Saurabh Kamal

Simple vs complex congenital nasolacrimal duct obstructions: etiology, management and outcomes.

The aim of this study was to report the comparative clinical profiles and outcomes of simple and complex congenital nasolacrimal duct obstruction (CNLDO).

Surgeon point-of-view recording: Using a high-definition head-mounted video camera in the operating room

Objective: To study the utility of a commercially available small, portable ultra-high definition (HD) camera (GoPro Hero 4) for intraoperative recording. Methods: A head mount was used to fix the camera on the operating surgeons head. Due care was taken to protect the patients identity. The recorded video was subsequently edited and used as a teaching tool. This retrospective, noncomparative study was conducted at three tertiary eye care centers. The surgeries recorded were ptosis correction, ectropion correction, dacryocystorhinostomy, angular dermoid excision, enucleation, blepharoplasty and lid tear repair surgery (one each). The recorded videos were reviewed, edited, and checked for clarity, resolution, and reproducibility. Results: The recorded videos were found to be high quality, which allowed for zooming and visualization of the surgical anatomy clearly. Minimal distortion is a drawback that can be effectively addressed during postproduction. The camera, owing to its lightweight and small size, can be mounted on the surgeons head, thus offering a unique surgeon point-of-view. In our experience, the results were of good quality and reproducible. Conclusions: A head-mounted ultra-HD video recording system is a cheap, high quality, and unobtrusive technique to record surgery and can be a useful teaching tool in external facial and ophthalmic plastic surgery.

Ocular Surface Squamous Neoplasia in 200 Patients: A Case-Control Study of Immunosuppression Resulting from Human Immunodeficiency Virus versus Immunocompetency

PURPOSEnTo describe and compare the clinical presentation, treatment outcomes, and histopathologic features of ocular surface squamous neoplasia (OSSN) based on human immunodeficiency virus (HIV) status.nnnDESIGNnCase-control study.nnnPARTICIPANTSnA total of 200 patients with OSSN, of whom 83 (41%) had positive results for HIV and were classified as cases and 117 (59%) had negative results for HIV and were classified as controls.nnnMETHODSnEnzyme-linked immunosorbent assay for HIV, conjuntival excision biopsy, extended enucleation, orbital exenteration.nnnMAIN OUTCOME MEASURESnClinical features, treatment outcomes, and histopathologic characteristics.nnnRESULTSnThe mean age at presentation of OSSN in both cases and controls was 40 years (median, 40 years; range, 13-65 years) and in controls was 40 years (median, 38 years; range, 15-80 years). On comparison of cases versus controls with OSSN, HIV-positive individuals had larger (12 vs. 8 mm; P < 0.001) and thicker (3.2 vs. 2.3 mm; P = 0.041) tumors, with a higher incidence of corneal (60% vs. 40%; P = 0.007), scleral (19% vs. 9%; P = 0.044), and orbital (13% vs. 3%; P = 0.019) invasion and a higher need for extended enucleation or exenteration (27% vs. 11%; P < 0.001). The bilateral presentation (11% vs. 4%; P = 0.13), need for lamellar sclerectomy (13% vs. 8%; P = 0.29), and tumor recurrence after primary treatment (30% vs. 20%; P = 0.12) was higher in HIV-positive cases compared with HIV-negative controls. However, these features were not statistically significant. Based on American Joint Committee on Cancer classification, T1 tumor was more common in controls (13% in cases vs. 35% in controls; P = 0.0009), and T4 tumor was more common in cases (13% in cases vs. 4% in controls; P = 0.019). None of the patients demonstrated systemic metastases or died of disease during a mean follow-up period of 10 months (median, 4 months; range, <1-75 months) in cases and 9 months (median, 4 months; range, <1-99 months) in controls.nnnCONCLUSIONSnOcular surface squamous neoplasia in HIV-positive individuals is aggressive with larger and thicker tumors and with higher incidence of corneal, scleral, and orbital invasion. These patients are associated with poor ocular prognosis with higher need for extended enucleation, exenteration, or both.

