Comprehensive Ophthalmology Free Papers - aioseducation

Comprehensive 

Ophthalmology 

Free Papers

Contents 

COMPREHENSIVE OPHTHALMOLOGY 

A Profile of Ocular Changes in Pregnancy--------------------------------------------445 

Dr. Madhavi M.R., Dr. Sahithya Tatineni, Dr. Nagasudhamani.M 

Colour Vision Problems in The Paintings by Rabindranath Tagore----------460 

Dr. Jajneswar Bhunia 

Early Rise in Intraocular Pressure (IOP) after Uncomplicated Cataract by 

Phacoemulsification: A Myth?-------------------------------------------------------------464 

Dr. Monika Jethani, Dr. Jitendra Jethani, Dr. Ramchandra Kaushik, Dr. Rupa Jain 

Ophthalmic Cellphone Imaging System – A Costless Imaging System----467 

Dr. Murali Mohan Gurram 

Ultrasound Biomicroscopy as an Important Diagnostic Adjunct in The 

Management of Limbal Tumors------------------------------------------------------------469 

Dr. Ruchi Kabra, Dr. Deepak C. Mehta, Dr. Hansa Thakkar 

Comparing Ultrasonic Pachymetry and Anterior Segment OCT (AS - OCT) 

for Central Corneal Thickness (CCT)---------------------------------------------------- 472 

Dr. Monika Jethani, Dr. Jitendra Nenumal Jethani, Dr. Aditi Jain, Dr. Rupa Jain 

Photographic and Digital Documentation of The Anterior Segment using 

Compact Digital Camera--------------------------------------------------------------------- 475 

Dr. Susil Kumar Pani 

Hemodynamic Response to Phacoemulsification among Surgeons during 

High Volume Cataract Surgery------------------------------------------------------------ 479 

Dr. Aravind P. Murugesan, Dr. Haripriya Aravind, Dr. Ravichandar A., Dr. Heber A. 

David 

In Vitro Antibiogram of Streptococcus Pneumoniae in Ocular Infections------483 

Dr. Priyanka Gogte, Dr. Prashant Garg, Dr. Mukesh Taneja, Dr. Suma N. 

Comprehensive Eye Examination in Camps—The Wireless Way-------------486 

Dr. Shailesh Chandra Suman, Dr. Sil Asim Kumar, Dr.Shoumya Jyoti Datta Mazumder 

439

Comprehensive Ophthalmology Free Papers 

COMPREHENSIVE OPHTHALMOLOGY 

Chairman: Dr. Purendra Bhasin; Co-Chairman: Dr. Saxena Anand 

Convenor: Dr. Sreeni Edakhlon; Moderator: Dr. Sharat Babu Chilukuri 

A Profile of Ocular Changes in Pregnancy 

Dr. Madhavi M.R., Dr. Sahithya Tatineni, Dr. Nagasudhamani.M 

To identify the changes in the eye during pregnancy including the eye 

changes in pregnancy induced hypertension, by testing visual acuity for 

distant with snellen’s test types, near vision with Jaeger’s chart, examination 

of cornea with keratometry for corneal curvature, examination of anterior 

chamber with slit lamp, intraocular pressure with schiotz tonometer and 

fundus examination with indirect ophthalmoscope along with hematological 

parameters. 

MATERIALS AND METHODS 

Study Design: This is a prospective study with randomly selected sample. 

The sample size is one hundred and thirty five. 

The subjects for the study have been selected from M.B.B.S., students of Mamata 

Medical College, Khammam, pregnant patients entering OP in Obstetrics 

department in Mamata Medical Hospital, Khammam by considering the 

inclusion criteria. 

Inclusion Criteria for Selection 

Control Group 

1. In the age group of 20-30 years 

2. Who attained menarche at normal age 11-15 years (to rule out precocious 

or delayed puberty) 

3. Unmarried with regular and normal menstrual cycles 

4. With no specific metabolic disease or chronic disease (elicited through 

history) 

5. With out any refractive errors 

6. Not using spectacles for any refractive error presently or previously 

Pregnant Women 

1. In the age group of 20-35 years. 

2. With known last menstrual period. 

445

70th AIOC Proceedings, Cochin 2012 

3. With no specific metabolic disease or chronic disease 

4. With regular antenatal check-ups 

5. With no history of ( previous) abortion 

Not on any treatment of refractive error with spectacles /ocular surgery. 

The criterion for selection of pregnancy induced hypertension is based on 

symptoms, signs of the disease and investigations to evaluate the significance 

of physiological eye changes during the course of pregnancy. 

Prior to the study, each subject was informed in detail of its objectives, the 

aim of the research protocol and the methods to be used. Their consent was 

obtained. They were well educated and motivated regarding the procedures 

so as to extend the best co-operation in various examination protocols. Their 

information was collected in a proforma. Along with antenatal examinations, 

local examination of both the eyes was performed by snellen’s test, Jaeger’s chart, 

is Chihara’s, slit lamp, keratometry, schiotz tonometry and ophthalmoscope. 

The Distant Visual Acuity: Measured by Snellen’s chart. 

Principle: Two distant points can be visible as separate only when they subtend 

an angle of 1 minute at the nodal point of the eye. 

Procedure: The subject is asked to read the chart with each eye separately and 

the visual acuity is recorded. Normal person should read at least the 7th line 

i.e. visual acuity of 6/6 (20/20 in terms of feet/ 20-20 vision). 

Visual acuity for near was measured by Jaeger’s chart. 

Keratometry / Ophthalmometry or Bausch & Lomb Keratometer 

Principle: The anterior surface of the cornea acts as a convex mirror; so the 

size of the image produced varies with its curvature. Therefore from the size 

of the image formed by the anterior surface of cornea (first Purkinje image), 

the radius of curvature of cornea can be calculated. The accurate measurement 

of the image size is obtained by using the principle of visible doubling. The 

radius of curvature of the anterior surface of the cornea is 7.7 - 7.8mm. 

Both the eyes of all the patients were examined thoroughly for anterior 

segment abnormalities with slit lamp bio-microscope. The intraocular 

pressure was measured with schiotz tonometer (three readings of IOP were 

measured and the mean was recorded). Pupillary reactions were noted with 

direct and indirect light reflexes. Fundus findings were recorded with indirect 

ophthalmoscopy. The media haze was noted, optic discs were examined for 

their margins, size, and color and cup to disc ratio is evaluated. Retinal blood 

vessels and background were examined for any pathological changes. Macula 

and foveal reflexes were observed. 

446


Hypertensive retinopathy was graded according to KEITH WAGNER and 

BAKER classification (1939). 

Grade Ι 

Grade ΙI 

Grade ΙII 

Grade ΙV 

Mild to moderate narrowing or sclerosis of smaller arterioles. 

Moderate to marked narrowing of arterioles, exaggeration of 

light reflex, changes at the arteriovenous crossings (AV crossings). 

[deflection of veins at AV crossings (Salu’s sign)] 

Along with grade II changes, copper wiring of arteries, banking 

of veins distal to AV crossings (Bonnet sign), tapering of veins 

on either side of AV crossings (Gunn’s sign), cotton wool spots , 

flame shaped hemorrhages. 

All features of grade ΙΙΙ as well as papilledema. 

Blood investigations like fasting/random blood sugar levels (to assess diabetic 

status), total and differential leucocytic counts and ESR were carried out. 

Complete macroscopic and microscopic urine examination was conducted 

to rule out urinary or systemic diseases. Tests for HIV and HbSAg were 

performed. Blood pressure evaluation was done to assess the hypertension 

status. 

RESULTS 

A total of 105 pregnant women visiting the Obstetric out patient department 

of Mamata General Hospital, Khammam were included in the present study. 

30 control group were taken from M.B.B.S students of same age group from 

Mamata Medical College. 

In the present study all the cases observed had normal visual acuity in all 

the trimesters of pregnancy, but visual disturbance has been observed with 

loss of vision approaching to 6/36 in eclamptic patients during 30 weeks of 

pregnancy which has recovered to 6/9 in the postpartum period. 

Among 135 patients, 105 patients were observed with increased pigmentation 

around cheeks and eyelids termed as chloasma. 

In this present study, one case of ptosis was observed and the patient was 

followed for 2 months postpartum which partially improved. 

Table 1: Corneal Curvature 

1st Trimester 

2nd Trimester 

EYE F-ratio MEAN SD MEAN SD P-value 

CORNEAL RE 48.719 7.7823 0.050 7.8587 0.012 < 0.001 

CURVATURE LE 50.248 7.7900 0.0511 7.8683 0.0136


0.050; in left eye it is 7.7900 +/- 0.0511, During 2nd trimester the mean corneal 

curvature in right eye is 7.8587 +/- 0.012; in left eye it is 7.8683 +/-0.0136 as 

shown in Table 1. Here the mean corneal curvature in both the eyes increased 

from first to second trimester. The estimated P value for 1st trimester and 2nd 

trimester corneal curvature in both the eyes is < 0.001. There is significant 

increase in corneal curvature. 

448 

Table 2 

1st Trimester 

3rd Trimester 


CORNEAL RE 48.719 7.7823 0.050 7.8783 0.033 < 0.001 

CURVATURE LE 50.248 7.7900 0.0511 7.8867 0.0345


trimester and control group corneal curvature in right and left eye is 0.19 and 

0.048 respectively. There is no significant difference between 1st trimester and 

control group. 

Table 5 

2nd Trimester 

3rd Trimester 


CORNEAL RE 48.719 7.8587 0.012 7.8783 0.033 0.207 

CURVATURE LE 50.248 7.8683 0.0136 7.8867 0.0345 0.260 

During 2nd trimester the mean corneal curvature in right eye is 7.8587 +/- 

0.012; in left eye is 7.8683 +/-0.0136. During 3rd trimester the mean corneal 

curvature in right eye is 7.8783 +/- 0.033; in left eye is 7.8867+/- 0.0345. The 

estimated P value for 2nd trimester and 3rd trimester corneal curvature in 

both the eyes is 0.2. There is no significant difference between 2nd and 3rd 

trimester. 

Table 6 

2nd Trimester 

PIH 


CORNEAL RE 48.719 7.8587 0.012 7.8800 0.040 0.401 

CURVATURE LE 50.248 7.8683 0.0136 7.8720 0.0242 1.000 

During 2nd trimester the mean corneal curvature in right eye is 7.8587 +/- 

0.012; in left eye it is 7.8683 +/-0.0136. In PIH the mean corneal curvature in RE 

is 7.880 ± 0.040; in LE it is 7.8720 ± 0.024. The estimated P value for 2nd trimester 

and in PIH corneal curvature in RE 0.4 and LE 1.000. There is no significant 

difference between 2nd trimester and PIH. 

