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Purpose To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer. Patient A 19-year-old male presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus exam showed inferior vitreous hemorrhage, retinal whitening, and pre-, intra-, and sub-retinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and post-septal orbital emphysema. Two months following injury, vitreous and retinal hemorrhages and macular hole resolved. Five months following injury, visual acuity improved to 20/20. Discussion Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. While this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.

To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques.We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX).A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3-156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective.This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.

Context Oxidative stress plays an indispensable role in pathogenesis of Graves’ orbitopathy (GO). Ferroptosis is a newly discovered form of cell death resulting from lipid peroxidation. Little is known about the role of ferroptosis in GO. Objective We aimed to identify the divergent role of ferroptosis in the GO and control orbital fibroblasts (OFs). Methods Orbital fat/connective tissues and serum immunoglobulins (Igs) were collected from GO and control subjects. Cell viability and lipid peroxidation were measured to evaluate ferroptosis sensitivity. Pyruvate dehydrogenase kinase 2 (PDK2) level and oxygen consumption rate were quantified to assess glycolysis status. Results Primary OFs were cultured from orbital tissues. Ferroptosis was induced by cystine deprivation and/or erastin treatment. The GO OFs possessed stronger resistance to ferroptosis than the control OFs. Selenium, a potential ferroptosis inhibitor, protected the control OFs from ferroptosis. Both transcriptomic and proteomic analyses indicated glycolytic shift in the GO OFs. Metabolic profiling, PDK2 quantification, and oxygen consumption assay confirmed enhanced glycolysis in the GO OFs. Inhibition of glycolysis by PDK2 knockdown and dichloroacetic acid (DCA) promoted ferroptosis sensitivity in the GO OFs. The ferroptosis-sensitizing effects of DCA were also observed when the GO OFs were treated with GO-Igs. IGF1R overexpression in the GO OFs contributed to glycolysis shift. IGF1R inhibitory antibodies facilitated ferroptosis induction in the GO OFs, but the effects were less remarkable under GO-Igs treatment. Conclusion These study findings establish that glycolysis facilitates ferroptosis resistance in the GO OFs, providing insights into the therapeutic role of glycolysis for GO treatment.

Background Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of active Thyroid eye disease (TED). The current study reviews its efficacy in chronic TED. Methods In this retrospective review, consecutive patients with chronic stable TED (>2 years), who had received ≥3 infusions of teprotumumab were included. All patients had measurements of proptosis, and calculation of the CAS and diplopia scores before and after therapy. Five-point strabismus scores were also calculated. Patients who had imaging within 4 months prior to therapy and 6 weeks post therapy underwent orbital 3D volumetric analysis. Results Thirty-one patients met the inclusion criteria. The mean (SD) duration of TED was 81 months (56) and the mean (SD) number of infusions received by each patient was 7 (2). Mean (SD) reduction in proptosis for each study orbit was 3.5 mm (0.4) and 3 mm (0.3) for the fellow orbit. The CAS response was 90% for the study orbit and 87% for the fellow orbit. Of the 15 patients who had diplopia at baseline, 67% had a clinically significant response, while 47% had complete resolution following treatment. Following teprotumumab, mean (SD) reduction of muscle tissue was 2011 mm3 (1847) in the study orbit and 1620 mm3 (1759) in the fellow orbit. The mean (SD) reduction of fat volume was 2101 mm3 (1681) in the study orbit and 1370 mm3 (1181) in the fellow orbit. Conclusion Teprotumumab significantly reduces proptosis, inflammation, diplopia, strabismus and orbital soft tissue volume in patients with chronic TED.

In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen.This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events.The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS (P0.01) and reduction in ocular motility restriction (P0.01) were maintained during interruption.Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

The purpose of this research is to identify correlates of bike station activity for Nice Ride Minnesota, a bike share system in the Minneapolis–St. Paul Metropolitan Area in Minnesota. The number of trips to and from each of the 116 bike share stations operating in 2011 was obtained from Nice Ride Minnesota. Data for independent variables included in the proposed models come from a variety of sources, including the 2010 U.S. Census; the Metropolitan Council, a regional planning agency; and the Cities of Minneapolis and St. Paul. Log-linear and negative binomial regression models are used to evaluate the marginal effects of these factors on average daily station trips. The models have high goodness of fit, and each of 13 independent variables is significant at the 10% level or higher. The number of trips at Nice Ride stations is associated with neighborhood sociodemographics (i.e., age and race), proximity to the central business district, proximity to water, accessibility to trails, distance to other bike share stations, and measures of economic activity. Analysts can use these results to optimize bike share operations, locate new stations, and evaluate the potential of new bike share programs.

