Lacrimal gland sinus generated by a retained cilium: case report and literature review.

Lacrimal gland stone(s) (LGSs) are rare and usually asymptomatic. LGSs should be distinguished from dacryoliths, as the former arise in the lacrimal gland. The aetiology of LGSs in many cases is likely related to a reaction to a hair within the palpebral lobe of lacrimal gland. Eye rubbing may contribute to the migration of the hair into the lacrimal gland. This case report describes the rare occurrence of an LGS with a central hair shaft (cilium) and associated sinus formation in a 39-year-old male presenting with persistent redness of, and discharge from the right eye for 4 weeks. Examination revealed a sinus opening onto the inferonasal surface of the palpebral lobe of the right lacrimal gland. The patient was treated with surgical excision of the sinus, with rapid and complete resolution of his symptoms.

Methicillin-resistant Staphylococcus aureus-associated orbital cellulitis: a case series.

PURPOSE: In recent years, methicillin-resistant Staphylococcus aureus (MRSA) orbital cellulitis (OC) has drawn increasing clinical and public health concern. We present a case series of MRSA OC encountered at four Australian tertiary institutions. METHODS: A multi-centre retrospective case series investigating MRSA OC in Australia from 2013 to 2022. Patients of all ages were included. RESULTS: Nine cases of culture-positive non-multi-resistant MRSA (nmMRSA) OC were identified at four tertiary institutions across Australia (7 male, 2 female). Mean age was 17.1 ± 16.7 years (range 13-days to 53-years), of which one was 13 days old, and all were immunocompetent. Eight (88.9%) patients had paranasal sinus disease, and seven (77.8%) had a subperiosteal abscess. Four (44.4%) had intracranial extension, including one (11.1%) case which was also complicated by superior sagittal sinus thrombosis. Empirical antibiotics, such as intravenous (IV) cefotaxime alone or IV ceftriaxone and flucloxacillin, were commenced. Following identification of nmMRSA, targeted therapy consisting of vancomycin and/or clindamycin was added. Nine (100%) patients underwent surgical intervention. Average hospital admission was 13.7 ± 6.9 days (range 3-25 days), with two patients requiring intensive care unit (ICU) admission due to complications related to their orbital infection. All patients had favourable prognosis, with preserved visual acuity and extraocular movements, following an average follow-up period of 4.6 months (range 2-9 months). CONCLUSION: NMMRSA OC can follow an aggressive clinical course causing severe orbital and intracranial complications across a wide demographic. However, early recognition, initiation of targeted antibiotics and surgical intervention when required can effectively manage these complications and achieve favourable visual outcomes.

Efficacy of patient-sided breath shields for slit-lamp examination.

OBJECTIVE: To evaluate the efficacy of patient-sided breath shields in preventing oronasal droplet transmission during slit-lamp examination. DESIGN: Experimental study testing the efficacy of patient-sided breath shields on a slit lamp. METHODS: Two commercially available patient-sided breath shields and a 3-dimensional (3D)-printed shield designed by the authors were attached to a slit-lamp chin rest for testing. Each shield was exposed to 3 standardized sprays of coloured dye from a spray gun with its nozzle adjusted to simulate the angular dispersion of a human sneeze. Any overspray not blocked by the shields was recorded and compared with spray with no shield (control). Image-processing software was used to ascertain the surface area of overspray not blocked by the tested shield compared with the control of no shield. RESULTS: With typical use, both commercially available patient-sided shields and the 3D-printed shield blocked 100% of forward-travelling measurable droplets from a simulated sneeze spray. Even when set to the furthest distance setting to simulate the worst-case scenario, shield 1 and the 3D-printed shield blocked 99.96% and 99.65% of overspray, respectively. However, slow-motion footage did reveal that a considerable amount of spray rebounded off the shields and extended peripherally past its borders. CONCLUSIONS: With typical use, all tested shields prevented 100% of oronasal transmission. To encourage accessibility, the authors offer a free 3D model and instructions for creating the tested patient-sided breath shield. Patient-sided shields should be combined with other infection-control measures to minimize transmission.

Biogeography of the human ocular microbiota.

