March-April 2017

Editor-in-chief Volume 22 No. 5
March-April
M. Vanathi 2017

Section Editors Editorial Capsule Innovations
Cataract & Refractive Retina & Uvea 5 DOS Shining… 47 Ranjan MSICS Marker: The
Umang Mathur Pradeep Venketesh Beginning of Topical, Flapless,
Saurabh Sawhney Parijat Chandra Featuring Sections Astigmatism Free MSICS Era
Sanjiv Mohan Manisha Aggarwal
S. Khokhar Shahana Majumdhar Refractive Surgery Community Ophthalmology
C ornea & Oular Surface Rohan Chawla 9 Bioptics 49 Determining an Ocular Health
Uma Sridhar Ravi Bypareddy
Deepa Gupta Ophthalmoplasty & Problem as a Public Health Issue
Umang Mathur Ocular Oncology
Ramendra Bakshi Neelam Pushker Cornea Snapshot
Manisha Acharya Maya Hada 13 Meibomian Gland Dysfunction 51 Rubeosis Iridis and Collaterals at
Noopur Gupta Sangeeta Abrol 19 Role of Imaging Modalities in Optic Disc Following
Glaucoma Rachna Meel Peripheral Ulcerative Keratitis Atherosclerosis
Dewang Angmo Squint &
Reena Sharma Neuro-ophthalmology Glaucoma 55 Traumatic Intraorbital
Sunita Dubey Digvijay Singh
Viney Gupta Zia Chaudhuri 21 Biometry for the Management of Encephalocele Presenting as
Kanak Tyagi Suma Ganesh Angle Closure in Young Patients Proptosis: A Case Report
25 Complications of 57 Dermoid
Delhi Advisory Board
Y.R. Sharma Mahipal Sachdev Trabeculectomy Miscellaneous
Atul Kumar Radhika Tandon
P.V. Chadha Jolly Rohtagi Retina 59 IRIS CLAW LENS – The Forgotten
Noshir M. Shroff J.C. Das 31 OCT Angiography Hero
Rajendra Khanna B.P. Gulliani 63 Dyes and Stains Used in
Vimla Menon Ritu Arora 37 Optical Coherence Tomography Ophthalmology
H.K. Yaduvanshi Kamlesh Based Classification of Diabetic
Anita Panda G.K. Das
Pradeep Sharma Lalit Verma Macular Edema DOS Crossword
Ramanjit Sihota Tanuj Dada
Harish Gandhi Abhishek Dagar Squint 69 DOS CROSSWORD-
Anup Goswami Sarita Beri
Rajpal P.K. Sahu 41 Clinical Examination of Paralytic Episode 5
Mandeep Bajaj Kamlesh
B. Ghosh Taru Dewan Strabismus DOS TIMES Quiz
Rajiv Garg H.S. Sethi
R.B. Jain H.K. Tewari Monthly Meeting Korner 71 QUIZ - Episode 5

National Advisory Board 45 The Invisible Scotoma – Role of
R.D. Ravindran Barun Nayak Retinal Reflectance Imaging
Debashish Bhattacharya Venketesh Prajna News Watch
R. Revathi S. Natarajan
Yogesh Shah Amod Gupta 75 DOS Clinical Monthly Meet–VI
Arup Charaborti Jagat Ram
Anita Raghavan Amar Agarwal DOS Membership fee Revision
Chandna Chakraborti Mangat Ram Dogra Please note that DOS Membership Fee for new
Sushmita Shah D. Ramamurthy
Sushmita Kaushik T.P. Lahane members has been revised to Rs. 5,600/-
Pravin Vadavalli Samar Basak with effect from September 10, 2016.
Somshiela Murthy Cyrus Mehta
Sri Ganesh Mahesh Shanmugam www. dos-times.org 1
M.S. Ravindra J. Biswas
Rohit Shetty Srinivas Rao
Mallika Goyal Nikhil Gokale
Partha Biswas Santosh Honavar
Nirmal Frederick Arulmozhi Varman
Abhay Vasavada Mohan Rajan
Mukesh Taneja Rakhi Kusumesh
Shalini Mohan Gopal S. Pillai
Ragini Parekh Subendu Boral
Tejas Shah Gunjan Prakash
Sujith Vengayil Pravin More
M. Kumaran Sajjad Ahmed Shiekh
Punith Kumar Santhan Gopal
Elankumaran

DOS Correspondents
Anita Ganger Dewang Angmo
Rebika Dhiman Shikha Yadav
Manish Mahabir Archita Singh
Raghav Ravani Meenakshi Wadwani
Divya Singh Mayank Bansal
Mukesh Patil Saranya

DOS TIMES
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Printer: New Pusphak Printers
Cover Design: Aman Dua

DOS Times will hitherto be published once every two months by Dr.
M. Vanathi, on behalf of Delhi Ophthalmological Society, DOS Secretariat,
Dr. R.P. Centre, AIIMS, New Delhi. All solicited & unsolicited manuscripts
submitted to DOS TIMES are subject to editorial review before acceptance.
DOS TIMES is not responsible for the statements made by the contributors.
All advertising material is expected to conform to ethical standards and
acceptance does not imply endorsement by DOS TIMES. ISSN 0972-0723

DOS EXECUTIVE MEMBERS

Executive Committee:

DOS Office Bearers

Dr. Rishi Mohan Prof. Kamlesh Dr. M. Vanathi
President Vice President General Secretary

Dr. Arun Baweja Dr. Vipul Nayar Dr. Ruchi Goel Dr. Deven Tuli
Joint Secretary Treasurer Editor Library Officer
DOS Representative to AIOS
Executive Members

Dr. Jatinder Singh Bhalla Dr. Bhuvan Chanana Dr. Anshul Goyal Dr. Avnindra Gupta Dr. Rohit Saxena

Dr. Rajat Jain Dr. Deepankur Mahajan Dr. J. K.S. Parihar Dr. Manavdeep Singh Dr. Ashu Agarwal

Ex-Officio Members

Dr. Cyrus M. Shroff Dr. Rajesh Sinha Dr. Sanjeev Gupta
Ex-President Ex-Secretary Ex-Treasurer

DOS HALL OF FAME Tejpal Saini Satinder Sabharwal Dos General Secretaries
DOS PRESIDENTS Satish Sabharwal A.K. Grover
N.C. Singhal J.C. Das Hari Mohan Arun Sangal
S.N. Mitter A.C. Chadha Madan Mohan Gurbax Singh R.S. Garkal R.V. Azad
H.S. Trehan M.S. Boparai Pratap Narain Noshir M. Shroff S.R.K. Malik B. Ghosh
Tej Pal Saini N.N. Sood (Brig.) R.C. Sharma Mahipal S. Sachdev Madan Mohan Mahipal Sachdev
L.P. Agarwal P.K. Jain B.N. Khanna Lalit Verma J.C. Bhutani Atul Kumar
D.C. Bhutani L.D. Sota R.N. Sabharwal S. Bharti S.C. Sabharwal Lalit Verma
R.C. Aggarwal L.D. Sota N.L. Bajaj Sharad Lakhotia A.C. Chadha Dinesh Talwar
S.N. Kaul S.K. Angra Mathew M. Krishna P.V. Chadha Pratap Narain Harsh Kumar
S.N. Kaul D.K. Mehta Prem Prakash B.P. Guliani S.K. Angra J S. Titiyal
H.S. Trehan Y. Dayal D.K. Sen Harbansh Lal G. Mukherjee Harbansh Lal
Hari Mohan K.P.S. Malik P.K. Khosla J S. Titiyal H.K. Tewari Namrata Sharma
R.S. Garkal R.B. Jain K. Lall Rajendra Khanna R. Kalsi Amit Khosla
J.C. Bhutani G. Mukherjee A.K. Gupta Cyrus Shroff D.K. Mehta Rohit Saxena
S.R.K. Malik R.V. Azad B. Pattnaik Rishi Mohan P.C. Bhatia Rajesh Sinha
K.P.S. Malik M. Vanathi

Sincere thanks to all DOS OFFICE STAFF : Office Secretary: Parveen Kumar w DOS Accountant: Sandeep Kumar w DOS TIMES Assistant: Sunil Kumar
DJO Assistant: Varun Kumar w Library Attendant: Niyaj Ahmad w Office Attendant: Harshpal

3 DOS Times - March-April 2017

Editorial Capsule

“Achievement is not always success, while reputed failure often is.
It is honest endeavor, persistent effort to do the best possible under any and all circumstances.”

DOS Shining…..

Dear DOS Members,

It was fireworks at AIOC 2017 for Delhi Ophthalmological Society, which fielded a record number of contestants
from its portals and also witnessed a huge mandate from the ophthalmologists across the country. As we exalt in our
success, we also extend our warm camaraderie to all the other contestants
from Delhi and across the country. As DOS stands tall with commitment to
excel in all endeavors and aspects of ophthalmology, I wish to express my
sincere gratitude for all your patronage, as your power of support is our
strength to perform and excel.

With the success of winterDOS 2016 & the Joint iDOS – COSL 2016 still
ringing high notes, we move on to the full swing of preparations for a fabulous
closing conference of the executive of DOS 2015 – 2017: the 68th Annual DOS
conference – DOSCON 2017: OPHTHALMIC SPECTRUM.

We saw many HIGHs and NEWs in our last year’s conferences of DOS Dr. M.Vanathi
introducing the scanning codes for badges, content and delighted trade
delegates with the Ophthalmic Exhibition placed under one roof, maximal
participation of ophthalmic companies and conference delegates from across
the country, introduction of several national society sessions (EBAI, Cornea
Society of India, ISCKRS, VRSI), introduction of Symposias and Instruction
Courses, Ophthalmic Photography and DALK – DSEK workshop in our
conference and much more, which has set standards and serves as role model
for all other ensuing conferences in the country.

DOSCON 2017 also promises to enthrall our delegates with many new sessions, the foremost being the first of its
kind, a joint session with the renowned international society ESCRS: DOS – ESCRS Refractive Symposium and DOS
– ESCRS Cataract Symposium. The Special Session on Complex cataract scenarios by renowned international and
national cataract FACULTY from the country promises to be a wonderful treat. There is also wide participation from

other National Societies with wonderful session of DOS with Glaucoma Society of India, Ocular Trauma Society
of India, Ophthalmoplasty Association of India, and SPOSI assembled in line for all. This year’s annual conference

brings to you a special INAUGURATION session with a difference. DOS Orations will now run as a separate session.
We will also feature all the regulars of DOSCON 2017 Quiz, free papers, posters, ophthalmic photography, eposters

and e-videos. Special attraction of NABH symposia and instruction courses on Eye Hospital Setup from successful
young ophthalmologists across the country and several other dedicated courses on OT Sterilisation, DMEK,
Macular surgery, SMILE to be conducted by veteran ophthalmologists from across the country also adds on to the
special features of this year’s DOSCON 2017.

Looking forward to greeting you all for DOSCON 2017: OPHTHALMIC SPECTRUM

With best regards

Dr. M.Vanathi MD
DOS General Secretary
& Prof of Ophthalmology
Cornea & Ocular Surface, Cataract & Refractive Services
Dr R P Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi 110029
[email protected]

www. dos-times.org 5

President Message

Respected Seniors and esteemed Colleagues,

Greetings from the DOS Executive!

It gives me great pleasure to write this Special Message in this issue of the DOS
Times. It has been an eventful couple of months since the last edition.

Heartiest Congratulations are due to our esteemed members who participated Dr. Rishi Mohan
wholeheartedly in the recently concluded AIOS Elections and helped elect the team
from Delhi. Our Members emerged victorious in the contests for various key posts and
committee memberships with great aplomb, reflecting the will of the people across the
nation. That leaders from Delhi command the love and respect of a wide diaspora is a

matter of great pride and a singular honour for our Society.

The iDOS-COSL Meeting in Colombo, SriLanka from December 22-24, 2016 was
a super-hit, with positive feedback from all quarters. In a first-time endeavor, delegate member groups from Delhi,
Mumbai and Chennai were coordinated to come together in Colombo. There was a superb mix of scientific deliberation,
relaxation and social events. The participation of our SriLankan colleagues and the quality exchange of views and

experience augurs well for the relations between our great Societies and our neighbours. Thanks are due to our

Secretary and Treasurer and all others who contributed to the success of the Meeting.

Innovative changes in last year’s Programme have influenced scientific programme structures in other conferences
across the country. More such innovations are on the anvil in the forthcoming “Ophthalmic Spectrum” DOSCON 2017
extravaganza and will, hopefully be appreciated by all. The ESCRS (European Society for Cataract and Refractive
Surgeons) shall be conducting 2 Joint Symposia with the DOS in the Conference. Special sessions have been
incorporated for Complex Cataract Scenarios and sub-speciality content as well as a full day of vibrant and robust
Live Surgery.

Swami Sivananda once said “Put your heart, mind, intellect and soul even to your smallest acts. This is the
secret of success”. We should collectively strive to live up to that ideal and continue to ensure that the DOS retains its
torchbearer status.

With Warm Regards,

Dr. Rishi Mohan
President, Delhi Ophthalmological Society
&
Director, MM Eyetech Institute of Ophthalmology,
Lajpat Nagar-3, New Delhi.
Tel: +91 9811107007
+91-11-29847700, 29847800

Refractive Surgery

Bioptics

Sudarshan Khokhar, Esha Agarwal, Ganesh Pillay

Sinceitsinception,refractivesurgeryhaschangedlives Indications
of millions imparting unaided near normal vision. In
Planned Bioptics
the past decade, refractive surgery has undergone
• High myopia or hyperopia with astigmatism

sea change, giving us more treatment options, • High myopia or hyperopia with difficult refraction
refining our surgical techniques and resulting in
better visual outcomes. Latest advancements such assessment or difficult intraocular lens power calculation.

• Moderate myopia with astigmatism with reduced corneal
as Femto LASIK and ICL have further broadened our treatment
indications, benefitting more patients. However, anatomical thickness that allows a limited laser ablation.
limitations such as thin cornea and shallow AC along with large • Presbyopia
• Keratoconus and Pellucid marginal degeneration

refractive errors still pose a hurdle for viability of a particular

refractive procedure. Unplanned Bioptics
Bioptics is a sequential method of treating large and
• Unexpected residual error after cataract surgery or phakic
complex refractive errors by combining refractive procedures lens implantation
targeting different mechanisms of action1,2. Hence a combination

of refractive procedures with similar mechanism is not true Reverse Bioptics
bioptics. It comprises of an intraocular implant (phakic or

pseudophakic intraocular lens) along with a modification of • Regressed corneal surgery and inopportune retreatment

corneal curvature(laser ablation, intrastromal implants, conic

intrastromal relaxing incisions, thermoplasty). This coalition Patient Assessment

not only offers correction of large refractive errors, but at the Comprehensive preoperative evaluation and appropriate

same time provides greater counselling of every patient

safety and predictability with Bioptics is a sequential method of treating undergoing any refractive
a chance to refine residual large and complex refractive errors procedure is imperative as
refractive error that may have by combining refractive procedures postoperative results depend
largely on preoperative workup.
been induced by primary

implantation surgery. targeting different mechanisms of Postoperative complications can

History action. Hence a combination of refractive be minimised by selecting most
procedures with similar mechanism is viable refractive procedure
The concept of bioptics not true bioptics based on patient evaluation and
was first described by Roberto expectation. This holds truer for
Zaldivar2 in 1996 when he patients undergoing bioptics

performed LASIK to treat (between intraocular surgery

residual refractive error in high myopes that had undergone and corneal procedure). Pre and perioperative assessment

phakic IOL correction. Thereafter, Jose Guell3,4,5 gave the include measurement of uncorrected visual acuity and best

concept of adjustable refractive surgery, where he performed corrected visual acuity with refraction (manifest refraction and

LASIK to correct residual ametropia following different types cycloplegic refraction), pupillometry, slit lamp examination,

of intraocular procedures. Since then ophthalmologists have corneal topography, anterior segment measurements

explored several techniques with IOL implantation succeeded (ACD, WTW), pachymetry, specular microscopy, A-scan

by laser corneal ablation to correct large and complex refractive ultrasonography, gonioscopy and dilated fundoscopy.
errors. Thus, the definition of bioptics has now expanded to

include phakic, pseudophakic and clear lens extraction with Technique

successive surgery on the corneal plane. In Planned Bioptics, the timing of LASIK flap creation is a

Classification major concern with varied approaches described in literature.
Some surgeons suggested a three phase approach4 (flap creation,

Planned Bioptics - To correct high and complex refractive intraocular surgery, laser ablation) to avoid complications like

errors using a sequential approach2-4. endothelial loss and IOL dislocation during suction. However,

Unplanned Bioptics - To improve the results of an this approach had an increased risk of epithelial ingrowth

imprecise primary surgery5,6. after lifting the flap for enhancement procedure. Thus, a safer

Reverse Bioptics - Where secondary refractive lens and more accurate technique was to perform bioptics in a

exchange or phakic intraocular lens implantation is done sequential fashion in which intraocular surgery was performed

following regressed corneal surgery7. first and refraction allowed to stabilize for 3 months prior

to LASIK enhancement8,9,10. The advantage of this approach

www. dos-times.org 9

Refractive Surgery

was that it minimized the incidence Reverse Bioptics meta-analysis16 calculated the risk of
of epithelial ingrowth and other flap retinal detachment to be 1.85% in each
related complications. Demonstration of • LASIK / PRK + Iris fixated phakic IOL eye at 43.5 months after surgery which
endothelial safety during suction, have • LASIK / PRK + Angle supported was only slightly higher compared to non-
led to abandoning the three phases now. operated high myopic eyes (1.5%).
phakic IOL
As bioptics is a combination of • LASIK + Phacoemulsification. Various studies have reported the
two refractive procedures corneal and safety and effectiveness of refractive lens
lenticular, various possible combinations These different combinations have exchange followed by LASIK enhancement
have been proposed for treating different their own advantages and disadvantages for treating high myopia with no retinal
type of refractive errors. in different refractive errors. complication8,17,18.

Myopia Bioptics in Myopia Bioptics in Hypermetropia

• Posterior chamber phakic IOL + Phakic IOLs Phakic IOLS
LASIK
Myopes owing to their relatively The surgical treatment of high
• Posterior chamber phakic IOL + PRK deep anterior chamber, make the hypermetropia is a big challenge due to
• Posterior chamber phakic IOL + implantation of phakic IOLs more safer unpredictability, regression, poor quality
and easier. The subsequent correction of of vision and significant loss of spectacle-
SMILE low residual myopic error can be easily corrected visual acuity. Phakic IOLs in
• Iris fixated phakic IOL + LASIK done with laser ablation having well this respect offer advantages such as
• Iris fixated phakic IOL + LASEK centered wide optical zone. Thus making reversibility, precision, wide range of
• Angle supported phakic IOL + LASIK this combination the most accepted form correction, stability, and preservation of
• Angle supported phakic IOL + PRK of bioptics in myopes. accommodation. However, Phakic IOLs
• Refractive lens exchange + LASIK in bioptic correction can be used only in
• Refractive lens exchange +PRK Zaldiver et al2 who first gave the limited hyperopes due to shallow anterior
concept of bioptics used STAAR collamer chamber19. Thus preferring Iris fixated
Hypermetropia plate lens and LASIK. They found it IOLs. The correction by IOL should aim at
effective and predictable for correcting leaving a myopic or mixed astigmatism.
• Iris fixated phakic IOL + LASIK myopia ranging from -18 to -35 D. Various Myopic LASIK is superior to hyperopic
• Refractive lens exchange + LASIK other possible combinations of phakic LASIK in efficacy and predictability,
• Refractive lens exchange + PRK IOLs with LASIK/PRK have also been apart from perfect centration which
investigated with good results in high is more critical in hyperopic LASIK20.
Presbyopia myopes. Studies have shown that LASIK Complications such as epithelial ingrowth
maneuvers after phakic IOLs do not cause and peripheral melting are also more
• Angle supported multifocal phakic further damage to the endothelium or IOL common after hyperopic LASIK.
IOL + PRK dislocation11-14.
Only few studies have been reported
• Multifocal IOL + PRK Recently, a new bioptic strategy in in the literature using this combination
• Multifocal IOL + LASIK which SMILE (small incision lenticular in hypermetropes. Munoz et al21 used
• Pseudoaccomodating IOL + LASIK extraction) was successfully used combination of Artisan phakic IOL
• Pseudoaccomodating IOL + PRK to correct residual refractive error and LASIK and found it to be safe and
following phakic posterior chamber IOL predictive for correcting high hyperopia.
Keratoconus and Pellucid Marginal implantation in high myopia has been 94.9% of eyes were within ± 1 D and
Degeneration reported15. 79.5% were within ± 0.5 D of emmetropia
in their study.
• Iris fixated phakic IOL + Intracorneal Refractive Lens Exchange
rings Refractive Lens Exchange
Refractive lens exchange consists of
• Posterior chamber phakic IOL + phacoemulsification and in the bag IOL Low risk of retinal complications,
Intracorneal rings implantation for refractive purposes. difficulty in placing phakic IOL and
Refractive lens exchange was earlier poor predictability of corneal surgery
• Phacoemulsification + Intracorneal considered to be associated with increased in high hyperopes makes refractive lens
rings risk of vitreoretinal complications exchange a preferred option.
in myopes. However, modern day
Bioptics after Cataract Surgery phacoemulsification techniques have
shown better safety profile. A recent
• Phacoemulsification + LASIK
• Phacoemulsification + PRK
• ECCE + LASIK

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,AIIMS, New Delhi

Dr. Sudarshan Khokhar MD Dr. Esha Agarwal MD Dr. Ganesh Pillay MD
10 DOS Times - march-april 2017

