Teprotumumab for Thyroid Eye Disease-related Strabismus.

PURPOSE: To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility. METHODS: We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab. RESULTS: Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation ( p < 0.001), without significant change in mean horizontal deviation ( p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye ( p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion. CONCLUSIONS: Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Systemic eosinophilic disease presenting as dacryoadenitis.

Eosinophilic disease with orbital involvement is rare. We present two patients with dacryoadenitis associated with local and systemic eosinophilia. A 32-year-old man presented with episodic dacryoadenitis, lower respiratory inflammation and peripheral eosinophilia. Lung and lacrimal gland biopsies demonstrated eosinophilic infiltrate without granuloma, necrosis, or vasculitis. He improved with oral corticosteroids and Mepolizumab, an IL-5 inhibitor. The second case involved a 33-year-old man who similarly presented with episodic dacryoadenitis, pulmonary inflammation and pain/swelling in the hands and feet. Lacrimal gland biopsy demonstrated a predominantly eosinophilic infiltrate without granuloma or vasculitis. Symptoms improved with oral corticosteroids. Although neither patient was provided a definitive diagnosis, both were determined to have an eosinophilic condition on the spectrum of eosinophilic asthma or eosinophilic granulomatosis with polyangiitis.

The Effect of Lighting and Photograph Exposure on Perceived Attractiveness.

PURPOSE: To assess the effect of various lighting conditions and photograph exposures on perceived attractiveness. METHODS: In the first experiment, 5 variably exposed photographs were taken of 10 subjects using a consistent lighting condition (45° superior box light). In the second experiment, 10 subjects were photographed under variable lighting conditions with consistent exposure: 1) 90° overhead box light, 2) ring light, 3) 45° superior box light, 4) built-in camera flash, 5) 2 straight on box lights, each 45° from midline, and 6) natural light. Participants were instructed to maintain a neutral expression, were placed in front of a standardized blue-gray background, and were photographed during a single session. Photographs were imported into an online survey platform (Qualtrics 2020) and displayed in random order. Volunteer survey respondents were instructed to rate the subject's attractiveness on a scale of 0 to 10. Between the two experiments, a total of 22,000 scored photographs were included in the analysis. Mixed ANOVA and pairwise comparisons with Bonferroni correction were used to compare between- and within-subject ratings. RESULTS: Lighting condition had a significant impact on perceived attractiveness ( p < 0.001), with the 90° overhead box light achieving lower scores and the 45° superior box light yielding greater scores of attractiveness relative to the other conditions. Photograph exposure did not have a significant impact on subjective attractiveness ( p = 1.000). CONCLUSIONS: Our findings suggest that perceived attractiveness is enhanced when a 45° superior box light is used for illumination, and attractiveness is reduced when 90° overhead exposure is utilized. Exposure did not play a prominent role in perceived attractiveness.

Glue Embolization Without Surgical Resection for Orbital Venolymphatic Malformation.

A 59-year-old man presented with worsening left-sided eye pain and headache from a left orbital venous-dominant venolymphatic malformation. He reported a history of sclerotherapy, experiencing only transient relief with this procedure. Oral analgesia had not helped alleviate the pain. He described the pain as dull and intermittent, and noted worsening with physical exertion. Physical examination revealed dense left optic neuropathy, motility restriction, enophthalmos, and Valsalva-induced proptosis. Given baseline enophthalmos and poor vision affecting the left eye, glue embolization without surgical resection was offered. He underwent 2 rounds of percutaneous n-Butyl cyanoacrylate embolization performed 11 months apart. Following these procedures, he reported sustained pain relief, as compared with prior sclerotherapy procedures. Glue embolization without surgical resection may provide a novel approach to orbital venolymphatic malformations in selected patients.

Transorbital Debulking of Sphenoid Wing Meningioma.

