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To describe the surgical outcomes and implant complications in 1,800 patients undergoing evisceration with primary implant.An Electronic Medical Record-driven analysis of 1,800 patients undergoing evisceration with primary implant between 2013 and 2019. Implant sizing was performed intra-operatively to place the largest implant without tension on the wound closure. Outcome measures included implant complications, prosthesis measurements, and incidence of a good aesthetic outcome. Good outcome was defined as2 mm enophthalmos and grade 1 or less superior sulcus deformity with a custom ocular prosthesis.Eighteen hundred eyes of 1800 patients were included. The mean age at surgery was 36 ± 21 years (median 32 years). Implants used were poly(methyl methacrylate) (PMMA) in 1737 (97%) and porous polyethylene in 63 (3%) patients. Two-petal sclerotomy was performed in 1512 (88%) and four-petal sclerotomy in 165 (10%) patients. The mean diameter of the implant used was 19.35 ± 1.18 mm (median 20, range 10-22 mm). The implant extrusion rate was 3% (56) and implant displacement was seen in none. The mean prosthesis volume and thickness were 2.22 ± 0.67 ml (median 2, range 1-6.5 ml) and 6 ± 1 mm (median 6, range 2-9 mm). The mean difference in prosthesis projection on Hertel's exophthalmometer was 0.28 ± 1 mm (median 0, range 0-1 mm). Good outcome was observed in 93%. The mean follow-up period was 351 ± 386 days (median 194).Evisceration with empirically selected primary orbital implant placement is associated with minimal implant complications and gives a good aesthetic outcome in 93% of the patients.

Mucormycosis is an aggressive and potentially fatal invasive fungal infection. The most common form of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). While it is commonly seen in immunocompromised patients, it is also known to affect healthy individuals. The global disease burden of ROCM has increased significantly following the surge in cases during the COVID-19 pandemic. Endoscopic sinus debridement, systemic antifungal therapy, and control of the underlying immunosuppressive condition are essential for the management of ROCM. Orbital involvement, however, presents a challenge to clinicians. Intervention strategies that have been described to treat orbital disease include orbital exenteration, conservative orbital debridement with or without irrigation with amphotericin B and transcutaneous retrobulbar injection of amphotericin B (TRAMB). Currently, there is a lack of clarity regarding the indications and outcomes of TRAMB as a treatment modality. In this review, the drug formulations used, the complications, and outcomes of previously described cases that have used TRAMB in cases of ROCM are discussed. Favorable outcomes following TRAMB depend on appropriate patient selection and radiological evidence of the orbital burden of the disease. This review aims to familiarize clinicians with objective parameters for patient selection for TRAMB, namely the extent of the disease, the clinical features, and radiological findings; viz. the clinical interpretation of areas of contrast uptake and those of necrosis. TRAMB can be considered as a viable option in select cases of orbital mucormycosis where exenteration or debridement are not indicated, or when there is limited orbital disease.

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

Purpose: To describe a series of sight-threatening ocular and adnexal involvement associated with dengue hemorrhagic fever and their treatment options. Methods: Retrospective, interventional, non-comparative case series. Medical records of patients who presented with ocular symptoms attributed to dengue hemorrhagic fever were reviewed. Demography, presenting features, and treatment outcomes were recorded. Outcome measures assessed included globe salvage, vision salvage, and visual improvement. The outcome was deemed as favorable if vision salvage was possible and unfavorable if the vision was lost. Results: Twenty-nine eyes of 23 patients were included. Bilateral ocular involvement was seen in 6 (26%) patients. The mean age was 37.62 ± 18.68 years (range: 14 to 81 years). Coexistent diabetes mellitus and enteric fever were present in three patients. History of blood transfusion was present in nine (40%) and thrombocytopenia in eight (35%) patients at the time of presentation with ocular complaints. Presenting features included endophthalmitis in 11 (38%), panophthalmitis in 10 (35%), orbital cellulitis with panophthalmitis in four (14%), isolated corneal or scleral melt in three (10%), and orbital hemorrhage with panophthalmitis in one (3%) patient. Globe salvage was achieved in 21/29 eyes (72.4%), vision salvage in 6/29 eyes (20.68%), and improvement in visual acuity was noted in 5/29 eyes (17.24%). Logistic regression analysis revealed no significant effect of any clinical-microbiological factors on globe salvage, vision salvage, and visual improvement. However, visual improvement and globe salvage were possible in eyes that underwent early endoscopic vitrectomy. Conclusion: Dengue fever can present with sight-threatening ocular and adnexal inflammation resulting in endophthalmitis and panophthalmitis, orbital cellulitis, corneal and scleral melt, and orbital hemorrhage. Early vitrectomy may improve vision and globe salvage in cases with significant vitritis.

Introduction Choroidal thickness is known to vary in various systemic diseases. In the current study, we aim to report the differences in choroidal thickness in thyroid eye disease (TED) and normals and its discriminatory value for differentiating various stages of TED. Methods Prospective, cross-sectional, non-interventional imaging study. In an institutional practice, 102 eyes of 51 patients were included and divided into five groups: normal controls (C), inactive TED (I), active TED (A), non-inflammatory active TED (NIA) and systemic thyroid disorder but no TED (SYS). Choroidal images were acquired using the swept-source optical coherence tomography (Topcon DRI OCT Triton) with automatic layer segmentation which provided an automatic measurement of the subfoveal choroidal thickness and the mean in nine subfields based on the Early Treatment Diabetic Retinopathy Study (ETDRS) grid. One-way analysis of variance (ANOVA), Youden index and area under the receiver operating characteristic curves (AUROC) were reported. Results Central choroidal thickness in the A group was 279±37.52 microns and in the NIA group was 302.5±59.22 microns. Both were comparable to each other and significantly higher than the C, I and SYS groups (p266 microns, the central sub-field had the strongest discriminatory potential to predict NIA. Conclusion Choroidal thickness is greater in active and non-inflammatory active TED. The inner nasal and central ETDRS sub-fields have value in differentiating the non-inflammatory active TED eyes from the inactive eyes.

Purpose To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM). Method Retrospective study. Results A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20-51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3-18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections. Conclusions Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.

