Canaliculocoele: A Case Series and Review of Literature

AIM

To report a case series on canaliculocoele and to review the existing literature.

METHODS AND MATERIALS

A retrospective analysis of the case records of all patients diagnosed with canaliculocoele between January 1st, 2018, and December 31st, 2019, was conducted. Only histopathologically proven cases of canaliculocoele with a minimum follow-up of 6 weeks were included.

RESULTS

Five cases of canaliculocoele that presented over 2 years were included. The mean age was 58.8 ± 9.63 years, with a female preponderance. The mean duration of symptoms was 22.2 ± 22.71 months. All patients had medial cystic swelling, either at the upper or lower lid. Four patients had gross stenosis of the punctum, while the punctum was absent in one patient. Ultrasound biomicroscopy showed canalicular cystic distension with intra-lesional hyper-reflective echoes. All patients were managed with a complete cystectomy, except for one where a marsupialization was done. Adjunctive mini-Monoka intubation was done in two patients. The histopathological diagnosis of all cases was consistent with canaliculocoele. The mean follow-up was 3.82 ± 2.77 months.

CONCLUSION

Canaliculocoele is mostly unilateral and seen in middle-aged women. A good clinical evaluation supported by diagnostic imaging along with an affirmative histopathology can confirm the diagnosis.

Dysthyroid optic neuropathy: Demographics, risk factors, investigations, and management outcomes

Purpose

To analyze the clinical presentations, risk factors, and management outcomes in patients presenting with dysthyroid optic neuropathy (DON).

Methods

This is a retrospective, single-center study carried out on consecutive patients presenting with DON over a period of 4 years (2013-2016). The VISA classification was used at the first visit and subsequent follow-ups. The diagnosis was based on optic nerve function tests and imaging features. Demographic profiles, clinical features, risk factors, and management outcomes were analyzed.

Results

Thirty-seven eyes of 26 patients diagnosed with DON were included in the study. A significant male preponderance was noted (20, 76.92%). Twenty patients (76.9%, P = 0.011) had hyperthyroidism, and 15 (57.69%, P = 0.02) were smokers. Decreased visual acuity was noted in 28 eyes (75.6%). Abnormal color vision and relative afferent pupillary defects were seen in 24 (64.86%) eyes, and visual field defects were seen in 30 (81.01%) eyes. The visual evoked potential (VEP) showed a reduced amplitude in 30 (96.77%, P = 0.001) of 31 eyes and delayed latency in 20 (64.51%, P = 0.0289) eyes. Twenty-six (70.27%) patients were treated with intravenous methyl prednisolone (IVMP) alone, whereas 11 (29.72%) needed surgical decompression. The overall best-corrected visual acuity improved by 0.2 l logMARunits. There was no statistically significant difference in outcome between medically and surgically treated groups. Four patients developed recurrent DON, and all of them were diabetics.

Conclusion

Male gender, hyperthyroid state, and smoking are risk factors for developing DON. VEP, apical crowding, and optic nerve compression are sensitive indicators for diagnosing DON. Diabetics may have a more defiant course and are prone to develop recurrent DON.

Microbiological profile of canaliculitis and their antibiotic susceptibility patterns: A 11-year review at a referral eye care centre

PURPOSE

To analyze the microbiological profile and in vitro antibiotic susceptibility patterns of bacterial isolates in canaliculitis, an infection of the lacrimal drainage system of the eye.

METHODS

The laboratory records of patients presenting with canaliculitis from whom specimens were obtained for microbiological investigations at our tertiary eye care centre in South India from January 2010 to December 2020, were reviewed.

