Correlation of clinical and radiological scores for evaluation of activity in patients having thyroid-associated orbitopathy: A prospective observational study.

PURPOSE: To find a correlation between the clinical (vision-inflammation-strabismus-appearance [VISA] score) and radiological (apparent diffusion coefficient [ADC] values) scores for evaluating disease activity in patients with thyroid-associated orbitopathy. DESIGN: A prospective comparative study. METHODS: Our study was performed for consecutively diagnosed thyroid-associated orbitopathy (TAO) patients. Clinical evaluation included the VISA classification system with the basic thyroid workup. An inflammatory score of <4/8 was considered inactive and ≥4/8 as an active disease. Every included patient underwent a diffusion-weighted magnetic resonance imaging (DW-MRI) scan of the orbits. The orbital parameters evaluated on imaging included the proptosis, thickness, as well as the ADC values of extraocular muscles. RESULTS: We studied 33 consecutive patients (23 females, 69.7%) with a mean age of 41.8 years. The majority (n = 27, 81.8%) were hyperthyroid, four were hypothyroid, and two were euthyroid. In the VISA classification, nine patients had active TAO (≥4/8 inflammation score), while 24 had inactive disease. There was a positive correlation between the inflammation score and ADC values of medial rectus (MR), inferior rectus (IR) and lateral rectus (LR). We had nine patients with inflammation scores ≥4. With receiver operating characteristic (ROC) curve analysis, we found that the ADC value of IR can predict disease activity with 68% sensitivity and MR-ADC can predict active TAO with 87% sensitivity. CONCLUSION: The ADC parameters of DW-MRI are objective and less operator dependent than the clinical TAO activity scores like VISA classification. A randomized control trial may provide robust data on this correlation.

Long-term outcomes of lacrimal canalicular trephination with viscoelastic-assisted monocanalicular stenting for canalicular obstructions.

Purpose: To study the long-term outcomes of lacrimal canalicular trephination (LCT) with viscoelastic-assisted monocanalicular stenting (VAMS) for the treatment of epiphora secondary to lacrimal canalicular obstructions (LCO). Methods: Our study was a retrospective interventional work. All patients diagnosed with LCO, having morbid epiphora (Munk's scale ≥ 2), were included. The LCO was divided as proximal (< 6mm from punctum) and distal (≥ 6mm from punctum). Sisler's lacrimal trephine (21 gauge) was used to recanalize the LCO with monocanalicular stent (0.64mm diameter) insertion, which was kept for a minimum of 6 weeks and a post-stent removal follow-up of 12 months was ensured. Fluorescein dye disappearance test and lacrimal irrigation were used as functional and anatomical tests for evaluation, respectively. Results: We included 73 eyes of 52 patients having a mean age of 44.5 years. Of the total, the proximal LCO was seen in 38 eyes (52.1%) and distal in 35 eyes (47.9%). The preoperative Munk's score of 5 was noted in the majority (n=57 eyes, 78.1%). The majority (n=32 eyes, 43.8%) had chronic blepharitis or meibomian gland disease as etiology. Monocanalicular stent was kept in place for a mean of 13.5 weeks. At a mean follow-up of 14.5 months, complete response was noted in 35.6% cases, while 50.7% had partial and 13.7% had a failure of the procedure. Conclusions: LCT (without DCR) is a minimally invasive, simple, and effective technique for the treatment of LCO in the long term. VAMS is a helpful innovation to facilitate the insertion of the flexible silicone stent.

Long-term efficacy and safety of imiquimod 5% and fluorouracil 1% creams in medical monotherapy of complex eyelid basal cell carcinomas.

