KSOS Journal Articles

The alignment of eyes at birth is variable. Transient exotropia may be seen which often disappears by 2 to 4
months of age. Esotropia that persists beyond 3 months is clearly abnormal.Esotropia in children can generally be categorized into two major categories – those that have an onset by six months of age, called congenital or infantile, and those that have a later acquired onset.There are certain clinical features unique to infantile esotropia which help make the diagnosis even when the history of exact date of noticing the esotropia is uncertain.

Almost all squint surgeries have good cosmetic results.The functional results are poor at the same time, in majorityof cases. In children below 2 years of age, after surgery they will develop good binocular vision. The majority of the aged, remain aligned, but has only single vision at the expense of binocular vision. A small percentage may suffer an intractable diplopia.Calculation of the exact angle of deviation is the important matter of concern in the treatment of strabismus.This study involves the measurement of deviatons, diplopia
responses and the angle at which these responses were elicited using prisms.

The correction of ametropia especially those in preverbal, possess several challenging
problems unlike in adults where we have a measurable end point – the best corrected visual
acuity. In children there are lot of confusing variables like the following.

1. Inability to obtain a reliable visual acuity
2. Subjective refraction may not always be
possible.
3. Control of accommodation is variable.
4. Association of strabismus.

Retinoscopy rather than autorefraction should form the basis. When the child is too
young for subjective input, prescription of spectacles is given based on retinoscopy reading
alone.

Historically, there are two opposing schools of thought with regard to the origin and development of binocular
vision. One maintained that man is born without binocularity or special orientation and that binocularity and
spatial orientation are learned functions acquired by trial and error through experience and assisted by all other senses especially the kinesthetic senses. This is the theory of empiricism.

Assessing visual acuity in children is not an easy job but can be made interesting and rewarding by gaining the confidence and cooperation of the child. Many a time, we may have to use several tests and these tests may even have to be repeated on subsequent follow up. The test series vary according to the age of the
child.

Colour defectiveness is usually congenital and at times acquired. Acquired colour defectiveness may be due to macular or optic nerve pathologies and rarely due to cataract. An unusual cause of unilateral colour defectiveness due to extrinsic Indentation of prechiasmatic segment of left optic Nerve by internal carotid artery is reported here.

A 4 1/2 year old boy was referred to the Regional Institute of Ophthalmology from the department of neurosurgery as a case of torticollis. He had been advised an MRI and was being considered for cervical spine surgery.

Isolated fracture of the medial orbital wall is infrequent .They often remain undetected as extensive facial trauma can mask the clinical features or they can be even asymptomatic. We here report a case of isolated medial blowout fracture who presented as divergent squint following trivial trauma

Uses for ultrasound in the eye

Journal Review

Guest Editorial

Calotropis procera (‘Erukku’ in Malayalam) is a commonly seen shrub with a world wide geographic distribution. (Fig. 1) It is commonly harvested for its medicinal properties. It exudes copious milky sap when cut or broken. (Fig. 2) Ironically, the sap is highly irritant to human tissues especially the skin and mucous membrane 2. This article attempts to highlight the importance of recognizing the damaging effects of this plant sap when it comes into contact with the eye and therefore the care one must take while handling this shrub.

Ciclosporin, cyclosporin or cyclosporine, is an
immunosuppressant drug widely used in post-allogeneic
organ transplant, to reduce the activity of the patient's
immune system and hence the risk of organ rejection.
It has been studied in transplants of skin, heart, kidney,
lung, pancreas, bone marrow and small intestine.
Cyclosporine is a cyclic nonribosomal peptide of
11 amino acids (an undecapeptide) produced by the
fungus Tolypocladium Inflatum Gams, initially isolated
from a Norwegian soil sample.

