Pediatric-Type Follicular Lymphoma of the Conjunctiva in Two Adolescents.

The authors present two cases of conjunctival pediatric-type follicular lymphoma. A 14-year-old Black boy and 14-year-old Black girl were each referred for evaluation of a painless salmon-colored conjunctival lesion. Both patients underwent excisional biopsy. Histopathology demonstrated follicles with germinal centers composed of atypical B-cells with high Ki67 proliferation index, positive staining for CD20, CD10, and BCL6, and negative for BCL2. This series contributes two cases to the limited literature and presents the first case reported in a female. [J Pediatr Ophthalmol Strabismus. 2024;61(4):e33-e38.].

Intraoperative Image Guidance in Orbital and Lacrimal Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the efficacy and safety of the use of intraoperative image guidance (IIG) in orbital and lacrimal surgery. METHODS: A literature search of the PubMed database was last conducted in November 2023 for English-language original research that assessed the use of any image guidance system in orbital and lacrimal surgery that included at least 5 patients. The search identified 524 articles; 94 were selected for full-text analysis by the panel. A total of 32 studies met inclusion criteria. The panel methodologist assigned a level II rating to 2 studies and a level III rating to 30 studies. No study met the criteria for level I evidence. RESULTS: Procedures reported on were as follows: fracture repair (n = 14), neoplasm and infiltrate biopsy or excision (n = 6), orbital decompression for Graves ophthalmopathy (n = 3), dacryocystorhinostomy (n = 1), and mixed etiology and procedures (n = 8). Four studies used more than one IIG system. One study that met level II evidence criteria compared the outcomes of orbital fracture repair with IIG (n = 29) and without IIG (n = 29). Borderline better outcomes were reported in the IIG group: 2% versus 10% with diplopia (P = 0.039) and 3% versus 10% with enophthalmos (P = 0.065). The other level II study compared the repair of fractures with navigation (n = 20) and without (n = 20). The group in which navigation was used had a measured mean volume reduction of 3.82 cm3 compared with 3.33 cm3 (P = 0.02), and there was a greater measured reduction in enophthalmos in the navigation group of 0.72 mm (P = 0.001). Although the remaining 30 assessed articles failed to meet level II criteria, all alleged a benefit from IIG. No complications were reported. CONCLUSIONS: A small number of comparative studies suggest that there are improved outcomes when IIG is used in orbital fracture repair, but each study suffers from various limitations. No high-quality comparative studies exist for the management of lacrimal surgery, neoplastic disease, or decompression. Complications attributable to the use of IIG have not been identified, and IIG has not been analyzed for cost savings. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery.

PURPOSE: Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms. METHODS: Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes. RESULTS: Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups. CONCLUSIONS: One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

Orofacial manifestations of child maltreatment: A review.

The recognition and reporting of child abuse and neglect continues to be a challenge in the healthcare setting. All healthcare providers, including dentists, should be aware of the high prevalence of orofacial injuries and conditions that are concerning for abuse and neglect. Sentinel injuries may appear trivial and do not require medical attention, but are unlikely caused by accidental mechanisms and, if not properly identified, often precede more severe abusive injuries. Concerning orofacial findings can manifest as bruising, eye injuries, intraoral injuries, pharyngeal perforations, facial bone fractures, and sexually transmitted infections. Abusive caregivers are likely to give inadequate explanations or no history at all to explain concerning findings. Medical providers' failure to make mandated reports about their concerns to the appropriate agencies can have significant long-term impacts on the physical and psychological well-being of children.

Management of traumatic globe subluxation with optic nerve and extraocular muscle transection.

