Cemiplimab for metastatic squamous cell carcinoma of the orbit, periocular adnexa, and thigh.

The current case presentation highlights the potential of cemiplimab, a programmed cell death protein-1 (PD-1) inhibitor, as first-line treatment for periocular metastatic cutaneous squamous cell carcinoma (SCC) without requiring curative surgery or radiotherapy. A 64-year-old male presented with a progressing 4.5 × 3.0 cm left upper eyelid lesion initially diagnosed as psoriasis. Work-up revealed cutaneous SCC with tumor invasion into extraconal fat and lacrimal gland, and metastasis to the left parotid lymph node. The patient also presented with a suspicious lesion on his left medial thigh found to be a second primary on pathology. To avoid orbital exenteration and treat the multifocal disease, the patient was started on intravenous cemiplimab immunotherapy. Following six doses, repeated FGD-PET-CT revealed a complete response of the left eyelid lesion and residual low-grade hypermetabolic activity of the left medial thigh lesion. Biopsy confirmed chronic inflammation and fibrosis with no signs of malignancy. This unique case with dual primary cutaneous SCC provides support for cemiplimab in treating locally invasive periocular SCC, and potentially abrogating the need for highly morbid exenteration procedures to preserve binocular vision.

Blink detection and magnetic force generation for correction of lagophthalmos, with specific regard to implant compatibility testing.

PURPOSE: The overall goal was to restore a normal and synchronous blink in unilateral lagophthalmos. We describe the biocompatibility profiling of a novel ferromagnetic implant used for electromagnetic eyelid force generation. METHODS: A non-contact blink detection system and an electromagnetic stimulation system were designed and tested. A modified Lester-Burch speculum equipped with strain gauge technology was used in blinking force measurement. Samarium-cobalt magnets were prototyped and coated with parylene-C. Biocompatibility testing was performed using NIH/3T3 mouse fibroblast cells with MTT colorimetric assay cytotoxic quantification. OUTCOME MEASURES: Cellular viability and interleukin concentrations. RESULTS: Our system was capable of detecting 95.5 ± 3.6% of blinks in various lighting conditions. Using our force measuring device, the difference between non-paralyzed and paralyzed orbicularis oculi (OO) for normal and forceful blinking closure was 40.4 g and 101.9 g, respectively. A 16.6 × 5.0 × 1.5 mm curved shaped samarium cobalt eyelid implant was successfully developed and showed a reproducible blink at 100 ms with full corneal coverage with external eyelid taping. Compared to gold weights, parylene-C coated samarium cobalt implants showed not only excellent cell viability (82.0 ± 4.9% vs. 88.4 ± 0.9%, respectively, p > .05), but also below detection threshold for pro-inflammatory marker concentrations (interleukin-6 < 2 pg/mL and interleukin-10 < 3 pg/mL). CONCLUSIONS: We demonstrated excellent in-vitro biocompatibility of our parylene-C coated samarium cobalt implants. We believe that our novel approach can improve the quality-of-life of affected individuals and provides new understanding of blinking biomechanics.

Transcranial Blade Injuries and Principles of Their Safe Extraction.

Retained cranial blade injuries are uncommon events lacking standardized recommendations for appropriate surgical extraction. The authors present a case of a 30-year-old male who sustained a penetrating blade injury of the left orbit with intracranial extension through the skull base into the temporal lobe. The patient walked to the emergency room and remained alert. Clinically, the patient had only a small laceration of the left upper eyelid with no gross visual impairment.The radiological investigation confirmed the presence of a knife blade in the orbit. Intraoperative management included an intracranial approach and an extracranial craniofacial dissection for blade visualization and soft tissue protection, globe protection and to avoid any major bleeding. A thorough review of the penetrating cranial injuries literature is presented and a trauma management algorithm is offered for the care of similar injuries.

Eyelid Mycetoma Masquerading as Sebaceous Carcinoma.

A 56-year-old Asian woman presented with an upper eyelid mass. The lesion was exposed after eversion of the eyelid revealing a thickened tarsus with yellowish areas. Working diagnosis was sebaceous carcinoma. Biopsy was performed. Histopathological studies showed a mycotic eumycetoma with Splendore-Hoeppli phenomena and - microbiologic cultures grew Scedosporium apiospermum. The patient was started on voriconazole 200 mg po bid with adequate serum levels. A complete response was observed after 18 weeks of voriconazole therapy. To the best of our knowledge, this is the first published case of S. apiospermum eumycotic mycetoma of the eyelid. It is important to consider mycotic infection in the differential diagnosis of eyelid tumors even in healthy patients.

