L4403 44 i i! d bid i” betes Por oe —<=~ FS SANKARA ACADEMY OS oF vision SANKARA EVE HOSPITAL SF ores eee Topics. Page No. 1. Artificial Intelligence. o1 2. TRIFOCALIOL 07 A Bionic Eye un 4. Extended Depth of Focus IOLs v7 5. Multifocal 10. 19 MODULAR OT 23 7. Dry Bye Disease Updates on Diagnosis and Management 33 AC Hie Stains Used in Ophthalmology 39 9. DIPLOPIA CHARTS 45 10, HESS SCREEN 51 | 11. Esotropia 87 | 12. Lasers in Glaucoma 67 | 13, Reverse Pupillary Block Glaucoma a1 | oem . 87 | 15. AntiVEGFs 93 | _PEOCK Angiography “07 17. Exenteration of the Orbit 15 18. Orbitotomy Approaches 125 3rd Eye — Postgraduate Update in Ophthalmology, Sankara Eye Hospital, Bangalore Pe noe Cae Scanned with CamScannerwrotrenodrol MHaozitnns a“ anol, model formal qyrouyy Fe 4) Rap 6. Ww Purpose of Al is to make computers mimic the way of our thinking, and improve our work ) 510M atticiency in the modern fast-pace life. The application of this technology of AI mainly [is application mainly concentrates on the diseases with a high incidence, such as diabetic retinopathy (DR), age-related macular degeneration (AMD), glaucoma, retinopathy of SANKARA ACADEMY yyy OF VISION uv : lenge Artificial intelligence prematurity (ROP), age-related or congenital cataract and few with retinal vein occlusion (RvO). Praline lenenringy- Deep te CRN 7 Wve newer Principle of Artificial Intelligence ete o MT ANN 5 Owede- ——, nino ‘Machine learning provides techniques or algorithms that can automatically build a model of complex relationships by processing the input available data and generalizing a performance standard, And it can be briefly described as enabling computers make successful predictions or judgments by repeatedly learning existing representative materials. To be able to form an accurate model, machine learning often requires a large number of training data. And most of ‘some other data are used to verify the established algorithm. That means the processes mainly include two parts, training set and validation set. Therefore, an important step is to collect a lot of representative training examples. Sooo ov cess eeveweeTue eclee ie "Ter ae mein wp ening mods autng sonvtton era nevar (ENN) and massive-tsning ati neural newer (MTANNYLLL. They ae povertltols for identifying and classifying images. To our knowledge, CNN and MTANN both have many webb bbb 6 ‘The automatic identification of DR has attracted-a lot of attention, with studies conducting microancurysm, hemorrhage, exudation, cotton-wool spot and neovascularization detection, ancien father csifes sages. of them We the ins images a8 pat. The computers receive many images labeled with diagnostic lesions, extract their characteristics Scanned with CamScannerZED sanana scroemy OF VISION, Se WS crm caivins nan ive a and finally build a model, And then, it can identify the new input images and gi ‘ %- Judgement. They report that the sensitivity of automatic DR screening ranges from 75 94.7%, also the specifi fan Figure 1 A fundus image is submitted to locate anatomic structures and lesions followed by feature extraction and analysis. The features are an index for s sarching the library to compare with similar images from database. It can also combine the patient's clinical metadata, Furthermore, there will be a few studies involved with multimodal data to verify a disease more precisely. For instance, combining macular optical coherence tomography (OCT) with fundus image indentify macular edema, which is the sign of timely treatment. After all, a study has reported an algorithm can detect and quantify subretinal or intraretinal fluid based on OCT images. Scanned with CamScannerPerr 77 FF9C6CFCHHTECECTECE EES S OF VISION ZS SANKARA ACADEMY SZ — [Optical coherence tomography ————— f Label probabilities ion of macular fluid in OCT Mlustration of the automated det ‘The intrarctinal cystoid Muid is marked in green, subretinal fluid is marked blue, AMD: Age- iabetic macular edema: RVO: Retinal vein ocelusion, related macular degeneration; DME: Apart from the above automatic detection and identification of DR, the study of the evaluation of deep learning models for DR grades. They reported the errors of deep learning models mainly concentrated on missing the microaneurysm and artifacts. For the moderate or worse DR, the sensitivity of deep learning models is about 97.1%, compared with the ophthalmologists’ 83.3%. AMD is a chronic and irreversible macular disease characterized by drusen, retinal pigment changes, choroidal neovascularization, hemorrhage, exudation and even geographic atrophy. It is one of the leading causes of central vision loss in people aged over 50. Many studies have reported their preliminary results, Most of them use fundus images as input original materials, and extract features of early, intermediate and late AMD to distinguish from the healthy images. They can obtain a sensitivity ranging from 87% to 100%, also with a relatively high accuracy. They think taking fundus photo as input is cheaper than OCT examination. But also, there exist researches combined spectral domain OCT with deep leaming about AMD, including the macular fluid quantity of neovascular AMD (nAMD) and the retinal layers segmentation of dry AMD. They believe that other Scanned with CamScannerZA SANKARA ACADEMY G&S OF VISION macular diseases will obtain the same effective results. intravitreal injection of anti-VEGF sami ZA} sanKana academy EGS oF vision TRIFOCALIOL Intermediate vision relates to activities which is generally at arm’s length, such as computer work, car driving (instrument panel), music playing (musical chart), etc. ‘These activities require a good uncorrected vision for distances comprising between 60 and 80 cm, glasses may be required despite satisfactory near and distance uncorrected vision. This is something the previous multifocal LOLs couldn't achieve. cals offer clear vision at intermediate distances, in ind far vision. ‘The latest-generation lenses called as addition to providing uncorrected ne: Binocular implantation of intermediate visual function. eal IOLs produces good distance visual acuity and near and + Zeiss AT LISA tri 839 and 939MP. + Alcon PANOPTIX + PhysIOL finevision Fine vision PhysTOL(renamed as MicroFineVision (Micro F) . J + First trifocal diffractive lens (Fine Vision, Physiol; Belgium). * Toric trifocal IOL is now available. + This 25% hydrophilic acrylic LOL has four closed haptics (5° angulation) with a biconvex and aspheric optic allowing for spherical aberrations. + Its optic diameter is 6.15 mm, and its total diameter 10.75 mm. + +10 D to +35 D (0.5 D steps) available. © An asymmetric ution of light energy among the three foci (near, interme: and far) allows for dominant distanee vision, improved intermediate vision, and non-impacted near vision. Scanned with CamScannerZ SANKARA ACADEMY SSS oF vision Se SS + The JOL is based on a fully