Cemiplimab for metastatic squamous cell carcinoma of the orbit, periocular adnexa, and thigh.

The current case presentation highlights the potential of cemiplimab, a programmed cell death protein-1 (PD-1) inhibitor, as first-line treatment for periocular metastatic cutaneous squamous cell carcinoma (SCC) without requiring curative surgery or radiotherapy. A 64-year-old male presented with a progressing 4.5 × 3.0 cm left upper eyelid lesion initially diagnosed as psoriasis. Work-up revealed cutaneous SCC with tumor invasion into extraconal fat and lacrimal gland, and metastasis to the left parotid lymph node. The patient also presented with a suspicious lesion on his left medial thigh found to be a second primary on pathology. To avoid orbital exenteration and treat the multifocal disease, the patient was started on intravenous cemiplimab immunotherapy. Following six doses, repeated FGD-PET-CT revealed a complete response of the left eyelid lesion and residual low-grade hypermetabolic activity of the left medial thigh lesion. Biopsy confirmed chronic inflammation and fibrosis with no signs of malignancy. This unique case with dual primary cutaneous SCC provides support for cemiplimab in treating locally invasive periocular SCC, and potentially abrogating the need for highly morbid exenteration procedures to preserve binocular vision.

Blink detection and magnetic force generation for correction of lagophthalmos, with specific regard to implant compatibility testing.

PURPOSE: The overall goal was to restore a normal and synchronous blink in unilateral lagophthalmos. We describe the biocompatibility profiling of a novel ferromagnetic implant used for electromagnetic eyelid force generation. METHODS: A non-contact blink detection system and an electromagnetic stimulation system were designed and tested. A modified Lester-Burch speculum equipped with strain gauge technology was used in blinking force measurement. Samarium-cobalt magnets were prototyped and coated with parylene-C. Biocompatibility testing was performed using NIH/3T3 mouse fibroblast cells with MTT colorimetric assay cytotoxic quantification. OUTCOME MEASURES: Cellular viability and interleukin concentrations. RESULTS: Our system was capable of detecting 95.5 ± 3.6% of blinks in various lighting conditions. Using our force measuring device, the difference between non-paralyzed and paralyzed orbicularis oculi (OO) for normal and forceful blinking closure was 40.4 g and 101.9 g, respectively. A 16.6 × 5.0 × 1.5 mm curved shaped samarium cobalt eyelid implant was successfully developed and showed a reproducible blink at 100 ms with full corneal coverage with external eyelid taping. Compared to gold weights, parylene-C coated samarium cobalt implants showed not only excellent cell viability (82.0 ± 4.9% vs. 88.4 ± 0.9%, respectively, p > .05), but also below detection threshold for pro-inflammatory marker concentrations (interleukin-6 < 2 pg/mL and interleukin-10 < 3 pg/mL). CONCLUSIONS: We demonstrated excellent in-vitro biocompatibility of our parylene-C coated samarium cobalt implants. We believe that our novel approach can improve the quality-of-life of affected individuals and provides new understanding of blinking biomechanics.

Optical Coherence Tomography of Peri-Ocular Skin Cancers: An Optical Biopsy.

INTRODUCTION: Optical coherence tomography (OCT) imaging has been used as a diagnostic tool for retinal disease for several years, and OCT apparatuses are becoming increasingly powerful. However, OCT has yet to reach its full potential in ophthalmology clinics. Alike retinal layers, it has been shown that OCT is able to generate cross-sectional images of the skin and allows visualization of skin lesions in a histopathology-like manner. OBJECTIVE: We aim to validate OCT as an imaging modality for peri-ocular skin cancer. Through a series of cases, we highlight findings for 3 common eyelid malignancies: basal cell carcinoma, squamous cell carcinoma and sebaceous carcinoma. We propose an OCT image-based signature for basal cell carcinoma. METHODS: This is a prospective study. Fifty-eight lesions suspicious of malignancy from 57 patients were subjected to OCT imaging prior to the surgical excision of the lesion. OCT images were analysed and scored according to previously identified OCT features. Eight representative examples are presented, highlighting the OCT patterns for each malignancy side by side to its corresponding histopathological sections. RESULTS: Out of the 58 lesions analysed, 53 were malignant. A loss of the dermal-epidermal junction is observed in all malignant lesions. A strong link is observed between the presence of subepithelial hyporeflective nests on OCT and the diagnosis of basal cell carcinoma (present in 83% of cases). Conversely, lesions of epithelial origin such as squamous cell carcinoma are most often represented on OCT by acanthosis. Two supplementary cases, one basal cell carcinoma and one sebaceous carcinoma, are provided to illustrate how OCT imaging is a valuable tool in cases where clinical observations may be unusual. CONCLUSIONS: We provide evidence supporting the use of OCT for the evaluation of peri-ocular cancers. OCT enables visualization of the skin layers in vivo, before biopsy. Our results show that certain OCT features can contribute to include or exclude a diagnosis of basal cell carcinoma. By integrating this non-invasive imaging methodology into the routine assessment of peri-ocular skin lesions, especially in health care centres where access to specialists is limited, OCT imaging can increase clinical precision, reduce delays in patient referral and enhance patient care.

