Thyroid Eye Disease and Its Association With Diabetes Mellitus: A Major Review.

PURPOSE: Thyroid eye disease (TED) associated with diabetes mellitus (DM) presents unique challenges. DM is a risk factor for TED. Standard management of TED with glucocorticoids (GC), orbital radiation, or teprotumumab can cause adverse events in poor glycemic control. The authors reviewed the literature on the relationship between TED and DM and the management of co-existing diseases. METHODS: The authors searched PubMed with keywords "thyroid eye disease," "diabetes mellitus," and similar terms from 2013 to 2022. The authors included relevant studies after screening the abstracts. Additional references to the selected studies were included where applicable. Data were extracted from the final articles according to the preplanned outline of the review. RESULTS: The initial search yielded 279 abstracts. The final review included 93 articles. TED and DM interact at multiple levels-genetic, immunologic, cellular, nutritional, and metabolic. Both DM and thyroid dysfunction exacerbate the morbidity caused by the other. Metabolic factors also affect the inflammatory pathway for TED. Patients with DM develop TED with greater frequency and severity, necessitating interventions for vision salvage. Agents (GC, teprotumumab, or radiation) used for TED are often unsuitable for treatment with DM, especially if there is poor glycemic control or diabetic retinopathy. There were no studies on using steroid-sparing agents in TED with DM. CONCLUSION: TED and DM co-exist because of multiple intersections in the pathophysiology. Challenges in the treatment include increased TED severity and risk of hyperglycemia and retinopathy. Multidisciplinary teams best undertake treatment of TED with DM.

A fungal epidemic amidst a viral pandemic: Risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis in India.

PURPOSE: To study the risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) during the COVID-19 pandemic in India. METHODS: Multi-centric retrospective case-control study conducted from October 2020 to May 2021. Cases comprised of consecutive patients of COVID-19-associated ROCM (CA-ROCM) presenting at the participating ophthalmic institutes. Controls comprised of COVID-19-positive or COVID-19-recovered patients who did not develop ROCM. Comparative analysis of demographic, COVID-19 infection, treatment parameters and vaccination status between cases and controls performed. Clinical and imaging features of CA-ROCM analyzed. RESULTS: There were 179 cases and 361 controls. Mean age of presentation in cases was 52.06 years (p = .001) with male predominance (69.83%, p = .000011). Active COVID-19 infection at the time of presentation of ROCM (57.54%, p < .0001), moderate to severe COVID-19 (p < .0001), steroid administration (OR 3.63, p < .00001), uncontrolled diabetes (OR 32.83, p < .00001), random blood sugar >178 mg/dl were associated with development of CA-ROCM. Vaccination showed a protective effect (p = .0049). In cases with intracranial or cavernous sinus extension there was history of steroid administration (OR 2.89, p = .024) and orbital apex involvement on imaging (OR 6.202, p = .000037) compared to those with only rhino-orbital disease. CONCLUSION: Male gender, active COVID-19 infection, moderate or severe COVID-19, uncontrolled diabetes, steroid administration during COVID-19 treatment are risk factors for developing rhino-orbital-cerebral mucormycosis. Vaccination is protective. Random blood sugar of >178 mg/dl in COVID-19 positive or recovered patients should warrant close observation and early detection of ROCM. Presence of ophthalmoplegia, blepharoptosis at first clinical presentation and orbital apex involvement on imaging are associated with intracranial extension in ROCM.

Propensity of aerosol and droplet creation during oculoplastic procedures: A risk assessment with high-speed imaging amidst COVID-19 pandemic.

