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Nandini Bothra, Richa Dharap Wagh, Mohammad Javed Ali Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad 500034, Telangana, IndiaCorrespondence: Nandini BothraGovindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500034, Telangana, IndiaEmail nan_bothra@yahoo.comIntroduction: Dacryocystocele can be congenital or acquired and acute or chronic, based on underlying pathology. An inferomedial anterior orbital mass lesion can masquerade an acquired dacryocystocele with similar symptomatology; however, the treatment varies. Hence, a careful examination of the swelling to differentiate these masquerades is needed to ensure rightful treatment.Patients and Methods: A retrospective, interventional study was performed on consecutive patients from January 2017 to October 2019 who presented with swelling in the lacrimal sac area of varying durations. They underwent computed tomography scans followed by surgical intervention. Their relation to the lacrimal drainage apparatus was explored.Results: During the study period, 5 such patients were found in the records. The radiology was consistent with anterior orbital mass lesions, not involving the lacrimal sac. Histopathology after surgical excision was consistent with three of the lesions being dermoid cysts, one was cavernous hemangioma and one was a solitary fibrous tumor.Conclusion: Inferomedial anterior orbital mass lesions can present as masquerades of acquired dacrycystoceles. Careful examination and high degree of suspicion is needed to distinguish these lesions and ensure correct treatment.Keywords: dacryology, dacryocystocele, lacrimal, medial orbital dermoid, solitary fibrous tumor of the lacrimal sac

Aim: Our aim was to analyze the clinical presentation, genealogical features and genetic mutations of three homogenous familial isolated pituitary adenoma (FIPA) families with acromegaly. Materials and Methods: Six cases from three FIPA families non multiple endocrine neoplasia (MEN1)/Carney complex (CC) were evaluated clinically, biochemically and genetically. Results: After reviewing clinical history, examination and laboratory profile (biochemical and hormonal) of all the family members, MEN1 and CC were ruled out. Median age at initial symptom was 22 years; most common presenting symptoms were acral enlargement and arthralgia. Two patients of one family (mother and son) had gigantism at presentation. All affected individuals were first-degree relatives. Index cases had either macro or micro adenomas on presentation whereas all individuals diagnosed on screening had macro adenomas. Two patients of one family (nephew and paternal uncle) had macro adenoma with cystic changes with partial empty sella on magnetic resonance imaging (MRI). All the patients except one, underwent trans-sphenoidal surgery and one required radiation post-operatively. One patient was treated with medical management. Genetic analysis is in process. Conclusion: In the absence of MEN1 or CC, somatotropinomas can occur within families as isolated pituitary adenomas. FIPA families have individuals affected across generations In this series 33% had micro adenoma, two of them had gigantism. Genetic characterization can give us further insight into their prognosis. [ABSTRACT FROM AUTHOR]

Background: To investigate the geometric morphological differences of the lacrimal punctum by analyzing its shape in relation to age and sex in a normal population., Methods: 960 high-magnification slit-lamp images were obtained from 320 puncta of normal asymptomatic Indian individuals across eight decades of life. Using advanced geometric morphometric techniques, including Elliptic Fourier Analysis and Principal Component Analysis, the intricate details of the lacrimal punctum's shape in a diverse population sample were categorized by age and sex. High-resolution images of the lacrimal punctum underwent standardization for scale and orientation, followed by precise landmark identification and coordinate data extraction., Results: The geometric morphometry of the lacrimal punctum shows significant changes as one ages. However, the gender differences, in isolation, without consideration of age, remain subtle and are not pronounced. Interestingly, detailed Principal Component scores analysis revealed potential sex- and age-related variations specifically for the left and right lower puncta, which warrant further investigation. These changes could reflect unique aging changes in the proximal lacrimal drainage system., Conclusion: The study is a starting point for geometric morphometric analysis of the lacrimal punctum and provides valuable insights into the punctal changes in size, orientation, and overall morphology across different age groups and between sexes. These findings highlight the significance of considering individual age-wise anatomical variations to better understand the lacrimal punctum., Competing Interests: Declaration of Competing Interest The authors declare no competing interests and no conflicts of interest., (Copyright © 2024 Elsevier GmbH. All rights reserved.)

