Dacryocystitis in a Patent Nasolacrimal Drainage System: A Literature Review.

INTRODUCTION: Acute dacryocystitis is an acute infection and the lacrimal sac secondary to pathogenic microorganism growth within the stagnant fluid in the lacrimal sac secondary to nasolacrimal duct obstruction. METHODS: A literature review was conducted on the PubMed database using the following search terms "dacryocystic retention" and "dacryocystitis" or "dacryolith" or "lacrimal duct" or "pseudo-dacryocystitis". RESULTS: The literature review suggests that dacryocystitis in a patent nasolacrimal drainage system can stem from diverse causes including the mechanical impaction by dacryoliths, viral infections and anatomical variations. It is believed that these causes lead to transient obstruction to the nasolacrimal excretory system predisposing to secondary infections. Idiopathic temporary dacryocystic retention is also highlighted in this review. CONCLUSIONS: This review broadens the understanding of dacryocystic retention and highlights the need for careful diagnosis and tailored treatment plans, particularly in cases deviating from the traditional etiological pathways.

Art or Artifact: Evaluating the Accuracy, Appeal, and Educational Value of AI-Generated Imagery in DALL·E 3 for Illustrating Congenital Heart Diseases.

Artificial Intelligence (AI), particularly AI-Generated Imagery, has the potential to impact medical and patient education. This research explores the use of AI-generated imagery, from text-to-images, in medical education, focusing on congenital heart diseases (CHD). Utilizing ChatGPT's DALL·E 3, the research aims to assess the accuracy and educational value of AI-created images for 20 common CHDs. In this study, we utilized DALL·E 3 to generate a comprehensive set of 110 images, comprising ten images depicting the normal human heart and five images for each of the 20 common CHDs. The generated images were evaluated by a diverse group of 33 healthcare professionals. This cohort included cardiology experts, pediatricians, non-pediatric faculty members, trainees (medical students, interns, pediatric residents), and pediatric nurses. Utilizing a structured framework, these professionals assessed each image for anatomical accuracy, the usefulness of in-picture text, its appeal to medical professionals, and the image's potential applicability in medical presentations. Each item was assessed on a Likert scale of three. The assessments produced a total of 3630 images' assessments. Most AI-generated cardiac images were rated poorly as follows: 80.8% of images were rated as anatomically incorrect or fabricated, 85.2% rated to have incorrect text labels, 78.1% rated as not usable for medical education. The nurses and medical interns were found to have a more positive perception about the AI-generated cardiac images compared to the faculty members, pediatricians, and cardiology experts. Complex congenital anomalies were found to be significantly more predicted to anatomical fabrication compared to simple cardiac anomalies. There were significant challenges identified in image generation. Based on our findings, we recommend a vigilant approach towards the use of AI-generated imagery in medical education at present, underscoring the imperative for thorough validation and the importance of collaboration across disciplines. While we advise against its immediate integration until further validations are conducted, the study advocates for future AI-models to be fine-tuned with accurate medical data, enhancing their reliability and educational utility.

Superficial Temple Lymphatic Malformation Appeared 13 Years after Initial Presentation With Orbital Lymphatic Malformation.

A 26-year-old male with a history of orbital lymphangioma and compressive optic neuropathy presented with recurrent proptosis in the OS. After examination and imaging, a left orbital lymphatic malformation and a new subcutaneous temporal-parietal vasculo-lymphatic malformation were diagnosed. The patient underwent a bleomycin injection for the orbital malformation and an excisional biopsy for the temporal lesion, leading to symptom resolution. Recurrence of lymphatic malformations and hemorrhage typically occurs at the same site, here we report a patient with the appearance of a new site lesion with orbital recurrence.

Ethmoid Osteoblastoma: A Case Report and Pooled Analysis of Cases.

