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www. dosonline.org l 3

EDITORIAL

5 Here comes the mid term

FOCUS

11 Infectious Keratitis

RETINA

23 Retinopathy of Prematurity - The New Challenge

Parag K. Shah, Saurabh Arora, V. Narendran, N. Kalpana29 Epiretinal Membrane: An Overview Ramesh KC Gupta, Kadri Venkatesh37 Internal Limiting Membrane (ILM) Peeling for Macular Disorders Tinku Bali RazdanCATARACT

45 Intraocular lens (IOL) as a Scaffold to Prevent Nucleus Drop Dhivya Ashok Kumar, Amar Agarwal53 Pediatric IOL - Power Calculation and Material Selection P.C. Dwivedi, Charudatt Chalisgaonkar, Syed ImranGRAND ROUNDS

59 Exogenous Endophthalmitis Bhuvan Chanana, Vinod Kumar AggarwalCLINICAL MEETING

65 Clinical Case-1: VOGT Koyanagi Harada Syndrome - A DiagnosticDilemma Niketa Rakheja, H. S. Sethi

COLUMNS

71 DOS Times Quiz

TEAR SHEET

79 Doses of Important Drugs in Ophthalmology (Part-2) Yogesh Bhadange, Brijesh Takkar, Bhavin Shah, Rajesh Sinha

Be a part of the next generation of quiz

aun Banega ChampionDOS Mid-term 12th-13th November, 2011

at India Habitat Centre, New Delhi


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Here comes the mid term

Respected Seniors & friends,

Rohit SaxenaSecretary,


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www. dosonline.org l

Infectious keratitis remains an important cause of ocular morbidity in ophthalmicpractice. Diagnosis and management of infectious keratitis still remains a seriousdilemma for most ophthalmic physicians. Dr. M. Vanathi MD, Associate Professorof Ophthalmology Cornea & Ocular Surface Services, Dr Rajendra Prasad Centrefor Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi spoke toseveral imminent Cornea Specialists in India and abroad regarding certain concerns ininfectious keratitis management. The panelists in this discussion on infectious keratitisinclude Prof. Anita Panda, Dr. M.Srinivasan, Prof. John Dart, Dr. Samar Basak, Dr. LimLi and Dr. Bhaskar Srinivasan. Please read on, as the following compilation gives avivid peek into the practice patterns of these dynamic corneal physicians as they sharesome of their experiences and practice pearls.

M. Vanathi: What is the type of infectious keratitis do you commonly encounter in yourpractice?

Anita Panda

M. Srinivasan

John Dart

Samar Basak

Pure Fungal Keratitis:

Pure Bacterial Keratitis:

Professor Anita Panda, MD, FICO, FAMS, MRCOph

Dr. M. Srinivasan

Professor John K.G. Dart

Dr. Samar K. Basak, MBBS, MD (AIIMS), DNB, FRCS

Dr. Lim Li, MBBS, MMed(Ophth), FRCS(Ed), FAMS(Spore)

Dr. Bhaskar Srinivasan,MS, DNB

Professor Anita Panda

Dr. M. Srinivasan

Professor John KG Dart

Dr. Samar K. Basak

Dr. Lim Li

Dr. Bhaskar Srinivasan


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l DOS Times - Vol. 17, No. 4 October, 2011

Mixed Bacterial + Fungal Keratitis:

Acanthamoeba keratitis:

Miscellaneous infection:

Undetermined suppurative keratitis:

Lim Li

Bhaskar Srinivasan

Keratitis has a wide geographical variation with thepractice patterns being dominated by the region of practice,socioeconomic status of the presenting population andlifestyle patterns.

M. Vanathi: What is your preferred approach to acase of infectious keratitis presenting to you?

Anita Panda

M. Srinivasan

John Dart


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Samar Basak A detailed history:

Risk factors:

Use of Topical medications:

A good clinical examination:

Status of eyelids:

Slit lamp examination:

Documentation:

Lim Li

Bhaskar Srinivasan

Thorough history, meticulous clinical examination toform a presumptive etiological clinical diagnosis, cornealscraping for smear and culture sensitivity, appropriateantimicrobial therapy with close follow-up remain themainstay in the diagnosis and management of infectiouskeratitis.

M. Vanathi: What do you advocate about role ofcorneal scraping as a diagnostic and therapeutic approachin infectious keratitis management?

Anita Panda

M. Srinivasan


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John Dart

Samar Basak

Procedure for scraping

Lim Li

Bhaskar Srinivasan

Diagnostic corneal scraping is a must is most ulcerslarger than 2mm in size at presentation and before initiation

in cases of CLIK may be closely monitored. Therapeuticcorneal scraping depends on the clinical presentation ateach follow-up and best practiced in expert hands as itstands a risk of perforation and increased scarring in thehealing response.

M. Vanathi: Your perspective on recent/changingtrends in infectious keratitis management..

Anita Panda

A few words about surgical therapy:-

The Objectives are:-

However, the following should be known prior tosurgery:

Measures to be taken prior to surgery:-


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M. Srinivasan

John Dart

Samar Basak

In my opinion:

In primary level:

In secondary level:

In tertiary level:

Lim Li

Bhaskar Srinivasan

Improved diagnostics with the advent of PCR andconfocal microscopy, availability of fourth generation intrastromal antifungals, amniotic membrane grafting andcorneal crosslinking therapy in infectious keratitis formthe most salient features in the changing perspectives ofinfectious keratitis.

