Multifocal infantile hemangioma of the eyelid causing amblyopia requiring surgical resection.

Cutaneous vascular lesions in the pediatric population are rare and may represent a variety of localized and systemic diagnoses with diverse treatment protocols. We present a unique case of an infant with multiple cutaneous vascular lesions, initially diagnosed as congenital disseminated pyogenic granuloma based on histopathologic findings and later diagnosed as multifocal infantile hemangioma with extracutaneous hepatic involvement. The largest vascular lesion in our patient was on the left upper eyelid, which failed medical treatment and ultimately required surgical excision to prevent amblyopia progression.

Oculoplastic fellow education during the COVID-19 crisis.

PURPOSE: In March 2020, the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) advised the suspension of all non-emergent oculofacial patient care, imparting unprecedented interruptions in fellowship training. METHODS: ASOPRS fellows and program directors were asked to complete an anonymous survey regarding their perceived impact of the COVID-19 crisis. RESULTS: Forty ASOPRS fellows (70.2%) participated, including 20 first-year and 20 second-year trainees, from all country regions. During the social distancing restrictions, 100% of fellows continued to participate in surgical procedures, including orbital biopsy (77.5%), abscess drainage (55.0%), fracture repair (45.6%), eyelid lesion excision (70.0%) and temporal artery biopsy (57.5%). ASOPRS fellows evaluated patients, including in emergency room (84.6%) and inpatient hospital (76.9%) settings, wearing surgical (85.0%) or N-95 (40.0%) masks, gloves (80.0%) and eye protection (62.5%).Most ASOPRS fellows (87.5%) participated in virtual interinstitutional education sessions and indicated a desire to continue this curriculum. Fellows also used available time for research (85.0%), independent study (77.5%), personal health (70.0%) and social interaction (60.0%).ASOPRS fellows reported COVID-19 restrictions to have a mild (72.5%) to moderate (27.5%) impact on their overall training, and most (75.0%) felt their surgical confidence to decline. Fellowship program directors also asserted a mild (72.2%), moderate (19.4%) or significant (5.6%) impact on subspecialty training, and 94.4% predict adverse effects on graduation case logs. CONCLUSIONS: During the COVID-19 restrictions most ASOPRS fellows participated in emergent clinical activities and novel telemedicine curriculum. Most fellows and program directors expressed concern regarding a negative impact on overall subspecialty education and surgical confidence.

Case Report of Conjunctival Melanoacanthoma.

PURPOSE: The purpose of this study was to describe a case of conjunctival melanoacanthoma, an exceedingly rare condition that has yet to be fully described in the literature. METHODS: Melanoacanthomas are most commonly seen on the skin or oral mucosa and are believed to result from local irritation or trauma. A 34-year-old Hispanic man presented with a painless, solitary, pigmented conjunctival lesion, in addition to bilateral pterygia suggesting chronic solar damage. The lesion was excised and sent for analysis. RESULTS: Histopathologic analysis of tissue samples demonstrated melanocyte proliferation and epithelial dysplasia, yielding a final pathologic diagnosis of conjunctival melanoacanthoma with dysplastic and acantholytic-type features. The patient is being closely followed and has not had recurrence of the lesion. CONCLUSIONS: Only 1 prior case of conjunctival melanoacanthoma has been documented. As such, there is no standard of care regarding appropriate management.

Acute retrobulbar hemorrhage after tooth extraction: Case report and treatment of a rare condition.

Retrobulbar hemorrhage (RBH) refers to hemorrhage within the bony orbital cavity and most commonly results from periorbital surgery or trauma. RBH following tooth extraction is a rare occurrence. Patients with RBH will endorse symptoms of periorbital pain, double vision, or vision loss, and present with evidence of proptosis, chemosis, or subconjunctival hemorrhage. Irreversible vision loss may occur if orbital compartment syndrome (OCS) results in the setting of RBH and is not expediently treated. Herein we present a case of a 72-year-old female who developed a RBH and OCS immediately after routine molar tooth extraction. Emergent treatment by the oral surgeon with a lateral canthotomy and inferior cantholysis led to full visual recovery. Dentists and oral surgeons should be aware of this potential rare vision-threatening complication of atraumatic tooth extraction and educated on the technique of decompressive lateral canthotomy and cantholysis.

