Rebika Dhiman

Medial transposition of split lateral rectus augmented with fixation sutures in cases of complete third nerve palsy

Surgical management of complete third nerve paralysis is a challenge. While several techniques have been described over the years, they result in less than satisfactory outcomes with residual deviations in primary gaze or postoperative drifts. One of the described techniques for management of oculomotor palsy has been medial transposition of the lateral rectus muscle which provides a good surgical alternative but often can result in undercorrection. We describe a modification of the existing technique of medial transposition of the split lateral rectus by force augmentation through the use of equatorial fixation sutures resulting in an improved outcome in primary gaze alignment. The modified technique involves splitting of the lateral rectus into two halves followed by transposing the superior half from below the superior oblique and superior rectus and inferior half from below the inferior oblique and inferior rectus to attach them at the superior and inferior edge of the medial rectus insertion, respectively. This is followed by placing non-absorbable sutures to fix each split belly of the transposed muscles to the sclera at the equator adjacent to the medial rectus such that the split muscles lie nearly parallel to the medial rectus till the equator before reflecting away. These sutures augment the force of the transposed muscles by redirecting the force vectors in the direction of action of the medial rectus. Satisfactory postoperative primary gaze alignment was achieved in three cases of complete third nerve paralysis.

Topical cyclosporine to control ocular surface disease in patients with chronic glaucoma after long-term usage of topical ocular hypotensive medications

PurposeTo evaluate changes in ocular surface and central corneal sub-basal nerve fiber layer (SBNFL) after topical cyclosporin therapy in chronic glaucoma patients on long-term topical antiglaucoma therapy.MethodsA prospective comparative study of ocular surface evaluation of chronic glaucoma patients on long-term topical therapy treated concurrently with a topical cyclosporine 0.05% twice daily for 6 months and controls was done. The study parameters evaluated at recruitment and at the 6-month follow-up included details of topical antiglaucoma medications, visual acuity, intraocular pressure, ocular surface evaluation parameters (TBUT, Schirmers I, ocular surface staining scores and ocular surface disease (OSD) index score (OSDI)), central corneal sensation (Cochet Bonnett aesthesiometer), and central confocal microscopy to study the SBNFL density (SBNFLD).ResultsThirty-two eyes of 16 patients with chronic glaucoma and 30 eyes of 15 normal subjects as controls were studied. Mean TBUT, pre/post CsA treatment was 8.67±3.01/12.24±1.83 s (P=0.007). Mean conjunctival/corneal staining scores pre/post CsA treatment were 3.38±1.93/1.50±0.718 (P=0.00) /5.19±1.82/1.81±0.78 (P=0.098), respectively. Mean OSDI pre/post CsA treatment scores were 30.63±14.61/14.76±6.06 (P=0.007). Mean corneal sensations scores pre/post CsA treatment were 4.64±0.46/4.94±0.39 (P=0.002). Central corneal SBNFLD pre and post CsA treatment was 8811.35±2985.29/10335.13±4092.064 μm/mm2 (P=0.0001).ConclusionsSchirmer’s test, ocular surface staining scores, OSDI, corneal sensations, and corneal SBNFLD showed a statistically significant improvement following a 6-month concurrent topical CsA therapy.

