Clinicodemographic profile of orbital exenteration in a tertiary eye care center - A 20-year experience.

PURPOSE: This study aimed to determine the clinical indications for orbital exenteration, demographic profile of these patients, and clinicopathologic correlations in the current times and to compare these results with previous published data. METHODS: It was a retrospective study. All exenterations performed at a tertiary eye care center over a period of 20 years (from January 2001 to June 2020) were retrospectively evaluated. Patient records were reviewed to obtain demographic data, presenting symptoms and their duration, laterality, and clinical and histopathologic diagnosis. RESULTS: A total of 352 cases (males:females = 222:130) who underwent exenteration were identified. Patients age ranged from 11 months to 87 years (mean: 43.86 years, median: 50 years). The most common indication for exenteration was found to be eyelid malignancy in 54.36%, followed by retinoblastoma in 18.75% and primary orbital tumors in 14.49%. Out of 156 cases of eyelid malignancies requiring exenteration, squamous cell carcinoma (SCC) was the most common histologic subtype ( n = 94, 60.26%), followed by sebaceous gland carcinoma ( n = 40, 25.64%) and basal cell carcinoma ( n = 20, 12.82%). The most common primary orbital tumors requiring exenteration were adenocystic carcinoma of the lacrimal gland in adults and rhabdomyosarcoma in the pediatric age group. Benign conditions requiring exenteration included fulminant fungal orbital infections and lymphangioma among others. CONCLUSION: The number of exenterations performed have significantly increased in terms of absolute numbers. However, the ratio of exenteration to other tumor-related surgeries, mainly excision biopsy, has reduced compared to that reported from a previous study. The most common indication in our study remains eyelid malignancy followed by intraocular malignancy. However, SCC has emerged as the most common tumor histologic subtype requiring exenterations.

Low-dose atropine 0.01% for the treatment of childhood myopia: a pan-India multicentric retrospective study.

OBJECTIVE: The objective of this study was to assess the efficacy of low-dose atropine 0.01% in controlling myopia progression among Indian children over a 2-year period. METHODS: This retrospective study, conducted across 20 centres in India, monitored the progression of myopia over 2 years after initiating treatment with 0.01% atropine eye drops. This included children between 6 and 14 years with baseline myopia ranging from -0.5 D to -6 D, astigmatism≤-1.5 D, anisometropia ≤ -1 D and documented myopia progression of ≥0.5 D in the year prior to starting atropine. Subjects with any other ocular pathologies were excluded. RESULTS: A total of 732 children were included in the data analysis. The mean age of the subjects was 9.3±2.7 years. The mean myopia progression at baseline (1 year before starting atropine) was -0.75±0.31 D. The rate of myopia progression was higher in younger subjects and those with higher baseline myopic error. After initiating atropine, myopia progression significantly decreased to -0.27±0.14 D at the end of the first year and -0.24±0.15 D at the end of the second year (p<0.001). Younger children (p<0.001) and higher baseline myopia (p<0.001) was associated with greater myopia progression and poor treatment response (p<0.001 for both). CONCLUSION: Low-dose atropine (0.01%) effectively reduces myopia progression over 2 years in Indian children.

Tonic down-rolling and eccentric down-positioning of eyes under sevoflurane anesthesia without non-depolarizing muscle relaxant and its relationship with depth of anesthesia.