Refractive Surgery

Refractive lens exchange followed surgery to refine the results28,29,30, both normal and post-corneal surgery
by PRK or LASIK has been successfully keeping in mind the additional risks eyes, is that the spherical equivalent
used for treatment of high hyperopia in they may carry. As cataract patients at autorefraction should be doubled to
various studies22,23. However, one of the comprise of an older population, higher obtain the IOL power. However, no IOL
study reported high rate (62%) of double incidence of epithelial related flap A-constant or IOL model is indicated in
in-the-bag IOL implantation (piggy back) problems must be expected along with their study. In another study, Lecissotti et
resulting in interlenticular opacification dry eye complications. For these reasons, al used Gills formula (originally proposed
in one third of piggy back IOL cases some surgeons prefer surface ablation for piggyback IOLs), in which auto-
because of unavailability of higher IOL procedures over LASIK in these patients. refraction is multiplied by 1.3–1.5 (long
powers. With availability of IOL powers of eye to short eye) and +1D is added and
upto 40 D and improved IOL formulas the Bioptics for Corneal Ectasias found it to be more accurate.
predictability of refractive lens exchange
has increased. Keratoconus and pellucid marginal Conclusion
degeneration often have irregular
Bioptics in Presbyopia astigmatism associated with corneal Through the years, bioptics have
or axial myopia which makes their been used to treat extreme refractive
Presbyopic correction is a dicey treatment difficult by single refractive errors with improved safety and
proposition in refractive surgery. Scleral procedure. Bioptics can play a major predictability. It helps patients with
expanding devices, intracorneal implants, role in this respect. Intracorneal rings degrees of astigmatism and refractive
presbyopic lens exchange using multifocal have been used with iris fixated phakic error outside the limits of each individual
IOLs or accommodative IOLs, bifocal and IOLs, posterior chamber phakic IOLs, and procedure obtaining satisfactory results.
multifocal phakic IOLs are the available phacoemulsification and in the bag IOL31 It allows maximization of the optical
options. Even minimal residual refractive with successful outcomes. In these cases, zone’s size as the optic of the IOL and the
errors after these IOLs may significantly intracorneal rings should be implanted effective optical zone following LASIK
affect both the multifocality and visual first to provide reliable K readings for IOL both diminish in diameter with increased
acuity with worsening of halos. Excimer power calculations. levels of attempted myopic correction, we
laser enhancement is commonly required were able to maximize the optical zone
after these IOLs to refine the results24. Reverse Bioptics of each by invoking both procedures. It
also helps to preserve corneal prolate
Leccisotti A25. performed PRK in 18 Phakic IOL or Refractive Lens asphericity, thus limiting induced
eyes for treatment of residual refractive Exchange after Corneal Procedure spherical aberrations.
error after presbyopic lens exchange
and found that although it improved Laser enhancements to treat Though the use of bioptics has become
distance visual acuity, there was limited unsuccessful corneal refractive surgery a valuable option for young patients who
improvement in halos. So, bioptics can’t have shown to induce recurrent haze and some years ago had no option other than
be used for treatment of halos after ectasia, and for many reasons are poorly the use of glasses or contact lenses. But
presbyopic lens exchange. predictable. Thus, Reverse Bioptics with at the same time patient has to accept the
phakic IOLs or refractive lens exchange, risks of IOL surgery (cataract, glaucoma,
PRK and LASIK enhancement are also offer a valuable option particularly in iol decentration, retinal detachment,
frequently used after angle supported those having thin corneas and large endophthalmitis etc.) as well as those of
multifocal phakic IOL for further regression. corneal refractive surgery, which include
refinement26,27. Newer avenues for future dry eye, irregular astigmatism, keratitis,
might be combining an intracorneal Vaz et al32 and Lecissotti et al have kerectasias and subjective complaints of
implant with an intraocular lens for successfully implanted iris fixated phakic halos, glare and ghost images.
treatment of presbyopia. Intracorneal IOLs and angle supported phakic IOLs
implant use can minimise the negative respectively to correct residual/regressed References
effects of multifocal IOL like glare and refractive errors after corneal refractive
halos by reducing the effective pupil size procedure. Nearly 70% were within 1D of 1. Guell JL, Vazquez M. Bioptics. Int
while simultaneously providing improved emmetropia. Regression must be stable Ophthalmol Clin 2000;40:133–143.
near vision through pinhole effect. and endothelium should be healthy
before undergoing IOL implantation. The 2. Zaldivar R, Davidorf JM, Oscherow S,
Bioptics after Cataract main problem in these cases is of IOL et al. Combined posterior chamber
Surgery power calculation. Lecissotti et al used phakic intraocular lens and laser in situ
van der Heijde formula and adjusted it keratomileusis: bioptics for extreme
Evolution in cataract surgical by overcorrecting myopia by 10% and myopia. J Refract Surg 1999;15:299–
techniques and advancements in IOL have achieved better predictability. 308.
blurred the line between cataract and
refractive surgery. Patients now expect In the presbyopic age group, 3. Guell JL, Vazquez M, Gris O, et al.
early and excellent uncorrected visual refractive lens exchange seems to be a Combined surgery to correct high
acuities following cataract surgery. Thus, better option to perform reverse bioptics. myopia: iris claw phakic intraocular
refining the refractive outcomes after IOL Here again, IOL power calculation poses a lens and laser in situ keratomileusis. J
surgery has become the most pressing problem. Ianchulev et al33 have suggested Refract Surg 1999;15:529–537.
challenge for the cataract surgeon today. intraoperative autorefractometry, which
is performed during phacoemulsification, 4. Guell JL, Vazquez M, Gris O. Adjustable
LASIK and surface ablation between cortical cleanup and IOL refractive surgery: 6-mm Artisan
procedures can be used successfully implantation. Their conclusion, in lens plus laser in situ keratomileusis
(planned and unplanned) after cataract for the correction of high myopia.
Ophthalmology 2001; 108:945–952.

5. Guell JL, Gris O, De Muller A, Corcostegui
B. LASIK for the correction of residual

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Refractive Surgery

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procedures. Ophthalmic Surg Lasers Surg 2003; 29:1167–1173. and multifocal refractive and diffractive
1999; 30:341–349. 15. Erick Hernandez-Bogantes et al. intraocular lenses: comparative clinical
6. Maloney RK, Chan WK, Steinert R, et al. Combined Posterior Phakic Intraocular study. J Cataract Refract Surg 2004;
A multicenter trial of photorefractive Lens and SMILE in a Patient With High 30:2494–2503.
keratectomy for residual myopia after Myopia. J Refract Surg. 2015; 31:5. 25. Leccisotti A. Secondary procedures
previous ocular surgery. Summit 16. Packard R. Refractive lens exchange for after presbyopic lens exchange. J
Therapeutic Refractive Study Group. myopia: a new perspective? Curr Opin Cataract Refract Surg 2004; 30:1461–
Ophthalmology 1995; 102:1042–1052. Ophthalmol 2005; 16:53 – 56.
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7. Leccisotti A. Bioptics: where do things 17. Zaldivar R, Oscherow S, Piezzi V. 26. Baikoff G, Matach G, Fontaine C, et
stand? Curr Opin Ophthalmol. 2006; Bioptics in phakic and pseudophakic al. Correction of presbyopia with
17:399-405. intraocular lens with the Nidek EC- refractive multifocal phakic intraocular
8. Velarde JL, Anton PG, de Valentin- 5000 excimer laser. J Refract Surg lenses. J Cataract Refract Surg 2004;
Gamazo L. Intraocular lens implantation 2002; 18:S336–S339. 30:1454–1460.
and laser in situ keratomileusis 18. Probst LE, Smith T. Combined 27. Baikoff G, Leccisotti A. Phakic multifocal
(bioptics) to correct high myopia and refractive lensectomy and laser in situ IOL. In: Smith R, Belville K, editors.
hyperopia with astigmatism. J Refract keratomileusis to correct extreme Presbyopia surgery: pearls and pitfalls.
Surg 2001;17:S234–S237. myopia. J Cataract Refract Surg 2001; Thorofare, NJ: Slack; 2006. pp. 41–55.
9. Pershin KB, Pashinova NF. Fine 27:632 – 635. 28. Ayala MJ, Perez-Santonja JJ, Artola A,
tuning excimer laser correction after 19. Rabsilber TM, Becker KA, Frisch et al. Laser in situ keratomileusis to
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2000; 16(suppl):S257-S260.
status measured with the Orbscan II 29. Kim P, Briganti EM, Sutton GL, et
10. Pershin KB, Pashinova NF, Miovich O. Topography System. J Cataract Refract al. Laser in situ keratomileusis for
LASIK over pseudophakia - bioptics. J Surg 2003; 29:2115 – 2121. refractive error after cataract surgery.
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11. Munoz G, Alio JL, Montes-Mico R, Belda Artisan iris-claw phakic intraocular lens 986.
JI. Angle-supported phakic intraocular followed by laser in situ keratomileusis 30. Kuo IC, O’Brien T, Broman T, et
lenses followed by laser-assisted in for high hyperopia. J Cataract Refract al. Excimer laser surgery for the
situ keratomileusis for the correction Surg 2005; 31:308–317.
correction of ametropia after cataract
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136:490–499. Oscherow, S. Results and complications 31:2104–2110.

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keratomileusis and photorefractive keratectomy or laser in situ 32. O’hEineachain R. Refractive IOL and
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vision restoration with refractive lens Refract Surg 2005; 31:1530–1536.


Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

12 DOS Times - march-april 2017

cornea

Meibomian Gland Dysfunction

Anita Raghavan, Sushma Poojary

The term Meibomian Gland Dysfunction (MGD) and the meibum is secreted into the ductules by apoptosis.
was first suggested by Korb and Henriquez1.
By definition MGD is a chronic diffuse Mechanical pressure by the orbicularis oculi and the ongoing
formation of meibocytes force the meibum towards the orifices
abnormality of the meibomian glands, commonly to replenish the tear film. The glands secrete continuously
but also deliver directly into the tear film during the blink
characterized by terminal duct obstruction
and/ or qualitative or quantitative changes in upstroke15. The nasal glands are more active than the temporal16

glandular secretion2. Pathological conditions can exclusively and all glands are not active at any given point of time17.

involve only the meibomian glands, but since the glands are a The lipid layer of the tear film retards evaporation of

critical component of the lacrimal functional unit, it is directly the tear film thereby promoting spreadability and stability,

or indirectly responsible for many of the symptoms and signs of prevents contamination from cutaneous sebum, decreases

dry eye disease and ocular surface disease3,4,5. surface tension and provides a smooth optical surface18.

The highly variable prevalence of MGD reported in the

literature (3.5% to 70%)6 is partly due to the plethora of Classification

definitions of MGD; but even after taking this into consideration, The first relevant classification by Gifford19 in
MGD still appears to be more common in Asiatic populations7,8. 1921, classified meibomian gland changes in chronic

Anatomy and Physiology blepharoconjuntivitis and emphasized adjacent structural
involvement.

The meibomian glands are branched alveolar sebaceous In a six part classification of blepharitis, McCulley et al20 in

glands located in the tarsal plates with approximately 40 1982 classified MGD into three categories based on secretion

glands in the upper, and 25 in the lower lid. Each gland has a and inflammation.

cluster of secretory acini draining into the main duct by shorter In 1991 Mathers’ group21 segregated MGD into four groups

ductules. The excretory duct opens onto the lid margin just based on tear osmolarity, Schirmer’s testing and meibography.

anterior to the Mucocutaneous Bron and workers22

Junction (MCJ). This junction The Meibomian glands are a critical classified MGD based on
is of critical importance as it biomicroscopic findings into
is the transition zone from the component of the lacrimal functional unit, seven groups (reduced number,

non-keratinized epithelium of and directly or indirectly responsible for replacement, hyposecretion,
the palpebral conjunctiva to the obstructive, hypersecretory,
keratinized stratified squamous many of the symptoms and signs of Dry neoplastic, and suppurative).

epithelium of the eyelid skin; in Eye Disease and Ocular Surface Disease. Foulks and Bron used this to

other words it demarcates the Therefore, patients with a diagnosis of provide a clinically oriented
hydrophilic mucosa from the MGD need to be evaluated for co-existent
lipophilic eyelid skin9. It is seen classification. The current
classification system proposed

as a smooth line parallel to the Dry Eye and Ocular Surface Disease by the International Workshop
on MGD uses the level of
posterior lid margin; with aging

this line becomes irregular10. secretions to categorise the

Marx’s line, the line of conjunctival epithelial staining behind various subgroups of MGD (Figure 1)23.

the MCJ can be visualised, with rose bengal and lissamine

green11. The orifices of the glands are visible as small opaque Risk Factors For MGD

rings on the slit lamp; with aging they may show signs of These may be ophthalmic, systemic, environmental, or
closure or stenosis12. The glands possess sympathetic and drug induced
parasympathetic innervation and androgen receptors which

promote lipogenesis and suppress keratinization, but the actual Ophthalmic
regulatory mechanisms are still unknown. Meibum is mainly
composed of the highly hydrophobic non-polar lipids and Patients with chronic anterior blepharitis24 with contact
sterol esters, with smaller amounts of mono and diglycerides, lens intolerance and giant papillary conjunctivitis25,26,27 or
neutral fats, free fatty acids and alcohols13. Surfactant proteins Demodex infestation are more likely to have MGD28.

and mucins interact with the aqueous component and are Systemic
responsible for tear film spread14. The prevalence of MGD increases with age29. Systemic

As the meibocytes mature the lipid content increases

www. dos-times.org 13

cornea

Clinical Features of MGD

The terms MGD and posterior
blepharitis have been used
interchangeably, however it is important
to remember that MGD is just one of the
causes of posterior blepharitis.

MGD may be asymptomatic or
symptomatic; primary or secondary; focal
or diffuse; cicatricial or noncicatricial;
and inflammatory or non-inflammatory.
Apart from being symptomatic in its own
right, it can give rise to symptoms by
contributing to ocular surface damage or
to dry eye44. Symptoms very often do not
correlate with signs.

The key signs of MGD are altered
meibomian gland secretion, meibomian
gland dropout and changes in lid
morphology.

Figure 1: Reprinted with permission from: Nichols KK, Foulks GN, Bron AJ et al. Figure 1 Altered Meibomian Gland
The International Workshop on Meilbomium Gland Dysfunction: Executive Summary. Invest Secretion
Ophthalmol Vis Sci. 2011;52:1922-1929.
Copyright ARVO (Association for Research in Vision and Ophthalmology, 1801 Rockwille Pike, Expressed meibum is like a drop of
Suite 400, MD 20852 USA) clear oil. In MGD apart from qualitative
and quantitative changes in the meibum,
factors that may promote MGD include orifices is perhaps the most common the expressibility is also affected. It is
menopause, Sjögren’s syndrome, cause. Hyperkeratinization of the terminal erroneously assumed that expressibility
cholesterol levels, psoriasis, atopy, ductules, accumulation of cellular and lipid and secretory activity are the same; it is
rosacea, hypertension, and benign material within duct lumina, narrowing however presumed that if meibomian
prostatic hyperplasia. of ductules due to desquamated cells, oil is freely expressible, secretion is
glandular and duct obstruction, cystic also normal. Expressibility, however,
Medications dilatation of the ducts, atrophy of the correlates well with functionality.
meibomian acini36,37, 38 and periglandular
13-cis retinoic exacerbates inflammatory changes39 are prominent in The altered meibum, also referred
or precipitates meibomian gland MGD. Normal individuals may or may not to as meibomian excreta, is a mixture
dysfunction by altering secretions have cholesterol esters40 but cholesterol of abnormal secretions and keratinized
and causing glandular atrophy30. esters are always present in MGD. Such epithelial debris45. The expressed lipid
Postmenopausal oestrogen therapy31 individuals have heavier colonization may be a clear cloudy fluid, or a viscous
decreases lipid synthesis32 and promotes with coagulase negative staphylococci and fluid with particulate matter, or an
dry eye disease33. Antidepressants and Staphylococcus aureus41. Staphylococcus inspissated, toothpaste-like material.
antihistaminics34 also increase the risk of aureus, Corynebacterium spp and Meibomian gland expression can be
MGD. Propionibacterium acnes commonly diagnostic, it provides samples for lipid
found on the lids produce lipases which analysis, and it can also be therapeutic.
Environmental factors can enhance growth of other bacteria42. Various grading scales exist to quantify
MGD increases tear electrolytes the volume, the viscosity, and the quality
Location, temperature, humidity, and uniformly. Increased concentrations of of the meibum and the degree of force
visual task may precipitate or exacerbate electrolytes are responsible for changes in applied to express meibum. Most scoring
MGD35. goblet cell density and corneal epithelial systems grade the quality of secretions
glycogen levels43. This contributes to the on a scale from 1 to 4, with 1 being ‘clear’
Pathophysiology of MGD conjunctival and corneal manifestations and 4 corresponding to ‘inspissated
of MGD. secretions’46.
The primary or precipitating event
is unknown. Obstruction of the gland An attempt has also been made
to grade the expressibility47,48 in terms
of assessment of a standard force for a

1. Senior Consultant, Cornea and Refractive Surgery,Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Peelamedu, Coimbatore
2. Medical Officer, Cornea and Refractive Surgery Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Peelamedu, Coimbatore

1Dr.Anita Raghavan DO, FRCS (Glas) 2Dr. Sushma Poojary MS
14 DOS Times - march-april 2017

cornea

given period of time or the expressibility categorised with several of these being meibum58 and gland dropout can occur.
to different levels of digitally applied incorporated into grading schemes. Treatment at this stage is straightforward,
pressure49. therefore meibomian gland expression is
Lid Margin: Changes include recommended to diagnose asymptomatic
Of the available methods, that of telangiectasia, thickening, rounding MGD. Early treatment could reverse
Korb and Blackie generates a Meibomian of the posterior lid margin, notching, changes or prevent progression.
Glands Yielding Liquid Secretion (MGYLS) hyperkeratinization, and irregularity of
score. In this method a standard force is the lid margin. Symptomatic MGD
applied to roughly one third of the lid.
Only glands that yield a liquid secretion Orifices: plugging or pouting, a The symptomatology is similar to
are evaluated. pathognomonic clinical sign of MGD other Ocular Surface Diseases. The 199559
occurs due to obstruction of the terminal and the 2007 DEWS does not differentiate
Meibomian Gland Dropout ducts and extrusion of meibomian features as characteristic of aqueous-
excreta. Other significant changes include deficient or evaporative dry eye or both.
Gland dropout occurs with aging. On reduction in number, capping, narrowing Features common to both include ocular
of orifices, opaque appearance, vascular surface damage, tear instability, and tear
lid eversion the characteristic grape like invasion of the outer and inner cuffs of hyperosmolarity.
the orifice, and retroplacement with duct
pattern is abnormal. Partial or total loss exposure and scarring. Non- Cicatricial vs Cicatricial
MGD
of acinar tissue is also characteristic of Cystoid expansion of the duct can
occur anywhere along its course as a The pathological events are different
MGD. Acinar tissue loss may be proximal, dark round or ovoid region. The visibility in the cicatrising and non cicatrising
of acini decreases with increasing variants. In aging, the MCJ migrates
central, distal, or may involve the whole inflammation. Concretions and chalazia forward60. Progressive disease alters
can occur. the position of the MCJ and the relative
gland. The impact of gland dropout varies location of the meibomian orifices. When
Mucocutaneous Junction: The the orifices retain their normal anatomic
with the location of acinar tissue loss. position may be altered with anterior relationship with the MCJ it is called non-
or posterior displacement with cicatricial MGD. Restoring the meibum
Distal dropout, due to its proximity to the corresponding movement of the gland delivery corrects the Tear Film Lipid Layer
orifices, has a greater functional impact. orifices. There is a ridge-like elevation of (TFLL). With orifice stenosis, obliteration,
the MCJ or of tissue between the orifices or periductal fibrosis, meibum can no
With extensive dropout there is increasing due to connective tissue scarring and longer be expressed. Non-cicatricial now
overlying mucosal thinning. This is a becomes irreversible.
evaporative water loss from the eye50. pathognomonic feature of the cicatricial
Gland dropout can be quantified by process. By contrast, in cicatricial disease
the orifices move posteriorly across
meiboscopy, meibography, and confocal Morphological changes of the lid can the MCJ and into the conjunctiva. As
be quantified to generate an aggregate they move into the tarsal plate they are
microscopy. Both meiboscopy and MGD score that can be combined with no longer visible. Sometimes, the MCJ
measures of gland expressibility and may be dragged posteriorly. Most of the
meibography quantify meibomian gland dropout. de Paiva et al. created an ducts are obstructed and sometimes
aggregate score with a scale range of produce clear meibum, however as their
dropout by using lid transillumination51 0 to 11 by combining meibographic orifices are located in the mucosa they
grading with a grading of lid changes cannot effectively contribute to the TFLL.
but meibography provides (orifice metaplasia, brush marks and Cicatricial MGD though most common
expressibility). Arita and coworkers with the various types of cicatrising
photodocumentation52. Non-contact however, attempted scoring based on the conjunctivitis, can occasionally be
presence or absence of lid abnormalities. primary or occur in non-cicatrising
meibography using Infrared photography conjunctivitis.
MGD Can Be Broadly
is superior to the transillumination Categorized Into Four MGD With Associated OSD
Subtypes
technique53. Matsumoto et al. have Possible pathological mechanisms
1. MGD alone - asymptomatic or in MGD associated with OSD include
measured meibomian gland density and symptomatic (non-cicatricial or evaporative dry eye mechanisms, and
cicatricial) the release of inflammatory cytokines.
the diameter of intact glands using in vivo Alteration of meibomian lipid by
2. MGD with associated ocular surface bacterial lipases is a significant source of
confocal microscopy on the everted tarsal damage inflammatory mediators. Ocular surface
damage can be assessed by corneal and
plate. Both a decrease in gland density 3. MGD-related evaporative dry eye conjunctival staining, by measurement
4. MGD associated with other ocular of inflammatory mediators in the tears,
and altered meibomian gland diameter by immunohistochemistry, or by flow
disorders cytometry on impression cytology
are indicative of MGD. specimens61.
Asymptomatic MGD
A number of workers,54,55 have www. dos-times.org 15
The preclinical stage may be
proposed various methods to assess the asymptomatic. Meibomian gland
expression is a prerequisite for diagnosis.
severity of meibomian gland dropout. The Qualitative or quantitative changes of the

gestalt system used by Nichols56 showed

excellent intra-observer and moderate

inter-observer reliability. The fractional

gland loss on a 1 to 4 scale is estimated -

wherein 1 is no gland loss and 2 is 25%, 3

is 25% to 75%, and 4 is >75% gland loss.