Proposal for a new classification for ocular surface squamous neoplasia

American Joint Committee for Cancer Classification (AJCC-TNM) is routinely used for ocular surface squamous neoplasia (OSSN) staging worldwide. However, recently some limitations of this classification have been reported. Sheilds et al. [1] mentioned the skewed distribution of cases among the various AJCC tumor grades in their study, with most cases being classified as grade T3. Similar trend was observed in our study, where 81% of tumors were classified as grade T3 [2]. This may be explained by the fact that majority of OSSN arise at the limbus [2], and therefore tend to involve the adjacent cornea. In AJCC classification, tumor with corneal involvement are clubbed in tumor grade T3 along with tumors that involve other adjacent structures like plica, eyelid, caruncle, lacrimal punctum, and eyelid margin. Unlike a small corneal involvement, extension to other specified structures usually reflects a more extensive disease in terms of area of involvement (Fig. 1). Therefore, smaller tumors with minimal corneal involvement should be classified separately. Second modification required is the separate categorization of tumors with overt intraocular extension (that is intraocular extension that can be picked up clinically or on ultrasound biomicroscopy (UBM)). Currently, these tumors are classified as AJCC grade T3. Unlike other T3 grade tumors that may be treated with wide surgical excision or immunotherapy/chemotherapy, tumors with intraocular extension require enucleation, and therefore are associated with a greater morbidity. Newer edition of AJCC (8th edition) has brought minor modifications to tumor grades T1 and T2, where histological criteria has been included along with clinical criteria [3]. Unlike previously when surgical excision was the gold standard for treatment, chemotherapy/immunotherapy is gaining popularity and has been accepted as the first line treatment for non-invasive cases. As excision biopsy has become less common and incision biopsy is a relative contraindication for OSSN, a histological grading becomes irrelevant to the current treatment scenario. Most medical management is done based on clinical diagnosis. With the availability of better anterior segment imaging like optical coherence tomography and UBM, invasion into sclera can be picked up without the need of tissue sampling. Therefore, we wonder how this modification may be applied in the current management scenario. Also, the current AJCC classification does not provide any guideline for the choice of treatment for different tumor stages. Hence, we propose a new classification scheme for OSSN that takes into account the limitations of AJCC classification, and in addition provides a rough guide for the treatment of tumor in the current management situation (Table 1). Here, we have classified the tumor grades on the basis of tumor size, and tumor invasion as picked up on imaging. Cases with invasion beyond the conjunctiva and into the sclera have been classified separately as grade II, and those with intraocular extension have been categorized as grade III. A treatment guide has been provided for various tumor grades based on risk of side effects of upfront surgical excision in non-invasive tumor, and tumor extension in coats, globe, or orbit.

Clinicodemographic profile and treatment outcome in patients of ocular surface squamous neoplasia

Purpose: The aim is to study the clinicodemographic profile and treatment outcome of ocular surface squamous neoplasia (OSSN). Methods: This was a retrospective observational study of 57 eyes (56 cases) with clinically diagnosed OSSN, presenting in our center over the past year. Results: The median age of presentation was 55 years with male:female ratio being 4.5:1. Systemic predisposing conditions were xeroderma pigmentosa (1) postkidney transplant immunosuppression (1), and human immunodeficiency virus infection (1). Patients with predisposing conditions had a younger median age of onset (33 years). The majority of tumors were nodular (61.4%), gelatinous (61.4%), and had limbal involvement (96%). On ultrasound biomicroscopy (UBM), mean tumor height was 2.93 ± 1.02 mm, and intraocular extension was evident in seven eyes. OSSN with intraocular extension had a mean tumor height of 4.3 ± 1.32 mm. Nodal metastasis was seen in one case at presentation. As per American Joint Committee for Cancer Classification seventh edition staging-two cases were T1, one was T2, 46 were T3 and eight were T4. Treatment advised included conservative therapy for 39; wide local excision (4 mm margin clearance) with cryotherapy for seven; enucleation in four; and exenteration in four eyes. Overall, complete regression was achieved in 88% of cases during a mean follow-up of 13.5 ± 4.6 months. Recurrence was seen in three cases, which were treated with exenteration, radical neck dissection, and palliative chemo-radiotherapy, respectively. Conclusion: Although associated with old age, earlier onset of OSSN is seen in patients with systemic predisposing conditions. Thicker tumors in the setting of a previous surgery or immunocompromised status should be considered high-risk features for intraocular extension and should be evaluated on UBM.

