Bilateral Facial Palsy: A Rare Presenting Symptom for Inclusion Body Myositis.

Inclusion body myositis is a common type of inflammatory myopathy among populations over the age of 50 years, classically presenting with weakness and atrophy of the forearms and quadriceps. While a third of patients may eventually present with mild facial weakness, findings of ptosis, facial palsy, or involvement of extraocular muscles are rarely, if ever, seen. The authors describe a unique case of inclusion body myositis in which a patient initially presented with bilateral severe facial palsy and exposure keratitis but minimal limb weakness. While midface weakness, unilateral lagophthalmos, and ptosis have been documented in one reported case, key presenting symptoms of bilateral facial palsy and symmetric paralytic lagophthalmos with corneal exposure have not been presented before. Therefore, this case serves as an important reminder to consider the inclusion body myositis in the differential diagnosis of bilateral facial palsy.

Cutaneous Mucormycosis of the Eyelid Treated With Subcutaneous Liposomal Amphotericin B Injections.

Cutaneous mucormycosis is a rare, opportunistic fungal infection that typically affects immunocompromised hosts. Current treatment consists of systemic antifungal therapy, surgical debridement, and when applicable, restoration of immune function. Despite intervention, the morbidity and mortality of invasive fungal disease remains high. There are few reports of primary or secondary cutaneous mucormycosis involving the ocular adnexa. The authors describe the course of 2 children with cutaneous mucormycosis of the eyelid treated with subcutaneous liposomal amphotericin B (LAmB) injections (3.5 mg/ml) in an off-label application as an adjunct to debridement and systemic antifungal therapy. To the authors' knowledge, these are the first 2 cases of invasive fungal disease involving the eyelid treated with subcutaneous LAmB injections, and the first reported case of disseminated fungal infection with secondary cutaneous involvement of the eyelid.

Outcomes for expanded polytetrafluoroethylene strip in frontalis suspension surgery.

PURPOSE: This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE). METHODS: This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized. RESULTS: Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period. CONCLUSION: An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high.

A Case of Orbital Sarcoidosis with Caseating Granulomatous Inflammation.

The authors report a rare case of orbital sarcoidosis with caseating granulomatous inflammation. A 55-year-old man presented with a 2-month history of progressively worsening diplopia and proptosis of the OS. Orbital CT demonstrated a diffuse orbital mass. Diagnostic anterior orbitotomy demonstrated caseating granulomas. Infectious testing, including special stains, cultures, and polymerase chain reaction testing, were negative for infectious causes. Chest CT demonstrated the presence of hilar lymphadenopathy with bronchoscopic biopsy showing noncaseating granulomas, supporting a diagnosis of sarcoidosis. The patient achieved clinical and symptomatic improvement at 8-month follow-up on methotrexate. While sarcoidosis is typically characterized by non-necrotizing granulomatous inflammation, sarcoid granulomas with necrosis have been previously described in pulmonary histopathology. This case emphasizes the importance of a comprehensive systemic workup, keeping systemic sarcoidosis on the differential, for necrotizing granulomatous inflammation of the orbit.

Risk factors for enucleation or evisceration in endophthalmitis.

PURPOSE: To identify clinical risk factors for enucleation or evisceration in patients with endophthalmitis at an academic institution. METHODS: A retrospective review of patients diagnosed with endophthalmitis at Wilmer Eye Institute from 2010 to 2019 was conducted. Clinical characteristics, including demographics, cause for endophthalmitis, microbial culture results, salvaging procedures and surgical intervention were recorded. In patients who underwent enucleation or evisceration, type of surgery and placement of a primary implant were recorded. Chi-squared, Student's t-tests and multivariate analysis were used to identify clinical factors that predicted enucleation or evisceration. RESULTS: Two hundred and fifty three patients treated for endophthalmitis over the study period were identified, of which 25 (9.88%) underwent enucleation or evisceration. Risk factors for enucleation or evisceration included poor presenting visual acuity (OR 7.86, CI: 2.26, 27.3), high presenting intraocular pressure (OR 1.07, CI: 1.03, 1.12), presence of relative afferent pupillary defect (OR 3.69, CI: 1.20, 11.37) and positive vitreous culture for methicillin-resistant staphylococcus aureus (MRSA) (OR 18.3, CI: 1.54, 219.2) on multivariate analysis. Patients undergoing enucleation or evisceration were also more likely to have trauma, corneal ulcer or combined causes for endophthalmitis and underwent fewer salvaging surgical and procedural interventions. There were no significant differences in characteristics of those receiving enucleation versus evisceration in our cohort. CONCLUSION: Patients with endophthalmitis who underwent enucleation or evisceration had more severe disease on presentation compared to those treated with eye sparing therapy. Presenting clinical characteristics may have a role in triage and management decisions for patients presenting with severe endophthalmitis.

