Aurora kinase A is overexpressed in human retinoblastoma and correlates with histopathological high-risk factors: implications for targeted therapy.

Retinoblastoma (RB) is an intraocular malignancy initiated by loss of RB1 function and/or dysregulation of MYCN oncogene. RB is primarily treated with chemotherapy; however, systemic toxicity and long-term side effects remain a significant challenge necessitating the identification of specific molecular targets. Aurora kinase A (AURKA), a critical cell cycle regulator, contributes to cancer pathogenesis especially in RB1-deficient and MYCN dysregulated tumors. Our immunohistochemistry study in patient specimens (n=67) discovered that AURKA is overexpressed in RB and elevated expression correlates with one or more histopathological high-risk factors such as tumor involvement of the optic nerve, choroid, sclera and/or anterior segment. More specifically, AURKA is ubiquitously expressed in majority of the advanced-stage RB tumors that show a sub-optimal response to chemotherapy. shRNA-mediated depletion/pharmacological inhibition studies in cell lines, patient-derived cells, in-vivo xenografts, and enucleated patient specimens confirm that RB cells are highly sensitive to a lack of functional AURKA. In addition, we deciphered that AURKA and MYCN associate with each other to regulate their levels in RB cells. Overall, our results demonstrate a previously unknown upregulation of AURKA in RB, facilitated by its crosstalk with MYCN, and elevated levels of this kinase may indicate unfavorable prognosis in tumors refractory to chemotherapy. This study provides a rationale and confirms that therapeutic targeting of elevated AURKA in RB could be a potential treatment approach.

Thyroid Eye Disease and Its Association With Diabetes Mellitus: A Major Review.

PURPOSE: Thyroid eye disease (TED) associated with diabetes mellitus (DM) presents unique challenges. DM is a risk factor for TED. Standard management of TED with glucocorticoids (GC), orbital radiation, or teprotumumab can cause adverse events in poor glycemic control. The authors reviewed the literature on the relationship between TED and DM and the management of co-existing diseases. METHODS: The authors searched PubMed with keywords "thyroid eye disease," "diabetes mellitus," and similar terms from 2013 to 2022. The authors included relevant studies after screening the abstracts. Additional references to the selected studies were included where applicable. Data were extracted from the final articles according to the preplanned outline of the review. RESULTS: The initial search yielded 279 abstracts. The final review included 93 articles. TED and DM interact at multiple levels-genetic, immunologic, cellular, nutritional, and metabolic. Both DM and thyroid dysfunction exacerbate the morbidity caused by the other. Metabolic factors also affect the inflammatory pathway for TED. Patients with DM develop TED with greater frequency and severity, necessitating interventions for vision salvage. Agents (GC, teprotumumab, or radiation) used for TED are often unsuitable for treatment with DM, especially if there is poor glycemic control or diabetic retinopathy. There were no studies on using steroid-sparing agents in TED with DM. CONCLUSION: TED and DM co-exist because of multiple intersections in the pathophysiology. Challenges in the treatment include increased TED severity and risk of hyperglycemia and retinopathy. Multidisciplinary teams best undertake treatment of TED with DM.

Prevalence and causes of visual impairment in Dongaria indigenous (tribal) community. Tribal Odisha eye disease study # 12.

Purpose: To document the spectrum and magnitude of eye disorders and visual impairment in the Dongaria-a Particularly Vulnerable Tribal Group in the Rayagada district of Odisha, India. Methods: A door-to-door screening protocol included a record of basic health parameters, visual acuity for distance, and near and flashlight examination of the eyes. Spectacles were dispensed to those who improved; those who failed the screening were referred to fixed (primary and secondary) eye care centers. Results: We examined 89% (n = 9872/11,085) of people who consented for screening. The mean age was 25.5 ± 18.8 years; 55% (n = 5391) were female; 13.8% (n = 1361) were under-five children, and 39% (n = 3884) were 6 to 16 years. 86% (n = 8515) were illiterate. 12.4% (n = 1224) were visually impaired, of which 9.9% had early moderate VI, and 2.5% had severe VI and blindness. Uncorrected refractive error was detected in 7.5% (n = 744) and cataracts in 7.6% (n = 754); among the adults, 41.5% (n = 924/2227) had presbyopia. In children, 20% (n = 790) had vitamin A deficiency, 17% (n = 234) had global acute malnutrition, and 18% (n = 244) were stunted for their age. Almost two-thirds (62%, n = 6144) confirmed habitual intake of alcohol, and 4% (n = 389) of adults had essential hypertension. Following the screening, 43.5% (n = 837) of referred patients reported to the fixed centers, and 55% (134/243) of people advised underwent cataract surgery. Spectacles were dispensed to 1496 individuals. Conclusion: Visual impairment and malnutrition are high in Dongaria indigenous community. Permanent health facilities and advocacy would improve this community's health and health-seeking behavior.

