APOS New & Views, Issue 1, 2010
EDITORIAL BOARD Editorial Warm greetings from the editorial board of APOS NEWS & VIEWS.
We have great pleasure in bringing you the first issue of this magazine. We believe that this provides a platform to express your views and experiences which will be shared by the ophthalmic fraternity. Professional bodies like IMA, AIOS and Dr. I. Venkata Rao Dr. Santhosh G Honavar APOS should become stronger and formulate guidelines to its 984 830 4001 970 184 1299 members for a better practice environment. Knowledge and [email protected] [email protected] experience should be dissiminated so that they supplement and guide individual practices. With a rich blend of scientific and general information about the day to day practice, this magazine should generate interest among the readers. However your contributions by way of articles, clinical and surgical experiences would provide a good base for the future issues. Dr. C.V. Gopala Raju Running a magazine of this nature with three issues every 988 511 6262 year is no mean job. We spare no effort at our end to make this [email protected] magazine interesting, informative and self sustaining . Sustained efforts are made by all world communities to manage and reduce the incidence of blindness. We are all aware of the leading causes of blindness viz Glaucoma, Diabetes, ARMD and Cataract to mention a few. Rapid inudstrialization has fall outs like pollution and accidents. Thanks to the Dr. K. Ravi Kumar Reddy Dr. Rishi Swarup multicentric studies which provide a plethora of valuable 924 652 1643 988 581 2617 information in dealing these maladies. [email protected] [email protected] Creating awareness among public and providing facilities Ex - Officio of APOS for surgical management of cataracts especially in rural areas resulted in a considerable reduction in Cataract morbidity. But President Dr. K. Sivaramakrishna we have a long way to go in achieving the targets. Infections Hon. General Secretary and Nutritional aspects especially in the developing world are Dr. Manoj Chandra Mathur big hurdles retarding economic progress. As we achieve better Chairman Scientific Committe standards of life expectency we have not been able to Dr. Mallika Goyal satisfactorily address the group of Age related diseases. High Chairman ARC Dr. C. Sharat Babu treatment costs make the remedies unavailable for majority of people in this age group. Let us all hope that this new year will bring down the Proof Reading / Assistance costs so that the modern investigations and treatment procedures Mrs.P.Hemalatha Mrs.I.Parvathi Rao will be with in the reach of many,who need them.. We have chosen Glaucoma as the main theme of Design & Graphics presentation for this issue. While our knowledge and Mr.E.Sai Krishna Kumar Mr.Uma Maheswara Rao understanding of Glaucoma is better now, lot of questions remain unanswered and it is still an enigmatic disease. Printers Please strengthen our efforts and send us your scientific Rama Krishna Printers Sankara Mattam contributions as soon as possible. Visakhapatnam apos.org 1 APOS New & Views, Issue 1, 2010
Andhra Pradesh State Ophthalmological Society Managing Committee 2009 - 10
President : Secretary Imm. Past President Dr Sivarama Krishna Dr Manoj Chandra Mathur Dr. K. Viswanath Sridevi Eye Hospital 8-3-678/24, Yousufguda Pushpagiri Eye Institute Bodemma Hotel Centre, Pragatinagar colony, Road No 9, West Marredpally BRP Road, Hyderabad 500 045 Secunderabad – 500026 Vijayawada 520001 [email protected] [email protected] 9848097949 939334 8827 9959744437 Advisor : Treasurer Chairman ARC Dr. N.S. Reddy Dr. K.B. Nand Kishore Dr. C. Sharat Babu 8-2-268/K/22, 1-1-336/36A, Vivek Nagar, Sharat Laser Eye Hospital Navodaya Colony, Chikkdapally Alankar Circle, Road 2, Banjara Hills, Hyderabad. Hanmakonda-506011 Hyderabad – 500034 [email protected] [email protected] [email protected] 94400 49555 98490 58355,9490124699 92461 66611 Jt. Secretary Editor Publications President Elect : Dr. V Krishnamurthy Dr. C V Gopal Raju Dr. Pradeep Swarup Flat No. 1,Arjun Apts., Visakha Eye Hospital Swarup Eye Centre K.V. Layout 8-1-64,Pedda Waltair 145, Dwarakapuri Colony, Tirupathi – 517501 Visakapatnam-530017 Panjagutta, Hyderabad-82 [email protected] [email protected] [email protected] 9440799235 98490 03639 9885116262 Vice President : Chairman Scientific Committee Co-opted Member / FBS Dr. Vidyavati Dr. Mallika Goyal Dr S V Katta 14B, Gandhi Nagar, Ophthalmologist Ranga Reddy Lions Eye Hospital st Behind Praga Tools, Apollo Eye Hospital 1 Floor, Palika Bazar Secunderabad. Jubilee Hills, Hyderabad Secunderabad [email protected] [email protected] [email protected] 9849790646 9849270994 9949540043
Co-opted Members : [email protected] Adilabad : Mahboobnagar : Dr P Ranga Reddy Special Invitee – Grievance Cell : Dr Badrinarayana Dr. Y. Mallikarjuna 10,Road No.13, Dr. K. Vengal Rao R P Road, S.V.Nursing Home (New Road No: 2) Bobbili Eye Hospital, Mancherial MainRoad, Banjara Hills, Bobbili, 504208, Adilabad ,A.P Narayan Pet Hyderabad-500034 Vijayanagaram (Dist) 532558 9866223525 Mahaboob Nagar Dist-10 9440019011 [email protected] Kareemnagar : Kurnool : 9848944650 [email protected] Dr M Sanjay Kumar Dr. K.A. Gopi Chand Members Managing Committee 2009-12 Pavani Eye Hospital & Civil Asst, Surgeon District wise : YAG Laser Centre Regional Eye Hospital Dr M Mohan Rao Hyderabad : Ashok Nagar, Kurnool - 2 Superintendent, Dr Virender S Sangwan Jagtial 505327,A.P Regional Eye Hospital, Anantapur : LV Prasad’s Eye Institute 9849043300 Opp. Bullayya College, Dr. B. Siva Prakash Rao Road No 2, Banjara Hills Vishakapatnam AP Warangal : Sri Prakash Eye Hospital Hyderabad 500034 [email protected] S.V. S. Policlinic 9849294656 Dr B Giridhar 9849903067 1-7-709,Shanti Nagar 21/1,Sai Nagar Hyderabad : Subedar, Anantapur - 515001 Dr Rishi Swarup Hanmakonda – 506001 Kadapa : Dr N. Sai Murali 157, Dwarakapuri Colony, [email protected] Dr. N. Swarupa Rani Bollineni Eye Hospital Punjagutta,Hyderabad-500082. 9866168889 Bharathi Hospital 9885812617 Dargamitta, Nellore-524003. Khammam : R.S. Road Medak : [email protected] Kadapa. 9848017009 Dr B Krishnamurthy Dr. Madiraju Ashok H.No. 9-2-31, Gandhi Chowra Old Club Road Chitoor : Siddipet – 502103 Khammam 507001 Dr. P.A.S. Chalapati Reddy Dr K Ratan Kumar 9849422871 Nalgonda : 3-1-55 Chief Consultant Ophthalmologist Nizamabad : Dr. L. Amar Vidyanagar Colony Tirupati - 517502 , A.P. Rotary Eye Hospital Dr P B Krishna Murthy C/o. B. Bhadru, Katuru Road Behind Telephone Exchange, Sri Rama Netra Vaidyashala Special Invitees : Vuyyuru-521165 Opp. Sudha Nursing Home Naya Nagar, Past President’s Forum Krishna District AP Khaleelwadi, Nizamabad Kodada Other Special invitee 9440157392 9849290234,220060, 231060 Nalgonda Dist
2 apos.org APOS New & Views, Issue 1, 2010
Nellore : Dr.Brindavolu Krishna Murty Table of Contents Address: 27/1117 Ramjinagar Children Park, NELLORE [email protected] 9396203347,0861 2304192 1 Editorial Board and Editorial Prakasham : Dr.Aluri Bhaskara Rao Aluri Eye Hospital 2 APOS Management Committee & Contents ONGOLE -523002 [email protected] 9440211566.08592-233767 4 Current Concepts : Current Concepts in the Diagnosis of Angle Closure Guntur : Glaucoma Sriram Sonty MD FACS,Clinical Associate Professor University of Illinois Dr.Y.Sreerama Murty Chicago Renukanetralayam Muppirisetty vari veedhi 7 Clinical Update : The Limbus, the Fornix and the Options for Trabeculectomy Kothapeta,GUNTUR-522 001 9390080806,0863-2225767/002 Compiled by Dr.C.V..Gopala Raju, source : Eyenet Magazine Guntur : 10 Expert’s Views : Management of Normal Tension Glaucoma Dr. Ganesuni Rajesh Sudarsani Eye Hospital 14 Trend Setter : - Dr Sriram C Ravula, NEC, Kakinada Main Road, Kothapeta,Guntur-522 001. [email protected] 16 Biography : - Prof P Siva Reddy 9394101616,Fax:0863 2216795. Is Advertising Ethical ? : - Prof K Vengal Rao East Godavari : 18 Ethics in Ophthalmology : Dr. A. S. R. Murthy 20 33rd APOS Conference : Minutes of management committee meeting, Parade East Vaisakhi Eye Con 2009 Rajahmundry-533104 East Godavari : 24 Journal Review : - Dr G Seshubabu - Glaucoma ,Archives of Ophthalmology Dr. Srirama Chandra Murthy Ravula 65-14-5, Narasanna Nagar 27 Remembering : Dr J Agarwal Kakinada - 533033 West Godavari : 28 Test Your Knowledge Dr. U.V. Ramana Raju C/o. U.V.S.M. Eye Hospital 29 Family Benefit Scheme Juvalapalem Road Bhimavaram Krishna : List of Advertisers Dr. S.Venugopala Rao Surapanenei Eye Hospital Vijayawada Alcon India Ltd - Surgical & Pharama Krishna : Allergan India Ltd Dr. P.Chandra Sekhar Samatha Nursing Home Ophtechnics Unlimited Vuyyur,Krishna Dist. Visakhapatnam : Hesh Store (Maruti Opticians) Dr. M.Mohan Rao Superintendent Entod Pharamaceuticals Ltd Govt. Regional Eye Hospital Visakhapatnam Cipla [email protected] 9849903067 Visakhapatnam : APOS Wishes to Congratulate Dr.C.Phanendra 54-13-8,Sitammadhara Vishakapatnam-530013 Vizianagaram : Dr.G.N.Rao - “World Cornea congress Medal for 2010 Dr. K.V. Appa Rao Bobbili Eye Hospital Bobbili Srikakulam : Dr.Saibaba Goud - “Siva reddy International Award” Dr. K.L. Naidu AIOC2010,Kolkata Plot No. 9, A.S.N. Colony Near Bondilipuram Srikakulam apos.org 3 APOS New & Views, Issue 1, 2010
Current Concepts
Current Concepts in the Diagnosis of Angle Closure Glaucoma Sriram Sonty MD FACS,Clinical Associate Professor University of Illinois Chicago Email : [email protected]
Introduction : divided by Stages(14)Stage1:Narrow those that develop ACG (17). Among the various Angles(Angle-Closure Suspect) an anatomical Anatomical Factors Pupillary Block, Anterior Glaucoma is the leading cause of predisposition to Angle Closure. by Gonioscopy, Lens, Thick Iris or Hump, Iris Insertion irreversible blindness worldwide with an estimated van Herick Technic and by both. Stage 2. Angle (Anterior vs Posterior) and Plateau Iris play an 5.2 to 6.7 million thought to be blind from the Closure - Partial or total Closure of the angle with important role in combination of contribution disease (1,2) Recent glaucoma prevalence studies Synechiae and/or raised IOP (height and towards ACG. Pupillary Block can be relieved among Mongolians(3), Singaporean Chinese(4) cumulative circumference of the PAS should be by Iridotomy while other factors may need and South Indians(5) reported Primary Angle- recorded) (a) Non - ischemic - No iris Atrophy Pilocarpine Miotic use except in Anterior Lens Closure Glaucoma(PACG) as major form of and (b) Ischemic with Iris stromal Atrophy Stage displacement. Glaucoma in these populations. With the Chinese 3 : Angle Closure with Glaucomatous Optic and Indian populations making the majority of the Neuropathy . Physiological Factors : World Population (2/6 Billion) PACG becomes a UBM videos show dramatic changes Major Cause of Visual Morbidity after Cataract Angle Closure Glaucomas by Mechanism : in the angle as the pupil enlarges and constricts. and Trachoma.