M. Vanathi: When do you advocate systemicantibiotics/antifungal therapy in infectious keratitis?

Anita Panda

Systemic antibiotics are indicated in:-

M. Srinivasan

John Dart

Samar Basak

infection

Lim Li

Bhaskar Srinivasan

The consensus on the use of systemic antimicrobialtherapy is in cases with severe ulceration, anterior chamberinvolvement, impending or frank perforation, pediatric andone eyed patients, postoperative cases, refractory ulcersand associated endophthalmitis.

M. Vanathi: What are your views on combinationversus monotherapy in bacterial keratitis?

Anita Panda


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M. Srinivasan

John Dart

Samar Basak The indications for monotherapy:

The ideal choice:

The combination therapy includes:

drop

Lim Li

Bhaskar Srinivasan

Monotherapy may be advocated for small cornealulcerations and where the etiological organism andsensitivity patterns are known. Larger corneal ulcerations by the culture sensitivity patterns and clinical response. combination therapy also need to be considered.

M. Vanathi: How often do you use voriconazole inyour practice for management of fungal keratitis? Yourviews on role of voriconazole in fungal keratitis? Wouldyou prefer to add topical antibiotics to antifungal therapy

in a case of smear positive mycotic keratitis? Anita Panda

M. Srinivasan

John Dart

Samar Basak

Lim Li

Bhaskar Srinivasan

The availability of voriconazole has broadened the

antifungal therapy arena in recent times. However mostprefer to use topical voriconazole as second line or inrefractory mycotic ulcerations. There seems to be a mixedresponse on the use of antibiotics in mycotic keratitis.Antibiotic therapy as an addendum to antifungal therapyis recommended in mixed corneal infections.

M. Vanathi: What are you recommendations on useof intracameral / intrastromal amphotericin /voriconazolein management of mycotic keratitis?

Anita Panda


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M. Srinivasan

John Dart

Samar Basak

Lim Li

Bhaskar Srinivasan

Intracameral / intrastromal antifungals are betterreserved for use of deep mycotic infections with intactoverlying epithelium. They are to be used with caution, asintracameral injections may be associated with intenseanterior chamber reactions and secondary glaucoma.

M. Vanathi: What is your preferred approach toacanthamoeba keratitis management? Some practicepearls..

Anita Panda

M. Srinivasan

John Dart

Samar Basak


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Lim Li

Bhaskar Srinivasan

Successful management of acanthamoeba keratitis acanthamoeba therapy. Treatment needs to be prolongedfor a period of at least 6 months beyond healing. Limbitisand scleritis are poor prognostic indicators. Keratoplastyresults are poor in acanthamoeba cases. Lamellar

transplants might help in cases without deep involvement.M. Vanathi: What is your opinion on the role of

collagen crosslinking in the management of infectiouskeratitis?

Anita Panda

M. Srinivasan

John Dart

Samar Basak

Lim Li

Bhaskar Srinivasan

treatment in infectious keratitis are increasing in literaturein recent times. Our experience is still evolving and thereis need for more evidence to establish its role in aidingresolution in infectious keratitis.

M. Vanathi: Your opinion on the use of In-vivoconfocal microscopy in the diagnosis and management ofinfectious keratitis?

Anita Panda

M. Srinivasan

John Dart

3

Samar Basak

Lim Li


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Bhaskar Srinivasan

The consensus on the application confocal microscopyin the diagnosis of infectious keratitis is on its usefulness ulcers in their early stage. Accessibility and appropriateexpertise in its interpretation remain limiting factors.

M. Vanathi: What are the common types of contactlens induced keratitis you encounter in your practice? management of these patients?

Anita Panda

M. Srinivasan

John Dart

Samar Basak

Lim Li

Bhaskar Srinivasan

Bacterial keratitis in a common complicationassociated with contact lens wear besides Acanthamoebainfections. Fungal keratitis has also been seen to affectcontact lens wearers. Contact lens induced keratitis needsto be managed promptly and effectively. Proper counseling

of patients prior to commencement of contact lens wearon proper contact lens wear and replacement schedules,contact lens care, hygiene and sterilization goes a longwear in effective prevention of corneal infections in lenswear.

M. Vanathi: What is your experience with post-C3Rtreatment infectious keratitis?

Anita Panda

M. Srinivasan

John Dart

Samar Basak

Lim Li

Bhaskar Srinivasan

Post C3R infectious keratitis a cause for seriousconcern. With increasing reports in literature on bacterialand fungal keratitis in Post C3R treatment cases,ophthalmic physicians need to be well aware of thiscondition which can result in severe ocular morbidity.Transepithelial C3R treatment for keratoconus might be asafer approach.

M. Vanathi: What is your opinion on the use of gluewith bandage contact lens in management of infectiouskeratitis?

Anita Panda

M. Srinivasan

John Dart

Samar Basak


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Lim Li

Bhaskar Srinivasan

Cyanoacrylate glue application with bandagecontact lens placement is recommended in cases of smallperforation with no active infection. Underlying roughareas ensures better adhesion and longer stay on of theglue aiding in resolution and hence removing the need for afurther surgical intervention. Glue application needs to beperformed deftly to achieve optimal results.

