Aio Vol 1 Issue 1 Sep 2013

AIO Journal of Ophthalmology 1
Know Thy Instrument

Chief Editor
Dr. K. Preetha
Editorial Committee
Dr. Priya Nambiar
Dr. Divya Menon
Dr. Dolly Nazia P.M.
Editorial Board
Dr. J. Muthiah
Dr. Rajesh P.
Dr. M.A. Safarulla
Dr. Kunal Kumar
Dr. Manish Shyamkul
Dr. Syed Basheer
Dr. Dheeresh Kadukanvelli
Dr. Shaji Hussain
Advisory Board
Dr. Muhammed Swadique
Dr. K. Preetha
Consultant Ophthalmologist
Al Salama Eye Hospital, Arayidathupalam Junction, Calicut - 673004
Emai l : reachpreetha@gmail.com
Mobile : 9895878764
Landline : 0495 3930123
This journal is the official scientific
publication of the Al Salama
Institute of Ophthamology & its
allied hospitals with two issues
being published every year. It
welcomes original articles, reviews,
case reports, book reviews & other
materials of academic interest in
ophthalmology & medicine.
AIO Journal of Ophthalmology
Volume I, Issue I, September 2013
Address for correspondence
CONTENTS
5 Editorial
Original Article
7 Role of corneal wavefront guided LASIK treatment in
highly aberrated corneas

Muhemmed Swadique, Padmaja Krishnan

Reviews
14 Blepharoptosis

Kunal Kumar
20 Recurrent corneal erosion

Divya Menon
25 Contracted socket

Kunal Kumar
28 Phakic Intraocular Lens
Dolly Nazia P.M
Cutting edge ophthalmology
31 Refractive lenticule extraction (ReLEx)

Priya Nambiar
CONTENTS
4 AIO Journal of Ophthalmology
CONTENTS
Case Korner
34 Posterior embryotoxon and its significance
Manish Shyamkul
36 Ankyloblepharon filiforme adenatum
Manish Shyamkul
Know Thy Instrument
38 Optical coherence biometry: How coherent is the master ?
K. Preetha
Eureka!
45 This is all about smart phone-o-graphy

Shaji Hussain
The Ophthalmic Paraphernalias
48 Oculocardiac reflex an overview
Muhammad Hasif M.K.
50 An Ophthalmic Potpourri
K. Preetha
51 Fun-Tastica
K. Preetha
53 Ready Reckoner
Muhemmed Swadique
Editorial
Greetings from the editorial desk!
Welcome!
I
n your hands is the maiden issue of AIO JOURNAL OF OPHTHALMOLOGY. As
the tag line states this journal is the offcial scientifc journal of the Al Salama Institute
of Ophthalmology (AIO) & its allied hospitals. Envisaged as a half yearly journal
with a minimum of two issues a year, we plan to make this journal a forum for ophthalmic
interactions of the highest quality.
Ophthalmology is in the midst of a knowledge boom with quite a few journals coming
out every year. The fate of most of these publications is that the ophthalmologist fips through
most of them cursorily without actually going through the material. Our endeavor is to make
this journal interesting enough so that the reader is enticed to read it thoroughly.
Inside this issue, The Review Section features articles on Ptosis, RCES, Contracted
Socket & Phakic IOL. The section Original Articles features an interventional study on
the role of corneal wave front guided lasik treatment in highly aberrated corneas . The results
are promising with a signifcant reduction in corneal higher order aberrations with coma
components.
The section Cutting Edge Ophthalmology focuses on the latest innovation in refractive
surgery- ReLex. Case Korner features two interesting cases seen in our hospital. In Know
Thy Instrument the focus is on the IOL Master recently acquired at our Calicut branch.
Our guest column Ophthalmic paraphernalias features a writeup on oculocardiac refex
a nemesis for surgeons; Eureka features a brilliant innovation to use smart phones for slit
lamp photography, Potpourri is an aviyal of ophthalmology information while funtastica
is the dessert after the feast. We fnally wind off with a Ready Reckoner on the present day
modalities for managing Keratoconus.
Here is hoping that this information collage is as interesting for you to peruse as it was
for us to assemble. Please feel free to give your reviews, opinions & criticism about this
issue & also about any novel ideas you want incorporated in the journal.
Regards
Editorial Board
ORIGINAL ARTICLE
Role of Corneal Wavefront Guided lasik Treatment in Highly
Aberrated Corneas
Dr. Muhemmed Swadique, FRCS, Prof. Padmaja Krishnan, MS
Introduction
L
aser in situ keratomileusis (LASIK), is developed to
correct refractive errors. It involves moulding of
corneal surface with the help of excimer laser. It is
a safe and efective procedure.
1
Even though the un aided
acuity of vision improves, the quality of vision decreases
after LASIK procedure. This is due to the increase in the in-
duced aberrations which reduces the contrast sensitivity
2-4

and also causes photic phenomena like glare and halos.
The optical aberrations may be the cause for non attain-
ment of maximal acuity of retinal limit of 6/3
5
.
The aim of refractive surgery has shifted to maintain
or even improve the quality of vision
6
. This target can be
attained by decreasing the induced aberrations and also
by decreasing the pre-existing aberrations
6
. This can be at-
tained by the use of Corneal wavefront guided LASIK treat-
ment.
This study aims at evaluating the safety and efcacy of
Corneal wavefront guided LASIK treatment in highly aber-
rated corneas. Also it evaluates the changes in the higher
order aberrations, glare, halos and contrast sensitivity.
Materials and Methods
This non randomised, interventional, prospective study
comprised 76 consecutive symptomatic eyes of 38 pa-
tients with a hyperopic or myopic spherical equivalent (SE).
Inclusion criteria were symptomatic myopia, hyperopia,
or astigmatism and a signifcant level of primary corneal
coma aberration. The level of corneal coma was considered
signifcant when the associated root mean square (RMS)
for the corneal primary coma (measured over a pupil of 6.0
mm) was higher than 0.5 m.
This criterion was chosen based on previously reported
physiologic levels of corneal HOAs
16
; that is, the 0.5 m cut-
of point was selected because the associated probability
of it being a normal value was less than 1%.
16
Exclusion cri-
teria were formal contraindication to LASIK.
Patients wearing contact lenses to correct the residual
error were instructed to discontinue lens use for at least
4 weeks before the preoperative examination. Before
surgery, patients received a complete explanation of the
surgery and its risks and benefts and signed an informed
consent in accordance with the Declaration of Helsinki. No
treatment was performed if the refraction was not stable
at 2 consecutive examinations performed at least 3 weeks
apart. The target postoperative refraction was emmetropia
in all cases. The postoperative follow-up was 6 months.
Preoperative Examination
The preoperative examination included uncorrected deci-
mal visual acuity (UCVA); best spectacle-corrected decimal
visual acuity (BSCVA); manifest and cycloplegic refractions;
slitlamp biomicroscopy; applanation tonometry; ultrasonic
pachymetry; scotopic, low, and high mesopic pupillome-
try; contrast sensitivity, corneal topography (Opticon Kera-
ton Scout); and fundus evaluation.
Corneal aberrations were derived from corneal topog-
raphy following the protocol described below in Corneal
Aberrations. In addition, patients were asked to evaluate
the levels of halos and glare they perceived at night using
the following qualitative scale: none, low, moderate, high,
or severe.
Ablation Profile
The corneal wavefrontguided customized ablation was
designed and calculated using commercially available
ORK-CAM software. With this system, after the Opticon
Keraton Scout corneal topography fle is imported into the
ORK-CAM software and clinical information (eg, patient
age, subjective spherocylindrical refraction, central corneal
pachymetry, fap thickness) is introduced, the software au-
tomatically designs the ablation profle to best minimize all
corneal aberrations.
The calculation requires a topographic examination
during which at least 7.0 mm of corneal area is analyzed
in all meridians. Then, the optical zone is modifed accord-
ing to the pachymetry and the more signifcant or disturb-
ing terms from the Zernike decomposition are chosen for
inclusion in the calculation of the customized ablation.
ORIGINAL ARTICLE
The main goal of the designed ablation in all cases was to
minimize the primary coma aberration Z(3,1). Therefore,
the ablation profle was designed according to the corneal
shape and refractive error and by modifying the optical
zone and number of Zernike terms treated.
The aim was to create a corneal surface with an el-
evation profle that would generate a minimally distorted
wavefront. In addition, all treatments were designed to
leave an expected residual stromal bed thicker than 300
m in the central cornea.
Surgical Technique
All LASIK procedures were performed by the same surgeon
at Al Salama Eye Hospital, Perinthalmanna, Kerala, India.
First, the treatment designed using ORK-CAM software
was loaded into the computer of the excimer laser (Esiris,
Schwind eye-tech-solutions). The surgeon then reviewed
and confrmed the data. The Esiris is a fying-spot laser with
a para-Gaussian spot of 0.8 mm diameter.
The laser incorporates an eye-tracker system with a
frequency of 330 Hz. The temperature and humidity condi-
tions were maintained within the ranges indicated by the
laser manufacturer. The optical zone of the treatment was
selected according to the preoperative scotopic pupil size.
Depending on the pachymetry, optical zones with a diam-
eter at least as large as the scotopic pupil were targeted to
prevent unwanted optical phenomena.
Corneal Aberrations
Corneal aberrations were derived from the data of the
anterior surface of the cornea obtained with the Optikon
Keraton Scout topography system. The systems software
converts the corneal elevation profle into corneal wave-
front data using Zernike polynomials with an expansion up
to the 7th order.
This topography system analyzes 6144 corneal points
on a corneal area enclosed in a circular annulus defned by
an inner radius of 0.33 and an outer radius of 10.0 mm re-
spective to the corneal vertex. Aberration coefcients and
RMS values for a 6.0mmpupil were obtained in all cases.
The total RMS value was calculated based on all existing
optical errors. In addition, the RMS was computed for the
primary coma, Z(3, 1)
Postoperative Follow-up
Patients were examined on the frst postoperative day and
at 1, 3, and 6 months. On the frst postoperative day, a de-
tailed slitlamp examination was performed to evaluate the
fap position and integrity of the cornea. At the other post-
operative visits, UCVA, manifest refraction, BSCVA, slitlamp
biomicroscopy, contrast sensitivity and corneal wavefront
aberrations were recorded. In addition, patients were asked
again about night-vision symptoms using the same criteria
as preoperatively. An independent observer performed all
the postoperative examinations.
Statistical Analysis
Statistical analysis was performed using SPSS software
for Windows (version 16 SPSS, Inc.). The Student t test for
paired data was used for comparison. The signifcance of
diferences between preoperative and postoperative data
was calculated. Diferences were considered statistically
signifcant when the P value was less than 0.05.The efcacy
index was calculated as the ratio of postoperative UCVA to
preoperative best corrected visual acuity (BCVA) and the
safety index, as the ratio of postoperative BCVA to preop-
erative BCVA.
Results
The mean age of the 38 patients was 23.56 years 9.79
(SD) (range 18 to 35 years). The mean preoperative SE was
-2.99 1.96 diopters (D) (range -6.88 to +1.63 D). Seventy
fve eyes (98.6%) had a myopic SE and one eye (1.32%),
a hyperopic SE. The mean preoperative scotopic pupil size
was 6.38 0.05 mm and the mean optical zone, 6.23 0.24
mm (range 6.00 to 7.00 mm). The mean total ablation zone
UCVA = uncorrected visual acuity, BCVA = best corrected visual acuity, SE = spherical equivalent
Table 1. Refractive outcome over time
Mean SD (Range)
Parameter Pre Operative Post op 1 Month Post op 3 Months Post op 6 Months
UCVA (decimal) 0.4440.19 (0.1 to 0.8 0.900.17 (0.4 to 1.5) 0.900.17 (0.4 to 1.5) 0.900.17 (0.4 to 1.5)
Spherical Equivalent (D) -2.99 1.96 (-6.88 to 1.63) -0.7 0.24 (-1.25 to 0.12) -0.057 0.22 (-1.25 to 0.12) -0.04 0.13 (-1.25 to 0.12)
BCVA (decimal) 0.9 0.17 (0.3 to 1) 0.9 0.17 (0.4 to 1.5) 0.9 0.16 (0.4 to 1.5) 0.92 0.16 (0.4 to 1.5)
Efficacy 1.02 0.23 (range1 to 3)
Safety 1.05 0.2.1 (range 1 to 3)
Wavefront Lasik
designed with ORK-CAM software was 7.31 0.06 mm
(range 6.50 to 8.50 mm).
Refractive Outcomes
Table 1 shows the refractive results. Statistically signif-
cant reductions were observed in sphere and cylinder at 1
month (both P < .01, Student t test for paired data) (Table
3). The mean SE was -2.99 1.96 diopters (D) (range -6.88 to
UCVA = uncorrected visual acuity, BCVA = best corrected visual acuity, SE = spherical equivalent
Table 2. Change in corneal aberrations over time
Mean SD (Range)
Parameter Pre Operative Post op 1 Month Post op 3 Months Post op 6 Months Total reduction
Total RMS (m) 6.712.97(0.97 to 13.23) 3.461.60 (0.65 to 8.10) 3.441.60 (0.65 to 8.10) 3.401.56 (0.65 to 8.10) 3.313.03 (6.01 to 9.38)
Coma (m) 0.72 0.23 (0.50 to 2.03) 0.270.30 (0.01 to 1.6) 0260.30 (0.01 to 1.6) 0.260.29 (0.01 to 1.6) 0.450.28 (0.99 to 10.7)
mal BCVA postoperatively. Eleven eyes (14.47%) gained
one to two lines of Snellen BCVA The loss of 2 to 3 lines in 2
eyes (2.63%) was due to numular keratitis.
The contrast sensitivity is signifcantly improved at 6
months P > 0.01. (Table 3 )
Corneal Aberrations:
Table 2 shows the changes in corneal aberrations postop-
Paired Differences
Mean Std. Deviation Std. Error 95% Confidence Interval t df Sig.
Mean of the Difference (2-tailed)
Lower Upper
Table 3. Paired Samples Test
Pair 1 UCVA Preop - UCVA 6M -0.4599 0.2573 0.0295 -0.5187 -0.4011 -15.581 75 0
Pair 2 BCVA pre op - BCVA 6M -0.0224 0.1015 0.0116 -0.0456 0.0008 -1.922 75 0.058
Pair 3 HOA total RMS Pre Op -
HOA total RMS 6M 3.31E+00 3.030499 0.347622 2.618686 4.003683 9.525 75 0
Pair 4 Coma Pre Op - Coma 6M 0.456763 0.288005 0.033036 0.390951 0.522575 13.826 75 0
Pair 5 SE Pre Op - SE 6 M -2.958 1.985 0.228 -3.412 -2.505 -12.994 75 0
Pair 6 SPH pre op - SPH 3 M -2.4441 2.014 0.231 -2.9043 -1.9839 -10.58 75 0
Pair 7 CYL pre op - CYL 3 M -1.047 0.826 0.095 -1.237 -0.857 -10.977 74 0
Pair 8 CS Pre Op - CS 6 M 4.868 7.023 0.806 3.264 6.473 6.044 75 0
Pair 9 Halos Preop - Halos 6M 1.737 1.204 0.138 1.462 2.012 12.575 75 0
Pair 10 Glare Pre Op - Glare 6 M 1.513 0.931 0.107 1.3 1.726 14.171 75 0
eratively. At 1 month, there was a statistically signifcant
reduction in total RMS (P < .01, paired Student t test), astig-
matic and coma RMS (P < .01, paired Student t test). There
were no signifcant changes in these aberrometric param-
eters between 3 months and 6 months.
Subjective Symptoms
Graph 1 & 2 summarizes patients perceptions of halos and
glare at night. For both phenomena, the center of the dis-
tribution of the answers moved from the high and severe
levels preoperatively to the none and low levels postopera-
tively. At 6 months, 93.42% of eyes did not perceive ha-
+1.63 D), preoperatively and -0.05 1.37D (range -1.25 to
+0.12 D) 1 month postoperatively; the diference between
the 2 time points was not statistically signifcant (P = .06,
paired Student t test). At 6 months, 97.36% of eyes had an
SE within 0.50 D of emmetropia and 100%, within 1.50
D. At 6 months, the mean efcacy index was 1.02 0.23
(range1 to 3) and the mean safety index, 1.05 0.16 (range
1 to 3). (Table 1)
Six months postoperatively, the UCVA was statistically
signifcant better (P < .01, paired Student t test), although
the change in BCVA was not signifcant. (P = .06, Student t
test for paired data). (Table 3) shows the changes in deci-
ORIGINAL ARTICLE
6 M
3 M
1 M
Pre Op
7
7
27
11
16
12
2
38
68
68
0
20
40
60
80
2
Number of patients
0 - No glare 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe
Number of patients
0 - No haloes 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe
T
i
m
e

