Orbit/ Oculoplasty Free Papers - AIOS · PDF fileDr. Mukesh Sharma, ... fat prolapse, upper lid crease height and contour, excessive lid skin, lid margin ... Orbit / Oculoplasty Free

Orbit/ OculoplastyFree Papers

Contents

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ORBIT / OCULOPLASTY - ISimultaneous Upper and Lower Lid Blepharoplasty with Internal Browpexy in East Indian Eyelids .......................................................................................720Dr. (Mrs) Kasturi Bhattacharjee, Dr. Nilutparna Deori

Orbital Echinococcosis: A rare Case Report ...............................................722 Dr. Jayashree Dora, Dr. Prangya Panda, Dr. Gayatri Rath, Dr. Jogendra Prasad Behera

A Study of Clinical Profile and Management of Orbital Foreign Bodies ....725Dr. (Col) Vinod Kumar Baranwal, Dr. (Col) Rajendra Prasad Gupta, Dr. (Brig) TS Ahluwalia, Dr. (Brig) J.K.S. Parihar

Evaluation of Diagnostic Validity of Computed Tomography (CT) in Orbital Lesions ...............................................................................................................728Dr. Ruchi Kabra, Dr. Sanil Shah, Dr. Deepak C. Mehta

Orbital Dermoids; Clinical Manifestations and Outcomes ..........................731Dr. Tarjani V. Dave, Dr. Mohd. Javed Ali, Dr. Milind Naik, Dr. Santosh G. Honavar

Eyelid Retraction: Results with Our Technique of Scleral Graft Interposition .............................................................................................................................735 Dr. Sridevi Gunda, Dr. Subhashis Mukherjee, Dr. Usha Kim

Periorbital Biometric Measurements: Standardi-zation of Measurement and Assessment of Intra and Inter-observer Variability using Image J ............738Dr. Rajyalakshmi R, Dr. Milind Naik, Dr. Winston Prakash, Dr. Santosh G Honavar

Orbital tumors and Orbitotomy: The Effect on Extraocular Motility and Diplopia .............................................................................................................. 741Dr. Digvijay Singh, Dr. Neelam Pushker, Dr. Rohit Saxena, Dr. Supriyo Ghose

Retroplacement and Shortening of MPL for Correction of Telecanthus in Blepharophimosis Syndrome (BPS) ..............................................................744 Dr. V. P. Gupta

Orbital Floor Fracture Repair: A 5 Years Retrospective Study ...................748Dr. Rituraj Baruah, Dr. Ashok Kumar Grover, Dr. Shaloo Bageja

ORBIT / OCULOPLASTY - IIOrbital Decompression Via A Modified Transconjunctival Swinging Eyelid Approach in Graves’ Ophthalmopathy ...........................................................750Dr. Shaloo Bageja, Dr. Ashok Kumar Grover

Evisceration with Primary Orbital Implant in Endophthalmitis/Panophthalmitis – Should It Be Done? ..........................................................752 Dr. Devjyoti Tripathy, Dr. Suryasnata Rath

70th AIOC Proceedings, Cochin 2012

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A Case of Burkitts Lymphoma Masquerading as Ptosis and Eoms Palsy.. ..755Dr. Jayesh B Patil, Dr. Chhaya Ashok Shinde, Dr. (Mrs.) Potdar Nayana Anil, Dr. Piyush Jain

Evaluation of Retinal Nerve Fibre Layer Thickness Using Optical Coherence Tomography In Thyroid Ophthalmopathy Patients.......................................758Dr. Apjit Kaur, Dr. Neha Sinha, Dr. Sandeep Saxena

CSF Leak, A Landmine in Orbital Surgeries ..................................................761Dr. Apjit Kaur, Dr. Neha Sinha

There is Lot of Work for Oculoplasty Surgeons ...........................................764Dr. Ather Mohammed, Dr. V. Naga Suresh, Dr. G. Narendranath Reddy, Dr. K. Bharani Kumar Reddy

Bilateral Lacrimal Gland Amyloidosis ............................................................765 Dr. Manjoo S. Reddy, Dr. Andrew Vasnaik, Dr. Yamini Priya, Dr. Raghavendra

Foam Sclerotherapy for The Periocular Vascular Malformations-Our Experience .........................................................................................................768Dr. Mukesh Sharma, Dr. Rajesh Goyal, Dr. Neha Mohan, Dr. Nupur Goel


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Simultaneous Upper and Lower Lid Blepharoplasty with Internal Browpexy in East Indian EyelidsDr. (Mrs) Kasturi Bhattacharjee, Dr. Nilutparna Deori

Improvisation in the aesthetic appearance of the ageing face has been documented since early human civilization. The lid- eyebrow region

forms the emotional and expressive centre of the human face. Loss of skin tone and muscle laxity around the eyes manifests as hooding of the upper eyelids, wrinkles, brow ptosis, fat prolapse, lusterless skin etc. in the ageing face. Implications of blepharoplasty in these patients is therefore two-fold: functional as well as cosmetic.

However, in the North-eastern part of the country, the anatomical characteristic of the eyelid shows a more Asian lid configuration with single lid crease and descent of juxtabrow lateral tissue. Therefore, the aim of the surgical procedure was to create a symmetrical and aesthetically pleasing lid crease and brow contour in these patients by combining upper and lower lid blepharoplasty with internal browpexy.

MATERIALS And METhOdSStudy : Prospective hospital-based study of 22 consecutive patients.

Duration : January 2007 to December 2009

Inclusion criteria: Patients with characteristic Asian lid configuration having single lid fold and descent of juxtabrow lateral tissue

Exclusion criteria: Patients with intraocular and adnexal disease or tumor, propensity for keloid formation.

Pre-operative evaluation: complete ophthalmologic (BCVA, corneal status, dry eye, allergic reaction, extraocular eye movement, glaucoma, trauma, infection etc.) and medical examination (use of anti-coagulants, bleeding time and clotting time, infectious diseases, drug reaction, propensity for formation of hypertrophied scar or keloid etc.).

Pre-operative patient counselling was mandatory in all cases.

Upper lid assessment (in sitting position): amount of brow ptosis, amount of fat prolapse, upper lid crease height and contour, excessive lid skin, lid margin position, ptosis evaluation if present, dermatochalasis/ blepharochalasis.

ORBIT / OCULOPLASTY - IChairman: Dr. Bajaj M.S.: Co-Chairman: Dr. Bipasha Mukherjee Convenor: Dr. Debraj Shome; Moderator: Dr. Mukesh Sharma

Orbit / Oculoplasty Free Papers

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Lower lid assessment (in sitting position): fat herniation on upgaze, sclera show, snap back test, lid tumor, pigmentation or previous scar, assessment of periorbital area.

Assessment of brow ptosis (in sitting position): descent of the juxtabrow in relation to the superior orbital rim.

Anaesthesia: surgery was performed under monitored local anaesthesia along with some amount of tumescent fluid infiltration. Adrenaline was avoided in hypertensive patients and some amount of sedation was administered in anxious and apprehensive patients.

Upper lid blepharoplasty: the surgical procedure was tailored according to the height and contour of the lid crease, amount of excess skin and amount of fat herniation. The markings were done pre-operatively with the patient in the sitting position in primary gaze. Central portion of the upper lid was marked 8.5 to 10mm above the lashes which was then extended 5mm medially and 6mm laterally, respectively. The crease marking was fashioned to converge medially in a nasally tapered crease and kept parallel in a parallel crease. By everting the tarsus, central height of the tarsus was measured. Upper lid crease was measured and considered as the lower incisional marking. The amount of skin resection was quantified according to the desired elevation and post-operative facial symmetry. Bunching of the loose skin at the lateral 1/3rd was done with plain forceps. After the eyebrow and upperlid was infiltrated with local anaesthesia and tumescent fliud, skin incision was made in a trapezoidal approach with a no. 15 Bard-Parker blade. The orbital septum was then reached by transecting through the orbicularis layer. On opening up the orbital septum, the preaponeurotic fat pad was exposed and the excess fat removed in a controlled and uniform fashion with a bipolar wetfield cautery and Westcott scissors. Care was exercised not to injure the superior oblique tendon while removing the medial fat pad. Any prolapse of the lacrimal gland was repositioned with a 5-0 vicryl. Finally, the myocutaneous flap was trimmed and apposed through the lower incision line, along the superior tarsal border. The skin incision was then closed with 6-0 prolene suture.

Internal Browpexy: prior to closure of the upper blepharoplasty incision, blunt dissection was extended in an equidepth fashion along the submuscular plane towards the lateral aspect of the eyebrow above the superior orbital rim. Excess amount of ROOF was excised and 4-0 vicryl suture used to anchor the sub-brow tissue to the periosteum. In cases of excessive laxity of sub-muscular tissue, the excess lax tissue was excised and the lower end of the cut portion was mobilized to a higher plane along the orbital rim.

Transconjunctival Lower lid blepharoplasty: Following local anaesthetic and tumescent fluid infiltration, a conjunctival incision was made 4mm below


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the tarsus; a retroseptal approach helped in easy identification of the fat pads. The lateral fat pad is deeply seated and covered with more septa, therefore a blunt dissection down to the arcus marginalis at the inferolateral orbital rim was done. Belly of the inferior oblique muscle separates the central and medial fat compartment, therefore careful fat isolation, beginning with the central fat pad was done. Hemostasis was achieved with bipolar cautery throughout the procedure. End point of fat excision was reached when the fat was flush with the orbital rim while applying light pressure on the globe. A check on the external eyelid contour was kept intermittently throughout the entire procedure. Subperiosteal repositioning of the fat over the inferior orbital rim onto the superior face of the maxilla was then done to overcome the tear trough deformity which rendered a more aesthetic appearance. Conjunctiva was closed with 6-0 vicryl suture.

RESULTSSurgery was done in 44 upper and 44 lower eyelids of 22 consecutive patients.

Age range was 54 to 61 years with a mean age of 58 years; SD of 8.2. There were 17 females and 5 males.

Postoperatively, 1.76% had lower lid ectropion and scleral show. This was attributable to middle lamellar cicatrix following the transcutaneous lower blepharoplasty approach. 4.5% had unwanted multiple upper lid folds because of partial correction of dermatochalasis which was done in order to prevent lagophthalmos. And 1 patient had bilateral hollow eyes due to over resection of the fat pads. 86.4% of patients were very satisfied with the functional and cosmetic outcome.

Follow up of the patients ranged from 1 to 3 years and all the patients demonstrated good aesthetic outcome uniformly.

In conclusion this surgical technique is simple and easily reproducible and is an attempt to harmonize three surgeries to give a natural-appearing aesthetic outcome to the patients.

Orbital Echinococcosis: A rare Case Report Dr. Jayashree Dora, Dr. Prangya Panda, Dr. Gayatri Rath, Dr. Jogendra Prasad Behera

ECHINOCOCCOSIS is a zoonotic disease caused by the larval stage of the cestode, genus Echinococcus. Four species are recognized within

the genus Echinococcus,: E granulosus that causes cystic echinococcosis, E multilocularis that causes alveolar echinococcosis, and E oligarthrus and


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E vogeli that cause polycystic echinococcosis The most common sites of infestation in humans are the liver and lung and less frequently the heart, spleen, kidney, brain, thyroid, bones and muscles. Orbital involvement may be seen in 1–2% of cases, Orbital echinococcosis predominantly is caused by E granulosus, which typically manifests as a unilocular cyst.

RESULTSA 30 yrs. male Presented with a massive painless proptosis with gradual loss of vision OD of 1 yr duration. Examination of OD revealed severe proptosis (down and out) of soft and pthisical, non tender globe with severe conjunctival chemosis, total corneal haze, restriction of ocular movements in all cardinal directions of gaze. A large nontender cystic mass was felt behind globe. OS was Normal with VA 6/6. Visual acuity in OD was No P.L. with this clinical picture, Diagnosis of PANOPHTHALMITIS came into mind. But as there was no pain/tenderness of globe and feeling of nontender cystic mass behind proptosed pthisic globe, diagnostic dilema arised. So CT scan of right orbit was done.

CT Scan of Right Orbit: A single hypo dense, unilocular,well-defined ,thin-walled, homogenous mass with hyperdense rim, pushing the globe. Which is presumptive of Hydatid cyst.

Haematological investigation showed no eosinophilia, ESR was 4 mm 1 hr. Abdominal ultrasound and CT Brain revealed no abnormality. Chest X-ray was Normal.

Surgical excision of the cyst was performed through transconjunctival route after enucleation of phthisical globe( OD). Cyst was ruptured in the middle of surgery. Ruptured cyst wall was excised completely, sent for Histopathological study. Albendazole was given for 4 weeks (30 mg/kg body wt). Postoperative period was uneventful, patient recovered completely.


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dISCUSSIOnOrbital echynococcosis usually present with slowly progressive and pain less proptosis; the globe is displaced according to cyst position In long-standing cases ocular structures may be completely destroyed. As seen in this case.The most common sites are intraconal and extraconal spaces but involvement of the extraocular muscles and ocular tissue are also seen. This case was an extraconal involvement.

Gross picture of mass H&E x 10X

H&E x 40X PAS Stain x 100 X

Microsection: An outer laminated periodic acid Schiff positive membrane and an inner membrane with numerous brood capsules and protoscolices attached to it.

