Incidence and severity of asymptomatic ocular injury in adult and pediatric orbital fractures.

PURPOSE: To evaluate the incidence of severe ocular injury requiring emergent ophthalmic evaluation in visually asymptomatic patients presenting with orbital fractures. METHODS: We performed a retrospective chart review of all adult and pediatric orbital fractures between 2012-2022 at a level 1 trauma center. Ocular injuries were categorized into severe, moderate, and mild. We evaluated symptoms, mechanism of injury, visual acuity (VA), and severity of injuries using the Cochran-Armitage and linear-by-linear tests. RESULTS: Of the 2495 cases, 1534 had ophthalmology evaluation. The mean ± standard deviation age was 40.4 ± 20.4 years. Most patients were male (73.1%) and Caucasian (75.9%). The mean time to evaluation was 0.6 ± 2.5 days. 486 (31.7%) were visually symptomatic, 760 (49.5%) were asymptomatic, and 288 (18.8%) were unknown. Of the symptomatic, 135 (27.8%) had severe injuries, 108 (22.2%) had moderate injuries, 216 (44.4%) had mild injuries, and 27 (5.6%) had no injuries. Of the asymptomatic, 67 (8.8%) had severe injuries, 183 (24.1%) had moderate injuries, 468 (61.6%) had mild injuries, and 42 (5.5%) had no injuries. Symptoms correlated with injury severity (p-value <.001). The most common mechanism of injury were falls (24.0%), assaults (22.2%), and motor vehicle accidents (14.8%). CONCLUSIONS: Visually asymptomatic orbital fractures were less likely to have severe ocular injuries; however, many patients were unable to express symptoms. Emergent ophthalmology evaluation should be considered in all patients presenting with orbital fractures, especially patients with visual symptoms or are unable to report symptoms.

Ipilimumab-related orbitopathy: a case report.

Ipilimumab, an immune checkpoint inhibitor used in the treatment of metastatic melanoma, can cause immune-related adverse events including rare ocular-related inflammation. This is a case of a 54-year-old man with metastatic melanoma and bilateral orbital inflammation associated with ipilimumab that occurred after drug rechallenge 6 years after initial orbital inflammation with ipilimumab use. Imaging revealed tendon-involving myositis. He was managed with intravenous corticosteroid and intravenous immunoglobulin therapy with improvement in his orbital inflammation. This case demonstrates the potential ocular effects of ipilimumab use, differentiation of ipilimumab-associated orbital inflammation from thyroid orbitopathy and management considerations to effectively reduce orbital inflammation.

The Emergence of Zoonotic Onchocerca lupi Infection in the United States--A Case-Series.

This case-series describes the 6 human infections with Onchocerca lupi, a parasite known to infect cats and dogs, that have been identified in the United States since 2013. Unlike cases reported outside the country, the American patients have not had subconjunctival nodules but have manifested more invasive disease (eg, spinal, orbital, and subdermal nodules). Diagnosis remains challenging in the absence of a serologic test. Treatment should be guided by what is done for Onchocerca volvulus as there are no data for O. lupi. Available evidence suggests that there may be transmission in southwestern United States, but the risk of transmission to humans is not known. Research is needed to better define the burden of disease in the United States and develop appropriately-targeted prevention strategies.

Angiosarcoma of the Eyelid With Superimposed Enterobacter Infection.

Angiosarcoma is a rare, aggressive, malignant endothelial neoplasm with a variable clinical presentation. The authors describe a case of angiosarcoma involving the eyelid that was complicated by a superimposed Enterobacter infection. Following positive cultures for E. aerogenes and multiple biopsies suspicious but not definitive for angiosarcoma, a final biopsy was consistent with angiosarcoma.

Proptosis Caused by Rhabdomyomatous Mesenchymal Hamartomata Occurring in the Orbit.

Two infants were referred for progressive orbital proptosis. MRI in both cases demonstrated a homogenous mass in the orbit adherent to and isointense with a rectus muscle. Histopathology in both cases demonstrated a bland proliferation of spindle cells with entrapped skeletal muscle. Immunochemistry demonstrated that the abnormal tissue was of skeletal muscle origin, consistent with rhabdomyomatous mesenchymal hamartoma (RMH). Observation was elected due to the reported benign nature of RMH. In contrast to RMH of the cutaneous tissues that typically follows a benign course, RMH of the orbit may present with rapid growth.

