Orbital mass as the presenting symptom of diffuse large B-cell lymphoma causing spontaneous tumor lysis syndrome and rapid multisystem organ failure.

A 68-year-old male presented with a one-month history of progressive proptosis and vision loss in the left eye. Examination of the left eye showed visual acuity of NLP, marked relative proptosis of 10 mm, and complete external ophthalmoplegia. CT orbits showed an extensive left orbital lesion with proptosis. Urgent orbital biopsy was undertaken. Intraoperatively, the patient developed new atrial flutter and fever. Bloodwork revealed metabolic derangements suggestive of tumor lysis syndrome. Systemic evaluation revealed a large tumor burden involving the retroperitoneal space. Histopathology of the orbital specimen showed non-germinal center diffuse large B-cell lymphoma. The patient passed away 3 days postoperatively due to rapidly progressive multisystem organ failure. Our case demonstrates an unusually aggressive presentation of DLBCL in which orbital mass was the first presentation of spontaneous tumor lysis syndrome owing to large systemic tumor burden.

Localized ocular crystal-storing histiocytosis and associated lymphoma - Report of two cases and review of literature.

PURPOSE: To add to the existing yet limited body of knowledge around crystal-storing histiocytosis (CSH) with two case reports of localized ocular CSH and associated mucosa-associated lymphoid tissue (MALT) lymphoma involving the lacrimal and orbital soft tissues without underlying systemic lymphoproliferative disorders and to provide a literature review of all cases of CSH with associated ophthalmic findings reported to date. OBSERVATIONS: A 62-year-old male presented with a one-year history of right greater than left upper eyelid swelling and epiphora. Ophthalmic exam and computed tomography (CT) head scan revealed bilateral soft tissue masses superior to the globe encasing the supraorbital artery with poor margins from the superior rectus muscle. A biopsy of the lesion showed low grade B-cell lymphoma and associated CSH with lymphoma making up the bulk of the tumor and with CSH comprising a minor component of the overall tumor volume. Further investigations did not show any evidence of systemic lymphoproliferative disorders. He received local irradiation of orbits, which resulted in complete resolution of disease.An 85-year-old female with no significant past ocular history referred to ophthalmology services for an incidental finding of an enlarged left lacrimal gland on a CT head scan. Ophthalmic exam and subsequent magnetic resonance imaging (MRI) demonstrated an enlarged left lacrimal gland. A biopsy of the lesion showed MALT lymphoma associated with CSH. In this case, CSH comprised the bulk of the clinical mass rather than lymphoma. Following negative systemic investigations, she received a short course of localized radiotherapy with a 50% regression of disease seen on follow-up CT scan. CONCLUSION AND IMPORTANCE: These two cases demonstrate a spectrum of morphology associated with CSH. In addition, they show that although localized ocular CSH is rare, CSH should be considered in the differential of an orbital mass and should lead to consideration of further investigation for systemic lymphoproliferative disorders.

An In Vitro Model Assessing the Penetration of Hyaluronidase through Optic Nerve Dura for Management of Hyaluronic Acid Facial Filler Embolism.

BACKGROUND: Blindness from ophthalmic or central retinal artery embolism is one of the most devastating complications of cosmetic filler facial injections. A proposed therapy to mitigate visual loss is prompt retrobulbar injection of hyaluronidase into the retrobulbar space. Despite Zhu et al. showing a lack of evidence and very limited published literature for reversing visual loss with this intervention, it is still widely accepted as a treatment for filler-related emboli. The purpose of this study was to evaluate the penetration of hyaluronidase through optic nerve dura using an in vitro model. METHODS: At study conclusion, five 1-cm-long segments of fresh optic nerve were obtained and injected with highly crosslinked hyaluronic acid filler, then ligated on both ends in a watertight fashion. The sections were immersed in three concentrations of hyaluronidase solution for 24 hours. Histopathologic examination of the specimen was performed to assess the presence of filler. RESULTS: The optic nerve sections were 1.1 cm (range, 0.8 to 1.2 cm). Three were immersed in 20 ml of 1500 IU/ml hyaluronidase solution and two were immersed in saline as control. After 24 hours, there was a persistence of hyaluronic acid within the optic nerves. CONCLUSIONS: There is a lack of evidence for penetration of optic nerve sheath by hyaluronidase. This raises question about the effectiveness of retrobulbar injection of hyaluronidase in reversing filler-related blindness. Further studies are needed before this can be adopted as the treatment of choice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A rare case of orbital granulomatous inflammation from explosive hydraulic oil masquerading as orbital cellulitis.