Table 7 

2nd Trimester 

Control 


CORNEAL RE 48.719 7.8587 0.012 7.8090 0.012 < 0.001 

CURVATURE LE 50.248 7.8683 0.0136 7.8133 0.0132 < 0.001 

During 2nd trimester the mean corneal curvature in right eye is 7.8587 +/- 0.012; 

in left eye it is 7.8683 +/-0.0136. In control group the mean corneal curvature in 

RE is 7.8090 ± 0.012; in LE it is 7.8133 ± 0.0132. Here the mean corneal curvature 

is increased in 2nd trimester when compared with control group in both 

the eyes. The estimated P value for 2nd trimester and control group corneal 

curvature in both the eyes is < 0.001. There is significant increase in corneal 

curvature. 

449


Table 8 

3rd Trimester Control 


CORNEAL RE 48.719 7.8783 0.033 7.8090 0.012


Comparision of Intraocular Pressure Values 

Table 1 

1st Trimester 

2nd Trimester 

INTRA EYE F-ratio MEAN SD MEAN SD P-value 

OCULAR RE 82.828 14.000 0.687 12.440 0.996 < 0.001 

PRESSURE LE 115.872 13.520 0.854 12.533 1.097 < 0.001 

During first trimester the mean IOP in right eye is 14.000 ± 0.687, in left eye it 

is 13.520 ± 0.854. During second trimester the mean IOP in RE is 12.440 ± 0.996; 

in left eye it is 12.533 ± 1.097. Here the mean IOP decreased from first to second 

trimester. The estimated p value for 1st trimester and 2nd trimester in both the 

eyes is < 0.001. There is decrease in IOP. 

Table 2 

1st Trimester 

3rd Trimester 


OCULAR RE 82.828 14.000 0.687 11.620 0.969 < 0.001 

PRESSURE LE 115.872 13.520 0.854 11.240 0.906 < 0.001 

During first trimester the mean IOP in right eye is 14.000 ± 0.687, in left eye 

it is 13.520 ± 0.854. During 3rd trimester the mean IOP in RE is 11.620 ± 0.969; 

in left eye it is 11.240 ± 0.906. Here the mean IOP decreased from first to third 

trimester. The estimated P value for 1st trimester and 3rd trimester in both the 

eyes is


During first trimester the mean IOP in right eye is 14.000 ± 0.687, in left eye it 

is 13.520 ± 0.854. In control the mean IOP in RE 15.893 ± 1.201; in left eye it is 

16.290 ± 1.006. Here the mean IOP decreased in 1st trimester when compared 

with control group. The estimated P value for 1st trimester and control group 

in both the eyes is


Table 8 

3rd Trimester 


OCULAR RE 82.828 11.620 0.969 12.720 1.095 0.006 

PRESSURE 

LE 115.872 11.240 0.906 12.760 0.768 < 0.001 

During 3rd trimester the mean IOP in RE is 11.620 ± 0.969; in left eye it is 11.240 

± 0.906. In PIH the mean IOP in RE is 12.720 ± 1.095; in LE it is 12.760 ± 0.768. 

The estimated P value for third trimester and PIH IOP in right and left eye is 

0.006 and < 0.001 respectively. Here the IOP decreased In 3rd trimester when 

compared with PIH. 

Table 9 

3rd Trimester 

PIH 

Control 


OCULAR RE 82.828 11.620 0.969 15.893 1.201 < 0.001 

PRESSURE 

LE 115.872 11.240 0.906 16.290 1.006 < 0.001 

During 3rd trimester the mean IOP in RE is 11.620 ± 0.969; in left eye it is 11.240 

± 0.906. In control the mean IOP in RE 15.893 ± 1.201; in left eye it is 16.290 ± 

1.006. Here the mean IOP decreased in 3rd trimester when compared with 

control group. The estimated P value for 3rd trimester and control group in 

both the eyes is < 0.001. There is significant decrease in IOP. 

Table 10 

PIH 

CONTROL 


OCULAR RE 82.828 12.720 1.095 15.893 1.201 < 0.001 

PRESSURE 

LE 115.872 12.760 0.768 16.290 1.006 < 0.001 

In PIH the mean IOP in RE is 12.720 ± 1.095; in LE it is 12.760 ± 0.768. In control 

the mean IOP in RE 15.893 ± 1.201; in left eye it is 16.290 ± 1.006. Here the mean 

IOP decreased in PIH when compared with control group. The estimated P 

value for PIH and control group in both the eyes is < 0.001. There is significant 

decrease in IOP. 

A case of uveitis was observed during 24 weeks gestational age presented 

with chronic non-infectious anterior uveitis with inferiorly distributed brown 

coloured keratic precipitates, mild flare, and 2+ cells (i.e. 10-20 cells/cu mm). 

She was instructed not to use any medication. Patient was followed monthly. 

Uveitis activity gradually decreased during the course of pregnancy and 

flared up 2 months after postpartum period. This shows that pregnancy has a 

beneficial effect on uveitis. 

453


Among 15 cases of PIH, we found two cases (13.3%) presenting with headache 

and pedal edema for 6 days. The blood pressure was above 140/100 mmHg 

and vision was 6/6 for both of the cases. Anterior segment examination 

was normal. Fundus picture showed hypertensive retinopathy changes 

like moderate arteriolar narrowing and arteriovenous crossing changes 

i.e. deflection of veins at AV crossings (Salu’s sign). Diagnosed as Grade ΙΙ 

Hypertensive retinopathy in both cases. 

Two cases presented with serous retinal detachment. 

The clinical manifestations of these women are presented here. 

Patient 1 Patient 2 

Age (years) 22 25 

Gestational age at the 32 weeks 34 weeks 

time of admission 

Blood pressure 160/120 mmHg 180/130 mmHg 

Visual acuity at the time RE-6/18 RE-6/12 

of presentation LE6/60 LE-6/6 

RE –localized exudative Retinal edema surrounding 

Ophthalmologic detachment inferior to macula the macula and small serous 

examination LE- localized exudative retinal detachment inferior 

detachment involving macula and temporal to macula 

excluding fovea, hemorrhagic in right eye is present. 

spot inferior to macula 

Left eye is normal 

Visual acuity in RE-6/6 RE-6/6 

postpartum period LE-6/9 LE-6/6 

3 weeks postpartum 

Fundus picture during Retinal detachment Complete recovery is 

postpartum period was no longer present present without any 

residual changes within 

a month of postpartum 

period 

Central Serous Retinopathy 

Serous Retinal Detachment 

454


In this present study we found one case (35 weeks GA) presenting with 

central scotoma for ten days. Her visual acuity at the time of presentation 

was 6/12 in right eye and 6/6 in left eye. Anterior segment examination was 

normal. On fundus examination, there was retinal edema surrounding the 

macula and white subretinal exudate temporal to the macula in right eye and 

normal fundus picture in left eye. Right eye was diagnosed as central serous 

retinopathy. During postpartum period her vision gradually improved and 

she attained vision of 6/6 in both the eyes. Fundus picture showed resolution 

of retinal edema, mild mottling and subretinal exudate in right eye. 

We found a case presenting with convulsions, 4-5 episodes on the day of 

presentation. History of associated headache and epigastric pain, pedal edema 

and facial puffiness was present. Her visual acuity at the time of presentation 

was 6/36 in both eyes. Anterior segment was normal. Fundus picture showed 

bilateral disc edema and hemorrhages surrounding the optic disc, cotton wool 

spots and retinal edema surrounding macula in right eye. The diagnosis was 

grade ΙV hypertensive retinopathy. During postpartum period her vision 

improved to 6/12 in both eyes within a month. Fundus picture showed 

regression of optic disc edema and cotton wool spots. 

DISCUSSION 

Pregnancy is often associated with ocular changes which may be more 

commonly transient but occasionally permanent. 

Visual acuity is one such condition where it is not affected because of the 

normal refractive status despite the increased corneal curvature and decreased 

refractive index during normal pregnancy. In the present study all had normal 

visual acuity in all trimesters of pregnancy except in PIH cases where there is 

decreased visual acuity which returned to normal in the postpartum period. 

Chloasma is a hormonally mediated process, characterized by increased 

pigmentation around eyes and cheeks. In the present study 105 pregnant 

women showed chloasma most of them showed around cheeks. 

Somani S98 reported a case of unilateral ptosis during and after normal 

pregnancy. In this present study a case of ptosis was observed and patient 

followed for 2 months postpartum where the ptosis partially improved. 

Corneal Curvature 

Park Steve B et. al. prospectively followed 24 women during pregnancy, 

postpartum period and after cessation of breast feeding. Six (25%) women 

developed contact lens intolerance during the study period. Statistically 

significant (P value- 0.05) increase in corneal curvature during the second and 

third trimester which resolved postpartum was observed. 

455


It is seen that corneal curvature increases as the pregnancy advances. 

According to graph 3 (right eye) and graph 4 (left eye), in the present study 

there is statistical significant increase in corneal curvature in second trimester 

(P value-


Figure 1: IOP Compared among different 

groups in RE 

IOP Compared among Different Groups 

in LE 

Qureshi IA et. al. (1996) investigated whether or not the high blood pressure 

found in late pregnancy influences the known ocular hypotensive effect of 

late pregnancy. In the second and third trimester subjects, they found the 

mean intraocular pressure was significantly lower than in the non-pregnant 

control group. The difference between 1st and 2nd, 1st and 3rd, and 2nd and 

3rd trimesters of pregnancy were (mean ± s.d) -0.5 ± 1.2(P < 0.05), -1.5 ± 1.7 (P 


trimester hypertensive and third trimester normotensive pregnant women 

was RE- P 0.006, LE -< 0.001. 

Uveitis 

C-C Chan et. al. observed four pregnant women in their first trimester with 

chronic non-infectious uveitis and were followed monthly till 6 months after 

delivery. They found uveitis 

activity decreased after the 

first trimester, but flared in 

early postpartum period. 

Kubicka-Trzasks A (2004) 

followed four pregnant 

women aged 16-21 years 

with uveitis of unknown 

etiology. Vitreous flare and 

cells were present in all 

cases. They were followed 

during pregnancy as well as 3-8 months after delivery. In all patients gradual, 

total regression of intraocular inflammation with the improvement of visual 

acuity in three cases were noted. This shows that pregnancy has a positive 

influence on pregnancy. 

A case of uveitis was observed in the present study with unknown etiology 

during 2nd trimester presented with chronic non-infectious anterior uveitis 

and was instructed not to use any medication. Flare and cells present. 

Gradually the activity got reduced during the course of pregnancy and flared 

up two months after postpartum period. This shows that pregnancy has 

beneficial effects in pregnancy. 

Retinal Changes 

Significant fundus changes are expected in PIH when compared to normal 

pregnancy. Focal and less often generalized, retinal arteriolar narrowing 

is the most common ocular change seen in preeclampsia. Early studies by 

Wagner found these changes in 40% to 100% of preeclampsia patients, but 

the study of Schreyer found these changes in only 5 out of 106 cases (4.7%) 

of preeclampsia and in one of 21 severe preelamptic patients. These studies 

suggest that arteriolar changes may help to distinguish those patients with 

preexisting chronic hypertension from those with preeclampsia. Sathish S et. 

al. reported spasm and narrowing of retinal veins in 70% of cases of toxemia. 

