Epithelial-Myoepithelial Carcinoma of the Lacrimal Gland: Case Report of Youngest Patient.

The authors report a case of extremely uncommon malignancy of lacrimal gland epithelial-myoepithelial carcinoma. This carcinoma is more commonly encountered in salivary glands and comprises 1% of all salivary gland tumors. Its occurrence in the orbit is very rare with only 6 cases reported in the literature, most of which arose in a pleomorphic adenoma. Epithelial-myoepithelial carcinoma is primarily a tumor of older adults, with a peak incidence in the sixth and seventh decades of life. The present case is the youngest patient reported to date and had no history of preexisting neoplasm in the lacrimal gland. Histological diagnosis of epithelial-myoepithelial carcinoma is challenging because of the similarity with other lacrimal gland epithelial tumors like malignant adenoid cystic carcinoma and benign pleomorphic adenomas.

"Pinch and Stretch" technique to overcome ocular hypotony during scleral suturing of recti muscles.

During extraocular muscle surgery, an uneventful scleral suture pass is very essential. In presence of normal intraocular tension, the surgery is quite predictable and safe. However, in the presence of significant hypotony, it becomes challenging. Therefore, to mitigate complication rate in these cases, we have adopted a simple technique, that is, the "pinch and stretch" technique. The surgical steps of this technique are as follows: In eyes with significant ocular hypotony, the surgery is initiated with a routine forniceal/limbal peritomy, following which the muscle is sutured and dis-inserted. Using three tissue fixation forceps, the scleral surface is stabilized. Using first forceps, the surgeon rotates the globe toward themself from the muscle stump, and with the remaining two forceps, the assistant pinches and stretches the episcleral tissue in an outward and upward direction just beneath the intended marks. This creates a flat scleral surface with significant firmness. Sutures are passed over this rigid sclera and the surgery is completed without any complications.

A pilot randomized clinical trial comparing muscle transplant versus hang back recession in extra-large angle exotropia.

PURPOSE: For extra-large angle exotropia (>60 prism diopters, PD), single-setting surgical alternatives are scarce; frequently, more than two muscle or two eye procedures are indicated. To evaluate the viability of single eye surgery, a current randomized comparative trial is undertaken. METHODS: Twenty adult patients with extra-large angle exotropia underwent a thorough orthoptic evaluation before being divided into two groups at random. Ten patients in group 1 underwent medial rectus resection (5.5-7.5 mm), followed by transplant-aided lateral rectus recession (effective length: 4-5.5 mm) (9 mm). In group two, ten different patients underwent medial rectus resection (5.5-7 mm), but this time, the lateral rectus recession (9 mm) was aided with a hang-back suture (5-7 mm). The two procedures were compared at baseline and six months post-operatively. RESULTS: There was no significant difference in the groups' median ages (P = .95). In groups one and two, the median corrections achieved were 81.00 (79.50-85.50) PD and 81.00 (79.75-86.50) PD, respectively. The differences in corrections were statistically insignificant (p = .99). In all patients, abduction limitation was frequently noted in the immediate post-operative period, which improved over time. In each group, there were two patients (>90 prisms) with residual deviation of at least 30 PD, for which the contralateral eyes were operated. CONCLUSIONS: The hang-back recession was as successful as muscle transplant procedure in correcting 80-90 PD of exotropia with notable clinical benefits and ease.

Auricular skin-cartilage sandwich graft technique for full-thickness eyelid reconstruction.

Full-thickness deficiency of eyelid tissues can result in coloboma or retraction or both. Here we report our initial experience on the use of auricular skin-cartilage sandwich graft technique for full-thickness eyelid deformities. Five patients (4-32 years) underwent the procedure. Patients with full-thickness eyelid deformity were included. Three patients were operated for large-sized coloboma and two for eyelid retraction. One patient had congenital, and four patients had acquired etiology. The following parameters were specifically assessed: correction of deformity, ocular surface problems, graft status, and epithelization of skin-cartilage graft. All the patients had a good correction of eyelid position, except one patient who had severe eyelid retraction (8 mm) at presentation. None of our patients had corneal erosion/defect, persistent ocular surface redness, or graft loss. The auricular skin-cartilage sandwich graft technique produces optimal results with no graft loss. Advancement of orbicularis muscle in between the auricular skin and cartilage grafts (sandwich technique) is an imperative step that leads to the survival of both grafts.

Large orbital glial heterotopia- A rare entity.

