Comparative study of the outcomes of newly developed polypropylene-based modified trabeculectomy and glaucoma shunt surgery in neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a secondary glaucoma with a poor visual prognosis. Trabeculectomy with antifibrotic agents, glaucoma drainage devices (GDDs), and cyclo-destructive procedures are recommended in patients who are refractory to medical management. However, due to the poor success rate of conventional trabeculectomy and the higher cost of GDDs, alternative procedures need to be looked at. PURPOSE: To compare the surgical outcomes and economic aspects of a newly developed polypropylene suture bed-based modified trabeculectomy to Ahmed glaucoma valve (AGV) implantation for NVG. METHODS: It was a prospective interventional study conducted at a tertiary care center between 2018 and 2020. Consecutive patients with NVG with a minimum follow-up of 18 months were included. Surgical outcomes are mainly based on intraocular pressure (IOP) control and the cost of surgery. RESULTS: Sixty eyes were included out of which 40 (60.6%) underwent modified trabeculectomy and 20 (33.7%) underwent AGV. At the final follow-up, no significant difference (P < 0.05) was found between the surgical outcomes of both groups. The complete success rate (IOP < 21 mm Hg without antiglaucoma medications) was 60 and 65% while the qualified success rate (IOP < 21 mm Hg with antiglaucoma medications) was 30 and 25% in modified trabeculectomy and AGV groups, respectively, at final follow-up. The cost of surgery was significantly higher in the AGV group (P < 0.0001). CONCLUSION: Modified trabeculectomy as described might be a better alternative for NVG eyes.

A comparison of novel silicone plate vs. auricular cartilage in upper eyelid reconstruction following excision of malignant tumor.

Purpose: To compare surgical and functional outcomes, safety, efficacy and cost of silicone plate vs. autogenous auricular cartilage (AAC) as alternate material to tarsal plate for upper eyelid reconstruction after excision of malignant tumor. Methods: A prospective, comparative, interventional study of over 3 years was conducted on two groups of twenty patients each. All the patients had undergone the Modified Cutler Beard procedure with AAC being used as tarsal substitute in one group and a novel silicone plate in the other. Post-operative MRD 1, LPS action, Central Lid Thickness, and Lid contour were recorded at one week, one month and six months follow-up. Results: The pre-operative MRD 1 in the silicone plate and AAC group was -2.95 ± 1.19 mm and -3.05 ± 1(1).05 mm, post-operative in the silicone plate group 3.8 ± 0.4 mm, and in the AAC group, 3.8 ± 0.41 mm. The pre-operative LPS action in the silicone plate and AAC group was 1.2 ± 1.1 mm and 1.0 ± 0.9 mm and post-operative it was 13.8 ± 0.4 mm for the silicone plate group and 13.7 ± 0.4 mm for the AAC group. The post-operative lid thickness for the silicone plate group was 4.4 ± 0.17 mm and for the AAC group it was 4.4 ± 0.08 mm. Conclusion: The cosmetic outcome in terms of lid contour maintenance is better in the silicone plate group, in which it markedly reduces the surgical time, provides earlier rehabilitation, and eliminates disease transmission. Harvesting of AAC is a skillful and time-consuming procedure and adds to the post-operative morbidity due to the presence of a second surgical site. The low manufacturing cost of silicone plate as opposed to other allogenic and synthetic tarsal substitutes makes it readily available to resource limited populations. The silicone plate is reckoned to become the material of choice as tarsal substitute in the future. Abbreviations: AAC = Autogenous auricular cartilage, MRD-1 = Margin reflex distance-1, LPS = levator palpebrae superioris, PFH = palpebral fissure height.

Total or subtotal replacement of tarsal plate by novel silicone plate for upper eyelid reconstruction in malignant tumors.

