Indian Journal of Ophthalmology

Improving the outcome of prosthetic rehabilitation following orbital exenteration Dear Sir, Apropos the article recently published on prosthetic rehabilitation after orbital exenteration.[1] We commend the authors of the article for their scrupulous effort of rehabilitating such complex cases. Although the esthetic outcome achieved in all the cases is fairly good, yet as prosthodontists, actively involved in the rehabilitation of patients with ocular and orbital defects, we would like to some modalities that can further enhance the outcome of prosthetic rehabilitation in such cases. Pruthi et  al.[1] have rightly mentioned that silicone gives more life‑like appearance and margins can be more precisely merged with the skin of the patient. However, it would have been appreciable if they would have mentioned the specific type of silicone used in such cases, that is medical grade heat temperature vulcanized (HTV) silicone. HTV silicone is preferable over room temperature vulcanized silicone due to its superior mechanical, esthetic and handling properties, owing to which it is possible to make the margins of the prosthesis feather edged so as to allow merging with the patient’s skin.[2] In our clinical practice, we have seen few ill‑treated cases where following the use of prosthesis, patient’s reported allergic skin and mucosal reactions as industrial grade silicone/poor quality adhesive being cheaper materials had been used for fabrication/ retention of facial prosthesis. The esthetic outcome in Fig 3 and 4 illustrated by Pruthi et  al.[1] would have been improved with the use of optical camouflage methods such as progressively tinted lens or negative sphere spectacle lens that provide the illusion of depth and improve the appearance of an orbital prosthesis.[3] Apart from this, the use of pin and socket of electric plug and magnetic buttons of wallet for retention though novel and cheaper methods, have a potential to harm the patient as a result of corrosion and hence it is prudent to use these options with caution. Nowadays, to add to the liveliness of orbital prosthesis, a photodynamic iris that utilizes liquid crystal display technology and shows light reactive pupillary constriction, may be incorporated in the ocular component of the prosthesis instead of a static iris. [3] Furthermore, orbital prosthesis with a built‑in blinking mechanism is gaining popularity that blinks almost synchronously with the natural eye.[3] With the advent of osseointegrated implants, today’s anophthalmic patient does not need to be conscious about their prosthesis falling off. Placement of osseointegrated implants in the superior and lateral orbital bony rim can provide a stable and more retentive means of securing the prosthesis. However, appropriate case selection is necessary so as to rule out the presence of any risk factor associated with implant failure. It is also important for the maxillofacial prosthodontist to know about the various surgical procedures of the eye and their indications. Pruthi et  al.[1] have erroneously mentioned that indications for exenteration include

Vol. 62 No. 11

painful blind eye, disfiguring blind eye and prevention of sympathetic ophthalmia. For the above‑mentioned conditions, enucleation is the treatment of choice and not radical exenteration.[4] Before rehabilitating such defects, it is important to collaborate with the ophthalmologist to precisely know the diagnosis/cause of defect/disfigurement and the adjunct ophthalmological/oculoplasty procedures which can alter/enhance the outcome of prosthetic rehabilitation so that individualized treatment plan may be formulated and the expected outcome can be explained to the patient before the initiation of prosthetic treatment.

Pradeep Kumar, Himanshi Aggarwal, Pooran Chand, Prashanti E1 Department of Prosthodontics, Faculty of Dental Sciences, King George’s Medical University, Lucknow, Uttar Pradesh, India, 1 Faculty of Dentstry, Melaka Manipal Medical College, Melaka, Malaysia Correspondence to: Dr. Himanshi Aggarwal, Room No. 404, E Block, Gautam Buddha Hostel, King George’s Medical University, Lucknow, Uttar Pradesh, India. E‑mail: [email protected]

References 1. Pruthi G, Jain V, Rajendiran S, Jha R. Prosthetic rehabilitation after orbital exenteration: a case series. Indian J Ophthalmol 2014;62:629‑32. 2. Begum Z, Kola MZ, Joshi P. Analysis of the properties of commercially available silicone elastomers for maxillofacial prostheses. Int J Contemp Dent 2011;2:1‑5. 3. Aggarwal H, Kumar P. Surgical reconstruction or prosthetic rehabilitation following orbital exenteration: The clinician’s dilemma. Indian J Plast Surg 2014;47:146‑7. 4. Takahashi A, Akimoto M, Hama S, Shirai Y, Minamiguchi S. Enucleation assisted with fillerfor open‑globe injury. Eye Rep 2011;1:3‑4. Access this article online Quick Response Code:

Website: www.ijo.in DOI: 10.4103/0301-4738.146731 PMID: ***

Multimedia interventions on the informed consent process for cataract surgery Dear Sir, We read with interest the article by Karan et al.[1] describing the efficacy of multimedia interventions on the informed consent process for cataract surgery. The authors utilized multimedia aids during the informed consent process, providing patients with information on the surgical and postoperative procedure and general information regarding cataracts.