Orbital penetrating injuries from pencils are rare. This report describes a case of penetrating orbital injury in a young child with a retained blue-colored pencil core foreign body, which led to rapid onset of orbital abscess requiring surgical drainage. Intraoperatively, orbital tissues were stained a bright-blue color. Histopathological study of specimen also highlighted bright blue aggregates of foreign material infiltrating the orbital tissues. Cultures grew Streptococcus mitis and Exophiala jeanselmei , which are rare causes of orbital abscess. Unique properties of retained colored pencil core as compared to graphite pencil core are herein discussed. Due to differences in composition, colored pencil core foreign bodies may require more timely surgical intervention compared to noncolored graphite pencil core.

A 65-year-old male presented with headaches and painless episodes of unilateral vision loss. He had a history of renal cell carcinoma, in remission following surgery and immunotherapy with ipilimumab and nivolumab, discontinued 2 years and 3 months before presentation, respectively. MRI revealed an optic nerve sheath mass and perineuritis. After 1 month of corticosteroid therapy, there was a robust clinical and radiographic response, which relapsed dramatically following cessation. An optic nerve sheath biopsy showed chronic mild inflammation, and extensive work-up for alternative etiologies of orbital inflammation was negative. Following a prolonged taper of corticosteroids, he demonstrated complete response. In the setting of ocular immune privilege, ophthalmic immune-related adverse events (irAE) are rare, although multifarious. While on-treatment irAE are well-characterized, posttreatment irAE have become increasingly recognized across multiple organ systems. We report a case of a delayed-onset inflammatory optic nerve sheath mass and perineuritis after cessation of immunotherapy.

Lacrimal sac squamous cell carcinoma is a rare but life-threatening disease that is often a delayed diagnosis secondary to difficulty in differentiating from other causes of dacrocystitis and acquired nasolacrimal duct obstruction. Chronic inflammation, including that of an underlying autoimmune disease, prior instrumentation, and poor wound healing, may be risk factors in the development to lacrimal sac squamous cell carcinoma. The authors present the first case of lacrimal sac squamous cell carcinoma associated with antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4 positivity. Rather than an overlap syndrome between antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4-related disease, high immunoglobulin G4 positivity may be considered an inflammatory marker of disease severity in the setting of antineutrophil cytoplasmic antibody-associated vasculitis and underlying malignancy. Inflammation-mediated tumorangiogenesis should be considered in the development of malignancy and red flags of chronic uncontrolled inflammation should warrant a lower threshold for further workup.

Floppy eyelids are usually asymmetrical, and more severe on the side the patient sleeps on. This has been related to the mechanical basis of this entity’s pathophysiology. Patients who exhibit floppy eyelid syndrome (FES) tend to suffer from obstructive sleep apnea and other sleeping disorder such as snoring; therefore, their spouses are likely to be found sleeping facing away from them. In this study, we aim to assess this correlation between FES laterality and the spouse’s sleeping side. 185 patients with floppy eyelid were assessed. Upper lids were pulled cephalad towards the orbital rim to assess which side everted and was more floppy. Based on the upper lid distraction test, a prediction was made to which side of the bed the spouse slept on. 185 patients with floppy eyelid syndrome were assessed, 160 male patients and 25 females, at an average age of 68. All 25 female patients, and 117 of the male patients, had spouses that slept in the same bed. Their side of sleep was predicted correctly in 87% of cases. The physician extrapolated the spouse slept on the opposite side facing away from the snoring spouse and was correct in 91% of cases. There is a high correlation between FES laterality and the patient’s spouse’s sleeping side. These data strengthen the mechanical etiology, and can also be used to confirm the worse-affected side in FES patients.

