Surgical Outcomes in Cases of Marcus-Gunn Jaw-Winking Phenomenon.

BACKGROUND: Markus-Gunn Jaw-winking Phenomenon (MGJW) is a congenital ptosis associated with synkinetic movement of upper lid on masticating movements of jaw. It results from aberrant connection between motor division of trigeminal nerve and oculomotor nerve. OBJECTIVE: To investigate the clinical characteristics of MGJW phenomenon and evaluate its surgical outcomes of unilateral levator excision and frontalis suspension. METHOD: It is a retrospective analysis of nine cases of MGJW phenomenon seen from 2007 to 2013 AD. The clinical features were recorded and analysed. Unilateral levator excision and frontalis suspension for the correction of synkinesis and ptosis was done for all the patients. The result of surgery was analysed. RESULT: MGJW phenomenon was seen more in males. All the cases had unilateral ptosis with jaw winking phenomenon. Ipsilateral hypotropia and refractive errors were seen in 44%. One week post operative margin reflex distance was good in 67% of cases. Persistent jaw-winking was seen in 3 cases, two underwent repeat surgery to abolish the synkinesis. At one year follow up, 33% had good margin reflex distance of more than 4mm and 22% had fairly good margin reflex distance of 3mm. CONCLUSION: Patients with Marcus Gunn jaw winking synkinesis can present at a wide age range. There may be an associated vertical muscle imbalance, which should be managed before ptosis surgery to avoid ptosis under correction. Unilateral frontalis flap suspension combined levator excision can correct ptosis very well for patients with Marcus-Gunn syndrome.

Outcomes of external dacryocystorhinostomy and endoscopic endonasal dacryocystorhinostomy in the management of nasolacrimal duct obstruction.

INTRODUCTION: Dacryocystorhinostomy (DCR) is the treatment of choice for nasolacrimal duct obstruction. Although external DCR is regarded as the gold standard, endoscopic DCR is evolving as an equally-effective alternative. Objectives To compare the success rate of treating nasolacrimal duct obstruction by endoscopic endonasal method compared to the conventional DCR surgery. Materials and methods This prospective, comparative, non-randomised study was conducted in 2009 - 2010. Thirty consecutive patients undergoing endoscopic endonasal DCR (Group 1) and 30 consecutive patients undergoing external DCR (Group 2) between July 2009 and September 2010 at the oculoplasty unit of the Tilganga institute of ophthalmology were included in this study. A patent lacrimal passage on syringing and symptomatic improvement at six months after surgery was defined as a successful outcome. The intraoperative and postoperative complications were also compared. Results Our study included 31 eyes of 30 patients in Group 1 and 34 eyes of 30 patients in Group 2. The success rate for endoscopic endonasal dacryocystorhinostomy was 90.3 % (95 % confidence interval 80 - 100) and external dacryocystorhinostomy was 94.1 % (95 % confidence interval 80 - 100). The difference of surgical success among the two methods was not statistically significant (p = 0.7). The rate of intra-operative and post-operative complications was similar in the two methods (p = 0.5). CONCLUSION: The short term outcomes and complication rates of endoscopic endonasal dacryocystorhinostomy and external dacryocystorhinostomy were similar.

Frontalis Sling Operation using Silicone Rod Compared with Autogenous Fascia Lata for Simple Congenital Ptosis.

INTRODUCTION: To evaluate the cosmetic results and recurrence of unilateral frontalis sling surgery using a silicone rod compared with autogenous fascia lata in cases of simple congenital ptosis. METHODS: This is a retrospective comparative study of 59 patients who underwent a frontalis sling operation for congenital ptosis. Patients were divided into two groups according to the sling material used; an autogeneous fascia lata (fl) group (n = 24) and a silicone rod group (sl) (n = 35). Cosmetic results and recurrence rates were compared between these 2 groups. The cosmetic results of the frontalis sling operation were assessed as good, fair, or poor based on the difference between the Margin Reflex Distance (MRD) of both eyelids and graded as good if the difference in two eyes was ≤1mm and poor if it was 2mm or more. Recurrence was defined as the conversion of the cosmetic result from good or fair to poor category. RESULTS: At postoperative day seven and 30, MRD of both the groups were good but on three months follow-up MRD of silicon rod group dropped, however it was not statistically significant .Lid contour was good in both the groups, however, lid symmetry was poor in two cases of fascia lata at three months follow-up. Repeat surgery for poor outcome was done in 8.6% of cases in silicon rod and 8.3% of fascia lata group. CONCLUSIONS: The frontalis sling operation using either a silicone rod or autogenous fascia lata showed equally good cosmetic results and lower recurrence rate at three months follow up.