OBJECTIVE: To describe the clinical features and outcomes of patients who underwent transorbital debulking of sphenoid wing meningioma. METHODS: Patients with a diagnosis of sphenoid wing meningioma who underwent transorbital debulking were included in this series. Preoperative and postoperative symptoms and examination findings, including best corrected visual acuity (BCVA) and proptosis were extracted from patient charts. All imaging studies, records of additional surgical and medical management, and complications of surgery were collated. RESULTS: Eight patients were included. The most common symptoms at presentation were blurred vision (6/8) and proptosis (6/8). The most common clinical findings at presentation were decreased visual acuity and proptosis. Mean BCVA preoperatively was 0.93 in logMARunits andmeanrelative proptosis preoperatively was 4.88 mm. All patients underwent orbitotomy with or without bone flap with decompression of hyperostotic bone and subtotal resection of soft tissue mass. Mean follow-up time was 14months. Five of eight patients experienced postoperative improvement in BCVA, for mean change of 0.32. All patients demonstrated reduction in proptosis postoperatively with a mean reduction of 3.63 mm. CONCLUSIONS: Sphenoid wing meningioma can present with decreased visual acuity and/or proptosis. It is possible to address both of these problems in selected patients with transorbital debulking, an approach that avoids the aesthetic and functional consequences of craniotomy. The aim of this technique is not surgical cure, but rather improvement in vision and disfigurement.

Upper eyelid weighting for lagophthalmos results in contralateral upper eyelid elevation.

INTRODUCTION: Upper eyelid weighting decreases lagophthalmos by improving blink dynamics. The effect of weighting on static eyelid position is less well understood. This study describes the effect of upper eyelid weighting on ipsilateral and contralateral upper eyelid position. METHODS: Patients with unilateral lagophthalmos who underwent upper eyelid weight implantation were included. Primary outcome measures were ipsilateral and contralateral margin to reflex distance 1 (MRD1), preoperatively and postoperatively. MRD1 symmetry was assessed as a secondary outcome measure. Weight mass was examined as a covariate of MRD1 change. RESULTS: 23 patients (16 female, 7 male) met inclusion criteria. After weighting, contralateral MRD1 increased from mean [SD] 2.91 [1.41] mm to 3.77 [1.75] mm (p < .05). Ipsilateral (weighted) MRD1 did not significantly change (2.64 [1.41] mm to 2.40 [1.18] mm, p = .11). Preoperatively, paretic and normal side MRD1 were not different (p = .52). Postoperatively, weighted and unweighted MRD1 were significantly different (p < .05). Weight mass was not a covariate of MRD1 change, neither ipsilateral nor contralateral (p = .76, p = .71, respectively). The proportion of patients with MRD1 asymmetry ≥ 1 mm preoperatively (12/23, 52.2%) did not change following surgery (17/23, 73.9%, p = .12). CONCLUSION: Weight insertion led to contralateral eyelid elevation, a manifestation of Hering's law. Weight mass did not impact the magnitude of MRD1 change, and the proportion of patients with MRD1 asymmetry ≥ 1 mm did not change following surgery. These findings may guide surgeons in their preoperative planning and in counseling of patients.

Oxidized mitochondrial DNA activates the NLRP3 inflammasome during apoptosis.

We report that in the presence of signal 1 (NF-κB), the NLRP3 inflammasome was activated by mitochondrial apoptotic signaling that licensed production of interleukin-1ß (IL-1ß). NLRP3 secondary signal activators such as ATP induced mitochondrial dysfunction and apoptosis, resulting in release of oxidized mitochondrial DNA (mtDNA) into the cytosol, where it bound to and activated the NLRP3 inflammasome. The antiapoptotic protein Bcl-2 inversely regulated mitochondrial dysfunction and NLRP3 inflammasome activation. Mitochondrial DNA directly induced NLRP3 inflammasome activation, because macrophages lacking mtDNA had severely attenuated IL-1ß production, yet still underwent apoptosis. Both binding of oxidized mtDNA to the NLRP3 inflammasome and IL-1ß secretion could be competitively inhibited by the oxidized nucleoside 8-OH-dG. Thus, our data reveal that oxidized mtDNA released during programmed cell death causes activation of the NLRP3 inflammasome. These results provide a missing link between apoptosis and inflammasome activation, via binding of cytosolic oxidized mtDNA to the NLRP3 inflammasome.

The Effect of Zero Gravity on Eyelid and Brow Position.

