Open Globe Injuries with Concurrent Orbital Fractures - Clinical Settings and Factors Predicting Outcomes.

AIM: We describe the clinical settings and the factors predicting outcomes in open globe injuries with concurrent orbital fractures. METHODS: Retrospective, consecutive, non-comparative study. All eyes from January 2014 to January 2021 with concurrent open globe injuries with orbital fractures that underwent management were included. The clinical data of each patient who underwent a comprehensive ophthalmic examination was entered into a browser-based electronic medical records system (eyeSmart EMR) by uniformly trained ophthalmic personnel and supervised by an ophthalmologist using a standardized template. Favorable functional outcome was defined as the final best corrected visual acuity of >20/200 as per the World Health Organization (WHO) definitions of severe visual impairment and blindness. A favorable anatomic outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. Multivariate logistic regression analysis was done to assess the effect of various demographic and clinical factors and the type of orbital fracture on the final anatomic and functional outcome. RESULTS: Ninety-one eyes of 91 patients were included in the study. Females accounted for 74/91 (81.3%) of the eyes. Modes of trauma was rupture in 67%, perforating in 5.5% and penetrating in 27.5% of the cases. Orbital rim involvement was seen in 79.1%. The most common isolated fracture seen was a medial wall (19.78%), which was followed by the orbital floor (15.38%). Favorable functional outcome was seen in 10 eyes (11%), while a favorable anatomic outcome was achieved in 45 (49.5%). Odds of a favorable functional outcome were 6.12 (95% CI 1.22 to 30.71), p = .02 for an open globe injury with orbital fracture in the absence of a concurrent retinal detachment. Odds of a favorable anatomic outcome were 55.55 (95% CI 2.43 to 1250), p = .01 when the injury did not involve zone 3, 9.94 (95% CI 2.05 to 48), p = .004 when concurrent retinal detachment was absent, 16.3 (95% CI 1.42 to 187.19), p = .02 when the orbital rim was intact and 7.83 (95% CI 1.09 to 56.19), p = .04 when only one orbital wall was involved. CONCLUSIONS: Open globe injuries with concurrent orbital fractures result in a very poor functional outcome. Concurrent retinal detachment is a negative predictive factor. Associated fractures involving the orbital rim increase the risk of eyeball loss.

Two-Year Outcomes of Transcutaneous Non-Image Guided Bleomycin Sclerotherapy in Conjunctival Lymphatic Malformations: A Protocol-Based Management in 16 Eyes.

OBJECTIVES: To study the efficacy and the 2-year outcomes of treating conjunctival lymphatic malformations (LM) with protocol-based bleomycin sclerotherapy. METHODS: A retrospective interventional study of 16 eyes with conjunctival LM treated with bleomycin sclerotherapy between December 2016 and 2019. A clinical resolution was assessed as poor (less than 25% decrease in size), fair (25%-50% decrease in size), good (50%-75% decrease in size), excellent (more than 75% decrease in size), and complete resolution. RESULTS: Mean age at presentation was 18 ± 13.09 (15 years, 3 to 59 years) years. The conjunctival component was classified based on clinical appearance as conjunctival mass (12) and microcystic LM (4). Mean clock hours of involvement were 3.32 ± 5.29 clock hours (4, 2-9 clock hours). An average per session dose of 1.8 ± 0.3 IU (median 2 IU, range 1-2 IU) and a cumulative dose of 3 ± 1.5 IU (3, 1-6 IU) of bleomycin were injected over an average of 1.6 ± 0.7 (median 2, range 1-3) treatment sessions per patient. Excellent response was observed in 11 (69%) cases. A residual lesion requiring surgical debulking was noted in 1 case. Recurrence was noted in 2 (13%) cases one of which was treated with repeat sclerotherapy resulting in complete resolution. Adverse reactions included restricted extraocular motility in extreme gaze in 2 eyes (13%). Sustained tumor resolution was observed over a mean follow-up of 29.24 + 9.45 months (24, 24-38 months). CONCLUSIONS: Bleomycin sclerotherapy gives excellent response in conjunctival LMs and is an effective first-line therapy in these cases.

