Disseminated sporotrichosis presenting as left nasolacrimal duct obstruction.

Sporotrichosis, a subacute or chronic mycosis caused by the Sporothrix schenckii complex, is commonly seen in tropical or subtropical parts of the world, especially in individuals who are in contact with cats or engage in gardening activities. Sporotrichosis generally presents with skin ulceration at the site of inoculation and follows a lymphocutaneous pattern; however, it can present in various confounding ways. Here, we present a case of disseminated sporotrichosis in an immunocompromised patient who did not seem to have any of the commonly associated risk factors and initially presented with a left nasolacrimal duct obstruction caused by lacrimal sac sporotrichosis, but then was found to have monoarticular involvement of his knee also secondary to disseminated sporotrichosis. Thorough clinical and microbiological evaluation, as well as multidisciplinary work, can lead to correct diagnosis and treatment of sporotrichosis, especially for atypical presentations in immunocompromised individuals.

Review of sociodemographic risk factors for presentation with advanced non-melanoma skin cancer.

PURPOSE: Non-melanoma skin cancers (NMSC) are often localized and associated with an excellent prognosis but a minority present with locally advanced or metastatic disease requiring extensive resection or systemic treatment. Medical factors that increase the risk of advanced skin cancers such as tobacco use, systemic immunosuppression or genetic syndromes have been described but the sociodemographic risk factors are relatively uninvestigated and under reported. In this review a cohort of patients presenting with periorbital NMSC is reviewed for social determinants of health correlated with presentation with advanced disease. METHODS: Patients presenting with periorbital NMSC during a 10-year period are categorized as advanced (those tumors requiring extensive local resection, sacrifice of the globe or systemic therapy) or non-advanced and demographic features are compared between the two groups. RESULTS: 274 cases of periorbital NMSC were classified as either non-advanced (177) or advanced (97). Patients with public safety net health insurance were twice as likely to present with advanced disease (25% vs 13%). Patients with advanced disease were significantly less likely to be under the care of a primary care physician, lived in economically depressed areas with lower mean household incomes, and lived further from tertiary medical care. CONCLUSION: Financial and sociodemographic features are strongly associated with presentation with advanced NMSC. Further work is needed to determine which sociodemographic features are independent risk factors. A better understanding of the relevant barriers to care may reduce the burden of advanced disease at presentation in the future.

Clinical correlation recommended: accuracy of clinician versus radiologic interpretation of the imaging of orbital lesions.

Purpose: To assess the accuracy of radiographic interpretation between the clinician and radiologist when compared to histopathology of orbital lesions. Methods: A retrospective chart review of patients at the University of California Davis Eye Center who underwent orbitotomy from 1/1/2000 to 5/22/2019 was performed. Charts with a preoperative imaging report, preoperative clinical assessment including the clinician's interpretation of imaging, and histopathologic diagnosis were included. The specific diagnoses were grouped into related classes of pathology for the analysis. The clinical and radiologic assessments were compared against the final histopathologic diagnosis for concordance. A concordance analysis was performed. Results: 242 patients (mean age 49 years, 53.5% female) were reviewed. Of these records 185 documented the clinician's clinical impression, the radiology report, as well as the histopathology report. The clinician's preoperative assessment had substantial agreement [kappa = 0.72 (0.65,0.79)] with the final histopathologic result and was correct in 75.7% (140/185) of cases whereas the radiology report was correct in 52.4% (97/185) with a moderate level of agreement [kappa = 0.47 (0.39, 0.55)]. In 49.2% (91/185) of cases the final histopathology correlated with both the clinical impression and radiology report [kappa = 0.58 (0.55, 0.61)]. Conclusions: The accurate interpretation of orbital imaging is a challenge and histopathologic examination remains the gold standard for diagnosis. While orbital imaging is a valuable diagnostic tool the interpretation of these studies is most accurate when conducted in the context of the patient's medical history, clinical exam, and with the physician most familiar with various orbital lesions.

Eyelid abscess masking underlying sebaceous cell carcinoma.

Sebaceous cell carcinoma is well known as the "great masquerader" mimicking other benign or malignant eyelid conditions and lesions. We present a case of a middle age male presenting with a subacute left upper lid abscess who was ultimately diagnosed with malignant sebaceous cell carcinoma after incision and drainage and treatment with broad spectrum antibiotics. This case highlights the deceptive clinical and radiographic appearance of this tumor and the importance of histologic examination in atypical or refractory periorbital abscesses.

Safety and Efficacy of Resident-Performed Functional Upper Eyelid Blepharoplasty.

