00_pao cover - Philippine Journal of Ophthalmology

A PUBLICATION OF THE PHILIPPINE ACADEMY OF OPHTHALMOLOGY • FOUNDED IN 1969VOL 32 NO. 2 • JULY - DECEMBER 2007Rate of aqueous-humor flow in Filipino eyesTriamcinolone acetonide vs. antifibriotic agent in filtration surgeryFixed-concentration vs. fixed-volume perfluoropropane: which is better?Noninvasive way to measure tear-breakup timeEffect of dorzolamide and timolol on CCT and endothelial-cell countPractical methods of testing vision potentialLupus vulgaris of the ocular adnexaA chronicle of eye banking in the PhilippinesPHISSSN0031–7659PAPI Cert. No. 291

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULY– DECEMBER 2007EDITOR IN CHIEFPatricia M. Khu, MD, MScASSOCIATE EDITORSSantiago A.B. Sibayan, MD, PhDHarvey S. Uy, MDASSISTANT EDITORSJessica Marie R. Abaño, MDRuben Lim Bon Siong, MDJocelyn L. Sy, MDJoseph Anthony J. Tumbocon, MDMarissa N. Valbuena, MD, MHPedMANAGING EDITORCarlos G. Naval, MDEDITORIAL BOARDRomeo V. Fajardo, MDFOUNDING EDITOR, PHILIPPINESSalvador R. Salceda, MDPHILIPPINESRossina Lydia A. Ramirez, MD, MHScPHILIPPINESRoger W. Beuermann, PhDSINGAPORE/USADonald Tan, MD, FRCSSINGAPOREThe PHILIPPINE JOURNAL OF OPHTHALMOLOGY (PJO), the officialjournal of the Philippine Academy of Ophthalmology, aims toprovide a venue for exchange of ideas and information amongophthalmologists and other physicians. It publishes peer-reviewedreports of original clinical and laboratory investigations,epidemiological studies done in the Philippines and other countries,major reviews of specific topics, evaluation of diagnostic and surgical techniques,treatment methods, latest updates, and controversial issues in ophthalmology.Published biannually, Number One of Volume One is dated January–March 1969.Entered as a third-class mail matter at the Manila Post Office on February 13, 1969.Journal International Standard Serial Number: PHISSN 0031 - 7659. Vol. 29No.1, March 2004.Copyright 2007. All rights reserved.Philippine Academy of OphthalmologyUnit 815 Medical Plaza MakatiAmorsolo Street, corner De la Rosa Street1229 Makati City, PhilippinesTelephone : +63-2-8135324Fax : +63-2-8135331Email : pjo@pao.org.phPublishing and Editorial Consultants5/F King’s Court II2129 Chino Roces Avenue1231 Makati City, PhilippinesTelephone : Nos. +63-2-8112206 to 10 • Fax +63-2-8112182Email : edit@medobserver.comNOTICE TO READERS AND CONTRIBUTORSSUBMISSIONManuscripts should be submitted to theeditorial offices of the PHILIPPINE JOURNAL OFOPHTHALMOLOGY (PJO) at the PhilippineAcademy of Ophthalmology (PAO), Unit815 Medical Plaza Makati, Amorsolo Street,corner Dela Rosa Street, 1229 Makati City,Philippines.Authors must submit, along with themanuscript, a duly accomplished and signedcopyright transfer. No manuscript will bereviewed until the signed copyright transferis received.The author/s shall pay for the cost of thecolor separation processing for colorphotographs included in the manuscript.Manuscripts submitted for considerationare reviewed by editors and other experts inthe field. Reviewers are consultants to theeditor and are instructed not to discuss thepaper with the authors. Reviewers should notcite the manuscript or refer to the work itdescribes before it has been published.Reviewers should refrain from using theinformation contained in the manuscript forthe advancement of their own work or thatof their colleague or institution.SUBSCRIPTIONThe Journal is published biannually;subscribers will receive two issues per yearwith supplements on special topics that theeditors deem of interest or significance. PAOmembers in good standing are automaticallyenrolled subscribers with no additional feesexcept for the supplements. Nonmembersmay subscribe at the following rates, whichinclude delivery fees and online access to thePJO website.IndividualLocal PhP 1,200.00Foreign USD 70.00InstitutionalLocal PhP 1,400.00Foreign USD 90.00Particular issues may be purchased at thefollowing rates per copy subject to availability:IndividualLocal PhP 700.00Foreign USD 40.00InstitutionalLocal PhP 900.00Foreign USD 50.00DISCLAIMERStatements and opinions expressed in thearticles and communications herein arethose of the author(s) and not necessarilythose of the Editor(s) or the Publisher(Philippine Academy of Ophthalmology).The Editors and the PAO assume noresponsibility for any injury and/or damageto persons or property as a matter of productliability or negligence or which otherwisearise from use or operation of any methods,products, instructions, or ideas cited ordiscussed in any article in the Journal.Although all advertising materials areexpected to conform to ethical (medical)standards, the appearance of advertising inPJO does not constitute a guarantee orendorsement by the PJO or the PAO of thequality or value of such product or the claimsmade for it by its manufacturer.REPRINTS/ ADVERTISINGReprint requests and advertising inquiriesmay be addressed to the Managing Editor,PHILIPPINE JOURNAL OF OPHTHALMOLOGY, Unit815 Medical Plaza Makati, Amorsolo St., cornerDela Rosa St., 1229 Makati City, Philippines.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 51

PHILIPPINE JOURNAL OFOphthalmologyVOL. 32 • NO. 2 JULY – DECEMBER 2007LETTER53 Dr. David Gosiengfiao points out adifference in the first-generationFDT and the newer Matrix TMmodel as regards the “hill ofvision.”EDITORIAL54 Research challengesDr. Harvey Uy suggests ways toimprove medical research in thePhilippines.ORIGINAL ARTICLE56 Fluorophotometric measurementsof aqueous-humor flow in FilipinoeyesG E Comia, MD, et al.REVIEW81 Practical methods ofvision-potential testingH S Uy, MD, et al.LECTURE88 Eye-cornea bank for sightrestoration in the PhilippinesS R Salceda, MDORIGINAL ARTICLE 60Efficacy of intraoperative subconjunctival triamcinolone acetonide asantifibrotic agent in filtration surgeryK G Gruezo, MD, et al.A single, 4-mg dose of triamcinolone acetonide given subconjunctivally inrabbit eyes can delay wound healing in the early period after filtrationsurgery.ORIGINAL ARTICLE 66Comparison of two techniques for perfluoropropane gas fillin the management of retinal detachmentH S Uy, MD, et al.Fixed-concentration and fixed-volume methods of C3F8 gas fill arecomparable in terms of postinjection gas volume, intraocular pressures, andretinal-reattachment rates.ORIGINAL ARTICLE 70A prototype xeroscope for the noninvasive measurementof tear-breakup timeJ E D Herrera, MD; R Lim Bon Siong, MDNIBUT measurement using the prototype xeroscope has a positivecorrelation with the standard TBUT measurement and may be a goodalternative for measuring tear-film stability without disturbing normalphysiology.ORIGINAL ARTICLE 76Effect of dorzolamide compared with timolol maleate on the centralcorneal thickness and endothelial-cell count of glaucomatous eyesE D Golez III, MD, et al.Dorzolamide did not cause a significant change in CCT and endothelial-cellcount over 1 month of treatment.CASE REPORT 84Lupus vulgaris of the ocular adnexaM R Quilendrino, MD, et al.Awareness of lupus vulgaris, with its variousclinical manifestations, is crucial in its earlydiagnosis and treatment, preventingextensive and irreparable damage toinvolved and surrounding structures.52 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyEDITORIALResearch challengesJULY – DECEMBER 2007There is much work to be done to enhance Philippineresearch capabilities. The first step is to recognize the problem.The next will be to device solutions and test them. Thenfinally to implement.RESEARCH output sets developed countries apartfrom developing countries. Nearly all advances inophthalmology (and other fields of medicine) comefrom places where research investments are made andwhere scientists are supported: intraocular lenses weredeveloped in England, lasers in Germany, optical instrumentsin Japan, pharmaceuticals and phacoemulsificationmachines in the USA. While these advances werebrought to fruition in developed countries, theirapplications have improved the quality of life of patientsin rich and poor countries alike.Singapore and India have realized the value ofresearch and revved up their capabilities. My esteemedco-fellow at the Immunology Service of the MassachusettsEye and Ear Infirmary, Dr. Virender Sangwanof LV Prasad Eye Hospital in Hyderabad, India, wasrecently featured in Fortune magazine for developing atechnique to grow and transplant corneal epithelium.Scientific achievement leads to marketing credibilitythat translates to revenues from local and internationalpatients who seek out the best, cost-effective eye-careproviders. It is no accident that Singapore and Indiaattract large numbers of medical tourists who believein their technological capabilities.Why are there so few Filipino contributions to themedical sciences? It is certainly not due to a lack ofCorrespondence toHarvey Siy Uy, MD 1Asian Eye Institute9F Phinma Plaza Bldg., Rockwell Center1200 Makati City, PhilippinesTelephone : +632-8982020Fax : +632-8982002E-mail : harveyuy@yahoo.com1Research Committee Chairman, Philippine Academy of OphthalmologyDirector for Research, Asian Eye InstituteResearch Coordinator, Sentro Oftalmologico Jose Rizalpatients or clinical material; Singapore is a prolificresearch country with a population 5% that of thePhilippines. It is not due to a lack of resources—theresearch budgets of the National Institutes of Healthin Manila and the University of the Philippines ResearchImplementation and Development Organization(RIDO) are underutilized and not consumed. Thereare few takers for the vast funding that the St. Luke’sResearch and Biotechnology Division (RBD) provides.Basic science facilities are present in major Philippineuniversities like University of the Philippines, Universityof Santo Tomas, De La Salle University, and Ateneo deManila University, and can be tapped for collaboration.High-technology medical devices like OCT machinesor UBM can be loaned for research purposes byaccommodating equipment suppliers only too eager togenerate sales. It is not due to a lack of qualifiedpersonnel—there are innumerable, fellowship-trainedeye MDs in the country who have studied underprominent, respected academic ophthalmologistsworldwide.The missing ingredients are passion and the systemsto support and incentivize researchers. Virender’scornea breakthrough did not come about because ofsome unique super technology—their facilities in Indiaare present in the Philippines. Virender has simplyworked on this project for a decade, no doubt encounteringmany failures and obstacles along the way butalways persevering. He could do so because his hospitalprovided him an adequate salary to support his wifeand 2 kids regardless of the number of patients he sawor number of surgeries he did. He could concentrateon his work.This “salaried-researcher model” is followed byleading academic institutions worldwide and needs tobe created in the Philippines. Early steps in this54 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

direction include the St. Luke’s RBD which created apaid Research Fellowship position for practicingclinicians who devoted some of their time for research.Research production should be incentivized—thePhilippine Academy of Ophthalmology providesresearch cash awards for indexed publications.Our current system, which relies on graduatingresidents to produce research, needs to be overhauled—it does not work well. Of the 4 international publicationsthat received the PAO Eye Research Awards (PERA) thisyear, all were consultant-led. This is not surprising.Residents can do the legwork but lack problemidentification,writing, and publication skills. Theyusually do not have blocked time for research and arepressed to do many nonmedical tasks.The problem continues after graduation when theformer residents find themselves without any income.Naturally, they devote all their energies to survival. Bythe time they have established their practice, they haveforgotten the importance of research. Many promisingscientist-clinicians “lose their way” in their careers andwind up being unproductive in research.For institutions relying on residents for researchoutput, residents should be freed from most clerical andoptometry work to focus on developing surgical,medical, and research competencies. Eye-careinstitutions should hire ophthalmic assistants andoptometrists to perform visual-acuity/intraocularpressuremeasurements, dilation, surgical assisting, anddocumentation. This is a win–win situation for everyone:technicians and optometrists gain employment,residents have more time to study and research. Becauseinstitutions need fewer residents for manpower, theywill graduate fewer residents, which means less eventualcompetition for consultants in clinical practice.The ideal system is the clinician-scientist model.Here, practicing eye MDs who are in touch with patients’needs create and investigate research questions. Theyare required to spend a certain amount of time to seepatients and earn revenues and are paid decent salarieswith an incentive system based on research output.Typically, support systems for research are available inhouse,like research assistants to do legwork,statisticians, and ophthalmic technicians.There is much work to be done to enhancePhilippine research capabilities. The first step is torecognize the problem. The next will be to devicesolutions and test them. Then finally to implement. Ifwe can.Kaya natin ‘to!PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 55

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYORIGINAL ARTICLE– DECEMBER 2007George Emmanuel S.J. Comia, MD 1Margarita Lat-Luna, MD 1Manuel B. Agulto, MD 1,21Department of Ophthalmology and VisualSciencesUniversity of the Philippines–PhilippineGeneral HospitalManila, Philippines2Institute of OphthalmologyNational Institutes of HealthUniversity of the PhilippinesManila, PhilippinesFluorophotometricmeasurementsof aqueous-humor flowin Filipino eyesABSTRACTObjectiveThis study determined the rate of aqueous-humor flow in Filipino eyes.MethodsPatients were recruited from the outpatient eye clinic of the PhilippineGeneral Hospital. All underwent a complete eye evaluation, gonioscopy,dilated-fundus examination, ultrasonic pachymetry, and fluorophotometry.After instillation of 2% fluorescein dye into the eye, three scans were made oneach eye every 30 minutes for 2 hours and the rate of aqueous-humor flowwas determined. Kruskal-Wallis analysis of variance was used to determinevariation of aqueous-humor flow across age groups. Pearson correlation wasused to determine association between ocular parameters.Correspondence to:George Emmanuel S.J. Comia, MDDepartment of Ophthalmology and Visual SciencesUniversity of the Philippines–Philippine General HospitalTaft Avenue, Ermita1000 Manila, PhilippinesTelephone : +63-2-3022488Fax : +63-2-3022491Email : georgecomia@yahoo.comNo financial assistance was received for this study.The authors have no proprietary or financial interest inany product used or cited in this study.ResultsA total of 74 eyes (37 patients) were included in the study. The mean age ofthe participants was 46.6 years ± 11.1 years. The mean rate of aqueous-humorflow was 2.78 ± 0.27 mL/min and this was not affected by the eye assessed(p = 0.77), sex (p = 0.19), nor age expressed as decades (p = 0 .084). Aqueoushumorflow was directly and fairly correlated with anterior-chamber volumeand depth (r = 0.35, p = 0.002 and r = 0.36, p = 0.002) respectively. Aqueousoutflowfacility was inversely and fairly correlated with pachymetry (r = –0.32,p = 0.006).ConclusionsThe rates of aqueous-humor flow in Filipino eyes were similar to thosereported in the literature. There is direct but fair correlation of the aqueoushumorflow with anterior-chamber depth and volume.Keywords: Fluorophotometry, Fluorophotometer, Aqueous-humor flow, Aqueous-outflow facilityPHILIPP J OPHTHALMOL 2007; 32(2): 56-59 © PHILIPPINE ACADEMY OF OPHTHALMOLOGY56 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

AQUEOUS humor is the clear liquid of the anteriorand posterior chambers that inflates the globe andmaintains adequate intraocular pressure (IOP); providesnutrition for the lens, cornea, and trabecular meshwork;and facilitates cellular and immune responses. It is formedby the nonpigmented epithelium of the ciliary processesby three mechanisms: diffusion, active secretion, andultrafiltration. 1 The rate of formation is affected by theintegrity of the blood–aqueous barrier, blood flow to theciliary body, and neurohormonal regulation, and has beensaid to vary diurnally and drop during sleep. It alsodecreases with age. 2, 3The rate of flow of the aqueous humor through theanterior chamber is one of the major determinants ofIOP. 1, 2, 3 This rate can be measured using a fluorophotometer.Fluorophotometry is a noninvasive method of determiningthe concentration of fluorescent tracers (fluoresceindye) in living ocular tissues. 1 Fluorescein may beadministered intravenously or topically. These are fundamentalto measuring aqueous flow inside the eye. 2 In thePhilippines, the only fluorophotometer machine availableis the Ocumetrics Fluorotron TM Master (Ocumetrics Inc.,Mountain View, CA, USA). It was originally designed tomeasure the leakage of fluorescein dye from the retinainto the vitreous in a similar fashion that fluoresceinangiography photographs this leakage. This product hasnow been further developed for eye research involvingthe anterior segment. The Fluorotron TM Master comeswith a special computer algorithm for subtracting backgroundand vascular fluorescence so that only penetratedfluorescein is measured. It also utilizes various mathematicalalgorithms, such as the Yablonski principle, to determineendothelial permeability and aqueous flow. Coupledwith IOP readings, this information can be used to determineaqueous-outflow facility.The barrier between the blood system and the anteriorsegment of the eye is not tight, as some fluoresceincan penetrate it even under normal conditions. However,since the Fluorotron TM Master can make a precise measurementof the amount of fluorescein that gets in, it caneasily differentiate a normal amount from an abnormallyhigh amount.Aqueous flow can be determined by instilling thecul-de-sac with 2% fluorescein. 1, 2 This dye is safe and hasno adverse effects to the function of the eye when usedtopically. It distributes itself evenly into the depths of thecornea within 15 to 20 minutes. After 2 to 3 hours, theconcentration of fluorescein in the cornea falls as theconcentration in the anterior chamber rises. The dye leavesthe cornea by diffusion through the endothelium. 1, 4, 5 Afterthis period, the concentrations fall in a very constantmanner. The Fluorotron TM Master automatically calculatesthese values to determine aqueous flow.The most common risk factor in glaucoma is IOP, whichis determined by aqueous-flow rate, aqueous-outflow rate,and episcleral venous pressure. Understanding thesefactors that determine IOP could lead to a better understandingof the disease. In a study by Bloom and associates,differences in aqueous flow in adult eyes between races(white and black) were noted. 3 No reports, however, werepublished examining the aqueous-humor flow in Asianeyes.This study determined the rate of aqueous-humor flowin Filipino eyes using the Ocumetrics Fluorotron TM Masterfluorophotometer. Factors associated with aqueous humorflow and aqueous outflow were determined.METHODOLOGYThis study was conducted at the Sentro OftalmologicoJose Rizal of the University of the Philippines–PhilippineGeneral Hospital in accordance with the guidelines setby the Declaration of Helsinki. Informed consent wasobtained from all the subjects after a thorough explanationof the nature and possible risks and benefits of thestudy.Subjects were recruited from the Outpatient Eye Clinicof the Department of Ophthalmology and VisualSciences between January 2007 to October 2007. Patients18 years and older who were seen at the outpatient clinicunderwent basic ophthalmologic evaluation, includingcollection of demographic data; ocular, medical, surgical,and medication history; applanation tonometry (Haag-Streit); slitlamp biomicroscopy of the anterior segment;stereoscopic funduscopy; and gonioscopy employingstandard methodology. Excluded were patients withglaucoma; ocular hypertension or an IOP response tosteroids; diabetes mellitus; thyroid-related eye disease;intraocular infection; meibomian-gland dysfunction;dysfunctional-tear syndrome; lid abnormalities ordiseases; uveitis; retinal pathology; corneal abnormalitiessuch as neovascularization, opacities, or dystrophies;history of trauma or those who wore contact lenses orhad undergone any form of intraocular laser andincisional surgery.Those who fulfilled the inclusion criteria underwentadditional examinations such as ultrasonic pachymetry(Pocket II, Quantel Medical, France), A-scan (OTI Scan1000, Ophthalmic Technologies Incorporated, Canada),dilated-fundus examination using an indirect ophthalmoscope(Keeler Vantage), and fluorophotometry(Fluorotron Master) performed in the morning. Twopercentfluorescein dye (Fluorets, Chaurvin Pharmaceuticals,England) was instilled on the cul-de-sac threetimes, three drops every five minutes. The eye was washedwith balanced saline solution 15 minutes later to removePHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 57

the excess fluorescein. To ensure that the fluorescein inthe anterior chamber was in steady state with the cornea,fluorophotometric scans were made 4 hours after instillationof fluorescein. Three scans were made on each eyeevery 30 minutes for 2 hours. Data were collated usingthe fluorophotometer to arrive at a specific rate of aqueousflow and, with the determined IOP, the aqueous-outflowfacility as well.The following outcome measures were recorded: age,sex, IOP, central corneal thickness, anterior-chamber (AC)depth, anterior-chamber volume, rate of aqueous flow, andaqueous-outflow facility.Descriptive statistics including mean, standard deviationfor continuous variables, and percentage frequencydistribution for categorical data were obtained. NonparametricKruskal-Wallis analysis of variance was used todetermine the variation of aqueous-humor flow acrossspecified age groups due to the skewed age stratification.Statistical correlation between continuous variables wasperformed using Pearson moment product correlation(r):0 – 0.25 (or – 0.25) = little or no relationship, 0.25 – 0.50(or – 0.25 to – 0.5) = fair relationship, 0.50 – 0.75 ( or-0.50 to – 0.75) = moderate to good, and > 0.75 (or -0.75)= very good to excellent relationship. All tests of significancewere pegged at 0.05 alpha level of significance, 95%confidence interval, using Statistica version 1999.RESULTSOut of 957 patients examined, 37 were included in thestudy. A total of 74 eyes underwent fluorophotometry. Themean age of the study population was 46.6 ± 11.1 years(range 19 to 69), with the fourth decade having the mostcommon cluster (26 cases or 35%), followed by the fifthdecade (24 cases or 32 %), third decade (10 cases or13.5%), and the sixth decade (6 cases or 8%). There weremore females (40) than males (34).An equal representation of both eyes was seen. Thedifferent ocular parameters are shown in Table1. Themean rate of aqueous-humor flow was 2.78 ± 0.27 µL/min. Figure 1 shows an almost symmetric normal curve.The rates did not vary with the eye assessed nor withgender (Table 2). Similarly, no significant variation wasnoted with the flow rate across the decades of liferepresented (Table 2).Among all variables analyzed, a positive but fair relationshipwas seen with aqueous-humor flow and AC volumeand depth (r = 0.35, p = 0.002 and r = 0.36, p = 0.002)respectively. No statistical association was noted withpachymetry and age (Table 3).Aqueous-outflow facility was inversely and fairlycorrelated with pachymetry. (r = –32, p = 0.006). Noassociation was noted with age and AC volume and depth(Table 4).Table 1.Ocular parameters of the study population.CharacteristicEye examinedODOSIntraocular Pressure (mmHg)Mean ± SDRangePachymetry (µm)Mean ± SDRangeAnterior-Chamber Depth (mm)Mean ± SDRangeAnterior-Chamber Volume (µL)Mean ± SDRangeRate of Aqueous Flow (µL/min)Mean ± SDRangeAqueous Outflow Facility (µL/min)Mean ± SDRangeFrequencyFigure 1.20100Mean = 2.78 ± 0.27N = 74 eyesFrequency(n=74)Histogram of the aqueous-flow rate of the study population.373712.8 ± 2.49 – 18530.7 ± 27.8466 – 5923.1 ± 0.362.01 – 3.78209 ± 44.393 – 302.42.78 ± 0.272.01 – 3.430.74 ± 0.380.25 – 2.162.0 2.1 2.2 2.3 2.5 2.6 2.7 2.8 3.0 3.1 3.2 3.30 3 5 8 0 3 5 8 0 3 5 8uL/minDISCUSSIONFluorophotometry is a noninvasive method of determiningthe concentration of fluorescent tracers in livingocular tissues. 1 With the use of fluorescein as a traceradministered topically to the eye, aqueous-humor flowcan be measured.Aqueous-humor flow has been said to peak in themorning, slightly decrease in the afternoon, and is lowestduring sleep. These changes throughout the day reflect abiologic pattern. The mean rate of aqueous-humor flowbetween 8 in the morning and noon is 2.97 ± 0.77 uL/min. The normal rate is 1.5 to 4.5 uL/min. 6 In this study,58 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Table 2. Comparison of fluorophotometric measurements ofaqueous-humor flow rate across different parameters.CharacteristicEye examinedOD (n=37)OS (n=37)SexMale (n=34)Female (n=40)Age (Decade)20 th (n=8)30 th (n=10)40 th (n=26)50 th (n=24)60 th (n=6)Significant difference if p-value is

