Assessment of risk of obstructive sleep apnea with thyroid eye disease and its activity.

PURPOSE: To evaluate the association between obstructive sleep apnea (OSA) and thyroid eye disease (TED) and its effect on disease activity. METHODS: A prospective case-control study was conducted from January 2020 to March 2022. All TED patients (group A) were clinically evaluated. The activity of thyroid eye disease was calculated based on the clinical activity score (CAS), and grading of severity was done according to the EUGOGO classification. All TED patients (group A) were screened for OSA using the Snoring Tired Observed Pressure (STOP)-Bang survey. Age- and gender-matched control group patients (group B) without TED were screened for OSA. RESULTS: One hundred TED patients and 138 control patients without TED were included in the respective groups. Sixty-two (62%) patients in group A and 48 (34.78%) patients in group B were having high risk of OSA, and this difference was statistically significant (P = 0.001). Further, in group A patients, on univariate analysis, TED activity was significantly associated with a high risk of OSA (P = 0.009). On multivariate logistic regression analysis, OSA also showed significant association with TED activity (odds ratio [OR]: 4.14, 95% confidence interval [CI]: 1.11-18.85 at 10% level; P = 0.05). CONCLUSION: Our study showed that OSA is significantly associated with TED disease and its activity. However, no significant association was found between OSA and severity of the disease.

Treatment outcomes of oral propranolol in the treatment of periocular infantile capillary hemangioma and factors predictive of recurrence and incomplete resolution: A multi-centric study.

AIM: This study aims to evaluate the treatment outcomes of periocular capillary hemangioma with oral propranolol (OP) and list the factors predictive of recurrence and incomplete resolution after treatment. METHODOLOGY: Data were collected by retrospective review of medical files of patients with infantile hemangioma (IH) treated with OP during January 2014-December 2019 from two tertiary eye institutes from India. Patients presenting with symptoms of IH with/without any history of prior treatment were included. All patients were started on OP with the dose of 2-2.5 mg/Kg body weight and continued till complete resolution or till the lesion reached a plateau response. Details about the ophthalmic examination at each visit and availability of imaging findings were noted down from the records. Primary outcome: Study the treatment outcome of patients treated with OP and discussed our observations regarding factors that may predict nonresponse, poor response, or recurrence. Secondary outcome: complications/side effects of therapy. Response to treatment was judged as fair, good, and excellent depending on resolution <50%, >50%, and complete resolution, respectively. Univariate analysis of factors related to treatment response was judged as fair, good, and excellent depending on resolution <50%, >50%, outcome and recurrence was studied using Mann-Whitney U test and Fisher's exact test. RESULTS: A total of 28 patients were included in the study, out of which 17 were female and 11 were male. The mean age of onset of the lesion was 1.08 (± 1.484) months, 11 being congenital in origin. The mean age at presentation was 4.15 (± 2.92) months. 46.43% (n = 13) of patients showed complete resolution, while 25% (n = 7) showed more than 50% reduction in lesion size. Fair response was noted in 28.57% (n = 8). The mean duration of follow-up after stopping OP was 17.7 (± 20.774) months. The recurrence rate noted was 14.28%. The factors which were associated with incomplete resolution were age at presentation >3 months, later age of appearance of the lesion, superficial lesions with no orbital involvement. Male gender and congenital lesions responded best to OP therapy. Minor complications were noted with a rate of 25% (n = 7). Younger age at presentation was more commonly associated with complications. CONCLUSION: OP is a safe and effective treatment for capillary hemangioma except for a smaller subset of patients who show suboptimal response to this drug. However, specific factors responsible for suboptimal response or recurrence after OP therapy remain elusive. Although not statistically significant, there was an increasing trend toward higher age at presentation, low birth weight, and superficial lesions with a poorer response. Furthermore, these factors along with the male gender were commonly associated with recurrence in our series. Larger prospective studies focused on evaluating clinical factors responsible for incomplete resolution and recurrence will help in prognosticating and suggesting alternative treatment regimes.

Spontaneous posterior dislocation of the cataractous lens in a patient with Parkinson-plus syndrome.

PURPOSE: To report a case of unilateral posterior dislocation of the cataractous lens and subluxation of the lens in the fellow eye of a patient with Parkinson-plus syndrome. OBSERVATIONS: A 67-year-old-man who was a known case of Parkinson-plus syndrome on long-term dopamine agonists and anti-psychotic medications demonstrated apraxia of lid opening associated with moderate-to-severe blepharospasm. He had unilateral posterior dislocation of the cataractous lens and subluxation of the lens in the fellow eye with no prior history of trauma or other known ocular risk factors. CONCLUSION AND IMPORTANCE: This case may represent an unusual example of spontaneous lens dislocation secondary to apraxia of lid opening and concurrent blepharospasm, which is associated with Parkinson-plus syndrome.