diffractive optic with gradual attenuation of the diffractive step height throughout the entire optic, resulting in a continuous change of the light energy distribution directed to the three primary foci. RET non re DLP fff PT TP Pckhelelladled i e © ¢ e P ¢ e * A second diffractive IOL model introduced later in 2012. - * #3.33 D near add and +1.66 D intermediate add at the IOL plane. & e * Lower light loss (14.3 percent ) ae t * The 1OL optic distributes tight energy among the 3 focal points within the central a 4.34-mm optical zone and beyond this it is exclusively bifocal (near and vision). « e € e © Scanned with CamScannerS-i- HH. CHAT ?? tt 2??? set 1?FAaTP PP MoE Le ZB} sanicara academy S= CS OF VISION + With a 2.0 mm pupil-the lens transmits 50 percent of the usable light to the distance focus (dependant on pupillary size), 30 percent to intermediate (independent of pupillary size) and 20 percent to near + At larger pupil (6mm) - the bifocal periphery - IOL strongly distance-dominant-nearly 60 percent of light goes to distance vision, “pupil.ntermediate focal point remains at about 30 percent, the fraction of light devoted to near vision plummets to well under 10 percent. + The lens has an aspheric aberration correcting design with an overall diameter of 11.0 mm, and a 6-mm optic zone diameter. + The IOL is available from +0.0 to+30.0 D in steps of 0.50 D and blocker —— 10-9 to 3 1. Tarun Arora.Trifocal IOL. DOS Times. January, 2015, 20: 219-21 2. Professor Michael Lawless and Dr. Rick Wolfe.Trifocal Intraocular Lenses for Presbyopes. miophthalmology insights AUG 15 :104 Scanned with CamScanner~~ rer yew er wrweewe eww ewe BS Re AN SANKARA ACADEMY OF VISION aa Ww Conal tors Bionic eye | yisuar PRostnesie In the normal vi H travel ial pathway, through the tear film, cornea, aqueous, pupil, and vitreous, to activate the light sensitive photoreceptors and set up the trans-synaptic connections of the retina, In conditions where blindness is due to a disease in the photoreceptors in the resin Tike Rotiniis Pigmenlos (RP) or Age Relsted Macular eration wherein the neural connections are intact, in cortical tumours and lesions Depending upon location along the visual pathway this prosthetic device could be in the visual cortex, on the optic nerve or at the retina Photphenes ~~ Pateoned | pont It was demonstrated that phosphenes and patterned perceptions could be evoked, by electrically stimulating the occipital cortex by implanted electrodes. Researchers implanted arrays with over 50 electrodes subdurally over the occipital pole, thus providing evidence of Cortical Prosthesis — f the ability.to return the sensation of vision to ind anterior to the visual cortex Since most of the visual cortex lies deep within the calcarine fissure and is inaccessible to cortical surface electrodes, intra cortical stimulation was introduced in the hope of remedying the shortcomings of surface stimulation via low current high-fidelity systems. Current models of the intracortical prosthesis includes ‘ Ut electrode anay-multipe 4.2 mm with a platinum electrode at the tip of cach spike -on spikes organised in a square grid measuring 4.2 x Scanned with CamScannerSANKARA ACADEMY OF VISION ©) Advantage It bypasses all diseased visual pathway neurons rostral to the primary visual cortex. 1 Histological changes induced by a chronically implanted cortical prosthesis which needs tobe investigated, The organisation of the visual field is very complex at the level of the primary cortex than at the retina or opticnerve. we the device does not penetrate the optic nerve sheath, it relies on the Advantages 1. The entire visual field is represented in a small area, which can be reached surgically. Scanned with CamScanner=~ ZR SANKARA ACADEMY. SS OF VISION SY =] Disadvantages Wye, bi How Of bl evel WAC surgical manipulation ofthis area requires ecton/or tne hon sth oe inten gee bra of infections and possibly interruption of blood flow to the optic nerve. . _ Bipvlaw Meron {AX The optic nerve and the retinal ganglion cells (RGC) represent higher-order structures, than the bipolar cells targeted by the retinal prosthe: A Macnloy tibacs Lastly, the nerve fibres from the macula lie most centrally within the optic nerve. The cuff electrodes are thus, further away from the macular fibres and this will dramatically limit the use of this approach. Retinal Prosthesis — End- stage RP_has revealed that 78.4% of inner nuclear and 29.7% of ganglion layer cells were retained compared to only 4.9% of photoreceptors. It was also seen in legally blind neovascular AMD patients that 93% of RGCs were spared and an increase in inner nuclear layer cells was noted by 10. These results imply that theoretically it is possible to stimulate the remaining retinal neurons electrically to elicit useful visual perceptions. ‘These initial observations have led to the development of intraocular retinal prostheses in various centres. VAC Epiretinal - when the device is implanted into the vitreous cavity and attached to the inner retinal surface, so theelectrical stimulation meets the inner retina fir. 2c Subretinal re deviee is implanted in the potential space between the retinal pigment epithelium andthe neuro sensory retina, so the electrical stimulation meets the outer retina first.) Epiretinal Prosthesis Epiretinal implants rely on ima; 3 Scanned with CamScanner©) ener Worle. lwplarteble mirnoenliow Eriemek wel" 8) Pouut botrate ! ———— SANKARA ACADEMY OF VISION ; thi wearable intraocular retinal prosthesis (IRP). ‘This IRP includes both an external, we : 4 ists of component and an implantable, intraocular component, The external component consists © fa spectacle incorporated with a light weight camera, pocket batteries and a visual processing unit. Power and data is sent by wireless link from the external unit to the internal portion of the prosthesis. The intraocular portion consists of a receiver, stimulating chip and a microelectrode array including 16 platinum electrodes of approximately 500 um in diameter. The electrode array is affixed to the epiretinal surface by a retinal tack. This model captures digital video and translates it to a pixelated image externally. The final processed data and power is then transferred to the implanted portion of the prosthesis. The implanted portion of the device then converts the transferred visual data into controlled patterns of electrical pulses to stimulate the remaining retinal neurons. 