Sarcomatoid Carcinoma of Orbit in a Patient With Xeroderma Pigmentosum.

Spindle cell carcinoma (SpCC), also referred to as sarcomatoid carcinoma, makes up less than 3% of all head and neck squamous cell carcinomas (SCCs). It is an uncommon and unusual biphasic malignant tumor primarily affecting the upper aero-digestive tract. SpCC consists of spindled or pleomorphic tumor cells. Mostly, these tumors are seen in the fifth or sixth decades of life and are strongly associated with smoking and alcohol. We hereby report an infrequently encountered case of SpCC in a patient with xeroderma pigmentosum (XP), who was young, nonsmoker, and did not consume alcohol. The mass arose from the right orbit and involved the entire right face. The postoperative histopathological report showed SpCC. Surgical excision of the mass was performed. We aimed to add to the prevailing literature by reporting this case.

Cataract among Patients with Renal Transplantation in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Intensive immunosuppressant therapy after renal transplantation has found to cause systemic and ocular side effects among them is cataracts. Studies on a similar topic have still remained explored in our setting. The aim of the study was to find out the prevalence of cataract among patients with renal transplantation in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among patients of renal transplantation at tertiary care centres from 1 May 2021 to 31 October 2021. The data was collected after the ethical approval from Institutional Review Committee [Reference number: 397(6-11) e2077/078]. Study proforma recorded the number of patients with cataracts, duration of steroid use, mean age and other comorbidities. A convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of 31 renal transplant patients, 10 (32.26%) (15.80-48.72, 95% Confidence Interval) had cataract. Conclusions: The prevalence of cataract among renal transplantation patients was found to be lower than similar studies done in similar settings. Keywords: cataract; prevalence; renal transplantation; steroid.

Ocular Findings among the Patients of Renal Transplantation.

INTRODUCTION: Renal diseases are on rise globally due to increased incidence of non-communicable diseases as well as primary-kidney diseases and frequent use of nephrotoxic drugs. Only definite treatment of End-Stage-RenalDisease (ESRD) is renal transplantation. Immuno-suppressive-drugs are prescribed lifelong after renal transplantation especially steroids which can lead to various sight-threatening complications. METHODS: This cross sectional, observational study included 62 eyes of 31 patients who had undergone renal transplantation, at least 3 months prior were referred from Nephrology Department. Comprehensive eye evaluation was done at B. P. Koirala Lions Centre for Ophthalmic Studies (BPKLCOS), Department of Ophthalmology, Institute of Medicine. RESULTS: The average age of participants was 37 ±10.57 years with 77.4 % (n=24) male. Mean duration of renal transplant was 5.10 ± 3.61 years. Fifty-eight percent (n=18) had hypertensive kidney disease. Diabetes Kidney disease, recurrent UTI, CKD of unknown causes and combined case of diabetes plus hypertension were seen in 6.4% (n=2) each. Sixty percent of the patients had some kind of ocular involvement. Twenty-nine percent (n=18) had subnormal visual acuity of ≤ 6/9. Cataract was seen in 29% (n=18) of eyes followed by pinguecula (17.7%, n=11) and hypertensive-retinopathy (17.7%, n=11). Glaucoma and Diabetic-retinopathy were seen only in 6.4% (n= 4) of each eyes. There was no association seen between ocular findings with cause of renal transplant, duration of transplant and renal function status in bivariate analysis. CONCLUSIONS: Some form of ocular abnormality is commonly seen in patients of renal transplantation who are on immunosuppressive drugs. However, incidence of sight threatening complications are rare.

Management of unusual missed diagnosis of a Intra-orbital wooden foreign body: A case report and review of literature.

Introduction: Although intra-orbital foreign bodies (IOrFBs) are commonly seen in daily ophthalmology practice, rarely, they can have very unusual clinical presentations, especially nonmetallic FBs. Presentation of case: A 33-year-old male presented with sudden onset right lower lid swelling and tearing. He was initially tolerating the symptoms, however, it got progressively worse, so he came two weeks after the initiation of symptoms. His eye vitals were within normal limit, including the visual acuity of 6/6 OU. Additionally, slit lamp and fundus examinations were benign. Concern was for infectious etiology with unclear source. After a lengthy conversation, he recalled falling on the ground with face down about 16 months ago. However, he stated that he had remained asymptomatic and never went for treatment after the incident. Non-contrast CT of head and orbit showed hyperdense tract in medial aspect of right eye adjacent to the globe, piercing across the bilateral ethmoidal sinuses. Thus, a diagnosis of retained IOrbFB was made. He underwent surgery where a 5cm rotten wood was extracted. Post-surgical course was uncomplicated. Not all penetrating intra-orbital foreign bodies present immediately after the incident. In our case the patient remained asymptomatic for 16 months. Conclusion: Therefore, when dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

Panophthalmitis secondary to retained intraocular foreign body amidst a national lockdown during the COVID-19 pandemic: A case series and review of literature.

