COVID-19-associated rhino-orbito-cerebral mucormycosis: a single center prospective study of 264 patients.

PURPOSE: Outbreaks of mucormycosis were reported worldwide throughout the COVID-19 pandemic. We report clinical outcomes of a treatment protocol for COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM). METHODS: Patients with biopsy-proven mucormycosis and COVID-19 were included. All received intravenous amphotericin B deoxycholate 1 mg/kg and surgical endoscopic sinus debridement (FESS). Those with rhino-orbital or cerebral disease limited to the cavernous sinus were eligible for transcutaneous retrobulbar amphotericin B (TRAMB). Patients were followed with weekly imaging, endoscopic examinations, and serial debridement as necessary. Patients were discharged on oral posaconazole for 6 months. RESULTS: In total, 264 patients were followed for a mean of 2.5 months. On presentation, 163 patients (174 eyes) had eye involvement. Of these, 141 eyes (81.0%) had light perception or worse vision. By the last follow-up, 163 patients (176 eyes) were affected, and of these, 96 eyes (54.5%) had no light perception. Twenty-one patients (8%) died and 3 orbits (0.5%) were exenterated. There was no change in mortality (p = 0.38) or exenteration (p = 0.38) in the 55 patients who received TRAMB compared to patients with rhino-orbital or cerebral disease limited to the cavernous sinus who did not. Asymptomatic COVID-19 was associated with higher mortality than symptomatic COVID-19 (p = 0.025). Uncontrolled diabetes was a risk factor for death (p = 0.022). New diabetes was associated with increased mortality versus pre-existing diabetes (p = 0.005). CONCLUSION: A multidisciplinary approach is crucial to manage COVID-19-ROCM. In our cohort, TRAMB therapy did not increase mortality or exenteration rates. While poor vision on presentation was profound, some vision recovery was noted with treatment. COVID-19 immune dysregulation may predispose patients to ROCM, particularly those with asymptomatic disease.

A Rare Case of Methotrexate-Associated Lymphoproliferative Disease in the Orbit.

An 80-year-old Caucasian female with a history of rheumatoid arthritis presented with a 6-month history of progressive right upper eyelid ptosis, edema, erythema, and pain. MRI demonstrated a superior orbital mass. An incisional biopsy was performed, and pathologic analysis revealed an atypical lymphoid infiltrate, co-expressing both B and T-cell markers, with a low proliferation rate. Flow cytometry and IgH rearrangement study did not demonstrate any B- or T-cell monoclonal proliferation. Based on these findings, she was diagnosed with an iatrogenic immunodeficiency-associated lymphoproliferative disorder. Discontinuation of methotrexate resulted in the complete resolution of her symptoms, and she remains in remission 18 months later. Given the increased risk of lymphoproliferative disease in patients with rheumatoid arthritis, careful evaluation and close monitoring upon immunosuppressive medication withdrawal is necessary to confirm the diagnosis.

Treatment of ocular-involving monkeypox virus with topical trifluridine and oral tecovirimat in the 2022 monkeypox virus outbreak.

Purpose: To report a case of ocular involving monkeypox infection in the United States during the 2022 outbreak, and to review the literature regarding its clinical manifestations and management known to date. Observations: A 36-year-old man with well controlled HIV presented to the emergency department with anal pain, diffuse rash, right eye pain, and right eye redness after he tested positive for monkeypox one week prior. Ocular examination showed bilateral periorbital vesicular lesions, right eye conjunctival injection, and a single white plaque on his right medial bulbar conjunctiva. Macular, vesicular, and pustular lesions were noted throughout his body, including the genital and perianal region. His ocular and systemic symptoms completely resolved after treatment with a ten-day course of 1% trifluridine and moxifloxacin drops in both eyes, as well as two weeks of oral tecovirimat. Conclusion and Importance: In July of 2022, monkeypox virus was declared a global health emergency by the World Health Organization; however, there are no standard guidelines for monkeypox treatment. Data on its clinical presentation and course, especially pertaining to ocular manifestations, is limited. We highlight the importance of recognizing ophthalmic manifestations of monkeypox virus and a possible therapeutic approach to help guide the management of these patients.

