Matthew S. Pihlblad

Eyelid laxity, obesity, and obstructive sleep apnea in keratoconus.

Purpose: The association between floppy eyelid syndrome and keratoconus (KCN) has been well established, but the converse relationship has not yet been examined and is the objective of this study. The study also investigates the prevalence of obesity and obstructive sleep apnea (OSA) in KCN patients. Methods: A prospective case–control study of KCN patients with age-, sex-, race-, and body mass index–matched controls was conducted at the Ross Eye Institute, Buffalo, NY. Fifteen patients were enrolled in each group. Extensive eyelid laxity measurements were performed on both groups. Complete medical/ophthalmic history and Epworth Sleepiness Scales were completed on 50 KCN patients and were compared with the normal population. Results: Increased eyelid measurements of the vertical lid pull, lower lid pull, medial canthal tendon distraction, and palpebral width were found in the KCN group compared with the matched control group (P = 0.001, 0.005, 0.04, and 0.01, respectively), and a more rubbery tarsus (P = 0.03), increased corneal diameter (P = 0.02), and increased exophthalmometry measurements (P = 0.01) were also found. The prevalence of OSA (24%, 14/50) and obesity (52%, 26/50) were higher in the KCN patients versus the normal population. Conclusions: KCN patients have increased laxity to their eyelids, along with a more rubbery tarsus, which may be along the spectrum of floppy eyelid syndrome. KCN patients had a high prevalence of OSA and obesity. The high prevalence of OSA in KCN patients is an important association that carries an increased risk of death from any cause and stroke.

Hypertropia in unilateral isolated abducens palsy

PURPOSE To evaluate the incidence and features of hypertropia in abducens nerve palsy. METHODS The records of consecutive patients with unilateral, isolated, previously unoperated abducens nerve palsy were reviewed for binocular alignment on cover testing, Krimsky measurement, or Hess screen testing. Patients with associated cranial nerve palsy (including bilateral abducens palsies), orbital disease, myasthenia gravis, Horner syndrome, hemiplegia, cerebellar signs, arteritis, or previous strabismus surgery were excluded. Control subjects underwent complete examination to confirm normality. RESULTS A total of 79 patients were included (40 males; mean age 49.2 years). Hypertropia in lateral or central gazes was present in 15 of 79 cases (19%) on alternate cover or Krimsky testing, in 32 of 56 cases (57%) on Hess screen testing, and absent in all 30 normal controls. Of cases with hypertropia, the mean of the greatest hypertropia in lateral or central gaze on was 5.0(Δ) ± 2.3(Δ) (standard deviation; range, 1(Δ)-8(Δ)) routine clinical examination, and 5.8(Δ) ± 4.2(Δ) (range, 2(Δ)-24(Δ)) on Hess screen testing. Of 39 cases with partial abducens palsy evaluated by Hess screen testing, the ipsilesional eye was hypertropic in 24 (61%) and hypotropic in 15 cases (39%). CONCLUSIONS Small-angle hypertropia is common in isolated, unilateral abducens and does not imply existence of multiple cranial neuropathies or skew deviation.

Anterior Segment Optical Coherence Tomography of the Horizontal and Vertical Extraocular Muscles With Measurement of the Insertion to Limbus Distance

PURPOSE To assess the possibility of determining the insertion distance from the limbus of horizontal and vertical extraocular rectus muscles with anterior segment optical coherence tomography (AS-OCT). METHODS The right eyes of 46 patients underwent AS-OCT. The horizontal and vertical extraocular rectus muscle insertion distances from the limbus were measured in a masked fashion by two pediatric ophthalmologists. RESULTS Forty-two lateral rectus, 43 medial rectus, 35 inferior rectus, and 40 superior rectus muscles of the right eyes of 46 patients were included. Insertion to limbus measurements (mean ± SD) were as follows: lateral rectus = mean 6.8 ± 0.7 mm, range = 4.8 to 8.4 mm; medial rectus = mean 5.7 ± 0.8 mm, range = 4.3 to 7.8 mm; inferior rectus = mean 6.0 ± 0.6 mm, range = 4.8 to 7.0 mm; superior rectus = mean 6.8 ± 0.6 mm, range = 5.5 to 8.1 mm. The intraobserver and interobserver correlation coefficients for the insertion to limbus measurements of all four rectus muscles exceeded 0.75 (excellent correlation). CONCLUSIONS The study showed that AS-OCT is capable of imaging all four of the rectus muscle insertions and measuring the insertion to limbus distance, and is the second AS-OCT study to image the superior and inferior rectus muscle insertions. The insertion to limbus measurements between examiners and on repeat measurements were consistent and reproducible. The ability to accurately image extraocular rectus muscle insertions may have future implications for the preoperative procedure planning in patients who have had previous surgery. [J Pediatr Ophthalmol Strabismus. 2016;53(3):141-145.].

