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Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis., Competing Interests: None

A 3-month-old infant presented with unilateral proptosis. Ophthalmic and physical examinations, computed tomography, and histopathologic examination of a biopsy specimen were performed. Histopathologic examination confirmed fungal orbital cellulitis. The patient responded to 6 weeks of antifungal therapy. Fungal orbital cellulitis should be included in the differential diagnosis for infants with proptosis.

Purpose: To present a review of all patients younger than 16 years who presented to us with orbital space-occupying lesions., Methods: Retrospective case study., Results: We analyzed the records of 119 children younger than 16 years of age who had presented to us with proptosis during the 10-year study period. Myogenic tumors were the most common lesion seen (24%), followed by metastatic and secondary orbital tumors (17%), vasculogenic lesions (15%), cystic lesions (10%), inflammatory lesions simulating tumors (7.5%), optic nerve and meningeal tumors (7.5%), peripheral nerve tumors (5%), lacrimal fossa lesions (4%), lymphoid tumors and leukemias (2.5%), primitive neuroectodermal tumors (3%), and others (2.5%)., Conclusion: We analyzed the profile of orbital lesions that underwent surgical procedures and were proven histopathologically. We found 63 malignancies among the 119 cases, for a malignancy rate of 53%. Orbital rhabdomyosarcoma and retinoblastoma with orbital spread were the most common causes of proptosis among the children.

Background: Ptosis surgery is one of the more widely performed surgeries in ophthalmology. Preoperative lagophthalmos, Bell's phenomenon, corneal sensation and dry eye are important factors to be assessed in these cases, which influence the functional and cosmetic results. We herein describe the interesting complication of transient inversion of Bell's phenomenon observed following extensive levator resection performed for congenital ptosis., Methods: Three patients are described who underwent levator resection and showed an inversion of the Bell's phenomenon in the postoperative period, with the eye going down instead of up, during eyelid closure., Results: The Bell's phenomenon reverted to normal in all three cases within 2 weeks and there were no corneal complications. The patients were given frequent lubricating eye drops during this period., Conclusions: It is important to look for variations in Bell's phenomenon in all cases of congenital ptosis, especially following levator resection. In cases with a poor or ineffective Bell's phenomenon, it is imperative to keep a close watch on the cornea along with copious lubrication during the early postoperative period.

Purpose: To study fundus changes associated with orbital mass lesions., Methods: In a prospective, interventional case series, 28 patients undergoing surgery for discrete orbital masses had detailed fundus examination under dilation using direct and indirect ophthalmoscopy. Preoperative visual acuity and the amount and duration of proptosis were noted. Fundus photographs were taken, and postoperative changes were documented. The main outcome measures were the frequency of various fundus changes and their correlation with other clinical features., Results: Nineteen (68%) of 28 patients had fundus changes; the commonest change was optic disk edema, seen in 14 patients (50%). The mean amount of proptosis +/- SD was 7.7 +/- 7.1 mm for patients with fundus changes and 4.22 +/- 2.1 mm for patients with normal fundus. Of 19 patients with fundus changes, 12 (63%) had an intraconal mass, and 11 (58%) had globe indentation. Twenty patients (71%) had diminished visual acuity preoperatively; of these patients, 8 (40%) had improvement in vision after surgery, 10 (50%) did not have any change in vision, and 2 (10%) had a postoperative decrease in visual acuity. Five (62%) of 8 patients with postoperative improvement in visual acuity had proptosis for < 2 years before surgery was undertaken, while only 1 (10%) of 10 patients retaining their preoperative vision had a duration of proptosis of < 2 years., Conclusion: Fundus changes are frequently seen with orbital masses. An increased amount of proptosis, intraconal location, and globe indentation are associated with fundus changes. Postoperative improvement in visual acuity is less likely in patients with a longer duration of symptoms.

Evisceration is a neglected surgery usually performed by the most junior ophthalmologists in unsalvageable eyes with panophthalmitis. It is universal knowledge that evisceration is contraindicated in eyes with intraocular malignancy. We report 2 patients who presented to us with squamous cell carcinoma (SCC) in eviscerated sockets. While one of them was diagnosed with SCC on histopathological examination of the eviscerated contents, the other had history suggestive of conjunctival SCC prior to evisceration. The second patient presented to us with complaints of poorly fitting prostheses. We conclude that it is imperative to rule out not just intraocular but also adnexal malignancy prior to evisceration, and these eyes should be regularly followed up and carefully examined if poor fitting of the prostheses develops.

