Gangadhara Sundar

Congenital lacrimal fistula: A major review.

ABSTRACT The purpose of this article is to review and summarize the etiopathogenesis, symptomatology, systemic associations, management, complications and clinical outcomes of congenital lacrimal fistulae. The authors performed an electronic database (PubMed, MEDLINE, EMBASE and Cochrane Library) search of all articles published in English on congenital lacrimal fistulae. Congenital subsets of patients from series of mixed lacrimal fistulae were included in the review. These articles were reviewed along with their relevant cross-references. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. The prevalence of congenital lacrimal fistulae is reported to be around 1 in 2000 live births. They are frequently unilateral, although familial cases tend to be bilateral. Lacrimal and systemic anomalies have been associated with lacrimal fistulae. Exact etiopathogenesis is unknown but mostly believed to be an accessory out budding from the lacrimal drainage system during embryogenesis. Treatment is indicated when significant epiphora or discharge is present and is mostly achieved by various fistulectomy techniques with or without a dacryocystorhinostomy. Congenital lacrimal fistulae are a distinct clinical entity with unique features. Surgical management can be challenging and successful outcomes are usually achieved with widely accepted protocols.

Unusual Merkel cell carcinoma of the eyelid.

Merkel cell carcinoma of the eyelid is a rare tumor with less than 100 reported cases worldwide. We describe an unusual presentation of Merkel cell carcinoma of the eyelid in a 60 year old Asian male. He presented with multiple left lower lid conjunctival nodules, intense conjunctival erythema, as well as ipsilateral cervical lymphadenopathy. An incisional biopsy diagnosed him with Merkel cell carcinoma with a PET scan showing distant metastatic disease. He was then treated with chemotherapy. The combination of a presentation of conjunctival nodules and erythema, location in the lower eyelid and the conjunctiva, the presence of metastatic disease on diagnosis as well as an unusual immunohistochemical profile make this an unusual case.

Bilateral Orbital Haematomas in an Anticoagulated Patient with Severe H1N1 Influenza

A previously healthy woman was admitted to the intensive care unit (ICU) with severe H1N1 influenza. She had prolonged hospital stay due to multiple complications of critical illness, including pelvic deep vein thrombosis (DVT), which was treated with subcutaneous enoxaparin. The patient was referred to the ophthalmology service for bilateral proptosis. On examination, she had bilateral tense proptosis, worse on the left side with exposure keratopathy. Laboratory tests showed that she had thrombocytopenia and raised activated partial thromboplastin time (APTT). A CT scan revealed well-circumscribed soft tissue density lesions in the superolateral orbits and was reported as bilateral lacrimal gland enlargement. However, based on a clinical suspicion of subperiosteal hematoma collection, a diagnostic tap was performed. Following aspiration of six mls of dark blood from the left superior orbit, there was a reduction of proptosis with improvement in chemosis and resolution of exposure keratopathy. Enoxaparin is one of several antithrombotic agents which are increasingly being used for DVT prophylaxis in severely compromised patients. Furthermore, ICU patients ventilated for prolonged periods are at risk of developing chemosis and exposure keratopathy. Thus, the clinician should maintain a high index of suspicion in identifying subperiosteal hematomas, when managing such cases. The spontaneous bilateral vision threatening subperiosteal hematoma was probably caused by a combination of enoxaparin therapy and prolonged ventilation.

Lacrimal Trauma and Its Management

Injury of the lacrimal drainage apparatus, usually in the form of canalicular lacerations, are relatively common in periorbital and facial trauma. This is most frequently encountered in otherwise young healthy males, although it may be seen in young children, the women, and the elderly. Less frequently encountered is injury of the nasolacrimal duct, usually in midfacial and naso-orbit-ethmoid (NOE) fractures. The incidence of lacrimal system injuries has been reported to vary from 7 to 20 % depending upon the mechanism of the injury and reporting. Failure to recognize and manage lacrimal injuries is one of the common complications of eyelid/midfacial injuries. We shall herewith outline the predisposing factors and evaluation of the patient and discuss details of principles and mechanisms of management including long-term follow-up.

