Multiple Cavernous Haemangioma of Orbit and Cranium: A Case Report.

A 32-year-old male presented with painless proptosis and diminution of vision in left eye. Imaging shows multiple well-defined masses, suggestive of cavernous haemangioma, in orbit and cranium with adjoining bones being thickened with cystic spaces. Histopathology proved the diagnosis. Cavernous haemangioma usually presents as a solitary intraconal and sometimes extraconal mass with vision usually preserved unless it extends to the apical portion. Here we report a rare case of multiple simultaneous locations of cavernous haemangiomas in orbit and cranium with significant diminution of vision.

Outcome of Injection Botulinum Toxin in Blepharospasm.

INTRODUCTION: Blepharospasm is a condition of involuntary spasm of the orbicularis oculi muscle which leads to intermittent or complete closure of the eyelids. Botulinum toxin is the currently recommended first line treatment for such blepharospasm. This study aims to find out the outcome of injection Botulinum toxin Type A in Blepharospasm. MATERIALS AND METHODS: It was a hospital based, prospective, interventional study conducted on patients diagnosed as Benign essential blepharospasm (BEB), Meige syndrome (MS) and Hemifacial spasm (HFS) by oculoplastic surgeon at Oculoplasty department OPD, Tilganga Institute of Ophthalmology, from December 2018 to November 2019. After taking all standard precautions for botulinum toxin injections, 6 to 8 sites for injecting 2.5 to 5 IU of the toxin were given. All the patients were evaluated before and after injections according to Jankovic spasm grading and improvement in functional impairment scale and followed on one week, one month, three month and when the symptoms reappeared. RESULTS: A total of 43 cases which included 32 cases of Benign essential Blepharospasm, 9 Hemifacial spasm and 2 Meige syndrome. The mean Jankovic severity score was 3.51 ± 0.51 (range 3-4). The mean improvement in functional score was 2.60 ± 0.54 (range 1-3), was statistically significant (p-value <0.001).The effective period of injection was 130 ± 20.82 (93 - 189) days.38 patients had repeated injections after reappearance of symptoms. 4 patients had side effects of redness and hematoma at one site. CONCLUSION: This study concludes that Botulinum toxin type A is effective in the management of Benign essential blepharospasm, Hemifacial spasm and Meige syndrome. This along with a good safety profile justifies its role as a first line treatment therapy in blepharospasm. However, it is a temporary treatment option where the effect lasts for a short period of time and repeated injections are required.

Ocular involvement in metastatic and systemic malignancies is not rare.

BACKGROUND: Metastatic disease to the eye most commonly involves choroid followed by orbit leading to varied ocular manifestations. By comparison, it is relatively rarer than primary malignancies of eye as well as metastasis in other parts of the body. AIM: The aim of this study is to evaluate the common eye and orbital structures involved in secondary ocular and metastatic disease, to describe its clinical manifestations and outline the management done. METHODS: A retrospective study of newly diagnosed cases of ocular metastasis in last 2 years conducted in our recently established department of ocular oncology at a tertiary eye care hospital in Nepal. Demography, age and sex distribution were noted. The patients were segregated into those with secondary or metastatic ocular malignancies. Detail study on the metastatic disease to eye was made in regards to presenting symptoms, signs, primary site of cancer, and the treatment done. Details of the investigations done, like biopsy and imaging were also recorded. RESULTS: There were a total of 28 patients, whose age group ranged from 9 years to 69 years with median age of 43 years. Females constituted 46% of total patients. Both the eyes were involved in 9 patients (32%). Eye was secondarily involved by paranasal sinus tumors and Non Hodgkin lymphoma (7 patients each). Ocular metastasis was commonly seen from broncogenic carcinoma in four and breast carcinoma in three patients. Simultaneous metastasis to other parts of the body was also seen in 61% of our patients. Diminution of vision in 49% was the most common presenting feature followed by proptosis in 16% and palpable mass in 14% of patients. Orbit in 43% cases is the commonest ocular structure involved. Histopathologic diagnosis was done in 32% only while rest was based on imaging alone. The most common treatment done was chemotherapy in 57% patients. CONCLUSION: Ocular metastasis can display a wide variety of clinical and imaging features and therefore a high degree of suspicion is required. It is often associated with simultaneous metastasis to other parts of the body as well, hence the importance of earlier diagnosis and metastatic workup.

