Qualitative use of ICG angiography and lymphography in periorbital surgery.

PURPOSE: Open imaging fluorescence devices have been utilized in surgical oncology, vascular and plastic surgery; however, the role of indocyanine green (ICG) in periorbital surgery and lymphatics has not been explored. METHODS: A prospective, single-center diagnostic study was conducted from 2021 to 2022 utilizing ICG to assess both the periorbital vasculature and lymphatics. Fluorescence was captured with open-imaging fluorescent devices. For ICG angiography, a total of 5-10 mg of ICG was given intravenously at various time points to visualize intraoperative blood flow to eyelid flaps, vascular tumors, or extraocular muscles. For ICG lymphography, 0.03-0.06 mg of ICG was injected subcutaneously to visualize the periorbital and facial lymphatic drainage. RESULTS: Twenty-two patients underwent ICG angiography. Periorbital vascular supply was seen in eyelid reconstructions (n = 8), anophthalmic reconstructions (n = 2), lacrimal gland tumors (n = 2), orbital venous malformations (n = 2), tumor metastasis (n = 1) and benign tumors (n = 1). The anterior ciliary arteries were visualized to the extraocular muscles in fracture repairs (n = 3) and muscle biopsies (n = 2). Ten patients underwent ICG lymphangiography highlighting the global periorbital lymphatic system. CONCLUSION: ICG allows for visualization of the vasculature of extraocular muscles and tumors, assessing perfusion of flaps during reconstruction and the global periorbital lymphatic drainage pathways.

Medical Accuracy of Patient Discussions in Oculoplastic Surgery on Social Media.

PURPOSE: The aim of this study was to characterize major topics of discussion in oculoplastic surgery on a social media forum and to evaluate the medical accuracy of the content discussed on these platforms. METHODS: A cross-sectional analysis of oculoplastics key search terms was performed on 2 active forums (r/PlasticSurgery and r/CosmeticSurgery) on Reddit. The content analysis involved the top posts in Reddit's history from 2008 to 2022. Medical accuracy was determined by actively practicing, board-certified, and fellowship-trained oculoplastic surgeons. RESULTS: The most common topics of patient discussions involved inquiring for advice regarding a procedure (44%) and sharing before-and-after photos (34%). The most common topics of patient discussions included providing support, encouragement, or sympathy for a patient (80%) and the cost of a procedure (62%). Misunderstanding of the medical pathophysiology of the patient's condition was seen in 68% of discussions on this social media platform. Medically inaccurate information was seen in 31% of all analyzed statements. When the type of physician performing a given procedure was disclosed, half reported an oculoplastic surgeon performed the surgery. CONCLUSIONS: The social media platform, Reddit, is a popular source of advice and information for current and prospective oculoplastic surgery patients. Such social media forums should be used as a sort of psychosocial and psychological support rather than as a primary source of medical information.

Association of Patient Age and the Thyroid Eye Disease-Clinical Activity Score.

PURPOSE: To investigate the association between age and clinical activity score (CAS) in patients with active, untreated thyroid eye disease. METHODS: A retrospective review was conducted of patients with active, untreated thyroid eye disease at a single institution between 2010 and 2020 whose ophthalmologic symptoms began no more than 9 months prior to the initial visit. Exclusion criteria included surgical or systemic thyroid eye disease treatment before or during the study period. Demographic and clinical data were collected for all patients, including a 7-point CAS at visit 1 (CAS1) and a 10-point score at visit 2 (CAS2). Patients were stratified by age: Group 1 (18-45), Group 2 (46-70), and Group 3 (71-85). RESULTS: A total of 156 patients were included: mean age 51.7 ± 15.8 years, 79.5% female. CAS1 differed significantly across groups: 1.9 ± 1.0 (Group 1), 2.7 ± 1.4 (Group 2), and 2.2 ± 1.6 (Group 3), p = 0.005. Findings were similar for CAS2: 2.2 ± 1.4 (Group 1), 3.0 ± 1.8 (Group 2), and 2.8 ± 1.9 (Group 3), p = 0.030. Post hoc analysis showed a statistically significant difference between Groups 1 and 2 (p = 0.004, visit 1; p = 0.025, visit 2) but not between other pairs. Patients with CAS1 of 0-3 (n = 129) were younger on average than those with CAS1 4-7 (n = 27): 50.4 ± 16.2 versus 58.2 ± 12.8 years (p = 0.009). Conjunctival redness (p = 0.019) and chemosis (p ≤ 0.001) were more common in older patients at both visits. CONCLUSIONS: Patients aged 46-70 years with active, untreated thyroid eye disease had significantly higher CAS1 and CAS2 than younger patients in this study, largely driven by differences in conjunctival redness and chemosis.