In the present study we found two cases (13.3%) presenting with headache 

and pedal edema for 6 days. The blood pressure was above 140/100 mmHg 

and vision was 6/6 for these cases. Anterior segment examination was normal. 

458


Fundus picture showed grade ΙΙ hypertensive retinopathy in both the cases 

(i.e. moderate arteriolar narrowing and arteriovenous crossing changes). 

CSR 

Gass JDM 35 reported that 90% of pregnant women with central serous 

retinopathy develop white fibrinous subretinal exudates usually in third 

trimester. Cruysberg J.R et. al. reported CSR in three pregnant women. 

All of them presented with central scotoma and symptoms disappeared 

spontaneously after delivery. 

In this present study we found one cases (6.6%) (35 weeks GA) presenting with 

central scotoma for ten days. Her visual acuity at the time of presentation was 

6/12 in right eye and 6/6 in left eye. On fundus examination there was retinal 

edema surrounding macula and white subretinal exudate temporal to macula 

in right eye and normal fundus picture of left eye. Right eye was diagnosed 

as central serous retinopathy. During postpartum period her vision was 

gradually improved and she attained vision of 6/6 in both the eyes. Fundus 

picture showed resolution of retinal edema, mild mottling and subretinal 

exudate in right eye. 

In conclusion the intraocular pressure decreased in 1st, 2nd, 3rd trimester 

and PIH cases when compared to the control group. Intraocular pressure 

levels decreased more in 3rd trimester when compared to 1st trimester with P 

value


Colour Vision Problems in The Paintings by 

Rabindranath Tagore 

Dr. Jajneswar Bhunia 

Nobel Laureate Rabindranath Tagore is internationally well known for his 

extra-ordinary literary works, especially the “Geetanjali”. He had started 

drawing sketches and created many color paintings towards the later part of 

his life. Plenty of comments from many prominent personalities regarding the 

unusual use of color in Rabindranath’s paintings are available in literatures 

and biographies. 1,2 

Tagore met the famous intellectual Romain Rolland at Villeneuve in Italy in 

July, 1926. According to Rolland, “Tagore said that he could respond very little 

or not at all to the ‘red’ color. In Italy, Tagore was not at all attracted to the 

wide fields of red poppy flowers, almost like a spreading fire engulfing the 

countryside. On the other hand, he used to have immense pleasure in looking 

at the various shades of blue and violet colors”. 2 

Stella Kramrisch 1 was the famous international art historian from Austria. 

Rabindranath invited her for teaching the students of Kalabhaban at 

Shantiniketan. She had spent long time staying within the campus of 

Shantiniketan around 1920s and closely watched the paintings of Rabindranath. 

She commented “Reds would be dark or even black while greens would be 

light in tone, and, in using these colors in ‘conjoint effect’ Tagore would be 

influenced by differences of tone and perhaps not at all by the differences of 

colors as we see them.” 2,9 

John Dalton first reported about defective color vision as an experience of his 

own color blindness named as “Extraordinary facts relating to the Vision of 

Colors” in 1794. He had described “That part of the image which others call 

red appears to me little more than a shade, or defect of light”. In common 

with his brother he confused Scarlet with Green and Pink with Blue. Dalton 

supposed that his vitreous humour was tinted blue, selectively absorbing 

longer wavelengths. He instructed that his eyes should be examined after his 

death. His family physician did an autopsy examination of the eyes only to 

find out that the vitreous was perfectly clear. After 150 years David M. Hunt 

et. al. did a chemical analysis of the old DNA extracted from the preserved eye 

of John Dalton to arrive at a resolution that the great scientist John Dalton was 

a Dichromat…….a Deuteranope. 3 

John Dalton himself was aware of his defective color perception and left a 

vivid description of his mistakes and confusions in recognizing colors. His 

preserved eye was also available for DNA analysis. Accordingly David M. 

Hunt et. al. could conduct a direct chemical analysis of his body tissue as well 

460


as compare the phenotype available from Dalton’s own descriptions. 

The situation for Rabindranath is different and difficult. We have only his 

color paintings for study and analysis for arriving at a decision regarding his 

defective color perception. 

Aims of the study is to considering all the above information it was decided 

to make a thorough search and review of all the available scientific literatures 

regarding defective color perception of Rabindranath and related articles and 

analyse them for arriving at a decision. The aims and objectives of this study 

are: 

1. To collect together the research works on the defective color perception of 

Rabindranath and related articles. 

2. Arriving at a decision whether Rabindranath had defective color 

perception or not. 

3. To categorise the type of his color defect if possible. 


Published research works and books having the following criteria were 

collected and studied: 

1. Study on the paintings of established color defective painters. 

2. Study on the paintings of color defective painter while copying from a 

normal color painting. 

3. Study of the paintings of Rabindranath to find out the evidence of his 

defective color perception. 

Researches on Rabindranth’s defective color perception is scanty and only one 

such published article was located. However plenty of research works on the 

colored paintings of color defective artists are available. 

An exhaustive book in Bengali language is available displaying the evidences 

of extensive research works on the defective color perception of Rabindranath 

Tagore. 

All these available informations have been collectively discussed in this study. 

RESULTS 

R W Pickford 4 has reported about the artist of Edinbugh, Mr. John T. Nicol 

who was having defective color perception as tested by Ishihara pseudo= 

isochromatic color plates, Edridge Green Lantern and Pickford Nicholson 

Anomaloscope. The category of his defect was Protanope. His 12 paintings 

were analysed by the author. He had a small weakness in the Green/ Blue 

test but his vision for blue and yellow was not affected. Most of his paintings 

461


were mainly using browns and black, but yellow / green and blue were used 

sometimes. He never used reds and greens together in the same painting. 

Charles Meryon, 5 an important artist of the 19th century, was color defective 

that was noted on his medical examination while joining the Navy. Meryon’s 

famous oil painting “Ghost Ship” reveals the color-defective artist’s typical 

preference for blue and yellow. He also shifted to the art of etching later in life. 

An amateur artist 6 was diagnosed as having extreme deuteranomaly using 

standard clinical tests. The artist limited his palette to short-wave blues and 

blue-greens and long wave yellow, orange and red. He avoided use of yellowgreens 

of which he was uncertain. When asked to copy an existing art work 

by a normal artist, the most obvious area of difficulty he experienced was in 

reproducing greens and yellow-greens. He especially made mismatches for 

the colors of red and yellow in shade areas. 

Richard Liebreich 7 pointed out in a London exhibition of 1871, a painting 

showed roofs as oxen red on the sunny side but green where shadowed. 

He suggested that it indicated that the painter was a red–green color vision 

defective. Angelucci called this “Liebreich’s sign” when he described the works 

of six painters known to be red–green defectives, whose pictures showed this 

characteristic. 

R. W. Pickford has described that a deuteranomalous artist’s preference in 

painting was to employ subdued colors in which red and green were used very 

little or not at all, but can display strong constructional patterns in yellows and 

blues. 7 Protanope’s possible difficulties and faults which might be caused by 

his peculiarities of color vision are red, may be greatly darkened for him, and 

red or green, in so far as red can be seen at all, are indistinguishable. What a 

protanope calls yellow, orange and red are most probably different intensities 

and saturations of what we should call green. A protanomalous subject, uses 

red, gold and blue to build strong designs, but very seldom makes any use of 

green. 8 

R. W. Pickford and Dr. J. Bose have studied the drawings and paintings of 

Rabindranath Tagore at Shantiniketan and analysed 5 of his paintings. 2 The 

five pictures they studied were quite compatible with the possibility that 

Rabindranath Tagore was a protanope, and, indeed, their coloring definitely 

suggested such a hypothesis. Three of his paintings have been done mainly 

with very dark colors, such as black or dark brown, sometimes reddish, 

bluish or purplish, and dark brown and black might be equivalent to red for 

a protanope in hue. It is evident that none of them show Liebreich’s Sign— 

red is not represented by green when in shadow in any of them. However 

Pickford studied Liebreich’s Sign, which is that red where shadowed should be 

represented by green (1967). He studied 118 pictures by twenty colour vision 

462


defective artists and showed that the sign was not a reliable guide. 7 Many of 

the paintings of faces by Rabindranath have displayed an excessive use of 

dark brown color and that has been described by almost all the literatures in 

this regard being characteristic of a protanope. 

Ketaki Kushari Dyson, Sushovan Adhikary and Robert Dyson have done an 

extensive research work on the defective color perception of Rabindranath 

and published a book of more than 800 pages named “Ronger Rabindranath” 

in this regard in Bengali language. Analysing all the related literatures, 

personal letters of Rabindranath, comments of relatives and of course many 

colored paintings by Rabindranath they have concluded Rabindranath to be 

a protanope. 9 

In conclusion congenital color vision defect is a genetic disorder and mistakes 

in the choice of color by a color defective artist are the expression that is the 

phenotype of his genetic defect. All these studies under consideration are 

based on the expressions of errors in the choice of colors of a color defective 

painter, reflected in his created paintings. The conclusion arrived is only on 

the retrospective study of the phenotypes. 

We must recall that the study and analysis of the vivid descriptions of Dalton’s 

own confusions of colors led the researchers to arrive at a decision that Dalton 

was a protanope. Contrary to this conclusion the chemical analysis of the 

extracted DNA from Dalton’s preserved eye ultimately established that Dalton 

was a Deuteranope. 3 

No tissue sample of Rabindranath is available for the chemical analysis of 

DNA and so it will be prudent by studying only the phenotype that is the 

paintings of Rabindranath, only to conclude that Raindranath Tagore was 

having defective color perception of red=green deficiency. 

REFERENCES 

1. Amrit Sen : “Beyond Borders”: Rabindranath Tagore’s Paintings and Visva-Bharati: 

Rupkatha Journal Vol. 2 No 1; pp. 34-43. 

2. R. W. Pickford and J. Bose : colorVision and Aesthetic Problems in Pictures By 

Rabindranath Tagore : Bnttsh Journal of Aesthetics, 1987;27:70-5 (winter). 

3. David M. Hunt, Kanwaljit S. Dulai, James K. Bowmaker, John D. Mollon: The 

Chemistry of John Dalton’s color Blindness: Science; 1995;267:984-8. 

4. R W Pickford : A color vision defective artist : Brit J Aesthetics 1973;13:384-7. doi: 

10.1093/bjaesthetics/13.4.384 

5. James G. Ravin, MD, Nancy Anderson,and Philippe Lanthony, MD: An Artist with 

a Color Vision Defect: Charles Meryon: Survey of Ophthalmology. 1995;39:403-8. 

6. Barry L Cole Ph D M App Sc BSc LOSc, Jonathan Nathan DSc (hc) MAppSc BSc 

LOSC: An artist with extreme deuteranomaly: Clinical and Experimental Optometry 

2002;85.5:300-5. 

