8%) an emergency tectonic penetrating keratoplasty wasperformed of which only five grafts (33.3%) remained clearat a mean follow up of 7.3 (6.8) months (range 3-24 months).Seven eyes underwent optical penetrating keratoplasty; ofwhich four grafts (57.14%) remained clear at a mean followup of 6.4 (3.6) months (range 3-12 months). None of thesecould achieve a visual acuity better than 6/60.The studyconcludes that corneal grafting surgery in keratomalacia isassociated with poor visual outcome.

Macular image changes of opticalcoherence tomography afterphacoemulsificationCheng B, Liu Y, Liu X, Ge J, Ling Y, Zheng X. ZhonghuaYan Ke Za Zhi. 2002 May;38(5):265-7.

Authors had investigated the effects of phacoemulsifi-cation on the macula following uncomplicatedphacoemulsification by optical coherence tomography(OCT).In this study eighty eyes of the senile cataract werechosen randomly. The uncomplicated phacoemulsification

JOURNAL ABSTRACTS


was performed. OCT was examined preoperatively and 1week after the surgery. Preoperative visual acuity, the reti-nal thickness and phaco power were compared with thoseafter surgery. This study founds that in 80 eyes, the preop-erative mean foveal thickness was (142.9 +/- 16.7) microme-ter and the postoperative (157.9 +/- 36.7) micrometer, thedifference being not significant (P > 0.05). Three eyes hadmacular edema 1 week after surgery. In 11 eyes with Tyndallsign (+ +), the mean postoperative foveal thickness wasthicker than the mean preoperative value (P < 0.05). In lowerphaco power group, the mean postoperative foveal thick-ness was (156.2 +/- 18.3) micrometer and the higher phacopower group was (172.6 +/- 32.9) microm (P < 0.05). Thebest corrected

Visual acuity after surgery had a negative correlation withthe retinal thickness. The study concludes that he retinalthickening and macular edema can be found after uncom-plicated phacoemulsification. The higher phaco power re-sults in significant inflammation and thicker retina. The vi-sual consequences were proportional to the degrees of macu-lar thickening.

Long-term progression of astigmatismafter penetrating keratoplasty forkeratoconus: evidence of laterecurrenceDe Toledo JA, De La Paz MF, Barraquer RI, Barraquer JCornea. 2003 May;22(4):317-23.

The purpose of the study was to evaluate the changes inastigmatism throughout a 20-year period using keratometryand refraction in patients who underwent penetrating kerato-plasty (PKP) for keratoconus. Authors reviewed the chartsof patients who underwent PKP for keratoconus from 1975to 1979 and recorded preoperative refraction, stage of kera-toconus, laterality of surgery, graft size, suture technique,time of suture removal, keratometry, subjective refraction at1, 3, 5, 7, 10, 15, 20,and 25 years after suture removal, andslit-lamp findings. The study founds that eighty eyes with amean follow-up of 20 years (range, 15-25) were included inthe study. Graft size, suture technique, and time of sutureremoval had no significant influence on the astigmatism atthe last examination. We observed a stabilization of

keratometric astigmatism in the first 7years (4.05 +/- 2.29 D 1 year after sutureremoval, 3.90 +/- 2.28 D at year 3, 4.03+/- 2.49 D at year 5, 4.39 +/- 2.48 D atyear 7) followed by a progressive in-crease from 10 years after suture removaluntil the last follow-up visit (5.48 +/-3.11 D at year 10, 6.43 +/- 4.11 D at year15; 7.28 +/- 4.21 D at year 20, and 7.25+/- 4.27 D at year 25). The mean abso-lute value of the difference vector (DV)calculated by vector analysis was 7.17+/- 4.35 D (0-18.33). In 70% of cases, pro-gression of the astigmatism was evidentwith mean absolute DV of 9.10 +/- 3.65D. There was a significant correlationbetween the preoperative and final axisof astigmatism (Pearson r = 0.39, p =0.0008). There was also a slight positivecorrelation coefficient between the DVof the eyes in bilateral cases, but it wasnot significant (Spearman’s r = 0.2226,p = 0.34). The major late slit-lamp find-ing was a peripheral crescent-shapedthinning at the graft-host junction withabsence of Bowman’s layer on histopa-thology. Authors concludes that in spiteof refractive stability obtained during thefirst years after PKP for keratoconus, in-creasing astigmatism thereafter suggeststhat there is a progression of the diseasein the host cornea.