Spheno-Orbital Meningioma - Treatment Outcomes and Factors Influencing Recurrence.

PURPOSE: To determine treatment outcomes, recurrence rates, and predictors of recurrence, to inform future therapeutic approaches for spheno-orbital meningiomas (SOM). METHODS: A retrospective single-center study of SOM treated from 1990 to 2021 was conducted with comprehensive neuro-ophthalmologic follow-up at Columbia University Medical Center (CUMC). Recurrence requiring reintervention was defined clinically as worsening of visual acuity, visual field defect, or ocular motility after an initial period of stabilization or 6 months of improvement following treatment, or radiologically as either a regrowth with an increase in tumor size by 20% at the site of previous growth or a new region of tumor growth. RESULTS: In total 46 patients met the inclusion criteria. The mean follow-up was 106 months (range 1-303). Dictated by the phenotype of the disease, patients underwent either gross- (50%), near- (17%), or subtotal resection (26%). Removal of the anterior clinoid process (ACP) was performed in 52% of patients. Nine patients (20%) required an enucleation or exenteration. Radiotherapy was employed at some point of treatment in 50% of cases. Inherited cases (24%) were referred to CUMC for treatment following 1 or more recurrences. The total recurrence rate, including inherited cases, was 54%, occurring at a mean interval of 43 months. The recurrence rate of patients treated solely at CUMC was 40%, occurring at a mean interval of 41 months. A subset of patients (32%) had 2 or more recurrences. Histopathology at the first surgery was WHO grade I (87%) and II (13%) and at the final surgery was WHO grade I (74%), II (21%), and III (4%). A subset of grade I tumors that received radiotherapy (35%) evolved to a higher grade or developed multiple recurrences without a change in histologic grade I. Grade II tumors and treatment with radiotherapy increased the odds of recurrence. Removal of the ACP and gross total resection decreased the odds of recurrence. CONCLUSION: Due to the routinely long interval to tumor recurrence, lifelong surveillance of patients with SOM is prudent. ACP resection and gross total resection, where possible, reduce tumor recurrence and the need for further treatment. Radiotherapy should be reserved for higher-grade meningiomas and select grade I tumors.

Globe Compression by Bone Fragments in Orbital Blow-in Fractures: A Case Series and Systematic Review.

PURPOSE: The purpose of this study was to describe the clinical characteristics, management, and outcomes of orbital blow-in fractures involving compression of the globe by bone fragments. METHODS: A retrospective case series and systematic literature review were performed. RESULTS: Three male patients (mean age 29 years) with orbital blow-in fractures causing globe indentation presented with extraocular movement restriction, choroidal folds, and B-scan ultrasonography demonstrating deformation of the globe contour by a hyperechoic bone fragment. All underwent surgical repair within 1 day of presentation resulting in improved visual outcomes. An additional 10 cases were identified in the literature review. The majority of patients were male (80%) with a mean age of 29 years. Fractures originated primarily from the lateral orbital wall (50%) or the orbital roof (40%). Globe compression was evident on CT of the orbit (100%) and ultrasonography (30%). Common presenting signs included decreased visual acuity (70%), restriction of supraduction (40%) or abduction (40%), choroidal folds (30%), brow laceration (40%), periorbital edema (40%), and hypoglobus (40%). Most patients underwent surgical intervention (80%) involving fracture reduction (50%) or fragment removal (38%). Reported postsurgical outcomes were excellent with resolution of diplopia, motility, and visual acuity. CONCLUSION: Globe indentation from blow-in fractures are rare. Clinicians should be suspicious in cases of high-velocity trauma to the superolateral orbit with hypoglobus, motility limitation, and indentation of the globe upon dilated exam. Prompt diagnosis and early surgical removal of the compressive orbital bone fragments in a multidisciplinary fashion can lead to good visual, functional, and cosmetic outcomes.

