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Journal of APOS | Vol 1 | Issue I | 2015

apos.co.in

Ex - Officio of APOS

President Prof V Krishanmurthy

Hon. General SecretaryDr. V Sambasiva Rao

Chairman Scientific CommitteeDr. C V Gopala Raju

Chairman ARCDr B S Naik

Proof Reading / AssistanceMrs.P.Hemalatha, Mrs.I.Parvathi Rao & Dr. C Varalakshmi

Design & GraphicsMr. Pradeep, Mr. Soloman Raju

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Journal of APOSPublication of Andhra Pradesh Ophthalmoic Society

Reg No. 192 of 2014

Table of Contents

EDITORIAL BOARD

Dr. Seshubabu Gosala9848177109

[email protected]

Dr. Y. Sujatha9866 333 162

[email protected]

Dr. Virender Sachideva950 952 0647

[email protected],Mobile

Dr. I. Venkata Rao970 184 1299

[email protected]

Dr. Ajay Sharma944 146 9633

[email protected]

Dr. Leela V RajuAdvisor

412 651 3086 (USA)rajulv@@gmail.Com

1. Editorial Board 1

2. Editorial 3

3. Leader Article : The wheels are Turning for IndianOphthalmology 4Dr. I. Venkata Rao, Consultant Surgeon, Visakha Eye Hospital.Journal Editor, Visakhapatam.

4. Original Article : Visual outcome after PCIOL Implantation inlens induced Glaucoma 5Dr. M. Vijaya Rama Raju (Prof & HOD), Dr. Bharathi.K(Post-Graduate), S.V.S Medical College, Mehabubnagar.

5. Visual performance in high myopes following STAAR ICLimplantation 8 Dr.K. Madhavi, DO,DNB. Dr. Kasu Prasad Reddy. DO,FRCO,Dr.M. Swathi Mani, MS, Dr. V.Tripura, MS, Maxivision eyehospital,Vijayawada,Krishna District, Andhra Pradesh, India.

6. Keratoconus : Old Disease - New Management Strategies 11Dr. V.K.Raju, Dr. Leela Raju(USA), Dr. I.V.Rao, 1&2, MonongaliaEye Clinic, Morgantown, WV, USA, 3,Consultant Eye Sugeon,Visakha Eye Hospital

7. Strabismus after pterygium excision - unique presentation andmanagement. 13 Dr. Virender Sachdeva, MS, DNBConsultant, Nimmagada PrasadChildren's Eye Care Centre, Department of PediatricOphthalmology, Strabismus and Neurophthalmology, L V PrasadEye Institute, GMRV Campus, Visakhapatnam, Andhra Pradesh,Email: [email protected]

8. Review Article :Ocular Surface Disorders - Part 1 15VK Raju, MD, FRCS, FACS, Leela V. Raju, MD, G. Madhavi, DNB,1,2 Monongalia Eye Clinic, Morgantown, WV, USA, 1,2,3 GoutamiEye Institute, Rajahmundry, AP, India

9. A Case report : Morning Glory Syndrome 18Dr. N.V.Annapurna, P.G, 3rd year M.S Ophthalmology,,Dr.M.VijayaramaRaju (Prof &HOD), Dr.D.Chandrakanth Reddy(Assoc.Prof).S.V.S Medical College, Tirupati.

10. The Inquisitive Learner 19

11. APOS News & Views : Vol 1, Issue I, 2015 21

12. Editorial 23

13 APOC 2014 Rajahmundry Historical Meeting 26

14. APOS Annual Conference : APOC2015 Tirupathi 28

15. APOS Scientific Committee 30

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Journal of APOSPublication of Andhra Pradesh Ophthalmic Society

Instructions to Authors All manuscripts must be sent by email to the editor.

Manuscripts details

Original articles: Randomized controlled trials, interventionstudies, studies of screening and diagnostic test, outcome studies,cost effectiveness analysis, case-control series, and surveys withhigh response rate come in this category. The limit of the text is3000 words excluding about 30 references and structured abstract of250 words.

Review articles: This include, Systemic critical assessments ofliterature and data sources. The limit of the text is 4000 wordsexcluding 90 references and abstract. For review articles, include themethod (literature search) in abstract as well as in the introductionsection.

Community ophthalmology: The limit of the text is 3000 wordsand 30 references

Ophthalmic practice/perspective: It should summarize and suggestprevailing practice pattern in cases of multiple, diverse options.The word count for the text should be 2500 and abstract 250 words.

Current ophthalmology: It should summarize the latestdevelopments in a particular field with a limit of word count for text2500 and abstract 250 words.

Research methodology: This includes educative articles related tothe conduct of research with word count up to 3000 and referencesup to 30.

Symposia: These are commissioned articles by the editorial board

Brief Communication: it is like original article with insufficientpower with some limitations in the study. The articles should bewith unstructured abstract 150 words and main text 1000 wordsexcluding 10 references.

Case reports: new/interesting/very rare cases can be reported. Caseswith clinical significance or implications will be given priority.However, mere reporting of a rare case may not be considered. Thelimit is 1000 words excluding references and abstract with a maximumof 10 references.

Letter to the Editor: Should be short, decisive observation. Theyshould not be preliminary observations that need a later paper forvalidation. The limit is 500 words and 5 references.

Announcements of conferences, meetings, courses, and other itemslikely to be of interest to the readers should be submitted with thename and address of the person from whom additional informationcan be obtained.

The text of original articles should be divided into sections withthe headings: Abstract, Key-words,Introduction, Material andMethods, Results, Discussion, References, Tables and Figure legends.For a brief report include Abstract, Key-words Introduction, Casereport, Discussion, Reference, Tables and Legends in that order. Donot use subheadings in these sections. The text should be in MSWord format. Use double spacing throughout. Number pagesconsecutively, beginning with the title page. The language should beAmerican English. Illustrations (Figures), Upload the images inJPEG format. Figures should be numbered consecutively accordingto the order in which they have been first cited in the text.

Copy Right: Journal of APOS/ APOS News & Views has no copyrights. For any clarification, please contact the Editor.

Editorial

Friends,

As I pen the editorial of this maiden edition of our

esteemed quarterly journal, I seem to harbor mixed feelings.

Of joy that we are here together as a responsible body of

the renamed ANDHARAPRADESH OPHTHALMIC

SOCIETY registered at Vijayawada. Of disappointment at

the inevitable division of our parent body which is past

legacy now.

This infant body needs all your support for growth,

development and evolve as an able performer.

The legacy I inherited from my younger and better

organized SAVYA SACHI Dr. C.V. Gopala raju, is no smaller,

infact, as I now work free of his shadow I am beginning to

realize how huge and big is the responsibility. My past

experience goads me to better brace up and deliver the

very best. In order to accomplish this and to live up to all

your expectations it is mandatory that you all do your bits

of homework, call what you like and mail the material

soonest for editing and preparing the manuscript for

submission to the printer. New thoughts abound in my

mind and we are in the mode of restructuring and furbishing

for a better product.

Some of the new concepts and items are : Pioneers

in ophthalmology, spotters, who sed it. These appear under

the category "the inquisitive learner".

Editor and Journal need all your support. Let us

cultivate the culture of unity and cooperation for a better

finish which should serve as torch bearer for others to

emulate.

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1 Dr. I. Venkata Rao, Consultant Surgeon,

1Visakha Eye Hospital. Editor, APOS Publications, Visakhapatam.

THE WHEELS ARE TURNING FOR INDIANOPHTHALMOLOGY

Leader Article

Cataract ManagementI was stunned to see a smart British Surgeon Dr Eric Arnot (StThoma's Hospital ?) playing golf with a patient he just operated(Phaco with IOL) in a slide presentation (OSUK).It was in 1975, novideo was available at that time. The smile on the patient's facereflected the sheer delight of improved vision. How does thiscontrast with the FDA approved FAMTOSECOND CATARCTINSTRUMENTATION that is currently available in many Indianhospitals?Childhood CataractsGone are the days when young children were wearing those thickaphkicglasses post-surgery. Consider the wide spectrum of IOLs,Piggy back, Intraocular CLiols you name it ,they come custom made to suit your and patient'sneeds.AMBLYOPIA management is so different now even if an Orthoptistunavailable. Emphasis on early recognition, counseling and goodfollow up have considerably reduced visual morbidity andimproved the outlook of these young clients.Eye BanksModern Eye Banks have contributed to the rehabilitation onCorneal Blind victims. See the impact of research exemplified here.Three people can now be benefit form on donated cornea, unheardof till recently. Not too long ago a tiny country like Srilanka wassupplying donor eyes to us.Corneal AilmentsDo I need to elaborate how this field has become a prerogative ofthe specialist ophthalmologists. Rightly so. If Eximer laser was aboon, Femtosecond laser is a wonder addition to modern ocularsurgery. Management of Keraconus is so vastly different with theimproved results.Community Ophthalmology too has made considerable differencein reducing vitamin deficiency related blindness. Thanks to theVastly improved governmental strategies supported by WHO.Much work needs to be done however.Research and Development We could not have travelled this far without R/D. Sadly though

this is lagging behind partly due to the high costs involved inrunning a LAB, lack of dedicated team, long periods necessarilyneeded for tangible outcomes not to speak of hurdles ofgovernmental bureaucracy.Tele Ophthalmology and Training programmersThese have vastly improved the quality of and stature of ourbudding ophthalmologists. These are the people who will shoulderthe responsibility of delivering health care to the needy masses.Gadgetatary and instrumentationYou only need to browse the net if you are unable to attend andsee the trade exhibits that are part of our confos of all kinds.Dexterity is inborn however this can be cultivated over a period oftime, add to the plethora of high tech ,easy to operate items thatcan be bought or hired.It seems to me that SKY IS THE LIMIT, be it learning, training oranything to do with patient care. The question is how far are youprepared to go. Can I say here that Indian trained eye physiciansand surgeons are among the world leaders. I see many a youngophthalmologist in the international conferences makingwonderful presentations and gaining recognition globally. Thewest is now looking to the east in many respects. Who said that itis a FLATWORLD. It is for you to keep eyes and ears open grabwhat you think you need and DO YOUR BEST ALWAYS. Becareful not to tumble. What if somebody laughs at your mistakestoday. Those are the people who may not have even thought ofattempting to do half or less that you are able to perform.

Personally I don't believe in miracles. They seem to happen all the same. Science and technology have invaded and are an integralpart of modern medicine. This may be a gross understatement of facts considering the easy to see results of the later .I am a greatbeliever in the teachings I received in my medical college days that fundamentals of clinical examination and bedside medicine areindispensable even in the modern era despite the bold and loud talk of EVIDENCE BASED MEDICINE that has the neededsupportive gadgetry. Undoubtedly this has become an integral part of present day health care delivery system.

Courtesy costs nothing. Shoud be a way of civilised life weare welive.Punctuality is the spice of life.To make a mistake is human. Learn from them, or from othersmistakes. To have not attempted is accepting defeat.Truth and cleanliness are best exaples of godliness. Truthful livingis even higher.

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1 Dr. Bharathi.K (Post-Graduate), 2 Dr. M. Vijaya Rama Raju (Prof & HOD)

1,2 S.V.S Medical College, Mehabubnagar.

