Eyelid Surgery in Thyroid Eye Disease.

PURPOSE: To review and summarize a comprehensive synopsis of surgery of the eyelid in thyroid eye disease (TED). METHODS: A PubMed search for specific eyelid manifestations of TED was performed. Studies reporting surgical management of these were reviewed, along with the author's own experience. RESULTS: The most common eyelid manifestations of TED include eyelid retraction, blepharoptosis, entropion, and epiblepharon, with most of them requiring surgical intervention. The correction of eyelid retraction has received maximum attention, with several surgical techniques that have stood the test of time. Blepharoptosis in TED that requires surgical intervention is usually aponeurotic. Entropion and Epiblepharon are rare in TED, and may resolve spontaneously, or following orbital decompression. CONCLUSIONS: Retraction is the commonest eyelid manifestation of TED, with multiple surgical options available for its correction. Blepharoptosis, entropion, and epiblepharon are rare eyelid findings in TED, that may occasionally require surgical correction.

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.

Lower eyelid entropion in thyroid eye disease.

PURPOSE: To report the clinical features, ultrasound biomicroscopic features, and management outcome in patients presenting with thyroid eye disease (TED) and lower eyelid entropion. METHODS: Retrospective interventional case review of patients with TED presenting with lower eyelid entropion over a 12-year period. RESULTS: Five patients (eight eyes) of a total of 1211 presented with lower eyelid entropion as one of the presenting signs of TED (0.41%). The average age was 28.8 years (18-39 years), and three patients were males. Three had systemic hyperthyroidism, and two were euthyroid. Four (80%) had bilateral TED, three had inactive disease, and two were active. The average Hertel exophthalmometry reading was 24.6 mm. All patients had upper lid retraction. Four (80%) had concomitant lower eyelid retraction. Entropion was medial in five and complete in three eyes. Symptomatic corneal epitheliopathy was noted in four eyes. UBM was performed in four eyes which showed a thickened middle lamella. In four eyes (three patients), the entropion was managed conservatively as the patient was not contemplating surgery for proptosis. In the remaining four eyes (two patients) orbital decompression was performed and the lower eyelid retractor release corrected the symptomatic entropion. The average follow-up was 11.6 months (range 1-30). CONCLUSION: Lower eyelid entropion is a rare presenting sign in TED. The mechanism is multifactorial and could be caused by the thickened and fibrosed lower lid retractors, as demonstrated by UBM. Young age and globe projection may play a role. Decompression approaches that involve lower lid retractor release correct the entropion.

Blepharoptosis in thyroid eye disease: etiopathogenesis, clinical features and correlation with thyroid eye disease.

PURPOSE: To report the etiopathogenesis and clinical features of blepharoptosis in patients with thyroid eye disease. METHODS: A 10-year retrospective interventional study. The etiopathogenesis, laterality, clinical features, and management of Blepharoptosis in thyroid eye disease (TED) were assessed. RESULTS: A total of 1000 patients of TED were evaluated in the 10-year period, of which 55 (5.5%) presented with Blepharoptosis. The average age at presentation was 44.8 years, and 31 (56.4%) were males. Of the 41 cases where referral diagnosis was available, TED was suspected in only 2 cases. Of the 55, 25 patients were inactive (TED duration ≥ 12 months), and 29 were silent presenters (TED duration ≤ 12 months, but clinical activity score ≤ 3). Ptosis was the primary presenting symptom in 14 cases. Ptosis was aponeurotic in 38 cases, myasthenic in 13 cases, congenital in 2 cases, and indeterminate in 2 cases. Orbital imaging was available in 26 cases, of which fat disease was noted in 14 cases. Average amount of ptosis was 2.21 mm (range 1-6 mm). Lower eyelid retraction (average 2.1 mm) was noted in 49 patients. Surgical management was performed in 10 patients, of which 4 underwent a unique combined surgery (orbital decompression with levator reattachment/resection). CONCLUSIONS: In patients with TED, blepharoptosis constitutes 5.5% at presentation to a tertiary eye care centre. Blepharoptosis masks upper eyelid retraction as a clinical sign of TED. Commonest cause was acquired aponeurotic ptosis. A combined levator surgery is possible with orbital decompression in such cases.

Retrobulbar Hyaluronidase Injection: Does It Reach the Eye?

