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To study the risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) during the COVID-19 pandemic in India. Multi-centric retrospective case-control study conducted from October 2020 to May 2021. Cases comprised of consecutive patients of COVID-19-associated ROCM (CA-ROCM) presenting at the participating ophthalmic institutes. Controls comprised of COVID-19-positive or COVID-19-recovered patients who did not develop ROCM. Comparative analysis of demographic, COVID-19 infection, treatment parameters and vaccination status between cases and controls performed. Clinical and imaging features of CA-ROCM analyzed. There were 179 cases and 361 controls. Mean age of presentation in cases was 52.06 years (p = .001) with male predominance (69.83%, p = .000011). Active COVID-19 infection at the time of presentation of ROCM (57.54%, p < .0001), moderate to severe COVID-19 (p < .0001), steroid administration (OR 3.63, p < .00001), uncontrolled diabetes (OR 32.83, p < .00001), random blood sugar >178 mg/dl were associated with development of CA-ROCM. Vaccination showed a protective effect (p = .0049). In cases with intracranial or cavernous sinus extension there was history of steroid administration (OR 2.89, p = .024) and orbital apex involvement on imaging (OR 6.202, p = .000037) compared to those with only rhino-orbital disease. Male gender, active COVID-19 infection, moderate or severe COVID-19, uncontrolled diabetes, steroid administration during COVID-19 treatment are risk factors for developing rhino-orbital-cerebral mucormycosis. Vaccination is protective. Random blood sugar of >178 mg/dl in COVID-19 positive or recovered patients should warrant close observation and early detection of ROCM. Presence of ophthalmoplegia, blepharoptosis at first clinical presentation and orbital apex involvement on imaging are associated with intracranial extension in ROCM.

Introduction: Epiphora in the presence of patent lacrimal system (functional epiphora) has remained one of the complex lacrimal problems. There is a lack of consensus regarding its diagnostic crite...

Purpose: To report clinical presentations and factors affecting outcomes in rhino-orbital-cerebral mucormycosis following COVID-19. Methods: Retrospective multi-centric interventional case series of 58 eyes with rhino-orbital-cerebral mucormycosis. Demography, clinical parameters and management outcomes were noted. Factors affecting outcome and mortality were analyzed. Outcome was defined as favorable when complete resolution or stabilization without further progression of the infection was noted at last visit. Results: Mean age was 55 ± 11 years (median 56). The mean HbA1c value was 10.44 ± 2.84 mg% (median 10.5). The duration between the diagnosis of COVID-19 and rhino-orbital-cerebral mucormycosis was 16 ± 21 days (median: 8 days). Thirty-six eyes (62%) had no vision at presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (41%), cavernous sinus involvement (30%), and central nervous system (CNS) involvement (33%). All the patients were treated with systemic Liposomal amphotericin-B and sinus debridement. Twenty-two eyes (38%) underwent exenteration. One eye underwent transcutaneous retrobulbar amphotericin-B. The mean follow-up duration was 5.62 ± 0.78 months (median 6). Favorable outcome was seen in 35 (60%) cases. Presence of uncontrolled diabetes (p = 0.001), orbital apex involvement (p = 0.04), CNS involvement (p = 0.04), and history of steroid use (p < 0.0001) resulted in unfavorable outcome. CNS involvement was the only factor predicting mortality (p = 0.03). Mortality was seen in 20 (34%) patients. Conclusion: Over a third of patients with rhino-orbital-cerebral mucormycosis following COVID-19 have an unfavorable clinical outcome. Uncontrolled diabetes mellitus at presentation, involvement of the orbital apex, CNS, and the usage of steroids were associated with poorer outcomes. CNS involvement was a factor determining mortality., In 58 patients with rhino-orbital-cerebral mucormycosis post-COVID-19, favorable outcome was seen in 35 (60%) cases. Uncontrolled diabetes, orbital apex involvement, cavernous sinus involvement, and use of steroids for COVID-19, resulted in unfavorable outcome.

Purpose To report the epidemiology, histopathological spectrum, and surgical outcomes of peripunctal mass lesions. Methods Multicentric retrospective case series involving 6 centers in India. All cases of peripunctal masses with histopathological diagnoses and minimum follow up of 3 months were included. Demographic data, clinical photographs, objective assessments of clinical improvement were assessed before and after treatment. Results A total of 50 patients were included. The mean age was 46.4 years (range: 12-76 years). The mean duration of complaints was 27.4 months (range: 1-120 months) and mean follow-up period after surgery was 15.8 months (range: 3-120 months). The most common presenting complaints were a mass lesion/cosmetic concern (82%), followed by epiphora (48%) and foreign body sensation (16%). The most common lesion was melanocytic nevus (19/50; 38%), followed by squamous papilloma (8/50; 16%), hidrocystoma (7/50; 14%), and epidermoid cyst (7/50; 14%). Three cases of malignant tumors were diagnosed: 2 cases of sebaceous gland carcinoma and 1 case of squamous cell carcinoma. In all, 21 of 50 (42%) cases underwent excision with the placement of a Mini-Monoka stent, whereas the remaining 29 cases underwent only excision. At final follow up, a healed punctal opening was visible in 46 of 50 (92%) of the cases; 2 (4%) cases had a slit-like punctum and in 1 case (2%), a stenosed punctum was visible. However, only 1 case (2%) reported epiphora at follow up. Conclusions Peripunctal masses are largely benign and present most commonly on the lower eyelid. Melanocytic nevus is the most common peripunctal mass lesion. In the series, stent placement did not play a significant role in the functional outcome.