JOURNAL ABSTRACTS

Application Invited from Institutions forHolding the DOS Monthly Clinical MeetingsAs per the DCRS ratings 2 institution have been dropped from the

monthly calender (RML Hospital & Appllo Hospital). We request all thehospitals/institutions interested in holding the DOS monthly meeting tokindly see if they fulfill the criteria given below. They may apply to theSecretary’s Office with details latest by with 20th July 2003. (Those whohave already applied/are already holding the meeting, need not do soagain).

No meeting is held in May and June. Meetings are usually held on thelast Saturday of the month.

Criteria for selection of a place:(a) Seating capacity of 100-200 persons, preferably AC mini auditorium

/ hall definitely within the premises of the institutions.(b) Audio Visual facilities to be available

– moving mike 1 set– multimedia projector 1 set– double slide projectors 1 set

(c) Institute should send the details of the meetings/CME etc., held atthat institute in past 2 years to the DOS office

(d) A sizeable staff in Ophthalmology who would be able to conduct themeeting themselves without any major outside participation as speak-ers/presenters.– Before the submission of application for holding the DOS clini-

cal meeting, all the above mentioned criteria should be met.– These may be verified by President and Secretary.

– Dr. Jeewan S. Titiyal, Secretary, DOS


—————————————————————————————————————————————————————Event Conference Date Venue Contact Person and Address——————————————————————————————————————————————————————

Indian Contact Lens Education 20th-24th Education Centre L.V. Prasad Marg, Banjara Hills,Program July 2003 L.V. Prasad Eye Hyderabad-500 034,

Institute, Hyderabad E-mail: <[email protected]

6th International Advanced 24th-26th Aditya Jyot Eye Contact: Dr. S. Natrajan, Aditya Jyot EyeVitreo Retinal Surgery Course July, 2003 Hospital, Mumbai Hospital, Aashirwad, 168, Vikas Wadi,Chennai Dr. Ambedkar Road, Dadar T.T.,

Mumbai-400014

National Workshop on 17th-18th Dr. R.P. Centre Contact : Prof. R.B. Vajpayee, Dr. Jeewan S. TitiyalPhacoemulsification Sept. 2003 for Ophthalmic 492, 4th Dr. R.P. Centre for Ophthalmic Sciences,

Sciences, AIIMS, AIIMS, New Delhi - 110029, IndiaNew Delhi Ph : 26593192, 26588852-65, Ext. 3192, 3146

Fax : 011-26588919 Email : [email protected]

Ophthacon 2003 10th-11th LLRM Medical College, Contact Person : Dr. Sandeep Mithal,(38th U.P.State Ophthalmology Oct. 2003 Meerut, (U.P.) Upgraded Department of Ophthalmology,Conference) LLRM Medical College, Meerut, (U.P.)

Email : [email protected] : 91 - 121 - 2763133

Eye Topia 2003 19th India Habitate Centre Contact Person: Dr. Jeewan S. Titiyal,Mid Term DOS Oct. 2003 Lodhi Road, New Delhi Secretart (DOS) R.No. 476, 4th Floor,

Dr. R.P. Centre for Opthalmic Sciences,New Delhi - 110 029Ph.: 26589549, Fax : 26588919,E-mail: [email protected]: dosonlin.org

Annual DOS Conference 3rd-4th India Habitate Centre — do —April 2004 Lodhi Road, New Delhi

Forthcoming Events – NATIONAL

Event Conference Date Venue Contact Person and Address———————————————————————————————————————————————————Seventh Annual Glaucoma 2nd Aug. San Francisco, Glaucoma Research & Education Group,Symposium 2003 CA (USA) 490 Post Street, suite 644, San Francisco,

CA 94102; Tel (415) 986-0835; Fax: 986-0876;e-mail: [email protected].

