Sarcomatoid Carcinoma of Orbit in a Patient With Xeroderma Pigmentosum

Spindle cell carcinoma (SpCC), also referred to as sarcomatoid carcinoma, makes up less than 3% of all head and neck squamous cell carcinomas (SCCs). It is an uncommon and unusual biphasic malignant tumor primarily affecting the upper aero-digestive tract. SpCC consists of spindled or pleomorphic tumor cells. Mostly, these tumors are seen in the fifth or sixth decades of life and are strongly associated with smoking and alcohol. We hereby report an infrequently encountered case of SpCC in a patient with xeroderma pigmentosum (XP), who was young, nonsmoker, and did not consume alcohol. The mass arose from the right orbit and involved the entire right face. The postoperative histopathological report showed SpCC. Surgical excision of the mass was performed. We aimed to add to the prevailing literature by reporting this case.

Cataract among Patients with Renal Transplantation in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Intensive immunosuppressant therapy after renal transplantation has found to cause systemic and ocular side effects among them is cataracts. Studies on a similar topic have still remained explored in our setting. The aim of the study was to find out the prevalence of cataract among patients with renal transplantation in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among patients of renal transplantation at tertiary care centres from 1 May 2021 to 31 October 2021. The data was collected after the ethical approval from Institutional Review Committee [Reference number: 397(6-11) e2077/078]. Study proforma recorded the number of patients with cataracts, duration of steroid use, mean age and other comorbidities. A convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of 31 renal transplant patients, 10 (32.26%) (15.80-48.72, 95% Confidence Interval) had cataract. Conclusions: The prevalence of cataract among renal transplantation patients was found to be lower than similar studies done in similar settings.

Management of unusual missed diagnosis of a Intra-orbital wooden foreign body: A case report and review of literature

Introduction

Although intra-orbital foreign bodies (IOrFBs) are commonly seen in daily ophthalmology practice, rarely, they can have very unusual clinical presentations, especially nonmetallic FBs.

Presentation of case

A 33-year-old male presented with sudden onset right lower lid swelling and tearing. He was initially tolerating the symptoms, however, it got progressively worse, so he came two weeks after the initiation of symptoms. His eye vitals were within normal limit, including the visual acuity of 6/6 OU. Additionally, slit lamp and fundus examinations were benign. Concern was for infectious etiology with unclear source. After a lengthy conversation, he recalled falling on the ground with face down about 16 months ago. However, he stated that he had remained asymptomatic and never went for treatment after the incident. Non-contrast CT of head and orbit showed hyperdense tract in medial aspect of right eye adjacent to the globe, piercing across the bilateral ethmoidal sinuses. Thus, a diagnosis of retained IOrbFB was made. He underwent surgery where a 5cm rotten wood was extracted. Post-surgical course was uncomplicated. Not all penetrating intra-orbital foreign bodies present immediately after the incident. In our case the patient remained asymptomatic for 16 months.

Conclusion

Therefore, when dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

•

Recognizing retained orbital foreign bodies secondary to trauma can be a challenge.

•

Organic IOrbFB following a penetrating injury can remain asymptomatic for a significant period, resulting in delayed diagnosis and treatment.

•

When dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

Evaluation of Intraocular Pressure in Thyroid-associated Orbitopathy

BACKGROUND

Elevated intraocular pressure in thyroid associated orbitopathy may lead to development of secondary glaucoma in them. This study evaluated IOP in primary gaze correlation with clinical activity score in them.

METHODS

A cross-sectional study was conducted from November 2020 to October 2021.Information on age, gender, thyroid function test, intraocular pressure, cup-disc ratio and clinical activity score were recorded. Purposive sampling was done. Statistical analysis was done using Statistical Package for Social Sciences version 21.

RESULTS

Total of 74 thyroid dysfunction patients was included in the study. There were14.86% patients with raised intraocular pressure. The mean intraocular pressure in hyperthyroidism was 15.4 ± 1.92 mm Hg and 15.48 ± 2.11mm Hg on right and left eyes respectively and in hypothyroidism, it was 15.08 ± 2.7mmHg and 15.12 ± 3.02 mmHg on right and left eyes respectively. The mean clinical activity score was 1.06 ± 1.23 mmHg. The mean intraocular pressure in eyes in active stage (n=9) was 16.3 ± 3.4 mm Hg, which was not significantly different from the mean intraocular pressure of 15 ± 2.4 mm Hg in inactive eyes (64), p= 0.1. Clinical activity score showed a significant correlation (p=0.03) with intraocular pressure in right eyes whereas it showed no significant correlation with intraocular pressure in left eyes (p=0.37).