PURPOSE To demonstrate the utility of an ultrasonic aspirator (Sonopet, Stryker Corporation; Kalamazoo, MI) for debulking firm, soft tissue masses of the orbit. METHODS Case series. The ultrasonic aspirator was used to debulk firm, soft tissue masses in 3 cases. The initial patient had a large orbitofacial mass extending to the inferior and lateral orbital apex secondary to IgG4 disease. The second patient had a lacrimal sac adenocarcinoma extending to the medial orbital apex. The third patient had a large orbital mass extending to the apex secondary to granulomatosis with polyangiitis. RESULTS The ultrasonic aspirator facilitated debulking of infiltrative firm soft tissue masses of the orbit. The device's ability to emulsify, irrigate, and aspirate, along with its small footprint, facilitated precise sculpting and debulking to an extent which would have been difficult otherwise due to location. CONCLUSIONS The ultrasonic aspirator allows precise sculpting of infiltrative firm soft tissue masses in the orbit and is particularly useful in cases with challenging anatomical access.

Herpes zoster ophthalmicus (HZO) is a neuro-oculo-dermic infection caused by reactivation of latent varicella zoster virus in the dorsal root ganglia of the ophthalmic division of the trigeminal nerve. Although a rare diagnosis in an otherwise healthy, vaccinated pediatric patient, this entity may occur with increasing frequency among those with preceding trauma, particularly in the month prior to presentation. Herein, we highlight a case of HZO in a vaccinated, immunocompetent adolescent in the setting of recent facial trauma.

Purpose: To describe the demographic and clinical characteristics of patients with thyroid eye disease (TED) who present with predominate superior rectus/levator complex involvement.Methods...

The authors report the case of a 75-year-old man with preexisting glaucoma and recurrent retinal detachment who underwent intraocular silicone oil placement OD resulting in subsequent retrolaminar silicone oil migration to the optic chiasm and vision loss OS. MRI showed silicone oil tracking posteriorly along the right optic nerve to the chiasm. He was placed on high-dose corticosteroids and underwent a successful optic nerve sheath fenestration with improvement of vision in the contralateral eye. Clinicians should be cognizant of the potential for translaminar posterior migration of intraocular silicone oil, as well as the utility of optic nerve sheath fenestration to decompress the anterior visual pathways and restore vision.

Purpose To analyze the clinical significance of the periorbital features associated with the facial asymmetry that is common in deformational posterior plagiocephaly (DPP). Patients and methods We identified 32 patients with DPP, photographed their faces and tops of their head, and performed a complete eye examination. Four examiners analyzed the patient's periorbital features on the photographs. Results Median age was 6.5 months (range 3-12 months). Pseudoptosis was identified in 30 patients and pseudo-brow ptosis in 19. Pseudoptosis was marked in 17 patients. Five patients were misdiagnosed with congenital blepharoptosis and received regular follow-ups for amblyopia checks until the diagnosis of pseudoptosis was established. All patients had normal levator function and symmetric eyelid crease. One patient with pseudoptosis and physiologic anisocoria was diagnosed with pseudo-Horner syndrome after a negative 10% cocaine test. None of the patients developed meridional or occlusion amblyopia. Conclusion DPP is the most frequent form of skull deformation in infants. Its main features are occipital flatness and facial asymmetry. Infants with DPP may present with pseudoptosis and pseudo-brow ptosis on the contralateral side of the occipital flatness. The pseudoptosis in DPP is non-amblyogenic, therefore, ophthalmologic intervention and regular follow-ups are not necessary unless other abnormalities co-exist.

