The role of CT-DCG in hardware - associated secondary acquired lacrimal duct obstruction: SALDO update study - (SUP) - Paper III

Purpose

To study cases of hardware-associated secondary acquired lacrimal duct obstructions (SALDO) and the role of computed tomography dacryocystography (CT-DCG) scans in its diagnosis and management.

Observations

Retrospective, interventional case review of four patients diagnosed as Hardware-associated SALDO, with primary maxillofacial repair performed elsewhere, were analyzed. The mean age was 36.5 years (range: 22-74 years), three of them being males. Left and right lacrimal systems were equally involved. Epiphora, swelling and discharge were the main presenting features. Three lacrimal sacs and nasolacrimal ducts on CT-DCG showed the screws of the orbital fracture plate directly piercing their walls, whereas a single case showed the sac displaced and pierced by the medial side of the orbital floor implant. Two cases underwent dacryocystorhinostomy with intubation, and the remaining two had to undergo dacryocystectomy due to extensive damage. Post-operatively all four cases were doing well at a mean follow-up of 2 months.

Conclusions

The present series highlights the role of CT-DCG in delineating spatial relationship of lacrimal drainage system with the surrounding structures, facilitating planning as well as choice of surgery, and anticipating the intraoperative challenges. It also signifies importance of interdisciplinary coordination between oculoplastic and maxillofacial surgeons to avoid iatrogenic trauma to the lacrimal drainage system.

Early trends of secondary acquired nasolacrimal duct obstruction in COVID-19 associated sino-orbital mucormycosis: SALDO update study (SUP) - Paper IV

Purpose

To study the emerging trend of development of secondary acquired nasolacrimal duct obstruction (SALDO) in the cases treated for rhino-orbito-cerebral mucormycosis (ROCM).

Observations

Prospective, interventional case series of five patients who developed SALDO post-surgical and medical management of ROCM. The mean age was 45.4 years (range: 40-62 years), all five being males. Right lacrimal drainage pathways was involved slightly more than the left (right:left = 3:2). Epiphora and discharge were the main presenting features. All five patients were treated with extensive debridement of the nose, sinuses, orbit and cerebral involvement as needed followed by medical management for ROCM. CT- Dacryocystography for all 5 patients showed obstruction at the lower end of the nasolacrimal duct. The patients underwent external dacryocystorhinostomy with mitomycin-C with or without intubation with good anatomical and functional outcomes at 6 months follow-up.

Conclusions and importance

The present series highlights the possible etiology of development of SALDO in cases treated for ROCM, its management and discusses the role of Computed Tomography Dacryocystography (CT-DCG) in understanding the pathophysiology of the development of SALDO along with delineating the spatial relationship of the lacrimal drainage system with the surrounding structures.

Acute dacryocystitis: changing practice pattern over the last three decades at a tertiary care setup

AIM

To compare the demographics, clinical features, and changes in the management pattern of acute dacryocystitis at a tertiary care eye institute.

METHODS

A retrospective review was performed of electronic medical records of all patients diagnosed with acute dacryocystitis from January 2013 to January 2023. Data retrieved include demographics, history, presenting symptoms, duration of symptoms, surgical interventions, associated systemic conditions, management, complications, and outcomes. A successful anatomical outcome was defined as patency on lacrimal irrigation, and a successful functional outcome was defined as the resolution of infection and epiphora. The data parameters obtained were compared with the historical published data of the earlier two decades from the same Institute.

RESULTS

A total of 363 eyes of 349 patients were enrolled in this retrospective study. The median age was 45 years (range: 19-94 years). There were 216 (62%) females and 133 (38%) males. Surgery was performed in 320 (88%) patients. Needle aspiration or incision and drainage were performed in 102(32%) patients with lacrimal abscesses. Of the 320 patients, an endoscopic DCR was performed in 138 (43%) patients and an external DCR in 182 (57%). Of the 320 patients who underwent DCR surgery, 308 (96%) demonstrated anatomical and functional success at 1-year follow-up.

CONCLUSION

There is a changing trend towards endoscopic DCR being incorporated as the primary procedure for managing acute dacryocystitis with the advantages of quicker resolution and reduced morbidity. There is a trend for choosing needle aspiration over the traditional incision and drainage in the initial management of lacrimal abscess.

Lacrimal gland activity in lacrimal drainage obstruction: exploring the potential cross-talk between the tear secretion and outflow

PURPOSE

To investigate the effects of lacrimal drainage obstructions on the lacrimal gland activity and if there exists a potential link between the two.

METHODS

Direct assessment of the lacrimal gland activity from the palpebral lobe was performed in consecutive patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction (PANDO), along with Ocular Surface Disease Index (OSDI), non-invasive tear break up time (NIBUT; Oculus K5M), tear meniscus height and Schirmer I. The primary outcome measure was the difference in the tear flow rate between the eye with PANDO and the contralateral uninvolved eye.

RESULTS

Thirty patients (median age, 45.5 years; 25 females) with unilateral PANDO had epiphora for a mean duration of 20 months. The mean OSDI score was 6.3. NIBUT (mean 11.56 vs 11.58 s; p=0.49) and Schirmer I values (mean 18.83 vs 19.4 mm; p=0.313) were not significantly different between PANDO and non-PANDO eyes. The morphology of the palpebral lobe (size 29.3 vs 28.6 mm2, p=0.41) and the number of lacrimal ductular openings (median 2 vs 2.5) were similar between the two eyes. The mean tear flow from the lacrimal glands of the PANDO side was significantly reduced compared with the contralateral uninvolved side (0.8 vs 0.99 µL/min; p=0.014)).