Purpose: To report clinical presentations and factors affecting outcomes in rhino-orbital-cerebral mucormycosis following COVID-19. Methods: Retrospective multi-centric interventional case series of 58 eyes with rhino-orbital-cerebral mucormycosis. Demography, clinical parameters and management outcomes were noted. Factors affecting outcome and mortality were analyzed. Outcome was defined as favorable when complete resolution or stabilization without further progression of the infection was noted at last visit. Results: Mean age was 55 ± 11 years (median 56). The mean HbA1c value was 10.44 ± 2.84 mg% (median 10.5). The duration between the diagnosis of COVID-19 and rhino-orbital-cerebral mucormycosis was 16 ± 21 days (median: 8 days). Thirty-six eyes (62%) had no vision at presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (41%), cavernous sinus involvement (30%), and central nervous system (CNS) involvement (33%). All the patients were treated with systemic Liposomal amphotericin-B and sinus debridement. Twenty-two eyes (38%) underwent exenteration. One eye underwent transcutaneous retrobulbar amphotericin-B. The mean follow-up duration was 5.62 ± 0.78 months (median 6). Favorable outcome was seen in 35 (60%) cases. Presence of uncontrolled diabetes (p = 0.001), orbital apex involvement (p = 0.04), CNS involvement (p = 0.04), and history of steroid use (p < 0.0001) resulted in unfavorable outcome. CNS involvement was the only factor predicting mortality (p = 0.03). Mortality was seen in 20 (34%) patients. Conclusion: Over a third of patients with rhino-orbital-cerebral mucormycosis following COVID-19 have an unfavorable clinical outcome. Uncontrolled diabetes mellitus at presentation, involvement of the orbital apex, CNS, and the usage of steroids were associated with poorer outcomes. CNS involvement was a factor determining mortality., In 58 patients with rhino-orbital-cerebral mucormycosis post-COVID-19, favorable outcome was seen in 35 (60%) cases. Uncontrolled diabetes, orbital apex involvement, cavernous sinus involvement, and use of steroids for COVID-19, resulted in unfavorable outcome.

We describe a case of right eye tubercular (TB) panuveitis with corneal involvement where repeated intraocular sampling was unsuccessful. Finally, evisceration and histopathology of ocular tissue confirmed the diagnosis of ocular tuberculosis. A chest X-ray showed signs of pulmonary TB. The patient was lost to follow-up but reported 2 months later with the right eyelid margin nodules with surface ulceration. Both eyelid and pulmonary lesions were resolved with anti-TB therapy.

Purpose: To assess the outcome of aspiration and sclerotherapy with sodium tetradecyl sulfate in the management of conjunctival inclusion cysts. Methods: Retrospective interventional case series of 6 patients with clinical diagnosis of conjunctival inclusion cysts treated with cyst aspiration and foam sclerotherapy with 3% sodium tetradecyl sulfate. The volume of the sclerosant was 20% of the aspirated cyst volume. Results: Four patients had an inclusion cyst in anophthalmic sockets and 2 patients in sighted eyes. Average time lag between primary surgery and cyst formation was 14.6 months (range 2–30 months). Average amount of fluid aspirated from cyst was 3.07 ml (range 1–9 ml). Average volume of sclerosant injected was (20% of the aspirated volume) 0.55 ml (range 0.2–1.1 ml). All 6 patients showed complete resolution of cyst at a mean follow-up period of 15.6 months (range 9–24 months). All but one showed complete resolution of cyst with single injection sclerosant. Only 1 patient required a second sclerosant injection. There was no ocular surface or implant-related complications in this cohort. Conclusions: Cyst aspiration and sodium tetradecyl sulfate foam sclerotherapy is a minimally invasive procedure for the management of conjunctival inclusion cysts in anophthalmic sockets and sighted eyes. The injection of sodium tetradecyl sulfate in a dose of 20% of the aspirate is effective in the management of conjunctival inclusion cysts over a follow-up period of 13 months. The procedure is safe, with insignificant inflammation and without ocular surface or implant complications.

Purpose: To compare differences in clinical presentation and management outcomes of orbital and periorbital dermoid cysts in children and adults. Methods: A retrospective interventional comparative consecutive case series. 203 patients in (148 children [Age ⩽18 years] and 55 adults [Age >18 years]), who underwent excision biopsy for orbital/periorbital dermoid cyst were included. Outcome measures included the differences in demography, clinical presentations, radiological features, surgical outcomes and histopathology of cysts between children and adults with dermoid cysts. Results: The mean age noted at excision was 15 years in this cohort of 148 children and 55 adults. Commonest clinical finding observed was a subcutaneous painless mass (94%) and external angular dermoids were commonest in both groups 1 and 2 (51% and 56%). Diminution of vision ( p = 0.007), proptosis ( p = 0.008), extraocular motility limitation ( p = 0.001), strabismus ( p = 0.003) and relative afferent pupillary defect ( p = 0.02) were significantly more in adults. Orbital involvement and dumbbell dermoids were not significantly different between children and adults. Radiologically, bony fossa formation ( p = 0.03), temporal fossa extension ( p = 0.04), full thickness bony defect ( p = 0.03) and intraosseous presentation ( p = 0.005) were significantly more in adults. Comparison of proportion of lesions having intra-operative rupture of dermoid cyst ( p = 0.009) and evidence of inflammation on histopathology ( p = 0.01) were significantly more in adults. However, recurrence rates were not different between children and adults. Conclusions: Dermoid cysts are commoner in children, but can also present in adulthood. Secondary visual, orbital, radiologic changes and intra-operative rupture of dermoid cyst are more common in adults compared to children.

