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EDITORIAL
5 HcrccnmcsthcmIdtcrm
FOCU5
11 InfcctInusKcratItIs
RETINA
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Parag K. Shah, Saurabh Arora, V. Narendran, N. Kalpana
29 EpIrctIna!Mcmbranc:AnOvcrvIcw
Ramesh KC Gupta, Kadri Venkatesh
37 Intcrna!LImItIngMcmbranc(ILM)Pcc!IngfnrMacu!arDIsnrdcrs
Tinku Bali Razdan
CATARACT
45 Intrancu!ar!cns(IOL)asa5caffn!dtnPrcvcntNuc!cusDrnp
Dhivya Ashok Kumar, Amar Agarwal
53 PcdIatrIcIOL-PnwcrCa!cu!atInnandMatcrIa!5c!cctInn
P.C. Dwivedi, Charudatt Chalisgaonkar, Syed Imran
GRANDROUND5
59 ExngcnnusEndnphtha!mItIs
Bhuvan Chanana, Vinod Kumar Aggarwal
CLINICALMEETING
65 C!InIca! Casc-1: VOGT KnyanagI Harada 5yndrnmc - A DIagnnstIc
DI!cmma
Niketa Rakheja, H. S. Sethi
COLUMN5
71 DO5TImcsQuIz
TEAR5HEET
79 DnscsnfImpnrtantDrugsInOphtha!mn!ngy(Part-2)
Yogesh Bhadange, Brijesh Takkar, Bhavin Shah, Rajesh Sinha
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DOS Mid-term 12th-13th November, 2011
at India Habitat Centre, New Delhi
www. cscn|inc.crgl 5
HcrccnmcsthcmIdtcrm
RespecledSeniors&friends,
Our hrsl lig evenl is upon us and ve shaII aII cone logelher in lhe genlIe
vinlers of Novenler al lhe India Halilal Cenlre in lhe hearl of Nev DeIhi.
Il is lhe line lo recharge our knovIedge ceIIs and inleracl vilh lhe lesl in
lhe lusiness. Ask queslions lhal have leen pIaguing us and discuss lopics
ve couId nol undersland. Afler aII lhey say lhal 2 ninds are leller lhal one and here ve viII gel nany hundreds.
The Mid lern conference pronises lo le a 2 day exlravaganza of scienlihc presenlalions, oulslanding laIks and
par exceIIence acadenic discussions. The scienlihc progranne is aIready in pIace and pronises lo aclivale your
neurons Iike never lefore. Nol lo forgel an evening of enlerlainnenl and IiveIy nusic.
WhiIe ve viII le lringing for you aII lhe expecled, sone nev lhings in slore for you are:
An enjoyalIe and fun hIIed quiz lo enlerlain and enIighlen
SpeciaIly Iive surgery: See lhe lesl in lhe heIds perforning Iive surgery in squinl, gIaucona, ocuIopIasly, cornea
and relina.
Increased nunler of haIIs
AII lhis and nore on 12lh and 13lh of Novenler. The nidlern conference of DOS is ligger and IiveIier lhan
nosl slale conferences and hopefuIIy viII gel ligger and leller every line. This line loo lhe execulive is Ieaving
no slones unlurned lo nake lhis evenl nenoralIe. We Iook forvard lo your aclive parlicipalion.
So pIease le lhere.
Wilh lesl vishes,
RnhIt5axcna
Sccrc|arq,
DeIhi OphlhaInoIogicaI Sociely
www. cscn|inc.crgl 7
www. cscn|inc.crgl 9
www. cscn|inc.crgl 11
Infectious keratitis remains an important cause of ocular morbidity in ophthalmic
practice. Diagnosis and management of infectious keratitis still remains a serious
dilemma for most ophthalmic physicians. Dr. M. Vanathi MD, Associate Professor
of Ophthalmology Cornea & Ocular Surface Services, Dr Rajendra Prasad Centre
for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi spoke to
several imminent Cornea Specialists in India and abroad regarding certain concerns in
infectious keratitis management. The panelists in this discussion on infectious keratitis
include Prof. Anita Panda, Dr. M.Srinivasan, Prof. John Dart, Dr. Samar Basak, Dr. Lim
Li and Dr. Bhaskar Srinivasan. Please read on, as the following compilation gives a
vivid peek into the practice patterns of these dynamic corneal physicians as they share
some of their experiences and practice pearls.
M.VanathI:WhatIsthctypcnfInfcctInuskcratItIsdnynucnmmnn!ycncnuntcrInynur
practIcc?
AnItaPanda: acleriaI keralilis, foIIoved ly nixed nicroliaI (lacleriaI and fungaI) is vhal
I connonIy see in ny praclice.
M.5rInIvasan: I gel lolh fungaI and lacleriaI keralilis in equaI nunlers. There is no seasonaI
varialion. Nocardia is aloul 6 lo 12 and Acanlhanoela 1. Had 2 cases of nicrosporidiun, of
vhich one vas liIaleraI.
JnhnDart: acleriaI keralilis 85, Acanlhanoela and Iungi in 15 and rareIy nycolacleria
and nicrosporidiaI keralilis.
5amarBasak: eing a lerliary care hospilaI, ve see pIenly of nicroliaI keralilis in day-lo-
day praclice in our cornea cIinic, approxinaleIy 9O-1O5 nev cases/nonlh. Anong lhese lhe
dislrilulion is as foIIovs:
- Purc|unga|Kcra|i|is. 61 and noslIy vilh AspergiIIus spp.
- Purc8ac|cria|Kcra|i|is. 22.
Prnfcssnr AnIta Panda, MD, ||CO, |AMS, MRCOpn is currenlIy Senior Irofessor of
OphlhaInoIogy, Cornea Services, Dr Rajendra Irasad Cenlre for OphlhaInic Sciences, AII
India Inslilule of OphlhaInic Sciences, Nev DeIhi, India & Vice Iresidenl of lhe AII India
OphlhaInoIogicaI Sociely of India.
Dr.M.5rInIvasan, MS, DO is currenlIy lhe Direclor - Lnerilus, Aravind Lye Care Syslen &
Ioslgraduale Inslilule, and Senior Cornea ConsuIlanl of Aravind Lye HospilaI, Madurai, India
PrnfcssnrJnhnK.G.Dart, MA DM IRCOphlh is currenlIy ConsuIlanl OphlhaInoIogisl (CorneaI
& LxlernaI Disease Service) and Depuly Direclor of Research al MoorheIds Lye HospilaI, Hon.
Irofessor, Universily CoIIege of London, UK and Chairnan of lhe Infeclion ConlroI Connillee,
London, UK.
Dr. 5amar K. Basak, M88S, MD (A||MS), DN8, |RCS is lhe Direclor & Senior ConsuIlanl
(Cornea and LxlernaI Lye Diseases) Disha Lye HospilaIs & Research Cenlre, arrackpore,
KoIkala, India, MedicaI Direclor, IROVA LYL ANK, arrackpore, Vice-Iresidenl, Lye ank
Associalion of India, and Ldilor of Iroceedings, AII India OphlhaInoIogicaI Sociely.
Dr. LIm LI, M88S, MMc(Opn|n), |RCS(|), |AMS(Spcrc), is a Senior ConsuIlanl
OphlhaInoIogisl in CorneaI and LxlernaI eye disease services of Singapore NalionaI Lye
Cenlre & Depuly Direclor of lhe Singapore Lye ank, Singapore.
Dr.Bhaskar5rInIvasan,MS,DN8is ConsuIlanl , C.}. Shah Cornea Services and C. SilaIakshni
CIinic for OcuIar Surface Disorders, Sankara NelhraIaya, Chennai, India
)RFXV
Professor Anita Panda
Dr. M. Srinivasan
Professor John KG Dart
Dr. Samar K. Basak
Dr. Lim Li
Dr. Bhaskar Srinivasan
12 l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
- Mixc8ac|cria|+|unga|Kcra|i|is. 11
- Acan|namcc|a|cra|i|is. O.5
- Miscc||anccusinfcc|icn. O.5
- Unc|crmincsuppura|itc|cra|i|is. 5
LIm LI: Conlacl Iens reIaled infeclive keralilis is
connonIy seen in ny praclice in Singapore.
Bhaskar 5rInIvasan: IungaI keralilis especiaIIy
hIanenlous fungi is lhe connonesl cause of infeclive
keralilis al our cenlre in Chennai.
Keratitis has a wide geographical variation with the
practice patterns being dominated by the region of practice,
socioeconomic status of the presenting population and
lifestyle patterns.
M. VanathI: What Is ynur prcfcrrcd apprnach tn a
cascnfInfcctInuskcratItIsprcscntIngtnynu?
AnItaPanda: When a case of corneaI uIcer cones lo us
hrsl ve ruIe oul lhe viraI keralilis vhich incIudes: alsence
of cIinicaI hndings vilh nornaI conjunclivaI sensalions
and nornaI corneaI sensalion in lhe cIear corneaI area. We
go ahead vilh corneaI scraping and specinens are senl
for direcl nicroscopic evaIualions, lacleriaI and fungaI
cuIlures irrespeclive of duralion size and exlenl of lhe
uIcers and prior lherapy received. If lhe uIcer is snaII,
ve slarl nonolherapy vilh anliliolics drops vilh olher
supporlive lherapy Iike cycIopIegic drops. If lhe uIcer is
exlensive or if il does nol respond lo lhe nonolherapy, ve
slarl conlinalion lherapy vilh forlihed cefazoIin 5 eye
drops 2 hourIy and forlihed lolranycin 1.3 eye drops 2
hourIy aIong vilh cycIopIegic eye drops 2 (honalropine
eye drops). When lhe nicrolioIogicaI reporls are avaiIalIe
lhe lherapy is adjusled accordingIy. If lhe uIcer cIinicaIIy
resenlIes fungaI and supporled ly direcl nicroscopy
hndings lhen ve add anli-fungaI drops. Ior hIanenlous
fungi Iike Iusariun species, nalanycin 5 eye drops are
prescriled. Ior Candida, and resislanl hIanenlous fungaI
infeclion such as AspergiIIus, Anpholericin eye drops
O.15 - O.3. Though TopicaI voriconazoIe is effeclive, ve
keep il reserve for non responsive fungaI uIcer as nosl of
our palienls cannol afford lhe drug due lo ils cosl. In non
responsive cases VoriconazoIe 1 eye drops 2 hourIy is
preferred. Sone nay require syslenic anlifungaI agenls.