Periorbital Pyoderma Gangrenosum Associated With a Cocaine-Induced Midline Destructive Lesion: Case Report and Review of the Literature.

A 72-year-old woman with a history of chronic cocaine use presented 9 months after a dog bite with a large facial ulceration and absent sinonasal structures. Biopsies were negative for infectious, vasculitic, or neoplastic pathologies. The patient was lost to follow up for 15 months and returned with a significantly larger lesion despite abstinence from cocaine. Additional inflammatory and infectious workup was negative. Intravenous steroids were administered with clinical improvement. Therefore, she was diagnosed with pyoderma gangrenosum and cocaine-induced midline destructive lesion due to cocaine/levamisole. Pyoderma gangrenosum is a rare dermatologic condition that uncommonly involves the eye and ocular adnexa. Diagnosis involves clinical examination, response to steroids, exclusion of infectious or autoimmune conditions, and identifying potential triggers including cocaine/levamisole. This report highlights a rare presentation of periorbital pyoderma gangrenosum causing cicatricial ectropion associated with concomitant cocaine-induced midline destructive lesion and reviews important aspects of clinical manifestations, diagnosis, and management of pyoderma gangrenosum and cocaine/levamisole autoimmune phenomenon.

Spontaneous regression of a presumed orbital apex cavernous venous malformation.

A 42-year-old non-menopausal, non-pregnant woman presented with an incidentally noted right orbital apex lesion producing mild compressive optic neuropathy. Imaging revealed an apical, intraconal, inhomogenously enhancing mass consistent with a cavernous venous malformation displacing the optic nerve. The patient was monitored over a 15-year period with serial orbital imaging and clinical examinations and ultimately demonstrated significant regression in the size of the lesion, accompanied by the complete resolution of optic neuropathy. She was non-menopausal when the regression was noted and remained non-pregnant throughout the follow-up period.

Ophthalmic artery occlusion following n-butyl cyanoacrylate embolization of an orbital arteriovenous malformation.

A 33-year-old pregnant woman presented with six months of right-sided proptosis. Neuroimaging revealed a right orbital arteriovenous malformation arising from the second segment of the ophthalmic artery. As she was 9 weeks pregnant, the decision was made to monitor her closely. Over the following six months, her proptosis progressed, accompanied by decreased visual acuity, afferent pupillary defect, and red desaturation concerning for compressive optic neuropathy. After planned c-section, she underwent embolization with n-butyl cyanoacrylate. Upon awakening after embolization, she had no light perception vision from her right eye and was found to have ophthalmic artery obstruction. She ultimately developed a blind painful right eye and underwent enucleation with histopathology demonstrating glue in the central retinal artery, posterior ciliary arteries, and choroid. This case highlights ophthalmic artery occlusion as a rare complication of orbital arteriovenous malformation embolization and demonstrates correlating histopathological findings, which have not previously been reported.

Evolution of asymmetric proptosis during the active phase of thyroid eye disease.