Lacrimal and nasal masquerades of congenital nasolacrimal duct obstructions: etiology, management, and outcomes

AbstractnThe purpose of this study was to report various conditions masquerading as congenital nasolacrimal duct obstruction (CNLDO). Retrospective review was designed in a tertiary hospital setting. 92 eyes of 65 consecutive patients were included in this study. All patients presenting with CNLDO symptomatology but where the diagnosis of CNLDO was subsequently ruled out were included in the study. The study patients were recruited from a single surgeon’s (MJA) tertiary eye care practice over a 3-year period from 2011 to 2013. A detailed clinical evaluation and a further lacrimal system evaluation were performed under general anesthesia. The main outcome measure was other lacrimal and nasal conditions masquerading as CNLDO. Average age at presentation was 43.49xa0±xa031.78xa0months. All cases had symptoms of either watering or discharge with an increase tear meniscus or abnormal fluorescein dye disappearance test. The commonest masquerades of congenital nasolacrimal duct obstruction include incomplete punctal canalisation (27.2xa0%), functional epiphora (14.1xa0%), punctal agenesis (14.1xa0%), monocanalicular obstructions (10.8xa0%), and presaccal stenosis (8.7xa0%). Each masquerade was managed specifically and at the last follow-up of 5.85xa0±xa010.85xa0months, 63xa0% eyes (58/92) had no epiphora and 2.2xa0% (2/92) eyes had occasional epiphora. Parents of patients with punctal agenesis were counseled for option of conjunctivodacryocystorhinostomy in future. Incomplete punctal canalisation is the commonest masquerade among many conditions that may mimic CNLDO and mandates a careful evaluation. Specific management of each masquerade results in satisfactory outcomes.

Endoscopic ultrasonic dacryocystorhinostomy: clinical profile and outcomes

Ultrasonic endoscopic dacryocystorhinostomy (UEnDCR) is emerging alternative modality of managing nasolacrimal duct obstructions. The aim of this study was to report the clinical profile and outcomes with a UEnDCR with mitomycin C and silicone intubation. Prospective interventional case series performed on all consecutive patients undergoing an ultrasonic endoscopic dacryocystorhinostomy over a 1-year period from September 2013 to October 2014. All surgeries were performed by a single surgeon (MJA). Data collected include demographics, presentation, indications for surgery, past interventions, intraoperative and post-operative complications and outcomes. The main outcome measures were anatomical and functional success of the surgery. 44 procedures were performed in 41 patients. The mean age was 31.6xa0years. Children with complex congenital nasolacrimal duct obstructions refractory to probing and intubation accounted for 17xa0% (7/41) of the cohort. Past history of acute dacryocystitis was noted in 35.6xa0% (15/41). Two patients (4.9xa0%, 2/41) had failed external DCR. A minimal follow-up of 6xa0months following surgery was taken for final analysis. Complications included intraoperative focal epithelial burn in one patient that healed spontaneously and post-operative ostium granulomas in 15.9xa0% (7/44) of the ostia. At the 6-month follow-up, anatomical and functional successes were noted in 93.1xa0% (41/44) and 88.6xa0% (39/44), respectively. Ultrasonic dacryocystorhinostomy is a safe and effective alternative modality in the management of nasolacrimal duct obstructions in pediatric and adult age groups. Setup was easy and no additional technical difficulties were observed.

Conjunctival Leiomyosarcoma: A Report of Two Cases.

ABSTRACT Purpose: Leiomyosarcoma is a common soft tissue tumor in the body. However, ocular leiomyosarcoma is rather uncommon. Herein, we describe the clinical and histopathological features of two cases of conjunctival leiomyosarcoma. There have only been three previously documented cases of conjunctival leiomyosarcoma. Results: A 34-year-old male presented with a 2-year history of a whitish mass in the right eye. He underwent an incisional biopsy of the mass, which supported the diagnosis of leiomyosarcoma on histopathological examination. Computed tomography showed orbital extension of the mass, following which he underwent an eyelid sparing orbital exenteration of the right side. The second case was that of a 39-year-old male, who had a history of a whitish limbal mass, which had been previously excised elsewhere. The pre-operative clinical photographs and histopathology slides of the excised mass were reviewed. A histopathological diagnosis of conjunctival leiomyosarcoma was established and due to base positivity, he was treated with plaque radiotherapy. Both the cases showed no tumor recurrence or systemic metastasis at one-year follow-up. Conclusion: Primary conjunctival leiomyosarcoma is uncommon. Appropriate treatment of the tumor is associated with good prognosis.