(6) In China alone an estimated 3.5 1. Primary and 2. Secondary Recent quantitative measurements of the iris and million are afflicted with this disease while another A. Pupillary Block. B. Anterior non pupil block angle with Anterior Segment Optical Coherence 28 million are estimated to have occludable angles - including Plateau Iris and Iris Crowding.C. Lens Tomography that took pupil’s size into account (7) In the Singapore Study reported an annual rate Related and.D. Factors behind the Lens-iris showed that the angle’s narrowing on dilation of Acute Primary Angle Closure(APAC) as 12.2 diaphragm(Table1)The Older symptoms based is partially due to changes in Iris Volume (18). per 100,000 among persons over 30 years of classification is not satisfactory on the basis of As the pupil constricts ,the iris gets fatter, age(8).The risk of APAC is Nine times greater Acute, Subacute/intermittent and Chronic Angle swelling with more aqueous humor water and among persons above 60 Years of age compared closure categories. This scheme has little or no then loses volume on dilation, much like a to those under 59 Years. Women are more prognostic value, does not guide management sponge. Eyes with ACG lose l less iris volume frequently involved to males at a Two to One Ratio and does not distinguish between elevated IOP on dilation, making angle closure more likely. among various studies from Japan, Israel , Finland and Glaucomatous Optic Neuropathy ( 15). This physiological Risk Factor may vary and Thailand(9). Review of a database revealed ethnically, providing one explanation for 2,864 patients with Angle Closure found only 2.3% Anatomical Factors : racial differences in ACG. Current under 40 years of age, Plateau Iris in 52% and Although ACG occurs more provocative tests do not predict who will evidence of pupillary block in 3%(10). Among the commonly in short eyes anatomic risk factors develop the disease , but the dynamic Caucasians in Northern Italy found to have overall do not explain why many people with small eyes physiological tests might( 19) prevalence of 0.6% indicating PACG is probably and narrow angles never develop the Other mechanisms may contribute to not as rare (11). Chronic asymptomatic Primary disease.Chinese persons have a fivefold higher ACG. A hole in the iris eliminates papillary Angle Closure Glaucoma (CPACG) is incidence of ACG than Europeans, yet the block mechanism, but one-third of the eyes are predominant form the disease among the Asian proportion of small eyes among the Chinese is goniscopically narrow after iridotomy ( Plateau Populations( 12,13).This asymptomatic form was not greater than among Europeans or Africans ( Iris Configuration). Very few of these develop also quite frequent 58% PACG among white 16) Cross sectional evidence among the Chinese high IOP after dilation(20). Some surgeons population(11). PACG is responsible for most shows greater shallowing of the anterior recommend Iridoplasty for these eyes but there bilateral glaucoma blindness in Mongolia, chamber with age than in Europeans or is no controlled evidence to support this. These Singapore and China. In Andhra Pradesh 41% of Africans.Gonioscopy and Ultrasound eyes may lose less iris volume upon pupil’s those with manifest PACG had blindness in one Biomicroscopy(UBM)however do not separate dilation because the Iris insertion into the Ciliary or both eyes resulting from PACG (5). In Singapore many patients with Benign Narrow Angles from Body.(21) study 25% of persons with PACG became blind almost double those with POAG (7) .The Angle Table 1: Parallel Classification of Stage and Mechanism of Primary Angle Closure Closure Glaucoma awareness is very low even in Singapore where 60% of blindness and incidence Disease Staging : of angle closure is very high.The persons with Stage 1 : Narrow -angle ( angle-closure suspect) - an anatomical predisposition to closure Chronic(Asymptomatic)AngleClosure Stage 2 : Angle Closure - Partial or total closure of the angle with synechiae and/or raised Glaucoma(CACG) require careful gonioscopy for IOP (height and cumulative circumference recognition, which is rarely practiced as a screening of PAS should be recorded) tool in China where PACG is endemic. (a) : Non-Ischaemic : (b) : Ischaemic : with Iris Atrophy Clinical Types of Angle Closure Stage 3 : Angle Closure with glaucomatous Optic Neuropathy. Glaucoma : Mechanism of Closure : A.Pupillary Block According to the AAO 's Preferred B.Anterior non-pupil block-Including Plateau Iris and peripheral iris crowding Practice Pattern for Angle Closure Glaucoma ,the C.Lens-related Angle Closure Glaucoma clinical types can be D.Factors behind the lens.
4 apos.org Current Concepts in the Diagnosis of Angle Closure Glaucoma APOS New & Views, Issue 1, 2010 Bibliography : Table 2: Classification Systems for Primary Angle Closure 1. Quigley HA Number of people with glaucoma worldwide Br J Ophthalmol 80:389- 393 ( 1996) AAO Preferred Practice Pattern Research Definition Symptom-based System Anatomic Narrow Angle 2.Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY : Global Primary Angle Closure Acute:abruptonset, data on blindness Bull World Health Organ 73: 115-121(1995) (PACSuspect):the Suspect:ITC in three or more symptomatic, elevated IOP. 3. Foster PJ,Bassanhu J, Alsbirk PH et al : Glaucoma in Mongolia- peripheral iris is located quadrants; normal IOP, that is not self limiting a population based survey in Hovsgol Province, Northern Mongolia close to , but does not touch, disc,field, no evidence of Subacute/Intermittent : Arch Ophthlmol 114: 1235-1241(1996) the posterior (pigmented) PAC. abruptonset, symptomatic, 4 Foster PJ, Oen FT, Machin D et al: The prevalence of Glaucoma trabecular meshwork Primary Angle Closure : elevated IOP that is self limiting in Chinese residents of Singapore: a cross-sectional population Primary Angle Closure : ITC in three or more survey of the Tanjong Pagar District. Arch. Ophthalmol 118: and recurrent 1105-1111( 2000) narrow/closed angle plus quadrants with raised IOP Chronic: elevated IOP or evidence including elevated 5. Dandona L, Dandona R, Mandal P et al : Angle Closure Glaucoma and /or primary PAS, disc PAS resulting from angle in an urban population In Southern India . The Andhra Pradesh IOP, PAS, Sector Iris and field normal closure that is asymptomatic Eye Disease Study. Ophthalmology 107: 1710-1726 ( 2000) atrophy,or Glaucomflecken, Primary Angle Closure 6. Quigley HA, Congdon NG, Friedman DG : Glaucoma in China can be acute, intermittent or Glaucoma : ITC in three or ( and worldwide) : Changes In established thinking will decrease chronic. more quadrants, with raised preventable blindness Br J Ophthalmol 85: 1277-1282 (2001) Primary Angle Closure IOP, and/or primary PAS, 7. Foster PJ Johnson GJ: Glaucoma in China : how big is the problem Glaucoma : PAC plus plus disc and/or field ? Br J Ophthalmol 85: 1277-1282 ( 2001) glaucomatous optic evidence for Glaucomatous 8. Seah SK, Foster PJ, Chew PT et al : Incidence of Acute Primary neuropathy Angle-closure glaucoma In Singapore Arch Ophthalmol 115: Optic Neuropathy. 1436-1440 ( 1997) 9. Foster PJ : The Epidemiology of Primary Angle Closure and Abbr: PAC: Primary Angle Closure, PAS : Peripheral Anterior Synechiae ITC : Irido associated glaucomatous Optic neuropathy Semin Ophthalmol 17:50-58 ( 2002) Trabecular Contact 10.Ritch R, Chang BM, Liebmann JM : Angle closure in Younger Patients Ophthalmology 110 : 1880-1889 ( 2003) 11.Bonomi L, Marchini G, Maraffa M et al : Epidemiology of angle- Choroidal Expansion : mechanisms. Gonioscopy is limited by the closure glaucoma, Prevalence, clinical types, and association alteration of the angle configuration with Light with peripheral anterior chamber depth in Egna-Neumarket Another dynamic physiological risk glaucoma study. Ophthalmology 107: 998-1003 (2000) factor in ACG is Choroidal Expansion. A study exposure and pupillary miosis. Mastering 12.Congdon N, Wang F, Tielsch JM: Issues in the epidemiology by Quigley et al ( 22) proposes that eyes with ACG Gonioscopy is rather challenging to few. and population based Screening of primary angle-closure have a greater tendency for the Choroidal glaucoma Surv Ophthalmol 36: 411-423 (1992) AS-OCT offers the advantages of Non 13.Salmon JF, Mermoud A, Ivey A et al: The prevalence of primary Expansion, which accounts for Flat Anterior Contact Testing, and does not require highly angle-closure glaucoma and open angle glaucoma in Mamre, Chambers post trabeculectomy in these eyes. skilled technician. Once Scleral Spur is identified Western Cape, South Africa Arch ophthalmol 111: 1263- Nanophthalmos is an extreme example. This was like with UBM various irido-corneal parameters 1269(1993) evidenced in Secondary Angle Closure due to 14. Eye 20 ( 1) : 3-12 ( 2006 ) Cited in Glaucoma P.42. Vol 7 can be measured. Other benefits are efficient No. 5 ( 2009) Choroidal Hemorrhage, topiramide induced or Popular Screening, to identify people at risk for 15. Goldsmith JA Diagnostic Tools for Primary Angle Closure Valsalva induced anterior movement of the lens- angle closure AS-OCT cannot penetrate beyond Glaucoma 7 ( 5) : 37- 42 (2009) iris diaphragm as well as in Primary ACG (23) Iris.( 26) 16. Congdon NG, Qi Y, Quigley HA et al : Biometry and primary Malignant Glaucoma is also an extreme example, angle-closure glaucoma among Chinese, white, and black UBM penetrates deep enough to image populations. Ophthalmology 104: 1489-1495 (1997) where vitreous has poor fluid conductivity the Ciliary Body . The main disadvantages with 17. Wojciechowski R, Congdon NG, Anninger W, Broman AT : Age, gender, biometry, refractive error, and the anterior chamber Diagnostic Tools for Primary Angle UBM are it needs highly skilled technician, and angle among Alaskan Eskimos Ophthalmology 110:365- Closure needs direct contact, which can alter the anatomy 375(2003) Diagnostic tools for the detection of of angle structures. It can identify the non-pupillary 18. Quigley HA, Silver DM, Friedman DS et al: Iris volume block mechanisms in causing Angle Closure, decreases with pupil dilation and its dynamic behavior is a Primary Angle Closure include age old technics potential risk factor in angle closure J glaucoma 18:173-179 like Gonioscopy, Slitlamp estimation of Limbal which is quite common among the Asian eyes.(26) (2009) Anterior Chamber Depth as well as new Both UBM and AS-OCT can identify Narrow vs 19. Sihota R, Mohan S, Dada T et al: An evaluation of the darkroom prone provocative test In family members of primary angle- technologies that yield High resolution, cross Closed angles with reasonable performance. But closure glaucoma patients. Eye 21: 984-989(2007) sectional images of the angle. In addition to their they can not differentiate Appositional vs 20. Lee DA, Brubaker RF, Ilstrup DM : Anterior Chamber diagnostic potential Anterior Segment Optical Synechial Closure. In both these technics dimensions in patients with narrow Angles and angle-closure Coherence Tomography (AS-OCT) and identifying the Scleral Spur is very essential. glaucoma Arch Ophthalmol. 102:46-50(1984) 21. Pavlin CJ, Ritch R, Foster FS: Ultrasound Biomicroscopy in Ultrasound Biomicroscopy(UBM) have provided Non-pupillary block mechanisms of Plateau Iris Syndrome Am J Ophthalmol. 113:390-395 (1992) insight into newly identified mechanisms of Angle Closure include Plateau Iris 22. Quigley HA, Friedman DS, Congdon NG. Possible mechanisms primary angle closure that go beyond the effect of of Primary Angle-closure and Malignant Glaucoma. J Glaucoma Configuration, and Choroidal Effusion. Relative Pupillary Block. Other imaging modalities 12:167-180(2003) Much of the research to date on 23. Sihota R, Dada T. Aggarwal A et al. Does an iridotomy provide including Scheimpflug Photography (24) and the protection against narrowing of the anterior chamber angle during Scanning Peripheral Anterior Chamber Depth diagnostic tools for primary angle closure has Valsalva maneuver in eyes with primary angle closure Eye 22: Analyser (25) are currently under investigation but focused on STATIC biometric parameters. The 389-393(2008) do not provide direct images of the angle recess. researchers are beginning to understand that 24. Friedman DS He M : Anterior Chamber angle assessment many important parameters are DYNAMIC and techniques Surv Ophthalmol 53(3): 250-273 (2008) Gonioscopy is the most comprehensive 25. Wong HT, Chua JL, Sakata LM et al. Comparison of Slitlamp subject to physiologic fluctuation , including diagnostic tool for angle closure. It can assess the Optical Coherence Tomography and scanning peripheral anterior pupillary dilation and its recently described chamber depth analyzer to evaluateAngle closure in Asian Eyes. angle/iris relationship, distinguish between relationship to Iris Volume and Choroidal Arch Ophthalmol 127(5): 599-603 ( 2009)26. Radhakrishnan S, appositional and synechial closure and provide Expansion ( 27) Future predictive models may Goldsmith J, Huang Detal .Comparison of Optical Coherence visualization of the Double hump sign of Plateau Tomography and Ultrasound Biomicroscopy for detection of narrow include Dynamic variables and provocative Iris and the Vessels of the Neovascular angle anterior chamberAngles Arch Ophthalmol 123(8): 1053-1059 tests based on these variable parameters may (2005) closure. This test also provides clues to Pigment be developed to forecast the risk for angle 27. Quigley HA . Angle-Closure Glaucoma- Simpler Answers to Dispersion and Exfoliation Syndromes. Along with closure than static variables studied to date. Complex Mechanisms LXVI Edward Jackson Memorial Lecture Elevated Episcleral Venous Pressure as the causal Amer J Ophthalmol 148: 657-669(2009)
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APOS New & Views, Issue 1, 2010
Clinical Update
The Limbus, the Fornix and the Options for Trabeculectomy
Compiled by Dr C V Gopala Raju , Source : Eyenet Magazine.