1) EGET Weigh Corman Y Revie 9 ViSuAY Prtcsty web : = z Dacre arvana Subretinal Prosthesis , , Meus pratrdrode Arran. The subretinal approach to the retinal prosthesis involves im lanting mi " array(MPOA) betwee Planting microphotodiode d_ retinal pigy jithen — the bipolar cell layer an accomplished surgically either via'an intraocal a ret interno) ora transscleral approach (abextemo), mnotomy site (ab Scanned with CamScannerFt SS SANKARA ACADEMY OF VISION (©) Advantages Closer proximity to the next surviving neurons to the visual pathway (Le. bipolar eel!) and therefore less current requirement othe lack of'a mechanical means of fix: Disadvantages uC Limited subretinal space to place electronies . Close proximity of the retina to the electronics which would increase the Trenermat injury to the neurons Inner retina Outer retina Implant in the subretinal space ety “The Argus ‘The Argus 11 is an epiretinalstimulating device designed t0 improve visual functioning in people who are blind from severe RP the yy to perceive black: and white images and motion, Argus Il is meant to cont higher resolution images. people who are blind—or, more accurately, {0 give abilit electrodes, wl hhich would further help in providing Scanned with CamScanner= ZES SANKARA ACADEMY OS OF VISION Camera Glasses Coil AlphalMs ~ Only retinal prosthesis that has undergone long-term testing in humans. Unlike Argus, it does not require an extemal eyeglass- mounted camera. Ratherit uses a Wireless subretinal chip, which moves with the eye, containing 1,500 electrodes, which ‘rans- form the incoming light to electrical signals. These signals, after passing through an amplification circuit, stimulate intact retinal cells to induce visual perceptions. References www.dosonline.org — bionic eye - Dr. Vs Gurunadh American academy of ophthalmology ~ bionic vision — Jean Shaw Scanned with CamScanner= ZS Sankara ACADEMY CGS oF vision nded Depth of Focus LOLs Tels Colsele THe ES | Monofocsl 101s are used to restore vision 00 for one area of focus-usvally distance. Reading glasses may stil be peat sexe ufo tts provide hua vson i mole daunensathermctson Ca Sion distance custo to utthe =e] patients lifestyle. They may oerease freedom from gasses. weag ————> INTERMEDIATE "FAR Near FAR Extended Depth of Focus (EDOF that has recently emerged in the treatment of P In contrast to multifocal intraocular lenses (IOLs) used in treatment of presbyopia, EDOF Jenses work by. lass. Ae LOGS facts light in a specific way that it transmits Tight over a range of distance by constructive interference-elongates the focal point- extended depth of focus)( Figure 1) + Negative spherical aberration +“ Aetromatie technology compensates for chromatic aberration Bre or EDF), of Extended Range of Vision, is a new technology TECNIS Symfony JOL is the first EDA approved lens of its cl st FDA approved lens of 1s Properties : Scanned with CamScannerSANKARA ACADEMY OF VISION Micro monovision Overall jameter is 13.0mm, with an optical zone of 6.0mm ... ©) Available in power ranges from +5.0 to +34.0 D Ultraviolet light-absorbing filter, Figure 1: Design and mechanism of action of extended range of vision TECNIS Symfony IOL INDICATIONS FOR USE: ‘The TECNIS® Symfony Extended Range of Vision IOL — indicated in adult patients with less than 1 diopter of pre-existing corneal astigmatism, in whom-a cataractous lens has been removed. + The TECNIS® Symfony Toric Extended Range of Vision IOLs, are indicated in adult patients with greater than or equal to 1 diopter of preoperative corneal astigmatism, in whom a cataractous lens has been removed. : a nl SE OERATIENEUOADATTON em pi References: 1, Jefirey.F.McMahon et al.Extended depth of focus.J 0; yhthi a 0.org/Extended_Depth_of Focus, TOT ae 7017; 2017:7095734 Scanned with CamScannerBAS SANKARA ACADEMY SS OF VISION SY ae Multifocal 1OL, Je IOL with 2 or more focal points, PREOPERATIVE DIAGNOSTIC EVALUATION: + Slit lamp examination atism - best if less than 0.75D cylinder + Keratometry + Biometry - partial coherence interferometry — Barrett 2 formula + Topography — rule out irregular astigmatism + Angle Kappa(0.36mm+/-0.22mm), angle alpha (<0.Smm) + Macular OCT. + Aberrometry- check HOA, especially coma and keratoconus PREOPERATIVE Ri )UIRME +. Age- within the age group 35 to 75. tere © + Strong desire to be spectacle independent. + Should not have unrealistic expectations + Functional & Occupational Requirements + Occupational night drivers 7 Refractive + Diffractive _Apodised diffractive Refractive Mf10L : + Intraocular lens with several refractive optical zones on it. + These zones provide various focal points. + Helps in distance, intermediate, and near vision. Scanned with CamScanner\\ ZB} sanana acaveny SOS ce vision’ WSS ran mteaes Bull's eye 1OL ‘Modified Bull's eye 1OL PHARMACIA (3-zone) 1,3,5-distant vision 2, 4—near vision Light distribution — 60% distance 40% near and intermediate ‘Limitations of reftdetive Mao Pupil dependence, variable — High sensitivity for lens ce Intolerance to kappa angle which varies fom Patient t0 patient 1S are as follows: depending on the design ntration Scanned with CamScanner= PED SANKARA ACADEMY SOS OF VISION Se SS 7 _ Potential for halos and glare due to rough areas between the zones _ Loss of contrast sensitivi Jifleactive optic prineiple (Muy, ety point of a waveftont ean be thought of ws being its own source of secondary s0-called al cist sading.in a spher tion steps/microstructures on the intaveular lens. wavelets, subsequent + They have dittiaetiv + They distribute incoming light rays into two principal foci. _-*” The diffracted light contributes to the near focus and the undiffracted light to the far focus. eer revs Example: TECNIS MPIOL, ZEISS AT LISA 809M, ALCON ACRYSOF RESTOR Apodized diffractive MIIOL: > To apodize means to reduce the height of the steps. > Centre 3.6mm — Apodised diffractive optics within which centre Imm —refractive + [2concentric rings of various step heights on anterior surface (from 1.3 to 0.2 4m) Scanned with CamScannerZB sancara ACADEMY vv EGS Sevigny Ere S= Exremded Kanye ; For near and distance clongeled depth oy FRE of Vien > Periphery — refractive zone For distance vision Distrubutes light in response to size of the pupil * Apodisation increases energy distrubuted to distance at larger pupil diameter. Draw backs of MfIOL: ion through different focal points. Glare and halos due to scattering of light at the dividing linc of the different zones. f Off axis aberrations in decentered IOLs Time for neuroadaptation ee ee __ REFRACTIVE MULTIEOCALIOLS DIFFRACTIVE MULTIFOCAL 10} Sa a errr : Sits vata 1. Piyush Kapur et al.Multifocal 1OLs, DOs ies. January, 2007 4 - Vol, 19 N 2. Christopher P. Majka et al, When to Use Multifocal Intraocut, ee j huinsi/vwww.sno,ore/evencvarticlehwherr casings embet 2006 3. Rosa Braga-Mele et al Multifocal imc: a ular Tenses: Relative inde: mplantaion. J Cataract. Refhan, Mas amons_and ra/sites ef ulfilestesourccs/Mulifoealeop ote Ot “513-322 4. Jorge L. Alio et al. Multifocal intros 8ea%2010L§ Uy !) pd ‘ocular lenses: qj ee ophthalmology 2017; 62: 611-634 snses: An overview. Survey of : Scanned with CamScanner—_ FOS SANKARA ACADEMY Ye OF VISION MODULAR OT PERATION THEATRE SES/OT General Modular OT/General OT/Normal OT * Should preferably be Square in shape and