P
e
r
i
o
d
T
i
m
e

P
e
r
i
o
d
Pre Op
1 M
18
0 20 40 60 80
63
63
3 M
6 M
Graph 1. Change in subjective symptoms over time - Glare
Graph 2. Change in subjective symptoms over time Halos
Wavefront Lasik
los and 94.73% of eyes had no glare or a low level of glare.
Complications
No fap related or ablation related complications occurred
during the treatment. No eye required retreatment dur-
ing the postoperative follow-up. There were two eyes with
reduced BCVA by two lines at 6 months due to nummular
keratitis.
Discussion
Ocular or total wavefrontguided ablations are efective in
correcting aberrations in eyes without previous refractive
surgery.
1722
This type of treatment partially reduces HOAs
and minimizes the induction of new aberrations. In addi-
tion, total wavefrontguided ablations have been shown
to be safe and efective in the correction of low to moder-
ate levels of HOAs, providing only partial reduction in cases
with more extreme aberrations.
810, 2326
The wavefront sen-
sors available today analyze up to only 1452 points
18
.
Therefore, this type of customized ablation is less efec-
tive in patients with high levels of corneal aberrations (eg,
previous refractive surgery with older algorithms, surgical
complications during LASIK, corneal scars or wounds and
patients with high levels of primary corneal aberrations).
Other limitations of ocular wavefront sensing include the
crowding or superimposition of the light spots or the as-
sumption that the slope of the wavefront in each analyzed
portion is locally fat in highly aberrated eyes. With topog-
raphy systems, more than 6000 points can be studied and
an exhaustive analysis performed. Although topography-
guided and corneal wavefront guided ablations have
been evaluated by several authors,
1115
the changes in
HOAs were not recorded in all cases.
The terms topography guided and corneal wavefront
guided can be confusing. Normally, systems that try to re-
duce corneal irregularity by changing the corneal shape
without considering corneal wavefront analysis are called
topography guided. These systems are less accurate and
thus were improved by the introduction of corneal wave-
front data derived from corneal elevation data in the cal-
culation of the ablation profle. Nevertheless, this nomen-
clature can vary depending on the investigator. Several
studies
2731
report the results of corneal wavefrontguid-
ed technology in highly aberrated corneas, such as after
complicated refractive surgery, keratoplasty, or corneal
penetrating injury. The results in these studies confrm the
applicability of these excimer laser profles. In addition, we
found several justifcations for the use of corneal wave-
frontguided ablations:
1. The frst refractive interface corresponding to air
cornea is the most important contributor to the total pow-
er of the eye because the greatest diference in refractive
indexes between materials in the eye is found at that point.
2. In highly aberrated corneas, the contribution of the
aberrations in the cornea generated by the surgery will be
the most signifcant source of optical errors.
3. The sample provided by most ocular wavefront sen-
sors or aberrometers is more limited than that obtained
with corneal topographers.
4. Ocular wavefront sensors or aberrometers have limi-
tation in the analysis of highly aberrated eyes; drawbacks
include the crowding or superimposition of the light spots
or the assumption of a fat slope for each analyzed portion
of the wavefront (Hartmann-Shack devices).
Therefore, treatment using corneal wavefront guided
ablations seems to be the best option to restore quality of
vision in corneas that are highly aberrated. In our study, we
evaluated the usefulness of the corneal wavefrontguided
ablations generated with ORK-CAM software in improving
visual performance and optical quality in patients with
high levels of corneal higher order aberrations and coma.
The correction of higher order aberrations with the ORK-
CAM ablations was successful. In terms of SE, predictability
has proved to be excellent.
The mean UCVA improved signifcantly, although the
mean BSCVA did not change. The improvement in UCVA
was mainly due to the reduction of the higher order com-
ponents, which have the strongest efect on visual quality.
One case with a signifcant loss of lines of BSCVA is related
to numular keratitis. Regarding the optical properties of
the cornea, the total RMS and Coma decreased signifcant-
ly in all cases.
Mean reduction in total HOA was 3.31. There was a
signifcant reduction of the primary coma, with the mean
postoperative RMS close to the physiologic range.
16
One
limitation of the customized refractive surgery technique
we used is the size of the laser spot. The ideal spot for com-
plete correction of HOAs is 0.5 mm or smaller.
32
The Esiris
laser had a spot size of 0.8 mm, which could have been re-
sponsible for the partial correction of some HOAs.
Another limitation of customized refractive surgery is
the wound-healing response of the cornea. The cornea is
made of complex structural composite material that un-
dergoes biomechanical changes and healing responses
after damage or injury.
33
The ablation of tissue with the
excimer laser could generate subtle unexpected modifca-
tions that could limit the efect of a customized ablation
34
.
Therefore, although the ablation profle was planned to
achieve a more regular corneal surface, biomechanical
changes and wound-healing responses could reduce
ORIGINAL ARTICLE
the efectiveness of the customized ablation. The improve-
ment observed in corneal aberrations after the corneal
wavefrontguided enhancement was related to a reduc-
tion in the bothersome symptoms perceived by patients
preoperatively. Specifcally, the presence of night halos and
glare was studied because patients with highly aberrated
corneas often report these symptoms and they are easy to
describe and understand.
An increase in HOAs increases the incidence of night-
vision complaints,
7
especially after refractive surgery. These
optical errors signifcantly increase image distortion, espe-
cially when the pupil dilates because the most aberrated
part of the ocular optical system takes part in the genera-
tion of the retinal image. We did not report other symptoms
associated with aberrated vision, such as double vision or
ghost images. In future research of wavefront-guided re-
fractive surgery, a standardized survey including all subjec-
tive symptoms associated with aberrated vision must be
used to allow complete analysis of the patients subjective
perceptions. Corneal wavefrontguided LASIK treatment
using the ORK-CAM software was useful in treating cases
of high levels of primary coma. It provided excellent safety
and efcacy for correction of higher order components.
In addition, primary coma was signifcantly reduced and
night-vision symptoms were decreased.
Conclusion
Corneal wave frontguided ablation using is a valuable
safe and efective refractive surgical procedure to correct
cases with signifcant corneal higher order aberrations
with coma components. This treatment modality reduces
higher order aberrations and coma. The quality of vision
signifcantly improves with the procedure.
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fract Surg 2004; 20:432438
21. Kohnen T, Buhren J, Kuhne C, Mirshahi A. Wave-
front-guided LASIK with the Zyoptix 3.1 system for
the correction of myopia and compoundmyopic
astigmatismwith 1-year follow-up; clinical outcome
and change in higher order aberrations. Ophthalmol-
ogy 2004; 111:21752185
22. Awwad ST, Bowman RW, Cavanagh HD, McCulley JP.
Wavefront- guided LASIK for myopia using the LA-
DAR CustomCornea and the VISX CustomVue. J Re-
fract Surg 2007; 23:2638
23. Alio JL, Montes-Mico R. Wavefront-guided versus
standard LASIK enhancement for residual refractive
errors. Ophthalmology 2006; 113:191197
24. Castanera J, Serra A, Rios C. Wavefront-guided abla-
tion with Bausch and Lomb Zyoptix for retreatments
after laser in situ keratomileusis for myopia. J Refract
Surg 2004; 20:439443
25. Carones F, Vigo L, Scandola E. Wavefront-guided treat-
ment of symptomatic eyes using the LADAR6000 ex-
cimer laser. J Refract Surg 2006; 22:S983S989
26. Durrie DS, Stahl JE, Schwendeman F. Alcon LADAR-
Wave CustomCornea retreatments. J Refract Surg
2005; 21:S804 S807
27. Toda I, Yamamoto T, Ito M, et al. Topography-guided
ablation for treatment of patients with irregular
astigmatism. J Refract Surg 2007; 23:118125
28. Koller T, Iseli HP, Donitzky C, et al. Topography-guided
surface ablation for forme fruste keratoconus. Oph-
thalmology 2006; 113:21982202
29. Cosar CB, Acar S. Topography-guided LASIK with the
Wave- Light laser after penetrating keratoplasty. J Re-
fract Surg 2006; 22:716719
30. Rajan MS, OBrart DPS, Patel P, et al. Topography-
guided customized laser-assisted subepithelial
keratectomy for the treatment of postkeratoplasty
astigmatism. J Cataract Refract Surg 2006; 32:949
957
31. Lee D-H, Seo SJ, Shin S-C. Topography-guided exci-
mer laser ablation of irregular cornea resulting from
penetrating injury. J Cataract Refract Surg 2002;
28:186188
32. Latkany RA, Haq FE, Speaker MG. Advanced epithelial
ingrowth 6 months after laser in situ keratomileusis. J
Cataract Refract Surg 2004; 30:929931
33. Lumba JD, Hersh PS. Topography changes associ-
ated with sublamellar epithelial ingrowth after laser
in situ keratomileusis. J Cataract Refract Surg 2000;
26:14131416
34. Dupps WJ Jr, Wilson SE. Biomechanics and wound
healing in the cornea. Exp Eye Res 2006; 83:709720
35. Roberts C. Biomechanics of the cornea and wave-
front-guided laser refractive surgery. J Refract Surg
2002; 18:S589S592 l
Dr. Muhemmed Swadique, D.O., D.N.B., M.N.A.M.S, F.I.C.O., F.R.C.S., M.B.A
is currently the Medical director, Al Salama Eye Hospital. He is a cataract and
refractive surgeon with special interests in glaucoma & cornea
REVIEW
P
tosis refers to drooping or inferior displacement of
any anatomic tissue.
This short form is often used in place of the
more accurate term, blepharoptosis, to describe drooping
or inferior displacement of the upper eyelid.
CLASSIfICATIOn Of PTOSIS (Table 1)
Depending on onset
1.Congenital present from birth.
2. Acquired occurs anytime after birth due to an
aetiology.
Depending on aetiology
1. Myogenic 2. Aponeurotic 3. Neurogenic
4. Mechanical 5. Traumatic
Blepharoptosis
Congenital simple ptosis
Congenital myogenic ptosis is the commonest variety
in this group (Fig 1). Rather than normal muscle fbers,
fbrous and / or adipose tissue
is present in the muscle belly,
diminishing the ability to
contract (leads to ptosis) and
relax (leads to lid lag on looking
down and lagophthalmos).
Amount of levator function
is an indicator of the amount of
Blepharoptosis
True Ptosis
Congenital ptosis
Congenital simple ptosis (CSP)
CSP + Sup. Rectus weakness
Blepharophimosis
Synkinesis
Acquired ptosis
Aponeurotic ptosis
Myogenic ptosis
Neurogenic ptosis
Mechanical ptosis
Traumatic ptosis
Pseudoptosis
Vertical and horizontal shorten-
ing of palpebral fssure height.
Superior orbital rim fattening.
Nasal bridge hypoplasia.
Synkinesis
It may occur as:
l Marcus Gunn jaw wink-
ing Synkinesis. There is
aberrant connection between motor division of Vth
cranial nerve and levator muscle. (Fig 3a, 3b)
Dr. Kunal Kumar, DO, FMRF
Table 1. Classification of Blepharoptosis
normal muscle present.
It is characterised by a shallow / absent lid crease.
Congenital simple ptosis with superior rectus
weakness (Monocular elevation deficiency /
Double elevator palsy
There is maldevelopment of the superior rectus muscle
along with the congenital simple ptosis.
There is an associated poor Bells phenomenon and /
or vertical strabismus.
Blepharophimosis: (Fig 2)
It is an autosomal dominant condition characterised by:
Telecanthus i.e. increased distance between the two
medial and lateral canthus.
Epicanthus inversus skin fold from lower to upper eyelid.
Fig 1
Simple congenital ptosis
Fig 2: Blepharophimosis
syndrome
Blepharoptosis
l Congenital IIIrd cranial nerve palsy.
l Congenital Horner syndrome.
l Duane retraction syndrome.
Aponeurotic ptosis
It is the commonest type of acquired ptosis
and is due to failure of aponeurosis to insert in its normal
position (Fig 4).
Because of involutional changes, chronic ocular infam-
mation, surgical trauma, repetitive trauma like frequent
eye rubbing or insertion and removal of rigid contact
lenses, the levator aponeurosis undergoes disinsertion,
dehiscence or stretching.
It is characterised by good levator function as levator
muscle is healthy and high or absent upper eyelid crease
because of loss of insertion of levator fbres into the skin.
This type of ptosis may worsen on reading due to frontalis
muscle relaxation.
Myogenic ptosis
It is an uncommon variety of ptosis occurring due to local-
ised or difuse muscular disease e.g.
l Myasthenia gravis.
l Muscular dystrophy.
l Chronic progressive external ophthalmoplegia.
l Oculopharyngeal dystrophy.
Neurogenic ptosis
It may be due to:
l IIIrd cranial nerve palsy: Vasculopathic aetiology
(diabetes, hypertension, atherosclerosis) usually
spares the pupil and spontaneously resolves within
3 months. If it does not resolve by 3 6 months, than
it requires further investigations. Compressive aetiol-
ogy (neoplastic / aneurysms) afects the pupil and
requires further investigations.
l Horner syndrome.
l Iatrogenic botulism.
l Guillain Barre syndrome.
Mechanical ptosis
Large chalazion or tumor like capillary haemangioma (Fig
5), squamous cell carcinoma, etc. may mechanically pull
the eyelid down. It can even be caused by post traumatic
or post surgical oedema.
Traumatic ptosis
Blunt or sharp trauma to the aponeurosis or muscle can
lead to ptosis.
Eyelid laceration exposing the pre aponeurotic fat indi-
cates transection of orbital septum and possible damage
to the levator aponeurosis.
Pseudoptosis
Apparent eyelid drooping without any pathology in the lid
may be due to:
l Abnormally low eyelid as in:
Hypotropia Lid follows the eye downwards.
Enophthalmos.
Microphthalmos.
Anophthalmos.
Phthisis bulbi.
Superior sulcus defect.
l Contralateral upper eyelid retraction (Fig 6 ).
l Dermatochalasia: excess upper eyelid skin over-
hangs eyelid margin.
l Brow ptosis
Fig 3 A & B : Marcus Gunn jaw winking phenomenon Fig 4: Aponeurotic ptosis Fig 5 : Mechanical ptosis
Fig 6
Right eye ptosis causing the pseudo lid retraction of left eye
REVIEW
EvALuATIOn Of PTOSIS
History
To suggest the provisional diagnosis of the ptosis:
l Duration: Congenital / Acquired.
l Pre-disposing factors: h/o pregnancy and delivery,
trauma, surgery, medical conditions.
l Progression.
l Variability: time of day, jaw winking.
l Functional limitation: restricted superior feld / full
feld of vision. difculty while reading
l Associated symptoms: diplopia, dysphonia, dys-
phagia, dyspnoea (Myasthenia gravis)
l Family history: Blepharophimosis, some forms of
congenital ptosis.
Examination
To confrm provisional diagnosis and decide on treatment.
Full ocular and adnexal examination with emphasis on:
l Facial examination: Chin up, frontalis overaction,
brow ptosis, dermatochalasia, telecanthus, epican-
thus inversus.
Presence of ptosis
l Vertical palpaebral fssure height: Patient fxates on
a distant object in primary gaze. Measure the widest
point between upper and lower eyelid (Fig 7 ). Value
of < 9 mm indicates ptosis.
l Margin refex distance (MRD):
MRD
1
= With patient looking at the torch in the primary
gaze, the distance from the upper eyelid margin to the cor-
neal light refex is measured.
Normal MRD
1
value is 4 to 4.5
mm.
Light may be obstructed
by the eyelid in severe cases
and therefore have a zero or
negative value.
MRD
1
helps to exclude
cases of lower lid malposi-
tions which lead to decreased
palpaebral fssure height.
Grading of ptosis
In unilateral cases, one can compare the droop with the
contralateral eyelid position. However in bilateral ptosis
(can be used also for unilateral ptosis), we have to measure
the diference between a point 9 mm above the inferior
limbus and the upper eyelid margin in primary position.
Using MRD
1
, ptosis can be graded as the amount in
mm, the MRD
1
value is less than the normal value of 4 mm.

2 mm is Mild ptosis
3 mm is Moderate ptosis
4 mm is Severe ptosis.
Levator function
It is measured as the amount of upper eyelid excursion
from extreme downgaze to extreme upgaze, with the
frontalis muscle immobilised by the examiner manually
fxing the eyebrow in its normal position (Fig 8 ).
Levator action in mm Functional classifcation
10 15 Excellent
8 9 Good
5 7 Fair
0 4 Poor
l In infants and uncooperative young children, the ILI-
FF sign is elicited to determine the levator function. When
the upper lid is everted in infants with fair to good levator
function, the agitated infant is able to fip back the lid to
its normal position. If levator function is poor to nil, the lid
will not return to its normal position and will have to be
manually reinverted.
l Lid position in downgaze:
Lid lag compared to the contralateral upper eyelid on
downgaze in the absence of previous surgery or trauma
suggests dystrophy of the levator muscle which will nei-
ther relax nor contract properly (Fig 9). This is the impor-
tant fnding in congenital ptosis. In involutional ptosis,
drooping of the lid may worsen on downgaze because of
frontalis muscle relaxation.
Cong. Myogenic ptosis Acquired Aponeurotic ptosis
Lid crease Absent / weak Higher position
Levator function Reduced Near normal
On downgaze Eyelid lag Eyelid drop
Comparison between:
Fig 7: Measurement of
Palpebral fissure height
17
Blepharoptosis
Fig 8 : Measurement of levator function Fig 9 : Lid lag on down gaze Fig 10 : Bells phenomenon
l Upper eyelid skin crease:
Skin crease is often shallow or absent in congenital ptosis.
Margin crease distance (MCD) is the distance between
the upper eyelid crease and the eyelid margin. The high
crease (large MCD) suggests an aponeurotic defect.
l Aberrant eye movements:
On lateral jaw movement or eye movements:
Marcus Gunn jaw winking Synkinesis.
Aberrant regeneration of the Vth cranial nerve.
Duane retraction syndrome.
l Refractive error and vision:
To diagnose amblyopia due to occlusion of pupil, high
astigmatism or strabismus.
l Pupillary examination:
Horner syndrome will present with miosis while IIIrd cra-
nial nerve palsy will present with mydriasis.
l Ocular motility:
To diagnose
Ptosis with superior rectus weakness.
IIIrd cranial nerve palsy
Chronic progressive external ophthalmoplegia
Myasthenia gravis
l Ancillary tests:
Tests for Horner syndrome:
Cocaine and amphetamine test.
Test to rule out Pancoast tumor, carotid artery aneurysm
or dissection.
Tests for Myasthenia gravis:
Edrophonium chloride (Tensilon) test
Ice pack test
Acetylcholine receptor antibody test.
l Test to predict post-op complication:
Lagophthalmos
Bells phenomenon (Fig 10 )
Evaluation for dry eye Corneal sensation
TREATMEnT (Table 3)
Choice of surgery depends upon:
l Type of ptosis.
l Amount of ptosis.
l Degree of levator function.
l Surgeons experience with various type.
Ptosis
Moderate Mild Severe
Good
Fasanella Servat
Fair Good Poor
Large Resection
Moderate Resection Supramaximal Maximal Resection/
Sling
Sling
Fair Poor
Table 3. Decision making in ptosis surgery
AIO Journal of Ophthalmology
REVIEW
Surgical Procedures
Fasanella Servat procedure:
Principle: The upper border of tarsus is excised with the
lower part of Mullers muscle and the conjunctiva (Fig 11).
Indications:
l Mild congenital ptosis with a levator function better
than 10 mm
l Horners syndrome
l Mild involutional ptosis if not associated with frank
aponeurotic weakness.
Levator resection:
The extent of the resection is modifed by the degree of
the ptosis.
Levator function Resection
8 10 mm 14 18 mm
6 7 mm 18 22 mm
4 5 mm 22 26 mm
If the superior rectus muscle is weak, the resection should
be increased by about 4 mm.
Anterior approach levator resection:
Principle
The aponeurosis is ap-
proached through a skin
incision.
The muscle is shortened
and sutured to the tarsus.
The skin crease reformed
with sutures which pick
up the underlying levator
muscle (Fig 12).
Fig 11A, Fig 11B and Fig 11C Fasanella Servat procedure
Indications
A ptosis with 4 mm or more of levator function;
Lid exploration;
Maximum levator resection;
Preservtion of tarsus and conjunctiva;
Skin crease defect.
Aponeurosis surgery:
It is indicated for patients with an aponeurotic defect and
good levator function i.e. usually better than 10 mm. Intra
operatively, the lid is set at the same level or a little higher
than the other side.
Anterior approach aponeurosis repair:
Principle
The aponeurosis is approached through a skin incision. It
is advanced and sutured to the tarsus or the defect is re-
paied directly. Excess skin is excised and the skin crease
reformed with sutures which pick up the underlying
aponeurosis.
Indications
Repair or exploration of an aponeurotic defect, especially
if there is an excess skin to be excised.
Brow suspension
Principle
The frontalis muscle normally lifts the eyebrow and con-
tributes to eyelid elevation. This action of lifting the eyelid
is enhanced by connecting the frontalis muscle and eye-
brow to the eyelid with a subcutaneous sling for which
various materials can be used. A unilateral sling will always
produce asymmetrical result on downgaze. For a defnitive
cosmetic procedure it is better to do a bilateral suspension
with weakening of other levator muscle if this is normal.
Fig 12: Ligation of LPS during
LPS resection surgery
Blepharoptosis
Indications
Ptosis with less than 4 mm of levator function;
The prevention of amblyopia in an infant with severe pto-
sis in whom an assessment of levtor function is not pos-
sible;
Following a levator excision.
Levator division or excision:
Principle
The action of the levator muscle is abolished by dividing
or excising it.
Indications
The abolition of aberrant eye movement e.g. jaw winking.
To promote the use of frontalis muscle and create sym-
metry in patients undergoing a bilateral brow suspension
procedure for a unilateral ptosis.
Post Operative Complications:
Exposure keratitis.
Undercorrection
Overcorrection
Contour defects, notching of lid margin.
Lash ptosis and entropion
Lash eversion and ectropion
Defective skin crease
Conjunctival prolapse
Symblepharon
Extra ocular muscle involvement (Strabismus)
Haemorrhage
Infection.
Congenital ptosis with superior rectus weakness:
If the eye is straight in the primary position of gaze but the
superior rectus muscle is weak, more extensive ptosis sur-
gery is required to lift the lid by a given amount since the
superior rectus muscle normally contributes to upper lid
movement via its common sheath with the levator mus-
cle. When a levator resection is performed, an extra 4 mm
of levator muscle is arbitrarily resected. If the eye is hypo-
tropic in the primary position, it must be elevated before
the ptosis correction is undertaken.
Blepharophimosis:
l The treatment of the ptosis depends on the levator
function. This is usually poor and bilateral brow sus-
pension procedure is required. The epicanthus and
telecanthus should be corrected 6 months prior to
ptosis surgery. For telecanthus trans nasal wiring or
medial canthoplasty can be done.
Marcus Gunn jaw winking Synkinesis:
l If the ptosis is the main problem, it can be corrected
with the ptosis surgery based on levator function.
If the aberrant movement of the eyelid is the
main problem, it can be corrected by leva-
tor excision and brow suspension procedure.
This can be done bilaterally to obtain the most sym-
metrical result.

