Descemetocele

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EDITORIAL
5 HcrccnmcsthcmIdtcrm
FOCU5
11 InfcctInusKcratItIs
RETINA
23 RctInnpathynfPrcmaturIty-ThcNcwCha!!cngc
Parag K. Shah, Saurabh Arora, V. Narendran, N. Kalpana
29 EpIrctIna!Mcmbranc:AnOvcrvIcw
Ramesh KC Gupta, Kadri Venkatesh
37 Intcrna!LImItIngMcmbranc(ILM)Pcc!IngfnrMacu!arDIsnrdcrs
Tinku Bali Razdan
CATARACT
45 Intrancu!ar!cns(IOL)asa5caffn!dtnPrcvcntNuc!cusDrnp
Dhivya Ashok Kumar, Amar Agarwal
53 PcdIatrIcIOL-PnwcrCa!cu!atInnandMatcrIa!5c!cctInn
P.C. Dwivedi, Charudatt Chalisgaonkar, Syed Imran
GRANDROUND5
59 ExngcnnusEndnphtha!mItIs
Bhuvan Chanana, Vinod Kumar Aggarwal
CLINICALMEETING
65 C!InIca! Casc-1: VOGT KnyanagI Harada 5yndrnmc - A DIagnnstIc
DI!cmma
Niketa Rakheja, H. S. Sethi
COLUMN5
71 DO5TImcsQuIz
TEAR5HEET
79 DnscsnfImpnrtantDrugsInOphtha!mn!ngy(Part-2)
Yogesh Bhadange, Brijesh Takkar, Bhavin Shah, Rajesh Sinha
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DOS Mid-term 12th-13th November, 2011
at India Habitat Centre, New Delhi
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HcrccnmcsthcmIdtcrm
RespecledSeniors&friends,
Our hrsl lig evenl is upon us and ve shaII aII cone logelher in lhe genlIe
vinlers of Novenler al lhe India Halilal Cenlre in lhe hearl of Nev DeIhi.
Il is lhe line lo recharge our knovIedge ceIIs and inleracl vilh lhe lesl in
lhe lusiness. Ask queslions lhal have leen pIaguing us and discuss lopics
ve couId nol undersland. Afler aII lhey say lhal 2 ninds are leller lhal one and here ve viII gel nany hundreds.
The Mid lern conference pronises lo le a 2 day exlravaganza of scienlihc presenlalions, oulslanding laIks and
par exceIIence acadenic discussions. The scienlihc progranne is aIready in pIace and pronises lo aclivale your
neurons Iike never lefore. Nol lo forgel an evening of enlerlainnenl and IiveIy nusic.
WhiIe ve viII le lringing for you aII lhe expecled, sone nev lhings in slore for you are:
An enjoyalIe and fun hIIed quiz lo enlerlain and enIighlen
SpeciaIly Iive surgery: See lhe lesl in lhe heIds perforning Iive surgery in squinl, gIaucona, ocuIopIasly, cornea
and relina.
Increased nunler of haIIs
AII lhis and nore on 12lh and 13lh of Novenler. The nidlern conference of DOS is ligger and IiveIier lhan
nosl slale conferences and hopefuIIy viII gel ligger and leller every line. This line loo lhe execulive is Ieaving
no slones unlurned lo nake lhis evenl nenoralIe. We Iook forvard lo your aclive parlicipalion.
So pIease le lhere.
Wilh lesl vishes,
RnhIt5axcna
Sccrc|arq,
DeIhi OphlhaInoIogicaI Sociely
Infectious keratitis remains an important cause of ocular morbidity in ophthalmic
practice. Diagnosis and management of infectious keratitis still remains a serious
dilemma for most ophthalmic physicians. Dr. M. Vanathi MD, Associate Professor
of Ophthalmology Cornea & Ocular Surface Services, Dr Rajendra Prasad Centre
for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi spoke to
several imminent Cornea Specialists in India and abroad regarding certain concerns in
infectious keratitis management. The panelists in this discussion on infectious keratitis
include Prof. Anita Panda, Dr. M.Srinivasan, Prof. John Dart, Dr. Samar Basak, Dr. Lim
Li and Dr. Bhaskar Srinivasan. Please read on, as the following compilation gives a
vivid peek into the practice patterns of these dynamic corneal physicians as they share
some of their experiences and practice pearls.
M.VanathI:WhatIsthctypcnfInfcctInuskcratItIsdnynucnmmnn!ycncnuntcrInynur
practIcc?
AnItaPanda: acleriaI keralilis, foIIoved ly nixed nicroliaI (lacleriaI and fungaI) is vhal
I connonIy see in ny praclice.
M.5rInIvasan: I gel lolh fungaI and lacleriaI keralilis in equaI nunlers. There is no seasonaI
varialion. Nocardia is aloul 6 lo 12 and Acanlhanoela 1. Had 2 cases of nicrosporidiun, of
vhich one vas liIaleraI.
JnhnDart: acleriaI keralilis 85, Acanlhanoela and Iungi in 15 and rareIy nycolacleria
and nicrosporidiaI keralilis.
5amarBasak: eing a lerliary care hospilaI, ve see pIenly of nicroliaI keralilis in day-lo-
day praclice in our cornea cIinic, approxinaleIy 9O-1O5 nev cases/nonlh. Anong lhese lhe
dislrilulion is as foIIovs:
- Purc|unga|Kcra|i|is. 61 and noslIy vilh AspergiIIus spp.
- Purc8ac|cria|Kcra|i|is. 22.
Prnfcssnr AnIta Panda, MD, ||CO, |AMS, MRCOpn is currenlIy Senior Irofessor of
OphlhaInoIogy, Cornea Services, Dr Rajendra Irasad Cenlre for OphlhaInic Sciences, AII
India Inslilule of OphlhaInic Sciences, Nev DeIhi, India & Vice Iresidenl of lhe AII India
OphlhaInoIogicaI Sociely of India.
Dr.M.5rInIvasan, MS, DO is currenlIy lhe Direclor - Lnerilus, Aravind Lye Care Syslen &
Ioslgraduale Inslilule, and Senior Cornea ConsuIlanl of Aravind Lye HospilaI, Madurai, India
PrnfcssnrJnhnK.G.Dart, MA DM IRCOphlh is currenlIy ConsuIlanl OphlhaInoIogisl (CorneaI
& LxlernaI Disease Service) and Depuly Direclor of Research al MoorheIds Lye HospilaI, Hon.
Irofessor, Universily CoIIege of London, UK and Chairnan of lhe Infeclion ConlroI Connillee,
London, UK.
Dr. 5amar K. Basak, M88S, MD (A||MS), DN8, |RCS is lhe Direclor & Senior ConsuIlanl
(Cornea and LxlernaI Lye Diseases) Disha Lye HospilaIs & Research Cenlre, arrackpore,
KoIkala, India, MedicaI Direclor, IROVA LYL ANK, arrackpore, Vice-Iresidenl, Lye ank
Associalion of India, and Ldilor of Iroceedings, AII India OphlhaInoIogicaI Sociely.
Dr. LIm LI, M88S, MMc(Opn|n), |RCS(|), |AMS(Spcrc), is a Senior ConsuIlanl
OphlhaInoIogisl in CorneaI and LxlernaI eye disease services of Singapore NalionaI Lye
Cenlre & Depuly Direclor of lhe Singapore Lye ank, Singapore.
Dr.Bhaskar5rInIvasan,MS,DN8is ConsuIlanl , C.}. Shah Cornea Services and C. SilaIakshni
CIinic for OcuIar Surface Disorders, Sankara NelhraIaya, Chennai, India
)RFXV
Professor Anita Panda
Dr. M. Srinivasan
Professor John KG Dart
Dr. Samar K. Basak
Dr. Lim Li
Dr. Bhaskar Srinivasan
12 l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
- Mixc8ac|cria|+|unga|Kcra|i|is. 11
- Acan|namcc|a|cra|i|is. O.5
- Miscc||anccusinfcc|icn. O.5
- Unc|crmincsuppura|itc|cra|i|is. 5
LIm LI: Conlacl Iens reIaled infeclive keralilis is
connonIy seen in ny praclice in Singapore.
Bhaskar 5rInIvasan: IungaI keralilis especiaIIy
hIanenlous fungi is lhe connonesl cause of infeclive
keralilis al our cenlre in Chennai.
Keratitis has a wide geographical variation with the
practice patterns being dominated by the region of practice,
socioeconomic status of the presenting population and
lifestyle patterns.
M. VanathI: What Is ynur prcfcrrcd apprnach tn a
cascnfInfcctInuskcratItIsprcscntIngtnynu?
AnItaPanda: When a case of corneaI uIcer cones lo us
hrsl ve ruIe oul lhe viraI keralilis vhich incIudes: alsence
of cIinicaI hndings vilh nornaI conjunclivaI sensalions
and nornaI corneaI sensalion in lhe cIear corneaI area. We
go ahead vilh corneaI scraping and specinens are senl
for direcl nicroscopic evaIualions, lacleriaI and fungaI
cuIlures irrespeclive of duralion size and exlenl of lhe
uIcers and prior lherapy received. If lhe uIcer is snaII,
ve slarl nonolherapy vilh anliliolics drops vilh olher
supporlive lherapy Iike cycIopIegic drops. If lhe uIcer is
exlensive or if il does nol respond lo lhe nonolherapy, ve
slarl conlinalion lherapy vilh forlihed cefazoIin 5 eye
drops 2 hourIy and forlihed lolranycin 1.3 eye drops 2
hourIy aIong vilh cycIopIegic eye drops 2 (honalropine
eye drops). When lhe nicrolioIogicaI reporls are avaiIalIe
lhe lherapy is adjusled accordingIy. If lhe uIcer cIinicaIIy
resenlIes fungaI and supporled ly direcl nicroscopy
hndings lhen ve add anli-fungaI drops. Ior hIanenlous
fungi Iike Iusariun species, nalanycin 5 eye drops are
prescriled. Ior Candida, and resislanl hIanenlous fungaI
infeclion such as AspergiIIus, Anpholericin eye drops
O.15 - O.3. Though TopicaI voriconazoIe is effeclive, ve
keep il reserve for non responsive fungaI uIcer as nosl of
our palienls cannol afford lhe drug due lo ils cosl. In non
responsive cases VoriconazoIe 1 eye drops 2 hourIy is
preferred. Sone nay require syslenic anlifungaI agenls.
Infacl appropriale iniliaI lherapy is nosl crilicaI
in lhe nanagenenl of severe corneaI uIcers. In such
eyes, aggressive lroad speclrun anliliolic coverage is
advocaled.
TopicaI adninislralion is lhe nosl efhcienl neans of
deIivering anliliolics lo lhe cornea. In addilion lo providing
lherapeulicaIIy effeclive concenlralion of lhe drug, lopicaI
drops vash avay lacleria, anligens, and polenliaIIy
deslruclive enzynes fron lhe ocuIar surface. Ienelralion
of lhe drug inlo lhe cornea is increased vilh higher
concenlralion of drug, grealer frequency of appIicalion,
nore IipophiIic anliliolics, and Ionger conlacl line. Sone
palienls nay respond lo lhe connerciaI slrenglh of lopicaI
anliliolics (e.g., ciprooxacin) given al frequenl inlervaIs,
lul forlihed anliliolics are nosl effeclive. IniliaIIy given
as a Ioading dose, nore drug is deIivered lo lhe cornea.
Iorlihed anliliolics are given every 15 lo 3O ninules
(aIlernaling vhen nuIlipIe anliliolics are used) for lhe hrsl
24 lo 36 hours. The conlinalion of forlihed cefazoIin 5
and lolranycin 1.3 is effeclive againsl nosl lacleria.
Il is preferalIe lo vilhhoId anlifungaI lherapy, unliI
lhere is Ialoralory conhrnalion lhal lhe infeclion is fungaI,
especiaIIy in viev of polenliaI loxicily of anlifungaI drugs,
and lecause fungaI keralilis does nol progress as fasl as
lacleriaI. Nalanycin as a 5 percenl suspension is lhe drug
of choice vhen hyphaI eIenenls are seen in lhe corneaI
snear, al 1 hourIy frequency. Anpholericin (O.15) is
lhe drug of choice for yeasl or pseudohyphaI keralilis and
is a good second agenl for hIanenlary fungaI keralilis.
TopicaI uconazoIe drop is indicaled for candida infeclion.
TopicaI Nalanycin or anpholericin al 1 hourIy inlervaI
for lhe hrsl 48 hours is reconnended. A Ioading pallern
for anpholericin nay le considered. CeneraIIy fungaI
keralilis inproves sIovIy, and for lhal reason proIonged
lherapy shouId le advocaled. OraI uconazoIe, a valer
soIulIe lriazoIe is veII loIeraled, preferenliaIIy laken
up ly cornea, has lroad speclrun and exceIIenl ocuIar
pharnacokinelic prohIe for vhich il nay le vaIualIe in lhe
lrealnenl of fungaI keralilis caused ly a variely of fungi.
Decision lo change lherapy is lased on:-
a) CIinicaI response and loIerance lo iniliaI lherapy
l) Severily of lhe keralilis
c) Anlicipaled or reporled in vilro suscepliliIilies
Sul conjunclivaI anliliolics are nol indicaled in presenl
era due lo olvious side effecls.
In suspecled Acanlhanoela keralilis, nicroliaI
invesligalions are very essenliaI so aIso for specihc keralilis
Iike Nocardia, MycolacleriaI infeclions and lrealed
accordingIy. If lhe corneaI sensalions are alsenl ve slarl
anliviraI agenls AcycIovir 3 oinlnenl 5 lines a day. If
Herpes Zosler skin Iesions or uveilic signs are presenl, oraI
anliviraIs (AcycIovir 8OO ng 5 lines a day) is slarled.
M. 5rInIvasan: I aIvays do Cran slain and KOH
snear on aII cases presenling lo ne irrespeclive of size
of lhe uIcer. RuIe oul dialeles and IacrinaI sac infeclion.
IniliaI snear viII heIp lo slarl specihc lherapy. I do cuIlure
as a rouline.
Jnhn Dart: eing a leaching cenlre nosl cases have
snears, are cuIlured, and in vivo confocaI nicroscopy is
readiIy avaiIalIe for lhose vilh cIinicaI signs suggeslive
of fungaI or Acanlhanoela keralilis. Therapy is slarled
depending on lhe resuIls of snears and confocaI
nicroscopy, and depending on evaIualion of risk faclors for
infeclion such as conlacl Iens vear, and pre-exisling ocuIar
surface disease. We see 1-2 nev Acanlhanoela keralilis or
fungaI keralilis cases per nonlh, oflen in conlacl Iens users
in vhon lhe index of suspicion for lhese causes is high.
SiniIarIy in palienls vilh ocuIar surface disease candida
keralilis is reIaliveIy connon.
Hovever lecause of lhe preponderance of lacleriaI
keralilis in our popuIalion ve slarl nosl cases on inlensive
(hourIy) Ievooxacin 5 drops vhich are conlinued hourIy
for 5 days. There is nininaI resislance lo quinoIones in
lhe UK, and resislance lo nonolherapy vilh a quinoIone
such as Ievooxacin is onIy aloul 2, vhich is siniIar
lo resislance lo duaI lherapy vilh genlanicin 1.5 and
cefuroxine 5 (lhe nosl videIy used duaI lherapy
conlinalion in lhe UK). I do nol advocale lhe use of sleroids
in cases vilhin 5 days of lhe slarl of lherapy and lhen onIy
for a posilive indicalion such as severe inannalion, of
faiIure lo epilheIiaIize, in palienls in vhon lhe diagnosis
of lhe causalive organisn is reasonalIy cerlain. Regarding
lhe earIy use of lopicaI sleroid, one recenl randonized
conlroIIed lriaI has shovn no effecl, and lhe resuIls of
anolher fron Aravind are availed
Ior fungaI keralilis ve use LconazoIe 1 hourIy iniliaIIy
for 5 days, as our hrsl Iine agenl for hIanenlary fungaI
infeclion, and add oraI IlraconazoIe (cheaper) VoriconazoIe
(nore expensive) for hIanenlary fungaI keralilis (or if lhe
lype of fungus is uncerlain) and oraI IIuconazoIe for candida
keralilis, in palienls vilh deep or peripheraI disease. Ior
Candida aIlicans ve use Anpholericin O.15 hourIy
iniliaIIy for 5 days. As second Iine agenls for unresponsive
cases ve use lopicaI VoriconazoIe 1 hourIy vilh or vilhoul
lopicaI Anpholericin O.15. We use lopicaI chIorhexidine
O.2 as a lhird Iine agenl. The iniliaI frequency is hourIy
for 5 days or Ionger and lrealnenl frequency is reduced
lo 4-6x daiIy over 2 veeks and conlinued for 3-4 nonlhs
for hIanenlary fungaI infeclion and 1-2 nonlhs for candida
keralilis. In progressive cases ve have used inlraslronaI
and/or inlracaneraI voriconazoIe 5O-1OO ncg/O.1nI. We
rareIy use lopicaI sleroids in hIanenlary fungaI keralilis
(Iess reIuclanlIy in candida keralilis). In lranspIanled eyes
ve use lopicaI cicIosporin.
Ior Acanlhanoela keralilis ve use IHM O.O2
conlined vilh Hexanidine O.1 as hrsl Iine lherapy,
and chIorhexidine O.O2 and propanidine O.1 as
second Iine lherapy. Ior palienls vilh persislenlIy cuIlure
posilive Acanlhanoela keralilis ve use IHM O.O6 or
ChIorhexidine O.2, and oraI VoriconazoIe vilh lopicaI
VoriconazoIe 1. This lrealnenl is conlinued unliI lhe
corneaI inannalion has resoIved and leen unchanged,
vilhoul lhe use of lopicaI sleroids, for a nonlh.
Ior nycolacleriaI keralilis ve use lopicaI anikacin
2.5 and Ievooxacin 5 hourIy iniliaIIy as hrsl Iine
agenls and, in cIinicaIIy resislanl cases, ve add lopicaI
cIarilhronycin 1 and noxioxacin (has lo le inporled
speciaIIy) lo anikacin. We use oraI cIarilhronycin in severe
cases.
Ior slronaI nicrosporidiaI keralilis ve have IunadiI
O.3 avaiIalIe vilh oraI AIlendazoIe lul lhe success rale
has leen Iov.
5amarBasak: A detailed history:
- Ris| fac|crs. Ioreign lody/ injury vilh vegelalIe
naleriaIs/CL use/ use of lopicaI sleroids
- Usc cf Tcpica| mcica|icns. anlilacleriaIs/
anlifungaIs/anliviraIs/olhers
- ConpIiance lo lhe lopicaI reginens previousIy
prescriled
A good clinical examination:
- VisuaI Acuily
- S|a|us cf cqc|is. for lrichaisis/enlrpion,
IagophlhaInos
- Sac exaninalion for chronic dacryocyslilis
Slit lamp examination:
- Area invoIved
- Size and deplh of Iesion
- Size of epilheIiaI defecl
- Degree of slronaI edena
- ScIeraI invoIvenenl
- CorneaI lhinning
- Inpending/frank perforalion
- AC reaclion/ Hypopyon
- Lxanine for specihc fealures of fungaI
keralilis (dry Iooking inhIlrales, fealhery
nargins, saleIIile Iesions, innune rings, hxed
hypopyon, pignenlalion vilh sone fungi),
CorneaI sensalion
Documentation: Diagrannalic represenlalion and/or
CIinicaI pholograph: This is lo expIain lhe severily of lhe
infeclion and prognosis lo lhe palienl as veII as for foIIov
up assessnenl.
LIm LI: This depends on lhe cIinicaI hndings. If lhe
infeclive keralilis Iooks Iike pseudononas keralilis vhich is
nosl connonIy seen reIaled lo conlacl Iens vearers and is
nore lhan 1 nn in dianeler, I Iike lo do a corneaI scraping
for cuIlure and sensilivily and slarl lhen enpiricaIIy on
forlihed lopicaI lroad speclrun anliliolics. When lhe
cuIlure and sensilivily resuIls are knovn, lhe lrealnenl
viII le nodihed accordingIy.
Bhaskar 5rInIvasan: AII cases vouId undergo a
corneaI scraping for Crans slaining and KOH nounl and
specinen vouId le senl for lacleriaI and fungaI cuIlure.
ased on cIinicaI appearance and hislory if any olher
specihc invesligalion is required il vouId le ordered for. In
cases of lacleriaI keralilis I vouId slarl vilh a 4lh generalion
uoroquinoIone aIong vilh forlihed cephaIosporin or
aninogIycoside lased on lhe nicrolioIogicaI reporl. ased
on cIinicaI inprovenenl/ nicrolioIogicaI sensilivily reporl
vouId decide on changing lhe anliliolics. In case of fungaI
keralilis I vouId slarl lhe palienl on lopicaI nalanycin and
vouId add voriconazoIe or anpholericin lopicaIIy or
inlracaneraI in case of a deep slronaI or endolheIiaI Iesion.
Thorough history, meticulous clinical examination to
form a presumptive etiological clinical diagnosis, corneal
scraping for smear and culture sensitivity, appropriate
antimicrobial therapy with close follow-up remain the
mainstay in the diagnosis and management of infectious
keratitis.
M. VanathI: What dn ynu advncatc abnut rn!c nf
cnrnca!scrapIngasadIagnnstIcandthcrapcutIcapprnach
InInfcctInuskcratItIsmanagcmcnt?
AnIta Panda: As a diagnoslic looI, corneaI scrapings
heIp lo diagnose lhe specihc agenl and ils sensilivily lo
parlicuIar anlinicroliaI agenls, so lhal ve can svilch over lo
lhe accurale lrealnenl reginen. As a lherapeulic approach
il renoves lhe necrolic or inannalory sulslance lhal
heIps for leller alsorplion of lhe anlinicroliaI agenls and
il aIso reduces lhe Ioad of lhe infecling organisn. As lhe
cIinicaI hndings are cIassicaI in viraI keralilis I personaIIy
do nol prefer scraping in such eyes. Iurlher, if lhe uIcer is
very snaII (< 2 nn) one can avoid scraping.
M. 5rInIvasan: CorneaI scraping is nandalory in
nanaging infeclious keralilis in India lo legin specihc
lherapy. In a sludy conducled ly ne lherapeulic scraping
increases lhe chance of perforalion
1
. I donl do lherapeulic
scraping.
Jnhn Dart: CorneaI scraping is done vhere possilIe
and praclicaI. We use il al MoorheIds Lye HospilaI, for aII
signihcanl cases of keralilis lul nol for snaII inhIlrales as
are oflen seen in conlacl Iens users.
5amarBasak: Yes, I slrongIy advocale corneaI scraping
in aII lhe cases of nicroliaI keralilis, Ior lhree lasic reasons:
1. To prepare snears for KOH vel nounl preparalion
and Cran slaining
2. Il decreases nicroliaI Ioads fron lhe corneaI
surface
3. Il heIps in penelralion of lhe lopicaI anlinicroliaI
agenls
One shouId al Ieasl aIvays go for KOH vel nounl
preparalion lo delecl fungaI hyphae. Lxperienced
ophlhaInoIogisl can aIso diagnose Candida,
Acanlhanoela, Nocardia or even Microsporidia in KOH
preparalion. Il does nol expensive, and is very sinpIe and
quick.
Procedure for scraping
- Scraping shouId le done under sIil Ianp
visuaIizalion / or aided ly linocuIar Ioupe
- InsliII 1-2 drops of lopicaI anaeslhelic agenl. Wail
for 3 ninules.
- Keep 2 cIean gIass sIides having 1cn circIe vilh
gIass penciI on reverse side of sIide.
- Scrape lase and edges of corneaI uIcer vilh a
sleriIe No. # 15 I lIade.
- Slreak over gIass sIide vilhin circIe: for KOH
nounl and Cran slain.
- AppIy KOH, cover vilh cover sIip.
- Lxanine under Iighl nicroscope.
The corneaI scrapings and reIaled naleriaI- Iike Conlacl
Iens (CL), CL case and CL soIulion shouId le suljecled lo
cuIlure if faciIilies are avaiIalIe.
CuIlure shouId le done in aII cases of nicroliaI
keralilis if lhe faciIilies are avaiIalIe. Direcl cuIlure in
specihc cuIlure pIale nediun is reconnended. Sensilivily
pallern is lo le delernined for lacleriaI keralilis.
LIm LI: CorneaI scraping is an inporlanl looI in
lhe diagnosis of infeclive keralilis. The scrapes shouId
le direclIy inocuIaled on lhe cuIlure nedia lo enhance
lhe cuIlure posilive rale. Il can aIso le perforned for
lherapeulic purposes and lo enhance drug penelralion.
Bhaskar 5rInIvasan: I roulineIy use il as a diagnoslic
looI excepl in very snaII peripheraI uIcers or uIcers on
lrealnenl vhich on presenlalion aIready shov signs of
scarring. As a lherapeulic looI I use il in cases of fungaI
keralilis especiaIIy lhose associaled vilh pIaque Iike Iesion.
