Mandeep S. Bajaj

Invasive Aspergillosis of Orbit in Immunocompetent Patients: Treatment and Outcome

OBJECTIVE Invasive sino-orbital aspergillosis in immunocompetent patients is a rare clinical entity and often misdiagnosed. Invasive sino-orbital aspergillosis is potentially fatal; however, mortality may be avoided with timely treatment. Presently, there are no universal guidelines for its treatment. We present the clinical features, treatment, and outcome in 15 cases of invasive sino-orbital/orbital aspergillosis in healthy individuals. DESIGN Retrospective case series. PARTICIPANTS Fifteen cases of invasive sino-orbital/orbital aspergillosis in immunocompetent individuals. METHODS We retrospectively analyzed all patients with sino-orbital/orbital aspergillosis who were treated at the Dr. Rajendra Prasad Center for Ophthalmic Sciences between June 1999 and September 2009. Diagnosis was based on histopathologic documentation of tissue invasion by septate fungal hyphae with acute angle branching and presence of granulomatous inflammation. MAIN OUTCOME MEASURES Treatment outcome in terms of patient survival, resolution of symptoms, and resolution of orbital mass on imaging. RESULTS Fifteen patients (11 male and 4 female) were studied. Mean age of patients was 35 years. One patient declined treatment. Surgery was performed for orbital disease in 6 patients. Medical therapy consisted of intravenous amphotericin B followed by itraconazole in 10 patients, itraconazole alone in 2 patients, and voriconazole followed by itraconazole in 2 patients. Eleven patients are alive without recurrence at a median follow-up of 20 months. Of these patients, 5 had residual mass on imaging at last follow-up. One patient died of progressive disease. CONCLUSIONS This is a large case series of orbital aspergillosis reported in healthy individuals. The role of orbital surgery is not clear in treatment of this entity and requires further evaluation. Newer antifungal agents alone seem to be effective in controlling the infection.

Evaluation of polytetrafluoroethylene suture for frontalis suspension as compared to polybutylate-coated braided polyester

Purpose: To evaluate the efficacy of polytetrafluoroethylene (Gore‐Tex) suture as compared to polybutylate‐coated braided polyester (Ethibond) suture as sling materials for frontalis suspension in bilateral congenital ptosis.

Atypical presentations of retinoblastoma

PURPOSE To study the atypical presentations of retinoblastoma in our institution. METHOD Retrospective, clinical study. RESULTS A total of 392 cases of retinoblastoma were reviewed; 72.2% of the patients had leukocoria, 13% had proptosis, 10% had strabismus, 1.5% were asymptomatic (detected on screening), and 3.3% had atypical presentations. Fourteen different atypical findings were observed including endophthalmitis (0.76%), secondary glaucoma (0.76%), uveitis (0.5%), corneal edema (0.5%), phthisis bulbi (0.5%), orbital cellulitis (0.5%), cataract (0.25%), pseudohypopyon (0.25%), iris nodules (0.25%), hyphema (0.25%), iris neovascularization (0.25%), microphthalmos (0.25%), exposure keratopathy (0.25%), and corneal blood staining (0.25%). All of the patients had Reese-Ellsworth grade V disease. On histopathology, invasion of neighboring structures was seen in 10 patients. All patients underwent enucleation with adjuvant radiotherapy, chemotherapy, or both. CONCLUSIONS Retinoblastoma can mimic any orbital or ocular pathology. Atypical presentations of retinoblastomas are usually associated with advanced disease. The possibility of ocular tumor should be entertained whenever there is an unusual presentation that is unresponsive to the usual therapy. Ultrasonography and computed tomography should be performed in all such patients, especially if the posterior segment is not visible.

Orbital and adnexal cysticercosis

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro‐orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro‐orbital cysticer‐cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.

Correlation between Clinical Features, Magnetic Resonance Imaging, and Histopathologic Findings in Retinoblastoma: A Prospective Study

OBJECTIVE To correlate clinical features with histopathology findings in advanced intraocular retinoblastoma and to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting tumor invasion. DESIGN Prospective, nonrandomized case series. PARTICIPANTS We included 75 patients with group E retinoblastoma. METHODS Demographic and clinical features were recorded at presentation. Contrast-enhanced MRI was performed to study tumor characteristics and extent of invasion. Primary enucleation was performed and histopathologic features noted. Statistical analysis was done using the Kruskal-Wallis test to determine correlation between clinical features and histopathology. Sensitivity, specificity, and accuracy of MRI in detecting tumor invasion were determined. MAIN OUTCOME MEASURES Significant associations between clinical findings at presentation and high-risk histopathology, and correlation between MRI results and histopathologic evidence of tumor invasion. RESULTS A significant association was found between iris neovascularization and choroidal invasion (P = 0.032), intraocular pressure and optic nerve invasion (P = 0.034), and shallow anterior chamber and iris invasion (P = 0.021). Corneal diameter did not show any significant correlation with high-risk histopathology. On MRI, tumor volume showed a significant association with optic nerve invasion (P = 0.023). The accuracy of MRI in detecting choroidal invasion was 68% (sensitivity, 60%; specificity, 80%). Prelaminar invasion was correctly identified in 9 out of 15 eyes (accuracy, 84%; sensitivity, 60%; specificity, 90%), whereas the accuracy of MRI in detecting postlaminar invasion was 76% (sensitivity, 61.9%; specificity, 81.5%). Ciliary body invasion was correctly identified in 5 out of 7 eyes (accuracy, 93.3%; specificity, 95.6%) and scleral invasion in 5 out of 6 eyes (accuracy, 98.7%; specificity, 100%). CONCLUSIONS As far as we are aware, this is the first prospective study on the correlation of clinical features and MRI findings with histopathologic risk factors in eyes primarily enucleated for retinoblastoma. Neovascularization of iris, intraocular pressure, shallow anterior chamber, and tumor volume correlated well with high-risk histopathology. Because MRI has limitations in reliably predicting microscopic infiltration of the choroid and optic nerve, decision in favor of neoadjuvant chemotherapy on the basis of suspected postlaminar invasion on MRI is not justified in the absence of histopathologic evidence of disease.