Introduction: The utilization of endoscopy in lacrimal surgeries has been increasing in the recent past with increasing indications. With the advent of newer generation of telescopes, the practice ...

PURPOSE To evaluate and compare the success rate of transcanalicular laser-assisted dacryocystorhinostomy with endonasal augmentation, with and without intubation, in patients suffering from primary acquired nasolacrimal duct obstruction, at 1 year of follow up. METHODS A prospective, randomized interventional pilot study was conducted at a tertiary care center, in accordance with the guidelines of Declaration of Helsinki. Sixty eyes of 60 adult patients with primary acquired nasolacrimal duct obstruction were included. The participants were divided randomly into 2 equal groups (A and B-without and with bicanalicular intubation, respectively). An osteotomy was first created using 980 nm diode laser (set at 8W continuous mode) transcanalicularly and then enlarged intranasally using Blakesley's nasal forceps, followed by bicanalicular silicon intubation in group B patients. The tubes were removed at the end of 8 weeks. The ostium size was assessed endoscopically at 8 weeks and again at the end of follow up, at 1 year. A successful outcome was defined in terms of ostium patency at the end of 1 year. The results were analyzed at the end of a follow up of 1 year, using various statistical tests (p < 0.05). RESULTS The mean age of the patients was 35.3 ± 15.89 years, with 23 male and 37 female patients, the 2 groups having a similar male:female ratio. An overall success rate of 90% was achieved at the end of 1 year with no statistically significant difference between the groups. Postoperative complications like tube displacement and punctal, canalicular injury were more in the intubated group. The average osteotomy size was 8.06 ± 5.4 mm at the end of 1 year. CONCLUSIONS Transcanalicular laser-assisted dacryocysto rhinostomy, with endonasal augmentation, is a scarless, effective, daycare procedure, for treatment of primary acquired nasolacrimal duct obstruction with no additional advantage offered by silicone intubation.

Introduction : Intubation in primary transcanalicular laser assisted dacryocystorhinostomy (TCLADCR) is performed to increase the success rates. However, the associated inflammation and infection can have adverse effects. Objective : To study the microbial infection and drug susceptibility of extubated silicone tubes and final anatomical patency in patients undergoing TCLADCR. Materials and methods : A non-randomised prospective interventional study was conducted in a tertiary care eye centre. The study included twenty consecutive adult patients with primary nasolacrimal duct obstruction. They underwent TCLADCR with bicanalicular silicone intubation. The stents were removed at 2 months and subjected to culture sensitivity, followed by administration of appropriate antimicrobial agents. Main outcome measures studied were the microbial spectrum on the cultured tubes, their sensitivity profile and its correlation with final anatomical patency. Results : A positive culture was obtained in 100% cases, comprising of normal commensals and pathogenic organisms. Of the total 24 isolates, 16 (66.6%) Gram positive bacteria (75% Staphylococcus aureus) and 8 (33.3%) Gram negative bacteria (commonest E.coli) were found, with 4 tubes having more than one isolate. No fungal growth was seen. Ninety percent success rate was achieved at one year following appropriate antimicrobial therapy except in 2 patients with gram negative isolates who had failed to take the prescribed antibiotics following sensitivity reports. There was no correlation between multiple infections and success rate. However, by using the Fisher exact test, a positive correlation was obtained between appropriate antibiotic treatment and the final anatomical patency (p

Purpose To review and summarize the clinical features, presentations, diagnostic modalities and management of dacryolithiasis. Methods A comprehensive PubMed search of all English articles on dacryolithiasis was reviewed. Although this review primarily relied on articles written in English, non-English-language articles that had abstracts translated into English were also reviewed. Data reviewed included epidemiology, pathogenesis, appearance and composition, clinical features, presentations, diagnostic modalities, management of dacryolithiasis and the implications of incidental dacryoliths found during lacrimal surgery. Results Although an unknown proportion of dacryolithiasis cases may remain asymptomatic; epiphora, acute and/or recurrent dacryocystitis, punctal discharge, and localized swelling are the most common presenting features of dacryolithiasis. It may also present as partial nasolacrimal duct obstruction. Dacryoliths exhibit a variety in external appearances. While some minimally invasive techniques for the removal of dacryoliths have been described, dacryocystorhinostomy with removal of the dacryoliths remain the most effective treatment in cases of symptomatic dacryolithiasis. The expression and production of certain proteins and peptides, namely those of the trifoil factor family play a significant role in the pathogenesis of dacryoliths. Conclusions The management of dacryolithiasis is driven by the goal of resolution of secondary obstruction and/or inflammation. Although a large number of dacryoliths are incidentally found during dacryocystorhinostomy, certain clinical features such as unilateral sac distension, particularly those with a palpable firm medial canthal mass, might lead one to have a high index of suspicion. It remains unclear if the incidental finding of a dacryolith during a dacryocystorhinostomy has a favorable prognostic value.