Augmentation of telemedicine post-operative follow-up after oculofacial plastic surgery with a self-guided patient tool.

PURPOSE: This study evaluates a web-based tool designed to augment telemedicine post-operative visits after periocular surgery. METHODS: Adult, English-speaking patients undergoing periocular surgery with telemedicine follow-up were studied prospectively in this interventional case series. Participants submitted visual acuity measurements and photographs via a web-based tool prior to routine telemedicine post-operative visits. An after-visit survey assessed patient perceptions. Surgeons rated photographs and live video for quality and blurriness; external raters also evaluated photographs. Images were analyzed for facial centration, resolution, and algorithmically detected blur. Complications were recorded and graded for severity and relation to telemedicine. RESULTS: Seventy-nine patients were recruited. Surgeons requested an in-person assessment for six patients (7.6%) due to inadequate evaluation by telemedicine. Surgeons rated patient-provided photographs to be of higher quality than live video at the time of the post-operative visit (p < 0.001). Image blur and resolution had moderate and weak correlation with photograph quality, respectively. A photograph blur detection algorithm demonstrated sensitivity of 85.5% and specificity of 75.1%. One patient experienced a wound dehiscence with a possible relationship to inadequate evaluation during telemedicine follow-up. Patients rated the telemedicine experience and their comfort with the structure of the visit highly. CONCLUSIONS: Augmented telemedicine follow-up after oculofacial plastic surgery is associated with high patient satisfaction, rare conversion to clinic evaluation, and few related post-operative complications. Automated detection of image resolution and blur may play a role in screening photographs for subsequent iterations of the web-based tool.

Symptom-Based Risk Factors for Retinal Tears and Detachments in Suspected Posterior Vitreous Detachment.

INTRODUCTION: The aim of this study was to determine symptom-level risk factors for retinal tear/retinal detachment (RT/RD) in our patients presenting with symptoms of posterior vitreous detachment (PVD). METHODS: We conducted a prospective cohort study of patients presenting to outpatient ophthalmology clinics at a single academic institution with complaint(s) of flashes, floaters, and/or subjective field loss (SFL). Patients received a standardized questionnaire regarding past ocular history and symptom characteristics including number, duration, and timing of flashes and floaters, prior to dilated ocular examination. Final diagnosis was categorized as RT/RD, PVD, ocular migraine, vitreous syneresis, or "other." Simple and multivariate logistic regressions were used to identify symptoms predictive of various pathologies. RESULTS: We recruited 237 patients (age 20-93 years) from March 2018 to March 2019. The most common diagnosis was PVD (141, 59.5%), followed by vitreous syneresis (38, 16.0%) and RT/RD (34, 14.3%). Of those with RT/RD, 16 (47.1%) had retinal tear and 15 (44.1%) had RD. Significant differences in demographic and examination-based factors were observed between these groups. Symptom-based predictive factors for RT/RD were the presence of subjective visual reduction (SVR; OR 2.77, p = 0.03) or SFL (OR 2.47, p = 0.04), and the absence of either floaters (OR 4.26, p = 0.04) or flashes (OR 2.95, p = 0.009). The number, duration, and timing of flashes and floaters did not predict the presence of RT/RD in our cohort. Within the RT/RD group, patients with RT were more likely to report floaters (100% vs. 66.7%, p = 0.018) and less likely to report SFL (0% vs. 86.7%, p < 0.001) compared to those with RD. CONCLUSION: While well-known demographic and exam-based risk factors for RT/RD exist in patients with PVD symptoms, the relative importance of symptom characteristics is less clear. We found that the presence of SVR and SFL, as well as the absence of either flashes or floaters, predicts RT/RD in patients with PVD symptoms. However, the number, duration, and timing of flashes and floaters may be less relevant in the triage of these patients.

Epidemiologic Trends in Oculoplastics-Related Emergency Department Visits in the United States, 2006-2015.