Diagnostic Performance and Clinical Utility of Conventional PCR Assay in Early Diagnosis of COVID-19 Associated Rhino-Orbito-Cerebral Mucormycosis.

Early diagnosis and treatment of rhino-orbital-cerebral mucormycosis (ROCM) are crucial. Potassium hydroxide with Calcofluorwhite (KOH + CFW) smears can demonstrate the fungal hyphae, but mixed infections caused by both mucorales and non-mucorales pose a diagnostic challenge. Polymerase chain reaction (PCR) can detect mixed infections and differentiate mucorales from non-mucorales. This study aimed to evaluate the utility of a single reaction PCR in the diagnosis of ROCM and the efficacy of nasal biopsy and endonasal swab in the detection of fungus. Sixty-six clinical samples were collected from 33 patients and were subjected to KOH + CFW smear, culture and PCR. PCR was performed using pan-fungal primers targeting the 28S large subunit rRNA gene, and the amplified products were further sequenced to identify the fungi. KOH + CFW smear, culture and PCR detected mucorales in 54.6%, 27.3% and 63.6% patients, respectively. PCR detected mixed infection in 51.5% patients compared to 9.1% by KOH + CFW smear. PCR detected fungus in 90% of nasal biopsies and 77.8% of endonasal swabs. Rhizopus spp. was the most common fungi identified in 43.2% of PCR-positive samples. PCR is effective in detecting mixed infection and in the diagnosis of ROCM. Nasal biopsies had better fungal detection rates than endonasal swabs.

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.

The Oncogene MYCN Modulates Glycolytic and Invasive Genes to Enhance Cell Viability and Migration in Human Retinoblastoma.

Retinoblastoma is usually initiated by biallelic RB1 gene inactivation. In addition, MYCN copy number alterations also contribute to RB pathogenesis. However, MYCN expression, its role in disease progression and correlation with RB histological risk factors are not well understood. We studied the expression of MYCN in enucleated RB patient specimens by immunohistochemistry. MYCN is overexpressed in RB compared to control retina. Our microarray gene expression analysis followed by qRT-PCR validation revealed that genes involved in glucose metabolism and migration are significantly downregulated in MYCN knockdown cells. Further, targeting MYCN in RB cells using small molecule compounds or shRNAs led to decreased cell survival and migration, increased apoptosis and cell cycle arrest, suggesting that MYCN inhibition can be a potential therapeutic strategy. We also noted that MYCN inhibition results in reduction in glucose uptake, lactate production, ROS levels and gelatinolytic activity of active-MMP9, explaining a possible mechanism of MYCN in RB. Taking clues from our findings, we tested a combination treatment of RB cells with carboplatin and MYCN inhibitors to find enhanced therapeutic efficacy compared to single drug treatment. Thus, MYCN inhibition can be a potential therapeutic strategy in combination with existing chemotherapy drugs to restrict tumor cell growth in RB.

Aurora Kinase B Expression, Its Regulation and Therapeutic Targeting in Human Retinoblastoma.

