Suspected orbital myositis associated with COVID-19.

A 44-year-old male patient developed proptosis, edema, and erythema progressing to complete ptosis and supraduction deficit 2 days after positive COVID-19 test. He failed to improve on systemic antibiotics. MRI showed thickening and T2 enhancement of the superior rectus/levator complex consistent with orbital myositis. He improved on intravenous corticosteroids and experienced continued gradual improvement on oral steroids.

Spheno-Orbital Meningiomas: An Analysis Based on World Health Organization Classification and Ki-67 Proliferative Index.

PURPOSE: To evaluate the clinical behavior of spheno-orbital meningiomas with regard to World Health Organization (WHO) tumor grade and Ki-67, a cellular marker of proliferation. METHODS: A retrospective review over a 16-year period of the demographic, clinical, radiographic, and surgical data of all patients with spheno-orbital meningioma who underwent surgical resection. Tumor specimens were examined histologically using the current WHO 2016 classification and immunohistochemically using Ki-67/MIB-1 monoclonal antibody. RESULTS: Thirty-eight patients met all inclusion criteria: 78.9% of tumors were WHO grade I with a mean Ki-67 of 3.76, and 93% of patients were clinically stable at last follow up; 10.5% of lesions were WHO grade II (atypical) with a mean Ki-67 of 14.93, and 10.5% of lesions were WHO grade III (anaplastic) with a mean Ki-67 of 58.3. All grade II and III meningiomas exhibited an aggressive clinical course. There were statistically significant correlations between disease clinical progression and WHO tumor grade (p < 0.001), between disease clinical progression and Ki-67 (p < 0.001), and between increasing Ki-67 index and higher WHO grade (p < 0.001). For WHO grade I lesions, a Ki-67 of ≥3.3 correlated with recurrence (p = 0.0256). Overall, disease-specific mortality occurred in 5 (13%) patients. CONCLUSIONS: Ki-67 index is a valuable marker to use in conjunction with WHO grade to predict meningioma behavior, particularly in histologically borderline lesions, and possibly to identify a subset of WHO grade I tumors at risk of recurrence. This combination of methods can aid in tailoring treatment and surveillance strategies.

Laboratory Investigations for Diagnosis of Autoimmune and Inflammatory Periocular Disease: Part II.

PURPOSE: To review the important laboratory serological investigations routinely performed for the diagnosis of autoimmune and inflammatory diseases of the orbit and ocular adnexa. METHODS: Review of the literature as well as personal clinical experience of the authors. Due to the extensive nature of the topic, the review has been split into 2 parts. Part I covers thyroid eye disease, IgG4-related disease, and myasthenia gravis. In part II of the review, sarcoidosis, vasculitis, Sjögren syndrome, and giant cell arteritis will be discussed. RESULTS: Several relatively specific serologic tests are available for the diagnosis of a variety of inflammatory and serologic diseases of the orbit. CONCLUSION: In cases of limited orbital or sino-orbital disease, serologic testing may be negative in a significant number of patients. Specifically, the clinician should be wary of ruling out limited orbital sarcoid or sinoorbital granulomatosis with polyangiitis based on serologic testing alone. Part I of this review has covered serologic testing for thyroid eye disease, IgG4-related disease, and myasthenia gravis. In part II, the authors discuss serologic testing for sarcoidosis, vasculitis, Sjögren syndrome (SS), and giant cell arteritis (GCA).

Orbital Compartment Syndrome Following Post-Traumatic Subgaleal Hematoma.

Orbital extension of subgaleal hematoma is rare. This report describes the case of an otherwise healthy 10-year-old girl who developed delayed contralateral proptosis and external ophthalmoplegia after relatively minor right-sided forehead trauma. She was found to have bilateral subgaleal hematomas communicating with a left superior subperiostial orbital hematoma. Over the course of 2 days, she developed an orbital compartment syndrome requiring emergent canthotomy and cantholysis, followed by surgical incision and drainage of her scalp hematoma without orbitotomy. Hematologic work-up revealed heterozygous factor VII deficiency.

