Orbital Compartment Syndrome in Severe Burns: Predictive Factors, Timing, and Complications of Intervention.

PURPOSE: Severe burn patients require high-volume fluid resuscitation, which increases risk for orbital compartment syndrome (OCS). We aimed to understand surgeons' practice patterns and to examine risk factors for OCS, timing of lateral canthotomy and cantholysis (LCC), and complications of intervention. METHODS: A survey of American Society of Ophthalmic Plastic and Reconstructive Surgery and North American Society of Academic Orbital Surgeons' practice patterns in burn patients was undertaken. In addition, a retrospective analysis was conducted of 107 patients with burns greater than 20% total body surface area at 1 institution from January 1, 2009, to June 1, 2018. Patients with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis, frostbite, or no ophthalmologic consultation were excluded. Risk factors for OCS, timing of LCC, and complications of the intervention were examined. RESULTS: In the survey, 37 of 54 respondents had treated burn patients, of which 29 followed no protocol. Threshold intraocular pressure for intervention varied widely, and nearly all reported having seen complications from LCC in burn patients. For the retrospective analysis, 107 patients met criteria, of which 22 (20.6%) required LCC. Renal failure, inhalation injury, eyelid burns, higher total body surface area, elevated lactate, increased number of escharotomies, and greater total fluid required were significantly associated with the clinical decision that the patient was at risk for OCS requiring LCC. Fluid resuscitation in excess of the Ivy Index (250 ml/kg) increased odds of LCC 8.6 times. Average time of LCC was 15.8 hours after burn. LCC patients experienced higher rates of complications including eyelid retraction, exposure keratopathy, and corneal ulceration. CONCLUSIONS: Severe burn patients should be monitored closely by an ophthalmologist during the first 48 hours for signs of OCS. Further studies should aim to recommend protocols guiding evaluation and intervention.

Hematic Pseudocyst Masquerading as Orbital Cellulitis and Sinusitis.

Hematic pseudocysts are fibrous, nonepithelial lined capsules containing blood byproducts that typically present remotely following orbital fracture hardware implantation. Trauma, implant migration, and tissue erosion are believed to cause hemorrhage to pool within the capsular space. Risk factors include inadequate posterior fracture reduction and use of nonporous material which prevents fibrovascular ingrowth and stabilization. Mass effect from these lesions may cause patients to present with pain, lid swelling, hyperglobus, proptosis, lid retraction, motility restriction, or blurry vision. Pseudocysts associated with fracture hardware have been misdiagnosed as tumors or in one prior case as an infection. Herein we report a unique case of hematic pseudocyst masquerading as orbital cellulitis with maxillary sinusitis. A 59-year-old man presented with periorbital pain, hyperglobus, proptosis, and ptosis 2 years after repair of an orbital floor fracture. CT demonstrated a soft tissue collection adjacent to an implant as well as maxillary sinus opacification. He did not improve with antibiotics, at which point surgery revealed a pseudocyst and its contents were removed. This report describes a unique presentation of orbital pseudocyst and summarizes the literature on this entity.

Severe Diesel Injection Injury to the Face, Neck and Orbit: Surgical Management and Critical Care Considerations.

The purpose of this report is to discuss high-pressure injection injuries involving the face and orbit and discuss factors affecting prognosis and management as these injuries are rare and uniquely challenging to manage given the complex anatomy and extensive damage that may occur. In this case, we present severe injury to the left orbit, maxillofacial region, and neck of a 29-year-old male who suffered a high-pressure diesel injection injury requiring several surgical debridements, intensive care unit (ICU) level care, and ultimately sub-total exenteration. Initial management involved systemic antibiotics, steroids, and surgical debridement; however, our patient experienced subsequent rapid deterioration resulting in admission for more aggressive subspecialty intervention. Decision-making was guided by serial CT of the face and orbits, and C-reactive protein (CRP) levels in addition to the physical examination. His course was complicated by progressive extensive soft tissue necrosis requiring 8 surgical debridements and optic nerve tenting despite orbital decompression resulting in loss of the OS. Ultimately, definitive treatment required sub-total exenteration and negative wound pressure therapy over the orbit followed by eyelid reconstruction as an outpatient. We conclude that without prompt recognition and meticulous debridement, the resultant injury from high-pressure injection injuries can be devastating and lead to permanent vision loss, loss of an eye, loss of facial function, and airway compromise depending on the location of the injury. A multi-disciplinary team involving oculoplastics, otolaryngology, infectious disease, and ICU should be assembled based on the complexity of this injury and its sequela. CRP can be useful to monitor patient recovery and the need for further surgical intervention. When debridement results in complex wounds over the orbit and face, negative pressure wound therapy should be considered.

An intraocular solitary fibrous tumor/hemangiopericytoma with extrascleral extension: Case report and review of literature.