Purpose: Aurora kinase B (AURKB) plays a pivotal role in the regulation of mitosis and is gaining prominence as a therapeutic target in cancers; however, the role of AURKB in retinoblastoma (RB) has not been studied. The purpose of this study was to determine if AURKB plays a role in RB, how its expression is regulated, and whether it could be specifically targeted. Methods: The protein expression of AURKB was determined using immunohistochemistry in human RB patient specimens and immunoblotting in cell lines. Pharmacological inhibition and shRNA-mediated knockdown were used to understand the role of AURKB in cell viability, apoptosis, and cell cycle distribution. Cell viability in response to AURKB inhibition was also assessed in enucleated RB specimens. Immunoblotting was employed to determine the protein levels of phospho-histone H3, p53, p21, and MYCN. Chromatin immunoprecipitation-qPCR was performed to verify the binding of MYCN on the promoter region of AURKB. Results: The expression of AURKB was found to be markedly elevated in human RB tissues, and the overexpression significantly correlated with optic nerve and anterior chamber invasion. Targeting AURKB with small-molecule inhibitors and shRNAs resulted in reduced cell survival and increased apoptosis and cell cycle arrest at the G2/M phase. More importantly, primary RB specimens showed decreased cell viability in response to pharmacological AURKB inhibition. Additional studies have demonstrated that the MYCN oncogene regulates the expression of AURKB in RB. Conclusions: AURKB is overexpressed in RB, and targeting it could serve as a novel therapeutic strategy to restrict tumor cell growth.

Point-of-care rapid antigen testing for COVID-19 at a tertiary eye care facility: Role in commencement of elective surgeries, contact tracing and implementation of back-to-work policy.

PURPOSE: The aim of this study was to report the use and the impact of a point-of-care rapid antigen test (PoC-RAT) at a tertiary eye care facility in facilitating commencement of elective surgeries, contact tracing of exposed health care professionals (HCPs) and ancillary hospital staff, and implementation of back-to-work (BTW) policy for them. METHODS: Retrospective analysis of subjects undergoing PoC-RAT for COVID-19 infection at a tertiary level dedicated eye care facility. Decision making with regard to commencement of elective surgeries post COVID-19 related discontinuation of services, contact tracing of HCPs and ancillary hospital staff exposed to known COVID-19 cases and implementation of back-to-work policy for all staff based upon the results of PoC-RAT were studied. RESULTS: A total of 311 subjects (224 patients and 87 hospital staff) were tested. Overall positivity rate was around 7%. Asymptomatic patients who were screened preoperatively had a lower positivity rate at around 3% compared to the staff (who were either known contacts or were symptomatic) at around 17%. Contact tracing found three-quarters of the staff at low risk and only one quarter at medium or high risk. Among patients, 97% of those followed up for at least 2 weeks after the test remained healthy. For staff, this was around 65%. CONCLUSION: Based on our preliminary results, we suggest that PoC-RAT may be considered routinely for indication-based preoperative screening of asymptomatic patients, and for on-campus screening, contact tracing and implementation of BTW policies for HCPs and ancillary hospital staff at a tertiary level eye care facility.

Behavior and outcomes of 70 adult lacrimal sac mucoceles.

Purpose: To study the clinical profile and outcomes in adults with lacrimal sac mucoceles.Methods: A retrospective, interventional study on consecutive adult patients with lacrimal sac mucoceles who underwent dacryocystorhinostomy (DCR)/dacryocystectomy surgery. Primary outcome measure was subsidence of lacrimal sac swelling after intervention. Secondary outcome measure was anatomical patency of the lacrimal system.Results: A total of 70 patients were studied, mean age of the group being 49.2 ± 13.5 years. Majority of the patients were female (n = 49; 70%) and all had unilateral disease. An appreciable number (n = 14; 20%) presented with acute dacryocystitis of which 6(8%) developed a lacrimal sac fistula. Encystment of the lacrimal sac mucocele was seen in 47 (67%) patients, 3(4%) developed preseptal cellulitis and 3(4%) needed imaging. Resolution of sac swelling after intervention was seen in 70 (100%) patients. Definitive management was DCR in 57 (81%) patients, of which anatomical patency was achieved in 55 (96%) patients, mean duration of follow up of the group being 138 ± 70.2 days. A trend to prefer adjuvants like Mitomycin-C and/or intubation was noted in 56 (98%) of patients.Conclusions: Adult lacrimal sac mucocele is more commonly seen in females and unilaterally. Complications of this entity include encysted mucocele (67%), acute dacryocystitis (20%), lacrimal sac fistula (8%), and preseptal cellulitis (4%). It is essentially a clinical diagnosis and favourable outcomes are seen with DCR surgery.

Sight-Threatening Thyroid Eye Disease: Role of Diabetes Mellitus and Interaction with Other Risk Factors.