The genes in the 9p21 locus (CDKN2B-AS1 &amp, CDKN2B) are widely associated with Primary open-angle glaucoma (POAG). However, the functional importance of this locus in POAG pathogenesis is still unexplored. This study investigated the role of CDKN2BAS1-CDKN2B axis in POAG. We observed significant association of CDKN2B-AS1 SNP rs4977756 with POAG and its endophenotypic traits (vertical cup-disc ratio (p = 0.033) and central corneal thickness (p = 0.008)) by screening African American POAG cases (n = 1567) and controls (n = 1600). A luciferase reporter assay in Human embryonic kidney 293T (HEK293T) cells revealed that the region surrounding rs4977756 likely serves as a transcriptional repressor. siRNA-mediated knockdown of CDKN2B-AS1 in HEK293T cells and trabecular meshwork (TM) cells resulted in significantly increased expression of CDKN2B, which was also observed in human POAG ocular tissues. Pathway focused qRT-PCR gene expression analysis showed increased cellular senescence, TGF&beta, signaling and ECM deposition in TM cells after CDKN2B-AS1 suppression. In conclusion, we report that CDKN2B-AS1 may act as a regulator, and it could function by modulating the expression of CDKN2B. In addition, increase in CDKN2B levels due to CDKN2B-AS1 suppression may result in the senescence of trabecular meshwork cells leading to POAG pathogenesis.

To describe the histopathologic and immunohistochemical characteristics of peri-orbital implant capsule and correlate the observed changes with delayed implant extrusion.Prospective, ex-vivo, histopathologic, immunohistochemical study of peri-implant capsules excised from capsules surrounding a poly-methyl metha acrylate (PMMA) implant. Thirteen capsules were harvested and divided into two groups. Group 1 (implant extrusion group) consisted of capsules harvested from around exposed/extruded implants and Group 2 (implant non-extrusion group) from implants that were surgically exchanged for volume augmentation. Data collected included demography, clinical presentations, etiology of the explantation, age of the capsule in months, inflammatory cells noted/high power field (HPF), CD3, CD20, and CD68, percentage Masson's trichrome staining and mean capsular thickness.Mean patient age at presentation was 33 ± 13 years. Of the 13 capsules included, 7 belonged to group 1and 6 to group 2. Mean age of the fibro-collagenous membranes were 33 ± 57 months (median 13 months). Median CD3, CD20, and CD68 positivity was 80%, 9%, and 7% denoting a predominant T-lymphocytic response. Mean capsular thickness was 733 ± 422µ (median 678µ). Age of the harvested capsule showed a linear correlation with inflammatory cells/HPF (r = 0.93,PMMA orbital spherical implant incites a predominantly T-cell mediated inflammatory response which clinically presents as a peri-implant capsule. Increasing inflammation in the absence of significant fibrosis may be responsible for delayed PMMA implant exposure and extrusion.

Anthony Vipin Das,1 Tarjani Vivek Dave2 1Department of eyeSmart EMR & AEye, L V Prasad Eye Institute, Hyderabad, Telangana, India; 2Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, IndiaCorrespondence: Tarjani Vivek DaveOphthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad 500034, Telangana, IndiaTel +91-7680849900Email tvdeye@gmail.comPurpose: To describe the prevalence, demographics and clinical presentations of chalazion in patients presenting to a multi-tier ophthalmology network in India.Materials and Methods: This was a cross-sectional observational multi-centric hospital-based study of 1,982,058 new patients presenting between 2010 and 2019. Patients with both symptoms and signs of chalazion were considered as subjects. The data were retrieved using an electronic medical record system.Results: Overall, 11,270 (0.57%) new patients were diagnosed with chalazion. Of these, 1,085 (10%) patients had recurrent chalazia. The prevalence rates were 0.95% in children and 0.51% in adults. Males accounted for 51% of the cases, and 79% had unilateral affliction. The commonest age group affected was the third decade of life (31%). Of the 13,691 affected eyes with chalazion, 39% were located in the upper eyelid, 6% were lateral in position and 3% have multiple swellings at presentation. Conservative treatment was the preferred treatment modality in 85%. Incision and curettage were performed in 15% eyes and intralesional steroid in 0.55% eyes. Of the 15% patients that were advised surgery, 9% underwent the procedure with a conversion rate of 58%.Conclusion: Only a miniscule percentage of patients seeking eye care in India are affected by chalazion. It is slightly more common in males and is usually unilateral and largely affects the upper eyelids. It is recurrent in a tenth of the cases. Conservative management is the preferred modality.Keywords: chalazion, epidemiology, big data, electronic medical records

Objectives To study the efficacy and the long-term outcomes of treating micro and macrocystic orbital and/or adnexal lymphatic malformations (OA-LM) with protocol-based bleomycin sclerotherapy. Methods A retrospective interventional study of 69 eyes having OA-LM treated with non-image guided transcutaneous or transconjunctival bleomycin sclerotherapy (1IU/ml aqueous solution) between December 2014 and December 2018. Based on clinical regression, the outcomes were classified as excellent, good, fair and poor. Results The mean age at presentation was 20 ± 16 years (median 16; range 1 month to 70 years). The orbital-palpebral variant was the most common presentation, seen in 29 patients (42%). Microcystic morphology was seen in 34(49%), macrocystic in 22 (32%) and mixed cyst in 13 (19%) patients. Mean units of bleomycin injected per patient were 9 ± 8 IU (median 5.5 IU, range 1-38 IU). Mean number of treatment sessions required were 2 ± 1 (median 2, range 1-6). The response was excellent in 43 (62%), good in 12 (17%), fair in 9 (13%) and poor in 5 (7%) patients. These responses were comparable across the morphological subgroups (p = 0.24, chi-square test). Adverse reactions noted were inflammation in 11 eyes (16%) and peri-ocular pigmentation in 15 (22%). There was a sustained tumour regression over a mean follow-up duration of 3.5 years (median 3; range 1.5-5 years). Conclusions Seventy-nine percent of eyes with OA-LM showed a good outcome with transcutaneous and/or transconjunctival non-image guided bleomycin sclerotherapy with no serious adverse events. The results were promising over long-term follow-up.

Aim: To test if hyaluronic acid gel injection in the upper eyelid achieves correction of congenital cicatricial ectropion and reduction in lagophthalmos, in preparation for intraocular surgery. Methods: This case reports the long-term outcome of hyaluronic acid gel injection in the upper eyelid for the correction of ectropion prior to cataract surgery. One millilitre of hyaluronic acid gel was injected in both the upper eyelids of a child with congenital ichthyosis in the suborbicularis plane, prior to cataract surgery. Results: Lagophthalmos reduced by 15 mm in the right eye and 13 mm in the left eye. Subsequently, the child underwent cataract surgery without any complications. Conclusion: We demonstrate the long-term outcome of using hyaluronic acid gel injection for successful, non-surgical correction of cicatricial ectropion in ichthyosis.

