Outcome of extraocular retinoblastoma in a resource limited center from low middle income country.

Retinoblastoma (RB) is the most common ocular malignancy in children, and is managed by multimodal treatment. There is a paucity of data regarding the clinical profile and outcome of children with extraocular retinoblastoma from Low Middle Income Countries (LMIC) including India. Case records of children with newly diagnosed extraocular RB from January 2013 to August 2016 treated at our unit were analysed for clinical profile, treatment, and outcome. Over the 44 month study period, 91 children were diagnosed with RB, out of which 41 had extraocular disease. While 26 children had extraocular spread limited to orbit (IRSS stage III), 15 had a distant spread to brain (IRSS stage IV). Median lag period for diagnosis was eight months. Treatment abandonment rates were 38.5% and 46.6% in International Retinoblastoma Staging System (IRSS) stage III and IV respectively. With a median follow up of 31.5 months, the projected overall survival for IRSS III at one, two, and three years was 87.5%, 55.6%, and 39.7%. All patients with stage IV disease died after a median follow up duration of three months. High treatment abandonment rates and limited availability of resources lead to suboptimal survival in children with extraocular RB from LMIC. Initiatives aimed at improving early diagnosis, so that the disease is detected in the intraocular stage, are critical to improve the survival in children with RB.

A palliative approach for rehabilitation of a pediatric patient with retinoblastoma.

Retinoblastoma is a highly malignant neoplasm. Most of the cases are usually far advanced at the time of detection, requiring enucleation to salvage the child's life. However, the cosmetic rehabilitation of these patients should always be an integral part of their treatment, which helps in their re-integration in the society. This paper presents a case of 5-year-old patient who had undergone enucleation of her left eye due to retinoblastoma. A multidisciplinary approach, including ophthalmologist, psychotherapist, and a prosthodontist, was adopted to meet her physical, psychological, functional, emotional, social, and cosmetic demands. The patient was rehabilitated cosmetically with precisely fabricated ocular prosthesis. An ocular prosthesis is a highly positive and non-invasive approach to improve the cosmetic appearance and psychological well-being of patient.

Functional Transnasal Endoscopic Conjunctivorhinostomy.

The various surgical options for lacrimal tract reconstruction include canaliculodacryocystorhinostomy; fundal transposition; Conjunctivodacrocystorhinostomy with Jones tube; and in extreme cases conjunctivo-rhinostomy (CR) for total lacrimal bypass. The first three require partial lacrimal tract presence/ integrity while CR is indicated when the canaliculi and/or sac are nonfunctional. This report describes a novel technique of minimally invasive CR through a predominantly endoscopic endonasal approach and further discusses its advantages over other established techniques.

Comparison between two intravitreal injection techniques with respect to fluid reflux, intraocular pressure, and therapeutic effect.

CONTEXT: Effect of fluid reflux on intraocular pressure (IOP) and therapeutic benefits. AIMS: The aim of this study is to compare two intravitreal injection techniques in terms of fluid reflux, short-term IOP changes, and therapeutic effect. SETTINGS AND DESIGN: A prospective, double-blinded, randomized interventional study. SUBJECTS AND METHODS: Sixty eyes were randomly allocated to two groups (direct intravitreal injection technique and oblique intravitreal injection technique). IOP was measured before and immediately after the injection of 0.1 ml comprising of bevacizumab (1.25 mg/0.05 ml) and dexamethasone (0.2 mg/0.05 ml) and then at 30 min after the injection. Occurrence and amount of vitreous reflux were recorded. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were assessed preinjection and 6 weeks postinjection. RESULTS: IOP (mmHg ± standard deviation) increased significantly immediately after injection to 24.30 ± 3.02 (direct intravitreal injection) and 31.50 ± 3.49 (oblique intravitreal injection). These pressure rise differed significantly between both groups (mean difference: 7.2, P < 0.0001). Thirty minutes after injection, there was no significant difference in IOP increase between the groups. Occurrence and amount of fluid reflux were significantly higher with direct intravitreal injection. There was no significant difference in BCVA and CMT outcome between both groups. CONCLUSIONS: Direct intravitreal injection technique has lower rise in IOP and higher incidence of fluid reflux than the oblique intravitreal technique. Fluid reflux does not cause a therapeutic compromise in terms of BCVA or CMT changes, so the reflux fluid must be the vitreous not the drug. Thus, direct injection technique seems to be the preferred technique.