CONCLUSION

Tear flow rate from palpebral lobes of patients with unilateral lacrimal outflow obstruction shows a significant reduction compared with the contralateral side. The potential ways of communications between the tear drainage and the tear production mechanisms need to be explored further.

Post-traumatic canalicular fistula: description and review of literature - SALDO update study (SUP) - paper II

PURPOSE

To discuss the clinical spectrum and management strategies in patients with post-traumatic canalicular fistula (PTCF).

METHODS

Retrospective, interventional case series of consecutive patients diagnosed with PTCF over a 6-year study period between June 2016 and June 2022. The demographics, mode of injury, location, and communication of the canalicular fistula were noted. The outcomes of several management modalities including dacryocystorhinostomy, lacrimal gland therapies, and conservative approaches were assessed.

RESULTS

Eleven cases with PTCF over the study period were included. The mean age at presentation was 23.5 years (range: 6-71 years), with male: female ratio of 8:3. The median time interval between trauma to presentation at the Dacryology clinic was 3 years (range: 1 week to 12 years). Seven had iatrogenic trauma and four had the canalicular fistula following primary trauma. Management modalities pursued include conservative approach for minimal symptoms, and dacryocystorhinostomy, dacryocystectomy, and lacrimal gland botulinum toxin injection. The mean follow-up period was 30 months (range: 3-months-6 years).

CONCLUSION

PTCF is a complex lacrimal condition and the management of the PTCF needs a tailored approach guided by its nature and location and patient symptomatology.

Caruncle and plica hypertrophy causing mechanical secondary acquired lacrimal duct obstruction: - SALDO update study (SUP) - paper I

PURPOSE

To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy.

METHODS

Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height (TMH) pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora.

RESULTS

The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma.

CONCLUSION

The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

Lacrimal gland targeted therapies for refractory epiphora: quantitative changes in the gland activity

PURPOSE

To investigate the effect of botulinum toxin (BTX) and partial orbital lobe dacryoadenectomy (POLD) on the main lacrimal gland functions using the direct assessment of its secretory activity.

METHODS

A pilot study involving 14 subjects (mean age, 42.16 years) with proximal bicanalicular block (n = 9) or complete punctal effacement (n = 5) received either intraglandular 2.5 units of BTX (n = 7) or underwent the POLD procedure (n = 7). Dynamic assessment of tear secretion from the palpebral lobes was performed as per standard protocols. The parameters studied included Schirmer I, changes in the glandular outflow, and the neurosensory secretory lag.

RESULTS

Schirmer I values showed a mean reduction of 5.25 mm (range, 2-8 mm) following BTX injection, and mean tear flow decreased from 1.46 μ l / min to 1.11 μ l / min (P = 0.15). The POLD group showed a significant mean reduction of 0.45 μ l / min in mean tear flow at 1 month (P = 0.03) and 0.32 μ l / min at 3 months of follow-up (P = 0.20). However, there was no statistically significant change of the Schirmer values in the POLD group at 3 months.

CONCLUSION

Direct assessment of lacrimal gland function can be used to monitor changes following the gland therapies. Although POLD shows a significant reduction in short term, significant surgical improvisation would be needed for it to be effective in long term. A larger study is ongoing to further our understanding.

Epstein-Barr Virus-Associated Acute Dacryocystic Retention

Epstein-Barr virus (EBV) associated dacryocystic retention presents with an acute swelling in the lacrimal sac area with epiphora and lymphadenopathy. The patient would usually have a preceding history of infectious mononucleosis with clinical features of fever, pharyngitis, preauricular and cervical lymphadenopathy, hepatosplenomegaly, subclinical hepatitis, nausea, and palatine petechiae. The present case is of a 3-year-old child who presented with a sudden painless swelling in the lacrimal sac region with epiphora. Investigations and a biopsy helped in establishing the diagnosis of EBV-associated dacryocystic retention which resolved completely with conservative management.

Lower eyelid entropion following transconjunctival orbital fracture repair: Case series and literature review

Lower eyelid malpositions following transconjunctival repair of the floor and the zygomaticomaxillary complex fractures are rarely observed. The case series includes three patients (mean age, 22 years; 3 males) who developed lower eyelid entropion following orbital fracture repair (two complexes, one isolated type) using titanium mesh (n = 2) or iliac bone grafting (n = 1) through the transconjunctival approach. Entropion repair was attempted with scar release and Jones procedure in one, and posterior lamellar lengthening with mucous membrane graft in two patients. At a median follow-up of 25 months (range, 3-24), two patients had symptomatic relief without any lash globe touch, and one patient had persistent entropion after multiple interventions including failed mucous membrane graft (n = 1), full-thickness blepharotomy with everting sutures (n = 1), and scleral spacer grafting for posterior lamellar lengthening (n = 1). The literature is inconclusive about the association between eyelid malpositioning and any specific implant material, type of fracture, or incision closure technique.

Keratoconus in two siblings with congenital distichiasis

PURPOSE

To describe a previously unreported association of keratoconus in congenital distichiasis.

METHODS

Observational case series of ocular findings in 2 siblings with congenital distichiasis.