Objective: To describe the management and outcomes of patients with radiation-induced acquired lacrimal duct obstructions (RALDO)., Methods: A retrospective chart review from July 2018 to December 2023 of all cases undergoing surgical intervention for RALDO by a single surgeon. Data collected included demographics, tumor type and anatomic location, radiation treatment (including radiation type, dosage, and duration), interval between radiation and reported onset of epiphora, oculoplastic clinical examination, management, and outcomes. Lacrimal irrigation was done prior to surgery in all patients., Results: Seventeen eyes of 16 patients with a mean age at presentation of 63.3 years and over half the patients being females (56.3%) were included in the study. The right lacrimal drainage system (LDS) was involved in 4 (23.6%), and the left side was involved in 13 (76.4%). The mean onset of epiphora symptoms after radiation was 9.5 months. The underlying tumor type were intraocular having uveal melanoma in four, cutaneous squamous cell carcinoma in 2, basal cell carcinoma involving forehead and nose in one and sino-nasal indications present in 8 patients. One patient had metastasis to the orbit and eyelid. Four patients (25%) received external beam radiotherapy (XRT) (one case had bilateral LDS involvement), 6 patients (37.5%) received intensity-modulated radiation therapy (IMRT), 5 patients (31.25%) received proton beam irradiation (PBI), and one (6.25%) received stereotactic body radiotherapy (SBRT). Mean radiation dosage was 61.31 Gy in 15 patients (data was missing in 1 patient). Punctum was effaced in 3, canalicular stenosis in 1, proximal canalicular obstruction in 8, distal canalicular obstruction in 2, and nasolacrimal duct obstruction (NLDO) in 3. Treatment was based on the site and nature of obstruction and varied from minimally invasive techniques like serial dilatation with bicanalicular silicone tube or Guibor tube to surgical interventions like dacryocystorhinostomy (DCR) or conjunctivo-dacryocystorhinostomy (C-DCR). Only 10% with primary lacrimal intubation had good response. Of the six cases that underwent C-DCR with Jones tube either as primary or secondary procedure, four cases showed improvement in epiphora (67%). Three with NLDO did well after external DCR. In total, four patients had a secondary procedure after the first failed while 7 with failed initial surgery elected against secondary surgery. The mean follow-up was 9.6 months (range 2-24 months)., Conclusions: In patients with RALDO, salvage treatment with silicone lacrimal intubation has poor results, CDCR with Jones tube has better results, although imperfect and in cases with NLDO, DCR has good outcomes.

Purpose: To explore the endoscopic and histopathologic characteristics of the lacrimal sac (LS) and the nasolacrimal duct in cases with punctal agenesis presenting with LS swellings., Methods: This is a prospective, interventional study of 13 LSs of 8 patients presenting with punctal agenesis and LS swellings over a 5-year study period (June 2018-July 2023). Complete ophthalmic examination was performed along with CT scans of the orbits. The LS was exposed with an anterior lacrimal crest incision and explored. The exterior and interior of the sac swelling were examined and LS flaps were sent for histopathological analysis., Results: The mean age of the patients was 23 years with a male:female ratio of 5:3. All patients presented with swelling in the LS region. Occasional epiphora was the presenting feature in 6 patients. All patients had both upper and lower punctal agenesis on the affected side with associated LS swelling. CT scans showed a hypodense cystic swelling with expansion of the LS fossa and bony nasolacrimal duct ending abruptly short of the inferior meatus. Intraoperatively, the LS had thin, translucent walls with mucoid secretion and an absence of common canalicular opening. Histopathological analysis showed epithelium consistent with LS with less robust development of the sac walls and poorly structured lacrimal drainage-associated lymphoid tissue with scanty stromal inflammation., Conclusions: The development of LS and the nasolacrimal duct is structurally affected in patients with punctal agenesis. Retrograde approaches for epiphora resolution are not logical in such cases but conjunctivodacryocystorhinostomy with Jones tube can be a feasible option., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

3p deletion syndrome or deletion 3p25-pter syndrome is an exceptionally rare genetic disorder characterized by deletion of the distal segment of the short arm of chromosome 3. There are less than a hundred reported cases worldwide. Clinical characteristics include severe physical and mental retardation, trigonocephaly, micrognathia, and diffuse hypotonia. The common ocular manifestations include congenital ptosis and canthal anomalies. To the best of the authors' knowledge, no lacrimal drainage anomalies have been reported earlier. The present case describes proximal lacrimal drainage anomalies in a patient with 3p deletion syndrome. The patient was successfully managed with membranotomy and punctal and canalicular dilatation, resulting in a complete resolution of epiphora.

Pierre-Robin sequence consists of a classical triad of micrognathia, glossoptosis, and upper airway obstruction. The common ocular manifestations include congenital glaucoma, high myopia, maculopathy, and retinal detachment. Except for a mention of a nasolacrimal duct obstruction without many details, lacrimal drainage anomalies have not been reported earlier to the best of the authors' knowledge. The present case describes several lacrimal drainage anomalies including supernumerary puncta, canalicular wall hypoplasia, grossly dilated nasolacrimal duct, and complex congenital nasolacrimal duct obstruction in a patient of Pierre Robin sequence. The patient was successfully managed with endoscopic guided probing and marsupialization of the large intranasal cyst resulting in a complete resolution of epiphora.

Objective: To describe in detail the lacrimal drainage system anomalies and review of literature in patients with Goldenhar syndrome, Rubinstein-Taybi syndrome (RTS), and Ectodermal-Ectrodactyly-Clefting syndrome (EECS), their management and outcomes., Methods: A retrospective chart review from January 2011-June 2023 of all cases presenting to the Dacryology clinic with Goldenhar syndrome, RTS, and EECS was obtained. Data collected included demographics, laterality, clinical presentations, proximal and distal lacrimal drainage anomalies, associated systemic features, management, and outcomes., Results: Eight children with Goldenhar syndrome ( n  = 13), three with RTS ( n  = 5) and three with EECS ( n  = 5) presented with lacrimal drainage system involvement. Cases with Goldenhar syndrome showed male predominance (5/8), and the mean age at presentation was 14.75 months. Four cases had simple CNLDO, seven cases with complex CNLDO (4 - buried probe and 3 - atonic sacs) and a single neonate presented with bilateral dacryocele. Patients with RTS presented with mean age of 36.33 months with male predominance. Probing under endoscopic guidance explored the anatomy thoroughly and those with altered nasal anatomy increased the probability of complex CNLDO. Those with EECS ( n  = 5) presented with a greater involvement of proximal lacrimal drainage system compared with Goldenhar syndrome and RTS, including anomalies like punctal agenesis, incomplete punctal canalization (IPC), ectopic puncta, canalicular stenosis, and complex CNLDO., Conclusions: A step-wise approach to assessing the proximal and lacrimal drainage system in those affected with craniofacial malformations and addressing them can result in satisfactory outcomes for the majority of patients.

