Ved Prakash Gupta

Retinopathy of Prematurity- Risk Factors

Objective: Improved survival of low birth weight, premature babies have increased the incidence of retinopathy of prematurity. This hospital-based, prospective, study was undertaken to determine its incidence and risk factors in our neonatal unit.Methods: Neonates with gestational age ≤ 35 weeks and/or birth weight ≤ 1500 gm born over a one-year period were examined by indirect ophthalmoscopy between 2 to 4 weeks after birth, and followed up till retinal vascularisation was complete. Maternal and neonatal risk factors were noted and data analyzed by statistical package SPSS-10.0.Results: Sixty babies were thus examined. The incidence of retinopathy was 21.7% in the cohort, 33.3% in babies ≤32 weeks gestation and 36.4% in babies weighing ≤1250 gm. Oxygen (p=0.01), sepsis (p=0.04) and apnoea (p=0.02) were independent risk factors. Retinopathy was significantly more severe in babies with hyaline membrane disease (p=0.02) and lower birth weight (p=0.02). Severe disease was never seen before 6.5 weeks of age.Conclusion: Indirect ophthalmoscopy should be performed at 4 weeks of post natal age in all preterm babies with birth weight ≤ 1500 gm, and intensified in the presence of risk factors like oxygen administration, apnoea and septicemia.

Comparison of three surgical procedures of differing complexity in the correction of trachomatous upper lid entropion: a prospective study.

objective To compare the efficacy of three common surgical procedures of increasing complexity in the correction of trachomatous entropion. materials and methods In a prospective study, lids with moderate or severe (without lid gap) trachomatous entropion were randomly allocated to undergo either terminal tarsal rotation (I, n = 30), tarsal rotation with tarso-conjunctival advancement (II, n = 30), or anterior lamellar repositioning with lid margin split and wedge resection of tarsus (III, n = 30). The procedures were compared for improvement of symptoms, duration of surgery, cosmesis, rate and type of complications, anatomical correction, failure and recurrence. One-way and repeated-measure ANOVA, Chi-square and Fishers exact tests were used. results The study included 90 eyes of 77 patients (age range: 30-85 years). Symptomatic improvement was comparable after each procedure (p > 0.05). Procedure I, the simplest in technique, took significantly less time (p < 0.001). The three procedures were comparable in achieving cosmesis (p = 1.0), anatomical correction (p = 0.35), and rate of complications (p = 0.43). Failure of surgery was seen in two lids (procedure II), and recurrence in one lid (procedure III). conclusion In developing countries, where manpower and other resources are limited and patient-load high, ophthalmic surgeons should choose a procedure that is simple, quick and effective. This study suggests that terminal tarsal rotation after transverse tarsotomy should be the procedure of choice in the correction of moderate or severe (without lid gap) trachomatous entropion.

Onset and Pattern of Tear Secretions in Full-Term Neonates

Purpose: Serial evaluations of total, basal and emotional tear secretion in full-term normal neonates to determine the time after birth when these parameters attain normal adult values. Method: Both eyes of 102 full-term normal neonates were prospectively evaluated for tear secretions in the Department of Ophthalmology, over a period of one year. Serial recording of the Schirmer I test (total tear secretions), Basal Secretion Test, and Schirmer II test (emotional tears) was done, the first one being within 6 hours of birth. All the tests were repeated in each infant until normal adult values for each test were obtained. Results: The average values of the Schirmer I test, Basal Secretion Test and Schirmer II test at birth were 23.2 (± 3.96) mm, 6.2 (±2.15) mm and 19.2 (±4.94) mm, respectively. A statistically significant correlation of birth weight but not of gestational age was found with basal secretions (p = 0.004) as well as with emotional tears (Schirmer II test, p = 0.010). At birth, 98% of infants had total tear secretion, 3.9% had basal tear secretion and 2.9% had emotional tear secretion comparable to normal adult values. All the parameters of tear secretions increased with time, so that 100% of infants had total tear secretion comparable to normal adult values within 12 hours of birth. The basal secretions took three weeks and emotional tears took four weeks to attain normal adult values in all the neonates. Conclusion: Total tear secretions were the earliest to reach normal adult values, followed by basal secretions and, lastly, emotional tears. Reduced basal tears at birth may predispose neonates to corneal drying during prolonged ocular examinations such as indirect ophthalmoscopy and procedures under general anesthesia.