Infacl appropriale iniliaI lherapy is nosl crilicaI
in lhe nanagenenl of severe corneaI uIcers. In such
eyes, aggressive lroad speclrun anliliolic coverage is
advocaled.
TopicaI adninislralion is lhe nosl efhcienl neans of
deIivering anliliolics lo lhe cornea. In addilion lo providing
lherapeulicaIIy effeclive concenlralion of lhe drug, lopicaI
drops vash avay lacleria, anligens, and polenliaIIy
deslruclive enzynes fron lhe ocuIar surface. Ienelralion
of lhe drug inlo lhe cornea is increased vilh higher
concenlralion of drug, grealer frequency of appIicalion,
nore IipophiIic anliliolics, and Ionger conlacl line. Sone
palienls nay respond lo lhe connerciaI slrenglh of lopicaI
anliliolics (e.g., ciprooxacin) given al frequenl inlervaIs,
lul forlihed anliliolics are nosl effeclive. IniliaIIy given
as a Ioading dose, nore drug is deIivered lo lhe cornea.
Iorlihed anliliolics are given every 15 lo 3O ninules
(aIlernaling vhen nuIlipIe anliliolics are used) for lhe hrsl
24 lo 36 hours. The conlinalion of forlihed cefazoIin 5
and lolranycin 1.3 is effeclive againsl nosl lacleria.
Il is preferalIe lo vilhhoId anlifungaI lherapy, unliI
lhere is Ialoralory conhrnalion lhal lhe infeclion is fungaI,
especiaIIy in viev of polenliaI loxicily of anlifungaI drugs,
and lecause fungaI keralilis does nol progress as fasl as
lacleriaI. Nalanycin as a 5 percenl suspension is lhe drug
of choice vhen hyphaI eIenenls are seen in lhe corneaI
snear, al 1 hourIy frequency. Anpholericin (O.15) is
lhe drug of choice for yeasl or pseudohyphaI keralilis and
is a good second agenl for hIanenlary fungaI keralilis.
TopicaI uconazoIe drop is indicaled for candida infeclion.
TopicaI Nalanycin or anpholericin al 1 hourIy inlervaI
for lhe hrsl 48 hours is reconnended. A Ioading pallern
for anpholericin nay le considered. CeneraIIy fungaI
keralilis inproves sIovIy, and for lhal reason proIonged
lherapy shouId le advocaled. OraI uconazoIe, a valer
soIulIe lriazoIe is veII loIeraled, preferenliaIIy laken
up ly cornea, has lroad speclrun and exceIIenl ocuIar
pharnacokinelic prohIe for vhich il nay le vaIualIe in lhe
lrealnenl of fungaI keralilis caused ly a variely of fungi.
Decision lo change lherapy is lased on:-
a) CIinicaI response and loIerance lo iniliaI lherapy
l) Severily of lhe keralilis
c) Anlicipaled or reporled in vilro suscepliliIilies
Sul conjunclivaI anliliolics are nol indicaled in presenl
era due lo olvious side effecls.
In suspecled Acanlhanoela keralilis, nicroliaI
invesligalions are very essenliaI so aIso for specihc keralilis
Iike Nocardia, MycolacleriaI infeclions and lrealed
accordingIy. If lhe corneaI sensalions are alsenl ve slarl
anliviraI agenls AcycIovir 3 oinlnenl 5 lines a day. If
Herpes Zosler skin Iesions or uveilic signs are presenl, oraI
anliviraIs (AcycIovir 8OO ng 5 lines a day) is slarled.
M. 5rInIvasan: I aIvays do Cran slain and KOH
snear on aII cases presenling lo ne irrespeclive of size
of lhe uIcer. RuIe oul dialeles and IacrinaI sac infeclion.
IniliaI snear viII heIp lo slarl specihc lherapy. I do cuIlure
as a rouline.
Jnhn Dart: eing a leaching cenlre nosl cases have
snears, are cuIlured, and in vivo confocaI nicroscopy is
readiIy avaiIalIe for lhose vilh cIinicaI signs suggeslive
of fungaI or Acanlhanoela keralilis. Therapy is slarled
depending on lhe resuIls of snears and confocaI
nicroscopy, and depending on evaIualion of risk faclors for
infeclion such as conlacl Iens vear, and pre-exisling ocuIar
surface disease. We see 1-2 nev Acanlhanoela keralilis or
fungaI keralilis cases per nonlh, oflen in conlacl Iens users
in vhon lhe index of suspicion for lhese causes is high.
SiniIarIy in palienls vilh ocuIar surface disease candida
keralilis is reIaliveIy connon.
Hovever lecause of lhe preponderance of lacleriaI
keralilis in our popuIalion ve slarl nosl cases on inlensive
(hourIy) Ievooxacin 5 drops vhich are conlinued hourIy
for 5 days. There is nininaI resislance lo quinoIones in
lhe UK, and resislance lo nonolherapy vilh a quinoIone
such as Ievooxacin is onIy aloul 2, vhich is siniIar
lo resislance lo duaI lherapy vilh genlanicin 1.5 and
cefuroxine 5 (lhe nosl videIy used duaI lherapy
conlinalion in lhe UK). I do nol advocale lhe use of sleroids
in cases vilhin 5 days of lhe slarl of lherapy and lhen onIy
for a posilive indicalion such as severe inannalion, of
faiIure lo epilheIiaIize, in palienls in vhon lhe diagnosis
of lhe causalive organisn is reasonalIy cerlain. Regarding
www. cscn|inc.crgl 13
lhe earIy use of lopicaI sleroid, one recenl randonized
conlroIIed lriaI has shovn no effecl, and lhe resuIls of
anolher fron Aravind are availed
Ior fungaI keralilis ve use LconazoIe 1 hourIy iniliaIIy
for 5 days, as our hrsl Iine agenl for hIanenlary fungaI
infeclion, and add oraI IlraconazoIe (cheaper) VoriconazoIe
(nore expensive) for hIanenlary fungaI keralilis (or if lhe
lype of fungus is uncerlain) and oraI IIuconazoIe for candida
keralilis, in palienls vilh deep or peripheraI disease. Ior
Candida aIlicans ve use Anpholericin O.15 hourIy
iniliaIIy for 5 days. As second Iine agenls for unresponsive
cases ve use lopicaI VoriconazoIe 1 hourIy vilh or vilhoul
lopicaI Anpholericin O.15. We use lopicaI chIorhexidine
O.2 as a lhird Iine agenl. The iniliaI frequency is hourIy
for 5 days or Ionger and lrealnenl frequency is reduced
lo 4-6x daiIy over 2 veeks and conlinued for 3-4 nonlhs
for hIanenlary fungaI infeclion and 1-2 nonlhs for candida
keralilis. In progressive cases ve have used inlraslronaI
and/or inlracaneraI voriconazoIe 5O-1OO ncg/O.1nI. We
rareIy use lopicaI sleroids in hIanenlary fungaI keralilis
(Iess reIuclanlIy in candida keralilis). In lranspIanled eyes
ve use lopicaI cicIosporin.
Ior Acanlhanoela keralilis ve use IHM O.O2
conlined vilh Hexanidine O.1 as hrsl Iine lherapy,
and chIorhexidine O.O2 and propanidine O.1 as
second Iine lherapy. Ior palienls vilh persislenlIy cuIlure
posilive Acanlhanoela keralilis ve use IHM O.O6 or
ChIorhexidine O.2, and oraI VoriconazoIe vilh lopicaI
VoriconazoIe 1. This lrealnenl is conlinued unliI lhe
corneaI inannalion has resoIved and leen unchanged,
vilhoul lhe use of lopicaI sleroids, for a nonlh.
Ior nycolacleriaI keralilis ve use lopicaI anikacin
2.5 and Ievooxacin 5 hourIy iniliaIIy as hrsl Iine
agenls and, in cIinicaIIy resislanl cases, ve add lopicaI
cIarilhronycin 1 and noxioxacin (has lo le inporled
speciaIIy) lo anikacin. We use oraI cIarilhronycin in severe
cases.
Ior slronaI nicrosporidiaI keralilis ve have IunadiI
O.3 avaiIalIe vilh oraI AIlendazoIe lul lhe success rale
has leen Iov.
5amarBasak: A detailed history:
- Ris| fac|crs. Ioreign lody/ injury vilh vegelalIe
naleriaIs/CL use/ use of lopicaI sleroids
- Usc cf Tcpica| mcica|icns. anlilacleriaIs/
anlifungaIs/anliviraIs/olhers
- ConpIiance lo lhe lopicaI reginens previousIy
prescriled
A good clinical examination:
- VisuaI Acuily
- S|a|us cf cqc|is. for lrichaisis/enlrpion,
IagophlhaInos
- Sac exaninalion for chronic dacryocyslilis
Slit lamp examination:
- Area invoIved
- Size and deplh of Iesion
- Size of epilheIiaI defecl
- Degree of slronaI edena
- ScIeraI invoIvenenl
- CorneaI lhinning
- Inpending/frank perforalion
- AC reaclion/ Hypopyon
- Lxanine for specihc fealures of fungaI
keralilis (dry Iooking inhIlrales, fealhery
nargins, saleIIile Iesions, innune rings, hxed
hypopyon, pignenlalion vilh sone fungi),
CorneaI sensalion
Documentation: Diagrannalic represenlalion and/or
CIinicaI pholograph: This is lo expIain lhe severily of lhe
infeclion and prognosis lo lhe palienl as veII as for foIIov
up assessnenl.
