Eyelid Swelling Research Articles

SYMPTOMS OF IMPAIRED CEREBRAL VENOUS HEMODYNAMICS 
 IN ADOLESCENTS WITH CONNECTIVE TISSUE DYSPLASIA

The aim of the paper was to study clinical manifestations of cerebral venous insufficiency in adolescents with connective tissue dysplasia (CTD).
 Materials and Methods. The authors examined 156 adolescents. The main group consisted of 82 adoles-cents with CTD symptoms. The comparison group included 74 adolescents without CTD manifestations. Connective tissue dysplasia was assessed according to L.N. Abakumova scoring system (2006). Patient intake and examination revealed clinical signs of cerebral venous insufficiency.
 Results. The following complaints were peculiar for the patients of the main group: headache, which in-tensity increased when working in an inclined position, during or after a nocturnal sleep, with coughing and on straining, and decreased in the afternoon and after moderate physical activity; vertigo, which worsened in case of postural change, head rotation and bending; puffiness/pasty face and eyelids in the morning, “high pillow” symptom, “tight collar” symptom, sandy-gritty sensation in the morning; night-mares, frequent night awakenings because of the headaches; nasal stuffiness without ARD symptoms. The patients of the main group also demonstrated symptoms of cerebral venous insufficiency: facial puffi-ness, eyelid swelling; sclera injection; venous network on the anterior chest / neck; lip or nasolabial tri-angle cyanosis, hypoesthesia of the 1st or 2nd branch of the trigeminal nerve. 
 Conclusion. Clinical symptoms of cerebral venous insufficiency are more prominent in adolescents with CTD than in the comparison group. This fact indicates the need for early detection of venous hemodynam-ic disorders, subsequent dynamic monitoring and preventive measures to avoid the early development of cerebrovascular diseases in adolescents.

Epidemiology and Management of Orbital Cellulitis in Children.

The epidemiology of orbital cellulitis likely has evolved due to the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and the adoption of pneumococcal conjugate vaccination. In the absence of published guidelines, management is highly variable. We characterized epidemiology and management over an 11-year period. A retrospective cohort study of children 0 to 21 years of age with orbital cellulitis +/- subperiosteal orbital abscess hospitalized at a large quaternary children's hospital from January 2008 to June 2018. We reviewed charts for demographic characteristics, clinical features, management, and outcomes. Using multivariable logistic regression, we evaluated predictors of surgical intervention and assessed whether corticosteroid use or antibiotic duration was related to clinical outcomes. Among 220 patients, methicillin-susceptible S. aureus was the most common organism (26.3%), with MRSA found in only 5.0%. Rates of vancomycin use fluctuated annually from 40.9% to 84.6%. Surgery was performed in 39.5% of the patients. Corticosteroids, used in 70 patients (32.1%), were unrelated to treatment failure (n = 9), defined as persistent signs and symptoms or initial clinical improvement followed by worsening (P = .137). The median antibiotic duration was 17 days (interquartile range 14-26). After controlling for age, gender, proptosis, eye pain with movement, eyelid swelling, neutrophil count, and corticosteroid use, treatment failure was not significantly associated with receipt of ≥ 3 weeks of antibiotic therapy (8/84, 9.5%) compared with > 2 but < 3 weeks (0/51, 0.0%) or ≤ 2 weeks (1/85, 1.2%) (adjusted odds ratio = 5.83 for ≥ 3 vs ≤2 weeks; 95% confidence interval: 0.58, 59.0). Although MRSA was rare, empiric vancomycin use was high. Treatment failure was uncommon in patients who received ≤ 2 weeks of therapy, suggesting that shorter durations are adequate in some patients.

Management of Tolosa-Hunt syndrome with Ayurveda therapeutic measures and interventions

BACKGROUND: Tolosa-Hunt syndrome (THS) is a rare disorder characterized by episodic periorbital pain associated with paralysis of either one or more of the III, IV, or VI cranial nerves. It is usually self-resolving, but relapse may be seen. In Ayurveda, a clinical condition “Vatahata Vartma” is narrated, resembling THS. Based on the resemblance, a diagnosed case of THS was treated by Ayurveda measures and treatment described for the management of Vatahata Vartma. MATERIALS AND METHODS: A 50-year-old man, who was previously diagnosed and underwent treatment for THS, presented with complaints of increased drooping and swelling at his left upper eyelid along with strenuous eyeball movements since February 2021. Drooping of the eyelids was measured by the amount of ptosis, margin-reflex distance, and the function of the levator palpebrae superioris. The patient was treated with Ayurveda oral medicines (herbal decoctions, herbal clarified butter, herbal powders, and herbal tablets), biopurification (therapeutic purgation and retention of medicine in the buccal cavity), and external Ayurveda ocular therapy (ocular irrigation, bolus sudation, eye drops, herbal paste over the eyelids, retention of herbal clarified butter over the eyes, collyrium, paste over the head, and irrigation over the head). The total duration of therapy was 11 months. RESULTS: Swelling and ptosis of the left upper eyelid were reduced, and the patient could do the normal movement of the left upper eyelid. CONCLUSION: THS can be treated with Ayurveda measures and interventions narrated in Ayurveda under Vatahata Vartma. A clinical study on large sample size is required to validate the result obtained in the present case study.