Retinoblastoma: geographic distribution and presentation at a tertiary eye care centre in Kathmandu, Nepal.

INTRODUCTION: Several aspects of retinoblastoma in Nepal remain enigmatic. OBJECTIVE: To assess the demographic and geographic distribution, clinical presentation, and treatment methods of retinoblastoma at a tertiary level ophthalmic institution in Kathmandu, Nepal. MATERIALS AND METHODS: A retrospective analysis of all the patients diagnosed with retinoblastoma at Tilganga Institute of Ophthalmology from July 2004 to June 2008 was performed. The main outcome measures included region of residence, treatment options and histopathological findings. The histopathological analysis was performed on enucleated and exenterated specimens. STATISTICS: The statistical analysis was performed with SPSS Version 11.5. Descriptive statistics are represented as mean ± standard deviation. All tests were two-sided and the P-values of less than 0.05 were considered statistically significant. RESULTS: Thirty patients presented with retinoblastoma during the study period. The mean age at presentation was 2.5 ± 1.6 years (range five months to seven years). Ten of the 12 patients who presented with bilateral retinoblastoma (83 %) were from the Terai region of Nepal. The ratio of unilateral to bilateral cases in the Terai region was 1:2. This differed significantly with the ratio in the hilly region (Fisher's Exact Test, p = 0.0012). The mean duration of symptoms before presentation was 2.5 3.2 months (range three days to 12 months). Twenty-four patients (80 %) presented with leukocoria. Eleven patients (36.6 %) presented with leukocoria as their only symptom. Ninety-seven percent of the patients underwent either enucleation (90 %) or exenteration (6.7 %) of at least one eye. CONCLUSION: Bilateral retinoblastoma is more prevalent in the Terai region of Nepal. The majority of the patients present with leucokoria and are treated with enucleation.

Bilateral retinoblastoma in early infancy.

INTRODUCTION: Retinoblastoma is the most common primary intraocular malignancy of childhood. It is usually diagnosed before the age of 5 years. In spite of its early onset in most children, retinoblastoma is rarely diagnosed congenitally or even within the first 3 months of life. OBJECTIVE: To report a case of retinoblastoma in early infancy. CASE: This was a case of the earliest presentation of retinoblastoma in a female child 20 days after birth. The presenting complaint was of leucokoria noticed by the mother 13 days after birth. The father of the child was also found to have a suspicious lesion of retinocytoma in one eye and regressed retinoblastoma in the other eye. CONCLUSION: For early diagnosis of the disease, awareness and knowledge about the modes of presentation of the disease are very important. Similarly, the ophthalmic examination of the parents and siblings with retinoblastoma should always be done to exclude the disease.

Bruckner red light reflex test in a hospital setting.

BACKGROUND: Childhood blindness is a major problem in developing world including Nepal that needs to be addressed. OBJECTIVE: The objective of study was to measure the effectiveness of the Bruckner red reflex test for screening of posterior segment opacities in children. METHODS: Patients aged less than five years who came to the Tilganga Institute of Ophthalmology, Kathmandu from March to August, 2009 were recruited in this cross-sectional descriptive study. Children were screened with the Bruckner red light reflex test in a dark room. Patients with abnormal Bruckner tests had their eyes dilated for further investigations. Abnormalities were recorded. The number of patients with an abnormal Bruckner test was recorded and correlated with their potential pathology. RESULTS: A total of 172 patients with 97 boys and 75 girls were included. Twenty-three had abnormal Bruckner test results in either one or both eyes. Four of these twentythree patients had no pathology diagnosed; hence the sensitivity of the Bruckner screen to diagnose significant pathology was calculated at 82.6%. Of the 153 patients with normal results, two patients were found to have pathology detected, which included cataract and strabismus. Hence, the specificity of this test was 98.7%. The screening test had a positive predictive value of 90.5% and a negative predictive value of 97.4%. CONCLUSION: Bruckner test screening is a sensitive and specific marker for detecting the posterior segment opacities in children. We recommend utilizing the test to evaluate these problems where other technologies are rare.