minimum size-Gm_x 6m for effectiveness of Laminar flow system avoiding convenient pockets of stagnant air caused microbial growth and for better asepsis. Height of OT room shall preferably be > 4.25 m for convenience of setting of Laminar Plenum and HVAC ducting. + Should preferably be free of beam. The beam inside the OT should be avoided for convenience of fitting of internal ducting and installation of Laminar Plenum. If beam is there in the OR, it should not be at the centre of the room. Beam should be either at the wall or at the offset from the centre of the OR. There should not be any projected portion or any sharp comer of column/wall inside the OT. Double brick wall/wall pane! should be made to cover- up projection of column. There should not be any shaft inside the OT. _2-No sewage/drain pipe/ Water pipe should be inside the General OT/Modular OT/Normal OT. _-2-No fire pipe and sprinkler should be inside the General OT/Modular OT/Normal OT. ‘+ The area of the OT for CTVS, Hybrid and Robotic surgery should be 270 Sqm and hei 45m. a Each OT must have Scrub station and Anti Room in its adjacent for regulating traffic in _General OT/Modular OT/Normal OT. _© Bach General OT/Modular OT/Normal OT should have one for patient entry and another for doctor's entry from Scrubber’s room. = Location of the door of General OT/Modular OT/Normal OT for patient entry should be in the middle of wall and the door from the + Scrubber side must be at least 1.0m away from one side of the OT Room for placement of Return air ducts at the corners. + Each General OT/Modular OT/Normal OT should have preferably be one hermetically sealed window (Size-1500 x 1200 Approx) with double toughened glass and Motorized Venetian blinds sandwiched/toughened Frosted glass with dark film to prevent claustrophobia of the Surgeon and other OT staff. OT window should be flushed to inside wall ofthe OT. ‘“Tnternal ducting inside OT should be of prefabricated Aluminium insulated with Nitrile Rubber/Polyethylene. © Déor shall be’ Automaiic Hermetically sealed sliding door with PUF sandwiched HPL board and vision panel-300 x 300 min for General {{j0T/Modular-OT/Normal OT and Double teat hinge typed flushed door of PCGUS$-304 material with vision panel-300 x 300 mm for General OT/Normal OT/Minor OT. Double Leaf / Every Modular OT should have dedicated ANU of 6000 CFM capacity Super Specialty OT aid AHY of 4500 CFM for Normal/General OT. AHU should be placed in the nearby of OT to prevent energy consumption. 5AHU should be of double skinned PCGI wall with comer coving and VFD. AHU is eithe for supply of 100% fresh air with 25 ACPH or 25 ACPH with 5 fresh air as per NABH, Ideally, ‘AHU blower should run 24 x7 to keep OT free from bacteria, At the idle condition of OT, ‘AHU Blower will run without air-conditioning, Scanned with CamScannerZA sanxara acavemy CGS oF vision SY d terminal i it la lyester sheet and ninar flow system with two mono filament precisely woven pol 1 OT. f formal OT. HEPA filter of O.3micron should be installed in the General OT/Modular OT/N Laminar plenum with built-in light may be optional. fel * Laminar size shall be 2400 x 2400 mm for Super specialty and 2400 x 1800 mm for Gen OT Normal OT. Laminar Plenum should be fitted at the centre of the OT room * Required condition of air management in the Modular OT (Super specialty OT) * Classification - 100 (particles measuring 0.5 microns or larger/cu.ft as per NABH e for Super specialty OT) Bacteriological class Particle decontamination kinetics Biological decontamination kinetics GMP Annex I classification ISO 14644/1/NABH classification © -B(SCFU/m3)-5 min © -Smin-Class A * ISO S(at rest condition) ‘The air quality at the supply ie at the grill evel Should be class 1000 (particles measuring 0.5 microns or larger/cu.ft as per NABH) /ISO class 6(at rest condition) for General OT, '& C with coreesponding relative humidity between 45 to 60% should be maintained inside the OT all the time. Sealed with Silicon gasket for SMS Panel/PUF Panel Mi letallic at the four corners should be covered with “Swal panel * Comer panel in General OT/Normal OT, Scanned with CamScannerZS SANKARA ACADEMY F S S * Oe GN oF vision = ‘+ The inside wall and ceiling, Antibacterial p 1 face of the False ceiling shall be plastered and coated with nVEpoxy/PU paints before fitting of False Ceiling, = Cor s inside OT should have coving, © General OT/Modular OT/Normal OT antibacteri all/ Metallic panel should be coated with epoxy painting by 300-400 micron {ethickness after putty and primer. Panels/Finished Walls shall be smooth and perfectly Mat without any undulation, «Flooring of General OT/Modular OT/Normal OT should be made antistatic with 2 mm thick PVC Roll/3mm thick Epoxy. The floor finish should pass over a concealed cove former and continue up the wall upto 100mm, + Before PVC/Epoxy flooring, Copper grounding strip (0.05 thick, 50 mm width) should be laid flat on the floor in the conductive adhesive sfrand connected to main copper earth wire for grounding, One earthing Copper lead should be brought out of from every 150 Sq/ft area and attaching it to main earthing Copper strip/ground. «Sealed (Air tight) Clean room fitting Peripheral light with dimmable facility should flush to the False Ceiling, Peripheral Light shall be required to generate 400-500 Lux inside the OT. LED light/Fluorescent (2°x2")(I'x 3°) Fluorescent lights with anodized Aluminum reflectors and optical antiglare system for adjustable light distribution. + Laying of PVC conduits, Modular Switch Boxes, Modular Switches-sockets, Power and Light wiring including Earthing wire for all the lighting controls, Pendant and other equipment fixtures and fittings inside the theatre Wiring with low leakage current wires of PRLS wires should be as per requirements, 5/15 Amps antibacterial switched socket outlet set- 2 Nos shall be equidistant flushed in each wall at 325mm height from FFL of OT. Wiring for 250 volts single phase and earth 4 sq.mm and 2.5 squmm PVC insulated copper conductor 1100 volts stranded flexible wires should be concealed with conduit for switch & sockets. One switch and socket along with suitable size of wire must be fited inside the OT for operating ‘C°Arm. Installation of all electrical cabling must be of IS: 1554 (As per latest amendment) standard and wiring as per IS: 732 standard and proper earthing of OT and other accessories in the OT oom as per standard guidelines of BIS. Fittings should be sealed on accordance with the ‘tandard 1P54. Earthed equipotent bonding ofall exposed metal work should be provided. «Medical Gas pipeline system with medical graded copper pipeline and Gas outlets should be fitted inside the OT thorough Pendant s General OT/Modular OT/Normal OT should be equipped with the following equipmentiitems. Anaesthetic Pendant (To be fitted atthe right and Top ofthe head end ofthe patient). Pendant