Acute dacryocystitis: changing practice pattern over the last three decades at a tertiary care setup.

AIM: To compare the demographics, clinical features, and changes in the management pattern of acute dacryocystitis at a tertiary care eye institute. METHODS: A retrospective review was performed of electronic medical records of all patients diagnosed with acute dacryocystitis from January 2013 to January 2023. Data retrieved include demographics, history, presenting symptoms, duration of symptoms, surgical interventions, associated systemic conditions, management, complications, and outcomes. A successful anatomical outcome was defined as patency on lacrimal irrigation, and a successful functional outcome was defined as the resolution of infection and epiphora. The data parameters obtained were compared with the historical published data of the earlier two decades from the same Institute. RESULTS: A total of 363 eyes of 349 patients were enrolled in this retrospective study. The median age was 45 years (range: 19-94 years). There were 216 (62%) females and 133 (38%) males. Surgery was performed in 320 (88%) patients. Needle aspiration or incision and drainage were performed in 102(32%) patients with lacrimal abscesses. Of the 320 patients, an endoscopic DCR was performed in 138 (43%) patients and an external DCR in 182 (57%). Of the 320 patients who underwent DCR surgery, 308 (96%) demonstrated anatomical and functional success at 1-year follow-up. CONCLUSION: There is a changing trend towards endoscopic DCR being incorporated as the primary procedure for managing acute dacryocystitis with the advantages of quicker resolution and reduced morbidity. There is a trend for choosing needle aspiration over the traditional incision and drainage in the initial management of lacrimal abscess.

The FICI grading for a dacryocystorhinostomy ostium.

PURPOSE: The objective of this study is to propose a simple grading to assess the health of a dacryocystorhinostomy (DCR) ostium. METHODS: Prospective case series of 237 Ostia evaluated following dacryocystorhinostomy were included in the study. All the ostia were assessed for 10 parameters in detail using the earlier published DCR ostium scoring (DOS scoring). Each of the 10 parameters were scored individually, and final DOS scores were obtained. The anatomical and functional outcomes of each of the surgery were noted. The most significant parameters that influenced the success were determined using the binary recursive partitioning in a conditional inference framework. Data management and statistical tests were performed using the statistical "Software R" and the library "partykit" toolkits. RESULTS: The most significant DCR ostium parameters that influenced the outcomes were anatomical and functional fluorescein dye transit (p < 0.001), dynamicity of internal common opening (ICO) on the blink (p < 0.001), end-on threats to ICO from granuloma, membrane or a synechia, and cicatricial closure of the Ostia. Each of these significant factors (FICI - Fluorescein endoscopy dye test, ICO dynamicity, Cicatricial ostium closure and ICO threats) were assigned simple scoring and the final scores were graded from 0 (poor DCR ostium) to +5 (excellent DCR ostium). FICI grading can guide the physician on the health status of the DCR ostium and the possible need for intervention. CONCLUSION: FICI DCR ostium grading is a simple, easy to perform, and physician-friendly system. More studies with larger sample size would help in further validating the FICI grading.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1.

Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management. Methods: This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021. Results: Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05). Conclusion: : Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Cone Beam Computerized Tomography Dacryocystography (CBCT DCG) for the Evaluation of Lacrimal Drainage System Dysfunction.

PURPOSE: Lacrimal outflow imaging has been limited in clinical practice due to a combination of modality limitations and efficacy of clinical testing. Cone beam computed tomography dacryocystography (CBCT DCG) has certain advantages over other modalities that may enhance clinical utility. This study was intended to understand the relationships between symptoms, syringing and CBCT DCG in a population of patients presenting with tearing. METHODS: Cross-sectional cohort study of adult patients undergoing both CBCT DCG and clinical probing and irrigation. Concordance analysis between symptoms, clinical examination, and CBCT DCG was performed at baseline and postoperatively in patients who were treated with dacryocystorhinostomy. RESULTS: CBCT DCG findings correlate fairly well with probing/irrigation (Cohen kappa = 0.376). Excluding cases of canalicular obstruction identified by either method, the correlation between CBCT DCG and probing/irrigation was moderately improved (Cohen kappa = 0.488). There was no statistically significant difference in correlation with patient symptoms between CBCT DCG and probing/irrigation (p = 0.877). Fifteen patients (17 lacrimal systems) patients underwent endoscopic dacryocystorhinostomy (DCR) surgery. Ten demonstrated absence of symptoms 90 days postoperatively, 3 endorsed continued tearing and 2 were lost to follow up. All 3 who demonstrated continued tearing, demonstrated canalicular obstruction on CBCT DCG which was not initially detected on probing/irrigation. CONCLUSIONS: CBCT DCG correlates moderately well with probing and irrigation, as well as patient symptoms. This technology may assist in identification of functional/anatomic canalicular obstruction.