Purpose: To study the proportion of eyelid malignant tumors in an Asian Indian population and to review their clinical features and outcomes. Methods: This is a retrospective study of 536 patients. Results: The mean age at presentation with eyelid malignancy was 58 years. Histopathology-proven diagnoses of these patients included sebaceous gland carcinoma (SGC) (n = 285, 53%), basal cell carcinoma (BCC) (n = 128, 24%), squamous cell carcinoma (SCC) (n = 99, 18%), and miscellaneous tumors (n = 24, 4%). The statistically significant differences between eyelid malignant tumors included age at presentation, tumor location, and tumor extent. The clinicopathological correlation of SGC, BCC, SCC, and miscellaneous tumors was 91, 86, 46, and 38% (p = 0.001), respectively. Comparing SGC with BCC, SCC, and miscellaneous tumors, SGC was more commonly associated with tumor recurrence (21 vs. 3, 8, and 13%; p = 0.001), systemic metastasis (13 vs. 0, 4, and 13%; p = 0.001), and death (9 vs. 0, 4, and 0%; p = 0.004). Compared to SGC, BCC, and SCC, locoregional lymph node metastasis was more common with miscellaneous tumors (26 vs. 16, < 1, and 8%; p = 0.001) over a mean follow-up period of 19 months. Conclusion: In Asian Indians, SGC is twice as common as BCC and 3 times more common than SCC. SGC is associated with poorer prognosis compared to other eyelid malignant tumors.

AIM To determine whether evisceration with optic nerve disinsertion and nonporous implant placement increases the risk of implant migration. METHODS This was a single-center, retrospective consecutive comparative interventional case series including patients undergoing evisceration with nonporous implant between January and December 2014. Patients were grouped into 2 groups: group I where the optic nerve was not disinserted (n = 37) and group II with optic nerve disinsertion (n = 50). Implant migration was assessed clinically and on patient photographs. Migration was subclassified as decentration that did not affect the prosthetic outcome and displacement that affected the prosthetic outcome. The secondary outcome measures were the mean implant diameter, volume of the custom ocular prosthesis, and implant-related complications like exposure and extrusion between the 2 groups. RESULTS At a mean follow up of 12.5 months, none of the sockets in group I and 3 (6%) sockets in group II (p = 0.35) had evidence of implant decentration. There were no cases of implant displacement in both groups. The mean implant diameter in group I was 16.97 mm ± 0.65 mm and in group II 19.2 mm ± 0.83 mm (p = 0.0001). Implant extrusion was not different between the 2 groups. The mean custom ocular prosthesis volume in group I was 3.86 ml ± 0.52 ml and in group II 2.50 ml ± 0.68 ml (p < 0.0001). CONCLUSIONS The rate of nonporous implant migration due to optic nerve disinsertion is not statistically or clinically significant in evisceration with optic nerve disinsertion, allowing placement of a larger implant and fabrication of a custom ocular prosthesis with an ideal weight.

To report the outcomes of external dacryocystorhinostomy (Ext DCR) in paediatric patients.A single-centre, retrospective, interventional, non-comparative case series was performed on all paediatric patients who underwent Ext DCR between July 2010 and July 2014. Surgery was performed as per standard Ext DCR protocols with only anterior flap suturing. Data collected include demographics, clinical presentations, primary diagnosis, associated systemic anomalies, past interventions, indications for the surgery, use of adjuvants, intraoperative and post-operative complications, aetiology of DCR failure, anatomical and functional successes.135 eyes of 114 children underwent Ext DCR during the study period. Mean age was 9.68 ± 4.36 years and epiphora was the most common presentation (92.5%, 125/135). Persistent congenital nasolacrimal duct obstruction refractory to earlier interventions of probing or intubation was the most common indication for the surgery noted in 57% (77/135). Adjuvants like mitomycin C and intubation were used in 70% (95/135) and 72% (98/135) of the surgeries, respectively. At a 6-month follow-up, anatomical and functional successes were noted in 91.1% (124/135) and 90.3% (123/135), respectively. 12 eyes showed anatomical failure and one eye showed functional failure. The most common cause of DCR failure was a complete cicatricial closure of the ostium (83.4%, 10/12).This study shows that Ext DCR is a safe surgery for paediatric populations with a high success rates of beyond 90%.

This study aims to report a rare case of melanoacanthoma of the eyelid. Melanoacanthoma is very rare variant of seborrheic keratosis presenting as a rare benign pigmented lesion composed of both melanocytes and keratinocytes usually presenting over the head, neck, and trunk of elderly people. A 61-year-old female presented with 8 mm × 4 mm × 3 mm brownish black mass in her right lower lid for the past 4 years associated with itching. Clinical differential diagnosis of seborrheic keratosis and nevus was offered. The patient underwent shave biopsy, and biopsy tissue was sent for histopathological examination. A diagnosis of melanoacanthoma was made on histopathology. Melanoacanthoma of the eyelid is a rare entity, and one should consider in differential diagnosis of pigmented lesion of the eyelid mass.

Objective To demonstrate the techniques and utility of 3-dimensional reconstruction (3DR) of the target pathologies for subsequent navigation guidance in ophthalmic plastic surgery. Design Prospective interventional case series. Methods Stereotactic surgeries using 3D reconstruction of target lesions as the intraoperative image-guiding tool were performed in 5 patients with varied etiopathologies. All the surgeries were performed using the intraoperative image-guided StealthStation system in the electromagnetic mode. 3DR was performed using StealthStation 3D model software. The utility of 3D reconstruction for extensive orbital mass lesions, large orbital fractures, intraconal foreign body, and delineation of perilesional intricate structures was studied. The intraoperative ease and usefulness for the navigation of a 3D lesion at crucial phases of the surgery were noted. Results Intraoperative geometric localization of the 3D lesions was found to be enhanced and precise. 3D reconstruction of the lesion along with the major vessels and nerves in the vicinity helped the surgeon to prevent potential injuries to these structures. The fracture defects could be navigated in a 3D plane and this helped in moderate customization of the implants intraoperatively. Foreign body located in difficult access positions could be accurately targeted for geometric localization before safe retrieval. Detailed preoperative 3D reconstruction by the surgeon was found to be beneficial for successful outcomes. Conclusions Three-dimensional navigation is very useful in providing detailed anatomical delineation of the targets and enhances the precision in certain complex cases in ophthalmic plastic surgery.