Causative Factors of Unsuccessful Dacryocystorhinostomy and the Surgical Technique of Revision External Dacryocystorhinostomy

ting the inferior portion or dividing the medial canthal tendon [3, 4] . However, the cut ends must be sutured while closing the wound [4] . Even a disinserted canthal tendon needs to be sutured to the periosteum over the nasal process of maxilla. The authors irrigated methylene blue in the lacrimal sac for identification. This does not facilitate the sac incision site over the internal common canalicular ostium and offers no advantage over visualization of the Bowman probe to ensure full-thickness incision [2] . Moreover, methylene blue spills in the surgical field following incision into the sac and interferes with subsequent tissue identification [2] . We would like to highlight the few additional operative steps routinely performed by us in revision DCRs. All the measures to prevent intraoperative bleeding are adopted. To prevent damage to the nasal mucosa, the nasal pack is removed before osteotomy and reinserted after osteotomy [2] . The ideal osteotomy includes removal of all bone between the medial wall of the sac and the nose, 3–4 mm of anterior lacrimal crest, deroofing of the upper part of the nasolacrimal canal and removal of the 5-mm bone opposite the common canaliculus opening [4] . Longitudinal incision in the sac must involve the lowest part of the sac to avoid sump syndrome. Internal punctoplasty is required We highly appreciate the article by Konuk et al. [1] . We would like to share additional findings observed in unsuccessful endonasal or external dacryocystorhinostomy (DCRs). Absent bony ostium, intact lacrimal fossa with anterior lacrimal crest and nonperforation of the sac have been encountered frequently in our practice. The osteotomy anterior to anterior lacrimal crest with intact lacrimal fossa bones was noted in 4 cases despite 1–4 previous DCRs. The bone opposite the common canaliculus had not been removed in the majority of cases. Anastomosis of lacrimal fascia flaps with nasal mucosal flaps, diverticula, fibrous membrane occluding common internal punctum and postoperative lacrimal fistula which turned out to be tubercular were other causes of failure of DCR. Surgery for unsuccessful DCR remains difficult, time consuming and challenging. The anesthetic infiltration at the medial canthus as mentioned by the authors [1] may not sustain the prolonged revision DCR surgery. We prefer infraorbital, infratrochlear and anterior ethmoidal nerve blocks, infiltration at incision site and nasal packing [2] . The authors disinserted the anterior limb of the medial canthal tendon, which may result in iatrogenic telecanthus. Exposure of the upper part of the lacrimal sac may be achieved by cutPublished online: March 16, 2011

CONJUNCTIVAL AMYLOIDOSIS : IS IT RELATED TO TRACHOMA ?

Abstract. Due to presence of trachoma in a large percentage of cases of conjunctival amyloidosis, trachoma has been blamed for causing secondary localized amyloidosis. However, there is no study to demonstrate evidence of amyloidosis in tarsoconjunctival specimens of trachomatous lids. 50 eyes of 35 patients having trachomatous eyelids with thickened tarsal plate, trichiasis and entropion had a tarsoconjunctival biopsy (3 mm × 20 mm) from the upper lid. Histopathological examination using Haematoxylin – eosin and congo red stains failed to reveal evidence of amyloid deposition in any of the biopsies. This is the first histopathological study of amyloidosis in trachomatous patients. Our study rules out the long‐standing concept of trachoma having causal relationship with conjunctival amyloidosis. It is concluded that conjunctival amyloidosis occurring in trachomatous lids should be considered as primary localized amyloidosis.