Canalicular Curettage to the Rescue: a report of three cases.

INTRODUCTION: Canalicular curettage is a surgical procedure used to remove canalicular contents and debris from canaliculi. It is usually indicated for chronic, persistent or recalcitrant canalicular diseases with no resolution of symptoms after conservative management. We describe 3 different cases of persistent canalicular diseases which needed canalicular curettage to rescue from the conditions leading to successful outcomes. Cases and observations: • Case 1: A 45-year-old male presented with recurrent punctal granuloma 3 months after DCR surgery. Canalicular exploration and curettage with one-snip punctoplasty following excision of the mass revealed a segment of remnant silicone stent. There was no recurrence of mass in subsequent follow up visits. • Case 2: A 35-year-old female presented with recurrent canaliculitis for last 6 months. Canalicular curettage revealed multiple small calcified masses of varying size and shape. The patient had good postoperative recovery and showed no recurrence of symptoms. • Case 3: A 32-year-old female presented with gradually increasing pedunculated mass arising out of punctum for last one month. Excision of mass with canalicular curettage was done. Biopsy proved it to be squamous papilloma of the canaliculi. There was no recurrence of mass. CONCLUSION: Canalicular curettage is a simple, safe and effective surgical intervention to rescue from the recalcitrant canalicular conditions like canaliculitits, retained foreign bodies, canalicular neoplasms leading to successful outcomes.

Isolated peripunctal sebaceous gland carcinoma in a young adult: An unusual presentation.

Sebaceous gland carcinoma (SGC) of the eyelid is one of the leading peri-ocular eyelid malignancies in Asian-Indians. It usually affects elderly women and has a high rate of local recurrence, regional and distant metastasis. This is partly attributable to a delay in clinical diagnosis since it mimics more benign conditions of the eyelid like chalazia. To the best of our knowledge, this is the first case report of a peri-punctal SGC. Atypical location and the young age of the patient resulted in a relatively conservative excisional biopsy under frozen section control and eyelid reconstruction with a favorable outcome.

Role of Retrobulbar Hyaluronidase in Filler-Associated Blindness: Evaluation of Fundus Perfusion and Electroretinogram Readings in an Animal Model.

PURPOSE: Hyaluronic acid gel filler-associated blindness is an uncommon but devastating complication. Hyaluronidase can potentially dissolve intravascular filler and improve perfusion; however, its role in filler-associated blindness has yet to be determined. The purpose of this study is to determine the effect of retrobulbar hyaluronidase on hyaluronic acid gel-induced ophthalmic artery occlusion in a rabbit model. METHODS: New Zealand red rabbits were used to simulate hyaluronic acid gel filler-associated vascular occlusive blindness. Ophthalmic artery occlusion and subsequent ischemia were confirmed by both retinal fundus photography and electroretinogram changes. Retrobulbar hyaluronidase 1,000 IU was injected 30 minutes after occlusion. Fundus photography and electroretinogram changes were recorded at 30, 60, 90, and 120 after administration of retrobulbar hyaluronidase. RESULTS: A total of 6 rabbits were used, for a total of 12 eyes. Four eyes were used as controls. Of the 8 experimental eyes, 2 eyes had recorded partial occlusion and 6 eyes had fully occluded ophthalmic arteries by angiographic evaluation. One of the partially occluded eyes demonstrated some improvement in perfusion 60 minutes after injection of retrobulbar hyaluronidase; however, electroretinogram readings remained flat over the 120-minute period of observation. Six eyes with completely occluded ophthalmic arteries showed no improvement in retinal perfusion with corresponding flat electroretinogram readings at 120 minutes following retrobulbar hyaluronidase injection. CONCLUSIONS: In this rabbit model, 1,000 IU of retrobulbar hyaluronidase administered 30 minutes after occlusion failed to reverse obstruction or restore function following hyaluronic acid gel occlusion of the ophthalmic artery.

Eyebrow Contouring with Hyaluronic Acid Gel Filler Injections.