PURPOSE: To describe the effect of spaceflight on upper eyelid and brow position. MATERIALS AND METHODS: Images of astronauts on earth and in space were collected from a National Aeronautics and Space Administration image library. For each astronaut, front facing portraits captured within a 5-year period were obtained. At least 6 photos were collected per astronaut, 3 taken on earth, and 3 in zero gravity. Measurements from the center of the pupil to the upper eyelid margin (MRD1) and center of the pupil to the inferior eyebrow margin [pupil-to-brow (PTB)] were performed digitally for each image and averaged for each condition and each individual. Differences in mean MRD1 and PTB were assessed to illustrate the effects of zero gravity on eyelid and eyebrow position respectively. Linear-mixed effects modeling, analysis of variance and post hoc power analysis were performed. RESULTS: One hundred and twelve photographs (55 earth, 57 space) from 18 astronauts (4 women, 14 men; mean age 45.9 years) were retrieved. Zero gravity resulted in a mean PTB increase of 3.7 mm (p < 0.01) but did not result in significant change in MRD1 (p = 0.21). Post hoc power analysis of the measured MRD1 difference was performed by simulation. At an MRD1 difference of 0.5 mm, the probability of a type II error is 2.6%, equivalent to a beta power of 97.4%. Thus, we can be 97.4% confident that a difference in MRD of 0.5 mm or greater would be detected. CONCLUSIONS: While spaceflight led to significant elevation of PTB, it did not consistently alter MRD1. As such, the brow and eyelid appear to be independently regulated with respect to gravitational changes.

Multiple Arterial Vascular Anomalies in the Periorbital, Paranasal, and Intracranial Spaces Treated With Systemic Bevacizumab.

ABSTRACT: Arteriovenous malformations of the orbit are rare congenital hamartomas defined by a direct connection between the arterial and venous systems without an intervening capillary bed. Treatment can be challenging, as these lesions are anatomically complex, often involve multiple locations, and have a tendency to recur. A multidisciplinary approach is typically required, involving endovascular and surgical teams. The authors present a case of a 33-year-old man with a complex, recurrent orbital arteriovenous malformations in the context of wider head and neck vascular anomaly syndrome involving the paranasal sinuses, deep facial tissues, and intracranial spaces. The complex and evolving clinical manifestations of this disease are presented with emphasis on the interdependence of the anomalies and biologic management strategies.

Ophthalmic and orbital considerations in the evaluation of skull base malignancies.

INTRODUCTION: The orbital contents, afferent and efferent visual pathways, and the cranial nerves involved in eye movement, corneal sensation and eyelid closure traverse the skull base, a region bounded by the intracranial cavity, the paranasal sinuses, and the deep spaces of the face and head. As such, tumors from above or below have potential to affect some aspect of the visual system. METHODS: We discuss here the clinical ophthalmologic and orbital considerations in the evaluation of patients with these tumors, as well as the ophthalmic sequelae of treatment with radiation or surgery (or both). And for the surgeon, we discuss the ophthalmic and orbital considerations in surgical planning, the role of the orbital surgeon in skull base surgery, and briefly discuss transorbital approaches to the skull base. RESULTS AND CONCLUSION: Ophthalmic and orbital dysfunction may be the main source of disability in patients with skull base malignancy; it is thus incumbent on those who manage patients with tumors of this region to be aware of the ophthalmic, neuro-ophthalmic and orbital manifestations, so as to best tailor therapy and monitor treatment outcomes.

Anatomic Features of Head and Neck Keratinocyte Cancer in Virginia.

BACKGROUND: Keratinocyte cancer (KC) patients benefit from early diagnosis. We describe here the anatomy of head/neck KCs to help guide screening efforts. OBJECTIVE: To examine lesion frequency and anatomic distribution of head and neck KC. METHODS: This retrospective cohort study of 4,770 consecutive pathology reports, 1998 to 2015, analyzes 5,463 head and neck KCs (3,664 basal cell carcinoma [BCC], 1,259 squamous cell carcinoma [SCC], and 540 SCC in situ) from 3,581 patients. RESULTS: Basal cell carcinoma relative tumor density (RTD) was highest on the nose; SCC RTD was highest on the cheek. Basal cell carcinoma-to-SCC ratio was highest on eyelid and lowest on scalp. Temple, ear, and neck SCC predominated in men; nose and cheek SCC in women. Scalp, temple, and ear BCC showed male predominance, while cheek, nose, and chin predominated in women. Left-sided ear SCC in situ and BCC were more common than right-sided ear lesions. CONCLUSION: This study demonstrates gender- and laterality-specific differences that comport with patterns of solar exposure.

