Radiation-Induced Acquired Lacrimal Drainage Obstructions: Management and Outcomes.

OBJECTIVE: To describe the management and outcomes of patients with radiation-induced acquired lacrimal duct obstructions (RALDO). METHODS: A retrospective chart review from July 2018 to December 2023 of all cases undergoing surgical intervention for RALDO by a single surgeon. Data collected included demographics, tumor type and anatomic location, radiation treatment (including radiation type, dosage, and duration), interval between radiation and reported onset of epiphora, oculoplastic clinical examination, management, and outcomes. Lacrimal irrigation was done prior to surgery in all patients. RESULTS: Seventeen eyes of 16 patients with a mean age at presentation of 63.3 years and over half the patients being females (56.3%) were included in the study. The right lacrimal drainage system (LDS) was involved in 4 (23.6%), and the left side was involved in 13 (76.4%). The mean onset of epiphora symptoms after radiation was 9.5 months. The underlying tumor type were intraocular having uveal melanoma in four, cutaneous squamous cell carcinoma in 2, basal cell carcinoma involving forehead and nose in one and sino-nasal indications present in 8 patients. One patient had metastasis to the orbit and eyelid. Four patients (25%) received external beam radiotherapy (XRT) (one case had bilateral LDS involvement), 6 patients (37.5%) received intensity-modulated radiation therapy (IMRT), 5 patients (31.25%) received proton beam irradiation (PBI), and one (6.25%) received stereotactic body radiotherapy (SBRT). Mean radiation dosage was 61.31 Gy in 15 patients (data was missing in 1 patient). Punctum was effaced in 3, canalicular stenosis in 1, proximal canalicular obstruction in 8, distal canalicular obstruction in 2, and nasolacrimal duct obstruction (NLDO) in 3. Treatment was based on the site and nature of obstruction and varied from minimally invasive techniques like serial dilatation with bicanalicular silicone tube or Guibor tube to surgical interventions like dacryocystorhinostomy (DCR) or conjunctivo-dacryocystorhinostomy (C-DCR). Only 10% with primary lacrimal intubation had good response. Of the six cases that underwent C-DCR with Jones tube either as primary or secondary procedure, four cases showed improvement in epiphora (67%). Three with NLDO did well after external DCR. In total, four patients had a secondary procedure after the first failed while 7 with failed initial surgery elected against secondary surgery. The mean follow-up was 9.6 months (range 2-24 months). CONCLUSIONS: In patients with RALDO, salvage treatment with silicone lacrimal intubation has poor results, CDCR with Jones tube has better results, although imperfect and in cases with NLDO, DCR has good outcomes.

Deep-Learning Based Automated Segmentation and Quantitative Volumetric Analysis of Orbital Muscle and Fat for Diagnosis of Thyroid Eye Disease.

Purpose: Thyroid eye disease (TED) is characterized by proliferation of orbital tissues and complicated by compressive optic neuropathy (CON). This study aims to utilize a deep-learning (DL)-based automated segmentation model to segment orbital muscle and fat volumes on computed tomography (CT) images and provide quantitative volumetric data and a machine learning (ML)-based classifier to distinguish between TED and TED with CON. Methods: Subjects with TED who underwent clinical evaluation and orbital CT imaging were included. Patients with clinical features of CON were classified as having severe TED, and those without were classified as having mild TED. Normal subjects were used for controls. A U-Net DL-model was used for automatic segmentation of orbital muscle and fat volumes from orbital CTs, and ensemble of Random Forest Classifiers were used for volumetric analysis of muscle and fat. Results: Two hundred eighty-one subjects were included in this study. Automatic segmentation of orbital tissues was performed. Dice coefficient was recorded to be 0.902 and 0.921 for muscle and fat volumes, respectively. Muscle volumes among normal, mild, and severe TED were found to be statistically different. A classification model utilizing volume data and limited patient data had an accuracy of 0.838 and an area under the curve (AUC) of 0.929 in predicting normal, mild TED, and severe TED. Conclusions: DL-based automated segmentation of orbital images for patients with TED was found to be accurate and efficient. An ML-based classification model using volumetrics and metadata led to high diagnostic accuracy in distinguishing TED and TED with CON. By enabling rapid and precise volumetric assessment, this may be a useful tool in future clinical studies.

Bilateral Dacryocystoceles in Congenital Arhinia.