XXI Congress of thre ESCRS 6-10 Sept. MUNICH, Contact: ESCRS Temple House, Temple Road2003 GERMANY Blackrock, Co. Dublin, Ireland

Tel: + 353 1 209 1100, Fax: + 353 1 209 1112e-mail: [email protected]

Joint Meeting of the European 13-16 Sept. LISZT, Contact: Ferenc KuhnVitreoretinal Society & 2003 HUNGARY Web: www.evrs.org/meetingsInternational Society ofOcular Trauma

United Kingdom and Ireland 18-19 Sept. CHESTER, Tel: +44 164 2854 054, Fax: +44 164 2231 154Society of Cataract and 2003 UK Email: [email protected] Surgeons Web: www.euroasiancongress.com

Joint European Research 8-11 Oct. ALICANTE, SPAIN Contact: EVER, Fax +32 16336785Meeting in Ophthalmology 2003 Web: www.ever.be, Email: [email protected]

INTERNATIONAL

EVENTS


Dear Trader,The Delhi Ophthalmological Society is today the premier society of our country boasting a membership of

more then 3000 Ophthalmologists from all over India, growing at the rate of at least 300 member ophthalmolo-gists yearly.

DOS Times – The monthly magazine of around 50 pages – is its flag bearer and is a prized possession ofeach ophthalmologist for which they wait with great anticipation. This position of DOS Times has been achievedbecause it gives important clinical material to ophthalmologists of all walks of life. Besides it also carries allimportant notices and hence form an important part of every member’s life.

The bookings are likely to be heavy, hence we request you to send in your booking at the earliest accompa-nied by DD in the name of “Delhi Ophthalmological Society” payable at Delhi to the Dr. Jeewan S. Titiyal,Secretary, DOS.

Advertisement Tariff for “ DOS Times” Magazine

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Three months Advertisement is aceptable for DOS Times

In Order to Qualify for the whole year/Multiple Advertisement Rates,All Payments should be made in Advance

Size of Journal : 8-1/4”

Frequency : Monthly (10 Issues in a year)

Model of Printing : Offset

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Advt. Material : For Black & White : Positive films (with proper density dots)

For Colour : Positive films with proofs and progressive

Payment : All payment to be made in advance byDemand Draft in favour of “Delhi Ophthalmological Society”payable at Delhi.

Mailing and Contact : Dr. Jeewan S. Titiyal, SecretaryRoom No. 476, 4th Floor, Dr. R.P. Centre for Ophthalmic Sciences,AIIMS, Ansari Nagar, New Delhi – 110029, IndiaPh : 26589549(Direct), EPABX: 26588852-65 Ext. 3146Fax: 011-26588919

Email : [email protected]

Meeting Time : 4:00-6:00 p.m.

With warm personal regards,

Dr. Jeewan S. TitiyalSecretary, DOS

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Specification: Advertisement size 540 × 40 pixelsFile format required : gif file or progressive jpg

Sponsorship for DOS Monthly Clinical MeetingsTariff for DOS Monthly Clinical Meeting: Rs. 50,000/-

Includes Audio Visual Advertisement during meeting and banner (as provided by the trader)Provide for meeting : Pen, Folder with few sheets of paper / notepad / spiral pad with companylogo / product name, Tea & Snacks / Refreshments etc.


The rate of technological and academic obsolescencein Ophthalmology has reached astronomical levels inrecent times. What was advanced yesterday may al-ready be obsolete today. The rapid strides in skills andknowledge have created a need for an extremely inten-sive Continuing Medical Education programme.