Visual outcome after PCIOL Implantation inlens induced Glaucoma

Original Article

Introduction

Lens induced glaucomas are a common occurence in India. Anattempt was made to understand the clinical modes of presentationand post operative visual results in 50 patients with lens inducedglaucoma, attending our institute duringthe period January 2013to march 2014.With a cataract backlog of around 12 million andannually increasing at an estimated rate of 3.8 million, it is notsurprising that the occurrence of lens induced glaucomas is notan infrequent event in India. Though not all inclusive, these lensinduced glaucomas (LIG) are either secondary angle closureglaucomas (phacomorphicglaucomas) or secondary open angleglaucomas (phacolyticglaucomas).Whatever be the mode ofsurgical intervention, the prognosis for good post operative visualrecovery in these conditions remains guarded.

Objectives

1. To evaluate the characteristics and risk factors of Lens InducedGlaucomas.

2. To assess Visual Outcome and Intra Ocular Pressure post-operatively in Lens Induced Glaucomas

Materials and methods

This study included 50 cases of different types of lens inducedglaucoma, admitted in the ophthalmic wards of the SVS MedicalCollege & Hospital, Mahabubnagar, during the period January2013 to march 2014.

All consecutive patients diagnosed as LIG on the basis of clinicalsymptoms and signs were included. Clinical features includedpain, diminution of vision, redness of the eye, presence of anintumescent, mature or hypermature cataract associated withraised IOP of more than 21 mm Hg.

Detailed history pertaining to the causation of glaucoma in theaffected eye was ascertained. The details of history included theduration and progress of diminution of vision, onset of pain,redness, watering and photophobia in the affected eye andassociated symptoms such as headache, nausea and vomitingwere taken. Any history of ocular trauma or previous surgery inthe eye was enquired.

The physical examination of all these 50 patients included athorough examination of their general and systemic conditions.Examination of the globe and adenexa included all the features

that help in diagnosing the condition and also the features thatmay affect the final visual outcome.

A detailed clinical examination of both eyes included the status ofthe lens, depth of the anterior chamber by slit lamp biomicroscopyand schiotz tonometry. Based on the slit lamp examination thetype of LIG was determined. The clinical features were noted inthe study-defined proforma, after patients signed the written andinformed consent. At presentation, in the affected eye Visual Acuitywith Snellen's Chart and retinal function test was done by assessingthe perception of light and projection of rays, intraocular pressurewas measured using Schiotz tonometer, two readings were takento establish the final IOP. In cases where there was corneal edema,IOP was measured after reducing the pressure with IV Mannitol.None of the cases had fundal glow at presentation.

Other routine tests like lacrimal syringing, A-scan biometry, urinesugar, blood pressure recording were done.

The management of these 50 cases consisted, with the aim ofpreserving useful vision, relief from pain and reduction of theelevated ocular tension to almost normal levels, achieved by bothmedical and surgical methods. Relief from pain was by bringingdown the IOP and by systemic administration of analgesics. Antiemetics were given in cases of severe vomiting.

Inclusion Criteria

The following criteria were applied to clinically diagnose thevarious types of lens induced glaucomas:

1. Phacomorphic glaucoma:

o Shallow anterior chamber

o Intumuscence of mature cataract

o Raised IOP

2. Phacolytic glaucoma:

o Deep anterior chamber

o Hypermature cataract

o Raised IOP

o Varying degree of aqueous flare and cells and no K. P's.

Exclusion Criteria

1. Patients with co-incident cataract and glaucoma.


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Visual outcome after PCIOL Implantation in lens induced Glaucoma

2. Other secondary glaucomas (such as due to traumainflammation, neovascular glaucoma).

3. Abnormal material deposition in anterior chamber(mainlypigment dispersion, pseudoexfoliation) complicated cataract.

4. Patients unfit for surgery due to very poor general condition.

Preoperative medical line of treatment

In all cases, preoperative medication to reduce IOP included topicaltimolol 0.5% twice a day, oral acetazolamide 500mg twice a dayand intravenous mannitol 20% stratum, and also just before thesurgery in refractory cases. Topical mydriatics, phenylephrine 10%and cycloplegics were started just before surgery, for goodcapsulotomy. Local antibiotics like ciprofloxacin, chloramphenicol,polymyxin, ofloxacin, gatifloxacin were used in differentcombination to make the conjunctival sac sterile. Systemic, oralciprofloxacin (500 mg) 12 hourly was given as prophylaxis toprevent postoperative infection. In phacolytic glaucoma, topicalprednisolone every two hours was also added. In case of anteriordislocation of lens miotics were used.

Surgical line of management

In all patients cataract extraction with IOL implantation was offeredunder guarded prognosis, written consent was taken for all thepatients who underwent surgery. Irrespective of the level of fall oftension, all the patients were taken for surgery either on same dayor on following days depending upon patient's condition. In allthe patients, after peribulbar block, digital pressure was applied,for nearly 8-10 minutes to achieve good hypotony. Planned extracapsular cataract extraction with IOL implantation was done in all.Thorough anterior chamber wash with normal saline was given.At the end of procedure, subconjunctival injection of steroid andantibiotic was given along with local instillation of antibiotic drops.

Post operatively in the ward, all the patients received topicalantibiotic-steroid combination, six times a day and mydriatic-cycloplegic, twice a day. If severe uveal inflammation was present,then short course of systemic steroids was given. If the tensionappeared to be on higher side, topical timolol 0.5% or betoxolol0.5% twice daily, were instilled and in severe cases, oralacetazolamide or IV mannitol 20% stratum, was given dependingon the severity.

All the patients were followed up regularly at 2, 4 and 6 weeksinterval. At every visit, patients were evaluated for visual acuitywith Snellen's chart, IOP by schiotztonometer, slit lamp examinationof anterior segment and posterior pole examination with directophthalmoscope and 90D lens.

Complications

Most common complication post operatively in this study wasuveitis, followed by cystoids macular oedema and bullouskeratopathy. There were very few cases of intra operative vitreous

loss, post operativehyphema, posterior capsular opacity and opticcapture of intra ocular lens.

The analysis comparing selected characteristics such as durationof raisedintraocular pressure and presenting IOP between thosepatients who regained good visual acuity (?6/12) and who did notwere performed.

Results

q Phacomorphicglaucomas were present in 34 patients andphacolyticglaucomas in 16 patients.

q It is observed that, the mean duration of symptoms inphacomorphic glaucoma cases was 21.29 ± 21.77 days and inphacolytic glaucoma it was 13.46± 10.35 days. Of a total 50cases, 10 (20%) have presented with symptoms of more than2 weeks and 40(80%) cases with symptoms of less than 2weeks.

q The follow-up ranged 2-6weeks and the visual acuity at thelast follow-up was taken as the postoperative visual acuity.

q A corrected visual acuity of 6/12 or better was taken as goodvisual acuity and accordingly 50% of thephacomorphicglaucomas and 56.25% of thephacolyticglaucomas recovered to a good visual acuity

q There was no statistical difference between the two groupson the final postoperative visual recovery.

q Clinically, significant proportion of cases with IOP atpresentation less than 35 mm Hg (58.80%) achieved goodvisual acuity, than cases with IOP more than 35 mm Hg(33.34%), whereas no significant difference was found forpoor outcome.

q The correlation between height of IOP and visual outcomewas, clinically significant but statistically not significant(p>0.05).

q The total mean preoperative intraocular pressure was44.18±11.61 mm Hg (range 22-60). After the administration ofhypotensive medications, 17 eyes (34%) had an IOP>35 mmHg.

q The intraocular pressure was controlled in 95% of patients (<21 mmHg) without the need for any anti-glaucoma medicationand the mean postoperative final intraocular pressure was14±6.5 mmHg for the phacomorphic group and 12±2.6 mmHgfor phacolytic group.

q There was a significant risk of obtaining poor visual acuitywhen the duration between the onset of pain and surgeryexceeded 2 weeks and the presenting IOP>35mm Hg.

Discussion

Lens induced glaucomas are a common occurrence in India, hardlysurprising in a situation where the incident of cataract cases farexceeds the total number of surgeries performed currently. Though

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these are clinically distinct entities, they have certain commonfactors in that they are lens induced, they compromise the functionof the optic nerve due to rise of intraocular pressure, cataractsurgery is curative in these cases, and finally they uniformly sharea guarded prognosis.

This study was undertaken to outline the different characteristicsof glaucomas, to determine the postoperative visual resultsfollowing a planned extracapsular cataract extraction and toevaluate any risk factors which may play a role in the determinationof final postoperative visual acuity.

In our study, of these two groups of glaucomas, phacomorphicwas slightly more common (68%) than phacolytic (32%). All thesepatients were managed by a planned extracapsular cataractextraction after attempting to bring the preoperative intraocularpressure within normal limits.

The surgical procedure by itself was not different from a routineextracapsular cataract extraction and there was no specific increasein the intraoperative complication rate. The rate also did not differbetween both the groups of patients except for shallow anteriorchamber seen in the phacomorphic group. However the postoperative period was more stormy in these cases than a regularcataract extraction and they were managed by more frequentapplication of topical steroids and antibiotics. The phacomorphicgroup had more common occuranceofhyphema and pupillarycapture of PC-IOL.

There was no statistically significant difference in thepostoperative final visual acuity between the two groups. 17(50%)patients ofphacomorphicglaucomas and 9(56.25%) patients ofphacolyticglaucomasattained postoperative corrected visualacuity of 6/12 and better. None of these patients had acompromised optic nerve due to the glaucomatous process. 7

patients (20.58%) withphacomorphicglaucomasand 3 patients(18.75%) with phacolyticglaucomas had visual acuity less than 6/60. All these 7 patients with phacomorphicglaucomas and 2 of the3 patients with phacolyticglaucomas had compromised opticnerves due to the glaucomatous process itself. The reason for thevisual acuity remaining poor in the rest of the two patients withphacolytic glaucoma was due to severe persistent postoperativeuveitis and resultant cystoid changes in the macula.

Conclusion

q Good visual acuity can be achieved in lens-induced glaucomapresenting within two weeks, with intraocular pressure of lessthan 35 mm Hg and with meticulous control of intraocularpressure and inflammation with medications pre operatively.

q Planned extracapsular cataract extraction with IOL implantation,minimal tissue handling, a good follow up with efficientmanagement of attendant complications and inflammation, arethe key factors in the management.

q In other words a delay in presentation of more than two weeks,and intraocular pressure of more than 35 mm Hg would resultin severe inflammation affecting the optic nerve, the cause forpoor vision in 12 cases (24.00%) were due to severepostoperative inflammation, bullous keratopathy and cystoidmacular edema. which would ultimately jeopardize vision, inthese potentially blinding lens induced glaucomas.

q This study has highlighted the characteristics, risk factorsand their consequences in lens induced glaucomas, and alsothe importance of early diagnosis, and efficient medicalmanagement to control IOP and inflammation, with meticuloussurgery and IOL implantation and also proficient postoperativemanagement and follow up would probably achieve excellentvisual prognosis.

Visual outcome after PCIOL Implantation in lens induced Glaucoma

LIST OF ADVERTISERSAlcon India Ltd. - Surgicals & Pharma

Allergan India LtdAppasamy AssociatesCarl Zeiss India Ltd

Intra Ocular Care Pvt.LtdRegardia

Zydus Occucare

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1 Dr.K. Madhavi, DO,DNB. 2 Dr. Kasu Prasad Reddy. DO,FRCO, 3Dr. M. Swathi Mani, MS, 4Dr. V.Tripura, MS,

1,2,3,4 Maxivision eye hospital,Vijayawada, Krishna District, Andhra Pradesh, India.