Osteoblastoma is a typically noncancerous bone tumor commonly found in the spine and long bones of the arms and legs. It is exceedingly rare for this tumor to occur in the paranasal sinuses. We present a case of osteoblastoma in a 13-year-old boy affecting the ethmoid sinus, which manifested as exophthalmos. A computed tomography scan revealed an expansive lesion in the right ethmoid sinus, causing compression and displacement of the orbital contents to the right. The lesion exhibited a mix of ground glass opacity and dense bone. On magnetic resonance imaging, the less dense areas of the tumor showed strong enhancement, while the densely sclerotic regions appeared as signal voids on all imaging sequences. A combined transorbital and transnasal approach was performed to remove the tumor. Histologically, the tumor consisted expansile growth surrounded by a sclerotic rim of inter-anastomosing trabeculae of woven bone set within loose edematous fibrovascular stroma. This case highlights the unusual occurrence of osteoblastoma in the ethmoid sinus, a location seldom associated with this type of tumor, and adds to the existing literature on this topic and offers a new surgical approach to managing this entity.

Orbital abscess with white eye in patients treated with oral antibiotics for orbital cellulitis.

PURPOSE: To report a case series of seven patients with late presentation of orbital/subperiosteal abscess following oral treatment of orbital cellulitis. METHODS: A retrospective case series of all patients presented with orbital abscess following oral treatment of orbital cellulitis from two tertiary-care eye centres in Riyadh, Saudi Arabia, was conducted. Demographic profiles, risk factors, initial clinical presentation, management regimens, and final outcome were analysed. RESULTS: Patients presented mainly with proptosis and limitation of extraocular motility without external ophthalmic inflammatory signs. Most patients needed surgical evacuation despite the appropriate initiation of intravenous antibiotics following presentation to our hospitals. CONCLUSION: Treating orbital cellulitis with oral antibiotics may lead to delayed presentation of orbital abscess without external ophthalmic inflammatory signs.

Cosmetic outcomes of epicanthoplasty for epicanthus tarsalis.

PURPOSE: Epicanthus is a term that refers to the semilunar eyelid skin fold over the medial aspect covering the medial canthal angle. Epicanthus tarsalis is the most common type and is most evident in the Asian population with a prevalence of 40% as opposed to 2%-5% in the non-Asian population. Epicanthoplasty has not been studied in patients of a population of heavier skin pigmentation. METHODS: A retrospective review of patients that underwent Park's modified Z-epicanthoplasty from January 2018 to August 2020. They were categorized based on their Fitzpatrick skin type. Their preoperative and postoperative pictures were analyzed for epicanthal fold correction with focus on scar visibility, pigmentation, and elevation. The patients were contacted over the phone for a questionnaire about their subjective scar assessment and satisfaction rate. RESULTS: A total of 35 patients with mild epicanthus tarsalis were included in this study. Twenty-two patients had Fitzpatrick skin type 3, seven patients had type 4, and six had type 5. Normal postoperative scar pigmentation was reported 37.1% (n = 13) of patients. Scar hypopigmentation was reported in 28.6% (n = 10) and scar hyperpigmentation was reported in 34.3% (n = 12). The final cosmetic satisfaction rate score was a median of 9/10 on the 1-10 scale with 40% recording 10/10 satisfaction. On the scar visibility scale, the median was 3/10. About 82.9% (n = 29) had no scar elevation or hypertrophy. Only one patient had scar hypertrophy and elevation and three patients had a vertical depression scar. No clinical or statistical significance was found when correlating scar visibility and pigmentation with Fitzpatrick skin type. CONCLUSION: Epicanthoplasty is a commonly performed surgery, especially in China and South Korea. In our population, Z-epicanthoplasty has proven to be effective in epicanthus tarsalis with high cosmetic satisfaction rate, low scar visibility, and acceptable scar pigmentation.

Cost Consequence Analysis of Belimumab versus Standard of Care for the Management of Systemic Lupus Erythematosus in Saudi Arabia: A Retrospective Cohort Study.