LIm LI: This depends on lhe cIinicaI hndings. If lhe
infeclive keralilis Iooks Iike pseudononas keralilis vhich is
nosl connonIy seen reIaled lo conlacl Iens vearers and is
nore lhan 1 nn in dianeler, I Iike lo do a corneaI scraping
for cuIlure and sensilivily and slarl lhen enpiricaIIy on
forlihed lopicaI lroad speclrun anliliolics. When lhe
cuIlure and sensilivily resuIls are knovn, lhe lrealnenl
viII le nodihed accordingIy.
Bhaskar 5rInIvasan: AII cases vouId undergo a
corneaI scraping for Crans slaining and KOH nounl and
specinen vouId le senl for lacleriaI and fungaI cuIlure.
ased on cIinicaI appearance and hislory if any olher
specihc invesligalion is required il vouId le ordered for. In
cases of lacleriaI keralilis I vouId slarl vilh a 4lh generalion
uoroquinoIone aIong vilh forlihed cephaIosporin or
aninogIycoside lased on lhe nicrolioIogicaI reporl. ased
on cIinicaI inprovenenl/ nicrolioIogicaI sensilivily reporl
vouId decide on changing lhe anliliolics. In case of fungaI
keralilis I vouId slarl lhe palienl on lopicaI nalanycin and
vouId add voriconazoIe or anpholericin lopicaIIy or
inlracaneraI in case of a deep slronaI or endolheIiaI Iesion.
Thorough history, meticulous clinical examination to
form a presumptive etiological clinical diagnosis, corneal
scraping for smear and culture sensitivity, appropriate
antimicrobial therapy with close follow-up remain the
mainstay in the diagnosis and management of infectious
keratitis.
M. VanathI: What dn ynu advncatc abnut rn!c nf
cnrnca!scrapIngasadIagnnstIcandthcrapcutIcapprnach
InInfcctInuskcratItIsmanagcmcnt?
AnIta Panda: As a diagnoslic looI, corneaI scrapings
heIp lo diagnose lhe specihc agenl and ils sensilivily lo
parlicuIar anlinicroliaI agenls, so lhal ve can svilch over lo
lhe accurale lrealnenl reginen. As a lherapeulic approach
il renoves lhe necrolic or inannalory sulslance lhal
heIps for leller alsorplion of lhe anlinicroliaI agenls and
il aIso reduces lhe Ioad of lhe infecling organisn. As lhe
cIinicaI hndings are cIassicaI in viraI keralilis I personaIIy
do nol prefer scraping in such eyes. Iurlher, if lhe uIcer is
very snaII (< 2 nn) one can avoid scraping.
M. 5rInIvasan: CorneaI scraping is nandalory in
nanaging infeclious keralilis in India lo legin specihc
lherapy. In a sludy conducled ly ne lherapeulic scraping
increases lhe chance of perforalion
1
. I donl do lherapeulic
scraping.
14 l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
Jnhn Dart: CorneaI scraping is done vhere possilIe
and praclicaI. We use il al MoorheIds Lye HospilaI, for aII
signihcanl cases of keralilis lul nol for snaII inhIlrales as
are oflen seen in conlacl Iens users.
5amarBasak: Yes, I slrongIy advocale corneaI scraping
in aII lhe cases of nicroliaI keralilis, Ior lhree lasic reasons:
1. To prepare snears for KOH vel nounl preparalion
and Cran slaining
2. Il decreases nicroliaI Ioads fron lhe corneaI
surface
3. Il heIps in penelralion of lhe lopicaI anlinicroliaI
agenls
One shouId al Ieasl aIvays go for KOH vel nounl
preparalion lo delecl fungaI hyphae. Lxperienced
ophlhaInoIogisl can aIso diagnose Candida,
Acanlhanoela, Nocardia or even Microsporidia in KOH
preparalion. Il does nol expensive, and is very sinpIe and
quick.
Procedure for scraping
- Scraping shouId le done under sIil Ianp
visuaIizalion / or aided ly linocuIar Ioupe
- InsliII 1-2 drops of lopicaI anaeslhelic agenl. Wail
for 3 ninules.
- Keep 2 cIean gIass sIides having 1cn circIe vilh
gIass penciI on reverse side of sIide.
- Scrape lase and edges of corneaI uIcer vilh a
sleriIe No. # 15 I lIade.
- Slreak over gIass sIide vilhin circIe: for KOH
nounl and Cran slain.
- AppIy KOH, cover vilh cover sIip.
- Lxanine under Iighl nicroscope.
The corneaI scrapings and reIaled naleriaI- Iike Conlacl
Iens (CL), CL case and CL soIulion shouId le suljecled lo
cuIlure if faciIilies are avaiIalIe.
CuIlure shouId le done in aII cases of nicroliaI
keralilis if lhe faciIilies are avaiIalIe. Direcl cuIlure in
specihc cuIlure pIale nediun is reconnended. Sensilivily
pallern is lo le delernined for lacleriaI keralilis.
LIm LI: CorneaI scraping is an inporlanl looI in
lhe diagnosis of infeclive keralilis. The scrapes shouId
le direclIy inocuIaled on lhe cuIlure nedia lo enhance
lhe cuIlure posilive rale. Il can aIso le perforned for
lherapeulic purposes and lo enhance drug penelralion.
Bhaskar 5rInIvasan: I roulineIy use il as a diagnoslic
looI excepl in very snaII peripheraI uIcers or uIcers on
lrealnenl vhich on presenlalion aIready shov signs of
scarring. As a lherapeulic looI I use il in cases of fungaI
keralilis especiaIIy lhose associaled vilh pIaque Iike Iesion.
Diagnostic corneal scraping is a must is most ulcers
larger than 2mm in size at presentation and before initiation
RI DQWLPLFURELDO WKHUDS\ 6PDOOHU LQOWUDWHV HVSHFLDOO\
in cases of CLIK may be closely monitored. Therapeutic
corneal scraping depends on the clinical presentation at
each follow-up and best practiced in expert hands as it
stands a risk of perforation and increased scarring in the
healing response.
M. VanathI: Ynur pcrspcctIvc nn rcccnt/changIng
trcndsInInfcctInuskcratItIsmanagcmcnt..
AnItaPanda: Wilh respecl lo invesligalive nodaIilies,
poIynerase chain reaclion (ICR) is lhe never enlily lhal
gives quick resuIls even vilh a ninule quanlily of lhe
sanpIe. ul il cannol differenliale lhe aclive or Ialenl
infeclion, vialIe or nonvialIe, and il cannol perforn drug
sensilivily. And cosl is aIso anolher faclor lhal Iinils ils
use.
Regarding lacleriaI keralilis, corneaI crossIinking
seens lo le effeclive, and can le lried as an adjuncl lo
anlilacleriaI agenls for quick recovery
4
.
Anong anlifungaI agenls voriconazoIe 1 eye drops
and oraI voriconazoIe adninislralion is very effeclive lul
is expensive.
A few words about surgical therapy:-
a) Repealed delridenenl is vaIualIe in nanagenenl
of corneaI uIcer. Il heIps ly reducing lhe organisn
Ioad & enhancing drug penelralion.
l) CyanoacryIale gIue, and nore recenlIy hlrin gIue,
is usefuI for repair in progressive corneaI necrosis,
desceneloceIes, and perforaled corneaI uIcers
vilh perforalion size Iess lhan 2nn. esides
acling as a lanponade, lhe gIue has an addilionaI
anlilacleriaI effecl.
c) ConjunclivaI ap
d) Tarsorrhaphy- Il enhances heaIing ly reducing
nechanicaI friclion of uIcer lo lhe Iid.
e) Ialch grafl nay le considered for snaII perforalion
as a leclonic supporl vhich couId nol le nanaged
ly gIue.
f) MuIliIayered anniolic nenlrane lranspIanlalion
(MLAMT) is considered for non heaIing corneaI
uIcers.
g) Therapeulic penelraling keralopIasly is allenpled
eilher afler faiIure of aII nelhods or if one can judge
cIinicaIIy lhe possiliIily of non inprovenenl.
The Objectives are:-
1. To eIininale infeclion
2. To reslore lhe inlegrily of cornea
3. To preserve/reslore vision
However, the following should be known prior to
surgery:
1. ResponsilIe organisn (polenliaI of nedicaI
response and risk of endophlhaInilis)
2. Irevious slalus of lhe cornea (e.g. herpes sinpIex
viraI keralilis)
3. The severily of lhe slronaI inannalion and/
or perforalion (Iocalion and size of lhe required
penelraling grafl)
4. Slalus of lhe inlraocuIar slruclures
Measures to be taken prior to surgery:-
1. Try lo sleriIize lhe cornea uIcer and reduce
inannalion lo nininun
2. Use of scIeraI supporl ring is essenliaI
www. cscn|inc.crgl 15
3. Refornalion of anlerior chanler vilh viscoeIaslic
lefore lrephinalion lhrough a side porl.
4. Ire & Iosl operalive syslenic sleroid can le given
judiciousIy.
5. Iosl operalive anli gIaucona lherapy is varranled.
Therapeulic scIerokeralopIasly is advocaled if lhere
is invoIvenenl of lolaI cornea vilh or vilhoul scIeraI
invoIvenenl.
M. 5rInIvasan: Lven loday lhe elioIogicaI agenls are
sane and incidence aIso sane. I do nol see any change in
nedicaI nanagenenl. Iev reconnend ITK, C3R, and
IaneIIar grafls.