Purpose: To analyze the relationship between eccentric downward eye movement/eccentric downward eye-positioning (EDEM/EDEP) encountered in patients undergoing ophthalmic surgeries and its return to a centralized position under general anesthesia (GA) with the depth of anesthesia (DOA). Methods: Patients undergoing ophthalmic surgeries (6 months-12 years) under sevoflurane anesthesia without non-depolarizing muscle relaxant (NDMR) who witnessed a sudden tonic EDEM/EDEP were both retrospectively (R-group) and prospectively (P-group) enrolled (ambispective study). R-group included data-points after induction (AI) till the time surgery lasted while P-group compiled data both during induction (DI) and AI. DOA in terms of MAC (minimum alveolar concentration) at the time of EDEM/EDEP and centralization of eyeball and their timings were noted and compared for both AI and DI data-points. Also, vertical eccentric eye positions were scored and correlated with MAC. Results: AI data included 22 (14R+8P) events and their mean MAC of EDEM/EDEP and centralization were 1.60 ± 0.25 and 1.18 ± 0.17 respectively (p = 0.000). DI data included 62 (P) cases and its mean MAC of EDEM/EDEP and centralization was 2.19 ± 0.43 and 1.39 ± 0.26 respectively (p = 0.000). Median (IQR) eye positions during down-positioning in 84 events was -3 (-3.9 to -2.5). It was preceded by an eccentric upward drift of eyes in 10/22 (6R+4P) AI cases. A strong negative correlation was seen between DOA and eccentric eye positions (r = -0.77, p = 0.000). Conclusions: Tonic down-rolling of eyes is not uncommon in children seen without NDMR with higher depths of sevoflurane anesthesia compared to point of centralization and fluctuations in DOA should be avoided to circumvent inadvertent complications during ocular surgery.

Visual field indices in children and adults with comparable retinal nerve fiber layer thickness.

PURPOSE: To compare visual field indices in normal children and adults with similar retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT). METHODS: This cross-sectional study included 59 eyes of 59 normal children 6-18 years of age compared to normal adults. The children underwent visual field testing on the Humphrey Field Analyzer (HFA) and RNFL thickness measurement on OCT. Normal adults who had undergone OCT and visual field testing were retrieved from the OCT database. The mean deviation (MD) in each child was compared with the MD in RNFL thickness-matched eyes of normal adults. Children 6-11 years and 12-18 years were analyzed separately. RESULTS: Overall, the MD of children was significantly less than that of the normal adults despite having the same RNFL thickness (-2.42 ± 1.42 dB vs -1.61 ± 1.47 dB [P = 0.006]). When stratified by age, the difference in MD of children <12 years was significantly less than normal adults (-2.72 ± 1.5dB vs -1.53 ± 1.2 dB [P = 0.003) while in children >12 years, the difference did not reach statistical significance (-2.18 ± 1.2 vs -1.51 ± 1.32 [P = 0.12]). CONCLUSIONS: In our study cohort, children <12 years had lower visual field indices than adults. Their visual fields may appear worse than they would for an adult with the same RNFL thickness. Normal children >12 years of age seem to have a retinal sensitivity comparable to the adult normative database. It is worthwhile to consider the development of a separate pediatric normative database for the visual field assessment of children <12 years of age.

Efficacy of 0.01% low dose atropine and its correlation with various factors in myopia control in the Indian population.

We aimed to evaluate the efficacy and safety of low-dose atropine compared to placebo in the Indian population and also to study the impact of various modifiable and non-modifiable factors on myopia progression (MP) and drug efficacy (DE). It was a single-centre prospective placebo-controlled interventional study. 43 participants aged 6-16 years with progressive myopia received 0.01% atropine in the right eyes (treatment) and placebo in the left eyes (control) for 1-year. The main outcome measures were annual MP and axial length elongation (ALE) in treatment and control eyes and their percentage difference between two eyes (drug efficacy). Secondary outcome measures were the occurrence of any adverse events and the correlation of MP, ALE, and DE with various factors. 40 participants (80 eyes) completed the follow-up. After 1-year, MP was 0.25 D (IQR 0.13-0.44) and 0.69 D (IQR 0.50-1.0) (p < 0.001) in treatment and control respectively (63.89% reduction) with respective ALE of 0.14 mm (IQR 0.05-0.35) and 0.32 mm (IQR 0.19-0.46) (p < 0.001) (44.44% reduction). No adverse events were noted. Reduction in MP and ALE was statistically significant in all children irrespective of age-group, baseline MP, family history, screen-time, near and outdoor-time. The strongest determinants of annual MP were age (Treatment: r = - 0.418, p = 0.007; Control: r = - 0.452, p = 0.003) and baseline MP (Treatment: r = 0.64, p = 0.000; Control: r = 0.79, p = 0.000). Screen-time in control eyes was associated with greater ALE (r = 0.620, p = 0.042). DE was higher when outdoor time exceeded 2 h/day (p = 0.035) while the efficacy was lower with prolonged near activities (p = 0.03), baseline fast-progressors (p < 0.05) and history of parental myopia (p < 0.05). 0.01% atropine is effective and safe in retarding MP and ALE in Indian eyes.