PURPOSE: The human eye is composed of numerous microhabitats. The aim of this study was to understand the communality and differences in the microbiomes of various regions of the eye. METHODS: Four ocular sites from different subject groups were assessed including the eyelid margin tissue from patients with lid abnormalities (n = 20), fornix and limbus conjunctival tissue from patients with pterygia (n = 23), ocular (conjunctival) surface swabs (n = 45) and facial skin swabs (n = 16). Microbial communities were analysed by extracting total DNA from samples and sequencing the 16S ribosomal(r)RNA gene using the Illumina MiSeq platform. Sequences were quality filtered, clustered into unique sequences (zOTUs) using the UNOISE pipeline in USEARCH and taxonomically classified using SILVA. RESULTS: A difference in bacterial richness and diversity was found between sites (P < 0.001) and for age (P < 0.035) but not for sex (P > 0.05). There was a difference in bacterial community structure and composition between sites (P < 0.001). Bacterial distribution could be broadly classified into three groups - zOTUs resident on the skin and lid margin but with low abundances at other sites (Corynebacterium, Staphylococcus), zOTUs found mainly on the ocular surface (Acinetobacter, Aeribacillus) and zOTUs mostly present in the conjunctiva and lid margin (Pseudomonas). CONCLUSION: The microhabitats of the human eye (ocular surface, conjunctiva, lid margin and skin) have a distinct bacterial biogeography with some bacteria shared between multiple regions while other bacteria occupy a more confined niche.

Endoscopic resection of a huge orbital ethmoidal mucocele masquerading as dacryocystocele.

Paranasal mucoceles are cystic masses lined with epithelium thought to result from chronic obstruction of an impaired sinus ostia. If sufficiency large, they can cause ophthalmological sequelae including diplopia, visual acuity, globe displacement as well as the rhinological symptoms of facial pain and headache. We present the case of a 57-year-old man who presented with a 1-year history of epiphora and right globe prominence with associated diplopia. Imaging demonstrated a mass located within the medial aspect of the orbit, closely associated to the lamina papyracea and nasolacrimal duct consistent with a dacryocystocele. An alternate diagnosis of an ethmoidal mucocele was considered preoperatively following rhinologist opinion. Complete endoscopic resection of the cyst was undertaken. Histopathology confirmed diagnosis of an ethmoidal mucocele. Our report highlights mucocele should be considered in patients with chronic symptoms secondary to a mass situated in the nasolacrimal duct without radiological orbital bone destruction.

Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases.

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006-2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.

Enhanced Fasanella-Servat Procedure for the Graded Repair of Blepharoptosis.

PURPOSE: To describe in detail a technique for a modified Fasanella-Servat procedure that provides a simplified method for graded Mueller muscle excision with minimal and controlled tarsal excision. METHODS: A retrospective study of 71 patients (102 eyelids) who underwent the modified Fasanella-Servat procedure is reported. Measurements include the preoperative, post-phenylephrine, and postoperative margin-to-reflex distance-1, and postoperative upper eyelid height symmetry as determined by the absolute difference between right- and left-sided margin-to-reflex distance-1. Postoperative complications are reported. RESULTS: The average increase in margin-to-reflex distance-1 was 2.4 mm with an average postoperative upper eyelid height symmetry of 0.4 mm. Postoperative asymmetry was 1.5 mm or less in 68 patients, a success rate of 96%. Four patients (6%) exhibited overcorrection, 2 of which required additional surgery. No lagophthalmos or notable eyelid contour abnormalities were seen. CONCLUSIONS: The modified Fasanella-Servat technique offers a simple method to isolate and resect Mueller muscle and a minimal segment of tarsus in a quantitative fashion, allowing for a graded repair of blepharoptosis and thereby decreasing the risk of postoperative overcorrection, lagophthalmos, and eyelid contour asymmetry whilst preserving the bulk of tarsus.

Bisphosphonate-Induced Orbital Inflammation: A Case Series and Review.

