Periorbital Pyoderma Gangrenosum Associated With a Cocaine-Induced Midline Destructive Lesion: Case Report and Review of the Literature.

A 72-year-old woman with a history of chronic cocaine use presented 9 months after a dog bite with a large facial ulceration and absent sinonasal structures. Biopsies were negative for infectious, vasculitic, or neoplastic pathologies. The patient was lost to follow up for 15 months and returned with a significantly larger lesion despite abstinence from cocaine. Additional inflammatory and infectious workup was negative. Intravenous steroids were administered with clinical improvement. Therefore, she was diagnosed with pyoderma gangrenosum and cocaine-induced midline destructive lesion due to cocaine/levamisole. Pyoderma gangrenosum is a rare dermatologic condition that uncommonly involves the eye and ocular adnexa. Diagnosis involves clinical examination, response to steroids, exclusion of infectious or autoimmune conditions, and identifying potential triggers including cocaine/levamisole. This report highlights a rare presentation of periorbital pyoderma gangrenosum causing cicatricial ectropion associated with concomitant cocaine-induced midline destructive lesion and reviews important aspects of clinical manifestations, diagnosis, and management of pyoderma gangrenosum and cocaine/levamisole autoimmune phenomenon.

Malignant optic nerve glioma in a young woman with 7 year follow up without recurrence.

PURPOSE: To report diagnostic and management challenges of a case of WHO Grade III glioma of the optic nerve occurring in an unusually young patient with more than 7 years of survival without recurrence. OBSERVATIONS: An 18-year-old woman reported rapidly progressive vision loss in the right eye in the setting of a right optic nerve lesion, central retinal artery occlusion, central retinal vein occlusion, and neovascularization of the optic disc. An orbital MRI with contrast demonstrated enhancement of the intraocular, intraorbital, and intracanalicular portion of the right optic nerve. Biopsy of a portion of the intraorbital optic nerve was negative, however, biopsy of the intracranial optic nerve confirmed WHO Grade III glioma (anaplastic astrocytoma). Although the tumor was excised, there remained positive margins at the optic chiasm. The patient was then managed with a combination of radiation and temozolomide. Postoperatively, the initial neovascularization of the optic nerve that had resolved, re-emerged with gliosis. In this setting a concern for intraorbital tumor arose and the globe was enucleated, definitively ruling out neoplasm. The patient has remained tumor free seven years after resection. CONCLUSIONS AND IMPORTANCE: Malignant optic pathway glioma is rare and carries a high 5-year mortality rate. Diagnosis can be elusive given orbital MRI with contrast often appears to be non-specific. Inflammatory changes can be confounding such that a biopsy in the respective area will yield a negative pathologic result. Repeat biopsy is recommended if clinical suspicion is high. Combination treatment of optic nerve tumor resection, temozolomide and radiation has been effective in treating this patient who continues to be followed closely and has had no clinical or radiographic evidence of recurrence in over 7 years. The re-emergence of neovascularization with gliosis/fibrosis of the optic nerve, was driven by ischemia and further precipitated by radiation. To our knowledge this patient represents the youngest reported case of malignant optic nerve glioma with the longest reported survival in the literature to date (over seven years).

The Flipped Classroom: An Innovative Approach to Medical Education in Ophthalmology.

OBJECTIVE: The aim of the study is to report the creation of a flipped ophthalmology course and preclinical medical student perceptions and knowledge gains before and after a flipped ophthalmology course. DESIGN: The form of the study discussed is an observational study. SUBJECTS: The subjects involved in the study are second-year (U.S.) United States medical students at the University of Miami, Miller School of Medicine (n = 401). METHODS: Second-year medical students participated in a 1-week "flipped classroom" ophthalmology course geared toward primary care providers at the University of Miami, Miller School of Medicine. Eleven hours of traditional classroom lectures were condensed into 4.5 hours of short videos with self-assessment quizzes, small group discussions, and a large group case-based discussion. Fifty-seven short videos (<9 minutes) focused on major ophthalmology topics and common conditions were viewed by the students at their leisure. Students completed a pre- and post-course evaluation on their perceptions and opinions of the flipped classroom approach. Final exam scores in the flipped classroom cohort were compared with the final exam scores in the traditional didactic format used in years prior. MAIN OUTCOME MEASURES: The main outcome measures include: student final exam performance; student satisfaction, opinions, and perceptions. RESULTS: Over the course of 2 years, 401 second-year U.S. medical students participated in the flipped classroom ophthalmology course. The majority of students enjoyed the flipped classroom experience (75.3%) and expressed interest in using the approach for future lessons (74.6%). The flipped classroom videos were preferred to live lectures (61.2%). Over 90% of students stated the self-assessment quizzes were useful, 79% reported that the small group discussions were an effective way to apply knowledge, and 76% cited the large group case-based discussion as useful. Pre-course knowledge assessment scores averaged 48%. Final examination scores in the flipped group (average ± standard deviation [SD] = 92.1% ± 6.1) were comparable to that of the traditional group when evaluating identical questions (average ± SD = 91.7% ± 5.54), p = 0.34. CONCLUSION: The flipped classroom approach proved to be a well-received and successful approach to preclinical medical education for ophthalmology. This was achieved using 35% less course time than our traditional course. This innovative approach has potential for expansion to other medical schools, medical education abroad, and for other medical school modules.