A systemically normal 12-year-old woman presented to our center with a conjunctival lesion in the left eye, which was clinically suggestive of ocular surface squamous neoplasia (OSSN) and was confirmed by histopathology. OSSN in healthy young children, in absence of systemic risk factors like Xeroderma pigmentosa (XP) or human immunodeficiency syndrome (HIV), is rare, and to the best of our knowledge it has not been reported in the literature so far. This case report indicates that OSSN can occur in healthy young children albeit rarely, and emphasizes the need for a high index of clinical suspicion, comprehensive eye evaluation, and early intervention.

This case report describes the unique presentation of post buckle infection, inclusion conjunctival cyst. A 17-year-old male presented with pain, redness and a mass lesion in the left eye status post an infected scleral buckle removal. Surgical exploration revealed retained sutures and the capsule presumed to be formed around the buckle. After removal of both, patient was asymptomatic with stable BCVA and fundus findings. Surgical management includes not just the removal of the buckle material, but also the buckle sutures and the capsule formed around the episcleral buckle implant to completely remove the foci of infection and inflammation.

This report describes a rare case coincident keratoconus and Iridocorneal Endothelial (ICE) syndrome in a 43-year-old male with atopy who presented with progressively declining vision. A beaten silver appearance of the right endothelium with a dark-light reversal pattern and endothelial pleomorphism was consistent with the Chandler's syndrome variant of ICE. Keratoconus was demonstrated by irregular astigmatism with thinning and steepening on corneal tomography. He remained stable throughout 14 years with no evidence of secondary glaucoma or progression in keratoconus with conservative management. Coincident ICE and keratoconus is a rare entity with only one other published case of the Chandler's syndrome variant.

Superficial anterior lamellar keratoplasty (SALK) is a useful therapeutic modality to treat anterior and mid-stromal corneal opacities due to various pathologies including trachoma. The interface created during the surgery due to host and donor stroma-to-stroma apposition can be associated with potential complications that can affect its final surgical outcome. Collection of fluid in the interface after sutureless SALK has, rarely, if ever been reported. A 62-year-old man with bilateral pseudophakia and trachomatous keratopathy underwent microkeratome and fibrin-glue-assisted SALK for anterior stromal opacity in the left eye with an improvement of visual acuity to 6/18. Interface fluid was noted 1 week after the surgery which progressed to appear like a cyst subsequently. The visual acuity declined to 3/60. The fluid was drained and graft sutured under the guidance of intraoperative optical coherence tomography. No recurrence was noted till 3-months follow-up and the visual acuity resumed to 6/18.

Herbal medicine Isotine eye drop contains extract from Butea monosperma, Achyranthes aspera, Boerhavia diffusa and elements such as aluminum, boron, copper, and zinc. Multiple indications are claimed and the only reported side effects are ocular irritation and foreign body sensation. Herein, a case of keratouveitis with glaucoma and pupillary abnormality is reported following its uniocular use for three days. Toxic and immunomodulatory properties of the ingredients are discussed.

A 55-year-old female presented with painless, diminution of vision in the right eye for 6 months. She had episodes of knee pain in the past. Slit lamp bio-microscopy revealed crystal-like deposits in the deeper corneal stroma in the right eye. Anterior segment optical coherence tomography and confocal microscopy revealed crystalline deposits. Systemic work-up revealed tophi in the right great toe with persistently high serum uric acid over the past ranging from 9 to 12 mg%. The patient is on follow-up and currently on medical therapy for gout. Gout may be associated with crystalline deposits in corneal stroma that may cause blurring of vision.

