Safety and Efficacy of Mucograft Porcine Collagen Bioengineered Acellular Dermal Matrix as a Spacer Graft in Lower Eyelid Elevation Surgery.

Background: Recent regulatory changes have limited the access to a widely used commercially available bioengineered acellular dermal matrix (BADM) product as a spacer graft in the surgical correction of lower eyelid retraction. We report our off-label usage of Mucograft, a porcine BADM, as an alternative BADM. Methods: A retrospective review was conducted of patients undergoing bilateral lower lid surgery with Mucograft (12 eyes) at a single institution. Results: For the six patients, there was a mean lower lid elevation of 1.93 mm, without any serious complications. There was greater elevation of the lower lid position for the Mucograft group compared with four septo-retractor control patients (1.93 versus 0.94mm, P = 0.008). Conclusion: Mucograft performed satisfactorily, and further investigation is warranted regarding its longer-term safety and efficacy.

Demography, Clinical Settings and Outcomes in Evisceration with Implant: An Electronic Medical Records Driven Analytics of 2071 Cases.

PURPOSE: To describe the demography, clinical settings and outcomes in 2071 patients undergoing evisceration across a multi-tier ophthalmology hospital network and comparison of results with the global scenario of clinical settings for evisceration. METHODS: An analysis of 2071 patients undergoing evisceration and implant between 2013 and 2019. RESULTS: The mean age at surgery was 39 ± 22 years. Children constituted 303(15%) of the cases. The four leading indications for surgery included painful blind eye in 760(37%), phthisis bulbi in 552(27%), staphyloma in 215(10%) and open globe injury in 195(9%) patients. The clinical settings encountered were trauma in 852(41%), ocular infection in 714(34%), glaucoma in 198(10%), post ocular surgery in 146(7%), congenital in 95(5%) and uveitis in 21(1%). Trauma and infection remained the commonest clinical settings in the urban (843,75%), rural (622,77%) and metropolitan (101,71%) areas. Decade wise distribution suggested trauma to be the commonest clinical setting in the first 4 decades and infection in the next 6 decades. The mean follow-up period was 351 ± 386 days (median 194). While trauma remained one of the commonest clinical setting in both the developed and the developing economies, painful blind eye and intractable glaucoma were other common clinical settings in the developed economies and infection was one of the leading clinical setting in the developing economies. CONCLUSION: Most patients undergoing evisceration are young. The commonest indications for surgery include painful blind eye and phthisis bulbi. Trauma and infection remain the commonest clinical settings for evisceration in developed and developing economies.

Single-stage upper eyelid switch flap for the repair of post-traumatic contracted socket and lower eyelid coloboma.

The use of eyelid switch flap in the correction of lower eyelid coloboma in a post-traumatic contracted socket is described. The lower eyelid, inferior fornix and lateral canthus were successfully created in a single stage with a switch flap from the upper eyelid. A satisfactory cosmetic outcome and a stable fornix for placement of a custom ocular prosthesis was achieved.

Congenital Nasolacrimal Duct Obstruction Update Study (CUP Study): Report III. Analysis of Earlier Failed Probing without Endoscopy Guidance.

AIM: The purpose of this study was to report the profile and outcomes of children with an earlier failed probing that was performed without endoscopy guidance. METHODS: Retrospective interventional case study was performed on all the patients who were referred with a diagnosis of a single or multiple failed probing from Jan 2016 to June 2019 to a tertiary care Dacryology center. All the patients had a blind probing without an endoscopy assistance before referral. The parameters evaluated were patient demographics, number of earlier probings, prior operative notes, clinical presentation, findings of endoscopy guidance during the repeat procedure, simple vs complex CNLDO, types of complex CNLDO, management, complications and outcomes. RESULTS: One hundred eyes of 82 children had a failed probing experience without endoscopic guidance elsewhere. The mean age of the children was 55.7 months (range: 9-168 months). Of these, 63 eyes underwent repeat probing under endoscopic guidance, 35 eyes being simple CNLDO (35/63, 55.5%), and 28 eyes (28/63, 44.5%) being complex CNLDO. Among the complex subset, balloon dacryoplasty was performed for five cases and monoka-Crawford stents for eight cases under direct endoscopy visualization. Buried probes were managed successfully by standard protocols of probe exteriorization. The two cases of misdirected probes were re-directed under endoscopy guidance for appropriate recanalization and the single case of granuloma at the NLD opening was excised followed by intubation without any recurrence. CONCLUSION: Endoscopy guidance plays a crucial role in the management of CNLDO with an earlier failed probing.

Outcomes and complications of evisceration with primary implant: an electronic medical record driven analytics of 1800 cases.

