Clinicopathological presentations of eyelid malignancy in COVID era versus pre-COVID era.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic led to overall interrupted medical care, resulting in disease progression and morbidity. The study aimed to evaluate clinicopathological presentations and severity of eyelid malignancy during the COVID era, comparing the results with patients presented during pre-COVID era and evaluating the reasons for delayed presentation in patients with advanced eyelid malignancy in the COVID-era. METHODS: This was a comparative, ambispective observational study. Data regarding demographic, clinical, histopathology, and treatment modalities of confirmed cases of eyelid malignancy admitted during the period from March 2020 to September 2022 (defined as COVID era group) were collected and compared with retrospectively collected data from March 2017 to March 2020 (defined as pre-COVID era group). COVID era patients were further categorized as localized and advanced disease. Patients with advanced eyelid malignancy during COVID era were further subjected to a questionnaire to evaluate the reasons for delayed presentation. RESULTS: In total, 115 patients of eyelid malignancy were studied [COVID era group 40 (35%) and pre-COVID era group 75 (65%)]. A statistically significant increase in the duration of disease (P = 0.0001) and advanced tumor T-stage (P = 0.03) was noticed in the COVID era group. Demographic, histopathology, and ocular morbidity details were similar in both groups. The common reasons that led to delay in presentation and treatment in advanced T-stage patients during the COVID era were fear of acquiring COVID, lockdown, and lack of medical facilities. CONCLUSION: During the COVID-19 pandemic, both hospital- and patient-related factors contributed to delay in presentation, leading to advanced-stage disease indicating need of triaging of eyelid malignancy in the event of such pandemics in future.

Targeted orbital intervention in the management of sino-orbital mucormycosis cases.

INTRODUCTION: Many countries from South-East Asia reported an epidemic of sino-orbital mucormycosis (SOM), otherwise a rare disease, during the coronavirus disease 2019 pandemic. SOM, a potentially fatal disease, is typically treated with orbital exenteration and systemic antifungals after metabolic stabilization. There is no clear evidence of survival benefit of exenteration in the literature, and thus, there have been attempts at globe conserving treatments like orbital infusion after limited debridement and intraorbital injections with Amphotericin B (IOAB). METHODS: We conducted a prospective comparative interventional study at a tertiary eye care hospital to evaluate treatment outcomes with the use of adjunctive IOAB in cases of SOM with mild to moderate orbital disease. RESULTS: Thirty-six patients of SOM with mild to moderate orbital disease were recruited in the study. In the intervention group, 23/26 (885%) eyes had stable orbital disease at the end of treatment (4-6 weeks). No deterioration in visual acuity was noted as a result of treatment. In 8/26 (30.77%) patients, inflammation was noted as a side effect of IOAB requiring temporary discontinuation of injections. The mean follow-up for cases was 14.2 months (range 12-15 months). 1/23 (4.35%) patients had relapse of orbital disease at 3 months. Twenty-one patients are alive on last follow-up. Of the patients who refused treatment (controls), 2/9 (22.22%) patients relapsed. One of these patients with relapse underwent exenteration, while the other was managed with IOAB. At a follow-up of 14 months (range 12-15 months), eight patients are alive. On evaluating the ocular parameters in salvaged eyes, improvement in extraocular movements was noted in 75-80% cases. The degree of proptosis and resistance to retropulsion did not change significantly. CONCLUSION: In the current study, an improvement in the globe salvage rates was noted in cases of SOM with mild to moderate orbital disease treated with adjunctive IOAB as compared to controls at a mean follow-up of 14 months, although it did not achieve statistical significance. The study supports the inclusion of IOAB in routine management of mild to moderate orbital disease.

Neoadjuvant Chemotherapy in Non-Metastatic Eyelid Sebaceous Gland Carcinoma: A Report in 10 Cases.