Background: Giant disfiguring cranial tumors are exceptionally rare and develop over the course of many years, typically in patients who lack access to medical care. Here, we describe four patients who were flown to our center for treatment by a multidisciplinary surgical team, who had previously been turned down for treatment at multiple international centers in Africa, Europe, and the United States (US) due to complexity and financial concerns. The case series describes socioeconomic implications and the feasibility of offering such care to patients from outside the US. Case Descriptions: Four patients with giant skull disfiguring tumors were flown internationally and treated by a surgical team consisting of a complex cranial neurosurgeon, a craniofacial reconstructive plastic surgeon, and an oculoplastic surgeon. All patients underwent aggressive surgical therapy with the aim of complete tumor removal and simultaneous cranial reconstruction. A patient with osteogenic sarcoma underwent two additional resections in 3 years, with delayed reconstruction. They returned home but ultimately succumbed to the disease. A patient with ossifying fibroma required two follow-up procedures for cosmetic reconstruction and sought asylum in the US, where they remain today. Two additional patients, one with a giant plexiform neurofibroma and one with a cerebellopontine angle meningioma, achieved good results and returned to Africa 1 month and 3 weeks after surgery, respectively. Conclusion: Resection of giant disfiguring cranial tumors and reconstruction of the impacted region requires an experienced multidisciplinary team. These cases can be managed by transporting such patients from areas without access to medical care to specialized centers able to provide excellent care.

Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of active Thyroid eye disease (TED). The current study reviews its efficacy in chronic TED.In this retrospective review, consecutive patients with chronic stable TED (2 years), who had received ≥3 infusions of teprotumumab were included. All patients had measurements of proptosis, and calculation of the CAS and diplopia scores before and after therapy. Five-point strabismus scores were also calculated. Patients who had imaging within 4 months prior to therapy and 6 weeks post therapy underwent orbital 3D volumetric analysis.Thirty-one patients met the inclusion criteria. The mean (SD) duration of TED was 81 months (56) and the mean (SD) number of infusions received by each patient was 7 (2). Mean (SD) reduction in proptosis for each study orbit was 3.5 mm (0.4) and 3 mm (0.3) for the fellow orbit. The CAS response was 90% for the study orbit and 87% for the fellow orbit. Of the 15 patients who had diplopia at baseline, 67% had a clinically significant response, while 47% had complete resolution following treatment. Following teprotumumab, mean (SD) reduction of muscle tissue was 2011 mmTeprotumumab significantly reduces proptosis, inflammation, diplopia, strabismus and orbital soft tissue volume in patients with chronic TED.

Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact quality of life. While there are several known forms of congenital ptosis, acquired ptosis (appearing later in life, due to a variety of causes) is the predominant form of the condition. This review summarises the prevalence, causes, identification, differential diagnosis, and treatment of acquired ptosis. Particular attention is paid to the differential diagnosis of acquired ptosis and emerging treatment options, including surgical and pharmacologic approaches.摘要: 上睑下垂是视光学和眼科临床中最常见的上睑疾病之一。以上睑下垂为特征的单侧或双侧上睑下垂会影响外观和视觉功能, 这两种情况都会对生活质量产生负面影响。目前已知有几种先天性的上睑下垂, 但获得性上睑下垂 (由各种原因所导致并出现在其后的生活中) 是该病的主要形式。本文就获得性上睑下垂的发病率、病因、鉴别诊断及治疗作一综述。并特别研究获得性上睑下垂的鉴别诊断以及新的治疗方法, 包括手术和药理治疗途径。.

The study aimed to investigate the role of pyruvate dehydrogenase kinase (PDK) in regulating glycolysis and proliferation of perimysial orbital fibroblasts (pOFs) during the pathogenesis of thyroid-associated ophthalmopathy (TAO). EdU and BrdU incorporation assays were performed to examine cell proliferation. Lactate production and oxygen consumption assays were conducted to evaluate glycolysis. Real-time PCR was adapted to quantify PDK mRNA levels. Capillary Western immunoassay was adapted to quantify PDK2, Akt, pAkt308 and GAPDH in protein samples. The TAO pOFs exhibited stronger proliferation activity, higher intracellular lactate concentration, and lower oxygen consumption rate than the control pOFs. The PDK inhibitor dichloroacetic acid (DCA) dose-dependently suppressed the proliferation of both TAO and control pOFs. DCA reduced lactate production and promoted oxygen consumption in the TAO pOFs but showed no significant effects on glycolysis in the control pOFs. Among four PDK isotypes, PDK2 was overexpressed in the TAO pOFs. The potential PDK signaling mediator, cytoplasmic Akt, was more abundant in TAO pOFs than control pOFs. Knockdown of PDK2 resulted in lower lactate production, stronger oxygen consumption, weaker proliferation activity, and less cytoplasmic Akt in the TAO pOFs but showed no significant effects in the control pOFs. The Akt inhibitor MK2206 suppressed proliferation in both TAO and control pOFs, and lactate production was inhibited by MK2206 in the TAO OFs but not the control pOFs. To conclude, PDK2 overexpression enhances glycolysis and promotes proliferation via Akt signaling in the TAO pOFs. These findings yield insights that PDK2 is a potential therapeutic target for TAO treatment.