Jnhn Dart: The liggesl change for us has leen lhe
inlegralion of confocaI nicroscopy inlo lhe diagnosis
of cases of presuned Acanlhanoela, fungaI and
nicrosporidiaI keralilis. We aIvays conline lhis
invesligalion vilh cuIlure, and inlerprel lhe hndings vilh
caulion. Having said lhis, ils ready avaiIaliIily has leen a
sulslanliaI advance in lhe nanagenenl here.
5amar Basak: In India, lhere is a vide varialion of
causalive organisns vilh differenl regions and geographicaI
area. So for enpiricaI lrealnenl: a lhorough knovIedge
regarding geographicaI dislrilulion of causalive organisn
is inporlanl.
|n mq cpinicn. lhe lrealnenl shouId le considered
depending upon lhe silualion al lhree differenl IeveIs:
- |n primarq |ctc|. Iike soIo ophlhaInoIogisl: OnIy
lroad speclrun anliliolic and cycIopIegics and lo
refer lhe palienl vilhin 24 hours.
- |nscccnarq|ctc|.Iike snaII hospilaI: A KOH vel
nounl preparalion and lreal as fungaI or lacleriaI.
Wail for 7 days lo see lhe response and lhen refer
if necessary lo lerliary IeveI.
- |n |cr|iarq |ctc|. in cornea deparlnenl: Invesligale
and lreal lhe palienl liII il is resoIved
LImLI: Due lo lhe videspread and oflen indiscrininale
use of anliliolics, nore anliliolic resislanl slrains of
lacleria is encounlered. Of parlicuIar concern is genlanicin
resislanl Iseudononas aeruginosa. OphlhaInoIogisls
are prescriling uoroquinoIones nore oflen nov due
lo anliliolic resislance lo hrsl Iine anliliolics such as
genlanicin.
Bhaskar5rInIvasan: eller nicrolioIogicaI supporl in
lhe forn of ICR is heIping us idenlify lhe causalive agenl
nore accuraleIy. Advances in anliliolics and anlifungaIs
especiaIIy lhe inlroduclion of voriconazoIe has heIped us
nanage fungaI keralilis leller.
Improved diagnostics with the advent of PCR and
confocal microscopy, availability of fourth generation
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intrastromal antifungals, amniotic membrane grafting and
corneal crosslinking therapy in infectious keratitis form
the most salient features in the changing perspectives of
infectious keratitis.
M. VanathI: Whcn dn ynu advncatc systcmIc
antIbIntIcs/antIfunga!thcrapyInInfcctInuskcratItIs?
AnIta Panda: When lhe uIcer is progressive even
vilh reguIar anliliolic/anlifungaI reginen ve adninisler
syslenic anlilacleriaI or anlifungaI.
Sqs|cmican|i|ic|icsarcinica|cin.-
- Neisseria gonorrhea keralilis,
- In young chiIdren,
- In liIaleraI uIcers, vilh scIeraI suppuralion,
- In perforaled uIcers,
- Severe keralilis vilh polenliaI for inlraocuIar
spread,
- In associalion vilh perforaling injuries lo lhe
cornea and scIera,
- In silualions vhere ideaI IocaI reginen cannol le
given due lo poor conpIiance.
M. 5rInIvasan: I reconnend syslenic drugs vhen
lhe corneaI uIcer invoIves lhe Iinlus, perforalion occurs,
suspecling endophlhaInilis and syslenic anlifungaIs in
one eyed palienls nol responding lo lopicaI anlifungaI
lherapy.
JnhnDart: I prescrile syslenic anliliolics for lacleriaI
keralilis vhen lhere has leen a corneaI perforalion and in
severe fungaI, Acanlhanoela and nycolacleriaI keralilis.
5amarBasak:
- Inpending / Irank perforalion
- Severe deep keralilis / TolaI or SullolaI uIcers
- Iosl perforaling injury / Iosl KeralopIasly
infeclion
- ScIeraI invoIvenenl / TunneI alscess
- If associaled vilh endophlhaInilis
- If lhe cuIlures reveaI lacleriaI agenls Iike Neisseria,
HaenophiIus spp
- One eyed vilh deep keralilis
LIm LI: Syslenic anlifungaIs are indicaled vhen lhe
fungaI keralilis is severe and nol responding lo lopicaI
nedicalion, infeclions lhal have penelraled lhe cornea inlo
lhe anlerior segnenl or causing endophlhaInilis, infeclions
lhal have spread lo and leyond lhe Iinlus.
Bhaskar 5rInIvasan: syslenic anliliolics are very
rareIy prescriled ly ne excepl in lhe scenario of an
endophlhaInilis. I prescrile syslenic anlifungaIs in cases
of very Iarge fungaI uIcers especiaIIy near lhe Iinlus or
invoIving lhe scIera and in cases of fungaI endophlhaInilis.
The consensus on the use of systemic antimicrobial
therapy is in cases with severe ulceration, anterior chamber
involvement, impending or frank perforation, pediatric and
one eyed patients, postoperative cases, refractory ulcers
and associated endophthalmitis.
M. VanathI: What arc ynur vIcws nn cnmbInatInn
vcrsusmnnnthcrapyInbactcrIa!kcratItIs?
AnIta Panda: Monolherapy has lo le inilialed hrsl,
lo decrease epilheIiaI loxicily as conlinalion of drugs
nay induce epilheIiaI loxicily vhich nay aggravale lhe
preexisling condilion.
Al any inslance nonolherapy shouId le kepl in
nind. ul, al presenlalion if lhe uIcer is severe lhal
needs innediale lrealnenl vilh conlinalion of forlihed
cefazoIin and forlihed lolranycin eye drops, even lefore
cuIlure and sensilivily reporls,. Hovever, afler inilialion of
16 l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
lhe epilheIisalion, il can le changed lo nonolherapy. Thal
neans in any case nonolherapy shouId le preferred as far
as possilIe.
M. 5rInIvasan: CurrenlIy ve have poverfuI
anliliolics eg: 4lh generalion ouroquinoIones lhal are
highIy effeclive againsl Cran posilive and Cran negalive
lacleriae. So I prefer nonolherapy if I knov lhe agenl.
eg: I use Moxioxacin againsl Iseudononas ralher lhan
conlinalion of genlanycin and ciprooxacin.
Jnhn Dart: We use nonolherapy al MoorheIds Lye
HospilaI. We conlinuaIIy assess resislance lo lhis and have
had no prolIens lo dale. Hovever ve do nol advocale il
for use oulside lhe UK, unIess lhe pallern of sensilivily of
lhe range of causalive organisns is veII eslalIished and
shovs no signihcanl resislance.
5amarBasak: Tncinica|icnsfcrmcnc|ncrapq.
- UIcer is peripheraI or nid-peripheraI (avay fron
lhe visuaI axis)
- SuperhciaI uIcer
- Size < 4 nn
- Wilhoul hypopyon
Tncica|cncicc.
- Ior suspecled Cran posilive - Moxioxacin or
Calioxacin eye drop.
- Ior suspecled Cran negalive organisn - Iorlihed
lolranycin 1.3 or Ciprooxacin eye drop.
Tncccm|ina|icn|ncrapqinc|ucs.
- Iorlihed CefazoIin 5 and Iorlihed lolranycin
1.3 eye drop
- Iorlihed CefazoIin 5 and Ciprooxacin eye
drop
The choice of anliliolic shouId le guided ly lhe
sensilivily pallern as veII as prevaIenl organisns
LIm LI: Conlinalion lopicaI lherapy vilh forlihed
anliliolics is preferalIe lo nonolherapy if lhe inhIlrale is
Iarger lhan 1 - 2nn
Bhaskar 5rInIvasan: I do nol prefer nono lherapy
excepl in case of a very snaII peripheraI uIcer. I vouId
use a lroad speclrun uoroquinoIone aIong vilh forlihed
cephaIosporin / aninogIycoside or lase il on cuIlure
sensilivily reporls.
Monotherapy may be advocated for small corneal
ulcerations and where the etiological organism and
sensitivity patterns are known. Larger corneal ulcerations
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by the culture sensitivity patterns and clinical response.
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combination therapy also need to be considered.
M. VanathI: Hnw nftcn dn ynu usc vnrIcnnazn!c In
ynur practIcc fnr managcmcnt nf funga! kcratItIs? Ynur
vIcwsnnrn!cnfvnrIcnnazn!cInfunga!kcratItIs?Wnu!d
ynuprcfcrtnaddtnpIca!antIbIntIcstnantIfunga!thcrapy
InacascnfsmcarpnsItIvcmycntIckcratItIs?
AnItaPanda: As discussed earIier, lopicaI voriconozoIe
1 is given for non responsive cases. If cosl is nol a
prolIen, il can le slarled as an iniliaI lherapy. Il is very
effeclive in nany cases of resislanl fungaI keralilis. As per
lhe roIe of anliliolics in nycolic keralilis, lhere is no need
if lhe cuIlure for lacleria is negalive.
M.5rInIvasan: If I gel Iusariun posilivily in cuIlure, I
aIvays use nalanycin. If nol responding even afler a veek
of lherapy as inpalienl lrealnenl lhen I viII svilch over lo
lopicaI voricanazoIe or anpholericin . VoriconazoIe is ny
second Iine. I do nol add anliliolics vilh anlifungaIs.
Jnhn Dart: We onIy use voriconazoIe for severe and
cIinicaIIy resislanl cases as aIlernalive lopicaI or oraI
lherapy. In viev of lhe resuIls of lhe recenl randonized
conlroIIed cIinicaI lriaI al Aravind Lye HospilaI, ve lhink
lhis is appropriale. We donl add lopicaI anlililoics in a
case of snear posilive fungaI keralilis unIess ve have good
reason lo leIieve lhere is poIynicroliaI infeclion vilh lolh
fungi and lacleria (vhich occurs in 1O of our cases).