Fungal Endophthalmitis Developing in Asthmatic Individuals Treated With Inhaled Corticosteroids

Candida albicans is a normal component of human microbial flora of the skin and gastrointestinal tract. When it gains access to the bloodstream, resulting in fungemia, susceptible patients may develop endogenous fungal endophthalmitis (EFE). A number of risk factors have been associated with Candida endophthalmitis and are shown in the Table. These include long-term intravenous therapy, intravenous drug abuse, and even lithotripsy. In this article, we propose another risk factor for EFE—the use of inhaled corticosteroids in the treatment of asthma. Oral candidiasis secondary to the treatment of asthma with inhaled corticosteroids has been welldocumented in the medical literature. We hypothesize that oral candidiasis may cause transient fungemia, which can seed the choroid and lead to EFE. Report of a Case. Case 1. The patient was a 68-year-old woman with a history of asthma and decreased, “cloudy” vision in both eyes for a period of 2 days. She had recently experienced an asthma exacerbation treated with inhaled corticosteroids and subsequently developed oral candidiasis treated with local application of nystatin. Examination revealed a visual acuity of counting fingers at 1 foot in both eyes, 1 conjunctival injection, and 4 cell in the anterior chamber with 1-mm hypopyon and posterior synechiae bilaterally (Figure). The anterior vitreous of the right eye was poorly visualized owing to a small pupil, while the left eye revealed vitreous cells. The media was hazy, and vitreous debris was seen on B-scan bilaterally. A clinical diagnosis of bilateral EFE was made, and she was treated with 200 mg of oral fluconazole twice daily for 1 month. In addition, she was given topical corticosteroids and cycloplegic eye drops. At the 1-month follow-up, her visual acuity was 20/25 in both eyes. As a result of fluconazole treatment, the patient resolved her infection and experienced a significant improvement in visual acuity, confirming our clinical diagnosis. Case 2. The patient was a 67-yearold woman with a history of steroiddependent asthma and chronic obstructive pulmonary disease who presented with 2 days of decreased visual acuity in the left eye and retroorbital and facial pain. In the 2 months prior, she had 3 hospital admissions for asthma exacerbations that were treated with inhaled corticosteroids. During these episodes, she developed oral candidiasis treated locally with nystatin. The patient’s left eye had a visual acuity of counting fingers at 6 inches, 2 conjunctival injection, 4 cell and flare in the anterior chamber with 0.5 mm hypopyon, 3 anterior vitreous cells, hazy fundus view with dull red reflex, and a “chalky white” lesion in the posterior pole. She was diagnosed clinically with EFE and treated with an intravitreal injection of 5 μg/0.1 mL of amphotericin B as well as corticosteroid and cycloplegic eye drops. At the 2-week follow-up, the patient had decreased vision and increased pain in the left eye. Exami-

Percutaneous embolization of an orbital hemangiopericytoma with Onyx facilitates its surgical excision.

This is a case report on the surgical treatment of orbital hemangiopericytoma. The patient initially underwent an attempted excision of the tumor with significant hemorrhage elsewhere, which precluded its complete excision. Due to continued growth and pain, the patient underwent percutaneous embolization with Onyx-18 under fluoroscopic radiographic guidance. The patient continued to have pain, progressive enlargement of the tumor, and underwent surgical excision. The excision was noted to have minimal bleeding and was relatively easy to dissect and excise compared with the typical hemangiopericytoma. Embolization with Onyx-18 may be a useful preoperative treatment option for hemangiopericytomas and other vascular lesions of the orbit, and elsewhere.

Anterior Segment Optical Coherence Tomography of Previously Operated Extraocular Muscles