Diagnostic corneal scraping is a must is most ulcers
larger than 2mm in size at presentation and before initiation
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in cases of CLIK may be closely monitored. Therapeutic
corneal scraping depends on the clinical presentation at
each follow-up and best practiced in expert hands as it
stands a risk of perforation and increased scarring in the
healing response.
M. VanathI: Ynur pcrspcctIvc nn rcccnt/changIng
trcndsInInfcctInuskcratItIsmanagcmcnt..
AnItaPanda: Wilh respecl lo invesligalive nodaIilies,
poIynerase chain reaclion (ICR) is lhe never enlily lhal
gives quick resuIls even vilh a ninule quanlily of lhe
sanpIe. ul il cannol differenliale lhe aclive or Ialenl
infeclion, vialIe or nonvialIe, and il cannol perforn drug
sensilivily. And cosl is aIso anolher faclor lhal Iinils ils
use.
Regarding lacleriaI keralilis, corneaI crossIinking
seens lo le effeclive, and can le lried as an adjuncl lo
anlilacleriaI agenls for quick recovery
4
.
Anong anlifungaI agenls voriconazoIe 1 eye drops
and oraI voriconazoIe adninislralion is very effeclive lul
is expensive.
A few words about surgical therapy:-
a) Repealed delridenenl is vaIualIe in nanagenenl
of corneaI uIcer. Il heIps ly reducing lhe organisn
Ioad & enhancing drug penelralion.
l) CyanoacryIale gIue, and nore recenlIy hlrin gIue,
is usefuI for repair in progressive corneaI necrosis,
desceneloceIes, and perforaled corneaI uIcers
vilh perforalion size Iess lhan 2nn. esides
acling as a lanponade, lhe gIue has an addilionaI
anlilacleriaI effecl.
c) ConjunclivaI ap
d) Tarsorrhaphy- Il enhances heaIing ly reducing
nechanicaI friclion of uIcer lo lhe Iid.
e) Ialch grafl nay le considered for snaII perforalion
as a leclonic supporl vhich couId nol le nanaged
ly gIue.
f) MuIliIayered anniolic nenlrane lranspIanlalion
(MLAMT) is considered for non heaIing corneaI
uIcers.
g) Therapeulic penelraling keralopIasly is allenpled
eilher afler faiIure of aII nelhods or if one can judge
cIinicaIIy lhe possiliIily of non inprovenenl.
The Objectives are:-
1. To eIininale infeclion
2. To reslore lhe inlegrily of cornea
3. To preserve/reslore vision
However, the following should be known prior to
surgery:
1. ResponsilIe organisn (polenliaI of nedicaI
response and risk of endophlhaInilis)
2. Irevious slalus of lhe cornea (e.g. herpes sinpIex
viraI keralilis)
3. The severily of lhe slronaI inannalion and/
or perforalion (Iocalion and size of lhe required
penelraling grafl)
4. Slalus of lhe inlraocuIar slruclures
Measures to be taken prior to surgery:-
1. Try lo sleriIize lhe cornea uIcer and reduce
inannalion lo nininun
2. Use of scIeraI supporl ring is essenliaI
3. Refornalion of anlerior chanler vilh viscoeIaslic
lefore lrephinalion lhrough a side porl.
4. Ire & Iosl operalive syslenic sleroid can le given
judiciousIy.
5. Iosl operalive anli gIaucona lherapy is varranled.
Therapeulic scIerokeralopIasly is advocaled if lhere
is invoIvenenl of lolaI cornea vilh or vilhoul scIeraI
invoIvenenl.
M. 5rInIvasan: Lven loday lhe elioIogicaI agenls are
sane and incidence aIso sane. I do nol see any change in
nedicaI nanagenenl. Iev reconnend ITK, C3R, and
IaneIIar grafls.
Jnhn Dart: The liggesl change for us has leen lhe
inlegralion of confocaI nicroscopy inlo lhe diagnosis
of cases of presuned Acanlhanoela, fungaI and
nicrosporidiaI keralilis. We aIvays conline lhis
invesligalion vilh cuIlure, and inlerprel lhe hndings vilh
caulion. Having said lhis, ils ready avaiIaliIily has leen a
sulslanliaI advance in lhe nanagenenl here.
5amar Basak: In India, lhere is a vide varialion of
causalive organisns vilh differenl regions and geographicaI
area. So for enpiricaI lrealnenl: a lhorough knovIedge
regarding geographicaI dislrilulion of causalive organisn
is inporlanl.
|n mq cpinicn. lhe lrealnenl shouId le considered
depending upon lhe silualion al lhree differenl IeveIs:
- |n primarq |ctc|. Iike soIo ophlhaInoIogisl: OnIy
lroad speclrun anliliolic and cycIopIegics and lo
refer lhe palienl vilhin 24 hours.
- |nscccnarq|ctc|.Iike snaII hospilaI: A KOH vel
nounl preparalion and lreal as fungaI or lacleriaI.
Wail for 7 days lo see lhe response and lhen refer
if necessary lo lerliary IeveI.
- |n |cr|iarq |ctc|. in cornea deparlnenl: Invesligale
and lreal lhe palienl liII il is resoIved
LImLI: Due lo lhe videspread and oflen indiscrininale
use of anliliolics, nore anliliolic resislanl slrains of
lacleria is encounlered. Of parlicuIar concern is genlanicin
resislanl Iseudononas aeruginosa. OphlhaInoIogisls
are prescriling uoroquinoIones nore oflen nov due
lo anliliolic resislance lo hrsl Iine anliliolics such as
genlanicin.
Bhaskar5rInIvasan: eller nicrolioIogicaI supporl in
lhe forn of ICR is heIping us idenlify lhe causalive agenl
nore accuraleIy. Advances in anliliolics and anlifungaIs
especiaIIy lhe inlroduclion of voriconazoIe has heIped us
nanage fungaI keralilis leller.
Improved diagnostics with the advent of PCR and
confocal microscopy, availability of fourth generation
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intrastromal antifungals, amniotic membrane grafting and
corneal crosslinking therapy in infectious keratitis form
the most salient features in the changing perspectives of
infectious keratitis.
M. VanathI: Whcn dn ynu advncatc systcmIc
antIbIntIcs/antIfunga!thcrapyInInfcctInuskcratItIs?
AnIta Panda: When lhe uIcer is progressive even
vilh reguIar anliliolic/anlifungaI reginen ve adninisler
syslenic anlilacleriaI or anlifungaI.
Sqs|cmican|i|ic|icsarcinica|cin.-
- Neisseria gonorrhea keralilis,
- In young chiIdren,
- In liIaleraI uIcers, vilh scIeraI suppuralion,
- In perforaled uIcers,
- Severe keralilis vilh polenliaI for inlraocuIar
spread,
- In associalion vilh perforaling injuries lo lhe
cornea and scIera,
- In silualions vhere ideaI IocaI reginen cannol le
given due lo poor conpIiance.
M. 5rInIvasan: I reconnend syslenic drugs vhen
lhe corneaI uIcer invoIves lhe Iinlus, perforalion occurs,
suspecling endophlhaInilis and syslenic anlifungaIs in
one eyed palienls nol responding lo lopicaI anlifungaI
lherapy.
JnhnDart: I prescrile syslenic anliliolics for lacleriaI
keralilis vhen lhere has leen a corneaI perforalion and in
severe fungaI, Acanlhanoela and nycolacleriaI keralilis.
5amarBasak:
- Inpending / Irank perforalion
- Severe deep keralilis / TolaI or SullolaI uIcers
- Iosl perforaling injury / Iosl KeralopIasly
infeclion
- ScIeraI invoIvenenl / TunneI alscess
- If associaled vilh endophlhaInilis
- If lhe cuIlures reveaI lacleriaI agenls Iike Neisseria,
HaenophiIus spp
- One eyed vilh deep keralilis
LIm LI: Syslenic anlifungaIs are indicaled vhen lhe
fungaI keralilis is severe and nol responding lo lopicaI
nedicalion, infeclions lhal have penelraled lhe cornea inlo
lhe anlerior segnenl or causing endophlhaInilis, infeclions
lhal have spread lo and leyond lhe Iinlus.
Bhaskar 5rInIvasan: syslenic anliliolics are very
rareIy prescriled ly ne excepl in lhe scenario of an
endophlhaInilis. I prescrile syslenic anlifungaIs in cases
of very Iarge fungaI uIcers especiaIIy near lhe Iinlus or
invoIving lhe scIera and in cases of fungaI endophlhaInilis.
The consensus on the use of systemic antimicrobial
therapy is in cases with severe ulceration, anterior chamber
involvement, impending or frank perforation, pediatric and
one eyed patients, postoperative cases, refractory ulcers
and associated endophthalmitis.
M. VanathI: What arc ynur vIcws nn cnmbInatInn
vcrsusmnnnthcrapyInbactcrIa!kcratItIs?
AnIta Panda: Monolherapy has lo le inilialed hrsl,
lo decrease epilheIiaI loxicily as conlinalion of drugs
nay induce epilheIiaI loxicily vhich nay aggravale lhe
preexisling condilion.
Al any inslance nonolherapy shouId le kepl in
nind. ul, al presenlalion if lhe uIcer is severe lhal
needs innediale lrealnenl vilh conlinalion of forlihed
cefazoIin and forlihed lolranycin eye drops, even lefore
cuIlure and sensilivily reporls,. Hovever, afler inilialion of
lhe epilheIisalion, il can le changed lo nonolherapy. Thal
neans in any case nonolherapy shouId le preferred as far
as possilIe.
M. 5rInIvasan: CurrenlIy ve have poverfuI
anliliolics eg: 4lh generalion ouroquinoIones lhal are
highIy effeclive againsl Cran posilive and Cran negalive
lacleriae. So I prefer nonolherapy if I knov lhe agenl.
eg: I use Moxioxacin againsl Iseudononas ralher lhan
conlinalion of genlanycin and ciprooxacin.
Jnhn Dart: We use nonolherapy al MoorheIds Lye
HospilaI. We conlinuaIIy assess resislance lo lhis and have
had no prolIens lo dale. Hovever ve do nol advocale il
for use oulside lhe UK, unIess lhe pallern of sensilivily of
lhe range of causalive organisns is veII eslalIished and
shovs no signihcanl resislance.
5amarBasak: Tncinica|icnsfcrmcnc|ncrapq.
- UIcer is peripheraI or nid-peripheraI (avay fron
lhe visuaI axis)
- SuperhciaI uIcer
- Size < 4 nn
- Wilhoul hypopyon
Tncica|cncicc.
- Ior suspecled Cran posilive - Moxioxacin or
Calioxacin eye drop.
- Ior suspecled Cran negalive organisn - Iorlihed
lolranycin 1.3 or Ciprooxacin eye drop.
Tncccm|ina|icn|ncrapqinc|ucs.
- Iorlihed CefazoIin 5 and Iorlihed lolranycin
1.3 eye drop
- Iorlihed CefazoIin 5 and Ciprooxacin eye
drop
The choice of anliliolic shouId le guided ly lhe
sensilivily pallern as veII as prevaIenl organisns
LIm LI: Conlinalion lopicaI lherapy vilh forlihed
anliliolics is preferalIe lo nonolherapy if lhe inhIlrale is
Iarger lhan 1 - 2nn
Bhaskar 5rInIvasan: I do nol prefer nono lherapy
excepl in case of a very snaII peripheraI uIcer. I vouId
use a lroad speclrun uoroquinoIone aIong vilh forlihed
cephaIosporin / aninogIycoside or lase il on cuIlure
sensilivily reporls.
Monotherapy may be advocated for small corneal
ulcerations and where the etiological organism and
sensitivity patterns are known. Larger corneal ulcerations
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by the culture sensitivity patterns and clinical response.
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combination therapy also need to be considered.
M. VanathI: Hnw nftcn dn ynu usc vnrIcnnazn!c In
ynur practIcc fnr managcmcnt nf funga! kcratItIs? Ynur
vIcwsnnrn!cnfvnrIcnnazn!cInfunga!kcratItIs?Wnu!d
ynuprcfcrtnaddtnpIca!antIbIntIcstnantIfunga!thcrapy
InacascnfsmcarpnsItIvcmycntIckcratItIs?
AnItaPanda: As discussed earIier, lopicaI voriconozoIe
1 is given for non responsive cases. If cosl is nol a
prolIen, il can le slarled as an iniliaI lherapy. Il is very
effeclive in nany cases of resislanl fungaI keralilis. As per
lhe roIe of anliliolics in nycolic keralilis, lhere is no need
if lhe cuIlure for lacleria is negalive.
M.5rInIvasan: If I gel Iusariun posilivily in cuIlure, I
aIvays use nalanycin. If nol responding even afler a veek
of lherapy as inpalienl lrealnenl lhen I viII svilch over lo
lopicaI voricanazoIe or anpholericin . VoriconazoIe is ny
second Iine. I do nol add anliliolics vilh anlifungaIs.
Jnhn Dart: We onIy use voriconazoIe for severe and
cIinicaIIy resislanl cases as aIlernalive lopicaI or oraI
lherapy. In viev of lhe resuIls of lhe recenl randonized
conlroIIed cIinicaI lriaI al Aravind Lye HospilaI, ve lhink
lhis is appropriale. We donl add lopicaI anlililoics in a
case of snear posilive fungaI keralilis unIess ve have good
reason lo leIieve lhere is poIynicroliaI infeclion vilh lolh
fungi and lacleria (vhich occurs in 1O of our cases).
5amar Basak: I an using lopicaI voriconazoIe in
approxinaleIy in 5O cases of fungaI keralilis and on a
reguIar lasis. Again in snaII ( < 4nn), superhciaI and off-
lhe axis uIcer - I an using il as nonolherapy. ul in severe
cases I an conlining il vilh anpholericin or nalanycin
depending upon vhelher lhe organisn is AspergiIIus or
Iusariun. We do nol gel cases of Candida in lhis region.
As nalanycin eye drop avaiIaliIily is nol a very consislenl,
I an nov nore conforlalIe vilh voriconazoIe.
Yes, ve prefer lo add a 4lh generalion ouroquinoIone
qid for 1O - 14 days. As I have nenlioned earIier lhal in our
region > 1O infeclious keralilis are of nixed infeclion.
LIm LI: VoriconazoIe is reslricled lo fungaI keralilis
nol responding lo slandard anlifungaI lrealnenl such as
nalanycin and anpholericin, and if lhe infeclion is severe
or has penelraled inlo lhe anlerior chanler.
Bhaskar5rInIvasan: Nalanycin is sliII lhe connonesl
anlifungaI lhal I vouId prescrile hovever in cases of deep
slronaI alscess or poslerior slronaI Iesions or fungaI
endophlhaInilis I vouId consider voriconazoIe lopicaIIy or
inlraslronaI/inlracaneraIIy. In cases of endophlhaInilis if
lhe Iiver funclion lesls are nornaI I vouId even consider
adding syslenic anlifungaI nedicalions. I prefer lo use
a singIe anliliolic even in nycolic keralilis lo prevenl
secondary lacleriaI infeclion, aIso quile a fev cases lhal ve
have seen are of nixed infeclion (lacleriaI & fungaI) so one
lroad speclrun lopicaI anliliolic is roulineIy prescriled.
The availability of voriconazole has broadened the
antifungal therapy arena in recent times. However most
prefer to use topical voriconazole as second line or in
refractory mycotic ulcerations. There seems to be a mixed
response on the use of antibiotics in mycotic keratitis.
Antibiotic therapy as an addendum to antifungal therapy
is recommended in mixed corneal infections.
M. VanathI: What arc ynu rccnmmcndatInns nn usc
nfIntracamcra!/Intrastrnma!amphntcrIcIn/vnrIcnnazn!c
InmanagcmcntnfmycntIckcratItIs?
AnIta Panda: When lhere are deep slronaI inhIlrales
or exudales in anlerior chanler lhal are nol responding lo
lhe lopicaI anlinycolic agenls, ve reconnend inlraslronaI
anpholericin / voriconazoIe for deep slronaI inhIlrales
and inlracaneraI for exudales in lhe anlerior chanler.
Iurlher, inlraslronaI roule is nore preferred lhan inlra
caneraI.
M. 5rInIvasan: In deep nycolic keralilis, vilh
epilheIiun inlacl, I vouId lry 5O nicrons inlra slronaI
voriconazoIe and repeal 3 - 4 lines if I nolice a favouralIe
response. Inlra caneraI is used vhen a TIK is done. Inlra
slronaI anlifungaIs under lopicaI anaeslhesia couId heIp in
deep slronaI and endolheIiaI pIaques.
Jnhn Dart: I have used inlraslronaI voriconazoIe on
lvo occasions and il resuIled in resoIulion of lhe keralilis,
lul al lhe expense of very severe corneaI and anlerior
chanler inannalion, vhich nighl have leen lhe resuIl
of an inannalory response lo a nassive kiII of lhe
fungus. I nov onIy use lhis as a Iasl Iine of lherapy lefore
corneaI lranspIanlalion. I have used inlracaneraI onIy once
and vilh success. In lhe UK ve depend on sludies and
guideIines fron our coIIeagues, in India and lhe Soulhern
USA, for fungaI keralilis as ve have so fev cases here.
5amarBasak:
- UIcers non-responsive lo nedicaI lherapy > 3
veeks of lherapy
- Thick hypopyon > haIf anlerior chanler
- Irofuse endolheIiaI exudales
- Deep IungaI alscess (epilheIiun heaIed)
LIm LI: InlracaneraI anpholericin is used
inlraoperaliveIy al lhe line of lherapeulic or leclonic
keralopIasly for lhe lrealnenl of severe fungaI keralilis.
I have nol used inlraslronaI anpholericin injeclions.
Reporls shov favoralIe resuIls in lhe use of inlraslronaI
anpholericin injeclions.
Bhaskar 5rInIvasan: I do use il in recaIcilranl cases
and cases nol responding lo rouline anlifungaI lrealnenl
vilh nalanycin. In case of a lherapeulic keralopIasly I
vouId roulineIy give inlracaneraI anlifungaI injeclion on
conpIelion of lhe surgery.
Intracameral / intrastromal antifungals are better
reserved for use of deep mycotic infections with intact
overlying epithelium. They are to be used with caution, as
intracameral injections may be associated with intense
anterior chamber reactions and secondary glaucoma.
M. VanathI: What Is ynur prcfcrrcd apprnach tn
acanthamncba kcratItIs managcmcnt? 5nmc practIcc
pcar!s..
AnItaPanda:
1. CIinicaI hndings
2. ConfocaI scanning lo docunenl lhe cysls
3. CuIlure on nulrienl agar pIale vilh L.coIi overIay
4. Slarl vilh IHM O.O2 eye drops 1 hourIy vilh
propanidine iselhionale O.1 eye drops 1 hourIy
5. If IHM nol avaiIalIe ve repIace vilh
ChIorhexidine O.O2 eye drops
6. When lhe keralilis slarls responding, and lhe
heaIing is evidenl lhe hourIy dosage is lapered.
7. Afler 3 lo 6 nonlhs vhen lhe uIcer conpIeleIy heaIs
anli-acanlhanoela drugs shouId le conlinued as
T.I.D dosage lo prevenl recurrence
M. 5rInIvasan: Use IHM or chIorhexidine. One
has lo lry for severaI veeks. RareIy I have lried lopicaI
ilraconazoIe.
Jnhn Dart: We have a very Iarge experience of
Acanlhanoela keralilis anounling lo severaI hundred
cases since lhe earIy 199Os
2
. Hovever in lrief ve slarl
lrealnenl, as descriled alove vilh IHM O.O2 and
Hexanidine O.1 hourIy for 5-7 days (as lhe innalure
cysls are nore susceplilIe for lhe hrsl fev days foIIoving
encyslnenl). We avoid using lopicaI sleroids for al Ieasl
2 veeks and nol al aII unIess lhe corneaI inannalion is
severe and nol resoIving. TopicaI sleroids can produce
a dranalic inprovenenl in cases if inlroduced afler 2
veeks of effeclive lopicaI lherapy vilh liguanides (IHM
or ChIorhexidine) +/- a dianidine (Iropanidine or
Hexanidine). The palienls are regarded as cured vhen
lhe signs of corneaI inannalion have resoIved for one
nonlh, afler sIov vilhdravaI of sleroids (if lhese have
leen necessary), and lopicaI anlianoelics are conlinued
for a nonlh afler sleroid vilhdravaI OR resoIulion of
inannalion. This nay le possilIe vilhin 6-8 veeks of
lhe slarl of lherapy, lul in olher cases lhis nighl require
sone nonlhs or Ionger. We use chIorhexidine O.O2 and
propanidine O.1 as second Iine agenls. Ior resislanl
cases, vhich is persislenlIy cuIlure posilive, ve use IHM
O.O6 drops or chIorhexidine O.2 drops vilh voriconazoIe
1 drops and oraI voriconazoIe. The evidence for lhe use
of voriconazoIe is poor and lhese reconnendalions nay
change.
Linlilis and scIerilis are oflen overIooked and are
lhe connonesl cause of pain and Ioss of lhe eye in our
experience. Linlilis is an earIy nanifeslalion, vhereas
scIerilis is forlunaleIy nuch Iess connon and usuaIIy
occurs 2-3 nonlhs fron lhe onsel of disease and is a poor
prognoslic sign. LxlracorneaI inannalion is VLRY
RARLLY due lo exlracorneaI invasion ly lhe organisn
lul is inslead a secondary innune response of uncerlain
aelioIogy, lhe sane appIies lo choriorelinilis. I reconnend
using syslenic non sleroidaI anli-inannalories (NSAIDS)
for lolh Iinlilis and scIerilis, ve use urliprofen lul
iluprofen nay vork as veII. If lhese are nol effeclive I lhen
inlroduce inlensive lopicaI sleroids. If lhese do no vork
ve use syslenic innunosuppressive lherapy, usuaIIy oraI
prednisoIone slarling al 8O ng oraI daiIy, and lapered over
2 nonlhs, logelher vilh oraI cicIosporin al 3.5 - 5.O ng/kg.
MycophenoIale can le used as an aIlernalive lo cicIosporin.
I donl reconnend keralopIasly unIess lhe disease
is cured lecause aloul 5O of cases lranspIanled suffer
recurrence of infeclion vilhin veeks, or a nonlh or lvo, of
a lranspIanl.
5amar Basak: As, Dianidines (Iropanidine
iselhionale) are nol freeIy avaiIalIe in India, liaguanides
are used as nonolherapy. I prefer ChIorhexidine O.O2
eye drop (prepared fron noulhvash - avaiIalIe freeIy in
chenisl shop).
- I prescrile lhis one hourIy for 48 hours round lhe
cIock, lhen lapered lo hourIy drops ly day for nexl
3 days, 2 hourIy afler 5 days for 3 lo 4 veeks. The
lrealnenl shouId le conlinued for 6 -12 nonlhs in
a 4 hourIy reginen afler one nonlh of heaIing of
lhe uIcer.
- I aIso add neosporin eye oinlnenl 5 lines daiIy for
3-4 veeks in severe cases.
- If lhe visuaI axis is invoIved - depending upon
lhe response - A lherapeulic IK done vilh oplicaI
grade lissue.
LImLI: Il is inporlanl lo have a high index of suspicion
especiaIIy in susceplilIe individuaIs such as conlacl
Iens vearers. Acanlhanoela keralilis is oflen nislaken
for dendrilic keralilis. As acanlhanoela is a faslidious
organisn and is oflen difhcuIl lo ollain a cuIlure posilive
resuIl, il is inporlanl lo direclIy pIale lhe corneaI scrape
onlo diagnoslic nedia such as non-nulrienl agar vilh
L coIi overIay. Laloralory experlise vilh experience in
idenlifying lhe organisn is aIso inporlanl.
Conlinalion lherapy vilh lroIene (propanidine)
and IHM (poIyhexanelhyIliguanide) eyedrops is
reconnended. The oulcone depends on lhe severily of lhe
infeclion, earIy superhciaI infeclions usuaIIy do very veII.
More eslalIished infeclions vilh slronaI invoIvenenl
nay le difhcuIl lo lreal vilh nedicalion aIone and usuaIIy
require proIonged nedicalion vilh signihcanl loxicily
issues such as epilheIIiopalhy. Unresponsive infeclions viII
require lherapeulic keralopIasly. I usuaIIy perforn deep
IaneIIar keralopIasly ralher lhan penelraling keralopIasly
if lhe Iesion has nol fuIIy penelraled lhe cornea. LaneIIar
keralopIasly preserves lhe hosl endolheIiun and resuIls in
a Iover incidence of grafl rejeclion and grafl allrilion.
Bhaskar5rInIvasan: I vouId slarl vilh lroIene group
of drugs (goIden eye drop) and IHM every hourIy aIong
vilh neosporin oinlnenl. In resislanl cases vouId consider
chIorhexidine.
Successful management of acanthamoeba keratitis
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acanthamoeba therapy. Treatment needs to be prolonged
for a period of at least 6 months beyond healing. Limbitis
and scleritis are poor prognostic indicators. Keratoplasty
results are poor in acanthamoeba cases. Lamellar
transplants might help in cases without deep involvement.