Mohammad Javed Ali,1 Swati Singh,1 Milind N Naik,1 Swathi Kaliki,2 Tarjani Vivek Dave1 1Govindram Seksaria Institute of Dacryology, 2The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Hyderabad, Telangana, India Aim: The aim of this study was to report the preliminary experience with the techniques and utility of navigation-guided, 3D, computed tomography–dacryocystography (CT-DCG) in the management of secondary acquired lacrimal drainage obstructions.Methods: Stereotactic surgeries using CT-DCG as the intraoperative image-guiding tool were performed in 3 patients. One patient had nasolacrimal duct obstruction (NLDO) following a complete maxillectomy for a sinus malignancy, and the other 2 had NLDO following extensive maxillofacial trauma. All patients underwent a 3D CT-DCG. Image-guided dacryolocalization (IGDL) was performed using the intraoperative image-guided StealthStation™ system in the electromagnetic mode. All patients underwent navigation-guided powered endoscopic dacryocystorhinostomy (DCR). The utility of intraoperative dacryocystographic guidance and the ability to localize the lacrimal drainage system in the altered endoscopic anatomical milieu were noted.Results: Intraoperative geometric localization of the lacrimal sac and the nasolacrimal duct could be easily achieved. Constant orientation of the lacrimal drainage system was possible while navigating in the vicinity of altered endoscopic perilacrimal anatomy. Useful clues with regard to modifications while performing a powered endoscopic DCR could be obtained. Surgeries could be performed with utmost safety and precision, thereby avoiding complications. Detailed preoperative 3D CT-DCG reconstructions with constant intraoperative dacryolocalization were found to be essential for successful outcomes.Conclusion: The 3D CT-DCG-guided navigation procedure is very useful while performing endoscopic DCRs in cases of secondary acquired and complex NLDOs. Keywords: CT-dacryocystography, image guidance, navigation, lacrimal drainage, nasolacrimal duct obstruction, powered endoscopic DCR

PURPOSE To develop a standardized and universally reproducible grading scale for artistic outcome of a custom ocular prosthesis. METHODS A retrospective review of photographs of patients with custom ocular prosthesis. From the ocularistry database of a tertiary eye care hospital, photographs of patients with custom ocular prosthesis (30 random photos with additional 18 repetitions, total n = 50) were selected. Two independent oculoplastic surgeons, on the basis of characteristics of limbus, vascularity, and pigmentation, graded these photos. The photos were adjusted for confounders like magnification and illumination, and both graders used the same display system. The surgeons were blinded to each other. The characteristics were graded on a scale of 0 to 2 and total score was calculated for each photo. Inter-observer and intra-observer agreement was calculated using the kappa statistic. RESULTS The inter-observer kappa coefficient for the three characteristics (95% confidence interval) were as follows: limbus 0.7 (0.55-0.85), vascularity 0.76 (0.58-0.94), and pigmentation 0.6 (0.34-0.85). The intra-observer kappa coefficient for the first surgeon was as follows: limbus 0.88 (0.7-0.95), vascularity 0.88 (0.73-0.95), and pigmentation 0.82 (0.54-0.93). The intra-observer kappa coefficient for the second surgeon was as follows: limbus 0.8 (0.44-0.93), vascularity 0.55 (0.13-0.8), and pigmentation 0.76 (0.6-0.84). CONCLUSIONS A good intra- and inter-observer agreement was demonstrated. In view of no existing grading for prosthesis, this is a unique system to objectively grade the outcome of custom ocular prosthesis and can be incorporated in ocularistry teaching modules for standardization of outcomes.

Mohammad Javed Ali,1 Swati Singh,1 Milind N Naik,1 Swathi Kaliki,2 Tarjani Vivek Dave1 1The Institute of Dacryology, 2The Operation Eyesight Universal Institute for Eye Cancer, L.V. Prasad Eye Institute, Hyderabad, India Purpose: The aims of this study were to report the preliminary experience of using telescopes, which were enabled for navigation guidance, and their utility in complex endoscopic lacrimal surgeries. Methods: Navigation enabling of the telescope was achieved by using the AxiEM™ malleable neuronavigation shunt stylet. Image-guided dacryolocalization was performed in five patients using the intraoperative image-guided StealthStation™ system in the electromagnetic mode. The “look ahead” protocol software was used to assist the surgeon in assessing the intraoperative geometric location of the endoscope and what lies ahead in real time. All patients underwent navigation-guided powered endoscopic dacryocystorhinostomy. The utility of uninterrupted navigation guidance throughout the surgery with the endoscope as the navigating tool was noted. Results: Intraoperative geometric localization of the lacrimal sac and the nasolacrimal duct could be easily deciphered. Constant orientation of the lacrimal drainage system and the peri-lacrimal anatomy was possible without the need for repeated point localizations throughout the surgery. The “look ahead” features could accurately alert the surgeon of anatomical structures that exists at 5, 10 and 15 mm in front of the endoscope. Good securing of the shunt stylet with the telescope was found to be essential for constant and accurate navigation. Conclusion: Navigation-enabled endoscopes provide the surgeon with the advantage of sustained stereotactic anatomical awareness at all times during the surgery. Keywords: telescope, endoscope, image guidance, navigation, lacrimal surgery, powered endoscopic DCR

Purpose: To study the prevalence and types of lacrimal drainage system (LDS) anomalies inchildren with congenital microphthalmia anophthalmia coloboma (MAC) complex.Methods: This is a prospective, ...

Purpose: The aim of this study was to perform a histopathological assessment of the efficacy of sclerosing agents in dacryocystosclerotherapy (DCST) and to evaluate its role as an alternati...