A case of isolated bilateral cataract following high-voltage electrical injury.

High voltage electric burns can cause various ocular injuries and may manifest in the form of conjunctival hyperemia, corneal opacities, uveitis, miosis, spasm of accommodation, cataract, retinal edema, papilledema, choroidal rupture, chorio-retinal necrosis/atrophy, retinal detachment and optic atrophy. The involvement of crystalline lens exclusively with sparing of other ocular structures is rare. We report a case of 16 year old male with bilateral total cataract after electrical injury by over-head high tension electric transmission cable accidentally falling on patient's head 6 months back. B scan showed no abnormality in both the eyes. The intra ocular pressure in both the eyes was within normal limits. Patient underwent lens aspiration with posterior chamber intraocular lens (PCIOL) implantation in both the eyes, under peribulbar anaesthesia (with an interval of 1 week between both the operations). Intra-operative and post-operative period were uneventful. Post operative BCVA was 6/6 in both eyes and fundus examination was within normal limits. Outcomes after surgery are very good if not associated with other ocular lesion like optic atrophy, chorio-retinal lesion, uveitis etc. This observation should encourage the ophthalmologist to undertake surgery for electric cataract, where necessary.

Manual small incision cataract surgery under topical anesthesia with intracameral lignocaine: study on pain evaluation and surgical outcome.

UNLABELLED: The authors here describe manual small incision cataract surgery (MSICS) by using topical anesthesia with intracameral 0.5% lignocaine, which eliminates the hazards of local anesthesia, cuts down cost and time taken for the administration of local anesthesia. AIMS: To evaluate the patients' and surgeons' experience in MSICS using topical anesthesia with intracameral lignocaine in terms of pain, surgical complications, and outcome. SETTINGS AND DESIGN: Prospective interventional case series. MATERIALS AND METHODS: Ninety-six patients of senile cataract were operated by MSICS under topical anesthesia with intracameral lignocaine using "fish hook technique." The patients and the single operating surgeon were given a questionnaire to evaluate their experience in terms of pain, surgical experience, and complications. STATISTICAL ANALYSIS USED: Statistical analysis software "Analyseit." RESULTS: There were 96 patients enrolled in the study. The mean pain score was 0.7 (SD +/- 0.97, range 0-5, median 0.0, and mode 0.0). Fifty-one patients (53%) had pain score of zero, that is, no pain. Ninety-one patients (approximately 95%) had a score of less than 3, that is, mild pain to none. All the surgeries were complication-free except one and the surgeon's experience was favorable in terms of patient's cooperation, anterior chamber stability, difficulty, and complications. The ocular movements were not affected, and hence, the eye patch could be removed immediately following the surgery. CONCLUSIONS: MSICS can be performed under topical anesthesia with intracameral lignocaine, which makes the surgery patient friendly, without compromising the outcome.

Cortical blindness due to cerebral infarct in advanced pancreatic cancer.

A 65-year-old man, a known case of advanced pancreatic cancer on cisplatin and gemcitabine-based chemotherapy, presented with sudden bilateral painless loss of vision with altered sensorium. Clinical examination showed a normal pupillary light reaction, normal anterior segment and normal fundus. MRI brain showed bilateral parieto-occipital infarct. This report highlights the incidence of cortical blindness due to thromboembolism at the cerebral level in pancreatic cancer. Cerebral ischaemic events occur at an advanced stage of pancreatic cancer already diagnosed at stroke onset and portend a poor prognosis. Anticoagulation therapy, especially low molecular weight heparin, remains the best strategy to prevent recurrences.

Trojan horse anaesthesia: A novel method of anaesthesia for pars plana vitrectomy.