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7. R W Pickfors : Liebreich’s Sign for Defective color Vision among Artists: Nature 

215,542 (29 July 1967); doi:10.1038/215542a0. 

8. R W Pickford : The Influence of color Vision defects on Paintings: Brit J Aesthetics 

1965;5(3):211-26. doi: 10.1093/bjaesthetics/5.3.211. 

9. Ketaki Kushari Dyson, Sushobhan Adhikary and Robert Dyson: Ronger 

Rabindranath: Ananda Publishers Pvt. Ltd. 1997. 

Early Rise in Intraocular Pressure (IOP) 

after Uncomplicated Cataract by 

Phacoemulsification: A Myth? 

Dr. Monika Jethani, Dr. Jitendra Jethani, Dr. Ramchandra Kaushik, 

Dr. Rupa Jain 

There is a rise in intraocular pressure following cataract surgery in the 

immediate postoperative period. 1-4 Various causes like incision size, 

trabecular meshwork distortion, trabeculitis, unwashed viscoelastic etc. have 

been attributed to this rise in IOP in the immediate postoperative period. 1-6 

The central corneal thickness (CCT) may increase immediate post cataract 

surgery (phacoemulsification) and corneal hysteresis (CH) has been shown to 

reduce. 7 We did a study to evaluate the immediate postoperative IOP following 

uncomplicated cataract surgery. 


A total of 80 patients (80 eyes) were included in this prospective interventional 

study. All the surgeries were uncomplicated standard cataract surgeries with 

phacoemulsification. Goldmann applanation tonometer (Zeiss, Germany) 

was used to measure the preoperative and postoperative IOP at 6 hours 

postoperative (RK). Ultrasonic pachymeter (Sonomed, India) was used 

measure the CCT preoperative and immediate postoperatively by one of the 

authors (MJ). Patients with severe inflammation (cells 2+), corneal edema, 

visual acuity less than 6/12 at the time of examination were excluded from the 

study. The findings were recorded and analysed using a microsoft excel sheet. 

RESULTS 

A total of 80 patients (80 eyes) were included in the study. Mean age of patients 

was 62.6+/- 10.4 years. Mean CCT preoperative and postoperative was 518.4+/- 

33.7 microns and 575.1+/-50.9 microns respectively. Mean IOP before surgery 

was 16.1+/-3.1 mm of Hg. Mean postoperative IOP was 17.8+/-3.6 mm of Hg. A 

student t test was performed and P value was 0.03 which is suggestive of a rise 

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in IOP. It is here the importance of CCT comes into the picture. On correcting 

the preoperative and postoperative IOP with regards to CCT the result was 

surprising. Mean IOP preoperative on correction with the standard CCT 

correction chart was 18.1+/-7.5 mm of Hg and postoperatively corrected IOP 

was 15.8+/-7.4 mm of Hg. Again a student t-test was performed which clearly 

showed that in fact there was a significant reduction of IOP and the difference 

was statistically significant. 

On further analysis with regards to the type of IOL either rigid IOL (Single 

piece 5 mm PMMA) or foldable IOL (single piece acrylic hydrophobic) the 

patients were sub grouped into two. The rigid IOL was implanted in 49 eyes 

and foldable IOL was implanted in 31 eyes. All the rigid IOLs were of a single 

company and the foldable IOLs were also of a single company. 

The results were surprising. The rigid IOL group has a preoperative CCT of 

519.1 +/- 32.2 microns and postoperative CCT of 580.3 +/- 53.2 microns. The 

preoperative IOP was 15.8 +/- 3.0 mm of Hg and postoperative IOP was 16.3 +/- 

6.1 mm of Hg. The P value was 0.6 and was not significant. The CCT corrected 

IOP was 17.4 +/- 3.9 mm of Hg pre-operatively and postoperatively it was 13.8 

+/- 5.7 mm of Hg. The P value was 0.0004 which was highly significant. 

DISCUSSION 

A lot of work has been done on the change in IOP, CCT and corneal hysteresis 

following cataract surgery of various types including extraceapsular, small 

Incision cataract surgery and phacoemulsification; 1-7 however, the only few 

studies have actually correlated and measured CCT 7 and its relation to the early 

postoperative IOP changes. 8,9 Bhallil et. al. found decrease in IOP after clear 

corneal phacoemulsification which was recorded on the 15th day, lst, 2nd, 3rd 

and 6 months after surgery. 10 Sharma et. al. 9 found IOP rises significantly on 

day one in extra capsular cataract surgery and small incision cataract surgery 

thereafter comes down slightly by day 2 and rapidly by day 7. After 1 week to 3 

months, IOP decline is very gradual and there after ceases to decrease. Cohen 

et. al. observed that 6% of their patients had rise in IOP on the 1st post-op day. 

Hager et. al. 7 measured CCT and intraocular pressure by non contact tonometry 

(NCT) and Goldmann applanation tonometry (GAT) in clear corneal cataract 

surgery. CCT increased from 556.82 +/- 32.5 micron before surgery to 580.26 

+/- 45.5 micron after surgery (P < .001). NCT values rose from 17.85 +/- 3.8 mm 

Hg before surgery to 20.10 +/- 6.3 mm Hg after surgery. GAT values were 14.85 

+/- 2.8 mm Hg before surgery and 15.24 +/- 4.1 mm Hg after surgery (P = .52). 

Thirumalai et. al. 8 measured IOP pre-operatively and 2 hours, 1 day, and 1 

week postoperatively. From 1 week before surgery, there was a mean rise in 

IOP of 8.14 mm Hg 2 hours after surgery followed by a mean fall of 5.18 mm Hg 

465


at 24 hours (next-day review). The mean fall in IOP at 1 week was 2.94 mm Hg. 

10 percent of patients had an IOP greater than or equal to 35 mm Hg 2 hours 

postoperatively. 

Although a lot of literature has been available on the measurement of 

postoperative IOP after cataract surgery, none of the studies have been planned 

properly. Only two studies actually measure the pressure within 6 hours of 

the surgery. Both the studies Sharma et. al. 9 and Thirumalai et. al. 8 have not 

measured CCT and therefore show an increase in the post-op IOP which may 

be secondary to thicker cornea postoperatively. 

Our findings are similar to Hager et. al. 7 with regards to increase in CCT 

after uncomplicated phacoemulsification. Also, GAT readings of their study 

are similar to our study. They have not tried to compare the reduction of IOP 

secondary to this rise in CCT post-cataract surgery which is obvious. Other 

studies failing to measure the CCT do indicate that there is a rise in IOP in 

immediate postoperative period which gradually falls whereas it is actually 

the CCT which may gradually reach to preoperative value and thus pseudostabilize 

the IOP. 

In conclusion our study clear implicates the rise in CCT postoperatively and 

links this with the pseudo-rise of IOP recorded immediately after cataract 

surgery. It is conclusively proved that there is rise in CCT in the immediate 

postoperative period of an uncomplicated phacoemulsification. 

REFERENCES 

1. Gormaz A. Ocular tension after cataract surgery. Am J. Ophthalmol 1962;53:832. 

2. Rich WJ, Radke ND, Cohan BE. Early ocular hypertension after cataract extraction. 

Br J. Ophthalmology 1974;58:725. 

3. Raduis RL, Schultz K, Sobocinski K, Schultz RO, Easom H. Pseudophakia and 

intraocular pressure. Am J. Ophthalmol 1984;97:738. 

4. Gross JG, Meyer DR, Robin AL, Filar AA, Kelly JS. Increased pressure in the 

immediate postoperative period after extra capsular cataract extraction. Am J. 

Ophthalmology 1989;105:466. 

5. Kim JW. Comparative study of intraocular pressure change after cataract surgery: 

phacoemulsification and extra capsular cataract extraction. Korean Journal of 

Ophthalmology. 1996;10:104-8. 

6. Cohen VM, Demetria H, Jordan K, Lamb RJ, Vivian AJ. First day post-operative 

review following uncomplicated phacoemulsification. Eye (Lond). 1998;1:634-6. 

7. Hager A, Loge K, Fullhas MO, Schroeder B, Grhbherr M, Wiegand Wolfgang. 

Changes in Corneal Hysteresis After Clear Corneal Cataract Surgery. Am J. 

Ophthalmol 2007;144:341-6. 

8. Thirumalai B, Baranyovits PR. Intraocular pressure changes and the implications 

on patient review after phacoemulsification. J. Cataract Refract Surg. 2003;29:504-7. 

466


9. Sharma PD, Madhavi MR. A comparative study of postoperative intraocular 

pressure changes in small incision vs conventional extra capsular cataract surgery. 

Eye (Lond). 2010;24:608-12. 

10. Bhallil S, Andalloussi I, Chraibi F, Daoudi K, Tahri H. Changes in intraocular 

pressure after clear corneal phacoemulsification in normal patients. Oman J. 

Ophthalmol 2009;2:111-3. 

Ophthalmic Cellphone Imaging System – A 

Costless Imaging System 

Dr. Murali Mohan Gurram 

Imaging is an important procedure for various purposes. If we want to share 

our clinical cases with others, the best way for that is with images. A single 

image can tell more tales than 100 words. In day to day professional life, we 

come across many interesting cases. These can be shared with students or 

others with good images. Imaging is very important for various purposes like 

teaching, documentation, patient education, progress of disease etc. 

Slit lamp imaging system are very expensive with MNC one being 

approximately 6 lakhs and indigeneous ones approximately 3.5 lakhs. Many 

of the private practitioners do not have this system. A digital camera can 

be used for the same purpose, but needs some investment, some hardware 

modifications and it needs to be carried. 

There is a search for an instrument which can give images and doesnot need 

any extra equipment. I found the answer in my cellphone. 

My Cell Phone 

My cellphone is Motorola A1600, which has an effective 2 MP camera. It gives 

a resolution of 1536 x 2048 pixels. It gives reasonably good images of anterior 

segment. With little learning we can capture good images of anterior segment. 

With little extra effort, we can even take Optic disc images. Most important 

of all, I need not carry any equipment, as my mobile is always in my pocket. 


I use an old model of Appasamy slitlamp. The imaging is an uniocular 

procedure. Room lights are switched off for a better contrast. The lesion is 

focused with necessary slitlamp adjustments. Diffuse light is used for large 

lesions like pinguecula and pterygium. Slit beam is used for corneal and lens 

sections. Retroillumination for media opacities. The illumination of slit lamp 

is reduced to reduce the dazzling light reflex. Lesion is seen uniocularly in both 

objectives. The objective with better focusing is selected. Low magnification 

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Examples of Bitot’s Spot 

Early Mid Classic 

is initially used. The 

cell phone camera is 

placed at the respective 

eyepiece and image 

PCO 

Slightly Displaced 

is seen on the mobile 

screen. Minor focusing 

adjustments are done 

with micro-movements 

of joystick. Once the 

image is focused, click 

the button to acquire the image. As many images can be taken as desired. Save 

the image. Next an image is taken in high magnification (10x). The image gets 

stored in the memory card of the phone. A memory card of 4 GB can store 

more than 5000 images. 