Purpose: To report a case of intraocular solitary fibrous tumor/hemangiopericytoma (SFT/HPC) complicated by extrascleral extension and to review the current literature regarding intraocular SFT/HPC. Observations: A twenty-two year old male presented with decreased vision in his left eye and was found to have a subretinal mass with extrascleral extension. He underwent enucleation of his left eye and histopathology confirmed a diagnosis of SFT/HPC. Conclusions and importance: To our knowledge, this is the seventh case of intraocular SFT/HPC ever reported and the first to report extrascleral extension. At the time of publication, there was no evidence of metastases. Extensive clinical, ophthalmic and radiographic imaging, and histopathologic data are presented to contribute to the current understanding of intraocular SFT/HPC.

Dupilumab-associated cicatrizing ocular disease.

Purpose: To describe three cases of bilateral cicatrizing conjunctivitis associated with dupilumab treatment for atopic dermatitis. Observations: Case 1 is a 69 year-old male with a history of mild, stable cicatrizing conjunctivitis thought to be secondary to atopic dermatitis. His cicatrizing disease progressed significantly after starting dupilumab, and then stabilized after dupilumab was discontinued. Case 2 is a 72 year-old male who presented with bilateral cicatrizing conjunctivitis. His symptoms of ocular erythema and irritation started shortly after initiating dupilumab for atopic dermatitis. The dupilumab was discontinued and the patient's symptoms resolved and ocular surface scarring stabilized. Case 3 is a 47 year-old male with a history of allergic conjunctivitis who was found to have new onset unilateral symblepharon approximately 12 months after starting dupilumab for atopic dermatitis. The dupilumab was discontinued and his ocular disease stabilized. However, his cutaneous symptoms worsened significantly, so dupilumab was restarted at half the previous dose. His atopic dermatitis symptoms improved and cicatrizing conjunctivitis remained stable on this regimen. Conclusions and importance: Cicatrizing conjunctivitis with symblepharon formation distinct from ocular cicactricial pemphigoid is a potential side effect of dupilumab therapy for atopic dermatitis. Progression of the cicatrization appears to halt with discontinuation, or potentially dose reduction, of dupilumab.

Physician burnout in ophthalmology: U.S. survey.

PURPOSE: To determine the prevalence of physician burnout among ophthalmologists in the United States and identify associated risks. SETTING: All practice types within the United States. DESIGN: Cross-sectional study. METHODS: A survey was distributed through email listservs to several national ophthalmology societies. Participants completed a modified Mini Z Burnout Survey, a 10-item questionnaire measured in 5-point Likert scales, followed by demographic questions. The Mini Z Burnout survey assessed 3 main outcomes: stress, burnout, and work satisfaction. The percentage of subgroups experiencing burnout were presented and comparisons made with odds ratios from logistic regression modeling. RESULTS: Of the 592 ophthalmologists responding to the survey, 37.8% (224) self-reported symptoms of burnout with a low of 30.8% (12/39) for vitreoretinal specialists to a high of 45.4% (30/66) for uveitis specialists. Most of those reporting burnout were categorized as mild (65.2% [146/224]), followed by moderate (29.5% [66/224]) and severe (5.4% [12/224]). Women had almost twice the odds of reporting burnout (odds ratio [OR] = 1.9 [95% CI: 1.3-2.7]; P = .0005). Physicians employed in academic (OR = 2.0 [95% CI: 1.2-3.2]; P = 0.007) and hospital facilities (OR = 2.4 [95% CI: 1.3-4.6]; P = .008) reported higher rates of burnout compared with those in large private groups. Burnout was associated with self-reported low work control, insufficient time for documentation, and misalignment with departmental leaders (P < .0001). CONCLUSIONS: Ophthalmologists exhibited a high degree of self-reported burnout in the U.S. This study highlights sex, employment autonomy, and practice type as major factors associated with burnout.

Histopathologic Observations of Eyes in Exenterated Orbits After Neoadjuvant Intra-Arterial Cytoreductive Chemotherapy for Adenoid Cystic Carcinoma of the Lacrimal Gland.

