Comparison of the clinical characteristics of benign and malignant eyelid lesions: an analysis of 1423 eyelid lesions, compared between ophthalmology department and plastics department.

PURPOSE: Oculoplastic surgeons excise and reconstruct eyelid tumors, although plastic surgeons have traditionally managed these cases. Current demand of this surgery is growing, and planning referral services is a health management necessity. This pilot study retrospectively reviewed same population eyelid specimens excised by both disciplines comparing data. METHODS: Clinical and epidemiologic features of 1423 eyelid lesions biopsied between 2015- 2020 in Emek Medical Center (EMC), Israel were reviewed. RESULTS: Among 1423 specimens, 1210 (85.0%) were benign and 213 (15.0%) were malignant/pre-malignant. Mean age at diagnosis was significantly higher in malignant tumors than in benign tumors (76 and 59 years respectively, p value < 0.001). The most common benign eyelid lesions were soft fibroma (20.1%), seborrheic keratosis (11.0%) and melanocytic nevus (10.3%). The most common malignant/pre-malignant eyelid tumors were basal cell carcinoma (BCC) (9.2%), actinic keratosis (2.6%) and Bowen's disease (1.9%). Ophthalmology removed 37 malignant/pre-malignant lesions (5.4%) out of 683 compared to plastics removing 142 malignant/pre-malignant lesions out of 740 (19.2%) specimens. Eyelid malignancy in the plastics department was significantly higher than in the ophthalmology department (p value < 0.001). 270 (70.0%) lesions caused by UV exposure were removed by plastics and 116 (30.0%) were removed by ophthalmology (p value < 0.001). CONCLUSIONS: Eyelid lesions in patients aged 76 or older are more likely to be malignant. Ophthalmology eyelid specimens in younger patients are more commonly benign and related to inflammation. Specimens from the plastics department are more commonly malignant, related to UV-exposure, and are from older patients. This difference may be due to a misconception that plastic surgeons have more eyelid cancer reconstruction experience than oculoplastic surgeons, or less awareness of the oculoplastic expertise available today.

Molluscum contagiosum presenting as periorbital abscess in immunocompetent children.

Molluscum contagiosum presenting as a periorbital region abscess is unusual. The virus generally causes a self-limiting localized disease in children. Presentation as an abscess has been reported mainly in immunocompromised patients. We performed a retrospective study of ten children treated for Molluscum contagiosum infection presenting as periorbital abscess. Data investigated included age, immunocompetence, systemic antibiotic treatment, clinical findings, and histopathology. All children were immunocompetent. Bacterial cultures taken in six of the ten children were positive in two. Seven patients received oral antibiotics before presentation but required IV antibiotics on admission. One patient received IV antibiotics only. All antibiotic treatment had very limited effect. Two patients had no antibiotic treatment. CT imaging in one case where orbital cellulitis was suspected showed no significant intraorbital findings with anterior involvement only. Nine out of ten children had surgery and intra-operative cryotherapy at our center with immediate improvement and recovery. One child whose parents initially refused surgical excision had initial limited clinical improvement of periorbital swelling with antibiotics. However, the lesions were excised shortly following discharge from our hospital at another medical center with a complete cure. Molluscum is a cause of periorbital abscess in immunocompetent children which should be part of the differential diagnosis in periorbital/adnexal infection. Antibiotic treatment has a limited effect, and the abscess is most likely a virally triggered reaction. Surgical excision and intra-operative cryotherapy are curative of the disease in our experience.

Is Demodex Blepharitis Connected With Cataract Surgery?

