Clinicopathological profile, management and clinical outcomes in recurrent cases of ocular surface squamous neoplasia at a tertiary care centre.

PURPOSE: This study was taken up to look into the various causes of recurrence, clinicopathological profile and final outcomes in recurrent cases of ocular surface squamous neoplasia (OSSN). METHODOLOGY: A prospective cohort study was conducted and total 18 patients were recruited. All patients were subjected to detailed history, comprehensive eye examination and imaging studies. A treatment plan was formulated based on the size and extent of the lesion. The primary outcome measure was complete response to treatment with no evidence of recurrence after12 months and secondary outcome measure was complication associated with each treatment modality. RESULTS: The common cause of recurrence in our study was misdiagnosis of the lesion as in 15 cases it was diagnosed as pterygium and in 03 cases it was actinic keratosis. Excision Biopsy with adjunctive cryotherapy was the preferred treatment modality followed by topical interferon-alpha 2b drop-in our study. We could achieve good outcomes in terms of complete response to the treatment in 16 cases. The complication associated with this treatment was minimal in our study as few patients complained redness and irritation which subsided after application of topical lubricants. There was no sign of recurrence even at 12 months of follow-up in all 18 cases. CONCLUSION: The current study provided clinicopathological characteristics and treatment outcomes in recurrent cases of OSSN. In our study, adopting appropriate treatment strategy, regular follow-up to assess the response to treatment and change over to new treatment plan in cases with inadequate response helped in achieving good outcomes in recurrent cases of OSSN.

Surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in unilateral congenital ptosis with poor levator function.

PURPOSE: To compare the surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in patients of unilateral congenital ptosis with poor levator function (≤ 4 mm). MATERIALS AND METHODS: This randomized control study was conducted over a period of 18 months. 44 patients were enrolled in the study group. The study population was randomly divided into two groups (22 in each group). In Group A, congenital ptosis was treated with tarsofrontalis sling surgery using silicon rod and supramaximal levator resection was done in the group B. Follow-up examination was done at postoperative day 1, one week, 1 month, 6 months and 12 months. Surgical outcome measures were change in marginal reflex distance-1 (MRD 1), vertical palpebral fissure height (VPFH) and inter-eyelid difference of margin reflex distance 1 and complications in two groups. RESULTS: The mean age of patients in group A was 7.25 ± 6.10 years ranging from 1-18 years and mean age of patients in group B was 5.64 ± 2.44 years ranging from 3 to 11 years. Good surgical outcome was obtained in 73-77% of both groups. MRD1and VPFH increased significantly after surgery from baseline in both the groups (p value < 0.001). Inter-eyelid MRD 1 difference also improved significantly in both groups following ptosis surgery. CONCLUSION: Both supramaximal levator resection and tarsofrontalis sling surgery are equally effective in cases of unilateral ptosis patients with poor levator function and should be part of the surgical armamentarium for treating congenital ptosis.

Comparison of changes in blood pressure in phacoemulsification cataract surgery performed via topical and peribulbar anaesthesia: A cohort study.

Background: The purpose of study was to compare the changes in blood pressure in patients undergoing phacoemulsification cataract surgery under topical and peribulbar anaesthesia during preoperative, intraoperative and postoperative period. Methods: In this prospective cohort study, 240 patients undergoing phacoemulsification were divided into topical (Group 1) and peribulbar (Group 2) equally. Proparacaine 0.5% drops were used for topical anaesthesia, and Inj lignocaine with Inj bupivacaine were used to give peribulbar anaesthesia. Preoperative blood pressure was taken 30 min before surgery with automated sphygmomanometer. Intraoperative blood pressure was taken during phacoemulsification, and postoperative blood pressure was taken 1 h after surgery. Outcomes assessed were systolic, diastolic and mean blood pressure. Results: Systolic blood pressure in Group 1 was significantly increased in the intraoperative phase, whereas it was significantly decreased in Group 2 in the intraoperative phase. Diastolic and mean blood pressure in Group 1 showed no significant change, whereas in Group 2, both showed significant reduction in intraoperative and postoperative phases. Conclusion: The increase in intraoperative systolic blood pressure in topical group could be due to discomfort from microscope light, iris manipulation, irrigation and aspiration during surgery. The decrease in intraoperative systolic and diastolic blood pressure in peribulbar group could be due to systemic absorption of local anaesthetic. The mean preoperative systolic blood pressure was also higher in the topical group, which could be due to anxiety or stress under topical anaesthesia. The changes in blood pressure need to be observed so that timely intervention can be made to achieve favourable postoperative outcome.