PURPOSE: To assess the evolution of proptosis asymmetry during the active phase of bilateral thyroid eye disease (TED). METHODS: A retrospective study was conducted on patients with bilateral, active TED. Patients were measured by a single observer, using Hertel exophthalmometry from the time of initial presentation, during the active phase of TED, to the stable phase, 24-months later. Asymmetric proptosis was defined as a >2 mm intra-orbital difference in Hertel measurements. RESULTS: Fifty-one patients were enrolled. Patients presented at a mean time of 1.1 ± 2.9 months following the onset of TED symptoms. Stability of TED was established at 15.7 ± 12.3 months. At initial presentation, 41% of patients demonstrated asymmetric proptosis. Upon reaching the stable phase, asymmetric proptosis persisted in only 22% of patients. A decline in the rate asymmetric proptosis was greatest within the first 3 months of the active phase. CONCLUSIONS: Asymmetric proptosis is common in the setting of early active TED and decreases by 50% when the stable phase is reached. Therefore, diagnostic imaging is not routinely required to exclude alternative pathology in the cases of asymmetric TED. Perhaps more importantly, this finding supports the surgical paradigm of stable phase, graded orbital decompression, performed when the ultimate globe positions are achieved to avoid late postoperative asymmetry, resulting from the unanticipated evolution of proptosis when surgery is performed during the active phase of TED.

A single-institution review of lacrimal gland biopsies between 1962 and 2017.

PURPOSE: To examine the clinical and histopathologic characteristics of lacrimal gland biopsies at a tertiary academic center. METHODS: A retrospective chart review of patients undergoing lacrimal gland biopsy or excision between 1962 and 2017 was performed via the ocular pathology specimen log. All cases were reviewed for demographics, clinical presentation, and histopathologic diagnoses. RESULTS: Four hundred and two eyes in 356 patients were included in the analysis. Median age was 49 (range 5-91) with a female predominance (255, 72%, p < .001). Most had unilateral involvement (308, 86.5%) and visual acuity of 20/50 or better (332 eyes, 83%). Limitation in extraocular motility was present in 71 eyes (18%), relative afferent pupillary defect in 10 eyes (2.5%), and intraocular pressure 20 mmHg or above in 80 eyes (20%). The pre-operative radiology report commented on the enlargement of the lacrimal gland in 236 eyes (58.7%), and lack thereof in 73 eyes (18.2%). The most common histopathologic diagnoses were nonspecific inflammation or orbital pseudotumor (170, 42%), lymphoma (65, 16%), pleomorphic adenoma (22, 5.5%), adenoid cystic carcinoma (19, 4.7%), granulomatous inflammation (19, 4.7%), and normal lacrimal gland (16, 4%). Three hundred and seven cases were benign (76%) and 95 malignant (24%). The biopsy specimen was diagnostic in 343 (85%), and non-diagnostic in 59 (15%). CONCLUSIONS: This is a comprehensive review of one of the largest ocular pathology databases of lacrimal gland lesions. This study confirms the wide range of inflammatory and neoplastic conditions affecting the lacrimal gland and highlights the nuances of histopathologic diagnoses and diagnostic yield of biopsies in clinical practice.

Congenital Eyelid Imbrication and Floppy Eyelid Syndrome in a Patient With Cat Eye Syndrome.

A newborn male with cat eye syndrome presented with progressively worsening bilateral upper eyelid imbrication, floppy eyelids, and ptosis. Despite conservative management, he remained unable to open his eyelids. Surgical correction was planned to prevent bilateral sensory deprivation amblyopia and was delayed until 5 months of age due to systemic health concerns. Bilateral full-thickness wedge excision and frontalis suspension with silicone rods in a double rhomboid fashion was performed. Postoperatively, the patient demonstrated spontaneous eyelid opening, resolution of spastic eversion of the upper eyelids, and adequate eyelid closure. The authors present the first case of concurrent floppy eyelid syndrome and upper eyelid imbrication reported in a cat eye syndrome patient.

GNA11 Mutation in an Intracranial Melanocytoma with Orbital Involvement and Nevus of Ota.

