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Orbital tuberculosis is a manifestation of extra-pulmonary tuberculosis that is challenging to diagnose and treat. Here, we describe the pivotal role of serial imaging in the diagnosis and treatment of orbital tuberculosis. A 28-year-old male presented with recurrent right upper eyelid swelling and a supraduction deficit associated with a firm painless orbital mass, seen on initial computed tomography to be an extensive superomedial lesion producing mass effect. Biopsy revealed a tuberculosis-like granulomatous inflammation, which, coupled with a positive QuantiFERON gold test, led to empiric anti-tuberculin treatment. Serial radiologic imaging following initiation of treatment showed progressive reduction in mass size, supporting the diagnosis and determining the length of treatment. This rare case demonstrates the utility of serial radiologic exams in the diagnosis and treatment of orbital tuberculosis.

Omar Moussa,1 Tahvi Frank,2 Ives A Valenzuela,1 Joah Aliancy,1 Dan Gong,3 Joaquin O De Rojas,4 Lora R Dagi Glass,1 Bryan J Winn,5 George A Cioffi,1 Royce WS Chen1 1Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, NY, USA; 2Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; 3Department of Ophthalmology, Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; 4Center for Sight, Sarasota, FL, USA; 5Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USACorrespondence: Royce WS Chen, Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, 635 W. 165th St, New York, NY, 10032, USA, Tel +1 212-305-9535, Email rc2631@cumc.columbia.eduPurpose: To evaluate efficacy of a novel risk stratification system in minimizing resident surgical complications and to evaluate whether the system could be used to safely introduce cataract surgery to earlier levels of training.Materials and Methods: This is a retrospective cross-sectional study on 530 non-consecutive cataract cases performed by residents at Columbia University. Risk scores, preoperative best corrected visual acuity (BCVA), intraoperative complications, postoperative day 1 (POD1), and month 1 (POM1) exam findings were tabulated. The relationship between risk scores and POD1 and POM1 BCVA was modeled using linear regression. The relationship between risk scores and complication rates was modeled using logistic regression. Logistic regression was used to model the rates of complications across different levels of training. Rates of complications were compared between diabetic versus non-diabetic patients using t-tests.Results: Risk scores did not have significant association with intraoperative complications. Risk scores were predictive of corneal edema (OR = 1.36, p = 0.0032) and having any POM1 complication (OR = 1.20, p = 0.034). Risk scores were predictive of POD1 (β = 0.13, p < 0.0001) and POM1 (β = 0.057, p = 0.00048) visual acuity. There was no significant association between level of training and rates of intraoperative (p = 0.9) or postoperative complications (p = 0.06). Rates of intraoperative complication trended higher among diabetic patients but was not statistically significant (p = 0.2).Conclusion: Higher risk scores were predictive of prolonged corneal edema but not risk of intraoperative complications. Our risk stratification system allowed us to safely introduce earlier phacoemulsification surgery.Keywords: cataract, cataract risk stratification, resident phacoemulsification surgery

Teprotumumab, a monoclonal antibody targeted against the insulin-like growth factor 1 (IGF-1) receptor, was recently approved by the United States Food and Drug Administration for the treatment of thyroid eye disease (TED). Phase 1 studies of teprotumumab for the treatment of malignancies demonstrated an acceptable safety profile but limited effectiveness. Basic research implicating the IGF-1 receptor on the CD-34+ orbital fibrocyte in the pathogenesis of TED renewed interest in the drug. Two multicenter, randomized, double-masked, clinical trials (phase 2 and 3) evaluated the efficacy of 8 infusions of teprotumumab every 3 weeks versus placebo in 170 patients with recent-onset active TED, as defined by a clinical activity score (CAS) of at least 4. Teprotumumab was superior to placebo for the primary efficacy end points in both studies: overall responder rate as defined by a reduction of 2 or more CAS points and a reduction of 2 mm or more in proptosis (69% vs. 20%; P < 0.001; phase 2 study) and proptosis responder rate as defined by a reduction of 2 mm or more in proptosis (83% vs. 10%; P < 0.001; phase 3 study). In both studies, treatment with teprotumumab compared with placebo achieved a significant mean reduction of proptosis (-3.0 mm vs. -0.3 mm, phase 2 study; -3.32 mm vs. -0.53 mm, phase 3 study) and CAS (-4.0 vs. -2.5, phase 2 study; -3.7 vs. -2.0, phase 3 study). Teprotumumab also resulted in a greater proportion of patients with a final CAS of 0 or 1, higher diplopia responder rate, and a larger improvement in the Graves' Ophthalmopathy Quality of Life overall score. More than half of patients (62%, phase 2 trial; 56%, phase 3 trial) who were primary end point responders maintained this response at 51 weeks after the last dose of therapy. The most common adverse events reported with teprotumumab included muscle spasms (25%), nausea (17%), alopecia (13%), diarrhea (13%), fatigue (10%), hearing impairment (10%), and hyperglycemia (8%). Teprotumumab is contraindicated for those with inflammatory bowel disease and who are pregnant. Although the current dosing regimen has proven effective for TED, dose-ranging studies including variable concentrations, infusion frequencies, and durations of teprotumumab therapy in the setting of TED have not been performed.