Corneal transplantation: A walk to vision.

Corneal diseases are a major cause of blindness in the world. Corneal transplantation has been a cornerstone in the management of several of these advanced pathologies. This article discusses the evolution of corneal transplantation over a century, its indications, complications and briefly the various surgical techniques. Such tremendous technical improvisations from total corneal transplantation to lamellar keratoplasties have generated significant interest in the ophthalmic world and garnered momentum to the fight against blindness. Armed Forces Medical Services are also in vogue more than ever in this forward surge.

Efficacy and safety of injection Botulinum toxin in canalicular obstruction due to trauma.

Background: The treatment of epiphora has undergone tremendous change in the past, and minimally invasive techniques are being preferred over traditional surgical options. One of them is the use of Inj Botulinum toxin, but there are very few studies that have explored its role in treating post-traumatic epiphora. This study was undertaken to find out the safety and efficacy of injection Botulinum toxin in treating epiphora due to canalicular obstruction following trauma. Methods: A longitudinal interventional study was done, and a total of 50 patients were recruited. All patients were subjected to Inj Botulinum toxin in the lacrimal gland (10 units). The study was done for a period of 6 months, and patients were followed up for a period of another 6 months. Changes in Munk score, Schirmer test, and tear meniscus height were considered the main outcome measures. Results: In our study, there were 38 males and 12 females. The age of the patients varied from 24 yrs to 67 yrs. Inj Botulinum toxin was found to be effective in 80% (n = 40/50) of cases as they reported a reduction in watering from eyes after administration of this injection. The complication associated with this treatment was minimal in our study as four patients reported diplopia, whereas two patients developed Ptosis that resolved spontaneously within two months. Conclusion: Inj Botulinum toxin was found to be effective in epiphora caused by canalicular obstruction due to trauma. This treatment should be considered as an alternative treatment modality as it often leads to satisfactory reduction in epiphora in patients with less complications compared to surgical intervention.

Recurrent spontaneous subluxation of the eye globe managed with orbital decompression: A case report with literature review.

Spontaneous subluxation of the eyeball is a rare phenomenon as there are only few cases reported in the literature. It is a sight-threatening condition and very traumatising for the patient. The globe has to be reposited back within the socket immediately to save vision and to prevent exposure keratitis and optic neuropathy. In all published reports about subluxation of the eyeball, the underlying aetiology which was responsible for this condition was found. Herein, we report a case of recurrent spontaneous subluxation of the eyeball in which the cause could not be ascertained in a middle-aged male patient even after thorough clinical examination and investigation. The case was managed successfully with three-wall orbital decompression and tarsorrhaphy. The patient did not experience any episode of subluxation of the globe following surgery as orbital decompression increased the available space for the orbital contents, thereby averting its occurrence.

Small incision lenticule extraction (SMILE) refractive surgery: Our initial experience.

Background: Small incision lenticule extraction (SMILE) is femtosecond laser based, minimally invasive, flap-free refractive surgery gaining worldwide acceptance as a safe alternative to flap based refractive surgeries. Methods: A retrospective data review study was done where preoperative and postoperative data were collected for 202 eyes of 101 patients who underwent SMILE surgery at a tertiary care Armed Forces hospital from Jan 2019 to Dec 2019. All participants included in the study were followed up for 3 months postoperative period. Results: Mean age of the participants was 24.139 ± 0.515 years (males 22.1 years, females 25.3 years). Male participants were 36 (72 eyes) while female participants were 65 (130 eyes). Of the participants, 75.2% underwent the procedure for cosmetic indication, while 24.8% underwent clearing some medical examination later. Preoperative UCVA was 1.049 ± 0.028 logMAR units, which improved on first postoperative day to 0.038 ± 0.01 logMAR units, at 1 wk 0.015 ± 0.01 logMAR units, at 1 month 0.006 ± 0.005 logMAR units and at 3 months postoperative period to 0.03 ± 0.003 logMAR units. There were two adverse events of difficult lenticule extraction with small (<1 mm) cap tear. Conclusion: SMILE surgery is a flap-free refractive surgical technique. It reduces postoperative complications like dry eyes and flap-related complications. Hence, it may be recommended for all serving personnel after a thorough preoperative screening protocol.

