Tarjani Vivek Dave

Etiologic analysis of 100 anatomically failed dacryocystorhinostomies.

Background The aim of this study was to assess the etiological factors contributing to the failure of a dacryocystorhinostomy (DCR). Patients and methods Retrospective review was performed in 100 consecutive patients who were diagnosed with anatomically failed DCR at presentation to a tertiary care hospital over a 5-year period from 2010 to 2015. Patient records were reviewed for demographic data, type of past surgery, preoperative endoscopic findings, previous use of adjuvants such as intubation and mitomycin C, and intraoperative notes during the re-revision. The potential etiological factors for failure were noted. Results Of the 100 patients with failed DCRs, the primary surgery was an external DCR in 73 and endoscopic DCR in 27 patients. Six patients in each group had multiple revisions. The mean ages at presentation in the external and endoscopic groups were 39.41 years and 37.19 years, respectively. All patients presented with epiphora. The most common causes of failure were inadequate osteotomy (69.8% in the external group and 85.1% in the endoscopic group, P=0.19) followed by inadequate or inappropriate sac marsupialization (60.2% in the external group and 77.7% in the endoscopic group, P=0.16) and cicatricial closure of the ostium (50.6% in the external group and 55.5% in the endoscopic group, P=0.83). The least common causes such as ostium granulomas and paradoxical middle turbinate (1.37%, n=1) were noted in the external group only. Conclusion Inadequate osteotomy, incomplete sac marsupialization, and cicatricial closure of the ostium were the most common causes of failure and did not significantly differ in the external and endoscopic groups. Meticulous evaluation to identify causative factors for failure and addressing them are crucial for subsequent successful outcomes.

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.

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.

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.

DIFFUSE CHOROIDAL HEMANGIOMA MASQUERADING AS CENTRAL SEROUS CHORIORETINOPATHY TREATED WITH ORAL PROPRANOLOL.

PURPOSE To describe a case of diffuse choroidal hemangioma with exudative retinal detachment treated successfully with oral propranolol. METHODS Single interventional case report of a 14-year-old boy, known case of Sturge-Weber syndrome, presented with decreased vision in the right eye since 2 months. Presenting vision was finger-counting at 3 m. Examination revealed a neurosensory detachment at the macula clinically appearing like central serous chorioretinopathy. Fundus fluorescein angiogram, B-scan ultrasound, and optical coherence tomography were consistent with an underlying diffuse choroidal hemangioma with secondary exudative macular detachment. The patient could not afford radiotherapy and thus was treated with oral propranolol. RESULTS Serial clinical examinations and optical coherence tomographies showed gradual resolution of the subretinal fluid. Vision at the last visit 4 months after treatment was 6/9 best corrected. CONCLUSION Choroidal hemangioma can be mistaken clinically to be central serous chorioretinopathy. Oral propranolol is an effective and economical treatment option in patients not affording other standard modalities of treatment.

Development and Validation of a Grading Scale for Custom Ocular Prosthesis.

Purpose To develop a standardized and universally reproducible grading scale for artistic outcome of a custom ocular prosthesis. Methods A retrospective review of photographs of patients with custom ocular prosthesis. From the ocularistry database of a tertiary eye care hospital, photographs of patients with custom ocular prosthesis (30 random photos with additional 18 repetitions, total n = 50) were selected. Two independent oculoplastic surgeons, on the basis of characteristics of limbus, vascularity, and pigmentation, graded these photos. The photos were adjusted for confounders like magnification and illumination, and both graders used the same display system. The surgeons were blinded to each other. The characteristics were graded on a scale of 0 to 2 and total score was calculated for each photo. Inter-observer and intra-observer agreement was calculated using the kappa statistic. Results The inter-observer kappa coefficient for the three characteristics (95% confidence interval) were as follows: limbus 0.7 (0.55–0.85), vascularity 0.76 (0.58–0.94), and pigmentation 0.6 (0.34–0.85). The intra-observer kappa coefficient for the first surgeon was as follows: limbus 0.88 (0.7–0.95), vascularity 0.88 (0.73–0.95), and pigmentation 0.82 (0.54–0.93). The intra-observer kappa coefficient for the second surgeon was as follows: limbus 0.8 (0.44–0.93), vascularity 0.55 (0.13–0.8), and pigmentation 0.76 (0.6–0.84). Conclusions A good intra- and inter-observer agreement was demonstrated. In view of no existing grading for prosthesis, this is a unique system to objectively grade the outcome of custom ocular prosthesis and can be incorporated in ocularistry teaching modules for standardization of outcomes.