M. Vanathi: Your experience with post-LASIKkeratitis.

Anita Panda

M. Srinivasan

John Dart

Samar Basak

Lim Li

Bhaskar Srinivasan

Reference1. N V Prajna et al. Comparison of Natamycin and Voriconazole for the

Treatment of Fungal Keratitis. Arch Ophthalmol. 2010; 128(6):672-

678)2. Dart JKG, Saw PJ, Kilvington S. Acanthamoeba keratitis: diagnosis

and treatment update 2009. A perspective. Am J Ophthalmol 2009

148(4):487-4993. Hau, S. C., Dart, J. K et al. (2010). Diagnostic accuracy of microbial

keratitis with in vivo scanning laser confocal microscopy. Br J

Ophthalmol 94(8), 982-987)

DOS CorrespondentM. Vanathi


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3

Risk Factors

Among the crucial risk factors of ROP are

Other risk factors include

Pathogenesis

R

Saurabh Arora

Parag K. Shah DNB, Saurabh Arora DNB, V. NarendranDNB,N. KalpanaDNBPediatric Retina & Ocular Oncology Department, Aravind Eye Hospital

& Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu

Figure 1:Schematic diagram of right eye (RE) and lefteye (LE) showing zones to describe location of disease

and clock hours to describe extent of ROP.

Figure 2:Fundus picture of RE showing stage 1demarcation line (black arrows)


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5

6

Classication

7,8,9

Location of disease:

Zone 1:

Zone 2:

Zone 3

Extent of disease:

Stage 1 - Demarcation line:

Stage 2 Ridge:

(EPF):

Stage 4 Partial retinal detachment:

Stage 5 Total retinal detachment:

Aggressive posterior ROP (AP-ROP):

Plus disease:

Pre-plus disease:

Figure 4:Fundus picture of LE showing stage 3,

proliferation (white arrows)

Figure 3:Fundus Picture of LE Showing Stage 2


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Screening strategies

When to screen?

Whom to screen?

How to screen?

Figure 5:Fundus picture of RE showing stage 4A partialretinal detachment (black arrows) nasal to optic disc

Figure 6:Fundus picture of LE showing stage 4B

(black arrows)

Figure 7:Fundus picture of RE showing totalretinal detachment

Figure 8:Fundus picture of RE showing AP-ROP.


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Management pearls of ROP

When to treat?

Threshold disease:

Prethreshold Disease:

Type 1 ROP or High Risk Prethreshold:

Type 2 ROP or Low Risk Prethreshold Disease:

How to treat?

Cryotherapy:

Laser Photocoagulation:

Figure 12:Fundus picture of RE showinglaser scars (black arrows)

Figure 9:Fundus picture of RE showingdilatation and tortuosity of posterior pole

Figure 10:Fundus picture of RE showing preplus disease

Figure 11:Schematic diagram of fundus showingmultiple white cryo burns (black arrows) in


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Surgical treatment:

For stage 4A or 4B

(Note: Vascularly inactive and stable 4A ROP can only beobserved)

For stage 5:

Role of anti vascular endothelial growth factor (VEGF)injections in ROP:

Examination schedule

Conclusion

References1.

vascular sheath behind each crystalline lens: I Preliminary report. Am J

Ophthalmol 1942; 25:203-204.2. Haddad MA, Sei M, Sampaio MW, et al. Causes of visual impairment

in children: a study of 3,210 cases. J Pediatric Ophthalmol Strabismus

2007; 44:232240.3. The STOP-ROP Multicenter Study Group. Supplemental Therapeutic

Oxygen for Prethreshold Retinopathy of Prematurity (STOP-

ROP), a randomized controlled trial: Primary Outcomes. Pediatrics

2000;105:295-310.4. Fielder A. Retinopathy of prematurity: aetiology. Clinical Risk 1997;

3:4751.5. Flynn JT. Retinopathy of prematurity. Pediatric Clinics of North

America 1987; 34:1487-1516.6. Foos RY. Retinopathy of prematurity. Pathologic correlation of clinical

stages. Retina. 1987; 7:260276.7.

Ophthalmol. 1984; 102:1130-1134.8.

Ophthalmol. 1987; 105: 906-912.9.

prematurity revisited. Arch Ophthalmol. 2005; 123:991-999.10.

Section on Ophthalmology, American Academy of Pediatrics, AmericanAcademy of Ophthalmology, American Association for Pediatric

Ophthalmology and Strabismus. Screening examination of premature

infants for retinopathy of prematurity. Pediatrics 2006; 117:572576.11. Cryotherapy for Retinopathy of Prematurity Cooperative Group.

Multicenter trail of cryotherapy for retinopathy of prematurity.

Preliminary results. Arch Ophthalmol. 1988; 106:471-479.12. Early Treatment of Retinopathy of Prematurity Cooperative Group.

Revised indications for the treatment of retinopathy of prematurity. Arch

Ophthalmol 2003; 121:1684-96.13. Wright KW, Sami D, Thompson L, Ramanathan R, Joseph R, Farzavandi

S. A physiologic reduced oxygen protocol decreases the incidence of

threshold retinopathy of prematurity. Trans Am Ophthalmol Soc 2006;

104:78-84.14. Chow LC, Wright KW, Sola A. Can Changes in Clinical Practice

Decrease the Incidence of Severe Retinopathy of Prematurity in Very

Low Birth Weight Infants? Pediatrics 2003; 111;339-345.


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R

Ramesh KC Gupta

Ramesh KC Gupta, Kadri VenkateshSankara Nethralaya

Gass classify ERM on the basis of the clinical appearance

Grade 0

Grade 1

Grade 2

in 1865:

Pathology

Extracellular matrix Cells

Classication of ERM

Etiological classicationIdiopathic Epiretinal membrane

Secondary Epiretinal membrane- Membrane developssecondary to other ocular pathology

Common Cause includes-

,

Figure 1:Grade 0 ERM (cellophane maculopathy)


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Foos et al classication I periretinal membranes

Simple ERM-

Intermediate ERM

Complex Periretinal Membrane:

Clinical Presentation

Figure 2:Grade 1 ERM (crippledcellophane maculopathy)

Figure 3:Grade 2 ERM (macular pucker)

Figure 4:Amsler grid

Figure 5:M-chart


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Monocular diplopia is also another troublesome condition forpatients.