Around eight years ago Peng T. Khaw, PhD, MD, professor of glaucoma and ocular healing at Moorfields Eye Hospital in London, began publicizing the Moorfields Safer Surgery system, a technique for achieving good bleb morphology. He was in spired by one of the first patients he’d treated with mitomycin C, a young child, who, after several years of well controlled pressure, lost his sight after developing endophthalmitis from a thin avascular cystic bleb. Dr. Khaw, who said that though complications had been accepted as an inevitable consequence of using MMC, “I felt we really had to improve the way we carried out filtration surgery, particularly with antimetabolites like mitomycin C.” Through 1.Localized bleb resulting from limbus-based conjunctival incision; filtration is not directed posteriorly. clinical observation and laboratory experiments, 2.Diffuse bleb with posterior extension resulting from fornix-based conjunctival flap. Dr. Khaw, concluded that these blebs always had two features: 1) a ring of scar tissue surrounding said the result is a dramatic improvement of bleb the bleb, the so called ring of steel, which appearance and a reduction from 20 percent to “ Broader application of restricts flow and creates a higher more cystic 0.5 percent in longterm blebrelated problems in MMC, larger scleral flap, bleb, and 2) a point of anterior limbal drainage highrisk patients. And for better postoperative of aqueous To achieve healthier blebs, to reduce aqueous flow and intraocular pressure control, fornix-based conjunctival the tendency for blebs to migrate down to the Dr. Khaw uses an intraoperative infusion and cornea, and to avoid complications such as adjustable sutures to secure the scleral flap. flap avoids a posterior blebitis and endophthalmitis, Dr. Khaw changed his treatment tech-nique. Liberal MMC, tight closure: scar restricting the Both Alan S. Crandall, MD, and Garry posterior flow of aqueous ” “A ring of scar tissue P. Condon, MD, speaks of a paradigm shift that occurred at the time Dr. Khaw began advocating Variations on a Theme: surrounding the bleb, the Moor fields system. “Some of the pictures Peng Khaw published made us rethink Conjunctival closure .The Moorfields Safer the so called ring of trabeculectomy technique,” said Dr. Condon, Surgery system hasn’t rendered all other surgical professor and chairman of ophthalmology and techniques obsolete. “There are as many ways to steel, which restricts director of the glaucoma service at Allegheny do trabs as there are surgeons,” Dr. Crandall said. flow and creates a General Hospital in Pittsburgh. The bottom line, “My closure, and variations of it, is still easily he said, is creating a cut that allows for a diffuse doable with the new shift.” Dr. Crandall’s higher more cystic bleb” application of MMC and the absolute, watertight conjunctival wound closure technique is designed closure of the fornix-based flap. “Without to decrease the incidence of wound leakage watertight closure in these cases, you shouldn’t following trabeculectomy. He leaves a small edge Dr. Khaw’s Technique: be doing them,” he said. Dr. Crandall said that of conjunctiva adherent to the limbus to facilitate when doctors first used MMC in the early ’90s, conjunctival closure. Using a 10-0 vicryl vascular Prevent the ring of scar tissue; he uses they applied it with one or two small sponges needle, he creates a running mattress suture to a much broader application of MMC, rather than over a small surface area around the half scleral close the limbal conjunctiva in a routine fornix- a smaller sponge of MMC. He also makes a thickness site. But late bleb leaks often occurred, based flap. larger scleral flap not cut all the way to the and thinning blebs developed, and it was hard In 2001, Dr. Condon switched from limbus, thus directing aqueous flow posteriorly. to achieve good pressures. “Then Peng limbus to fornix-based flaps following a And he has converted completely too fornix- rediscovered opening up a diffuse area and presentation by Dr. Khaw. “I did that with based flaps for good exposure of the sclera and putting in eight or nine sponges,” said Dr. trepidation because the whole operation depends to avoid a posterior scar restricting the posterior Crandall, professor and vice chairman of on watertight closure,” Dr. Condon said. But he flow of aqueous. Also, rather than manually ophthalmology at the University of Utah in Salt has been convinced that fornix-based surgery cutting with a blade and scissors, he performs a Lake City sclerostomy with a 0.5 mm scleral punch. He produces a better bleb, with fewer complications.
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Crimp and stretch. posteriorly and prevents the anterior migration Today, to achieve watertight closure, “ Patient will not have an associated with cystic blebs. Dr. Condon uses a modified technique proposed early postoperative wound in the early 1990s by James B. Wise, MD, in The fornix-based technique is which he leaves a lip of conjunctiva along the leak with a limbus-based appropriate in some circumstances, Dr. Singh edge of the limbus. When making the anterior said. If there is inadequate ocular exposure to limbal incision, Dr. Condon leaves approach ” allow an incision 10 mm posterior to the limbus, approximately 0.5 mm of limbal conjunctiva or if the surgeon is not comfortable with his at the corneoscleral junction. Then he uses the approach, said Kuldev Singh, MD, MPH, who closure technique, it might be better to take the Wise mattress suturing technique to attach the is among that group. “I have greater faith that higher (but not necessarily high) risk of wound edge of the conjunctival flap directly to the my patient will not have an early postoperative leakage with fornix-based trabeculectomy. And corneoscleral tissue beneath this anterior lip of wound leak with a limbus-based approach,” said the limbus-based flap is not for everyone. It’s a residual conjunctiva. The anterior lip acts as a Dr. Singh, professor of ophthalmology and more technically challenging approach and often bolster, reducing the tendency for early leakage. director of the glaucoma service at Stanford requires an assistant, Dr. Singh said. But he said University. the greater technical difficulty is justified because “ The fornix-based approach it almost completely elim-inates the risk of early Pratap Challa, MD, assistant professor wound leakage. Dr. Singh added that, for years, tends to have more wound of ophthalmology at Duke University, is another he has been applying MMC broadly over three limbus-based proponent. “The fornix-based to four clock hours extending approximately 10 leaks post•operatively approach tends to have more wound leaks mm posterior to the limbus, with limbus-based post-operatively because it can be difficult to get flaps. because it can be difficult to the conjunctiva tacked down im-mediately after get the conjunctiva tacked surgery,” he said. “ The fornix-based
down immediately after Dr. Khaw acknowledged that concern. technique is appropriate in “The main reason that people don’t use the surgery ” fornix-based approach is they are some circumstances, If understandably worried about leaks, which you there is inadequate ocular All of Dr. Condon’s conjunctival and can see as the cut is at the limbus,” he said. “But scleral suture bites are longer than any distance with newer techniques of fornix-based flap exposure to allow -an between them. This produces alternate closure, such as corneal conjunctival closure, or crimping and stretching of the conjunctival the short conjunctival frill method described by incision 10 mm posterior edge, tightly applying it to the sclera. “I fell in Alan Crandall, leaking is not really an issue.” love with this procedure because I had as to the limbus, or if the predict-able a watertight closure as I did with While leaks are not common when the surgeon is not comfortable a limbal-based approach,” he said. fornix-based flap is properly closed, Dr. Singh said that when leaks do occur, the postoperative with his closure technique, Dr. Condon stressed that he has course is generally rocky and the long-term modified his trabeculectomy technique by success of trabeculectomy is significantly it might be better to take using the Ex-Press mini shunt (Optonol), which reduced. he inserts under the scleral flap in hopes of the higher risk of wound better outflow control and fewer hyphemas. There are three key elements to Dr. leakage with fornix-based The 400 ìm wide by 3-mm long, stainless-steel Singh’s limbus-based technique: device is placed in a microscopic opening trabeculectomy ” inside the scleral flap, probed with a 27gauge needle. The minimally invasive procedure Creating an incision as far posteriorly as Miriam Karmel, contributing writer of this avoids the need for an iridectomy and lowers possible (about 10 mm posterior to the limbus). article, copied from Eyenet Magazine. the incidence of hyphema, Dr. Condon said. Using a diffuse application of MMC. The Case for the Limbus-Based Incorporating the posterior, but not anterior, Flap : tenon’s capsule in the closure. For more than two decades, Important Notice ophthalmologists have been debating which Regarding the third point: He flap yields better results. “The disadvantage of explained that incorporating the anterior Tenon’s APOS Members are requested limbal-based flaps is that visibility of the scleral capsule in the closure may cause the incision area is more difficult because there is a large line to migrate anteriorly in the postoperative to send their Mobile numbers conjunctival flap present while you are doing period, thus decreasing the size of the bleb and and Email ID to the Secretary, the surgery,” said Dr. Condon. increasing the likelihood it will become APOS for effective and fast cystic.On the other hand, incorporating the But a substantial number of communication. posterior Tenon’s capsule anchors the incision ophthalmologists still use the limbus-based
apos.org 9 APOS New & Views, Issue 1, 2010
Expert’s Views
A case of Normal Tension Glaucoma (NTG) is presented for group discussion. A group of panelists were asked to express their views on management.
Case Summary :
A 50 yr old myopic lady diagnosed as NTG by a Local ophthalmologist based on (A) typical glaucomatous cups, (B) visual field changes diagnostic of POAG,and (C) OCT changes of RNFL loss and (D) Normal IOP. She was treated with Latanoprost, in both eyes for six months. She was referred to a Glaucoma specialist for advice on further management.
Clinical Findings :
A healthy lady with no F/H of glaucoma.
BCVA of 6/6, N6 with -2.50Dsp and -3.00Dsp in right and left eyes respectively. Slit lamp examination was unremarkable. Intraocular pressures (Applanation) were 18 and 16mm of Hg in right and left eyes. Diurnal Variation of 4mm of Hg was noted. Central Corneal thickness was 550microns in both eyes.
Gonioscopy showed 3600 open angle with no pathology.
Fundus :
Left eye
Right eye Myopic Disc
Myopic Disc 0.8 cupping
0.7 cupping Superior and Inferior notch Superior Notch
Humphry Fields : Left Eye : suprerior and inferior nasal steps with Right Eye : Full Inferior arcuate scotoma.
10 apos.org Expert’s Views. APOS New & Views, Issue 1, 2010
Ocular coherence tomography (OCT)
OCT demonstrates thinning of the nerve fiber layer in the superior and inferior portion of the both optic nerves.
A) Right eye shows loss of nerve fiber layer with an average thickness of 74.43 microns.
B) Left eye shows more substantial loss of nerve fiber layer with an average thickness of 62.05 microns. Larger portions of the superior and inferior optic nerve head are affected. This correlates with the appearance of the optic nerves on photography.
Cardiologist and Neurologist examinations were unremarkable. Final Diagnos : Normal Tension Glaucoma with visual field defects and OCT changes demonstrated RNFL loss a shade worse on the left side. She was advised to continue Latonoprost in both eyes. Follow up : At a six month follow-up Visual acuity and IOP readings were normal as at her first visit. While subsequent Visual Field defects and OCT changes have worsened.