DOS has always been in the forefront of efforts toensure that its members remain abreast with the latestdevelopments in Ophthalmology. Among the impor-tant objectives formulated by the founders of our con-

DOS Credit Rating System (DCRS)

If any of the presentations is given an Award –Additional 20 bonus Credits.

Member who have earned 100 Credits, are enti-tled to:

a) Certificate of Academic Excellence in Ophthal-mic Practice.

b) 50% exemption of Registration fee at next An-nual DOS Conference.

c) Certificate of Academic Excellence in Ophthal-mic Practice (3 years in row) will entitle the mem-ber to a proposed academic grant of Rs.5,000/- onlyto enable him/her to attend any international con-ference outside India to present his/her own ac-cepted presentation (proof required).

If any member earns 200 Credits, he/she shall,in addition to above, be awarded Certificate of Dis-tinguished Resource-Teacher of the Society.

stitution was the cultivation and promotion of the Sci-ence of Ophthalmology in Delhi.

In a bid to strengthen our efforts in this direction andfulfil the vision of our society’s founders, DOS announcesthe DOS Credit Rating System (DCRS), the details ofwhich are given below. Our Primary objective is topromote value-based knowledge and skills in Ophthal-mology for our members and give recognition and creditfor efforts made by individual members to achieve stand-ards of academic excellence in Ophthalmic Practice.

DOS announces a new era in Continuing Medical EducationDOS CREDIT RATING SYSTEM (DCRS)

(A new chapter in CME)Credits

1) Attending Monthly Clinical Meeting* † (For full attendence) 10

2) Making Case Presentation at Monthly Meeting** 15

3) Delivering a Clinical Talk at Monthly Meeting** 15

4) Free Paper Presentation at Annual Conference (To Presenter)** 15

5) Speaker/Instructor** in : Monthly Symposium 15

: Mid Term Symposium 15

: Annual Conference 15

6) Registered Delegate at Mid Term DOS Conference 20

7) Registered Delegate at Annual DOS Conference 30

8) Full Article publication in Delhi Journal of Ophthalmology (Visiscan) 15

9) Letter to Editor/Correspondence/Published Article in DOS Times 10——————————————————————————————————————————————

Institutional assessment for best performancewill be based on the total score of members whoattend divided by number of members who at-tended. Institutional assessment regarding deci-sion to retain the institute for the next year will bebased on total score by all delegates who attendthe meeting divided by average attendence of all8 meetings.

Please note that the Institutions’ grading in-creases if the attendance at its meeting is higher(i.e. more than the average attendence of the eightmonthly meetings).——————————————————————* Based on Signature in DCAC** Subject to Submission of Full Text to Secretary, DOS† Credits will be reduced in case attendence is only forpart of the meeting.

DCRS


Attention D.O.S. MembersThe Hi-tech DOS Library has started functioning on Ground Floor, Dr. R.P. Centre, Delhi Ophthalmic

Sciences, AIIMS, New Delhi-110029 from 12.00 Noon to 9.00 P.M. on week days and 10.00 A.M. - 1.00P.M. on Saturday, Sunday. The Library will remain closed on Gazetted Holidays. Members are Requestedto utilise the Facilities Available i.e. Computer, Video Journals Viewing, Latest Books and Journals. Weare planning to subscribe two journals member can give suggestion in this regard.

Dr. Lalit VermaLibrary Officer, D.O.S.

