The role of CT-DCG in hardware - associated secondary acquired lacrimal duct obstruction: SALDO update study - (SUP) - Paper III.

Purpose: To study cases of hardware-associated secondary acquired lacrimal duct obstructions (SALDO) and the role of computed tomography dacryocystography (CT-DCG) scans in its diagnosis and management. Observations: Retrospective, interventional case review of four patients diagnosed as Hardware-associated SALDO, with primary maxillofacial repair performed elsewhere, were analyzed. The mean age was 36.5 years (range: 22-74 years), three of them being males. Left and right lacrimal systems were equally involved. Epiphora, swelling and discharge were the main presenting features. Three lacrimal sacs and nasolacrimal ducts on CT-DCG showed the screws of the orbital fracture plate directly piercing their walls, whereas a single case showed the sac displaced and pierced by the medial side of the orbital floor implant. Two cases underwent dacryocystorhinostomy with intubation, and the remaining two had to undergo dacryocystectomy due to extensive damage. Post-operatively all four cases were doing well at a mean follow-up of 2 months. Conclusions: The present series highlights the role of CT-DCG in delineating spatial relationship of lacrimal drainage system with the surrounding structures, facilitating planning as well as choice of surgery, and anticipating the intraoperative challenges. It also signifies importance of interdisciplinary coordination between oculoplastic and maxillofacial surgeons to avoid iatrogenic trauma to the lacrimal drainage system.

Early Drainage of Suprachoroidal Hemorrhage Combined with Surgical Correction of Hypotony after Trabeculectomy.

Aims and background: Delayed suprachoroidal hemorrhage (DSCH) is a vision-threatening complication of intraocular surgeries with a higher prevalence in postglaucoma filtering surgeries. Through these case series of trabeculectomy complicated with DSCH, we aim to emphasize that correction of hypotony (inciting factor) is fundamental for complete resolution and prevention of recurrence. Case description: All three glaucoma patients underwent trabeculectomy surgery followed by DSCH on postoperative day 1. Drainage of DSCH using a 23 gauge trocar cannula within 48 hours of onset was performed along with exploration for the cause of hypotony. All three patients had satisfactory visual and anatomical outcomes. Conclusion: Early drainage using 23 gauge trocar cannulas gives good results in DSCH. The cause of hypotony must simultaneously be corrected during the drainage of DSCH. Preventive measures against hypotony should be taken while doing glaucoma filtering surgery. Clinical significance: Surgical exploration for the cause of hypotony must simultaneously be performed during drainage of DSCH. Primary preventive measures against hypotony and bleeding during glaucoma filtering surgeries, like the use of releasable sutures, viscoelastic in the anterior chamber, and discontinuation of anticoagulants, can be done. Early drainage using trocar cannulas gives satisfactory results in DSCH postglaucoma surgeries. How to cite this article: Beri N, Verma S, Bukke AN, et al. Early Drainage of Suprachoroidal Hemorrhage Combined with Surgical Correction of Hypotony after Trabeculectomy. J Curr Glaucoma Pract 2024;18(1):23-27.

Delayed infections following polybutylate-coated polyester (Ethibond) suture frontalis suspension surgery for severe blepharoptosis.

PURPOSE: To describe the incidence and management of delayed infections following frontalis sling suspension with polybutylate-coated polyester suture (Ethibond). METHODS: Retrospective, interventional case series of 177 eyes of 150 patients, who underwent frontalis suspension surgery with Ethibond (Johnson and Johnson, USA), at L V Prasad Eye Institute, Hyderabad, India, between January 2016 and February 2022. Patients were assessed for chronic secondary sling infection, defined as infection/suture granuloma occurring beyond 6 weeks post-surgery. All patients received postoperative oral antibiotics. The clinical profile, microbiological evaluation, antibiotic sensitivity patterns, and management outcomes were analyzed. RESULTS: Delayed infection following Ethibond sling suspension was noted in 14 eyes of 13 patients (7.9%). Of these, eight cases (61.5%) were females. The average time interval from surgery to presentation was 7.5 months (range: 2.5 months to 2.5 years). Eleven eyes underwent sling removal. Of the three who received initial antibiotic course, two eventually needed sling removal. Microbiological evaluation was available in seven eyes (50%), with Staphylococcus aureus as the most common organism. Of the six positive cultures, five (83.3%) were resistant to fluoroquinolones (FQs). CONCLUSION: Frontalis suspension with Ethibond has an 8% incidence of delayed infections, with Staphylococcus aureus as the most common organism. The authors recommend early sling removal in all patients with infection and recommend consideration of an alternative material in the event of future revision surgery.