Planned extracapsular cataract extraction with posterior

chamber intraocular lens implantation is the “gold

standard” procedure for managing cataracts. Posterior

chamber intraocular lenses have several distinct

advantages which include a lower rate of retinal

detachment, cystoid macular oedema, a proven track

record especially when implanted in eyes with

co-existing ocular diseases such as diabetic retinopathy,

uveitis and glaucoma.

It is a dream of every graduate in ophthalmology to start their own practice. This article is meant to offer guidance on that journey.

Advances in intraocular lens (IOL) design have significantly improved the visual outcomes of cataract surgery. Multifocal IOLs are designed to reduce dependence on spectacles after cataract surgery, and IOLs are gaining acceptance as potential refractive surgical options in selected patients.

The ultrasound biomicroscope works on the principle of an ultrasound but at a higher frequency.
The normal B scan probe works at a resolution of 10 to 12 Mhz while the UBM probe works at a frequency
of 35 - 50 Mhz or higher.

Computers are used World wide for various purposes including diagnosis and treatment of Ophthalmic
ailments. But can computers themselves produce eye disease? We cannot think about a world without
computers. But it is time for us to think about the health problems produced by computers on those
who use them regularly. Now we are facing a new group of patients suffering from a variety of ailments – all
common symptoms of a condition known as Computer Vision Syndrome, due to excessive and prolonged use of computers.

Principles of Scanning Laser Ophthalmoscopy

To investigate the intraocular pressure (IOP) response after an intravitreal injection of traimcinolone
acetonide as treatment of intraocular oedematous disease.

Aim: To study the clinical and histopathological profiles of orbital tumors and its surgical management
and frequency of biopsy proven orbital tumors.

“‘Necessity is the mother of invention”

Investigations and procedures in our field are very
costly. But in India, the majority of our patients are very
poor.

In a government set up like a Taluk Hospital or District
Hospital, the facilities available are very minimal. We have
a small room as OT, a low cost microscope, government
supply IOLs and 10-0 nylon suture. So we have to deal with
all the problems of our poor patients with this.
In this set up, a very poor 76 year old man came with a
traumatic anterior dislocated cataractous lens with
secondary angle closure glaucoma and corneal oedema.
The only means to give him useful vision in that eye was
lens removal with scleral fixation IOL, which be could not
afford- He was not ready to go to higher centres also.
So we designed a new cheap, but simple method for
trans scleral fixation of PCIOL using the locally available
materials.

Optical Coherence Tomography, or OCT, is a laserbased,non contact , noninvasive, transpupillary imaging
technique used to obtain high (10-17micron) resolution cross-sectional images of the retina.OCT was developed through a collaborative effort between the New England Eye Center, Tufts University
School of Medicine, the Department of Electrical Engineering and Computer Science at MIT, and Lincoln
Laboratory, MIT, under the guidance of Dr. James Fujimoto. It is the first instrument to allow doctors to see crosssectional images of the retina.

Neuroretinitis is a particular form of optic neuropathy characterised by acute unilateral visual loss in the
setting of optic disc swelling and hard exudate arranged in a star figure around the fovea.1 It affects persons of all ages, although it occurs more often in the third and fourth decades of life, with no gender predilection.It
is mostly unilateral and may be precipitated by various, known and unknown factors.
Neuroretinitis is a rare clinical entity often confused with the more common papillitis or papilledema. The
fundus pictures have several common features and can be mistaken for one another by ill-experienced clinicians and sometimes even by ophthalmologists and neurologists. However, there are diagnostic features distinctive for neuroretinitis. It is a distinct clinical entity with a different etiopathogenesis. Likewise its management and prognosis too differs from fundoscopically similar entities such as papilledema and papillitis, which are encountered more often in our clinical practice.

Diabetic retinopathy is one among the leading causes of blindness in developed countries. Though it ranks behind cataract in magnitude in developing countries the number of blindness cases due to diabetic retinopathy is catching up. There is increasing prevalence and incidence of diabetes with increase in age. The number of diabetic population in India will increase from 19 million in 1995 to 57 million in 2025. There are about 12 million blind people in India and the increase in diabetic population will add to this number in the coming years. The situation is worsened by illiteracy and lack of awareness of largely preventable diabetic retinopathy complications in a country like India. There are few well-conducted population based studies from western countries. From India data is available on diabetic retinopathy status in urban population and hospital based studies.

