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External Free Papers 70th AIOC Proceedings, Cochin 2012

External Diseases

Role of Tacrolimus Ointment (0.03%) in Refractory Vernal (VKC) and Dry ------550 Dr. Sheetal Deolekar, Dr. Samar Kumar Basak, Dr. Sanjib Banerjee

Surgical Management of SINS (Surgically Induced Necrotising )------553 Dr. Uma Sridhar

Tacrolimus 0.03% Ointment for Seborrhoeic -An Open Label Pilot Study------556 Dr. Saswata Biswas, Dr. Santanu Mitra

Conjunctival Telangiectasia Mimicking as in A Child With Port-Wine (PW) Stain------559 Dr. Anup Kumar Goswami, Dr. Col. B.L.Goswami

Autoblood as Tissue Adhesive for Conjunctival Autograft Fixation in ------562 Dr. Santanu Mitra, Dr. Samar K Basak, Dr. Debasish Bhattacharya

Controlled Trial of Cyclosporine Versus Olopatadine Topically in Treatment of Vernal Keratoconjuntivitis------566 Dr. (Mrs.) Eva Tirkey, Dr. (Prof) M. K. Rathore, Dr. (Mrs.) Shashi Jain, Dr. S.C.L. Chandravanshi

Active Pulmonary Tuberculosis Presenting with Phlyctenular Keratoconjunctivitis------568 Dr. Minu Ramakrishnan

Critical Evaluation and Management of Epibulbar Dermoid------570 Dr. Anita Panda, Dr. Anoop, Dr. Sasikala NK

Comparison of Carboxymethylcellulose with and without Osmoprotective Agents in Dry ------573 Dr. Gupta P, Dr. Jain M, Dr. Jain R and Dr. D’Souza P.

Unusual OSSN – Role of Radio-Imaging. Where are we Today?------582 Dr. Rama Rajagopal, Dr. Ravi Daulat Barbhaya, Dr. Bipasha Mukherjee, Dr. Olma Veena Noronha, Dr. Krishna Kumar S.

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External Chairman: Dr. Vemuganti Geeta Kashyap; Co-Chairman: Dr. Satyamurthy K.V. Convenor: Dr. Shreesh Kumar K.; Moderator: Dr. Ayan Mohanta

Role of Tacrolimus Ointment (0.03%) in Refractory Vernal Keratoconjunctivitis (VKC) and Dry Eye Dr. Sheetal Deolekar, Dr. Samar Kumar Basak, Dr. Sanjib Banerjee KC is a chronic ,bilateral conjunctival inflammatory condition common in Vindividuals with atopic background. The disease itself and its treatment with long-term topical steroids can cause significant complications and are potentially blinding. The current treatment modalities include topical steroids, mast cell stabilizers and antihistamines. Though topical steroids can bring relief of symptoms they need to be tapered quickly to avoid and but the recurrent and chronic nature of disease leads to prescribing steroids for very long duration by many of the ophthalmologists. The incidence of visual loss due to steroid induced glaucoma varies from 2%1 to 7.69%2 in two series. The incidence of visual loss secondary to steroid induced cataract was 15.32% in the same series.2 Dry eye is a multi factorial disease and the current management includes tear substitutes as the mainstay of treatment. Cyclosporin A, a calcineurin inhibitor is being used as anti-inflammatory agent and is not associated with any significant ocular or systemic adverse reaction. Perry et. al. demonstrated better results in improvement of dry signs in severe disease than mild to moderate disease.3 The main factor limiting widespread use of this drug is the high cost of the available preparations. Tacrolimus (FK-506) is a strong immunosuppressant that inhibits the proliferative response of lymphocytes to alloantigen stimulation and a variety of T cell associated immune reactions. It has been isolated from the fermentation broth of Streptomyces tsukubaenis. Tacrolimus suppresses the immune responses by inhibiting the inflammatory cytokine release e.g. ( , interleukin-2, IL-3, IL-4, IL-5, IL-8, interferon-gamma, tumor necrosis factor-α) and also down-regulates the high-affinity IgE receptor I (FcRI) expression on Langerhans cells.4 Tacrolimus shares several immunosuppressive properties with cyclosporine A, although it is known to be 10 to 100 times more potent in this regard.5 Its safety and efficacy in the treatment of atopic dermatitis have been demonstrated in short- and long-term studies with adult and pediatric patients.6 The purpose of this study is to evaluate efficacy and safety of off label

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tacrolimus ointment 0.03% in severe VKC and dry eye refractory to conventional .

MaterialS and Methods Patients were divided into two groups according to disease Group A VKC and Group B Severe dry eye. Group-A: 20 eyes of 10 patients of severe VKC with papillae (>5 each>3 mm). All patients were known to have had a long-standing VKC that was previously treated with steroid eye drops. Some of them presented elevation of the and cataract due to previous steroid treatment or were refractory to the standard steroid regime. None of the patients had a history of chemical, thermal, radiation , bacterial, viral or toxic cicatrical conjunctivitis, or underwent any ocular surgery that would create an ocular surface problem. Group-B: 10 eyes of 5 patients with severe dry eye (Schirmer<5mm, Rose Bengal score>4) None of these patients were on topical cyclosporine before starting tacrolimus. One of the patient had severe dry eye secondary to Steven Johnson syndrome. Tacrolimus ointment 0.03% (Tacroz, Glenmark Pharma) was advised twice daily. The dermatological ointment available in the market was attached with the specially designed nozzle to deliver intended quantity of the drug (5 mm ribbon). (Figure 1). Followup was done on day 7, 30, 60 and 90. Figure 1: Specially designed nozzle Both groups evaluated by symptom score attached to dermatological ointment and serial photographs in Gr-A and tear function tests in Gr-B. Adverse reactions if any were noted.

Results All patients completed the study. Two of five dry eye patients complain of burning or heat sensation, the most common adverse effects of the tacrolimus ointment which resolved over a period of 2 weeks. None of the patients presented episode of herpetic during the treatment with tacrolimus. No significant changes in the intraocular pressure, , , or anterior chamber occurred in any patients during the treatment with

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topical tacrolimus. Significant subjective improvement in itching, was observed and objectively significant decrease in the size of papillae on anterior segment photography and inflammation on slit lamp examination was noticed.. Two representative cases of improvement in clinical findings in limbal and tarsal papillae after 1 month of treatment with tacrolimus is shown (Figure 2,3). Group-B: Improved Schirmer and Rose Bengal score (p<0.05% used student t test)

Discussion Tacrolimus is an approved drug for atopic dermatitis; it has an immunosuppressive effect in the inflammatory cascade. Currently, there are 2 FDA-approved concentrations of tacrolimus—0.1% and Figure 2: Pre and Post treatment VKC 0.03% (for children under 2 years of age). limbal form at 1 month Recent studies in children showed that both concentrations of tacrolimus are safe and effective for use in moderate to severe atopic dermatitis. PMK Tam et. al. have also shown topical tacrolimus as effective monotherapy in VKC.7 For ophthalmic use, topical tacrolimus ointment has been used in atopic keratoconjuctivitis, blepharo keratoconjunctivitis, chronic follicular conjunctivitis, and vernal keratoconjuctivitis. was reported as a potential adverse effect of topical tacrolimus in the case series described by Joseph et. al.8 Studies in animals have proved that topical tacrolimus increases aqueous tear secretion and can be used in Figure 3: Reduction in size of papillae keratoconjunctivitis sicca refractory to post treatment at 1 month. cyclosporine9 but it was not used in humans in past. Our study shows significant improvement in shirmers test accompanied by subjective improvement and improved visual acuity.

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In conclusion tacrolimus skin ointment is safe, effective and well tolerated in severe VKC and refractory dry eye. It may be considered as an alternative to steroid or cyclosporine in both cases. Future prospective studies with further follow-up and more cases are necessary regarding the long-term efficacy of this therapeutic approach for patients with VKC and refractory dry eye.

References 1. Bonini S, Lambaise A, Marchi S et. al. Vernal keratoconjunctivitis revised: a case series of 195 patients with long-term follow-up. . 2000;107:1157-63. 2. Tabbara KF. Ocular complications of vernal keratoconjunctivitis. Can J Ophthalmol. 1999;34:88-92 3. Perry HD, Solomon R, Donnenfeld ED et. al. Evaluation of topical cyclosporine for the treatment of dry eye disease. Arch Ophthalmol. 2008;126:1046-50. 4. Reitamo S, Remitz A, Kyllonen H, Saarikko J. Topical noncorticosteroid immunomodulation in the treatment of atopic dermatitis. Am J. Clin Dermatol. 2002;3:381–8. 5. Ezeamuzie CI. Anti-allergic activity of cyclosporin-A metabolites and their interaction with the parent compound and FK 506. Int J. Immunopharmacol. 1996;18:263–70. 6. Kang S, Lucky AW, Pariser D, Lawrence I, Hanifin JM. Long-term safety and efficacy of tacrolimus ointment for the treatment of atopic dermatitis in children.J Am Acad Dermatol. 2001;44(Suppl):S58–64. 7. PMK Tam, AL Young, LL Cheng et. al. Topical tacrolimus 0.03% monotherapy for vernal keratoconjunctivitis- case series. Br J. Ophthalmol 2010;94:1405-6. 8. Mark Joseph et. al. Topical tacrolimus ointment for treatment of refractory anterior segment disorders. Cornea. 2005;24:417-20. 9. Hendrix DV, Adkins EA, Ward DA et. al. An investigation comparing the efficacy of topical ocular application of tacrolimus and cyclosporine in . Vet med Int. 2011.2011:487592; Epub2011 May 23.

Surgical Management of SINS (Surgically Induced Necrotising Scleritis Dr. Uma Sridhar mong the not so common post operative complications of intra ocular Aand extra ocular is surgically induced necrostising scleritis. However, it can be devastating enough to cause loss of vision and sometimes necessitate removal of the eye. In severe cases, there is inflammation of the in the surgical site leading to melting of the sclera and exposure of uveal tissue. The procedures which are more likely to cause this complication are those in which there is dissection of and episclera i.e. procedures

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such as squint surgery1, pterygium excision2,3 small incision cataract surgery, extracapsular cataract extraction 4 and sclera buckling for . The aim is to share our experience in managing five such cases of surgically induced necrotizing scleritis.

