Reticular Bullous Epithelial Corneal Edema after Netarsudil Use for Elevated Intraocular Pressure with Concurrent Fuchs Endothelial Corneal Dystrophy: A Case Report.

Introduction: We describe a case of reticular bullous corneal epithelial edema associated with the use of netarsudil ophthalmic solution (0.02%) for elevated intraocular pressure. Case Presentation: A 74-year-old man with a complex ocular medical history, including Fuchs dystrophy and primary open-angle glaucoma, developed progressively worsening loss of vision 3 weeks following the initiation of topical netarsudil for increased intraocular pressure. Visual acuity in the left eye was counting fingers at 3 feet and intraocular pressure in the left eye was 7 mm Hg. A characteristic "honeycomb" pattern epitheliopathy was seen on ocular examination. Conclusion: Reticular bullous epithelial corneal edema is an uncommon finding associated with netarsudil use, which can be overlooked in favor of corneal edema associated with Fuchs dystrophy. This is especially relevant given Fuchs dystrophy itself is a predisposing risk factor for netarsudil-induced reticular bullous corneal epithelial edema. Improvement of both the corneal edema and visual acuity should be expected after discontinuing netarsudil and undergoing superficial keratectomy.

Is Blepharoplasty Cost-effective? Utility Analysis of Dermatochalasis and Cost-effectiveness Analysis of Upper Eyelid Blepharoplasty.

PURPOSE: This cross-sectional prospective study measured utility values of upper eyelid dermatochalasis to quantify its impact on quality of life and assess cost-effectiveness of upper blepharoplasty. METHODS: Utility of dermatochalasis was assessed using the standard reference gamble and time trade-off methods, with dual anchor points of perfect eye function and perfect health. The utility value obtained was used to create a Markov model and run a cost-effectiveness analysis of blepharoplasty as a treatment for dermatochalasis while utilizing the societal perspective. RESULTS: One hundred three patients with dermatochalasis recruited from an urban outpatient ophthalmology clinic completed the utility survey. The authors determined utility values for dermatochalasis ranging from 0.74 to 0.92 depending on the measurement method (standard reference gamble/time trade-off) and anchor points. The cost-effectiveness analysis yielded an incremental cost-effectiveness ratio of $3,146 per quality-adjusted life year, well under the conventional willingness-to-pay threshold of $50,000 per quality-adjusted life year. Probabilistic sensitivity analysis with Monte Carlo simulation demonstrated that blepharoplasty would be cost-effective in 88.1% of cases at this willingness-to-pay threshold. CONCLUSIONS: Dermatochalasis has an impact on quality of life that is significantly associated with level of perceived functional impairment. Rising health care costs have underscored the importance of providing value-based treatment to patients, and the results of this study suggest that blepharoplasty is a cost-effective treatment option for symptomatic bilateral upper eyelid dermatochalasis.

Conjunctival Perivascular Epithelioid Cell Neoplasm With RBM10-TFE3 Fusion Presenting as Recurrent Subconjunctival Hemorrhage.

Subconjunctival hemorrhages commonly present to eye care professionals and are frequently regarded as benign self-limited conditions. In selected cases, subconjunctival hemorrhages can be a harbinger of more severe disease. Perivascular epithelioid cell tumors, or PEComas, are rare mesenchymal neoplasms believed to originate from perivascular myoid cells and are rarely present in ocular structures. We present a rare case of a conjunctival perivascular epithelioid cell tumor that initially presented with recurrent subconjunctival hemorrhage. To our knowledge, this is the first description of a PEComa with a RBM10-TFE3 gene fusion, only previously seen with renal cell carcinoma. Physicians should be aware of this rare condition, its location in the fornix and its presentation as a recurrent subconjunctival hemorrhage.

Cutaneous Squamous Cell Carcinoma With Orbital Extension.

A 72-year-old homeless man was referred for management of a recurrent cutaneous squamous cell carcinoma of the right temple and brow. He was seen again 5 months later with an enlarged crusting and ulcerating lesion of the right temple/brow. What would you do next?

Thyroid eye disease reactivation associated with COVID-19 vaccination.