PURPOSE: The study uses principles of liquid and gas mechanics to verify and quantify the generation of aerosols in oculoplastic procedures, namely surgery using a scalpel, electrosurgical device, and a mechanized drill. METHODS: Surgical techniques were performed ex vivo using the electrosurgical device, scalpel, and mechanized drill on the muscle and bone of commercially available chicken. The liquid and gas dynamics were observed using a high-speed high-resolution Photron SA5 camera (0.125 to 8 ms temporal resolution, 0.016 to 0.054 mm/pixel spatial resolution) and stroboscopic lighting (Veritas 120 E LED Constellation). The analysis was performed using in-house algorithms and ImageJ software. RESULTS: The use of a mechanized drill at 35000 rpm and a 3 mm fluted burr generated aerosol with particle size 50 to 550 microns with a spread of 1.8 m radius. Surgical smoke was generated by an electrosurgical device in both cutting and coagulation modes. Dispersion of the smoke could be controlled significantly by the use of suction, mean smoke spread ratio being 0.065 without suction and 0.002 with use of suction within 2 cm. CONCLUSION: The quantification of the aerosol generation will help surgeons take practical decisions in their surgical techniques in the pandemic era.

Malignant tumors of the eyelid in India: A multicenter, multizone study on clinicopathologic features and outcomes.

PURPOSE: To analyze data on eyelid malignancy in India, clinical and pathologic features, and outcomes. METHODS: A multicentre study, from oculoplastic practices in four geographic zones in India. The centers perform similar documentation and protocol-based management for eyelid tumors. Clinical features, pathology, American Joint Committee on Cancer (AJCC) class, management, and the outcomes were analyzed. RESULTS: The study included 129 patients, with slight female preponderance and mean age 62.7 years. The median delay to the consultation was 9 months. Rural patients traveled a mean distance of 115.2 km; there was no difference between the city and outstation patients in the delay to consultation or follow up. Pathology included 55/129 (42.6%) sebaceous gland carcinoma (SGC), 47/129 (36.4%) basal cell carcinoma (BCC), squamous cell carcinoma (SCC) in 15 (11.6%), and 12 (9.3%) other tumors. Commonest AJCC class was T2b/T3a in 80/111 (72%), invasion of the orbit was present in 16 (12.4%). Surgery with margin clearance was performed in 103. With a mean follow-up of 21.44 months, local recurrence and/or metastasis were seen in 12%. The diagnosis of SGC was strongly associated with adverse outcomes (odds ratio: 7.36). On multiple logistic regression analysis, diagnosis of SGC (P = 0.011) was significant in having adverse outcomes. CONCLUSION: The multicenter Indian data shows the highest prevalence of SGC, with the commonest AJCC class T2b. Most tumors were locally resectable at presentation. The histopathologic diagnosis of SGC is the factor strongly associated with adverse outcomes.

Visual morbidity in thyroid eye disease in Asian Indian patients.

Purpose: To describe visual morbidity in thyroid orbitopathy in Asian Indians and the factors influencing its onset. Methods: A retrospective chart review was performed for patients with thyroid related orbitopathy seen between May 2014 and April 2019. Three hundred and one patients were included in the study. Relevant history, clinical findings, investigations, and treatment were documented. Results: Nineteen percent of patients had at least 1 visual morbidity feature such as compressive optic neuropathy, exposure keratopathy or diplopia, requiring intravenous glucocorticoid. Male gender, older age, and diabetes were the significant risk factors for high visual morbidity (all P < 0.05). Systemic thyroid status, degree of proptosis, and duration of disease were not significant. Average dose of intravenous glucocorticoid needed was 3.8 g; 24 (7.9%) patients required orbital decompression, and 13 (4.3%) needed eyelid surgery. At the last follow-up, 97% of patients had vision 6/12 or better in both eyes. Conclusion: There is significant visual morbidity found in Indian patients with TED, even with moderate proptosis and systemic control of thyroid status. This is the first set of data on the subject.

Tele-consultations in the wake of COVID-19 - Suggested guidelines for clinical ophthalmology.

While telemedicine has been around for a few decades, it has taken great importance and prominence in recent times. With the fear of the virus being transmitted, patients and physicians across specialties are using consultation via a telephone call or video from the safety of their homes. Though tele-ophthalmology has been popular for screening, there are no clear guidelines on how to comprehensively manage patients seeking advice and treatment for a particular eye condition. Some major barriers to diagnosis and management are compromised detailed examination, no measurement of the visual acuity or intraocular pressure and a retinal evaluation not being feasible. Despite these limitations, we do need to help those patients who need immediate care or attention. Hence, this article has put together some guidelines to follow during such consultations. They are important and timely due to the medicolegal and financial implications.

