Pharmacologic Mydriasis Secondary to Topical Glycopyrronium Tosylate Cloths: Clinical Characterization From a Multicenter Analysis.

BACKGROUND: Topical glycopyrronium tosylate (GT) is an anticholinergic medication for treatment of axillary hyperhidrosis. Pharmacologic mydriasis and anisocoria from topical GT has been reported and may be underrecognized. This study aims to clinically characterize patients presenting with pharmacologic mydriasis from exposure to this medication. METHODS: This study is a retrospective observational case series. A multicenter chart review of 16 patients diagnosed with pharmacologic mydriasis secondary to topical GT was performed. RESULTS: Eight patients (50.0%) were age 18 years and younger, and 14 patients (87.5%) were female. Unilateral mydriasis (anisocoria) occurred in 14 patients (87.5%). Fourteen patients (87.5%) did not initially volunteer topical GT as a "medication," and the history of topical GT exposure needed to be elicited with further questioning. Hand hygiene details were known for 12 patients, and all reported that they did not wash their hands after GT application. Six patients (37.5%) were soft contact lens users. One patient had possible exposure through a family member's use of the medication. Ocular symptoms were common (blurry vision [11 patients, 68.8%] and eye dryness [7 patients, 43.8%]), but systemic anticholinergic symptoms were uncommon (such as constipation [1 patient, 6.3%] and urinary symptoms [3 patients, 18.8%]). CONCLUSIONS: Mydriasis associated with topical GT seems to be a consequence of local exposure rather than systemic toxicity. Because patients may not volunteer topical GT as a medication, eliciting a history of exposure often requires further specific questioning. Soft contact lens wear and poor postapplication hand hygiene seem to be associated with mydriasis in GT use.

Reconstruction of full width, full thickness cicatricial eyelid defect after eyelid blastomycosis using a modified tarsoconjunctival flap advancement.

Following effective treatment with systemic antifungal therapy, eyelid lesions from blastomycosis infection may be replaced by disfiguring fibrosis and scarring, which may be surgically challenging to correct. A 68-year-old man with biopsy-proven eyelid blastomycosis was treated with 6 months of oral voriconazole, but resolution of the lesion was complicated by cicatricial changes causing complete lower eyelid defect, epicanthal web, cicatricial mechanical ptosis, and skin plaques. Although repair adhered to the fundamentals of eyelid reconstruction, cicatricial changes associated with blastomycosis infection necessitated a modified approach and attachment sites. A tarsoconjunctival flap (Hughes flap) with modified flap connections utilizing cicatrix and remaining viable tissue was employed to reconstruct the lower eyelid defect and combined with tissue advancement using a Mustardé four-flap epicanthoplasty and post-auricular full-thickness skin graft. Satisfactory cosmetic outcome was achieved at last follow-up of 3.5 months postoperatively. This case demonstrates a feasible technique for reconstruction of significant eyelid defects following robust cicatricial changes such as those after blastomycosis. This report also presents the first description of reconstruction of lower eyelid defect and of posterior lamellar loss after blastomycosis infection.

Precision in Oculofacial Surgery: Made-To-Specification Cast-Molded Implants in Orbital Reconstruction.

PURPOSE: To describe the utilization of customized made-to-specification porous polyethylene implants and to evaluate clinical characteristics and outcomes of patients who received these implants for unilateral orbital defects. METHODS: A retrospective review of 9 patients was performed. Three-dimensional surface models were generated from high-resolution computed tomography scans. Orbital constructs were modeled after the normal, contralateral orbits and mirrored across the vertical midline to generate the target orbital implant. Measured outcomes included globe position, extraocular motility, facial symmetry, and diplopia. RESULTS: Patients ranged 25-56 years old (mean: 37) and included 6 males and 3 females. Cases consisted of 6 orbital floor fractures due to trauma, 1 lateral wall defect after neurofibroma resection, 1 floor/medial wall defect after myxoma resection, and 1 superior orbital rim defect after intraosseous hemangioma resection. Seven patients had ≥1 prior repair. All patients had previous hard and soft tissue defects and varying degrees of restrictive globe motility. Patients exhibited improved ductions after implant placement and improved facial appearance and symmetry. Post-operatively, 1 patient was found to have a small orbital hematoma between the implant and orbital floor, resolving within weeks. CONCLUSIONS: Precision, personalized oculofacial surgery is the next wave in tailoring surgical care to the individual patient. Customizable implants are manufactured to specifically mold to an individual patient's unique bony architecture, which can lead to superior outcomes in reconstructing orbital and craniofacial bony defects. This technique is particularly useful in patients with prior unsuccessful repair.

