Devjyoti Tripathy

Ocular parasitoses: A comprehensive review

Parasitic infections of the eyes are a major cause of ocular diseases across the globe. The causative agents range from simple organisms such as unicellular protozoans to complex metazoan helminths. The disease spectrum varies depending on the geographic location, prevailing hygiene, living and eating habits of the inhabitants, and the type of animals that surround them. They cause enormous ocular morbidity and mortality not because they are untreatable, but largely due to late or misdiagnosis, often from unfamiliarity with the diseases produced. We provide an up-to-date comprehensive overview of the ophthalmic parasitoses. Each section describes the causative agent, mode of transmission, geographic distribution, ocular pathologies, and their management for common parasites with brief mention of the ones that are rare.

Primary Nonendoscopic Endonasal Versus Delayed External Dacryocystorhinostomy in Acute Dacryocystitis.

PURPOSE Conventional treatment for acute dacryocystitis consists of medical management followed by elective delayed external dacryocystorhinostomy (EXT-DCR). The purpose of this study was to compare the outcome after primary nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR) versus conventional treatment in acute dacryocystitis. METHODS Retrospective chart analysis of all consecutive patients of acute dacryocystitis presenting between 2011 and 2015 was performed. Group A had patients who underwent primary NEN-DCR within 2 weeks of presentation. Group B comprised age- and gender-matched patients who received conventional treatment. RESULTS Forty-six patients were included with 23 patients in each group. Mean age (45.2 ± 14.7 vs. 47.5 ± 14 years) and gender distribution (women 17/23 in group A vs. 15/23 in group B) in both groups were comparable. Mean duration from presentation to surgery was 7.82 ± 4.65 days for group A versus 27.3 ± 12 days for group B (p = 0.00001, independent T test). Mean time for complete resolution of symptoms was 21.4 ± 6 days for group A versus 38.69 ± 15.8 for group B (p = 0.000014, independent T test). Mitomycin-C usage (0.04%; 17 vs. 14) and mean follow up of both groups (6.4 vs. 5.7 months) were comparable. While functional success was similar (20/23) in both, anatomical success was seen in 22/23 and 21/23 in groups A and B, respectively. Complications included disfiguring scar in 4, recurrent acute dacryocystitis in 3, and punctal ectropion in one patient in the EXT-DCR group. CONCLUSIONS Primary NEN-DCR leads to faster resolution facilitating earlier rehabilitation with comparable anatomical and functional outcomes compared with conventional delayed EXT-DCR in acute dacryocystitis.

Tufted angioma (Angioblastoma) of eyelid in adults-report of two cases

AbstractTufted angioma, first recognized in Japanese literature as “Angioblastoma of Nagakawa”, is a rare benign vascular tumour with a variable clinical presentation. It commonly manifests as a macule, papule or nodule in infancy or childhood in the region of the upper trunk and neck. Here in we report two cases of this rare progressive angioma as lesions of the eyelid in adults. Tufted angioma has a classical “cannon ball” like appearance of vascular tufts on histopathology. Immunohistochemical staining with actin highlights the spindly stromal cells surrounding the capillaries. Complete physical examination and haematological work up is recommended in patients with tufted angioma to exclude rare association of port wine stain and Kasabach-Merritt syndrome with this rare entity. To the best of our knowledge, our cases illustrate the first case report of tufted angioma presenting as an eyelid lesion.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1230909536950947.