RESULTS

A total of 130 canalicular pus samples were collected from 112 patients and submitted for microbiological studies during the study period. A total of 183 micro-organisms were isolated from 115 culture-positive specimens. The micro-organisms isolated were predominantly aerobic Gram-positive bacteria (83.44%), with Coagulase-negative Staphylococci (CoNS/Other Staphylococcus spp) (31.69%), Corynebacterium spp (15.3%), Staphylococcus aureus (9.84%) and Viridans Streptococci (9.84%) accounting for a majority of the isolates. Actinomycesspp (6.56%) was the most common anaerobic bacterium isolated. Our study revealed several bacteria not previously associated with canaliculitis namely Ottowia spp, Elizabethkingiameningoseptica, Aeromonassalmonicida, Capnocytophagaochracea and Campylobacter gracilis. Polymicrobial aetiology was observed in 39.13% of culture-positive samples. Analysis of antibiotic susceptibility patterns of the isolates revealed a high proportion of Gram-positive bacteria susceptible to chloramphenicol (90.16%) compared to fluoroquinolones including ciprofloxacin (74.42%), norfloxacin (64.15%) and gatifloxacin (60.49%).

CONCLUSION

This study represents the largest series of canaliculitis reporting the microbiological profile and antibiotic susceptibilities of the isolated micro-organisms, till date. Gram-positive bacteria accounted for a majority of isolates, predominated by Staphylococcus spp. The increasing resistance of Gram-positive bacteria to fluoroquinolones warrants antibiotic treatment in canaliculitis is based on in vitro antimicrobial susceptibility patterns.

The undesirable wink

Background:

Marin-Amat syndrome is a rare acquired oculofacial synkinesis first reported in 1918. It manifests as involuntary eyelid closure on jaw opening or on lateral movement of the jaw following a peripheral facial nerve palsy. The increased orbicularis tone due to aberrant connections between the cranial nerve (CN) V and CN VII results in an undesirable wink with major psychosocial impact.

Purpose:

Most cases in literature were either observed or administered botulinum toxin injection to the orbicularis muscle. There are few sporadic reports of surgical interventions with successful outcomes.Hence there was a need to generate awareness regarding various modes of management of this rare entity.

Synopsis:

We present a video on the clinical presentation and management of six such patients, of whom one was bilateral. Five patients were females. Traumatic facial nerve paralysis and Bell’s palsy was previously diagnosed in one and five patients respectively. The mean age was 52 ± 9.48 years. The mean MRD (margin reflex distance) 1 and MRD 2 was 3.17 ± 0.60 and 5.33± 0.65 mm respectively. On smiling or on movement of the jaw the MRD 1 and 2 was reduced by 2. 50±0.40 and 1.50+/-0.40 mm respectively. Of the six patients four patients opted for nil intervention.

Highlights:

Botulinum toxin injection and preseptal orbicularis resection in the upper and lower eyelid along with blepharoplasty was performed in 1 patient each. Satisfactory reduction in the synkinetic movement was achieved in both. Marin-Amat syndrome is a rare often underdiagnosed synkinetic disorder following peripheral facial nerve palsy. Botulinum toxin injection and preseptal orbicularis resection are viable management options.

Video link:

https://youtu.be/YQbRecp449w

Iatrogenic nasolacrimal duct obstruction after adnexal intervention: An avoidable consequence

PURPOSE:

Isolated cases of nasolacrimal duct obstruction (NLDO) secondary to rhino-orbito-facial reconstructive surgeries have been reported previously. We report the clinical profiles and management outcomes of a series of patients with iatrogenic INDO.

MATERIALS AND METHODS:

Case records of all patients who presented with secondary NLDO over 5 years were retrospectively analyzed. The case series included seven patients with NLDO secondary to orbito-facial surgeries.

RESULTS:

The study included six males and one female patient with a mean age of 29 ± 12.58 years. All the patients had a history of road traffic accidents following which they underwent an open reduction and internal fixation by maxilla-facial surgeons. All of them presented to the Ophthalmology outpatient department with epiphora following the surgical intervention. Imaging revealed the implants were responsible for obstructing the nasolacrimal ducts in all seven cases. Five patients underwent external dacryocystorhinostomy while dacryocystectomy was performed in two. Implant removal was necessary for five patients without any compromise on the structural integrity of the orbital walls.

CONCLUSION:

Precise knowledge of the orbital anatomy, especially that of the lacrimal drainage system is imperative for surgeons performing surgeries in the midface area. A multidisciplinary approach and inclusion of surgeons trained in lacrimal surgeries can prevent such avoidable complications.