On funds examination there may be a thin sheen likemembrane to a thick opaque membrane, associated withvascular tortuosity, straightening and dragging of vesseltoward the fovea.

There may be small intraretinal hemorrhage, cystic changes

in macula, cotton wool spots and macular edema.Cause of Visual Loss in ERM

which causes fall in vision

metamorphopsia and monocular diplopia.

Investigations

Amsler grid- It is chart used to monitoring the metamorphopsiaobjectively.

M-chart- this chart objectively scoring the metamorphopsiabased on the visual angle subtended on the fovea. It contains19 lines that varies from a continuous line to the broken linesin which a line made up of a number of dots separated fromeach other by equal distance, at each step increment in line number according to the visual angle, patient is asked to seethe chart at 30 cm distance and ask whether he see a straightline or distorted line, at the line when patient see the straightline is considered as score of metamorphopsia. Test should bedone in vertical and horizontal meridian both.

Like M chart, PHP based on hyper acuity charting may alsouse for metamorphopsia scoring.

FFA- Fluorescein angiography can show retinal vasculartortuosity, straightening and leakage, as well as cystoidmacular edema also helps in excluding the other retinal

for the following parameter before undergo surgery.

Figure 6:FFA images of ERM showing tortuosity of major vessels along with dragging ofvessels toward macula, straightening of vessels

Figure 7:Oct images shows cellophane maculopathy,and thick ERM with cystic spaces under fovea and sub


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Lamellar macular hole Macular pseudo hole

Figure 8: architecture and helps in localizing the site for

separation of ERM (arrow)

Differential diagnosis of ERM

Combined Hamartoma of the Retina and RPE

Management

Surgical Management

Case Selection

Surgery

Surgical Principles

Outside-in method


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Figure 10:Combined hamartoma ofretina and RPE

Inside-out method

Scissors Segmentation

Scissors Delamination

Vitreous Cutters for ERM

Power-Actuated Scissors and Forceps

Stabilised Surgery

Enzymatic Vitrectomy

Visual Results

Complications

Figure 9:microperimetry showing decreased


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34 l DOS Times - Vol. 17, No. 4 October, 2011

Offers Anterior Segment Fellowship to youngophthalmologists (MS, MD or DNB)for a 2-year period:

Fellows will be taught SICS-Fishhook (3,000 to 7,000),Phaco (100-400), combined SICS/Trabeculectomy,Trabeculectomy, Oculoplasty and Laser.

Fellows will also be involved in all other hospitalactivities.

Free accomodation in hospital campus and a salaryof IRs. 38,000 to 46,000 (Stepwise increase) will beprovided.

Please apply with C.V. including details of surgicalexperience and two references with phone/mobilenumbers.

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No. of posts : 2 : MS or MD in

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Recently passed candidates are also encouragedto apply. The hospital is a professionally managedorganization of repute with more than 93,000 OPDsand 12,000 surgeries in 2010. Interested candidates arerequested to send their application with complete bio-data through Email or Fax soonest possible to:

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Email: [email protected]; Fax: 00977 81 522737

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Ophthalmologist Requiredat a reputed Eye Hospital

Clinical Pearls

surgery.

outcome.

References

1. Diagnosis of macular pseudoholes and lamellar macular holes by optical

coherence tomography belkacem haouchine et al. Am j ophthalmol 2004

nov; 138(5):732-9

2. Treatment of epiretinal membrane: an update fsm ting akh kwok hong

kong med j 2005;11:496-5023. Involvement of mller glial cells in epiretinal membrane formation

andreas bringmann & peter wiedemann graefes arch clin exp ophthalmol

(2009) 247:8658834. The impact of optical coherence tomography on surgical decision making

in epiretinal membrane and vitreomacular traction diana v. Et altrans

am ophthalmol soc 2006;104:161-166

5. Preoperative factors predictive of postoperative decimal visual acuity >1.0following surgical treatment for idiopathic epiretinal membrane hiroshi

kunikata, toshiaki abe, jiro kinukawa, kohji nishida. Clin ophthalmol 3 feb

2011.6. Idiopathic macular epiretinal membrane surgery and ilm peeling:

anatomical and functional outcomes constantin j. Pournaras, ahmed

emarah, and ioannis k. Petropoulos seminars in ophthalmology, 26(2),

4246, 20117. Enzymatic vitrectomy by intravitreal autologous plasmin injection as

initial treatment for macular epiretinal membranes and vitreomacular

traction syndrome daz-llopis m1, udaondo p2, cervera e3, garca-delpech

s4, salom d2, quijada a5, romero fj6 arch soc esp oftalmol 2009; 84: 91-

1008. Idiopathic epiretinal macular membrane and cataract extraction:

combined versus consecutive surgery brice dugas am j ophthalmol. 2010

feb;149(2):302-6.9.


