Chronic inflammation as a proposed risk factor for ocular surface squamous neoplasia.

PURPOSE: Chronic inflammation is a predisposing factor for metaplastic changes and ultimately dysplasia. We describe cases of OSSN occurring in the setting of chronic ocular surface inflammation. METHODS: Sixteen eyes from 14 individuals were included from one ocular oncology clinic between 2010 and 2023. Patients presented with ocular surface squamous neoplasia (OSSN) in the setting of chronic inflammation. The diagnosis of OSSN was made using anterior segment high-resolution optical coherence tomography (HR-OCT) and confirmed by histopathological analysis in all cases. RESULTS: Median age on presentation was 61 [IQR 47.5-69.2] years. Eleven (86%) individuals were male and five (36%) identified as White Hispanic. Ten eyes were referred with ocular surface diagnoses including pannus (n = 4), scarring (n = 3), pterygium (n = 2), and herpetic keratitis (n = 1). Only six eyes were referred as possible neoplasia. All individuals had a history of ocular surface inflammation. The most common inflammatory conditions were ocular rosacea (seven individuals) and atopic keratoconjunctivitis (AKC) (five individuals). Two individuals were found to have bilateral OSSN, one in the setting of ocular rosacea and the other in the setting of AKC. All 16 eyes from 14 individuals were suspected to have OSSN based on HR-OCT findings which guided the location of the incisional biopsies that subsequently confirmed histopathological diagnosis in all cases. CONCLUSION: OSSN may arise in the setting of chronic inflammation on the ocular surface. Identification of the tumor can be challenging in these cases, and HR-OCT can be a key diagnostic tool in detecting OSSN.

Role of Topical 5-Fluorouracil in Demodex -Associated Blepharitis.

PURPOSE: The aim of this study was to report clinical observations suggesting the efficacy of topical 1% 5-fluorouracil (5-FU) in treating Demodex -associated blepharitis. METHODS: An observational retrospective review of 13 eyes from 13 individuals with conjunctival neoplastic lesions and concomitant Demodex lash infestation that received topical 1% 5-FU eye drops. Patients underwent slit-lamp examination at each follow-up visit. Clinical photographs of the lash line were obtained after treatment initiation. In a subset of patients, lashes were epilated bilaterally and microscopically analyzed for presence of Demodex mites before and after treatment initiation. RESULTS: The mean age of the population was 68 ± 14 years (range: 30-84 years) and 92% were male. In all 13 patients, a marked reduction in cylindrical dandruff was noted in the treated eye by slit-lamp examination after 2 cycles of 5-FU. There was complete resolution of cylindrical dandruff in 10 of 13 treated eyes compared with 0 resolution of cylindrical dandruff in untreated eyes ( P = 0.0001). In the 6 patients who received epilation, the lashes from the treated eye showed no Demodex , whereas lashes from the fellow untreated eye revealed persistent Demodex . CONCLUSIONS: Topical 1% 5-FU shows efficacy in treating Demodex -associated blepharitis. Further studies are indicated to reproduce our findings and evaluate the potential use of 5-FU as a treatment ingredient.

Treatment of ocular-involving monkeypox virus with topical trifluridine and oral tecovirimat in the 2022 monkeypox virus outbreak.

Purpose: To report a case of ocular involving monkeypox infection in the United States during the 2022 outbreak, and to review the literature regarding its clinical manifestations and management known to date. Observations: A 36-year-old man with well controlled HIV presented to the emergency department with anal pain, diffuse rash, right eye pain, and right eye redness after he tested positive for monkeypox one week prior. Ocular examination showed bilateral periorbital vesicular lesions, right eye conjunctival injection, and a single white plaque on his right medial bulbar conjunctiva. Macular, vesicular, and pustular lesions were noted throughout his body, including the genital and perianal region. His ocular and systemic symptoms completely resolved after treatment with a ten-day course of 1% trifluridine and moxifloxacin drops in both eyes, as well as two weeks of oral tecovirimat. Conclusion and Importance: In July of 2022, monkeypox virus was declared a global health emergency by the World Health Organization; however, there are no standard guidelines for monkeypox treatment. Data on its clinical presentation and course, especially pertaining to ocular manifestations, is limited. We highlight the importance of recognizing ophthalmic manifestations of monkeypox virus and a possible therapeutic approach to help guide the management of these patients.