Epiphora as first presenting sign of primary extranodal NK/T-cell lymphoma of the lacrimal sac.

A 28-year-old Caucasian female presented with a six-month history of epiphora of the right eye. Diagnostic lacrimal syringing revealed obstruction of the right nasolacrimal duct. During external dacryocystorhinostomy (DCR), the lacrimal sac had an unusual papillary appearance. Frozen sections suggested malignant lymphoid cells. Pathologic examination revealed extranodal NK/T-cell lymphoma, nasal type. Imaging revealed a mass lesion centered on the lacrimal sac. The authors describe the youngest Caucasian patient with a primary NK/T-cell lymphoma of the lacrimal sac, as well as the first case presenting with epiphora as the sole presenting symptom, reported in the literature. Extranodal NK/T-cell lymphomas rarely occur in the orbit, and are known to be rapidly growing, aggressive lesions. Despite chemotherapy, the patient succumbed to her disease twelve months after diagnosis. Lacrimal surgeons should maintain a high index of suspicion in all cases of primary nasolacrimal duct obstruction. Pre- or intra-operative clinical suspicion of malignancy in the lacrimal sac necessitates biopsy.

Evaluation of tearing in oculoplastics assisted by tear osmolarity measurement.

PURPOSE: To determine the tear osmolarity in patients with tearing secondary to dry eye and other pathologies, and to determine the prevalence of dry eye disease among patients with tearing in an oculoplastics setting. METHODS: 108 eyes of 54 patients with a chief complaint of tearing were prospectively recruited. Subjects were excluded if they used eye drops or contact lenses within 2 hours of assessment, had a history of refractive surgery, an active ocular allergy, or evidence of a systemic disease which affects tear production. A full medical and ocular history was taken with a complete eye exam pertinent to dry eye. Tear osmolarity was measured using the TearLab device. A clinical diagnosis of dry eye was made based on findings, without reference to tear osmolarity. RESULTS: Among 86 eyes symptomatic for tearing, 32 eyes had dry eye disease (37%). Patients with dry eye had a significantly higher median tear osmolarity compared to that in patients with other diagnoses (308 mOsm/L vs. 294 mOsm/L, p < 0.0001). At a cut-off of 308 mOsm/L, tear osmolarity resulted in a sensitivity of 50% and a specificity of 88% for the diagnosis of dry eye. CONCLUSIONS: A significant proportion of patients with tearing in an oculoplastics practice had dry eye disease. The high specificity of tear osmolarity may render it a useful tool to rule in dry eye disease and may assist the oculoplastic surgeon in more accurately determining the cause of tearing.

Cyanoacrylate glue as a novel skin substitute in periocular skin excisions: case series and literature review.

OBJECTIVE: Despite the widespread use of cyanoacrylate glue (CA) as an alternative for wound closure, its potential as a sole skin substitute material in periocular skin surgery remains unexplored. The primary objective was to determine the viability of CA as a sole skin substitute in periocular skin surgery after excision. DESIGN: Single-centre retrospective observational case series. METHODS: All patients were treated at the McGill University Health Centre from August 2023 to November 2023, where CA served as the sole skin substitute material after periocular skin excision. RESULTS: Three female and one male patient, with a mean age of 75 years, received treatment with CA after skin excision for both cancerous and benign skin lesions. Specifically, histopathology revealed 2 cases of basal cell carcinoma, 1 case of squamous cell carcinoma in situ, and 2 benign lesions. The skin defects after excision ranged from 4 × 3 mm to 15 × 30 mm. No complications were observed between CA graft insertion and final skin re-epithelization. Complete re-epithelization was achieved in all patients at final follow-up without evidence of excessive skin contraction. CONCLUSIONS: This study presents a novel approach by using CA as a skin substitute material in periocular skin excisions. Its liquid form allows for easy application and conforms well to irregular wound surfaces. CA may offer economic advantages, including lower material cost and shorter surgical operating times, compared with traditional skin substitutes. Further research is needed to comprehensively evaluate CA's role as a skin substitute in periocular skin reconstruction.

Severe visual loss and orbital infarction following periorbital aesthetic poly-(L)-lactic acid (PLLA) injection.