The prognostic value of mutations in G-protein genes GNAQ and GNA11 in patients with intracranial and orbital melanocytomas is unknown. The authors present a case of GNA11 mutation (GNA11Q209L) in a 32-year-old male suffering from a meningeal melanocytoma with orbital involvement and ipsilateral Nevus of Ota. The patient underwent gamma knife stereotactic radiosurgery without biopsy and later partial transcranial resection of the melanocytic tumor that was subject to immunohistochemical and molecular analysis. A 50-gene next-generation sequencing panel revealed a 626A>T mutation in the GNA11 gene. One year later, intracranial extension of the melanocytoma necessitated a ventriculoperitoneal shunt and immunotherapy. Future work is needed to determine how GNA11 mutations in melanocytomas influence prognosis and monitoring strategies.

The Arched Rainbow Brow in Thyroid Eye Disease.

PURPOSE: To morphologically describe and mathematically quantify a novel clinical feature of thyroid eye disease (TED). METHODS: A retrospective study was conducted of TED patients and age-sex-matched normal controls. The arched Rainbow Brow appearance in TED patients was determined by unanimous agreement of 3 oculoplastic surgeons. Eyebrow curvature was assessed by plotting 15 points along the eyebrow in ImageJ. The fourth-degree polynomial ( y = ax4 + bx3 + cx2 + dx + e ) was fitted to each eyebrow. RESULTS: Two hundred seventy-one eyes were analyzed (200 TED and 71 age-sex-matched normal controls). A Rainbow Brow was identified in 42% of TED patients. A unilateral Rainbow Brow was seen in 15% of patients. The fourth-degree polynomial coefficients yielded significant differences between Rainbow Brow patients and age-sex-matched normal controls for the coefficients a, b, c , and d . Similar analysis of TED patients with and without a Rainbow Brow showed differences in coefficients a and b . Age >50 years ( p = 0.009) and the presence of brow fat expansion ( p < 0.001) were associated with the presence of a Rainbow Brow. Proptosis >24 mm showed a trend toward association with the presence of a Rainbow Brow ( p = 0.057). When considering the contribution of these features in a multivariable analysis, only brow fat expansion was a significant contributing factor ( p = 0.009). CONCLUSIONS: The Rainbow Brow is a distinct entity in TED and is likely consequent to brow fat pad expansion. Patients with a Rainbow Brow have different eyebrow curvature as compared to both normal age-sex-matched controls and TED patients without a Rainbow Brow.

Ophthalmic Virtual Visit Utilization and Patient Satisfaction During the COVID-19 Pandemic.

Background:Due to the COVID-19 pandemic, there was a surge in synchronous ophthalmic telehealth visits. The purpose of this study is to analyze the utilization and patient satisfaction of synchronous ophthalmic video visits over the course of the COVID-19 pandemic.Methods:In this retrospective, single-center cross-sectional study, 1,756 patients seen through synchronous video visits between March 1, 2020, and March 31, 2021, were identified using billing codes. E-mails containing a validated, 11-item, telehealth satisfaction scale were sent to patients who had at least one video visit within the study period. Questions were scored on a 1-4 scale, corresponding to poor, fair, good, and excellent. Main outcome measures included patient satisfaction scores, frequency of repeat video visits, and primary visit diagnoses.Results:The top 3 subspecialties by virtual visit volume were oculoplastic surgery (999 visits, 42.9%), neuro-ophthalmology (331 visits, 17.0%), and cornea (254 visits, 14.2%). The top 3 diagnoses seen were chalazion/hordeolum, dry eye, and meibomian gland dysfunction. The overall survey response rate was 14.3% (252 participants). The mean patient satisfaction score was 3.67 ± 0.63, with no significant difference in scores between specialties. A total of 380 (21%) patients had repeat virtual visits. Mean survey response scores were significantly higher for patients with repeat visits than those without (3.82 ± 0.42 vs. 3.62 ± 0.68, p = 0.03). Patients undergoing oculoplastic services were more likely to have repeat visits (odds ratio 2.58, 95% confidence interval 2.18-3.06, p < 0.001). Multivariate regression analysis found that provider thoroughness/skillfulness was the most predictive feature of the patient returning to a telehealth encounter (p = 0.01).Conclusions:Our study suggests that synchronous videoconferencing for ophthalmology is a highly satisfactory delivery method and will likely find continued success in select subspecialties as the pandemic fades.