PURPOSE: To characterize demographics and trends in oculoplastics-related emergency department (ED) visits. METHODS: The authors conducted a retrospective, multiyear study of the nationwide ED sample database. The nationwide ED sample was queried for oculoplastics-related International Classification of Disease-ninth revision codes identified from a comprehensive list and categorized based on anatomic location, urgency, and trauma status. Demographics, clinical characteristics, procedure requirement, and cost data were analyzed. Variables associated with inpatient admission were assessed using univariate and multivariate logistic regression. RESULTS: The authors identified an estimated 4.2 million ED visits in the United States with oculoplastics-related primary diagnoses, of which pathology was 80.8% eyelid/adnexal, 17.4% orbital, and 1.74% lacrimal. Overall, 31.3% of the visits were deemed to be nonurgent. Orbital pathology was more likely to be caused by trauma (70.6%), to be urgent (98.0%), and to require a procedure (45.6%) (p < 0.001). While less than 5% of all patients required hospitalization, predictors for inpatient admission were urgent diagnoses (odds ratio, 14.9; CI, 13.7-16.1), presentation to a level 1 trauma center (odds ratio, 3.19; CI, 2.7-3.79), and presence of orbital pathology (odds ratio, 6.09; CI 5.73-6.47). Incidence of ED visits decreased in all categories; however, total inflation-adjusted charges increased. CONCLUSIONS: Over half of oculoplastics-related ED visits are for trauma, with orbital pathology being less common but requiring a high level of care. Although trends show a potentially decreasing incidence of oculoplastics-related ED visits, increasing costs and high proportion of nonurgent visits pose an opportunity for mitigating periocular trauma and increasing outpatient access to care, respectively.

Detection of Human Papillomavirus in Squamous Lesions of the Conjunctiva Using RNA and DNA In-Situ Hybridization.

In-situ hybridization provides a convenient and reliable method to detect human papillomavirus (HPV) infection in formalin-fixed paraffin-embedded tissue. Cases of conjunctival papillomas, conjunctival intraepithelial neoplasia (CIN), conjunctival carcinoma in situ (cCIS), and invasive squamous cell carcinoma (SCC), in which low-risk (LR) and/or high-risk (HR) HPV types were evaluated by RNA or DNA in-situ hybridization, were retrospectively identified. LR HPV types were frequently detected in conjunctival papillomas (25/30, 83%), including 17/18 (94%) with RNA probes, compared to 8/12 (75%) with DNA probes. None of the CIN/cCIS or SCC cases were positive for LR HPV by either method. HR HPV was detected by RNA in-situ hybridization in 1/16 (6%) of CIN/cCIS cases and 2/4 (50%) of SCC cases, while DNA in-situ hybridization failed to detect HPV infection in any of the CIN/cCIS lesions. Reactive atypia and dysplasia observed in papillomas was generally associated with the detection of LR HPV types. Collectively, our findings indicate RNA in-situ hybridization may provide a high-sensitivity approach for identifying HPV infection in squamous lesions of the conjunctiva and facilitate the distinction between reactive atypia and true dysplasia. There was no clear association between HPV infection and atopy in papillomas or dysplastic lesions.

Characteristics of Orbital Floor Fractures in the United States from 2006 to 2017.

PURPOSE: To examine the incidence, characteristics, and economic burden of orbital floor fractures in the United States. DESIGN: Retrospective, longitudinal study of the Nationwide Emergency Department Sample (NEDS). PARTICIPANTS: Patients in the Emergency Department (ED). METHODS: The NEDS, a representative sample of all hospital-based EDs in the US, was used to identify and describe ED visits with a primary diagnosis of orbital floor fracture from 2006 to 2017. Linear regression was used to estimate the trends in annual incidence and inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission. MAIN OUTCOME MEASURES: Incidence, injury mechanisms, demographics, clinical characteristics, disposition, and economic burden. RESULTS: From 2006 to 2017, there were an estimated 350 379 ED visits in the US with a primary diagnosis of orbital floor fracture. The incidence increased by 47% over the study period (P < 0.001): from 7.7 (95% confidence interval [CI], 6.9-8.5) to 11.3 (95% CI, 10.0-12.6) per 100 000 population. The majority were male (67%), aged 21 to 44 years (46%), and from low-income households (32%). The most common cause was assault (43%), which was most frequent in young adults (65%) and increased modestly over time (3.5 to 4.5 per 100 000 population; P = 0.02). The second most common cause was falls (26%), most frequent in patients aged ≥65 years (86%) and more than doubled over time (1.6 to 3.5 per 100 000 population; P < 0.001). The rate of inpatient admission was 14%, with a higher likelihood for patients aged ≥65 years (odds ratio [OR], 2.21; 95% CI, 1.99-2.46; P < 0.001) and falls (OR, 1.54; 95% CI, 1.27-1.86; P < 0.001). The total inflation-adjusted ED charges over the study period exceeded $2 billion, with the mean charge per visit increasing 48% (P < 0.001): from $5881 (95% CI, 5499-6263) to $8728 (95% CI, 8074-9382). CONCLUSIONS: Orbital floor fractures are becoming an increasingly common and costly injury in the United States. Preventive strategies aimed at reducing assault and falls will be crucial to mitigate the burden of orbital floor fractures on the healthcare system.