OLM

Brood capsules

Protoscolices PAS +ve OLM


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A Study of Clinical Profile and Management of Orbital Foreign BodiesDr. (Col) Vinod Kumar Baranwal, Dr. (Col) Rajendra Prasad Gupta, Dr. (Brig) TS Ahluwalia, Dr. (Brig) J.K.S. Parihar

Eye injuries are a severe and common consequence of modern warfare and insurgency. Because of exposure of face in combat and the susceptibility

of orbit to small particles, orbital foreign bodies are common in war and insurgency areas. Penetrating orbital trauma due to missile injuries are potentially dangerous as the fragments often lie close to important structures. They may cause perforating or contusive injury to the eyes or violate the anterior and middle cranial fossa. In addition optic nerve, extraocular muscles, lacrimal system may also be involved. Computed Tomography is the single most informative diagnostic modality for investigation as it accurately localizes these foreign bodies and demonstrate the extent of associated injuries. Removal of these foreign bodies from the orbit is difficult and existing loss of function and potential for further damage from future reaction. This report details our experience of managing a large number of cases of orbital foreign bodies.

The diagnosis is mainly based on clinical grounds in a typically young patient living in an endemic area, but imaging techniques such as USG, CT scanning and MRI can aid in the diagnosis by demonstrating single or multiple cystic lesions with dense well-defined borders.

Treatment modalities include surgical excision and cryoextraction. Precaution-nary measures to tackle anaphylaxis should be kept ready as this has been reported in cases of intraoperative rupture of cyst (A common surgical complication, as happened in this case). In inoperable cases oral Albendazole is given for 4- 6 weeks.

In unilateral, massive, painless proptosis of long duration, Differential diagnosis of Hydatid Cyst should be kept in mind. In this case, If patient would have presented at an early stage, perhaps eye would have been salvaged.

REfEREnCES1. McMannus DP, Zhang W, Bartley PB. Echinococcosis. Lancet2003;362:1295–1304.2. Khuroo MS. Hydatid disease: current status and recent advances. Ann Saudi

Medicine 2002;22:56–64. 3. Abbas Bagheri, MD, Mohammad Reza Fallahi etal :Two Different Presentations of

Orbital Echinococcosis: A Report of Two Cases and Review of the Literature Orbit, 2010;29:51–6.


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MATERIALS And METhOdS129 cases of penetrating missile injuries to orbit reported to the authors during last 13 years in insurgency-hit parts of India and war torn Democratic republic of Congo in Africa forms the basis of this study. Fragments of improvised explosive devices, artillery shells, bullets and other sharp objects caused the injuries. They were evaluated clinically, plain X-ray and by CT (Computed Tomography) and managed. The patients often had multiple injuries and prioritization for treatment was done as per standard protocols.1,2 Neurological assessment was done as per Glasgow coma scale. Evaluation of visual function, ocular injury, extraocular muscles, lacrimal apparatus, optic nerve function was done. All patients were investigated by CT scan and treated as per the location and damage caused to eye and associated structures.

RESULTS129 patients reported with orbital foreign bodies during the 13 years period. Their mean age was 26 years (range 18-52 years). 120 patients were males and 9 females. Gun Shot wounds were seen in 12 patients (9.3%) and splinter injuries

Table 1: Region wise distribution of injuries Region Number of cases Head 62 Orbit 129 Facio-maxillary 27 Neck 26 Chest 18 Abdomen 12

Note: Most Patients had multiple injuries.

Table 2: Findings in Penetrating orbital injuries (n=129) Finding Number of patients 1. Penetrating ocular injuries 47 2. Associated intracranial fragment 06 3. Optic nerve transaction 02 4. Orbital fractures 37 5. Retrobulbar haemorrhages 05 6. Surgical emphysema 14 7. Lacrimal sac damage 11 8. No orbital / ocular damage 61 9. Infection 02

Note: Most Patients had multiple injuries.


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in 115 (89.1%). 2(1.6%) patients had bow and arrow injury. Associated injuries to head, limbs, abdomen or chest were present in 73 cases. One patient on X-ray revealed large intraorbital splinter causing irreparable damage to the globe. However, on evisceration splinter could not be felt. CT revealed deep-seated splinter partly in the orbit and partly intracranially. It was removed with the help of neurosurgeon. Two patients had complete loss of vision. CT revealed completely transected optic nerve. Five patients had retrobulbar haemorrhage due to splinter injuries. CT revealed retroorbital location of foreign bodies causing damage to orbital blood vessels. They were managed by lateral canthotomy. Splinter penetrating the orbit damaged the orbital walls in 37 cases. They were managed with the help of maxillo-facial surgeon. Lacrimal sac damage by splinter was caused in 11 cases. 81 cases revealed splinter though lying intraorbitally but not causing any problem. Splinters were removed in 21 cases lying superficially. In 68 cases, splinters lying deeply and not causing any problem were left. In 19 cases, only superficially lying splinters were removed while deep splinters, not causing any problem left. In 5 cases, splinter removal was tried but we failed to locate the foreign body. In 4 cases damage to blood vessels leading to bleeding and damage to levator occurred in 1 case.

dISCUSSIOnOrbital foreign bodies are encountered in modern war scenario. On occasion the orbital foreign body may be accompanied by simultaneous ocular, cranial or visceral injuries. Detailed clinical evaluation for cranial and ocular

Table 3: Treatment of orbital foreign bodies (n=129)1. (a) SURGICAL TREATMENT and SPLINTER REMOVAL ( n=59 ) - Ocular injuries 37 - Associated intracranial fragment 06 - Orbital fractures 27 - Lacrimal sac damage 11 - Retrobulbar haemorrhages 05 -Asymptomatic orbital splinter 21 (b) CONSERVATIVE TREATMENT (n=70) - Optic nerve transaction 02 - Asymptomatic deep orbital splinters 68

Table 4: Surgical complications (n=12) 1. Inability to locate foreign body 05 2. Blood vessel damage 04 3. LPS damage 01


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Evaluation of Diagnostic Validity of Computed Tomography (CT) in Orbital LesionsDr. Ruchi Kabra, Dr. Sanil Shah, Dr. Deepak C. Mehta

Orbital lesions are uncommon but extremely challenging problems for clinicians, radiologists and pathologists due to their critical location

and availability of limited diagnostic tools. Imaging techniques play a very important role in establishing the management protocol. Computed Tomography is often the first radiological investigation ordered for evaluation of orbital lesions3 probably due to its wider availability and comparatively lower cost. Keeping in mind the above background and the non availability of literature regarding validity of CT in orbital lesions, we were inspired to conduct this study.

MATERIALS And METhOdSA cross-sectional study was carried out in 122 patients having orbital lesions who attended our oculoplasty clinic from April 2008 to March 2011. CT scan was done in all patients. Diagnosis of 70 cases were confirmed by Biopsy or FNAC and in remaining 52 cases where HPE was not feasible or in lesions where biopsy could not be taken as in capillary haemangioma, orbital varices, chloroma, cysticercosis, orbital cellulitis, MRI, clinical features and treatment

involvement is of utmost importance. Computed Tomography is the single most informative diagnostic modality for investigating penetrating orbital injuries. It accurately localizes these foreign bodies, demonstrates the missile track and damage of vital structures. This preoperative information facilitates the critical decision making in management. Contrast enhanced studies are especially useful in cases where vascular injuries are suspected. CT scan assumes greater role in the evaluation of these cases as MRI is contraindicated in presence of metal projectiles.

An orbital foreign body can cause a variety of signs and symptoms related to the size, location, velocity and composition of foreign object. As most of the splinters are inert and sterile, they did not cause any infection and damage due to its mere presence in the orbit as seen in our series. Surgical complications in form of inability to localize the foreign body, damage to soft tissue, muscle damage etc. may occur in attempt to remove the splinters. Also metallic projectile are easy to detect but difficult to remove. In view of the above, it is recommended that the judgment to remove the foreign body should be made by balancing the risk from additional trauma with surgery against the existing loss of function and potential for further damage for future reaction.


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trial were taken as standard for comparison against CT diagnosis. Data was analyzed by applying various validity tests like sensitivity, specificity, positive predictive value, negative predictive value. Sensitivity measures the proportion of actual positives which are correctly identified as such.4 Specificity measures the proportion of persons without a disease who are correctly identified by a test.4 Negative predictive value measures probability that a patient with a negative test result really is free of the condition for which the test was conducted.5 Positive predictive value measures probability that a person with a positive test result has that the disease.5

True PositiveSensitivity = ---------------------------------------- x 100 True positive + false negative

True NegativeSpecificity = ---------------------------------------- x 100 True negative + false positive

Positive predictive value [PPV] = true positive x 100 True positive + false positive

Negative Predictive Value [NPV] = true negative x 100 True negative + false negative

CT- actual diagnosis correlation = Agreement between two groups divided by total no of patients.

RESULTSIn this study, all the subjects were between 1 to 70 years. The mean age was 23.57 years. Out of 122 patients, 58(47.54%) were males and 64(52.46%) were females. Out of total 122 patients [according to tissue diagnosis] maximum no of patients 63( 51.64%) were having inflammatory lesions followed by cystic 18(14.75%), vascular 16( 13.11%), malignant 16(13.11%) and neurogenic 9(7.38%). CT Scan provisional diagnosis was noted in each case and then validity tests were applied to calculate diagnostic accuracy of CT for broader pathological groups.

Table 1: Validity tests for various groups of orbital lesionsLesion Sensitivity Specificity PPV NPV CT-actual diagnosis correlationCystic lesion 83.33% 97.12% 83.33% 97.12% 66.67%Malignancy 75% 97.17% 80% 96.26% 68.75%Inflammatory lesion 96.83% 93.22% 93.85% 96.49% 85.71%Vascular lesion 87.50% 98.11% 87.50% 98.11% 62.50%Neurogenic lesions 77.78% 99.12% 87.50% 98.25% 77.78%


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dISCUSSIOnCT scan has highest sensitivity for inflammatory lesions(96.83%) and lowest for malignancies (75%), it suggests that it is most likely to identify most of the patients with inflammatory lesions.

CT has highest specificity for neurogenic lesions (99.12%) whereas it is lowest for inflammatory lesions (93.22%).

CT has highest positive predictive value for inflammatory lesions (93.85%) and lowest for malignancies, suggesting that for inflammatory lesions, a patient with a positive test result has 93.85% chances of having the pathology. CT has highest negative predictive value for neurogenic lesions (98.25%) and NPV is lowest for group -malignancy.

Hence, looking at the results we find that overall CT has reasonably high validity test values for all broader groups of pathology in the orbit. However tissue type diagnosis is not accurate with this imaging technique. This means that CT accurately identifies broader groups of pathology but it has lower CT- actual diagnosis correlation. It suggests that it often confuses between etiologies of same broad group for example CT often confuses lymphangioma with varices and capillary haemangioma. In a study done by Hu Yanhua et al they compared results of CT scan with HPE and found CT:histological correlation for inflammatory lesions to be 71.4%, for vascular lesions to be 82.6% and for dermoid to be 83.3%.

In conclusion it is essential to keep in mind the diagnostic accuracy of CT scan in orbital masses and about the common lesions confused by CT. A wrong presumptive diagnosis can lead to wrong treatment and wrong decision to operate in patients with inoperable conditions which may lead to intraoperative disasters. Our study suggested that overall Computerised Tomographic scanning in orbital lesions have reasonably high validity values for broader groups of pathology however, the tissue type diagnostic accuracy is unclear with this technique.

REfEREnCES1. Brijesh Kumar Gupta,PK Agarwal,J Agarwal, A-scan ultrasonography in orbital

lesions. Indian J Ophthalmol 1983;31(4):353-357. 2. M. Hansen-Knarhoi and M.D. Poole. Preoperative difficulties in differentiating

intraosseous meningiomas and fibrous dysplasia around the orbital apex. Journal of Cranio-Maxillofacial Surgery. 1994;22(4):226-30.

3. Mehran Midia, Zinat Miabi, Ramin Midia, Omid Mashrabi, Radiological evaluation of orbit tumors, Research J of Applied Sciences. 2007;2:998-1000.

4. Wikipedia –the free encyclopedia: http://en.wikipedia.org/wiki/Sensitivity_and_specificity.


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5. The free dictionary by farlex: http://medical-dictionary.thefreedictionary.com/positive + predictive+value.

6. Hu Yanhua, Wang Jie and Xiao Shiyi, Clinical and CT histological diagnosis of orbital tumors. 2000;20:82-5.

Orbital dermoids; Clinical Manifestations and OutcomesDr. Tarjani V. Dave, Dr. Mohd. Javed Ali, Dr. Milind Naik, Dr. Santosh G. Honavar

• Dermoid cyst is the most common space occupying orbital lesion of childhood that arises from congenital rests of epithelial and subepithelial tissues.1

• It is an epithelial-lined structure with dermal appendages in its wall and keratin and hair in its lumen (Fig-1).

• The most common location is superotemporally near the zygomaticofrontal suture (External Angular Dermoid). Dermoids can also be located near the Frontomaxillary suture (Internal Angular Dermoid)

• Orbital dermoid cysts have been classified into juxtasutural, sutural and soft tissue types.

• The characteristic clinical finding is of a slowly progressive, painless, subcutaneous mass near the lateral aspect of the eyebrow. It is firm on palpation, located deep to the dermis and usually fixed to the bone.

Figure 1: (a) H and E stained section of epithelial wall of the cyst showing brown colored hair shafts, (b) High magnification H and E stained section showing inflammatory cell infiltrate.

a b

Figure 2: Clinical and CT photo for internal angular dermoid.

Figure 3: Clinical and CT photo of external angular dermoid


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Deep orbital dermoid cysts are infrequently seen, less easily diagnosed and require more extensive surgery.

• An orbital dermoid cyst can sometimes assume a dumbbell configuration with part of the cyst in the orbit and part in the temporal fossa connected by a defect in the bone at the site of the zygomaticofrontal suture.

• Orbital dermoid cysts can leak material within the cyst or can rupture spontaneously, inciting an intense inflammatory response in the orbital soft tissues.