Mathematical Modeling of Eyebrow Curvature.

The aim of the study is to describe a mathematical model for analyzing eyebrow curvature that can be applied broadly to curvilinear facial features. A total of 100 digital images (50 men, 50 women) were obtained from standardized headshots of medical professionals. Images were analyzed in ImageJ by plotting either 8 or 15 points along the inferior-most row of contiguous brow cilia. A best-fit curve was automatically fit to these points in Microsoft Excel. The second derivative of the second-degree polynomial and a fourth-degree polynomial were used to evaluate brow curvature. Both techniques were subsequently compared with each other. A second-degree polynomial and fourth-degree polynomial were fit to all eyebrows. Plotting 15 points yielded greater goodness-of-fit than plotting 8 points along the inferior brow and allowed for more sensitive measurement of curvature across all images. A fourth-degree polynomial function provided a closer fit to the eyebrow than a second-degree polynomial function. This method provides a simple and reliable tool for quantitative analysis of eyebrow curvature from images. Fifteen-point plots and a fourth-degree polynomial curve provide a greater goodness-of-fit. The authors believe the described technique can be applied to other curvilinear facial features and will facilitate the analysis of standardized images.

Utilizing a mobile platform to obtain quantitative measurements of exophthalmos.

PURPOSE: This study introduces a novel exophthalmometry method utilizing a mobile platform to obtain calibrated quantitative measurements of globe position and compares its reliability to Hertel exophthalmometry. METHODS: A prospective, comparative study included 50 patients (99 eyes) for a total of 594 mobile measurements. Healthy individuals from the community in Augusta, Georgia, and individuals from a routine oculoplastics clinic at Mayo Clinic in Rochester, Minnesota, were included to represent variety within the population. The main outcome was the inter-modality correlation and agreement between Hertel and mobile exophthalmometry, and the intra-observer and inter-observer reliability with repeated mobile measurements. RESULTS: There was no significant difference in the measurements obtained by Hertel exophthalmometry and mobile exophthalmometry. There was a strong linear correlation between Hertel and mobile exophthalmometry with a Pearson Correlation Coefficient of 0.910 and 0.888 for the right and left eyes, respectively (p < .001, 2-tailed). Bland-Altman plot analysis showed excellent agreement between the two modalities. The mobile platform demonstrated high intra-observer reliability with a Cronbach's alpha of 0.992 and 0.985 for the right and left eyes. An intraclass correlation coefficient of 0.992 (95% CI: 0.987-0.995) for the right eye and 0.986 (95% CI: 0.978-0.991) for the left eye demonstrated excellent reliability between observers. CONCLUSIONS: Mobile exophthalmometry may be a promising tool for obtaining calibrated quantitative measurements of globe position for situations in which Hertel exophthalmometry is not available. The strong correlation and excellent agreement between Hertel and mobile measurement suggest that mobile exophthalmometry can yield reliable and accurate measurements.

Thrombosed orbital arteriovenous malformation in a patient with lymphangioleiomyomatosis.

A 47 year-old female with lymphangioleiomyomatosis developed right periorbital pain worsened while chewing, six months prior. Neuroimaging demonstrated a heterogenous inferotemporal right orbital mass extending through the inferior orbital fissure into the temporalis fossa, with flow voids. Given the patient's past medical history, the lesion was presumed to be a perivascular epithelioid cell tumor, a manifestation of lymphangioleiomyomatosis. A lateral orbitotomy revealed a well-circumscribed bluish-red lesion with areas of hemorrhage that was resected in total. Histopathology, however, was consistent with a thrombosed orbital arteriovenous malformation likely arising from the zygomaticotemporal neurovascular bundle. Lymphangioleiomyomatosis is a rare progressive disease that causes cystic destruction of the lungs and is frequently associated with extrapulmonary tumor infiltration, typically of the kidney and liver. Lymphangiomyoleiomyomatosis cell pathogenesis includes a pro-angiogenic micro-environment, classically expressing vascular endothelial factor-C and -D, which we postulate may have contributed to the development of the orbital arteriovenous malformation.