PURPOSE: To describe the surgical outcomes and implant complications in 1,800 patients undergoing evisceration with primary implant. METHODS: An Electronic Medical Record-driven analysis of 1,800 patients undergoing evisceration with primary implant between 2013 and 2019. Implant sizing was performed intra-operatively to place the largest implant without tension on the wound closure. Outcome measures included implant complications, prosthesis measurements, and incidence of a good aesthetic outcome. Good outcome was defined as <2 mm enophthalmos and grade 1 or less superior sulcus deformity with a custom ocular prosthesis. RESULTS: Eighteen hundred eyes of 1800 patients were included. The mean age at surgery was 36 ± 21 years (median 32 years). Implants used were poly(methyl methacrylate) (PMMA) in 1737 (97%) and porous polyethylene in 63 (3%) patients. Two-petal sclerotomy was performed in 1512 (88%) and four-petal sclerotomy in 165 (10%) patients. The mean diameter of the implant used was 19.35 ± 1.18 mm (median 20, range 10-22 mm). The implant extrusion rate was 3% (56) and implant displacement was seen in none. The mean prosthesis volume and thickness were 2.22 ± 0.67 ml (median 2, range 1-6.5 ml) and 6 ± 1 mm (median 6, range 2-9 mm). The mean difference in prosthesis projection on Hertel's exophthalmometer was 0.28 ± 1 mm (median 0, range 0-1 mm). Good outcome was observed in 93%. The mean follow-up period was 351 ± 386 days (median 194). CONCLUSION: Evisceration with empirically selected primary orbital implant placement is associated with minimal implant complications and gives a good aesthetic outcome in 93% of the patients.

Visual field-based grading of disease severity in newly diagnosed primary open angle glaucoma patients presenting to a tertiary eye care centre in India.

PURPOSE: To evaluate the severity of primary open angle glaucoma (POAG) at presentation using visual field analysis and its relationship to demographic and ocular factors in patients presenting to a tertiary eye care centre. DESIGN: Cross-sectional study. METHODS: Newly diagnosed POAG patients were classified as early, moderate, or severe stage in the worse eye based on the Humphrey visual field testing using Hodapp-Parrish-Andersons criteria. The groups were compared for differences in demographics and ocular characteristics. Statistical analysis was done using STATA 14.1 (Texas, USA). RESULTS: The average age of 71 eligible patients was 60.04 ± 9.53 years, and the cohort had 29.5% females. Among the subjects, 19 (26.7%) had early, 24 (33.3%) had moderate and 28 (38.89%) had severe POAG at presentation. There was no statistically significant difference among different stages of glaucoma with respect to age and sex groups. No statistical association was found with education, occupation status, presenting complaints, family history of glaucoma, or systemic diseases between the different stages of severity. 5.6% with severe disease presented with a relative afferent pupillary defect (RAPD). The mean intraocular pressure (IOP) in the severe stage was 22.54 ± 5.27 mmHg, which was not statistically higher than the other groups (P = 0.726). CONCLUSIONS: Newly diagnosed POAG patients predominantly present at moderate or severe stage of disease, reflecting either the asymptomatic nature of the disease or a lack of access to vision care services. Existing screening programmes need to be improved, with special attention to women and individuals less than 50 years of age.

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.

Congenital nasolacrimal duct obstruction update study (CUP study): paper I-role and outcomes of Crigler's lacrimal sac compression.

PURPOSE: To assess the exclusive role and outcomes of Crigler's lacrimal sac compression in the management of congenital nasolacrimal duct obstruction (CNLDO). METHODS: Retrospective interventional case-series was performed on patients diagnosed with CNLDO and who were advised Crigler's lacrimal sac compression (CLSC) at a tertiary care Dacryology Institute from Jan 2016 to June 2019. CNLDO patients who were practicing incorrect techniques of lacrimal sac compression at presentation were separately assessed. All the patients were assigned to four groups (Gr 1: 0-3 months, Gr 2: >3 & <6 months, Gr 3: >6 & <9 months and Gr 4: >9 and <12 months) based on the age at which the CLSC was initiated and followed up quarterly or as needed till at least 1 year of age. The parameters studied include patient demographics, clinical presentation, age of initiation of CLSC, success rate with CLSC, and need for additional interventions. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test. RESULTS: A total number of 1240 patients with CNLDO were assessed. Of these, 1037 patients were advised correct techniques of CLSC from the beginning, and the remaining 203 patients were referred but performing it incorrectly at presentation. Of the 1037 patients, 236 were lost to follow-up; hence, a total of 1004 patients (801 + 203) were included for final analysis. CLSC was found to be an effective conservative strategy in the management of CNLDO. The rate of resolution of CNLDO in Gr 1 to Gr 4 was 87.3%, 78.9%, 77.9%, and 76.8%, respectively. There were no statistically significant differences in the outcomes based on the age of CLSC initiation. The referred patients whose techniques were rectified following the initial incorrect techniques showed a resolution of 61.2% (79/129). The correct techniques of CLSC appeared to influence the outcomes. However, the age of its initiation did not substantially impact the outcomes. Significantly high resolution was noted even beyond nine months of age and encouraging results beyond 12 months of age. CONCLUSIONS: It is crucial to initiate the correct techniques of Crigler's lacrimal sac compression to achieve favourable outcomes. Age of initiation of CLSC in infancy does not appear to influence the outcomes. The resolution rate continued to be significantly high up to 1 year of age. There is a need to assess the role of CLSC beyond 12 months of age.