Efficacy of Orbital Color Doppler Imaging and Neuroimaging in the Diagnosis of Carotid Cavernous Fistulas.

PURPOSE: To evaluate the diagnostic sensitivity and specificity of orbital color Doppler imaging (CDI) and conventional neuroimaging (CT/MRI) compared with cerebral angiography in patients with carotid-cavernous fistulas (CCFs). METHODS: The study design was a retrospective patient chart and imaging review. The authors reviewed 655 charts of all patients who underwent CDI and neuroimaging (CT/MRI) between 2006 and 2015 at one institution. Sixty patients had a presumptive diagnosis of CCF without thrombosis. Thirty-seven patients with 43 events met the inclusion criteria of the study. The diagnostic sensitivity of the 3 noninvasive imaging modalities (CDI, CT, MRI) for CCF was compared with the gold standard 6-vessel cerebral angiography. Significance testing was performed using the 2-tailed Fisher test. RESULTS: Color Doppler imaging had high sensitivity (96.8%) but low specificity (41.7%) for the diagnosis of CCFs with anterior orbital findings. A negative CDI had more diagnostic value than a positive CDI. While an arterial wave form in the superior ophthalmic vein was the most common finding of CCF on CDI, enlargement of the superior ophthalmic vein was the only statistically significant finding. Posterior cortical venous drainage was noted in about 10% of the patients with indirect (low-flow) fistulas, who presented with unilateral orbital signs and symptoms, a finding not previously reported in the literature. CONCLUSION: Color Doppler imaging is a useful noninvasive, radiation-free modality for diagnosis of CCF with anterior drainage, with higher sensitivity than CT or MRI, but equivalent specificity. A significant limitation of CDI is the lack of usefulness in diagnosing fistulas with posterior cortical venous drainage, which carry a risk of intracerebral hemorrhage and stroke. In this series, 10% of unilateral CCFs with anterior orbital signs and symptoms showed angiographic evidence of posterior cortical venous drainage.

IMPACT OF PHYSICIAN COMMUNICATION ON DIABETIC EYE EXAMINATION ADHERENCE: Results From a Retrospective Cohort Analysis.

PURPOSE: To evaluate the effect of written communication between an ophthalmologist and a primary care physician (PCP) on patient adherence to diabetic eye examination recommendations. METHODS: In a retrospective cohort study of a multiethnic population at an urban ophthalmology center, records of all patients with diabetes and clinic visits between 2007 and 2010 were reviewed. Data collected included patient demographics, insurance status, hemoglobin A1C, severity of diabetic retinopathy, follow-up examinations, and written communication between a patient's ophthalmologist and PCP. Statistical analyses were performed to examine the relationship between physician communication and adherence to diabetic eye examination based on the American Academy of Ophthalmology-published recommendations. RESULTS: A total of 1,968 people with diabetes were included. Written communication from an ophthalmologist to a PCP was associated with increased adherence to follow-up eye examination recommendations (Odds Ratio: 1.49; 95% Confidence Interval: 1.16-1.92; P = 0.0018). Communication from a PCP to an ophthalmologist was also associated with increased adherence (Odds Ratio: 1.94; 95% Confidence Interval: 1.37-2.77; P = 0.0002). Multivariable analysis controlling for other factors associated with examination adherence confirmed that communication both to and from an ophthalmologist was independently and significantly associated with increased follow-up adherence. CONCLUSION: Patients with communication between ophthalmologists and PCPs are more likely to adhere to diabetic eye examinations.

Laboratory Investigations for Diagnosis of Autoimmune and Inflammatory Periocular Disease: Part I.

