Rajasthan Journal Of Ophthalmology 2013 Page 1

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1 Rajasthan Journal Of Ophthalmology 2013 Page 1

2 RAJASTHAN JOURNAL OF OPHTHALMOLOGY 2013 ROS Executive Committee President President Elect Past President Hony. Gen Secretary Treasurer Chairman Scientific Committee Editor Journal Executive Members Dr S.P. Vyas Dr Anil Kothari Dr S.K. Nair Dr Mahesh Punjabi Dr J.S.Saroya Dr Mukesh Sharma Dr Sudhir Singh Dr Ajeet Jakhar Dr Neeraj Khungar Dr Anil Sharma Dr Vivek Jain Dr Harshul Tak Advisors Dr K Lal Dr L.K. Nepalia Rajasthan Journal Of Ophthalmology 2013 Page 2

3 Editorial Respected my teachers, seniors and colleagues Greetings from the desk of the editor ROS journal It gives me an immense pleasure to present Rajasthan Journal of Ophthalmology 2013.This is again an e-journal as well as online journal like previous year. In this issue there are many interesting original articles as well as case reports based on our population. I would like to thank all the members of ROS have more faith in me than I do myself. This is my last year as the editor journal Rajasthan ophthalmological society. This was a wonderful experience for me. I have learned so many new things of editing, publishing and online publishing in my tenure. I would like thank my entire editorial team for their invaluable support for last three years. We are also very grateful to our advisors Prof. P.K. Mathur and Dr Pavan Shorey for their guidance and advice. We wish to express our sincere gratitude to all the advirtisers. Please accept our heartfelt gratitude for your financial support over the last three years. In last but not I want to thank my family and friends who have supported me over the past three years in my pursuit of publishing this journal. Yours truly Sudhir Singh Rajasthan Journal Of Ophthalmology 2013 Page 3

4 RAJASTHAN JOURNAL OF OPHTHALMOLOGY 2013 Editor Dr Sudhir Singh Advisors Prof. P.K Mathur Dr Pavan Shorey Editorial Board Dr Anshoo Choudhary Dr Arun Kshetrapal Dr Gulam Ali Kamdar Dr L S Jhala Dr Mayank Agrawal Dr Mukesh Sharma Dr Sandeep Arora Dr Sonu Goel Dr Subodh Saraf Dr Sukesh Tandon Dr Sunil Gupta Dr Suresh Kumar Pandey Dr Swati Tomar Dr Virendra Agrawal Editor's Office Dr Sudhir Singh Sr. Consultant & Head Dept of Ophthalmology JW Global Hospital & Research Centre Mount Abu Rajasthan drsudhirsingh@gmail.com Contents 1. Editorial Dr Sudhir Singh 2. First Post Operative Day Visual Outcome Following 6 mm Manual Small Incision Cataract Surgery (MSICS) Using Intratunnel Phacofracture Technique 5 Dr Sudhir Singh, Dr Sumit K Singh 3. Etiological Analysis And Clinical Evaluation Of Chronic Ocular Irritation 13 Dr. Asim Khan, Prof. D. C. Gupta M.S., Dr. Nisha Dulani M.S., Prof G.L. Verma, M.S 4. Pattern of ocular trauma in western Rajasthan 20 Dr V.K. Sharma, MS; Dr Amit Mohan, MS; 5. Surgical Outcome Of Incomitant Exotropia In Patients With Partial Third Nerve Palsy 26 Dr Amit Mohan, MS; Dr Sudhir Singh, MS; Dr V.C. Bhatnagar, MS, DNB 6. Post-Operative Choroidal Detachment In An Elderly Patient: A Case Report 34 Dr Sudhir Singh, MS, Amit Mohan, MS, Zeeshan Jamil, MBBS 7. Case Report :Rickets With Ocular Involvement In A Female Child 38 Dr Seema Laad; DOMS; Dr Amit Mohan Dr Anita Bisht, MBBS 8. LASIK Journey 40 Dr Virendra Agrawal,MD ;Dr, P.K. Mathur,MS; Dr.V.S. Chaudhari.MS;Dr Anita Agrawal,MS; Ankur Dr Midha,MS; Dr Khushbu Jindal,MS Please visit us Rajasthan Journal Of Ophthalmology 2013 Page 4

5 First post operative day visual outcome following 6 mm manual small incision cataract surgery (MSICS) using intratunnel phacofracture technique. Sudhir Singh, MS; Sumit Singh, DOMS Dr Sudhir Singh M.S. Ophthalmology Senior Consultant & HOD Dept of Ophthalmology JW Global Hospital & Research Centre Mount Abu Rajasthan drsudhirsingh@gmail.com ABSTRACT Object : to study first post operative day visual outcome following 6 mm manual small incision cataract surgery (MSICS) using intratunnel Phacofracture technique Design: Retrospective design. Setting: Tertiary eye care centre. Participants: A total of 216 patients who underwent MSICS performed by a single surgeon at the Global Hospital & Research Centre, Mount Abu, India from April 2012 to March Cataracts patients with any other ocular co morbidity were not included.136 cataract patients (72 Male / 64 Female) with a mean age of years (range 40-80years) were included in the study. All surgeries were performed by 6 MSICS using Intratunnel Phacofracture technique by single surgeon. Outcome measures: The first post operative uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA) along with the rates and types of complications were recorded. Results: A total of 136 surgeries were performed by 6 mm manual small incision cataract surgery (MSICS) using intra tunnel phacofracture. All the surgeries were performed by single experienced surgeon. The mean UCVA and mean BCVA at first post operative day were (Snellen equivalent 20/46) and 0.226(Snellen equivalent 20/33) log MAR units respectively. No serious per and post operative complication encountered. Conclusions: The 6 mm MSICS is a safe, fast and low cost, cataract extraction technique. It is an effective alternate to costly phacoemulsification Introduction The cataract remains the leading cause of avoidable blindness in the world. According to the latest assessment, cataract is responsible for 51% of world blindness, which represents about 20 million people (2010). Although cataracts can be surgically removed, in many countries barriers exist that prevent patients to access surgery. Manual small incision cataract surgery (MSICS) and phacoemulsification are the most popular methods of cataract extraction today. Manual small incision cataract surgery (MSICS) is significantly faster, less expensive and less technology-dependent than phacoemulsification. MSICS has been extensively practiced in developing countries like India. The most commonly practiced MSICS techniques are Blumenthal, visco-expression, irrigating wire vectis and fish hook needle. These techniques require a 7 to 9 mm large incision, which leads to more astigmatism. So if nucleus is managed to remove though a sub 6mm incision at appropriate site would result approximately same astigmatism as 3.2 mm phacoemulsification 2-5. To the best of our knowledge, this is the first study to study post operative day visual outcome following 6 mm manual small Rajasthan Journal Of Ophthalmology 2013 Page 5

6 incision cataract surgery (MSICS) using intra-tunnel phacofracture method of nucleus delivery. Material and Methods We examined the records of 216 patients who underwent MSICS performed by a single surgeon at the Global Hospital & Research Centre, Mount Abu, India from April 2012 to March We included all cases with immature senile cataracts (IMSC), mature senile cataracts (MSC), hyper mature senile cataracts (HMSC), posterior subcapsular cataract (PSC), posterior polar cataracts (PPC) and nuclear cataracts. Cataracts patients with any other ocular co morbidity were not included One hundred thirty six cataract patients (72 Male / 64 Female) with a mean age of years (range 40-80years) were included in the study. Cataracts patients with good fixation and without any other ocular co morbidity were included. A full preoperative ophthalmic examination was done. Preoperative data collection for each eye included the patient age and gender, preoperative visual acuity (uncorrected and best corrected visual acuity; UCVA and BCVA respectively), details of slit lamp examination. The intraocular pressure was recorded by Sctiotz tonometry in all cases. The posterior pole was examined with slitlamp biomicroscopy and indirect ophthalmoscopy. Axial length measurements and keratometry recordings were done and SRK-II formula 14 was used to calculate the intraocular lens (IOL) power required. Surgical Technique: 6 mm manual SICS with intra tunnel phacofracture technique: All surgeries were performed under peribulbar / topical anesthesia by single experienced surgeon (SS). A 4/0 silk bridle suture was placed beneath the tendon of the superior rectus muscle. Superotemporal quadrant for right eye and superonasal quadrant for left eye was chosen if K1 and K2 difference was equal or less than 1.0 D. If K1 and K2 difference more than 1.0 D then incision was on steeper axis. A fornix based conjunctival flap at the limbus with a chord length of approximately 6.5 mm was made. After careful dissection of the Tenon s capsule, light cautery was applied. A 6 mm scleral frown incision, 1.5 mm from the limbus was made with a 15 number Bard Parker blade (Figure1). A funnel shaped sclerocorneal pocket incision was created with a steel crescent knife. One side ports was made 90 degrees apart on either side of the scleral tunnel with a 15 degree knife temporally in right eye and nasally in left eye. With a 2.8 mm keratome, the anterior chamber was entered 1.5 mm into the clear cornea. Rajasthan Journal Of Ophthalmology 2013 Page 6

7 may vary from 5.5 mm to 7.5 mm (Figure 3). Fig 1 Anterior chamber is entered with 1.5 mm in clear cornea with help of 3.2 mm keratotome (Figure2). Fig 3 If nucleus size was anticipated large then two relaxing incisions were made at the margins of CCC. The hydrodessection was made with 26 gauze cannula place on 2 CC syringe filled irrigating fluid. The internal incision of the tunnel was enlarged sideways to 7 mm the 5.1 mm keratotome (Figure 4). Fig 2 The hydroxyl propyl methyl cellulose 2 % (HPMC) viscoelsatic is injected into anterior chamber.the central circular capsulorhexis (CCC) was made with help of 26 gauze needle capsulotome. If glow was poor then capsule was stained with trypan blue dye under the air bubble. Then viscoelastic was injected and CCC done. The size of CCC is depends on the size of the nucleus.it Fig 4 Enough viscoelastic was placed between cornea and superior surface of the nucleus to protect endothelium and between nucleus and iris to keep away iris from nucleus. The nucleus was Rajasthan Journal Of Ophthalmology 2013 Page 7