RESULTS

A 17-year-old male presented with tearing and photophobia in both eyes. His parents revealed that he was photophobic since birth. He had a lid surgery previously in both eyes. Clinical examination revealed a central scar with Descemet membrane tear suggestive of healed hydrops in the right eye. The left eye showed topographic features of keratoconus. His younger sibling, a 14-year-old female, also had similar symptoms of photophobia and tearing since birth. She had undergone electrolysis in both eyes. At the present visit, she had an epithelial defect with congestion in the right eye. Electrolysis of the distichiatic eyelashes was performed along with bandage contact lens application, which relieved her symptoms. Her topography revealed subclinical keratoconus in both eyes. The siblings' father also had complaints of photophobia since birth and had lid surgery and electrolysis in the second decade of his life.

CONCLUSIONS

Patients with congenital distichiasis may have associated keratoconus. Chronic ocular irritation and subsequent eye rubbing in distichiasis could be the risk factor for keratoconus.

Lacrimal Drainage Infections with Sphingomonas paucimobilis: Clinical Presentations, Complications and Outcomes

PURPOSE

To report the clinical presentations, complications, and outcomes of Sphingomonas paucimobilis-specific lacrimal drainage infections.

METHODS

A retrospective chart review of all patients diagnosed with Sphingomonas paucimobilis lacrimal infections and managed at a tertiary care Dacryology Service from November 2015 to May 2022 over a 6.5-year period were recruited and analyzed. Data collected include demographic details, clinical presentation, microbiological diagnosis, antibiotic susceptibility profiles, management, complications, and outcomes. The microbiological techniques employed were aerobic and anaerobic cultures, phenotypic identification with VITEK 2^R system, polymerase chain reaction, antibiotic sensitivity profile and minimal inhibitory concentration.

RESULTS

Twelve Sphingomonas-specific lacrimal drainage infections of 11 patients were identified. Of these five were canaliculitis and seven were acute dacryocystitis. All the seven acute dacryocystitis presented in an advanced stage; five were with lacrimal abscess and two with orbital cellulitis. The antibiotic susceptibility profile of canaliculitis and acute dacryocystitis were comparable and the organism was sensitive to several classes of antibiotics. The outcomes of punctal dilatation and nonincisional curettage were effective for canaliculitis. Patients with acute dacryocystitis had advanced clinical stage at presentation but responded well to intensive systemic management and had excellent anatomical and functional outcomes with dacryocystorhinostomy.

CONCLUSION

Sphingomonas-specific lacrimal sac infections can have aggressive clinical presentations and need early and intensive therapy. The outcomes are excellent with multimodal management.

Strabismus in pediatric orbital wall fractures

Purpose

To assess the clinical profiles and outcomes of strabismus in pediatric patients with orbital wall fractures.

Methods

A retrospective interventional study of all consecutive children of age ≤16 years who presented with traumatic orbital wall fractures with and without resultant strabismus was conducted. The details of patient demographics, clinical features, interventions, and outcomes were obtained.

Results

Forty-three children presented with traumatic orbital fractures to a tertiary care center. The mean age at presentation was 11 years and there was a male predominance (72.09%). Isolated floor fracture involvement was the most common (n = 24, 55.81%), and almost half of the children had a white-eyed or trapdoor fracture (n = 21, 48.83%). Twenty-six (60.46%) children had surgical repair of fracture(s). Manifest strabismus following orbital fracture was documented in 12 children (27.90%). Of these, an exotropia was noted in seven (58.33%), hypotropia in two (16.67%), hypertropia in one (8.33%), and esotropia in one patient (8.33%), while an exotropia with hypotropia was noted in one patient (8.33%). Restrictive nature of strabismus due to either muscle entrapment or local trauma was more commonly observed in 11/12 patients (91.66%). Primary position diplopia before orbital wall fracture repair was observed in four children and after repair was observed in two children with manifest strabismus. Four children underwent strabismus surgery post-fracture repair.

Conclusion

An improvement in strabismus and ocular motility was noted in majority of the patients after fracture repair. The few that underwent strabismus surgery had a restrictive nature of strabismus. Trapdoor fractures and the nature of trauma in children vary compared to adults. Persistence of strabismus may be due to an excessive time interval between trauma and fracture repair or the extensive nature of trauma.

Age-Related Changes in the Lacrimal Punctum Morphology in a Normal Population: Punctum Update (PUP) Study-Paper 1

PURPOSE

To define the clinical and optical coherence tomography (OCT) morphology of the lacrimal punctum and assess the age-related changes across 8 decades of life in a normal population.

METHODS

A total of 1310 high-magnification slit-lamp, Fourier-domain OCT (FD-OCT), and optical coherence tomography angiography (OCTA) images were obtained from 320 puncta of normal asymptomatic individuals representing the Indian population. The punctum and peri-punctal area were defined with the help of 2 rims (inner punctal rim and outer punctal rim ) and 3 zones (white zone [Wz], separation zone [Sz], and peri-punctal vascularity). FD-OCT images were used to measure the external punctal diameters and internal lacrimal punctal diameters and the reflectivity patterns of the 3 punctal layers. OCTA was used to assess the branching and extent of vascular networks.