Rifle Blast Exacerbating Hearing Loss in a Patient Treated With Teprotumumab for Thyroid Eye Disease.

Teprotumumab is a promising new immunomodulatory therapy for thyroid eye disease. One unique adverse effect observed in clinical trials was hearing impairment; however, all adverse auditory effects in prior clinical trials resolved spontaneously after completion of teprotumumab therapy. The authors present a case of a patient on teprotumumab for thyroid eye disease who experienced sustained hearing loss secondary to shooting a rifle without ear protection. In this case, it is suspected the teprotumumab infusions resulted in increased susceptibility of the inner ear hair cells to noise-induced trauma secondary to IGF-IR inhibition. Specific ear protection protocols may need to be implemented in the future for patients on teprotumumab therapy to prevent sustained hearing loss, especially for susceptible patient populations.

Autologous Fat Transfer Harvest-site Complications: Incidence, Risk Factors, and Management.

PURPOSE: Autologous fat transfer is an effective tool for volume restoration to the aging face. Although numerous reports exist regarding injection site complications, there is limited data on donor-site morbidity in the cosmetic surgery literature. METHODS: This study is a large-scale retrospective review to determine incidence of fat harvest-site complications, identify risk factors, and describe management strategies. Records of all patients who underwent autologous fat harvesting and facial grafting at a single oculofacial plastic surgery practice from 2010 to 2019 were reviewed. Patient demographics and clinical data were collected and assessed. A statistical analysis was performed using a two-tailed T-test with p values of <0.05 considered significant. RESULTS: Four-hundred sixteen patients were followed for an average of 6.2 months postoperatively. There was an overall 5.5% harvest-site complication rate. There was no correlation of harvest-site complications with gender (p = 0.249) or age (p = 0.881). Harvest location did not significantly correlate with complication rate. The most common complications were contour irregularities, prolonged induration, and prolonged erythema. Low body mass index was associated with higher complication rate (p = 0.003), even when excluding those patients with contour irregularities (p = 0.001). Various treatment modalities were used to manage donor-site morbidity with consistent improvement. CONCLUSIONS: Autologous fat transfer used for facial volume augmentation has low donor-site morbidity. Minor harvest-site complications occur more commonly in patients with low body mass index, irrespective of age, gender, or fat source.

Simultaneous presentation of orbital mantle cell lymphoma and endocrine mucin-producing sweat gland carcinoma.

Mantle cell lymphoma is a rare malignancy to present in the orbit, comprising only 1-5% adnexal lymphomas. Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is an equally uncommon adnexal tumor of sweat gland origin that may present on the eyelid. Herein we present a case of a 77-year old man with no previous cancer history who presented with painless progressive left globe proptosis and an enlarging left upper lid margin lesion, ultimately determined upon biopsy to be simultaneous orbital mantle cell lymphoma with systemic involvement and isolated eyelid EMPSGC. The pathogenesis, clinical manifestation, and management for each rare disease entity are reviewed and concept of collision tumors is discussed.

Disseminated Coccidioidomycosis With Orbital Osteomyelitis and Periorbital Abscess.

Coccidioidomycosis osteomyelitis involving the orbital bones is exceedingly rare and is often misdiagnosed initially as other inflammatory or infectious conditions. No clear guidelines currently exist regarding appropriate management. The authors present an atypical presentation of disseminated coccidioidomycosis in an immunocompetent child with frontal bone superotemporal orbital rim osteomyelitis and associated periorbital abscess, successfully managed with surgical debridement through an upper eyelid crease incision.

Atypical acute presentation of an optic nerve sheath meningioma.

PURPOSE: Primary optic nerve sheath meningiomas (ONSM) are benign lesions that typically present with findings of painless proptosis (59%), optic nerve pallor (55%), and decreased peripheral vision (35%). Herein we share an atypical case of a patient who presented acutely with periorbital pain and optic nerve head edema, and was ultimately determined to have a low-grade optic nerve meningioma. OBSERVATIONS: A 36-year-old healthy woman presented with acute onset of left periorbital discomfort. She was found to have intact visual acuity, full peripheral vision, and ipsilateral optic nerve edema. MRI imaging revealed a large intraconal mass partially encircling the left optic nerve. Incisional biopsy revealed a diagnosis of meningioma, WHO grade 1. CONCLUSIONS: Low-grade optic nerve sheath meningiomas may uncommonly present with acute pain and optic nerve head swelling, and absence of classic disease features.