Background: The eyebrow region presents challenges for filling: the skin is thick, the three-dimensional anatomy is complex and there is a predisposition towards fat atrophy and skeletonization with aging. Hyaluronic acid gel fillers are well known for their use in the periorbital region. We report our long-term experience with eyebrow filling over a period of five years. Methods: Twenty cases of periorbital eyebrow filling with hyaluronic acid gel fillers were followed up over a period of five years. The eyebrow filling was customized based on the patient's anatomical features in a three-dimensional plane. Standardized photographs before and after the procedure in standard lighting conditions were evaluated. Results: Hyaluronic acid gel fillers were tolerated well in the eyebrow region. There were no cases with blue-gray dyschromia or prolonged edema as is the case with lower eyelid injections. The eyebrow gained volume and looked fuller immediately after the injection. There were three cases with excessive eyebrow puffiness noted on a long-term follow-up which may be the accumulated filler weighing the eyebrow. No other adverse events were noted. Conclusion: The eyebrow anatomy is a complex three-dimensional structure. Deflation in the eyebrow area along with the superior sulcus occurs with aging. Filling the eyebrow with hyaluronic acid gel fillers is a useful tool in the armamentarium of the cosmetic facial surgeon and can be used in isolation in select patients or as an adjunct to surgical rehabilitation. We believe the fillers last longer and are well tolerated in the eyebrow region due to the complex anatomy specific to this region.

Long-Term Follow-Up of Lateral Canthal Resuspension.

PURPOSE: To evaluate the long-term results of lateral canthal resuspension over time. DESIGN: A cohort study of adults (n = 25, 45 eyelids) undergoing lateral canthal resuspension. METHODS: Marginal reflex distance 2 (MRD2), inferior scleral show, lateral canthal height, lateral canthal angle, horizontal palpebral aperture, and lateral scleral triangle area were measured preoperatively and at postoperative week 1, month 3, and the final follow-up visit. RESULTS: Minimum follow-up time was 6 months (mean, 15.1 months). At the final follow-up visit, MRD2 decreased by 0.41 ± 0.14 mm, inferior scleral show decreased by 0.27 ± 0.05 mm, and lateral canthal height increased by 0.81 ± 0.15 mm. The overall function of time was found to be significant for change in MRD2 (P < 0.01). In multiple comparisons, all time point values were significantly different from one another (Bonferroni corrected, P < 0.05), except for 3 months and the final position, which were not. Similarly, the overall effect of time on lateral canthus position was also significant (P < 0.01). All time points were significantly different from one another (Bonferroni corrected, P < 0.05). The overall effect of time on inferior scleral show was also significant (P < 0.01). Differences were significant from preoperative to final postoperative position, although the other time points were not significant (Bonferroni corrected, P < 0.05). No complications were noted. CONCLUSIONS: Minimally invasive lateral canthal resuspension provides durable, albeit modest, improvements in MRD2, inferior scleral show, and lateral canthal height without significantly changing lateral canthal angle, horizontal palpebral aperture, or lateral scleral triangle area.

Lateral Rectus Muscle Expands More Than Medial Rectus Following Maximal Deep Balanced Orbital Decompression.

PURPOSE: It has been reported that extraocular muscles can enlarge following orbital decompression in thyroid eye disease. In this article, the authors studied the changes in extraocular muscles size following maximal deep lateral and medial balanced decompression in a large sample of thyroid eye disease patients. METHODS: Imaging data were reviewed preoperatively and postoperatively. Radiologic proptosis was assessed. Maximal axial muscle width of the medial and lateral recti was measured. RESULTS: Data from 48 consecutive patients (75 orbits) were included. There was a significant increase in the width of both the lateral and medial recti after decompression (p < 0.01). The mean (standard deviation [SD]) change was less for the medial rectus (0.7 mm) than for the lateral (2.7 mm). This difference was significant (p < 0.01). For the lateral rectus, 80% of all decompression surgeries were associated with an increase in width of >1 mm. Mean (SD) proptosis reduction was 8.2 mm (3.4 mm). CONCLUSION: These results suggest that the extraocular muscles enlarge in the most deep lateral wall decompressions. For decompression as performed in this article, expansion tends to be more commonly found and of a greater magnitude in the lateral rectus compared with medial.

Double Vision After Minimally Invasive Orbital Decompression.