Bilateral cranial nerve involvement with facial asymmetry in a case of goldenhar syndrome.

A 9-year-old male patient presented with recurrent episodes of corneal ulcers in both eyes since the age of 2 years. The patient had profound bilateral hearing loss and multiple left-sided preauricular skin tags. He was diagnosed with neurotropic keratitis with bilateral corneal anesthesia in both eyes and on further work-up was diagnosed to have Goldenhar Syndrome with features of left-sided facial skeletal hypoplasia and bilateral auditory nerve atresia. The patient was managed by multiple specialities with standard of care medications, therapies, and procedures and is presently thriving. Goldenhar syndrome is a rare congenital disorder which involves ocular, auricular, and cranial nerves along with facial and vertebral anomalies. The insufficient knowledge of its pathogenesis and variable clinical presentations present a challenge in timely diagnosis and management of these cases. The involvement is generally unilateral and unilateral skeletal asymmetry with bilateral cranial nerve involvement is a rare event. The wide variation in clinical presentation and under diagnosis of these cases in India mandates a better understanding of this entity among medical professionals to facilitate early diagnosis and favorable clinical outcomes.

Tear film abnormalities in pseudoexfoliation syndrome and normal healthy participants: A comparative analysis.

BACKGROUND: Pseudoexfoliative material is being implicated in causing tear film abnormalities, and the aim of the present study was to prove it and to compare with the normal healthy participants. METHODS: A total of 398 eyes of 200 participants were studied, and two groups were formed. The first, pseudoexfoliation syndrome (PEXS) group, included 198 eyes of 100 patients, and the second, age-matched control group, included 200 eyes of 100 participants. Tear film abnormalities were compared in the two groups by tear meniscus height (TMH), Schirmer test I, Schirmer test II and tear film break-up time (TBUT). RESULTS: On comparing the two groups using independent t-test, a significant difference was found in Schirmer test I, Schirmer test II, and TBUT between the PEXS group (Schirmer test I: 23.98 ± 10.68 mm, Schirmer test II: 17.11 ± 8.78 mm, and TBUT: 9.778 ± 5.54 s) and the age-matched control group (Schirmer test I: 27.08 ± 9.58 mm, Schirmer test II: 19.98 ± 8.48 mm, and TBUT: 13.495 ± 5.65 s) (p = 0.003 [Schirmer test I]; p = 0.001 [Schirmer test II]; and p < 0.001 [TBUT]). However, an insignificant difference was found in terms of TMH (p = 0.195) between the two groups. CONCLUSION: PEXS affects tear production and leads to unstable tear film.

Hyperglycaemia as a risk factor for the development of retinopathy of prematurity: A cohort study.

BACKGROUND: Retinopathy of prematurity (ROP) is a preventable cause of childhood blindness. Without treatment, over 45% of eyes can develop permanent visual loss. Hyperglycaemia has recently been described as a risk factor for the development of retinopathy of prematurity (ROP), a proliferative vascular disease of the retina that primarily affects premature infants. The characteristic neoproliferative growth of blood vessels in the retina is very well under stood with the clinical and experimental experiences with Diabetic retinopathy. The purpose of this study was to evaluate a possible relation between glucose levels in VLBW (Very Low Birth Weight) infants and development of ROP. METHOD: All at risk infants of a Neonatal Intensive Care Unit (NICU) of a tertiary care centre in western India were included in the study. The blood sugar values of the neonates were recorded at multiple times during their first week of life. On completion of 31 weeks of gestational age or 04 weeks of birth age, the neonates were subjected to ROP screening as per standard protocols. RESULT: A total of 103 neonates were included in the study and were subjected to ROP screening. A total of 32 neonates developed ROP at the end of the study. It was found with statistical significance that the neonates with higher average blood glucose values in the initial period of life had higher incidence of ROP at the time of screening with a Relative Risk of 2.506 (CI = 1.287, 4.882). CONCLUSION: A high average blood glucose level in neonates during the first week of life is an indicator for developing ROP at a later date. These neonates should be kept under close follow up in order to facilitate timely detection and prompt intervention.