PURPOSE: The aim of the study was to investigate whether diabetes mellitus (DM) is an independent risk factor in sight-threatening thyroid eye disease (ST-TED) and explore the interaction of DM with other known risk factors in TED. METHODS: This was a retrospective cohort study and included 202 consecutive TED patients presenting between 2013 and 2019. Data collected included demography, history of smoking, thyroid dysmetabolism, and presence of DM, TED-duration, activity and severity, best-corrected visual acuity (BCVA), and follow-up. Primary outcome measure was development of ST-TED and secondary outcome measures included change in BCVA, activity, and bilateral ST-TED. RESULTS: Mean age of the cohort was 52.14 + 9.14 years and 74 (36%) were male. DM was present in 49 (24%) and a positive history of smoking in 65 (32%) TED patients. Cox's proportional hazards showed the presence of DM (hazard ratio [HR] 2.22; P = 0.02) and a positive history of smoking (HR 3.62; P = 0.003) were significant risk factors for development of ST-TED and dysthyroid optic neuropathy (DON). Older age was a risk factor (HR 1.05; P = 0.02) for DON. DM increased the risk of developing bilateral ST-TED (OR 4.14; P = 0.004). Median follow-up was 4 months (range 0.1-96 months). A linear mixed model to predict longitudinal interaction between risk factors, found TED patients in DM group were likely to have worsening of visual function and a positive history of smoking accentuated this adverse outcome. CONCLUSION: DM and smoking are major independent risk factors predictive of ST-TED. Coexisting DM either singularly or in combination with smoking may predict worsening of visual function in TED patients.

Primary De novo ductal adenocarcinoma of the lacrimal gland.

BACKGROUND: Primary ductal adenocarcinoma of the lacrimal gland is a rare and aggressive malignant epithelial lacrimal gland neoplasm, morphologically and phenotypically resembles salivary duct carcinoma, and both strongly resemble infiltrating ductal carcinoma of breast. METHOD: Retrospective Chart review of cases of malignant lacrimal gland tumors from 2013 July to 2020 July. Authors describe the clinico radiological, morphological and immunohistochemical features of primary ductal adenocarcinoma (PDA) of lacrimal gland. Extensive review of literature of PDA of lacrimal gland and salivary gland ductal carcinoma has been performed. RESULTS: Retrospective chart review of the last 7 years yielded 22 malignant lacrimal gland neoplasms of which 4 cases demonstrated features of primary ductal adenocarcinoma of lacrimal gland, 2/4 cases showed an evidence of a pre existing pleomorphic adenoma and 2 were found to be de novo ductal adenocarcinomas. PDA of lacrimal gland showed expression of CK7, CK19, AR, HER2, cyclin D1 and were negative for CK5/14, CK 20, ER, PR, PSA, TTF-1, S-100 and SMA. Expression of GCDFP-15 was noted in one case. The presence of multiple events of loco-regional recurrences and/or distant metastasis necessitated a multidisciplinary approach. CONCLUSIONS: Authors have expressed the need of clinical correlation; thorough tissue sampling and extensive immunohistochemical work up in identification of de novo PDA's and their molecular subtypes. A multi-institutional study might help in formulating the diagnostic criteria, identification of actionable targets, and thus study the role of targeted therapy in this rare and aggressive tumor which may result in better patient outcomes.

Microbiological spectrum of microbial keratitis in patients presenting with nasolacrimal duct obstruction.

PURPOSE: To study the type of bacteria and their antibiotic susceptibility pattern from corneal scrapings of patients with infectious keratitis presenting with concurrent nasolacrimal duct obstruction. METHODS: A retrospective analysis was carried out of patients with microbial keratitis and co-existing nasolacrimal duct obstruction during a 5-year period (January 2012 to December 2016). Antibiotic susceptibility profile data was collected from the microbiology records. RESULTS: The study included 56 (M:F = 33:23; OD:OS = 34:22) eyes. The mean age of patients was 60.2 ± 12.3 years. Microscopic examination of corneal scrapings showed 52% of gram-positive (n = 29/55) and 2% of multiple (>1; n = 1/55) bacteria. Streptococcus pneumoniae (32%, n = 18/56), coagulase-negative Staphylococcus (25%, n = 14/56), and Staphylococcus aureus (11%, n = 6/56) were the most common bacteria. Streptococcus pneumoniae was found to be susceptible to ciprofloxacin (72.2%), ofloxacin (94.4%), gatifloxacin (61.1%), and moxifloxacin (83.3%). CONCLUSION: Corneal infection associated with nasolacrimal duct obstruction is commonly caused by gram-positive-bacteria. Irrigation of nasolacrimal duct should be mandatory test in microbial keratitis. The gram-positive bacteria isolated showed maximum susceptibility to vancomycin and cefazolin. Early treatment by surgery and appropriate medical management is recommended for its control.