• On Computed tomography (CT) imaging it typically is well defined with an enhancing wall and a non enhancing lumen. The typical Hounsfield (HU) value for dermoids is around -80 HU (Fig 4a and b).

• The goal of treatment is complete excision of the cyst without disruption of the cyst wall as incomplete excision can cause recurrence. If the cyst is too large to remove intact its contents can be aspirated to facilitate removal. Anterior orbital cysts are best removed by the superior eyelid crease incision, while the deeper lesions may need lateral orbitotomy.

Purpose

• To describe the common and highlight the confounding clinical manifestations of orbital dermoid cysts

• To propose a management plan

MATERIALS And METhOdSRetrospective Interventional Clinico-Histolopathologic case series

• Included 110 consecutive patients (110 eyes) of orbital and periorbital dermoids at a tertiary care center in Southern India from January 1996 to Dec 2010

• Demographics, common and confounding clinical features, treatment and outcome were analyzed

Figure 4: (a) CT image showing a typical dermoid cyst with enhancing wall and non enhancing lumen, (b) CT image showing the a HU of -47

ba


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RESULTSDemographics

• Median age 8 years (Range 3 months – 51 years)

Presenting symptoms

• Painless subcutaneous mass 98 (89%)

• Pain 5 (0.5%)

• Diminished vision related to Dermoid cyst 3 (0.28%), (2 Dumbell and 1 Giant Orbital Dermoid)

Tumor location

• 78 Juxtasutural (71%) (Fig 5a).

• 19 Sutural (17%) (Fig 6a and b).

• 15 Soft tissue dermoids (14%) (Fig 7a and b).

Surgical approach

• 11 Deep Lateral orbitotomy

• 99 Anterior orbitotomy

• 49 sub-brow

• 40 Eyelid crease

• 11 modified Lynch

Rupture

• 31 Ruptured during excision (28%)

Recurrence

• 1 patient

Dumbell dermoids

• n=9

Figure 5: Clinical photo of a boy with juxtasutural dermoid; Excised dermoid of the same patient showing thinning of periosteum

Figure 6: (a) Clinical photo showing mild fullness in superotemporal quadrant of right eye; (b) axial CT showing a juxtasutural dermoid; (c & d) closer look at other scan sections of the same patient showing sutural extension

a

b

c

d

Figure 7: Clinical and CT photo of a patient with soft tissue dermoid


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• 6 excised in toto • Technique of excision: separate periosteum on either side, remove bone of

lateral orbital wall and deliver the tumor.• Frontal sinus dermoids• n = 3

Confounding presentations• 1 simulating neurilemmoma • 2 simulating lymphangioma • 1 simulating a frontal mucocele • 1 simulating a pleomorphic adenoma of the lacrimal gland • 2 simulating adenoid cystic carcinoma of lacrimal gland

Complications

• Discharging sinus n = 2

In conclusion:

• Dermoids can have myriad presentations

• Imaging should be considered when the posterior extent of the cyst is not palpable, its immobile or bony defect is palpable. Role of 3D CT reconstruction is justified in confounding presentations and in planning surgical management.

• Juxtasutural dermoids may have periosteal thinning at the posterior surface and this area should be excised last.

• For lesions with sutural extension, i.e. with limited mobility clinically or CT evidence of sutural extension, this area should be approached last during dissection to avoid rupture.

• Anterior orbitotomy suffices for most presentations, however deep lateral orbitotomy may be needed for giant orbital dermoids and dumbell dermoids.

• The limitation of our study includes its retrospective nature.

• We conclude that orbital dermoid cysts can have a plethora of confounding presentations, however a step-by-step approach to diagnosis and management would be appropriate in a confounding case of proptosis.

REfEREnCES1. Orbital Dermoid Cysts: Clinicopathologic Correlation, Classification and

Management. Shields JA, Kaden IH, Eagel RC, Shields CL. OPRS 1997;13:265-76.2. Orbital Dermoids in Children. Ahuja R, Azar NF. Seminars in Ophthalmology,

2006;21:207–11.


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Eyelid Retraction: Results with Our Technique of Scleral Graft Interposition Dr. Sridevi Gunda, Dr. Subhashis Mukherjee, Dr. Usha Kim

A prospective interventional non-comparative study to evaluate the surgical outcome of scleral spacer graft in eyelid retraction. To evaluate

the usefulness of this procedure to reduce corneal exposure keratitis and its sequelae in eyelid retraction.

MATERIALS And METhOdSRecords of 30 eyelids (6 upper and 24 lower) of 24 consecutive patients were evaluated, operated and prospectively reviewed from May 2008 to December 2009 at Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai in department of Orbit and Oculoplasty. Data regarding age, gender, condition (etiology), indication, visual acuity, slit-lamp findings, corneal exposure, examination in terms of palpebral fissure height (PFH), marginal reflex distance (MRD 1), lid retraction measured in terms of scleral show, lagophthalmos, Bell’s phenomenon, corneal sensation, surgeon and size of spacer were noted. Scleral spacer implantation for upper lid or lower lid was done as indicated. Post-operatively patients were followed up over a period of 1, 3, 6 months and assessed for PFH, MRD1, scleral show, residual lagophthalmos, corneal exposure and complications (if any). The final anatomic, functional and cosmetic result was evaluated. Upper lid correction was considered to be good if (1) the upper 1.5mm to 2.0 mm of the cornea at 12’O clock position was covered by the lid; (2) the lid margin contour was smooth; (3) the lid crease was within 7 to 10 mm of lid margin; (4) there was bilateral symmetry. An acceptable result was considered to be 1-2mm over or undercorrection or mild asymmetry. Lower lid correction was considered to be good if the lower lid margin touched the limbus at 6 O’clock position and the contour was smooth. When there was a gap between the lid and the limbus of not more than 1mm, it was considerd acceptable. Duration of the study was 18 months. Informed consent was obtained from the patient before including in the study.

Inclusion criteria: 1. Lagophthalmos in facial palsy 2. Lagophthalmos in grave’s orbitopathy, 3. Post enucleation socket syndrome

Exclusion criteria: 1. Acute onset facial nerve palsy 2. Chemical injury in acute cases 3. Cicatrising causes of ectropion such as Steven Johnson Syndrome, pemphigoid

Lagophthalmos Is measured as a distance(in mm) between upper lid margin and lower lid margin with eyes open and in primary gaze position and on attempted lid


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closure. In case of lower lid retraction, distance between upper lid margin and lower limbus in vertical pupillary plane is measured.

Surgical ProcedurePre-Medication

No premedication was used.

Preparation / Anaesthesia

The eye to be operated was painted with 10% povidone iodine solution and draped to expose the lids. All patients were operated under local anaesthesia with subcutaneous injection of 2% xylocaine with1 in100,000 adrenaline over the injection sites.

TechniqueScleral graft placement in upper eyelid: The scleral graft was placed from an anterior skin approach. The orbicularis muscle is dissected free from the anterior surface of the levator aponeurosis and the orbital septum. The levator aponeurosis and the Muller’s muscle are incised at the superior tarsal border. Muller’s muscle is then dissected along its posterior surface from the conjunctiva and the medial and lateral horns of LPS are transected. Care should be taken laterally to avoid lacrimal ductules. The dissection both anteriorly and posteriorly is continued until the tarsus is free from action of upper eyelid retractors (levator palpabrae aponeurosis, Muller’s muscle). A scleral graft is fashioned to be vertically wider in the lateral aspect than medially since usually the retraction is most marked laterally. Medially the vertical width of the graft is two times the amount of preoperative retraction, increasing to three times the amount of retraction laterally. This reduces the likelihood of temporal retraction.

The graft tapers to a point on each end. The superior edge of the graft is sutured to the recessed levator and Muller’s muscles with running 6-0 vicryl suture. The skin and orbicularis muscle are closed with eyelid crease sutures and running 8-0 vicryl. The contours of the eyelid margin, eyelid crease and eyelid height, are evaluated multiple times during the procedure and adjustments are made to the retractor dissection or scleral graft configuration as necessary. A firm dressing is applied.

Scleral graft placement in lower eyelid: Traction sutures are placed in the eyelid margin and the eyelid is everted over Desmarres retractor. An incision is made in the conjunctiva at the inferior tarsal border and extended medially and laterally. The conjunctiva is then dissected off the inferior tarsal muscle to the level of inferior fornix. An incision is made along the inferior tarsal border through the lower eyelid retractors (inferior tarsus muscle and capsulopalpebral fascia). These are dissected from the orbicularis muscle and


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the orbital septum until the movement of the eyelid margin on up and down gaze is minimal. A scleral graft is fashioned with a vertical width of two times the amount of lower eyelid retraction.

If there is more marked retraction laterally, the graft can be made correspondingly wider. The length of the graft is the same length as the incision, with the graft being tapered medially and laterally. The graft is sutured inferiorly to the edge of the retractors with a running 6-0 catgut suture. The superior edge of the graft and the conjunctiva are sutured to the inferior tarsal border with one running 6-0 catgut suture. The eyelid contour and height is checked during the procedure.

Donor ScleraSclera is harvested from the donor eyeballs available in the eye bank after processing. Post-operatively the following day assessment of lid contour, lagophthalmos and scleral show was done. Presence of complications like graft extrusion, wrinkling of the graft, softening of the graft, uncorrected retraction and eyelid thickening were carefully looked for and managed subsequently.

RESULTSScleral graft interposition gave good result in 2 of 6 (33%) cases of upper lid retraction. 4 of 6 cases (67%) gave acceptable results. In cases of lower lid retraction good results were achieved in 8 of 13(61%) cases and acceptable results in 4 of 13 (31%)cases. 1 of 13(8%) cases was considered as poor outcome.

The average age of patients undergoing scleral transplantation in our study was 24 and the age group ranged between 21-40 yrs.

Exposure keratopathy was assessed preoperatively by presence of fluoroscein positive punctate epitheliopathy. 27 of 27 eyes had exposure keratopathy which is why it was a surgical indication for spacer graft placement. By end of 3 months postoperatively, in 92.6% (i.e. 25 of 27) cases, punctate epitheliopathy resolved and subjective ocular discomfort was relieved.

In conclusion the use of sclera as spacer material in eyelid retraction has consistent and predictable results with minimal complications. It should be considered as procedure of choice for lower eyelid retraction as alternative approaches are limited. Eye bank sclera is an excellent spacer material as it is easily available, inexpensive, biocompatible with no donor site morbidity and restores lid height, contour, coaptibility and symmetry predictably and favourably. Our results of scleral spacer interposition in upper and lower eyelid retraction are comparable with other studies. Our study yields less acceptable results for upper lid retraction but satisfactory results for lower lid retraction. Hence we recommend sclera as spacer graft for lower eyelid retraction.


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Periorbital Biometric Measurements: Standardi-zation of Measurement and Assessment of Intra and Inter-observer Variability using Image JDr. Rajyalakshmi R, Dr. Milind Naik, Dr. Winston Prakash, Dr. Santosh G Honavar

Image J has been successfully used as a measurement tool in various subspecialties of medicine. There are limited reports of Image J for

periorbital and facial measurements. Though Image J provides an objective measure of periorbital biometry, its inter and intra-observer variability in the measurement of clinically significant periorbital parameters is not known. In this study, we aimed to determine the reliability and repeatability of periorbital biometric measurements using Image J, and assess if Horizontal Visible Iris Diameter (HVID) provides reliable measurement scale in the periorbital biometric measurements using Image J.

MATERIALS And METhOdSAim of the study

• To determine the intra-observer and inter-observer variability in periorbital biometric measurements using Image J

• To assess if corneal diameter can be reliably used as a reference for these measurements

Study design: Prospective single blind study.

Study centre: Ophthalmic Plastic Service, LV Prasad Eye Institute, Hyderabad, India.

Sample size: One hundred volunteer patients.

Inclusion criteria

• Age > 18 years

• Informed consent for photograph

• Subjects with normal anterior segment

• Refractive error ranging from +4D to -6D

Exclusion criteria

• Obvious facial asymmetry syndromes

• Trauma/prior orbital or maxillofacial surgery

• Contact lens wearers


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• Subjects using any topical medications that could affect lid height

• Poor quality photographs

The study was approved by the Institute Review Board and Ethics Committee. The study consisted of two components:

• Orbscan examination of the right eye was carried out by Bausch & Lomb Zyoptix OrbscanIIz Anterior Segment Analyzer. Five readings were taken, and the average HVID of the right eye was then calculated and entered in patient data sheet.

• Standardized face photographs of 100 consecutive subjects were taken in a standardized manner with a Nikon D2X Digital SLR Camera with indirect lighting from a distance of 45 cms. All the images were uniformly cropped to include Trichion to Menton vertically, and tragus to tragus horizontally. Image size was 6inches (height) by 4.5 inches (width), stored at 300 dpi in TIFF format.

All photographs were imported in Adobe Photoshop 7, magnified to 600x, and the centre of both the pupils were manually marked using the ‘pencil tool’ set at 1 pixel size. This was performed to enable all measurements along the mid-pupillary plane. The photographs were then opened in Image J. The photographs were magnified to 600x times for all the measurements. The average HVID (as measured by Orbscan) was taken as the reference measurement for the respective photograph. In each photograph, HVID was then manually marked using the line tool. The pixel length along the measured line was equated to the average HVID scale in millimeters. Once the scale was set, the following measurements were taken by two clinicians (MN and RR).• Vertical Palpebral fissure height• Horizontal Palpebral fissure height• Margin Reflex Distance 1• Margin Reflex Distance 2 • Medial Brow height• Central Brow height • Lateral Brow height • Lid fold height • Inter medial canthal distance • Inter-pupillary distance• Canthus to oral commisure distance

Measurements were performed twice, by each observer. First set of measurement used patient’s individual HVID as a scale for measurement.