Tarsal Epithelial Cysts: Prevalence, Case Series, and Synthesis of Existing Literature.

PURPOSE: Tarsal epithelial cysts (TECs) are squamous epithelial-lined lesions of the eyelid that are often mistaken for chalazia or epidermal inclusion cysts. They remain poorly described in the literature. This study is designed to characterize the prevalence and clinical features of TEC. METHODS: We conducted a single-center retrospective review of adult patients with a diagnosis of eyelid neoplasm, eyelid cyst, hordeolum, stye, or chalazion between January 1, 2011 and July 1, 2017. Among this cohort, we identified patients with a histopathologic diagnosis of TEC. We also conducted a PubMed literature review and synthesis of existing clinical data of patients reported to have TEC, noting common clinical and histopathological features. RESULTS: Of 7,516 patients, we identified 6 patients with a histopathological diagnosis of TEC, amounting to a prevalence of 0.08% amongst patients with eyelid lesions. Average age was 49.7 years (range 18-76 years), with a 1:1 male to female ratio. The most common presenting symptom was a painless eyelid mass, and the majority (66.6%) had a preoperative diagnosis of chalazion. All but 1 patient had surgical excision from the posterior approach and there was 1 recurrence in the follow-up period. On review of the literature, we identified 68 prior cases of TEC from 18 clinical studies, with clinical features mirroring our case series. CONCLUSIONS: TEC has stereotypical clinical and histologic features that distinguish it from other tarsal lesions. Our review identified TEC as a relatively rare cause of eyelid lesions.

Evaluation and implementation of a mannequin-based surgical simulator for margin-involving eyelid laceration repair - a pilot study.

BACKGROUND: Repair of margin-involving eyelid lacerations is a challenge for beginning ophthalmology residents, yet no commercially-available simulation models exist for learning this skill. The objective of the study was to modify a mannequin-based surgical simulator originally developed for trachomatous trichiasis surgery training to teach margin-involving eyelid laceration repair and to evaluate its success within a residency wet-lab environment. METHODS: We modified a previously developed mannequin-based training system for trachomatous trichiasis surgery into a simulator for margin-involving eyelid laceration repair. Six ophthalmology residents from a tertiary care academic institution performed at least one simulated margin-involving eyelid laceration repair using the surgical simulator between September 2019 and March 2020. Each session was video recorded. Two oculoplastic surgeons reviewed the videos in a blinded fashion to assess surgical proficiency using a standardized grading system. Participants were surveyed on their comfort level with eyelid laceration repair pre- and post-completion of simulation. They were also queried on their perceived usefulness of the surgical simulator compared to past methods and experiences. RESULTS: Six residents completed 11 simulation surgeries. For three residents who completed more than one session, a slight increase in their skills assessment score and a decrease in operative time over two to three simulation sessions were found. Self-reported comfort level with margin-involving eyelid laceration repairs was significantly higher post-simulation compared to pre-simulation (p = 0.02). Residents ranked the usefulness of our surgical simulator higher than past methods such as fruit peels, surgical skill boards, gloves, and pig feet (p = 0.03) but lower than operating room experience (p = 0.02). Residents perceived the surgical simulator to be as useful as cadaver head and emergency department/consult experience. CONCLUSIONS: We developed a surgical simulator for teaching eyelid laceration repair and showed its utility in developing trainees' surgical skills. Our surgical simulator was rated to be as useful as a cadaver head but is more readily available and cost effective.

The Human Eye Proteome Project: Updates on an Emerging Proteome.

The human eye is a complex organ consisting of multiple compartments with unique and specialized properties that reflect their varied functions. Although there have been advancements in ocular imaging and therapeutics over the past decade, the pathogenesis of many common eye diseases remains poorly understood. Proteomics is an invaluable tool to gain insight into pathogenesis, diagnosis, and treatment of eye diseases. By 2013, when the Human Eye Proteome Project (also known as the EyeOme) was founded, there were 4842 nonredundant proteins identified in the human eye. Twenty-three recent papers on the human eye proteome were identified in PubMed searches. These papers were used to compile an updated resource of 9782 nonredundant proteins in the human eye. This updated catalogue sheds light on the molecular makeup of previously undescribed proteomes within the human eye, including optic nerve, sclera, iris, and ciliary body, while adding additional proteins to previously characterized proteomes such as aqueous humor, lens, vitreous, retina, and retinal pigment epithelium/choroid. Although considerable advances have been made to characterize the complete proteome of the human eye, additional high-quality data are needed to confirm and quantify previously discovered eye proteins in both health and disease.

