Epidemiological and Clinical Presentation of Retinoblastoma among Nepalese Children in 2019.

Suresh B.K. RasailyObjectives Retinoblastoma (RB) is rare but potentially fatal if left untreated. This study aimed to evaluate the epidemiological profile, clinical manifestation, classification, and affordability of RB treatment among Nepalese children in the year 2019. Materials and Method A multicentric, multiethnic hospital-based cross-sectional study after ethical approval from the National Health Research Council was conducted from January 2019 to December 2019 by incorporating ophthalmologists all over the nation. Twenty-seven RB centers were selected. All the RB presented in the RB centers either newly diagnosed or ongoing treatment consented to the study were included and failed to consent for the study, RB survivors were excluded from the study. Data based on demographic profile, clinical manifestation, ethnical and geographical distribution, and treatment received were collected in the customized Google Form. Each case was classified at the time of diagnosis as per the International Classification of Retinoblastoma groups and different treatment modalities offered as per grouping and staging. The affordability of treatment was calculated using a catastrophic approach. Statistical Analysis Data were entered into Microsoft Excel 2010 and analyzed using Statistical Package for Social Sciences version 20. Result A total of 34 RB cases, 21 (61.76%) in ongoing treatment group and 13 (38.2%) in newly diagnosed group presented in the RB centers. Out of total, 32 (64.7%) had unilateral and 12 (35.3%) cases had bilateral involvement. The majority of patients was from Province 1 (35.3%) and belonged to the upper caste (38.2%). Leukocoria was the most common presentation (73.9%) followed by proptosis, red eye, and phthisis bulbi. More than 75% patients presented at advanced group D (54%) and E (21%) and stage 0 (90%). More than 90% of patients received systemic chemotherapy, and 42.6% received transpupillary thermotherapy. The average cost of RB treatment was estimated to be 521% of the nonfood expense of the family which is unaffordable to almost all cases (100%). Conclusion Leukocoria is the most common mode of clinical presentation in both unilateral and bilateral RBs. Early diagnosis and appropriate treatment are key to success for saving life, sight, and eye. However, community awareness programs against RB, active referral networks, and the establishment of chemotherapy centers with trained human resources are needed to reduce loss of life, sight, and eye.

Endoscopic Endonasal Dacryocystorhinostomy under Local Anesthesia or Assisted Local Anesthesia.

INTRODUCTION: Endoscopic Endonasal Dacryocystorhinostomy (EENDCR) is effective, safe and less time consuming procedure and scar free to manage patients with epiphora. Traditionally, EENDCR is performed under general anesthesia. Limited general anesthesia facility in our country has made EENDCR surgery limited to the hospitals with GA facilities. EENDCR surgery under local or assisted local anesthesia could be an alternative solution. The aim of the study was to study the pain tolerability of the patient undergoing EENDCR under local anesthesia (LA) or assisted local anesthesia (ALA). To the best of our knowledge, there is a lack of similar studies in Nepal. MATERIALS AND METHODS: This was a prospective, nonrandomized, interventional study done at a tertiary eye care center. After sample collection the study was aimed to evaluate the pain tolerability of patients undergoing EENDCR under LA or ALA. The case collection and the surgery were done by a single surgeon from 2018 Jan- 2019 April and followed for 6 to 24 months. All consecutive cases were enrolled in the study. Informed consent was obtained from all the patients. Inclusion criteria included chronic dacryocystitis with NLDO (Nasolacrimal duct obstruction), lacrimal sac mucocele and lacrimal sac pyocele. Previously failed DCR surgery was not included in the study. Total of 100 patients of EENDCR with a tube who completed a minimum 6 months follow up postoperatively were included in the study. Verbal rating scale (VRS) was used to report response to pain during different steps of surgery. RESULTS: There were 100 patients within the age range of 13-41 years of age. One hundred and six EENDCR were performed on 100 patients. Eighty-seven patients were adult (19-41) years and 13 patients were of pediatrics age group (13-18) years. There were 74 female and 26 male patients. Thirty-seven were RE (right eye), 57 were LE (Left eye) and 6 were BL (bilateral). Duration of illness was less than 6 months in 9 patients and more than 6 months in 91 patients. Ninety-two eyes were operated under LA and fourteen eyes of 11 patients asked for sedation in addition to local anesthesia (ALA). Patients reported pain during the creation of the bony ostium with Keryson's rounger (24 eyes, VRS 3-4) and while using the drill (19 eyes, VRS 5-6). On pain scoring, there was no pain (0-2) in patients who underwent EENDCR under ALA. Pain scoring in patients who underwent EENDCR under LA showed no pain (0-2) in 51.08%, mild pain (3-4) in 26.08%, and moderate pain (5-6) in 20.65%. Duration of surgery ranged from 15 to 45 minutes. Duration of follow up was 6- 24 months. There was a 96.2% success rate in this study. CONCLUSION: EENDCR can be done under LA or ALA depending on the indication and demand of the patient.