Intracanalicular antibiotic ointment loading as a management option for canaliculitis

AIM

The aim of the study is to describe intracanalicular antibiotic ointment loading as a treatment option for canaliculitis.

MATERIAL AND METHODS

It was an interventional prospective study. The study was conducted over a 3 year period from June 2015 to June 2018. All patients of canaliculitis managed with intracanalicular antibiotic ointment loading and with a minimum follow up of 3 months were included in the study. The antibiotic ointment was loaded into the canaliculus based on the antibiotic sensitivity of the material expressed out from the canaliculus. Patients' demographics, clinical details, microbiological profile and management outcomes were evaluated.

RESULTS

A total of 24 patients were included in the study. Mean age at presentation was 58.41 ± 9.4 years. The right eye was involved in 15 (62.5%, p = .0424) cases. The incidence of lower canaliculus involvement (14, 58.33%, p = .022) was significantly higher as compared to the upper canaliculus (8, 33.33%). Staphylococcus epidermidis and Actinomyces israelii (6, 25%) were the most commonly isolated organisms. Mean number of intracanalicular antibiotic loading sessions required was 4.21 ± 1.69 (range 2-8). Complete resolution of canaliculitis was seen in all (100%) cases.

CONCLUSION

Canalicular antibiotic ointment loading is a minimally invasive, safe, and effective procedure. It preserves the anatomy and function of the punctum and canaliculus and can be considered as one of the management options for canaliculitis.

Orbital and adnexal amyloidosis: Thirty years experience at a tertiary eye care center

Purpose:

The aim of this work was to study the clinical presentation, management and outcomes of orbital and adnexal amyloidosis.

Methods:

This retrospective analysis included all the patients diagnosed with orbital and adnexal amyloidosis between January 1990 and December 2019. Positive staining with Congo Red and apple-green birefringence on polarized light microscopy established the diagnosis. Data analyzed included demographic profile, varied presentations, management, and outcome.

Results:

Thirty-three eyes of 26 patients were included. The male:female ratio was 1:1. The mean age of the study population was 42.6 ± 16 years. The median duration of symptoms was two years. Unilateral involvement was seen in 19 eyes (right = 11, left = 8). The most common presenting feature was acquired ptosis. Eyelid was the most commonly affected site followed by orbit and conjunctiva. Two patients had systemic involvement in the form of multiple myeloma and lymphoplasmacytic lymphoma. Complete excision was done in seven (26.9%) cases while 19 (73.1%) cases underwent debulking. Three patients underwent ptosis surgery. The median duration of follow-up was 1.5 years. Three cases had recurrence and underwent repeat surgery.

Conclusion:

Orbit and adnexa is a rare site for amyloidosis. It is usually localized; however it can occur as a part of systemic amyloidosis. Eyelid is the most common site of involvement and patients usually present as eyelid mass or ptosis. Complete excision is difficult and most of the patients usually undergo debulking surgery. All patients should undergo screening for systemic amyloidosis

Outcomes of canaliculotomy in recalcitrant canaliculitis

Purpose

To evaluate outcomes of canaliculotomy in cases of recalcitrant canaliculitis.

Methods

All cases diagnosed with canaliculitis who subsequently underwent canaliculotomy over a 15 year period were included in the study. We reviewed and analyzed demographic data, clinical presentation, microbiological profile and management outcomes.

Results

Out of 40 patients, 21 (52.5%) were males. Age range was 17–89 years. Lower canaliculus was affected most commonly (53.81%). Mean duration of symptoms was 8 months (range- 0.5–60 months, median 6 months). The most common presenting symptom was watering (34, 85%) while pouting puncta (32, 80%) was the most frequently documented clinical sign. Concretions were seen in 20 (50%) patients and Actinomyces was the most commonly isolated micro organism in the concretion group. Polymicrobial growth was seen in 18 (45%) patients. Commonly isolated bacteria on culture were Staphylococcus epidermidis (16, 40%) followed by Actinomyces (14, 34%) and Corynebacterium species (5, 12.5%). Complete resolution was seen in 39 cases post-operatively (97.5%, p = 0.0002). Mean follow up period was 21 months (range- 3–180 months).