References
l Orbits, eyelids and lacrimal system. Section 7. Basic
and clinical science course. Edition: 2000-2001. The
Foundation of the American Academy of Ophthal-
mology. Blepharoptosis. Pages: 189 204.
l J.R.O. Collin. Manual of systematic eyelid surgeries.
2nd Edition. Butterworth Heinemann. Ptosis. Pages:
41 72.
l Homblass A (Ed). Oculoplastic, Orbital, and recon-
structive surgery, 1988, Williams & Wilkins, Balti-
more, MD
l Ptosis, Chapter 24, Repair and Reconstruction of or-
bital region, C.Beard and J.C. Mustarde, pages 411-
443. l
Dr. Kunal Kumar, DO, FMRF - (Orbit, Oculoplasty &Reconstructive Surgery)
Sankara Netralaya., Chennai is currently working as Orbit & Oculoplastic
surgeon in the Al Salama group of Eye Hospitals Calicut & Perinthalmanna
REVIEW
Recurrent Corneal Erosion Syndrome
Etiology
R
ecurrent corneal erosion is a disorder of the eyes
characterized by the failure of the cornea's outer-
most layer of epithelial cells to attach to the under-
lying basement membrane (Bowman's layer). Defective
adhesion of the epithelium to the Bowman's membrane
causes recurring cycles of epithelial breakdown. Multiple
recurrences are common, because the epithelial cells re-
quire at least 8-12 weeks regenerating or repairing the
epithelial basement membrane .The condition is excruci-
atingly painful because the loss of these cells results in the
exposure of sensitive corneal nerves.
Typically, recurrent corneal erosion syndrome (RCES)
develops 3-10 days after the insult but in some cases, it
may not develop until several months later. There is often
a history of previous corneal injury (corneal abrasion or
ulcer), but also may be due to corneal dystrophy or cor-
neal diseases. In other words, one may sufer from corneal
erosions as a result of another disorder, such as map dot
fngerprint disease. [1]
The common causes that trigger the process
of are:
a) superfcial trauma to the cornea including corneal
abrasions due to contact lens wearing
b) A clean cut abrasion (such as a paper cut) is more
likely to cause the problem than a ragged abrasion.
c) Other types of trauma may include alkali burns, for-
eign bodies and exposure keratopathy,entropion,ectropio
n,blepharitis,lagophthalmos.
There may be more unusual trigger factors (all involv-
ing disruption of the epithelial basement membrane) such
as following cataract surgery or refractive surgery. Other
iatrogenic causes include vitrectomy (surgical removal of
the vitreous) and photocoagulation.[2]
Systemic diseases which may predispose to this
condition include
l Diabetes[1]
l Junctional epidermolysis bullosa
l Alport's syndrome
l Mnchausen's syndrome
l Malnutrition
Drugs associated with the development of RCES
include
l Thiomersal (found in contact lens solutions).
l High-dose topical neomycin.
l Topical paromomycin.
l Topical diamidines and propamidine.
To a certain extent, all topical anaesthetic medication
causes some degree of epithelial cell damage but this is
most marked with cocaine, which is associated with RCES
more than others. A variety of RCES associated with au-
tosomal dominant inheritance has been described but is
rare.
Epidemiology [2]
l There are no accurate statistics relating to the exact
incidence and prevalence of this condition as it often
goes undiagnosed or misdiagnosed.
l It tends to occur slightly more commonly in females.
l It is a problem seen in adulthood, usually from the
fourth decade of life onwards, unless it is associated
with one of the corneal dystrophies (eg Reis-Bcklers
dystrophy) or Alport's syndrome, in which case it can
arise in children.
Symptoms
Symptoms include recurring attacks of severe acute ocular
pain, foreign-body sensation, photophobia (i.e. sensitivity
to bright lights, this occurs if corneal oedema develops)),
and tearing often at the time of awakening or during sleep
when the eyelids are rubbed or opened, decreased visual
acuity. In its early stages, the condition may be asympto-
matic. Later, there may be recurrent attacks of acute pain
(typically towards the end of sleep or on waking) associ-
ated with lacrimation, photophobia and a foreign body
sensation. There may be an associated blepharospasm
(inability to open the lids). The problem may be unilateral
Dr. Divya Menon, D.O.M.S., FICO
RCES
or bilateral. Symptoms may gradually subside over the
course of the day and then start all over again the next
morning. The unpredictability of these episodes may lead
to an associated anxiety.
Signs
Signs of the condition include corneal abrasion or lo-
calized roughening of the corneal epithelium, some-
times with map-like lines, epithelial dots or micro-
cysts, or fngerprint patterns. An epithelial defect may
be present, usually in the inferior interpalpebral zone.
Loose edges, intraepithelial cysts,stromal
edema,blepharospasm. (Fig 1)
Diagnosis
Diagnosis is made on history and examination. Severe cas-
es may warrant corneal topography to outline the degree
of corneal damage or help in the diagnosis of a corneal
dystrophy (most of which are diagnosed on examination).
The erosion may be seen by a doctor using the magnifca-
tion of a slit lamp biomicroscope , although usually fuo-
rescein stain must be applied frst and a blue-light used.
(Fig 2). In vivo confocal microscopy and videokeratogaphy
are other methods of diagnosis.
Management of episodes
The type of tears being produced has little adhesive prop-
erty. Water or saline eye drops tend to be inefective. Rath-
er a 'better quality' of tear is required with higher 'wetting
ability' (i.e. greater amount of glycoproteins) and so artif-
cial tears are applied frequently. Individual episodes may
settle within a few hours or days but additional episodes
(as the name suggests) will recur at intervals.
The easy remedy for recurrent attacks is to apply a
pressure patch.
Prevention
Since episodes tend to occur on awakening and managed
by use of good 'wetting agents', approaches has to be tak-
en to help prevent episodes .Prophylaxis revolves around
long-term lubrication in the frst instance, eg night-time
lubricating ointment for three months.[7] The success of
this approach depends on the patient understanding the
importance of continuing this treatment in the absence
of symptoms. More severe cases may require a protective
bandage contact lens.
There is evidence to suggest that a 12-week course of
systemic tetracyclines (eg oxytetracycline 250 mg bd) may
be benefcial (they inhibit matrix metalloproteinase activ-
ity and promote epithelial stability)
Fig 1 Fig 2
Prevention includes
a) Environmental
Ensuring that the air is humidifed rather than dry, not
overheated and without excessive airfow over the face.
Also avoiding irritants such as cigarette smoke.[2]
l Use of protective glasses especially when gardening
or playing with children.[2]
b) General personal measures
l Maintaining general hydration levels with adequate
fuid intake.[2]
l Not sleeping-in late as the cornea tends to dry out
the longer the eyelids are closed.[2]
c) Pre-bed routine
l Routine use of long-lasting eye ointments applied
before going to bed.[2]
l Occasional use of the anti-infammatory eyedrops
before going to bed if the afected eye feels infamed,
dry or gritty
l Use of a hyperosmotic ointment before bed reduces
the amount of water in the epithelium, strengthen-
ing its structure
l Use the pressure patch as mentioned above.
d) Waking options
l Learn to wake with eyes closed and still and keeping
artifcial tear drops within reach so that they may be
instilled under the inner corner of the eyelids if the
eyes feel uncomfortable upon waking.[2]
l It has also been suggested that the eyelids should be
rubbed gently, or pulled slowly open with your fn-
gers, before trying to open them, or keeping the af-
fected eye closed while "looking" left and right to help
spread lubricating tears. If the patient's eyelids feel
stuck to the cornea on waking and no intense pain is
present, use a fngertip to press frmly on the eyelid to
push the eye's natural lubricants onto the afected
REVIEW
area. This procedure frees the eyelid from the cornea
and prevents tearing of the cornea.[2]
Surgical
A punctal plug may be inserted into the tear duct by an
ophthalmologist, decreasing the removal of natural tears
from the afected eye. [5]
The use of thin contact lenses may help prevent the
abrasion during blinking. However they need to come for
frequent follow-up visits because there is an increased risk
of infection.[2]
Alternatively, under local anaesthetic, the loose cor-
neal layer may be gently removed with a fne needle and
cautery (heat or laser) or 'spot welding can be attempted
with laser. The procedures are not guaranteed to work,
and in a minority may exacerbate the problem.
Anterior Stromal Puncture is an efective and simple
treatment. This is a minor procedure carried out under
topical anaesthesia in the eye clinic. Numerous tiny punc-
tures are made away from the central visual axis, which
induces cicatrisation and promotes more permanent epi-
thelial adherence. It may be performed using Nd-YAG la-
ser.[5] or 24-26G needle.
An option for minimally invasive and long-term efec-
tive therapy [6] is laser phototherapeutic keratectomy.
Laser PTK involves the surgical laser treatment of the cor-
nea to selectively ablate cells on the surface layer of the
cornea. It is thought that the natural regrowth of cells in
the following days are better able to attach to the base-
ment membrane to prevent recurrence of the condition.
Laser PTK has been found to be most efective after epi-
thelial debridement for the partial ablation of Bowman's
lamella[7], which is performed prior to PTK in the surgical
procedure. This is meant to smoothen out the corneal area
that the laser PTK will then treat. In some cases, small-spot
PTK[8], which only treats certain areas of the cornea may
also be an acceptable alternative
.Keratectomy is the removal of corneal tissue and is
reserved for severe and difcult cases (usually in patients
with associated corneal dystrophies).[3] It involves either
laser treatment or surgical removal (knife, diamond burr):
the entire epithelium is removed and allowed to regrow
from new over the following 5-7 days. It can be carried out
more than once if the problem recurs. It can also be com-
bined with a refractive correction.
Presence of blepharitis,meibomitis,and flaments over
the corneal surface should be treated accordingly.
30-60 days autologous serum drops can be given. We
have to educate the patient regarding the refrigeration
and sterile preservation of the drops .
Alcohol delamination is a newer procedure that has
shown good efcacy and safety.[6]
Medical
Patients with recalcitrant recurrent corneal erosions often
show increased levels of matrix metalloproteinase (MMP)
enzymes.[9] These enzymes dissolve the basement mem-
brane and fbrils of the hemidesmosomes, which can lead
to the separation of the epithelial layer.
Treatment with oral tetracycline antibiotics (such as
doxycycline or oxytetracycline) together with a topical
corticosteroid (such as prednisolone), reduces MMP activ-
ity and may rapidly resolve and prevent further episodes
in cases of unresponsive to conventional therapies.[10]
[11] Some have now proposed this as the frst line therapy
after lubricants have failed.[3]
Assessment
l Check the patient's visual acuity (a drop of local an-
aesthetic will temporarily relieve the pain and the as-
sociated blepharospasm).
l Examine as much of the anterior segment of both
eyes (even if symptoms are unilateral). This includes
fuorescein staining of the cornea. The idea is to rule
out other possible diferentials .
Differential diagnosis
l Corneal abrasion.
l Corneal foreign body.
l Contact lens-related problem.
l Dry eye syndrome.
l One of a variety of corneal dystrophies.
l Floppy eyelid syndrome.
l Herpes simplex keratitis.
l Other form of keratitis.
Recurrent corneal erosion syndrome (RCES) can also occur
following prolonged eye patching.
Staging
There is no formal staging of recurrent corneal erosion
syndrome (RCES) but a note is made of the depth of cor-
neal involvement, as this dictates treatment options and
prognosis.
Management
First if there is an abrasion, cover with an antibiotic (such
as a topical fuoroquinolone given as directed in the pre-
scribing information) and a bandage contact lens until
healed. Once the cornea is reepithelialized, the following
RCES
regimen can be followed for the treatment of RCE.
a) 5%hypertonic saline (5% NaCl) ointment at bedtime
for 2 months. This helps reduce overnight edema and
improves epithelial adherence just prior to the morn-
ing (when most RCEs occur).
b) Preservative free lubricating drops 4 times a day.
c) (loteprednol etabonate 0.5%) or fuoromethalone four
times a day for 2 weeks, then twice a day for 6 weeks
(check intraocular pressure within 1 month).
d) Oral doxycycline (either 20mg or 50 mg) twice a day for
2 months.
Long-term, management, especially in cases of epithelial
basement membrane dystrophy, should include:
a) Cyclosporine 0.05% twice a day
b) Artifcial tear substitution
c) Omega-3 free fatty acid supplementation
d) Lubricating eye ointment for 2 months during night
time. The negative pressure in the sac is neutralised
with this.
e) Soft BCL for 2-3 weeks.
Note: Avoid topical steroid till the epithelium is healed .
Complications
l Infectious keratitis.
l Corneal scarring.
l Decreased visual acuity (due to either of the above).
Prognosis
With the right treatment, generally the prognosis is good
with most patients responding well to topical treatment.[2]
This relies on any underlying conditions being diagnosed
and treated and good patient education on the long-term
management. Few patients will have their vision perma-
nently afected.
further reading & references
1. Kanski J. Clinical Ophthalmology; A Systematic Ap-
proach (5th Ed) Butterworth Heinemann (2003)
2. Recurrent corneal abrasions/erosion, Kinshuck D, Good
Hope Eye Department, Heart of England NHS Founda-
tion Trust; (excellent patient resource with good dia-
grams)
3. Ramamurthi S, Rahman MQ, Dutton GN, et al; Patho-
genesis, clinical features and management of recurrent
corneal erosions. Eye (Lond). 2006 Jun;20(6):635-44.
Epub 2005 Jul 15.
4. Verma A et al, Corneal Erosion, Recurrent, Medscape,
Jun 2009
5. Ewald M, Hammersmith KM; Review of diagnosis and
management of recurrent erosion syndrome. Curr
Opin Ophthalmol. 2009 Jul;20(4):287-91.
6. Watson SL, Barker NH; Interventions for recurrent
corneal erosions. Cochrane Database of System-
atic Reviews 2007, Issue 4. Art. No.: CD001861. DOI:
10.1002/14651858.CD001861.pub2.
7. Tsai TY, Tsai TH, Hu FR, et al; Recurrent corneal ero-
sions treated with anterior stromal puncture by neo-
dymium: Ophthalmology. 2009 Jul;116(7):1296-300.
Epub 2009 May 8.
8. Singh RP, Raj D, Pherwani A, et al; Alcohol delamina-
tion of the corneal epithelium for recalcitrant recur-
rent corneal Br J Ophthalmol. 2007 Jul;91(7):908-11.
Epub 2007 Feb 14.
9. Das S, Seitz B; Recurrent corneal erosion syndrome.
Surv Ophthalmol. 2008 Jan-Feb;53(1):3-15
10. Review of Ophthalmology, Friedman NJ, Kaiser PK,
Trattler WB, Elsevier Saunders, 2005, p. 221
11. Verma A, Ehrenhaus M (August 25, 2005) Corneal Ero-
sion, Recurrent at eMedicine
12. Wang L, Tsang H, Coroneo M (2008). "Treatment
of recurrent corneal erosion syndrome using the
combination of oral doxycycline and topical cor-
ticosteroid". Clin. Experiment. Ophthalmol. 36 (1):
812. doi:10.1111/j.1442-9071.2007.01648.x. PMID
18290949.
13. Liu C, Buckley R (January 1996). "The role of the ther-
apeutic contact lens in the management of recurrent
corneal erosions: a review of treatment strategies".
CLAO J 22 (1): 7982. PMID 8835075.
14. Tai MC, Cosar CB, Cohen EJ, Rapuano CJ, Laib-
son PR (March 2002). "The clinical efcacy of sili-
cone punctal plug therapy". Cornea 21 (2): 1359.
doi:10.1097/00003226-200203000-00001. PMID
11862081.
15. Baryla J, Pan YI, Hodge WG (2006). "Long-term ef-
cacy of phototherapeutic keratectomy on recurrent
corneal erosion syndrome.". Cornea 25 (10): 1150
1152. doi:10.1097/01.ico.0000240093.65637.90.
PMID 17172888.
16. Kampik D, Neumaier K, Mutsch A, Waller W, Geerling
G (2008). "Intraepithelial phototherapeutic keratec-
tomy and alcohol delamination for recurrent corneal
erosions--two minimally invasive surgical alterna-
tives.". Klinische Monatsbltter fr Augenheilkunde

