Tocilizumab use for optic nerve compression in thyroid eye disease: a prospective longitudinal cohort.

PURPOSE: To assess the effectiveness of tocilizumab in reverting the signs and symptoms of dysthyroid optic neuropathy (DON) in thyroid eye disease and the need for emergency orbital decompression. The secondary outcomes are to identify the optimal number of tocilizumab cycles to achieve the primary outcome, to analyze the association between thyroid stimulating immunoglobulin (TSI), clinical activity score (CAS) and proptosis in response to the treatment and the need for rehabilitative orbital decompression. METHODS: Prospective longitudinal cohort study that included 13 patients who had unilateral or bilateral dysthyroid optic neuropathy (DON) due to severe and progressive sight-threatening thyroid eye disease based on the CAS system. Patients were seen in this facility starting from July 2017, and all had received intravenous tocilizumab. RESULTS: Initial visual acuity mean was 0.52 ± 0.38 and the final were 0.93 ± 0.11 with a mean difference of 0.41 and P < 0.00245. The mean CAS prior to the initiation of the treatment was 7.92 ± 0.66 and the final was 2.85 ± 1.03 with mean difference of 5.07 and P < 0.00001. Initial mean proptosis was 24.85 ± 2.31 and the final was 21.78 ± 2.18 with a mean difference of 3.07 and P < 0.000497. No emergency orbital decompression was performed. TSI was high initially in all cases with a wide range of 2.4 to 40 IU/L and with a mean of 10.70 ± 13.40. The final TSI mean was 2.90 ± 3.90 with a mean difference of 7.81 and significant P value (P < 0.0272). CONCLUSION: Tocilizumab use in optic nerve compression showed promising results as it can be the primary or an alternative treatment option.

A 46-Year-Old Woman with a 4-Year History of Graves Disease, with Severe Corticosteroid-Unresponsive Thyroid Eye Disease, Successfully Treated with Tocilizumab.

BACKGROUND Tocilizumab is a therapeutic biologic antagonist of the interleukin-6 (IL-6) receptor that has been approved to treat some autoimmune and chronic inflammatory diseases. This report is of a patient with a history of Graves disease and severe corticosteroid-unresponsive thyroid eye disease that included edema of the optic nerve and choroid, which was successfully treated with tocilizumab. CASE REPORT A 46-year-old woman with a 4-year history of Graves disease presented with acutely progressive bilateral severe optic nerve compression, severe bilateral optic nerve edema, bilateral restriction of eye movement, and bilateral choroidal folds. The patient was managed with an initial high dose of systemic steroid without any success. She then underwent bilateral orbital wall decompression without any noticeable amelioration. She subsequently received 4 doses of a tocilizumab (8 mg/kg) infusion. This resulted in a considerable decrease in inflammatory signs and improvement in optic nerve function, thereby improving her quality of life. The patient did not have any adverse reactions to the tocilizumab. CONCLUSIONS The findings from this case support recent case reports and clinical trials indicating that tocilizumab may be effective in corticosteroid-resistant thyroid eye disease associated with autoimmune hyperthyroidism.

Tocilizumab use in pediatric thyroid eye disease: First documented case.

PURPOSE: To report the first case of Tocilizumab treatment for progressive pediatric thyroid eye disease (TED) in a 9-year-old female. OBSERVATIONS: A 9-year-old female with a history of hyperthyroidism for 4 months presented with bilateral proptosis (more in the right eye) associated with retrobulbar pain, tearing, and conjunctival and caruncular redness. The exophthalmometry reading on presentation was 21mm OD and 17 mm OS. The patient was managed with observation and control of hyperthyroidism in the beginning. However, on a subsequent visit 3 months later it was observed that the symptoms and clinical findings were rapidly worsening. The exophthalmometry reading upon subsequent follow-up was 22 OD and 22 OS. After multidisciplinary team (MDT) discussions it was decided to treat the patient with four doses of 8mg/kg Tocilizumab injection on monthly basis. Notable improvement of proptosis and resolution of pain, conjunctival and caruncular redness was observed. The exophthalmometry reading 4 months after treatment was 20 OD and 19 OS. CONCLUSION AND IMPORTANCE: This case report opens an important gateway for the use of Tocilizumab in progressive TED in pediatric age groups.

Bilateral Central Retinal Vein Occlusion in a 40-Year-Old Man with Severe Coronavirus Disease 2019 (COVID-19) Pneumonia.

BACKGROUND COVID-19 is the disease caused by the novel virus, severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). The spectrum of disease seen in patients with COVID-19 infection ranges from asymptomatic or mild symptoms to severe pneumonia and even acute respiratory distress syndrome, which often requires invasive ventilation and intensive care. COVID-19-associated infection can be catastrophic, leading to both arterial and venous occlusion, microinfarcts, and multiorgan failure, although retinal vein occlusion has not yet been reported. CASE REPORT We present the case of a 40-year-old man who presented with a 3-day history of shortness of breath, cough, and fever. He also reported right calf pain and blurring of vision in both eyes. His medical history included hypertension and morbid obesity. The patient was found to have severe COVID-19 pneumonia on high-resolution computed tomography of the chest, right leg deep venous thrombosis on Doppler ultrasonography, and bilateral central retinal vein occlusion (RVO) on fundal examination. He was started on full-dose anticoagulation and discharged on rivaroxaban for 3 months. After 2 weeks of therapy, he had fully recovered from his COVID-19 symptoms and had near-normal vision. CONCLUSIONS COVID-19 infection can cause RVO. Early full-dose anticoagulation should be considered in high-risk patients with severe COVID-19 infection. Ophthalmologists and other clinicians should have a high index of suspicion for RVO in patients with COVID-19 infection who presenting with blurred vision and severe pneumonia.

