A randomized control trial on the role of tranexamic acid in preventing intraoperative bleeding during external dacryocystorhinostomy

Purpose

To evaluate the role of tranexamic acid in controlling intra-operative and immediate post-operative bleeding during external dacryocystorhinostomy.

Methods

This was a double-blinded randomized placebo-controlled trial. All patients diagnosed with primary acquired nasolacrimal duct obstruction presenting between June 2018 to December 2019 were included in the study. All patients in the study group received a single dose of 1 gm tranexamic acid injection intravenously 30 minutes before the surgery, whereas the patients from group B (placebo) received normal saline. The effect of the injection was measured in terms of duration of the surgery, surgical field grading, amount of total blood loss during the surgery, and the need for postoperative nasal packing.

Results

A total of 96 patients were included, of whom 45 were males and 51 were females. The study group (Group A) included 51 patients (27 males and 24 females) and the control group (Group B) included 45 patients (18 males and 27 females). There were no statistically significant differences between the two groups in terms of the duration of surgery (48.43 ± 20.01 minutes vs. 53.38 ± 19.8 minutes, P = 0.228), view of the surgical field (P = 0.084), the amount of intraoperative blood loss (88.63 ± 69.34 mL vs. 88.89 ± 51.93 mL, P = 0.984) and requirement of postoperative nasal packing (54.9% vs 62.2%, P = 0.471).

Conclusion

There seems to be little to justify the role of preoperative intravenous tranexamic acid injection in controlling intra-operative and immediate postoperative bleeding during external dacryocystorhinostomy.

Optic nerve sheath fenestration for visual rehabilitation in moyamoya disease

A 13-year-old female presented with decrease in vision in both eyes with headache and vomiting for 15 days. Her visual acuity was perception of light with inaccurate projection in the right eye and counting fingers close to face in the left eye. Pupils were nonreactive. Fundus showed bilateral disc edema. Magnetic resonance angiography showed an attenuated caliber of the left internal carotid artery with occlusion of the left middle cerebral artery with collaterals, characteristic of moyamoya disease. The patient underwent right optic nerve sheath fenestration, following which her vision improved to 6/36 in the right and 6/24 in the left eye. Moyamoya disease is an occlusive disease of the cerebral vasculature most commonly seen in the Japanese. Children usually present with ischemic events. In the literature, visual symptoms secondary to raised intracranial tension in moyamoya disease are not well described. Ophthalmologists should be aware of this disease and the treatment options for salvaging vision.

Watt-level and sub-100-fs self-starting mode-locked 2.4-µm Cr:ZnS oscillator enabled by GaSb-SESAMs

Femtosecond lasers with high peak power at wavelengths above 2 µm are of high interest for generating mid-infrared (mid-IR) broadband coherent light for spectroscopic applications. Cr²⁺-doped ZnS/ZnSe solid-state lasers are uniquely suited since they provide an ultra-broad bandwidth in combination with watt-level average power. To date, the semiconductor saturable absorber mirror (SESAM) mode-locked Cr:ZnS(e) lasers have been severely limited in power due to the lack of suitable 2.4-µm SESAMs. For the first time, we develop novel high-performance 2.4-µm type-I and type-II SESAMs, and thereby obtain state-of-the-art mode-locking performance. The type-I InGaSb/GaSb SESAM demonstrates a low non-saturable loss (0.8%) and an ultrafast recovery time (1.9 ps). By incorporating this SESAM in a 250-MHz Cr:ZnS laser cavity, we demonstrate fundamental mode-locking at 2.37 µm with 0.8 W average power and 79-fs pulse duration. This corresponds to a peak power of 39 kW, which is the highest so far for any saturable absorber mode-locked Cr:ZnS(e) oscillator. In the same laser cavity, we could also generate 120-fs pulses at a record high average power of 1 W. A comparable laser performance is achieved using type-II InAs/GaSb SESAM as well. These results pave the way towards a new class of high-power femtosecond SESAM mode-locked oscillators operating directly above 2-µm wavelength.

Plasma cell granuloma of the conjunctiva in a young female

Plasma cell granuloma is a rare non-neoplastic inflammatory condition of unknown etiology commonly involving lung and gastrointestinal tract. Conjunctival disease per se is very rare and usually associated with involvement of other organs. We report a case of conjunctival plasma cell granuloma without any systemic involvement in a 9-year-old girl who presented with bilateral reddish vascularised subconjunctival episcleral mass. An excision biopsy of the mass in the left eye followed by histopathologic examination and Immunohistochemistry confirmed the diagnosis. At 1 year follow-up, the child had no recurrence in the operated eye whereas the lesion remained the same in the other eye despite systemic treatment with immunosuppressants. This case is being reported for its rarity and to insist on the mandatory need for a thorough systemic workup to identify multiorgan involvement as well as to rule out other systemic disorders.