M. VanathI: What Is ynur npInInn nn thc rn!c nf
cn!!agcn crnss!InkIng In thc managcmcnt nf InfcctInus
kcratItIs?
AnItaPanda: Wilh ny personaI experience I found lhal
coIIagen crossIinking effeclive as an adjuncl in lacleriaI
keralilis, refraclory lo convenlionaI nedicaI lherapy. In
acanlhanoela keralilis aIso ve found il lo le effeclive, lul
in fungaI keralilis furlher sludies have lo le done lo cIearIy
reporl ils efhcacy. In viraI keralilis, sludies in Iileralure
slale lhal il aggravales lhe condilion for vhich so far ve
have nol inilialed lhe sane.
M. 5rInIvasan: I do nol do coIIagen crossIinking
lrealnenl, lul I have lrealed palienls having infeclive
keralilis foIIoving C3R. I have read fev arlicIes lried
in hunan and aninaIs and reconnended as adjuvanl
lrealnenl.
JnhnDart: I do nol see lhe ralionaIe for lhis in palienls
vilh severe disease, vhich is lolh usuaIIy deep (loo deep
lo le lrealed ly UV) and loo peripheraI (invoIving lhe
periIinlaI cornea) vhere lrealnenl nighl le expecled
lo cause slen ceII faiIure. Olher cases respond veII lo
convenlionaI lherapy.
I lhink a Iol nore sludy needs lo le done lo ensure
lhal lhis lherapy is safe and effeclive, and lo shov lhal lhe
polenliaI lenehls oulveigh lhe polenliaI risks.
5amarBasak:
- We are doing C3R lrealnenl in keraloconus
lo arresl ils progression. I have no experience
in lrealing nicroliaI keralilis vilh coIIagen
crossIinking.
- In coIIagen crossIinking ve use Iong vaveIenglh
UV ray (UV-A al 365 nn) and il does nol have
any gernicidaI aclivily. There is a prolaliIily of
slrenglhening lhe sofl cornea in corneaI uIcer if
lrealed vilh C3R ve use for keraloconus.
- OnIy shorl vaveIenglh UV rays (UV-C al 254 nn)
has laclericidaI, fungicidaI and veridicaI aclivily
lul ve do nol use lhal vaveIenglh in C3R.
LIm LI: SeveraI reporls shov good conlroI of lhe
infeclion vhen used in conjunclion vilh convenlionaI
anlinicroliaI lherapy.
Bhaskar5rInIvasan: lhe fev recenl reporls of lhe use
of coIIagen cross Iinkage for infeclive keralilis seens quile
an inleresling oplion lo nol onIy kiII lhe organisn lul
aIso lo prevenl slronaI neIls and perforalions aIIoving
a sulsequenl oplicaI penelraling keralopIasly lo le
perforned al a Ialer dale vhen lhe eye is quiel. Il seens lo
le a pronising lrealnenl oplion lul ve need lo conducl
nore cIinicaI sludies and vaIidale lhe resuIls vhich have
leen reporled so far.
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treatment in infectious keratitis are increasing in literature
in recent times. Our experience is still evolving and there
is need for more evidence to establish its role in aiding
resolution in infectious keratitis.
M. VanathI: Ynur npInInn nn thc usc nf In-vIvn
cnnfnca!mIcrnscnpyInthcdIagnnsIsandmanagcmcntnf
InfcctInuskcratItIs?
AnIta Panda: Though confocaI nicroscopy can
le heIpfuI in diagnosing lacleriaI, viraI, fungaI and
acanlhanela keralilis, as nany of lhe sinpIe diagnoslic
nodaIilies are avaiIalIe for lacleriaI, viraI and fungaI ve
depend on confocaI onIy for acanlhanoela keralilis lo
knov lhe disease progression or disease response lo lhe
lrealnenl.
M.5rInIvasan: Il adds lo your diagnoslic looIs and in
experls hands il gives nore specihc resuIls. Il is coslIy and
onIy lerliary cenlres nay have lhe access.
JnhnDart: I lhink lhis has leen a najor slep forvard in
diagnosis of fungaI and Acanlhanoela keralilis, hovever
lhe sensilivily and specihcily of lhis as a slandaIone
diagnoslic looI is reIaliveIy Iov in our hands
3
. If a case is nol
progressing as expecled lhen ve pursue a lissue diagnosis
ly cuIlure of scrapes and/or liopsies.
5amarBasak:
- I have no experience in lhe use of confocaI
nicroscopy and onIy in lerliary and inslilulionaI
IeveI is il possilIe lo diagnose and lreal sone cases
of nicroliaI keralilis vilh ils appIicalion.
- Il is usefuI especiaIIy, in suspecled Acanlhanoela
keralilis for denonslraling lhe cysl. Iresence
of hyphae in cases of hIanenlous fungi and
pseudohyphae in cases of Candida keralilis can
aIso le sonelines denonslraled ly confocaI
nicroscopy.
LIm LI: In vivo confocaI nicroscopy is usefuI in lhe
diagnosis of infeclions such as fungus and acanlhanoela
and viII expedile lhe lrealnenl of such infeclions. Il is aIso
usefuI in lhe noniloring of lhe efhcacy of lrealnenl.
Bhaskar 5rInIvasan: al lhis poinl of line lhe onIy
infeclive keralilis vhere il is very heIpfuI is acanlhanoela
keralilis resl of lhe infeclions il is nore of a research looI
lhe resoIulion need lo gel leller lefore ve can use il for
olher infeclive keralilis
The consensus on the application confocal microscopy
in the diagnosis of infectious keratitis is on its usefulness
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ulcers in their early stage. Accessibility and appropriate
expertise in its interpretation remain limiting factors.
M. VanathI: What arc thc cnmmnn typcs nf cnntact
!cns Induccd kcratItIs ynu cncnuntcr In ynur practIcc?
Hnw havc ynu mndIcd ynur practIcc pattcrn In thc
managcmcntnfthcscpatIcnts?
AnIta Panda: MechanicaI epilheIiaI defecls, chenicaI
epilheIiaI defecls, hypoxia reIaled nicroepilheIiaI
cysls are nore connon, foIIoved ly sleriIe inhIlrales
and Acanlhanoela keralilis, in conlacl Iens vearers.
Iseudononas infeclion is frequenl, fungaI infeclion is nol
rare.
We reconnend reguIar foIIov-up of lhe palienls
using conlacl Iens, and reguIar cIeaning of lhe Ienses vilh
slandard disinfecling soIulions.
M. 5rInIvasan: I have seen pseudononas infeclions.
HeaIlh educalion is lhe key lo prevenl CL reIaled infeclions.
I have never seen fungaI uIcer in conlacl Iens vearers in ny
hospilaI.
JnhnDart: We see lacleriaI, parlicuIarIy Iseudononas
spp., Acanlhanoela and hIanenlary fungaI infeclion
(usuaIIy Iusariun spp.). There is nov a high index of
suspicion of fungaI or anoelic keralilis in conlacl Iens
users vilh keralilis lhal is nol rapidIy resoIving vilh
lopicaI anliliolics OR lhal has an unusuaI appearance, and
a nore indoIenl course.
5amarBasak:
- Conlacl Iens induced nicroliaI keralilis is nuch
Iess connon in our region. We see nainIy
pseudononas keralilis anong CL vearers. RareIy,
ve see CL induced Acanlhanoela keralilis.
- ul ve see Iol of landage conlacl Iens (CL) vearer
is having lacleriaI keralilis. olh Iseudononas
and Nocardia keralilis. Ialienls non conpIiance,
Iack of reguIar CL change, sinuIlaneous use of
lopicaI sleroids - aII are inporlanl faclors.
- Iroper palienls educalion, educalion of generaI
ophlhaInoIogisl and oplonelrisls are very
inporlanl.
LIm LI: The connonesl vouId le Iseudononas
aeruginosa keralilis. CurrenlIy, lopicaI forlihed genlanicin
is sliII lhe hrsl Iine eye drops lhal I prescrile as nosl
connunily acquired Iseudononas aeruginosa keralilis is
sliII sensilive lo genlanicin.
Bhaskar 5rInIvasan: The connon conlacl Iens
keralilis ve encounler sliII is Cran posilive cocci ralher
lhan pseudononas keralilis. The cause for lhe keralilis
noslIy slenned fron non conpIiance vilh lhe cIeaning
and nainlenance issues and il vas reinforced lo lhe palienl.
In sone of lhe palienls vho vere sliII nol conpIianl ve
offered lhe oplion of refraclive surgery inslead of conlacl
Ienses.
Bacterial keratitis in a common complication
associated with contact lens wear besides Acanthamoeba
infections. Fungal keratitis has also been seen to affect
contact lens wearers. Contact lens induced keratitis needs
to be managed promptly and effectively. Proper counseling
of patients prior to commencement of contact lens wear
on proper contact lens wear and replacement schedules,
contact lens care, hygiene and sterilization goes a long
wear in effective prevention of corneal infections in lens
wear.
M. VanathI: What Is ynur cxpcrIcncc wIth pnst-C3R
trcatmcntInfcctInuskcratItIs?
AnIta Panda: I have nol encounlered any posl C3R
lrealnenl infeclious keralilis in any case of keraloconus
as I aIvays go for lransepilheIiaI lechnique. Hovever,
foIIoving convenlionaI epilheIiaI delridenenl lechnique
lhere are severaI reporls on Iileralure for vhich ve slriclIy
reconnend lransepilheIiaI nelhod for CXL in keraloconus.
M.5rInIvasan: I have lrealed 3 cases in lhe Iasl 2 years.
AII vere done eIsevhere. One Iosl lhe gIole and in lhe
olher, a nedicaI sludenl, I had lo do a 9nn lherapeulic IK
vhich vas fungaI lo save lhe gIole.
Jnhn Dart: We have seen one case of nycolacleriaI
keralilis. C3R lrealnenl is nol yel very videIy used in lhe
UK.
5amar Basak: No experience. The reason aIready
expIained.
LImLI: I have nol encounlered any posl CXL lrealnenl.
Bhaskar5rInIvasan: so far I have nol seen posl coIIagen
cross Iinkage infeclive keralilis.
Post C3R infectious keratitis a cause for serious
concern. With increasing reports in literature on bacterial
and fungal keratitis in Post C3R treatment cases,
ophthalmic physicians need to be well aware of this
condition which can result in severe ocular morbidity.
Transepithelial C3R treatment for keratoconus might be a
safer approach.
M.VanathI:WhatIsynurnpInInnnnthcuscnfg!uc
wIth bandagc cnntact !cns In managcmcnt nf InfcctInus
kcratItIs?
AnItaPanda: Il is heIpfuI in cases of infeclious keralilis
vilh snaII perforalion.
M. 5rInIvasan: Il is good oplion vhen you see
inpending perforalion or a liny perforalion Ieading lo al
chanler.
Jnhn Dart: I use lhis for aII palienls vilh snaII
perforalions lo aIIov lherapy lo conlinue and lo pernil
conlinued lrealnenl of lhe disease nedicaIIy unliI il has
resoIved. If lhe gIue lecones Ioose I renove il, as IooseIy
allached gIue is associaled vilh a high risk of secondary
keralilis. I reappIy gIue if necessary.
5amar Basak: There is dehnile roIe in sone cases of
infeclious keralilis: CynoacryIale gIue has an addilionaI
anli-nicroliaI properly. Il is very usefuI, Quick and a very
easy procedure.
2O l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
- Indicaled for perforalions (2nn or Iess) or
inpending perforalion
- CorneaI hsluIa vilh or vilhoul pseudocornea
fornalion. A posilive SeideIs lesl is very inporlanl
lo diagnose a nicro-Ieak.
- Does nol have nuch roIe in lrue DesceneloceIe.
The procedure can le perforned under lopicaI
aneslhesia. Air injeclion inlo lhe AC nay le required in
sone cases. Iirsl, dry lhe surface and led of lhe perforalion.
Afler, roughing lhe edges of lhe surrounding area, a lhin
hIn of adhesive using a 26-gauge disposalIe needIe is lo
le appIied. Upon drying, a CL is lo le pIaced.
LImLI: If aclive infeclion is presenl, hisloacryI gIue is
nol reconnended. Hovever, il can le used inlraoperaliveIy
lo aid in lhe surgery, for exanpIe in perforaled cases of
infeclive keralilis.
Bhaskar 5rInIvasan: CynoacryIale gIue and conlacl
Iens is a very usefuI looI in lhe hands of an ophlhaInoIogisl
especiaIIy vhen deaIing vilh a snaII perforalion or
inpending perforalions. il can heIp in deIaying or even
avoiding a penelraling keralopIasly in sone palienls.
The difhcuIly vilh lhe gIue is il is difhcuIl lo olserve
lhe progress/regress of lhe infeclion under lhe gIue. The
praclicaI lip for il vouId le lo go ahead vilh gIue if lhere
is al Ieasl sone evidence of resoIulion/scarring indicaling
lhal lhe lrealnenl is effeclive. A cIoser foIIov up vouId le
required in lhese palienls
Cyanoacrylate glue application with bandage
contact lens placement is recommended in cases of small
perforation with no active infection. Underlying rough
areas ensures better adhesion and longer stay on of the
glue aiding in resolution and hence removing the need for a
further surgical intervention. Glue application needs to be
performed deftly to achieve optimal results.
M. VanathI: Ynur cxpcrIcncc wIth pnst-LA5IK
kcratItIs.
AnIta Panda: I can say il is a reaI disasler. The
nanagenenl is Iike lhal of any olher infeclive keralilis. Il is
an ialrogenic uIcer. One nusl slop lhe lopicaI corlicosleroid
and lake care of ocuIar surface.
M.5rInIvasan: I had one case of fungaI infeclion in one
eye vilhin 2 days. Il vas A.avus and lrealed lhe palienl
for 4 nonlhs vilh anlifungaI, Nalanycin and Ialler vilh
cIolrinazoIe. The ap vas parlIy anpulaled. Has 6/24
vilh correclion I have lrealed fev palienls done eIsevhere,
aII vere pseudononas keralilis.
Jnhn Dart: IorlunaleIy snaII, lul I have seen lhis
caused ly lolh lacleriaI and nycolacleriaI infeclion.
5amar Basak: So far, I have nol encounlered any
palienl vilh Iosl LASIK keralilis.
LImLI: This is lhe nosl serious conpIicalion foIIoving
LASIK and aIlhough rare, palienls need lo le counseIed
of lhis possiliIily pre-operaliveIy. The infeclions can le
cIassihed as earIy, occurring vilhin 1-2 days of LASIK,
inlernediale, occurring lelveen 3-7 days and Iale, and
occurring afler 7 days. The IikeIy organisns for lhe
earIy infeclions incIude pseudononas aeruginosa, lhe
inlernediale ones IikeIy lo le gran posilive organisns and
Iale infeclions IikeIy nycolacleria or fungaI.
Risk faclors incIude lIepharilis, dry eyes, syslenic
condilions such as dialeles, and epilheIiaI defecls foIIoving
LASIK ap fornalion.
The lrealnenl is lo slop sleroids and connence
inlensive forlihed lopicaI lroad speclrun anilliolics such
as cephazoIin and genlanicin eye drops. Never generalion
uoroquinoIones such as noxioxacin eye drops can aIso
le used. Syslenic anliliolics shouId le slarled for severe
infeclions. If nycolacleriaI infeclion is suspecled, lopicaI
anikacin can le used. Consider ap irrigalion vilh
anilliolics.
Bhaskar 5rInIvasan: LuckiIy nol a Iol. I have seen
and lrealed a coupIe of palienls vilh posl LASIK viraI
slronaI reaclivalion of herpes keralilis and a coupIe
vilh alypicaI nycolacleriaI keralilis vhich responded
lo lopicaI lrealnenl vilh 4lh generalion uroquinoIone
and cephaIosporine. We needed lo Iifl lhe ap and coIIecl
lhe naleriaI for cuIlure sensilivily for lhe LASIK led and
under surface of lhe ap.
Iosl LASIK keralilis is lhe nosl feared of aII lhe
conpIicalions of LASIK procedure resuIling in vilh a vision
deliIilaling silualion necessilaling keralopIasly in lhe vorsl
scenario cases. Iroper asepsis, vilh parlicuIar allenlion lo
sleriIizalion and aulocIaving of LASIK inslrunenlalion
vouId le heIpfuI. Lfhcienl palienl counseIing and
posloperalive noniloring pIay an inporlanl roIe as veII.
Ironpl lherapy vilh oplinaI nicrolioIogicaI supporl goes
a Iong vay in effeclive lrealnenl of posl LASIK keralilis.
Reference
1.
NVPrajnac|a|.CcmpariscncfNa|amqcinanVcriccnazc|cfcr|nc
Trca|mcn|cf|unga|Kcra|i|is.ArcnOpn|na|mc|.2010,128(6).672-
678)
2.
Dar| ]KG, Sau P], Ki|ting|cn S. Acan|namcc|a |cra|i|is. iagncsis
an |rca|mcn| upa|c 2009. A pcrspcc|itc. Am ] Opn|na|mc| 2009
148(4).487-499
3.
Hau,S.C.,Dar|,].Kc|a|.(2010).Diagncs|icaccuracqcfmicrc|ia|
|cra|i|is ui|n in titc scanning |ascr ccnfcca| micrcsccpq. 8r ]
Opn|na|mc|94(8),982-987)
DOSCorrespondent
M.Vanathi
R
elinopalhy of Irenalurily (ROI) is a hlrovascuIar
proIiferalive disorder, vhich affecls lhe deveIoping
peripheraI relinaI vascuIalure of prenalure infanls. Iirsl
descriled ly Terry in 1942 as relroIenlaI hlropIasia,
1
ROI is unique in lhal il affecls an innalure, inconpIeleIy

vascuIarised relina. ROI is a prevenlalIe cause of lIindness
and renains one of lhe Ieading causes of visuaI Ioss in
chiIdren.
2
AIlhough lhe STOI ROI
3
lriaI has shovn lhal suppIenenlaI
oxygen does nol prevenl lhe progression of prelhreshoId
lo lhreshoId ROI, sludies supporl lhe nolion lhal lolh
hyperoxia and hypoxia seen lo le inporlanl faclors in lhe
palhogenesis of ROI, lheir effecls possilIy leing nedialed ly
vascuIar endolheIiaI ceII-grovlh faclor, vhich is produced ly
MuIIer ceIIs and aslrocyles of lhe deveIoping relina.
4
Wilh lhis rising rale of prenalurily and inproving survivaI,
lhe need for ongoing ROI screening, lrealnenl oplions, and
Iong-lern foIIov-up is grealer lhan ever. Recenl advances in
lrealnenl for ROI offer lhe pronise of inproved oulcones
and prevenlion of IifeIong vision Ioss.
Risk Factors
Amcng|nccrucia|ris|fac|crscfROParc
- irlh veighl
- CeslalionaI age
- Nunler of days oxygen adninislered
O|ncrris|fac|crsinc|uc
- MuIlipIe lirlhs
- Iood lransfusions
- Respiralory Dislress Syndrone (RDS)
- Sepsis
- Inlra VenlricuIar Henorrhage (IVH)
- Inlra Ulerine Crovlh Relardalion (IUCR)
- Vilanin L dehciency
- Anenia
- Seizures
Pathogenesis
NornaIIy, relinaI vascuIar deveIopnenl occurs in lvo phases
vherein phase 1 is independenl of vascuIar endolheIiaI
Rc.:.
Saurabh Arora
Parag K. Shah DN8,Saurabh Arora DN8,V. NarendranDN8,N. KalpanaDN8
Pcia|ricRc|inacOcu|arOncc|cgqDcpar|mcn|,Aratin|qcHcspi|a|
cPcs|graua|c|ns|i|u|ccfOpn|na|mc|cgq,Ccim|a|crc,Tami|Nau
grovlh faclor (VLCI) and occurs fron 8-21 veeks of felaI
deveIopnenl. SpindIe ceIIs (nesenchynaI precursor ceIIs)
appear around oplic disc region and lhen cords of spindIe
ceIIs advance lovards ora serrala, vhich differenliale inlo
capiIIaries, vhich sulsequenlIy deveIop inlo arlerioIes and
venuIes. Laler, phase 2 dependenl on VLCI occurs fron 22 lo
4O veeks of deveIopnenl in vhich proIiferaling endolheIiaI
ceIIs nigrale fron exisling lIood vesseIs lo forn nev
capiIIaries.
Figure 1: Schematic diagram of right eye (RE) and left
eye (LE) showing zones to describe location of disease
and clock hours to describe extent of ROP.
Figure 2: Fundus picture of RE showing stage 1
demarcation line (black arrows)
ROI aIso occurs in prenalure lalies exposed lo high oxygen
afler lirlh, vhich Ieads lo vaso-olIileralion and cessalion
of vesseI grovlh due lo dovn reguIalion of VLCI. When
oxygen exposure is reduced lhere is a palhoIogicaI reIease of
VLCI fron avascuIar relina lhal Ieads lo neovascuIarizalion.
Differenl aulhors have descriled differenl palhogenic
changes: IIynn el aI
5
descriled lhal injury lo lhe endolheIiun
of lhe deveIoping capiIIary neshvork is lhe prinary evenl.
Afler injury, lhe nesenchyne and nalure relinaI arleries
and veins, vhich survive, nerge lo forn nesenchynaI
areleriovenous shunls. This shunl is Iocaled al lhe junclion
of avascuIar and vascuIarised relina and represenls lhe
palhognonic Iesion of acule ROI. Ioos
6
has given lhe
concepl of vanguard and rearguard lo descrile lhe ceIIuIar
conponenls of lhe deveIoping relina and suggesled a
palhogenic nechanisn of ROI lased on il. According lo
hin, lhe vanguard or lhe anlerior conponenl conlains
spindIe ceIIs, vhich pIay a roIe in nourishing lhe innalure
relina. The rearguard conlains prinilive endolheIiaI ceIIs. As
lhe relina nalures, lhe endolheIiaI ceIIs forn cords, vhich
Ialer Iunenize and forn prinordiaI capiIIaries of lhe relina.
Il is fron lhe rearguard lhal lhe neovascuIarisalion of ROI
deveIops.
Classifcation
InlernalionaI CIassihcalion of Relinopalhy of Irenalurily
(ICROI) vas deveIoped in 1984 and Ialer nodihed in 1987
and 2OO5.
7,8,9
This cIassihcalion is lased on lhree cIinicaI paranelers:
Location of disease: 3 zones of relinaI invoIvenenl are
recognized, each of vhich is cenlered al lhe disc (Iigure 1).
a. Zcnc 1. Wilh disc as cenler and lvice lhe dislance fron
disc lo fovea, lhe circIe forned is zone 1. Il sullends an
arc of aloul 6O
O
l. Zcnc 2. exlends fron lhe peripheraI lorder of zone 1 lo
nasaI ora serrala and corresponding area lenporaIIy.
c. Zcnc 3 is lhe renaining lenporaI crescenl of relina
anlerior lo zone 2.
Extent of disease: nunler of cIock hours invoIvenenl
(Iigure 1).
Slaging of disease: dehned according lo degree of vascuIar
changes aIong vilh Iocalion in zone & exlenl in cIock hours
for docunenlalion.
a) Stage 1 - Demarcation line: Is a lhin, reIaliveIy al, vhile
and Iies vilhin lhe pIane of lhe relina lul is a dehnile
slruclure lhal separales lhe avascuIar relina anleriorIy
fron lhe vascuIarized relina posleriorIy. (Iigure 2).
l) Stage 2 Ridge: Is a haIInark of slage 2 ROI, arises in lhe
region of lhe denarcalion Iine, has heighl and vidlh and
exlends alove lhe pIane of lhe relina (Iigure 3).
c) 6WDJH ([WUDUHWLQDO EURYDVFXODU SUROLIHUDWLRQ
(EPF): Il exlends fron lhe ridge inlo lhe vilreous and is
conlinuous vilh lhe poslerior aspecl of lhe ridge (Iigure
4). Il is furlher suldivided inlo niId, noderale or severe
depending on lhe exlenl of LII inhIlraling lhe vilreous.
d) Stage 4 Partial retinal detachment: Slage 4 is divided
inlo parliaI relinaI delachnenl nol invoIving fovea, slage
4A (Iigure 5) and invoIving fovea, slage 4 (Iigure 6).
VisuaI prognosis of slage 4 is poorer lhan 4A.
e) Stage 5 Total retinal detachment: These are generaIIy
lraclionaI and nay occasionaIIy le exudalive. (Iigure 7)
VisuaI prognosis is lhe vorsl for slage 5 ROI.
f) Aggressive posterior ROP (AP-ROP): An unconnon,
rapidIy progressing, severe forn of ROI. If unlrealed,
il usuaIIy progresses lo slage 5 ROI. The characlerislic
fealures of AI-ROI are ils poslerior Iocalion, proninence
of pIus disease and lhe iII-dehned nalure of lhe
relinopalhy (Iigure 8). Il is olserved nosl connonIy in
zone I, lul nay aIso occur in poslerior zone II.
