Temozolomide-associated blepharoconjunctivitis: a case report.

BACKGROUND: Temozolomide (TMZ) is an effective oral alkylating agent used in treating glioblastoma multiforme (GBM) and high-grade gliomas. It works by introducing methyl groups into DNA, inhibiting cell division. A case of blepharoconjunctivitis linked to the administration of TMZ is detailed in this report. CASE PRESENTATION: We present a case of a 58-year-old African-American man diagnosed with GBM. Following adjuvant TMZ treatment, he developed blepharoconjunctivitis, characterized by eyelid and conjunctival inflammation. Symptoms included eyelid swelling, crusting, and conjunctival discharge, which were promptly resolved with topical steroid cream and eye drops. CONCLUSIONS: Reports specifically linking TMZ to blepharoconjunctivitis are limited. The exact mechanism remains unclear but may involve inflammation extending from blepharitis to the conjunctiva. Healthcare providers must recognize and manage ophthalmic complications promptly. This case report highlights blepharoconjunctivitis associated with TMZ use in a GBM patient. While TMZ is an effective treatment, ophthalmic side effects can occur.

Isolated eyelid neonatal Langerhans cell histiocytosis.

Langerhans cell histiocytosis (LCH) is a condition characterized by clonal proliferation of the phagocytic cells derived from the bone marrow. In this article, we present an exceedingly rare case of congenital/neonatal LCH in a 3-week-old girl who initially presented with an isolated swelling of the eyelid, initially misdiagnosed as a chalazion. Subsequently, a biopsy was performed, and histopathological evaluation confirmed the diagnosis of LCH. A staging work-up revealed no evidence of multisystem involvement, and thus, local steroid injection was performed as the initial treatment for the residual lesion. Cases of localized LCH that manifest as eyelid masses are rare, and most reported cases involve children over the age of one year. To the best of our knowledge, this case represents the first reported instance of neonatal LCH presenting as an eyelid mass. Although neonatal LCH is rare, ophthalmologists must be aware of this presentation and include it in the differential diagnosis for eyelid lesions in infants during the first month of life.

Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke.

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP), the absence of structural lesions on neuroimaging, and normal cerebrospinal fluid composition. Cerebral venous sinus thrombosis (CVST) is a common cause of increased ICP and can be differentiated from IIH with magnetic resonance venography. We describe a young woman with typical IIH who underwent lumbar puncture and was treated with a short course of high-dose corticosteroids followed by acetazolamide. She subsequently developed CVST, subarachnoid hemorrhage, and stroke. Risk factors that may have resulted in CVST are discussed.

The Arkansas Tessier Number 3 Cleft Experience: Soft Tissue and Skeletal Findings With Primary Surgical Management: Four-Step Approach.

Tessier No 3 facial cleft (oro-nasal-ocular clefts) is the rarest and most challenging of all the Tessier clefts. Reports on Tessier No 3 clinical findings, surgical techniques, and outcomes are varied due to the scarcity of patients and the wide range of phenotypic findings. The authors present our experience of 2 children born with Tessier No 3 clefts who were both managed at the Arkansas Children's Hospital. Our purpose is to add knowledge on this rare craniofacial cleft by providing detailed soft tissue findings, skeletal findings, operative techniques, early postoperative outcome, and suggestions of a treatment protocol.Both were born at 38 weeks gestation and had multiple associated anomalies including: syndactyly, limb anomalies, cardiac defects, and encephalocele in Patient 1 and hydrocephalus and dysphagia in Patient 2. While both patients had a bilateral cleft lip and palate, Patient 1 had a severe left-sided cleft and Patient 2 had a right-sided incomplete cleft. A multidisciplinary team of specialists in Plastic Surgery, Otolaryngology, and Oculoplastics were assembled to devise a top-down approach for repair. In brief, our surgical sequence for both infants was a dorsal nasal Reiger flap to level the ala, cheek advancement flap along with medial canthal repositioning, and more traditional bilateral cleft lip repair using a modified Millard technique. Postoperatively, Patient 1 experienced some early scarring, medial canthal rounding, lagophthalmos, and cicatricial retraction of the lower lid and patient 2 demonstrated under-correction of the displaced ala but had satisfactory medial canthal position.Future evaluations will include serial photography and annual 3-dimensional computed tomography scans to evaluate the soft tissue and bony growth. After these initial procedures, both infants will be followed for routine cleft clinical and surgical care.