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T

Indications for ILM Peeling

Macular Hole

Epiretinal Membranes (Primary and secondary)

R

Tinku Bali Razdan

Tinku Bali RazdanMS, FRCSVitreoretinal Consultant, Deptt of Ophthalmology, Sir GangaRam Hospital, New Delhi

Chronic Macular Odema

6,7,8

Vitreomacular traction syndrome

Premacular SubILM Haemorrhage

Optic disc pit maculopathy 9

Technique of ILM Peeling

The following are the salient steps in ILM peeling

PVD induction


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Staining of ILM

Visualization

Starting manoeuvre

A Lift and peel technique

B Pinch and peel technique

Maculorrhexis

Figure 1:Brilliant Blue G Dye

Figure 2:

Figure 3: get the initial edge


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Special Surgical Considerations

Figure 7(b):

(a)

(b)

Figure 4(a): 4(b):

Figure 5: multiple grasp- and - peel technique

Figure 6:The Maculorrhexis should extend between

Figure 7(a): macular hole


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of pars plana vitrectomy with internal limiting membrane removal in

diabetic macular edema. Retina. 2007;27(5):557566.6. Raszewska-Steglinska M, Gozdek P, Cisiecki S, Michalewska Z,

Michalewski J, Nawrocki J. Pars plana vitrectomy with ILM peeling for

macular edema secondary to retinal vein occlusion. Eur J Ophthalmol.

2009;19(6):10551062.7. Mandelcorn MS, Nrusimhadevara RK. Internal limiting membrane

peeling for decompression of macular edema in retinal vein occlusion: a

report of 14 cases. Retina.2004;24(3):348355.8. Arai M, Yamamoto S, Mitamura Y, Sato E, Sugawara T, Mizunoya

for macular edema associated with branch retinal vein occlusion.

Ophthalmologica. 2009;223(3):172176.9. Ishikawa K, Terasaki H, Mori M, et al: Optical coherence tomography

before and after vitrectomy with internal limiting membrane removal in a

child with optic disc pit maculopathy. Jpn J Ophthalmol.2005; 49:411

3.10. Ferencz M, Somfai G, Farkas A, Kovacs I, et al. Functional assessment

of the possible toxicity of indocyanine green dye in macular hole surgery.

Am J Ophthalmol 2006; 142:765-770.11. Enaida H, Hisatomi T Goto T, Hata Y, et al. Preclinical investigation

of internal limiting membrane staining and peeling using intravitreal

Brilliant blue G. Retina 2006 ;26:623-630.12. Enaida H, Hisatomi T, Hata Y, et al. Brilliant blue G selectively stains

the internal limiting membrane. Retina 2006; 26:631-636.

Complications

Table 1

Indications of ILM Peeling

Table 2

References1. Value of internal limiting membrane peeling in surgery for idiopathic

macular hole stage 2 and 3: a randomised clinical trial. Christensen UC,

Kroyer K, Sander B et al.Br J Ophthalmol. 2009; 93(8):1005-15.2. Tognetto D, Grandin R, Sanguinetti G, et al. Internal limiting membrane

removal during macular hole surgery. Ophthalmology 2006; 113:1401-

1410.3. Aras C, Arici C, Akar S, et al. Peeling of internal limiting membrane

during vitrectomy for complicated retinal detachment prevents

epimacular membrane formation. Graefes Arch Clin Exp Ophthalmol.

2009;247(5):619623.4. Hartley KL, Smiddy WE, Flynn HW Jr, Murray TG. Pars plana

vitrectomy with internal limiting membrane peeling for diabetic macular

edema. Retina. 2008;28(3):410419.5. Yanyali A, Horozoglu F, Celik E, Nohutcu AF. Long-term outcomes

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8

Surgical Technique

C

Amar Agarwal

Dhivya Ashok KumarMD,Amar AgarwalMS,FRCS,FRCOpthDr.Agarwals Eye Hospital and Eye Research Centre, 19 Cathedral Road, Chennai

Figure 1:Posterior capsular rupture during

Figure 2:

Figure 3: in the ciliary sulcus


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Discussion

3

Figure 4: of the procedure

Figure 5: ciliary sulcus

Figure 6: the procedure

Figure 7:Nucleus in AC

Figure 8:


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Figure 12:

Figure 9:

Figure 10:

Figure 11:Haptic placed in sulcus

6

7 8

Summary

References1. Vejarano LF, Tello A. Posterior capsular rupture. In Amar Agarwal:

Phaco Nightmares; Conquering cataract catastrophes; Slack Inc, 2006,

USA 253-264.


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DOS Times Index2. Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK.Management of posterior capsule tears. Surv Ophthalmol. 2001 May-

Jun;45(6):473-883. Gimbel HV, Sun R, Ferensowicz M, Anderson Penno E, Kamal

A.Intraoperative management of posterior capsule tears in

2001 Dec;108(12):2186-9; discussion 2190-24. Dada T, Sharma N, Vajpayee RB, Dada VK. Conversion from

risk factors, and visual outcome. J Cataract Refract Surg. 1998

Nov;24(11):1521-45.

Cataract Refract Surg. 1999 Apr;25(4):462-3.6. Thatte S, Raju VK. Phacosandwich technique. J Cataract Refract Surg.

1999 Aug;25(8):1039-407. Chang DF, Packard RB. Posterior assisted levitation for nucleus retrieval

using Viscoat after posterior capsule rupture. J Cataract Refract Surg.

2003 Oct;29(10):1860-58. Michelson MA. Use of a Sheets glide as a pseudo-posterior capsule in

Implant Refract Surg 1993;5:70729. Hansson LJ, Larsson J.Vitrectomy for retained lens fragments in

Jun;28(6):1007-1110. Monshizadeh R, Samiy N, Haimovici R. Management of retained

intravitreal lens fragments after cataract surgery. Surv Ophthalmol.