PurposeTo investigate the ocular surface microbiome of patients with unilateral or asymmetric glaucoma being treated with topical ophthalmic medications in one eye and to determine whether microbial community changes were related to measures of ocular surface disease.MethodsV3-V4 16S rRNA sequencing was conducted on ocular surface swabs collected from both eyes of 17 subjects: 10 patients with asymmetric/unilateral glaucoma using topical glaucoma therapy on only one eye and seven age-matched, healthy controls with no history of ocular disease or eyedrop use. Samples were categorized into three groups: patients' glaucomatous eye treated with eyedrops, patients' contralateral eye without eyedrops, and healthy control eyes. Comparisons were made for microbial diversity and composition, with differences in composition tested for association with ocular surface disease measures including tear meniscus height, tear break-up time, and Dry Eye Questionnaire.ResultsSamples obtained from the patients' treated and untreated eyes both had significantly greater alpha-diversity and relative abundance of gram-negative organisms compared to healthy controls. The microbial composition of patient eyes was associated with decreased tear meniscus height and tear break-up time, whereas metagenomic predictions, based on 16S rRNA data, suggested increased synthesis of lipopolysaccharide.ConclusionsThe ocular surface microbiome of patients taking unilateral preserved glaucoma drops is characterized by a highly diverse array of gram-negative bacteria that is significantly different from the predominantly gram-positive microbes detected on healthy control eyes. These compositional differences were associated with decreased tear film measures and distinct inferred protein synthesis pathways, suggesting a potential link between microbial alterations and ocular surface inflammation.

This study evaluates a web-based tool designed to augment telemedicine post-operative visits after periocular surgery.Adult, English-speaking patients undergoing periocular surgery with telemedicine follow-up were studied prospectively in this interventional case series. Participants submitted visual acuity measurements and photographs via a web-based tool prior to routine telemedicine post-operative visits. An after-visit survey assessed patient perceptions. Surgeons rated photographs and live video for quality and blurriness; external raters also evaluated photographs. Images were analyzed for facial centration, resolution, and algorithmically detected blur. Complications were recorded and graded for severity and relation to telemedicine.Seventy-nine patients were recruited. Surgeons requested an in-person assessment for six patients (7.6%) due to inadequate evaluation by telemedicine. Surgeons rated patient-provided photographs to be of higher quality than live video at the time of the post-operative visit (p 0.001). Image blur and resolution had moderate and weak correlation with photograph quality, respectively. A photograph blur detection algorithm demonstrated sensitivity of 85.5% and specificity of 75.1%. One patient experienced a wound dehiscence with a possible relationship to inadequate evaluation during telemedicine follow-up. Patients rated the telemedicine experience and their comfort with the structure of the visit highly.Augmented telemedicine follow-up after oculofacial plastic surgery is associated with high patient satisfaction, rare conversion to clinic evaluation, and few related post-operative complications. Automated detection of image resolution and blur may play a role in screening photographs for subsequent iterations of the web-based tool.

A patient with thyroid-associated ophthalmopathy was treated with teprotumumab and developed symptoms concerning for inflammatory bowel disease after her sixth infusion. Colonoscopy was performed, and mucosal biopsies identified evidence of active colitis consistent with a diagnosis of ulcerative colitis. Despite treatment with budesonide and mesalamine, the patient continued to be symptomatic one and a half months after cessation of teprotumumab and required infliximab to achieve good control of her inflammatory bowel disease. This case represents the first report of new-onset inflammatory bowel disease arising during treatment with teprotumumab.

PURPOSE: Injection of corticosteroid into the peritrochlear region is a widely practiced and highly successful treatment option for trochleitis, conventionally employing a 25- or 27-gauge needle for the steroid injection. Injection into the vascular-rich peritrochlear region poses a risk, albeit rare, of central retinal artery occlusion or orbital hemorrhage. We describe a potentially safer method of delivering triamcinolone to the peritrochlear region using a 24-gauge intravenous catheter. METHODS: Interventional retrospective case series including all patients who received peritrochlear injections of triamcinolone via intravenous catheter for trochleitis by a single surgeon (BJW). Surgical technique: After a subcutaneous wheel of local anesthetic was delivered to the medial upper eyelid skin nearest to the trochlea, a 24-gauge intravenous catheter was used to penetrate the skin and orbital septum. Once past the septum, the needle was removed and the blunt catheter was advanced into the peritrochlear region. A 1-cc syringe filled with triamcinolone 40mg/ml was attached to the catheter. After pulling back to ensure that the catheter was not intravascular, triamcinolone was delivered to the orbit. The catheter was then removed. RESULTS: Ten catheter injections were performed on 3 patients over an eight-year period. There were no complications. CONCLUSION: Injection of corticosteroid into the peritrochlear region using the commonly available 24-gauge intravenous catheter is an effective and theoretically safer alternative to typical injection using a 25-gauge needle for treatment of trochleitis. Use of non-particulate steroid solutions may further decrease the risk of adverse events.