To describe the presentation of both new-onset and reactivation of thyroid eye disease (TED) following COVID-19 vaccination. Single-institution retrospective case series of patients presenting with symptoms and signs of new or reactivated TED coinciding with recent COVID-19 vaccination. Data collected included patient age, gender, presenting symptoms, ocular history, clinical signs, and interval duration between vaccination and onset of ocular symptoms. Three female patients were identified. All patients were over 18 years of age (range 45-66 years). Patients received either the Moderna or Pfizer COVID-19 vaccine and presented with symptoms of TED within 24 h to 21 days of receiving their first or second dose. None of the patients had previous infections with severe acute respiratory syndrome coronavirus 2. Two patients had a history of inactive TED with stable thyroid function tests: One of these patients had stable disease for at least 15 years and the other had stable disease for 5 years. The third patient had no previous history of thyroid dysfunction or TED and presented with low levels of thyroid-stimulating hormone. All three cases presented with proptosis. In two of three cases, periorbital edema, eyelid retraction, and diplopia were present. None were current smokers. One had prior facial hyaluronic acid filler injections. Symptoms in all cases were improving at 4 to 8 months. While the possibility of unrelated TED flaring concurrently with COVID-19 vaccination exists, questions remain on the effects of the COVID-19 vaccine in patients with autoimmune ophthalmic diseases. Physicians should be aware of this potential association and counsel patients appropriately.

Giant Deep Orbital Dermoid Cyst Presenting in Infancy.

ABSTRACT: Orbital dermoid cysts are benign choristomas that are very common in children and occur most often as a lateral or medial mass associated with the frontozygomatic or frontoethmoidal suture line. The authors present an unusual case of an occult giant deep orbital dermoid cyst in infancy that initially presented with a small, benign appearance and central upper eyelid location on clinical exam. Orbitotomy with complete excision prevented further ocular sequelae in this 11-month-old.

Minimal Dissection Direct Frontalis Muscle Advancement Flap for Congenital Ptosis Repair.

BACKGROUND: Frontalis flap advancement is an alternative means of congenital ptosis repair from frontalis suspension utilizing autologous fascia or allogenic implants. Variations in technique, including flap division, location and number of skin incisions, and dissection planes, are described in the literature. MATERIALS AND METHODS: A retrospective case series of patients with congenital myogenic ptosis treated with simplified, minimal dissection frontalis flap advancement involving a single upper eyelid crease incision with dissection in the preseptal and subcutaneous planes without division to mobilize the frontalis flap. Inclusion criteria: pediatric patients age < 18 years with either primary or recurrent congenital ptosis following previous surgical repair. Exclusion criteria: ptosis of neurogenic etiology or postoperative follow-up < 3 months. Primary outcome measures were postoperative margin-reflex distance 1 (MRD1), the difference in MRD1 between surgical and nonsurgical eyelids in unilateral ptosis, and lagophthalmos. Secondary outcome measures included recurrence and complications. RESULTS: Twenty-six patients met inclusion criteria, 24 males and 2 females. Mean postoperative MRD1 at last follow-up was 2.9 ±â€Š1.2 mm and the mean difference in MRD1 between surgical and nonsurgical eyelids at last follow-up was 1.1 ±â€Š1.0 mm. Average lagophthalmos at postoperative month 2 to 5 was 0.6 ±â€Š0.7 mm. One patient demonstrated postoperative lid retraction that required re-operation. Four of 31 eyelids (12.9%) demonstrated ptosis recurrence at 5, 12, or 24 months. CONCLUSIONS: In this retrospective series, the authors report clinically and statistically significant surgical eyelid height improvement and symmetry between nonsurgical and surgical eyelids in congenital ptosis patients treated with minimal dissection direct frontalis flap advancement.

Quality of Life Assessment of Severely Visually Impaired Individuals Using Aira Assistive Technology System.

Purpose: To assess patient-reported quality of life outcome improvements in severely visually impaired (SVI) individuals using the Aira system over a 1-year follow-up period. Methods: Aira is an on-demand assistive technology designed for SVI. Aira subscribers were recruited and administered the validated 28-item Impact of Vision Impairment-Very Low Vision Questionnaire by phone before starting Aira with follow-ups at 3 months and 1 year. Total score and validated subset scores of activities of daily living, mobility, and safety (ADLMS) and emotional well-being (EWB) were assessed. Pearson correlation analyses and paired t-tests were used to examine the data. Results: Fifty participants (mean, age, 52.5 years; 25 males, 25 females) were recruited with a mean of 401 ± 66.3 days to follow-up. The initial total score (mean, 53.1 ± 18.9) significantly improved at 1 year (mean, 63.1 ± 16.2; P = 0.0002). The initial ADLMS score (mean, 30.7 ± 11.3) significantly improved at 1 year (mean, 37.2 ± 10.7; P = 0.001). The initial EWB score (mean, 22.5 ± 8.5) significantly improved at 1 year (mean, 25.9 ± 8.0; P = 0.0001). There was no significant difference between the 3-month and 1-year total (P = 0.972), ADLMS (P = 0.897), and EWB scores (P = 0.700). There was a significant correlation between minutes used and improvement in total (r = 0.371; P = 0.009), ADLMS (r = 0.302; P = 0.035), and EWB (r = 0.439; P = 0.002) scores. Conclusions: Aira use significantly improves Impact of Vision Impairment-Very Low Vision total, ADLMS, and EWB scores for SVI individuals at 3 months. This improvement is sustained at the 1-year follow-up and correlated with total minutes used. Translational Relevance: Aira technology may provide sustained improvement in quality of life for SVI, and further study to evaluate the usefulness of this technology to assist SVI may be beneficial.