Demography, Clinical Settings and Outcomes in Evisceration with Implant: An Electronic Medical Records Driven Analytics of 2071 Cases.

PURPOSE: To describe the demography, clinical settings and outcomes in 2071 patients undergoing evisceration across a multi-tier ophthalmology hospital network and comparison of results with the global scenario of clinical settings for evisceration. METHODS: An analysis of 2071 patients undergoing evisceration and implant between 2013 and 2019. RESULTS: The mean age at surgery was 39 ± 22 years. Children constituted 303(15%) of the cases. The four leading indications for surgery included painful blind eye in 760(37%), phthisis bulbi in 552(27%), staphyloma in 215(10%) and open globe injury in 195(9%) patients. The clinical settings encountered were trauma in 852(41%), ocular infection in 714(34%), glaucoma in 198(10%), post ocular surgery in 146(7%), congenital in 95(5%) and uveitis in 21(1%). Trauma and infection remained the commonest clinical settings in the urban (843,75%), rural (622,77%) and metropolitan (101,71%) areas. Decade wise distribution suggested trauma to be the commonest clinical setting in the first 4 decades and infection in the next 6 decades. The mean follow-up period was 351 ± 386 days (median 194). While trauma remained one of the commonest clinical setting in both the developed and the developing economies, painful blind eye and intractable glaucoma were other common clinical settings in the developed economies and infection was one of the leading clinical setting in the developing economies. CONCLUSION: Most patients undergoing evisceration are young. The commonest indications for surgery include painful blind eye and phthisis bulbi. Trauma and infection remain the commonest clinical settings for evisceration in developed and developing economies.

Molecular diagnosis of rhino-orbital mucormycosis in a COVID-19 setting.

PURPOSE: Mucormycosis is a severe fungal infection caused by species of the order Mucorales. Early and accurate diagnosis is a prerequisite in the management of the disease. In the present study, we evaluated and compared two PCR-based techniques for the diagnosis and identification of mucormycosis in patients with rhino-orbital mucormycosis (ROM) post-COVID-19. METHODS: Diagnosed clinically and radiologically, 25 patients of ROM were included in the study and endoscopically or blind collected nasal swabs or orbital tissues were submitted for microbiological evaluation (direct microscopy + culture) and PCR using primers targeting two different loci (ITS and 28S rDNA region) for diagnosis. All PCR products were further processed for species identification using Sanger sequencing whenever possible. RESULT: Of the 25 samples included in the study, 16 samples were positive for presence of fungal filaments by Smear suggestive of Mucorales sp., but only 7/25 grew in culture. ITS-based PCR was able to identify mucormycosis in 7/25 (28%) samples and 28S rDNA PCR showed positivity for 19/25 (76%) samples. Rhizopus oryzae was found to be the predominant species in our study. The sensitivity and specificity of 28S rDNA PCR compared to culture were found to be 85.71% and 27.78%, respectively, while for ITS-based PCR, they were 42.86% and 77.78%, respectively. CONCLUSIONS: 28S rDNA-based PCR is a reliable and sensitive method for early diagnosis of mucormycosis. Molecular techniques have shown a promising future to provide quick and effective treatment by accurately identifying the aetiologic agent.

Immunopathology of COVID-19 and its implications in the development of rhino-orbital-cerebral mucormycosis: a major review.