Clinicopathologic Presentation and Management of Malignant Orbito-ocular Tumors at a Tertiary Care Hospital in Nepal.

INTRODUCTION: This study was conducted to evaluate the clinical presentations and management of various Orbito-ocular malignancies in Nepal. MATERIALS AND METHODS: This is a prospective study of ocular malignant cases conducted at a tertiary care eye hospital in Kathmandu, Nepal. One hundred and seventeen newly diagnosed eyes with ocular malignancy of 106 patients presenting to the clinic in a year from September 2018 to August 2019 were included for analysis. Patients' demography, clinical features, various types of malignancies seen in eyes and their management were evaluated. RESULTS: The mean age of patients was 30.35 years with a range from 1 month to 84 years and standard deviation of 26.63. 56% of the total were male. Red eyes and visible mass were the most common symptoms in 23% with intraocular contents in 48% being the most common site involved. Different types of ocular malignancies were detected, among which retinoblastoma was the most common in 38% of patients. Diagnosis in most patients was clinical and/or radiological; incision biopsy was required in 1.7% patients only. Surgical excision of the tumor was the most common treatment done in 29% followed by enucleation in 27% of eyes. Bilateral involvement of the eyes was seen in 10% of the patients. CONCLUSION: Malignant orbito-ocular tumors can be seen in any age group. Retinoblastoma is the commonest malignancy seen. With the help of imaging, diagnosis is near accurate; hence biopsy is not required in most cases before commencing treatment.

External Dacryocystorhinostomy and Patient Satisfaction: Perspective of General Ophthalmologist.

INTRODUCTION: This study aimed to evaluate patient satisfaction over time in patients undergoing external dacryocystorhinostomy for primary nasolacrimal duct obstruction when done by a general ophthalmologist. MATERIALS AND METHODS: This prospective interventional case series was done in a secondary level eye hospital in the Midwestern region of Nepal from 1st January 2018 to 30th December 2018. Fifty-four consecutive adult patients diagnosed with primary nasolacrimal duct obstruction who underwent external dacryocystorhinostomy performed by a general ophthalmologist were included. The surgical success rate was determined at six months on the basis of the resolution of symptoms with patency on syringing. Postoperative patient satisfaction was evaluated 6 months after surgery with a standardized Glasgow Benefit Inventory and post-intervention questionnaire. RESULTS: A total of 54 eyes were operated on within the study period and a larger number of surgeries were done in the age group 26-30 years. Female constituted 79.6 % and male 20.4% with a ratio of 3.9:1. Overall surgical success rate 6 months after surgery was 96.30%. The mean total Glasgow benefit inventory (GBI) score was 48.83 ± 23.87 (95% CI, 42.96- 56.95), mean general subscale score was 52.70± 23.28 (95% CI, 46.49-60.38), social support subscale was 49.69 ± 44.68 (95% CI, 41.15-60.35) and physical health subscale score was 37.07 ± 41.19 (95% CI, 27.48-49.26). CONCLUSION: The external dacryocystorhinostomy surgeries performed by general ophthalmologists achieved an excellent surgical success rate and good patient satisfaction proven by a validated questionnaire.

Transient Inverse Bell's Phenomenon Following Frontalis Sling-Suspension Ptosis Surgery: A Rare Ophthalmic Phenomenon.

INTRODUCTION: Inverse Bell's phenomenon is a rare ophthalmic phenomenon where downward instead of upward movement of the eyeball occurs during eyelid closure. It may be associated with peripheral facial nerve palsy, conjunctival scarring, and ptosis surgery. CASE REPORT: A 9-year-old male patient with right upper-lid congenital ptosis developed inverse Bell's phenomenon 2 days after frontalis sling-suspension ptosis surgery. At the 3-week postoperative visit, there had been spontaneous resolution of the inversion of Bell's phenomenon without any corneal complication. CONCLUSION: Inverse Bell's phenomenon, more often reported to be associated with levator-resection surgery, may develop following frontalis sling-suspension ptosis surgery. Close monitoring and frequent instillation of topical lubricants are necessary to prevent exposure keratopathy until the resolution of inverse Bell's phenomenon in patients with lagophthalmos after ptosis surgery.

Comparison of early versus standard timing for silicone stent removal following External Dacrocystorhinostomy under local anaesthesia.