Post-traumatic canalicular fistula: description and review of literature - SALDO update study (SUP) - paper II.

PURPOSE: To discuss the clinical spectrum and management strategies in patients with post-traumatic canalicular fistula (PTCF). METHODS: Retrospective, interventional case series of consecutive patients diagnosed with PTCF over a 6-year study period between June 2016 and June 2022. The demographics, mode of injury, location, and communication of the canalicular fistula were noted. The outcomes of several management modalities including dacryocystorhinostomy, lacrimal gland therapies, and conservative approaches were assessed. RESULTS: Eleven cases with PTCF over the study period were included. The mean age at presentation was 23.5 years (range: 6-71 years), with male: female ratio of 8:3. The median time interval between trauma to presentation at the Dacryology clinic was 3 years (range: 1 week to 12 years). Seven had iatrogenic trauma and four had the canalicular fistula following primary trauma. Management modalities pursued include conservative approach for minimal symptoms, and dacryocystorhinostomy, dacryocystectomy, and lacrimal gland botulinum toxin injection. The mean follow-up period was 30 months (range: 3-months-6 years). CONCLUSION: PTCF is a complex lacrimal condition and the management of the PTCF needs a tailored approach guided by its nature and location and patient symptomatology.

A Novel cause of Massive Hepatosplenomegaly with Fibrosis in two children: Transient Infantile Hypertriglyceridemia.

Background: Transient infantile hypertriglyceridemia (TIH) is a syndrome of hypertriglyceridemia, fatty liver, and deranged liver functions with progression to fibrosis and cirrhosis. It is an autosomal recessive disorder caused by mutations in Glycerol-3-phosphate dehydrogenase 1 gene present on Chromosome 12q12-q13, and has been reported in Israeli Arab families with high consanguinity. TIH is suspected by high serum triglyceride levels and steatosis on liver biopsy; however, diagnosis is confirmed on clinical exome sequencing. Clinical description: We present two cases of TIH belonging to the indigenous Hindu, hilly population of Himachal Pradesh in North India with no history of either consanguinity or family history. Management and outcome: The parents of both the cases were counselled regarding the disease and importance of growth and lipid level monitoring. Conclusion: Though TIH is an extremely rare entity, awareness about it is required as it is a contributor to non-alcoholic fatty liver disease (NAFLD) in children. Any child presenting with hepatomegaly and elevated fasting triglyceride levels should be further investigated for TIH.

Budd Chiari Syndrome with Portal Vein Thrombosis Managed Successfully with Direct Intrahepatic Portosystemic Shunt: A Case Report and Review of the Literature.

Budd -Chiari syndrome (BCS) is a hepatic vascular disorder which affects hepatic veins or inferior vena cava. Portal vein thrombosis (PVT) occurs in around 15%-25% of patients with BCS. The presence of PVT in patients with BCS makes it more difficult to intervene radiologically. We present a case of a BCS-related chronic liver disease that presented with a history of variceal upper gastrointestinal bleeding and worsening ascites. The patient had thrombosed hepatic veins (HV) and partial right portal vein thrombosis. He was started on anticoagulation, and treatment for portal hypertension was initiated. Given the inaccessibility of all the HVs for trans-jugular intrahepatic portosystemic shunts (TIPS), the patient underwent direct intrahepatic portosystemic shunts (DIPS). Next-generation sequencing identified the factor V Leiden mutation. Following DIPS, the patient's ascites disappeared, and liver function tests improved. On a nine-month follow-up, the patient was symptom-free with a patent DIPS. DIPS has been widely used in patients with BCS with thrombosed hepatic veins, but there are only a few case reports on the feasibility of DIPS in BCS patients with PVT. This is one of the very few case reports where a patient with BCS-PVT was successfully managed with DIPS.