The aim of this study was to illustrate the techniques and usefulness of navigation-guided computed tomography angiography in ophthalmic plastic surgery.Stereotactic surgeries using computed tomography angiography as the intraoperative image-guiding tool were performed in 3 patients. One patient had widespread eyelid and orbital vascular malformation and the other 2 had orbital mass lesions located in crucial vascular areas. Two procedures used the external approach and one was performed using the endoscopic orbital approach. All the surgeries were performed using the intraoperative image-guided StealthStation system in the electromagnetic mode. The usefulness of intraoperative angiographic anatomical guidance and the ability to anticipate and avoid vascular injuries at crucial phases of surgery were noted.Intraoperative geometric localization of feeder vessels to a lesion could be easily achieved. The cauterization of the direct feeder to the lesion reduced the much anticipated blood loss while operating a widespread vascular malformation. Orbital mass lesions with vessels in the vicinity could be operated upon with utmost vascular safety and precision, thereby avoiding complications. Detailed preoperative navigation-guided planning of risk structures with intraoperative distance control was found to be essential for successful outcomes.Computed tomography angiography-guided navigation surgery is very useful in cases with complex vascular malformations and while operating in the vicinity of crucial vascular structures in the orbit.

Tarjani Vivek Dave, Faraz Ali Mohammed, Mohammad Javed Ali, Milind N Naik The Institute of Dacryology, L V Prasad Eye Institute, Hyderabad, India Background: The aim of this study was to assess the etiological factors contributing to the failure of a dacryocystorhinostomy (DCR). Patients and methods: Retrospective review was performed in 100 consecutive patients who were diagnosed with anatomically failed DCR at presentation to a tertiary care hospital over a 5-year period from 2010 to 2015. Patient records were reviewed for demographic data, type of past surgery, preoperative endoscopic findings, previous use of adjuvants such as intubation and mitomycin C, and intraoperative notes during the re-revision. The potential etiological factors for failure were noted. Results: Of the 100 patients with failed DCRs, the primary surgery was an external DCR in 73 and endoscopic DCR in 27 patients. Six patients in each group had multiple revisions. The mean ages at presentation in the external and endoscopic groups were 39.41years and 37.19years, respectively. All patients presented with epiphora. The most common causes of failure were inadequate osteotomy (69.8% in the external group and 85.1% in the endoscopic group, P=0.19) followed by inadequate or inappropriate sac marsupialization (60.2% in the external group and 77.7% in the endoscopic group, P=0.16) and cicatricial closure of the ostium (50.6% in the external group and 55.5% in the endoscopic group, P=0.83). The least common causes such as ostium granulomas and paradoxical middle turbinate (1.37%, n=1) were noted in the external group only. Conclusion: Inadequate osteotomy, incomplete sac marsupialization, and cicatricial closure of the ostium were the most common causes of failure and did not significantly differ in the external and endoscopic groups. Meticulous evaluation to identify causative factors for failure and addressing them are crucial for subsequent successful outcomes. Keywords: failed DCR, etiologies, cicatricial closure, osteotomy, endoscopy

Purpose To describe a case of diffuse choroidal hemangioma with exudative retinal detachment treated successfully with oral propranolol. Methods Single interventional case report of a 14-year-old boy, known case of Sturge-Weber syndrome, presented with decreased vision in the right eye since 2 months. Presenting vision was finger-counting at 3 m. Examination revealed a neurosensory detachment at the macula clinically appearing like central serous chorioretinopathy. Fundus fluorescein angiogram, B-scan ultrasound, and optical coherence tomography were consistent with an underlying diffuse choroidal hemangioma with secondary exudative macular detachment. The patient could not afford radiotherapy and thus was treated with oral propranolol. Results Serial clinical examinations and optical coherence tomographies showed gradual resolution of the subretinal fluid. Vision at the last visit 4 months after treatment was 6/9 best corrected. Conclusion Choroidal hemangioma can be mistaken clinically to be central serous chorioretinopathy. Oral propranolol is an effective and economical treatment option in patients not affording other standard modalities of treatment.

Lacrimal sac tumors are extremely rare but can be life threatening. Seventy percent of lacrimal sac tumors are of epithelial origin. Inverted transitional cell papilloma of the lacrimal sac is a rare epithelial sinonasal tumor of benign etiology with local invasion and malignant potential. These lesions may remain undiagnosed or may present with signs and symptoms of dacryocystitis or may transform to transitional cell carcinomas. Most lesions are diagnosed intra-operatively while performing a dacryocystorhinostomy. Biopsy and histopathological examination of mass lesions arising from the lacrimal sac helps in timely management of these rare tumors.

Ocular pain is a common complaint which forces the patient to seek immediate medical attention. It is the primeval first response of the body to any severe condition of the eye such as trauma, infections and inflammation. The pain can be due to conditions directly affecting the eye and ocular adnexa; or indirect which would manifest as referred pain from other organ structures such as the central nervous system. Paradoxically, there are several minor and non-sight threatening conditions, which also leads to ocular pain and does not merit urgent hospital visits. In this perspective, we intend to provide guidelines to the practising ophthalmologist for teleconsultation when a patient complains of pain with focus on how to differentiate the various diagnoses that can be managed over teleconsultation and those requiring emergency care in the clinic. These guidelines can decrease unnecessary hospital visits, which is the need of the hour in the pandemic era and also beyond. Patients who are under quarantine and those who are unable to travel would be benefitted, and at the same time, the burden of increased patient load in busy hospital systems can be reduced.

Sebaceous gland carcinoma (SGC) of the eyelid is one of the leading peri-ocular eyelid malignancies in Asian-Indians. It usually affects elderly women and has a high rate of local recurrence, regional and distant metastasis. This is partly attributable to a delay in clinical diagnosis since it mimics more benign conditions of the eyelid like chalazia. To the best of our knowledge, this is the first case report of a peri-punctal SGC. Atypical location and the young age of the patient resulted in a relatively conservative excisional biopsy under frozen section control and eyelid reconstruction with a favorable outcome.