Thyroid eye disease survey: An anonymous web-based survey in the Indian subcontinent.

Purpose: To evaluate the current practice patterns in the treatment of thyroid eye disease (TED) in Indian subcontinent through a web-based survey of members of Oculoplastics Association of India (OPAI). Methods: This was an online web-based questionnaire survey disseminated via monkeysurvey.com to all ratified active members of OPAI between May 1, 2016 and June 30, 2016. Questions encompassed the background, training, region, and experience of oculoplastic surgeons along with the management protocol of TED. Results: Of the 435 emails sent to OPAI members, 9 bounced and 180 (42.3%) responded within the study period. A large majority (96%) of respondents were oculoplastic surgeons practicing in India and the remaining practiced within South-East Asia. Two-thirds of respondents were oculoplastic surgeons with less than 10 years of clinical experience; 82% were fellowship trained in Oculoplasty. Almost all (99%) favored a multidisciplinary management of TED. A large majority routinely grade the severity (89%) and activity (87%) of disease before management. While corticosteroid remained the treatment of choice, 54% preferred immune-modulators as the second-line of therapy for recalcitrant TED. Three-quarters did not use orbital radiotherapy as a management modality in active TED owing to concerns over its efficacy and/or safety. Conclusion: The survey gives useful insights to the practice patterns of TED management in Indian subcontinent. Multidisciplinary approach and grading of disease severity and activity were the rule rather than exception among OPAI members. Immune modulation was the preferred steroid-sparing agent in recalcitrant disease. Orbital radiotherapy was an uncommon treatment choice.

Small cell neuroendocrine carcinoma of the orbit presenting as an orbital abscess in a young female.

Small cell neuroendocrine carcinoma (SNEC) of the sino-nasal tract is a rare tumor with aggressive behavior. Invasion of the orbit, brain and base of skull is reported in advanced cases, however clinical presentation of SNEC, primarily as an orbital mass is distinctly rare. A 25-year-old female, presented to a local ophthalmologist with sudden protrusion of eyeball and was diagnosed as an orbital abscess which was incised and drained. She presented to us after six months of initial drainage with rapid increase in protrusion and associated eyelid swelling and was lactating at the time of presentation. The patient underwent clinico-pathological work up and was diagnosed as a primary case of orbital SNEC. She received chemotherapy, with an initial response followed by massive recurrence and subsequently succumbed to the disease after 18 months of presentation to us. The authors present a literature review and describe the challenges in diagnosis and management of a primary orbital SNEC, which has high propensity to progress, recur, invade neighboring sites, and show distant metastasis inspite of multimodal therapy. Author's recommend close follow up during disease free intervals.

External dacryocystorhinostomy for isolated lacrimal sac rhinosporidiosis - A suitable alternative to dacryocystectomy.

Purpose: To describe the outcome of external dacryocystorhinostomy (DCR) as a suitable alternative to dacryocystectomy (DCT) in cases of isolated lacrimal sac rhinosporidiosis. Methods: This was a retrospective, interventional case series. Institutional review board approval was obtained for the study. The chart review of 13 patients who underwent external DCR surgery for isolated lacrimal sac rhinosporidiosis between July 2012 and May 2018 was performed. Demographic details, clinical presentation, preoperative and intraoperative findings, surgical technique used, postoperative management, surgical outcome and duration of follow up were reviewed for each patient. Results: Thirteen patients were included in the study. Nine (69.2%) were male and four (30.8%) were female. The mean age was 22.1 years (range: 8-46 years). Involvement was unilateral in all cases. The commonest presenting complaint was epiphora with discharge seen in 10 cases (76.9%). An intrasac granuloma was grossly identified intraoperatively in 12 out of the 13 patients. Mean follow up was 26.9 months (range: 1.5-68 months). Till the last follow up, all cases were symptom free and did not have any evidence of recurrence of infection. Conclusion: From this series of cases reported by the authors, external DCR with appropriate precautions to prevent recurrence appears to be a suitable alternative to conventional DCT with excellent long-term outcomes without disease recurrence.

