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OBJECTIVES Ocular pain symptoms (e.g., hypersensitivity to light and wind, "burning" sensations) can be debilitating and difficult to treat. Neuromodulatory therapies targeting sensory trigeminal and central pain pathways may help treat chronic ocular pain refractory to traditional therapies. The current study evaluates the long-term effects of a trigeminal neurostimulator (TNS) on ocular pain. MATERIALS AND METHODS Retrospective review of 18 individuals at the Miami Veterans Affairs Eye Clinic with chronic, severe ocular pain who were prescribed and used TNS at home for ≥3 months. The primary outcome measures were 1) ocular symptom intensity over a 24-hour recall period (dryness, pain, light sensitivity, wind sensitivity, burning; rated on 0-10 scales) captured pre-TNS and at monthly follow-up intervals and 2) side effects. The frequency and duration of TNS was a secondary outcome measure. RESULTS The mean age of the population (n = 18) was 57.5 years (range, 34-85 years) with a male majority (67%). Two individuals discontinued use due to lack of efficacy and one due to confounding health issues. Initial mean weekly frequency of TNS use was 3.7 ± 1.9 sessions of 25.8 min at month 1 and 2.7 ± 2.3 sessions of 28.0 min at month 6. At six months, pain intensity (↓ 31.4%), light sensitivity (↓ 36.3%), wind sensitivity (↓ 32.6%), and burning sensation (↓ 53.9%) were all decreased compared to baseline (p

PURPOSE: To examine whether “activated” dendritic cells (aDCs) could serve as a biomarker of systemic immune disorders in individuals with dry eye (DE) symptoms. Secondarily, to examine the impact of a topical anti-inflammatory agent on aDC number. METHODS: Retrospective analysis was conducted to identify individuals with DE symptoms who had in-vivo confocal microscopy (IVCM) imaging between October 2018 and July 2020 at the Miami Veterans Hospital. aDCs were manually quantified based on morphology. Receiver operating curve (ROC) analysis examined relationships between aDC number and systemic immune disease status. Individuals were then grouped by aDC number (≥2 versus

a). PURPOSE: Confocal microscopy and aethesiometry have allowed clinicians to assess the structural and functional integrity of corneal nerves in health and disease. This review summarizes literature on nerves in dry eye disease (DED) and discusses how this data can be applied to DED diagnosis and treatment. b). RECENT FINDINGS: Subjects with DED have a heterogenous symptom and sign profile along with variability in nerve structure and function. Most studies have reported lower nerve density and sensitivity in aqueous tear deficiency, while findings are more inconsistent for other DED subtypes. Examining nerve status, along with profiling symptoms and signs of disease, can help categorize subjects into disease phenotypes (structural and functional patterns) that exist under the umbrella of DED. This, in turn, can guide therapeutic decision-making. c). SUMMARY: Due to the heterogeneity in symptoms and signs of DED, corneal nerve evaluations can be valuable for categorizing individuals into disease sub-types and for guiding clinical decision making.

Ocular surface pain is a frequent cause of visits to an eye care provider and has a substantial impact on healthcare cost, yet a complete understanding of its causative factors and tools for diagnostic workup are notably missing in many eye clinics. The cornea has the densest sensory innervation in the human body and has the potential to be a powerful producer of pain. Pain can manifest as a result of a noxious stimulus or disruption in the ocular surface anatomy (nociceptive pain), or it can result from abnormalities in the ocular surface neurosensory apparatus itself (neuropathic pain). Novel advances in neurobiology have sought to differentiate the two entities, particularly to identify when chronic dry eye symptomatology is driven by neuropathic ocular pain. In this review, we seek to provide an overview of the prevalence, physiologic factors, and management of ocular surface pain complaints.

On radiographic imaging, the finding of a right-sided heart location can be due to multiple etiologies and may be congenital or acquired. We present the case of a 71-year-old male with a self-reported past medical history of hiatal hernia and previously diagnosed dextrocardia. The patient experienced cardiovascular intervention following an ST-elevation myocardial infarction. In the cardiac workup, a low-voltage normal electrocardiogram confirmed dextroposition of the heart due to significant herniation of gastric contents into the thoracic cavity. This gentleman had presumably been diagnosed with dextrocardia, a right-left reversal of heart anatomy and electrophysiology, based on imaging and incomplete workup. Dextroposition refers to a rightward shift of the mediastinum with no changes in orientation of cardiac anatomy, and therefore unchanged directional orientation of conduction. This is an important distinction from dextrocardia, a mirror-image reversal of the cardiac chambers and heart location in the chest wall, such as that due to congenital ciliary dysfunction. A sliding hernia is an uncommon cause of the rightward mediastinal shift, with few such cases documented in the literature, and cardiovascular manifestations of hiatal hernias are discussed. This case exemplifies the role of an electrocardiogram in distinguishing between dextrocardia and dextroposition for accurate diagnosis and management.