BACKGROUND AND PURPOSE To assess the possibility of determining the insertion distance from the limbus of previously operated extraocular rectus muscles (EOM) with the Heidelberg Spectralis anterior segment optical coherence tomography (AS-OCT). PATIENT AND METHOD Subjects with a history of previous strabismus surgery underwent AS-OCT of the EOM before planned additional strabismus surgery. The EOM insertion distances from the limbus were measured pre-operatively on the AS-OCT and compared to the caliper distance measured during the strabismus surgery. RESULTS Ten previously operated muscles on nine subjects underwent AS-OCT before subsequent additional strabismus surgery. Four additional un-operated muscles subsequently operated on, were also imaged with the AS-OCT pre-operatively. Subject ages ranged from 13-52 years old (mean ± SD; 27.9 ± 13.2). The muscle insertion could be definitely identified in 6/10 muscles previously operated and 4/4 un-operated muscles. The difference between the two measurements of limbus to insertion in previously operated muscles was ≤1mm in 3/6, and ≤1.5mm in 6/6; <1mm in 4/4 un-operated muscles. Of the four insertions not readily identifiable, two revealed the presence of the muscle with scar tissue; the other two, the muscle insertions, were not visible, which showed that the muscle was at least a minimal amount from the limbus. CONCLUSION Our study showed that the Heidelberg AS-OCT is capable of imaging previously operated EOM, which can give valuable information to the strabismus surgeon. The information from the AS-OCT was useful in all cases. The insertion to limbus measurements between pre-operative and intra-operative were within 1.5mm in all of the cases that the muscle insertion was able to be identified. The ability to accurately image EOM insertions has significant implications for the pre-operative procedure planning in previously operated and complicated strabismus patients.

Eyelid desmoplastic trichilemmoma: 2 case reports and review.

Desmoplastic trichilemmomas (DTs) are a rare variant of trichilemmomas first described in 1985. Since then, 11 cases involving the eyelid have been reported. Two cases of this study raise this total to 13. DTs are often clinically confused with basal cell carcinoma and must be proven by biopsy to obtain the correct diagnosis. These lesions are more commonly present in patients older than 50 years. Despite the fact that they are benign, they are often associated with basal cell carcinomas and as such should be managed carefully, requiring excisional biopsy with frozen borders or Mohs controlled margins.

Anterior segment ischemia: etiology, assessment, and management

Anterior segment ischemia (ASI) is a potentially serious but rare complication of strabismus surgery. Among several risk factors, ASI occurs after strabismus surgery because of the nature of the anterior segment circulation. Disinsertion of rectus muscles leads to a decrease in the blood supply to the various anterior segment structures. We report a series of retrospective and prospective studies performed by our group focused on determining the risk of anterior segment ischemia following strabismus surgery, diagnosis, and modifications to surgical techniques to minimize the impact on anterior segment circulation. We found a significant decrease in postoperative anterior segment blood flow when operating vertical rectus muscles. Plication procedures preserve anterior segment circulation, and modifications to the technique allow the performance of adjustable sutures. Small adjustable selective procedures that spare the ciliary vessels have been demonstrated to be effective in patients with vertical and torsional diplopia. Ciliary sparing augmented adjustable transposition surgery decreases the risk of anterior segment ischemia while allowing management of potential post-operative alignment complications. Finally, ocular coherence tomography angiography is a valuable quantitative and qualitative technique to evaluate anterior segment ischemia. Strabismus surgeons should be aware of the risks of anterior segment ischemia when operating vertical rectus muscles. Modifications to standard surgical techniques allow surgeons to perform complex strabismus surgery in patients at risk for anterior segment ischemia.

Case 3: Painless Vision Loss in an Adolescent

1. Mariam Gabrial, MD* 2. Shamim Islam, MD, DTM&H† 3. Jamie Schaefer, MD‡ 4. Matthew Pihlblad, MD‡ 1. *Pediatric Residency and 2. †Division of Infectious Diseases, Women and Childrens Hospital of Buffalo, Buffalo, NY 3. ‡Department of Ophthalmology, Ross Eye Institute, Buffalo, NY A 13-year-old boy with attention-deficit/hyperactivity disorder presents with 5 days of painless left eye blurry vision and a central area of vision loss. Ten days before presentation he had a left-sided temporal headache that was associated with photophobia and lasted for 3 days before spontaneous resolution. Thereafter, he developed blurriness of vision in his left eye that progressively worsened, and he noted a black area in the center of his visual field. Two months before presentation, the patient had found a tick on his calf shortly after being in a wooded area in western New York. At that time, he developed a raised rash on the nape of his neck but did not have any fevers or neurologic or systemic symptoms. He went to an urgent care clinic, where he was treated presumptively for Lyme disease with 10 days of doxycycline; his rash resolved promptly, and he had no other interim symptoms. On initial assessment in the emergency department, the patient is afebrile and well-appearing. Both eyes appear normal, with no injection of the conjunctiva or signs of photophobia. On examination of the left eye by an ophthalmologist, his previously normal vision is noted to be limited to counting fingers at 1/2 ft distance, and he has a large central scotoma. Dilated fundoscopy reveals 4+ disc edema, with yellow exudates along the temporal disc …

Office-based needle aspiration of idiopathic acute subperiosteal hematoma

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