Vascular lesions of the orbit: Conceptual approach and recent advances

Vascular lesions of the orbit have always been an enigma to the ophthalmologist. They comprise around 7% of all orbital pathology and even to the oculoplastic surgeon have been the holy grail of all orbital disorders. Consequences included dense amblyopia, blindness, globe dystopia, orbital and orbitofacial deformity, pain and ulceration, and nonrecognition of incidental, noncontiguous clinical intracranial vascular anomalies which may result in intracranial vascular incidents with residual severe morbidity.[1] Visual loss and presentation may also vary from chronic to acute and even catastrophic.[2] In fact, many a surgeon of the past may recall disappointing and sometimes even disastrous outcomes following attempted surgical management for these challenging conditions.[3]

A study of sports-related orbital fractures in Singapore

ABSTRACT With an increased popularity of sport and active living worldwide, our study aims to explore the incidence and features of sports-related orbital fractures in Singapore. 1421 computer tomography (CT) imaging scans of the face and orbits done at the National University Hospital over a 24-month period from January 2013 and December 2014 were reviewed retrospectively for orbital fractures. We identified 483 orbital fractures of which sports injury was the fourth most common etiology (n = 65; 13.5%) after road traffic accident (n = 131; 27.1%), geriatric fall (n = 81; 16.8%) and workplace injury (n = 67; 13.9%). The three most common sport in orbital fractures were soccer (n = 20; 30.8%), bicycling (n = 11; 16.9%) and jogging (n = 8; 12.3%). The three most common fracture patterns were zygomatico-maxillary complex fractures (n = 24; 36.9%), isolated one wall blowout fractures (n = 19; 29.2%) and naso-orbito-ethmoid fractures (n = 7; 10.8%). Sports-related orbital fractures were associated with a low mean age of patients (45.9 years, range, 14-79 years), a higher proportion of males (n = 58; 89.2%) than that from geriatric falls (n = 37, 45.6%) (P < 0.01), a higher likelihood of unilaterality (n = 62; 95.4%) than that from traffic accidents (n = 99; 75.6%) (P < 0.01) and a lower likelihood of pan-facial involvement (n = 4; 6.15%) than that from traffic accident (n = 60; 45.8%) (P < 0.01). Sports-related orbital fractures are the fourth most common cause of orbital fractures. Though commonly seen in young male adults, in view of the aging population and people exercising more regularly, education of safety measures among sports users is paramount to preventing sports-related orbital fractures.

Surgical treatment outcome of medically refractory huge giant papillary conjunctivitis

Purpose To compare the surgical outcome of excision of giant papillae with and without amniotic membrane in a patient with bilateral medically refractory giant papillary conjunctivitis (GPC). Observations 27-year-old Chinese lady presented with bilateral itchy eyes, discomfort and fullness of upper lids for past two years. She was a long-term contact lens user but stopped completely 2 years ago. Not a known atopic, she had unusually large giant papillae involving both upper tarsal conjunctiva. She had used topical olopatadine(0.1%), intermittent dexamethasone(0.1%) and also underwent intralesional injection of Triamcinolone (40mg/ml) twice on each side without any improvement in past two years. We decided to excise the papillae with amniotic membrane transplantation (AMT) in left eye and only excision in the right eye. The results were compared after 2 years. Giant papillae were excised in both eyes under regional anesthesia on separate occasions. The left eye received AMT in addition to excision. A symblepharon ring was applied and left in place for two weeks in both eyes. She was treated with topical Prednisolone acetate (1%) and Levofloxacin 4 times a day for a month. Postoperative period was unremarkable and she recovered well. In 2 years follow-up, the upper tarsal conjunctiva was smooth in both eyes and there was no evidence of any recurrences. Conclusion and Importance Excision of giant papillae is a treatment option for cases with refractory GPC. Additional AMT after excision may not be necessary as there was no difference in surgical outcome.

Tumors of the Lacrimal Drainage System

The lacrimal drainage apparatus are paired structures that commence from the medial end of the upper and lower eyelid margins as the lacrimal puncta at the mucocutaneous junction, course through the medial end of the eyelid and the anterior limbs of the medical canthal tendon as the upper and lower canaliculi, which in most individuals merge into a common lacrimal canaliculus. The common canaliculus enters the lacrimal sac at its lateral wall with the fundus above and the body below, which then courses along the medial wall of the maxilla to open into the inferior nasal meatus under the inferior turbinate at the valve of Hasner. In general, tumors arising from the upper lacrimal drainage system are uncommon and when occur are usually benign especially at the punctal orifices. Tumors of the lacrimal sac and the nasolacrimal duct are extremely rare and when suspected, all efforts should be ensured to rule out malignancy.

A Safe and Accurate Method of Assessing the Size of Implants Required in Orbital Floor Reconstruction

Many methods to determine the size of an orbital floor implant depend on trial and error. However, this technique is imprecise and the repeated insertion and removal of the implant leads to soft tissue trauma and swelling. A method of measuring orbital floor dimensions intraoperatively using a waterproof paper ruler is presented in this study. This technique has the advantage of being simple, precise, safe, and expedient.