5amar Basak: I an using lopicaI voriconazoIe in
approxinaleIy in 5O cases of fungaI keralilis and on a
reguIar lasis. Again in snaII ( < 4nn), superhciaI and off-
lhe axis uIcer - I an using il as nonolherapy. ul in severe
cases I an conlining il vilh anpholericin or nalanycin
depending upon vhelher lhe organisn is AspergiIIus or
Iusariun. We do nol gel cases of Candida in lhis region.
As nalanycin eye drop avaiIaliIily is nol a very consislenl,
I an nov nore conforlalIe vilh voriconazoIe.
Yes, ve prefer lo add a 4lh generalion ouroquinoIone
qid for 1O - 14 days. As I have nenlioned earIier lhal in our
region > 1O infeclious keralilis are of nixed infeclion.
LIm LI: VoriconazoIe is reslricled lo fungaI keralilis
nol responding lo slandard anlifungaI lrealnenl such as
nalanycin and anpholericin, and if lhe infeclion is severe
or has penelraled inlo lhe anlerior chanler.
Bhaskar5rInIvasan: Nalanycin is sliII lhe connonesl
anlifungaI lhal I vouId prescrile hovever in cases of deep
slronaI alscess or poslerior slronaI Iesions or fungaI
endophlhaInilis I vouId consider voriconazoIe lopicaIIy or
inlraslronaI/inlracaneraIIy. In cases of endophlhaInilis if
lhe Iiver funclion lesls are nornaI I vouId even consider
adding syslenic anlifungaI nedicalions. I prefer lo use
a singIe anliliolic even in nycolic keralilis lo prevenl
secondary lacleriaI infeclion, aIso quile a fev cases lhal ve
have seen are of nixed infeclion (lacleriaI & fungaI) so one
lroad speclrun lopicaI anliliolic is roulineIy prescriled.
The availability of voriconazole has broadened the
antifungal therapy arena in recent times. However most
prefer to use topical voriconazole as second line or in
refractory mycotic ulcerations. There seems to be a mixed
response on the use of antibiotics in mycotic keratitis.
Antibiotic therapy as an addendum to antifungal therapy
is recommended in mixed corneal infections.
M. VanathI: What arc ynu rccnmmcndatInns nn usc
nfIntracamcra!/Intrastrnma!amphntcrIcIn/vnrIcnnazn!c
InmanagcmcntnfmycntIckcratItIs?
AnIta Panda: When lhere are deep slronaI inhIlrales
or exudales in anlerior chanler lhal are nol responding lo
lhe lopicaI anlinycolic agenls, ve reconnend inlraslronaI
anpholericin / voriconazoIe for deep slronaI inhIlrales
and inlracaneraI for exudales in lhe anlerior chanler.
Iurlher, inlraslronaI roule is nore preferred lhan inlra
caneraI.
www. cscn|inc.crgl 17
M. 5rInIvasan: In deep nycolic keralilis, vilh
epilheIiun inlacl, I vouId lry 5O nicrons inlra slronaI
voriconazoIe and repeal 3 - 4 lines if I nolice a favouralIe
response. Inlra caneraI is used vhen a TIK is done. Inlra
slronaI anlifungaIs under lopicaI anaeslhesia couId heIp in
deep slronaI and endolheIiaI pIaques.
Jnhn Dart: I have used inlraslronaI voriconazoIe on
lvo occasions and il resuIled in resoIulion of lhe keralilis,
lul al lhe expense of very severe corneaI and anlerior
chanler inannalion, vhich nighl have leen lhe resuIl
of an inannalory response lo a nassive kiII of lhe
fungus. I nov onIy use lhis as a Iasl Iine of lherapy lefore
corneaI lranspIanlalion. I have used inlracaneraI onIy once
and vilh success. In lhe UK ve depend on sludies and
guideIines fron our coIIeagues, in India and lhe Soulhern
USA, for fungaI keralilis as ve have so fev cases here.
5amarBasak:
- UIcers non-responsive lo nedicaI lherapy > 3
veeks of lherapy
- Thick hypopyon > haIf anlerior chanler
- Irofuse endolheIiaI exudales
- Deep IungaI alscess (epilheIiun heaIed)
LIm LI: InlracaneraI anpholericin is used
inlraoperaliveIy al lhe line of lherapeulic or leclonic
keralopIasly for lhe lrealnenl of severe fungaI keralilis.
I have nol used inlraslronaI anpholericin injeclions.
Reporls shov favoralIe resuIls in lhe use of inlraslronaI
anpholericin injeclions.
Bhaskar 5rInIvasan: I do use il in recaIcilranl cases
and cases nol responding lo rouline anlifungaI lrealnenl
vilh nalanycin. In case of a lherapeulic keralopIasly I
vouId roulineIy give inlracaneraI anlifungaI injeclion on
conpIelion of lhe surgery.
Intracameral / intrastromal antifungals are better
reserved for use of deep mycotic infections with intact
overlying epithelium. They are to be used with caution, as
intracameral injections may be associated with intense
anterior chamber reactions and secondary glaucoma.
M. VanathI: What Is ynur prcfcrrcd apprnach tn
acanthamncba kcratItIs managcmcnt? 5nmc practIcc
pcar!s..
AnItaPanda:
1. CIinicaI hndings
2. ConfocaI scanning lo docunenl lhe cysls
3. CuIlure on nulrienl agar pIale vilh L.coIi overIay
4. Slarl vilh IHM O.O2 eye drops 1 hourIy vilh
propanidine iselhionale O.1 eye drops 1 hourIy
5. If IHM nol avaiIalIe ve repIace vilh
ChIorhexidine O.O2 eye drops
6. When lhe keralilis slarls responding, and lhe
heaIing is evidenl lhe hourIy dosage is lapered.
7. Afler 3 lo 6 nonlhs vhen lhe uIcer conpIeleIy heaIs
anli-acanlhanoela drugs shouId le conlinued as
T.I.D dosage lo prevenl recurrence
M. 5rInIvasan: Use IHM or chIorhexidine. One
has lo lry for severaI veeks. RareIy I have lried lopicaI
ilraconazoIe.
Jnhn Dart: We have a very Iarge experience of
Acanlhanoela keralilis anounling lo severaI hundred
cases since lhe earIy 199Os
2
. Hovever in lrief ve slarl
lrealnenl, as descriled alove vilh IHM O.O2 and
Hexanidine O.1 hourIy for 5-7 days (as lhe innalure
cysls are nore susceplilIe for lhe hrsl fev days foIIoving
encyslnenl). We avoid using lopicaI sleroids for al Ieasl
2 veeks and nol al aII unIess lhe corneaI inannalion is
severe and nol resoIving. TopicaI sleroids can produce
a dranalic inprovenenl in cases if inlroduced afler 2
veeks of effeclive lopicaI lherapy vilh liguanides (IHM
or ChIorhexidine) +/- a dianidine (Iropanidine or
Hexanidine). The palienls are regarded as cured vhen
lhe signs of corneaI inannalion have resoIved for one
nonlh, afler sIov vilhdravaI of sleroids (if lhese have
leen necessary), and lopicaI anlianoelics are conlinued
for a nonlh afler sleroid vilhdravaI OR resoIulion of
inannalion. This nay le possilIe vilhin 6-8 veeks of
lhe slarl of lherapy, lul in olher cases lhis nighl require
sone nonlhs or Ionger. We use chIorhexidine O.O2 and
propanidine O.1 as second Iine agenls. Ior resislanl
cases, vhich is persislenlIy cuIlure posilive, ve use IHM
O.O6 drops or chIorhexidine O.2 drops vilh voriconazoIe
1 drops and oraI voriconazoIe. The evidence for lhe use
of voriconazoIe is poor and lhese reconnendalions nay
change.
Linlilis and scIerilis are oflen overIooked and are
lhe connonesl cause of pain and Ioss of lhe eye in our
experience. Linlilis is an earIy nanifeslalion, vhereas
scIerilis is forlunaleIy nuch Iess connon and usuaIIy
occurs 2-3 nonlhs fron lhe onsel of disease and is a poor
prognoslic sign. LxlracorneaI inannalion is VLRY
RARLLY due lo exlracorneaI invasion ly lhe organisn
lul is inslead a secondary innune response of uncerlain
aelioIogy, lhe sane appIies lo choriorelinilis. I reconnend
using syslenic non sleroidaI anli-inannalories (NSAIDS)
for lolh Iinlilis and scIerilis, ve use urliprofen lul
iluprofen nay vork as veII. If lhese are nol effeclive I lhen
inlroduce inlensive lopicaI sleroids. If lhese do no vork
ve use syslenic innunosuppressive lherapy, usuaIIy oraI
prednisoIone slarling al 8O ng oraI daiIy, and lapered over
2 nonlhs, logelher vilh oraI cicIosporin al 3.5 - 5.O ng/kg.
MycophenoIale can le used as an aIlernalive lo cicIosporin.
I donl reconnend keralopIasly unIess lhe disease
is cured lecause aloul 5O of cases lranspIanled suffer
recurrence of infeclion vilhin veeks, or a nonlh or lvo, of
a lranspIanl.
5amar Basak: As, Dianidines (Iropanidine
iselhionale) are nol freeIy avaiIalIe in India, liaguanides
are used as nonolherapy. I prefer ChIorhexidine O.O2
eye drop (prepared fron noulhvash - avaiIalIe freeIy in
chenisl shop).
- I prescrile lhis one hourIy for 48 hours round lhe
cIock, lhen lapered lo hourIy drops ly day for nexl
3 days, 2 hourIy afler 5 days for 3 lo 4 veeks. The
lrealnenl shouId le conlinued for 6 -12 nonlhs in
a 4 hourIy reginen afler one nonlh of heaIing of
lhe uIcer.