Porcine dermal collagen in lower eyelid retraction repair.

PURPOSE: To describe clinical outcomes of patients receiving porcine dermal matrix implants for lower eyelid retraction repair. METHODS: A retrospective review of all patients who underwent lower eyelid retraction repair with porcine dermal matrix implantation between June 2007 and July 2013 at a tertiary care center was conducted. Patient demographics, procedure(s) performed, preoperative and postoperative marginal reflex distance, inferior scleral show, and complications were reviewed. Patients with a prior history of lower eyelid surgery were excluded. The study is Health Insurance Portability and Accountability Act compliant, institutional review board approved, and adherent to the Declaration of Helsinki. RESULTS: One hundred patients (160 eyelids) received porcine dermal collagen implants. Fifty-six patients had thyroid eye disease, 23 had midface descent, 10 had seventh nerve palsies, and 11 had other etiologies of retraction. The average preoperative marginal reflex distance was 7.64 mm in the OD and 7.17 mm in the OS, compared with 6.40 mm in the OD and 6.22 mm in the OS postoperatively. The average preoperative inferior scleral show was 2.04 in the OD and 1.70 in the OS compared with 0.81 mm in the OD and 0.65 mm in the OS postoperatively. Follow up ranged from 1.46 to 66.04 months, with an average of 14.06 months and median of 8.84 months. Nineteen eyelids had implant-related complications: 7 with cyst formation, 7 with exposure/rejection, 2 with long-term pain, 2 with transient inflammation, and 3 with irregular implant contour. CONCLUSIONS: Porcine dermal matrix implants provide reliable support, integration, and function in lower eyelid retraction repair without significant resorption or complications in the majority of patients.

Chronic Conjunctivitis due to Nocardia nova Complex Formation on a Silicone Stent: A Case Report and Review of the Literature.

Nocardial conjunctivitis associated with silicone tubing is an extremely rare finding. The authors present a case of a 52-year-old woman with previous dacryocystorhinostomy and silicone tube placement 3 years prior who presented with OD redness and discharge for 1 week. On examination, the patient was noted to have mucoid discharge and crusting surrounding the silicone tube. The tube debris was sampled, and the culture was positive for Nocardia nova complex sensitive to trimethoprim/sulfamethoxazole and amikacin. Silicone tube colonization and N. nova complex conjunctivitis are both rare but should be considered in the differential diagnosis of patients with indwelling silicone tubes presenting with chronic conjunctivitis resistant to fluoroquinolones and tobramycin.

Changes in Intraocular Pressure During Orbital Floor Fracture Repair.

PURPOSE: To evaluate changes in intraocular pressure (IOP) during orbital floor fracture repair. METHODS: Retrospective chart review of patients undergoing isolated orbital floor fracture repair with implant placement at a level 1 trauma center and tertiary care center. Patients with combined zygomaticomaxillary or medial wall fracture repair, or other significant ocular injuries were excluded. IOP measurements using a handheld applanation tonometer were recorded immediately after induction of anesthesia, immediately after orbital floor implant placement, and on postoperative day 1. RESULTS: Nine patients who underwent isolated orbital floor fracture repair were examined. There was a statistically significant mean decrease of 4.66 mmHg (p < 0.05) in IOP from prior to surgical to immediately after implant placement. There was also a significant mean increase in IOP of 7.44 mmHg (p < 0.05) at postoperative day 1 compared with immediately after implant placement. There was no statistically significant difference in IOP between prior to surgical incision and postoperative day 1. CONCLUSIONS: All patients who underwent orbital floor fracture repair in this study had a significant decrease in IOP during orbital floor fracture repair that returned to immediately preoperative levels by postoperative day 1. This initial decrease in IOP may be because of intraoperative manipulation of the globe.

Mucosa-associated lymphoid tissue lymphoma masquerading as herniated orbital fat.