PURPOSE: To determine if retrobulbar injection of hyaluronidase reaches the vitreous cavity, and to determine its concentration in the vitreous. METHODS: Prospective case-control study. Patients undergoing evisceration with implant for noninfective blind eyes were enrolled in the study. Before the evisceration, a retrobulbar injection of 3,000 IU of hyaluronidase (2 ml) was injected. Time from injection to in vivo sampling of posterior vitreous was noted. Vitreous samples from controls were obtained from patients undergoing vitrectomy for retinal detachment or diabetic retinopathy. Concentration of hyaluronidase was assessed in all 30 samples. An ELISA-based microtiter-technique was used to evaluate the activity of hyaluronidase by an avidin-peroxidase-based procedure using an ELISA reader. Incubations were carried out at room temperature and at 37°C. All the samples were analyzed in duplicates, and the mean of each sample was plotted on a scatter plot. RESULTS: Total of 30 vitreous samples were analyzed, of which 15 were controls and 15 were test samples. Of the 15 test samples, injection-to-sampling time was 0 to 20 minutes in 4 samples, 20 to 40 minutes in 6 samples, and 40 to 60 minutes in 5 samples. The highest concentration of hyaluronidase detected in control and test samples were 2.9 and 3.0 µg/ml, and the lowest concentration was 1.7 and 1.5 µg/ml (SD 0.3), respectively. There was no significant difference between control and test groups. CONCLUSION: Retrobulbar injection did not result in higher concentration of hyaluronidase in the posterior vitreous compared with controls when measured up to 60 minutes following injection.

Spontaneous Orbital Wall Decompression in Thyroid Eye Disease: A Rare Feature.

Spontaneous orbital decompression is an incidental radiological finding in patients of thyroid eye disease. It is rare with few case reports in ophthalmic literature. The authors describe a 48-year-old female with thyroid eye disease who was found to have a spontaneous orbital decompression on computed tomography imaging.

Ultrasound biomicroscopic features of the normal lower eyelid.

PURPOSE: To report the ultrasound biomicroscopic features of normal lower eyelid structures. METHODS: Thirty lower eyelids of fifteen healthy adults were randomized and prospectively subjected to Ultrasound Biomicroscopy (Quantel Aviso with 50 MHz transducer) by two independent observers (an ophthalmologist and an optometrist). The measurements were performed in upgaze, with the probe perpendicular to the lower eyelid margin in the mid-pupillary line, two limbal lines, and two canthal lines. The tarsus, orbicularis, capsulopalpebral fascia, and retractor-conjunctiva complex were assessed for two parameters: echogenicity (hyper/hypoechoic) and measurement in millimeters. RESULTS: Mean age was 25 years (range 20-39 years), 15 (50%) were right lower eyelids and 8 were males. The first layer, skin-orbicularis complex appeared hyperechoic. The second layer was hypoechoic band which represents the tarsal plate superiorly and capsulopalpebral fascia inferiorly. This was noted to be continuous and of almost uniform thickness in the normal eyelids. The glandular structure of meibomian glands was identified in 100% cases. The hyperechoic layer below the capsulopalpebral fascia is the retractor-conjunctiva complex. The mean thickness of pretarsal and pre-septal orbicularis was 0.68 ± 0.18 mm and 0.89 ± 0.16 mm, respectively. The tarsal plate measured 0.57 ± 0.12 mm, capsulopalpebral fascia 0.42 ± 0.13 mm and the retractor-conjunctiva complex 0.79 ± 0.18 mm. On Bland-Altman analysis, the majority of the measurements had mean agreements between -0.14 mm and +0.12 mm. Anatomical differentiation was not useful in the canthal region. CONCLUSION: Echogenicity and thickness of normal lower eyelid structures as measured by UBM are reported. The test is non-invasive, with a good inter-observer agreement.

Demographic and clinical profile of 1000 patients with thyroid eye disease presenting to a Tertiary Eye Care Institute in India.