CONCLUSIONS

In this study elevated intraocular pressure occurred in about 1 in 7 thyroid associated orbitopathy. It also had positive correlation with clinically activity score in right eyes. Regular intraocular pressure measurement should be done in thyroid associated orbitopathy to prevent intraocular morbidity.

Bilateral Cryptophthalmus: First Case Report from Nepal

Introduction: Cryptophthalmus is characterized by a partial or complete casing of the eyeball by the skin. Cryptophthalmus alongside other systemic abnormalities is well-known as Fraser syndrome. It is an unusual genetic disorder with limited literature. The complexities of disease and limited experience pose challenges in its management. Case: A two-day-male neonate was brought by his parents with a complaint of swelling in the right orbital region and deformed left eye since birth. Examination revealed bilobed globular swelling in the right orbital region covered by a continuous sheet of skin from forehead to cheek with no visible ocular tissue. On the left side, there was absence of upper lid margin and eyelashes and superior symblepharon. He also had bilateral ear abnormalities and right renal agenesis. Surgical intervention was done. On the right side, removal of the globe and cyst was done. On the left side, upper eyelid reconstruction with symblepharon release was done with amniotic membrane transplantation. Conclusions: The management of cryptophthalmus is challenging. Reconstructive surgeries allow cosmesis but useful vision is rarely gained. This is the first case report from Nepal to date to the best of our knowledge.

Profile of Ophthalmic Tumors in Adult Nepalese Population in Central Nepal

INTRODUCTION

Ophthalmic tumors cover benign and malignant tumors of eyelids, conjunctiva, globe, and orbit. There is limited literature on ophthalmic tumors in Nepal. The objective of the study was to find the relative frequency of various ophthalmic tumors in the adult Nepalese population in Central Nepal.

MATERIAL AND METHODS

This is an observational descriptive study. A total of 100 consecutive patients, presenting with ophthalmic tumors to tertiary referral eye hospital were enrolled for the study. Demographic profile, detailed history, clinical features and diagnosis of the ophthalmic tumors were recorded. The tissue from incisional or excisional biopsy was then subjected to histopathological examination for confirmatory diagnosis.

RESULTS

Mean age of subjects with ophthalmic tumors was 51.5 ± 18.2 years with a female to male ratio of 1.2:1. Benign tumors (64%) were the most common tumors followed by malignant (26%) and premalignant tumors (10%). Most common benign tumor was naevus (26.5%); most common premalignant tumor was conjunctival intraepithelial neoplasia (60%), and most common malignant tumor was sebaceous gland carcinoma (30.8%). Eyelid was most frequently involved with ophthalmic tumors (59%) followed by conjunctiva (21%). Clinical diagnosis correlated with histopathological diagnosis in 77% of cases.

CONCLUSION

As different ophthalmic tumors present in a myriad of ways and a significant proportion of these cases presenting to hospital settings are malignant, it is prudent to confirm with a histopathological diagnosis for optimum management of such cases.

<p>Orbital Lipoma as an Uncommon Cause of Unilateral Proptosis: A Case Report</p>

A 36 year old male presented with a two-month history of a progressively increasing proptosis of the right eye associated with redness. MRI of brain and orbit revealed a mass in the intraconal compartment in the lateral aspect of the right orbit that had T1, T2, and FLAIR high signal intensity and was completely suppressed in the STIR image. Excisional biopsy of the mass resolved the proptosis, and histology revealed encapsulated tumor composed of lobules of mature adipocytes along with fibro collagenous septa. Thus, diagnosis of lipoma was established that has uncommon occurrence in the orbital region.