Lateral rectus dermoid cyst presenting as incomitant esotropia

A 24-year-old male presented with decreased vision associated with inward deviation of his left eye since childhood and gradually progressive prominence of left eye for 6 months. Left eye examination revealed visual acuity of 2/60, convergent squint with restricted abduction and medial dystopia. Computed tomography (CT) scan showed a well-circumscribed mass with fat fluid levels temporal to the optic nerve indistinguishable from the left lateral rectus. Intraoperatively, a well-encapsulated mass was identified within the lateral rectus muscle which was confirmed as dermoid cyst on histopathology. Patient subsequently underwent surgical correction of his esotropia and the final cosmetic outcome was satisfactory. Dermoid cysts are common orbital lesions usually found overlying suture lines. A dermoid cyst presenting within the ocular muscles is a rare entity. Deep dermoid cyst should be considered as one of the differentials for focal enlargement of extraocular muscles.

Triton tumor of the orbit

A triton tumor is a malignant peripheral nerve sheath tumor (MPNST) with rhabdomyomatous differentiation These tumors account for 5% of MPNSTs and have an extremely poor prognosis. We describe the case of a 14-year-old girl who presented with a history of painful, progressive protrusion of her right eye with a diminution of vision for the past five years. She had been diagnosed as having an embryonal rhabdomyosarcoma of the right orbit, and she had undergone surgical debulking followed by chemotherapy and radiotherapy. Despite undergoing multiple modalities of treatment, she had several recurrences prior to this consultation. We reviewed her histology slides. HPE features were consistent with a malignant triton tumor with cartilage and osseous differentiation. Immunohistochemistry was done to confirm the diagnosis. In view of the aggressive nature of the tumor with multiple recurrences; she was advised palliative radical excision to reduce the tumor burden.

Orbital fractures in children: clinical features and management outcomes

PURPOSE

To report the clinical characteristics and management outcomes of orbital fractures in children.

METHODS

The medical records of pediatric patients (<18 years of age) who presented with orbital fractures over a 15-year period (January 2001-December 2015) were reviewed retrospectively. The cause of injury, imaging findings, clinical features, management, and outcomes were noted.

RESULTS

A total of 52 patients (39 males) were included. Mean age at presentation was 10.9 years (range, 2-18). Road traffic accidents (18/52 [35%]) were the most common cause, with the orbital floor (42/52 [81%]) being the most common fracture site. The most common complaint was double vision (52%). Thirty-eight patients underwent surgical intervention, and extraocular muscle entrapment (56%) was the most common indication for surgery. Early surgical intervention within 15 days of injury resulted in complete resolution of diplopia.

CONCLUSION

In our study cohort, orbital floor fracture was most common. The trapdoor type of fracture was seen in almost half of the patients, with diplopia being the most common presenting complaint. Early surgical intervention was associated with complete resolution of ocular motility limitation and diplopia.s.

Safety and Efficacy of Intravitreal Dexamethasone Implant for Refractory Uveitic Macular Edema in Adults and Children

PURPOSE

To assess safety and efficacy of intravitreal dexamethasone (DEX) implant in refractory uveitic macular edema (ME).

METHODS

We retrospectively analyzed medical records of patients with nonresponsive ME secondary to chronic, noninfectious intermediate or posterior uveitis, treated with intravitreal DEX implants.

RESULTS

A total of 42 eyes of 34 patients (aged 6-67 years) received 56 implants. Mean follow-up was 19.2 ± 2.2 months after DEX implant. The mean visual acuity (0.48 ± 0.06 logMAR to 0.34 ± 0.1 logMAR) and mean central retinal thickness (472.2 ± 35 to 274.7 ± 60.6 µm) improved considerably before and after DEX implant. A total of 11 eyes needed repeat implants after a prolonged time to recurrence (12.6-20.9 months). A total of 10 eyes needed no additional treatment. Oral steroids could be stopped in 40% patients. Intraocular pressure increased in seven and cataract progressed in six eyes.

CONCLUSION

Intravitreal DEX implant is safe and effective adjunct therapy. It reduces dependence on systemic steroids, immunosuppressives and provides long-term effects.

An efficient broad-band mid-wave IR fiber optic light source: design and performance simulation

Design of a mid-wave IR (MWIR) broad-band fiber-based light source exploiting degenerate four-wave mixing (D-FWM) in a meter long suitably designed highly nonlinear (NL) chalcogenide microstructured optical fiber (MOF) is reported. This superior FWM bandwidth (BW) was obtained through precise tailoring of the fiber's dispersion profile so as to realize positive quartic dispersion at the pump wavelength. We consider an Erbium (Er(3+)) - doped continuous wave (CW) ZBLAN fiber laser emitting at 2.8 μm as the pump source with an average power of 5 W. Amplification factor as high as 25 dB is achievable in the 3 - 3.9 μm spectral range with average power conversion efficiency > 32%.