Introduction: Intraocular foreign bodies (IOFBs) can be serious as they may result in vision-threatening ocular inflammations and even loss of the eye. Delay in presentation or treatment by more than 24 hours from the time of injury results in a poor prognosis. In penetrating wounds, microorganisms enter the eye through penetrating objects. Both bacterial and fungal organisms are responsible for causing panophthalmitis. At the ocular level, these microorganisms produce irreversible damage which includes keratitis, uveitis, hypopyon, vitreous abscesses, retinal necrosis, detachment, and, finally, panophthalmitis. Case scenarios: In this case series, we report three cases of IOFB presenting with panophthalmitis secondary to delay in seeking medical attention. In our cases, there was a delay in the presentation by more than 24 hours of trauma. All cases had panophthalmitis at the time of presentation. In two cases, the causative organism was coagulase-negative staphylococci and in one case it was staphylococcus. Initially, we planned to manage them with intravitreous, intravenous and topical antibiotics till the inflammation subsides, then IOFB removal surgeries were planned. However, in two cases, the clinical presentation worsens with scleral necrosis. Therefore, they had to undergo evisceration. In one case, the antibiotics therapy was enough without IOFB removal surgery to manage her symptoms. All cases recovered uneventfully after the interventions. Discussion/Conclusion: In developing nations, like Nepal, transportation barriers can affect a person's access to health care services. This can be clearly explained from this case series as limited transportation options in rural regions are a major factor for all patients' delayed presentation to the hospital during the time of national lockdown in the second wave of the COVID-19 pandemic. The concerned authority must pay attention to solving such social determinants of health.

Evaluation of Intraocular Pressure in Thyroid-associated Orbitopathy.

BACKGROUND: Elevated intraocular pressure in thyroid associated orbitopathy may lead to development of secondary glaucoma in them. This study evaluated IOP in primary gaze correlation with clinical activity score in them. METHODS: A cross-sectional study was conducted from November 2020 to October 2021.Information on age, gender, thyroid function test, intraocular pressure, cup-disc ratio and clinical activity score were recorded. Purposive sampling was done. Statistical analysis was done using Statistical Package for Social Sciences version 21. RESULTS: Total of 74 thyroid dysfunction patients was included in the study. There were14.86% patients with raised intraocular pressure. The mean intraocular pressure in hyperthyroidism was 15.4 ± 1.92 mm Hg and 15.48 ± 2.11mm Hg on right and left eyes respectively and in hypothyroidism, it was 15.08 ± 2.7mmHg and 15.12 ± 3.02 mmHg on right and left eyes respectively. The mean clinical activity score was 1.06 ± 1.23 mmHg. The mean intraocular pressure in eyes in active stage (n=9) was 16.3 ± 3.4 mm Hg, which was not significantly different from the mean intraocular pressure of 15 ± 2.4 mm Hg in inactive eyes (64), p= 0.1. Clinical activity score showed a significant correlation (p=0.03) with intraocular pressure in right eyes whereas it showed no significant correlation with intraocular pressure in left eyes (p=0.37). CONCLUSIONS: In this study elevated intraocular pressure occurred in about 1 in 7 thyroid associated orbitopathy. It also had positive correlation with clinically activity score in right eyes. Regular intraocular pressure measurement should be done in thyroid associated orbitopathy to prevent intraocular morbidity.

Binocular vision findings in normally-sighted school aged children who used digital devices.

PURPOSE: To determine the binocular vision status in normally-sighted school aged children who used digital devices. METHODS: A cross-sectional study was conducted at B.P. Koirala Lions Center for Ophthalmic Studies, Kathmandu, Nepal for a duration of one year. One hundred and eighty school aged children (71 female and 109 male) aged 7 to 17 years were included in the study. All the children underwent detailed ophthalmic and binocular vision examinations. The duration of the use of digital devices by the children were asked to either the parents or guardians present at the time of the study. The study participants were divided into two groups: children who used digital devices for the last six months (users group) and those who hadn't used digital devices for the last six months (non users group). The users group was again divided into two subgroups: children who used digital devices for less than 3 hours per day and a day per week (low digital device users subgroup) and children who used digital devices for more than 3 hours per day and all days in a week (high digital device users subgroup). RESULTS: Accommodative amplitudes, accommodative facility, and positive fusional vergence for both near and distance were significantly reduced in the high digital device users group than in the low digital device users subgroup (p <0.01). Stereo acuity, near point of convergence, and negative fusional vergences for both near and distance were not statistically significantly different between the two subgroups. Prevalence of accommodative and vergence anomalies (except convergence insufficiency) was more in the high digital device users subgroup than in the low digital device users subgroup (p<0.01). CONCLUSIONS: Children who used digital devices for a significantly greater amount of time had significantly reduced amplitudes of accommodation, accommodative facility, and positive fusional vergence both at near and distance.