INTRODUCTION: To present a series of patients with bisphosphonate induced orbital inflammation, and to review the clinical presentation, radiological features, treatment options and outcomes. METHODS: We present a multicentre, retrospective case series review of patients with a clinico-radiological diagnosis of bisphosphonate induced orbital inflammation and review all the reported cases of this complication in the literature. RESULTS: Four new patients with bisphosphonate induced orbital inflammation were added to the 25 cases in the literature. Intravenous zoledronate was the commonest precipitant (22/29, 75.9%) and inflammation occurred 1-28 (mean 3) days post-infusion. Orbital imaging identified orbital inflammation in 22/29 cases and extra-ocular muscle enlargement in 8/29. Five patients presented with reduced vision of which one - with anterior ischaemic optic neuropathy - did not resolve. The vision resolved in all except one patient, with most requiring steroid treatment. CONCLUSIONS: Bisphosphonates have a pro-inflammatory effect, which can precipitate orbital inflammation. This rare, but potentially serious complication of bisphosphonate treatment should be considered by clinicians using bisphosphonate treatment and by ophthalmologists seeing patients with orbital inflammatory disease.

Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy.

IMPORTANCE: Approximately 5% to 10% of patients continue to experience persistent epiphora following an anatomically successful dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction or stenosis. OBJECTIVE: To investigate the management and success rate of so-called "functional failure" of DCR for nasolacrimal duct obstruction by experienced lacrimal surgeons. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective case series including 5 Australian and New Zealand centers. Participants included 61 patients (71% women [n = 46]; mean age, 66 years) with functional epiphora after 65 DCRs (69% transnasal) who were recruited over a mean of 7.6 years. Inclusion criteria included confirmed preoperative diagnosis of nasolacrimal duct obstruction or stenosis, age greater than 18 years, recurrent or persistent epiphora after DCR, an anatomically successful DCR, and follow-up longer than 6 months. Exclusion criteria included evidence of lacrimal hypersecretion, eyelid malposition, and punctal or canalicular abnormalities. MAIN OUTCOMES AND MEASURES: The number, type, timing, and success of all clinical interventions performed for the management of functional epiphora after DCR. RESULTS: Epiphora recurred a mean of 8.9 months after primary DCR; 89% of the cases (n = 58) had evidence of a patent ostium and 100% were patent on lacrimal irrigation. Intubation with a lacrimal stent was performed in 82% of the cases at the time of surgery, and all stents were removed a mean of 8 weeks postoperatively. Epiphora was reported immediately following DCR in 32% (n = 21) of the cases and within 6 weeks after removal of the stent in 31% (n = 20); late recurrence (>12 months after DCR) developed in 37% (n = 24) of the cases. In a total of 15% of the cases, participants declined any treatment following DCR. The remainder underwent a mean of 1.3 interventions (range, 1-3) during a mean of 23 to 41 months after primary DCR, following which 72% (n = 47) of the cases had a successful outcome; 12% (n = 8) failed to achieve improvement, and the patients declined further intervention. Thirty-nine interventions (60%) were intubation with a silicone stent with a 54% success rate. Almost half of those undergoing intubation elected to keep the stent permanently; 34% (n = 22) had an eyelid-tightening procedure with 50% success, and 15% (n = 10) required a Lester-Jones tube despite patent canaliculi, with a success rate of 90%. CONCLUSIONS AND RELEVANCE: Functional epiphora after DCR among patients with preoperative nasolacrimal duct obstruction or stenosis appears to be uncommon. Benefits can be achieved in most patients with intubation (transient or permanent) or eyelid tightening. More than one procedure is often required.

Successful "medical" orbital decompression with adjunctive rituximab for severe visual loss in IgG4-related orbital inflammatory disease with orbital myositis.

IgG4-related disease (IgG4-RD) is an inflammatory condition of unknown etiology that can cause tumefactive lesions in a number of tissues and organs, including the orbit and ocular adnexa. Diagnostic criteria for IgG4-RD, including pathology and clinical features and pathology, have been recently proposed. This study presents the first case of unilateral acute visual loss secondary to IgG4-related orbital inflammatory disease with orbital myositis that was complicated by severe compressive optic neuropathy. After initial treatment with pulsed intravenous methylprednisolone, followed by rituximab and radiotherapy, there was a marked improvement in orbital inflammation and clinical and radiological improvement in the compressive optic neuropathy. After 9 months of follow up, the orbital inflammatory disease remained in remission.

Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy.