PURPOSE: To study the long-term efficacy and safety of local application of imiquimod 5% and fluorouracil 1% creams in complex eyelid basal cell carcinomas (BCCs). METHODS: A retrospective, non-comparative study in biopsy-proven, complex (involving canthi or >50% of eyelid length) eyelid BCC patients who were medically unfit for surgical procedures. All patients were medically treated with either of the creams using fixed-dose regimens for a minimum of 3 months. All received oral vitamin C 500 mg QID for 3 months as an adjunct for collagen healing. A minimum of "post-treatment" follow-up of 12 months was observed. RESULTS: Of total 30 patients, imiquimod 5% and fluorouracil 1% were used in 16 and 14 patients, respectively. The mean age of our patients was 70.5 years. The co-morbidities included - severe coronary artery disease using blood-thinners (n = 19), poorly controlled diabetes (n = 12), poorly controlled hypertension (n = 6), on nebulization (n = 3), and tuberculosis with pulmonary fibrosis (n = 2). Complete clinical tumor resolution was noted in 10 and 8 patients over 12 and 16.5 weeks, respectively, in imiquimod and fluorouracil groups. Periocular skin erythema, chemical conjunctivitis, and skin depigmentation were seen in all the patients of imiquimod group. On the other hand, the local side-effect profile in fluorouracil patients was limited. CONCLUSION: The medical treatment of complex eyelid BCC is a useful alternative to surgery in the elderly with significant co-morbidities. It provides a promising long-term relief with a tolerable side-effect profile. A prospective, randomized, double-blinded trial would provide stronger evidence for the efficacy of these drugs.

Long-term ophthalmic anatomical and functional outcomes after surgical removal of intraorbital foreign bodies.

PURPOSE: To analyze the anatomical and functional ophthalmic parameters after the surgical removal of various intraorbital foreign bodies. METHODS: A retrospective analysis of medical records was performed featuring detailed history, ophthalmic examination, orbital computed tomographic scans, treatment details, and outcomes. The analyzed anatomical factors included extraocular movements, the position of the eyeball (proptosis, dystopia, and enophthalmos), and fullness of orbital sulci. The functional assessment was based on visual acuity, pupillary reactions, and diplopia. The outcomes were defined as complete, partial, and failure after a minimum follow-up of 1 year. RESULTS: Of 32 patients, the organic and inorganic intraorbital foreign bodies were surgically removed from 18 (56.25%) and 14 (43.75%) orbits, respectively. At presentation, anatomically the extraocular movement restriction, proptosis/dystopia/enophthalmos, and orbital sulcus fullness were noted in 26 (81.25%), 24 (75%), and 15 (46.88%), respectively. Functionally, diminished visual acuity, diplopia, and pupil abnormalities were seen in 27 (84.38%), 14 (43.75%), and 8 (25%), respectively. After intraorbital foreign body removal at a mean follow-up of 14 months, the improvement of anatomical factors (same sequence) were observed in 8 (30.77%), 20 (83.33%), and 12 (80%), respectively. In functional factors (same sequence), the improvement was noted in none (0%), 13 (92.86%), and 5 (62.5%), respectively. Hence, the majority of patients (n = 20, 62.5%) achieved partial success, while 8 (25%) had complete success. Four (12.5%) had treatment failure despite similar management protocols. CONCLUSION: The anatomical outcomes are better than the functional outcomes after surgical removal of the intraorbital foreign bodies. The visual acuity does not improve considerably after the surgical removal of intraorbital foreign bodies. Overall, the wooden intraorbital foreign bodies have poorer anatomical and functional prognosis.

Ophthalmic features and management outcomes of 30 children having Goldenhar syndrome.

PURPOSE: To study the ophthalmic clinical profile and the management outcomes of children having Goldenhar syndrome (GS). METHODS: Retrospective review of included children fulfilling the diagnostic criteria of GS was performed. The demography, ophthalmic features, systemic anomalies, and treatment outcomes were recorded manually from patient files. An ENT, pediatrics, cardiology, and orthopedics consultation was sought for all GS patients before taking up for any ophthalmic surgical procedure. The anatomical (ocular surface and eyelid) and functional {vision and extraocular movements (EOM)} factors were exclusively studied. We ensured a minimum postoperative follow-up of 12 months, and our data were compared with the major studies featuring 'ophthalmic features' of GS. RESULTS: Totally 30 children (females = 18, 60%) were included with a median presenting age of 48 months. Twenty-seven (90%) had unilateral ophthalmic involvement with major features being upper eyelid coloboma (n = 25, 75.76%), lipodermoid (n = 18, 54.55%), and limbal dermoid (n = 10, 30.3%). Diminution of visual acuity was recorded in 22 (73.3%), while five (16.7%) had limitation of EOM. Systemically, the prominent features included hemifacial hypotrophy (100%), auricular anomalies (80%), cardiac anomalies (10%), and scoliosis (6.67%). The eyelid colobomas were repaired with the direct closure ± cantholysis technique or using a Tenzel's flap. All children had satisfactory anatomical and functional outcomes after ophthalmic surgical interventions without any significant complications. CONCLUSION: The tailored ophthalmic surgical intervention(s) provides satisfactory restoration of anatomy and functionality of the eye. These children need specific multi-discipline consultations for the holistic management and complete care.