List of Books and Journals Available in Library

DOS Library Book List1. An Atlas of Ophthalmic Trauma

Editors - Thomas C Spoor2. Manual of Fundus Fluorescein

AngiographyEditors - Amresh Chopdar

3. Complications of GlaucomaTherapyEditors - Mark B. Sherwood. M.D.George L. Spaeth M.D.

4. Corneal Topography the State ofthe ArtEditors - James P. Gills

5. Radial Keratotomy SurgicalTechniquesEditors - Donald R. Sanders M.D.PHD.

6. Refractive Corneal SurgeryEditors - Donald R. Sanders M.D.PHD; Robert F. Hofmann-MD;JamesJ. Salz-MD

7. Second Edition-Laser Surgery OfThe Posterior SegmentEditors - Steven M. Bloom AlexanderJ.Brucker

8. Sixth Edition - Becker-Shafeer R.S.Diagnosis and Therapy of theGlaucomasEditors - H. Dundar Hoskins Jr.-Michael Kass

9. Phacoemulsification New Technol-ogy and Clinical ApplicationEditors - I. Howard Fine

10. Textbook of AdvancedPhacoemulsification TechniquesEditors - Paul S. Koch. James-A-Davison

11. Ocular Differential DiagnosisEditors - Frede’rick Hampton Roy

12. Retinal Detachment A ColourManual of Diagnosis & TreatmentEditors - Jack J. Kanski

13. Current Concepts in OphthalmicLasersRajvaradhan Azad, H.K. Tewari

14. Converting to Phacoemulsification(Thirgd Edition)Making the Transition to in-the-Bag PhacoPaul S. Koch.

15. Mastering Phacoemulsification (Asimplified Manual of Strategiesfor the Spring, Crack and Stop andChop Technique (Fourth Edition)Editors - Paul S. Koch

16. Ocular Infection Investigation andTreatment in PracticeEditors - Martin Dunitz

17. IOL and PhacoemulsificationSecretsEditors - V.K. Dada

18. Vitrectomy for BeginnersEditors - Rajvardhan Azad

19. Radial Keratotomy (Principles andPractice)Editors - Keiki R. Mehta

20. Radial KeratotomyEditors - Donald Sanders M.D.

21. Soft Implant Lenses in CataractSurgeryEditors - Thomas R. Mazzocco MD.George M. Rajacich MD.Edward Epstein M.D.

22. Computerized Perimetry A.Simplified Guide(Second Edition) Editors - Mar L.F.Lieberman Michael V. Drake

23. Fun with PhacoEditors - V.K. Dada

24. Practical Atlas of Retinal Diseaseand TherapyEditors - William R. Freeman

25. Retina and Vitreous Text Book ofOphthalmologyEditors - Steven M. Podos and MyronYanoff

26. A Practical Manual of IndirectOphthalmoscopyEditors - Rajvardhan Azad H.K.Tewari

27. Phacodynamics Mastering theTools and Techniques ofPhacoemulsification Surgery(Second Edition)Editors Barry S. Seibal

28. Techniques of PhacoemulsificationSurgery Intraocular Lens Implanta-tionEditors - Moshe Yalon

29. Cataract Surgery and its Complica-tions (Sixth Edition)Editors - S. Jaffe

30. A Colour Atlas of Lens Implanta-tionEditors - Piers Percival

31. Cataract and IOLEditors - D. Singh R. Singh J. WorstR. Singh

DOS Library Journal List1. Survey of Ophthalmology

Vol.44 No.3 November-December-99.2. Survey of Ophthalmology

Vol.44 Supplement 1. October-993. Survey of Ophthalmology

Vol.44 No.2 September-October-99.4. Survey of Ophthalmology

Vol.43 No.6 May-June-995. Survey of Ophthalmology

Vol.43 No.6 May-June-996. Ophthalmology Clinics of North

AmericaOcular Infections: Update onTherapyEditor - Terrence-P-O Brien M.D.

7. Ophthalmology Clinics of NorthAmericaSports and Industrial OphthEditor Louis D. Pizzarello MD-Mphand Michael Easterbook MD

8. Ophthalmology Clinics of NorthAmericaOcular OncologyEditor Joan M.O. Brien MD

LIBRARY


DOS Library Books1. Update On General Medicine

(American Academy Ophthalmol-ogy)