PURPOSE: To present a literature review on various immunopathologic dysfunctions following COVID-19 infection and their potential implications in development of rhino-orbital-cerebral mucormycosis (ROCM). METHODS: A literature search was performed via Google Scholar and PubMed with subsequent review of the accompanying references. Analogies were drawn between the immune and physiologic deviations caused by COVID-19 and the tendency of the same to predispose to ROCM. RESULTS: Sixty-two articles were reviewed. SARS-CoV-2 virus infection leads to disruption of epithelial integrity in the respiratory passages, which may be a potential entry point for the ubiquitous Mucorales to become invasive. COVID-19 related GRP78 protein upregulation may aid in spore germination and hyphal invasion by Mucorales. COVID-19 causes interference in macrophage functioning by direct infection, a tendency for hyperglycemia, and creation of neutrophil extracellular traps. This affects innate immunity against Mucorales. Thrombocytopenia and reduction in the number of natural killer (NK) cells and infected dendritic cells is seen in COVID-19. This reduces the host immune response to pathogenic invasion by Mucorales. Cytokines released in COVID-19 cause mitochondrial dysfunction and accumulation of reactive oxygen species, which cause oxidative damage to the leucocytes. Hyperferritinemia also occurs in COVID-19 resulting in suppression of the hematopoietic proliferation of B- and T-lymphocytes. CONCLUSIONS: COVID-19 has a role in the occurrence of ROCM due to its effects at the entry point of the fungus in the respiratory mucosa, effects of the innate immune system, creation of an environment of iron overload, propagation of hyperglycemia, and effects on the adaptive immune system.

Local Infiltration Anesthesia for Orbital Exenteration in Patients With Rhino-Orbital Cerebral Mucormycosis: A Case Series.

Orbital exenteration is occasionally required for rhino-orbital cerebral mucormycosis. Multiple associated comorbidities can pose a risk for general anesthesia. There is only 1 report of exenteration being performed under trigeminal nerve block. We describe 5 patients who underwent orbital exenteration under local infiltration anesthesia with sedation. Patients and surgeons reported satisfactory conditions, with stable hemodynamics and successful day care management. Orbital exenteration under local infiltration anesthesia can be a safe and effective alternative for patients with rhino-orbital mucormycosis who are at risk with use of general anesthesia.

Choroidal vascularity index in thyroid eye disease: comparison with controls and application in diagnosing non-inflammatory active disease.

PURPOSE: To report the differences in choroidal vascularity index (CVI) in thyroid eye disease (TED) and normals and its discriminatory value for differentiating various stages of TED. METHODS: Prospective, cross-sectional, non-interventional imaging study. Ninety-four eyes of 54 patients were included and divided into 5 groups - normal controls (C), inactive TED (I), active TED (A), non-inflammatory active TED (NIA) and systemic hyperthyroid disorder but no TED (SYS). Choroidal images were acquired using the swept-source optical coherence tomography and the choroid was binarized to calculate the CVI. RESULTS: Ninety-four eyes were included. Mean age was 44.52 ± 10.02 years (median 46 years, range 19-65 years). Mean IOP was 16.1 ± 3.37 mm Hg (median 16 mm Hg, range 16-24 mm Hg). Mean Spherical equivalent (SE) was -0.08 ± 1.86 diopters (median 0, range -2.5 to +2.25). Intra-rater agreement was 0.84 (p < 0.001). Inter-rater agreement was noted to be 0.85 (p < 0.001) for consistency and 0.77 (p < 0.001) for absolute agreement. CVI in the A group was 70.11 ± 3.38% and in the NIA group was 69.32 ± 3.5%. Both were comparable to each other and significantly higher than the C, I and SYS groups (p < 0.001). Multiple regression showed that the Clinical Activity Score (CAS) had a positive effect and spheroequivalent had a negative effect on the CVI. At CVI of 66.83%, active TED can be diagnosed with sensitivity of 91.67% and specificity of 82.14%                 . CONCLUSIONS: CVI is significantly higher in active TED and NIA TED compared to other groups. It has a good value in differentiating the non-inflammatory active TED eyes from the inactive eyes.

Retinal vascularity, nerve fiber, and ganglion cell layer thickness in thyroid eye disease on optical coherence tomography angiography.