Orbital Fractures and Risk Factors for Ocular Injury.

Purpose: To identify factors predictive of serious ocular injury requiring urgent consultation by ophthalmology in patients presenting with blunt trauma orbital fractures. Methods: This is a retrospective study of adult patients diagnosed with orbital fractures after blunt trauma at a university medical center emergency room. Patient records were examined over a three-year period. Data including mechanism of injury, fracture location, ocular symptoms, and examination findings were recorded. Ocular injuries were divided into three levels of severity: mild, moderate, and severe. Fracture characteristics, patient demographics, and examination findings were analyzed using multinomial regression to identify risk factors for more severe injury. Results: One hundred and eighty-six patients met inclusion criteria. For 29.6% of patients, urgent ophthalmologic consultation was required. Ruptured globes occurred in 2.2% of injuries. There was a statistically significant association between severe ocular injury and three examination findings: poor vision (OR 14.5; p < 0.001), afferent pupillary defect (OR 44.8; p < 0.001), and abnormal pupillary reaction (OR 28.0; p < 0.001). Likewise, blurry vision (OR 3.6; p = 0.018), ocular pain (OR 3.7; p = 0.011), and facial pain (OR 4.4; p = 0.031) were also associated with an increased risk of severe ocular injury. Abnormal pupillary reaction was associated with moderate injury (OR 4.5; p = 0.041). Demographic factors, mechanism of injury, anti-coagulant use, fracture location, diplopia, no documented vision, subconjunctival hemorrhage, chemosis, and motility restriction were not associated with injury severity. Conclusion: Most patients who presented to the emergency room with an orbital fracture did not require urgent ophthalmologic consultation. The presence of blurry vision, ocular pain, facial pain, poor vision, and afferent pupillary defect significantly increased the odds of severe injury. Abnormal pupillary reaction was associated with both moderate and severe injury.

Once-Daily Low Inflammatory Foods Everyday (LIFE) Smoothie or the Full LIFE Diet Lowers C-Reactive Protein and Raises Plasma Beta-Carotene in 7 Days.

Serum C-reactive protein (CRP), a marker of systemic inflammation, is associated with increased risk for numerous inflammation-driven chronic diseases. A prior longitudinal study showed that the Low Inflammatory Foods Everyday (LIFE) diet, which is rich in dark green leafy vegetables (DGLV), lowered CRP over a mean follow-up period of 6 months. In this retrospective study, we investigate whether patients who consume the LIFE diet or their regular diet plus one component of the LIFE diet (LIFE smoothie), experience reductions in high-sensitivity CRP (hsCRP) in 7 days. Sixteen patients in a community practice met inclusion criteria. Patient compliance was assessed by patient interviews and measurements of beta-carotene, which is abundant in DGLV. Following the interventions, CRP decreased in both the LIFE diet (-0.47 mg/L, P = .02) and smoothie groups (-1.2 mg/L, P = .04). No statistically significant difference in reduction was observed between groups (P = .18). Plasma beta-carotene increased in both groups (+23.2, P = .02; +20.6, P = .006, respectively). These findings suggest that the LIFE diet or a regular American diet supplemented with the LIFE smoothie may quickly reduce systemic inflammation and the risk of many chronic diseases.

Local recurrence of uveal melanoma and concomitant brain metastases associated with an activating telomerase promoter mutation seven years after secondary enucleation.