A care algorithm for partial globe subluxation cases with optic nerve and at least one extraocular muscle (EOM) transection is presented after a literature review was performed using key term variations of globe, ocular, subluxation, optic nerve evulsion or transection, and trauma. Partial globe subluxation cases with transection of the optic nerve and at least 1 EOM were included. Exclusion criteria included globe rupture, complete enucleation defined by a globe without at least 1 EOM attachment, or unclear details confirming optic nerve transection. Including the patient presented herein, a total of 24 patients with 26 eyes were analyzed. About 73.08% of cases underwent initial repositioning (n = 19), with 11.54% of those requiring secondary enucleation or evisceration (n = 3). Of the secondarily managed cases, 2 of the 3 cases listed pain (n = 2) and inadequate cosmesis (n = 1) as rationale. We found that 26.92% of cases underwent initial enucleation (n = 7), citing lack of visual potential and limiting later complications. Most cases favored repositioning, which was typically sustainable. Initial repositioning can improve cosmetic outcome and psychological impact. Given the low risk of later management, cases of traumatic partial subluxation with EOM and optic nerve transections should attempt initial repositioning.

Giardia and Cryptosporidium in resident wildlife species in Arctic Alaska.

Giardia and Cryptosporidium are zoonotic protozoan parasites that can infect humans and other taxa, including wildlife, often causing gastrointestinal illness. Both have been identified as One Health priorities in the Arctic, where climate change is expected to influence the distribution of many wildlife and zoonotic diseases, but little is known about their prevalence in local wildlife. To help fill information gaps, we collected fecal samples from four wildlife species that occur seasonally on the northern Alaska coastline or in nearshore marine waters-Arctic fox (Vulpes lagopus), polar bear (Ursus maritimus), Pacific walrus (Odobenus rosmarus divergens), and caribou (Rangifer tarandus)-and used immunofluorescence assays to screen for Giardia cysts and Cryptosporidium oocysts. We detected Giardia cysts in 18.3% and Cryptosporidium oocysts in 16.5% of Arctic foxes (n = 109), suggesting that foxes may be potentially important hosts in this region. We also detected Giardia cysts in a single polar bear (12.5%; n = 8), which to our knowledge represents the first such report for this species. Neither parasite was detected in walruses or caribou.

Perceptions of Parental Leave Among Ophthalmologists.

Importance: Benchmarking attitudes surrounding parental leave among posttraining North American ophthalmologists may reveal possible areas for intervention. Objective: To evaluate perceptions of current parental leave policy and culture among posttraining North American ophthalmologists. Design, Setting, and Participants: This nonvalidated survey used a 19-item online questionnaire. A convenience sample of 186 self-identified North American-based ophthalmologists who had completed training was obtained using listservs, residency program coordinators, and social media. Data collection occurred from May to July 2022. Main Outcomes and Measures: Descriptive analysis demonstrated response frequencies. Pearson χ2 comparison of means was performed for categorical variables. Two-tailed t tests were performed for continuous variables. Results: Among the 186 surveys completed, 105 respondents (56.5%) identified as female, 76 (40.9%) worked in academia, 133 (71.5%) were 1 to 20 years out of training, and 156 (83.9%) had children. Attitudes toward stop-the-clock policies, or delays in tenure/promotion/partnership review when taking leave, were mixed. Of 171 respondents, 78 (45.6%) thought that stop-the-clock policies should be optional, 39 (22.8%) thought that they should be required, and 31 (18.1%) thought that they should be removed. Of 76 academicians responding, 56 (73.7%) and 49 (64.5%) were unaware if their institution had a stop-the-clock policy for tenure review or promotion review, respectively. Male and female respondents differed in feeling comfortable with taking leave (36 of 66 [54.5%] vs 67 of 90 [74.4%], respectively; P = .04), as well as in their ratings of stress about peer perception on a scale of 0 to 10 (3.70 vs 4.81, respectively; P = .05). Private practitioners and academicians differed in confirmation of leave options for both parents (52 of 101 [51.5%] vs 49 of 69 [71.0%], respectively; P = .02) and ratings of financial stress (7.10 vs 5.43, respectively; P = .004) and research considerations (1.60 vs 3.85, respectively; P < .001). Conclusions and Relevance: Results of this survey study support the hypothesis that demographic factors affect attitudes toward parental leave among posttraining ophthalmologists; policies could be better publicized. Feelings regarding policies and leave were mixed. These findings should be viewed as hypothesis generating because the survey was not validated and the associations provided could be due to confounding factors.