Congenital arhinia is a rare anomaly characterized by a syndrome called Bosma arhinia microphthalmia syndrome. A 22-year-old woman with a history of congenital arhinia presented with bilateral discharge and enlarged bilateral lacrimal sacs, with imaging consistent with bilateral dacryocystoceles and complete absence of nasal structures. This is the first case in the literature that describes surgical management of bilateral dacryocystoceles in a patient with Bosma arhinia microphthalmia syndrome.

Recalcitrant postoperative bleeding after ectropion repair in the setting of undiagnosed chronic disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is characterized by abnormal activation of the coagulation cascade, which leads to simultaneous hypercoagulation and excessive bleeding. While it typically occurs in systemic diseases, such as infection, inflammation, obstetric complications, and malignancy, it can rarely manifest postoperatively. This case report describes a patient who presented with prolonged, refractory bleeding after ectropion repair via a lateral tarsal strip procedure. Due to the inability to control the patient's bleeding with conservative measures followed by surgical exploration and electrocautery, the patient underwent a hematologic work-up. Laboratory studies were consistent with DIC, attributed to his large burden of endovascular stents. He was treated with anticoagulation using apixaban in addition to tranexamic acid to achieve lasting hemostasis. This case highlights the importance of thorough preoperative assessments, even for minor surgical procedures, and systemic workup for atypical postoperative bleeding.

Periorbital necrotizing sweet syndrome: A report of two cases mimicking necrotizing soft tissue infections.

Purpose: Two cases are described of necrotizing Sweet syndrome (nSS), a rare variant of acute febrile neutrophilic dermatosis that mimics necrotizing soft tissue infections. Observation: A 74-year-old female with myelodysplastic syndrome (MDS) presented with isolated periorbital nSS that closely mimicked necrotizing fasciitis (NF); she displayed pathergy to debridement, was exquisitely responsive to corticosteroids, and underwent successful first-stage reconstruction of the eyelid with full-thickness skin grafting. A second 40-year-old female patient with relapsed acute myelogenous leukemia (AML) presented with multifocal nSS most prominently involving the eyelid. Positive herpes zoster virus (HSV) PCR and bacterial superinfection complicated the diagnosis. She improved with chemotherapy for AML and corticosteroid therapy. Conclusion: nSS is rare and a high level of clinical suspicion as well as an understanding of its distinguishing features is necessary to avoid undue morbidity. Identification of pathergy, histopathology, microbiology, and clinical context are critical to avoid misdiagnosis of infection.

Antisynthetase Syndrome Causing Necrotizing Myositis Involving Extraocular Muscles.

The authors describe the clinical, histologic, and serologic findings of a patient with necrotizing myositis of the extraocular muscles in the setting of antisynthetase syndrome, as well as subsequent management. This is the first case in the literature of a systemic necrotizing myositis to have associated ophthalmic findings.

Melanoma Arising Beneath the Lateral Rectus Muscle in a Teenager With Ocular Melanocytosis: Possible Origin From Intrascleral Melanocytes.

Ocular melanocytosis is a well-established risk factor for choroidal melanomas but, despite its reported associations in the literature, it is infrequently discussed in relation to orbital melanomas. The authors describe a teenage patient with ocular melanocytosis who presented with an asymptomatic ipsilateral right orbital mass associated with the lateral rectus muscle. An exploratory orbitotomy revealed a lesion lightly adherent to the underlying sclera. Histopathology demonstrated a markedly atypical epithelioid melanocytic proliferation, bound by a thin rim of superficial sclera, implying an origin from intrascleral melanocytes, likely within an emissary canal. Next-generation sequencing identified GNAQ and NF1 mutations. The histopathology and molecular genetics designated the lesion as having a uveal melanoma-like profile, suggesting that it may behave as a choroidal melanoma. This case underscores the importance of the association between ocular melanocytosis and orbital melanoma and provides additional evidence for primary orbital melanoma etiopathogenesis.

Microbial patterns and culture utility in orbital cellulitis.

