Usha Yadava

Modified grey line split with anterior lamellar repositioning for treatment of cicatricial lid entropion.

To determine the success rate of surgery of modified grey line split with anterior lamellar repositioning in patients with cicatricial lid entropion and to determine the risk factors of failure of the procedure, 40 patients (84 lids) with either lid involvement caused by cicatricial lid entropion of different etiologies were enrolled in this study. All the lids were operated on using the technique of modified grey line split and anterior lamellar repositioning. The success of the procedure was assessed by restoration of anatomical and physiological functioning of the lid without any residual symptom to the patient. Patients were examined initially at weekly intervals for 1 month and subsequently followed up at 2, 3, and 12 months following surgery. Among the various causes for cicatricial lid entropion, infectious etiology (72/84 lids) was found to be the most common one. A success rate of modified grey line split with anterior lamellar repositioning was 88.09% (74/84 lids). The underlying etiology of cicatricial lid entropion was the sole predictor of failure of surgery. Those with the etiology of infection had more than 6 times the odds of surgery failure (OR: 6.73; 95% CI: 2.79-16.73) as compared to a patient without infectious etiology. The role of other factors such as the age of the patient, degree of entropion, previous entropion surgery, the lid (upper or lower) involved, irregular lid margin, and defective lid closure were statistically insignificant. The underlying etiology of cicatricial lid entropion is the only risk factor that significantly influences the outcome of surgery with this technique. Otherwise, this procedure gives good results with fewer complications in patients with cicatricial lid entropion.

Efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique.

OBJECTIVE : To determine the efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique. METHODS : Fifty patients (92 lids) diagnosed as having cicatricial lid entropion were operated by the tarsal fracture technique. There was defective lid closure in 34/92 lids, irregular lid margin in 48/92 lids, distichiatic or metaplastic cilia in 28/92 lids and a history of previous entropion surgery in 34/92 lids. All patients were followed up for one year and the surgical failures at the end of this period were subjected to lamellar division. These subjects were further followed up for one more year./ RESULTS : An overall success rate of 28.26% (26/92 lids) was obtained with the tarsal fracture technique. A correction was achieved in all the 20 lids having cicatricial entropion without any associated features. However, this technique succeeded in only six of the remaining 72 lids (8.33%) with a history of previous surgery or the associated features stated above. Furthermore, it was not effective in correcting associated anomalies such as defective lid closure, irregular lid margin and distichiatic or metaplastic cilia. Reoperation using lamellar division gave good correction in 97% of the lids (64/66). CONCLUSIONS : Lamellar division is a better procedure for treating cicatricial lid entropion, especially in patients with associated complications or with a previous history of entropion surgery.

Primary localised nodular amyloidosis of the eyelid and conjunctiva: a case report

Sir, Amyloidosis is characterised by the deposition of abnormal fibrillar protein in the extracellular spaces of the body causing alterations of the tissue architecture and function. It may present as systemic amyloidosis, or it may be restricted to a single site as in localised amyloidosis with a variable clinical picture. We report an unusual case of a nodular amyloid eyelid tumour involving the conjunctiva without systemic amyloid involvement or myeloma. A 65-year-female presented to the ophthalmology outpatient department with a 1-year history of progressive painless thickening of the lower left eyelid. Physical examination revealed a healthy appearing woman. The patient’s visual acuity was 20/20 in OS with normal anterior segment. The lower lid was thickened with a firm, painless, nodular tumour extending onto and involving the conjunctiva (Fig. 1). There was no evidence of healed trachoma or any other chronic inflammatory process in either eye. There was no previous history of medical or surgical treatment or drug therapy or chemical burns. CT scan showed uniform thickening of the lower eyelid with no infiltration into the orbit. With a clinical differential diagnosis of chronic tarsitis, squamous cell carcinoma, or meibomian cell carcinoma, an incisional wedge biopsy was taken. Histologically, large nodular deposits of amorphous, eosinophilic, hyaline-like material was seen filling the entire papillary and reticular dermis and focally within the walls of deep dermal blood vessels and eccrine sweat gland coils. It involved both the eyelid and conjunctiva (Fig. 2). The overlying epidermis was thinned out with loss of rete pegs. At the periphery of the deposits many mature plasma cells were found admixed with a few lymphocytes and occasional giant cell. These deposits were congophilic with an apple green birefringence on polaroscopy and showed metachromasia with methyl violet. Immunohistochemical studies showed staining for kappa immunoglobulin light chains only, indicating that the amyloid deposits were derived from a monoclonal population of plasma cells or B cells. The scattered plasma cells within the deposits did not show monoclonality by kappa (k) or lambda (l) light chain immunohistochemical staining, which excluded a focal plasmacytoma. A work-up was negative for systemic amyloidosis including complete blood count, comprehensive metabolic panel, serum electrophoresis, sedimentation rate and liver function tests. Ultrasonography of the abdomen was unremarkable. Multiple myeloma was ruled out by the absence of Bence Jones proteins in urine, normal serum electrophoresis and unremarkable bone marrow examination. Chest radiography, echocardiogram and renal ultrasound were normal. Biopsy of buccal and rectal mucosa was negative for amyloid. Owing to the localised nature of the lesion, the patient opted for conservative management and is on continued follow-up. Cutaneous amyloid deposits may occur in systemic forms or may be localised to skin in the absence of other organ involvement. Systemic forms of amyloidosis that may exhibit cutaneous involvement include primary systemic amyloidosis, myeloma with systemic amyloidosis and certain hereditary syndromes such as familial amyloid polyneuropathy, familial Mediterranean fever and Muckle– Wells syndrome. Primary localised cutaneous amyloidosis (PLCA) includes macular amyloidosis, lichen amyloidosis and nodular amyloidosis. Amyloid deposits in nodular amyloidosis originate from immunoglobulin light chain (AL type). Both l and k light chain amino acid homologies have been found, with l chains being more common. However, our patient showed a k derivation. Fig. 1 Nodular amyloid tumour causing thickening of left lower eyelid. Inset shows involvement of conjunctiva also.