INTRODUCTION: New onset Diplopia following orbital decompression in thyroid eye disease patients is estimated to occur in up to 30% to 40% of decompression patients, mostly related to deep lateral and medial wall decompressions. METHODS: A retrospective chart review of all minimally invasive (fat and minimal bone orbital decompression performed at the UCLA Stein Eye Institute between 2005 and 2015. Inclusion criteria were thyroid eye disease patients older than 18 years undergoing fat only orbital decompression with no previous muscle surgery. RESULTS: The chart review revealed only 5 patients with new onset diplopia after this surgery. The cases are discussed and a possible mechanism for the diplopia is proposed. DISCUSSION: Double vision following minimally invasive orbital decompression is rare and the mechanisms are poorly understood.

Vemurafenib (BRAF Inhibitor) Therapy for Orbital Erdheim-Chester Disease.

Erdheim-Chester disease is a rare xanthogranulomatous systemic disease, which involves the orbit in some cases. Through this case report, the authors review the treatment modalities used in orbital Erdheim-Chester disease and explore a newer modality of treatment. Cases of orbital Erdheim-Chester disease were identified in the literature utilizing a PubMed search and all the treatment modalities were reviewed. The response to treatment of orbital Erdheim-Chester disease has been poor with the various medical and surgical treatment modalities used in the past. The authors report the use of BRAF inhibitor with a remarkable response in our case.

Interferon alfa-2b in the management of recurrent conjunctival papillomatosis.

A 2-year-old boy presented with a recurrent strawberry-like reddish mass arising from the left caruncular region for 8 months. An incisional biopsy was performed elsewhere 2 months earlier, followed by an increase in size of mass, significant epiphora, and intermittent bleeding. On examination, exuberant exophytic gelatinous mass with multifocal origin was observed arising from inferior forniceal conjunctiva and caruncle. Clinical differential of multifocal conjunctival papilloma was kept, and topical interferon alfa-2b (INFα-2b) was started. No clinical reduction in mass or symptomatology was observed over 6 weeks. Excision biopsy with cryotherapy and subconjunctival injection of INFα-2b was performed over all foci. Conjunctival papilloma was confirmed on histopathology, and topical INFα-2b was continued in postoperative period for 3 months. At 14 months of follow-up, no recurrence, epiphora, or bleeding was noticed. We advocate a possible role of local INF therapy in managing and preventing recurrences of conjunctival papillomatosis.

Prognosis of eyelid sebaceous gland carcinoma based on the tumor (T) category of the American Joint Committee on Cancer (AJCC) classification.

The purpose of this study was to evaluate the clinical features and prognosis of eyelid sebaceous gland carcinoma (SGC) based on the T category of the American Joint Committee on Cancer (AJCC) classification (7th edition). This is a retrospective interventional case series study. Based on the T category of the AJCC classification, 191 patients with eyelid sebaceous gland carcinoma were classified as T1 (n = 1, 1 %), T2 (n = 111, 58 %), T3 (n = 76, 40 %), and T4 (n = 3, 2 %). Based on multivariate analysis, the factors predictive of regional lymph node metastasis included duration of symptoms >6 months (p = 0.04) and orbital tumor extension (p < 0.001). The factors predictive of systemic metastasis included orbital tumor extension (p < 0.001) and perivascular invasion (p = 0.007). The factor predictive of death due to systemic metastasis included orbital tumor extension (p < 0.001). Kaplan-Meier estimates of regional lymph node metastasis at 5 and 10 years, respectively, were 0 and 0 % for T1, 11 and 11 % for T2, 44 and 59 % for T3, and 100 and 100 % for T4 (p < 0.001). Kaplan-Meier estimates of systemic metastasis at 5 and 10 years, respectively, were 0 and 0 % for T1, 6 and 6 % for T2, 35 and 35 % for T3, and 100 and 100 % for T4 (p < 0.001). Kaplan-Meier estimates of death due to metastasis at 5 and 10 years, respectively, were 0 and 0 % for T1, 3 and 3 % for T2, 30 and 50 % for T3, and 100 and 100 % for T4 (p < 0.001). Primary tumor (T) category of the AJCC classification predicts the prognosis of patients with eyelid SGC. The risk of systemic metastasis and death increases with increasing tumor category.

Minimally invasive surgery for thyroid eye disease.