Corneal squamous neoplasia: masquerades and management outcomes at a rural eyecare centre.

The authors describe two cases of corneal ocular surface squamous neoplasia (OSSN), presenting at our rural eyecare centre, which were initially misdiagnosed as viral epithelial keratitis and corneal pannus with focal limbal stem cell deficiency. Both the cases were refractory to initial treatment and corneal OSSN was suspected. Anterior segment-optical coherence tomography (AS-OCT) revealed a thickened, hyper-reflective epithelium with abrupt transition and an underlying cleavage plane, features typical of OSSN. Topical 1% 5-fluorouracil (5-FU) therapy was initiated and in two cycles (first case) to three cycles (second case), complete resolution was noted both clinically and on AS-OCT, with no significant side effects. Both patients are currently free of tumour at the 2-month follow-up period. The authors report the rare, atypical presentations of corneal OSSN, discuss the masquerades and highlight the role of primary topical 5-FU in managing corneal OSSN in limited resource settings.

Utility of dual energy CT angiography in the evaluation of acute non-variceal gastrointestinal hemorrhage: comparison with digital subtraction angiography.

PURPOSE: To evaluate the utility of dual energy CT angiography (DECTA) in acute non-variceal gastrointestinal hemorrhage (ANVGIH) compared to digital subtraction angiography (DSA) as gold standard. MATERIALS AND METHODS: 111 Patients (mean age: 39.2 years; 94 males) of ANVGIH who underwent both DECTA and DSA between January 2016 and September 2021 were included. Virtual monochromatic (VM) images at 10 keV increments from 40 to 70 keV and blended (120kVp equivalent) images of arterial phase of DECTA were evaluated independently by two readers blinded to DSA information. Quantitative analysis included measurement of attenuation in the major arteries (abdominal aorta, celiac artery, superior mesenteric artery), suspected vascular lesion, and lesion feeding artery to calculate contrast-to-noise ratios (CNRs) and signal-to-noise ratios (SNRs). Qualitative analysis assessed the image quality of each data set using a 3-point Likert scale. Findings on DSA were evaluated by a third reader and both DECTA and DSA were compared. RESULTS: On linear blended images, vascular lesion was identified by reader 1 in 88 (79.3%) and by reader 2 in 87 (78.4%) patients and DSA showed lesion in 92 (82.9%) patients. The sensitivity and specificity of blended images and VM images of DECTA for lesion detection were not significantly different from each other. The CNR and SNR of arteries, vascular lesion and feeding artery were significantly higher at 70 keV (p < 0.005) compared to blended and other VM images. Although subjective scores for image quality were higher for 60 keV images by both readers, the difference was not statistically significant (p = 0.3). The interobserver agreement was mostly good. CONCLUSION: In the assessment of ANVGIH, the 60 keV and 70 keV VM images improved the image quality and contrast, respectively, but there was no increase in diagnostic accuracy of VM image datasets compared to linearly blended images. Hence, the diagnostic utility of DECTA in ANVGIH is still uncertain.

Outcome of transcanalicular laser dacryocystorhinostomy with endonasal augmentation in acute versus post-acute dacryocystitis.

OBJECTIVE: To study the outcomes of transcanalicular laser dacryocystorhinostomy (TCL-DCR) with endonasal augmentation in acute versus post-acute dacryocystitis and compare it with external DCR in post-acute settings. METHODS: A prospective, randomised study was conducted in 90 adult cases of Acute dacryocystitis. All the patients were started on systemic antibiotics and a 4 mm × 4 mm osteotomy was created using TCL-DCR. The osteotomy was enlarged to 8 mm × 8 mm by endonasal augmentation at the same sitting in group 1, after 10 days in group 2 and after 10 days with external DCR in group 3. The cases were assessed for symptomatic relief and complications. Success was defined as functional and anatomical patency at 36 months. RESULTS: The mean age was 45.33 ± 15.06 years and the male: female ratio was 1:2. The presenting complaints were painful swelling (100%), epiphora or discharge (88.8%), fistula (33%) and fever (6%). The average number of acute episodes was 2.96. The intra-group pain reduction from day 1 to day 4, was significant in all three groups (p = 0.000). Intra-operative (p = 0.015, χ2 = 8.37) and post-operative complications (p = 0.002, χ2 = 0.002) were higher in group. Anatomical success was achieved in all the three groups, however, the functional success in Group 3, Group 2 and Group 1 was 100%, 86.7% and 66.7% respectively (p = 0.002, χ2 = 12.86). CONCLUSIONS: The creation of osteotomy using TCL-DCR provides early relief in symptoms. Single-stage surgery in inflamed tissues is associated with higher complication rates. External DCR in post-acute settings gives the best outcomes with minimal complications, endoscopic augmentation requires a close follow-up.

Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study.

PURPOSE: Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL. METHODS: Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors. RESULTS: A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL. CONCLUSION: Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.

Emergent Management of Gastric Variceal Bleed in the Setting of Acute Pancreatitis-Related Sinistral Hypertension With Partial Splenic Embolization: A Series of Two Cases.

Sinistral portal hypertension in the setting of acute pancreatitis is a known complication owing to splenic vein thrombosis. It can lead to upper gastrointestinal bleeding due to the development of fundal gastric varices due to the shunting of blood via short gastric veins. However, in the setting of acute pancreatitis, surgical procedures can have high post-operative morbidity. Emergent management of cases with absent gastro-renal shunt can be done by partial splenic arterial embolization, as it is minimally invasive and can provide similar results. Herein, we report a case series of two cases of acute pancreatitis complicated with splenic vein thrombosis and gastric varices, which were managed by partial splenic artery embolization.

Giant jelly bump deposits on therapeutic contact lens: an unusual finding following ptosis surgery.

The authors report two cases of unusually large deposits on their therapeutic bandage contact lens (BCL) following uneventful surgery for congenital ptosis. The first case presented at 6 weeks with decreased vision, large jelly-bump deposits over the contact lens and sterile corneal infiltrates. The infiltrates rapidly resolved with restoration of vision following contact lens removal and topical antibiotics. The second case presented 2 weeks after surgery with visual loss and similar deposits but with no corneal involvement. Following replacement of BCL and topical lubricants, her vision improved to 20/20. Studies on the role of BCL in ptosis surgery are scarce with literature supporting its use for ocular surface protection and minimising postoperative discomfort. The authors hypothesise impaired blink mechanism as the accelerating factor for this unusual occurrence in the early postoperative period and recommend frequent replacement of the contact lens and a closer follow-up in all these cases.

Intraosseous solitary myofibroma of the orbit in an adolescent woman.

A 16-year-old woman presented with a painless, progressive, hard swelling in the left inferolateral orbital wall for the past 1 year. There was no diminution of vision or limitation of ocular motility. Imaging revealed an intraosseous, well-defined, expansile, soft tissue lesion in the inferolateral wall of the left orbit. A left anterior orbitotomy with complete surgical excision was performed. Histopathological evaluation of the specimen revealed fascicular pattern of spindle cells with a rich network of slit-like, branching blood vessels. Tumour cells exhibited smooth muscle actin and vimentin positivity but were negative for CD-34 and STAT-6. In absence of any systemic manifestation, a diagnosis of intraosseous solitary orbital myofibroma was made. The case highlights the importance of integrating clinical, radiological and histopathological features in overcoming the diagnostic challenge of differentiating myofibroma from other mesenchymal neoplasms. It also brings forth the importance of complete resection and curettage to prevent recurrence.

Massive Retinal Gliosis in Microphthalmic Globe With Cyst Masquerading as a Neoplasm.

We report a rare case of a bilaterally blind, 33-year-old male, who presented with rapidly progressive, painless swelling in the right orbit for two months, in the absence of ocular trauma. Suspecting an intraocular neoplasm, a contrast-enhanced MRI (CE-MRI) orbit was performed, which was suggestive of a right-sided superomedial eccentric soft-tissue lesion with bilateral rudimentary globes associated with cyst, hypoplastic optic nerves, and focal areas of calcification. Diffusion-weighted MRI demonstrated diffusion restriction and yielded an indeterminate value of apparent diffusion coefficient (ADC). A right enucleation with excision of the cyst was performed. Histopathological examination confirmed the diagnosis of a right-sided massive retinal gliosis (MRG) with bilateral microphthalmia with cyst. This case demonstrates the role of a detailed histopathological analysis along with immunohistochemistry (IHC) in differentiating MRG from a neoplasm.

