Thyroid Eye Disease Following COVID-19 Vaccine in a Patient With a History Graves' Disease: A Case Report.

A 50-year-old woman with a history of controlled Graves' disease without clinical ophthalmopathy presents with 2 months of left more than right periorbital swelling and proptosis. Her eye symptoms and signs began 3 days following her second vaccination against the COVID-19 virus. Orbital imaging, elevated thyroid stimulating immunoglobulin, and negative systemic work up for other diseases were consistent with a diagnosis of active thyroid eye disease. The temporal relationship to her vaccination was likely consistent with autoimmune/inflammatory syndrome associated with adjuvants. Clinicians should remind patients of the symptoms and signs of thyroid eye disease and to seek appropriate medical and ophthalmic advice if they occur after the COVID-19 vaccine.

Stenotrophomonas maltophilia-Associated Dacryocystitis in Leukemia-Infiltrated Lacrimal Sacs: Case and Review of Literature.

A 91-year-old female with a history of chronic lymphocytic leukemia developed recurrent bouts of bilateral dacryocystitis. She underwent incision and drainage of the lacrimal sac with culture demonstrating the rare bacteria Stenotrophomonas maltophilia. She underwent subsequent dacryocystectomy with biopsy revealing bilateral involvement of chronic lymphocytic leukemia in the lacrimal sac. Stenotrophomonas maltophilia has been associated with immune suppression and is rarely seen in dacryocystitis. Local and/or systemic immune deregulation or suppression may play a role in lacrimal sac infection with this bacterium in some patients.

Necrotizing Granulomatous Dacryoadenitis With Non-Necrotizing Granulomatous Scar Hypertrophy: Two Histological Variants of Sarcoidosis in the Same Patient.

Orbital involvement with histologic necrosis is a rare manifestation of systemic sarcoidosis. The authors present a case of necrotizing dacryoadenitis in addition to non-necrotizing granulomas in a hypertrophic scar that is consistent with a diagnosis of sarcoidosis. A 60-year-old female presented with 2 months of painless right upper eyelid fullness and ptosis. CT imaging demonstrated right greater than left lacrimal gland enlargement. A biopsy demonstrated necrotizing granulomatous inflammation of the lacrimal gland. Additional workup was negative for infectious or lymphoproliferative disease. On further investigation, the patient noted thickening of a longstanding abdominal scar, and a subsequent punch biopsy of the scar demonstrated non-necrotizing granulomas suggestive of scar sarcoidosis. CT chest identified mediastinal lymphadenopathy. A diagnosis of sarcoidosis was determined. The authors thereby present an unusual case of 2 histologic variants of sarcoidosis presenting with necrotizing granulomatous dacryoadenitis and non-necrotizing scar granulomas.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Management of postoperative pain in ophthalmic plastic surgery: a major review.

PURPOSE: Clinicians are becoming increasingly aware of the risks of opioid analgesics, and, consequently, are searching for alternatives to these agents. This review considers the existing literature regarding the management of pain after ophthalmic plastic surgery. METHODS: A literature search was performed through the PubMed database. Articles were assessed for relevance, and the appropriate data was extracted from the medical literature regarding pain management strategies after oculoplastic procedures. RESULTS: An emerging body of literature suggests the efficacy of a variety of non-narcotic agents in post-operative pain management. Many of these medications prevent the development of pain, and several have been studied in randomized trials. Specifically, pregabalin, ketorolac, acetaminophen, memantine, local anesthetics, and alternative therapies all have documented benefit in this setting. CONCLUSIONS: Several medications may prevent and treat pain after ophthalmic plastic surgery. These agents are well-tolerated, and many decrease the requirement for opioid analgesics. Clinicians should be aware of these therapies when considering non-narcotic pain management.

Odontogenic Abscess With Orbital Extension Through the Inferior Orbital Fissure Treated With Bony Decompression.

A 49-year-old otherwise healthy male presented with an odontogenic abscess and mild left facial swelling. CT imaging revealed gaseous hypodensities within the inferior orbital fissure and pterygopalatine fossa in addition to infection of the left masseter and temporalis muscle. Despite dental drainage, this rapidly progressed to orbital cellulitis with temporalis muscles abscess leading to compartment syndrome and globe tenting. He had an excellent outcome after canthotomy and cantholysis, urgent endoscopic and transconjunctival orbital decompression, temporalis muscle abscess drainage, and intravenous antibiotics. This case describes the use of bony orbital decompression for orbital compartment syndrome and globe tenting from odontogenic orbital cellulitis. In addition, this case radiographically demonstrates a transinferior orbital fissure passageway of an odontogenic abscess in the orbit.

Long-Term Outcomes of StopLoss Jones Tubes for Epiphora in Patients With Early or Multiple Loss of Lester Jones Tubes.