Investigation of goldmann perimetry in evaluation of patients for upper eyelid blepharoplasty.

PURPOSE: To determine if preoperative Goldmann Visual Field (GVF) testing in patients with functional dermatochalasis accurately depicts the postoperative superior visual field (SVF) outcome. METHODS: A prospective cohort study was done to compare preoperative and postoperative GVF field tests in patients undergoing upper eyelid blepharoplasty for treatment of dermatochalasis. This study was conducted in accordance with the Declaration of Helsinki and approved by the University of Arkansas for Medical Sciences institutional review board. A preoperative GVF was obtained with the eyelids in the natural position (untaped) and then again with excess skin elevated (taped). One month post-blepharoplasty, another GVF was conducted with eyelids untaped. The pre- and post GVF tests were analyzed to determine if preoperative testing accurately predicts the SVF improvement post-blepharoplasty. RESULTS: Forty-six eyelids (23 patients) who underwent blepharoplasty for dermatochalasis were included. The preoperative testing underestimated 76% (35/46) of cases by a mean of 61%; and overestimated the final outcome in 24% (11/46) of cases by mean of 23%. Overall, the preoperative GVF testing underestimated the postoperative outcome by a mean of 35%. CONCLUSION: Improvement of the SVF after a blepharoplasty is typically greater than the preoperative GVF testing predicts.

Consideration for eliminating conjunctival closure in the enucleation procedure.

To compare post-operative results and complications in patients who undergo enucleation with or without suture closure of the conjunctiva. This was a retrospective chart review study. Review of 50 cases of enucleation surgery at the University of Arkansas for Medical Sciences and Arkansas Children's Hospital between July 2011 and December 2014. Criteria for inclusion in the study were all cases of enucleation that had extraocular muscles attached to a spherical orbital implant with or without conjunctival closure, and at least 2 months of postoperative follow up. Post-operative complications were evaluated. A total of 36 cases fulfilled the criteria for inclusion in the study; 12 cases with direct sutured layered direct closure of Tenon's and then conjunctiva and 24 cases with Tenon's capsule sutured closure but without direct conjunctival sutured closure. No implant complications were identified in either group (p = 1.0). Mean follow-up for all groups was 16.71 months (range 2 to 43 mo., SD 11.94). Mean follow up for the non-closure group was 14.42 months (range 2.25 to 36 mo., SD 10.35). Two cases in the conjunctival closure group developed a conjunctival cyst, affecting prosthesis fit, approximately 3 months postoperatively: no such cysts were identified in the non-conjunctival closure group. Fisher exact test for cyst formation between the two groups was not statistically significant (p = 0.1048). Direct conjunctival closure following enucleation surgery does not appear to increase the risk of extrusion, exposure, or infection. Foregoing direct closure decreases surgical time and reduces cost. It is unclear if this decreases conjunctival cyst formation.

Choroidal Ganglioneuroma and Orbital Plexiform Neurofibroma Presenting as Buphthalmos in an Infant With Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant familial tumor predisposition syndrome characterized by the growth of benign and malignant tumors involving the peripheral and central nervous system. In the following report, the authors describe a case of a 1-year-old child with NF-1, who underwent enucleation for a blind, proptotic, painful eye with subsequent histopathological examination revealing choroidal ganglioneuroma, a very rare entity.

Naphazoline as a confounder in the diagnosis of carotid artery dissection.

Diagnosing Horner Syndrome can be difficult in the setting of an incomplete triad. A 27-year-old man presented with unilateral eyelid droop and intermittent ipsilateral headaches, having already seen 7 physicians. Physical examination revealed unilateral ptosis but no pupillary miosis or facial anhidrosis. Inspection of his clinical photographs revealed elevation of the ipsilateral lower eyelid, suggesting sympathetic dysfunction. On further questioning, he admitted to naphazoline dependence. Reexamination after ceasing the naphazoline unveiled the anisocoria. Vascular imaging subsequently revealed carotid dissection, and the patient was started on anticoagulant and antiplatelet therapy. The ptosis persisted after conjunctival Müllerectomy. External levator resection was recommended, but patient declined. This case underscores the importance of clinical photography, meticulous medical record review, and complete medication history including over-the-counter preparations. Clinicians should meticulously inspect the lower eyelid in cases of atypical blepharoptosis and consider the effects of eye drops when inspecting pupils for miosis.