Sheets glide-assisted versus Busin glide-assisted insertion techniques for descemet stripping endothelial keratoplasty (DSEK): A comparative analysis.

BACKGROUND: The donor lenticule insertion techniques play a crucial role in outcomes following descemet stripping endothelial keratoplasty (DSEK) and the current study is aimed to compare two of the commonly performed donor lenticule insertion techniques in DSEK. METHOD: Descemet stripping endothelial keratoplasty was performed in 48 eyes of 48 patients at two tertiary eye care centers from January 2014 to December 2016. At one center (Group 1), 26 patients had Sheets glide-assisted lenticule insertion whereas at other center (Group 2), 22 patients had Busin glide-assisted insertion of donor lenticule. Best corrected visual acuity (BCVA), manifest spherical equivalent, manifest cylinder, endothelial cell density (ECD) and percentage of endothelial cell loss (ECL) were compared between the two groups at 6 months after DSEK. In addition, intraopertaive and postoperative complications were also compared. RESULTS: At 6 months after DSEK, an insignificant difference was observed in BCVA [Group 1: 0.48 logarithm of the minimum angle of resolution (log MAR); Group 2: 0.50 log MAR (p = 0.74)], mean manifest spherical equivalent [Group 1: 0.64 diopter (D); Group 2: 0.59 D (p = 0.74)], mean manifest cylinder [Group 1: 1.35 D; Group 2: 1.32 D (p = 0.92)] and mean ECL [Group 1: 26.75%; Group 2: 28.76 (p = 0.44)] between the two groups. In addition, the rate of complications is similar between the two groups. CONCLUSIONS: Both Sheets glide-assisted and Busin glide-assisted donor lenticule insertion techniques are associated with similar surgical outcomes after DSEK.

Study of distribution of white-to-white corneal diameter and anterior chamber depth in study population obtained with optical biometry using intraocular lens (IOL) master.

BACKGROUND: This study was conducted to measure the distribution of white to white (WTW) corneal diameter and anterior chamber depth (ACD) in the study population by using optical biometry. METHODS: It was a cross-sectional observational study conducted at an Ophthalmology Out Patient Department of a Tertiary Care Centre. Optical biometry was performed in 650 eyes of the 325 patients using IOL Master and WTW and ACD were recorded. Differences in gender, and age-related alterations were analysed statistically. RESULTS: 195 (60%) subjects were males and 130 (40%) were females. Age of the study population ranged from 13 to 82 years and the mean age was 36.79 years. The mean WTW in the study population was 11.79 mm ± 0.05 mm and the mean ACD was 2.74 mm ± 0.03 mm. Mean WTW and ACD in male subjects was significantly greater than that of female subjects (p value < 0.001). No significant difference in WTW or ACD was seen between the various age groups. No correlation was seen between WTW and ACD in the study population. CONCLUSION: Mean WTW and ACD were smaller as compared to other population studies using intraocular lens (IOL) Master. This distribution has paved the way for a population based nomogram for our country which will help us plan surgeries in a better way.

A clinical study to describe the corneal topographic pattern and estimation of the prevalence of keratoconus among diagnosed cases of vernal keratoconjunctivitis.