Plus disease: Il is an addilionaI sign indicaling lhe severily
of aclive ROI. This incIudes increased venous diIalalion
and arlerioIar lorluosily of lhe poslerior relinaI vesseIs
(Iigure 9) and nay Ialer increase in severily lo incIude iris
vascuIar engorgenenl, poor pupiIIary diIalalion (rigid pupiI)
and vilreous haze.
Pre-plus disease: Il is dehned as vascuIar alnornaIilies of
lhe poslerior poIe lhal is insufhcienl for lhe diagnosis of pIus
disease lul denonslrales nore arleriaI lorluosily and nore
venous diIalalion lhan nornaI (Iigure 1O).
Figure 4: Fundus picture of LE showing stage 3,
TKFIGDNCEMCTTQYUCPFGZVTCTGVKPCNDTQXCUEWNCT
proliferation (white arrows)
Figure 3: Fundus Picture of LE Showing Stage 2
'NGXCVGFTKFIGDNCEMCTTQYU
Screening strategies
When to screen?
The deveIopnenl of ROI correIales according lo lhe infanls
poslneslruaI age (geslalionaI age + posl nalaI age) ralher
lhan lhe line since lirlh (chronoIogicaI age).
As per reconnendalions ly Anerican Acadeny of
OphlhaInoIogy and Iedialrics and Associalion of Iedialric
OphlhaInoIogy and Slralisnus in 2OO6, iniliaI eye
exaninalion is lo le done ly 31 veeks poslnenslruaI age or
4 veeks of chronoIogicaI age vhich ever is Ialer.
1O
Hovever,
an easier vay lo renenler is lhal hrsl relinaI exaninalion
shouId le done ly hrsl nonlh of Iife.
Whom to screen?
Recenl reconnendalions ly Anerican Acadeny of
OphlhaInoIogy and Iedialrics and Associalion of Iedialric
OphlhaInoIogy and Slralisnus in 2OO6
1O
suggesl fundus
exaninalion for aII infanls vilh lirlh veighl (W) < 15OOg
or vilh geslalionaI age (CA) < 3O veeks and aIso for any
prenalure infanl veighing lelveen 15OO - 2OOO gns or CA
> 3O veeks vilh an unslalIe cIinicaI course leIieved lo le
al risk ly lhe allending pedialrician. UK guideIines slale
lhal lalies vilh geslalionaI age < 31 veeks or lirlh veighl <
15OOg shouId le screened for ROI.
Screening crileria fornuIaled according lo Indian scenario:
- AII infanls vilh W < 18OOg or CA < 34 veeks.
- AII infanls requiring suppIenenlaI oxygen or vilh
unslalIe neonalaI course feIl as high risk ly lhe allending
neonalaIogisl, irrespeclive of CA or W, shouId aIso le
screened. This is caIIed sickness crileria.
How to screen?
Screening is done in a lenperalure conlroIIed roon / nursery
in lhe presence of a neonaloIogisl, since such lalies are
susceplilIe lo hypolhernia, lradycardia, apneic episodes
and faII in oxygen saluralion. A relina speciaIisl or a pedialric
ophlhaInoIogisl does screening vilh lhe heIp of indirecl
ophlhaInoscope, +28/+2O D Iens, scIeraI depressor (vire
veclis) and aIphonso specuIun aIong vilh O.5 proparacaine
drops for lopicaI aneslhesia and haIf slrenglh lropicanide pIus
(O.4 lropicanide vilh 2.5 phenyIephrine) for pupiIIary
diIalalion. RecenlIy, a nev digilaI canera, Relcan is avaiIalIe
for screening vhich is a noliIe seIf-conlained syslen, has
inslanl & accurale docunenlalion and provides slale-of lhe
arl vide heId pedialric relinaI inaging (13O degrees).
Figure 5: Fundus picture of RE showing stage 4A partial
retinal detachment (black arrows) nasal to optic disc
CPFXKVTGQWUJGOQTTJCIGYJKVGCTTQYQXGTOCEWNC
Figure 6: Fundus picture of LE showing stage 4B
RCTVKCNTGVKPCNFGVCEJOGPVKPXQNXKPIVJGOCEWNC
(black arrows)
Figure 7: Fundus picture of RE showing total
retinal detachment
Figure 8: Fundus picture of RE showing AP-ROP.
Management pearls of ROP
When to treat?
Threshold disease: As per CRYO-ROI sludy,
11
is dehned as
Slage 3 in zone I or II invoIving > 5 conliguous or 8 cunuIalive
cIock hours vilh pIus disease. This vas lhe previous cul off
slage for lrealnenl.
Prethreshold Disease: LarIy Trealnenl ROI (LTROI) sludy
12
has revised lhe lrealnenl guideIines. This sludy proved lhal

earIier lrealnenl (Ire ThreshoId slage) has a leller oulcone.
They divide prelhreshoId ROI inlo
a. Tqpc 1 ROP cr Hign Ris| Prc|nrcsnc|. This is lhe nev
cul off for lrealnenl and is supposed lo le lrealed
innedialeIy.
i. Zone 1 any slage vilh pIus disease or
ii. Zone 1 slage 3 vilhoul pIus disease or
iii. Zone 2 slage 2 or 3 vilh pIus disease.
l. Tqpc2ROPcr|cuRis|Prc|nrcsnc|Discasc. These shouId
le considered for lrealnenl onIy if lhey progress lo lype
1 or lhreshoId ROI.
i. Zone 1 slage 1 or 2 vilhoul pIus disease or
ii. Zone 2 slage 3 vilhoul pIus disease.
How to treat?
IrincipIe is alIalion of lhe ischenic peripheraI relina slops
lhe reIease of angiogenic faclors. Tvo oplions are avaiIalIe:
Cryotherapy: MuIlipIe appIicalions are nade lo lreal enlire
avascuIar relina anlerior lo lhe ridge (Iigure 11). Hovever
cryolherapy requires generaI aneslhesia, has nore IocaI
conpIicalions Iike severe Iid edena and for zone I cases, lhe
cryo prole cannol reach posleriorIy lecause of lhe reslriclion
caused ly lhe conjunclivaI fornix.
Laser Photocoagulation: Il is a praclicaI aIlernalive afler lhe
advenl of indirecl Iaser deIivery syslen. The nain advanlages
are lhal il can le perforned under lopicaI aneslhesia,
syslenic and IocaI conpIicalions are nuch Iess conpared
lo cryolherapy, and il can le done as oul palienl procedure
(vilh aneslhelisl or neonaloIogisl slandly) and poslerior
relina in zone I cases can le lrealed easiIy (Iigure 12).
Laser or cryolherapy can onIy le done liII slage 3 ROI.
Managenenl of slages 4 and 5 is surgicaI and hnaI oulcone is
very poor for lhese slages.
Figure 12: Fundus picture of RE showing
laser scars (black arrows)
Figure 9: Fundus picture of RE showing
dilatation and tortuosity of posterior pole
XGUUGNUUKIPKH[KPIRNWUFKUGCUG
Figure 10: Fundus picture of RE showing pre
plus disease
Figure 11: Schematic diagram of fundus showing
multiple white cryo burns (black arrows) in
CXCUEWNCTTGVKPCCPVGTKQTVQTKFIGYJKVGCTTQY
Surgical treatment: Surgery is advocaled if Iaser or
cryolherapy is unsuccessfuI in prevenling progression lo
slage 4 or 5. SurgicaI oplions avaiIalIe are
|crs|agc4Acr48
a. ScIeraI luckIing
l. Lens sparing vilreclony
(Note: Vascu|ar|q inac|itc an s|a||c 4A ROP can cn|q |c
c|scrtc)
|crs|agc5.
c. Lenseclony + vilreclony
d. Open sky vilreclony
ROI nanagenenl doesnl end vilh Iaser or surgery. Once
lrealed, IifeIong foIIov up (yearIy) is nandalory. AII olher
prenalure infanls irrespeclive of having ROI yearIy foIIov
up liII lhe age of 5 years is advisalIe lo ruIe oul refraclive
errors (nosl connon), squinl and anlIyopia (Iazy eye).
Role of anti vascular endothelial growth factor (VEGF)
injections in ROP:
Il is very conlroversiaI, as VLCI is aIso needed for nornaI
vascuIarizalion of lhe relina lo le conpIeled. Thus anli
VLCI injeclions nay slop grovlh of nol onIy alnornaI nev
vesseIs lul aIso of lhe nornaI ones. Syslenic alsorplion of
lhese drugs nay cause vascuIar deveIopnenl deIay in olher
deveIoping organs. Thus currenlIy anli-VLCI injeclions are
used in ROI onIy vhen lhe slandard lrealnenl (vhich is
Iaser) faiIs and lhe disease progresses. Il is nol reconnended
as lhe hrsl Iine of lrealnenl.
Examination schedule
As per reconnendalions
1O
, lhe foIIoving scheduIe shouId le
foIIoved for exaninalion of lalies vho do nol need alIalive
lrealnenl:
a) One veek or Iess foIIov up
- Slage 1 or 2, zone 1 ROI
- Slage 3, zone 2 ROI
l) One lo lvo veek foIIov-up
- Innalure vascuIarizalion zone 1-No ROI
- Regressing ROI zone 1
c) Lvery lvo veek foIIov-up
- Regressing ROI zone 2.
d) Tvo lo lhree veek foIIov up
- Innalure vascuIarizalion zone 2-No ROI
- Slage 1 or 2, zone 3 ROI
- Regressing ROI zone 3
IoIIov-up exaninalions are carried oul liII conpIelion of fuII
relinaI vascuIarisalion.
Conclusion
A lvo-pronged approach is needed lo lackIe lhe energing
epidenic of lIindness due lo ROI in India, and lhis
viII require cIose coIIaloralion lelveen neonaloIogisls,
pedialricians and ophlhaInoIogisls. NeonaloIogisls can pIay
a pivolaI roIe in prevenling ROI ly reducing suppIenenlaI
oxygen excepl lo lhose lalies vho reaIIy need il. The use
of 1OO oxygen shouId le avoided. AII lalies receiving
oxygen shouId aIso le cIoseIy and conlinuousIy nonilored,
avoiding uclualions lhal are knovn lo le harnfuI. There
is aIso an increasing lody of evidence lhal Iover largel
oxygen saluralions are proleclive, even in very Iov lirlh
veighl infanls and noniloring shouId ain lo keep oxygen
IeveIs lelveen 83-93 and nol higher.
13,14
OphlhaInoIogisls
aIso pIay a key roIe in prevenling lIindness fron ROI, ly
underlaking reguIar, ongoing screening progrannes lo
delecl and lreal lype 1 prelhreshoId ROI. OphlhaInoIogisls
need lo deveIop evidence lased screening crileria reIevanl lo
lhe popuIalion of lalies. They are responsilIe for lo ensure
lhal aII lalies al risk of ROI needing lrealnenl are exanined.
In nany sellings in India lhis viII nean lhal Iarger, nore
nalure lalies shouId aIso le exanined lhan indicaled ly
screening guideIines deveIoped for use in lhe UK, USA,
Canada elc. As lalies vho have leen discharged as veII as
inpalienls need lo le exanined il is crilicaIIy inporlanl lhal
parenls undersland lhe need for lineIy exaninalion, and lhal
arrangenenls are nade for lhis eilher on lhe neonalaI unil, or
in an eye deparlnenl/hospilaI.
References
1.
Tcrrq T|. |x|rcmc prcma|uri|q an f|rc||as|ic ctcrgrcu|n cf pcrsis|cn|
tascu|arsnca|n|cnincacncrqs|a||inc|cns.|Prc|iminarqrcpcr|.Am]
Opn|na|mc|1942,25.203-204.
2.
Haa MA, Sci M, Sampaic MI, c| a|. Causcs cf tisua| impairmcn|
in cni|rcn. a s|uq cf 3,210 cascs. ] Pcia|ric Opn|na|mc| S|ra|ismus
2007,44.232240.
3.
Tnc STOP-ROP Mu||iccn|cr S|uq Grcup. Supp|cmcn|a| Tncrapcu|ic
Oxqgcn fcr Prc|nrcsnc| Rc|incpa|nq cf Prcma|uri|q (STOP-
ROP), a rancmizc ccn|rc||c |ria|. Primarq Ou|ccmcs. Pcia|rics
2000,105.295-310.
4.
|ic|cr A. Rc|incpa|nq cf prcma|uri|q. ac|ic|cgq. C|inica| Ris| 1997,
3.4751.
5.
||qnn ]T. Rc|incpa|nq cf prcma|uri|q. Pcia|ric C|inics cf Ncr|n
Amcrica1987,34.1487-1516.
6.
|ccs RY. Rc|incpa|nq cf prcma|uri|q. Pa|nc|cgic ccrrc|a|icn cf c|inica|
s|agcs.Rc|ina.1987,7.260276.
7.
Tnc Ccmmi||cc fcr |nc c|assifca|icn cf Rc|incpa|nq cf Prcma|uri|q.
An in|crna|icna| c|assifca|icn fcr rc|incpa|nq cf prcma|uri|q. Arcn
Opn|na|mc|.1984,102.1130-1134.
8.
|CROP Ccmmi||cc fcr |nc c|assifca|icn cf |a|c s|agcs cf rc|incpa|nq
cf prcma|uri|q, ||. Tnc c|assifca|icn cf rc|ina| c|acnmcn|. Arcn
Opn|na|mc|.1987,105.906-912.
9.
An in|crna|icna| ccmmi||cc fcr |nc c|assifca|icn cf rc|incpa|nq
cf prcma|uri|q. Tnc in|crna|icna| c|assifca|icn cf rc|incpa|nq cf
prcma|uri|qrctisi|c.ArcnOpn|na|mc|.2005,123.991-999.
10.
Scc|icncnOpn|na|mc|cgq,AmcricanAcacmqcfPcia|rics,Amcrican
Acacmq cf Opn|na|mc|cgq, Amcrican Assccia|icn fcr Pcia|ric
Opn|na|mc|cgq an S|ra|ismus. Scrccning cxamina|icn cf prcma|urc
infan|sfcrrc|incpa|nqcfprcma|uri|q.Pcia|rics2006,117.572576.
11.
Crqc|ncrapq fcr Rc|incpa|nq cf Prcma|uri|q Cccpcra|itc Grcup.
Mu||iccn|cr |rai| cf crqc|ncrapq fcr rc|incpa|nq cf prcma|uri|q.
Prc|iminarqrcsu||s.ArcnOpn|na|mc|.1988,106.471-479.
12.
|ar|q Trca|mcn| cf Rc|incpa|nq cf Prcma|uri|q Cccpcra|itc Grcup.
Rctiscinica|icnsfcr|nc|rca|mcn|cfrc|incpa|nqcfprcma|uri|q.Arcn
Opn|na|mc|2003,121.1684-96.
13.
Irign|KI,SamiD,Tncmpscn|,Ramana|nanR,]cscpnR,|arzatani
S. A pnqsic|cgic rcucc cxqgcn prc|ccc| ccrcascs |nc incicncc cf
|nrcsnc|rc|incpa|nqcfprcma|uri|q.TransAmOpn|na|mc|Scc2006,
104.78-84.
14.
Cncu |C, Irign| KI, Sc|a A. Can Cnangcs in C|inica| Prac|icc
Dccrcasc |nc |ncicncc cf Sctcrc Rc|incpa|nq cf Prcma|uri|q in Vcrq
|cu8ir|nIcign||nfan|s?Pcia|rics2003,111,339-345.
Rc.:.
Ramesh KC Gupta
Ramesh KC Gupta, Kadri Venkatesh
San|araNc|nra|aqa
Gass classify ERM on the basis of the clinical appearance
Gradc 0- CeIIophane nacuIopalhy- il is conpIeleIy
lransIucenl nenlrane lareIy visilIe cIinicaIIy.
There is no dislorlion of foveaI conlour and relinaI lraclion
Gradc1- CrippIed ceIIophane nacuIopalhy-
- Conlraclion or shrinkage of lhe LRM
- Menlrane causes an irreguIar vrinkIing of inner relinaI
surface
- If vrinkIing is severe enough, para nacuIar vesseIs nay
le puIIed lovards lhe fovea in a corkscrev fornalion.
This is seen veII on IIA
NornaIIy cysloid nacuIar edena, relinaI henorrhage,
exudales and relinaI pignenl epilheIiaI dislurlances are
alsenl.
Gradc2- MacuIar pucker
- Menlrane viII le lhick and opaque, especiaIIy for lhose
nenlranes vhich deveIop foIIoving relinaI delachnenl
surgery
L
pirc|ina| mcm|ranc (|RM) uas frs| cscri|c |q |uancff
in 1865. Il is an avascuIar, hlro ceIIuIar nenlrane lhal
proIiferales on lhe inner surface of lhe relina and produces
various degrees of visuaI inpairnenl. Incidence of LRM is
nuch varialIe according lo IearIslone incidence of LRM 6.4
in 1OOO conseculive rouline eye exans in palienls oIder lhan
age 5O, vilh 2O leing liIaleraI. Ioos el aI reporled incidenl
as 2 in palienl over 5Oyr of age and 2O in palienl over 75
yr. of age. Idiopalhic LRM is usuaIIy associaled vilh parliaI
or conpIele IVD in 75 of lhe cases.
Pa|nc|cgq-LRM is a hlrous proIiferalive nenlrane Iike
slruclure consisls of ceIIs inlerspersed vilh in exlraceIIuIar
nalrix. CeIIuIar conponenls depend on lhe elioIogy of LRM.
Extracc!!u!armatrIx Cc!!s
CoIIagen CIiaI ceIIs incIuding
nicrogIia,
Laninin MIIer ceIIs and hlrous
aslrocyles
Tenascin LpilheIiaI ceIIs fron lhe RIL
Iilroneclin Iood-lorne innune ceIIs
Vilroneclin nacrophages, Iynphocyles,
Thronlospondin elc. neulrophiIs, hlrocyles, and
nyohlrocyles
Classifcation of ERM
Etiological classifcation
Idiopathic Epiretinal membrane
AIso knovn as sinpIe LRM found in 2 of popuIalion over
5O yr. of age and in 2Oof 75 yr. of age.
Secondary Epiretinal membrane- Membrane develops
secondary to other ocular pathology
CcmmcnCauscinc|ucs-
- OcuIar inannalory diseases
- RelinaI vascuIar diseases
- Trauna
- Chronic ocuIar diseases
- InlraocuIar surgery (nosl inporlanl is cryolherapy,
endoIaser procedure, YAC capsuIolony, YAC II,
calaracl exlraclion elc.)
Figure 1: Grade 0 ERM (cellophane maculopathy)
- IuII lhickness puckering of lhe nacuIa nay le presenl
aIong vilh edena, snaII henorrhages, collon-vooI spols
and sonelines IocaIized relinaI delachnenl
- Vision viII le severeIy deliIilaled vilh VAs oflen vorse
lhan 6/6O
Foos et al classifcation I periretinal membranes
A. SinpIe LRM
. Inlernediale LRM,
C. ConpIex LRM (syn. IVR)
Simple ERM-
- IncidenlaI
- No conlraclion fealures
- No associaled ocuIar condilions
Intermediate ERM
- Have conlraclion fealures and pignenl
- Thicker lhan sinpIe LRM
- Syn. As Idiopalhic LRM, sponlaneous surface vrinkIing
relinopalhy, idiopalhic nacuIar pucker, CeIIophane
nacuIopalhy, MacuIar pucker, Recurrenl nacuIar
pucker, Surface vrinkIing relinopalhy, IrerelinaI
nacuIar hlrosis, Iignenled prerelinaI nenlranes
Complex Periretinal Membrane: These are lhe IVR changes
around relina and in vilreous.
C|inica|Prcscn|a|icn - LRM can affecl any parl of relina, il goes
unnoliced vhen invoIving lhe peripheraI relina, synplon
produces onIy vhen il invoIves lhe nacuIa or perinacuIar
area.
Iaclors responsilIe for synplons in LRM are -
- Menlrane lhickness
- RelinaI dislorlion and lraclion lecause of LRM
- Micro delachnenl of poslerior poIe
- MacuIar edena
Ialienl usuaIIy presenl vilh graduaI painIess Ioss of vision
aIong vilh nelanorphopsia.
Melanorphopsia is lhe nosl lroulIesone prolIen for lhe
palienl.
Figure 2: Grade 1 ERM (crippled
cellophane maculopathy)
Figure 3: Grade 2 ERM (macular pucker)
Figure 4: Amsler grid
Figure 5: M-chart
MonocuIardipIopiaisaIsoanolherlroulIesonecondilionfor
palienls.
On funds exaninalion lhere nay le a lhin sheen Iike
nenlrane lo a lhick opaque nenlrane, associaled vilh
vascuIar lorluosily, slraighlening and dragging of vesseI
lovardlhefovea.
There nay le snaII inlrarelinaI henorrhage, cyslic changes
innacuIa,collonvooIspolsandnacuIaredena.
Cause of Visual Loss in ERM
- Conlraclion of lhe LRM causes eIevalion of lhe nacuIa
vhichcausesfaIIinvision
- RelinaI dislorlion and lraclion is responsilIe for lhe
nelanorphopsiaandnonocuIardipIopia.
- MacuIar edena
Investigations
Ams|crgri-Ilischarlusedlononiloringlhenelanorphopsia
oljecliveIy.
M-charl- lhis charl oljecliveIy scoring lhe nelanorphopsia
lasedonlhevisuaIangIesullendedonlhefovea.Ilconlains
19IineslhalvariesfronaconlinuousIinelolhelrokenIines
invhichaIinenadeupofanunlerofdolsseparaledfron
each olher ly equaI dislance, al each slep increnenl in Iine
visuaI angIe increase ly O.1 degree, each Iine have a specihc
nunleraccordinglolhevisuaIangIe,palienlisaskedlosee
lhecharlal3Ocndislanceandaskvhelherheseeaslraighl
IineordislorledIine,allheIinevhenpalienlseelheslraighl
Iineisconsideredasscoreofnelanorphopsia.TeslshouIdle
doneinverlicaIandhorizonlaIneridianlolh.
LikeMcharl,IHIlasedonhyperacuilycharlingnayaIso
usefornelanorphopsiascoring.
IIA- IIuorescein angiography can shov relinaI vascuIar
lorluosily, slraighlening and Ieakage, as veII as cysloid
nacuIar edena aIso heIps in excIuding lhe olher relinaI
palhoIogies lhal nay cause LRM fornalion.
OCT- nosl vilaI invesligalion for LRM heIps in diagnosis,
decision naking and pIanning for surgery for LRM. We Iook
forlhefoIIovingparanelerleforeundergosurgery.
Figure 6: FFA images of ERM showing tortuosity of major vessels along with dragging of
vessels toward macula, straightening of vessels
Figure 7: Oct images shows cellophane maculopathy,
and thick ERM with cystic spaces under fovea and sub
TGVKPCNWKF'4/YKVJXKVTGQOCEWNCTVTCEVKQP
1. CML
2. VMT
3. LocaIizing lhe edge and lhickesl parl of LRM
4. To differenliale IaneIIar nacuIar hoIe fron pseudo hoIe.
Lamc!!armacu!arhn!c Macu!arpscudnhn!c
LMH resuIls fron an alorled process of nacuIar MacuIar pseudo hoIe is lhe resuIl of cenlripelaI
hoIe fornalion or lhe resuIl of chronic CML LRM conlraclion
AvuIsion/Ioss of parl of lhe nacuIar lissue No Ioss of nacuIar lissue
The edges of lhe foveaI defecl are usuaIIy spIil ly a VerlicaIizalion of lhe foveaI sIope
cIefl lelveen lhe inner and ouler relina on lhe OCT
Decrease in cenlraI foveaI lhickness NornaI lo alove nornaI cenlraI foveaI lhickness
Has poor response lo surgery Inprovenenl in vision seen afler surgery
Figure 8:1%6KOCIGUUJQYKPIVJGNQUUQHHQXGCN
architecture and helps in localizing the site for
separation of ERM (arrow)
MuIlifocaI LRC - Il heIps in oljeclive assessnenl of funclionaI
slalus of relina.
Microperinelry- nicroperinelry is SLO lased device lhal
neasures poinl lo poinl relinaI sensilivily, heIps lo quanlify
lhe relinaI funclionaI slalus nay heIp in pIanning of surgery
and have sone prognoslic signihcance.
Diferential diagnosis of ERM
- VilreonacuIar lraclion syndrone
- Ironinenl nacuIar Iighl reex in young palienls
- Cysloid nacuIar edena (pseudophakic or aphakic)
- Idiopalhic nacuIar hoIe
- Ccm|incHamar|cmacf|ncRc|inaanRP| - Seen in Iale
chiIdhood or earIy aduIlhood vilh slralisnus, lIurred
vision or nelanorphopsia. Deep greyish pignenlalion
vilh superhciaI vhilish gIiosis resuIling in relinaI
vrinkIing and vascuIar lorluosily. The Iesion is usuaIIy
juxlapapiIIary, peripapiIIary or al lhe poslerior poIe.
Large Iesions nay cause 'dragging of lhe disc or nacuIa.