Another option is to count the number

of intact glands in the region of interest,

but this approach can miss focal disease.

An ideal approach would be to assess the

tarsal plate in its entirety.

Meibomian gland dropout is a

useful index of obstructive MGD. It can

differentiate evaporative dry eye from

those without dry eye, but not aqueous-
deficient dry eye57 or inflammatory from
non-inflammatory MGD.

Changes In Lid Morphology

The involvement of the lid, the
orifices, the acini and the MCJ can be

cornea

MGD-Related Evaporative Dry A suggested guideline for diagnosis antibiotics has been extensively evaluated.
Eye of MGD-Related Disease within a General The excessive bacterial colonization of
Clinic by the International Workshop on the lids in patients with blepharitis79,80,
Evaporative dry eye is probably the MGD includes may be an epiphenomenon secondary
most common form of dry eye disease. 1. Administration of a symptom to the altered microenvironment of
In cicatricial and non-cicatricial MGD the the lids. Doxycycline, tetracycline,
level of lipid is insufficient to maintain a questionnaire and minocycline81 reduce bacterial
normal TFLL. Altered meibum aggravates 2. Measurement of the blink rate and colonization and inflammation of the lid
the disturbances in the TFLL. The end margin. The tetracyclines also suppress
result is increased evaporative water loss calculation of the blink interval (BI) some of the lipase breakdown of the
and all its attendant consequences. 3. Measurement of tear meniscus meibum. Sub anti microbial doses of these
drugs have potent anti-inflammatory
Documented abnormalities of height activity. Of these, the use of tetracycline
the TFLL include abnormal spreading 4. Measurement of tear osmolarity has been extensively studied in rosacea.
patterns62, vertical interferometric 5. Measurement of the tear film Tetracycline has beneficial effects
patterning, and reduced TFLL stability. on symptomatology, ocular surface
breakup time by fluorescein (TFBUT) inflammation, the lid margin and also
Changes in the spreading pattern of 6. Calculation of The Ocular Protection on tear film stability. Its efficacy on the
TFLL can also occur in Aqueous Deficient cornea is less82,83 and prolonged therapy
Dry Eye (ADDE)63,64,65 due to thinning Index as the ratio of TFBUT/BI. A is however required84. Topical antibiotics
of the aqueous layer66. Thus, increased value of <1 is abnormal, and the also suppress bacterial colonization and
evaporative tear loss occurs in this setting lower the value the greater the inflammation, and provide symptomatic
even in the absence of MGD67. degree of tear film instability relief.
7. Grading of conjunctiva and cornea
MGD Associated with Other 8. Schirmer test or phenol red thread Topical erythromycin has been
Ocular Disorders test supplanted by azithromycin. Its broad
9. Assessment of MGD spectrum activity, anti inflammatory
OSD in its most advanced If a specialized unit is available, activity and excellent tissue penetration
additional testing such as measure makes it ideal for topical application85.
form presents as meibomian of tear osmolarity, tear secretion by The qualitative improvement of lipid86
fluorescein clearance rate, volume decreases orifice plugging resulting
keratoconjunctivitis. Characterisitic of tears by fluorophotometry and in improved gland function87. Topical
meniscometry, TFBUT by interferometry, metronidazole can be considered for
features include both anterior and tear evaporation by evaporimetry can be ocular rosacea especially when combined
done. Tests for inflammatory mediators with lid hygiene88.
posterior blepharitis and a greater and the presence of inflammatory cell
markers though not specific, can also be The Role Of Artificial Tears
likelihood of skin disorders such as acne done.
Increased osmolarity which
rosacea, or atopy. Therapy is the central mechanism in the
pathophysiology of dry eye can occur
MGD And Contact Lens (CL) Warm compresses and eyelid due to increased evaporation of tears and
Wear hygiene has been the mainstay of reduced production. Supplementation
therapy75. However, as noted by Olson of the tear film can address the “final
Gland dropout and increased and Blackie et al76 the temperature at common pathway”. Increasing tear
viscosity of expressed secretions is more which warm compresses are applied volume reduces hyperosmolarity89
in CL wearers with GPC than without is critical. Olson et al reported that 5 dilutes the concentration of inflammatory
GPC69. The severity of GPC usually minutes of treatment with compresses mediators90 and reduces friction between
correlates with the severity of the MGD70. at a temperature of 40 degrees applied to the components of the ocular surface91.
Arita et al71 noted that the decrease in the the closed eyelids significantly increased Preservative-free tears are preferred
number of functional meibomian glands the thickness of the tear film lipid layer. especially with increasing frequency
is proportional to the duration of CL wear. There was no increase in tear film of application and in the presence of
lipid layer thickness with 5 minutes of severe ocular surface damage, to avoid
Mixed Anterior Blepharitis treatment at room temperature (24°C) the additive toxicity of preservatives92,93.
and MGD applied to the contra-lateral control eyes. As evinced by many investigators, higher
Blackie et al. recommends the continuous viscosity artificial lubricants may be more
Anterior and posterior blepharitis application of 45°C hot compresses for at effective94,95.
can coexist. Seborrheic blepharitis, and least 4 minutes and replacement of the
atopic blepharitis can occur with MGD72,73 compress after 2 minutes. Emulsion eye drops containing
and as a specific complication of systemic lipids can improve lipid layer thickness96
retinoid therapy74. LipiFlow treatment offers the twin stabilise the tear film and retard tear
advantages of warming the internal evaporation97.
Diagnosis surfaces of the upper and lower eyelids
and simultaneously massaging the lids. Cyclosporine A
A diagnosis of MGD may be made It is a significantly superior to warm
by the demonstration of a single affected compresses77. Improvement in both Cyclosporine A has a positive
gland, but clinically relevant disease symptoms and signs with Lipiflow effect not only on the conjunctiva and
is due to the involvement of multiple treatment has been demonstrated by
glands. Therefore, diagnosis requires a Greiner et al.78
qualitative and a quantitative approach.
The role of topical and systemic
As there is considerable overlap
between MGD, OSD and Dry Eye, all
patients with a diagnosis of MGD need to
be evaluated for coexistent Dry Eye and
OSD.

16 DOS Times - march-april 2017

cornea

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Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

18 DOS Times - march-april 2017

cornea

Role of Imaging Modalities in Peripheral
Ulcerative Keratitis

Divya Singh, Mukesh Patil, M. Vanathi

Awide variety of investigations are called into Diffuse anterior scleritis
play in managing a case of peripheral ulcerative
keratitis1. The local and systemic effects can There is a localized area of inflammation adjacent to the
either be a cause or effect of the pathogenesis of dilated vessels. The edema extends throughout the area of
the disease and consequently the investigations inflammation upto the limbus including the episclera and
would also follow a path according to the need about half to two-thirds depth of the sclera. There is the gross
of the specific clinical situation. A wide array of tests with separation of collagen fibres (Figure 1).

possibilities for variable interpretations can be utilized to Necrotising anterior scleritis
help in successfully establishing the diagnosis of the patient at
ocular as well as systemic level. It is indeed a known fact that This condition is characterized by the destruction of the
the diagnosis of peripheral ulcerative keratitis is based upon collagen fibres and the thinning of the sclera. The posterior
the microbiological, serological, and other imaging modalities. scleral surface is easily observed with irregularly arranged and
Here, we would like to emphasize upon the role of various dense reflective collagen fibres.

imaging modalities in peripheral ulcerative keratitis. Nodular anterior scleritis

Role of imaging modalities This condition is marked by the hyporeflective

Role of Ultrasonography A wide variety of investigations are nodule surrounded by the
called into play in managing a case of hyperreflective sclera. AS-OCT
The B mode clearly illustrates the swollen
ultrasonography is helpful
tissue mixed with the blood
in imaging both anterior and peripheral ulcerative keratitis. The vessels and the inflammatory
posterior scleritis. However, its
main role is in monitoring the local and systemic effects can either be cells (Figure 2). of SD-OCT
The advent
posterior scleritis. The retinal, a cause or effect of the pathogenesis has proved to be of significant
choroidal, and scleral complex is
seen as the heterogenous layer of the disease and consequently the improvement in increasing the
surrounded by the echogenic investigations would also follow a path sensitivity of diagnosis. It also
helps in monitoring the disease
orbital fat and the echolucent according to the need of the specific
vitreous. In posterior clinical situation progression in scleral disease
scleritis, there is reduction in and to monitor changes post-
operatively.
echogenecity of the posterior

coats of the eyeball. The fluid in Tenon’s capsule and the optic Role of low dose fluorescein angiography
nerve sheath gives rise to the “T-sign”. The vertical bar of the
Fluorescein angiography has been described to be a helpful
‘T’ being formed by the dilated optic nerve which is echolucent modality in monitoring the scleritis. The area of interest is first
and the horizontal bar formed by the echolucent tenon’s fluid. photographed at 10X, and 16X magnification. Fluorescein

Role of Anterior segment Optical Coherence angiography is then performed after injecting 5 ml of 10%
Tomography sodium fluorescein into the antecubital vein and the images are
captured using the same camera at one second intervals, starting
AS-OCT is an important tool to confirm the clinical ten seconds after the injection of the dye. Low dose fluorescein
diagnosis of scleritis. The differences in the type of collagen angiography is preferred over the conventional fluorescein
angiography as it utilizes lesser dose of the fluorescein dye and
and their distribution between the cornea and sclera results use of the more sensitive photographic film. This results in less
leakage and better picture quality3,4.
in the different optical properties. This is the reason why
Sclerokeratitis
we are able to differentiate between the corneal layers and
Low dose anterior segment fluorescein angiography can
the sclera based on AS-OCT2. The scleral image is seen as a be helpful in making the diagnosis and assess the response
highly reflective structure while cornea is a weakly scattering
structure. The images are very useful in showing the full extent
of the inflammatory process.

www. dos-times.org 19

cornea

Figure 1: AS-0CT shows area of inflammation with edema and gross Figure 2: ASOCT demonstrating hyporeflective nodule surrounded by
separation of the collagen fibres hyperreflective sclera

to treatment in patients with peripheral limbus with disruption of the normal or the sinus infiltration. It is however,
ulcerative keratitis or sclerokeratitis. It limbal arcade which in turn is replaced unsuitable for monitoring the course of
determines the leakage into the cornea by the new vessels stretching into the the disease as it employs the X-rays6.
from the limbal capillaries and the newly superficial stroma.
formed vessels which are associated with References
ongoing inflammation and the response In the peripheral ulcerative keratitis
to therapy5. there is a complete non perfusion of 1. Ayse Yagci. Update on peripheral
the vessels sometimes extending till
Stromal keratitis the insertion of the rectus muscles. ulcerative keratitis. Clin
The arteries fill normally but there
There is an area of poor perfusion is poor perfusion of the limbal and Ophthalmol.2012;6:747-754.
adjacent to the limbus with new vessels episcleral venular arcades.4 Leakage is
extending from the surrounding vascular not prominently seen. New vessels are 2. Watson P, Romano A. The impact of new
loops into the cornea. These can be usually seen to spread into the superficial
derived from either deep or superficial part of the peripheral ectatic area which methods of investigation and treatment
vascular plexus. Leakage is seen on may form. This is most commonly seen in
either side of the advancing tip in the rheumatoid arthritis. on the understanding of the pathology
active inflammatory phase. The leakage of scleral inflammation. Eye (Lond).
stops as soon as the treatment becomes Role of Computerised tomography
effective3-5. scan 2014;28:915-30.
3. Saari KM. Anterior segment fluorescein
Destructive keratitis CT scanning utilizes the X-rays to
generate the cross sectional scans of the angiography in inflammatory diseases of
In the mildest form, there is poor eye and the orbit.6 It is particularly useful
perfusion of vessels surrounding the in the presence of granulomatous scleritis the cornea. Acta Ophthalmol (Copenh).
where there is destruction of the bone
1979;57:781-93.

4. Watson PG, Bovey E. Anterior segment
fluorescein angiography in the diagnosis
of scleral inflammation. Ophthalmology.

1985;92:1-11.

5. Pinar Aydin, Yonca A Akova, Sibel

Kadayifçila. Anterior segment

indocyanine green angiography in scleral
inflammation. Eye. 2000;14:211–215.

6. Biswas J, Mittal S, Ganesh SK, Shetty NS,
Gopal L. Posterior scleritis:clinical profile

and imaging characteristics. Indian J

Ophthalmol. 1998;46:195-202.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,AIIMS, New Delhi

Dr. Divya Singh Dr. Mukesh Patil Dr. M.Vanathi Dr. Noopur Gupta Dr. Radhika Tandon
MD, DNB MD, FICO MD MS, DNB, PhD MD, DNB, FRCOphth

Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

20 DOS Times - march-april 2017

GLAUCOMA

Biometry for the Management of Angle
Closure in Young Patients

Neha Midha, Karthikeyan Mahalingam, Viney Gupta

Primary angle closure (PAC) predominantly occurs after 40 years of age. With age
the lens thickness (LT) increases, anterior chamber depth (ACD) decreases, thus
predisposing to relative pupillary block and angle closure. Secondary etiologies like
short axial length, relative anterior nanophthalmos, increased lens thickness, plateau
iris syndrome have been implicated

Primary angle closure (PAC) predominantly Figure 1a: Anterior segment OCT image of case 1 depicting shallow
occurs after 40 years of age. With age the lens ACD and marginally increased lens vault in RE
thickness (LT) increases, anterior chamber depth
(ACD) decreases, thus predisposing to relative The patient IOP ranges between 12- 14 mmHg on 2 topical
pupillary block and angle closure. Secondary medication.
etiologies like short axial length, relative anterior
nanophthalmos, increased lens thickness, plateau iris syndrome Case 2
have been implicated1. We report three consecutive cases of A 38 year old female patient, with LE operated
angle closure in young patients along with their biometric
findings that helped in proper management. Trabeculectomy presented to our Glaucoma clinic with pain
in RE and headache. On examination her visual acuity was
Case 1 6/9 in right eye (RE) and finger counting at 1 meter in LE. On
examination of the RE we found a shallow anterior chamber,
A 39 year old male presented with complaints of occasional clear lens, and an IOP of 36 mmHg (Figure 2a). Her LE eye
ocular pain BE with headache in evenings for past 6 months. On had a complicated pseudophakia with an IOP of 8 mmHg. BE
examination his vision was 6/9 BE, shallow anterior chamber
(Figure 1a), clear lens, IOP right eye (RE) 40mmHg and left eye
(LE) 42mmHg, with BE glaucomatous cupping - cup disc ratio
(CDR) of 0.7:1 in RE and 0.8:1 in LE (Figure 1b). Gonioscopy
revealed closed angles in BE. Humphrey Visual Field (HVF)
showed a superior arcuate scotoma in BE. The ACD was shallow
(Table 1) in BE.

Management

The IOP was controlled with intravenous, oral and topical
anti glaucoma medications After the IOP was controlled the
patient underwent BE Nd:YAG peripheral iridotomy(PI).

Table 1: Biometry values of our three cases

Case 1 Case1 Case 2 Case 3 Case 3
RE (39/M) LE (39/m) RE (38/F) RE(19/M) LE(19/M)
19.19mm
Axial length 22.04 mm 22.06 mm 21.76 mm 19.08mm 47.25/47.75
Keratometry 43.35/44.12 43.35/44.12 @ 17/107
40.25/41.25 46.25/46.75 1.84mm
Anterior chamber depth @ 174/84 @ 20/110 4.13mm
Lens thickness 430 microns
Lens Vault 1.84 mm 1.88 mm 1.49 mm 1.881mm 0.215
LT/AL
4.31 mm 4.18mm 5.04 mm 4.06mm www. dos-times.org 21

650 micron 630 microns 1120 microns 570 microns

0.195 0.189 0.231 0.212

GLAUCOMA

Figure 1b: ASOCT image of case 1 depicting shallow ACD

Figure 2: ASOCT image of case 2, RE depicting a significantly increased lens vault

had glaucomatous cupping - CDR of glaucoma medication. Next the patient diagnosis of nanophthalmos. His ASOCT
0.8:1 in RE and 0.9:1 in LE. Gonioscopy underwent RE clear lens extraction with confirmed a shallow anterior chamber
revealed closed angles in RE. Humphrey intraocular lens implantation. A 24 hour and normal lens vault (Figure 3b).
Visual Field (HVF) showed a superior diurnal IOP control was done 3 weeks
arcuate scotoma in RE. ASOCT, showed later and target IOP of 10-14 mmHg was Management: After medical control
a significantly increased lens vault found to be achieved on 2 topical anti
(Figure 2b). Past records of LE surgery glaucoma medications. of IOP patient underwent BE Nd:YAG
showed that patient had shallow anterior
chamber and intumescent lens after left Case 3 PI. After 1 week his IOP was 36mmHg
eye Trabeculectomy. Anterior chamber
reformation and lens aspiration was A 19 years old male presented with RE and left eye (LE) 18mm Hg on
required in early post operative period. pain BE with headache. On examination
Her RE had iridotomy in the past his vision was 6/6 in both eye (BE), shallow topical anti glaucoma medication and
anterior chamber (Figure 3a), clear lens,
Management IOP RE 42mmHg and LE 30mmHg, ONH oral acetzolamide. Patient underwent
IOP of RE was first controlled with anti showed small crowded disc and a CDR
of 0.2:1 in BE. Biometry established a RE Trabeculectomy with mitomycin.
LE IOP was controlled with E/d
Latanoprost 0.005% and E/d timolol.
Post operative period was uneventful

with well controlled IOP in the range of

10-12 mm of Hg. We did not encounter

any complication like uveal effusion,

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,AIIMS, New Delhi

Dr. Neha Midha MD Dr. Karthikeyan Mahalingam MBBS Dr.Viney Gupta MD
22 DOS Times - march-april 2017

GLAUCOMA

Figure 3a: ASOCT image of case 3 RE depicting shallow ACD and marginally increased lens vault. Figure 3b: ASOCT image of case 3 LE depicting shallow ACD

malignant glaucoma, retinal detachment2. closure. In this case the IOP could not REFERENCES
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Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

www. dos-times.org 23

GLAUCOMA

Complications of Trabeculectomy

Suresh Kumar, Henna Garg

Glaucoma Filtering Surgeries (GFS) are different patients (460 eyes) hyphema and microhyphema were the most
from other ocular surgeries in the sense that frequent early- onset complications, followed by hypotony, bleb
leak, and choroidal effusion or hemorrhage, respectively. The
complete healing is not desired. Good or excessive most frequent complication at 3 months and later was late bleb
healing in GFS will essentially mean that filtration leak, which persisted and often led to a surgical intervention.
across the scleral fistula is compromised leading The second most frequent late-onset complication was
to failure of surgery. hypotony followed by late choroidal effusion1.

A number of ways like advanced microsurgical techniques, Complications will be discussed under the following
headings:
careful handing of delicate ocular tissues and common use I. Intra-Operative
Ii. Early Postoperative
of antimetabolites intraoperatively or postoperatively have Iii. Late Postoperative

contributed to the long-term success of GFS. The postoperative

management following trabeculectomy is key for future control

of intraocular pressure (IOP).

PREVENTION OF POSTOPERATIVE COMPLICATIONS INTRAOPERATIVE COMPLICATIONS

With the advent of modern operating microscopes, wet- Injury To Superior Rectus Muscle: Superior Rectus
field cautery and microsurgical instruments the exact surgical muscle traction suture can cause buttonholing of conjunctiva,

technique, tissue handling and tissue alignment has improved. cause bleeding and in extreme cases can damage or disinsert

The smooth forceps for conjunctival and tissue handling the muscle. Instead, corneal fraction suture using 6-0 dacron

prevents buttonholing thereby decreasing the chances of suture about 1mm anterior to conjunctival insertion can be

postoperative wound leakage. used to avoid these problems.
The meticulous conjunctival flap
closure using running suture A number of ways like advanced However, one has to be careful
microsurgical techniques, careful
with round bodied needle handing of delicate ocular tissues so that it doesn’t cause corneal

reduces the risk of shallow perforation.

Conjunctival Button-

anterior chamber and hypotony and common use of antimetabolites Holing: Use of sharp toothed
in the early postoperative forceps, cutting needles,
intraoperatively or postoperatively have excessive use of cautery,
period.

Intraoperative use contributed to the long-term success of intraoperative antifibrotic
of antifibrotic agents like glaucoma filtering surgeries
agents and improper handling
Mitomycin C (MMC) and
of tissue can cause conjunctival

5 Flourouracil (5FU) will tears. Any buttonhole of

modulate fibrosis and ensure the long term success of filtration. conjunctiva detected during the surgery must be sutured with

However, MMC can lead to thin and cystic bleb which in turn can round bodied needle2,3.

lead to chronic leaks, blebitis and endophthamitis. Decreasing Scleral Flap Related Complications: Careless handling

exposure time, decreased concentration and more diffuse

application of antimetabolite can minimize these complications

Discontinuation of antiglaucoma medication 3-5 days

prior to the day of surgery may decrease vascular congestion

and inflammation. Topical steroids prior to surgery and

intravitreal bevacizumab in patients having underlying uveitis

and Neovascular Glaucoma (NVG) may decrease inflammation

and improve surgical outcome.