Ocular surface squamous neoplasia as the initial presenting sign of human immunodeficiency virus infection in 60 Asian Indian patients

PurposeTo study the importance of routine human immunodeficiency virus (HIV) screening in patients with ocular surface squamous neoplasia (OSSN) and describe their clinical features and management.MethodsRetrospective study.ResultsOf 228 cases of OSSN screened for HIV by enzyme-linked immunosorbent assay, 86 (38%) patients were HIV positive. Of these 86 patients, 60 (70%) were unaware of their HIV-positive status prior to HIV screening. These 60 (26%) patients with newly detected HIV-positive status were included in this study. Ocular surface squamous neoplasia was the sole presenting feature of HIV infection in these patients. Mean age at presentation was 41xa0years. Bilateral involvement occurred in 9 (15%) cases. The mean tumor basal diameter was 11xa0mm. Orbital involvement was noted in 6 (9%) cases, and intraocular tumor extension occurred in 1 (1%) case. Based on American Joint Committee Classification, T2 (nxa0=xa035, 51%) was most common. The primary treatment for OSSN included excision biopsy (nxa0=xa052, 75%), topical chemotherapy with Mitomycin-C (nxa0=xa05, 7%), extended enucleation (nxa0=xa04, 6%), and orbital exenteration (nxa0=xa08, 12%). Tumor recurrence occurred in 23% cases during a mean follow-up period of 9xa0months. On histopathology, invasive squamous cell carcinoma was more common (nxa0=xa038, 55%).ConclusionOSSN was the presenting sign of underlying HIV infection in 26% cases, and 70% were unaware of their HIV-positive status prior to HIV screening. In this study, T2 tumor was most common, and 26% cases required extended enucleation/orbital exenteration to achieve complete tumor resection.

Primary Acquired Nasolacrimal Duct Obstruction (PANDO) and Secondary Acquired Lacrimal Duct Obstructions (SALDO)

Epiphora resulting from nasolacrimal duct obstruction (NLDO) is common and accounts for about one-third of cases [1]. Symptomatic acquired NLDO has an average annual incidence rate of 30.47 per 100,000 [2]. It is commonly encountered in ophthalmic clinics especially ophthalmic plastics and dacryology clinics. NLDO can be classified as either primary acquired nasolacrimal duct obstruction (PANDO) when it is idiopathic or secondary acquired lacrimal duct obstructions (SALDO) when it is secondary to various etiologies [3, 4]. The term PANDO was given by Linberg and McCormick in 1986 [4]. They described a female preponderance, a usual onset of epiphora after the age of 40 years, subsequent development of associated symptoms, and signs of chronic or acute dacryocystitis, which constitute the clinical syndrome of primary acquired nasolacrimal duct obstruction (PANDO) [4].

Minimally invasive surgery for thyroid eye disease.

Thyroid eye disease (TED) can affect the eye in myriad ways: proptosis, strabismus, eyelid retraction, optic neuropathy, soft tissue changes around the eye and an unstable ocular surface. TED consists of two phases: active, and inactive. The active phase of TED is limited to a period of 12–18 months and is mainly managed medically with immunosuppression. The residual structural changes due to the resultant fibrosis are usually addressed with surgery, the mainstay of which is orbital decompression. These surgeries are performed during the inactive phase. The surgical rehabilitation of TED has evolved over the years: not only the surgical techniques, but also the concepts, and the surgical tools available. The indications for decompression surgery have also expanded in the recent past. This article discusses the technological and conceptual advances of minimally invasive surgery for TED that decrease complications and speed up recovery. Current surgical techniques offer predictable, consistent results with better esthetics.

Ocular Adnexal Lymphoma: Clinical Presentation, Diagnosis, Treatment and Prognosis

Ocular adnexal lymphoma (OAL) is a rare tumor with an incidence of 0.2 per 1,00,000 individuals. However, it constitutes the most common orbital tumor especially in older population with an incidence ranging from 11% to 24%. OAL can involve conjunctiva, orbital soft tissues, eyelid, or adnexal structures such as lacrimal gland and lacrimal drainage system. The most common primary OAL is low-grade malignant extranodal marginal zone B-cell lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT) type. Though various classification and staging systems have been proposed for OAL, currently, American joint committee on cancer (AJCC) TNM (tumor node metastasis) staging is most commonly used. Most commonly, conjunctival lymphoma typically presents as ‘salmon-colored patch’ and orbital lymphoma presents as proptosis, which on imaging shows characteristic appearance of molding around the globe without any globe indentation or bone erosion. Orbital radiotherapy and systemic chemotherapy forms the mainstay of treatment. Newer treatment modalities include immunotherapy with interferon and anti-CD20 antibody rituximab that have been shown to be useful either when used alone or in combination with chemotherapy or as radio-immunotherapy.