Fontal Sinus Mucocele Manifests as Persistent Draining Abscess of Upper Eyelid.

Paranasal sinus mucocele and pyomucocele have a wide spectrum of symptomology and chronicity of clinical manifestations. We present a case of a 52-y/o previously healthy homeless male that presented with a 2-week history of a non-tender, persistently draining upper eyelid abscess, and 1-year history of nonspecific change of general appearance to his left eye.

Basal cell carcinoma appearing to emanate from the punctum.

Purpose: To present the clinical and histological characteristics of a basal cell carcinoma, which appears to emanate from the lacrimal punctum. Observations: An 81-year-old caucasian female presented with an irritating lesion arising from the left upper punctum for approximately four months. Examination demonstrated a pedunculated pinkish lesion emerging from the left upper punctum. The patient elected to pursue the removal of the lesion. An excisional biopsy was performed by placing a curette within the upper eyelid punctum, and the lesion was scooped out. Pathology showed invasive nodular basal cell carcinoma. Following the diagnosis, a wedge resection of the left upper punctal region was performed, which showed no residual carcinoma. Conclusion and importance: This case describes a unique instance of a basal cell carcinoma clinically appearing to arise solely from the upper eyelid punctum. A level of suspicion should be maintained when excising benign-appearing eyelid lesions, and a histopathological analysis is warranted.

Vismodegib as an adjuvant treatment for periorbital basal cell carcinoma: a case report and review of literature.

Background: Basal cell carcinoma (BCC) is the most common cancer type worldwide. Although there are several treatment options for the treatment of BCC, selecting the best treatment option for periorbital BCC is challenging and it varies case by case. More than half of periocular BCC cases initially occur on the inner angle and lower lid. The treatment options for BCC include radical surgical excision using Mohs micrographic technique, radiotherapy, neoadjuvant vismodegib, imiquimod, and combination therapy followed by reconstruction for functionality and aesthetic outcome. Selection of each treatment varies based on the severity and extension of BCC. Case Description: We report a case of periorbital BCC invading the left lower eyelid in a 50-year-old Caucasian male which was initially excised a few years ago, and, following recurrence, the patient underwent Mohs micrographic surgery. Due to a recurrence after Mohs micrographic surgery, treatment with oral vismodegib was started, which led to near-total tumor shrinkage. To determine the outcome of periorbital BCC treated with vismodegib, we reviewed the literature on the periorbital BCC treated with vismodegib, their follow-up period, outcome, and whether they were metastatic or had recurrence. Conclusions: Neoadjuvant vismodegib, followed by surgery excision, such as Mohs micrographic surgery, has shown a promising clinical and aesthetic outcome in the treatment of periorbital BCC.

Investigating the role of metal fatigue in a case of ritleng probe fracture: its causes and prevention.

Complications with the Ritleng probe have not been reported previously. Herein, we report a case in which the Ritleng probe tip fractured during use on a patient undergoing nasolacrimal duct intubation requiring subsequent retrieval. A root-cause analysis was conducted which help to elicit possible ways to prevent such a complication in the future. Most notably the use of the stylet, documented as a cleaning device, seems to offer additional support to prevent metal fatigue and tip fracture.

Electronically assisted nasolacrimal duct silicone intubation.

PURPOSE: Nasolacrimal duct intubation (NLDI) with silicone stents is a common procedure used by general ophthalmologists, oculoplastic surgeons, and otolaryngologists, among others. The procedure can be difficult to teach and to master. The authors investigated the usefulness and safety of an electronic device to aid endonasal retrieval of the lacrimal stent used in NLDI. METHODS: A prospective interventional surgical technique case series was designed and executed with institutional review board approval. Twelve adult patients who were scheduled to undergo NLDI were enrolled. The audible alarm device was used during endonasal retrieval of the probe in each patient. Each patient underwent intraoperative rigid nasal endoscopy at the conclusion of the case. RESULTS: The electronic device successfully localized the endonasal probe in each patient. Nasal endoscopy revealed healthy mucosa with no evidence of thermal or electrical injury. CONCLUSIONS: Electronically assisted NLDI with audible feedback is a small technological advance with potential to improve the safety and efficacy of NLDI. The technique is safe and effective in localizing the intranasal portion of a metal lacrimal probe. Further testing will assess its usefulness in complex cases and as a teaching tool.