Purpose: To analyse retrospectively 32 cases of pleomorphic adenoma of the lacrimal gland diagnosed over a 10-year period in a tertiary referral eye centre from North India., Methods: The clinical features of 32 cases of pleomorphic adenomas diagnosed between 1991 and 2000 were analysed and the histopathological features reviewed light microscopically., Results: Among the clinical features, a marked male predominance with younger age of presentation and left-sided dominance was noted. The duration of symptoms was less than 10 months in 28% cases. Histopathologically, the features included presence of cystic degeneration (15.6%) and squamous metaplasia (18.7%). Calcification, osteoid formation and malignant transformation (3.1% each) were occasionally observed., Conclusions: Pleomorphic adenomas of the lacrimal gland may present with duration of symptoms of less than 10 months. Cystic degeneration, squamous metaplasia, calcification or ossification may be observed in lacrimal gland pleomorphic adenomas, as has been described in pleomorphic adenomas of salivary glands. However, the presence of calcification and bone erosion radiologically in a lacrimal gland tumour does not necessarily indicate malignancy.

Purpose: To evaluate the efficacy of polytetrafluoroethylene (Gore-Tex) suture as compared to polybutylate-coated braided polyester (Ethibond) suture as sling materials for frontalis suspension in bilateral congenital ptosis., Methods: Frontalis sling surgery by modified Crawford's double triangle technique was performed on 30 patients (60 eyes) with bilateral ptosis. The patients were randomized into two groups depending on the type of suture material used: polytetrafluoroethylene or braided polyester., Results: Polytetrafluoroethylene suture achieved a statistically significant better and more stable ptosis correction, with slightly more lagophthalmos, than braided polyester suture over a mean (+/- SD) follow-up period of 16 +/- 3.24 months. There were more postoperative complications with braided polyester suture, but the difference was not statistically significant., Conclusion: This is the first clinical study in which polytetrafluoroethylene in the form of suture has been studied. Polytetrafluoroethylene suture was found to be a safe and effective sling material for frontalis suspension and it can be recommended for clinical use.

Purpose: This study aimed to determine the clinical indications for orbital exenteration, profile of these patients and clinicopathological correlations, and to compare these results with previous published data., Methods: A retrospective analysis was conducted of exenterations performed in adults at a tertiary eye care centre in India over a period of 10 years (January 1990 to December 2000). Patient records were reviewed to obtain demographic data, presenting symptoms and their duration, laterality, and clinical and histopathological diagnosis., Results: A total of 26 cases were identified. Patients ranged in age from 32 to 72 years (mean +/- SD 58.7 +/- 9.23 years). No sex predilection was observed. Classification of cases on histopathological criteria showed that exenterations were performed mostly for squamous cell carcinoma (10 cases), followed by sebaceous gland carcinoma (six cases) and basal cell carcinoma (two cases) of the eyelid. Conjunctival malignant melanoma contributed to 5 of 26 cases of exenteration. Adenoid cystic carcinoma of the lacrimal gland (one case), neurofibroma (one case) and orbital fungal infection (one case) were the other indications of exenteration. The clinicopathological correlation was 100% for squamous cell carcinoma, 100% for basal cell carcinoma, 80% for malignant melanoma and 75% for sebaceous gland carcinoma., Conclusion: Exenteration is mainly performed as a life-saving treatment for advanced malignant tumours with epithelial tumours being the commonest. In comparison to previous published data, the indications of surgery in India differed, as squamous cell carcinoma and sebaceous gland carcinoma were the commonest indications for exenteration.

Purpose: To describe the ultrasound features seen in orbital hydatid disease, which may confirm the diagnosis preoperatively., Design: Interventional case series., Methods: Nine patients of orbital hydatid cyst were evaluated preoperatively with ultrasound and computed tomography scans. The diagnostic features seen on ultrasound as well as the CT features are described. All patients underwent surgery to remove the cyst, and the diagnosis was confirmed surgically in all nine cases., Results: We found that ultrasound was most helpful in diagnosing a hydatid cyst, even more so than a computed tomography scan, and we saw a diagnostic "double wall" sign in all cases, on ultrasound, a sign not previously described in orbital hydatids., Conclusions: It is difficult to diagnose an orbital hydatid cyst preoperatively. However, we found that the double wall sign could be elicited ultrasonically in all cases of hydatid cyst, if looked for carefully, and the diagnosis could be confirmed.

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro-orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro-orbital cysticer-cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.