Materials and methods Five cases of SINS (surgically induced necrotizing scleritis) were managed in a tertiary care eye hospital. Three cases were due to small incision cataract surgery. Case one was a non diabetic, non hypertensive, immunocompetent lady with no known collagen vascular disorder, who had an uneventful small incision cataract surgery. On post operative day one, there was good recovery of vision with a clear cornea and well formed anterior chamber. However, the intraocular pressure was low and Seidel’s test was positive. Wound exploration was done. Sutures could not be placed due to cheese wiring in the thin sclera. Scleral patch graft was placed at the wound and anchores with 10-0 nylon sutures. Conjunctiva was mobilized to cover the area. Post operatively, the IOP was normal and the patient was discharged. One week later, she developed a large epithelial defect in the cornea. The epithelial defect did not heal inspite of medical management. She had a stromal infiltrate under the epithelial defect and on further follow up. Medical treatment after corneal scraping which revealed Gram positive cocci and intravitreal antibiotics did not improve her condition. Ultimately the eye was unsalvageable and had to be eviscerated. Case two and three were referred to us within a month after small incision cataract surgery with scleral thinning in the area of scleral incision. Both these patients had symptoms of pain and watering, but there was good visual acuity (BCVA 6/12 and 6/18 respectively). Wound exploration was done and sclera patch grafts were placed. In these two cases fibrin glue was used to anchor the scleral patch grafts and conjunctiva was sutured over the grafts. In one case the conjunctiva retracted over the patch graft. Both the cases had good anatomical and visual outcome and after two years of follow up, were symptom free with good visual acuity. Cases four and five were pterygium surgeries with bare sclera perfomed by surgical residents in a community set up. The patients presented a week after surgery in both cases with pain and watering. There was scleral thinning seen in the ares of pterygium excision with a vascularity. Double layered amniotic membrane graft was used as a substrate and free conjunctival graft was placed. All were anchored with fibrin glue. Both the cases had good anatomical and visual outcomes. Initial microbiological work up was negative in all patients as was collagen vascular workup. All were immunocompetent and nondiabetic. Case number

554 External Diseases Free Papers one had Gram positive cocci in the corneal infiltrate. All patients were medically managed pre and post operatively with topical steroids and systemic non steroidal anti-inflammatory drugs. No patient was and systemically immunosupressed.

Results Case number one had poor anatomical and surgical outcome and ultimately the eye could not be salvaged. Case number two had a BCVA of 6/12 and was symptom free. Case number three had a BCVA of 6/18 and the sclera patch graft had taken up very well. The two cases after pterygium surgery also were symptom free with both had BCVA of 6/6. Anatomically also, the area over the bare sclera was well covered by the conjunctival autograft and vascularity was restored.

Discussion SINS is a challenge which needs to be managed on a war footing. Outcomes are not always good as seen with our first case. Use of fibrin glue certainly helped in better anchoring of the sclera and conjunctival grafts and cheese wiring due to sutures could be avoided. Many case reports of SINS after surgery are in patients with collagen vascular disorders which was persisting or discovered after surgery.2 In most cases systemic immunosupression was used and medical managent was done along with surgical treatment.2,3,4,5 Presentation in many cases was months or years after the surgery. In our cases presentation was early, only topical steroids were used and infection was present only in case number one. None of our cases had any collagen vascular disorders as seen by negative collagen work up. In conclusion SINS can be a devastating complication after ocular surgery and needs to be investigated and managed promptly for good anatomical and visual outcome.

References 1. Gregory ME, Weir CR, Ramaesh K. Excision of granulation tissue and free conjunctival autograft in the management of necrotizing scleritis. Cornea. 2010;29:577-9. 2. Jain V, Shome D, Natarajan S, Narverkar R. Surgically induced necrotizing scleritis after pterygium surgery with conjunctival autograft. Cornea. 2008;27:720-1. 3. Gokhale NS, Samant R. Surgically induced necrotizing scleritis after pterygium surgery. Indian J Ophthalmol. 2007;55:144-6. 4. Sen J, Kamath GG, Clearkin LG. Surgically induced diffuse scleritis: comparison of incidence in phacoemulsification and conventional extracapsular cataract extraction. Br J. Ophthalmol. 2002;86:701; Cornea. 20 02;21:305 -7. 5. Sridhar MS, Bansal AK, Rao GN.Surgically induced necrotizing scleritis after pterygium excision and conjunctival autograft. Cornea. 20 02;21:305 -7.

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Tacrolimus 0.03% Ointment for Seborrhoeic Blepharitis-An Open Label Pilot Study Dr. Saswata Biswas, Dr. Santanu Mitra eborrhoeic Dermatitis is characterized by erythematous pruritic patches Sand plaques with greasy scale that occurs in sebaceous areas like face, ears and scalp affecting over 3% of general population. Seborrhoeic blepharitis is often associated with the dermatitis. Soft scales along the lid margins and are associated with the symptoms of burning, itching and foreign body sensation. Both the dermatitis and blepharitis have chronic and relapsing course. They are treated with topical steroid ointments which causes rapid relief but long term side effects like intra ocular pressure rise and skin atrophy limits their use. Tacrolimus stands for Tsukuba Macrolide Immunosuppresant. When used topically, it is a calcineurin inhibitor with immunosuppressant action, used for seborrhoeic dermatitis and has been proven to be effective without causing skin atrophy.1 Moreover when tried in ocular disorders like atopic keratoconjunctivits and vernal conjunctivitis, it has not elevated the IOP or caused any serious adverse effect.2 So it was decided to be tried in seborrhoeic blepharitis in lowest concentration of 0.03%. Purpose of this study is objective of this study is to determine the efficacy of topical Tacrolimus in seborrhoeic blepharitis as an unique treatment.

Materials and methods Ten consecutive patients from hospital OPD were enrolled for an open label uncontrolled prospective trial. All of them were directed to apply 0.03% Tacrolimus ointment to the twice daily for 4 weeks. All patients were informed of the aim of the trial. Patients with known medical conditions which may alter their immune response (, AIDS, malignancy) were excluded from the study. Pregnant and lactating mothers were other exclusions. Patients using conventional therapy for the ocular condition were asked to discontinue that for 2 weeks. Slit lamp biomicroscopy, IOP measurement and visual acuity assessment were done. Symptoms of pruritus, burning and foreign body sensation were measured using a 4 point scale (Grade 1-4). Clinical sign of scaling was graded according to sign score scale (Grade 1-4). Global assessment of disease severity by patients and investigators were performed at each visit (1-4). Serial photography was done. Assessment was done at baseline (0), at week 2 and at week 4. Local adverse effects of Tacrolimus (burning, tingling, pain, others) were enquired for and noted (1- 4). A lubricant (carboxymethyl cellulose 0.5%) was added to minimize local

556 External Diseases Free Papers discomfort of the trial drug in 4 patients. Burning sensation was then dropped from the symptoms score.

RESULTS There was significant improvement of in all patients except one. Mean clinical scores of scaling, pruritus and foreign body sensation improved from 3, 2.8 and 2.7 at baseline to 1.4, 1.1 and 1.2 at 4 weeks respectively. Photography was not very helpful as it was difficult to show the greasy scales, but in 4 of the patients the improvement was successfully recorded. 6 of the patients (60%) reported marked improvement of symptoms after 2 weeks of use, 3 (33.3%) moderate improvement, 1 slight improvement. 9 (90%) reached the marked improvement level at 4 weeks. One dissatisfied patient had poor compliance. Examiner global assessment was almost same. 4 of the patients (40%) complained of burning on initial application which subsided within a day or two. As three of them had that complaint at baseline, the lubricant was thought to be necessary for compliance. One patient had transient tingling sensation and eyeache which did not require any medication.

Table 1: Global Disease Severity Assessment Degree of 2nd Week 4th Week improvement Number of Number of Number of Number of patients (%)by patients(%)by patients(%)by patients(%)by patients patients physicians assessment assessment assessment assessment Marked improvement 70% 70% 90% 90% Moderate improvement 20% 20% 0% 0% Slight improvement 10% 10% 10% 10% No improvement 0% 0% 0% 0%

Table 2: Mean Sign And Symptoms Score Pre-treatment Post-treatment (4 weeks) Scaling 3 1.4 Pruritus 2.8 1.1 F B Sensation 2.7 1.2

Table 3: Mean Non-Contact Tonometry Pre-treatment Post-treatment (2 wks) Post-treatment (4 wks) Right Eye 13.4 13.2 13.2 Left Eye 13.7 13.4 13.3

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DISCUSSION It was truly a novel application of Tacrolimus as PUBMED search did not yield any result. But interestingly, dermatologist Kenneth A Arndt and Jeffrey T.S.Hsu in their book “Manual of Therapeutics” prescribed the use of the drug in seborrhoeic blepharitis. Whenever a new drug is used, safety is of primary concern. When used as a systemic drug to suppress organ transplant rejection, it has got a long list of possible adverse effect. But Cheer SM et. al. 3 stated Tacrolimus ointment penetrates human skin with no systemic accumulation after repeated applications; systemic absorption is generally low, with most patients in clinical trials having blood concentrations of the drug below the limit of quantification. So it is not surprising that Cook BA et. al.4 found long term topical use of the drug in atopic dermatitis did not cause any increase in infection rate, photo carcinogenicity or signs of immunosuppression. The standard therapy of steroid ointment carries the risk of IOP rise. Nivenius E. et. al.5 found the application of Tacrolimus ointment to the eyelids in atopic keratoconjunctivitis did not cause any rise in IOP. In our trial non contact tonometry was done at each visit, but there was no significant increase in any patients. Usually seborrhoeic blepharitis is associated with meibomitis so hot fomentation, lid massage and oral Doxycycline tablet are added to the regime. Here we have not prescribed those to get the efficacy of Tacrolimus as a single drug therapy. In real life scenario if those are added, there should be faster relief of symptoms. Limitation of Study As our sample size was small and it was a short term study, we tried to establish the efficacy of the drug only in the particular condition. In conclusion as it has been proven to be effective; the study attains its goal and should pave the way for a larger controlled long term study to establish the safety and tolerability of the drug. Then the drug can be prescribed as a regular therapy of seborrhoeic blepharitis.

