Swati Singh

The Usefulness of Continuously Variable View Rigid Endoscope in Lacrimal Surgeries-First Intraoperative Experience.

Aims: The aims of this study were to illustrate the techniques and usefulness of a new rigid, variable-view endoscope in lacrimal surgeries. Methods: A 4-mm continuously variable view rigid endoscope (EndoCAMeleon) was used to assess 4 intraoperative scenarios in lacrimal surgeries. The endoscope offers variable views from 15° to 90° in one single plane while remaining shape invariant. Multiple planes were assessed after changing the direction of the endoscopic shaft. The ease of handling and optical performance was noted in each plane. Results: Enhanced visualization over a wide angle range without moving the endoscope was found to be very beneficial intraoperatively. Accurate assessment of extent of cicatrization or synechiae causes of dacryocystorhinostomy failure, monitoring of internal common opening during trephination, and postoperative ostium evaluation was possible with wider and superior visualization. A complete endoscopic overview in one plane without the need of multiple angled endoscopes made the inspections detailed and less time consuming. Because the tip of the endoscope does not move, it was found to be effective in narrow working spaces without causing any collision with the tissues in the vicinity. Conclusion: Enhanced field of vision, quicker assessment, and ability to optimize visualization in a continuous mode are advantages of using a variable-view endoscope in lacrimal surgeries.

Interactive navigation-guided ophthalmic plastic surgery: the utility of 3D CT-DCG-guided dacryolocalization in secondary acquired lacrimal duct obstructions

Aim The aim of this study was to report the preliminary experience with the techniques and utility of navigation-guided, 3D, computed tomography–dacryocystography (CT-DCG) in the management of secondary acquired lacrimal drainage obstructions. Methods Stereotactic surgeries using CT-DCG as the intraoperative image-guiding tool were performed in 3 patients. One patient had nasolacrimal duct obstruction (NLDO) following a complete maxillectomy for a sinus malignancy, and the other 2 had NLDO following extensive maxillofacial trauma. All patients underwent a 3D CT-DCG. Image-guided dacryolocalization (IGDL) was performed using the intraoperative image-guided StealthStation™ system in the electromagnetic mode. All patients underwent navigation-guided powered endoscopic dacryocystorhinostomy (DCR). The utility of intraoperative dacryocystographic guidance and the ability to localize the lacrimal drainage system in the altered endoscopic anatomical milieu were noted. Results Intraoperative geometric localization of the lacrimal sac and the nasolacrimal duct could be easily achieved. Constant orientation of the lacrimal drainage system was possible while navigating in the vicinity of altered endoscopic perilacrimal anatomy. Useful clues with regard to modifications while performing a powered endoscopic DCR could be obtained. Surgeries could be performed with utmost safety and precision, thereby avoiding complications. Detailed preoperative 3D CT-DCG reconstructions with constant intraoperative dacryolocalization were found to be essential for successful outcomes. Conclusion The 3D CT-DCG-guided navigation procedure is very useful while performing endoscopic DCRs in cases of secondary acquired and complex NLDOs.

Primary Nonendoscopic Endonasal Versus Delayed External Dacryocystorhinostomy in Acute Dacryocystitis.

PURPOSE Conventional treatment for acute dacryocystitis consists of medical management followed by elective delayed external dacryocystorhinostomy (EXT-DCR). The purpose of this study was to compare the outcome after primary nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR) versus conventional treatment in acute dacryocystitis. METHODS Retrospective chart analysis of all consecutive patients of acute dacryocystitis presenting between 2011 and 2015 was performed. Group A had patients who underwent primary NEN-DCR within 2 weeks of presentation. Group B comprised age- and gender-matched patients who received conventional treatment. RESULTS Forty-six patients were included with 23 patients in each group. Mean age (45.2 ± 14.7 vs. 47.5 ± 14 years) and gender distribution (women 17/23 in group A vs. 15/23 in group B) in both groups were comparable. Mean duration from presentation to surgery was 7.82 ± 4.65 days for group A versus 27.3 ± 12 days for group B (p = 0.00001, independent T test). Mean time for complete resolution of symptoms was 21.4 ± 6 days for group A versus 38.69 ± 15.8 for group B (p = 0.000014, independent T test). Mitomycin-C usage (0.04%; 17 vs. 14) and mean follow up of both groups (6.4 vs. 5.7 months) were comparable. While functional success was similar (20/23) in both, anatomical success was seen in 22/23 and 21/23 in groups A and B, respectively. Complications included disfiguring scar in 4, recurrent acute dacryocystitis in 3, and punctal ectropion in one patient in the EXT-DCR group. CONCLUSIONS Primary NEN-DCR leads to faster resolution facilitating earlier rehabilitation with comparable anatomical and functional outcomes compared with conventional delayed EXT-DCR in acute dacryocystitis.

Entire lacrimal sac within the ethmoid sinus: outcomes of powered endoscopic dacryocystorhinostomy.

