R. Balasubramanya

Posterior corneal topographic changes after partial flap during laser in situ keratomileusis.

Aim: To study the posterior corneal topographic changes in eyes with partial flaps during laser assisted in situ keratomileusis (LASIK). Methods: Case records of 16 patients, who had partial flap in one eye during LASIK (group 1) and uncomplicated surgery in the other eye (group 2), were studied. Following occurrence of partial flap intraoperatively, laser ablation was abandoned in all the eyes. A 160/180 μm flap was attempted during the initial procedure using the Hansatome microkeratome (Bausch & Lomb Surgicals, Munich, Germany). LASIK surgery in all cases was performed using a 180 μm plate, at the mean interval of 4.16 (SD 1.5) months following the initial procedure. None of the eyes had intraoperative complication during LASIK. Relative posterior corneal surface elevation above the best fit sphere (BFS) before the initial procedure, before, and after LASIK were compared using the Orbscan slit scanning corneal topography/pachymetry system. Results: Posterior corneal elevation was comparable in the two groups, both preoperatively (group 1; 16.4 (4.8) μm, group 2; 16.1 (4.8) μm) and after final surgery (group 1; 57.2 (15.6) μm, group 2; 54.3 (13.1) μm). In group 1 after occurrence of partial flap, the posterior corneal elevation was 16.9 (4.4) μm, and this increase was not significant statistically (p=0.4). On multiple linear regression analysis, residual bed thickness (p<0.001) was independently the significant determinant of final posterior corneal elevation in both groups. Conclusion: The inadvertent occurrence of partial flap during LASIK procedure does not contribute to the increase in posterior corneal elevation.

Dentigerous cyst in the maxillary sinus: A rare cause of nasolacrimal obstruction

The main types of maxillary cysts are antral mucoceles, retention cysts, pseudocysts, dentigerous cysts and keratocysts. Despite the theoretical possibility of maxillary sinus cysts leading to nasolacrimal duct obstruction, only two cases have been reported in the literature so far. The present authors report this rare presentation of a dentigerous cyst with a tooth in the roof of the maxillary sinus, which led to nasolacrimal duct obstruction.

Acquired capillary haemangioma of the eyelid during pregnancy.

A 28-year-old woman presented with protrusion of her left eye and loss of vision following an accident. The injury was reportedly sustained in a road traffic accident in which a metallic handle hit her on the bridge of the nose and the medial canthal region of the left eye. She presented to us within 4 h of the injury. On local examination, a deep lacerated wound was seen on the bridge of the nose and there was forward and lateral prolapse of the left eyeball (Fig. 1). The eyelids were tightly closed behind the globe. On palpation there was no obvious bony injury. She had a visual acuity of 6/6 OD and no light perception OS. The movements of the left eye were grossly restricted in all gazes. There was a vertical conjunctival and Tenon’s capsule laceration on the medial side of the limbus through which the insertion site of the medial rectus was visible, but the muscle itself could not be visualized. The cornea was cloudy and had multiple small epithelial defects. The pupil was dilated and non-reactive. Fundus examination revealed an excavated defect in the area of the optic disc with haemorrhages fanning out from it. Retinal oedema and folds were visible in the surrounding area. Examination of the other eye was normal except for an absent consensual pupillary reaction. Radiographs of the skull, orbits and paranasal sinuses did not reveal any bony injury. Orbital exploration and repositioning of the globe was done within an hour, under general anaesthesia. No perforation of the globe or bony injury was detected. The retracted medial rectus muscle was identified and reinserted to its original insertion site. The globe was then repositioned into the orbit by applying gentle pressure anteroposteriorly. This manoeuvre was facilitated with the use of a flat spatula along the medial orbital wall, which helped in guiding the globe to its normal position. The conjunctival laceration and nasal wound were sutured. Postoperatively, the patient was started on intravenous antibiotics and steroids as well as local antibiotics and lubricants. A visual field test performed for the fellow eye was normal. Over a 1-year follow up, the globe was well placed and the ocular movements were adequate in all gazes except restriction on adduction with left exotropia (Fig. 2). The final visual acuity in the left eye remained at no perception of light. D ISCUSSION

Efficacy of trypan blue in posterior capsulorhexis with optic capture in pediatric cataracts [ISRCTN48221688]

BackgroundTo evaluate the efficacy of trypan blue (0.06%) in posterior capsulorhexis with optic capture in pediatric cataracts.MethodsIn this prospective randomized controlled study, trypan blue dye assisted posterior capsulorhexis with optic capture was performed in 18 eyes (group 1) and no dye was used for posterior capsulorhexis (group 2) in 17 eyes.ResultsThe mean size of the posterior capsulorhexis was 4.6 +/-1.77 mm and 4.0 +/- 0.93 mm in the group 1 and 2 respectively. Optic capture was possible in 17 eyes in the group 1 and 11 eyes in the group 2.ConclusionTrypan blue facilitates posterior capsulorhexis with optic capture of AcrySof IOL in cases of pediatric cataracts.