Conjunctival papilloma treatment outcomes: a 12-year-retrospective study.

BACKGROUND: Conjunctival papilloma is often resistant to treatment. Various therapies have been reported with no gold standard. The purpose of this study was to compare treatment outcomes after various therapies. METHODS: A retrospective chart review of 30 conjunctival papilloma patients from 2009-2020. Data on demographics, tumour characteristics, primary treatment and outcomes were collected. The primary outcome was the frequency of complete tumour resolution and recurrence rate of each primary therapy. The secondary outcome was treatment related side effects. RESULTS: The mean age was 57.5 years (3-93 years) with male predominance (n = 22, 73.3%). Eleven eyes were treated with interferon α-2b (IFN), seven with 5-fluorouracil (5FU), and 10 with excision biopsy and cryotherapy (6 with adjuvant therapy with IFN). The frequency of tumour resolution was 36.4% (4/11), 28.5% (2/7), and 100% (10/10) in each group, respectively. The mean time to resolution was faster in the surgical group compared to the medical group (1 day vs 159 days, p < 0.001). There was higher tumour recurrence with 11% in the surgical vs 0% in the medical group at 6 months and at 12 months, 22% recurrence in the surgical and 0% in the medical group (p = 0.52). However, the differences were not statistically significant. CONCLUSION: Papilloma resolution is faster with surgical excision as compared to medical therapy. However, recurrences are more frequent after surgical versus medical treatment.

Optical coherence tomography angiography in the evaluation of vascular patterns of ocular surface squamous neoplasia during topical medical treatment.

PURPOSE: Optical coherence tomography angiography (OCTA) was utilized to examine changes in ocular surface squamous neoplasia (OSSN) vascular patterns over time in individuals treated with topical medical therapy. METHODS: Ten individuals with OSSN diagnosed by clinical examination and high resolution (HR)-optical coherence tomography (OCT) were recruited. All individuals received topical immuno- or chemotherapy. OCTA images were obtained and analyzed at three points: presentation, mid-treatment and tumor resolution. Tumor metrics including tumor area (TA), tumor volume (TV), tumor depth (TD), and total tumor density (TTD) were calculated. Vessel area density (VAD) was also quantified within the OSSN, the subepithelium under and adjacent to the OSSN and the subepithelium of the uninvolved, contralateral eye. Vascular network changes were also subjectively evaluated. RESULTS: TA, TV, TD and TTD all significantly decreased with time (p < 0.001). The mean VAD within the OSSN significantly decreased (p < 0.001) between visits (presentation: 26.52 ± 6.8%, mid-treatment: 7.19 ± 5.88%, tumor resolution: 0.11 ± 0.34%). The mean subepithelial VAD under the OSSN also decreased with time (23.22 ± 11.03%, 20.99 ± 5.99% and 19.58 ± 7.08%), and after resolution the sub-tumor VAD (19.58 ± 7.08%) was comparable to the subepithelial VAD in the contralateral eye (15.47 ± 4.37%, p > 0.05). The mean VAD in the subepithelium adjacent to the OSSN increased with treatment, then decreased significantly between mid-treatment and resolution (23.26 ± 4.54, 28.30 ± 7.43% and 21.68 ± 6.10%, p = 0.009). Qualitatively, the tumor subepithelial vascular network was complex and dense but with tumor resolution appeared less tortuous and similar to the uninvolved eye. CONCLUSION: OCTA provided insight into the pathophysiology of tumor angiogenesis, showing decreased vascular density and normalization of vascular networks associated with tumor resolution.

The use of high resolution optical coherence tomography (HR-OCT) in the diagnosis of ocular surface masqueraders.