Management
MedicaI nanagenenl- lhere is no roIe of any nedicaI
nanagenenl in cases of idiopalhic LRM. Iirsl lo ruIe oul lhe
olher ocuIar causes of LRM fornalion, if any lreal lhen hrsl
lhen go for surgery.
Surgical Management
Case Selection
There is no sulslilule for elhicaI, sound cIinicaI judgnenl in
naking lhe decision lo operale.
- Lxlenl of visuaI Ioss, nelanorphopsia
- VisuaI needs
- Slalus of lhe olher eye
- Age
- Duralion
- Iresence of olher ocuIar diseases
Surgery
LRM renovaI vilh/ vilhoul ILM peeIing
Surgical Principles
Outside-in method
- Michener popuIarized il.
- Searching for an edge increases lhe risk of naking a
relinaI lreak.
Figure 10: Combined hamartoma of
retina and RPE
Inside-out method
- IeeIing is inilialed ly surface grasping lhe LRM vilh
end-opening forceps
- MicrovilreorelinaI (MVR) lIade vas earIier reconnended
lo nake a sIil in lhe apparenl cenlre of lhe LRM, lul lhis
is nol necessary vilh lhe AIcon 2O-gauge or 25-gauge
(preferred) DSI forceps
- If lhere is a parlicuIarIy slrong allachnenl lo lhe relina,
do nol puII avay fron lhe sile of allachnenl
- IuII lhe nenlrane fron around lhe allachnenl 36O
degrees and lhen over lhe lop of il.
Iine end-grasping forceps vhich proved lo le quile effeclive
for peeIing epinacuIar nenlranes (LMM) as veII as inlernaI
Iiniling nenlrane (ILM) during nacuIar hoIe surgery.
Scissors Segmentation
- Segnenlalion originaIIy uliIized verlicaI scissors
vhich require exlending lhe Iover scissors lIade inlo lhe
space or polenliaI space lelveen lhe nenlrane and lhe
relina.
- If lhere is no space, lhis aclion nay resuIl in learing lhe
relina vilh lhe Iover lIade.
- Segnenlalion resuIls in so-caIIed epicenlers of LRM
renaining on lhe relinaI surface.
- ResiduaI LRM has cul edges conlaining lransecled vesseIs
vhich oflen lIeed. Iood cIols lhen lridge lelveen
epicenlers of LRM, crealing a sulslrale for recurrenl gIiaI
proIiferalion.
Scissors Delamination
- In conlrasl, deIaninalion neans lhal lolh lIades of
horizonlaI scissors are inlroduced lelveen lhe LRM
and lhe relina.
- DeIaninalion resuIls in aII LRM leing renoved fron lhe
relina, reducing posl-operalive gIiaI proIiferalion as veII
as reducing residuaI relinaI eIevalion and dislorlion.
Vitreous Cutters for ERM
Vilreous cullers can le used lo renove LRM allached al
discrele poinls lo lhe surface of convoIuled relina in dialelic
lraclion delachnenl and siniIar cases.
Power-Actuated Scissors and Forceps
An advanlage of povered scissors and forceps is lhal
inadverlenl novenenl caused ly hngerlip aclualion is
avoided.
Ineunalic - povered verlicaI scissors. LIeclricaIIy povered
nenlrane peeIer culler (MIC)
S|a|i|isc Surgcrq- inanuaI surgery vilh high culling rale,
using ChandeIier Iighl source aIong vilh Ier-uorocarlon
Iiquid used for slaliIizalion of uidic forces on relina.
Enzymatic Vitrectomy
- IIasnin is a prolease vilh enzynalic aclion on Ianinin
and hlroneclin, vhich is Iocaled lelveen lhe poslerior
vilreous corlex and lhe inlernaI Iiniling nenlrane of lhe
relina.
- Il vas nol effeclive in lhe lrealnenl of LRM as such, lul
resoIved VMT successfuIIy, and inproving lhe visuaI
acuily and reIeasing lhe relinaI lraclion vilhoul lhe need
for associaled pars pIana vilreclony
Visual Results
- More lhan 85 of lhe palienls inproved lvo Iines or
grealer in visuaI acuily.
- Il is noled lhal lhose vilh grealer visuaI Ioss (1/2OO lo
5/2OO) preoperaliveIy inprove lo approxinaleIy lhe
2O/2OO IeveI posloperaliveIy.
- Those in lhe 2O/2OO region preoperaliveIy lypicaIIy
relurn lo lhe 2O/5O lo 2O/6O IeveI posloperaliveIy.
- Those vilh 2O/5O vision preoperaliveIy usuaIIy relurn lo
lhe 2O/2O lo 2O/25 IeveI.
Complications
- RelinaI lreaks= 5-7
- Rhegnalogenous RD=5
- IVR recurrence
- CML= 3
Figure 9: microperimetry showing decreased
HQXGCNUGPUKVKXKV[
34l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
Offers Anterior Segment Fellowship to young
ophthalmologists (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 hospital
activities.
Free accomodation in hospital campus and a salary
of IRs. 38,000 to 46,000 (Stepwise increase) will be
provided.
Please apply with C.V. including details of surgical
experience and two references with phone/mobile
numbers.
For detail, please see our website www.erec-p.org
AppIylo:
Dr.A.HcnnIg
SagarnalhaChoudharyLyeHospilaI,Lahan
LnaiI:sceherec-p.org
Eastern Regional Eye Care
Programme, NEPAL
IahanfyeHospitaI&iratnagarfyeHospitaI
With more than 84,000 operations annually
No.ofposts :2
QuaIications : MS or MD in
Ophthalmology.
Remuneration : IRs. 40,000 IRs. 1,00,000
depending upon skills.
Accommodation : well furnished free
accommodation will be
provided within the hospital
compound situated 180
km from Lucknow, near
Rupaidiha, Distt. Bahraich
UP at Nepalganj, Nepal.
Recently passed candidates are also encouraged
to apply. The hospital is a professionally managed
organization of repute with more than 93,000 OPDs
and 12,000 surgeries in 2010. Interested candidates are
requested to send their application with complete bio-
data through Email or Fax soonest possible to:
The Hospital Manager
NepaINetra)yotiSanghan|e,
Fateh-Bal Eye Hospital, Nepalganj, Nepal.
Email: kverma@wlink.com.np; Fax: 00977 81 522737
Tel: 00977 81 520598
Ophthalmologist Required
at a reputed Eye Hospital
- ITMH
- LndophlhaInilis= O.7
- Recurrence of LRM= 1.6
- RelinaI vhilening
- Calaracl
Clinical Pearls
- CIassify lhe LRM inlo idiopalhic or secondary
- Ierforn OCT lo assess CIT and lo ruIe oul LMH
- Case seIeclion for surgery
- Ireoperalive VisuaI acuily of 2O/4O and alove have a
higher prolaliIily of allaining 2O/2O vision afler surgery.
- Ireoperalive CIT of Iess lhan 4OO nicrons is associaled
vilh a higher prolaliIily of allaining 2O/2O vision afler
surgery.
- ILM peeIing aIong vilh LRM renovaI causes no
difference in lhe posl op analonicaI and funclionaI
oulcone.
- ILM peeIing reduces recurrence of LRM.
References
1.
Diagncsiscfmacu|arpscucnc|csan|amc||armacu|arnc|cs|qcp|ica|
ccncrcncc|cmcgrapnq|c||accmnacucnincc|a|.Amjcpn|na|mc|2004
nct,138(5).732-9
2.
Trca|mcn|cfcpirc|ina|mcm|ranc.anupa|cfsm|inga|n|uc|ncng
|cngmcj2005,11.496-502
3.
|ntc|tcmcn| cf m||cr g|ia| cc||s in cpirc|ina| mcm|ranc fcrma|icn
anrcas|ringmanncpc|cruiccmanngracfcsarcnc|incxpcpn|na|mc|
(2009)247.865883
4.
Tncimpac|cfcp|ica|ccncrcncc|cmcgrapnqcnsurgica|ccisicnma|ing
in cpirc|ina| mcm|ranc an ti|rccmacu|ar |rac|icn iana t. || a||rans
amcpn|na|mc|scc2006,104.161-166
5.
Prccpcra|itcfac|crsprcic|itccfpcs|cpcra|itcccima|tisua|acui|q>1.0
fc||cuingsurgica||rca|mcn|fcriicpa|niccpirc|ina|mcm|rancnircsni
|uni|a|a,|csnia|ia|c,jirc|inu|aua,|cnjinisnia.C|incpn|na|mc|3fc|
2011.
6.
|icpa|nic macu|ar cpirc|ina| mcm|ranc surgcrq an i|m pcc|ing.
ana|cmica| an func|icna| cu|ccmcs ccns|an|in j. Pcurnaras, anmc
cmaran, an icannis |. Pc|rcpcu|cs scminars in cpn|na|mc|cgq, 26(2),
4246,2011
7.
|nzqma|ic ti|rcc|cmq |q in|rati|rca| au|c|cgcus p|asmin injcc|icn as
ini|ia| |rca|mcn| fcr macu|ar cpirc|ina| mcm|rancs an ti|rccmacu|ar
|rac|icnsqnrcmciaz-||cpism1,uacncp2,ccrtcrac3,garcia-c|pccn
s4,sa|cm2,quijaaa5,rcmcrcfj6arcnscccspcf|a|mc|2009,84.91-
100
8.
|icpa|nic cpirc|ina| macu|ar mcm|ranc an ca|arac| cx|rac|icn.
ccm|inctcrsusccnsccu|itcsurgcrq|riccugasamjcpn|na|mc|.2010
fc|,149(2).302-6.
9.
|qcpa|i| cpirc|ina| mcm|ran|t nas|a|ara san|ra| rc|ina fcn|siqcnunun
mi|rcpcrimc|ri i|c cgcr|cniri|mcsi
T
he inlernaI Iiniling nenlrane (ILM) is lhe innernosl
Iayer of lhe relina. Il is a 2.5 n, hne nuIliIaninar
senilransparenl nenlrane vhich forns a loundary lelveen
lhe vilreous and lhe relina and is a parl of lhe vilreorelinaI
inlerface. Il has a snoolh inner (vilreaI) surface and an
irreguIar relinaI surface, in cIose apposilion vilh lhe pIasna
nenlrane of lhe MuIIer ceIIs. In facl lhe ILM derives fron
lhe MuIIer ceIIs and acls as a lasaI nenlrane for lhen
The ILM pIays a key roIe in lhe palhogenesis of various
vilreorelinaI inlerface diseases in lhe nacuIa. Under
palhoIogicaI condilion, lhe ILM acls as lhe scaffoId for hlrin
and nicrohlrolIasls lo nigrale. Since lhese nicrohlrolIasls
have conlracliIe properlies, lhey produce vrinkIing of lhe
nenlrane, vhich aIlers lhe foveaI surface and signihcanlIy
reduces visuaI acuily. MacuIar hoIes are caused vhen lhis
conlraclion produces langenliaI lraclion. Recenl sludies have
suggesled lhal lhe ILM has a nain roIe in lhe deveIopnenl
and resislance lo lrealnenl of diffuse dialelic nacuIar
edena, as il lhickens aInosl lhree lines ils nornaI size. Il
aIso pIays an inporlanl parl in nacuIar edena secondary lo
cenlraI relinaI vein and lranch vein occIusion.
Indications for ILM Peeling
ILM IeeIing is nov used in lhe surgicaI lrealnenl of various
nacuIar diseases and has proven lo le effeclive in analonicaI
and funclionaI inprovenenls.
Macu|ar Hc|c - ILM peeIing vas inlroduced for nacuIar
hoIe surgery and is nov videIy accepled as il inproves
cIosure rales.
1
ILM peeIing renoves langenliaI lraclion
and guaranles renovaI of vilreonacuIar lraclion, residuaI
poslerior vilreous corlex and any epirelinaI nenlrane lhal
nighl le presenl. ILM peeIing nighl aIso pronole gIiaI repair
ly inducing IocaI expression of grovlh faclors.
2
An addilionaI roIe for ILM peeIing is increasing relinaI
conpIiance ly approxinaleIy 5O so lhe invard-direcled
surface lension force fron a gas lullIe can aInosl
innedialeIy reapproxinale lhe inner nargins of lhe hoIe
|pirc|ina|Mcm|rancs(Primarqanscccnarq) - An ILM peeIing
in epirelinaI nenlrane surgery ensures conpIele renovaI
of lhe epirelinaI nenlrane and produces a reduclion in
recurrence rales as lhe scaffoId for ceII proIiferalion is
renoved. An addilionaI lenehl is eIininalion of residuaI
slriae lherely, producing leller visuaI oulcones and fasler
inprovenenl. Il has leen reconnended lhal ILM peeIing
le perforned afler siIicone oiI renovaI lo prevenl Iale
posloperalive conpIicalion such as secondary nacuIar
pucker.
Rc.:.
Tinku Bali Razdan
Tinku Bali Razdan MS,|RCS
Vi|rccrc|ina|Ccnsu||an|,Dcp||cfOpn|na|mc|cgq,SirGangaRamHcspi|a|,NcuDc|ni
Cnrcnic Macu|ar Ocma - Iars pIana vilreclony vilh ILM
IeeIing is done for 'chronic refraclory diffuse dialelic
nacuIar edena (DML)
4,5
chronic posl surgicaI cysloid nacuIar
oedena and nacuIar oedena secondary lo vein occIusive
diseases such as cenlraI relinaI vein occIusion or lranch relinaI
vein occIusion
6,7,8
. ILM peeIing reduces langenliaI lraclion,
slinuIales gIiosis vhich in lurn, causes lhe conlraclion of lhe
relinaI Iayers vilh a sulsequenl decrease in lhe exlraceIIuIar
spaces. ILM peeIing aIso faciIilales diffusion of lIood and
uid fron lhe relina inlo lhe vilreous cavily.
Vi|rccmacu|ar |rac|icn sqnrcmc - The ILM is generaIIy
lhickened in lhese cases. ILM peeIing, in addilion lo Iars
pIana vilreclony (IIV), resuIls in good analonicaI and
visuaI oulcones.
Prcmacu|arSu|||MHacmcrrnagc - In condilions vhere lIood
dissecls lhe ILM fron lhe nerve hlre Iayer (eg. VaIsaIva
relinopalhy, relinaI arlery nacroaneurysn, Tersons
syndrone ) IIV vilh ILM peeIing, foIIoved ly aspiralion of
lhe underIying lIood gives good resuIls.
Op|ic isc pi| macu|cpa|nq - AnecdolaI reporls have leen
pulIished descriling palienls vilh oplic pil nacuIopalhy in
vhon allening of lhe nacuIar delachnenl and inprovenenl
in lhe nacuIar funclion (in lerns of visuaI acuily and pallern
eIeclrorelinogran) vas achieved foIIoving IIV vilh ILM
peeIing and posloperalive gas lanponade.
9
Technique of ILM Peeling
The surgicaI lechnique for ILM peeIing is denanding in
lerns of line and skiII. ILM is a lransparenl slruclure and
peeIing lecones easier afler seIeclive slaining of ILM vilh
a vilaI dye. Indocyanine green (ICC) vas one of lhe hrsl
dyes used for ILM peeIing. Hovever, ils use has recenlIy
decIined due lo an increasing nunler of reporls of ils loxic
effecl on lhe relinaI pignenl epilheIiun (RIL) and gangIion
ceIIs
1O
. Trypan lIue appears lo le safe for inlraocuIar use, lul
il slains lhe ILM very fainlIy and is used for LRM slaining.
In recenl years, riIIianl lIue C (C) has lecone lhe agenl
of choice for slaining lhe ILM. Il appears lo have no relinaI
loxicily in hunans, is easy lo use and seIecliveIy slains lhe
ILM exlreneIy veII, naking ils renovaI easy
11,12
.
The following are the salient steps in ILM peeling
PVD induction - Irior lo ILM renovaI a slandard pars pIana
vilreclony (IIV), incIuding delachnenl and renovaI of lhe
poslerior hyaIoid, is perforned. ConpIele renovaI of lhe
poslerior hyaIoid during IIV is inporlanl lo eIininale any
possilIe scaffoIding for ceIIuIar proIiferalion and sulsequenl
relinaI lraclion.
Staining of ILM - Once lhe poslerior hyaIoid has leen
delached and renoved, lhe ILM is slained lo inprove ils
visuaIizalion. Ior slaining lhe dye used is riIIianl lIue C,
vhich cones under lhe lrade nane of riIIianl IeeI ( IIuoron/
Ceuder, Cernany) or OculIue IIus (AuroIal, India).
(Iigure 1) Aloul O.5 nI of lhe dye is injecled over lhe nacuIa
vilh a 23- or 25-gauge slraighl cannuIa (Iigure 2). There is no
need of perfoning a uid air exchange. Hovever lhe infusion
cannuIa shouId le pul off during dye injeclion lo prevenl ils
dispersion. Afler a 3O second vail, lhe dye is renoved ly
aclive aspiralion and ve can proceed lo lhe acluaI peeIing of
lhe nov lIue slained ILM.
Visualization - Afler conpIeling IIV, IVD induclion and
slaining, vilh a vide angIe vieving syslen one shouId
svilch lo a disposalIe high-resoIulion conlacl Iens lo gel a
high-dehnilion viev of lhe nacuIa. Very high nagnihcalion
is nol reconnended. Make sure lo Iover lhe lenperalure of
lhe operaling lhealre lo prevenl fogging of lhe Iens.
The Iighl source nusl le adjusled avay fron lhe fovea in an
angIed nanner lo nininize gIare and phololoxicily.
Starting manoeuvre - The lasic conponenls of ILM renovaI
are crealing an edge, visuaIizing lhe ap and renoving lhe
nenlrane. This hrsl ap nusl le nade lenporaIIy al Ieasl
lvo disc dianelers oulside lhe parafoveaI zone, diagonaIIy
paraIIeI lo lhe axons and avoiding lhe papiIIonacuIar lundIe
and Iarge relinaI vesseIs.
The lvo lasic peeIing lechniques are-
A|if|anpcc||ccnniquc - A separale inslrunenl (MVR lIade,
Tanos dianond-dusled nenlrane scraper (Synergelics),
26-g needIe vilh lenl leveIed edge, or a relinaI pick) is
used lo creale a lreak in lhe ILM foIIoved ly peeIing of lhe
nenlrane vilh end-grasping forceps
8Pincnanpcc||ccnniquc- Lnd grasping ILM forceps aIone are
used lo pinch and peeI an unvioIaled ILM. (Iigure 3)
We use AIcon 25-g disposalIe ILM end-grasping forceps
vhich has an exceIIenl gripping pIalforn and heIps lo
nainlain good conlroI of lhe nenlrane (Iigure 4). We prefer
lhe pinch and peeI lechnique as lhis lechnique is safer , does
nol cause unnecessary relinaI surface danage and does nol
require a change of inslrunenls. The Lckardl ILM forceps
(Dulch OphlhaInic USA) can aIso le used for lhis purpose. If
a henorrhage deveIopes aIong lhe pinch Iine or gralling of
lhe ILM edge is unsuccessfuI, lhe nanoeuvre can le repealed
eIsevhere.
Maculorrhexis - Once lhe ILM edge is crealed, a snaII anounl
of dye can le reinjecled, especiaIIy near lhe crealed edge, lo
aIIov slaining of lolh sides of lhe ILM ap, providing good
visuaIizalion for sulsequenl peeIing. Iorceps are lhen used
lo renove lhe ILM in a circuIar novenenl, siniIar lo lhal
seen during crealion of a capsuIorrhexis. The free edge of lhe
ILM is grasped and il is peeIed, sIovIy and circunferenliaIIy
vilh a nuIlipIe grasp-and-peeI lechnique vilh nininaI
louch lo lhe underIying relinaI Iayers. Il is cruciaI lo grasp
lhe proxinaI edge (lhe edge nearesl lo lhe relina surface) of
lhe ap and lo guide lhe novenenl avay fron lhe relina,
il is aIso inporlanl nol lo lear lhe ap and hnish lhe peeI in
one slrip. As peeIing progresses, il lecones easier lo idenlify
lhe slained ILM fron lhe naked relinaI surface vhich lurns
sIighlIy vhile afler ILM renovaI due lo niId axonaI oedena.
(Iigure 5).
In sone cases, lhe ILM is fragiIe and lends lo lear. In such a
case lhe edge of lhe sonelines sliII adherenl ILM has lo le
re-engaged. Sonelines disseclion nay have lo le reinilialed
in lhe opposile direclion. The ILM is usuaIIy renoved fron
an area exlending lo lhe vascuIar arcades. The dianeler of lhe
nacuIorrhexis nusl incIude lhe area lelveen lhe arcades lo
reIease lhe nechanicaI lraclion (Iigure 6).
Quile oflen, superhciaI, pelechia-Iike henorrhages occur
during ILM renovaI, lecause lhe ILM inserls direclIy onlo
lhe superhciaI relinaI vesseIs, vhich are devoid of inner
nerve hler Iayer. These do nol appear lo le of any cIinicaI
consequence.
Figure 1: Brilliant Blue G Dye
Figure 2:$TKNNKCPV$NWGF[GKPLGEVGFQXGTOCEWNCTCTGC
Figure 3:2KPEJKPIOCPQGWXTGYKVJ+./(QTEGRUVQ
get the initial edge
Surgery is hnished ly perforning a uid-air exchange and
depending on lhe palhoIogy, injeclion of gas inlo lhe vilreous
cavily.
Special Surgical Considerations
ILM peeIing requires perfecl aIignnenl of lhe forceps lIades
al lhe lip vhich cannol le nainlained vilh reusalIe looIs or
reuse of disposalIe forceps. SnaIIer 23-gauge and 25-gauge
forceps are nore vuIneralIe lo danage during cIeaning and
upside-dovn lo cover lhe nacuIar hoIe (inverled ILM ap
lechnique). This lechnique inproves lolh lhe funclionaI and
analonic oulcones in surgery for Iarge, Iong slanding hoIes
In cases of diffuse dialelic nacuIar oedena (DML), lhe
adhesion of lhe ILM lo lhe nacuIa is slronger and lhe
nanipuIalion nusl le nore deIicale. Repealed slaining nay
le needed. The Tanos dianond-dusled scraper nay have lo
le used lo peeI slrong adhesive ILM, parlicuIarIy in cases of
DML and young palienls.
Figure 7(b):4GUKFWCN+./KUPQVRWNNGF
HQTEGHWNN[DWVTGOQXGFYKVJVJGEWVVGT
(a)
(b)
Figure 4(a):+./2GGNKPI(QTEGRU4(b):/CIPKGF
XKGYQHHQTEGRUVKR
Figure 5:+./2GGNKPICTQWPFOCEWNCTJQNGYKVJ
multiple grasp- and - peel technique
Figure 6: The Maculorrhexis should extend between
VJGXCUEWNCTCTECFGU
Figure 7(a):4GUKFWCN+./CVVCEJGFVQGFIGQH
macular hole
sleriIizalion. Therefore lo ollain precision, il is advisalIe
lo use eilher fresh disposalIe forceps or disposalIe lips on
handheId forceps for every case.
The ILM shouId aIvays le peeIed lovards and never fron
lhe nacuIar hoIe, lo avoid enIargenenl of lhe hoIe. If sone
residuaI ILM naleriaI is allached lo lhe nacuIar hoIe edge,
il is inporlanl lhal il is nol puIIed forcefuIIy lecause lhe
nacuIar lissue nay le lorn radiaIIy. The lesl approach is lo
cul il vilh lhe vilreclony culler (Iigure 7a & l) or curved
scissors.
In case of Iarge hoIes (>4OO n), inslead of conpIeleIy
renoving lhe ILM , a rennanl allached lo lhe nargins of lhe
nacuIar hoIe is Iefl in pIace. This ILM rennanl is lhen inverled
cf pars p|ana ti|rcc|cmq ui|n in|crna| |imi|ing mcm|ranc rcmcta| in
ia|c|icmacu|arccma.Rc|ina.2007,27(5).557566.
6.
Raszcus|a-S|cg|ins|a M, Gczc| P, Cisicc|i S, Micna|cus|a Z,
Micna|cus|i],Naurcc|i].Parsp|anati|rcc|cmqui|n||Mpcc|ingfcr
macu|ar ccma scccnarq |c rc|ina| tcin ccc|usicn. |ur ] Opn|na|mc|.
2009,19(6).10551062.
7.
Manc|ccrn MS, Nrusimnactara RK. |n|crna| |imi|ing mcm|ranc
pcc|ingfcrcccmprcssicncfmacu|arccmainrc|ina|tcinccc|usicn.a
rcpcr|cf14cascs.Rc|ina.2004,24(3).348355.
8.
Arai M, Yamamc|c S, Mi|amura Y, Sa|c |, Sugauara T, Mizuncqa
S. |ffcacq cf ti|rcc|cmq an in|crna| |imi|ing mcm|ranc rcmcta|
fcr macu|ar ccma assccia|c ui|n |rancn rc|ina| tcin ccc|usicn.
Opn|na|mc|cgica.2009,223(3).172176.