Visual performance in high myopes followingSTAAR ICL implantation

Original Article

Disclosure statementThis paper has been presented in Andhra Pradesh ophthalmicsociety state conference. I certify that all co-authors have readthe final manuscript within their respective areas of expertise andparticipated sufficiently in the study to take responsibility for itand accept its conclusions. Source of funding: None, Conflictsof interest: None

Abstract

Purpose: To evaluate the visual outcome in patients whounderwent STAAR ICL implantation with pre-operative BCVA of6/12 or less.

Methods: 36 eyes of 19 patients with mean pre-operative myopiaof ?12.25 DS (range ?7.00 to ?18.50 DS) and astigmatism ranging -1.00 to-3.50DC who underwent STAAR ICL implantation, sphericalor toric under topical anesthesia through a 3 mm temporal clearcorneal incision with superior surgical iridectomy at MaxivisionEye Hospital,Vijayawada , between January 2012 to December2013, were retrospectively analyzed. Pre-operatively UCVA, BCVAwere recorded. All patients had detailed ocular examination bothanterior and posterior segment,Orbscan ,AS-OCT, gonioscopyand specular microscopy. Standard inclusion criteria for ICLimplantation were adopted. Post-operatively UCVA was recordedand followed up for 6 months.

Results: Post-operatively, all eyes had a significant increase inuncorrected visual acuity, allowing the patients to manage theiractivities without spectacles. The UCVA post-operatively wasbetter than BCVA pre-operatively with an improvement of 4 linesin 13.89%, 3 lines in 27.78%, 2lines in 16.67% and 1 line in 41.67%of patients.

Conclusion: In patients not suitable for other refractive surgeries,ICL implantation is an excellent option for better visualrehabilitation and spectacle independence.

Key Words: Myopia, Implantable Collamer Lens(STAARICL),Uncorrected visual acuity(UCVA),Best spectacle correctedvisual acuity(BSCVA).

Introduction

The rejection rate for laser in situ keratomileusis (LASIK) is about25-30% 1 which was the same in our institute too. The mostcommon reasons for rejection are suboptimal corneal thickness,high myopia, keratoconus and forme fruste keratoconus(keratoconus suspect). Alternatives to LASIK for the correctionof moderate to high myopia include clear lens extraction (CLE)and implantation of a phakic intraocular lens (PIOL).2 Severalpublished studies have confirmed ICL implantation as a feasible

treatment to correct myopia,3-5 hyperopia and astigmatism,6-11 withclinical and visual results as good as or better than laserprocedures. The majority of published studies on the ICL haveshown good predictability, stability, a high level of safety, lowcomplication rates and good or better visual rehabilitation for thetreatment of moderate to high myopia6.

Material and Methods

A hospital-based retrospective study was performed to assessthe visual outcome after ICL implantation for the treatment ofhigh myopia and myopic astigmatism with pre-operative bestcorrected visual acuity 6/12 or less. The ICL procedure wasperformed by 2 experienced ophthalmic surgeons at MaxivisionEye Hospital, Vijayawada. The implantations were carried outbetween January 2012 and December 2013. 36 eyes of 19consecutive patients were enrolled (12 females and 7 males) inthis study, aged 18-30 years. Follow up time was 6-24 months afterICL surgery. Patients were enrolled with mean preoperativemyopia of ?12.25 DS (range ?7.00 to ?18.50 DS). A maximum of -4.00D of manifest cylinder was allowed. Patients were required tohave documented stable refraction for one year prior toimplantation. All patients enrolled in the study were above age of18 years and there were no restrictions as to gender or race. Patientswith an anterior chamber depth (ACD) of less than 2.8 mm(measured from the corneal endothelium to the anterior lenscapsule) were excluded from the study. Additional exclusion criteriaincluded clinical signs of iritis, uveitis, cataract, glaucoma andpatients who were pregnant or nursing. An evaluation of cornealcurvature , shape and thickness were evaluated with acomputerized corneal topography (Bausch and Lomb OrbscanIIz) was carried out by 2 trained technicians. Corneal topographywas used to detect early or suspicious keratoconus and pellucidmarginal degeneration. Any irregular astigmatism was alsodetected. Measurement of ACD( Visante AS-OCT,Orbscan) andwhite-to-white measurement(WTW) and axial length by A-scanultra-sonography (Carl Zeiss IOL Master). The ICL power wascalculated by STAAR Surgicals based on subjective refraction,keratometry, pachymetry, White to White diameter and ACD. TheICL implantation was performed by two experienced refractivesurgeons under topical anaesthesia with a clear corneal temporalincision and a superior surgical peripheral iridectomy .Postoperative examinations were conducted on day 1, 1 week andthen 1, 3, 6 and 12 months and thereafter, once a year. The minimumfollow up period was six months.1 patient was lost to follow up.All patients had preoperative prophylactic peripheral retinal laserphotocoagulation. Statistical analysis were performed using theStatistical Package for Social Sciences version 18.0 (SPSS Inc,

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Chicago, IL, USA).

Results

A total of 36 eyes of 19 patients were included in the study. Themajority of the patients who underwent surgery were aged 18-21years (47.2%) (Table 1). 52.77% of patients had preoperative bestcorrected visual acuity 6/12-6/18 (Table 2). 58.33% of patientsunderwent spherical ICL implantation (Table 3).

Most common post operative complication was pigmentdispersion which is seen in 13.89 % of patients followed by raisedIOP in 8.33% (Table 4). Two patients were lost to follow-up. Postoperative symptoms were not seen in 77.78%.(Table 5).

Uncorrected visual acuity (UCVA) between 6/6-6/9 were noted in77.8% on 1st post operative day (Table 6). Uncorrected visualacuity between 6/6-6/9 were noted in 88.9% after 1 week and 6weeks post operative follow up (Table7,8). There was improvementin postoperative UCVA in 100% of the patients with animprovement of 4 lines in 13.89%, 3 lines in 27.78%, 2lines in 16.67%and 1 line in 41.67% of patients. (Table 9)

Table 1: Age frequency

Age Frequency Percentage

18-21 17 47.2

22-25 11 30.6

26-29 8 22.2

Total 36 100.0

Table 2: Preoperative best corrected visual acuity

Preoperative BCVA Frequency Percentage

6/12-6/18 19 52.77

6/24-6/36 17 47.23

Total 36 100.0

Table 3 : Type of ICL implanted

Type of ICL Frequency Percentage

Spherical 21 58.33

Toric 15 41.66

Total 36 100.0

Table 4: Prevalence of Postoperative Complications

Postoperative Complications Frequency PercentageNo complication 25 69.44Raised IOP 3 8.33

AC reaction 1 2.78

Pigment dispersion 5 13.89

Fibrin membrane 1 2.78

Raised IOP+AC reaction 1 2.78

Total 36 100.0

Table 5: Prevalence of Postoperative SymptomsPostoperative Symptoms Frequency PercentageNo Symptoms 28 77.78Coloured holos 4 11.1Glare 3 8.33Diplopia 1 2.78Total 36 100.0

Table 6: Uncorrected visual acuity 1st day postoperativelyUCVA Frequency Percentage6/6-6/9 28 77.86/12-6/18 8 22.2Total 36 100.0

Table 7: Uncorrected visual acuity 1 week postoperativelyUCVA Frequency PercentageLost for follow up 2 5.66/6-6/9 32 88.96/12-6/18 2 5.6Total 36 100.0

Table 8: Uncorrected visual acuity 6 weeks postoperativelyUCVA Frequency PercentageLost for follow up 2 5.66/6-6/9 32 88.96/12-6/18 2 5.6Total 36 100.0

Table 9 : Change in preoperative BSCVA lines versuspostoperative UCVA

Pre-op BSCVA versus Frequency PercentagePost op UCVAGain 4 lines 5 13.89Gain 3 lines 10 27.78Gain 2 lines 6 16.67Gain 1 line 15 41.67

DiscussionGender distribution showed that females (63.15%) were more thanmales (36.85%). This finding correlates well with other similarstudies.12,13

No intraoperative complications such as laceration of the anteriorlens capsule, placement of an inverted ICL or ICL decentrationwere identified.Post operative complications like rise in intra ocular pressure wasseen in 8.33%(Table 4) which resolved with topical anti glaucomatherapy ,this finding corresponds with other studies.14,15,7 and

Visual performance in high myopes following STAAR ICL implantation


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pigment dispersion is seen which is also reported in otherstudies16,17.Glare and halos is most common post operative symptom18.(Table 5)Preservation of BCVA commonly considered as the primarycriterion for assessing the safety of a refractive surgical procedure,was extremely high in this study.Table 9 shows preoperative BSCVA versus 6 months postoperativeUCVA, with number of lines gain in visual acuity after ICLimplantation . At 6 months follow-up, 100% of eyes had an increasein UCVA(Table 6,7,8) with an improvement of 4 lines in 13.89%, 3lines in 27.78%, 2lines in 16.67% and 1 line in 41.67% ofpatients(Table 9). Other studies showed Best spectacle-correctedvisual acuity was maintained or improved in all eyes.19,20,21

In this study, , there were no complications of incorrect ICL sizing,toric ICL rotation, erosion of the angle structures inducedglaucoma, pupil deformation. These predictable results were dueto accuraate ACD measurements done by Orbscan IIz and Anteriorsegment OCT and corneal WTW diameters measured by calipersand Orbscan IIz In this study no patient developed pupillary block glaucoma whichwe attribute to the surgical PIConclusionSpherical ICL and toric ICL implantation appears to be an effective,safe and predictable technique for the correction of high myopiaand myopic astigmatism. Further randomized, larger clinical studiesare needed to confirm the result.References1. Bamashmus M, Saleh M, Abdulrahman M, AlKershy N.

Reasons for not performing LASIK in refractive surgerycandidates in Yemen. Eur J Ophthalmol 2010;20:85864.

2. Huang D, Schallhorn SC, Sugar A, Farjo AA, Majmudar PA,Trattler WB, et al. Phakic intraocular lens implantation forthe correction of myopia: A report by the American Academyof Ophthalmology. Ophthalmology 2009;116:224458

3. Sanders DR, Doney K, Poco M. United States Food and DrugAdministration clinical trial of the Implantable CollamerLens (ICL) for moderate to high myopia: three-year follow-up. Ophthalmology. 2004;111(9):1683-1692.

4. Arne JL, Lesueur LC. Phakic posterior chamber lenses forhigh myopia: functional and anatomical outcomes. JCataract Refract Surg. 2000;26(3):369-374.

5. Lackner B, Pieh S, Schmidinger G, et al. Outcome aftertreatment of ametropia with implantable contact lenses.Ophthalmology. 2003;110(11):2153-2161.

6. Alfonso JF, Fernandez-Vega L, Fernandes P, González-MéijomeJM, Montés-Micó. Collagen copolymer toricposterior chamber phakic intraocular lens for myopicastigmatism: one-year follow- up. J Cataract Refract Surg.2010;36(4):568-576.