BACKGROUND: Belimumab use for the management of systemic lupus erythematosus (SLE) has been limited, in part due to its high acquisition cost relative to the standard of care (SoC) and the uncertainties about its cost-effectiveness. Therefore, the aim of this study was to compare the cost and effectiveness of belimumab versus the SoC alone for the management of SLE using real-world data from the perspective of public healthcare payers in Saudi Arabia. METHODS: Data were retrieved from a national prospective cohort of SLE, Saudi Arabia. Adult SLE patients (≥18 yrs.) treated with belimumab plus the SoC or the SoC alone for at least six months were recruited. The effectiveness was measured using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K). Unit costs for health services and prescription drugs were retrieved from the Saudi ministry of health. Nonparametric bootstrapping with inverse probability weighting was conducted to generate the 95% confidence limits for the cost and effectiveness. RESULTS: A total of 15 patients on belimumab plus the SoC and 41 patients on the SoC alone met the inclusion criteria and were included in the analysis. The majority of patients were females (91.07%) with a mean age of 38 years. The mean difference in cost and SLEDAI-2K score reduction between belimumab versus the SoC were USD 5303.16 [95% CI: USD 2735.61-USD 7802.52] and 3.378 [95% CI: 1.769-6.831], respectively. Belimumab demonstrated better effectiveness but higher cost in 96% of the bootstrap cost-effectiveness distributions. CONCLUSION: Future studies should use more robust research designs and a larger sample size to confirm the findings of this study.

Dacryops and clinical diagnostic challenges.

OBJECTIVE: The study aims to describe the clinical and histopathologic features of different types of dacryops and their clinical diagnostic challenges. METHODS: This is a retrospective cohort study of all surgically excised cases of dacryops in 2 tertiary eye hospitals in Riyadh, Saudi Arabia. RESULTS: The study included 58 dacryops specimens from 55 patients with an average age of 41.2 years (range, 4-78 years). The most common location was the upper lid (60.3%), whereas the least expected location was the caruncle (6.9%). The most common site of dacryops occurrence was in the accessory lacrimal gland (55.2%), the main lacrimal gland (32.8%), and then ectopic dacryops (12%). All patients presented with lid swelling alone except for 3 patients who experienced secondary mechanical ptosis. On physical examination, conjunctival scarring existed in 4 patients (6.9%). Preoperative diagnosis of dacryops was accurate in 44.8% of the cases. Dacryops of the main lacrimal gland was accurately diagnosed clinically in all cases compared with other locations, which was statistically significant (p < 0.001). The causes of inaccurate clinical diagnoses were hidrocystoma (26.9%), inclusion cyst (11.5%), and dermoid cyst (7.7%), whereas the remaining cases were diagnosed as cysts without a specific subtype (53.9%). Recurrence of the lesion was observed in 2 cases (3.5%). No clinical or histopathologic factors were associated with a risk of recurrence. CONCLUSION: Dacryops can represent a diagnostic challenge to ophthalmologists. Familiarity with clinical presentations and findings is required to diagnose dacryops outside the main lacrimal gland.

Long-term surgical outcomes of levator resection in patients with Marcus-Gunn jaw-winking ptosis.

PURPOSE: To report long-term surgical outcomes of a series of MGJWS patients with moderate ptosis who underwent levator resection. MATERIALS AND METHODS: A retrospective review of medical records of 10 MGJWS patients with moderate ptosis who underwent levator resection was performed in two major eye centers in Riyadh, Saudi Arabia from January 1987 to December 2019. Clinical features, pre-operative and post-operative data of the 10 patients were recorded. OUTCOME MEASURES: Long-term upper eyelid position. RESULTS: The mean patient age at presentation was 5.4 years. Seven patients were female and three were male. All patients had moderate ptosis with marginal reflex distance ranged from 1 to 2 mm. The mean age at surgery was 9.5 years. After initial good ptosis correction for all patients, seven of them had a recurrence of ptosis several months after levator resection. CONCLUSIONS: Levator resection in MGJWS patients with moderate ptosis and good levator function is associated with a high rate of ptosis recurrence and less predictable surgical results.

The impact of social media accounts on periocular cosmetic surgeries.