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., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To investigate the effects of lacrimal drainage obstructions on the lacrimal gland activity and if there exists a potential link between the two., Methods: Direct assessment of the lacrimal gland activity from the palpebral lobe was performed in consecutive patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction (PANDO), along with Ocular Surface Disease Index (OSDI), non-invasive tear break up time (NIBUT; Oculus K5M), tear meniscus height and Schirmer I. The primary outcome measure was the difference in the tear flow rate between the eye with PANDO and the contralateral uninvolved eye., Results: Thirty patients (median age, 45.5 years; 25 females) with unilateral PANDO had epiphora for a mean duration of 20 months. The mean OSDI score was 6.3. NIBUT (mean 11.56 vs 11.58 s; p=0.49) and Schirmer I values (mean 18.83 vs 19.4 mm; p=0.313) were not significantly different between PANDO and non-PANDO eyes. The morphology of the palpebral lobe (size 29.3 vs 28.6 mm 2 , p=0.41) and the number of lacrimal ductular openings (median 2 vs 2.5) were similar between the two eyes. The mean tear flow from the lacrimal glands of the PANDO side was significantly reduced compared with the contralateral uninvolved side (0.8 vs 0.99 µL/min; p=0.014))., Conclusion: Tear flow rate from palpebral lobes of patients with unilateral lacrimal outflow obstruction shows a significant reduction compared with the contralateral side. The potential ways of communications between the tear drainage and the tear production mechanisms need to be explored further., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To discuss the clinical spectrum and management strategies in patients with post-traumatic canalicular fistula (PTCF)., Methods: Retrospective, interventional case series of consecutive patients diagnosed with PTCF over a 6-year study period between June 2016 and June 2022. The demographics, mode of injury, location, and communication of the canalicular fistula were noted. The outcomes of several management modalities including dacryocystorhinostomy, lacrimal gland therapies, and conservative approaches were assessed., Results: Eleven cases with PTCF over the study period were included. The mean age at presentation was 23.5 years (range: 6-71 years), with male: female ratio of 8:3. The median time interval between trauma to presentation at the Dacryology clinic was 3 years (range: 1 week to 12 years). Seven had iatrogenic trauma and four had the canalicular fistula following primary trauma. Management modalities pursued include conservative approach for minimal symptoms, and dacryocystorhinostomy, dacryocystectomy, and lacrimal gland botulinum toxin injection. The mean follow-up period was 30 months (range: 3-months-6 years)., Conclusion: PTCF is a complex lacrimal condition and the management of the PTCF needs a tailored approach guided by its nature and location and patient symptomatology.

Purpose: To investigate the effect of botulinum toxin (BTX) and partial orbital lobe dacryoadenectomy (POLD) on the main lacrimal gland functions using the direct assessment of its secretory activity., Methods: A pilot study involving 14 subjects (mean age, 42.16 years) with proximal bicanalicular block ( n  = 9) or complete punctal effacement ( n  = 5) received either intraglandular 2.5 units of BTX ( n  = 7) or underwent the POLD procedure ( n  = 7). Dynamic assessment of tear secretion from the palpebral lobes was performed as per standard protocols. The parameters studied included Schirmer I, changes in the glandular outflow, and the neurosensory secretory lag., Results: Schirmer I values showed a mean reduction of 5.25 mm (range, 2-8 mm) following BTX injection, and mean tear flow decreased from 1.46 μ l / min to 1.11 μ l / min ( P  = 0.15). The POLD group showed a significant mean reduction of 0.45 μ l / min in mean tear flow at 1 month ( P  = 0.03) and 0.32 μ l / min at 3 months of follow-up ( P  = 0.20). However, there was no statistically significant change of the Schirmer values in the POLD group at 3 months., Conclusion: Direct assessment of lacrimal gland function can be used to monitor changes following the gland therapies. Although POLD shows a significant reduction in short term, significant surgical improvisation would be needed for it to be effective in long term. A larger study is ongoing to further our understanding.

Purpose: To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy., Methods: Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height (TMH) pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora., Results: The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma., Conclusion: The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

Epstein-Barr virus (EBV) associated dacryocystic retention presents with an acute swelling in the lacrimal sac area with epiphora and lymphadenopathy. The patient would usually have a preceding history of infectious mononucleosis with clinical features of fever, pharyngitis, preauricular and cervical lymphadenopathy, hepatosplenomegaly, subclinical hepatitis, nausea, and palatine petechiae. The present case is of a 3-year-old child who presented with a sudden painless swelling in the lacrimal sac region with epiphora. Investigations and a biopsy helped in establishing the diagnosis of EBV-associated dacryocystic retention which resolved completely with conservative management.