Cone Beam Computerized Tomography Dacryocystography (CBCT DCG) for the Evaluation of Lacrimal Drainage System Dysfunction.

PURPOSE: Lacrimal outflow imaging has been limited in clinical practice due to a combination of modality limitations and efficacy of clinical testing. Cone beam computed tomography dacryocystography (CBCT DCG) has certain advantages over other modalities that may enhance clinical utility. This study was intended to understand the relationships between symptoms, syringing and CBCT DCG in a population of patients presenting with tearing. METHODS: Cross-sectional cohort study of adult patients undergoing both CBCT DCG and clinical probing and irrigation. Concordance analysis between symptoms, clinical examination, and CBCT DCG was performed at baseline and postoperatively in patients who were treated with dacryocystorhinostomy. RESULTS: CBCT DCG findings correlate fairly well with probing/irrigation (Cohen kappa = 0.376). Excluding cases of canalicular obstruction identified by either method, the correlation between CBCT DCG and probing/irrigation was moderately improved (Cohen kappa = 0.488). There was no statistically significant difference in correlation with patient symptoms between CBCT DCG and probing/irrigation (p = 0.877). Fifteen patients (17 lacrimal systems) patients underwent endoscopic dacryocystorhinostomy (DCR) surgery. Ten demonstrated absence of symptoms 90 days postoperatively, 3 endorsed continued tearing and 2 were lost to follow up. All 3 who demonstrated continued tearing, demonstrated canalicular obstruction on CBCT DCG which was not initially detected on probing/irrigation. CONCLUSIONS: CBCT DCG correlates moderately well with probing and irrigation, as well as patient symptoms. This technology may assist in identification of functional/anatomic canalicular obstruction.

Photochemical Collagen Cross-Linking Reverses Elastase-Induced Mechanical Degradation of Upper Eyelid Tarsus.

INTRODUCTION: The floppy eyelid syndrome describes an eyelid disorder characterized by floppy tarsal plates that may be caused by a loss of elastin. The authors attempted to create floppy eyelids by digesting elastin from cadaveric tarsus and then treated them with cross-linking using ultraviolet A and riboflavin. METHODS: Nine right and 9 left upper eyelids were excised from cadavers. Four vertical strips of central tarsus were removed from each eyelid. One strip of tarsus from each eyelid was treated with 10 units/ml of elastase for 2 hours. Another tarsal strip from each eyelid was immersed in normal saline for 2 hours (control). A third strip from the same eyelid was cross-linked using ultraviolet A at 6 mW/cm for 18 minutes. Finally, a fourth strip of tarsus was cross-linked in the same manner following treatment with elastase for 2 hours. A microtensile load cell was used to measure the Young modulus (stiffness) of each tissue. RESULTS: Mean (standard deviation) Young modulus for controls (18.9 ± 3.6 MPa) was significantly higher than samples treated with elastase alone (6.6 ± 3.8 MPa, p <0.01). Samples that were treated with cross-linking after elastase had a mean (standard deviation) Young modulus of 26 ± 2.3 MPa, while those treated with cross-linking alone had a mean (standard deviation) Young modulus of 34 ± 0.15 MPa. The differences in stiffness between all groups were significant (p <0.01). DISCUSSION: Treatment with elastase significantly reduces the stiffness of tarsal plates. This effect is reversed by cross-linking, raising the possibility of using this modality for the treatment of FES.

Orbital mantle cell lymphoma presenting as myasthenia gravis.

A 69-year-old man, previously treated with pyridostigmine for myasthenia gravis (manifesting as ptosis and diplopia) was evaluated for several concomitant bilateral anterior orbital masses. Imaging revealed 3 discrete, solid masses within and around the orbits. An incisional biopsy demonstrated atypical lymphocytes positive for CD20 and Cyclin-D1, consistent with mantle cell lymphoma. The patient received induction chemotherapy with a rituximab-based regimen. He experienced resolution of his diplopia and ptosis after one cycle of chemotherapy and achieved complete remission of the orbital masses and myasthenia symptoms after 6 cycles. Myasthenia gravis is most commonly associated with thymoma, but may also be observed with other malignancies. Recognition that orbital lymphoma may coexist with myasthenia gravis will help in expediting the diagnosis of future cases and in guiding treatment decisions.

