Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab.

PURPOSE: In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen. METHODS: This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events. RESULTS: The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption. CONCLUSIONS: Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

Vision Loss Secondary to COVID-19 Associated Bilateral Cerebral Venous Sinus Thromboses.

A young, morbidly obese woman with recent SARS-CoV-2 infection requiring hospitalization presented with visual and neurologic complications secondary to bilateral cerebral venous sinus thromboses. With elevated intracranial pressure and severe papilledema, she rapidly progressed to complete bilateral vision loss despite anticoagulation, therapeutic lumbar punctures with lumbar drain, bilateral optic nerve sheath fenestrations, and endovascular thrombectomy. It is possible that obese patients with a SARS-CoV-2 infection may be at greater risk of hypercoagulable cerebrovascular complications. It is impossible to know if an even more rapid response would have led to a different outcome, but we report this case in the hope that publishing this and similar cases may result in improved treatment protocols to preserve vision.

Periocular non-tuberculous mycobacterial infection after autologous fat transfer with micro-needling and fractional radiofrequency skin resurfacing.

A 59-year-old woman with prior bilateral lower eyelid autologous fat transfer, subdermal micro-needling and fractional radiofrequency skin resurfacing presented with delayed left-sided preseptal cellulitis with small multinodular abscesses unresponsive to oral outpatient antibiotic regimens and inpatient intravenous antibiotics. Wound culture revealed Mycobacterium chelonae infection treated successfully with a 4-month regimen of clarithromycin and tedizolid without recurrence. This case highlights (1) the need for vigilance and a broad differential in delayed post-operative wound infections including non-tuberculous mycobacterial infections, (2) resolution of infection without recurrence on clarithromycin and novel tedizolid oral antibiotic therapy, and (3) that caution should be exercised when performing combination autologous fat transfers with subdermal micro-needling procedures as the breakdown in skin integrity may potentiate infection.

Posttraumatic Emphysema of the Optic Nerve Sheath.

The authors describe the case of a 19-year-old female who suffered posttraumatic emphysema of the optic nerve sheath. She suffered massive head trauma requiring emergent neurosurgery and was incidentally found to have air in her optic nerve sheath on CT scan. At 6 weeks follow up, her visual acuity (20/25 uncorrected) and color perception in the affected eye were excellent. Her examination was notable for an afferent pupillary defect, mild disc pallor, and optic nerve atrophy on optical coherence tomography. This is a case of a patient with posttraumatic optic nerve sheath emphysema who recovered excellent visual function and received follow-up ophthalmic imaging.

Doxycycline Injection for Sclerotherapy of Lower Eyelid Festoons and Malar Edema: Preliminary Results.

PURPOSE: To investigate the safety and efficacy of direct, intralesional doxycycline hyclate injection for improving the appearance of cosmetically significant lower eyelid festoons and malar edema. METHODS: An Institutional Review Board approved, retrospective review was performed of 15 consecutive patients with malar edema and/or festoons injected with doxycycline hyclate at a concentration of 10 mg/ml. Pre- and postinjection photographs were reviewed and graded on a scale of 0 to 3 (0: no festoon; 1: small festoon; 2: medium festoon; 3: large festoon) by 2 masked physician observers. Patients were excluded from the final analysis if they received an alternate dose concentration, had incomplete photographic records, or did not follow up. Student t test was used for statistical analysis. RESULTS: Twenty consecutive treatment areas of 11 patients were included in the analysis. Final follow up ranged from 3 to 104 weeks, with a mean follow up of 22.5 weeks. The average (standard deviation) initial festoon grade of 2.5 (0.58) decreased to 0.9 (0.82) with a p value of <0.001. The average number of injections performed per side was 1.4 (range: 1-2). The mean volume per injection was 0.72 ml (range: 0.15-2.0 ml). Commonly documented subjective complaints were burning sensation with injection, pain, bruising, and erythema. There were no other dermatologic or visual complications following treatment. CONCLUSIONS: These preliminary results suggest that intralesional injections of doxycycline hyclate at a concentration of 10 mg/ml may be an effective treatment option for cosmetically significant lower eyelid festoons and malar edema. Future prospective studies with increased patient numbers, increasing concentrations, combination therapies with local anesthetic or regional nerve blocks, and longer follow up are needed to validate these results and determine optimal injection technique.

Orbital corticosteroid injections for the treatment of active thyroid eye disease.

