Conjunctival nodule as a primary manifestation of disseminated histoplasmosis.

Histoplasmosis is a granulomatous infection caused by dimorphic fungus-Histoplasma capsulatum. Ocular involvement is mainly in the form of retinal or choroidal involvement as presumed ocular histoplasmosis mostly in immunocompromised patients. Conjunctival, scleral, and adnexal involvement is rarely reported. We report a case of disseminated histoplasmosis with conjunctival lesion as the initial clinical manifestation clinching the diagnosis.

Utility of pig head model as an oculoplastic wet lab surgical training tool.

PURPOSE: To assess the utility of pig head model as an oculoplastic surgical training tool. METHODS: Fresh pig head was availed for surgical workshop for entropion correction, eyelid margin repair, and evisceration with implant for oculoplastic surgery-naïve participants. Skill improvement, surgical understanding, and performance of the participants were evaluated both subjectively and objectively by trained oculoplastic surgeons. Subjective assessment was done by a standardized questionnaire based on Likert scale shared with the participants post training. Objective evaluation was done by the faculty based on a three-point scale and a competency-based surgical assessment rubric. RESULTS: There were 18 surgery-naïve participants in the workshop which comprised ophthalmology residents and comprehensive ophthalmologists. About 88.88% of the participants were able to perform the lid margin and sub-tarsal dissection in entropion surgery. While performing lid tear repair, 94.44% were correctly able to identify the grey line and anterior and posterior lamellae. About 83.33% of the participants were able to place an implant in the scleral shell or intraconal space. About 83.33% of the participants noted that texture and tissue maneuvering were similar to the human eye while performing surgical steps. About 94.44% of the participants reported better understanding, development of skill and additional confidence after training. The median score on objective assessment was 3. The performance on real patients resulted in a median score of 4 for entropion correction. CONCLUSION: Porcine orbital dissection is an available, affordable, and useful tool for oculoplastic surgical training. Training on porcine model can improve anatomical understanding, clinical judgement, and surgical efficiency in trainees.

The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument.

PURPOSE: To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery. METHODS: A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. RESULTS: The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. CONCLUSION: A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Choroidal thickness in thyroid eye disease and its correlation with disease activity.

CONTEXT: This study adds to the existing body of literature on the role of optical coherence tomography (OCT) parameters in active thyroid eye disease (TED) among the Indian population. PURPOSE: Comparison of choroidal vascularity index (CVI) and subfoveal choroidal thickness (SFCT) in active and inactive TED. SETTINGS AND DESIGN: An observational, cross-sectional analytical study conducted at a tertiary eye care hospital in North India that included patients with active and inactive TED. METHODS: Demographic details and clinical evaluation were performed for all TED patients. SFCT was determined with OCT by using the Cirrus linear measurement tool. CVI was calculated using Image J software. The SFCT and CVI measurements were compared between both groups. STATISTICAL ANALYSIS USED: Comparison between active and inactive TED groups was done using Mann-Whitney U test for non-parametric data and Student t test for parametric data. Multivariate regression analysis was performed with SFCT and CVI as dependent variables. RESULTS: Sixty-two eyes of 31 patients were included. Thirteen eyes had active TED, and 49 eyes had inactive TED. SFCT was significantly lower in eyes with higher clinical activity score (CAS) and older age. No significant difference was found in CVI between active and inactive TED eyes. CONCLUSION: SFCT was lower in eyes with higher CAS and older age. Our findings differ from previous studies, which showed a positive correlation between SFCT and CAS. There was no significant difference in CVI between active and inactive TED eyes.

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.

Dacryoadenitis post COVID-19 infection and immunization.

Dacryoadenitis can be a rare presentation following COVID-19 infection or can be an immunological response post COVID-19 vaccination. Herein we report two cases of lacrimal gland involvement, one post COVID-19 infection, and the other post COVID-19 vaccination. A definitive causal relationship, however, remains uncertain.

Retinoblastoma: A review of the molecular basis of tumor development and its clinical correlation in shaping future targeted treatment strategies.

Retinoblastoma is a retinal cancer that affects children and is the most prevalent intraocular tumor worldwide. Despite tremendous breakthroughs in our understanding of the fundamental mechanisms that regulate progression of retinoblastoma, the development of targeted therapeutics for retinoblastoma has lagged. Our review highlights the current developments in the genetic, epigenetic, transcriptomic, and proteomic landscapes of retinoblastoma. We also discuss their clinical relevance and potential implications for future therapeutic development, with the aim to create a frontline multimodal therapy for retinoblastoma.

