The authors report a rare case of conjunctival molluscum contagiosum in a 4-year-old male with hyperimmunoglobulin E syndrome and disseminated molluscum contagiosum infection. The patient presented with bilateral periorb...The authors report a rare case of conjunctival molluscum contagiosum in a 4-year-old male with hyperimmunoglobulin E syndrome and disseminated molluscum contagiosum infection. The patient presented with bilateral periorbital and right conjunctival lesions, along with lesions on the face, neck, ears, trunk, back, and genitalia. He was being prepared for a bone marrow transplant, and surgical excision of the lesions was performed to reduce the viral load. Although this case demonstrates the atypical presentation of molluscum contagiosum in immunocompromised individuals, the conjunctival lesions have a unique presentation, which highlights the importance of considering underlying immunodeficiency in patients with unusual ocular manifestations of common viral infections.
PURPOSE: To review the mechanism, differential diagnosis, and management of ethmoiditis mimicking acute dacryocystitis (EMAD) through a case series and prior reports. METHODS: A systematic review of the literature was pe...PURPOSE: To review the mechanism, differential diagnosis, and management of ethmoiditis mimicking acute dacryocystitis (EMAD) through a case series and prior reports. METHODS: A systematic review of the literature was performed on PubMed, Medline, and Google Scholar to capture all well-documented cases of EMAD. RESULTS: The current series includes 5 patients with EMAD documented by a single oculofacial plastic surgeon over 24 months. When adding 6 previously published cases, 11 patients with EMAD have been reported. In all cases, EMAD was considered an anterior ethmoid sinus infection extending into the orbit, adjacent to the lacrimal sac. However, on both computed tomography imaging and external examination, EMAD mimicked an abscess within the confines of the lacrimal sac, yielding an initial misdiagnosis of acute dacryocystitis. Ethmoiditis mimicking acute dacryocystitis was distinguished by free lacrimal irrigation in 100% of patients and frank ipsilateral anterior ethmoid sinusitis in 73%. Furthermore, dacryocystography and endoscopy have confirmed that the infectious mass lies medial to the lacrimal sac. Medical management included systemic antibiotics (100%), nasal decongestants (45%), and systemic glucocorticoids (9%). Recurrence after medical management occurred in 55%, who all subsequently underwent curative anterior ethmoidectomy. CONCLUSIONS: Ethmoiditis mimicking acute dacryocystitis is an anterior ethmoid air cell infection that extends into the orbit, adjacent to the lacrimal sac. Ethmoiditis mimicking acute dacryocystitis is underreported-as evidenced by a consistent misdiagnosis of acute dacryocystitis, as well as the current series identifying 5 cases over just 24 months. Greater awareness of EMAD is important, as its management differs significantly from that of dacryocystitis.
Bispecific T-cell engager (BiTE) immunotherapy is a growing treatment option for various oncologic disorders and is associated with inflammatory side effects. We report a unique case of orbital inflammation following BiT...Bispecific T-cell engager (BiTE) immunotherapy is a growing treatment option for various oncologic disorders and is associated with inflammatory side effects. We report a unique case of orbital inflammation following BiTE therapy. Two days after xaluritamig administration, a 70-year-old man developed right-sided periorbital swelling with significantly reduced vision, proptosis, and restricted extraocular motility. MRI revealed right optic nerve sheath enhancement with retrobulbar fat edema. Symptoms resolved with intravenous methylprednisolone followed by an oral taper. BiTE therapy was resumed, and 5 months later, the patient re-presented with similar symptoms developing in the left orbit, which again resolved with corticosteroids. This is the first reported case of BiTE-associated orbital inflammation. BiTE therapies may elicit off-target orbital inflammation via immune activation pathways similar to those described with immune checkpoint inhibitors, despite their distinct mechanisms of T-cell engagement. This case underscores the need for vigilant ocular monitoring and judicious steroid management during BiTE therapy.