Association of Absent or Trace Fluid in the Maxillary Sinus and Inferior Rectus Muscle Entrapment in Patients With Orbital Floor Fracture.

Inferior rectus (IR) entrapment requires urgent surgical intervention in patients with traumatic orbital floor fracture (OFF). We evaluated 47 patients who underwent CT showing acute OFF, 10 of whom had surgically confirmed entrapment. Absent or trace dependent fluid in the ipsilateral maxillary sinus had sensitivity of 40% and specificity of 95% for entrapment. In comparison, sensitivity and specificity were 80% and 78% for IR thickening and 70% and 59% for sinus herniation of orbital contents.

Orbital tuberculosis: a case report and update on the role of imaging in treatment.

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.

Efficacy of Preoperative Risk Stratification on Resident Phacoemulsification Surgeries.

Purpose: 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 (ß = 0.13, p < 0.0001) and POM1 (ß = 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.

The Arched Rainbow Brow in Thyroid Eye Disease.

PURPOSE: To morphologically describe and mathematically quantify a novel clinical feature of thyroid eye disease (TED). METHODS: A retrospective study was conducted of TED patients and age-sex-matched normal controls. The arched Rainbow Brow appearance in TED patients was determined by unanimous agreement of 3 oculoplastic surgeons. Eyebrow curvature was assessed by plotting 15 points along the eyebrow in ImageJ. The fourth-degree polynomial ( y = ax4 + bx3 + cx2 + dx + e ) was fitted to each eyebrow. RESULTS: Two hundred seventy-one eyes were analyzed (200 TED and 71 age-sex-matched normal controls). A Rainbow Brow was identified in 42% of TED patients. A unilateral Rainbow Brow was seen in 15% of patients. The fourth-degree polynomial coefficients yielded significant differences between Rainbow Brow patients and age-sex-matched normal controls for the coefficients a, b, c , and d . Similar analysis of TED patients with and without a Rainbow Brow showed differences in coefficients a and b . Age >50 years ( p = 0.009) and the presence of brow fat expansion ( p < 0.001) were associated with the presence of a Rainbow Brow. Proptosis >24 mm showed a trend toward association with the presence of a Rainbow Brow ( p = 0.057). When considering the contribution of these features in a multivariable analysis, only brow fat expansion was a significant contributing factor ( p = 0.009). CONCLUSIONS: The Rainbow Brow is a distinct entity in TED and is likely consequent to brow fat pad expansion. Patients with a Rainbow Brow have different eyebrow curvature as compared to both normal age-sex-matched controls and TED patients without a Rainbow Brow.

COVID-19 and micronutrient deficiency symptoms - is there some overlap?

BACKGROUND & AIMS: COVID-19 is highly inflammatory and when it affects the elderly who have multiple comorbidities, the risk of malnutrition is high. The aim of this review is to highlight the evidence for COVID-19 and risk for malnutrition (macro- and micro-nutrient deficiency) sharing two case reports. METHODS: We report two cases of patients with COVID-19. The first case includes a 75-year-old male with increasing confusion, delirium and malnutrition once he had clinically resolved from his COVID-19 diagnosis. The patient had a number of comorbidities and was treated with diuretics before and after his hospital admission. He was treated with intravenous thiamine and enteral nutrition. The second case includes a 77-year-old male with diabetes who presented with suspected vitamin C deficiency likely due to chronic aspirin use nearly two weeks prior to being diagnosed with pneumonia and COVID-19. The patient recovered from his COVID-19 diagnosis but continued to decline nutritionally and was readmitted sixty days later with failure to thrive. RESULTS: The first case had significant improvements in his appetite and neurological conditions following thiamine infusion and enteral nutrition and was discharged to home after a 19-day hospital stay. The second case presented with a vitamin C deficiency before testing positive for COVID-19. Although he did recover from COVID-19 he struggled to meet nutritional needs post-COVID and passed away 60 days after his COVID-19 diagnosis with pneumonia and failure to thrive. CONCLUSION: Elderly patients with chronic diseases who use nutrient depleting medications are particularly high risk for micronutrient deficiency when they also experience the inflammatory insult of COVID-19. Patients who continue to have poor nutrition intake even after they appear to be clinically resolved from the virus should be closely monitored.