COMPLICATIONS Figure 1: Diffuse slit lamp examination shows large bleb with increased
vascularity and shallow AC
Trabeculectomy can have per-operative and postoperative
complications. Postoperative complications can be further
divided into early and late complications. The complications
which occur immediately and within 10–12 weeks
postoperatively are generally considered early postoperative
and complications occurring beyond this period are labelled as
late postoperative complications. In a retrospective, population-
based study done at Mayo Clinic, Minnesota involving 334

www. dos-times.org 25

GLAUCOMA

Figures 2&3: Fundus photo showing dome shaped elevations of choroid and retina and B-scan showing hypoechoic elavations of peripheral choroid.

of scleral flap may macerate or disinsert EARLY POSTOPERATIVE typically lead to huge bleb
it. Meticulous reattachment should be COMPLICATIONS
attempted using 10-0 nylon sutures to formation due to excessive
avoid excessive filtration and shallow Shallow AC with Low IOP: outflow. Trabeculectomy with
chambers postoperatively4. tight scleral closure and use of
a) Wound leakage: Most of the wound
Hyphema: Iridectomy is leading leaks occur in first postoperative releasable sutures have decreased
cause of hyphema during trabeculectomy. week. If IOP is low (0 to 6 mmHg),
Large hyphema must be drained to avoid shallow AC and hypotony due to
inflammation and rise in Intraocular wound leak should always be hyperfitration. Clinically patient
Pressure (IOP)5. will have shallow anterior chamber,
suspected. These patients may have
Vitreous Loss: The risk of vitreous shallow or flat anterior chamber hypotony and diffuse large bleb on
loss is high in eyes with distorted anatomy in addition to hypotony with flat day 1 postoperatively12. Simmons
like buphthalmic eyes with thin sclera, or low bleb alongwith conjunctival
high myopia, aphakia and vitreous loss in temponade shells can compress the
the contralateral eye during surgery. injection. Positive Seidel test will scleral flap and provides resistance
confirm wound leakage. Seidel test is to aqueous flow13. Simple pressure
Shallow AC: Excessive shallowing done with 2% fluorescein strip. With patch for few days can be equally
of AC should be avoided during surgery. patient looking down, fluorescein is effective14.
Pre-placed scleral flap sutures may applied over conjunctival incision
facilitate wound closure particularly in c) Choroidal detachment: Choroidal
aphakic, pseduophakic or myopic eyes. area as well as entire bleb. Using detachment can clinically present
Viscoelastics can also be used to maintain cobalt blue filter, a green lake in
anterior chamber during surgery6. dark brown background will confirm as shallow AC and hypotony just
wound leakage9. Use of firm pressure like wound leak or overfiltration.
Anaesthesia Related Complications patch may facilitate leak closure10. However, on examination there

Topical anaesthesia with local A large soft contact lens (18 to will be no wound leak (Negative
subconjunctival or subtenon infiltration
provides adequate anaesthesia with 24mm) protects the leak area from Seidel’s test) and bleb will not be
minimum risk of complications7. Regional
or local anaesthesia with retrobulbar trauma due to eyelid movements and exuberant. Fundus examination
or peribulbar injections have potential
disadvantages for glaucomatous promotes reepithelization. If the leak will reveal smooth round like
eyes. Sudden rise in IOP may result in
compromised optic nerve blood flow and is persistent despite these measures elevations of peripheral choroid and
may worsen existing damage8. retina15. Management of choroidal
and anterior chamber remains
detachment is conservative with
shallow, suturing the leak with 8-0
cycloplegic, mydriatics and oral
or 9-0 vicryl suture with atraumatic steroids (1mg/kg body weight).
Indications for surgical drainage of
needle is required11.
suprachoroidal space are lenticular
b) Overfiltration: Full thickness
touch, corneal odema, kissing
Glaucoma Filtering Surgeries choroidals and failing bleb16.

Government Medical College and Hospital, Chandigarh

Dr. Suresh Kumar MS Dr. Henna Garg MS
26 DOS Times - march-april 2017

GLAUCOMA

Figure 4: Slit lamp examination shows layered hyphema in almost one- Figure 5: Slit lamp examination on diffused light shows flat bleb, with
third of chamber increased vascularity and corkscrewing of vessels indicating failing
bleb

Figure 6: Diffuse light examination shows smooth, dome shaped bleb Figure 7: Slit lamp examination with diffused light shows milky white
with thick capsule bleb

Shallow AC with High IOP: vitreous cavity or posterior to along with normal or elevated
vitreous body. Ultrabiomicroscope IOP. However for the diagnosis
Shallow anterior chamber and may reveal forward rotation of ciliary of pupillary block, the peripheral
high intraocular pressure is much more process18. Medical management of iridectomy should not be patent.
serious development than shallow malignant glaucoma includes topical The anterior chamber is shallow
chamber with hypotony. β-blockers, carbonic anhydrase in the periphery and central AC
a) Malignant glaucoma: During early inhibitors, mydriatic/cycloplegics. If is well formed. Patent peripheral
malignant glaucoma doesn’t resolve iridectomy rules out the diagnosis
postoperative period, shallow with conservative treatment, YAG of pupillary block glaucoma. Doing
anterior chamber (AC) and high laser disruption of anterior hyaloid laser iridotomy will be curative.
normal or rising IOP denotes or posterior capsule can be effective c) Suprachoroidal hemorrhage: This
malignant glaucoma. The important in few patients (pseudophakes). complication is seen in first week
differential diagnosis includes Surgical management may be after GFS. The patient will present
pupillary block glaucoma and required if other modalities with abrupt onset of severe pain and
suprachoroidal hemorrhage. Eyes don’t work satisfactorily. Surgical redness of eye. Slit lamp examination
with malignant glaucoma have treatment includes rupturing the will reveal inflamed eye, shallow
shallow peripheral and central AC anterior hyaloids face, aspiration anterior chamber and very high
with patent peripheral iridectomy. of posterior vitreous by pars plana IOP. Posterior segment examination
The aqueous humor is misdirected route and formation of anterior will reveal hemorrhagic chorodial
towards the vitreous cavity. This chamber with air. detachment. USG A and B (C scan)
posterior movement of aqueous b) Pupillary Block: Pupillary block will differentiate between chorodial
leads to forward movement of lens glaucoma may develop during the detachment and suprachorodial
iris or hyaloids iris, diaphragm early postoperative period. The hemorrhage. In suprachoroidal
resulting in flat anterior chamber anterior chamber will be shallow hemorrhage, USG will show
and elevated IOP17. B-Scan USG
may reveal lakes of aqueous within

www. dos-times.org 27

GLAUCOMA

Figure 8: Fundus photo showing choroidal striae alongwith vascular Figure 9: Slit lamp examination shows shallow AC and intumescent
engorgement cataract post filtering surgery

moderate to high intensity echoes in Wipe Out Phenomenon (Snuff out) Bleb Encapsulation (Tenon’s cyst)
detached choroids as compared to
no echoes in choroidal detachment19. Loss of central island of vision Diffuse, elevated bleb is early
Predisposing factors can be advanced sometimes can complicate GFS. The postoperative period denotes a
age, hypertension, high myopia, high incidence is around 1-2 % in various functioning bleb. However this bleb in
IOP, prior PPV, severe postoperative studies. Eyes with split fixation or next few weeks gets transformed into
hypotony20. extensive visual field loss involving 5 high domed smooth, 2 layered bleb that
degree of fixation can make these patients is impervious to aqueous humour. This
Hyphema prone to snuff-out phenomenon23. results in highly elevated IOP. This bleb
encapsulation typically occurs 8 weeks
Most of the hyphemas tend to occur Prevention: in susceptible eyes, following surgery. The reported incidence
in 1st week postoperatively. Majority of sub-tenon’s anaesthesia should be given is from 10-28% in various studies30.
the patient have mild hyphema which without epinephrine. IOP should be Treatment is mostly medical management
typically clear spontaneously within checked 4 to 6 hours after surgery24. with aqueous suppressants. With time and
24-48 hours. NVG patients undergoing IOP control, the tenon’s cyst undergoes
trabeculectomy is more likely to have Late Postoperative remodelling of the cyst wall which
hyphema which can be persist for longer Complications eventually becomes more permeable to
duration. aqueous humour. Intraocular pressure
Failing Bleb stablizes within 2 to 4 months with this
Endophthalmitis treatment. If conservative treatment
Functioning bleb can be diffuse or fails, needling of bleb with MMC may
Acute endopthalmitis immediately localized, thin walled, nonvascular with improve the condition31. In addition to
after GFS has been reported in 0.1% diffuse microcysts and can have variable aqueous suppressant, digital massage
of patients. Streptococcus species are height25. The most active phase of healing and intensive topical steroids therapy
seen more frequently in endopthalmitis process occurs during first 2 weeks after may be beneficial.
following GFS21. surgery. Bleb appearance is single most
important factor in recognizing impending Needling: This technique involves
Decompression Retinopathy failure26. Vascularity, injection along with elevation of the conjunctiva off the
flattened bleb is early indication that surface of the globe with balanced salt
The complication occurs in eyes there is failure of filtration in these eyes27. solution or anaesthetic with a small
where IOP is persistently very high in the Gonioscopy must be done to determine gauge needle. The underlying episcleral/
immediate preoperative period. When the site of obstruction of aqueous flow. Tenon’s capsule scarring is then incised
there is sudden and large decrease in The internal obstruction can be partially with the needle. Pederson and Smith
IOP during surgery, there is transient or fully occluded by iris, vitreous, blood, achieved successful control of IOP in
increase in retinal and choroidal blood cilliary body or descemet’s flap. If there is 96% of cases with or without complete
flow resulting in acute extravasation of internal blockade, Nd- YAG laser may be surgical revision32.
blood in extravascular space. Fundus helpful in relieving the block28. If internal
examination of these eyes reveal ostium is free of any obstruction, then the Blebitis/ Endophthalmitis
intraretinal, subretinal and preretinal problem is at the level of episcleral ocular
hemorrhages in the midperiphery. This surface. Digital compression can result Blebitis or endopthalmitis is
retinopathy responds to conservative in bleb filling with aqueous and decrease potentially serious and blinding
treatment and visual outcome is usually in IOP. If digital pressure is not raising complication. The incidence of
good22. the bleb, next logical step is release of postoperative infection has certainly
releasable suture (if applied) or laser increased with the advent of mitomycin
suture lysis29. C and 5 F.U. use in GFS. The reported

28 DOS Times - march-april 2017

GLAUCOMA

incidence of bleb infection C documented severe
is around 2%-5%. However inflammatory reaction, corneal

the incidence of bleb related odema with complete absence

enopthalmitis after GFS of endothelium and necrosis

ranged from 0.2% to 9.6%33. of iris as well as ciliary body.

In delayed endopthalmitis, the In humans Mitomycin C is

route of infection is thought used intraoperatively during

to be migration of bacteria trabeculectomy to decrease
through the bleb wall thereby post-operative fibrosis. The

increasing the incidence if there initial dosage was 0.04%

is a thin cystic bleb. Clinically solution applied in sponge

the patient will present with for 3-5 minutes under the
acute inset of pain, conjunctival scleral flap before entering the

injection around bleb area anterior chamber. A number of

and associated discharge. On complications were reported

examination, earliest sign is with the use of mitomycin C.

conjunctival injection with Figure 10: Slit lamp showing thin cystic bleb post MMC use during Recent studies reported bleb
peribleb halo of blood vessels. trabeculectomy. leaks as the most common

A milky white appearing bleb complication of trabeculectomy

is important characteristic with mitomycin and as a

of bleb related endopthalmitis. A late leaks. These leaking blebs are at predisposing factor for blebitis and
hypopyon may be present. As the bleb is increased risk of developing both blebitis endophthalmitis44. Other reported
continuous with anterior chamber, any and endophthalmitis. The late bleb complications like higher risk of blebitis,
bleb infection is essentially presumed leaks are a big management challenge. endophthalmitis, late bleb leaks and
endopthalmitis. A culture of bleb surface, Simple patching and Bandage contact hypotonic maculopathy. Scleral melt
conjunctiva should be immediately lens (BCL) have been used with variable has also been seen. Topical mitomycin C
performed. Bleb must be evaluated for success. Laser photocoagulation of bleb, drops used after pterygium surgery has
any leak by seidel’s test. USG must be cryotherapy, chemical or focal cautery reported scleral melt and necrosis. There
done to rule out vitreous involvement. and intrableb injection of autologus bleb was titration of dosage of mitomycin C
Prompt start of topical antibiotics like are other treatment options. Thin walled from 0.04% to 0.02% and for shorter
fluoroquinolones, cycloplegics and cystic bleb often require bleb revision duration spread over wide area to
topical steroids is quite important. with resection of thin, friable conjunctiva decrease undesirable side effects45.
Vitreous tap along with intravitreal and mobilization of healthy conjunctiva
injection of ceftazidime and vancomycin from superior part40. 5-Flourouracil: Some degree of
should be done. Oral prednisolone (1mg/ corneal punctate epitheliopathy and
kg body weight) is started after ruling Overhanging Bleb: With the frequent corneal epithelial defects are seen in most
out fungal endopthalmities34. Organisms use of mitomycin C, problem of large of these patients. These complications
responsible for endopthalmitis can be bleb has increased. A large bleb which are dependent on total cumulative dose
staphylococcus species, streptococcus is overlying over clear cornea is known of 5 F.U. Other complications include
species and sometimes gram negative as overhanging bleb41. These blebs are filamentary keratitis, dellen formation,
organisms35. cosmetically disturbing and can present corneal endothelial toxicity and corneal
with foreign body sensations, discomfort, keratinization and scarring. Fortunately
Hypotonic Maculopathy corneal astigmatism,and ocular surface all these side effects are transient and self
abnormalities. Dellen formation because limiting.

Chronic hypotony is diagnosed if of drying of adjacent cornea is fairly RELEASABLE SUTURE RELATED
IOP is less than 6mm of Hg on 2 different common in these eyes42. Most of the COMPLICATIONS
occasions at least a month apart36. If this symptoms can be controlled by medical

hypotony is accompanied by swelling treatment with lubricating drops. Releasable sutures can help in

of macula, choroidal or retinal folds, it Excision of corneal part and suturing decreasing problems like shallow

is labeled as hypotonic maculopathy37. of conjunctival part with 10-0 nylon anterior chamber and hypotony and
The reported incidence of hypotonic suture may be required in larger and also in titration of aqueous outflow

maculopathy varies from. With the cosmetically unacceptable patients. during early postoperative period. The

introduction of MMC and 5 FU, this Cataract: Anterior chamber releasable sutures are most effective

complication is more likely to occur38. shallowing is the only surgical during initial 2 weeks following
Most of the cases will require bleb complication that independently surgery as fibrosis set in after this. The

revision or a scleral patch in cases of predicted cataract progression in the TVT reported complications after RS are

scleral melt39. Study43. windshield wiper karatopathy, suture

breakage, subconjunctival hemorrhage,

Late Bleb Leak COMPLICATIONS RELATED TO endophthalmitis, suprachoroidal

Late leakage of bleb can occur ANTIFIBROTIC AGENTS hemorrhage and hypotony46.

months to years after trabeculectomy. MMC: In experimental studies

Thin cystic bleb typically following on rabbits, intracameral mitomycin

use of MMC are more likely to develop

www. dos-times.org 29

GLAUCOMA

REFERENCES Ophthalmol 1983;101:1917. 32. Pederson JE, Smith SG: Surgical
17. Epstein DL et al: Experimental management of encapsulated filtering
1. Jessica A. Olayanju, BS; Mohamed B.
Hassan, BA; David O. Hodge, MS; Cheryl perfusions through the anterior and blebs, Ophthalmology 1985;92:955.
L. Khanna, MD Trabeculectomy-Related vitreous chambers with possible
Complications in Olmsted County, relationships to malignant glaucoma, 33. Scott DR, Quigley HA: Medical
Minnesota, 1985 Through 2010. JAMA Am J Ophthalmol 1979;88:1078.
Ophthalmology 2015;133:5. 18. Tello C et al: Ultrasound biomicroscopy management of a high bleb phase after
in pseudophakic malignant glaucoma,
2. Blok MDW et al : Use of the Megasoft Ophthalmology 1993;100:1330. trabeculectomies, Ophthalmology
bandage lens for treatment of 19. Frenkel REP,Shin DH: Prevention and
complications after trabeculectomy, management of delayed suprachoroidal 1988;95:1169.
Am J Ophthalmol 1990,110: 264. hemorrhage after filtration surgery,
Arch Ophthalmol 1986;104:1459. 34. Sugar HS, Zekman T: Late infection
3. Iliff CE: Flap perforation in glaucoma 20. Gressel MG, Parrish RK 2, Hueur DK: of filtering conjunctival scars, Am J
surgery sealed by a tissue patch, Arch Delayed nonexpulsive suprachoroidal
Ophthalmol. 1964;71:215. hemorrhage, Arch Ophthalmol Ophthalmol 1958;46:155.
1984;102:1757.
4. Riley SF, Smith Tj, Simmons RJ: 21. Lambrou FH Jr, Meredith TA, Kaplan 35. Menikoff JA et al: A case-control
Repair of a disinserted scleral flap HJ: Secondary surgical management of
in trabeculectomy, Ophthalmic Surg expulsive choroidal hemorrhage, Arch study of risk factors for postoperative
1993; 24:3491. Ophthalmol 1987;105:1195.
22. Katz LJ, Cantor LB, Spaeth GL: endophthalmitis, Ophthalmology
5. Namba H: Blood reflux into the anterior Complications of surgery in glaucoma:
chamber after trabeculectomy, Jpn J early and late bacterial endophthalmitis 1991;98:1761.
Ophthalmol 1983;27:616. following glaucoma filtering surgery,
Ophthalmology 1985;92:959. 36. Mandelbaum S et al: Late onset
6. Barak et al: The protective effect 23. Fechtner RD et al: Complications
of early intraoperative injection of of glaucoma surgery. Ocular endophthalmitis associated with
viscoelastic material in trabeculectomy, decompression retinopathy, Arcg filtering blebs, Ophthalmology
Ophthalmic Surg 1992;23:206. Ophthalmol 1992;110:965.
24. Langerhorst CT, De Clercq B, Van 1985;92:964.
7. Buys YM, Trope GE: Prospective Den Berg TJTP: Visual field behavior
study of sub-tenon’s versus after intraocular surgery in glaucoma 37. Pederson JE: Ocular hypotony. In Ritch
retrobulbar anaesthesia for inpatient patients with advanced defects, Doc
and day-surgery trabeculectomy, Ophthalmol 1990;75:281. R, Shields MB, Krupin T, eds: The
Ophthalmology 1993;100:1585. 25. Prevention: O’Connell EJ, Karseras
AG: Intraocular surgery in advanced glaucomas, St Louis, 1989, Mosby.
8. Morgan CM et al: Ocular complications glaucoma, Br J Ophthalmol
associated with retrobulbar injections, 1976;60:124. 38. Newhouse RP, Beyrer C: Hypotony as
Ophthalmology 1988:95:660. 26. Franks WA, Hitchings RA: Complications
of 5-fluorouracil after trabeculectomy, a late complication of trabeculectomy,
9. Cain WJ, Sinskey RM: Detection of Eye 1991;5:385.
anterior chamber leakage with Seidel’s 27. Sugar HS: Course of successfully Ann Ophthalmol 1982;14:685.
test, Arch Ophthalmol 1981;99:2013. filtering blebs, Ann Ophthalmol
1971;3:485. 39. Stamper RL, McMenemy MG, Lieberman
10. Melamed S et al: The use of glaucoma 28. Stewart WC et al: Early postoperative
shell tamponade in leaking filtration prognostic indicators following MF: Hypotonous maculopathy after
blebs, Ophthalmology 1986;93:839. trabeculectomy, Ophthalmic Surg 1991,
22:23. trabeculectomy with subconjunctival
11. Grady Fj, Forbes M: Tissue adhesive 29. Brown RH et al: Internal sclerectomy 5-fluorouracil, Am J Ophthalmol
for repair of conjunctival buttonhole with an automated trephine for
in glaucoma surgery, Am J Ophthalmol advanced glaucoma, Ophthalmol 1992;114:544.
1969;68:656. 1998;95:728.
30. Costa VP et al: Wound healing 40. Ruderman J, Allen R: Simmon’s
12. Christiansson J: Ocular hypotony after modulation in glaucoma filtration
fistulizing glaucoma surgery, Acta surgery, Ophthalmic Surg 1993;24:152. tamponade shell for leaking
Ophthalmol (Copenh) 1967;45:837. 31. Sherwood MB et al: Cysts of Tenon’s filtration blebs, Arch Ophthalmol
capsule following filtration surgery:
13. Simmons RJ, Savage JA: The shell medical management, Arch Ophthalmol 1985;103:1708.
tamponade in filtering surgery 1987;105:1517.
for glaucoma, Ophthalmic Surg 41. Ritch R, Schuman JS, Belcher CD:
1979;10:17.
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14. Gehring JR: A new method for re-
forming anterior chambers after Glaucoma 1993;2:114.
glaucoma operations, Arch Ophthalmol
1962;68:473. 42. Soong HK, Quigley HA: Dellen
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hypotony after trabeculectomy,
Ophthalmic Surg 1988;19:865. 43. Surgical Complications in the Tube

16. Dellaporta A: Scleral trephination Versus Trabeculectomy Study During
for subchoroidal effusion, Arch
the First Year of Follow-up. Steven

J. Gedde, et al. American Journal of

Ophthalmology january 2007;143:1.