Giant facial congenital melanocytic nevus associated with conjunctival melanoma.

Giant congenital melanocytic nevi involving the face are benign lesions and malignant transformation to cutaneous melanoma involving the eyelid has been rarely reported. This report highlights the rare association of a giant facial melanocytic nevus and conjunctival primary acquired melanoses and melanoma.

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.

Intra-arterial chemotherapy in refractory and advanced intraocular retinoblastoma.

Purpose: To evaluate the efficacy of secondary and salvage intra-arterial chemotherapy (IAC) as a globe salvage treatment modality in advanced and refractory intraocular retinoblastoma. Methods: A retrospective chart review of advanced intraocular retinoblastoma (groups D and E International Classification of Retinoblastoma [ICRB] classification) patients refractory to intravenous chemotherapy (IVC) and undergoing IAC as the secondary and salvage treatment modality between December 2018 and June 2021 was carried out. All patients underwent the IAC procedure by super-selective ophthalmic artery catheterization and with triple-drug chemotherapeutic agents of melphalan, topotecan, and carboplatin. Data were collected about tumor regression, eye salvage, metastasis, and survival outcome at follow-up. Results: Out of 13 patients, 12 patients received secondary IAC after being primarily treated with IVC and focal therapies and one patient received rescue IAC after recurrence following primary IAC. Mean number of IAC cycles administered was 2. Overall, globe salvage rate was 53.84%, with a mean follow-up of 17.53 months (range 6-37 months), three patients had enucleation for residual tumor or tumor recurrence. One patient developed metastasis post enucleation and two patients who were lost to follow-up after enucleation advice for residual tumor developed orbital tumor extension and eventually died of metastasis. Conclusion: Secondary triple-drug IAC following failure of IVC, along with other adjunct treatment modalities might a be a cost-effective option for eye salvage in advanced intraocular retinoblastoma patients who refuse enucleation, with a globe salvage rate of 53.84%. It can also be an effective approach to improve treatment compliance and can help in addressing the barrier of treatment refusal when enucleation is advised.

Primary orbital yolk sac tumor presenting as fungating mass.

Primary yolk sac tumor of the orbit is a rare entity. Orbital involvement is usually seen in young children and proptosis is the commonest presentation. Aggressive orbital involvement and presentation as a fungating mass is rarely seen. We report a case of primary orbital yolk sac tumor with an aggressive presentation that responded well to systemic chemotherapy.

Single-Staged Surgical Correction of Eyelid Sequelae Along With Lid Margin Mucous Membrane Grafting in Stevens-Johnson Syndrome and Other Cicatricial Ocular Surface Diseases.

PURPOSE: The purpose of this study was to study the outcome of single-staged entropion surgery along with lid margin mucous membrane grafting for cicatrizing ocular surface disease. METHODS: Retrospective review of medical records of patients who underwent single-staged surgical correction of cicatricial entropion along with lid margin mucous membrane grafting for lid margin keratinization. RESULTS: Twenty-six eyes of 19 patients were studied. The mean age of patients was 42.5 years (standard deviation, SD-17.67), of which 7 patients were male and 12 were female. The most common disorder was Stevens-Johnson syndrome (SJS) sequelae (83.33%, n = 20), followed by mucous membrane pemphigoid (n = 4, 16.67%). The most common eyelid changes observed were cicatricial entropion in all 26 eyes (100%, n = 26), followed by trichiasis in 13 eyes (50%, n = 13). Lid margin keratinization was noted in all eyes. Postoperative improvement in corneal surface staining was noted in 70% of the patients (n = 13), no change in 20% of the patients (n = 4), and worsening of corneal surface staining in 10% of the patients (n = 2). Postoperative visual acuity improvement was noted in 50% of the eyes (n = 13), no improvement in 39% of the eyes (n = 10), and vision worsened in 12% of the eyes (n = 3). An entropion recurrence rate of 25% (n = 6) was observed over an average 10-month follow-up, whereas 75% (n = 20) reported no recurrence. CONCLUSIONS: Single-staged correction of eyelid cicatricial entropion with a lid margin mucous membrane graft (MMG) has promising outcomes in ocular surface diseases. It can decrease the need for multiple surgeries and provide symptomatic relief in patients with chronic cicatricial surface changes.

Association of clinical course with thyroid-stimulating immunoglobulin in Graves' ophthalmopathy in Mongolians.