The images are transferred to the computer through USB ports. They can be 

transferred to the patients mobile with bluetooth technology (Now a days, 

most of the mobiles come with this technology). 

For the disc images, it is almost the same technique. Slitlamp illumination 

is not so low. Slit height is reduced to 3 to 5 mm. Use 10x. A rectangular 

illumination is used as a larger light will reduce the details of image. Focus 

468 

Festooned Pupil Blood staining of Wiegert’s ring,Ant. 

Post.Capsule 

Hyaloid face


the disc with 90 D or contact lens biomicroscopy. Its easier with CLB as the eye 

is stabilized. Focus it uniocularly. Place the mobile over the eyepiece and see 

the image. Click, once its focused. Its quite difficult to get the right focus. That 

task is easier with CLB. 

For the videos, the procedure is same. Once the lesion is focused. Start the 

video recording in the cellphone. Place it over the eyepiece. Move the joystick 

as required. The cellphone keeps focusing the image which gives small jerky 

movements of the video. 

Advantages of Cell Phone Imaging System 

1. The camera is never forgotten. It is always in your pocket. 

2. No extra investment. 

3. Very portable and handy. 

4. It can be used in your other working places where there is no imaging system. 

5. Images from a fundus camera can be captured by cell phone. 

6. Your images are always in your pocket. 

7. Images of CT scans and MRI scans. 

8. Easy transferability through “blue tooth” to patient’s mobile. No need for printer. 

Ultrasound Biomicroscopy as an Important Diagnostic 

Adjunct in The Management of Limbal Tumors 

Dr. Ruchi Kabra, Dr. Deepak C. Mehta, Dr. Hansa Thakkar 

Clinical assessment to assess the extent and depth of limbal masses with 

conjunctival and corneal extension is generally crude and the posterior 

margins are typically revealed either during surgery or histopathological 

examination. Pavlin and Foster were the first to describe the use of high 

frequency ultrasound to examine conjunctival tumors. 1 Over time high 

frequency ultrasound biomicroscopy (UBM) has become a well established 

method for imaging anterior segment tumors. UBM provides useful 

information regarding tumor configuration and invasion which prove to be 

of immense help in deciding the treatment protocol. In our study we report 

herein the characteristic ultrasonographic features in limbal tumors. Our aim 

was to assess in a prospective manner the posterior extent and invasion of 

limbal tumor prior to surgical intervention. 


63 cases of primary limbal tumors with conjunctival and/or corneal extension 

were enrolled in our prospective non-randomized study done between 1 April 

2008 to 31 March 2011. All patients with limbal tumors and anterior segment 

tumors are routinely subjected to imaging at the very first visit at our institute. 

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Table 1 

Clinicopathological diagnosis 

No. of patients=54 

Dermoid 18 

Lipodermoid 1 

Nevus 1 

Melanoma 2 

Haemangioma 1 

Squamous cell carcinoma 24 

CIN 7 

Table 2 

Sl. No. Features - UBM No. of Patients 

A Solid Acoustic 58 

B 

Internal 

Pattern Homogenous 47 

Hetrogenous 16 

C Thickness (Mean) mm 2.2 

D Tumor Shape-Flat 12 

Dome 32 

Sphere 5 

Multinodular 11 

E Posterior Shadowing 3 

F 

Tumor Margin Visibility 

Posterior 51 

Lateral 42 

G Breach In Descements 3 

H Involvement of Angle Structures 4 

Anteriorchamber Shallowing 4 

Ultrasound biomicroscopy uses high frequency ultrasonography 50 MHz 

and requires an eye bath to obtain images. All the patients were scanned in a 

supine position after anaesthetizing the ocular surface with topical Paracain 

drops. Photographic record was kept on thermographic paper and in electronic 

format. These images obtained had 50 micron resolution. A transverse scan 

is acquired when the back and forth movement of the transducer occurs 

parallel or tangential to the limbus. Depending on how far anterior the probe 

sweeps, this movement can produce a cross-sectional image of the cornea, 

iris, sclera, ciliary body, anterior uveal tissue. For longitudinal scanning the 

probe movement is rotated 90 degree from the position of the transverse scan. 

High frequency longitudinal B-Scan cuts are oriented much like the spokes 

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of a wheel with pupil at its centre. Longitudinal and Transverse scans were 

acquired in all cases in the study. 

Demographic data including patient age, gender, address were recorded. 

Tumor features based on slit lamp examination regarding color, size, 

shape, extent, location, dimension were noted. UBM features were recorded 

separately. Acoustic features (hollow/solid), internal pattern (homogenous/ 

heterogeneous), tumor configuration (flat, dome, sphere, mixed), tumor 

dimension, tumor thickness were noted along with extent of posterior and 

lateral margins. The invasion of descement’s membrane, anterior chamber, 

cilliary body, anterior choroid by tumor growth was recorded. The extent of 

posterior shadowing in presence of pigmented masses was noted. 

RESULTS 

During the time interval April 2008-March 2011, 63 patients were examined by 

us in our prospective study. The mean age was 48 years. 39 were males and 24 

were females. Only 54 patients were operated upon and the specific diagnosis 

according to the clinicopathological data obtained was as follows. 

Reasonably good quality images delineating the boundaries of the tumor with 

visualization of the tumor configuration was possible in most of the cases. 

The tumor surface was hyper-echoic in all patients most likely due to acoustic 

impedance between water and solid tumor surface. In contrast the stroma was 

generally hypo-echoic. The other UBM features of all the 63 cases enrolled for 

the study are as depicted in Table 2. 

DISCUSSION 

The utility of routine ultrasonography (10,20 MHz) as an imaging technique 

for a limbal tumors has limited role as most of the limbal masses are superficial 

and do not have a deep penetration. Shields et. al. in a comparative study 

in assessing anterior segment tumors by UBM and anterior segment OCT 

concluded that for anterior segment tumors UBM offers better visualization 

of the posterior margin and provides overall better images for entire tumor 

configuration compared with AS-OCT. 2 In our study we found that the detailed 

imaging of tumor configuration in limbal tumors with high frequency UBM 

is of immense help in deciding the treatment protocol in our patients also in 

tumors where deeper invasion of anterior segment tissue is suspected UBM 

proves to be a very useful diagnostic adjunct due to its ability to penetrate 

through the lesion into the eye and provide images of the posterior extension 

of the tumor. 

REFERENCES 

1. PavLinCJ,MCWhaeJA,MCGowanHD.Ultrasound biomicroscopy of anterior 

segment ocular tumors. Ophthalmology 1992:99;1220-8. 

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2. Carlos Bianciotto, MD, Carol L. Shields et. al.. Assessment of Anterior Segment 

Tumors with Ultrasound Biomicroscopy versus Anterior Segment Optical 

CoherenceTomography in 200 Cases. Ophthalmology 2011:118;1297-1302. 

3. Paul T Finger et. al. High-Frequency Ultrasonographic Evaluation of Conjunctival 

Intraepithelial Neoplasia and Squamous Cell Carcinoma. Arch Ophthalmol. 

2003;121:168-72. 

4. D H Char, G Kundert, R Bove, J B Crawford 20 MHz high frequency ultrasound 

assessment of sclera and intraocular conjunctival squamous cell carcinoma. Br J. 

Ophthalmol 2002;86:632–5. 

5. Tunc M, Char DH, Crawford JB, et. al.. Intraepithelial and invasive squamous cell 

carcinoma of the conjunctiva: analysis of 60 cases. Br J. Ophthalmol 1999;83:98–103. 

Comparing Ultrasonic Pachymetry and Anterior 

Segment OCT (AS - OCT) for Central Corneal 

Thickness (CCT) 

Dr. Monika Jethani, Dr. Jitendra Nenumal Jethani, Dr. Aditi Jain, 

Dr. Rupa Jain 

Central corneal thickness (CCT) is an important parameter in ophthalmology 

in the assessment of corneal disease and for risk profiling in ocular 

hypertension and glaucoma. CCT can be measured using a number of 

modalities including optical pachymetry, ultrasound pachymetry, Scheimpflug 

imaging, optical coherence tomography (OCT), and even Magnetic Resonance 

Imaging. 1 An extensive meta-analysis of the available literature has shown 

that mean measured pachymetry values are slightly higher with ultrasonic 

than with traditional optical pachymetry. 2 CCT measured using OCT has been 

reported in a number of studies using retinal OCT equipment adapted for 

anterior segment use. Overall, these suggest a similar systematic reduction in 

comparison with ultrasonic pachymetry, in keeping with the optical basis of 

OCT. 3–5 However, this has not been a consistent finding and other authors have 

not found a significant difference 6 or have even reported thicker CCT by OCT. 7 

The purpose of this study is to compare CCT measurements using AS- 

OCT with conventional ultrasonic pachymetry in a prospective manner to 

investigate the degree of systematic difference and the level of agreement 

between AS-OCT and ultrasonic pachymetry. 


For each of the 90 eyes, at least two horizontal OCT scans of 7 mm fixed depth 

were obtained and stored for later analysis. CCT measurements were obtained 

from scans by anterior segment OCT with a Stratus III (Zeiss, Germany, version 

472


6.0.3) using the corneal reflectivity profile. The central cornea was identified 

from the peak of the reflectivity profile on the horizontal axis. The calipers were 

then aligned on the peak reflections at the anterior and posterior boundaries 

of the cornea, in the axis of the corneal apex. The two measurements were 

averaged for right eye only to avoid any bias. Ultrasound testing was also 

performed twice for right eye only. The cornea was first anesthetized with one 

drop of pro-paracaine hydrochloride 0.5% (Paracain, Sunways, India). It would 

be very difficult to assess whether the two instruments took measurements 

at the same exact location. However, to ensure that ultrasound CCT was 

measured at the center of the cornea, we placed the probe tip at the very center 

of the cornea and kept the pachymeter horizontal. If the patient moved and 

the probe decentered, then the measurements were repeated. Ultrasound 

pachymetry was performed in each case by one of two authors (Dr. MJ and Dr. 

AJ) to measure the inter individual variability. Ten sequential measurements 

were obtained from the center of the cornea and averaged. Values with standard 

deviation (SD) of 5 micron or less were considered suitable for inclusion. 

Statistical Analysis. Pearson correlation was used to assess the strength of 

correlation of the two measurements. The measurements were also compared 

with the paired t-test. Since AS-OCT measurements involved caliper 

measurements made by the observer all eyes were remeasured by a second 

observer to study inter observer agreement. 

RESULTS 

Mean age was 32.9 +/- 16.1 years with 41 male and 49 female patients. Mean CCT 

with ultrasonic pachymetry for observer 1 and 2 were 523.2 +/- 28.6 microns 

and 522.5 +/- 30.9 respectively. Mean CCT with AS-OCT for observer 1 and 2 

were 526.6 +/- 26.7 and 525.8 +/- 26 microns respectively. The value with AS 

OCT is slightly higher than with ultrasonic pachymetry but the P value is not 

significant. The P value was 0.405 and 0.436 between ultrasonic pachymetry 

and AS OCT for observer 1 and 2 respectively which is not significant. 