Purpose: To describe a case of local recurrence of uveal melanoma with concomitant brain metastases after secondary enucleation. Observations: A 73 year-old patient presented with dizziness and gait instability. MRI of the orbits and brain showed an anophthalmic socket with an orbital implant and an associated optic nerve mass as well as multiple mass lesions in the brain. The patient's history was significant for secondary enucleation for uveal melanoma recurrence seven years prior to presentation. Histopathology of the enucleated eye revealed no signs of extrascleral extension or optic nerve invasion. Biopsy of the optic nerve mass confirmed recurrent uveal melanoma with somatic mutations in GNAQ (Q209L) and the telomerase (TERT) promoter (c.1-124C > T) found on targeted next-generation sequencing (NGS). The same mutations were found in the primary tumor in the patient's archived enucleation samples. Conclusions: Local recurrence of uveal melanoma can occur after enucleation and is associated with an increased risk of systemic metastases. It is important for clinicians to monitor patients for local recurrence and systemic metastases even after enucleation. Genetic biomarkers may play an important role in identifying tumors at highest risk of local recurrence and metastasis. To our knowledge, this is the first case study to describe the TERT promoter mutation c.1-124C > T in the setting of recurrent uveal melanoma.

Reduction in Ferritin Concentrations among Patients Consuming a Dark-Green Leafy Vegetable-Rich, Low Inflammatory Foods Everyday (LIFE) Diet.

Background: Ferritin is an iron-containing protein and acute-phase reactant, which may be elevated due to systemic iron overload or inflammation. Various diseases are associated with excess iron, but therapeutic iron chelation is suboptimal. Prior studies suggest that several plant phytochemicals possess iron-chelating properties, indicating that a plant-based diet may benefit patients with iron overload. Objectives: The aim was to investigate whether patients who consume a nutrient-dense, dark-green leafy vegetable-rich diet, called the Low Inflammatory Foods Everyday (LIFE) diet, experience reductions in ferritin concentrations. Methods: This was a retrospective study in which patients were intensively counseled to follow the LIFE diet. Compliance was assessed by patient interviews and serum B-carotene measurements. Primary outcomes included changes in ferritin, B-carotene, and C-reactive protein (CRP). Patients with elevated CRP concentrations at baseline were excluded in order to separate the impact of inflammation from iron overload on ferritin concentrations. Premenopausal women, who lose iron from menstruation, were also excluded. Results: Thirty-two patients met the inclusion criteria. The median follow-up was 183 d.   Following the dietary intervention, ferritin decreased (-81 µg/L, P = 0.006) and B-carotene increased (46 µg/L, P < 0.0001), whereas CRP remained unchanged (-0.02 mg/L, P = 0.86). Adherent patients had greater reductions in ferritin compared with nonadherent patients (-138 µg/L vs. 15 µg/L, P = 0.001). Among all patients, there was an inverse relation between B-carotene and ferritin (-2.02, P = 0.03). Conclusions: The LIFE diet, or similar dark-green leafy vegetable-rich, whole-food plant-based diets, may benefit patients with disorders of iron overload and iron-induced oxidative stress.

Chronic migraine reversal and prevention with the LIFE diet: a nutrient dense whole food plant-based diet (WFPBD).

We report a case of a 60-year-old man who struggled with frequent migraines for 12.5 years, which were refractory to all conventional therapies. Six months before initial consultation, these migraines become chronic. The patient was then advised to follow the Low Inflammatory Foods Everyday (LIFE) diet, a nutrient-dense, dark green leafy vegetable-rich, whole food plant-based diet. Within 2 months, his headache frequency declined from 18 to 24 headache days per month to 1, and he discontinued his preventive and abortive migraine medications. After 3 months, the patient had no headaches. These results far exceed the goal of migraine treatment with medication, which is to reduce migraine frequency by >50% per month. In addition, the results were durable; this patient has been migraine-free for 7.5 years. Serum beta-carotene more than tripled after the patient started the LIFE diet, consistent with its high content of dark green leafy vegetables. Weight, high-sensitivity C-reactive protein (hsCRP), complete blood count (CBC), hydration status, sodium and other electrolytes remained constant throughout the study.

Bilateral Pseudomonas aeruginosa Keratitis in 7 Patients.