REFERENCES 1. Cook BA, Warshaw EM. Role of topical calcineurin inhibitors in the treatment of seborrheic dermatitis: a review of pathophysiology, safety, and efficacy. Am J Clin Dermatol. 2009;10:103-18. doi: 10.2165/00128071-200910020-00003. 2. Remitz A, Virtanen HM, Reitamo S, Kari O. Tacrolimus ointment in atopic blepharoconjunctivitis does not seem to elevate intraocular pressure. Acta Ophthalmol. 2011;89:e295-6. doi: 10.1111/j.1755-3768.2009.01834. 3. Cheer SM, Plosker G. Tacrolimus ointment. A review of its therapeutic potential as a topical therapy in atopic dermatitis. Am J Clin Dermatol. 2(6):389-406. 4. Cook BA, Warshaw EM. University of Minnesota School of , Minneapolis, Minnesota, USA. Role of topical calcineurin inhibitors in the treatment of

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seborrheic dermatitis: a review of pathophysiology, safety, and efficacy. Am J Clin Dermatol. 2009;10:103-18. doi: 10.2165/00128071-200910020-00003. 5. Nivenius E, van der Ploeg I, Jung K, Chryssanthou E, van Hage M, Montan PG Tacrolimus ointment vs steroid ointment for dermatitis in patients with atopic keratoconjunctivitis. Eye (Lond). 2007;21:968-75. Epub 2006 May 5.

Conjunctival Telangiectasia Mimicking as Conjunctivitis in A Child With Port-Wine (PW) Stain Dr. Anup Kumar Goswami, Dr. Col. B.L.Goswami cular redness typically brings to mind diagnoses such as conjunctivitis Oand iritis, with the typical associated symptoms. However, there are a number of ocular conditions where ocular redness is neither from an infectious cause, nor from a primarily inflammatory ocular cause such as iritis, scleritis, or glaucoma. Conjunctival telangiectasia is one such condition leading to . Presence of vascular malformation in skin, such as salmon patch (naevus simplex) and port wine stain (naevus flammeus), or any systemic1,2 disorder, in cases of red eye should be viewed with high index of suspicion for possible presence of other ocular abnormalities. We report a case of segmental conjunctival telangiectasia misdiagnosed as conjunctivitis associated with port-wine stain (Incomplete bisymptomatic Sturge-Weber syndrome) in an otherwise healthy child. Case Report A 10 year old male child came to OPD with complaint of poor relief in redness of RE being treated elsewhere. He was having a reddish-purple patch/port- wine stain (Fig. 1) on right side of face involving eyelids. History revealed that the patch was present since birth. There were no ocular/ systemic complaints owing to the patch except poor cosmesis. Ocular Examination Torch-light examination showed mild superficial congestion of inferior fornicial and bulbar conjunctiva of RE suggesting partially treated conjunctivitis. Function and anatomy of lids was normal. Ocular motility was within normal limits. VA was 6/6 BE. Careful Slit-lamp examination revealed that presumed superficial conjunctival congestion suggesting conjunctivitis did not conform to usual pattern and of conjunctivitis. Pink-red dilated and tortuous conjunctival and subconjunctival vessels were seen without discharge (Fig. 2). The congestion was limited to Fig. 1: Right-sided port-wine stain the lower half of bulbar

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conjunctiva while the upper fornicial and bulbar conjunctiva didn’t show any congestion (Fig.3). There was no history of any discharge from the eye, any treatment for systemic disease, any vernacular treatment at home or a traditional healer. Tonometry and pupillary reactions were normal. The diagnosis was revised to segmental conjunctival telangiectasia. Ongoing treatment in form of topical moxifloxacin was stopped and patient was reviewed on third and seventh day. There was no change in congestion pattern and color, and a diagnosis of segmental conjunctival telangiectasia with P-W stain Figure 1: Right-sided port-wine stain (Incomplete bisymptomatic Sturge-Weber syndrome) was confirmed. Persistent unilaterality of the condition was also a factor for suspecting a condition other than conjunctivitis as examination of left eye (Fig.3) did not show any lesion. Normal CT scans of brain ruled out Complete Sturge-Weber syndrome. The patient was reassured and six monthly follow-up was advised. Figure 2: Tortuous conjunctival and subconjunctival vessels in Right eye. Examination of Port-Wine stain (Fig.- 1) showed that it was extending from 5mm above the medial one-third of right eyebrow involving medial two-thirds of upper lid whole of lower lid, right cheek to right half of upper lip, which was hypertrophied leading to a gentle pout. No facial palsy or any other cranial nerve involvement was noted.

Systemic examination by paediatrician Figure 3: Congestion free upper bulbar didn’t reveal any disorder/anomaly thereby conjunctiva of RE and normal LE. r u l i n g o u t a s s o c i a t i o n w i t h a n y s y n d r o m e .

DISCUSSION Capillary vascular malformations (telangiectatic naevi) often referred to as flat haemangiomas, are in fact malformed dilated blood vessels in the skin.

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Lesions appear as blotches of red or purple skin discolouration on any part of the body. Two common malformations are salmon patch (naevus simplex) and port wine stain (naevus flammeus). Salmon patch are common in newborns and found at the nape of neck, on the forehead between the eyebrows or on eyelids. Most lesions disappear within the first year of life. Port wine stain are less common than salmon patches. Face is most commonly affected. They do not shrink or disappear spontaneously and may deepen in color over time. Some rare syndromes may present with this kind of birthmark such as- • Sturge-Weber syndrome • Parkes Weber syndrome • Klippel-Trenaunay-Weber syndrome • Beckwith-Wiedemann syndrome The diagnosis of present case (conjunctival telangiectasia with port wine stain) conforms to incomplete bisymptomatic Sturge-Weber syndrome described as: Sturge-Weber syndrome (SWS) is also known as encephalotrigeminal angiomatosis. It is the association of capillary vascular malformation affecting the skin supplied by one branch of the trigeminal nerve of the face with defects in brain(atrophy, calcification, meningeal angioma) and eye abnormalities3 (glaucoma, optic atrophy, hemangiomas in conjunctiva, episclera, , , ). Eye, skin, and central nervous system may be affected at different times. The 3 types of SWS are: • Complete trisymptomatic SWS - All 3 organ systems are involved • Incomplete bisymptomatic SWS-Involvement is oculocutaneous or neurocutaneous • Incomplete monosymptomatic SWS- Only neural or cutaneous involvement is noted Secondary glaucoma may present at any age, and therefore all patients with Sturge-Weber syndrome (SWS) need regular follow-ups4 for life. Gonioscopic evaluation may be required to plan the management of glaucoma. In our case IOP was found normal and six monthly follow-up was advised for possible development of glaucoma. Capillary vascular malformations are diagnosed clinically and no investigations are necessary. Ultrasound scan/CT/MRI/angoigraphy is often performed to know whether underlying tissues are affected or to plan treatment. Perimetry is indicated for damage resulting from glaucoma, retinal degeneration and vascular abnormalities in occipital lobe. Complex syndromes require careful assessment, often by a team of specialists that may include a dermatologist, paediatrician, radiologist and plastic/ vascular surgeon besides an ophthalmologist to rule out varied systemic involvement.

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Port wine stains usually may not cause any functional loss but are cosmetically unacceptable. Treatment of port wine stains depends on the site, extent and nature of the lesion. Many can be successfully removed or their appearance improved by laser treatment. The pulsed dye laser appears to be the treatment of choice for most port wine stains. Specialist advice and referral for treatment is best done before school entry because port-wine stain affecting face and neck, may have a severe impact on the child’s social, psychological and economic development. Continued support, including monitoring behavior and educating the child about his or her appearance as seen by others, has to be encouraged. Counseling of parents and teachers also needs to be done to prevent psychological trauma and promote personality development of the child. To conclude, whenever a facial vascular skin lesion is found in a child, a complete ophthalmologic and systemic assessment for the potentially serious associated disorders has to be done thereby preventing needless/wrong treatment. The case also illustrates the value of systemic examination5 in a patient presenting with an ocular problem. Segmental nature of telangiectasia is a rarity and to best of our knowledge, has not been reported else were, is hereby reported. Finally, role of meticulous examination under magnification cannot be undermined even in a case like suspected conjunctivitis.

REFRENCES 1. Ali MM, Teimory M, Sarhan M. Generalized essential telangiectasia with conjunctival involvement. Clin Exp Dermatol. 2006;31:781-2. 2. Mannis MJ, Bindi CS, Huntley AC. Ocular manifestations of generalized essential telangiectasia. Cornea. 1999;18:731-3. 3. Sharan S, Swamy B, Taranath DA, et. al. Port-wine vascular malformations and glaucoma risk in Sturge-Weber syndrome. JAAPOS. 2009;13:374-8. 4. Govori V, Gjikolli B, Ajvazi H, Morina N. Management of patient with Sturge-Weber syndrome: a case report. Cases J. Dec 23 2009; 2:9394. 5. Soong HK, Pollock DA. Hereditary hemorrhagic telangiectasia diagnosed by the ophthalmologist. Cornea 2000;19:849–50.