We report a unique case of infectious crystalline keratopathy (ICK) caused by Burkholderia cepacia in a 47-year-old patient with history of multiple penetrating keratoplasties (PKPs). Slit-lamp examination revealed a white nonsuppurative needle-like branching anterior stromal infiltrate. Microscopic examination of the Gram-stained smear showed gram-negative bacilli. Cultures revealed Burkholderia cepacia, which was multidrug resistant and sensitive to piperacillin/tazobactam. Based on antibiotic sensitivity report, patient was started fortified piperacillin-tazobactam (0.32%) eye drop on an hourly basis. After 8 weeks of aggressive therapy, the infiltrate resolved with subsequent corneal scarring and vascularization. To our knowledge, this is the first reported case of Burkholderia-related ICK. ICK, first described by Gorovoy et al.^[1] in 1983, is an indolent keratitis with characteristic needle-like branching opacities in the absence of corneal or anterior segment inflammation.^[2] The presence of an immunocompromised corneal state, such as chronic topical steroid use post PKP, is a known risk factor for the development of ICK. Other risk factors include surgical procedures such as lamellar keratoplasty, corneal cross-linking, laser-assisted in situ keratomileusis, pterygium excision, and trabeculectomy with 5- FU. Topical anaesthetic abuse as a risk factor has also been described.^[3] Burkholderia is a group of Gram-negative bacteria, composed of at least 20 different species. We describe a case of Burkholderia keratitis presenting as ICK in a patient who underwent multiple PKPs and a history of long-term topical steroid therapy.

A 62 yearold male had a primary failed descemet stripping automated endothelial keratoplasty (DSAEK) following an eventful DSAEK surgery and was kept on long-term topical steroid in a tapering dosage. 5 months later, the turgid host cornea developed a pearly white crystalline anterior stromal infiltrate suggestive of infectious crystalline keratopathy (ICK). Gram stain smear revealed gram-positive, round to oval, large, budding cells which exhibit blue-white florescence with calcofluor white stain. Species level identification as Candida parapsilosis, in addition to the antifungal sensitivity, was aided by a yeast reagent card on VITEK 2 compact automated microbiology system. Based of antifungal sensitivity report, the patient was treated with both oral fluconazole and topical antifungals and responded to the management. Clinical diagnosis of ICK with a mandatory microbiological workup is prudent for a successful outcome.

Staphylococcus caprae is a catalase-positive and coagulase-negative organism that has been implicated in many systemic human infections but rarely in ocular infections. We present a rare case of S. caprae keratitis after phacoemulsification surgery. A 63-year-old male presented with the complaints of pain, redness in OS for 3 days following a phacoemulsification surgery. Cornea had an epithelial defect with a ring-shaped deep infiltrate. Temporary keratoprosthesis-associated pars plana vitrectomy was done followed by penetrating keratoplasty. Staphylococcus caprae was identified in culture. This case report points out to the pathogenic potential of S. caprae in keratitis in immunocompetent patient.

A gentleman with microbiological proven fungal keratitis developed pigmented keratic precipitates with increased anterior chamber reaction on antifungals. Presumed HSV iritis was suspected. Topical steroids were contraindicated. Complete resolution was observed with oral Acyclovir and anti-fungal therapy. A year later acute granulomatous anterior uveitis occurred which responded to topical steroids but progressed to corneal melt with perforation. Following penetrating keratoplasty, he has a clear graft and 20/80 vision. Concomitant HSV iritis with active fungal keratitis is extremely rare. This management dilemma necessitated only oral Acyclovir while continuing anti-fungal therapy while avoiding steroids for HSV kerato-uveitis.

We report a case of Nocardia keratitis following corneal cross-linking for progressive keratoconus. A 26-year-old otherwise healthy woman underwent crosslinking for keratoconus in her left eye. She presented with corneal infiltrates with a wreath-like pattern, on the seventh postoperative day. Gram's and acid-fast staining revealed Nocardia. She was managed with topical fortified amikacin 2.5% eye drops. The keratitis resolved to leave dense vascularization which was managed with topical prednisolone 1% eye drops.

A 30-year-old woman diagnosed of Cogan's syndrome (CS) with a chronic interstitial keratitis suffered from fungal keratitis and endophthalmitis after penetrating keratoplasty (PK). Microbiological cultures revealed a Candida albicans infection of the corneal graft. The corneoscleral rim was found out to be contaminated by this fungal species. Antifungal treatment, lensectomy and PK were performed. Fungal-related postoperative complications might be considered in a torpid postoperative course after PK specifically in immunosuppressed patients such CS. Routine corneoscleral rim culture may help to identify those patients who could benefit of prophylactic treatment.

High levels of iron may be toxic and cause various pathologies in the human body, including the eye. Studies have shown increased iron concentration in certain subtypes of senile cataracts. High serum levels of its non-reactive depot form, ferritin, has also been associated with juvenile cataracts in hereditary hyperferritinemia-cataract syndrome. Whereas this form of hyperferritinemia is inherited, there is no report on cataract formation in iatrogenic hyperferritinemia. Herein, we report a 43-year-old case who was diagnosed with bilateral cataracts a few years after she received intensive intravenous iron replacement therapy for severe iron deficiency anemia.