Tuberculosis of Eyelid Presenting as a Chalazion

Inflammatory and neoplastic lesions of the eyelid may present clinically as a primary or recurrent chalazion. We present a case of isolated unilateral tuberculosis of the eyelid masquerading as a partially prolapsed chalazion, missed initially because the curetted material was not sent for histopathology, but diagnosed later when the patient presented with delayed wound healing and accelerated submandibular lymphadenitis. A 17-year-old male student presented with a painless swelling and redness of the left lower lid of about 3 weeks’ duration with no other significant history. His best-corrected visual acuity was 20/20 in the right eye and 20/50 in the left eye. Intraocular pressure was 16 mmHg in both eyes. Examination showed a nodular swelling of the lid with an unremarkable skin surface. A prolapsed granuloma with erythema and congestion was noted on lid eversion. The rest of the ocular surface, anterior segment, and fundus were unremarkable. Regional lymph nodes were not palpable. With a clinical diagnosis of a partially prolapsed chalazion, incision and curettage was carried out. Curetted material was not submitted for histopathology. At 1 week follow-up, delayed wound healing was noted and secondary wound infection was suspected (Fig 1A, available at http://aaojournal.org). The patient was managed conservatively with oral antibiotics. He presented 1 week later with increased inflammation of the lower lid and a grossly enlarged, erythematous, fluctuant, and tender left submandibular lymph node (Fig 1B, available at http://aaojournal.org). A clinical diagnosis of secondary wound infection with suppurative lymphadenitis was made. Fine-needle aspiration biopsy from the lymph node yielded purulent material smears of which showed sheets of polymorphonuclear leucocytes in a background of debris (Fig 2A, available at http://aaojournal.org). Epithelioid cells, granulomas, and caseous necrosis were absent. Grams, Ziehl-Neelsen (ZN), and Gomori’s methenamine silver stains were done to look for infectious etiology. Slender acid fast bacilli were seen with ZN stain (Fig 2B, available at http://aaojournal.org). A diagnosis of tubercular lymphadenitis was thus made. Purulent material was processed for direct microscopy and culture in the microbiology laboratory. Although Gramand Giemsa-stained smears did not show any organisms, slender acid-fast bacilli were seen with ZN-stained smears. Culture on Lowenstein-Jensen’s medium grew rough, buff, and tough colonies after 3 weeks’ incubation at 37°C, which was identified as Mycobacterium tuberculosis. Multiplex polymerase chain reaction targeting IS6110, MPB64, and protein b for M tuberculosis complex showed amplification of 2 (MPB 64, protein b) out of 3 target genes (Fig 2C, available at http://aaojournal.org).The organism was confirmed to be M tuberculosis. Biopsy from the primary surgical site showed stratified squamous to stratified columnar epithelium ulcerated at places. Stroma showed numerous well-formed granulomas (Fig 3A, available at http://aaojournal.org) composed of epithelioid histiocytes, lymphocytes, and plasma cells (Fig 3B, available at http://aaojournal.org). Numerous polymorphonuclear leucocytes were present in the lumen of the Crypts of Henle. On ZN staining, there were single, acid-fast bacillus in the granulomatous infiltrate. Gomori’s methenamine silver and Gram stain were negative for fungus and bacteria. A diagnosis of tuberculosis of the eyelid with tubercular lymphadenitis was made. Detailed systemic evaluation for tuberculosis was noncontributory, with no evidence of immunosuppression. With antitubercular treatment, the eyelid wound healed with significant regression of the lymphadenitis was evident at 2 months’ follow-up (Fig 4, available at http://aaojournal.org). A PubMed search of the literature revealed only 3 cases of tuberculosis of eyelid and tarsal conjunctiva mimicking a chalazion. Only 1 of the 3 cases had isolated unilateral tuberculosis of upper tarsal conjunctiva without systemic disease, whereas the other 2 were bilateral and associated with pulmonary tuberculosis. This case emphasizes the importance of routine histopathologic evaluation of curetted material from suspected chalazia. In a large series of 1060 clinically diagnosed chalazia, 6.4% of cases showed a discrepancy between the clinical and histopathologic diagnoses. Various types of benign and malignant eyelid lesions, especially chronic inflammation of different types, and sebaceous carcinoma may mimic a chalazion. Although rare, tuberculosis of the eyelid should be considered in the differential diagnoses of a chalazion. Suppurative inflammation without granulomas on fine-needle aspiration biopsy of regional lymph nodes in early tuberculosis is not unknown in literature, although not reported in ophthalmic literature. Staining of aspiration smears with inexpensive acid-fast stain can help to unmask tubercular lymphadenitis without use of more expensive molecular diagnostic techniques.