Introduction: Eyelid sebaceous gland carcinoma (SGC) is an aggressive malignancy. Surgical excision is the standard treatment for non-metastatic eyelid SGC. This study aimed to evaluate treatment outcomes with use of neoadjuvant chemotherapy (NACT) and any change in ease/difficulty of surgical treatment in such cases. Methods: This was a prospective interventional study conducted over 24-month period. Histopathologically, confirmed cases without any systemic metastasis were included. Clinico-demographic details were collected for 30 patients. 10 patients received NACT using cisplatin and 5-FU. Tumour response was evaluated using RECIST criteria. An ease of surgery questionnaire was used to assess difficulty of surgical treatment before and after NACT. Results: Of the 30 patients evaluated for recruitment, 37% had recurrent SGC and 72% had advanced tumour stage. Ten patients were recruited for NACT. There was partial response in 80% and complete response in 10% cases. Tumour T category downstaging was seen in 50% of cases. While tumour dimensions/volume reduced substantially, surgical ease improved in only 40% cases. Conclusion: A significant proportion of SGC patients evaluated in our study presented with recurrent and/or advanced disease. NACT caused tumour regression in 90% of cases. However, surgical ease improvement was limited, pointing to a need for surgical modification in such cases. Corneal ulceration was noted in 2 cases with large tumours causing a complete mechanical ptosis. Overall, the study introduced an ease of surgery questionnaire and provided insights into benefits and challenges of using NACT for eyelid SGC management.

GLP-1 Receptor Agonists and Risk for Cirrhosis and Related Complications in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease.

Importance: Metabolic dysfunction-associated steatotic liver disease (MASLD) is an increasing cause of cirrhosis. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are effective in improving liver inflammation in patients with MASLD. Objective: To determine whether use of GLP-1 RAs is associated with lower risk of developing cirrhosis and its complications, including decompensation and hepatocellular cancer (HCC), among patients with MASLD. Design, Setting, and Participants: This retrospective cohort study with an active comparator, new-user design used data from the national Veterans Health Administration Corporate Data Warehouse and Central Cancer Registry. Patients with MASLD and diabetes who were seen at 130 Veterans Health Administration hospitals and associated ambulatory clinics and who initiated either a GLP-1 RA or dipeptidyl peptidase 4 inhibitor (DPP-4i) between January 1, 2006, and June 30, 2022, were included. Patients were followed up from baseline until one of the study outcomes or the end of the study period (December 31, 2022), whichever came first. Exposures: Each GLP-1 RA new user was propensity score matched in 1:1 ratio to a patient who initiated a DPP-4i during the same month. Separate analyses were conducted among patients without and with cirrhosis at baseline. Main Outcomes and Measures: For patients without cirrhosis, the primary outcome was progression to cirrhosis defined by validated diagnoses codes or a noninvasive marker of liver fibrosis, and secondary outcomes were cirrhosis complications defined both as a composite and individual complications, including decompensation, HCC, or liver transplant, and all-cause mortality. For patients with cirrhosis, the primary outcome was a composite outcome of cirrhosis complications, and secondary outcomes were decompensation, HCC, and all-cause mortality. Results: Of 16 058 patients who initiated GLP-1 RAs, 14 606 did not have cirrhosis (mean [SD] age, 60.56 [10.31] years; 13 015 [89.1%] male), and 1452 had cirrhosis (mean [SD] age, 66.99 [7.09] years; 1360 [93.7%] male) at baseline. These patients were matched to an equal number of patients who initiated a DPP-4i. In patients without cirrhosis, GLP-1 RA use, compared with DPP-4i use, was associated with a lower risk of cirrhosis (9.98 vs 11.10 events per 1000 person-years; hazard ratio [HR], 0.86; 95% CI, 0.75-0.98). Similar results were seen for the secondary outcomes. GLP-1 RA use, compared with DPP-4i use, was associated with a lower risk of the composite outcome of cirrhosis complications (1.89 vs 2.55 events per 1000 person-years; HR, 0.78; 95% CI, 0.59-1.04) and mortality (21.77 vs 24.43 events per 1000 person-years; HR, 0.89; 95% CI, 0.81-0.98). There were no associations between GLP-1 RA use and outcomes in patients with cirrhosis. Conclusions and Relevance: In this cohort study, GLP-1 RA use was associated with a lower risk of progression to cirrhosis and mortality among patients with MASLD and diabetes. The protective association was not seen in patients with existing cirrhosis, underscoring the importance of treatment earlier in the disease course.

Silicone sling surgery for congenital ptosis: Tarsal tunnel technique.