REVIEW - RCES
225 (4): 27680. doi:10.1055/s-2008-1027174. PMID
18401793.
17. Van Westenbrugge JA. (2007). "Small spot photother-
apeutic keratectomy for recurrent corneal erosion.". J
Refract Surg 23 (7): 7214. PMID 17912944.
18. Ramamurthi S, Rahman M, Dutton G, Ramaesh K
(2006). "Pathogenesis, clinical features and manage-
ment of recurrent corneal erosions.". Eye 20 (6): 635
44. doi:10.1038/sj.eye.6702005. PMID 16021185.
19. Hope-Ross M, Chell P, Kervick G, McDonnell P, Jones
H (1994). "Oral tetracycline in the treatment of recur-
rent corneal erosions.". Eye 8 (Pt 4): 3848. PMID 782^
Review of Ophthalmology, Friedman NJ, Kaiser PK,
Trattler WB, Elsevier Saunders, 2005, p. 221
20. Verma A, Ehrenhaus M (August 25, 2005) Corneal Ero-
sion, Recurrent at eMedicine
21. Wang L, Tsang H, Coroneo M (2008). "Treatment
of recurrent corneal erosion syndrome using the
combination of oral doxycycline and topical cor-
ticosteroid". Clin. Experiment. Ophthalmol. 36 (1):
812. doi:10.1111/j.1442-9071.2007.01648.x. PMID
18290949.
22. Liu C, Buckley R (January 1996). "The role of the ther-
apeutic contact lens in the management of recurrent
corneal erosions: a review of treatment strategies".
CLAO J 22 (1): 7982. PMID 8835075.
23. Tai MC, Cosar CB, Cohen EJ, Rapuano CJ, Laib-
son PR (March 2002). "The clinical efcacy of sili-
cone punctal plug therapy". Cornea 21 (2): 1359.
doi:10.1097/00003226-200203000-00001. PMID
11862081.
24. Baryla J, Pan YI, Hodge WG (2006). "Long-term ef-
cacy of phototherapeutic keratectomy on recurrent
corneal erosion syndrome.". Cornea 25 (10): 1150
1152. doi:10.1097/01.ico.0000240093.65637.90.
PMID 17172888.
tives.". Klinische Monatsbltter fr Augenheilkunde
225 (4): 27680. doi:10.1055/s-2008-1027174. PMID
18401793.
44. doi:10.1038/sj.eye.6702005. PMID 16021185.
H (1994). "Oral tetracycline in the treatment of recur-
rent corneal erosions.". Eye 8 (Pt 4): 3848. PMID 782
tives.".
Klinische Monatsbltter fr Augenheilkunde 225
(4): 27680. doi:10.1055/s-2008-1027174. PMID
18401793.
44. doi:10.1038/sj.eye.6702005. PMID 16021185.
H (1994). "Oral tetracycline in the treatment of re-
current corneal erosions.". Eye 8 (Pt 4): 3848. PMID
7821456.
33. Dursun D, Kim M, Solomon A, Pfugfelder S (2001).
"Treatment of recalcitrant recurrent corneal erosions
with inhibitors of matrix metalloproteinase-9, doxy-
cycline and corticosteroids.". Am J Ophthalmol 132
(1): 813. doi:10.1016/S0002-9394(01)00913-8. PMID
11438047. l
Dr. Divya Menon, D.O.M.S., FICO is currently working as Consultant in
General Ophthalmology at the Al Salama Eye Hospital Perinthalmanna
REVIEW
Dr. Kunal Kumar, DO, FMRF
Contracted Socket
C
ongenital anophthalmia is the congenital ab-
sence of any ocular tissue in the orbit resulting
from failure of budding of optic vesicle. Clinical
anophthalmia refers to reduced volume socket result-
ing in small cul-de-sac, lid phimosis, eyelid malposition
and peripalpebral fbrosis. The term microphthalmia is
reserved for a structurally normal, small eye, with axial
length two standard deviations below that of the popu-
lation age-adjusted mean. The eye is essentially normal
except for its decreased total axial length and typically
correlates to an axial length below 21 mm in adult eyes.
Anophthalmia and microphthalmia are thought to be
caused by disturbances of the morphogenetic pathway
that controls eye development. Contracted Socket is an
anophthalmic socket which cannot support a prosthetic
eye. A contracted socket has been classifed based upon
the clinical presentation (Table 1).
Socket Contracture
Congenital
This involves contracted socket due to conditions such as
anophthalmia and microphthalmia where there is virtually
no stimulus for the bony growth.
Acquired
An acquired contracted socket is the result of tissue shrink-
age due to various factors (as discussed below) which
leads to inadequate space for the prosthesis to be retained
properly. Tumors such as retinoblastoma pose a special
problem when the sufering patient is treated with irradia-
tion. Physical trauma such as globe rupture necessitating
the removal of precious tissue like conjunctiva leads to
posterior lamellar shortening. Chemical insult due to alkali
burns are a big hurdle in the management of the resultant
contracted socket. Mustarde called them the Malignantly
Contracted Sockets as these are very difcult to manage.
The anterior and posterior lamellae are lost partially or
completely and the recurrent cicatricial process yields to
repeated failure of any treatment modality. Staphylococ-
cal infections especially in post traumatic infections, cause
necrosis and destruction of tissue causing contracture.
Iatrogenic factors also play an important role in causa-
tion of a contracted socket. An enucleation done badly or
with inadequate knowledge about the anatomy of the lid
and socket very often leads to tissue defciency. Failure to
place a conformer immediately after enucleation or evis-
ceration procedure or when placed initially, not using it in
post operative period for adequate duration result in shal-
lowing or obliteration of fornices
Pathophysiology
The exact cause of a contracted socket is not been clearly
understood. It has however been attributed to factors
such as volume defcit and volume redistribution. Vol-
ume defcit can be because of loss of the globe and tis-
sue, inadequate sized implant and defcient conjunctiva.
Volume redistribution refers to an alteration in the quality
or placement of the tissue such as contraction of Tenons
capsule, retraction of periocular muscle (eyelid retractors)
and downward and forward shifting of orbital fat. There is
also a role of myofbroblast which is controversial.
Clinical features
A patient with a contracted socket presents to the clinic
with cosmetic deformity and problems in prosthesis ft
which causes a nuisance, embarrassment and mental de-
pression to the patient. Features of a contracted socket are
sunken socket, inability to retain prosthesis in the socket,
lagophthalmos, ptosis, entropion, pain and discharge. Post
Enucleation Socket Syndrome (PESS) refers to a condition
of contracture of socket following enucleation character-
ized by enophthalmos, ptosis, entropion and superior sul-
cus deformity.
Clinical Evaluation
Clinical evaluation of a case of contracted socket includes
a detailed history, indication and age at enucleation/ evis-
ceration, previous history (trauma, tumor), presence or
absence of implant at primary procedure, history of any
radiation therapy and allergy to some medication. Exami-
nation of eyelids includes measuring the amount of ptosis,
lagophthalmos, and vertical and horizontal palpebral fs-
sure height. Adequacy of the cul-de-sac, superior sulcus
deformity and presence of cicatricial element (scar/band/
contracture) should be noted. Keeping the possibility
REVIEW
Table 1. Classification of contracted socket
Classifcation I
Mild Superfcial Contraction of conjunctival fornix
Severe Superfcial Contraction of eyelids and conjunctival fornix
Mild Deep Contraction of conjunctival fornix and orbital fat
Severe Deep Absence of fornix and severe contraction of orbital fat
Total All of the above with bony abnormality
Classifcation II
Mild l Mild entropion
l Fairly deep socket/ fornix
l Minimal shortening of the posterior lamella.
Moderate l Inferior fornicial shallowing
l Mild increase in superior sulcus deformity
l Prosthesis overrides the lower lid margin
l Prosthesis starts getting displaced
Severe Upper and lower fornicial shallowing
Palpebral fssure height and length shortening
No space to introduce examiners fngers
Prosthesis cannot be retained
Classifcation III
Congenital Anophthalmia
Microphthalmia
Acquired Tumor
Trauma
l Physical
l Chemical
Irradiation
Infection
Iatrogenic
of a membrane graft in mind, one should also examine the
condition of oral mucosa, oral hygiene and the ability of
the patient to open mouth.
Management
The primary aim in the management of a contracted sock-
et is to make the socket capable enough to maintain the
prosthesis and provide better cosmesis for the patient. The
management of a contracted socket can be divided into
surgical and prosthetic treatment.
Congenital contracted socket
The aim of managing a congenital contracted socket is to
stimulate the growth of the orbit. Maximum growth oc-
curs in the frst year of life and hence intervention should
be initiated as early in life as possible. Since there is an ab-
sence of globe which does not provide any stimulus for
the bony development, placement of conformers of in-
creasing sizes act as substitutes. Mild to moderate contrac-
tion is managed conservatively by insertion of conform-
ers. A conformer of increasing size is changed every week
for socket and soft tissue expansion followed by a change
every month to provide bony expansion. The end point
is when a suitable sized prosthesis can be worn. Severe
contraction requires volume replacement using implants,
expanders and dermis fat grafts and often need orbital os-
teotomies. Conjunctival sac and lid reconstruction may be
benefcial to the overall cosmetic efect.
Mildly contracted socket (fig 1)
This is associated with mild en-
tropion resulting from shorten-
ing of posterior lamella. The for-
nices are fairly deep and there is
no problem with the ftting of a
prosthesis. A transverse blepha-
rotomy (lid split) with marginal
rotation (Weis procedure) is the
preferred surgical procedure for the entropion. If hori-
zontal lid laxity is also present, the marginal rotation can
be combined with horizontal lid shortening procedure
(Quickert procedure).
Moderately contracted socket (fig 2)
A moderately contracted socket is associated with loss
of both superior and inferior fornices along with some
amount of volume defcit. Contractures, bands or sym-
blepharon when present can be easily treated with band
release followed by Z plasty with placement of a con-
former. For extensive contractures, either a split thick-
ness graft or a full thickness mucus membrane graft can
be used. However, a full thick-
ness mucus membrane graft is
preferred over a split thickness
graft because of less contrac-
ture. Volume defciency can be
managed by a secondary ball
implant, dermis fat graft (DFG)
or a temporary muscle fap
transfer.
Severely contracted socket (fig 3)
In a severely contracted socket, there is complete oblit-
eration of the fornices with or
without bony deformity making
it impossible to place or retain
prosthesis. For severe bony de-
formity, extensive craniofacial
reconstruction with external
wiring can be undertaken al-
Fig 1, Mild contracted
socket with mild entropion
Fig 2, Moderate contract-
ed socket with Inferior
fornicial shallowing
Fig 3, Severly contracted
socket following enucleation
Contracted Socket
though the whole procedure is tedious, time consuming
and may not always yield satisfactory results. Surface def-
cit can be managed by split thickness graft or a full thick-
ness mucus membrane graft. Secondary ball implant, der-
mis fat graft (DFG) or a temporary muscle fap transfer can
address the volume replacement.
Graft Materials
Various types of graft materials have been used in the past
for the replacing the damaged or defcient palpebral la-
mella such as conjunctiva, mucus membrane grafts (inner
side of the lower lip, gums, buccal mucosa, opening of the
parotid duct near the upper second molar avoiding the
Stensons duct, hard palate mucosa, nose, nasal septum or
nasal cartilage with mucosal lining, prepuce, vagina, labia
minora, and rectum), hard palate, skin, muscle faps, tem-
poralis fascia, and dermis fat graft (DFG).
General Principles
All scar must be removed. All raw surfaces must be cov-
ered with grafts that will survive. Size of mucus membrane
graft should be 1.5 to 2.0 times the size of defect since
some amount of tissue shrinkage is unavoidable. All grafts
must be placed on a vascularized tissue and that absolute
immobility of the graft is achieved. Shifting of the graft
can result in loss of blood supply. Skin and mucosa should
not be mixed in the same socket (Fig 4 and Fig 5).
Complications
The incidence and occurrence of complication of a con-
tracted socket depends on the surgical technique, pres-
ence of infection and tissue reactivity. The various com-
plications are graft failure, oral cicatrix formation, mucus
membrane granuloma formation, socket infection, recur-
rence of contractures, and ankyloblepharon
Prevention of socket contracture
Inadequate dissection of the tissues leads to socket con-
tracture in the early post operative period. Care should be
taken to carefully dissect and preserve as much Tenons
capsule and conjunctiva as possible and suture them in
separate layers over the implant without tension.
Adequate and prolonged expansion of fornicial tissue
is essential for socket expansion and prevention of forni-
cial shortening. The prosthesis should be frequently evalu-
ated for roughening of the surface and ill ftting. This can
be a source of constant irritation and discomfort to the
patient and can result in disuse of the prosthesis which in
turn would cause socket contracture. At this stage, palpe-
bral phimosis and symblepharon formation can result in
severe socket contracture which is difcult to manage.
References:
1) Complex socket deformities, Stephen Bosniak, Page
no: 97-142
2) Ophthalmology monographs, AAO, Surgery or eyelid
orbit and lacrimal system, vol 3, page no: 128-132
3) Smiths Ophthalmic plastic and reconstructive sur-
gery, page no: 1114- 1120
4) Color atlas and text of Ocular plastic surgery, page no:
275- 297
5) Repair and reconstruction in the orbital region, by
J.C.Mustarde. Page no: 335-340 l
Fig 4
Preserve conjunctiva as far as possible
Limited fornicial dissection
Correct EOM placement to prevent fornicial shortening
Placement of conformer postoperatively for longer duration
Use of implants
Proper fitting of prosthesis
Precautions to prevent Contracted Socket
Fig 5
Dr. Kunal Kumar, FMRF - (Orbit, Oculoplasty &Reconstructive Surgery)
Sankara Netralaya., Chennai is currently working as Orbit & Oculoplastic
surgeon in the Al Salama group of Eye Hospitals Calicut & Perinthalmanna
REVIEW
Dr Dolly Nazia P.M., MD (Ophthalmology), FICO
Phakic Intraocular Lens
P
hakic intraocular lenses are intraocular lenses im-
planted in eyes with normal crystalline lens for re-
fractive correction. The history of PIOL dates back to
1953 when Italian surgeon Benedetto Strampelli success-
fully implanted a PIOL in the anterior chamber for correc-
tion of myopia. But PIOL fell into disrepute because of in-
creased incidence of post operative complications, lack of
microsurgical devices and poor understanding of endothe-
lial functions.
Even though laser vision correction is simpler and easily
accepted by patients, it yields less than satisfactory results
in case of patients with high myopia (>10 D).These patients,
albeit being 2% of myopic population, constitutes 13 15%
of patients presenting for refractive surgery. LASIK in such
patients may result in signifcant residual error, loss of best
spectacle corrected visual acuity, induction of iatrogenic
keratectasia, higher order aberrations and tear flm abnor-
malities. In recent years, phakic intraocular lens (PIOL ) has
emerged as a reliable and predictable alternative to laser
refractive correction, in higher grades of refractive error.
Indications for PIOL
l Myopia > - 12D
l Hyperopia >+4D
l Corneal thickness < 480 microns
l Residual bed thickness after LASIK likely
to be < 280 microns
l Topography suggestive of keratoconus
Types of phakic IOLs
Depending on site of insertion they are of 3 types (fg. 1, 2, 3)
Angle supported PIOL
First generation PIOL.eg- Baikof, NUVITA. Foldable eg- Vi-
varte( Ciba), and Acrysof (Alcon).
Iris supported anterior chamber PIOL
Also called iris clip lens ; fxate the IOL to mid peripheral iris
by enclavation of loop tips, to produce a pillar of iris tissue
over most peripheral part of haptics. The size of this type of
PIOL is not dependent on the eye dimension one size fts
all. Eg : Artisan (Ophtec) and Verisyse (AMO)
Posterior chamber PIOL: (figure 4a, figure 4b)
Figure 1
Angle supported PIOL 1
STAAR Implantable contact
lens (ICL) available in India.
It is made of highly biocom-
patible silicone collagen co-
polymer called collamer. It
is available in powers from
-2 to -20D and +3 to +17 D.
Toric version available with
myopic powers can correct
up to 6D of astigmatism.
CIBA Vision Phakic refractive lens (PRL) made of ultra
thin hydrophobic silicone. it has no anatomical fxation site
and foats on layer of aqueous humor in posterior chamber.
IOLTECH Sticklens: made of hydrophilic acrylic material,
which sticks to anterior surface of crystalline lens.
Pre requisites for PIOL
l Age >18 years, refractive status stable for at least 1year
l Endothelial count >2000/ sq mm
l Anterior chamber depth >3mm
l Angle width >30 degree
l Pupil smaller than 6mm in scotopic luminance
l No refractive eye pathology
l No systemic pathology
l 2 Fully patent Nd : YAG laser iridotomies made 1 to2
weeks before surgery
Contraindications
Preexisting intraocular disease such as a compromised cor-
neal endothelium, iritis, signifcant iris abnormality, rube-
osis iridis, cataract
Power calculation for PIOL
Three essential parameters for PIOL power calculation are
l Spectacle power at vertex distance of 12mm
l Anterior chamber depth
l Horizontal and vertical radii of curvature of cornea
The measures are sent to the manufacturer and exact IOL
power is calculated using specifc software and normo-
Figure 2
Iris supported PIOL
Figure 3
Sulcus supported PIOL
PHAKIC IOL
grams (fgure 5).
For iris clip lens the Vander Heijde formula is used, and
for ICL and PRL, Olson Feingold and Holladay Refractive
formulae respectively are used.
Clinical Examination:
l Uncorrected visual acuity
l Manifest and cycloplegic refraction
l Spectacle and/ contact lens corrected visual acuity
l Slit lamp examination of anterior segment and adnexa
l Intra ocular pressure
l Pupil size under scotopic conditions
l Biometry to calculate the axial length and anterior
chamber depth
l White to white corneal diameter in case of angle sup-
ported and posterior chamber PIOL
l It is measured with calipers under a microscope and
verifed with an orbscan to obtain appropriate size of
lens. Sizing is important to ensure appropriate vault
and separation between back of PIOL and the anterior
capsule.
l Keratometry and VKG - Fundus examination by indi-
rect ophthalmoscopy
l Field charting
Surgical procedure for insertion of posterior
chamber PIOL(figure 6)
Surgery is done under topical or peribulbar anesthesia with
the pupil fully dilated and preferably through a temporal
clear corneal or near limbal incision. The loading of these
lenses has to be precise and there are markers (diferent for
spherical and toric versions; current PRL has 2 tiny dots on
the haptics to avoid inverted implantation) to indicate and
assist in proper placement of lens. Low molecular weight
viscoelastics are recommended for both loading of lens and
during surgical procedure.
The ICL / PRL is injected through a less than 2.5mm in-
cision. Smooth and gentle retro positioning of footplates
involves maneuvering the haptics through 1 mm side ports
with sandblasted visco cannula or specifcally designed
STAAR PIOL in situ
Fig 4a: on slit lamp
tuckers. Bimanual irrigation aspiration is then done to re-
move the viscoelastic agent.
Post operative complications
Angle supported PIOL: progressive pupillary distortion,
UGH syndrome, corneal decompensation.
Iris supported anterior chamber PIOL: anterior chamber
infammation, glaucoma, iris atrophy on fxation sites, IOL
decentration, dislocation, endothelial cell loss.
Posterior chamber PIOL: inverted implantation el-
evated IOP, cataractogenesis, endothelial cell damage, de-
centration, infammation and pigment dispersal.
Advantages of PIOL:
l Additive procedure, not subtractive as in LASIK
l Preservation of corneal sphericity
l Preservation of accommodation (versus refractive lens
exchange)
l Rapid visual recovery and stable post operative refrac-
tion
l Excellent refractive accuracy even with signifcant
astigmatism
l Optical advantage of PIOL placed much closer to
nodal point of eye; hence the efective optical zone of
PIOL is 1.25 times on corneal surface
l No initial investment on costly equipment
l Technique can be comfortably incorporated into prac-
tice by good anterior segment surgeon
Disadvantages of PIOL
l It is an intra ocular surgery. Even though very low,
chances of endophthalmitis and retinal detachment
are present.
l Steep learning curve is present. Surgical dexterity is
essential as the intra ocular surgical maneuvering has
to be performed in the 3 mm space between corneal
endothelium and anterior lens capsule.
l Cost of imported phakic intra ocular lens is high.
l Long term data on performance of PIOL is sparse.
Recent Literature
k Meta-analysis of randomized controlled trials compar-
ing excimer laser and phakic intraocular lenses for myopia be-
tween 6.0 and 20.0 diopters.
Barsam A, Allan BD. Cornea. 2012 Apr;31(4):454-61.
Results
This review included 3 RCTs with a total of 228 eyes. The
range of myopia was 6.0 to 20.0 D with up to 4.0 D of astig-
matism. The PIOL group was less likely to lose 2 or more
Fig 4b
Scheimpflug photography
REVIEW
Figure 5: software for power calculation of sulcus fixated PIOL
lines of best spectacle-corrected visual acuity at 12 months
(odds ratio, 0.35; 95% confdence interval, 0.19-0.66, P =
0.001). PIOL surgery scored more highly on patient satisfac-
tion/preference questionnaires.
Conclusions
The results of this systematic review show that PIOLs are
safer within 1 year of follow-up compared with excimer
laser surgical correction for myopia between 6 and 20 D.
There is weaker evidence for superior visual quality in PIOL
recipients. Further RCTs adequately powered for subgroup
analysis with long-term follow-up are necessary to establish
the ideal myopic range for excimer laser & PIOL treatments.
k (Foldable iris-fxated phakic intraocular lens vs femtosec-
ond laser-assisted LASIK for myopia between -6.00 and -9.00
diopters. Albarrn-Diego C, Muoz G et al. J Refract Surg.
2012 Jun;28(6):380-6.)
Methods
Forty-six myopic patients were randomized to undergo bi-
lateral Artifex (Ophtec BV) PIOL implantation or bilateral
femtosecond laser-assisted conventional LASIK with the
VISX S2 (Abbott Medical Optics). Refraction, uncorrected
(UDVA) and corrected (CDVA) distance visual acuity, con-
trast sensitivity, corneal endothelial cell count, rate of re-
treatment, and complications
were compared.
Results
Twelve months after surgery,
no statistically signifcant
diferences were noted in
spherical equivalent refrac-
tion (P=.19) or UDVA (P=.28), whereas CDVA was better in
the PIOL group (P<.001). Spherical equivalent refraction
was within 0.50 D in 42 (91.3%) LASIK eyes and 41 (89.1%)
PIOL eyes (P>.99). The percentage of eyes gaining lines of
CDVA was signifcantly higher in the PIOL group (50.0% vs
8.7%; P<.001). Contrast sensitivity was better for PIOL eyes
at 1.5 cycles per degree (cpd) (P=.03) and 6 cpd (P=.008).
The LASIK eyes showed a mean endothelial cell count in-
crease of 3.7%2.8%, whereas PIOL eyes showed a mean
decrease of 9.1%2.0% (P<.001). The rate of retreatment
was similar (P=.37), and no serious complications occurred
in either group.
Conclusions
The Artifex PIOL provided better CDVA and contrast sensitiv-
ity at high spatial frequencies than femtosecond laser-assist-
ed conventional LASIK, suggesting that PIOL implantation is
a reasonable option for myopia between -6.00 and -9.00 D.
References
1. Christopher J. Rapuano, Wachler et al,Section13, Refrac-
tive Surgery, Basic Science And Clinical Course, Ameri-
can Academy Of Ophthalmology 2011-2012, 125-136.
2. Boxer Wachler BS, Scruggs RT, Yuen LH, Jalali S. Com-
parison of the Visian ICL and Verisyse phakic intraocular
lenses for myopia from 6.00 to 20.00 diopters. J Refract
Surg. 2009;25(9),765 - 770.
3. Kamiya K, Shimizu K, Igarashi A, Hikita F, Komatsu M.
Four-year follow-up of posterior chamber phakic in-
traocular lens implantation for moderate to high myo-
pia. Arch Ophthalmol. 2009;127(7);845- 850.
4. Lovisolo CF, Reinstein DZ. Phakic intraocular lenses.
Surv OphthaLmol. 2005;50(6):549- 587 l
Figure 6: insertion of PCPIOL
Dr Dolly Nazia P.M
M.D. (Ophthalmology), FICO is currently working as Consultant in General Ophthalmology
at the Al Salama Eye Hospital Calicut
CUTTING EDGE OPHTHALMOLOGY
Dr. Priya Nambiar, M.S., D.O., FICO
Refractive Lenticule Extraction(Relex)
F
rom a humble beginning more than half a century
ago, refractive surgery has witnessed a technology
explosion with an exciting array of microkeratomes
,excimer lasers, femtosecond lasers and a wide variety
of procedures to choose from. ReLEx is an exciting new
procedure in the refractive surgical armamentarium that
holds the potential to herald a paradigm shift for the fu-
ture of refractive surgery, since it addresses most of the
risks and variables related to the microkeratome blade
and excimer laser.
Background
Lamellar refractive surgery was developed from the con-
cepts and work of Dr.Jose Barraquer in the 1950s. In the
1980s, microkeratome was developed and in 1982, Trokel
and coworkers suggested the use of excimer laser for cor-
neal reprofling. Pallikaris described the use of automated
microkeratome to make a hinged corneal fap followed by
excimer laser ablation and called it LASIK. The last decade
has witnessed many advancements and refnements in
microkeratomes and excimer lasers leading to signifcant
improvement in clinical outcomes. Later on, femtosecond
laser technology was developed and LASIK with femtosec-
ond faps became popular.
ReLEx is an all femtosecond laser vision correction,
utilizing it for the creation and extraction of a refractive
lenticule from the corneal stroma so that the radius of cur-
vature of the tear flm- anterior corneal interface is altered
as desired. This procedure can correct myopia, compound
myopic astigmatism, mixed astigmatism and has the po-
tential to correct hyperopia, although not approved yet.
ReLEx encompasses 2 diferent approaches, the frst
being femtosecond lenticule extraction or ReLEx fex pro-
cedure which is similar to conventional LASIK in that it cre-
ates a hinged corneal fap which is lifted for the removal of
intrastromal lenticule and later on the fap repositioned.
In small incision lenticule extraction or ReLEx smile
technique, the refractive lenticule created in the intact
cornea is removed through a small access incision without
lifting any fap and hence less invasive and fapless.
Selection criteria
Preoperative selection criteria for ReLEx are similar to
those for any LASIK procedure .With the potential for su-
perior biomechanical stability and greater accuracy, these
criteria could be revised in future.
Surgical parameters
The range of myopia which can be treated ranges from
-0.75 to -10 dioptres, with a maximum cylinder of 5D ,
the combined sphere and cylinder not exceeding -10D.
The superfcial cap/fap thickness is 100 microns.The lenti-
cule diameter which is equivalent to trhe optical zone can
be 5-7 mmand the depth of tissue removed per dioptre
of refractive correction is similar to LASIK.However as no
transition zone is involved,the efective depth of ablation
may be less than that required for excimer laser ablations .
Surgical technique
After entering the relevant clinical details according to
treatment plan,a sterile contact lens is attachedto the la-
ser aperture cone of the machine and internal calibration
done. Under topical anaesthesia, a self retaining specu-
lum is inserted and cornea dried. The patient bed is then
repositioned so that the cornea comes in contact with the
contact lens. The cornea slightly applanates and centres,
aiming for the vertex and the eye is immobilized with low
corneal suction. The increase in IOP is low enough for the
patient to see through the procedure.The laser is then
activated by the foot pedal.Once the femtosecond cut is
completed, the suction is disengaged and patient then re-
positioned under microscope for removal of the lenticule.
During the femtosecond procedure, fex and smile dif-
fer only in the last step ie the circumferential extent of