Traumatic Orbital Compartment Syndrome: A Sight Threatening Emergency

Orbital compartment syndrome is a rare presentation of orbital trauma and is an ophthalmic emergency. Delay in clinical diagnosis and subsequent surgical intervention will lead to loss of vision in nick of time. We presented a case series of orbital compartment syndrome secondary to trauma who presented to the emergency department of Tribhuvan University Teaching Hospital during the devastating earthquake in April 2015. Clinical diagnosis of orbital compartment syndrome was made in the bedside and all the patients underwent emergency lateral canthotomy and inferior cantholysis. This case series was aimed to describe clinical features and management of orbital compartment syndrome.

Orbital Teratoma: A rare congenital tumour

BACKGROUND

Orbital teratomas are congenital, unilateral germ cell tumors, which are present at birth with moderate to massive proptosis. The rare tumour has to be managed individually and is at times difficult.

CASE

A female child in her 2nd day of life was brought to our department with complains of forward bulging of the left eye which was noticed since the time of her birth.

OBSERVATION

Examination and investigations revealed a mass with scattered foci of calcification. The mass was causing expansion of left orbit with thinning and scalloping of bony boundaries of left orbit with no intracranial component. The scan suggests the diagnosis of orbital teratoma which was further confirmed by histopathological examination.

CONCLUSION

The rare tumour presents a challenge in management. The aim of management depends upon the extent of tumour, preservation of vision whenever possible, promotion of normal orbital growth and cosmesis.

A case of transorbital intracranial injury presenting with subtle neurological deficit

Background: Ocular trauma is a major cause of visual morbidity. Objective: To present a rare case of transorbital intracranial injury extending up to the left internal carotid artery (ICA) with no other systemic neural deficit except for the ocular manifestations. Case: A 14-year-old female presented to our out-patient department (OPD) with the history of trauma to her left eye with stumps of bamboo shoots secondary to a fall injury. Examination and investigations revealed a foreign body extending from left inferior conjunctival fornix into the intracranial cavity, occluding the various segments of left ICA. The patient subsquently underwent craniotomy and foreign body removal by a combined team of neurosurgeons and ophthalmologists. On discharge, the patient had slight improvement in extraocular motility of her left eye. However the trauma rendered the affected eye, non-seeing. Conclusion: The intracranial extent of a foreign body entering the cranium via the transorbital route cannot be judged merely by the clinical findings of the nervous system and ocular examination. These patients need timely management by the combined effort of ophthalmologists, neurosurgeons and radiologists.

Recurrence of uveal malignant melanoma: a case report

BACKGROUND

Malignant melanoma of uveal tract is a rare ocular malignancy. It is one of the significant causes of ocular morbidity and mortality which is less commonly seen in children.

CASE

We report an unusual case of orbital recurrence of malignant melanoma in a 14-year old boy who had previously undergone enucleation of the left painful blind eye 8 months ago. He was diagnosed to have uveal malignant melanoma elsewhere which was confirmed by histopathology. Orbital recurrence was managed with modified exenteration with adjuvant chemotherapy and radiotherapy.

CONCLUSION

In all treated cases of uveal melanoma, close follow up examination and monitoring is necessary for early diagnosis of the recurrence and to plan for further management.

A Rare Malignant Transformation of Benign Lacrimal Tumor

Lacrimal gland tumors are common in middle age group individuals. Proptosis is one of theircommon presentations. Sometimes the tumors may undergo malignant changes which if neglectedcan be life threatening. Here we present a case of 49 years male with gradual painless protrusion anddiminution of vision in his right eye for eight years and more since last 2 months, with restrictionof ocular motility in right lateral gaze. Expecting a benign mass, superolateral orbitotomy withexcisional biopsy was done which astonishingly revealed carcinoma ex pleomorphic adenomawith components of adenocarcinoma and squamous cell carcinoma without any lymphovascularinvasion. Proptosis and vision of the patient in right eye improved post excisional biopsy withoutany residual mass in respective follow ups._______________________________________________________________________________________Keywords: adenocarcinoma; lacrimal gland; malignant transformation; proptosis._______________________________________________________________________________________

A rare malignant transformation of benign lacrimal tumor

Lacrimal gland tumors are common in middle age group individuals. Proptosis is one of their common presentations. Sometimes the tumors may undergo malignant changes which if neglected can be life threatening. Here we present a case of 49 years male with gradual painless protrusion and diminution of vision in his right eye for eight years and more since last 2 months, with restriction of ocular motility in right lateral gaze. Expecting a benign mass, superolateral orbitotomy with excisional biopsy was done which astonishingly revealed carcinoma ex pleomorphic adenoma with components of adenocarcinoma and squamous cell carcinoma without any lymphovascular invasion. Proptosis and vision of the patient in right eye improved post excisional biopsy without any residual mass in respective follow ups.