INTRODUCTION: Ocular surface masqueraders encompass any ocular surface lesion masquerading as another ocular surface lesion. High resolution optical coherence tomography (HR-OCT) has emerged as an adjunctive tool to clinical acumen. This study's purpose is to evaluate the utility of HR-OCT images in guiding the diagnosis and management of those lesions. MATERIAL AND METHODS: 22 individuals with a clinically ambiguous ocular surface lesion with slit lamp photographs (SLP), HR-OCT images, and histopathological examination were included in the study. The presumptive clinical diagnosis based on SLP was compared to the diagnosis suggested by HR-OCT findings and to definitive diagnosis by histopathology. The main outcome of this study was the frequency in which HR-OCT findings guided the clinician to the correct diagnosis. RESULTS: 7 lesions were epithelial, 3 had an epithelial and a subepithelial component, and 12 were subepithelial. HR-OCT was most effective in discerning lesion location, successfully identifying the location in 100% of cases. Classic HR-OCT findings were detected in 68.2% of cases while suggestive features were detected in 31.8% of cases. The epithelial lesions' mean epithelial thickness was 265.4 ± 140.6 µm, the subepithelial lesions' mean was 58.0 ± 25.0 µm, and the combined lesions' mean was 140.0 ± 70.0 µm. The epithelium was significantly thicker in epithelial lesions compared to subepithelial and combined lesions. By ROC analysis we identified that using a cut off of 156 µm, the sensitivity was 86% and the specificity was 93%. DISCUSSION: HR-OCT can be a valuable diagnostic tool, assisting in the differentiation of ambiguous ocular surface pathologies by providing a cross-sectional, morphological image of the lesion.

Silk Suture Granuloma 37 Years After Scleral Buckle Surgery: A Case Report.

PURPOSE: To present a rare presentation of pyogenic granuloma arising almost 4 decades after a scleral buckle for retinal detachment. METHOD: We describe the clinical presentation, diagnostic workup, and management of a suspicious conjunctival lesion in an immunocompromised patient. We report the histopathological findings and the postoperative outcome. RESULTS: A 58-year-old man with human immunodeficiency virus presented for evaluation of a possible malignant conjunctival lesion in the left eye. The patient reported that the lesion had appeared 1.5 months before presentation with significant growth over the past month. The patient denied any trauma to the eye other than an ocular history of retinal detachment repair with scleral buckle 37 years earlier. Clinical examination revealed a pink, fleshy, mobile, and lobulated conjunctival lesion measuring 7 mm by 10 mm, emanating from the superior-nasal bulbar quadrant. A high-resolution optical coherence tomography revealed highly cellular infiltrate and hyperreflective mass with significant posterior shadowing. Further exploration of the lesion revealed a white, stringy, cauliflower-like material on the underside of the lesion. Surgical excision and pathology subsequently confirmed a diagnosis of pyogenic granuloma with remnants of silk suture. CONCLUSIONS: A diagnosis of pyogenic granuloma secondary to retained silk sutures should be considered in patients with a history of intraocular surgery irrespective of other risk factors and length of time since procedure.

Epipremnum aureum Keratopathy: Case Report and Review of the Literature.

OBJECTIVES: To report a novel case of Epipremnum aureum toxicity masquerading as bilateral infectious keratitis and review the literature on ocular manifestations of Epipremnum exposure. METHODS: Case report and literature review. RESULTS: A 70-year-old man with a history of photorefractive keratectomy presented with a 3-day history of bilateral eye pain. The patient reported exposure to plant debris while performing yard work and also water exposure while cleaning his coral fish tanks. Clinical examination revealed bilateral epitheliopathy progressing to frank epithelial defects with underlying stromal necrosis 6 days after exposure. Empiric topical antibiotic drops were initiated, but multiple cultures, corneal biopsy, and confocal microscopy were all negative for an infectious agent. Over a 2-week period, the epithelial defects worsened and a suspicion for a toxic etiology was raised. The patient later recalled rubbing his eyes after exposure to Epipremnum aureum (Golden Pothos/Devils Ivy) sap. He was thus treated conservatively with artificial tears, topical corticosteroids, and amniotic membrane. After 3 months, the epithelial defects resolved, but with corneal scarring, prominently in the left eye and underwent penetrating keratoplasty. Five years after presentation, best-corrected visual acuity with hard contact lenses was 20/25 in the right eye and 20/20 in the left eye. CONCLUSION: Epipremnum aureum toxicity is a rare cause of keratitis. It can mimic acanthamoeba keratitis or anesthetic abuse and should be considered in cases of culture negative nonhealing corneal ulcerations. Eliciting a history of plant sap exposure can facilitate appropriate supportive care for this toxic keratitis.