BACKGROUND: Association of keratoconus with vernal keratoconjunctivitis is well known, but there are few topographic studies describing actual prevalence especially in India where it is a common condition. There is also scarce literature on the topographic patterns and subclinical topographic anomalies in cases of vernal catarrh and their relationship with various subtypes. This study was conducted to estimate the prevalence of subclinical keratoconus among Indian subjects with vernal keratoconjunctivitis and describe the various topographic abnormalities which can help in screening for these cases. METHODS: In the cross-sectional study conducted at a tertiary care center, 76 established cases of vernal keratoconjunctivitis were evaluated with placido disc-based videokeratography for topographic abnormalities and early keratoconus based on modified Rabinowitz-McDonnell criteria. RESULTS: Seventeen (11.2%) eyes satisfied both the modified Rabinowitz-McDonnell criteria of keratoconus. Corneal topographic pattern analysis showed asymmetric bowtie with inferior steepening in 17.11% of the patients. None of these patients had clinical evidence of keratoconus. CONCLUSIONS: The study showed 11.2% prevalence of keratoconus in patients suffering from vernal keratoconjunctivitis. The findings highlight the importance of using a simple placido disc-based corneal topography system for screening the patients with vernal keratoconjunctivitis for keratoconus. This can help in early detection and preventive intervention.

Prevalence of corneal astigmatism before cataract surgery in Western Indian Population.

BACKGROUND: The prevalence and nature of corneal astigmatism among cataract surgery candidates has not been well-documented in Indian population. The purpose of the study is to analyse prevalence and presentation patterns of corneal astigmatism (CA) in cataract surgery candidates. METHODS: Keratometric values were measured in patients before cataract extraction. Descriptive statistics of CA were analysed including the assessment with age ranges. RESULTS: Mean CA of 223 eyes of 223 patients [mean age 61 ± 10 years (range, 29-90 years)] was 0.88 ± 0.61 (95% CI, 0.80-0.96) with 27.8%, 51.1% and 21.1% having with the rule (WTR), against the rule (ATR) and oblique astigmatism (OBL) respectively. Between 40 and 50 years, ATR exceeds WTR and reaches 100% by 80 years. A trend of less negative CA was seen up to 60 years and then increases up to 90 years. CA was below 0.25 dioptre (D) in 17.5% of eyes, between 0.25 and 1.25 D in 63.7% and ≥1.50 D in 18.8% of eyes. CONCLUSIONS: Considering CA < 1.25 D in majority of cataract surgery candidates, it is preferable to perform inexpensive keratorefractive procedures rather expensive toric IOLs, especially in developing world.

A clinical correlation of conjunctival microangiopathy with grades of retinopathy in type 2 diabetes mellitus.

BACKGROUND: Conjunctival microangiopathy has been described among diabetics similar to retinal vessel angiopathy. Correlation of these conjunctival microangiopathy changes with retinopathy may form the basis of screening by external examination without expert fundus evaluation. METHODS: Conjunctival vessels widths and tortuous segment length of conjunctival vessels of 96 patients with type 2 diabetes mellitus were photographed and measured by the Zeiss Fundus camera Visupac software. The measurements were correlated with retinopathy grade in those eyes. RESULTS: The mean conjunctival vessel width was 40.61 µ (SD 17.25) with a uniform increase from 34.4 µ (SD 8.70) in mild NPDR to 53.50 µ (SD 33.45) in the PDR group which was statistically significant (p < 0.01). The tortuous conjunctival vessel segment length increased from 711.51 µ (SD 83.90) in the mild NPDR group to 921.94 µ (SD 129.26) in those with PDR (p < 0.01). Vessel width greater than 80 µ was seen only in PDR and tortuosity values greater than 900 µ were seen in severe grades (severe NPDR and PDR). Both conjunctival vessel width and tortuosity showed a positive statistical correlation with increasing severity of retinopathy (r = 0.386, r2 = 0.149 and r = 0.645, r2 = 0.415). CONCLUSION: A positive correlation was seen between conjunctival vessel width and tortuosity with severity of retinopathy. Widths over 80 µ and tortuous segment length over 900 µ are suggestive of severe grades of retinopathy.

Comparison of efficacy of three surgical methods of conjunctival autograft fixation in the treatment of pterygium.