Evaluation of lacrimal duct probing in adults with 0.02% and 0.04% mitomycin-C in primary acquired nasolacrimal duct obstruction: A randomized comparative pilot study.

PURPOSE: The purpose of the study is to evaluate the safety and efficacy of adjunctive use of mitomycin-C (MMC) using two different concentrations 0.2 mg/ml and 0.4 mg/ml for lacrimal duct probing to treat the nasolacrimal duct obstruction (NLDO) in adults. SUBJECTS AND METHODS: Prospective, an interventional comparative randomized pilot study of lacrimal duct probing conducted in the two study groups 0.02% MMC group (n = 30) and 0.04% MMC group (n = 30) in confirmed primary acquired NLDO of <1-year duration. Patency of lacrimal duct probing confirmed by syringing was compared at 1, 3, and 6-month follow-up in the two study groups, and corresponding subjective improvement of watering was appraised according to Kraft and Crawford grading. RESULTS: Patency of lacrimal duct probing in 0.02% MMC versus 0.04% MMC group was 66.66%/73.33% (P = 0.71) at 1 month, 46.66%/66.66% (P = 0.09) at 3 months and 46.66%/66.66% (P = 0.03) at 6-month follow-up, respectively. Subjective improvement of watering (no watering and mild watering) observed in 0.02% MMC versus 0.04% MMC group was 46.66%/73.33% (P = 0.03), at 1 month, 66.66%/83.33% (P = 0.13) at 3 months and 56.66%/73.33% (P = 0.17) at 6-month follow-up. CONCLUSION: Adult lacrimal duct probing with 0.04% MMC was associated with significant higher objective success rate than adult lacrimal duct probing with 0.02% MMC, without added concurrently side effects.

Ophthalmic presentations and long-term outcomes of subconjunctival and atypical orbital myocysticercosis.

PURPOSE: To study the clinical presentation, radiological features, diagnosis, and treatment response in subconjunctival and atypical orbital myocysticercosis. METHODS: Retrospective analysis of diagnosed subconjunctival and atypical (strabismus, diplopia, and blepharoptosis) orbital myocysticercosis was performed. A diagnostic criterion (2 of the 3) among clinical features, radiological findings, and treatment response was used in our study. A minimum of "post-treatment" follow-up of 12 months was observed. RESULTS: Thirty-five patients were included with a mean age of 16 years having male predominance (n = 22, 62.8%). All had a unilateral presentation, with 24 (68.6%) patients having subconjunctival cysticercosis, of which 22 were located in close proximity of the rectus muscle insertion. At presentation, 10 patients had diplopia, 7 had strabismus, and 6 had face turn. Pseudo Duane's and pseudo-Brown's syndrome were noted in 5 and 4 patients, respectively. Radiologically, single muscle myositis without scolex was seen in 12 (34.3%) cases. All patients first received medical treatment, and surgical intervention (cyst removal) was attempted after treatment failure. Complete resolution of symptoms was noted in 22 (after medical treatment only) and in 8 (after surgery). CONCLUSION: In the majority, the subconjunctival cysticercosis is found in proximity to the rectus muscle insertion, as a part of orbital myocysticercosis. In atypical scenarios, a satisfactory response to medical treatment can be considered as diagnostic of cysticercosis.

Comparison of the swept-source anterior segment optical coherence tomography and wide-field ultrasound biomicroscopy for imaging previously operated horizontal extraocular muscles.