should have Oxygen x 2, Vacuum x 2, Nitrous x 1, Medical Air(4 bar) x 2. AGSS 1 ‘Antibacterial switch and socket-8/10 Nos, Data cable-RJ45-2 Nos and adjustable Shelves. Load bearing capacity-200 Kg Scanned with CamScanner<7 LS SANKARA ACADEMY OF VISION e ¢ patient). Pendant Surgeon Pendant (To be fitted atthe left and bottom of the foot end ofthe p ,, yen x 2, CO2 x I. Should have Oxygen x 2, Vacuum x 2, Surgical Air(7 bag ogen a an Antibacterial switch and socket-8/10 Nos, Data cable-RJ4S-2 Nos and adjustable S Nos. Lond bearing capacity-200 Kg Dual dome LED OT Light (To be fitted the head of surgeon when it will be fitte Flat Monitor at the centre of the OT Room). Dome should not hit dat the ceiling height 3m from FFL. If Camera and are integrated with OT Light, they should be of full HD. ‘Surgeon Control Panel should flush (Present time, Elapsed time, Room Humidity, Lighting system, Telepho: on the OT wall. Surgeon control panel provide 9 services Pressure, Gas alarm, HEPA filter status, Temperature & me, Music Control jin the OT, X-Ray viewer(2/3 plates) should be flushed on the OT wall, ‘Writing Board shall be flushed on the OT wall Buil in storage cabinet to be flushed on the OT wall, Pressure relief dumper shall be placed tothe clean corridor and covered with grill, ass Box should be shed on the OT wall and connected with Diny corridor/Sluice room, A Scrubber made of S$-304 material should be installed in the scrubber room adjacent to OT, he Scrubber sink should be 3 bay equipped with inbuilt soap dispenser, Geyser, thermostatic hands free operation through infra-red sensor s and have manual foot and operation mode, Integrated Modular OT GENERAL, Integrated Modular OT should have ll requirements of Modular or Integration of equipment (Endoscopi camera, In light camera, Room camera, C-Arm, Navigation system, Microscope, Patient vital sign, Conferencing solution, archiving system tc.) inside the Integrated Modular OT Integration of Modular OT with 1 the Conference Room) Monitor facility, VAuditorium having projecto Gonsultant room and outside the hospital » mSor aa Integration OT to OT, Integration rei features in the OF. Digital Display Monitor ‘Audio Visual communication system Central Control System Scanned with CamScannerAS SANKARA ACADEMY sania OF VISION Vy SZ High definition Monitor for Image data man ment system + PTZ camera AMI Monitors should be of full HD, Monitors on the wall should be flushed + Touch sereen should be medical graded, + Dual dome LED OT L Jnt (To be fitted at the centre of the OT Room). Light dome should not hit the head of surgeon when it will be fitted at the eeiling height 3m from FFL, Camera and Flat Monitor integrated with OT Light should be of full HD. + Size of Minor OT may be same as/ smaller than the General OT . + Flooring of General OT/Modulae OT/Normal OT should be made antistatic with 2 mm thick PVC Roll/3mm thick Epoxy. The floor finish should pass over a concealed cove former and continue up the wall upto 100mm, «Before PVC/Epoxy flooring, Copper grounding strip (0.05 thick, $0 mm width) should be laid flat on the floor in the conductive adhesive and connected to main copper earth wire for rounding. One earthing Copper lead should be brought out-of from every 150 Sqft. area ‘igand attaching it to main earthing Copper strip/ground. «Ceiling of Minor OT should be with panel like SS-304/EGP backed with Gypsum board ot PUF sandwiched SS-304/EGP. Joints of SS- 304/EGP panel backed by Gypsum shall be filled with epoxy sealant. Silicon gasket shouldbe used for PUF sandwiched Metallic panel. «The inside wall and ceiling surface of the False cciing shall be plastered and coated with “Antibacterial painv/Epoxy/PU paints before fiting of False Ceiling, +All Comers inside OT should have coving «sealed (Air tight) Cleanroom Fiting Peripheral light with dimmable rity should flush to anecie Ceiling Peripheral Light shall be equied to, generate 400Ln-S00 by inside the ess tighutluorescent Q°X2°V/1"s 3°) Fiurescent Highs with anedized ‘Aluminum reflectors and optical anighre system for adjustable light distribution «Laying of PVC condhits, Modular Switch Boxes, Modulos Switehes-soekets, Power and Light wvving incding, Earthing wire forall he lighting comets Pendant and other equipment vtres ad fitings inside te theatre Wising with low leakage, cures? wires of FRLS wires aid be as per requirements. 15 Amps antibacterial switched socket outlet set-2.Nos shall be equidistant flushed in each wall at 325mm height from FFL of OT. Wiring for 250 volts singe phase and earth 4 sq.m and 2.5 sq.mm PVC insulated copper conductor 1100 volts stranded f Feult be concealed with conduit for switch & sockets. Ons switch any long with suitable sizeof wire must be fited inside the COT for operating *C'Arm. er Scanned with CamScannerSANKARA ACADEMY OF VISION Installation of all electrical cabling must be of IS: 1554 (As per latest amendment) standard and wiring as per IS: 732 standard and proper earthing of OT and other accessories in the OT room as per standard guidelines of BIS. Fittings should be sealed on accordance with the standard IPS4, Earthed equipotent bonding of all exposed metal work should be provided. fe! Two nos Diffusers (Size-610 x 610)mm for supply air shall be placed at the centre of the OT and four nos diffusers (Size-610 x 610)mm for return air at the four corners of the False iling inside the Minor OT. The temperature at 21 +/- 3 Deg C with corresponding relative humidity between 45% to 60% should be maintained inside the OT all the time. Medical Gas pipeline system with medical graded copper pipeline should be concealed to the wall and Gas outlets (Oxygen x 2, Vacuum x 2, Nitrous x 1, Medical Air (4 bar) AGSS x 1 should be fitted to the wall or Anaesthetic Pendant (To be fitted at the right and Top of the ‘ head end of the patient). Pendant should have Oxygen x 2, Vacuum x 2, Nitrous x 1, Medical Air(4 bar) x 2, AGSS x 1. Antibacterial switch and socket-8/10 Nos, Data cable-RJ45-2 Nos and adjustable Shelves. Load bearing capacity-200 Kg inside the OT. Double leaf Hinge door(SS-304/PCGI) with view panel Dual dome LED/Halogen ceiling OT light to be placed at the centre of the OT room. Dome should not hit the head of surgeon when it {Swill be fitted at the ceiling height 3m from FFL. Each Minor OT should have preferably be one hermetically sealed window (Size-1500 x 1200 Approx) with double toughened glass and Motorized Venetian blinds sandwiched/toughened Frosted glass with dark film to prevent claustrophobia of the Surgeon and other OT staff. OT window should be flushed to inside wall of the OT. X-Ray viewer(2/3 plates) should be flushed on the OT wall A Scrubber made of $S-304 material should be installed in the scrubber room adjacent to OT. The Scrubber sink should be 2/3 bayequipped with inbuil thermostatic control, hands free operation through infra-red sensor