RESULTS

The upper puncta were narrower and more circular than the lower puncta across the decades. The elevation of the punctal papilla began in the upper puncta in the fifth decade, involved the lower puncta in the sixth decade, and gradually became exaggerated by the eighth decade. A typical punctal narrowing in previously wide puncta began to appear in the sixth decade of life, peaks in the seventh decade, and reverses gradually and spontaneously by the end of the eighth decade of life. The third and fourth decades saw a narrowing of the Sz with prominent vascularity crossing the Sz to reach the Wz. The Sz became indistinct in the fifth and sixth decades of life. The FD-OCT showed gradual thickening and dominance of the fibrous layer from the fifth to eighth decade of life. The clinical vascularity in the peri-punctal region increases from the third decade onwards, with vascular networks becoming increasingly dense, intricate, and branched as the age progresses.

CONCLUSION

The present study defined and characterized the involutional changes in a normal population's first-eighth decades of life. Significant morphological changes were noticed across the different age groups with several clinical implications.

Lacrimal drainage anomalies in 3p deletion syndrome

3p deletion syndrome or deletion 3p25-pter syndrome is an exceptionally rare genetic disorder characterized by deletion of the distal segment of the short arm of chromosome 3. There are less than a hundred reported cases worldwide. Clinical characteristics include severe physical and mental retardation, trigonocephaly, micrognathia, and diffuse hypotonia. The common ocular manifestations include congenital ptosis and canthal anomalies. To the best of the authors' knowledge, no lacrimal drainage anomalies have been reported earlier. The present case describes proximal lacrimal drainage anomalies in a patient with 3p deletion syndrome. The patient was successfully managed with membranotomy and punctal and canalicular dilatation, resulting in a complete resolution of epiphora.

Histopathological Evidence of Canalicular Agenesis in Patients With Punctal Agenesis: Punctum Update Study 2

PURPOSE

The purpose of this study was to histologically assess the presence and extent of the canalicular tissue in cases of punctal agenesis.

METHODS

A prospective, interventional study was performed on 10 consecutive cases of punctal agenesis over a study period of 6 months. Exclusion criteria included cases with punctal dysgenesis or incomplete punctal canalization, secondary/acquired cases of punctal effacement, or any prior interventions. Following the exploration, the entire specimen of the tissue (length = 8 mm and depth = 3 mm) was sent for histopathological analysis to ascertain the presence and extent of the canalicular tissue.

RESULTS

The mean age of the patients at the time of exploration was 7.5 years (range 6-10 years). Histopathological analysis showed tissue surfaces lined with stratified squamous epithelium with occasional interspersed goblets cells (conjunctival epithelium), a few chronic inflammatory cells, and muscle fragments. Epithelium suggestive of proximal lacrimal drainage system was absent. Canalicular tissues were found to be absent in all cases of punctal agenesis.

CONCLUSION

The present series did not find any histologic evidence of canalicular tissues in cases of punctal agenesis. The findings of this study do not support retrograde approaches in cases of punctal agenesis.

Lacrimal drainage anomalies in Pierre Robin sequence

Pierre-Robin sequence consists of a classical triad of micrognathia, glossoptosis, and upper airway obstruction. The common ocular manifestations include congenital glaucoma, high myopia, maculopathy, and retinal detachment. Except for a mention of a nasolacrimal duct obstruction without many details, lacrimal drainage anomalies have not been reported earlier to the best of the authors' knowledge. The present case describes several lacrimal drainage anomalies including supernumerary puncta, canalicular wall hypoplasia, grossly dilated nasolacrimal duct, and complex congenital nasolacrimal duct obstruction in a patient of Pierre Robin sequence. The patient was successfully managed with endoscopic guided probing and marsupialization of the large intranasal cyst resulting in a complete resolution of epiphora.

Giant jelly bump deposits on therapeutic contact lens: an unusual finding following ptosis surgery

The authors report two cases of unusually large deposits on their therapeutic bandage contact lens (BCL) following uneventful surgery for congenital ptosis. The first case presented at 6 weeks with decreased vision, large jelly-bump deposits over the contact lens and sterile corneal infiltrates. The infiltrates rapidly resolved with restoration of vision following contact lens removal and topical antibiotics. The second case presented 2 weeks after surgery with visual loss and similar deposits but with no corneal involvement. Following replacement of BCL and topical lubricants, her vision improved to 20/20. Studies on the role of BCL in ptosis surgery are scarce with literature supporting its use for ocular surface protection and minimising postoperative discomfort. The authors hypothesise impaired blink mechanism as the accelerating factor for this unusual occurrence in the early postoperative period and recommend frequent replacement of the contact lens and a closer follow-up in all these cases.

Acquired lacrimal fistula: classification and management

PURPOSE

To classify the acquired lacrimal fistulae (ALF) and assess the outcomes following surgical management.

METHODS

Retrospective, interventional study of all patients presenting with ALF over a 3.5-year period was performed. The fistulae were classified based on photographic evidence with respect to their location, size and nature. Primary outcome measures were complete healing of the fistulous opening and resolution of discharge or leakage from it. Secondary outcome measures were resolution of epiphora and patency of the lacrimal drainage system.

RESULTS

84 eyes of 82 patients who had acquired lacrimal fistulae were analysed. The mean duration of the fistulae presence was 10.12 months. The etiology of ALF was spontaneous following lacrimal abscess rupture in 79 eyes and was secondary to incision and drainage in the remaining 5 eyes. Thirty eyes had fistulectomy along with definitive surgery for the associated nasolacrimal duct obstruction (NLDO), 15 eyes underwent definitive surgery without an additional fistulectomy and 4 fistulae healed spontaneously prior to intervention for NLDO. The resolution of ALF did not differ in between those who underwent fistulectomy versus those who did not. The exceptions were 2 chronic large fistulae with cutaneous lining which needed a definite fistulectomy for resolution along with surgery for NLDO.