Recording surgical procedures is of value for teaching and training in residency and fellowship programs. Operating external ophthalmic surgeries is not as easy as recording intraocular surgeries. In this communication, we describe the use of a video recorder mounted on a flexible tripod (Gorillapod®), a commonly available photography accessory; which is fixed to an IV fluid stand. This set up was used to record external ophthalmic surgeries and the recorded videos were of high quality in terms of stability and required no change in surgical technique to ensure that the area of interest was in focus. In our experience, early results show that a flexible tripod offers an economical mount for recording external surgeries with reproducible results.

PURPOSE The aim of the study was to assess practice patterns on the use of intraoperative Mitomycin-C (MMC) and lacrimal stents (intubation) in dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO) among oculoplastic surgeons in India. The survey was aimed at obtaining data on the duration of stent placement and specifics regarding MMC usage namely, concentration and duration of application. METHODS A survey that included questions on the management of lacrimal disorders was sent in April 2015 to members of the Oculoplastic Association of India, through an email communication. The results were tabulated and analyzed. RESULTS External DCR is the preferred surgery of choice to treat NLDO for most oculoplastic surgeons (86%) surveyed. A majority (58%) of the respondents do not place stents during DCR routinely in their practice. Lesser experienced oculoplastic surgeons (

To assess the preferred practice patterns in the management of congenital nasolacrimal duct obstruction (CNLDO) among oculoplastic surgeons in India. The survey was aimed at obtaining data on the timing of intervention, procedure of choice, and the use of adjunctive techniques such as silicone intubation and nasal endoscopy.An anonymized survey that included questions on the management of lacrimal disorders was sent in April 2015 to members of the Oculoplastic Association of India (OPAI), through an e-mail communication. The results were tabulated and analyzed.A large proportion (84%) of respondents indicated that they advise lacrimal sac compression up to 1 year of age. Fourteen percent (12/87) indicated 2 years as their upper age limit for advising sac compression. One year is the preferred minimum age for advising primary nasolacrimal duct (NLD) probing by majority (45%) of respondents and the upper age limit being 5 years for 62% of respondents. Based on experience, younger surgeons (10 years experience) when compared to more experienced surgeons are more likely to offer a trial of primary probing in children between 8 and 12 years age (29% versus 8%). Nasal endoscope is used by 50% (44/88) respondents during primary NLD probing. Nearly a third of the respondents (29/88) use intubation in all cases of NLD probing. Eighty one percent (71/88) of the surgeons would rather repeat NLD probing with adjunctive procedures over dacryocystorhinostomy (17%). Balloon Dacryoplasty is rarely used for CNLDO amongst our respondents.This study highlights the variation in practice pattern in the management of CNLDO across India. While there are certain trends that are global phenomena, such as the shift towards the use of a nasal endoscope; use of silicone intubation in repeated procedures and time of performing primary NLD probing; issues like the use of balloon dacryoplasty showed lesser degree of agreement.

PURPOSE To report the features of Fourier domain optical coherence tomography imaging of the normal punctum and vertical canaliculus. METHODS Prospective, interventional series of consecutive healthy and asymptomatic adults, who volunteered for optical coherence tomography imaging, were included in the study. Fourier domain optical coherence tomography images of the punctum and vertical canaliculus along with 3D and En face images were captured using the RTVue scanner with a corneal adaptor module and a wide-angled lens. Maximum punctal diameter, mid-canalicular diameter, and vertical canalicular height were calculated. Statistical analysis was performed using Pearson correlation test, and scatter plot matrices were analyzed. RESULTS A total of 103 puncta of 52 healthy subjects were studied. Although all the images could depict the punctum and vertical canaliculus and all the desired measurements could be obtained, occasional tear debris within the canaliculus was found to be interfering with the imaging. The mean maximum punctal diameter, mid-canalicular diameter, and vertical canalicular height were recorded as 214.71 ± 73 μm, 125.04 ± 60.69 μm, and 890.41 ± 154.76 μm, respectively, with an insignificant correlation between them. The maximum recorded vertical canalicular height in all the cases was far less than the widely reported depth of 2 mm. High-resolution 3D and En face images provided a detailed topography of punctal surface and overview of vertical canaliculus. CONCLUSION Fourier domain optical coherence tomography with 3D and En face imaging is a useful noninvasive modality to image the proximal lacrimal system with consistently reproducible high-resolution images. This is likely to help clinicians in the management of proximal lacrimal disorders.