PURPOSE: To assess the feasibility and accuracy of determining extraocular muscle insertion distance from the limbus of previously operated extraocular muscles with the swept-source anterior segment optical coherence tomography (AS-OCT) compared with wide-field ultrasound biomicroscope (UBM). METHODS: Patients with a history of previous strabismus surgery for whom additional strabismus surgery was planned were enrolled. The insertion distance was measured by AS-OCT and UBM before reoperation and compared to the caliper measurement at the time of surgery. Observers taking measurements were masked to patient data. Patient comfort for both machines was graded on a scale of 1-10 and timing of both imaging procedures was recorded. RESULTS: Thirteen previously operated muscles of 6 subjects (age 20.3 ± 4.4 years; range, 11-25) were imaged. The muscle insertion could be identified in 12 cases on AS-OCT and 10 cases on UBM. The difference between the imaging result and the caliper reading was ≤1 mm in 9 cases on AS-OCT and 5 cases on the UBM (69% vs 38%; P = 0.03). The maximum insertion distance on AS-OCT was 13.8 mm; on UBM, 10.4 mm. AS-OCT had a higher grade than UBM for patient comfort (P = 0.0005) and speed (P = 0.001). CONCLUSIONS: In our cohort, AS-OCT identified the muscle insertion distance more accurately than UBM. AS-OCT measurements were judged more comfortable to the patient, and images were acquired faster. In large recessions, wide-field UBM yields suboptimal results compared with AS-OCT.

Surgical strategy for third nerve palsy with aberrant regeneration: Harnessing the aberrant power.

Purpose: Our study aimed to evaluate the outcome of contralateral eye (CE) fixation duress squint surgery (FDSS) in third nerve palsy (3rd NP) with aberrant regeneration and compare the postoperative ptosis correction with preoperative ptosis improvement on adduction. Methods: Patients of 3rd NP with aberrant regeneration who underwent CE FDSS between December 2012-July 2015 in a tertiary-care eye hospital with a follow-up period of 1-year were retrospectively studied to analyze preoperative and postoperative details. Surgical success was defined as the correction of ptosis within 1 mm of preoperative ptosis improvement during maximal adduction of the affected eye, postoperative alignment ≤10Δ, and resolution of subjective diplopia in primary position. Results: A total of 14 eyes in 14 patients (mean age 23.6 ± 13.6 years) were included. Mean preoperative exotropia and ptosis in primary position in 14 patients was 53.4 ± 20pd and 4.89 ± 2.9 mm, respectively, and mean hypotropia in 6 patients was 23.67 ± 5.89pd. The mean improvement of ptosis on adduction and supraduction in all patients was 4.07 ± 2.64 mm and 2.89 ± 2.22 mm, respectively (P = 0.213). All patients underwent large recession of CE lateral rectus (mean 12.4 ± 2.7 mm), 9 patients underwent CE medial rectus resection/plication (mean 6.0 ± 0.9 mm) and 6 patients underwent CE superior rectus recession (mean 6.6 ± 0.67 mm). Postoperatively, mean ptosis and exotropia correction was 3.7 ± 2.4 mm (P = 0.000) and 15 ± 9.6pd (P = 0.000), respectively, and mean hypotropia was 2.17 ± 4.02pd (P = 0.000). Surgical success was achieved in 6 patients. Postoperative ptosis correction showed strong positive correlation with preoperative improvement of ptosis on adduction (r = 0.87; P = 0.00). Conclusion: Preoperative lid excursion on adduction in 3rd NP can be regarded as a prognostic sign of the success of CE FDSS which can simultaneously correct both ptosis and squint.

Intraoperative absent bilateral medial recti in syndromic craniosynostosis.

Patients with syndromic craniosynostosis are usually associated with the complexity of the malformation complex. We describe here detailed oculo-motility disorder and a remarkable finding of hypoplastic bilateral media recti on imaging and its intraoperative absence in patients with phenotypic features resembling Shprintzen-Goldberg syndrome (SGS). SGS is a rare congenital disorder with craniosynostosis affecting multiple systems including mentation and having a considerable overlap of its phenotypic features with Marfan syndrome. Large A-pattern exotropia found in these patients may be related to the craniofacial features and their bearing on extraocular muscle development and function. In this paper, we aimed to sensitise ophthalmologists and strabismologists concerning the necessity to recognise syndromic associations of patients with craniosynostosis presenting with a large squint, be aware of the intraoperative surprises and consider the challenges in its management.