Autoblood as Tissue Adhesive for Conjunctival Autograft Fixation in Pterygium Surgery Dr. Santanu Mitra, Dr. Samar K Basak, Dr. Debasish Bhattacharya terygium surgery remained an enigma through ages. Since the time of its Pfirst ever documentation by the great Indian surgeon Sushruta in 600 BC, pterygia have been “incised, split, transplanted, excised, cauterized, grafted, inverted, galvanized, heated, dissected, rotated, coagulated, repositioned and irradiated” (Rosenthal AJO 1953)… “… and you have learned that a pterygium

562 External Diseases Free Papers is an illness that always recurs, even when you have done everything in your power to cure it!” (Ambrose Pare, XVI century). Current management for primary and recurrent pterygium surgery is excision with conjunctival autograft,1 first done by Kenyon et. al. in 1985. This has an acceptable low recurrence rate, good cosmesis, and no gross post operative complication.2 Graft fixation is done usually with polygalactin or nylon sutures. Suture related problems like chronic inflammation, granuloma formation and an irritable post operative period are mostly encountered. Sutureless graft fixation with use of fibrin glue as tissue adhesive in pterygium surgery has recently gained popularity since the work of Koryani et. al. in 2004.3 It outweighs the suturing technique with the advantages of faster surgical time, faster and more c o m f o r t a b l e r e c o v e r y p e r i o d , g o o d c o s m e s i s a n d l e s s e r r e c u r r e n c e r a t e . Fibrin glue is derived from fibrinogen and thrombin, two elements of human blood and when mixed, works by simulating the later stages of coagulation process. But it carries the potential risks of anaphylaxis, prion disease transmission, apart from its higher cost and difficulty in availability. If the synthetic glue can be prepared from elements of human blood, why not the natural blood can be used as a tissue adhesive? Sutureless grafting without synthetic fibrin glue has been successfully used in gingival grafts.4 Conjunctiva, representing a similar mucosal surface, is fixated on the scleral bed by using the natural fibrin clot derived from the oozing blood during the operation.5 Purpose of this study is to analyse the outcomes of using oozing autoblood as tissue adhesive for conjunctival graft fixation.

Materials and methods Prospective, non-comparative, interventional case series of 19 consecutive primary and recurrent pterygium operated with conjunctival autografts. Graft fixation was done using the oozing blood clotted over the bare area as tissue adhesive. Peribulbar anaesthesia was used. Surgery time was recorded. Eye patch was removed after 2 hours. Follow up was done on day 1, day 14, then every 3 months . Surgical Steps After doing a reverse stripping for the head of the pterygium, the body was dissected from the overlying conjunctiva down to bare sclera, for 3.5 to 4 mm from the limbus. Once the pterygium and the conjunctiva were excised, the bare area defect size was measured using Castoviejo callipers. A thin film of blood clot was allowed to form undisturbed over the bare area. Any active bleeding was stopped by direct tamponade.

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A 0.5 mm oversized donor graft area was marked usually on supero-lateral quadrant. A thin tenon free conjunctival autograft, with or without inclusion of limbal stem cells, was fashioned with the help of Radio frequency knife. The graft was aligned, epithelial surface over cornea, by the side of the bare area. The donor area conjunctiva was apposed at a single point with autoblood or bipolar cauteruy. The conjunctival graft was flipped over the blood film in the bare area, and point to point apposition was effected by holding the edges with forceps, giving adequate time (average 3-5 mins) for graft fixation. After fixation the graft was gently tested with merocel sponge for its stability. Post operatively steroid-antibiotic combination and lubricating eye drops were given four times daily, tapering the former one over a period of 2-3 weeks.

Results Table 1: Patient profile and Surgery Details Mean Age (yrs) 32±18 Male: Female 14:7 Primary pterygium 17 Recurrent pterygium 02 Mean Surgical Time (min) 11.3±0.7 Mean Graft Size (mm2) 26±1.5 Complications Commonest observation in the post operative period was the presence of sub-graft haemorrhage (14 cases) and graft edema (9 cases), which dissolved spontaneously with fibrinolysis. Medial edge recession of the graft margin was noticed in 2 cases, as seen with synthetic glue or other series with autoblood.6 But it didn’t require any intervention and also didn’t affect the final recurrence rate. No graft loss in the immediate or late post operative period was seen. In the small period of follow –up no recurrence was also noticed. Table 2 Graft Loss Nil Recurrence Rate Nil Sub-Graft Haemorrhage 14 Medial Edge Graft Recession 2 Graft Edema 9

Discussion Conjunctival graft fixation with fibrin glue, a tissue adhesive derived from two human blood clotting factors, fibrinogen and thrombin, is superior over sutures in respect to better cosmesis, faster surgical and more comfortable

564 External Diseases Free Papers patient rehabilitation time, better hemostasis and reduced post operative inflammation causing a reduction in recurrence rate. The two components of the glue when mixed simulate the later stages of human coagulation process, precipitating fibrin monomers, which acts as tissue adhesive within 30 seconds to 1 minute. But the glue is costly, less readily available and bio-degradable within 3 hours of preparation, carries the potential risk of transmission and anaphylactic reaction. The glue also acts very fast and that demands a certain amount of quick positioning in the graft alignment. The natural fibrin clot derived from the blood oozing over the operative field can be used as a tissue adhesive with all the benefits of synthetic glue minus its drawbacks. Shortage is no longer a problem, in rare cases where not much per operative bleeding occurs, the surgeon can puncture a minute vessel in the scleral bed to produce the necessary bleeding and clotting. Graft should be slightly oversized and as thin as possible to prevent the risk of graft retraction as described by Tan et. al.7 Edge to edge conjunctival apposition with graft positioning requires 3 to 5 minutes. Study Limitations It is a non-randomised study with small study population and a relatively short follow up period of 6 months. In conclusion autoblood may be a viable alternate tissue adhesive for conjunctival graft fixation in pterygium surgery. It demands no extra cost but provides all the benefits of fibrin glue without its drawbacks. A prospective randomized controlled trial to investigate the long term efficacy of this unique grafting technique is required.

References 1. Alpay A, Ugurbas SH, Erdogan B. Comparison techniques for pterygium surgery. Clin Ophthalmol. 2009;3:69-74. 2. Hirst W. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation (P.E.R.F.E.C.T). Ophthalmology. 2008;115:1663-72. 3. Koranyi G, Seregard S, Kopp ED. Cut and paste: a no suture, small incision approach to pterygium surgery. Br. J. Ophthalmol 2004;88:911-4. 4. Dorfman HS, Kennedy JE, Bird WC. Longituidinal evaluation of free autologous gingival grafts. A four year report. J. Periodontol 1982;53:349-52. 5. Sharma A, Moore J. Autologous fibrin glue for pterygium surgery with conjunctival autograft. Cont. Lens Anterior Eye 2009;32:209. 6. deWit D, Athanasiadis I, Sharma A, Moore J. Sutureless and glue-free conjunctival autograft in pterygium surgery: a case series. Eye 2010;24:1474-7. 7. Leonard PK Ang, Jocelyn LL Chua, Donald TH Tan. Current concepts and techniques in pterygium treatment. Curr. Opin Ophthalmol 2007;18:308-13.

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Controlled Trial of Cyclosporine Versus Olopatadine Topically in Treatment of Vernal Keratoconjuntivitis Dr. (Mrs.) Eva Tirkey, Dr. (Prof) M. K. Rathore, Dr. (Mrs.) Shashi Jain, Dr. S.C.L. Chandravanshi

ernal Keratoconjuntivitis (VKC) is a chronic recurrent non infectious Vallergic disease that generally affects children and young adults.1 Its onset is most common in spring and summer season i.e. the months of April and August.2 The condition occurs commonly between 5-20 years of age with peak incidence between 11-13 years of age, males being affected more often than girls. The three forms of vernal conjunctivitis are palpebral, limbal and mixed. Major symptoms include itching, tearing, photophobia, mucoid or ropy discharge and foreign body sensation. Signs include conjunctival erythema, chemosis, papillae, limbal infiltrates and corneal epithelial disease. Treatment modalities are topical , antihistaminics, mast cell stabilizers and immunomodulators along with avoidance of . Olopatadine is both, a mast cell stabilizer and selective H1–histamine antagonist, has rapid onset and longer duration of action. Cyclosporin-A is a potent immunomodulator that selectively suppresses the T-Lymphocytes activation by impairing the production of these T-cell growth factors.

Materials and Methods Clinical trial undertaken from Augest 2008 to September 2009 in which topical olopatadine (0.1%) was compared to topical cyclosporine (0.1%). 62 patients with VKC were enrolled for the study. They had not recived any VKC targeted therapy. In Group 1 (cyclosporine 0.1%)-30 patients and in Group-2 (olopatadine 0.1%) 32 patients were included. All patients received a complete ophthalmic examination including specific evaluation of symptoms and signs. Signs of VKC were graded separately for each eye. Signs and symptoms were recorded at weekly intervals for a period of one month (at entry, day 7, day 14, day 28). The scores for ocular symptoms were added to give a total symptoms score; the total score for the signs were added to give the total sign score. The symptoms and sign scores were added to give total symptom plus sign (TSS) scores. The symptoms, sign and TSS scores were compared at baseline and at each follow up visit both within and between the groups.

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Results

Table 1: Participant flow and follow up Group-1 (Cyclosporine) Group-2 Total (Olopatadine) Total no of patients 30 32 62 included in study Age range 5 – 30 yrs 5 – 30 yrs 5 – 30 yrs Gender Male 15 18 33 Female 15 14 29 Discontinued from treatment: missed visits/ personal reasons 5 6 11 Adverse effects 0 0 0 Total no of patients Male – 13 Male – 15 28 eligible for efficacy Female – 12 Female – 11 23 analysis

Table 2: Changes in composite scores within the groups Group-1 Group-1 (cyclosporin) (olopatadine) Symptoms Sign TSS Symptoms Signs TSS Day 0 56 43 99 58 44 102 Day 7 48 38 86 41 30 71 Day 14 31 29 60 33 30 63 Day 28 26 21 47 25 22 47

Table 3: Group analysis by subjective and objective improvements Subjective evaluation None Mild Moderate Severe Group-1 8 13 4 0 Group-2 9 14 3 0 Objective evaluation None Mild Moderate Severe Group-1 5 12 6 2 Group-2 6 14 4 2

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Table 4: Comparison of results in both groups No.of patients relieved Group - 1 Group - 2 Day 7 18 (60%) 24 (75%) Day 14 23 (76%) 25 (78%) Day 28 23 (76%) 24 (75%)

Discussion A total of 62 patients registered with 51 completing the study. In our study, it was observed that the disease has more prevalence in male, n=28 (54%) as compared to female, n=23 (45%). This is in concordance with study by Stefano Bonini et. al.5 Cyclosporine had 60% and 76% of patients relieved from symptoms in 1st and 2nd week respectively as compared to Olopatadine having 75% in 1st week and 78% in 2nd week. On 4th week follow up, cyclosporine showed significant improvement in symptom score with 76% patients relieved as compared to 75% in Olopatadine group. None of our evaluation could prove that cyclosporine is superior to Olopatadine in VKC. Both treatment modalities were found to be safe and effective in treating VKC. In 1st week Olopatadine was more effective but thereafter no statistically significant difference could be observed in their efficacy. Olopatadine is preferred for initial therapy of VKC cases because of its cost effectiveness. Cyclosporine with low recurrence rates is effective for long term control of VKC.