PURPOSE: A survey-based pilot study using Delphi methodology was used to reach a consensus on scope-appropriate oculoplastic procedures for a graduating ophthalmology resident. METHODS: An educational task force (ETF) ba...PURPOSE: A survey-based pilot study using Delphi methodology was used to reach a consensus on scope-appropriate oculoplastic procedures for a graduating ophthalmology resident. METHODS: An educational task force (ETF) based at the study institution recruited stakeholders for survey participation. A stakeholder group of practicing and board-certified ophthalmologists was recruited with diversity in training background, practice location and setting, and year of ophthalmology board certification. Three rounds of Delphi surveys were distributed to the stakeholder group via online questionnaires (Qualtrics). A Cronbach's alpha test was run to evaluate the internal consistency of the Likert data. Consensus was defined as ≥80% panelist agreement, average aggregate score of ≥4 on a Likert scale (5 equating to "strongly agree"), or Cronbach's alpha value of greater than 0.8. RESULTS: The educational task force generated a list of 28 oculoplastic procedure skills for the Delphi rounds. Thirty-four stakeholders were recruited. The response rate for the first survey was 91.2%. Eight procedures met the >80% threshold. Six additional procedures were recommended to be added. A software error resulted in no responses recorded for 3 procedures: botulinum toxin injection for benign essential blepharospasm, botulinum toxin injection for hemifacial spasm, and direct browplasty; thus, these procedures were not advanced to the next survey. The response rate for the second survey was 82.3%. Eight procedures met the ≥4 average Likert score threshold. The Cronbach's alpha was 0.90 for the second survey. The response rate for the third survey was 82.3%, and a final list of 13 oculoplastic procedures was generated. CONCLUSION: A list of 13 scope-appropriate oculoplastic procedural skills necessary and appropriate for a graduate of an ophthalmology residency was generated by Delphi consensus. This list is the sole work of the study institution and does not reflect the views of official organizations such as the American Academy of Ophthalmology, American Board of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgeons, or the Association of University Professors of Ophthalmology. This list requires further refinement and should not be used in isolation without further validation; however, it may aid in curricular development and be utilized to generate oculoplastic-specific competencies for ophthalmology residents.
PURPOSE: Patients with facial nerve paralysis (FNP) can have corneal decompensation resulting in poor visual outcomes. Here, we measure the associations between clinical parameters and corneal epitheliopathy in FNP. METH...PURPOSE: Patients with facial nerve paralysis (FNP) can have corneal decompensation resulting in poor visual outcomes. Here, we measure the associations between clinical parameters and corneal epitheliopathy in FNP. METHODS: In this cross-sectional cohort study, FNP patients from a 6-year period were reviewed. Etiology of FNP, visual acuity, grade of corneal epitheliopathy, and corneal sensation were recorded. Multivariate analysis was completed to assess the association between severe epitheliopathy and 4 ocular protective mechanisms: corneal innervation, House-Brackmann orbicularis score, Bell's phenomenon, and lagophthalmos. RESULTS: Forty patients (mean age 58.7 years) were included: 38% had an underlying central etiology, while 22% had peripheral causes and 40% Bell's palsy. Mean logMAR visual acuity on the ipsilateral side of FNP was 0.49. Severe epitheliopathy was identified in 18%. However, 35% of patients had decreased corneal sensation. Best corrected visual acuity was worse in patients with severe corneal epitheliopathy (p = 0.0003), and the rate of decreased corneal sensation was 4 times higher than in patients with normal corneas (p = 0.001). Multivariable analysis demonstrated a significant association between severe epitheliopathy and decreased corneal sensation (odds ratio [OR] = 14.97; p = 0.04), but not with House-Brackmann grading (OR = 1.86; p = 0.31), poor Bell's phenomenon (OR = 7.19; p = 0.13), or lagophthalmos (OR = 0.99; p = 0.95). Compared with patients with normal corneal sensation, those with reduced sensation had worse best corrected visual acuity and degree of corneal epitheliopathy (p = 0.005, p = 0.0003). CONCLUSIONS: Reduced corneal sensation was the most significant independent predictor of severe corneal epitheliopathy. Corneal sensitivity can affect visual outcomes and is an important variable to measure in patients with FNP.
We report a unique case of a 32-year-old woman with a 4-day history of painful right lacrimal gland swelling. MRI demonstrated enhancement and enlargement of the right lacrimal gland. There were nonenhancing, intraglandu...We report a unique case of a 32-year-old woman with a 4-day history of painful right lacrimal gland swelling. MRI demonstrated enhancement and enlargement of the right lacrimal gland. There were nonenhancing, intraglandular foci, with low signal on T2-weighted sequences and marked restricted diffusion. Surgical excision revealed multiple dacryoliths centered on an impacted eyelash. Microbiological evaluation yielded Streptococcus pneumoniae and histopathology confirmed noncalcified ductal dacryoliths with a background of acute inflammation. At 1-month follow-up, symptoms completely resolved with no evidence of recurrence. Lacrimal gland dacryolithiasis is rare and usually presents as refractory conjunctivitis or a chronic lateral conjunctival or canthal mass, rather than acute dacryoadenitis. This case expands the clinicoradiological spectrum of this rare entity and highlights novel MRI patterns that may aid preoperative diagnosis and timely management.