PURPOSE: To review the important laboratory serological investigations routinely performed for the diagnosis of autoimmune and inflammatory diseases of the orbit and ocular adnexa. METHODS: Review of the literature as well as personal clinical experience of the authors. RESULTS: Periocular inflammation is a blanket term which refers to a wide variety of conditions affecting the orbit and the ocular adnexa. Although the etiology of each of these conditions is different, their similarity lies in their clinical presentation and in the fact that each of them can be vision-threatening and even life-threatening if left untreated. CONCLUSIONS: This review covers important laboratory serological investigations specific to entities routinely encountered by orbitologists. The technique, parameters measured, and clinical importance of each of these laboratory tests are discussed in detail. Due to the extensive nature of the topic, the review has been split into 2 parts. Part I covers thyroid eye disease, IgG4-related disease, and myasthenia gravis. In part II of the review, sarcoidosis, vasculitis, Sjögren syndrome, and giant cell arteritis will be discussed.

Tension Pneumocephalus Following Orbital Exenteration.

Pneumocephalus is a known complication of skull base surgery, but is rarely seen by orbital surgeons. We report a case of postoperative mental status changes after exenteration due to tension pneumocephalus. After surgical and medical management, the patient's pneumocephalus resolved and she recovered fully. Risk factors for tension pneumocephalus, mechanism, clinical presentation, and management techniques are discussed.

Cultural and Cognitive Determinants of Personal Control in Older African Americans with Diabetes.

ACKNOWLEDGEMENTS: The study was funded by Pennsylvania Department of Health's Commonwealth Universal Research Enhancement (CURE) Program (SAP#4100051727). OBJECTIVE: To describe the determinants of personal control over diabetes complications in older African Americans (N=123) with type 2 diabetes. METHODS: We administered structured instruments to assess perceptions of personal control, time orientation, religiosity, depression, and cognition in this cross-sectional study. RESULTS: More years of education (p ≤ .001), better Clock Drawing (p ≤ .001), higher levels of Religiosity (p ≤ .04), and lower Present Time Orientation (p ≤ .01 ) were independent predictors of higher levels of Personal Control. DISCUSSION: Risk perceptions of control over diabetes complications vary among older African Americans according to cultural constructs, executive function, and education. This finding highlights the cultural diversity in this population and the potential impact of culturally-determined views and cognitive function on health behaviors. Cognitive screening of older persons with diabetes and interventions that incorporate perceptions of time and religion to increase rates of eye examinations are needed.

Depression and Risk Perceptions in Older African Americans With Diabetes.

Objective. The purpose of this study is to describe the impact of depression on perceptions of risks to health, diabetes self-management practices, and glycemic control in older African Americans with type 2 diabetes. Methods. The authors analyzed data on depression, risk perceptions, diabetes self-management, and A1C in African Americans with type 2 diabetes. T-tests, χ(2), and multivariate regression were used to analyze the data. Results. The sample included 177 African Americans (68% women) whose average age was 72.8 years. Thirty-four participants (19.2%) met criteria for depression. Compared to nondepressed participants, depressed participants scored significantly higher on Personal Disease Risk (the perception of being at increased risk for various medical problems), Environmental Risk (i.e., increased risk for environmental hazards), and Composite Risk Perception (i.e., overall perceptions of increased risk); adhered less to diabetes self-management practices; and had marginally worse glycemic control. Depression and fewer years of education were independent predictors of overall perception of increased health risks. Conclusion. Almost 20% of older African Americans with type 2 diabetes in this study were depressed. Compared to nondepressed participants, they tended to have fewer years of education, perceived themselves to be at higher risk for multiple health problems, and adhered less to diabetes self-management practices. It is important for diabetes educators to recognize the impact of low education and the fatalistic perceptions that depression engenders in this population.

Canalicular laceration repair: an analysis of variables affecting success.