PURPOSE: To compare the retinal vascularity, peripapillary vascularity, nerve fiber layer thickness and ganglion cell layer thickness between active, inactive thyroid eye disease (TED) and healthy eyes. METHODS: Retrospective comparative cross-sectional cohort study. Patients with TED, active and inactive on the VISA score, and healthy eyes were included. All patients underwent optical coherence tomography angiography with detailed demographic and clinical data capture. Using automated software, retinal and peripapillary vascularity index, nerve fiber layer thickness, and ganglion cell layer thickness were calculated and were compared between the groups. RESULTS: Twenty-four eyes with active TED, 102 eyes with inactive TED and 52 healthy eyes were included. Independent sample t test was used to compare parametric data and Mann-Whitney test to compare non-parametric data. The age and gender were comparable across groups. The peripapillary vascularity index (26.82 ± 4.13 versus 34.92 ± 5.08, p = .002) and the macular vascularity index (20.32 ± 2.5 versus 31.21 ± 3.89, p < .0001) were reduced in active TED eyes versus inactive eyes. Macular vascularity index was comparable in the inactive versus the healthy eyes. The RNFL thickness was increased in the active TED eyes versus the inactive eyes (45.11 ± 18.3 versus 35.55 ± 7, p = .03) and active versus healthy eyes (45.11 ± 18.3 versus 36.28 ± 7.89, p = .03). Ganglion cell layer thickness between all three groups was comparable. CONCLUSION: Decrease in peripapillary and macular vascular density and increase in RNFL thickness are seen in active TED compared to inactive TED and healthy eyes. In disease inactivity, these parameters are comparable to healthy eyes.

Long term outcomes of transcutaneous non-image guided bleomycin sclerotherapy in orbital/adnexal lymphatic malformations: a protocol-based management in 69 eyes.

OBJECTIVES: To study the efficacy and the long-term outcomes of treating micro and macrocystic orbital and/or adnexal lymphatic malformations (OA-LM) with protocol-based bleomycin sclerotherapy. METHODS: A retrospective interventional study of 69 eyes having OA-LM treated with non-image guided transcutaneous or transconjunctival bleomycin sclerotherapy (1IU/ml aqueous solution) between December 2014 and December 2018. Based on clinical regression, the outcomes were classified as excellent, good, fair and poor. RESULTS: The mean age at presentation was 20 ± 16 years (median 16; range 1 month to 70 years). The orbital-palpebral variant was the most common presentation, seen in 29 patients (42%). Microcystic morphology was seen in 34(49%), macrocystic in 22 (32%) and mixed cyst in 13 (19%) patients. Mean units of bleomycin injected per patient were 9 ± 8 IU (median 5.5 IU, range 1-38 IU). Mean number of treatment sessions required were 2 ± 1 (median 2, range 1-6). The response was excellent in 43 (62%), good in 12 (17%), fair in 9 (13%) and poor in 5 (7%) patients. These responses were comparable across the morphological subgroups (p = 0.24, chi-square test). Adverse reactions noted were inflammation in 11 eyes (16%) and peri-ocular pigmentation in 15 (22%). There was a sustained tumour regression over a mean follow-up duration of 3.5 years (median 3; range 1.5-5 years). CONCLUSIONS: Seventy-nine percent of eyes with OA-LM showed a good outcome with transcutaneous and/or transconjunctival non-image guided bleomycin sclerotherapy with no serious adverse events. The results were promising over long-term follow-up.

Transcutaneous retrobulbar injection of amphotericin B in rhino-orbital-cerebral mucormycosis: a review.

Mucormycosis is an aggressive and potentially fatal invasive fungal infection. The most common form of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). While it is commonly seen in immunocompromised patients, it is also known to affect healthy individuals. The global disease burden of ROCM has increased significantly following the surge in cases during the COVID-19 pandemic. Endoscopic sinus debridement, systemic antifungal therapy, and control of the underlying immunosuppressive condition are essential for the management of ROCM. Orbital involvement, however, presents a challenge to clinicians. Intervention strategies that have been described to treat orbital disease include orbital exenteration, conservative orbital debridement with or without irrigation with amphotericin B and transcutaneous retrobulbar injection of amphotericin B (TRAMB). Currently, there is a lack of clarity regarding the indications and outcomes of TRAMB as a treatment modality. In this review, the drug formulations used, the complications, and outcomes of previously described cases that have used TRAMB in cases of ROCM are discussed. Favorable outcomes following TRAMB depend on appropriate patient selection and radiological evidence of the orbital burden of the disease. This review aims to familiarize clinicians with objective parameters for patient selection for TRAMB, namely the extent of the disease, the clinical features, and radiological findings; viz. the clinical interpretation of areas of contrast uptake and those of necrosis. TRAMB can be considered as a viable option in select cases of orbital mucormycosis where exenteration or debridement are not indicated, or when there is limited orbital disease.