Retinoblastoma in a 37 years old man in Nepal: a case report.

Retinoblastoma is extremely rare in adults. We report a case of Retinoblastoma diagnosed by histopathology in an enucleated specimen of a 37 year old patient who presented with pain and diminished visual acuity with intraocular mass and serous detachment. CT head and orbit showed uniform hyperdense mass in nasal quadrant of left globe projecting into adjacent vitreous cavity. Chest X Ray and USG abdomen was unremarkable. Initially provisional diagnosis of amelanotic melanoma was made. In view of nil visual prognoses enucleation was done. Sections from the enucleated eyeball showed diffuse proliferation of tumour cells. These tumour cells were small sized with scanty cytoplasm, and oval and hyper chromatic nuclei. A diagnosis of poorly differentiated Retinoblastoma was made with TNM (AJCC) stage as T1NXMX. This paper highlights the delayed presentation of retinoblastoma in adult. Although retinoblastoma is rare in adult, we suggest keeping retinoblastoma in differential diagnosis of intraocular mass until proven histopathology report is available.

Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation.

BACKGROUND/AIMS: The aim of the study was to compare surgical outcomes of external dacryocystorhinostomy (DCR) with and without silastic intubation for treatment of primary uncomplicated nasolacrimal duct obstruction (NLDO). DESIGN: The study was a prospective randomised trial conducted at the Tilganga Eye Centre (Kathmandu, Nepal). METHODS: One-hundred consecutive patients with uncomplicated primary NLDO were randomly assigned into two groups (44 underwent DCR with silastic intubation and 56 underwent DCR without intubation). Patients were re-assessed at 1 week, 6 weeks and 6 months after surgery. Success was defined objectively by irrigation of the puncta without regurgitation and subjectively by the absence of epiphora or discharge. RESULTS: The success rate at 6 months was 90% for DCR with silastic intubation and 87% for DCR without silastic intubation. There was no statistically significant difference between the two groups (p = 0.77). No complications were encountered in either group. Silicone tubes increased surgical cost by 20% at the Tilganga Eye Centre. CONCLUSION: DCR without silastic intubation is less expensive than DCR with silastic intubation in primary uncomplicated NLDO, and has a similar success rate. DCR with silastic intubation may create increased burden for patients in the form of more post-surgical follow-up visits. In cases of uncomplicated primary NLDO, the use of silastic intubation in DCR may be unnecessary.

A retrospective study on the causes for evisceration at Tilganga Eye Centre.

BACKGROUND: Evisceration is one of destructive surgery of eye after which a patient loses his hope of restoration of sight forever. AIM AND OBJECTIVES: To identify the major causes of evisceration at a tertiary eye centre of Nepal. MATERIALS AND METHODS: This is hospital based retrospective study of patients presented at Tilganga eye centre, Kathmandu, Nepal over a period of two years (10 Nov 2004 to 10 Nov 2006). Out of 2,31,976 total OPD patients, 71 patients who had evisceration with or without implant were selected and finally, only 67 patients record were enrolled for study as data were insufficient in the remaining records to fi ll up the study format. Data processing and analysis done using computer SPSS 11.5. RESULTS: A total of 67 cases, with age ranging from 1.5 years to 85 years, out of which 33 male and 34 were female. Evisceration was performed most commonly due to trauma and it's subsequent sequele in 37 cases (55.2% of total cases), who were within the age group of 30 - 59 years (p = 0.033) and predominantly male 25 cases(p = 0.001). Most of the patients presented from outside Kathmandu valley, with visual acuity of no perception of light. CONCLUSION: Evisceration without implant was most common surgical procedure, with trauma being the leading cause for it and most of the trauma was seen in active, potential and young male patients. So prevention of ocular injuries together with early treatment protocol is best way to decrease the rate of evisceration due to ocular trauma. To prevent ocular injuries news paper, television and health education may play an important role.