Clinical profile of thyroid eye disease and factors predictive of disease severity.

Purpose: To describe the clinical features of thyroid eye disease (TED) in patients presenting at a tertiary eye care centre in North India and to identify factors predictive of severe disease. Methods: This observational cross-sectional study involved clinical evaluation of all patients with TED who presented at the oculoplastic clinic based on the ITEDS VISA proforma. Risk factors for the severe disease were assessed using univariate and multivariate logistic regression. Results: A total of 106 patients (50 males, 56 females; mean age 41.30 ± 14.76 years) were identified during the study period, 46.23% hyperthyroid, 33.96% hypothyroid and 19.81% euthyroid. The proportion of the patients with hypothyroid was higher as compared with prior studies and most patients with hypothyroid had the mild disease (63.89%). Orbitopathy symptoms were the presenting feature leading to the diagnosis of systemic thyroid abnormality in 25% of the patients with hypothyroid and 59.18% of the patients with hyperthyroid, respectively (P < 0.05). Eyelid and orbitopathy signs were more common in the patients with hyperthyroid (51.2% and 87.7%) as compared with hypothyroid where the commonest presenting symptoms were related to dry eye (50.1%). Active disease was seen in 22.6% of the patients. Mild, moderate to severe and sight-threatening disease was seen in 54.7%, 37.7% and 7.5%, respectively. On multivariate analyses, hyperthyroid status and activity was associated with severe disease. Smoking was not associated with activity or severity. Conclusion: There is no significant difference in the gender profile of the patients with TED in this cohort. The patients with hypothyroid have a milder disease compared to the patients with hyperthyroid, and dry eye symptoms are the commonest presenting symptoms in hypothyroid subjects. Hyperthyroidism and activity were associated with severe and sight-threatening disease.

Nocardia endophthalmitis in a child: Distinct clinical and imaging features on orbital CT scan.

Nocardia is a rare cause of endophthalmitis in immunocompetent individuals with poor visual outcomes. We, herein report a 15 month otherwise healthy child, who presented with hyphema, vitreous hemorrhage and secondary glaucoma following a vague history of trauma in the left eye 2 months before presentation. He presented a week later with features of panophthalmitis which were confirmed on B-scan and orbital CT scan. CT scan with contrast revealed the presence of multiple ring enhancing abscesses in the vitreous cavity and also in the intraconal space. Evisceration was done and smear and cultures revealed Nocardia. Rare presentation in a healthy pediatric patient and typical CT scan findings are discussed.

Non-surgical management of congenital ichthyosis using hyaluronic acid gel injection.

AIM: To test if hyaluronic acid gel injection in the upper eyelid achieves correction of congenital cicatricial ectropion and reduction in lagophthalmos, in preparation for intraocular surgery. METHODS: This case reports the long-term outcome of hyaluronic acid gel injection in the upper eyelid for the correction of ectropion prior to cataract surgery. One millilitre of hyaluronic acid gel was injected in both the upper eyelids of a child with congenital ichthyosis in the suborbicularis plane, prior to cataract surgery. RESULTS: Lagophthalmos reduced by 15 mm in the right eye and 13 mm in the left eye. Subsequently, the child underwent cataract surgery without any complications. CONCLUSION: We demonstrate the long-term outcome of using hyaluronic acid gel injection for successful, non-surgical correction of cicatricial ectropion in ichthyosis.

Unilateral Frontalis Suspension With Silicone Sling Without Levator Extirpation in Congenital Ptosis With Marcus Gunn Jaw Winking Synkinesis.