An accurately sized Phakic Intra-Ocular lens (PIOL) helps achieve adequate vault which in turn also provides for rotational stability. Toric PIOL implantation was done for a case with bilateral myopic astigmatism. Both eyes had similar spherical equivalent and ocular biometric parameters; thus, same sized PIOLs were implanted. Right eye post-operative course was uneventful but left eye repeated rotation was noted. An inadvertently placed smaller sized PIOL in left eye could explain rotation. Re-evaluation confirmed similar ocular and PIOL parameters in both eyes, but a shallow vault (444 μ) in left eye compared to right (602 μ). Post PIOL extraction, measurement confirmed the left PIOL size to be lesser (11.61 mm) than the expected size (12.75 mm).

Glaucoma surgeries are rarely combined with toric intraocular lenses (IOL) to address the astigmatism in a glaucoma patient. We report a case of a young woman with glaucoma secondary to steroid usage post femtosecond laser assisted keratoplasty for progressive keratoconus. The patient was operated for combined trabeculectomy with phacoemulsification and a customized toric IOL was implanted. Postoperatively the patient maintained good uncorrected visual acuity and stable intraocular pressure. Toric IOLs can provide a safe and convenient way of correcting high astigmatism and can be successfully combined with trabeculectomy to provide a better visual outcome.

We describe the clinical features of a rare congenital ectodermal dysplasia - Keratitis Icthyosis Deafness (KID) syndrome in a 45-year-old female patient, who presented with corneal neovascularization and advanced cataract in both eyes. Sequential bilateral extracapsular cataract extraction with implantation of posterior chamber intraocular lens (PCIOL) in the bag was performed for visual rehabilitation. A review of published literature for this rare disease is also presented.

Intrascleral haptic fixation of intraocular lens fixation by Yamane's technique is a popular technique of scleral fixation of intraocular lens (IOL). We herein describe two eyes of two patients with cyclodialysis cleft formation as a complication of Yamane's technique and its subsequent management.

Penetrating ocular injury is an important cause of loss of vision and may be associated with the presence of intraocular foreign body (IOFB). Missed IOFB may present with non-specific clinical features which may delay accurate diagnosis and proper management. We are presenting a case of unusual retained intraocular foreign body in a 38-year-old woman which emphasizes the need of careful review of patient's traumatic history and need of investigation like anterior segment optical coherence tomography (ASOCT) in diagnosis, localization of foreign body and follow-up after foreign body removal.

Hallermann–Streiff syndrome (HSS), an asymmetric second branchial arch defect affects growth, cranial and dental development. A 40-year-old lady with HSS developed severe pain and redness in her right eye due to raised intraocular pressure (IOP; 51 mmHg). A ruptured anterior capsule with cortical lens matter and granulomatous reaction was seen in anterior chamber (AC) along with absorbed cataract. Treatment with antiglaucoma medications, steroids followed by AC wash, anterior capsulotomy with anterior vitrectomy normalized IOP and inflammation reduced. Lens particle glaucoma is a rare presentation of HSS. Therefore, early cataract surgery is recommended that also avoids the risk of suppression amblyopia.

Cornea plana is a rare congenital condition, usually occurring bilaterally, characterized by flat cornea and low refractive power. Glaucoma due to angle closure is a more common association owing to the shallow anterior chamber. We report a case of an elderly lady with bilateral cornea plana with immature cataract and open-angle glaucoma, and unilateral microcornea. The patient is visually rehabilitated. Her glaucoma is stable, maintained on a single anti-glaucoma medication. In conclusion, IOP measurement in these patients can be biased due to varied corneal morphology. However, with proper evaluation, these challenging cases can be well managed.

We report a rare ocular presentation of bilateral corneal haze and unilateral glaucoma in a 33-week old preterm infant diagnosed to have congenital erosive and vesicular dermatosis.