In this prospective, small case series, 3 patients with simple dacryops were analyzed along with a review of literature. All 3 patients in this series had classical clinical features of simple dacryops. All of them underwent complete cyst removal with the aid of a cryoprobe. Histopathology was compatible with dacryops. In 2 of the 3 patients, the cyst revealed calcification, which to the best of our knowledge has not been reported. None of the patients developed a recurrence. In conclusion, simple dacryops is an easily recognized clinical entity. This entity has been infrequently reviewed in the older literature, and in the last decade only 6 cases have been reported. Most of the patients underwent complete excision of the cyst with no recurrences., (Copyright 2002 S. Karger AG, Basel)

Orbital hydatid disease is rare, even in endemic areas. We present a case of disseminated hydatid disease involving the orbit, spleen, lung and liver in a lady aged 35 years. Based on a typical clinical presentation, presence of eosinophilia, a positive indirect haemagglutination test for hydatid disease and presence of similar disseminated, anechoic cystic masses in the liver, lung, spleen and orbit on imaging studies, the diagnosis of hydatid cyst was seriously considered before surgery. Aspiration of the cyst, followed by cryo-extraction of the cyst wall through transconjunctival route was safely performed. Histopathological examination confirmed the diagnosis. In conclusion, multisystemic involvement of liver, lung and spleen in a case of orbital hydatid cyst has never been reported before. The surgical technique adopted in this case is safe and effective., (Copyright 2002 S. Karger AG, Basel)

Extraskeletal mesenchymal chondrosarcoma of the orbit is a rare tumour and generally presents in young females. We report the clinical presentation and histopathological features of a case of orbital mesenchymal chondrosarcoma in a middle-aged man. The prognosis of this tumour is poor and though rare it should be kept in the differential diagnosis of orbital masses.

A 5-year-old girl presented with a large swelling measuring 50 x 35 mm in the left upper lid. The mass was firm to hard in consistency. Fine-needle aspiration showed a few spindle-shaped cells arranged in clusters. The mass was excised in toto and the histopathological examination revealed dermatofibroma, which is an extremely rare condition affecting the eyelid.

A 15-year-old boy presented with diminution of vision which rapidly progressed to no perception of light. In the ocular fundus, a neuroretinitis-like picture was seen. On CT-scan & ultrasonography, an optic nerve swelling was detected with a shadow of scolex. Medical therapy in the form of steroids along with albendazole was ineffective. Surgical removal by lateral orbitotomy was done and a complete cyst with scolex was removed, which was confirmed histopathologically as a case of retrobulbar optic nerve cysticercosis.

Histopathology and various immunohistochemical markers were studied in 40 cases of human retinoblastoma. In histopathology, tumour type, extent and invasion were studied. In immunohistochemistry, both glial and neural markers were used to know the histogenesis of this tumour. The glial markers, glial fibrillary acidic protein and vimentin, were detected in retinal astrocytes and Muller's cells in normal retina and perivascular glia in retinoblastoma. The neural marker, neurone-specific enolase stained neurones in outer and inner nuclear layers in normal retina, Flexner-Wintersteiner rosettes in retinoblastoma and tumour cells is differentiated retinoblastoma. Another neural marker, neurofilament triplet polypeptide stained neurones in inner nuclear layer of normal retina and Flexner-Wintersteiner rosettes in well-differentiated retinoblastoma. These results support the view that retinoblastoma has predominantly neuronal origin.

Specific antibodies against neuron-specific enolase, leukocyte common antigen and desmin were assessed for their usefulness in the cytodiagnosis of 23 cases of pediatric orbital round cell tumors (10 cases of orbital recurrence of retinoblastoma, 11 cases of embryonal rhabdomyosarcoma and 2 cases of inflammatory pseudotumor). Alcohol-fixed, Papanicolaou-stained smears were decolorized and stained with monoclonal antisera using the peroxidase-antiperoxidase procedure. Twenty of 23 aspirates were positively immunostained with antisera against leukocyte common antigen, desmin and neuron-specific enolase. Eight of 10 cases of clinically diagnosed orbital recurrence of retinoblastoma showed strong monotypic staining with anti-neuron-specific enolase antiserum. More than 50% of tumor cells in 9/11 cases of embryonal rhabdomyosarcoma were also immunopositive with this antiserum. Desmin positivity was seen in 10/11 cases of embryonal rhabdomyosarcoma, whereas immunopositivity with leukocyte common antigen was detected in both cases of inflammatory pseudotumor. These results indicate that the use of a panel of monoclonal antibodies on aspirate smears is imperative for establishing the diagnosis and classification of pediatric round cell orbital tumors.