The Effect of Ptosis Surgery on Brow Position and the Utility of Preoperative Phenylephrine Testing.

INTRODUCTION: Many reports have suggested that upper eyelid position and brow height can be interdependent; however, the relation is not universally observed. This study aims to understand the prevalence of this phenomenon and examine the utility of phenylephrine testing in predicting brow height change after surgery. METHODS: Ptotic eyelids undergoing Muller's muscle conjunctiva resection surgery in which phenylephrine testing was performed were included. The distance from both the center of the pupil to the upper eyelid and the lower brow margin were measured in the midpupillary line. Measurements were performed based on photographs taken on presentation, after phenylephrine testing and at postsurgical follow-up. Change in eyelid margin and brow position between each of these conditions was assessed. Associations between changes in eyelid margin and brow position were analyzed, and a receiver operating characteristic curve for brow change after phenylephrine instillation as a predictor of postoperative brow change was fit. RESULTS: In the sample of 125 eyes, there was a significant change in mean marginal reflex distance one both with application of phenylephrine and after surgery (p < 0.05). There was no significant change in brow height with instillation of phenylephrine (p > 0.05). There was a significant change in brow height with surgery (1 mm; p < 0.05). Change in marginal reflex distance one with surgery or with phenylephrine was not significantly correlated with change in brow height after surgery (Pearson's r = 0.06; p > 0.05). Brow height change with phenylephrine was significantly correlated with brow height change after surgery (p < 0.05). Clinically relevant brow height change was defined as mean change minus one standard deviation, for a total decrease of 3.8 mm. By this criterion, 13.6% patients (n = 17) demonstrated clinically relevant brow height change. These patients had a greater preoperative brow height (p < 0.05) and a greater response to phenylephrine (p < 0.05). Based on receiver operating characteristic analysis, a threshold change of 3.5 mm in brow height with phenylephrine had a sensitivity of 0.94, and specificity of 0.10 for postoperative brow height change. CONCLUSIONS: Approximately 15% of the population studied tends to have a significant change in brow position with ptosis surgery. Patients who do not demonstrate a reduction in brow height of at least 3.5 mm after phenylephrine instillation preoperatively are unlikely to have clinically relevant brow height reduction after surgery.

Mueller's Muscle Conjunctival Resection With Skin-Only Blepharoplasty: Effects on Eyelid and Eyebrow Position.

PURPOSE: To determine the effect of concurrent blepharoplasty and Mueller's muscle conjunctival resection (MMCR) surgery on eyelid position and eyebrow height. METHODS: Clinical data from 274 eyes that met inclusion criteria for this study were reviewed. Mueller's muscle conjunctival resection surgery was performed alone in 198 eyes and was performed with concurrent blepharoplasty in 76 cases. In this study blepharoplasty consisted of only skin removal, leaving the muscle, fat, and tarsus intact. Preoperative and postoperative pupil to eyebrow, and eyelid margin to eyebrow distances were calculated and compared. RESULTS: Preoperative margin reflex distance 1 (MRD1) was similar for both groups of patients (p > 0.05) as was the postoperative MRD1 (p > 0.05). The change in MRD1 was similar between patients undergoing MMCR alone versus those undergoing MMCR with blepharoplasty (1.5 mm vs. 1.3 mm, respectively, p = 0.36). For similar amounts of tissue resection, the postoperative change in MRD1 was similar for patients undergoing MMCR-only surgery and MMCR with blepharoplasty (p > 0.05). Eyebrow height significantly decreased following both MMCR with blepharoplasty (0.73 mm, p < 0.05) and MMCR-only surgery (0.87 mm, p < 0.05), and this change in eyebrow height was not significantly different between the 2 groups. CONCLUSION: Combining MMCR surgery with skin-only blepharoplasty does not significantly alter eyelid height when compared with MMCR surgery alone for the correction of upper eyelid ptosis. This may assist in preoperative planning for combined MMCR with skin-only blepharoplasty.