PURPOSE: To evaluate the outcomes of all canalicular lacerations at a high-volume urban tertiary eye care center and calculate the impact of variables of repair on success. METHODS: A retrospective review over a 10-year span of all primary canalicular laceration repairs was performed. Variables included patient demographics, repair setting, surgeon level of training, mechanism of injury, associated injuries, type of stent used, and success of repair. RESULTS: One hundred thirty-seven patients met the inclusion criteria and were used for analysis. The mechanism of injury was primarily due to altercations (31.4%), followed by accidents (21.9%). Most repairs were performed in the operating room (72.3%) with an overall success rate of 85.9% compared with 36.8% in the minor procedure room. The success rate varied significantly by level of training, with a fellowship-trained oculoplastic surgery attending physician attaining the highest success rate of 84.0%. The success by primary surgeon training level was statistically significant (p<0.0001). The efficacy of a monocanalicular stent was also studied and was not significantly different from bicanalicular stenting when other variables were accounted for (p=0.1186). CONCLUSION: The overall success of canalicular laceration repair is good. However, the setting of repair and level of training greatly affect the success of repair. In a tertiary care setting, an attending surgeon with subspecialty training in oculoplastic surgery should participate in the canalicular laceration repair to maximize the success rate. Performing the repair in the operating room rather than a minor procedure room setting may further improve the patient outcomes.

Orbital amyloidosis masquerading as metastatic breast carcinoma.

One of the most common causes of enophthalmos is previous orbital fracture. In a patient with a known history of breast carcinoma, enophthalmos is concerning for metastatic disease. This report presents a patient with a history of scirrhous breast carcinoma and enophthalmos who was found to have orbital amyloidosis. This is the first report of enophthalmos as the presenting sign of orbital amyloidosis.

Perineural invasion of cutaneous squamous cell carcinoma along the zygomaticotemporal nerve.

The vast majority of periocular squamous cell carcinoma spreads intraorbitally along the supraorbital and infraorbital nerves into the cavernous sinus. A patient presented with a history of resected squamous cell carcinoma and pain in the zygomatic distribution. She was found to have temporalis involvement of the malignancy and invasion of the zygomaticotemporal nerve by histopathology. She underwent aggressive resection and adjuvant treatment with no evidence of recurrence at 8-month follow up. This case illustrates an uncommon route of squamous cell carcinoma spread through the zygomaticotemporal sensory nerve distribution.

Ophthalmic patients' utilization of technology and social media: an assessment to improve quality of care.

BACKGROUND: E-health tools have the potential to improve the quality of care for ophthalmic patients, many of whom have chronic conditions. However, little research has assessed ophthalmic patients' use or acceptance of technological devices and social media platforms for health-related purposes. The present study evaluated utilization of technological devices and social media platforms by eye clinic patients, as well as their willingness to receive health reminders through these technologies. SUBJECTS AND METHODS: A 31-item paper questionnaire was administered to eye clinic patients (n=843) at an urban, tertiary-care center. Questions focused on technology ownership, comfort levels, frequency of use, and preferences for receiving health reminders. Demographic data were also recorded. RESULTS: Eye clinic patients most commonly owned cellular phones (90%), landline phones (81%), and computers (80%). Overall, eye clinic patients preferred to receive health reminders through phone calls and e-mail and used these technologies frequently and with a high level of comfort. Less than 3% of patients preferred using social networking to receive health reminders. In addition, age was significantly associated with technology ownership, comfort level, and frequency of use (p<0.05). The majority of patients 18-45 years of age preferred to receive appointment reminders via text message (57%) and e-mail (53%). This age group also used these technologies more frequently and with a higher comfort level (p<0.001). CONCLUSIONS: These data support the proposal that e-mail and text-messaging e-health tools are likely to be immediately adopted by eye clinic patients and therefore have the greatest potential to improve health outcomes and increase quality of care. Eye clinic patients are interested in these technologies for appointment reminders, general eye and vision health information, asking urgent medical questions, and requesting prescription refills. Future controlled trials could further explore the efficacy of e-health tools for these purposes.

Giant cell arteritis incidence: analysis by season and year in mid-Atlantic United States.