Immunoreduction of locally advanced orbito‐conjunctival squamous cell carcinoma with intraorbital interferon alpha‐2b injection: a globe saving approach

Conjunctival squamous cell carcinoma (SCC) is the most common malignancy of ocular surface. Several studies report that interferon alpha-2b (IFα2b) is effective in 70%–80% cases of conjunctival carcinoma in situ (CIS) and/or SCC. It is administered as topical drops or subconjunctival perilesional injections. Herein, we describe a globe-salvaging approach in management of locally advanced ocular surface SCC with orbital extension using intraorbital IFα2b injections. It enabled us to achieve excision with tumour free margins, thus avoiding exenteration or adjuvant radiotherapy. A 60-year-old female patient was referred to us with ocular surface squamous neoplasia of left eye. She had received two cycles of 0.04% topical mitomycin-C (MMC) with no response to treatment. At presentation, best-corrected visual acuity was 20/60 in left eye. On slit lamp examination, there was a fleshy ocular surface mass, extending from nasal limbus to medial and superior fornix. Four clock hours of limbus were involved (7–11 o’clock) with 2 mm radial extension into cornea (Fig. 1a). There were no anterior chamber cells. On gonioscopy, angle was free of tumour. There was immature senile cataract that explained vision in that eye. Extraocular movements were full, and intraocular pressure was 18 mm (non-contact tonometry). An ultrasound biomicroscopic examination showed tumour height of 8 mm without any invasion into sclera. Fundus examination was within normal limits. Draining lymph nodes were not enlarged. An impression cytology from the lesion revealed dysplastic cells. In view of forniceal involvement by the tumour, a contrast-enhanced computed tomography (CECT) scan orbit was performed. It revealed tumour extension into medial orbit up to equator, along medial rectus muscle (Fig. 1b). A metastatic workup including liver function tests, ultrasound abdomen and CT scan chest was not suggestive of any metastasis. Thus, patient had a locally advanced conjunctival SCC having T4aN0M0 stage (7th edition of AJCC). In view of good vision, patient was given an option of immunoreduction of the tumour using intraorbital IFα2b injections with explained risk of metastasis. A total of 3 injections (9 million IU) were given at weekly interval, around the tumour in anterior orbit using half inch long 26 gauge needle. During the procedure, needle was placed adjacent to the tumour and directed away from it so as to avoid tumour penetration and injection into the tumour and thus tumour spillage. A CECT scan orbit was repeated at 2 weeks from last injection. Significant tumour reduction was noted both clinically and on CECT scan (Fig. 1c,d). A wide surgical excision was performed with cryotherapy (double freeze thaw) of conjunctival margins and intraoperative application of 0.04% MMC. Histopathological examination revealed a well-differentiated tumour with large number of keratin pearls; margins were free of tumour (Fig. 1e). Topical interferon (1 million IU/mL – four times a day) drops were continued for 3 months after surgery. Postoperatively mild symblepharon was noted in superomedial fornix. A repeat CECT scan orbit done at 6 months of follow-up was within normal limits. At last follow-up of 24 months, patient is free of tumour clinically and radiologically (Fig. 1f ). Exenteration remains the most frequently used treatment in locally advanced conjunctival SCC with orbital extension despite some reports in literature documenting successful conservative management using radiotherapy and/or systemic chemotherapy. Immunoreduction with interferons and chemoreduction with topical MMC is extremely useful in treating giant/diffuse SCC of conjunctiva not involving orbit, allowing complete excision. The fact that majority of conjunctival SCC shows a remarkable response to interferon therapy which unlike MMC can be administered as perilesional injections made us wonder of a possible role of intraorbital injection of interferons in locally advanced conjunctival SCC with limited orbital extension and good visual acuity. Studies from Competing/conflicts of interest: None declared.

Contact lens induced Pseudomonas keratitis following descemet stripping automated endothelial keratoplasty

UNLABELLED To report a case of bandage contact lens induced infectious keratitis caused by Pseudomonas aeruginosa following DSAEK. CASE REPORT A 56-year-old female who underwent DSAEK at our institute for pseudophakic bullous keratopathy, developed contact lens induced keratitis in the fifth post operative week. Best corrected visual acuity (BCVA) reduced to perception of light in the left eye. Slit lamp examination revealed an epithelial ulcer measuring 4.7mm×6mm with surrounding infiltrates in the anterior stroma with hypopyon. The interface was clear. The corneoscleral rim culture of the donor tissue showed no growth on bacterial and fungal culture ruling out the possibility of donor-to-host transmission of infection. Microbiological evaluation identified the causative agent to be Pseudomonas aeruginosa. Based on culture and sensitivity report patient was started on hourly instillation of topical polymyxin B 20,000IU and fortified ceftazidime 5%. A response to treatment was noted and there was a complete resolution of keratitis with residual scarring. DISCUSSION There have been case reports suggesting a host to donor transmission of infection which manifests during the postoperative period. To the best of our knowledge there are no reports of bandage contact lens associated Pseudomonas keratitis in a case that has undergone DSAEK. The prolonged use of bandage contact lens, lens contamination, stagnation of tear film behind the lens, compromised ocular surface and post operative use of topical steroids can contribute to infectious keratitis in DSAEK cases.