Oral versus single intravenous bolus dose antibiotic prophylaxis against postoperative surgical site infection in external dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction - A randomized study.

PURPOSE: To compare the efficacy of a single perioperative bolus dose of intravenous antibiotic versus postoperative oral antibiotic prophylaxis for prevention of surgical site infection (SSI) in external dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (PANDO). METHODS: This was a prospective randomized controlled study with a noninferiority design. Patients undergoing external DCR surgery were randomized into two groups A and B. Patients in group A received a single bolus dose of intravenous cefazolin 1 g at surgery, whereas those in group B received oral cephalexin 500 mg postoperatively twice a day for 5 days. Allocation concealment was ensured by sequentially numbered opaque sealed envelopes (SNOSEs). Both groups were advised identical postoperative local wound care regimens. Any clinical evidence of SSI at 4 weeks of follow-up in either group was the main outcome measure. RESULTS: In all, 338 patients randomized into two groups of 169 patients each participated in this study. At follow-up of 4 weeks, only one patient in group B developed postoperative SSI. None in group A developed postoperative SSI. Other potential risk factors for postoperative SSI were also analyzed by univariate and multivariate analyses but none achieved statistical significance in either group. CONCLUSION: Our results demonstrate that a single bolus dose of perioperative intravenous antibiotic offers adequate prophylaxis against postoperative SSI and compares favorably with the more commonly used oral antibiotic prophylaxis in external DCR for PANDO in our population and our practice scenario.

The Incidence of Lacrimal Drainage Disorders Across a Tertiary Eye Care Network: Customization of an Indigenously Developed Electronic Medical Record System-eyeSmart.

PURPOSE: To assess the incidence of lacrimal drainage disorders across a tertiary eye care network in India. METHODS: A 5-year retrospective review of all the patients who were diagnosed with lacrimal drainage disorders across the tertiary care network of L.V. Prasad Eye Institute was performed from January 2013 to December 2017. All the patient data were retrieved using all the diagnostic terms assigned to the lacrimal drainage disorders in the in-house electronic medical record system eyeSmart. The incidence of each disorder, demographic details, and clinical presentations were captured. RESULTS: A total of 20,102 patients were diagnosed with lacrimal drainage disorders in the 5-year period. The 2 most prevalent disorders were primary acquired nasolacrimal duct obstruction (n = 10,364, 51.56%) followed by congenital nasolacrimal duct obstruction (CNLDO; n = 5394, 26.83%). The most frequently encountered proximal lacrimal disorder was punctal stenosis (n = 603, 3%). More than 2/3rd of the patients presented with epiphora as their presenting complaint (n = 13,907, 69.18%) followed by a discharge (n = 4023, 20.01%). Although two-thirds of the patient with primary acquired nasolacrimal duct obstruction were females (n = 7081, 68.32%), the same was not true for the CNLDO group, where there was a near equal gender distribution (M:F = 1.06:1). Predisposition to laterality was neither noted in primary acquired nasolacrimal duct obstruction nor in CNLDO. The prevalence of complex CNLDO was 16.80% (n = 907), the rest being simple CNLDO. It was easy to capture the incidence of lacrimal disorders with the electronic medical record system; however, the same was not true for the surgical details. The reasons for this were lack of clarity with surgical codes, no separate drop downs for success/failure or complications, and variations in the documentation. CONCLUSIONS: This study depicts the incidence of various lacrimal drainage disorders in a very large cohort of patients. There is a need to modify the International Classification of Diseases (ICD) classification to incorporate all the diagnostic terminologies commonly used so as to capture the real global scenario. The present study helped to further customize the electronic medical record system that caters to the intricacies of lacrimal disorders.

Concurrent Microbial Keratitis and Nasolacrimal Duct Obstruction: Concordance, Etiopathogenesis, and Outcome.