CUTTING EDGE OPHTHALMOLOGY
the anterior side cut and hence the technique required for
removal of the refractive lenticule varies.
During fex, the sharp edge of a double armed ReLEx
manipulator identifes the edge of the fap and the blunt
end is used to create the plane anterior to the lenticule.
Then, as in LASIK,the fap is lifted,the lenticule similarly
separated from the stromal bed, peeled of and the fap
repositioned.
While doing smile, the same instrument is used to
identify the lip of the anterior fap and the dissect the
figure 1: Relex steps
Preoperative cornea
Lenticule Cut
Lenticule Side Cut
Anterior Cut
Anterior Side Cut Flex Anterior Side Cut Smile
Relex
planes superfcial and deep to the lenticule 360 degrees
to ensure complete separation.A 21 G forceps is then
introduced through the smile incision and the lenticule
grasped and pulled out. The lip of the incision is then
smoothened. Both eyes are generally treated on the same
day. Post operatively, topical antibiotics , steroids and lu-
bricants are given.
Advantages of Relex
1. Refractive results are more accurate and better con-
trast sensitivity since higher order aberrations are
less, as compared to excimer lasers , especially in
moderate and high refractive errors due to the fol-
lowing reasons.
l Perfect centration of cap relative to the lenticule .
l Since it involves cutting instead of ablation, the
time taken for treatment is considerably less and
the same irrespective of the magnitude of refrac-
tive error and hence variable results due to drying of
cornea, ablation interruptions due to patient move-
ments which are common in the correction of high
errors are absent.
l Ambient room conditions such as
temperature,humidity, presence of perfumes or
deodorants donot afect the laser performance .
l Less potential for misalignment errors as compared
to femtoLASIK since shifting of patient is avoided .
2. ReLEx smile has additional advantages over fex in
that
l There are no fap complications
l Faster wound healing and visual rehabilitation.
l Less chance of interface infammations due to debris
or blood.
l Less chance of dry eyes since fewer corneal nerves
being cut.
l Better corneal biomechanical stability.
l Procedure time is further less .
3. Fluence check and gas change not necessary and
hence individual treatments are cost efective.
4. Purchase and maintenance of a single laser instead
of two in femtoLASIK.
Limitations
Greater surgical skill is needed for smile since the surgical
planes superfcial and deep to the lenticule needs to be
precisely delineated .Also retreatment for primary under-
correction or regression is difcult and hence surface abla-
tions will have to be performed.
Conclusion
The evolution of refractive surgery has been in leaps and
bounds and now it has gone one step further by using
smaller incision and thereby preserving corneal biome-
chanics. Refractive surgeons are now aiming at achiev-
ing aberration free treatment and ReLEx smile is one step
closer to this quest. We can say that it is the cutting edge
of refractive surgery because there is almost no cut edge.
References
1. Pallikaris.I.G:Laser in situ Keratomileusis,Lasers Surg
Med 10:463,1990
2. Sekundo.W,Kunert.K,Russmann.C et al: First efcacy
and safety study of femtosecond extraction for the
correction of myopia,six month results. J.Cataract Re-
fractive Surgery:2008; 34:1513-1520.
3. Shah.R,Shah.S,Sengupta.S: Results of small inci-
sion lenticule extraction- all in one femtosecond
laser refractive surgery.J. Cataract Refractive Sur-
gery:2011;37:127-137.
4. Shah.R,Shah.S,A New Refractive method:ReLEx FLEx.
In:Buratto L, Stephen SG,Tavolato.M.LASIK:The Evolu-
tion of Refractive Surgery. 1st edition;2011:125-128. l
Dr. Priya Nambiar
M.S., D.O., FICO is currently working as senior consultant General
ophthalmology & refractive surgeon at Al Salama group of Eye Hospitals Calicut
& Perinthalmanna
CASE KORNER
Dr. Maneesh Shyamkul, M.S. (Ophthalmology), Fellow LVPEI
Posterior Embryotoxon and its Signifcance
Introduction
P
osterior embryotoxon (PE) is a corneal abnormality
that is visible with slit-lamp biomicroscopy as a thin
grey-white, arcuate ridge on the inner surface of the
cornea, adjacent to the limbus. (Figure 1&2)
Gonioscopically
It is an anteriorly displaced Schwalbes line, the junction of
Descemets membrane and the uveal trabecular meshwork.
Histologically
It consists of a central collagen core surrounded by a thin
layer of Descemets membrane & is separated from the an-
terior chamber by a layer of endothelium. It may be an iso-
lated fnding or seen in the presence of other ocular anom-
alies, in particular AxenfeldRiegers syndrome or systemic
diseases such as Alagille's syndrome.
1
Overview
PE is found to be present in anything from 8 to 32% of the
general population.
1, 2, 3, 4, 5
PE occurs in up to 95% of patients
with Alagille's syndrome.
6
This has led to the proposal that
its presence could be used as a screening tool to aid diag-
nosis & avoid the need for more invasive tests in children
with chronic cholestasis. However, an incidence of PE in the
general population of 30% makes it useless for this task.
PE was frst described by Axenfeld in 1920. The inci-
dence of PE varies between studies and many are hampered
by the small sample size or the nature of the sample selec-
tion. previous studies found it to be present in up to 20% of
eyes.
3
Burian et al
7
found an incidence of 15% both clinically
and histologically, and showed that this was similar for both
foetus and adult eyes. They recognised that glaucoma oc-
curs in the presence of anomalies of the iris and angle, not
just isolated PE. Forsius et al
3
studied 498 subjects from an
isolated Finnish Island community and found an incidence
of 32%. Alkemade
4
looked at 200 patients and found that
although present in 12% of people, it afected only 8% of
eyes. He could not confrm an association with iris stromal
hypoplasia and found no diference in the rate of PE in a
group of 100 patients with glaucoma. A recent study of 440
randomly selected patients in Japan found that 24.3% of pa-
tients had PE, many with associated abnormalities and neu-
ral crest cell maldevelopment.
5
The relatively high number
of associated abnormalities may arise from the nature of the
patients being seen in a university hospital setting.
PE is seen with anterior segment abnormalities, which
are thought to result from developmental arrest of struc-
tures derived from neural crest cell origin late in gestation.
8,
9
This neurocristopathy may be a unifying concept for the
associated optic nerve anomalies & systemic disease seen in
conditions such as Alagille or AxenfeldReiger syndromes.
Molecular genetic studies reveal that a number of muta-
tions in genes controlling anterior segment development
will result in the formation of PE & other abnormalities.
10, 11

For eg, defects in PITX2 & FOXC1 are associated with Axen-
feldReiger syndrome & JAG1 with Alagille's syndrome.
2, 10, 11
AxenfeldReiger syndrome
AxenfeldReiger syndrome is an autosomal dominant con-
dition characterised by iris strands spanning the angle to
insert into the prominent Schwalbes line.
10
The PE while
often extensive in this condition may only be visible with
gonioscopy. It carries a 50% risk of glaucoma, usually of
early onset. All younger patients with PE should therefore
be examined with gonioscopy.
Alagille syndrome (AS)
Is an autosomal dominant disorder (OMIM 118450) asso-
ciated with abnormalities of the liver, heart, skeleton, eye,
and kidneys and a characteristic facial appearance.
1
In 1973,
Watson and Miller reported 9 cases of neonatal liver disease
with familial pulmonary valvular stenosis.
2
Then in 1975,
Alagille et al described several patients with hypoplasia of
the hepatic ducts with associated features.
3
Typical facial
features of Alagille syndrome are broad forehead, deep-
set eyes and pointed chin. Mild-to-moderate mental retar-
dation also may be present. Mutations in either jagged-1
(JAG1) or notch-2 (NOTCH2) have been reported in patients
Figure 1 Figure 2