INTRODUCTION: The first line treatment for nasolacrimal duct obstruction (NLDO) is external dacrocystorhinostomy (DCR). Following DCR, patients are required to return to Tilganga Institute of Ophthalmology (TIO) six weeks postoperatively for the removal of a silicone stent. As the majority of patients travel large distances at significant cost to reach TIO, most often patients remain within Kathmandu during this six weeks interval. This places a large financial burden on patients. METHODS: A randomized controlled trial was designed to compare patient outcomes after early (two weeks postoperatively) versus standard (six weeks postoperatively) removal of silicone stents. 50 selected patients were randomized into two equal groups. RESULTS: At the time of publication, 31 patients (14 in group A and 17 in group B) had completed three months follow up. A success rate of 92.9% was noted in Group A and a success rate of 94.1% observed in group B. No significant difference was found between the two groups for success rate and rate of complications. CONCLUSION: Early tube removal post DCR appears to cause no significant difference in outcome or complication rates compared to standard tube removal.

Choroidal Melanoma: Our Experience.

BACKGROUND: Choroidal melanomas are diagnosed in approximately 6 out of one million Americans per year, and although their incidence is low, they are the most common primary intraocular tumor in adults. METHODS: Choroidal melanoma is rare tumors and till date no such reports with sclera involvement has been reported from Nepal. It is a prospective case series. The aim of this study is for awareness of the severity of the Choroidal melanoma and it's management. Besides, it is also to study the demography, presentation, histopathological variations and management of cases of choroidal melanoma. All the consecutive cases of Choroidal melanoma presenting between Jan 2017 to May 2018 and those who were within the inclusion criteria were included in this study. RESULTS: There were eight patients, five male and three female, within age range of 18-73, median age was 47. All patients presented with decreased vision ranging from 6/24 to PL of less then three months to 2 years duration. Fund us showed choroidal mass associated with Vitreous hemorrhage (VH), and retinal detachment (RD). Two patients were managed with enucleation with External beam radiotherapy (EBRT). Four underwent only enucleation. One patient with lesion size less then 10mm under went plaque brachy therapy. One patient underwent initially Plaque brachy therapy but later had to undergo Enucleation. Histopathological examination (HPE) of enucleated patient revealed epitheloid cell melanoma grade three in four and Spindle cell melanoma in three patients. Each one patient of epitheloid cell melanoma and spindle cell melanomahad scleral involvement. Indication for radiotherapy was scleral involvement. CONCLUSION: With 8 cases of Choroidal melanoma in a single year in a single hospitalgives us a clue that there may be much more undiagnosed cases of Choroidal melanomain Nepal that should be taken seriously. Going for annual eye examination with routine dilated fund us exams can help in prevention and early diagnosis of this life and sight threatening condition and to reduce the mortality rate.

Congenital Microphthalmia with Orbital Cyst: A Case Series.

Microphthalmos results from incomplete invagination of the optic vesicle or closure of the embryonic fissure. We present three patients with unilateral congenital microphthalmia with cyst. None of them had vision in the affected eye since birth. There was gradually increasing left eye orbital mass encroaching towards lower fornix and lower eyelid ectropion. On examination and investigations, patients had large orbital cyst with microphthalmia pushing the eyeball superiorly and posteriorly in affected orbit. Microphthalmic globe with cyst was surgically excised and histopathologically studied. Orbital cavity was big enough to occupy the conformer and the prosthetic eye after 6 weeks. Diagnosis was confirmed as large communicating orbital cyst with microphthalmia without systemic association in all the patients. None of the mothers of patients had regular antenatal check up. All the parents had consanguineous marriage. Antenatal check up with ultrasound at 14 to16 weeks of pregnancy is important for genetic counselling. Targeted abdominal ultrasound examination of pregnant women focused on the orbital region of foetus is recommended, in mothers who have children with congenital eye anomalies. Keywords: congenital anomaly; cyst; eye; microphthalmos.

Work Related Ocular Injury: Nepal.

INTRODUCTION: Occupational eye injuries comprise a major source of ocular trauma. Knowledge of the epidemiology of occupational eye injuries is essential to formulate viable safety strategies. OBJECTIVES: To evaluate the demographics, patterns of protective eye wear use, and patterns of occupational eye injury among workers in Hetauda, Nepal. MATERIALS AND METHODS: Community based cross-sectional prospective survey was carried out from September 2010 to July 2011. Survey included all workers irrespective of their age and those who are willing to participate in survey by filling details on structured questioners and comprehensive eye examination at community level. RESULTS: 1236 surveys were collected. 38.3% (473) of workers surveyed reported experiencing a work-related eye injury. Over two-thirds [68.3% (844)] of workers surveyed reported never wearing safety eyewear while at work. There was a positive correlation between male sex (P<0.001), reported previous work-related injury (P<0.001), and attending school (P=0.016) and use of personal protective equipment (PPE). CONCLUSIONS: The population studied demonstrates a significant level of work related injury. There are potentially modifiable factors that could lead to increased use of eye protection.