A 15-month-old child was brought to the ophthalmology outpatient department with his parents complaining of a large mass located on the nasal side of his right eye since birth. On examination, an irregular mass was seen to be located on the nasal side of his right orbit, obscuring the visual axis. On a contrast-enhanced computed tomography scan, a heterogenous lesion was seen to be located on the bridge of the nose and the medial aspect of the right orbit without any bony defect or communication with the brain or sinuses. In view of the possibility of developing amblyopia, the lesion was surgically removed. On histopathological examination, a diagnosis of extranasal glial heterotopia was made. To the best of our knowledge, this is the largest extranasal glial heterotopia in the orbit to be ever reported.

Clinical features and orbital anomalies in Fraser syndrome and a review of management options.

Purpose: Fraser syndrome is a rare congenital disorder comprising cryptophthalmos, syndactyly, and many times, urogenital anomalies. Herein, the authors aimed to study and report the clinical features and orbital anomalies in cases diagnosed with Fraser syndrome. Methods: The authors retrospectively evaluated the records of patients with Fraser syndrome who had presented to a tertiary eye care hospital in northern India in the last 2 years (from January 2019 to December 2020). The clinical features were studied, entered in MS Excel, and the data was evaluated. Results: Data of 15 patients with Fraser syndrome were found. Majority of the patients were males and presented in the pediatric age group. Bilateral involvement was more common, and the most common variant of cryptophthalmos was abortive. Complete and medial madarosis of the eyebrows was the most common periocular finding. Complete cryptophthalmos was associated with cystic globes, whereas abortive forms had superior symblepharon. Common systemic features included syndactyly, bifid nose, and urogenital anomaly. Conclusion: Fraser syndrome is an extremely rare developmental disorder; it encompasses a wide range of ocular, periocular, and orbital anomalies, along with multiple pre-existing systemic anomalies. The treating ophthalmologist should always be careful in examining these patients.

Tessier cranio-facial clefts presenting to a tertiary eye care center in Northern India: Ophthalmic features and a review of management.

Purpose: Tessier classification is used to classify congenital facial cleft disorders utilizing the anatomical location of the cleft and its extension. The orbital and ocular morbidities associated with the birth disorder are numerous. The authors decided to perform a retrospective analysis of the clinical features of the patients who presented to a tertiary care hospital with orbito-cranial clefts. Methods: The authors retrospectively evaluated the records of patients with craniofacial clefts who had presented to a tertiary eye care hospital in northern India in the last 2 years (January 2019-December 2020). The clinical features were studied, entered in MS Excel, and the data were evaluated. Results: The data of 40 patients with Tessier cleft were found. The majority of the patients were male and presented in the pediatric age group. Unilateral involvement was more common, with maxillary hypoplasia being the most common facial anomaly associated. Eyelid coloboma and euryblepharon was the most common periocular finding; lateral epibulbar dermoid and corneal opacity were the most common ocular surface anomaly. The majority of patients had presented for cosmetic correction. The syndromic association was with Goldenhar syndrome (n = 13), Fraser (n = 2), and one each of Treacher Collins, blepharocheilodontic, organoid nevus, and oculo-dento-digital syndrome. Combined clefts were also seen. Conclusion: Tessier cleft classification is a useful tool to classify cranio-facial left anomalies. Multitudes of ocular and orbital anomalies can be associated with their different forms. Better knowledge and understanding of the classification will aid immensely in predicting the ocular defects and planning their management.

Orbital Aspergillosis, a great masquerader: a series of three unusual cases and a review of the literature.

Fungal infections of the orbit are infrequent. They typically affect immunocompromised individuals but, in some instances, can also affect an immunocompetent person. They mimic much orbital pathology clinically. Ours is a series of three patients eventually diagnosed with orbital aspergillosis but who, initially, were thought to have some other pathology.

Contralateral field defect in traumatic globe luxation with optic nerve injury.