Correlation coefficient between ultrasonic pachymetry and AS-OCT was 0.95 

(observer 1) and 0.93 (observer 2). Correlation between the two observers, to 

assess the inter individual variability for ultrasonic pachymetry and AS-OCT 

was 0.96 and 0.97 respectively. 

DISCUSSION 

Doughty and Zaman 2 (300 patients) found that mean normal CCT was 

530 microns for slit-lamp-based optical pachymetry and 544 microns for 

ultrasonography. Subsequent reports using retinal OCT adapted for the 

anterior segment 3–5 suggest a similar effect; other authors have reported no 

significant difference 6 or even thicker measurements of CCT by OCT. 7 

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AS-OCT has the advantages over ultrasonic pachymetry in that it is a 

noninvasive, non contact modality, as well as having the ability to examine 

other structures as mentioned above. The disadvantage is that it is slower to 

perform in a busy clinic than a hand-held pachymeter and requires greater 

expertise. Unlike ultrasonic pachymetry, AS-OCT can easily be used to assess 

regional differences in the cornea and the facility for the patient to fixate on a 

target allows more accurate identification of the central corneal surface. 

Zhao et. al. 8 has reported CCT using AS-OCT found a systematic difference 

between AS-OCT and ultrasonic pachymetry. It is unclear whether ultrasound 

or OCT measurements more accurately reflect the true corneal thickness. 

Kim et. al. 9 presented their data with another AS-OCT machine that is SL- 

OCT (Heidelberg Eye Explorer v1.5.9.0) and found that though the correlation 

was excellent between the two machine 0.82 there was a significant difference 

in the average standard deviation (SD) around 26.3 micron and the AS-OCT 

measurements were slightly lower than the pachymetry measurements. Our 

measurements showed that there was excellent correlation between the two 

methods and the AS-OCT showed a minimally higher value which has been 

reported earlier by Fishman et. al.. 6 and Leung et. al.. 7 We did not see much 

difference in the SD range also and the two methods correlated well for both 

the observers separately. 

For OCT, uncertainty of the true index of refraction of infrared radiation in the 

cornea may create a source of error in calculating the CCT. 8 There could also be 

small calibration errors in either system. 

In conclusion, AS-OCT is a promising non contact and reproducible diagnostic 

method that is comparable to ultrasonic pachymetry in the evaluation of 

corneal thickness and the inter observer variability is low, though the AS-OCT 

may been slightly more time consuming but has the advantage of being totally 

noninvasive. 

REFERENCES 

1. Wolffsohn JS, Davies LN. Advances in anterior segment imaging. Curr Opin 

Ophthalmol 2007;18:32–8. 

2. Doughty MJ, Zaman ML. Human corneal thickness and its impact on intraocular 

pressure measures: a review and metaanalysis approach. Surv Ophthalmol 

2000;44:367–408. 

3. Wirbelauer C, Scholz C, Hoerauf H, et. al.. Noncontact corneal pachymetry with 

slit-lamp–adapted optical coherence tomography. Am J. Ophthalmol 2002;133:444- 

50. 

4. Wong AC, Wong CC, Yuen NS, Hui SP. Correlational study of central corneal 

thickness measurements on Hong Kong Chinese using optical coherence 

tomography, Orbscan, and ultrasound pachymetry. Eye 2002;16:715–21. 

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5. Bechmann M, Thiel MJ, Roesen B, et. al. Central corneal thickness determined 

with optical coherence tomography in various types of glaucoma. Br J. Ophthalmol 

2000;84:1233–7. 

6. Fishman GR, Pons ME, Seedor JA, Liebmann JM, Ritch R. Assessment of central 

corneal thickness using optical coherence tomography. J. Cataract Refract Surg. 

2005;31:707–11. 

7. Leung DY, Lam DK, Yeung BY, Lam DS. Comparison between central corneal 

thickness measurements by ultrasound pachymetry and optical coherence 

tomography. Clin Experiment Ophthalmol 2006;34:751–4. 

8. Zhao PS, Wong TY, Wong W-L, et. al. Comparison of central corneal thickness 

measurements by Visante anterior segment optical coherence tomography with 

ultrasound pachymetry. Am J Ophthalmol 2007;143:1047–9. 

9. Kim HY, Budenz DL, Lee PS, Feuer WJ, Barton K. Comparison of Central Corneal 

Thickness using Anterior Segment Optical Coherence Tomography vs Ultrasound 

Pachymetry. Am J Ophthalmol 2008;145:228–32. 

Photographic and Digital Documentation of The 

Anterior Segment using Compact Digital Camera 

Dr. Susil Kumar Pani 

The aim of the study is to simplify the process of documentation of the 

diseases of the anterior segment of the eye by the use of easily available 

compact digital camera. 

METHODS AND MATERIALS 

Every eye care professional uses a slit lamp bio-microscope to examine the 

anterior segment of the eye. To document, the slit lamp needs to have a standard 

beam splitter, image capturing device or a digital camera back fitting on to 

the beam splitter, video, audio interface, all connected to a standard desktop 

computer. Most of them come with proprietary software to capture and edit 

the photograph. The whole system other than slit lamp costs minimum of Rs 

100,000 from the Indian companies and more than Rs 300,000 from abroad. I 

have tried to use the ordinary digital camera which is easily available in market 

from standard known companies available from Rs 5000 to Rs 10,000 very easily. 

In my study I have used Sony compact camera model DSC W520. This camera is 

a 14 MP camera costing about Rs 8000 at the beginning of study. I will describe 

the camera controls to be used in documenting the slit lamp photography. The 

routine method used by me is to place the compact camera tightly against the 

eye piece of the slit lamp while the bio-microscope and the light are already 

sharply focused on the area to be photographed. One will be able to see the live 

picture on the screen of the camera before capturing the image. 

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Camera Controls 

ISO: The ISO represents the sensitivity of the film or sensor to light. Normally 

the option given is auto ISO, 100, 200, 400, 800, 1600 and rarely 3200 or more. 

The higher the number, the more sensitive is the ability to capture the image. 

As you increase the ISO, pictures can be taken at low light conditions. This will 

produce a graininess of the picture. Hence for slit lamp photography set the 

ISO always 100 or 200 or maximum at 400. 

White Balance 

This feature deals with the type of light used for lighting the object photographed. 

To be more precise it means the color temperature of the light falling on the object. 

The options available in a compact digital camera is auto white balance, day light, 

cloudy, fluorescent under natural white light, incandescent light and flash. In 

auto white balance setting the camera tries to recognize the color temperature 

of the light falling on the object and sets the white balance. Incandescent white 

balance is when the light source is an ordinary bulb or a Halogen light. As most 

of the slit lamps use the Halogen bulb as the light source, this is the white balance 

to be used for slit lamp photography. Flash can be used for gross photography 

of the eye and the face. Otherwise while taking photos, the slit lamp is used as 

the source of the light and magnification, hence the white balance to be used 

is always incandescent light. 

Focus 

The compact digital cameras give option of multiple auto focus points and 

central auto focus point. In the multi auto focus points the camera tries to 

focus on the entire exposed screen. In case of central auto focus the camera 

focuses only at the centre of the object in front of the camera. In case of slit 

lamp photography it is better to use the central auto focus mode keeping 

the area of interest right at the centre of the frame. In case of taking general 

photograph of eye or face one can use multi auto focus mode. 

Metering Mode 

Most compact digital cameras provide at least 3 metering modes. Metering 

mode means the exposure time to capture the image. This exposure time 

is decided by two main factors, the shutter speed and aperture. Three to be 

precise, the ISO, shutter speed and aperture. The shutter speed is the amount 

of time the aperture remains open to capture the image. The lower the shutter 

speed the more is the exposure, faster the shutter speed lesser is the exposure. 

Aperture is the size of the opening through which the light reaches the film 

or the sensor. The aperture is otherwise called F stop. The larger the aperture 

the more the exposure, the smaller the aperture the less is the exposure. The 

aperture is designated as 1.2, 1.8, 2.8, 3, 3.5, 4….22. The lower the number is 

the larger aperture and the larger the number the narrower the aperture. The 

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metering modes usually available are multi, central and spot in case of most of 

compact digital cameras. In the multi metering mode the exposure is decided 

by taking reading of light falling on entire frame to be captured. In case of 

central metering the exposure is calculated on the brightness or light falling at 

the centre of the frame to be captured. Spot metering decides the exposure of 

the brightness of the small central point. In case of high end compact cameras 

and digital SLR the spot in the frame can be changed by the user. In case of slit 

lamp photography it is best to use either central or spot meter to get the correct 

exposure of the picture taken. 

Exposure Compensation 

It is important to use a compact digital camera with a facility to adjust the 

exposure. In this one can increase or decrease the brightness from the exposure 

reading mode by the camera. In slit lamp photography the Halogen light 

falling on the eye and viewed through the slit lamp is quite bright at the centre 

and the surrounding areas are reasonably dark. Hence the camera metering is 

fooled to believe that there is less light. Hence the exposure in normal mode 

results in washout of all the details in the centre which is the main area to be 

captured and documented, this happens even when spot metering is used. 

Hence most of the time it is essential to reduce the exposure to either -1 or -2 

steps below the exposure reading made by the camera. 

Steady Shot 

This reduces the vibration of the hand while taking the picture and should be 

always on 

Image Size 

In principle always use the highest resolution available in the camera for 

capturing the images. 

Flash 

Most compact cameras gives multiple options of using the in built flash. They 

are usually auto flash, flash ON, slow synchronization flash and flash OFF. In 

documenting the anterior segment through the slit lamp always set the flash 

to OFF mode. In case of direct photographing the eye and the face the flash can 

be set at either mode OFF or flash ON. 

Zoom 

Always use the optical zoom to a minimum extent to maintain good depth of field. 

DRO 

In DRO OFF mode there is no recovery of the shadow details. In case of slit 

lamp photography always put OFF the DRO, as the area of interest is already 

brightly lit with slit lamp light. 

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Picture Capture Modes 

Most of the standard compact cameras provide multiple modes to take 

pictures. Some of standard modes available are scene selection mode, complete 

478


auto mode, program auto mode and rarely full manual mode. In the scene 

selection mode it provides for multiple options like: landscape mode, twilight 

mode, portrait mode, beach mode and high brightness mode. In complete 

auto mode the camera decides all the settings including the ISO, Metering, 

Focus, Aperture, Shutter, White Balance and others. For general purpose 

photography full auto is acceptable to get average results. In program auto 

mode the camera can be adjusted (set by the photographer) for the parameters 

like ISO, White Balance, Exposure Compensation, Metering, flash, focus, etc. 

but the camera decides the aperture and shutter speed. In full manual mode 

in addition one can also control the aperture, shutter speed or both. Some 

cameras allow additional features to control the exact color temperature in 

white balance, exposure bracketing etc. Hence from above features it always 

better to use either the programme auto mode with adjustable settings or full 

manual mode to take pictures in the slit lamp to get the best results. 