Specular microscopy enables a direct view of the endothelial cells.A complete qualitative and quantitative analysis of the endothelium is undertaken to define the cell conformation ,boundaries and the intersections along with definition of mean cell area and cell density
using the fixed frame analysis or a variable frame analysis .Individual cell analysis is also possible using a digitizer.So specular microscopy helps in predicting corneas which are more likely to decompensate when subjected to stress like trauma or surgery. This study is an attempt to understand the age related changes in the corneal endothelium in a normal
population both in terms of endothelial cell density and average cell area

Recalcitrant macular oedema is one of the most important causes for significant visual loss in diabetic patients. In these patients the diabetic status is complicated by the presence of other systemic conditions such as hypertension, hyper lipidemias, and nephropathy. Eyes with gross retinal thickening and presence of plaques of hard exudates will respond poorly to laser photocoagulation (Fig :1). Presence of a thickened taut posterior hyaloid membrane exerting traction on the macula resulting in shallow macular detachment could be another cause for recalcitrant macular oedema in a diabetic. Treatment modalities include laser photocoagulation , Intravitreal steroid injection,parsplana vitrectomy or a combination of these. This prospective randomized study was conducted over a period of 36 months to compare the efficacy of various treatment modalities for recalcitrant diabetic macular oedema.

Steven Johnsons Syndrome [SJS] is an important cause of ocular morbidity. We present a series of 14 SJS patients who presented to our institution in the acute phase. All patients with the diagnosis of SJS over last 2 years were included. Possible etiologic factors, various ocular manifestations in acute phase is discussed. Early aggressive management included separating the lids frequently, cleaning the discharge, glass rod sweeping along the fornices and voluntarily moving the eyes. This prevented formation of symblepharon, ankyloblepharon and other sequlae. All patients recovered without any sight threatening
sequlae. Mild sequlae included - one patient had ankyloblepharon and punctual stenosis, another had inferior corneal opacity, mild dry eye was seen in 11 cases. This study lays emphasis on the importance of early aggressive management in preventing and reducing the severity of sight threatening sequlae of SJS.

Prostaglandins comprise the latest class of drugs added to the list of glaucoma medications. They are ubiquitous local hormones that produce ocular inflammation and hypertension in high levels but in smaller amounts reduce 10P^1-4. 'Ambache' ^5-6 made the first observation
of prostaglandin effects in the eye by isolating a substance which was a mixture of PGE₂ and F₂α ^7-9 iniris extracts that could produce miosis in cats. Four agents are included in the category of prostaglandins also called hypotensive lipids.

The outcome of uncomplicated cataract surgery performed by phacoemulsification in the present scenario is excellent. Posterior capsular rent, reported to occur in 0.5 to 7.5% of cases is a significant potential intraoperative complication of phacoemulsification. An improperly managed posterior capsular rent, with or without vitreous disturbance can mar this excellent outcome. Vitreous loss appears to be the crucial factor determining eventual clinical outcome. When the posterior capsule is broken without accompanying vitreous disturbance there is an increased risk of CME, vitreous prolapse into the anterior chamber and pseudophakic retinal detachment. Once vitreous is lost, the postoperative course is complicated in 30% of patients with an increased incidence of hyphaema, retained cortex, corneal edema, blurred vision and long term retinal problems including chronic CME, macular holes and retinal detachment. However, today, the control rendered through closed chamber modern surgical techniques may allow for a final outcome that is not much different from an uncomplicated case.