PURPOSE: Extrusion is the most common cause of failure in conventional Lester Jones tubes (LJTs). StopLoss Jones tubes (SLJTs) with distal flange are designed to reduce this complication. This study compared the survival of SLJTs with their prior LJTs and control patients with LJTs-only. METHODS: Retrospective review of consecutive LJT or SLJT insertion between January 2014 and December 2016. RESULTS: Twenty-eight eyes of 23 patients had 31 SLJTs. Before their SLJTs, these patients had 116 cumulative failed LJTs. Forty-seven eyes of 34 patients had 59 LJTs only. Fifty-two percent of SLJT group and 18% of LJT-only group had complex medial canthal conditions (p = 0.003). Compared to their previous LJTs, the SLJTs were less likely to extrude (3% SLJT vs. 64% prior LJT, p < 0.0001); there was no statistical difference in rates of sinking in (26% SLJT vs. 13% prior LJT, p = 0.0964). The median survival of LJTs in those who went on to have a SLJT was 3.5 months. SLJT insertion significantly lengthened the median survival to 26 months (p < 0.0001), comparable to the LJT-only group (25.5 months, p = 0.45). While extrusion was also the most common complication in the LJT-only group, this occurred only in 20% of eyes; tube failure from sink-in occurred in 14% of eyes. CONCLUSIONS: SLJTs, in patients prone to multiple or early prior LJT losses, can be used to rescue this group and allow them to regain a similar survival curve to the less complicated LJT-only group. Rates of tube extrusion are significantly reduced with the use of SLJT.

Lacrimal Gland Orbital Lobe Cysts Associated With Lymphoid Hyperplasia or Mucosa-Associated Lymphoid Tissue Lymphoma in Patients With Chronic Autoimmune Disease.

Large cysts in the orbital lobe of the lacrimal gland are rare and are associated with Sjögren syndrome and B-cell mucosa-associated lymphoid tissue lymphoma. The authors describe 4 new cases of large orbital lobe lacrimal gland cysts. The first 2 patients, both with Sjögren syndrome, had unilateral cysts associated with chronic inflammation. Mucosa-associated lymphoid tissue lymphoma was also identified in the cyst wall of the second case and could not be completely excluded in the first case. The third patient, with a history of rheumatoid arthritis, had bilateral cysts, again associated with mucosa-associated lymphoid tissue lymphoma. The fourth patient, with no history of systemic disease, had a unilateral cyst associated with reactive lymphoid hyperplasia. Finally, the authors report the long-term outcomes of 3 previously reported cases.

The Translaminar Pressure Gradient: Papilledema After Trabeculectomy Treated With Optic Nerve Sheath Fenestration.

INTRODUCTION: Trans-lamina cribrosa pressure has been postulated to be a contributor in the development of a glaucomatous optic nerve versus optic nerve edema, depending on the pressure gradient. Uncertainty remains in the therapeutic outcome of adjusting this gradient. CASE REPORT: We discuss a unique case of idiopathic intracranial hypertension presenting as asymmetric optic disc edema following trabeculectomy. It was treated via optic nerve fenestration due to the patient remaining symptomatic on maximum tolerated acetazolamide. Intraocular pressure stabilized into target range and the optic nerve edema resolved. CONCLUSIONS: Rarely, intraocular pressure reduction can unmask elevated intracranial pressure, leading to optic nerve edema. Optic nerve sheath fenestration is a practical therapeutic modality to consider when treating this occurrence.

Phenotypes of Thyroid Eye Disease.

PURPOSE: To describe a new classification system of thyroid eye disease (TED) based on the phenotypic features (clinical and radiologic) of the disease. METHODS: Clinical features, photographic, and orbital imaging of TED patients were considered in relation to their natural history and treatment response in the experience of the author. Phenotypically distinct categories of patients were identified and described. RESULTS: Six phenotypes of TED are observed: 1) congestive (active inflammatory), 2) "white eye" expansion, 3) "hydraulic" apex, 4) "white eye" apex, 5) cicatricial active, and 6) cicatricial passive. CONCLUSIONS: The observable characteristics of TED are determined by the underlying pathophysiology of the disease. TED is heterogeneous in its underlying pathogenesis, clinical manifestations, and response to medical and surgical treatment modalities. Several previous categorizations of the clinical appearance of TED exist, but they are dichotomous and underrepresent the heterogeneity of the disease. The authors present clinical and radiologic features of 6 different classes or phenotypes of TED and their response to different treatments.

Ocular/adnexal lymphoma: dissimilar to systemic lymphoma.

Ocular adnexal lymphoma and intraocular lymphoma, whether occurring simultaneously or sequentially, are often similar to associated systemic lymphoma. We describe 4 cases of ocular adnexal lymphoma or intraocular lymphoma with a dissimilar systemic lymphoma. Two of the cases represent Richter transformation of chronic lymphocytic leukemia/small-cell lymphoma into diffuse large B-cell lymphoma. In the third patient, conjunctival extranodal marginal zone lymphoma developed following treatment for Hodgkin lymphoma. The fourth patient had a remote history of systemic diffuse large B-cell lymphoma with a subsequent diagnosis of orbital extranodal marginal zone lymphoma. Clinical-pathological correlation is reported for all cases in addition to pertinent review of the literature.