8 rotated within the capsule using a Sinskey hook. The nucleus was prolapsed into anterior chamber using a Sinskey hook. A Sinskey hook was used to retract the capsulorrhexis to engage the equator and lever out one pole of the nucleus outside the capsular bag and the rest of the nucleus was rotated into the anterior chamber. If the nucleus was too large then two or three relaxing incision were made at the capsulorrhexis margins at equidistance (Figure 5). tunnel. By viscoelastic the engaged part of the nucleus was pushed back into AC and rotated so its longitudinal axis was coincided with longitudinal axis of the tunnel. Again viscoelastic was placed between the cornea and superior surface of the nucleus and between the nucleus and iris. The lens loop was introduced through the tunnel and positioned between the iris and the remaining part of the nucleus. The part of the nucleus was engaged in the lens loop and slowly withdrawn from the anterior chamber while the posterior lip of the tunnel was depressed. Most of the times remaining part of the nucleus came out. If it still broke down then remaining part again pushed in the AC with help of viscoelsatic and previous steps were repeated till it came out (Figure 6). Fig 5 The globe was stabilized and the small Levis lens loop (AA 1915 from Appasamy Associate, India) was introduced through the tunnel and positioned between the iris and the nucleus. The nucleus was engaged in the lens loop and slowly withdrawn from the anterior chamber while the posterior lip of the tunnel is depressed. Once the nucleus got engaged in the tunnel, then the wire vectis was pulled posteriorly and upwards. This caused breaking and removal of a part of the nucleus and other part remains engaged in the Fig 6 The remaining cortical matter clean up was done with direct 23 gauge Simcoe irrigating aspirating cannula. The AC was formed with viscoelastics. A single piece PMMA intraocular lens of 6mm optic size and 12.5 mm total size was implanted into the capsular bag. The AC was washed out thoroughly by Simcoe IA cannula using Ringer s lactate Rajasthan Journal Of Ophthalmology 2013 Page 8

9 solution.the conjunctival flap is reposited back and cauterized at the edges. Tunnel and side ports were hydrated. A 0.5 cc subconjuctival gentamycin with dexamethasone injection was given. (Fig 7) Table 1.Patients Demographic Data Patients Number (%) Mean Age (Range)In Years Male 72(52.94) 59.16(40-80) Female 64(47.06) 60.5(45-75) Total 136(100) 59.75(40-80) Fig 7 Tobramycin 0.3 % with dexamethasone eye drops were administered three times a day in for 30 days. Moxifloxacin 0.3% eye drop were administered three times a day for the first 5 days and then discontinued. The Patients were examined on next day. The uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), slit lamp examination finding were recorded. Video on YouTube (Internet connection required) Results A total of 216 cases 6 mm MSICS with intra tunnel phacofracture of which 136 satisfied the above mentioned Inclusion criteria and were reviewed. The mean age at presentation was years with male: female ratio of 1.3:1. Mean age was years (range years) (Table 1). Out of the 136 patients, 45 (33.08%) had immature senile cataract (IMSC), 10 (7.35%) had mature senile cataract (MSC), 26(19.11%) had hyper mature senile cataract (HMSC), 7 (5.14 %) had posterior subcapsular cataracts (PSC), 12 (8.82%) had posterior polar cataracts (PPC) and 36 (26.74%) had nuclear cataract (Table 2). Table 2. Types of cataracts Type of Patient Number (%) Cataracts IMSC 45(33.8) MSC 10(7.35) HMSC 26(19.11) PSC 12(8.82) PPC 07(5.14) Nuclear Cataract 36(26.47) First postoperative day uncorrected visual acuity (UCVA) out of the 136 patients, 07 (5.14%) had 6/6, 29(21.32%) had 6/9, 32(23.62%) had 6/12, 48 (35.29 %) had 6/18, 16 (11.76 %) had 6/24 and only 4 (2.94%) had 6/36.Cumilatvely 50% presented with 6/12 or better UCVA and 85.29% had 6/18 or better UCVA (Table 3). The mean UCVA was Log MAR (Snellen equivalent 20/46). Rajasthan Journal Of Ophthalmology 2013 Page 9

10 Table 3. First post operative uncorrected visual acuity(ucva) Visual Acuity Patient Number (%) Patient Cumulative Number (%) 6/6 7(5.14) 7(5.14) 6/9 29(21.32) 36(26.47) 6/12 32(23.52) 68(50.00) 6/18 48(35.29) 116(85.29) 6/24 16(11.76) 132(97.05) 6/36 4(2.94) 136(100) First postoperative day best corrected visual acuity (BCVA) out of the 136 patients, 20 (14.7%) had 6/6, 56(41.17%) had 6/9, 48(35.29 %) had 6/12, 9 (6.61 %) had 6/18, 01 (0.73 %) had 6/24 and only 2 (1.47%) had 6/36.Cumilatvely 55.9% presented with 6/9 or better UCVA and 91.17% had 6/12 or better UCVA (Table 4). The mean BCVA was (Snellen equivalent 20/33). Table 4. First post operative best corrected visual acuity(bcva) Visual Acuity Patient Number (%) Patient Cumulative Number (%) 6/6 20(14.70) 20(17.17) 6/9 56(41.17) 76(55.88) 6/12 48(35.29) 124(91.17) 6/18 9(6.61) 133(97.79) 6/24 1(0.73) 134(98.52) 6/36 2(1.47) 136(100) The most frequent postoperative complication encountered was transient corneal edema 9 out of 136 patient had mild corneal edema,4 out of 136 patients had moderate corneal edema and Case was recovered well topical steroids within a week (Table 5). Table.5 First post operative day complications details Cataract Types UCVA BCVA Complication NS++++ 6/24 6/12 Mild corneal edema MSC 6/18 6/12 Mild corneal edema IMSC 6/18 6/12 Mild corneal edema PSC 6/18 6/12 Mild corneal edema PSC 6/24 6/12 Mild corneal edema NS++++ 6/18 6/12 Mild corneal edema IMSC 6/18 6/12 Mild corneal edema HMSC 6/24 6/18 Mild corneal edema NS+++ 6/18 6/12 Mild corneal edema HMSC 6/24 6/18 Mod corneal edema HMSC 6/24 6/18 Mod corneal edema HMSC 6/36 6/36 Mod corneal edema PPC 6/24 6/18 Mod corneal edema IMSC 6/36 6/36 Severe corneal edema Discussion The cataract is the leading cause of blindness worldwide behind cataract 1. It accounts for 50 % of the worlds blind. Manual SICS is already a proven technique for cataract extraction in terms of safety and efficacy. The outcomes following MSICS when compared with phacoemulsification, which is the gold standard, suggests that it is a safe alternative. The advantages of MSICS as a low-cost, equally effective technique make it an attractive alternative for the developing world 6-8. A prospective trial comparing 3.2-mm incisions with 5.5-mm incisions Rajasthan Journal Of Ophthalmology 2013 Page 10

11 in Japan had found the difference in astigmatism of 0.3D. 2 A study from Mumbai, India had found temporal and superotemporal tunnels to induce less astigmatism as compared with superior tunnels for MSICS 3.A study comparing endothelial cell loss and surgically induced astigmatism among ECCE, MSICS, and phaco had found the induced astigmatism slightly more in MSICS than phaco but much less than ECCE. There was no significant difference in the endothelial cell loss among the three techniques 4. The average astigmatism was 0.7 diopter (D) in the phaco and 0.88 D in the MSICS ( P = 0.12) in the Nepal study 5.In our study, all sizes and hardness nucleus were removed from 6 mm width tunnel using intratunnel phacofracture method. The mean first postoperative day UCVA, BCVA in log MAR were (Snellen equivalent 20/46) and 0.23 respectively (Snellen equivalent 20/33). The surgical results obtained in our study compare favorably with those mentioned in the literature for MSICS. However, to the best of our knowledge; there are no prior reports of the first visual outcomes and complications in 6 mm MSICS using References 1. ses/priority/en/index1.html 2. Oshika T, Nagahara K, Yaguchi S, Emi K, Takenaka H, Tsuboi S, et al. Three year prospective randomized evaluation of intraocular lens implantation through 3.2 and 5.5 mm incisions. J Cataract Refract Surg 1998;24: intra tunnel phacofracture technique. So a sub 6 mm scleral incision at appropriate site is the key factor to attain visual outcomes comparable to 3.2 mm incision phaco surgery. But large size nucleus remains the hurdle in the MSICS. Various methods of nucleus size reduction are described in the literature. But maneuvers were done inside the AC. In our method phacofracture was done inside the tunnel, so there were less chances of endothelium damage. There were few post operative complications, like mild transient corneal edema at first postoperative day. Only one case had severe corneal edema. This was subsided in a week. Drawbacks of the study are the retrospective study design. We recommend further studies to document results using 6 mm MSICS using intra tunnel phacofracture technique. Conclusion 6 mm MSICS using intra tunnel phacofracture technique is a safe, effective, reproducible and economic technique.it is an alternative to expensive phacoemulsification. 3. Gokhale NS, Sawhney S. Reduction in astigmatism in manual MSICS through change in astigmatism site. Indian J Ophthalmol 2005;53: George R, Rapauliha P, Sripriya AV, Rajesh PS, Vahan PV, Praveen S. Comparision of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small incision surgery Rajasthan Journal Of Ophthalmology 2013 Page 11

12 and phacoemulsification. Ophthal Epidemiol 2005;12: Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD, Joshi SA, Palimkar A, et al. Safety and efficacy of phacoemulsification compared with manual small incision cataract surgery by a randomized controlled clinical trial: Six weeks results. Ophthalmology 2005;112: Gogate P, Deshpande M, Nirmalan PK. Why do phacoemulsification? Manual small-incision cataract surgery is almost as effective, but less expensive. Ophthalmology 2007;114: Gogate PM, Kulkarni SR, Krishnaiah S, et al. Safety and efficacy of phacoemulsification compared with manual smallincision cataractsurgery by a randomized controlled clinical trial: six-week results. Ophthalmology 2005;112: Ruit S, Tabin G, Chang D, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007;143:32 8. Contents ROS JOURNAL ROSTIMES.COM Rajasthan Journal Of Ophthalmology 2013 Page 12