Lymphomas are the most common primary orbital malignancies in adults. The authors present a 62-year-old Hispanic woman with a 2-year history of slowly enlarging bilateral lower eyelid masses that the patient described as "bags." On palpation, firm, mobile, nontender masses with associated tear trough deformities were noted. Biopsy of the left lower eyelid mass was consistent with a mucosa-associated lymphoid tissue lymphoma. Herniated orbital fat is an extremely common finding in the aging population and is often associated with a prominent tear trough. The patient with orbital lymphoma appeared to have herniated orbital fat with associated tear trough deformities. Lymphoma resembling herniated orbital fat is uncommon but should be considered in all patients with prominence in the periorbital region.

PROSE treatment for lagophthalmos and exposure keratopathy.

Prosthetic replacement of the ocular surface ecosystem is a treatment developed by the Boston Foundation for Sight that uses a Food and Drug Administration-approved prosthetic device for the treatment of severe ocular surface disease to improve vision and discomfort in addition to supporting the ocular surface. Facial nerve paralysis has multiple causes including trauma, surgery, tumor, stroke, and congenital lagophthalmos. Subsequent lagophthalmos leading to exposure keratitis has been treated with copious lubrication, tarsorrhapy, eyelid weights, chemodenervation to yield protective ptosis, and palpebral spring insertion. Each of these treatments, however, has limitations and potential complications. The prosthetic replacement of the ocular surface ecosystem device provides a liquid bandage to protect the cornea from eyelid interaction and dessication in addition to improving vision. This report describes 4 patients with exposure keratitis who were successfully treated with prosthetic replacement of the ocular surface ecosystem devices at 2 clinical sites.

Strenotrophomonas maltophilia-related chronic dacryocystitis.

Dacryocystitis related to Stenotrophomonas maltophilia is rare. We describe a case of Strenotrophomonas maltophilia-related chronic dacryocystitis with associated coagulase-negative Staphylococcus. Following external dacryocystorhinostomy without intraoperative or postoperative antibiotics, her discharge and lacrimal sac fullness resolved.

Eyelid lipomas: a case report and review of the literature.

Simple lipomas of the eyelid are rare. We present a case of a 61-year-old man, who presented with 6 months of a slowly worsening blepharoptosis. On examination, that patient was noted to have a palpable, soft mass in the medial left upper eyelid. Histopathological examination of the mass revealed mature adipose tissue most consistent with lipoma. Simple lipomas of the eyelid are very unusual but should be considered in the differential diagnosis of patients presenting with mechanical ptosis.

Tuberculosis of the nasolacrimal duct.

Nasolacrimal tuberculosis is rare. The authors present a young Peruvian-born female with subacute onset of right eye epiphora, isolated right inferior turbinate enlargement, and ipsilateral cervical lymphadenopathy. Turbinate and neck mass incisional biopsies demonstrated histopathological findings consistent with tuberculosis. QuantiFERON-TB Gold-In-Tube testing was positive. Complete resolution of symptoms occurred after dacryocystorhinostomy and 9 months of standard 4-drug antituberculosis therapy. Tuberculosis of the nasolacrimal duct is highly unusual but should be considered in patients with tuberculosis risk factors who present with nasolacrimal obstruction from an inferior turbinate mass.

Face Mask-Associated Ocular Irritation and Dryness.

During the current coronavirus disease 2019 (COVID-19) epidemic, the concern for reducing disease transmission has led to a worldwide increase in face mask utilization. During this period, we have observed a corresponding increase in ocular irritation and dryness among regular mask users. This finding has not been previously described in the literature but has important implications on eye health and infection prevention, as mask use is likely to continue for the foreseeable future.

Posterior ischemic optic neuropathy associated with migraine.

Posterior ischemic optic neuropathy (PION) is an uncommon form of optic nerve ischemia that results from damage to the intraorbital, intracanalicular, or intracranial optic nerve. It has been reported perioperatively, in association with systemic vasculitis, and in the nonsurgical setting with no identifiable cause. Review of the literature reveals only 2 patients with PION associated with migraine in a single report. We report a patient who developed PION in the setting of a migraine headache without any other identifiable risk factors.