Endoscopic Endonasal Dacryocystorhinostomy under Local Anesthesia or Assisted Local Anesthesia.

INTRODUCTION: Endoscopic Endonasal Dacryocystorhinostomy (EENDCR) is effective, safe and less time consuming procedure and scar free to manage patients with epiphora. Traditionally, EENDCR is performed under general anesthesia. Limited general anesthesia facility in our country has made EENDCR surgery limited to the hospitals with GA facilities. EENDCR surgery under local or assisted local anesthesia could be an alternative solution. The aim of the study was to study the pain tolerability of the patient undergoing EENDCR under local anesthesia (LA) or assisted local anesthesia (ALA). To the best of our knowledge, there is a lack of similar studies in Nepal. MATERIALS AND METHODS: This was a prospective, nonrandomized, interventional study done at a tertiary eye care center. After sample collection the study was aimed to evaluate the pain tolerability of patients undergoing EENDCR under LA or ALA. The case collection and the surgery were done by a single surgeon from 2018 Jan- 2019 April and followed for 6 to 24 months. All consecutive cases were enrolled in the study. Informed consent was obtained from all the patients. Inclusion criteria included chronic dacryocystitis with NLDO (Nasolacrimal duct obstruction), lacrimal sac mucocele and lacrimal sac pyocele. Previously failed DCR surgery was not included in the study. Total of 100 patients of EENDCR with a tube who completed a minimum 6 months follow up postoperatively were included in the study. Verbal rating scale (VRS) was used to report response to pain during different steps of surgery. RESULTS: There were 100 patients within the age range of 13-41 years of age. One hundred and six EENDCR were performed on 100 patients. Eighty-seven patients were adult (19-41) years and 13 patients were of pediatrics age group (13-18) years. There were 74 female and 26 male patients. Thirty-seven were RE (right eye), 57 were LE (Left eye) and 6 were BL (bilateral). Duration of illness was less than 6 months in 9 patients and more than 6 months in 91 patients. Ninety-two eyes were operated under LA and fourteen eyes of 11 patients asked for sedation in addition to local anesthesia (ALA). Patients reported pain during the creation of the bony ostium with Keryson's rounger (24 eyes, VRS 3-4) and while using the drill (19 eyes, VRS 5-6). On pain scoring, there was no pain (0-2) in patients who underwent EENDCR under ALA. Pain scoring in patients who underwent EENDCR under LA showed no pain (0-2) in 51.08%, mild pain (3-4) in 26.08%, and moderate pain (5-6) in 20.65%. Duration of surgery ranged from 15 to 45 minutes. Duration of follow up was 6- 24 months. There was a 96.2% success rate in this study. CONCLUSION: EENDCR can be done under LA or ALA depending on the indication and demand of the patient.

Orbital Myocysticercosis different Presentation and Management in Eastern Nepal.

INTRODUCTION: Ocular cysticercosis is a preventable cause of blindness. It is caused by parasitic infestation caused by the larval form of Taenia solium. Poor sanitation and improper management of food and meat products are the major causes for cysticercosis infestation. CASE: Two cases of myocysticercosis presented to our hospital differently. A 12 years boy, first case presented with drooping of right eye (RE) upper lid with recurrent swelling, pain, redness with mild headache and intermittent vomiting for 1 and half months. On examination swelling of RE upper lid, mild ptosis, abaxial proptosis with restricted motility in upgaze was noted. Orbital CT (computer tomography) scan and ocular ultrasound reports showed findings suggestive of myocysticercosis of superior rectus muscle of RE. Routine microscopic examination (RME) of stool demonstrated eggs of Taenia. Complete blood count (CBC) showed eosinophilia. As a suspected case of myocysticercosis and since the patient resided at an endemic zone, empirical therapy with albendazole and steroid was started to continue for 4 weeks. After one week the patient presented with features suggestive of RE orbital cellulitis. With proper counseling about medical therapy and cyst excision, the patient recovered well with only mild RE upper lid ptosis of 2mm. The histopathological examination (HPE) of the excised cyst was suggestive of inflammatory cystic lesion. A 55 years male presented as a second case to us with gradually increasing mass in the RE lower lid with a history of pain, difficulty in opening RE and intermittent swelling of RE 2 months back. On examination RE lower lid mass with exotropia of 15 degree, mild hypertropia was noted. CT scan showed presence of cystic mass 3.5x2x1.5cm in the right orbit involving the right inferior rectus muscle, abutting and displacing the globe superolaterally. CBC showed eosinophilia. Post cyst excision patient recovered well with remaining mild restriction in infraduction most probably due to fibrosis. HPE was conclusive of cysticercus cellulosae. Both the patients improved well with no recurrence until last visit 17 months in 12 years boy and 6 months in 55 years male after which he lost to follow. CONCLUSION: Myocysticercosis can occur at any age. There is equal importance of clinical, radiological, microbiological and histopathological support for proper diagnosis and management of cysticercosis. Medical therapy along with surgical excision of the cyst with it's content may be needed in the management of myocysticersosis.

Amniotic membrane transplantation: Current indications in a tertiary eye hospital of eastern Nepal.

INTRODUCTION: Amniotic membrane has unique properties that can be helpful to treat different ocular surface diseases. OBJECTIVES: To report our experience with 100% glycerol preserved amniotic membrane at 4°C and fresh amniotic membrane transplantation (AMT) with and without limbal graft for ocular surface reconstruction. MATERIALS AND METHODS: Retrospective case study of 211 eyes of 211 patients was conducted at Biratnagar Eye Hospital from June 2008 to March 2014. The cases were evaluated in terms of demographic parameters, preoperative diagnosis and the type of surgery performed. RESULTS: The most common indication for surgery was Pterygium (90 eyes, 42.65%), followed by symblepharon (57 eyes, 27.01%), chemical injury (35 eyes, 16.58%), socket reconstruction (9 eyes, 4.26%), shield ulcer (6 eyes, 2.84%), PED (4 eyes, 1.89%), Steven Jonson's syndrome (5 eyes, 2.36%), dry Eye (2 eyes, 0.94%), Corneal Degeneration (2 eyes, 0.94%), bullous keratopathy (1 eye, 0.47%). The mean age was 28.12 ±17.2 years (age range 3-78 years). More men (161, 76.30%) underwent surgery than women (50 eyes, 23.69%). Symblepharon (24 eyes, 36.36%) was the major cause of surgery in pediatric group. The mean follow-up was 7 months (range 2-36, months). Resurgery was needed in (18 eyes, 8.53%) of which symblepharon (7eyes, 39%) was the major cause. AMT was done in 189 (89.57%) eyes and AMT with conjunctival limbal graft was done in 22(10.42 %) cases. Infectious, inflammatory, or allergic reactions were not encountered in any patient. CONCLUSION: All patient experienced increased ocular comfort with anatomical restoration of corneal and conjunctival surfaces. AMT alone or in combination with limbal graft aids in ocular surface reconstruction.