Thyroid eye disease (TED) can affect the eye in myriad ways: proptosis, strabismus, eyelid retraction, optic neuropathy, soft tissue changes around the eye and an unstable ocular surface. TED consists of two phases: active, and inactive. The active phase of TED is limited to a period of 12-18 months and is mainly managed medically with immunosuppression. The residual structural changes due to the resultant fibrosis are usually addressed with surgery, the mainstay of which is orbital decompression. These surgeries are performed during the inactive phase. The surgical rehabilitation of TED has evolved over the years: not only the surgical techniques, but also the concepts, and the surgical tools available. The indications for decompression surgery have also expanded in the recent past. This article discusses the technological and conceptual advances of minimally invasive surgery for TED that decrease complications and speed up recovery. Current surgical techniques offer predictable, consistent results with better esthetics.

Solitary Trichoepithelioma of the Eyelid: A Clinico-Pathological Correlation.

Solitary trichoepithelioma of the eyelid is a very rare tumor, which needs to be differentiated from basaloid epithelioma and basal cell carcinoma. Diagnosis is based on clinical and histopathological examination. We present a case of an eyelid trichoepithelioma presenting as a long standing nodule with associated dermatochalasis. Although rare, this entity should be kept in the differential diagnosis of chronic, firm, nodular eyelid lesions.

NEWLY DIAGNOSED ACTIVE RETINOBLASTOMA IN ADULTS.

PURPOSE: To describe the clinical features, treatment, and outcome of retinoblastoma in adults. METHODS: Retrospective case series. RESULTS: The mean age at initial presentation of retinoblastoma was 30 years (median, 26 years; range, 22-48 years). There were four males and four females, and all manifested unilateral retinoblastoma. The mean duration of symptoms was 22 months (median, 12 months; range, 1-100 months). Six patients had intraocular retinoblastoma, and 2 had secondary orbital involvement. The eyes with intraocular retinoblastoma were classified according to the International Classification of Retinoblastoma as Group D (n = 3) or Group E (n = 3). The primary treatment for intraocular retinoblastoma (n = 6) included systemic chemotherapy (n = 1), external beam radiotherapy (n = 2), and enucleation (n = 3). Secondary treatment for tumor recurrence included enucleation (n = 2), and combination of intraarterial chemotherapy, intravitreal chemotherapy, and plaque radiotherapy (n = 1). The eyes with orbital extension of retinoblastoma were classified according to the International Retinoblastoma Staging System as Stage 3a (n = 2). The primary treatment for those with orbital extension of retinoblastoma included multimodality treatment (combination of systemic chemotherapy, orbital exenteration, and external beam radiotherapy). Systemic metastasis and related death occurred in one case. CONCLUSION: Retinoblastoma in adults is uncommon. Active tumor in this age group is usually advanced, necessitating enucleation and/or orbital exenteration.

Clinical features predictive of high-risk retinoblastoma in 403 Asian Indian patients: a case-control study.

PURPOSE: To identify the clinical features predictive of high-risk retinoblastoma on histopathology. DESIGN: Case-control study. PARTICIPANTS: A total of 145 cases with histopathologic high-risk features of retinoblastoma and 258 controls without high-risk features. METHODS: Enucleation and adjuvant chemotherapy. MAIN OUTCOME MEASURES: High-risk features on histopathology were defined as the presence of anterior chamber seeds, iris infiltration, ciliary body infiltration, massive (≥ 3 mm) choroidal invasion, postlaminar optic nerve invasion, invasion of optic nerve transection, combined nonmassive choroidal and prelaminar/laminar optic nerve invasion, or scleral/extrascleral infiltration. RESULTS: Of 403 patients who underwent primary enucleation for the treatment of retinoblastoma, 145 (36%) had high-risk features on histopathology (cases) and 258 (64%) had no high-risk features (controls). High-risk retinoblastoma occurred in 16% of (8/50) group D eyes and 39% of (137/353) group E eyes. The histopathologic high-risk features in these 145 patients included anterior chamber seeds (n = 25, 17%), iris infiltration (n = 12, 8%), ciliary body infiltration (n = 17, 12%), massive (≥3 mm) choroidal invasion (n = 69, 48%), postlaminar optic nerve invasion (n = 71, 49%), invasion of optic nerve transection (n = 3, 2%), combined choroidal and optic nerve invasion (n = 17, 12%), scleral infiltration (n = 20, 14%), and extrascleral involvement (n = 8, 6%). The mean number of high-risk features was 2 (median, 2; range, 1-7). The significant clinical features in cases versus controls included prolonged duration of symptoms of >6 months (21% vs. 7%; P < 0.001), poor visual acuity at presentation (74% vs. 64%; P = 0.05), buphthalmos (16% vs. 7%; P = 0.005), secondary glaucoma (47% vs. 15%; P < 0.001), iris neovascularization (46% vs. 22%; P < 0.001), ectropion uveae (39% vs. 14%; P < 0.001), and orbital cellulitis (3% vs. <1%; P = 0.05). On the basis of International Classification of Intraocular Retinoblastoma, group E tumor had a statistically significant higher incidence of high-risk retinoblastoma compared with controls (39% vs. 16%; P = 0.01). Multivariate analysis of clinical features at presentation that predicted high-risk features on histopathology included prolonged duration of symptoms of >6 months (P = 0.008) and secondary glaucoma (P = 0.021). CONCLUSIONS: In this study, the clinical features at presentation predictive of high-risk features on histopathology included prolonged duration of symptoms of >6 months and secondary glaucoma. Globe-preserving methods of treatment should be used with caution in patients with these features.