Our aim primarily was to compare the recurrence rate with three techniques of conjunctival fixation (suture versus fibrin glue versus autologous in situ blood coagulum) over bare sclera following pterygium excision. Ninety eyes of 90 patients with primary pterygium were randomly divided into three groups: group I (30 eyes) underwent autografting and fixation with 8-0 vicryl sutures, group II (30 eyes) with fibrin glue and group III (30 eyes) with autologous in situ blood coagulum. The patients were reviewed on 2nd day, weeks 1 and 4, and at every 3 months till 12 months after surgery. Rate of recurrence was similar (p = 0.585) across the three groups. Time taken for surgery for Group 1 was more as compared to group 2 (p < 0.001) and group 3 (p < 0.001). Also, group 2 cases took significantly more time as compared to group 3 (p < 0.001). Postoperative patient discomfort (foreign body sensation, epiphora, pain and irritation) was more in suture-assisted autografting as compared to the other two groups. However, at some points along the time line, patient discomfort was significantly more in group III as compared to group II. Complications like graft retraction, graft displacement and cyst formation were seen in a few patients but were not statistically significant across the three groups. All three techniques were found to be useful methods and were associated with similar rate of recurrence.

Clinicodemographic profile, management, and treatment outcomes in advanced retinoblastoma at a tertiary care center in North India.

PURPOSE: The study was undertaken to look into the clinicodemographic profile, management, and clinical outcomes of advanced retinoblastoma at a tertiary care center. METHODS: A prospective cohort study was conducted from Jan 2019 to Dec 2022. Forty-two patients of intraocular advanced retinoblastoma were assessed. The treatment protocol was formulated based on size, extension of tumor, and laterality. Primary outcome measure was response to the treatment in terms of regression of tumor and seeds and no evidence of recurrence after 12 month in enucleated eyes. Secondary outcome measures were complications like implant exposure, metastasis, and death associated with each treatment modality. RESULTS: The mean age of the study group was 13 months. The most common presentation was leukocoria with diminished vision. Most of the patients had group E retinoblastoma ( n = 40, 95%) as per the International Classification of Retinoblastoma. In 12 patients with group E retinoblastoma, primary enucleation was performed and in six patients, secondary enucleation was done, in which initially, globe salvage treatment was tried. In 30 patients, globe salvage treatment was attempted and we could manage to save 23 eyes. The most common treatment modality was intra-arterial chemotherapy using a triple-drug regimen. One patient developed intracranial spread and died due to systemic metastasis during the follow-up period. CONCLUSION: The current study showed that globe salvage is possible in advanced retinoblastoma if appropriate therapy is instituted depending upon the extent of the tumor and availability of latest treatment modalities. Intra-arterial chemotherapy using triple drugs can be offered as a first-line therapy in advanced unilateral retinoblastoma as it has been found to be very effective in the present study.

An observational study on the presence of perilimbal conjunctival pigmentation in vernal keratoconjunctivitis.

Purpose: To evaluate presence of perilimbal pigmentation (PLP) in Indian patients with vernal keratoconjunctivitis (VKC). Methods: A cross sectional study was conducted from 2019 to 2020 at a tertiary eye care center in Western Maharashtra, India. In this study, 152 cases of VKC were identified. The presence, type, color, and extent of PLP were recorded. The incidence of presence of PLP was calculated. Its correlations with severity and duration of VKC were analyzed using Wilcoxon-Mann-Whitney U test and Chi square test. Results: Of 152 cases, 79.61% were males. Mean age at presentation was 11.4 ± 5.6 years. The characteristic PLP was present in 81 cases (53.29%; 95% confidence interval [CI]: 45.03%-61.42%; P < 0.001), of which 15 cases (18.5%) had this pigmentation in all the four quadrants. There was a significant difference between the groups with respect to quadrants involvement in terms of the extent of PLP in clock hours (χ2 = 73.85, P < 0.001). However, the extent did not correlate with age (rho = 0.08, P = 0.487), sex (P = 0.115), time since onset in months (rho = 0.03, P = 0.77), duration of VKC and type or color of PLP (P = 0.12). Conclusion: Perilimbal pigmentation seems to be a consistent clinical finding seen in a significant number of VKC cases. It may benefit ophthalmologists in treating VKC cases when the palpebral/limbal signs are elusive.