Canalicular Curettage to the Rescue: a report of three cases.

INTRODUCTION: Canalicular curettage is a surgical procedure used to remove canalicular contents and debris from canaliculi. It is usually indicated for chronic, persistent or recalcitrant canalicular diseases with no resolution of symptoms after conservative management. We describe 3 different cases of persistent canalicular diseases which needed canalicular curettage to rescue from the conditions leading to successful outcomes. Cases and observations: • Case 1: A 45-year-old male presented with recurrent punctal granuloma 3 months after DCR surgery. Canalicular exploration and curettage with one-snip punctoplasty following excision of the mass revealed a segment of remnant silicone stent. There was no recurrence of mass in subsequent follow up visits. • Case 2: A 35-year-old female presented with recurrent canaliculitis for last 6 months. Canalicular curettage revealed multiple small calcified masses of varying size and shape. The patient had good postoperative recovery and showed no recurrence of symptoms. • Case 3: A 32-year-old female presented with gradually increasing pedunculated mass arising out of punctum for last one month. Excision of mass with canalicular curettage was done. Biopsy proved it to be squamous papilloma of the canaliculi. There was no recurrence of mass. CONCLUSION: Canalicular curettage is a simple, safe and effective surgical intervention to rescue from the recalcitrant canalicular conditions like canaliculitits, retained foreign bodies, canalicular neoplasms leading to successful outcomes.

Congenital Microphthalmia with Orbital Cyst: A Case Series.

Microphthalmos results from incomplete invagination of the optic vesicle or closure of the embryonic fissure. We present three patients with unilateral congenital microphthalmia with cyst. None of them had vision in the affected eye since birth. There was gradually increasing left eye orbital mass encroaching towards lower fornix and lower eyelid ectropion. On examination and investigations, patients had large orbital cyst with microphthalmia pushing the eyeball superiorly and posteriorly in affected orbit. Microphthalmic globe with cyst was surgically excised and histopathologically studied. Orbital cavity was big enough to occupy the conformer and the prosthetic eye after 6 weeks. Diagnosis was confirmed as large communicating orbital cyst with microphthalmia without systemic association in all the patients. None of the mothers of patients had regular antenatal check up. All the parents had consanguineous marriage. Antenatal check up with ultrasound at 14 to16 weeks of pregnancy is important for genetic counselling. Targeted abdominal ultrasound examination of pregnant women focused on the orbital region of foetus is recommended, in mothers who have children with congenital eye anomalies. Keywords: congenital anomaly; cyst; eye; microphthalmos.

Prevalence of Histopathologically Diagnosed Ophthalmic Neoplastic Lesion Among Ophthalmic Biopsies in a Pathology Laboratory of Tertiary Hospital of Nepal.

INTRODUCTION: Many vision threatening or life threatening neoplastic conditions often mimic less aggressive neoplastic or non-neoplastic inflammatory variants. This study aims to comprehensively analyze the histopathological spectrum of ophthalmic neoplastic lesions tumors in a pathology laboratory in a tertiary care hospital. METHODS: A descriptive cross-sectional study was conducted in the Department of Pathology at Birat Medical College and Teaching Hospital, Morang, Nepal over a period from November 2016 to October 2018. Ethical clearance was taken from Institutional Review Committee of Birat Medical College. Sample size was calculated and convenience sampling was done. Data was collected in excel and analyzed in Statistical Package for Social Sciences version 16. Point estimate at 95% Confidence Interval was calculated and frequency and percentage was calculated for binary data. Subgroup analysis was done based on age, sex, nature of lesions and site of lesions. RESULTS: Prevalence of ophthalmic neoplastic lesion was 139 (55.37%), of which 74 (53.24%) were benign and 65 (46.76%) were malignant. Benign was mostly seen in females and of second decade and malignant was common in males and seventh decade of life respectively. Nevus in 18 (24.3%) and squamous cell carcinoma in 30 (17.6%) was found to be the most common benign and malignant lesions among the specimens. Conjunctiva and cornea in 52 (37.41%) was the most common location for those neoplastic lesions. CONCLUSIONS: The most common ophthalmic neoplastic lesion was benign. Nevus is common in females and second decade and squamous cell carcinoma is common in males and seventh decade of life.