PURPOSE: The study aims to assess the impact of social media on patients who underwent periocular cosmetic surgeries during 2019 and to determine the appropriate platforms to enrich the knowledge and awareness of the general Saudi population regarding periocular cosmetic surgeries. METHODS: A cross-sectional study was conducted at Ibn Rushd Hospital, Riyadh, Saudi Arabia. Three hundred and ninety-five participants with periocular cosmetic surgeries in 2019 were recruited for the study. The questionnaire included 43 questions distributed under four domains: demographics, personal and family history of periocular eye surgeries, influence of social media on cosmetic eye procedures, and psychological effects of social media. RESULTS: Periocular cosmetic surgeries were more common among women, with eyelid surgery being the most popular type. About 48.9% of the participants knew their oculoplastic surgeons from social media platforms, and over 57% who used accounts on social media were interested in cosmetology managed by nonphysicians. The majority of the participants (64.1%) chose Instagram as a social media platform to find an oculoplastic surgeon. Consequently, 91.6% stated that seeing before and after photos on social media platforms affected their decision in selecting their oculoplastic surgeon. Besides, 82.8% revealed that visiting surgeons' clinic came as a step next to their search for their accounts on social media. CONCLUSION: The majority of the participants were, somewhat or another, affected by social media and this is due to people's belief regarding social media as a beneficial source of medical information that can provide reviews and expert opinion. The accuracy of the information presented in social media accounts managed by both physicians and nonphysicians is essential in making the appropriate decision for undergoing this kind of surgeries or not.

A child with refractory orbital cellulitis after water pipe smoking.

Orbital cellulitis in children rarely occurs secondary to smoking water pipe. A 3-year-old girl who presented with fever, eyelid swelling, pain, and proptosis of the left eye for 4 days after water pipe consumption. The patient was given the usual course of antibiotics for a few days along with subperiosteal abscess drainage however no improvement was noticed for a week. Cultures were positive for methicillin-resistant Staphylococcus aureus and pseudomonas aeruginosa. Intravenous dexamethasone was co-administered in three courses for 3 weeks, during which residual symptoms was slowly resolving. In conclusion, attempt of dexamethasone in children can shorten hospital stay and augment full recovery.

Isolated eyelid coloboma in association with complex choristoma in a newborn: A case report.

Ocular choristomas are rare lesions that have been reported at the conjunctiva, sclera, orbit, or intraocularly with significant potential for visual disturbance. The complex type of choristomas shows a mixture of different cartilaginous, glandular, and muscular tissue in addition to fat. We present a patient with an associated eyelid coloboma and complex choristoma. A 12-day-old baby boy was referred to our hospital with an upper medial eyelid coloboma affecting almost two-thirds of the eyelid length with an additional sub-brow mass since birth. The baby also had secondary findings to the eyelid coloboma defect: temporal conjunctival symblepharon, vascularized cornea, and inferior pannus. The patient underwent an upper eyelid reconstruction with excisional biopsy of the sub-brow mass, which was diagnosed as a complex choristoma. This is the first case of an eyelid coloboma-associated with complex choristoma without any other systemic associations.

Acute dacryocystitis in pediatric patients and frequency of nasolacrimal duct patency.

Purpose: To study acute dacryocystitis in a pediatric age group, focusing on patients' demographic profiles, clinical presentation, and management outcome. Methods: A retrospective case series of all acute dacryocystitis in pediatric patients (0-17 years) from two tertiary-care eye centres in Riyadh, Saudi Arabia was conducted. Demographic profile, risk factors, initial clinical presentation, management regimens, and final outcome were analysed. Results: A total of 51 patients were included in the study. The mean age of presentation was 3.9 ± 4 years (1 month-13 years). Thirty-eight patients (74.5%) reported symptoms of congenital nasolacrimal duct obstruction (NLDO) prior to presentation, four patients (7.8%) had congenital dacryocystocele, two (3.9%) had a history of traumatic NLDO, and ten (19.6%) had an attack of acute dacryocystitis in the absence of NLDO or any other known risk factors. Four patients (7.8%) progressed to orbital cellulitis while another three (5.8%) had lacrimal sac fistula secondary to acute dacryocystitis. Systemic antibiotics were the initial management in all 51 patients. Twenty-five (49%) underwent probing after the resolution of the acute attack while 12 (23.5%) patients underwent dacryocystorhinostomy (DCR). Conclusions: Early recognition and urgent management for acute dacryocystitis are required to prevent further potential complications and achieve excellent outcomes. Congenital NLDO is the main risk factor for the development of acute dacryocystitis in the pediatric age group. In a small set of patients, acute dacryocystitis can develop despite the presence of a patent lacrimal drainage system on clinical evaluation with lack of tearing and discharge before and after the attack of acute dacryocystitis.