Visual loss following esthetic treatment of the face is a rare but devastating iatrogenic complication. The authors report a case of a 43-year-old man with blindness and ophthalmoplegia of the left eye following a treatment of the left periorbital region with the subcutaneous filler poly-(L)-lactic acid. The patient's symptoms began immediately following one of the tunneled injections. On presentation, the patient had clear signs of ocular and orbital ischemia. Angiography and further history suggested an embolic orbital infarction as the mechanism of injury. The increased usage of subcutaneous fillers for facial rejuvenation had introduced a small but proven risk of embolization of these viscous materials to the eye and orbit.

Optical Coherence Tomography of Peri-Ocular Skin Cancers: An Optical Biopsy.

INTRODUCTION: Optical coherence tomography (OCT) imaging has been used as a diagnostic tool for retinal disease for several years, and OCT apparatuses are becoming increasingly powerful. However, OCT has yet to reach its full potential in ophthalmology clinics. Alike retinal layers, it has been shown that OCT is able to generate cross-sectional images of the skin and allows visualization of skin lesions in a histopathology-like manner. OBJECTIVE: We aim to validate OCT as an imaging modality for peri-ocular skin cancer. Through a series of cases, we highlight findings for 3 common eyelid malignancies: basal cell carcinoma, squamous cell carcinoma and sebaceous carcinoma. We propose an OCT image-based signature for basal cell carcinoma. METHODS: This is a prospective study. Fifty-eight lesions suspicious of malignancy from 57 patients were subjected to OCT imaging prior to the surgical excision of the lesion. OCT images were analysed and scored according to previously identified OCT features. Eight representative examples are presented, highlighting the OCT patterns for each malignancy side by side to its corresponding histopathological sections. RESULTS: Out of the 58 lesions analysed, 53 were malignant. A loss of the dermal-epidermal junction is observed in all malignant lesions. A strong link is observed between the presence of subepithelial hyporeflective nests on OCT and the diagnosis of basal cell carcinoma (present in 83% of cases). Conversely, lesions of epithelial origin such as squamous cell carcinoma are most often represented on OCT by acanthosis. Two supplementary cases, one basal cell carcinoma and one sebaceous carcinoma, are provided to illustrate how OCT imaging is a valuable tool in cases where clinical observations may be unusual. CONCLUSIONS: We provide evidence supporting the use of OCT for the evaluation of peri-ocular cancers. OCT enables visualization of the skin layers in vivo, before biopsy. Our results show that certain OCT features can contribute to include or exclude a diagnosis of basal cell carcinoma. By integrating this non-invasive imaging methodology into the routine assessment of peri-ocular skin lesions, especially in health care centres where access to specialists is limited, OCT imaging can increase clinical precision, reduce delays in patient referral and enhance patient care.

Unilateral upper eyelid eversion and kink associated with epidemic keratoconjunctivitis.

PURPOSE: Upper lid eversion in adults from non-cicatricial causes is rare. We report a case of upper eyelid eversion secondary to epidemic keratoconjunctivitis (EKC). OBSERVATIONS: A 37 year-old female presented with unilateral upper lid eversion. Known for left upper lid ptosis repair in childhood, the patient presented with seven-day history of severe bilateral conjunctivitis and eversion of her left upper lid three days prior. On exam, she had follicular conjunctivitis, punctate epithelial keratopathy with subepithelial infiltrates and membranes bilaterally, with an everted upper lid tarsus, and swollen and ulcerated palpebral conjunctiva. She received topical and oral prednisone to quickly reduce the inflammation, as well as moxifloxacin drops and lubrication. When the swelling subsided, the tarsus adopted a kinked and everted configuration, and was managed successfully with reversion, pressure patching, shielding and close follow-up. CONCLUSIONS AND IMPORTAMCE: This is the first reported case of upper lid eversion secondary to EKC, likely due to sudden marked inflammation and edema of the posterior lamella caused by the adenoviral infection. This case was successfully managed with conservative therapy.

Guidelines for vismodegib in the management of periocular basal cell carcinoma.

OBJECTIVE: The management of advanced basal cell carcinoma (BCC) in the periocular region remains a clinical challenge. Vismodegib (ErivedgeTM) has been approved in 2013 by Health Canada for adult patients with "histologically confirmed metastatic BCC or locally advanced BCC inappropriate for surgery or radiation." An expert consensus was sought to create a standardised approach in the use of this novel treatment. METHODS: Fourteen practicing oculoplastic surgeons across Canada were involved in formulating and reviewing guidelines until consensus was reached. A consultancy meeting was followed by further ratification of guidelines over email. Two voting surveys were performed of the group to objectively assess agreement over each statement within the guidelines. Ratification continued until at least two-thirds of the group agreed on every guideline statement. RESULTS: The guidelines summarize 21 statements in a major and minor criteria format. A multidisciplinary team review is suggested for each patient with the involvement of recommended specialists. The internal survey revealed 100% agreement over 9 statements, 91.7% agreement over 8 statements, 83.3% agreement over 4 statements, and 2 statements had 66.7% and 58.7% agreement each. All statements with less than 91.7% agreement were surveyed again, and they were kept, modified, or removed on the basis of a consensus of over 66.7%. CONCLUSIONS: These guidelines serve to act as a framework for physicians considering vismodegib for the medical management of patients with advanced or metastatic periocular BCC. Future applications, including neoadjuvant uses of the drug, may become apparent through further research.