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYORIGINAL ARTICLE– DECEMBER 2007Krishlex G. Gruezo, MD 1Paolo Antonio S. Silva, MD 1Patricia M. Khu, MD, MS 1, 2Rafael M. Valenzuela, MD 2Yasmine C. Ronquillo, MD 21Department of Ophthalmology and VisualSciences and Sentro Oftalmologico Jose RizalUniversity of the Phillippines–PhilippineGeneral HospitalManila, PhilippinesEfficacy of intraoperativesubconjunctival triamcinoloneacetonide as antifibrotic agentin filtration surgery2Institute of OphthalmologyUniversity of the Phillippines–NationalInstitutes of HealthManila, PhilippinesABSTRACTObjectiveThis study determined the effects of administering a single dose (4 mg) ofintraoperative subconjunctival triamcinolone acetonide (TA) on the activity/proliferation of conjunctival fibroblasts in albino rabbits undergoing filtrationsurgery.MethodsAn experimental animal study was performed to compare the effects onfiltration surgery of a single, 4-mg subconjunctival TA injection with balancedsalt solution (BSS) and mitomycin-C (MMC, 0.4mg/mL).Correspondence toKrishlex G. Gruezo, MDDepartment of Ophthalmology and Visual SciencesSentro Oftalmologico Jose RizalUniversity of the Philippines–Philippine General HospitalTaft Avenue, Ermita1000 Manila, PhilippinesTelephone : +63-2-3022486Email : krishlex@yahoo.comPresented at the annual meeting of the PhilippineAcademy of Ophthalmology, December 2007.No financial assistance was received for this study.ResultsA single, 4-mg dose of intraoperative subconjunctival TA prolonged theaverage bleb survival to 14.7 days versus 11 days with BSS, and 19.8 days withMMC. Intraocular pressures (IOP) were all significantly reduced on the firstpostoperative day. Mean IOP was lower with TA than with BSS during the firstweek postoperatively, while IOP reduction with MMC extended beyond thetenth postoperative day. Bleb height postoperatively was not different amongthe groups, except on postoperative day 2 when TA had significantly higherbleb height than the other 2 groups. Mean fibroblast counts for the 3 treatmentgroups were not statistically different at the time of bleb failure.ConclusionA single, 4-mg dose of triamcinolone acetonide given subconjunctivally inrabbit eyes can delay wound healing in the early period after filtration surgery.Keywords: Triamcinolone acetonide, Filtering bleb, Filtration surgery, Wound healing, GlaucomaThe authors have no proprietary or financial interest inany product used or cited in this study.PHILIPP J OPHTHALMOL 2007; 32(2): 60-65© PHILIPPINE ACADEMY OF OPHTHALMOLOGY60 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

THE PURPOSE of glaucoma filtration surgery is tobypass the pathological obstruction of the outflowchannels of the eye. It lowers the intraocular pressure(IOP) by creating an opening between the anteriorchamber and the subconjunctival space for drainage ofaqueous humor from the eye. It is generally thought thatvision is preserved in glaucomatous eyes when pressure iskept at a lower level than that at which damage to theoptic nerve has occurred. 1A major risk of glaucoma filtration surgery is obstructionof the surgical site where drainage of aqueous humoroccurs postoperatively. This obstruction is most commonlydue to the normal ocular-wound-healing process, 2 whichis a complex and time-limited series that begins whentissue is injured in surgery. A complex cascade of interrelatedevents that include inflammation, extravasationof intravascular components, migration and proliferationof fibroblasts, extracellular matrix deposition, and scarformation occurs 3 —and the result is formation of scartissue which ultimately blocks the passage of aqueoushumor from the surgical site.Modulation of the wound-healing process to preventexcessive fibroblast proliferation and scar formation canplay a major role in improving the outcome of glaucomafiltering surgery. 4 Antimetabolites that can inhibit DNAor RNA replication, cell division, protein synthesis, andfibroblast proliferation are used as adjunctive therapy toprevent excessive scar formation in glaucoma surgery.Commonly used agents are mitomycin-C (MMC) and5-Flurouracil (5–FU), which have been shown effective5, 6, 7in inhibiting fibroblast formation in vitro and in vivo,especially in those at high risk for failure such as in eyeswith previous ocular surgeries, in young patients, and inuveitic and neovascular glaucoma. In addition, corticosteroidsare routinely used to reduce inflammation inglaucoma surgery. The reason for this is not clear but it isgenerally perceived that inflammation induces fibrosis,which in turn increases scar formation. Hence, use of anyform of steroids to decrease ocular inflammation postoperativelyshould theoretically decrease the scarring associatedwith the surgery.Previous studies reported an improvement in the successrate of trabeculectomy in primary open-angle glaucoma(POAG) and primary angle-closure glaucoma (PACG)with the use of topical corticosteroid and no additionalbenefit with the use of systemic steroids. 8 Others thatstudied the effect of TA given subconjunctivally near thetarget tissue a few days before the filtering surgery in highriskglaucoma cases showed moderate success with 14 of15 eyes having IOP of 18 mm Hg or less (mean 12.4 ± 4.6)and three requiring additional antiglaucoma medications.9 The authors concluded that there were noadditional risks of the subconjunctival TA to the surgicalprocedure, but the small sample and lack of randomizationmade the interpretation of the results difficult.Another study found that some eyes given subconjunctivalTA induced dramatic fragility of the conjunctiva, microhemorrhagesand dense fibrous reaction surrounding thedrug depot leading to closure of the trabeculectomy flap. 10Whether steroids inhibit fibroblast formation bydecreasing inflammation intraocularly is not known. Inparticular, whether the subconjunctival injection of asteroid depot like TA near the bleb can decrease fibroblastformation needs clarification. This will involve examiningthe bleb histologically and comparing its use with a knownantifibrotic agent such as MMC.This study determined the effects of administering asingle dose (4 mg) of intraoperative subconjunctival TAon the activity/proliferation of conjunctival fibroblasts inalbino rabbits undergoing filtering surgery. The effectswere measured in terms of IOP reduction, bleb height,and days to bleb failure (bleb survival).METHODOLOGYAn experimental study was conducted involving 12albino rabbits weighing between 1 to 1.5 kilograms. Allrabbits underwent preoperative eye examination with ahand-held slitlamp biomicroscope.General anesthesia was induced with intramuscularinjection of ketamine given at 50 mg/kg. The filteringprocedure adopted was as described by Lee et al: 11 Afterthe lid speculum was inserted, an 8-0 vicryl traction suturewas placed at the superior cornea. A limbal-based conjunctivalflap was created superiorly with Wescott scissors andcarried up to the limbus. Tenon’s tissue overlying thesclera was excised. A limbal groove was fashionedsuperiorly with blade #15 and extended to clear cornea.The anterior chamber was entered and a 1 mm x 3 mmblock of scleral tissue and trabecular meshwork was excisedwith Vannas scissors. The edges of the posteriorsclerectomy were cauterized as needed and a peripheraliridectomy was performed. The conjunctival incision wasclosed with running 8-0 vicryl sutures. Normal salinesolution was injected to the anterior chamber throughthe paracentesis site to inflate the bleb and confirm thepatency of the sclerostomy. The bleb was inspected toensure no leakage. One drop of atropine sulphate 1%and erythromycin ophthalmic ointment were instilled atthe conclusion of the surgery. Postoperative medicationsincluded topical moxifloxacin at 4 times a day andatropine eye drops once daily.The rabbits were randomly allocated to 3 treatmentgroups: Group 1 (control) received balanced salt solution(BSS, Alcon, Forth Worth, Texas); Group 2 (TA) received4 mg subconjunctival triamcinolone acetonide (KenacortA, Squibb, Agnani, Italy); Group 3 (MMC) received 0.4PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 61

mg/ml mitomycin-C (Mitomycin C, Kyowa Hakko KogyoCo. Ltd., Tokyo, Japan). A Weck-Cel sponge measuring 4mm x 1 mm soaked in either BSS or 0.4mg/ml MMC wasgiven to the respective treatment groups. This sponge wasplaced between the conjunctiva and the sclera over theplanned filtration site for 1 minute. This was repeated 3times with freshly soaked sponges for a total of 4 minutesof exposure. The area was then thoroughly irrigated with30 ml of sterile distilled water prior to entry to the anteriorchamber. 0.1 ml of a 40mg/ml suspension of triamcinoloneacetonide was injected posterior to the bleb inGroup 2 at the conclusion of the surgery. All surgerieswere done by the same surgeon.An observer, masked as to the intraoperative treatmentassignments of the groups, made all the postoperativeobservations and measurements. The IOP readings wereobtained with a tonopen (Medtronic Solan Tonopen XL)after anesthetizing the cornea with 1% proparacaine. Thelids were retracted gently without applying pressure onthe globe. The IOPs recorded were the mean of threereadings within 2 mm Hg of each other that achieved 5%level of reliability. The bleb height was graded as 0 forflat, 1 for low, 2 for moderate, and 3 for high. The parameterswere recorded on days 1, 3, 5, 7 and then every 3days until no surviving bleb remained. The eyes of therabbits were examined twice weekly with fluorescein anda cobalt blue light for the presence of bleb leakage.Bleb failure is said to have occurred when any of thefollowing was present: (1) when IOP equaled or surpassedthe baseline IOP recorded prior to surgery; (2) when theIOP equaled or surpassed that of the fellow unoperatedeye; or (3) when the bleb height was recorded as 0 or flat(bleb disappearance). The time to bleb failure wasrecorded in days.The rabbits were euthanized once bleb failure occurredby injecting intracardiac pentobarbital. The eyes wereremoved, taking care not to disturb the superior conjunctiva,and fixed in 10% buffered formalin solution. Afterat least 48 hours in fixative, the bleb was dissected fromthe surrounding tissues. A cross-section of the bleb thatincluded the corneoscleral limbus and the peripheralcornea was obtained and processed in paraffin. Onceembedded in paraffin blocks, sections were cut and placedon slides and stained with hematoxylin eosin.The slides were examined under a light microscopeand photomicrographs were obtained. Fibroblast-cellcounts were done at sampled sites nearest the corneoscleraljunction and closest to the epithelium. Twoophthalmic pathologists, masked as to the treatmentassignments, performed the cell counts on the photomicrographsof the sampling sites.All the rabbits were handled in accordance with theARVO resolution on the use of animals in research.Outcomes measured were IOP reduction, days tobleb failure, bleb appearance, and fibroblast counts ofthe different groups. Comparison of values across daysof observation within each group was carried out usingWilcoxon signed-rank test. Mann-Whitney U test wasused to compare the two groups across each period ofobservation. Categorical outcomes were comparedacross groups using chi-square. Kaplan-Meier survivalanalysis was performed to determine the mean andmedian survival time of the blebs in each category. Logranktest was done to determine the statistical significanceof the three survival curves. All analyses wereperformed at 0.05 level of significance and 95%confidence interval using Statistical Package for theSocial Sciences (SPSS ver. 14).RESULTSA total of 12 eyes from 12 rabbits were analyzed. Thebaseline IOP of the operated eye, the nonoperatedcontralateral eye, and bleb height at postoperative day 1are summarized in Table 1. Baseline IOP and bleb heightat postoperative day 1 were homogeneous betweentreatment groups.BSS versus TAThere was no statistically significant difference in themean change (mean drop) in IOP between days ofmeasurements within groups. In the BSS group, a dropin mean IOP from 15 to 7.7 mm Hg was noted on thefirst postoperative day, which was statistically significant(p = 0.002). No significant differences were seen in IOPchanges from day 1 to 3 (p = 0.07), 3 to 5 (p = 0.72), 5to 7 (p = 0.11), 7 to 13 (p = 0.18) and 13 to 16 (p = 0.18)(Figure 1).In the TA group, a large drop in mean IOP was observed(mean 14.7 mm Hg to 6.5 mm Hg) which was statisticallysignificant (p = 0.02). As in the BSS group, no significantdifferences were noted across the other days (day 1 to 3,p = 0.068; day 3 to 5, p = 0.71; day 5 to 7, p = 0.10; and (day7 to 13, p = 0.18).Between the two groups, a significant difference in IOPwas observed on the third postoperative day. The TAgroup had significantly lower mean IOP than the BSSgroup (5.9 ± 1.8 versus 10.5 ± 2.7 respectively).BSS versus MMCIn the MMC group, a statistically significant drop inmean IOP was noted from baseline to the first postoperativeday (16.5 to 4.6 mm Hg, p = 0.002). Compared withthe BSS group, no significant difference was noted in themean IOP at day 1 and 3 (p = 0.09), day 3 and 5 (p = 0.33),day 5 and 7 (p = 0.56), day 7 and day 10 (p = 0.34), and atday 13 and day 16 (p = 0.11) (Figure 1).62 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

MMC versus TAIn the MMC group, a statistically significant drop inmean IOP was noted from baseline to the first postoperativeday (16.5 to 4.6 mm Hg, p = 0.002). No significantdifferences were observed in the succeeding changes inthe IOP measurements from day 1 to 3 (p = 0.46), 3 to 5Table 1. Baseline intraocular pressure and bleb height (N = 12).CharacteristicIOP (OD)Mean ± SDMedianRangeIOP (OS)Mean ± SDMedianRangeBleb Grade 3LowMediumHighTable 2. Conjunctival fibroblast counts among treatment groups.Fibroblast CountMean ± SDRangeCut-off value< 36> 36BSS(n = 4)15 ± 0.9614.814 – 16.315.4 ± 2.615.113 – 18.3220BSS(n = 4)31 ± 820 – 3622Triamcinolone(n = 4)14.7 ± 0.9514.514 – 1615.7 ± 0.9515.515 – 171211Significant p value if

Bleb SurvivalThe 12 eyes were observed for a total of 22 days. Theshortest mean survival time of the blebs observed withthe BSS group was 11 days (95% CI 6.4–15.6), while themedian survival time was 10 days (95% CI 2.2–17.8). Thiswas followed by the TA group with an average of 14.7 days(95%CI 7.7–19) and median of 13 days (95% CI 8–18).The MMC group had the longest survival time with a meanof 19.8 days (95% CI 17–22) and median of 19 days (95%CI 15–23). The mean days of survival, however, were notstatistically different across the three groups (p = 0.08)(Figure 3). There was also no statistically significantdifference in the survival distributions of the three drugs(log-rank test = 4.74, p = 0.094).Fibroblast countsOf the 12 eyes enucleated, one was not satisfactory forhistopathologic examination. Mean fibroblast countsobtained from 4 tissue sections were higher in thetriamcinolone group, followed by the MMC group, andthe BSS group. However, these differences were notstatistically significant (p = 0.57).Based on the mean counts of fibroblasts, no significantdifference in the proportion above and below the meancut-off value was noted among the three groups (p =0.88).Fibroblast counts were statistically lower in thenonoperated eyes than in the BSS, triamcinolone, andMMC groups (p < 0.001).DISCUSSIONThe wound-healing response in both rabbits andmonkeys is known for its vigor and completeness ascompared to humans, with uniform closure of routinesclerostomies by postoperative day 14. 12 This study inrabbit eyes showed similar findings in terms of averagesurvival time of the filtering blebs. Survival time was 11days for the BSS group, 14.7 days for the triamcinolonegroup, and 19.8 days for the mitomycin C group.A single 4-mg dose of intraoperative subconjunctivalTA prolonged the bleb survival by 3.7 days on averagecompared to the BSS group in a rapidly healing rabbitmodel. Blebs treated with MMC had longer survival meantime of 19.8 days, 5 days longer than the triamcinolonetreatedgroup, showing that MMC prolongs bleb survival.This is consistent with findings in other studiesdemonstrating that MMC is an antifibrotic agent. 13-14 Totaldays of survival were not statistically different across thethree groups (p = 0.08) but the trend was there.The baseline characteristics of the 3 groups were similar,with similar reduction in IOP and bleb height on the firstpostoperative day. However, the mean IOP 1 weekpostoperatively was lower for the TA group than the BSSgroup, especially on the third postoperative day, indicatingthat triamcinolone somehow modulated the woundhealingresponse. The MMC-treated group generally hada lower IOP compared with the BSS group. IOP reductionby MMC was seen beyond the 10th postoperative day,indicating stronger antifibrotic effects than TA.No significant difference was seen in bleb height amongthe groups, except on postoperative day 2 when triamcinolonehad significantly higher bleb than the other 2groups. This implied that triamcinolone may delay ormodify wound healing in the early postoperative periodbut was not strong enough to sustain the effect. Meanfibroblast counts for the 3 treatments groups were notstatistically different at the time of bleb failure.Bleb survival was longest with MMC, followed bytriamcinolone. Survival analysis showed that 50% oftriamcinolone-treated blebs sur vived by the 10thpostoperative day compared with BSS, and 50% of MMCtreatedbleb survived by the 20th postoperative daycompared with triamcinolone, indicating that triamcinolonewas intermediate compared with MMC and BSS, andthat its antifibrotic effect was much less than that of MMC.In the triamcinolone group, 1 bleb failed by day 7 and 2blebs failed by day 13.Only a few drugs have been used clinically to influenceor modify the wound-healing process following filteringsurgery. Corticosteroids applied in the early postoperativeperiod have an antifibroblastic potential and theireffectiveness has been shown in clinical studies. 15 Topicalsteroids are commonly used to decrease ocular inflammationto avoid related complications such as significantiritis and choroidal detachment, especially in the immediatepostoperative period. Direct application of anantimetabolite or antifibrotic agent intraoperatively hasadvantages over postoperative applications. These includedelivery to the tissues at the very start of the scarringprocess, direct delivery to the desired tissues at higherconcentrations, and the minimization of the exposure tothe drug of other tissues such as the corneal epithelium. 12To be more effective at modulating the wound healing,the steroid is better given subconjunctivally as a depot sothat continuous drug delivery to the site is assured.In summary, a single, 4-mg dose of triamcinoloneacetonide given subconjunctivally in rabbit eyes has thepotential of delaying or inhibiting wound-healing responsein the early postoperative period following filtrationsurgery.References1. Lee D. Antifibrosis agents and glaucoma surgery. Invest Ophthalmol & Vis Sci 1994;35: 3789-3791.2. Lee D. Antiproliferative therapy for filtration surgery. In: Epstein, David et al. eds.Chandler and Grant’s Glaucoma, 4th ed. Baltimore: Williams & Wilkins, 1997; chap.62, p 527-528.64 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