Overexpression of pyruvate dehydrogenase kinase 1 in retinoblastoma: A potential therapeutic opportunity for targeting vitreous seeds and hypoxic regions

Pyruvate dehydrogenase kinase 1 (PDK1), a key enzyme implicated in metabolic reprogramming of tumors, is induced in several tumors including glioblastoma, breast cancer and melanoma. However, the role played by PDK1 is not studied in retinoblastoma (RB). In this study, we have evaluated the expression of PDK1 in RB clinical samples, and studied its inhibition as a strategy to decrease cell growth and migration. We show that PDK1 is specifically overexpressed in RB patient samples especially in vitreous seeds and hypoxic regions and cell lines compared to control retina using immunohistochemistry and real-time PCR. Our results further demonstrate that inhibition of PDK1 using small molecule inhibitors dichloroacetic acid (DCA) and dichloroacetophenone (DAP) resulted in reduced cell growth and increased apoptosis. We also confirm that combination treatment of DCA with chemotherapeutic agent carboplatin further enhanced the therapeutic efficacy compared to single drug treatment. In addition, we observed changes in glucose uptake, lactate and reactive oxygen species (ROS) levels as well as decreased cell migration in response to PDK1 inhibition. Additionally, we show that DCA treatment led to inhibition of PI3K/Akt pathway and reduction in PDK1 protein levels. Overall, our data suggest that targeting PDK1 could be a novel therapeutic strategy for RB.

Comparative Evaluation of the Ostium After External and Nonendoscopic Endonasal Dacryocystorhinostomy Using Image Processing (Matlabs and Image J) Softwares.

PURPOSE The purpose of this study was to compare the characteristics of the ostium after external dacryocystorhinostomy and nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR). METHODS This cross-sectional study included patients who underwent a successful external dacryocystorhinostomy or NEN-DCR and had ≥1 month follow up. Pictures of the ostium were captured with a nasal endoscope (4 mm, 30°) after inserting a lacrimal probe premarked at 2 mm. Image analyses were performed using Image J and Contour softwares. RESULTS Of the 113 patients included, external dacryocystorhinostomy group had 53 patients and NEN-DCR group had 60 patients. The mean age of patients in the NEN-DCR group (38 years) was significantly (p < 0.05) lower than the external dacryocystorhinostomy group (50 years). There was no statistically significant difference (2 sample t test, p > 0.05) in mean follow up (6 vs. 4 months), maximum diameter of ostium (8 vs. 7 mm), perpendicular drawn to it (4 vs. 4 mm), area of ostium (43 vs. 36 mm), and the minimum distance between common internal punctum and edge of the ostium (1 vs. 1 mm) between the external and NEN-DCR groups. CONCLUSIONS Image processing softwares offer simple and objective method to measure the ostium. While ostia are comparable in size, their relative position differs with posteriorly placed ostia in external compared with inferior in NEN-DCR.

Canalicular lacerations: Factors predicting outcome at a tertiary eye care centre

ABSTRACT To determine the factors predictive of outcome in canalicular laceration repair at a tertiary eye care centre. A retrospective review of the medical records of all primary canalicular laceration repairs managed at a tertiary eye care centre between the years 2006 and 2014 was done. Thirty-nine patients were included and majority were male (79.5%) with a mean age of 30.05 + 16.2 years (range 2–65). Most (n = 34) had monocanalicular laceration and 5 had bicanalicular laceration. All surgeries were done in the operating room setting. Overall patency by irrigation was seen in 74.4% at a median follow-up of 19.89 weeks (range 21–910). Anatomical outcome was different among the stents and best after Mini-Monoka monocanalicular stent (17/19; 89.5%) followed by bicanalicular annular stents (n = 6; 60%) and 20G Silicone rod (8/14, 57%). The factors predictive of poor outcome were related to the mode of injury [road traffic accidents; Hazard ratio (HR)19.57; p = 0.048] and the type of stent [20G silicone rod (HR 35.7; C.I 3.04 - 419.14; p = 0.004)] by multivariate analysis. Skill of the surgeon was critical as the outcome for fellows-in-training showed a trend towards failure (HR 6.66, p = 0.07). Complications included stent extrusion (n = 28.2%), punctal granuloma (n = 5.1%) and stent exposure (n = 2.5%). The mode of injury - road traffic accidents and type of stent - 20 G silicone rod were risk factors predictive of poorer outcome after canalicular laceration repair. Individual skill of operating surgeon may be a critical factor suggesting a review of training protocols.

