Enlarging Orbital Rim Mass Due to Old Pencil Injury.

A 54-year-old female noticed a 2-month history of an enlarging left inferomedial orbital rim mass. The patient remembered a pencil injury at approximately 7 years of age. Her complete ophthalmic examination was otherwise unremarkable. She underwent CT orbital imaging, demonstrating a centrally hyperdense lesion along the left inferomedial orbital rim. There was no involvement of the nasolacrimal duct system. The patient underwent an excisional biopsy. The pathology disclosed noncaseating granulomatous inflammation to particulate black material consistent with graphite.

Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab.

PURPOSE: 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. METHODS: 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. RESULTS: 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, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption. CONCLUSIONS: Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

Microbial profile of lacrimal system Dacryoliths in American Midwest patient population.

PURPOSE: Dacryoliths of the canalicular pathway are classically attributed to Actinomyces species as the most common organism. However, global shifts toward Streptococcus and Staphylococcus species have been reported. The objective of this article is to update the American Midwest epidemiology of lacrimal system dacryoliths for targeted clinical treatment. MATERIALS AND METHODS: A retrospective chart review from January 2015 to 2021 of patients with a history of surgical procedure for lacrimal removal of dacryolith for canaliculitis, canalicular obstruction, dacryocystitis, and nasolacrimal duct obstruction was included. Specimens were sent for histopathological evaluation and microbial culture. RESULTS: A total of 48 specimens were included. The most common organism isolated for canalicular pathology was Actinomyces spp (23%), followed by Staphylococcus spp (21%) and Streptococcus spp (19%). Histopathological staining accounted for 45% of Actinomyces isolation when culture data inconclusive. In a subgroup analysis of lacrimal sac dacryoliths, the most common organism was Staphylococcus spp (29%). Actinomyces species were not isolated from the lacrimal sac or nasolacrimal duct. CONCLUSION: Actinomyces maintains a microbial predominance in canalicular dacryoliths and requires careful culture and histopathological analysis for its fastidious nature. Lacrimal sac and nasolacrimal duct dacryolith found no isolates of Actinomyces, and the most common organism was Staphylococcus.

Globe dislocation and optic nerve avulsion following all-terrain vehicle accidents.

Purpose: Open-air motor vehicles present unique trauma risks to the eyes and face. We describe two patients who suffered a crash while riding an all-terrain vehicle (ATV), leading to globe dislocation with optic nerve avulsion in order to raise awareness about the risks associated with ATV accidents. Observations: In both cases, the injury was caused by high-speed trauma to the orbit involving a tree branch. One patient sustained a life threatening arrythmia requiring a short stay in the intensive care unit, and both patients required emergent surgical management and eventual socket reconstruction. Conclusions and Importance: These cases highlight the need for greater advocacy on behalf of rider safety. The authors encourage ophthalmologists to counsel patients who use ATVs to wear helmets, seatbelts, and protective eyewear to prevent these types of injuries in the future.

Expert Consensus on the Use of Teprotumumab for the Management of Thyroid Eye Disease Using a Modified-Delphi Approach.

BACKGROUND: Teprotumumab is the first treatment for thyroid eye disease (TED), a debilitating autoinflammatory condition, approved by the Food and Drug Administration in the United States, which reduces proptosis and improves quality of life. In the absence of guidelines, clinical recommendations were developed for using teprotumumab in patients with TED in the United States. METHODS: A 3-round modified-Delphi panel was conducted between October 2020 and February 2021 with experts in the management of patients with TED. Key areas regarding the use of teprotumumab were investigated, including eligible patient populations, concomitant treatments, and assessment of response and adverse events. This used 2 survey rounds via an online questionnaire, where statements were scored using 9-point Likert scales. Statements with conflict were included in the third round, involving a consensus meeting via videoconference. RESULTS: Consensus was obtained for all statements (n = 75); of which, 56% were revised to enable agreement of the group. The consensus meeting provided agreement regarding which populations should receive teprotumumab therapy, including all adult patients with TED with a clinical activity score of ≥4. Treatment with teprotumumab can also be considered for TED patients displaying the following characteristics: a CAS of <3, lid retraction of ≥2, and mild or early optic neuropathy with close clinical observation. Further recommendations included suitability of treatment for those beyond 16 months following the initial diagnosis of TED, low CAS concomitant treatment with steroids in some cases, retreatment for those who have relapses, and finally a recommendation to continue therapy for all 8 infusions despite the lack of response by the fourth infusion. CONCLUSIONS: This work constitutes the first consensus on guidelines for the use of teprotumumab. The modified Delphi approach involved physicians with significant experience with the clinical use of teprotumumab, and recommendations were based on current evidence.