A Pilot Nurse-Led Tele-Counseling Intervention to Parents of Children With Cerebral Visual Impairment on Adherence to Eye Activities During COVID-19 Pandemic: A Pre-experimental Study.

AIM: To assess the impact of a culturally appropriate and theoretically driven nurse-led tele-counseling intervention to parents of children with cerebral visual impairment (CVI) on the adherence to visual therapy advised by the ophthalmologists. DESIGN: A pre-experimental design was used. METHODS: Parents of children with CVI aged 2-9 years were enroled telephonically during the coronavirus disease 2019 (COVID-19) pandemic through the Pediatric Ophthalmology Clinic of a tertiary eye care center. Pre-assessment of participants was done telephonically as per the interview schedule. As per the protocol, the trained nurse-delivered tele-counseling intervention two times weekly for the first 2 weeks and weekly for the next 2 weeks via audio and video two-way tele-interaction with parents. A CVI information booklet was shared with parents via WhatsApp interface and individualized visual therapy was reinforced in accordance with the advice of the treating ophthalmologist. It was based on a thorough review of clinical records of the child, such as a detailed CVI questionnaire, history, and findings of clinical examination and neuro-visual behavior of a child. In addition, parents were encouraged to maintain a diary of the daily sessions of visual therapy and share recorded videos of their training exercises which were then evaluated and discussed with the ophthalmologist for any deviation. Outcome measures included adherence to eye activities for 7-8 sessions per day. Data were analyzed by using SPSS statistics for windows, version 20. RESULTS: Overall, improvement of adherence to visual therapy was observed among children with CVI (p < 0.0001). Nearly half (47.6%) of participants adhered to 3-4 sessions/day and only 28.6% were adherent to the recommended 7-8 sessions/day. CONCLUSION: The pilot study demonstrated the potential of the nurse-led tele-counseling intervention to supplement the ongoing health treatment of patients in improving the adherence to eye activities among parents of children with CVI.

Horizontal Gaze Palsy, Scoliosis, and Split Pons Sign in a 6-Year-Old Girl.

ABSTRACT: A 6-year-old girl presented with complaints of absent horizontal eye movements since birth. There was also associated progressive scoliosis for past 1 year. Neuroimaging revealed split pons sign, butterfly-shaped medulla, and prominent inferior olivary nuclei. The presence of congenital horizontal gaze palsy, childhood onset progressive scoliosis, and abnormal neuroimaging findings confirmed the diagnosis of horizontal gaze palsy with progressive scoliosis. This case highlights the importance of neuroimaging in a child presenting with horizontal gaze palsy and scoliosis that helped for starting early rehabilitation of the child, prevention of permanent vision loss, and parental counseling for future pregnancies.

Pigment dispersion syndrome presenting as endothelial dystrophy: An atypical presentation.

PURPOSE: To describe an atypical presentation of pigment dispersion syndrome (PDS) with diffuse, homogeneous pigment deposition on the corneal endothelium and its management. METHODS: A 44-year-old female was referred to a cornea clinic as a case of endothelial dystrophy. Slit-lamp examination revealed bilateral, diffuse, and homogeneous pigment deposition on entire corneal endothelium without any iris transillumination defects. Intraocular pressure (IOP) at presentation were 18 mmHg OD and 16 mmHg OS. Gonioscopy showed dense, homogeneous pigment deposition in the angles. The optic nerve head examination revealed a cup disc ratio of 0.6:1-0.7:1 in both eyes with neuroretinal rim thinning. RESULTS: Peripheral Nd:YAG laser peripheral iridotomy (PI) was performed. On follow-up, a localized clear pigment free endothelial area was noted over the iridotomy sites bilaterally. IOP was well controlled within 12-14 mmHg with prostaglandin analogue at last follow-up of 24 months. CONCLUSIONS: Diffuse homogeneous pigment dispersion on the endothelium may occur in atypical cases of PDS which may clear in the areas overlying the PI site and, therefore, should not be confused with endothelial disease. This case demonstrates the significance of a thorough clinical evaluation in cases with unusual presentation.