Total Tear IgE Levels Correlate with Allergenic and Irritating Environmental Exposures in Individuals with Dry Eye.

Dry eye (DE) and allergic conjunctivitis may present similarly, and it remains unclear whether some individuals have an underlying allergic component to their DE. To better understand this relationship, we performed a cross-sectional study in 75 individuals with DE symptoms and/or signs. Immunoglobulin E (IgE) levels in tear samples were quantified and home environmental exposures assessed via standardized survey. Tears were collected by Schirmer strip, and total tear IgE levels were quantified using enzyme-linked immunosorbent assay (ELISA). Data were analyzed using descriptive statistics and linear and logistic regressions. The main outcome measures were total tear IgE levels and their association with environmental exposures. The mean age of the subjects was 66.2 ± 7.8 years. Sixty-two individuals had dry eye symptoms (Dry Eye Questionnaire-5 ≥ 6), and 75 had one or more signs of DE. Detectable total tear IgE levels were observed in 76% of subjects, and 17.3% had high levels (>1 ng/mL). Individuals with exposure to pet(s) (odds ratio (OR) 11.5, p = 0.002) and smoke (OR 38.6, p = 0.008) at home were more likely to have high IgE levels compared to those not exposed. Individuals with tears collected during spring or summer were 3.9 times (p = 0.028) more likely to have high IgE compared to those sampled at other times of year. Subjects born in the US were 3.45 times (p = 0.010) more likely to have high IgE compared to individuals born outside the US. To conclude, a majority of individuals with DE symptoms and/or signs had detectable IgE levels in their tears. High tear IgE levels were correlated with allergy season and exposures in the home linked with allergy.

Update on Diagnosis and Management of Conjunctival Papilloma.

Conjunctival papilloma is an acquired benign squamous cell tumor that can present at any age, but most frequently in the third and fourth decades of life. Papillomas have been associated with human papilloma virus (HPV) infection, usually types 6 and 11. Although histopathological diagnosis remains the gold standard, the advent of newer non-invasive imaging modalities such as optical coherence tomography (OCT) is transforming the way we diagnose and treat ocular surface tumors, including conjunctival papilloma. Management of these lesions can prove a challenge to the treating physician since not all lesions respond to medical and/or surgical therapy and in fact may worsen after surgical manipulation. In this review, the epidemiology, pathophysiology, clinical characteristics, and diagnosis of conjunctival papilloma including the use of OCT are discussed. Indications, efficacy, and side effects of currently available management options are also reviewed to guide the selection of the best treatment approach.

Diseases Linked to Polypharmacy in Elderly Patients.

INTRODUCTION: Polypharmacy in several cases is deemed necessary and elderly patients are prone to this phenomenon. The objective of this study was to identify the prevalence and the predictors of polypharmacy among consecutively unplanned admissions of patients aged ≥65 years. PATIENTS AND METHODS: In 310 patients (51% women), mean age 80.24 years (95% CI 79.35-81.10), demographic characteristics, medical history, medications, and cause of admission were recorded. Parametric tests and multiple logistic regression analysis were applied to identify the factors that have significant association with polypharmacy. RESULTS: 53.5% of patients belonged to polypharmacy group. In multivariate analysis the independent predictors of polypharmacy were arterial hypertension (p = 0.003, OR = 2.708, and 95% CI 1.400-5.238), coronary artery disease (p = 0.001, OR = 8.274, and 95% CI 3.161-21.656), heart failure (p = 0.030, OR = 4.042, and 95% CI 1.145-14.270), atrial fibrillation (p = 0.031, OR = 2.477, and 95% CI 1.086-5.648), diabetes mellitus (p = 0.010, OR = 2.390, and 95% CI 1.232-4.636), dementia (p = 0.001, OR = 4.637, and 95% CI 1.876-11.464), and COPD (p = 0.022, OR = 3.626, and 95% CI 1.208-10.891). CONCLUSIONS: Polypharmacy mainly was linked to cardiovascular diseases. If deprescribing is not feasible, physicians must oversee those patients in order to recognise early, possible drug reactions.