Orbital Mass Identified With Point-of-Care Ultrasound in a Child Presenting With Eyelid Swelling.

ABSTRACT: Point-of-care ultrasound was used in a child presenting to the emergency department with progressively worsening left eyelid swelling. The early use of ultrasound was helpful in detecting a soft tissue mass that is exhibiting pressure effect on the eyeball. Point-of-care ultrasound helped expedite advanced imaging and consultation with the specialist. The patient eventually had a biopsy and was diagnosed with idiopathic orbital inflammation.

Lower eyelid entropion in thyroid eye disease.

PURPOSE: To report the clinical features, ultrasound biomicroscopic features, and management outcome in patients presenting with thyroid eye disease (TED) and lower eyelid entropion. METHODS: Retrospective interventional case review of patients with TED presenting with lower eyelid entropion over a 12-year period. RESULTS: Five patients (eight eyes) of a total of 1211 presented with lower eyelid entropion as one of the presenting signs of TED (0.41%). The average age was 28.8 years (18-39 years), and three patients were males. Three had systemic hyperthyroidism, and two were euthyroid. Four (80%) had bilateral TED, three had inactive disease, and two were active. The average Hertel exophthalmometry reading was 24.6 mm. All patients had upper lid retraction. Four (80%) had concomitant lower eyelid retraction. Entropion was medial in five and complete in three eyes. Symptomatic corneal epitheliopathy was noted in four eyes. UBM was performed in four eyes which showed a thickened middle lamella. In four eyes (three patients), the entropion was managed conservatively as the patient was not contemplating surgery for proptosis. In the remaining four eyes (two patients) orbital decompression was performed and the lower eyelid retractor release corrected the symptomatic entropion. The average follow-up was 11.6 months (range 1-30). CONCLUSION: Lower eyelid entropion is a rare presenting sign in TED. The mechanism is multifactorial and could be caused by the thickened and fibrosed lower lid retractors, as demonstrated by UBM. Young age and globe projection may play a role. Decompression approaches that involve lower lid retractor release correct the entropion.

Diagnostic Capability of a New Objective Method to Assess Meibomian Gland Visibility.

SIGNIFICANCE: The diagnosis of dry eye disease and meibomian gland dysfunction (MGD) is challenging. Measuring meibomian gland visibility may provide an additional objective method to diagnose MGD. PURPOSE: This study aimed to evaluate the ability of new metrics to better diagnose MGD, based on measuring meibomian gland visibility. METHODS: One hundred twelve healthy volunteers (age, 48.3 ± 27.5 years) were enrolled in this study. Ocular surface parameters were measured using the Oculus Keratograph 5M (Oculus GmbH, Wetzlar). Subjects were classified according to the presence or absence of MGD. New metrics based on the visibility of the meibomian glands were calculated and later compared between groups. The diagnostic ability of ocular surface parameters and gland visibility metrics was studied through receiver operating characteristic curves. Logistic regression was used to obtain the combined receiver operating characteristic curve of the metrics with the best diagnostic ability. RESULTS: Statistically significant differences were found between groups for all ocular surface parameters and new gland visibility metrics, except for the first noninvasive keratograph breakup time and gland expressibility. New gland visibility metrics showed higher sensitivity and specificity than did current single metrics when their diagnostic ability was assessed without any combination. The diagnostic capability increased when gland visibility metrics were incorporated into the logistic regression analysis together with gland dropout percentage, tear meniscus height, dry eye symptoms, and lid margin abnormality score (P < .001). The combination of median pixel intensity of meibography gray values and the aforementioned ocular surface metrics achieved the highest area under the curve (0.99), along with excellent sensitivity (1.00) and specificity (0.93). CONCLUSIONS: New meibomian gland visibility metrics are more powerful to diagnose MGD than current single metrics and can serve as a complementary tool for supporting the diagnosis of MGD.

Neuro-Ophthalmologic Features and Outcomes of Thalamic Infarction: A Single-Institutional 10-Year Experience.