13 Etiological analysis and clinical evaluation of chronic ocular irritation Asim Khan, D. C. Gupta M.S., Nisha Dulani M.S., G.L. Verma,M.S. Dr G.L.Verma Professor and Head of Department of ophthalmology Department of Ophthalmology, Mahatma Gandhi University of Medical Sciences and Technology Jaipur ,INDIA PURPOSE: Etiological analysis and clinical evaluation of chronic ocular irritation and to determine correlation of dry eye with other causes. MATERIAL AND METHODS: The study was conducted on 500 cases visiting eye department with presenting complaint of chronic ocular irritation. Patients have undergone McMonnies Dry Eye Questionnaire 1, 2, detailed slit lamp biomicroscopy examination, evaluation of blinking rate (BR), tear break up time (TBUT) Schirmer s test I, Staining with fluorescein, lissamine green and rose bengal stain. Staining pattern was graded as per Oxford grading scale 4 and Modified VanBijsterveld conjunctival grading map 5. RESULTS: Higher prevalence of chronic ocular irritation was seen in middle and older age group and rural population. Prevalence of chronic ocular irritation was observed highest in allergic conjunctivitis (30.40%) followed by dry eye (20.60%). Most common disease associated with dry eye in our study was found to be meibomitis (57.14%), followed by pterygium (51.00%), blepharitis (35.85%). [X 2 = DF= 5, P< 0.05]. There was a statistically significant difference in rural and urban distribution of Pterygium, vernal keratoconjunctivitis(vkc) and computer vision syndrome amongst patients complaining of chronic ocular irritation( P <0.001). Staining with lissamine and rose bengal stain method (sensitivity-94.14%) were superior than Schirmer s test1(sensitivity-90.62%) and tear film breakup time (TBUT) sensitivity-82.81% in establishing dry eye diseases as cause of chronic ocular irritation. CONCLUSIONS: Our study shows that Staining methods with lissamine and rose bengal dyes are more helpful in diagnosis and assessment of dry eye disorder associated with chronic ocular irritation than Schirmer s test and TBUT. Most common disease associated with dry eye in our study was found to be meibomitis. There is a need to increase awareness amongst rural population regarding causative elements of pterygium and vernal keratoconjunctivitis which have higher prevalence in rural population Introduction Chronic ocular irritation is an extremely distressing situation both for patients and ophthalmologists.it can be caused by a group of conditions and diseases, but most often it is non-specific in nature. Often tear film abnormality leading to dry eye syndrome is a common cause but frequently associated other common causes responsible for chronic ocular irritation are meibomitis, blepharitis, chalazion, pterygium, allergic conjunctivitis, vernal keratoconjunctivitis, computer vision Syndrome, contact lens use, prolonged topical medication etc. Early identification of causative factors for chronic ocular irritation of eyes is essential for proper management of patients Rajasthan Journal Of Ophthalmology 2013 Page 13

14 and prevents serious ocular morbidity Material and Methods. The study was approved by institutional ethics committee of Mahatma Gandhi University of Medical Sciences and Technology. The study was conducted on 500 outdoor cases visiting ophthalmology department with presenting chief complaint of chronic ocular irritation during the period from 1 January 2012 to 31 December Patients underwent a comprehensive medical and ophthalmic history. All patients had undergone hematological workup, blood sugar, complete urine analysis and if desired essential investigations for autoimmune disorders including antinuclear antibody, rheumatoid factor test. Patients on prolonged topical drugs, infected eyes, foreign body and injury, recent surgery, entropion, trichiasis and dystichiasis, glaucoma, uveitis, primary corneal pathology, contact lens users, inflammatory lacrimal sac conditions, extremes of age, uncooperative patients, and children below 5 years of age were excluded.patients underwent a comprehensive medical and ophthalmic history and examination. McMonnies Dry Eye Questionnaire 1, 2 were used for subjective assessment of chronic ocular irritation. Objective Assessment. Assessment of the lids, lashes, conjunctiva and cornea was done using slit lamp biomicroscopy. Blinking Rate: Number of blinks in one minute was counted with the help of stopwatch. TBUT (Tear film break up time). Noninvasive Test. Reflected mires of keratometer [Bausch & lomb keratometer] were used for Non-invasive tear film stability measurement. Time between the blink and the first sign of a distortion or disruption of the mires was noted with the help of stop watch. An average of at least three values was recorded for each eye. Invasive Test. We used fluorescein dye strip and the time interval was measured between a complete blink to the first appearance of a dry spot in the precorneal tear film with the help of stop watch as described by Norn and revised by Lemp MA Holly 3 Schirmer I Test It was done without anaesthesia, using Whatman filter paper 41and schirmer strips were placed at the junction of the middle and lateral third of the lower eyelid. Ocular Surface [Diagnostic Dye Evaluation] Corneal and conjunctival cellular damage was determined using various staining agents. Fluorescein, viewed with a barrier filter, highlighted epithelial cell loss, Rajasthan Journal Of Ophthalmology 2013 Page 14

15 while rose bengal or lissamine green highlighted epithelial surfaces that had been deprived of mucin protein protection or which had exposed epithelial cell membranes. The severity of staining was scored according to oxford grading scale 4. Fluorescein showed characteristic diffuse sub epithelial or punctuate staining. Rose bengal and lissamine green dyes were used for Van Bijsterveld grading scale 5 that divides the ocular surface into three zones: nasal bulbar conjunctiva, cornea, and temporal bulbar conjunctiva. Results Prevalence of chronic ocular irritation was more in young and middle aged males and old females. Male to female ratio was 0.96:1. [ F = 16.67/1821 = 0.01, P = 0.928, F=0.01 P=0.928, X 2 = DF=4, P= 0.0] - Table1. Table.1 Age and Sex distribution of chronic ocular irritation Age Female Male N [%] Group N [%] [32.65%] 58[22.74%] [ [56.86%] %] >60 52[21.22%] 52[20.39%] Total Between SS DF 1 MS Within SS 7283 DF 4 MS Total F = 16.67/1821 = 0.01, P=0.928 X 2 = DF=4, P= 0.0 P = F=0.01 Female preponderance was seen in dry eye, blepharitis, meibomitis and allergic conjunctivitis. Male preponderance was seen in VKC and computer vision syndrome Table2. Table-2 Gender distribution of various aetiological factors producing chronic ocular irritation. Etiology Male Female N= 245 % N= 255 Dry eye Blepharitis Meibomitis Chalazion Pterygium Allergic conjunctivi tis % VKC Computer vision syndrome Overall prevalence of Allergic Conjunctivitis was highest (30.74 rural and 30.04% urban) among all other etiologies of chronic ocular irritation. The rural and urban distribution of pterygium, vernal keratoconjunctivitis and computer vision syndrome was statistically Rajasthan Journal Of Ophthalmology 2013 Page 15

16 significant (P<0.001 # SEP Z P<0.001, ## SEP Z P<0.001, ### SEP Z 3.937) Table3. Table-3 Rural & urban distribution of etiological factors Etiology Rural N=257 [%] Urban N=243[%] Dry eye 47 [18.29%] 56 [23.04%] Blepharitis 27 [10.50%] 26 [10.70%] Meibomitis 35 [13.62%] 28 [11.52%] Chalazion 15 [5.84%] 10 [4.11%] # Pterygium 25 [9.73%] 10 [4.11%] Allergic Conjunctivitis 79 [30.74%] 73 [30.04%] ## VKC 22 [8.56%] 10 [4.11%] ### Computer vision syndrome 7 [2.72%] 30 [12.35%] # SEP Z P<0.001## SEP Z P<0.001 ### SEP Z P<0.001 Association of symptom of dryness of eyes with meibomitis was highest followed by pterygium, blepharitis, allergic conjunctivitis, chalazion, VKC and which was highly significant in our study. [X 2 = DF= 5, P< 0.05] -Table4. TBUT mildly reduced in 51(24 %) cases, moderately reduced in 67(31.6 %) cases and severely reduced in 94(44.33%) cases. Schirmer s test mildly to moderately reduced in94 (40.51%) cases and severely reduced in138 ( %) cases - Table5. There were 72 cases diagnosed as grade-i Oxford scale but Schirmer s test reading below 10mm/5minute wetting was observed only in 63 cases. Cases of grade-ii tov Oxford grading scale with Staining represented dry eye similar to Schirmer s test I as shown in figure-1. Rajasthan Journal Of Ophthalmology 2013 Page 16

17 sensitive diagnostic test than Schirmer test-i, TBUT, blinking rate Discussion Chronic irritation of eyes derives its importance because it can be caused by a group of conditions and diseases. It is an extremely distressing situation both for patients and doctors. It may be the only symptom of many ocular surface diseases including dry eye syndrome. Staining method with lissamine and rose bengal is more sensitive diagnostic method than Schirmer s test and TBUT. [Sensitivity of staining methods = 94.14%, Sensitivity of Schirmer s test = 90.62%, Sensitivity of TBUT. = 82.81%] -Table6. Staining method with lissamine green and rose bengal is more In this study both sexes were equally symptomatic as regards complaint of ocular irritation, the male to female ratio being 0.96:1. However, it was observed that in age group there was clear female preponderance. This could be explained by the fact that some diseases which are causative factors for chronic ocular irritation [e.g. dry eye] are more common in females particularly in the above mentioned age group and there was male predominance in 0-29 years age group in our study and this tendency can be explained partly because in this age group male computer working population is more and also the fact that males exceed females in the total population. Both sexes tend to develop chronic ocular irritation in the late age of their life presumably because there are more chances of developing tear film instability and inadequacy. No age was found to be immune for chronic ocular irritation but it showed increasing Rajasthan Journal Of Ophthalmology 2013 Page 17