PURPOSE: To determine whether there is an increased incidence of Demodex of the eyelashes among patients after cataract extraction surgery. DESIGN: Prospective, noncomparative clinical study. METHODS: A cohort of patients who underwent cataract extraction surgery had several eyelashes removed preoperatively that were examined independently by the hospital laboratory for the presence of the Demodex mite. This was repeated 3 weeks after surgery. During several postoperative weeks, patients received the standard treatment of steroid drops alone for a period as individually required. RESULTS: A total of 62 patients were included in the study (31 men and 31 women), with a mean age of 71.04 years (range, 47-87). In the group positive for Demodex, the male-to-female ratio was 2:3 (P = .2772). Demodex colonization was observed in 22.58% of samples before cataract surgery and in 32.26% after cataract surgery and topical postoperative steroid therapy (P = .0143). CONCLUSIONS: There is a statistically significant increase in Demodex colonization of eyelashes after cataract surgery and postoperative topical steroid treatment. Although Demodex colonization does not necessarily cause blepharitis, our findings of increased colonization should raise the possibility of Demodex blepharitis being considered by ophthalmologists in patients with chronic postoperative eye discomfort after cataract surgery. This study was carried out at the Emek Medical Center.

Impact of Otorrhea and Positive Cultures on Tympanoplasty Outcomes.

BACKGROUND: Chronic suppurative otitis media is a long-standing middle ear infection with a perforated tympanic membrane. Tympanoplasty is the mainstay of treatment. Most surgeons prefer to operate on dry ears; however, this may be difficult to achieve. OBJECTIVES: To investigate the effect of otorrhea and positive cultures on the outcome of tympanoplasty. METHODS: This retrospective analysis reviewed patients with chronic suppurative otitis media who underwent tympanoplasty 2008-2015. Patients were divided into three groups: active discharge and bacterial growth, active discharge without bacterial growth, and no ear discharge. Surgical outcomes were compared among the groups. RESULTS: Among 101 patients included, 43 ears (42.6%) had discharge preoperatively, 58 (57.4%) were dry. Overall closure rate was 81.2% (82/101). Preoperative active discharge closure rate was 88.3% (38/43) and without discharge 75.9% (44/58). There were 38 positive cultures preoperatively and five negative cultures. Cultures were not obtained in 58 cases. Success rates were 89.5%, 80%, and 75.9%, respectively. No significant difference was found between patients who had positive or negative cultures before the procedure (P > 0.48) or among the three groups (P = 0.25). The most common bacteria were Pseudomonas aeruginosa (n=17), followed by Staphylococcus species (n=10). None was significantly associated with operative failure (P = 0.557). The postoperative air threshold difference was not affected by culture results (P = 0.3). CONCLUSIONS: Tympanoplasty success rates and postoperative air threshold differences were not affected by the presence of preoperative otorrhea or positive ear cultures. Surgery can be performed even when the ear is not dry.

Diplopia from abducens nerve paresis as a presenting symptom of COVID-19: a case report and review of literature.

Neurological manifestations of novel coronavirus disease 3019 (COVID-19) remain unclear. We report the case of a 44-year-old febrile man who presented with double vision and headache 2 d after initial symptoms of fatigue, generalized muscle weakness, and loss of appetite. He was subsequently diagnosed with COVID-19 and transient abducens nerve paresis. He did not present with any respiratory symptoms or additional specific neurological findings. We recommend that with the rising number of cases across the world, physicians develop a greater index of suspicion for COVID-19 in patients with cranial neuropathies, even in those with mild disease without typical respiratory symptoms.

C-KIT Expression in Orbital Cavernous Venous Hemangiomas.

Orbital (slow flow) cavernous venous hemangiomas (OCVH) are the most common benign orbital tumors in adults. The c-KIT is a tyrosine kinase receptor, which is expressed on several types of cells, is thought to play a key role in tumor pathogenesis. The purpose of this study was to evaluate the presence of the receptor c-KIT in OCVH. Our retrospective study examined 16 orbital cavernous venous hemangiomas from 16 cases operated on between 2006-2016 at Emek Medical Center. The mean tumor size was 18.4 mm. Symptoms appeared between 6 months and 22 years before operation. All specimens were analyzed for the c-KIT receptor through immunohistochemistry. The c-KIT was expressed by the endothelium in all 16 preparates. Staining was strong in two cases, moderate in six, and weak in eight cases, with no statistically significant correlation between staining and tumor size (p = 0.69) or the symptom duration (p = 0.15). We conclude that c-KIT may play an important role in the pathogenesis of OCVH. This pilot study is significant in that tumor-targeted therapy such as Imatinib Mesylate and Sunitinib may have a role in treating surgically complicated cases located in the orbital apex. A large multicenter collaborative study is necessary to examine the role of c-KIT in OCVH.