The nasal endovision system or the nasal endoscopy unit is a useful addition to the oculoplastic clinic due to its prominent role in the disorders of the lacrimal sac and nasolacrimal duct. The preoperative evaluation of the nasal cavity before primary or revision, endonasal or external DCR, postoperative ostium evaluation, and monitoring of the lacrimal stents are of paramount importance. Moreover, its role in the management of failed probing has been established to look for and manage the inferior turbinate or inferior meatus-related factors responsible for the failure of previous probing(s).

Lacrimal stents and intubation systems have been used in past to keep the lacrimal pathways patent after surgery, trauma, reconstruction etc. Recently, its physiological role for functional epiphora has been highlighted. Over the years materials, surgical techniques and various designs have evolved. The precise knowledge about design and proper technique of insertion provides the best possible outcomes in terms of anatomical and functional success for various disorders. The present review aims to provide a comprehensive knowledge of various available lacrimal stents and their role in management of lacrimal disorders.

Purpose To describe and compare the clinical presentation, treatment outcomes, and histopathologic features of ocular surface squamous neoplasia (OSSN) based on human immunodeficiency virus (HIV) status. Design Case-control study. Participants A total of 200 patients with OSSN, of whom 83 (41%) had positive results for HIV and were classified as cases and 117 (59%) had negative results for HIV and were classified as controls. Methods Enzyme-linked immunosorbent assay for HIV, conjuntival excision biopsy, extended enucleation, orbital exenteration. Main Outcome Measures Clinical features, treatment outcomes, and histopathologic characteristics. Results The mean age at presentation of OSSN in both cases and controls was 40 years (median, 40 years; range, 13–65 years) and in controls was 40 years (median, 38 years; range, 15–80 years). On comparison of cases versus controls with OSSN, HIV-positive individuals had larger (12 vs. 8 mm; P P = 0.041) tumors, with a higher incidence of corneal (60% vs. 40%; P = 0.007), scleral (19% vs. 9%; P = 0.044), and orbital (13% vs. 3%; P = 0.019) invasion and a higher need for extended enucleation or exenteration (27% vs. 11%; P P = 0.13), need for lamellar sclerectomy (13% vs. 8%; P = 0.29), and tumor recurrence after primary treatment (30% vs. 20%; P = 0.12) was higher in HIV-positive cases compared with HIV-negative controls. However, these features were not statistically significant. Based on American Joint Committee on Cancer classification, T1 tumor was more common in controls (13% in cases vs. 35% in controls; P = 0.0009), and T4 tumor was more common in cases (13% in cases vs. 4% in controls; P = 0.019). None of the patients demonstrated systemic metastases or died of disease during a mean follow-up period of 10 months (median, 4 months; range, Conclusions Ocular surface squamous neoplasia in HIV-positive individuals is aggressive with larger and thicker tumors and with higher incidence of corneal, scleral, and orbital invasion. These patients are associated with poor ocular prognosis with higher need for extended enucleation, exenteration, or both.

Leiomyosarcoma is a common soft tissue tumor in the body. However, ocular leiomyosarcoma is rather uncommon. Herein, we describe the clinical and histopathological features of two cases of conjunctival leiomyosarcoma. There have only been three previously documented cases of conjunctival leiomyosarcoma.A 34-year-old male presented with a 2-year history of a whitish mass in the right eye. He underwent an incisional biopsy of the mass, which supported the diagnosis of leiomyosarcoma on histopathological examination. Computed tomography showed orbital extension of the mass, following which he underwent an eyelid sparing orbital exenteration of the right side. The second case was that of a 39-year-old male, who had a history of a whitish limbal mass, which had been previously excised elsewhere. The pre-operative clinical photographs and histopathology slides of the excised mass were reviewed. A histopathological diagnosis of conjunctival leiomyosarcoma was established and due to base positivity, he was treated with plaque radiotherapy. Both the cases showed no tumor recurrence or systemic metastasis at one-year follow-up.Primary conjunctival leiomyosarcoma is uncommon. Appropriate treatment of the tumor is associated with good prognosis.

The purpose of this study is to study the operative difficulties and success rate of transcanalicular laser-assisted endoscopic dacryocystorhinostomy in patients of chronic dacryocystitis with deviated nasal septum (DNS). A prospective interventional clinical study of 36 consecutive patients suffering from chronic dacryocystitis with nasolacrimal duct obstruction with DNS undergoing primary TCLADCR from March to June 2011 was carried out. Diode laser was used to create a 16-mm(2) ostium which was enlarged to 64 mm(2) using Blakesley's forceps. Success was defined as anatomical patency and absence of symptoms at 12 months of follow-up. Out of the 36 patients, 25 were females with ages 20-72 years, and 19 were left sided. There were 12 high, 12 mid and 12 basal DNS towards the side of surgery, mild to moderate in severity. Intraoperatively there was difficulty in visualising the aiming beam in the nose, tedious manipulation of endoscope and excessive bleeding in 3 patients. Increased bleeding and failures were significantly higher in high DNS (Fisher exact test-2 tailed: 0.0045). The procedure was successful in 94.4 % cases with average ostium size of 21.94 mm(2) at 12 months and no statistically significant difference in success rates between mild and moderate DNS (Fisher exact test-2 tailed: 1.000). Also there was no difference in the complication rate between mild and moderate DNS (Fisher exact test-2 tailed: 0.0841). TCLADCR is an effective procedure in patients with mild to moderate mid and basal DNS and obviates the need for multiple procedures and a cutaneous scar.

