Orbital abscess: 20 years' experience at a tertiary eye care center.

PURPOSE: To study the clinical, microbiological profile and management outcomes of orbital abscess at a tertiary care center in South India. MATERIAL AND METHOD: In a retrospective interventional case series, we reviewed all patients diagnosed with orbital cellulitis from 2000-2020. The data analyzed included demographic profile, clinical and radiological features, microbiological profile, and management outcome. RESULTS: A total of 921 cases of orbital and periorbital infections were reviewed. Seventy-two cases were diagnosed as orbital cellulitis. Thirty-four cases (47.22%) had radiological evidence of orbital abscess. The median age was 20.63 years. Three patients (8.82%) were neonates. A male preponderance was noted (23, 67.65%). Sinusitis (10, 29.41%) and diabetes (5, 14.7%), were the most common predisposing factors. Optic neuropathy was seen in 15 (44.11%) patients, cavernous sinus thrombosis in two patients (5.88%), and septicemia in one patient (2.94%) Multiple orbital abscesses were noted in 7 (20.59%) cases. All patients underwent surgical drainage. Methicillin-sensitive Staphylococcus aureus was the most common organism isolated in 14 patients (41.18%). Vision improvement or stabilization was seen in all except 3 (8.82%). CONCLUSION: Orbital abscess is a potential sight-threatening orbital infection. The infective process can spread and ascend up to involve cavernous sinus thereby becoming life-threatening. A timely diagnosis and intervention can halt the disease process and help restore vision in many cases.

Clinical profile, imaging features and short term visual outcomes of Indian optic neuritis patients with and without seromarkers for myelin oligodendrocyte glycoprotein and neuromyelitis optica.

PURPOSE: To analyze clinical profile, imaging features, and short-term visual outcomes of optic neuritis patients in Indian population with and without seromarkers for myelin oligodendrocyte glycoprotein (MOG)/neuromyelitis optica (NMO). METHODS: Electronic medical records of 203 optic neuritis patients who presented between June 2018 and December 2019 to the Neuro-ophthalmology services of a tertiary care center in India were retrospectively analyzed. RESULTS: Of 203 patients, 57 patients (28.08%) were positive for MOG-antibody and 20 patients (9.85%) were positive for NMO antibody. 114 patients (56.16%) were double-negative (negative for both antibodies) and 12 patients (5.91%) were diagnosed as multiple sclerosis (MS). None of the patients had both antibodies. Mean age of presentation was 31.29 ± 1.035 years. There was female preponderance in NMO-optic neuritis (NMO-ON) and MS-optic neuritis (MS-ON) groups (1:5). Mean vision on presentation was worse (logMAR 1.570 ± 0.863) in NMO-ON group. The mean visual acuity showed statistically significant recovery (logMAR 0.338 ± 0.639) in the final follow-up in MOG-optic neuritis (MOG-ON) group. Multivariate logistic regression analysis revealed poor visual outcome in patients presenting with retrobulbar neuritis, optic disc pallor, bilateral sequential optic nerve involvement, and with positive NMO antibody. Optic neuritis patients presenting with disc edema associated with pain and positive for MOG antibody were found to have a better visual outcome. CONCLUSION: In this Indian optic neuritis cohort, the prevalence of MOG-ON was higher than NMO-ON. MOG-ON had a better visual outcome than NMO-ON. The incidence of MS-ON was less compared to the western literature. A significant number of patients (114 patients, 56.16%) were double negative for both seromarkers and yet had presented with optic neuritis with no clinical or imaging features suggestive of MS/MOG associated disease (MOG AD)/NMO spectrum disorder (NMO SD).

Intraocular Pressure in the Eyes of Patients With Carotid-Cavernous Fistulas: Profile, Intereye Asymmetry, and Treatment Outcomes.