18 trend with age. Female preponderance was seen in dry eye, blepharitis, meibomitis and allergic conjunctivitis. Male preponderance was seen in VKC and computer vision syndrome. The urban and rural distribution of pterygium, VKC and computer vision syndrome were statistically significant (P<0.001). In the present study the most common cause of chronic ocular irritation was allergic conjunctivitis 152cases (30.40%) followed by dry eye 103cases (20.60%), a higher prevalence than reports of 20% of ocular allergy in the general population by Bonini ET al 6. In our study VKC male to female ratio was 2.2:1which is similar to reports of Buckley 7. We found staining with Lissamine and Rose Bengal superior(sensitivity-94.14%) in identifying cases of dry eye leading to symptoms of chronic ocular irritation than Schirmer s test(sensitivity-90.62%) and TBUT(Sensitivity-82.81%). This could be because the quantity of tear production is decreased with advancing age as measured by Schirmer s values by Milder 8. The most common condition causing dry eye in our study was found to be Meibomitis with 36 out of 63[57.14%] patients of Meibomitis diagnosed as dry eye patients [ X 2 = DF= 5, P< 0.05 ] much higher prevalence than reports of 25% cases of dry eye by Mc culley et al 9. However, Mather WD 10 showed the frequency of dry eyes to be as high as 56% in patients with blepharitis. Our study shows significant demographic data as regards age, sex, rural and urban distribution of various aetiological factors leading to chronic ocular irritation and objective value of not only tear film assessment but also ocular surface staining by rose bengal and lissamine green. Conclusion Our study shows that chronic ocular irritation is a significant reason for presentation of the patient to the ophthalmology OPD. Proper and timely identification of the causative factor by the ophthalmologist through proper history taking and appropriate clinical evaluation helps in diagnosing the underlying disease and carrying out the patient s disease management. There is also a need to increase awareness amongst rural population regarding causative elements of Pterygium and vernal keratoconjunctivitis which have higher prevalence in rural population. Staining methods with Lissamine and Rose Bengal dyes are more helpful in diagnosing and assessment of dry eye disorder associated Disclosure Rajasthan Journal Of Ophthalmology 2013 Page 18

19 The authors have no proprietary or financial interest in the instruments or dyes mentioned in the article References 1.McMonnies CW. Key questions in a dry eye history. J Am Optom Assoc. 1986; 57(7): Eye Res 2004; 78: [Review] 10.Mather WD, Ocular evaporation in meibomian gland dysfunction and dry eye. Ophthalmology 1993; 100 [3]; McMonnies C Ho A, Wakefield D. Optimum dry eye classification using questionnaire responses. Adv Exp Med Biol.1998 ; 438: Lemp M.A., Holly F.J. Recent advances in ocular surface chemistry. Am J Optom Arch Am Acad Optom. 1970; 47: Bron AJ, Evans VE, Smith JA. Grading of corneal and conjunctival staining in the context of other dry eye tests.cornea. 2003; 22: van Bijsterveld OP. Diagnostic tests in the Sicca syndrome. Arch Ophthalmol 1969; 82: Bonini S. Allerg.conjunct.Chibert Int J Ophthalmol 5; 12, Buckley RJ.Vernal conjunctivitis. Int. Ophthalmol. Clin. 28 ; 303, Milder B.The lacrimal apparatus. In; Moses RA ed. Adler s physiology of the eye-clinical application. St Louis; CV Mosby Co. 1981; McCulley J.P., Shine W.E.: The lipid layer of tears: dependent on meibomian gland function. Exp Contents ROS JOURNAL ROSTIMES.COM Rajasthan Journal Of Ophthalmology 2013 Page 19

20 Pattern of ocular trauma in western Rajasthan Amit Mohan, MS; V.K. Sharma, MS Dr V.K.Sharma, MS Sr.Consultant Global Hospital Institute Ophthalmology Aburoad, Sirohi Introduction Ocular trauma is a leading cause of acquired unilateral blindness. Ocular injuries account for approximately 8-14% of total injuries and the major cause for emergency hospitalisation. The visual impairment caused by ocular injuries adds to the social, emotional, economical and psychological impact on the sufferers. The significance of the problem is compounded by the fact that most of the injuries are preventable, thus making it social and medical concern. The purpose of this study was to identify the risk factors, demographic and clinical profile and prognostic factors in the management of ocular injuries in a tertiary care centre in western Rajasthan. Materials and Methods A retrospective study was conducted by the authors from April 2011-March 2012 on 404 patients with ocular trauma, presented to the eye emergency services in the Global Hospital Institute of ophthalmology, Abu Road. Specially designed protocol was used to record the information based on the demographic data, nature and cause of injury, time interval between the time of injury and time of presentation along with any treatment received was recorded. Data underwent descriptive analysis and diagnosis classification according to the Ocular Trauma Classification Ocular Traumatology Terms (The Ocular Trauma Classification Group; AJO 1997; 123: ) Eye Wall - Sclera & cornea Closed Globe - The eye wall (corneosclera) does not have a full thickness wound Open Globe- The eye wall (corneoscleral) has full thickness wound Rupture - Full thickness wound caused by a blunt object Laceration- Full thickness wound caused by a sharp object Penetrating- Single, full thickness wound of eye wall, usually caused by a sharp object Rajasthan Journal Of Ophthalmology 2013 Page 20

21 IOFB injury - The retained foreign object causes a single entrance wound Perforating injury -Two full thickness wounds :entrance & exit of the eye wall usually caused by a missile Superficial FB - Projectile FB lodged into the conjunctiva &/or eye wall, does not result in full thickness eye wall defect. Record was made on detailed history, visual acuity, anterior segment and fundus finding along with recording of intraocular pressure and gonioscopy where possible in closed globe Rajasthan Journal Of Ophthalmology 2013 Page 21

22 injuries. The final best corrected visual acuity was recorded during follow up. Details of surgical intervention were also noted. Open Globe injuries 124 Corneal perforation 44 Corneo-scleral perforation 41 Scleral perforation 18 IOFB 08 Endophthalmitis / Panophthalmitis 13 Mean age of injury was years, ranging from 3months to 80 years of age. Closed globe injuries were 258 while open globe injuries were 124. Nature of Injury Closed Globe injuries Number 258 Corneal abrasion/laceration 55 Corneal Foreign Body 98 Cataract 34 Hyphema 12 Secondary Glaucoma 11 Vitreous Hemorrhage & RD 18 Lid & Canalicular tear 30 Chemical Injuries % of injuries occurred in outdoor activity, 37.7% occurred in home and 15.8% occurred in workplace. Outdoor activity- 46.5% Home- 37.7% Work place- 15.8% 14 cases sustained multiple injuries due to road traffic accident and bear bite requiring multiple disciplinary approach. 290(71.78%) cases presented after 24 hrs of trauma while 144(28.22%) cases presented to us within 24 hrs of trauma. There was almost near equal involvement of both eyes. Pain is the most common symptom Rajasthan Journal Of Ophthalmology 2013 Page 22

23 (in 83.9% cases) followed by reduced vision (in 41.4% cases) The snellen s visual acuity at time of presentation and final outcome in closed, open and chemical injuries are shown in following table Discussion Surgery Cross Tabulation: Foreign Body removal- 98 Lid & canalicular tear repair- 30 Corneoscleral tear repair- 85 Cataract extraction+/- IOL - 24 Lensectomy- 10 IOFB+ intravitreal injection- 8 Trabeculectomy- 11 Evisceration- 13 RD surgery, vitrectomy- 14 Children are at risk of ocular trauma because of experiment with new objects and to intimate adult behaviors without being aware of the risk. Most of these hazards occur from careless and unsupervised games. Our study showed maximum incidence of ocular trauma in age group of 0-20years. 1 Older age groups are also prone for ocular trauma because of their inability to avoid hazards. Our study demonstrates incidence of ocular trauma is 27% in >60yrs age group. 2 In our study 258 eyes had closed globe injuries with an initial visual acuity of <6/60 in 105 eyes Rajasthan Journal Of Ophthalmology 2013 Page 23

24 (40.69%).While 124 eyes of open globe injuries 61 eyes (49.19%) had visual acuity <6/60. Poor visual outcome in the open globe injuries were related to multiple ocular structure injury and severity of ocular damage mainly caused by sharp objects and vegetable matter leading to evisceration or enucleation. 3 Most of the open globe injuries, 110 eyes (88.71%) needed immediate surgical intervention. Immediate intervention results in good visual outcome. Foreign body removal by quacks in villages is one of the major cause of poor visual outcome in closed globe injury cases. Breakage of spectacles made of glasses during trauma is also a major cause of ocular morbidity in children (5-15 years age group).most of the road traffic accident occurred under influence of alcohol. In our study 32 cases of road traffic accident out of 48 cases i.e.66.67% are under influence of alcohol. Injury at work places is mostly due to improper safety measures. Prevention of Eye Injuries As prevention is better than cure, eye injuries can be avoided by the use of following: Plastic derived lenses in the frame which do not break easily like glass. Impact resistance lenses prepared out of polyester and polycarbonate are used to avoid industrial hazards. Safety goggles and occupational spectacles for workers at high risk of injury. Head and face protectors are particularly given to workers doing welding and sandblasting. Face shields and helmets to avoid sport injuries as in cricket, hockey etc. Combined wire and polycarbonate face guard In sports like cricket, hockey etc. To increase the awareness of grievous nature of ophthalmic injuries in public masses as well as school going children so that acts like throwing stones or arrow are avoided. There is a strong need for counseling of parents and teachers for supervision of children during play at home and school. There is need of education of public to follow the rules of road and prohibit strictly the mixture of drinking and driving. Rajasthan Journal Of Ophthalmology 2013 Page 24

25 References 1. Saxena R, Sinha R, Purohit A, DadaT, Vajpayee RB. Pattern of pediatric ocular trauma in India, Indian j. of ophthalmology 2002;69; Parver LM. Eye trauma: the neglected disorder, Arch ophthalmol,1986;104(10): La Roche GR, Mc Intyre L, Scheletzer RM. Epidemiology of severe eye injuries; ophthalmology 1988,95: Contents ROS JOURNAL ROSTIMES.COM Rajasthan Journal Of Ophthalmology 2013 Page 25