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Second set of measurement was repeated using the average HVID of the population (11.34) as the measurement scale.

RESULTS• Total subjects: 111

• Excluded : 11

• Mean age : 25.6 yrs (Range: 18-78 yrs)

• Orbscan HVID: Avg 11.34 (Range: 10.7–12.7mm)

Intra class correlation coefficient (ICC) was >90 (intra and inter observer)

ICC was the lowest for Brow Height (79% and 86%)

Good test-retest reliability (>90%).

Test-retest reliability was lowest for Brow Height (66% and 77%).

In conclusion our prospective comparative study concluded that Periorbital biometric measurements using Image J are reproducible and repeatable. A good test-retest reliability for the intra-observer and inter-observer measurements (>90%) was found, except for medial brow height measurement. When mean HVID (11.34 mm) was used, all measurements showed good correlation, indicating that average HVID of the population as measured by Orbscan can be used as a reliable scale for facial measurements.

REfEREnCES1. Beard C. Examination of the ptosis patient. In: Ptosis. St Louis: Mosby 1981;3:76–83.2. Collin JRO. Ptosis. In: A manual of systematic eyelid surgery. London: Churchill

Livingstone, 1989;2:41–72.3. Douglas T. Edwards, MD, George B. Bartley, MD, et al. Eyelid Position Measurement

in Graves’Ophthalmopathy: Reliability of a Photographic Technique and Comparison with a Clinical Technique. Ophthalmology 2004;111:1029–34.

4. K Boboridis, A Assi, A Indar, et al. Repeatability and reproducibility of upper eyelid measurements. Br J Ophthalmol 2001;85:99–101.

5. Boboridis K, Assi A, Indar A, et al. Repeatability and reproducibility of upper eyelid measurements. Br J Ophthalmol 2001;85:99–101.

6. Wendy D. Wilson, MD, Amy S, et al. Sonographic Quantification of Ovarian Tumor Vascularity. J Ultrasound Med. 2006;25:1577–81.

7. Brian A. Irving, Judy Y. Weltman, David W. Brock, et al. NIH Image J and Slice-O-Matic Computed Tomography Imaging Software to Quantify Soft Tissue. Obesity. 2007;15:370-6.

8. R. Carmona, D.Mac´ias, J. A. Guadixa, et al. Simple technique of image analysis for specific nuclear immunolocalization of proteins. Journal of Microscopy. 2007;225: 96–9.


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9. Simon A. W. G. Dello, Ronald M. van Dam , Jules J. G. Slangen, et al. Volumetry Plug and Play: Do It Yourself with Image J. World J Surg. 2007;31:2215–21.

10. Ronald mancini,M.D., Mehryar Taban, M.D., Alan Lowinger, B.A., et al. Use of Hyaluronic Acid Gel in the management of paralytic lagophthalmos: The Hyaluronic acid gel “Gold Weight”. Ophthal Plast Reconstr Surg, Vol.25, No. 1, 200, pp. 23-26.

Orbital tumors and Orbitotomy: The Effect on Extraocular Motility and diplopiaDr. Digvijay Singh, Dr. Neelam Pushker, Dr. Rohit Saxena, Dr. Supriyo Ghose

Orbital tumors form up to a third of all the ocular tumors seen by an ophthalmologist.1 They could be primary or secondary, have varied

origin, may be located within the intraconal or extraconal space and be benign or malignant.2 The confined space in the orbit causes any space occupying lesion to have a direct or indirect impact on ocular motility. Diplopia is a likely complaint in this situation. In this study, we aimed to evaluate the effect of an orbital tumor on ocular motility and document any changes after orbitotomy surgery.

MATERIALS And METhOdSA prospective interventional comparative study was conducted at a tertiary care eye hospital after prior approval from the ethics committee. Patients with a well defined unilateral orbital tumor who later underwent surgical intervention were recruited. Exclusion criteria included those patients with best corrected visual acuity in either eye worse than 20/200, those aged below 5 years, patients who were uncooperative or unwilling for evaluation or follow up and those who had another associated ocular disease in either eye. All patients underwent an ocular examination with special focus on ocular motility and diplopia. The appropriate imaging was done for the type, extent and location of tumor mass. On the basis of location of the main tumor mass, tumors were divided into intraconal or extraconal. Surgical excision of the tumor was done and the patient followed up at 2 weeks, 1 month and 3 months postoperatively. Ocular motility defects were documented diagrammatically. Diplopia charting was done with the help of Red-Green glasses. The data was analysed with appropriate statistical tests comparing the preoperative and postoperative status of ocular motility and diplopia.

RESULTSTwenty eight patients were recruited with a mean age of 28 (±14.11) years and an equitable gender distribution. Proptosis and decrease of vision were the


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commonest presentation with the mean duration of symptoms being 2.8 years. The mean proptosis was 7.3 (±5.3) mm. The commonest tumors encountered were vascular in origin followed by lacrimal gland lesions (Table 1). There was an equal distribution (14/28) of intraconal and extraconal tumors.

20/28 patients had a limitation in their extra ocular motility in the affected eye which improved to 18/28 in the postoperative period. This improvement was not significant though (p=0.3, chi square test). Extra ocular motility limitation had a strong agreement with diplopia with 13 cases showing diplopia preoperatively and 5 cases showing suppression of the eye with tumor on diplopia charting. Post surgery, 10 cases continued to show diplopia while 5 cases of suppression persisted. This change was also not significant. (p>0.05, chi square).

dISCUSSIOnThe cases of orbital tumors recruited for this study may be considered as a representative sample from the expected distribution. The age distribution of our cases is similar to that in a previous study on orbital tumors from our centre.3 The frequency and distribution of tumor diagnosis in our series is in accordance to past studies which have also demonstrated a relatively higher frequency of vascular and lacrimal gland tumors among other operable orbital tumors.3-6 The age specific distribution of orbital tumors in our study is in agreement with current literature.5-8

Seventy one percent of our cases had an extra ocular motility limitation which did not significantly improve after surgery. This extra ocular motility limitation had been described previously by Golberg RA in 1990 who commented that diplopia and extra ocular motility limitation were common

Table 1: Table depicting the varied tumor diagnosisDiagnosis Number of CasesCavernous Hemangioma 10Dermoid 3Lymphangioma 3Pleomorphic adenoma 2Adenoid cystic carcinoma (lacrimal) 2Hydatid 2Schwannoma 2Pleomorphic adenocarcinoma 1Rhabdomyosarcoma 1Meningioma 1Lipoma 1


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signs and symptoms in his series of 38 metastatic orbital tumors.9 Zhang CH had also worked on metastatic orbital tumors but found only 3 of the 22 cases to have diplopia.10 Murat T in his paper describing 26 patients with lymphangiomas found 46% to have EOM limitation.11 In our series, we found that diplopia was less common than extra ocular motility limilattion and the reason for this was active ignorance of image from the eye with tumor by the brain. This ignorance was in cases with poor visual acuity and did not completely disappear in the 3 month follow up. Overall there was a strong agreement between the presence of extra ocular motility limitation and diplopia. The postulated factors causing extra ocular motility limitation include mechanical restriction, neurogenic causes (such as compression of neural plexuses, neurogenic tumors such as schwanommas etc.) or tumors of the muscle themselves such as rhabdomyosarcoma. Post-operative transient diplopia has been described and our study supports this finding.12-14

In conclusion the impact of orbital tumors on ocular motility is clearly demonstrated in this study. A residual extraocular motility deficit is expected to persist in most cases even three months after surgery.

REfEREnCES1. Sunderraj P. Malignant tumours of the eye and adnexa. Indian J Ophthalmol

1991;39:6-8. 2. Gogi R, Nath K, Ahuja L, Shukla M. Ocular and adnexal tumours. Indian J

Ophthalmol 1979;27:25-8.3. Sharma V, Betharia SM. Prospective evaluation of fundus changes in patients with

orbital mass lesions. Retina 2006;26:415-21.4. Friberg TR, Grove AS. Choroidal folds and Refractive errors associated with orbital

tumors. Arch Ophthalmol 1983;101:589-603. 5. Nath K, Gogi R. Primary orbital tumours. Indian J Ophthalmol 1977;25:10-6.6. Ohtsuka K, Hashimoto M, Suzuki Y. Review of 244 Orbital tumors in Japanese

patients during a 21 year period: Origin and locations. Jpn J Ophthalmol 2005;49:49-55.

7. Shields JA, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: The 2002 Montgomery Lecture, part 1. Ophthalmology 2004;111:997-1008.

8. Bajaj MS, Pushker N, Chaturvedi A, et al. Orbital space-occupying lesions in Indian children. J Pediatr Ophthalmol Strabismus 2007;44:106-11.

9. Goldberg RA, Rootman J .Clinical characteristics of metastatic orbital tumors. Ophthalmology. 1990;97:620-4.

10. Zhang CH, Zhang TC et al. Early diagnosis of the tumors in orbital apex and optic nerve. Chinese Journal of Ophthalmology. 2004;40:34-6.

11. Murat T et al. Orbital lymphangiomas: an analysis of 26 cases. Br J Ophthalmol 1999;83:76–80


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12. F. Sulimma, WELieb, Orbital surgery: perioperative problems and results. Ophthalmologe 1999;96:724 -7.

13. Hyun Joon Park, Seung-Ho Yang et al. Surgical treatment of orbital tumors at a single institution. J Korean Neurosurg Soc 2008;44:146-50.

14. Bernardini FP, Kersten RC et al, Outcomes after surgical excision of large and massive orbital tumors. Ophthal Plast Reconstr Surg. 2008;24:280-3.

Retroplacement and Shortening of MPL for Correction of Telecanthus in Blepharophimosis Syndrome (BPS) Dr. V. P. Gupta

Blepharophimosis-ptosis-epicanthus inversus (BPES) syndrome is a rare congenital disorder and occurs either as an autosomal dominant

trait or sporadically. Von Ammon was the first one to describe the term blepharophimosis. Mustarde1 coined the term telecanthus to describe the abnormal intercanthal distance (ICD) due to congenital long medial canthal ligament (MCL) and wide nose.

In 1971, Kohn and Romano described the tetrad of this syndrome, which includes blepharophimosis, blepharoptosis, epicanthus inversus, and telecanthus.2 All the features may not be always present in all the patients. BPS occurs in 3-6% cases of congenital ptosis. 3 types of BPS are described. Type I is the classical with ptosis, epicanthus inversus and telecanthus. Type II consists of ptosis, telecanthus and lowerlid ectropion. Type III has hypertelorism in addition to type II findings. The condition may occur either as an autosomal dominant trait (type I and type II) or sporadically. Type I is more prevalent and affected female subjects are infertile and type II is transmitted both in affected male and female subjects.

BPES not only causes a significant cosmetic disfigurement but is often associated with amblyopia and strabismus. Systemic abnormalities in BPES include – microcephaly, mental retardation, ovary dysfunction, short stature, mental abnormalities, syndactyly, cup-lop ears and various chromosomal abnormalities. The syndrome requires surgical correction of epicanthus, telecanthus, horizontal palpebral fissure length, ptosis and rarely lower lid ectropion. However, the management of telecanthus still remains the most challenging and difficult aspect of this syndrome. It is time consuming and often disappointing surgical experience. Despite several modifications an ideal technique providing best cosmetic results in all the cases is still lacking. We herein describe the results of retroplacement and shortening of MPL for


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correction of telecanthus in a large series of 30 eyes of blepharophimosis syndrome (BPS) with long follow-up.

MATERIALS And METhOdSThis is a retrospective, interventional case series report. 30 eyes of 15 consecutive patients of blepharophimosis syndrome were studied in this interventional study. The patients were selected from oculoplasty, orbital and lacrimal services clinic, department of ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi–110095. Detailed preoperative assessment was conducted which included measurement of horizontal and vertical palpebral aperture, levator function, intercanthal distance, inter pupillary distance and examination for type of epicanthus, Bell’s phenomenon, lagophthalmos, ocular motility, ocular deviation, lower lid ectropion if any. Routine laboratory investigations like haemogram and urine analysis and pre anaesthetic check up were done. Photographic documentation was done pre and post operatively. All the operations were done under general anaesthesia by the same surgeon (VPG) after obtaining informed consent.

Operative technique – The technique of retroplacement and shortening of MPL for correction of telecanthus was combined with Y-V plasty, Agnew’s lateral canthoplasty and excision of soft tissues in the medial canthus region. The sites of actual medial canthus and desired medial canthus were marked with gention violet paint and joined with a horizontal straight line. This is the stem of the Y. The paramarginal lines were marked 3mm away from the actual site of medial canthus and paralleled to lid margin forming a Y configuration. The ends of arms of Y were joined with the desired canthal site. The incisions were made with a no. 11 Bard Parker Scalpel on the marked lines. The skin thus included was excised. The skin edges were undermined. The excess fibrofatty tissue and the deep orbicularis muscle were dissected and removed. Bleeding points were cauterized using a bipolar cautry. Agnew’s lateral canthoplasty was performed. Fine lacrimal probes were passed from the lower and upper punctum to the common canaliculus to prevent iatrogenic damage. MCL was identified and disinserted from its anterior attachment. Two bony openingsof 3mm size were created posterior to the insertion of MPL. Retroplacement and shortening of MPL was done by passing it through the posterior bony opening and taken out from anterior one, where it was anchored with 4–0 prolene suture. The Y incision was then closed as V by advancing the actual canthal site to the desired canthal site. The suturing was done in 2 layers; skin was closed with 6-0 black silk. Firm pressure dressing was done for 48 hrs. Postoperatively steroid – antibiotic ointment was applied over the incisions for a week. Sutures were removed after 7 days. Ptosis correction was done after 6-8 weks based on levator function.