2. Fundamentals & Principles Of Oph-thalmology (American AcademyOphthalmology)

3. Optics Refraction & Contact Lenses(American Academy Ophthalmol-ogy)

4. Ophthalmic Pathology & Intraocu-lar Tumors (American AcademyOphthalmology)

5. Neuro Ophthalmology (AmericanAcademy Ophthalmology)

6. Pediatric Ophthalmology & Strabis-mus (American Academy Ophthal-mology)

7. Orbit Eyelids & Lacrimal System(American Academy Ophthalmol-ogy)

8. External Disease & Cornea (Ameri-can Academy Ophthalmology)

9. Intraocular Inflammation And Uvei-tis (American Academy Ophthal-mology)

10. Glaucoma (American AcademyOphthalmology)

11. Lens And Cataract (American Acad-emy Ophthalmology)

12. Retina And Vitreous (AmericanAcademy Ophthalmology)

13. (1-12 Master I Ndex (American Acad-emy Ophthalmology)

14. The Cornea (Third Edition) – (GilbertSmolin, Ricard)

15. Principales And Practice Of Refrac-tive Surgery- (Elander, Rich, Robin)

16. The Glaucomas Clinical Science (Sec-

ond Edition) – (715-1372 Ritch,Schields, Krupin)

17. The Glaucomas, Basic Sciences(Sedond Edition) - (1-714 Ritch,Schields, Krupin)

18. The Glaucomas Glaucomas Therapy(Second Edition) - 1373-1807 Ritch,Schields, Krupin)

19. Ophthalmic Plastic And Reconstruc-tive Surgery (Second Edition) - Nesi,Lismanlevine

20. Practical Orthoptics In The Treat-ment Of Squint (Fifth Edition) - LyleAnd Jackson. S

21. Binocular Vision And OcularMontility (Fifth Edition) - Von.Noorden

22. Principles And Practice Of Ophthal-mology (Vol - 1 Second Edition) -Albert, Jakobiec.Azar






28. Handbook Of Lasik Surgery -Vajpayee, T.Dada, R. Snibson

29. Community Ophthalmology - P.K.Khosla

30. Community Ophthalmology - P.K.Khosla

31. Fluorescein Angiography - A UsersManual - H.K. Tewari, Lalit Verma,Pradeep Venkatesh

32. Text Book of Ocular Therapeutics –Ashok Garg

DOS Library Journals1. Ocular Surgery For The New Millen-

nium (Part II - March 2000. 13:1) Oph-thalmology Clinics Of North America- Editor Gergel. Spaeth. Md)

2. Information Technology In Ophthal-mology (June 2000 13:2) Ophthal-mology Clinics Of North America -Editor Leonard Goldschmidt)

3. Ocular Surgery For The New Mil-lennium Part I (Dec 1999 12:4) Oph-thalmology Clinics Of NorthAmerica - Georgel Spath. Md)

4. Retinal Vascular Disorders (Dec1998 11:4) (Ophthalmology ClinicsOf North America (Dr. Pran N.Nagpal - Donated By Dr. B. Patnaik)

5. Survey Of Ophthalmology (Vol 44No.4 Jan-Feb 2000)

6. Survey Of Ophthalmology (Vol 44No.5 March-April 2000)

7. Survey Of Ophthalmology (Vol 44No.6 May-Jul 2000)

8. Survey Of Ophthalmology (Vol 45No.1 July-August 2000)

9. International Ophthalmology (Vol23 No.1 Pp-1-60 1999)

10. Retina The Journal Of Retinal AndVitreous Diseases (Vol 20 No.1 2000)

11. Journal Of Cataract Refractive Sur-gery (Vol 26 No.8 August 2000)

List of Books and Journals (New Arrivals) in Library

Nx = Highest attendance of all meetings

N = Total number of delegates

n = Total number of internal delegates

Methodology for Monthly Clinical Meeting:Criteria for Selection

Formula: Institution's MarksAttendance of institution (N)

Average marks A (outside delegates) x 0.7 + �� x 3maximum attendance in any monthly meeting (Nx)

Total marks by outside delegates (M)A = ��

Total number of outside delegates (N-n)