Community Pharmacists' Views of the Enforced Antibiotics Dispensing Law and Its Impact on Oral Antibiotics Sales in Saudi Arabia.

OBJECTIVES: The aim of this study was to explore community pharmacists' views toward the antibiotics dispensing law that was enforced in May 2018 and bans the sale of antibiotics without a prescription in community pharmacy settings in Saudi Arabia. Moreover, the potential impact of the law enforcement on the sales of oral antibiotics in Saudi Arabia was also explored. METHODS: A questionnaire-based cross-sectional study was conducted between September 2019 and March 2020 in Riyadh, Saudi Arabia. A multistage sampling technique was used to recruit community pharmacists from different districts. Pharmacists who consented to participate and reported practicing prior to the law enforcement were interviewed about their views of the law using a 14-item newly developed questionnaire. The annual sales of oral antibiotics for the years of 2017, 2018, and 2019 were retrieved from the Saudi Food and Drug Authority (SFDA) database. RESULTS: Two hundred and eighty six pharmacists consented to participate and met the inclusion criteria. After the law enforcement, approximately 51% of the participants reported that the percentage of patients seeking antibiotics without a prescription is less than 25%. Moreover, the majority (87.41%) reported a drop in the sales of antibiotics. Additionally, about 90% of the participants believed that the rate of inappropriate use of antibiotics will decrease as a result of the law enforcement. About 41% of the participants reported that the law has negatively impacted their pharmacies' profits. The sales of oral antibiotics have seen a 16.6% drop in the year of 2019 as compared to 2017. CONCLUSION: The antibiotics dispensing law is favorably perceived among community pharmacists in Saudi Arabia despite some concerns about its impact on their sales. Exploring different business models that delink the profits from the volume of antibiotics sales is necessary for this vital industry to thrive.

Whipple's disease scleral nodules: a novel presentation in 2 consecutive patients.

BACKGROUND: Whipple's disease (WD) is a rare, chronic, infection caused by gram-positive filamentous aerobic actinobacterium Tropheryma whipplei occurs classically in the gastrointestinal tract and shows histopathologically foamy macrophages with typical numerous PAS-positive, non-acid fast particles. Ocular WD in the form of uveitis may occur in the absence of systemic disease but has not been reported to present with scleral manifestation. We describe for the first time to the best of our knowledge 2 cases of scleral nodules with typical histopathological morphology of WD and without systemic involvement. CASE PRESENTATION: The first was a 53-year old diabetic male farmer who presented with 2 nontender right eye scleral nodules for 3 months, had a negative systemic workup, and surgical excision showed Periodic acid Schiff (PAS)-positive eosinophilic structures inside macrophages. Grocott's methenamine silver (GMS) stain and acid-fast bacilli (AFB) stain of the tissue itself were negative. The second case was a 60-year old male who presented with an asymptomatic superior scleral nodule for 4 months, which showed similar appearance and negative GMS and AFB stains. CONCLUSION: WD should be included in the differential diagnosis of scleral nodules even in the absence of systemic symptoms. Surgical excision without systemic treatment resulted in successful outcome without recurrence.

Marcus Gunn Jaw-Winking Synkinesis With Ipsilateral Eyelid Myokymia.

PURPOSE: To describe a novel observation of ipsilateral eyelid myokymia in the context of Marcus Gunn jaw-winking synkinesis (MGJWS). METHODS: A retrospective case series of 5 patients observed to have myokymia in the context of MGJWS in 2 tertiary hospitals in Riyadh, Saudi Arabia was conducted. Demographic profile including age and gender, and clinical features were analyzed. RESULTS: Five patients (3 males and 2 females) with MGJWS were noted to demonstrate the phenomenon of ipsilateral eyelid myokymia. All but 1 had right-sided MGJWS. The myokymia was seen as upper eyelid twitching in a vertical fashion along the levator palpebrae superioris muscle field of action. All subjects also had ipsilateral Monocular elevation deficiency. CONCLUSION: Ipsilateral upper eyelid myokymia is a potential feature of MGJWS. Monocular elevation seems to be a constant feature among MGJWS patients with levator muscle myokymia.Marcus Gunn jaw-winking synkinesis (MGJWS) is not well understood. Ipsilateral eyelid myokymia is a potential feature of MGJWS. This finding suggests that peripheral dysinnervation is likely to be a part of MGJWS.Supplemental Digital Content is available in the text.