Background The aim of this study was to report the outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) in patients with lacrimal sac within the sinus. Materials and methods Retrospective analysis was performed on all patients who underwent PEnDCR and were intraoperatively documented to have complete lacrimal sac in sinus. Data collected included demographics, clinical presentations, associated lacrimal and nasal anomalies, intraoperative findings, intraoperative guidance, complications, postoperative ostium behavior, and anatomical and functional success. A minimum follow-up of 6 months postsurgery was considered for final analysis. Results A total of 17 eyes of 15 patients underwent PEnDCR using standard protocols, but with additional intraoperative guidance where required and careful maneuvering in the ethmoid sinus. The mean age of the patients was 37.2 (range 17–60) years. Of the unilateral cases, 69% (nine of 13) showed left-side predisposition; 80% of patients showed regurgitation on pressure over the lacrimal sac area. Associated lacrimal and nasal anomalies were observed in 13.3% (two of 15) and 40% (six of 15), respectively. At a mean follow-up of 6.6 months, anatomical and functional success were observed in 93.3% (14 of 15). One patient showed failure secondary to cicatricial closure of the ostium. Conclusion An entire sac within an ethmoid sinus poses a surgical challenge. Good sinus-surgery training, thorough knowledge of endoscopic anatomy, careful maneuvering, and use of intraoperative navigation guidance result in good outcomes with PEnDCR.

Long-term outcomes of cruciate marsupialization of intra-nasal cysts in patients with congenital dacryocele

OBJECTIVES To evaluate the long-term outcomes of cruciate marsupialization of intranasal cysts associated with congenital dacryocele. METHODS This is a retrospective review of 15 patients of dacryoceles with intranasal cysts who underwent cruciate marsupialization of the medial wall of the cyst. Post-operative follow up for a minimum of 9 months was an inclusion criterion for analysis. Data analyzed include demographics, clinical presentations, previous interventions, associated systemic abnormalities, clinical course following marsupialization and recurrences. Primary outcome measures were resolution of the dacryocele and symptomatic relief from epiphora. RESULTS The mean age at presentation was 1.6 months with a female preponderance (60%). History of prematurity (pre-term) was noted in 20% (3/15). Swelling in the lacrimal sac area (dacryocele) was the universal presentation. Five patients (33.3%) had a prior conservative treatment. Four patients (26.6%) had respiratory distress with feeding. Acute dacryocystitis was noted in 26.6% (4/15). At a mean follow up of 19.1 months, successful outcomes were achieved in 86.6%. CONCLUSION Cruciate marsupialization of intranasal cysts achieves good results in patients with congenital dacryocele, which are maintained over a long period of time. Early diagnosis and management may prevent acute dacryocystitis in these patients.

Image-guided lacrimal drainage surgery in congenital arhinia-microphthalmia syndrome

ABSTRACT The aim of this study was to illustrate the surgical techniques and utility of stereotactic or image-guided navigation in the management of lacrimal drainage obstruction in congenital arhinia-microphtalmia syndrome and review the relevant literature. Image-guided combined external and endoscopic dacryocystorhinostomy was performed in a female, aged 16 years with congenital partial arhinia and ipsilateral microphthalmus. The lacrimal sac was bypassed to the contra lateral nasal cavity through a septal window. The surgical procedure was performed using the intra-operative optical image-guided Nav 1 PicoTM ENT navigation system with real-time intra-operative instrument geometry. Different phases of the surgical technique, adjunctive endoscopic procedures, intra-operative anatomical guidance, and utility at crucial phases of surgery were noted. A review of the literature was performed pertinent to arhinia and navigation guided lacrimal surgeries. Lacrimal bypass into the contra lateral nasal cavity even through a malformed septum is possible in partial arhinia syndromes. Detailed preoperative evaluation including 3D imaging studies, navigation guided planning of risk structures with intra-operative distance control and construction of meticulous surgical roadmaps were found to be essential factors in successful outcomes. At six months follow up after surgery, there was a complete and contiguous healed mucosal anastomosis with lacrimal system patent on irrigation and resolution of epiphora. Combined external and endoscopic approach is useful in partial arhinia syndromes. Image guidance is a very useful adjunctive tool that facilitates safe and precise surgery in the management of such complex lacrimal surgeries.