N = Total Attendance of an instituton(Outside + internal delegates)

LIBRARY

INFLAMMATION & DISTENSION OF LIDS(fever, periorbital pain, redness, swelling, local rise of temperature)

CHEMOSIS, PROPTOSIS, OPHTHALMOPLEGIA

ABSENTPRESEPTAL CELLULiTIS

ChildrenHb, TLC, DLC, Culture (Pus, Blood)

Treatment : Mild infection/ >5yr old : T. Augmentin 40mg/kg/dP.O (in3divided doses ) X 10dayssevere infection / <5 yr old : i/v antibiotics for at least3 days followed by oral antibiotics for 1 weeki/v cefuroxime 30-100mg/kg/d in divided doses orI/v ceftriaxone 50-100mg/kg/d in 2 divided doses

Treatment : i/v antibiotics followed by oral antibiotics Initial broadspectrum antibiotics effective against G+, G- ± - anaerobes, laterspecific antibiotics according to culture. i/v cefuroxime(0.75-1.5g8hrly) or ceftriaxone(1-2g/d) or combination of vancomycin (15mg/kg 12hrly) with Tobramycin (1-1.5mg/kg 8hrly) or amikacin (15mg/kg/d) ± - i/v metronidazole Total duration of treatment (10d-3wk)depends on patient’s response (decrease in orbital congestive signs,such as Proptosis, gaze limitation, edema)Surgical intervention: Abscess, foreign body, worsening of propto-sis despite 48 hrs of i/v antibiotics, progression of vision loss andworsening of ocular motility

Orbital Cellulitis: ManagementCOMPLICATION

Ocular : Exposure keratitis,Raised IOP, CRAO, CRVO,Optic Atrophy

Orbital : Subperiosteal abscess,orbital abscess, CECT,t/t Surgical drainage

Cavernous sinus ThrombosisDecreased vision,contralateral involvement

Meningitis, Brain AbscessBacteremia

TEAR SHEET NO. 1

PRESENTORBITAL CELLULITIS

AdultHb, TLC, DLC, Culture (Pus, Blood, sinus discharge )

Orbital USG (B-Scan), CECT.Monitor optic nerve functions

(vision, Pupillary reactions, color vision, contrast senstivity, VEP)

POST WITH ENDOGENOUSTRAUMATIC DERMATOBLEPHARITISH/o trauma, skin infection, stye, Upper respiratoryLid laceration Int hordeolum, or middle earInsect bite. Infection.S. aureus S. pyogenes H. influ type bStrep (B hemo) S. pneumoniae

WITH SINUSITIS ENDOGENOUS EXOGENOUS most common valveless ophthalmic Injury penetrating ethmoiditis veins allow direct orbital septum, Pansinusitis spread of infection surgery (squint, RD, S. pneumoniae dental infection, otitis blepharoplasty) S. aureus, Strep, dacryocystitis,SABE Animal biteH.influ, Anaerobes scalp infection S.aureusENT consultation

MUCORMYCOSISDiabetic ketoacidosis, Immunosup-pression, rare opportunistic infn

Mucor, Rhizopus invades bloodvessels causes ischemic Infarction,foul d/s, Black eschar. Nasal & sinusendoscopy CECT INDISPENSABLETreatment : i/v amphotericin B1mg/kg/d total dose 2-4 gmdebridement / exenteration Hyper-baric oxygen, correction of metabolicacidosis

Suggested Readings:1. Jones, D. B, Steinkuller, P. G. Strategies for the initial management of acute preseptal and orbital cellulitis. Trans Am Ophthalmol Soc. 1988;86:94-112.2. Donahue, S. P, Schwartz, G. Preseptal and orbital cellulitis in childhood: A changing microbiologic spectrum. Ophthalmology. 1998;105(4):1902-1905.

Usha Yadava, Amit Bhatia,Swarna PanigrahiGuru Nanak Eye Centre, MaulanaAzad Medical College, New Delhi.

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