PURPOSE: To assess the demographic and clinical profile of thyroid eye disease (TED) presenting to a Tertiary Eye Care Institute in India. METHODS: All patients who were diagnosed to have TED between the year 2007 and 2017 at the Ophthalmic Plastic Surgery Service, LV Prasad Eye Institute, were included in this retrospective observational study. The demographic details of parameters such as age, gender and laterality, presenting signs and symptoms, clinical activity at presentation, and systemic thyroid status were assessed. RESULTS: A total of 1000 consecutive patients of TED were evaluated in the 10-year period. Average age at presentation was 44.9 years (range 8-89). Of the 1000, 529 (53%) were males, and 358 (36%) had unilateral TED. At presentation, the TED was active (time since onset ≤ 12 months) in 476 (48%) cases and 71 (7%) had dysthyroid optic neuropathy. Of the 913 patients where systemic thyroid status was available at the time of presentation, 342 (37%) were euthyroid at presentation. Of the patients who were active at presentation (n = 476), 349 (70.3%) were 'Silent presenters' (Active as per timeline, but CAS ≤ 3). A prominent eye was the most common presenting symptom in 563 (64%) patients. Presenting signs in order of frequency were proptosis in 582 (58%), lower lid retraction (49%), upper lid retraction (48%), strabismus (6%), ptosis (5.5%), and corneal ulcer (1.3%). CONCLUSIONS: TED in India presents to the tertiary eye center with slight male preponderance. One-third (37%) are euthyroid and half (48%) are active at presentation. One-third (35%) are silent presenters, with minimal clinical activity during the active phase of TED.

Infantile Endoscopic Dacryocystorhinostomy: Indications, Anatomical Considerations, and Outcomes.

The purpose of this case series is to report the demographic profile, indications, anatomical considerations, and outcomes of Endonasal endoscopic DCR in the infants. Five eyes of 3 infants underwent IEnDCR with a mean age of 4.26 months (range: 23 days-8 months). There were 2 males and 1 female. Two of the infants underwent bilateral surgery. The indication for surgery in the infant undergoing unilateral surgery was recurrent acute dacryocystitis and lacrimal abscess formation secondary to refractory and complex congenital nasolacrimal duct obstruction. Infants undergoing bilateral lacrimal surgery had refractory complex congenital nasolacrimal duct obstruction and were in need for an early intraocular surgery for associated ocular morbidities. Mitomycin-C (0.02% for 3 minutes) and silicone intubation was used in all cases. At follow up of 9 months, all the 3 infants demonstrated anatomical and functional success. The surgical technique requires certain modifications in order to cater to the unique challenges. It is safe and effective in experienced hands and can be considered as an alternative to an external DCR in infants.

Conjunctival melanoma in patients with xeroderma pigmentosum: a series of four cases.

PURPOSE: To study the demographic features, treatment, histopathology, and outcomes in patients of xeroderma pigmentosum (XP) with conjunctival melanoma. METHODS: Retrospective case series. RESULTS: The median age at presentation was 18 years (range 9-30 years). There were three females and one male patient presenting with a median duration of symptoms of 3 months (range 1-60 months). The tumor was located in the bulbar conjunctiva in all 4 patients. All patients had corneal involvement by the tumor. The median tumor basal diameter was 7 mm (range 4-15 mm). Wide tumor excisional biopsy with alcohol keratoepithelectomy, cryotherapy to the free margins, and amniotic membrane grafting was done in three patients. One patient underwent orbital exenteration for extensive tumor. One patient also received adjuvant plaque brachytherapy for microscopic residual tumor. Over a median follow-up of 22 months (range 2-101 months), there were no recurrences, metastasis, or death. CONCLUSION: Conjunctival melanoma in XP is rare and manifests at a younger age.

Lacrimal Drainage Anomalies in CHARGE Syndrome: Case Report and Review of Literature.

The common ocular manifestations of CHARGE syndrome include colobomatous defects in the eye, strabismus, nystagmus, and micropthalmia. Lacrimal drainage anomalies have been rarely reported and to the best of the authors' knowledge, only 5 such cases have been reported earlier. The present case describes CHARGE syndrome associated with bilateral complex congenital nasolacrimal duct obstruction with multiple prior attacks of acute dacryocystitis and left lower punctal agenesis, successfully managed with a right-sided dacryocystorhinostomy and awaiting a left dacryocystorhinostomy.Lacrimal drainage anomalies in CHARGE syndrome include complex CNLDO, punctal agenesis, and acute dacryocystitis.

Conjunctival Melanoma in Asian Indians: A Study of 42 Patients.