Subsequent Humphrey visual fields :
Right Eye : Small inferior nasal Left Eye : Paracentral scotoma with superior and step has developed. inferior nasal step. Field now shows development of superior arcuate defect.
apos.org 11 Expert’s Views. APOS New & Views, Issue 1, 2010
Further Management : Expert’s Views. Progression: conditions causing increased tendency for vascular thrombotic disease, practice of yoga Dr. G Chandra Sekhar Progression in visual field changes is with head down posture which tends to increase the gold standard. Confirmed progression by Dr. Sirisha Senthil the IOP; all these need to be ruled out. visual fields requires a good base line and Information about the baseline IOP and GlaucomaServices, subsequently two sets of 2-3 fields with in a gap the highest IOP at presentation may help to LVPEI, Hyderabad. of 3 months by the NTG study criteria. For the decide on the target pressure. Issues related to Management of progressive glaucoma is a current new GPA program in the HVF the compliance, the prostaglandin being generic or challenge, and managing a case of progressing requirement is 5 fields in 3 years. In the current branded proper maintenance of cold chain and if normal tension glaucoma is a greater challenge. study, there is a 6 month follow up and there are information on diurnal variation in IOP etc. might no details of how many fields were performed Establising the diagnosis of normal tension help understand the possible reason for and how progression was diagnosed. glaucoma (NTG) as well as documenting progression. progression of visual field loss are time and labor OCT detects structural changes in the If progression is confirmed then, we intensive as learnt from the NTG study. The next ONH and RNFL and is reported to be useful in would recommend the following in addition to course of action for a patient of NTG progressing glaucoma diagnosis. However, there are no some of the points raised above. To establish the on medical therapy is a trabeculectomy with validated progression programs which can be base line IOP it might be useful to stop the MMC. As this intervention has its own risks and used clinically to detect progression. The use of medication and wait for a period of 4-6 weeks the NTG study has shown that close to 50 percent OCT in myopic eyes should be done cautiously. for wash out during which oral acetazolamide of NTG patients do not progress, it is mandatory It has been shown that moderately myopic can be used to control IOP. The decision to go that the diagnosis of NTG and its progression subjects tend to have thin peripapillary retinal this route will obviously require a detailed discussion with the patient and consent for the are established with reasonable certainity. We nerve fiber layer, mainly at the superior and 1 same. An alternative approach would be to set a would like to address these issues before actually inferior poles, as measured by Stratus OCT. These factors should be considered when target IOP of low teens (<14 mm Hg), and detailing our management plan is this situation. interpreting OCT measurements in myopic achieve the same with whatever medication it Diagnosis: subjects either to diagnose takes and confirm progression with repeat visual Gonioscopy needs to be repeated to glaucoma or its progression. For fields evaluations. confirm the findings under appropriate testing OCT event analysis the If the response is good, (that is diurnal conditions. Quite often PACG patients are progression criterion is the IOPs < 14 mm Hg with fluctuations less than 3 misdiagnosed as normal tension glaucoma, as the change in RNFL thickness that mm hg and stable visual fields, the treatment chronic asymptomatic form of PACG can present exceeds reproducibility error; could be continued with IOP (every 3 months) with deep anterior chamber and normal IOP. for OCT trend analysis the progression criterion and visual field (6-12 months) monitoring. If Unless the correct diagnosis is made and the basic is the RNFL thickness slope if it significantly the glaucoma still progresses then consider pathology is addressed by an iridotomy, they exceeded the expected rate of progression in the Trabeculectomy with adjunctive Mitomycin-C continue to progress due to intermittent rise in after explaining the risks and benefits of the IOP (as a result of pupillary block) which may normal population. Progression of OCT was be missed with one or two IOP readings in the defined as reproducible mean retinalnerve fiber surgery to the patient. office hours. Topical medication to control the layer thinning of at least 20 µm. Sixty-six percent IOP might blunt these IOP spikes but the angle of eyes were stable throughout follow-up, closure could potentially progress. whereas 22% progressed by OCT alone, 9% by “Consider
Also with aging the lens becomes VF mean deviation alone, and 3% by VF and OCT. A greater likelihood of glaucomatous Trabeculectomy with cataractous and the antero-posterior diameter of progression was identified by OCT vs. the lens increases leading to progressive adjunctive automated perimetry. This might reflect OCT hypersensitivity or true damage identified by Mitomycin-C after “Managing a case OCT before detection by conventional methods. explaining the risks 2 One cannot confirm progression based on OCT of progressing only. and benefits of the normal tension Systemic work up: surgery to the patient” glaucoma is a In the systemic evaluation, a past greater challenge” history of unequivocal hemodynamic crisis References : could point towards a possible one time damage 1.Rauscher, Frederick M, Sekhon, Navneet, Feuer, which is unlikely to be progressive. Evaluation William J, Budenz, Donald L. Myopia Affects Retinal of risk factors like nocturnal hypotension (use Nerve Fiber Layer Measurements as Determined by narrowing of the angle. These eyes develop Optical Coherence Tomography. Journal of Glaucoma combined mechanism glaucoma where the angle of anti-hypertensive medications in the night that 2009 ;18 : 501-505. closure component has to be addressed. Hence, might cause hypotension and could potentially 2.Wollstein G, Schuman JS, Price LL, et al. Optical Coherence Tomography Longitudinal Evaluation of periodic gonioscopy is a must to assess the status compromise the optic nerve blood supply), Retinal Nerve Fiber Layer Thickness in Glaucoma. Arch of the drainage angle. Migraine/ Reynaud’s phenomenon, rheological Ophthalmol. 2005; 123: 464-470.
12 apos.org Expert’s Views. APOS New & Views, Issue 1, 2010
Dr.R.Ramakrishnan for the disc changes and field changes. In The principle guidelines of glaucoma Director and Head, Glaucoma Services, addition we should look at other vascular management applicable to this case Aravind Eye Care System, Thirunalveli factors such as blood pressure and medication suggest that In this particular case we are missing for it that may cause or worsen disc changes. some important information like 1.You need to have 3 baseline fields to detect I assume in this case those factors were looked mean and pattern deviation at progression. in to before making the diagnosis of NTG. If both point of time and baseline the diagnosis of NTG is certain and the disease 2.You need data from 5 fields to detect Rate and final IOP. Because, before shows progression these are my of progression. manipulating existing treatment, recommendations. we must know the rate of 3.You have to aim a target pressure 30% less progression and percen-tage “Diagnosis of NTG is a than baseline initially and if there is progression reduction of intraocular pressure from the then you have to revise it further 20 % lower. baseline visit after inititiation of therapy. “disease of exclusion”. 4.If still there is progression then we have to However, based on this history we know that Before labeling an consider drainage procedures with anti subject is a moderate myopic and we can assume metabolite treatment. that her RNFL could be relatively lower then individual as NTG, we the normals and after using prostaglandin should definitely exclude analogue, any gross progression is least likely “An important in only six months. other causes for the disc factor in NTG cases is changes and field “Add Brimonidine, a to prefer drugs which changes” neuroprotective agent help in vasoperfusion 1.OCT is not a great technology to while observing better comment about progression. May be HRT is a and vasoprotection better tool for this. eye by continuing previ- like Dorzolamide ous drug for atleast four 2.I will depend upon the optic discs (if possible stereo and months, and if we still photographs) and visual fields for progression. Never depend Prostaglandins” find progression we will upon single field progression for opt for Trabeculectomy judgment. Field should be repeated to confirm progression. This should The management in this case indicates a with Mitomycin-C” be correlated well with disc changes. lowering of IOP of about 2-4 mm Hg. (10-20% 3.If the progression is genuine and not due in comparison to the expected In such a case we would like to repeat to long term fluctuation we should think of drop of about 30-40%). A rather visual fields (HFA 24-2) to look for reproducible adding a medication to bring down IOP further practical approach indicates defect and progression and will take her down. Topical CAI is my choice since it also setting up of target pressure of stereoscopic fundus photograph to mark as an has better control of IOP in the night. Continue about 12-14 mm Hg. In this evidence of presence and magnitude of NRR and Latanoprost and follow-up the patient very situation as a first step I would NFL loss. Since her left eye is more affected we closely. consider substituting Latanoprost can add alpha agonist like Brimonidine Tartrate (with original if a generic is used earlier) or with which is thought to have neuroprotective effect 4.Re look at systemic health that may be Bimatoprost / Travoprost and adding Timolol. A over Latanoprost twice a day while observing adding to the so called progression. combination of these two drugs can be preferred. better eye by continuing previous drug for atleast I would record the IOP after two weeks and if four months, and if we still find progression we Dr Manoj Chandra Mathur required add Dorzolamide to achieve the target will opt for Trabeculectomy with Mitomycin-C Glaucoma specialits pressure. An important factor that can be kept in for the worse eye meanwhile adding Hyderabad mind in NTG cases is to prefer drugs which help brimonidine twice or thrice a day to the better This is a female patient aged 50 yrs in vasoperfusion / vasoprotection like eye, depending on the rate of progression. with moderate myopia and without positive Dorzolamide / prostaglandins. family history already diagnosed NTG with no relevant cardiac and neurological parameters. I would prefer to repeat fields and OCT after Dr L Vijaya Director, Glaucoma Services, The baseline IOP was 20mmHg 3 months. If further progression is detected then Sankara Nethralaya, Chennai which on treatment with latanoprost for 6 I would consider Trabeculectomy with MMC. Diagnosis of NTG is a “disease of months is now 18mm Hg. OD and 16 mm Hg. exclusion”. Before labeling an individual as OS. There is also progression in visual fields NTG, we should definitely exclude other causes and OCT.
apos.org 13 APOS New & Views, Issue 1, 2010 Trend Setters Dr Sriram C Ravula Nayana Eye Care, Kakinada. Email:[email protected],Mobile: 91 988 525 0000
In this category we present you a visiting surgeons from Hyderabad on a regular the functioning of local Eye Bank. His activites biosketch of an ophthalmologist who excelled basis. More encouraging is that he conducts CME do not end there. He runs a voluntary organization with his colegues to care for homeless streat professioanlly and set himself an example for programmes and group discussions regularly. A others to emulale. daily attendence of 150-200 out patient cases and a monthly turn over of around 200 surgeries We have chosen a young and speaks very well of an overall performance. “Dr Sriram is an dynamic surgeon,Dr.Sriram.Through his hard active Rotarian and work and dedication, progressed from an “A daily attendence of individual set up to a well established associates himself 150-200 out patient institution with good working environment. with the activities cases and a monthly Dr.Sriram graduated from Rangaraya of Lion's club and Medical College in 1980. Soon after he had a short turn over of around stint of junior residency in Dr. Ram Manohar other NGOs. “ lohia hospital, New Delhi . He associated with 200 surgeries speaks Singareni Colliries in Belumpalli for six years, very well of an overall children-"PARIVARTHANA". For his first three years as a medical officer and later three outstanding professional services he received the more years as an ophthalmologist. He secured performance.” "Vijayasree Award". D.O from Surat in 1987 with a distinction as a He has participated in many ophthalmic NEC is an Andhra Pradesh State topper in that batch. His first job as a consultant conferences as an invited faculty we watched his Government recognised service center, and is was at Swathanthra Hospital, Rajahmundry. participation in the APOS Eyecon at empannelled by several local industrial Two years later he joined Srikiran Visakhapatnam, a debate that dealt with establishments. It is also recognised for training group at Kakinada, under the guidence of Dr V institutional practice Vs individual practice. He ophthalmic technicians by Government of India. K Raju, who as we all know is a very inspired the audience with his eloquent Dr Sriram is an active Rotarian and accomplished surgeon in USA. This provided him presentation in favour of individual ophthalmic associates himself with the activities of Lion's a good fillip and a chance to secure an practice. He extended advice to the young club and other NGOs. He actively participates in ophthalmology fellowship in Morgan Town, West ophthalmologists. In case if you missed it then, Virginia, USA. Dr Raju not only trained him in these are his suggestions. his institute but introduced him to a reputed Work hard Retinal Surgeon Dr N. Jabbour where he did his medical retina fellowship. On his return to Update yourself Srikiran, he provided his expertise to that institute Be available and affordable for a five year period (1993-97). This in turn gave him enough experience and drive that led to the Be honest to the patient and yourself. establishment of his own eye hospital "Nayana APOS extends warm greetings to him and his team Eye Care (NEC)" in 1997. at NEC, Kakinada. “This center is unique Nayana Eye Hospital which provides 14 hours “He has done daily service all round ophthalmology fellowship the year to the public” in Morgan Town, West
This center is unique which provides Virginia, USA under Dr 14 hours daily service all round the year to the V K Raju and Medical public. It has a compliment of three ophthalmologists and all the ancillary staff needed Retina fellowship under to run an eye institute. In addition specialist services in Retina and Squint are provided by Dr N. Jabbour”
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APOS New & Views, Issue 1, 2010
Biography
Dr Perugu Siva Reddy A true legend