26 Surgical outcome of incomitant exotropia in patients with partial third nerve palsy Amit Mohan, MS ; Sudhir Singh, MS ; Dr V.C. Bhatnagar, MS, DNB Dr Amit Mohan, MS Jr.Consultant Global Hospital Institute Ophthalmology Aburoad, Sirohi Abstract Aim Exotropia secondary to oculomotor nerve palsy is one of the most common conditions encountered in clinical practice. In recent past various surgical modalities like lateral rectus deactivation, globe fixation, superior oblique transposition etc has been described for total 3 rd nerve palsy. However if the 3 rd nerve is only paretic and significant medial rectus muscle function is present the eye may be aligned in primary position with horizontal recti resection/recession, supraplacement of horizontal muscle and superior oblique weakening. Material and Methods We present the result of strabismus surgery in 21 consecutive patients with partial 3 rd nerve palsy with partly functional medial rectus muscles. Results 21 patients with partial third nerve palsy underwent different procedure depending on the angle of strabismus and residual muscle function. The age of surgery ranged from 3 to 45 years. Lateral rectus recession and medial rectus resection were performed in 16 patients with mild to moderate (-1 to -3) medial rectus muscle paresis. Six patients with associated limited vertical deviation underwent one half to one muscle tendon width superior transposition to correct hypotropia simultaneously. In two cases horizontal muscle were transfixed to the level of superior rectus muscle. All these patients attained post operative alignment with in 10PD in primary position but exotropic shift in angle of deviation observed in most of cases. In one case of isolated inferior division of oculomotor nerve palsy superior rectus recession was done with lateral rectus recession, satisfactory post operative result was not obtained.in two cases superior oblique weakening were done to correct significant vertical deviation with A pattern, no significant change in post operative angle was noted in primary gaze but pattern abolished.superior oblique was transposed to MR insertion in one patient, post operatively hypertropia occurred and sustained till last follow up. Conclusion Patients with partial third nerve palsy achieve reasonable cosmesis with recess/resect procedure of horizontal muscle by judicious selection of surgical technique. It is easier to perform and preservation of residual motility of functional muscle is more acceptable to the patient than other newer technique which necessitate acceptance of limited motility of the involved eye. Introduction Exotropia secondary to ocumotor nerve palsy is one of the most common conditions encountered in clinical practice, either in total or partial form 1. Patients with partial palsy of the oculomotor nerve can be divided in to two categories; those with isolated muscle involvement and those with multiple muscle involvement. Management of each patient varies according to differences in the extent of paresis and recovery. If the third nerve is only paretic and significant medial rectus muscle function is Rajasthan Journal Of Ophthalmology 2013 Page 26

27 present, the eye may be aligned in the primary position with a large recession of the lateral rectus muscle and resection of the medial rectus muscle 2. Material and Methods After obtaining institutional review board approval, the computer data base retrieval system at the medical record section was used to search all patients who underwent surgery for partial third nerve palsy from January 2004 to December consecutive patients comprising 13 males and 8 females form the cohort of this study. All patients underwent complete ophthalmic examination including best corrected visual acuity using snellen s chart, Cambridge single and crowding cards, sheriden-gardner charts and the hundreds and thousands test as appropriate for the age of the patient, slit lamp biomicroscopy, refraction including full cycloplegic refraction in children, dynamic refraction in adults, fundus examination and ocular motility evaluation. Ocular deviation was measured by alternate prism cover test both near (33cms) and distance (6 meters) using fixation target with full optical correction. Neutralising prisms were placed on the eye with third nerve palsy to measure the primary deviation, which formed the target angle for surgery. Forced duction test was performed pre operatively in cooperative patients and was done intra operatively for uncooperative patients in order to verify the restrictions. The active force generation test, in order to assess medial rectus muscle function was also performed. Ductions and versions were quantified on a four point scale of -1 to -5 as follows; mild limitation= -1, moderate limitation= -2, severe limitation= -3, no adduction beyond mid line= -4 and no adduction movement per se= -5. All the patients had measurement of deviation at day one, one month and six months after surgery as well as during their last follow up visit. Post operatively ocular deviations were measured by placing prisms in front of the operated eye. Based on the surgical procedure undertaken, patients were divided in to three subgroups; Group 1: Horizontal muscle (LR and MR), recession and resection combined with or without upward displacement done in 17 patients, while in one patient only LR recession was done and in one patient LR recession was combined with displacement of the MR to the SR. Group 2: Superior oblique muscle surgery with or without other muscle surgery was done in 3 patients. In one patient superior oblique was transposed to MR insertion combined with LR recession. In one patient SO tenectomy was done and one patient underwent SO tenotomy only. Group 3: Superior rectus recession combined with lateral rectus recession in one patient. In this study, grouping has been based on the surgical procedure performed. Rajasthan Journal Of Ophthalmology 2013 Page 27

28 Small to moderate angle exotropia respond well to recession of LR and resection of MR only. In presence of significant vertical deviation, recession and resection of LR and MR has to be combined with upward displacement of the muscle (group 1). In selected cases according to the globe position and angle of horizontal and vertical deviation, surgery of superior oblique brings good results. Lastly specific muscle involvement due to third nerve palsy can have a bearing on the surgical procedure chosen (group 3). In one case weakening of the over acting epsilateral SR was done in addition to LR recession. Results 21 patients with partial 3 rd nerve palsy underwent different procedure depending on the residual muscle function and the angle of strabismus. The mean age at surgery in this study was years with a range of 2 to 70 years. The male patients were 13(61.91%) and the female patients were 8(38.09%). RE was involved in 16(76.19%) cases and LE was in 5(23.81%) cases. The best corrected visual acuity ranged from 6/6 to 2/60 in the affected eye. The pre operative ocular deviation varied from 10PD to large angle exotropia >50PD in primary position with 13 cases with hypotropia of 4PD to 30PD. One patient had hypertropia of 20PD. 13(61.91%) patients had evidence of binocular single vision at near with chin up position when tested with worth 4 dot test. All others had suppression at near and distance. All patients preferred fixation with non paretic eye. After first day to six months of post operative follow up, residual horizontal deviation ranged from 0 to 35PD of exotropia and residual vertical deviation ranged from 4PD to 35PD of hypotropia. Post operatively no patients in any group gained BSV; only those patients who had BSV pre operatively maintained it after surgery with improvement in chin up position. The BCVA also did not improved beyond the pre operative level in any of the patients. Discussion The surgical management of exotropia resulting 3 rd nerve paralysis presents a formidable challenge to the strbismologist. Since the ocumotor nerve controls the function of four extra ocular muscles, the management of each patient also varies according to differences of extent of paresis and recovery. Lesion of oculomotor nerves may be located anywhere from the nuclei to the terminus of the nerves in the extra ocular muscles 3. Lesions at different sites result in various extra ocular muscles afflictions. Past clinical practice indicates that appropriate surgical procedure should be selected according to severity of oculomotor nerve palsy. It is important to carry out detailed pre operative examination and to plan reasonable surgical design. Hence the goal of the surgery in these patients is to achieve a straight eye in primary position. Successful alignment of eyes with oculomotor nerve paralysis has been described following different surgical modalities. The procedure of choice is determined by the angle of deviation, Rajasthan Journal Of Ophthalmology 2013 Page 28

29 GROUP 1 TABLE 1 No Age/sex MR function Pre operative deviation Surgical procedure Post operative deviation Post operative deviation Post operative deviation Day 1 1 month 6 months 1 23/F -3 >50PD XT 14mm LR recession+ 12 mm MR resection 10PD XT 25PD XT 25PD XT 2 20/M -1 40PD XT+ 25PD hypo 8mm LR recession+ 5 mm MR resection with 5mm upshift 20PDXT+ 20PD hypo 20PDXT+ 20PD hypo 20PDXT+ 20PD hypo 3 70/ F -3 >50PD XT+6PD hypo 10mm LR recession+ 8 mm MR resection 8PD hypo 8PD hypo 25PD XT+ 10PD hypo 4 6/M -2 40PD XT 7mm LR recession+ 5mm MR resection 8PD ET 6PD XT 15PD XT 5 44/F -1 35PD XT+15PD hypo 7mm LR recession+ 4mm MR resection with upshift 10PD XT 10PD XT + 4PD hypo 12PD XT + 6PD hypo 6 28 / F -3 >50PD XT+10PD hypo 8+4mm LR recession(hangback) + 7mm MR resection 10PD XT + 10PD hypo 15 PD XT+10PD hypo 20PD XT+10PD hypo 7 34/M -2 35PD XT 7mm LR recession+ 4mm MR resection ORTHO 8PD XT 15PD XT 8 6 /M -1 20PD XT 10mm LR recession ORTHO 5PD XT 10PD XT 9 26 /F -3 35PD XT+4PD hypo 8mm LR recession+ 6 mm MR resection 10PD ET + 4PD hypo 5PD ET 12PD XT 10 4/F -2 >50PD XT+35PD hypo 9mm LR recession with one muscle width upshift + 6mm MR resection transfixed to SR 15PD XT + 10PD hypo 20PD XT+25PD hypo 30PD XT+25PD hypo 11 9/M -3 40PD XT+18PD hypo 8mm LR recession+ 6 mm MR resection with half muscle width upshift 12PD XT+ 10PD hypo 20PD XT+ 10PD hypo 20PD XT+ 10PD hypo / M -2 >50PD XT+ 15PD hypo 8mm LR recession+ 6 mm MR resection with full muscle width upshift 15PD XT+ 8PD hypo 25PD XT+ 8PD HYPO 30PD XT+ 12PD HYPO 13 4 / F -2 30PD XT+25PD hypo 9mm LR recession and displaced to SR 20PD XT+ 10PD hypo 20PD XT+ 10PD hypo 25PD XT+ 12PD hypo 14 27/ M -2 35PD XT 7.5mm LR recession+ 4mm MR resection 15 30/ M -1 30PD XT 5mm LR recession+ 4 mm MR resection 6PD ET 6PD ET ORTHO ORTHO ORTHO 8PD XT 16 29/ F -3 20PD XT 8mm LR recession 6PD XT 8PD XT 10PD XT /M -2 >50PD XT+12PD hypo 10mm LR recession+ 7 mm MR resection 25PD XT + 12PD hypo 25PD XT + 12PD hypo 25PD XT + 12PD hypo Rajasthan Journal Of Ophthalmology 2013 Page 29

30 GROUP 2 TABLE 2 N o Age/sex MR function Pre operative deviation Surgical procedure Post operative deviation Post operative deviation Post operative deviation Day 1 1 month 6 months 1 6years/ M -1 20PD XT+ 25PD hypo SO tenectomy 20PD XT+ 12PD HYPO 20PD XT+ 12PD HYPO 20PD XT+ 12PD HYPO 2 8years/ M -2 10PD XT with 12 PD hypo in up gaze and pp, 40 PD XT in downgaze SO tenotomy 10PD HYPO 10PD HYPO 10PD HYPO 3 2years/ M -4 >50PD XT+20PD hypo SO transposed to MR + 10mm LR recession 16PD XT+ 8PD HYPER 16PD XT+ 8PD HYPER 20PD XT+ 10PD HYPER Rajasthan Journal Of Ophthalmology 2013 Page 30