Primary nonendoscopic endonasal versus external dacryocystorhinostomy in nasolacrimal duct obstruction in children

Purpose: The aim is to compare the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN DCR) with external DCR (EXT-DCR) in the treatment of nasolacrimal duct obstruction (NLDO) in children. Methods: A retrospective, comparative chart analysis of all consecutive children <16 years after EXT-DCR or NEN-DCR between June 2012 and February 2016. Results: Seventy-one children (79 eyes) underwent DCR in the study, of which 37 children (40 eyes) underwent EXT-DCR and 34 (39 eyes) NEN-DCR. Mean age of both groups (8.7 vs. 7.7 years) was comparable. Etiologically, persistent congenital NLDO was the most common indication (50% vs. 72%), followed by acquired and secondary NLDO. Mean duration was shorter for NEN-DCR (47 vs. 37 min; P = 0.0021). Mitomycin C 0.04% was used more often in NEN-DCR (10% vs. 56.41%). Success after primary EXT-DCR was 100% as compared to 75% for primary NEN-DCR at median follow-up of 12 and 16 months respectively. At revision, the main cause of failure was granuloma (60%). After revision, all eyes were symptom-free at a median follow-up of 9.5 months. Conclusion: Primary NEN-DCR has a poorer outcome than EXT-DCR in the treatment of NLDO in children and is more likely to need a revision procedure.

Orbital tuberculosis: Clinicopathological correlation and diagnosis using PCR in formalin-fixed tissues

ABSTRACT This article describes the clinicopathological correlation and challenges encountered in the diagnosis of orbital tuberculosis (TB). Retrospective, interventional case series. A chart review of six patients who underwent biopsy for an orbital mass between January 2012 and December 2013 was performed. Institutional review board approval was obtained for the study. Clinical, radiological, and laboratory findings were documented, and response to antitubercular therapy (ATT) was noted. Age at presentation ranged from 18 to 64 years and duration of complaints varied from 2 weeks to 2 months. Pain, redness, and swelling with an orbital mass on computerized tomography (CT) were the common features. None of the patients was clinically suspected to have orbital TB at presentation. History of prior contact with a patient of TB and history of prior TB were present in one case each. Chest radiography (CXR) showed pulmonary consolidation in one case. Tuberculin skin test (TST) readings ranged from nonreactive to 23 mm. The presence of sputum acid fast bacilli (AFB) was tested in three cases and was negative. Polymerase chain reaction (PCR) for MPB64 gene was positive in all six cases. All cases responded to ATT. Clinical presentation of orbital TB can be variable and can simulate conditions like inflammatory disease and malignancy. Biopsy with histopathology plays a key role in diagnosis. Supportive laboratory investigations are necessary to clinch the diagnosis in cases where histopathology is suggestive of TB. In this regard, PCR for Mycobacterium tuberculosis (MTB) on tissue biopsy specimens may be a sensitive diagnostic tool.

Unilateral Migratory Relapsing Orbital Myositis While on Immunosuppressant Therapy: An Uncommon Entity.

A young healthy female presented with acute onset left ocular pain, restricted ocular motility, and binocular diplopia. CT imaging showed left lateral rectus myositis that resolved with oral corticosteroids. Two sequential relapses occurred subsequently involving the superior rectus-levator complex followed by the medial rectus. Biopsy revealed orbital inflammatory disease with lymphocytic vasculitis. Detailed systemic work up was normal. The second relapse was seen while on long-term oral methotrexate although initial disease remission had been achieved with the same drug. A changeover to oral azathioprine was able to achieve disease remission after the second relapse. All relapses involved the same side and the contralateral orbit was not affected. This report presents the curious phenomenon of unilateral migratory relapsing orbital myositis of unknown cause that recurred even while on immunosuppressant therapy. It highlights the unpredictable nature of this uncommon entity and the challenges faced in managing such cases.