Long-Term Ophthalmic Outcomes in Pediatric Orbital Cellulitis: A Prospective, Multidisciplinary Study From a Tertiary-Care Referral Institute.

PURPOSE: To analyze the clinical profile, radiological features, and ophthalmic outcomes of the multidisciplinary management of children with pediatric orbital cellulitis. METHODS: A prospective, interventional study of patients diagnosed as having pediatric orbital cellulitis was conducted. A complete history, clinical examination, laboratory work-up, radiology (computed tomography [CT]), multidisciplinary consultations (otolaryngology, pediatrics, and microbiology), and treatment plan were obtained for all children. The patients were admitted to the hospital and administered intravenous broad-spectrum antibiotics. Orbital and subperiosteal abscesses were drained via an endonasal or external route. Functional endoscopic sinus surgery was performed when necessary. After a minimum follow-up of 12 months, visual acuity, pupillary reaction, extraocular movements, and proptosis were evaluated as the outcome measures. RESULTS: Forty patients (male = 28, 70%) had unilateral presentation of pediatric orbital cellulitis at a mean age of 7.5 years (range: 4 to 12 years). At presentation, all patients had eyelid edema, conjunctival congestion, and chemosis: 38 (95%) had proptosis, 36 (90%) had decreased extraocular movements and pain, 16 (40%) had a relative afferent pupillary defect, and 6 (15%) had exposure keratitis and optic disc edema. CT scans showed sinusitis in 30 (75%) patients, orbital abscess in 14 (35%) patients, and subperiosteal abscess in 5 (12.5%) patients. At a mean follow-up of 15 months, 30 (75%) patients had complete success, 8 (20%) patients had partial success, and the treatment failed in 2 (5%) patients. No patient had any life-threatening complications. CONCLUSIONS: The multidisciplinary management of pediatric orbital cellulitis provides satisfactory long-term ophthalmic outcomes. Ethmoidal sinusitis is the most common etiology of pediatric orbital cellulitis, and endoscopic abscess drainage and functional endoscopic sinus surgery are minimally invasive and provide rapid relief in children. [J Pediatr Ophthalmol Strabismus. 2019;56(5):333-339.].

Nasal endoscopic features and outcomes of nasal endoscopy guided bicanalicular intubation for complex persistent congenital nasolacrimal duct obstructions.

Purpose: To study the clinical presentation, nasal endoscopic features, and outcomes of nasal endoscopy guided (NEG) bicanalicular intubation (BCI) in children with complex persistent congenital nasolacrimal duct obstruction (pCNLDO). Methods: A prospective, interventional study including eligible children (age ≤ 12 years) having complex pCNLDO. The demographics, number of previous probings, nasal endoscopy findings, and outcomes; were noted in all children who underwent NEG-BCI with Crawford's stents. Matting of eyelashes (MoE, upper, and lower eyelid), tear-film height (TFH), and fluorescein dye disappearance test (FDDT) was assessed pre and postoperatively. The minimum stent in-situ period was 12 weeks, and the minimum follow-up was 6 months (after stent removal). Results: Total 32 children (36 eyes) including 18 females (56.25%) were studied. At a mean age of 4.9 years, all children had epiphora and discharge with MoE (both upper and lower), raised TFH and positive FDDT. Previously, all children underwent conventional probing (s)- once in 12 (33.3%), twice in 18 (50%) and thrice in 6 (16.7%) eyes. The general ophthalmologists performed the majority (n = 21, 58.33%) of those. The BCI was performed under GA in all eyes, and at a mean follow-up of 8.5 months, the "complete" success was noted in 29 eyes (80.5%), 'partial' success in 4 (11.1%) and failure in 3 (8.3%). The stent prolapse was seen in three. Conclusion: NEG-BCI may provide a satisfactory resolution to complex pCNLDO after single or multiple failed probings. NEG provides confident and efficient management of coexistent intranasal complexities related to the inferior turbinate and meatus.

