Suryasnata Rath

Orbital Cysticercosis: Clinical Manifestations, Diagnosis, Management, and Outcome

PURPOSE To describe the clinical manifestations, diagnosis, management, and outcome of orbital cysticercosis in a tertiary eye care center in Southern India. DESIGN Retrospective observational case series. PARTICIPANTS A total of 171 patients with orbital cysticercosis. METHODS Retrospective case series involving consecutive patients with orbital cysticercosis from March 1990 to December 2001. MAIN OUTCOME MEASURES Clinical resolution and significant residual deficit. RESULTS The median age at presentation was 13 years (range 2-65 years), and 93 patients (54.4%) were male. The 3 main symptoms at presentation were periocular swelling (38%), proptosis (24%), and ptosis (14%) with a median duration of 2 (range 0-24) months. The 3 main signs at presentation included ocular motility restriction (64.3%), proptosis (44.4%), and diplopia (36.8%). The cyst locations in the decreasing order of frequency were anterior orbit (69%), subconjunctival space (24.6%), posterior orbit (5.8%), and the eyelid (0.6%). In all, 80.7% of patients had cysts in relation to an extraocular muscle. The superior rectus (33.3%) was the most commonly involved extraocular muscle. Contact B-scan ultrasonography was diagnostic of cysticercosis in 84.4% of patients. Orbital cysticercosis was managed medically in 158 of 166 patients. Although 149 patients received a combination of oral albendazole and prednisolone, 1 patient received oral albendazole alone, 7 patients received oral prednisolone alone, and 1 patient received oral praziquantel. Surgery was performed in 8 patients. Clinical resolution was seen in 128 of 138 patients (92.8%) at 1 month and 81 of 85 patients (95.3%) at 3 months. A significant residual deficit was present in 29 of 138 patients (21.0%) at the final follow-up and included proptosis in 7 patients, ptosis in 6 patients, ocular motility restriction in 3 patients, diplopia in 2 patients, strabismus in 2 patients, and a combination of the above in 9 patients. CONCLUSIONS Orbital cysticercosis is a common clinical condition in the developing world. It typically affects young individuals and has a wide spectrum of clinical manifestations. Both B-scan ultrasonography and computed tomography scan are useful in confirming the diagnosis. Despite resolution of cysticercosis with medical management, a significant proportion of patients may have residual functional deficits.

Reevaluating intracameral cefuroxime as a prophylaxis against endophthalmitis after cataract surgery in India.

Purpose To determine whether an intracameral injection of cefuroxime sodium at the conclusion of cataract surgery lowers the incidence of acute‐onset postoperative endophthalmitis. Setting Tertiary eye care center, Bhubaneswar, India. Design Prospective comparative interventional cohort study. Methods Under a uniform protocol, cataract surgery with posterior chamber intraocular lens (PC IOL) implantation was performed from September 27, 2006, to July 31, 2010 (Group 1). All eyes were evaluated 1 day, 7 days, and 5 weeks ± 1 (SD) postoperatively. Treatment of eyes suspected to have developed infectious endophthalmitis was managed by retina–vitreous surgeons. From August 1, 2010, to August 31, 2012, the same surgeons performed cataract surgery with PC IOL implantation in another group of eyes, in which they administered intracameral cefuroxime prophylaxis (Group 2). All other protocols of postoperative care and microbiological investigation of the vitreous samples were similar. The rate of clinical and culture‐positive endophthalmitis was compared between the 2 study groups: eyes without intracameral cefuroxime (Group 1) and eyes with intracameral cefuroxime (Group 2). Results The incidence of clinical endophthalmitis in Group 1 (0.155% [12/7756 eyes]) and in Group 2 (0.108% [8/7366 eyes]) was not significantly different (P = .57). The culture positivity rate in Group 1 (0.09 % [7 eyes]) and in Group 2 (0.04% [3 eyes]) was also not significantly different (P = .38). In the treatment without intracameral cefuroxime, there was a minimal, statistically insignificant increase in postoperative acute endophthalmitis (odds ratio, 1.42; 95% confidence interval, 0.53‐4.02; P = .506). Conclusion There is not strong evidence to support use of intracameral cefuroxime to reduce the rate of acute endophthalmitis after cataract surgery; however, the marginal benefit might justify its use. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Orbital radiotherapy for thyroid eye disease.

Purpose of review Orbital radiotherapy has been used for over 60 years to treat thyroid eye disease (TED) alone or in conjunction with glucocorticoids or orbital decompression surgery. However, numerous observational and randomized controlled trials have yielded conflicting results concerning its efficacy. This review highlights recent systematic reviews concerning the use of radiotherapy for TED. Recent findings Three recent systematic analyses have drawn different conclusions about its efficacy. This relates to the varied nature of the disease, the different selection criteria, and different outcome measures (often focussing on global indices or clinical activity scores rather than subjective quality of life scores and individual disease parameters as specified by the VISA Classification). Summary Radiotherapy should only be offered in the early active phase, is most effective in combination with glucocorticoids, and may have specific indications for dysthyroid optic neuropathy (DON), inflammatory periocular changes, or progressive motility disturbance. Future research may study its potential benefit in preventing or treating DON and compare the ability of combination radiotherapy/intravenous (i.v.) glucocorticoids versus i.v. glucocorticoids monotherapy for limiting complications from progressive TED.

Mucous membrane graft for cicatricial ectropion in lamellar ichthyosis: an approach revisited.