Dr Siva Reddy graduated in medicine Academy of Medical Sciences, Vice President from Madras Medical college (1946) but Andhra of IAPB, Advisor in Ophthalmology to the “In due recognition of his Pradesh was where he lived and served ,till his Government of India and Consultant professional and untimely death in 2005(6,Sept).Andhra university Ophthalmologist to the President of India. A awarded him the Masters degree in his chosen visiting professor to the Sun Yat Sen University community services in the faculty(1952).Soon after his ophthalmology career of China and Superintendent at the SD Eye field of ophthalmology commenced in Osmania Medical college, Hospital for a long time. Dr Reddy was also the Hyderabad. President, Chief Patron and Advisor of the Government of India “This great man founded Andhra Pradesh State Ophthamological Society. awarded him "P Siva Reddy Award" is given the first eye bank in the annually during the meeting of AIOS to a "Padmashree" (1971) member for outstanding research.His country in 1964 and by contribution to Ophthalmology earned him the and 1968 he had successfully honours of Lifetime Achievement Award of "Padmabhushan" (1973)” AIOS in 1999. In due recognition of his created sub-speciality professional and community services in the field Singapore University of Medical Sciences (1992) of ophthalmology Government of India awarded departments for Cornea, 8.Adenwala Gold Medal of AIOS him "Padmashree" (1971) and "Padmabhushan" 9.Josh Rizal Medal of APAO. Retina and Orthoptics in (1973). 10.B C Roy Award - First in 1981 (Socio Medical Sarojini Devi Eye “He has to his credit over Relief) and again in1987 (Medical man cum Hospital” Statesman) 500 surgical eye camps, 11.Bharatratna Rajiv Gandhi Puraskar in 1995 He was the founder director of Sarojini towards growth of Science & Technology Devi Eye Hospital at Hyderabad. This great man which he pioneered and founded the first eye bank in the country in 1964 performed over 2.5 lakhs 12.International award of IAPB for services and by 1968 he had successfully created sub- through Eye Camps speciality departments for Cornea, Retina and surgeries, over 200 13.Souvenir by late Smt. Indira Gandhi on Orthoptics. It was he who established regional scientific papers completion of 1 lakh surgeries. institutes of ophthalmology in Visakhapatnam, 14.Y Subbarao Gold Medal during Centenary Warangal and Kurnool, in the state of Andhra mind boggling figures celebrations at Kurnool. Pradesh. He organized several CME's, national and international conferences/workshops in indeed and very difficult Dr P. Siva Reddy actively served Andhra Pradesh. to surpass” scientific and educational organizations like His contribution to community Bharatiya Vidya Bhavan, Chaitanya Institute of Engineering & Technology and Andhra Pradesh ophthalmology was monumental. He has to his Some of the other Awards/ Fellowships Academy of Sciences. Many (graduates,post credit over 500 surgical eye camps, which he /Memberships conferred on him were: pioneered and performed over 2.5 lakhs graduates and his associates) would remember and surgeries, mind boggling figures indeed and very 1.Fellowship of International College of cherish the memories.His physique may be small difficult to surpass. Surgeons (1970) but he had a big heart and a great stature as a quietly spoken statesman,strict disciplinarian he was Dr Reddy presented over 200 scientific 2.Fellowship of Academy of Medical Sciences ,would be fondly remembered by all those who papers at different fora. He authored 2 books in (1973) had a chance to see, meet and work with him.His ophthalmology for undergraduates and co- 3.Doctorate D.Sc from S.V.University Tirupati characteristics and personality are exemplary in authored a book on fundamentals in (1979) many ways and we all owe a great deal to this ophthalmology. During the course of a pioneering 4.International Membership of IAPB (1980) person who cotributed immensely for the growth research he discovered a rare worm called Gordia and development of ophthalmology not only in our Worm, which was named after him as Gordia 5.Membership of American Academy of state but nationally. We salute and pay respects to Reddy at WCO in Munich in 1964. Ophthalmology (1983) this " PERSON EXTRORDINARIE " He was the President of All India 6.Membership of ICO (1987) Ophthalmological Society (AI OS) and National 7.Honorary doctorate of Malaysian
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APOS New & Views, Issue 1, 2010
Ethics in Ophthalmology Is Advertising Ethical ? By Prof.K.Vengala Rao & Dr.K.V.Appa Rao Email : [email protected],Mobile : 91 944 001 9011
This article is written to generate treatment here is lower compared to those in provision of information about the medical healthy debate amongst our colleagues about the the West,Indian doctors can expect to attract services they offer. The AMA believes that all such place & validity of advertisement by doctors and patients frustrated by long waiting lists in their information should: A) be demonstrably true in health providers in various print, electronic and own countries. all respects; B) not be misleading, vulgar or cyber media. We remain unconvinced of the sensational; C) maintain the decorum and dignity There are bound to be divergent views 'benefits' of advertising and one worried about of the profession; D). not contain any testimonial amongst our professional colleagues on this its ill effects.. Given the non-existent control on or endorsement of clinical skills; E) not claim that subject. medical malpractice in India, even in the digital one doctor is superior to others, not contain endorsement for any particular doctor; and F). According to the view that is held by age. avoid aggressive forms of competitive persuasion, many senior professional colleagues advertising such as those that prevail in commerce and is unethical. Younger generation may feel that “American Medical industry. professional advertising is ethical and necessary. Association feels that so In accordance with the general Let us discus both the opinions : guidelines detailed above, the chief purpose of Advertising by doctors is unethical long as the advertisement any advertisement for a doctor's services should according to MCI. does not contain any false be to present information that is reasonably needed by any patient to make an informed discussion Most codes on ethics in medicine or deceptive information, about the appropriateness and availability of the restrict advertising by doctors. There are good medical services offered. reasons for the prohibition. As professionals, it physician is free to ill behoves us to publicly sing our own praises or solicit patients. We must await clients by advertise through any “Information about doctors, referrals from colleagues or by word of mouth. commercial or other form their qualifications, fees Were physicians to advertise, patients run the risk of being lured to the one with the fanciest media of public communication” and services they provide coverage rather than to the most competent and is of obvious value to the experienced . This prohibition gains greater Now let us examine the view held validity in a country such as India where by younger generation of doctors that there community.” ignorance and gullibility abound. Noteworthy should be no restrictions on advertising. contributions to medical theory or practice are As the socio-political scene changed, UNETHICAL ACTS - MCI RULES : legitimately published in medical journals after in The United States, The American Medical A physician shall not aid or abet or being subject to review by peers and can Association's ban on advertising by physicians commit any of the following acts which shall be command admiration from colleagues. was successfully challenged in the U.S. Supreme construed as unethical- Court in 1975. The AMA subsequently revised “According to senior its statutes. Advertising : Soliciting of patients directly or indirectly, by a physician, by a group of physicians professional colleagues Today, so long as the advertisement or by institutions or organizations is unethical. A advertising is unethical. does not contain any false or deceptive physician shall not make use of him/her (or his/ information, an American physician is free to her name) as subject of any form or manner of Younger generation may advertise her or himself through any commercial advertising or publicity through any mode either feel that professional or other form of public communication. alone or in conjunction with others which is of Information about doctors, their qualifications, such a character as to invite attention to him or to advertising is ethical and fees and services they provide is of obvious his professional position, skill, qualification, value to the community. The Australian Medical achievements, attainments, specialities, necessary” Association's guidelines underscore this point. appointments, associations, affiliations or honor There were three reports in the " Times The Australian Medical Association and/or of such character as would ordinarily result of India " . These suggest that 'medical tourism' (AMA) believes that a doctor's reputation and in his self aggrandizement. A physician shall not to India could be yet another source of foreign capacity to increase their practice should be give to any person, whether for compensation or exchange for this country. Since the cost of based on good medical practice and appropriate otherwise, any approval, recommendation,
18 apos.org Is Advertising Ethical ? APOS New & Views, Issue 1, 2010 endorsement, certificate, report or statement with Change of location, temporary Though advertising has been deemed respect of any drug, medicine, nostrum remedy, absence, fee structure etc for public information. unethical, only the conventional media has been surgical or the rapeutic article, apparatus or Printing of self photograph, or any such material included in the code of ethics. There is no reference appliance or any commercial product or article of publicity in the letter head or on sign board of to advertisement by doctors on the web. In fact with the respect of any property, quality or use the consulting room or any such clinical the whole issue of the ethics of advertising by thereof or any test, demonstration or trial thereof, establishment shall be regarded as acts of self doctors needs to be dealt with in much more detail for use in connection with his name, or advertisement and unethical conduct on the part taking into account consumer protection legislation photograph in any form or manner of advertising of the physician. However, printing of sketches, . diagrams, picture of human system shall not be through any mode nor shall he boast of cases, In conclusion we feel, like most things treated as unethical. operations, cures or remedies or permit the in our country, that the MCI code of ethics is publication of report thereof through any mode. Consequences of unrestricted advertising in admirable on paper. What is sorely needed is its A medical practitioner is however permitted to India : strict implementation. make a formal announcement in press regarding the following. Exploitation of patients has become commonplace in our country where legal Reference : oversight is scanty.. Unscrupulous practitioners “MCI allowed a medical may abuse the right of free speech. However, Pandya SK. Advertising remains unethical even in the digital the remedy is better education, not restrictive age. Issues in medical ethics 2001; 9 (1): 15. practitioner to make a legislation against advertising. "Word of mouth" is also advertising of a kind. It is not paid for Dr. Bashir Mamdani, Dr. Meenal Mamdani, 811 N. Oak Park formal announcement in with money but with services rendered. It is often Avenue, Oak Park, IL 60302, USA E-mail: press regarding the inaccurate and has greater room for hyperbole. [email protected] Word of mouth dissemination provides the Change of location, physician with the added loophole that he was MCI. Indian Medical Council (professional conduct, Etiquette misunderstood or he never made such claims. and Ethics) Regulations, 2002. temporary absence, fee One can take a doctor to court for false structure etc for public advertising in the print media or on the web. However, word of mouth dissemination of information” exaggerated claims of efficacy cannot be litigated easily.
apos.org 19 APOS New & Views, Issue 1, 2010 Andhra Pradesh Ophthalmological Society
Minutes of the Managing Committee Meeting Held at Kalavani Port Trust Auditorium Vishakapatnam on 2-10-2009 In Chair: Dr K Viswanath – President Members Present : Dr Sivarama Krishna, Dr Pradeep Swarup, Dr Manoj Mathur, Dr Nand Kishore, Dr Madhukar Reddy, Dr Subrahmanyam, Dr Sharat Babu, Dr NS Reddy, Dr Soma Madhava Rao, Dr USN Murthy, Dr Aluri Bhaskar Rao, Dr P Ranga Reddy, Dr SV Katta and Dr K Vengal Rao
Minutes as per agenda : k.Rs 20000 grant given to SDEH for conducting l.Thanked the Chairman, Org Sec & all the LOC 1.The Sec Dr M C Mathur convened the MC a CME members of the 33rd conf of APOS &the EC for meeting which happens to be the last meeting of l.Editor to oversee publications of 2 newsletters their help & cooperation. the term of the present committee & requested & 1 journal each year 7.Scientific Committee Report- The Chairman Dr the President Dr K Viswanath to conduct the m.The LOC of Vijayawada sent a DD for Rs Madhukar Reddy informed that a record 118 proceedings. 36000 as contribution to APOS. papers were received & that merit & quality of 2Dr K Viswanath welcomed the mc & thanked n.Inspection of venue done by Drs MC Mathur the paper were the sole criteria for selection. He the seniors & all the executive committee & K Madhukar Reddy proposed a best research paper award. He members for their help during his tenure. He o.The FBI conducted an MC meeting and the welcomed the next scientific comm. brought to notice few issues details shall be presented as per agenda. 