We report a case of a 47-year-old female who experienced periorbital swelling while descending from a Himalayan mountain climb and was found to have bilateral superior ophthalmic vein thromboses (SOVT). Infectious, autoimmune, and hypercoagulability work-up were negative with no cavernous sinus involvement. Symptoms resolved upon initiation of anticoagulation and oral steroids. SOVT is a rare but serious condition and has a risk of extending into the cavernous sinus if not treated early. Although infection is the most common etiology, venous thrombosis can be precipitated under high altitude and low oxygen pressure environments. We present a case of superior ophthalmic vein thrombosis associated with high-altitude conditions.

The association between Henoch-Schönlein purpura (HSP) and neoplasia is rare and has been more commonly reported in cases of solid tumors rather than hemotological malignancies. To the authors' knowledge, HSP in association with orbital lymphoma has not been previously reported. An 84-year-old man underwent anterior orbitotomy with biopsy for a rapidly growing orbital mass. Immediately following this procedure, he developed petechial rash, flash pulmonary edema, and kidney dysfunction with hematuria and proteinuria. Orbital biopsy revealed diffuse large B-cell lymphoma while skin and kidney biopsies showed features consistent with HSP. Multidisciplinary team involvement and treatment with chemotherapy and corticosteroid resulted in an excellent clinical response. Clinicians should be aware that HSP and orbital diffuse large B-cell lymphoma can co-occur, potentially leading to life-threatening rapid fluid shifts and metabolic derangements.

To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS).Retrospective cohort study.Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020.A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality.Identification of initial, preintervention MRI findings associated with visual and mortality outcomes.The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; Plt; 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001).Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality.

ObjectivesTo evaluate whether use of an antibiotic improves the efficacy of care for a chalazion or hordeolum.MethodsA cross-sectional retrospective review was performed. All patients treated for a newly diagnosed chalazion or hordeolum at the University of California, San Francisco from 2012 to 2018 were identified. Patients were excluded when clinical notes were inaccessible or there was inadequate documentation of treatment modality or outcome. Patient demographics, setting of initial presentation, treatment modalities, antibiotic use, and outcomes were analyzed.ResultsA total of 2,712 patients met inclusion criteria. Management with an antibiotic was observed in 36.5% of patients. An antibiotic was 1.53 times (95% confidence interval [CI], 1.06-2.22, P=0.025) more likely to be prescribed in emergency or acute care setting for a chalazion. Older age was associated with a higher risk of receiving an antibiotic for a hordeolum (adjusted RR 1.07 per decade, 95% CI, 1.05-1.11, P

Background: Understanding how periocular nonmelanoma skin cancer (NMSC) impacts quality of life (QoL) provides insight into the patient experience. Objective: To prospectively measure QoL of indivi...

Purpose : To assess whether a modified treatment ladder algorithm incorporating transcutaneous retrobulbar amphotericin B (TRAMB) for invasive fungal rhino-orbital sinusitis (IFROS) can reduce the risk of exenteration without compromising survival. Design : Retrospective, comparative clinical study with historical controls. Methods : Fifty consecutive patients with biopsy-proven invasive fungal sinusitis and radiographic evidence of orbital involvement were evaluated at a single tertiary institution from 1999-2020. TRAMB was incorporated as part of the treatment algorithm in 2015. Demographics, underlying immune derangement, infective organism, ophthalmic examination, surgical care, and survival were compared in a quasi-experimental pre-post format, dividing patients into a pre-2015 group and a post-2015 group. Risk of exenteration and mortality were the primary outcomes. Results : Baseline characteristics did not differ significantly between the two groups. Nearly all patients underwent a surgical intervention, which most commonly was functional endoscopic sinus surgery with debridement. TRAMB was administered to 72.7% of the post-2015 group. Exenteration was more common in the pre-2015 group (36.4% vs. 9.1%; 95% CI [5.2, 48.8]; p = 0.014), while mortality was similar (40.0% vs. 36.7%; 95% CI [-22.1, 29.3]; p = 0.816). After adjusting for potential confounders, patients treated after 2015 were found to have lower risk of exenteration (RR 0.28; 95% CI [0.08, 0.99]; p = 0.049) and similar risk of mortality (RR 1.04; 95% CI [0.50, 2.16]; p = 0.919). Conclusion : In comparison to historical controls, patients with IFROS who were treated with a modified treatment ladder algorithm incorporating TRAMB had a lower risk of disfiguring exenteration without an apparent increase in the risk of mortality.