3. Skuta GL, Parrish RK Jr. Wound healing in glaucoma filtering surgery. SurvOphthalmol 1987; 32: 149-170.4. Addicks EM, Quigley H, Green WR, Robin l. Histologic characteristics of filteringblebs. Arch Ophthalmol 1983; 101: 795-798.5. Pasquale LR, Thibault D, Dorman-Pease M, et al., Effect of topical mitomycin C onglaucoma filtration in monkeys. Ophthalmology 1992; 99: 14-18.6. Pinilla I, Larrosa JM, Polo V, Honrubia FM. Subconjunctival injection of low dosesof mitomycin C: effect on fibroblastic proliferation. Ophthalmologica 1998; 212: 306-309.7. Khaw PT, Doyle JW, Sherwood MB, et al., Prolonged localized tissue effects from5-minute exposures to fluorouracil and mitomycin C. Arch Ophthalmol 1993; 111:263-267.8. Starita RJ, Fellman RL, Spaeth GL, et al. Short- and long-term effects ofpostoperative corticosteroids on trabeculectomy. Ophthalmology 1985; 92: 938-946.9. Giangiacomo J, Dueker D, Aldenstein E. The effect of preoperative subconjunctivaltriamcinolone administration on glaucoma filtration: trabeculectomy followingsubconjunctival triamcinolone. Arch Ophthalmol 1986; 104: 838-841.10. Ball S. The effects of triamcinolone acetonide. correspondence. Arch Ophthalmol1986; 104: 1749-1750.11. Lee DL, Flores R, Anderson PJ. Glaucoma filtration surgery in rabbits usingbioerodible polymers and 5-FU. Ophthalmology 1987; 94: 1523-1530.12. Doyle W, Sherwood MB, Khaw PT, et al. Intraoperative 5-fluorouracil for filtrationsurgery in the rabbit. Invest Ophthalmol & Vis Sci 1993; 34: 3313-3319.13. Khaw PT, Doyle JW, Sherwood MB, et al., Effects of intraoperative 5-FU or mitomycinC on glaucoma filtration surgery in the rabbit. Ophthalmology 1993; 100: 367-372.14. Bergstrom J, Wilkinson WS, Skuta GL, et al. The effects of subconjunctival mitomycinC on glaucoma filtration surgery in rabbits. Arch Ophthalmol 1991; 109: 1725-1730.15. Holger M, Chevez-Barrios P, Feldman RM, Lieberman MW. Suramin inhibits woundhealing following filtering procedures for glaucoma. Br J Ophthalmol 1998; 82: 812-820.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 65

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYORIGINAL ARTICLE– DECEMBER 2007Harvey S. Uy, MD 1,2Miguel D. de Leon, MD 1, 3Pearl T. Villalon, MD 11Sentro Oftalmologico Jose RizalUniversity of the Philippines–PhilippineGeneral HospitalManila, Philippines2Asian Eye InstituteMakati, PhilippinesComparison of two techniquesfor perfluoropropane gas fillin the management of retinaldetachment3Cagayan de Oro Medical CenterCagayan de Oro, PhilippinesABSTRACTObjectiveThis study compared the efficacy and safety of fixed-concentration (FC)and fixed-volume (FV) methods of perfluoropropane (C3F8) gas fill followingretinal-detachment surgery.MethodsWe conducted a prospective, interventional, randomized clinical trialinvolving consecutive eyes with retinal detachment and proliferativevitreoretinopathy (Grade C) that underwent combined pars plana vitrectomy,lensectomy, panretinal photocoagulation, perfluoropropane gas (C3F8)/fluidexchange, and scleral buckling. Ten eyes underwent C3F8/air exchange using50 cc of 20% C3F8 (FC method) and 10 eyes received a single pars plana injectionof 1 cc of 100% C3F8 (FV method). The main outcome measures includedpostoperative gas volumes (GV), intraocular pressure (IOP), and retinalreattachmentrate. The mean follow-up period was 10 weeks.ResultsOn weeks 0, 2, 4, 8, the mean GV were 3%, 7%, 50%, and 9% for the FCgroup and 94%, 4%, 49%, and 13% for the FV group. One eye from eachgroup developed IOP elevation above 30 mm Hg. There were no significantdifferences in GV and IOP between the two groups during the 10 weeks offollow-up. The retinal reattachment rate was 90% for both groups.Correspondence toHarvey S. Uy, MDAsian Eye Institute9F Phinma Plaza Bldg., Rockwell Center1200 Makati City, PhilippinesTelephone : +632-8982020Fax : +632-8982002E-mail : harveyuy@yahoo.comNo financial assistance was received for this study.ConclusionFC and FV methods of C3F8 gas fill are comparable in terms of postinjectionGV, IOP, and retinal-reattachment rates.Keywords: Perfluoropropane gas, Retinal detachment, Retinal-reattachment surgery, ProliferativevitreoretinopathyThe authors have no proprietary or financial interest inany product used or cited in this study.PHILIPP J OPHTHALMOL 2007; 32(2): 66-69© PHILIPPINE ACADEMY OF OPHTHALMOLOGY66 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

PERFLUOROPROPANE (C3F8) is an expandingfluorinated hydrocarbon gas used during vitreoretinalsurgery to provide prolonged internal retinal tamponade. 1, 2C3F8 has been demonstrated to increase the rate of retinalreattachment in the management of rhegmatogenousretinal detachment (RRD) complicated by proliferativevitreoretinopathy (PVR). 3, 4 The primary complication ofC3F8 use is intraocular-pressure (IOP) elevation that maylead to glaucomatous nerve damage. 5 To prevent thispotentially sight-threatening event, surgeons attempt toachieve a nonexpanding concentration of 12 to 20% C3F8by either passing a large-volume infusion of the nonexpandingconcentration through the air-filled vitreouscavity (fixed-concentration (FC) method) or by injectinga finite volume of 100% C3F8 that, when mixed with thevolume of air present in the vitreous, produces anonexpanding concentration (fixed-volume (FV)method). 3, 6This study compared the safety and efficacy of FC andFV methods of achieving gas tamponade for retinal reattachmentsurgery. The effectiveness measures were reattachmentrate, gas volume (GV) and longevity, while themain safety measures included postoperative IOP andcomplication rate.METHODOLOGYTwenty eyes of 20 consecutive patients with RRD andPVR (grade C) seen from January 1 to December 31,2000 at the Retina Service of the Department of Ophthalmologyand Visual Sciences, Philippine General Hospitalwere included. We excluded patients with a history ofglaucoma, ocular hypertension, uveitis, and prior retinasurgery. All eyes under went combined pars planavitrectomy, lensectomy, panretinal photocoagulation,perfluoropropane gas (C3F8)/fluid exchange, andscleral buckling performed by a single surgeon (HSU)under periocular anesthesia with sedation. Informedconsent was obtained from all patients. The studyprotocol was approved by the Institutional Review Boardof the University of the Philippines College of Medicine.Prior to sclerotomy closure, the eyes were randomizedby toss coin to one of two groups. In the FC group, one ofthe sclerotomy ports was first closed with vicryl 7-0 sutures.A 50-ml syringe containing 20% C3F8 gas was preparedby mixing 10 ml of 100% C3F8 with 40 ml of filtered roomair. Approximately 45 ml of 20% C3F8 was slowly injectedthrough the infusion cannula into the eye while intraocularair was expelled through the remaining unclosedsclerotomy. This allowed for exchange of air with 20%C3F8. The remaining sclerotomy was closed followed byremoval of the infusion line and closure of the infusionsclerotomy. The IOP was checked using a sterile Schiotztonometer. If the eye was hypotonic (IOP 20% by the end of week 8. By week10, only one patient per group had observable gas bubbles.The mean IOP from week 0 to week 10 are shown inTable 2. A similar pattern of IOP measurements waspresent in FC and FV groups (Figure 2). The highest IOPswere measured on week 0 (postoperative day 1): the meanFC IOP was 18 ± 7 mm Hg (range, 8 to 32) while the meanFV IOP was 18 ± 8 mm Hg (range, 7 to 31). Only onepatient from each group (10%) received medical treatmentfor IOP ≥ 30 mm Hg. By week 3, none of the eyes inboth groups had IOP > 22 mm Hg. None of the eyesneeded removal of gas to lower IOP to safe levels. No casesof hypotony were observed in either group.Nine of 10 eyes in each group achieved successful reattachmentafter surgery. Other than IOP rise, there wereno other complications observed in both groups.DISCUSSIONWe compared 2 techniques of intraocular gas fill forinternal retinal tamponade and found both methods to besimilarly safe and effective. The FC method flushes out air(0% C3F8) and replaces it with a nonexpanding concentrationof C3F8. This technique may minimize the risk ofPHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 67

overfilling and IOP rise; however, FC method is more costlyas a greater volume of 100% C3F8 is used to prepare theC3F8/air mixture. The FC method uses 10 ml to prepare50 ml of 20% C3F8/air while the FV method uses only 1ml. The potential for gas leak from the open sclerotomyport or infusion line, used to vent the air/C3F8 mixture,may result in underfilling and insufficient gas tamponade.The FV method is more efficient in its use of C3F8 andis faster to perform. There is less potential for underfillingsince all the ports are closed when injection is done. Thereis a greater risk for postinjection IOP rise if the eye volumeis smaller than average. However, careful determinationof intraoperative IOP and intraoperative withdrawal of gasor aqueous can adjust the intraoperative GV and preventunwanted postoperative IOP rise.The duration of gas tamponade affects the success ratefor retinal reattachment. Compared to short-acting agentslike sulfur hexafluoride (SF6), long-acting gases like C3F8have been shown to increase the success rate for repair ofcomplex retinal detachments. 4, 7 A 0.3-ml gas bubbletamponades 90 degrees of arc while 0.8-ml tamponades120 degrees of arc. 9 Because tamponade effectiveness isinfluenced by GV, longer and larger GV during thepostoperative time period can improve the chances forsuccessful reattachment. However, longer gas duration alsoresults in prolonged visual recovery and greater risk ofIOP rise.A longer gas duration also extends the postoperativeprohibitive period for entering high altitudes where loweratmospheric pressures may cause expansion of intraocularC3F8 GV with consequent IOP rise and potentiallyblinding, pressure-induced cessation of retinal circulation.Gas Volume (%)1009080706050403020100Weeks after injectionFCFVFigure 1. Mean C3F8 volumes (%) over time (weeks) using fixed-concentration (FC) andfixed-volume (FV) methods of gas fill after pars plana vitrectomy and C3F8/air exchange.Mean IOP (mmHg)20181614121086420Weeks after surgeryFCFVFigure 2. Mean intraocular pressures (mmHg) over time (weeks) using fixed-concentration(FC) and fixed-volume (FV) methods of gas fill after pars plana vitrectomy and C3F8/airexchange.Table 1. Mean C3F8 volumes (%) over time (weeks) using fixed-concentration (FC) and fixed-volume (FV) methods of gas fill after pars plana vitrectomyand C3F8/air exchange.W0 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10FCFVp 1CI 2 93 ± 894 ± 110.82-10.0486 ± 1387 ± 140.87–13.6977 ± 1074 ± 200.68–11.8663 ± 1659 ± 200.63–13.0250 ± 1549 ± 180.89–14.5738 ± 1637 ± 150.89–13.5727 ± 1332 ± 150.44–18.1918 ± 922 ± 110.36–13.449 ± 713 ± 90.29–11.576 ± 77 ± 90.78–8.571 ± 33 ± 90.51–8.38.04 11.69 17.86 21.02 16.57 15.57 8.19 5.44 3.57 6.57 4.31p value, computed by t-test2confidence interval, computed by t-testTable 2. Mean intraocular pressures (mm Hg) over time (weeks) using fixed-concentration (FC) and fixed-volume (FV) methods of gas fill after parsplana vitrectomy and C3F8/air exchange..FCFVp 1CI 2W018 ± 718 ± 81.0-7.067.06W116 ± 817 ± 60.76-7.645.641p value, computed by t-test2confidence interval, computed by t-testW212 ± 416 ± 60.1-8.790.79W312 ± 414 ± 40.28-5.761.76W413 ± 414 ± 40.58-4.762.76W513 ± 613 ± 41.0-4.794.79W612 ± 414 ± 30.22-5.321.32W713 ± 514 ± 40.63-5.253.25W812 ± 313 ± 40.53-4.322.32W913 ± 512 ± 40.63-3.255.25W1013 ± 412 ± 50.63-3.255.2568 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

It is believed that air travel may be safe when the GV is20% or less. This study suggests that almost all patientsmay expect to travel by the eighth week after surgery. 10The nonexpanding concentration of C3F8 has beenreported to be between 12 to 20%. 2, 6 The half-life of C3F8greatly depends on this initial concentration. The halflifeof 20% C3F8 has been reported to be 12.5 ± 1.1 days. 9However, studies have demonstrated wide, interindividualvariations in GV disappearance rates. 11 The results of thisstudy demonstrate these wide variations in GV longevityand the need for careful postoperative observation whenusing intraocular gases.In summary, use of perfluoropropane is a very effectivetool for the repair of rhegmatogenous retinal detachment.Both FC and FV methods were comparable in terms ofGV and gas duration, postoperative IOP, and retinalreattachment rate. With proper precautions andtechnique, an injection of 1.0 ml of 100% C3F8 into anair-filled eye may be a safer, less costly, and equally effectivemethod of achieving retinal tamponade than a largervolume exchange of 20% C3F8.References1. Lincoff H, Mardirossian J, Lincoff A, et al. Intravitreal longevity of threeperfluorocarbon gases. Arch Ophthalmol 1980; 98: 1610-1611.2. Chang S, Lincoff HA, Coleman DJ, et al. Perfluorocarbon gases in vitreous surgery.Ophthalmology 1985; 92: 651-656.3. Bonnet M, Santamaria E, Mouche J. Intraoperative use of pure perfluoropropanegas in the management of proliferative vitreoretinopathy. Graefes Arch Clin ExpOphthalmol 1987; 225: 299-302.4. Silicone Study Group. Vitrectomy with silicone oil or perfluoropropane gas in eyeswith severe proliferative vitreoretinopathy: results of a randomized clinical trial.Silicone Study Report 2. Arch Ophthalmol 1992; 110: 780-792.5. Barr CC, Lai MY, Lean JS, et al. Postoperative intraocular pressure abnormalitiesin the Silicone Study. Silicone Study Report 4. Ophthalmology 1993; 100: 1629-1635.6. Han DP, Abrams GW, Bennett SR, Williams DF. Perfluoropropane 12% versus 20%:effect on intraocular pressure and gas tamponade after pars plana vitrectomy. Retina1993; 13: 302-6.7. Silicone Study Group. Vitrectomy with silicone oil or sulfur hexafluoride gas in eyeswith severe proliferative vitreoretinopathy: results of a randomized clinical trial.Silicone Study Report 1. Arch Ophthalmol 1992; 110: 770-779.8. Parver LM, Lincoff H. Geometry of intraocular gas used in retinal surgery. ModProbl Ophthalmol (Basel) 1977; 18: 338-343.9. Thompson JT. The absorption of mixtures of air and perfluoropropane after parsplana vitrectomy. Arch Ophthalmol 1992; 110: 1594-1597.10. Mills MD, Devenyi RG, Lam WC, et al. An assessment of intraocular pressure risein patients with gas-filled eyes during simulated air flight. Ophthalmology 2001;108: 40-44.11. Meyers SM, Ambler JS, Tan M, et al. Variation of perfluoropropane disappearanceafter pars plana vitrectomy. Retina 1992; 12: 359-363.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 69

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYORIGINAL ARTICLE– DECEMBER 2007James Edward D. Herrera, MDRuben Lim Bon Siong, MDInternational Eye InstituteSt Luke’s Medical CenterQuezon City, PhilippinesA prototype xeroscope for thenoninvasive measurementof tear-breakup timeABSTRACTObjectiveTo develop a noninvasive method for measuring tear-breakup time (TBUT)using readily available materials.MethodsA prototype xeroscope was made using acetate with concentric rings printedon it, and cut to a diameter of 3.6 cm. The cut-out was attached to the front ofan ordinary flashlight and reflected onto the patient’s cornea. Viewed througha slitlamp, the interval between a complete blink and the appearance ofrandomly distributed progressive distortion on the concentric rings wasmeasured in seconds and designated as noninvasive breakup time (NIBUT).The standard method of using fluorescein dye for TBUT evaluation wasperformed for comparison. The prototype was tested on 50 adult patientswho had no apparent ocular pathology except error of refraction and cataract.Measurement of NIBUT was done for both eyes followed by TBUT. Resultswere subjected to linear-regression analysis.ResultsA total of 50 subjects (100 eyes) were included in the study. The meanNIBUT was 24.25 seconds and 25.20 seconds for the right and left eyes respectively.The mean TBUT was 18.23 seconds and 18.96 seconds for the right andleft eyes respectively. Taken together, the mean NIBUT for both eyes was 24.71seconds (range 9.44 to 49.03); and the mean TBUT was 18.63 seconds (range4.28 to 41.65). The mean difference between NIBUT and TBUT was 6.09seconds. There was a linear correlation between NIBUT and TBUT for boththe right and left eyes. There was also a significant correlation between theright and left eyes for both NIBUT alone and TBUT alone. Regressioncorrelation analysis revealed that TBUT is positively correlated with NIBUT(r = 0.994, p < 0.0001).Correspondence toJames Edward D. Herrera, MDInternational Eye InstituteSt. Luke’s Medical CenterE. Rodriguez Avenue1000 Manila, PhilippinesTelephone : +63-2-7275546E-mail : jademd@yahoo.comNo financial assistance was received for this study.ConclusionNIBUT measurement using the prototype xeroscope has a positivecorrelation with the standard TBUT measurement and may be a goodalternative for measuring tear-film stability without disturbing normalphysiology.Keywords: Tear-breakup time, Tear film, Lacrimal glands, XeroscopeThe authors have no proprietary or financial interest inany product used or cited in this study.PHILIPP J OPHTHALMOL 2007; 32(2): 70-75© PHILIPPINE ACADEMY OF OPHTHALMOLOGY70 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

THE TEAR film is a complex composite whose componentshave multiple sources, which include the lacrimalglands, meibomian glands, goblet cells, and accessorylacrimal glands of the ocular surface. Its functions includelubrication, protection from disease, and provision ofnutrition for the cornea. It also plays a critical role in theoptical properties of the eye. 1It is has three major components, namely, lipid,aqueous, and mucin. The condition of the lipid layer determinesthe predisposition of the tear film for rupture. Themiddle aqueous layer contains soluble mucin and proteinsthat turn into a hydrated gel essential for maintaininghigh-quality vision and ocular comfort. 1Maintaining a healthy and comfortable ocular surfacerequires stability and constant renewal of the preoculartear film. Eye disorders that disturb tear volume, composition,and hydrodynamic factors can threaten this stability.An unstable tear film is the hallmark of various dry-eyestates. 1 Patients with mild tear-film instability complain ofannoying eye irritations. Those with severe tear-film instabilitymay experience constant and disabling eye irritation,and develop ocular-surface epitheliopathy.Measurement of tear-breakup time (TBUT) usingfluorescein dye is the most widely used clinical assessmentof tear-film stability. Originally described by Norn as“wetting time,” this test involves observing the cornea aftera complete blink, and measuring the interval from thatblink to the first evidence of a discontinuity in the tearfilm. This is most easily visualized by instilling 0.1% sodiumfluorescein into the conjunctival cul-de-sac. The patientis then asked to blink several times to assure mixing ofthe fluorescein with the tear film. The clinician examinesthe precorneal tear film with a slitlamp using a cobaltbluefilter. The TBUT value is the time, in seconds, fromblink to the appearance of the first dry spot. Valuesbelow 10 seconds are generally considered abnormal. 2Measuring TBUT using fluorescein is inexpensive, readilyavailable, and easy to perform. On the other hand, instillationof the dye may alter the physiologic compositionand volume of the tear film, as well as induce reflex tearing,affecting the real or physiologic TBUT. Thus, it is classifiedas an invasive type of measurement.Xeroscopes have been developed to measure TBUTnoninvasively. The Keeler Tearscope Plus is a commerciallyavailable device that can estimate tear-film quality, quantity,and stability. It is designed to avoid any disruption of thetear film during examination and to give a single view ofthe whole cornea. Goto and colleagues evaluated thevideokeratography machine, which is used for cornealtopography, for the measurement of TBUT. Results wereconsistent with those of the standard fluorescein TBUT. 3All these sophisticated machines use placido rings orgrid lines projected onto the corneal surface to measuretear-film stability. Their advantage is that they are carriedout in a noninvasive, objective, and reproducible fashionwith significantly increased sensitivity. These machines,however, are very expensive and are neither practical norreadily available to most ophthalmologists.Using the same basic concept behind the tearscope andvideokeratography machines, this study proposed aprototype xeroscope using readily available materials as asimple, noninvasive, and inexpensive alternative tomeasure TBUT. It used a simple flashlight as a light sourceand placido rings were projected on the corneal surface.Time to appearance in distortion of the projected rings ishypothesized to be equivalent to breakup time of thepreocular tear film.METHODOLOGYFifty patients (100 eyes), 21 years old and above, withno apparent ocular pathology except error of refractionand cataract, were enrolled into the study. Patients on anytopical ophthalmic medications, using contact lenses,those with ocular-surface disease (blepharitis, meibomiangland dysfunction, Steven-Johnson syndrome, chemicalburn, etc.) or eyelid abnormalities (ptosis, blepharospasm,ectropion, entropion, trichiasis, coloboma, etc.), and thosewho had any form of eye surgery or eye trauma wereexcluded from the study.The procedure was thoroughly explained to all subjects.Informed consent approved by the Institutional ReviewBoard was obtained prior to performing the tests.A series of 6 concentric rings, each with a thickness of 1mm, and separated from the next by 1 mm, were printedover acetate using an inkjet printer. The print out was thencut to fit the front surface of a 3v flashlight, whose diametermeasured 3.6 cm (Figure 1). The cut-out was placedin front of the flashlight, which was fastened to a stainlessgooseneck measuring 2 feet, to allow the flashlight to bebent and subsequently be positioned at the desired locationin front of the subject’s eye (Figure 2). The gooseneckwas fixed to a 2.5 cm x 10 cm x 22 cm base made of gauge-15 galvanized-iron sheet. This base was then positionedbeside the slitlamp using a table clamp (Figure 3).Each patient was positioned in front of a D7 Topconslitlamp biomicroscope set at 10x magnification (Figure4). The subjects were asked to make a complete blink andkeep their eyes open. The eyelids were held open by theexaminer to prevent reflex blinking. They were theninstructed to fixate at the center of the prototypexeroscope, which was positioned in front and slightlytemporal to the eye. The examiner viewed the projectedplacido rings through the oculars of the slitlamp focusedon the corneal surface. The only light source was theprototype xeroscope (Figure 4).The timer was started after the patient blinked. ThePHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 71