Conjunctival Sparing Ptosis Correction by White-Line Advancement Technique.

PURPOSE: To describe a modified technique of white line advancement posterior ptosis surgery and to report the success rate of the procedure. METHODS: A retrospective case series of 60 patients who presented with ptosis with good levator function. The success rate was defined as an MRD1 of greater than or equal to 3.5 mm, symmetrical eyelid position with an intereyelid height asymmetry of ≤1 mm, and a satisfactory eyelid contour at 3 months follow-up. RESULTS: Sixty patients (91 eyelids) met the inclusion criteria. Mild postoperative complications occurred in 11 patients that resolved without surgical intervention. Seven patients had recurrence of ptosis: four patients had early recurrence and 3 had late recurrence. The success rate was 88.33% with an average follow-up of 9 months. CONCLUSION: This procedure is a promising technique in cosmetic and functional ptosis correction. The advantage of this posterior approach procedure is that there is no conjunctival resection; it is suitable for young patients who do not have excess eyelid skin. The procedure is quick with a short recovery period. Additionally, it can be combined with another procedure and in different pathology.

Concomitant orbital aspergillosis and mucormycosis in a 17 months old immunocompetent child.

Isolated multiple orbital fungal infection (aspergillosis & mucormycosis) is extremely rare disease in immunocompetent individuals and especially in children. Placement of prosthetic device during the surgery could be one of the risk factors. The presentation is usually masquerading other entities which make early diagnosis a challengeable. This case presenting a 17 months old immunocompetent child who is diagnosed with isolated multiple orbital fungal infection: aspergillosis & mucormycosis. The presentation was mimicking orbital cellulitis and chronic dacryocystitis. The definitive diagnosis was made by tissue biopsy. The child was managed by surgical debridement and IV amphotericin B liposomal. High index of suspicion to fungal infection should be considered after surgical intervention with insertion prosthetic materials. To the best of our knowledge, orbital aspergillosis in immunocompetent young children is exceptionally rare.

Orbital and Orbitocranial Trauma From Pencil Fragments: Role of Timely Diagnosis and Management.

PURPOSE: To emphasize the importance of early detection and radiologic evaluation of retained organic foreign bodies (FBs) in orbital or orbitocranial penetrating injuries by pencil. DESIGN: Retrospective case series. METHODS: A retrospective chart review of patients who had penetrating orbital or orbitocranial trauma at 2 tertiary hospitals was conducted. Patients whose mechanism of injury was penetrating trauma by pencil were included. The patients' demographics, time between initial trauma and detection of foreign body, radiologic images, and resulting sequelae were reviewed. RESULTS: Four patients were included in this study. All patients were male; 3 were less than 2 years of age and 1 was 34 years old. Accidents were witnessed in 2 cases, and initial detections of FBs were delayed in 3 cases, from 2 days to 7 weeks. Three cases involved the right orbit. Computed tomography (CT) imaging of the head demonstrated penetration of the orbital walls in 3 cases. Three-dimensional CT scans were used to differentiate the penetrating graphite pencil fragments from the orbital wall, and catheter angiography was used in 1 case of suspected orbital apex penetration. Vision was lost in 1 patient while other severe neurologic deficits were fully recovered after removal of FB. CONCLUSIONS: Penetrating injury by pencils to the periorbital structures and delayed detection of retained pencil fragments can result in threat to life and vision. Radiologic examinations are essential to the detection of these retained FBs. Prompt detection and removal of the FBs within 48 hours and treatment with antibiotics can save vision and life.

Alcohol delamination of the corneal epithelium for recalcitrant recurrent corneal erosion syndrome: a prospective study of efficacy and safety.

AIM: To investigate the safety and efficacy of alcohol delamination of the corneal epithelium for recalcitrant recurrent corneal erosion syndrome (RCE) in a prospective non-comparative interventional case series. METHODS: Patients with RCE who remained symptomatic despite topical lubrication and 3-month use of an extended wear (bandage) contact lens were included. The intensity of pain on a scale of 1 to 10, and duration and frequency of attacks were recorded. Patients were treated with alcohol delamination and followed up at 1 week, 1 month and then at 12 months, which was the minimum follow up time. Success was defined as a resolution of symptoms after 1 month of treatment, and partial success as a significant reduction in symptoms manageable with topical lubricants, and failure where symptoms were unchanged or worsened. RESULTS: 20 eyes of 20 patients with RCE caused by trauma (n = 14), anterior basement membrane dystrophy (n = 5) or idiopathic (1) were studied. The mean age of patients was 44 years and mean follow-up 24 months. Two eyes were lost to follow-up. 15 (83%) eyes were qualified as successes, 3 as partial successes and no failures were seen. No intraoperative complications were observed. 1 patient developed transient subepithelial haze that resolved with topical steroid, 1 had a change in refraction and 1 developed herpetic stromal keratitis 2 months postoperatively, which was successfully treated. No loss of vision was observed in any of the patients. CONCLUSION: Alcohol delamination of the corneal epithelium is a safe and effective method for treating patients with recalcitrant RCE.