Bilateral Cryptophthalmus: First Case Report from Nepal.

INTRODUCTION: Cryptophthalmus is characterized by a partial or complete casing of the eyeball by the skin. Cryptophthalmus alongside other systemic abnormalities is well-known as Fraser syndrome. It is an unusual genetic disorder with limited literature. The complexities of disease and limited experience pose challenges in its management. CASE: A two-day-male neonate was brought by his parents with a complaint of swelling in the right orbital region and deformed left eye since birth. Examination revealed bilobed globular swelling in the right orbital region covered by a continuous sheet of skin from forehead to cheek with no visible ocular tissue. On the left side, there was absence of upper lid margin and eyelashes and superior symblepharon. He also had bilateral ear abnormalities and right renal agenesis. Surgical intervention was done. On the right side, removal of the globe and cyst was done. On the left side, upper eyelid reconstruction with symblepharon release was done with amniotic membrane transplantation. CONCLUSIONS: The management of cryptophthalmus is challenging. Reconstructive surgeries allow cosmesis but useful vision is rarely gained. This is the first case report from Nepal to date to the best of our knowledge.

Orbital Lipoma as an Uncommon Cause of Unilateral Proptosis: A Case Report.

A 36 year old male presented with a two-month history of a progressively increasing proptosis of the right eye associated with redness. MRI of brain and orbit revealed a mass in the intraconal compartment in the lateral aspect of the right orbit that had T1, T2, and FLAIR high signal intensity and was completely suppressed in the STIR image. Excisional biopsy of the mass resolved the proptosis, and histology revealed encapsulated tumor composed of lobules of mature adipocytes along with fibro collagenous septa. Thus, diagnosis of lipoma was established that has uncommon occurrence in the orbital region.

Profile of Ophthalmic Tumors in Adult Nepalese Population in Central Nepal.

INTRODUCTION: Ophthalmic tumors cover benign and malignant tumors of eyelids, conjunctiva, globe, and orbit. There is limited literature on ophthalmic tumors in Nepal. The objective of the study was to find the relative frequency of various ophthalmic tumors in the adult Nepalese population in Central Nepal. MATERIAL AND METHODS: This is an observational descriptive study. A total of 100 consecutive patients, presenting with ophthalmic tumors to tertiary referral eye hospital were enrolled for the study. Demographic profile, detailed history, clinical features and diagnosis of the ophthalmic tumors were recorded. The tissue from incisional or excisional biopsy was then subjected to histopathological examination for confirmatory diagnosis. RESULTS: Mean age of subjects with ophthalmic tumors was 51.5 ± 18.2 years with a female to male ratio of 1.2:1. Benign tumors (64%) were the most common tumors followed by malignant (26%) and premalignant tumors (10%). Most common benign tumor was naevus (26.5%); most common premalignant tumor was conjunctival intraepithelial neoplasia (60%), and most common malignant tumor was sebaceous gland carcinoma (30.8%). Eyelid was most frequently involved with ophthalmic tumors (59%) followed by conjunctiva (21%). Clinical diagnosis correlated with histopathological diagnosis in 77% of cases. CONCLUSION: As different ophthalmic tumors present in a myriad of ways and a significant proportion of these cases presenting to hospital settings are malignant, it is prudent to confirm with a histopathological diagnosis for optimum management of such cases.

Traumatic Orbital Compartment Syndrome: A Sight Threatening Emergency.

Orbital compartment syndrome is a rare presentation of orbital trauma and is an ophthalmic emergency. Delay in clinical diagnosis and subsequent surgical intervention will lead to loss of vision in nick of time. We presented a case series of orbital compartment syndrome secondary to trauma who presented to the emergency department of Tribhuvan University Teaching Hospital during the devastating earthquake in April 2015. Clinical diagnosis of orbital compartment syndrome was made in the bedside and all the patients underwent emergency lateral canthotomy and inferior cantholysis. This case series was aimed to describe clinical features and management of orbital compartment syndrome.

Congenital Microphthalmia with Intraorbital Cyst: A Rare Case Report.

Microphthalmia is considered to be the most common congenital malformation of the eye after congenital cataract. However, its association with intraorbital cyst is considered to be very rare. Most of the lesions are still misdiagnosed as orbital tumor and teratomas as there is a general paucity of data reported in literature. Herein, we report a rare case of congenital microphthalmia with intraorbital cyst in an eight-month-old male patient.