Oculodermal melanocytosis (ODM) is a rare condition with glaucoma being the most common complication in these eyes. Open angle glaucoma is the commonest variant and presence of angle closure in these eyes should raise a suspicion of ciliary body or uveal tumor, which needs to be evaluated before any surgical intervention is planned. We report a case of unilateral ODM with secondary angle closure glaucoma. Angle closure in an eye with ODM is extremely rare, ultrasound B-scan showed thickened choroid, and ultrasound biomicroscopy showed 360° ciliary body hypertrophy. Incisional biopsy & fine needle aspiration cytology of the ciliary body tissue was performed, and histopathological features were suggestive of a benign hypertrophy ruling out ciliary body melanoma. Subsequently, a glaucoma drainage device surgery was performed in the right eye. To the best of our knowledge, benign ciliary body hypertrophy causing intractable angle closure glaucoma in a case of ODM has not been reported.

Radius–Maumenee syndrome (SRM) is an idiopathic uncommon disorder that occurs with a dilation of the episcleral vessels and an increase in intraocular pressure (IOP). Most cases of dilated episcleral vessels can be attributed to carotid-cavernous-sinus fistula, cavernous sinus thrombosis, dural arteriovenous shunt, superior vena cava syndrome, Sturge–Weber syndrome, or Obstructive orbital lesions. There are rare cases without an underlying cause. It is a syndrome that constitutes a diagnostic and therapeutic challenge. The aim of our work was to report a case of Radius–Maumenee syndrome and to describe the diagnostic procedure for this relatively rare condition.

Micropulse–transscleral–cyclophotocoagulation [MPTSCPC] delivered with the G6 laser system is one of the newer laser systems which purports greater safety without compromising efficiency in the reduction of intraocular pressure. This is due to the pulsed nature of the delivery of the laser in on and off cycles. We report the initial results of the laser used at low energy levels in consecutive Indian eyes [n = 8] with advanced or end-stage glaucoma, in one session. Three representative cases are described in this case series.

Valved Glaucoma Drainage Devices like Ahmed Glaucoma Valve (AGV) are prone to bleb encapsulation around the endplate with subsequent uncontrolled intraocular pressure. Aqueous suppression may or may not lead to resolution and the valve may eventually fail. We report the management in a series of 3 eyes of 3 patients who had failed AGV surgery and after receiving transscleral diode cyclophotocoagulation (TSCPC) treatment, presented with hypotony and decreased vision.

Transposition of lateral rectus to medial rectus, though an alluring and effective method in managing complete third nerve palsy, is not without its complications. We report a rare but known complication of choroidal effusion with neurosensory detachment after medial transposition of Y split lateral rectus, in a case of posttraumatic complete third nerve palsy with aberrant regeneration. This led to a severe drop in visual acuity which did not resolve spontaneously and was managed by release of the scleral suture and topical, intravenous, and oral steroids subsequently leading to its complete resolution and restoration of visual acuity.

Approximately 60%–90% of the isolated aniridia (IA) in India is reported to be sporadic (simplex) in nature, with much lesser contribution by autosomal dominant inheritance. The Indian genomic profile for IA indicates the commonest mutations to be single nucleotide variations in PAX6, whereas copy number variants, especially deletions, are rare. Deletions involving PAX6 along with another gene are even rarer. Our paper highlights an unreported Indian scenario of prenatal genetic counseling for sporadic IA due to PAX6 and ELP4 exon deletions and expands the mutation spectrum associated with IA in India.

A 52-year-old woman was diagnosed with bilateral necrotizing scleritis (NS) and peripheral ulcerative keratitis secondary to the antineutrophil cytoplasmic antibody (ANCA)-negative granulomatosis with polyangiitis (GPA) as evidenced by increased erythrocyte sedimentation rate, bilateral multiple cavitation lung nodules, and persistent microscopic hematuria. Infective workup and autoimmune tests were negative including the ANCA test. She received multiple courses of high dose intravenous methylprednisolone, intravenous cyclophosphamide, and oral methotrexate. Multiple tectonic patching operations were performed. Despite all the treatment, the disease continued to progress. Eventually, few doses of rituximab were given and the disease was stable for at least a year without any reactivation.

Preretinal exudates have been described in various ocular diseases. We present a case of preretinal exudates in tubercular retinal vasculitis with an inflammatory choroidal neovascular membrane (CNVM). The patient was treated with a tapering dose of oral corticosteroids, antitubercular therapy. Inflammatory CNVM which develops in active disease or during regression can be treated with intravitreal bevacizumab. In our case, the resolution of exudates was seen within 8 weeks of starting the treatment without any scar formation. In conclusion, we report a picture of exudates in a novel plane (preretinal) concerning tubercular vasculitis.