8.ARC Report- Dr. M Subrahmanyam the A.Advised to alter the Presidents medal p.Dr Saimurali org sec 2010 conf at Nellore co- chairman informed that PG workshops were held B.Anguish over use of official logo for personal opted as mc member at KMC Warangal, SVMC Tirupati & Rangaraya election propaganda q.Decided that single auditor will manage accts Medical College Kakinada & that no application C.Call from LOC regarding holding of the conf of APOS, Sunayana fund, ARC, Scientific for Research assistance was received this year. DFelt that ARC chairman should preferably be a committee & FBI He proposed to depute one ophthalmologist to teacher in Ophthalmology &suggested a 6.Secretary's Report- Conveyed regards to one teach about latest advances. He presented the constitutional amendment for the same and all criteria for selection of best teacher & thanked all E.Feels that hands on workshops should be held a.Informed that Vijcon2008 was a scientific for their help. for practitioners also success but a financial disappointment & 9.Editors Report-Dr Sharat Babu informed that 5 3.The managing committee condoled the death suggested cost cutting measures issues on news & views were published during of 2 of our members Drs Pullam Raju & b.Society now registered & Pan Number allotted the last 3 years. He apologised to the president Adisheshudu during the year & also the death of c.Obtained clearance for transfer of Sunayana for using the official logo for his personal our CM Dr Y S Rajashekar Reddy. A minutes Fund to APOS campaign. silence was observed & the secretary proposed d.Decided to introduce a best teacher award of 10.Treasurers Report was read in absentia. The to send a draft of the motion of condolence to all MC was informed that there was Rs 2,22,206 in the 3 bereaved families. APOS acct, Rs 38,446 in ARC & approx 19 & 4.The Sec presented the minutes of the last MC odd lacs in FDS with Andhra Bank Masab tank meet at Vijayawada & sought ratification for the branch. same which was Okayed. It was decided to 11.FBI report-It was decided that only the circulate MC meet minutes preferably within one chairman of FBI if required will be invited to the month. EC & he will intimate the proceedings to the 5.Points arising & ATR. secretary FBI. The EC can give suggestions to a.Members up to LM No 926 were ratified at the the Chairman who shall discuss it in the MC of GBM at Vijayawada. FBI for implementation. The MC advised the FBI b.Dr Mathur informed that reconciliation of to adhere to the regulations as incorporated in the accounts has been done & returns filed. Next year constitution regarding the termination of the same would be tried to be done by April-May defaulting members of the FBI and this can be itself. discussed threadbare in the GBM. The payment cEfforts on for 12A exemption of Fraternity benefit should be done only to the d.APOS website launched & active nominated person and cannot be paid to anybody e.Membership has gone upto 988 else. f.Decided to present Rs 50000 worth of text 12.Since Dr Gangadhar Reddy was delayed it was books in ophthalmology to each of the eight decided to take up the election issue in the GB. medical colleges during the inauguration from 13.New members upto 988 were ratified. the Sunayana fund as also to award a best teacher Rs 25000 from Sunayana fund 14For the 2011 conference since only the HOA award as per the recommendations of the e.Dist chapters taking shape as also grievance cell had requested the same was allotted to Hyderabad. chairman ARC & a plenary Sunayana session & Past Presidents forum 15.It was decided to persist with the present where the best paper would be given Rs 10000 f.Mentioned the achievements of various sub auditors Msrs Laxminiwas Neeth & Co with an & the others Rs 2500, best video & best pg paper committees annual fee of Rs 12500 incl. all taxes for auditing Rs 2500 each g.Congratulated the various orators & award all the accts. g.The Grievance cell being active & the members winners & 16.Any other matter: can now approach with their problems. h.Dr Saibaba Goud on his being conferred the a.Dr Vengal Rao suggested that host organisation hThe Past presidents forum was formed & active. Padmashri should not contest for any posts in the election & Through this forum the members were nominated i.Dr Santosh Honavar for being awarded the said the same may be incorporated in the election to the MC. Shanthi Swarup Bhatnagar award rules. He also suggested that the EC members i.Decided to integrate account of Sunayana Fund j.Dr G Suresh for taking charge as state IMA should not propose or second any candidature. with APOS president 17.Dr Nand Kishore Joint Secretary proposed a j Dr G V Narendra was nominated for LDPAIOS k.Congratulated Swarup eye centre, Pushpagiri vote of thanks. at Jaipur Eye Institute & Aravinda Lasek centre for conducting CME's
20 apos.org APOS New & Views, Issue 1, 2010 Vaisakhieyecon 2009
Summary of 33rd Andhra Pradesh Ophthalmological Society (APOS) annual conference held in Kalavani Port Auditorium, Visakhapatnam from 2nd to 4th October, 2009
33rd Andhra Pradesh Ophthalmo- logical Society (APOS) annual conference was held in sprawling lush green picturesque Kalavani Port Auditorium, Visakhapatnam from 2nd to 4th October, 2009 . Visakha Ophtalmic Association of three north coastal Andhra Pradesh districts of Visakhapatnam, Vizianagarm and Srikakulam and Govt Regional Eye Hospital, Visakhapatnam organized the conference under the leadership of Dr C V Gopala Raju, Chairman LOC and Dr M Mohan Rao, Organising Secretary LOC. Local organizing committee worked hard and sincerely for the last one year and presented a wonderful bonanza of scientific and entertaining event. “Record number of 650 pre-registered and the first session things were in place by post lunch presentations were transmitted live to the out side another 70 spot session. lobby and also to the trade area to keep track of Totally six hundred pre-registered and another the proceeding in the scientific sessions. registered delegates seventy spot registered delegates attended the General Body Meeting and Inauguration : attended the conference” conference. Ninety Postgraduates and fifty APOS general body meeting was held associate delegates were among the attended total on 2nd October, 2009. President and Hon Secretary number. This was the highest number so far in a of APOS successfully conducted the proceedings To accommodate more scientific state conference. with positive discussion from members. Some presentations this year conference was spread to Trade : Trade exhibition was organized in suggestions were adopted / accepted for better two and a half days with first session starting from sprawling exclusive air conditioned indoor first day morning itself. Simultaneously sessions stadium with in the same complex. Forty trade were started in all the four halls in one go. exhibitors including equipment manufacturers “Over whelming 118 Inclement weather could not stop the delegates and pharmaceutical companies participated with responses from attending the sessions in big numbers. 80% of a good display of all ranges of products. the registered delegates collected the registration Appasamy Associates, Intraocular care Pvt Ltd, members to present material by the end of the first day first session. Allergan India Ltd, Alcon India Ltd and zeiss their work in different Probably the quality of scientific material scored India Ltd to mention few were the prominent over other factors. Except few hiccoughs during exhibitors with their latest models. Hall A categories of sessions”
functioning of the society. Inaugural function was held on 3rd October, 2009 in the main hall of the venue. . Dr C V Gopala Raju chairman LOC welcomed the gathering and Prof Viswanath, President APOS and Dr Manoj Chandra Mathur ,Hon Secretary APOS conducted the proceedings. Sri Ajay Kallam IAS, Chairman Visakhapatnam Port Trust was the chief guest and inaugurated the conference. Chief guest presented medals for this Years orators and various scientific Sessions prizes. G Prof M J Somayajulu, Superintendent, King George Hospital, Visakhapatnam released the souvenir and Prof Bhagya Rao, Principal, Andhra Medical College released a book and CD, special and 4th Issue of journal by Visakha Ophthalmic Association "Clinical Practice". Excellent
apos.org 21 Vaisakhieyecon 2009 APOS New & Views, Issue 1, 2010
a) Orations Special Invited Lectures: Prof.P.Siva Reddy Oration : Dr K V Challam, Director Vitreo-retina service, University of Florida College of Medicine, USA has conferred the medal and delivered the lecture on "Non-invasive Live Histology (Spectral Domain OCT) of Retina in different Retinal conditions". Dr Rustom Ranji Oration : Dr Samar K Basak, founder member, Disha Eye Hospital and Research Center, Kolkota was chosen to deliver the oration and he presented his experience on first 300 cases of Deep Stromal Endothelial Keratoplasty. Dr R.Suryaprasada Rao Oration : Dr E Hemalatha, former Superintendent, Govt work of the souvenir committee mainly Dr I Banquet was organized on the beach Regional Eye Hospital, Visakhapatnam delivered Venkat Rao, Dr C Srihari Rao and Dr M Srirama side famous open air venue of heritage importance the oration on "Aid and the Eye". She stressed Chandra Murthy in bringing out this book was " Hawa Mahall " with a beautiful sea view. the need of every ophthalmologist to keep up to well appreciated by the delegates and it was the Weather god blessed the delegates with clear sky date about the HIV as it is going to be a major highlight of the conference / contents in the and delegates enjoyed the evening with musical challenge globally. conference bag Dr.Viswanath welcomed the orchestra by Roshan Lal. Medical students added incoming president Dr Sivarama Krishna and spice to the party with their thrilling dances and Dr Malleswara Rao Oration :Dr G.R.Reddy handed over the charge until next annual stealed the entire show. of Thadepalligudem was chosen to deliver the oration. He spoke on "Importance of Visual fields “Keynote addresses and Scientific Sessions/Programme : in the diagnosis and management of glaucoma". Scientific committee under the As he is an authority in Visual Fields analysis with special invited lectures leadership of Dr K his experience of writing a book on this field every really added variety and Madhukar Reddy has body enlightened about visual field analysis. done excellent job in Special Invited Lecture : Dr Gullapalli N Rao quality to the sessions. As making the sessions with his vast experience in the field of they were delivered by very interesting and ophthalmology globally was invited to deliver a also improved the special lecture. He spoke on " The Problem of most experienced and standards to a new/ eminent people it is a greater height. Quality “Continuously for the third of the Scientific good opportunity to listen Programme has drawn big crowds to the time Andhra Medical to them” scientific halls. It changed the trend of other College won the quiz wise a routine in the conferences like "vacant conference. Dr N Subramanya Reddy, Advisor, scientific halls and gossiping in crowded competition” Dr Pradeep Swarup, president elect, Prof coffee and trade areas". Scientific Subrahmanyam, Chairman ARC, Prof committee has put together a set of topics Vidyavathi, Vice-president, Dr Nanda Kishor, which are of clinical interest. The topics were Joint Secretary, Dr C Sarat Babu Editor APOS appreciated equally by post graduates, News & Views are the other members who graced the occasion. Dr M Mohan Rao organizing general ophthalmologist and sub-specialists. Secretary LOC concluded the meeting with vote The feed back from the conference is of thanks. unanimous agreement of high quality of the scientific sessions. No doubt it helped in over all success of the conference. Over whelming response of the members to present their work by active participation cannot be ignored. There were 118 responses to present in different categories of sessions. Scientific committee Blindness - What can Ophthalmologist do ? ". He had a tough time in analyzing the papers as highlighted the present and future blindness all of them were equally good. It was a very scenario both nationally and internationally and positive change and it helped in improving the responsibility of each ophthalmologist to tackle the overall standard of the conference. The the problem. It was a very enlightening and society is grateful to all of them. motivating lecture
22 apos.org Vaisakhieyecon 2009 APOS New & Views, Issue 1, 2010
e) Swarup's Video Session : Fourteen videos Open Forum (Non-competitive free papers) : were accepted to be presented during the Ten papers were presented in this session. conference and out of these the video on "Loop Sunayana Best free paper session : Best Myopexy for the management of Myopic papers from Dr Vengal Rao medal session, Dr Strabismus Fixus" by Dr Ramesh Murthy was Raghavachar medal session, PG Free paper selected as the best video. session and Dr Madiraju Ashok Non-competitive f) Quiz: Allergan sponsored Quiz competition free paper session were presented and the best for the post graduates was conducted by Dr paper will be awarded as Sunayana best free paper Santosh Honavar and Dr Manoj Mathur. award - Dr.Md.Ather won this award this year Continuously for the third time Andhra Medical with a cash prize of Rs 10,000/- other three papers College won the quiz competition. Victorious received Rs 2,500/- as cash prize. This session team members were Dr.Sirisha, Dr.Kiranmayee was sponsored from the funds of Sunayana Funds. and Dr.Jayasree.K. Valedictory Function: Function was held on 4th a fortune for those who were present. g) Poster Presentations : Twenty seven October, 2009 at 2pm. Local organizing presentations were accepted for poster exhibits. Keynote Address : They really added variety Posters were displayed all three days and good and quality to the session. As they were delivered “SMS Feed backs - number of delegates attended the exhibition. Sri by most experienced and eminent people it was a Kiran poster award was won by Dr.K.V.Ravi good opportunity to listen to them. We were Well organized, Kumar. fortunate to have Dr M Srinivasan and Dr K Scientific sessions Ramakrishnan from Aravind Eye Care System, h) Free Papers : Free papers were presented who were instrumental in training most of us in in six different categories. were very useful” some form or the other. We were able to share Competitive PG papers session : Ten papers their rich clinical experience in some of the other were presented out of which the paper on " committee thanked all the delegates and central sessions too. Dr K V Chalam and Dr Samar K Treatment modalities for refractory Diabetic organizing committee for the co-operation during Basak in addition to their oration lectures, shared macular edema authored by Dr C Anjali " and the conference for the successful conduction of the their experience through keynote addresses. Dr T conference. LOC also thanked all those people who P Das, Dr Savithri Sharma, Dr R.Hanumantha have helped directly or indirectly during the Reddy, Dr A S Rathore and Dr Kasu Prasada conference. APOS flag was handed over to Nellore Reddy were also among us fortunately during LOC where 34th APOS annual conference will be these three day's of scientific bonanza. held next year. b) Insturction Courses : Ten instruction SMS Feed backs :Well organized, Scientific courses on various subjects were conducted by sessions were very useful. Very good except, experienced people / specialists in those subjects vegetarian food which was not up to the mark. which were very useful for post-graduates as well Organization is not up to the standard, Seminar hall's as practitioners. Retina, Uveitis, Glaucoma, sound system not up to the mark. Better to conduct Paediatric ophthalmology, Trauma, Oculoplasty, Endophthalmitis and Ocular Allergy were covered in detail. paper on "Impression cytology in the diagnosis c) Symposia : Eleven symposia were conducted of OSSN authored by Dr K Tulasi Priya" were by eminent people in their own field. Cataract, selected as the best papers. Glaucoma, Practice Management, evidence based medicine, Cornea, Retina, Community Dr Vengal Rao's Medal Competitive Free ophthalmology, Neuro-ophthalmology, paper session : Six papers were presented in Strabismus and Refractive Surgery were some of this session and the paper on "Correlation the specialties covered this time. between Retinal nerve fiber layer thickness and d) Dr Ramachader Clinical Challenges : Optic nerve head parameters using Spectral Challenging cases were presented and experiences domain OCT" presented by Dr.M Tarannum of different people were shared during the Mansoori was selected for the prize. discussion. Presence of Dr M Srinivasan and Dr Dr Raghavachar's Medal Competitive K Ramakrishnan helped us in a big way. Free paper session : Three papers were presented in this session and the paper on in other seasons except rainy season. The immense "Incidence of ocular involvement in HIV positive talent of UGs over shadowed the orchestra on the clients attending integrated counselling and banquet day, food was not properly organized, testing center" presented by Dr.Md.Ather was CD's of Journal and Souvenir are good. selected as the best paper. Dr Madiraju Ashok's Non-competitive “The Conference was a free paper session : Eleven papers were presented in this session." Management of Grand Success and set an Neovascular Glaucoma" presented by Dr Hima Bindhu was selected to be presented in the example for future” Sunayana best free paper session.