Ocular Surface Squamous Neoplasia with Intraocular Extension: Clinical and Ultrasound Biomicroscopic Findings

Purpose: To study the clinical profile, ultrasound biomicroscopy (UBM) findings, and treatment outcome of ocular surface squamous neoplasia with intraocular extension (OSSN-IO). Methods: It was a retrospective case series of 7 eyes of OSSN-IO treated at our center from March 2015 till December 2016. Results: Mean age of presentation was 53 years. Clinical signs of intraocular involvement were evident in 3 cases (43%). In the remaining 4 cases (57%), it was diagnosed on UBM alone. Mean tumor height on UBM was 5.06 mm (6.6 mm for nodular and 3.8 mm for nodulo-ulcerative pattern). Of 7 cases, 2 were managed with exenteration, 4 cases with enucleation + limited excision ± external beam radiotherapy, and 1 was lost to follow-up. Complete regression was noted in 83% cases (5/6) and they remain disease free at a mean follow-up of 23.2 months. One case died of metastasis at 7 months. Histopathological examination showed well- to moderately differentiated tumor in all cases. Conclusions: Use of UBM in high-risk OSSN cases may help pick up IO invasion. Tumors that are at high risk for IO invasion are thick nodular tumors (> 5 mm), tumors with nodular or ulcerative morphology, and those with prior surgical intervention.

Isolated Extranodal Natural Killer T-Cell Lymphoma of the Orbit in a Young Patient: Complete Regression with the SMILE Regimen

Purpose: Natural killer T-cell lymphoma (NKTL) is a highly malignant tumor that typically arises in the nose and/or paranasal sinuses. Isolated orbital involvement by NKTL is extremely rare, and only few case reports exist in the literature. Herein, we report a case of primary orbital NKTL in a young patient who showed very good response to chemotherapy with the SMILE regimen. Methods: A 28-year-old healthy female presented to us with epiphora and fullness of the lower eyelid. She had previously been diagnosed as orbital pseudotumor and was prescribed oral steroids. However, there was no response to the treatment. She also had a history of recurrent sinusitis. An incision biopsy revealed NKTL. A systemic workup did not reveal any other site of involvement. The patient received 6 cycles of chemotherapy (SMILE) and external beam radiotherapy. Results: The tumor showed complete regression after 2 cycles of chemotherapy. The patient is disease free at 24 months of follow-up. Conclusion: Reported median survival for primary orbital NKTL is extremely poor. This is perhaps the first report of a primary orbital NKTL demonstrating a remarkable treatment response to a newer chemotherapy regimen (SMILE) in combination with radiotherapy.

Anterior segment optical coherence tomography of intrastromal corneal donor lenticule for recurrent intrastromal epithelial inclusion cyst in a corneal graft

Intracorneal cysts are uncommon lesions that occur either due to congenital or traumatic pathology. Treatments described include cyst excision, drainage or intracyst injection of chemical solutions, such as ethanol. Recurrences commonly occur with these modalities and there is no clear consensus on the best approach to take. In this article, the authors present a rare case of a recurrent intrastromal epithelial corneal cyst following suture removal in an 11-year-old boy who had undergone optical penetrating keratoplasty in his left eye. It was managed effectively with an innovative technique of lamellar excision and donor corneal stromal lenticule lamellar placement to prevent recurrence. Serial postoperative anterior segment optical coherence tomography (ASOCT) was performed to monitor for cyst recurrence. No recurrence was observed for one and a half years with clear corneal graft. ASOCT is an effective tool in the diagnosis and follow-up of a recurrent intrastromal epithelial inclusion cyst.