Risk factors for orbital implant exposure after evisceration: A case control study of 93 patients.

Purpose: The study aims to analyze risk factors for exposure of orbital implants after evisceration by comparison of patients with and without exposure of implants. Methods: This is a case control study in retrospective interventional case series; Group A- implant exposures after evisceration, Group B - Patients on follow up after evisceration with implant, without exposure, with matched duration of follow up. The sample size is calculated for a power of 80. Results: Group A comprised 32 sockets with implant exposure, presenting at median 18 months after surgery; Group B included 61 eviscerated sockets, without implant exposure, with follow up median 36 months. Odds Ratio (OR) was calculated; infected eyes -OR 1.3, P = 0.6; phthisical eye - OR 1.4, P = 0.43; multiple prior surgeries- OR 1.55, P = 0.33. Group A had 59.3% porous implants, Group B 55.7%, - OR 1.3, P = 0.5. Mean implant size in Group A 19.06 mm, Group B 18.78 mm- showed no statistical difference. Multiple logistic regression analysis showed no significant risk factor for exposure. Surgeon factor was not analyzed since there were multiple surgeons. Conclusion: This is the first study with calculated sample size, comparing implant exposure patients to a control group. Porous implant material, presence of infection, phthisical scleral shell, and prior surgery showed higher trend of exposure (Odds ratio >1), but none was conclusive. Larger size of implant was not a risk factor for exposure. Eliminating the role of several factors in implant exposure allows the surgeon to make better surgical choices: such as place an implant of appropriate size, of a material of surgeon's choice, and do primary placement of implant in a patient with evisceration post-corneal ulcer or endophthalmitis. A hypothesis and a recommendation is that meticulous attention be paid to surgical technique.

Histopathologic risk factors in retinoblastoma in India.

CONTEXT: The presence of histopathologic risk factors is associated with development of metastasis in a patient with retinoblastoma. Adjuvant chemotherapy administered to such patients decreases the risk of metastasis. OBJECTIVE: To analyze the incidence of histopathologic risk factors in our patient population and the clinical predictors of such risk factors. DESIGN: This is a retrospective case series, with review of clinical data and histopathologic slides, in 142 consecutive eyes enucleated for retinoblastoma between 1996 and 2002. RESULTS: Histopathologic risk factors were present in 54.2% of 142 eyes enucleated for retinoblastoma and included infiltration of iris (7%), ciliary body (9%), choroid (40%), optic nerve lamina cribrosa (11%), retrolaminar optic nerve (17%), optic nerve to the line of transection (8%), sclera (9%), and extrascleral structures (6%). On univariate analysis, histopathologic risk factors correlated with age greater than 24 months at presentation and with glaucoma and iris neovascularization at presentation. On multivariate logistic regression analysis, age greater than 24 months and iris neovascularization correlated with infiltration of the choroid, while iris neovascularization correlated with infiltration of the retrolaminar optic nerve. CONCLUSION: Histopathologic risk factors are present in a significant proportion of patients enucleated for retinoblastoma and have identifiable clinical predictors.

Bicanalicular laceration managed with two Mini-Monoka monocanalicular stents.

Bicanalicular lacerations have been traditionally managed using bicanalicular nasal intubation or annular stents. The Mini Monoka monocanalicular stent has been described for the management of monocanalicular lacerations. A bicanalicular laceration can also be successfully managed using two Mini Monoka monocanalicular stents, and this technique has several advantages. We report this simple and minimally invasive alternative in the management of bicanalicular laceration.

Orbital metastasis from hepatocellular carcinoma.

We report a case of orbital metastasis from hepatocellular carcinoma and review the literature. A 45-year-old healthy male patient presented with proptosis due to an orbital mass. Histopathologic examination indicated that the tumor was a secondary from a hepatocellular carcinoma, and further investigations revealed the primary tumor in the liver. Hepatocellular carcinoma is a rare source of metastasis to the orbit, and to our knowledge, only 14 histopathologically proven cases have been reported previously. Proptosis was the most common presenting feature in the reviewed reports. A majority of patients had occult primary tumors at presentation and the diagnosis of the orbital mass was based on histopathologic features.