Figure 1. A cut-out made of acetate paper containing 6 concentric rings was placed infront of a 3v flashlight.Figure 4. Patient positioned in front of a D7 Topcon slitlamp biomicroscope andxeroscope prototype.The flashlight was fastened to a gooseneck attached to a gauge -15 galvanized-Figure 2.iron base.Figure 5.Concentric rings reflected on the cornea.Figure 3.Xeroscope prototype clamped on a slitlamp table.Figure 6.Distorted concentric rings reflected on the cornea.72 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

interval between the complete blink and the appearanceof the first randomly distributed progressive distortion onthe concentric rings was measured in seconds using a stopwatchand designated as NIBUT (Figures 5 and 6). Thetest was repeated three times for the right eye and themean was recorded. The same procedure was then replicatedfor the left eye.Ten percent AK-FLUOR (Akron Inc., Buffalo Grove,IL, USA), unpreserved sterile fluorescein dye used for fluoresceinangiography, was diluted with 100 ml of sterilebalanced salt solution to make a 0.1% solution. After arest period of three minutes, 0.1 ml of the prepared dyewas instilled over the eye. Excess dye was dabbed usingclean tissue paper. The same slitlamp was used under thesame magnification; but this time, cobalt-blue light withyellow filter was used. The subjects were asked to make acomplete blink before the start of the test and to keeptheir eyes open. The eyelids were held open by the examinerto prevent reflex blinking. Timer was started after acomplete blink. The interval between a complete blinkand the appearance of the first randomly distributedprogressive dark areas in the precorneal tear film wasmeasured in seconds using a stopwatch and designated asTBUT. The test was repeated three times for the right eyeand the mean was recorded. The same procedure was thenreplicated for the left eye. All the tests were done by asingle examiner (JEDH) under standard room conditions.The two values were then subjected to linear-regressionanalysis to determine their correlation.RESULTS0.00Fifty patients (100 eyes), 18 males and 32 females,completed the study. All subjects had no apparent ocularPatientspathology except error of refraction and cataract. Themean age of the patients was 51.74 years (range 23 to 76).Figure 8.The combined NIBUT for the right and left eyes rangedfrom 9.44 to 49.03 seconds, while the fluorescein TBUTranged from 4.28 to 41.65 seconds. The mean NIBUT was24.71 seconds and the mean TBUT using fluorescein was5018.63 seconds. The average difference between NIBUTand TBUT was 6.09 seconds.40Figures 7 and 8 show a linear correlation betweenNIBUT and TBUT for each eye. When the TBUT value of30an eye was high, a corresponding high value for theNIBUT was also demonstrated. Comparison of the difference20between NIBUT and TBUT values of each eye wasnot statistically significant (5.92 for the right, 6.24 for the10left). This means that for the sample population in thisstudy, we can more or less expect the same difference0between NIBUT and TBUT regardless of which eye wastested.Right NIBUT (seconds)There was also a significant correlation between theright and left eyes for both NIBUT alone and TBUT alone Figure 9. Correlation of NIBUT between right and left eyes.SecondsSecondsLeft NIBUT (seconds)45.0040.0035.0030.0025.0020.0015.0010.005.000.00Figure 7.50.0045.0040.0035.0030.0025.0020.0015.0010.005.00Comparison between NIBUT and TBUT of the right eyes.18 LEFT8 LEFT17 LEFT27 LEFT48 LEFT43 LEFT15 LEFT46 LEFT16 LEFT11 LEFT21 LEFT34 LEFT9 RIGHT48 RIGHT33 RIGHT27 RIGHT20 RIGHT23 RIGHT35 RIGHT21 RIGHT11 RIGHT34 RIGHT8 RIGHT6 RIGHT37 RIGHT1 RIGHT50 RIGHT14 RIGHT49 RIGHT2 RIGHT3 RIGHT12 RIGHT40 RIGHT22 RIGHT44 RIGHT25 RIGHT19 RIGHTPatientsComparison between NIBUT and TBUT of the left eyes.26 LEFT37 LEFT30 LEFT50 LEFT24 LEFT38 LEFT32 LEFT2 LEFT13 LEFT44 LEFT29 LEFT22 LEFT4 LEFTr = 0.694p < 0.00010 10 20 30 40 50NIBUTTBUTNIBUTTBUTPHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 73

(Figures 9 and 10). The average NIBUT was 24.25 secondsand 25.20 seconds for the right and the left eye respectively.The average fluorescein TBUT was 18.23 secondsand 18.96 seconds for the right and the left respectively.Regression-correlation analysis revealed that NIBUTwas positively correlated with TBUT (r = 0.994, p < 0.0001)(Figure 11).DISCUSSIONTear-film instability is one of the hallmarks of dry-eyesyndrome or dysfunctional-tear syndrome. An unstabletear film can lead to ocular-surface damage and inflammationcausing visual symptoms, as well as ocularsymptoms of discomfort and irritation. Being able tomeasure the stability of the tear film accurately is,therefore, essential in evaluating the health of the ocularsurface.Measuring tear-film stability by invasive techniques suchas the fluorescein TBUT test is easy to perform and widelyused by most clinicians. However, variations in pH andconcentration of the fluorescein dye, volume of instilleddrops, and the presence of preservatives are factors thatalter tear physiology and yield variable results. 4 Themanner in which the test is performed can also significantlyinfluence its outcome. For example, holding thelids apart stretches the tear film, resulting in fasterbreakup. Air currents, slitlamp-heat intensity, and otherfactors also affect results. In our study, we tried our bestto prevent these factors from affecting the outcome ofour tests for TBUT by instilling a constant volume of liquiddye, which we prepared ourselves (0.1ml of 0.1% solution).This enabled us to at least control the concentration andvolume of the solution we used as against using fluoresceinstrips in which we cannot quantify exactly how much dyeis contained per strip and how much dye is instilled onthe eyes. Tests for each eye were also performed separatelyso as to prevent factors such as drying from prolonged lidstretching or unnecessary irritation from prolongedcontact with the dye from occurring.Several noninvasive, reproducible methods have beendeveloped to try to overcome the limitations imposed byinvasive techniques. The NIBUT projects a regular imageonto the precorneal tear film and looks for the firstdisruption of the image. 2 A study by Mengher andcolleagues of 33 patients (65 eyes) with varying severity(mild, moderate, and severe) of dry eyes and 66 age- andsex-matched normal subjects (132 eyes) showed that thecritical value of 10 seconds for the NIBUT providessensitivity of 82% and specificity of 86%. 5 Hand-helddevices employing this principle are commerciallyavailable (Tearscope Plus, Keeler) but are expensive andnot readily available.Our study utilized a xeroscope prototype made fromLeft TBUT (seconds)504030201000 10 20 30 40Right TBUT (seconds)Figure 10. Correlation of TBUT between right and left eyes.NIBUT (seconds)5040302010r = 0.679p < 0.000100 10 20 30 40 50TBUT (seconds)r = 0.994p < 0.0001Figure 11. Correlation of TBUT using fluorescein dye and xeroscope-prototype NIBUTin both eyes.simple materials that can easily be obtained at a cost ofless than PhP1,000. A linear correlation between fluoresceinTBUT and the NIBUT was demonstrated with thisxeroscope, indicating that it can be used as an alternativeto the current standard for measuring stability of the tearfilm without the drawbacks of instilling fluorescein. It canparticularly be used for evaluating patients with dysfunctionaltear syndrome. The normal TBUT cut-off value ofour prototype xeroscope is 16 seconds and greater. Thisvalue is the sum of the accepted normal cut-off value ofthe fluorescein TBUT (10 seconds) and the averagedifference between NIBUT and TBUT in this study (6seconds). Our value is consistent with the normal valuefor NIBUT of 15 seconds based on a publication of theUniversity of Illinois Eye and Ear Infirmary. 2In conclusion, NIBUT measurement using the prototypexeroscope has a positive correlation with the standard74 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

fluorescein TBUT measurement and may be a goodalternative for measuring tear-film stability withoutdisturbing normal physiology. Further improvement canbe done on our prototype xeroscope with regard to theconcentric rings to cover the entire corneal surface.Studies involving a larger number of subjects to includepatients with dry-eye syndrome are recommended.References1. Djalilian A, Hamrah P, Pflugfelder S. Dry Eye. In: Krachmer JH, Mannis MJ, HollandEJ, eds. Cornea, 2nd ed. Philadelphia: Mosby-Year Book, Inc. 1997. v1, chap. 42.2. Dry Eye Tests and Eye Exam. The Eye Digest. University of Illinois Eye & Ear Infirmary,Chicago, IL. Jun 2007. http://www.agingeye.net/dryeyesdryeeyeseyeexam.php3. Goto T, Zheng X, Klyce SD, et al. A new method for tear-film-stability analysis usingvideokeratography. Am J Ophthalmol 2003; 135: 607-612.4. Kojima T, Ishida R, Dogru M, et al. A new noninvasive tear-stability-analysis systemfor the assessment of dry eyes. Invest Ophthalmol Vis Sci 2004; 45: 1369-1374.5. Mengher LS, Pandher KS, Bron AJ. Noninvasive tear-film breakup time: sensitivityand specificity. Acta Ophthalmol 1986; 64: 441-444.AcknowledgmentKaice Cristobal, Clinical Epidemiology Unit, St. Luke’s Medical Center, for her invaluableassistance in the statistical analysis of the data.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 75

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYORIGINAL ARTICLE– DECEMBER 2007Ernesto D. Golez III, MD 1Manuel B. Agulto, MD 1, 2Margarita L. Luna, MD 11Department of Ophthalmology andVisual SciencesSentro Oftalmologico Jose RizalUniversity of the Philippines–PhilippineGeneral HospitalManila, Philippines2Institute of OphthalmologyUniversity of the Philippines–NationalInstitutes of HealthManila, PhilippinesEffect of dorzolamide comparedwith timolol maleate on thecentral corneal thicknessand endothelial-cell countof glaucomatous eyesABSTRACTObjectiveThis study determined the effect of topical dorzolamide versus timolol oncentral corneal thickness (CCT) and endothelial-cell count of glaucomatouseyes.MethodsA randomized controlled trial was conducted involving 37 eyes of 37 patientsdiagnosed with primary open-angle glaucoma, ocular hypertension, normotensiveglaucoma, pigmentary glaucoma, or pseudoexfoliative glaucoma, whomay or may not be on antiglaucoma medication, and with a cup-disc ratio of

DORZOLAMIDE hydrochloride is a carbonic anhydrase(CA) inhibitor formulated for topical use in thetreatment of glaucoma. This drug is a potent inhibitor ofcarbonic anhydrase isoenzyme II (CA-II), 1 found in theciliary processes of human eyes, 2 suppressing aqueoushumorsecretion, 3 thereby decreasing intraocular pressure(IOP). 4,5The corneal endothelium possesses CA-I and CA-IIisoenzymes, both of which play a role in its pumpingfunction. 2 This pumping function regulates the flow ofwater into the corneal stroma. Two endothelial-pumpmechanisms have been described to contribute to therelative dehydrated state of the stroma: 6 the bicarbonatedependentMg 2+ -ATPase pump, 7 which utilizes both CA-Iand CA-II isoenzymes, and the Na + ,K + -ATPase pump. 8 Theimportance of these 2 pumps in stromal deturgescenceremains unknown. Because dorzolamide inhibits CA-IIisoenzyme, it may have a potential to interfere with thebicarbonate-dependent Mg 2+ -ATPase pump. It is,therefore, essential to assess any short- and long-termadverse effects of dorzolamide on endothelial function.The relationship of central corneal thickness (CCT)with IOP has been the subject of several studies. Patientswith thinner corneas tend to have underestimated IOPs(their true IOP is higher than the measured value),whereas those with thicker corneas tend to have overestimatedIOPs (their true IOP is lower than the measuredvalue). 9 Thus, CCT has become a significant factor in thediagnosis and treatment of glaucoma because a low CCTmay lead to underdiagnosis and undertreatment while a9, 10high CCT may lead to overdiagnosis and overtreatment.Because endothelial CA plays a role in the mechanismof fluid transportation, there is some concern that theuse of dorzolamide may have a significant effect on thecornea and CCT. Corneas of eyes treated with dorzolamidewere reported to be either thicker than those of untreatedones, 11-13 to be slightly thicker, 14 or to maintain the samethickness after treatment. 15 In a study by Wilkerson et al.,significant increase in CCT was seen after one month ofinstillation of the drug. 11CCT among different races was shown to be different. 16-17Among normal Filipino eyes, it ranged from 451.0 µm to653.6 µm with a mean of 531.5 µm ± 33.8 µm. A significantlinear correlation between CCT and IOP was alsoobserved. 17 It is possible that differences in CCT may affectpatients’ responses to dorzolamide and the measurementof IOP.For the past 30 years, timolol has been the gold standardin the treatment of open-angle glaucoma and ocular hypertension.It has been compared with new antiglaucomamedications. Using timolol as the control drug, this studydetermined the effect of 2% topical dorzolamide on theCCT of glaucomatous eyes of Filipinos. It compared theeffect of dorzolamide versus timolol on CCT andendothelial-cell count after one month, and correlatedCCT and IOP measurements.METHODOLOGYWe performed a randomized controlled trial at theGlaucoma Clinic of the Sentro Oftalmologico Jose Rizal,Philippine General Hospital. The study populationincluded 37 eyes of new and follow-up patients, 18 yearsand above, diagnosed with primary open-angle glaucoma(POAG), ocular hypertension (OHT), normotensiveglaucoma (NTG), pigmentary glaucoma, or pseudoexfoliativeglaucoma (PXE), with or without medications, andwith a cup-disc ratio of

The outcome measures includedCCT, endothelial-cell count, and IOP.Endothelial-cell count was determinedupon enrollment and afterone month of treatment. CCT andIOP were determined at baseline, day1, week 1, week 2, and week 4 of treatment.Only the results of one eye of eachpatient were included in the statisticalanalysis. Descriptive statistics includedmeasures of central tendency (meanand standard deviation). Tests ofhomogeneity of sample included chisquarefor categorical variables andindependent t-test for continuousvariables.Within-groups comparison includedWilcoxon signed-rank test whilebetween-groups comparison utilizedMann-Whitney U test. For repeatedobservations (measuring the effect oftimolol and dorzolamide at baselineand up to nth months of observation)factorial analysis of variance was done.Posthoc comparisons includedBonferroni and Scheffe’s tests.All tests of significance werecarried out at .05 alpha level of significanceand 95% confidence levelusing STATA version 7.Table 1. Profile of the study population.Age (years)MeanSexMaleFemaleMean baseline corneal endothelial-cellcountMean baseline corneal thickness (µm)Mean baseline intraocular pressure(mm Hg)Primary diagnosisPOAG 1OHT 2NTG 3Pigmentary glaucomaPseudoexfoliative glaucoma1Primary open-angle glaucoma2Ocular hypertension3Normotensive glaucomaDorzolamide61.1 ± 14.68 (53.3%)7 (46.7%)2640.5 ± 141.7533.9 ± 35.616.1 ± 4.05 (33.3%)3 (20.0%)6 (40.0%)0 (0%)1 (6.7%)Sample-size calculationAssuming that a 2 µm mean differencein corneal thickness is notedbetween eyes treated with timolol anddorzolamide (based on previousforeign studies) with a standarddeviation of ± 2 from the mean (twotailedtest) and that the standarddeviations assumed for each interventionis assumed to be equal andthat an intervention may produce noobservable effect; the sample that willbe required to detect this truedifference is 16 per arm (total n = 32).This sample size is sufficient to rejectthe hypothesis of equality at .05 alphalevel of significance producing a typeII error of 20% generating a studypower of at least 80%. The estimationof sample is shown as:n = 2s 2 x f (α, β)∆ 2n = 2 (.05) 2 x 7.852 2n = 2 (2) 2 x 7.854n = 16 per armAn allowable 20% drop out rateTimolol62.5 ± 11.96 (31.6%)13 (68.4%)2539.6 ± 231.3511.4 ± 23.817.1 ± 5.311 (57.9%)2 (10.5%)5 (26.3%)0 (0%)1 (5.3%)Total61.9 ± 12.914 (41.2%)20 (58.8%)2585.4 ± 199.5521.3 ± 31.516.6 ± 4.716 (47.1%)5 (14.7%)11 (32.3%)0 (0%)2 (5.9%)p0.7500.2000.1510.0150.3230.552(n=36), hence the working minimumsample is 18 per arm.RESULTSThirty-seven were initially enrolledin the study but 3 (8.1%) were eventuallyexcluded. Two patients haduncontrolled IOP on monotherapyand one was lost to follow-up. Theremaining 34 patients were between20 and 78 years of age with a mean of61.9 ± 12.9 years. Of the 15 patientsin the dorzolamide group, 8 weremales and 7 were females with a meanage of 61.1 ± 14.6 years. Of the 19patients in the timolol group, 6 weremales while 13 were females with amean age of 62.5 ± 11.9 years. Baselineendothelial-cell count rangedfrom 2067 to 2968 cells/mm 2 with amean of 2585.4 cells/mm 2 ± 199.5.The mean baseline endothelial-cellcount was 2640.5 cells/mm 2 ± 141.7in the dorzolamide group and 2539.6cells/mm 2 ± 231.3 in the timololgroup (Table 1). Baseline CCTranged from 466 to 609 µm with amean of 521.3 µm ± 31.5. The meanbaseline CCT was 533.9 µm ± 35.6 inthe dorzolamide group and 511.4 µm± 23.8 in the timolol group (Table 1).Baseline IOP averaged 16.6 mm Hg± 4.7 for all patients, 16.1 mm Hg ±4.0 in the dorzolamide group and17.1 mm Hg ± 5.3 in the timololgroup. Five patients had OHT (3 indorzolamide and 2 in timolol), 16 hadPOAG (5 in dorzolamide and 11 intimolol), 2 had PXE (one for eachgroup), and 11 had NTG (6 indorzolamide and 5 in timolol).A comparison of the effect ofdorzolamide versus timolol on thechange in CCT over the four-weekperiod was not statistically differenteven when at baseline the CCTbetween the 2 groups were different(Table 2).There seemed to be a trend towardincrease in CCT in both groupsinitially which returned to baseline atweek 4 of treatment (Figure 1).The endothelial-cell count before78 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Table 2. Comparison of the effect of dorzolamide versus timolol on theendothelial-cell count after 1 month.Mean CCT ChangeDay 1Week 1Week 2Week 4One-month ECC changeDorzolamide-1.6 ± 7.50.8 ± 9.32.0 ± 9.40.3 ± 9.1-6.9 ± 177.7Table 3. Correlation of mean IOP to mean CCT.Change in CCT from baselineBaselineDay 1Week 1Week 2Week 42.521.510.50-0.5-1-1.52Figure 1.Dorzolamide0.534-0.0270.1510.2140.071DorzolamidePeriodRate of change of central corneal thickness.Timolol1.4 ± 6.00.9 ± 8.7-0.1 ± 8.4-0.1 ± 9.11.0 ± 247.3TimololTimolol0.6760.1410.6190.6060.667p0.290.990.510.900.92baseline day 1 week 1 week 2 week 4and after 1 month of treatment showed no statisticallysignificant difference between both groups (Table 2).The correlation between mean IOP and mean CCT ineach group was maintained throughout the four-weektreatment (Table 3).DISCUSSIONDorzolamide is a potent inhibitor of CA-II isoenzyme,which is found in various parts of the eye including thecorneal endothelium. 1-2 There has been a growingconcern that the drug may exert an adverse effect on thecorneal-endothelial cells by inhibiting the bicarbonatepump. Corneal-endothelial-cell function can be determinedby measuring the corneal thickness. In this study,we compared the effects of dorzolamide and timolol onCCT and found no statistically significant difference after1 month of treatment. In a three-month study by Kaminski,an initial increase in CCT was seen on day 1 with dorzolamide,but the CCT subsequently returned to baselinein the succeeding days. 14 A study by Lass et al. showed atrend toward an increase in CCT in a span of 1 year in thedorzolamide group and a decrease in CCT in the timololgroup although the difference was not statistically significant.15 This study, however, did not record the findingsduring the first month of treatment. Another study by Lassand colleagues on the corneal effects of latanoprost,latanoprost–timolol, and timolol in patients with glaucomashowed no significant increase in CCT in the timolol groupat 6 and 12 months. 19 Our findings were consistent withthe results of this study in which timolol had no changein CCT at week 4 of treatment.Another way to study endothelial-cell function is thedetermination of endothelial-cell count although it cannotequate with endothelial function because of significantfunctional reserve of this cell layer. 18 The method ofdetermination of endothelial-cell count is also subject totechnical variables such as cell size, variations in cell area,total number of cells counted, clarity of image, cornealthickness, position of the cornea where image was taken,image magnification, and observer variability. To minimizethe effect of these variables, the same instrument andresults were read by a single, masked technician. In ourstudy, there was no significant difference between the twogroups after 1 month of treatment.Luna et al. showed a correlation between CCT and IOPas measured with the Goldmann applanation tonometryamong Filipinos with normal eyes. 17 Our study found lowto no correlation among glaucomatous eyes at baselineand at 1 month of treatment.In conclusion, dorzolamide did not cause a significantchange in CCT and endothelial-cell count of glaucomatouseyes at 1 month of treatment. Further studiesinvolving a larger sample and longer observation periodare needed to confirm whether dorzolamide has asignificant effect on the endothelial-pump mechanismsof the human eye.References1. Sugrue M. The preclinical pharmacology of dorzolamide hydrochloride, a topicalcarbonic anhydrase inhibitor. J Ocular Pharmacol Ther 1996; 12: 363-376.2. Wistrand P, Schenholm M, Lonerolm G. Carbonic anhydrase isoenzyme CA-1 andCA-11 in the human eye. Invest Ophthalmol Vis Sci 1986; 27; 419-428.3. Maus T, Larsson L, McLaren J, et al. Comparison of dorzolamide and acetazolamideas suppressors of aqueous-humor flow in humans. Arch Ophthalmol 1997; 115:45-49.4. Maren T. Basic sciences in clinical glaucoma. The development of topical carbonicanhydrase inhibitors. J Glaucoma 1995; 4: 49-62.5. Stralman E, Tipping R, Vogel R, et al. A six-week dose-response study of the ocularhypotensive effect of dorzolamide with a one-year extension. Am J Ophthalmol1996; 122: 183-194.6. Waring G, Bourne, W, Edelhauser H, Kenyon K. The corneal endothelium: normaland pathologic structure and function. Ophthalmology 1982; 89: 531-590.7. Fischbarg J, Hernandez J, Liebovitch L, et al. The mechanism of fluid and electrolytetransport across corneal endothelium: critical revision and update of model. CurrEye Res 1985; 4: 351-360.8. Wigham C, Turner H, Ogbuchi K, Hodson S. Two pathways for electrogenicbicarbonate ion movement across the rabbit corneal endothelium. Biochem BiophysActa 1996; 1279: 104-110.9. Suan, S. Accurate intraocular-pressure measurement. The myth of modernophthalmology. Ophthalmol 2000; 107: 1805-1807.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 79