PURPOSE: Postoperative nausea and vomiting remain significant concerns in surgical care, impacting patient recovery, satisfaction, and healthcare costs. This study evaluates the efficacy of 40 mg oral aprepitant in reduc...PURPOSE: Postoperative nausea and vomiting remain significant concerns in surgical care, impacting patient recovery, satisfaction, and healthcare costs. This study evaluates the efficacy of 40 mg oral aprepitant in reducing postoperative nausea and vomiting incidence and severity compared with placebo. METHODS: A randomized, double-blind study was conducted on patients undergoing oculoplastic procedures. Patients were assigned to receive either 40 mg oral aprepitant or placebo preoperatively. Postoperative nausea and vomiting severity was assessed postoperatively using the modified Baxter Nausea Scale, with additional data collected on rescue antiemetic and opioid use. Statistical analysis, including Fisher exact test and 95% confidence intervals, was performed using Microsoft Excel. RESULTS: Patients in the aprepitant group reported significantly lower nausea severity scores and a reduced incidence of vomiting compared with the placebo group. Additionally, patients receiving aprepitant required fewer postoperative doses of ondansetron and opioids. The safety profile of aprepitant was consistent with previous studies, with no significant adverse effects reported. CONCLUSIONS: Aprepitant demonstrated efficacy in reducing postoperative nausea and vomiting and decreasing reliance on rescue antiemetics and opioids. These findings support its potential integration into standard prophylactic regimens for postoperative nausea and vomiting prevention in oculoplastic surgery.
Castleman disease constitutes a rare spectrum of conditions with rheumatologic, hematologic, and oncologic features. Orbital involvement is extremely rare with only several cases involving the lacrimal gland. This report...Castleman disease constitutes a rare spectrum of conditions with rheumatologic, hematologic, and oncologic features. Orbital involvement is extremely rare with only several cases involving the lacrimal gland. This report describes Castleman disease in a 15-year-old patient who presented with progressive left eye bulging and intermittent periorbital pain. Neuroimaging demonstrated a well-defined, enhancing, homogeneous left lacrimal gland mass with decreased diffusivity, smooth bone remodeling, and anteromedial globe displacement, and no other systemic findings. The lesion was excised in toto and histopathology revealed features of hyaline vascular-type Castleman disease. This is the first reported case of Castleman disease in a pediatric patient with an isolated lacrimal gland lesion. It emphasizes the importance of considering Castleman disease among other lymphoproliferative diseases in the differential diagnosis for patients presenting with a well-circumscribed, homogeneous orbital mass associated with decreased diffusivity and bone remodeling.
PURPOSE: To review and assess published imaging evidence for optic nerve stretch (ONS) in patients with dysthyroid optic neuropathy (DON), evaluating its prevalence, measurement methods, and potential association with di...PURPOSE: To review and assess published imaging evidence for optic nerve stretch (ONS) in patients with dysthyroid optic neuropathy (DON), evaluating its prevalence, measurement methods, and potential association with disease pathophysiology. METHODS: PubMed, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov were searched using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, for computerized tomographic or magnetic resonance imaging studies of ONS in thyroid eye disease. Data were extracted on imaging modality, ONS definition, and association with DON. Pooled proportions were calculated using random-effects models with logit transformation, and heterogeneity assessed with I2. RESULTS: Sixteen studies, comprising 1,277 orbits (508 DON and 769 non-DON), met the inclusion criteria. Five noncomparative studies, mostly earlier papers, report ONS in 43% (0%-100%) of 75 DON orbits. Eleven studies (1,202 orbits) compared orbits with and without DON: 6 studies examined optic nerve contour (317 DON and 435 non-DON) and reported ONS in 66% of DON and 37% of non-DON orbits. Only 2 studies reported ONS as being significantly associated with DON (74% and 64% of orbits), and both reported marked apical crowding (70% and 67%). The pooled ONS proportion was 56% (95% confidence interval: 37%-74%) in orbits with DON and 31% (95% confidence interval: 12%-59%) in non-DON orbits, with high heterogeneity (I2 > 80%). CONCLUSIONS: While optic-nerve stretch is frequently observed in DON, current evidence does not establish it as an independent cause. ONS may reflect geometric changes due to orbital soft-tissue expansion, and the principal mechanism for DON probably remains apical compression and microvascular ischemia of the optic nerve.