7. Alfonso JF, Baamonde B, Madrid-Costa D, Fernandes JP,Jorge J, Montés-Micó. Collagen copolymer toric posteriorchamber phakic intraocular lenses to correct high myopicastigmatism. J Cataract Refract Surg. 2010;36(8):1349-1357.

8. Sanders DR, Schneider D, Martin R, et al. Toric ImplantableCollamer Lens for moderate to high myopic astigmatism.Ophthalmology. 2007;114(1):54-61.

9. Chang J, Lau S. Toric Implantable Collamer Lens for highmyopic astigmatic Asian eyes. Ophthalmology.2009;116(12):2340- 2347.

10. Elies D, Alonso T, Puig J, Gris O, Güell JL, Coret A. Visiantoric implantable collamer lens for correction of compoundmyopic astigmatism. J Refract Surg. 2010;26(4):251-258.

11. Lindland A, Heger H, Kugelberg M, Zetterstrom C. Vaultingof myopic and toric Implantable Collamer Lenses duringaccommodation measured with Visante optical coherencetomography. Ophthalmology. 2010;117(6):1245-1250

12. Sanders DR, Doney K, Poco M; ICL in Treatment of MyopiaStudy Group. United States Food and Drug Administrationclinical trial of the Implantable Collamer Lens (ICL) formoderate to high myopia: three-year follow-up.Ophthalmology 2004; 111: 1683-1692

13. Arne JL, Lesueur LC, Hulin HH. Photorefractive keratectomyor laser in situ keratomileusis for residual refractive errorafter phakic intraocular lens implantation. J CataractRefract Surg 2003; 29: 1167-1173.

14. Chang J, Lau S. Toric Implantable Collamer Lens for highmyopic astigmatic Asian eyes. Ophthalmology.2009;116(12):2340-2347.

15. Chun YS, Park IK, Lee HI, Lee JH, Kim JC. Iris and trabecularmeshwork pigment changes after posterior chamber phakicintraocular lens implantation. J Cataract Refract Surg.2006;32(9):1452-1458.

16. Sanchez-Galeana CA, Zadok D, Montes M, Cortés MA,Chayet AS. Refractory intraocular pressure increase afterphakic posterior chamber intraocular lens implantation. AmJ Ophthalmol. 2002;134(1):121-123

17. Park IK, Lee JM, Chun YS. Recurrent occlusion of laseriridotomy sites after posterior chamber phakic IOLimplantation. Korean J Ophthalmol. 2008;22(2):130-132

18. Mahfouth A. Bamashmus, FRCS (Ed), FRC (Ophth), AmmarH. Al-Arabi, BSc, MSc (Optometry), Mohammed A. Alawad,MSc, PhD. Saudi Med J 2013; Vol. 34 (9): 913-919

19. Gonvers M, Othenin-Girard P, Bornet C, Sickenberg M.Implantable contact lens for moderate to high myopia: short-term follow-up of 2 models. J Cataract Refract Surg2001;27(3):380-8.

20. Menezo JL, Peris-Martínez C, Cisneros A, Martínez-CostaR. Posterior chamber phakic intraocular lenses to correcthigh myopia: a comparative study between Staar andAdatomed models. J Refract Surg 2001;17(1):32-42.

21. Pesando PM, Ghiringhello MP, Tagliavacche P. Posteriorchamber collamer phakic intraocular lens for myopia andhyperopia. J Refract Surg 1999;15(4):415-23.

Visual performance in high myopes following STAAR ICL implantation

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1 Dr. V.K.Raju, 2Dr. Leela Raju(USA), 3 Dr. I.V.Rao

1&2,Monongalia Eye Clinic, Morgantown, WV, USA, E-mail : [email protected] 3,Consultant Eye Sugeon, Visakha Eye Hospital, Visakhapatnam

KERATOCONUS : Old Disease - New Management StrategiesOriginal Article

Introduction

As the name implies keratoconus is an ectatic corneal disease,progressive and non-inflammatory in nature, predominantly seenin young individuals, often of genetic predisposition . Its impacton the vision and nature of life can be profound. There is aspectrum of disease in corneal ectatic disorders that have beenclinically given different names such as keratoconus or pellucidmarginal degeneration. In addition, post-LASIK ectasia, whilehopefully less frequent as exclusion criteria become betterunderstood, remains an issue and can be treated with similarmethods as keratoconus.

Clinical Features

It manifests as corneal thinning and the cornea assumes a conicalshape and steep corneal curvature. Folds can be noted at thelevel of Descemet membrane. In more advanced diseased, a "V"deformity of lower lid increasing in downward gaze (Munson sign)can be seen. This can lead to blurred vision / poor visual acuitiesdue to increasing myopia and astigmatism. Later in the disease, asudden break in Descemet membrane can lead to sudden swellingof the stroma called corneal hydrops. This can result in scarring atlevel of basement membrane and further decrease visual acuity.

Placido disc imaging will reveal distortions in the spacing betweenthe concentric rings in keratoconus. Irregular astigmatism with aclaw shaped pattern on tomography (ie Humphrey Atlas) or largeamounts of astigmatism, 3D or more, suggest the diagnosis. Moresubtle posterior findings, such as in formefrustekeratoconus, aremore easily identified with Schiempflung camera systems

(iePentacam or Orbscan). This may help reduce the chance ofinducing post- LASIK ectasia by identifying early signs ofkeratoconus. These patients may require observation for a yearor so with repeated topographies. If a refractive candidate cannotbe corrected to 6/6 then closer examination of the cornea must beperformed.

In some children, diagnostic problems can arise especially thosewith a small degree of corneal astigmatism, a healthy appearingcornea on slit lamp, a normal fundus, and vision only correctableto vision of 6/9+. In such patients, a hard contact lens trial cangive 6/6 vision and can save time and money by preventing theneed for expensive and unnecessary investigations.

Management strategies depend on when keratoconus isdiagnosed and the degree of visual improvement required for thepatient. Some patients may be happy with the quality of visionthrough spectacles, while others require speciality fit contactlenses. While early in the course of keratoconus, soft contactlenses may provide quality vision and comfort, with continuedprogression of the cone, intolerance may require the use of rigidgas permeable, scleral, or hybrid lenses. These specialty lensesoften have a higher cost and require more time on the part of thepatient and the person fitting the lenses.

Recent advancements may decrease the contact lens difficultiesfor patients. Collagen cross linking (CXL) strengthens thebiochemical and structural rigidity of cornea as lamellar fibersbecome more compact and therefore withstand stress better.Riboflavin drops saturate the cornea while UV light then createsnew bonds between the lamellar fibers. The cornea flattens as thecone decreases. Kymionis et al have published 5 year data of 21eyes that underwent crosslinking and demonstrated an averageflattening of 3 D and no significant change in endothelial density(Cornea. 2014 Oct;33(10):1071-9).

Intra corneal (stromal) rings are another method to flatten theanterior surface of cornea. Several sizes and diameters of PMMA


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segments can be placed at 75% of the thinnestparacentralpachymetry. The central cornea flattens with aplacement of 1 or 2 corneal ring segment. It can reduce irregularastigmatism and myopia - up to 3 D in some cases. This may meanthe patient is happy with a pair of glasses or a more comfortablyfitting contact lens in about 70% of cases. Criteria and nomogramsto help determine which patients would be best served with thistreatment modality are presently being studied. This proceduredoes not preclude other corneal surgery in the future and can bedone in conjunction with crosslinking. (Figure 2)

When keratconus has progressed past the point that improvementcan be achieved with the techniques mentioned above, deep

anterior lamellar keratoplasty (DALK) and penetratingkeratoplasty (PKP) should be considered. While historically PKPhas been performed for keratoconus (Figure 3), the advent ofDALK has greatly improved the survival of corneal grafts byremoving the cause for rejection- donor endothelium. While theprocedure can be more difficult and take longer than a PKP -especially if manual dissection is necessary, the benefit to thepatient in the long run is undeniable. A number of papers have

shown decreased endothelial cell loss in DALKs. Zhang andcolleagues have shown that DALKs exhibited less rejection,endothelial cell loss, and secondary glaucoma when compared toa penetrating keratoplasty cohort. J Zhejiang UnivSci B. May2013; 14(5): 438-450.

Discussion and Conclusion :

Keratoconus is a non-inflammatory, progressive disease, with agenetic predisposition. It usually presents in the second decade,and can worsen until early in the fifth decade of life. It rarelyprogresses after this point because it has been postulated thatsunlight crosslinks the cornea over time. It has also been linkedwith retinitis pigmetosa, vernal keratoconjunctivitis, retinopathyof prematurity, Ehlers-Danlos, Down's syndrome, and Leber'sHereditary Congenital Amaurosis.

The aim of treatment in the past had been visual rehabilitation andthus improvement quality of life by non-invasive methods until adefinitive procedure such as PKP was required.

However, more widespread use of CXL has allowed for earlystabilization of the disease and can halt progression. Collagencross linking can also be used in combination with other treatmentmodalities such as PRK. Results of IC rings show that they canprovide good visual quality and halt progression for up to 10years or possibly longer.

Twenty to twenty-five percent of patients may need surgery asother procedures do not restore good vision and conical changesprogress. In advanced disease- state of the art lamellarkeratoplasty( DALK) now offers a better chance of cornea graftsurvival for patients. In the future, understanding the geneticbasis of keratoconus and how to apply this new methodology todiagnose and control the disease may be the most effectivetreatment.

Editor's Note : No referances are cited hear, as the data presentedis from multiple source practices.

KERATOCONUS : Old Disease - New Management Strategies

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"To succeed in your mission, you must have single -minded devotion to your goal"

- Dr. A.P.J. Abdul Kalam, Former President of India

"Was once asked for a message by a JournalistHis reply : My life is my message

- Late Mohan Das Karam Chand Gandi

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1 Dr. Virender Sachdeva, MS, DNBConsultant

Nimmagada Prasad Children's Eye Care Centre, Department of Pediatric Ophthalmology, Strabismus and NeurophthalmologyL V Prasad Eye Institute, GMRV Campus, Visakhapatnam, Andhra Pradesh, Email: [email protected]

STRABISMUS AFTER PTERYGIUM EXCISION- Unique presentation and management.

Original Article

IntroductionStrabismus after pterygium excision is a rare but disablingcondition. It usually manifests as an incomitantesotropia andlimitation of abduction due to extensive scarring over medial rectus(MR) muscle or an incomitantexotropia with a negative forcedduction test (FDT) due to a slipped muscle. We report a case of 33years old female, who presented with an incomitantexotropia,marked limitation of adduction and a positive forced duction testthat presented a dilemma as to the underlying etiopathogenesis.Attention to intra-operative findings revealed presence of anextensive peri-muscular scarring and damage to the medial rectusmuscle, combined effect of which led to a diagnostic andmanagement dilemma.Clinical caseA 33 years female presented with complaints of persistent diplopiain left gaze for 2 months following a right eye primary nasalpterygium excision 2 months back. There was no history of headtrauma.Her best corrected visual acuity (BCVA) was 20/20 and 6/6 in botheyes. On external examination, she had a left face turn of about 30degrees (Figure 1a). The patient was orthotropic in her preferredhead position, but was 35 XT in forced primary position and 45XT on left gaze, (Figure 1b). Ocular motility examination showedpresence of marked limitation of adduction (-3) in the right eyewhereas in the left eye movements were full and free. Her anteriorsegment evaluation showed presence of a slightly elevatedconjunctival scar 3mm nasal to the limbus in right eye from herpterygium excision (Figure 2a). Computerized Tomography scan (CT scan) of the orbits showedthe normal insertion of medial rectus (MR) muscle (Figure 2b).