Lacrimal and nasal masquerades of congenital nasolacrimal duct obstructions: etiology, management, and outcomes.

The purpose of this study was to report various conditions masquerading as congenital nasolacrimal duct obstruction (CNLDO). Retrospective review was designed in a tertiary hospital setting. 92 eyes of 65 consecutive patients were included in this study. All patients presenting with CNLDO symptomatology but where the diagnosis of CNLDO was subsequently ruled out were included in the study. The study patients were recruited from a single surgeon's (MJA) tertiary eye care practice over a 3-year period from 2011 to 2013. A detailed clinical evaluation and a further lacrimal system evaluation were performed under general anesthesia. The main outcome measure was other lacrimal and nasal conditions masquerading as CNLDO. Average age at presentation was 43.49 ± 31.78 months. All cases had symptoms of either watering or discharge with an increase tear meniscus or abnormal fluorescein dye disappearance test. The commonest masquerades of congenital nasolacrimal duct obstruction include incomplete punctal canalisation (27.2 %), functional epiphora (14.1 %), punctal agenesis (14.1 %), monocanalicular obstructions (10.8 %), and presaccal stenosis (8.7 %). Each masquerade was managed specifically and at the last follow-up of 5.85 ± 10.85 months, 63 % eyes (58/92) had no epiphora and 2.2 % (2/92) eyes had occasional epiphora. Parents of patients with punctal agenesis were counseled for option of conjunctivodacryocystorhinostomy in future. Incomplete punctal canalisation is the commonest masquerade among many conditions that may mimic CNLDO and mandates a careful evaluation. Specific management of each masquerade results in satisfactory outcomes.

Simple vs complex congenital nasolacrimal duct obstructions: etiology, management and outcomes.

BACKGROUND: The aim of this study was to report the comparative clinical profiles and outcomes of simple and complex congenital nasolacrimal duct obstruction (CNLDO). METHODS: The study was a retrospective chart review of all patients presenting with CNLDO from a single surgeon's (M.J.A.) database. All patients underwent irrigation and probing under nasal endoscopic guidance. A detailed lacrimal system evaluation was performed, intraoperative findings including nasal endoscopy were documented, and etiologies of complex CNLDO were noted. Outcome measures were comparative profiles, and anatomical success and functional success of the interventions. Statistical analyses were performed using the Shapiro-Wilk test, Fisher's exact test, and Wilcoxon rank sum test. RESULTS: Ninety-five eyes of 81 patients with simple CNLDO and 100 eyes of 83 patients with complex CNLDO were compared. The mean age at presentation was 17.6 months in simple CNLDO and 45.6 months in complex cases (p < 0.001). Epiphora and discharge were the most common symptoms; 89.4% among simple cases and 92% in the complex group. The most common causes of complex CNLDO were bony obstructions (23%), craniofacial syndromes (12%), and buried probe (10%). At a mean follow-up of 5.85 months for simple CNLDO and 4.68 months for complex CNLDO, anatomical success and functional success was noted in 97.8% and 94.7%, respectively, in simple CNLDO, and in 58% and 51%, respectively, in complex CNDLO (p < 0.001). CONCLUSION: Bony obstruction, craniofacial syndrome, and buried probe were the most common reasons for a complex CNLDO, noted commonly in older children, with irrigation and probing having much poorer outcomes when compared with simpler obstructions.