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

Objective: To study the utility of a commercially available small, portable ultra-high definition (HD) camera (GoPro Hero 4) for intraoperative recording. Methods: A head mount was used to fix the camera on the operating surgeon's head. Due care was taken to protect the patient's identity. The recorded video was subsequently edited and used as a teaching tool. This retrospective, noncomparative study was conducted at three tertiary eye care centers. The surgeries recorded were ptosis correction, ectropion correction, dacryocystorhinostomy, angular dermoid excision, enucleation, blepharoplasty and lid tear repair surgery (one each). The recorded videos were reviewed, edited, and checked for clarity, resolution, and reproducibility. Results: The recorded videos were found to be high quality, which allowed for zooming and visualization of the surgical anatomy clearly. Minimal distortion is a drawback that can be effectively addressed during postproduction. The camera, owing to its lightweight and small size, can be mounted on the surgeon's head, thus offering a unique surgeon point-of-view. In our experience, the results were of good quality and reproducible. Conclusions: A head-mounted ultra-HD video recording system is a cheap, high quality, and unobtrusive technique to record surgery and can be a useful teaching tool in external facial and ophthalmic plastic surgery.

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

Purpose: To evaluate the safety and efficacy of a new technique of circumostial mitomycin C (COS-MMC) injection in dacryocystorhinostomy (DCR) and to evaluate the outcomes. Methods: A prospective, interventional consecutive case series involving 110 DCR surgeries performed over a period of 1 year using the COS-MMC technique were evaluated. All patients were operated by a single surgeon (M.J.A.). After fashioning of the mucosal flaps, all patients underwent an intramucosal injection of 0.02% MMC at 4 points (0.1 ml at each point) along the edges of the freshly created ostium. All patients were intubated, and stent removal was done at 12 weeks following the surgery. All patients underwent regular monitoring of the ostium to look for any complications. A minimum follow up of 6 months after stent removal was considered for final analysis. The outcome measures analyzed were anatomical and functional success, complications, and ostium. Results: The mean age at presentation was 39.91 years. The diagnosis was primary acquired nasolacrimal duct obstruction in 60.9% (67/110) and persistent congenital nasolacrimal duct obstruction in 9.1% (10/110) of the patients. Twenty-six patients were known cases of failed DCR and underwent a revision DCR. Of the total patients, 19.1% (21/110) had a history of acute dacryocystitis, of which, 73% (80/110) of the surgeries were performed by an external approach and 27% (30/110) by endoscopic endonasal route. Anatomical success was noted in 97.3% (107/110) and functional success in 96.4% (106/110). All the 4 failures were due to cicatricial closure of the ostium. None of the patients were noted to have mucosal burns in the area where MMC was injected, and none of the Ostia showed any features of necrosis, infection, or any other complications. Conclusions: COS-MMC is a safe and effective adjunctive modality in DCR. No adverse effects on the ostium were noted. The technique appears to be promising for the success of cases with high risk of failures like revision DCR and traumatic secondary acquired nasolacrimal duct obstruction.

Glial heterotopia is an extremely rare clinical entity mostly presenting in head and neck region secondary to an abnormal development of an isolated mature central nervous system (CNS) tissue at an abnormal location without any continuity with the brain, spinal cord, or meninges. Its origin is either due to mechanical isolation of glial tissues by the developing cranial bones or secondary to misdirected or sequestered embryonic neuroectodermal stem cells outside the CNS. The authors present an exceptionally rare case of a heterotopic glial nodule masquerading as a dacryocystocele, its radiological features along with a brief clinicopathological correlation.

Objective To evaluate the efficacy and complications of lower eyelid suspension with the modified Safdarjung hospital technique using 5:0 polypropylene suture for punctal ectropion. Study design Prospective case series. Method Thirty one eyelids in 19 patients with mild and moderate ectropion and all types of laxity including involutional and paralytic were included. All patients underwent lower eyelid suspension with the modified Safdarjung hospital technique. A 5:0 polypropylene suture was passed in the pre-tarsal plane between the attachments of the lateral and medial canthal tendons near their insertion at the orbital rim. Successful outcome was judged by the anatomical restoration of the apposition of the punctum to the globe in the upward gaze and the physiological relief of epiphora. The recurrence of lid laxity, overall lid/globe apposition and complications were also noted. Results At 1 year follow up anatomical success was achieved in 28 (90%) patients and functional success noted in 27 (87%) patients. Recurrence of lid laxity was noted in 2 patients. There was a suture exposure in one case and a suture granuloma in another case. The results did not correlate to the degree of ectropion and type of laxity. Conclusion Lower eyelid suspension using 5:0 polypropylene suture is a useful procedure for the treatment of involutional and paralytic punctal ectropion. It is simple and effective with minimal complications. However, the effect on scleral show and the concern related to suture material biodegradation over years needs to be further evaluated.