BACKGROUND: Dacryocystorhinostomy (DCR) is commonly performed for epiphora, dacryocystitis and during tumor surgery. External (EXT-DCR) and endoscopic DCR (END-DCR) are both practiced. END-DCR was initially performed with laser (EL-DCR) but has shifted to careful bone removal with mechanical drills (EM-DCR). High level evidence from comparative cohorts was sought to compare outcomes. METHOD: Medline (1966 - January 28th, 2013) and Embase (1980 - January 28(th), 2013) were searched for comparative studies (RCT/cohorts) of END-DCR to EXT-DCR for acquired nasolacrimal duct (NLD) obstruction. Primary outcome was DCR success, defined as resolution of symptoms and/or patent NLD on irrigation or dacroscintography. Secondary outcomes were scarring, infection and post-operative bleeding. Meta-analysis was performed with the Mantel-Haenszel Method and presented as Risk Ratios (RR) with Confidence Intervals (CI). RESULTS: The search identified 3582 studies and 355 were reviewed after screening. Full text review yielded 19 studies (4 RCTs and 15 cohorts). Overall, EXT-DCR had slightly better success rates than END-DCR (RR 0.96, CI 0.93-1.00). However, EM-DCR outcomes were comparable to EXT-DCR (RR 1.02, CI 0.98-1.06), whereas EL-DCR had poorer outcomes (RR 0.85, CI 0.79-0.91) when compared separately. The RR for scarring, bleeding and infection with END-DCR versus EXT-DCR was 0.07 (CI 0.02-0.22), 0.72 (CI 0.46-1.13) and 0.24 (CI 0.11- 0.54), respectively. The rates of reported revision surgery were similar. CONCLUSION: DCR is a procedure with high success rates. Endoscopic procedures differ greatly by technique with EM-DCR offering comparable results to EXT-DCR, without the risk of cosmetically unacceptable scars.

Orbit and orbital apex.

Pathology affecting the orbit and orbital apex is diverse and heterogeneous. Many of the differential pathologies require management in a multidisciplinary team involving both otolaryngology and ophthalmology. This article discusses the differential pathologies. Emphasis has been placed on Graves orbitopathy, traumatic optic neuropathy, and the indications for decompression in each. The differential diagnosis for a lesion within the orbit and orbital apex is diverse. The presentation, investigation, and appropriate management of these conditions is discussed with emphasis on traumatic optic neuropathy and Graves orbitopathy.

Synchronous radiation-induced orbital meningioma and multiple cavernomas.

Synchronous radiation-induced tumours are extremely rare. We present the first reported case of synchronous radiation-induced orbital meningioma and cavernomas of the cerebellum and bilateral basal ganglia, presenting 16 years after ionizing radiation therapy for parietal anaplastic ependymoma, at the age of five. This case again underscores the risks of radiotherapy to children.

Primary orbital liposarcoma.

PURPOSE: To describe 6 new cases of primary orbital liposarcoma and provide a review of the relevant literature. DESIGN: Noncomparative consecutive case series and literature review. PARTICIPANTS: Six patients with primary orbital liposarcoma. METHODS: Review of patient charts, imaging, and histopathology; literature review. MAIN OUTCOME MEASURES: Patient demographics; clinical presentations; results of radiologic imaging; histopathology; surgical techniques used and their complications; other treatment modalities; outcomes and recurrences. RESULTS: Six cases of primary orbital liposarcoma were identified, 5 of which were primary presentations and 1 of which was a recurrence. In 4 cases, exenteration was deferred, resulting in recurrence of disease in all 4. All cases were exenterated, and 2 cases had local recurrence despite exenteration. Two cases were associated with the Li-Fraumeni syndrome and other malignancies. Literature review identified 34 other cases of primary orbital liposarcoma, which, partly because of its rarity, is frequently initially misdiagnosed. The most common subtype is myxoid (56.8%); other types are pleomorphic (10.8%) and well differentiated (29.7%). Well-differentiated tumors have the best prognosis. Non-exenterating surgery was associated with recurrence, although recurrence post-exenteration also occurred. Although radiotherapy has an established role in the treatment of nonorbital liposarcoma, the role of both radiotherapy and chemotherapy in the management of primary orbital liposarcoma is still unclear. CONCLUSIONS: Orbital liposarcoma remains a diagnostic and surgical challenge. Exenteration remains the treatment of choice, but clinicians must also be aware that liposarcoma may herald the diagnosis of the Li-Fraumeni familial cancer syndrome.