Outcomes and complications of evisceration with primary implant: an electronic medical record driven analytics of 1800 cases.

PURPOSE: To describe the surgical outcomes and implant complications in 1,800 patients undergoing evisceration with primary implant. METHODS: An Electronic Medical Record-driven analysis of 1,800 patients undergoing evisceration with primary implant between 2013 and 2019. Implant sizing was performed intra-operatively to place the largest implant without tension on the wound closure. Outcome measures included implant complications, prosthesis measurements, and incidence of a good aesthetic outcome. Good outcome was defined as <2 mm enophthalmos and grade 1 or less superior sulcus deformity with a custom ocular prosthesis. RESULTS: Eighteen hundred eyes of 1800 patients were included. The mean age at surgery was 36 ± 21 years (median 32 years). Implants used were poly(methyl methacrylate) (PMMA) in 1737 (97%) and porous polyethylene in 63 (3%) patients. Two-petal sclerotomy was performed in 1512 (88%) and four-petal sclerotomy in 165 (10%) patients. The mean diameter of the implant used was 19.35 ± 1.18 mm (median 20, range 10-22 mm). The implant extrusion rate was 3% (56) and implant displacement was seen in none. The mean prosthesis volume and thickness were 2.22 ± 0.67 ml (median 2, range 1-6.5 ml) and 6 ± 1 mm (median 6, range 2-9 mm). The mean difference in prosthesis projection on Hertel's exophthalmometer was 0.28 ± 1 mm (median 0, range 0-1 mm). Good outcome was observed in 93%. The mean follow-up period was 351 ± 386 days (median 194). CONCLUSION: Evisceration with empirically selected primary orbital implant placement is associated with minimal implant complications and gives a good aesthetic outcome in 93% of the patients.

Clinical Presentations, Management and Outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) Following COVID-19: A Multi-Centric Study.

PURPOSE: To report clinical presentations and factors affecting outcomes in rhino-orbital-cerebral mucormycosis following COVID-19. METHODS: Retrospective multi-centric interventional case series of 58 eyes with rhino-orbital-cerebral mucormycosis. Demography, clinical parameters and management outcomes were noted. Factors affecting outcome and mortality were analyzed. Outcome was defined as favorable when complete resolution or stabilization without further progression of the infection was noted at last visit. RESULTS: Mean age was 55 ± 11 years (median 56). The mean HbA1c value was 10.44 ± 2.84 mg% (median 10.5). The duration between the diagnosis of COVID-19 and rhino-orbital-cerebral mucormycosis was 16 ± 21 days (median: 8 days). Thirty-six eyes (62%) had no vision at presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (41%), cavernous sinus involvement (30%), and central nervous system (CNS) involvement (33%). All the patients were treated with systemic Liposomal amphotericin-B and sinus debridement. Twenty-two eyes (38%) underwent exenteration. One eye underwent transcutaneous retrobulbar amphotericin-B. The mean follow-up duration was 5.62 ± 0.78 months (median 6). Favorable outcome was seen in 35 (60%) cases. Presence of uncontrolled diabetes (p = 0.001), orbital apex involvement (p = 0.04), CNS involvement (p = 0.04), and history of steroid use (p < 0.0001) resulted in unfavorable outcome. CNS involvement was the only factor predicting mortality (p = 0.03). Mortality was seen in 20 (34%) patients. CONCLUSION: Over a third of patients with rhino-orbital-cerebral mucormycosis following COVID-19 have an unfavorable clinical outcome. Uncontrolled diabetes mellitus at presentation, involvement of the orbital apex, CNS, and the usage of steroids were associated with poorer outcomes. CNS involvement was a factor determining mortality.

Magnetic resonance imaging in rhino-orbital-cerebral mucormycosis.

