Figure 1: Clinical photograph showing frontal bossing and mutiple milia on forehead; Figure 2: Broad nasal root, linear ulcerated pigmented lesion on lower lid of right eye; Figure 3: Multiple pigmented lesions on face and neck; Figure 4: Clinical picture showing multiple palmer pits; Figure 5 (a,b,c): Hughes tarsoconjuctival bridge flap procedure with post auricular skin grafting (stage 1); Figure 5 (d): Clinical photograph after division of tarsoconjunctival flap (stage 2); Figure 6: Histopathological picture showing features of basal cell carcinoma. (Thin arrow-basaloid cells, thick arrow-palisading)

The purpose of this study is to study the operative difficulties and success rate of transcanalicular laser-assisted endoscopic dacryocystorhinostomy in patients of chronic dacryocystitis with deviated nasal septum (DNS). A prospective interventional clinical study of 36 consecutive patients suffering from chronic dacryocystitis with nasolacrimal duct obstruction with DNS undergoing primary TCLADCR from March to June 2011 was carried out. Diode laser was used to create a 16-mm(2) ostium which was enlarged to 64 mm(2) using Blakesley's forceps. Success was defined as anatomical patency and absence of symptoms at 12 months of follow-up. Out of the 36 patients, 25 were females with ages 20-72 years, and 19 were left sided. There were 12 high, 12 mid and 12 basal DNS towards the side of surgery, mild to moderate in severity. Intraoperatively there was difficulty in visualising the aiming beam in the nose, tedious manipulation of endoscope and excessive bleeding in 3 patients. Increased bleeding and failures were significantly higher in high DNS (Fisher exact test-2 tailed: 0.0045). The procedure was successful in 94.4 % cases with average ostium size of 21.94 mm(2) at 12 months and no statistically significant difference in success rates between mild and moderate DNS (Fisher exact test-2 tailed: 1.000). Also there was no difference in the complication rate between mild and moderate DNS (Fisher exact test-2 tailed: 0.0841). TCLADCR is an effective procedure in patients with mild to moderate mid and basal DNS and obviates the need for multiple procedures and a cutaneous scar.

To evaluate the effects and side-effects of serial sub-conjunctival injections of 5-fluorouracil (5-FU) in early postoperative period for recurrent anophthalmic contracted socket.

ObjectiveTo evaluate the efficacy and complications of lower eyelid suspension with the modified Safdarjung hospital technique using 5:0 polypropylene suture for punctal ectropion.Study designProspective case series.MethodThirty one eyelids in 19 patients with mild and moderate ectropion and all types of laxity including involutional and paralytic were included. All patients underwent lower eyelid suspension with the modified Safdarjung hospital technique. A 5:0 polypropylene suture was passed in the pre-tarsal plane between the attachments of the lateral and medial canthal tendons near their insertion at the orbital rim. Successful outcome was judged by the anatomical restoration of the apposition of the punctum to the globe in the upward gaze and the physiological relief of epiphora. The recurrence of lid laxity, overall lid/globe apposition and complications were also noted.ResultsAt 1 year follow up anatomical success was achieved in 28 (90%) patients and functional success noted in 27 (87%) patients. Recurrence of lid laxity was noted in 2 patients. There was a suture exposure in one case and a suture granuloma in another case. The results did not correlate to the degree of ectropion and type of laxity.ConclusionLower eyelid suspension using 5:0 polypropylene suture is a useful procedure for the treatment of involutional and paralytic punctal ectropion. It is simple and effective with minimal complications. However, the effect on scleral show and the concern related to suture material biodegradation over years needs to be further evaluated.

Amyloidosis and its ophthalmic manifestations are rare. The unusual presentation can result in diagnostic delay and increase ocular morbidity. Additionally, there are various predisposing conditions and systemic involvement can affect various organs. Hence, localized disease warrants a thorough clinical evaluation and laboratory investigation. We report two cases of primary localized amyloidosis presenting as a tarsal mass and ptosis. The diagnosis was established on histopathology. There were no predisposing conditions and no systemic involvement. The disease was probably related to the local immunocyte disorder.

Purpose. To compare the feasibility of cataract surgery with implantation of endocapsular supporting devices and intraocular lens (IOL) in subluxated cataract in phacoemulsification and manual small incision cataract surgery (MSICS). Design. Prospective randomized intervention case series consisting of 60 eyes with visually significant subluxated cataract. Method. The patients were randomly distributed between the two groups equally. The main outcome measure was implantation of in-the-bag IOL, requirement of additional procedure and complications, if any. Results. Capsular bag retention in subluxated lenses is possible in 90% cases in phacoemulsification versus 76.67% cases in MSICS (P = 0.16). Both groups, achieved similar best corrected visual acuity (P = 0.73), although additional procedures, intraoperative, and postoperative complications were more common in MSICS. Conclusions. Achieving intact capsulorhexis and nuclear rotation in MSICS may be difficult in cases with large nucleus size and severe subluxation, but subluxated cataracts can be effectively managed by both phacoemuslification and MSICS.