A patient with thyroid-associated ophthalmopathy was treated with teprotumumab and developed symptoms concerning for inflammatory bowel disease after her sixth infusion. Colonoscopy was performed, and mucosal biopsies identified evidence of active colitis consistent with a diagnosis of ulcerative colitis. Despite treatment with budesonide and mesalamine, the patient continued to be symptomatic one and a half months after cessation of teprotumumab and required infliximab to achieve good control of her inflammatory bowel disease. This case represents the first report of new-onset inflammatory bowel disease arising during treatment with teprotumumab.

Significance Hemolacria (bloody tears) is a rare clinical presentation with varied underlying etiologies. Thorough clinical evaluation is essential to diagnosis and management. Purpose This study aimed to report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature. Case report A 21-year-old female contact lens wearer presented to the clinic after three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, nontender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office, and pathological examination of the lesion was consistent with pyogenic granuloma. Conclusions Unilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. Thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions.

Acute invasive fungal rhinosinusitis is a rare, although highly morbid, infection primarily affecting immunosuppressed individuals. The same population is at particularly high risk of complications and mortality in the setting of SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome. The authors present a case of acute invasive fungal rhino-orbital mucormycosis in a patient with COVID-19 and discuss the prevalence, diagnosis, and treatment of fungal coinfections in COVID-19. Prompt recognition, initiation of therapy, and consideration of the challenges of rapidly evolving COVID-19 therapy guidelines are important for improving patient survival., The authors report a case of acute invasive rhino-orbital mucormycosis in the setting of concurrent COVID-19-associated acute respiratory distress syndrome and the dilemma posed of treating both entities concurrently.

Teprotumumab, a monoclonal antibody targeted against the insulin-like growth factor 1 (IGF-1) receptor, was recently approved by the United States Food and Drug Administration for the treatment of thyroid eye disease (TED). Phase 1 studies of teprotumumab for the treatment of malignancies demonstrated an acceptable safety profile but limited effectiveness. Basic research implicating the IGF-1 receptor on the CD-34+ orbital fibrocyte in the pathogenesis of TED renewed interest in the drug. Two multicenter, randomized, double-masked, clinical trials (phase 2 and 3) evaluated the efficacy of 8 infusions of teprotumumab every 3 weeks versus placebo in 170 patients with recent-onset active TED, as defined by a clinical activity score (CAS) of at least 4. Teprotumumab was superior to placebo for the primary efficacy end points in both studies: overall responder rate as defined by a reduction of 2 or more CAS points and a reduction of 2 mm or more in proptosis (69% vs. 20%; P0.001; phase 2 study) and proptosis responder rate as defined by a reduction of 2 mm or more in proptosis (83% vs. 10%; P0.001; phase 3 study). In both studies, treatment with teprotumumab compared with placebo achieved a significant mean reduction of proptosis (-3.0 mm vs. -0.3 mm, phase 2 study; -3.32 mm vs. -0.53 mm, phase 3 study) and CAS (-4.0 vs. -2.5, phase 2 study; -3.7 vs. -2.0, phase 3 study). Teprotumumab also resulted in a greater proportion of patients with a final CAS of 0 or 1, higher diplopia responder rate, and a larger improvement in the Graves' Ophthalmopathy Quality of Life overall score. More than half of patients (62%, phase 2 trial; 56%, phase 3 trial) who were primary end point responders maintained this response at 51 weeks after the last dose of therapy. The most common adverse events reported with teprotumumab included muscle spasms (25%), nausea (17%), alopecia (13%), diarrhea (13%), fatigue (10%), hearing impairment (10%), and hyperglycemia (8%). Teprotumumab is contraindicated for those with inflammatory bowel disease and who are pregnant. Although the current dosing regimen has proven effective for TED, dose-ranging studies including variable concentrations, infusion frequencies, and durations of teprotumumab therapy in the setting of TED have not been performed.

The O-to-Z plasty, devised by Marvin Quickert, is a rotational flap, which can be used in the reconstruction of the anterior lamella of a lower eyelid or medial canthus after tumor excision or trauma. In this procedure, a circular defect is repaired by forming two triangular rotational skin flaps along normal tension lines and aligning them in a diagonal fashion to create a Z closure (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). This technique minimizes vertical tension which could lead to lower lid retraction or ectropion. The procedure requires mild to moderate laxity of the eyelid skin and is best suited for small- to medium-sized defects of the lower eyelid or medial canthus. This procedure is not suited for defects involving the eyelid margin, tarsus, or lacrimal drainage system.

The lateral tarsal strip operation is a procedure used to address eyelid laxity by horizontally shortening the lower eyelid at the lateral canthus. Evaluation of horizontal eyelid laxity includes the eyelid distraction test and the eyelid snap test (Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). Patients with incipient involutional ectropion often complain of tearing, especially in the wind and cold. In such patients, it is important to evaluate the lacrimal system. When punctal eversion accompanies involutional ectropion, one must determine whether shortening the lower eyelid horizontally will reposition the punctum to its correct anatomical position alone. If stretching the lower eyelid laterally at the slit lamp does not correct punctal eversion, a medial spindle procedure may be used in combination with a lateral tarsal strip procedure to address both the involutional ectropion and punctal eversion (Nerad, Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). In a medial spindle procedure, the posterior lamella is shortened vertically and pulled inwards to tip the punctum back into globe apposition.