This was a prospective, interventional, comparative study conducted on patients with congenital simple severe ptosis. A novel method of silicone rod fixation to the tarsus (tarsal tunnel technique, group 1) was done compared with a conventional technique of silicone rod fixation (suture fixation technique, group 2) in frontalis suspension surgery. A total of 30 patients were randomized into two groups of 15 patients each. Postoperatively, MRD1, vertical palpebral aperture, and eyelid fold height were comparable in both groups till the last follow-up with stability in eyelid position. Patient satisfaction scores showed similar results with good-fair satisfaction grading in 13 patients in group 1 and 11 patients in group 2 at 6 months follow-up. No significant complications occurred in either group. Tarsal tunnel fixation of silicone rods is a novel method in sling surgery with optimal cosmetic and function outcomes. Further long-term studies are needed to validate the results of the technique.

Voriconazole in the treatment of invasive aspergillosis of orbit.

Background: The aim of the study was to evaluate the outcomes of voriconazole in terms of functional recovery and response on imaging in the management of invasive aspergillosis of orbit. Methods: This was a prospective non-comparative interventional study. Diagnosed cases of invasive orbital aspergillosis were studied in a tertiary care hospital. Intravenous voriconazole followed by oral treatment was given. Sinus debridement was done, where needed. The response to treatment was assessed clinically and on radiology. Results: A total of 10 diagnosed cases of invasive orbital aspergillosis were studied. Nine cases (90%) occurred in immunocompetent patients. Predisposing sinus infection was seen in 8 patients (80%). The most common presenting complaint was the protrusion of eye. On voriconazole treatment, there was a statistically significant improvement in vision and extraocular movements from first week onwards (p = 0.01 and p = 0.02, respectively) and reduction in proptosis from second week onwards (p = 0.003). Imaging was done at three months follow-up which revealed a good response to treatment in 90% of patients. All patients tolerated the drug well except one who had transient hepatic dysfunction. The mean follow-up was 5.8 months (range: 3-12 months). There was no recurrence of disease till the last follow-up. Conclusion: Invasive orbital aspergillosis commonly presents as sino-orbital disease, mostly in immunocompetent adult patients. Voriconazole is a safe and effective drug with good short-term clinical outcome.

Ophthalmologic manifestations of organoid nevus syndrome: A series of 13 cases.

Background: The organoid nevus syndrome is a rare neurocutaneous syndrome typified by cutaneous sebaceous nevus, seizures and epibulbar choristomas. The condition is associated with multiple ocular abnormalities. Herein, the authors aim to study and report the ophthalmic features of cases diagnosed with organoid nevus syndrome. Methods: The authors retrospectively evaluated the records of patients with the organoid nevus syndrome who had presented to a tertiary care eye hospital in northern India. The ocular features were studied and entered in MS excel and the data were evaluated. Results: Data of 13 patients with the organoid nevus syndrome were found. All 13 patients had cutaneous features in the form of Sebaceous nevus of Jadasson, 8 patients had alopecia of the scalp area, 2 had history seizures and 10 had arachnoid cysts on neuroimaging of the head. All 13 patients had a complex choristoma involving the ocular surface. Conclusions: We conclude that the most common ophthalmologic features associated with organoid nevus are complex choristoma of the bulbar surface, scleral coat calcification and upper eyelid coloboma.

Clinicodemographic profile of orbital exenteration in a tertiary eye care center - A 20-year experience.

PURPOSE: This study aimed to determine the clinical indications for orbital exenteration, demographic profile of these patients, and clinicopathologic correlations in the current times and to compare these results with previous published data. METHODS: It was a retrospective study. All exenterations performed at a tertiary eye care center over a period of 20 years (from January 2001 to June 2020) were retrospectively evaluated. Patient records were reviewed to obtain demographic data, presenting symptoms and their duration, laterality, and clinical and histopathologic diagnosis. RESULTS: A total of 352 cases (males:females = 222:130) who underwent exenteration were identified. Patients age ranged from 11 months to 87 years (mean: 43.86 years, median: 50 years). The most common indication for exenteration was found to be eyelid malignancy in 54.36%, followed by retinoblastoma in 18.75% and primary orbital tumors in 14.49%. Out of 156 cases of eyelid malignancies requiring exenteration, squamous cell carcinoma (SCC) was the most common histologic subtype ( n = 94, 60.26%), followed by sebaceous gland carcinoma ( n = 40, 25.64%) and basal cell carcinoma ( n = 20, 12.82%). The most common primary orbital tumors requiring exenteration were adenocystic carcinoma of the lacrimal gland in adults and rhabdomyosarcoma in the pediatric age group. Benign conditions requiring exenteration included fulminant fungal orbital infections and lymphangioma among others. CONCLUSION: The number of exenterations performed have significantly increased in terms of absolute numbers. However, the ratio of exenteration to other tumor-related surgeries, mainly excision biopsy, has reduced compared to that reported from a previous study. The most common indication in our study remains eyelid malignancy followed by intraocular malignancy. However, SCC has emerged as the most common tumor histologic subtype requiring exenterations.