Fig1a) Pre-operativeface turn to the left ofabout 30 degrees with thepatient looking at a faraway target

Fig 1b) Nine gaze ocular motilityshowing an incomitantexotropiathat increases in the left gaze and amarked limitation of adduction in theright eye (black arrow) while all theremaining ocular movements arecomplete.

Figure 2a. Slit lamp photograph of both eyes showing thepresence of a hypertrophic scarring in the medial conjunctivaat the site of previous pterygium excision (asterix).

A possible diagnosis of slipped muscle or traumatic medial rectuspalsy following pterygium excision was made.A surgical plan was made to explore the muscle and perform MRadvancement along with faden operation on lateral rectus left eyewith goals of achieving alignment in primary gaze, reduce doublevision and increase the field of binocular vision. Intra-operatively,forced duction test (FDT) was positive for adduction suggestiveof mechanical restriction of medial rectus muscle. Medial rectusmuscle was found attached at its original insertion at 5.5 mm fromlimbus, however, there was extensive scar tissue found extending3 mm from limbus involving insertion of MR and posteriorly up tomuscle pulley. So MR was hooked and scar tissue was meticulouslydissected; Forced duction testing repeated after scar tissuedissection was negative suggestive of scarring being the causefor adduction limitation. An intra-operative decision was taken toperform right eye LR recession (6.5mm) with MR resection (6.0mm)to correct 35 PD exotropia. On the first post-operative day, therewas presence of a mild lid edema. There was no diplopia in primarygaze and there was presence of an exophoria in the primary gaze. After 6 weeks of follow up, there was no head turn and there wasflick exotropia of 8 PD in primary gaze with complete movementsin all gazes (figure 3).

Figure 2b.CT scan of the orbits of the patient showing thepresence of a normal attachment of the medial rectus to the scleraruling out possibility of a lost medial rectus muscle.


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Her field of binocular vision (assessed subjectively by asking thearea in which she could fuse) had increased from preoperativenasal field of about 10 degrees to about 35 degrees nasally.DiscussionPterygium excision is a routinely performed safe surgery, but likeother surgeries it has some complications associated with it -most common being the recurrence. Strabismus is rare but seriouscomplication reported after pterygium excision especially afterexcising deep, large1 and recurrent pterygium.1, 2 Possible reportedmechanisms of development of strabismus following a pterygiumsurgery include direct trauma to rectus muscles, scarring of theconjunctiva-perimuscular connective tissue complex3, thick fleshypterygium4, pterygium recurrence1 and extraocular muscledisinsertion2 leading to two different distinct pattern of clinicalpresentations. In the first scenario, as reported by Dalmenet al3 the patient usuallypresents with an incomitant small angle esotropia and limitedabduction. In their retrospective series, a total of 6 patientspresented with an incomitantesotropia, limited abduction, andhorizontal binocular diplopia following pterygium excision. In theirseries, mean angle of deviation was 6 PD in the primary positionwhich increased in abduction. The authors attributed restrictedfull abduction to scar tissue formation and cicatrization of theoperated area causing a limitation of ocular rotation in thecontralateral gaze. Second clinical presentation was reported by Raabet al1 and Ugrinet al2 who reported large angle exotropia increasing in adductionwith marked limitation of adduction. Intraoperatively, in these casesa lost medial rectus was found retroinserted with extensiveproliferation of fibrous tissue.In the present report, we highlight a case that underwent pterygiumexcision and presented with large angle exotropia in whichintraoperatively MR was found at its original insertion but theexotropia was due to extensive scarring simulating a slipped orlost muscle. This is in contradiction to what is expected, as scarringaround the MR is more likely to lead to a limitation of abductionand an incomitantesotropia.As our case presented with large angle incomitantexotropia withmarked limitation of adduction in operated eye, lost muscle afterpterygium surgery was suspected but the imaging showed normalinsertion of muscle which was confirmed intraoperatively.Extensive fibrosis was found intraoperatively, so we believe thatthere could have been a combined mechanism of both intra-operative damage to the medial rectus muscle and subsequent

scarring that lead to an incomitantexotropia; limitation of adductionand a positive forced duction test for the medial rectus muscle.Management of pterygium following strabismus surgery dependson whether there is an extensive fibrosis or slipped or lost muscle.For the present case, a careful MR dissection was done and musclewas hooked while taking care to prevent any further inadvertentdamage to the medial rectus as recommended by Dalmen et al.3

Since the picture was not suggestive of a slipped/ lost muscleafter meticulous dissection a lateral rectus recession and medialrectus resection was performed with a plan to do contralateral(left) eye lateral rectus faden procedure at a later stage, if required.However, patient did not complain of any diplopia and eyes werewell aligned, therefore, no further intervention was planned.To conclude, strabismus after pterygium surgery is a rare butdisabling condition. There is no large series reported in theliterature describing this condition. Previous reported casesdescribe patients with either incomitantesotropia following anextensive scarring or an incomitantexotropia following a slipped/lost muscle. However, the present report, describes a patient withan incomitantexotropia and adduction lag following pterygiumexcision with extensive fibrosis. We propose that it might havebeen caused by an intra-operative damage to the medial rectusmuscle causing a paresis of the muscle that led to an exotropiaand adduction lag; however ensuing healing process may haveresulted in extensive fibrosis that led to a positive forced ductiontest for the muscle. Thus, large angle incomitantexotropia withmarked limitation of adduction in operated eye may not alwayssignify slipped/ lost muscle. Underlying muscle damage withoverlying extensive scarring may cause mixed pattern of deviation- esotropia or exotropia. Imaging has an important role to play insuch a condition to rule out slipped or lost muscle In such a case,careful pre-operative evaluation and meticulous attention to theintra-operative findings decide the actual plan of management.References1. Raab EL, Metz HS, Ellis FD. Medial rectus injury after

pterygium excision. Arch Ophthalmol.1989; 107(10):1428.2. Ugrin MC, Molinari A. Disinsertion of the medial rectus

following pterygium surgery: signs and management.Strabismus 1999;7(3):147-152

3. Ela-Dalman N, Velez FG, Rosenbaum AL. IncomitantEsotropia Following Pterygium Excision Surgery. ArchOphthalmol.2007; 125(3):369-373.

4. Hirst LW. Treatment of pterygium. Survey of Ophthalmol2003; 48(2):145-180. presence of conjunctival scarring atthe medial and temporal bulbar conjunctiva followingstrabismus surgery.

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Figure 3 Flick exotropia and a marked improvement in theadduction (to near complete normalization). Note the presenceof conjunctival scarring at the medial and temporal bulbarconjunctiva following strabismus surgery.

Strabismus After Pterygeum Exicion

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1 VK Raju, MD, FRCS, FACS, 2 Leela V. Raju, MD, 3G. Madhavi, DNB

1,2 Monongalia Eye Clinic, Morgantown, WV, USA1,2,3 Goutami Eye Institute, Rajahmundry, AP, India

Ocular Surface Disorders - Part 1A Review Article

IntroductionThe cornea, conjunctiva and the limbus comprise tissues at theocular surface. The primary function of the ocular surface is toprovide clear vision when the eye is open as the anterior surfaceof the cornea contributes two thirds of the total refractive powerof the eye.The initial phase of the ocular surface exam should begin withexamination of1. Puncta - position, inflammation (pouting punctum- volcano

sign), patency2. Lid position - blink, which includes infrequent blink,

incomplete blink and floppy eye lids.3. Lid margin - lashes, blepharitis, meibomian gland orifices, sq

metaplasia, telangiectasias4. Tear spread5. Tear meniscus, fornix depth6. Conjunctivochalasis, redness, symblepharon7. Bells' phenomenon

It takes less than a minute to do this portion of the exam.8. Then go to cornea: Because the cornea suffers because of

abnormalities of the adnexa. (Primarily it is not cornealpathology. When the eye is open, the ocular surface healthis dictated by a stable pre-ocular tear film.

Example: Remember the last case of S.J. Syndrome you haveseen. During the first few weeks or months, these patients' corneasare clear without any scars. When the surrounding structuresslowly fail, ultimately the cornea fails. Not uncommonly we givetoo many therapeutic agents without thinking of the primarystructural abnormalities, which can cause medicamentosa.Early recognition of tear film deficiency, placing punctal plugs,bandage contact lens, or even punctal cautery may save thecornea. This prevents microtrauma due to lid anomalies and tearfilm deficiency. The new breed of contact lens (scleral lenses) arerecent advancements and should be used before it is too late. Insome instances you need to tell the patient that he/she needs toblink frequently and also watch for nocturnal exposure.(Parkinson's, old alkaline burns or just old age). Next time, whilethe patient is waiting in the room, watch his or her blink pattern.Stable pre ocular tear film is essential for normal vision. It ismaintained by 2 factors (compositional and hydrodynamic)1. Compositional ( mucin, aqueous, meibum)2. Hydrodynamic: A stable tear film cannot be formed without

kinetic movement of the eyelid that helps the spread of tearcomponents into a thin layer over the entire ocular surface.Blink also facilitates the expression of meibum lipids from thelid margin; the blink also clears "old tears" into thenasolacrimal drainage system (tear clearance).

Both compositional and hydrodynamic factors are controlled bya neuroanatomical integration via two neural reflexes; both aretriggered by corneal sensitivity mediated by the ophthalmicdivision of the trigeminal nerve (V1).The efferent limb of the reflexthat controls the compositional factors is through theparasympathetic branch of the facial nerve (VII), while the reflexthat controls the hydrodynamic factor, is mediated by the motorbranch of the facial nerve(VII).Through such neuroanatomical integration, activation of thecompositional reflex induces secretion of all tear components,while activation of the hydrodynamic reflex induces eyelidblinking and closure. These two reflexes operate subconsciouslyand autonomously without eliciting conscious acknowledgementduring most daily activities.As a result, the entire ocular surface and all external adnexa functionas a single unit for a common purpose.This concept refutes an age old belief that all tearing is subdividedinto basic and reflex tearing, of which the former was thought tobe produced by accessory lacrimal glands and the latter by themain lacrimal gland. Based on the concept described, both basicand reflex forms of tearing are mediated by the same neuronalreflex and that the difference between the two is that the former isdriven by a minimal stimulation, while the latter is driven by maximalstimulation.1. Increased eyelid blinking compensates unstable tear filmUnder the normal open-eye situation, the tear film needs to bestable only during the time period between blinks. For an individualwith normal compositional factor, the demand for a stable tear filmincreases when the blink rate slows, the exposure zone enlargesor a combination of both. On the other hand, when tear filmstability is threatened by compositional deficiency; it can becompensated for by closing the eyelids. In other words,compositional deficiency can be compensated by hydrodynamicfactors.The control of lid blinking, exerted by the motor branch of thefacial nerve, is a complex task mediated by local neuronal reflexesdriven by corneal and supraorbital touch (pain), and light stimuli,and modified by supranuclear pathways. Deficiency in thisneuronal control will diminish the compensatory mechanism ofblinking. For example, the blink rate slows when one is engagedin concentrated visual tasks, e.g. reading, knitting, watching TV/movies, or driving. As a result, symptoms of dry eye patientsmanifest particularly on these occasions, and may even developin normal individuals working on video display terminals whenthe up gaze dominates.One can, thus, conclude that thecompositional factor works in concert with the hydrodynamicfactor and that deficiency of one increases the demand for theother. Failure to meet such a demand by the other can lead to anunstable tear film. For this reason, the clinical work-up shouldalways be directed to exploring the status of all elements in these