A 45 year old female presented with painless swelling over the inner side of both eyes since one year. Magnetic resonance imaging (MRI) scan revealed well defined lesions in the bilateral lacrimal sac area with extension along the naso-lacrimal duct. Systemic work up showed polyclonal hyperglobulinemia, raised erythrocyte sedimentation rate (ESR) and anemia. The patient also had subcutaneous swelling in thoracic area over back. The histopathology of the bilateral excised tumor and fine needle aspiration cytology of thoracic swelling was consistent with features of Rosai-Dorfman syndrome.

Thyroid associated orbitopathy/ophthalmopathy is an autoimmune disorder. It is most prevalent among females and is usually associated with thyroid dysfunction. Clinical manifestations include soft tissue signs, lid retraction, lid lag, proptosis, restrictive myopathy, corneal exposure and optic neuropathy. Thyroid function tests, thyroid antibodies and imaging to demonstrate extraocular muscle enlargement aid diagnosis. Treatment involves correction of thyroid dysfunction, supportive therapy, immunosuppression for moderate to severe active disease and orbital decompression surgery.

We read with great interest the article by Cetinkaya and Kersten1Cetinkaya A. Kersten R.C. Surgical outcomes in patients with bilateral ptosis and Hering's dependence.Ophthalmology. 2012; 119: 376-381Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar entitled, “Surgical outcomes in patients with bilateral ptosis and Hering's dependence.” The authors concluded that bilateral ptosis cases with documented Hering's dependency yield better results when both eyes are operated in the same session, rather than delaying surgery for the second eyelid. After careful reading of the article, we would like to offer some suggestions regarding the methodology and interpretation/statistical analysis of the data. A key flaw in the methodology stems from the study being retrospective. Exclusion of brow ptosis is necessary but was not mentioned in the study. Data regarding the side of ocular dominance and greater ptosis in not available and this could affect the study groups. As reported by Lyon et al,2Lyon D.B. Gonnering R.S. Dortzbach R.K. Lemke B.N. Unilateral ptosis and eye dominance.Ophthal Plast Reconstr Surg. 1993; 9: 237-240Crossref PubMed Scopus (27) Google Scholar the contralateral lid droop is significantly more common when ptosis is greater in the dominant eye, suggesting that the levator tone is influenced by eye dominance when ptosis was present. This means that if more ptotic eye is dominant there will be significant droop of the less ptotic eye and such a patient is likely to be included in Hering's dependency group. But if more ptotic eye is nondominant, the drooping of the contralateral eyelid may not be significant, and such a patient is likely to be included in control group (without Hering's dependence). Hence, without documentation of ocular dominance, the patient can be inappropriately labelled as Hering's dependent or nondependent. In addition to the documentation of the side of initial operation in the sequential group, the authors should also have noted that whether the more ptotic lid was operated first or not. In the present study, the postoperative asymmetry in simultaneous group was better as compared with sequential group. Simultaneous surgeries in 139 patients yielded 8 postoperative asymmetric results (5.8%), compared with 17 (22.1%) of 77 cases in the sequential surgery group (P = 0.001). We believe that during simultaneous surgery, since both the lids are under local anaesthetic (lidocaine and epinephrine) effect, there will be abolition of Hering's effect, as well as paralysis of orbicularis and stimulation of Muller's muscle. Also the amount of edema in 2 lids will be similar while the adjustment of lid height is carried out. Hence, there may be more chance for better symmetry between the 2 lids. The statistical analysis (23.4% vs 8.4%; P = 0.011) of the postoperative asymmetry rate in sequential surgeries between the Hering's dependence and control group is misleading. As the randomization was based on patient's preference to undergo simultaneous or sequential surgeries, there were very few patients in the control group for sequential surgery. Hence, the authors compared the sequential surgeries in Hering's group with all the surgeries in control group citing that the 2 subgroups of control patients were statistically similar. But this is inappropriate because even the 2 subgroups of the control group should not be compared because of very few patients in sequential subgroup. On further statistical analysis, the postoperative asymmetry in simultaneous group between Hering's dependent and the control group is statistically insignificant (2.2% vs 7.4%, P = 0.40). Also, the postoperative asymmetry in all cases between Hering's dependent and the control group is statistically insignificant (14.6% vs 8.4%, P = 0.22). Therefore, properly to comment upon the difference between the sequential surgeries in 2 groups, the study is lacking appropriate number of patients. We believe that during simultaneous surgery, since both the lids are under the effect of anesthetic, the role of ocular dominance and Hering's dependence is unlikely. This helps to provide better lid height adjustment and symmetry subsequently. However, with the sequential surgery their role becomes much more significant. Nevertheless, this series provides useful insights in evaluating the role of Hering's dependency and laterality of surgery in cases of bilateral acquired ptosis. Further confirmation of study findings by prospective series is required. Surgical Outcomes in Patients with Bilateral Ptosis and Hering's DependenceOphthalmologyVol. 119Issue 2PreviewTo assess whether sequential or simultaneous ptosis repair yields a better postoperative outcome in patients with documented preoperative Hering's dependency. Full-Text PDF Author replyOphthalmologyVol. 119Issue 6PreviewWe thank Kamal et al for their interest and comments on our paper. The authors state that in our study the higher success of simultaneous eyelid surgery actually depends on the abolition of Hering's effect due to local anesthesia effect and list some flaws in methodology mainly related with the retrospective nature of the study. However, we would kindly disagree with them on the many of the points they discussed. Full-Text PDF