PURPOSE: To determine the safety and efficacy of resident-performed functional upper eyelid blepharoplasty. METHODS: The authors retrospectively looked at functional upper eyelid blepharoplasty surgery performed on 836 eyes of 448 patients under the supervision of one oculoplastic surgery attending at the University of California Davis Eye Center from January 1, 2013, to December 31, 2017. The primary surgeon was a resident on 427 eyes and was an attending on 409 eyes. Patients (73.5%) were female, and the mean age was 66.0 ± 10.0. All patients had at least 2 postoperative visits, and eyes that underwent other concurrent upper eyelid or brow procedures were excluded. The authors looked at major and minor complications, percentage of initially dissatisfied patients, and percentage of cases that required a revision procedure within 6 months. Chi-square tests were used for statistical analysis. RESULTS: There were no major complications in either group. There was no difference in the rate of minor complications (10.8% vs. 7.6%, p = 0.11), percentage of patients who were initially dissatisfied with the procedure (3.5% vs. 2.0%, p = 0.17), or percentage of patients requiring a revision procedure (5.2% vs. 3.2%, p = 0.15). The most common minor complications were inclusion cysts (45, 5.4%), wound dehiscence (9, 1.1%), and hypertrophic scars (9, 1.1%), and the most common revision procedures were removal of inclusion cyst(s) (17, 2.0%) and suturing or placement of topical skin adhesive for wound dehiscence (9, 1.1%). CONCLUSIONS: Ophthalmology residents can perform functional upper eyelid blepharoplasty safely and effectively under the supervision of an attending physician.Resident-performed functional upper eyelid blepharoplasty under the direct supervision of an attending is a safe and effective procedure with similar complication rate, number of revision procedures, and patient satisfaction to attending-performed functional upper eyelid blepharoplasty.

Pembrolizumab and epacadostat induced fatal myocarditis and myositis presenting as a case of ptosis and ophthalmoplegia.

We report the first case of fatal myocarditis presenting as bilateral ptosis in a patient on combination therapy with pembrolizumab and epacadostat. An 83 year-old man with stage III high-grade urothelial carcinoma presented with acute onset droopy eyelids one month after starting pembrolizumab and epacadostat. Exam showed myogenic ptosis and ophthalmoplegia. He was later found to have acute myocarditis with complete heart block and subsequently passed away. Pembrolizumab in combination with epacadostat can induce a potentially fatal myocarditis. Although immune mediated myocarditis is a rare established side effect, more reported fatalities are needed in the literature to highlight the urgency for standardized cardiac monitoring of even asymptomatic patients to prevent fatal outcomes, as well as a consensus on treatment protocols. Cancer immunotherapy complications are not well known to ophthalmologists. This case is unique in that the presenting sign was ptosis, which prompted the patient to call his ophthalmologist first.

State of the Art in Congenital Eyelid Deformity Management.

The eyelids are crucial in maintaining the health of the ocular surface and have an important role in facial aesthetics. Interruption in eyelid development can lead to congenital eyelid deformities. This article reviews eyelid anatomy, the most common congenital eyelid abnormalities such as congenital ptosis, eyelid coloboma, and epiblepharon, and the management of these conditions.

Extraocular muscle enlargement leading to the diagnoses of Burkitt lymphoma and acquired immune deficiency syndrome.

Orbital involvement in nonendemic Burkitt lymphoma is rare. The authors report a unique case of a patient who sought treatment for extraocular muscle enlargement without a concurrent orbital mass, which subsequently led to the diagnoses of Burkitt lymphoma and acquired immune deficiency syndrome in an adult patient. The case report adhered to the principles of the Declaration of Helsinki and Health Insurance Portability and Accountability Act compliance. This single case report was institutional review board exempt, given that it does not meet the definition of human subjects' research.

Anxiety and Depression after Traumatic Open-Globe Injury.

Introduction: This cross-sectional interview-based study aimed to assess the prevalence and severity of probable anxiety and depression in patients with traumatic open-globe injury and to identify factors associated with anxiety and depression following open-globe injury. Methods: Two hundred and twenty-five patients with open-globe injury were identified at the UC Davis Medical Center between 2008 and 2019. Prisoners and patients under 18 at the time of recruitment were excluded from the study. One hundred and twenty-four patients provided consent to participate in the study, which involved a phone interview and chart review. The interview consisted of a section on sociodemographic data and potential associations followed by the Hospital Anxiety and Depression Scale, a standardized 14-question survey that has been validated in previous studies as an excellent predictor of anxiety and depression. A score of 8 for anxiety or depression was considered a positive test, and patients with a positive test in either category were advised to seek further evaluation with their primary care doctors. The prevalence of probable anxiety and depression was calculated, and linear regression was used to identify factors associated with anxiety and depression. Results: The average age was 50.5 ± 19.2, and 75.8% of patients were male. The anxiety score was positive in 37.9% of patients and the depression score was positive in 28.2%. The mean anxiety and depression scores were 6.3 ± 4.7 and 5.5 ± 4.8, respectively. The P value of the linear regressions for anxiety score and depression score were both < 0.001, with R2 = 0.429 and 0.363, respectively. Younger age (P = 0.002) and unemployment at the time of the interview (P = 0.038) were associated with higher anxiety scores. Patients who were bothered by the appearance of their injured eye had higher anxiety scores (P < 0.001) and depression scores (P < 0.001). Patients without a high school diploma had higher depression scores (P < 0.001). Gender, enucleation status, number of people in support network, use of a prosthetic or scleral shell, final logMAR visual acuity, marital status, months since the initial injury, and presence of an intraocular foreign body were not significantly associated with anxiety or depression scores. Conclusions: Traumatic open-globe injury is associated with a high prevalence of probable anxiety and depression. Dissatisfaction with the appearance of the injured eye was associated with higher anxiety and depression scores. Younger age and unemployment were associated with increased anxiety scores, and lack of a high school diploma was associated with higher depression scores.

Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms.

Introduction: This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries. Methods: A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020. Results: Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001). Conclusions: Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Clinical image: Rare photographic documentation of uveal melanoma progression.

To present clinical images of a patient with neovascular glaucoma and hypermature cataract masking orbital extension of a uveal melanoma. Observations: A 67-year-old female was referred for neovascular glaucoma and found to have an intraocular tumor with massive orbital extension. She refused surgery and returned one year later with progression of the tumor with metastases and expired seven months later. Conclusions and importance: Unexplained glaucoma and cataract should be investigated for harboring underlying intraocular tumors to prevent delays in diagnosis. Providers also should obtain greater understanding of psychosocial and socioeconomic barriers to healthcare.

Histoplasmosis presenting as a cutaneous malignancy of the eyelid.

Cutaneous histoplasmosis is an uncommon infection and can occur as a primary infection. A manifestation imitating a cutaneous neoplasm is rare, and eyelid involvement is rarer still. The authors report a case of histoplasmosis that presented as an ulcerated lesion on the lower eyelid margin that clinically resembled a basal cell carcinoma. Given its worldwide distribution, it is important to include this disease in the differential diagnosis of nonhealing eyelid lesions. Biopsy and tissue culture are paramount to establishing the diagnosis. This case describes a rare presentation of histoplasmosis on the eyelid and highlights the importance of histopathologic evaluation.

Traumatic Optic Neuropathy Management: A Survey Assessment of Current Practice Patterns.

INTRODUCTION: The treatment of traumatic optic neuropathy (TON) is highly controversial with a lack of substantiated evidence to support the use of corticosteroids or surgical decompression of the optic nerve. The aim of the study was to determine if there was a general consensus in the management of TON despite controversy in the literature. METHODS: An anonymous survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the North American Neuro-Ophthalmology Society regarding their practice patterns in the management of patients with TON was performed. RESULTS: The majority of 165 respondents indicated that they treated TON with corticosteroids (60%) while a significant minority (23%) performed surgical interventions (P < 0.0001). Subgroup analysis comparing rates of treatment with steroids among oculoplastic surgeons and neuro-ophthalmologists (67% vs. 47%) was not significant (Fisher's Exact test [FET], P =0.11) while results did suggest that a higher proportion of oculoplastic surgeons (33%) than neuro-ophthalmologists (11%) recommended surgical intervention (FET, P =0.004). In cases where visual acuity exhibited a downward trend treatment with steroids was the most commonly employed management. In general, neuro-ophthalmologists trended toward observation over treatment in TON patients with stable visual acuity while oculoplastic surgeons favored treatment with corticosteroids. CONCLUSIONS: In spite of the lack of class I evidence supporting intervention of TON, the majority of respondents were inclined to offer corticosteroid treatment to patients whose visual acuity showed progressive decline following injury.

Presumed primary orbital neuroblastoma in a 20-month-old female.

Neuroblastoma is the most common malignant disease of childhood, and it often arises from either the adrenal gland or along the sympathetic chain. The authors report a case of a 20-month-old female with a presumed primary neuroblastoma of the orbit. Radiologically, the tumor showed a brightly enhancing mass lesion of the left side with intraorbital, temporal extraorbital, transsphenoid, and intracranial components. Histopathologically, the tumor was composed of small round blue cells. Immunohistochemical staining was positive for neuron-specific enolase. To the best of the authors' knowledge, primary orbital neuroblastoma has only been previously reported once in children, although it has been reported twice in adults.

Eyelid fistula caused by a scleral buckle.