CONTEXT: Topical anesthesia has been used for pars plana vitrectomy (PPV) with limited patient comfort. Thus, augmenting topical anesthesia with intracameral anesthesia (Trojan horse anesthesia) will provide pain-free experience during PPV. AIMS: This study was undertaken to evaluate the patient comfort and surgical safety using 2% lignocaine jelly augmented with intracameral 1.0% lignocaine solution for anesthetizing the eyes undergoing PPV. SETTINGS AND DESIGN: This was a prospective interventional case series at tertiary care hospital. SUBJECTS AND METHODS: Patients planned for PPV for indications other than retinal detachment were included in the study. The pain perception of the participants undergoing PPV under Trojan horse anesthesia was evaluated using visual analog scale (VAS). STATISTICAL ANALYSIS USED: Data analysis was done using descriptive statistics and nonparametric analysis with level of significance at P < 0.05. RESULTS: There were 114 eyes of 114 patients in the study out of which 68.4% (n = 78) were males. The mean age was 42.31 years (range 14-80 years, standard deviation [SD] 18.7). The mean surgical time was 34.0 min (range 13-80 min, SD 14.2). The pain perception on VAS scale averaged 3.0 (range 0-8, SD 1.59, median 3.0). Pain scores were not affected by the age (Pearson correlation = 0.098, P = 0.3), gender (P = 0.44), or the educational status of the participant (P = 0.28). The pain scores were not affected by the indications of surgery (P = 0.58) or the use of silicone oil (P = 0.07). CONCLUSIONS: Trojan horse anesthesia provides adequate analgesia for comfortable and safe 23-gauge PPV with high patient acceptability.

Linezolid-induced optic neuropathy in XDR pulmonary TB: A case series.

Optic neuropathy has been reported as a side effect of long-term use of linezolid. This is particularly seen in cases of extensively drug resistant tuberculosis (XDR-TB) where treatment with linezolid may continue for about 24-30 months. We, hereby, report two cases of XDR-TB treated patients with a regimen containing linezolid who developed progressive painless loss of vision during the course of treatment. In both the cases, the visual symptoms resolved completely on withdrawing linezolid. Early recognition of this rare side effect and timely withdrawal may salvage the eyesight of such patients.

Trabeculectomy Under Augmented Topical Anesthesia: Study on Pain Evaluation and Surgical Feasibility.

PURPOSE: Performing trabeculectomy under topical anesthesia using lignocaine jelly with intracameral anesthesia may offer painless surgery with immediate visual gain and avoid the increase in intraocular pressure associated with locally injected anesthesia. In this context, we evaluated topical anesthesia using 2% lignocaine jelly with intracameral 1.0% lignocaine for trabeculectomy in terms of pain during surgery and the surgeon's experience. DESIGN: This was a tertiary care center-based interventional case series. METHODS: Patients scheduled for trabeculectomy as the first surgery for medically controlled glaucoma underwent standard ab externo trabeculectomy under topical anesthesia. Pain evaluation was done using a visual analog scale with the modified Wong-Baker FACES Pain Rating Scale, within 1 hour after surgery. RESULTS: Fifteen eyes of 14 patients were included in the study with a mean (SD, range) age of 61.3 (17.54, 40-90, distributed normally) years. Patients' pain score analysis showed a mean (SD, range) visual analog scale score of 0.73 (0.59, 0-2) on a scale of 0 to 10. The mean (SD, range) surgeon's satisfaction score was 3.2 (0.4, 3-4) on a scale of 3 to 9. The intraocular pressure of all patients was well controlled at 2 weeks [mean (SD, range), 9.2 (2.9, 4-16)] and at 4 weeks [mean (SD, range), 13.2 (1.2, 11-15)] postoperatively without any topical or systemic antiglaucoma medications. CONCLUSIONS: Trabeculectomy can be done under augmented topical anesthesia, which provides adequate analgesia for acceptable patient and surgeon comfort with favorable outcomes. Anesthesia provided by topical application of lignocaine 2% jelly and intracameral 1.0% lignocaine is sufficient for safe trabeculectomy surgery with acceptable discomfort to the patient.

Transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens in aphakic nonvitrectomized eyes.

PURPOSE: To evaluate the outcome of transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens (PCIOL) in aphakia in nonvitrectomized eyes. MATERIALS AND METHODS: Patients with postcataract surgery aphakia, trauma with posterior capsule injury, subluxated crystalline lens, and per operative complications where sulcus implantation was not possible were included over a 1-year period. Scleral fixation of acrylic hydrophilic PCIOL was performed according to the described technique, and the patients were evaluated on the day 1, 3, 14, and at 3 and 12 months postoperatively for IOL centration, pseudophakodonesis, change in best-corrected visual acuity (BCVA), and any other complications. RESULTS: Out of twenty-nine eyes of 24 patients, who completed the study, 25 (86.2%) eyes had improved, 2 (6.9%) eyes showed no change, and 2 (6.9%) eyes had worsening of BCVA. Three (10.3%) eyes developed postoperative complications. A significant improvement in mean BCVA (P < 0.0001) was observed after the procedure. Mean duration of follow-up was 26.2 months (range 22-35 months). CONCLUSION: The use of closed loop haptic acrylic IOL for scleral fixation appears to be safe and effective alternative to conventional scleral fixated polymethyl methacrylate intraocular lenses.