Adult respiratory distress syndrome (ARDS) is the leading cause of death associated with SARS-CoV-2 infection and COVID-19. IGF-1 has been implicated in ARDS, yet its role in relation to COVID-19-related lung injury has not been investigated. We hypothesize that blockage of the IGF-1 receptor (IGF-1R) mitigates lung injury and decreases the risk of death in patients COVID-19-related ARDS. Patients with fibroproliferative ARDS have been shown to have increased IGF-1 and IGF-1R staining in lung tissue specimens. Rising levels of IGF-1 in bronchioalveolar fluid (BAL) and increased IGF-1 mRNA expression in lung tissues (but declining serum IGF-1 levels) have been found in late stage ARDS compared with early lung injury. Blockage of IGF-1R decreases lung tissue damage and increases survival in bleomycin-induced as well as H1N1 influenza-related lung injury in animal models. Teprotumumab is a monoclonal antibody directed against the IGF-1R that was FDA-approved in 2020 for the treatment of Graves' orbitopathy. In order to determine if teprotumumab may reduce lung injury and death related to ARDS in the setting of COVID-19, preliminary clinical data is needed. IGF-1 levels in serum and BAL fluid must be measured in patients with COVID-19-related ARDS. Histopathology from lung samples from patients with COVID-19-related ARDS must be examined for increased expression of the IGF-1R. Once these are ascertained, and if the data support IGF-1 involvement, a randomized, placebo-controlled phase 2A trial of teprotumumab therapy in the setting of COVID-19-related ARDS and non-COVID-19-related ARDS designed to generate initial data on short-term efficacy, safety, dosing and administration should be performed.

Purpose To describe a reversible syndrome of epiphora, functional punctal stenosis, and chronic pretarsal conjunctivitis associated with corticosteroid or corticosteroid-antibiotic eyedrop use. Methods This is an Institutional Review Board-approved retrospective review of patients diagnosed with epiphora, punctal stenosis, and chronic conjunctivitis by a single surgeon (B.J.W.). These patients were subsequently invited to participate in a prospective study involving allergy skin patch testing for ophthalmic drops, common excipients, and active ingredients. Results Thirteen patients received a diagnosis of punctal congestion syndrome. The average age was 63 years (range, 41-93) and 69.2% were female. Findings were bilateral in 61.5%. All had used preserved drops in the affected eye(s). Various antecedent diagnoses resulted in treatment with preserved drops. Patients experienced epiphora for an average of 3.8 months (median, 3 months; mode, 3 months; range, 1-8 months) prior to presentation. Two patients had undergone punctoplasty which failed to resolve symptoms. 92.3% of patients had been taking tobramycin-dexamethasone drops, loteprednol drops, or a combination of both prior to presentation. All were taken off preserved drops. 69.2% were also treated with a preservative-free loteprednol etabonate 0.5% ophthalmic ointment taper. All improved. Partial relief of symptoms was achieved by an average of 1.6 months (median, 2 months; mode, 2 months; standard deviation, ±0.7 months) and resolution of symptoms by 2.5 months (median, 2 months; mode, 2 months; standard deviation, ±1.7 months). One patient underwent patch testing with strong positive reactions to formaldehyde and neomycin and a weak positive reaction to gentamicin. Conclusions Functional punctal stenosis is associated with topical ophthalmic preparations, especially preserved corticosteroids and antibiotic-corticosteroid combinations. Treatment consists of removal of all preserved eyedrops. Symptoms often improve over several months.

PurposeTo identify the role of gender and other factors in influencing ophthalmologists' compensation.DesignCross-sectional study.ParticipantsU.S. practicing ophthalmologists.MethodsBetween January and March 2020, an anonymous survey was sent to U.S. residency program directors and practicing ophthalmologists who recently completed residency training. Respondents who completed residency ≤ 10 years ago and responded to questions about gender, fellowship training, state of practice, and salary were included. Propensity score match (PSM) analysis was performed with age, academic residency, top residency, fellowship, state median wage, practice type, ethnicity, and number of workdays. Multivariate linear regression (MLR) analysis controlled for additional factors along with the aforementioned variables.Main outcome measuresBase starting salary with bonus (SWB) received in the first year of clinical position was the main outcome measure. A multiplier of 1.2 (20%) was added to the base salary to account for bonus.ResultsOf 684 respondents, 384 (56% were female, 44% were male) from 68 programs were included. Female ophthalmologists received a mean initial SWB that was $33 139.80 less than that of their male colleagues (12.5%, P= 0.00). The PSM analysis showed an SWB difference of-$27 273.89 (10.3% gap, P= 0.0015). Additionally, SWB differences were calculated with the number of workdays substituted by operating room (OR) days (-$27 793.67 [10.5% gap, P= 0.0013]) and clinic days (-$23 597.57 [8.90% gap, P= 0.0064]) in separate PSM analyses. The SWB differences between genders were significant using MLR analyses, which also controlled for work, clinic, and OR days separately (-$22 261.49, $-18 604.65, and $-16 191.26, respectively; P= 0.017, P= 0.015, P= 0.002, respectively). Gender independently predicted income in all 3 analyses (P&nbsp