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two factors, so as to gain a full grasp of each patient's ocularsurface defense. Failure to do so will provide incompleteinformation for understanding the pathogenesis of the patient'socular surface problems.2. Neurotrophic keratopathy is the worst form of dry eyeThe ocular sensitivity mediated by V1 is the single most importantdriving force controlling the integrity of both compositional andhydrodynamic factors of the entire ocular surface defense. Ascorneal sensitivity decreases with age, there is a high prevalenceof dry eye among the elderly. Deficiency in ocular sensitivity isalso the hallmark of the neurotrophic state. Because aqueous teardeficiency can take place as a result of the compositional factorand increased exposure can develop as a result of inadequateblinking, the worst form of dry eye (defined as an unstable tearfilm) is found in patients with neurotrophic keratopathy. Thedecreased corneal sensitivity noted in a number of disordersisfrequently associated with dryness-induced keratopathy. In aprolonged state of dry eye, epithelial defects with ulceration candevelop and progress, resulting in severe complications. Such apathologic effect mediated via disturbances of the ocular surfacedefenses is in fact a secondary neurotrophic effect is clinicallyindistinguishable from that of keratitis sicca due to aqueous teardeficiency. Denervation of the cornea can cause a "primary"neurotrophic effect to the corneal epithelium by depriving essentialneurotrophic factors (or neurotrophins).3. Exposure keratopathy is a commonly neglected entityExposure keratopathy results from desiccation of the ocular surfacedue to failure of hydrodynamic factors. This may result fromincomplete or infrequent blinking, incomplete eyelid closure and/or reduced Bell's phenomenon. Although incomplete eyelid closureis widely recognized as a cause for exposure keratopathy, othercauses of this condition are commonly overlooked. Incompleteclosure may cause keratopathy even in the presence of normalcompositional factor, and the corneal involvement may beaggravated if protective Bell's phenomenon is diminished, leadingto nocturnal exposure. However, in the presence of compromisedcompositional factor, exposure keratopathy may be more likely tooccur in eyes with reduced blink rate and/or where an incompleteblink might not be as apparent.4. Tear clearance represents final integration of both reflex arcsThe final neuroanatomic integration of these two reflex arcs isalso manifested in tear clearance (turnover). The "hydrodynamic"reflex arc that gives rise to lid blinking also generates a pumpfunction to remove the tear fluid from the tear meniscus into thenasolacrimal drainage system.The "compositional" reflex arccontrols the production of aqueous tear fluid, of which the volumedictates the tear clearance. The latter also explains why decreasedtear secretion in keratoconjuctivitis sicca is frequently associatedwith a decreased clearance rate as measured by fluorophotometry.By using fluorescein as a tracer, the tear clearance rate can also bemeasured by a modified method using serialSchirmer paper strips.Such measurements are consistent with those measured byfluorophotometry, and are useful to help diagnose more accuratelythe dry eye state. This test also helps to distinguish aqueous teardeficiency dry eye associated with Sjogren's syndrome from non-Sjogren's syndrome aqueous tear deficiency based on thepresence or absence of reflex tearing triggered by nasalstimulations.Adequate tear clearance is important to allow constant refreshingof the tear components and effective elimination of debris and

irritants that can potentially harm and irritate the ocular surface.Dysfunction in tear clearance, in the context of delayed tearclearance, has been found commonly, often overlooked, and maybe pathogenic in several ocular surface disorders. Besidesdecreased tear secretion, delayed tear clearance can be inducedby ineffective or decreased blinking (functional block), andmucosal inflammation and edema in the nasolacrimal drainagesystem (partial anatomic block). The former is contributed to bysuch risk factors as old age, female gender, decreased cornealsensitivity, and lid laxity, including floppy lids. In the context ofocular surface defense, an unstable tear film leading to dry eyeand delayed tear clearance leading to accumulation of inflammatorydebris are the two major pathogenic process identified.5. Clinical manifestationThe sensory supply of the previously mentioned reflexes is aninput summation from areas innervated in both eyes by the V1division which includes cornea, lid margin/lashes, conjunctiva andanterior nasal mucosa. Therefore, in conditions reducing thesensation of these structures, an unstable tear film may ensue. Forexample, reduced corneal sensation (due to chronic contact lenswear, HSV keratitis, or LASIK), reduced lid and lash sensation (dueto chronic blepharitis with lash loss), reduced conjunctival sensation(due to atopy, allergy, floppy lid, or conjunctivochalasis), andreduced nasal mucosa sensation (due to nasal allergy) can onlyincrease the severity of reduced ocular sensitivity, leading to aneurotrophic state. Dry eye after LASIK is due to cutting of thecorneal nerves and is accentuated if any of these conditions arepresent. Therefore, it is important to consider all these conditionsas risk factors for developing dry eye in patients undergoing LASIK.In addition to the above factors, neurotrophic keratopathy maybe caused by involvement of sensory nerves anywhere fromterminal nerve endings in the cornea along its course to thetrigeminal nerve ganglion. The common causes for reduced cornealsensation are increasing age, and herpes simplex and herpes zostervirus infections, multiple ocular surgeries, chemical burns, systemicdisease such as diabetes mellitus, and topical medications (Table 1).Clinically, neurotrophic keratopathy should be suspected in anypatient presenting with ocular surface symptomatic complaintsdisproportionately less than the clinical signs or in those patientspresenting with a decreased blink rate. In patients withneurotrophic keratopathy, two types of ocular changes may beseen. First, there are some primary effects in the cornea that maybe followed by secondary effects in the ocular surface. The primaryeffect is intrinsic epithelial degeneration due to deprivation ofneurotrophic factors (neurotrophins). The secondary effect is anunstable tear film (dry eye) due to interruption of the two neuralreflexes mediated by V1. It is important to distinguish these twoneurotrophic effects. This can be demonstrated by differentialdye staining with fluorescein and rose Bengal. Althoughfluorescein detects the epithelial defect caused by both, roseBengal staining pattern is also helpful to differentiate thesecondary effect from the primary effect. In eyes with primaryneurotrophic effect, rose Bengal staining is confined to theepithelial defect; but in eyes with secondary neurotrophic effectit extends beyond that into the exposure zone of the conjunctiva,similar to that of Sjogren syndrome. Following the dye staining,one can then use fluorescein clearance test (FCT) to verify thepresence of the secondary effect by showing reduced tearsecretion. Once detected, eyes with a secondary neurotrophiceffect need punctal occlusion as the first step in the managementof neurotrophic keratopathy.

Ocular Surface Disorders - Part 1

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6. Exposure keratopathyIncomplete eyelid closure can be caused by neurogenic diseasessuch as seventh nerve palsy, cicatricial or restrictive eyeliddiseases such as ectropion, previous blepharoplasty, and skindisorders such as Stevens-Johnson syndrome or xerodermapigmentosum. Proptosis caused by thyroid orbitopathy or otherinflammatory or infiltrative orbital diseases can also result inexposure keratopathy. Although reduced blink rate or incompleteblinking may be seen in old age or disease conditions such asParkinson's disease, a common denominator is reduced cornealsensation.Exposure keratopathy is characterized by a punctate staining of

the corneal epithelium that usually involves the most exposedarea, e.g., inferior third of the cornea, although the entire cornealsurface can be involved in more severe cases. Indeed, incompleteblinks leading to inferior corneal fluorescein staining patterns hasbeen reported in 67% of all forms of exposure keratopathy.Large,coalescent epithelial defects may result, leading to ulceration,melting, and perforation. Symptoms are similar to those associatedwith dry eye, including foreign body sensation, photophobia,and tearing, unless there is an associated neurotrophic componentresulting in corneal anesthesia. Most persistent corneal epithelialdefects can be explained by the above mentioned neurotrophickeratopathy that is complicated by factors that aggravate exposureor by factors that may damage the epithelium such as medicationtoxicity.

Table 1. Etiologic Causes of Neurotrophic KeratopathyInfectious Herpes Simplex Virus*, Herpes Zoster

virus*,Mycobacterium lepraeToxic Acid*, Alkali*, Carbon disulfide,

Hydrogen sulfideNeurogenic Inflammatory: Cavernous Sinus

Syndrome, orbital apex syndrome,Gradenigo syndromeNeoplasia: Acoustic neuromaVascular: AneurysmSurgical ablation of trigeminal nucleusor ganglionCongenital: Familial dysautonomia(Riley-Day syndrome), Goldenhar-Gorlinsyndrome, Mobius syndrome, familialhypoplasiaTrauma: facial or intracranial trauma totrigeminal nerve

Topical medications Beta-blockers*, anesthetics, diclofenacsodium

Corneal dystrophies Lattice, MacularMetabolic disease Diabetes mellitus*, vitamin A deficiencyIatrogenic Corneal surgery*: PK,LK,RK,LASIK

Contact lens use*Ciliary nerve damage*: Retinalphotoablation, retinal surgery, choroidalinflammation

Miscellaneous Aging*, Adie's syndrome, Oraldecongestants

Table 2. Corneal diseases manifesting Limbal Stem CellDeficiency (LSCD)

HereditaryAniridia

Keratitis associated with multiple endocrinedeficiencyEpidermal dysplasia (ectrodactyly-ectodermal dysplasia-clefting syndrome)

AcquiredChemical or thermal burans includingmustard gasStevens-Johnson syndrome, toxic epidermalnecrolysisMultiple surgeries or cryotherapy to limbusContact lens-induced keratopathySevere microbial infection ext4ending tolimbusAntimetabolite uses (5-FU or mitomycin C)RadiationChronic limbitis (vernal, atopy, phlyctenular)Peripheral ulcerative keratitis (Mooren's ulcer)Chronic bullous keratopathyIdiopathic

Adapted fromKheirkhah A, Raju VK, Tseng SCG. Ocular Surface Disorders(chapter). Majumder P, Luchs J, Trattler W, ed. Cornea Essentials.SLACK Inc. Thorofare, NJ. 2007

Ocular Surface Disorders - Part 1

Large Corneal abrasion withcentral facet.

Corneal dystrophy Inferior corneal tear Post coreal onlay membranegraft


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Dr. N.V.Annapurna, P.G, 3rd year M.S Ophthalmology,Dr.M.VijayaramaRaju (Prof &HOD), Dr.D.Chandrakanth Reddy (Assoc.Prof).S.V.S Medical College, Tirupati.