An unusual orbital tumor in an adult: Granuloma annulare.

PURPOSE: Granuloma annulare (GA) is a rare clinical entity that does not classically arise from the peri-orbital area in adults. The purpose of this case report is to present a 69-year-old female with GA of the orbit. As well, the pathological and immunohistochemical features of these tumors will be discussed. OBSERVATIONS: One case of GA of the orbit was identified from a tertiary ophthalmology referral centre. Clinical and histopathological features of the case were reviewed. Other cases of GA were also retrieved from the literature and addressed in this report. CONCLUSION AND IMPORTANCE: Granuloma annulare is a rare orbital lesion in adults. It is known to typically arise on the hands and feet of children. This lesion must be distinguished from necrobiotic xanthogranuloma (NXG), which is a progressive peri-orbital dermatosis seen in middle age men and women. GA is thought to be a benign, often self-resolving condition, whereas NXG tends to be linked to other systemic conditions and may have a poorer prognosis.Differentiating this rare orbital tumor from necrobitotic xanthogranuloma (NXG) is essential, as both a systemic work-up and follow-up must be appropriately arranged. A comprehensive description of pathognomonic microscopic features of GA and NXG is reviewed to achieve the correct diagnosis.

Novel application of anterior segment optical coherence tomography for periocular imaging.

OBJECTIVE: This study aims to assess the use of optical coherence tomography (OCT) imaging for periocular skin lesions and to determine which characteristic features of these images can be correlated to histopathology. DESIGN: This is an ongoing prospective study with Research Ethics Board approval. PARTICIPANTS: Fifty patients over 18 years old with lesions clinically suspicious of nonmelanoma skin cancer on the periocular region were included in this study. METHODS: After consent was obtained, clinical photographs and dermatoscopic images were obtained (DermLite II Hybrid M) from the lesion and its contralateral side. Subsequently, the patient was subjected to OCT imaging using the anterior segment module of a spectral domain OCT (Optovue Avanti) and images of the contralateral skin were also obtained. Surgical excision of the lesion was performed and sent for histopathological examination as per routine treatment. OCT images were then correlated to their matching digitalized histopathology section (Philips Ultra Fast Scanner 1.6 RA). RESULTS: Based on the OCT images acquired from 50 patients, 8 predominant architectural features have been correlated to histopathology: hyperkeratosis, acanthosis, loss of dermal-epidermal junction delineation, hyporeflective tumour nests, cystic structures, "bunch of grapes" nodules, hyperreflective nests, and ulcerations. Results observed from 45 malignant lesions (basal cell carcinoma, squamous cell carcinoma, and sebaceous gland carcinoma) suggest that groups of features and their layout within the same OCT image may be associated to specific tumour characteristics. CONCLUSIONS: Current data suggest that anterior-segment OCT imaging is a noninvasive imaging modality for periocular lesions and may be a valuable tool to help differentiate between some tumour types before a biopsy is performed.

Anetodermic variant of a periorbital pilomatricoma.

Pilomatricoma usually presents as a solitary hard nodule located deep in the dermis. However, a variant termed anetodermic is often seen in the elderly. Instead of a hard nodule, a rapidly growing bullous lesion is seen. The authors report a 60-year-old man who presented with an erythematous bullous lesion at the left medial canthus. The lesion started as a small 3-mm papule and grew significantly to a 12-mm lesion in 5 weeks. Histopathologically, the tumor was composed of basophilic and keratinized shadow cells typical of pilomatricoma. Anetodermic changes could also be seen, represented by intralesional hemorrhage, dilated blood and lymphatic vessels, and disruption of dermal collagen fibers. The anetodermic variant of pilomatricoma was described in 1943 and accounts for only 2% of cases. Compression of vessels by the neoplastic process and peritumoral inflammatory infiltration are the proposed pathogenic mechanisms underlying the atypical findings.