The management of cicatricial ectropion resulting from epidermal growth factor receptor (EGFR) inhibitors is unclear. We describe two cases of bilateral cicatricial ectropion following the use of an EGFR inhibitor who were treated with oral doxycycline, topical ophthalmic steroid and antibiotic ointment to the eyelids, and topical facial steroid cream with lubrication. The first case resolved with discontinuation of panitumumab infusions along with institution of the aforementioned regimen. However, it is unclear whether the resolution was from discontinuation of the infusions or from the instituted regimen. The second case resolved without a dose adjustment of cituximab. This case may provide support for the use of this regimen prior to discontinuation of the offending agent, as there was a successful outcome without alteration of the infusions. Additional cases are necessary to determine if this is a successful means of treating bilateral lower-lid cicatricial ectropion from EGFR inhibitors.

Purpose Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV. Methods An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed. Results Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively. Conclusion Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.

To summarize the ocular and systemic associations of floppy eyelid syndrome (FES) as well as provide an up-to-date review on the pathogenesis and treatment strategies.Virtually all patients with FES have obstructive sleep apnea (OSA). However, a significantly lower proportion of patients with OSA have FES. Although some studies demonstrate no association between OSA and FES, almost all show at least an association with increased eyelid laxity, which may be a less severe form of FES. FES has also been associated with keratoconus (KCN) and glaucoma. Decreased corneal hysteresis has been found in FES, KCN, glaucoma, and OSA and may be related to matrix metalloproteinase (MMP) upregulation. Hypoxia-reperfusion injury, leptin resistance, and mechanical forces all may lead to increased MMP activity, contributing to elastin breakdown in the tarsus and other tissues throughout the body. Management of FES begins with investigation for OSA. Treating OSA with continuous positive airway pressure (CPAP) or surgical uvulopalatoplasty may improve FES. Surgical treatments for FES should reduce horizontal eyelid laxity while maximizing the stability of the tarsus. Collagen crosslinking may prove a helpful modality for stabilizing the tarsus in the future.FES is associated with OSA, glaucoma, and KCN. MMP upregulation and lower corneal hysteresis have been found in these conditions, pointing toward a potential common pathogenesis.

IMPORTANCE: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear. OBJECTIVE: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency. DESIGN, SETTING, PARTICIPANTS: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018. MAIN OUTCOMES AND MEASURES: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status. RESULTS: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, −15.0 [95% CI, −22.2 to −7.8]; P

PURPOSE To study the effect of periocular steroid use on intraocular pressure (IOP). METHODS Charts of adult patients with atopic dermatitis or eczema treated with topical periocular steroid creams and ointments from January 1st, 2007 to October 1st, 2017 were reviewed. Patients with the following were excluded: glaucoma, ocular hypertension, known systemic/topical/injectable steroid history, and lack of documented IOP prior to or during treatment with periocular steroid ointment. Patient data were collected regarding gender, treatment regimen, as well as IOP prior to and during treatment. Steroid responders were identified. Statistical analysis was performed using linear mixed effects models adjusting for follow-up time to test the relationship between pre and posttreatment IOP change adjusting for intereye correlations. RESULTS Thirty-one patients were identified. Twenty-one were treated bilaterally and 10 unilaterally. Five patients were glaucoma suspects. The mean treatment period was 14.2 weeks with a range of 0.1-83.9 weeks. Patients were treated with fluorometholone (42%), loteprednol etabonate (23%), dexamethasone-neomycin-polymyxin B (13%), hydrocortisone 1% or 2.5% (3%), and tobramycin-dexamethasone (19%). In the combined sample, there was no significant IOP change even after adjusting for follow-up time (mean change: +0.44 mm Hg, p = 0.126). However, eyes with baseline IOP ≥ 14 mm Hg had a significant increase (+0.73 mm Hg/year, p = 0.032). Individual steroid responses included the following: 1 intermediate and 30 low responders, of which 19 patients had an IOP change of

Orbital inflammatory disease encompasses a large collection of entities which can be grouped into infectious and noninfectious inflammations. Infectious causes can be bacterial, fungal, or viral. Noninfectious causes may be autoimmune, vasculitic, granulomatous, inflammatory, drug-related, and idiopathic. Orbital inflammation can be vision and life-threatening and is often intimidating and challenging to the clinician. The paragraphs below divide orbital inflammation into infectious and noninfectious categories and provide the clinician with a framework for accurate diagnostic work-up and management.