PURPOSE To compare outcomes of frontalis sling (FS) silicone and levator resection (LR) in ptosis associated with monocular elevation deficiency. METHODS Retrospective interventional comparative case series of FS and LR in monocular elevation deficiency associated ptosis. Favorable outcome was defined as difference in margin reflex distance 1 of ≤1 mm between the 2 eyes in unilateral cases and margin reflex distance 1 of 4 mm in bilateral cases at last follow-up visit. RESULTS One hundred four eyes of 95 patients were included. Median age at surgery was 14 years, and the mean follow-up period was 19.75 ± 34.55 months. Ptosis was severe in 91 (87.5%) patients. Associated Marcus Gunn jaw-winking (MGJW) phenomenon was seen in 43 (42%) patients. Frontalis sling was performed in 76 (73%) and LR in 28 (27%). Mean pre- and postoperative margin reflex distance 1 were -1.27 ± 2.17 mm and 2.18 ± 1.49 mm (p < 0.0001). The mean improvement in margin reflex distance 1 was significantly more with FS (4.46 ± 2.19) compared with LR (1.85 + 2.5) (p < 0.0001). There were no cases of exposure keratopathy requiring reversal of surgery in either group. The number of resurgeries required was 42 (55%) in the FS group and 10 (36%) (p = 0.08) in the LR group. Favorable outcome was seen in 54 (71%) in FS group and 16 (57%) (p = 0.17) in LR group. CONCLUSIONS When compared with levator resection, frontalis suspension with silicone gives a better eyelid elevation but has greater regression requiring more resurgeries. In spite of a poor Bells phenomenon, exposure keratopathy is not a concern.

To study the concordance between intra-operative rapid frozen section and permanent section diagnoses of surgical margins following wide surgical excisional biopsy of malignant eyelid tumors. This is a retrospective study of 120 cases and 429 frozen section slides. Of 120 cases, 75 (63%) had sebaceous gland carcinoma, 34 (28%) had basal cell carcinoma, and 11 (9%) had squamous cell carcinoma. All cases with these malignant eyelid tumors underwent wide surgical excisional biopsy under frozen section control of surgical margins. A total of 429 frozen section slides were reviewed for rapid frozen section diagnosis. Eyelid reconstruction was performed in all cases after clearance was obtained by rapid frozen section diagnosis of surgical margins as negative for tumor infiltration. Permanent section diagnosis of surgical margins was positive for tumor infiltration in 5 (1%) slides, which were reported as negative on rapid frozen section diagnosis of surgical margins, and was negative for tumor infiltration in 3 (

Congenital microphthalmos belongs to a spectrum of diseases ranging from true anophthalmos to congenital clinical anophthalmos to microphthalmos. These conditions are frequently associated with an orbitopalpebral cyst, and pathologically, this represents a failure in the closure of the embryonic fissure at the 7-14 mm stage of gestation. The cyst develops as an outpouching from the eyeball and is generally helpful as it provides a stimulus for the orbit to expand. The general management guideline is to retain the cyst till it provides a stimulus for the orbit to expand and then to consider aspiration and sclerotherapy once orbital expansion is achieved. However, in eyes that have visual potential, sclerotherapy is contraindicated. The authors present an unusual case of a mildly microphthalmic eye with visual potential and a communicating cyst that was excised with a good result. The challenges faced in the excision of the communicating cyst with a wide pedicle and the management of the case are highlighted.

This study aims to describe the clinicopathological features and outcomes of patients who underwent orbital exenteration at a tertiary eye care center in south India. Retrospective chart reviews were performed on all patients undergoing orbital exenteration from January 1999 to December 2012. Parameters recorded include demographic data, clinical presentations, past medical or surgical interventions, exenteration notes, histopathological diagnosis, adjunctive treatment, follow-up examination findings, recurrences, complications, and their management. Orbital exenteration was performed on 119 orbits of 119 patients over a 14-year period. The mean age was 48.9 years (range 1-82 years). The indications were malignancies in 90.7 % (108/119), while 9.3 % (11/119) of cases were exenterated for non-malignant indications. Among the malignancies, the commonest tissue of origin was conjunctiva, noted in 45.4 % (49/108), followed by eyelids (25.9 %, 28/108), orbit (19.4 %, 21/108), and intraocular tissues (9.3 %, 10/108). The commonest malignancies noted in this series were an extensive ocular surface squamous neoplasia (OSSN) (44.4 %, 48/108) and sebaceous gland carcinoma of eyelids with an orbital involvement (18.5 %, 20/108). Extensive fungal granuloma (mucormycosis-4, aspergillosis-4) was the commonest (81.8 %, 9/11) indication among the non-malignant group. All complications were wound related, and none had a recurrence at a mean follow-up of 12.8 months. Extensive orbital involvement with OSSN and SGC were the commonest indications for exenteration. There is a need of creating awareness among general ophthalmologists in specific geographical regions regarding early diagnosis, standardized protocols of management, and appropriate referral.

Lacrimal drainage obstructions causing epiphora is a common lacrimal disorder. Depending on the age of the patient and the pathophysiology of the condition, the disorder can either be relieved by simple probing or by a dacryocystorhinostomy (DCR). In certain conditions, the success rates of the treatment can be improved by intubating the lacrimal system. Canalicular intubation is also indicated in the management of lacerated canaliculus. Intubation is achieved commonly by placing a silicone stent in the lacrimal passages. The silicone stent maintains the passages where it is present and is also believed to allow tissue healing around itself, thus maintaining lacrimal patency.

Purpose To report a single-center experience with nonsurgical correction of epiblepharon using hyaluronic acid gel. Methods The medical records of consecutive patients with symptomatic epiblepharon treated over a 3-year period with hyaluronic acid gel injection were reviewed retrospectively. Hyaluronic acid gel was injected transcutaneously into the suborbicularis plane to obliterate the abnormal skin fold or evert the eyelid margin. Successful treatment was defined as eversion of the eyelid margin as assessed by lash-cornea touch. Results Ten eyelids of 8 patients (7 girls [88%]) underwent transcutaneous hyaluronic acid gel injection for correction of epiblepharon. Average age at presentation was 16.5 months (range, 1-72 months). Two patients had bilateral involvement. Of 10 eyelids, 8 had a distinct skin fold with a “valley” above it. Nine of 10 eyelids had lash-cornea touch in the primary gaze; 1 in downgaze. All 10 eyes had punctate corneal epitheliopathy on fluorescein staining. An average of 0.19 ml (range, 0.1–0.3 ml) of hyaluronic acid gel was injected per eyelid. After injection, 9 of 10 eyelids showed no lash-cornea touch in downgaze, and all 10 eyelids showed resolution of symptoms and epitheliopathy. Patients remained symptom-free for an average final follow-up of 19.1 months (range, 5-42 months). No procedure-related complications were noted. Conclusions In our small case series, transcutaneous hyaluronic acid gel injection into the lower eyelid effectively corrected symptomatic epiblepharon; the effect was long lasting.