Orbital Teratoma: A rare congenital tumour.

BACKGROUND: Orbital teratomas are congenital, unilateral germ cell tumors, which are present at birth with moderate to massive proptosis. The rare tumour has to be managed individually and is at times difficult. CASE: A female child in her 2nd day of life was brought to our department with complains of forward bulging of the left eye which was noticed since the time of her birth. OBSERVATION: Examination and investigations revealed a mass with scattered foci of calcification. The mass was causing expansion of left orbit with thinning and scalloping of bony boundaries of left orbit with no intracranial component. The scan suggests the diagnosis of orbital teratoma which was further confirmed by histopathological examination. CONCLUSION: The rare tumour presents a challenge in management. The aim of management depends upon the extent of tumour, preservation of vision whenever possible, promotion of normal orbital growth and cosmesis.

A Case of Orbital Myiasis in Recurrent Eyelid Basal Cell Carcinoma Invasive into the Orbit.

Introduction. Orbital myiasis is the infestation of the orbital tissues by fly larvae or maggots. Compromise of periorbital tissues by malignant disease, surgery, ischemia, or infection may predispose the patient to orbital myiasis. Case Report. A 73-year-old male patient with neglected recurrent basal cell carcinoma of the eyelid invasive into the orbit presented with complaints of intense itching and crawling sensation with maggots wriggling and falling from the wound of left orbit. The patient improved following manual removal of the maggots along with oral Ivermectin treatment. Recurrence of the basal cell carcinoma was confirmed by punch biopsy from the wound and extended exenteration of the orbit followed by reconstructive surgery was done. Conclusion. Orbital myiasis is a rare and preventable ocular morbidity that can complicate the malignancies resulting in widespread tissue destruction. The broad spectrum antiparasitic agent, Ivermectin, can be used as noninvasive means to treat orbital myiasis. In massive orbital myiasis and those associated with malignancies, exenteration of the orbit must be seriously considered.

A case of transorbital intracranial injury presenting with subtle neurological deficit.

BACKGROUND: Ocular trauma is a major cause of visual morbidity. OBJECTIVE: To present a rare case of transorbital intracranial injury extending up to the left internal carotid artery (ICA) with no other systemic neural deficit except for the ocular manifestations. CASE: A 14-year-old female presented to our out-patient department (OPD) with the history of trauma to her left eye with stumps of bamboo shoots secondary to a fall injury. Examination and investigations revealed a foreign body extending from left inferior conjunctival fornix into the intracranial cavity, occluding the various segments of left ICA. The patient subsquently underwent craniotomy and foreign body removal by a combined team of neurosurgeons and ophthalmologists. On discharge, the patient had slight improvement in extraocular motility of her left eye. However the trauma rendered the affected eye, non-seeing. CONCLUSION: The intracranial extent of a foreign body entering the cranium via the transorbital route cannot be judged merely by the clinical findings of the nervous system and ocular examination. These patients need timely management by the combined effort of ophthalmologists, neurosurgeons and radiologists.

A rare malignant transformation of benign lacrimal tumor.

Lacrimal gland tumors are common in middle age group individuals. Proptosis is one of their common presentations. Sometimes the tumors may undergo malignant changes which if neglected can be life threatening. Here we present a case of 49 years male with gradual painless protrusion and diminution of vision in his right eye for eight years and more since last 2 months, with restriction of ocular motility in right lateral gaze. Expecting a benign mass, superolateral orbitotomy with excisional biopsy was done which astonishingly revealed carcinoma ex pleomorphic adenoma with components of adenocarcinoma and squamous cell carcinoma without any lymphovascular invasion. Proptosis and vision of the patient in right eye improved post excisional biopsy without any residual mass in respective follow ups.

Ocular and orbital metastases presenting as a first sign of gastric adenocarcinoma.

The authors report a case of simultaneous choroidal and orbital metastases with optic nerve involvement presenting as an initial manifestation of gastric adenocarcinoma. To our knowledge, this is the first case of its kind reported in the literature where a 60 years male presented with 6 months history of progressive painful diminution of vision in his left eye associated with inward and upward rotation of the same globe. Examination of left eye revealed displacement of the globe superomedially by an inferolateral mass with restriction of ocular motility in levoversion. Fundus examination showed exudative retinal detachment with a subretinal mass which was supported by the ocular ultrasonography. Intraocular and orbital tumour was demonstrated by CT. Endoscopic biopsy revealed adenocarcinoma of the stomach. The left orbit was exenterated and specimen was sent for histopathological examination which confirmed the presence of same metastatic tumour cells in the eye and orbit. The patient underwent chemotherapy and radiotherapy for gastric carcinoma but the patient died after 6 months.