The role of tissue resection length in the determination of post-operative eyelid position for Muller's muscle-conjunctival resection surgery.

PURPOSE: To investigate the relationships between pre-operative marginal reflex distance (MRD), tissue resection length, phenylephrine response, and change in MRD with surgery for a cohort of individuals undergoing Muller's muscle conjunctival resection (MMCR) surgery. METHODS: All cases of MMCR surgery performed over a 13-year period at a single institution were screened for entry. Individuals with adequate photographic documentation and follow up were included. Patients with previous or concurrent upper eyelid, orbital or eyebrow disease of surgery were excluded. Marginal reflex distance (MRD) was calculated based on photographs utilizing public domain software. Data was plotted for inspection and appropriate statistical tests were performed. RESULTS: During the study period 198 eyes fit criteria for analysis. A loose association between tissue resection length and change in MRD with surgery was found (r = 0.176, p < 0.05); this relationship was not significant in ANOVA analysis (p = 0.367). There was a strong association between MRD change with surgery and pre-operative MRD (r = 0.498, p < 0.01). Approximately 28% of the sample responded to 2.5% phenylephrine drop instillation with a greater than 2 mm increase in MRD. The response to phenylephrine was strongly associated with pre-operative MRD (r = -0.441, p < 0.01). A regression on change in MRD with surgery with tissue resection, phenylephrine response >2 mm and pre-operative MRD as variables revealed a model with pre-operative MRD as the only significant predictor (p < 0.01). CONCLUSION: Tissue resection length and phenylephrine response play small roles relative to pre-operative MRD in the determination of change in MRD with MMCR surgery.

Orbitocranial Penetration of Ball Bearing Gun Trauma: A Prospective Human Cadaveric Study.

Objective We completed a prospective human cadaveric study to determine the ability of a ball bearing (BB) pellet to penetrate the orbit and/or surrounding structures. Methods A single trained sergeant officer discharged an alloy steel air rifle to eight cadaver orbits from four adult human cadaver heads. Five BB pellets each were aimed at three locations (caruncle, upper eyelid, or lower eyelid) at 10 cm and 1 m, and then less specifically, at the orbital region for 3- and 5-m distances. Computed tomography (CT) of the cadaver heads was performed. Final locations of BB pellets are divided into three categories: intracranial, surrounding orbital structures including the pterygopalatine fossa and infratemporal fossa, and orbit. Results Of 40 BB pellets, 37 penetrated soft tissue and were visualized on CT: 19 (51%) rested in the intracranial space, 17 (46%) in surrounding orbital structures, and 1 (3%) within the orbit. The deepest position of a pellet was in the parietal lobe, and most superficial location anterior to the frontal bone. Pellets discharged from 1 m were more likely to rest in the intracranial space compared with those from 10 cm ( p < 0.001), 3 m ( p = 0.011), and 5 m ( p = 0.004). The distance of discharge was associated with final pellet location ( p = 0.001). Conclusion BB guns should be considered dangerous and potentially deadly when aimed at the orbit. Although the thick calvarium can protect the intracranial space from BB penetration, the orbit may be a vulnerable entry point with relatively low resistance, allowing penetration of the intracranial and periorbital spaces.

Perceived Conjunctival Foreign Material Egress in Morgellons Disease: A Case Study.

The purpose of this report is to present a case of a 63-year-old man with orbital Morgellons disease. A 63-year-old man presented reporting 15 years of daily egress of different foreign bodies apparently found in the superior fornices of both eyes, exhibiting a classic manifestation known as the matchbox sign. He described the symptoms starting after a facial trauma. The patient stated that at several points over the 15-year course of his condition, he was so distressed that he had contemplated suicide. On multiple exams by a range of ophthalmic professionals, there was no evidence of foreign body. Further investigation involving MRI and plain radiographs demonstrated similar lack of findings. A trial of gabapentin was performed without improvement in symptoms. He discontinued care 5 months later. Morgellons disease is a poorly understood condition, particularly ophthalmic presentations of the disease. Despite extensive investigation, the exact cause of Morgellons disease remains unclear, and there is no definitive treatment for the condition. We highlight the importance of empathetic listening in building trust, as a means of helping the patient to seek psychological help.