References 1. J Mendicute. Topical cyclosporine 2% in the treatment of vernal keratoconjuctivitis. Eye 1997;11:75-8. 2. Esen Karamural, Akpek. A randomized trial of low dose Mitomycin c in treatment of VKC. Ophthalmology 2000;107:263-9. 3. Bonini S Bonini . Ige and non-ige mechanisms in ocular allergy, 1993. 4. Pucci, Neri. Anal of allergy, asthma and 2002;89:298-300. 5. Bonini s bonini. VKC Revisited. Ophyhalmology 2000;107:1157-63.

Active Pulmonary Tuberculosis Presenting with Phlyctenular Keratoconjunctivitis Dr. Minu Ramakrishnan ase report of 3 paediatric patients (aged 2, 4 and 7 yrs) presenting to the Cophthalmic clinic with redness, pain, photophobia in one eye, diagnosed 568 External Diseases Free Papers as phlyctenular keratoconjunctivitis. There was no evidence of blepharitis or rosacea, no skin lesions,no palpable lymph nodes and no history of passing worms in stools. On enquiry, all 3 patients gave history of low grade fever of 10-15 days duration, cough and loss of appetite. One patient had positive family history of pulmonary Kochs. They all belonged to the urban poor population, with no knowledge of communicable diseases like tuberculosis. Systemic work up revealed lymphocytosis, raised ESR, positive Mantoux test and Xray chest showed active infiltration suggestive of pulmonary Kochs. Patients were started on 4-drug AKT systemically in consultation with a paediatrician, and topical steroids for the phlyctens. All patients showed good response to steroids, but on tapering, one of them developed recurrent phlyctens, related to her stoppage of AKT for some reason. The patient was referred back to the peadiatric dept. and restarted AKT, steroids hiked up and she did well after that.

Discussion Phlyctenular keratoconjunctivitis (PKC) is a manifestation of immunological response to a variety of antigens, tubercular focus being commonest in India.1 It has also been associated with posterior blepharitis and rosacea,2 and in the presence of intestinal worms.3 A study done in Delhi by Rohatgi J et. al4 in 2000, out of 112 patients with phlycten, 76.7% were associated with tuberculosis, 12.4% with worm infestations and 6.2% with staphylococcal blepharitis. They have shown that in patients where tuberculosis was the only association, severe lesions were seen only in 37% of cases, whereas patients who had tuberculosis with other associations of PKC like worms/blepharitis, had severe lesions in 84.6% cases. They have documented recurrence on FU of 3 patients who were on MDT and 2 patients with tubercular allergy. Lungs and lymph nodes are the predominant underlying focus associated with phlyctenular keratoconjunctivitis, although some authors1 have reported PKC with lupus vulgaris and scrofuloderma. Tuberculous PKC has usually been noted in malnourished older children and is more common in girls. Severity of symptoms depends on the site of involvement. Corneal involvement indicates a much more severe form of the disease. Recurrence is frequent and may occur at a different site. Two of our patients had severe corneal involvement (one with recurrence), without any other associated diseases. In conclusion as is evident from these cases,ocular symptomatology is of

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more concern for patients belonging to low socioeconomic status. Low grade fever and cough are not considered serious enough to warrant a doctor’s consultation. This places the onus on the consulting ophthalmologist to properly explain about need for investigations and appropriate and early treatment, with the aim to reduce the burden and complications associated with untreated pulmonary tuberculosis. Also, the role of socioeconomic status and immunity levels in the urban-poor population, especially the children, cannot be underestimated in inciting this type of allergic response to tuberculoprotein.

References 1. Singal A, Aggarwal P, Pandhi D, Rohatgi J. Cutaneous tuberculosis and phlyctenular keratoconjunctivitis. A forgotten association. Indian J. Dermatol Venereol Leprol 2006;72:290-2. 2. Neiberg MN, Sowka J. Phlyctenular keratoconjunctivitis in a patient with staphylococcal blepharitis and ocular rosacea. Optometry. 20 08,79:133 -7. 3. Al-Amry MA, Al- Amri A, Khan AO. Resolution of childhood recurrent corneal phlyctenulosis following eradication of an intestinal parasite. J AAPOS 2008;12:89-90. 4. Rohatgi J, Dhaliwal U. Phlyctenular eye disease: a reappraisal. Jpn J. Ophthalmol. 2000;4:146-50.

Critical Evaluation and Management of Epibulbar Dermoid Dr. Anita Panda, Dr. Anoop, Dr. Sasikala NK pibulbar dermoid, also known as “limbal dermoid”1 is seen on the Eanterior part of involving the limbus. In comparison to the common congenital dermoid cysts of the eyebrow region, these are rarer, but the gravity of this problem is much more considering their serious cosmetic and functional hazards. The aim of this study was to critically evaluate the patients with epibulbar dermoids attending our services in a span of 26 years in the terms of laterality of involvement, eye preponderance, isolated or multiple lesions, variation in size of the lesions, affiliated sites, associated ocular and systemic findings and the type of management necessitated .

Materials and Methods All patients with epibulbar dermoid attending out patient department of our eye center and referred to the Pediatric Ophthalmology and Cornea services between 1997 to 2006 were recruited in this study.

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All the patients had full ocular and systemic examinations performed by ophthalmic residents and the findings were confirmed by senior consultant. The sites of the lesions were noted in a topographic chart. Slit lamp examination was carried out in all the patients. Gonioscopy, corneal topography, ultrasonography and ultrasound biomicroscopy (UBM) were performed where ever indicated and when ever available. The type of the surgical procedure was decided as per the extension and depth of the lesions.

Results Lesions were unilateral in 211 and bilateral in rest 27 patients .Right eye was involved in 145 and left in 120. Single lesions were observed in 220 eyes (83.0%), double in 28 (10.5%) and triple in 17 eyes (6.4%). Seventy (21.4%) lesions were less than 3 mm in size, 69 (21.1%) between 3.1 to 6 mm , 175 (53.5%) between 6.1 to 12 mm and rest 13 (3.9%) were more than 12 mm. All but 6 bilateral patients had asymmetrical involvement. Of the total 238 patients the ratio of male and female was M:F:: 135 :103. The number of boys brought to the hospital during the first decade of life was 108/135 (80.0%) against 57/103 (55.3%) girls of the same age group . Gonioscopy was possible only in 53 of the 137 eyes for assessment of deep involvement of angle. UBM images of dermoid were done to confirm angle involvement, which could be detected in one case. No surgery was required for 74 (22.6%) lesions. Of these 62 were flat and 0–3 mm in size, and another 12 lesions were raised but the size was less than 4 mm. Moreover, these were not associated with any visual problem and irritating symptoms. Simple excision was carried out in 89 (27.2%) superficial lesions of which 81 improved cosmetically. Either restoration of vision or gain in visual acuity was achieved in 84/89 eyes (94.3%) .Five eyes (5.6%) with simple excision developed corneal vascularisation and resulting in reduced visual acuity. A total number of 164 (50.1%) eyes underwent excision along with lamellar keratoplasty of which 145 had cosmetic gain and 162 either showed improved vision or retained the pre operative visual acuity.

Discussion Dermoid is the most common congenital tumor of the eye and the most frequent benign ocular tumor in all ages.2-4 They are composed of ectodermal (keratinized epithetium , sebaceous and sudoreferous glands, nerves, smooth muscle and less frequently teeth); and mesodermal elements (fibrous tissues, blood vessels, fat and cartilage) combined in different proportion. These are of two: Limbal dermoid (at limbus), and Lipodermoid (at lateral canthus). If fat dominates the histology of tumor it is called lipodermoid.

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Though epibulbar dermoids are less frequent than the more common dermoid cysts, they are more important from the visual point of view. Because Dermoids lead to flattening of the meridian that involves the cornea, resulting into astigmatism5 which can lead to in children. Isolated limbal dermoids, on other hand, are more conspicuous cosmetically and induce oblique with a plus cylinder axis in the meridian of the lesion which does not get corrected by simple excision of the dermoid.5 There are 2 components of astigmatism: i) congenital structural component ii) Tractional component similar to pterygium. Topography is a valuable aid to assess the astigmatism.6 The patients seek ophthalmologists’ advice when there is cosmetic blemish or poor visual acuity. Other modes of presentations are and irritating symptoms. In tropical climates these lesions may undergo metaplasia and malignant transformation may occur as a result of chronic irritation due to secondary exposure.7,8 However, no comment could be given as no histopathological study was carried out for all specimens in this study. Most of the lesions as reported in the literature are unilateral. The present study also reveals the more number of unilateral involvement (88%). Bilateral occurrence is considered to be less frequent but when occurs it is usually symmetrical. In our series one patient with bilateral annular dermoid, one with bilateral corneal dermoid and five with bilateral limbal dermoids were symmetrical, the rest 20 bilateral lesions being asymmetrical. Involvement of the angle does occur. Therefore it is necessary to evaluate the angle region by gonioscopy. In children gonioscopy must be performed under anaesthesia. However, sometimes it is difficult to perform gonioscopy because of extensive growth at the limbus. To overcome this problem, more recently ultrasound biomicroscopy has been chosen as an effective tool. UBM showes reflective and predominantly homogenous lesion compared with unaffected corneal stroma. Descemets membrane beneath dermoid cannot be visualized in most of the cases because of strong sound attenuation inside the lesion. Indications of the surgery in limbal dermoid include (i) Cosmetic reason (ii) Irritative symptoms (iiii) Poor vision (iv) Large and keratinized dermoid causing exposure, dryness, ulceration and scarring (v) Diplopia. The type of surgery again depends upon the size, site, depth of involvement and nature of the growth.2 The goal of the surgery is to perform a superficial keratectomy and make the corneal topography as near as possible6. Few cases may require lamellar or penetrating (sclero) keratoplasty for restoration of structural intergrity. Limbal dermoids often induce oblique astigmatism which was present in majority of our patients indicating the structural alteration of the cornea in the

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form of flattening.7 Following surgery the amount of astigmatism got reduced remarkably. 2,6 Budak et. al6 found that steeping of the flattened meridian occurred after excision of the dermoid. This is especially seen in superficial dermoids. After removal patients can be fitted with contact lens. In conclusion, the results of this study demonstrate that epibulbar dermoid is not a very uncommon lesion. It is associated with a number of ocular and systemic disorders of importance. Astigmatism is a frequent problem due to flattening of the cornea. Rational surgery is quite encouraging both for cosmetic and functional aspects.