44. Solomon A, Ticho U, Frucht-Pery J. Late-

onset, bleb-associated endophthalmitis
following glaucoma filtering surgery
with or without antifibrotic agents. J

Ocul Pharmacol Ther. 1999;15:283-93.

45. N Anand, S Arora, M Clowes. Mitomycin

C augmented glaucoma surgery:
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46. Releasable suture technique for

trabeculectomy. Pushpa Jacob, Ravi

Thomas et al. Indian Journal of

Ophthalmology.

Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

30 DOS Times - march-april 2017

RETINA

OCT Angiography

Priyanka Gupta, Charu Gupta, Cyrus Shroff

Optical coherence tomography angiography (OCT-A) is a novel non-invasive three
dimensional imaging technique for visualizing the retinal vasculature and choroidal
vascular layers in the macular area. It provides depth–resolved structural and
functional information on blood flow in these vessels

Optical coherence tomography angiography 4. Radial peripapillary area lesions and deep retinal plexus
(OCT-A) is based on the concept that in a static are much better visualized on OCT-A compared to other
eye the only moving structure is blood flowing imaging modalities. Subsequently newer disease entities
through the vessels. Sequential b-scans are like PAMM (Paracentral Acute Middle Maculopathy) have
taken at precisely the same cross-section. recently been described.
Stationary tissue structures will show little
change, whereas moving structures (the flow of blood through 5. Not contraindicated in pregnancy and kidney diseases.
vessels) show changes from one image to the next. Within a
region of the retina, discrete tissue locations are sampled by the Disadvantages of Oct-A
OCT instrument, and a numerical value based on the reflectivity
of the location is generated (Figure 1). This memory location is 1. Nascent technology with a limited field of view.
called a ‘voxel’. The resultant image looks like an angiogram but 2. Inability to study leakage patterns.
is derived only from signals generated intrinsically from tissue, 3. Inability to detect and study high flow (large retinal
without the need for contrast agent injection.
COMPARING OCT A WITH FFA & ICG-A and choroidal vessels, polyp) and low flow lesions
Table 1 gives a brief description of the differences in the (microaneurysms, fibrotic CNVM).
imaging modalities. 4. Increased potential for artifacts (blinks, vessel ghosting,
Advantages of Oct-A movement). Artifacts are more marked in poorly fixating
1. Non invasive, fast and easy to repeat. eyes.
2. It is three dimensional and scans segmented to specific
depths can be achieved that visualize both retinal and OCT-A of a Normal Eye
choroidal vasculature.
3. Lesions under the RPE (like Occult CNVM) can be visualized Most of the OCT-A machines have standard scanning
well and their size delineated more accurately. patterns – 2x2, 3x3, 6x6, 8x8 and some of the newer ones
to 12x12. For each of the scan pattern, B-scan and en face
Figure 1: Principle of OCT-A structural images are generated along with three dimensional
microvascular maps of the retinal and choroidal circulation.
The instrument provides settings for default en face images but
boundary layers can be manually manipulated to study the exact
area of interest. There are three distinct layers in the retina:
superficial, deep plexus and outer plexus. En face presentation
of OCT angiography helps us to segment these layers and
recognise retinal & choroidal vascular patterns associated with
various vascular pathologies. The standard segmentation slabs
are (Figure 2):
• Superficial retinal layer: It extends from the internal

limiting membrane to inner plexiform. This layer includes
the superficial retina plexus which is seen as a fine
capillary network. The perifoveal arcade (FAZ) is well
delineated and the arteries are distinguished from veins
by the presence of a surrounding hypointense halo.
• Deep retinal layer: The deep retinal plexus is found in
this layer which extends from the inner nuclear layer to
the outer plexiform layer. This layer is seen as a dense
capillary network with sinuous arborisation ending in
a well distinguished draining capillary vortex. FAZ area
is well defined and larger as compared to superficial
plexus (Mean value of FAZ is 0.266 +/- 0.795mm2 in the

www. dos-times.org 31

RETINA

Figure 2: Normal OCT-A scan showing Superficial capillary plexus (Top left), deep capillary superficial plexus compared to 0.495
plexus, Avascular layer & choriocapillaries. +/- 0.227 mm2 in the deep plexus).
Bottom left showing fundus photo & corresponding OCT B scan. This is the first in vivo examination
of the deep capillary plexus which is
Table 2: Comparing different Retinal Imaging Modalities
not imaged well with conventional
FFA ICG OCT A fluorescein angiography.
• Avascular layer: It extends from
Nature Invasive Invasive Non-Invasive 110microns to 60 microns above

Time 4-5 min 25-30 min Seconds the RPE. There is no vasculature
Field of view Wide field Wide field
Maximum of in this segmentation slab. If there
12x12mm is flow and abnormal appearing
microvasculature in this layer
Dye injection & its Yes Yes Dye less
risks then the segmentation lines and

Resolution Low Low High corresponding B-scans and en face

Motion artefacts Less affected Less affected More affected images should be examined carefully
to ensure that the flow represents
Dimensional Bi-dimensional Bi-dimensional 3-dimensional pathology.

Image Details Retinal vasculature Choroidal Retinal & Most OCT-A machines have a total
vasculature choroidal
vasculature retina colour- coded depth map which

Leakage Pattern of leakage, Pattern of Leakage pattern represents the entire retinal vasculature.
pooling and leakage(hot spot, not seen On the Zeiss Angioplex, the superficial
Axial location of staining well polyp, plaque) well retinal layer is coded in red, the deep
pathology appreciated delineated En-face
segmentation of retinal layer in green and any detectable
Difficult to identify Difficult to identify layers makes it flow in the avascular layer is represented
possible by blue.
• Choriocapillaries: This slab extends

from 29microns to 49 microns

beneath the RPE. This layer is seen

as a homogenous pattern of hyper or

hypointense dots which corresponds

to the richly anastomosed vascular

layer of the choriocapillaris. No

vascular channels are clearly

detectable at this level.
• Choroid: This slab extends from

64 microns to 115 microns below

Bruch’s membrane. This layer

shows hypointense linear structures

corresponding to choroidal vessels

on a greyish background. The

diffuse hyperintense signal of the

choriocapillaris partly masks the

Figure 3: OCT-A image with Zeiss Angioplex in a patient with Diabetic Retinopathy. Left sided image at the superficial capillary plexus shows
CNP areas outside FAZ. Red arrow in this image shows a micro aneurysm. Right sided image at the deep capillary plexus shows CNP areas and
microvascular anomalies.
32 DOS Times - march-april 2017

RETINA

Figure 4: Top Left FFA image shows leaking NVE at posterior pole.
Corresponding OCT B scan.
(Bottom) OCT-A image on Zeiss Angioplex showing gross NVE at
vitreoretinal interface and at superficial capillary plexus.

visualization of the choroidal vessels. On OCT angiography, pathology is patients with concomitant renal disease.
To get a more complete information identified by the absence or reduction
and to decrease the projection artifacts it of flow in normally vascular layers or It is possible to visualize retinal
is beneficial to manually scroll the image abnormal vascular patterns in normally
from ILM down and to compare it to the avascular layers. microvascular abnormalities such as
corresponding B-scan image.
OCT-A in Diabetic Retinopathy micro aneurysms, vascular remodelling
Clinical Applications &
Interpretations of OCT-A OCT-A is an effective method for adjacent to the foveal avascular zone
evaluating retinal vasculature in diabetic
Various studies have described retinopathy without dye injection. It (FAZ), enlarged FAZ, capillary tortuosity
the potential efficacy of OCT-A in the represents a novel complement as of now
evaluation of common retinal diseases and maybe an alternative to fluorescein and dilation on OCT-A (Figure 3). Even
such as AMD, Diabetic retinopathy, angiography in the years to come. Being early NVE/NVD has been reported
Vascular Occlusions, CSR, Idiopathic juxta non-invasive it has the advantage of (Figure 4).
foveal telangiectasia (IJT) and even in being easy to repeat. Also, since no dye
glaucoma. is required, it is not contraindicated in Micro aneurysms are seen as
sacciform dilatations in either superficial
or deep retinal plexus. Some micro

aneurysms may be missed because of
the slow flow through these lesions.
The phenomenon of capillary drop out

is well appreciated in the deep capillary

Shroff Eye Centre,A-9, Kailash Colony, New Delhi

Dr. Priyanka Gupta DNB Dr. Charu Gupta MS Dr. Cyrus Shroff MD
www. dos-times.org 33

RETINA

Figure 5: Type I Neovascularisation: (Top left) FFA image shows Figure 6: FFA image (top left) shows leakage with retinal-retinal
staining with mild leak at centre. OCT-A image on Zeiss angioplex anastomoses. Corresponding OCT B scan shows cystic spaces above
(Top right) through the choriocapillaris layer shows dilated tangled the neovascular complex. OCT-A on Zeiss Angioplex (bottom left)
web of vessels with hyper flow area. Corresponding OCT B-scan image showing retinal-retinal anastomosis at deep capillary plexus and tuft
(Bottom) shows neurosensory detachment. shaped lesion at level of choriocapillaris beneath it.

plexus. Some machines (Optovue- SSADA or identification of a hotspot. On OCT-A, Coscas et al based on OCT-A findings
algorithm) have a software to quantify no flow is seen in the avascular layer. The classified Wet AMD into 2 patterns which
the vessel density and area of perfusion. neovascular network which is seen in the helped in making a treatment decision.
Studies have reported a significant choriocapillaris layer is often extensive, The features analysed were:
decrease in retinal capillary perfusion has high flow and often has feeder vessels 1. Pattern of vessels- A well-defined
density with increase in severity of (Figure 5).
DR. de Carlo et al, in a study on 61 eyes (lacy-wheel or sea-fan shaped) CNV
with diabetes mellitus with no clinical Morphology is varied and has lesion in contrast to one with long
diabetic retinopathy and 28 control eyes appearances like Coral shaped, Fan shape, filamentous linear vessels.
of healthy subjects, reported that OCT-A Medusa shape, Tangled arborisation. 2. Branching – numerous tiny
was able to image microvascular changes In the early or acute phase, the capillaries (recent lesion) in contrast
not detected by clinical examination. neovascularisation has the appearance to large mature vessels (mature
FAZ area was 0.348 mm2 in diabetic of a tangled web of fine vessels without lesion).
eyes and 0.288mm2 in control eyes. FAZ dilated feeder vessels while chronic 3. Presence of anastomosis and loops
remodelling was seen more often in lesions are characterized by a core trunk 4. Morphology of vessel termini-
diabetic than in control eyes (36% vs with multiple large feeder vessels and presence of peripheral arcade in
11%) and so was capillary nonperfusion is referred to as “pruned vascular tree” contrast to a ‘dead tree’ appearance.
(21% of diabetic eyes vs 4% of control pattern. 5. Presence of perilesional hypo intense
eyes). halo.
Type 2 New Vessels Lesions were labelled Pattern I if it
OCT-A appears to have a promising shows all or at least three of the above
role in imaging of diabetic retinopathy These vessels referred to as ‘Classic’ features and Pattern II if it shows less
and may help in early detection. originate from the choriocapillaris but than three of the above features. Pattern
extend through the RPE and are localized 1 lesions were active and required
OCT-A in Age related Choroidal in the sub retinal space. On OCT-A, typical treatment while Pattern II were inactive
neovascularisation flow patterns are seen in the outer retina and did not require treatment, This
(avascular zone) and the choriocapillaris showed a high level of correspondence
Non-invasive OCTA allows for layer. The neovascular network is smaller to the treatment decision taken on
the study & classification of choroidal than type 1 vessels and morphology is conventional multimodal imaging.
new vessels (CNV), highlighting their varied though not to extent seen in Type1.
morphology, flow & exact axial location. Besides qualitative information on
The most common forms seen are vessel morphology and axial location,
Type 1 New Vessels Medusa shape and glomerulus shape. OCT-A can also provide quantitative
information regarding CNV flow, vessel
Formerly called as ‘occult’, this is the Type 3 New Vessels density and lesion area. This can be
most common neovascular subtype of an important non invasive tool for
AMD and the vessels are present under On OCT-A the neovascular complex monitoring the response to Anti VEGF
the retinal pigment epithelium (RPE). of type 3 neovascularisation (RAP) is therapy.
OCT-A helps in identifying and evaluating seen as a small tuft of bright , high flow
the morphology of the neovascular tiny vessels with curvilinear morphology OCT-A in Dry AMD
complex which up till now were only originating in the outer retina layers,
indirectly inferred on FA and ICG by the extending into the subretinal space OCT-A helps to visualize alterations
presence of pooling within a PED and/ and also communicating to the choroid
(Figure 6).

34 DOS Times - march-april 2017

RETINA

in the choriocapillaris in patients the superficial plexus and image

with dry AMD. Early stages the deep vascular plexus which

are characterized by patchy is poorly visualized with FA.
thinning of the choriocapillaris, Absence of fluorescein –induced

while geographic atrophy choroidal flush on OCT-A makes

is associated with loss of the area of retinal capillary

choriocapillaris underlying non perfusion more easily

the area of geographic atrophy discernible. Precise localization

and asymmetric alteration of retinal capillary ischemia

of choriocapillaris at the with OCT-A in RAO may help to

margins of the geographic prognosticate visual recovery.

atrophy. Use of high speed, Often RAO patients may have

long wavelength swept source concomitant medical problems

OCT for angiography will so OCT-A, a dye-free modality,

enable better detection of these would be safer. findings
choriocapillaris changes. Study Characteristic

of these structural changes of acute and chronic retinal
in choriocapillaris and flow vein occlusions are well

impairments could help in demonstrated on OCT-A.

detecting and monitoring the Figure 7: Vascular anastosmosis and congestion not clearly seen on FA Changes are seen in both
progression of dry AMD and (top image) & clearly visible in both the superficial (bottom left image)
treatment responses in future and deep retinal plexus (bottom right image) on OCT-A superficial and deep plexus. In
the superficial plexus, vessels

clinical trials. close to the FAZ are narrower

OCT – A in Vascular Occlusions enables three-dimensional and en face and more tortuous. Loss of capillary
visualization of flow in the retinal and perfusion is usually more marked in the

OCT-A may have advantages over choroidal vasculature. Thus, it can deep plexus. Vascular looping, collaterals,
other imaging techniques for eyes with telangiectasia vessels, vessel thickening
retinal artery occlusion (RAO), OCT-A reveal deficiencies involving acute flow and focally dilated micro aneurysms
interruption in RAO, reveal finer details of

Figure 8: Top left FA image (late frame) Pooling of dye with obscured
FAZ margins. OCT B scan (Top right). OCT-A (Bottom left) showing
widened FAZ and non perfusion areas and bottom right image of
deep capillary plexus showing marked vascular congestion and non
perfusion areas.

www. dos-times.org 35

RETINA

at the border of ischemic areas are Pachychoroid neovasculopathy
present in both superficial and deep
vascular plexuses. OCT-A highlights the (PNV) is distinguished from
two vascular networks compromised
in venous occlusions otherwise which neovascular AMD by several features,
are masked by leakage of dye in FFA.
Thereby, the anastomosis, vascular loops including younger age at onset of
and capillary drop out areas are well
seen (Figure 7,8). Cystoid macular edema neovascularization, a relative absence
appears as round dark areas with smooth
borders on OCT-A. of drusen, and a thick choroid with

OCT-A has a few limitations in pachyvessels. In pachychoroid
imaging in vascular occlusions. In cases
with significant retinal thinning and neovasculopathy, neovascularization is
gross macular edema the distortion of
retinal architecture makes delineation most commonly Type 1 (Sub RPE) which
of the layers difficult. Another drawback
as of now is the limited field that can be as discussed earlier is best evaluated with
imaged.
OCT-A. Figure 9: White line artifact.
OCT-A in Idiopathic
Juxtafoveal Telangiectasia Identification of polyps in PCV on vessels in nonvascularised zone.
OCT-A can be difficult because of the high 3) Segmentation artifact: En face
Idiopathic Juxtafoveal Telangiectasia blood flow in these lesions. However, the
or Macular Telangiectasia Type 2 imaging relies on segmentation
(MacTel 2) is a neurodegenerative branching vascular network (BVN) is strategies. It has its limitations in
disease of the macular area that affects retinal oedema, atrophy and high
all microvascular layers of the retina. consistently and clearly detected in the myopes.
The earliest changes on OCT-A in MacTel
are seen on the temporal aspect of the choriocapillaris layer. Conclusion
parafoveal deep capillary plexus. There
is dilation and enlargement of the OCT-A in Glaucoma OCT-A is a nascent technology with
vessels with large intervascular spaces, enormous potential. Besides enabling
telangiectatic vessels, reduction and/or OCT-A has been found to be beneficial diagnosis of common ophthalmic
loss of capillary density. As the disease in evaluating the optic disc perfusion. In disorders it is also showing great promise
progresses, dilated anastomoses which in understanding tissue perfusion in
form between the superficial and deep glaucomatous eyes, the normally dense the absence of morphological changes.
plexuses have been demonstrated. In This will help in decreasing disease
some patients, the anastomoses between peripapillary network is attenuated in morbidity through earlier detection and
the plexuses progresses to subretinal both the superficial disc vasculature intervention.
neovascularisation, with connections to and the deeper lamina cribosa. Flow
the choroidal vasculature. On OCT-A, the In the future, faster scanning speeds,
neovessels are seen predominantly in the index is another parameter that can be use of higher wavelength (swept-source)
avascular layer with some connection to and better eye-tracking devices will help
the underlying choriocapillaris layer. calculated on OCT-A and has been shown in acquisition of larger fields of view with
to have a high sensitivity and specificity higher resolution, decreased artifacts and
OCT-A in Pachychoroid in differentiating glaucomatous eyes from better inter-operator and inter-session
diseases repeatability.
normal eyes.
Pachychoroid spectrum is a group
of macular diseases that manifest ARTIFACTS in OCT-A REFERENCES
similar choroidal findings – thickened
choroid with dilated choroidal vessels. Artifacts are common and originate 1. de Carlo, Romano A, Waheed NK,
Central serous Chorioretinopathy (CSC), in relation to image acquisition, intrinsic
pachychoroid pigment epitheliopathy, ocular characteristics, eye movement, Duker JS. A review of optical coherence
pachychoroid neovasculopathy, and image processing and display strategies.
Polypoidal choroidal vasculopathy( PCV) tomography angiography(OCTA).
are entities of the pachychoroid clinical Main artifacts commonly seen are
spectrum. Diagnosis of Pachychoroid 1) Movement artefact: International journal of Retina and
neovasculopathy and PCV are helped by • ‘white line artifact’: Commonly
OCT-A. Viterous. 2015;1:5.
seen as white line at the junction
of two images (Figure 9) 2. Spaide RF, Fujimoto JG, Waheed NK.
• Gap defect: when the motion
control software tries to Image artifacts in optical coherence
reposition segments of image
due to some eye movements tomography angiography. Retina 2015;
some information is missed.
This appears as a gap defect. 35:2163-80.
• Stretch artefact: When two
images not of same region 3. F. Bandello. OCT Angiography in Retinal
are combined resulting
in a stretched / smeared and Macular Diseases. Dev Ophthalmol.
appearance.
2) Projection artifact: This is an Basel, Karger,2016, vol 56.
important limitation. There is
perception that flow is occurring 4. Hwang et al. OCT angiography in Diabetic
at levels other than where original
vessels are located. Example, Retinopathy. Retina. 2015; 35: 2371-6.
drusenoid pigment epithelial
detachment gives projection of 5. Rispoli et al. OCT Angiography in BRVO.

Retina. 2015; 35:2332-8.

6. Coscas et al. OCT Angiography in

exudative AMD. Retina; 2015; 35:2219-

28.

Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

36 DOS Times - march-april 2017

RETINA

Optical Coherence Tomography Based Classification
of Diabetic Macular Edema

Neha Chawla, B.P. Guliani, Myuresh P. Naik

Diabetic macular edema (DME) occurring alone or reduced intraretinal reflectivity and expanded areas of lower
with proliferative or non proliferative diabetic reflectivity
retinopathy in patients with diabetes mellitus
has been the leading cause of blindness. With 2. Cystoid Macular Edema: the intraretinal cystoid
increasing prevalence of diabetes, blindness
due to DME is bound to increase. Diagnosis spaces at the macular area
3. Serous Retinal Detachment: seen as sub retinal fluid

accumulation with distinct outer border of the detached retina.

and treatment modalities are changing with the advancing Source: Otani T, Kishi S, Maruyama Y. Patterns of diabetic

technology and availability of newer drugs. macular edema with optical coherence tomography. American

Since 1985 as per Early Treatment Diabetic Retinopathy journal of ophthalmology. 1999;127(6):688–693.
Study (ETDRS)1 recommendations, focal/grid laser Diabetic macular edema: an OCT - based classification

photocoagulation has been the gold standard for the treatment [Panozzo et al., 2004]3 considers five parameters: retinal
for DME. ETDRS defined clinically significant macular edema
thickness, volume, morphology, diffusion and epiretinal traction

(CSME) based on slit lamp bio-microscopy examination of 1. Retinal thickness (RT) Retinal thickness is taken for

macula (Figure 1). macular edema the fixation point, for the central

Further DME is classified Diabetic (DME) macular zone, and cumulatively
occurring alone or with proliferative/
into focal, diffuse and ischaemic non proliferative diabetic retinopathy in for the perifoveal and peripheral
areas. RT values are classified
types based on fundus
fluorescein angiography (FFA) as: normal ,borderline and

findings. Some authors use patients with diabetes mellitus has been edema (definite thickening)
this for grid/ focal treatment The zones with retinal
decision. Both FFA and slit the leading cause of blindness thickness over borderline values

lamp biomicroscopy involve are recorded to give information

subjectivity and are not able to detect small changes. on the extension of the edema.