Congenital nasolacrimal duct obstruction update study (CUP study): Paper II - Profile and outcomes of complex CNLDO and masquerades.

OBJECTIVE: To assess the profiles and outcomes of complex congenital nasolacrimal duct obstruction (C-CNLDO). METHODS: Retrospective interventional case-series was performed on patients diagnosed with C-CNLDO and managed at a tertiary care Dacryology Institute from Jan 2016 to June 2019. Complex CNLDO was diagnosed based on intraoperative findings during probing and are defined as entities where CNLDO is secondary to, or associated with complex embryonic entities like buried probe, mal-development or non-development of bony NLD, additional proximal lacrimal dysgenesis, atonic sac, or associated craniofacial syndromes and craniofacial dysostosis. The parameters studied include patient demographics, clinical presentation, types of C-CNLDO, management modalities, and outcomes. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test. For patients who underwent a dacryocystorhinostomy (DCR), a minimum follow-up of 1-year post-DCR was considered for outcome analysis. RESULTS: Of the 2714 cases of CNLDO managed during this period, 482 (17.75%) were diagnosed as complex CNLDO. C-CNLDO showed predilection to the male gender (60.3%, 291/482). A significant number of patients (40.2%, 194/482) presented beyond 36 months of age. The common subtypes of C-CNLDO were atonic sacs (33.8%, 163/482), buried probes (19.7%, 95/482), and associated proximal lacrimal drainage anomalies (11.2%, 54/482). Since C-CNLDO is usually confirmed during the initial endoscopy-guided probing, the managements varied based on the type of C-CNLDO. Silicone intubation and/or balloon dacryoplasty (BDCP), and/or additional minimally invasive procedures were added to the initial endoscopy-guided irrigation and probing based on the nature of C-CNLDO. The overall resolution rate with these non-bypass modalities was 72.6% (350/482). Although the success rates start dropping in C-CNLDO patients beyond 3-years of age, significant success rates with multi-modal (non-bypass) management were noted in age-groups 3-5 years (71.8%, 79/110) and encouraging results (38.5%, 27/70) in 5-10 years age group. The anatomical and functional outcomes in those who underwent endoscopic or external dacryocystorhinostomy with a follow-up beyond 1-year was 96.4% (55/57). CONCLUSION: The age at presentation is delayed in patients with C-CNLDO. Multi-modal endoscopy-guided management facilitates the identification of several sub-types of C-CNLDO, and achieves significantly high favourable outcomes in older children. C-CNLDO refractory to probing, intubation and BDCP demonstrates high success with external or endoscopic dacryocystorhinostomy.

Multidrug-Resistant Escherichia coli Canaliculitis.

Escherichia coli canaliculitis is an exceptionally rare organism to cause primary canaliculitis. The present case describes unilateral canaliculitis refractory to conventional therapy with a significant history of recurrent culture proven E. coli urinary tract infection. Microbiological analysis revealed E. coli bacilli and histological examination showed goblet cell metaplasia, subepithelial edema with acute and chronic inflammatory infiltrate. The possibility of an endogenous infection or autoinoculation secondary to urinary tract infection cannot be ruled out.

Punctal dilatation and non-incisional canalicular curettage in the management of infectious canaliculitis.

OBJECTIVE: To describe the outcomes of punctal dilatation and non-incisional canalicular curettage in patients with infectious canaliculitis. METHODS: A retrospective analysis of 53 canaliculi of 47 eyes of 46 consecutive patients diagnosed with canaliculitis was performed from November 2015 to December 2018. All patients were treated with punctal dilatation and a non-incisional canalicular curettage. Parameters studied include demographics, clinical presentation, microbiological analysis, management and treatment outcomes. The outcome measures were clinical resolution of canaliculitis and resolution of epiphora. RESULTS: The mean age at presentation was 59.34 years with female preponderance (M:F = 19:28). Left eye was more affected (64%, n = 30) as compared to the right (36%, n = 17). Only one patient presented bilaterally. Lower canaliculus was most commonly involved (68%, n = 32). Six eyes showed involvement of both upper and lower canaliculus. Presenting symptoms include discharge (81%), swelling of the eyelids (64%), watering (55%), redness (51%) and pain (39%). Punctal dilatation and non-incisional canalicular curettage were performed using punctum dilator and a small chalazion scoop (1 mm Meyhoefer chalazion curette). Of the 53 involved canaliculi, 14 canaliculi of 14 eyes underwent a repeat curettage for complete resolution and 1 canaliculus underwent the same procedure thrice. The most common micro-organisms isolated were Streptococci species (28% cases). At a mean follow-up of 6.8 months, resolution of canaliculitis was achieved in all patients; however, epiphora persisted in two eyes (4%). CONCLUSION: Non-incisional canalicular curettage is a minimally invasive technique with good preservation of the punctal and canalicular anatomy. It also facilitates good anatomical and functional outcomes in infectious canaliculitis.