To report the case of a 49-year-old man who presented with profound visual loss in his right eye because of a central retinal artery occlusion, accompanied by a stroke in the ipsilateral middle cerebral artery with left upper extremity sequelae.The patient underwent a comprehensive ophthalmologic examination, fluorescein angiography, thorough neuroophthalmology evaluation, including magnetic resonance imaging and magnetic resonance angiography, 12-lead electrocardiogram, transesophageal echocardiogram, bilateral carotid artery Doppler, Holter monitoring, comprehensive laboratory testing, bone marrow biopsy, and genetic testing.Despite an initially normal hematocrit, the etiology of the central retinal artery occlusion and that of the nearly concomitant stroke in the right medial cerebral artery territory was confirmed by bone marrow biopsy to be polycythemia vera (positive JAK2 mutation). Patient received treatment with aspirin, serial phlebotomies, and hydroxyurea, demonstrating a slight improvement in vision and substantial normalization of neurologic and hematological status. At the time of this report, 2 years later, patient remains stable.Central retinal artery occlusion, a disease with a frequently devastating visual outcome, is often not an "isolated" ocular occurrence. In the absence of an obvious local trigger, a thorough work-up is always warranted, especially in younger patients, as the ocular pathology oftentimes may herald severe cerebro-cardiovascular events.

Objective To determine the effect of bicanalicular silicone intubation (SI) on dacryocystorhinostomy (DCR) success rate in adult primary acquired nasolacrimal duct obstruction. Design Meta-analysis of randomized controlled trials (RCTs). Methods PubMed, Embase, Cochrane CENTRAL, Ovid Medline, Google Scholar, and grey literature search was performed from inception to June 2017. All prospective DCR trials with randomization of SI were considered. Cases with non-SI or adjunctive mitomycin were excluded. Where possible we analysed only 1 eye from each subject. Random effects meta-analysis was performed. Results We retrieved 1142 articles and after filtering there were 14 RCTs with a total of 1311 DCR cases. There were 444 external DCRs and pooled estimate showed risk ratio (RR) was 1.08 (95% confidence interval [CI] 1.01–1.15). There were 867 predominantly endonasal DCR with RR 1.04 (95% CI 0.99–1.09). When all DCR modalities were combined the RR was 1.05 (95% CI 1.01–1.09). Conclusions Overall, there was a 5% statistically significant improvement in DCR success rate with SI, but more endonasal DCR RCTs are required.

Purpose Despite multiple studies regarding modes of eyebrow measurement and movement over time, the lateral aspect of the brow has been relatively ignored in the literature. Therefore, we arranged a study of the most lateral aspect of the eyebrow; in doing so, we hoped to ascertain the most practical line or angle of measurement. Methods In this cross-sectional study, adults age 18 years and older with no history of congenital or acquired periorbital or orbital pathology or surgery, brow tattooing or heavy plucking, phthisis, or strabismus were measured using a combination of in-office metrics and computer analysis. Subjects were asked to identify their ethnicity and country of origin. Models of age, gender, and ethnicity were created. Results One thousand twenty-four subjects were included (1,944 eyes). Measurements of nasal ala to lateral brow (NALB), lateral brow plumb line (LBPL; the vertical line between the tail of the brow and a horizontal line extending from the lateral canthus), and angle from the midbrow to the lateral brow tail showed statistically significant decline over time. The angle and LBPL varied mostly by ethnicity. The angle narrowed approximately 3° per 20 years, while the LBPL fell approximately 2.5 mm per 20 years. The NALB varied most by age and fell approximately 3 mm per 20 years. Conclusions The lateral tail of the brow descends with age. Measurements of its location and rate of change vary between genders and within ethnic groups. Two easily measured values-NALB and LBPL-can be used for preoperative planning and postoperative documentation.

Empirically determined doses of onabotulinum toxin A for aesthetic treatments are as much as 5 times higher for the upper than for the lower facial muscles.To use electromyography (EMG) to determine objectively whether the disparity between doses is due to intrinsic differences between the muscle groups' responses to onabotulinum toxin A or to variable amounts of paralysis required to achieve the desired aesthetic outcomes.We collected EMG data before and at 2 to 4 weeks and 3 months after 8- and 2-U onabotulinum toxin A injections to the corrugator and depressor anguli oris muscles, respectively.A private oculofacial plastic surgery practice.Twenty-six subjects recruited from February 1 through April 1, 2009.Electromyography recordings and cosmetic onabotulinum toxin A injections.Mean motor unit (MU) durations and maximal amplitudes at baseline and 2 to 4 weeks and 3 months after injection.Baseline mean MU amplitudes were similar for the corrugator and depressor anguli oris muscles. At 2 to 4 weeks after injection, 78% MU and 64% maximal amplitude reduction for the corrugator muscle were detected, but only 54% MU and 18% maximal amplitude reduction for the depressor anguli oris (P = 2.7 × 10-8 and P = 1.3 × 10-14, respectively). At 3 months, function was partially recovered for both muscle groups.Onabotulinum toxin A causes a similar dose-dependent reduction in MU and maximal voluntary amplitudes for muscles of the upper and lower face. The dose disparity appears to result from differences in the amount of paralysis required to achieve desirable aesthetic results.2.