Background: Necrobiotic xanthogranuloma (NXG) is a rare non-Langerhans histiocytosis with cutaneous manifestations, most commonly of the periorbital skin, and is often associated with hematologic disorders such as monoclonal gammopathy. Treatment of NXG is notoriously difficult, and fraught with recurrence and progression. Case Presentation: The authors describe a case of NXG with periorbital involvement in a patient with a complex autoimmune and hematologic medical history. The biopsy of this rare lesion prompted subsequent evaluation for an underlying disorder, which led to the diagnosis of multiple myeloma. Her NXG lesions demonstrated remarkable clinical improvement after treatment with intravenous immunoglobulin (IVIG). Conclusions: This case demonstrates the ophthalmologist’s critical role in the diagnosis and management of NXG, as early detection cannot only prevent ophthalmic consequences such as ocular perforation and blindness, but also prompt further investigation that may reveal an underlying disorder or systemic involvement, including hematologic malignancy as in this case. NXG has been effectively treated with IVIG in a handful of reported cases. To the author’s knowledge, this is the third case of periorbital NXG successfully treated with IVIG, and the first in the ophthalmic literature.

Hintergrund: Das nekrobiotische Xanthogranulom (NXG) ist eine seltene Nicht-Langerhanszell-Histiozytose mit kutanen Manifestationen, die vor allem die periorbitale Haut betrifft und oft mit hämatologischen Erkrankungen wie beispielsweise einer monoklonalen Gammopathie assoziiert ist. Die Therapie des nekrobiotischen Xanthogranuloms gestaltet sich schwierig und wird häufig durch einen rezidivierenden und progredienten Verlauf erschwert. Vorstellung des Falls: Die Autoren beschreiben einen Fall von NXG mit periorbitaler Beteiligung bei einer Patientin mit einer omplexen Vorgeschichte an Autoimmun- und hämatologischen Erkrankungen. Aufgrund der Biopsieergebnisse dieser seltenen Läsion erfolgte eine Suche nach der Grunderkrankung, die zur Diagnose «Multiples Myelom» führte. Unter der Behandlung mit intravenösem Immunglobulin (IVIG) besserten sich die NXG-Läsionen der Patientin deutlich. Schlussfolgerungen: Dieser Fall unterstreicht, welche wichtige Rolle der Augenarzt bei der Diagnose und Behandlung des NXG spielt, da eine frühzeitige Erkennung nicht nur die Auswirkungen auf die Augen wie Augenperforation und Erblindung verhindern kann, sondern darüber hinaus auch Anlass für weitere Untersuchungen sein kann, die - wie im vorliegenden Fall - eine mögliche Grunderkrankung oder Systembeteiligung, einschließlich maligner hämatologischer Erkrankungen, aufdecken. In einer Handvoll berichteter Fälle wurde das NXG erfolgreich mit IVIG behandelt. Soweit den Autoren bekannt, ist dies der dritte Fall eines erfolgreich mittels IVIG behandelten periorbitalen NXG, und der erste Fall in der ophthalmologischen Literatur. Übersetzung aus Case Rep Ophthalmol 2018;9:70-75 (10.1159/000485913).