Duane's retraction syndrome is a congenital form of strabismus characterized by horizonatal eye movement limitation, globe retraction and palpebral fissure narrowing in attempted adduction. The syndrome is classified in three types based on the presence of defect in adduction, abduction or both. Numerous theories concerning the etiology and pathogenesis of DRS have been proposed including agenesis of the abducens nucleus, but the majority of investigators concur that the characteristic findings are best explained by a paradoxical innervation of the lateral rectus muscle, which subsequently causes a cocontraction of the horizontal rectus muscles. When required, surgical procedure are used to improve the primary gaze alignment, face turn and postural position.

Ophthalmomyiasis is a rare infection seen in susceptible individuals. We report a case of orbital myiasis in squamous cell carcinoma (SCC) in a patient of xeroderma pigmentosum. On presentation, reddish brown ulcerated mass with numerous maggots in orbit were seen. Computed tomography scan showed the presence of soft tissue lesion without any bony destruction. Following debridement, emergency exenteration with sacrifice of eyelid skin was performed. The diagnosis of SCC was confirmed on histopathologic evaluation. The maggots belonged to family Calliphoridae and secondary bacterial infection with Klebsiella organism was identified. Management issues included extensive involvement requiring exenteration, non-availability of skin graft, delayed secondary healing and recurrence of pigmented lesions in skin lining of orbit. The skin grafting was avoided as it can harbour the neoplasm.

The field of soft tissue augmentation has had a rapid growth over the past several years, mainly due to the development of fillers which are now routinely utilized for rejuvenation of the skin. Understanding the different characteristics, capabilities, risks, and limitations of the available dermal and subdermal fillers can help physicians improve patient outcomes and reduce the risk of complications. The longer lasting, less immunogenic and more convenient hyaluronic acid fillers have now become the gold standard.

Symptomatic epiphora due to nasolacrimal duct obstruction (NLDO) is a common disorder and external dacryocystorhinostomy (DCR) is still considered the gold standard for its treatment. But with minimally invasive scar less surgery becoming the demand of the modern day ophthalmic surgery, there has been a renewed interest in the development of endoscopic technology. The transnasal approach to DCR was initially described a century ago. A rekindling of interest in this route led to the use of lasers in DCR. In this article we made an attempt to highlight the contemporary technigues of endoscope assisted DCR, theiradvantages, disadvantages & complications.

Glaucoma is seen in about 20% of the patients with uveitis. Anterior uveitis may be acute, subacute, or chronic. The mechanisms by which iridocyclitis leads to obstruction of aqueous outflow include acute, usually reversible forms (e.g., accumulation of inflammatory elements in the intertrabecular spaces, edema of the trabecular lamellae, or angle closure due to ciliary body swelling) and chronic forms (e.g., scar formation or membrane overgrowth in the anterior chamber angle). Careful history and follow-up helps distinguish steroid-induced glaucoma from uveitic glaucoma. Treatment of combined iridocyclitis and glaucoma involves steroidal and nonsteroidal antiinflammatory agents and antiglaucoma drugs. However, glaucoma drugs can often have an unpredictable effect on intraocular pressure (IOP) in the setting of uveitis. Surgical intervention is required in case of medical failure. METHOD OF LITERATURE SEARCH: Literature on the Medline database was searched using the PubMed interface.

Symptomatic epiphora due to nasolacrimal duct obstruction (NLDO) is a common disorder and external dacryocystorhinostomy (DCR) is still considered the gold standard for its treatment. But with minimally invasive scar less surgery becoming the demand of the modern day ophthalmic surgery, there has been a renewed interest in the development of endoscopic technology. The transnasal approach to DCR was initially described a century ago. A rekindling of interest in this route led to the use of lasers in DCR. In this article we made an attempt to highlight the contemporary technigues of endoscope assisted DCR, theiradvantages, disadvantages & complications.

INTRODUCTION:The lens coloboma results from a segmental defective or absent development of the zonules. It is usually unilateral and bilateral cases are rare. These eyes are at greater risk of complications during cataract surgery due to ocular malformations. In addition the capsular bag requires stabilization using modified capsule tension ring, capsular tension segment or capsular anchor.METHODS:Lens extraction is indicated for cataract or subluxation if visual function is sufficiently compromised. We report our surgical experience in a patient with bilateral isolated lens coloboma by performing manual small incision cataract surgery (MSICS) in left eye and phacoemulsification in right eye.RESULTS:The nuclear rotation was hampered because of the lack of zonules and presence of lens coloboma. MSICS was converted to the intracapsular technique in left eye, though breaking the nucleus into pieces during phacoemulsification in right eye enabled its mobilization and successful completion with implantation of modified capsule tension ring.CONCLUSIONS:A patient with lens subluxation and lens coloboma is better managed by phacoemulsification as compared to the MSICS.