PURPOSE: : To evaluate the cost, safety, surgical outcome, and efficacy of modified Cutler-Beard eyelid reconstruction utilizing a novel silicone plate as a tarsal plate replacement in the repair of 60% to 100% eyelid defects following the excision of large malignant tumors. METHODS: : A prospective, noncomparative, interventional study of 30 eyes was done over 3 years. Fourteen patients were female, and 16 patients were male. In all the cases, a silicone plate, the synthetic, artificial tarsal plate, was utilized for a total or subtotal replacement of the tarsal plate. The created defect was measured in mm (length and width) and later expressed in percentage. Pre- and postoperative action of levator palpebrae superioris (LPS) was measured. Pre- and postoperative measurements of the margin-to-margin reflex distance (MRD1) were noted. RESULTS: : Preoperative LPS action was 1.23 ± 1.35 mm, whereas postoperative LPS actions at the end of 1 week and 18 months were 11. 8 ± 0.88 mm and 13.53 ± 0. 73 mm, respectively. Preoperative MRD1 was - 3.0 ± 1.144 mm, whereas postoperative MRD1 values at the end of 1 week and 18 months were 2.18 ± 0.27 mm and 4.16 mm ± 0.35, respectively. The mean created defect after the removal of the tumor was 87.3% ±11.10. The mean length of the silicone plate implanted in this study was 27.53 ± 2.48 mm. The follow-up period for the study participants was 18 months. CONCLUSION: : The synthetic novel silicone plate was successful as a tarsal plate replacement. A second surgical site for ear cartilage harvesting is avoided. Cadaver transfer of Achilles tendon carries the risk of transmission of communicable diseases, for example, hepatitis B and HIV. Silicone is an inert, nonreacting, and tissue-tested material, thus eliminating the possibility of graft rejection. This material is readily available and cost-effective. The novel silicone plate is considered to be the most promising alternative material as a tarsal replacement in the future generation.

Surgical outcomes of Tenzel rotational flap in upper and lower lid reconstruction without repair of posterior lamella: A modified approach.

Aim: To evaluate the efficacy and usefulness of Tenzel rotational flap in upper and lower lid reconstruction in malignant tumors, to determine the anatomical alignment, functional, and cosmetic outcome after lid reconstruction and recurrence of the tumor and to observe the canthal and fornix status. Methods: Prospective, non-comparative,interventional clinical study of 30 patients over a period of 18 months. The study was conducted with strict inclusion and exclusion criteria. Evaluation parameters were LPS (Levator palpebrae superioris) action Pre and post operative, MRD-1 (Margin Reflex Distance-1) values pre and post operative, central vertical palpebral fissure height (PFH) pre and post operative,and the calculation of the created defect express in percentage preoperatively. None of the case posterior lamina was repaired. It formed or strengthened automatically. Results: The diagnosis of Sebaceous cell carcinoma was 14/30 by FNAC and 17/30 by histopathology. The mean MRD-1 pre-operatively was -1.09 ± 1.54 mm to 4.02 ± 0.36 mm postoperatively in the upper lid. The mean LPS action pre-operatively was 4.35 ± 0.96 mm to 12.42 ± 1.24 mm postoperatively in the upper lid tumor. The mean pre-operative central palpebral aperture was 4.76 ± 0.88 mm and post-operative central palpebral aperture was 10.47 ± 0.88 mm in the upper lid tumor. The mean incision length was 8.16 ± 0.61 mm in upper lid and 9.27 ± 0.87 mm in lower lid Tenzel reconstruction respectively. In all the cases, posterior lamella grew normally. In addition, no strengthening procedure was required. Conclusion: This reconstructive procedure was useful to repair 40%-60% of the upper lid and 40%-70% created a defect in the lower eyelid after the removal of the malignant tumor. Histopathological diagnosis of the specimen was more accurate than FNAC. No repair of posterior lamella was made. No extra surgical procedure was needed. Thus, the surgical procedure time was markedly reduced. After the surgery, all the patients presented a good uplift of the upper lid, good closure of the eyelids, and were visually and functionally well rehabilitated. The aesthetic appearance was excellent.

Surgical Outcomes of Unilateral Marcus Gunn Jaw Winking Ptosis Correction: A Novel Whitnall's Ligament Approach.