Punctal keratin cyst (PKC) is a rare disorder believed to be due to ectasia of the vertical canaliculus. The etiopathogenesis of this disorder is very poorly understood due to the paucity of literature. To the best of authors' knowledge, only two cases of punctal keratin cyst have been described earlier, which presented as cystic lesions. The authors report four cases of punctal keratin cyst which differ in clinical presentation and also describe the anterior segment ocular tomography features, which aids in recognition and diagnosis of this rare disorder. The key message of the article is that lack of a defined cyst on clinical examination and optical coherence tomography (OCT) cannot rule out the presence of a PKC. A combination of clinical, radiology, and histopathology are confirmative of the diagnosis. Once diagnosed, the subsequent outcomes with membranotomy and keratin curettage are excellent.

Purpose: To investigate the presence of septae within the lacrimal abscess and to explore simple aspiration as an alternative to the traditional management by incision and drainage., Methods: Prospective, interventional pilot study involved eight lacrimal sac abscesses of eight patients over a period of three months. All patients underwent a pre-operative MRI with surface coils followed by aspiration of the abscess ( n  = 4) or incision and drainage of the abscess ( n  = 4). An intra-sac endoscopic evaluation was performed during the abscess drainage. Primary outcome measures - presence or absence of septae on MRI scan images and endoscopic evaluation of the abscess cavity. Secondary outcome measures - relief from pain and symptoms following aspiration and anatomical patency following definitive management., Results: Eight patients underwent either aspiration ( n  = 4) or incision and drainage of the abscess ( n  = 4). Mean age of the patients 43.3 years and male to female ratio was 1:1. Left eye involvement was more common (Right: left = 1:3). Average duration of acute symptoms - 3.75 days. High resolution MRI showed a well- defined abscess cavity with few undulations which on endoscopic evaluation correlated with oedematous mucosal folds. There was absence of a loculi or septae within the abscess cavity. Definitive surgery in the form of endoscopic DCR was performed for all the patients with post-operative FICI grading was +5., Conclusion: The present study refutes the presence of septae within the abscess cavity and proposes aspiration of the lacrimal sac abscess as a minimally invasive procedure with minimal logistics and a shallow learning curve.

Competing Interests: M.J.A. receives royalties from Springer for his treatise “Principles and Practice of Lacrimal Surgery,” and “Atlas of Lacrimal Drainage Disorders,” and “Video Atlas of Lacrimal Drainage Surgery.” The remaining authors declare that they have no conflicts of interest to disclose.

Competing Interests: M.J.A. receives royalties from Springer for his treatise “Principles and Practice of Lacrimal Surgery,” and “Atlas of Lacrimal Drainage Disorders,” and “Video Atlas of Lacrimal Drainage Surgery.” N.B. declares that there is no conflicts of interest to disclose.

Competing Interests: None

Purpose: To describe a previously unreported association of keratoconus in congenital distichiasis., Methods: Observational case series of ocular findings in 2 siblings with congenital distichiasis., Results: A 17-year-old male presented with tearing and photophobia in both eyes. His parents revealed that he was photophobic since birth. He had a lid surgery previously in both eyes. Clinical examination revealed a central scar with Descemet membrane tear suggestive of healed hydrops in the right eye. The left eye showed topographic features of keratoconus. His younger sibling, a 14-year-old female, also had similar symptoms of photophobia and tearing since birth. She had undergone electrolysis in both eyes. At the present visit, she had an epithelial defect with congestion in the right eye. Electrolysis of the distichiatic eyelashes was performed along with bandage contact lens application, which relieved her symptoms. Her topography revealed subclinical keratoconus in both eyes. The siblings' father also had complaints of photophobia since birth and had lid surgery and electrolysis in the second decade of his life., Conclusions: Patients with congenital distichiasis may have associated keratoconus. Chronic ocular irritation and subsequent eye rubbing in distichiasis could be the risk factor for keratoconus.

The efficient electrochemical conversion and storage devices can be boosted by the development of cost-effective and durable electrocatalysts. However, simultaneous in-depth understanding of the reaction mechanism is also required. Herein, we report the preparation, characterization, and electrochemical activities of bimetallic Ni x Co 1- x NPs and core-shell Ni x Co 1- x @Ni x Co 1- x O NPs stabilized on N-doped carbon nanotubes (NCNTs). The electrocatalyst is derived from a bimetallic MOF {[Ni 0.5 Co 0.5 (bpe) 2 (N(CN) 2 )](N(CN) 2 )·(5H 2 O)} n (1) via pyrolysis followed by calcination. Pyrolysis of the bimetallic MOF gives rise to bimetallic nanoparticles stabilized on NCNTs, which, when subsequently calcined, leads to the formation of a core-shell structure with a semiconducting oxide shell (Ni x Co 1- x O) encapsulating the Ni x Co 1- x bimetallic NP core. Detailed evaluation of the electrocatalytic performance of Ni x Co 1- x @Ni x Co 1- x O/NCNT proves its worth as a bifunctional catalyst with 380 mV overpotential for oxygen evolution reaction at 10 mA cm -2 current density and 0.87 V (vs RHE) onset for oxygen reduction reaction in the alkaline medium. Additionally, the prepared electrocatalyst efficiently catalyzes the hydrogen evolution reaction with a nominal overpotential of 74 mV (vs RHE) for reaching 10 mA cm -2 current density in acidic medium. The practical applicability of this catalyst is further upheld in the fabrication of a zinc-air battery having high specific capacity with high round-trip efficiency and adequate cycle life. DFT calculations establish that the structure of Ni x Co 1- x @Ni x Co 1- x O/NCNT is crucial for its electrochemical activity since it has the threefold advantages of cooperative charge transfer from Co to Ni, synergistic relationship between the conductive alloy core and semiconducting oxide shell, and a highly conductive N-doped CNT matrix.