Posterior Embryotoxon
with Alagille syndrome.
4, 5
Most children are evaluated when younger than 6
months for either neonatal jaundice (70%), or cardiac mur-
murs and symptoms (17%). Patients who are less afected,
such as family members, are often diagnosed after an index
case. Ocular abnormalities are common
9
. The most frequent
ophthalmologic fnding is a posterior embryotoxon, which
was observed in more than 75% of patients in one large se-
ries conducted by Emerick et al
10
.
Lab work up demonstrates fat-soluble vitamin defcien-
cies, Prolongation of prothrombin time (PT) or activated
partial thromboplastin time (aPTT), Hypercholesterolemia
(>200 mg/dL) and hypertriglyceridemia (500-2000 mg/dL),
raised Gamma-glutamyl transpeptidase (GGT) and alkaline
phosphatase levels, elevated Serum bile acids .Diagnostic
tests include-abdominal USG for abnormal hepatobiliary
tree pattern and hepatic and renal parenchyma. Chromo-
somal analysis for mutations within the JAG1 gene (20p12)
confrms diagnosis of Alagille syndrome
Isolated PE
Shields
9
showed no increased risk for glaucoma in the pres-
ence of isolated PE, but the association of other anterior
segment abnormalities with glaucoma is well recognised.
The extent of PE viewed externally does not predict the
presence of any underlying condition, and no link between
refractive error, astigmatism, and the position of PE has
been demonstrated . The presence of PE may be helpful
in putting together the features of Alagille syndrome syn-
drome, but it is not diagnostic and would not necessarily
prevent the need for more invasive investigations.
In one study the prevalence of PE in the general oph-
thalmic clinic was found to be 6.8%. No particular features of
PE suggest that it is pathological rather than physiological,
but the presence of other anterior segments abnormalities
is signifcant. The presence of PE should prompt careful an-
terior segment examination and gonioscopy. It is important
to identify any anterior segment syndromes, such as Axen-
feldReiger, that will require long-term follow-up because
of the risk of glaucoma. Children seen in the ophthalmic
clinic with PE should be carefully examined for evidence of
anterior segment dysgenesis, and any associated systemic
or genetic abnormalities. A family history should be sought
and because of the variability of expression an examination
of parents and siblings considered.
References
1. Waring GO, Rodrigues MM & Laibson PR. Anterior cham-
ber cleavage syndrome. Surv Ophthalmol 1975; 20: 327.
2. Azuma N & Yamada M. Missense mutation at the C termi-
nus of the PAX6 gene in ocular anterior segment anoma-
lies. Invest Ophthalmol Vis Sci 1998; 39: 828830.
3. Forsius H, Eriksson A & Fellman J. Embryotoxon corneae
posterius in an isolated population. Acta Ophthamol
1964; 42: 424
4. Alkemade P. Dysgenesis Mesodermalis of the Iris and the
Cornea Charles C Thomas: Assen, Netherlands 1969;.
5. Ozeki H, Shirai S, Majima A, Sano M & Ikeda K. Clinical
evaluation of posterior embryotoxon in one institution.
Jpn J Ophthalmol 1997; 41: 422425
6. Hingorani M, Nischal KK, Davies A, Bentley C, Vivian A &
Baker AJ et al.. Ocular abnormalities in Alagille syndrome.
Ophthalmology 1999; 106: 330337. |
7. Burian HM, Braley AE & Allen L. Visibility of the ring of
Schwalbe and the trabecular zone. Arch Ophthalmol
1955; 53 (6): 767782. Johnston MC, Noden DM & Hazel-
ton RD. Origins of avian ocular and periocular tissue. Exp
Eye Res 1979; 29: 2743.
8. Shields MB. AxenfeldRieger syndrome: theory of mech-
anism & distinctions from the iridocorneal endothelial
syndrome. Trans Am Ophthalmol Soc 1983; 81: 73678
9. Alward LWM. AxenfeldRieger syndrome in the age of
mol. genetics. Am J Ophthalmol 2000; 130: 107115.
10. Hanson IM, Fletcher JM, Jordan T, Brown A, Taylor D & Ad-
ams RJ et al.. Mutations at the PAX6 locus are found in
heterogeneous anterior segment malformations includ-
ing Peter's anomaly. Nat Genet 1994; 6: 168173.
11. Jones EA, Clement-Jones M & Wilson DI. JAGGED1 expres-
sion in human embryos: correlation with the Alagille syn-
drome phenotype. J Med Genet 2000; 37: 658662. l
Dr. Maneesh Shyamkul
M.S. (Ophthalmology), Fellow LVPEI is currently working as Consultant in
Pediatric Ophthalmology in the Al Salama group of Eye Hospitals Calicut &
Perinthalmanna
CASE KORNER
Ankyloblepharon Filiforme Adnatum
Dr. Maneesh Shyamkul, M.S. (Ophthalmology), Fellow LVPEI
A
nkyloblepharon Filiforme Adnatum is a rare con-
genital anomaly wherein the lid margins are con-
nected by fne bands of extensile tissue which
reduce the palpebral fssure by interfering with the move-
ments of the lids. ( Figure 1)
Ankyloblepharon fliforme adnatum can present as an
isolated fnding,, or as part of a well-defned syndrome . We
report a case of ankyloblepharon fliforme adnatum in a
newborn, with congenital anomalies.
Introduction
The developing eyelid margins remain fused until the ffth
month of gestation, but may not be completely separated
until the seventh month [1].anomalies occurring between
7 -15 weeks may give rise to eyelid anomalies. Anky-
loblepharon fliforme adnatum (AFA) is a rare benign con-
genital anomaly which is characterised by partial or com-
plete fusion of the lid margins. However, it can occur in an
autosomal dominant pattern associated with cleft lip and
palate.
Case presentation
Baby R., female, aged 25 days presented at the outpatient
section of Alsalama Eye Hospital ,Calicut Kerala on 16th
January 2012. This baby was unable to open her eyes as
both the lids were adherent on both sides since birth.
Baby 'R' is the frst child of the parents and is a full term
baby with normal delivery. The pregnancy was normal and
the mother denied having taken any drugs or being ex-
posed to X rays .
family history
Father aged 30yrs Years and mother 26 yrs are healthy and
without any congenital abnormality. There was no family
history of congenital anomalies or consanguinity.
Ophthalmic examination
Revealed multiple fne bands of elastic tissue connecting
the upper and lower lid margins (Figure 1,2,3,4). The elastic
adhesions were divided with a Wescott conjunctival scissors
without any bleeding. The posterior surfaces of the eye-
lids appeared normal, as were ocular movement, anterior
segment,retinoscopy and fundus examination. Neither se-
dation nor local anaesthetic
was necessary. The vestigial
remnants on the eyelid mar-
gins disappeared complete-
ly within 48 hours.
Histological
examination
The band was composed of
central vascular connective tissue surrounded by squamous
epithelium. The connective tissue was highly cellular. No
muscle fbers or signs of infammation could be found.
Discussion:
AFA was frst described by Josef von Hasner in 1881, and
is characterized by partial or complete adhesion of the cili-
ary edges of the upper and lower eyelids [2]. Usually, AFA
constitutes a solitary malformation of sporadic occurrence.
However, it can occur in an autosomal dominant pattern
associated with cleft lip and palate. In addition, it has been
reported in the context of trisomy 18 (Edwards syndrome),
Hay-Wells syndrome (a variant of the ectodactylyecto-
dermal dysplasia-cleft lip palate syndrome), the popliteal
pterygium syndrome (characterized by intercrural webbing
of the lower limbs), and CHANDS (curly hair-ankyloblepha-
ron-nail dysplasia). Other associations may include hydro-
cephalus, meningocoele, an imperforate anus, bilateral
syndactyly, infantile glaucoma and cardiac problems such
as patent ductus arteriosus and ventricular
septal defects [3].
Neuman and Shulman (1961) described a 3-day-old boy
with AFA who had in addition adhesions between the alve-
olar processes of both upper and lower jaws, a papilla and a
sinus on the left side of the lower lip, and a cleft palate(6). Bi-
lateral syndactyly of the fourth and ffth toes, partial adher-
ence of the left ear to the skin of the head, and a ventricular
septal defect of the membranous type with a patent ductus
arteriosus were associated abnormalities reported by Rog-
ers (1961) in a premature baby(7). A 'familial' tendency was
invoked by Howe and Harcourt (1974), who described the
condition in identical twins, and by Khanna (1957), who
reported the condition in sisters, one of whom had cleft
lip and palate(8). Hecht and Jarvinen (1967) described 2
Figure 1
Ankyloblepharon Filiforme Adnatum
families in whom a mother and
2 of her children were afected.
They noted wide variability of
expression of the syndrome and
postulated autosomal domi-
nant inheritance(9). Gorlin et al.
(1968) also suggested that the
syndrome was inherited as an
autosomal dominant trait with
incomplete penetrance and variable expressivity(10).
The aetiology of AFA is unknown, but failure of ap-
optosis at a critical stage in eyelid development has been
suggested [4]. Timely separation of the eyelids is crucial to
avoid the development of occlusion amblyopia.
Conclusion
A case of Ankyloblepharon Filiforme Adnatum associated
with cleft-lip and cleft palate which had no hereditary back-
ground is reported. The relevant literature is reviewed.
This case report also demonstrates the simplicity in treating
AFA; and highlights that its presence should alert the clini-
cian to the possibility of an underlying congenital disorder.
References
1. Sharkey D, Marlow N, Stokes J: Ankyloblepharon fli-
forme adnatum. J Pediatr 2008, 152:594.
2. Jain S, Atkinson AJ, Hopkisson B: Ankyloblepharon fli-
forme adnatum. Br J Ophthalmol 1997, 81:708.
3. Williams MA, White ST, McGinnity G: Ankyloblepharon
fliforme adnatum. Arch Dis Child 2007, 92:73-74.
4. Mohamed YH, Gong H, Amemiya T: Role of apoptosis
in eyelid development. Exp Eye Res 2003, 76:115-123.
5. Duke-Elder, S. (1964). System of Ophthalmology, vol. 3,
part 2, p. 869.
6. Neuman, Z., and Shulman, J. (1961). Congenital sinus-
es of the lower lip. Oral Surgery, 14, 1415-1420
7. Rogers, J. W. (1961). Ankyloblepharon fliforme adna-
tum.Archives of Ophthalmology, 65, 114-117. Sood, N.
N., Agarwal, T. P., and Ratnaraj, A. (1968).Ankyloblepha-
ron fliforme adnatum with cleft lip and palate. Journal
of Pediatric Ophthalmology, 5, 30-32
8. Khanna, V. N. (1957). Ankyloblepharon fliforme adna-
tum.American Journal of Ophthalmology, 43, 774-777.
9. Hecht, F., and Jarvinen, J. M. (1967). Heritable dysmor-
phic syndrome with normal intelligence. Journal of
Pediatrics, 70, 927-935.
10. Gorlin , R. J., Cervenka, J., and Pruzansky, S. (1971). Fa-
cial clefting and its syndromes. Birth Defects: Original
Article Series, 7, 15.
11. Howe, J., and Harcourt, B. (1974). Ankyloblepharon fli-
forme adnatum afecting identical twins. British Jour-
nal of Ophthalmology, 58, 630-632.
12. Judge, H. V., Mott, W. C., and Gabriels, J. A. C. (1929).
Ankyloblepharon fliforme adnatum. Archives of Oph-
thalmology,2, 702-708.
13. Kazarian, E. L., and Goldstein, P. (1977). Anky-
loblepharon fliforme adnatum with hydrocephalus,
meningomyelocele,and imperforate anus. American
Journal of Ophthalmology,84, 355-357.
14. Gorlin, R. J., Sedano, H. O., and Cervenka, J. (1968).Pop-
liteal pterygium syndrome. Pediatrics, 41, 503-509
15. Long, J. C., and Blandford, S. E. (1962). Ankyloblepha-
ron fliforme adnatum with cleft lip and palate. Ameri-
can Journal of Ophthalmology, 53, 126-129.
16. Ankyloblepharon fliforme congenitum associated
with harelip and cleft palate. Acta Ophthalmologica,
48, 465-467.
17. Escobar, V., and Weaver, D. (1978). Popliteal pterygium
syndrome: a phenotypic and genetic analysis. Journal
of Medical Genetics, 15, 35-42 l
Figure 2 Figure 3
Dr. Maneesh Shyamkul
M.S. (Ophthalmology), Fellow LVPEI is currently working as Consultant in Pediatric
Ophthalmology in the Al Salama group of Eye Hospitals Calicut & Perinthalmanna
Figure 4
KNOW THY INSTRUMENT
Optical Coherence Biometry: How Coherent is the Master?
Dr. K. Preetha, M.S. (Ophthalmology)
C
ataract surgery, in recent times, has undergone a
paradigmal shift entering into the realm of refrac-
tive surgeries with the emphasis now being on
achieving the desired refractive outcome in a consistent,
reproducible & accurate fashion. Sutureless incisions, state
of the art phacoemulsifcation systems, improved fuidics,
premium IOLs (with increasingly sophisticated IOL de-
signs, IOLs in 0.25-diopter steps, aspheric designs for pow-
ers as high as +40.0 diopters, and the limited correction of
higher-order aberrations) have ushered in a new era in cat-
aract extraction. However without an accurate IOL power
calculation, an appreciation of these advancements is lost.
visual outcome after surgery
The refractive outcome after cataract surgery is depend-
ent on several factors, including axial length, keratometry,
anterior chamber depth, IOL power calculation formula,
optimized lens constant, and confguration of the capsu-
lorhexis. The preoperative measurement of axial length
(AL) is considered to be the key determinant in calculating
the IOL power to be implanted with 54% of postoperative
refractive surprises being attributed to axial length errors
1
If keratometry is inaccurate by 0.50 diopters, then the
fnal refractive outcome will be inaccurate by that same
amount. If the capsulorhexis is made larger than the optic
of the IOL, an anterior shift in position may occur during
capsular bag contraction, resulting in more postoperative
myopia than anticipated. Optimization of IOL constants
and the IOL power calculation formulae are the other pa-
rameters that also infuence the refractive outcome. Errors
in axial length measurement by 0.1mm will cause 0.3 di-
opters of IOL power variation.
2
Biometry over the ages
The history of IOL power calculation began in 1949 when
Harold Ridley implanted the rst IOL in a blind eye. The
surgery was reported to be successful (the patient still
could not see) but the refractive error was found to be -18
DS/-6DC X 120.
3
Since those pioneering days, biometry
has evolved over time, from putting in a standard IOL of
fxed power to the precise calculation of IOL power in each
eye. A-mode contact ultrasound ocular biometry has been
considered the gold standard for decades for AL and ACD
measurement.
4, 5
Optical biometers are new entrants in the feld with
the laser partial coherence interferometry (PCI) based
IOLMaster (Carl Zeiss Meditec AG, Jena, Germany) being
introduced in 1999. More recently, a new biometry device,
the Lenstar LS 900 (Haag Streit AG, Bern, Switzerland) us-
ing low-coherence optical refectometry (LCOR) technol-
ogy was introduced in 2008. This article is a brief overview
of the IOL master recently acquired at Al Salama Calicut
ultrasound vs optical biometry
4
A-scan ultrasonography, with a longitudinal resolution of
approximately 200 m and an accuracy of approximately
100150 m, is routinely employed in the measurement of
the ocular Axial Length (AL). A special crystal embedded
in a probe oscillates to generate a high-frequency sound
wave that penetrates the eye. This results in a one-dimen-
sional time-amplitude representation of echoes received
along the beam path. The distance between the echo
spikes provides an indirect measurement of tissue such as
globe length or lens thickness (LT). The height of the spike
is indicative of the strength of the tissue sending back the
echo. There are two types of A-mode ultrasound biometry
available, including contact applanation biometry and im-
mersion biometry. Contact type biometry requires a probe
placed on the cornea and is prone to errors due to corneal
Figure 1 Figure 3
Optical Coherence Biometry
indentation and of-axis measurements besides carrying
the risk of transmitting infections. Immersion type biome-
try requires placing a saline flled scleral shell between the
probe and the eye. As no pressure is applied on the eye,
corneal indentation is prevented. Although diferences in
the AL between immersion and applanation ultrasonogra-
phy up to 0.36 mm have been reported, owing to pressure
exerted by the transducer during applanation ultrasonog-
raphy, the latter continues to be very commonly used.
6
Perhaps the greatest single step forward in biometry
measurement has been the switch from measuring dis-
tance using ultrasound to measuring using light. Optical
biometry uses a 780-m light wave that has eight to nine
times the resolution of a 10-MHz sound wave & measure-
ment accuracy is increased from 0.10 mm to between 0.02
mm and 0.01 mm, an improvement of approximately fve
times
Its precision of about 20 pm is unrivalled by the
US technique. The total accuracy is better (< 50 nm com-
pared to 120 to 200 nm) which is operator independent; it
is easy to use, less time consuming and very comfortable
for the patient. It is a noncontact technique that requires
no anesthesia and avoids the risk of corneal infection.
5