BACKGROUND: Neuro-ophthalmologic deficit after thalamic infarction has been of great concern to ophthalmologists because of its debilitating impacts on patients' daily living. We aimed to describe the visual and oculomotor features of thalamic infarction and to delineate clinical outcomes and prognostic factors of the oculomotor deficits from an ophthalmologic point of view. METHODS: Clinical and neuroimaging data of all participants were retrospectively reviewed. Among the 12,755 patients with first-ever ischemic stroke, who were registered in our Stroke Data Bank between January 2009 and December 2018, 342 were found to have acute thalamic infarcts on MRI, from whom we identified the patients exhibiting neuro-ophthalmologic manifestations including visual, oculomotor, pupillary, and eyelid anomalies. RESULTS: Forty (11.7%) of the 342 patients with thalamic infarction demonstrated neuro-ophthalmologic manifestations, consisting of vertical gaze palsy (n = 19), skew deviation with an invariable hypotropia of the contralesional eye (n = 18), third nerve palsy (n = 11), pseudoabducens palsy (n = 9), visual field defects (n = 7), and other anomalies such as isolated ptosis and miosis (n = 7). Paramedian infarct was the most predominant lesion of neuro-ophthalmologic significance, accounting for 84.8% (n = 28) of all patients sharing the oculomotor features. Although most of the patients with oculomotor abnormalities rapidly improved without sequelae, 6 (18.2%) patients showed permanent oculomotor deficits. Common clinical features of patients with permanent oculomotor deficits included the following: no improvement within 3 months, combined upgaze and downgaze palsy, and the involvement of the paramedian tegmentum of the rostral midbrain. CONCLUSIONS: Thalamic infarction, especially in paramedian territory, can cause a wide variety of neuro-ophthalmologic manifestations, including vertical gaze palsy, skew deviation, and third nerve palsy. Although most oculomotor abnormalities resolve spontaneously within a few months, some may persist for years when the deficits remain unimproved for more than 3 months after stroke.

Spectral Signatures in the Different Layers of the Human Eyelid by Photoacoustic Imaging.

BACKGROUND AND OBJECTIVES: The eyelids are susceptible to a number of skin cancers, which are challenging to excise radically without sacrificing excessive healthy tissue. Photoacoustic (PA) imaging is an emerging non-invasive biomedical imaging modality that could potentially be used for intraoperative micrographic control of the surgical margins of eyelid tumors. In this study, non-cancerous human eyelid tissue was characterized using PA as a first step in the development of this technique. STUDY DESIGN/MATERIALS AND METHODS: Twelve full-thickness samples from nine patients were analyzed ex vivo using PA imaging. Two-dimensional PA images were acquired using 59 wavelengths in the range of 680-970 nm to obtain the spectral signatures of the skin, orbicularis oculi muscle, and the tarsal plate. Three-dimensional images were obtained by scanning the tissues using a linear stepping motor. Spectral unmixing was performed to visualize the chromophore distribution. RESULTS: The resulting PA spectra could be used to differentiate between the orbicularis oculi muscle and the other two structures (P < 0.05). The signals from the skin and the tarsal plate were more similar in appearance, probably due to similarities in their molecular composition. Spectral unmixing provided a clear visualization of the overall architecture of the eyelids. CONCLUSIONS: PA imaging can be used to differentiate between the orbicularis oculi muscle and the eyelid skin and tarsal plate. The main structures of human eyelids could be visualized in three dimensions using PA imaging. This technique could potentially be used to examine eyelid tumors intraoperatively in the future. However, further studies on tumors in vivo are needed before considering such clinical use. Lasers Surg Med. © 2019 Wiley Periodicals, Inc.

Sinus pericranii in the upper eyelid: diagnosis and management guidelines.