Most of the entry level compact cameras record the picture in JPEG format 

which is a compressed form of recording the picture data but is good enough. 

RESULTS 

A sample collage of picture are attached in the end. 

DISCUSSION 

I have used a simple digital camera available to document the diseases of the 

anterior segment of the eye through the slit lamp to get consistent excellent 

results. I hope this will help all eye care professionals to use them even if they 

do not have access to an anterior segment imaging system. 

REFERENCE 

1. Fogla R, Rao Sk ophthalmic photography using digital camera. Indian journal 

ophthalmology 2003:51-269-72. 

Hemodynamic Response to Phacoemulsification 

among Surgeons during High Volume Cataract 

Surgery 

Dr. Aravind P. Murugesan, Dr. Haripriya Aravind, Dr. Ravichandar A., 

Dr. Heber A. David 

Surgical Procedures are mentally demanding and every surgeon feels the 

strain subjectively. This may be especially true in this high volume tertiary 

care setup where the average surgeon performs about 1500 cataract surgeries 

per year. 

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The autonomic nervous system is a major determinant of the functional 

properties of the heart in that it alters spontaneous sinus node de polarization 

and cardiac rhythm, which can be assessed by the rhythm of the sinus node. 

The variations of the surgeon’s heart rate in comparison to their respective 

baseline and the blood pressure were the chosen parameters to monitor 

physical and mental states and to measure the sympathovagal balance. 

The purpose of this study to investigate the individual hemodynamic response 

to the stress of performing routine Phacoemulsification (PE) among normal, 

healthy ophthalmic surgeons in a high-volume setup. 


In a tertiary eye care institution, 14 qualified ophthalmologists who were 

trained in performing PE were recruited in the study. They were selected 

across different age groups, gender and levels of experience. Each of them 

was examined by a general physician and pre-existing systemic complaints 

were recorded. The blood glucose, total cholesterol and hemoglobin for 

all participants were noted. For surgeons over 40 years of age, a baseline 

electrocardiogram was also recorded. The baseline blood pressure and heart 

rate of the surgeons was recorded in a calm, non-operating room setup on 

three different occasions by an examiner. In the operating room (OR) the 

surgeons were explained the procedure and consent was obtained. They were 

then connected to an electronic multi-monitor under their sterile surgical 

gowns. The surgeons underwent continuous electronic monitoring of their 

hemodynamic parameters while performing multiple PEs during the course 

of the operating day. Each surgery was divided into five serial stages – Wound 

construction, Capsulorrhexis, Phacoemulsification, Irrigation-aspiration and 

IOL implantation. The heart rate (HR) corresponding to each stage and blood 

pressure (BP) at the end of each surgery were recorded by the anesthesiologist. 

Since the third stage was the longest, the maximum and minimum heart rate 

were noted and their average taken for calculation. 

RESULTS 

The difference of the heart rate from the established baseline to the particular 

step in surgery was calculated for every individual and averaged for the total 

number of surgeries performed in that single day. Mean pulse difference from 

baseline peaked during stage 3 (Phacoemulsification stage) consistently for 

all surgeons. However the change in BP over the course of multiple surgeries 

analyzed using repeated measures ANOVA was not significant. The group was 

stratified based on age, gender, experience and number of surgeries performed 

on that particular day. The analysis showed no statistical significance but it 

was possible to see the difference between individual surgeons over their 

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performance curves. 

Among this 

group, two 

surgeons showing 

consistently high HR 

during surgery were 

re-examined and 

counseled for stress 

management by the 

physician. 

DISCUSSION 

Mental strain in the operating room is very difficult to define and to measure. 

Measuring heart rate variability (HRV) is currently the best method of assessing 

mental strain and is more sensitive than measuring heart rate alone. Needless 

to say, ophthalmic surgeons are always under tense mental and socio-legal 

strain to yield optimum results for their patients. The results themselves could 

be assessed from various points of view. Quantitative and qualitative audits of 

performance of ophthalmic surgeons are of intense general interest and under 

critical surveillance in this institution. 

481


This study observed two facts. One was that the rise in heart rate of the surgeons, 

an indicator of strain in response to stress and problems, was the highest in 

the Phacoemulsification stage of all operations and is fairly stabilized before 

and after it. This tendency was observed throughout the operating day while 

performing relatively straightforward PE cases. Second was that most of the 

surgeons did not show any alarming rise in heart rate or blood pressure at any 

stage of surgery, contrary to our expectations. Two surgeons had high heart 

rates and this was probably a reflection of their personality. 

Each of the surgeons is capable of performing 15 to 30 cataract surgeries 

continuously on a single operating theatre turn. The high output is facilitated 

by a team of well trained, dedicated middle level ophthalmic personnel 

(MLOP). They organise the OR, escort the patients, clean and drape them, 

assist in surgery and verify the biometry and identity of the patient. This 

streamlines the system and allows the surgeon to focus only on the surgery 

at hand. It is implied that this smooth operation of the high volume cataract 

surgery assembly line enhances surgeon comfort and enables them to perform 

multiple surgeries with the least mental stress. 

The limitations of this study include that it measured heart rate and not HRV, 

as continuous Holter monitoring of surgeons was not feasible. This limitation 

could be overcome by a future study measuring the HRV of several surgeons. 

In summary, this study is the first report to measure and evaluate the intraoperative 

hemodynamic changes of ophthalmic surgeons as a measure of 

their mental state and equilibrium. 

In conclusion Surgeons’ stress in PE is reflected in excitement of the 

cardiovascular system. Though it varies among individuals, PE stage seems 

uniformly hemodynamically significant. A planned support system, trained 

staff and OR tranquility ensure minimal mental stress. 

Financial Interest: The authors do not have any financial interest in any of the 

equipment, medications or techniques mentioned above. 

REFERENCES 

1. Min-Ho Song et. al. Intra-operative heart rate variability of a cardiac surgeon 

himself in coronary artery bypass grafting surgery. Interact Cardio Vasc Thorac 

Surg. 2009;8:639-41. 

2. Payne RL, Rick JT. Heart rate as an indicator of stress in surgeons and anesthetists. 

J. Psychosomatic Res. 1986;30:411–20. 

3. Task Force of the European Society of Cardiology and the North American Society 

of Pacing and Electrophysiology. Heart rate variability: standards of measurement, 

physiological interpretation, and clinical use. Circulation 1996;93:1043–65. 

4. Becker WG, Ellis H, Goldsmith R, Kaye AM. Heart rates of surgeons in theatre. 

Ergonomics 1983;26:803–7. 

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In Vitro Antibiogram of Streptococcus 

Pneumoniae in Ocular Infections 

Dr. Priyanka Gogte, Dr. Prashant Garg, Dr. Mukesh Taneja, Dr. Suma N. 

The eye may be infected from external sources or through intraocular 

invasion of micro-organisms that are carried by the blood stream. 1 External 

bacterial infections of the eye are usually localized but may frequently spread 

to other tissues. The eyelid and conjunctiva have a normal microbial flora 

controlled by its own mechanism and by the host. Modification of this normal 

flora contributes to ocular infections such as blepharitis, conjunctivitis, 

canaliculitis, orbital cellulitis, endophthalmitis, etc. 

Timely institution of appropriate therapy must be initiated to control the 

infections and thereby minimize ocular morbidity. If they are not treated 

promptly, it may lead to sight threatening condition. 2 For this timely 

intervention, it is essential to correctly identify the causative organism with 

the help of a thorough microbiological work up and then initiate the therapy 

based on the sensitivity pattern of the organism. However to a community 

based ophthalmologist without access to a laboratory set up, the information of 

common ocular pathogens and the trends in the current antibiotic sensitivity 

pattern form the basis of treatment initiation. Also it has been observed 

that the causative organisms and their response to antibiotic therapy is not 

static and varies according to their geographic location. Thus it is essential to 

periodically study these parameters and revise treatment protocols. 3,4 

Streptococcus pneumoniae is a Gram positive cocci and is the main cause of 

central corneal ulceration among bacterial keratitis in South India. 5 According 

to another study from a tertiary care center in South India, Gram positive 

organisms accounted for 69.1% of all bacterial isolates with Streptococcus 

pneumoniae being one of the 5 most common causative organisms. Therefore, 

the purpose of this article is to study the in vitro antibiotic sensitivity pattern 

of Streptococcus pneumoniae in ocular infections. 


Retrospective analysis of microbiology records of patients clinically diagnosed 

and treated for ocular infections between January 2010 and December 2010 

was done. All culture positive samples of significant growth of Streptococcus 

pneumoniae were included in the study and the antibiotic susceptibility was 

determined using the Kirby-Bauer disc diffusion test. 

Corneal scrapings were obtained using standard techniques 6 with a sterile 

Bard Parker blade (#15). Collection of vitreous samples was done in a standard 

manner. The samples were inoculated directly onto sheep blood agar, 

chocolate agar, thioglycolate, and brain heart infusion broth. These media 

483


were incubated at 37°C. The blood agar plates were each incubated under 

aerobic and anaerobic conditions and chocolate agar was incubated in 5% 

carbon dioxide. Media and nutrients to enable growth of fungi and parasites 

(Acanthamoeba) were also included as part of the standard corneal scraping 

culture protocol, as was microscopic evaluation of corneal smears by Gram 

stain, Giemsa stain, KOH preparation and KOH with calcofluor white under 

fluorescence. Acid-fast stains (Ziehl-Neelsen and Kinyoun) and immunocytochemistry 

stains were performed when indicated. 

The identification of Streptococcus pneumoniae was made on the basis of 

colony morphology on culture medium which showed the presence of alpha 

hemolytic colonies on blood agar. The smear showed the presence of lanceolate, 

diplococcic. The culture was considered positive when there was growth of the 

same organism on two or more media, confluent growth at site of inoculation 

on one solid medium, growth in one medium with consistent direct microscopy 

findings, or growth of the same organism on repeated sampling. In vitro 

susceptibility testing was performed by Kirby-Bauer disc diffusion method 

and interpreted using Clinical and Laboratory Standards Institute’s serum 

standards. The antibacterial agents (Hi-media Laboratories Pvt. Ltd., Mumbai, 

India) used were amikacin (30 μg/disk), tobramycin (10 μg/disk), gentamicin 

(10 μg/disk), cefazolin (30 μg/disk), cephotaxime (30 μg/disk), ceftazidime (30 

μg/disk), ciprofloxacin (5 μg/disk), norfloxacin (10 μg/disk), ofloxacin (5 μg/ 

disk), gatifloxacin (5 μg/disk), moxifloxacin (5 μg/disk), chloramphenicol (30 

μg/disk) and vancomycin (30 μg/disk) and were consistently tested for their 

efficacy against standard American Type Culture Collection (ATCC) bacteria 

(Staphylococcus aureus ATCC 25923, Str. pneumoniae ATCC 49619, Haemophilus 

influenzae ATCC 49241, Ps. aeruginosa ATCC 27853, Escherichia coli ATCC 25922) 

as a general quality control laboratory procedure. Susceptibility was graded as 

resistant (R), intermediate sensitivity (I), or sensitive (S). 