operation mode, It soap dispenser, Geyser, Fs and have manual foot and false ceiling Internal ducting ineluding supply air and return air ducting and fitin i with suspended GI string, ing of Laminar plenum Scanned with CamScanner= AS SANKARA ACADEMY OF VISIO! Se | Fitting of OT light Bracket and Pendants’ brackets + Wall panelling and False ce | iting of hermetically sealed window and other equipment, OT Light and Pendants, Pass Box, Surgeon control panel, X-Ray Viewer, Writing Board + Wall painting | Y Y + Antistatie Mooring Y + Fitting of Hermetically sealed sliding door y + Fitting of Scrubber + Entry into Pre-Op should preferably be at the entry Airlock of the OT complex if + Scrubber should preferably be in between OTs or at the nearby place of OT. Scrubber area should always be equipped with plumbing line for supply of soft water and drain Tine. + TSSU room in the OT complex should be well ventilated and equipped with requisite plumbing system for supply of RO water of 1SPPM and drain line with flow trap system.. + OT complex should not have any toilet inside the clean area, Toilet should be before entry to the change room. © No toilet should be placed in the top floor of the OT complex. There should not be any sewage or drain pipe or any other water pipeline passing through OT complex. + Seepage or dampness inside the OT should not be present in the OT complex . + OT compl ng door or double swing door with vision panel at the entry and exit for ease of movement. + OT complex should be consisting of Operation Theatres, Scrubber room, Clean corrider, Diny corridor, Pre Op, Post Op, TSSU, Equipment store, Linen store, Pharmacy store, Doctors’ room, Nurses’ Room, Anesthetists’ room, Sluice area, Preparation’ Anaesthesia room, Staff rest room, Conference room, Reception, Trolley bay, Record room, Change rooms (M & F) and Toil before Change room. OT complex should have rooms for AHUs, UPS and OT con its adjacent area. Waiting area for patients should be adjacent to the entry to the OT comp! < should have auto sli Scanned with CamScanner= oS SANKARA ACADEMY

sanxara academy A oS OF VISION ACPH shall be maintained with comfort condition of Temperature 23420C and RH- 43 9% throughout year. Air pressure of corridor and Scrubber area shall be less than the air pressure prevailed inside the Operation Theatre. Dedicated AHU should be equipped with fine filters for OT complex. Continuous air circulation system (24x7) should be provided inside OT complex with AHU References: + Modular OT concept ~ Mr Jay Shankar + Revised NABH guidelines for operation theatre Scanned with CamScannerSANKARA ACADEMY 6 on the Dry E: 2 ry Eye Questionnaire (DE Ocular Surface Disease Index (OSD1)) for the iopaicaroess ote | Scanned with CamScanner[meee corer) | None so mid Fiamemay kes | mons Oong | : incon Gn [RCD ROE — [oer | [reared [a= o= Times «(eae [omen [ Sy gD wr Gd RTO i Drv eve disease staining pattern : SICCA Ocular Staining Score | | Right Eve Staining pattern sco exire points-fuorescein ony: ‘rare at rence (Srocrescein 22070) rota! Ocular Staining score: (J ] ross! caular staining scores of O10 12 per eve assess the range of severity for Kersiocaryonet 359 Scanned with CamScannerSANKARA ACADEMY ZS ZGS Sea key mechanisms in dry eye, regardless of ability and increased tear osmolarity etiology." film osmometers like electrical impedance osmometers — tear film osmolarity to identify increased levels of inflammatory markers in the tear film like * Immuno ass MMP-9 + Analysis and imaging of MGD — Ocular surafec analyser, LipiView I Johnson & Johnson Vision), Lipiscan (Johnson & Johnson Vision), Keratograph ete DED Management: STEP 1 + Education regarding the condition, its management, treatment and prognosis, + Modification of local environment + Dietary modifications (including oral essential fatty acid supplementation) + Modification/elimination of offending systemic and topical medications + Ocular lubricants of various types (if MGD is present, then consider lipid containing supplements) + Lid hygiene and warm compresses of various types STEP2 + Non-préserved ocular lubricants to minimize preservative-induced toxicity + Tea tree oil treatment for Demodee (if present) + Tear conservation + Punetal occlusion + Moisture chamber spectacles/goggles + Overnight treatments (such as ointment or moisture chamber devices) + Invoffice, physical heating and expression of the meibomian glands (including device- assisted therapies, such as LipiFlow) + In-office intense pulsed light therapy for MGD + Prescription drugs to manage DED. aciinaddmepye + Topical antibiotic or amtibiotic/steroid combination appli ; , blepharitis (if present) plied to the lid margins for anterior + Topical corticosteroid (limited-duration) + Topical secretagogues + Topical non-glucocortic immunomodulatory drugs (such as cyclosporine) Bon 80 LS Scanned with CamScannerOF VISION Lat + Oral macrolide or tetraey agonist drugs (such as lifitegrast) nto + Topical LE. STEPS + Therapeutic contact lens options Y¥ Soft band: scleral lenses lenses + Amniotic membrane + Surgical punctal ocel + Other surgical approaches ( ‘orrhaphy, salivary gland transplantation) 2, Managing lid conditions Intense pulsed light (IPL) has been extensively studied and reported to have a beneficial effect ‘on erythema and telangiectasia.”* Light energy absorbed by hemoglobin converts to heat and causes the destruction of superficial blood vessels (thrombosis). In meibomian gland dysfunction (MGD). the destruction of abnormal erythematous blood vessels decreases the inflammatory mediators, therefore removing a main cause of inflammation from the eyelids and meibomian gland: R DRUGS 1 — A small-molecule integrin inhibitor binds to lymphocyte function-associated ‘nel (LFA-1) and blocks the interaction of LFA-1 with ICAM-1 which results in decrease T-cell activation + Rebamipide - amino acid analog of 2(1H)- quinolinone and increases mucin levels over the conjuctiva and comea. Upregulates the gene and protein expression of MUCI, MUC4, and MUCI6 in human corneal epithelial cells.Recently been shown to increase epithelial cell proliferation.(2 % REBAPAMIDE USE ~ FOR 4 WEEKS, 4 TIMES A DAY) Scanned with CamScannerZe SANKARA ACADEMY EQS oF vision Sy : S ProKera amniotic membranes (BioTissue) is another alternative to speed up the healing of severe DED. The application of the amniotic membrane is a suture-free, in-office procedure.”° It is made by clipping a piece of amniotic membrane tissue in between two rings made out of @ clear, flexible material, The amniotic membrane used here is thin and clear like the tissue on the surface of the eye and protects damaged tissue when inserted. REFERENCES : 1. TFOS DEWS II Definition and Classification Report; J.P. Craig et al. / The Ocular Surface 15 (2017) 276 — 283 2. TFOS DEWS II WORKSHOP KEY UPDATES ~ AAO 2017; Scanned with CamScannerPAS SANKARA ACADEMY M OF VISION SS sit HISTOPATHOLOGY STAINS USED IN OPHTHALMOLOGY - A BRIEF REVIEW Specimens most commonly evaluated for ocular histopathological examination : 1. Eyeballs ~removed following enucleation, as part of exenteration specimen or autopsy. 