Sinus pericranii (SP) is a rare malformation involving aberrant connections between the dural venous sinuses and extracranial veins. Classically considered congenital pathology, there are reported instances of post-traumatic SP in adults. Very rarely, the upper eyelid is involved and the resulting ptosis can obstruct the visual axis. In these cases, surgical removal may be warranted. Because of the high risk of massive intraoperative hemorrhage, careful preoperative identification and diagnostic workup is essential. The authors report a patient with new onset, asymmetric eyelid ptosis referred for evaluation, and subsequently diagnosed with SP. Through a multi-disciplinary assessment, deferring surgical intervention was determined to be appropriate management. The lesion was monitored clinically, and at 6 months follow-up, there were no noted adverse outcomes.

Intravascular papillary endothelial hyperplasia of the periocular region.

Intravascular papillary endothelial hyperplasia (IPEH) is a benign vascular lesion, typically found in the skin, consisting of a papillary proliferation of endothelial cells intimately related to a thrombus; it appears to be a rare variant of an organizing process. IPEH very rarely develops in the periocular region, with fewer than 20 such cases currently reported in the English language literature. We describe one of the largest ever case series of this uncommon lesion occurring in the periocular region and discuss its clinical features, imaging characteristics, and surgical management.

Eyelid abscess masking underlying sebaceous cell carcinoma.

Sebaceous cell carcinoma is well known as the "great masquerader" mimicking other benign or malignant eyelid conditions and lesions. We present a case of a middle age male presenting with a subacute left upper lid abscess who was ultimately diagnosed with malignant sebaceous cell carcinoma after incision and drainage and treatment with broad spectrum antibiotics. This case highlights the deceptive clinical and radiographic appearance of this tumor and the importance of histologic examination in atypical or refractory periorbital abscesses.

Value of ultrasound biomicroscopy in assessment of small masses at medial canthal region.

PURPOSE: Conventional imaging techniques are not sensitive enough to reveal detailed structures of lacrimal drainage system (LDS) and its surrounding tissue (ST). Our study aimed to explore utility of ultrasound biomicroscopy (UBM) in assessment of small masses at the medial canthal region and compare performance of UBM with conventional imaging techniques. METHODS: We prospectively recruited cases with small mass (long axis < 1 cm) at the medial canthal region (upper LDS-located area) from June 2017 to October 2018. UBM ± color Doppler flow imaging (CDFI) and conventional imaging techniques (computed tomography, magnetic resonance imaging, and dacryocystography) were conducted by four independent practitioners. Results were analyzed against gold standards with Cohen's kappa test in three aspects including LDS patency, mass location, and presumptive diagnosis. Corresponding gold standards were syringe and dacryocystography, intraoperative findings, and pathological/empirical diagnosis. RESULTS: Seventy-two cases were recruited, including 20 cases of LDS lesions and 52 cases of ST lesions. Female (odds ratio 7.14) and age ≥ 37 (odds ratio 9.80) were risk factors for LDS lesion, and age range of 15-25 (odds ratio 9.17) was a risk factor for inflammatory ST lesion. In terms of LDS patency, UBM results were reliable for the detection of pre-saccal obstruction (kappa = 0.920), but were not reliable for intra-saccal and post-saccal obstruction (kappa = 0.106). In terms of mass location, the UBM (kappa = 0.766) performed better than conventional techniques (except for dacryocystography) to sort out ST lesions, with sensitivity of 93.8% and specificity of 83.3%. In terms of diagnosis, the UBM (kappa = 0.882) outweighed conventional techniques (except for magnetic resonance imaging) to distinguish cysts from nodules, with sensitivity of 93.8% and specificity of 94.4%. Notably, the UBM + CDFI achieved better performance than the UBM when screen out inflammatory lesions (kappa = 0.926 vs kappa = 0.689) and LDS-adjacent lesions (kappa = 0.815 vs kappa = 0.673), resulting in sensitivity of 91.7% and specificity of 100% for both testing items. If deep lesions (at the lacrimal sac-harbored area) were excluded, UBM reliability to detect inflammatory lesions (kappa = 0.915) and LDS-adjacent lesions (kappa = 0.770) improved, achieving sensitivity of 90.0% and 88.9%, and specificity of 100.0% and 92.7%, respectively. CONCLUSIONS: The UBM is a valuable tool to assess superficial masses at the medial canthal region regarding pre-saccal obstruction, mass location, and presumptive diagnosis. TRIAL REGISTRATION: This work was registered on Chinese Clinical Trial Registry website with registration number ChiCTR1800018956 .