Improvement in Patient-Reported Quality of Life Outcomes in Severely Visually Impaired Individuals Using the Aira Assistive Technology System.

PURPOSE: We evaluate patient-reported quality of life outcomes in severely visually impaired (SVI) individuals using the Aira system, an on demand assistive wearable technology. METHODS: Aira is an on-demand assistive wearable technology designed for the severely visually impaired (visual acuity of better eye <20/200). The user wears glasses with a video camera mounted that, when activated, livestreams to a human agent who assists the user in the specified task. Aira subscribers were recruited consecutively and administered the 28-item Impact of Vision Impairment-Very Low Vision (IVI-VLV) Questionnaire, a previously validated survey for vision-related quality of life specifically for low vision individuals. The questionnaire was administered by phone before starting Aira and at 3-month follow-up. Total score as well as validated subset scores of activities of daily living, mobility and safety (ADLMS) and emotional wellbeing (EWB) were assessed. RESULTS: A total of 69 participants (mean age, 52.1; 35 female, 34 male) were recruited with a mean of 108 (SD = 19.7) days to follow-up. Mean total minutes used over the interval were 334.1 (SD = 318.5). Initial total score (mean 51.7 ± 18.6) significantly improved at follow-up (mean 62.2 ± 15.0; P < 0.0001) with mean change +10.4 ± 12.5. ADLMS subset score (mean 30.4 ± 10.8) significantly improved at follow-up (mean 36.6 ± 8.8; P < 0.0001) with mean change +6.5 ± 8.7. EWB subset score (mean 21.6 ± 8.8) significantly improved at follow-up (mean 25.6 ± 7.9 respectively; P < 0.0001) with mean change +4.0 ± 5.2. There was no correlation between minutes used and improvement in total (r = -0.205, P = 0.098), ADLMS (r = -0.237, P = 0.055), and EWB (r = -0.242, P = 0.051) scores. CONCLUSIONS: In this exploratory study, regardless of minutes used, the use of Aira significantly improves IVI-VLV total score and ADLMS and EWB subscores for SVI individuals. This improvement is not correlated with total minutes used. TRANSLATIONAL RELEVANCE: The Aira assistive technology system may provide improvement in quality of life for low vision patients and is worthy of further study to assess the use of this technology to assist SVI patients.

The ability of single site, single depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex.

OBJECTIVE: To determine the physiologic effectiveness of single site, single depth sacral lateral branch injections. DESIGN: Randomized, controlled, and double-blinded study. SETTING: Outpatient pain management center. PATIENTS: Fifteen asymptomatic volunteers. INTERVENTIONS: The dorsal sacroiliac ligament was probed and the sacroiliac joint was injected with contrast medium until capsular distension occurred. The presence or absence of pain with each maneuver was noted. Under double-blind conditions, subjects returned 1 week later for L5 dorsal ramus and S1-4 lateral branch injections; 10 subjects received 4% lidocaine (active) injections while five subjects received saline (control) injections. After 30 minutes, subjects had repeat ligamentous probing and capsular distension of the same sacroiliac joint that was previously tested. The presence or absence of pain with each maneuver was noted. In a parallel anatomic study, S1 and S2 lateral branch injections with green dye were performed on two nonembalmed cadavers. Dissection was undertaken to quantify the degree of staining of these target lateral branch nerves. OUTCOME MEASURES: Presence or absence of pain for ligamentous probing and sacroiliac joint capsular distension. RESULTS: Forty percent had no discomfort upon repeat ligamentous probing after active lateral branch injections while 100% retained pain upon repeat ligamentous probing with control lateral branch injections. Forty percent of the active group and 20% of the control group did not feel repeat capsular distension of the sacroiliac joint after the lateral branch injections. In the anatomic study, 11 lateral branch nerves were isolated while staining occurred in only four cases or 36%. CONCLUSIONS: Anatomic limitations exist with single site, single depth sacral lateral branch injections rendering them physiologically ineffective on a consistent basis.