PURPOSE: To determine the prevalence and types of pathogens found in children with orbital cellulitis and to evaluate the utility of nonoperative cultures. METHODS: This was a retrospective cohort study of children with imaging-confirmed orbital cellulitis over a period of 8 years. Outcomes included prevalence and types of organisms, polymicrobial infection, mixed aerobic-anaerobic infection, effect of age, and culture utility. RESULTS: Of 220 children with orbital cellulitis, 112 (51%) had cultures taken; 69 (31%) had surgical intervention. Culture sources for the 112 children with cultures included blood (57 patients [51%]), sinus (53 [47%]), orbit (42 [38%]), brain (6 [5%]), and skin/conjunctiva/lacrimal sac (6 [5%]). Streptococcus anginosus group strains grew in cultures from 19 children (17%); methicillin-sensitive Staphylococcus aureus (MSSA), in 15 (13%); Streptococcus pyogenes, in 12 (11%); methicillin-resistant Staphylococcus aureus (MRSA), in 6 (5%); anaerobic/facultative gram negative rods, in 8 (7%); anaerobic Gram-positive cocci, other Viridans group streptococci, and Streptococci pneumoniae, in 3 (3%) each; and normal respiratory/skin flora, in 23 (21%). Polymicrobial infection (P = 0.08) and anaerobic organisms (P = 0.58) did not differ by age (range, 0.1-16.8 years). In all 220 (100%) children, nonoperative cultures were either not obtained (108 [49%]), not helpful in avoiding surgery (69 [31%]), showed no growth (39 [18%]), or grew an organism that did not change management from empiric therapy (4 [2%]). CONCLUSIONS: While many organisms may be cultured from children with orbital cellulitis, Streptococcus and MSSA were the most common in our study cohort. MRSA is uncommon, so initial empiric coverage is not necessary. Rates of polymicrobial and anaerobic infection were similar across ages. Our results indicate that nonoperative cultures are not indicated in the initial medical management of orbital cellulitis; in our cohort, they neither resulted in treatment changes nor helped avoid surgery.

Eosinophilic Angiocentric Fibrosis of the Orbit: A Clinicopathologic Review of 6 Novel Cases With Review of the Literature.

PURPOSE: To describe 6 cases and review the current state of knowledge of eosinophilic angiocentric fibrosis (EAF) involving the orbit. DESIGN: Retrospective clinicopathologic case series and review of the current literature METHODS: Clinical records and histopathologic data of orbit-involving EAF were gathered between 2004 and 2022 from a single academic institution. The patients' presenting clinical symptoms and signs, laboratory data, radiographic studies, and management documentation were collected. RESULTS: Retrospective review identified 6 novel cases, totaling 31 cases of EAF involving the orbit described as of this writing. Fourteen patients were male, and the average age of presentation was 49.8 years (range 25-78 years). Eighteen patients had concurrent sinonasal involvement, whereas 13 had primary orbital involvement. The median duration of symptoms prior to evaluation was 24 months, with nasal symptoms, proptosis, periorbital swelling, and pain being the most common presenting symptoms. The majority of patients underwent surgical debulking, as well as treatment with glucocorticoids and steroid-sparing agents, such as rituximab, with varied results. CONCLUSION: EAF involving the orbit is uncommon. The histopathologic findings include a perivascular, eosinophil-rich infiltrate and a pauci-inflammatory storiform type of fibrosis concentrated around small vessels. Orbital involvement usually results from local extension from adjacent sinuses, but primary orbital involvement has been described. Surgical debulking and immunosuppressive agents such as rituximab have been shown to stabilize disease.

Ocular Findings in Children with Headache.

PURPOSE: To determine the prevalence of ophthalmological findings suggesting an ocular cause for headache or occult neurological disease, among children with headache. METHODS: Retrospective cross-sectional study on children with headache at a tertiary outpatient ophthalmology clinic. All children underwent sensorimotor, anterior segment, and dilated fundoscopic examinations, with or without cycloplegic refraction. Prevalence of one or more new findings of ocular or occult neurological cause of headache, including glaucoma, uveitis, optic nerve elevation, or possible asthenopia from strabismus or refractive issues. Headache characteristics and associated symptoms were evaluated as risk factors for ocular findings. RESULTS: Among 1,878 children with headache (mean age 10 yrs, range 2-18), 492 (26.1%, 95% CI 24.3-28.2%) children had one or more new ocular findings that could cause headache or indicate intracranial disease: refractive issues (342, 18.2%), strabismus (83, 4.4%), optic nerve elevation (51, 2.7%; 26 with papilledema, 25 with pseudopapilledema), uveitis (6, 0.3%), and glaucoma (2, 0.1%). Shorter headache duration was associated with ocular findings (p = .047), but headache frequency, photophobia, nausea/vomiting, and visual changes were not. In univariable analysis, visual changes (p ≤ .001), nausea/vomiting (p ≤ .002), and morning headache (p = .02) were associated with optic nerve elevation. CONCLUSION: An ophthalmologic examination including cycloplegic refraction is indicated in children with headache, as one-quarter have a treatable ocular condition, which may be related to the headache, or sign of intracranial pathology. While nausea, visual changes, or morning headache should raise concern, coincident visual, ocular, or systemic symptoms are not reliable predictors of discovering ocular pathology in a child with headache.