Aim To assess the practice patterns pertaining to pre-cataract screening for nasolacrimal duct obstruction (NLDO) among oculoplastic surgeons in India. The survey was aimed at obtaining data on the current screening and treatment strategies for NLDO and the interval between lacrimal surgery and subsequent cataract surgery. Methods An online survey was sent to all members of Oculoplastic Association of India. All valid responses were tabulated and analyzed. Results Majority of the respondents (92%) felt that nasolacrimal duct patency should be checked prior to performing cataract surgery: 59.6% felt that checking for regurgitation on pressure over the lacrimal sac (ROPLAS) was sufficient and 32.6% preferred to perform lacrimal irrigation to check for NLD patency. Dacryocystorhinostomy (DCR) was the preferred surgery for NLDO thus detected. The preferred interval between a DCR and subsequent cataract surgery was 4weeks (48.9%). A small minority (7.9%) of the respondents felt that pre-cataract screening for NLDO was not required. Also, a small but significant number (12.6%) felt that no treatment was required for NLDO in such patients and that to could go ahead with cataract surgery even in the presence of coexisting NLDO. Conclusions There is a general agreement on the need for pre-cataract screening for NLDO and a majority indicated that checking for ROPLAS was sufficient. Most surgeons prefer to perform a DCR in cases of NLDO and wait for 4weeks before intraocular surgery. There is however, a lacuna in the literature on guidelines regarding the optimal interval between lacrimal surgery and subsequent intraocular surgery.

PURPOSE Epiphora caused by common canalicular obstruction is difficult to manage. Distal common canalicular block caused by membranous obstruction near its junction with the lacrimal sac can be managed by modified dacryocystorhinostomy (DCR) consisting of internal membranectomy. We report our experience with this technique during long-term follow-up. DESIGN A prospective interventional case series was performed at a tertiary care center including 15 patients with a diagnosis of distal common canalicular obstruction. METHODS External DCR was performed, and after lacrimal sac opening, membranous obstruction at the distal end of the common canaliculus was identified and managed successfully in all cases. Mitomycin C was applied, and silicone intubation was done for 2 months. The main outcome measures were anatomical success (patent syringing) and functional success (complete relief of epiphora) at a minimum follow-up period of 1 year. RESULTS Fourteen (93%) cases were completely relieved of epiphora with patent lacrimal syringing at a mean follow-up of 15.4 months (P = 0.0001, McNemar test). The postoperative complications occurred in 4 cases and included nasal bleeding, lateral displacement of silicone tube at medial canthus, complete extrusion of silicone tube (at 4 weeks), and noticeable incisional scar. CONCLUSIONS Distal common canalicular obstruction can be successfully managed with DCR with internal membranectomy and silicone intubation with mitomycin C. It avoids excision of common canaliculus as compared with canaliculo-DCR. The procedure is safe and effective with minor complications.

To study the importance of routine human immunodeficiency virus (HIV) screening in patients with ocular surface squamous neoplasia (OSSN) and describe their clinical features and management. Retrospective study. Of 228 cases of OSSN screened for HIV by enzyme-linked immunosorbent assay, 86 (38%) patients were HIV positive. Of these 86 patients, 60 (70%) were unaware of their HIV-positive status prior to HIV screening. These 60 (26%) patients with newly detected HIV-positive status were included in this study. Ocular surface squamous neoplasia was the sole presenting feature of HIV infection in these patients. Mean age at presentation was 41 years. Bilateral involvement occurred in 9 (15%) cases. The mean tumor basal diameter was 11 mm. Orbital involvement was noted in 6 (9%) cases, and intraocular tumor extension occurred in 1 (1%) case. Based on American Joint Committee Classification, T2 (n = 35, 51%) was most common. The primary treatment for OSSN included excision biopsy (n = 52, 75%), topical chemotherapy with Mitomycin-C (n = 5, 7%), extended enucleation (n = 4, 6%), and orbital exenteration (n = 8, 12%). Tumor recurrence occurred in 23% cases during a mean follow-up period of 9 months. On histopathology, invasive squamous cell carcinoma was more common (n = 38, 55%). OSSN was the presenting sign of underlying HIV infection in 26% cases, and 70% were unaware of their HIV-positive status prior to HIV screening. In this study, T2 tumor was most common, and 26% cases required extended enucleation/orbital exenteration to achieve complete tumor resection.