CONCLUSION

Most of the acquired fistulae heal by themselves irrespective of the nature, size and location and need no additional treatment in the form of fistulectomy. However, this is not true for those that are large and have a cutaneous lining.

Endoscopic and radiological evidence refuting intra-abscess septae

PURPOSE

To investigate the presence of septae within the lacrimal abscess and to explore simple aspiration as an alternative to the traditional management by incision and drainage.

METHODS

Prospective, interventional pilot study involved eight lacrimal sac abscesses of eight patients over a period of three months. All patients underwent a pre-operative MRI with surface coils followed by aspiration of the abscess (n = 4) or incision and drainage of the abscess (n = 4). An intra-sac endoscopic evaluation was performed during the abscess drainage. Primary outcome measures - presence or absence of septae on MRI scan images and endoscopic evaluation of the abscess cavity. Secondary outcome measures - relief from pain and symptoms following aspiration and anatomical patency following definitive management.

RESULTS

Eight patients underwent either aspiration (n = 4) or incision and drainage of the abscess (n = 4). Mean age of the patients 43.3 years and male to female ratio was 1:1. Left eye involvement was more common (Right: left = 1:3). Average duration of acute symptoms - 3.75 days. High resolution MRI showed a well- defined abscess cavity with few undulations which on endoscopic evaluation correlated with oedematous mucosal folds. There was absence of a loculi or septae within the abscess cavity. Definitive surgery in the form of endoscopic DCR was performed for all the patients with post-operative FICI grading was +5.

CONCLUSION

The present study refutes the presence of septae within the abscess cavity and proposes aspiration of the lacrimal sac abscess as a minimally invasive procedure with minimal logistics and a shallow learning curve.

Neurotization of the human cornea - A comprehensive review and an interim report

We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords “corneal nerves,” “neurotization,” “esthesiometry,” “corneal anesthesia,” and “neurotrophic keratopathy.” All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3–6 months, while nerve regeneration on confocal microscopy can take as long as 6 months–1 year.

Clinical Profiles and Surgical Outcomes of Strabismus Following Orbital Wall Fractures: A Large Cohort From a Tertiary Eye Care Center

PURPOSE

To evaluate the demographic details, clinical presentation, and surgical outcomes in patients presenting with strabismus following orbital wall fractures.

METHODS

A retrospective review was conducted over a 6-year period on 347 consecutive patients with strabismus who presented after orbital wall fractures. The patients were evaluated for their demographic data, clinical presentation, and profiles, management, complications, and outcomes of strabismus.

RESULTS

Strabismus following orbital wall fractures was noted in 347 patients: 87.03% were men (n = 302) and 12.97% were women (n = 45). Fracture of the orbital floor in isolation or in combination with other walls was more frequently noted in 72.3% of patients (n = 251). The resultant strabismus included paralytic, restrictive, or both etiologies. Exotropia was noted most frequently in 25.65% of patients (n = 89), followed by exotropia with hypotropia in 20.75% of patients (n = 72). Ten percent of patients with strabismus (n = 34), who were observed for at least 6 months after injury, underwent surgical correction for strabismus. Preoperative diplopia was observed in 79.41% of patients (n = 27) and persisted after strabismus surgery in 15% of patients (n = 6). A successful outcome regarding the postoperative angle of deviation of 10 prism diopters or less horizontal and/or 5 prism diopters or less of vertical deviation with elimination of diplopia was observed in 41.17% of patients.

CONCLUSIONS

Strabismus following orbital wall fractures is complex and requires a tailored strategy. The current study found the orbital floor to be more frequently involved in orbital wall fractures. However, the resultant strabismus was a combination of paralytic and restrictive etiologies. [J Pediatr Ophthalmol Strabismus. 2022;59(3):172-179.].

The Cry of the Third Eye: Exceptionally Rare Location of a Post-Traumatic Acquired Lacrimal Fistula

PURPOSE

To report an unusual case of an ectopic lacrimal fistula in a setting of a naso-orbito-ethmoid fracture.

CASE REPORT

The present case demonstrates a right-sided ectopic lacrimal fistula just below the glabella on the contralateral side on the outer edge of the midline. CT-Dacryocystography demonstrated a large dilated right lacrimal sac with a partly sequestered fundus traversing through the frontal process of the maxilla and frontal bone, close to the skull base and communicating with the fistula. The connection of the fistula with the sac was severed at the superior-most point, and the long fistulous tract was removed using external and endoscopic approaches, followed by endocautery and subsequent dacryocystorhinostomy. Post-operatively, the fistulous opening healed, ostium score was FICI grade 5, and the patient was asymptomatic.

CONCLUSION

The case demonstrates multiple surgical challenges while managing an ectopic fistula with a long fistulous tract traversing several bony structures.

Update on the Long-Term Outcomes Following the Management of Incomplete Punctal Canalization

PURPOSE

To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC).

METHODS

Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship's punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes.

RESULTS

Ninety-eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization-external membrane variant was seen in 62% (61/98) and internal membrane variant in 38% (37/98). Seventy-eight puncta (78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship's punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean follow up of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively.

CONCLUSIONS

The long-term outcomes of membranotomy for IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC.