Prophylactic postoperative antibiotics for enucleation and evisceration.

PURPOSE: To investigate the necessity and usefulness of prophylactic postoperative antibiotics in patients undergoing enucleation or ocular evisceration. METHODS: A retrospective, multicenter, comparative case series was designed. After obtaining Institutional Review Board authorization, a medical records' review was conducted. Demographics, indication for surgery, surgical technique, postoperative antibiotic dosing, and postoperative course were evaluated. Records were grouped according to antibiotic protocols, and presence or absence of postoperative wound infection (orbital cellulitis) was recorded. Rates of postoperative infection were analyzed statistically. RESULTS: Between 1996 and 2011, 666 evisceration or enucleation surgeries were conducted at 4 institutions. Six hundred forty-eight records were available for analysis, of which 4 were excluded due to insufficient follow-up data. All the remaining 644 patients received a single, perioperative, intravenous dose of antibiotics. Five hundred seventy-eight patients (90%) received an orbital implant, while 66 (10%) did not. Three hundred eighty-one patients (59%) received postoperative antibiotics, and 263 patients (41%) did not. Two cases were identified with signs suggestive of infection, but no culture-positive infections were found, and no patient was admitted to the hospital for management. Of the 2 suspicious cases, 1 was found in the group that received postoperative antibiotics (group 1) and 1 in the group that did not receive postoperative antibiotics (group 2). No statistically significant difference in postoperative infection rate was noted between the 2 groups (p=0.52). While patients with infectious indications for surgery were more likely to receive postoperative antibiotics (p<0.001), there was no statistically significant difference in rates of infection among patients with infectious indications for surgery based on receiving or not receiving postoperative antibiotics (p=0.79), and no patients with infectious indications for surgery not receiving postoperative antibiotics developed a postoperative infection. CONCLUSIONS: This study demonstrates the clinical safety of withholding postoperative prophylactic antibiotics in orbital surgery even when implanting alloplastic material in a sterile field. Furthermore, Centers for Disease Control and Prevention guidelines mandate cessation of postoperative antibiotics within 24 hours of surgery. Surgeons are cautioned not to generalize these results to nonsterile surgery such as sinonasal or nasolacrimal surgery.

A tale of two Purtscher's retinopathy.

PURPOSE: To characterize the outcome in two cases of unilateral traumatic Purtscher's retinopathy that developed after blunt head trauma. METHODS: Observational case series of two patients diagnosed at the University of Arkansas for Medical Sciences with Purtscher's retinopathy following blunt head trauma. All patients underwent a comprehensive ophthalmic examination, which included best corrected visual acuity, slit lamp biomicroscopy, dilated fundus exam, and retinal imaging fundus photography and high-definition Spectral domain optical coherence tomography (HD-SDOCT). RESULTS: Two cases of Purtscher's retinopathy after blunt head trauma were diagnosed between July 2011 and December 2011. Case 1 was involved in a motor vehicle accident and underwent observational management with no change in initial baseline vision (20/400) after follow-up of 4 months. Case 2 fell from a 16-foot high deer-stand and managed with systemic steroids, wherein vision improved after one month from 20/60 (initial presentation) to 20/25; vision remained stable after follow-up of 4 months. CONCLUSION: Purtscher's retinopathy can have different visual outcomes depending on the initial and final degree of injury to the retinal architecture. Steroids may help limit damage and improve the overall outcome in patients with Purtscher's retinopathy.

Timing of Jones Tube Placement After Excision of Nasal or Lacrimal Drainage System Malignancy: A Survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS).

