A case of concurrent silent sinus syndrome, thyroid eye disease, idiopathic orbital inflammatory syndrome, and dacryoadenitis.

This is a retrospective case description of a single female patient found to have concomitant bilateral silent sinus syndrome, bilateral thyroid eye disease, unilateral dacryoadenitis, and idiopathic orbital inflammation that presented as progressive unilateral right-sided proptosis. The spectrum of inflammatory orbital diseases can make discerning between different entities challenging, but more unique in this case was the simultaneous presentation with bilateral silent sinus syndrome, a rare entity in its own right. Identifying each of these concurrent disease processes is important to establishing a multidisciplinary treatment approach to address all the patient's orbital and peri-orbital pathology. We hope to highlight the clinical and radiographic findings unique to each of these entities and share our approach to treatment in this complex case.

Tension Pneumocephalus Following Orbital Exenteration.

Pneumocephalus is a known complication of skull base surgery, but is rarely seen by orbital surgeons. We report a case of postoperative mental status changes after exenteration due to tension pneumocephalus. After surgical and medical management, the patient's pneumocephalus resolved and she recovered fully. Risk factors for tension pneumocephalus, mechanism, clinical presentation, and management techniques are discussed.

Lymphoma masquerading as occlusive retinal vasculitis: A case study.

PURPOSE: To describe a case of retinal lymphoma presenting as an occlusive retinal vasculitis without vitritis that was exquisitely responsive to intravitreal dexamethasone implant (IVDI). OBSERVATION: A 66-year old male presented with decreased vision in the right eye and was diagnosed with occlusive retinal vasculitis and prominent cystoid macular edema though he lacked vitritis. A complete systemic workup for infectious, inflammatory, and infiltrative etiologies was unremarkable. Intravenous methylprednisolone and cyclophosphamide had no clinical effect. Due to persistent perivascular exudates and refractory macular edema, IVDI was administered with marked improvement in vision and clinical findings. Subsequent retinal vasculitis in the left eye responded to IVDI as well. The patient remained disease free for months while on weekly adalimumab. He then presented with acute vision loss in the left eye due to a lymphomatous subretinal infiltration and a new lesion in the corpus callosum. He has remained disease free for more than two years after intravitreal methotrexate injections and rituximab with an autologous stem cell transplant. CONCLUSION AND IMPORTANCE: Lymphoma may present as an occlusive retinal vasculitis without vitritis and can be masked due to its response to IVDI.

Coats' Disease-Related Macular Edema Treated with Combined Aflibercept and Laser Photocoagulation.

PURPOSE: To describe the clinical response of refractory macular edema associated with Coats' disease following treatment with aflibercept and laser photocoagulation. METHODS: Case report. RESULTS: A 17-year-old female presented with decreased vision of the left eye. Ophthalmic exam demonstrated intraretinal hemorrhages and exudation with associated edema centrally. Angiographic evaluation revealed central leaking microaneurysms and peripheral capillary dropout. These findings and a systemic work-up that yielded an incidental Factor V Leiden mutation lead to a diagnosis of Coats' disease. Initial treatment consisted of laser photocoagulation and intravitreal bevacizumab but with poor response. Switching to intravitreal aflibercept resulted in resolution of the refractory macular edema and improvement of visual acuity to 20/25 in the left eye. CONCLUSION: We describe a case of refractory macular edema which responded more favorably to intravitreal aflibercept compared with bevacizumab when combined with laser photocoagulation in a patient with Coats' disease.

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH RETINAL ARTERY OCCLUSION AFTER COSMETIC FILLER INJECTION.

PURPOSE: To report a single case of paracentral acute middle maculopathy in association with retinal artery occlusion in the setting of ipsilateral facial cosmetic filler injection. METHODS: Case report. PATIENT: A 35-year-old woman presenting with sudden vision loss to finger count vision immediately after left nasal fat pad cosmetic filler injection. RESULTS: Dilated funduscopic examination revealed a swollen optic disc with multiple branch arterial occlusions with visible embolic material. Fluorescein angiography confirmed multiple branch arterial occlusions in addition to a focal choroidal infarction in the macula. Spectral-domain optical coherence tomography revealed middle retinal hyperreflectivity in the superotemporal macula consistent with paracentral acute middle maculopathy. En face optical coherence tomography demonstrated a superotemporal area of whitening at the level of the deep capillary plexus corresponding to the paracentral acute middle maculopathy lesion seen on spectral-domain optical coherence tomography. On twelve-month follow-up, final visual acuity was 20/100 due to optic neuropathy. CONCLUSION: Emboli from cosmetic facial filler injections may rarely result in ipsilateral arterial occlusions and now have a novel association with paracentral acute middle maculopathy likely due to deep capillary plexus feeder vessel occlusion.

Ophthalmic Complications Associated with Direct Oral Anticoagulant Medications.