PURPOSE: To report 7 patients (14 eyes) with bilateral Pseudomonas aeruginosa keratitis (PAK). METHODS: Case records of patients with bilateral PAK were reviewed at a single academic medical center from April 2009 to December 2020. RESULTS: Seven patients aged 29 to 94 years presented with bilateral P. aeruginosa corneal ulcers. All patients were soft contact lens wearers except one elderly patient with a complex ocular history. Three patients wore specialty contact lens, including one cosmetic contact lens wearer, one multifocal contact lens wearer, and one extended-wear contact lens wearer. The remaining three patients were not overnight contact lens wearer but regularly showered in contact lens or used tap water for contact lens case cleaning. All patients presented with asymmetric disease, with visual acuity ranging from 20/20 to light perception. Ulcers were located centrally in 5 eyes (35.7%), diffusely over the entire cornea in 5 eyes (35.7%), temporally in 2 eyes (14.2%), and nasally in 1 eye (7.14%), and in 1 eye (8.3%), the ulcer location was not recorded. Corneal thinning was noted in 7 eyes (50%). Hypopyon was also noted in 7 eyes (50%). Two patients required procedures because of progressive stromal necrosis. All other patients were treated nonsurgically, with antibiotic drops, which resulted in ulcer resolution. Final visual acuity on last recorded follow-up ranged from 20/20 to no light perception. CONCLUSIONS: This is the largest case series of bilateral PAK, which occurred primarily in contact lens wearer. This case series reiterates the risk of contact lens infection related to poor hygiene.

Comparison of Clinical Features and Treatment Outcomes of Pseudomonas aeruginosa Keratitis in Contact Lens and Non-Contact Lens Wearers.

PURPOSE: To compare the outcomes of Pseudomonas aeruginosa keratitis (PAK) in contact lens wearers (CLWs) and non-contact lens wearers (non-CLWs) and identify risk factors for poor visual acuity (VA) outcomes in each group. DESIGN: Retrospective cohort study METHODS: Two hundred fourteen consecutive cases of PAK were included between January 2006 and December 2019. Clinical features, microbiologic results, and treatment course were compared between CLW and non-CLW groups. Analyses of clinical features predicting poor final VA were performed. RESULTS: This study identified 214 infected eyes in 207 patients with PAK, including 163 eyes (76.2%) in CLWs and 51 eyes (23.8%) in non-CLWs. The average age was 39.2 years in CLWs and 71.9 years in non-CLWs (P < .0001). The average logMAR visual acuity (VA) at presentation was 1.39 in CLWs and 2.17 in non-CLWs (P < .0001); average final VA was 0.76 in CLWs and 1.82 in non-CLWs (P < .0001). Stromal necrosis required a procedural or surgical intervention in 13.5% of CLWs and 49.0% of non-CLWs (P < .0001). A machine learning-based analysis yielded a list of clinical features that most strongly predict a poor VA outcome (worse than 20/40), including worse initial VA, older age, larger size of infiltrate or epithelial defect at presentation, and greater maximal depth of stromal necrosis. CONCLUSIONS: Non-CLWs have significantly worse VA outcomes and required a higher rate of surgical intervention, compared with CLWs. Our study elucidates risk factors for poor visual outcomes in non-CLWs with PAK.

Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients.

BACKGROUND: Many plastic surgeons avoid the administration of venous thromboembolism (VTE) chemoprophylaxis out of concern for surgical bleeding in abdominoplasty. Although previous studies have attempted to address the relationship between abdominoplasty and bleeding or VTE, poor reporting techniques remain a challenge. As a result, there has been a lack of reliable data to guide clinical practice. OBJECTIVES: The authors sought to determine the prevalence of bleeding and VTE in abdominoplasty with and without chemoprophylaxis. METHODS: A systematic review was performed following PRISMA guidelines utilizing PubMed, CINAHL, and Cochrane Central. Patient demographics, comorbidities, risk category (if available), bleeding events, VTE events, and chemoprophylaxis information were recorded. RESULTS: Across 10 articles, 691 patients received chemoprophylaxis in the setting of abdominoplasty: 68 preoperatively, 588 postoperatively, and 35 received both; 905 patients did not receive chemoprophylaxis. A total of 96.8% of patients were female, 73% underwent concomitant liposuction, and none were clearly risk stratified. The overall incidence of VTE and bleeding was 0.56% (9/1596) and 1.6% (25/1596), respectively. Compared with no chemoprophylaxis, chemoprophylaxis was not associated with increased incidence of bleeding (1.3% [9/671] vs 0.91% [8/881], P = 0.417) or decreased incidence of VTE (0.87% [6/691] vs 0.33% [3/901], P = 0.187). CONCLUSIONS: The prevalence of bleeding in abdominoplasty was low. Chemoprophylaxis was not associated with increased risk of bleeding or decreased risk of VTE, though the lack of risk stratification and heterogeneity of the cohort precludes firm conclusions. This study underscores the importance of utilizing validated risk-stratification tools to guide perioperative decision-making.