Coronavirus disease-associated mucormycosis (CAM) is an established clinical entity in India. In the past 4 months, there has been a sharp upsurge in the number of CAM cases in most parts of the country. Early diagnosis can be lifesaving. Magnetic resonance imaging (MRI) imaging remains the corner stone of management in patients with ROCM. This review discussed the utility of MRI imaging in ROCM with an emphasis on the ideal MRI protocol in a suspected case of ROCM, the pathways of spread of infection, the classic diagnostic features, MRI for staging of the disease, MRI for prognostication, MRI for follow up, and imaging features of common differentials in ROCM. The pit falls of MRI imaging and a comparison of CT and MRI imaging in ROCM are discussed. The clinical interpretation of areas of contrast uptake and those of necrosis and its relevance to treatment are discussed. This review aims to familiarize every member of the multidisciplinary team involved in managing these patients to be able to interpret the findings on MRI in ROCM.

Human primary retinal cells as an in-vitro model for investigating defective signalling caused by OPTN mutants associated with glaucoma.

Studies carried out on the pathogenesis of glaucoma using murine cell lines and animal models require to be validated in human cells. Therefore, we explored the possibility of using human primary retinal cells (hPRCs) in culture as a model for molecular studies and testing of potential therapeutic drugs. For this purpose, central retinal tissue, obtained from the enucleated eyes of patients with anterior staphyloma, was digested with trypsin and grown in a medium containing supplements (basic fibroblast growth factor and fetal bovine serum). hPRCs at passage 1 and 2, show expression of either GFAP, a glial cell marker, or ß-III tubulin, a retinal ganglion cell (RGC)-specific marker. But at passages 3-5 nearly all of hPRCs express several RGC-specific markers (Brn3 proteins, Thy-1, ß-III tubulin, RBPMS and NeuN) but not GFAP. Expression of these markers indicated that these cells may have functional properties of RGCs. As RGCs are sensitive to glaucoma-associated mutants of OPTN, we analysed the survival of hPRCs upon overexpression of OPTN mutants. Glaucoma-associated mutants, E50K-OPTN and M98K-OPTN, induced significantly higher cell death in hPRCs compared to WT-OPTN, whereas an amyotrophic lateral sclerosis-associated mutant, E478G-OPTN, did not. TBK1 inhibitor Amlexanox protected hPRCs from E50K-OPTN and M98K-OPTN induced cell death. M98K-OPTN induced cell death was suppressed by inhibitors of CaMKKß and AMPK in hPRCs as well as in 661W, a mouse cell line that expresses several markers of RGCs and RGC precursor cells. Our results suggest that hPRCs under appropriate culture condition show RGC-like properties. These cells can be used to explore the molecular mechanisms of cell death relevant for glaucoma pathogenesis and for testing of cytoprotective compounds.

Thermal Imaging of the Ocular Surface in Thyroid Eye Disease: A Comparison between Active, Inactive and Healthy Eyes.

Aim: To report the temperature differences on the ocular surface using infrared thermal imaging (TI) in thyroid eye disease (TED) and healthy eyesMethods: Prospective, consecutive, comparative case series comparing TI parameters between active and inactive TED with healthy controls. The data captured included baseline demography, activity of TED and the TI parameters. Area under the receiver operating characteristic curves (AUROC) were calculated for the temperature values to determine the sensitivity and specificity in distinguishing active from inactive TED. The Youden index and the predictor cut off values were also reported.Results: The study included 11 eyes with active TED, 46 eyes with inactive TED and 40 eyes healthy patients. Temperatures of pre-determined points on the ocular surface in degrees were compared between the three groups. Temperature at the caruncle, medial and lateral conjunctiva was noted to be significantly higher in the active TED group compared to inactive TED and healthy eyes. The most favorable Youden index (0.7) was noted for the caruncle with an AUROC value of 0.91, a sensitivity of 91% and a specificity of 79%. Correlation coefficient for the caruncular temperature with the corresponding CAS (clinical activity score) was 0.65 (95% C.I. 0.45 to 0.78, p < .0001).Conclusion: Thermal imaging in TED is an objective way of documenting surface inflammation by the surrogate marker of temperature change. It supplements CAS in clinically evident cases and could be useful in staging eyes with subtle clinical signs as well as those where signs have reduced following initiation of treatment.