PURPOSE: To assess whether exenteration specimens obtained after neoadjuvant intra-arterial cytoreductive chemotherapy (IACC) for adenoid cystic carcinoma of the lacrimal gland demonstrate significant ocular histopathologic alterations that might preclude future pursuit of globe-preserving therapy. METHODS: Retrospective histopathologic analysis of globes in IACC-treated exenteration specimens among the same cohort of patients whose survival outcomes have been reported. RESULTS: Twenty patients had specimens available. Nineteen globes revealed no abnormalities of the iris, ciliary body, lens, retinal pigment epithelium, choroid, or chorioretinal vasculature. Eighteen globes showed no optic nerve abnormalities. One globe from a patient who refused exenteration until adenoid cystic carcinoma recurrence supervened demonstrated optic nerve edema with a peripapillary hemorrhage and cotton wool spot, as well as hemorrhage and necrosis within an extraocular muscle. Eighteen globes showed no retinal abnormalities attributable to intra-arterial chemotherapy. Three globes showed incidental retinal findings: 2 globes contained 1 to 2 small peripheral retinal hemorrhages and 1 had a pigmented retinal hole. Seven demonstrated mild, chronic extraocular muscle inflammation, and 13 had unremarkable musculature. The single patient who received IACC via the internal carotid rather than the external carotid artery developed ophthalmic artery occlusion with orbital apex syndrome prior to exenteration, and diffuse necrosis and hemorrhage were evident histopathologically. CONCLUSIONS: Neoadjuvant IACC does not cause significant histopathologic damage to key ocular structures or compromise visual function in patients receiving intra-arterial chemotherapy through the external carotid artery. However, delivering chemotherapy through the internal carotid artery may result in visually significant thrombotic vascular events. The generally benign histopathological findings in these exenteration specimens support the concept of IACC delivery through the external carotid system as the cornerstone of a future globe-preserving strategy for lacrimal gland adenoid cystic carcinoma.

Dog bite injuries of the eye and ocular adnexa.

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.

Endoscopic Management of Paranasal Sinus Mucoceles: Meta-analysis of Visual Outcomes.

Objective Paranasal sinus mucoceles are benign cystic lesions originating from sinus mucosa that can impinge on adjacent orbital structures, causing ophthalmic sequelae such as decreased visual acuity. Definitive treatment requires surgery. We present the first meta-analysis quantifying the effect of preoperative visual function and time to surgery on postoperative visual acuity outcomes. Data Sources PubMed, Ovid, Embase, Web of Science, and the Cochrane Library. Methods Two independent authors systematically reviewed articles describing outcomes after endoscopic sinus surgery for paranasal sinus mucoceles presenting with visual loss. Available data from case reports and series were combined to analyze the associations among preoperative visual acuity, time to surgery, and postoperative outcomes. Results Eighty-five studies were included that provided data on 207 patients. The average presenting visual acuity was 1.57 logMAR (logarithm of the minimum angle of resolution), and the average postoperative visual acuity was 0.21 logMAR, with visual improvement in 71.5% of cases. Preoperative visual acuity ≥1.52 logMAR correlated with postoperative improvement >1 logMAR ( R = 0.4887, P < .0001). A correlation was found between a time to surgery <6 days and postoperative improvement ( R = 0.297, P < .0001). Receiver operator curve analysis of these thresholds demonstrated a moderately accurate prognostic ability (area under the curve: 75.1 for preoperative visual acuity and 73.1 for time to surgery). Conclusion Visual loss resulting from paranasal sinus mucoceles is potentially reversible in most cases, even those presenting with poor vision. When possible, surgery should be performed promptly after diagnosis, but emergency surgery does not appear to be necessary for vision restoration.

External Ophthalmomyiasis Due to Dermatobia hominis Masquerading As Orbital Cellulitis.

Human parasitization by oestrid flies is a rare occurrence. The authors report a case of ophthalmomyiasis externa caused by Dermatobia hominis infestation in a 10-year-old female. Misdiagnosis resulted in a delay in treatment, which can be potentially devastating in cases of orbital or ocular involvement. The treatment of choice is early surgical removal of the larvae to minimize the inflammatory response and the extent of surgery. Patients should also be screened for multiple sites of cutaneous infestation. When the organism is completely excised, the prognosis is good.

The Spectrum of Pediatric Orbital BB Gun Injuries: A Case Series.

Three cases of pediatric BB orbital injury are reported demonstrating varying outcomes. Pediatric orbital BB injuries have a wide spectrum of clinical outcomes depending on the ocular structures involved. Improved safety education of patients and parents is necessary to reduce the burden of these vision-threatening injuries.

Optic neuropathy associated with the use of over-the-counter sexual enhancement supplements.

This case report details an association of the use of over-the-counter sexual enhancement supplements with atypical optic neuropathy. A 42-year-old man presented with right-sided headache and vision loss of the right eye, which deteriorated to a single quadrant of hand motion over 11 days. Serial orbital magnetic resonance imaging scans demonstrated progressive orbital optic nerve enhancement extending into the optic canal despite high-dose steroid treatment. The patient eventually admitted to using several over-the-counter sexual enhancement supplements prior to the onset of symptoms and throughout the course of his steroid treatment, which he subsequently discontinued. His vision improved to 20/200 with an expanded visual field. Anterior ischemic optic neuropathy has been reported in association with phosphodiesterase (PDE)-5 inhibitor use, but visual loss in association with unregulated sexual enhancement supplements has not been studied. While one case cannot establish association, our case is suggestive of potential dangers of over-the-counter sexual enhancement supplements, which may contain PDE-5 inhibitors, "male hormones," and "substances that enhance blood production." The case also underscores the importance of obtaining a careful history of supplements in patients with optic neuropathies.