Atypical presentation of punctal keratin cyst: an underdiagnosed entity

Punctal keratin cyst (PKC) is a rare disorder believed to be due to ectasia of the vertical canaliculus. The etiopathogenesis of this disorder is very poorly understood due to the paucity of literature. To the best of authors' knowledge, only two cases of punctal keratin cyst have been described earlier, which presented as cystic lesions. The authors report four cases of punctal keratin cyst which differ in clinical presentation and also describe the anterior segment ocular tomography features, which aids in recognition and diagnosis of this rare disorder. The key message of the article is that lack of a defined cyst on clinical examination and optical coherence tomography (OCT) cannot rule out the presence of a PKC. A combination of clinical, radiology, and histopathology are confirmative of the diagnosis. Once diagnosed, the subsequent outcomes with membranotomy and keratin curettage are excellent.

Isolated eyelid chondroid syringoma: a study of two cases

Chondroid syringoma is a benign mixed tumour arising from the sweat glands which can be apocrine (found throughout the surface of the eyelid) or eccrine with a mean age of presentation being 50 years. Here we report two cases of chondroid syringoma of the upper eyelid, one in a young male patient and the other in an elderly woman. Both cases had well-defined lesions involving upper eyelid in the sub-brow region, underwent excisional biopsy, and histopathological findings were consistent with an apocrine type of chondroid syringoma in one case and eccrine type of chondroid syringoma in the second case. It is important to be aware of this entity as a rare cause of eyelid lesion due to the fact that although it is a benign neoplasm, incomplete excision may be associated with recurrence or malignant transformation.

Orbital involvement in lacrimal drainage disorders

Lacrimal sac is situated anterior to the orbital septum, which acts as a barrier, thus limiting the posterior migration of the pathologies affecting the lacrimal drainage system. Certain pathologies can breach this barrier and secondarily involve the orbit causing significant clinical manifestations. This posterior migration of pathology also has a significant influence on the management and outcomes. The present paper will discuss the lacrimal pathologies which secondarily involve the orbit and its influence on the management and outcomes.

Congenital Nasolacrimal Duct Obstruction Update Study (CUP Study): Report III. Analysis of Earlier Failed Probing without Endoscopy Guidance

AIM

The purpose of this study was to report the profile and outcomes of children with an earlier failed probing that was performed without endoscopy guidance.

METHODS

Retrospective interventional case study was performed on all the patients who were referred with a diagnosis of a single or multiple failed probing from Jan 2016 to June 2019 to a tertiary care Dacryology center. All the patients had a blind probing without an endoscopy assistance before referral. The parameters evaluated were patient demographics, number of earlier probings, prior operative notes, clinical presentation, findings of endoscopy guidance during the repeat procedure, simple vs complex CNLDO, types of complex CNLDO, management, complications and outcomes.

RESULTS

One hundred eyes of 82 children had a failed probing experience without endoscopic guidance elsewhere. The mean age of the children was 55.7 months (range: 9-168 months). Of these, 63 eyes underwent repeat probing under endoscopic guidance, 35 eyes being simple CNLDO (35/63, 55.5%), and 28 eyes (28/63, 44.5%) being complex CNLDO. Among the complex subset, balloon dacryoplasty was performed for five cases and monoka-Crawford stents for eight cases under direct endoscopy visualization. Buried probes were managed successfully by standard protocols of probe exteriorization. The two cases of misdirected probes were re-directed under endoscopy guidance for appropriate recanalization and the single case of granuloma at the NLD opening was excised followed by intubation without any recurrence.

CONCLUSION

Endoscopy guidance plays a crucial role in the management of CNLDO with an earlier failed probing.

Magnetic resonance imaging in rhino-orbital-cerebral mucormycosis

Coronavirus disease-associated mucormycosis (CAM) is an established clinical entity in India. In the past 4 months, there has been a sharp upsurge in the number of CAM cases in most parts of the country. Early diagnosis can be lifesaving. Magnetic resonance imaging (MRI) imaging remains the corner stone of management in patients with ROCM. This review discussed the utility of MRI imaging in ROCM with an emphasis on the ideal MRI protocol in a suspected case of ROCM, the pathways of spread of infection, the classic diagnostic features, MRI for staging of the disease, MRI for prognostication, MRI for follow up, and imaging features of common differentials in ROCM. The pit falls of MRI imaging and a comparison of CT and MRI imaging in ROCM are discussed. The clinical interpretation of areas of contrast uptake and those of necrosis and its relevance to treatment are discussed. This review aims to familiarize every member of the multidisciplinary team involved in managing these patients to be able to interpret the findings on MRI in ROCM.

Long-term outcomes of revision endoscopic dacryocystorhinostomy aided by 4-mm coronary balloon catheter dacryoplasty

Our purpose was assess the long-term efficacy of 4-mm coronary balloon catheter dacryoplasty in revision endoscopic dacryocystorhinostomy (RevEnDCR). This retrospective interventional case-series was performed for patients who underwent RevEnDCR aided by a 4-mm coronary balloon catheter (CBC) dacryoplasty. The indications for the surgery were previously failed DCRs by external or endoscopic approach where the ostium showed near total cicatrization with or without the presence of organized granuloma threatening the internal common opening (ICO). The coronary balloon (4 × 10 mm, SPALNO, Cardiomac, Haryana, India) with the guidewire was used and a minimum of >12 months of follow-up was considered for analysis. Ten lacrimal systems of eight patients with mean age of 48.8 years underwent CBC-assisted revision endoscopic DCR. Of the 10 failed DCRs, 6 had a previous external approach DCR and 4 were endoscopic DCRs. Grossly stenosed ostium with near total cicatricial closure were noted in half of the patients (50%, 5/10) while the remaining half, in addition, showed organized granulomas threatening the ICO. The surgical technique using CBC was found to be minimally invasive, easy to perform with multiple advantages like uniform clearance of the area in front of ICO and more predictable lacrimal sac flaps. At a mean follow-up of 20 months, anatomical and functional success were achieved in 90% (9/10) of the eyes. We conclude that coronary balloon catheter-assisted revision endoscopic DCR is a minimally invasive and viable alternative in select group of patients of failed DCR with near total cicatrisation or organized granulomas threatening ICO.