Evaluation of anterior segment parameters with two anterior segment optical coherence tomography systems: Visante and Casia, in primary angle closure disease.

PURPOSE: To determine the comparability of anterior chamber biometric measurements in primary angle closure disease (PACD) patients using two commercially available anterior segment optical coherence tomography machines (ASOCT): Visante and Casia. METHODS: This was a cross-sectional observational study, which included clinically, diagnosed cases of PACD. Anterior segment biometric measurements were done using Casia and Visante ASOCT. Parameters studied were central corneal thickness (CCT), anterior chamber depth (ACD), nasal (N) and temporal (T) angle opening distance at 500 µm (AOD500) and 750 µm (AOD750), and N and T trabecular iris space area at 500 µm (TISA500) and 750 µm (TISA750). RESULTS: Total 36 PACD patients (72 eyes) with average age of 59.48 ± 7.95 years were recruited, out of which 25 were females (69.44%) and 11 males (30.56%). The mean measurements of CCT, ACD, AOD500, and TISA on Casia and Visante machines were 522.5 ± 34.75 µm and 539.55 ± 29.56 µm (P = 0.00); ACD- 2.144 ± 0.38 mm and 2.133 ± 0.39 mm (P = 0.487); AOD500-0.27 ± 0.16 µm and 0.21 ± 0.10 µm (P = 0.04); and TISA500-0.100 ± 0.07 µm and 0.063 ± 0.03 µm (P = 0.00), respectively. A statistically significant difference was noted in CCT, N and T AOD, and TISA. A good corelation for ACD and CCT (ACD = 0.9816 and CCT = 0.772) only were noted between the two machines. The Bland-Altman plot analysis of different parameters between two machines has revealed good agreement of measurement of ACD and CCT but poor agreement for rest of the parameters. CONCLUSION: It is advisable not use the two machines interchangeably because of the wide limits of agreement and poor correlation of angle measurement values of Casia and Visante ASOCT.

Sonographic Assessment of Optic Disc Cupping and its Diagnostic Performance in Glaucoma.

PURPOSE: The purpose of this study was to assess the optic cup diameter sonographically in glaucoma patients and in the normal population and correlate it with their photographic parameters to propose a cut-off value as a predictive index of glaucoma. METHODS: A total of 95/50 primary open-angle glaucoma and 87/44 control patients with clear media underwent visual field assessment, fundus photography, and B-scan ultrasound. Photographic vertical cup diameter (PVCD) of cases and controls were recorded after magnification correction using the Bengtsson formula. Sonographic vertical cup diameter (SVCD) was measured in the vertical transverse position. RESULTS: The mean SVCD was 1.13±0.23 mm in glaucoma and 0.72±0.25 mm in controls (P=0.001). The mean PVCD was 1.024±0.199 mm in glaucoma and 0.636±0.217 mm in controls (P=0.001). A strong correlation between PVCD and SVCD in both groups was found (correlation coefficient r=0.857; P=0.001; glaucoma and r=0.795; P=0.001; control). SVCD had a positive correlation with vertical cup disc ratio (r=0.675; P=0.001 in glaucoma patients) and (r=0.797; P=0.001 in controls) cup area (r=0.798; P=0.001; glaucoma) and (r=0.727, P=0.001; control) a negative correlation with vertical neuroretinal rim diameter (r=-0.5187; P=0.000; glaucoma patients) and (r=-0.699; P=0.001; controls). No correlation of SVCD was found with severity of field grade changes. The receiving operative curve analysis was performed, and Youden's optimal cut-off method was used to find a cut-off value for SVCD, which came out to be 1.06, with 65.3% (95% confidence interval, 54.8-74.7) sensitivity and 94.3% (95% confidence interval, 87.1-97.1) specificity. CONCLUSIONS: The sonographic evaluation of the optic cup is a reliable noninvasive procedure and a potentially useful tool in the assessment of nonviewable suspected glaucomatous cups.