PURPOSE: To systematically describe the morphogenesis of the lacrimal system and its associated adnexal structures along the developmental timeline, from their earliest identifiable embryonic stages through fetal maturat...PURPOSE: To systematically describe the morphogenesis of the lacrimal system and its associated adnexal structures along the developmental timeline, from their earliest identifiable embryonic stages through fetal maturation, and to characterize postnatal anatomical and functional changes. METHODS: The authors conducted an extensive review of classical and contemporary studies of the last 200 years (1837-2025) detailing the morphogenesis of the human lacrimal excretory system-including the puncta, canaliculi, lacrimal sac, and nasolacrimal duct-across embryonic, fetal, and postnatal stages. All cited sources, irrespective of their original language, were comprehensively incorporated. Texts in German, French, and Italian underwent meticulous translation by the authors to ensure linguistic accuracy and contextual fidelity. This systematic synthesis integrates anatomical, histological, and molecular data, with particular emphasis on epithelial-mesenchymal interactions and canalization dynamics. Controversial viewpoints regarding the origin and canalization of the nasolacrimal duct and punctal structures are critically appraised. RESULTS: Lacrimal excretory system development proceeds through 3 morphogenetic stages. Embryonic phase (weeks 1-8): Initiated by ectodermal thickening in the nasolacrimal groove, formation of the lacrimal lamina, and cellular proliferation into the lacrimal cord. Canaliculi arise from bifurcations at the proximal (lateral) end of the cord, while the distal end differentiates into the lacrimal sac and the nasolacrimal duct. Fetal phase (week 9-term): Canalization of the lacrimal cord begins around week 10, forming a continuous lumen. Horner-Duverney muscle fibers envelop the canaliculi, and the canalicular epithelium makes contact with the palpebral conjunctiva forming an imperforate double-layered epithelial lamina occluding the presumptive puncta that typically opens just prior to birth. The distal nasolacrimal duct forms a similar continuous imperforate double epithelial lamina with the nasal epithelium at the developing inferior meatus. Functional maturation of the lacrimal pump mechanism probably starts after eyelid separation (weeks 28-30 postfertilization). Postnatal phase: Tear drainage is physiologically active at birth in most infants, but the distal ductal membrane (valve of Hasner-better term is valve of Bianchi-Zinn) may not perforate until 6-12 months later in some infants. Lacrimal gland secretory function continues to mature for several years postnatally. CONCLUSIONS: Development of the lacrimal excretory system is a tightly orchestrated process requiring coordinated contributions from surface ectoderm, neuroectoderm, and cranial neural crest-derived mesenchyme. The various elements of the drainage system develop sequentially along the embryologic timeline from fertilization to early childhood. A foundational understanding of lacrimal excretory system morphogenesis is useful for elucidating the embryologic basis of congenital lacrimal disorders and for advancing therapeutic strategies. Purportedly, shared molecular pathways between fetal and adult lacrimal tissues (both secretory and excretory) suggest a future potential for regenerative therapies.
The authors present the second example of a cystic panfolliculoma of the eyelid. A woman in her early 90s presented with a worsening crateriform lesion of the left eyelid and the inferior edge of the eyebrow for approxim...The authors present the second example of a cystic panfolliculoma of the eyelid. A woman in her early 90s presented with a worsening crateriform lesion of the left eyelid and the inferior edge of the eyebrow for approximately 1 year. The lesion fluctuated in size, was painless, and occasionally had a "scab" come off the lesion's surface with drainage of material. Excisional biopsy revealed a well-demarcated cystic panfolliculoma in the dermis, connected to the epidermis. The lumen contained corneocytes (squames) with a basket-weave pattern (infundibular differentiation), blue-gray corneocytes (inner sheath differentiation), and shadow (ghost) cells typical of hair differentiation. The cyst wall showed infundibular, isthmic, inner root sheath, matrical, and germinative cell differentiation. A focus of advanced follicular differentiation had germinative cells enclosing clear cells typical of outer sheath differentiation, surrounding inner sheath cells with eosinophilic trichohyalin granules. Cytological atypia and fully mature hair follicles were not identified. Immunohistochemical stains showed a predominance of cells with outer root sheath and germinative cell immunophenotypes. Panfolliculomas are rare neoplasms with peaks at 50 to 59 and 70 to 79 years, a 1.4:1 male-to-female ratio, and a predominantly scalp- and face-based distribution. There are 3 histological variants, nodular, superficial, and cystic, and all are benign without local recurrence following complete surgical excision.