Comparing outcomes of pediatric and adult external dacryocystorhinostomy in Nepal: Is age a prognostic factor?

We determine whether age is a prognostic factor for surgical outcomes of external dacryocystorhinostomy (Ex-DCR). This retrospective cohort study conducted at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) compared pediatric Ex-DCR procedures (age ≤ 15 years) to adult Ex-DCR procedures (age > 15 years) and was performed between January 2013 and December 2013, with a minimum follow-up period of 6 months. Primary outcome measure was rate of success, defined as complete resolution of subjective symptom(s) of epiphora (subjective success), combined with patent lacrimal passage on syringing (anatomical success) at last follow-up visit. Other outcome measures included clinical presentation, diagnosis, intraoperative complications and post-operative complications. In total, 154 Ex-DCR procedures were included, with an age range of 8 months to 81 years (mean age 36.4 ± 21.0 years). In all, 38 pediatric Ex-DCR procedures were compared to 116 adult procedures. Success rates were 97% in the pediatric group and 95% in the adult group, with no clinically or statistically significant difference in success rate or complication rate between groups (p > 0.05). Our study yielded high success rates of Ex-DCR in both pediatric and adult age groups suggesting that Ex-DCR remains an optimal treatment choice for all age groups. With no difference in surgical outcomes between pediatric and adult patients, including complication rate, we conclude that age is not a prognostic factor for Ex-DCR failure. We do not recommend adjuvant therapy for pediatric patients.

Surgical outcome of pediatric dacryocystorhinostomy in Nepal.

PURPOSE: To report the indications and surgical outcome of dacryocystorhinostomy (DCR) in children treated at a single tertiary eye hospital in Nepal. METHODS: The medical records of consecutive pediatric patients who underwent external DCR with silicon tube intubation after failed nasolacrimal irrigation and probing from January 2010 to June 2011 were retrospectively reviewed. Surgical success was defined as resolution of epiphora, normal tear film height, negative fluorescein dye disappearance test and anatomic patency determined by irrigation of the lacrimal system. RESULTS: The etiology of the nasolacrimal duct obstruction was acquired nasolacrimal duct obstruction (NLDO) in 63%, congenital NLDO in 23%, trauma in 1% and congenital bony abnormality in 1 patient. Of the 38 patients who completed follow-up, 37 (97%) had a successful result. CONCLUSIONS: External DCR effectively treated a variety of pediatric NLDO etiologies, with a low rate of complications.

External dacryocystorhinostomy: do we really need to repair the posterior flap?

PURPOSE: This study aims to compare a simplified technique of external dacryocystorhinostomy (DCR), where the posterior flap is excised, with the more traditional approach of double flap repair. METHODS: A prospective, comparative, single surgeon, single centre clinical trial was conducted of eighty-three patients who received external DCR, with either anterior and posterior flap anastomosis (Group A), or anterior flap anastomosis and excision of the posterior flap (Group B), in a tertiary referral hospital in Nepal. Patients with nasolacrimal duct obstruction and epiphora were assigned to one of two groups. Follow up was a minimum of 6 months for inclusion in the study. Success was defined objectively by irrigation of the puncta without regurgitation and subjectively by the absence of epiphora or discharge. RESULTS: The overall success rate of external DCR was 89.2%, after a mean follow up of 13.5 ± 2.2 months. There was no difference in success between the two groups (p-value = 0.73), with 90.7% success in Group A and 87.5% in Group B. The frequency of complications was not statistically different between Groups A and B (p-value = 0.79). CONCLUSIONS: Excision of the posterior flap and anastomosis of only the anterior flap is not disadvantageous to the outcomes of external DCR surgery when compared with the more traditional approach of anastomosis of both flaps. We believe this simplified procedure can be implemented as the standard technique for external DCR, particularly in developing nations such as Nepal.

Retinoblastoma: ten years experience at Kanti Children's Hospital.