Mathematical Modeling of Eyebrow Curvature.

The aim of the study is to describe a mathematical model for analyzing eyebrow curvature that can be applied broadly to curvilinear facial features. A total of 100 digital images (50 men, 50 women) were obtained from standardized headshots of medical professionals. Images were analyzed in ImageJ by plotting either 8 or 15 points along the inferior-most row of contiguous brow cilia. A best-fit curve was automatically fit to these points in Microsoft Excel. The second derivative of the second-degree polynomial and a fourth-degree polynomial were used to evaluate brow curvature. Both techniques were subsequently compared with each other. A second-degree polynomial and fourth-degree polynomial were fit to all eyebrows. Plotting 15 points yielded greater goodness-of-fit than plotting 8 points along the inferior brow and allowed for more sensitive measurement of curvature across all images. A fourth-degree polynomial function provided a closer fit to the eyebrow than a second-degree polynomial function. This method provides a simple and reliable tool for quantitative analysis of eyebrow curvature from images. Fifteen-point plots and a fourth-degree polynomial curve provide a greater goodness-of-fit. The authors believe the described technique can be applied to other curvilinear facial features and will facilitate the analysis of standardized images.

Exploring Potential Schedule-Related and Gender Biases in Ophthalmology Residency Interview Scores.

Purpose Prior studies have revealed grading discrepancies in evaluation of personal statements and letters of recommendation based on candidate's race and gender. Fatigue and the end-of-day phenomenon can negatively impact task performance but have not been studied in the residency selection process. Our primary objective is to determine whether factors related to interview time and day as well as candidate's and interviewer's gender have a significant effect on residency interview scores. Methods Seven years of ophthalmology residency candidate evaluation scores from 2013 to 2019 were collected at a single academic institution, standardized by interviewer into relative percentiles (0-100 point grading scale), and grouped into the following categories for comparisons: different interview days (Day 1 vs. Day 2), morning versus afternoon (AM vs. PM), interview session (Day 1 AM/PM vs. Day 2 AM/PM), before and after breaks (morning break, lunch break, and afternoon break), residency candidate's gender, and interviewer's gender. Results Candidates in the morning sessions were found to have higher scores than afternoon sessions (52.75 vs. 49.28, p < 0.001). Interview scores in the early morning, late morning, and early afternoon were higher than late afternoon scores (54.47, 53.01, 52.15 vs. 46.74, p < 0.001). Across all interview years, there were no differences in scores received before and after morning breaks (51.71 vs. 52.83, p = 0.49), lunch breaks (53.01 vs. 52.15, p = 0.58), and afternoon breaks (50.35 vs. 48.30, p = 0.21). No differences were found in scores received by female versus male candidates (51.55 vs. 50.49, p = 0.21) or scores given by female versus male interviewers (51.31 vs. 50.84, p = 0.58). Conclusion Afternoon residency candidate interview scores, especially late afternoon, were significantly lower than morning scores, suggesting the need to further study the effects of interviewer's fatigue in the residency interview process. The interview day, presence of break times, candidate's gender, and interviewer's gender had no significant effects on interview score.

Ophthalmology Medical Student Directors, Associate Residency Program Directors, and Program Directors: A Benchmarking Study of Work and Life Metrics.