Long-Term Outcomes of Oral Anti-Tubercular Therapy in Patient with Tubercular Dacryoadenitis: A Case Series.

Purpose: To describe the clinico-radiological features and long-term outcomes in patients with tubercular dacryoadenitis (TbD) Methods: Retrospective, observational study of TbD patients who underwent a thorough clinical examination, orbital imaging study, and tailored ancillary investigations. Polymerase chain reaction (PCR) and microscopy were done in specific cases. A 4-drug anti-tubercular therapy (ATT) was started and clinical response was monitored in all. Patients with a minimum follow-up of 6 months "off-ATT" were included. Results: All patients were women and three presented with pain, blepharoptosis, and bilateral involvement. In all, ESR was raised, Mantoux test was positive and orbital imaging revealed enlarged lacrimal gland/s. Positive PCR and granulomatous inflammation on microscopy were seen in two patients. At a mean follow-up of 17.25 months, all women responded with no relapse or clinical recurrence. Conclusion: Bilateral lacrimal gland enlargement, positive Mantoux & PCR with early response to ATT may provide sufficient evidence for diagnosing TbD.

Clinico-radiological features and treatment outcomes in children with traumatic orbital subperiosteal hematoma.

PURPOSE: To study the clinical findings, imaging features, and treatment outcomes in children diagnosed with traumatic orbital subperiosteal hematoma (OSpH). METHODS: The medical records of eligible OSpH children treated either via needle aspiration or open surgical drainage were reviewed retrospectively. Three anatomical factors (inferior globe displacement, superior orbital sulcus fullness, extraocular movements) and two functional parameters (visual acuity, pupillary reactions) were used to determine overall success. RESULTS: A total of 10 children (mean age, 6.8 years; 8 males) were included. All had a history of blunt trauma, unilateral presentation, inferior globe displacement, fullness of superior orbital sulcus, and raised retrobulbar resistance. Diminution of vision and restricted elevation was noted in 7 children, and 4 had a relative afferent pupillary defect. Computed tomography (CT) revealed superior OSpH in all 10 children and, additionally, orbital wall fracture in 4. Needle aspiration of the OSpH was performed in 8 children; 2 underwent open surgical drainage. At a mean follow-up of 8.5 months, all children showed satisfactory improvement in both anatomical and functional parameters:1 child had a persistent nebulomacular corneal opacity, and 1 had minimal upper eyelid edema. CONCLUSIONS: A high index of suspicion, appropriate radiology (CT of orbits), and early management through needle aspiration of OSpH may help in early and satisfactory anatomical and functional outcomes.

Role of amniotic membrane and full-thickness skin graft in reconstruction of kissing nevus of eyelids.

A 20-year-old girl presented with a large pigmented lesion over the temporal aspect of left lateral canthus involving the lateral one-third of both eyelids, since birth. A slow increase in its size had been noticed for the past 2 years. On examination, a hairy nevus measuring 34 mm × 22 mm was noticed involving left eyelid skin, the mucocutaneous junction (MCJ), palpebral conjunctiva, and lateral canthus. The surface was irregularly thick and covered with long, thick, and pigmented hairs. A clinical diagnosis of kissing nevus of eyelids was kept and a surgical resection with reconstruction planned. A customized full-thickness skin graft (FTSG) and amniotic membrane grafts (AMGs) were used for the reconstruction of cutaneous and MCJ, respectively. Histopathology showed the features of junctional nevus. At 4 months of follow-up, a well taken FTSG and healthy/sharp MCJ were noticed with no recurrence. We advocate a possible role of AMG, particularly in the reconstruction of the conjunctival mucosa and MCJ.

Ocular ischemic syndrome: a classical presentation of an uncommon condition.