Purpose: To report the clinical presentations, complications, and outcomes of Sphingomonas paucimobilis-specific lacrimal drainage infections., Methods: A retrospective chart review of all patients diagnosed with Sphingomonas paucimobilis lacrimal infections and managed at a tertiary care Dacryology Service from November 2015 to May 2022 over a 6.5-year period were recruited and analyzed. Data collected include demographic details, clinical presentation, microbiological diagnosis, antibiotic susceptibility profiles, management, complications, and outcomes. The microbiological techniques employed were aerobic and anaerobic cultures, phenotypic identification with VITEK 2 R system, polymerase chain reaction, antibiotic sensitivity profile and minimal inhibitory concentration., Results: Twelve Sphingomonas- specific lacrimal drainage infections of 11 patients were identified. Of these five were canaliculitis and seven were acute dacryocystitis. All the seven acute dacryocystitis presented in an advanced stage; five were with lacrimal abscess and two with orbital cellulitis. The antibiotic susceptibility profile of canaliculitis and acute dacryocystitis were comparable and the organism was sensitive to several classes of antibiotics. The outcomes of punctal dilatation and nonincisional curettage were effective for canaliculitis. Patients with acute dacryocystitis had advanced clinical stage at presentation but responded well to intensive systemic management and had excellent anatomical and functional outcomes with dacryocystorhinostomy., Conclusion: Sphingomonas -specific lacrimal sac infections can have aggressive clinical presentations and need early and intensive therapy. The outcomes are excellent with multimodal management.

Purpose: To report an unusual case of an ectopic lacrimal fistula in a setting of a naso-orbito-ethmoid fracture., Case Report: The present case demonstrates a right-sided ectopic lacrimal fistula just below the glabella on the contralateral side on the outer edge of the midline. CT-Dacryocystography demonstrated a large dilated right lacrimal sac with a partly sequestered fundus traversing through the frontal process of the maxilla and frontal bone, close to the skull base and communicating with the fistula. The connection of the fistula with the sac was severed at the superior-most point, and the long fistulous tract was removed using external and endoscopic approaches, followed by endocautery and subsequent dacryocystorhinostomy. Post-operatively, the fistulous opening healed, ostium score was FICI grade 5, and the patient was asymptomatic., Conclusion: The case demonstrates multiple surgical challenges while managing an ectopic fistula with a long fistulous tract traversing several bony structures.

Competing Interests: The authors have no financial or conflicts of interest to disclose.

Purpose: To assess the clinical profiles and outcomes of strabismus in pediatric patients with orbital wall fractures., Methods: A retrospective interventional study of all consecutive children of age ≤16 years who presented with traumatic orbital wall fractures with and without resultant strabismus was conducted. The details of patient demographics, clinical features, interventions, and outcomes were obtained., Results: Forty-three children presented with traumatic orbital fractures to a tertiary care center. The mean age at presentation was 11 years and there was a male predominance (72.09%). Isolated floor fracture involvement was the most common (n = 24, 55.81%), and almost half of the children had a white-eyed or trapdoor fracture (n = 21, 48.83%). Twenty-six (60.46%) children had surgical repair of fracture(s). Manifest strabismus following orbital fracture was documented in 12 children (27.90%). Of these, an exotropia was noted in seven (58.33%), hypotropia in two (16.67%), hypertropia in one (8.33%), and esotropia in one patient (8.33%), while an exotropia with hypotropia was noted in one patient (8.33%). Restrictive nature of strabismus due to either muscle entrapment or local trauma was more commonly observed in 11/12 patients (91.66%). Primary position diplopia before orbital wall fracture repair was observed in four children and after repair was observed in two children with manifest strabismus. Four children underwent strabismus surgery post-fracture repair., Conclusion: An improvement in strabismus and ocular motility was noted in majority of the patients after fracture repair. The few that underwent strabismus surgery had a restrictive nature of strabismus. Trapdoor fractures and the nature of trauma in children vary compared to adults. Persistence of strabismus may be due to an excessive time interval between trauma and fracture repair or the extensive nature of trauma., Competing Interests: None