Purpose: To elicit, from a survey of oculoplastic surgeons, the timing and reason for delaying Jones tube placement after the excision of nasal or lacrimal drainage system malignancy. Methods: The authors reviewed current literature and distributed an anonymous survey to 627 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) to determine the length of time members wait to perform a Jones tube placement after the removal of nasal or lacrimal drainage system malignancy. The survey also included questions about the rationale for this waiting period. Results: Fifty-eight members of ASOPRS (9.3%) responded to our survey, 49 (84.4%) of whom had performed Jones tube placement on patients who had an excision of a nasal or lacrimal drainage system malignancy. Nearly 52% of respondents waited one year for Jones tube placement. However, a sizeable number of respondents opted to wait five years (15.1%). The most common rationale for waiting was a concern for tumor recurrence (42 responses). Conclusion: There is no consensus on when to perform Jones tube placement after the excision of nasal or lacrimal drainage system malignancy. This survey demonstrates a broad array of waiting periods between operations, although most surgeons wait 12 months.

Idiopathic sclerosing orbital inflammation: a review of demographics, clinical presentation, imaging, pathology, treatment, and outcome.

PURPOSE: To characterize clinical features, diagnostics studies, treatments, and outcomes of patients with histologically proven idiopathic sclerosing orbital inflammation (ISOI), to define optimal management for this recalcitrant disease, and to determine changes in characterization and management by comparing our results with the last significant literature review. METHODS: A search of the U.S. National Library of Medicine: National Institutes of Health's electronic database for cases and case series in the English literature of biopsy-proven ISOI published between March 1994 and September 2010 was conducted. A cross-literature review was performed to tabulate demographics, clinical findings, studies, treatments, and outcomes, which were compared with the ISOI data published by Rootman et al. (1994). RESULTS: Sixty-one cases, 71 eyes from 17 published reports, met inclusion criteria. No ethnic, sex, or comorbidity predilection was established. Patients typically presented in the fourth decade with proptosis (73%), pain (49%), and normal vision (44%). Orbital imaging and histopathology were sparsely reported. Most common treatments involved systemic corticosteroids either alone (34%) or combined with other modalities (51%). CONCLUSIONS: Characteristics of the disease remain unchanged, and best management was not determined due to inconsistent reporting methods across the literature. Collaboration with established groups (i.e., European Group On Graves Orbitopathy (EUGOGO), International Thyroid Eye Disease Society (ITEDS)) or the formation of a new group of physicians and scientists to help develop a systematic approach for future reporting and evaluation was proposed.

Ocular TASER Probe Injury Managed with Primary Evisceration: Case Report.

A 34-year-old male presented to the emergency department with a penetrating injury of the left globe and orbit from a Thomas A Swift's Electric Rifle (TASER®) probe. The severity of the globe injury precluded primary closure of the globe; a primary evisceration was performed. In this article, we discuss not only the case in detail but also the TASER® rifle and the literature to support our decision in performing an evisceration rather than an enucleation, which historically has been taught to decrease the risk of sympathetic ophthalmia (SO) in the fellow eye. We are of the opinion, after reviewing the literature, that SO is not an overwhelming reason to choose enucleation over evisceration and that evisceration has an advantage over enucleation with regard to functional and cosmetic outcomes.

North American blastomycosis of the eyelid.

A 26-year-old diabetic man presented with a papillomatous eyelid lesion. Histopathology was consistent with Blastomyces dermatitidis. A 1-year course of itraconazole led to resolution in this case. Although skin is the most common extrapulmonary site of blastomycosis, eyelid involvement is rare. Prompt diagnosis and treatment improve morbidity and mortality.

Microkeratome-assisted anterior lamellar keratoplasty.

Microkeratome-assisted anterior lamellar keratoplasty has emerged as a surgical option for conditions affecting the clarity of the outer 200 mum of the cornea. Herein we describe the outcome of a simple procedure in which the excimer laser can be used to augment deep tissue removal after both recipient bed and donor graft are prepared with the microkeratome. Our noncomparative interventional case series involved 5 eyes of 4 patients with lattice corneal dystrophy who underwent microkeratome-assisted anterior lamellar keratoplasty. Outcome measures include preoperative and postoperative best spectacle-corrected Snellen visual acuity. Visante ocular coherence tomography data are reported for several of the patients.