We report a 47-year-old male who presented with acute mono-ocular vision loss, and had classical signs of global ocular ischemia in the right eye. Fundus fluorescein angiography demonstrated delayed choroidal filling and no perfusion of retinal vasculature. Carotid Doppler and computed tomogram (CT) angiography studies revealed extensive bilateral atherosclerotic disease involving the carotid circulation. Ophthalmologists must be aware of the possibility of this potentially fatal condition, which is extremely rare. An astute clinical diagnosis, targeted workup for systemic associations and a prompt referral may turn out to be life-saving.

Role of Lacrimal Canalicular Trephination and Mini-Monoka Stent in the Management of Idiopathic Distal Canalicular Obstructions: Our Experience of 23 Cases.

PURPOSE: Different techniques have been mentioned in literature for management of idiopathic lacrimal canalicular obstructions. The aim of this study was to report surgical outcomes with use of Sisler's lacrimal trephine and role of Mini-Monoka monocanalicular stent in patients of idiopathic distal canalicular obstructions. DESIGN: This was a prospective, interventional case series. METHODS: Twenty-three patients of idiopathic distal canalicular obstruction were managed surgically from August 2011 to October 2012. Lacrimal canalicular trephination was done in all followed by on-table syringing and Mini-Monoka stent insertion. RESULTS: There were 15 women and 8 men. Mean age of patients was 50.33 ± 12.06 years. Average duration of complaints was 20.58 ± 23.01 months. Twenty-four eyes were included in the study. Common canalicular obstruction was present in 15 eyes (62.5%), whereas 9 (37.5%) had distal lower canalicular obstruction. Mini-Monoka stent was kept in place for a minimum of 8 weeks. Twenty eyes (83.33%) reported absent epiphora, whereas 2 eyes (8.33%) reported improvement at average post-stent removal follow-up of 8.66 ± 3.17 months. No significant complication was observed in intraoperative and postoperative period except for 2 spontaneous tube extrusions, which were managed with tube reinsertion. CONCLUSIONS: Lacrimal canalicular trephination with Mini-Monoka stent insertion is an easy, monocanalicular and lesser invasive technique, which has never been reported earlier in literature. We conclude that this repeatable procedure has good anatomical and functional success rates with minimal complications as compared with the other available treatment modalities for lacrimal canalicular obstructions.

Primary orbital teratoma with tooth in an adult: a rare association with cataract and corectopia.

INTRODUCTION: Orbital teratoma is a known cause of proptosis in neonates but it is rare in adults. CASE REPORT: An adult female presented with primary orbital teratoma with a well formed tooth inside the multicystic mass. Anterior orbitotomy with cyst excision was done with retrieval of a canine tooth. COMMENT: This report documents a unique case of orbital teratoma presenting in an adult with well formed canine tooth inside. Microcornea, corectopia and cataract were other distinctive coexisting features of our case.

Clinico-Radiological Spectrum and Management of Orbital Schwannomas: A Tertiary Care Institute Study.

Abstract Purpose: The aim is to study clinical presentations, radiological features and outcome in histopathologically proven orbital schwannomas. Methods: A retrospective and longitudinal study of 16 patients between January 1999 and July 2011 was undertaken by reviewing the appropriate charts. Clinical and radiological data of all orbital schwannomas patients were analyzed. Results: Mean age was 28.18 years (range 8-40 years). Of 16 patients, 10 were males and 6 females. Duration of symptoms was chronic in 15(93%). Chief complaints were proptosis in 10(62.5%), eyelid swelling in 5(31%) and eyelid mass lesion in 2(12.5%). This included a rare case of cystic schwannoma with microphthalmos. Mass was extraconal in 11(69%). Radiological findings varied from solid to cystic, intraconal to extraconal, no enhancement to intense enhancement and presence of calcification. Thirteen (81%) were excised via anterior orbitotomy route while fronto-orbital craniotomy was done in 3(19%). Postoperatively, vision improved or remained stable in 15(94%) and worsened in one (6%). Final visual acuity of 6/6 was achieved in 11(69%), 6/9 in 2, 6/36 in one. Conclusions: Schwannomas may mimic a variety of mass lesions in the orbit because of variable clinical or imaging features and should be considered in the differential diagnosis of all well circumscribed orbital lesions.