9.
|sni|aua K, Tcrasa|i H, Mcri M, c| a|. Op|ica| ccncrcncc |cmcgrapnq
|cfcrcanaf|crti|rcc|cmqui|nin|crna||imi|ingmcm|rancrcmcta|ina
cni|ui|ncp|iciscpi|macu|cpa|nq.]pn]Opn|na|mc|.2005,49.411
3.
10.
|crcnczM,ScmfaiG,|ar|asA,Kctacs|,c|a|.|unc|icna|asscssmcn|
cf|ncpcssi||c|cxici|qcfinccqanincgrccnqcinmacu|arnc|csurgcrq.
Am]Opn|na|mc|2006,142.765-770.
11.
|naia H, Hisa|cmi T Gc|c T, Ha|a Y, c| a|. Prcc|inica| intcs|iga|icn
cf in|crna| |imi|ing mcm|ranc s|aining an pcc|ing using in|rati|rca|
8ri||ian|||ucG.Rc|ina2006,26.623-630.
12.
|naiaH,Hisa|cmiT,Ha|aY,c|a|.8ri||ian|||ucGsc|cc|itc|qs|ains
|ncin|crna||imi|ingmcm|ranc.Rc|ina2006,26.631-636.
In cases of nacuIar pucker, peeIing lolh lhe ILM and lhe
overIying LpirelinaI nenlrane (LRM) logelher is possilIe
using lhe sane lechnique. If lhe LRM is separaled fron lhe
ILM, dye slaining can le repealed.
In nyopic eyes vilh fuII-lhickness nacuIar hoIe associaled
vilh relinaI delachnenl, ILM peeIing can le difhcuIl
due lo lhe increased relinaI noliIily around lhe hoIe. In
order lo perforn ILM renovaI in lhese cases a lullIe of
perurocarlon Iiquid can le used lo slaliIize lhe relina
aiding lhe ILM peeIing.
Complications
Connon conpIicalions IikeIy reIaled lo ILM peeIing incIude-
1. Minor relinaI edena and haenorrhages- usuaIIy resoIve
sponlaneousIy vilh no knovn pernanenl danage
2. IaracenlraI scolonas - usuaIIy asynplonalic. Caused
due lo nechanicaI lrauna lo lhe nerve hler Iayer
3. MacuIar edena.
4. Ialrogenic eccenlric fuII lhickness nacuIar hoIes
5. SulnacuIar haenorrhage
Table 1
IndIcatInnsnfILMPcc!Ing
- MacuIar HoIes
- LpirelinaI Menlranes
- Chronic MacuIar Ldena
- VilreonacuIar lraclion
- Sul ILM Haenorrhage
Table 2
Advanlages Of riIIianl Iue C Dye
- Non loxic lo relina
- Ready lo use (No reconslilulion needed)
- SeIeclive slaining of ILM
- No phololoxicily
- Iasl acling
- Does nol require uid-air exchange
References
1.
Va|uc cf in|crna| |imi|ing mcm|ranc pcc|ing in surgcrq fcr iicpa|nic
macu|arnc|cs|agc2an3.arancmiscc|inica||ria|.Cnris|cnscnUC,
KrcqcrK,Sancr8c|a|.8r]Opn|na|mc|.2009,93(8).1005-15.
2.
Tcgnc||cD,GraninR,Sanguinc||iG,c|a|.|n|crna||imi|ingmcm|ranc
rcmcta|uringmacu|arnc|csurgcrq.Opn|na|mc|cgq2006,113.1401-
1410.
3.
Aras C, Arici C, A|ar S, c| a|. Pcc|ing cf in|crna| |imi|ing mcm|ranc
uring ti|rcc|cmq fcr ccmp|ica|c rc|ina| c|acnmcn| prctcn|s
cpimacu|ar mcm|ranc fcrma|icn. Gracfcs Arcn C|in |xp Opn|na|mc|.
2009,247(5).619623.
4.
Har||cq K|, Smiq I|, ||qnn HI ]r, Murraq TG. Pars p|ana
ti|rcc|cmqui|nin|crna||imi|ingmcm|rancpcc|ingfcria|c|icmacu|ar
ccma.Rc|ina.2008,28(3).410419.
5.
Yanqa|i A, Hcrczcg|u |, Cc|i| |, Ncnu|cu A|. |cng-|crm cu|ccmcs
SITUATION VACANT
For
OPTHALMOLOGIST
For 60 bedded Modren Eye
Hospital [Estd 1992]
Contact/Send CV to:
GANGA MATA EYE HOSPITAL
Sapat Rishi Link Road
HARIDWAR-249410
Fax: 0133-4260175
M: 09412931046
Email-gmeh_hdr@indiatimes.com
I
oslerior capsuIar ruplure (ICR) is one of lhe connon
conpIicalions during phacoenuIsihcalion
1-3
. ICR vilh
vilreous proIapse and lhe nucIeus sliII in lhe capsuIar lag
is an inpending silualion for nucIeus drop. As a prevenlive
slep il is usuaI for lhe calaracl surgeon lo exlend lhe corneaI
incision and deIiver lhe nucIeus
4-6
. Lens gIide or Viscoal
assisled Ievilalion has aIso leen done lo renove lhe nucIear
fragnenls
8
. Anolher nelhod is lo enuIsify lhe nucIeus in
lhe anlerior chanler vilh Iov ov rale and vacuun. In lhis
lechnique, ve have used lhe foIdalIe inlraocuIar Iens (IOL) as
a scaffoId for prevenling lhe nucIeus drop vilhoul exlending
lhe incision.
Surgical Technique
When lhere is a poslerior capsuIe ruplure vilh lhe nucIeus in
lhe lag, an anlerior chanler (AC) nainlainer is inlroduced
(Iigure 1). Anlerior vilreclony is done vilh lhe vilreclony
culler lo renove lhe vilreous proIapsed in lhe anlerior
chanler. WhiIe doing lhis an AgarvaI gIole slaliIisalion
road (Kalena, USA), pushes lhe fragnenl avay fron lhe ICR
lhus prevenling lhe nucIeus fron faIIing dovn. A foIdalIe
IOL is lhen injecled via lhe exisling corneaI vound and is
noved leIov lhe nucIeus. The Ieading haplic of lhe IOL
is posilioned in lhe suIcus and lhe lraiIing haplic is pIaced
jusl oul of lhe incision (Iigure 2). The nucIeus fragnenl is
lhen renoved vilh lhe vilreclony culler or a phaco prole
depending on lhe densily of lhe nucIeus (Iigure 3). Once lhe
C....c
Amar Agarwal
Dhivya Ashok KumarMD,Amar AgarwalMS,|RCS,|RCOp|n
Dr.Agarua|s|qcHcspi|a|an|qcRcscarcnCcn|rc,19Ca|ncra|Rca,Cncnnai
vhoIe nucIeus is renoved, lhe relained corlex is lhen cIeaned
vilh lhe vilreclony culler vilh genlIe aspiralion (Iigure 4).
The olher haplic of lhe IOL is lhen posilioned in lhe ciIiary
suIcus (Iigure 5 and 6) and lhe AC nainlainer is renoved.
Il is easier lo nanipuIale lhe IOL ly pIacing one haplic alove
lhe iris. The non doninanl hand adjusls lhe olher oplic haplic
Figure 1: Posterior capsular rupture during
RJCEQGOWNUKECVKQPQHVJGPWENGWU
Figure 2:(QNFCDNG+1.CUCUECHHQNF
RTGXGPVUVJGPWENGWUFTQR
Figure 3:(QNFCDNG+1.RQUKVKQPGF
in the ciliary sulcus
junclion so lhal lhe IOL is veII cenlered vhiIe enuIsifying
lhe nucIeus (Iigure 7-12).
Discussion
Ioslerior capsuIar ruplure (ICR) is knovn lo occur al any
slage of phacoenuIsihcalion
3
. When il happens vilh lhe
nucIeus sliII Iefl lo enuIsify, excess nanipuIalion can cause
exlension of lhe ICR. The ain of any nelhod al lhis slage
is lo prevenl lhe nucIeus fragnenl fron dropping inlo
lhe vilreous. The chances of nucIeus drop increases vilh
increasing size of lhe ICR and vilreous Ioss. Though a
snaII fragnenl vhich descends inlo lhe vilreous is Iefl for
olservalion, Iarge nucIeus fragnenls aIvays require surgicaI
renovaI
9,1O
. NucIeus drop can induce vilrilis and nacuIar
edena lherely affecling lhe lesl correcled vision
1O
. Moreover
a second surgery for relrieving lhe dropped nucIeus again
can cause addilionaI lrauna lo lhe eye. Hence il is seIdon
leller lo prevenl lhe conpIicalion fron happening ly proper
nanagenenl of lhe ICR.
Though lhere have leen lechniques perforned lo prevenl
nucIeus fragnenl fron descending inlo lhe vilreous afler
inlraoperalive ICR, lhis IOL scaffoIding nelhod has nol
leen reporled earIier. Conversion of phacoenuIsihcalion lo
Figure 4:+1.YGNNEGPVGTGFCVVJGGPF
of the procedure
Figure 5:(QNFCDNG+1.RQUKVKQPGFKPVJG
ciliary sulcus
Figure 6:+1.YGNNEGPVGTGFCVVJGGPFQH
the procedure
Figure 7: Nucleus in AC
Figure 8:+1.+PLGEVGFYKVJJCRVKECDQXGVJGKTKU
exlra capsuIar calaracl exlraclion (LCCL)
4,5
is done vhen a
Iarge nucIeus is sliII Iefl. Sone surgeons prefer lo use lhe Iens
gIide lo deIiver lhe nucIeus. In lolh lhe condilions, corneaI
Figure 12:2%+1.KPUWNEWU
Figure 9:+1.CEVUCUCUECHHQNF0QVGVJGPQPFQOKPCPV
JCPFWUKPICFKCNGTVQJGNREGPVGTVJG+1.
Figure 10:0WENGWUGOWNUKGF
Figure 11: Haptic placed in sulcus
vound exlension is required and lhis can increase lhe risk
of posl operalive sulure induced aslignalisn. Anolher vay
is lhe nucIeus renovaI ly phaco sandvich nelhod
6
, vhere
a veclis and a spaluIa are used. Hovever lhe incision in a
phaco sandvich is scIero corneaI and requires exlension.
In eyes vilh nucIeus dispIaced in lhe anlerior vilreous,
poslerior Viscoal assisled Ievilalion
7
is done foIIoved ly
nucIeus enuIsihcalion vilh phacoprole alove a lrinned
sheels gIide
8
afler vound exlension. In lhe IOL scaffoId
lechnique, lhe vound renains cIear corneaI and lhere is
no vound exlension. The foIdalIe IOL acls as lhe vilreous
larrier and vorks Iike an arlihciaI poslerior capsuIe. Since
one haplic is kepl al lhe incision sile lhe IOL posilion can le
readiIy adjusled if lhe nucIeus rolales in lhe anlerior chanler
and lhe chances of IOL drop is aIso nol lhere as lhe haplic is
conlroIIed fron lhe incision sile. In aII lhe 3 eyes ve did nol
encounler vilrilis or endophlhaInilis. There vas no Ioss of
lesl correcled vision in any of lhe eyes.
When conpared lo an open vound (afler exlension), ICR
during phacoenuIsihcalion is associaled vilh a reIaliveIy
Iov incidence of vilreous Ioss lecause lhe seIf seaIing snaII
cIear corneaI vound provides conlroI of ocuIar inlegrily. This
nainlains lhe anlerior chanler and inlraocuIar pressure,
discouraging forvard novenenl of lhe vilreous, vhich
vouId occur in lhe presence of an "open gIole" as in LCCL.
Summary
Avoiding ICR is lhe goaI of every calaracl surgeon. If a
lear occurs, nanagenenl lechniques and skiIIs are required
for prevenling furlher conpIicalions. LarIy recognilion of
poslerior capsuIar ruplure conlined vilh prevenlion of
coIIapse of lhe anlerior chanler nay prevenl exlension of
lhe lear, forvard novenenl of lhe vilreous and dispIacenenl
of lhe Iens posleriorIy. Here in lhis lechnique, lhe anlerior
chanler is nainlained ly sIov infusion, forvard novenenl
of lhe vilreous is prevenled ly lhe IOL scaffoId and lhe
nucIeus fragnenl drop is slopped ly lhe IOL vhich acls as
a physicaI larrier. Thus, ve favor lhis nev IOL scaffoIding
lechnique in ICRs vilh non enuIsihed noderale lo sofl
nucIeus during phacoenuIsihcalion. Hovever, in cases of
hard calaracl conversion lo LCCL is ideaI.
References
1.
Vcjaranc ||, Tc||c A. Pcs|cricr capsu|ar rup|urc. |n Amar Agarua|.
Pnacc Nign|marcs, Ccnqucring ca|arac| ca|as|rcpncs, S|ac| |nc, 2006,
USA253-264.
Advertisers Name Page No.
M/s. KLB Instruments 1,84
M/s. Abott Medical Optics 2,6,42-43
M/s. Alcon Laboratories 22,28,41,49
M/s. Appasamy Associates 35,44
M/s. Epsilon Eye Care Pvt. Ltd. 50-51
M/s. Carl Zeiss 36,67
M/s. National Industrial Co. 58,81
M/s. Pharmatak 8
M/s. Allergan India 52
M/s. Medica International 74
M/s. Raymed 70
M/s. Technolas 77
M/s. Biomedix 4
M/s. Centre For Sight 10
M/s. Metro System 64,68-69
M/s. Venus Surgitech 78
M/s. Biocover Laboratories 82
M/s. NRI Vision Care Pvt. Ltd. 83
DOS Times Index
2.
Vajpaqcc R8, Snarma N, Daa T, Gup|a V, Kumar A, Daa VK.
Managcmcn| cf pcs|cricr capsu|c |cars. Surt Opn|na|mc|. 2001 Maq-
]un,45(6).473-88
3.
Gim|c| HV, Sun R, |crcnscuicz M, Ancrscn Pcnnc |, Kama|
A.|n|racpcra|itc managcmcn| cf pcs|cricr capsu|c |cars in
pnacccmu|sifca|icn an in|raccu|ar |cns imp|an|a|icn. Opn|na|mc|cgq.
2001Dcc,108(12).2186-9,iscussicn2190-2
4.
Daa T, Snarma N, Vajpaqcc R8, Daa VK. Ccntcrsicn frcm
pnacccmu|sifca|icn |c cx|racapsu|ar ca|arac| cx|rac|icn. incicncc,
ris| fac|crs, an tisua| cu|ccmc. ] Ca|arac| Rcfrac| Surg. 1998
Nct,24(11).1521-4
5.
Prasa S, Kama|n GG. Ccntcr|ing frcm pnacccmu|sifca|icn |c |CC|. ]
Ca|arac|Rcfrac|Surg.1999Apr,25(4).462-3.
6.
Tna||cS,RajuVK.Pnaccsanuicn|ccnniquc.]Ca|arac|Rcfrac|Surg.
1999Aug,25(8).1039-40
7.
CnangD|,Pac|arR8.Pcs|cricrassis|c|cti|a|icnfcrnuc|cusrc|ricta|
using Viscca| af|cr pcs|cricr capsu|c rup|urc. ] Ca|arac| Rcfrac| Surg.
2003Oc|,29(10).1860-5
8.
Micnc|scn MA. Usc cf a Sncc|s g|ic as a pscuc-pcs|cricr capsu|c in
pnacccmu|sifca|icn ccmp|ica|c |q pcs|cricr capsu|c rup|urc. |ur ]
|mp|an|Rcfrac|Surg1993,5.7072
9.
Hansscn |], |arsscn ].Vi|rcc|cmq fcr rc|ainc |cns fragmcn|s in
|nc ti|rccus af|cr pnacccmu|sifca|icn.] Ca|arac| Rcfrac| Surg. 2002
]un,28(6).1007-11
10.
Mcnsnizacn R, Samiq N, Haimctici R. Managcmcn| cf rc|ainc
in|rati|rca| |cns fragmcn|s af|cr ca|arac| surgcrq. Surt Opn|na|mc|.
1999Mar-Apr,43(5).397-404
P.C. Dwivedi MS,|SVH, Charudatt Chalisgaonkar MS, Syed Imran M88S
S.S.Mcica|Cc||cgc,Rcua,ManqaPracsn
C....c
Syed Imran
I
n 1992 WHO eslinaled lhal lhere are 1.5 niIIion chiIdren
vilh lIindness in lhe vorId, of vhich 1 niIIion Iive in
Asia. This hgure viII increase lo 2 niIIion ly 2O2O. One of lhe
Ieading elioIogies of lIindness in chiIdren is calaracl. AInosl
12 of chiIdhood lIindness is caused ly calaracl.
,
Wilh a
decrease in corneaI lIindness due lo Iarge-scaIe neasIes
innunizalion, vilanin A suppIenenlalion and lrachona
reduclion calaracl is leconing a nore proninenl cause of
chiIdhood lIindness.
Connon causes of pedialric calaracl in India are
- Idiopalhic -3O-5O
- Heredilary- 7-2O
- CongenilaI ruleIIa syndrone- 1O-2O
- Secondary lo nelaloIic diseases- 5-1O
- Traunalic- 1O
Wilh age-reIaled calaracl surgery leing lransforned
fron a najor surgicaI procedure requiring severaI days
of hospilaIizalion lo an oulpalienl procedure, pedialric
calaracl surgery aIso undervenl severaI advancenenls. IOL
inpIanlalion is nov lhe preferred hrsl Iine nanagenenl
in pedialric calaracls. Hovever, lhe difhcuIlies lhal are
encounlered vilh lhe inpIanlalion of IOL in chiIdren incIude
lhe seIeclion of appropriale Iens naleriaI, size, design and
nosl inporlanlIy accurale IOL pover caIcuIalion.
Anatomical Considerations
AIlhough lhe pedialric eye is snaII, il is nol a ninialurized
aduIl eye. Il has ils ovn specihc analonicaI and physioIogicaI
characlerislics. Il has shorler axiaI Ienglh, sleeper cornea
vilh higher keralonelry vaIue and snaIIer anlerior chanler
deplh. asic knovIedge of lhe dinensions and grovlh of
pedialric eye is essenliaI for leller nanagenenl of pedialric
calaracls.
Axial length
Al lirlh axiaI Ienglh is 16.8 nn vhich increases lo 2O nn al
1 year, 22 nn al 3 years and a presuned endpoinl of 23 nn
al 13 year.
4
Mosl of lhe changes in axiaI Ienglh occur in hrsl
2 years of Iife vilh an increase of O.62 nn/nonlh in hrsl 6
nonlhs and O.19 nn/nonlh fron 6 lo18 nonlhs.
5
Keratometry
6
- Keralonelry lecones slalIe ly 12-18 nonlhs
- In prenalure infanls 53.1+/-1.5D
- Neonales 48.4+/-1.7D
- 1 nonlh 45.9+/-2.3
- 36 nonlhs 42.9+/-1.3D
Lens Power
Lens pover changes fron +34.4 D al lirlh lo +18.8 D in
aduIlhood. Il drops ly 1OD in hrsl year and lhen ly 3 - 4D
fron 2 -1O years.
Figure 1: Dens bilateral congenital cataract
Figure 2: Change in Axial length with Age
Diameter of the lens
The nean dianeler of lhe cryslaIIine Iens al lirlh is 6nn,
8.3nn al 2 years and 9.3nn al 16 years.
Capsular diameter
- Al lirlh- 7 nn
- Al 2 yrs - 9 nn
- Al 16 yrs - 1O.5 nn
Aparl fron lhe alove nenlioned changes during lhe
iniliaI years of Iife pseudophakia and aphakia aIso have a
signihcanl effecl on ocuIar grovlh. These effecls hovever
renain conlroversiaI naking IOL pover caIcuIalion furlher
conpIicaled.
7,8,9
Biometry
Tuc ccu|ar mcasurcmcn|s arc cri|ica| |c |O| pcucr ca|cu|a|icn.
axiaI Ienglh and corneaI curvalure. Ofhce neasurenenl
of axiaI Ienglh and cornea curvalure can le chaIIenging or
inpossilIe in very young chiIdren. Il is leller lo lake lhese
neasurenenls in lhe operaling roon vhiIe lhe chiId is
sedaled. Consider reneasurenenl if lhe IOL pover is oulside
lhe expecled range or if lhere is signihcanl asynnelry
lelveen lhe eyes.
Axial length-AxiaI Ienglh neasurenenl ly innersion
lechnique has leen found lo le nore accurale lhen
appIanalion lechnique. AppIanalion lechnique pIaces lhe
uIlrasound prole direclIy on lhe cornea, vhich sIighlIy
indenls lhe surface. This nay inlroduce a neasurenenl error
in recorded axiaI Ienglh. Using lhe innersion lechnique, lhe
uIlrasound prole does nol cone inlo direcl conlacl vilh lhe
cornea, lul inslead uses a coupIing uid lelveen lhe cornea
and prole prevenling corneaI indenlalion. Lrrors in axiaI
Ienglh neasurenenl affecl IOL pover caIcuIalion lhe nosl,
vilh an average error of 2.5 D per niIIineler of axiaI Ienglh in
aduIls, il increases lo 3.75 D per nn in chiIdren. ConnerciaI
lionelers are oplinaIIy adapled for neasurenenl of aduIl
eyes, nosl of lhen use average sound veIocily (155O n/s),
lul in snaII eyes vilh congenilaI calaracl lhe Iens is a grealer
proporlion of lhe lolaI axiaI Ienglh and lherefore lhe average
veIocily vouId le fasler. Il is lherefore essenliaI lo ensure
lhal inslrunenls are caIilraled lo accepl shorler axiaI Ienglh
readings.
Partial coherence interferometry-Il is an oplicaI lionelry
nelhods vhich uses Iaser doppIer lo neasure lhe echo deIay
and inlensily of infrared Iighl reecled lack fron lissue
inlerfaces. Il is cIained lo have high accuracy reproduciliIily,
conlacl-free neasurenenl and olserver independence of lhe
neasurenenls. ul il requires palienl cooperalion and lhus
nay nol le a vialIe oplion in infanls and young chiIdren.
AIso neasurenenls are nol possilIe in lolaI calaracl and in
palienls vilh associaled nyslagnus.
Keratometry-The sleeper corneas of infanls nay resuIl in
inaccuracy in keralonelry, aIlhough lhe overaII effecl is
IikeIy lo le snaII in lhe caIcuIalion of IOL pover. SeveraI
keralonelry readings shouId le laken ly a handheId
keraloneler and an acceplalIe K vaIue ollained ly averaging
lhen.
Choosing the Right Formula
IOL caIcuIalion fornuIa is an unresoIved issue in pedialric IOL
inpIanlalion. ecause aII inlraocuIar Iens pover caIcuIalion
fornuIas are derived fron consideralions regarding lhe
aduIl eye, il is yel uncIear vhelher lhey can le appIied in
chiIdren vilh lhe sane degree of conhdence, especiaIIy vilh
shorl axiaI Ienglhs and high keralonelry vaIues and a largel
refraclion lhal nay le signihcanlIy differenl fron pIano.
InlraocuIar Iens pover caIcuIalion fornuIas faII inlo lvo
najor calegories,
Regression formulas- SRK II, CiIIs, Thonpson-Maunenee
and Donzis-KaslIe-Cordon fornuIae.
TheorelicaI fornuIas- SRK/T, HoIIaday and Hoffer Q
fornuIae.
In aduIls, oIder fornuIae such as SRK and SRK II have leen
denonslraled as Iess prediclalIe lhan lhe lheorelicaI fornuIae
such as lhe SRK/T, HoIIaday and Hoffer Q especiaIIy in
shorler eyes.
-17
HoIIaday II fornuIa is considered lo le nosl
accurale for eyes vilh an axiaI Ienglh lelveen 22 and 26 nn.
The Hoffer Q fornuIa is considered lo le nosl accurale for
shorl eyes (<24.5nn). The SRK/T fornuIa is considered
oplinaI for Iong eyes (>26nn).
18
In chiIdren hovever, Andreo el aI.
19
found no signihcanl
difference in accuracy lelveen SRK-II, SRK-T, HoIIaday and
Hoffer Q. The average iniliaI posloperalive refraclive error
vas lelveen 1.2 and 1.4 D in aII fornuIas. Anolher sludy
found lhal lhe nean difference lelveen lhe predicled and lhe
acluaI posloperalive refraclions vas sIighlIy nore accurale
using lheorelic fornuIas (1.O6 D, vs. 1.22 D vilh regression
fornuIas).
2O
AIlhough no fornuIa has leen proven lo have
an advanlage over olhers, never lheorelic fornuIas such
as HoIIaday II lhal lake anlerior segnenl neasurenenls
inlo accounl, resuIling in nore accurale caIcuIalions in very
shorl eyes nay le reconnended for pedialric IOL pover
caIcuIalion.