2. Portion of the eye moved during various surgical procedures, e.g.: | | + Comeal button — following keratoplasty + Lens— following cataract surgery + Trabeculectomy specimen — following glaucoma surgery + Vitreous Specimen following vitrectomy + Epiretinal membrane, retinal or retinochoroidal tissue—following retinal surgery or biopsy for specific conditions 3. Biopsy — from: * Lid and lacrimal sac + Conjunctiva | + Comea + Iris © Orbit + Retina, choroid or retinochoroidal tissue 4, Aspiration material from anterior chamber or vitreous cavity or any’ cystic lesion of the eye and orbit, 5. Seraping from superficial structures, e.g. conjunctiva or cornea. 6. Temporal artery for biopsy ns for microsco) |A. CONVENTIONAL LIGHT MICROSCOPY : HEMATOXYLIN AND EOSIN PREPARATION | B, SPECIAL STAINS (tablel.1) « “Aleian blue at various pH levels stains acid imucopolyseccharides, keratan sulphate, heparan sulphate, dermatan sulphate and hyaluronic acid, In ma ular dystrophy of the cornea, these MPS accuinulate in the endothelium, inthe keratocytes, and in clumps beneath the epithelium, The best way is to use the colloidal iron or the Aleian blue stains, Mucopolysaccharides do not stain with H&E. 39 Scanned with CamScanner| S> ZB sankara academy EGS oF vision re 3 nee jocytic « Masson-Fontana stain melanin granules black: useful for the study of melan activity in the conjunctival epithelium. + Prussian blue stains ferrous and ferric iron breakdown products of blood and to time the prior occurrence example, the eves of battered or shaken babies. = Silver stains for reticulin demonstrate the walls of bloo jerentiating between haemangioendothelioma and haemangiopericytoma and for the study of fibroblastic tumour + Trichrome stains (Masson, Mallorv or piero-Mallory differentiate between smooth and striated muscle (red) and collagen (green or blue)Squamous epithelium (pin keratin (red) and neural tissue purple. Bowman's layer of the cornea is clearly outlined. * Oil red O and Sudan black stain fat globules dark blue, is useful to identify the of haemorthage in, for R id vessels; useful for STAINS IN DIAGNOSTIC OCULAR HPE — 1 CONVENTIONAL SPECIAL ELECTRON IMMUNOHIST STAINS STAINS MICROSCOPY OCHEMICAL OTHERS Unda high mogrcatin apo .0000 FLow cyToMTERY celloganetes ie melanosomes con ssugensnd ta se ientfed Amthodes se bound fo er tert ‘rae partles which appears, Se a Shukdetson misogrphs is coe wiiieriechcageipenfene localise epitopes present in cel, eee ; imemtane of oranales ‘ Per { isin i ' HYBRIDISATION STAINS IN INFECTIVE CONDITIONS ~ IDENTIFICATION OF MICROORGANISMS BACTERIA - MICROSPORIDIA uns FUNGI KOH, CALCOFLUI y FLUOR WHITE Gomori METHANAM INE SILY E a FACTOPHENOL COTTON BL ‘LUORESCEIN STAINS ~ AURANINE AMD Scanned with CamScanner— SANKARA ACADEMY S OF VISION SS . Stain Organisms Angearance Gram stain? Bacteria Gram postive welt que) = Gram negative Fung. Fungal amos exit varie trang ato Yess wet fig]. Fungal Hanan - Gram negation any stained eat of fr ath unstind tops Seay 26% 50 Acantiameto (stam postive OH et preparaon?™* ful amets Flat and prominent, Snsty 698 spechaty- 93-97% CE stain wet preparation Fug laments Acambarooba igh wit, sersioy 8-6 (CE + HOH Giomsa sta? Camyei wachomas in Indsenbotns and yp of oa response inte pital ces ial ages ove prods Easinpiicincsion bodes rd ype of cali esponse Acnamoeks Cystdable wala ye ha cel wals tind dak and cytolasstaied be Bacteria Da be bc ot coc Actinonyetes Login lanes with benches rng hin cod Tah Aedsen stir cist baci Fire] Ad baci a be bach ound died Nelsen sin wih Noearda eames bai TRysufric acid asthe decobuie® — Acinomycatas ‘he faneniosbcl Fungal filets ‘Bak alr agent at geen bolground GUS stain Fungal lements Magena clr AS sae Fons Sesto 8% speci of 51% Laetophenl can the Fungus (Fig 6] Inmunaturescerce sting Ra spc, rd sntive a and cays aniens Immunoproidase™ Aconthanosba ‘GUS — Gama tearing st Babitha V, Jyothi 2017;29:72-8 Pao ais Se CFV ~ Cait HO — Pos aie Microbiology for general eplthalmoldgists. Kerala J Ophthalmat BACTERIA - GRAMS, GIEMSA. PORIDIA GIEMSA. — Ter an KOH, CALCOFLUOR WHITE, 7 GOMORI METHANAMINE SILVER, LACTOPHENOL COTTON BLUE ACANTHAMEBA FLUORESCEIN STAINS - AURAMINE. c imuNOUISFOCHEMISTRY : z cells by type is achieved by applying 3 sp: nly labelled with a ifie antibody t0 an Precise identification of cific antibody antigenic epitope within the cell. The antibody is subsequer ht Scanned with CamScannerES SANKARA ACADEMY “OS oF vision SZ = chromogen which ca immunohistochemical rea dto H&E appearance is inconclusi Immunohistochemistry is an ideal tool Lymphoma, Conjunctival Melanoma and incerta Ocular Cicatrising Conjune antigen antibody complexes are seen at the level of be visualised by light or fluoresce poorly differentiate ; a ve (For example in metastatic disease) to identify conjunctival 1 inflammatory pathologies like 's, Steven Johnson Syndrome wher Basement membrane noe microscopy: A battery of d tumours when the neoplasms like re in deposition of ann RRND Os is ( Table 1.1. A summary ofthe spacial stains used in routine diagnostic histopathology. 2 of stain Reactions (colours) Diagriostic use 4 Alcian blue ‘Mucopolysaccharides (blue) Azarin ed CChelates calcium (red) Bodian ‘Axons (black) Cotoidal ron Mucopolysaccharide (blue) Gren Bacteria: dilering cll wall staining ‘characteristics Gram postive (dark blue) ‘Gram negative (rea) Lover Myotin (lack) Masson trichrome Epithelium (rea) Connective tissue (green) Periodic acid-Sehill(PAS) Basement membranes (bright pink) Prussian blue (Ports) Ferrous(Fe) and aie) iron (dark biuo) Muscle (yellow) Connective tissue (ed) Otten combined stain for elastin (back) ‘van Gieson (combined with von Kossa Phosphates in ected tasve (black ~ precipitated aa shor Zichl-Neeisen Acid-tast bacilli = Myabacerim ap ‘NocartaSp (oink staining rods) Macular dystrophy Thyroid eye disease (muscle) ‘ Caleicaton in tssue5, 9. band Kertonaty pte aropny Macular dystrophy 1 Thyroid eye disease (muscte) Idenilication and classification of becteia 4 Demyetinating diseases (e.g. multiple sclerais) , Optic aiophy Cornea: damage to Bowman's layer 1 Lens: fibrous metaplasia Corea: epithelial basement membrane, Doscemot’s membrane Lens: capsule Retina: inne it imiting membrane Others: lungat elements 'ron-containing sats and blood products. 