31 GROUP 3 TABLE 3 N o Age/sex MR function Pre operative deviation Surgical procedure Post operative deviation Post operative deviation Post operative deviation Day 1 1 month 6 months 1 41years/ M -2 25PD XT+ 25PD HYPER 9mm LR recession+ 5mm SR recession 10PD HYPER 10PD XT+ 10PD HYPER 15PD XT+ 15PD HYPER Rajasthan Journal Of Ophthalmology 2013 Page 31

32 associated vertical deviation and function of the medial rectus in selected cases.in presence of significant residual medial rectus muscle function, the eyes may be aligned in primary position with a large recession of the lateral rectus muscle combined with resections of the medial rectus 4, 5. But in the absence of medial rectus function, the horizontal muscle surgery will at best create only a temporary improvement of eye position. In our series of cases in 16 patients LR recession and MR resection were performed in patients with mild to moderate (-1 to -3) medial rectus paresis. 6 patients associated with limited vertical deviation underwent one half to one muscle tendon width superior transposition to correct the hypotropia simultaneously. In two cases horizontal muscle were transfixed to the level of superior rectus muscle to achieve simultaneous correction of significant vertical and horizontal deviation. Same surgical procedure was used as for concomitant strabismus, but with a greater amount of recession and resection. All these patients attain post operative deviation aligned to within 10 PD in primary position. But an exotropic shift in the angle of deviation was observed in most of these cases in long term follow up specifically in cases in which pre operative medial rectus function was moderate(-2 to -3). The conventional procedure for correction of the horizontal strabismus in total third nerve palsy is supramaximal horizontal muscle surgery 6, 7. Up shift (supraplacement) of their tendon by approximately 1mm for each 2PD hypotropia in primary position also has been performed 8. But by themselves these modalities have been found to be generally inadequate. Several additional procedures have been advocated like anchoring the eye ball to medial palpebral ligament 9, lateral rectus deactivation 10 and superior oblique transposition for total third nerve palsy in which medial rectus is totally dead. However if the medial rectus is functional, these procedures can t be performed. Superior oblique transposition on the medial aspect of globe with LR recession was done in one patient. Tenotomy of the superior oblique tendon removes a source of abduction and its reinsertion medially stabilizes the eye. This procedure gives better results 9, 11. However hypertropia has been noted in some cases in those reports and in our own experience in past as well. Another disadvantage with this procedure is that the superior oblique muscle should remain healthy. In this series of cases we had performed superior oblique tendon transposition in one case that had large angle hypotropia associated with large angle exotropia. Post operatively hypertropia sustained till last follow up. One case had a significant vertical deviation of 20PD of hypotropia with 10PD exotropia in primary gaze associated with A pattern, only posterior superior oblique tenotomy was done in the involved eye, no significant change in the post operative angle of deviation was noted in primary gaze but the pattern abolished to a certain extent. Rajasthan Journal Of Ophthalmology 2013 Page 32

33 In one case of isolated inferior division of oculomotor nerve palsy, superior rectus muscle was recessed combined with lateral rectus recession instead of transposition of inferior oblique. Satisfactory post operative result was not obtained. Conclusion We feel though the surgical correction of strabismus in third nerve paralysis is one of the most formidable challenges in the field of strabismus, can be satisfactorily managed by judicious selection of the surgical technique. Our surgical results show that an appropriate surgical procedure according to the muscle involved can successfully achieve acceptable eye alignment. References 1. Rosenbaum AI, Santiago AP, et al. Eds. Clinical strabismus management: principles and surgical technique. Philadelphia; W.B. Saunders. Page Plager DA, Parks MM, Von Noorden GK. Strabismus surgery: Basic and advanced strategies. New York: Oxford University Press 2004 page Miller NR, Newman NJ. Walsh and Hoyt s clinical neuroophthalmology. 6 th Ed. New York; Lippincott Williams and Wilkins, Page Harley RD: paralytic strabismus in children. Etiologic incidence and management of the 3 rd, 4 th and 6 th nerve palsies. Ophthalmology 87:24, Peter LC: The use of the superior oblique as an internal rotator in third nerve paralysis. Am J Ophthal. 17:297, Von Noorden GK. Surgical therapy of paralytic strabismus. In: Von Noorden GK, camposec, editors. Binocular vision and ocular motility. Theory and management of strabismus. 6 th ed. St Louis (MO) Inc; Wiener M. Correction of defects due to third nerve paralysis. Arch ophthal 1928:57: Biglan AW, Walden PG. Results following surgical management of oculomotor nerve palsy with a modified knapp procedure. Ophthal surg 1985; 16: Kuldeep kumar srivastava, MS, Kannan Sundaresh,MS, and Perumalsamy Vijayalakshmi, MS. A new surgical technique for ocular fixation in congenital 3 rd nerve palsy. J AAPOS 2004; 8: Contents ROS JOURNAL ROSTIMES.COM Rajasthan Journal Of Ophthalmology 2013 Page 33

34 Case report Post-operative choroidal detachment in an elderly patient: A case report Sudhir Singh,MS, Amit Mohan, MS, Zeeshan Jamil,MBBS Dr Sudhir Singh M.S. Ophthalmology Senior Consultant & HOD Dept of Ophthalmology JW Global Hospital & Research Centre Mount Abu Rajasthan drsudhirsingh@gmail.com Abstract We report here, a case of post operative choroidal detachment in a 93 year old woman who underwent right eye cataract surgery with trabeculectomy. Prior to surgery patient was suffering from subluxated large nuclear cataract secondary glaucoma. Despite the maximum antiglucoma treatment her intraocular pressure remained uncontrolled. It was decided to operate her with explained guarded prognosis. Threre was complete choroidal detachment when she came for second follow up 10 th post operative day. Key-words: Choroidal detachment, Secondary angle glaucoma, cataract surgery, filteration surgery and elderly. Case History A 93 year old woman known case hypertensive and diabetic since ten years, reported with painful diminution of vision in the right eye for last three weeks. Both eyes had grade four nuclear sclerosis with large nuclei, while the right eye had a dense posterior subcapsular cataract with subluxation in addition. Fundus glow was not visible but the left eye showed a cup disc ratio of 0.5:1, and thinning of the superior and inferior neuroretinal rims. There was no evidence which was suggestive of diabetic retinopathy. The intra-ocular pressures after maximum anti glaucoma therapy were 37.2 mm Hg in right eye and 17.3 mm Hg in left eye and. In right eye gonioscopy angle was narrow secondary to large subluxated cataractous lens (only schwalabes line was visible).left eye gonioscopy showed open angles in all the quadrants of both the eyes. Perimetry of the right eye could not be done, while the visual field of the left eye was unreliable. The patient underwent an uneventful manual small incision cataract surgery with trabeculectomy. The eye left aphakic as lens was subluxated. The first post operative vision in the right eye was perception of hand movement. Neither wound leak nor shallowing of the anterior chamber was detected. There was no evidence of any uveal inflammation or Rajasthan Journal Of Ophthalmology 2013 Page 34

35 pupillary block either. The posterior segment of the right eye could be visualized at this time and examination revealed a cup disc ratio of Intraocular pressures were recorded as 12.2 mm Hg in the right eye and 14.6 mm Hg in the left eye.. When patient reported back 7 days after discharge for second follow up. Posterior segment examination revealed a 360 degrees choroidal detachment in the right eye, which was documented by Ultrasound B scan ([Fig 1-B] scan of the right eye showing choroidal detachment). 3. Injection Dexamethsone 8 mg intramuscularly twice a day for three days. When patient came for third follow up about two week later, choroidal detachment was found to be resolving. The fundus was visible with clear look of optic dic, macula. The resolving choroidal detachment was also visible (Fig.2-7) The best corrected visual acuity was 2/60. Fig.2 Table 1[B-scan showing total choroidal detachment (choroidal kissing sign)] Management The following treatment was started: 1. Atropine 1% eye drops twice a day for two weeks Fig.3 2. Ofloxacin 0.3% + Prednisolone 1.0% combination Eye drops one hourly for two weeks Rajasthan Journal Of Ophthalmology 2013 Page 35

36 Discussion: Fig.5. Fig.6 Fig.7 Choroidal detachment is a rare complication after ocular surgery that may lead to severe visual deterioration or blindness. Choroidal detachment is a detachment of the uvea from the sclera and usually there is a sudden effusion of serous humour but no blood into the suprachoroidal space. The underlying reason for this trend remains to be determined. However, one of the mechanisms suggested regarding choroidal detachment is that the dissociation in the ciliary body of the hypotonic eye allows the aqueous humor to flow into the suprachoroidal space. (1) Another explanatory mechanism is that hypotony enhances the vascular permeability of the choriocapillaris. (2, 3) Similarly, the eyes of older individuals might contain relatively fragile connective tissue, which would enhance fluid movement through the uveal tissue and the vascular wall. Glaucoma surgery carries the highest risk for the complication. The rate of choroidal detachment can reach six per cent, or when the patient is aphakic and the rate can be as high as 10 per cent. Around 10 per cent of patients with choroidal detachment will also have retinal detachments. In aphakic patients, vitreous prolapse into anterior chamber and kissing choroids are fairly common. The systemic risk factors for the choroidal detachment include advanced age, arterial hypertension and diabetes. The ocular risk factors are aphakia, pseudophakia after glaucoma operations, and retro bulbar block anaesthesia. The study by Ding C and Zeng J identified the following risk factors for choroidal detachment after trabeculectomy with Rajasthan Journal Of Ophthalmology 2013 Page 36