PRECIS: Secondary ocular hypertension (OHT) is common in carotid-cavernous fistulas (CCFs). Management of elevated intraocular pressure (IOP) is possible with a multidisciplinary approach. The ipsilateral normal eyes may have higher IOP than the contralateral eyes. PURPOSE: To study the IOP profile of the eyes of patients with a CCF, treatment outcomes for elevated IOP, and intereye IOP asymmetry in the eyes with normal IOP. METHODS: This was a retrospective case series. A total of 64 eyes of 60 patients with digital subtraction angiography-proven CCF diagnosed from the year 2000 to 2016 were included. The demographics, clinical features, management, and outcomes were recorded. The primary outcome included understanding of the cause of elevated IOP. The secondary outcomes included comparison of the IOP between contralateral eyes and ipsilateral normal eyes (IOP <21 mm Hg) and management outcomes for elevated IOP. RESULTS: The mean age of the patients was 45.6±18.2 years. In the study population, 70% of the patients were males. Indirect CCF was present in 55% of the eyes. It was found that 64.06% (n=41) of the eyes had elevated IOP, glaucoma, or were glaucoma suspects. Among all the eyes, 40.62% (n=26) of the eyes had secondary OHT due to elevated episcleral venous pressure, whereas 7.81% (n=5) of the eyes had secondary open-angle glaucoma. The mean IOP was higher in the ipsilateral eyes than in the other eyes (22.95±7.1vs. 15.11±2.99 mm Hg; P<0.001). The mean IOP in the ipsilateral normal eyes was higher than that in the contralateral eyes, with a mean difference of 2.92±2.29 mm Hg (confidence interval of the mean difference: 1.90-3.94 mm Hg; P<0.0001). IOP reduction (<21 mm Hg) was achieved in 70.7% of the patients following CCF management with intermittent carotid massage, endovascular treatment, IOP-lowering medications, or a combination among these. CONCLUSIONS: Secondary OHT due to elevated episcleral venous pressure was more common than secondary open-angle glaucoma. Ipsilateral normal eyes had higher IOP than contralateral eyes. IOP-lowering agents and management of CCF resulted in IOP control in most patients.

Diagnosis in a case total ophthalmoplegia - where time is life.

Rhino-orbito-cerebral mucormycosis is a potentially fatal fungal infection seen in poorly controlled diabetics or immunocompromised patients who can present initially to an ophthalmologist, otorhinolaryngologist or a neurologist. The clinical presentation to an ophthalmologist may be that of painful ophthalmoplegia.The confirmation and further management of the infection requires an interdisciplinary approach. A timely diagnosis and intervention can be life-saving. This article depicts the typical fulminant course and diagnostic evaluation of rhino-orbito-cerebral mucormycosis.

A Time Bomb Defused, In Time! A Traumatic Optic Neuropathy To Be Wary Of.

Authors describe a case of traumatic pseudoaneurysm of cavernous internal carotid artery in a young male who presented with complaints of progressive decrease in vision, inability to move the eye, and delayed epistaxis 8 months after the head injury sustained during a motor vehicle accident. The presence of optic atrophy and epistaxis in the setting of head trauma alerted the authors to look for this potentially life-threatening condition. Timely intervention in the form of endovascular coil occlusion of the internal carotid artery was performed and the epistaxis stopped without any ischaemic or thromboembolic sequaelae.

A Tale of Absent Crystalline Lens in an Eye with Retinoblastoma.

PURPOSE: To report the clinicopathological correlation of absent crystalline lens in an eye with retinoblastoma. METHODS: A 1-year-old female child was brought to our patient services for pain and swelling in the right eye since the past few months. The child was diagnosed to have bilateral retinoblastoma and was suspected to have absence of crystalline lens in the right eye on the basis of clinical findings and ocular imaging. After 3 cycles of chemotherapy for suspected extraocular extension of tumor, she underwent enucleation. Absence of crystalline lens was confirmed on both gross and microscopic pathology. RESULTS: We present a child with retinoblastoma, suspected to have absence of crystalline lens clinically and on ocular imaging (ultrasound and MRI), which was finally confirmed on ocular pathology examination post enucleation. CONCLUSION: We report for the first time clinicopathologically proven absence of crystalline lens in an eye with retinoblastoma.

ACCIDENTAL DUPLICATION: Role of Intralesional Bleomycin in Orbital Lymphangioma: A Prospective Study.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jaapos.2017.03.007. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

A prospective study of the role of intralesional bleomycin in orbital lymphangioma.