10. Brandt J, Beiser J, Gordon M, et al. Central corneal thickness and measured IOPresponse to topical ocular hypotensive medication in the ocular hypertensiontreatment study. Am J Ophthalmol 2004; 136: 717-722.11. Wilkerson M, Cyrlin M, Lippa EA, et al. Four-week safety and efficacy study ofdorzolamide, a novel, active topical carbonic-anhydrase inhibitor. Arch Ophthalmol1993; 111: 1343-1350.12. Herdon LW, Choudhri SA, Cox T, et al. Central corneal thickness in normal,glaucomatous, and ocular hypertensive eyes. Arch Ophthalmol 1997; 115: 1137-1141.13. Inoue K, Okugawa K, Oshika T, Amano S. Influence of dorzolamide on cornealendothelium. Jpn J Ophthalmol 2003; 47: 129-133.14. Kaminski S, Hommer A, Koyuncu D, et al. Influence of dorzolamide on cornealthickness, endothelial cell-count, and corneal sensitivity. Acta Ophthalmol Scand1998; 76: 78-79.15. Lass JH, Khosrof SA, Laurence JK, et al. A double-masked, randomized, one-yearstudy comparing the corneal effects of dorzolamide, timolol, and betaxolol.Dorzolamide Corneal Effects Study Group. Arch Ophthalmol 1998; 116: 1003-1010.16. Aghaian E, Choe JE, Lin S, Stamper RL. Central corneal thickness of Caucasians,Chinese, Hispanics, Filipinos, African Americans, and Japanese in a glaucomaclinic. Ophthalmology 2004; 111: 2211-2219.17. Lat-Luna M, Guerrero P, Flores J. Correlation of central corneal thickness andGoldmann applanation tonometry among Filipinos. Philipp J Ophthalmol 2004; 29:79-82.18. American Academy of Ophthalmology. Corneal endothelial photography: three-yearrevision. Ophthalmology 1997; 104: 1360-1365.19. Lass JH, Eriksson GL, Osterling L, et al. Comparison of corneal effects of latanoprost,fixed-combination latanoprost–timolol, and timolol: a double-masked, randomized,one-year study. Ophthalmology 2001; 108: 264-271.80 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYREVIEW– DECEMBER 2007Harvey Siy Uy, MDPik Sha Chan, MDLexie Lee, ODAsian Eye InstituteMakati, PhilippinesPractical methods ofvision-potential testingPREMIUM intraocular lenses (IOLs) are technologically advanced IOLsthat correct presbyopia (multifocal and accommodative) and astigmatism(toric), or provide sharper vision especially under low-light or nighttimeconditions (aspheric). These are currently utilized for patients undergoingcataract surgery or refractive-lens exchange and have raised expectations forpostoperative visual outcomes. While these IOLs potentially confer improvedvisual capability, they are more expensive. Because ophthalmologists arepressured to deliver consistently excellent visual outcomes after surgery, theability to evaluate retinal visual acuity and predict postoperative vision hasbecome an essential tool for setting patient expectations and identifying whichpatients may benefit from these technologies. Several factors such as poorpreoperative visual acuity, cataract type or severity, and coexisting posteriorsegmentdisease may affect the accuracy of predictive tests, and these shouldbe considered when interpreting predicted vision, especially in preoperativecounseling of patients. 1 We review here 3 commonly used and practicalmethods of prognosticating visual outcomes after cataract surgery.I. PINHOLE TESTThere are two major categories of blurred vision: 1) Refractive or opticalmedia problems that improve with glasses or by removal of media opacities;and 2) Nonoptical problems due to disease processes affecting the retina oroptic nerve. A quick way to differentiate between the two is by performing thepinhole test (PH).Correspondence toHarvey Siy Uy, MDAsian Eye Institute9F Phinma Plaza BuildingRockwell Center1200 Makati, PhilippinesTelephone : +63-2- 8982020Fax : +63-2-8982002Email : harveyuy@yahoo.comProcedureCreate a pinhole approximately 2 mm in diameter by perforating a card orpiece of paper with a pen tip. Using proper distance correction, check oneeye at a time by occluding the other eye. Instruct the patient to read thecharacters on a wall-mounted reading chart (eg. Snellen) or projected chart.Record the distance best-corrected visual acuity (BCVA). Then look at thesame object through the pinhole and record the PH BCVA. If the BCVAimproves using the PH, a refractive error or optical media problem (eg. cataractor vitreous hemorrhage) is present.No financial assistance was received for this study.Keywords: Cataract, Intraocular lens, Pinhole test, Potential-acuity meter, Potential-acuity pinholeThe authors have no proprietary or financial interest inany product used or cited in this study.PHILIPP J OPHTHALMOL 2006; 31(2): 81-83© PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 81

ApplicationsIn a prospective study of 64 eyes with mild to moderatecataract that underwent uneventful phacoemulsification,the PH correctly predicted BCVA in 5% of eyes. The PHacurately predicted BCVA within 1, 2, and 3 lines in 23%,40%, and 54% of eyes respectively. The accuracy of PHtest was found to decrease in eyes with poorer preoperativevisual acuity or denser cataracts. 2PH vision is a quick method to assess best-correctedvision. By looking through a pinhole, the refractive errorsof the peripheral cornea and crystalline lens of the eyeare significantly reduced or eliminated, and PH acuitysimulates that with proper glasses in place or clearing ofmedia opacity. PH test may be used to predict BCVA afterrefractive surgery, cataract extraction, vitrectomy forhemorrhage, or asteroid hyalosis.II. POTENTIAL-ACUITY METERThe Guyton-Minkowski Potential-Acuity Meter (PAM)measures retinal visual acuity behind a cataract or othermedia opacity. First introduced in 1983, the PAM hasmainly been used to estimate visual outcomes after cataractsurgery. The PAM projects a Snellen eye chart via a narrowbeam of light, which converges to an aerial aperture oropening measuring 0.1 mm. This opening is placed ontoless-dense areas or “windows” within the cataract allowingthe eye chart to be focused onto the retina with minimalcataract-induced light scattering. Because the PAM testuses a smaller aperture than the pinhole (1 mm), it ismore accurate in measuring retinal acuity and in providingan estimate of postsurgical visual results. 3ProcedurePAM testing is performed in a dimly lighted room.Other eye charts are turned off to avoid confusion. ThePAM is mounted on a slitlamp set to the lowest magnificationand whose illumination is turned off to avoid glare.Pupil dilation is preferable because more “windows” aremade available for the PAM light beam to pass through.Amblyopic patients may do better after patching of thegood eye. The eye should not be exposed to bright lightsjust prior to performing the test. The operator then setsthe dioptric setting to the approximate spherical equivalentof the eye.The operator explains to the patient that a light willappear and that letters or numbers will be visible; theclarity of the characters may change during the test. Thepatient is instructed to avoid head movement as this willdisplace the light beam and delay the procedure. Thepatient should report what characters are visible throughclenched teeth, to minimize head movement. The basictechnique is to focus the beam onto the patient’s retinathrough the cataract. The patient is encouraged to readaloud the lines of the chart until no other smaller, legiblelines are encountered. The process is repeated until theexaminer is confident that the patient cannot read anyfiner lines. If the patient correctly reads any 3 charactersin a certain line, that level of visual acuity is established.The PAM result is the smallest line where the patient reads3 characters even if he loses sight of it in subsequentretesting. The light beam should be repositioned in orderto try other “windows” to enable the patient to seeadditional finer lines. The test takes 5 to 10 minutes pereye.PAM is mostly used for patients about to undergocataract surgery, but it may also be used for other ocularmedia problems: large refractive errors, corneal/vitreousopacities, partial hyphema, IOL deposits, posteriorcapsular opacities, and asteroid hyalosis. In general, if anyretinal detail is clinically visible, there is an adequatewindow for PAM testing. This is possible because the PAMlight beam is only 0.1 mm in diameter, which is smallerthan the size of the pupil needed to see the retina. Foropaque corneas, mature cataracts, thick pupillarymembranes, dense vitreous hemorrhage, and severe opticnerveor retinal disease, the patient may report that thePAM light is not visible. Nonocular conditions that makePAM testing difficult to impossible include poor patientposture or mental status, literacy, nystagmus, and patientfatigue.ApplicationsIn their original report, Minkowski-Guyton noted thatamong cataractous eyes having best preoperative visualacuity of 20/200+, the postoperative visual acuity wascorrectly predicted to within 3 lines in 100% of cases andto within two lines in 91% of cases. PAM correctlypredicted postoperative visual outcomes of 20/40+ in 95%of cases. Most studies report that PAM correctly predictsvisual acuity to within 2 lines in approximately 80 to 90%of patients. PAM testing tends to underestimate potentialacuity so postsurgical results are usually better thanpredicted. The accuracy of the PAM test decreases whenthe cataract is denser and when preoperative visual acuityis poorer. 2-5 Patients with these characteristics should notbe excluded from cataract surgery on the basis of poorPAM results. In our practice, PAM results are a basis forIOL selection. Patients with poor PAM results are excludedfrom receiving multifocal IOLs since good retinal acuityis a requisite for obtaining good results with theseexpensive IOLs.PAM is used to test retinal acuity in eyes with othermedia problems, for rapid potential vision screening inpatients with vitreoretinal diseases, microphthalmia, andlarge or irregular refractive errors. PAM testing is also usedto identify which patients with posterior capsular opacities82 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

may benefit from YAG capsulotomy. 6 When both eyes havecataracts and similar preoperative visual acuities, PAM canbe used to select which eye will first undergo cataractsurgery.PAM testing is used to identify patients with coexistingocular diseases (e.g. retinal or nerve pathology) who maybenefit from cataract surgery. A few studies have reportedthat PAM is potentially useful in predicting postsurgicalresults in patients with cataracts and coexisting posteriorsegmentdisease such as macular degeneration andmacular hole. There is a tendency for PAM to generatefalse positive (overestimated) results in patients withmacular degeneration. The combination of PAM andautomated visual-field testing was useful in predictingoutcomes following combined cataract surgery andtrabeculectomy.The clinical reliability of PAM in predicting treatmentresults for noncataractous conditions has not beenestablished. PAM testing is not consistently reliable inpredicting visual results after macular-hole surgery. Anintriguing but limited case series has suggested that PAMmay be useful for predicting improvement after treatmentfor cystoid macular edema by identifying intact butdysfunctional photoreceptors. 8III. POTENTIAL-ACUITY PINHOLEPotential-Acuity Pinhole (PAP) test is easy to performand requires only instruments available in any examinationlane. It has been shown to approximate the resultsof PAM.ProcedureThe patient is given reading correction on a trial lensor vision tester. The eye not tested is occluded while thetested eye is allowed to see through a pinhole and readletters on an illuminated pocket near vision chart held ata standard 14 inches away from the eye. The distanceequivalent is recorded as the result.ApplicationsA prospective trial compared the reliability of PAP toPAM. The PAP test predicted visual outcomes within 2lines in 100%, 100%, and 56% of eyes with preoperativeBCVA of 20/50 and better (group 1), 20/60 to 20/100(group II), and 20/200 and worse (group III) respectively.The PAM correctly predicted visual outcomes within 2lines for the same groups in 42%, 47%, and 0%respectively. Mean lines of inaccuracy of PAP predictionswere 0.83, 1.11, and 3.50 lines for groups I, II, and III.Mean lines of inaccuracy for PAM predictions were 2.50,2.68, and 6.22 lines for the same groups. Differences inlines of prediction between PAM and PAP were 1.67(p = 0.004) for group I, 1.58 (p = 0.0002) for group II,and 2.72 lines (p = 0.0001) for group III.There was no statistically significant correlation betweenPAP predictions and preoperative myopic sphericalequivalent. The study concluded that the PAP test is asimple, inexpensive, and relatively reliable method toestimate visual outcome after uncomplicated cataractsurgery in eyes without comorbidity. PAP was less accuratein patients with preoperative BCVA worse than 20/200. 7SUMMARYThe advent of premium IOLs has intensified the needto do predictive testing for eyes undergoing cataractsurgery. Pinhole testing is inexpensive and readilyavailable; however, it is not as reliable for dense cataractsnor as accurate as PAM. The PAP is a refinement of thepinhole test with improved accuracy but requires moreeffort and time. The PAM apparatus is fairly low cost, easilysourced, more accurate, and easy to incorporate into apractice. Other systems such as laser interferometry aremore expensive and difficult to source.Current high patient expectations and the increasinguse of costly, premium IOLs have clearly established a needfor a predictive screening tool before cataract surgery orother procedures such as YAG capsulotomy. PAM is animperfect but reasonably reliable and easily availablemethod for predictive testing and has a definite place incurrent clinical practice.References1. Lasa MS, Datiles MB III, Freidlin V. Potential vision tests in patients with cataracts.Ophthalmology 1995; 102: 1007-1011.2. Uy HS, Munoz M. A comparison of the potential-acuity meter and pinhole tests inpredicting postoperative visual acuity after cataract surgery. J Cataract Refract Surg2005; 31: 548-552.3. Minkowski JS, Palese M, Guyton DL. Potential-acuity meter using a minute aerialpinhole aperture. Ophthalmolgy 1983; 90: 1360-1368.4. Chang MA, Airiani S, Miele D, Braunstein RE. A comparison of the potential-acuitymeter (PAM) and the illuminated near card (INC) in patients undergoingphacoemulsification. Eye 2006; 20: 1345-1351.5. Gus PI, Kwitko I, Roehe D, Kwitko S. Potential-acuity meter in cataract patients. JCatract Refract Surg 2000; 26: 1238-1241.6. Klein TB, Slomovic AR, Parrish RK II, Knighton RW. Visual-acuity prediction beforeneodymium-YAG laser posterior capsulotomy. Ophthalmology 1986; 93: 808-810.7. Melki SA, Safar A, Martin J, et al. Potential-acuity pinhole: a simple method tomeasure potential visual acuity in patients with cataracts, comparison to potentialacuitymeter. Ophthalmology 1999; 106: 1262-1267.8. McDonnell PJ, Ryan SJ, Walonker AF, Miller-Scholte A. Prediction of visual-acuityrecovery in cystoid macular edema. Ophthalmic Surg 1992; 23: 354-358.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 83

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYCASE REPORT– DECEMBER 2007Mary Ruth Quilendrino, MD 1Jacinto Dy-Liacco, MD 1, 2Ruben Lim Bon Siong, MD 11Department of Ophthalmologyand Visual SciencesUniversity of the Philippines-PhilippineGeneral HospitalManila, PhilippinesLupus vulgaris of the ocularadnexa2Institute of OphthalmologyUniversity of the Philippines-NationalInstitutes of HealthManila, PhilippinesABSTRACTObjectiveTo describe a case of lupus vulgaris of the ocular adnexa with secondarypyogenic infection.MethodThis is a case report.ResultA three-year-old boy presented with a well-defined, reddish skin lesion withulceration, necrosis, and granuloma formation, topped with pustules andcrusts, on the right eyelid, malar and nasal area. Mantoux test and acid-fastbacilli smear of skin punch biopsy were positive. Culture of the dischargefrom the lesion revealed Streptococcus pyogenes and Staphylococcus aureus. Afterantibiotic treatment and triple-drug antituberculous therapy, there was markedimprovement of the lesion, but leaving behind ectropion and skin defect ofthe right lower lid.Correspondence toMary Ruth Quilendrino, MDDepartment of Ophthalmology and Visual SciencesUniversity of the Philippines–Philippine General HospitalTaft Avenue, Ermita1000 Manila, PhilippinesTelephone : +63-2-3022487No financial assistance was received for this study.ConclusionAwareness of lupus vulgaris, with its various clinical manifestations, is crucialin its early diagnosis and treatment, preventing extensive and irreparabledamage to involved and surrounding structures.Keywords: Lupus vulgaris, Ocular adnexa, Cutaneous tuberculosis, GranulomaThe authors have no proprietary or financial interest inany product used or cited in this study.PHILIPP J OPHTHALMOL 2007; 32(2): 84-87© PHILIPPINE ACADEMY OF OPHTHALMOLOGY84 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

LUPUS vulgaris is a chronic and progressive form oftuberculosis of the skin, occurring in individuals withmoderate to high degree of immunity. Cutaneous tuberculosisaccounts for approximately 2.5% to 10% of all casesof extrapulmonary tuberculosis. 1 Lupus vulgaris has beenreported to be the most common form of cutaneoustuberculosis in most case series worldwide. It is the mostcommon type in Europe and Hong Kong. 2 To date, thereare no published data on its incidence in the Philippines.Lupus vulgaris is at times difficult to diagnose since it alsohas the most variable presentation. It has a tendency tospread, causing destruction of surrounding structures. Insome cases, it is self-limiting.We report a case of lupus vulgaris that has causedsignificant disfigurement of the right eyelid and malararea, but has been prevented from spreading to the ocularsurface and causing visual impairment with prompt andcorrect diagnosis and adequate treatment.CASE REPORTA three-year-old boy consulted at the University of thePhilippines–Philippine General Hospital because of anonhealing wound over the right eyelid and cheek. Thecondition started 4 months prior to consultation as a small,nontender, nodular skin lesion at the right medial canthalarea, which progressively increased in size and ruptured,spreading to involve the right eyelid and malar area. Thewound was cleaned with a concoction from guava leavesand occasionally with povidone–iodine solution. Thewound enlarged, with purulent discharge, increasedswelling, and redness of surrounding areas, causing theeyelid to close. The parents noted multiple enlargedcervical lymph nodes.Review of history revealed the child had recurrent boutsof cough with poor weight gain. No similar illness wasreported among the patient’s family and householdmembers, and none had been hospitalized for any specificdisease.Examination revealed a malnourished, irritable childin moderate respiratory distress. There was a 5.5 cm x 6.0cm well-circumscribed, reddish skin lesion, withalternating areas of ulceration and granuloma formation,topped with reddish papules, pustules, honey-coloredcrusts and necrotic tissue, overlying the right eyelid andmalar area and extending to the right lacrimal sac andright nasal area. There was destruction of the right lowereyelid, with ectropion, madarosis and exposure ofunderlying orbicularis oculi muscle. There was nolagophthalmos or fixation to the underlying bone. Theglobe was intact, with good mobility, but the conjunctivawas very congested (Figure 1). Visual acuity was fingerplay at 6 meters. He had normal sclera, clear cornea,formed anterior chamber, normal iris, ocular tension softto palpation, and normal posterior pole. The left eye andits surrounding structures were essentially normal.The patient also had multiple, bilateral, enlarged,matted, nontender, submandibular, cervical, and inguinallymph nodes. There was a solitary, discrete, erythematousulcer with raised borders at the left upper back. Therewere intercostal retractions, rhonchi, and crackles on bothlower-lung fields. The rest of the systemic findings werenormal.The patient was admitted to the Ophthalmology wardwith an initial impression of preseptal cellulitis,community-acquired pneumonia, and malnutrition. Hewas worked up for sepsis and started on intravenousoxacillin 200 mg/kg/day and cefuroxime 100 mg/kg/day.The wound was cleaned with hydrogen peroxide oncedaily and dressed with erythromycin ointment 4 times aday. Carbomer eye gel was applied to the right eye 4 timesa day as a preventive measure against exposure keratitis.Upon consultation at the External Disease Clinic, theperiorbital lesion was assessed to be TB granuloma,probably lupus vulgaris, prompting work-up fortuberculosis.With initiation of intravenous antibiotics, there was noteof significant improvement in the skin lesions withdecrease in swelling and amount of purulent discharge,and sloughing off of necrotic debris and crusts revealingreddish, raw tissue with hyperkeratotic, raised borders(Figure 2).Complete blood count showed moderate leukocytosisand microcytic, hypochromic anemia. Blood culture wasnegative for growth. Wound gram stain showed Grampositivecocci in pairs with polymorphonuclear neutrophilsper oil-immersion field. Wound culture showedmoderate growth of Staphylococcus aureus and Group Abeta-streptococcus, which were sensitive to the intravenousand topical antibiotics administered. Mantoux test wasgrade 4+ with abscess formation (Figure 3). Chest X-raywas negative for tuberculosis. Sputum and gastric acidfastbacilli (AFB) smears and skin AFB culture werenegative. Skin biopsy AFB stain demonstrated one acidfastbacilli per 100 fields.The patient was started on antituberculous regimen ofisoniazid 80 mg/day, rifampicin 80 mg/day, andpyrazinamide 250 mg/day. There was marked, gradualhealing of the skin lesion in the weeks that followed. Withcompletion of the intravenous antibiotics and resolutionof pneumonia, the patient was discharged from thehospital.Hematoxylin and eosin-stained histologic sections fromthe skin biopsy revealed nodular granuloma formationwith epithelioid histiocytes and Langhans giant cells,changes consistent with lupus vulgaris (Figure 4). The skinlesion continued to show healing on follow-up withPHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 85