Teprotumumab in advanced reactivated thyroid eye disease.

Purpose: To report the case of a patient with reactivated, refractory thyroid eye disease (TED) treated with teprotumumab. Observations: A 51-year-old female with a 16-year history of thyroid eye disease previously treated with orbital decompression and multiple eyelid surgeries presented in a recurrent flare of the disease. The disease recurrence was refractory to intravenous steroid therapy and only partially responsive to oral steroid therapy, and the patient developed dysthyroid optic neuropathy in the right eye with decreased visual acuity and color vision. Clinical activity score was 8/10 and proptosis measurements were 27 mm OD and 26 mm OS. The patient underwent treatment with eight infusions of teprotumumab coinciding with a low taper of oral prednisone and experienced resolution of dysthyroid optic neuropathy, decrease of clinical activity score to 1, and dramatic improvement in proptosis (17 mm OD, 17 mm OS) and extraocular muscle size on imaging. Thirty weeks after completion of teprotumumab and 2 weeks after the second dose of the COVID vaccine, she experienced another flare and subsequently underwent bilateral orbital decompressions. Conclusion: This case report suggests teprotumumab may be used in patients with reactivation of longstanding thyroid eye disease. Reduction of extraocular muscle size and improvement in proptosis suggest teprotumumab may be disease-modifying even in advanced cases.

Thyroid eye disease with choroidal folds.

Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED).Methods: A multi-center retrospective case series of patients with TED who developed CRF.Results: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF (p = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF.Conclusions: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.

Ophthalmic Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome): A Systematic Review of the Literature.

PURPOSE: To review and summarize the clinical features, presentations, diagnostic modalities, and management of ophthalmic manifestations of eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss Syndrome). METHODS: A systematic PubMed search of all English articles on EGPA with ophthalmic involvement was performed. Emphasis was placed on English-language articles, but any article with an abstract translated into English was also included. Only those cases that satisfied the American Rheumatology criteria (1990) for diagnosis were included. Data examined included epidemiology, pathogenesis, presentations, diagnostic modalities, and management. RESULTS: There was a wide range in ophthalmic manifestations of EGPA. In order of most frequent presentation to least frequent, these include central retinal artery or vein occlusion, ischemic optic neuropathy, conjunctival nodules, orbital myositis, proptosis, dacryoadenitis, retinal vasculitis/infarcts/edema, cranial nerve palsy, and amaurosis. The 46 qualifying cases were divided into the categories of ischemic vasculitis versus idiopathic orbital inflammation due to prognostic significance. Ischemic vasculitis cases tended to be older patients (p = 0.03), unilateral (p = 0.006), require immunosuppressive therapy beyond steroids (p = 0.015), and were less likely to show improvement on therapy (p = 0.0003). CONCLUSIONS: Prompt diagnosis of EGPA by the ophthalmologist can decrease patient morbidity and mortality. This requires knowledge of likely ophthalmic EGPA presentations, as well as recommended workups and treatment.

Diode Laser-Assisted Endocanalicular Dacryocystorhinostomy: A Prospective Study.

PURPOSE: To evaluate the efficacy of the diode laser in endocanalicular dacryocystorhinostomy. METHODS: A prospective, noncomparative, interventional case series using the diode laser for endocanalicular dacryocystorhinostomy in patients with tearing and nasolacrimal duct obstruction. Outcome measures included subjective tearing complaints and objective patency of the nasolacrimal system. Success was defined as improvement of symptoms with patency of nasolacrimal drainage. Patients were followed for 12 months. Institutional review board approval was obtained. RESULTS: Forty eyes (28 unilateral, 6 bilateral) underwent surgery. Five cases were excluded because of inadequate follow-up. Patients ranged in age from 27 to 88 years (66.7 ± 15.7). Seventy-seven percent were female and 23% were male. At 1 week, 88% had improvement in tearing, 12% had no change or worsening of symptoms, and all patients were patent on irrigation. At 1 month, 86% had improvement, 14% had no change, and all patients were patent on irrigation. At 3 months, 83% had improvement and were patent on irrigation. Seventeen percent had no change or worsening with reflux and were considered failures. At 6 months, 77% had improvement and were patent on irrigation. Five additional patients had no change, reflux on exam and were failed surgeries. At 12 months, 74% had complete resolution and were patent. One additional patient failed. Nine surgeries in 35 cases were considered failures by 12 months. CONCLUSIONS: Subjective complaints of tearing correlated with patency of the nasolacrimal system after 3 months. A success rate of 74.3% (26 out of 35 cases) was observed by 12 months.