Introduction of optical coherence tomography technology 2. Retinal Volume is not essential to the diagnosis

changed the concept of diagnosis and treatment of DME. Now of edema; however, it offers important data on thickness of

we all know that it is difficult to manage DME without OCT macular area considered as a whole. The data are meaningful

as it not only displays various layers as histological section

of retina but also provides detailed information about retinal

microstructure and measures retinal thickness.

Introuction of intravitreal steroids and anti-VEGFs in

the management of DME led to resolution of edema and

improvement in vision. Many authors described different OCT

patterns in DME. Some authors have even correlated the visual

acuity with central macular thickness as on OCT before and

after intravitreal injections. Introduction of Spectral domain-

OCT (SD-OCT) improved further the resolution and better

understanding of DME.

DME has been classified in different ways based on OCT

patters. We have compiled all these classifications in this

article. Before we describe the various OCT patterns in DME,

it is important to understand normal macular structure on SD-

OCT (Figure 2).

Classifications of DME Figure 1: CSME as per ETDRS

DME with OCT [Otani et al., 1999]2 showed three
patterns of diabetic macular edema:

1. Retinal Swelling: increased retinal thickness with

www. dos-times.org 37

RETINA

Figure 2: Normal macular structure – SD OCT representation of retinal Figure 3: posterior hyaloid thickening and neurosesosy detachment
layers: inner limiting membrane (ILM), nerve fiber layer (NFL), ganglion
cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL),
outer plexiform layer (OPL), outer nuclear layer (ONL), external limiting
membrane (ELM), inner segments (IS) and outer segments (OS) of the
photoreceptors, IS/OS junction (IS/OS), and the retinal pigment
epithelium layer (RPE).

Figure 4: Vitreo macular adhesion and traction Figure 5: Spongy retinal edema

only for diffuse edema involving at least Normal Borderline Edema
170–210mm ≥ 210mm
the center and the 1st ring, and not for Fixation Point 150 ± 20mm 190–230mm ≥230mm
250–290mm ≥290mm
focal edema. Central Zone 170 ± 20mm
• Normal: 6.5mm3 ± 1
• Borderline: up to 8.0mm3 Perifoveal and peripheral areas 230 ± 20mm
• Abnormal: ≥8.0 mm3
E2a: mild: Retinal thickening appearance.
3. Retinal Morphology Three main associated with 2–4 central
small cysts (horizontal diameter 4. neuroepithelial detachment
morphologies are recognized: 150–200mm, vertical diameter
• E1: simple thickening: Compact 400mm) The retina is detached by the presence of
sub- retinal liquid (non-reflecting space)
retinal thickening without E2b: intermediate: Retinal above the hyper- reflecting line of the
thickening associated with cysts pigmented epithelium. This detachment
clinically visible cystoid spaces. with petaloid configuration
• E2: cystoid thickening or with central big cysts can be isolated or associated with simple
(horizontal diameter 300mm,
(increasing severity from a to vertical diameter 600mm). or cystoid retinal thickening.

c) Retinal thickening associated E2c: severe: Retinal thickening 5. Epiretinal traction: Presence
with cysts, defined as circular or associated with coalescence of well-defined and continuous hyper-
ovoid space with no reflectivity of cysts with retinoschisis reflecting line over the inner retinal
with minimum horizontal surface with at least one point of adhesion

diameter of 150mm and to the retina in at least one of the six

minimum vertical diameter of scans of the retinal map. Four grades of

300mm as measured by manual

caliper.

1. Senior Resident, Department of Ophthalmology, Sanjay Gandhi Memorial Hospital, Delhi.
2. Department of Ophthalmology, Safdarjung Hospital, New Delhi

1Dr. Neha Chawla DNB 2Dr. B.P. Guliani MS 2Dr. Myuresh P. Naik MS
38 DOS Times - march-april 2017

RETINA

increasing severity are given: Retinal morphology

• T0: absence of epiretinal hyper- 1. Simple non-cystoid macular edema –
reflectivity increased retinal thickness, reduced
intraretinal reflectivity, irregularity
• T1: presence of a continuous of the layered structure, flattening
line of flat hyper-reflectivity and of the foveal depression, without
presence of cystoid spaces
adherent to the retina without
2. Cystoid macular edema – the above
significant retinal distortion criteria, associated with presence
• T2: presence of continuous of well defined intraretinal cystoid
spaces
line of hyper-reflectivity with
• mild cystoid macular edema –
multiple points of adhesion to cystoid spaces with horizontal
the retina and with significant diameter < 300μm

retinal distortion • intermediate cystoid macular
edema – cystoid spaces with
• T3: antero-posterior traction horizontal diameter ≥300μm <
with“gullwings”configuration 600μm

Source: Panozzo G, Parolini B, • severe cystoid macular
edema – cystoid spaces with
Gusson E, Mercanti A, Pinackatt S, Figure 6: Central macular thickening horizontal diameter ≥ 600μm,or
large confluent cavities with
Bertoldo G, et al. Diabetic macular 2006;142:405–412. retinoschisis appearance
edema: an OCT-based classification.
3. Serous macular detachment –
Semin Ophthalmol. 2004;19:13–20. any of the above, associated with
serous macular detachment (hypo-
Optical Coherence Tomoaki Murakami (2011) reflective area under the detached
neurosensory retina and over the
Tomographic Patterns of Diabetic et al.5 in article on Association of hyper-reflective line of the pigment
epithelium),
Macular Edema [Kim B Y et al, Pathomorphology, Photoreceptor
Retinal topography
2006]4 The various patterns Status, and Retinal Thickness With
1. Non-significant macular edema;
of DME were scored based on Visual Acuity in Diabetic Retinopathy 2. Clinically significant macular edema,

their unique appearance on OCT classified pathomorphology of DME as defined by ETDRS and evaluated
on the OCT retinal topography map.
imaging: into 3 types:
Presence and severity of macular
1. diffuse retinal thickening 1. SRD type: SRD but not cystoid traction (incomplete PVD and/or
ERM)
(DRT) as increased retinal thickness spaces at foveal centre
1. No macular traction – presence of
(defined as greater than 200μm) with 2. CME type: Predominantly complete PVD (Weiss ring detected
reduced intraretinal reflectivity and on ophthalmoscopy), or no PVD (no
expanded areas of lower reflectivity, foveal cystoid spaces and sometimes visible posterior hyaloid line on SD
OCT), and no ERM
accompanied by minimal SRD
2. Questionable macular traction –
especially in the outer retinal layers 3. Diffuse type: Neither SRD nor incomplete PVD with perifoveal
greater than 200μm in width. or peripapillary adhesion and/
cystoid spaces at the presumed fovea or globally adherent ERM without
detectable distortion of retinal
2. Cystoid macular edema Source: Murakami T, Nishijima K, surface contour at the points of
(CME) was identified by the adhesion
Sakamoto A, Ota M, Horii T, Yoshimura
3. Definite macular traction –
localization of intraretinal cystoid- N. Association of Pathomorphology, incomplete PVD with perifoveal
adhesion and/or focal ERM with
like spaces that appeared as round Photoreceptor Status, and Retinal detectable distortion of retinal
contour at the points of adhesion
or oval areas of low reflectivity with Thickness With Visual Acuity in Diabetic
highly reflective septa separating the Retinal outer layers integrity (IS/OS
Retinopathy. American Journal of and ELM):

cystoid-like cavities. Ophthalmology. 2011;151:310–7. 1. IS/OS and ELM intact

3. Posterior hyaloid Optical Coherence Tomography

thickening [PHT] was defined as Findings in Diabetic Macular

a highly reflective signal arising Edema,Diabetic Retinopathy Desislava

from the inner retinal surface and Koleva-Georgievaet al. (2012)6

extending towards the optic nerve or described following patterns

peripherally. Retinal thickness

4. Subretinal fluid/SRD a. No macular edema – normal macular
morphology and thickness not
was defined as an accumulation of reaching the criteria for subclinical
DME;
subretinal fluid (which appeared
b. Early subclinical macular edema – no
dark) beneath a highly reflective and clinically detected retinal thickening
on ophthalmoscopy, OCT measured
elevation, resembling a dome, of the retinal thickness exceeding normal
+2SDs for central fixation point and
detached retina. The identification of fovea;
the highly reflective posterior border
c. Established macular edema –
of detached retina distinguished retinal thickening and evident
subretinal from intraretinal fluid; morphological characteristics of
edema.
and
5. TRD, defined as a peak-

shaped detachment of the retina

Source: Kim BY, Smith SD, Kaiser

PK. Optical Coherence Tomographic

Patterns of Diabetic Macular Edema.

American Journal of Ophthalmology.

www. dos-times.org 39

RETINA

• vitreoretinal traction
Source: Atta Allah H, Mohamed

YH. Optical coherence tomography
classification of diabetic cystoid macular
edema. Clinical Ophthalmology. 2013

Aug;1731.

Common OCT patterns in DME in

our experience are as under: (Figure

3,4,5,6,7)

Figure 7: Cystoid macular edema B – cysts with ELM disruption CONCLUSION
C – cysts with IS/OS disruption
2. IS/OS and ELM with disrupted D – cysts with disruption of both Based on One’s clinical experience
integrity and referring to these classifications,
Source: Desislava Koleva-Georgieva ELM and IS/OS junction lines. can develop methodlogy to diagnose and
II. External limiting membrane (ELM)
(2012). Optical Coherence Tomography plan treatment strategies for DME so that
Findings in Diabetic Macular Edema, status: Any disruption of the external
Diabetic Retinopathy, Dr. Mohammad blindness due to DME can be prevented.
Shamsul Ola (Ed.), ISBN: 978-953- limiting membrane (ELM) was
51-0044-7, InTech, Available from: References
h t t p : / / w w w. i n t e c h o p e n . c o m / searched for within the central 1
books/diabetic retinopathy/optical- 1. Early Treatment Diabetic Retinopathy
coherence-tomography-findings-in- mm of the fovea. If the ELM line Study Research Group. Photocoagulation
diabeticmacular-edema. for diabetic macular edema. Early
appeared to be complete at the Treatment Diabetic Retinopathy Study
Optical coherence tomography report number 1. Arch Ophthal. 1985;
classification of diabetic cystoid fovea in all scans, it was diagnosed 103:1796–806.
macular edema Yasser M. Helmy et al
(2013)7 as an intact ELM. Any discontinuity 2. Otani T, Kishi S, Maruyama Y. Patterns
I. cystoid macular edema based on the of diabetic macular edema with optical
or interruption of the ELM line in coherence tomography. American journal
ratio of vertical size of the largest of ophthalmology. 1999;127:688–693.
macular cyst in relation to the size one scan or more was considered a
of maximum macular thickness into 3. Panozzo G, Parolini B, Gusson E,
four groups: disrupted ELM Mercanti A, Pinackatt S, Bertoldo G, et
CME I: cysts less than (30%) of III. Integrity of the inner segment/ al. Diabetic macular edema: an OCT-
macular thickness based classification. Semin Ophthalmol.
CME II: between 30% and 60% of outer segment (IS/OS) line beneath 2004;19:13–20.
macular thickness the fovea using the same criteria
CME III: between 60% and 90% of 4. Kim BY, Smith SD, Kaiser PK. Optical
macular thickness described for the ELM line. If the Coherence Tomographic Patterns of
CME IV: was diagnosed when the size Diabetic Macular Edema. American
of the cyst became more than 90% of line appeared to be complete at the Journal of Ophthalmology. 2006;142:405–
the macular thickness 412.
Each grade was then subdivided into fovea in all scans, it was diagnosed as
A, B, C, and D an intact IS/OS line. If there was an 5. Murakami T, Nishijima K, Sakamoto A, Ota
A – cysts without any disruption to incomplete IS/OS line in one scan or M, Horii T, Yoshimura N. Association of
the ELM or IS/OS junction lines more, it was considered a disrupted Pathomorphology, Photoreceptor Status,
IS/OS and Retinal Thickness With Visual Acuity
IV. The presence of hyper-reflective in Diabetic Retinopathy. American Journal
foci in the outer retinal layers from of Ophthalmology. 2011;151:310–7.

the ELM to the retinal pigment 6. Desislava Koleva-Georgieva (2012).
Optical Coherence Tomography Findings
epithelium within the 1 mm scanned in Diabetic Macular Edema,Diabetic
Retinopathy, Dr. Mohammad Shamsul Ola
area centered on the fovea was (Ed.), ISBN: 978-953-51-0044-7, In Tech,
Available from: http://www.intechopen.
given a plus sign (+ was added if the com/books/diabetic retinopathy/optical-
patient had hyper-reflective foci). coherence-tomography-findings-in-
V. Associations diabeticmacular-edema
• neurosensory detachment
7. Atta Allah H, Mohamed YH. Optical
coherence tomography classification of
diabetic cystoid macular edema. Clinical
Ophthalmology. 2013;1731.

Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

40 DOS Times - march-april 2017

SQUINT

Clinical Examination of Paralytic Strabismus

Sagnik Sen, Mukesh Patil, Rohit Saxena

Paralytic strabismus is a type of incomitant strabismus, i.e., the deviations measured
using the non-paretic eye fixing (primary deviation) and the paretic eye fixing
(secondary deviation) are different. This can be congenital or acquired, the latter

being more common

Paralytic strabismus is a type of incomitant Face turn to right
strabismus, i.e., the deviations measured using
the non-paretic eye fixing (primary deviation) Chin down
and the paretic eye fixing (secondary deviation)
are different. This can be congenital or acquired, Head tilt to right
the latter being more common. The major nerves
controlling extraocular movements are the 3rd, 4th and Figure 1: Head positions
6th cranial nerves and any isolated/ combined affection of
these nerves can lead to the eyeballs moving haywire. As an Visual acuity assessment
ophthalmologist, one should be astute enough to determine Vision is the prime important factor in any patient
how to identify the condition, how to take a proper history, how
to examine it, how to narrow down the diagnosis to the cranial presenting with diplopia. Ptotic eyelid must be raised before
nerve that is affected and how to manage the condition, both assessing vision. Visual acuity may get affected if there is
conservatively and surgically if required. associated mydriasis. Methods of visual acuity assessment used
are:
History taking I. ETDRS chart
II. Snellen’s chart
Patient evaluation starts from the history itself. Importance III. E chart
should be given to the following points in the history: IV. Cardiff’s acuity chart (2-3 years age)
a. Age of onset: If the squint has been present from an early V. Teller’s acuity chart (6 months- 2 years age)

age, it signifies a high chance of amblyopia. Mostly, paralytic Head posture
squints are acquired in older age groups with systemic risk Patients assume a particular head posture (Figure 1) where
factors.
b. Probable cause: History of fever, head injury, trauma and the diplopia is absent or minimum. This should be checked to
diseases like hypertension, diabetes and neurological look for any upgaze or downgaze palsies and head tilts also
diseases should be taken. History of drooping of eyelids, should be assessed to rule out any palsy of muscles controlling
weakness in limbs, slurring of speech, headache, nausea, torsional movements (3th, 4th CN) and face turn (6th CN).
etc. are also asked for.
c. History of diplopia: Nature of the diplopia, whether it Pupillary reaction
is crossed or uncrossed and whether it is present in the Mesopic pupil size, direct and consensual pupillary
primary gaze or in secondary gazes should be elicited.
d. Previous treatments: Patients are advised patching of the reactions, near reflex and a relative afferent pupillary defect
better eye. The natural course of the disease should be
asked from the patient and it should be determined if the www. dosonline.org 41
diplopia is improving or static.
e. Surgical history: It is very important to ask if the patient
has already undergone any squint surgery previously as it
would change the planning of future management.

Clinical examination

A general physical examination should be performed on
a patient with suspected ocular motor nerve palsy looking
into ocular deviation, ptosis, palpebral fissure asymmetry,
lagophthalmos, facial asymmetry, head posture, proptosis,
conjunctival congestion, and chemosis.

SQUINT

should be checked for. Pupillomotor fibers Spielman’s occluder is a one-way Figure 2: Extorted fundus in an eye with
are more superficial in the CN III and get occluder, i.e., the observer can see the superior oblique palsy
compressed in lesions like aneurysm, eye underneath the occluder, however Figure 3: Examination of muscle actions in all
tumors. etc. earlier. Hence these lesions the patient won’t be able to see anything 9 gazes (right sixth nerve palsy)
mostly lead to pupil involving third nerve through.
palsy. However, microangiopathies, e.g., Figure 4: Hirschberg test
hypertension and diabetes mostly lead Examination of extraocular muscle
to pupil sparing CN III palsy, as the vasa movements Figure 5a: PBCT showing measurement of
vasorum in the center of the cranial nerve deviations in different gazes
is affected. Movements are checked (Figure
3) in the form of versions (binocular
Ptosis movements), ductions (uniocular
movements) and vergences (convergence
In case of presence of ptosis, the and divergence). The different
upper eyelid is lifted before any kind of extraocular muscles have their own
assessment is done. In case of bilateral positions for testing, for eg, CN IV should
ptosis, myasthenia may be suspected be tested in the down and out position as
and may require an ice pack test or a this is the position where the superior
neostigmine test to be performed. oblique muscle intorsion action can be
fully assessed. It is important to check
Convergence for unilateral versus bilateral signs and
extent of limitations (ductions) versus
In case of a medial rectus palsy, version movements.
convergence is affected.
Measurement of amount of
Accommodation squint
In cases affecting the pupillary fibers Hirschberg test

and the ciliary body, accommodation A simple torchlight is held at 33 cm to
reflex is affected. form light reflexes on the cornea of both
eyes and the position in relation to the
Anterior and posterior segment pupillary centre is assessed (Figure 4).
examination When the light reflex lies on the pupillary
margin, deviation in degrees is 15 and at
This should be done to rule out any the limbus is 45, with every millimetre
pathology causing the muscle paralysis. In leading to a change of 5 degrees.
the fundus, one should check for evidence
of vasculitis, vascular disease, choroidal Prism bar cover test (PBCT)
folds, chorioretinitis, etc. (Figure 2). Also
any cyclovertical muscle palsy can be A glass or plastic Fresnel prism
detected by the inadvertent extorsion or is classically kept in front of the
intorsion of the fovea relative to the disc. normal eye fixating on the 6/9 line of a
Snellen’s chart and cover-uncover test
Identification of squint is done with increasing power of prisms
Hirschberg test tillneutralisationis achieved (Figure 5).
For neutralisation of esotropia, they
A torchlight is held at a distance of are kept base in and for exotropia they
33 cm mid-way between the pupils and are kept base out. Similarly, in cases of
the light reflex on the center of the cornea hypertropia, primsms are kept base down
is observed. A person without squint will and for hypotropia they are kept base up.
have the light reflex centered on the pupil. The test is done for 6 meters on Snellen’s
chart and 33 cm on Jaeger’s chart.
Cover test Sometimes in patients with poor visual
When the fixing eye is covered, acuity in non-fixing eyes, Hirschberg

the non-fixing eye takes fixing position.
An occluder can be any opaque object.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences,AIIMS, New Delhi

Dr. Sagnik Sen MBBS Dr. Mukesh Patil MD, FICO Dr. Rohit Saxena MD, PhD
42 DOS Times - march-april 2017

SQUINT

Figure 5b

Primaty deviation Secondary deviation

Dextroversion Primary Levoversion Dextroversion Primary Levoversion
gaze
gaze 20ΔBO
Can’t fix 20ΔBO
>85ΔBO 45ΔBO 12ΔBO Can’t fix 20ΔBO

>85ΔBO 45ΔBO 12ΔBO Can’t fix Can’t fix
>85ΔBO 45ΔBO 12ΔBO Can’t fix Can’t fix

reflex is used to measure the deviation
in the non-fixating eye with increasing

strengths of prism in dioptres. The test is

done for 6 meters and 33 cm both and can
be done using a Snellen’s chart/ Jaeger’s
chart for fixating or the Hirschberg reflex

simply to measure the deviation (Krimsky

test).

Maddox rod test Figure 6: Maddox rod Figure 8: Synaptophore
Figure 7: Principle behind the double Maddox
The test is carried out at 33 cm and rod test Figure 9: Charting of diplopia with red-green
5 meters along with the Maddox tangent goggles
scale with the set of red horizontally from the eye (Figure 9). The bar of light
serrated lens in front of the right eye is moved in the direction of gaze, and the
(Figure 6). Measurement of the position patient describes the image separation
of the red line on the scale as perceived by and appearance. The most distal image
the patient gives the amount of deviation. belongs to the under-acting eye. The
position of the image is the reverse of
Double maddox rod test the position of the eye, and crossed and

Red and green Maddox rods are
kept in front of the right and left eyes
respectively (Figure 7). In cases of
cyclodeviations, the two lines would not
be parallel and the one in the paretic eye
will be tilted. One Maddox rod is then
rotated till super-imposition of the lines
is achieved and this amount of rotation
can be recorded in degrees indicating the
extent of cyclodeviation.

Synaptophore

The synaptophore is an instrument
used to measure the angle of deviation
by dissociating the two eyes and giving
them separate images to fix upon, which
the patient can fuse (Figure 8). It can
thus be used to investigate the potential
for binocular function in the presence
of a manifest squint and is of particular
value in assessing young children (from
age 3 years). It is also used to detect
suppression. The synaptophore can
measure horizontal, vertical and torsional
misalignments simultaneously.

Charting of nature and amount of Figure 10: Hess’s charting of right eye lateral rectus palsy
diplopia

Diplopia charting
A vertical bar of light is viewed

through red and green goggles (red before
right, green before left) at a fixed distance

www. dosonline.org 43

SQUINT

uncrossed diplopia can be ascertained by
this method.