Recurrence was noted in 6(15%) cases, of which 4 were males (66.67%, p = 0.069) Four (66.67%, p = 0.069) patients had associated diabetes and 5 (83.33%, p = 0.046) had associated concretions. Six (15%) patients complained of persistent epiphora.

Conclusion

Canaliculotomy is a safe and effective method for management of recalcitrant canaliculitis with a success rate of 85%. Presence of concretions was associated with higher risk of recurrence in our study.

Effect of dietary supplementation of organic chromium on performance, carcass traits, oxidative parameters, and immune responses in commercial broiler chickens

An experiment was conducted to study effect of supplementing graded concentrations (0, 100, 200, 300, or 400 μg/kg diet) of organic chromium (Cr) on performance, carcass traits, oxidative stress, and immune responses in commercial broiler chickens reared in open-sided poultry house under tropical climatic conditions. Each diet was fed ad libitum to eight replicates consisting of six birds in each pen from 1 to 42 days of age. Body mass gain and feed efficiency at 21 and 42 days of age and relative mass of liver, abdominal fat, and ready to cook yields at 42 days of age were not affected (P > 0.05) by supplementing organic Cr in broiler diet. Body mass loss during pre-slaughter holding period (12 h) reduced and relative breast mass increased nonlinearly (P < 0.01) with concentration of Cr in diet. Lipid peroxidation decreased, while activities of glutathione peroxidase and glutathione reductase in plasma increased nonlinearly with Cr supplementation. The ratio between heterophyl and lymphocyte was not affected (P > 0.05) with Cr supplementation in broiler diet. Relative mass of lymphoid organs (bursa, spleen, and thymus) and antibody production to Newcastle disease vaccination were not affected (P > 0.05) by the treatments employed. The cell-mediated immunity (lymphocyte proliferation ratio) increased nonlinearly with dietary Cr concentration. The results of the present study indicated that supplementation of organic Cr did not influence body mass and feed efficiency. However, supplementation of the Cr reduced pre-slaughter holding losses, increased the relative mass of breast, and increased antioxidant status and lymphocyte proliferation in broilers reared in tropics.

Effect of dietary α -tocopherol concentration on performance and some immune responses in broiler chickens fed on diets containing oils from different sources

1. An investigation was carried out into the effects of dietary α-tocopherol (α-T) concentration and source of supplemental oil on performance, activity of anti-oxidative enzymes and some immune responses in broilers from day-old to 41 d of age. 2. Three dietary concentrations of α-T (10, 50 and 100 mg/kg) with three sources of supplemental oil (sunflower - SFO, palm - PMO and safflower - SAO) were provided using a 3 × 3 experimental design. 3. Body weight gain and food conversion efficiency were not affected by either interaction or concentrations of α-T and sources of oil in diet. 4. Concentrations of total protein, globulin, triglycerides and cholesterol in sera increased significantly with dietary α-T concentration irrespective of the source of oil. Significantly higher concentration of serum albumin was evident in broilers fed on the SFO-based diet and the concentration of globulin was higher in groups fed on those diets containing PMO and SAO. 5. The lipid peroxidation (LP), measured as MDA release, decreased with the concentration of α-T in a dose-related manner with SFO- and SAO-based diets, although not with the PMO-based diet. With different oil sources, LP was significantly lower with the PMO-based diet compared to the others. Activities of glutathione peroxidase and RBC catalase increased and heterophil: lymphocyte ratio was reduced with concentration of α-T for each source of oil tested. 6. Assays for humoral and cell-mediated immune responses indicated no effect of the source of dietary supplemental oil or interaction, although an increasing concentration of dietary α-T improved cell-mediated immune responses. 7. It is concluded that sunflower oil, palm oil and safflower oil can be used as sources of oil for broiler diets without having any effect on performance, immune responses or the activity of anti-oxidizing enzymes. Higher concentrations of dietary α-tocopherol (50 or 100 mg/kg) reduced lipid peroxidation activity and enhanced activities of anti-oxidative enzymes, they also improved the cell-mediated immune responses in commercial broilers.