However, signifcant media opacities limit the use of
IOL Master. PCI has a signifcant failure rate, particularly
in the presence of dense cataracts, besides in certain ran-
domized controlled trials the calculation of IOL power
based on ocular AL measurement using PCI technology
provided no clinical advantage over conventional AUS, as
measured by postoperative refractive outcome
8
.
IOL Master the frst commercial version of Optical co-
herence biometry has been in clinical practice for over a
decade now
9, 10
. The IOL master 500 is the latest version of
the biometer launched in 2011 with better technical speci-
fcations .( Figure 1)
Principle
7, 11, 13
IOL Master employs the principle of Optical coherence
Biometry (OCB). It uses partially coherent infrared light
beams of 780 nm diode laser with coherence length of
130 micron
11
. Special feature incorporated is use of dual
beams. In interferometer eye needs to be absolutely sta-
ble so as not to disturb interference patterns. Use of dual
beams makes IOL Master insensitive to longitudinal move-
ments and measurements can be made with ease. Laser
light emitted is split up into two beams in a modifed
Michelson Interferometer. One mirror of interferometer is
fxed and other is moved at constant speed making one
beam out of phase with other. Both beams are projected
in the eye and get refected at cornea and retina. The light
Figure 2
refected from the cornea interferes with that refected by
the retina if the optical paths of both beams are equal. This
interference produces light and dark band patterns which
is detected by a photo detector. The signals are amplifed,
fltered and recorded as a function of the position of the
interferometer mirror. An optical encoder is used to con-
vert the measurements into axial length measurements .
(fgure 2) OCB measures the axial length from corneal apex
to retinal pigmentary epithelium while A scan measurers
up to vitro retinal interface only. IOL Master thus gives the
true refractive length rather than anatomical axial length.
Furthermore, it measures the corneal curvature, the
anterior chamber depth, and the corneal diameter and it
calculates the optimum IOL power by the acquired biom-
etry data, employing several IOL power calculation formu-
las built into its computer software.
Procedure
12,14,15,2
After entering patient data, overview mode (fgure 3)
is activated for coarse image alignment prior to taking
measurements. The patient is asked to look straight at
the small yellow fxation light and then the instrument-
to-patient distance is adjusted until the six light spots
(refex points on the patients pupil) appear to be in focus.
The small circle of lights and the cross hairs should be
approximately centered in the patients pupil.
In the IOL master 500 version a trafc light display changes
from red to yellow to green as the optimum measurement
position is reached. This optimum position is the starting
point for fne adjustments in the subsequent measurement
modes.
Axial Length Measurement Mode
Switching to ALM mode will automatically change the
LASER LIGHT
REFERENCE MIRROR
PHOTO
DETECTOR
AMPLIFIER
PCI
DISPLAY
AXL
ROTATING
MIRROR
R2
R
C
C2
C1
R1
BEAM
SPLIT
ER 2
BEAM
SPLIT
ER 1
KNOW THY INSTRUMENT
magnifcation ratio: a
smaller section of the eye
becomes visible with the
refection of the align-
ment light and a vertical
line. Patient is asked to
look directly at the small
red fxation light. On the
display a cross hair with
a circle in the middle
appears. The operator
adjusts the focus of the
video image to get the
refection of the light in the centre of the cross hair (Figure
4). This alignment causes axial length measurements to
be made to the centre of the macula, giving the refractive
axial length, rather than the anatomic axial length. Meas-
urements with and without glasses are exactly the same.
Measurements through contact lenses lead to measure-
ment errors. If patient is using contact lens its use should
be discontinued at least 24 hrs prior to measurements. In
high refractive error (more than 6.00 D), measurement is
to be taken with the patient's glasses in place to ensure
adequate fxation. For eyes with high to extreme myopia,
with a type 1 peripapillary posterior staphyloma, being
able to measure to the fovea is an enormous advantage
over conventional Ascan ultrasonography.
To measure aphakic eyes, pseudophakic eyes flled
with silicone oil, corresponding mode is selected from the
AL settings menu. The instrument will automatically be re-
set to the phakic mode by changing the side (moving to
other eye), or by measuring a new patient. In AL setting 9
diferent modes are available. (Figure 5)
Interpretation of Signal Curves
Axial lengths measurements are displayed in the form of
signal curves graphs. The Signal to Noise Ratio value is a
gauge of the quality of measurement. Ideal display of axial
length graphs termed as valid signal curves characteristi-
cally shows very good signal-to-noise ratio (SNR > 10). It
has narrow primary maxima with central terminal peak.
Secondary maxima are present symmetrically on either
side, separated by approximately 800 m from primary
peak. Tertiary and quaternary peaks are visible with low
and even base line (Figure 6,7). Clear signal has SNR >2.0.
Borderline SNR as displayed in graph (Figure 8) has SNR
value between 1.6 -2.0. Graph display is uneven with pri-
mary maxima having short peak and indistinct secondary
maxima. Such display is seen with moderate grade cata-
ract and should be interpreted with caution.
Invalid signal displays are seen with SNR value less
than 1.6 with indistinguishable primary maxima. Display
graph is irregular (Figure 9) with high variations in axial
length displayed. Also machine gives "error" message and
these results need to be discarded. Unsteady (non fxat-
ing) patient, strong ametropia and dense medial opacity
along the visual axis gives invalid signal display.
The IOLMaster 500 displays a single signal of the axial
length measurement in red and marked with an S on the
ordinate. The SNR (signal-noise ratio) is shown on the x-
axis. In contrast, the compos-
ite signal is shown in blue
and marked with a C on the
ordinate. The increased SNR
of the composite signal is
likewise shown on the x-axis.
The SNR ranges are displayed as a trafc light.
l Red = MeasuringError
l Yellow = Uncertain or Borderline Value
l Green = Value with Good SNR
Take at least FIVE individual measurements:The frst
Figure 6
Figure 4
Figure 5
four measurements are displayed as usual . From the ffth
measurement on, a composite signal is calculated in the
background. After which, for each individual measure-
ment, the axial length signal is displayed for about 1 sec-
ond (red), followed by the display of the composite sig-
nal (blue). If no axial length reading appears after the frst
fve individual measurements, additional measurements
should be taken. With stronger lens opacities; it may be
advisable to defocus the device.. Also try measurements
by height variation (turning the joystick) of the refocused
refection at the lower and/or upper edge of the circle on
the display. Defocusing and shifting the refection within
the circle will have no efect on the result, because inter-
ferometric axial length measurement is completely inde-
pendent of distance. Avoid measurements of eyes with
retinal detachment. In such cases, measuring errors can-
not be precluded
SnR Categories
While the system is internally calculating the axial length
from the interference signal, it automatically analyzes the
SNR.
Reasons for Low Snr:
l Dense medial opacity along the visual axis
l Restless patient
l Alignment of device to patient eye is not optimal
l Very high ametropia (> 6 D)
l Corneal scars
l Pathological changes in the retina.
RED SnR display --> read-
ing should not be used
This means that the true
measuring signal does not
stand out sufciently from
the noise. As a rule, the results
of such readings are not us-
able and should be rejected.
Keratometry
After activating Keratometry
mode, patient is asked to fo-
cus straight and blink several
times to get an even tear flm.
On video screen examiner
sees 6 peripheral points lo-
cated in the feld between the
two auxiliary circles (Figure
10). The instrument is aligned
so that the six peripheral
measuring points are sym-
metrical, within the circular
cross hairs and appear op-
timally focused.The central
point is usually not focused
and is not evaluated.W hen
the optimum measurement
position has been reached,
the trafc light will change
from red to yellow to green
(Figure 11). Five internal in-
dividual measurements are
taken for a single keratometer measurement within 0.5
seconds. If a measurement point is not correctly identi-
fed, a blue fashing dot will appear. In the printout this
will be marked by an x. These readings should not be used
and a new measurement should be taken as a precaution.
Keratometer measurements may be repeated as often as
desired; however, only the last three measurements will be
displayed.
The IOL Master requires THREE keratometer measure-
ments to be taken! Only then will a mean value be passed
on to the IOL calculation.The corneal curvature results
are displayed in mm or diopters along with respective
axial orientation and the astigmatic diference. If cornea
is completely spherical then only one radius or power is
displayed. Knowing the steeper axis helps in planning the
incision during surgery.
Figure 10
Green SnR display --> reading is valid (Fig. 7)
Yellow SnR display --> reading is uncertain
("Borderline SNR") (Fig. 8)
Figure 11
Fig. 9
KNOW THY INSTRUMENT
It needs to be remembered that IOL Master measures
central 2.5 mm diameter compared to manual keratom-
eter which measures central 3 mm zone. Since IOL Mas-
ter measures more centrally, keratometry readings show
steeper K value than manual keratometry. In pseudopha-
kic eyes multiple images appear due to refection from an-
terior surface of IOL leading to measurement errors. Tip in
such cases is to move the IOL Master approximately 1 mm
away (defocusing). Corneal image becomes slightly larger,
while the artifacts of the IOL become fainter. Measure-
ment is then possible.Presence of corneal scars, severe dry
eyes, epithelial defects and partially concealed refections
due to half open lids or ptosis leads to measurement er-
rors. The following plausibility tests will be made with the
keratometer reading:
l R > 8.4 mm 2 Possible fat corneal curvature,
keratoglobus
l R < 7.2 mm 2 Very steep corneal curvature
l R < 7.0 mm 2 Possible keratoconus
l |R1 - R2| > 0.5 mm 2 High astigmatism
Dual Measurement Mode
IOL Master 500 has a dual
mode where both axial length
& keratometry can be meas-
ured in a single measurement
step using twin technology.
The basic principles are same
as for individual measure-
ment. (fgure 12)
Anterior Chamber Depth Mode
Anterior chamber depth on
the IOL Master is interpreted
as the distance between the
anterior vertex of the cor-
nea and the anterior vertex
of the lens. Hence, the dis-
played distance includes
the thickness of the cornea.
On activating ACD measurement lateral slit illumination
will automatically be turned on. The fxation point is dis-
played in optimum focus in the rectangle on the screen
(Figure13). Throughout the examination the patient is di-
rected straight ahead on a small yellow fxation light. Five
internal individual measurements are taken for a single
anterior chamber depth measurement within 0.5 seconds,
Calculation of the anterior chamber depth requires the
input of the corneal radius. If a valid keratometer meas-
urement was performed prior to ACD measurement, the
system will automatically use the measured radius for the
calculation. ACDmeasurement values are required in IOL
power calculation formulae like Holladay 2, and Heigis.
The anterior chamber depth may only be measured on
phakic eyes! ACD measurements of pseudophakic eyes
result in measuring errors.
White-to-White Measurement (WTW)
IOL Master can give easy measurements of WTW distance.
As operator activates the function, a cross bar appears.
Trick is to focus on the iris rather than cornea. Align the IOL
Master so that the six peripheral light spots are symmetri-
cal to the cross hairs and the iris structures or the edge of
the pupil appears optimally focused (Figure 14). The fxa-
tion point in the centre of the six light dots is usually not
in the centre of the pupil or iris, because only in the rarest
cases does the visual axis correspond to the optical axis of
the eye. Measuring WTW distance is useful in calculation
of phakic IOL. The WTW value is the horizontal diameter
of the iris. In addition to the WTW value, the deviation of
the visual axis from the centre of the iris (x, y) will also be
displayed . The values are stated in millimetres with refer-
ence to a Cartesian coordinate system, the zero point of
which is assumed to be in the established centre of the iris
or pupil. If the visual axis is above the iris or pupil centre,
the Y value will be positive; if it is below, the value will be
negative. X values to the left of the centre are negative;
those to the right are positive.
IOL Power Calculation
Before the system calculates IOL options, you must have
entered the desired lens types into database. The IOL for-
mulas HoferQ, Holladay, Haggis, SRK/t and SRK 11 are
listed across the top.
After taking axial length and keratometry readings, IOL
Figure 14
Figure 13
Figure 12
power mode is activated. The values of mean axial length
and keratometry are passed on automatically. Operator
needs to select the surgeon to enable the activation of
IOL power calculation. Surgeon must have entered the
parameters of his preferred IOLs in database beforehand.
Soft ware then calculates IOL power for the diferent types
of lenses. Results for four diferent types of lenses are
displayed at a time (Figure 15). Up to 20 surgeons name
and correspondingly data of their preferred lenses can be
entered. Only constants optimised for optical biometry
should be used for calculating the suggested strength of
the intraocular lens to be implanted with the IOL Master,
not the manufacturers IOL constants
IOL powers are displayed in the steps of 0.5 diopters
or 0.25 diopters. Included in the standard IOL master soft
ware package are fve popular IOL power calculation for-
mulae, Haigis, Holladay, SRK II, SRK/T and Hofer Q. While
calculating IOL power surgeon can choose his preferred
formula from the task bar.IOL Master 500 has mode for
phakic IOL and post refractive surgery patients. After re-
fractive corneal surgery the Haigis-L or Prior refractive sur-
gery tabs may be selected.
Optimisation
Included in the IOL Master is the most important part that
is ability to optimise or fne tune the IOL power as per
the surgeons choice of IOL. It must be remembered that
A constants which are provided by the manufacturer are
based on contact A scan and manual keratometry. This val-
ue represents where we anticipate the IOL to sit in relation
to cornea. Specifcally how near or far from cornea. The
"constant" will decrease with ACIOL as compared to PCIOL.
As ACIOL sits closure to cornea, less power is needed. The
manufacturer estimates the A constant by approximating
from similar lens models. The fnal lens position in capsular
bag will be infuenced by IOL style (optic - haptic design,
fexibility, angulations, reaction to fbrosis) and surgical
technique (rhexis, incision, phaco technique). Therefore
A constant provided by manufacturer needs to be opti-
mised as per surgeon's technique.
Initially, surgeon can use optical lens constants avail-
able on the ULIB web page which gives lens constants for
diferent types of lenses as per data pooled in from world
wide IOL Master users. To derive his own optimized A con-
stant surgeon needs to select minimum of 20-25 cases.
All these cases should be operated by same surgeon with
same surgical technique using same type of lenses. Post
operative data and fnal post operative refraction at end
of 6 weeks are noted. This data needs to be entered in IOL
Master which then calculates the new optimised lens con-
stant for that type of lens for that particular surgeon
IOL MASTER in practice
IOL Master has become the most important tool now a
days available to refractive surgeons who aim for perfec-
tion in their every aspect of surgery. IOL Master gives the
most accurate and consistent IOL power for most choices
of IOL.
16
In individual practice studies, the new IOLMaster 500
has been shown to complete all measurements in as few
as 80 seconds
17
The average time needed to take a reading
on the IOLMaster 500 is up to 4 times faster compared to
other optical devices
18
OptiIical biometry along the visual
axis is highly accurate. High ametropia, pupil size as well
as state of accommodation do not afect the accuracy of
measurement.
Whereas the principal application of the device will be
in cataract surgery , the relatively high order of dioptric
resolution for axial length (~plus or minus 0.03 D) is espe-
cially valuable in studies of myopia the IOLMaster is likely
to fgure signifcantly in future myopia research
Limitations
4,13
IOL Master is not suitable in cases of:
l In dense cataract
l Restless patient with inability to fxate light
l Patient with nystagmus
l Retinal detachment
l Very high ametropia
l Thick posterior capsular plaque
l In severe dry eye or scarred cornea keratometry is not
possible
l Anterior chamber depth cant be measured in apha-
kic eyes.
l media opacities like vitreous hemorrhage
Figure 15