The differential diagnosis for acute orbital inflammation is broad. We report a case of granulomatous orbital inflammation due to high-pressure oil injury to the orbit presenting as an atypical orbital cellulitis. Here we review the presentation and treatment of orbital inflammation from oil.

LAMELLAR HOLE-ASSOCIATED EPIRETINAL PROLIFERATION: A Clinicopathologic Correlation.

PURPOSE: To correlate clinical and optical coherence tomographic features with histopathological and immunohistochemical findings in an eye undergoing surgical excision of lamellar hole-associated epiretinal proliferation (LHEP). METHODS: An eye with a lamellar macular hole and LHEP without a tractional epiretinal membrane component was identified with spectral-domain optical coherence tomographic imaging and underwent pars plana vitrectomy with LHEP and internal limiting membrane peeling and gas tamponade. The surgically excised LHEP specimen was analyzed with histopathological and immunohistochemical staining using flat-mount preparation techniques. Postsurgical outcomes including visual acuity and optical coherence tomographic imaging were reviewed. RESULTS: With spectral-domain optical coherence tomography, the lamellar macular hole was found to be closed with no residual LHEP after the surgery. Visual acuity improved from 20/200 preoperatively to 20/40 at 6 months after the surgery. Histopathological and immunohistochemical analyses of the LHEP specimen revealed retinal glial cells that reacted positively with anti-glial fibrillary acidic protein and anti-glutamine synthetase, a Müller cell-specific antibody. CONCLUSION: Lamellar macular hole with LHEP may demonstrate closure after pars plana vitrectomy with LHEP and internal limiting membrane peeling and gas tamponade. There was considerable improvement in visual acuity. It is possible that LHEP originates from middle retinal layers of the lamellar hole defect because it contains retinal glial cells, specifically Müller cells.

DEVELOPMENT OF EPSTEIN-BARR VIRUS UVEITIS AFTER REMISSION OF PRIMARY VITREORETINAL LYMPHOMA.

PURPOSE: To describe a case of Epstein-Barr virus (EBV) uveitis that occurred after the treatment and remission of primary vitreoretinal lymphoma (PVRL). METHODS: Descriptive case report. Complete ophthalmologic evaluation, cytology, polymerase chain reaction, cytokine analysis of aqueous humor, and diagnostic vitrectomy were performed. RESULTS: A 66-year-old Caucasian woman developed uveitis in the same eye 20 months after remission of PVRL. Empiric chemotherapy failed to treat the suspected PVRL recurrence, and aqueous humor cytology showed an absence of malignant cells. Qualitative polymerase chain reaction of aqueous humor confirmed the presence of EBV. Treatment for EBV resulted in remission of the uveitis. CONCLUSION: The authors describe a rare case of EBV uveitis that was preceded by PVRL. It is important to consider EBV in cases where suspected recurrence of PVRL does not respond to appropriate treatment.

Prediction of remission in obsessive compulsive disorder using a novel machine learning strategy.

The study objective was to apply machine learning methodologies to identify predictors of remission in a longitudinal sample of 296 adults with a primary diagnosis of obsessive compulsive disorder (OCD). Random Forests is an ensemble machine learning algorithm that has been successfully applied to large-scale data analysis across vast biomedical disciplines, though rarely in psychiatric research or for application to longitudinal data. When provided with 795 raw and composite scores primarily from baseline measures, Random Forest regression prediction explained 50.8% (5000-run average, 95% bootstrap confidence interval [CI]: 50.3-51.3%) of the variance in proportion of time spent remitted. Machine performance improved when only the most predictive 24 items were used in a reduced analysis. Consistently high-ranked predictors of longitudinal remission included Yale-Brown Obsessive Compulsive Scale (Y-BOCS) items, NEO items and subscale scores, Y-BOCS symptom checklist cleaning/washing compulsion score, and several self-report items from social adjustment scales. Random Forest classification was able to distinguish participants according to binary remission outcomes with an error rate of 24.6% (95% bootstrap CI: 22.9-26.2%). Our results suggest that clinically-useful prediction of remission may not require an extensive battery of measures. Rather, a small set of assessment items may efficiently distinguish high- and lower-risk patients and inform clinical decision-making.