PURPOSE: Nasolacrimal duct obstruction (NLDO) is believed to be a risk factor for microbial keratitis (MK). The primary objective of this study was to look at microbiological concordance between corneal scraping and lacrimal sac flora in patients with concurrent MK and NLDO. The secondary objective was to compare microbiological isolates from MK and NLDO, MK alone, NLDO alone, and healthy subjects. METHODS: A prospective comparative study of 146 subjects with standard microbiological analyses was performed between February 2014 and October 2017. RESULTS: Of the 146 subjects, 35 had concurrent MK and NLDO, 35 had MK, 41 had NLDO, and 35 were healthy subjects. Overall, mean age and sex distribution among groups were similar. In the MK and NLDO group, coagulase-negative staphylococci (CNS) were the most common isolates from the corneal scraping (n = 12/35, 34%) and lacrimal sac (n = 10/35, 29%) with 58% concordance. CNS were also the most common isolates from the NLDO group and healthy subjects, fungus being the most common isolate in the MK group. Anatomical success was achieved in 31 patients (89%) after dacryocystorhinostomy (DCR) in the MK and NLDO group. The difference between the number of patients who had successful DCR surgery but failure of medical therapy for MK (1/31) versus those who failed DCR and medical therapy for MK (3/4) was statistically significant (P = 0.002, Fisher exact test). CONCLUSIONS: CNS are the most common organisms in concurrent MK and NLDO (58% concordance), in patients with NLDO alone, and as commensals in healthy subjects. Persistence of NLDO may be responsible for a poorer outcome of MK in a concurrent setting.

High-Resolution Anterior Segment Optical Coherence Tomography in Intraepithelial Versus Invasive Ocular Surface Squamous Neoplasia.

PURPOSE: To evaluate the imaging characteristics of intraepithelial and invasive ocular surface squamous neoplasia (OSSN) on high-resolution anterior segment optical coherence tomography (ASOCT). METHODS: In this prospective cross-sectional study, 17 consecutive patients (10 intraepithelial and 7 invasive) with histopathologically proven OSSN were included. All patients underwent slit-lamp imaging and time-domain ASOCT at premarked sites. Management included standard complete surgical excision with margin clearance and cryotherapy for all cases. The correlation between imaging characteristics and histopathology sections at the premarked sites was analyzed to determine surrogate markers that may help differentiate intraepithelial from invasive OSSN. In addition, 3 patients with presumed OSSN underwent serial ASOCT for surveillance. RESULTS: All tumors were staged as T3N0M0 except 2 that were staged as T1N0M0 by the eighth edition of the American Joint Committee on Cancer (AJCC). Mean age was comparable between the 2 groups (56 years vs. 54 years for intraepithelial and invasive groups, respectively, P = 0.79). ASOCT characteristics included all cases (100%) showing a hyperreflective thickened epithelium and abrupt transition between normal and abnormal epithelium. Nine of 10 (90%) intraepithelial OSSN showed a clear plane of separation. A hyperreflective basal membrane was seen in 60% of intraepithelial OSSN, and hyporeflective zones were seen in 57% of invasive OSSN. Mean thickness was 924 and 1662 µm in intraepithelial and invasive OSSN, respectively (P = 0.02, Mann-Whitney test). CONCLUSIONS: A visible clear plane of separation and increased thickness on ASOCT may serve as surrogate markers of intraepithelial OSSN and help differentiate it from invasive OSSN.

Endoscope-assisted harvest of autogenous fascia lata in frontalis suspension surgery: A minimally invasive approach revisited.

PURPOSE: To report endoscope-assisted fascia lata harvest (EAFH) as a minimally-invasive technique for correction of severe blepharoptosis. METHODS: This was a retrospective case series between January 2013 and April 2017. Medical records of all consecutive patients who underwent frontalis suspension by EAFH in the study period were reviewed and outcome was analyzed. RESULTS: Fourteen patients (10 males) were included in the study. Mean age of the group was 18.14 + 17.03 years (range 4-65 years) and 11 patients had simple congenital blepharoptosis. Blepharophimosis syndrome was seen in 3 patients. Eleven patients had bilateral blepharoptosis. The mean preoperative and postoperative MRD1 was -1.60 ± 0.87 mm and +2.12 ± 1.37 mm respectively. Mean lengths of the incision and fascial harvest were 2.25 ± 0.43 cm and 13.0 ± 2.35 cm (range 10-17 cm) respectively. The median follow-up of patients was 4.57 + 4.03 months (range 1-15 months). Complications included a wound dehiscence in two patients and these were resutured. The donor sites healed well in all patients leaving a small thigh scar and none needed scar revision. CONCLUSION: EAFH is a promising minimally-invasive technique performed with a small incision and achieved adequate length of fascial harvest.