Axial Length and IOL Power
If hand heId keraloneler is nol avaiIalIe, lased on axiaI
Ienglh IOL pover can le chosen as foIIovs
24
Target Postoperative Undercorrection
IdeaIIy one shouId ain for a refraclive slale lhal vouId
give lhe lesl heIp for hghling anlIyopia in chiIdhood (Iess
iniliaI hyperopia), vhiIe inducing lhe Ieasl refraclive error in
aduIlhood. ul vilh lhe conpIexilies invoIved allaining such
a refraclive goaI is very difhcuIl. There is no consensus in lhe
Iileralure on lhe ideaI posloperalive refraclion in infanls and
Figure 3: Change in Keratometry with Age
chiIdren afler IOL inpIanlalion. Differenl surgeons adopl
differenl praclices for IOL inpIanlalion in chiIdren:
IniliaI Lnnelropia-An allenpl al ennelropizalion vouId
avoid lhe need of speclacIe correclion and lhe inninenl
danger of anlIyopia. Hovever, lhe disadvanlage of lhis
lechnique is lhal signihcanl nyopia vouId evenluaIIy
deveIop in aduIlhood.
Signifcan| ini|ia| nqpcrcpia cr cmmc|rcpia a| qcung au||ncc-
Undercorrecling lhe chiId lo conpensale for lhe nyopic
shifl caused ly ocuIar grovlh vouId resuIl in ennelropia
in aduIlhood. ul lhe resuIlanl iniliaI hyperopia is dehnileIy
anlIyogenic and vouId require innediale oplicaI correclion.
S|ign| ini|ia| nqpcrcpia cr s|ign| mqcpia a| qcung au||ncc-
SIighl iniliaI undercorreclion vouId nake lhe chiId sIighlIy
hyperopic so lhal as an aduIl he vouId lecone sIighlIy
nyopic.
Thus ennelropic pover risks a signihcanl nyopia al ocuIar
nalurily vhiIe earIy high hyperopia nay creale hurdIes in
lhe nanagenenl lallIe againsl anlIyopia.
Various faclors need lo le considered vhiIe delernining lhe
largel posloperalive undercorreclion
Age at cataract surgery- The cIoser lo lirlh lhe inpIanlalion
is perforned, lhe nore narked lhe undercorreclion viII
need lo le. Hov nuch shouId one undercorrecl and al vhal
age` To reduce nyopic shifl in fulure lhere are lvo vays lo
undercorrecl as per age:
Melhod lased on percenlage of undercorreclion
2O undercorreclion if lhe chiId is Iess lhan age 2 years
1O undercorreclion for age 2-8 years
Melhod lased on alsoIule vaIue of undercorreclion
22,23
Status of the fellow eye-The deveIopnenl of good vision is
dependenl on conpIex inleraclions lelveen lhe linocuIar
visuaI inpul and lhe lrain's deveIopnenl: differences in
inage quaIily lelveen lhe eyes rapidIy Iead lo anlIyopia
and slralisnus in young chiIdren. Therefore, vhelher lhe
calaracl is uniIaleraI or liIaleraI nusl le faclored inlo lhe
choice of IOL pover. In a nonocuIar calaracl or vilh a
pseudophakic feIIov eye, il is inporlanl lo delernine lhe
refraclive slalus of lhe feIIov eye lo nininize lhe aniseikonia.
In liIaleraI calaracl, a Iarger anounl of hyperopia nay le
acceplalIe, since aniseikonia can le avoided ly largeling a
nearIy equivaIenl refraclion in lolh eyes.
Expected compliance- Il is leller lo Ieave Iess refraclive error
if lhe chiId and/or faniIy are expecled lo conpIy poorIy vilh
gIasses, conlacl Ienses or occIusion lherapy.
Parents refractive error- Il is aIso inporlanl lo ask aloul high
refraclive error especiaIIy nyopia in lhe parenls. Iarenls
vho have nyopia lend lo have chiIdren vilh nyopia. The
prevaIence of nyopia in chiIdren vilh lvo parenls vilh
nyopia is 3O lo 4O, decreasing lo 2O lo 25 in chiIdren
vilh one parenl vilh nyopia and lo Iess lhan 1O in chiIdren
vilh no parenls vilh nyopia.
25-27
These eyes nay le Iefl vilh
nore hyperopia lhen slaled.
Site of the IOL implantation - The IOL inlended for capsuIar
lag pIacenenl shouId le decreased ly 1 D lo 2 D, vhen
pIaced in lhe ciIiary suIcus.
Despile our lesl efforls, il nay le lhal sone chiIdren nay
evenluaIIy need an IOL exchange or refraclive surgery.
IOL Size
28
Rapid grovlh phase of Iens is conpIele ly 2 years of age, so
dovnsizing of IOL is essenliaI lefore lhis age and slandard
size IOL can le inpIanled aflervards.
- |cragc<2qcars. OveraII dianeler 1Onn
- |cragc>2qcars. Slandard size 12-12.5nn
|mp|an|ing an au|| sizc |O| in cni|rcn |c||cu 2 qcars cf agc
maq |ca |c: DifhcuIl diaIing, asynnelric IOL hxalion,
decenlralion of IOL, poslerior capsuIe slrelching causing Iens
epilheIiun nigralion Ieading lo ICO fornalion and zonuIar
slress vhich nay aIler ocuIar grovlh.
IOL Material
IrolIen of naleriaI used for nanufacluring of IOLs for
inpIanlalion in chiIdren is very inporlanl lecause lhe IOL
in a chiId viII renain in lhe eye for nany decades.
So lhese eyes shouId le spared fron lhe Iong-lern
conpIicalions associaled vilh a synlhelic naleriaI in
lhe eye. ionaleriaIs used for lhe nanufaclure of IOL can
le divided inlo lvo najor groups: acryIic and siIicone.
AcryIic Ienses can le furlher divided as foIIovs: rigid Ienses
nanufaclured fron IMMA and sofl or foIdalIe Ienses
nanufaclured eilher fron hydropholic acryIic naleriaIs e.g.
AcrySof or fron hydrophiIic acryIics aIso knovn as hydrogeIs
e.g. Hydroviev.
Lens naleriaI lioconpaliliIily is an inporlanl aspecl of IOL
seIeclion in chiIdren. ioconpaliliIily of lhe IOL naleriaI can
le divided inlo uveaI and capsuIar. UveaI lioconpaliliIily
descriles lhe IeveI of foreign lody reaclion lo lhe IOL
lionaleriaI. CapsuIar lioconpaliliIily descriles lhe IeveI
of lionaleriaI-Iens epilheIiaI ceII inleraclion, resuIling in
AxIa!!cngth(Inmm) IOLpnwcr(InDInptcrs)
17 25
18 24
19 23
2O 21
21 19
Agc RcsIdua!RcfractInn
< 1.9 nonlhs +1OD
2.O-3.9 nonlhs +9D
4.O-5.9 nonlhs +8D
6.O-11.9 nonlhs +7D
1.O-1.9 years +6D
2.O-3.9 years +5D
4.O-4.9 years +4D
5.O-5.9 years +3D
6.O-6.9 years +2D
7.O-7.9 years +1.5D
8.O-9.9 years +1D
1O.O-13.9 years +O.5D
> 14 years +OD
various IeveIs of Iens epilheIiaI ceII oulgrovlh, anlerior
capsuIe opacihcalion, poslerior capsuIe opacihcalion (ICO)
and capsuIar conlraclion.
PMMA Lenses - Rigid inpIanls nanufaclured fron
poIynelhyInelhacryIale (IMMA) have leen inpIanled
since 1949. IMMA has lhe Iongesl safely record in lolh
aduIls and chiIdren. IMMA IOLs, aIlhough line lesled, are
associaled vilh a Iover lioconpaliliIily and higher rale of
conpIicalions. Al 3 years of foIIov up, IMMA Ienses vere
associaled vilh nore ICO (56) lhan siIicone (4O) and
poIyacryIic Ienses (1O).
29
Heparin has leen successfuIIy
used for surface nodihcalion of rigid IMMA IOLs. Sludies
have shovn lhal heparin-surface-nodihcalion of IMMA
IOL increases ils lioconpaliliIily. ul vhen conpared lo
hydropholic acryIic Ienses heparin-surface-nodihed IMMA
IOL sliII have higher inannalory ceII adhesion and capsuIar
opacihcalion rale.
3O,31
Hovever, lhe nain disadvanlage of
lhe cIassic IMMA IOL has leen ils rigidily, vhich lherefore
precIudes inpIanlalion via nodern snaII incision procedure.
Silicone Lenses - SiIicone IOLs are Iov noIecuIar veighl
poIyners of oxygen and siIicone. They are highIy exilIe vilh
high uveaI and capsuIar lioconpaliliIily, lul are associaled
vilh increased rale of an|cricr Capsu|c Ccn|rac|icn.
32-34
The
siIicone IOL poIyner has lhe Iovesl lhreshoId for Iaser-
induced danage and a grealer Iinear exlension of danage
lhan lhe IMMA and acryIic IOL poIyners.
35
eing sIippery,
il is difhcuIl lo nanipuIale, especiaIIy if vel. During inserlion
in lhe lag il unfoIds rapidIy, vhich can Iead lo unconlroIIed
inserlion and inlraocuIar danage.
Hydrophilic acrylics or Hydrogels Lenses - These IOLs are
sofl and have an exceIIenl lioconpaliliIily lecause of lheir
reIaliveIy hydrophiIic Iens surface. They are exilIe and shov
IillIe or no surface aIleralions or danage fron foIding vilh
inserlion.
36
ecause of lheir hydrophiIicily lhey have high
uveaI lioconpaliliIily, as veII as danage polenliaI vhen
louching lhe corneaI endolheIiaI ceIIs. Hovever, hydrogeIs
seen lo have a Iover capsuIar lioconpaliliIily, resuIling
in nore Iens epilheIiaI ceII oulgrovlh, anlerior capsuIe
conlraclure and ICO fornalion afler calaracl surgery.
37
Hydrophobic acrylic lenses - Hydropholic acryIic Ienses are
nade of copoIyners of acryIale and nelhacryIale, vhich
nakes lhen exilIe and duralIe. They have higher refraclive
index (1.44-1.55) lhan siIicone (1.41-1.46) and IMMA (1.49),
lherefore lhe Ienses are usuaIIy lhinner. The lioconpaliliIily
of hydropholic acryIic Ienses exceeds lhal of IMMA Ienses
vilh fever poslerior synechiae and fever Iens deposils vhen
inpIanled in chiIdren.
38
They are easier lo inserl in a snaII
eye and lhe squared edge of lhe IOL oplic design (as vilh
AcrySof) nay resuIl in deIayed poslerior capsuIe opacihcalion
in young eyes. The AcrySof hydropholic acryIic IOL (AIcon
Laloralories) has leen shovn lo le very lioconpalilIe
for pedialric eyes.
38-4O
So hydropholic acryIic Ienses vilh a
square poslerior oplic edge is nov lhe nosl preferred IOL in
pedialric palienls.
Accurale delerninalion of IOL pover and seIeclion of Iens
naleriaI are najor chaIIenges in lhe Iong-lern care of chiIdren
undergoing calaracl surgery. CarefuI pIanning of lhe surgicaI
procedure, seIeclion of lhe IOL and use of appropriale IOL
pover are essenliaI sleps for achieving exceIIenl visuaI
oulcones in pedialric calaracls.
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32.
A|c|a-|crmanc| C, Amcn M, Scni| G, c| a|. Utca| an capsu|ar
|icccmpa|i|i|i|qcfnqrcpni|icacrq|ic,nqrcpnc|icacrq|ic,ansi|iccnc
in|raccu|ar|cnscs.]Ca|arac|Rcfrac|Surg2002,28.50-61.
33.
A|c|a-|crmanc| C, Amcn M, Scnaucr|crgcr ], c| a|. Rcsu||s cf
nqrcpni|icacrq|ic,nqrcpnc|icacrq|ic,ansi|iccncin|raccu|ar|cnscs
in utci|ic cqcs ui|n ca|arac|. ] Ca|arac| Rcfrac| Surg 2002,28.1141-
1152.
34.
HaqasniK,HaqasniH.|n|raccu|ar|cnsfac|crs|na|maqaffcc|an|cricr
capsu|cccn|rac|icn.Opn|na|mc|cgq.2005|c|,112(2).286-92.
35.
Ncu|an T], McDcrmc|| M|, ||ic|| D, c| a|. |xpcrimcn|a|
nccqmium.YAG |ascr amagc |c acrq|ic, pc|q(mc|nq| mc|nacrq|a|c),
an si|iccnc in|raccu|ar |cns ma|cria|s. ] Ca|arac| Rcfrac| Surg
1999,25.72-76.
36.
Kcnncn T, Magcus|i G, Kccn DD. Scanning c|cc|rcm micrcsccpic
ana|qsis cf fc|a||c acrq|ic an nqrcgc| in|raccu|ar |cnscs. ] Ca|arac|
Rcfrac|Surg1996,22.1342-1350.
37.
Hc||ic| |], Spa||cn D], Ursc|| PG. Surfacc cq|c|cgic fca|urcs cn
in|raccu|ar |cnscs. Can incrcasc |icccmpa|i|i|i|q natc isatan|agcs?
ArcnOpn|na|mc|1999,117.872-878.
38.
Ii|scnM|,|||ic|||,]cnnscn8,Pc|crscimMM,RanS,Icrncr|,c|
a|. AcrqScf acrq|ic in|raccu|ar |cns imp|an|a|icn in cni|rcn. c|inica|
inica|icnscf|icccmpa|i|i|i|q.]AAPOS2001,5.377-380.
39.
Hc||ic| |], Spa||cn D], Ursc|| PG, Panc MV, 8arman SA, 8cqcc ]|,
Ti||ing K (1999) Tnc cffcc| cf pc|qmc|nq|mc|nacrq|a|c, si|iccnc, an
pc|qacrq|ic in|raccu|ar |cnscs cn pcs|cricr capsu|ar cpacifca|icn 3 qcars
af|crca|arac|surgcrq.Opn|na|mc|cgq106.4954
40.
Ii|scnM|,TritciRH,8uc||cq|G,Granc|D8,|am|cr|SR,P|agcr
DA,Sins|cqRM,VasataaAR(2007)ASCRSuni|cpapcr.nqrcpnc|ic
acrq|icin|raccu|ar|cnscsfcrcni|rcn.]Ca|arac|Rcfrac|Surg33.1966
1973
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Bhuvan Chanana
Q.1. What Is thc dcnItInn nf Endnphtha!mItIs?
Ans. The lern refers lo inlraocuIar inannalion
predoninanlIy invoIving lhe vilreous cavily (Ieading
lo exudalion in vilreous cavily) and anlerior chanler
connonIy as a resuIl of inlraocuIar coIonizalion ly
nicro-organisns. Conliguous ocuIar slruclures such
as relina or choroid nay le invoIved.
Q.2. What arc thc prcscntIng symptnms and sIgns nf
Endnphtha!mItIs?
Ans. Decrease visuaI acuily
Iain (pain nay le alsenl)
Iholopholia
Anlerior chanler reaclion +/- Hypopyon
Reduced or alsenl fundaI gIov
Vilrilis, exudales over relina
CorneaI edena
O|ncrs. Iid sveIIing, discharge, conjunclivaI hyperenia,
chenosis.
Q.3. Hnw Is Endnphtha!mItIs c!assIcd?
Ans. 1) Lndogenous/Melaslalic
2) Lxogenous:
a) Iosloperalive.
l) Iosllraunalic.
c) Iel associaled.
d) MisceIIaneous e.g. sulure reIaled, nicroliaI
keralilis, infeclious scIerilis
Q.4. WhatarcthcnrganIsmsmnstcnmmnn!yInvn!vcdIn
varInustypcsnfEndnphtha!mItIs?
Ans. Post cataract surgery:
- CoaguIase-negalive SlaphyIococcus (33-77) fron lhe
naluraI conjunclivaI ora. The singIe nosl connon
cause of exogenous endophlhaInilis is SlaphyIococcus
epidernidis, vhich is aIso nornaI ora of lhe skin and
conjuncliva.
- SlaphyIococcus aureus
- Slreplococci species
- Cran negalive lacleria
Delayed onset (chronic) post cataract:
- Iropionilacleriun acnes
- SlaphyIococcus epidernidis
- Candida
3RVWJODXFRPDVXUJHU\DVVRFLDWHGZLWKOWHULQJEOHEV
- Slreplococcus species
- HaenophiIus inuenzae
Post traumatic:
- aciIIus species
- Slreplococcus species
- Iungi
Q.5. WhIch typc nf cndnphtha!mItIs Is mnst cnmmnn!y
cncnuntcrcd?
Ans. Iosl-operalive endophlhaInilis is lhe nosl connon
forn. Il conprises 7O of infeclive endophlhaInilis.
The one foIIoving calaracl surgery is lhe nosl
connonIy encounlered vilh an eslinaled incidence of
O.O7 lo O.13.
Q.6. Hnw Is pnst-npcratIvc Endnphtha!mItIs c!assIcd?
Ans. Three forns of cIinicaI presenlalion can le dislinguished
a. Severe acule forn, usuaIIy fuIninanl, occurs vilhin
1-4 days afler surgery, nosl connonIy due lo
SlaphyIococcus aureus, Slreplococci species, Serralia
narcescens, Iseudononas and Iroleus species.
l. MiId sul-acule forn, sIovIy deveIoping, occurs 7-14
days afler surgery due lo SlaphyIococcus epidernidis,
CoaguIase negalive cocci.
c. Chronic or deIayed forn, occurs 4 veeks or nore afler
surgery, due lo Iropionilacleriun acnes
Q.7. Hnw Is mcdIa c!arIty c!assIcd In Endnphtha!mItIs
(hnwdnwcgradcscvcrItynfcndnphtha!mItIs)?
Ans. Media clarity in Endophthalmitis:
Grac1. Cood gIov (visuaI acuily 6/12)
Grac 2. Can visuaIize second order relinaI vesseIs
(visuaI acuily < 6/12)
Grac3. Sone relinaI vesseIs visuaIized haziIy
Grac4. Iainl gIov lul relinaI vesseIs nol seen
Grac5. No gIov, red reex alsenl
Q.8. WhatIsthcmaInsnurccnfInfcctInnInpnstnpcratIvc
Endnphtha!mItIs?
Ans. Lye Iids and conjuncliva are nain source of infeclion.
O|ncrscurccs.c.g.
- IacrinaI drainage syslen
- Infecled sockel in conlraIaleraI proslhelic eye.
- Conlaninaled surgicaI inslrunenls, irrigaling uids
eye drops
Q.9. HnwwI!!ynudIagnnscacascnfEndnphtha!mItIs?
Ans.
- Diagnosis is nainIy cIinicaI
- DeIay in diagnosis is nol unconnon (due lo use of
sleroids, associaled conpIicalions, expecled posl-
operalive inannalion).
- -scan is an aid, lul sonelines can le nisIeading.
- If in doull, le safe and consider il as LndophlhaInilis.
- Ollain vilreous sanpIes lo isoIale causalive organisn.
Q.10. HnwwI!!ynuIsn!atccausatIvcnrganIsm?
Ans.
- Vilreous is lhe nosl inporlanl source (Highesl yieId
rale, 6O lo 7O) lo knov lhe causalive organisns.
- Vilreous lap using a 23 gauge needIe. The needIe is
passed lhrough pars pIana and O.2nI of undiIuled
vilreous is vilhdravn.
Aspiralion nay nol provide adequale sanpIe
as vilreous is denser and conlain inannalory
nenlranes in LndophlhaInilis. There is aIso a risk of
relinaI delachnenl.
- Vilreous liopsy using a vilreclony prole pIaces Iess
lraclion on inaned and fragiIe relina - Safesl nelhod
- Aqueous nay aIso le cuIlured lul lhe yieId is Iover as
conpared lo lhe vilreous.
CuIlure and Laloralory evaIualion of inlraocuIar
specinens: Vilreous specinens shouId le pronplIy
inocuIaled direclIy onlo cuIlure nedia. Drops of lhe
sanpIe shouId le pIaced onlo lIood agar (aerolic
nediun), Salrourauds agar, chocoIale agar and
lhiogIycoIale lrolh.
In chronic posl operalive endophlhaInilis, lhe
anaerolic cuIlure is kepl for 2 veeks as I. acnes lakes
Ionger lo grov.
One drop of vilreous sanpIe pIaced on cIean sIides
for Cran, Ciensa slains, KOH nounl for lacleria and
fungi.
Q.11. WhatIsthcrn!cnfu!trasnnngraphy?
Ans. Ior diagnosis and noniloring response lo lrealnenl
To delecl relinaI delachnenl
Relained Iens naller (nucIear fragnenl)
Q.12. WhatdIffcrcntIa!dIagnnscsshnu!dbccnnsIdcrcd?
- Toxin anlerior segnenl syndrone (TASS) |TalIe 1j
- ConpIicaled, proIonged surgery
- Ireexisling uveilis
- Relained Iens naleriaI
- Associaled ocuIar injury vilh inannalion
Note: |n |nc prcscncc cf signifcan| ti|ri|is, a|uaqs crr cn |nc
siccfinfcc|icuscncpn|na|mi|is,un|i|prctcnc|ncruisc.
Q.13. What arc thc rccnmmcndatInns nf EV5
(Endnphtha!mItIsVItrcctnmy5tudy)study?
Ans. LVS reconnended:
- Vilreous lap + anlerior chanler sanpIing + inlravilreaI
anliliolics - in cases vision > hand novenenls al 2 feel.
- Vilreclony + inlravilreaI anliliolics in cases vilh
vision < hand novenenls.
According lo LVS syslenic anliliolics do nol appear
lo have any effecl on lhe course and lhe oulcone of
LndophlhaInilis.
Q.14. WhatwcrcthccascsInc!udcdInEV5study?
Ans. Ialienls vho deveIoped endophlhaInilis vilhin
6 veeks afler calaracl surgery vilh prinary IOL
inpIanlalion or secondary IOL inpIanlalion.
Table 1
5Ignsand5ymptnms TA55 InfcctInusEndnphtha!mItIs
Onsel 12-24 hours usuaIIy 2-7 days usuaIIy
Iain UsuaIIy none lul can le niId lo noderale UsuaIIy severe
InlraocuIar pressure May increase suddenIy UsuaIIy nol eIevaled
Anlerior chanler Moderale-lo-severe anlerior chanler Moderale-lo-severe anlerior chanler
inannalion reaclion vilh increased vhile lIood reaclion. Iilrin is varialIe. Hypopyon
ceIIs and hlrin. Hypopyon nay le noled. oflen presenl (75 of lhe line).
Vilrilis Very rare AIvays presenl
Lid sveIIing UsuaIIy nol evidenl Oflen presenl
VisuaI acuily Decreased Decreased
Response lo sleroids Dranalic inprovenenl LquivocaI
Q.15. WhIchdrugsshnu!dbcuscdfnrIntravItrca!InjcctInn?
Ans. Most commonly used drugs:
- Vanconycin 1 ng in O.1 nI - lroad-speclrun aclivily
againsl nosl gran posilive species (is aclive againsl
MRSA), has lecone an agenl of choice
- Ceflazidine 2.25 ng in O.1nI - covers gran negalive
laciIIi incIuding Iseudononas.
These lvo shouId never le nixed in syringe as il Ieads
lo precipilalion of drug.
Other drugs used are:
- Cenlanicin 1ng in O.1nI vas used, lul vas found lo
le associaled vilh nacuIar infarclion.
- Anikacin O.4ng in O.1nI (4 lines Iess relinaI loxicily
lhan genlanicin) - Anikacin covers Iarge nunler of
gran negalive organisns and lhose resislanl lo olher
aninogIycosides.
An|i-funga|rugs(incascsui|nsuspcc|cfunga|c|ic|cgq)
- Anpholericin 5-1O g/O.1 nI
- IIuconazoIe 25 g/O.1 nI.
Q.16. WhatIsthcrn!cnfsystcmIcantIbIntIcsInmanagcmcnt
nfEndnphtha!mItIs?
Ans. LVS slaled no roIe of syslenic anliliolics in posl-
operalive anliliolics. Hovever lhe roIe is Iiniled and
shouId le individuaIized depending on case. Syslenic
anliliolics nay le given in cerlain cases Iike:
- Severe fuIninanl posloperalive cases
- Traunalic LndophlhaInilis especiaIIy vhen associaled
vilh inlraocuIar foreign lody
- Associaled corneaI alscess
- Associaled scIera luckIe infeclion, infeclious scIerilis,
proplosis, Ioss of exlraocuIar novenenls
- LIevaled lody lenperalure or Ieukocyle counl vilh
endophlhaInilis
Q.17. WhIch systcmIc antIbIntIcs havc gnnd Intra-ncu!ar
pcnctratInn?
Ciprooxacin vhen given oraIIy shovs exceIIenl
inlraocuIar penelralion. Never fourlh generalion
uoroquinoIones such as galioxacin and noxioxacin
have aIso leen shovn lo readiIy penelrale inlo lhe
vilreous cavily vhen adninislered syslenicaIIy and
achieve MIC vaIues.
Q.18. WhatIsthcrn!cnfstcrnIdsInEndnphtha!mItIs?
Ans. In LndophlhaInilis, lhere is inlense inannalory
response and loxins are reIeased ly lacleriaI Ieading.
Syslenic (oraI) sleroids are reconnended lo reduce
inannalion in exogenous LndophlhaInilis. Sleroids
do nol have any negalive effecl on lhe infeclion course.