1999 Mar-Apr;43(5):397-404


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P.C. DwivediMS, FSVH,Charudatt ChalisgaonkarMS,Syed ImranMBBSS.S. Medical College, Rewa, Madhya Pradesh

C

Syed Imran

,

Anatomical Considerations

Axial length

5

Keratometry

6

Lens Power

Figure 1:Dens bilateral congenital cataract

Figure 2:Change in Axial length with Age


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Diameter of the lens

Capsular diameter

7,8,9

Biometry

Two ocular measurements are critical to IOL power calculation:

Axial length

Partial coherence interferometry

Keratometry

Choosing the Right Formula

Regression formulas

Axial Length and IOL Power

Target Postoperative Undercorrection

Figure 3:Change in Keratometry with Age


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Slight initial hyperopia or slight myopia at young adulthood

Age at cataract surgery

Status of the fellow eye

Expected compliance

Parents refractive error

Site of the IOL implantation

IOL Size28

For age < 2 years:

For age > 2 years:

Implanting an adult sized IOL in children bellow 2 years of agemay lead to

IOL Material

Axial length ( in mm) IOL power (in Diopters)

Age Residual Refraction


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PMMA Lenses

Silicone Lenses

anterior Capsule Contraction 35

Hydrophilic acrylics or Hydrogels Lenses 36 37

Hydrophobic acrylic lenses

38

References1. World Health Organization. Prevention of childhood blindness. Geneva:

WHO; 1992.

2. Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness in India:

causes in 1318 blind school students in nine states. Eye 1995; 9:545-50.3. Gilbert CE, Canovas R, Hagan M, Rao S, Foster A. Causes of childhood

blindness: results from West Africa, South India and Chile. Eye 1993; 7:

184-8.

4. Trivedi RH, Wilson ME. Biometry data from Caucasian and African-

American cataractous pediatric eyes. Invest Ophthalmol Vis Sci. 2007

Oct; 48(10):4671-8.5. Fledelius HC, Christensen AC. Reappraisal of the human ocular growth

curve in fetal life, infancy, and early childhood. Br J Ophthalmol 1996

Oct;80(10):918-21.6. Pediatric Ophthalmology and Strabismus, Third edition, Editors- David

Taylor, Creig Hoyt, Publishers: Elseivier Saunders, 2005, chapter 2, page

36.7. Vasavada AR, Raj SM, Nihalani B. Rate of axial growth after congenital

cataract surgery. Am J Ophthalmol 2004;138:915-24.8. Griener ED, Dahan E, Lambert SR. Effects of age at time of cataract

surgery on subsequent axial length growth in infant eyes. J CataractRefract Surg 1999; 25:1209-13.

9 Filtcroft DI, Knight-Nanan D, Bowell R, Lanigan B, OKeefe M.

Intraocular lenses in children: changes in axial length, corneal curvature,

and refraction. Br J Ophthalmol 1999;83:265-9.10. Jansson F, Koch E. Determination of the velocity of ultrasound in the

human lens and vitreous. Acta Ophthalmol 1962;40:4203311. Hussin HM, Spry PGD, Majid MA, et al: Reliability and validity of the

partial coherence interferometry for measurement of ocular axial length

in children. Eye 20:1021--4, 200512. Hoffer KJ. The Hoffer Q formula: A comparison of theoretical and

regression formulas. J Cataract Refract Surg 1993;19:700 12.13. Retzlaff JA, Sanders DR, Kraff MC. Development of the SRK/T

intraocular lens implant power calculation formula. J Cataract Refract

Surg 1990;16:333 40.14. Barrett GD. An improved universal theoretical formula for intraocular

lens power prediction. J Cataract Refract Surg 1993;19:71320.

15. Richards SC, Steen DW. Clinical evaluation of the Holladay and SRK II

formulas. J Cataract Refract Surg 1990;16:71 4.16. Sanders DR, Retzlaff JA, Kraff MC, et al. Comparison of thevSRK/T

formula and other theoretical and regression formulas. J Cataract Refract

Surg 1990;16:341 6.17. Olsen T, Thim K, Corydon L. Accuracy of the newer generation

intraocular lens power calculation formulas in long and short eyes. J

Cataract Refract Surg 1991;17:18793.18. Sanders DR, Retzlaff JA, Kraff MC, et al: Comparison of the SRK/T

formula and other theoretical and regression formulas. J Cataract Refract

Surg 16:341--6, 199019. Andreo LK, Wilson ME, Saunders RA. Predictive value of regression

Figure 4:Single-piece hydrophobic acrylic Lens.


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and theoretical IOL formulas in pediatric intraocular lens implantation.

J Pediatr Ophthalmol Strabismus 1997;34:240-243.20. Mezer E, Rootman DS, Abdolell M, et al. Early postoperative refractive

outcomes of pediatric intraocular lens implantation. J Cataract Refract

Surg 2004;30:603-610.21. Neely DE, Plager DA, Borger SM, Golub RL. Accuracy of intraocular

lens calculations in infants and children undergoing cataract surgery. J

AAPOS. 2005 Apr;9(2):160-5.