Interactive Navigation-Guided Ophthalmic Plastic Surgery: The Usefulness of Computed Tomography Angiographic Image Guidance.

Aim: The aim of this study was to illustrate the techniques and usefulness of navigation-guided computed tomography angiography in ophthalmic plastic surgery. Methods: Stereotactic surgeries using computed tomography angiography as the intraoperative image-guiding tool were performed in 3 patients. One patient had widespread eyelid and orbital vascular malformation and the other 2 had orbital mass lesions located in crucial vascular areas. Two procedures used the external approach and one was performed using the endoscopic orbital approach. All the surgeries were performed using the intraoperative image-guided StealthStation system in the electromagnetic mode. The usefulness of intraoperative angiographic anatomical guidance and the ability to anticipate and avoid vascular injuries at crucial phases of surgery were noted. Results: Intraoperative geometric localization of feeder vessels to a lesion could be easily achieved. The cauterization of the direct feeder to the lesion reduced the much anticipated blood loss while operating a widespread vascular malformation. Orbital mass lesions with vessels in the vicinity could be operated upon with utmost vascular safety and precision, thereby avoiding complications. Detailed preoperative navigation-guided planning of risk structures with intraoperative distance control was found to be essential for successful outcomes. Conclusions: Computed tomography angiography-guided navigation surgery is very useful in cases with complex vascular malformations and while operating in the vicinity of crucial vascular structures in the orbit.

Interactive navigation-guided ophthalmic plastic surgery: assessment of optical versus electromagnetic modes and role of dynamic reference frame location using navigation-enabled human skulls

Aim The aim of this study was to assess the anatomical accuracy of navigation technology in localizing defined anatomic landmarks within the orbit with respect to type of technology (optical versus electromagnetic systems) and position of the dynamic reference marker on the skull (vertex, temporal, parietal, and mastoid) using in vitro navigation-enabled human skulls. The role of this model as a possible learning tool for anatomicoradiological correlations was also assessed. Methods Computed tomography (CT) scans were performed on three cadaveric human skulls using the standard image-guidance acquisition protocols. Thirty-five anatomical landmarks were identified for stereotactic navigation using the image-guided StealthStation S7™ in both electromagnetic and optical modes. Three outcome measures studied were accuracy of anatomical localization and its repeatability, comparisons between the electromagnetic and optical modes in assessing radiological accuracy, and the efficacy of dynamic reference frame (DRF) at different locations on the skull. Results The geometric localization of all the identified anatomical landmarks could be achieved accurately. The Cohen’s kappa agreements between the surgeons were found to be perfect (kappa =0.941) at all predetermined points. There was no difference in anatomical localization between the optical and electromagnetic modes (P≤0.001). Precision for radiological identification did not differ with various positions of the DRF. Skulls with intact anatomical details and careful CT image acquisitions were found to be stereotactically useful. Conclusion Accuracy of anatomic localization within the orbit with navigation technology is equal with optical and electromagnetic system. The location of DRF does not affect the accuracy. Navigation-enabled skull models can be potentially useful as teaching tools for achieving the accurate radiological orientation of orbital and periorbital structures.

Intubation in Lacrimal Surgery: Devices and Techniques

Lacrimal drainage obstructions causing epiphora is a common lacrimal disorder. Depending on the age of the patient and the pathophysiology of the condition, the disorder can either be relieved by simple probing or by a dacryocystorhinostomy (DCR). In certain conditions, the success rates of the treatment can be improved by intubating the lacrimal system. Canalicular intubation is also indicated in the management of lacerated canaliculus. Intubation is achieved commonly by placing a silicone stent in the lacrimal passages. The silicone stent maintains the passages where it is present and is also believed to allow tissue healing around itself, thus maintaining lacrimal patency.

Epibulbar schwannoma in a 12-year-old boy: A case report and review of literature

Schwannomas are benign, encapsulated, primary neurilemmal tumors composed of proliferating Schwann cells. Schwannomas are commonly seen in the orbit, but are rare on the epibulbar surface. Herein, we report a case of a 12-year-old boy who presented to us with a slow-growing painless subconjunctival mass in the left eye. There was no intraocular extension of the mass and intra-operatively, the mass could be clearly delineated and was excised off the underlying sclera. Histopathological examination of the mass showed typical features of schwannoma and immunohistochemistry helped to confirm the diagnosis. There was no recurrence of the lesion observed at follow-up 26 months after surgery. Here, we describe this uncommon tumor and review the available literature. Although rare, an epibulbar schwannoma should be considered in the differential diagnosis of an amelanotic, painless subconjunctival nodular mass. Excision of the lesion is the recommended treatment.