Background: Dermis fat grafts are used in orbital reconstruction in a variety of procedures. However, there have been few controlled studies testing their effectiveness. This is a prospective study on 40 patients., Methods: Primary and secondary orbital dermis fat grafts were evaluated with regard to the long-term cosmetic results of two thicknesses, 10 and 20 mm, of fat pad, keeping all other parameters as constant as possible. Adequacy of the socket, lid anomalies; superior sulcus deformity, exophthalmometry, and motility of the prosthesis were assessed periodically., Conclusion: There was a significantly lower incidence of enophthalmos and superior sulcus deformity with the use of a fat pad thickness of 20 mm, without any compromise in the motility of the prosthesis or take of the graft.

Fine needle aspiration (FNA) biopsy was performed on 35 patients with orbital and adnexal masses. Histopathologic study was performed on 15 of the cases. Examples of benign and malignant primary orbital neoplasms, as well as inflammatory lesions diagnosed this way, are described. The diagnostic accuracy of the technique in evaluating orbital masses was 97.1%; there was one false-negative case. The study indicated that this simple technique has considerable diagnostic value in palpable orbital masses.

Two patients with osseous hemangioma of the orbit, and with typical features on plain radiography and computed tomography, are reported. The typical features of osseous hemangioma of the orbit on computerised tomography (CT) are: expansile bony lesion limited by a thin sclerotic rim, bony trabeculae radiating from the centre to the periphery of the lesion, and absence of an associated extra-tumoral soft tissue mass. To the best of our knowledge this is the first report of osseous hemangioma of the orbit evaluated by CT.

Two unusual cases of Marcus Gunn phenomenon in adults are presented. The first case was characterised by a bilateral jaw-winking phenomenon along with an asymmetric bilateral congenital ptosis, whereas the second case had bizarre spontaneous movements of the affected lid, deficient abduction and pseudoptosis in association with jaw-winking. The pathogenesis of Marcus Gunn phenomenon is discussed.

A rare case of leiomyoma located anteroinferiorly in the orbit of a 39-year-old male patient is reported. The histopathogenesis and management is discussed.

A rare case of facio-orbital anamoly having dermolipoma with posterior extension, lid notch, ectropion, assymetric hypertelorism and lipoma of corpus callosum is presented. The classification of the facial cleft deformities and the surgical management is highlighted.

Modified peribulbar anesthesia was administered with a 26-gauge, half-inch, insulin needle to 367 eyes of 360 patients in three eye camps in India. The intraocular procedures consisted of cataract extraction in 349 eyes, trabeculectomy in 11 eyes, and combined cataract extraction and trabeculectomy in seven eyes. The overall success rate of the anesthesia technique was 90.2% (supplemental anesthesia was required in 36 eyes). There was good lid and globe akinesia and anesthesia, adequate pupillary dilatation for intracapsular cataract extraction, and excellent hypotony. No significant local or systemic complications were observed, except for mild to moderate chemosis in some eyes, which did not produce any intraoperative or postoperative problems. We found this technique easy to learn, relatively safe, effective, and well tolerated by our patients.

The results of split thickness autologous skin grafting along with the use of a dental impression material (Compo), a thermoplastic substance are presented in a series of 11 patients of acquired, severely contracted, anophthalmic sockets. Only the fornix fixation sutures and the central tarsorrhaphy were employed for the proper placement of graft without the use of retention devices. Artificial eyes were successfully fitted and retained subsequently after 6 weeks of grafting.

A modified simple technique for transconjunctival levator resection is presented. Fifteen patients with congenital ptosis with a varying amount of levator action were operated on with this technique. The modification included different techniques for passing the sutures and avoiding separate sutures to form the lid fold. Lidocaine injections administered subconjunctivally and beneath the skin orbicularis lamina facilitate the dissection of the levator, and as much of the levator can be resected as is required. The use of a ptosis clamp was avoided by means of white cotton stay sutures passed through the levator. The postoperative reaction was minimal, and excellent dynamic lid folds were formed.

A modified simple technique of brow suspension by using 4-0 Supramid (non-absorbable thread) suture and only one skin incision is described in 25 eyes of 15 cases of ptosis, including cases of congenital and mechanical ptosis and ptosis with Marcus Gunn phenomenon. This technique avoids the use of any special instruments such as the Reese ptosis knife and Wright needle.