22. Mezer E, Rootman DS, Abdolell M, Levin AV. Early postoperativerefractive outcomes of pediatric intraocular lens implantation. J Cataract

Refract Surg. 2004 Mar;30(3):603-10.23. Tromans C, Haigh PM, Biswas S, Lloyd IC. Accuracy of intraocular lens

power calculation in paediatric cataract surgery. Br J Ophthalmol. 2001

Aug;85(8):939-4.24. Dahan E, Drusedau MU. Choice of lens and dioptric power in pediatric

pseudophakia. J Cataract Refract Surg. 1997;23 Suppl 1:618-23.25. Ashton GC. Segregation analysis of ocular refraction and myopia. Hum

Hered. 1985;35:232239.26. Gwiazda J, Thorn F, Bauer J, Held R. Emmetropization and the

progression of manifest refraction in children followed from infancy to

puberty. Clin Vis Sci. 1993;8:337344.27. Mutti DO, Zadnik K. The utility of three predictors of childhood myopia:

a Bayesian analysis. Vision Res. 1995;35:13451352.28. Bluestein EC, Wilson ME, Wang XH, et al. Dimensions of pediatric

crystalline lens: implications for intraocular lenses in children. J Pediatr

Ophthalmol Strabismus 1996;33:18-2029. Hollick EJ, Spalton DJ, Ursell PG, Pande MV, Barman SA, Boyce JF,

et al. The effect of polymethylmethacrylate, silicone, and polyacrylic

cataract surgery. Ophthalmology 1999; 106:49-54.30. Basti S, Aasuri MK, Reddy MK, Preetam P, Reddy S, Gupta S,

cataract surgery: prospective randomized study. J Cataract Refract Surg.

1999 Jun;25(6):782-7.31. Tognetto D, Toto L, Minutola D, Ballone E, Di Nicola M, Di Mascio

polymethylmethacrylate intraocular lens: a biocompatibility study.

Graefes Arch Clin Exp Ophthalmol. 2003 Aug;241(8):625-30. Epub

2003 Jul 17.32. Abela-Formanek C, Amon M, Schild G, et al. Uveal and capsular

biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone

intraocular lenses. J Cataract Refract Surg 2002;28:50-61.33. Abela-Formanek C, Amon M, Schauerberger J, et al. Results of

hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lensesin uveitic eyes with cataract. J Cataract Refract Surg 2002;28:1141-

1152.34. Hayashi K, Hayashi H. Intraocular lens factors that may affect anterior

capsule contraction. Ophthalmology. 2005 Feb;112(2):286-92.35. Newland TJ, McDermott ML, Eliott D, et al. Experimental

neodymium:YAG laser damage to acrylic, poly(methyl methacrylate),

and silicone intraocular lens materials. J Cataract Refract Surg

1999;25:72-76.36. Kohnen T, Magdowski G, Koch DD. Scanning electrom microscopic

analysis of foldable acrylic and hydrogel intraocular lenses. J Cataract

Refract Surg 1996;22:1342-1350.37. Hollick EJ, Spalton DJ, Ursell PG. Surface cytologic features on

intraocular lenses: Can increased biocompatibility have disadvantages?

Arch Ophthalmol 1999;117:872-878.38. Wilson ME, Elliott L, Johnson B, Peterseim MM, Rah S, Werner L, et

al. AcrySof acrylic intraocular lens implantation in children: clinical

indications of biocompatibility. J AAPOS 2001;5:377-380.39. Hollick EJ, Spalton DJ, Ursell PG, Pande MV, Barman SA, Boyce JF,

Tilling K (1999) The effect of polymethylmethacrylate, silicone, and

after cataract surgery. Ophthalmology 106:495440. Wilson ME, Trivedi RH, Buckley EG, Granet DB, Lambert SR, Plager

DA, Sinskey RM, Vasavada AR (2007) ASCRS white paper: hydrophobic

acrylic intraocular lenses for children. J Cataract Refract Surg 33:1966

1973

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41/52


Bhuvan ChananaMD DNB FICO, MNAMS,Vinod Kumar AggarwalMS, DNB, MNAMS, FICO, FRCS (Glasg),

Vitreo-retina services, Department of Ophthalmology, University College of MedicalSciences and GTB Hospital, New Delhi

G

Bhuvan Chanana

Ans.

Q.2. What are the presenting symptoms and signs ofEndophthalmitis?

Ans.

Others:

Ans.

Q.4. What are the organisms most commonly involved invarious types of Endophthalmitis?

Ans. Post cataract surgery:

Delayed onset (chronic) post cataract:

Post traumatic:

Q.5. Which type of endophthalmitis is most commonlyencountered?

Ans.

Ans.

(how do we grade severity of endophthalmitis)?

Ans. Media clarity in Endophthalmitis:

Grade 1:

Grade 2:


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Grade 3:

Grade 4:

Grade 5: Q.8. What is the main source of infection in post operative

Endophthalmitis?

Ans.

Other sources: e.g.

Q.9. How will you diagnose a case of Endophthalmitis?

Ans.

Q.10. How will you isolate causative organism?

Ans.

Q.11. What is the role of ultrasonography?

Ans.

Q.12. What differential diagnoses should be considered?

Note:

side of infectious endophthalmitis, until proven otherwise.Q.13. What are the recommendations of EVS

(Endophthalmitis Vitrectomy Study) study?

Ans.

Q.14. What were the cases included in EVS study?

Ans.

Table 1

Signs and Symptoms TASS Infectious Endophthalmitis


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Q.15. Which drugs should be used for Intravitreal injection?

Ans. Most commonly used drugs:

Other drugs used are:

Anti-fungal drugs (in cases with suspected fungal etiology)

Q.16. What is the role of systemic antibiotics in managementof Endophthalmitis?

Ans.

Q.17. Which systemic antibiotics have good intra-ocularpenetration?

Q.18. What is the role of steroids in Endophthalmitis?

Ans.

19. What are the indications of vitrectomy?

Q.20. What are the advantages and disadvantages of earlyvitrectomy?

Ans. Advantages:

Disadvantages:

Q.21. What are the indications and advantages of silicone

oil injection?Ans.

Advantages:

Q.22. What is the management of chronic delayed onset

Endophthalmitis?

Ans.

Problems:

Step 1:

Step 2:

Step 3

Q.23. What is the incidence of traumatic Endophthalmitis?