- I aIso add neosporin eye oinlnenl 5 lines daiIy for
3-4 veeks in severe cases.
- If lhe visuaI axis is invoIved - depending upon
lhe response - A lherapeulic IK done vilh oplicaI
grade lissue.
18 l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
LImLI: Il is inporlanl lo have a high index of suspicion
especiaIIy in susceplilIe individuaIs such as conlacl
Iens vearers. Acanlhanoela keralilis is oflen nislaken
for dendrilic keralilis. As acanlhanoela is a faslidious
organisn and is oflen difhcuIl lo ollain a cuIlure posilive
resuIl, il is inporlanl lo direclIy pIale lhe corneaI scrape
onlo diagnoslic nedia such as non-nulrienl agar vilh
L coIi overIay. Laloralory experlise vilh experience in
idenlifying lhe organisn is aIso inporlanl.
Conlinalion lherapy vilh lroIene (propanidine)
and IHM (poIyhexanelhyIliguanide) eyedrops is
reconnended. The oulcone depends on lhe severily of lhe
infeclion, earIy superhciaI infeclions usuaIIy do very veII.
More eslalIished infeclions vilh slronaI invoIvenenl
nay le difhcuIl lo lreal vilh nedicalion aIone and usuaIIy
require proIonged nedicalion vilh signihcanl loxicily
issues such as epilheIIiopalhy. Unresponsive infeclions viII
require lherapeulic keralopIasly. I usuaIIy perforn deep
IaneIIar keralopIasly ralher lhan penelraling keralopIasly
if lhe Iesion has nol fuIIy penelraled lhe cornea. LaneIIar
keralopIasly preserves lhe hosl endolheIiun and resuIls in
a Iover incidence of grafl rejeclion and grafl allrilion.
Bhaskar5rInIvasan: I vouId slarl vilh lroIene group
of drugs (goIden eye drop) and IHM every hourIy aIong
vilh neosporin oinlnenl. In resislanl cases vouId consider
chIorhexidine.
Successful management of acanthamoeba keratitis
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acanthamoeba therapy. Treatment needs to be prolonged
for a period of at least 6 months beyond healing. Limbitis
and scleritis are poor prognostic indicators. Keratoplasty
results are poor in acanthamoeba cases. Lamellar
transplants might help in cases without deep involvement.
M. VanathI: What Is ynur npInInn nn thc rn!c nf
cn!!agcn crnss!InkIng In thc managcmcnt nf InfcctInus
kcratItIs?
AnItaPanda: Wilh ny personaI experience I found lhal
coIIagen crossIinking effeclive as an adjuncl in lacleriaI
keralilis, refraclory lo convenlionaI nedicaI lherapy. In
acanlhanoela keralilis aIso ve found il lo le effeclive, lul
in fungaI keralilis furlher sludies have lo le done lo cIearIy
reporl ils efhcacy. In viraI keralilis, sludies in Iileralure
slale lhal il aggravales lhe condilion for vhich so far ve
have nol inilialed lhe sane.
M. 5rInIvasan: I do nol do coIIagen crossIinking
lrealnenl, lul I have lrealed palienls having infeclive
keralilis foIIoving C3R. I have read fev arlicIes lried
in hunan and aninaIs and reconnended as adjuvanl
lrealnenl.
JnhnDart: I do nol see lhe ralionaIe for lhis in palienls
vilh severe disease, vhich is lolh usuaIIy deep (loo deep
lo le lrealed ly UV) and loo peripheraI (invoIving lhe
periIinlaI cornea) vhere lrealnenl nighl le expecled
lo cause slen ceII faiIure. Olher cases respond veII lo
convenlionaI lherapy.
I lhink a Iol nore sludy needs lo le done lo ensure
lhal lhis lherapy is safe and effeclive, and lo shov lhal lhe
polenliaI lenehls oulveigh lhe polenliaI risks.
5amarBasak:
- We are doing C3R lrealnenl in keraloconus
lo arresl ils progression. I have no experience
in lrealing nicroliaI keralilis vilh coIIagen
crossIinking.
- In coIIagen crossIinking ve use Iong vaveIenglh
UV ray (UV-A al 365 nn) and il does nol have
any gernicidaI aclivily. There is a prolaliIily of
slrenglhening lhe sofl cornea in corneaI uIcer if
lrealed vilh C3R ve use for keraloconus.
- OnIy shorl vaveIenglh UV rays (UV-C al 254 nn)
has laclericidaI, fungicidaI and veridicaI aclivily
lul ve do nol use lhal vaveIenglh in C3R.
LIm LI: SeveraI reporls shov good conlroI of lhe
infeclion vhen used in conjunclion vilh convenlionaI
anlinicroliaI lherapy.
Bhaskar5rInIvasan: lhe fev recenl reporls of lhe use
of coIIagen cross Iinkage for infeclive keralilis seens quile
an inleresling oplion lo nol onIy kiII lhe organisn lul
aIso lo prevenl slronaI neIls and perforalions aIIoving
a sulsequenl oplicaI penelraling keralopIasly lo le
perforned al a Ialer dale vhen lhe eye is quiel. Il seens lo
le a pronising lrealnenl oplion lul ve need lo conducl
nore cIinicaI sludies and vaIidale lhe resuIls vhich have
leen reporled so far.
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treatment in infectious keratitis are increasing in literature
in recent times. Our experience is still evolving and there
is need for more evidence to establish its role in aiding
resolution in infectious keratitis.
M. VanathI: Ynur npInInn nn thc usc nf In-vIvn
cnnfnca!mIcrnscnpyInthcdIagnnsIsandmanagcmcntnf
InfcctInuskcratItIs?
AnIta Panda: Though confocaI nicroscopy can
le heIpfuI in diagnosing lacleriaI, viraI, fungaI and
acanlhanela keralilis, as nany of lhe sinpIe diagnoslic
nodaIilies are avaiIalIe for lacleriaI, viraI and fungaI ve
depend on confocaI onIy for acanlhanoela keralilis lo
knov lhe disease progression or disease response lo lhe
lrealnenl.
M.5rInIvasan: Il adds lo your diagnoslic looIs and in
experls hands il gives nore specihc resuIls. Il is coslIy and
onIy lerliary cenlres nay have lhe access.
JnhnDart: I lhink lhis has leen a najor slep forvard in
diagnosis of fungaI and Acanlhanoela keralilis, hovever
lhe sensilivily and specihcily of lhis as a slandaIone
diagnoslic looI is reIaliveIy Iov in our hands
3
. If a case is nol
progressing as expecled lhen ve pursue a lissue diagnosis
ly cuIlure of scrapes and/or liopsies.
5amarBasak:
- I have no experience in lhe use of confocaI
nicroscopy and onIy in lerliary and inslilulionaI
IeveI is il possilIe lo diagnose and lreal sone cases
of nicroliaI keralilis vilh ils appIicalion.
- Il is usefuI especiaIIy, in suspecled Acanlhanoela
keralilis for denonslraling lhe cysl. Iresence
of hyphae in cases of hIanenlous fungi and
pseudohyphae in cases of Candida keralilis can
aIso le sonelines denonslraled ly confocaI
nicroscopy.
LIm LI: In vivo confocaI nicroscopy is usefuI in lhe
diagnosis of infeclions such as fungus and acanlhanoela
www. cscn|inc.crgl 19
and viII expedile lhe lrealnenl of such infeclions. Il is aIso
usefuI in lhe noniloring of lhe efhcacy of lrealnenl.
Bhaskar 5rInIvasan: al lhis poinl of line lhe onIy
infeclive keralilis vhere il is very heIpfuI is acanlhanoela
keralilis resl of lhe infeclions il is nore of a research looI
lhe resoIulion need lo gel leller lefore ve can use il for
olher infeclive keralilis
The consensus on the application confocal microscopy
in the diagnosis of infectious keratitis is on its usefulness
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ulcers in their early stage. Accessibility and appropriate
expertise in its interpretation remain limiting factors.
M. VanathI: What arc thc cnmmnn typcs nf cnntact
!cns Induccd kcratItIs ynu cncnuntcr In ynur practIcc?
Hnw havc ynu mndIcd ynur practIcc pattcrn In thc
managcmcntnfthcscpatIcnts?
AnIta Panda: MechanicaI epilheIiaI defecls, chenicaI
epilheIiaI defecls, hypoxia reIaled nicroepilheIiaI
cysls are nore connon, foIIoved ly sleriIe inhIlrales
and Acanlhanoela keralilis, in conlacl Iens vearers.
Iseudononas infeclion is frequenl, fungaI infeclion is nol
rare.
We reconnend reguIar foIIov-up of lhe palienls
using conlacl Iens, and reguIar cIeaning of lhe Ienses vilh
slandard disinfecling soIulions.
M. 5rInIvasan: I have seen pseudononas infeclions.
HeaIlh educalion is lhe key lo prevenl CL reIaled infeclions.
I have never seen fungaI uIcer in conlacl Iens vearers in ny
hospilaI.
JnhnDart: We see lacleriaI, parlicuIarIy Iseudononas
spp., Acanlhanoela and hIanenlary fungaI infeclion
(usuaIIy Iusariun spp.). There is nov a high index of
suspicion of fungaI or anoelic keralilis in conlacl Iens
users vilh keralilis lhal is nol rapidIy resoIving vilh
lopicaI anliliolics OR lhal has an unusuaI appearance, and
a nore indoIenl course.
5amarBasak:
- Conlacl Iens induced nicroliaI keralilis is nuch
Iess connon in our region. We see nainIy
pseudononas keralilis anong CL vearers. RareIy,
ve see CL induced Acanlhanoela keralilis.