Morning Glory Syndrome

A Case report

IntroductionMorning Glory Syndrome was first discovered by Handmann in1929 & later described by Kindler in 1970. It is an extremely rarecongenital anomaly of the optic nerve head with an incidence of 1in 2 million. Undiagnosed thyroid problem in mother is consideredas a risk factor. It is sporadic, more common in females (2:1) andusually isolated in occurence with wide spectrum of severity. Butit may be associated with panhypopituitarism, Neurofibromatosis- 2, Frontonasal dysplasia, PHACE syndrome, CHARGE syndrome,Aicardi syndrome &Papillorenal syndrome.Case Presentation

The 6-yr old female patient was evaluated using Snellen'sVisual Acuity chart, Ishihara colour charts, Torch, Slit Lamp, Direct& Indirect Ophthalmoscopy, Fundus camera, Lab & Radiologicalinvestigations.History: A 6 -yr old female patient born out of non-consanguinousmarriage presented to OPD with complaint of defective vision inthe right eye for the past 1 year. The child had normal milestonesand is an active child with good academic performance. She givesno H/O seizures, deviation of eye, head tilt or face turn. Also,there is no H/O redness, watering, pain, photophobia, floaters &flashes of light. Her family history is insignificant.On Examination: Her general examination is within normal limits.Visual Acuity is OD - 6/60 not improving with pinhole &OS - 6/6.BCVA in OD 6/60 & OS 6/6. On slit lamp examination, anteriorsegment is normal in both eyes. No RAPD .Fundus examination: OD - shows funnel shaped excavation ofoptic disc with whitish glial tissue in the centre surrounded byraised annulus of pigmented chorioretinal tissue. Blood vesselsare arranged at the periphery of the disc in a radial pattern likespokes of a wheel with no clear differentiation between arteries &veins. Macula is spared. OS - Fundus is normal.InvestigationsColour vision with Ishihara charts - normalECG & 2D ECHO - normalB - Scan OU - normalUSG Abdomen - normalMRI Scan - normalSerum FSH/LH, TSH & Prolactin - normalBlood urea & Serum creatinine - normalTSH levels in mother - normal.ResultsBased on the clinical picture & investigations, the patient wasdiagnosed with Right Eye Isolated sporadic Morning GlorySyndrome with no other associated ocular or systemic anomaly.Treatment No active intervention was done & the patient's parents were

counseled regarding the need for regular follow ups to monitorfor further complications. This patient was followed up over aperiod of 1 yr & no further deterioration was noted.DiscussionMorning Glory Syndrome is a unilateral, usually sporadic conditionmore common in females, diagnosed around school going age.The patient usually presents withvision <6/36, altered colourvision & depth perception, with or without squint & abnormalhead posture. These patients usually have no neurologicalabnormality & have normal intellect. Morning Glory Syndromepatients can also have associated lid hemangioma,microphthalmos, lenticonus, cataract & persistent hyperplasticprimary vitreous. Fundus picture is pathognomomic of thecondition & resembles Morning Glory flower, which gives thecondition its name. The complications of this anomaly include -retinal detachment ( 30%) which occurs more commonly inperipapillary area; squint &choroidal neovascularization.TAKE HOME MESSAGE The ophthalmologist plays a crucialrole in patients with Morning Glory syndrome - in educating thepatient & parents about the disease condition and in stressingthe importance of regular follow ups for early detection &intervention in case complications occur.

OS Fundus - Normal

OD Fundus - shows funnel shaped excavation of disc with whitishglial tissue in the centre. Blood vessels are arranged at the

periphery of the disc in a radial pattern like spokes of a wheel.

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WHO SAID ITIf Coco Cola can sell millions of sodas and MacDonald's billionsof burgers why can't we (?) sell millions of sight restoring operationsand strengthen the belief that we too can attain PERFECTION.The same sage says that money can be saved by selling a cup ofCOFFEE at rupees two than by selling it for rupees fifteen. Treatthis as MADHAVA SEVA.His (V) mission carries with it unwritten philosophy caring for thepoor massage globally. Consider this : In an institution 70%patients receive free (uncompromised quality) treatment while therest 30% pay and help to subsidize the costs and add up to thecapital. Dr JPJ Abdul Kalam paid rich tributes to this great soul bycomparing him to a BEACON that affected millions of lives andinspired many an EYE PRIOVDER globally. We could have morelike the departed person for sheer enlightenment who never caredfor personal recognition or glory.

FOR THE KNWLEDGE SEEKER1 Glaucoma therapy; best topical agent in situations of

pregnancy and lactation.2 WHITE LINE OF GANNERI: What is it? Location and

significance.3 Human Visual Cortex: Consider this statement and think:

In visual cortex upper half visual field is represented inthe ipsilateral upper visual cortex.

4 Do you like ZIN? Think of eye sites where you may findit.

FOR ANSWERS PLEASE BROWSE THE MAGAZINE SECTION

LEGENDS IN OPHTHALMOLOGYALLWAR GULLSTRAND (1911): He is probablythe only OPHTHALMOLOGIST to havereceived the coveted NOBEL PRIZEPHYSIOLOGY/MEDICINE OR OPTICALPHYSICS.A Swedish ophthalmologist applied the methods ofphysical mathematics to the study of optical images and ofrefraction of light in the eye. His greatest innovation was the SLITLAMP BIOMICROSCOPE.His research on astigmatism andimprovement in the ophthalmoscope and corrective lenses foruse after cataract removal. Diffraction of light was his other fieldof interest.

The Inquisitive Learner

About AfricaSome species of locusts are found to have ten thousandmicroscopic eyes, with 3600 Strio Scopic vision. Thisenables them to see objects 15 meters.Source : National Geographic Wild, Jurasic Jungle

APPEALOur association needs your unstinted support for survivaland growth. In order to fullfill the ideals and objective wemust cultivate a sence of togetherness. Therefore pleasebecome a life member if you are not already on our list.Your duty doesn't just end there. Encourage your friendsto join and strenghten our august body.

Spotters : RetinaStudy the images, compare with the answers in the next section

What do these pictures suggest : answers in the next section


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APOS Annual Conference at TirupathiIt is with great Pleasure we announce the first APOS conference (after the division) to be held in the abode of the

super god Balaji.

Tirupathi is beconing you all to be there and enjoy the hospitatlity of the local organising ctommittee.

Lord Venkateswara will bless with health and prospreity. It is possible that you will have a hasle free darshan of theLord of the Seven Hills. Dakshin Netra, SROC - 11,12,13th Sept. 2015 Tirupathi, Andhra Pradesh.

For more details please refered page no. 21.

ANDHRA PRADESH OPHTHALMIC SOCIETYRegistered under Societies Act, Reg No 192 of 2014

PresidentDr V Krishnamurthy

Tirupati

President ElectDr T Satyanarayana Reddy

Anaparti

Vice PresidentDr Sudhakar Rao

Kurnool

Hon. Gen SecretaryDr. V. Sambasiva Rao

Vijayawada

Joint SecretaryDr Pharni Kumar

GunturTreasurer

Dr. A. SrinivasVijayawada

APOC2015, Tirupati

ADVISORY COMMITTEE

Joint TreasurerDr Siva Prasad

Guntur

Dr VishnuvardhanEluru

Scientific Committee ChairmanDr. C V Gopala Raju,

Visakhapatnam

Academic Research Committee ChairmanDr B S Naik

Tirupati

Editor, PublicationsDr I Venkata RaoVisakhapatnam.

Editor ProceedingsDr G Satyanarayana Raju,

Bhimavaram

ChairmanDr K Vengal Rao

Bobbili

MemberDr. C Madhava Sai,

Guntur

MemberDr. M A Padmanabham

Eluru

EXECUTIVE COMMITTEEDr Sriram C Ravula

Kakinada.

AIOS RepresentativesDr M N RajuVijayawada.

Grievience CellChairman Dr K Sivarama

KrishnaVijayawada.

Past Presidents ForumChairman Dr C Srirama Murthy,

Guntur

WebsiteDr Y SujathaVijayawada.

APOS News & Views | Vol 1 | Issue I | 2015

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CHALLENGEFriends,

Who said that life is a challenge? It is our learned friend Dr. lalit verma (in the info booklet, Jan 2015).

In fact it is a bigger challenge designing and producing a well-balanced scientific text for presenting to our readers. It isa pleasure to do just this and not please anybody in particular.

I am not seeking a vote for a post or position. In fact there was no OPPOSITION. You all know what it means. APOS EBwill deliver goods on time every time.

This product is the result of hard and dedicated team work. It should be comprehensive, informative and useful toeveryone in the field of eye care delivery system.

Judge us only on this score. We invite your valuable suggestions and constructive comments. We are all ready to facethis bigger challenge with your support of course.

Editorial

APOS ACADEMIC RESEARCH COMMITTEE (ARC)Conducting its first meeting in Vizag on 1st March, 2015 - Wetlab on Glaucoma Diagnostics

Charirman: Dr B S Naik, TirupatiMembers: Dr G V Narendra, Vijayawada. 9985455042, [email protected]

Dr P A S ChalapatiReddy, Tirupati, 9849012366, [email protected] M.Sreeramachandra Murty.Vizag-9849123790, [email protected]

Hearty congratulations toDr.V Sambasiva Raofor being awardedthe prestigiousAPAO DistinguishedService Award 2015

OBITUARY

Sudden demise of our Life member,Dr Sai Muralifrom Nellore.

May his soul rest in peaceand our condolenses

to his family.

Congratualtions



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PRESIDENT'S MESSAGE

I am happy to know that the Andhra Pradesh Ophthalmic Society (APOS) is bringing out a Bulletin on the occasion of thenewly formed APOS in the newly emerged state of Andhra Pradesh. It is indeed a befitting activity to mark the occasion. I amquite sure that the Bulletin could provide an opportunity to the members of the APOS to interact mutually for progress anddevelopment in research and development activities in the field of Ophthalmology and allied areas.

In promoting human development in its diverse aspects, the APOS gives particular attention to underprivileged and thedeprived in achieving health for all in Andhra Pradesh. Acknowledging our obligation to future generations, the APOS alsoworks for the regeneration of a healthy Indian society and the protection of our family welfare. We have a long way to go beforeIndia becomes a self-reliant healthy society, but our innovation and ideas are an important step in that direction and meet a realneed. It is my hope that the health sector in our country will continue to grow in vitality, at the same time becoming moretransparent and accountable.

I convey my best wishes to the APOS and urge its members to continue their work with even greater zeal, with enrolling alarge number of new members. We began to put together a road map to make APOS a more viable and financially self-sufficientin implementing its agenda. I urge the support and cooperation of all the members for strengthening the APOS in all respects.

I thank the energetic Secretary Dr. V. Sambasiva Rao and Knowledgeable editors publication Dr. I. Venkatrao and Dr.C.V.Gopala Raju for their labor of love in bringing out the Bulletin. The APOS, I am confident, will continue to play a dynamic rolein strengthening our services and promoting the health and wealth of people in newly formed State of Andhra Pradesh.

I extend a personal invitation to every member of APOS for attending its 3-day South Zone Conference to be held at Tirupation 11, 12 and 13 September, 2015. I wish a happy and prosperous New Year-2015 and Sankranthi to all the members and well-wishers of APOS.

I extend my full support and convey my best wishes for the successful publication of the Bulletin.

[PROF. V. KRISHNAMURTHY]

President, APOS

Andhra Pradesh Ophthalmic SocietyRegistered under Societies Act, Reg No. 192 of 2014


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APOS ARC Committee

Dear Collegues,

Wish You A Happy New Year 2015

It gives me great pleasure and honor to write to you as Hon. Gen. Secretary of APOS(Andhra Pradesh Ophthalmic Society).