Magnetic resonance imaging for tumor restaging after chemotherapy in retinoblastoma with optic nerve invasion.

PURPOSE: Extraocular retinoblastoma with optic nerve invasion is treated by a multimodal protocol consisting of neoadjuvant chemotherapy, enucleation, and adjuvant therapy. This study was conducted to evaluate the performance of magnetic resonance imaging (MRI) used for tumor restaging in these children after systemic chemotherapy administration. METHODS: Contrast-enhanced MRI scan of orbits and brain was performed at diagnosis and patients were treated with neoadjuvant chemotherapy. After chemotherapy, MRI scan was repeated for tumor restaging and residual post-laminar thickening and/or enhancement of the affected optic nerve, if any, was recorded. MRI findings were correlated with histopathology in enucleated specimens. The main outcome measures were specificity, sensitivity, and accuracy of MRI in predicting post-laminar invasion after neoadjuvant chemotherapy. RESULTS: A total of 46 eyes (46 patients) were studied. Optic nerve thickening on MRI had a sensitivity, specificity, and accuracy of 100% (95% Confidence Interval (CI): 64.6-100%), 76.9% (95% CI: 61.7-87.4%), and 80.4% (95% CI: 66.8-89.4%), respectively. Optic nerve enhancement had a sensitivity, specificity, and accuracy of 85.7% (95% CI: 48.7-97.4%), 79.5 % (95% CI: 64.5-89.2%), and 80.4% (95% CI: 66.8-89.4%), respectively. Combined thickening and enhancement of the optic nerve had a sensitivity, specificity, and accuracy of 100% (95% CI: 60.9-100%), 82.4% (95% CI: 66.5-91.7%), and 85% (95% CI: 70.9-92.9%), respectively. CONCLUSION: MRI is a valuable tool for restaging of retinoblastoma and predicting residual optic nerve disease after neoadjuvant chemotherapy. Combined thickening and enhancement on MRI appeared to be a more reliable indicator of post-laminar invasion as compared to thickening or enhancement alone.

Bilateral medial rectus aplasia and a modified surgical approach of transposition myopexy of vertical recti.

A 16-year-old girl presented with left eye large-angle exotropia. On examination, we found bilateral limitation of adduction. CT orbit showed hypoplastic medial rectus bilaterally, but intraoperatively we found absent medial recti on both sides. This case report explains discrepancy between the imaging and the intraoperative findings and discusses the management dilemma in view of the risk of anterior segment ischaemia and how marked exodeviation and adduction limitation was tackled by the new technique of transposition myopexy, a modification of the procedure described by Nishida along with recession of lateral rectus to achieve good alignment. This procedure changes the vector forces of the vertical rectus without splitting or tenotomy of the muscles.

Association between lactate levels in vaginal fluid and time of spontaneous onset of labor in suspected cases of prelabor rupture of membranes.

PURPOSE: To assess correlation between lactate levels in vaginal fluid and onset of labor in suspected PROM. METHOD: A prospective observational study conducted at the Dept. of Obstetrics and Gynecology and Pathology from 2008 to 2009. 118 women with complaints of leaking per vaginum underwent a sterile speculum examination and vaginal fluid was taken to estimate lactate level. Then, women were followed till the spontaneous onset of labor. The association was presented as Odds ratio with 95 %CI. RESULTS: The median time of onset of spontaneous labor and examination was 12 h in patients with lactate levels >5.0 mmol/L and 76 h in patients with lactate levels <5.0 mmol/L. Among 62 women with lactate levels >5.0 mmol/L, 67.7 % of women (n = 42) had spontaneous onset of labor within 24 h and 83.87 % women of (n = 52) within 48 h. CONCLUSION: A lactate level >5.0 mmol/L is significantly associated with the spontaneous onset of labor within 24 and 48 h in suspected cases of PROM.