PURPOSE: To evaluate the efficacy of intralesional bleomycin injection in the management of lymphangiomas of the orbit. METHODS: This prospective noncomparative interventional case study included 13 patients with orbital lymphangiomas. Reconstituted bleomycin 1-5 ml (0.5 IU/kg body weight; maximum, 15 IU/ml) was injected with 2% lignocaine in the lesion as seen on imaging or, in deeper lesions, under ultrasound guidance. Repeat injections were administered when required after every 4 weeks. The decision to retreat was based on clinical and radiological evidence of response. RESULTS: Patients were treated with 1-6 injections of bleomycin 0.5 IU/kg body weight. Dramatic response was achieved in all cases. During the mean follow-up period of 19.69 months (range, 7-26 months) none of the patients experienced recurrence or significant complication. CONCLUSIONS: In this patient cohort lymphangiomas of the orbit showed favorable and promising results with intralesional injections of bleomycin. This treatment should be considered as a first-line therapy for lymphangiomas of the orbit.

Role of high-resolution computerized tomography chest in identifying tubercular etiology in patients diagnosed as Eales' disease.

BACKGROUND: The high resolution computerized tomography of chest is an important diagnostic imaging tool to identify any pulmonary tubercular lesion. It's role in Eales' disease to identify any possible association with pulomonary tuberculosis has not been studied earlier. So, this study was conducted to assess the role of high resolution computerized tomography (HRCT) chest in identifying tuberculous etiology in Eales' disease. RESULTS: It was a retrospective study conducted at a tertiary care eye hospital in South India between January 2009 and October 2014 were included. A total of 29 diagnosed cases of Eales' (24 male and 5 female) were included in the study. These patients were followed up for a mean period of 739.75 days. Out of them, 13 (44.8%) had bilateral and 16 (55.2%) had unilateral ocular involvement. Eight cases (34.5%) patients had vitreous inflammation. Mantoux test was positive in 12 (41.4%) cases and chest x-ray suggestive of TB was present in four cases (13.8%). QuantiFERON TB gold was positive in 15 (51.7%) and HRCT chest suggestive of TB was positive in 15 (51.7%) case. Out of 15 Eales' cases with positive HRCT scan suggestive of TB, the commonly noted lesions were calcified nodules 34.5%, mediastinal hilar lymphadenopathy 13.8%, parenchymal soft tissue lesions in 3.4%. Five (17.2%) cases underwent pars plana vitrectomy for non resolving vitreous hemorrhage and one case underwent retinal attachment surgery with encirclage. Six patients were started on 9 months regimen of ATT by the chest physician. Final visual outcome improved in 17(40.5%) eyes, maintained in 21(50%) eyes but vision deterioration in 7(16.7%) eyes. CONCLUSIONS: HRCT chest is an important diagnostic tool to rule out pulmonary tuberculosis in Eales' disease.

The diagnostic yield of neuroimaging in sixth nerve palsy--Sankara Nethralaya Abducens Palsy Study (SNAPS): Report 1.

AIMS: The aim was to assess the etiology of sixth nerve palsy and on the basis of our data, to formulate a diagnostic algorithm for the management in sixth nerve palsy. DESIGN: Retrospective chart review. RESULTS: Of the 104 neurologically isolated cases, 9 cases were attributable to trauma, and 95 (86.36%) cases were classified as nontraumatic, neurologically isolated cases. Of the 95 nontraumatic, isolated cases of sixth nerve palsy, 52 cases were associated with vasculopathic risk factors, namely diabetes and hypertension and were classified as vasculopathic sixth nerve palsy (54.7%), and those with a history of sixth nerve palsy from birth (6 cases) were classified as congenital sixth nerve palsy (6.3%). Of the rest, neuroimaging alone yielded a cause in 18 of the 37 cases (48.64%). Of the other 19 cases where neuroimaging did not yield a cause, 6 cases were attributed to preceding history of infection (3 upper respiratory tract infection and 3 viral illnesses), 2 cases of sixth nerve palsy were found to be a false localizing sign in idiopathic intracranial hypertension and in 11 cases, the cause was undetermined. In these idiopathic cases of isolated sixth nerve palsy, neuroimaging yielded no positive findings. CONCLUSIONS: In the absence of risk factors, a suggestive history, or positive laboratory and clinical findings, neuroimaging can serve as a useful diagnostic tool in identifying the exact cause of sixth nerve palsy. Furthermore, we recommend an algorithm to assess the need for neuroimaging in sixth nerve palsy.

Cataract surgery in a case of carotid cavernous fistula.

A carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. The ocular manifestations include conjunctival chemosis, proptosis, globe displacement, raised intraocular pressure and optic neuropathy. Although management of CCF in these patients is necessary, the ophthalmologist may also have to treat other ocular morbidities such as cataract. Cataract surgery in patients with CCF may be associated with many possible complications, including suprachoroidal hemorrhage. We describe cataract extraction surgery in 60-year-old female with bilateral spontaneous low-flow CCF. She underwent phacoemulsification via a clear corneal route under topical anesthesia and had an uneventful postoperative phase and recovered successfully. Given the various possible ocular changes in CCF, one must proceed with an intraocular surgery with caution. In this communication, we wish to describe the surgical precautions and the possible pitfalls in cataract surgery in patients with CCF.

Tubercular sclerouveitis masquerading as an ocular tumor: a case report.

PURPOSE: To report the diagnosis of a case of tubercular sclerouveitis, which masqueraded as an ocular tumor. DESIGN: Case report. METHODS: Retrospective medical chart review including serological, radiological, and histopathological investigative results. RESULTS: A patient presented with recurrent episodes of sclerouveitis in his right eye. Serological investigations for infective and connective tissue disorders were negative. Radiological investigation was suggestive of a scleral perforation. The eye was enucleated and histopathological examination showed chronic inflammation. Polymerase chain reaction of the ocular tissue was positive for IS1160 for Mycobacterium tuberculosis. CONCLUSION: Infective scleritis should be suspected in cases of scleritis that progress despite treatment. Polymerase chain reaction is instrumental in diagnosing challenging cases.

Clinical profile, evaluation, management and visual outcome of idiopathic intracranial hypertension in a neuro-ophthalmology clinic of a tertiary referral ophthalmic center in India.

AIM: To discuss the clinical features and management of patients who presented with optic disc edema and had features of presumed idiopathic intracranial hypertension (IIH). MATERIALS AND METHODS: Case series of all patients diagnosed to have IIH from January 2000 to December 2003 in the neuro-ophthalmology clinic of a tertiary referral ophthalmic institution, were retrospectively analyzed. Analysis was done for 50/106 patients who fulfilled modified Dandy's criteria and had optic disc edema and a minimal follow-up period of two years. RESULTS: Most (40/50, 80%) of the patients were females and the mean age of presentation for all the 50 patients was 32.89 years. Chief complaints were headache in 38 (76%) patients, 24(48%) patients had transient visual obscuration, 24 (48%) patients had reduced vision, 15 (30%) patients had nausea, vomiting, 4(8%) patients had diplopia. Bilateral disc edema was seen in 46 (92%) patients and unilateral disc edema in 4 (8%) patients. 60 eyes had enlarged blind spot as the common visual field defect. Neuroimaging revealed prominent perioptic CSF spaces in 14 patients and empty sella in three patients. CSF opening pressure was 250-350 mm H2O (water) in 39 patients and was >350 mm H2O in 11 patients. Medical treatment was started for all patients; whereas 35 [70%] patients responded, 15 [30%] patients had to undergo LP shunt.

Extraocular muscle cysticercosis - a clinical challenge to the ophthalmologists.

PURPOSE: To report our experience with extraocular myocysticercosis, to highlight the role of ultrasound and orbital computerized tomography (CT) scan in these cases and to discuss the management. METHODS: This is retrospective study of 35 cases of orbital myocysticercosis confirmed on ultrasound and CT scan of the orbit. RESULTS: There were 18 males and 17 females. The average age of these patients was 19.6 years. The most common presenting feature was restricted ocular motility with diplopia and recurrent pain and redness. Ultrasound examination and CT scan of the orbit done for all these patients identified the cyst and the affected muscle. All extraocular muscles were noted to be involved in myocysticercosis. However the lateral rectus, medial rectus and the superior oblique were affected to a greater extent. All cases dramatically improved on treatment with albendazole and oral steroids. Surgical excision of cyst was done in 6 cases. CONCLUSION: A high index of suspicion should be entertained for extraocular muscle cysticercosis, especially in cases of acquired ocular motility disorder with recurrent ocular congestion. Ultrasound and CT scans of orbit play a vital role in diagnosis. Medical therapy with albendazole under cover of steroids is effective in most of the cases.