References 1. Duke Elder S. Congenital Deformities. In System of Ophthalmology. 1964;3:819-26. St. Lous: Mosby, 2. Panda A, Ghose S, Das H, Khokhar S. Surgical management of epibulbar dermoids. J. Paed Ophthalmol 2002;39:241-3. 3. Ash J E. Epibulbar Tumors. Am J. Ophthalmol 1950;33:1203. 4. Elsaa FJ, Green WR. Epibulbar tumors in childhood. Am J Opthalmol 1975;79:1001. 5. Robb RM. Astigmatic refractive errors associated with limbal dermoids. J. Paed Ophthalmol Strabismus. 1996;33:241-3. 6. Budak K, Khater TT, Friedman NJ, Koch DD. Corneal topographic changes induced by excision of perilimbal lesions. Ophthalmic Surg Lasers. 1999;30:458-64. 7. Maertens K, Blodifc. Epibulbar lesions among Bantus. Am J. Ophthalmol 1972;74:680. 8. Templeton AC. Tumors of the eye and adnexa in Africans of Uganda. Cancer 1967;20:1689. 9. Mattos J, Contreras F, O’Donnell FF. Ring dermoid syndrome. Arch Ophthalmol, 1980;98:1059-61. 10. Magli A, Demarcor, Capassol. Presence of bilateral limbal dermoids in a family with inherited limbal dermoids. Ophthlmic Genet. 1999;20:101-6.

Comparison of Carboxymethylcellulose with and without Osmoprotective Agents in Dry Eyes Dr. Gupta P, Dr. Jain M, Dr. Jain R and Dr. D’Souza P. arboxymethycellulose (CMC) is a tear substitute used commonly in the Ctreatment of dry eye. It is available with and without preservative. The new pathophysiological concept of dry eye is “increased osmolarity of the tear film”, causing a condition known as osmotic stress.1-3 This in turn affects the conjunctival and corneal epithelial cells and causes it to lose water, absorb solutes and release pro-inflammatory substances.1,4 Therefore, osmoprotective

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agents are added to preservative free tear substitutes to prevent a hyperosmolar tear film from damaging the ocular surface. Newer osmoprotective agents (compatible solutes) used are Glycerol, L-carnitine and erythritol which have been used along with CMC to enhance this action and its surface retention.1 This preparation is now available in Indian market. The present study was undertaken to compare and evaluate the effect of topical CMC with and without osmoprotective agents on the tear film and the conjunctiva in dry eye.

Materials and Methods Study design: Prospective randomized Non–interventional, observational study. This prospective randomized study was conducted from November 2008 to March 2010. 80 eyes (40 patients) of new cases of dry eye with symptoms of dry eye, age ≥ 40 years and with Schirmer’s basic secretion test ≤ 10 mm were randomly divided into 2 groups as follows : Group I : (n = 20 ;40 eyes) were prescribed topical 0.5% CMC with SOC; Group II : (n = 20;40 eyes) were prescribed topical 0.5% CMC with SOC with osmoprotective agents. 80 eyes of 40 normal age and sex matched subjects, were taken as controls for baseline values. Exclusion criteria were recent use of topical or systemic medications like beta-blockers, anti cholinergics and anti histaminics; patients with blepharitis and lid deformities; history of intolerance or hypersensitivity to any component of the study medications or any history or evidence of external ocular infection, intraocular inflammation; contact lens wearers; pregnant or lactating females; patients who had undergone punctal occlusion, recent ocular surgery or trauma; with history of systemic disease like collagen disorders, arthritis and mucocutaneous diseases. At the initial visit, all selected patients were subjected to a detailed clinical history including occupational and medication history e.g. regular, prolonged exposure to air conditioned environment; working on computer ; exposure to chemical fumes and excessive industrial pollution; use of antitussives, decongestants, antihistaminics, antihypertensives and antidepressants. Mc Monnies ‘Dry eye Questionnaire’ was used for grading the symptoms. Examination included visual acuity, eyelids, adnexa, conjunctiva, anterior and posterior segment evaluation. Tear film studies included Schirmer’s basic secretion test, tear film break up time (BUT), fluorescein staining of the cornea. Conjunctiva was studied by conjunctival impression cytology (CIC) which was performed as detailed by ICEPO (1998). Specimens were taken from the supero-temporal conjunctiva and analysed for epithelial cells, goblet cells, mucin spots, mucin strands, foreign body debris and for inflammatory cells like polymorphonuclear leukocytes. At initial visit all tests were done and follow up was done at 2 weeks interval

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(2, 4, 6, 8, 10 and 12) for a period of 12 weeks after starting the topical drops. Tests performed at each visit included Schirmer’s basic secretion test, Tear- film break-up time (TBUT) and Fluorescein staining. Conjunctival impression cytology was done only at 4, 8 and 12 weeks only, after starting the treatment. Controls were subjected to tear film and conjunctival impression cytological study at the initial visit only for baseline values. Goblet cell density (GCD) The number of goblet cells and epithelial cells are counted in ten high power fields of good cellular area, of each specimen. GCD is expressed as the number of goblet cells per 100 epithelial cells. Goblet cells x 100 GCD = Epithelial cells For normal eyes, the goblet cell density on the interpalpebral bulbar and inferior palpebral conjunctiva is 443 (SD + 266) and 1972 (SD + 862) cells/ sq.mm respectively. (Nelson et. al. 1984). Squamous metaplasia The severity of transformation of normal columnar epithelium into stratified squamous epithelium is graded in accordance with the modified Grading System. Grade Cell Size Cytoplasmic Edge N/C Ratio Mild (Gr. 1) Slight increase Slight coagulation 1:3 Moderate (Gr. 2) Two times Marked coagulation 1:4 - 1:5 Severe (Gr. 3) Four times Rolling of edges >1:6 The study was approved by the Institutional ethical committee. Statistical analysis – was done on SPSS software and significance was calculated with unpaired t-test for age; Chi square test, Fisher’s exact test, Mc Nemar test, Bowker’s test were used to calculate significance of symptoms, signs, fluorescein staining and squamous metaplasia. ANOVA followed by Dunnet’s and Tukey’s tests were used for Schirmer’s, TBUT and Goblet cell density

Results The demographic data of cases of both the groups is shown in Table 1. There was no statistically significant difference in age and sex distribution between all the groups (age : p value = >0.05, sex : p value = >0.05) Symptoms: Symptoms of foreign body sensation and burning were present in all the 40 eyes of both the groups. Itching was experienced by 32 eyes of group

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Table 1 Patient characters Group I Group II Controls Age (years) Range 45 – 60 45 – 65 45 – 65 Mean age 49.6 51 50.85 Standard Deviation 4.32 5.05 4.71 Sex Male 6 8 18 Female 14 12 22 Total 20 20 40

I and 16 eyes of group II; photophobia by 6 eyes of group I and 12 eyes of group II; tiredness by 40 eyes of group I and 29 eyes of group II; watering by 32 eyes of group I and 27 eyes of group II; grittiness by 40 eyes of group I and 38 eyes of group II. Group I and group II showed statistically significant (p<0.003) improvement in all the symptoms except photophobia. Improvement in photophobia was significant in group II (p<0.003) at 6 weeks but not in group I. The symptomatic relief as per the questionnaire was achieved earlier (2 weeks) in group II which was significant (p<0.003) between 2 – 8 weeks for foreign body sensation and burning; between 2 - 6 weeks for itching, watering and grittiness; between 2 – 4 weeks for tiredness. However, at the end of 12 weeks the comparative results between group I and group II were not statistically significant (p>0.003). Clinical Changes: (Table 2) Schirmer’s test values in the control group ranged from 10 mm to 35 mm with a mean of 19.99 mm. In group I, 1 eye (2.5%) had Schirmer’s value of ≤ 2 mm. 9 eyes (22.5%) had >2 mm but ≤ 5 mm and 30 eyes (75%) had schirmer’s of > 5 mm but ≤ 10 mm. Whereas, in group II, 4 eyes (10%) had Schirmer’s value of ≤ 2 mm. 16 eyes (40%) had > 2mm but ≤ 5 mm and 20 eyes (50%) had schirmer’s of > 5 mm but ≤ 10 mm. Therefore, group II had 50% cases of moderate to severe dry eye in comparison to 25% cases in group I. Mean Schirmer’s value of group I at the initial visit was 6.55 mm and that of group II was 5.75 mm which after treatment with the tear substitutes for 12 weeks, improved to 10.725 mm and 14.95 mm respectively. The improvement in both the groups was highly significant statistically (p<0.001). The comparative improvement in the mean schirmer’s value between group I and group II was found to be highly significant at 10 and 12 weeks (p<0.05). In the control group value of TBUT was 10 to 23 seconds with a mean of 16.2 seconds. TBUT also showed statistically significant improvement (p<0.001) from a mean of 6.55 seconds at initial visit to 14.125 seconds at 12 weeks in patients of group I and 6.87 seconds to 14.30 seconds in patients of group II. However, the results in group I were comparable to that of group II at all weeks and were not statistically significant (p>0.05).