Inflammatory bowel disease is a chronic disorder of the gastrointestinal tract that is frequently associated with extra-intestinal manifestations. Ocular manifestations generally include episcleritis, scleritis, and anterior uveitis. Vision-threatening complications like retinal vascular occlusions and retinal vasculitis have been anecdotally reported in these patients. We present a case of ulcerative colitis who presented with bilateral occlusive retinal vasculitis and retinal neovascularization, 10 years after being diagnosed with the disease. She was successfully managed with oral immunosuppressive agents and scatter laser photocoagulation. This case highlights the importance of ophthalmic examination in patients with ulcerative colitis, which is considered to be infrequently associated with ocular manifestations.

A 36-year-old male suffered a traumatic open globe injury to his right eye resulting in phthisis. One year later, he developed a sudden progressive decrease in vision in the fellow (left) eye. Examination revealed arteriolar attenuation, multifocal deep subretinal infiltration, retinal edema, and necrosis. The patient underwent diagnostic vitrectomy in the left eye, and diagnostic enucleation of the phthisical right eye after suboptimal response to intravenous corticosteroid, antiviral, and antibiotic therapy. Detailed immuno-histopathological evaluation revealed extensive retinal disorganization with photoreceptor loss, perivascular infiltration, Dalen-Fuchs nodules, and granulomatous inflammation with central necrosis and melanin pigment, suggestive of a rare variant of sympathetic ophthalmia.

Rubella is a viral disease that affects human particularly pregnant females and causes transplacental spread to affect the fetus in utero. Congenital rubella in a child can manifest from mild to severe involvement. We report a case of a young boy with bilateral blindness and sensorineural deafness. Enucleated eye revealed the evidence of rubella eye disease. TORCH titer showed increase of IgG antibody in the serum. An extensive systemic examination and investigations by physician did not show any other signs of extended rubella syndrome.

Variceal dilations of vortex vein are not uncommon in eyes with high myopia. However, its occurrence in emmetropic eyes and posterior location has rarely been reported. We report a case of 55-year-old man who presented with a reddish orange sub-retinal lesion at the macula with subtle pulsation and collapse on pressure indentation. The lesion appeared hyerfluorescent on early frames of FFA with persistent silhouette in the late frames. ICGA showed dilated and tortuous vascular complex with hyperfluorescence in the mid phase without any evidence of late leakage. On SD–OCT the lesion appeared as a hypo-reflective sinusoidal space extending from the Hallers layer to the choriocapillary bed with distortion of the overlying RPE. The En-face Angio-OCT imaging was suggestive of a flow void sinusoidal tract with internal septa. The clinical features and collaborative findings on multimodal imaging were suggestive of variceal dilatation of the vortex vein ampulla.

Perifoveal exudative vascular anomalous complex is an unilateral, isolated, perifoveal aneurysm with adjacent exudative maculopathy. It has been hypothesized to develop due to progressive endothelial injury leading to aneurysmal changes. Usually, it is unresponsive to routinely used anti-VEGF agents. We present a case of a 33-year-old woman presented with PEVAC who was treated with a thermal focal laser. Complete resolution of PEVAC and improvement in BCVA was noted.

Venomous snake bites, a serious health issue in Asian countries, may be associated with multiorgan involvement, although ocular manifestations are relatively uncommon. Herein, we report a case of snakebite induced macular infarction. A seventeen-year-old girl presented with a history of viper snake bite in the right ankle, followed by a sudden painless drop in vision in the left eye, 20 days back with BCVA of 20/600. Left eye fundus examination revealed temporal pallor of the optic disc with retinal whitening in the macular area, and sclerosed macular branch arteriole, consistent with macular infarction. She was managed conservatively.