Re: "Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure".

Authors mention that patients developed no postoperative complications. However, contour deformity is evidently noticed in the newly constructed eyelid depicted in Figure 3. Though the convexity of the contour is partially hidden by the fold of skin in primary position, it could have been very clearly visible in the photograph in looking down position that the authors have failed to include. We believe that this contour deformity or convexity of the newly constructed eyelid margin could be due to convexity of superior border of free tarsoconjunctival graft forming the eyelid margin. We suggest that refashioning the convex upper tarsus by carefully trimming the superior tarsal border without damaging the attached conjunctiva may circumvent this problem. Authors mention that Case 2 continued to do well without entropion or eyelid retraction.1 However, as this patient had blepharoptosis, eyelid retraction would not be expected. Authors conclude that this unique technique offered 3 major advances. However, in our opinion, Yoon and McCulley’s modification appears to offer yet another advantage of reconstruction of deep superior fornix in the upper eyelid. Yoon and McCulley’s modification used a full-thickness lower eyelid flap and additionally placed a secondary tarsoconjunctival graft at the time of division of flap, whereas Hsuan and Selva reported a modified Cutler-Beard flap technique of upper eyelid reconstruction with a free tarsal graft and only a cutaneous lower eyelid advancement flap that was devoid of muscle and conjunctival layers compared with full-thickness lower eyelid flap. Thus, Yoon and McCulley’s modification provides additional conjunctiva that facilitates deep superior superior fornix.

Is it really a silicone sling assisted temporalis muscle transfer

Sir, We read an article by Gupta et al.[1] with keen interest. We wish to express following comments. Paralytic lagophthalmos remains the most serious complication of facial nerve palsy. Temporalis muscle transfer (TMT) for paralytic lagophthalmos, though a dynamic procedure, remains difficult, challenging and time-consuming surgery despite several modifications.[2,3,4] We appreciate the authors for commendable attempt to manage paralytic lagophthalmos by modified silicone sling assisted TMT.[1] Authors[1] mention that the temporalis muscle (TM) is used in dynamic procedures as it is spared in a case of facial palsy that conveys the impression as if TM is innervated by 7th nerve. The fact remains that TM is used because it is innervated by 5th nerve. Authors[1] mention that slings were advanced in the lids between the paralyzed orbicularis oculi and the skin, which in our opinion appears to be superficial. The sling is also visible through the skin. Such a superficial insertion of sling may suffer several disadvantages including extrusion. The silicone sling should have been placed submuscular between orbicularis muscle and the tarsal plate.[2,3] Postoperative day has not been mentioned in the postoperative picture.[1] However, it seems to be early postoperative picture as skin sutures are still intact. Authors[1] have failed to report long-term follow-up results after 3 months. Even postoperative photographs of the palpebral aperture in the primary position and on mastication in early and at 3 months postoperative are not presented. Moreover, authors[1] have failed to document the dynamicity of their procedure. Frey et al.[4] documented dynamic lid closure following TMT using three-dimensional video analysis system. In our opinion, the procedure described by Gupta et al.[1] is hardly any TMT, as the length of muscle shown is quite small, it fails to reach even up to the lateral canthus and is far posterior to the lateral canthus. It appears that TM is mainly acting as muscle stump for just anchoring the silicone rod. Dynamic reanimation of eyelids by TMT has not been achieved using silicone sling. Thus, it does not appear to be a silicone assisted TMT, rather it is more appropriate to call it a TM assisted silicone sling in the eyelid for management of paralytic lagophthalmos. We believe that similar postoperative results can be achieved by passing silicone sling in eyelid as described by Arion.[5] Authors[1] did not comment about postoperative patients training for chewing exercise. We believe that the patient must be educated about the need to clench the jaw in order to close eyelids voluntarily.[6] Practicing this in front of the mirror is helpful to develop a visual think-blink reflex to achieve dynamic lid closure.[6] As the silicone is a synthetic material, its integration with TM or eyelid tissues is unlikely. Moreover, in long-term with contraction of TM, silicone rod may cut through or lose its elasticity and TM may retract to its original position, resulting in recurrence. Thus, permanency of the procedure seems yet another concern.