Schwannomas are benign, encapsulated, primary neurilemmal tumors composed of proliferating Schwann cells. Schwannomas are commonly seen in the orbit, but are rare on the epibulbar surface. Herein, we report a case of a 12-year-old boy who presented to us with a slow-growing painless subconjunctival mass in the left eye. There was no intraocular extension of the mass and intra-operatively, the mass could be clearly delineated and was excised off the underlying sclera. Histopathological examination of the mass showed typical features of schwannoma and immunohistochemistry helped to confirm the diagnosis. There was no recurrence of the lesion observed at follow-up 26 months after surgery. Here, we describe this uncommon tumor and review the available literature. Although rare, an epibulbar schwannoma should be considered in the differential diagnosis of an amelanotic, painless subconjunctival nodular mass. Excision of the lesion is the recommended treatment.

To study the clinical and histopathological features of eyelid sebaceous gland carcinoma (SGC) and to evaluate the prognosis in the Asian-Indian population.This is a retrospective study of 191 patients with SGC.The mean age at presentation of eyelid SGC was 57 years (median, 56 years). The tumor epicenter was most commonly located in the upper eyelid (n=125, 65%). The mean tumor basal diameter was 15 mm (median, 10 mm). There was evidence of tumor extension into the orbit (n=30, 16%), paranasal sinuses (n=3, 2%), and brain (n=1, 1%). Wide excision biopsy (n=146, 78%) was the most common treatment modality. Tumor recurrence was noted in 42 (24%) patients over a mean follow-up period of 29 months (median, 20 months). On the basis of the Kaplan-Meier estimate, lymph node metastasis occurred in 18%, systemic metastasis was detected in 10%, and death occurred in 2% of patients at 10 years. On multivariate analysis, the factors predicting locoregional lymph node and systemic metastasis were medial canthal involvement (P=0.004; P=0.013), lateral canthal involvement (P=0.013; P=0.025), tumor basal diameter10 mm (P=0.002; P=0.002), and perivascular invasion (P=0.043; P0.001), respectively. The factors predicting death due to metastasis on multivariate analysis were medial canthal involvement (P=0.012) and tumor basal diameter10 mm (P=0.001).Advanced eyelid SGC is a tumor associated with poor prognosis. In this study, canthal involvement, larger tumor diameter, and perivascular invasion were poor prognostic factors.

Clinical examinations section is a whole different ball game as compared to theory examinations. Often most students find it rather easy to score in a theory examination, but when it comes to a clinical case examination it seems a tough cookie to crack. In this article, we would like to share a few tips and some dos and don'ts with respect to taking a clinical examination successfully.

Purpose: The aims of this study were to determine the acceptability levels of different styles of the doctors’ dress and the expectations from the initial phases of physician-patient encounter. Methods: The study design was a cross-sectional descriptive type using the survey methodology. A survey based on a five-point questionnaire was performed on all consecutive patients or their caregivers, aged ≥15, visiting the ophthalmic plastics outpatient clinics at a tertiary eye care institute. The participants were shown three sets of photographs and were required to answer a questionnaire which consisted of five questions. Data collected include participant demographics and their preferences with regards to the physician's attire and initial communications. Results: A total of 300 consecutive responses were analyzed. The mean age of the participants was 37.2 years. Among the participants, 87.6% (263/300) and 90.3% (271/300) preferred a white coat for the male and female physicians, respectively (P < 0.001). The most common second preference was scrubs for both the males and female physicians. 92.3% (277/300) preferred the attire to have an identification display. The overwhelming majority of respondents (95.6%, 287/300) preferred the physicians to address them by their name and 98.6% (296/300) liked if their physicians smiled while addressing them. Conclusions: White coat was the main preferred attire among respondents. Increased awareness of the patient's expectations plays a crucial role in enhancing their satisfaction.

PURPOSE To report the cosmetic and functional outcomes of subciliary incision for external dacryocystorhinostomy (DCR). METHODS Prospective interventional study reporting subciliary incision to perform external DCR for primary acquired nasolacrimal duct obstruction. Successful functional outcome was defined as relief from epiphora, and patent lacrimal irrigation. Final cosmetic outcome of the scar was evaluated by subjective grading of the scar by the patient, and objective grading by the physician using high-resolution digital photographs. RESULTS Seventeen eyes of 16 patients (4 males) with a mean age of 41.75 years (range, 26-71) underwent subciliary approach external DCR over a period of 22 months (March 2010 to December 2011). Pre-operative diagnosis was primary acquired nasolacrimal duct obstruction in all cases. Anatomic and functional success was noted in all 17 (100%) eyes. At the final follow up, objective grading of the scar by the physician reported 47% scars to be invisible (grade 0), and 88.2% scars to be invisible or minimally visible (grade 0-1). At the final follow up, subjective scar grading by the patient reported 88% scars to be invisible (grade 0), and 100% scars to be invisible or minimally visible (grade 0-1). In 2 (11.7%) cases, the physician reported the final scar as moderately visible (grade 2). Average follow up after surgery was 29 weeks (range, 6-72 weeks). In 2 eyes (first 2 cases), the incision extended medially by 2 mm. No other surgery related complications were noted. CONCLUSIONS Subciliary DCR provides an excellent functional cosmetic scar outcome while retaining the access and advantages of external DCR procedure.

Combined hamartoma of the retina and retinal pigment epithelium is a congenital non‐hereditary benign retinal tumour of unknown aetiology possibly due to translocation between the short arms of chr...