Macular hole in uveitic pathologies is a rare entity. Spontaneous closure of macular hole with conversion to a type 2 choroidal neovascular membrane has been reported even more sparsely. We present an interesting case of a 51-year-old woman with convalescent stage of Vogt-Koyanagi-Harada disease of 20 years duration, who developed a macular hole along with reactivation of the disease. Immunosuppressive therapy was started to control the ocular inflammation, while the macular hole was observed. One and half years later, there was a repeat episode of inflammation when she presented with a decline in vision in the same eye with a choroidal neovascular complex and spontaneous closure of the macular hole. She received two intravitreal injections of ranibizumab biosimilar under systemic immunosuppressive cover. The CNV was stable and the macular hole remained closed over a 6-month drug free interval from the last injection. This is the first report of spontaneous closure of a macular hole with a concurrent neovascular membrane in a case of VKH.

Valsalva retinopathy is a prominent cause of premacular hemorrhage in young patients. We report the case of a young male patient with premacular hemorrhage due to Valsalva retinopathy who underwent Neodymium-doped Yttrium Aluminum Garnet (Nd: YAG) laser evacuation of the blood. Within 5 minutes, there was a significant clearance of the blood from the macular area. A week later we could demonstrate a vascular sign on fluorescein angiography. It is known that the source of blood in Valsalva retinopathy is the rupture of perifoveal capillaries. Based on the findings on fluorescein angiography we could postulate that the bleeding in our case could have been due to the rupture of a larger retinal venule.

A 16-year-old female presented with a sudden onset painless diminution of vision in the right eye. Fundus examination showed retinal whitening at the posterior pole with a cherry red appearance of fovea suggestive of CRAO. Swept-source Optical coherence tomography (SS-OCT) showed increased thickness, hyperreflective inner retina, and an empty vessel. Optical coherence tomography angiography (OCT-A) confirmed the absence of perfusion in the vessel. After intervention, reperfusion in the vessel was appreciated both on SS-OCT and OCT-A. We report a novel finding of detection of empty vessels on SS-OCT in a case of central retinal artery occlusion (CRAO).

A 58-year-female with a history of chronic kidney disease presented with defective vision in both the eyes (BE). Her vision was 20/120 in the right eye (RE) and 20/200 in the left eye (LE). Fundus evaluation revealed retinal arteriolar calcification, neovascularization of the disc (NVD), and drusen at the posterior pole in BE. Optical coherence tomography (OCT) images passing through the retinal arterioles indicated hyper reflective structures with back shadowing suggestive of intravascular calcification. En-face OCT angiography images over the optic discs were suggestive of NVD in BE. Blood investigation revealed elevated levels of phosphate and the product of calcium and phosphate levels. The patient was treated with pan-retinal photocoagulation in BE. However, the visual outcome was poor.

A 2-month-old premature infant (37 weeks post-menstrual age) was referred for persistent pre-retinal bleed following laser treatment for retinopathy of prematurity. Detailed examination revealed a reddish purple, raised, lobulated lesion at the junction of the vascularised retina and laser scars. Typical clinical findings along with fluorescein angiography helped establish the diagnosis of retinal cavernous haemangioma. This report describes the youngest reported case of retinal cavernous haemangioma in a premature child.

We report the first case of bilateral exudative retinal detachment in treatment naïve zone one aggressive posterior retinopathy of prematurity. Exudative detachments in retinopathy of prematurity have been reported in literature following laser photocoagulation or cryotherapy. But exudative detachment as an initial presentation in APROP is rather rare. The abnormality in our case was noticed at the second visit. A 20-day-old infant (born at 32 weeks of gestation) was diagnosed to have APROP. He was advised intravitreal bevacizumab injection (0.625 mg) in both eyes. Two days later when the infant was brought in for injection, he was found to have bilateral exudative retinal detachments almost reaching the posterior pole. We administered the intravitreal injections of bevacizumab in both eyes and the baby was followed up at regular intervals. Review at 1-month post-injection revealed resolution of detachments.

Peripapillary pachychoroid syndrome (PPS) is a novel variant in the pachychoroid disease spectrum in which pachychoroid features are more prominent around the optic nerve head and are associated with intraretinal and/or subretinal fluid. The choroidal thickness in PPS is characterized by its atypical distribution with nasal macular choroid being thicker than the temporal counterpart. There are a few case reports of PPS in the literature that describe the morphological features of PPS but the management protocols are yet to be established. We hereby describe the clinical course of a 54-year-old gentleman who came to us with complaints of a gradual decrease in vision. On basis of multimodal imaging, a diagnosis of PPS was made. Since the patient was symptomatic, he was treated with intravitreal aflibercept which showed a favorable anatomical and functional outcome.