Digital photography is an expensive affair with sophisticated equipments for slitlamp and fundus photography. Anterior segment imaging using a WEB CAMERA attached to a slitlamp is described. A PC, a web camera, and a slit lamp are required for this purpose. Web cameras cost less than Rs 2000. If you already have a software for clinical data, these pictures can be added to the case sheet which will be of great help in documenting your findings and for Medico-legal purposes.

Diabetic retinopathy has been earmarked as one large pandemic which will have gross implications in India and all over the world by 2020. It has already grown into one of the biggest ocular problems in the developed nations. It is projected that India will overtake China as the single largest population of diabetics by 2025. We can rest assured that diabetic retinopathy will be on the rise in the years to come Diabetic macular edema is the most common cause of diminution of vision among diabetics. In the Wisconsin epidemiologic study of diabetic retinopathy (WESDR), which is the largest epidemiologic study on diabetic retinopathy till date, it was documented that about 20 % of IDDM patients and 25 % of NIDDM patients on insulin will have macular edema after 10 years of diabetes. In this short review we will go into the methods of diagnosis, evaluation and management of diabetic macular edema and chalk down the currently accepted practice patterns in the management of diabetic macular edema.

Von Hippel angiomatosis is a congenital hereditary capillary angiomatous hamartoma of the retina and optic nerve. Visual loss in this condition occurs due to lipid-rich exudation at the macula, exudative retinal detachment, vitreous hemorrhage, epiretinal membrane formation and rhegmatogenous retinal detachement. 1 Though cryotherapy and photocoagulation are the most common treatment modalities they are associated with various complications like increased macular exudation, macular scar, macular hole and combined traction and rhegmatogenous retinal detachment. 2 This case report describes the management of an angioma dragged forward due to vitreous traction (floating angioma) in an eye with good visual potential.

After a good cataract surgery with excellent postoperative visual rehabilitation, we are often nagged by some patients with persistent vague complaints. We put them down as psychosomatic in origin. However a body of scientific evidence is emerging that these may be due to induced dry eye. I am reporting a case which went into severe dry eye following uneventful phacoemulsification surgery.

Pituitary Macroadenoma, Prolactin, Proptosis

Aim: To perform the Small Incision Cataract Surgery through a single radial incision. Methodology: 181 patients underwent cataract surgery through a single radial incision, 3.5mm in length, beginning at the limbus and 300 micron in depth. A partial thickness scleral dissection was made on either side and carried on into the cornea Results: The post operative astigmatism was significantly reduced. 76% had astigmatism of = 0.5D and 41% of these had no astigmatism. Conclusion: The single radial incision is an excellent alternative incision for the small incision cataract surgery. Key words: SICS, SINRAD, POST OP ASTIGMATISM

The main goal of the practice of Ophthalmology is to deliver quality eye care to the patients with eye ailments. All Ophthalmologists have an obligation to prevent impairment of vision by proper control of eye disease and restore sight to the blind. They often fulfill this obligation through private practice, working in Government and private hospitals or in Ophthalmic institutes.

32 years old male presented with increasing floaters and defective vision of acute onset in both his eyes.

A 60 year old female, a chronic diabetic and hypertensive of more than 15 yrs under reasonable good control presented with a vision of hand movements (HM) in both her eyes. Visual loss was of sudden onset in her left eye and of 4 months duration Right eye had poor vision due to long standing posterior pole traction retinal detachment which on evaluation proved to be inoperable.

Books:

Step by step small incision cataract surgery
Editors: Anita Panda & Tanuj Dada. Jaypee Brothers, New Delhi

Step by step Neuro ophthalmology-clinical
examination and diagnosis
Editors: Satya Karna. Jaypee Brothers, New Delhi

Journals:

Trabeculectomy with internal Tube Shunt - A novel
Glaucoma surgery
Michael E Yablonski. Journal of Glaucoma 2005; Volume 14, Number 2:91-97.