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RESULTS30 eyes of 15 patients of BPS were operated upon using this new technique. There were 6 females and 9 males in the age group of 3 to 25 years. 12 patients had severe ptosis with poor levator function and 3 patients had moderate ptosis with fair levator action. All the patients had significant telecanthus and epicanthus inversus. Preoperative ICD ranged from 36mm to 44mm. Postoperative ICD ranged from 27 to 32mm. telecanthus was corrected by 8-12mm decrease in ICD. Cosmetically acceptable epicanthus correction was achieved in all the patients. Lateral canthoplasty increased the horizontal palpebral fissure length by 5-6 mm. 2 patients (20%) complained of postoperative mild epiphora occasionally. No recurrence of deformity occurred during 2 year to 5 years follow-up. No cosmetically unsightly scars were observed. Natural depth of medial canthus was achieved in all the cases. Epicanthus was also corrected in all the patients. No recurrence has been noted during 6 months to 10 years follow-up.

The procedure was not associated with any complication. Excellent final results were achieved after appropriate ptosis surgery in all the cases.

dISCUSSIOnBlepharophimosis syndrome (BPES) is a complex of multiple eyelid malformations.

Many surgical techniques are available in the literature for correction of epicanthus and telecanthus associated with BPES.1-5 However, none of the techniques provides a perfect result in all patients. It is well established the management of canthal deformities in BPS is complex and very challenging. Even Axenfeld and Brons had mentioned the difficulty of its management. Management of BPES involves correction of canthal deformities (epicanthus and telecanthus), ptosis and horizontal palpebral aperture. Exact timing of correction still remains controversial. Correction of canthal deformities should be deferred until preschool years to allow some growth of the nasal bridge which results in some decrease in epicanthal folds and provides enough space for surgical correction. Correction of canthal deformities should precede ptosis correction. Early procedure for epicanthus correction excised elliptical, arrowhead or semilunar skin pieces from the medial canthal area. Modern repair techniques intend to correct the shortage of vertical skin in medial canthal area. These techniques include Y-V plasty, and Mustarde’s double rectangular flap technique. Kohn modified Y-V plasty to a C- shaped incision to reduce scarring and the scar conforms to Langers skin folds.1 Disadvantages of Mustarde’s technique include meticulous measurements required, multiple rectangular flaps, difficulty in aligning flaps, many sutures in a small area, wound reaction, scarring, keloid formation, suboptimal results and recurrence of folds.


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Anderson and Nowinski claim good results using flap technique in 14 patients.4 Surgeries for telecnthus include medial canthal tendon shortening, plication, transnasal wiring, custom designed titanium medial canthal tendon screws at the anterior lacrimal crest. The transnasal wiring of the medial canthi though effective, has its own drawbacks i.e. the fear of retaining a foreign nonabsorbable material in a relatively infected area. One-stage surgical correction of all the lid and canthal defects of blepharophimosis syndrome has been currently advocated and yields satisfactory results.5 One-stage procedure consisted of lateral canthotomy, medial canthoplasty, transnasal wiring for medial canthal tendon shortening, and frontalis suspension using donor fascia lata or levator resection.

The author’s new technique of surgical correction of telecanthus in BPS consisted of disinsertion of medial palpebral ligament (MPL), retroplacement and shortening of MPL by passing it through two bony openings created posterior to the insertion of MPL. The technique was combined with excision of soft tissues and correction of epicanthus by Y–V plasty. Telecanthus improved with creation of depth of medial canthus in all patients without any complications. Epicanthus was also corrected. Removal of excess muscle and fibrofatty tissue overlying MCL additionally facilitates retroplacement of medial canthal tendon. It appears that lateral canthoplasty not only increased the horizontal palpebral fissure length by 5-6 mm but also facilitated the surgeries at medial canthus by releasing the traction. The present technique corrected all the defects in one stage except ptosis which was corrected after 6-8 weeks. Author’s technique did not involve fashioning of multiple skin flaps, thus avoided scarring. The scars of y-v plasty were conspicuous only in the early postoperative period. Excellent cosmetic appearance was achieved in all the cases without any recurrence of deformity during 6 months to 10 years follow up. It is thus concluded that this new technique was found to be very effective and safe technique for correction of telecanthus in 30 eyes of 15 patients of BPS without any recurrence during long follow-up.

REfEREnCES1. Mustarde JC: The treatment of ptosis and epicanthal folds. Br. J. Plast Surg. 1959;12:

252-8.2. Kohn R, Romano MD: Blepharoptosis, blepharophimosis, epicanthus inversus and

telecanthus – a syndrome with no name. Am J Ophthalmol 1971;72:625-32. 3. Beard, C: Ptosis 3rd ed. The C. V. Mosby co. Saint Louis, 1981: p211-231.4. Anderson RL, Nowinski TS: The five flap technique for blepharophimosis

syndrome. Arch Ophthalmol 1989;107:448-52.5. Wu SY, Ma L, Tsai YJ, Kuo JZ. One-stage correction for blepharophimosis syndrome.

Eye (Lond). 2008;22:380-8.


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Orbital floor fracture Repair: A 5 Years Retrospective StudyDr. Rituraj Baruah, Dr. Ashok Kumar Grover, Dr. Shaloo Bageja

Orbital floor fractures may result when a blunt object, which is of equal or greater diameter than the orbital aperture, strikes the eye. Globe rupture

is rare as the resultant force is transmitted throughout the orbit causing a fracture of the orbital floor. Signs and symptoms can be quite varied, ranging from asymptomatic with minimal bruising and swelling to enophthalmos, h y p o p h t h a l m o s , diplopia resulting from extraocular muscle dysfunction and hypoesthesia of the cheek and upper gum on the affected side due to involvement of infraorbital nerve.

Aim is to retrospec-tively analyze the demographic detail, presentation, etiology, intervention and success rate of orbital floor fracture repair.

MATERIALS And METhOdSRetrospective data were retrieved along with photograph of all the patient who presented to the out patient department or got admitted in the last 5 years. Demographic details, mode of injury, time of presentation, signs and symptoms were noted. CT scan was done in all these cases. CT scan images were meticulously noted in terms of the position, extent and the number of walls involved. Moreover, incarcerations of the orbital contents were also noted.

RESULTSA total of 98 patients with fracture floor record was retrieved and analyzed. Age varied from 2 years to 58 years (mean age 30 years). Males (59 cases) seem to be more prone to orbital fracture than females (39 cases). Only 20 cases (19.6%) presented within 2 weeks of injury. Road traffic accident was the leading cause of orbital fracture followed by accidental fall and assault.

Figure 1: CT Scan showing floor fracture with soft tissue entrapment.


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Most common complain was of enophthalmos (73.5%) followed by diplopia (60.0%), hypoasethesia of cheek (40.0%).

Associated fracture of other walls was found not to be rare. Medial wall 9 cases, lateral wall 4 cases and four walls 3 cases were involved in addition to the floor fracture.

Repair was done with PTFE plate (72), bone graft (12) medpor (12), titanium mesh (2) either by transconjunctival (81.6%) or subciliary(18.4%) approach. Diplopia was relieved in 42 of 59 patients and enophthalmos corrected significantly in 61 of 72 patients. No implant related complications were noted.

In conclusion orbital floor repair with implants is successful in relieving enophthalmos and diplopia if intervened early. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination and large orbital floor fracture.

Figure 2: Enophthalmos due to fracture floor Figure 3: Motility restriction


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Orbital Decompression Via A Modified Transconjunctival Swinging Eyelid Approach in Graves’ OphthalmopathyDr. Shaloo Bageja, Dr. Ashok Kumar Grover

Orbital decompression via a modified Transconjunctival swinging eyelid approach in Graves’ ophthalmopathy.

Orbital decompression has been the treatment modality of choice for compressive optic neuropathy and severe proptosis with exposure keratopathy in Graves’ ophthalmopathy.1 With advancements in the surgical technique and aesthetic awareness, the cosmetic indications for disfiguiring exophthalmos have also increased.2

Orbital decompression is achieved by removal of bony orbital walls, so that the orbital contents herniate into the periorbital space. This may or may not be combined with fat removal.

Various approaches have been described in the literature3 the transconjunctival approach with lateral cantholysis, provides adequate exposure to the orbital floor , medial and lateral wall besides being more aesthetic.4

Aim is to describe our experience of an aesthetic approach to orbital decompression at a teriary care centre.

MATERIALS And METhOdSThirteen eyes (7 patients) with thyroid orbitopathy operated by a transconjunctival swinging eyelid incision between March 2006 and March 2011 were studied retrospectively. Four patients were females and three were males .The age ranged from 42 to 65 years(mean of 53.5 yrs). The indications were compressive optic neuropathy, exposure keratopathy and disfiguring exophthalmos. The amount of proptosis was assessed using Hertel’s exophthalmometer. Best corrected visual acuity, IOP, slit lamp examination and fundoscopy were noted. Postoperatively, improvement in visual acuity, ocular motility and exophthalmos were analyzed. Visual fields and VEP whereverdone was noted. Postoperative complications were recorded.

Surgical technique: Surgery was performed under general anesthesia. After local infiltration along the lower eyelid and lateral canthus, incision was given

ORBIT / OCULOPLASTY - IIChairman: Dr. Trivedi Nitin Vinaykant: Co-Chairman: Dr. Verma Malay

Convenor: Dr. Senthilnathan C.; Moderator: Dr. Sujatha Y.


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below the tarsus extending from the caruncle to lateral canthus. A lateral canthotomy with inferior cantholysis was performed. The septum was opened and the prolapsing fat was resected. The periosteum was incised just anterior to the orbital margin and lifted along with the periorbita. A part of the orbital floor was removed starting approximately 1 cm posterior to the orbital rim. A chisel was used to fracture and elevate the bone lateral to infraorbital fissure. The bone overlying the infraorbital nerve was left intact. The bone medial to infraorbital fissure was removed leaving behind the orbital strut.

The lateral and medial walls were also removed depending upon the amount of decompression required.

For lateral wall decompression, a high-speed drill was used to break through the thin anterior wall of the lateral orbit, and the anterior bone was removed with a drill or bone punch. Posteriorly, the dissection was extended into the sphenoid bone till the dura was exposed. For medial wall decompression, lamina papyracea was removed along with portions of the anterior, middle, and posterior ethmoidal air cells. The medial wall was removed up to the posterior end of the ethmoid sinus in cases of compressive optic neuropathy.

The periorbita was opened to allow herniation of orbital fat into the surrounding sinuses. The periosteum and conjunctiva were closed with absorbable 5’0 vicryl suture and the lateral canthus was reconstructed with 6’0 silk suture.

Postoperatively, intravenous antibiotics, anti-inflammatory drugs and analgesics were prescribed.

RESULTSOf the 7 patients, 2 had compressive optic neuropathy, 1 had sight threatening exposure keratopathy and 4 had disfiguring exophthalmos. The mean proptosis reduction at 3 months was 4 mm (2-6 mm). Visual acuity improved in both the patients of compressive optic neuropathy. In one patient visual acuity improved to 6/36 and 6/18 at 8 weeks postoperatively from counting fingers at 4 metres in right eye and 6/60 in the left eye. In another patient visual acuity improved to 6/24 and 6/12p from 6/60 in both the eyes. The patients were extremely satisfied as far as aesthetic improvement was concerned. Additional strabismus and eyelid surgery was carried out in 3/7 patients. Complications included early postoperative edema, transient diplopia and permanent hypoaesthesia of infra-orbital nerve (1 patient). No infective complications were noted and no scar was visible.

dISCUSSIOnTransconjunctival orbital decompression with fat debulking is associated with significant improvement in proptosis in the study group. The overall


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improvement of visual acuity in our series is comparable with our studies5

and that reported after either transantral or transnasal decompression.6,7 No severe complications was noted.8,9

This versatile procedure is safe, efficacious and patient friendly. Advantages are the concealed scar, low incidence of induced diplopia and periorbital hypoesthesia and quick patient recovery. The main disadvantage is limited exposure of the posterior medial and lateral wall.

REfEREnCES1. Siracuse-Lee DE, Kazim M. Orbital decompression: current concepts. Curr Opin

Ophthalmol 2002;13:310–6.2. Olivari N. Transpalpebral decompression of endocrine ophthalmopathy (Graves’

disease) by removal of intraorbital fat: experience with 147 operations over 5 years. Plast Reconstr Surg. 1991;87:627–43.

3. McCord Jr CD. Current trends in orbital decompression. Ophthalmology 1985;92: 21–33.

4. McCord Jr CD. Orbital decompression for Graves’ disease. Exposure through lateral canthal and inferior fornix incision. Ophthalmology 1981;88:533–41.

5. D Paridaens, A Lie, R J Grootendorst and W A van den Bosch. Efficacy and side effects of ‘swinging eyelid’ orbital decompression in Graves’ orbitopathy: a proposal for standardized evaluation of diplopia. Eye 2006;20:154–62. doi:10.1038/sj.eye.6701827; published online 4 March 2005.

6. Tjon F, Sang M, Knegt P, Wijngaarde R, Poublon R, van der Schans E et al. Transantral orbital decompression for Graves’ disease. Clin Otolaryngol 1994;19:290–4.

7. Michel O, Oberländer N, Neugebauer P, Neugebauer A, Russmann W. Follow-up of transnasal orbital decompression in severe Graves’ ophthalmopathy. Ophthalmology 2001;108:400–4.