Prevalence and distribution of VZV in temporal arteries of patients with giant cell arteritis.

OBJECTIVE: Varicella-zoster virus (VZV) infection may trigger the inflammatory cascade that characterizes giant cell arteritis (GCA). METHODS: Formalin-fixed, paraffin-embedded GCA-positive temporal artery (TA) biopsies (50 sections/TA) including adjacent skeletal muscle and normal TAs obtained postmortem from subjects >50 years of age were examined by immunohistochemistry for presence and distribution of VZV antigen and by ultrastructural examination for virions. Adjacent regions were examined by hematoxylin & eosin staining. VZV antigen-positive slides were analyzed by PCR for VZV DNA. RESULTS: VZV antigen was found in 61/82 (74%) GCA-positive TAs compared with 1/13 (8%) normal TAs (p < 0.0001, relative risk 9.67, 95% confidence interval 1.46, 63.69). Most GCA-positive TAs contained viral antigen in skip areas. VZV antigen was present mostly in adventitia, followed by media and intima. VZV antigen was found in 12/32 (38%) skeletal muscles adjacent to VZV antigen-positive TAs. Despite formalin fixation, VZV DNA was detected in 18/45 (40%) GCA-positive VZV antigen-positive TAs, in 6/10 (60%) VZV antigen-positive skeletal muscles, and in one VZV antigen-positive normal TA. Varicella-zoster virions were found in a GCA-positive TA. In sections adjacent to those containing VZV, GCA pathology was seen in 89% of GCA-positive TAs but in none of 18 adjacent sections from normal TAs. CONCLUSIONS: Most GCA-positive TAs contained VZV in skip areas that correlated with adjacent GCA pathology, supporting the hypothesis that VZV triggers GCA immunopathology. Antiviral treatment may confer additional benefit to patients with GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.

Adult-Onset Asthma Associated With Simultaneous Conjunctival, Eyelid, and Orbital Xanthogranulomatosis Responsive to Systemic Immunosuppression.

Adult xanthogranulomatous disease involving the ocular or orbital tissues is rare. The authors present a 63-year-old asthmatic woman with progressive left eyelid ptosis and fatigue in whom this diagnosis was clinically suspected on the basis of the characteristic waxy indurated yellow periocular and conjunctival lesions. These findings prompted an incisional biopsy which found evidence of Touton giant cells, necessitating a systemic evaluation which excluded the presence of hematological abnormalities or malignancy. The simultaneous occurrence of conjunctival, eyelid, and orbital xanthogranulomas has not been previously described in adult-onset asthma and periocular xanthogranuloma. The lesions were responsive to long-term systemic immunosuppression.

Periocular mass lesions secondary to dermatologic fillers: report of 3 cases.

OBJECTIVE: To describe findings in patients who received dermal fillers and later developed peri-ocular mass lesions. DESIGN: Retrospective case series. PARTICIPANTS: Patients who presented with peri-ocular masses secondary to dermal filler use. METHODS: Retrospective chart review. RESULTS: Three patients with remote filler injection (hyaluronic acid and polyalkylimide), not volunteered on initial history, presented with peri-orbital swelling and/or inflammation that was suspicious in each case for more serious pathology. CONCLUSIONS: It is important for the injecting physician, the ophthalmologist, and the patient to recognize this complication to permit appropriate investigation and management.

Rules ventral prefrontal cortical axons use to reach their targets: implications for diffusion tensor imaging tractography and deep brain stimulation for psychiatric illness.