apos.org 23 APOS New & Views, Issue 1, 2010
Journal Review
Dr.Seshu Babu Visakhapatnam,Email:[email protected]
Selected journal articles suspected of having the disease. Also, it suggests progression for different individuals. Ocular or related to Glaucoma from Archives of a potential role for longitudinal assessment of systemic risk factors, associated with a faster rate Ophthalmology were reviewed. the optic disc as an end point in clinical trials of visual field (VF) loss, are combination of and as a reference for evaluating diagnostic tests variables, such as the extent of baseline optic nerve Prediction of Functional Loss in in glaucoma. and VF damage, life expectancy, help in estimate Glaucoma from Progressive Optic Disc Editorial : the risk of loss of visual function and to determine Damage future management. Using standard achromatic Ocular Hypertension Treatment Study perimetry (VF global indices like mean deviation, Felipe A. Medeiros, MD, PhD; Luciana M. Alencar, MD; showed that while reducing intraocular pressure Linda M. Zangwill, PhD;Christopher Bowd, PhD; Pamela A. pattern deviation), investigations to find whether Sample, PhD; Robert N. Weinreb, MD. Arch Ophthalmol. (IOP) halved the relative risk of developing baseline VF characteristics are associated with 2009;127(10):1250•1256. glaucoma (from 9.5% to 4.4%), the absolute risk increased risk of future disease progression, do Progressive neuroretinal rim thinning, reduction was only 5%, with around 90% of the not provide spatial information. Glaucomatous increased excavation, and diffuse and localized subjects randomized to only observation not field loss often begins with localized injury that loss of the retinal nerve fiber layer are all developing glaucoma. The Ocular Hypertension respects the horizontal meridian and subsequently recognizable features of structural damage in Treatment Study demonstrated the potent role of spreads in an arcuate pattern consistent with the glaucoma. Their precise relationship with IOP in the development of glaucoma, yet it also orientation of the retinal nerve fiber bundles functional deterioration in patients with glaucoma highlighted that risk profiling for factors in progresses to presence of scotomata, in both remains largely unclear. Currently acceptable end addition to IOP was necessary to more accurately hemifields, may threaten fixation. predict which subjects were likely to develop points according to the Food and Drug This study hypothesize that eyes with glaucoma and who required change in Administration include only intraocular pressure VF defects in both hemifields early in the disease management, especially regarding treatment and (IOP) and methods for assessment of visual course are more likely to experience progressive frequency of follow-up. Older age, larger vertical function, such as standard automated perimetry functional injury. Evaluation whether VF loss cup-disc ratio, increased pattern standard (SAP). However, IOP is only a surrogate for affecting both hemifields could be the harbinger deviation, and thinner central corneal thickness clinically relevant outcomes in glaucoma and its of a worse prognosis in eyes with similar baseline are additional risk factors. Individuals with relationship with disease progression is certainly global VF damage than those with a similar degree suspected glaucoma who have progressive disc imperfect. There is evidence to suggest that many of total damage limited to one field showed that change are more than 25 times more at risk for patients may show evidence of progressive optic initial damage to both visual hemifields connotes subsequent visual field loss compared with disc damage before functional loss is detected by a worse prognosis than does more localized subjects not showing progressive disc change. SAP. This study was evaluated the value of damage limited to one hemifield, even when there There is accumulating evidence that scanning progressive optic disc damage detected by expert is early VF loss (MD smaller than ?6.0 dB). This laser tomography and OCT performs well assessment of longitudinal stereophotographs in involvement of both hemifields is an independent compared with clinical judgements of predicting future development of visual field loss predictor of more rapid future VF injury in eyes conventional disc photographs and may help to in suspected glaucoma. with early functional damage and greatly increases close the gap between the actual and optimal Baseline and follow-up annual the risk of progression. This study confirms the frequency of optic disc imaging in clinical examinations consisted of a comprehensive role of higher baseline IOP and thinner CCT as settings. Progressive optic disc change as an end ophthalmologic examination that included a risk factors for progression. Despite an initial point in clinical studies and trials may be of medical history review, best-corrected visual mean baseline IOP of 17 mm Hg in eyes with early significant value in patients with established acuity, slitlamp biomicroscopy, IOP measurement VF loss, the risk of progression increased 7% for glaucoma; in individuals with suspected using Goldmann applanation tonometry, each additional 1mmHg. A thinner CCT was also glaucoma without perimetric loss, it may be even gonioscopy, dilated funduscopic examination a risk factor for progression, increasing the risk more valuable. using a 78-diopter (D) lens, stereoscopic optic disc by 27% for each 40-?m decrease. Age was not a Glaucoma With Early Visual Field Loss photography, and SAP using Full-Threshold or 24- significant risk factor in the final multivariate Affecting Both Hemifields and the Risk 2 Swedish Interactive Threshold Algorithm, and model, suggesting that other factors, such as central corneal thickness (CCT). The study of Disease Progression disease stage, treatment, and other covariates, may showed evidence of progressive optic disc damage Carlos Gustavo V. De Moraes, MD; Tiago S. Prata, MD; play stronger roles in predicting progression in on longitudinal stereophotographs, a highly Celso Tello, MD; Robert Ritch, MD; Jeffrey M. Liebmann, this treated population. For the practicing predictive indicator of development of functional MD. Arch Ophthalmol. 2009;127(9):1129-1134 (Retrospective study) physician, this study suggests that a lower target loss in glaucoma. The findings suggest the IOP may be warranted for patients with initial, importance of careful monitoring of the optic disc Glaucoma is a multifactorial disease reproducible damage extending to both appearance in patients with glaucoma and subjects that results in different patterns and rates of hemifields.
24 apos.org Journal Review APOS New & Views, Issue 1, 2010
Diffuse Glaucomatous Structural and head structure and visual function. There are relationship between RNFL atrophy in the Functional Damage in the Hemifield reports of diffuse RNFL damage in eyes with apparently normal hemifields and glaucoma Without Significant Pattern Loss. localized visual field abnormalities. With the severity using TD-OCT, SDOCT, and SLPECC Dilraj S. Grewal, MD; Mitra Sehi, PhD; David S. evidence of incidence of RNFL atrophy in 90° (SLPECC, scanning laser polarimetry with Greenfield, MD Arch Ophthalmol. 2009;127(11):1442•1448 to 120° quadrants corresponding to normal visual enhanced corneal compensation). It could show Examination of the optic disc and hemifields in a small population of individuals that diffuse RNFL atrophy and retinal sensitivity retinal nerve fiber layer (RNFL) are essential for with glaucomatous eyes and with visual field loss loss exist in glaucomatous eyes with localized the diagnosis and monitoring of glaucoma. localized to the opposite hemifields, this study SAP deficits and are linearly proportional to Imaging technologies such as confocal scanning hypothesized that recent advancements in glaucoma severity. The RNFL imaging techniques laser ophthalmoscopy (CSLO), Heidelberg structural imaging technology may better of SD-OCT, TDOCT, and SLPECC demonstrate Retina Tomograph, scanning laser polarimetry quantify the presence of diffuse glaucomatous similar performance for quantifying structural (SLP), and optical coherence tomography(OCT) RNFL atrophy in eyes with localized visual field changes in the apparently normal SAP hemifields provide objective and quantitative measurements abnormalities in a population of individuals with of eyes with localized visual field loss. that are highly reproducible and show good normal eyes, patients with suspected glaucoma, agreement with clinical estimates of optic nerve and patients with glaucoma and to evaluate the
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apos.org 25
APOS New & Views, Issue 1, 2010 Remembering
Dr J Agarwal (1930-2009) Collected by Dr.I.Venkata Rao,Visakha Eye Hospital
In the death of Dr Jayveer Agarwal, the Achievement Award", by the All India He was the president of All India Ophthalmic fraternity has lost a good friend, Ophthalmological Society in the year 2001 and Ophthalmological Society during its golden philonthrophist , skilled professional and a great by Tamilnadu Ophthalmic Association in 2002, jubilee year in 1992. Not liking to limit himself humanitarian.As a chairman of the reputed started his career in ophthalmology in a humble only with treatment, he widened his horizon by Agarwal Eye Hospital he brought glory not only way, way back in 1957. Dr.Agarwal's eye hospital sharing his and other stalwart's knowledge with to his institute but to the whole of South India. - is the only one that was built in the shape of an his fellow doctors by conducting various His is a family of 13 doctors and five eye, listed as a Major Eye Centre of the World educational and CME programs. ophthalmologists of great repute probably has by the International congress of ophthalmology He has conducted many conferences not few parallels.His greatest dedication was and has found a place in the Ripley's "Believe it only in India but also abroad. Infact he was the eradication of blindness.Towards that goal he or not". man behind the legendary meeting of 6th Afro worked tirelessly with his dedicated team.A fitting He was able to bring about Custom Asian Congress of Ophthalmology in 1976. coincidence that his illustrious son Amar removed Duty Exemption for Sight Saving Instruments Special mention has to be made of his association his father’s corneae which were transplanted by the Govt. of India in 1988 and this saw a new with Dr.Hudson Silva and Sri Lanka Eye Bank almost immediately to restore vision in two blind horizon emerging on the scenario of Indian which goes back to early 70's. He was one of the victims. His hard nosed campaigns for Ophthalmology. Now our eye surgeons implant earliest to receive eyes from Colombo. He was eyedonation and concerted efforts in correcting lenses without having to pay the duty for also one of the first to propagate eye donation in refractive errors among school children will microscopes, IOLs, lasers and other sight saving India in a big way. May his soul rest in peace. always be remembered, and represent a landmark equipment. This Custom Duty Exemption was achievement in ERADICATION OF not given to any other branch of Medicine. " Dr.Agarwal epitomises dedication, devotion and BLINDNESS. his heart for the poor brethren, is unparalleled " A great pioneer, he combined hectic “ Dr.Agarwal epitomises " His thirst towards the eradication of blindness practice with research, he took his hospital to dedication, devotion and has virtually blinded him to everything but great heights and ensured that it was at the cutting ophthalmology ". edge of developments in ophthalmic surgery.He his heart for the poor pioneered Refractive keratoplasty with cryolathe brethren, is unparalleled. and has been credited with many firsts including the phacoknit, 700 micron cataract surgery,no He has carved a niche for anaesthesia cataract surgery and more recently with the Glued IOL. himself by establishing an It is said that Jaiveer (as he was organisation called Eye affectionately called).had Rs 60 with him when he landed in Madras, which he used to establish Research Centre in 1978, his eye clinic. This small clinic has taken a through which he has done gigantic leap over the years with 30 hospitals staffing 150 doctors. yeoman service for the Dr.J.Agarwal F.I.C.S., D.O.M.S., F.O.R.C.E., was honoured with the "Life Time rural poor blind. ”
Dr G Prem Sagar (1952-2009) Obituary Dr G Prem Sagar son of Late G Ramayya Chetty ,Rtd Professor of Ophthalmology, Andhra Medical College. MBBS : 1971-77, Rangaraya Medical College & Andhra Medical College. APOS Life Members Diploma In Ophthalmology: 1978-79, Egmore Eye Hospital, Chennai. Fellowship : Sankara Nethralaya, Chennai, 1989, L V Prasad Eye Institute, Hyderabad, 1993, Consultant Dr. Sri Seetha Ramanjaneyulu Ophthalmologist : 1979-2009. Ponnur Married to Smt G Padma Sagar MA, housewife, son G Harsha Vardhan, BDS, doing DDS at New York, USA married to Manas Veena BTech, USA. A very honest man of simple living followed ophthalmic practice in the tradition established Dr. Harihara Nath by his late father. He devoted part of his time in rendering service to the needy and poor through Satya Kurnool Sai Seva organization. We extend our condolences to his family on the bereavement.
apos.org 27 APOS New & Views, Issue 1, 2010
Test Your Knowledge Dr Mallika Goyal Chairman, Questions : Scientific Committee's Desk: New email address : I have created an email address “[email protected]”. Please use this address to submit abstracts and obtain information about course details for the APOS meetings. This will remain permanant (even after the chair person changes ). Send your Email and Figures 1-2. This is a Humphrey's visual field FROM a man who comes in for Mobile numbers to a neuroophthalmic eye exam Secretary, APOS to prepare date base and for fast / effective communication. I. Figure 1 & 2 ? 1. Describe the visual field defect. 2. What is the most likely cause of such a visual field defect ? Important Dates to remember : 3. What else can cause this visual field defect? 34th APOS Conference tentatavively 1-3rd 4. What type of nystagmus can be associated with this field defect ? Oct,2010 II) Total number of Retinal Ganglion cells in a healthy individual, Any guess ? Last Date for Early bird Registration : III) Medical Treatment of Glaucoma: Several combination therapies are presently August, 15th available except. Last Date for Abstract Submission for 1) Brimonidine and Timolol Maleate Instruction Course : 1st June. 2) Prostaglandin Analog and Timolol Maleate Last Date for Abstract Submission for Free 3) Pilocarpine and Timolol Maleate Papers / Videos / Posters. 30th June. 4) Dorzolamide and Brimonidine Answers: see below
“APOS News & Views”. is a multicolor magazine.The issues of the series will be released in the months of February / June / October of each year.More than thousand copies will be in circulation. The details of tariff for advertisement are given below :
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Brimonidine and Dorzolamide combination is unavailable. is combination Dorzolamide and Brimonidine Answer: III.