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(1.82) 9.88 10.725 14.125 12.75 (1.54) (1.31) (1.21) (1.76) 13.50 13.05 14.30 <0.05 (2.09) <0.001 <0.001 <0.001 <0.001 10 wks10 0-10 wk0-10 0-10 wk0-10 0-10 wk0-10 0-10 wk0-10

>0.05

(1.76) 8.625 (1.92) (1.65) >0.05 (0.95) 8 wks 11.975 11.025 11.275 0-8 wk 0-8 wk 0-8 wk 0-8 wk <0.001 <0.001 <0.001 <0.001 >0.05

8.17 9.95 (1.61) 10.77 10.33 (1.83) (1.64) >0.05 (0.83) 6 wks 0-6 wk 0-6 wk 0-6 wk 0-6 wk <0.001 <0.001 <0.001 <0.001 >0.05

7.90 8.95 9.175 (1.78) 8.575 (1.07) (1.57) (1.56) >0.05 >0.05 4 wks 0-4 wk 0-4 wk 0-4 wk 0-4 wk <0.001 <0.001 <0.001 <0.001

7.10 7.65 7.90 (1.76) (1.79) 8.075 (1.28) (1.36) >0.05 2 wks 0-2 wk 0-2 wk 0-2 wk 0-2 wk >0.001 >0.001 <0.001 <0.001

>0.05

5.75 6.87 6.55 6.55 (2.5) 0 wk (1.41) (1.72) (1.42) 19.99 (1.92) >0.05 >0.05 (6.38)

16.2

p value p value p value p value Group I Group I Control Control Group II Group II I vs Gp II I vs Gp II p value Gp p value Gp

TBUT Schirmer’s test Mean (sec) (S.D.) Mean (S.D.) (mm) Table 2

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In group I Fluorescein staining was observed in 6 eyes at initial visit only which was not statistically significant (p>0.003). In group II Fluorescein staining was observed in 15 eyes initially which decreased to 7 eyes at 6 weeks and 1 eye at 12 weeks which was statistically significant (p<0.003). But the comparative results between group I and group II at all weeks were not statistically significant (p>0.003). Conjunctival Changes: (Table 3) In the control group, goblet cell density ranged from 15.04% to 30% with a mean of 21.42%. In group I, mean goblet cell density increased from 3.87% at the initial visit to 10.086% at 12 weeks and in group II from 3.531% to 13.486% which was highly significant (p<0.001). The comparative results between two groups were statistically significant at the end of 12 weeks (p<0.05). In group I, at initial visit, 9 eyes had mild, 4 eyes had moderate and 1 eye had severe squamous metaplasia whereas at 12 weeks only 4 eyes showed mild and 1 eye showed moderate squamous metaplasia. In group II, at initial visit, 11 eyes had mild, 5 eyes had moderate and 2 eyes had severe squamous metaplasia. At 12 weeks, only 2 eyes had mild squamous metaplasia. This reversal of squamous metaplasia was observed at all weeks and was statistically significant (p<0.003) in group II at 12 weeks, but not in group I. There was comparable improvement in both the groups.

Table 3 0 wk 4 wks 8 wks 12 wks GCD Group I 3.87 5.011 7.166 10.086 Mean (%) (1.25) (1.60) (2.15) (2.63) (S.D.) p value <0.001 <0.001 <0.001 Group II 3.531 6.012 9.218 13.486 (1.41) (2.15) (2.62) (3.35) p value <0.001 <0.001 <0.001 Control 21.42 (3.18) p value Gp I >0.05 >0.05 >0.05 0.025(<0.05) vs Gp II Presence of Group I 14 12 10 5 squamous p value 0-4 wk 0-8 wk 0-12 wk metaplasia 0.082 0.029 0.011 (no. of eyes) Group II 18 15 10 2 p value 0-4 wk 0-8 wk 0-12 wk 0.046 0.011 0.000 Control 0 p value Gp I 0.807 0.853 1.000 0.432 vs Gp II 578 External Diseases Free Papers

Discussion The commonest symptoms observed were foreign body sensation, tiredness, burning and grittiness, followed by itching and watering which were graded as per Mc Monnie’s questionnaire. Photophobia was the least common symptom. These findings were similar to those seen by Nichols et. al. who observed feeling of dryness as the common symptom. However, Begle et. al. reported discomfort and itching as the two main symptoms in dry eye. In one study grittiness was the most common symptom. In this study, there was a statistically significant improvement in symptoms which started at 2 weeks, was seen in both the groups and was maintained at subsequent visits at 4, 6, 8, 10 and 12 weeks. The complaints of itching, photophobia and blurred vision were almost relieved by 10 – 12 weeks, but the relief was earlier in group II than in group I, i.e., 4 – 6 weeks. There was marked improvement in other symptoms like foreign body sensation, tiredness, burning, watering and grittiness at the end of 12 weeks but the improvement was more in group II. However, the comparative results between the two groups were not statistically significant (p>0.003) at 12 weeks except at 2, 4, and 6 weeks when group II showed statistically significant improvement (p< 0.003) in the relief of foreign body sensation, itching, watering and grittiness. This implies that CMC with SOC provides gradual relief in the symptoms over a long period of time after initiation of the treatment and most of the symptoms are relieved at 12 weeks. Bruix A et. al.5 also observed that CMC causes significant decrease in the frequency of subjective symptoms of mild to moderate dry eye. CMC with osmoprotective agents provided earlier improvement and it was maintained at subsequent visits. Kaercher et. al.6 also observed an improvement in the symptoms of the patients of keratoconjunctivitis sicca treated with CMC with compatible solutes. Similarly, clinical signs like presence of tortuous conjunctival vessels and absence of corneal lustre showed significant improvement with both the tear substitutes (p< 0.001) at 2 weeks. But the comparative results between group I and group II were not statistically significant (p>0.05) indicating that both the tear substitutes provided comparable relief. The improvement in conjunctival hyperemia, seen in dry eye, by tear substitutes has also been shown by Brown and Brodwall et. al. The most common site of staining with fluorescein in the study was the inferior quadrant of the cornea. There was significant improvement in all the patients of the study group. The improvement started at 2 weeks and none of the eyes had staining at 12 weeks. However, the comparative results between the two groups were not statistically significant (p>0.003) at any stage. The Schirme’r test values in both the groups increased, which was statistically

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significant in group I starting at 2 weeks (p>0.001). The improvement was maintained in both the groups at subsequent visits till 12 weeks. The comparative results between group I and group II showed statistically significant difference at 10 and 12 weeks. The improvement in mean Schirmer’s value of >10 mm was achieved earlier in group II (6 weeks) than in group I (12 weeks). Tear film break up time (TBUT) measures the tear film instability. It has a diagnostic and prognostic implications. It serves as a tool in determining the efficacy of tear substitutes. The TBUT increased at 2, 4, 6, 8, 10 and 12 weeks in both the groups. The increase in mean TBUT at 2 weeks and thereafter at each visit was statistically significant in both the groups (p<0.001). However, the comparative improvement between both the groups was not statistically significant (p>0.05). The results were in accordance with those observed by David R. Hardten et. al. in which CMC with osmoprotective agents showed improvement in TBUT after 3 months. A study on CIC by Rojas et. al.7 has shown that there is statistically significant difference in the grade of squamous metaplasia and goblet cell density between normal and dry eyes. In the present study, the mean goblet cell density improved significantly in both the groups after initiation of treatment and this improvement was maintained in subsequent visits. The changes at all visits were statistically significant (p<0.001). Also the increase in goblet cell density when compared between group I and II was statistically significant at 12 weeks (p<0.05). This shows that increase in group II was significantly greater than group I. Changes in squamous metaplasia seen in conjunctival cytology is associated with dry eye and the same has been observed in this study. The study showed a progressive decrease in the number of eyes with squamous metaplasia, in both the groups, after starting the treatment with the tear substitutes but the change was not statistically significant (p>0.003) in group I as compared to group II which was significant at 12 weeks (p<0.003). There was no statistical difference in the reversal of squamous metaplasia between both the groups (p>0.05). According to study by Bruix et. al.5, conjunctival impression cytology did not provide significant improvement in goblet cell density when treated with CMC. Whereas a study by Lenton LM et. al. noticed significantly greater increase in the mean goblet cell density with CMC. Previous research has shown that CMC improves squamous metaplasic states of epithelial cells of the conjunctiva observed through conjunctival impression cytology.8 In our study, the conjunctival changes at the initial visit were much more (GCD - 3.87% in Gp I and 3.531% in Gp II) as compared to tear film changes (mean Schirmer’s - 6.55 mm in Gp I and 5.75 mm in Gp II; TBUT – 6.55 sec in Gp I and 6.87 mm in Gp II). Mean Schirmer’s value and TBUT improved to normal at 12 weeks, however, GCD did not improve to the normal value. Thus, conjunctival changes take longer time to revert back to normal and hence, longer duration of treatment is required with tear substitutes.