Evaluating a new surgical dosage calculation method for esotropia.

PURPOSE: To evaluate a simplified method for correction of ocular deviation in patients of infantile and acquired basic esotropia. MATERIALS AND METHODS: Thirty-six consecutive patients of infantile and acquired basic esotropia were selected for this study. Patients underwent unilateral recession-resection surgery as per the new norm gram. Patients underwent 3.5-7 mm recession of medial rectus (MR) in one eye depending on the pre-operative deviation and patient's age. Together they also underwent 6 or 7 mm resection of the lateral rectus (LR) in the same eye depending on patient's age (6 mm for 3 years and below and 7 mm for older age). In patients 3 years and below, a correction of 6, 7, or 8 PD/mm of recession of MR was expected when the pre-operative deviation was lesser than 30 PD, between 30 and 60 PD, or above 60 PD, respectively. Similarly, these values were 5, 6, and 7 PD/mm of MR recession in patients above 3 years. A ratio between achieved and expected correction was calculated and the calculation was deemed successful for a patient if this ratio fell between 0.9 and 1.1. METHODS: Thirty-six consecutive patients of infantile and acquired basic esotropia were selected for this study. Patients underwent unilateral recession-resection surgery as per the new norm gram. Patients underwent 3.5-7 mm recession of medial rectus (MR) in one eye depending on the pre-operative deviation and patient's age. Together they also underwent 6 or 7 mm resection of the lateral rectus (LR) in the same eye depending on patient's age (6 mm for 3 years and below and 7 mm for older age). In patients 3 years and below, a correction of 6, 7, or 8 PD/mm of recession of MR was expected when the pre-operative deviation was lesser than 30 PD, between 30 and 60 PD, or above 60 PD, respectively. Similarly, these values were 5, 6, and 7 PD/mm of MR recession in patients above 3 years. A ratio between achieved and expected correction was calculated and the calculation was deemed successful for a patient if this ratio fell between 0.9 and 1.1. RESULTS: The calculation procedure was successful in 33 out of 36 patients (91%). The two-tailed probability on paired Wilcoxon test was 0.187. CONCLUSIONS: This simplified method of surgical dosage calculation using MR recession as basis is predictable in patients of infantile and basic Esotropia. It may serve as a useful tool for minimizing variability of surgical results.

Cataract surgery under topical anesthesia: Gender-based study of pain experience.

BACKGROUND: Pain perception, expression, tolerance, and the healthcare provider's evaluation and management of pain are affected by the gender of the patient. To the best of our knowledge, there is lack of gender-based evaluation of pain during cataract surgery under topical anesthesia. AIMS: This study has been initiated to evaluate and determine pain experience during cataract surgery under topical anesthesia and to study the gender-based differences of the same. SETTINGS AND DESIGN: Hospital-based study involving cataract surgery under topical anesthesia using standard cataract surgery. It was an interventional comparative case series. MATERIALS AND METHODS: One hundred and sixty patients were included in four groups, according to the gender and choice of surgery. Patients underwent either phacoemulsification with foldable intra ocular lens (IOL) or manual small incision cataract surgery with rigid IOL under topical anesthesia. Patients ranked their pain experience on VAS scale after the surgery and the surgeon recorded the ease/difficulty accordingly using a questionnaire. STATISTICAL ANALYSIS USED: MedCalc version 10.2.0.0 (www.medcalc.be) for windows was used to analyze the results. Analysis of variance (ANOVA) test and Kruskal-Walis test were used to analyze the data. RESULTS: The overall visual analog scale (VAS) score was 0.8 (SD 1.3 range 0-8), with no statistical difference among the groups (P=0.5). The average surgeon's score was 3.3 (SD 0.71 range 3-7), with no statistical difference between the groups (P=0.37).There were no sight threatening complications during the surgery in any group. CONCLUSIONS: The outcome of the study demonstrates that the patients undergoing cataract surgery under topical anesthesia perceive comparable pain and discomfort irrespective of their gender.