Severe ocular and adnexal complications in dengue hemorrhagic fever: A report of 29 eyes.

Purpose: To describe a series of sight-threatening ocular and adnexal involvement associated with dengue hemorrhagic fever and their treatment options. Methods: Retrospective, interventional, non-comparative case series. Medical records of patients who presented with ocular symptoms attributed to dengue hemorrhagic fever were reviewed. Demography, presenting features, and treatment outcomes were recorded. Outcome measures assessed included globe salvage, vision salvage, and visual improvement. The outcome was deemed as favorable if vision salvage was possible and unfavorable if the vision was lost. Results: Twenty-nine eyes of 23 patients were included. Bilateral ocular involvement was seen in 6 (26%) patients. The mean age was 37.62 ± 18.68 years (range: 14 to 81 years). Coexistent diabetes mellitus and enteric fever were present in three patients. History of blood transfusion was present in nine (40%) and thrombocytopenia in eight (35%) patients at the time of presentation with ocular complaints. Presenting features included endophthalmitis in 11 (38%), panophthalmitis in 10 (35%), orbital cellulitis with panophthalmitis in four (14%), isolated corneal or scleral melt in three (10%), and orbital hemorrhage with panophthalmitis in one (3%) patient. Globe salvage was achieved in 21/29 eyes (72.4%), vision salvage in 6/29 eyes (20.68%), and improvement in visual acuity was noted in 5/29 eyes (17.24%). Logistic regression analysis revealed no significant effect of any clinical-microbiological factors on globe salvage, vision salvage, and visual improvement. However, visual improvement and globe salvage were possible in eyes that underwent early endoscopic vitrectomy. Conclusion: Dengue fever can present with sight-threatening ocular and adnexal inflammation resulting in endophthalmitis and panophthalmitis, orbital cellulitis, corneal and scleral melt, and orbital hemorrhage. Early vitrectomy may improve vision and globe salvage in cases with significant vitritis.

Novel Histopathologic and Immunohistochemical Observations in Explanted Orbital Peri-implant Capsules.

PURPOSE: To describe the histopathologic and immunohistochemical characteristics of peri-orbital implant capsule and correlate the observed changes with delayed implant extrusion. MATERIALS AND METHODS: Prospective, ex-vivo, histopathologic, immunohistochemical study of peri-implant capsules excised from capsules surrounding a poly-methyl metha acrylate (PMMA) implant. Thirteen capsules were harvested and divided into two groups. Group 1 (implant extrusion group) consisted of capsules harvested from around exposed/extruded implants and Group 2 (implant non-extrusion group) from implants that were surgically exchanged for volume augmentation. Data collected included demography, clinical presentations, etiology of the explantation, age of the capsule in months, inflammatory cells noted/high power field (HPF), CD3, CD20, and CD68, percentage Masson's trichrome staining and mean capsular thickness. RESULTS: Mean patient age at presentation was 33 ± 13 years. Of the 13 capsules included, 7 belonged to group 1and 6 to group 2. Mean age of the fibro-collagenous membranes were 33 ± 57 months (median 13 months). Median CD3, CD20, and CD68 positivity was 80%, 9%, and 7% denoting a predominant T-lymphocytic response. Mean capsular thickness was 733 ± 422µ (median 678µ). Age of the harvested capsule showed a linear correlation with inflammatory cells/HPF (r = 0.93, p < .0001, 95% C.I. 0.73 to 0.98), with CD3 positivity (r = 0.6, p = .04, 95% C.I. 0.02 to 0.9), with capillary proliferation/HPF (r = 0.85, p = .003, 95% C.I. 0.43 to 0.96) and with percentage of cells showing Masson's trichrome stain positivity (r = 0.71, p = .03, 95% C.I. 0.08 to 0.93). In the extrusion group, the capsules demonstrated high inflammation and low fibrosis. CONCLUSIONS: PMMA orbital spherical implant incites a predominantly T-cell mediated inflammatory response which clinically presents as a peri-implant capsule. Increasing inflammation in the absence of significant fibrosis may be responsible for delayed PMMA implant exposure and extrusion.