A 39-year-old woman presented with inability to close left eye for 1 day and headache for 1 week. Neurologist evaluation revealed left lower motor neuron facial palsy and was treated for migraine with facial palsy. On developing nausea and vomiting, fundus examination showed papilledema and magnetic resonance imaging (MRI) with magnetic resonance venogram (MRV) revealed cortical venous thrombosis. Blood investigations revealed microcytic hypochromic anemia. She recovered completely by 6 months after anticoagulant therapy, hematinics, and anti-edema medications. This rare presentation of facial palsy in CVT highlights the need for early fundus examination and imaging with MRV to prevent morbidity and mortality.

Acute dysautonomia or dysfunction of the autonomic nervous system is characterized by severe postganglionic sympathetic and parasympathetic dysfunction, with a relative or complete sparing of motor and sensory function. Acquired cholinergic dysautonomia, a very rare condition of failure of the parasympathetic system leads to complete bilateral internal ophthalmoplegia, impaired secretion of tears, and may present with visual symptoms. Herein, we report a rare case of acute cholinergic dysautonomia in an 11-year-old girl.

In a boy aged 6 years left unilateral congenital ptosis with medial rectus-levator palpebrae superioris (MR-LPS) synkinesis; the coexisting hitherto unreported likely lateral rectus-superior rectus (LR-SR) dysinnervation is reported. Ocular movements were full and cover test did not reveal any ocular misalignment. Such a presentation can only arise from two concurrent dysinnervations: first one between inferior and superior divisions of third nerve and second one between third and sixth cranial nerve. The dysinnervation may conform to a forme-fruste TUBB3 (Tubulin, Beta 3 Class III Gene) pathogenic variant phenotype and may be classed as a novel congenital cranial dysinnervation disorder (CCDD).

Horizontal gaze palsy and progressive scoliosis (HGPPS) is an autosomal recessive disease with a mutation in the ROBO3 gene. Features include horizontal gaze palsy, preserved vertical eye movements, and convergence. Progressive scoliosis is present in all patients. On MRI, HGPPS is characterized by brainstem hypoplasia, bifid medulla, split pons sign, and absence of facial colliculi. We report two siblings who presented with characteristic ocular and neuroimaging features of HGPPS but no scoliosis. The diagnosis was confirmed by neuroimaging and genetic analysis. This case report highlights the role of suspecting HGPPS in children with gaze palsy and characteristic neuroimaging findings even when there is an absence of clinical manifestation of scoliosis. Subsequent referral should be made to the orthopedician to rule out scoliosis both clinically and radiologically.

A 9-year-old boy with complete lateral rectus palsy, following the treatment for his embryonal rhabdomyosarcoma of the right lateral rectus muscle, underwent temporal hemi-transposition of lower 2/3^rd of medial rectus muscle beneath the inferior rectus muscle. Satisfactory alignment and resolution of diplopia was achieved postoperatively. He developed staphylococcal scleromalacia after surgery that was successfully managed with scleral patch graft, oral and topical antibiotics, and steroids.

Inferior rectus aplasia is a rare cause of apparent inferior rectus palsy presenting as upward deviation of eye since birth. An ideal procedure to manage these cases should correct the deviation in primary gaze and improve motility of the eye. It has been managed in the past by full or partial tendon transplantation of horizontal recti muscles which poses a risk of anterior segment ischemia and is usually done in a staged manner. We report a case of inferior rectus aplasia confirmed preoperatively by imaging and successfully managed by a no split, no tenotomy method done in a single stage.

A number of vertical rectus transposition procedures have been described for nonresolving complete sixth nerve palsy. Overcorrections following transposition procedures may be treated by reversing/adjusting the transposition or advancing the medial rectus (if previously recessed). Undercorrections require transposing an additional vertical rectus or recessing the medial rectus. Of the many available transposition procedures for sixth nerve palsy, Nishida's procedure offers the advantage of not having to disinsert the vertical recti and sparing the ciliary circulation. There are no reports on management of overcorrections following this procedure to the best of our knowledge. We report a patient with complete sixth nerve palsy, who developed a consecutive exotropia and anterior segment ischemia after Nishida's transposition with medial rectus recession. He was successfully treated by cutting the transposition suture on superior rectus.

