Congenital Eyelid Imbrication and Floppy Eyelid Syndromes Complicated by Eversion due to Prostaglandin E Infusion in a Patient With Trisomy 21 and Tetralogy of Fallot.

Congenital eyelid imbrication syndrome is a rare eyelid finding where a long upper lid overlaps the lower lid when the eyes are closed. To date, congenital eyelid imbrication syndrome has been described in the literature less than 10 times. We present a case of congenital eyelid imbrication syndrome in a patient with trisomy 21 and tetralogy of Fallot on a prostaglandin E infusion to maintain a patent ductus arteriosus prior to definitive heart surgery. While on the infusion, the patient developed peripheral edema and flushing due to vasodilation. This coincided with eyelid swelling, conjunctival chemosis, and eversion of the eyelids. Upon cessation of the prostaglandin E1 infusion, his eyelid eversion resolved.

Non-visual complications of orbital cellulitis (NVCOC) in pediatric vs adult populations.

PURPOSE: There have been many publications evaluating the visual outcomes of patients treated for orbital cellulitis. The aim of this study was to evaluate non-visual complications of post-septal orbital cellulitis (NVCOC) present 30 days after discharge from index hospitalization. METHODS: This was an IRB-approved, retrospective chart review. RESULTS: Ninety patients (45 pediatric, 45 adults) were identified with OC. NVCOC were significantly more common in adult patients as compared to children (40.0% vs 15.6% respectively; p < 0.05). The most common NVCOC among children was persistent ptosis, while clinically significant scarring was most common in adults. NVCOC were less persistent in children as compared to adults with 71.4% of complications in children resolving spontaneously by 6 month follow up as compared to 11.1% adults. (p < 0.05). The only statistically significant risk factor identified for the development of NVCOC in children and adults was the presence of ICE (intracranial extension) during index hospitalization (p < 0.05) and the presence of an infected orbital implant (p < 0.05) respectively. CONCLUSIONS: Adult patients experience NVCOC complications more often than children. Furthermore, the nonvisual complications in children are more likely to resolve spontaneously than those in adults. The intracranial spread of infection is a significant risk factor for late complications in children. The presence of an orbital wall/floor implant is a significant risk factor for late complications in adults. There are many differences in the etiology, pathophysiology, and course of NVCOC in children and adults, so information on these two populations should be reported separately.

Progression of Subperiosteal Orbital Abscess after Clinical Resolution on Intravenous Antibiotics and Steroids.

We present a case of a 7-year-old boy who was presented with a small medial subperiosteal orbital abscess (SPOA) and trace superior phlegmon and who was initially treated with intravenous (IV) antibiotics, corticosteroids, and observation. After clinical resolution and discharge, the patient returned with superior migration of his abscess requiring surgical drainage. Potential factors leading to readmission are discussed, including the anti-inflammatory and immunosuppressant effects of steroids, and presence of early surgical indictors such as bony dehiscence and proptosis. This case highlights the need for careful consideration of initial imaging and presence of a non-medial phlegmon prior to initiation of steroids.

A Novel Approach to Teaching Fundoscopy Using a Virtual Format.

Introduction: Ophthalmology education has been underemphasized in medical school curricula despite the fact that patient eye-related complaints are commonplace across primary care specialties. Although previous curricula used direct ophthalmoscopy to teach medical students the fundamentals of ophthalmic examination, there has been a growing call to teach these fundamentals through reading fundus photos due to the increasing prevalence and decreased costs of fundus cameras in primary care settings. We developed a virtual workshop to teach ophthalmoscopy to medical students using fundus photography. Methods: First-year medical students were enrolled in a 2-hour, synchronous, virtual ophthalmoscopy workshop as part of an advanced physical exam curriculum at the University of Pittsburgh School of Medicine. Students participated in a pretest, introductory lecture, interactive small-group session, and posttest. Breakout groups were led by senior medical students or residents. We compared pre- and posttest results for improved understanding of concepts covered in the workshop. Results: Of 147 students, the average scores on the pretest and posttest were 39% and 75%, respectively (p < .01). Students were significantly more confident in their ability to identify various pathologies on fundus photography. After the workshop, the student preceptors indicated increased comfort in a teaching role and greater interest in medical education. The preceptors were also more confident in their own ability to interpret fundus photography and in their understanding of various ocular pathologies. Discussion: Our virtual, interactive workshop is effective in teaching medical students a systematic approach to the interpretation of fundus photographs.

Look beyond the retinopathy: The incidental finding of a brain tumour.

We report the case of a 33-year-old woman who was found to have optic-nerve head swelling on fundus photographs obtained for telemedicine diabetic retinopathy screening. The patient was found to have a large vestibular schwannoma on brain imaging. This case shows the added benefit of implementing timely changes in management in response to significant incidental findings on tele-ophthalmology diabetic retinopathy screening, which can lead to potentially life- and vision-saving interventions.

Microbiology of orbital cellulitis with subperiosteal abscess in children: Prevalence and characteristics of Streptococcus anginosus group infection.