Complications of scleral buckle procedures for retinal detachments are rather uncommon yet may result in a broad scope of problems. The authors report a case of a chronic eyelid fistula caused by a scleral buckle. The patient was an 81-year-old woman who presented with a nonhealing left upper eyelid wound that was repeatedly misdiagnosed as a chalazion, but diagnostic workup revealed an extruded scleral buckle to be the cause. The patient was treated surgically with removal of the scleral buckle and full-thickness fistula repair and her wound healed well. A scleral buckle can erode through conjunctiva and the full thickness of an eyelid, causing an eyelid fistula and necessitate removal of the buckle.

Rare Signet Ring Cell Adenocarcinoma of the Colon Metastasis to the Orbit.

Metastases arising from primary tumors of the gastrointestinal tract are not commonly encountered in the orbit. Colorectal carcinomas are subcategorized based on morphological and genetic characteristics with these distinctions bearing therapeutic and prognostic significance. The behavior of these subcategories, including their propensity for orbital metastasis, differs, and clinicians treating these tumors must be aware of their metastatic profiles. This report describes a 51-year-old female with right upper lid swelling and ptosis ultimately found, what we believe to be, the first reported case of signet ring cell colon carcinoma metastasizing to the levator muscle and superior orbit. This case serves as a reminder to all clinicians to consider orbital metastasis even in malignancies not typically found in this location.

Large Orbital Pediatric Intraosseous Hemangioma.

A five-year-old male presenting with progressive right facial swelling underwent multiple biopsies before being diagnosed with a polyostotic frontal-zygomatic primary intraosseous hemangioma. Intraosseous hemangiomas are rare, more frequently afflict adult females, and very rarely involve the orbit. Our case with bony destruction and surrounding soft tissue mass measured 5.3 cm in a child mimicked a more ominous malignancy. This case is unique with its rapid progression and largest reported size, leading to additional challenges such as difficulty in achieving an adequate tissue sample and in the surgical management with respect to significant blood loss in a small child.

Misdiagnosis of Bell's palsy: Case series and literature review.

Although Bell's palsy is a common etiology for isolated facial paralysis, it is important clinicians perform a complete neurologic examination to avoid misdiagnosis. Multiple cranial neuropathy is often caused by tumor or infection.

Previously undiagnosed neuroendocrine tumour mimicking breast cancer metastasis to the orbit.

Metastatic neuroendocrine neoplasms to the breast are rare and histopathologic overlap with mammary carcinomas has led to misdiagnosis. We present a case of a middle-aged woman with diplopia and a right medial rectus mass. Metastatic breast cancer was initially suspected based on a history of invasive ductal carcinoma. Detailed immunohistochemistry of the orbital biopsy, gallium-68 dotatate positron emission tomography-CT, and reevaluation of her prior breast specimen, demonstrated that her initial breast carcinoma diagnosis was in error and she was ultimately diagnosed with a previously unknown gastrointestinal neuroendocrine tumour metastatic to both the orbit and breast. This case highlights the challenges of differentiating between metastatic neuroendocrine tumours and invasive mammary carcinomas with neuroendocrine differentiation both in the breast and in the orbit. It is important to recognise the overlap so that a primary neuroendocrine neoplasm is not missed, or treatment significantly delayed.

Effect of surgical correction of congenital ptosis on amblyopia.

PURPOSE: To determine if amblyopia improves following surgical correction of congenital ptosis. METHODS: Clinical records from 130 congenital ptosis patients presenting to the Childrens Hospital Los Angeles Department of Ophthalmology between January 1999 and April 2006 were retrospectively reviewed. Patient ages ranged from 2 months to 17 years old. Amblyopia was defined as best-corrected visual acuity of less than 20/40 and greater than 2 Snellen lines of difference between the 2 eyes. In younger patients, amblyopia was defined by a lack of fixation in the ptotic eye compared with the nonptotic one. All patients diagnosed with amblyopia were treated with occlusion therapy. RESULTS: Of the 130 patients, amblyopia was found in 21.5% (28/130), associated strabismus was found in 16.2% (21/130), and associated anisometropia was found in 14.6% (19/130). There were 50 congenital ptosis patients treated surgically. Of these patients, using an upper age limit of 8 years, 15 patients were diagnosed with preoperative amblyopia (37.5%) reducing to 2 patients (5%, p < 0.005) postoperatively (average follow-up 19.8 months). There were 40 congenital ptosis patients without associated anisometropia or strabismus treated surgically. In this group, using an upper age limit of 8 years, 9 (27%) were diagnosed with preoperative amblyopia reducing to 1 (3%, p < 0.0196) postoperatively (average follow-up 18.1 months). No new cases of amblyopia were diagnosed postoperatively. Comparatively, in the nonsurgical group, amblyopia was present on initial examination in 8.7% (2/23), and was present in 17% (4/23) of these patients at follow-up (mean, 17.2 months). CONCLUSION: Surgical correction of congenital ptosis may aid in the treatment of amblyopia.