Clear Cell Syringoma of the Eyelids, a Distinctive Histopathologic Variant Associated with Diabetes Mellitus.

The authors describe the clinical and histologic findings of the clear cell variant of syringoma. Three adult female patients (age range 39-76 years old) were found to have multiple, flesh-colored lower eyelid papules, clinically consistent with syringomas, but histologically displaying abundant clear cell change. Two patients had known diagnoses of uncontrolled diabetes.

Dedicated Chalazion Clinic as a Tool for Early Surgical Education in Ophthalmology Residency.

Objective Ophthalmology residency programs aim to improve resident surgical teaching through increased surgical exposure over a 4-year period. Resident-centric surgical clinics across various surgical specialties have been established to help develop surgical autonomy and experience. We present the first demonstration of a resident-centric chalazion incision and drainage clinic (chalazion clinic) in an ophthalmology residency with the goal of increasing early surgical exposure to residents. Design The chalazion clinic was founded in July 2019. It is a once weekly procedure clinic conducted by an ophthalmology resident and supervised by an ophthalmology attending. Patients with chalazia were referred directly to this clinic for evaluation and management, rather than the oculoplastics clinic as they were in the past. Retrospective review of Accreditation Council for Graduate Medical Education (ACGME) case logs of all residents per academic year before and after establishment of the chalazion clinic was performed in order to assess the impact on residents' chalazion procedures numbers per academic year. Setting The study involved a single academic ophthalmology department. Participants Ophthalmology residents of all years were present. Results A resident of any year performed an average of 3.0 chalazion procedures per year in the 2018 to 2019 academic year, 3.8 in 2019 to 2020, and 8.4 in the 2020 to 2021, which represents a 180% increase in procedure numbers per resident. Among post-graduate-year 2s (PGY)2s, the average number of chalazion procedures increased from 2.1 procedure per year to 22.3 per year (961.9% increase). Conclusion To the best of our knowledge, this is the first description of a dedicated resident-centric chalazion clinic in an ophthalmology residency program. PGY2s demonstrated the largest increase in procedural numbers. While chalazion incision and drainage is a minor procedure, increased exposure to surgical procedures early in training could help improve residents' skills and confidence. This clinic provides a proof of concept of a dedicated minor procedure clinic for ophthalmology residents to increase early procedural volume.

Bilateral consecutive choroidal neovascularization in Best vitelliform macular dystrophy.

Best vitelliform macular dystrophy (BVMD) is a slowly progressive macular disease caused by a pathogenic variant of the Bestrophin (BEST1) gene. Examination coupled with multimodal imaging and genetic testing are used to guide diagnosis and treatment. A 12-year-old girl was examined for decreased vision in the left eye and showed bilateral "egg-yolk"-like macular lesions with choroidal neovascularization (CNV) in the left eye. Six months later, she experienced decreased vision with appearance of CNV on optical coherence tomography angiography in the right eye. Injections of anti-vascular endothelial growth factor helped restore vision from 20/125 to 20/20 in the right eye with stabilization of her left eye (vision 20/40). Genetic testing revealed c.851A > G (p.Tyr284Cys), a heterozygous variant of the BEST1 gene. The same variant was found in her father, who was initially misdiagnosed with toxoplasmosis due to a peripheral retinal lesion in the left eye. This is the first report of bilateral consecutive CNV secondary to BVMD. Additionally, it highlights the likely pathogenic role of a novel variant of the BEST1 gene.

Posterior Ischemic Optic Neuropathy in the Setting of Cocaine-Induced Orbital and Sinonasal Inflammation.