A 26-year-old woman with congenital lamellar ichthyosis presented with bilateral cicatricial ectropion of the upper and lower eyelids. There was severe exposure keratopathy with corneal perforation in the left eye. The generalized skin involvement necessitated the use of an alternative to correct the cicatricial ectropion. Mucous membrane graft harvested from the oral cavity was used to correct the cicatricial ectropion of upper and lower eyelid of both eyes. Six months after treatment, the mucous membrane graft was keratinized and a significant reduction in lagophthalmos was seen. Mucous membrane graft offers a promising alternative to correct cicatricial ectropion in lamellar ichthyosis.

Ocular surface squamous neoplasia – Review of etio-pathogenesis and an update on clinico-pathological diagnosis

Ocular surface squamous neoplasia (OSSN) has a varied clinical presentation, the diagnosis of which rests on the histopathological examination of the excised lesion. The term OSSN includes mild dysplasia on one end of the spectrum and invasive squamous cell carcinoma on the other end. This lesion has a multi factorial aetiology with interplay of several factors like exposure to ultraviolet radiation, various chemical carcinogens and viral infections, however role of individual agents is not well understood. With the upsurge of infection with human immunodeficiency virus, a changing trend is seen in the clinical presentation and prognosis of patients of OSSN even in developed countries. Anterior segment optical coherence tomography (OCT) and confocal microscopy, hold promise in in-vivo differentiation of intraepithelial neoplasia from invasive squamous cell carcinoma. Variants of squamous cell carcinoma like Mucoepidermoid carcinoma, spindle cell carcinoma and OSSN associated with HIV infection should be suspected in a case of aggressive clinical presentation of OSSN or with massive and recurrent tumours. Surgery, chemotherapy and immunotherapy are the various treatment modalities which in combination show promising results in aggressive, recurrent and larger tumours.

Fungal periorbital necrotizing fasciitis in an immunocompetent adult.

A 55-year-old man presented with profound swelling of the upper face and fever with a history of preceding insect bite. He was nonalcoholic and immunocompetent. Orbital CT showed a predominantly preseptal soft-tissue swelling. Empiric treatment with broad-spectrum antibiotics resulted in partial response. Surgical debridement and microbiologic evaluation of the necrotic tissue were performed. Gram stain showed budding yeast cells. Candida and Aspergillus spp. grew in culture after 48 hours. The patient received oral fluconazole, 200 mg once a day for 8 weeks. Complete resolution was documented at 16 weeks. In tropical regions, Candida and Aspergillus spp. may cause periorbital necrotizing fasciitis in immunocompetent adults.

Neoadjuvant chemotherapy in recurrent sebaceous carcinoma of eyelid with orbital invasion and regional lymphadenopathy.

A 35-year-old man presented with a recurrent temporal conjunctival mass (25 × 12 mm) involving about six-clock hours of the limbus in the left eye. The mass encroached onto the temporal half of cornea and showed surface keratin, large intrinsic and feeder vessels. It infiltrated the deep corneal stroma. There were no cells in the anterior chamber. Ultrasound biomicroscopy confirmed infiltration of deep corneal stroma without intraocular invasion. Surgery involved excision of the conjunctival component with 4-mm margin, lamellar sclerectomy and a penetrating sclerokeratoplasty with 3 mm of healthy corneal margin. Cryotherapy (double-freeze-thaw) was done to the conjunctival margins. Histopathology showed it to be invasive sebaceous cell carcinoma. A thin layer of deep corneal stroma and all conjunctival margins were uninvolved. At thirty-six weeks after treatment the left eye recorded a visual acuity of finger counting at 1 meter distance and no recurrence.

Evisceration in Unsuspected Intraocular Tumors

fusion for retinoblastoma. Doc Ophthalmol. 2009; 119(1):13-22. 3. Reese AB, Hyman G, Tapley N, Forrest AW. The treatment of retinoblastoma by x-ray and triethylene melamine. AMA Arch Ophthalmol. 1958; 60(5):897-906. 4. Mohri M. The technique of selective ophthalmic arterial infusion for conservative treatment of recurrent retinoblastoma [in Japanese]. Keio J Med. 1993;70:679-687. 5. Yamane T, Kaneko A, Mohri M. The technique of ophthalmic artery infusion therapy for patients with intraocular retinoblastoma. Int J Clin Oncol. 2004;9(2):69-73.

Optic nerve and chiasmal germinoma.

A 15-year-old boy presented with visual acuity of 20/200 OD and no light perception OS. The anterior segment of the left eye showed a relative afferent pupillary defect. A large (4.5 x 4.5 x 2.0 mm) infiltrative optic nerve head lesion with dilated vessels was seen OS with disc pallor OD. MRI of the brain and orbit revealed lobulated optic nerve thickening and chiasm. A biopsy revealed features consistent with germinoma and was positive for marker placental alkaline phosphatase. Systemic examination, chest x-ray, abdominal ultrasound, cerebrospinal fluid, and serology were normal. He received 27 Gy to the craniospinal region followed by a boost of 27 Gy to the left optic nerve. Eight months postirradiation, vision stabilization was achieved with 20/200 OD and light perception with inaccurate projection of rays OS.

Ocular parasitoses: A comprehensive review

Parasitic infections of the eyes are a major cause of ocular diseases across the globe. The causative agents range from simple organisms such as unicellular protozoans to complex metazoan helminths. The disease spectrum varies depending on the geographic location, prevailing hygiene, living and eating habits of the inhabitants, and the type of animals that surround them. They cause enormous ocular morbidity and mortality not because they are untreatable, but largely due to late or misdiagnosis, often from unfamiliarity with the diseases produced. We provide an up-to-date comprehensive overview of the ophthalmic parasitoses. Each section describes the causative agent, mode of transmission, geographic distribution, ocular pathologies, and their management for common parasites with brief mention of the ones that are rare.