Supernumerary puncta are uncommon lacrimal anomalies. Besides being a rare condition, it is usually overlooked. In this study, we report 3 cases of supernumerary lacrimal puncta. While two patients presented with epiphora; one patient was asymptomatic. In biomicroscopic examination, two lacrimal puncta on the lower lid were observed. A supernumerary punctum should be considered in patients with excessive tearing. Supernumerary puncta may alter the efficacy of topical medications, therefore, patients need to be informed about this rare anomaly.

We report the case of a 23-year-old man with Robinow syndrome (RS) and bilateral epiphora due to nasolacrimal duct obstruction associated with bilateral mucoceles. The patient underwent endoscopic dacryocystorhinostomy (DCR) on the right and endoscopic revision DCR on the left, an anterior ethmoidectomy, and a septoplasty. Subsequently, he was disease-free at his 3-month follow-up. Like patients with midface anomalies, patients with RS frequently have lacrimal system pathologies. Since early recognition of this type of midface anomaly can minimize morbidity by facilitating optimal surgical therapy, we recommend a thorough ocular evaluation of patients with RS.

Morning Glory Syndrome (MGS) is a well-established association of basal encephalocele and usually presents with midline cranio-facial anomalies. 45-year-old female presented with Secondary Acquired Nasolacrimal Duct Obstruction (SANDO) in left eye. She had a broad nasal bridge, hypertelorism and a swelling inferomedial to medial canthus. Fundus examination in right eye showed Morning Glory disc anomaly. CT of the orbit and brain disclosed left naso-ethmoidal encephalocele. CT Dacryocystography showed partial dehiscence of nasolacrimal duct bilaterally. The patient underwent surgical repair of encephalocele followed by resolution of epiphora. The association of MGS with contralateral naso-ethmoidal encephalocele and SANDO is presented for its rarity.

In the presented clinical case of a patient with worsening postenucleation socket syndrome, we demonstrate using of modern computed methods for preoperative diagnostics, surgery planning, and production of a custom implant. We consider that computed tomography being accompanied by three-dimensional reconstruction and parameter measurements of the orbital tissues in the medical images enable ophthalmologists to gain comprehensive and precise information. All these enable us to provide better clinical results and better quality of life for the patients with monolateral anophthalmos.

Multiple cranial nerve palsies are clinical conundrums that can be solved by determining zones of the proximity of the affected nerves. The affliction of two or more contiguous neuroanatomic structures helps in the localization of the causative lesion. However, there are certain caveats to this method of estimation when it may not be applicable such as in cases of multifocal or diffuse pathologies and large mass lesions. Orbital apex disorders refer to the clinical spectrum arising from lesions in the orbital apex, superior orbital fissure, and cavernous sinus. Besides, large neoplasms in the middle cranial fossa too may have a similar presentation. It is essential to consider the possibility of false localizing signs, as is highlighted in our two case reports, both of which initially appeared to be caused by orbital apex region lesions.

A 32-year-old female with a right frontal lobe glioma underwent an elective frontotemporal craniotomy. One hour postoperatively, the patient developed a right orbital compartment syndrome (OCS) with unilateral acute vision loss, proptosis, afferent pupillary defect, and complete ophthalmoplegia. The patient underwent emergent lateral canthotomy and inferior cantholysis. Neuroimaging revealed extensive vascular congestion along the extraocular muscles at the orbital apex. Retinal imaging demonstrated an ophthalmic artery occlusion. OCS following a frontal or frontotemporal craniotomy relates to increased orbital venous congestion from direct compression of the myocutaneous flap and subsequent intraorbital pressure elevation, vascular compromise, and ocular ischemia.

We report two patients presenting with acute orbital inflammation as an unusual manifestation of metastatic carcinoid tumors. Neuroimaging revealed rim enhancing lesions mimicking orbital abscesses in both. Histopathology confirmed the diagnosis of metastatic neuroendocrine tumors with primary in the gastrointestinal tract. Atypical presentation of orbital metastases with inflammatory signs of a “hot” orbit is usually misdiagnosed. The clinical features of inflammation may result from the spontaneous release of inflammatory mediators intrinsic to neuroendocrine tumors. In elderly patients with bilateral, multiple extraocular muscle involvement, or acute-onset proptosis with inflammatory signs should alert the clinician to the rare possibility of metastatic neuroendocrine carcinoma.