Role of oncogenic viruses in the development ocular surface squamous neoplasia.

PURPOSE: The pathogenesis of ocular surface squamous neoplasia is not fully understood. Therefore, we evaluated the role of oncogenic viruses in the pathogenesis of ocular surface squamous neoplasia in Israel. METHODS: Patients with ocular surface squamous neoplasia were enrolled in this retrospective study. The specimens were taken during 2004-2015 from two big centers: Emek Medical Center, Afula and the Hadassah Medical Center, Jerusalem. All the specimens (totally 26) were analyzed by immunohistochemistry for evidence of oncogenic viruses that included Human Papilloma virus, Herpes Simplex virus and Cytomegalovirus infection and 14 samples were examined by polymerase chain reaction. In addition, all the samples were examined for Epstein Barr virus infection by immunohistochemistry and Epstein Barr encoding region test. RESULTS: Twenty-six patients were included with a mean age of 61.81 [Formula: see text] 3.83 years (mean [Formula: see text]. Immunohistochemistry staining and Epstein Barr encoding region test did not detect any of the oncogenic viruses in the 26 samples. Human Papilloma virus-16 and -18, and Herpes Simplex virus were detected by polymerase chain reaction in 14.2%, 7% and 7%, respectively. CONCLUSION: We conclude from our study that oncogenic viruses may play a role in the pathogenesis of ocular surface squamous neoplasia in Israel.

CT definition of the surgical apex in the orbit.

The orbital apex is an undefined but well understood concept of Orbital Surgeons. We sought to determine the surgical apex area specifically where the volume ratio decreases significantly impacting on the optic nerve. A retrospective analysis using PACS program processing, measured the right retrobulbar space volume changes in 100 randomly selected cases without orbital pathology where CT was performed for non-ophthalmic indications. Volume of the retrobulbar space was measured between two recognizable landmarks. The first landmark being the point of exit of the optic nerve from the eye and the second landmark the optic nerve's point of exit from the orbit. The measured length between these two points was divided into five equal segments, V1-V5. The volumes of all 5 segments were compared and the most significant area of volume depletion was established. The mean numeric value of measured orbital volumes was compared. A ratio difference of V1/V2 was less than 2, V2/V3 was 2.32 (± 0.27), V3/4 was 3.24 (± 0.39), and V4/V5 was 5.67 (± 1.66). The most remarkable difference in ratio was between V4 and V5 (mean 5.67 ± 1.66 with p < .0001). The V3 segment (the posterior 3/5 of the retrobulbar space volume) is the location where decrease in orbital volume impacts, and measured ratios are statistically significant. We defined the surgical apex as the posterior 3/5 of the retro-bulbar orbital space. It is consequently the area of higher risk for optic nerve compression. This definition could be routinely utilized by ophthalmologists and neuroradiologists when evaluating masses affecting the orbit.

Ophthalmic Assessment in Patients With Darier Disease.

PURPOSE: To assess the prevalence of ophthalmic findings in patients with Darier disease, an autosomal dominant genetic skin disorder, in an effort to evaluate the need for eye examinations in the management of the disease. DESIGN: Prospective observational case series. METHODS: Thirty-six individuals with Darier disease were evaluated by both ocular assessment questionnaire and a comprehensive ophthalmic examination (visual acuity, refraction, external examination, and slit-lamp examination) with emphasis on the eyelids, conjunctiva, and cornea. In addition, questionnaire-based medical interview and skin examination were conducted. RESULTS: According to the medical questionnaire, 39% of patients reported eye problems, 36% dry eye, and 42% eye fatigue after prolonged reading. Ocular examination revealed Darier disease lesions on the eyelids in 55% of the patients, blepharitis in 44%, conjunctival hyperemia in 28%, and short tear film break-up time in 83%. There was no significant relationship between any of these ophthalmic findings and systemic retinoid therapy, sex, or age. CONCLUSIONS: The high prevalence of blepharitis and dry eye highlights the importance of ophthalmologic evaluation of patients with Darier disease.