Acute post-partum vision loss due to pilocytic astrocytoma.

PURPOSE: We report an unusual case of a thirty-three-year-old woman who presented with acute unilateral vision loss following pregnancy and was ultimately discovered to have a pilocytic astrocytoma of the optic nerve. OBSERVATIONS: A thirty-three-year-old previously healthy female presented one month following Caesarean section with unilateral vision loss. She was found to have significantly decreased visual acuity, an afferent pupil deficit, proptosis, optic nerve edema and choroidal folds. Imaging revealed a large lesion of the optic nerve. Biopsy was performed and pathologic analysis revealed a pilocytic astrocytoma, WHO grade 1. The patient opted for close observation without further management and demonstrated mild improvement in visual function. CONCLUSIONS/IMPORTANCE: Optic pathway gliomas (OPG) most commonly present in the pediatric patient population with painless proptosis, slowly progressive vision loss, and clinical findings of chronic optic neuropathy.( Farazdaghi et al., 2019 Sep) 1 Acute presentations of this disease in adulthood are rare. This case demonstrates a rare case of acute optic nerve glioma presentation during the post-partum period.

Pneumatic retinopexy for retinal detachment occurring after prior scleral buckle or pars plana vitrectomy.

BACKGROUND AND OBJECTIVE: To report outcomes of pneumatic retinopexy (PR) for retinal detachment (RD) occurring after prior scleral buckling surgery (SB) or pars plana vitrectomy (PPV). PATIENTS AND METHODS: Single-center study evaluating all patients treated between January 2000 and March 2013. RESULTS: Ten eyes underwent PR after prior SB. Nine of these 10 eyes had persistent subretinal fluid posterior to the buckle in the setting of an open break on the scleral buckle. The mean time to PR in these cases was 8.5 days after SB. PR achieved anatomic reattachment in eight of 10 eyes, but two of 10 eyes required additional PPV to achieve retinal reattachment. Seven eyes underwent PR after prior PPV. The average time to RD after PPV was 67 days (range: 15-232 days). The location of the break was superior in four eyes, horizontal in two, and inferior in one. Anatomic reattachment with PR alone occurred in four of seven eyes (57%). CONCLUSION: In the setting of recurrent RD after initial SB, pneumatic retinopexy was usually successful in the early postoperative course. In the setting of a new-onset RD after PPV, pneumatic retinopexy was a useful option, but recurrent RD was more common.

Outcomes and complications of pneumatic retinopexy over a 12-year period.

BACKGROUND AND OBJECTIVE: To evaluate anatomic and clinical outcomes of pneumatic retinopexy for treatment of primary retinal detachment. PATIENTS AND METHODS: Noncomparative, single-center, consecutive, interventional case series evaluating all patients treated between 2000 and 2012. Patients with less than 1 month of follow-up or coexisting neovascular age-related macular degeneration, uveitis, endophthalmitis, or prior posterior segment surgery were excluded. RESULTS: Sixty-three eyes of 63 patients with primary retinal detachment treated with pneumatic retinopexy were included. Median follow-up was 10.3 months. Single-operation success (SOS), defined as anatomic reattachment with pneumatic retinopexy alone, occurred in 40 eyes (63%). The retina was successfully reattached in 21 of the other 23 eyes (91%) with one additional surgery. There was no difference in visual acuity outcomes between SOS and additional surgical intervention (P = .85). New or missed breaks were identified in 19 of 63 eyes (30%). Postoperative subretinal fluid was observed in 22 of 63 eyes (35%) and persisted at last follow-up in two of 63 eyes (3%). At final follow-up, the retina was fully attached in 97% of eyes. CONCLUSION: Pneumatic retinopexy remains a reasonably successful option in the management of primary retinal detachment. No difference in best corrected visual acuity outcomes in eyes achieving SOS versus those requiring additional surgery was demonstrated.

Multimodal imaging of sarcoid choroidal granulomas.