OBJECTIVE: To describe the clinical features and management of six patients with ocular complications associated with direct oral anticoagulants (DOACs). METHODS: The medical records of all adult patients known to be taking a DOAC and with an unusual bleeding event at a large tertiary referral center over a one-year period were reviewed. Patients with less than one-month follow-up were excluded. Data collection included relevant clinic notes, operative reports, surgical videos, and clinical images (fundus photography, optical coherence tomography, B-scan ultrasonography, and fluorescein angiography). RESULTS: Six eyes in six patients were identified with an unusual bleeding event associated with DOAC use. One patient was taking apixaban, two patients were taking dabigatran, and three patients were taking rivaroxaban. Two patients had large submacular hemorrhage (including one with vitreous hemorrhage breakthrough), three patients had vitreous hemorrhage, and one patient had recurrent hyphema. Presenting visual acuity ranged from 20/40 to light perception. Three individuals required therapeutic and/or diagnostic pars plana vitrectomy for vitreous hemorrhage. Final visual acuity ranged from 20/25 to count finger vision. The associated DOAC was permanently discontinued in two of the six cases. Follow-up was one to four months from onset of identified DOAC-related complication. CONCLUSIONS: DOAC use may be associated with ocular bleeding. Ophthalmologists should be aware of potential hemorrhagic complications and obtain consultation with primary providers regarding DOAC cessation guidelines.

Effect of Serial Intrasilicone Oil Bevacizumab Injections in Eyes With Recurrent Proliferative Vitreoretinopathy Retinal Detachment.

PURPOSE: To investigate the effect of serial intrasilicone oil bevacizumab injections (1.25 mg/0.05 mL) on visual acuity (VA) and anatomic outcomes in eyes undergoing proliferative vitreoretinopathy (PVR)-related retinal detachment (RD) repair. DESIGN: Prospective, nonrandomized, historical-control pilot study. METHODS: setting: Tertiary care center. STUDY POPULATION: Nondiabetic eyes undergoing pars plana vitrectomy (PPV) and silicone oil tamponade with or without scleral buckling procedure (SBP) for recurrent RD due to PVR. INTERVENTION: Intrasilicone oil injection of 1.25 mg bevacizumab was performed intraoperatively and at postoperative months 1, 2, and 3. OUTCOMES: Retinal reattachment rate, final VA, and rate of epiretinal membrane (ERM) formation at month 6. RESULTS: Twenty eyes of 20 patients were enrolled and compared to a historical control group composed of 35 age- and sex-matched controls. In the study group, logMAR VA improved from mean 1.78 ± 0.43 (Snellen 20/1205) to 1.43 ± 0.70 (Snellen 20/538, P = .04), retinal reattachment was achieved in 14 of 20 eyes (70%), and ERM formation was observed in 7 of 20 eyes (35%) at 6 months. In the control group, logMAR VA improved from mean 1.50 ± 0.74 (Snellen 20/632) to 1.43 ± 0.58 (Snellen 20/538, P = .64), retinal reattachment was achieved in 25 of 35 eyes (71%), and ERM formation was observed in 7 of 35 eyes (20%) at 6 months. No significant difference in final VA (P = .96), retinal reattachment rate (P = .75), or ERM formation (P = .33) was observed between groups. No intrasilicone oil injection-related adverse events occurred. CONCLUSIONS: Serial intrasilicone oil injections of bevacizumab did not improve retinal reattachment rate, improve final VA, or reduce ERM formation in patients undergoing PVR-related RD surgery.

A critical review of the use of carvedilol in ischemic heart disease.

ß-Adrenergic receptor antagonists (ß-blockers) have been recognized for their cardioprotective properties, prompting use of these pharmacologic agents to become more mainstream in acute myocardial infarction (AMI) and congestive heart failure (CHF). Despite their popularity as a class, the ability to protect the myocardium varies significantly between different agents. Carvedilol is a non-selective ß-blocker with α1-adrenergic receptor antagonism properties. It is unique among ß-blockers because in addition to improving exercise tolerance and its anti-ischemic properties secondary to a reduction in heart rate and myocardial contractility, carvedilol exerts other beneficial effects including: antioxidant effects; reduction in neutrophil infiltration; apoptosis inhibition; reduction of vascular smooth muscle migration; and improvement of myocardial remodeling post-AMI. These properties, documented in animal models and subsequent clinical trials, are consistent with established evidence demonstrating decreased morbidity and mortality in patients with CHF and post-AMI. This article reviews the role of carvedilol compared with other ß-blockers in the treatment of CHF and post-AMI management.

Male gender significantly increases risk of oxidative stress related congenital anomalies in the non-diabetic population.

OBJECTIVE: Oxidative stress (OS) is an important mechanism of teratogenesis. Recent work suggests increased OS in males. We evaluated whether male gender increased the risk of cyanotic congenital heart defects (CCHD) whose development is linked to OS and other common congenital anomalies (CA) in non-diabetic pregnancies. METHODS: CDC-National Center for Health Statistics data for 19 states in 2006 were reviewed. CCHD, anencephaly, spina bifida, congenial diaphragmatic hernia (CDH), omphalocele, gastroschisis, limb defects, cleft lip with or without cleft palate (CL/P) and isolated cleft palate were evaluated. Adjusted odds ratio (OR) (95% CI) were calculated for CA in males with females as the reference group. RESULTS: Of 1,194, 581, cases analyzed after exclusions, 3037 (0.25%) had major CA. Males had elevated adjusted OR (95% CI) for CCHD: 1.198 (1.027, 1.397), CDH: 1.487 (1.078, 2.051), and CL/P: 1.431 (1.24, 1.651). There was a significant interaction between cigarette use and (male) fetal gender and also with maternal age in the CL/P group. CONCLUSIONS: In non-diabetic pregnancies, male gender appears to be an independent risk factor for some types of CA believed to be associated with OS. Cigarette smoking, a well recognized source of OS only increased the risk of CL/P in males.