TopicaI sleroids nay aIso le given if cornea is nol
invoIved ly infeclious process.
19. WhatarcthcIndIcatInnsnfvItrcctnmy?
- VisuaI acuily < Hand Movenenls
- Associaled vilh RD, RIOI
- Nol responding lo inlravilreaI injeclions
Recenl sludies reconnend prinary vilreclony,
inlravilreaI anliliolics and sleroids as a goId slandard
of nanagenenl of LndophlhaInilis.
Q.20. WhatarcthcadvantagcsanddIsadvantagcsnfcar!y
vItrcctnmy?
Ans. Advantages:
1. LarIy vilreclony decrease lacleriaI Ioad
2. Renove nosl of lhe inannalory deslrucling ceIIs
and nedialors and lacleriaI loxins
3. Renove lhe scaffoId (vilreous) for lacleriaI
proIiferalion
4. CIearing ocuIar nedia
Disadvantages:
IragiIe necrolic relina - chances of relinaI lreaks and
hence relinaI delachnenl
Q.21. What arc thc IndIcatInns and advantagcs nf sI!Icnnc
nI!InjcctInn?
Ans. Indicalions of siIicone oiI injeclion are:
- Associaled RD
- RelinaI necrosis
- RelinaI lreaks/diaIysis during vilreclony
Advantages:
- SiIicone oiI provides a cIear nedia
- ConparlnenlaIizalion (no space/scaffoId for
organisns lo grov)
- Reslore ocuIar analony and funclions
Q.22. What Is thc managcmcnt nf chrnnIc dc!aycd nnsct
Endnphtha!mItIs?
Ans. Chronic LndophlhaInilis is very connonIy
nisdiagnosed as uveilis or posl operalive inannalion.
Problems:
a) High rale of recurrence.
l) DifhcuIly in cuIluring lhe organisn (noslIy I. acnes)
lecause il is encIosed in lhe synechised capsuIar lag.
Step 1: Inlra-vilreaI vanconycin (drug of choice for I.
acne) 1ng /O.1 nI.
Step 2: If no inprovenenl, consider IIV + inlravilreaI
anliliolics + poslerior capsuIolony.
Step 3: If no inprovenenls vilh slep 2, IOL expIanlalion
+ renovaI of surrounding lag (lolaI capsuIeclony).
Q.23. WhatIsthcIncIdcnccnftraumatIcEndnphtha!mItIs?
Ans. Incidence of lraunalic LndophlhaInilis is 2.4 - 8.O ,
increasing up lo 3O in ruraI sellings or vilh relained
inlraocuIar foreign lody.
Q.24. What arc thc rIsk factnrs fnr dcvc!npIng
Endnphtha!mItIsInpcnctratIngInjury?
Ans. Risk faclors for deveIoping posllraunalic
endophlhaInilis are:-
- DeIayed prinary repair of open gIole injury ly grealer
lhan 24 hours
- InlraocuIar Ioreign ody (IOI)
- Injury conlaninaled vilh soiI, ruraI or organic naller
- Lens ruplure
- Vilreous proIapse lhrough lhe open gIole vound
- Age grealer lhan 5O years
- IenaIe gender
- Large vound size, Iocalion of vound (poslerior
scIera Iaceralion vilh vilreous proIapse), ocuIar lissue
proIapse
- IIacenenl of prinary inlraocuIar Iens (IOL), and
- RuraI IocaIe.
Q.25. What arc thc cnmmnn nrganIsms Invn!vcd In
traumatIcEndnphtha!mItIs?
Ans. SlaphyIococcus epidernidis is nosl connon organisn
aciIIus cereus is nosl connonIy isoIaled vilh
lraunalic LndophlhaInilis (25- 32)
Figure 4: Chronic delayed Endophthalmitis with
sequestration of Propionibacterium acnes in capsular bag
Figure 1: Vitreous exudates with poor glow in
Endophthalmitis
Figure 2: Traumatic Endophthalmitis - Slit beam
examination shows ciliary congestion and corneal
edema. Hypopyon and seclusio pupillae with total
ECVCTCEVCTGRTGUGPV+TKUFGVCKNUCTGPQVCRRTGEKCDNG
Figure 3: Slit beam examination shows
hypopyon in a case of Endophthalmitis
Q.26. Hnw Is managcmcnt nf traumatIc Endnphtha!mItIs
dIffcrcnt?
Ans. More aggressive approach is required.
Syslenic (inlravenous anliliolics) shouId le
adninislered.
Sleroids are lo le given lo conlroI inannalion.
Vilreclony shouId le considered earIy - organisns are
nore deslruclive.
Q.27. What arc thc rIsk factnrs fnr dcvc!npIng
Endnphtha!mItIs assncIatcd wIth !tcrIng b!cbs?
Ans. Risk faclors for deveIoping LndophlhaInilis associaled
vilh hIlering lIels are:-
- Thin-vaIIed lIels due lo Milonycin-C use
- InferiorIy pIaced lIels
- Leaking hIlering lIels
Q.28. What arc thc varInus mcasurcs fnr prcvcntIng
Endnphtha!mItIs?
- An|iscp|ics. 5 povidone - iodine for al Ieasl 3 ninules
is lhe nosl inporlanl prophyIaxis in nany sludies,
decreasing conjunclivaI and periorlilaI skin ora.
- AvaiIalIe dala in lhe Iileralure shovs no reduclion
of risk of endophlhaInilis vilh preoperalive culling
of eye Iashes. Taping lack of lhe Iashes and excIusion
fron lhe surgicaI heId is hovever reconnended.
- Any IocaI/syslenic source of infeclion shouId le ruIed
oul.
- SingIe use inslrunenls are aIvays preferalIe especiaIIy
lulings.
- TopicaI anliliolics especiaIIy 4lh generalion
uoroquinoIones appear lo le very effeclive in
reducing conjunclivaI ora Ioad. ul no conlroIIed
cIinicaI lriaIs prove lheir effecl in reducing incidence of
LndophlhaInilis.
- SiniIarIy, lhe efhcacy of anliliolics in lhe infusales and
posloperalive sulconjunclivaI anliliolics is unproved.
Q.29. WhatarcthcprngnnstIcfactnrsInEndnphtha!mItIs?
Ans. Irognosis in endophlhaInilis depends on:
- CuIlure resuIls (leller prognosis in cuIlure negalive
cases)
- Tining of disease onsel (good prognosis vilh deIayed
onsel)
- ViruIence of organisn: More viruIenl organisns such
S, aureus, Slreplococcus species, aciIIus species,
Iseudononas cause rapidIy progressive danage and
carry lhe vorsl visuaI oulcones.
Lov viruIenl organisns such as S. epidernidis and I.
acnes are associaled vilh indoIenl course and carry
leller visuaI oulcones.
Monthly Clinical Meeting, October 2011 MMM hll Cll l O bb MMMMMoooonnnnnttttthhhhhlllllyyyy CCCCllliiinnnniiiiicccaaaallll MMMMMeeeeeeeetttttiiiiinnnnnggggg,,, OOOOccccttttoooobbbbbeeeeerrrr 2222000011111111 MMMooonnnttthhhlllyyy CCCllliiinnniiicccaaalll MMMeeeeeetttiiinnngggg,, OOOccctttooobbbbeeerrr 222000111111
Vcnuc: Audiloriun, Curu Nanak Lye Cenlre, Nev DeIhi
Datc&TImc: 3Olh Ocloler, 2O11 (Sunday)
RLAKIAST & RLCISTRATION: 1O:OO a.n.
C!InIca!Cascs:
1. Monilored approach lo lhe nanagenenl of severe peIIucid
narginaI degeneralion : Dr. Rilu Arora
2. AlypicaI noliIily presenlalion : Dr. I.K Iandey
C!InIca!Ta!k:
- ICC nedialed pholo lhronlosis: A cosl effeclive
aIlernalive in poslerior segnenl diseases : Dr. . Chosh
MInI5ympnsIum: Never Trealnenl ModaIilies
Chairperson: Dr. I.K. Iandey, Dr. }.L. CoyaI
1. OrlhokeraloIogy for nyopia regression A vialIe oplion : Dr. Kirli Singh
2. Never lrealnenl nodaIilies in LaIes disease : Dr. Meenakshi Thakar
3. Laser assisled DCR lhe currenl scenario : Dr. Ruchi SangaI
Lunch: 1:OO I.M. onvards 2O LarIy ird Irizes
A
28 year oId vas doing veII aloul 15-2O days lack vhen
he noliced dininulion of vision of his righl eye. Il vas
associaled vilh fever vhich vas of noderale inlensily,
lhere vas associaled neck sliffness and pain on novenenl,
headache and nausea, and ringing in ears. Over lhe period
of nexl 3-4 days lhe vision in his righl eye vorsened and he
even slarled nolicing sone vision Ioss in his Iefl eye. He nov
cane lo Safdarjajng HospilaI. Al lhis line visuaI acuily in his
righl eye vas 6/6O (6/24) on pin hoIe and lhal of Iefl eye vas
6/9. olh eyes Conjuncliva, cornea, anl chanler, iris, pupiI,
Iens vere WNL, lul lolh eyes fundus exaninalion reveaIed:
C!.:.c.! Hcc.:. r!.:.c.! r.c:
Niketa Rakheja
Niketa Rakheja, H. S. Sethi
Dcpar|mcn|cf|qc,SafarjungHcspi|a|,NcuDc|ni
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)
Oplic disc-hyperenia, nacuIar foIds, areas of shaIIov serous
relinaI delachnenl. IrovisionaI Diagnosis of /L poslerior
uveilis vas nade and palienl vas advised adnission lul he
didnl lurn up.
He cane lo us 3 days Ialer, lhis line vilh addilionaI
conpIainls of valering, severe congeslion, disconforl in
opening eyes in Iighl, pain in lolh lhe eyes aIong vilh
vorsening of visuaI Ioss in lolh lhe eyes and he vas adnilled
vilh foIIoving piclure: visuaI acuily righl eye 2/6O and Iefl
eye ICCI IL+, IR= accurale, olh eyes had circunciIiary
congeslion, nullon fal kps ceIIs 3+, are 2+, poslerior
synechiae, snaII, irreguIar, non reacling pupiI. Al lhis poinl,
fundus gIov vas presenl lul nedia vas hazy and delaiIs
vere nol cIearIy seen. Nov, USC scan vas done al lhis
poinl and il reveaIed presence of relino-choroidaI lhickening,
exudalive relinaI delachnenl, vilreous delris (lolh lhe eyes).
Revised diagnosis of iIaleraI panuveilis vas nade al lhis
poinl, and foIIoving differenliaIs vere kepl in nind: VKH,
Synpalhelic ophlhaInia, TulercuIosis, Sarcoidosis, ehcels
disease. Invesligalions reveaIed: Hl : 13.5 gn, TLC :96OO
ceIIs/nn, DLC :I 6O L33 M2 L5,LSR:O5 nn/hr, nonloux
lesl: 5x6 nn, Randon lIood sugar:1O7ngKIT:urea=23,cr
=O.6,VDRL:non reaclive, HIV 1 and 2: negalive, Serun ACL:
WNL, Serun caIciun: WNL, CRI: negalive, Urine (R n M) :
1-2 pus ceIIs., no RCs, Serun LLISA for T negalive, CSI
ceIIs: 14/cunn CSI prolien and sugar(2O and 6O), Serun
anliphosphoIipid anlilody: negalive, Chesl x ray-nornaI,
Serun ANA: negalive, Audionelry (lolh ears)-nornaI.
Ialienl vas slarled on inlravenous sleroid puIse lherapy
(1OO ng dexanelhasone in 25O nI DNS) over 45 ninules
x3 conseculive days TopicaI Ired acelale 1 given 2 hrIy
in lolh lhe eyes. Lye drops Alropine 1 given lhree lines
a day lopicaIIy in lolh lhe eyes. Lxaninalion afler 4 days
of slarling sleroid lherapy reveaIed lolh eyes ,visuaI acuily
6/18, circunciIiary congeslion decreased ,nullon fal kps+,
ceIIs- niI, are 2+, pignenls + in a ring on lo anl IenlicuIar
surface, fundus: gIov +,oplic disc-hyperaenia +, nacuIar
foIds+, areas of shaIIov serous RD couIdnl le apprecialed.
A narked inprovenenl in synplons and visuaI acuily vas
noled over lhe foIIov up period and palienl vas nainlained
on high dose oraI sleroids and azalhioprine. A hnaI diagnosis
vas nade: /L panuveilis
`CouId il le inconpIele VOCT-Koyanagi-Harada syndrone
Discussion
VKH syndrone or uveoneningilic syndrone is a syslenic
disorder. Il vas hrsl descriled ly an Iersian physician (AIi-
iln-Isa 94O-1O1OA.D.)
Il has prediIeclion for nore darkIy pignenled races. Mosl
palienls are in lhe second lo hflh decade, vonen are affecled
nore frequenlIy lhan nen. The auloinnune aspecl in VKH
incIudes a ceIIuIar innune response againsl neIanocyles.
Our palienl couId le a possilIe candidale of inconpIele
VKH, according lo AUS Diagnoslic crilerion for VKH
(crileria 1-3 AND 4 or 5). Ialienl is leing foIIoved up for any
deveIopnenl of Iale inlegunenlary changes or occurrence of
lypicaI pignenlary changes in lhe fundus. A cIear diagnosis
can le expecled onIy in line lo cone....
References
1. Cunningnam|T,c|a|.Am]Opn|na|mc|Nct1995,120(5).675-7
2. Mccr|nqRS,c|a|.SurtcqcfOpn|na|mc|cgq1995,39(4).265-92
3. Sa|amc|cT,c|a|.ArcnOpn|na|mc|1991,109.1270-4
4. |cs|crD],c|a|.A]OMarcn1991,111(3).380-2
5. Ru|samcnP|,Gass]DM.ArcnOpn|na|mc|1991,109.682-7
1. Visiling ConsuIlanls (Sul SpeciaIily) - IeIIovship cerlihcalion preferred
(1) CIaucona (3) OcuIopIaslics
(2) Cornea (4) Vilreo-relina
2. Irojecl OphlhaInoIogisls - Connunily Lye Care Irojecl
3. Senior Residenls in OphlhaInoIogy (MS/DO)
AppIy in conhdence lo Adninislralor, ADLH ly enaiI, or in person, afler prior appoinlnenl.
Arunodaya Deseret Eye Hospital (ADEH)
Sector-55, Plot # NH-4, Gurgaon 122003, Haryana, INDIA
Tel.: (0124) 4116003/04/05
Email: arunodayai@yahoo.com
Web: www.adeh.org.in, www.acteyecare.com
AWorIdCIassfyeHospitaI
Invites Ophthalmologists with a vision to join ADEH in
its crusade to reverse the tide of curable blindness
Instructions:
1. IIease relurn your ansvers lo doslines1OgnaiI.con or naiI lhen lo ThcQuIzmastcr, DOS Tines Quiz, Dr. Rohil
Saxena, Roon No. 479, Dr. R.I. Cenlre for OphlhaInic Sciences, AII India Inslilule of MedicaI Sciences, Ansari Nagar,
Nev DeIhi - 11OO29. IIease vrile your DOS nenlership nunler aIong vilh your ansvers.
2. The ansvers shouId reach nol Ialer lhan 23rd Novenler 2O11.
The quiz can aIso le vieved and direclIy ansvered on our velsile vvv.dosonIine.org
3. The resuIls viII le announced al lhe DOS nonlhIy cIinicaI neeling on 27lh Novenler 2O11. The correcl enlry viII le
awardcd a prIzc nf Rs. 2100 a!nng wIth a ccrtIcatc. If lhere are nore lhan one correcl enlries, lhe vinner of lhe prize
viII le decided ly drav of Iols. Al lhe end of lhe year lhe person vho has gol lhe naxinun nunler of correcl enlries
viII le avarded.
QuIzcnmpI!cdbyDr.DIgvIjay5Ingh
Menlership No. ____________________ Nane : ____________________________________________________
MoliIe No. __________________________________ LnaiI: ____________________________________________
Answer to DOS Times Quiz October 2011
A. __________________________________________ . _________________________________________
C. __________________________________________ D. _________________________________________

(B) (C)
(A)
QuizPrizcsSpcnscrc|q
M/s. Raymed Pharmaceuticals Ltd.
(D)
The DOS Times Quiz for July 2011 issue received 45 responses of which the correct answers were
given by 1. Dr. Sheetal Bakshi, Ahmedabad 2. Dr. Tarun Arora, Delhi 3. Vivek Pravin Dave, Mumbai
4. Dr. Ankit Soni, Aligarh. The winner of the prize money decided by a draw of lots is:
Dr. Rishi Mehta, Udaipur, Membership No. 4766
Answers of DOS Times Quiz July 2011 are:
1. Moorens UIcer / PeripheraI uIcerative |eratitis. 3. Hyphema
2. OccIudabIe AngIe (Gonioscopy Photography) 4. Type 1 Duanes retraction syndrome
The DOS Times Quiz for August 2011 issue received 21 responses of which the correct answers were
given by 1. Dr. Neha Rathi, New Delhi 2. Sparshi Jain, Noida 3. Gunjan Abhijit Deshpande, Nagpur
4. Ranjeet Kishore Rana, Delhi 5. Shalini Mohan, Kanpur 6. Anusha V., New Delhi were correct. The
winner of the prize money decided by a draw of lots is:
Dr. Mayee Rishi|esh Charudatta, Nagpur, Membership No. CD-13S8
Answers of DOS Times Quiz August 2011 are:
A
1
S T I G
2
M A T
3
I S M L
4
M
5

M R O I A
6
A
A E A
7
R C N
8
E P A F E N A C
U E I I G U
R N A
9
C U T E
10
D S
11
I L
O G P T O A
S
12
I N U S
13
A A
14
N I R I D I A I
I C R K I D
S
15
C O
16
P O L A M I N E N S
R T G R T
V
17
B O A A
18
M S L E R G R I D
I I M R T E
D
19
O T A H
20
Y P O P Y O N A O
21

A O P K P
R T
22
R I C H I A S I S S T
A U
23
N A I
B
24
U L L S E Y E K C
I C R I
25
R I S
26
C L A
27
W P
N E A E I I
E
28
N T R O P I O N C
29
A T A R A C T
Answer for DOS Times Quiz month of
)uIy&August2011
Yogesh BhadangeM88S,Brijesh TakkarM88S,Bhavin ShahM88S,Rajesh SinhaMD
Dr.RajcnraPrasaCcn|rcfcrOpn|na|micScicnccs,A||MS,NcuDc|ni
Tc.. |cc
Yogesh Bhadange
Tc.. |cc
4. Intracameral Agents
A. Antibiotics and Antifungals
IrophyIaclic as veII as Therapeulic uses.
Bn!usdnscnfcnmmnn!yuscdantIbIntIcs
Vanconycin 1ng/O.1nI
CefazoIin 1ng/O.1nI
Cefuroxine 1ng/O.1nI
Calioxacin 1OOnicrogran/O.1nI
Moxioxacin 1OOnicrogran/O.1nI
Anpholericin 5-1O nicrogran/O.1nI
AntIbIntIcs used in irrigaling uids
Drugs DI!utInnIn FIna!cnnccntratInn
IrrIgatIng 0uId
Vanconycin O.5nI is nixed 25-5O nicrogran/nI
(5O ng/nI) vilh 5OOnI
irrigaling uid
Cenlanycin O.1nI is nixed O.OO8ng/nI
(4O ng/nI) vilh 5OOnI (O.OOO8)
irrigaling uid
B. Mydriatics
AdrenaIine larlarale (O.1 v/v, 1:1OOO) is diIuled len lines
ie.O .1 nI of adrenaIine diIuled in O.9nI of SS ,used as
loIus dose.
Ior nainlaining nydriasis O.8cc adrenaIine larlarale (O.1
v/v 1:1OOO) is diIuled in 35O nI of SS.
C. Miotics
Pilocarpine: O.1 nI of lhe drug (25ng/nI) is diIuled in
O.1nI ringer Iaclale, used as loIus dose.
O.8nI of piIocarpine (O.5 of ophlhaInic preparalion) is
added lo 35O cc of SS, used as nainlenance dose.
5. Posterior Subtenon Injection:
2Ong / O.5nI of lriancinoIone acelonide preservalive free
preparalion (reliIone\ aurocol) is injecled using lhe Snilh
and Novaks lechnique vilh 26 Cauge needIe or lhe cannuIa
lechnique.
6. Posterior Juxta Scleral Depot Injection:
Anacorlave acelale, a corlisone, synlhelic anaIogue of
corlisoI acelale vilh no gIucocorlicoid aclivily, acls ly
suppression of exlraceIIuIar proleases eIaloraled ly
aclivaled endolheIiaI ceIIs and aIso decreases VLCI IeveI.
Dose-15ng poslerior juxla scIeraI depol injeclion every 6
nonlhs for lrealnenl of vel ARMD.
7. Intravitreal Drugs:
A. Antibiotics:
VancnmycIn(1mg\0.1m!)avaI!ab!ccnmmcrcIa!!yas500
mgpnwdcr
Add 1O nI of Ringer Laclale 5OOng in 1OnI
Take O.2 nI Has 1O ng
Make il 1 nI 1O ng in 1 nI
Take O.1 nI 1 ng in O.1 nI
CcftazIdImc (2.25mg\0.1m!) avaI!ab!c cnmmcrcIa!!y as
500mgpnwdcrInjcctInn
Add 2 nI 5OOng in 2nI
Take O.1nI 22.5ng in O.1nI
Make il lo 1 nI 22.5 ng in 1nI
Take O.1nI 2.25ng in O.1nI
B. Antifungal
AmphntcrIcIn B: (5 mIcrngram\0.1m!) avaI!ab!c
cnmmcrcIa!!yas50mgpnwdcr
Add 1OnI in 5 dexlrose 5O ng in 1OnI
Take O.1 nI O.5 ng
Add 9.9nI O.5 ng in 1OnI
O.OO5 ng in O.1nI
VnrIcnnazn!c(avaI!ab!ccnmmcrcIa!!yas200mgpnwdcr)
50-100mIcrgram\0.1m!
Add19 nI disliIIed valer 2OOng in 2OnI
Take 1 nI
Add 9nI disliIIed valer 1Ong in 1OnI
Take O.O5nI or O.1nI for inj. 5Onicrogran or
1OOnicrogran
C. Intravitreal Drugs List in Tabular form
Drugs Dnsagc
Antibacterials
Vanconycin 1 ng/O.1nI
Ceflazidine 2.25 ng/O.1nI
Anikacin 4OO nicrogran/O.1nI
Cenlanycin 2OO nicrogran/O.1nI
An|ifunga|s
Anpholericin 5 nicrogran/O.1nI
VoriconazoIe 5O-1OO nicrogran/O.1nI
An|itira|s
AcycIovir 1O-4O nicrogran/O.1nI
CancycIovir 2 ng/O.1nI
S|crcis
Dexanelhasone 4OOncg/O.1nI
TriancinoIone acelonide 1-4 ng/O.1 nI of
preservalive free
TriancinoIone acelonide
(4Ong/nI)
Anti VEGFs
Iegaplinil (Macugen) O.3ng/O.O9nI of prehIIed
syringe
evacizunal (Avaslin) 1.25ng/O.O5nI
1 anpouIe- O.2nI
1 viaI- 4nI or 16nI of
25ng/nI
Ranilizunal (Lucenlis) O.5ng/O.O5nI
VLCI lrap O.O5-4 ng (underlriaI)
SiRNA 7O-3OO nicrogran
(underlriaI)
Implants
CancycIovir inpIanl (vilraserl) 4.5 ng in 2.5 nn
liodegradalIe inpIanl.
ReIeases al 1 nicrogran/
hour
Therapeulic IeveIs for 8
nonlhs
Dexanelhasone inpIanl O.7 ng nicrogran
(ozurdex) liodegradalIe inpIanl
Therapeulic IeveIs for 37
days. Uses NOVADUR
deIivery syslen.
IIuocinoIone acelonide (reliserl) O.59 ng liodegradalIe
inpIanl. ReIeases O.4
nicrogran/day.
Therapeulic IeveIs for 3O
nonlhs.
D. Intraocular Gases:
Gas Mn!.Wt. ExpansInn LnngcvIty Nnn- Vn!.
(purcgas/ Days ExpansI!c InjcctcdIn
100%cnnc.) Cnnc. PncumatIc
RctInn-
pcxy
Air 29 O 5 - 7 - 1.O nI
SI
6
146 2 lines 1O-14 18 O.5 nI
C
3
I
8
188 4 lines 55-65 14 O.3 nI
Dr. Rajvardhan Azad, MD, FRCSed, FICS, FAMS, for being appointed as Chief,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi. He is
also Professor of Ophthalmology and Head, Vitreo-Retina, Ocular Trauma and
ROP Services at the Centre.
CongratuIations

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ROI is unique in lhal il affecls an innalure, inconpIeleIy

has revised lhe lrealnenl guideIines. This sludy proved lhal

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