The prevalence of intermetallic charge transfer is a marvel for fine-tuning the electronic structure of active centers in electrocatalysts. Although Pauling electronegativity is the primary deciding factor for the direction of charge transfer, we report an unorthodox intra-lattice 'inverse' charge transfer from Mo to Ni in two systems, Ni 73 Mo alloy electrodeposited on Cu nanowires and NiMo-hydroxide (Ni : Mo = 5 : 1) on Ni foam. The inverse charge transfer deciphered by X-ray absorption fine structure studies and X-ray photoelectron spectroscopy has been understood by the Bader charge and projected density of state analyses. The undercoordinated Mo-center pushes the Mo 4d-orbitals close to the Fermi energy in the valence band region while Ni 3d-orbitals lie in the conduction band. Since electrons are donated from the electron-rich Mo-center to the electron-poor Ni-center, the inverse charge transfer effect navigates the Mo-center to become positively charged and vice versa . The reverse charge distribution in Ni 73 Mo accelerates the electrochemical hydrogen evolution reaction in alkaline and acidic media with 0.35 and 0.07 s -1 turnover frequency at -33 ± 10 and -54 ± 8 mV versus the reversible hydrogen electrode, respectively. The corresponding mass activities are 10.5 ± 2 and 2.9 ± 0.3 A g -1 at 100, and 54 mV overpotential, respectively. Anodic potential oxidizes the Ni-center of NiMo-hydroxide for alkaline water oxidation with 0.43 O 2 s -1 turnover frequency at 290 mV overpotential. This extremely durable homologous couple achieves water and urea splitting with cell voltages of 1.48 ± 0.02 and 1.32 ± 0.02 V, respectively, at 10 mA cm -2 ., Competing Interests: There are no conflicts of interest to declare., (This journal is © The Royal Society of Chemistry.)

Purpose: To define the clinical and optical coherence tomography (OCT) morphology of the lacrimal punctum and assess the age-related changes across 8 decades of life in a normal population., Methods: A total of 1310 high-magnification slit-lamp, Fourier-domain OCT (FD-OCT), and optical coherence tomography angiography (OCTA) images were obtained from 320 puncta of normal asymptomatic individuals representing the Indian population. The punctum and peri-punctal area were defined with the help of 2 rims (inner punctal rim and outer punctal rim ) and 3 zones (white zone [Wz], separation zone [Sz], and peri-punctal vascularity). FD-OCT images were used to measure the external punctal diameters and internal lacrimal punctal diameters and the reflectivity patterns of the 3 punctal layers. OCTA was used to assess the branching and extent of vascular networks., Results: The upper puncta were narrower and more circular than the lower puncta across the decades. The elevation of the punctal papilla began in the upper puncta in the fifth decade, involved the lower puncta in the sixth decade, and gradually became exaggerated by the eighth decade. A typical punctal narrowing in previously wide puncta began to appear in the sixth decade of life, peaks in the seventh decade, and reverses gradually and spontaneously by the end of the eighth decade of life. The third and fourth decades saw a narrowing of the Sz with prominent vascularity crossing the Sz to reach the Wz. The Sz became indistinct in the fifth and sixth decades of life. The FD-OCT showed gradual thickening and dominance of the fibrous layer from the fifth to eighth decade of life. The clinical vascularity in the peri-punctal region increases from the third decade onwards, with vascular networks becoming increasingly dense, intricate, and branched as the age progresses., Conclusion: The present study defined and characterized the involutional changes in a normal population's first-eighth decades of life. Significant morphological changes were noticed across the different age groups with several clinical implications., Competing Interests: Dr. Mohammad Javed Ali receives royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery” and for the treatise “Atlas of Lacrimal Drainage Disorders.” Other authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: The purpose of this study was to histologically assess the presence and extent of the canalicular tissue in cases of punctal agenesis., Methods: A prospective, interventional study was performed on 10 consecutive cases of punctal agenesis over a study period of 6 months. Exclusion criteria included cases with punctal dysgenesis or incomplete punctal canalization, secondary/acquired cases of punctal effacement, or any prior interventions. Following the exploration, the entire specimen of the tissue (length = 8 mm and depth = 3 mm) was sent for histopathological analysis to ascertain the presence and extent of the canalicular tissue., Results: The mean age of the patients at the time of exploration was 7.5 years (range 6-10 years). Histopathological analysis showed tissue surfaces lined with stratified squamous epithelium with occasional interspersed goblets cells (conjunctival epithelium), a few chronic inflammatory cells, and muscle fragments. Epithelium suggestive of proximal lacrimal drainage system was absent. Canalicular tissues were found to be absent in all cases of punctal agenesis., Conclusion: The present series did not find any histologic evidence of canalicular tissues in cases of punctal agenesis. The findings of this study do not support retrograde approaches in cases of punctal agenesis., (Copyright © 2022 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

The authors report two cases of unusually large deposits on their therapeutic bandage contact lens (BCL) following uneventful surgery for congenital ptosis. The first case presented at 6 weeks with decreased vision, large jelly-bump deposits over the contact lens and sterile corneal infiltrates. The infiltrates rapidly resolved with restoration of vision following contact lens removal and topical antibiotics. The second case presented 2 weeks after surgery with visual loss and similar deposits but with no corneal involvement. Following replacement of BCL and topical lubricants, her vision improved to 20/20. Studies on the role of BCL in ptosis surgery are scarce with literature supporting its use for ocular surface protection and minimising postoperative discomfort. The authors hypothesise impaired blink mechanism as the accelerating factor for this unusual occurrence in the early postoperative period and recommend frequent replacement of the contact lens and a closer follow-up in all these cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To classify the acquired lacrimal fistulae (ALF) and assess the outcomes following surgical management., Methods: Retrospective, interventional study of all patients presenting with ALF over a 3.5-year period was performed. The fistulae were classified based on photographic evidence with respect to their location, size and nature. Primary outcome measures were complete healing of the fistulous opening and resolution of discharge or leakage from it. Secondary outcome measures were resolution of epiphora and patency of the lacrimal drainage system., Results: 84 eyes of 82 patients who had acquired lacrimal fistulae were analysed. The mean duration of the fistulae presence was 10.12 months. The etiology of ALF was spontaneous following lacrimal abscess rupture in 79 eyes and was secondary to incision and drainage in the remaining 5 eyes. Thirty eyes had fistulectomy along with definitive surgery for the associated nasolacrimal duct obstruction (NLDO), 15 eyes underwent definitive surgery without an additional fistulectomy and 4 fistulae healed spontaneously prior to intervention for NLDO. The resolution of ALF did not differ in between those who underwent fistulectomy versus those who did not. The exceptions were 2 chronic large fistulae with cutaneous lining which needed a definite fistulectomy for resolution along with surgery for NLDO., Conclusion: Most of the acquired fistulae heal by themselves irrespective of the nature, size and location and need no additional treatment in the form of fistulectomy. However, this is not true for those that are large and have a cutaneous lining.