Histiocytic sarcoma is an extremely rare malignancy typically presenting in extranodal sites, including the gastrointestinal tract, lung, nasal cavity, and soft tissue. Primary presentation in the skin is an even rarer e...Histiocytic sarcoma is an extremely rare malignancy typically presenting in extranodal sites, including the gastrointestinal tract, lung, nasal cavity, and soft tissue. Primary presentation in the skin is an even rarer entity, with only one prior case reported in the eyelid skin. Herein, we describe a case of histiocytic sarcoma that presented in the eyelid of an 80-year-old man. The lesion presented as a rapidly growing left lower eyelid lesion over 4 months. Shave biopsy revealed histologic and immunophenotypic findings most consistent with a morphologically low-grade histiocytic sarcoma. Complete excision was performed with an additional 2 mm peripheral and deep margins, which were found to be clear of malignancy. Systemic work-up and whole body imaging showed no evidence of metastases or other associated malignancy. The decision was made to forego radiation and proceed with close observation every 3 months. Two years from presentation, the patient had no evidence of recurrence.
PURPOSE: To evaluate the long-term functional and aesthetic outcomes of orbicularis myectomy in patients with medically refractory benign essential blepharospasm and to contextualize findings within current surgical lite...PURPOSE: To evaluate the long-term functional and aesthetic outcomes of orbicularis myectomy in patients with medically refractory benign essential blepharospasm and to contextualize findings within current surgical literature. METHODS: A retrospective analysis was conducted on 80 patients (129 eyelids) who underwent subtotal orbicularis myectomy between 2014 and 2023. Bilateral procedures were performed sequentially. Mean follow-up was 84 months (range: 24-144.3). Surgery was offered after failure of initial botulinum toxin injections, with a mean delay of 18.5 months. RESULTS: At 6 and 12 months postoperatively, 72% of patients experienced functional improvement, with a mean 53% reduction in spasm severity. However, only 41% maintained long-term benefit. Spasms recurred in 86%, and only 7.5% achieved complete resolution without further botulinum toxin injections. Aesthetic outcomes were favorable in 96% of cases and remained stable over time. The frequency of botulinium toxin injections decreased from 1 every 3 months to every 4 months, though this change was not statistically significant (p = 0.12). Botulinum toxin dose was significantly reduced at 12 months (p < 0.001), but not at final follow-up (p = 0.2872), suggesting a temporary postoperative benefit. No major complications were observed. Transient lagophthalmos occurred in 3% of cases; 1 case required surgical revision. There was no significant association between long-term disabling symptoms and age (p = 0.61), gender (p = 0.12), or active smoking (p = 0.49). CONCLUSION: Orbicularis myectomy provides early symptom relief and durable cosmetic improvement, but its functional effect tends to decline over time. Minimally invasive techniques may help reduce complications while maintaining efficacy.
PURPOSE: To evaluate the performance of deep learning models using optical coherence tomography (OCT) volumes, clinical photographs, and their multimodal fusion to classify eyelid lesions as benign or malignant, using hi...PURPOSE: To evaluate the performance of deep learning models using optical coherence tomography (OCT) volumes, clinical photographs, and their multimodal fusion to classify eyelid lesions as benign or malignant, using histopathology as the reference standard. METHODS: Prospective cohort study conducted between January 2023 and January 2025 at a single tertiary academic oculofacial plastic surgery center. A total of 65 patients with 71 periocular lesions undergoing routine biopsy were imaged with spectral-domain OCT and slit-lamp photography before biopsy. Images were processed into 3 Vision Transformer architectures: an OCT model, a photograph model, and a multimodal fusion model integrating both modalities. Classification performance for benign versus malignant lesions was evaluated with 5-fold cross-validation. Performance metrics included sensitivity, specificity, accuracy, kappa, and area under the receiver operating characteristic curve. RESULTS: Of 71 lesions, 52% were benign and 48% malignant. The OCT model achieved 73.9% accuracy, 74.4% sensitivity, and an area under the receiver operating characteristic curve of 82.5%. The photograph model reached 82.3% accuracy, 89.6% sensitivity, and an area under the receiver operating characteristic curve of 91.7%. The multimodal fusion model performed best, with 83.2% accuracy, 91.8% sensitivity, 81.1% precision, kappa of 0.68, and an area under the receiver operating characteristic curve of 92.1%. CONCLUSIONS: This study demonstrates the feasibility of analyzing OCT volumes using deep learning, with diagnostic accuracy improved through multimodal integration with clinical photography. These results suggest that multimodal artificial intelligence may serve as a scalable, noninvasive, and physician-independent tool to distinguish benign from malignant periocular lesions and streamline patient triage. As models evolve to identify histopathologic features more reliably, they may also reduce dependence on incisional biopsy prior to definitive treatment.