Introduction During a time of increased interest in physician well-being, this study benchmarks current work life, home life, and burnout scores for ophthalmology medical student directors (MSD), associate program directors (APD), and program directors (PD). Methods An anonymous cross-sectional survey was disseminated through the Association of University Professors of Ophthalmology (AUPO) listserve, with queries regarding leadership positions, work time allotment, extracurricular activities, family life, and burnout. Answers were analyzed descriptively through Fisher's exact test, Kruskal-Wallis test, and Poisson regression models. Results Nineteen percent of listed MSD, 15% of APD, and 29% of PD queried responded to the survey. MSD, APD, and PD are statistically similar in terms of work and home life, with the exception of time spent performing administrative tasks for the position. PD spend more time on administrative tasks, and are paid more. All groups score positively on burnout surveys. Conclusion This benchmarking survey demonstrates that MSD, APD, and PD are intensively involved in both their work and home lives, with a seemingly high correlation of sense of worth both personally and in their careers.

Teprotumumab and Hearing Loss: Case Series and Proposal for Audiologic Monitoring.

PURPOSE: To present a protocol for audiologic monitoring in the setting of teprotumumab treatment of thyroid eye disease, motivated by 4 cases of significant hearing loss, and review the relevant literature. METHODS: Cases of hearing loss in the setting of teprotumumab were retrospectively elicited as part of a multi-institutional focus group, including oculoplastic surgeons, a neurotologist and an endocrinologist. A literature review was performed. RESULTS: An aggregate of 4 cases of teprotumumab-associated hearing loss documented by formal audiologic testing were identified among 3 clinicians who had treated 28 patients. CONCLUSIONS: Teprotumumab may cause a spectrum of potentially irreversible hearing loss ranging from mild to severe, likely resulting from the inhibition of the insulin-like growth factor-1 and the insulin-like growth factor-1 receptor pathway. Due to the novelty of teprotumumab and the lack of a comprehensive understanding of its effect on hearing, the authors endorse prospective investigations of hearing loss in the setting of teprotumumab treatment. Until the results of such studies are available, the authors think it prudent to adopt a surveillance protocol to include an audiogram and tympanometry before, during and after infusion, and when prompted by new symptoms of hearing dysfunction.

OPTIMIZATION OF FECAL FLOTATIONS IN MARINE PARASITOLOGY AND DETERMINATION OF THE SPECIFIC GRAVITY OF HELMINTH EGGS IN PINNIPEDS.

Recent studies have sought to optimize the fecal flotation procedure to improve the detection of helminth eggs in terrestrial domestic species. It is unclear, however, whether these efforts in optimization are applicable to parasite species of marine environments, and verification of veterinary diagnostic procedures is clinically important. It was hypothesized that the eggs belonging to the parasites of pinnipeds would have different specific gravities (SpG) than those belonging to terrestrial hosts. Fecal samples were collected from each of 25 stranded pinnipeds representing three species (Zalophus californianus, Phoca vitulina, Mirounga angustirostris), and modified double centrifugal flotations were performed on 1-g samples. Among the 22 California sea lions sampled, trematode, ascarid, and cestode eggs were detected in 17/22 (77%), 10/22 (45%), and 4/22 (18%) individuals, respectively. Sugar-gradient modified centrifugation flotations were then conducted on a subset of 10 samples from California sea lions to evaluate the distribution of eggs in fractions representing varying SpG. Higher numbers of ascarid eggs were found in fractions representing a lower SpG (1.00-1.15), whereas trematode eggs belonging to the genus Zalophotrema were found in significantly higher numbers in the fraction representing 1.25 (P < 0.05). In conclusion, the SpG of trematode, ascarid, and cestode eggs from pinnipeds appears to be similar to those from terrestrial hosts, but numerous factors may affect their ability to be detected using traditional diagnostic approaches. Further exploration into the nature of the variability noted may lead to improved diagnostics in marine parasitology.