The ventral prefrontal cortex (vPFC) is involved in reinforcement-based learning and is associated with depression, obsessive-compulsive disorder, and addiction. Neuroimaging is increasingly used to develop models of vPFC connections, to examine white matter (WM) integrity, and to target surgical interventions, including deep brain stimulation. We used primate (Macaca nemestrina/Macaca fascicularis) tracing studies and 3D reconstructions of WM tracts to delineate the rules vPFC projections follow to reach their targets. vPFC efferent axons travel through the uncinate fasciculus, connecting different vPFC regions and linking different functional regions. The uncinate fasciculus also is a conduit for vPFC fibers to reach other cortical bundles. Fibers in the internal capsule are organized according to destination. Thalamic fibers from each vPFC region travel dorsal to their brainstem fibers. The results show regional differences in the trajectories of fibers from different vPFC areas. Overall, the medial/lateral vPFC position dictates the route that fibers take to enter major WM tracts, as well as the position within specific tracts: axons from medial vPFC regions travel ventral to those from more lateral areas. This arrangement, coupled with dorsal/ventral organization of thalamic/brainstem fibers through the internal capsule, results in a complex mingling of thalamic and brainstem axons from different vPFC areas. Together, these data provide the foundation for dividing vPFC WM bundles into functional components and for predicting what is likely to be carried at different points through each bundle. These results also help determine the specific connections that are likely to be captured at different neurosurgical targets.

Validation of the digital opacity compliance system under regulatory enforcement conditions.

U.S. Environmental Protection Agency (EPA) Emission Measurement Center in conjunction with EPA Regions VI and VIII, the state of Utah, and the U.S. Department of Defense have conducted a series of long-term pilot and field tests to determine the accuracy and reliability of a visible opacity monitoring system consisting of a conventional digital camera and a separate computer software application for plume opacity determination. This technology, known as the Digital Opacity Compliance System (DOCS), has been successfully demonstrated at EPA-sponsored Method-9 "smoke schools", as well as at a number of government and commercially operated industrial facilities. Results from the current DOCS regulatory pilot study demonstrated that, under regulatory enforcement conditions, the average difference in opacity measurement between the DOCS technology and EPA Reference Method 9 (Method 9) was 1.12%. This opacity difference, which was computed from the evaluation of 241 regulated air sources, was found to be statistically significant at the 99% confidence level. In evaluating only those sources for which a nonzero visible opacity level was recorded, the

Field verification of sound attenuation modeling and air emission testing in support of missile motor disposal activities.

The U.S. Department of Defense-approved activities conducted at the Utah Test and Training Range (UTTR) include both operational readiness test firing of intercontinental ballistic missile (ICBM) motors, as well as the destruction of obsolete or otherwise unusable ICBM motors through open burn/open detonation (OB/OD). Within the Utah Division of Air Quality, these activities have been identified as having the potential to generate unacceptable noise levels, as well as significant amounts of volatile organic compounds (VOCs). Hill Air Force Base, UT, has completed a series of field tests at the UTTR in which sound-monitoring surveillance of OB/OD activities was conducted to validate the Sound Intensity Prediction System (SIPS) model. Using results generated by the SIPS model to support the decision to detonate, the UTTR successfully disposed of missile motors having an aggregate net explosive weight (NEW) of 81,374 lb without generating adverse noise levels within populated areas. In conjunction with collecting noise-monitoring data, air emissions were collected to support the development of air emission factors for both static missile motor firings and OB/OD activities. Through the installation of 15 ground-based air samplers, the generation of combustion-fixed gases, VOCs, and chlorides was monitored during the 81,374-lb NEW detonation event. Comparison of field measurements to predictions generated from the US Navy energetic combustion pollutant formation model, POLU4WN, indicated that, as the detonation fire ball expanded, organic compounds, as well as CO, continued to oxidize as the combustion gases mixed with ambient air. VOC analysis of air samplers confirmed the presence of chloromethane, vinyl chloride, benzene, toluene, and 2-methyl-1-propene. Qualitative chloride analysis indicated that gaseous HCl was generated at low concentrations, if at all.

The Brown Longitudinal Obsessive Compulsive Study: clinical features and symptoms of the sample at intake.