- ul ve see Iol of landage conlacl Iens (CL) vearer
is having lacleriaI keralilis. olh Iseudononas
and Nocardia keralilis. Ialienls non conpIiance,
Iack of reguIar CL change, sinuIlaneous use of
lopicaI sleroids - aII are inporlanl faclors.
- Iroper palienls educalion, educalion of generaI
ophlhaInoIogisl and oplonelrisls are very
inporlanl.
LIm LI: The connonesl vouId le Iseudononas
aeruginosa keralilis. CurrenlIy, lopicaI forlihed genlanicin
is sliII lhe hrsl Iine eye drops lhal I prescrile as nosl
connunily acquired Iseudononas aeruginosa keralilis is
sliII sensilive lo genlanicin.
Bhaskar 5rInIvasan: The connon conlacl Iens
keralilis ve encounler sliII is Cran posilive cocci ralher
lhan pseudononas keralilis. The cause for lhe keralilis
noslIy slenned fron non conpIiance vilh lhe cIeaning
and nainlenance issues and il vas reinforced lo lhe palienl.
In sone of lhe palienls vho vere sliII nol conpIianl ve
offered lhe oplion of refraclive surgery inslead of conlacl
Ienses.
Bacterial keratitis in a common complication
associated with contact lens wear besides Acanthamoeba
infections. Fungal keratitis has also been seen to affect
contact lens wearers. Contact lens induced keratitis needs
to be managed promptly and effectively. Proper counseling
of patients prior to commencement of contact lens wear
on proper contact lens wear and replacement schedules,
contact lens care, hygiene and sterilization goes a long
wear in effective prevention of corneal infections in lens
wear.
M. VanathI: What Is ynur cxpcrIcncc wIth pnst-C3R
trcatmcntInfcctInuskcratItIs?
AnIta Panda: I have nol encounlered any posl C3R
lrealnenl infeclious keralilis in any case of keraloconus
as I aIvays go for lransepilheIiaI lechnique. Hovever,
foIIoving convenlionaI epilheIiaI delridenenl lechnique
lhere are severaI reporls on Iileralure for vhich ve slriclIy
reconnend lransepilheIiaI nelhod for CXL in keraloconus.
M.5rInIvasan: I have lrealed 3 cases in lhe Iasl 2 years.
AII vere done eIsevhere. One Iosl lhe gIole and in lhe
olher, a nedicaI sludenl, I had lo do a 9nn lherapeulic IK
vhich vas fungaI lo save lhe gIole.
Jnhn Dart: We have seen one case of nycolacleriaI
keralilis. C3R lrealnenl is nol yel very videIy used in lhe
UK.
5amar Basak: No experience. The reason aIready
expIained.
LImLI: I have nol encounlered any posl CXL lrealnenl.
Bhaskar5rInIvasan: so far I have nol seen posl coIIagen
cross Iinkage infeclive keralilis.
Post C3R infectious keratitis a cause for serious
concern. With increasing reports in literature on bacterial
and fungal keratitis in Post C3R treatment cases,
ophthalmic physicians need to be well aware of this
condition which can result in severe ocular morbidity.
Transepithelial C3R treatment for keratoconus might be a
safer approach.
M.VanathI:WhatIsynurnpInInnnnthcuscnfg!uc
wIth bandagc cnntact !cns In managcmcnt nf InfcctInus
kcratItIs?
AnItaPanda: Il is heIpfuI in cases of infeclious keralilis
vilh snaII perforalion.
M. 5rInIvasan: Il is good oplion vhen you see
inpending perforalion or a liny perforalion Ieading lo al
chanler.
Jnhn Dart: I use lhis for aII palienls vilh snaII
perforalions lo aIIov lherapy lo conlinue and lo pernil
conlinued lrealnenl of lhe disease nedicaIIy unliI il has
resoIved. If lhe gIue lecones Ioose I renove il, as IooseIy
allached gIue is associaled vilh a high risk of secondary
keralilis. I reappIy gIue if necessary.
5amar Basak: There is dehnile roIe in sone cases of
infeclious keralilis: CynoacryIale gIue has an addilionaI
anli-nicroliaI properly. Il is very usefuI, Quick and a very
easy procedure.
2O l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
- Indicaled for perforalions (2nn or Iess) or
inpending perforalion
- CorneaI hsluIa vilh or vilhoul pseudocornea
fornalion. A posilive SeideIs lesl is very inporlanl
lo diagnose a nicro-Ieak.
- Does nol have nuch roIe in lrue DesceneloceIe.
The procedure can le perforned under lopicaI
aneslhesia. Air injeclion inlo lhe AC nay le required in
sone cases. Iirsl, dry lhe surface and led of lhe perforalion.
Afler, roughing lhe edges of lhe surrounding area, a lhin
hIn of adhesive using a 26-gauge disposalIe needIe is lo
le appIied. Upon drying, a CL is lo le pIaced.
LImLI: If aclive infeclion is presenl, hisloacryI gIue is
nol reconnended. Hovever, il can le used inlraoperaliveIy
lo aid in lhe surgery, for exanpIe in perforaled cases of
infeclive keralilis.
Bhaskar 5rInIvasan: CynoacryIale gIue and conlacl
Iens is a very usefuI looI in lhe hands of an ophlhaInoIogisl
especiaIIy vhen deaIing vilh a snaII perforalion or
inpending perforalions. il can heIp in deIaying or even
avoiding a penelraling keralopIasly in sone palienls.
The difhcuIly vilh lhe gIue is il is difhcuIl lo olserve
lhe progress/regress of lhe infeclion under lhe gIue. The
praclicaI lip for il vouId le lo go ahead vilh gIue if lhere
is al Ieasl sone evidence of resoIulion/scarring indicaling
lhal lhe lrealnenl is effeclive. A cIoser foIIov up vouId le
required in lhese palienls
Cyanoacrylate glue application with bandage
contact lens placement is recommended in cases of small
perforation with no active infection. Underlying rough
areas ensures better adhesion and longer stay on of the
glue aiding in resolution and hence removing the need for a
further surgical intervention. Glue application needs to be
performed deftly to achieve optimal results.
M. VanathI: Ynur cxpcrIcncc wIth pnst-LA5IK
kcratItIs.
AnIta Panda: I can say il is a reaI disasler. The
nanagenenl is Iike lhal of any olher infeclive keralilis. Il is
an ialrogenic uIcer. One nusl slop lhe lopicaI corlicosleroid
and lake care of ocuIar surface.
M.5rInIvasan: I had one case of fungaI infeclion in one
eye vilhin 2 days. Il vas A.avus and lrealed lhe palienl
for 4 nonlhs vilh anlifungaI, Nalanycin and Ialler vilh
cIolrinazoIe. The ap vas parlIy anpulaled. Has 6/24
vilh correclion I have lrealed fev palienls done eIsevhere,
aII vere pseudononas keralilis.
Jnhn Dart: IorlunaleIy snaII, lul I have seen lhis
caused ly lolh lacleriaI and nycolacleriaI infeclion.
5amar Basak: So far, I have nol encounlered any
palienl vilh Iosl LASIK keralilis.
LImLI: This is lhe nosl serious conpIicalion foIIoving
LASIK and aIlhough rare, palienls need lo le counseIed
of lhis possiliIily pre-operaliveIy. The infeclions can le
cIassihed as earIy, occurring vilhin 1-2 days of LASIK,
inlernediale, occurring lelveen 3-7 days and Iale, and
occurring afler 7 days. The IikeIy organisns for lhe
earIy infeclions incIude pseudononas aeruginosa, lhe
inlernediale ones IikeIy lo le gran posilive organisns and
Iale infeclions IikeIy nycolacleria or fungaI.
Risk faclors incIude lIepharilis, dry eyes, syslenic
condilions such as dialeles, and epilheIiaI defecls foIIoving
LASIK ap fornalion.
The lrealnenl is lo slop sleroids and connence
inlensive forlihed lopicaI lroad speclrun anilliolics such
as cephazoIin and genlanicin eye drops. Never generalion
uoroquinoIones such as noxioxacin eye drops can aIso
le used. Syslenic anliliolics shouId le slarled for severe
infeclions. If nycolacleriaI infeclion is suspecled, lopicaI
anikacin can le used. Consider ap irrigalion vilh
anilliolics.
Bhaskar 5rInIvasan: LuckiIy nol a Iol. I have seen
and lrealed a coupIe of palienls vilh posl LASIK viraI
slronaI reaclivalion of herpes keralilis and a coupIe
vilh alypicaI nycolacleriaI keralilis vhich responded
lo lopicaI lrealnenl vilh 4lh generalion uroquinoIone
and cephaIosporine. We needed lo Iifl lhe ap and coIIecl
lhe naleriaI for cuIlure sensilivily for lhe LASIK led and
under surface of lhe ap.
Iosl LASIK keralilis is lhe nosl feared of aII lhe
conpIicalions of LASIK procedure resuIling in vilh a vision
deliIilaling silualion necessilaling keralopIasly in lhe vorsl
scenario cases. Iroper asepsis, vilh parlicuIar allenlion lo
sleriIizalion and aulocIaving of LASIK inslrunenlalion
vouId le heIpfuI. Lfhcienl palienl counseIing and
posloperalive noniloring pIay an inporlanl roIe as veII.
Ironpl lherapy vilh oplinaI nicrolioIogicaI supporl goes
a Iong vay in effeclive lrealnenl of posl LASIK keralilis.
Reference
1.
NVPrajnac|a|.CcmpariscncfNa|amqcinanVcriccnazc|cfcr|nc
Trca|mcn|cf|unga|Kcra|i|is.ArcnOpn|na|mc|.2010,128(6).672-
678)
2.
Dar| ]KG, Sau P], Ki|ting|cn S. Acan|namcc|a |cra|i|is. iagncsis
an |rca|mcn| upa|c 2009. A pcrspcc|itc. Am ] Opn|na|mc| 2009
148(4).487-499
3.