Intralesional bleomycin injection for periocular capillary hemangiomas.

Dear Editor, We read the article by Smit and Meyer[1] with keen interest. We wish to express the following comments: Intralesional bleomycin injection (IBI) is a newer form of therapy for capillary hemangioma with encouraging results.[1,2,3,4,5] IBI was used for the first time for complicated cutaneous hemangiomas.[2] Experience with IBI for periocular capillary hemangiomas is very limited. Authors diagnosed capillary hemangioma by clinical examination only.[1] We believe clinical evaluation should have been combined with ultrasonography or magnetic resonance imaging or color doppler to differentiate hemangioma from vascular malformation.[3,4,5] Color doppler is also of immense utility during follow-up in detecting size, color, and blood flow changes after IBIs. Blood flow in capillary hemangioma declines after four to five IBIs; blood flow signal disappears earlier than color (usually after five to six IBIs for a lesion diameter less than 4 cm).[3,4] Authors discontinued therapy after administering nine IBIs in case one and after five IBIs in case two.[1] We appreciate the result with respect to opening of eye and increase in vertical height of palpebral fissure which might be adequate to prevent stimulus deprivation amblyopia, however, post IBI Figures 2 and 4 clearly depict significant residual capillary hemangioma covering the forehead, nose, upper lip, and even left upper eyelid of case 1 and forehead, nose and right upper eyelid of case 2 respectively.[1] We believe the treatment should not have been stopped at this stage. The hemangioma involving forehead, nose, and lips still required intralesional bleomycin. It has been suggested that the interval of injection should be 3-4 weeks with total times lesser than 7 times during one therapeutic period.[3,4] Another therapeutic period may be started 3 months later if further treatment was necessary. The total quantity of bleomycin for a child should be less than 40 mg in one treatment periods.[3,4] Luo and Jhao reported very large series of 82 cases of infantile hemangiomas which involuted completely after treatment with the sclerosing mixture composed of 2% lidocaine, 5 mg dexamethasone and 8 mg bleomycin A5 and also used oral prednisolone (2-5 mg/kg every other day).[3,4] Combination of dexamethasone with bleomycin as well as oral prednisolone has been advocated to treat effectively the patients at proliferating stage observed in the 3rd and 6th month in many cases of infantile hemangioma and also to circumvent the dose restriction of bleomycin i.e., the drug quantity given in one time may be deficient for big hemangioma(>4 cm).[3,4] Authors suggest use of bleomycin in the treatment of eyelid hemangiomas where conventional modalities have been unsuccessful or where treatment with beta-blockers may be contraindicated.[1] Many investigators recommend oral propranolol as the first line of therapy for infantile hemangioma.[6] Readers would be interested to know why authors[1] did not treat these cases with oral propranolol as first line therapy.

Measurement of peripapillary retinal nerve fiber layer thickness and macular thickness in anisometropia using spectral domain optical coherence tomography: a prospective study

Purpose To study whether there is a difference in central macular thickness (CMT) and peripapillary retinal nerve fiber layer (RNFL) thickness between the two eyes of individuals having anisometropia >1 diopter (D) using spectral domain optical coherence tomography (OCT). Material and methods One hundred and one subjects, 31 with myopic anisometropia, 28 with astigmatic anisometropia, and 42 with hypermetropic anisometropia, were enrolled in the study. After informed consent, detailed ophthalmological examination was performed for every patient including cycloplegic refraction, best corrected visual acuity, slit lamp, and fundus examination. After routine ophthalmic examination peripapillary RNFL and CMT were measured using spectral domain OCT and the values of the two eyes were compared in the three types of anisometropia. Axial length was measured using an A Scan ultrasound biometer (Appa Scan-2000). Results The average age of subjects was 21.7±9.3 years. The mean anisometropia was 3.11±1.7 D in myopia; 2±0.99 D in astigmatism; and 3.68±1.85 D in hypermetropia. There was a statistically significant difference in axial length of the worse and better eye in both myopic and hypermetropic anisometropia (P=0.00). There was no significant difference between CMT of better and worse eyes in anisomyopia (P=0.79), anisohypermetropia (P=0.09), or anisoastigmatism (P=0.16). In anisohypermetropia only inferior quadrant RNFL was found to be significantly thicker (P=0.011) in eyes with greater refractive error. Conclusion There does not appear to be a significant difference in CMT and peripapillary RNFL thickness in anisomyopia and anisoastigmatism. However, in anisohypermetropia inferior quadrant RNFL was found to be significantly thicker.