CLINICAL RELEVANCE: Traumatic globe luxation is rare vision-threatening event. Besides causing loss of vision in traumatised eye, it may also cause injury to contralateral optic nerve. Any such limitation in a one-eyed patient can make him crippled in his day-to-day activities. Here we hypothesise cause of contralateral field defect in such patients. BACKGROUND: Traumatic globe luxation is a rare event that leads to profound vision loss due to injury of the ipsilateral optic nerve and rarely a visual field defect in the contralateral eye. Through this communication, we report similar case scenarios and intend to hypothesize the mechanism that results in the occurrence of the contralateral visual field defect. METHODS: It is a retrospective, observational study. All cases with traumatic globe luxation were enrolled. Visual field analysis of the contralateral normal eye was main outcome measure. RESULTS: Four patients with traumatic globe luxation and optic nerve injury were studied. There was complete loss of vision in the traumatised eye in all the patients. One patient had complete transection of the optic nerve, whereas in three patients, the course of the optic nerve was intact, on imaging. Three patients had quadrantanopia in the contralateral normal eye for which oral steroids were given. At 1-month follow-up, there was complete recovery of the visual field defect in two patients. We noticed that all the three patients with an intact course of the ipsilateral optic nerve had quadrantanopia in the contralateral normal eye. CONCLUSION: We hypothesize that in scenarios where globe luxation is associated with incomplete transection or no transection of the optic nerve, a continuous long standing stretch on the optic nerve, transmits the pulling force to the chiasma which might result in a contralateral field defect as compared to those associated with the complete transection of the optic nerve.

Novel Inferior Oblique Muscle Y Splitting Procedure to Minimize the Anti-Elevation Syndrome: A Pilot Study.

Purpose: To describe novel Y splitting procedure of inferior oblique muscle to mitigate the anti-elevation syndrome. Methods: A pilot, prospective interventional study was undertaken to assess the effect of inferior oblique muscle Y-splitting in patients with unilateral 3+ or more overaction. To correct primary gaze hypertropia and the excyclotorsion, a Y-splitting procedure was performed (along with routine horizontal muscle surgery as per the deviation) in 14 subjects. The effect of surgery was assessed at baseline and at 6 months post-intervention. Results: The mean age of 14 subjects was 25.14±7.70 years. The mean pre-operative hypertropia, excyclotorsion and inferior oblique muscle over-action was 18.42±3.50 PD, 14.14±2.65 degrees, and +3.21±0.42 respectively. Following surgery, this was reduced to 1.57±1.74 PD of residual hypertropia (a net correction of 16.85±2.31 PD, p = 0.005), 3.85±1.46 degrees of residual excyclotorsion (a net correction of 10.28±1.72 degrees, p < 0.05), and +0.28±0.46 of residual inferior oblique over-action (a net correction ~+3) at the end of 6 months. Amongst fourteen patients, three patients still experienced residual/variable anti-elevation effect, and during the study period none of them experienced any adverse event and none of them required any additional surgeries. Conclusion: While anteriorizing the inferior oblique muscle to correct primary gaze hypertropia and the excyclotorsion, a novel "Y splitting" procedure can be followed to achieve the desired results with mitigated anti-elevation effect.

Animal and cadaver human eyes for residents' surgical training in ophthalmology.

In ophthalmology residency programs surgical training plays a vital role in creating confident and skillful surgeons. As almost all ophthalmic surgery needs microscope training, creating a well-taught environment for hand-eye coordination, ocular tissue handling, and anticipation of complications is essential. Wet lab training with animal or cadaver human eyes offers diverse possibilities. We conducted a thorough literature search on various databases to identify the existing literature on wet labs. The results revealed constructive efforts for training novice surgeons in all surgical ophthalmology subspecialties. Wet lab models were initially used only to practice cataract surgery; however, now various complex ocular procedures can be practiced. Ocular surface, corneal, iris, lenticular, scleral, vitreoretinal, extraocular, eyelid, and other adnexal surgeries were reproduced and mastered in many ways. Importantly, with repeated surgical practice, residents gained an increasing level of confidence with enhanced surgical accuracy. In addition, we propose a few novel techniques of various other procedures.

Cysticercosis in ophthalmology.

Cysticercosis is caused by Taenia solium, a cestode or tapeworm that preferentially affects the subcutaneous tissue, brain, muscle, and the eye. It is traditionally a disease of low socioeconomic regions, but large-scale population migration has made it a matter of global concern. Its ocular invasion is a potentially blinding disease. In the last two decades, there has been considerable discussion of cysticercosis; however, most comes from a limited number of case observations. Thus, to overcome this limitation, we summarize and analyze twenty years of medical literature (from 2000 to 2020) on cysticercosis in ophthalmology.

Simulation of complex strabismus surgical procedures on goat eyes.