Microbial synthesized surfactants are used in contaminated soil bioremediation processes and have multiple applications in various industries. These compounds minimize the negative influences in soil via absorption by detoxifying the toxic metals or compounds. Further, applications of biosurfactants are detected in treating chronic diseases or synthetic drugs alternatives in current periods. Various surfactant molecules can provide many benefits due to their diversities in structural and functional groups. These compounds showed a wide array of applications in multiple sectors such as biomedical or pharmaceutical fields. Agricultural, food processing, laundry, or other sectors. Many microbial systems or plant cells are utilized in biosurfactant production as confirmed by biochemical analysis of genome sequencing tools. Biosurfactant compounds can alter drug transport across the cell membrane. Different nature of biosurfactant compounds exhibited their antifungal, antibacterial, antiviral activities, or antiadhesive coating agents used in reduction of many hospital infections. These distinct properties of biosurfactants pushed their broad spectrum applications in biomedical, agriculture sectors and bioremediation tasks. Additionally, many strains of fungi or bacteria are utilized for biosurfactant synthesis involved in the detoxification of soil/other components of the environment. In these reviews, authors explained various biosurfactants molecules and their mode of actions. Also, applications of microbial originated biosurfactants along with their process technologies are described. Future perspectives of biosurfactants and their scope are also critically explained so that this review paper can be used as a showcase for production and application of biosurfactants., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: None

We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords "corneal nerves," "neurotization," "esthesiometry," "corneal anesthesia," and "neurotrophic keratopathy." All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3-6 months, while nerve regeneration on confocal microscopy can take as long as 6 months-1 year., Competing Interests: None

Purpose: To study the presentation, management, and outcomes of infantile acute dacryocystitis., Methods: Retrospective study of infants diagnosed with acute dacryocystitis over a period from June 2016 to December 2019. Data collected include demographics, clinical history, presenting features, management, complications, and outcomes. Treatment provided was intensive medical care followed by early probing under endoscopic guidance. Further interventions, where needed, were performed based on intraoperative findings during probing. Successful outcomes were defined as resolution of infection, subjective relief from epiphora, and anatomical patency determined by a normal fluorescein dye disappearance test., Results: Twenty-seven eyes of 27 infants were analyzed during the study period. The mean age of infants was 3.26 months, and males were more affected than females (male:female 15:12). The mean duration of symptoms was 4.66 weeks, with 96% (26/27) presenting with symptoms of redness, watering, discharge, and swelling. Preseptal cellulitis was seen in 74% (20/27) infants, lacrimal abscess in 67% (18/27) infants, and lacrimal fistula in 37% (10/27). Most infants had complex congenital nasolacrimal duct obstruction (62%, 13/27), of which 7 also had intranasal cysts. One infant successfully underwent endoscopic dacryocystorhinostomy. At a mean follow-up period of 7.95 months, successful outcomes were observed in 90.4% (19/21) infants. The 2 failed cases were complex congenital nasolacrimal duct obstruction with associated sac diverticula and are scheduled for an endoscopic dacryocystorhinostomy., Conclusion: Infantile acute dacryocystitis is a distinct clinical entity. The outcomes of systemic antibiotics and early probing are excellent., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To evaluate the demographic details, clinical presentation, and surgical outcomes in patients presenting with strabismus following orbital wall fractures., Methods: A retrospective review was conducted over a 6-year period on 347 consecutive patients with strabismus who presented after orbital wall fractures. The patients were evaluated for their demographic data, clinical presentation, and profiles, management, complications, and outcomes of strabismus., Results: Strabismus following orbital wall fractures was noted in 347 patients: 87.03% were men (n = 302) and 12.97% were women (n = 45). Fracture of the orbital floor in isolation or in combination with other walls was more frequently noted in 72.3% of patients (n = 251). The resultant strabismus included paralytic, restrictive, or both etiologies. Exotropia was noted most frequently in 25.65% of patients (n = 89), followed by exotropia with hypotropia in 20.75% of patients (n = 72). Ten percent of patients with strabismus (n = 34), who were observed for at least 6 months after injury, underwent surgical correction for strabismus. Preoperative diplopia was observed in 79.41% of patients (n = 27) and persisted after strabismus surgery in 15% of patients (n = 6). A successful outcome regarding the postoperative angle of deviation of 10 prism diopters or less horizontal and/or 5 prism diopters or less of vertical deviation with elimination of diplopia was observed in 41.17% of patients., Conclusions: Strabismus following orbital wall fractures is complex and requires a tailored strategy. The current study found the orbital floor to be more frequently involved in orbital wall fractures. However, the resultant strabismus was a combination of paralytic and restrictive etiologies. [ J Pediatr Ophthalmol Strabismus . 2022;59(3):172-179.] .