Filler Migration to the Orbit.

BACKGROUND: Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications. OBJECTIVES: We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed. METHODS: A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections. RESULTS: Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively. CONCLUSIONS: Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

Common Orbital Infections ~ State of the Art ~ Part I.

Infections of the orbit and periorbita are relatively frequent, and can cause significant local and systemic morbidity. Loss of vision occurs in more than 10% of patients, and systemic sequelae can include meningitis, intracranial abscess, and death. Numerous organisms infect the orbit, but the most common are bacteria. There are many methods through which orbital infections occur, with infection from the neighboring ethmoid sinuses the most likely cause for all age groups. Prompt management is essential in suspected orbital cellulitis, and involves urgent intravenous antibiotics, rehydration, and treatment of any co-existent underlying systemic disease, e.g., diabetes, renal failure. This review summarizes the common infectious processes of the orbit in both pediatric and adult groups. We review pathophysiology, symptoms, signs, and treatment for infectious orbital processes.

Rare Orbital Infections ~ State of the Art ~ Part II.

Infections of the orbit and periorbita are relatively frequent. Identifying unusual organisms is crucial because they can cause severe local and systemic morbidity, despite their rarity. Opportunistic infections of the orbit should be considered mainly in debilitated or immunocompromised patients. The key to successful management includes a high index of suspicion, prompt diagnosis, and addressing the underlying systemic disease. This review summarizes unusual infectious processes of the orbit, including mycobacterial, fungal, and parasitic infections, as well as their pathophysiology, symptoms, signs, and treatment.

Long-term uveal melanoma survivors: measuring their quality of life.

PURPOSE: Patients with uveal melanoma (UM) undergo lifelong follow-up as metastases can occur more than 20 years after diagnosis. Little is known about the quality of life (QoL) of UM survivors over such an extended period. To investigate their QoL, we used various estimating factors. METHODS: A cohort of patients diagnosed and treated for UM with regularly scheduled follow-up visits was asked to fill in a European Organization for Research and Treatment of Cancer (EORTC) questionnaire comprised of the EORTC QLQ-C30 and EORTC QLQ-OPT30 modules. An additional open question examined other changes in the patients' lifestyle since diagnosis. Independent demographic and medical data were collected from patient records. RESULTS: Two hundred and thirty-two of 294 patients agreed to complete the questionnaire. General QoL correlated highly with the eye-related QoL. Statistically significant higher QoL was associated with tumours not involving the ciliary body, and with better best-corrected visual acuity (BCVA). A subgroup of 39% of the patients reported severe disability affecting eye-related tasks. Thirty-three per cent were highly concerned about various aspects of their future health. Patients who underwent enucleation reported lower eye-related QoL and described problems related to body image in response to the open question. CONCLUSION: General QoL of UM patients is only slightly affected by their malignancy. However, body image and psychosocial adjustment are major issues involved in evaluating QoL. Continuous long-term psychosocial treatment is needed from the time of diagnosis in a subgroup of patients suffering from eye-related disabilities.

Characteristics of orbital lymphoma: a clinicopathological study of 26 cases.