scarring at the lateral canthal area, with ectropion andskin defect at the right lower lid (Figure 5). The externalocular surface remained intact. The patient was advisedectropion surgery and reconstruction of lid defect at alater date.DISCUSSIONLupus vulgaris is a form of cutaneous tuberculosis thatusually infects the skin of a person who had beenpreviously infected by Mycobacterium tuberculosis elsewherein the body. It is generally considered to be a benign,slowly progressive skin lesion. It usually spreads from anendogenous source of tuberculosis through hematogenous,lymphatic, or contiguous extension. In someinstances, it is acquired exogenously following directFigure 3. A positive Mantoux test on the volar surface of the patient’s left forearm.Figure 4. Hematoxylin and eosin-stained histologic sections from the skin biopsyrevealed nodular granuloma formation with epithelioid histiocytes and Langhans giantcells.Figure 1.The patient on initial consult without treatment.Figure 2. The patient 10 days after initiation of intravenous and topical antibiotictreatment.Figure 5. The patient 22 weeks from initial consult, showing skin defect at the left lowerlid, cicatricial ectropion, and scarring at the lateral canthal area.86 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

inoculation of the mycobacteria into the skin or bacillicalmette-Guerin (BCG) vaccination. 2, 3 It is morepredominant in females than in males at 2-3:1 ratio, andmore common in children.In 80 to 90% of cases, the lesion appears on the headand neck, particularly around the nose and earlobes. 3Involvement of the lower extremities, buttocks, and trunkis common in the tropics and subtropics. Rarely, the eyelidand genitalia can be affected. It typically starts as a smallnodular TB deposit under the epithelium of the skin,pushing its way to the surface to appear as a translucentmass of variable size, with surrounding erythema. As itslowly increases in size and becomes more protuberant,nodules increase in number, spreading by peripheraldeposition. The spread is very slow, but eventually a lupuspatch is formed. Its irregular periphery shows activelyspreading changes, while the center shows retrogressivechanges of cicatrization or ulceration, which in either caseleaves a scar.The lesion has a tendency to spread. There may beinvolvement of the nasal, buccal, and conjunctival mucosaprimarily or by extension. Conjunctival involvement canpresent as hypertrophic papillar y conjunctivitis,ulceration, or tumor formation. Extension to the anteriorocular surface can cause irreversible visual damage. 1Destruction of cartilage within the affected area may alsobe seen, but bone is usually spared.Clinical diagnosis of lupus vulgaris is difficult to makesince it presents in various forms and mimics other diseaseentities. It can present in plaque, hypertrophic, ulcerative,and vegetative forms. 1, 2 It typically manifests in its plaqueform, characterized by discrete, reddish to brown papulesof gelatinous consistency (“apple jelly” nodules), whichevolve slowly by peripheral extension and central atrophyand scarring into large plaques. Its active edge may bethickened and keratotic. The hypertrophic form showssoft tumor nodules, is deeply infiltrating, but relativelyleaves no ulceration and scarring. In the ulcerative form,there is crust formation over necrotic and friable tissue.Involvement of deep tissues and underlying cartilage canlead to contracture and deformity. The vegetative form ischaracterized by marked necrosis and ulceration, proliferativeand papillomatous granulation tissue, and minimalscarring. Complications of lupus vulgaris are secondarybacterial infection, deformity and mutilation, contractures,and malignant degeneration. 2In this case, the skin lesion was limited to the eyelid,malar, and nasal areas with no involvement of the ocularsurface or underlying nasal cartilage. It presented as theulcerating and necrotizing form of lupus vulgaris,complicated by secondary streptococcal and staphylococcalinfection. Differential diagnoses included atypicalmycobacterial infection, necrotizing fasciitis, ecthymagangrenosum, pyoderma gangrenosum, and cryptococcosis,all of which can present as ulcerative lesions.Ideally, the diagnosis of lupus vulgaris is based onpositive findings in chest radiograph, Mantoux test,incisional biopsy, AFB culture, and polymerase chainreaction (PCR). However, culture for bacilli may not alwaysyield positive results. Several reports showed that only 6%of cutaneous cultures from patients with lupus vulgariswere positive. 3 Furthermore, demonstration of AFB maybe difficult especially in chronic lesions and with a highdegree of immunity against infection. PCR provides rapid,specific and sensitive testing for Mycobacterium tuberculosis;however, its high cost and need of expertise limits itsroutine use. Because of this, the diagnosis is mainly basedon the Mantoux test, histopathologic picture, andresponse to chemotherapy. 4, 5 In the present case, AFB wasdemonstrated in the skin biopsy, but culture for AFByielded negative results. Mantoux test was positive. Thehistopathologic studies showed chronic granulomatousinflammation with epithelioid cells and multinucleatedgiant cells. Marked improvement in the skin lesion wasalso noted after initiation of triple antituberculous therapy.Treatment of lupus vulgaris is based on the multidrugregimen recommended for systemic tuberculosis becauseof the strong association of cutaneous tuberculosis withsimultaneous visceral involvement. Response to treatmentcan be used as a basis for diagnosis.Awareness of the possibility of lupus vulgaris, with itsvarious clinical manifestations in cases of chronic, progressivelyenlarging skin lesions is very important. Early andcorrect diagnosis and prompt and adequate treatment,can prevent extensive and irreparable damage to involvedstructures.References1. El-Ghatit AM, El-Deriny SM, Mahmoud AA, Ashi AS. Presumed periorbital lupusvulgaris with ocular extension. Ophthalmology 1999; 106: 1990-1993.2. Barbagallo J, Tager P, Ingleton R, et al. Cutaneous tuberculosis: diagnosis andtreatment. Am J Clin Dermatol 2002; 3: 319-328.3. Farina M, Gegundez I, Pique E, et al. Cutaneous tuberculosis: a clinical,histopathologic, and bacteriologic study. J Am Acad Dermatol 1995; 33: 433-440.4. Ramesh V, Misra RS, Beena KR, Mukherjee A. A study of cutaneous tuberculosisin children. Pediatr Dermatol 1999; 16: 264-269.5. Mlika RB, Tounsi J, Fanniche S, et al. Childhood cutaneous tuberculosis: a 20-year retrospective study in Tunis. Dermatology Online Journal 2006; 12: 11.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 87

VOL. 32 • NO. 2PHILIPPINE JOURNAL OFOphthalmologyJULYLECTURE– DECEMBER 2007Salvador R. Salceda, MDUniversity of the Philippines ManilaManila, PhilippinesGeminiano T. De Ocampo Medical ResearchFoundation Centennial LectureEye-cornea bank for sightrestoration in the PhilippinesTHE CORNEA is the clear, transparent circular structure that constitutesthe anterior one-fifth of the outermost coat of the eye. It serves as the firstwindow of the eye for light to reach the photosensitive layers of the retina.More than simply permitting light transmission, the cornea is also a powerfulrefracting medium. Its refractive property is due to 5 attributes: surface,curvature, refractive index, interference pattern, and transparency. When anyof these attributes is lost because of disease, as in scarring, the cornea fails toperform its most important function—to help provide clear vision. Surgicalreplacement of the diseased cornea becomes necessary for the eye to regainfunctional vision, hence the need for an eye or cornea bank.Diseases of the cornea are not uncommon in the Philippines. Valentonet al., in a 20-year study (1971 to 1991) of patients seen at the ExternalDisease Clinic of the Philippine General Hospital (PGH), showed that 6,176or 43.2% of the 14,553 cases were diseases of the cornea. 1 Relevantpublished reports from 1936 to 1995 2-9 indicated that 6.8% to 14.7% ofblindness cases in one or both eyes were due to corneal diseases. That themajority of them could benefit from corneal transplantation was shown inanother study. At the PGH Cornea Clinic, of the 448 new cases seen in a12-month period (1971 to 1972), 244 or 54% needed corneal grafting 10 torestore useful vision. Thus, the need for human eyes or corneas.It can be rightly said that the progress of ophthalmology in the Philippinescannot proceed without a functioning eye bank.Correspondence toSalvador R. Salceda, MDEmeritus Professor, OphthalmologyUniversity of the Philippines ManilaPedro Gil Steet, Ermita1000 Manila, PhilippinesTelephone : +63-2-7237944Delivered at the Geminiano T. de Ocampo MedicalResearch Foundation Centennial Lecture, September4, 2007, Philippine Science Heritage Center.The BeginningThe seminal work on human-eye banking in the Philippines started in 1948.It was three years after the American eye surgeon, Dr. R. Townley Paton,established the Eye Bank for Sight Restoration in 1945 in New York City. 11Dr. Edmundo Reyes, a Filipino Eye-Ear-Nose-Throat (EENT) specialist andhis brother, Justice J.B.L. Reyes, were requested by Dr. Geminiano de OcampoKeywords: Cornea, Corneal transplant, Eye bank, Organ donation, BlindnessThe author has no proprietary or financial interest inany product used or cited in this study.PHILIPP J OPHTHALMOL 2007; 32(2): 88-93© PHILIPPINE ACADEMY OF OPHTHALMOLOGY88 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

to craft a bill on human-organ donation for medical andscientific purposes. 12 The bill was introduced in the PhilippineCongress by Senator Lorenzo Tanada in April 1948.It became the Republic Act (RA) 349, signed by PresidentElpidio Quirino on May 17, 1949 as the first law ondonation of human organs including the eyes.Dr. Geminiano de Ocampo returned to Manila in 1947.He completed a year of Kellogg fellowship, which introducedhim to corneal transplantation, among other fields,at the Johns Hopkins University in Baltimore, Marylandand at the Columbia Presbyterian University in New YorkCity. He was a member of the consultant staff of the EENTDepartment at PGH, the national medical referral centerin the country at the time. He was aware of the highprevalence of blindness due to corneal pathologies amongFilipinos. Sourcing eyeballs for those suffering fromcorneal blindness became his obsession. Thus, an eye bankwas organized at the PGH in May 1948 even before thepassage of the law on human-organ donation. 12 It was withthe approval of the hospital director, Dr. Antonio G. Sison,and the chief of clinics, Dr. Carmelo Reyes. The bankpaved the way for the first full-thickness corneal graftingto be performed by Dr. Geminiano de Ocampo in June1949 at St. Luke’s Hospital. 13With RA 349 permitting the removal of eyeballs formedical and scientific purposes as long as the donor hadexecuted a deed of donation before death, it was just amatter of time before the first national eye bank wasestablished. This happened on November 27, 1950through the efforts of American Ray Higgins of thePhilippine Blood Bank, Dr. Geminiano de Ocampo, andDr. Jesus Tamesis Sr. When incorporated in 1951, the bankbecame known as the Philippine Eye Bank for SightRestoration (PEBSR). It became the first eye bank inSoutheast Asia, ahead of those in Japan, India, Ceylon,and Hong Kong.The existence of the law and the eye bank notwithstanding,donations of human eyeballs for medical purposeswere scarce and far between. During the first 2 years ofthe bank’s operations, it became clear that RA 349 neededsome amendments, specifically on the matter of thedonor’s consent.RA 349 as amended became RA 1056, signed byPresident Elpidio Quirino on June 12, 1954. The newprovision explicitly stated that permission to remove theeyeballs “may be granted by his nearest relative or guardianat the time of his death or in the absence thereof by hisnearest relative or guardian at the time of his death or inthe absence thereof by the person or head of the hospitalor institution having custody of the body of the deceasedprovided, however, that the said person or head of thehospital or institution has exerted reasonable effort tolocate the aforesaid guardian or relative.” The newprovision had the prior endorsement of Secretary TeodoroEvangelista, Health Secretary Juan Salcedo, and JusticeSecretary Jose Bengson. Senator Lorenzo Tanada, theoriginal author of RA 349, with the help of Senator JoeLocsin, Congressman Arturo Tolentino, and CongressmanVenancio Ziga successfully worked for the inclusion of thenew provision.In 1956, Pope Pious XII issued an encyclical stating thatthe Catholic Church was not against the donation ofhuman organs and eyeballs for medical purposes. It washoped that the papal blessings would help the work onhuman-eye banking.Early State of Eye BankingIn the 1950s, the scientific and technologic knowledgeand practices on eye banking were simple if not primitiveby present standards. The collection and storage procedureswere less demanding than present eye banking. Atthe time, the eyeballs were enucleated within 6 hours afterdeath, cleansed in solutions with penicillin, and stored inthe moist chamber of sterile stoppered bottles at –4degrees Celsius inside an average refrigerator. When usedas full-thickness grafts for visual purposes, the corneas hadto be transplanted within 48 hours after enucleation.It was not unusual that corneas were immediately transplantedafter enucleation. Patients for keratoplasty werealready in the hospital. Eyeballs not used within 2 daysafter enucleation or considered inappropriate for fullthicknessvisual keratoplasties were transferred and storedin absolute glycerin. Their corneas were used either foranterior lamellar, tectonic, or therapeutic keratoplasties.Unused eyeballs became materials for research.There were, however, important problems that stoodin the way of the future and progress of the country’s firsteye bank. The Filipino’s cultural bias against organdonation, raging professional rivalries, lack of committedleadership with the willingness to “manage interdependence”among varied but complementary expertiseand resources contributed to the “touch and go” affairthat was the fate of the first eye bank. Succeeding leadershipsof the eye bank did everything possible not to letthe bank wither on the vine. To support its work, 2 majorprograms were organized and institutionalized: SightSaving Week and the Society for the Prevention ofBlindness.Sight Saving WeekThe problem of eye donations was addressed formallywhen President Ramon Magsaysay issued a proclamationin 1953 for the annual observance of the Sight SavingWeek. 12 With the help of Dr. Romero Atienza, presidentof the Philippine Medical Assocation, the Philippine EyeBank (PEB) worked for the presidential proclamation.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 89

The Sight Saving Week had 2 main objectives: to makeFilipinos aware of the importance of sight and encouragethem to organize special groups assigned for the week’scelebration. Prominent civic-minded businessmen wererequested to head the groups. Romeo Villongco, ErnestoRufino, Leopoldo Rovira, Manuel del Rosario, and HenryAng were some of them.Philippine Society for the Prevention of BlindnessThe positive response of the public to the Sight SavingWeek led to a decision to expand the activities on sightpromotion and blindness prevention. In 1959, the PhilippineSociety for the Prevention of Blindness was organizedthrough the efforts of Dr. Geminiano de Ocampo, representingthe PEB, and Dr. Carlos Sevilla as president of thePhilippine Society of Ophthalmology and Otolaryngology.Dr. Severino Lopez became the society’s first president.The society took over the work on the observanceof the Sight Saving Week. It conducted regular nationwidepublic-information campaigns on the importance ofsight and eye care while appealing for eyeball donations.The society was active until Martial Law was declared in1972. It was rehabilitated in 1979 with Dr. Edgardo Caparasas secretary general. 14Human-Cornea BankBy the 1960s, the PGH Cornea Clinic, established in1950, had become the largest referral unit for patientswith corneal diseases from all over the Philippines. Manyof the patients needed corneal transplantation for visualreasons. Studies on the use of corneal heterografts, e.g.,chicken and monkey eyes, proved unavailing because ofimmunologic rejection. 15 The need to unravel the Mindorocorneal blindness was high on the research agenda at theclinic. 16 Keratoprosthesis was yet in the seminal stages.In 1964, I was a research associate at the Cornea Clinicfor projects funded by the National Science DevelopmentBoard (NSDB). Arrangements were made between theDepartments of Pathology and Ophthalmology to permitthe latter to collect corneas from human cadavers broughtto the morgue for autopsy. I started collecting cornealbuttons for patients already admitted to the beds of theEye Department of the PGH and for the studies on cornealviability. 17-20In a period of 2 years, 322 corneal buttons werecollected: 118 full thickness, 188 anterior lamellae, and16 posterior lamellae. Of these specimens, 86 were usedfor homografting for various types of corneal disorders:28 full thickness, 56 anterior lamellar, and 2 posteriorlamellar keratoplasties. The rest of the specimens wereused in various experiments on corneal viability. 21I returned to Manila in 1967, after a two-year US Public-Health, Education, and Welfare postdoctoral researchfellowship at the Institute of Neurological Diseases of theNational Institutes of Health in Bethesda, Maryland, tofind a full-functioning cornea bank. Many innovations hadbeen introduced, 22 foremost of which was the system ofpostmortem cooling of cadaver eyes prior to harvestingthe corneas and the subsequent cooling of the harvestedcorneas. 23 Dr. Mario Valenton invented an instrument thatfashioned black plastic conformers from used X-ray platesfor repairing the anterior segment of the eyes after thecorneas had been removed.Renewed Efforts for Human-Eye DonationsWhile the PGH eye patients could hope to have cornealgrafting, it was not so in other hospitals. Dr. Jesus TamesisSr., who performed the second corneal transplantationin the country in 1950, was largely dependent on whatthe PEB could occasionally provide him. So did Dr. CarlosSevilla who also began performing corneal transplantation.Dr. Sevilla had the distinction of helping mobilizethe society’s elite to support the work of the eye bank.Dr. Manuel Hechanova returned to the Philippines in1965 after training in the USA. He informed me thatBenjie Kosloff was a very active chairperson of the PEB.Together, they helped establish a linkage between theBureau of Prisons and the PEB to enable the latter tosecure donations from inmates.Other Filipino eye surgeons had to rely on eyeballs thatbegan to trickle to Manila from Sri Lanka. Some of thesesurgeons included Dr. Cayetano Mangahas, Dr. CosmeNaval, and Dr. Rodolfo Chuanico. Dr. Naval’s first cornealtransplant, done in 1970, was in fact an autotransplantfor want of a donor homograft.The media was once again requested to help in thesolicitation of donors for human eyeballs. Letty JimenezMagsanoc was one of those who wrote articles about theeye problems in the country. In one of her articlespublished in the Philippine Panorama on July 5, 1970, shequoted the assistant director of the Philippine EyeResearch Institute: “The need for sufficient numbers ofhuman corneas, both for clinical uses and researchpurposes, has not been adequately met by us. While inthe USA and in most countries of Europe, such specimensare in abundance, in the Asia-Pacific area, including thePhilippines, there is a dire need for them.” 24The help of the media continued for several years. Anarticle by Jennie Ilustre of the Times Journal published onMarch 29, 1975 carried the subtitle “The Philippine EyeBank for Sight Restoration Inc. is a unique bank. It is alwaysempty.” 25 This essentially captured the state of the PEB inthose years.But the public was not totally indifferent. Earlier,Rosalinda Orosa in her column, Week of Gallant Gestures,in the March 22, 1976 issue of the Philippine Daily Express 2690 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

wrote about how the famous Betsy Westerndorp de Briasgenerously donated the eyes of her deceased husbandAntonio Brias, an executive of San Miguel Corporation.The corneas were used on 2 indigent patients at the PhilippineGeneral Hospital.Miss Orosa wrote further: “Ever since Dr. Salcedaperformed the said corneal transplant (using herhusband’s eyes), Mrs. Brias has made the cause of the blindpeople her own, encouraged as she is by the lastingbenefits that have been derived from her husband’sdonation. She has now pledged her own eyes to the eyebank. Her three daughters—Sylvia, Isabel, and Carmen—have followed suit.”“Moved beyond words by these facts, Mrs. Brias has sincethen made the campaign for the blind her magnificentobsession. One Saturday, when the “Saturday Group”—established painters and neophytes who meet to paintevery weekend—gathered in her house for one of theirregular sessions, she lost no time in soliciting donations.”“The first person she talked to was Galo Ocampo whospread the word during his conference. They quicklyresponded and before the afternoon was over, HROcampo, Cesar Legaspi, Cenon Rivera, Tony Nuyda, OnibOlmedo, along with recent art recruits like HernandoAbaya, have verbally pledged their eyes to the eye bank.”“Most famous donor on that same occasion was sirenturned-photographerGina Lollobrigida. With three morethan willing assistants in tow, the famous Lollo ha[d] cometo take pictures of the artists’ model.”The sustained support by the media to the PEB drewpublic attention to ophthalmology in the Philippines. Theextensive media coverage of the 1974 epidemic of hemorrhagicconjunctivitis in the country served to rally publicsupport to the work on eye banking.In 1974, no less than Doña Josefa Edralin-Marcos,mother of then president Ferdinand Marcos, generouslyserved as the honorary chairperson of the Philippine EyeBank. She helped solicit eye donations. During theobservance of the Sight Saving Week in August 1974, shetransferred the many pledges to Mrs. Gloria Mascardo,chairperson of the PEB. Present during the ceremonieswere Mrs. Trinidad Mangubat representing the LionsClub, and the Director of the Philippine Eye ResearchInstitute who was concurrently the president of theNational Council on Blindness. 27Mrs. Mascardo became the chairperson of the PEB in1971 when Mrs. Benjie Kosloff left for the USA. Mrs.Mascardo was the wife of customs collector Mr. SalvadorMascardo. She strengthened the arrangement with theBureau of Prisons, such that eyeballs can be collected fromdeceased inmates. She also facilitated donations of eyeballsfrom Ceylon.On November 19, 1971, Mr. A.T. Artyaratne personallyhandcarried 4 human eyeballs to Manila. 28 Mr. Artyaratnewas the 1969 Ramon Magsaysay Awardee for CommunityService. Ceylon (Sri Lanka) Charge d’Affaires Mr.N.M.M.T. Hussain and his lovely wife tendered a receptionfor the awardee on November 21, 1971. Officers ofthe PEB and the 4 Filipino ophthalmologists who were touse the corneas for transplantation were invited. The eventmarked the beginning of the regular shipment of eyeballsfrom Ceylon to Manila via Philippine Airlines.The supply of eyeballs from Ceylon continued for almosta decade. Dr. Hudson Silva, who became the president ofthe Eye Bank of Sri Lanka, visited the Philippines on March20 and September 20, 1980. Mrs. Mascardo hosted Dr. Silva’smeeting with local ophthalmologists at her office at theCentral Bank. Dr. Silva also gave lectures on eye banking atthe then Philippine Eye Research Institute, UP HealthScience Center.Rather than being fully dependent on foreigndonations of eyeballs, several Filipino ophthalmologistsdedicated time to help the Philippine Eye Bank. Notablewas Dr. Liborio Mangubat whom I accompanied on twooccasions to meet with Mrs. Mascardo. The agenda was toexplore how the Philippine Society of Ophthalmologycould help the eye bank. Dr. Mangubat was president anda very active member of the San Juan Lions Club.Dr. Edgardo Caparas also explored how the Rotary Clubof Manila could help the eye bank. In 1993, he thought ofsituating an eye bank at the Eye Referral Center. Hisinterest was the natural consequence of his first-handexperience with people suffering from corneal blindness.Dr. Caparas was very much involved in the outreach eyeclinics of the Rotary Club in various parts of the country.Breakthrough for Cornea BankingMeanwhile, the technology of eye and cornea preservationwas unraveling. The specular microscope had arrivedfor in vivo observation of the human corneal endothelium.Early basic studies and experiments on animal and humancorneal endothelium were beginning to show their clinicalusefulness. The structural and functional integrity of thecorneal endothelium could already be preserved forextended periods of time. In media containing nutrientsin appropriate pH and osmolarity, and stored at +4 degreesCelsius, endothelial cells could remain viable for as longas 14 days. 29-32 When used in homograft full-thicknesskeratoplasties, corneas so preserved resulted in cleargraft. 33-35The preservation media prolonging the viability of theendothelium facilitated the storage and transfer of donorcorneas. Corneal buttons and not eyeballs were beingcollected. The new and improved collection and preservationof corneal buttons contributed to the increase inthe number of donor materials.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 91