Considerations for refractive surgery in the glaucoma patient.

PURPOSE OF REVIEW: Given the popularity of keratorefractive surgery, and an aging populous of patients who have undergone these procedures, there is an increasing need for updated management protocols. This is particularly relevant for patients with chronic progressive diseases such as glaucoma, due to the variety of related diagnostic and management challenges inherent to these diseases. Here, we will review the current literature to provide an update on the management of patients with glaucoma who are undergoing, or have had laser ablative refractive surgery. Preoperative testing and eligibility considerations, intraoperative factors, and postoperative observation and follow-up will be discussed. RECENT FINDINGS: Intraoperative intraocular pressure (IOP) rise during flap creation is associated with low risk of acute complications, and furthermore do not appear to have significant long term effects. Modern technologies have improved our ability to determine accurate IOP after refractive surgery despite postoperative changes in corneal architecture. Furthermore, advances in structural imaging allow for earlier detection of even subtle glaucomatous nerve damage. SUMMARY: Although glaucoma remains a relative contraindication to refractive surgery, it is a safe procedure for many patients with appropriate perioperative management and follow-up. Advancements in diagnostic modalities have allowed for earlier detection of glaucomatous disease, and subsequent earlier intervention when appropriate. Standardized diagnostic algorithms and rigorous perioperative assessment are critical to safe management of glaucoma patients undergoing refractive corneal surgery.

Altering workplace attitudes for resident education (A.W.A.R.E.): discovering solutions for medical resident bullying through literature review.

BACKGROUND: Physicians-in-training are challenged every day with grueling academic requirements, job strain, and patient safety concerns. Residency shapes the skills and values that will percolate to patient care and professional character. Unfortunately, impediments to the educational process due to medical resident mistreatment by bullying remain highly prevalent in training today. METHODS: A PubMed literature review was undertaken using key terms to help define resident mistreatment by bullying, determine its prevalence, identify its potential causes and sequelae, and find suggestions for changing this detrimental culture of medical training. RESULTS: We identified 62 relevant articles. The most frequently noted form of mistreatment was verbal abuse, with the most common perpetrators being fellow physicians of higher hierarchical power. Mistreatment exists due to its cyclical nature and the existing culture of medical training. These disruptive behaviors affect the wellbeing of both medical residents and patients. CONCLUSIONS: This article highlights the importance of creating systems that educate physicians-in-training about professional mistreatment by bullying and the imperative in recognizing and correcting these abuses. Resident bullying leads to increased resident stress, decreased resident wellbeing as well as risks to patient safety and increased healthcare costs. Solutions include education of healthcare team members, committee creation, regulation of feedback, and creation of a zero-tolerance policy focused on the health of both patients and residents. Altering workplace attitudes will diminish the detrimental effects that bullying has on resident training.

Etiology and Characteristics of Patients Presenting with Eyelid Lacerations at a Level 1 Trauma Center.

Purpose: To investigate the etiology and demographic associations of patients presenting with eyelid lacerations to a US level 1 trauma center emergency department (ED). Patient and Methods: A retrospective chart review of all patients with eyelid lacerations presenting to the ED at a single level 1 trauma center was performed. Eyelid lacerations were categorized as simple eyelid lacerations, eyelid lacerations with eyelid margin involvement, and eyelid lacerations with nasolacrimal system involvement. Data on demographics and clinical characteristics were analyzed. Results: A total of 303 eyelid laceration cases were identified, 56% were simple eyelid lacerations, followed by 24% with nasolacrimal involvement and 20% involving the eyelid margin. Sixty percent of animal bites/scratches resulted in a nasolacrimal system involving laceration, most commonly affecting children. Falls were the most common etiology in children and patients over the age of 60. Black patients, patients presenting with concomitant ophthalmic injuries, and those with Medicaid insurance were more likely to have an assault etiology (p < 0.05 for all). Conclusion: Falls were the most common etiology for eyelid lacerations in children and the elderly, while assault was the most common in adults. Identifying the most common etiology by demographic factors can help raise awareness regarding targeted prevention strategies for high-risk populations.