Baseline and Post-NACT Imaging in Retinoblastoma With Optic Nerve Involvement: Can MRI Predict Prognosis?

PURPOSE: To describe a staging system for optic nerve invasion using magnetic resonance imaging (MRI) and report any correlation with survival outcome. METHODS: This was a ambispective study. Twenty-one patients with retinoblastoma who had optic nerve involvement on MRI were staged at baseline based on contrast enhancement and/or thickening and length of involvement. Response to neoadjuvant chemotherapy (NACT) was noted according to proposed response evaluation criteria and results were correlated with survival outcome. RESULTS: Baseline MRI staging was able to predict event-free survival (EFS) (P = .0015) using the log-rank test for trends. Patients with optic nerve enhancement alone showed 100% survival prognosis. Optic nerve thickening cases with complete or partial response to NACT showed better EFS (P > .90) than those with stable disease according to response evaluation criteria. CONCLUSIONS: The modified staging system for optic nerve invasion used in the current study significantly predicted EFS. The study also showed that response to NACT may be affected by baseline staging. The authors recommend that cases with optic nerve enhancement only, irrespective of the length of involvement (stage 0), may be treated with upfront enucleation. Cases with optic nerve thickening may be staged to evaluate the correlation with survival outcome in a larger cohort in future studies. [J Pediatr Ophthalmol Strabismus. 2024;61(2):98-105.].

Can Enhancement Pattern in Normal-Sized Optic Nerves on Magnetic Resonance Imaging Better Predict Tumor Invasion in Retinoblastoma Eyes?

Introduction: Optic nerve (ON) enhancement alone without ON thickening on contrast-enhanced magnetic resonance imaging (CE-MRI) can be associated with post-laminar optic nerve invasion (PLONI) in eyes with group E retinoblastoma. A few case reports and retrospective studies in the literature show a poor correlation between ON enhancement on MRI and ON invasion on histopathological examination (HPE). There is no universal consensus on the management of such cases. It is desirable that the presence and extent of a true ON invasion be reliably picked up before planning upfront enucleation in order to avoid stage II disease. Methods: In a prospective study conducted at a tertiary eye care center in North India, all retinoblastoma patients presenting with ON enhancement on imaging were evaluated. Demographic and imaging details, histopathological findings, and treatment details were recorded. The length and pattern of enhancement noted on MRI were correlated with histopathology. Follow-up was done till the end of the study period. Results: Six group E retinoblastoma eyes were evaluated. 3 eyes (50%) showed solid enhancement, 2 eyes (33.33%) had tram track pattern and 1 eye (16.66%) showed punctate enhancement pattern on CE-MRI. On histopathology, 5 (83.33%) cases showed PLONI and all 6 (100%) had ON head infiltration. The cut end of the ON was free in all cases. On correlating MRI and HPE, all eyes with solid enhancement pattern showed PLONI, of which 2/3 (66.6%) had diffuse ON infiltration. Only 50% of eyes with tram track patterns showed PLONI. The case which showed a punctate enhancement pattern showed focal infiltration by tumor cells with vacuolated cytoplasm on HPE. At the last follow-up, all patients were alive and free of disease. Conclusion: ON enhancement patterns may make it more predictive for PLONI on HPE. Solid enhancement pattern appears to correlate better with the extent of ON invasion on HPE, and longer lengths of solid ON enhancement may be considered for neoadjuvant chemotherapy rather than upfront enucleation.

Transconjunctival excision of external angular dermoid cyst: A novel approach.