Intranasal cocaine abuse can lead to significant sinus and orbital complications, including optic neuropathy. A 46-year-old man with a history of recurrent cocaine-induced sino-orbital inflammation and infection with bony destruction presented with acute, painless, vision loss. Examination revealed no light perception vision. MRI of the orbits demonstrated new restricted diffusion of the right optic nerve on diffusion-weighted imaging and apparent diffusion coefficient sequences, consistent with posterior ischemic optic neuropathy. This is the first among cases of cocaine-induced optic neuropathy in the literature to illustrate ischemic changes on MRI in the optic nerve, highlighting the utility of diffusion-weighted imaging/apparent diffusion coefficient sequences when optic neuropathy is suspected and further suggesting an underlying ischemic etiology in similar cases.

Path Analysis of RCT Recruitment: Secondary Analysis of Results from a Systematic Review.

We examine recruitment processes for 71 pragmatic and comparative effectiveness trials identified in a systematic review, using path analysis to examine rates of refusal to screen, test, and consent to trial participation. Our analysis suggests that refusal rates might be on net slightly higher if potential subjects are screened or asked to undergo physical eligibility tests, but this was not significant in our sample of trials (p = .11 by Mann-Whitney test). We find that rates of refusing to provide informed consent are much lower for trials in which subjects have agreed to screening or testing (odds ratio = 0.40, Wilcoxon rank-sum z = 2.67, p = .008). We also observe that the overwhelming majority of trials examined secured consent after determining eligibility, even in trials involving screening or testing activities. The ethical implications and areas for future research are discussed.

Refusal rates and waivers of informed consent in pragmatic and comparative effectiveness RCTs: A systematic review.

BACKGROUND: Pragmatic and comparative effectiveness randomized controlled trials (RCTs) aim to be highly generalizable studies, with broad applicability and flexibility in methods. These trials also address recruitment issues by minimizing exclusions. The trials may also appeal to potential subjects because of lower risk and lower burdens of participation. We sought to examine rates of refusal and uses of waivers of informed consent in pragmatic and comparative effectiveness RCTs. METHODS: A systematic review of pragmatic and comparative effectiveness RCTs performed wholely or in part in the United States and first published in 2014 and 2017. RESULTS: 103 studies involving 105 discrete populations were included for review. Refusal data was collected for 71 RCTs. Overall, studies reported an average rate of 31.9% of potential subjects refused participation; on an individual basis, 38.4% of people asked to take part refused at some point during recruitment. 23 trials (22%) were performed, at least in part, with a waiver of informed consent, 7 (30%) of which provided any form of notice to subjects. CONCLUSIONS: Overall refusal rates for pragmatic and comparative effectiveness RCTs appear roughly the same as other types of research, with studies reporting about a third of people solicited for participation refuse. Moreover, informed consent was waived in 22% (95% Binomial exact Confidence Interval 13.9-30.5%) of the trials, and further study is needed to understand when waivers are justified and when notice should be provided.

Symmetry of Disease in Retinopathy of Prematurity in the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study.

PURPOSE: To determine the symmetry of retinopathy of prematurity (ROP) between fellow eyes in a broad-risk cohort. METHODS: A retrospective cohort study, the Postnatal Growth and ROP (G-ROP) Study, of 7483 infants undergoing ROP examinations conducted at 29 hospitals in the United States and Canada from 2006 to 2012. The main outcomes were the symmetry for the highest stage and the most severe type (1, 2, not 1 or 2, no ROP) of ROP and disease course of the fellow eye when only one eye developed type 1. RESULTS: 93% of infants had eyes symmetric for the highest stage and 94% for type. Among 459 infants who developed type 1, 379 (82.6%) did so in both eyes simultaneously and were treated bilaterally; 44 (10%) were treated for type 1 in one eye and type 2 in the fellow eye; and 36 (8%) were treated unilaterally initially, of which 6 fellow eyes developed type 1 and were treated (4 within 2 weeks, all within 4 weeks); 5 developed type 2 and regressed; and 25 developed ROP less than type 1 or 2, which was treated in 13 cases and regressed spontaneously in 12 cases. CONCLUSIONS: ROP was highly symmetric between eyes with respect to the presence and severity of disease in a large, broad-risk cohort representative of infants undergoing ROP screening. When type 1 develops in one eye and type 2 in the fellow eye, the risk of progression to type 1 in the fellow eye appears very low if it has not occurred within 4 weeks.