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CMC is a good tear substitute in the treatment of mild to moderate dry eye as shown in the study, by the improvement of subjective symptoms and clinical signs of dry eye. The addition of osmoprotective agents has however shown an earlier and statistically significant improvement in dry eye as shown by the increase in mean Schirmer’s value. Though the improvement of TBUT in both the groups is equivocal. This could be due to the fact that CMC exhibits retensive properties which contribute to the lubrication and wetting of the ocular surface. It also increases the stability of the precorneal tear film which in turn protects the ocular surface. Osmolytes like carnitines have osmoregulatory properties which overcome osmolar stress in dry eye. It is observed that reduced levels of carnitine in the tear film is associated with less retention of water in aqueous layer leading to hyperevaporation and hyperosmolarity, increased oxidative stress and apoptosis on the corneal surface. Therefore, addition of carnitine may prevent ocular surface damage due to its anti inflammatory, anti oxidative and anti apoptotic activities. It also increases retention of water in aqueous layer of the tear film which is evident by statistically significant improvement in Schirmer’s value in group II (p<0.05). Both the tear substitutes, at the end of 12 weeks are equally efficacious in relieving the subjective symptoms, clinical signs and objective parameters like Schirmer’s, TBUT and cytological changes but CMC with osmoprotective agents (Group II) has an added advantage as it has shown marked improvement in clinical parameters at 2 weeks. Therefore, CMC without osmoprotective agents can be prescribed in mild to moderate dry eye however, in moderate to severe dry eyes, CMC with osmoprotective agents should be the preferred drug of choice.

References 1. Corrales RM Luo L, Chang EY, et. al. Effects of osmoprotectants on hyperosmolar stress in cultured human corneal epithelial cells. Cornea. 2008;27:575–9. 2. Liu H, Begley C, Chen M et. al. A link between tear instability and hyperosmolarity in dry eye. Invest Ophthalmol Vis Sci. 2009;50:3671-9. 3. Messmer EM. Osmprotection as a new therapeutic principle. Ophthalmologe. 2007; 104:987-90. 4. Li DQ, Chen Z, Song XJ et. al. Stimulation of matrix metalloproteinases by hyperosmolarity via a JNK pathway in human corneal epithelial cells. Invest Ophthalmol Vis Sci. 2004;45:4302-11. 5. Bruix A, Adan A, Casaroli – Marano RP. Efficacy of sodium carboxymethylcellulose in the treatment of . Arch Soc Esp Oftalmol. 2006;81:85-92. 6. Kaercher T, Buchholz P, Kimmich F. Treatment of patients with keratoconjunctivitis sicca with Optive: results of a multicenter,open-label observational study in Germany. Clin Ophthalmol. 2009;3:33-9.

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7. Rojas MV, Rodriguez MT, Cesblanco JA. Salorio M. Impression Cytology in Patients with Keratoconjunctivitis Sicca . 1993;4:347-55. 8. Gilbard JP, Rossi SR. An electrolyte based solution that increases corneal glycogen and conjunctival goblet cell density in a rabbit model for keratoconjunctivitis sicca. Ophthalmology. 1992;99:600-4.

Unusual OSSN – Role of Radio-Imaging. Where are we Today? Dr. Rama Rajagopal, Dr. Ravi Daulat Barbhaya, Dr. Bipasha Mukherjee, Dr. Olma Veena Noronha, Dr. Krishna Kumar S. cular Surface Squamous Neoplasia (OSSN) is a term used to describe a Ospectrum of conjunctival and corneal lesions of squamous cell origin, ranging in severity from intraepithelial (in situ) neoplasia to invasive squamous cell carcinoma, when it invades the conjunctival substantia propia, the sclera, the eye or the .1,2,3 Before treatment, the extent of most OSSN lesions is defined by slit lamp biomicroscopy and documented by photography. The clinical method to assess whether the tumor invades the eye wall is to check mobility. To complement this assessment, the current pre-operative imaging modalities used to assess the ocular extent and invasion of OSSN are high frequency ultrasonic imaging (20 and 50 MHz)4, X-Ray Computed Tomography (CT scan)5, Magnetic Resonance Imaging (MRI scan)5, High Resolution Optical Coherence Tomography (OCT)6 and Confocal Microscopy.7 The information provided by the imaging studies are valuable in the surgical planning of patients with atypical presentations of OSSN.

materials and Methods Retrospective, single centre, non- comparative, non-randomised study of 16 eyes of 16 patients who presented with unusual OSSN between September 2005 to March 2011. Relevant clinical data was collected from the medical records .The eyes were clinically divided into Atypical Non Infiltrative OSSN (Table 1) and Infiltrative OSSN (Table 2) based on clinical findings at presentation. Cases which presented with atypical features like ill- defined diffuse lesion, lesion extending to the caruncle or fornices, and pigmented tumours, were categorised as Atypical Non Infiltrative OSSN. All patients underwent radio- imaging (CT/MRI) of the orbit .All patients in the infiltrative OSSN group underwent metastasis work-up including ultrasound of abdomen and neck , liver function tests and chest x-ray .

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The main outcome measure was the degree of correlation between the imaging findings and the intra-operative and/or histopathology findings.

Results There were 10 male and 6 female patients. The mean age of presentation was 57.8 years (range 14-82 years). 7 eyes presented with clinically Atypical Non Infiltrative OSSN (Table 1) and 9 eyes with Infiltrative OSSN (Table 2). All cases were treated surgically based on the imaging findings (Table 3). Table 1: Atypical Non Infiltrative OSSN Group No. Age Radio Reason Radioimaging findings Intra- Histo Sex -imaging for RI Scleral Orbital Intra opera patho- (RI) involve involve ocular tive logy ment ment involve correla correla ment -tion -tion 1 41/M MRI Ill-defined - - - + + diffuse lesion 2 75/F CT Involvement of - - - + + lower fornice and,caruncle 3 82/F MRI Ill-defined - - - + + diffuse lesion 4 69/M MRI Ill-defined diffuse - - - + + lesion,Recurrence (twice) 5 32/M MRI Involvement + - - + + of Caruncle 6 14/F MRI Xeroderma - + - + + pigmentosa, multi- centric, recurrence 7 62/F MRI Pigmented - - - + + diffuse tumour

Table 2: Infiltrative OSSN Group No. Age Radio Radioimaging findings Intra- Histo Sex -imaging Scleral Orbital Intraocular operative (RI) involve involve involve correla correla ment ment ment -tion -tion 8 48/M MRI +/- indented + - + + 9 60/M MRI + + - + + 10 60/M MRI + + - + + 11 72/M MRI + + - + + 12 41/F MRI + + - + + 13 62/M CT + + - + + 14 56/M CT + - + + + 15 80/F CT - + - + + 16 72/M CT + + - + +

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Table 3: Surgical Procedures No. Procedure 1 Excision biopsy+Cryotherapy+Amniotic Membrane Transplantation 2 Excision biopsy with frozen section +Cryotherapy+Amniotic Membrane Transplantation 3 Excision biopsy with frozen section +Cryotherapy+Amniotic Membrane Transplantation 4 Excision biopsy with frozen section +Cryotherapy+Amniotic Membrane Transplantation 5 Excision biopsy with frozen section +Cryotherapy+ Scleral patch graft +Amniotic Membrane Transplantation 6 Excision biopsy with frozen section +Myomectomy+ Cryotherapy+ Scleral patch graft +Amniotic Membrane Transplantation 7 Excision biopsy with frozen section +Cryotherapy+Amniotic Membrane Transplantation 8 Enucleation 9 Exenteration 10 Exenteration 11 Exenteration 12 Exenteration+Cervicofacial Flap 13 Exenteration 14 Exenteration 15 Exenteration 16 Exenteration

Discussion OSSN can rarely present in unusual forms. Besides clinical assessment, radioimaging studies can be used as a guide to evaluate the depth and extent of the tumour and this in turn enables better surgical planning. In one patient, in the clinically Atypical non infiltrative group with positive radiological findings, it enabled us to perform a globe saving myomectomy procedure. In the infiltrative OSSN group the radioimaging finding were confirmed by histopathological examination of the enucleated/ exenterated specimens. In all our patients, findings on radioimaging co-related 100% with the histopathology and /or intra-operative findings. MRI gives better soft tissue resolution than CT scan, MRI with surface coil technique gives good resolution of the posterior extent of the tumour. MRI also can detect scleral involvement fairly accurately. In context of OSSN, radioimaging studies have certain limitations. Limitations in the form of artifacts from the lids may cause difficulty in interpretation. Difficulty arises in cases where tumour is close to the tendon of the muscles.

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Histopathology is the gold standard of diagnosis for OSSN. Limitations in histopathology study are related to the quality of specimen provided for examination .In multicentric OSSN, areas of involvement may be missed. In cases of Atypical non infiltrative OSSN multiple bits of tissue from the base of the tumour needs to be provided to rule out any infiltration. From our study we would like to conclude that radioimaging has a definite role to play especially in patients with atypical presentations of OSSN. Imaging is an essential pre- requisite to plan surgery in eyes with unusual OSSN. Surgery can be tailored to the area of involvement and this can be globe salvaging in some cases.

References 1. Lee GA, Hirst LW. Ocular surface squamous neoplasia. Surv Ophthalmol. 1995;39:429-50. 2. Basti S, Macsai MS. Ocular surface squamous neoplasia: a review. Cornea. 2003;22:687–704. 3. Tunc M, Char DH, Crawford B, Miller T. Intraepithelial and invasive squamous cell carcinoma of the conjunctiva: analysis of 60 cases. Br J Ophthalmol. 1999;83:98-103. 4. Paul T. Finger et. al. High-Frequency Ultrasonographic Evaluation of Conjunctival Intraepithelial Neoplasia and Squamous Cell Carcinoma. Arch Ophthalmol. 2003;121:167-72. 5. Thomas E. Johnson et. al. Secondary Squamous Cell Carcinoma of the Orbit. Arch Ophthalmol. 1997;115:75-8. 6. Mohamed Abou Shousha et. al. Diagnosis and Management of Conjunctival and Corneal Intraepithelial Neoplasia UsingUltra High-Resolution Optical Coherence Tomography. Ophthalmology 2011;118:1531–7. 7. Carolina M. Gentile et. al. In Vivo Confocal Microscopy Study of Ocular SurfaceNeoplasia Manifesting After Radial Keratotomy and Laser In Situ Keratomileusis. Cornea. 2009;28:357-9.

585 Empress Maria Theresa (1717-1780): the most powerful Empress of Austria, established the first Dept of Ophthalmology in Europe at the University of Vienna in 1773. Dr. Josef Berth of Malta was the first Chairperson.

Slit Lamp Examination Indirect Ophthalmoscopy