Intestinal parasitosis among subjects undergoing cataract surgery at the eye camps in rural hilly areas of Nepal.

Present study investigated the intestinal parasitosis among 221 subjects undergoing cataract surgery (M: 129 and F: 92; aged 13-86 years) at the eye camps in three rural hilly districts (Ramechhap, Sindhupalchok and Dhading) in 2006. Stool samples collected in clean, dry, screw capped plastic containers were examined locally by direct smear technique and anti-parasitic drugs were distributed to parasite positive subjects. The remaining stool samples were fixed with 10% formal-saline, transported to Shi-Gan Health Foundation/Nat'l Inst of Trop Med and Public Health Research, Kathmandu and re-examined by formal-ether sedimentation technique. A total of 148 samples (66.9%) were positive for some kind of intestinal parasites (F: 68.5% and M: 65.9%; P > 0.05). Ramechhap (Manthali) and Sindhupalchok (Chautara) had higher positive rate (71.8% and 70.7%, respectively) than in Dhading (Salyantar) (60.0%) (P > 0.05). Tibeto-Burman (indigenous nationalities) ethnic group had highest positive rate (70.1%) compared with Indo-Aryan (64.7%) and Dalits (57.7%). Subjects without toilet (latrine) had marginally higher positive rate (69.7%) than those having toilet at their home (65.5) (P> 0 .05). Age was independent of positive rate. Vegetarians had marginally higher parasitic infection rate compared to their non-vegetarian counterparts. Helminths were more common than protozoa. Overall, hookworm was the commonest parasite detected. However, Ascaris was common in Dhading District. Entamoeba histolytica was most common among protozoa and was followed by Cyclospora and others.

Involuntary human bite to the eyebrow.

Human bites to the face are very rare and only one case of human bite to the eyebrow has so far been reported. The final functional and cosmetic result of reconstruction mainly depends on the size of the injury, the viability of the tissue and the promptness of surgical intervention. We here present one case of human bite to the eyebrow that resulted in complete avulsion and loss of tissue due to delayed presentation to the hospital. The lesion was reconstructed in two stages with good functional and decent cosmetic outcome. Unfortunately long term follow up was not possible for this patient.

A scale to assess activities of daily living in persons affected by leprosy.

The aim of this study was to develop a scale for identifying disability among people in the rural areas of developing countries. The studies were carried out in the Green Pastures Hospital and the leprosy field programme of the Western Region of Nepal. With the help of staff experienced in working with people with disability, a 68-question questionnaire was made, based on the International Classification of Impairments, Activities and Participation (ICIDH-2). A survey was carried out of 269 people affected by leprosy who had impairments, as well as a sample of those who were unimpaired. The survey results were used to develop the questionnaire into a scale, using standard scale development methods. This included checking of criterion validity, discrimination and reliability and stability using weighted kappa statistics. Of the 68 questions, 38 were included in the second draft of the instrument. Eight questions were added to identify difficulty in relationships, about the use of aids and about occupation and employment. The sum score of the scale against the expert score gave a Spearman correlation coefficient of 0.72. Intra- and inter-interviewer reliability coefficients were 0.77 (95% CI 0.73-0.81) and 0.61 (95% CI 0.56-0.67), respectively. The stability test gave an overall kappa of 0.76 (95% CI 0.70-0.82). Four questions with particularly poor results were omitted from the final draft of the instrument. An interview-based instrument was developed for identifying limitations in activities of daily living (disability) in people living in a rural setting in a developing country--the Green Pastures Activity Scale (GPAS). The scale performed well during validity and reliability testing. It consists of 34 activity questions, five relationship questions, and three questions on the use of aids, occupation and employment.