Unilateral upper eyelid eversion and kink associated with epidemic keratoconjunctivitis.

PURPOSE: Upper lid eversion in adults from non-cicatricial causes is rare. We report a case of upper eyelid eversion secondary to epidemic keratoconjunctivitis (EKC). OBSERVATIONS: A 37 year-old female presented with unilateral upper lid eversion. Known for left upper lid ptosis repair in childhood, the patient presented with seven-day history of severe bilateral conjunctivitis and eversion of her left upper lid three days prior. On exam, she had follicular conjunctivitis, punctate epithelial keratopathy with subepithelial infiltrates and membranes bilaterally, with an everted upper lid tarsus, and swollen and ulcerated palpebral conjunctiva. She received topical and oral prednisone to quickly reduce the inflammation, as well as moxifloxacin drops and lubrication. When the swelling subsided, the tarsus adopted a kinked and everted configuration, and was managed successfully with reversion, pressure patching, shielding and close follow-up. CONCLUSIONS AND IMPORTAMCE: This is the first reported case of upper lid eversion secondary to EKC, likely due to sudden marked inflammation and edema of the posterior lamella caused by the adenoviral infection. This case was successfully managed with conservative therapy.

Guidelines for vismodegib in the management of periocular basal cell carcinoma.

OBJECTIVE: The management of advanced basal cell carcinoma (BCC) in the periocular region remains a clinical challenge. Vismodegib (ErivedgeTM) has been approved in 2013 by Health Canada for adult patients with "histologically confirmed metastatic BCC or locally advanced BCC inappropriate for surgery or radiation." An expert consensus was sought to create a standardised approach in the use of this novel treatment. METHODS: Fourteen practicing oculoplastic surgeons across Canada were involved in formulating and reviewing guidelines until consensus was reached. A consultancy meeting was followed by further ratification of guidelines over email. Two voting surveys were performed of the group to objectively assess agreement over each statement within the guidelines. Ratification continued until at least two-thirds of the group agreed on every guideline statement. RESULTS: The guidelines summarize 21 statements in a major and minor criteria format. A multidisciplinary team review is suggested for each patient with the involvement of recommended specialists. The internal survey revealed 100% agreement over 9 statements, 91.7% agreement over 8 statements, 83.3% agreement over 4 statements, and 2 statements had 66.7% and 58.7% agreement each. All statements with less than 91.7% agreement were surveyed again, and they were kept, modified, or removed on the basis of a consensus of over 66.7%. CONCLUSIONS: These guidelines serve to act as a framework for physicians considering vismodegib for the medical management of patients with advanced or metastatic periocular BCC. Future applications, including neoadjuvant uses of the drug, may become apparent through further research.

Novel application of anterior segment optical coherence tomography for periocular imaging.