BACKGROUND: Evaluate the incidence of biopsy-proven giant cell arteritis for seasonal or annual variability in the Mid-Atlantic United States. DESIGN: Retrospective chart review of all patients undergoing temporal artery biopsy from 1994 to 2011. PARTICIPANTS: The charts of 744 patients were reviewed, and 215 patients were diagnosed with giant cell arteritis based on positive temporal artery biopsy results. METHODS: All results between 1994 and 2011 were reviewed. Giant cell arteritis incidence data were evaluated by year, season and month for any trends or cyclic patterns. MAIN OUTCOME MEASURE: Incidence of biopsy-proven giant cell arteritis. RESULTS: The majority of patients were female (74%) and over the age of 60 (98.6%). The diagnosis of biopsy-proven giant cell arteritis was found in 215 of 744 (28.9%) patients. The incidence of biopsy-proven giant cell arteritis by year varied, with the peak incidence in 1996. The monthly incidence peaked in July and had a trough in October. However, Poisson regression analysis did not show any statistically significant trend over time or cyclic pattern to the incidence by year, season or month. CONCLUSIONS: The incidence of biopsy-proven giant cell arteritis in the population studied did not have any significant cyclic pattern over the last 17 years. The highest incidence by month was noted in July with a trough in October. However, this was not a significant pattern by month or season to support infectious or periodic environmental factors inciting giant cell arteritis.

The ultrasonic bone aspirator in transnasal endoscopic dacryocystorhinostomy.

PURPOSE: To evaluate the outcomes of endoscopic dacryocystorhinostomy (eDCR) with and without the use of ultrasonic bone aspirator (UBA; Sonopet). METHODS: A retrospective, institutional review board approved chart review of all eDCRs over 49 months. Data included demographics, indication/etiologic factors of nasolacrimal duct obstruction, comorbidities, intraoperative findings, epiphora symptoms pre- and postoperatively, and complications. Patients were grouped in eDCR with or without UBA. RESULTS: One hundred and twenty-three primary eDCRs in 99 patients were included, 59 with UBA and 64 without UBA. Most patients were Caucasians (80.8%) and women (72.0%), with a mean age of 55.9 years (range, 9-89). There were no significant differences in the demographics of the 2 subgroups. Complete resolution of symptoms was obtained in 81.3% of procedures without UBA and in 79.7% with UBA. Most patients (72.7%) were deemed idiopathic preoperatively. Lacrimal sac biopsy demonstrated significant pathologic factors in 9 (7.3%) cases, with 7 (5.7%) of these resulting in a new diagnosis for the patient. There were no cases of cerebrospinal fluid leakage, visual loss, diplopia, infection, or uncontrolled epistaxis in either group. CONCLUSIONS: Early results of eDCR with UBA appear to show reasonable efficacy. The overall success and failure rates of eDCR with and without UBA are similar. Neither group had any complications in this study, although any conclusion on the overall safety of the procedure is limited by the power of this study.

Air reflux and other sequelae following endoscopic dacryocystorhinostomy.

PURPOSE: To assess postoperative sequelae of endoscopic dacryocystorhinostomy (endoDCR), including rates of air reflux and other otolaryngologic sequelae. METHODS: Patients who underwent endoDCR over a 5-year period were included in a follow-up questionnaire regarding side effects after surgery. The questionnaire included questions regarding tearing, air reflux, and nasal symptoms. RESULTS: Results were obtained on 82 patients (101 endoDCRs). Most patients were women (70.7%) and white (85.4%). The mean postoperative period was 39.7 months (range 8-66 months). The most common sequela was air reflux from the puncta (46 cases, 45.5%). Of the 82 patients, 58.7% experienced symptoms only "rarely," while 18.5% had symptoms daily. Air reflux was most commonly associated with nose blowing (73.9%). Success of endoDCR correlated with presence of air reflux (p = 0.0044). All patients with air reflux preferred having air reflux to epiphora. Epistaxis was present in 8 cases (7.9%) and nasal congestion in 21.8% of the cases. CONCLUSIONS: Treatment for epiphora with endoDCR results in air reflux in almost half of patients, which is minimally bothersome to patients. The presence of air reflux highly correlates with resolution of epiphora and has a similar incidence in external and endoDCRs.