Purpose: If not recognized and treated promptly, nontraumatic orbital subperiosteal hemorrhage (NTSOH) can have serious sequelae including compressive optic neuropathy and permanent vision loss. The following case establishes erotic asphyxiation as a cause of NTSOH. Observations: A 29 year-old patient presented with diplopia and periorbital edema and ecchymosis. Complete ophthalmologic exam showed no optic neuropathy. Computed tomography of the orbits revealed a subperiosteal fluid collection in the right orbit. The patient had no risk factors for NTSOH, but after detailed questioning she admitted to participating in erotic asphyxiation prior to the onset of her symptoms. She was observed and subsequently lost to follow up. Conclusions and Importance: To the authors' knowledge, erotic asphyxiation as a cause of orbital subperiosteal hematoma has not been previously reported. Lack of knowledge about erotic asphyxiation amongst healthcare providers may contribute to hesitance to directly question patients about the practice. Clinicians should be aware of erotic asphyxiation as a potential cause of orbital subperiosteal hemorrhage. Keywords: Erotic asphyxiation, Nontraumatic orbital subperiosteal hemorrhage, Orbital hematoma

The objective of this study was to observe the effect of medical cannabis in benign essential blepharospasm (BEB) as an adjunct to botulinum toxin. A retrospective chart review was performed on patients certified for medical cannabis use for BEB from September 2015 to May 2016. Patient demographics and responses, cannabis history, and severity indices were collected. Ten patients were certified for medical cannabis use. Five met the inclusion criteria, which was any patient with a diagnosis of BEB receiving standard botulinum toxin treatment who had started medical cannabis treatment by a registered distributor within the state, and was contactable by phone. Four patients discontinued use. Three out of four patients (75%) reported symptomatic improvement. Medical cannabis is an accepted therapy for muscle spastic disorders. Its potential as an adjunctive therapy for BEB remains unknown, and further investigations would be of benefit.

A 48-year-old man presented with a longstanding left upper eyelid mass that increased in size when bending forward. The mass was associated with enophthalmos and slowly increased in size with Valsalva maneuver. Magnetic resonance imaging and arteriography demonstrated a vascular malformation without an abnormal arterial component. Because of his increasing pain, the vascular malformation was excised in a multidisciplinary approach involving intraoperative fluoroscopic mapping, cyanoacrylate embolization, and surgical excision. Histopathology was consistent with a benign vascular malformation. Clinically, this was a low-flow, distensible venous malformation—or orbital varix.

To determine effect of upper eyelid surgery on headache symptoms. Consecutive adults undergoing upper eyelid surgery for obscuration of superior visual field, who also reported headache symptoms for greater than 1 year completed a pre- and postoperative Headache Impact Test-6 quality of life questionnaire (study group). A cohort of patients undergoing other oculoplastic procedures with headaches also completed the questionnaire pre- and postoperatively (control group). The study was conducted over a 2-year period. Neither the patients nor the study investigators were masked. Twenty-eight patients met criteria for the study group, and 19 patients in the control group. Mean age was 58.7 and 60.7 years, respectively. There was no statistically significant difference in preoperative location of headaches. There was no significant difference in mean Headache Impact Test-6 scores preoperatively, 57.7 study group, 58.1 control group, p = 0.86. Mean postoperative scores were lower (improved) in the study arm, 45.3, as compared with the control arm, 58.6, p < 0.05. There was no statistically significant difference between individual preoperative survey questions between the study arm and control group, while every Headache Impact Test-6 question significantly improved in the study arm compared with the control arm. Mean Headache Impact Test-6 score improved 12.4 points in the study arm after surgery (p < 0.05), while the mean postoperative score worsened by 5 points in the control arm, but this was not significant (p = 0.48). Subjectively, 25 of 28 study patients, and 4 of 19 control patients noticed at least some improvement in headache symptoms after surgery. Correction of visually significant upper eyelid position may improve chronic headache symptoms.

A 10-year-old male was referred for evaluation of a right orbital mass present for 3 weeks with associated tenderness to palpation. Magnetic resonance imaging (MRI) and computed tomography imaging (CT) revealed a solid mass centered in the frontal bone with extension into the orbit. Surgical excision and histologic analysis of the lesion was consistent with a diagnosis of a Giant Cell Tumor (GCT) of the frontal bone. The patient tolerated the procedure without complication and is doing well upon follow-up.