Purpose To compare levator plication with resection in congenital ptosis. Methods Prospective comparative randomized trial involving 20 eyes of 20 patients with age > 4 yrs, simple mild-to-moderate congenital ptosis with good-to-fair amount of levator action were included. Patients were randomized to either levator resection or plication. Outcome was compared in terms of eyelid height and course of postoperative events. Data was compared using the paired and unpaired t-test. Results The mean M.R.D. 1 at the end of 3 months in Group A was 2.8 +/- 1.23 mm and in Group B was 1.12 +/- 0.83 mm (p value = 0.001). Plication did not improve levator action much. Resection lead to more alterations in Bell's, lid lag, lagophthalmos and persisting edema (3 cases). Conclusion In 70% cases of congenital ptosis, good cosmetic outcome can be achieved with levator resection. With levator plication there are greater chances of drooping from fourth week onwards. The technique of plication, though simpler in approach failed to correct dystrophic muscle in congenital ptosis.

Ocular adnexal lymphoma (OAL) is a rare tumor with an incidence of 0.2 per 1,00,000 individuals. However, it constitutes the most common orbital tumor especially in older population with an incidence ranging from 11% to 24%. OAL can involve conjunctiva, orbital soft tissues, eyelid, or adnexal structures such as lacrimal gland and lacrimal drainage system. The most common primary OAL is low-grade malignant extranodal marginal zone B-cell lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT) type. Though various classification and staging systems have been proposed for OAL, currently, American joint committee on cancer (AJCC) TNM (tumor node metastasis) staging is most commonly used. Most commonly, conjunctival lymphoma typically presents as ‘salmon-colored patch’ and orbital lymphoma presents as proptosis, which on imaging shows characteristic appearance of molding around the globe without any globe indentation or bone erosion. Orbital radiotherapy and systemic chemotherapy forms the mainstay of treatment. Newer treatment modalities include immunotherapy with interferon and anti-CD20 antibody rituximab that have been shown to be useful either when used alone or in combination with chemotherapy or as radio-immunotherapy.

Ultrasonic endoscopic dacryocystorhinostomy (UEnDCR) is emerging alternative modality of managing nasolacrimal duct obstructions. The aim of this study was to report the clinical profile and outcomes with a UEnDCR with mitomycin C and silicone intubation. Prospective interventional case series performed on all consecutive patients undergoing an ultrasonic endoscopic dacryocystorhinostomy over a 1-year period from September 2013 to October 2014. All surgeries were performed by a single surgeon (MJA). Data collected include demographics, presentation, indications for surgery, past interventions, intraoperative and post-operative complications and outcomes. The main outcome measures were anatomical and functional success of the surgery. 44 procedures were performed in 41 patients. The mean age was 31.6 years. Children with complex congenital nasolacrimal duct obstructions refractory to probing and intubation accounted for 17 % (7/41) of the cohort. Past history of acute dacryocystitis was noted in 35.6 % (15/41). Two patients (4.9 %, 2/41) had failed external DCR. A minimal follow-up of 6 months following surgery was taken for final analysis. Complications included intraoperative focal epithelial burn in one patient that healed spontaneously and post-operative ostium granulomas in 15.9 % (7/44) of the ostia. At the 6-month follow-up, anatomical and functional successes were noted in 93.1 % (41/44) and 88.6 % (39/44), respectively. Ultrasonic dacryocystorhinostomy is a safe and effective alternative modality in the management of nasolacrimal duct obstructions in pediatric and adult age groups. Setup was easy and no additional technical difficulties were observed.

Germ cell tumor can affect extragonadal sites. Teratoma is a well-recognized extragonadal tumor in the orbit. Primary yolk sac tumor (YST) or endodermal sinus tumor of orbit is rare and only few cases have been reported in the literature. Its clinical presentation may mimic many common pediatric orbital conditions, and delay in diagnosis affects ocular morbidity and mortality. In the past orbital YST has been treated with multimodal therapy including surgery, systemic chemotherapy, and radiotherapy. Herein we describe a case of primary orbital YST and reviewed the literature for similar cases. The review aims to describe the clinical presentation, imaging features, histopathological characteristics, and management of orbital YST.