Dry eye disease (DED) is a multifactorial disease that manifests in patients with a variety of symptoms and signs such as ocular pain, visual issues, rapid tear evaporation and/or decreased tear production. It is a global health problem and is the leading cause of optometry and ophthalmology clinic visits. The mainstay therapy for DED is artificial tears (ATs), which mimics tears and improves tear stability and properties. ATs have been found to improve symptoms and signs of disease in all DED subtypes, including aqueous deficient DED and evaporative DED. However, given the heterogeneity of DED, it is not surprising that ATs are not effective in all patients. When AT fails to relieve symptoms and/or signs of DED, it is critical to identify the underlying contributors to disease and escalate therapy appropriately. This includes underlying systemic diseases, meibomian gland dysfunction, anatomical abnormalities and neuropathic dysfunction. Thus, this review will discuss the benefits and limitations of ATs and review conditions when escalation of therapy should be considered in DED.

Traumatic myositis ossificans (MO) circumscripta is an uncommon nonhereditary pathophysiological result of muscular trauma that is detected by radiographic imaging three to four weeks following initial trauma. It is responsible for great global morbidity, with symptoms of prolonged pain, diminished flexibility, and stiffness. There is frequently a delay in diagnosis due to the generalized symptoms and varying radiographic presentation. The goal of therapy is to rule out serious complications (such as soft tissue sarcoma) and to restore strength and range of motion (ROM) as soon as possible. Here we detail the case of a 32-year-old male with a delayed diagnosis of MO who presented to the hospital with left lower extremity pain and swelling following a motor vehicle accident (MVA) that occurred one month prior.

Mycobacterium avium intracellulare (MAI) is an opportunistic infection that typically manifests itself as pulmonary infection. In immunocompromised patients, however, MAI can uncommonly cause disseminated disease and diffuse gastrointestinal involvement. Small bowel obstruction with concurrent MAI infection is rarely documented in literature. Here, a 60-year-old female with a past medical history significant for a gastrointestinal stromal tumor, two small bowel obstructions, and a bowel perforation repair presented to the emergency department with sharp abdominal pain due to a small bowel obstruction. Cultures obtained from the laparoscopic release of small bowel obstruction confirmed the presence of MAI. An antibiotic course of ethambutol, azithromycin, and rifampin was initiated and continued upon transfer to a long-term acute care facility. We describe this case to highlight the possibility of MAI infection in patients with postoperative abdominal pain resulting from small bowel obstruction, review the underlying pathophysiology, and discuss its epidemiology.

Prolonged and continuous daily use of digital screens, or visual display terminals (VDTs), has become the norm in occupational, educational, and recreational settings. An increased global dependence on VDTs has led to a rise in associated visual complaints, including eye strain, ocular dryness, burning, blurred vision, and irritation, to name a few. The principal causes for VDT-associated visual discomfort are abnormalities with oculomotor/vergence systems and dry eye (DE). This review focuses on the latter, as advances in research have identified symptomology and ocular surface parameters that are shared between prolonged VDT users and DE, particularly the evaporative subtype. Several mechanisms have been implicated in VDT-associated DE, including blink anomalies, damaging light emission from modern devices, and inflammatory changes. The presence of preexisting DE has also been explored as an inciting and exacerbating factor. We review the associations between digital screens and DE, mechanisms of damage, and therapeutic options, hoping to raise awareness of this entity with the goal of reducing the global morbidity and economic impact of screen-associated visual disability.

A 49-year-old perimenopausal female presented with abnormal uterine bleeding (AUB) and chronic lower abdominal pain with associated urinary urgency. The patient elected to have an abdominal supracervical hysterectomy with bilateral salpingo-oophorectomy for a large, symptomatic fibroid uterus. Preoperative ultrasounds revealed a uterine size of 22 x 20 x 17 cm and a 15.9 x 13 x 9 x 9.2 cm subserosal fibroid occupying the majority of the fundus and body of the uterus. Under general anesthesia, abdominal supracervical hysterectomy and bilateral salpingo-oophorectomy with a midline vertical incision were completed. Pathology reported a uterus with multiple leiomyomata as well as endometrial polyps with focal atypical endometrial hyperplasia and squamous metaplasia. Overall, the uterine corpus with one attached adnexa weighed 3433 g and was 25.8 x 20.3 x 15cm. Choice of surgical approach in a hysterectomy depends upon clinical circumstances, the surgeon's technical expertise, and patient preference. Although minimally invasive hysterectomies via vaginal and laparoscopic approaches are now preferred due to decreased hospitalization stays and postoperative recovering times, individualized treatment plans for patients should be considered depending on uterine size and the possibility of not achieving adequate exposure, which may lead to complications. As this case presents, an abdominal hysterectomy is an important option for certain patients where the use of other approaches could pose significant risk.