Effects of collagen crosslinking on porcine and human tarsal plate.

BACKGROUND: Floppy eyelid syndrome is a disorder in which the tarsal plate is easily distensible and is currently treated with conservative or surgical measures. Human tarsal plate contains type I collagen, which is crosslinked in corneal tissue as a treatment for keratoconus. We hypothesized that collagen crosslinking would similarly stiffen tarsal plate tissue and investigated this in porcine and human tarsal plate specimens. METHODS: Riboflavin-sensitized porcine and human tarsus samples were irradiated with ultraviolet-A light. Porcine experiments were analyzed with gross photographs, anterior segment optical computed tomography (AS-OCT) imaging, and tensile testing. A prospective study of human tarsus was performed on samples from patients undergoing wedge resection for floppy eyelid syndrome and was analyzed with AS-OCT and tensile testing. RESULTS: 73 porcine adnexa and 9 patients (16 eyelids) who underwent wedge excision were included in the study. Grossly, greater stiffness was observed in crosslinked porcine tissue. AS-OCT imaging in porcine tissue showed a distinct hyperreflective band in crosslinked specimens whose area and intensity increased with longer treatment time (P = 0.003); this band was also visible in crosslinked human specimens. Tensile testing was performed, but results were not statistically significant. CONCLUSIONS: AS-OCT imaging, which has not been previously described for tarsal plate, showed a characteristic change in crosslinked porcine and human specimens. Tissue stiffness was increased grossly, but changes in tensile properties were not statistically significant. Further study is warranted to determine relevance as a potential treatment for floppy eyelid syndrome.

MR imaging features of orbital Langerhans cell Histiocytosis.

BACKGROUND: To investigate the magnetic resonance imaging (MRI) features of orbital Langerhans cell histiocytosis (LCH) to improve diagnostic accuracy. METHODS: We retrospectively reviewed clinical manifestations and MRI findings of 23 patients with histopathology-confirmed LCH of the orbit. The findings were evaluated for the following: (a) symptoms, (b) disease duration, (c) location, (d) configuration, (e) margin, (f) MR imaging signal intensity and enhanced performance. RESULTS: Eighteen patients (78%) in our series were male, only five (22%) patients were female, and the mean age at presentation was 6.3 years. The common symptoms include swollen eyelids, exophthalmos, and a palpable mass. Fourteen patients presented with swollen eyelids and/or exophthalmos. Twenty-two cases involved unilateral orbits, and one case involved bilateral orbits. In our study, there was one patient with cough and expectoration, and one patient with polydipsia and polyuria. Lesions were located in the superior or superlateral orbital roof of seventeen patients (74%). Lesions formed masses or irregular shapes. The 12 out of 23 (52.2%) cases appeared heterogeneous isointense and 10 out of 23 (43.5%) cases showed iso-hypointense on T1-weighted imaging, there were 15 out of 23 (65.2%) cases showed hyper-hypointense mixed signals on T2-weighted imaging. 7 cases found patchy hyperintense signal on T1WI, and 11 cases showed markedly hyperintense signal near the edge of lesions on T2WI. After enhancement, 21 out of 23 (91.3%) cases lesions presented marked enhancement at the edges and the surrounding tissues, and with heterogeneous obvious enhancement of the lesion center. Besides, four cases lesions were surrounded by a low circular signal. CONCLUSION: There were several characteristics MRI features that can provide crucial information for clinicians and improve our understanding and the diagnostic accuracy of the orbital LCH.

Update on the association between dry eye disease and meibomian gland dysfunction.

Dry eye disease is one of the most common ophthalmic complaints; it results from the activity of various pathways and is considered a multifactorial disease. An important factor that contributes to the onset of dry eye disease is meibomian gland dysfunction. Meibomian gland dysfunction causes a disruption in the tear film lipid layer which affects the rate of tear evaporation. This evaporation leads to tear hyperosmolarity, eventually triggering the onset of dry eye disease. Dry eye disease and meibomian gland dysfunction are strongly associated with each other, such that many of their risk factors, signs, and symptoms overlap. This review aimed to provide an update on the association between dry eye disease and meibomian gland dysfunction. A stepwise approach for diagnosis and management is summarised.