Lamellar ichthyosis presenting as bilateral spontaneous corneal perforation

Introduction: Lamellar Ichthyosis is an autosomal recessive, inherited skin disorder characterized by thickening, fissuring and scaling of the skin. Objective: To report a case of lamellar icthyosis and highlight the importance of monitoring corneal health in these patients. Case: We report a rare case of bilateral spontaneous corneal perforation in a patient with lamellar ichthyosis .The patient presented with complaints of diminution of vision, foreign body sensation, watering and discharge in both of his eyes for the last three months followed by pain and redness for one week. Visual acuities were light perception in both the eyes. Cicatricial ectropion was seen in both the lower eyelids. Corneal perforation was seen in both the eyes. Lamellar ichthyosis was diagnosed on the basis of scaling and excessive dryness of the entire body skin and was confirmed by skin biopsy. Peneterating keratoplasty of both eyes was done with cataract surgery of the right. The systemic anti-ichthyosis therapy was started. Ectropion of the right eye was corrected, and on follow-up at three months, the patient had a visual acuity of 4 /60 and CFCF in the right and the left eye respectively. Conclusion: In patients with cicatricial ectropion and dry eye secondary to ichthyosis, corneal health should be closely monitored because of the perforation risk. Nepal J Ophthalmol 2013; 5(9):117-119 DOI: http://dx.doi.org/10.3126/nepjoph.v5i1.7838

Ocular manifestations in herpes zoster ophthalmicus

BACKGROUND

Ocular complications of herpes zoster ophthalmicus (HZO) may lead to substantial visual disability, severe post-herpetic neuralgia and rarely fatal cerebral complications.

AIM

To identify the pattern of ocular manifestation in herpes zoster ophthalmicus.

MATERIALS AND METHODS

A cross-sectional descriptive study was under taken including the clinically diagnosed cases of HZO. All of them underwent a complete ophthalmological evaluation.

RESULTS

Sixty-eight cases of HZO were examined, of which 37 (54.4 %) were male and 31 (45.6%) female. The mean age was 48.7 ± 18.5 years. Most of the patients (64.7 %) were above the age of 40 years. 77.94 % of the patients had some form of ocular involvement. Pain (77.9 %) was the commonest ocular complaint. In young patients less than 35 years, HIV was the most common risk factor (19.3 %).Visual status was good in the majority (73.5 %) of patients at presentation. Lid and adnexal findings (45.8 %) were most common ocular involvement followed by conjunctivitis (41.1 %). Corneal complication was seen in 38.2 % of cases, uveitis in 19.1 % and post-herpetic neuralgia (PHN) and secondary glaucoma each in 5.8 %.

CONCLUSION

Eyelid and ocular adnexal involvement is most commonly found in patients with herpes zoster ophthalmicus followed by corneal complication and uveitis. There needs to be awareness of ocular involvement, which can be sight threatening, among the HZO patients and other medical departments and an increased emphasis on regular ophthalmic examination.

Malignant transformation of kissing nevus- a rare entity

BACKGROUND

Kissing nevus is a congenital nevus in adjacent parts of the eyelids. Malignant transformation of kissing or divided nevi of the eyelids is rarely described.

OBJECTIVE

To report a very rare case of malignant transformation of kissing nevus with ocular and extraocular spread.

CASE

A 57- year- old man with 6/6 visual acuity in both eyes presented with a kissing nevus present since birth in right upper and lower eyelids which had a slow growth phase. The upper lid in the area of the nevus was thickened with a 20x12x15 mm black pigmented crusted hemorrhagic nodular lesions. The lower lid had a 6 mm black pigmented ulcerated lesion over the pre-existing nevus in the lateral third of the lid with full thickness infiltration. Another 5x4 mm pigmented lesion over the lower medial lid margin with a thickness of about 3 mm extended to the conjunctival side of the lower lid. Right sided pre-auricular and sub-maxillary nodes were palpable. A biopsy of tissue samples from the eyelid and pre-auricular nodes were consistent with malignant melanoma.