An elusive case of malignant optic nerve glioma with a suprasellar mass.

A 67-year-old man with multiple comorbidities presented with 3 weeks of orbital pain, proptosis, and no light perception vision in the left eye. Examination was notable for a left orbital apex syndrome with CN III, VI palsies, an optic neuropathy, and central retinal vein occlusion. Magnetic resonance imaging of the orbits was notable for extensive enhancement, enlargement, and T2 hyperintensity of the optic nerve, with perineural sheath enhancement, and chiasmal hyperintensity. Inflammatory workup and lumbar puncture were unremarkable. No improvement was seen after a 3-day course of intravenous solumedrol. Initial optic nerve biopsy revealed necrotic nerve tissue, macrophage infiltration, increased vascularization, and peripheral gliosis. The volume of tissue was inadequate for genomic analysis. The patient was lost to follow-up but returned 5 months later with right-sided vision loss. Repeat neuroimaging showed a new suprasellar mass and progressive expansion and enhancement of both optic nerves. Biopsies of the suprasellar mass and left nerve at this time were consistent with a high-grade glial neoplasm, WHO grade IV. This is a rare case of glioblastoma involving the optic nerves and suprasellar region. In such cases, molecular profiling can improve diagnosis and may provide for targeted treatments in the future.

Atypical presentation of invasive myoepithelioma in a pediatric patient.

A 15-year-old girl presented with a mobile lesion with yellowish hue on the posterior lamella of the right lower eyelid adjacent to the punctum. Four years prior, a lesion thought to be a chalazion was excised from the same location. There was subsequent progressive painless enlargement. The patient ultimately underwent an internal excision of the mass. Histopathology demonstrated infiltrative nests and cords of epithelioid and plasmacytoid cells with abundant eosinophilic myxoid-collagenous stroma along with focal infiltration of skeletal muscle with immunohistochemical staining consistent with an invasive myoepithelioma of mixed-cell type. Given concern for invasive disease, the patient underwent subsequent Mohs resection resulting in a 25% full thickness eyelid defect, which was repaired with direct closure of the wedge defect. There has been no recurrence of the disease for 7 months since the Mohs resection. This case illustrates the atypical presentation of an invasive myoepithelioma of the eyelid in a pediatric patient.

Natural killer T-cell lymphoma causing bilateral recurrent recalcitrant dacryocystitis.

A 35-year-old female with a history of chronic extensive rhinosinusitis, previously treated twice with functional endoscopic sinus surgery, presented with recurrent dacryocystitis despite prior dacryocystorhinostomy. Histopathological specimens taken at the most recent sinus surgery demonstrated a lymphocytic inflammatory reaction without evidence of angiodestruction or necrosis. Flow cytometry was normal. Over the following 9 months, the patient developed worsening hypertelorism and bilateral recurrent acute dacryocystitis with a fistula tract to the skin. Neuroimaging revealed a hyperintense enhancing soft tissue expansion into the periorbital regions, invading the nasolacrimal canals, and obstructing the paranasal sinuses. A skin biopsy at the fistula site revealed natural killer T-cell lymphoma. Metastatic work-up disclosed lung, spleen, and bone marrow involvement. The patient underwent chemotherapy with mixed clinical response, and ultimately passed away from metastatic disease. The authors present a rare case of natural killer T-cell lymphoma involving the nasolacrimal sac, presenting as recurrent dacryocystitis and diagnosed by skin biopsy of the fistula site.