High-definition dacryoendoscopic features of a canalicular squamous papilloma

Canalicular papillomatosis is a rare disorder arising from one of the canalicular walls from a stalk attached to the epithelium. A systemically healthy male patient, aged 48 years, presented with swelling at the medial end of the left lower lid associated with epiphora of a 6 month duration. The swelling was not associated with any pain or discharge. Examination of the lacrimal system revealed a large, dilated puncta with small reddish brown lesion in the vertical canaliculus (Fig. 1a). A diagnostic high-definition dacryoendoscopy (HD-DEN) was performed (Fibertech, Japan). HD-DEN showed a grossly enlarged punctum and the vertical canaliculus (Fig. 1b) with a brownish red mass lesion on the medial wall of the vertical canaliculus (Fig. 1b, c). The ampulla was grossly dilated (Fig. 1b, c). Further diagnostic exploration revealed the mass lesion to involve the entire horizontal canaliculus up to the distal end, where it completely occupied the canalicular lumen (Fig. 1d, e), and hence further view was not possible. The upper canaliculus showed edematous mucosa with complete obliteration of the distal canaliculus. Since there was an extensive involvement, potential risk of seeding the nasal cavity along with high suspicion of a malignancy because of the pigmented nature and vascularity, the entire canaliculus was excised en bloc along with a dacryocystectomy. Histopathological evaluation showed an extensive polypoidal proliferation and papillary fronds of the stratified squamous epithelium of the canaliculus with the underlying stroma showing proliferation of thin-walled vascular channels and lymphoplasmacytic infiltration (Fig. 1f). There was no evidence of cellular atypia or koilocytosis. Histopathological features were consistent with an extensive squamous papilloma of the canaliculus. There were no recurrences at 6 month follow-up.

Interactive navigation-guided ophthalmic plastic surgery: navigation enabling of telescopes and their use in endoscopic lacrimal surgeries.

Purpose The aims of this study were to report the preliminary experience of using telescopes, which were enabled for navigation guidance, and their utility in complex endoscopic lacrimal surgeries. Methods Navigation enabling of the telescope was achieved by using the AxiEM™ malleable neuronavigation shunt stylet. Image-guided dacryolocalization was performed in five patients using the intraoperative image-guided StealthStation™ system in the electromagnetic mode. The “look ahead” protocol software was used to assist the surgeon in assessing the intraoperative geometric location of the endoscope and what lies ahead in real time. All patients underwent navigation-guided powered endoscopic dacryocystorhinostomy. The utility of uninterrupted navigation guidance throughout the surgery with the endoscope as the navigating tool was noted. Results Intraoperative geometric localization of the lacrimal sac and the nasolacrimal duct could be easily deciphered. Constant orientation of the lacrimal drainage system and the peri-lacrimal anatomy was possible without the need for repeated point localizations throughout the surgery. The “look ahead” features could accurately alert the surgeon of anatomical structures that exists at 5, 10 and 15 mm in front of the endoscope. Good securing of the shunt stylet with the telescope was found to be essential for constant and accurate navigation. Conclusion Navigation-enabled endoscopes provide the surgeon with the advantage of sustained stereotactic anatomical awareness at all times during the surgery.

Ocular surface squamous neoplasia in a setting of fungal keratitis: a rare co-occurrence

AbstractPurposeTo describe a rare co-occurrence of ocular surface squamous neoplasia (OSSN) in a patient with microbial keratitis.MethodsCase report.ResultsWe describe a 68-years female who developed ocular surface squamous neoplasia (OSSN) in an eye with culture proven severe fungal keratitis of 5 months duration, which progressed to endophthalmitis. She was managed with extended enucleation for left eye. Histopathology examination was consistent with squamous cell carcinoma of ocular surface with no corneal stromal/scleral/anterior chamber involvement. She received adjuvant chemotherapy with topical Interferon alpha2b (3 cycles) for positive margins. Six months after treatment, she is completely tumor free.ConclusionCo-occurrence of OSSN and chronic fungal keratitis is rare. We recommend that patients with chronic ocular infections should be examined and followed closely for abnormally thickened limbal areas.

Recombinant interferon alpha 2b for ocular surface squamous neoplasia: An efficient and cost-effective treatment modality in Asian Indian patients

Purpose: The purpose was to study the efficacy of interferon alpha 2b (INF α2b) in the treatment of ocular surface squamous neoplasia (OSSN) and analyze its cost-effectiveness in India. Study Design: This was a retrospective study of thirty patients with OSSN treated with topical INF α2b (1 MIU/cc) ± perilesional INF α2b (5 MIU/cc). Results: The tumor involved cornea (n = 9, 30%), conjunctivo-limbal-corneal surface (n = 19, 63%), or bulbar conjunctiva (n = 2, 7%). The mean basal dimension of the tumor was 16 mm. The tumors belonged to Tis (n = 6, 20%) or T3 (n = 24, 80%) based on the American Joint Committee Classification, 7th edition. In the six patients with Tis, three cycles of topical INF α2b were used for immunoprevention. In the remaining 24 patients, INF α2b was advised for immunoreduction, but served as immunotherapy with 100% tumor regression in 22 (92%) cases, and resulted in 95% immunoreduction in 2 (6%) cases. Complete tumor regression by immunotherapy (n = 22) was achieved with a mean number of three topical INF α2b cycles and two perilesional injections. All these 22 patients received three additional topical INF α2b cycles after complete tumor regression. For immunoreduction (n = 2), both patients received six cycles of topical INF α2b which was three perilesional INF α2b injections. The mean total treatment cost per patient with INF α2b was INR 9164 (