Marcus Gunn jaw-winking synkinesis (MGJWS) is not well understood. Ipsilateral eyelid myokymia is a potential feature of MGJWS. This finding suggests that peripheral dysinnervation is likely to be a part of MGJWS. Supplemental Digital Content is available in the text.

Clinical features differentiating intratarsal keratinous cyst from chalazion.

PURPOSE: To present the differentiating clinical findings between intratarsal keratinous cyst (IKC) and chalazion. METHOD: A retrospective review of medical records of all patients who presented between 2010 and 2018 at King Abdulaziz University Hospital with proven histopathological diagnosis of IKC was done. Complete ophthalmologic evaluation at presentation, surgical procedures performed, complications, histopathological findings, response to treatment and follow-up were recorded. RESULTS: Twelve patients were found to have IKC. All patients presented with an eyelid mass with no signs of local inflammation. All lesions were fixed to the tarsus with freely mobile overlying skin, which was found to be slightly pale compared to the surrounding skin in six patients. On palpation, IKC had well-defined boarders. Isolation with clear surgical plane for cyst excision was achieved in nine patients as they were superficially involving the tarsus. When IKC involved the deep part of the tarsus, bluish/ whitish nodules were seen upon eyelid eversion. Six patients were misdiagnosed and surgically treated as a chalazion elsewhere prior to presentation to us with recurrence. CONCLUSION: Differentiating IKC from chalazion can be challenging. Careful clinical evaluation helps reaching the right diagnosis and providing the correct treatment, which involves complete excision of IKC to prevent recurrence.

Granulomatous reaction to migrating silicone oil clinically mimicking a xanthelasma: A case report.

INTRODUCTION: Silicone oil has been used for many years in retinal surgeries for retinal detachment. One of its reported complications is oil migration to the periorbital area, resulting in granulomatous reaction. PRESENTATION OF CASE: A 56-year-old lady, with history of retinal detachment that was repaired by vitrectomy, silicone oil removal and epi-retinal membrane peeling, presented to us with unilateral ptosis and a skin lesion that resembled xanthelasma. DISCUSSION: Histopathology of this lesion showed silicone oil infiltrating the surrounding connective tissue and fat with absence of foamy histiocytes. CONCLUSION: We are reporting a case of silicone oil migration with pseudo-xanthelasma lesion. This has been reported only twice to the best of our knowledge in the English-written literature.

Tarsal-related cysts: Different diagnoses with similar presentations.

PURPOSE: To study different tarsal cysts that share similar presentations and are commonly misdiagnosed clinically as a chalazion. METHODS: A retrospective review of medical charts of all consecutive patients who presented eyelid tarsal-related pathology that needed surgical excision between 2010 and 2016 to a tertiary hospital was done. The data collected included preoperative, intraoperative and postoperative observations. Complete ophthalmologic examination at presentation, surgical procedures needed, complications, histopathological findings, response to treatment and follow-ups were recorded. RESULTS: Out of 850 patients who had an eyelid tarsal-related pathology, ten patients were found to have an eyelid cystic lesion related to the tarsus. All patients presented with an eyelid mass with no sign of local inflammation. All lesions were fixed to the tarsus with freely mobile overlying skin. Five patients had a recurrent lesion that was misdiagnosed and surgically treated as a chalazion. All patients underwent a surgical removal of these cysts, and a histopathological examination was performed. An intratarsal keratinous cyst was found in six patients and epithelial inclusion cyst was in one patient. Two patients found to have cystic structure lined by double cuboidal epithelium with numerous goblet cells consistent with benign lacrimal duct cyst (Dacryops). CONCLUSION: Cysts related to the tarsal plate could have similar presentations. Careful clinical evaluation and histopathological examination play an important role in giving the right diagnosis and in providing the appropriate management.