BACKGROUND: Enhanced-depth imaging optical coherence tomography (EDI-OCT) provides high-resolution imaging of the choroid. Herein, we report multimodal imaging, including EDI-OCT, of a case of sarcoid choroidal granulomas. FINDINGS: A 63-year-old female with biopsy-supported sarcoidosis presented with unilateral multifocal choroidal granulomas. Enhanced-depth imaging optical coherence tomography (EDI-OCT) demonstrated a homogenous hyporeflective choroidal lesion with choriocapillaris thinning and sparing of the surrounding choroid. The patient was started on oral steroids with a weekly taper schedule. Within 5 weeks, the choroidal lesions had clinically resolved with return of normal-appearing choroidal architecture on EDI-OCT. Indocyanine green angiography, however, demonstrated hypofluoresence at the sites of choroidal granulomas 11 months after the clinical resolution, suggesting a longstanding choroidal perfusion deficit undetected by OCT. CONCLUSIONS: Choroidal imaging via EDI-OCT provides detailed morphologic information of sarcoid granulomas and can accurately demonstrate structural resolution of the lesions.

Retained lens fragments after cataract surgery: outcomes of same-day versus later pars plana vitrectomy.

PURPOSE: To compare visual acuity outcomes and adverse events in patients with retained lens fragments who underwent same-day versus later pars plana vitrectomy (PPV). DESIGN: Retrospective, interventional case series. METHODS: Single-center study evaluating all patients with retained lens fragments that underwent PPV over a 22-year period (1990 through 2011). RESULTS: The study included 569 eyes of 568 patients with a mean age of 74.6 years and a median follow-up of 8 months (range, 1 week to 100 months). One hundred seventeen patients (22%) underwent same-day vitrectomy, 131 patients (23%) underwent PPV within 1 week, and 321 patients (57%) underwent PPV more than 1 week later. Median time to vitrectomy in the same week group was 5 days, compared with 22 days in the delayed group. At the last examination, 61%, 63%, and 56% of patients undergoing PPV on the same day, within 1 week, and more than 1 week later, respectively, achieved best-corrected visual acuity (BCVA) of 20/40 or better (P = .35), and 16%, 15%, and 21%, respectively, had BCVA of 20/200 or worse (P = .29). There were no differences between groups when assessing cystoid macular edema (P = .96), retinal detachment (P = .096), elevated intraocular pressure (P = .88), or suprachoroidal hemorrhage (P = .26). CONCLUSIONS: Patients undergoing same-day versus a later PPV (within 1 week or more than 1 week later) for retained lens fragments had similar visual acuity outcomes and complication rates. Although same-day surgery may be attractive logistically in many cases, our retrospective data suggest equivalent outcomes for surgical timing.

A noninvasive bladder sensory test supports a role for dysmenorrhea increasing bladder noxious mechanosensitivity.

OBJECTIVE: Catheterization to measure bladder sensitivity is aversive and hinders human participation in visceral sensory research. Therefore, we sought to characterize the reliability of sonographically estimated female bladder sensory thresholds. To demonstrate this technique's usefulness, we examined the effects of self-reported dysmenorrhea on bladder pain thresholds. METHODS: Bladder sensory threshold volumes were determined during provoked natural diuresis in 49 healthy women (mean age, 24±8 y) using 3-dimensional ultrasound. Cystometric thresholds (Vfs, first sensation; Vfu, first urge; Vmt, maximum tolerance) were quantified and related to bladder urgency and pain. We estimated the reliability (1-wk retest and interrater). Self-reported menstrual pain was examined in relationship to bladder pain, urgency, and volume thresholds. RESULTS: Average bladder sensory thresholds (mL) were Vfs (160±100), Vfu (310±130), and Vmt (500±180). Interrater reliability ranged from 0.97 to 0.99. One-week retest reliability was Vmt=0.76 (95% CI, 0.64-0.88), Vfs=0.62 (95% CI, 0.44-0.80), and Vfu=0.63 (95% CI, 0.47-0.80). Bladder filling rate correlated with all thresholds (r=0.53 to 0.64, P<0.0001). Women with moderate to severe dysmenorrhea pain had increased bladder pain and urgency at Vfs and increased pain at Vfu (P's<0.05). In contrast, dysmenorrhea pain was unrelated to bladder capacity. DISCUSSION: Sonographic estimates of bladder sensory thresholds were reproducible and reliable. In these healthy volunteers, dysmenorrhea was associated with increased bladder pain and urgency during filling but unrelated to capacity. Plausibly, women with dysmenorrhea may exhibit enhanced visceral mechanosensitivity, increasing their risk to develop chronic bladder pain syndromes.