Hess/ Lee’s screen Figure 11: 3 step test of patient with right eye superior oblique palsy

This test depends on the dissociation movement resulting from contracture of

of the two eyes with the help of a mirror the ipsilateral antagonist (positive forced

(Lee’s chart) or red-green goggles duction test). Care must be taken not to
push/ retract the globe during the test.
(Hess chart) (Figure 10), with one eye
being shown the objects/ light cues Figure 12: Forced duction test on the left eye Active force generation test
and the other eye locating them in using a globe holding forceps
the corresponding field based on the This test is used to assess the
reflections on the mirror. Some points Figure 13: Active force generation test after remaining power in a palsied muscle.
should be remembered while interpreting asking patient to look in the direction of After anesthetizing the eye, toothed
a Hess/Lee chart: palsied muscle forceps is used to hold the limbal
• The smaller field is that of the conjunctiva and the patient is asked
vertically acting extra-ocular muscles, to look in the direction of the affected
affected eye, first step being to determine which eye muscle and this is felt as a ‘tug’ by the
• The normal eye shows overaction of is hypertropic in primary gaze, second, examiner (Figure 13).
which lateral direction has a worse
all its muscles hypertropia and the third, which sided This was just a brief overview into
• The largest under-action/ primary head tilt has worse hypertropia. (Figure the world of paralytic squints. Achieving
11) proper skill in the diagnosis of the same
deviation is normally in the direction needs extensive practice and in depth
Forced duction test knowledge of the subject, before one
of action of the paretic muscle, e.g., in The patient’s eye is anesthetized moves ahead to managing such cases.

left lateral rectus palsy, the deviation with topical anesthetic drops and with References
the limbal conjunctiva held with a
is maximum in levoversion toothed forceps, the patient is asked 1. Sharma P. Strabismus Simplified. New
• The largest over-action is seen in to rotate the eye in the direction of the Delhi. CBS Pub. 2013
palsied muscle. The eye is then rotated
the direction of the contralateral with the forceps further (Figure 12) in the 2. Duke-elder S, WYber K. System of
direction of motion of the palsied muscle, Ophthalmology vol. 6. Ocular motility
synergist. in order to detect any restriction of and strabismus. St Louis. Mosby – Year
The Hess/Lee chart findings are Book Inc. 1973
reflective of the natural history of any
paralytic squint: 3. Speilmann A. A translucent occluder to
study eye position under unilateral or
1. Paresis of the involved muscle bilateral cover test. Am Orthopt J. 1986.
36: 65
2. Overaction of the ipsilateral
4. Veronneau – Troutman S. Prisms in
antagonist muscle the medical and surgical treatment
of Strabismus. CV Mosby Co. St Louis.
3. Underaction of the antagonist of the 1994

contralateral synergist, also called 5. Von Noorden, Burian H M. Binocular
vision and ocular motility: Theory and
inhibitional palsy management of strabismus. CV Mosby
Co. St Louis. 1974
Special tests
6. Eds AL Rosenbaum, AP Santiago.
Bielchowsky’s head tilt test/ 3-step Clinical Strabismus Management:
test Principles and Surgical Techniques.
Philadelphia. WB Saunder. 1999.
In eyes with longstanding muscle
palsies, it gets difficult to differentiate a
superior oblique palsy from a superior

rectus palsy of the other eye. The patient
is asked to maintain a steady fixation at
a distance of 3 meters so that fixation
doesn’t favour either the SO or SR. The
patient is asked to tilt his/her shoulder
towards the hypertropic eye (SO palsy)

so that the incyclotorsion action of the

superior oblique (primary action) and the

corresponding superior rectus (tertiary

action) is stimulated. If the hypertropia

increases, it suggests an unopposed

elevating action of the superior rectus
of the same eye, hence confirming the
diagnosis of superior oblique palsy.

Parks used this information to devise a

three step test for differentiating the four

Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

44 DOS Times - march-april 2017

Monthly meeting korner

The Invisible Scotoma – Role of Retinal
Reflectance Imaging

Dr.Vaibhav Sethi DNB, FICO, FLVPEI
Vitreo Retinal Consultant
Arunodaya Deseret Eye Hospital
Sector 55, Gurgaon, Haryana

A30 yr old male, presented 5 weeks after road Figure 2: Optical coherence tomography (OCT) of the left eye showing
traffic accident with chief complaints of slight attenuation of the IS-OS junction nasal to the fovea
visualising a central scotoma with his left eye
which was sudden in onset since the time of the image showed a distinct hypo-reflectance pattern at the macula
incident in September 2016. No other relevant corresponding to the pattern of the scotoma seen on visual
history or systemic illness was elicited. fields testing of the left eye (Figure 3 & 4).
He had been previously investigated 4 weeks back
elsewhere and had been advised MRI Brain to rule out occipital Based on history, clinical findings and investigations, a
infarct and even a trail of oral steroids had been given which the diagnosis of subclinical Commotio Retinae was made and the
patient himself later discontinued. patient was managed conservatively.

On examination, both eyes had 6/6 (Log MAR 1.0) unaided On the next follow up visit 4 months later in Jan 2017, the
visual acuity. Anterior segment examination of both eyes was patient still complained of seeing the central scotoma. The OCT
within normal limits. Intraocular pressure was 19 mm of Hg in of the left eye was within normal limits having no attenuation of
the Right eye and 18 mm of Hg in the Left eye with Applanation the IS-OS junction (Figure 5).
tonometry. Colour vision of both eyes was normal.

Fundus examination of the Right eye was normal. Fundus
examination of the left eye showed a normal disc with healthy
neuroretinal rim and a normal looking macula with a good
foveal reflex (Figure 1).

Optical coherence tomography (OCT) of the left eye
showed slight attenuation of the IS-OS junction nasal to the
fovea (Figure 2), but other features were essentially normal.

However to our surprise, the Infrared reflectance overlay

Figure 1: Colour fundus photo of the left eye Figure 3: Infrared reflectance overlay image showing a distinct hypo-
reflectance pattern at the macula

www. dos-times.org 45

Monthly meeting korner

Figure 5: OCT of the left eye at 4 months follow up which was within
normal limits having no attenuation of the IS-OS junction

Figure 4: 10-2 Left eye visual fields showing scotoma corresponding to Figure 6: The Infrared reflectance overlay image showed significant
the distinct hypo reflectance pattern at the macula reduction in hypo-reflectivity at 4 month follow up visit

The Infrared reflectance overlay subclinical4. References
image showed significant reduction in
hypo-reflectivity (Figure 6). However, the Diagnosis of subclinical commotio 1. Berlin R. Zur sogenannten commotio
central 10 degrees visual fields did not retinae with infrared retinal reflectance retinae. Klin Monatsbl Augenheilkd. 1873;
change significantly. has been previously described by 1:42–78

DISCUSSION Nicholas and colleagues in a 68 yr old 2. Mansour AM, Green WR, Hogge C.
Histopathology of commotio retinae.
Commotio retinae (CR), a condition male. They inferred that the infrared Retina. 1992; 12:24–28
caused by a direct ocular injury, was hypo-reflectance in CR is caused by
first described by Berlin in 18731. It is increased absorption of infrared light by 3. Park JY, Nam WH, Kim SH, Jang SY, Ohn YH,
characterized by a transiently whitish an abnormal OS layer5. Park TK. Evaluation of the central macula
coloration, which is comparatively well- in commotio retinae not associated with
defined on the retina. Reflectance imaging using longer other types of traumatic retinopathy.
wavelength (near-infrared) light Korean J Ophthalmol. 2011;25:262–7
The most common finding in
histological studies of CR is the disruption penetrates into the deeper layers of the 4. Blanch RJ, Ahmed Z, Sik A, Snead DR,
or fragmentation of the photoreceptor retina to provide reflectance information Good PA, O’Neill J, et al. Neuroretinal
outer segment (OS) of the retina2. OCT at the level of the outer retina and RPE. cell death in a murine model of closed
non-invasively provides optical cross- globe injury: Pathological and functional
sectional images of the retina and This imaging modality has been found characterization. Invest Ophthalmol Vis
morphologic information similar to that Sci. 2012;53:7220–6.
obtained from histological studies. to be a useful adjunct for diagnosing
5. Andrew NH, Slattery JA, Gilhotra JS.
Cases of CR detectable on OCT retinal pathologies such as acute macular Infrared reflectance as a diagnostic
imaging, but not fundus examination have neuroretinopathy6 and age related adjunct for subclinical commotio retinae.
been described previously in literature3, macular degeneration7. Indian J Ophthalmol. 2014; 62:879-80.
confirming that some cases of CR are
Reflectance imaging can be overlaid 6. Tolou C, Mahieu L, Salmon L, Hamid
and combined for accurate comparison S, Suarez C, Garcia D, Pagot-Mathis V,
Gomane C, Berot A, Malecaze F, Soler V.
between clinical visits, allowing for [Multimodal imaging in the diagnosis of
acute macular neuroretinopathy]. J Fr
detection of subtle alterations in retinal Ophtalmol. 2014; 37:796-803.

anatomy, thus being a useful adjunct in 7. Ly A, Nivison-Smith L, Assaad N,
Kalloniatis M. Infrared reflectance imaging
multimodal imaging. in age-related macular degeneration.
Ophthalmic Physiol Opt. 2016;36:303-16.

Financial Interest: The author does not have any financial interest in any procedure/product mentioned in this manuscript.
Guest Case presented in the DOS Monthly Clinical Meeting at Ram Manohar Lohia Hospital, January 29, 2017.

46 DOS Times - march-april 2017

INNOVATIONS

Ranjan MSICS Marker:The Beginning of Topical,
Flapless,Astigmatism Free MSICS Era

Dr. Pratyush Ranjan MBBS, DO, MS, DNB, MAMS
Shaheed Bhagat Singh Eye Hospital,
Bareilly, Uttar Pradesh, India

Figure 1: Ranjan MSICS Marker (RMM)

Cataract remains 51% cause of blindness and 33%
cause of visual impairment worldwide according to
recent data (2010) of World Health Organization.
90% of these people are present in poorer parts
of the world like south East Asia & Sub Saharan
Africa, where cost remains a constraint for
providing best treatment1. In these communities blindness is

associated with disability and mortality. It also has a profound

societal and economic impact through loss of productivity of

both the blind and those who care for them. Because of the

significant reduction in life expectancy and quality of life for Figure 2: Serrated edges at the back, it fixes the globe during tunnel making.
the blind, sight-restoring cataract surgery is undoubtedly one

of most cost-effective medical interventions2. For these reasons, MSICS has emerged as a viable and

Phacoemulsification (Phaco) is the surgery of choice preferable alternative for many such settings. High quality, high

for cataract in the developed world. Several studies have volume cataract surgery using MSICS has been popularized in

demonstrated quicker recovery and superior post surgery community eye care centers to effectively manage the large

uncorrected visual acuity due to less post surgery astigmatism. backlog of cataract blindness. It provides excellent outcomes

Nevertheless there are no significant differences in visual at a fraction of the cost of Phaco
and with shorter surgical time.
rehabilitation, endothelial cell Cataract remains 51% cause of blindness
loss and complication rates When price is not the
constraint, Phaco remain
when compared with manual and 33% cause of visual impairment procedure of choice for cataract
small incision cataract surgery worldwide according to recent data
(MSICS)3.
extraction because of mainly 3
Phaco is often available in (2010) of World Health Organization. reasons:
the developing world to those 90% of these people are present in 1. Shorter hospital stay due
cataract patients who can
privately afford it. Compared poorer parts of the world like south East to topical (drop) anesthesia
2. Shorter recovery time
with MSICS, Phaco requires Asia & Sub Saharan Africa, where cost due to smaller size of incision
a significant capital purchase
and higher supply costs per remains a constraint for providing best and
3. Lesser need of
case. Annual Phaco machine treatment prescription glasses post

maintenance is an issue not surgery due to smaller size of

only of cost, but also of readily wound and careful wound construction taking account of

available qualified technical support. In addition, there is a steep axis & Surgeon Induced Astigmatism (SIA).

longer learning curve for new cataract surgeons to master Topical MSICS is being performed by many experts around

Phaco, which is particularly challenging in the developing the world with great results. MSICS with greater astigmatic

world given the poorer educational infrastructure available to control (comparable to Phaco) is seen with careful location,

ophthalmologists. Finally, the advanced mature cataracts and shape and size of incision.

brunescent hard cataracts that are so prevalent among poor Many studies have proven an ideal MSICS incision to be of

populations are more challenging to extract with Phaco, and the following attributes. The anterior limit of the incision should

complication rate is higher in most hands except in most skilled be 2–3 mm behind the limbus, in Koch’s incisional funnel to

and experienced Phaco surgeons. Multiple studies reported minimize post surgery astigmatism. The length of the incision

the safety and efficacy of MSICS for complicated cases, such as (the distance between the two ends, but not along the curvature)

brunescent and white cataract and cataracts associated with varies from 5.5 to 6 mm. The frown shaped incision is best

phacolytic and phacomorphic glaucoma4. suited for MSICS because it induces least astigmatism with less

www. dos-times.org 47

INNOVATIONS

Figure 3: The front surface showing corneal axis marker & Tunnel Marker. Figure 4: The marking of horizontal meridian of cornea using bubble marker.

Figure 5: Aligning pre marked horizontal meridian of cornea with Figure 6: Making incision over conjunctiva & sclera (together) using
corneal axis marker of RMM. tunnel marker of RMM as stencil.

tendency of wound edge separation as After draping is done, the corneal axis
compared with chevron shaped5.
marker is then aligned with pre marked
Ranjan MSICS Marker (RMM) is
designed to make topical flapless MSICS meridians on the patient’s cornea and
with greater astigmatic control a reality,
for beginners and mid level cataract steep meridian is marked (Figure 5).
surgeons (Figure 1). It is designed to help
in three critical steps of MSICS through its The RMM is then rotated to align tunnel
three different components.
1. The 2700 Serrated edges at the base: It marker axis to steep axis of cornea. A

fixes the globe during tunnel making perfect frown shaped incision of 6mm
obviating the need of superior rectus
bridle suture, obviating the need for length, 2 mm away from limbus is created
peribulbar block & post surgery eye
bandage. (Figure 2) using tunnel marker as stencil (Figure Figure 7: Constructing Scleral tunnel using
2. Tunnel Marker: It helps create perfect serrated edges at the back of RMM to stabilize
frown shaped 6 mm incision, 2 mm 6). The tunnel is created by stabilizing the globe without superior rectus bridle suture
away from limbus. The measured or colibri forceps.
location, length & shape of incision the globe by mildly pressing the RMM
will help surgeons to reproduce their interested can join by writing to me at
results. (Figure 3) on the globe, the serrated edges at the [email protected]
3. Corneal axis marker: It helps plan
incision on steeper axis, taking care undersurface provides excellent grip Reference
of pre existing astigmatism.
The Tunnel and Corneal axis marker obviating the need for toothed forceps or 1. The World Health Organization. Causes of
reduces post surgery astigmatism by blindness and visual impairment. http://
placing least astigmatic incision in Koch superior rectus bridle suture (Figure 7). w w w. w h o . i n t / b l i n d n e s s / c a u s e s / e n /
astigmatic funnel on the steep angle (accessed 5th February 2017).
taking care of both pre existing and The video explaining the use is available
surgery induced astigmatism. on the YouTube, titled “Ranjan MSICS 2. Venkatesh R1, Chang DF, Muralikrishnan R,
The 00 & 1800 meridian is marked Hemal K, Gogate P, Sengupta S. Manual Small
using bubble marker in sitting position Marker (Launch Video, Presented at Incision Cataract Surgery: A Review. Asia Pac
(Figure 4). Using pre operative J Ophthalmol (Phila). 2012;2:113-9.
keratoscopic data (K1 & K2), steep AIOC 2017, Jaipur)”. Those reading online
meridian of the patient is identified. 3. Gogate P, Optom JJB, Deshpande S, Naidoo
version can access the video by clicking K. Meta-analysis to Compare the Safety and
on its link: https://www.youtube.com/ Efficacy of Manual Small Incision Cataract
Surgery and Phacoemulsification. Middle
watch?v=4YiOwrwgrew&feature=share East African Journal of Ophthalmology.
The flapless topical MSICS using 2015;22:362-369.

Ranjan’s modifications (R-MSICS), shown 4. Gogate PM, Deshpande M, Wormald RP.
Is manual small incision cataract surgery
in above mentioned video is easily affordable in the developing countries?
A cost comparison with extracapsular
possible with Ranjan MSICS marker, cataract extraction. The British Journal of
Ophthalmology. 2003;87:843-846.
which also reduces surgery time, cost
5. Haldipurkar SS, Shikari HT, Gokhale V.
and stay at hospital making blindness Wound construction in manual small
incision cataract surgery. Indian Journal of
elimination more economical. Ophthalmology. 2009;57:9-13.

A multicentre study comparing

post surgery astigmatism in topical

phacoemuslification surgery

with monofocal intraocular lens

implantation vs topical R-MSICS using

RMM is underway; those who are

Financial Interest: The author does not have any financial interest in any procedure/product mentioned in this manuscript.

48 DOS Times - march-april 2017

Community Ophthalmology

Determining an Ocular Health Problem as a
Public Health Issue

Dr. Suraj Singh Senjam MBBS, MD disabilities like visual impairment, low vision, and blindness are
Associate Professor the outcome of every ocular disease. These outcomes as a whole
Community Ophthalmology are undoubtedly a public health problem irrespective of the
Dr. Rajendra Prasad Centre for Ophthalmic Science, disease status leading to them. However, in public health point
All India Institute of Medical Science, of view, it is of great importance to decide whether a particular
New Delhi

ocular disease and its outcome are in the cadre of public health

In the biomedical sciences, any health problem concerned or not. If the concerned disease is of public health
irrespective of the anatomy involved, it is important
to decide whether the concerned problem accounts as importance then it is important to decide where public health
a public health issue. If the problem is a public health
issue, then for the prevention and control, a public strategies should act upon in its natural history of disease. As
health action plan is needed. A public health action
of new, the etiological factors of common ocular diseases are
ill defined, so the public action plan should be at the level of
outcome prevention, not at the level of disease prevention. This

needs multilevel approaches and initiatives to make more is due to the fact that the prevention occurrence of common

awareness not only the health care providers, but also to the of ocular disease is practically not possible whereas outcome

general population about the prevention, for instances blindness, is possible. Therefore,

to identify any ocular disease
seriousness of the problem, A public health action needs multilevel is a public health issue; the
risk factors, opportunities for
early detection and treatment. It approaches and initiatives to make disease outcome status is more
important than the disease
requires working at all levels of more awareness not only the health prevalence status when we
the health care delivery system
to ensure the accessibility of care providers, but also to the general talk about the public health
the quality services. It also population about the seriousness of the prevention program. Five
different criteria should be met
requires generating scientific- problem, risk factors, opportunities for while evaluating for a public
based public health data, and
information, and sharing to early detection and treatment health issue of any ocular
problem (Figure 1). Similar
policy makers and healthcare
criteria were being applied in
planners to design an appropriate action plan.
assessing the condition of other health problems but using
The natural history of any disease signifies how a disease
disease status2.
evolves over the period of time from the earliest stage of its
1. Does the outcome of an ocular disease affect a lot
pre-pathogenesis phase to its outcome as recovery, disability or
of people in a particular region and amongst particular age
death in the absence of treatment or prevention1. In ophthalmic
groups (Magnitude of disease outcome)?
health, death or mortality as compared to disability outcome
This reflects the proportion of the population affected by
due to ocular problems is not so common. Most of the cases, the
the outcome. What is the nature of epidemiological distribution

of the outcome in the community? In eye health problems, the

magnitude of disease outcome, not the disease prevalence is

more important in defining public health issue. For example,

Magnitude of prevalence of the visual impairment (less than 20/60 in the
disease outcome better eye) due to cataract was reported as 33.8% in Delhi
amongst the aged 40 years and above3. Similarly, uncorrected

refractive error attributes up to 53.4% of the total visual

Preventability Public Health Burden impairment in the same aged group. A North India Myopia
of disease Issue of disease Study by Rohit, et al. reported that prevalence of visual
outcome outocme impairment due to myopia was 13.1% among school going
children4, whereas in some of Asian countries was ranging from

70-90 % among high school children5.

In certain cases, few ocular diseases may affect a lot of

Threat of Acceleration people, but disability outcome may not be adequately large
disease of disease enough to conclude as a public health issue. A population-based
outcome outcome study reported the prevalence of dry eye disease was 25%
among aged 40 years and above in north Indian population6.