Acute Inflammatory Optic Neuritis Associated with a Self-Taper of Oral Prednisone in a Patient Taking Adalimumab.

Therapies, such as adalimumab, aimed at inhibiting the pro-inflammatory cytokine "tumour necrosis factor" (TNF) are effective and are frequently used in combination with non-biologic disease-modifying anti-rheumatic drugs to treat rheumatoid arthritis (RA) and other autoimmune diseases. Some reports indicate that, rarely, demyelinating CNS disorders such as optic neuritis can present in association with therapy initiation, whilst others suggest that there is no association between the two. Oral corticosteroids such as prednisone, though similarly effective in the treatment of inflammatory or auto-immune conditions, can be associated with adverse effects upon their discontinuation or tapering. We present a patient who developed an acute inflammatory optic neuropathy shortly after a self-taper of oral prednisone while being treated with adalimumab for RA, and discuss the challenge of deciding whether or not to halt anti-TNF therapy.

Self-insertion of foreign bodies into the orbit and periocular tissue.

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Sudden-onset Blindness from a Spontaneous Carotid-cavernous Fistula with Secondary Central Retinal Artery Occlusion and Posterior Ischemic Optic Neuropathy.

Our case describes a patient diagnosed with a carotid-cavernous fistula (CCF) secondary to a spontaneously ruptured cavernous carotid aneurysm, presenting with sudden vision loss, and a concomitant central retinal artery occlusion as visualized by a cherry-red spot in the macula and posterior ischemic optic neuropathy. Computed tomography of the brain and orbits showed mild hydrocephalus, orbital fat haziness, and proptosis with concern for fluid in the basal cisterns. Cerebral angiography confirmed the suspected diagnosis of CCF. After angiography, a Magnetic resonance imaging of the brain demonstrated abnormal diffusion restriction in the posterior right optic nerve confirmed on the apparent diffusion coefficient map, consistent with ischemia of the optic nerve in this location. Two weeks after discharge, outpatient fundus photography showed resolution of her cherry-red spot, and optical coherence tomography showed thinning of the entire retinal nerve fiber layer as compared to the contralateral eye. In CCFs, congestive symptoms of proptosis, pain, and even central retinal vein occlusion findings are frequently described. However, our patient's no light perception vision and imaging findings suggest associated central retinal artery occlusion and ischemic optic neuropathy. These findings underscore the multitude of serious visual effects of high flow CCFs.

Steroids in the Management of Synkinesis after Traumatic Oculomotor Palsy in India.

Traumatic oculomotor nerve palsies may result in aberrant regeneration and synkinesis that can impair normal facial function. We retrospectively investigated 16 patients with traumatic oculomotor nerve palsies who were treated with and without steroids to evaluate the rates of aberrant regeneration. The overall rates of aberrant regeneration were similar between the two groups and in line with other published series. Some limitations to our study may limit our ability to detect real differences, and additional studies would be beneficial.

Diagnostic Challenge: Sequential Unilateral Cranial Neuropathies Due to Perineural Spread of Carcinoma.

An 86-year old man developed sequential dysfunction of trigeminal (V1), facial, abducens, trigeminal (v2), oculomotor, and hypoglossal cranial nerves on the right over 20 months. Magnetic resonance imaging (MRI) showed a lesion in the right cavernous sinus. Although there was clinical suspicion that this was related to perineural spread of an extracranial tumour, a primary lesion was not discovered. Stereotactic biopsies of the intracranial lesion were non-diagnostic, and the patient succumbed to his tumour following a period of rapid growth. Postmortem examination showed the intracranial lesion to be a carcinoma with squamous features. This case highlights the challenges of diagnosis of intracranial perineural spread and the potential for transformation from indolent to aggressive tumour behaviour.