PURPOSE: To excise external angular dermoid cyst (EADC) by transconjunctival approach and compare the surgical outcomes with the standard transcutaneous approach. DESIGN: This was a prospective, pilot, interventional, comparative study. METHODS: Patients with EADC with no or minimal fixity to the underlying bone on palpation and limited to eyelid were recruited. Patients were randomized into 2 groups; group 1 included patients with transcutaneous approach, and group 2 included patients with transconjunctival approach. The parameters assessed were intraoperative complications, duration and ease of surgery, postoperative complications, and overall satisfaction. RESULTS: Six children with a painless, round lesion in outer aspect of eyelid were recruited in each group. None of the patients had any intraoperative or postoperative complications, including dysfunction of eyelid contour and fold, persistence or late occurrence of lateral eyelid droop, excessive or recurrence of swelling, and ocular surface problems, especially in group 2, but a skin scar though hidden was inevitable in group 1. The duration of surgery was comparable with better ease of surgery in group 1 and a gradual learning curve in group 2. The overall satisfaction scores were significantly better in group 2 (p < 0.0001). In group 1, parents of 5 of 6 patients had to be reassured that the skin scar will fade with time. CONCLUSION: Transconjunctival excision of EADC is a viable and novel approach in patients with mobile cyst that is limited to the eyelid with no obvious bony fossa. Main limitations of the approach are that it requires surgical expertize, provides less surgical space, and has a gradual learning curve.

Autologous fat transfer for orbital volume augmentation in sockets with small nonseeing eyes.

OBJECTIVE: End-stage ocular diseases usually end up with atrophic bulbi or phthisis bulbi leading to orbital volume loss which needs to be addressed. We studied the use of autologous fat for volume augmentation of the orbit because it is minimally invasive and allows early rehabilitation with the use of an artificial eye. DESIGN: It was a prospective, interventional study. METHODS: A total of 14 eyes of 14 patients with atrophic bulbi with shrinkage or phthisis bulbi with no perception of light (PL) and aged older than 18 years were included for the study purpose. Painful or inflamed eyes or suspected intraocular tumors were excluded. An autologous fat graft was obtained from the lower abdomen or buttocks and injected into the retrobulbar space using a 20-gauge cannula after adequate peribulbar anesthesia. Outcomes measures were patient satisfaction, change in Hertel's exophthalmometry, vertical and horizontal palpebral aperture, and socket volume. RESULTS: Hertel exophthalmometry showed a significant improvement both with and without an artificial eye from 14.92 ± 2.3 mm to 16.71 ± 1.94 mm (p-value 0.003 without an artificial eye). The vertical palpebral aperture also showed a significant improvement from 5 ± 1.70 mm to 6.71 ± 1.58 mm (p-value < 0.001). There was a significant reduction in the socket volume from 1.22 ml to 0.39 ml (p-value < 0.001). No local or donor site complications were seen. CONCLUSIONS: Autologous fat transfer is a minimally invasive, safe, and effective procedure for orbital volume augmentation in small, nonseeing eyes. The short-term outcome of our study was good in most patients and can be considered for such patients.

Congenital Common Canalicular Lacrimal Fistula in an Asymptomatic Patient.

This case report discusses a diagnosis of congenital common canalicular lacrimal fistula in a 24-year-old asymptomatic patient.

Psychosocial factors among patients undergoing orbital exenteration.

CLINICAL RELEVANCE: Patients undergoing exenteration have significant anxiety and depression, and lower quality of life that worsens after surgery. Therefore, counselling by an eye health-care provider along with the team of psychologist and psychiatrist could be provided pre-operatively to assess baseline psychosocial status and be continued post-operatively to look for any deterioration. BACKGROUND: Orbital exenteration comes with psychological trauma of disfigurement of face. The study aimed to evaluate the quality of life, anxiety and depression in patients undergoing orbital exenteration, before and after the procedure; and also compared the same with patients previously rehabilitated by spectacle-mounted prosthesis after exenteration. METHODS: It was a prospective cohort study. Group I included patients who were planned to undergo orbital exenteration, and group II were those already using spectacle-mounted prosthesis post orbital exenteration for at least 3 months. Level of depression was assessed using Patient Health Questionnaire-9(PHQ-9), anxiety using Generalised Anxiety and Depression scale-7(GAD-7), and quality of life was assessed using Functional Assessment of Cancer Therapy- General (FACT-G) score. RESULTS: A total of 19 patients were recruited in group I and 10 patients in group II. The baseline demographic factors were comparable. The scores for PHQ-9 and GAD-7 were significantly higher at 3-month post-exenteration follow-up, indicating significantly higher levels of anxiety and depression after orbital exenteration in group I. Both these scores were significantly lower in group II compared to group I (3 months follow-up), indicating lower levels of anxiety and depression after rehabilitation with prosthesis. The FACT-G and its subscores were all significantly higher in group II patients compared to post-operative scores of group I patients, indicating higher overall quality of life after rehabilitation with prosthesis. CONCLUSIONS: Patients undergoing exenteration have a significant level of anxiety and depression, and lower quality of life that worsens after orbital exenteration.