PURPOSE: To evaluate the surgical, functional, and cosmetic outcome in moderate to severe ptosis with Marcus Gunn jaw winking phenomenon and recurrence of disease after ptosis correction. This procedure has been emphasized on a child. METHODS: This was a prospective, non-comparative, interventional study conducted over 4 years on 30 people. The ages range from 7 to 40 years. The eyelid was approached from behind to identify the Whitnall's ligament. Levator palpebrae superioris was first disinserted then dissected up to the superior border of the tarsal plate followed by 20 to 25 mm by resection which causes disabling of the levator palpebrae superioris action. Subsequently, "tarso frontalis sling with silicon rod" for ptosis correction. Compared with the preoperative and postoperative photograph. RESULTS: Margin reflex distance 1 values are in the affected eye preoperative 1.8 ± 0.87 mm to postoperative 3.96 ± 0.41 mm. Preoperative palpebral fissure height are means 5.05 ± 0.62 mm to postoperative palpebral fissure height means 9.3 ± 0.71 mm. Ptosis significantly improved which is statistically significant (p < 0.05). Lid excursion or Flickering's in affected eyes preoperative means 6.1 ± 3.47 mm to postoperative after 1 year means are 0.43 ± 0.81 mm. Follow-up period is 1 year. CONCLUSIONS: Unilateral posterior approach (Whitnall's ligament approach) is found better in surgical, functional, and cosmetic outcomes in the correction of Marcus Gunn jaw winking syndrome, especially in children. The risk of bilateral extensive surgery is avoided. After the surgery, the primary gaze face photo identity was well-accepted in official government documents. This study is stressed on bilateral lid height similarity in primary gaze unlike the traditional method of downgaze similarities. The patients were highly satisfied both physically and mentally.

Surgical Outcome of Epicanthus and Telecanthus Correction by Double Z-Plasty and Trans-Nasal Fixation with Prolene Suture in Blepharophimosis Syndrome.

INTRODUCTION: Blepharophimosis Syndrome (BPES) is a complex and rare disease characterized by epicanthus inversus, telecanthus, lateral ectropion, narrowed or shortened inter-palpebral fissure distance and ptosis. It is mostly bilateral and may or may not be symmetrical. It is typically inherited as an autosomal dominant trait. In sporadic cases, the disease may occur without a prior family history as a genetic mutation from a deletion or translocation of the FOXL2 gene, which maps to chromosome 3q23. Surgical treatment of this disease poses an oculoplastic challenge due to multiple complex eyelid deformities. AIM: To evaluate the functional and cosmetic outcome of telecanthus and epicanthus correction by a Mustarde's rectangular double Z-Plasty and trans-nasal fixation using 1-0 prolene suture in BPES. MATERIALS AND METHODS: This was prospective, interventional study of 16 patients over a period of three years. In this study, all patients had BPES with prominent epicanthus and telecanthus. Mustarde's double Z-plasty and trans-nasal fixation with 1-0 prolene suture was performed in the first of a two-stage operation. If ectropion was present, the lateral ectropion was corrected by a base-out flap transfer from the upper eyelid to the lower eyelid. After three months, a 2nd stage was undertaken, involving a lateral canthoplasty for horizontal widening of a short palpebral fissure and a tarso frontalis sling with silicone rod for correction of moderate to severe ptosis. Patients were followed up for six months to one year with postoperative ophthalmologic examinations and photographs. RESULTS: Out of 16 patients, 10 were females and six were males. All the patients had bilateral involvement. In this study preoperative Inner Intercanthal Distance (IICD) ranged from 38 mm to 42 mm and the mean IICD was 41.2±0.57 mm. Postoperative IICD ranged from 31 mm to 34 mm. Horizontal Palpebral Fissure Length (HPFL) ranged from 20 mm to 23 mm and the mean value of HPFL was 21.50 mm preoperatively. Postoperative HPFL ranged from 26 mm to 29 mm and had a mean value of 28.50 mm, which was much improved after a combined correction of telecanthus and lateral canthoplasty. The mean preoperative IICD and HPFL ratio was 1.77 and was reduced to a postoperative value of 1.2. The Marginal Reflex Distance1 (MRD-1) test value improved from +1.25 mm to +3.50 mm postoperatively after placement of a tarsofrontalis sling with silicone rod using the Fox's Pentagon technique. In this study, two eyes had minimal unequal correction but were cosmetically and functionally acceptable. Correction of IICD is possible up to 6 mm. No major complication e.g., CSF rhinorrhea was noted in this series and preoperative prominent epicanthal folds were abolished. CONCLUSION: Here we propose a two-staged procedure involving a combined Mustarde's double Z-plasty with transnasal fixation using a 1-0 prolene suture with a flap transfer from the upper lid to the lower lid in the first stage and a lateral canthoplasty with a tarsofrontalis sling and silicone rod in the second stage. This technique is effective to correct epicanthus, telecanthus, ptosis and lateral ectropion in BPES with good cosmetic and functional outcome.