PURPOSE: To describe the possibility of complex strabismus surgical simulation on goat eyes. METHODS: The goat eyes were procured from local slaughterhouse with retained extra ocular muscle tissues. The obtained eyes were inspected for globe integrity, muscle quality, muscle length, and the surrounding teno-conjunctival layers. The included eyes were then segregated for surgical simulation based on their insertion and orientation (as oblique or recti), and they were mounted on a mannequin head, with a fixation suture at free end to simulate the resting tension. Additionally, as per necessary, extra muscles were also transplanted along desired sites to simulate human extra ocular muscle anatomy. RESULTS: The inferior oblique, superior oblique, and all other four recti were successfully simulated in varying proportions in more than 50 eyes. Primarily, by simulating the lateral rectus, inferior rectus, and the inferior oblique muscle, staged weakening procedures of inferior oblique were successfully practiced (Fink's recession, Park's recession, Elliot and Nankin procedure, total anterior positioning, and antero-nasal trans-position or Stager's procedure). Similarly, by simulating superior rectus, inferior rectus, lateral rectus, and the medial rectus muscles, half width transposition, full width transposition, and other complex procedures were practiced (Knapp's procedure, augmented Knapp's, Nishida's procedure, Faden operation, and Y splitting procedure). Furthermore, by simulating superior oblique and the superior rectus muscles, superior oblique tuck, posterior tenectomy, loop tenotomy, and Harada Ito procedures were successfully practiced. CONCLUSIONS: On goat eyes, the complex strabismus surgical procedures can be successfully simulated and practiced after re-organizing the existing muscles in different patterns.

Myopia in India.

India is a culturally and geographically diverse nation. Its vast demographic nature does not allow a single definition for any of the given medical conditions in its territory. One important clinical condition which has created an uproar in the rest of the world is myopia. Its cause, prevalence, etiopathogenesis and other factors are being explored constantly; however, data with respect to Indian subcontinent are genuinely missing. Hence, in this review, we enumerate the country's myopia journey from last 4 decades. The epidemiology, genetics, ocular/systemic association, quality of life, imaging, and management in myopia with necessary future directives are discussed to augment the overall management in future.

Intraorbital wooden foreign body, legacy of a notorious scrap: a case report.

Wooden foreign bodies are notorious to be fragile and get retained as bits and bobs in the orbit. A 50-year-old woman presented to casualty with complaints of loss of vision and pain in the right eye associated with discharge from a wound in right eye upper lid. On imaging, a wooden foreign body was seen as continuous track of air. Meticulous dissection and search were done to remove bits and bobs of the wood. Patient, however, after 15 days of primary surgery reported with pus collection over wound site. Keeping suspicion of remnant wooden body piece(s), imaging and further exploration were carried out, removal of a 1 cm residual wooden piece was done. Retained wooden foreign body should always be suspected in postoperative cases of intraorbital wooden foreign body with infection. A close follow-up and knowledge of the same stay useful to remove any needless apprehension both of patient and surgeon.

Bilateral globe luxation with multiple facial fractures: what next?

Luxation of the globe is a rare, vision-threatening event that can presently spontaneously or following trauma. A 35-year-old man presented with bilaterally luxated globe, postroad traffic accident. On imaging, bilateral LeFort fracture type 1, 2 and 3 with palatal split along with nasal bone and orbital floor fracture. Both condyles and left parasymphysis of mandible were fractured. There was no evidence of intracranial injury. There was pneumothorax on the right side for which intercostal drainage (ICD) tube was placed. On exploring, bilateral optic nerve avulsion was present. Both the globes were repositioned and a temporary tarsorrhaphy was placed for cosmetic rehabilitation. On follow-up visits after 6 months, both eyes were in their sockets with minimal exodeviation. It is important to reposition the globes, even with extensive periorbital fracture at the earliest. The longer the globe and orbital structures are prolapsed, the poorer are the structural and cosmetic prognosis owing to ocular ischaemia.

Recurrent Ptosis in a Case of Dubowitz Syndrome.

Dubowitz syndrome is a relatively rare genetic and developmental disorder. An eight-year-old female presented with a complaint of drooping in her left eye since birth. She had undergone ptosis surgery two years back. There was a history of delayed speech and delayed dentition. She was of moderate built appropriate to her age. There was microcephaly, sparse hair, flat bridge of the nose with a prominent rounded tip, short stature, low-set ears, and micrognathia with subsequent protrusion of upper two incisors. Based on the clinical features a diagnosis of Dubowitz syndrome with left recurrent ptosis was made. She underwent frontalis sling surgery and had a satisfactory outcome.