Traumatic penetrating injuries to the orbit from pencils, while uncommon, have a plethora of presentations, both acute and delayed. With the most incidents occurring in the pediatric population where obtaining a detailed history is difficult, the ability to effectively evaluate and diagnose these injuries is cumbersome, yet important. The authors report a patient who presented with optic neuropathy, blepharoptosis, and strabismus 10 months after an orbital injury with pencil graphite.

Congenital nasolacrimal duct obstruction most often resolves spontaneously or following nasolacrimal probing with or without silicone intubation. If probing and intubation fail to resolve tearing in children with nasolacrimal duct obstruction, dacryocystorhinostomy is indicated. This may be performed either externally or endonasally. An endonasal approach has the advantages of no external scarring, shorter recovery time, and preservation of the lacrimal pump with a comparable success rate to external dacryocystorhinostomy. Unique anatomical considerations when performing endonasal dacryocystorhinostomy in children include the lower insertion of the cribriform plate and smaller overall dimensions of the nasal passages. Complications of endonasal DCR include extrusion of the silicone intubation tube, synechiae or granuloma formation, and nasal vestibule abrasion.

A 64-year-old woman with relapsed acute myelogenous leukemia (AML) undergoing salvage chemotherapy developed rapid onset of right-sided ophthalmoplegia, proptosis, optic neuropathy, and vision loss from 20/30 to hand motions over a 3-hour period on day 4 of her treatment. CT scan of her orbits revealed a superolateral orbital mass and periocular edema. She underwent immediate canthotomy and cantholysis, and lateral orbitotomy with debulking of the mass later the same day. The histopathology was consistent with aggregates of myeloid blasts. Her vision recovered to 20/20 on postoperative day 1. Orbital granulocytic sarcoma is a rare condition often concurrent with AML, typically in the pediatric population and rarely in adults. Presentation as a fulminant orbitopathy with rapidly progressive optic neuropathy and vision loss over several hours has not been previously reported.

A 40-year-old white woman presented to her general ophthalmologist for swelling of the left upper eyelid that began approximately 6 months before. CT scan of the orbits with and without contrast demonstrated homogenous enhancement of the left lacrimal gland. Examination was notable for left hypoglobus and proptosis. The patient underwent left lateral orbitotomy with biopsy of the mass and frozen section analysis showed lymphoid infiltrates. Subsequent histopathologic diagnosis was consistent with nodular lymphocyte predominant Hodgkin lymphoma, a rare subtype of Hodgkin lymphoma that has only once been previously reported in the orbit. The authors review the case and the relevant literature.

Switch/sucrose non-fermentable-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 (SMARCB1), also known as integrase interactor 1-deficient sinonasal carcinoma, is a rare entity that was first described in 2014. Since then, there have been 39 cases published in the literature, with basaloid or plasmacytoid/rhabdoid morphology being the most common pathological subtype. We report a patient with switch/sucrose non-fermentable-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 (integrase interactor 1)-deficient sinonasal carcinoma who had permanent vision loss after valsalva-induced acute hemorrhage and resultant orbital compartment syndrome.

PURPOSE: To assess changes in innervation and muscle morphology after repeated botulinum toxin A injections in subjects with benign essential blepharospasm. METHODS: Surgical waste specimens were processed for histologic examination of nerve fibers, neuromuscular junctions, fiber size, and central nucleation and compared to age matched controls and to two subjects with blepharospasm that had not received botulinum toxin A injections RESULTS: There was a significant increase in amount of nerve fibers and numbers of neuromuscular junctions in the orbicularis oculi muscles from subjects with blepharospasm treated repetitively with botulinum toxin A. In addition there was a significant decrease in mean muscle fiber cross-sectional area and an increase in central nucleation. The specimens from the subjects with only blepharospasm had the same density of nerves but had intermediate levels of neuromuscular junctions. CONCLUSIONS: These data suggest that repeated injections of botulinum toxin A has an effect on nerve and neuromuscular junction numbers, which are partly mirrored in orbicularis oculi muscle from subjects with blepharospasm only. These studies suggest the potential for modulating these changes in order to extend the duration of effectiveness of botulinum toxin.