November 2014

Their results showed that these measures are effective in improving patient comprehension. Given the success of their multimedia intervention, we would like to suggest that preoperative counseling for cataract surgery should also include counseling regarding possible intraoperative visual experiences that patients might encounter. Many studies have reported that patients encounter a variety of visual sensations during different types of ocular surgery, including cataract surgery,[2,3] LASIK,[4] and vitreous surgery.[5] An important observation is that up to 16.2% of patients may be frightened by the visual sensations that they encounter during cataract surgery.[2,6] Fear experienced during cataract surgery is of clinical relevance as it may incite a sympathetic stress response and cause patients to become less cooperative during the surgery. These may increase the intraoperative morbidity as most cataract patients are in the geriatric age group and have significant concurrent chronic diseases such as hypertension and ischemic heart disease.[2‑5] The variety of visual sensations experienced can be quite wide, ranging from experiencing the light, colors, movements, flashes, etc.[2,3] It has been shown that preoperative counseling reduces both the percentage of patients who experience fear, as well as the severity of fear that patients experience. In addition, many patients have indicated during postoperative interviews that they would have preferred to have been informed of the possibility of visual sensations preoperatively.[4,5] Since the use of multimedia material in counseling appears to be more effective, it would be ideal to incorporate information on visual experiences into this counseling. In summary, we agree with the authors that preoperative counseling is very important. We also urge the authors to incorporate counseling on visual sensations to their multimedia aids.

Milton C. Chew1, Louis W. Lim2, Colin S. Tan1,2 1 2


Letters to the Editor

Department of Ophthalmology, Tan Tock Seng Hospital, Fundus Image Reading Center, National Healthcare Group Eye Institute, Singapore Correspondence to: Dr. Colin S Tan, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. E‑mail: [email protected]

6. Ang CL, Au Eong KG, Lee SS, Chan SP, Tan CS. Patients’ expectation and experience of visual sensations during phacoemulsification under topical anaesthesia. Eye (Lond) 2007;21:1162‑7.

Access this article online Quick Response Code:

Website: www.ijo.in DOI: 10.4103/0301-4738.146732 PMID: ***

Posttraumatic horseshoe‑shaped macular tear Dear Sir, We read with interest the article “An unusual complication of blunt ocular trauma: A horseshoe‑shaped macular tear with spontaneous closure” by Karaca et al.[1] We congratulate the authors for their report, and describe a similar case with an alternate management and outcome. An 18‑year‑old boy presented with decreased vision in his right eye following trauma with a cricket ball 2 days before. On examination, his best‑corrected visual acuity (BCVA) was counting fingers at half meter with accurate projection of rays. Slit lamp showed corneal epithelial edema, dispersed hyphema, traumatic mydriasis and pigment on the anterior lens capsule. Applanation tonometry revealed an intraocular pressure (IOP) of 58 mmHg; he was started on maximum antiglaucoma medication. Once the media became clearer, dilated fundus examination showed resolving vitreous hemorrhage, a cup: disc ratio of 0.3:1 and a horseshoe‑shaped tear at the macula with surrounding pigmentary alterations [Fig. 1]. The retinal periphery was unremarkable. The left eye was within normal limits with a BCVA of 20/20.

References 1. Karan A, Somasundaram P, Michael H, Shayegani A, Mayer H. The effect of multimedia interventions on the informed consent process for cataract surgery in rural South India. Indian J Ophthalmol 2014;62:171‑5. 2. Tan CS, Au Eong KG, Kumar CM. Visual experiences during cataract surgery: What anaesthesia providers should know. Eur J Anaesthesiol 2005;22:413‑9. 3. Tan CS, Rengaraj V, Au Eong KG. Visual experiences of cataract surgery. J Cataract Refract Surg 2003;29:1453‑4. 4. Tan CS, Au Eong KG, Lee HM. Visual experiences during different stages of LASIK: Zyoptix XP microkeratome vs intralase femtosecond laser. Am J Ophthalmol 2007;143:90‑6. 5. Tan CS, Mahmood U, O’Brien PD, Beatty S, Kwok AK, Lee VY, et al. Visual experiences during vitreous surgery under regional anesthesia: A multicenter study. Am J Ophthalmol 2005;140:971‑5.

Figure 1: Fundus photograph of the right eye showing a horseshoeshaped tear at the macula (arrows) with preretinal hemorrhage inferiorly

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Multimedia interventions on the informed consent process for cataract surgery.

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