Diode Laser Transscleral Cyclophotocoagulation
as Primary Surgical Treatment for Medically Uncontrolled
Chronic Angle Closure Glaucoma, Long-term clinical
outcomes
Jimmy C.H. et al. Journal of Glaucoma 2005; Volume14, Number 2:114-119.

Intravitreal Triamcinolone Acetonide for Diabetic
Macular edema
Janet J Chieh et al. Retina 2005; Volume 25, Number 7:828-834.


Effect of Cataract Extraction on the Visual Fields of
Patients With Glaucoma
Monica M. Carrillo et al. Archives of Ophthalmology. July 2005;‘Volume 123, Number 7:929-932.

The major causes of blindness worldwide are diabetes and age related eye disorders. While the exact pathogenic mechanism for many of these disorders are not clearly known, there are evidences that protein glycation may play an important role in their etiology. Advanced glycation end products (AGEs) formed by Maillard reaction accumulate in the intracellular and/or extracellular environment of the ocular structure leading to crosslinking of various proteins, which may be involved in the development of various ocular diseases including cataract1. This review attempts to evaluate the link between AGEs, and various eye diseases such as diabetic retinopathy, cataract formation etc.

Thyroid eye disease is an autoimmune disease producing symptoms related to inflammation, accumulation of fluid in the orbit and also to adipogenesis raising intraorbital pressure. The management strategies revolve around reducing this inflammatory response, providing symptomatic support and preventing complications.

Calculating and selecting an “optimum” intraocular lens (IOL) power for the small eye of a growing child presents unique challenges. The need to implant a fixedpower lens into an eye that is still growing makes it difficult to chose an “optimum” IOL power that best benefits the child’s eye. The younger the child at the time of surgery, the more difficult is the problem. This is a challenging task to the ophthalmologist of the industrial countries, but probably more so for the ophthalmologist in the developing world setting. The lack of instrumentation in many of the developing world operating-room settings, such as the handheld keratometer and the A-scan ultrasound, increases the difficulty of calculating the IOL power to use for pediatric cataract surgery. Even with the availability of the A-scan and automated keratometer in the operating room, small eyes of children possess unique challenges when calculating an IOL power. Also remember, we are using formulas that were originally designed for adult eyes.

The aim of the study was to evaluate the outcome of multifocal intraocular lens implantation in a rural population and to undertake a long-term outcome analysis. 1000 patients underwent small incision cataract surgery with multifocal intraocular lens implantation (either rigid or foldable) .The outcome of the procedure was assessed by the final visual acuity and the dependence on glasses. Analysis of results showed that 98% achieved a visual acuity of 6/6 – 6/9 and 70% were not dependent on glasses.

To study the incidence of ocular complications in patients treated with anti tuberculous therapy.

Pterygium is a common conjunctival degenerative lesion often excised for cosmetic reasons. Due to various reasons the biopsy material is often not submitted for histopathological examination.

Vitreo-retinal diseases requiring surgical intervention in children differ from those in adults. Rhegmatogenous retinal detachment has an annual incidence of 12.4 cases per 100,000 in the adult population. Rhegmatogenous retinal detachment occurring in the pediatric age group (birth to 15 years of age) accounts for only 3.2% to 5.6% 1 of the total with over 40% of cases secondary to ocular trauma2. Other causes of retinal detachment in pediatric age group include high myopia, retinopathy of prematurity, familial exudative vitreoretinopathy, acute retinal necrosis, prior ocular surgery and retinoschisis. Given the 89% frequency of vision – threatening abnormalities in the fellow eyes, preserving vision in the detached eye is of great importance. The eye with the retinal detachment may be the better seeing eye in the long run.

To evaluate whether peripapillary Retinal nerve fibre layer thickness loss as estimated by the Optical Coherence Tomography 3 (OCT 3) in patients labelled as glaucoma suspects, actually converted to Short Wavelength Automated Perimetry (SWAP) changes within a study period of two years and to establish that Retinal nerve fibre layer thickness loss was the earliest evidence of primary open angle glaucoma.