Contracture of the conjunctiva of an anophthalmic socket is a common complication following enucleation (Int J Oral Maxillofac Surg 29(2):96–98, 2000; Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). The lower fornix is typically affected before the upper fornix (Int J Oral Maxillofac Surg 29(2):96–98, 2000; Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). Loss of forniceal depth can make it impossible for an ocularist to fit a prosthetic. In such cases, forniceal reconstruction may be considered (Int J Oral Maxillofac Surg 29(2):96–98, 2000; Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). If the conjunctiva is sufficiently elastic, fornix deepening sutures can be used to recreate the upper and lower fornices. However, if the conjunctiva is scarred and inelastic, mucous membrane grafting may be considered (Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). Buccal mucosa is similar in consistency to conjunctiva, consisting of non-keratinized squamous cell epithelium and a thin lamina propria (EAU-EBU Update Series 5(5):179–187, 2007). When harvesting buccal mucosa, care must be taken to avoid the parotid (Stensen) duct, located on the inner cheek, across from the second superior molar tooth. Additionally, damage to the underlying buccinator muscle should be avoided. When choosing the size of the graft to harvest, one should overestimate the amount of mucosa required, as oral mucosal grafts can shrink up to 20 % from their original size (EAU-EBU Update Series 5(5):179–187, 2007). After harvesting the graft, it is important to use a second set of sterile surgical instruments and replace the surgeons’ gloves in order to prevent contamination of the eye socket with oral bacteria (EAU-EBU Update Series 5(5):179–187, 2007).

Lower eyelid retraction secondary to thyroid eye disease or prior lower eyelid blepharoplasty can be addressed by disinserting the lower eyelid retractors and employing a spacer graft between the tarsus and lower eyelid retractors (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). Graft materials include hard palate, ear cartilage, sclera, or alloplastic materials. When using ear cartilage or sclera, the graft must be covered with conjunctival epithelium (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). Hard palate has the benefit of combining the structural rigidity of tarsus with the mucous membrane epithelium similar to that of the conjunctiva. The biggest disadvantage of hard palate grafting is donor site morbidity. Preoperative fitting of a palate protector and postoperative oral viscous lidocaine (2 %) gel can be used to improve patient discomfort. Anesthesia during hard palate grafting can be obtained with a greater palatine nerve block (Ophthalmic Plastic and Reconstructive Surgery 8:183–195, 1992) and direct infiltration of the hard palate. Local anesthesia is injected by the greater palatine foramen, medial to the alveolar process by the third molar. The hard palate is composed of epithelium, lamina propria, and submucosa. Hard palate harvesting is done in the submucosal plane and the submucosa is removed from the graft before implantation. The area of the alveolar process and midline raphe are devoid of submucosa and should therefore be avoided (Ophthalmic Plastic and Reconstructive Surgery 8:183–195, 1992). After harvesting the graft, the graft is rinsed in a 10 % betadine solution, a second set of sterile surgical instruments are opened, and the surgeon’s gloves are changed in order to prevent contamination of the eye socket with oral bacteria.

Involutional brow ptosis is generally more pronounced in the lateral brow than the medial brow (Techniques in Ophthalmic Plastic Surgery, Philadelphia, 2010). Brow ptosis can become visually significant, restricting the superior and lateral field of vision. The internal lateral browpexy can be used to correct mild lateral brow ptosis through an eyelid crease incision (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). This procedure may be performed in combination with an upper eyelid blepharoplasty and browplasty without additional incisions (Plastic and Reconstructive Surgery 86:248–254, 1990). Moderate amounts of brow ptosis are better corrected with a direct, mid-forehead, pretrichial, or endoscopic brow lift (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008).

Entropion of the lower eyelid can lead to ocular surface irritation due to the lashes and eyelid skin rubbing against the cornea. If not corrected, permanent scarring of the cornea and loss of vision can result. Involutional entropion is believed to occur secondary to dehiscence of the lower eyelid retractors, horizontal eyelid laxity, and overriding of the preseptal orbicularis over the pretarsal orbicularis (Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). In spastic entropion, ocular irritation or inflammation leads to spasm of the eyelids, resulting in entropion (Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). The Quickert suture technique, first described by Quickert and Rathbun (Arch Ophthalmol 85:304–305, 1971), temporarily corrects lower eyelid entropion by plicating the lower eyelid retractors. This technique does not address the horizontal laxity component that contribute to involutional entropion and is not a permanent solution for involutional or spastic entropion. It is, however, a powerful tool to temporarily relieve patient discomfort and prevent scarring of the cornea until definitive surgery can be performed.