Purpose: To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC)., Methods: Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship's punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes., Results: Ninety-eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization-external membrane variant was seen in 62% (61/98) and internal membrane variant in 38% (37/98). Seventy-eight puncta (78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship's punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean follow up of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively., Conclusions: The long-term outcomes of membranotomy for IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Economic and sustainable (ecological) energy storage forms a major pillar of the global energy sector. Bifunctional electrocatalysts, based on oxygen electrolysis, play a key role in the development of rechargeable metal-air batteries. Pursuing precious metal-free economic catalysts, here, we report K 2 CoP 2 O 7 pyrophosphate as a robust cathode for secondary zinc-air batteries with efficient oxygen evolution and oxygen reduction (OER||ORR) activity. Prepared by autocombustion, nanoscale K 2 CoP 2 O 7 exhibited excellent oxygen reduction and evolution reactions among all phosphate-based electrocatalysts. In particular, the OER activity surpassed that of commercial RuO 2 with low overpotential (0.27 V). First-principles calculations revealed that the bifunctional activity is rooted in the Co active site with the CoO 5 local coordination in the most stable (110) surface. This nanostructured (tetragonal) pyrophosphate can be harnessed as an economic bifunctional catalyst for zinc-air batteries.

Aim: The purpose of this study was to report the profile and outcomes of children with an earlier failed probing that was performed without endoscopy guidance., Methods: Retrospective interventional case study was performed on all the patients who were referred with a diagnosis of a single or multiple failed probing from Jan 2016 to June 2019 to a tertiary care Dacryology center. All the patients had a blind probing without an endoscopy assistance before referral. The parameters evaluated were patient demographics, number of earlier probings, prior operative notes, clinical presentation, findings of endoscopy guidance during the repeat procedure, simple vs complex CNLDO, types of complex CNLDO, management, complications and outcomes., Results: One hundred eyes of 82 children had a failed probing experience without endoscopic guidance elsewhere. The mean age of the children was 55.7 months (range: 9-168 months). Of these, 63 eyes underwent repeat probing under endoscopic guidance, 35 eyes being simple CNLDO (35/63, 55.5%), and 28 eyes (28/63, 44.5%) being complex CNLDO. Among the complex subset, balloon dacryoplasty was performed for five cases and monoka-Crawford stents for eight cases under direct endoscopy visualization. Buried probes were managed successfully by standard protocols of probe exteriorization. The two cases of misdirected probes were re-directed under endoscopy guidance for appropriate recanalization and the single case of granuloma at the NLD opening was excised followed by intubation without any recurrence., Conclusion: Endoscopy guidance plays a crucial role in the management of CNLDO with an earlier failed probing.

Chondroid syringoma is a benign mixed tumour arising from the sweat glands which can be apocrine (found throughout the surface of the eyelid) or eccrine with a mean age of presentation being 50 years. Here we report two cases of chondroid syringoma of the upper eyelid, one in a young male patient and the other in an elderly woman. Both cases had well-defined lesions involving upper eyelid in the sub-brow region, underwent excisional biopsy, and histopathological findings were consistent with an apocrine type of chondroid syringoma in one case and eccrine type of chondroid syringoma in the second case. It is important to be aware of this entity as a rare cause of eyelid lesion due to the fact that although it is a benign neoplasm, incomplete excision may be associated with recurrence or malignant transformation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To present first of its kind series on the clinical features and outcomes of lacrimal drainage disorders in Peters anomaly and Peters plus syndrome., Methods: A retrospective chart review was performed of all consecutive patients who were known cases of Peters anomaly or Peters plus anomaly and were diagnosed with associated congenital lacrimal drainage disorders. The study period was from June 2016 to Dec 2020. All these patients underwent examination under anaesthesia for a detailed assessment of lacrimal drainage anomalies. Where indicated, they were treated with probing, intubation, or in refractory patients with a dacryocystorhinostomy. The anatomical and functional outcomes were assessed., Results: Of the 282 patients with Peters anomaly, 4 (1.4%) patients had associated lacrimal drainage system anomalies while of the 16 Peters plus anomaly children, 3 (18.75%) had associated lacrimal drainage system anomalies. A total of 12 lacrimal drainage systems of 12 eyes of 7 patients of Peters anomaly were found to be involved. Upper or lower punctal agenesis were noted in 3 eyes. Three eyes had complex congenital nasolacrimal duct obstruction (CNLDO), two of which had a bony NLD block and one had a misdirected nasolacrimal duct through the inferior turbinate. One eye had a diffuse NLD stenosis without a CNLDO. Following appropriate management, at a mean follow-up of 25.7 months (range: 3-48 months), all the eyes except one (91%, 10/11) demonstrated anatomical and functional success., Conclusion: Lacrimal drainage involvement was more common in Peters plus syndrome. Multiple proximal and distal lacrimal drainage segment anomalies were noted in all the variants of Peters anomaly; however, Peters plus syndrome was noted to usually involve both the segments.