CONCLUSION

Malignant transformation of kissing nevus is rare. It can spread to the conjunctiva,pre-auricular and sub-mandibular lymphnodes.

Ocular and orbital metastases presenting as a first sign of gastric adenocarcinoma

The authors report a case of simultaneous choroidal and orbital metastases with optic nerve involvement presenting as an initial manifestation of gastric adenocarcinoma. To our knowledge, this is the first case of its kind reported in the literature where a 60 years male presented with 6 months history of progressive painful diminution of vision in his left eye associated with inward and upward rotation of the same globe. Examination of left eye revealed displacement of the globe superomedially by an inferolateral mass with restriction of ocular motility in levoversion. Fundus examination showed exudative retinal detachment with a subretinal mass which was supported by the ocular ultrasonography. Intraocular and orbital tumour was demonstrated by CT. Endoscopic biopsy revealed adenocarcinoma of the stomach. The left orbit was exenterated and specimen was sent for histopathological examination which confirmed the presence of same metastatic tumour cells in the eye and orbit. The patient underwent chemotherapy and radiotherapy for gastric carcinoma but the patient died after 6 months.

Prospective study of pattern of breast diseases at Nepalgunj Medical College (NGMC), Nepal

INTRODUCTION

Patients of breast diseases of female are very common cases attending surgical out patient department for treatment at NGMC, Banke, Nepal.

OBJECTIVES

To find out the magnitude of the breast diseases, its frequency distribution in different age group among the patients attending surgical OPD for surgical consultation.

MATERIAL AND METHOD

This is a prospective study conducted at NGMC, Nepalgunj, Nepal. Patients attending surgical OPD for one or another breast problem were included. They were assessed clinically and their diagnosis was confirmed by cytological (FNAC) or histopathological (biopsy) examination. Then they were subjected to appropriate treatment. It must be mentioned at the outset that no clinical mammography could be done in the case of this study as these facilities are not available at NGMC.

RESULTS

264 cases of breast disease were diagnosed. This includes 232 female and 32 male patients. The ratio between benign and malignant lesions was 13.6:1. The benign breast diseases (BBD) were the commonest lesions of the breast found in this study (93.2%) whereas malignant lesion was infrequent (6.8%). Among BBD, the commonest lesion was fibroadenoma (32.57%) followed by breast abscess (24.19%), Aberration of Normal Development and Involution (ANDI) which was 16.63% and gynecomastia (11.34%). 18 cases (6.80%) were of malignant lesion. This includes 16 female and 2 male cases. The common ages for BBD were, 20-40 years for fibroadenoma, 15-40 years for breast abscess, 18-40 years for ANDI and 10-19, 50-59 for gynecomastia respectively, whereas carcinoma breast was common in the age group of forties and fifties.

CONCLUSION

We conclude from this study that BBD were the most frequent breast lesion. Among the BBD fibroadenoma was the commonest lesion. Breast carcinoma cases were less frequent and reached to the hospital in very late stage of the disease.

Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal

CONTEXT

Most of the world's refugees are displaced within the developing world. The impact of torture on such refugees is unknown.

OBJECTIVE

To examine the impact of torture on Bhutanese refugees in Nepal.

DESIGN

Case-control survey. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD), anxiety, and depression.

SETTING

Bhutanese refugee community in the United Nations refugee camps in the Terai in eastern Nepal.

PARTICIPANTS

A random sample of 526 tortured refugees and a control group of 526 nontortured refugees matched for age and sex.

MAIN OUTCOME MEASURES

The Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and anxiety.

RESULTS

The 2 groups were similar on most demographic variables. The tortured refugees, as a group, suffered more on 15 of 17 DSM-III-RPTSD symptoms (P<.005) and had higher HSCL-25 anxiety and depression scores (P<.001) than nontortured refugees. Logistic regression analysis showed that history of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7; 95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety (OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal system- and respiratory system-related complaints (P<.001 for both).

CONCLUSION

Torture plays a significant role in the development of PTSD, depression, and anxiety symptoms among refugees from Bhutan living in the developing world.