CHANGE IS LAW OF LIFE. AND WHEN IT IS INEVITABLE WE HAVE TOACCEPT WITH HUMILITY, IN TOTO AND IN REALITY.

With the advent of AP STATE BIFURCATED INTO ANDHRA AND TELANGANASTATES, all the medical associations like Ima, Ent, Dermatology and Pediatricsets,our APO'S also has been bifurcated into APOS AND TOS IN RAJAMUNDRYSTATE CONFERENCE.

Best Wishes

SECRETARY'S MESSAGE

Andhra Pradesh Ophthalmic SocietyRegistered under Societies Act, Reg No. 192 of 2014



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ANDHRA PRADESH OPHTHALMOLOGICAL SOCIETY38th APOS ANNUAL CONFERENCE,

APOC 2014, OCT. 10th-12th, RAJAHMUNDRY.

HISTORIC LAST MEETINGOF ERSTWHILE COMBINED STATE OF AP.

Friends the conference was held in good spirit and friendship which was evident in all three days. It was wellattended. However "Hud-Hud" spoiled the last day of the meet. It was a big jolt as the devastation that resulted overthe next three days and later left a big BLACK MARK on the city of Visakhapatnam.

We are providing some pictures of the conference that will serve us a reminder of the fraternity and goodwillwe enjoyed while we were together.


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SCIENTIFIC COMMITTEE - APOC 2014: AWARD WINNERS

1. Gangadhar Quiz: G S L Medical college, Rajahmundry, ( Dr Hasika Ravula, Dr. Ravi Chandra and Dr.Lakshmi Spandana )- Winners of APOS Gangadhar quiz competition-2014Rangaraya Medical college, Kakinada, (Dr Rohi Sowjanya, Dr. Sarada Devi and Dr. Afsar Sharmili) - RunnersUp of APOS Gangadhar quiz competition-20142. N S Reddy Best Post graduate free paper: Hasika Ravula: "Schwannoma of lower eye lid: a rare differentialdiagnosis of eyelid swelling".- Winner 2014. Kavitha Mandalpu : "Anterior staphyloma with central corneal leucomatous opacity in a blind eye maskingmalignant melanoma of choroid" APOS- N S Reddy Second Best Post graduate Free paper -2014.3. Dr Vengal Rao medal : Avinash Patangey: "A new clinical sign in parafoveal telangectasia":4. V Raghavachari medal: Virender Sachdev: "Treatment of Non arteritic Ischaemic Optic Neuropathy(NAION)- Intra-vitreal Avastin Vs oral corticosteroids":5. Swarup's best video medal: Virender Sachdeva: " Re-operations in Strabismus: How to make the secondchance count?"6. Srikiran Institute of Ophthalmology Best poster medal: M L Karthika:"Two interesting cases ofinternuclear ophthalmolplegia"7. Best paper in Madiraju Ashok session- qualified for the Mathur session: Madhuri Venigalla: TREATMENTOUTCOME OF FUNGAL KERATITIS AT A TERTIARY CARE CENTRE IN GUNTUR DISTRICT"

*****



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Answers

1) Who said it?: The text is extracted from data provided by Aravind hospitals ,Madhurai. Dr. Venkata Swamy, founder of thisesteemed ,globally recognized institution is a pioneer in itself. Withit's dedicated staff, this body stands tall , a master piecedesigned by a humble ,down to the earth person. Let us salute to him.

2) Pregnancy and glaucoma: Not so common really. While no data is available in this regard, BRIMONIDINE is the preferredtopical drug of choice.

3) White line of GANNERI: This is a zone of white matter comprising of nerve fibers of the visual-sensory system.Its's locationis occipital cortex,located deep in the lobe .For details please refer to appropriate literature.

4) This statement is a physiological fact of human physiology. Please note that the statement refers to visual fields and notretina.

5) ZIN: A popular drink indded. Human eye also has a different kind of zinn :the locations are:a) Zonnule of Zinn.B)Iris Arterialcircle of Haller Zinn. c) Retina Can you contribute .please mail me Thanks Editor(compiler).

Fundus Image :

A 33yr old healthy lady undergoing teacher training presented to us with the complaints of gradual loss of vision RE>LE for thepast one year , rapid progression in the last three months and a central scotoma in the RE. VA- 6/36 (-2.0-0.75x90), LE-6/18 (-1.50-0.75x90). Anterior segments and IOPs are with in normal limits. Fundus shows multiple yellowish glistening lesions spread in theposterior pole.

Diagnosis-Bietti's crystalline dystrophy

Teatment- None.

They can have crystals in the cornea and night blindness which are absent in this patient.

Proptosis Image:

This is a middle aged female presented with painless progressive swelling with reasonably good vision. Best corrected vision was6/12 and N8 in both eyes with restriction of movements in left eye. After imaging it was found to be direct carotido-cavernousfistula(CCF). She was sent to neuroradiologist for further managment. Consider some related clinical situations : A). Dysthyroid EyeDisease. B). Orbital Cellulitis. C). Space Occupying lesions.

PLEASE NOTE THE DETAILS OF RATES/TARIFFS

I request all the people desirous of advertising in our APOS Journal/News and Views to send the textmaterial with logo etc to the EDITOR as soon as possible. We appreciate your support.

CATEGORY PER ISSUE PER YEAR

Front Inside 25,000/- 60,000/-

Back Inside 20,000/- 50,000/-

Back Page 35,000/- 90,000/-

Full Page 10,000/- 25,000/-



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Chairman : Dr C V Gopala Raju, Members : Dr G R Reddy, Thadepallegudem;Dr Avinash Pathangi, Visakhapatnam; Dr Sudhakar Potti, Guntur; Dr C Sandhya, Tirupati.

Andhra Pradesh Ophthalmic SocietyRegistered under Societies Act, Reg No 192 of 2014APOC2015, TIRUPATI, 11-13, SEPTEMBER, 2015

SCIENTIFIC COMMITTEE

Scientific committee is inviting for submission of abstracts fromthe members of APOS for the forth coming annual conference inTirupati on 11th, 12th & 13th September, 2015.Scientific committee conducts the following sessions. You canchoose any of the following categories.Competitive Sessions:a. Free Paper: 1. Dr K Vengal Rao’s free paper session. 2. V

Raghavachari Best free paper session. 3. Best PG paper session.b. Best Video presentation.c. Dr Gangadhar Reddy PG quitzd. Srikiran Institute’s best posterNon-competitive Sessions :a.Non-competitive free paper session.b. Videos for film festival.Commemorative Sessions :a.Dr K Sivarama Krishna Instruction course.b.Dr Narayan Reddy Senior Ophthalmologist sessionImportant Points:a. For all competitive presentations the presenting author should

be a ratified member of APOS and a member in waiting for PGcompetitive session.

b. For Instruction courses the chief author should be a ratifiedAPOS member.

c. For all non-competitive sessions one of the co-author shouldbe a ratified APOS member.

d. Abstract submitted for free paper will be considered for posterif not accepted.

e. The PG paper submitted for competitive session will beconsidered for no-competitive PG free paper session if notaccepted.

f. Video submitted for competition will be considered for filmfestival if not selected.

Important DatesLast date for submission of abstract for IC/Free paper/video CD -June,30th, 2015.Last date for intimation of acceptance - July, 15th, 2015.Last date for submission of accepted paper manuscript/IC topicswith speakers- July,31st, 2015.Modes of Abstract SubmissionFill in the abstract submission form and email it as attachment [email protected], [email protected] up the online abstract submission form from the websiteapos.org.Video CD must reach the office of chairman, scientific committeeby Courier.

GUIDELINESDr K Vengal Rao

free paper sessionDr. V. Raghavachari

Best Free paper session Best PG paper session Best Video /Posterpresentation

Paper sent specifically for this slot

Chief author should be the present-ing author & is eligible for award

Presenting author should be a ratifiedAPOS member

Age < 45 years

Only one presentation permitted

Topic not presented earlier at APOS/SROC

Author Not received an award in thiscategory earlier

Paper sent specifically for this slot

Chief author should be the present-ing author & is eligible for award

Presenting author should be aratified APOS member

No age restriction


Topic not presented earlier at APOS/SROC

Author who received an award inthis category earlier also eligible

Work to be certified by HOD (sendscanned certificate with abstract)Certificate from the Institute confirmingPG Status (produce after acceptance)

Chief author should be presenting author& should be APOS members- in- waiting

No age restriction


Could have been presented earlier


Edited films on difficult cases,technique.New Concepts, teaching material etcPoster with relevant Scientific content

Presenting Author should be aratified APOS member or memberin waiting.

No age restriction

No restriction to number ofpresentations

Could have been presented earlier



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Andhra Pradesh Ophthalmic SocietyRegistered under Societies Act, Reg No 192 of 2014APOC2015, TIRUPATI, 11-13, SEPTEMBER, 2015

SCIENTIFIC COMMITTEEChairman : Dr C V Gopala Raju, Members : Dr G R Reddy, Thadepallegudem;

Dr Avinash Pathangi, Visakhapatnam; Dr Sudhakar Potti, Guntur; Dr C Sandhya, Tirupati.

Abstract Submission Form

I. Details of the Author

Name of the presenting author :

Address for communication :

Names of the Co-authors :

APOS Membership Number :

Email: Mobile:

II. Abstract Submission category

Tick mark / Circle the appropriate category

a. Competitive Session :

Dr Vengal Rao's free paper/Dr. V. Raghavachari free paper/Best PG Paper/Best Video/Srikiran Institute best poster.

b. Non-competitive Session :

Free paper session/ Instruction course/Film festival/ Poster / Film Festival / Others

III. Abstract - Not more than 250 words:

Free paper/Poster: Aim, Materials and methods, Results and Conclusions of the study.

Instruction Course: Detailed program

Video: Summary of the video.

IV. Consent:

I give my consent to convert the category as appropriate : Yes / No

Signature of the Author



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Application for the Membership of Andhra PradeshOphthalmic Society

Registered under Societies Act, Reg No 192 of 2014

Applied for Life Member Member in Waiting

Name ( In Block Letters ) .........................................................................................................................................................................................

Father’s / Husband’s Name :.......................................................................................................................................................................................

Age :.....................................................................Sex :...........................................................Date of Birth :.....................................................

Native District :.......................................................................................................................................................................................

Address ( Present ) :.......................................................................................................................................................................................

:.......................................................................................................................................................................................

Address ( Permanent ) :........................................................................................................................................................................................

:.......................................................................................................................................................................................

Mobile : ......................................................................Email :........................................................................................................................................

Designation :.......................................................................................................................................................................................

Academic Qualification :.......................................................................................................................................................................................

Year of passing MBBS : .................................................. PG : MS, DO, DNB : .................................................. (for Lifemembers)

Year of joining in PG Ophthalmology .................................................................................. (for members in waiting)

Date : ........................................... Signature of the Candidate

Membership Fees : Life members Rs. 1100/-

Members in waiting Rs.400/-

DD / No :

Remarks of the Secretary :___________________________________________________________________________________________________________________

Kindly send the completed forms to : Dr. V. Sambasiva RaoHon.Gen.Secretary : APOS (A.P.Ophth Society)Aravinda Lasek Eye HospitalVenkataratnam st Suryaraopet,VIJAYAWADA-520 002, A.P , INDIAEmail: [email protected], [email protected] No : 8886941987,8662433018

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