Aesthetic concerns about upper eyelid and brow position are very common in ophthalmic practice. Management of brow descent and devolumization requires an approach customized to each patient taking into consideration preoperative examination and patient desires. This article will review several minimally invasive techniques that can be used to address the needs of patients with mild-to-moderate brow ptosis.Recent publications describe and analyse efficacy of several variations of browpexy techniques.Browpexy techniques provide a minimally invasive way to provide stabilization and modest elevation of the lateral brow. They can enhance outcomes of upper eyelid surgery in patients with both functional and cosmetic brow ptosis, who desire to avoid the cost and morbidity of more formal brow lifting techniques.

The management issues associated with pediatric ptosis begin with determining the etiology of the ptosis, and considering how the eyelid position affects the child's visual and psychosocial development. These ultimately determine if and when surgical management should be undertaken. Surgical challenges include the lack of intraoperative feedback regarding the dynamic eyelid height and contour under general anesthesia. When the eyelid elevators do not function or if there is little drive to lift the involved eyelid, obtaining good surgical outcomes can be extremely challenging. A plethora of surgical techniques and materials have been developed, each with their own benefits and drawbacks. Careful preoperative evaluation, planning and counseling can usually result in satisfactory surgical results with happy parents and patients. Families should always be aware that the child will need to be followed long term for visual development, ocular health, and they need to be counseled regarding the possibility of revision surgery.

To compare the outcomes of coaxial microincision cataract surgery (MICS) performed with 3 phacoemulsification techniques (phaco-chop, divide-and-conquer, and stop-and-chop) according to cataract density.Bucheon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea.Prospective randomized clinical trial.Eyes with nuclear density from grade 2 to 4 were randomly subdivided into 3 groups (phaco-chop, divide-and-conquer, and stop-and-chop). Intraoperative measurements included ultrasound time (UST), mean cumulative dissipated energy (CDE), and balanced salt solution use. Clinical measurements included preoperative and 1 day, 1 month, and 2 month postoperative corrected distance visual acuity, central corneal thickness, and endothelial cell count.Intraoperative measurements showed significantly less UST, CDE, and balanced salt solution use with the phaco-chop technique than with the divide-and-conquer and stop-and-chop techniques in the grade 4 cataract density group (P.05). The percentage of endothelial cell loss was significantly lower in the phaco-chop group than in the divide-and-conquer and stop-and-chop groups in the grade 4 cataract density group 2 months after cataract surgery (P.05).All 3 techniques may be effective for coaxial MICS in mild and moderate cataracts. However, in eyes with hard cataract having coaxial MICS, the phaco-chop technique can be more effective for lens removal, with less corneal endothelial damage, than the divide-and-conquer and stop-and-chop techniques.No author has a financial or proprietary interest in any material or method mentioned.

Background The risk of optic disc haemorrhages on visual outcome in idiopathic intracranial hypertension (IIH) is unknown. We report the type and frequency of optic disc haemorrhages and other funduscopic abnormalities at baseline in the study eye of the 133 subjects enrolled in the Idiopathic Intracranial Hypertension Treatment Trial completing 6 months of follow-up. Methods We reviewed optic disc photographs to tabulate the frequency and type of optic disc haemorrhages, other funduscopic abnormalities and papilloedema grades of the study eye at baseline and analyse if their presence is associated with a poor visual outcome. Results 27.2% of subjects had nerve fibre layer haemorrhages in at least one eye. Five of seven, 71% of subjects that met criteria for treatment failure, had nerve fibre layer haemorrhages in at least one eye (Fisher9s exact test: p=0.02). There was a good correlation between presence of nerve fibre layer haemorrhages and Frisen grade (Spearman9s correlation, p=0.002; r=0.271). Subjects with nerve fibre layer haemorrhages had a higher cerebrospinal fluid pressure (40.0 mm water, p=0.04). There was poor correlation between nerve fibre layer haemorrhages at baseline and the perimetric mean deviation change at 6 months. Cotton wool spots were present in 4% of subjects, exudates in 3% and pseudodrusen in 4%. Conclusions Nerve fibre layer haemorrhages are common in patients with IIH with mild visual loss and correlate with the severity of the papilloedema. They occur more frequently in treatment failure subjects and therefore may be associated with poor visual outcomes. Trial registration number NCT01003639, Post-results.