The Philippines became one of the recipients ofpreserved human corneal buttons. Donations fromAmerican eye banks to Manila were facilitated by the LionsInternational. I was one of the lucky recipients of regularcorneal buttons from USA through this system. 35 It maybe said that this new system of collecting and preservingcorneal buttons facilitated the establishment of corneabanks.The New Eye-Cornea Bank in the PhilippinesThe ebb and tide that characterized earlier work on eyebanking in the Philippines are, at long last, over. For thefirst time, the country has a truly operational eye-corneabank. The bank is predictably able to provide high-qualitycorneal and scleral tissues in sufficient quantity for visual,therapeutic, and tectonic transplantation proceduresamong truly deserving recipients irrespective of social andeconomic status. It has facilitated work on teaching andtraining Filipino ophthalmologists in corneal transplantationsurgery, and on the all-important need to undertakescientific research to help push the frontiers of ophthalmicscience specially as it pertains to Filipinos. 36-37The Sta. Lucia International Eye Bank of Manila(SLIEBM) started operating on October 16, 1995, some19 months after the Eye Bank Foundation of the Philippines(EBFP) was organized on March 17, 1994. Havingmet the required international quality standards andguidelines, the SLIEBM has developed into a world-classeye bank (Felton PA, De’ Lap DJ. Gold standard in internationaleye banking. Pesonal communication, 2007). Itis a recognized member in the world’s network of eyebanks that constitute the International Federation of Eyeand Tissue Banks International (IFETB/TBI).The SLIEBM as the Philippine Eye Bank and the Foundationthat operates it are the singular work and accomplishmentof Dr. Ma. Dominga B. Padilla. From the timeshe was completing her residency training in ophthalmologyat the Philippine General Hospital in 1987 to 1989and through her fellowship at the Institute ofOphthalmology in 1990, UP Manila, establishing a neweye bank had become her apostolate. This I know. In herown words, she talked about her rendezvous with destiny:“As you very well know, I always remember the brainstormingsessions we had in the Institute of Ophthalmology.You would usually pull both Vic Caparas andmyself and talk to us about not to be content beingordinary ophthalmic practitioners. You made us deeplyaware, being who we are, of our special responsibilities,and to seriously do something about the lack of an efficienteye-banking system in the country. Well sir, I believe youprophesied when you uttered these words then.”It must have been her growing interest in the corneaand eye bank that in 1991, she helped me set up theSpecular Microscopy Laboratory at the Institute ofOphthalmology. She worked for the donation of a KonanST 500 Contact Specular Microscope from the philanthropistDon Emilio Yap. At the time, the other specularmicroscope acquired in 1982 was in the Eye ReferralCenter.The work strategic to the birth, growth, and developmentof the new eye-cornea bank done by Dr. Padilla isdifficult to chronicle. A few may be mentioned: She singlehandedlyorganized the EBFP that operates the eye-corneabank. She helped in the amendment of the old RA 1056to become RA 7170, the Organ Donation Act of 1991.But more important was the crafting of the operative lawof the current eye-cornea banking. RA 7885 of 1995entitled An Act to Advance Corneal Transplantation inthe Philippines amended RA 7170 to permit the removalof the cornea with a rim of sclera for medical and scientificpurposes. No longer is it necessary to remove the entireeyeball. The amendment was approved in the House ofRepresentatives on February 13, 1995 and in the Senateon February 15, 1995.So thorough is Dr. Padilla’s understanding of thedynamics of eye-tissue banking that hers has been a systemsapproach to the problems involved. She resolved the legalbasis and dealt with the organizational and operationalissues of the bank. Once the bank was granted the neededspace at the Makati Medical Center, where it was originallylocated, she proceeded to establish the relevant supportmechanisms. These mechanisms include the hiring andtraining of the necessary personnel; the signing ofagreements with the Philippine Airlines, Aboitiz Air, andLBC couriers for transporting the eye tissues to differentparts of the country; the setting up of a Surgical Fund forIndigent Patients supported by ABS-CBN, AboitizFoundation, and the Tissue Bank International, amongothers; the establishment of the Hospital RetrievalProgram to help diversify sourcing of eye-tissue collections;and insuring the close collaboration and support of thePhilippine National Police and the National Bureau ofInvestigation. In May 2004, she signed a memorandum ofagreement with then Health Secretary Dr. Manuel Dayritfor the bank to include government hospitals as part ofthe network of institutions for cornea retrieval.Truly, the new eye-cornea banking under its dedicatedleadership provides new windows of opportunity forrestoring sight to those suffering from corneal blindness. 38The bank reported on March 31, 2004 that it had collected5,919 corneal and scleral tissues since the start of itsoperations in 1999. At present, the bank processes anaverage of 140 corneas a month. This size of the harvestenables the bank “to supply not just optical tissues aroundthe world, with priority to the Philippines, Asia, and theMiddle East, but tissue for training” (Padilla MDB.92 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Personal communication, June 21, 2007).The bank plans to start a training program on eyecorneabanking for people from other countries who wishto come to the eye bank for training. Indeed, the bank inits new home at the Sentro Oftalmologico Jose Rizal insidethe PGH Compound is awash with plans that includeprocessing other human tissues for glaucoma andophthalmic plastic surgeries.It is a tribute to Dr. Ma. Dominga B. Padilla, her fellowofficers and coworkers, and the members of the board oftrustees that the SLIEBM, known as the Philippine EyeBank, is rated a “world-class eye bank.” Accordingly, thebank has been the recipient of the Tissue Bank InternationalAward for “exemplary work in sight restorationfor the corneally blind” in 1998, and the First PhilippineAcademy of Ophthalmology-Jesus Tamesis Sr. Award forcommunity service in 2000.References1. Valenton MJ, Dy-Liacco JU, Espiritu CG. Corneal and external-disease problemsin the Philippines. Phillip J Ophthalmol 1993; 1: 2.2. Ubaldo A. Blindness among Filipinos. J Phil Med Asso 1936; 16: 223.3. Salceda SR. Towards a Program of Research in Ophthalmology. Manila: Instituteof Ophthalmology, University of the Philippines Manila, 1995.4. Fojas M, De Ocampo G, Portes J. Survey of blindness in Bay, Laguna. Phillip JOphthalmol 1969; 1: 14.5. Alianza LC. A study on the incidence of blindness. Phillip J Ophthalmol 1976; 8: 67.6. Fajardo R. Causes of blindness in the Philippines. Trans VI Congress of Asia PacificAcademy of Ophthalmology, Surabaya, 1976.7. Gestuvo R. Frequency of blindness in Davao City. Phillip J Ophthalmol 1977; 9:136.8. Ramirez RA. The Institute of Ophthalmology 1987 Blindness Survey. Manila: Instituteof Ophthalmology, University of the Philippines Manila, 1987.9. Olivar-Santos E. The Second National Survey of Blindness in the Philippines. PhillipJ Ophthalmol 1995; 25: 2.10. Salceda SR. Corneal ulcer: a cause of preventable blindness in the Philippines.Phillip J Ophthalmol 1975; 7: 110.11. Troutman RC. Microsurgery of the anterior segment of the eye. In: The Cornea:Optics and Surgery. St. Louis: CV Mosby Co, 1977; v. 11.12. De Ocampo G. Ang kasaysayan ng Linggo ng Pagingat ng Paningin sa Pilipinas. JPhilipp Med Asso 1963, 39: 8.13. De Ocampo G. Corneal transplantation. First case report in the Philippines. J PhilippMed Asso 1949; 25: 601.14. Caparas ET. Philippine Society for the Prevention of Blindness. Phillip J Ophthalmol1979; 11:.15. De Ocampo G, Sunga R, Cruz-Estrella C. The use of chicken and monkey corneain human corneal grafting. In: G De Ocampo, Choice of Keratoplasty. Transcript ofthe First Congress of Asia Pacific Academy of Ophthalmology, Manila, 1960.16. De Ocampo G, Salceda SR, Portes J. Mindoro blindness from corneal degeneration.J Philipp Med Asso 1963; 39: 12.17. De Ocampo G, Salceda SR. The human cornea bank. Oriental Arch Ophthalmol1965; 3: 14.18. De Ocampo G, Salceda SR. The use of acellular cornea in keratoplasty. Am JOphthalmol 1965; 59: 61.19. De Ocampo G, Salceda SR. Basic viability observation and experiences on cornealendothelium. J Philipp Med Asso 1965; 41: 867.20. De Ocampo G, Salceda SR. A biologic viability test for corneal endothelium. Am JOphthalmol 1966; 61: 1514.21. De Ocampo G, Salceda SR, De Leon A. A Human cornea bank. In: De OcampoArticles and Publications, Manila, 1968. v. 4.22. De Ocampo G , Salceda SR, De Leon A, et al. Some mechanical devices for corneaand eye bank. Presented during the National Science Technology week, First PostWar National Science Convention, Manila, 8 July 1968.23. De Ocampo G, Li JT, Gestuvo RG. Ocular postmortem cooling for preserving thehuman corneal endothelium. J Philipp Med Asso 1968; 44: 7.24. Jimenez-Magsanoc L. Victims of crisis: government lack of vision snags eyeresearches. Philippine Panorama, July 5, 1970.25. Ilustre JL. This bank is always empty. Times Journal, March 29, 1976.26. Orosa R. A week of gallant gestures. Gina donates eyes. Philippine Daily Express,March 22, 1976.27. Eye Donation Pledges. Philippine Daily Express, August 9, 1974.28. Francisco RS. Eye transplant. The Manila Times, November 21, 1971.29. McCarey BE, Kaufman HE. Improved corneal storage. Invest Ophthalmol 1974;13: 165.30. McCarey BE, Meyer RF, Kaufman HE. Improved corneal storage for penetratingkeratoplasties in humans. Ann Ophthalmol 1976; 8: 1488.31. Friedland BR, Forster RK. Comparison of corneal storage in McCarey-Kaufmanmedium, moist chamber of standard eye-bank condition. Invest Ophthalmol 1976;15: 143.32. Stein RM, Bourne WM, Campbell RJ. Chondroitin sulfate for corneal preservationat +4 C. Evaluation of electron microscopy. Arch Ophthalmol 1986; 104: 1356.33. Stark WJ, Maumenee AE, Kenyon KR. Intermediate-term corneal storage forpenetrating keratoplasty. Am J Ophthalmol 1975; 79: 115.34. Van Horn DL, Schultz RO. Corneal preservation: recent advances. Surv Ophthalmol1977; 21: 301.35. Salceda SR, Alejo-Ramirez LR, Marin JD. Intemediate-term preserved corneas inpenetrating keratoplasty. UP Manila Jour 1995; 1: 1.36. Padilla MDB, Sibayan SAB, Gonzales CSA. Corneal endothelial cell density andmorphology in normal Filipino eyes. Cornea 2004; 23: 129.37. Padilla MDB, Eltanal-Pascual MAT. Indication for penetrating keratoplasty in thePhilippines. Philipp J Ophthalmol 2005. 30: 4.38. Salceda SR. Challenges for the Filipino ophthalmologists in the next millenniumPAO Focal Point 2000; 5: 6.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 93

VOL. 32 • NO. 2JULYINDEX– DECEMBER 2007AAnterior chamberconcentration of fluorescein in, 57depth, in patients with normal-tenstion glaucoma,primary open-angle glaucoma, angle-closureglaucoma, ocular hypertension, 6association with central corneal thickness, 7-8Applanation tonometrypossible sources of error in, 5Aqueous humordefinition, 57flowdetermination of, 57determinant of intraocular pressure, 57variations in, 58correlation with anterior-chamber depth andvolume 56, 58-59factors that influence, 59fluorophotometric measurements of, in Filipinoeyes, 56gender difference in, 59formation, 57functions, 57Aqueous outflowfacilityassociation withage, 58anterior-chamber depth and volume, 58pachymetry, 58ratein relation to intraocular pressure, 57Artificial tearsin management of dry-eye disease, 19Autoclavecompared with glass-bead sterilizer, 25Autologous serumbeneficial effects, 23compared withartificial tears, 24conventional therapies, 24unpreserved hypromellose, 24unpreserved normal saline, 23early application in Sjogren’s syndrome, 19eye dropsbenefit to patients with severe dry eyes, 19compared with unpreserved hypromelose, 18tolerability of, in dry-eye disease, 23Axial lengthassociation with central corneal thickness, 7effect on central corneal thickness, 8BBacillus subtilissusceptibility to colloidal silver, 9, 11Balloon dacryocystoplastydescription, 49for treatment of congenital nasolacrimal-ductobstruction, 48Bicanalicular silicone intubation, 49Blebsurvival rate with triamcinolone, balanced salinesolution, mitomycin-C, 60Blindnessarising from corneal diseases, 88Bone decompressionin Graves’ orbitopathy, 29CCannulafor removal of silicone oil, 39advantages, disadvantages, 39Carbonic anhydrase inhibitor, 77See also dorzolamideCCT. See central corneal thicknessCentral corneal thicknessamong different races, 77among Filipino patients with ocular hypertension,glaucoma, 4association withanterior chamber, 7axial length, 7correction to avoid overestimation,underestimation, 8correlation withanteriod-chamber depth, 8axial length, 8intraocular pressure, 6, 79differences among racial and ethnic groups, 5in glaucomatous eyes, effect of dorzolamide on, 76in patients with ocular hypertension, glaucoma, 5, 694 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

normal value in Filipinos, 7risk factor for glaucoma, 5relationship with intraocular pressure, 4, 77source or error in applanation tonometry, 5Central-retinal-vein occlusiondevelopment in Frosted-branch angiitis, 40Chordomaintracranialassociation with multiple-cranial-nerve palsy, 42presentation, 43subtypes, 43Chorioretinopathycentral serouscharacteristics of, 33-34pathologic mechanisms in the development of, 33Choroidal hypofluorescencein Frosted-branch angiitis, 41CME. See cystoid macular edemaCNLDO. See congenital nasolacrimal-duct obstructionColloidal silverantimicrobial potency compared withtobramycin, lomefloxacin, and moxifloxacin, 9composition, 10conditions and agents that affect the stability of, 11inhibitory activity, 9against S. aureus, S. epidermidis, 11medical uses since the 1900s, 10potency of, 10resurgence in the use of, 10Competitivenessof Filipino doctors in a globalized world, 3Congenital nasolacrimal-duct obstructionfirst-line treatment for, 48treated with balloon dacryocystoplasty, 48Contact lensmonovisionacceptance for presbyopia, 14compared withbifocal-contact-lens correction, 16reading glasses, 12contrast sensitivity, 15factors that affect acceptability, 16effect on quality of life, 16stereoacuity, 15-16success rates in presbyopia, 15-16visual acuitycompared with binocular vision, 16in presbyopia, 14Corneabanking, history and development in the Philippines,88concentration of fluorescein in, 57diseased, surgical replacement of, 88diseases of, incidence in the Philippines, 88functions, 88technology for preservation of, 91Corneal endothelium, 79pumping function of, 77Corticosteroiduse in filtration surgery, 61CRVO. See central-retinal-vein occlusionCSC. See chorioretinopathy, central serousCystoid macular edemacauses of, 44description, 44role of optical coherence tomography in diagnosisand monitoring of, 44with inflammatory foveal mass, 44DDiplopiadevelopment after transantral decompression, 29incidence after lateral-wall decompression, 30Dorzolamideeffect oncentral corneal thickness, 76-77, 79corneal-endothelium cells, 79endothelial-cell count, 76Dry eyesaqueous-tear-deficient, 18pathology and treatment, 19Dry-eye syndrome, 74EEscherichia colisensitivity to colloidal silver, 9, 11Endothelial-cell countdetermination of, 79effect of dorzolamide on, 76Endothelial-cell function, 79Episcleral venous pressurein relation to inraocular pressure, 57Eye Bank Foundation of the Philippines, 92Eye bankinghistory and development in the Philippines, 88-93scientific knowledge and practices in, 89FFat decompression, 31FBA. See frosted-branch angiitisFLP. See focal laser photocoagulationFluorescein, 57use in measuring tear-breakup time, 74Fluorophotometrydefinition, 57uses of, 58PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 95