PURPOSE: To evaluate the predominant pathogens and clinical course in pediatric patients with orbital cellulitis (OC) complicated by subperiosteal abscess (SPA). METHODS: This is a single-center retrospective chart review evaluating pediatric patients with OC complicated by SPA treated at a tertiary care center in the Pacific Northwest. Data were analyzed for characteristics, rates of infection, and antibiotic resistance of the predominant pathogens in pediatric patients. RESULTS: Twenty-seven children were identified with OC complicated by SPA and bacterial cultures drawn. The average age (SD) of the patients was 9.2 years (4.8), median 9.6; 15 range 5 months to 17.2 years. Seventeen (63.0%) were male. Sinusitis was present in all patients. Streptococcus species were the most common pathogen accounting for 52% (17/33) of isolates. Streptococcus anginosus group (SAG) was the predominant species and were isolated in 10 out of 27 (37%) children in the study. Twenty-one (78%) patients required surgery for the treatment of SPA. Among surgically treated patients, females tended to be younger than males (p = .068). Pediatric patients with SAG infections required more surgery than children without this isolate, 100% and 65%, respectively (p = .030). Female patients tended to have SAG infections more often than males (p = .063). CONCLUSIONS: Orbital infections caused by SAG require surgical management more often than those caused by other pathogens. Our results suggest a difference in pathogenic organisms in male and female patients with SPA. SAG is one of the most common pathogens isolated in orbital cellulitis complicated by SPA in children.

Simultaneous Orbital and Intracranial Abscesses in 17 Cases.

PURPOSE: To describe the demographics, clinical presentation, treatment, and outcomes of a rare cohort with simultaneous orbital and intracranial abscesses. METHODS: A historical cohort study of 17 patients with simultaneous orbital and intracranial abscesses between 2010 and 2018 was performed. The demographics, location of abscesses, treatment, and outcomes of these patients were analyzed. RESULTS: The mean age was 26.9 years (range 5-83 years). Fourteen patients (82%) were male. In this cohort, the most common orbital abscess location was the superior orbit, involved in 14 patients (82%). The most common site of intracranial abscess was the frontal lobe, involved in 16 patients (94%). Concurrent sinus disease was present in 16 patients (94%). Surgical evacuation was the standard of treatment, with 94% of patients undergoing at least one surgical procedure. Streptococcus species were the most common, isolated from 6 sinus cultures (43%), 3 orbitotomy cultures (21%), and 4 craniectomy cultures (36%). Staphylococcus species were also common. Most patients (94%) had stable or improved mental status and visual function at the conclusion of their treatment. CONCLUSIONS: Simultaneous orbital and intracranial abscesses are rare. Local invasion from the orbit into the intracranial space may occur from direct spread, thus superior orbital abscesses pose the greatest risk for intracranial spread. Additional factors such as infection with Streptococcus and Staphylococcus species as well as male sex appear to be risk factors for intracranial spread. For those who develop intracranial abscesses, young age and absence of seizures or altered mental status at presentation may be associated with favorable outcomes.

Long term follow up after transorbital penetrating injury: A case report.

PURPOSE: Traumatic brain injury is the leading cause of mortality and disability among young individuals. Unfortunately, there are few publications concerning long term follow up of patients with these types of injuries. We present a case of trans-orbital penetrating brain injury with an 18 year follow up. OBSERVATIONS: A 43-year-old, previously healthy, male was accidently impaled on a fencing foil resulting in a penetrating brain injury. Initial symptoms included diplopia, ophthalmoparesis, a non-reactive pupil, decreased visual acuity, decreased sensation across the cheek, dysphagia and dysarthria. CT scan taken on presentation showed a clear tract of the foil traversing the various structures of the brain. One week after the trauma, the patient developed a unique constellation of paroxysmal attacks of autonomic dysfunction consisting of profuse diaphoresis and decreased skin temperature on the left side of the body, as well as dilation of the left pupil. Three months after the accident, the patient suddenly experienced severe constant pain affecting the left side of his body associated with thermal and tactile allodynia. On latest follow up, 18 years after the accident, the patient continues to have chronic pain, allodynia, and lack of temperature sensation throughout the left face, arm, and leg. He has a wide based, hemi-ataxic gait, with the left leg swinging out and around. EMG and nerve conduction studies have found no voluntary activity in the temporalis and masseter muscles resulting in atrophy and fibrosis. An MRI shows linear encephalomalacia along the path of the foil extending to the pons, involving the right spinothalamic tract, and cerebellum. CONCLUSIONS AND IMPORTANCE: Our case illustrates the importance of such a longitudinal follow up. It demonstrates the possible severity of the sequelae from these types of injuries including chronic pain and gait ataxia, as well as EOM and autonomic dysfunction. Due to the potential ongoing needs of such patients, it is important to plan a long-term, team-based approach that centers around physical therapy and improving long term quality of life.

Atriocaval Rupture After Right Atrial Isthmus Ablation for Atrial Flutter.

A patient with symptomatic typical atrial flutter (AFL) underwent right atrial isthmus ablation with an 8-mm catheter. Eight months later, his typical AFL recurred. Ten months later, he underwent a repeat right atrial isthmus ablation with an irrigated tip catheter and an 8-mm tip catheter. Six weeks after his second procedure, while performing intense sprint intervals on a treadmill, he developed an abrupt onset of chest pain, hypotension, and cardiac tamponade. He underwent emergency surgery to repair an atriocaval rupture and has done well since. Our report suggests that an association of multiple radiofrequency ablations with increased risk for delayed atriocaval rupture occurring 1 to 3 months after ablation. In conclusion, although patients generally were advised to limit exercise for 1 to 2 weeks after AFL ablation procedures in the past, it may be prudent to avoid intense exercise for at least 3 months after procedure.

500th birthday of Andreas Vesalius, the founder of modern anatomy: "vivitur ingenio, caetera mortis erunt" ("genius lives on, all else is mortal").

It is often said that regional anesthesia is the practice of applied anatomy. Therefore, it is fitting that on the occasion of his 500th birthday, we celebrate the life and work of the brilliant Flemish anatomist, Andreas Vesalius (1514-1564), the founder of modern anatomy.