Purpose: To describe the clinical features, treatment, and outcomes of conjunctival melanoma in Asian Indians. Methods: Retrospective study of 42 patients. Results: The mean age at presentation of conjunctival melanoma was 43 years (median, 45 years; range, 9-78 years). There were 20 (48%) males and 22 (52%) females. Nineteen patients (45%) had a known history of a preexisting pigmented conjunctival lesion. Bulbar conjunctiva (n = 28; 67%) was the most common tumor epicenter, and medial ocular surface quadrant (n = 15; 36%) was more commonly involved. The mean tumor basal diameter was 12 mm (median, 10 mm; range, 4-30 mm), and the mean tumor thickness was 4 mm (median, 2 mm; range, 1-30 mm). Majority of the patients had a pigmented tumor (n = 33; 79%). The tumors arose de novo (n = 17, 41%) or were associated with conjunctival nevus (n = 9; 21%) or primary acquired melanosis (n = 16, 38%). Wide excisional biopsy, adjunctive cryotherapy, and amniotic membrane grafting were performed in 27 (71%) patients, 11 (29%) underwent orbital exenteration, and 4 were lost to follow-up prior to definitive treatment. Over a mean follow-up period of 24 months (median, 9 months; range, <1 to 136 months), four (11%) patients had tumor recurrence, seven (18%) had locoregional lymph node metastasis, and four (11%) developed systemic metastasis and died due to metastatic disease. Conclusion: Conjunctival melanoma predominantly occurs in middle-aged Asian Indians and is associated with a high rate of systemic metastasis and death.

Microbial Keratitis in Thyroid Eye Disease: Clinical Features, Microbiological Profile, and Treatment Outcome.

PURPOSE: To report the incidence, clinical features, microbiologic profile, and risk indicators in the development of microbial keratitis in Thyroid Eye Disease (TED). METHODS: All patients who were diagnosed to have TED and developed microbial keratitis between the years 2009 to 2017 at the Ophthalmic Plastic Surgery service, LV Prasad Eye Institute were included in this retrospective interventional study. The clinical features, microbiological profile, and treatment outcome of the infection were studied. Possible risk factors leading to the development of microbial keratitis were studied. RESULTS: A total of 1,000 patients of TED were evaluated in the 10-year period. Of the 1,000, 13 patients (14 eyes, 1.4%) were diagnosed with microbial keratitis. The average age at presentation was 44 years (range 1969 years). Of the 13 patients, 10 (77%) were men, 12 (92%) were hyperthyroid, and 12 (92%) were active (average clinical activity score 3) at presentation. Average exophthalmometry value in the involved eye was 24.75mm, and severe eyelid retraction (>2mm scleral show) was noted in 13 of 14 eyes. None of the patients had optic nerve compression. Moderate motility restriction (2 in all gazes) was noted in 6 eyes, and severe motility restriction (4 in all gazes) in 8 eyes. At presentation, 11 (85%) had visual acuity of counting fingers at 1 meter or less, The mean follow up from the time of presentation was 18.3 months (range 566 months). Majority of the eyes (8/14) presented with severe infection (panophthalmitis with microbial keratits = 1, total corneal infiltrate with/without melt = 4, severe thinning/perforation = 4). Microbiological work up of 14 eyes revealed presence of gram-negative bacteria in 5 eyes which included Escherichia coli, Pseudomonas sp., and Acinetobacter sp., and gram-positive bacteria in 4 eyes including Streptococcus pneumoniae, Corynebacterium sp., and Staphylococcus sp. Three eyes revealed a mixed infection of E. coli with Alternaria sp, and E. coli with Corynebacterioum amycolatum while 1 had Corynebacterium pseudodiptheriticum, and S. pneumoniae. Two eyes of the bilateral case showed no growth. Antibiotic susceptibility revealed 6 of the 7 gram-negative isolates were multidrug resistant, whereas the gram-positive isolates were susceptible to most drugs tested. Surgical procedures required were tarsorrhaphy in 7 eyes, tissue adhesive with bandage contact lens in 4, evisceration in 4, levator recession in 2, 3-wall orbital decompression in 2, and penetrating keratoplasty in 1 eye. The visual acuity at presentation was counting fingers or worse in 10/14 eyes. Posttreatment, 10 eyes achieved resolution of infiltrate (with visual improvement in 2), and 4 required evisceration. CONCLUSIONS: In the authors large series of TED, microbial keratitis was noted in 1.3% of patients presenting to a tertiary eye center. Majority presented with advanced diseases and ended with a poor outcome. Gram-negative isolates showed multidrug resistance. An association with early phase of active TED (CAS 3 or more), severe eyelid retraction, and moderate-severe motility restriction is suggested.Microbial Keratitis occurs in 1.3% cases of Thyroid Eye Disease. It is more common in men, and in active disease. The microbiological spectrum and possible clinical risk factors are presented.