Ramamurthy Balasubramanya

Atypical presentations of retinoblastoma

PURPOSEnTo study the atypical presentations of retinoblastoma in our institution.nnnMETHODnRetrospective, clinical study.nnnRESULTSnA 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.nnnCONCLUSIONSnRetinoblastoma 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.

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

Purpose:u2002This 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.

Traumatic luxation of the globe with optic nerve avulsion.

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

Massive orbital and ocular invasion in ophthalmomyiasis

Myiasis in humans is caused by the infestation of tissues by the larval form of the Diptera fly.I.2 Infestation of the periorbital and orbital strucxad tures is called ophthalmomyiasis externa and that of the eyeball ophthalmomyiasis interna. 3 Most of the cases of ophthalmomyiasis externa reported to date were due to infestation of the conjunctiva; the numxad ber of cases of orbital involvement is very limitxad ed. I .2.4-8 In their review of orbital myiasis published in 1986 Kersten, Shoukrey and Tabbara l found only 16 well-documented cases in the literature, of which 2 were reported from India. Since that report, no more than 10 cases of orbital myiasis have been reported. 3 ,5-8 Massive involvement and destruction of both orbital and ocular contents, with probable intracranial involvement, is even rarer. We report such a case, in which more than 300 maggots were removed.

Acanthamoeba Keratitis After LASIK

PURPOSEnTo report a case of Acanthamoeba infection following LASIK.nnnMETHODSnA 20-year-old woman developed pain, redness, decreased vision, and corneal infiltrate in the right eye 15 days after bilateral LASIK. She did not use contact lenses postoperatively. Patient examination 3 months after surgery revealed a large, central, full-thickness corneal infiltrate with multiple satellite lesions in the right eye. Corneal scrapings were taken and the flap excised, and submitted for histopathologic examination.nnnRESULTSnMicroscopic examination of smears revealed Acanthamoeba cysts and non-nutrient agar showed a significant growth of Acanthamoeba. Histopathology examination of the excised flap demonstrated numerous Acanthamoeba cysts in tissue sections. The infiltrate was treated with a combination of topical polyhexamethylene biguanide, chlorhexidine, atropine sulfate, and oral itraconazole and resolved within 2 months.nnnCONCLUSIONSnLaser in situ keratomileusis can be complicated by Acanthamoeba infection. Microbiologic evaluation is essential for accurate early diagnosis and treatment.

Outcomes after laser in situ keratomileusis retreatment in high myopes.

PURPOSE: To evaluate the refractive and visual performance after laser in situ keratomileusis (LASIK) retreatment. METHODS: A retrospective study was performed on 33 eyes of 23 patients who underwent LASIK (Bausch & Lomb Technolas 217C) retreatment for residual myopia with or without astigmatism. Parameters evaluated were uncorrected and best spectacle-corrected visual acuity, spherical equivalent refraction, contrast sensitivity, glare acuity, and pachymetry, preoperatively and at 1, 3, and 6 months postoperatively. RESULTS: The mean spherical equivalent refraction before primary LASIK was -9.89 ± 4.00 D and before retreatment was -2.85 ± 2.17 D. Although contrast sensitivity and glare acuity decreased significantly after primary LASIK (P<.05), no significant change in these parameters was observed after retreatment. Smaller ablation zones were associated with decreased contrast sensitivity and glare acuity after primary LASIK as well as following retreatment. Contrast sensitivity and glare acuity following primary LASIK were significantly better in eyes with ablation zones ≥5 mm than those with <5 mm (P<.05). Eyes in which the ablation zone was the same as that for primary LASIK had significantly better contrast sensitivity than those with different ablation zones (increased or decreased) during retreatment. Attempted refractive correction during primary LASIK and retreatment had a significant negative correlation with contrast sensitivity and glare acuity following primary LASIK as well as retreatment. CONCLUSION: The ablation zones following primary LASIK and retreatment should be ≥5.00 mm and remain unchanged to improve visual performance.

Retreatment of LASIK.

PURPOSEnTo review the indications, techniques, and results of retreatment LASIK.nnnMETHODSnReview of the literature and the authors experience.nnnRESULTSnPatient selection is the key to successful LASIK enhancement. The enhancement procedure should generally be undertaken 3 months after the initial LASIK procedure. Relifting of the flap may be done easily within 1 year of previous LASIK surgery. A new LASIK flap is required in cases with previously complicated LASIK. LASIK retreatment by lifting the flap is an effective and safe procedure. Overall improvement is seen in uncorrected visual acuity (> or = 20/20 and > or = 20/40) and postoperative spherical equivalent refraction within +/- 0.5 D and +/- 1.0 D.nnnCONCLUSIONSnLASIK retreatment is an effective modality to treat regressions and residual refractive errors.

Atypical Presentations of Orbital Cysticercosis

We describe three patients with orbital cysticercosis who presented with atypical clinical or radiologic features previously unreported. All three patients had a cyst with a scolex on imaging studies. After 6 weeks of treatment, all three had almost complete resolution of their features.

Expansive mortar-induced ocular injury

We describe here a case of bilateral chemical injury (with an expansive mortar which is being used in recent times to cut the rocks). On examination limbal ischemia was more in the left eye (9 clock hours) than the right eye (2 clock hours). The case was managed by bilateral removal of foreign bodies, along with conjunctival resection and amniotic membrane transplantation in the left eye. At six-month follow-up, patient had best corrected visual acuity of 20/30 and 20/60 in the right and left eyes respectively. Since this being an occupational hazard, proper eye protection gear should be used by persons using this expansive mortar.