Hau,S.C.,Dar|,].Kc|a|.(2010).Diagncs|icaccuracqcfmicrc|ia|
|cra|i|is ui|n in titc scanning |ascr ccnfcca| micrcsccpq. 8r ]
Opn|na|mc|94(8),982-987)
DOSCorrespondent
M.Vanathi
www. cscn|inc.crgl 21
www. cscn|inc.crgl 23
R
elinopalhy of Irenalurily (ROI) is a hlrovascuIar
proIiferalive disorder, vhich affecls lhe deveIoping
peripheraI relinaI vascuIalure of prenalure infanls. Iirsl
descriled ly Terry in 1942 as relroIenlaI hlropIasia,
1
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(A)
QuizPrizcsSpcnscrc|q
M/s. Raymed Pharmaceuticals Ltd.
(D)
72 l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
The DOS Times Quiz for July 2011 issue received 45 responses of which the correct answers were
given by 1. Dr. Sheetal Bakshi, Ahmedabad 2. Dr. Tarun Arora, Delhi 3. Vivek Pravin Dave, Mumbai
4. Dr. Ankit Soni, Aligarh. The winner of the prize money decided by a draw of lots is:
Dr. Rishi Mehta, Udaipur, Membership No. 4766
Answers of DOS Times Quiz July 2011 are:
1. Moorens UIcer / PeripheraI uIcerative |eratitis. 3. Hyphema
2. OccIudabIe AngIe (Gonioscopy Photography) 4. Type 1 Duanes retraction syndrome
The DOS Times Quiz for August 2011 issue received 21 responses of which the correct answers were
given by 1. Dr. Neha Rathi, New Delhi 2. Sparshi Jain, Noida 3. Gunjan Abhijit Deshpande, Nagpur
4. Ranjeet Kishore Rana, Delhi 5. Shalini Mohan, Kanpur 6. Anusha V., New Delhi were correct. The
winner of the prize money decided by a draw of lots is:
Dr. Mayee Rishi|esh Charudatta, Nagpur, Membership No. CD-13S8
Answers of DOS Times Quiz August 2011 are:
A
1
S T I G
2
M A T
3
I S M L
4
M
5
M R O I A
6
A
A E A
7
R C N
8
E P A F E N A C
U E I I G U
R N A
9
C U T E
10
D S
11
I L
O G P T O A
S
12
I N U S
13
A A
14
N I R I D I A I
I C R K I D
S
15
C O
16
P O L A M I N E N S
R T G R T
V
17
B O A A
18
M S L E R G R I D
I I M R T E
D
19
O T A H
20
Y P O P Y O N A O
21
A O P K P
R T
22
R I C H I A S I S S T
A U
23
N A I
B
24
U L L S E Y E K C
I C R I
25
R I S
26
C L A
27
W P
N E A E I I
E
28
N T R O P I O N C
29
A T A R A C T
Answer for DOS Times Quiz month of
)uIy&August2011
www. cscn|inc.crgl 73
www. cscn|inc.crgl 79
Yogesh BhadangeM88S,Brijesh TakkarM88S,Bhavin ShahM88S,Rajesh SinhaMD
Dr.RajcnraPrasaCcn|rcfcrOpn|na|micScicnccs,A||MS,NcuDc|ni
Tc.. |cc
Yogesh Bhadange
Tc.. |cc
4. Intracameral Agents
A. Antibiotics and Antifungals
IrophyIaclic as veII as Therapeulic uses.
Bn!usdnscnfcnmmnn!yuscdantIbIntIcs
Vanconycin 1ng/O.1nI
CefazoIin 1ng/O.1nI
Cefuroxine 1ng/O.1nI
Calioxacin 1OOnicrogran/O.1nI
Moxioxacin 1OOnicrogran/O.1nI
Anpholericin 5-1O nicrogran/O.1nI
AntIbIntIcs used in irrigaling uids
Drugs DI!utInnIn FIna!cnnccntratInn
IrrIgatIng 0uId
Vanconycin O.5nI is nixed 25-5O nicrogran/nI
(5O ng/nI) vilh 5OOnI
irrigaling uid
Cenlanycin O.1nI is nixed O.OO8ng/nI
(4O ng/nI) vilh 5OOnI (O.OOO8)
irrigaling uid
B. Mydriatics
AdrenaIine larlarale (O.1 v/v, 1:1OOO) is diIuled len lines
ie.O .1 nI of adrenaIine diIuled in O.9nI of SS ,used as
loIus dose.
Ior nainlaining nydriasis O.8cc adrenaIine larlarale (O.1
v/v 1:1OOO) is diIuled in 35O nI of SS.
C. Miotics
Pilocarpine: O.1 nI of lhe drug (25ng/nI) is diIuled in
O.1nI ringer Iaclale, used as loIus dose.
O.8nI of piIocarpine (O.5 of ophlhaInic preparalion) is
added lo 35O cc of SS, used as nainlenance dose.
5. Posterior Subtenon Injection:
2Ong / O.5nI of lriancinoIone acelonide preservalive free
preparalion (reliIone\ aurocol) is injecled using lhe Snilh
and Novaks lechnique vilh 26 Cauge needIe or lhe cannuIa
lechnique.
6. Posterior Juxta Scleral Depot Injection:
Anacorlave acelale, a corlisone, synlhelic anaIogue of
corlisoI acelale vilh no gIucocorlicoid aclivily, acls ly
suppression of exlraceIIuIar proleases eIaloraled ly
aclivaled endolheIiaI ceIIs and aIso decreases VLCI IeveI.
Dose-15ng poslerior juxla scIeraI depol injeclion every 6
nonlhs for lrealnenl of vel ARMD.
7. Intravitreal Drugs:
A. Antibiotics:
VancnmycIn(1mg\0.1m!)avaI!ab!ccnmmcrcIa!!yas500
mgpnwdcr
Add 1O nI of Ringer Laclale 5OOng in 1OnI
Take O.2 nI Has 1O ng
Make il 1 nI 1O ng in 1 nI
Take O.1 nI 1 ng in O.1 nI
CcftazIdImc (2.25mg\0.1m!) avaI!ab!c cnmmcrcIa!!y as
500mgpnwdcrInjcctInn
Add 2 nI 5OOng in 2nI
Take O.1nI 22.5ng in O.1nI
Make il lo 1 nI 22.5 ng in 1nI
Take O.1nI 2.25ng in O.1nI
B. Antifungal
AmphntcrIcIn B: (5 mIcrngram\0.1m!) avaI!ab!c
cnmmcrcIa!!yas50mgpnwdcr
Add 1OnI in 5 dexlrose 5O ng in 1OnI
Take O.1 nI O.5 ng
Add 9.9nI O.5 ng in 1OnI
O.OO5 ng in O.1nI
VnrIcnnazn!c(avaI!ab!ccnmmcrcIa!!yas200mgpnwdcr)
50-100mIcrgram\0.1m!
Add19 nI disliIIed valer 2OOng in 2OnI
Take 1 nI
Add 9nI disliIIed valer 1Ong in 1OnI
Take O.O5nI or O.1nI for inj. 5Onicrogran or
1OOnicrogran
8O l DOS Times - Vc|.17,Nc.4Oc|c|cr,2011
C. Intravitreal Drugs List in Tabular form
Drugs Dnsagc
Antibacterials
Vanconycin 1 ng/O.1nI
Ceflazidine 2.25 ng/O.1nI
Anikacin 4OO nicrogran/O.1nI
Cenlanycin 2OO nicrogran/O.1nI
An|ifunga|s
Anpholericin 5 nicrogran/O.1nI
VoriconazoIe 5O-1OO nicrogran/O.1nI
An|itira|s
AcycIovir 1O-4O nicrogran/O.1nI
CancycIovir 2 ng/O.1nI
S|crcis
Dexanelhasone 4OOncg/O.1nI
TriancinoIone acelonide 1-4 ng/O.1 nI of
preservalive free
TriancinoIone acelonide
(4Ong/nI)
Anti VEGFs
Iegaplinil (Macugen) O.3ng/O.O9nI of prehIIed
syringe
evacizunal (Avaslin) 1.25ng/O.O5nI
1 anpouIe- O.2nI
1 viaI- 4nI or 16nI of
25ng/nI
Ranilizunal (Lucenlis) O.5ng/O.O5nI
VLCI lrap O.O5-4 ng (underlriaI)
SiRNA 7O-3OO nicrogran
(underlriaI)
Implants
CancycIovir inpIanl (vilraserl) 4.5 ng in 2.5 nn
liodegradalIe inpIanl.
ReIeases al 1 nicrogran/
hour
Therapeulic IeveIs for 8
nonlhs
Dexanelhasone inpIanl O.7 ng nicrogran
(ozurdex) liodegradalIe inpIanl
Therapeulic IeveIs for 37
days. Uses NOVADUR
deIivery syslen.
IIuocinoIone acelonide (reliserl) O.59 ng liodegradalIe
inpIanl. ReIeases O.4
nicrogran/day.
Therapeulic IeveIs for 3O
nonlhs.
D. Intraocular Gases:
Gas Mn!.Wt. ExpansInn LnngcvIty Nnn- Vn!.
(purcgas/ Days ExpansI!c InjcctcdIn
100%cnnc.) Cnnc. PncumatIc
RctInn-
pcxy
Air 29 O 5 - 7 - 1.O nI
SI
6
146 2 lines 1O-14 18 O.5 nI
C
3
I
8
188 4 lines 55-65 14 O.3 nI
Dr. Rajvardhan Azad, MD, FRCSed, FICS, FAMS, for being appointed as Chief,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi. He is
also Professor of Ophthalmology and Head, Vitreo-Retina, Ocular Trauma and
ROP Services at the Centre.
CongratuIations