Re: "Intralesional Tetracycline Injection for Treatment of Lower Eyelid Festoons".

154 Ophthal Plast Reconstr Surg, Vol. 32, No. 2, 2016 To the Editor: We read the article by Perry et al. with keen interest. We wish to express following comments. Festoons of the eyelids are redundant folds of lax skin and orbicularis muscle involving upper or lower eyelids that are suspended from canthus to canthus. Attenuation of orbicularis oculi and laxity of its attachments between orbicularis and deep fascia results in sagging of skin and muscle at different sites of lid and periorbital regions. Lower eyelid festoon may be pretarsal, preseptal, orbital, and malar. However, festoon most often represents malar mound with fluctuating edema and a skin fold. We appreciate the authors for reporting novel form of nonsurgical treatment of a very common problem of lower eyelid festoons by intralesional injection of 2% tetracycline.Authors mention that patients were graded on a scale of 0 (no festoon) to 4 (severe festoon). However, the authors have failed to describe the criteria of grading the festoon. Lam et al. graded malar mound as follows: grade 0: no malar mound present; grade 1: malar mound without swelling; grade 2: malar mound with variable swelling and normal overlying skin; grade 3: malar mound with fluctuating edema and a skin fold (festoon). Based on the site of occurrence of festoons in lower eyelid, it has been classified into pretarsal, preseptal, orbital, and malar festoon. Following studies by Pessa and Garza, it was found that the malar septum acts as a relatively impermeable barrier that allows tissue edema to accumulate above its cutaneous insertion. This septum defines the lower “boundary” of several clinical entities, e.g., malar mounds, malar edema, malar festoons. Based on these gradings and classification, we believe that a malar festoon itself represents severe form of festoon. Its further grading could be done according to the size of festoon. Authors injected 0.1 ml to 75 ml, 2% tetracycline into several planes of the festoon. Readers would be interested to know the basis of the concentration used and the quantity of tetracycline injected in this study. Additionally we wish to know the details of planes of intralesional injection and how much amount was injected in each plane. We believe that it would be difficult to distribute 0.1 ml in different planes. In our opinion, tetracycline should be injected in the cavity of festoon, i.e., between the orbicularis and deep fascia because that is the site where fibrosis needs to be created so that firm attachment is produced between orbicularis and deep fascia. We would be very keen to know whether 2% oxytetracycline injection could be used in place of tetracycline. In view of easy availability of commercial preparation of oxytetracycline injection, we have injected it in few cases of festoons intralesionally with good results. There was moderate edema and erythema involving lower eyelid in early postoperative period in all the patients. However, no ischemia, induration, and necrosis was encountered in any of these cases. Other important concerns which remained unanswered include 1) When was the maximum efficacy observed after the injection? 2) When to repeat intralesional injection?, and 3) What was the effect of length of follow up on the outcome? In our opinion, the maximum effect is likely to appear 3 months after the injection and repeat injection may be given after this period in case of suboptimal response or no response. Ved Prakash Gupta, M.B.B.S., M.D., D.N.B. Pragati Gupta, M.B.B.S., M.S. Rigved Gupta, M.B.B.S., M.S.