Cystadenoma of the lacrimal gland

Cystadenoma is a benign cystic tumor predominantly affecting the major and minor salivary glands. We present a case of bilateral cystadenoma of the lacrimal gland, which to the best of our knowledge has never been reported earlier. The patient had slowly increasing, painless, bilateral upper eyelid swelling. On examination, the tumors were multilobulated, mobile and transilluminant. Ultrasonography and CT-scan revealed cystic lesions with multiple septations in the region of both lacrimal fossae. Complete excision of the tumors was performed because of their potential for malignant transformation. The histopathological findings confirmed the diagnosis.

Multifocal cavernous hemangioma: A rare presentation

The clinical and histopathological findings in a 40-year-old man with a lacrimal sac tumor are reported. Although the clinical history indicated a lacrimal sac obstruction and recurrent dacryocystitis, the lesion was diagnosed by light microscopy as a squamous cell carcinoma.

Standardised clinical photography in ophthalmic plastic surgery

We read with keen interest the path breaking article by Calista et al regarding the successful treatment of an eyelid squamous cell carcinoma with intralesional cidofovir.1 The dramatic response of this highly malignant lesion to such a non-invasive form of therapy is remarkable and certainly worth further clinical evaluation. However, we would like to raise a few crucial issues pertaining to the documentation of this case. The authors have presented an extreme close up of …

Advancement of Whitnall's ligament via the conjunctival approach for correction of congenital ptosis

PURPOSE To conduct a preliminary study on ptotic eyelids with unilateral, congenital, simple partial ptosis, operated by advancement of Whitnalls ligament via the conjunctival route. METHOD A prospective, interventional, clinical study. RESULTS A total of 10 patients were recruited. The ptosis was 4 mm or less (range 2-4 mm; mean 2.7) and LPS action was greater than 5 mm (range 6-14 mm; mean 9.7). The ptosis was corrected by advancement of Whitnalls ligament by plication of the levator aponeurosis via the conjunctival route. Postoperatively, correction within 1 mm of the normal lid height was taken as good correction. All patients were assessed for a minimum of one year with regard to the amount of correction, residual ptosis, lid lag and lagophthalmos. In our study, good correction, i.e. within 1 mm of the normal fellow eye in primary gaze, was obtained in 80% of patients. Patients with more than or equal to 8 mm levator function gave better results. Undercorrection occurred in two patients. Lid lag and lagophthalmos occurred in all patients but was within acceptable limits. CONCLUSION Advancement of Whitnalls ligament by plication of the levator aponeurosis via the conjunctival route is a viable procedure, which has all the advantages of performing the same technique via the cutaneous approach, i.e. shorter surgical time, minimal dissection of tissue planes and reversibility. The conjunctival approach has the added advantage of being cosmetically more acceptable as there is no visible scar on the lid. The technique also offers satisfactory functional results with few (correctable) complications.

Visual Outcome in Macular Retinoblastoma Treated with Primary Chemotherapy

In this prospective clinical study, we treated 8 patients (8 eyes, 11 tumors) of macular retinoblastoma with chemotherapy alone, with the aim of avoiding visual loss because of retinal damage by radiation or adjuvant therapy and to assess their final visual outcome. The mean basal dimension of the tumor was 5.0 ± 2.6 mm and the mean height was 2.9 ± 1.3 mm. The fovea was involved in 4 patients (50%) and foveal detachment was present in 3 patients (37.5%). All the patients required less than 6 cycles for tumor control. Four patients (50%) obtained visual acuities ranging from 20/25 to 20/200. Two patients (25%) could gain visual acuity of 20/20. The mean follow-up of patients was 3.24 ± 0.9 years (range 2–5). No patient developed recurrence or metastatic disease. In conclusion, recent trends for ocular salvage have favored chemoreduction followed by focal therapy for the treatment of retinoblastoma. This study supports the consideration of chemotherapy alone as the primary treatment in eyes with macular retinoblastomas, under close supervision, with satisfactory visual outcome.

Conjunctival malignant melanoma

A 65-year-old woman was diagnosed clinically to have a tarsal conjunctival malignant melanoma of the upper eyelid. She also had multiple, diffusely pigmented, flat conjunctival lesions. No local or distant metastasis was detected. She was treated conservatively by a combination of surgery and cryotherapy as this was her only seeing eye. Histopathology of the tumor tissue and biopsy specimens of the flat conjunctival lesions proved them to be conjunctival malignant melanoma and primary atypical melanosis with atypia, respectively. Over a follow-up of two years, no clinical recurrence of the tumor was seen. To conclude, a malignant melanoma arising from the tarsal conjunctiva is extremely rare. The goal of treatment should be eradication of the tumor as well as preservation of a functionally and cosmetically acceptable eye.