Microvascular free flap reconstruction of orbitocraniofacial defects.

PURPOSE: To examine the etiology, surgical extent and techniques, complications, and outcomes of microvascular free flaps (MFF) in the reconstruction of orbitocraniofacial defects. DESIGN: A retrospective, institutional review board approved study was performed of all patients undergoing MFF to repair orbitocraniofacial defects over 51 months. PARTICIPANTS: Fifty-eight patients undergoing MFF to repair orbitocraniofacial defects were included. MATERIAL AND METHODS: Variables analyzed included demographics, etiology, resection area(s), donor site, flap size, duration of surgery, complications, length of hospital stay, flap survival, and mortality. RESULTS: Fifty-eight patients underwent 61 MFFs from June 2007 to September 2011. The majority of patients were white (79.3%) and male (72.4%). The mean age was 64.1 years. The most common etiology was intraorbital and skull base extension of cutaneous squamous cell carcinoma (29.3%) followed by sinonasal squamous cell carcinoma (13.8%). Dura and/or brain were exposed in 44.8% of cases. MFFs were harvested from the anteriolateral thigh in 71.4% of cases with a 180.9 cm(2) mean flap area. The mean length of hospital stay was 15.3 days and mean length of surgical time was 11 h and 17 min. CONCLUSIONS: Complex orbitocraniofacial defects require a multi-disciplinary team skilled in surgical extirpation and advanced reconstructive techniques. MFF should be considered in the management of large defects, especially when there is dura or brain exposure. Intensive postoperative monitoring is indicated for both systemic and flap-related complications. MMFs provide excellent coverage of large areas of exposed critical skull base structures, including dura and brain, and may allow for earlier adjuvant treatment.

Brow ptosis after temporal artery biopsy: incidence and associations.

OBJECTIVE: Temporal artery biopsy (TAB), performed for the diagnosis of giant cell arteritis, has a low reported rate of complications. One complication is damage to the facial nerve branches, which can result in brow ptosis and/or orbicularis oculi weakness. However, the incidence of facial nerve damage after TAB is unknown. DESIGN: Prospective, institutional review board-approved study of all TABs performed by 2 surgeons over a 17-month period. PARTICIPANTS: Seventy patients undergoing 77 TABs. METHODS: Demographic data, including age, gender, and race/ethnicity, were collected for all patients. Frontalis and orbicularis oculi muscle function were evaluated pre- and postoperatively in all patients. The use of blood thinners, location of the incision, length of incision and biopsy, biopsy results, and procedure difficulty were recorded. Incidence of postoperative facial nerve damage, other complications, and rates of facial nerve recovery were evaluated. Analysis of variables was performed for any potential correlation with facial nerve damage. MAIN OUTCOME MEASURES: Incidence of facial nerve damage. RESULTS: Analysis included 75 biopsies performed in 68 patients. The majority of the patients were white (75.0%) and female (67.6%). The mean age was 72.6 years (range, 51-96). Postoperative facial nerve damage was found in 12 patients (16.0%) and 58.3% of these fully resolved at an average of 4.43 months (range, 1-6). Two patients (2.7%) had postoperative infections. There was no correlation with facial nerve damage and use of blood thinners, biopsy result, surgeon, procedure difficulty, incision length, or specimen length. The distance from the incision to both the orbital rim and the brow was significant: Incisions farther from the orbital rim and brow were less likely to have postoperative facial nerve damage. CONCLUSIONS: There is a 16.0% incidence of postoperative facial nerve damage with TABs, which recovers fully in over half of patients. Incisions closer to the orbital rim and brow were more likely to have postoperative facial nerve dysfunction. Incisions >35 mm from both the orbital rim and brow or above the brow were less likely to have postoperative brow ptosis. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.