The eyes see what the mind seeks: a systematic review of abdominal imaging findings in patients with COVID-19.

OBJECTIVES: With the increasing recognition of gastrointestinal (GI) manifestation of coronavirus disease-19 (COVID-19), various abdominal imaging findings are increasingly being noted. We scoped the existing literature on the abdominal imaging findings in COVID-19. METHODS: A systematic literature search was performed on PubMed, Embase, Google scholar and World Health Organization COVID-19 database. RESULTS: 35 studies were included in the final descriptive synthesis. Among the studies reporting positive abdominal imaging findings in patients with COVID-19, majority described imaging abnormalities of the GI tract (16 studies), of which bowel wall thickening was most frequently reported. Other findings noted were abdominal imaging manifestations of bowel ischemia with thrombosis of the splanchnic vasculature, and imaging features suggestive of pancreatitis. Imaging findings suggestive of solid organ infarction were reported in nine studies. An association between imaging evidence of hepatic steatosis and COVID-19 was noted in three studies. Incidental lung base findings on abdominal imaging were noted in 18 studies, where patients presented with predominant GI symptoms. The most common finding was bilateral ground glass opacities (90.7%) with predominant multilobar (91.1%) and peripheral (64.4%) distribution. CONCLUSION: This systematic review provides insight into the abdominal imaging findings in patients with COVID-19. Knowledge of these imaging manifestations will not only help in further research but also will aid in curtailing transmission of the SARS-CoV-2. Further prospective studies are needed to gain better insight into the pathophysiology of these imaging manifestations. ADVANCES IN KNOWLEDGE: This review highlights the abdominal imaging findings in patients with COVID-19, to gain insight into the disease pathophysiology and gear the abdominal radiologist through the pandemic.

Clinical Presentation and Management Strategies in Intraorbital Foreign Bodies.

The authors present a retrospective, observational case study of seven patients, who presented with retained Intra-Orbital Foreign Bodies (IOrbFBs) following penetrating orbital injury at a tertiary eye hospital over a period of one year. Cases were reviewed for epidemiological features, mechanism of injury, nature of foreign body, clinical features, imaging modality, associated complications, management outcomes, and the final prognosis. The mean age of presentation was 27.43 years. Amongst the seven patients, two were children (aged <10 years). The male : female ratio was 4 : 3. Of the seven retained IOrbFBs, two were plastic, two wooden, and three metallic in nature (one gunshot injury, one ball projectile (commonly referred to as BB) injury, and one with knife). Two out of seven had no light perception at presentation. The periocular location of the foreign bodies was inferior in 4 cases and medial in 3 cases. Computed Tomography scan confirmed the diagnosis in five cases and Magnetic Resonance Imaging (MRI) was diagnostic in one. Surgical intervention was done in five cases, and two cases were managed conservatively. The authors conclude that favourable outcome can be achieved even without surgical removal in cases of inert metallic/inorganic IOrbFBs. The properties of plastic FBs can frequently render them invisible on imaging, or they may mimic chronic inflammatory conditions like tuberculosis. Long-standing wooden IOrbFBs evade identification radiologically due to prolonged hydration. The ultimate choice of intervention must be individualised, weighing the risks of retention against the risk of iatrogenic damage.

Hemorrhage and Rupture of an Unusual Benign Liver Lesion in Pregnancy: A Case Report.

Liver rupture in pregnancy is an acute condition with significant risk to the mother and fetus. It is known to occur with tumors such as hepatic adenoma, infective causes such as abscess, granulomatous diseases, and parasitic infections, and rarely spontaneously. Most of these conditions have overlapping clinicoradiological findings, almost always requiring histopathological confirmation. We report a case of a ruptured hepatic lesion, with an unusual diagnosis of Bartonella henselae infection causing cat-scratch disease, in a 24-year-old pregnant lady.