Correlation of Levator-Muller's Complex Thickness on Ultrasound Biomicroscopy to Botulinum Toxin A Injection in Thyroid-Related Upper Eyelid Retraction.

OBJECTIVES: To study the thickness of levator palpebra superioris-Muller's muscle complex (LMC) on ultrasound biomicroscopy (UBM) and to correlate with the clinical response to botulinum toxin A (BTA) injection in patients with inactive-stage of thyroid-related upper eyelid retraction (UER). We also studied the correlation of clinical parameters, preinjection with postinjection values. METHODS: This was a prospective, interventional study. Patients with thyroid-related UER who underwent subconjunctival injection of BTA were recruited. Demographic data and clinical details were evaluated. UBM (50 MHz) was done to measure the thickness of LMC. Patient's satisfaction was graded at each follow-up. Follow-up was done at 1 week, 1 month, and 3 months' time intervals. RESULTS: A total of 13 patients were recruited and 26 eyes were divided into two groups; group 1 included eyes with UER (n = 17), and group 2 included eyes without UER (n = 9). There was a statistically significant reduction in margin reflex distance 1 (MRD1) after BTA injection at 1-week, 1-month, and 3-months follow-up with maximum reduction at 1 month. The mean LMC thickness of 26 eyes was 0.96 mm which was found to be significantly more than normal controls. On comparison of mean LMC thickness with the amount of UER and reduction in MRD1, we did not find a significant difference. CONCLUSIONS: Patients with TED have significantly thicker LMC on UBM than controls. Further studies are needed with a larger sample size on the correlation of UBM features of levator aponeurosis with response to BTA injection.

Eyelid sebaceous gland carcinoma, validation of AJCC 8th edition T staging- a retrospective study from North India.

PURPOSE: This study compares the 8th edition staging of AJCC for prognosis of eyelid Sebaceous Gland Carcinoma (SGC) patients with respect to the 7th edition. METHODS: A retrospective study was undertaken over a period of 100 months. Ninety-nine histopathologically proven cases of eyelid SGC available for follow-up were recruited. Patients were staged by both the 7th and 8th editions of AJCC and followed up at six monthly intervals after surgery. RESULTS: Of the 99 eyelid SGC patients recruited, recurrence and orbital invasion developed in 22%, lymph node metastasis in 21% and 4% had distant metastasis and also died. High-risk features include tumour size>20 mm, orbital invasion, exenteration and staging by both the 7th and 8th editions of AJCC. Cox regression analysis revealed that staging by AJCC 8th edition was associated with greater risk for local recurrence (HR 3.01,95% CI-1.65-5.51%, p < 0.01) lymph node metastasis (HR 8.26, 95% CI 3.96-17.19%, p < 0.01) and disease-free survival (HR 4.61, 95% CI 2.81-7.54). The Kaplan-Meir survival curves of eyelid SGC patients by the 8th edition AJCC staging were also significantly associated with lymph node metastasis (p < 0.01), tumour-related deaths (p < 0.01) and reduced disease-free survival (p = 0.07). The higher Harrell's values by the 8th edition signify better predictive value for lymph node metastasis and DFS (disease-free survival). The lower AIC values indicate a better monotonicity of gradients for lymph node metastasis, recurrence and DFS. CONCLUSION: Staging by the 8th AJCC edition is, therefore, recommended for eyelid SGC as it gives a better perspective about disease outcome. The orbital extension was the single most important predictor of lymph node metastasis, recurrence and death.

Autologous fat grafting for the correction of cicatricial ectropion.