BackgroundPhotophobia is a potentially debilitating symptom often found in dry eye disease (DE), migraine and traumatic brain injury (TBI).MethodsWe conducted a review of the literature via a PubMed search of English language articles with a focus on how photophobia may relate to a shared pathophysiology across DE, migraine and TBI.ResultsDE, migraine and TBI are common conditions in the general population, are often comorbid, and share photophobia as a symptom. Across the three conditions, neural dysregulation of peripheral and central nervous system components is implicated in photophobia in various animal models and in humans. Enhanced activity of the neuropeptide calcitonin gene-related peptide (CGRP) is closely linked to photophobia. Current therapies for photophobia include glasses which shield the eyes from specific wavelengths, botulinum toxin, and inhibition of CGRP and its receptor. Many individuals have persistent photophobia despite the use of these therapies, and thus, development of new therapies is needed.ConclusionsThe presence of photophobia in DE, migraine and TBI suggests shared trigeminothalamic pathophysiologic mechanisms, as explained by central neuroplasticity and hypersensitivity mediated by neuropeptide CGRP. Treatment strategies which target neural pathways (ie, oral neuromodulators, transcutaneous nerve stimulation) should be considered in patients with persistent photophobia, specifically in individuals with DE whose symptoms are not controlled with traditional therapies.

The trigeminal nerve gives rise to the corneal subbasal nerve system, which plays a crucial role in sensations of touch, pain, and temperature and in ocular healing processes. Technological advancements in instruments, in particular in vivo confocal microscopy and aethesiometry, have allowed for the structural and functional evaluation of corneal nerves in health and disease. Through application of these technologies in humans and animal models, structural and functional abnormalities have been detected in several ocular and systemic disorders, including dry eye disease (DED), glaucoma, migraine, and fibromyalgia. However, studies across a number of conditions have found that structural abnormalities do not always relate to functional abnormalities. This review will discuss instruments used to evaluate corneal nerves and summarize data on nerve abnormalities in a number of ocular and systemic conditions. Furthermore, it will discuss potential treatments that can alleviate the main manifestations of nerve dysfunction, namely ocular surface pain and persistent epithelial defects.

Rosai-Dorfman disease (RDD) is a rare medical condition with bilateral painless lymphadenopathy. We present the case of a young man diagnosed with a very unique presentation of Rosai-Dorfman disease. A 40-year-old African-American man presented with a firm, non-tender, progressive chest and neck mass appeared three months ago. Imaging of the neck demonstrated an 8.6-cm anterior neck subcutaneous soft tissue mass extending into the anterior mediastinum through the sternum with erosive changes in the sternum and the lesion is abutting the right common carotid artery and innominate vein and surrounds the medial aspect of the clavicles bilaterally. Ultrasound (US)-guided biopsy showed marked polytypic-appearing plasma cell proliferation associated with relatively prominent histiocytes with hemophagocytosis/emperipolesis and focal neutrophils. There were S100+ histiocytes; however, findings were not typical for RDD. As that biopsy was not diagnostic, incisional biopsy with adequate sampling was performed. Surgical pathology demonstrated a very abnormal infiltrate with prominent histiocytes including areas with the features of extranodal RDD. BRAF V600E immunohistochemistry (IHC) was negative. Modified radical neck dissection, proximal sternal resection and superior mediastinal nodal dissection surgery was recommended. However, the patient refused the procedure. Typical manifestations are lymphadenopathy with fever that our patient did not experience. Bone involvement happens in 5-10% of cases. There is not enough data about blood vessel invasion which make our case unique. Treatment plan is still controversial. Clinical monitoring is recommended if the symptoms are tolerable as regression has been reported in many cases (20-50%). Surgery is reserved for patients with vital organ involvement or extra-nodal disease.

A 65-year-old woman with a medical history significant for anal cancer was referred by her primary care physician for a port-a-cath removal. The port was placed prior to treatment of squamous cell carcinoma of the anus, 11 years prior to this scheduled removal. She received chemotherapy and radiation in accordance with the Nigro protocol, treating the anal cancer to complete resolution. During port removal, a fibrous capsule was dissected and the port was removed from the left upper breast border along with proximal portion of the catheter. Significant difficulty was found in removing the remaining catheter despite sustained traction and guidewire insertion. Fluoroscopy revealed an intravascular adhesion of the catheter tip in the superior vena cava, which could not be freed. In order to prevent vascular injury, the adhesed portion of the distal catheter was left in place with three large surgical clips placed distally. This case highlights the very rare complication of complete vascular adherence of the terminal catheter tip and extended port intracorporeal time as a risk factor for adhesion. This case also highlights the importance of timely permanent central venous catheter removal following completion of its intended regimen.