OBJECTIVE: This study aims to assess the use of optical coherence tomography (OCT) imaging for periocular skin lesions and to determine which characteristic features of these images can be correlated to histopathology. DESIGN: This is an ongoing prospective study with Research Ethics Board approval. PARTICIPANTS: Fifty patients over 18 years old with lesions clinically suspicious of nonmelanoma skin cancer on the periocular region were included in this study. METHODS: After consent was obtained, clinical photographs and dermatoscopic images were obtained (DermLite II Hybrid M) from the lesion and its contralateral side. Subsequently, the patient was subjected to OCT imaging using the anterior segment module of a spectral domain OCT (Optovue Avanti) and images of the contralateral skin were also obtained. Surgical excision of the lesion was performed and sent for histopathological examination as per routine treatment. OCT images were then correlated to their matching digitalized histopathology section (Philips Ultra Fast Scanner 1.6 RA). RESULTS: Based on the OCT images acquired from 50 patients, 8 predominant architectural features have been correlated to histopathology: hyperkeratosis, acanthosis, loss of dermal-epidermal junction delineation, hyporeflective tumour nests, cystic structures, "bunch of grapes" nodules, hyperreflective nests, and ulcerations. Results observed from 45 malignant lesions (basal cell carcinoma, squamous cell carcinoma, and sebaceous gland carcinoma) suggest that groups of features and their layout within the same OCT image may be associated to specific tumour characteristics. CONCLUSIONS: Current data suggest that anterior-segment OCT imaging is a noninvasive imaging modality for periocular lesions and may be a valuable tool to help differentiate between some tumour types before a biopsy is performed.

Transcranial Blade Injuries and Principles of Their Safe Extraction.

Retained cranial blade injuries are uncommon events lacking standardized recommendations for appropriate surgical extraction. The authors present a case of a 30-year-old male who sustained a penetrating blade injury of the left orbit with intracranial extension through the skull base into the temporal lobe. The patient walked to the emergency room and remained alert. Clinically, the patient had only a small laceration of the left upper eyelid with no gross visual impairment.The radiological investigation confirmed the presence of a knife blade in the orbit. Intraoperative management included an intracranial approach and an extracranial craniofacial dissection for blade visualization and soft tissue protection, globe protection and to avoid any major bleeding. A thorough review of the penetrating cranial injuries literature is presented and a trauma management algorithm is offered for the care of similar injuries.

An unusual orbital tumor in an adult: Granuloma annulare.

PURPOSE: Granuloma annulare (GA) is a rare clinical entity that does not classically arise from the peri-orbital area in adults. The purpose of this case report is to present a 69-year-old female with GA of the orbit. As well, the pathological and immunohistochemical features of these tumors will be discussed. OBSERVATIONS: One case of GA of the orbit was identified from a tertiary ophthalmology referral centre. Clinical and histopathological features of the case were reviewed. Other cases of GA were also retrieved from the literature and addressed in this report. CONCLUSION AND IMPORTANCE: Granuloma annulare is a rare orbital lesion in adults. It is known to typically arise on the hands and feet of children. This lesion must be distinguished from necrobiotic xanthogranuloma (NXG), which is a progressive peri-orbital dermatosis seen in middle age men and women. GA is thought to be a benign, often self-resolving condition, whereas NXG tends to be linked to other systemic conditions and may have a poorer prognosis.Differentiating this rare orbital tumor from necrobitotic xanthogranuloma (NXG) is essential, as both a systemic work-up and follow-up must be appropriately arranged. A comprehensive description of pathognomonic microscopic features of GA and NXG is reviewed to achieve the correct diagnosis.

Cavernous sinus syndrome associated with metastatic colorectal cancer and perineural spread along the trigeminal nerve.

PURPOSE: We report the case of a patient with cavernous sinus syndrome associated with biopsy-confirmed metastasis from colorectal cancer. OBSERVATIONS: A patient known for laryngeal carcinoma and metastatic colorectal carcinoma presented with symptoms of left trigeminal neuralgia and progressive, near-complete ophthalmoplegia. Magnetic resonance imaging (MRI) revealed a mass in the left cavernous sinus, extending into Meckel's cave with perineural spread along the mandibular branch of the left trigeminal nerve. A transsphenoidal biopsy was performed and demonstrated metastatic colon adenocarcinoma. We review the existing literature on colorectal cancer associated cavernous sinus syndrome. CONCLUSIONS AND IMPORTANCE: Cavernous sinus metastasis from colorectal cancer is exceedingly rare. We report the second case of this entity with histopathologic confirmation, and the first case with concurrent perineural spread involving the trigeminal nerve. Cavernous sinus metastasis may represent a poor prognostic factor in colorectal cancer.