INTRODUCTION: Retinoblastoma is a malignant tumor of the embryonic neural retina. It is the most common intraocular tumor of childhood. It is a disease of early childhood with 80% cases diagnosed before the age of 4 years. The median age at diagnosis is 2 years. Bilateral cases are diagnosed earlier (median at 12 months and unilateral median age at 24 months). The incidence of retinoblastoma is approximately 1 in 15000-18000 live births in developed countries. The aim of the research is to study the clinical pathological features, treatment and survival of children with retinoblastoma over ten years. METHODS: A retrospective hospital based study was conducted from March 1998 to February 2008. Gender, age, clinical presentation, pathology reports, treatment, follow-up and outcome were recorded at time of diagnosis. RESULTS: A total of 42 children with retinoblastoma (85.7 % unilateral, 14.3% bilateral), with 50% having optic nerve involvement were studied. The most common presenting signs were extraoccular (28.6%), proptosis (23.8%), leukoria (23.8%), phthisis bulbi (16.7%), and strabismus (7.1%). The age at presentation ranged from 6-120 months with mean age of 46.6 months. The male to female ratio was 1.1:1.Two-thirds presented between 2-5 yrs, followed by 12-24 months (23.8%). Majority of children had poorly differentiated retinoblastoma (62 %), followed by well differentiated (28.6%), and moderately differentiated (9.5%). CEV based protocol used to treat, and over-all 10 yrs survival was 23.8 %, death 19 %, and lost to follow-up or left against medical advice 57.2%. CONCLUSIONS: Despite severe resource limitation, pediatric oncology unit has been successfully treating retinoblastoma with the success rate of 23.8%.

Age-based comparison of successful probing in Nepalese children with nasolacrimal duct obstruction.

PURPOSE: To compare the success rates of probing in Nepalese children younger than 2 years versus children older than 2 years with nasolacrimal duct obstruction (NLDO), and to identify factors associated with successful probing. MATERIALS AND METHODS: Data was collected and analyzed retrospectively on children who underwent probing under general anesthesia for NLDO at Tilganga Eye Centre, Nepal, from May 2004 to October 2008. We compared successful probing rates in children less than or equal to 2 years old (group 1) versus children greater than 2 years old (group 2), and analyzed whether various clinical factors were associated with successful probing. Successful probing was defined as complete resolution of all clinical signs (discharge, epiphora or increased tear lake) at the outcome visit one month following surgery. RESULTS: Data on 84 children (109 eyes) was reviewed. The mean age of children in group 1 and group 2 was 15.3 months and 37.3 months, respectively. The success rate of probing for the overall sample was 82.6% (90/109 eyes). The success rate in group 1 was 90.2% (55/61 eyes), and 72.9% (35/48 eyes) in group 2 (p=0.018). Increased age at time of probing (p=0.031) and duration of symptoms (p=0.027) were associated with decreased probing success. CONCLUSION: Early treatment of NLDO with probing, ideally prior to 2 years, is associated with better outcomes. Age appropriate intervention may reduce the incidence of complications from NLDO, which is highly prevalent in the low-lying areas of Nepal, including Kathmandu.

Retinoblastoma in Nepal: a clinical profile of 30 cases.

To determine the clinical profile of retinoblastoma and to provide baseline data for further studies on this subject. Prospective evaluation of 30 consecutive patients with retinoblastoma admitted at the B. P. Koirala Lions Center for Ophthalmic Studies, Kathmandu, Nepal, between October 1998 and July 2000 was carried out. Age, sex, laterality and time from onset of symptoms to diagnosis (lag time) were noted. Ancillary tests were undertaken to rule out metastasis. Male to female ratio was 1.1:1 and the median age of presentation was 3.1 years. Of 30 cases, 23 (76.6%) had unilateral involvement. Leukocoria was the presenting sign in 13 cases (43.3%) and fungating mass in 10 cases (33.3%). In 11 (36.7%), the latency period from onset of symptoms to diagnosis was 6-12 months. In bilateral cases, advanced disease was treated surgically and the fellow eye was treated with cryotherapy, photocoagulation and chemotherapy. Histopathological examination of 21 (70.0%) enucleated/exenterated cases revealed a poorly differentiated type of retinoblastoma. This is the first study of retinoblastoma from Nepal. Early diagnosis of this disease when it is localized to the eye is important to salvage the life of the child. An informational program directed toward the public in general, as well as careful screening of any white pupillary reflex by the pediatrician and/or primary health worker will encourage and support early diagnosis.