A case report on dermal filler-related periorbital granuloma formation.

We report a case of a 49-year old East-Asian female who presented with delayed onset granuloma formation at the right medial lower eyelid area. The clinical and radiologic presentation with pathologic correlation following synthetic hyaluronic acid filler injection and its management are described along with a review of literature following dermal-filler injections types. Dermal-filler-related granuloma formation should be included in the differential diagnoses of periorbital inflammatory and mass lesions. It is recommended that clinicians who perform this procedure should discuss these risks and possible late complications with patients and provide them with the relevant product information of the injected filler for appropriate management should such early or late complications occur.

Periocular thelaziasis presenting as an orbital mass - a case report.

Thelazia callipaeda is a rare parasitic infestation caused by spiruroid nematode of the genus Thelazia. We report a case of a 74-year-old gentleman who presented with a painless swelling of left lower lid since 15 days. Examination revealed a firm mobile mass along the inferior orbital rim. Magnetic Resonance Imaging showed a well-defined preseptal cystic lesion and Ultrasound screening revealed multiple mobile worms within. Patient underwent cyst excision in toto under local anesthesia. Four long refractile worms were isolated from within the cyst cavity. Species identification confirmed the parasite as Thelazia callipaeda. Periocular thelaziasis usually presents as free floating worms in the conjunctival sac, anterior chamber or vitreous cavity. It is important to be aware of this rare entity which should be considered as a differential diagnosis in endemic areas.

Orbital and peri-orbital amyloidosis: a report of four cases.

Our objective was to describe our experience with orbital amyloidosis, and illustrate the different forms of presentation. This was a retrospective case series of four patients with biopsy-proven orbital amyloi- dosis, over the period from 2014 to 2016. We describe its diagnostic and clinical characteristics, management and systemic study. The series comprised three women and one man of mean age 52 ± 9.4 years. Affected sites were the lacrimal gland, tarsal conjunctiva, lacrimal sac and orbit. In three of the four patients, calcifications were observed. Three patients had associated ptosis. The patient with orbital involvement suffered an unusual vascular complication during surgery and systemic disease was detected. Management included debulking and complete resection of the lesion. In conclusion, orbital amyloidosis presents as a wide variety of forms. Its diagnosis is biopsy-based. Calcifications in biopsy specimens or images should raise suspicion of amyloidosis. It is important to always check for systemic amyloidosis.

Periorbital Necrotizing Fasciitis Induced by Streptococcus pyogenes: A Case Report and Clarification.

Periorbital necrotizing fasciitis (PONF) is a rare condition of the face. PONF can lead to blindness, functional and esthetic sequelae, multiple-organ failure, and death. The aim of this report is to raise the awareness of this severe condition in maxillofacial surgeons. This report describes the case of a 30-year-old woman who presented with a bilateral palpebral edema and pain 3 days after a jugal wound was sutured. Necrosis of the skin of the left palpebral unit was extending rapidly. The patient had signs of sepsis. Surgical debridement was performed promptly and intravenous broad-spectrum empiric antibiotics were administered. The patient recovered slowly with no complication other than a residual skin defect of the 2 eyelids that was later corrected by full-thickness skin grafting. Special attention should be paid to signs of preseptal cellulitis because it can, in some cases, rapidly develop into PONF. Early diagnosis and treatment are the keys to a favorable outcome.

Magnetic resonance imaging study of eye congenital birth defects in mouse model.