8. McCord CD jr. Current trends in Orbital decompression. Ophthalmology 1985;92:21-33.9. Mourits MPh, Koornneef L, Wiersinga WM, et al. Orbital decompression for

Graves’ ophthalmopathy by inferomedial plus lateral , and by coronal approach. Ophthalmology 1990;97:636-41.

Evisceration with Primary Orbital Implant in Endophthalmitis/Panophthalmitis – Should It Be done? Dr. Devjyoti Tripathy, Dr. Suryasnata Rath

Evisceration is often the procedure of choice for blind, painful eyes with endophthalmitis1 and panophthalmitis. The remnant scleral shell is

believed to be a barrier to contiguous posterior spread of infection. Factors


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causative of implant extrusion after evisceration for endophthalmitis/panophthalmitis are still not very well understood in spite of the procedure being in practice for over a century now.2 Citing a higher likelihood of extrusion of a primary implant when placed in an infected site, some authors advocate awaiting resolution of infection before a delayed/secondary implant is attempted.3-6 Others however are of the opinion that this likelihood of extrusion is not significant enough to preclude the placement of a primary implant.7-11 This study aimed to look at and assess differences in outcome of evisceration with primary implant in blind eyes without and with infection.

MATERIALS And METhOdSThis was a retrospective, non randomized, comparative study. All patients undergoing evisceration with primary implant by a single surgeon between April 2007 and December 2010 were included. A total of 34 patients (34 eyes - 16 infective and 18 non infective) were studied. Preoperative workup included detailed clinical history, examination and ultrasonographic evaluation of the eye to be operated upon. All eyes undergoing the procedure were blind (no light perception). Informed consent was procured in all cases. A standard surgical technique was used for evisceration. Posterior sclerotomies were done when necessary. The patients were followed up to assess resolution of infection/inflammation, socket healing, complications and successful prosthesis fitting.

RESULTSAmong the 16 patients in the infective group, 1 case (6.2%) developed a Tenon’s cyst 13 months postoperatively which was successfully excised. 2 cases (12.5%) had extrusion of the implant. 1 case (6.2%), intraoperatively noted to have partly necrotic sclera, had no related complication postoperatively. 8 cases (50%) had no complications. All patients except one (93.75%) underwent successful prosthesis fitting with good cosmetic outcome.

Among the 18 patients in the non infective group, 1 case (5.5%) had slight volume deficit, 1 case (5.5%) had a conjunctival dehiscence (which resolved spontaneously), and 1 case (5.5%) had persistent conjunctival chemosis and prolapsed conjunctiva (which resolved spontaneously 8 weeks postoperatively). 1 case (5.5%) had exposure of the implant 8 weeks post surgery, was treated with a scleral patch graft and had a graft melt with extrusion of the implant 8 weeks later. 1 case (5.5%) had exposure of the implant on the 9th postoperative day and underwent a conjunctival autograft. All patients except two (88.9%) underwent successful prosthesis fitting with good cosmetic outcome.

Successful prosthesis fitting with good cosmesis was possible in 93.75% of cases in the infective group versus 88.9% in the non infective group. Minor complications were seen in 37.5% of cases in the infective group as compared


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to 16.7% in the noninfective group. Major complications were seen in 12.5% and 11.1% of cases in the infective and non infective groups respectively. Overall complication rate was 50% in the infective versus 27.8% in the non infective group but the difference between the complication rates in the two groups was not found to be statistically significant (p = 0.415, Fisher exact test).

dISCUSSIOnEvisceration and enucleation have both been advocated for eyes with endophthalmitis. Evisceration is said to offer the advantages of being an easier, less disruptive technique with fewer complications, and better ocular motility and cosmesis and also offers protection against the theoretical risk of meningitis that can occur after enucleation of an infected eye.

Studies that have looked specifically at the issue of primary implant placement in infected eyes undergoing evisceration8-11 have reported low complication rates and good implant retention. The area of concern is the risk of the primary implant getting exposed or extruded in the setting of ocular infection. Dresner et al8 reported one case of implant exposure in their series of 11 cases of primary implant placement after evisceration for endophthalmitis. Ozgur et al9 reported 3 patients (12%) with implant exposure in their series of 25 patients undergoing primary implant placement after evisceration for endophthalmitis. In their series of 67 patients, Tawfik et al10 reported an overall complication rate of 12 with 2 patients (3%) having extrusion of the implant.

In the current study, the overall complication rate of 50% was higher than other reports in the literature and the implant extrusion rate of 12.5% was also higher than similar reports.10,11 The overall complication rate of 27.8% and implant exposure/extrusion rate of 11.1% in the non infective group were higher than that reported in similar groups.11 The difference between the two study groups however was not found to be statistically significant.

A single stage procedure of placing primary implant in the socket during evisceration for endophthalmitis/panophthalmitis is an extremely cost effective measure, especially in developing economies, as compared to performing a delayed or secondary implant at a separate sitting. Though the current study has the limitations of being retrospective in nature with small study groups and a relatively short follow up, the apparent feasibility of this procedure does seem to make it worthwhile to offer it to such patients on a regular basis. A large, randomized, prospective study would seem in order to compare primary implants in evisceration in infected eyes versus in those without to establish this apparent feasibility more conclusively. It may also yield more information on the behaviour of different types of implant materials in the setting of ocular infection as well as whether any particular infective organism, as compared to others, actually predisposes to implant exposure/


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extrusion. This would likely lead to application of surgical techniques more specific to the situation at hand and would also improve the postoperative management of the patient ultimately leading to a better postoperative outcome.

REfEREnCES1. Walter WL: Update on enucleation and evisceration surgery. Ophthal Plast Reconstr

Surg. 1985;1:243–52.2. Mule PH. Evisceration of the globe with artificial vitreous. Trans Ophthalmol Soc.

UK 1885;5:200-6.3. Iliff CE, Iliff WJ, Iliff NT. Evisceration, enucleation and extruded implants. In:

Oculoplastic Surgery. Philadelphia: WB Saunders; 1979:203-8.4. Soll D. Enucleation and evisceration. In: Duane TD, ed. Clinical Ophthalmology.

Vol. 5. Hagerstown, Maryland: Harper and Row; 1980:1-18.5. Meltzer MA, Schaefer DP, Della Rocca RC. Evisceration. In: Smith BC, ed.

Ophthalmic Plastic and Reconstructive Surgery. St Louis: CV Mosby; 1987;2:1300-7. 6. Witteman GJ, Scott R. Enucleation and evisceration. In: Peyman GA, Sanders DR,

Goldberg MF, eds. Principles and Practice of Ophthalmology. Philadelphia: WB Saunders 1987:2334-48.

7. Baylis H, Shorr N, McCord CD, et al. Evisceration, enucleation and exenteration. In: McCord CD, Tanenbaum M, eds. Oculoplastic Surgery. 2nd ed. New York: Raven 1987:425-49.

8. Dresner SC, Karesh JW. Primary implant placement with evisceration in patients with endophthalmitis. Ophthalmology 2000;107:1661-5.

9. Ozgur OR, Levent A, Dogan OK. Primary implant placement with evisceration in patients with endophthalmitis. Am J Ophthalmol 2007;143:902-4.

10. Tawfik HA, Budin H. Evisceration with primary implant placement in patients with endophthalmitis. Ophthalmology 2007;114:1100–3.

11. Liu D. Comparison of implant extrusion rates and postoperative pain after evisceration with immediate or delayed implants and after enucleation with implants. Trans Am Ophthalmol Soc 2005;103:568-91.

A Case of Burkitts Lymphoma Masquerading as Ptosis and Eoms PalsyDr. Jayesh B Patil, Dr. Chhaya Ashok Shinde, Dr. (Mrs.) Potdar Nayana Anil, Dr. Piyush Jain

Burkitt lymphoma (BL) is a highly aggressive B-cell neoplasm characterized by the translocation and deregulation of the c-myc gene on chromosome

8. Burkitt’s lymphoma is one of the types of Non-Hodgkin lymphoma. It is


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the most rapidly growing tumor of human body. It is rare disease in adults. Burkitt’s lymphoma can be divided into three main clinical variants:

1) The endemic variant occurs in equatorial Africa. It is the most common malignancy of children in this area. The disease characteristically involves the jaw or other facial bone, distal ileum, cecum, ovaries, kidney or the breast.

2) The sporadic type (also known as “non-African”) The tumor cells have a similar appearance to the cancer cells of classical African or endemic Burkitt’s lymphoma. The jaw is less commonly involved, compared to the endemic variant. The ileo-cecal region is the common site of involvement.

3) Immunodeficiency-associated Burkitt lymphoma is usually associated with HIV infection or occurs in the setting of post-transplant patients who are taking immunosuppressive drugs. By morphology (i.e. microscopic appearance) or immunophenotype, it is almost impossible to differentiate these three clinical variants.

Although Burkitt lymphoma accounts for ~40% of all childhood non-Hodgkin lymphoma, it represents <5% of lymphoma cases in adults.1 Therefore there are fewer reports on the outcome of Burkitts lymphoma patients in adult than in pediatric series. When Burkitt lymphoma is treated with standard CHOP-based combination therapies, the outlook for survival is usually considered to be poor, with 2 and 5 year overall survival rates ranging from 50% to 65% and decreasing to <30% in case of bone marrow (BM) or central nervous system (CNS) involvement.2-4

We report an atypical presentation of Burkitts lymphoma in a young adult aged 21 yrs who presented with ptosis and EOMS restrictions.

Case History21 yr old male presented with backache and fever since a month, swelling and drooping of LE since 25 days. No h/o diplopia. Later he developed Lt lower limb weakness, tingling numbness on Lt side of face and deviation of tongue to Lt was noted. Pt was referred to medicine dept. and was admitted after doing imaging studies.

Ophthalmic examination- BCVA RE 6/9 and LE 6/6. No e/o proptosis in any


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eye, Mild RE upper lid ptosis, severe LE upper lid ptosis, BE anterior segment was WNL, both pupils NSRTL,EOMS- RE restricted in all directions except inferiorly, LE restricted laterally and superiorly. On indirect ophthalmoscopy RE fundus showed blurring of disc margins, LE fundus was WNL except for mild venous congestion.

Investigations• Pt. was initially evaluated with routine blood investigations. The values

were WNL–• Hb -11 gm/dl ; ESR 25 ; TLC -7500/ mm3 P– 63, L – 33, M – 3, E – 1

Plt – 2, 30,000/mm3 ; LFT – T. Bil-0.8, SGOT-36, SGPT-30, T. proteins-6.5gm/dl with albumin-3.3gm/dl ; RFT – Creat- 0.9mg/dl, uric acid- 9mg/dl, Ca- 8.8 mg/dl, ALK.PO4- 3.6mg/dl ; Sugars- 86 mg/dl and 110 mg/dl

• HIV ELISA – Non reactive.

MRI BRAIN revealed multiple abnormal signal lesions in b/l temporal, occipital, Rt parietal region. Abnormal lesions in b/l intraorbital extraconal compartments(R>L); causing mass effect on Rt lat. Rectus muscle and on optic nerve. On Lt side lesion is ill-defined extending into orbital apex and abutting retro orbital portion of Lt optic nerve. USG ABDOMEN showed hepatomegaly. HRCT and CECT CHEST findings were-A lobulated mass in upper lobe of left lung. No lymphadenopathy was found in chest. For further evaluation – CECT ABDOMEN and PELVIS was done, which showed multiple large masses in liver with significantly enlarged liver, scattered masses in both kidneys, pancreas, paravertebral masses in retroperitoneal region eroding vertebral bodies. No splenic involvement.

INCISION BIOPSY of liver mass was done and Immunohistochemical report was traced. The tumour cells were positive for LCA,CD20, CD10 and BCL6.The report gave the diagnosis of Burkitts lymphoma.

Pt came under stage IV under Ann Arbor staging. Pt was started on intrathecal methotrexate and chemotherapy cycle of cyclophosphamide, vinblastine and prednisolone. Unfortunately patient did not tolerate chemotherapy and succumbed after 1st cycle of chemotherapy.

dISCUSSIOnMost orbital lymphomas are NHL and tend to present in the sixth and seventh decade and present anteriorly in the orbit. [5] Presentation before the age of 20 is rare.[5] Ptosis and EOMS palsy can be a presenting sign of life threatening systemic neoplasia like Burkitts lymphoma. Hence we stress upon the early radiological and histopathological diagnostic tests keeping in mind the aggressive behavior and life threatening consequences of such tumors. Hence the need of proper systematic approach in orbital mass.


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REfEREnCES1. Bishop PC, Koneti Rao V, Wilson WH. Burkitt’s lymphoma: molecular pathogenesis

and treatment. Cancer Invest 2000;18:574–83.2. Diviné M, Lepage E, Brière J et al. Is the small non-cleaved-cell lymphoma histologic

subtype a poor prognostic factor in adult patients? A case-controlled analysis. J Clin Oncol 1996;14:240–8.

3. Longo DL, Duffey PL, Jaffe ES et al. Diffuse small noncleaved-cell, non-Burkitt’s lymphoma in adults: a high-grade lymphoma responsive to proMACE-based combination chemotherapy. J Clin Oncol 1994;12:2153–9.

4. Jost LM, Jacky E, Dommann-Scherrer et al. Short-term weekly chemotherapy followed by high-dose therapy with autologous bone marrow transplantation for lymphoblastic and Burkitt’s lymphomas in adult patients. Ann Oncol 1995;6:445–51.