Fluorotron Master, 57Focal laser photocoagulationfor treatment of central serous chorioretinopathy,33, 35Frosted-branch angiitisdescription, 40with retinal-vein occlusionangiographic and optical-coherence-tomographyfindings in, 40GGlass-bead sterilizercompared with autoclave, 25, 26uses in dental practice, 26Glaucomacorrelation of central corneal thickness andintraocular pressure in, 4filtration surgerypurpose, 61Glutaraldehydeuse in sterilizing ophthalmic instruments, 26Graves’ orbitopathy, 29HHypromellosecompared with autologous-serum eye drops, 18IIdiopathic retinal vasculitis and neuroretinitis, 46cases of, 47diagnosis of, 47use of steroids in, 48Intraocular lens, 81selection of, 82Intraocular pressureconversion factor for adjustment in relation tocentral corneal thickness, 7correction factor in relation to central cornealthickness, 5correlation with central corneal thickness, 6, 79effect of intraoperative triamcinolone on, 60factors that determine, 57in patients with normal tension glaucoma,angle-closure glaucoma, primary open-angleglaucoma, ocular hypertension, 6in retinal surgery using fixed-concentration andfixed-volume perfluoropropane, 67lowering, in filtration surgery, 61overestimation, 5relationship with central corneal thickness, 4, 77underestimation, 5Intraorbital fatremoval, 30IOL. See intraocular lensIOP. See intraocular pressureIRVAN syndrome. See idiopathic retinal vasculitis andneuroretinitisKeeler Tearscope Plus, 71Keratoplasty, 89KLLesionin lupus vulgaris, 87Lupus vulgarisclinical presentations, 85, 87complications, 87description, 85-86diagnosis, 84-85differential diagnosis, 87incidence, 85treatment, 84-85, 87MMitomycin-Cuse in filtration surgery, 61Mycobacterium tuberculosis, 86NNational Institutes of Health, 54Neuropathyopticin thyroid orbitopathy, 29reversal after orbital-fat decompression, 31OOcular adnexa, 84Ocular hypertensioncompared with glaucoma, 8correlation of central corneal thickness andintraocular pressure in, 4diagnostic criteria, 7Ocular Hypertension Treatment Study, 5Ocular-surface-disease indexin dry eye disease treated with autologous-serumeye drops, 23OHT. See ocular hypertensionOHTS. See Ocular Hypertension Treatment StudyOptical coherence tomographyfindings in frosted-branch angiitis, 40for diagnosis and treatment monitoring of cystoidmacular edema, 44Orbital decompressioncoronal approach, 29evolving techniques for thyroid orbitopathy, 2896 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

graded, 30indications for, 31indications in Graves’ orbitopathy, 29infraciliary approach, 29intranasal approach, 29lateral-wall only, 30Lynch incision in, 29medial wall, 30three-wall, 30transantral approach, 29transconjunctival approach, 29Organ Donation Act of 1991, 92OSDI. See ocular-surface-disease indexPPachymetrycorrelation with aqueous-outflow facility 58PAM. See potential-acuity meterPAP. See potential-acuity pinholePDT. See photodynamic therapyPerfluoropropanefixed-volume injection, 67advantages, 67, 68for repair of rhegmatogenous retinal detachment, 69nonexpanding concentration, 67, 69postoperative gas volume, 67use in vitreoreinal surgery, 67PH. See pinhole testPhilippine Eye Bank, 89, 93Philippine Eye Bank for Sight Restoration, 89Philippine Society for the Prevention of Blindness, 90Photodynamic therapyfor treatment of central serous chorioretinopathy, 33Pinhole test 81, 82Potential-acuity meteraccuracy in predicting postsurgery visualoutcomes, 82applications of, 82for testing retinal acuity, 82history of, 82procedure, 82Potential-acuity pinholeaccuracy of, 83applications of, 83for testing ocular diseases, 83procedure, 83Presbyopiadefined, 13incidence, 13monovision correction, 13treatment, 13Proptosisin bone decompression, 29reduction in lateral-wall decompression, 30reduction in orbital decompression, 31RRepublic Act 349, 89Republic Act, 7170, 92Researchchallenges for Filipinos, 54problems in the Philippines, 55salaried model, 54Retinal vasculitis, 40RPE. See retinal-pigment epitheliumSSEAGIG Practice Guidelines Study Group, 5Sight Saving Week, 89Silicone oilremoval using infusion cannula 37, 39tamponade, 38techniques of removal, 38Silveradverse effects of chronic exposure to, 10mechanism of action on microbes, 10St. Luke Research and Biotechnology Division, 54Sta. Lucia International Eye Bank of Manila, 92Staphylococcus aureussusceptibility to colloidal silver, 9, 11Staphylococcus epidermidis,susceptibility to colloidal silver, 9, 11Stereoacuityof monovision contact lens compared with readingglasses, 14Surgerycataractpredicting visual outcomes, 81filtrationpurpose, risks, 61retinal detachmentefficacy of fixed-concentration and fixed-volumeperfluoropropane, 66TTA. See triamcinolone acetonideTBUT. See tear-breakup timeTear filmcomponents and functions, 71instability, 71Tear-breakup timemeasurement of, 70using autologous-serum eye drops, 23with fluorescein dye, 71, 74with prototype xeroscope, 73with noninvasive methods, 74PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 97

Tear-filminstability, 74measurement of stability, 74Thyroid orbitopathydefinition, presentation, 29orbital decompression of, 28Timololeffect on central corneal thickness andendothelial-cell count, 76, 79for treatment of open-angle glaucoma and ocularhypertension, 77Transpupillary thermotherapyadvantages, 35treatment for central serous chorioretinopathy, 32, 33Triamcinolone acetonideefficacy as antifibrotic agent, 60effect onbleb height, compared with balanced saltsolution, mitomycin-C, 63bleb survival, compared with balanced saltsolution, mitomycin-C, 64intraocular pressure, 61, 62proliferation of conjunctival fibroblasts, 61in filtration surgery, 60TTT. See transpupillary thermotherapyTuberculosiscutaneous, 86UUniversity of the Philippines Research Implementationand Development Organization, 54VVideokeratography machine, 71Visionblurredcategories of, 81Vision potentialpractical methods of testing, 81Visual acuityof monovision contact lens versus reading glasses, 14WWound healingafer filtration surgery, 61drugs used to influence, 64effect of triamcinolone on, after filtration surgery, 60XXeroscopeprototype for measurement of tear-breakuptime, 70-71Agulto, M. B., 56, 76Ali, S. A., 42Bodla, A. A., 42Bunagan, G., 12Chan, P. S., 32, 81Comia, G. E. S. J., 56Concepcion, D. D., 9Cua, I., 12De Leon, M. D., 66Dy-Liacco, J. U., 84Golez III, E. D., 76Gruezo, K. G., 60Henson III, R. D. 48Henson, R. D., 48Herrera, J. E. D., 70Hocson III, S. I., 18Hutchison, B., 42Khu, P. M., 4, 60Lat-Luna, M. M., 4, 56, 76Lex, L., 81Lim Bong Siong, R., 12, 18, 70, 84Lo, K. T., 18Lucarelli, M. J., 28Nuevo, J. J. M., 9Palmero, M. O., 28Quilendrino, M. R., 84Ramli, N. M., 46Ronque, P. P. T., 25Ronquillo, Y. C., 60Salceda, S. R., 88Salvosa, F. A. M., 32Sibayan, S. A. B., 3Silva, P. A. S., 60Soriano, J. G., 4Tolentino, L., 12Uy, H. S., 32, 37, 40, 44, 54, 66, 81Valenzuela, R. M., 60Verzosa, L. G., 9, 25Villalon, P. T., 32, 66Zahari, M., 4698 PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Jessica Marie R. Abaño, MDCarlos S. Alberto, MDRobert Edward T. Ang, MDTeresita R. Castillo, MDRaul D. Cruz, MDJacinto U. Dy-Liacco, MDIvo John S. Dualan, MDKristine Margaret Bacsal-Flores, MDGregory Francis Anthony G. Germar, MDRichard C. Kho, MDPatricia M. Khu, MD, MScFranklin P. Kleiner, MDMa. Margarita Lat Luna, MDRuben Lim Bon Siong, MDLeonardo R. Mangubat, MDJesus F. Marin, MDJose Ma. G. Martinez Jr., MDRichard Raymond L. Nepomuceno, MDHeidi D. Remulla, MDJohann Michael G. Reyes, MDSantiago Antonio B. Sibayan, MDAnalyn T. Suntay, MDJocelyn L. Sy, MDJoseph Anthony J. Tumbocon, MDHarvey S. Uy, MDMarissa N. Valbuena, MDMary Rose Pe-Yan, MDAnna Lisa T. Yu, MDPHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007 99

PHILIPPINE JOURNAL OFOphthalmologyINSTRUCTIONS TO AUTHORSSUBMISSIONThe PHILIPPINE JOURNAL OF OPHTHALMOLOGY adheres tothe policies set forth in the “Uniform Requirements forManuscripts Submitted to Biomedical Journals” writtenby the International Committee of Medical Journal Editors(N Engl J Med 1997; 336:309-314).The journal publishes articles in the followingcategories:• Original Articles, including clinical or laboratoryinvestigations, clinical epidemiology, and evaluation ofdiagnostic and surgical techniques• Evidence-Based Medicine (EBM), includingsystematic review and metaanalysis• Lectures and Symposiums• Case Reports and Case Series• Brief Reports• Special MattersLetters, correspondence, and guest editorials may alsobe published.Manuscripts submitted to the journal must be originalmaterial that has not been published or accepted for publicationelsewhere. All papers are submitted to a panel ofexperts for peer review. Manuscripts may be sent to:Editor in ChiefPhilippine Journal of OphthalmologyUnit 815 Medical Plaza MakatiAmorsolo Street, corner Dela Rosa Street1229 Makati City, Metro ManilaPhilippinesOther Contact DetailsPhone: +63-2-8135324Fax: +63-2-8135331E-mail:pjo@pao.org.phMANUSCRIPT PREPARATIONSubmitted manuscripts should not exceed 18 doublespacedtypewritten pages (paper size 8.5 x 11 inches),including references, legends, tables, and figures(approximately 6-7 published pages). Use Times NewRoman font size 12. Submit 3 hard copies of the manuscriptand a digital copy in a compact disc (CD-ROM) or 3 .5floppy diskette. Manuscripts should begin each componenton a new page and be in the following order: (1) title page,(2) abstract, (3) text, (4) acknowledgments, (5) references,(6) legends for tables/figures, (7) tables, (8) figures(photographs, illustrations and graphs). A copyrighttransfer form with original signature and transmittal lettershould accompany the manuscript.TITLE PAGEThe title page should include:1. Title of the article which should be informative,concise, meaningful, as brief as possible, and no longerthan 135 characters.2. Name of each author with his or her highestacademic degree(s) and complete address of institutionalaffiliation.3. Financial support, if any. Provide the agency nameand city, company name and city, fellowship name, andgrant number.4. Proprietary interest statement. Each author isexpected to disclose any type of financial interest relatedto the manuscript, including stock or ownership of abusiness entity connected to a product described in thepaper, paid consulting for the company or competingcompanies, travel support or patent rights to a drug orpiece of equipment.5. List of any meeting(s) where the material is underconsideration for presentation or has been previouslypresented. Indicate name, place, month, and year of themeeting.6. Corresponding author’s name, mailing address,telephone, fax, and e-mail address. The correspondingauthor will be responsible for all questions about themanuscript and for reprint requests. Only one author isto be designated corresponding author and he/she doesnot need to be the first author on the manuscript.7. Appropriate footnotes.8. Five keywords.ABSTRACTProvide a structured abstract of 300 words or less withthe following four headings:Objective: State the purpose or objective of the study.Methods: The following must be included:• Study Design: Identify the study design using aphrase such as randomized or nonrandomized clinicaltrial, case-control study, cross-sectional study, cohortstudy, case series, case report, systematic review, metaanalysis,review, experimental study, or historicalmanuscript. Additional modifiers can be included(consecutive, retrospective, prospective, observational,interventional, nonconsecutive, etc).• Setting: Such as multicenter, institutional, clinicalpractice, etc.• Participants, Patients or Study Population: Numberof patients/eyes, selection procedures, inclusion/ii PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

clusion criteria, randomization procedure, and masking.• Intervention or Observation Procedure(s)• Main Outcome Measure(s)• Data and Statistical AnalysesResults: Briefly summarize the principal outcome measurements/dataobtained. Results should be accompaniedby data with confidence intervals and the exact level ofstatistical significance.Conclusions: Provide brief and concise conclusion(s)directly supported by the data.TEXTNumber the pages of the manuscript consecutively,beginning with the title page as page one. The text should,in general, not exceed 18 double-spaced typewritten pages.Organize and prepare the manuscript to include thefollowing sections:Introduction: The Introduction, without a heading,should refer only to the most pertinent past publicationsand should not be an extensive review of the literature.Include a brief background, the research question and/or rationale, objectives/purposes of the study, and majorhypothesis to be tested, if any.Methods: Methods should be written with sufficientdetail to permit others to duplicate the work. Thefollowing should be included:• Study Design: Identifies the study design using aphrase such as randomized or nonrandomized clinicaltrial, case-control study, cross-sectional study, cohortstudy, case series, case report, systematic review,metaanalysis, review, experimental study, or historicalmanuscript. Additional modifiers may be included (e.g.consecutive, nonconsecutive, retrospective, prospective,observational, interventional).• Setting: (e.g. multicenter, institutional, clinicalpractice)• Participants, Patients, or Study Population: Numberof patients/eyes, selection procedures, inclusion/exclusioncriteria, randomization procedure, and masking.• Intervention or observation procedure(s)• Main and secondary outcome measure(s)• Data and statistical analyses.For clinical studies, statements regarding adherence tothe Declaration of Helsinki, approval by InstitutionalReview Board (IRB)/Ethics Committee, and descriptionof the informed consent process should be included. Foranimal research, the Association for Research in Visionand Ophthalmology (ARVO) guidelines for animalresearch should be followed and adherence to the saidguidelines should be stated. Previously publishedprocedures should be identified by reference only.Results: Results must be concise. Provide demographicdata of the study population. Describe outcomes andmeasurements in an objective sequence with minimumdiscussion. Data should be accompanied by confidenceintervals (usually at the 95% interval) and exact p valuesor other indications of statistical significance.Discussion: The Discussion should be restricted to thesignificant findings presented. Avoid excessive generalizationand undue speculation. Digressions and theorizingare not appropriate. Elucidate on (but do not reiterate)the results, provide responses to other and contradictoryliterature, identify limitations or qualifications of the study,and state the conclusions that are directly supported bythe data. Give equal emphasis to positive and negativefindings, whether and what additional study is required,and conclude with the clinical applications or implicationssupported by the study. The conclusion(s) is (are) incorporatedinto the end of the discussion and should be directlysupported by the results. Authors should avoid makingstatements on economic benefits and costs unless theirmanuscript includes economic data and analyses. Avoidclaiming priority of the content unless you provide theliterature search protocol used.BRIEF REPORTSA brief report is an original contribution (generally aninteresting case, a case series, surgical technique, orexperimental study) with a concise message. Manuscriptmust adhere to the PJO format guidelines, except that theabstract should contain no more tha 150 words and thebody no more than 1,000 words. References should belimited to 5.ACKNOWLEDGMENTSAcknowledge statistical consultation and assistance(when provided by someone other than an author) in anacknowledgment at the end of the article, before thereferences. Include the name, degree, and affiliation of theindividual. Consultants (other than statistical consultants),editorial assistants, photographers, artists, laboratory associates,and others who assist in preparation of a manuscriptare not to be acknowledged, however valuable their service.Because readers may infer their endorsement of thedata and conclusions, all persons acknowledged must havegiven permission to be acknowledged and this must beconfirmed in the cover letter.PHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007iii

APPENDIXAn appendix should be used very sparingly. However,it is appropriate to provide survey forms, to list the membersof a study group, or explain complex formulas orinformation.In studies involving a study group, the writing groupauthors should be listed along with the group name (e.g.Smith TT, Jones JJ on behalf of the Pediatric AmblyopiaStudy Group) on the title page. Other group membersshould be listed in an appendix. When the study groupname alone is listed on the title page, the Copyright TransferAgreement requires only the original signature of theCorresponding Author. When a series of authors is listedon the title page in conjunction with the study groupname, the Copyright Transfer Agreement must includethe original signatures of these authors.REFERENCESList only references that are pertinent to the manuscript.Cite only published studies as references. Cite/Quote from the entire study, not the abstract. You mayacknowledge “unpublished data” or submitted articleswithin parentheses in the text. Reference to a “personalcommunication” within parentheses in the text must beaccompanied by a signed permission letter from the individualbeing cited.References should be numbered consecutively in thetext and in the reference list. In the text, referencenumbers are entered as superscripts. The referencesmust be verified by the author(s) against the originaldocuments. PubMed (http://www.ncbi.nlm.nih.gov)offers a useful reference checker. References to journalarticles should include: the author or authors (for morethan four authors, list only the first three followed by“et al.”), title, journal name (as abbreviated in IndexMedicus), year, volume number, and inclusive pagenumbers.References to books should include: the author orauthors, chapter title (if any), editor or editors (if any),book title, edition (other than the first), city of publication,publisher, copyright year, and inclusive pages of thechapter or section cited.Web site references must include author (or web siteowner), title of article, date article was posted, publication(if applicable), complete web site address, and dateaccessed.ExamplesJournal Article (If four or fewer authors, list all)Fishman GA, Alexander KR, Milam AH, Derlacki DJ.Acquired unilateral night blindness associated with anegative electroretinogram waveform. Ophthalmology 1996;103: 96-104.Journal Article (If five or more authors, list only the firstthree and add et al.)Vail A, Gore SM, Bradley BA, et al. Clinical and surgicalfactors influencing corneal graft survival, visual acuity, andastigmatism. Br J Ophthalmol 1996; 103: 41-49.Chapter in a BookParks MM, Mitchell PR. Cranial nerve palsies. In: TasmanW, Jaeger EA, eds. Duane’s Clinical Ophthalmology, revised ed.Philadelphia: JB Lippincott, 1993; v. 1, chap. 19: 550-551.BookMiller NR. Walsh and Hoyt’s Clinical Neuro-Ophthalmology,4th ed. Vol. 4. Baltimore: Williams & Wilkins, 1991; 2102-2114Web siteWorld Health Organization. Hospital infection controlguidelines for severe acute respiratory syndrome. April16, 2003: http://www.who.int/csr/sars/infectioncontrol/en (accessed April 24, 2003).TABLESTables should follow references. Each table must betitled and numbered consecutively using Arabic numbersas mentioned in text. The title should be brief and fullyunderstandable without reference to the text. Each tablecolumn and row must have a heading. Tables that indicatethe mean should have the corresponding standarddeviation. Legends must identify all symbols that appearon the tables and graphs.FIGURES (PHOTOGRAPHS, ILLUSTRATIONS, ANDGRAPHS)Submit three (3) identical complete sets of prints anda digital copy if available. Each print must be separatelylabeled with the author’s name, figure number and anindication (arrow) as to orientation (up). Put allinformation on a separate label on the back of theillustration to avoid writing on or damage to the prints.Prints of figures (clinical photographs, fluoresceinangiograms, CT, MRI, X-ray, photomicrographs, TEM,SEM, graphs, etc.) must be large enough to be easily read,preferably 4 x 6 inches. The digital copy of eachphotograph or illustration should be saved in individualfiles in either TIF or JPEG format with a resolution of atleast 300 dpi. Photographs and illustrations saved in“Power point” or “Word” format are not acceptable.Graphs may be submitted in “Power Point” or “Excel”format. Text in figures must not be smaller than 10 pointswhen finally reproduced in the Journal.Each figure must be numbered consecutively in Arabicnumerals by order of citation in the text. Each shouldiiiiv PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY

have a brief explanatory legend. Legends must identifyall symbols or letters that appear on the prints. Histologicfigures, stains, and magnifications should be noted in thelegend. Graphs that indicate the mean should include thestandard deviation. Any figure that has been publishedelsewhere should have an acknowledgment to the originalsource. A copy of the release to publish the figuresigned by the copyright holder must also be submitted.Clinical photographs should be masked when possibleto prevent identification of the patient. Clinical photographsthat permit identification of an individual mustbe accompanied by a signed statement by the patient orguardian granting permission for publication of the picturesfor educational purposes.Color reproduction of figures will be published at theauthor’s expense based on prevailing rates. Check with thePAO office for exact cost. If a manuscript has been reviewedand accepted with color photos, it must be published withcolor photos. The author may opt to have them printed inblack and white at no expense.ABBREVIATIONSRestrict abbreviations to those that are widely used andunderstood. Avoid abbreviations that have meaning onlyin the context of your specific manuscript. If an abbreviationis to be used, it should appear in parentheses immediatelyafter the term or phrase to which it refers when itis stated for the first time in the text.INSTRUMENTS, DRUGS, AND MANUFACTURERNAMESUse generic names only in the text body. State the tradename of a particular drug cited in parentheses includingmanufacturer’s name, city, state and/or country when firstmentioned in the text. With regard to instruments utilizedin the study, enclose in parentheses the specificmodel, manufacturer’s name, city, state and/or country.TRANSMITTAL LETTEREach submission must be accompanied with a letter tothe editor in chief. It must identify the correspondingauthor, list any meetings where the material is underconsideration for presentation or has been previouslypresented and disclose any conflict of interest. Thetransmittal letter must include a copyright transfer. Theeditorial office must be supplied with phone and faxnumbers for the corresponding and first author(s), ande-mail addresses, if available.COPYRIGHTConsideration of manuscripts for publication in thePHILIPPINE JOURNAL OF OPHTHALMOLOGY is dependent onthe assurance that the material (in whole or part) is notunder consideration by another journal, is not in press inany other format, and has not been previously published.Each author must sign a statement transferring copyrightownership to the Philippine Academy of Ophthalmology.Manuscripts which have been accepted for publicationmay be published in another journal after securing awritten consent from the editor in chief of the PHILIPPINEJOURNAL OF OPHTHALMOLOGY.These instructions may be downloaded from the PJO web site at www.pao.org.phPHILIPPINE ACADEMY OF OPHTHALMOLOGYPHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007ivv

PHILIPPINE JOURNAL OFOphthalmologyCOPYRIGHT TRANSFERTitle of Article________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Authors1. ________________________________2. ________________________________3. ________________________________4. ________________________________5. ________________________________In submitting the above-titled article, I/we hereby transfer, assign, or otherwise convey all copyright ownershipto the Philippine Academy of Ophthalmology in the event that such work is published in the PHILIPPINE JOURNALOF OPHTHALMOLOGY (PJO). Such conveyance covers any product, whether print or electronic, that may derive fromthe published journal. I/We affirm that this article has not been previously published in or submitted for publicationto another journal, except under circumstances communicated to PJO in writing at the time the articlewas first submitted.Each author must sign a Copyright Release form. The signatures need not appear on the same page. All manuscripts submittedbecome the property of the journal.Name (print) Proprietary Signature Dateor FinancialInterest(Yes/No * )1. _____________________________ _____________ _____________________________ ________________2. _____________________________ _____________ _____________________________ ________________3. _____________________________ _____________ _____________________________ ________________4. _____________________________ _____________ _____________________________ ________________5. _____________________________ _____________ _____________________________ ________________*If yes, please explain on the title sheet. See instructions to authors for details.Submit this signed transfer with your manuscript to:The Editor in ChiefPhilippine Journal of OphthalmologyUnit 815 Medical Plaza MakatiAmorsolo Street, corner Dela Rosa Street1229 Makati City, Metro ManilaPhilippinesOther Contact DetailsPhone: +63-2-8135324Fax: +63-2-8135331E-mail:pjo@pao.org.phThis form may be downloaded from the PJO web site at www.pao.org.phvi PHILIPP J OPHTHALMOL VOL 32 NO. 2 JULY - DECEMBER 2007PHILIPPINE ACADEMY OF OPHTHALMOLOGY