Advanced single-stage eyelid reconstruction: anatomy and techniques.

BACKGROUND: Skin cancers of the periocular tissue present formidable reconstructive challenges because of anatomic complexity, vital function, and cosmetic significance. OBJECTIVE: To review eyelid anatomy and reconstructive techniques from an oculoplastic surgery perspective. RESULTS: Eyelid structure and function are intimately linked, and good working knowledge is a prerequisite for successful reconstructive efforts. We discuss periocular anatomy, patient evaluation, and single-stage repair of both anterior lamellar and full-thickness defects. CONCLUSION: Despite the challenges of periocular skin cancer reconstruction, excellent cosmetic and functional results can be achieved with appropriate technique.

Nonablative fractional resurfacing.

Since its introduction in 2004 by Manstein et al, fractional resurfacing has revolutionized the manner in which we treat photoaging. Fractional resurfacing delivers microscopic beams of light to the skin resulting in coagulation or vaporization of fragments of the epidermis and dermis. The wavelengths of these devices may vary, yielding different clinical results. This article will discuss the various uses of fractional ablative and nonablative devices available today.

Diabetes-induced inhibition of voltage-dependent calcium channels in the retinal microvasculature: role of spermine.

PURPOSE: Although decentralized control of blood flow is particularly important in the retina, knowledge of the functional organization of the retinal microvasculature is limited. Here, the authors characterized the distribution and regulation of L-type voltage-dependent calcium channels (VDCCs) within the most decentralized operational complex of the retinal vasculature--the feeder vessel/capillary unit--which consists of a capillary network plus the vessel linking it with a myocyte-encircled arteriole. METHODS: Perforated-patch recordings, calcium-imaging, and time-lapse photography were used to assess VDCC-dependent changes in ionic currents, intracellular calcium, abluminal cell contractility, and lumen diameter, in microvascular complexes freshly isolated from the rat retina. RESULTS: Topographical heterogeneity was found in the distribution of functional VDCCs; VDCC activity was markedly greater in feeder vessels than in capillaries. Experiments showed that this topographical distribution occurs, in large part, because of the inhibition of capillary VDCCs by a mechanism dependent on the endogenous polyamine spermine. An operational consequence of functional VDCCs predominantly located in the feeder vessels is that voltage-driven vasomotor responses are generated chiefly in this portion of the feeder vessel/capillary unit. However, early in the course of diabetes, this ability to generate voltage-driven vasomotor responses becomes profoundly impaired because of the inhibition of feeder vessel VDCCs by a spermine-dependent mechanism. CONCLUSIONS: The regulation of VDCCs by endogenous spermine not only plays a critical role in establishing the physiological organization of the feeder vessel/capillary unit, but also may contribute to dysfunction of this decentralized operational unit in the diabetic retina.

NAD+-induced vasotoxicity in the pericyte-containing microvasculature of the rat retina: effect of diabetes.

PURPOSE: It was recently proposed that activation of P2X(7) purinoceptors may play a role in causing cell death in the pericyte-containing microvasculature of the diabetic retina. This hypothesis is supported by the observation that diabetes enhances lethal pore formation in retinal microvessels exposed to synthetic P2X(7) agonists. The goal of this study was to determine whether purinergic vasotoxicity can be triggered by the endogenous molecule nicotinamide adenosine dinucleotide (NAD(+)), which is a substrate for ecto-ribosylation reactions known to activate P2X(7) receptor/channels in other cell types. METHODS: Pericyte-containing retinal microvessels were isolated from normal and streptozotocin-injected rats. Trypan blue dye exclusion was used to assess cell viability, YO-PRO-1 uptake was used to identify cells with P2X(7)-induced pores, and ethenoadenosine antibodies were used to detect ecto-adenosine diphosphate (ADP)-ribosyltransferase (ART) activity. RESULTS: In freshly isolated retinal microvessels, it was found that extracellular NAD(+), but not its catabolites, caused cell death (half-maximal effective concentration [EC(50)] = 2 nM) by a mechanism involving the activation of P2X(7) purinoceptors and the formation of transmembrane pores. A series of experiments provided evidence that NAD(+), which is not a direct purinergic agonist, serves as a substrate for ecto-ribosylation reactions that subsequently trigger P2X(7)-dependent cell death in the retinal microvasculature. Soon after the onset of diabetes, the sensitivity of retinal microvessels to the vasotoxic effect of extracellular NAD(+) increased by approximately 100-fold. CONCLUSIONS: Purinergic vasotoxicity triggered by extracellular NAD(+) is a newly recognized mechanism that may contribute to the cell death observed in the pericyte-containing microvascular of the diabetic retina.