Though prevalence is high, but the visual disability outcome

Figure 1: Five criteria for public health issue in terms of visual impairment or blind is not prevalent widely,

Figure 1: Five criteria for public health issue www. dos-times.org 49

Community Ophthalmology

though severe dry eye disease may lead of the age-related ocular problems will plan to prevent and control the problem,
to visual problems. In this scenario, a continue to be increased, so its outcome. it is important to identify the concerned
population based epidemiological study For example, age-related macular ocular disease and its outcome as a
is warranted to rule out the prevalence degeneration, diabetic retinopathy, public health issue. A population-based
of visual disability or impact on visual glaucoma are likely to be accelerated epidemiological study encompassing all
function due to dye eye disease. over time due continue demographic these criteria needs to be conducted to
transition. know the status of problems and disease
2. Does the outcome contribute outcome.
a huge burden in terms of morbidity, 4. Is the ocular disease outcome
mortality, economically, also the perceived to be a threat to the public, References
quality of life (Burden of disease healthcare planners, policy makers
outcome)? (Threat of disease outcome)? 1. Park K. Textbook of Preventive and
Social Medicine- Concept of health
This criterion relates to the impact of This criterion implies the impact of and disease. 20th edition Baarsidas
the disease outcome to the individual and the disease outcome on the wider society Bhanot publishers Jabalpur, M.P. India.
family in term of financial cost, morbidity, or community or nation as well as health 2009;32-33.
mortality, etc. Since, mortality is less care planners and policy makers. This
frequent in the context of ocular problem; reflects the estimated loss of human 2. Vinicor F. Is diabetes a public health
burden due to visual impairment, resources in their daily activities, and disorder? Diabetes Care 1994;17 :22–7
blindness is to be assessed to towards the productivity and physical functioning and
financial implication and morbidity. performance affected by the outcome, 3. Saxena R, Vashist P, Tandon R, Pandey
and the cost of the intervention. RM, Bhardawaj A, Menon V, et al.
In some of ocular disease, the burden Prevalence of Myopia and Its Risk
of the ocular disease outcome might be 5. Is the prevention of the Factors in Urban School Children in
huge, but the magnitude of the outcome outcome feasible to act on a community Delhi: The North India Myopia Study
in the population may not be significantly or public level at a large (Preventable (NIM Study). PLoS ONE 2015;10:
large enough. For example, the impact of disease outcome)? e0117349.
on the burden of retinitis pigmentosa
to the individual may be high in terms Finally, it is important to consider 4. Pan CW, Ramamurthy D, Saw SM.
of DALY (Disability Adjusted Life Year) whether the outcome is potentially Worldwide prevalence and risk factors
or economically to the family, but the preventable or treatable at the for myopia. Ophthalmic Physiol Opt.
prevalence of blindness due to retinitis community setting or population level. 2012;32:3–16.
pigmentosa is not substained (anedoctal Early detection and screening should be
evidence) to signify as a public health amenable at the community level and 5. Schoolwerth AC, Engelgau MM,
problem. appropriate management should be Hostetter TH, Rufo KH, Chianchiano D,
available. McClellan WM, et al. Chronic kidney
3. Has the concerned outcome disease: a public health problem that
recently been increased and expected, Conclusion needs a public health action plan.
so in the future as the disease Prev Chronic Dis [serial online] 2006
prevalence increased (Acceleration of In ophthalmic sciences, every ocular Apr [date cited]. Available from: URL:
disease and its outcome)? disease is important irrespective of the h t t p : / / w w w. c d c . g o v / p c d / i s s u e s /
epidemiological status. However, when 2006/apr/05_0105.htm.
As the elder population increases the question arises the needs of public
due to demographic transition, some health approach and public health action 6. Gupta V, Vashist P, Malhotra S, Gupta
A, Tandon R. Population-Based
Prevalence of Dry Eye Disease in the
Adult Indian Population Ophthalmic
Epidemiology Free papers, APAO-AIOS
Hyderabad 2013;662-65.

Financial Interest: The author does not have any financial interest in any procedure/product mentioned in this manuscript.

Running Ophthalmic Practice of 35 Year Repute For Sale in
Daryaganj, Along with Premises and Equipment.

Premises 12000 Sq. Ft. Built Up Area, Facing Park.
Sale Preffered But Rental Can Be Considered.

Ideal For Eye Clinic / Nursing Home. Terms Negotiable.

Contact : Dr. Vivek Pal: 9810357871, 9810043640

50 DOS Times - march-april 2017

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Rubeosis Iridis and Collaterals at Optic Disc Following
Atherosclerosis

Kalpana Sharma, Praveen Panwar, Himanshu Goyal

Neovascularisation of the iris, popularly termed and brachial pulses were absent left side and bilateral carotid
rubeosis iridis1,2 occurs in association with, or and abdominal bruit was present. Blood investigations showed
secondary to, other systemic or ocular diseases, normal serum glucose level (95 mg/dl), serum total cholesterol
the most frequent being diabetic retinopathy was 127 mg, serum triglycerides 84 mg/dl, LDL was 77 mg/dl,
and central retinal vein occlusion3,4. Severe and HDL was 33 mg/dl. On carotid Doppler patient had >40%
carotid artery disease may occasionally present stenosis in right external carotid artery with >50% occlusion
with uncommon clinical symptoms. Rubeosis iridis secondary of right internal carotid artery and common carotid artery.
to ocular ischemia may be the first and sole ocular manifestation There was near complete occlusion of left internal carotid
leading to the diagnosis of carotid stenosis5,6. artery. There was soft and calcified (grade V) plaque in bilateral
common carotid artery, internal carotid artery and external
Case 1 carotid artery. On CT angiography (Figure 1,2) arch of aorta
showed multiple calcified and soft plaques (grade I) stenosis
We report a case of 67 yrs old male who presented in eye and left subclavian vein showed grade III stenosis. The diagnosis
OPD on Dec 13, 2014 with sudden painless diminution of vision of atherosclerotic vascular disease was made. The hyphema
in right eye for 1 month. The patient had no history of intake in the right eye was managed by propped up position of the
of anti-hypertensive or anti-diabetic medication. On detailed patient with restriction of physical activity. Oral Acetazolamide
ocular examination patient had perception of light in right eye, 250 mg BD, G. Prednisolone 1% 1 hrly tapering subsequently,
and 6/60 left eye. On slit lamp examination right eye showed G. Atropine 1% TDS, and G. Timolol 0.5% BD were given. We
grade 2 hyphema with diffuse corneal endothelial staining planned Panretinal photocoagulation for the left eye, but the
whereas the left eye had diffuse rubeosis iridis and posterior patient was lost to follow up.
subcapsular cataract. Fundus examination of the left eye was
within normal limits and in right eye fundus could not be Case 2
assessed due to grade 4 media haze. On Non-contact tonometry,
the intraocular pressure were 14 & 12 mm of Hg in the right The 2nd patient was 61 years old male who presented on
and left eye respectively. On B-scan the posterior segments of Jan 23, 2015 with diminution of vision right eye for 2 months.
both the eyes were normal. On systemic examination radial The patient had no history of intake of anti-diabetic medication.

Figure 1: CT angiography arch of aorta showing multiple calcified and Figure 2: CT angiography left subclavian vein showing grade III stenosis
soft plaques (grade I) stenosis www. dos-times.org 51

SNAPSHOT

Figure 3: Fundus Photograph of right eye showing fronds of vessels on Figure 4: Fundus fluorescence angiography showing early phase
the optic disc delayed choroidal filling at 20 seconds

On ocular examination patient had visual clinical sign associated with severe might cause dilation and contribute to
acuity of 6/12 in right eye and 6/6 in stenosis of the carotid artery. This neovascularisation10.
left eye. On Non-contact tonometry, the finding is often associated with ocular
ischemic syndrome (OIS) due to impaired Atherosclerosis is the main
intraocular pressure were 12 & 14 mm ocular arterial blood supply that causes cause of OIS. Other causes include
generalized ocular ischemia7,8. dissecting aneurysm of the carotid
of Hg in the right & left eye respectively. artery, giant cell arteritis, fibrovascular
Ocular ischemic syndrome occurs dysplasia, Takayasu arteritis, aortic arch
Anterior segment examination of right more frequently in patients with poor syndrome, Behcet’s disease, trauma or
collateral circulation between internal inflammation causing stenosis of the
eye revealed nuclear sclerosis grade I and external carotid arteries or between carotid arteries. Since OIS is associated
both internal carotid arteries9. The exact with atherosclerosis, patients usually
whereas the left eye was normal. In right pathogenesis of neovascularisation of have other related co-morbidities. The
the iris remains uncertain. The current mortality rate is as high as 40% within 5
eye fronds of vessels were seen on the hypothesis maintains that an ischemic years of onset.
optic disc (Figure 3). In order to confirm retina does release a factor or affects
the presence of neovascularisation the balance of vaso-stimulating and Cardiovascular disease is the main
vaso-inhibiting factors in the vitreous cause of death (approximately 66%),
or collaterals at optic disc, fundus and the retina. With altered regulation, followed by stroke as the second leading
fluorescence angiography (FFA) was neovascularisation is particularly cause of death, which is why patients with
done. FFA of the patient showed delayed prominent at the interface of hypoxic and OIS should be referred to the cardiologist,
choroidal filling at 24 seconds (normal normally oxygenated retinal tissue. This for imaging studies of the carotid arteries,
choroidal flush appears at 8 to 12 so-called vasoproliferative factor may and to the vascular surgeon11.
seconds) and prolonged arteiovenous gain access to the anterior chamber and
elicit abnormal vessels from the iris as it Visual loss in the affected eye is
transit time (Figure 4,5,6). As there was does in the retina. present in over 90% of patients with
no leakage of fluorescence dye at the optic OIS .It is usually related to chronic or
disc so the presence of collaterals at the Whereas Landers has postulated acute retinal ischemia or damage to the
optic disc were confirmed (Figure 7). On that oxygenation of the choroid may optic nerve due to secondary glaucoma.
echocardiography (Figure 8), the patient play a critical role. He argues that the In 67% of patients visual loss occurs
showed diffuse eccentric calcified plaque retinal vessels constrict or dilate in gradually over a few weeks or months, in
at bilateral common carotid artery and relation to oxygen tension. Thus, if 12% it occurs over a period of days, and
oxygen from the choroidal circulation, in another 12% the loss is sudden over a
large plaque in left common carotid artery or aqueous, can increase the tissue period of minutes.
oxygenation of the inner retina, the
bulb with left ventricular enlargement. retinal vessels will constrict in response Anterior segment signs may
to this. Likewise, decreased tissue oxygen be the single manifestation of OIS.
Blood investigations showed normal In approximately 66% of patients,
serum glucose level (115 mg/dl), serum neovascularisation of the iris and at the
total cholesterol was 99 mg/dl, serum
triglycerides 104 mg/dl, LDL was 49 mg/
dl, and HDL was 29 mg/dl.

Discussion

Rubeosis iridis due to iris

neovascularisation can be the only

Department of Ophthalmology,Indira Gandhi Medical College, Shimla, Himachal Pradesh

Dr. Kalpana Sharma MS Dr. Praveen Panwar MS Dr. Himanshu Goyal MS
52 DOS Times - march-april 2017

SNAPSHOT

irido-corneal angle is found, which results dilated. In some cases, both arteries and limits, Doppler imaging of retrobulbar
in impaired outflow of aqueous humor veins may be narrowed. Occasionally,
from the eyeball. However, increased spontaneous retinal arterial pulsations vessels, especially of the ophthalmic
IOP and neovascular glaucoma are noted are observed. Retinal hemorrhages are
in only 50% of patients, while in some very characteristic and are seen in about artery, should be performed. Carotid
ocular hypotony may be observed, in 80% of affected eyes. Hemorrhages are
spite of fibrovascular tissue secondary to mostly located in the external retinal arteriography is performed only in very
neovascularisation closing the angle. This layers, at the mid-periphery. They are not
is due to ischemia of the ciliary body and numerous and are almost never confluent. advanced cases before planned surgery
reduced production of aqueous humor. In They are most probably due to leakage of
patients with unilateral OIS, the lens in blood from the small retinal vessels or on the carotid arteries. New minimally
the affected eye is usually more opaque. from ruptured capillary microaneurysms.
As a result of ischemia and atrophy of the Microaneurysms are very frequent in OIS invasive methods such as computed
sphincter muscle of the pupil, the pupil is and may be located both in the macula
fixed and semi-dilated. There is a sluggish and at the mid-periphery. tomographic angiography and magnetic
reaction to light, which also may be due
to retinal ischemia. The other signs of OIS Imaging studies of the carotid resonance angiography can be also used
may include dilatation of conjunctival arteries are the essential diagnostic test
and episcleral vessels and corneal edema, in OIS. The most commonly used methods as the second-line test in carotid artery
which may lead to bullous keratopathy. In include non-invasive tests such as Doppler
very rare cases, liquefactive necrosis of ultrasound and ocular plethysmography stenosis.
the cornea may develop12,13. and invasive techniques such as carotid
arteriography. Non-invasive tests allow Fluorescein angiography of the
Posterior segment signs are more detection of carotid artery stenosis
frequent than anterior segment signs. in at least 75% of cases. When OIS is fundus is a test commonly used in the
On ophthalmoscopy, the retinal arteries suspected, but Doppler ultrasound scan
are narrowed and the retinal veins are of the carotid arteries is within normal diagnosis of OIS. The prolonged arm-to-

choroid and arm-to-retina circulation
time is a frequent sign. Irregular and/or
prolonged retinal filling time is present
in approximately 60% of patients with
OIS. The normal retinal filling time is
approximately 5 seconds, but in the

affected eyes it may be 1 minute or longer.
This is the most specific (but not the most
sensitive) fluorescein angiography sign of
OIS. The most sensitive angiographic sign

of OIS is prolonged retinal arteriovenous

time, which is present in up to 95% of

Figure 5,6: Fundus fluorescence angiography showing delayed AV transit time(from arteriovenous phase at 24 seconds to late venous at 30 seconds)

Figure 7: Fundus Photograph of right eye showing no leakage of Figure 8: Echocardiography showing diffuse eccentric calcified plaque
fluorescence dye at the optic disc confirmimg the the presence of at bilateral common carotid artery
collaterals at the optic disc
www. dos-times.org 53

SNAPSHOT

cases, but it is not OIS-specific. In 85% peripheral retina and trans-scleral diode Klin Exp Ophthalmol 1879;25:163-172.
of affected eyes, staining of the major laser retinopexy should be considered as 3. Schulze RR: Rubeosis iridis. Am J
retinal vessels (mostly arteries) and their alternative treatment modalities.
branches may be observed at the late Ophthalmol 1967;63:487-495
phase of the test and is attributed to the Carotid artery endarterectomy (CEA) 4. Gartner S, Henkind P:
increased permeability of the vessels. is a surgical method used in the treatment
It may be accounted for by endothelial of carotid artery stenosis. It is effective in Neovascularization of the iris (Rubeosis
cell damage due to chronic ischemia. symptomatic carotid artery stenosis of iridis). Surv Ophthalmol 1978;22:291-
Macular edema is seen in 17% of eyes 70–90% and in asymptomatic stenosis 312.
with OIS and is often accompanied by of at least 60%. An important possible 5. Alizai AM, Trobe JD, Thompson BG, Izer
hyperfluorescence of the optic disk, complication in the acute postoperative JD, Cornblath WT, Deveikis JP. Ocular
caused by leakage from disk capillaries. period following endarterectomy is ischemic syndrome after occlusion
In some cases, retinal capillary non- a sudden rise in IOP that can require of both external carotid arteries. J
perfusion can be seen, mostly located at emergent ocular treatment. Medical Neuroophthalmol 2005;25:268-72.
the mid-periphery. It is related to the loss treatment of increased IOP consists of 6. Mendrinos E, Machinis TG, Pournaras
of endothelial cells and pericytes in these ocular hypotensive agents that reduce CJ. Ocular ischemic syndrome. Surv
vessels and obliteration of their lumen. aqueous outflow as topical beta- Ophthalmol 2010;55:2-34.
adrenergic blockers or alpha-agonists 7. Bennett LW. Ocular ischemic syndrome
The most important aim of ocular along with topical and/or oral carbonic as initial manifestation of bilateral
management is to treat complications anhydrase inhibitors. When the increased carotid occlusive disease. J Am Optom
of OIS, especially in the posterior IOP is refractory to medical therapy Assoc 1997;68:250-60.
segment, as they are associated with the surgery, as trabeculectomy, aqueous 8. Chen CS, Miller NR. Ocular ischemic
highest risk of vision loss. One of the shunt implants or laser photocoagulation syndrome: review of clinical
treatment options employed in retinal is often needed. presentations, etiology, investigation,
ischemia is reduction of retinal oxygen and management. Compr Ophthalmol
demand by ablation of the peripheral, Conclusion Update 2007;8:17-28.
optically non-functional part of the 9. Clouse WD, Hagino RT, Chiou A,
retina. This inhibits neovascularisation Establishing the diagnosis is DeCaprio JD, Kashyap VS. Extracranial
at the irido-corneal angle and prevents therefore essential with respect not only cerebrovascular revascularization for
development of secondary glaucoma. to visual prognosis but also to patient chronic ocular ischemia.Ann Vasc Surg
Panretinal photocoagulation is indicated survival. The ophthalmologists therefore 2002;16:1-5.
in patients with iris and posterior have an important role in early diagnosis 10. Landers MB III: Retinal oxygenation
segment neovascularisation to prevent and in coordinating the systemic via the choroidal circulation. Trans Am
development of secondary neovascular evaluation of patients where an early Ophthalmol Soc 1978;76:528-556.
glaucoma and intraocular haemorrhages. referral to cardiologist is warranted. 11. Sivalingam A, Brown GC, Magargal
However, it is effective in only 36% LE. The ocular ischemic syndrome.
of treated eyes with OIS because Reference III. Visual prognosis and the effect
choroidal ischemia alone with no retinal of treatment. Int Ophthalmol.
ischemia may be sufficient to induce 1. Bader C: The natural and morbid 1991;15:15–20.
neovascularisation. If the fundus is not changes of the human eye and their 12. Mendrinos E, Machinie TG, Pournaras
visible due to media opacities or poor treatment. London, Trubner, 1868, p CJ. Ocular Ischemic Syndrome. Surv
dilation of the pupil, transconjunctival 394. Ophthalmol. 2010;55:2–34.
cryotherapy in the mid-peripheral and 13. Sharma S, Brown GC. In: Ocular
2. Deutschman R: Zur pathologischen Ischemic Syndrome. Ryan SJ, Hinton
antomie des haemorrhagischen DR, Schachat AP, et al., editors. Elsevier;
glaucoms. Albrecht von Graefes Arch 2006. 1491–502.
14. Dzierwa K, Pieniazek P, Musialek P,
et al. Treatment startegies in severe
symptomatic carotid and coronary
artery disease. Med Sci Monit. 2011;17:
191–97.

Financial Interest: The authors do not have any financial interest in any procedure/product mentioned in this manuscript.

54 DOS Times - march-april 2017

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Traumatic Intraorbital Encephalocele Presenting as
Proptosis : A Case Report

Vandna Sharma, Rajeev Tuli, Gaurav Sharma, Mandeep Tomar

Orbital roof fractures with concomitant head and displacing the right globe anteriorly, inferiorly and laterally
trauma are very rare1,2. Traumatic intraorbital (Figure 2). This was diagnosed as intraorbital encephalocele
encephalocele, a severe complication of these and the patient was referred for urgent surgical intervention.
types of fractures, is even rarer. As per literature
reviewed, only 36 cases have been reported Discussion
and proptosis was the most common orbital
symptom in these cases3,4,5. Because of relative rarity, data on Although the orbit and its components constitute very
incidence of orbital roof fractures is limited but studies on small portion of the body but trauma to this region may have
small series of orbital roof fracture suggest 5.2-14%6,7. catastrophic result. Nature has provided orbits for the protection
It may be accompanied with potentially life-threatening of the globe and closed cavity formed by its walls along with the
events such as CSF leakage and meningitis8. Therefore, it is eyeball and septum. Following trauma, there is edema of the
essential that these orbital injuries should be identified early retro-bulbar tissues leading to congestion of the veins which in
and managed appropriately as misdiagnosis and inadequate turn increases the edema; stretching the extraocular muscles
repair can result in severe functional loss and cosmetic and the nerves; resulting in forward displacement of the globe.
deformity. We present here a case of traumatic orbital Beyond a certain limit, this increasing intraorbital pressure,
encephalocele presenting as proptosis after road side accident gradually results in visual loss. This sequence of events gets
with head injury. exaggerated if there is a depressed fracture of the orbital wall,
which has further compromised the intra orbital space.

Case Report The incidence of orbital roof fractures in pediatric age
group was reported to be 7.1% of patients who suffered with

A 17-year, old boy was admitted to the emergency following head trauma, and 13% of those patients developed orbital

a motor vehicle accident. The encephaloceles10. Orbital

patient sustained injuries to his Orbital roof fractures with concomitant blunt trauma resulting in
head and right eye. Neurological head injury after a blunt trauma are orbital fractures can be briefly
examination revealed a Glasgow very rare. Traumatic intraorbital classified into two categories, as
coma scale (GCS) score of 9
blow-in and blow-out fractures.

[E2V2M5]. He had bilateral encephalocele a severe complication of The blow-in type of fractures
periorbital hematoma, which usually involves displacement
was more on the right side. this type of fractures is even rarer. As of the bone fragments into

Visual acuity and extraocular per literature reviewed, only 36 cases the orbit, causing an increase
muscle motility of both eyes in the intraorbital pressure
could not be evaluated due to have been reported and proptosis was and sometimes impingement

reduced level of consciousness the most common orbital symptom in syndromes, which may lead to
of the patient. On torch light irreversible neurological injury
examination, his pupillary these cases. It may be accompanied with especially in chronic cases11,12.

reaction was sluggish in right potentially life-threatening events such According to the involvement

eye and normally reactive in as CSF leakage and meningitis. of the orbital rim these can be
further classified as pure or
left eye. Cranial CT revealed

extra dural hematoma in the impure. These types of fractures

right frontal lobe and bilateral frontal lobe contusions with rarely occur. Traumatic encephaloceles are even rarer, with the

mild mass effect in the axial section. On 4th post traumatic day, first case been reported in 195113. Intraorbital encephalocele

patient developed proptosis and severe conjunctival chemosis, is a type of basal encephalocele; in which brain tissue herniate

this was gradually progressive, with exposure keratopathy through a defect in the skull base. It may be congenital,

in the right eye (Figure 1). As earlier CT scan didn’t reveal traumatic, tumoural or develop spontaneously. But almost

the suspected cause intraorbital encephalocele, patient was 96% of acquired encephaloceles have traumatic in origin. The

advised urgent MRI brain and orbits which suggested bony motor vehicle accidents in adults and fall in children are most

defect in lateral aspect of right orbital roof with herniation of common mechanisms of injury.

brain parenchyma along with the meninges into superolateral Proptosis and diplopia are two important features

part of orbit reaching up to right upper eyelid. This herniated of intraorbital encephalocele. Clinical presentation in

tissue was compressing superior rectus and superior oblique such patients can be in the form of either acute or gradual

www. dos-times.org 55