A histopathologic analysis of eyes primarily enucleated for advanced intraocular retinoblastoma from a developing country.

CONTEXT In eyes enucleated for retinoblastoma, presence of histopathologic high-risk factors is associated with a higher risk of local recurrence and systemic metastasis. OBJECTIVE To evaluate histopathologic features in children with retinoblastoma in our population and establish relationship between age, tumor differentiation, and high-risk features. DESIGN Retrospective histopathologic analysis of 609 consecutively enucleated eyes for advanced intraocular retinoblastoma during a 10-year period. A nonparametric test was used to establish relationship between age, differentiation, and high-risk features. RESULTS Poorly differentiated retinoblastoma presented in 80.3% and well-differentiated in 19.7% of eyes. Well-differentiated tumors presented earlier (median 1.2 years) than poorly differentiated tumors (median 2.5 years) (P < .001). One hundred fourteen eyes (18.7%) had 1 and 138 (22.7%) had at least 2 high-risk histopathologic factors. Invasion of anterior chamber was found in 10.0%, iris in 10.7%, ciliary body in 6.7%, sclera in 13.7%, massive choroid in 24.6%, postlaminar optic nerve in 16.1%, resected margin of the optic nerve in 7.4%, and extrascleral tissue in 4.1% of eyes. Extensive necrosis was seen in 31.0% of eyes. Poorly differentiated tumors were significantly associated with presence of more than 1 high-risk histopathologic feature (P < .001) and extensive necrosis (P < .001). CONCLUSION Poorly differentiated tumors present at a later age and are associated with presence of multiple high-risk factors and extensive necrosis. In our population, high-risk histopathologic factors are present in a significant number of eyes. Because we have included only primarily enucleated eyes, this could truly represent the distribution of high-risk histopathologic factors in children with retinoblastoma.

Traumatic globe luxation with optic nerve transection

Luxation of the globe is a rare event that results from severe trauma to the orbit, often causing orbital rim and wall fractures. Though associated globe rupture often necessitates enucleation, repositioning of the globe can be attempted in these cases if the globe is intact. We report a case of globe luxation and optic nerve transection with its surgical management. A 17-year-old male presented with anterior luxation of the right globe and optic nerve transection following blunt trauma to the orbit. Computerized tomography revealed an anteriorly subluxated globe with complete transection of the optic nerve and multiple fractures of the orbital walls. The orbit was explored and the globe repositioned in the orbit with reattachment of the muscles. Postoperatively, the globe was in normal position with moderate motility and excellent overall cosmesis. Though the visual prognosis in these cases is usually extremely poor and depends on the extent and duration of injury, preservation of the globe not only helps the patient recover psychologically from the trauma but also allows better cosmesis.

Pattern of orbital exenteration in a tertiary eye care centre in India

Purpose: This study aimed to determine the clinical indications for orbital exenteration, profile of these patients and clinicopathological correlations, and to compare these results with previous published data.

Orbital schwannoma with cystic degeneration.

Background:  Schwannoma is a benign, slowly growing, painless, peripheral nerve sheath tumour that is uncommon in orbit. Longstanding tumours may develop degenerative changes. Extensive cystic change in orbital schwannoma is quite rare. We conducted this study to analyse the cases of orbital schwannoma, which were predominantly cystic and describe their clinical, imaging and histopathological features.

Evaluation of Amniotic Membrane Grafting in the Reconstruction of Contracted Socket

Purpose: To study the use of amniotic membrane for the reconstruction of mild to moderate grades of contracted socket and compare it to mucous membrane grafting. Methods: A total of 20 patients with acquired, anophthalmic contracted socket of mild to moderate grades were studied and divided into two groups: the amniotic membrane graft (AMG) group (10 patients) and the mucous membrane graft (MMG) group (10 patients). The preoperative and postoperative measurements of forniceal depth and volume of socket were compared. After surgery, motility of the prosthesis was also compared. Results: The mean preoperative depth of the lower fornix in the AMG group and the MMG group was 1.5 mm and 1.4 mm, and after surgery, at final follow-up was 5.4 mm and 5.5 mm, respectively. The preoperative mean height of the upper fornix in the AMG group and the MMG group was 10.3 mm and 10.7 mm, and after surgery, at final follow-up was 12.6 mm and 13.2 mm, respectively. The mean preoperative volume of the socket was 0.84 ml in the AMG group and 0.80 ml in the MMG group, and after surgery, at final follow-up was 1.43 ml and 1.48 ml, respectively. The various quantitative parameters including motility of the prosthesis were comparable in the two groups. Conclusions: Amniotic membrane grafting gave cosmetically and functionally acceptable results in cases of mild to moderate grades of anophthalmic socket contraction. The results were comparable to those of mucous membrane grafting.