Topiramate-induced angle-closure glaucoma: cross-sensitivity with other sulphonamide derivatives causing anterior uveitis

Topiramate is a recognized cause of drug-induced acute angle-closure glaucoma. We describe a case presenting with bilateral acute angle-closure glaucoma caused by topiramate intake. Patient subsequently developed severe anterior uveitis caused by sulphonamide derivatives (acetazolamide and co-trimoxazole) due to cross-sensitivity, on two separate occasions. The present case also highlights the role of anterior segment optical tomography in diagnosis and follow-up. In a patient with known drug allergy to topiramate, other sulphonamide derivatives should be avoided to limit the ocular morbidity.

Unusual presentation of a case of Sjogren's syndrome with neurological and ocular manifestation

Sjogrens syndrome is an autoimmune disease that commonly presents to the ophthalmologist as a dry eye disease. We report an unusual presentation of a case of Sjogrens syndrome. A 33-year-old man presented with lid swelling, pseudomembraneous conjunctivitis with central corneal epithelial defect and history of limb weakness for past 2 years. There was progressive enlargement of the epithelial defect and conjunctival-scleral necrosis developed during follow-up. Evaluation for underlying connective tissue disorder was positive for SS-B/La antibody and, the rheumatoid factor, anti nuclear antibody, anti neutrophil cytoplasmic antibody titres were negative. Patient was diagnosed as a case of Primary Sjogrens syndrome. Resolution of the conjunctival-scleral necrosis occurred following treatment with combination of cyclosporine and prednisolone. Paramedian tarsorrhaphy was performed to promote healing of the corneal epithelium. The corneal epithelium healed, conjunctival-scleral necrosis resolved completely and the visual acuity improved to 6/36 in the right eye after 3 months of immunosuppressive therapy. The immunosuppressive therapy was discontinued after completion of 6 months of treatment. After 6 months follow-up of stopping immunosuppressive therapy, the ocular and systemic condition is stable.

Bilateral retrobulbar neuritis in an adolescent boy with lymphoma

A 13-year-old boy presented with bilateral retrobulbar neuritis. Three months later he presented with unilateral proptosis and cervical lymphadenopathy. Lymph node biopsy confirmed non-Hodgkins lymphoma, B-cell type. To the best of our knowledge, this is the first reported case of bilateral retrobulbar neuritis as the presumptive initial presentation of non-Hodgkins lymphoma.

Simultaneous use of amniotic membrane and Mitomycin C in trabeculectomy for primary glaucoma

Purpose: This study aimed to propose the role of amniotic membrane transplantation (AMT) as an additional modulator in primary Mitomycin C (MMC)-augmented trabeculectomy. Methods: This was a randomized prospective interventional study. Forty eyes of 39 adult patients with uncontrolled primary glaucoma were randomly divided into two equal groups. Control group underwent trabeculectomy augmented with MMC while the study group underwent additional AMT. Patients were followed up for 12 months and outcomes measured were intraocular pressure (IOP), need for additional intervention, and bleb morphology. Results: Complete success (defined as IOP <16 mmHg on no medication) could be achieved in 85% eyes in study group while it was 60% in control group (P = 0.04). IOP reduced by 71.1% in study group from 41.9 ± 10.6 to 12.1 ± 2.7 mmHg and from 40.5 ± 8.5 to 12.8 ± 4.5 mmHg in control group, a decline of 68.29%. Blebs in AMT group showed better bleb morphology in terms of significantly better extent (E3) on day 1 (P = 0.03) and better height (H2 and H3) (P = 0.04), according to the Indiana Bleb Appearance Grading Scale, at all follow-up visits along with normal vascularity. The study group required significantly lesser (P = 0.03) bleb needlings as compared to control group. Conclusion: Amnion enhanced the efficacy of MMC-modulated trabeculectomy in terms of eyes with complete success and lesser interventions such as bleb needling. This reiterates the role of amnion as a safe and effective bleb modulator. A diffusely elevated bleb with healthier conjunctiva can go a long way in predicting better health and longevity of the bleb.

Evaluation of pattern ERG as a visual prognosticator in chiasmatic tumours

Tumours compressing the optic pathway may lead to irreversible loss of vision that can be detected by pattern electroretinogram owing to its relation to ganglion cell function. This study aims to assess whether pattern electroretinogram is a useful tool to predict visual outcome following decompressive surgery for sellar and parasellar tumours.