each retinal ganglion cell receives inputs from about 100 rods and cones. and rods 100 about from inputs receives cell ganglion retinal each
na, on average on na, reti per photoreceptors million 105 about With retina. human a in exists photoreceptors million 1.5 to 1.2 that estimated is It Answer: II.
elevation of the intorting eye and depression of the extorting eye which appears as if the eyes are see-sawing up an down. an up see-sawing are eyes the if as appears which eye extorting the of depression and eye intorting the of elevation
There is There minute. per cycles 300 to 150 FROM eyes the of rotation counterclockwise then clockwise conjugate a is which nystagmus See-saw Answer: (4)
ia. hyster and detachments, retinal bilateral chloroquine, as such drugs eyelids, overhanging drusen, head nerve optic papilledema,
cotomas, s cecocentral pigmentosa, retinitis sector discs, optic tilted include, defects field bi-temporal pseudo chiasmal non of Causes Answer: (3)
A sellar chiasmal mass such as a pituitary adenoma is the most likely cause of such a visual field defect. field visual a such of cause likely most the is adenoma pituitary a as such mass chiasmal sellar A Answer: (2)
This is an incongruous bitemporal visual field defect that respects the vertical midline. vertical the respects that defect field visual bitemporal incongruous an is This : Answer (1) I.
s : s ’ Answer
28 apos.org APOS New & Views, Issue 1, 2010 From the Secretary FBS APOS Desk Report from the office of FBS APOS on January 27, 2010
My dear APOS members,
With warm greetings. Please open www.youtube.com and search family benefit insurance. In a nut shell, as on today Fbs members : 467, Expired: 22 -19 fully benefited and 3 recent (Dr. Premsagar of Vizag, Dr. Sri Seetha Ramanjaneyulu of Ponnur and Dr. Harihara Nath of Kurnool) are partially paid in advance before collection of FCs from SOD account (overdraft against securities / fixed deposits) to facilitate immediate help. Rest of the balance will be paid after collection of FCS. Total terminated: 25 (9 old and 16 recent) FBS members have to pay late payment surcharge of Rs.50/-per month for 6months.The membership gets automatically inactivated after 6 months. The FBI contribution will be capped at Rs 800/- and a registered notice will be sent to clear the dues by the specified time or face termination without further notice. Only one reminder notice after the due date will be sent for dues. Dr Mathur, Secretary APOS informed that he has written to all MC members of APOS to also coordinate the activities of FBI as its executive members in their respective districts. The full meeting of the FBI management will be held annually along with the MC meeting of APOS. The day to day activities will be managed by the office bearers and Ex-officio members only. They will meet as often as required. Those MC members wishing to participate in FBI activities are requested to join FBI. In the MC, It was resolved that in order to encourage youngsters to join the FBI, the scheme should be modified that they only have to pay Rs 250/ - FC if they join before the age of 30 yrs. up to the age of 45yrs. Later they pay @ Rs 500/- per FC as usual. The secretary FBI was requested to draft the proposal for implementation to be discussed in the MCM and GBM. Those APOS members residing outside A.P. are eligible to join FBS. FBS Application form can be downloaded through www.apos.in. Or contact me for further clarification.Awaiting suggestions. With regards. Dr.Katta Secretary FBS APOS [email protected] 09949540043(preferably between 9.30pm to 10pm)
FBS DUES AS ON 2ND FEB 2010. Please add Rs.200/- as late payment surcharge till feb ending. Later on March add Rs.250/-.In April add Rs.300/-.InMay inactive, In June termination. Please pay in time to keep account active & also facilitate to pay beneficiary in time.
S.N APOS No FBS NAME FBS DISTRICT FC-16 FC-17 FC-18 FC-19
1 191 9 Dr. V. Anil Kumar A HYDERABAD 250 500 2 50 28 Dr. K. Siva Rama Krishan S KRISHNA 500 3 75 31 Dr. Sree Ranganath S ANANTAPUR 500 4 168 34 Dr. S.M. Hussain H HYDERABAD 250 500 5 49 44 Dr.O.Bhanumathy devi B GUNTUR 500 6 177 80 Dr. C. Sharat Babu S WARANGAL 500 7 126 88 Dr. A. Srinivas S KRISHNA 500 8 125 92 Dr. M.N. Raju R KRISHNA 500 9 298 93 Dr. N. Vishnu Vardhan V WESTGODAVARI 250 500 10 304 95 Dr. S. Samba Siva Rao S EASTGODAVARI 500 11 325 98 Dr.Sivalingeswararao S GUNTUR 250 500 12 328 103 Dr. Venkateswara Rao Ayyagari V EASTGODAVARI 500 13 329 104 Dr. Aluri Bhaskar Rao B PRAKASAM 500 14 405 108 Dr. Rodile Narsimha Rao N GUNTUR 500 15 134 114 Dr. S. Venkateswarlu V GUNTUR 500 16 285 117 Dr. K. Annapurna A WARANGAL 500 17 80 132 Dr. K. Viswanath V HYDERABAD 500 18 386 139 Dr. M. Venkateswarlu V PRAKASAM 500 19 324 152 Dr. Alur Anjaneyulu A BANGALORE 500 20 136 153 Dr. P. Sudhakar Rao S KURNOOL 250 500 21 140 162 Dr. V. Laxmipathi L KRISHNA 500
apos.org 29 APOS New & Views, Issue 1, 2010
S.N APOS No FBS NAME FBS Dist FC-16 FC-17 FC-18 FC-19
22 293 167 Dr. Nalini Sandhya Rani S PRAKASAM 500 23 232 174 Dr. K. Prasad Reddy P HYDERABAD 500 24 82 175 Dr. K. Ravi Kumar Reddy R HYDERABAD 250 500 25 360 201 Dr. Nagabhyru Andhra Kumari A GUNTUR 500 26 443 204 Dr. B. Bheem Singh B NIZAMABAD 500 27 11 206 Dr. K. Kameswara Rao K VIZAG 500 28 394 210 Dr. Bachu Krishna Murthy K KURNOOL 500 29 979 215 Dr.Lavanyalaxmi L GUNTUR 250 250 500 30 83 219 Dr. Vittal Rao V HYDERABAD 500 31 86 222 Dr.T.Prakashrao,kamareddy P NIZAMABAD 500 32 483 230 Dr. Y. Mallikarjuna M MAHABOOBNAGAR 500 33 504 236 Dr. Penumatcha Krishnam Raju K SRIKAKULAM 500 34 450 262 Dr. Venkata Satyanarayana Bokka V EASTGODAVARI 500 35 365 270 Dr. K. Shobha Naveen S CHITTOR 250 500 36 60 273 Dr.A.Siddareddy,madanapally S CHITTOR 250 500 37 648 296 Dr.Naresh Kumar K.R. N NIZAMABAD 500 38 439 314 Dr. Ch.M. Subramanyaswara Rao S EASTGODAVARI 250 500 39 679 319 Dr.V.Santosh kumar S GUNTUR 500 40 343 320 Dr. K.A. J. Verma V WESTGODAVARI 250 500 41 362 322 Dr. P. Prabhakara Sastry P KRISHNA 500 42 238 327 Dr. K. Vijay Kumar V WARANGAL 250 500 43 388 342 Dr. K. Sukumar Babu S WARANGAL 500 44 164 343 Dr. K. Bhoonath Reddy B NIZAMABAD 500 45 635 354 Dr. B.P.V. Subba Reddy S KURNOOL 500 46 377 364 Dr. P. Paul P KRISHNA 500 47 732 366 DrG.Sudheer,machavaram S KRISHNA 500 48 739 367 Dr.S.Veerabhadrarao V EASTGODAVARI 500 49 391 369 Dr.BodduVenkatanarasaiah V KHAMMAM 500 50 626 375 Dr. Amal Kumar Mahata A HYDERABAD 500 51 827 382 Dr.MandaliBhusireddy B KURNOOL 250 500 52 735 386 Dr.lavudiya amar L NALGONDA 500 53 882 389 Dr.T.Kirankumar K KURNOOL 500 54 942 393 Dr.Voddiraj sreekanth V WARANGAL 500 55 866 395 Dr.R.Aruna A HYDERABAD 250 500 56 163 398 Dr.mamata narain M HYDERABAD 250 500 57 268 401 Dr. B. Siva Prasad Rao S ANANTAPUR 500 58 542 404 Dr. G.C.V. Ramana R WARANGAL 500 59 397 409 Dr.M.Mohan rao M VIZAG 500 60 907 412 Dr.D.Bharath kumar B GUNTUR 500 61 688 414 Dr.V.Srinivasa Rao S GUNTUR 500 62 911 418 Dr.Katta sivaji S WESTGODAVARI 500 63 912 419 Dr.P.Sunil kumar S GUNTUR 500 64 916 420 Dr.V.Ravi R NALGONDA 500 65 236 421 Dr. K. Bhaskar B ANANTAPUR 500 66 122 423 Dr. Upender Karne U HYDERABAD 500 67 220 426 Dr. Nasa Anada Rao A VIZAG 500 68 406 430 Dr.Bukka sidda naik S CHITTOR 500 69 925 431 Dr.K.Laxminarayana raju L KURNOOL 500 70 832 433 Dr.K.Muralikrishna M KARIMNAGAR 500 71 833 434 Dr. Bhookya Ratnamala R KARIMNAGAR 500 72 900 435 Dr.Shashidhar S KRISHNA 500 73 572 437 Dr. M. Manjulamma M NELLORE 500 74 939 440 Dr.Kottapalli subbarao S HYDERABAD 500 75 926 443 Dr.Kaleru sathyanarayana S WARANGAL 500 76 ? 446 Dr.Sudhakar tayini T WARANGAL 500 77 978 448 Dr.Mansingh M HYDERABAD 500 78 703 454 Dr.Thota Penchalaiah P CHITTOR 500 79 877 455 Dr.D.P.Prasanna P CHITTOR 500
FBS 446 is not apos member.Dr.Sudhakar tayini is requested to join immediately APOS.and make FBS account active by paying dues.Till then,FBS account is considered as inactive
30 apos.org APOS New & Views, Issue 1, 2010
Application for membership of Family benefit scheme of Andhra Pradesh Ophthalmic Society (Regd: No: 1147 of 2007)
Name :
S/O / W/O : Photo
Age: sex: Date of Birth :
Address for Correspondence :
E-Mail: Mobile: APOS LM.No : Admission Fee :
Age Up to 35 years 36 to 45 years 46 to 55 years 55 to 70 years
Amount Rs.1,600/- Rs.5,000/- Rs.10,000/- Rs.15,000/
I enclose D.D. No...... Dated ...... for Rs......
Drawn on bank...... towards membership of FBS-APOS. Declaration : I solemnly declare that I do not have a history of any acute illness in the last 12 months (acute disease/ cardiac or malignant disease). I further agree to abide by the rules & byelaws of APOS FBS.I accept any decision of EC/MC of FBS-APOS as final.
Nomination: I herewith nominate the following as my beneficiaries S.No. Nominee name Age / Sex Relationship Signature / photo 1 2 In case of Minor 1 Guardian signature 2
Name & address of the Guardian who represents minor: Witnesses : 1. 2. ( Signature / Name & Mobile)
Date:
Place : Signature of Candidate : Mail to : Dr. Katta SV Secretary, FBS APOS. Dr. Ranga Reddy Lions Eye Hospital, First floor, Palika Bazaar, Opp : Old Gandhi Hospital, Near Secunderabad Railway Station, Secunderabad500003. Ph040-27700454 Mobile: 9949540043 (9.30pm to10pm) Email: [email protected] Enclosures : 1) Age proof 2) D.D
apos.org 31 APOS New & Views, Issue 1, 2010
Application for the Membership of Andhra Pradesh State Ophthalmological Society Hyderabad A.P.
Photo
Applied for Life Member Member in Waiting
Name ( In Block Letters ) :......
Father’s / Husband’s Name :......
Age :...... Sex :...... Date of Birth :......
Native District :......
Address ( Present ) :......
......
......
Address ( Permanent ) :......
......
......
Mobile : ...... Email :......
Designation :......
Academic Qualification :......
MBBS Year : PG DO. MS DNB Year : ( for Life Member )
Joined PG in Ophthalmology year : ( for member in - waiting )
Date : ...... Signature of Candidate
Membership Fees :
DD / No :
Remarks of Secretary :
______Kindly fill it and send to : Dr.Manon Chandra Mathur Swarup Eye Centre,145, Dwarakapuri Colony Panjagutta, Hyderabad - 500 082
32 apos.org