RESULTS 

During the study period 4597 samples were submitted for microbiology 

evaluation and 122 were culture positive for Streptococcus pneumomiae. Of 

these the 58.2% samples were collected from males and the remaining 42.8% 

from female patients showing a slight male preponderance. The main source of 

samples was corneal scrapings accounting for 86.88% of the samples. Vitreous 

samples from clinically diagnosed cases of endophthalmitis accounted for 

9.01% of the cases while 4.09% samples were from other sources like endonasal 

swabs, eviscerated contents etc. 

The antibiotic susceptibility in decreasing order was as follows Cefazolin 

(99.19%), Vancomycin (98.38%), Cefuroxime and Gatifloxacin (97.58%), 

Moxifloxacin (95.16%), Chloramphenicol (94.35%), Ofloxacin (92.74%) 

484


and Ciprofloxacin (90.32%). Amikacin and Gentamicin showed the least 

susceptibility with 8.06% and 33.87 % respectively. Also 27.41% samples were 

susceptible to all tested antibiotics. This pattern is consistent with those 

reported in other studies from similar and varied geographic location. 2,4 

In conclusion as consistent with other reports, Streptococcus pnuemoniae is one 

of the important etiological factors for ocular infections and needs the initiation 

of prompt anti bacterial treatment. To our knowledge this is the first isolated 

analysis of in vitro susceptibility pattern of Streptococcus pnuemoniae. It can 

be concluded that this species shows a high susceptibility to Cefazolin and 

Vancomycin and therapy with these agents can be effective in controlling the 

ocular infections. Also fluoroquinolones still maintain a good susceptibility for 

this Gram positive organism and can be considered in the treatment initiation. 

It must be noted that these are in-vitro results, and one of the limitations of 

using in-vitro antibiotic sensitivity as a surrogate for in-vivo effectiveness is 

that antibiotic sensitivities do not always mirror the clinical response to an 

antibiotic for a variety of reasons, including direct topical delivery, corneal 

penetration of an antibiotic and host factors. 3 However this study provides 

a guide for treatment and would be helpful in initiating treatment where 

microbiology facilities are not available. However this should not replace the 

appropriate microbiology investigations and specific antibiotic treatment 

initiation based on culture and sensitivity wherever feasible. 

REFERENCES 

1. Williamson-Noble FA, Sorsby A. Etiology of the eye diseases; developmental 

defects; heredity. In: Conrad B, editor. The Eye and Its Diseases. 2nd ed. 

Philadelphia: W. B. Saundars Company; 1950. pp. 309–21. 

2. Wolfgang Haas, Chris M. Pillar, Mohana T, et. al. Monitoring Antibiotic Resistance 

in Ocular Microorganisms: Results From the Antibiotic Resistance Monitoring in 

Ocular MicRorganisms (ARMOR) 2009 Surveillance Study. Am J. Ophthalmol 

2011;152:567–574 

3. Sharma S, Kunimoto DY, Garg P, Rao GN. Trends in antibiotic resistance of corneal 

pathogens: Part I. An analysis of commonly used ocular antibiotics. Indian J. 

Ophthalmol 1999;47:95-100 

4. M Jayahar Bharathi, R Ramakrishnan, C Shivakumar, R Meenakshi and D 

Lionalraj . Etiology and antibacterial susceptibility pattern of community-acquired 

bacterial ocular infections in a tertiary eye care hospital in south India. Indian J 

Ophthalmol. 2010 Nov-Dec; 58(6): 497–507. 

5. M Srinivasan, Christine A Gonzales, Celine George, et. al. Epidemiology and 

aetiological diagnosis of corneal ulceration in Madurai, south India. British Journal 

of Ophthalmology 1997;81:965–971 

6. Jones DB, Liesegang TJ, Robinson NM. Laboratory Diagnosis of Ocular Infections. 

Washington DC: Cumitech 13, American Society for Microbiology; 1981. 

485


Comprehensive Eye Examination in Camps— 

The Wireless Way 

Dr. Shailesh Chandra Suman, Dr. Sil Asim Kumar, Dr.Shoumya Jyoti 

Datta Mazumder 

The eye camps in India are almost synonymous to cataract screening. Often 

non- cataract conditions are missed out. Most of the eye screening camps 

in rural India are carried out with the help of torch light only and by the 

ophthalmic technicians. With the help of wireless instruments (like portable 

slit lamp, indirect ophthalmoscope and Perkin’s tonometer) and ophthalmic 

team (comprising vision technician, ophthalmic assistant/optometrist, 

nurses, counsellor and doctors) a difference can be made. We had done study 

on ”comprehensive eye screening camps - the wireless way” to evaluate 

effectiveness of detecting non-cataract conditions during cataract screening in 

rural outreach camps. The patients were mostly from under served population, 

so need of comprehensive eye examination was immense for them. During 

three consecutive camps many non-cataract blinding conditions like glaucoma 

suspect and diabetic retinopathy were detected and sent to the base hospital 

for proper diagnosis and treatment. Wireless instruments have great value in 

comprehensive eye screening in large volume with reasonable time, cost and 

man-power. 

Rational of the study is while giving too much stress on cataract many a time 

we miss non-cataract blinding eye conditions and later regret. Comprehensive 

eye examination with reasonable utilization of time, cost, and man-power 

we can add value to cataract screening by picking up glaucoma suspects 

and different retinopathies co-existing with cataract. Wireless instruments 

like portable slit lamp, cordless indirect ophthalmoscope tremendously help 

in comprehensive examination in a shorter time. This study examines the 

effectiveness of this examination process. 

Aim and objectives of the study is (i) To evaluate the effectiveness of using 

wireless instruments in comprehensive eye screening in large volume outreach 

camps in terms of cost, man power and time. (ii) To evaluate the ability of the 

process to detect non-cataract blinding conditions like glaucoma and different 

retinopathies and prevent blindness. 


This was a retrospective cross sectional study to evaluate the effectiveness 

of wireless instruments in cataract screening camps to detect non-cataract 

conditions like glaucoma, Diabetic and other retinopathies. It was done in 

Purba Medinipur district of West Bengal in 3 consecutive camps. A regular 

486


comprehensive eye screening team comprised vision technician, ophthalmic 

assistant/optometrist, laboratory technician, nurses, counsellor and doctors 

conduct the examination using wireless instruments (Schiotz’s tonometer, 

Perkin’s tonometer, portable slit lamp, indirect and direct ophthalmoscope) 

and basic tools for refraction. The camps were done on 3 consecutive Sundays 

between February 6, 2011 and February 20, 2011. A total number of 1323 patients 

attended the camps comprising all age groups. All the 1323 patients attending 

the camps had detailed examinations including history (ocular and systemic) 

refraction where indicated, tonometry and dilated fundus examination. Pupil 

was not dilated in case of shallow anterior chamber. Fundus examination 

was not possible in mature and hypermature cataract, infective conditions. 

Glaucoma was suspect in eyes with high IOP, suspicious cup-disc ratio. Retinal 

changes were correlated with systemic diseases. Patients were counselled 

about the eye conditions and prognosis explained. Patients with posterior 

segment abnormalities were further examined at base hospital before cataract 

surgery to establish the diagnosis, explain prognosis and plan treatment. 

In our team, usually two ophthalmologists, 2-3 refractionists, 7-9 nurses, 1-2 

lab. technician, 2 counsellor are needed for a screening camp of 400-500. One 

ophthalmologist is posted per expected 150-200 patients. Travel time is a major 

consideration. One refractionist is posted per expected crowd of 150 (roughly 

50 out of 150 would need refraction). Usually 400-450 patients attend per 

screening camp. Usually 7-9 nurses are needed for a screening camp of 400-500, 

to perform vision testing, syringing, blood pressure recording, tonometry, and 

to assist doctors in clinical examination. 1-2 pathology laboratory technician 

is/are posted for urine/blood sugar examination. Local volunteers help to 

manage registration and patient flow. 

RESULTS 

Total number of patients screened were 1323 out of which 581(43.92%) were 

male and 742(56.08%) were female. 630 patients (47.6%) had operable cataract. 

Out of 630(47.6%) cases 278(44.13%) were males and 352(55.87%) were females. 

Out of 630 cataract cases 45(7%) were glaucoma suspects, 24(3.8%) had Diabetic 

retinopathy and 21(3.3%) had other retinopathies. Among 693(52.4%) nonoperable 

cases, 51(7.35%)were glaucoma suspects, 27(3.90%)cases were Diabetic 

retinopathy and 25(3.60%) cases had other retinopathies. So the above results 

show that substantial amount of patients were Glaucoma suspects or had 

Diabetic retinopathy and other retinopathies. In this way, this study tells the 

role of comprehensive eye examination even at high volume camps to detect 

non-cataract conditions and the usefulness of wireless instruments in doing 

so in optimal time. Screening started at 8-9 am and finished at 4-5 pm with 45 

min. lunch break. Totally it takes 8-10 hrs/day. 

487


DISCUSSION 

As we know that 80% blindness is avoidable (preventable plus curable). In a 

country like India 70% people live in rural area and one third are below the 

poverty line and have poor access to service. Most of the rural people might 

know about cataract only, but they don’t know about other leading causes of 

blindness like Glaucoma, Diabetic retinopathy, etc. Most of the cataract camps 

are limited to only cataract screening. Comprehensive eye examination at 

camps is an effective way to overcome this problem. In high volume situations 

matching time with quality is an issue. With the help of wireless instruments 

detection of non-cataract conditions become faster and easier. The strengths of 

our study are – (i) screening of non-cataract conditions like glaucoma suspects, 

DR etc. (ii) finding the effectiveness of wireless instruments in comprehensive 

eye examination in large volume situation. (iii) creating awareness about 

other causes of blindness in the rural population who attend the camp. 

In conclusion comprehensive eye examination is extremely important from 

blindness prevention point of view. Wireless instruments are light, portable 

and easy to operate. These instruments are very effective in managing high 

volume situation in remote areas. 

Recommendation: All screening camps particularly in rural areas should 

have wireless instruments with the ophthalmic team and it should be done in 

a comprehensive way so that non-cataract conditions are not missed out and 

blindness is prevented. 

REFERENCES 

1. Community Eye Health J. 2006:19:22-3. 

2. Indian Journal of Community Medicine 2010;35:355-358. 

3. Community Eye Health 2002;14:4-6. 

4. Http://Www.Curableblindness.Org/Region/South-Asia/India.Html. 

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