Lacrimal Fossa Bony Changes in Chronic Primary Acquired Nasolacrimal Duct Obstruction and Acute Dacryocystitis

PURPOSE

This study aims to assess the bony lacrimal fossa changes in chronic cases of primary acquired nasolacrimal duct obstruction versus acute dacryocystitis.

METHODS

A prospective study was performed on 25 bony lacrimal fossae of 25 eyes of 15 patients who underwent endoscopic dacryocystorhinostomy at a tertiary care Dacryology service over a period of 6 months. Ten patients with chronic PANDO (> 1 year) with bilateral involvement and five patients of unilateral acute dacryocystitis were recruited in the study. None of the patients had a history of trauma or previous surgeries or nasal disease in the past. The bone samples from the frontal process of the maxilla and the lacrimal bone were obtained during the osteotomy and subjected to routine histopathological examination. Special stains used were von Kossa, Masson trichrome, periodic acid Schiff, and Alcian blue. Immunohistochemistry was performed using CD68 antibodies. Patient demographics, clinical presentation, duration of the disease, and bony changes were analyzed in different patient subsets.

RESULTS

The mean disease duration in the chronic PANDO subset was 3.1 years, whereas acute dacryocystitis was 6.8 days. There was no correlation between the bony changes and the laterality in the chronic subset. Periosteal thickness and fibrosis were universal in the chronic group but not in the acute dacryocystitis. There were also differences in the number of osteocytes per sq mm, osteoblast, osteoclast, bony remodeling, bony canals structure, and intrastromal fibrosis between the subsets. These changes within the chronic group increased with the duration of the disease. Interestingly, there was no evidence of any bony inflammation across the subsets in all the samples studied.

CONCLUSION

Characteristic bony changes can be demonstrated in patients with chronic PANDO but not in acute dacryocystitis. The lack of bony inflammatory infiltrates may provide clues in understanding the peri-sac disease pathogenesis in acute dacryocystitis.

Congenital canaliculops with punctal agenesis: is there a possibility to establish patency?

Canaliculops is a non-inflammatory dilatation of the canaliculus which can be secondary to trauma, punctal agenesis, herpetic infections or chronic drug use. This condition can affect either canaliculi and has shown female preponderance. Treatment described so far has consisted of cyst marsupialization with no literature on the post-operative epiphora in these cases. We describe two cases of canaliculops with punctal agenesis where we have tried to establish lacrimal patency.

Lacrimal drainage system involvement in Peters anomaly: clinical features and outcomes

PURPOSE

To present first of its kind series on the clinical features and outcomes of lacrimal drainage disorders in Peters anomaly and Peters plus syndrome.

METHODS

A retrospective chart review was performed of all consecutive patients who were known cases of Peters anomaly or Peters plus anomaly and were diagnosed with associated congenital lacrimal drainage disorders. The study period was from June 2016 to Dec 2020. All these patients underwent examination under anaesthesia for a detailed assessment of lacrimal drainage anomalies. Where indicated, they were treated with probing, intubation, or in refractory patients with a dacryocystorhinostomy. The anatomical and functional outcomes were assessed.

RESULTS

Of the 282 patients with Peters anomaly, 4 (1.4%) patients had associated lacrimal drainage system anomalies while of the 16 Peters plus anomaly children, 3 (18.75%) had associated lacrimal drainage system anomalies. A total of 12 lacrimal drainage systems of 12 eyes of 7 patients of Peters anomaly were found to be involved. Upper or lower punctal agenesis were noted in 3 eyes. Three eyes had complex congenital nasolacrimal duct obstruction (CNLDO), two of which had a bony NLD block and one had a misdirected nasolacrimal duct through the inferior turbinate. One eye had a diffuse NLD stenosis without a CNLDO. Following appropriate management, at a mean follow-up of 25.7 months (range: 3-48 months), all the eyes except one (91%, 10/11) demonstrated anatomical and functional success.

CONCLUSION

Lacrimal drainage involvement was more common in Peters plus syndrome. Multiple proximal and distal lacrimal drainage segment anomalies were noted in all the variants of Peters anomaly; however, Peters plus syndrome was noted to usually involve both the segments.

Color Doppler Imaging Features of the Lacrimal Sac in Health and Diseased States

PURPOSE

The objective of this study is to present Color Doppler imaging (CDI) features of the lacrimal sac in normal and diseased states.

METHODS

Prospective study was performed on 20 lacrimal sacs of 20 eyes of 10 patients who underwent Color Doppler imaging at a tertiary care Dacryology service over a period of 6 months. All the patients were subjected to Duplex doppler scanning of the lacrimal sacs. Of the 20 lacrimal drainage systems studied, 8 were normal, 8 had primary acquired nasolacrimal duct obstruction (PANDO) and 4 were that of acute dacryocystitis (AcDac). Patient demographics, clinical presentation, duration of the disease and Color Doppler vascular characteristics like peri-sac vascular flow, peak systolic velocity (PSV), end-diastolic velocity (EDV), resistivity index (RI), arterial spectral waveforms and sac dimensions and wall thickness were analyzed.