9. metalic foreign body and hacmotthag2 Giant cet arteritis to demonstrate "@gmentation of internal elastic lamina Calcitication i ti keratopathy loenity acit i last pathogens i ‘nllammatory tissue a issues, e.9. band Scanned with CamScannerMe a AS SANKARA ACADEMY OF VISION Sy on Ya PATHOLOGY; Jyotirmay Biswas;Shwetha Abuja; 1, MANUAL OF OCULAR and Vision Research § Krishnakumar; Larsen and Toubro Ocular Pathology Medical Foundations; Sankara Nethralaya; 2010 pg 1-16 OPHTHALMIC EXAMINATION OF THE GLOBE; TECHNICAL ASPECTS; 2002; PG 18-23 An illustrated guide for clinicians; K Weng Sehu; and 3. Ophthalmic Pathology; University of Glasgow, UK; William R Lee; Tennent Institute of Ophthalmology, 2005 page 11-15, Scanned with CamScanner1) Diognasit ZS SANKAR ACADEMY 4) DO camming. Ae borline COS oF vision dope o = wu ~— D) Roving te innpro vend DIPLOPIA CHARTS tm bellow Mp. Introduction all nine position of a recording of subjective separation of double Diplopia charting is gazes Principle Each retinal point has its own value of direction in gazes so this subj diagnosis of the patient with diplopia tive test is used to aid in Importance Pre-requisites @ + Patient should hav. a a 4 + Patient should hav + Patient should bd’eo-operativey Materials required © Linear light source + Red- green goggles Scanned with CamScannerZA saniann acavemy ZGN oF vision wy SS Method The patient is seated comfortably. The procedure is explained to the patient in detail * Make sure that the head is held straight for the whole procedure. + Goggles are fitted such that the red glass is in front of the right eye. + The linear light is held vertically in the primary position and is asked about the diplopia. Data derived <~ The areas of single vision and diplopia. - ~The distance between the two images in the areas of diplopia LT Whether the images are on the same lev8l of not Whether one image is inclined or both are erect Whether the diplopia is homonymous or crossed. The above data is recorded appropiately Precautions * Patient must not be allowed to turn his head to look in any position of gaze. + The light source must be moved as far as possible in each direction of gaze checking that it is visible to both the eyes. * To complete the record, a note must be made about the distance between patient and the test-object because a change in distance will affect the separation of the images between the two eyes and may give rise to an erroneous interpretation on the progress of the paralysis on follow-up. Recording the diplopia chart + Patient's right and left side to be clearly labeled + Which eye projects the red image and green image to be noted + Record the separation of images and tilted images as described by the patient, he : Scanned with CamScannerZA SANKana academy CGS oF vision SZ — Interpretations + Iftvo images are joined together—no diplopia wre separated—confirms diplopia. Maximum separation is in the quadrant in which (the muscle moves the eye) the muscle is restricted. ‘The image is displaced towards the field of action of the paralyzed muscle. Disadvantages + Itis mainly a subjective test. + Needs a well cooperative patiet. | + Test isnot reproducible. (obierwe end PE «In many cases the patients are uncooperative or their intelligence is obscured by intracranial disease or contracture of the antagonistic muscles may have set in. if the paresis unmasks a The test may give false __ interpretations latent squint or the patient starts fixing with the paralyzed eye, especially if this eye has the greater visual acuity. Derm of Cth wmutchy Get be nated. Reading the diplopia chart 1. First note if recorded from patients point of view. ( 2. State the area of binocular single vision if any 3, Is there horizontal /vertical separation of images ? Is there tilt of images . Is the diplopia crossed or uncrossed ? Where is the maximum separation of images ~ horizontal _and vertical 2 in that position , ‘Which of the gaze position has recor ton right) Wt Scanned with CamScanner— = SANKARA ACADEMY >) SOF VISION ¢ ‘ ‘ ‘ Examples 4 allare with red goggles in front of right eye and green in front of left eye i ‘ 1. Left medial rectus underaction | ha ~~Seanned with CamScanner<= aay SANKARA ACADEMY CGF oF vision 3. Left superior oblique underaction 5, Left orbital floor fracture with inferior rectus entrapment hg Scanned with CamScannerTt 0 1 hy, AR SANKARA ACADEMY ah om eye 's Rypre thw pte Hess OE oF vision Unewhing G eos = We HESS SCREEN TEST Principle — It is a subjective test based on the haploscopic principle Pre-requisites + Good vision in both eyes + Central fixation * Normal retinal correspondence = Cooperative patient who are able to understand the test Hess screen + Internally illuminated + Have red points of light at the crossing of lines in such a way that there are eight points on the inner square and sixteen points on the outer square. + Used with diplopia red- green goggles Importance + To measure the degree of deviation, especially if torsional + To note the secondary changes in EOM as per muscle sequelae «To measure any progressive increase or decrease Muscle sequalae after paresis of one EOM 1. Contracture of ipsilateral antagonist 2. Overaction of contfalateral agonist ( yoke muscle) 3. Secondary inhibition palsy of antagonist to yoke muscle ( PAY) t= sec inhibition palsy of LR Example: RLR palsy ~ contracture of BMR — overaction of Lt 2. L80 palsy - contracture of LIO ~ overaction of RIR — see inhibition palsy of RSR _e-Performed with each eye fixating in turns <2 Distance between patient and screen i 50cm . - “the patient wears diplopia goggles, with green in front of the eye to be tested 5! Scanned with CamScannerZS SANKARA ACADEMY FGS oF vision SY — , ints illuminated in screen + Patient is asked to project a preen light over the red points ilfumin © Test is repeated for other eye with changing the goggles een chart. © ‘The observations are charted on F Interpretation © Position, size and shape are compared between the two eyes + Deviation of central dot indicates deviation in primary position + Each small square subtends an angle of 5 degree at SOcms. Hence, the displacement of the pointer from the central dot gives the measurement of deviation * Compression between plotted points shows underaction of muscle in that direction and expansion indicates overaction + Smaller fields indicates affected paretic eye, normal eye shows larger fields due to overaction of contralateral synergist * Charts with sloping fields indicates A or V pattern + Fields of similar size and shape indicates concomitant sq shapes indicates incomitance + In small strabismus, the inner field might appear normal. Outer field is helpful in these ‘cases where small deviation becomes apparent, t and dissimilar size and identify the muscle affected + To measure the degree of paralysis and deviation * Differentiate between neurogenic and mechanical causes * Differentiate between recent onset and long standing strabismus + To know about the extent of development of muscle sequelae * Assess the change overtime in follow up so helpful in knowing the prognosis © Can not be done if patient's vision is low if patient can’t understand the test Scanned with CamScanner