OBJECTIVE: Evaluation of the medical data of patients with orbital and adnexal lymphoma. DESIGN: Cohort study of all cases diagnosed with orbital or adnexal lymphoma at Meir Medical Center between 1993 and 2007. PARTICIPANTS: Twenty-six patients, with intraorbital or subconjunctival masses with orbital involvement, were examined and followed up between 1 and 8 years. MATERIALS AND METHODS: Examined data included: clinical presentation, age, gender, imaging, tumor location, surgical management, and pathological diagnosis. RESULTS: Presenting signs and symptoms included proptosis, eyelid lesions, tearing, chemosis, decreased visual acuity, ptosis, pain, squint, and optic nerve compression. In five cases, lymphoma was misdiagnosed on neuroimaging. Bone changes were seen in four patients. All cases were B cell lymphomas; with the majority (22 cases) of small B cell type; consisting of primary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue and two cases of small cell lymphoma. One small cell lymphomas was of follicular type on a background of CLL, and the other was CLL/SLL type. Fourteen cases were primary orbital disease, and 12 cases were systemic disease. Macroscopic appearance of lymphoma at open biopsy was characteristic in most cases. Flow cytometry phenotyping gave rapid reliable diagnosis of the disease. CONCLUSIONS: Epiphora or chemosis in the presence of an orbital mass should alert the ophthalmologist to suspect lymphoma. Lymphoma may be easily misinterpreted on neuroimaging for other diseases. Bone changes seen on CT are more common than is generally perceived. Macroscopic appearance at open biopsy was characteristic.

A novel eyelid motion monitor.

BACKGROUND: Eyelid motion analysis can provide important information about ophthalmic, neurologic, and systemic diseases. Routine assessment of eyelid function is currently based mainly on clinical examination estimating Levator Function and static palpebral fissure measurements. Most clinical tools developed to date are cumbersome expensive and difficult to operate. Currently there is no widely available, affordable device providing user friendly precision based evaluation of eyelid kinematics. Our goal is to develop a novel device for evaluation of eyelid kinematics providing rapid defined diagnosis of diseases involving eyelid movement. METHODS: A real-time prototype eyelid motion monitoring system was designed based on magnetic field sensors detecting movement of a tiny magnet located on the upper eyelid. Motion is recorded and analyzed using specially developed hardware and software, respectively, enabling both real-time and off-line data presentation. The Eyelid Motion Monitor correlates between blinking characteristics of eyelid movement and the output voltages produced by the system. Blink detection is defined as peak in voltage, caused by eyelid closure or opening. The device was tested on 20 healthy volunteers with normal clinical blinking patterns. RESULTS: The Eyelid Motion Monitor succeeded in detecting full blink motion. The system easily extracts different parameters of eyelid kinetics. CONCLUSIONS: An inexpensive prototype novel device was developed for monitoring and analyzing eyelid motion characteristics, including the inter-blink interval, eye closing/opening duration and entire blink duration. The device should allow early objective non- invasive diagnosis and follow-up of disease progression. It could be of great potential value in many ophthalmic, neurologic, and systemic diseases.

Ocular Paintball Injuries.

UNLABELLED: Background: One of the most alarming ocular injury trends in recent years has been the proliferation of paintball guns and the proportional increase in the number of ocular eye injuries caused by paintballs. OBJECTIVES: To describe five cases of paintball eye injuries that resulted in loss of functional vision in four of them. METHODS: We conducted a retrospective review of the clinical course in five patients with paintball eye injuries treated in the ophthalmology departments of two medical centers. RESULTS: Five young males were evaluated for paintball injuries caused by blunt trauma. There was one case of full-thickness laceration (globe rupture). Four patients required one to five surgical interventions: three of these involved the removal of traumatic cataract including two eyes with significant zonular dehiscence treated by lens capsule conservation using anchoring devices, one retinal surgery and two glaucoma filtration surgeries. However, final visual outcome was not favorable due to irreversible retinal damage. CONCLUSIONS: Paintball trauma often results in significant ocular injury and loss of functional vision despite successful surgical intervention. Most injuries occur in under-supervised settings and are easily preventable. Improved safety measures, strict regulation enforcement and appropriate public education could prevent such serious damage.

Identification of human papillomavirus in pterygium.