Purpose: To study the efficacy of orbital injections of triamcinolone acetonide mixed 1:1 with dexamethasone in the treatment of active thyroid eye disease. Methods: Patients that received orbital injection(s) of triamcinolone acetonide mixed 1:1 with dexamethasone for thyroid eye disease were included in this retrospective study. Demographic and clinical data were collected from the pre-treatment and 1 month follow up evaluations. Clinical data included subjective pain and diplopia scores, best-corrected visual acuity, Intraocular pressure, extraocular motility, clinical activity score, Hertel exophthalmometry, and upper eyelid margin to reflex distance. Results: Fifteen patients, 33 orbital injections, were included in the study. The average patient age was 59.2 years (SD ± 13.0) and 89% female. Subjectively, 67% of patients reported improvement of orbital pain and pressure versus 28% stable and 5% worse (p <0.001). Post-procedure clinical activity score decreased from 3.84 to 3.00 (p = 0.0004). There were no significant differences in upper eyelid margin to reflex distance (4.1 ± 1.4 mm vs. 4.3 ± 2.6 mm, p = 0.45), Hertel exophthalmometry (21.7 ± 9.4 mm vs. 21.8 ± 7.6 mm, p = 0.56), or extraocular motility (21% improved vs. 72% stable and 7% worsening, p = 0.50). No steroid-responsive increases in intraocular pressure or injection-related complications were reported. Conclusion: Orbital steroid injections can successfully reduce symptoms of TED and may be a reliable tool in the treatment of TED as a relatively safe, fast-acting, efficacious treatment option, particularly as a bridge to other therapies.

Microbial profile of lacrimal system Dacryoliths in American Midwest patient population.

PURPOSE: Dacryoliths of the canalicular pathway are classically attributed to Actinomyces species as the most common organism. However, global shifts toward Streptococcus and Staphylococcus species have been reported. The objective of this article is to update the American Midwest epidemiology of lacrimal system dacryoliths for targeted clinical treatment. MATERIALS AND METHODS: A retrospective chart review from January 2015 to 2021 of patients with a history of surgical procedure for lacrimal removal of dacryolith for canaliculitis, canalicular obstruction, dacryocystitis, and nasolacrimal duct obstruction was included. Specimens were sent for histopathological evaluation and microbial culture. RESULTS: A total of 48 specimens were included. The most common organism isolated for canalicular pathology was Actinomyces spp (23%), followed by Staphylococcus spp (21%) and Streptococcus spp (19%). Histopathological staining accounted for 45% of Actinomyces isolation when culture data inconclusive. In a subgroup analysis of lacrimal sac dacryoliths, the most common organism was Staphylococcus spp (29%). Actinomyces species were not isolated from the lacrimal sac or nasolacrimal duct. CONCLUSION: Actinomyces maintains a microbial predominance in canalicular dacryoliths and requires careful culture and histopathological analysis for its fastidious nature. Lacrimal sac and nasolacrimal duct dacryolith found no isolates of Actinomyces, and the most common organism was Staphylococcus.

RESOLUTION OF TREATMENT-RESISTANT SUBRETINAL FLUID IN A PATIENT WITH EXUDATIVE AGE-RELATED MACULAR DEGENERATION FOLLOWING ENDOPHTHALMITIS.

PURPOSE: This is the first report to the best of the authors' knowledge to show resolution of subretinal fluid and treatment requirement in a case of exudative age-related macular degeneration (eAMD) with persistent fluid despite treatment that resolved following an episode of culture-positive bacterial endophthalmitis. METHODS: A 73-year-old man with history of eAMD of the right eye presented with acute postinjection bacterial endophthalmitis 3 days after injection. He had a history of only partially treatment-responsive eAMD that had been treated over a period of 8 years. RESULTS: After tap-and-inject treatment of endophthalmitis with ceftazidime, vancomycin, and dexamethasone, the patient returned for follow-up with visual improvement and resolution of the subretinal fluid. The previously treatment-resistant eAMD remains quiescent without further treatment after 10 months of follow-up. CONCLUSION: It is possible that some aspect of the infection, inflammation, or treatment of endophthalmitis had a disease-modifying impact on the eAMD. Further research into the components of endophthalmitis and its treatment may result in the discovery of new treatment approaches or treatment targets.

Ipsilateral feeding-specific circuits between the nucleus accumbens shell and the lateral hypothalamus: regulation by glutamate and GABA receptor subtypes.

The nucleus accumbens shell (AcbSh) and the lateral hypothalamus (LH) are both involved in the control of food intake. Activation of GABA(A) receptors or blockade of AMPA and kainate receptors within the AcbSh induces feeding, as does blockade of GABA(A) receptors or activation of NMDA receptors in the LH. Further, evidence suggests that feeding induced via the AcbSh can be suppressed by LH inhibition. However, it is unclear if this suppression is specific to feeding. Adult male Sprague-Dawley rats with 3 intracranial guide cannulas, one unilaterally into the AcbSh and two bilaterally into the LH, were used to explore this issue. DNQX (1.25 µg) or muscimol (100 ng) infused into the AcbSh unilaterally elicited feeding, and this elicited intake was suppressed by bilateral LH injection of d-AP5 (2 µg) or muscimol (25 ng). The effectiveness of d-AP5 or muscimol infusion into either the LH site ipsilateral or contralateral to the AcbSh injection was compared. Ipsilateral LH injection of d-AP5 or muscimol was significantly more effective than contralateral injection in suppressing food intake initiated by AcbSh injection of DNQX or muscimol. These results add to the prior evidence that inhibition of the LH through pharmacological modulation of NMDA or GABA(A) receptors specifically suppresses feeding initiated by AcbSh inhibition, and that these two regions communicate via an ipsilateral circuit to specifically regulate feeding.