A Required Ophthalmology Rotation: Providing Medical Students with a Foundation in Eye-Related Diagnoses and Management.

Introduction: Current ophthalmologic training in medical school is inadequate in preparing medical students to handle basic eye complaints as nonophthalmology residents. Most medical students are uncomfortable performing eye examinations, but increased ophthalmology training improves confidence in this area. The University of Pittsburgh School of Medicine (UPSOM) teaches students the basics of ophthalmology with a required 1-week rotation during the 1-month specialty care clerkship (SCC), providing students with skills to perform rudimentary eye examinations as nonophthalmology providers. Methods: Within a 1-week ophthalmology rotation, we developed a series of interactive case-based teaching sessions, handouts, and homework that accompanied clinical instruction to familiarize third- and fourth-year medical students with ophthalmic equipment, terminology, diagnosis, and management. Of learners, 67 (roughly 11 per cohort) rotated on six consecutive SCCs beginning in May 2019. All learners completed an in-house exam and received resident clinical evaluations at the end of their rotation. Results: Of the 64 participants who responded to the survey, 100% rated the quality of teaching sessions outstanding or good, and 83% of students strongly agreed or agreed with the statement, "I believe the overall teaching in the ophthalmology clinical settings was good quality." The average clinical and exam score for ophthalmology over 6 months was 4.5 out of 5, and 83% respectively. Discussion: Generally positive student feedback as well as high clinical and exam scores suggested that the required UPSOM ophthalmology clerkship was both engaging and effective. This course can be easily adapted to teach students at other medical institutions.

An In-Depth Analysis of Research Output in Successful Integrated Plastic Surgery Match Applicants and Factors Associated With Matching at Top-Ranked Programs.

OBJECTIVE: With USMLE Step I score reports becoming pass/fail, research output may become a more important factor for applicants in the integrated plastic surgery match. The authors aim to assess the research output of successful applicants and bibliometric variables associated with matching at higher tier programs. DESIGN: A search of peer-reviewed publications up to or during September before the matriculant's match year was performed using PubMed, Google Scholar, and Scopus for each resident. Bibliometric variables were analyzed including those associated with matching at higher tier Doximity reputation/research programs. SETTING: University of Pennsylvania (Philadelphia, Pennsylvania). PARTICIPANTS: Integrated plastic surgery interns for the 2019 to 2020 and 2020 to 2021 academic years (n = 301). RESULTS: Three hundred one matriculants at 73 programs produced a total of 731 manuscripts. The mean number of publications and H-index per applicant was 2.43 ± 3.84 and 1.01 ± 1.30, respectively. The average and maximum journal impact factor was 2.8 ± 1.81 and 4.66 ± 5.59, respectively. H-index, total publications, plastic surgery-related and unrelated publications, and first-author studies were all associated with matching into both a higher ranked reputation and research tier program, respectively (p < 0.05). Highest impact factor publications were associated with matching at top tier research programs only (p < 0.05). Among students from US News Top 40 and non-Top 40 medical schools, total publications and first-author publications remained associated with matching at a higher tier reputation and research program (p < 0.05). However, plastic surgery-related publications were significantly linked to matching into a higher tier program for matriculants from non-Top 40 medical schools only (p < 0.05). CONCLUSIONS: Research productivity, particularly total publications and first-author publications, is associated with an increased likelihood of matching at a higher tier integrated plastic surgery residency. Regardless of their medical school's US News rank, students may gain a competitive edge in the match with increased research output.