BACKGROUND: Cicatricial ectropion can be corrected by invasive surgical modalities such as full-thickness skin graft, lateral tarsal strip procedure, etc., which are associated with donor site morbidity and additional scars. Use of autologous fat graft (AFG) in treatment of burn scars has previously shown encouraging clinical results as to skin color, texture, and softness. OBJECTIVE: We aim to introduce the use of AFG for the correction of mild to moderate grades of cicatricial ectropion of the lower eyelid in adult patients. METHODS: This was a prospective, interventional, non-comparative, pilot study including 5 patients with a cicatricial ectropion of grade I-III. All these patients underwent a pre-injection workup to assess anatomical outcomes (grade of ectropion, vertical palpebral aperture (VPA), lagophthalmos, and eyelid retraction), functional outcomes (dry eye status) and aesthetic outcome (change of scar color, thickness, pain, and consistency). RESULTS: At 6-months follow-up assessment, all patients had improvement in grade of ectropion, significant improvement in VPA and eyelid retraction, and almost complete resolution of lagophthalmos in all the three patients who had pre-injection lagophthalmos. There was a significant improvement in scar color, thickness and consistency on Visual Analogue Score (VAS) with no donor site or systemic complications after the procedure but mild pain on day 1 post-injection at the donor site CONCLUSION: AFG transfer of cicatricial ectropion not only eludes the need of a invasive surgery but provides satisfactory correction with stable outcome with an overall improvement in texture of the scar and has low risk.

Outcomes of canalicular trephination versus canaliculodacryocystorhinostomy in common canalicular blocks.

AIM: This study aimed to compare the outcomes and efficacy of canalicular trephination with monocanalicular stenting and canaliculodacryocystorhinostomy (canaliculoDCR) with silicone intubation. MATERIALS AND METHODS: A prospective comparative study was done in 30 patients (30 eyes) with common canalicular blocks who were randomized into two groups. Fifteen patients underwent canalicular trephination with monocanalicular stenting and 15 patients underwent canaliculoDCR with silicone intubation. Common canalicular obstruction was diagnosed by preoperative syringing and the location of block was confirmed on probing. Stents were kept in both the groups for 3 months and followed up till 6 months postoperatively. Success was defined based on both anatomical and functional outcomes. Anatomical success was defined by the free passage of fluid on syringing with the fluid felt in the throat. Functional success was defined in terms of relief from epiphora based on the subjective opinion and its categorization by Kraft and Crawford's grading and the fluorescein dye disappearance test (FDDT). RESULTS: Eighty percent of eyes in canalicular trephination group and 73.3% of eyes in canaliculoDCR group were anatomically patent on syringing at the final follow-up. Sixty-six percent of eyes in trephination group and 53.3% in canaliculoDCR group were reported to have absent epiphora (complete recovery). Ten eyes in both groups had Grade 0 and 1 FDDT indicating a functional success of 66.6% in both groups. CONCLUSIONS: Canalicular trephination can produce results comparable to canaliculoDCR with silicone intubation in cases of common canalicular blocks. The average duration of surgery is significantly less in canalicular trephination which gives this procedure an added advantage.

Metastatic Insulinoma Presenting With Postprandial Hypoglycemia.

Background/Objective: Patients with an insulinoma, a type of pancreatic neuroendocrine tumor, typically present with fasting hypoglycemia but can rarely present exclusively with postprandial hypoglycemia. Case Report: A 69-year-old man presented with episodes of postprandial blurry vision, sweating, and confusion for the last 2 years that were becoming more frequent over the last several weeks. Home blood glucose measurements revealed postprandial hypoglycemia (glucose level, 45-70 mg/dL), and symptoms were consistent with the Whipple triad. Continuous glucose monitoring revealed only postprandial hypoglycemia within 2 hours following meals. An outpatient fast was conducted with detectable insulin (6 µIU/mL) and C-peptide (2.0 ng/mL) levels with an elevated proinsulin (20.8 pmol/L) level when the serum blood glucose level dropped to 47 mg/dL (21 hours after the initiation of the fast). A computed tomography scan of the abdomen and pelvis showed a 1.6-cm hyperenhancing lesion in the distal body of the pancreas. He underwent endoscopic ultrasonography with fine-needle aspiration. Pathology revealed a low-grade, well-differentiated, neuroendocrine tumor with lymphovascular invasion and regional lymph node metastases, confirming the diagnosis of a pancreatic neuroendocrine tumor. Discussion: Exclusive postprandial hypoglycemia is estimated to occur in 6% of the insulinomas. Patients with postprandial hypoglycemia may be initially managed as those with reactive hypoglycemia; however, this case highlights the importance of evaluating for an insulinoma in a patient who has failed treatment for reactive hypoglycemia. This case also demonstrates the importance of including proinsulin levels in that evaluation. Conclusion: Pancreatic neuroendocrine tumor should be considered in postprandial hypoglycemia, even in the absence of fasting hypoglycemia. Measuring proinsulin levels is essential in the diagnostic workup of insulinoma causing hypoglycemia.