Know Thy Instrument
Other optical biometers
4,18
The new Lenstar LS 900 is LCOR (low-coherence optical
refectometry )-based & uses a 820 nm superluminescent
diode. Besides AL, it measures central corneal thickness
(CCT), as well as Lens Thickness. ACD measurements difer
between the IOLMaster and the Lenstar, as Lenstar meas-
ures ACD from the corneal endothelium to the anterior
lens surface while IOL Master measures ACD from corneal
epithelium to the anterior lens surface. The Lenstar also
measures crystalline LT and retinal thickness, as well as the
size and centricity of the pupil. K readings are calculated
by analyzing the anterior corneal curvature at 32 reference
points orientated in 2 circles at approximately the 2.30
mm and 1.65 mm optical zones.The LCOR-based device
measures more parameters than the PCI-based device,
including CCT, retinal thickness and pupil diameter. While
this is an advantage, measurements with the LCOR-based
device take twice as long as those with PCI-based device.
References
1. (Olsen T.: Sources of error in intraocular lens power cal-
culation. J Cataract Refract Surg 1992;18:1259)
2. Rakesh Maggon, D.P. Vats, J.K.S. Parihar: Optical Coher-
ence Biometry IOL Master: DOS Times 2006;12(1):51-54
3. Harold Ridley: Intra-ocular acrylic lenses:a recent de-
velopment in the surgery of cataract : Br J Ophthalmol
1952 36: 113-122
4. Afsun Sahin, Pedram Hamrah,: Clinically Relevant Bi-
ometry Curr Opin Ophthalmol. 2012 January; 23(1):
4753.
5. Hitzenberger CK, Drexler W, Dolezal C, et al. Meas-
urement of the axial length of cataract eyes by laser
Doppler interferometry. Invest Ophthalmol Vis Sci
1993;34:188693
6. Adam Watson, Mb ChB1, Robyn Armstrong : Contact or
immersion technique for axial length measurement?
:Australian and New Zealand Journal of Ophthalmol-
ogy: Vol 27, Issue 1, pages 4951, Feb 1999
7. Policy and Procedures Operations Manual for an oph-
thalmology practice
8. Simon Raymond, Ian Favilla and Linda Santamaria1:
Comparing Ultrasound Biometry with Partial Coher-
ence Interferometry for Intraocular Lens Power Calcu-
lations: A Randomized Study Investigative Ophthal-
mology & Visual Science, June 2009, Vol. 50, No. 6
9. Drexler W, Findl O, Menapace R, et al. Partial coherence
interferometry: a novel approach to biometry in cata-
ract surgery. Am J Ophthalmol 1998;126:524-34.
10. Kiss B, Findl O, Menapace R, et al. Refractive outcome
of cataract surgery using partial coherence interferom-
etry and ultrasound biometry: clinical feasibility study
of a commercial prototype II. J Cataract Refract Surg
2002;28:230-4.)
11. Fercher AF, Mengedoht K, Werner W. Eye length meas-
urement by interferometry with partially coherent
light. Opt Lett 1988;13:1868
12. IOL MASTER 500, advanced technology: user manual.
13. J Santodomingo- Rubido, E A H Mallen, B Gilmartin,
and J S Wolfsohn: .A new non-contact optical device
for ocular biometry. Br J Ophthalmol. 2002 April; 86(4):
458462.
14. www.doctor-hill.com
15. Prakashchand Agarwal, Chandrashekhar, G.N. Singh,
Namrata Sharma, Jeewan S. Titiyal: IOL Master: DOS
Times 2009;14(7):25-26
16. H Eleftheriadis. IOLMaster biometry: refractive results
of 100 consecutive cases. Br J Ophthalmol 2003 Au-
gust; 87(8): 960-3.
17. single-practice study conducted by Oliver Findl, MD,
Vienna Institute for Research in Ocular Surgery, Vienna,
Austria.
18. Chen YA, Hirnschall N, Findl O, Evaluation of 2 new opti-
cal biometry devices and comparison with the current
gold standard biometer, J Cataract Refract Surg. 2011
Mar;37(3):513-51
19. Maolong Tang,, Yan Li,, and David HuangAn Intraocular
Lens Power Calculation Formula Based on Optical Co-
herence Tomography: A Pilot Study :, : J Refract Surg.
2010 June; 26(6): 430437.
20. Thomas Olsen : Calculation of intraocular lens power: a
review: Acta Ophthalmologica Scandinavica :Volume
85, Issue 5, pages 472485, August 2007. l
Dr. K.Preetha, M.S. (Ophthalmology), is currently working as Consultant
in General Ophthalmology in the Al Salama Eye Hospital Calicut
EUREKA !
Dr. Shaji Hussain, FICO
How to use smart phones to get SLIT LAMP pictures:
All about Smart PHONE-o-graphy
I
know its an incredulous combination. But believe me,
the fusion of these disparate entities makes slit lamp
photography ridiculously simple & I believe simply
INNOVATIVE (Well, I dont know about you guys!!!).
Smart Phone-o-graphy: To Take high quality photo-
graphs with your smartphone (e.g., Samsung SII, I Phone).
Pre requisites
1. Have a mobile phone with at least 8 megapixels cam-
era.
2. Stabilize the camera with an adaptor (attachment be-
tween mobile & slit lamp).
3. Have an adequate light source.
Lighting: To prevent over exposure:
1. Use a dimmer light setting on the slit lamp or a DIF-
FUSER in the slit lamp.
2. Another easy solution for the SAMSUNG SII or iPhone
is to download a camera app (e.g., Procamera or Cam-
era ZOOM FX) that allows us to control the exposure.
Devices: Samsung SII / I PHOnE
Adapters
A slit lamp photo can be taken by placing the Smartphone
in line with the slit lamp ocular. But by using an adaptor
we can obtain higher quality photographs with precision.
Options available are:
1. Keeler Portable Slit Lamp I Phone 4 image adapter
2. Skylight.
3. EyePhotoDoc
4. SteadyPix
Keeler portable slit
lamp adapter costs
$ 3,250
What do you need? 3 things:
EUREKA !
A Similar adaptor metamorphosed by me from the top of Vatika: Suitable only for ZEISS Slit Lamp.
Now THATS MY INNOVATION
Some valuable tips:
1. Fill the Samsung SII screen with your image. Place the
camera in MACRO mode. Then tap the point of inter-
est for better image clarity.
2. Use a slit lamp magnifcation of 12xto get a good fo-
cus.
3. Use retro illumination for better images of ICL and
IOL
4. Difuser is always a savior in times of over exposure
5. Fundus can be seen clearly in video mode
Uses
1. In order to document in EMR
2. Easily compare the lesion during follow ups
3. To teach the residents by live demonstrations
4. Educate the patients regarding their ocular condition
(Cataract,ulcer,FB)
References:
http://eyewiki.aao.org/Smart-Phoneography:
HowtotakeslitlampphotographswithaniPhone
OR
Smart PHONE-o-graphy
To see examples of photographs
Dr. Shaji Hussain, FICO is currently working as consultant ophthalmologist at
Al Salama Eye Hospital Perinthalmanna
THE OPHTHALMIC PARAPHERNALIAS
Oculocardiac refex an overview
Dr. Muhammad Hasif M.K., MD (ANESTHESIA), DA
E
ver since the demonstration of oculocardiac refex
by Bernard Aschner and Guiseppe Dagnini in 1908,
this refex has been a nightmare for treating Oph-
thalmologists and Anesthesiologists. But clearly, the ach-
aryas and yogis from ancient India had a knowhow of the
oculo cardiac refex, as they used pressure on eyeball as
a method to calm the heart and stop the breathing (pra-
nayama).This inevitable refex during the ocular surgery is
usually initiated by traction on intraocular muscles, con-
junctiva, or the orbital structures and by direct pressure on
the globe. Moreover the refex may be elicited by ocular
trauma, by performance of retro bulbar block or by direct
pressure on tissue remaining in orbital apex after enuclea-
tion .Now it is identifed that this refex is a part of larger
oculo-medullary refex which includes oculo-emetic and
oculo-respiratory refexes.
Incidence
Reports on the alleged incidence of the oculo-cardiac re-
fex are remarkable in their striking variability. Berler et al
reported an incidence of 50%, but other sources quote
rates ranging from 16 to 82%. Commonly, those articles
disclosing a higher incidence included children in the
study population, and children tend to have more vagal
tone.
The Reflex
Traction on the extraocular muscles or pressures on the
globe are the usual triggers. Aferent arc is formed by f-
bres running in long and short ciliary nerves, via ciliary
ganglion, to the ophthalmic division of the trigeminal
nerve through the gasserian ganglion. The main sensory
nucleus is located in the foor of fourth ventricle. The af-
ferent pathway continues along the short internuncial fb-
ers in the reticular formation to connect with the eferent
pathway in the motor nucleus of the vagus nerve and to
respiratory and vomiting centres. Cardio inhibitory efer-
ent fbers arising from the motor nucleus of the vagus
nerve terminate on the myocardium. ( FIGURE)
Manifestations
Although the most common manifestation of the oculo
cardiac refex is sinus bradycardia, a wide spectrum of car-
diac dysrhythmias may occur, including junctional rhythm,
ectopic atrial rhythm, atrioventricular blockade, ventricu-
lar bigeminy, multifocal premature ventricular contrac-
tions, wandering pacemaker, idioventricular rhythm,
asystole and ventricular tachycardia. This refex may ap-
pear during either local or general anesthesia; however,
hypercarbia and hypoxemia are believed to augment the
1.trigeminal nucleus
2.reticular sytem fbres
3.vagal nucleus
lcn long ciliary nerve, scn short ciliary nerve, cg
ciliary ganglion, gg gasserian ganglion
Oculocardiac Refex
incidence and severity of the problem, as may inappropri-
ate anesthetic depth.
Prevention
Of course prevention is better than cure for oculo-cardiac
refex and a variety of maneuvers to abolish or obtund
the oculo-cardiac refex have been promulgated. None of
these methods has been consistently efective, safe, and
reliable. Inclusion of intramuscular anticholinergic drugs
such as atropine or glycopyrrolate in the usual premedi-
cation regimen for oculo-cardiac refex prophylaxis is inef-
fective.
Atropine given intravenously within 30 minutes of
surgery is believed to reduce incidence of the refex. How-
ever, reports difer concerning dosage and timing. Moreo-
ver, some anesthesiologists claim that prior intravenous
administration of atropine may yield more serious and re-
fractory cardiac dysrhythmias than the refex itself. Clearly,
atropine may be considered a potential myocardial irritant.
A variety of cardiac dysrhythmias and several conduction
abnormalities, including ventricular fbrillation, ventricular
tachycardia, and left bundle-branch block, have been at-
tributed to intravenous atropine.
Although administration of retrobulbar anesthesia may
provide some cardiac antidysrhythmic value by blocking
the aferent limb of the refex arc, such a regional tech-
nique is not devoid of potential complications, which in-
clude, but are not limited to, optic nerve damage, retro-
bulbar hemorrhage, and stimulation of the oculocardiac
refex arc by the retrobulbar block itself.
Topical local anesthetic application being used by
some surgeons and claimed to reduce incidence and It is
generally believed that the aforementioned prophylactic
measures, fraught with inherent hazards, are usually not
indicated in adults.
Management
If a cardiac dysrhythmia appears during ocular procedure
initially cease operative manipulation. Next, the patient's
anesthetic depth and ventilatory status are evaluated.
Commonly, heart rate and rhythm return to baseline with-
in 20 seconds after institution of these measures. Moreo-
ver, Moonie et al. noted that, with repeated manipulation,
bradycardia is less likely to recur, probably secondary to
fatigue of the refex arc at the level of the cardioinhibitory
center. However, if the initial cardiac dysrhythmia is espe-
cially serious or if the refex tenaciously recurs, atropine
should be administered intravenously, but only after the
surgeon stops ocular manipulation. Use of local anesthetic
instillation also found to be helpful in some studies
For pediatric strabismus surgery, however, some an-
esthesiologists administer intravenous atropine, 0.02 mg/
kg. Alternatively, glycopyrrolate, 0.01 mg/kg administered
intravenously, may be associated with less tachycardia
than atropine in this setting.
Oculomedullary reflex
Due to cross linking of respiratory centre and emetic cen-
tre to trigeminal nucleus in medulla by some internuncial
neurons, sometimes these centres are also stimulated
along with vagus during oculomedullary refex efecting
apnea, respiratory arrest, nausea and or emesis apart from
vagal efects on heart The incidence may go up to 5080%
in paediatric squint surgery. It can be moderated to some
extent by use of local anesthesia (to abolish the aferent
arc), avoiding hypercapnia (which appears to sensitize the
refex), and prophylactic antiemetics like ondansetrone,
metoclopramide or dexamethasone.
Reference
1. Millers Anesthesia 7th edition
2. Oxford Textbook of Anesthesiology
3. Wikipedia l
Dr. Muhammad Hasif M.K, M.D. (ANESTHESIA), D.A. is currently working
as Associate Professor in General Anesthesia at the Kozhikode Medical College
Hospital Calicut
The fact file
Ophthalmic Potpourri
In 1792, a priest in Germany
consulted a young doctor
about a buried corneal foreign
body hidden in a small, hard
mass that partly covered the
pupil. During removal of the
foreign body, the doctor in-
spected the corneal incision with a microscope to
confrm the suspected pres-
ence of the foreign body. This
may be the frst use of a micro-
scope in eye surgery.
REFERENCE: Wilhelm August
Gottlieb Manniske, MD (1769-
1835)Microscope Use Dur-
ing Removal of Buried Corneal
Body in 1792:J.Fraser Muirhead, :JAMA Ophthalmol.
2013;131(2):238-241.
Ophthalmology cases have the highest rate of incor-
rect procedures within the operating room, accord-
ing to a study in the Nov. 2009 issue of the Archives
of Surgery. The study found that 1.8 adverse events
were reported per 10,000, more so than any other
surgical specialty. This study reviewed 342 surgical
events involving the wrong side, patient, implant,
site, or procedure. When examining solely OR re-
ported adverse events, ophthalmology exhibited
the highest percentage of reports followed by ortho-
pedics, even though these 2 specialties did not have
the highest percentage of OR cases .Wrong-lens im-
plants constituted the highest percentage of surgi-
cal confusions in ophthalmologic cases.
REFERENCE: Julia Neily, RN, ; Peter D. Mills,; Noel El-
dridge; Edward J. Dunn et al: Incorrect Surgical Procedures
Within and Outside of the Operating Room : Arch Surg.
2009;144(11):1028-1034.
The Quagmire
16th January 2013: 15 years after a surgery, a woman
has been awarded compensation by the apex con-
sumer court which held the doctor & hospital negli-
gent for failng to ensure the patient did not move
while being given an anaesthesia injection in the eye
.The National Consumer Disputes Redressal Commis-
sion noted that the disturbance during administra-
tion of injection took place thrice indicating the
doctor had not anticipated human behavior in such a
situation. . The amicus curiae contended, the doctor
should have made sure the hands & head of the pa-
tient were held by his staf, when repeated attempts
were made to give the injection. The defence counsel
contended that at worst, it could be regarded as con-
tributory negligence for which he could not be held
liable for compensation .The commission upheld the
contention & directed the respondents to pay a com-
pensation of Rs 25000 with interest @ 6% p.a. from
the date of complaint till its actual payment.
REFERENCE: NCDRC NEW DELHI; REVISION PETITION NO.
2106 OF 2008 (From the order dated 08.02.2008 in Appeal
No. 367/2002 of Gujarat State Consumer Disputes Redressal
Commission) REVISION PETITION NO. 2112 OF 2008 (From
the order dated08.02.2008 in Appeal No. 837/2006of Gujarat
State Consumer Disputes Redressal Commission)
The Crystal Ball
The future Robot-assisted microsurgery?
The FDA has approved the
da Vinci Surgical System
which has become the
most commonly employed
robotic platform in human
surgery. Preliminary stud-
ies show good robot arm
responsiveness to human
controls for extra and in-
traocular surgical tasks.
Recent studies have better defned the range of mo-
tion required for robot-assisted ophthalmic surgery.
Tsirbas, A., C. Mango, et al reported the frst instance
of robotic ocular microsurgery in 2007 using the da
Vinci surgical robot in the porcine model. Their fnd-
ings support the use and establish a foundation for
further investigation of a surgical robot for ocular
surgery in controlled human trials.
REFERENCES: Pradeep Prasad, Allen Hu1 et al :Micro-
surgical Techniques in Ophthalmology Current Proce-
dures, Future Directions:: Chap 2: Advances in Ophthal
Edited by Dr Shimon Rumelt; intech; 2012 * Tsirbas, A.
. Mango et al. Robotic ocular surgery.BJO 2007; 91(1):
18-21
Blast from the Past
An Ophthalmic Potpourri

AIO Journal of Ophthalmology 51 51
Fun-Tastica

Ophtho - Crossword
CLuES
ACROSS
2 The manual aspiration cannula
(6)
7 causative agent of trachoma (9)
9 The recently discovered sixth
layer of cornea is named after
him (9,3)
10 Macular function test (6,4)
12 Valve of lacrimal system (6)
13 insertions of 4 recti form this
spiral(7)
15 bifocals were invented by this
english optician(6)
17 The steroid injected into
chalazia(13)
18 Lischs nodules are seen in (17)
19 Newest antifungal(12)
20 Direct gonioscope(6)
DOWN
1 During FFA , Fovea appears
avascular due to this pig-
ment(11)
3 The 193 nm LASER(7)
4 Measurement of axial length of
the eye(8)
5 The fungal agar(10,8)
6 Lucentis: the real name (11)
8 A decrease in the number of
lashes(9)
11 MRI contrast enhancer(10)
14 this drug induces bilateral acg,
uveal efusion & myopic shift(10)
16 Syndrome of lid coloboma,
limbal dermoid, mandibular hy-
poplasia & preauricular tags(9)
2
7 8
12
5 4
1
6
10
13
15
14
17
18
19
20
16
11
9
3
Fun-Tastica
l Our eye is equivalent to a 576 megapixel camera which can process 36,000 bits of information every hour, can
see 500 shades of grey & 2.7 million diferent colors.
l It's impossible to sneeze with your eyes open.
l The frst person who was blue eyed lived sometime before 6000-10000 years. Before then all people had
brown eyes.
l The largest eyeball on the planet is 18 inches wide, about the size of a large watermelon and it belongs to The
Giant Squid.
l They say in the blink of an eye because its the fastest muscle in the human body. A blink lasts 100-150 mil-
liseconds & it is possible to blink 5 times in a second
l Dolphins sleep with one eye open.
l Polarized sunglasses are great at reducing glare, but they can make it difcult to see the LCD on your cell
phone or an ATM screen..
l The entire length of eyelashes shed by a human in their life is more than 98 feet.
To suppose that the eye with all its inimitable contrivances for adjusting the focus to diferent distances, for ad-
mitting diferent amounts of light, and for the correction of spherical and chromatic aberration, could have been
formed by natural selection seems, I freely confess, absurd in the highest degree. Charles Darwin (Origin of Spe-
cies, CHAPTER VI DIFFICULTIES OF THE THEORY)
Amazing Eye
The Quotation Bang
Crossword - Answers
2
7 8
12 5 4
1
6
10
13
15
14
17
18
19
20
16
11
9
3
X
A
N
T
H
O
P
H
Y
L
L
R
A
N
I
B
I
Z
U
M
A
B
B
I
O
M
E
T
R
Y
T
O
P
I
R
A
M
A
T
G
A
D
D
L
I
N
I
U
M
G
O
L
D
E
N
H
A
R
E
X
C
I
M
E
R
M
A
D
A
R
O
S
I
S
S
A
B
O
U
R
A
U
D
S
D
E
X
T
R
O
S
T I L L U X
P I E R C
V O R I C O N A Z D L E
K O E P P E
N E U R O F I B R M T O S I S
R A M C I N D O E
M S L E R G I D
C H L A Y D A
A R M N D R
S I M C O
H A N E R
D A
Know Thy Instrument Ready Reckoner
Recent advances in Keratoconus Management
2 Corneal Collagen Cross linking (CXL / C3R)
Keratoconus is a progressive, non infammatory, ectatic disorder of cornea. It gets stabilized spontaneously by around 30
years of age. Crosslinking of collagen fbers increases their strength and makes them more resistant to enzymatic digestion.
UV-A light induces photopolymerisation reaction and ribofavin acts as photosensitiser. Even though, crosslinking is only
aimed to arrest the progression of keratoconus, in our experience we have noticed some amount of regression too. Cross
linking has revolutionized the management of keratoconus and decreased the necessity of corneal transplantation.
Indications
l Progressive Keratoconus
l CCT 400 or more
l Clear central cornea
l Iatrogenic keractectasia (post LASIK)
2 Rose K lenses
Rose K contact lenses are good tools which give a signifcant visual improvement in keratoconic patients. These lenses
ft better than RGP lenses and improve BCVA.
2 Intra Corneal Rings
Intra Corneal Ring segments stabilize the keratoconus. They also correct the refractive error to some extent.
2 ICL Phakic IOLs
In patients with central cones, ICL / TICL phakic IOLs can be tried after stabilization of Keratoconus. Eccentric cones needs
to be centralized by prior LASIK treatment with corneal wavefront guided profle. This will decrease higher order aberra-
tions and also irregular astigmatism to a reasonable extent and hence improves quality of vision.
2 Corneal transplantation (DALK / PK)
Keratoplasty is the ultimate answer in terminal stages of keratoconus.
Indications
l Very thin corneas. (CCT < 400 microns)
l Central corneal scarring
Contra Indications
l Corneal hydrops,
l Central corneal scarring
l No useful corrected visual acuity for their needs.
l CCT less than 400 microns.
Dr. Muhemmed Swadique, FRCS
Notes
Notes
Notes

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Know Thy Instrument

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