RESULTS

The vascular flow around the lacrimal sac was increased with higher flow velocities in PANDO as compared to normal and grossly enhanced in AcDac. Flow disturbances were also quite discernible in AcDac. The mean PSV and EDV were 9 & 3.87 cm/sec, 13.07 & 4.63 cm/sec and 18 & 8.5 cm/sec in normal, PANDO and AcDac, respectively. The mean vascular resistivity index increased in patients with PANDO (0.67) and decreased in AcDac (0.53) as compared to the normal (0.57). The arterial spectral waveforms in PANDO and AcDac showed low pulsatility, but the systolic peaks were sharper with more continuous forward flow through diastole in AcDac. This reflects vascular dilatation and reduced resistance to flow in AcDac.

CONCLUSION

Characteristic Color Doppler flow parameters can be demonstrated in patients with PANDO and acute dacryocystitis. Color Doppler techniques have the potential to enhance the understanding of lacrimal drainage pathophysiology.

Congenital nasolacrimal duct obstruction update study (CUP study): paper I-role and outcomes of Crigler's lacrimal sac compression

PURPOSE

To assess the exclusive role and outcomes of Crigler's lacrimal sac compression in the management of congenital nasolacrimal duct obstruction (CNLDO).

METHODS

Retrospective interventional case-series was performed on patients diagnosed with CNLDO and who were advised Crigler's lacrimal sac compression (CLSC) at a tertiary care Dacryology Institute from Jan 2016 to June 2019. CNLDO patients who were practicing incorrect techniques of lacrimal sac compression at presentation were separately assessed. All the patients were assigned to four groups (Gr 1: 0-3 months, Gr 2: >3 & <6 months, Gr 3: >6 & <9 months and Gr 4: >9 and <12 months) based on the age at which the CLSC was initiated and followed up quarterly or as needed till at least 1 year of age. The parameters studied include patient demographics, clinical presentation, age of initiation of CLSC, success rate with CLSC, and need for additional interventions. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test.

RESULTS

A total number of 1240 patients with CNLDO were assessed. Of these, 1037 patients were advised correct techniques of CLSC from the beginning, and the remaining 203 patients were referred but performing it incorrectly at presentation. Of the 1037 patients, 236 were lost to follow-up; hence, a total of 1004 patients (801 + 203) were included for final analysis. CLSC was found to be an effective conservative strategy in the management of CNLDO. The rate of resolution of CNLDO in Gr 1 to Gr 4 was 87.3%, 78.9%, 77.9%, and 76.8%, respectively. There were no statistically significant differences in the outcomes based on the age of CLSC initiation. The referred patients whose techniques were rectified following the initial incorrect techniques showed a resolution of 61.2% (79/129). The correct techniques of CLSC appeared to influence the outcomes. However, the age of its initiation did not substantially impact the outcomes. Significantly high resolution was noted even beyond nine months of age and encouraging results beyond 12 months of age.

CONCLUSIONS

It is crucial to initiate the correct techniques of Crigler's lacrimal sac compression to achieve favourable outcomes. Age of initiation of CLSC in infancy does not appear to influence the outcomes. The resolution rate continued to be significantly high up to 1 year of age. There is a need to assess the role of CLSC beyond 12 months of age.

Cerebral palsy and associated complex congenital nasolacrimal duct obstruction and pediatric acute dacryocystitis

Cerebral palsy (CP) is a congenital syndrome with systemic manifestations secondary to a non-progressive lesion of the immature brain. It is associated with numerous cerebral and non-cerebral malformations. The present report describes a 2-year-old baby with spastic CP, diplegic type, associated with congenital cardiac malformations and right eye complex congenital nasolacrimal duct obstruction (CNLDO) (bony nasolacrimal duct stenosis and buried probe) requiring endoscopic dacryocystorhinostomy and left eye simple CNLDO which resolved on probing the system. This report also lays emphasis on the need for examination of the lacrimal drainage system in all patients with CP, so as to treat them appropriately and reduce the morbidity.

Masquerades of Acquired Dacryocystocele

Introduction

Dacryocystocele can be congenital or acquired and acute or chronic, based on underlying pathology. An inferomedial anterior orbital mass lesion can masquerade an acquired dacryocystocele with similar symptomatology; however, the treatment varies. Hence, a careful examination of the swelling to differentiate these masquerades is needed to ensure rightful treatment.

Patients and Methods

A retrospective, interventional study was performed on consecutive patients from January 2017 to October 2019 who presented with swelling in the lacrimal sac area of varying durations. They underwent computed tomography scans followed by surgical intervention. Their relation to the lacrimal drainage apparatus was explored.

Results

During the study period, 5 such patients were found in the records. The radiology was consistent with anterior orbital mass lesions, not involving the lacrimal sac. Histopathology after surgical excision was consistent with three of the lesions being dermoid cysts, one was cavernous hemangioma and one was a solitary fibrous tumor.

Conclusion

Inferomedial anterior orbital mass lesions can present as masquerades of acquired dacrycystoceles. Careful examination and high degree of suspicion is needed to distinguish these lesions and ensure correct treatment.