Ans.

Q.24. What are the risk factors for developingEndophthalmitis in penetrating injury?

Ans.


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Q.25. What are the common organisms involved in

traumatic Endophthalmitis?

Ans.

Figure 4:Chronic delayed Endophthalmitis withsequestration of Propionibacterium acnes in capsular bag

Figure 1:Vitreous exudates with poor glow inEndophthalmitis

Figure 2:Traumatic Endophthalmitis - Slit beamexamination shows ciliary congestion and cornealedema. Hypopyon and seclusio pupillae with total

Figure 3:Slit beam examination showshypopyon in a case of Endophthalmitis

Q.26. How is management of traumatic Endophthalmitisdifferent?

Ans.

Q.27. What are the risk factors for developing

Ans.


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Q.28. What are the various measures for preventingEndophthalmitis?

Antiseptics:

Q.29. What are the prognostic factors in Endophthalmitis?

Ans.

Venue: Date & Time:

Clinical Cases:

Clinical Talk:

Mini Symposium: Chairperson:


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C

Niketa Rakheja

Niketa Rakheja, H. S. SethiDepartment of Eye, Safdarjung Hospital, New Delhi

Figure 3:Pre treatment (a,b) After treatment (c)

Figure 1:Slit lamp picture

Figure 2:Pre treatment After 23 days of treatment

(a)

(b)

(c)


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Discussion

References1. Cunningham ET, et al. Am J Ophthalmol Nov 1995;120(5):675-7

2. Moorthy RS, et al. Survey of Ophthalmology 1995; 39(4): 265-92

3. Sakamoto T, et al. Arch Ophthalmol 1991;109:1270-4

4. Foster DJ, et al. AJO March 1991;111(3):380-2

5. Rubsamen PE, Gass JDM. Arch Ophthalmol 1991;109: 682-7

Arunodaya Deseret Eye Hospital (ADEH)Sector-55, Plot # NH-4, Gurgaon 122003, Haryana, INDIA

Tel.:(0124) 4116003/04/05Email:[email protected]

Web:www.adeh.org.in, www.acteyecare.com

A World Class Eye Hospital

Invites Ophthalmologists with a vision to join ADEH inits crusade to reverse the tide of curable blindness


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Instructions: The Quizmaster

.

Quiz compiled by Dr. Digvijay Singh

Answer to DOS Times Quiz October 2011

(B) (C)

(A)

Quiz Prizes Sponsored by

M/s. Raymed Pharmaceuticals Ltd.

(D)


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The DOS Times Quiz for July 2011 issue received 45 responses of which the correct answers weregiven by 1. Dr. Sheetal Bakshi, Ahmedabad 2. Dr. Tarun Arora, Delhi 3. Vivek Pravin Dave, Mumbai4. Dr. Ankit Soni, Aligarh. The winner of the prize money decided by a draw of lots is:

Answers of DOS Times Quiz July 2011 are:

The DOS Times Quiz for August 2011 issue received 21 responses of which the correct answers weregiven by 1. Dr. Neha Rathi, New Delhi 2. Sparshi Jain, Noida 3. Gunjan Abhijit Deshpande, Nagpur4. Ranjeet Kishore Rana, Delhi 5. Shalini Mohan, Kanpur 6. Anusha V., New Delhi were correct. Thewinner of the prize money decided by a draw of lots is:

Answers of DOS Times Quiz August 2011 are:

A1 S T I G

2 M A T

3 I S M L

4 M

5

M R O I A6 A

A E A7 R C N

8 E P A F E N A C

U E I I G U

R N A9 C U T E

10 D S

11 I L

O G P T O A

S12

I N U S13

A A14

N I R I D I A I

I C R K I D

S15

C O16

P O L A M I N E N S

R T G R T

V17

B O A A18

M S L E R G R I D

I I M R T E

D19

O T A H20

Y P O P Y O N A O21

A O P K P

R T22

R I C H I A S I S S T

A U23

N A I

B24

U L L S E Y E K C

I C R I25

R I S26

C L A27

W P

N E A E I I

E28

N T R O P I O N C29

A T A R A C T

July & August 2011


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51/52


Yogesh BhadangeMBBS, Brijesh TakkarMBBS, Bhavin ShahMBBS,Rajesh SinhaMDDr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

T

Yogesh Bhadange

T

4. Intracameral Agents

A. Antibiotics and Antifungals

Bolus dose of commonly used antibiotics

Antibiotics

Drugs Dilution in Final concentration

B. Mydriatics

C. Miotics

Pilocarpine:

5. Posterior Subtenon Injection:

6. Posterior Juxta Scleral Depot Injection:

7. Intravitreal Drugs:

A. Antibiotics:

Vancomycin (1mg\0.1ml) available commercially as 500mg powder

Ceftazidime (2.25mg\0.1ml) available commercially as500mg powder injection

B. Antifungal

Amphotericin B: (5 microgram\0.1ml) availablecommercially as 50mg powder

Voriconazole (available commercially as 200mg powder)50-100micrgram\0.1ml


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C. Intravitreal Drugs List in Tabular form

Drugs Dosage

Antibacterials

Antifungals

Antivirals

Steroids

Anti VEGFs

Implants

D. Intraocular Gases:

Gas Mol. Wt. Expansion Longevity Non- Vol. (pure gas / Days Expansile injected in 100% conc.) Conc. Pneumatic Retino- pexy

6

3

8

Dr. Rajvardhan Azad, MD, FRCSed, FICS, FAMS, for being appointed as Chief,

Congratulations

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