5. Hindola K, Brian JC, Geoffrey ER. Lymphocytic, plasmacytic, histiocytic and hematopoietic tumors of the orbit. In: William T, Edward AJ, editors. Chapter 39, Vol 2 Duane’s Clinical Ophthalmology 2003 Edition on CD-ROM. Lippincott Williams and Wilkins Publishers, Inc: Philadelphia

Evaluation of Retinal nerve fibre Layer Thickness Using Optical Coherence Tomography In Thyroid Ophthalmopathy PatientsDr. Apjit Kaur, Dr. Neha Sinha, Dr. Sandeep Saxena

Thyroid ophthalmopathy (TO), is the most common extra-thyroidal manifestation of Thyroid disease. TO presumed to have an autoimmune

basis, causes increase in osmotic load leading to raised orbital volume. This study aims at detecting the early nerve fibre changes much before the intraocular pressure is raised and the vision is affected.

In graves orbitopathy there occurs increase in orbital volume due to mucopolysaccharide infiltration into the tissues leading to increase osmotic load. This leads to optic nerve compression causing ischemia and nerve damage. At this stage it is quite late and easily detectable. Since OCT can detect RNFL changes at a pre-clinical stage (e.g. in glaucoma and diabetic retinopathy), so it might detect an early RNFL change in patients of TO.

MATERIALS And METhOdSThe present study was conducted at the Department of Ophthalmology, Chhatrapati Shahuji Maharaj Medical University (formerly King George’s Medical University), Lucknow. It was a prospective longitudinal case control study done for duration of one year. All cases of thyroid ophthalmopathy


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(hyperthyroid, hypothyroid and euthyroid thyroid) visiting our department were included. 33 healthy controls of similar age group and sex were taken from outdoor of department of ophthalmology. The present study is a part of ongoing work in patients of thyroid ophthalmopathy in Department of Ophthalmology for last four years.

Inclusion Criteria: All patients of thyroid ophthalmopathy visiting the Department of Ophthalmology, CSMMU.

To prepare a normative pool for RNFL thickness data in each quadrant in Indian population a total of 33 controls were included. Considering both the eyes to behave similarly in the controls, both the eyes were considered making the normative data of 66 eyes. For study purpose the worse eye of each case was included.

Exclusion Criteria

1) Patient’s eyes with visual acuity less than 1 on LogMAR scale or < 6/60 on snellen’s chart.

2) All patients suffering from RNFL abnormality due to causes other than thyroid ophthalmopathy.

3) Signal strength less than 5/10 in OCT (for patients with signal strength more than 6 an average of three observation were taken).

The protocol has been adapted from the European Group for the study of Graves’ Orbitopathy (EUGOGO) guidelines. An informed consent was taken from all the patients. RNFL thickness analysis was done using Cirrus HD-OCT (Carl Zeiss). RNFL values obtained was studied in the form of four quadrant (temporal, superior, nasal and superior) and were compared with the nomative pool obtained from healthy 33 controls. Follow up was done after 3 months

RESULTSIn present study we had included 33 healthy individuals without any ocular problems. Considering both eyes to behave similarly in normal subjects a total of 66 eyes were examined for RNFL thickness using OCT in order to create a normative data pool. The 5th percentile and 95th percentile values of the normative data have been taken as the range of normal values and any deviation from these has been reported in terms of thinness or thickness from the normal values in reference ranges. A patient having deviation from normative data for any quadrant has been treated as having abnormal/deranged thickness.

On the basis of normative data for different quadrants the categories were divided as follows:


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Table 1: Classification of Retinal Thickness for different quadrants on the basis of Standardization through Normative DataSN Quadrant RNFL Values Thin Unaffected/ Normal Thick1. Temporal <51.45 51-45-82.40 >82.402. Superior <99.45 99.45-137.00 >137.003. Nasal <63.15 63.15-101.85 >101.854. Inferior <104.75 104.75-144.75 >144.75

Table 2: Distribution of Cases according to their retinal thickness status as per the criteria evolved during study (n=33) S.No. Outcome No. of cases Percentage 1. Thin 9 27.3 2. Normal 6 18.2 3. Thick 14 42.4 4. Mixed 4 12.1

Table 3: Overall Status – At Follow up (n=33) Before After SN Status Frequency Percent Frequency Percent 1. Thinning 9 27.3 13 41.9 2. Normal 6 18.2 3 9.7 3. Thickening 14 42.4 7 22.6 4. Mixed 4 12.1 8 25.8 Total 33 100.0 31 100.0

x2=2.109 (df=3); p=0.550s2 cases were lost to follow up.

dISCUSSIOnThe present study was taken up with the hypothesis that increase in intraorbital pressure secondary to orbital inflammatory changes causes RNFL changes due to optic nerve compression. We aimed to identify RNFL changes by quantifying the thickness as observed on OCT charts, using Ziess Cirrus HD OCT. Our data was analysed on the basis of the afore described methodology. For the purpose of cases, 33 patients with TO were included confirming to the inclusion and exclusion criteriaRNFL-OCT is a non-invasive, non-contact modality that can be used for measurement of peripapillary RNFL thickness. The RNFL thickness on OCT was calculated in four quadrant i.e. temporal, superior, nasal and inferior. The mean values in each quadrant among the normal healthy eyes came out to be different in all four quadrant with thickest being inferior quadrant and


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thinnest temporal. Similar observations were made in the study done by Sony et al1. The variability is quite high in all four quadrant which is explained by the variable anatomy of the optic nerve head in different individual. However as mentioned by Tarannum et al2 Spectral OCT has an excellent intra-session and inter-session reproducibility so the variation in same individual in the same and follow up session are minimized. The 5th and the 95th percentile values are obtained by arranging the values in ascending order below and beyond which the values were considered abnormal. This gave us the range of thickness in different quadrant.On the basis of criteria evolved during study RNFL thickness of the worst eye was considered. If values are similar or normal in both the eyes then the right eye was categorized as thick, thin, normal and mixed. Out of 33 cases 14 showed thickening, 9 showed thinning and 4 were mixed (showing both thinning and thickening in different segments). During follow up thinning was seen maximally followed by mixed category which was independent of the treatment status. Therefore it is evident that the disease does affect the RNFL thickness.In conclusion the exact pathogenesis of TAO being still unknown, an interplay of various genetic and environmental factors are supposed to be responsible for its causation. RNFL thickness in thyroid patient was never evaluated thoroughly so this study was undertaken to evaluate any change in RNFL thickness in patients of thyroid ophthalmopathy. It was hypothesized that increase in intraorbital pressure secondary to orbital inflammatory changes causes RNFL changes due to optic nerve compression. In relation to TAO, it is observed that there may occur a stage of thickening due to edema due to compression but thinning is the ultimate fate of the diseased RNFL. Follow up changes shows dynamic nature of the disease.

REfEREnCES1. P Sony, R Sihota, Hem K Tewari, P Venkatesh, R Singh, Quantification of the

retinal nerve fibre layer thickness in normal Indian eyes with optical coherence tomography. Indian Journal of Ophthalmolog 2004;52:303-9.

2. Tarannum M, Kalluri V, Nagalla B. Reproducibility of peripapillary retinal nerve fibre layer thickness measurements with spectral domain optical coherence tomography in normal and glaucomatous eyes; Br J Ophthalmol 2010.183020.

CSF Leak, A Landmine in Orbital SurgeriesDr. Apjit Kaur, Dr. Neha Sinha

Intra-operative CSF leakage is an infrequent complication of orbital surgeries. It presents as one of the most challenging tasks for orbital surgeons to

manage. Because of the risk of meningitis, this condition warrants immediate


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attention intra-operatively. The brain is normally isolated from the exterior by an anatomical barrier that basically consists of the skin or mucosa of the air sinuses, the periosteum, the skull bones, the duramater, and the arachnoid membrane. Fistulas may develop when a defect is formed in this barrier. This typically occurs at four anatomical locations: the frontal sinus, the cribriform plate and ethmoid roof, the sphenoid sinus, and the petrous bone. Since CSF is normally found in the subarachnoid space between dura and the brain, a bone fracture alone will not cause CSF leakage if the dura is intact. Therefore, if CSF leakage occurs, there exists a presumed dural tear. Operative techniques are usually aimed at closure of the dural defect rather than the bone. The adequate closure of either defect is sufficient to achieve a cure.

Case Summary

CASE 1- A 72 yrs male with biopsy proven adenoid cystic carcinoma with bone infiltration underwent exentration of left orbit under general anesthesia. Intraoperative CSF leak was encountered from roof of orbit during resection of the tumour. Standard wound closure was done. CSF leak was managed by external lumbar drain under antibiotic coverage in meningitic dose.

CASE 2- 6 yr male child with left sided microphthalmia with cyst underwent cyst excision via sub-brow approach under general anesthesia. Soon after excision, CSF leak was identified from the ligated stump which was initially managed by external lumbar drain under cover of antibiotics and anticonvulsive therapy. In post operative period, the CSF leak recurred so he was put again on the same treatment. A cisternography was done which showed leakage of contrast into the left orbit through the orbital fissure, coming through the orbital wound into the soft tissue of left side of paraorbital region and soaking the dressing. The contrast media was seen opacifying the subarachnoid space and ventricles. A second surgery was planned, in which previous skin incision was opened , sac was dissected all around. Through the annulus of zinn, optic nerve was traced. The sac was visualised through which CSF was leaking. Sac was transfixed and defect was closed using facia lata graft of size 1.5 x 1.5 cm and cyanoacrylate glue.

Till date both of the patients are doing well with no recurrence.

dISCUSSIOnCerebrospinal fluid leakage is an uncommon but significant complication of orbital and rarely lacrimal surgery which may have serious consequences including death. Prompt diagnosis and management usually results in uncomplicated recovery. CSF leak is a most drastic intraoperative complication. The CSF orbitorrhoea due to penetrating transorbital injury with CSF leak was first reported by Ide and Webb in 1971.1 The principle of closing a dural


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defect was first proposed by Grant in 1923.2 The CSF leak can be managed by conservative and surgical means. Suturing of the dural defect remains the most commonly used method of repair. However, the suture technique is often difficult to perform, particularly when dural defects cannot be identified or are located in relatively inaccessible areas. Other intraoperative alternatives include packing the area with autogenous fat, mucous membrane, fascia lata, temporalis fascia and muscle, or osteomucoperiosteal flap. However, most of these options require additional surgery, and none of the procedures assures a watertight closure.

The safety and effectiveness of tissue adhesives in the repair of CSF fistulas have been well documented in various studies. Carton and Kennedy used it in the management of intracranial aneurysms, leaking cerebral vessels, and small blood vessel surgeries. Samson and colleagues described its use in intracranial arteriovenous malformations and carotid-cavernous fistulas. The use of cyanoacrylate adhesives in clinical ophthalmology ranges from sealing corneal perforations to performing intentional tarsorrhaphies.

The advantages of a tissue adhesive in the management of CSF leak are as follows: (1) No toxic effect on neural and vascular tissue; (2) Strong and rapid bonding; (3) Adherence to bone, dura, fascia, and muscle; (4) Ability to bond in the presence of small amount of blood or CSF; (5) Bacteriotoxicity; (6) Simplicity of application; and (7) Watertight, sutureless closure.

We report two cases of CSF leakage, encountered during orbital surgery, one of the case was managed by putting a lumber drain only and in the other topical application of butyl-2-cyanoacrylate (Nectaryl) resulted in immediate cessation of the leak. The adhesive was used in the case in which repair was difficult with conventional techniques. The repair was performed extracranially.

The intent of this communication is to bring to the attention of orbital surgeons how to manage intraoperative CSF leak efficiently.

REfEREnCES1. lde CH and Webb RW : Penetrating trans-orbital injury with cerebrospinal

orbitorrhoea. Am J Ophthalmol 1971;71:1037-9. 2. Spetzer RF and Zabramski JM : CSF Fistulae: Their management and repair

In : Neurological Surgery, (Ed). Youmans JR : WB. Saunders company Philadelphia 1990;2227-86.


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There is Lot of Work for Oculoplasty SurgeonsDr. Ather Mohammed, Dr. V. Naga Suresh, Dr. G. Narendranath Reddy, Dr. K. Bharani Kumar Reddy

In the state of Andhra Pradesh Social welfare department had issued a Govt.order which state that visually handicap persons will be given pension

in cash every month. Total blind will be paid Rs. 1000/- PM, 70% blind will be paid Rs.750/-PM and 40% blind will be paid Rs. 500/-PM. Because of this populist measure every teaching hospital and district hospital was thronged by visually handicap persons for obtaining visually handicap certificate.

Regional eye hospital Kurnool which is a teaching hospital attached to Kurnool medical college,Andhra Pradesh has fixed every Saturday for issuing visually handicap certificate.

Aim of the study was to sort out Oculoplasty cases and counsel them to consult the oculoplasty surgeon from the clients coming for visually handicap certificates.

Materials and methods: Prospective study conducted at Regional eye hospital /Kurnool medical college. Period of study was between Jan 2009 to Dec 2009.

1391 candidates who came for visually handicap certificate were thoroughly examined by a board of Ophthalmologists, using Slit lamp, Direct and Indirect Ophthalmoscope, Snellen’s chart. Oculoplasty cases were sorted out and counseled to seek the help of Oculoplasty surgeon after issuing visually handicap certificate.

615 oculoplasty cases were counseled to seek the help of Oculoplasty surgeon. They were as follows:

1. Empty socket( congenital and acquired) : 106 2. Atrophic bulbi : 18 3. Pthisis bulbi : 446 4. Ptosis with amblyopia : 4 5. Symblepharon : 4 6. Anterior staphyloma : 36 7. Plexiform Neurofibroma : 1

RESULTS66 patients agreed for cosmetic treatment offered to them in addition to visually handicap certificate. All 66 patients were of younger age group. They were aged between 11- 25 years. 36 were females. 30 were males.