Total Upper Eyelid Reconstruction with Modified Cutler-Beard Procedure Using Autogenous Auricular Cartilage.

INTRODUCTION: Malignant tumour in upper lid is a surgical challenge to oculoplastic surgeon. Full thickness defect created after removal of large tumour promptly treated with modified cutler beard procedure using autogenous auricular cartilage. Surgical procedure is two staged: In first stage, removal of the tumour followed by full thickness flap repaired; In second stage, opening the closed lid with lid margin repair. Post-operatively, there is good anatomical, functional and cosmetic restoration of the eyelid similar to the other eye. AIM: To evaluate the efficacy of the modified Cutler-Beard procedure using autogenous ear cartilage for tarsal plate reconstruction in the repair of 70-100% upper eyelid defects. MATERIALS AND METHODS: This is a prospective, interventional case series of 16 patients over a period of three years. Patients with upper eyelid defects, secondary to removal of tumour, greater than or equal to 70% were included. Of these patients, those with lymph node involvement, distant metastasis, lower eyelid involvement, corneal infiltration or intra-orbital extension were excluded. FNAC was done in all the cases. Created defect was measured in mm (length and width) and later expressed in percentage. Pre and Post-operative measurement of Levator Palpebrae Superioris (LPS) was done. Pre and Post-operative measurement of Margin to Reflex Distance (MRD1) were also noted. RESULTS: Upper eyelid recreation was successful in all patients without complications. Pre-operative LPS action ranged from 0-4 mm, while post-operative LPS action was 12-14 mm. Pre-operative MRD1 ranged from -4 millimeters to -1 mm, while post-operative MRD1 was +3 to +4 millimeters. The follow-up period ranged from six months to two years. Every patient had a successful upper eyelid reconstruction. CONCLUSION: The modified Cutler-Beard procedure using an autogenous auricular cartilage graft is an effective procedure for repair of large upper eyelid defects, with acceptable functional and cosmetic results. Furthermore, it is particularly useful in resource-poor areas, due to lower cost than other available options.

Post Surgical Giant Epidermal Inclusion Cyst of the Lid and Orbit- A Rare Case.

Epidermoid cyst within the lid and orbit is extremely rare. Epidermoid tumours are inclusion of ectodermal elements in the site not normally containing these structures. It is of two types; primary type related to implantation of ectoderm at the time of closure of the neural groove and secondary type caused by post traumatic inclusion of the surface epithelium. A 45-year-old male had complaint of swelling on the right upper lid and orbital region. It first appeared two years back. It was painless progressively increased in size and shape. There was difficulty in opening of eye lid due to large swelling, feeling of heaviness in the right upper lid and occasional headache. There was history of right eye ocular infection following vegetative matter injury three years back. Evisceration of right eye was done for aforementioned reason. USG report shows cystic encapsulated mass with calcification foci in right upper lid-orbital region with fat component. MRI right orbit shows fairly large hyperintense cystic lesion seen involving right orbit with posterior extension up to optic canal. No intracranial extension. FNAC confirmed epidermal inclusion cyst. We did upper lid reconstruction with removal of mass. We have successfully removed the mass without any complication and with one year follow-up there is no recurrence.

Giant mass conjunctival rhinosporidiosis causing severe mechanical ectropion.