Intralesional Bleomycin for Orbital Lymphatic Malformations: Comparison of Clinical Versus Radiologic Regression by Volumetric Analysis.

PURPOSE: The aim of the study was to investigate the clinical resolution versus radiologic regression of orbital lymphatic malformations (LMs) following treatment with intralesional bleomycin sulfate sclerotherapy. METHODS: A retrospective interventional study of 24 eyes with orbital LMs treated with nonimage-guided bleomycin sclerotherapy. The clinical and radiologic outcomes were classified as excellent, good, fair, and poor. Regression was assessed clinically and by radiologic volumetrics. RESULTS: Mean age at presentation was 17 ± 18 years (median 11, range 5 months to 70 years). Lesion morphology was microcystic in 11 (46%), macrocystic in 8 (34%), and mixed in 5 (21%) eyes. Mean units of bleomycin injected per session were 4 ± 2 IU (median 5 IU, range 1-6 IU). Mean number of treatment sessions required was 2 ± 1 (median 2, range 1-6). Cumulative units of bleomycin injected were 11 ± 9 (median 9, range 1-38 IU). The clinical response was excellent in 19 (79%), good in 4 (17%), and fair in 1 (4%). The mean preoperative and postoperative lesion volumes were 7 ± 4 cm3 and 0.8 ± 1.2 cm3, respectively (p < 0.0001, 95% CI, -7.89 to -4.51). Radiologic resolution of LM was excellent in 6 (25%), good in 8 (33%), fair in 7 (29%), and poor in 3 (13%) eyes. Spearman's rank correlation coefficient for correlation between clinical and radiologic grading was 0.51 (p = 0.01, 95% CI, 0.13-0.75%). There was a sustained tumor resolution without recurrence over a mean follow-up duration was 2 years (median 18 months; range 12-60 months). CONCLUSIONS: Bleomycin sclerotherapy for orbital LMs gives an excellent to good clinical response in 93%. However, a parallel radiologic regression is seen only in 58%. The endpoint to assess response should be clinical. Treatment till complete radiologic resolution may not be necessary.

Orbital and periorbital dermoid cysts: Comparison of clinical features and management outcomes in children and adults.

PURPOSE: To compare differences in clinical presentation and management outcomes of orbital and periorbital dermoid cysts in children and adults. METHODS: A retrospective interventional comparative consecutive case series. 203 patients in (148 children [Age ⩽18 years] and 55 adults [Age >18 years]), who underwent excision biopsy for orbital/periorbital dermoid cyst were included. Outcome measures included the differences in demography, clinical presentations, radiological features, surgical outcomes and histopathology of cysts between children and adults with dermoid cysts. RESULTS: The mean age noted at excision was 15 years in this cohort of 148 children and 55 adults. Commonest clinical finding observed was a subcutaneous painless mass (94%) and external angular dermoids were commonest in both groups 1 and 2 (51% and 56%). Diminution of vision (p = 0.007), proptosis (p = 0.008), extraocular motility limitation (p = 0.001), strabismus (p = 0.003) and relative afferent pupillary defect (p = 0.02) were significantly more in adults. Orbital involvement and dumbbell dermoids were not significantly different between children and adults. Radiologically, bony fossa formation (p = 0.03), temporal fossa extension (p = 0.04), full thickness bony defect (p = 0.03) and intraosseous presentation (p = 0.005) were significantly more in adults. Comparison of proportion of lesions having intra-operative rupture of dermoid cyst (p = 0.009) and evidence of inflammation on histopathology (p = 0.01) were significantly more in adults. However, recurrence rates were not different between children and adults. CONCLUSIONS: Dermoid cysts are commoner in children, but can also present in adulthood. Secondary visual, orbital, radiologic changes and intra-operative rupture of dermoid cyst are more common in adults compared to children.