37 MMC: older age and reduced postoperative IOP. Subgroup analysis among the 201 patients with open angle glaucoma demonstrated that older age and reduced postoperative IOP were risk factors for choroidal detachment as well. Because choroidal detachment is a transient complication of trabeculectomy, the risk factors for choroidal detachment have not been previously analyzed in a large-scale case series. It has been well known that choroidal detachment occurs in hypotonic eyes after intraocular surgeries including trabeculectomy. (4, 5).In this case patient had following risk factors: Old age, hypertensive, diabetic, undergone ocular surgeries particularly trabeculectomy. This patient reported with choroidal detachment in right eye within 10 days of discharge with intraocular pressure in right 12.2 mmhg. Prophylaxis includes strict control of arterial hypertension and the intraocular pressure, using such means as hyper osmotic drugs and prolonged oculopression, with the aim of keeping blood pressure and intraocular pressure as close to normal throughout any ocular surgery. In addition, special care should be taken with anterior segment surgery in myopic, hyperopic or aphakic patients. (6) ciliochoroidal detachment. Effect on intraocular pressure and aqueous humor flow. Arch Ophthalmol. 1979;97(3): Capper SA, Leopold IH. Mechanism of serous choroidal detachment; a review and experimental study. AMA Arch Ophthalmol. 1956;55(1): Moses RA. Detachment of ciliary body anatomical and physical considerations. Invest Ophthalmol. 1965;4(5): Ding C, Zeng J. Clinical study on hypotony following blunt ocular trauma. Int J Ophthalmol. 2012;5(6): Lee JY, Jeong HS, Lee DY, Sohn HJ, Nam DH. Early postoperative intraocular pressure stability after combined 23-gauge sutureless vitrectomy and cataract surgery in patients with proliferative diabetic retinopathy. Retina. 2012;32(9): Jampel HD, Musch DC, Gillespie BW, Lichter PR, Wright MM, Guire KE, Collaborative Initial Glaucoma Treatment Study Group Perioperative complications of trabeculectomy in the collaborative initial glaucoma treatment study (CIGTS) Am J Ophthalmol. 2005;140(1): References 1. Pederson JE, Gaasterland DE, MacLellan HM. Experimental Contents ROS JOURNAL ROSTIMES.COM Rajasthan Journal Of Ophthalmology 2013 Page 37

38 Case report on rickets with ocular involvement Seema Laad; DOMS; Amit Mohan, MS ;Anita Bisht, MBBS Abstract: Dr Seema Laad, DOMS Consultant Global Hospital Institute Ophthalmology Aburoad, Sirohi We report here, a case of Rickets with ocular involvement in a 10 year old girl. She was having corneal opacity in right eye and cataract in left eye with other bony manifestation of rickets. Key-words: Young age, corneal opacity, developmental cataract, bone findings in Rickets. Case history: A 10 year old girl presented with diminution of vision in both eyes with FC 4metre in right eye and PL in left eye. Patient gave history of reduced vision since 2 years. There was central leucomatous opacity in right eye and total developmental cataract in left eye (fig. 1) On systemic examination it was found that patient was having frontal bossing, rachitic rosary marked widening of wrist and ankles and anterolateral bowing of legs. There was Harrison's sulcus and pot belly (fig. 2 and 3). The eruption of teeth was normal. There was no evidence of latenttetany. The scalp and body hair were normal. The weight was below the 25 th percentile for age. Patient was suffering from protein energy malnutrition (PEM). Examination of cardiovascular, respiratory and central nervous system did not reveal any abnormality. Biochemistry investigation showed blood level of calcium 7.8 mg/dl (normal mg/dl), phosphorus 3.3 mg/dl (normal mg/dl) and alkaline phosphatase 1000 IU/L (normal IU/L) respectively. Examination of urine revealed a ph of 7.5 specific gravity of 1018 and Mild generalised aminoaciduria; there was no glucosuria and albuminuria. The 24 hr urinary excretion of calcium and phosphorus was 75 mg (4.7 mg/kg/day) and 306 mg (20.4 mg/kg/day) respectively. Patient was diagnosed of rickets and referred to medicine department of Global hospital for further evaluation and treatment. For ocular problem Patient was advised to undergo cataract extraction surgery with IOL implantation in left eye but patient parents refused to undergo operation. Fig. 1 (R/E- lucomatous corneal opacity and L/E total developmental cataract) Rajasthan Journal Of Ophthalmology 2013 Page 38

39 Discussion: A study done by Reddy P S, Lakshmamma K, Rao K S to detect the various ophthalmic abnormalities in Paediatric Rickets. Out of 85 cases, 60% rickets children (51 cases) showed associated deficiency signs like corneal opacities 6% and congenital cataract 2%.Out of 40% refractory rickets (34 cases), 3% corneal dystrophy and 6% congenital cataract were found. Fig.2 Frontal bossing, rachitic rosary Harrison's sulcus and pot belly References: -Reddy P S, Lakshmamma K, Rao K S. Study of ophthalmic lesions in rickets. Indian J Ophthalmol [serial online] 1979 [cited 2013 Aug 4];27:229 Fig. 3 Anterolateral bowing of legs Contents ROS JOURNAL ROSTIMES.COM Rajasthan Journal Of Ophthalmology 2013 Page 39

40 LASIK journey Virendra Agrawal, MD ; P.K. Mathur, MS; V.S. Chaudhari.MS; Anita Agrawal, MS; Ankur Midha,MS; Khushbu Jindal,MS Dr Virendra Agrawal, MD Dr Virendra Agrawal Laser & Phaco Centre Tonk Phatak, Behind K S Ford car Showroom, Opp Times of India Office, Gandhi Nagar, Tonk Road, Jaipur drvirendra@yahoo.com Professor José I. Barraquer, MD, Father of Refractive Surgery, made initial strides in lamellar refractive surgery, and proposed the theory that adding or removing corneal tissue can modify the refractive power of the eye. 1 Right from beginning he realized the importance of preserving each layer of the cornea, a guiding force in the development of modern lamellar refractive procedures. Keratomileusis In Situ Dr. Barraquer s Contribution To The Refractive Surgery His original technique included the creation of a corneal lamellar disc followed by the removal of stroma, either from the bed (keratomileusis in situ) or the stromal surface of the corneal lamellar disc. The widely used term keratomileusis was derived from the Greek root words keras (hornlike = cornea) and smileusis (carving) to describe lamellar techniques. 2 While working with Paufique knife, a freehand lamellar dissection to remove the stroma of the anterior half of the cornea, he found it difficult and this led him to focus his research on refining lamellar resection and carving the resected corneal disc. 3 He designed the first manual microkeratome, applanator lenses, and suction rings of various heights. Dr. Barraquer appreciated the importance of maintaining constant contact between the microkeratome and the suction ring during the cut in order to create a smooth, even keratotomy. 4 Numerous disadvantages of the initial myopic keratomileusis procedure included induced corneal irregular astigmatism, corneal scarring, and complex instrumentation, 4 and ultimately gave rise to the development of alternative techniques, including epikeratophakia, 5-7 incisional keratotomy, 8-10 and IOL implantation. 11 Figure 1. Early microkeratomes, like the Barraquer-Krumeich- Swinger, utilized a nonfreeze keratomileusis technique. Chronology Of Corneal Refractive Procedures In the late 1980s, lamellar refractive surgery evolved in two directions: freezing and non-freezing procedures. According to reports, freezing lamellar procedures were often associated with corneal haze and induced irregular astigmatism In contrast, the nonfreezing techniques offered major advantages, including rapid patient Rajasthan Journal Of Ophthalmology 2013 Page 40

41 recovery and fewer complications, 12,13,15 but these procedures were technically difficult to perform. They involved the use of a manual keratome to perform a second cut on the stromal side of the resected lamellar disc. 12,13,15 The manually driven microkeratomes had several apparent drawbacks, including a lack of precision and predictability and low levels of safety. 17 Dr. Luis Ruiz of Bogota, Colombia, developed a nonfreeze procedure based on keratomileusis, known as automated lamellar keratoplasty (ALK). This procedure involved a primary keratectomy with an automated microkeratome to create a corneal disc, followed by a second keratectomy on the corneal bed that removed a small central piece of cornea in order to create a flatter central cornea when the corneal disc was replaced. As a result; the procedure was well received in the 1980s. The obvious advantages of this procedure rapid visual recovery, high levels of efficacy, and stability for the correction of high myopia were balanced by induced irregular astigmatism and low predictability of the procedure. 18 Early attempts by Gholam A. Peyman, MD, of New Orleans, Louisiana, to remove corneal tissue using a CO2 laser failed due to major complications, including scarring and tissue coagulation. 19 Dr. Peyman reported the Er:YAG laser to be successful in modifying the corneal curvature, however. 20 In 1983, Stephen L. Trokel, MD, and his group introduced photorefractive keratectomy (PRK).21 When performed with a 193-nm excimer laser, PRK for high myopia often resulted in severe corneal haze, regression of myopia, and poor predictability.22 LASIK The growing need for a safe and predictable corneal refractive procedure motivated the Pallikaris group to design and develop laser in situ keratomileusis (LASIK) in 1988 at the University of Crete, Greece. They worked on the original idea of manually creating a corneal cap and removing central tissue from the bed was first described by Nikolai P. Pureskin, Moscow, Russia, in They combined lamellar refractive corneal surgery with excimer laser photoablation of the cornea under a hinged corneal flap. 23 The first animal studies, which were intended to determine the wound-healing response after LASIK, began in 1987 and involved a Lambda Physik excimer laser (Lambda Physik AG, Göttingen, Germany) and a microkeratome designed to produce a 150-mm corneal flap. 24 They believed in the hypothesis that a mechanically cut flap would ensure a better tissue alignment after the intrastromal photoablation and along with this type of flap would barely affect the anatomical relations of the corneal layers because it would preserve the Bowman s layer and preserve greater integrity of the superficial nerve plexus of the cornea through the base of the flap. In June 1989, the first LASIK on a blind human eye was performed at the University of Crete, as part of an unofficial blind eye protocol. Human studies began in ,27 Three months after creating the flap, they observed that the cornea remained transparent and noted no significant Rajasthan Journal Of Ophthalmology 2013 Page 41