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Treatment offered was as follows:1. Evisceration of pthisical eyes, atrophic bulbi and anterior staphylomas and

implanting orbital implants and prosthesis in 40 eyes.2. Orbital implant for empty sockets with prosthesis in 22 eyes.3. Correction of congenital ptosis using Autograft Fascia lata by doing Frontalis sling

operation in 4 cases.

Bilateral Lacrimal Gland Amyloidosis Dr. Manjoo S. Reddy, Dr. Andrew Vasnaik, Dr. Yamini Priya, Dr. Raghavendra

Primary amyloidosis is a rare disorder that has a predilection for the lacrimal gland. Since there are no lymphatics in the orbit, the involvement

of the lacrimal gland is due to the presence of lymphatics in this gland. In most cases the involvement is unilateral. However, bilateral involvement is seen if there is systemic involvement.

MATERIALS And METhOdSA 68 year old male presented with painless swelling of both upper lids since 1 year and drooping of both upper eye lids since 6 months. The swelling first started in right upper lid which was insidious in onset and gradually progressive followed by a swelling in left upper lid. Patient did not have any other systemic illness.

On examination, best corrected visual acuity was 6/60 in right eye and 6/18 in left eye. Bilateral, symmetrical upper lid masses were noted measuring about 3cm x 2cm x 1cm with S-shaped deformity of lids. The mass was firm in consistency, immobile, with a smooth surface and well defined margins. A finger could not be insinuated between the mass and the swelling. Patient had senile immature cataract and fundus examination was in normal limits. Elevation of lids was significantly restricted in both the eyes.

Figure 1: (a) Clinical photograph showing bilateral mechanical ptosis due to lacrimal gland enlargement(b) Axial C. T. scan showing bilateral lacrimal gland enlargement

ba


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The anterior segment and fundus evaluation of the patient of the patient was normal except for the presence of immature cataract in both the eyes. The hard swelling of the lids posed a difficulty for performing cataract surgery.

A clinical diagnosis of bilateral lacrimal gland swelling causing mechanical ptosis due to a mass was made. Since the patient had significant ptosis, a decision was taken to biopsy the swelling of the lacrimal gland. The patient was otherwise asymptomatic except for the reduced vision due to cataract. There was no proptosis and extraocular movements did not show any limitation.

Routine blood investigations were in normal limits. Peripheral smear examination was not suggestive of any hematologic malignancy. Computed tomography showed well defined, homogenous, mass lesion, occupying the supero-lateral quadrant of the orbit, extending up to mid orbit; with no evidence of bony erosions or indentation of the globe.

Under general anaesthesia excision biopsy of lacrimal gland was performed first in right eye then in left eye through lid crease. Peroperatively, lacrimal gland was found to be diffusely enlarged lobulated in appearance and was firm in consistency.

Debulking of the mass was done for the bilateral lacrimal gland swelling. The tissue was also subjected to routine histopathological examination and subsequently for immune-histochemistry and electrophoresis. Biopsy confirmed the diagnosis of primary amyloidsis of both the lacrimal glands.

Histopathlogical examination showed fibro-collagenous tissue with dense deposits of amorphous eosinophilic material. Deposits were also seen in the wall of blood vessels. Few multinucleated giant cells seen along with dense aggregates of lymphocytes, plasma cells, macrophages and immunoblasts. Crystal violet stain showed metachromasia and congo red stain showed

a b

c d

Figure 2: Photomicrographs of lacrimal gland biopsy (x 400 mag.) (a) amyoid deposit (H&E); (b) metachromasia (crystal violet), (c) congoredstain showing congophilia; (d) amyloid with lymphoplasmacytic infiltrate


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congophilia with apple green birefrengence to polarised light, suggestive of amyloidosis with granulomatous response associated with dense lymphoid infiltrate.

Patient was referred to oncology center for serum electrophoresis to rule out lympho-proliferative disorder.

dISCUSSIOn Amyloidosis of the lacrimal gland is a rare disorder and seen to affect middle aged women more than men. Review of Indian literature has shown a 45 year old female patient who was reported to have unilateral primary amyloidosis.1 Our case describes an elderly male patient with bilateral primary amyloidosis without systemic involvement. Conlan has described a similar case of bilateral lacrimal gland amyloidosis2 The chemical nature of the deposit was characterized using light microscopy, immune-histochemistry, and immune-electron microscopy. The primary (immunocytic) nature of the amyloid was confirmed by immune-histochemistry demonstrating the presence of monoclonal lambda light chains in the amyloid deposits and in the plasma cells.

Isolated human SAP radiolabelled with 123I has been developed as a highly specific sensitive quantitative diagnostic tracer for all types of amyloidosis.3,4 This however could not be done in our patient.

CT soft tissue contour analysis of the lacrimal gland mass has been reported to show molding to adjacent orbital tissue.5

The disease process is truly local and not part of a systemic process. A majority respond to simple debulking with subsequent observation.6

Bilateral swelling in the region of the lacrimal gland is rare and the differential diagnosis should consider inflammatory disease, epithelial tumors and lymphomas. Sarcoidosis and other local lymphoproliferative disorder can be ruled out by tissue biopsy. Dacryops and amyloid deposition are unusual causes of lacrimal gland enlargement. The diagnosis of systemic amyloidosis can be established by serum electrophoresis, rectal biopsy or abdominal subcutaneous fat biopsy.

This patient is on regular follow up and has so far shown no progression or recurrence of the lesion. Bilateral surgical excision of the lacrimal gland has been effective and has not shown any ocular morbidity.

REfEREnCES1. Prabhakaran VC, Babu K, Mahadevan A, Murthy SR. Amyloidosis of lacrimal

gland. Indian J Ophthalmol. Nov-Dec;57(6):461-3.2. Conlon MR, Chapman WB, Burt WL, Larocque BJ, Hearn SA. Primary localized

amyloidosis of the lacrimal glands. Ophthalmology 1991;98:1556-9.


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Foam Sclerotherapy for The Periocular Vascular Malformations-Our ExperienceDr. Mukesh Sharma, Dr. Rajesh Goyal, Dr. Neha Mohan, Dr. Nupur Goel

Sclerotherapy has been a known modality of treatment for over more than a 200 years now and has fallen and risen in popularity as it has evolved.

Supposedly, first reported attempt at sclerotherapy was by D Zollikofer in Switzerland, 1682 who injected an acid into a vein to induce thrombus formation.[1] The aim of injecting the sclerosing agent is to damage the endothelium of the vessel primarily. Thereafter, pressure is applied to make the walls of the vessel stick together and hence prevent its refilling. Foam sclerotherapy involves mixing of a sclerosing agent with air or a physiological gas like carbon dioxide in various proportions, either in a syringe or using mechanical pumps. The foamed sclerosant has dual benefit. Firstly, it increases the surface area of the drug and secondly, the foam displaces the blood in the vessel, thereby avoiding dilution of the drug and hence giving maximal action. Sodium tetradecyl sulphate (STS-3%) and polidocanol(1%) are the commonest sclerosants in current use that can be used as foam.

MATERIALS And METhOdSFoamed drug formulation and administration

0.5ml of the STS (3%) was taken and mixed with air keeping the air to liquid ratio 1:1. With proper patient consent, this was given percutaneously into the lesion with tuberculin syringe, at multiple sites (0.1 ml each, maximum dose 1 ml) and then contained within the lesion using manual compression for 15 to 20 minutes. Immediately after the injection the area tended to become red and inflamed, hence post sclerotherapy, oral antibiotics and anti-inflammatory preparations were given for 5 days along with ice-pack applications. The

3. Hawkins PN, Lavender JP, Pepys MB. Evaluation ofsystemic amyloidosis by scintigraphy with 123I-labeledserum amyloid P component. NEnglJMed 1990;323:508-13.

4. Hawkins PN. Studies with radiolabelled serum amyloid P component provide evidence for turnover and regression of amyloid deposits in vivo. Clin Sci 1994;87:289-95.

5. Massry GG,Harrison W, Hornblass A.Clinical and computed tomographic characteristics of amyloid tumor of the lacrimal gland. Ophthalmology. 1996;103:1233-6.

6. Murdoch IE, Sullivan TJ, MoseleyI , Hawkins PN, Pepys MB, TanSY, Garner A, Wright JE. Primary localised amyloidosis of the orbit. Br J Ophthalmol. 1996;80:1083-6.


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injections were repeated after 1 month if needed, up to the maximum of 3 sessions.

Patient SelectionAny patient who had primarily extraconal periocular vascular malformation was considered for inclusion in the study. After thorough clinical evaluation, patients underwent an enhanced CT scan orbit for confirmation of nature of lesion. 10 patients of 5-35 years of age (mean age 18.9 years) with a minimum follow up of 6 months were included in the study in the time period between January 2009 - October 2010. Pregnant ladies, children less than 5 years and patients with intraconal vascular malformations were excluded from the study. Also patients with history of stroke, cardiovascular disease, thromboembolism or those allergic to STS were excluded.

RESULTSOut of the 10 patients, none resolved with single session of sclerotherapy; 2 patients (age 14 and 28 years) with localized lid lesions of visible size less than 2 cm diameter, resolved completely with 2 sessions and rest all took 3 sessions. Out of these 8 patients, 5 completely resolved (age 9,12,23,29 and 35 years ) having a visible size of less than 4 cm diameter , in 1 partial response was there and subsequently surgery was facilitated in this patient(age 26 years, visible size of 5 cm diameter) because of induced fibrosis ,surgery was done after 3 months of last injection . Remaining 2 out of these 8 patients did not show any significant improvement with 3 sessions also, these 2 patients with minimum response (age 5 and 8 years) had very large diffuse lesions of visible size of 8 and 10 cm diameter. All patients had pain and swelling for one week post injection, one patient had vomiting in initial 6 hours; other than these no other complications were noted. Therefore to sum up 80% patients showed total or near total resolution with our drug administration regimen. No recurrence

Table 1 S.No. Size of lesion Age (yr) Result of foam sclerotherapy 1. <2 cm 14 Resolved with 2 2. 28 sessions 3. 9 4. 12 Resolved with 3 sessions 5. 2-5 cm 23 6. 29 7. 35 8. 26 Facilitated surgery after 3 sessions 9. >5 cm 5 No significant resolution 10. 8


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has been noted during our limited follow up period of 6 months in the patients who showed resolution

dISCUSSIOnFoamed sclerotherapy has proven to be a promising therapy in the treatment of periocular vascular malformations in our study especially in localized lesions up to a visible size of less than 4 cm diameter and in patients older than 9 years. It may also be helpful in limiting and localizing the larger size lesions to facilitate their surgical removal. It may not be a very effective modality in children younger than 9 years because of natural growth pattern of periocular vascular malformations.

Classically, foam sclerotherapy has been used for varicose veins and haemorrhoids. Sodium tetradecyl sulfate (STS) was developed in 1946, a product still widely used to this day. George Fegan in the 1960s reported treating over 13,000 patients of varicose veins with sclerotherapy, significantly advancing the technique by focussing on fibrosis of the vein rather than thrombosis and emphasizing the importance of compression of the treated leg.3 Main complication seen with STS reported in literature, though rare is skin necrosis. It is seen primarily when the sclerosant is injected superficially and outside the vascular malformation. The systemic complications like stroke are very rare to foam treatment4 although this involved the injection of an unusually large amount of foam in the varicose veins. Visual disturbances such as scotomas have been reported by patients receiving sclerotherapy and appear to be far more common with the use of foam5 than with liquid sclerotherapy with a median rate of 1.4%.6 These events seem to correspond to migraines with aura in a recent study by Gillet et al.7 Above phenomenon have not been fully understood till now and whether or not periocular injections can lead to similar complication is yet to be determined with larger studies. Still remaining on the safer side, in our study we did not include and inject foam sclerosant in patients with intraconal vascular malformations and in our study, one patient had vomiting in initial 6 hours; other than this no other systemic complication was noted.

To summarize, Foam sclerotherapy using Sodium tetradecyl sulfate (STS) 3% and air in 1:1 ratio has proven to be a safe, effective, inexpensive and aesthetically superior therapy in the treatment of periocular vascular malformations especially in localized lesions up to a visible size of less than 4 cm diameter and in patients older than 9 years in our experience. Besides, it may also be helpful in limiting and localizing the larger size lesions to facilitate their surgical removal. Having said so, a study involving more no. of patients with longer follow up would be more conclusive in this regard.


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REfEREnCE1. Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein,

Hardcover Text, 2nd Ed, 1995.2. William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles and

Practice, 2004, WebMD (hardcover book).3. Sharmi S, Cheatle T. Fegan’s Compression Sclerotherapy of Varicose Veins,

Hardcover Text, 2003.4. MV, Grouden M, Moore DJ, Shanik G (2006). “Stroke after varicose vein foam

injection sclerotherapy”. J. Vasc. Surg. 43 (1):162- 4 doi:10.1016/j.jvs.2005.09.032.PMID 16414404.

5. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12 173 sclerotherapy sessions. Dermatol Surg. 2005;3:123–8.

6. Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. BJS 2007;94:925–36.

7. Gillet JL, Donnet A, Lausecker M, Guedes JM, Guex JJ, Lehmann P. Pathophysiology of visual disturbances occurring after foam sclerotherapy. Phlebology 2010. In press.

Surdas (1479-1586): foremost poets of Hindi, is best known for his work “Surasagar” (Ocean of Melody) which includes 1,25,000 poems, written in honour of Lord Bishnu. He was blind since early childhood due to unknown congenital defects of both eyes.

Helen Keller (1880-1968): was blind and deaf from the age of nineteen

months after a severe attack of measles.

Stevie Wonder (1950 - ): of Michigan is a pop superstar, the greatest Rock and Roll musicians. He was born 4 weeks premature and developed retinopathy of prematurity (ROP) and became blind in both eyes.

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