Rhinosporidiosis is a granulomatous disease of the mucous membrane caused by Rhinosporidium seeberi, an organism of uncertain taxonomic position, most probably a fungus. It usually infects mucous membrane of the nose and nasopharynx but may infect mucous membrane of all other parts even the skin. Inoculation of the eye and related structures are grouped as oculosporidiosis. In this case of a 50 years old male agriculturist from remote village had complaints of a mass protruding out from the palpebral fissure since last one year. It was gradually increasing in size and shape. There was recurrent redness, watering and discharge. This mass caused dragging of lower lid to produce mechanical ectropion. On examination there was a pedunculated polypoidal broad based conjunctival mass originated from inferior bulbar conjunctiva. It is chemosed with the evidence of necrosis and old haemorrhagic spot, engorged conjunctival vessel and in the exposed pert there is keratinisation. Conjunctival rhinosporidosis has predilection for agriculture workers so that contact with contaminated soil may be the causative factor. The only effective treatment is radical surgical excision followed by thermal and chemical coagulation, nevertheless relapse is the rule rather the exception. No such medical treatment has proved to be effective. Griseofulvin and amphotericin have been used without success.

Effect of glucocorticoid on protein and creatine content of inactivated muscle of rats.

In denervation, there was loss of protein in gastrocnemius muscles and this loss of was more in prednisolone treated animals. There was significant change of protein loss between tenotomy and tenotomy with prednisolone treatment. The reduction of protein in denervation and denervation with prednisolone treatment were also highly significant. Significant loss of muscle creatine was observed in denervation with prednisolone treatment. It was about 50% of the normal control group and about 40% when compared to other limb. In denervation alone, the creatine loss was about 24%. In tenotomy and in tenotomy with prednisolone treatment, the loss of creatine was also significantly high. All these figures regarding the reduction of muscle creatine in different experiments were highly significant. The reduction of muscle weight, protein and creatine content of muscle in denervation were due to inactivation of the muscle and due to trophic changes caused by loss of motor supply to the muscle. But in tenotomy, the reductions were only due to inactivation.

A hospital-based study on pulmonary function tests and exercise tolerance in patients of chronic obstructive pulmonary disease and other diseases.

A total of 105 male and 60 female patients were screened in the respiratory medicine outpatients' department, Institute of Postgraduate Medical Education & Research, Kolkata between December, 2002 and January, 2005. Chronic obstructive pulmonary disease patients were diagnosed on the basis of history and clinical examination while patients with body mass index > or =25 and otherwise disease-free were grouped as overweights. Patients suffering from other diseases like systemic hypertension, etc, were referred from other departments after proper evaluation. The patients and controls (n=10) each for male and female groups were subjected to spirometry using computerised electronic spirometer while exercise tolerance was evaluated by modified Harvard step test. Thirty-nine male and 21 female patients were diagnosed and grouped in chronic obstructive pulmonary disease group. Both purely obstructive [forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)% pred<70 and reduced FEV1% pred] and mixed (both obstructive and restrictive pattern ie, FEV1/FVC% pred normal or supernormal, FVC% pred <80 indicating restrictive pattern and forced expiratory flow between 25% and 75% of the vital capacity (FEF(25-75)) pred or peak expiratory flow rate (PEFR)% pred <70 indicating early small airway obstruction pattern were seen in both sexes. Although the exercise tolerance values were non-significant in both sexes in chronic obstructive pulmonary disease obstructive pattern group, in mixed pattern group it was seen significant reduction compared to control. Hypertensives (21 males and 7 females) showed obstructive spirometric pattern. Exercise tolerance values were significantly reduced compared to controls. Male overweights (n=13) showed restrictive pattern while female overweights (n=8) showed obstructive pattern in spirometry. Exercise tolerance values were non-significant compared to control in both the groups. In ischaemic heart disease patients (n=6) FEV1%pred showed significant reduction in spirometry. In patients suffering from type 2 diabetes mellitus (n=4), post-tuberculous group (n=7), hypothyroid (n=6), collagen vascular disease group (n=6) showed restrictive spirometric pattern and the above groups including IHD patients showed significant reduction in exercise tolerance values. Some authors have stated that mixed ventilatory defect is characterised by low FEV1/FVC% pred in spirometry and low lung volumes where the lung volumes have to be ascertained by other methods but in the present investigation it was observed that mixed ventilatory defect can be estimated by spirometry; PEFR and/or FEF(25-75%). pred <70% whereas FEV1/FVC% pred is normal or supernormal. This finding is completely new one to predict mixed ventilatory defect.