42 irregular astigmatism on corneal topography. The safety of sutureless LASIK was also suggested by Dr. Ruiz and perhaps others at that time.26 Buratto et al introduced an excimer laser for intrastromal keratomileusis of the corneal button in 1992, and suggested the term laser intrastromal keratomileusis. 28 the next year, Stephen Slade, MD, of Houston, Texas, used the automated microkeratome to create a flap. He called the procedure excimer ALK (E-ALK) or flap and zap. 29 In 1994, Pallikaris group reported the early experience of LASIK on sighted eyes as well as the first study comparing LASIK and PRK. 30,31 LASIK proved superior to PRK in terms of stability and predictability for the correction of myopia greater than D. In 1999, the SVS Apex Plus Excimer Laser (Summit Technologies) was FDA approved for LASIK. 32 Our Prospective All the progress in the field of LASER refractory surgery motivated us to take an initiative in the unexplored arena of LASIK in the state of Rajasthan as early in Overcoming the initial financial and social hiccups we were fortunate enough to be party in the journey of LASIK and different variants. We have witnessed evolution of everything from micro keratomes, Excimer hardware, tracking systems and softwares. Understanding regarding safety of LASIK procedures has increased with time. In the beginning, the initial microkeratomes were to be assembled on the eye and consequently had many assembly related errors; some serious ones like anterior chamber entry were reported. These are now replaced by pre assembled and disposable ones. Figure 2. Disposable Automatic Microkeratome Flap thickness was an issue since the initial thickness was around 160 to 180 microns and now it has come down to 90 to 100 microns. Regarding flap construction (nasal or superior), views changed with time. We started with nasal flaps, then some reports came which advocated superior flaps citing risk of nasal flaps dislocating on lid movement. Then due to increased dry eye complaints because of both corneal nerves severing, superior flaps were discouraged and again nasal flaps came in vogue. We started with broad beam Excimer systems then shifted to high frequency spot lasers. This resulted in reduced total energy delivery into the tissue and also made customized treatment possible. The advent of tracking system and controlled cone atmosphere ensured predictable laser delivery. Rajasthan Journal Of Ophthalmology 2013 Page 42

43 composed of carbon dioxide, water, nitrogen, and other elements. Figure 3. Diagrammatic demonstration showing Broad Beam v/s Flying Spot Laser With the wave front guided technology further higher order customization was made possible. The issues related to asphericity, astigmatism and hyperopic correction were better addressed with small spot scanning laser. Femto Technology Now time is again changing with the advent of Femto Technology. Femtosecond lasers produce a different tissue interaction, however, known as photodisruption (Figure 1). The application of many photons of laser energy at the same place and time leads to a nonlinear absorption of femtosecond laser energy. Due to the multiphoton effect, as well as the electron avalanche phenomenon, energy absorption by tissue eventually exceeds the threshold for optical breakdown. This process of photodisruption creates plasma. It also produces an acoustic shockwave, some thermal energy, and then a cavitation bubble, which expands at supersonic speed, slows down, and then implodes. A gas bubble subsequently forms that is Figure 4. The course of a photo disruptive process is shown. Due to multiphoton absorption in the focus of the laser beam, plasma develops (A).Depending on the laser parameter, the diameter varies between 0.5 μm to several micrometers. The expanding plasma drives as a shock wave, which transforms after a few microns to an acoustic transient (B).In addition to the shock wave s generation, the expanding plasma has pushed the surrounding medium away from its center, which results in a cavitation bubble (C).The maximum diameter of the cavitation bubble can reach 10 to 100 μm.its lifetime is only a few microseconds. After the collapse of the cavitation bubble,a gas bubble is left behind, containing carbon dioxide and other gas molecules (D). Femto SMILE lenticular extraction with the femtosecond laser is the real all LASER procedure. This involves making two lamellar cuts with a femtosecond laser to create an intrastromal lenticle of defined shape, which the surgeon removes. We have used the VisuMax in this fashion for myopic treatments. They create a huge optical zone and a slightly prolate cornea without any need for the excimer laser ablation of tissue. Our first results with a single small incision lenticule extraction procedure using only a femtosecond laser for the treatment of myopia and myopic astigmatism are very encouraging. In the technique, Rajasthan Journal Of Ophthalmology 2013 Page 43

44 a corneal lenticule is cut using a femtosecond laser and is extracted through a single small incision, without lifting a flap. No excimer laser is used. Our results indicate that the procedure can be done in relatively thin corneas, post LASIK discomfort is minimal with better tear film stability and for a surgeon it is free of nightmares regarding flap. Though the procedure is in infancy, we can say that it is safe, effective, and predictable. even greater strength if the lenticule is removed from deeper within the stroma. Figure 6. This is a diagrammatic representation showing the difference in incision in smile v/s normal LASIK with flap The Future of LASIK Corneal refractive surgery is one of the most evolving procedures in medicine today. Our experience regarding safety, predictability and Long term stability with all LASIK procedures have been excellent. Although the Femto LASERs will replace the Excimer ones in a decade or so, still the traditional LASIK will be the main stay of refractive surgery if performed with all detailed prior work up. REFERENCES Figure This is a diagrammatic demonstration showing the difference in strength of the remaining stroma after PRK, LASIK, and ReLEx SMILE. These diagrams show that the strength of the stroma remaining after ReLEx SMILE is greater than the equivalent treatment as both PRK and LASIK. The fact that Bowman's layer remains intact will also provide added strength. Finally, the two diagrams for ReLEx SMILE show the 1. Barraquer JI. Queratoplastia refractiva. Estudios Inform. 1949;10: Bores L. Lamellar refractive surgery. In: Bores L, ed. Refractive Eye Surgery. 1993; Barraquer JI. Keratomileusis. Int Surg. 1967;48: Barraquer JI. Results of myopic keratomileusis. J Refract Surg. 1987;3: Kaufmann HE. The correction of aphakia. Am J Ophthalmol. 1980;89: Werblin TP, Klyce SD. Epikeratophakia: the correction of aphakia. I. Lathing of corneal tissue. Curr Eye Res ;1: Kaufmann HE, Werblin TP. Epikeratophakia. A form of lamellar keratoplasty for the treatment of keratoconus. Am J Ophthalmol. 1982;93: Rajasthan Journal Of Ophthalmology 2013 Page 44

45 8. Bores LD, Myers W, Cowden J. Radial keratotomy: an analysis of the American experience. Ann Ophthalmol. 1981;13: Arrowsmith PN, Sanders DR, Marks RG. Visual, refractive and keratometric results of radial keratotomy. Arch Ophthalmol. 1983;101: Deitz MR, Sanders DR, Marks RG. Radial keratotomy: an overview of the Kansas City study. Ophthalmology. 1984;91: Shearing SP. Posterior chamber lens implantation. Int Ophthalmol Clin. 1982;22: Swinger CA, Barker BA. Prospective evaluation of myopic keratomileusis. Ophthalmology. 1984;91: Nordan LT, Fallor MK. Myopic keratomileusis: 74 consecutive non-amblyopic cases with one year follow-up. J Refract Surg. 1986;2: Maquire LJ, Klyce SD, Sawelson H, et al. Visual distortion after myopic keratomileusis: computer analysis of keratoscope photographs. Ophthalmic Surg. 1987;18: Nordan LT. Keratomileusis. Int Ophthalmol Clin. 1991;31: Barraquer C, Guitierrez A, Espinoza A. Myopic keratomileusis: short term results. Refract Corneal Surg. 1989;5: Arenas-Archila E, Sanchez-Thorin JC, Naranjo- Uribe JP, Hernandez-Lozano A. Myopic keratomileusis in situ: a preliminary report. J Cataract Refract Surg. 1991;17: Slade SG, Updegraff SA. Complications of automated lamellar keratectomy (comment). Arch Ophthalmol. 1995;113: Peyman GA. Modification of rabbit corneal curvature with the use of carbon dioxide laser burns. Ophthalmic Surg. 1980;11: Peyman GA, Baclaro RM, Khoobehi B. Corneal ablation in rabbits using an infrared (2.9 microns) erbium: YAG laser. Ophthalmology. 1989;96: Trokel S, Srinivasan R, Braren B. Excimer laser surgery of the cornea. Am J Ophthalmol. 1983;94: Seiler T, McDonnell PJ. Excimer laser photorefractive keratectomy. Surv Ophthalmol. 1995;40: Pallikaris I, Papatzanaki M, Stathi EZ, et al. Laser in situ keratomileusis. Lasers Surg Med. 1990;10: Pallikaris I, Papatzanaki M, Georgiadis A, Frenschock O. A comparative study of neural regeneration following corneal wounds induced by argon fluoride excimer laser and mechanical methods. Lasers Light Ophthalmol. 1990;3: Pureskin N. Weakening ocular refraction by means of partial stromectomy of the cornea under experimental conditions. Vestn Oftalmol. 1967;8: Pallikaris IG, Papatzanaki ME, Siganos DS, Tsilimbaris MK. A corneal flap technique for laser in situ keratomileusis. Arch Ophthalmol. 1991;109: Siganos DS, Pallikaris IG. Laser in situ keratomileusis in partially sighted eyes. Invest Ophthalmol Vis Sci. 1993;34: Buratto L, Ferrari M, Rama P. Excimer laser intrastromal keratomileusis. Am J Ophthalmol. 1992;113: Slade SG. Lamellar refractive surgery. Semin Ophthalmol. 1994;9(2): Pallikaris IG, Siganos DS. Excimer laser in situ keratormleusis and photorefractive keratectomy for the correction of high myopia. J Refract Corneal Surg. 1994;10: Pallikaris IG, Siganos DS. Corneal flap technique for excimer laser in situ keratomileusis to correct moderate and high myopia: two-year followup. Paper presented at: The ASCRS Symposium on Cataract, IOL and Refractive Surgery, 1994, pp FDA Talk Paper. FDA s report on new health care products approved in Available at: Accessed March 9, Pallikaris IG, Kymionis GD, Panagopoulou SI, et al. Induced optical aberrations following formation of a laser in situ keratomileusis flap. J Cataract Refract Surg. 2002;28: Pallikaris IG, Naoumidi II, Kalyvianaki MI, Katsanevaki VJ. Epi-LASIK: comparative histological evaluation of mechanical and alcohol-assisted epithelial separation. J Cataract Refract Surg. 2003;29: Pallikaris IG, Katsanevaki VJ, Kalyvianaki MI, Naoumidi II. Advances in subepithelial excimer refractive surgery techniques: Epi-LASIK Rajasthan Journal Of Ophthalmology 2013 Page 45

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