PURPOSE: The purpose of this study was to evaluate the involvement of human papillomavirus in the pathogenesis of primary and recurrent pterygium in northern Israel. METHODS: A retrospective study examined 100 randomly chosen pterygium specimens with solar elastosis, from 100 patients who underwent pterygium surgery during 2012-2013 at the Emek Medical Center. All the specimens were analysed for evidence of human papillomavirus infection by immunohistochemistry. RESULTS: Human papillomavirus was not detected in any of the 100 pterygia samples by immunohistochemistry. These used samples were taken from 100 patients with mean age of 51.5 years and a primary: recurrent ratio of 8.09:1. CONCLUSION: We conclude from our study that human papillomavirus infection does not appear to be an important pathogenic factor of pterygium in Israel.

Fornix triamcinolone injection for thyroid orbitopathy.

PURPOSE: In this pilot study we aimed to examine the association between eyelid fornices triamcinolone injections and clinical activity score in patients with active thyroid orbitopathy. METHODS: Adult patients aged 18 years or older, diagnosed with active thyroid orbitopathy and a clinical activity score ≥ 3 were recruited to this interventional prospective pilot study between 2010 and 2013. Three upper and lower fornices injections of triamcinolone acetate 20 mg (40 mg/ml) were administered at 4-week intervals. Each patient included was followed up for a period of 6 months. Clinical activity score was estimated at each monthly visit. Extraocular muscle thickness was measured by ultrasound examination at entrance and at the last visit. RESULTS: Eleven eyes of seven patients were included in our study. Initial clinical activity score was 3.81 ± 1.80 and fell to 0.63 ± 0.72 during a 6-month follow-up. There was a significant difference in clinical activity score between the baseline examination and the following visits (p-value < 0.0001). Ultrasound examination showed a significant decrease in medial and lateral rectus muscle thickness following treatment; median difference -0.93 and -0.58, respectively (p-value < 0.005). Lid retraction was reduced by the treatment. Side effects included a transitory increase in intraocular pressure in one patient, which was controlled with topical medication. CONCLUSIONS: In this pilot study a series of three separate triamcinolone fornix injections at 4-week intervals reduces the inflammatory effects of thyroid orbitopathy, as measured by clinical activity score. The treatment was simple, effective, and safe eliminating the side effects associated with systemic corticosteroid use.

[Leber's hereditary optic neuropathy].

Lebers hereditary optic neuropathy (LHON) is a maternally inherited disease characterized by subacute severe visual loss in both eyes, which usually manifests in young adulthood. The disease has maternal inheritance due to mitochondrial DNA mutation. The final diagnosis is genetic. There is still no proven treatment, but there is significant progress in developments on the genetics of the disease to reach gene therapy. In this article we review the latest literature relevant to this disease.

Rapid diagnosis of acanthamoeba keratitis using non-nutrient agar with a lawn of E. coli.

BACKGROUND: A patient presented with a corneal foreign body in his only eye. He was treated with prophylactic antibiotics and sent home, but deteriorated. FINDINGS: He returned to the hospital 5 days later, and on slit-lamp examination, there was ciliary injection, corneal oedema and a 1 mm × 1 mm corneal abscess with mild anterior uveitis. Corneal scrapings were taken for culture on a non-nutrient agar with a lawn of Escherichia coli, on chocolate agar and on blood agar. He was treated with fortified gentamicin and cefazolin drops. He improved and was discharged 4 days after admission. On day 5, the culture results showed acanthamoeba. He was brought back to the hospital and treated with hourly chlorhexidine drops, ofloxacin six times daily and neomycin/dexamethasone drops once daily. On day 7, he was discharged to continue treatment at home, at which time his visual acuity in that eye was 6/9, and slit-lamp examination showed punctate keratitis and a stromal opacity with mild peripheral infiltration. CONCLUSIONS: Culture on non-nutrient agar with a lawn of E. coli is a rapid, reliable and less invasive alternative to corneal biopsy for the diagnosis of acanthamoeba infection. We suggest using this method where acanthamoeba is suspected. Owing to the risk of corneal abscess, orthokeratology should be avoided in an amblyopic patient or an only eye. Acanthamoeba infection may be masked by other eye diseases.