PURPOSE: To evaluate the efficacy of unilateral tarso-frontalis silicone sling without levator extirpation or disinsertion in dampening the jaw wink in patients with congenital ptosis associated with Marcus Gunn Jaw Winking synkinesis phenomenon. METHODS: Retrospective review of medical records of all patients of congenital ptosis with moderate to severe Marcus Gunn jaw winking synkinesis who underwent unilateral tarsofrontal silicone sling surgery without extirpation of the levator muscle were retrospectively reviewed. Data were collected about the pre- and the postoperative severity of the ptosis and the amount of Marcus Gunn jaw winking excursion. RESULTS: Twenty-three patients were included in the study. Mean postoperative follow up duration was 31.2 (range 6-208) weeks. The severity of the preoperative jaw wink was mild (<2 mm excursion) in 0 patient, moderate (2-5mm) in 15 (65%) patients, and severe (>5 mm eyelid excursion) in 8 (35%) patients. Postoperatively, 20 (87%) patients had mild residual jaw wink, 3 (13%) patients had moderate jaw wink and none of the patient had severe residual jaw wink. CONCLUSION: Unilateral tarsofrontal silicone sling without disinsertion or extirpation of the levator can reduce the severity of the jaw wink excursion in patients with congenital ptosis with moderate to severe preoperative Marcus Gunn jaw winking synkinesis.

Intraocular amyloidosis with multifocal iris and anterior chamber translucent spherules.

Ocular amylodosis, although a rare entity, is known to affect the conjunctiva, extraocular muscles, orbit, lacrimal gland, and skin around the eyes. Intraocular deposition of amyloid mainly confines to the vitreous and cornea. In this report, we describe two cases of intraocular amyloidosis presenting as multiple iris and anterior chamber cysts. Histopathological examination with special stain like Congo Red and Transmission Electron Microscopy confirmed the diagnosis of amyloidosis. Systemic investigations ruled out systemic association confirming the diagnosis of primary ocular amyloidosis.

Conjunctival Retention Cysts: Outcomes of Aspiration and Sclerotherapy With Sodium Tetradecyl Sulfate.

PURPOSE: To assess the outcome of aspiration and sclerotherapy with sodium tetradecyl sulfate in the management of conjunctival inclusion cysts. METHODS: Retrospective interventional case series of 6 patients with clinical diagnosis of conjunctival inclusion cysts treated with cyst aspiration and foam sclerotherapy with 3% sodium tetradecyl sulfate. The volume of the sclerosant was 20% of the aspirated cyst volume. RESULTS: Four patients had an inclusion cyst in anophthalmic sockets and 2 patients in sighted eyes. Average time lag between primary surgery and cyst formation was 14.6 months (range 2-30 months). Average amount of fluid aspirated from cyst was 3.07 ml (range 1-9 ml). Average volume of sclerosant injected was (20% of the aspirated volume) 0.55 ml (range 0.2-1.1 ml). All 6 patients showed complete resolution of cyst at a mean follow-up period of 15.6 months (range 9-24 months). All but one showed complete resolution of cyst with single injection sclerosant. Only 1 patient required a second sclerosant injection. There was no ocular surface or implant-related complications in this cohort. CONCLUSIONS: Cyst aspiration and sodium tetradecyl sulfate foam sclerotherapy is a minimally invasive procedure for the management of conjunctival inclusion cysts in anophthalmic sockets and sighted eyes. The injection of sodium tetradecyl sulfate in a dose of 20% of the aspirate is effective in the management of conjunctival inclusion cysts over a follow-up period of 13 months. The procedure is safe, with insignificant inflammation and without ocular surface or implant complications.

Low-cost three-dimensional printed orbital template-assisted patient-specific implants for the correction of spherical orbital implant migration.

PURPOSE: To describe the outcomes of a patient-specific implant (PSI), fabricated using a three-dimensional (3D) printed orbital template and placed in the basin of the inferior orbital fissure to correct inferotemporally migrated spherical orbital implant. METHODS: This is a single-center, prospective, consecutive, interventional, case series of six patients, with non-porous, spherical, orbital implant migration that underwent implant recentration surgically with a novel technique. Migration was subclassified either as decentration that did not affect the prosthetic retention or as displacement that affected the prosthetic retention in the eye socket. Only implant displacements were treated. The primary outcome measure was centration of the implant clinically and radiologically, with ability to retain the prosthesis. RESULTS: At a mean follow-up of 21 months, all six orbital spherical implants remained centered. There were no cases of extrusion, exposure, or migration of either implants. There were no cases of PSI displacement. Additional procedures to optimize the aesthetic outcome of the customized ocular prosthesis (COP) required were simultaneous fornix formation suture in three patients, subsequent fornix formation with mucus membrane graft in two patients, and levator resection and sulcus hyaluronic acid gel injection in one patient each. The mean PSI implant weight was 2.66 ± 0.53 g. The mean COP weight was 2.2 ± 0.88 g postoperatively. The median patient satisfaction with the procedure was 9 on 10. CONCLUSION: A 3D printing-assisted PSI placed in the basin of the inferior orbital fissure allows recentration of the migrated implant over a follow-up of 21 months without complications.