PURPOSE: Embryonic eyelid closure is a well-documented morphogenetic episode in mammalian eye development. Detection of eyelid closure defect in humans is a major challenge because eyelid closure and reopen occur entirely in utero. As a consequence, congenital eye defects that are associated with failure of embryonic eyelid closure remain unknown. To fill the gap, we developed a mouse model of defective eyelid closure. This preliminary work demonstrates that the magnetic resonance imaging (MRI) approach can be used for the detection of extraocular muscle abnormalities in the mouse model. METHODS: Mice with either normal (Map3k1+/- ) or defective (Map3k1-/- ) embryonic eyelid closure were used in this study. Images of the extraocular muscles were obtained with a 9.4 T high resolution microimaging MRI system. The extraocular muscles were identified, segmented, and measured in each imaging slice using an in-house program. RESULTS: In agreement with histological findings, the imaging data show that mice with defective embryonic eyelid closure develop less extraocular muscle than normal mice. In addition, the size of the eyeballs was noticeably reduced in mice with defective embryonic eyelid closure. CONCLUSIONS: We demonstrated that MRI can potentially be used for the study of extraocular muscle in the mouse model of the eye open-at-birth defect, despite the lack of specificity of muscle group provided by the current imaging resolution.

A clinical utility assessment of the automatic measurement method of the quality of Meibomian glands.

BACKGROUND: Meibomian gland dysfunction (MGD) is one of the most common diseases observed in clinics and is the leading cause of evaporative dry eye. Today, diagnostics of MGD is not fully automatic yet and is based on a qualitative assessment made by an ophthalmologist. Therefore, an automatic analysis method was developed to assess MGD quantiatively. MATERIALS: The analysis made use of 228 images of 57 patients recorded by OCULUS Keratograph® 5 M with a resolution of 1024 × 1360 pixels concern 30 eyes of healthy individuals (14 women and 16 men) and 27 eyes of sick patients (10 women and 17 men). The diagnosis of dry eye was made according to the consensus of DED in China (2013). METHODS: The presented method of analysis is a new, developed method enabling an automatic, reproducible and quantitative assessment of Meibomian glands. The analysis relates to employing the methods of analysis and image processing. The analysis was conducted in the Matlab environment Version 7.11.0.584, R2010b, Java VM Version: Java 1.6.0_17-b04 with Sun Microsystems Inc. with toolboxes: Statistical, Signal Processing and Image Processing. RESULTS: The presented, new method of analysis of Meibomian glands is fully automatic, does not require operator's intervention, allows obtaining reproducible results and enables a quantitative assessment of Meibomian glands. Compared to the other known methods, particularly with the method described in literature it allows obtaining better sensitivity (98%) and specificity (100%) results by 2%.

Spontaneous upper eyelid ecchymosis: A rare presenting sign for frontal sinus mucocele.

Paranasal sinus mucoceles are benign lesions that commonly present with orbital signs due to their anatomic proximity. We are reporting a case of bilateral frontal sinus mucocele presenting with spontaneous eyelid ecchymosis. To our knowledge this is the first case report of eyelid ecchymosis as the initial sign of this condition. In addition, our patient lacked commonly described symptoms such as diplopia or pain. This report highlights the importance of including frontal sinus mucocele in the differential diagnosis of spontaneous periorbital ecchymosis.

Periocular dirofilariasis: A case series.

OBJECTIVE: To cite a series of patients presenting with complaints of a lid swelling associated with preseptal cellulitis. METHODS: Three patients on three different occasions came with complaints of a unilateral lid swelling associated with preseptal cellulitis. Examination showed palpable mass in the upper eyelid localized, firm in consistency and was freely mobile and occasionally disappeared during palpation. CT scan showed nonspecific preseptal inflammation. A trial of antibiotics was given in each of the cases with temporary reduction in the swelling but a consecutive flare up following which patient was subjected to excision biopsy. Each of the biopsies was subjected to histopathological and microbiological examination. RESULTS: On excision biopsy in all the three cases it was reported to be a parasitic infestation belonging to the genus Dirofilaria. CONCLUSIONS: Dirofilariaiasis is a common zoonotic infection among wild animals but rarely infects human beings with ocular involvement. Hence dirofilariasis should be considered as a differential diagnosis for migratory subcutaneous swellings and conjunctival nodules in the southern belt of India.