Graves' ophthalmopathy (GO) is a complex inflammatory condition affecting the orbit and is often associated with Graves' disease (GD). This study aims to determine the levels of thyroid-stimulating immunoglobulin (TSI) and thyroid-stimulating hormone receptor autoantibody (TSHR-ab) in the serum of patients with GO, compare it with the GD, and determine whether there is a correlation with the clinical course of GO. The cross-sectional study included 82 patients with GO, 81 patients with GD, and 75 healthy subjects. The ocular manifestations of GO were identified and evaluated by the clinical activity score (CAS) and severity of GO using the European Group of Graves' Orbitopathy (EUGOGO). TSI and TSHR-ab levels in the serum of participants were determined with ELISA kits and correlated with clinical findings. A total of 238 participant's data were analyzed. There were 14 patients (17%) with unilateral GO. The most common ocular signs were eyelid retraction 68 (82.3%) and proptosis 61 (74.4%). The mean CAS score was 2.65±1.64 in GO patients and was higher in men than women (P = 0.008). The mean of TSI was 37.95±35.41 in GO, 14.16±15.67 in GD, and 4.33±2.94 in healthy controls (P<0.0001). The TSI was significantly higher in patients with GO than in those with GD (P<0.0001). There were no correlations between TSI and TSHR-ab levels and CAS scores. However, we observed a correlation between the TSI level and the severity of GO (P = 0.023). The area under the ROC curve (AUC) of TSI was 0.933 and selected 14.1 IU/ml was the optimal cutoff value (98.78% of sensitivity, 83.97% of specificity). Our study showed that TSI is significantly related to GO and the severity of GO. Therefore, TSI can be used as a predictor of severe GO to help in prognostication, follow-up and treatment planning.

Does Multimodal Treatment Improve Eye and Life Salvage in Adenoid Cystic Carcinoma of the Lacrimal Gland?

PURPOSE: To evaluate the efficacy of multimodal treatment in adenoid cystic carcinoma (ACC) of the lacrimal gland. METHODS: A retrospective comparative case series of 40 consecutive patients with ACC of the lacrimal gland without systemic metastasis at the initial presentation and primarily managed by one of the 3 treatment protocols-surgery + external beam radiotherapy (EBRT) (group 1), surgery + EBRT + adjuvant chemotherapy (group 2), and neoadjuvant chemotherapy + surgery + EBRT + adjuvant chemotherapy (multimodal treatment) (group 3) at a tertiary care ocular oncology center. Local tumor control, eye salvage, and systemic metastasis were the primary outcome measures. RESULTS: The age ranged from 11 to 72 (mean ± SD, 36 ± 13; median, 36) years with 26 (65%) male and 14 (35%) female patients. Twelve (30%) patients belonged to group 1, 8 (20%) to group 2, and 20 (50%) to group 3. Primary surgery included tumor excision in 36 (90%) and orbital exenteration in 4 (10%). Chemotherapy composed of cisplatin + 5 fluorouracil (5FU) for 6 cycles in 28 (70%) patients. Extended-field stereotactic EBRT with a dose of 5,000-6,000 cGy included the entire pretreatment extent of the tumor with a 10-mm margin all around, superior orbital fissure, inferior orbital fissure, cavernous sinus, and temporal fossa. Mean duration of follow up after completion of treatment was 58 ± 26 (range, 29-180; median, 60) months. In all, local tumor recurrence occurred in 10 (25%) patients at a mean of 38 ± 23 (range, 12-120; median, 24) months. Local tumor recurrence was noted in 5 (42%) patients in group 1, 2 (25%) in group 2, and 3 (15%) in group 3. Overall, eye salvage was possible in 34 (85%) patients, with visual acuity >20/40 in 28 (82%). Systemic metastasis occurred in 10 (25%) patients at a mean of 53 ± 28 (range, 12-120; median, 43) months. Eight (67%) patients in group 1, 1 (13%) in group 2, and 1 (5%) in group 3 developed systemic metastasis. Six (15%) overall, 5 (42%) in group 1 and 1 (13%) in group 2, died with systemic metastasis. CONCLUSIONS: Multimodal treatment with sequential neoadjuvant chemotherapy, followed by surgery, extended-field stereotactic EBRT, and adjuvant chemotherapy seems relatively more effective in providing local tumor control and eye salvage and in minimizing the risk of systemic metastasis in ACC of the lacrimal gland.