To describe and compare the clinical presentation, treatment outcomes, and histopathologic features of ocular surface squamous neoplasia (OSSN) based on human immunodeficiency virus (HIV) status.Case-control study.A total of 200 patients with OSSN, of whom 83 (41%) had positive results for HIV and were classified as cases and 117 (59%) had negative results for HIV and were classified as controls.Enzyme-linked immunosorbent assay for HIV, conjuntival excision biopsy, extended enucleation, orbital exenteration.Clinical features, treatment outcomes, and histopathologic characteristics.The mean age at presentation of OSSN in both cases and controls was 40 years (median, 40 years; range, 13-65 years) and in controls was 40 years (median, 38 years; range, 15-80 years). On comparison of cases versus controls with OSSN, HIV-positive individuals had larger (12 vs. 8 mm; P0.001) and thicker (3.2 vs. 2.3 mm; P = 0.041) tumors, with a higher incidence of corneal (60% vs. 40%; P = 0.007), scleral (19% vs. 9%; P = 0.044), and orbital (13% vs. 3%; P = 0.019) invasion and a higher need for extended enucleation or exenteration (27% vs. 11%; P0.001). The bilateral presentation (11% vs. 4%; P = 0.13), need for lamellar sclerectomy (13% vs. 8%; P = 0.29), and tumor recurrence after primary treatment (30% vs. 20%; P = 0.12) was higher in HIV-positive cases compared with HIV-negative controls. However, these features were not statistically significant. Based on American Joint Committee on Cancer classification, T1 tumor was more common in controls (13% in cases vs. 35% in controls; P = 0.0009), and T4 tumor was more common in cases (13% in cases vs. 4% in controls; P = 0.019). None of the patients demonstrated systemic metastases or died of disease during a mean follow-up period of 10 months (median, 4 months; range,1-75 months) in cases and 9 months (median, 4 months; range,1-99 months) in controls.Ocular surface squamous neoplasia in HIV-positive individuals is aggressive with larger and thicker tumors and with higher incidence of corneal, scleral, and orbital invasion. These patients are associated with poor ocular prognosis with higher need for extended enucleation, exenteration, or both.

We report a case of naso-cutaneous fistula due to thermal injury during transcanalicular laser dacryocystorhinostomy followed by superadded infection with coagulase negative staphylococcus in a diabetic patient. The case highlights the importance of meticulous wound care in the management and possibility of its occurrence even with minor thermal injury in immunocompromised patients. Keywords: Fistula, Laser, Naso-cutaneous, Immunocompromised, Diode

Orbital implants are now routinely used after enucleation and evisceration. However exposure of the implant can lead to infection and extrusion. Hence, early repair of larger exposure with graft material is required. We describe three cases where early postoperative mucosal dehiscence was successfully managed with autologous serum.

Amyloidosis and its ophthalmic manifestations are rare. The unusual presentation can result in diagnostic delay and increase ocular morbidity. Additionally, there are various predisposing conditions and systemic involvement can affect various organs. Hence, localized disease warrants a thorough clinical evaluation and laboratory investigation. We report two cases of primary localized amyloidosis presenting as a tarsal mass and ptosis. The diagnosis was established on histopathology. There were no predisposing conditions and no systemic involvement. The disease was probably related to the local immunocyte disorder.

Purpose To report the clinical profiles and outcomes of buried probe variant of complex congenital nasolacrimal duct obstruction (CNLDO). Methods Retrospective chart review of all patients endoscopically diagnosed as a buried probe variant of complex CNLDO, over a 3.5 year period from a single surgeon's (MJA) database were included in the study. A detailed lacrimal system evaluation was performed and intraoperative findings including nasal endoscopy were documented. A minimum follow up of 3 months following the final intervention was considered for analysis. Anatomical and functional success of the interventions was assessed at the final follow up. Results Twenty-two eyes of 21 patients with buried probes were studied. The mean age at presentations was 41.2 months. Epiphora and discharge were the commonest presenting symptoms noted in 77.2% (17/22). Associated lacrimal anomalies include punctal agenesis, incomplete punctal canalization and atonic lacrimal sac. All patients underwent irrigation and probing under nasal endoscopic guidance. Further, 3 patients underwent endoscopic dacryocystorhinostomy for persistent CNLDO. At a mean follow up of 4.9 months, the final anatomical and functional successes were noted in 90.9% and 81.8%, respectively. Conclusions Buried probe is a variant of complex CNLDO, noted more commonly in older children. Endoscopic guidance is crucial for its diagnosis and satisfactory outcomes.

Purpose The purpose of the present study is to report authors' experience of primary powered endoscopic dacryocystorhinostomy in the setting of acute dacryocystitis and lacrimal sac abscess. Methods A prospective interventional case series of 20 primary powered endoscopic dacryocystorhinostomies were performed in 20 patients presenting with acute dacryocystitis and lacrimal sac abscess at a tertiary eye care center from April to December 2013. None of the patients received preoperative antibiotics. All cases were operated by single surgeon (M.J.A.) using a standard described technique. All patients were intubated for 6 weeks. A minimum follow up of 6 months after stent removal was considered for the final analysis. The main outcome measures were the resolution of infection and the anatomical and functional successes of the surgical procedure. Results The mean age at presentation was 39.2 years. Sixty percent of patients (12/20) presented with acute dacryocystitis, 35% (7/20) with a lacrimal abscess, and 5% (1/20) with a dacryopyocele following a failed probing. None of the cases received preoperative antibiotics. Ten percent of patients (2/20) underwent additional septoplasty. All the cases showed resolution of pain and swelling at 1 week follow up. Two patients were noted to have small edge granulomas of the ostium, which were successfully managed by focal excision. At the final follow up, anatomical success was achieved in 95% (19/20) and functional success in 90% (18/20) of the patients. Conclusions Primary powered endoscopic dacryocystorhinostomy is an effective modality in the management of acute dacryocystitis and lacrimal abscess, and result in rapid resolution of the disease.