OBJECTIVE: This article describes the method and intake findings of the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the naturalistic course of obsessive-compulsive disorder (OCD) in a large clinical sample using longitudinal research methodology. METHOD: Intake data, collected between June 2001 and October 2004, are presented for 293 adult participants in a prospective, naturalistic study of OCD. Participants had a primary diagnosis of DSM-IV OCD and had sought treatment for the disorder. RESULTS: Our findings indicate that OCD typically has a gradual onset and a continuous course regardless of age at onset. There is a substantial lag between the onset of the disorder and initiation of treatment. OCD, which almost always coexists with other psychiatric symptoms, leads to serious social and occupational impairment. Compared with participants with late-onset OCD, early-onset participants had higher rates of lifetime panic disorder, eating disorders, and obsessive-compulsive personality disorder. The groups also differed on the types of obsessive-compulsive symptoms that were first noticed, as well as on rates of current obsessions and compulsions. CONCLUSION: The demographics, clinical characteristics, comorbidity rates, and symptom presentation of the sample are consistent with those reported for cross-sectional studies of OCD, including the DSM-IV Field Trial. The current sample has a number of advantages over previously collected prospective samples of OCD in that it is large, diagnostically well characterized, recruited from multiple settings, and treatment seeking. This unique data set will contribute to the identification of meaningful phenotypes in OCD based on stability of symptom dimensions, prospective course patterns, and treatment response.

Metabolic imaging of anterior capsular stimulation in refractory obsessive-compulsive disorder: a key role for the subgenual anterior cingulate and ventral striatum.

UNLABELLED: High-frequency anterior capsular stimulation is a new, promising, and reversible neuromodulatory treatment in the research stage for patients with refractory obsessive-compulsive disorder (OCD). The mechanism of action is unknown but hypothesized to be secondary to interruption of the corticothalamostriatocortical circuit. METHODS: (18)F-FDG PET was performed on 6 consecutive OCD patients preoperatively and after stimulation. The results were compared with those of 20 age- and sex-matched healthy volunteers by using both a standardized volume-of-interest-based approach for subcortical areas and statistical parametric mapping. Correlations were investigated with Yale-Brown Obsessive Compulsive Scale scores (Y-BOCS) and Hamilton Depression Rating Scale scores (HAM-D). RESULTS: Chronic anterior capsular electrostimulation resulted in a further decrease of prefrontal metabolic activity, especially in the subgenual anterior cingulate (P < 0.001). Correlation analysis demonstrated that decreases in Y-BOCS and HAM-D with anterior capsular electrostimulation were inversely related to the metabolic activity changes in the left ventral striatum, left amygdala, and left hippocampus (P < 0.01). Preoperative resting metabolic activity in the subgenual anterior cingulate was predictive of therapeutic response (P = 0.001). CONCLUSION: These observations provide evidence that the subgenual anterior cingulate and ventral striatum have a key role in the neuronal circuitry involved in the pathophysiology of OCD with associated major depression and in the neuromodulatory mechanism of anterior capsular stimulation.

Complying with Executive Order 13148 using the Enterprise Environmental Safety And Occupational Health Management Information System.

All U.S. Department of Defense (DoD) facilities are required under Executive Order (EO) 13148, "Greening the Government through Leadership in Environmental Management," to establish quality-based environmental management systems (EMSs) that support environmental decision-making and verification of continuous environmental improvement by December 31, 2005. Compliance with EO 13148 as well as other federal, state, and local environmental regulations places a significant information management burden on DoD facilities. Cost-effective management of environmental data compels DoD facilities to establish robust database systems that not only address the complex and multifaceted environmental monitoring, record-keeping, and reporting requirements demanded by these rules but enable environmental management decision-makers to gauge improvements in environmental performance. The Enterprise Environmental Safety and Occupational Health Management Information System (EESOH-MIS) is a new electronic database developed by the U.S. Air Force to manage both the data needs associated with regulatory compliance programs across its facilities as well as the non-regulatory environmental information that supports installation business practices. The U.S. Air Force, which has adopted the Plan-Do-Check-Act methodology as the EMS standard that it will employ to address EO 13148 requirements.