Sarcoidosis: Hiding in Plain Sight

<h3>Introduction</h3> Sarcoidosis is a systemic disease that can masquerade as many conditions. Due to its often patchy distribution, myocardial biopsy is only ∼30% sensitive. Herein we present a case of sarcoidosis diagnosed from an extra-cardiac biopsy years after the onset of cardiomyopathy. <h3>Case Report</h3> A 54 year old man initially presented with dyspnea and fatigue due to new onset HFrEF of 20%. He had a significant family history of SCD. His workup revealed non-obstructive CAD, a myxomatous mitral valve with bileaflet prolapse and moderate regurgitation, and a cystic structure attached to the tricuspid valve. Given his frequent ventricular ectopy, he was discharged on guideline therapy for HFrEF and a wearable cardioverter defibrillator. Genetic testing for dilated cardiomyopathies revealed EYA4 and TTN variants of unknown significance. A cardiac MRI a few months later demonstrated no abnormal late gadolinium enhancement and persistent systolic dysfunction, so he underwent AICD implant. His course was further complicated by recurrent admissions for supraventricular and ventricular tachyarrhythmias. A cardiopulmonary exercise stress test demonstrated low-risk results. Further evaluation noted prolonged AV conduction. A RHC revealed mild post-capillary pulmonary hypertension and a mildly decreased cardiac index at 2.01 L/min/m². Months later, he underwent CRT-D upgrade. He started improving functionally until he developed left eyelid swelling, initially thought to be lymphoma. An orbital biopsy revealed non-caseating granulomas. A PET/CT demonstrated FDG uptake within subcarinal lymph nodes but no cardiac uptake. Initially he declined immunomodulatory therapy, but as his symptoms worsened, he started corticosteroids and transitioned to mycophenolate mofetil due to intolerance of methotrexate. Due to disease progression on repeat FDG-PET, he was switched to infliximab. <h3>Summary</h3> The diagnosis of sarcoidosis can be difficult due to its variable presentation, including heart block, heart failure, ventricular arrhythmias and sudden cardiac death. Cardiac involvement occurs in 25% of cases. Our case was complicated by a cMRI that was negative for cardiac involvement, which emphasizes the importance of complimentary inflammatory imaging with FDG-PET. A multidisciplinary approach is needed that engages sarcoid specialists for earlier diagnosis to ensure rapid initiation of therapy to reduce end-organ dysfunction.

Unilateral Orbital Lipoma in Young Woman Occurred 5 Years after Autologous Fat-graft

Purpose: To report a case of unilateral orbital lipoma in a 22-year-old woman after an autologous fat graft.Case summary: A 22-year-old woman visited our clinic with the chief complaint of persistent ptosis of the left upper eyelid for 6 months. Five years prior, she had undergone double eyelid surgery on both eyes, in which autologous fat grafting was performed. She had experienced swelling of the left upper eyelid that began 6 months prior to her visit. Examinations of her visual acuity, intraocular pressure, pupil reflex, extraocular movement, and fundus revealed no abnormal findings. Sagittal images from orbital contrast computed tomography scans revealed a translucent lesion in the posterior space of the orbital septum of the left upper eyelid. Histological examination of excisional biopsy specimens showed mature adipose cells surrounded by a fibrous capsule. The patient remained disease-free at the 3-month follow-up.Conclusions: Lipoma can occur both during and after autologous fat grafting. It is important that the patient is well-informed of this issue before surgery and that the appropriate treatment is provided when it occurs.

Kimura Disease Presenting as Unilateral Proptosis

Purpose: Kimura disease is a rare chronic inflammatory disease that usually presents with painless subcutaneous nodules at the head and neck area, but rarely occurs around the eyes. We report unique case of Kimura disease involving the orbit and arm, which has not been reported in Korea.Case summary: A 16-year-old boy presented with exophthalmos and eyelid swelling of right eye over the last 2 years. Orbital magnetic resonance imaging (MRI) showed hypertrophy of extraocular muscles of right eye. He also complained of multiple painless masses of the left forearm that persisted during the same period. The MRI showed hypertrophy of extraocular muscles of right eye and multiple lymphadenopathy along the brachial artery of the left elbow. Excisional biopsy of the left arm mass and lymph nodes was performed and the lesions were diagnosed as Kimura disease involving the dermal nodule and lymph nodes. The patient was managed with oral corticosteroid and cyclosporine and showed remarkable improvement of proptosis and hypertrophy of extraocular muscles.Conclusions: We report a rare case of Kimura disease causing hypertrophy of extraocular muscles which was successfully treated with immunosuppressive agents.

Regional Scalp Blockade for Painless Removal ofIntracranial Pressure Bolts: Technical Note and Patient-Reported Outcomes

Elective insertion of intracranial pressure (ICP) monitoring bolts is useful for the diagnosis and treatment of disorders of cerebrospinal fluid dynamics. Patients typically report severe discomfort on bolt removal, which negatively impacts overall patient satisfaction of ICP monitoring. We assessed the efficacy and safety of using supratrochlear and supraorbital nerve block-a commonly used form of scalp anesthesia-alongside oral analgesia before bolt removal. We compared the efficacy and safety of regional scalp block anesthesia alongside oral analgesia versus oral analgesia alone in a cohort of 85 patients undergoing removal of diagnostic ICP bolts between June 2017 and April 2019 using retrospective patient questionnaires, as well as electronic admission documentation. We found that scalp block alongside oral analgesia improved bolt removal experience (4/5 vs. 3/5 on a 1-5 point Likert scale) and that a majority (70.6%) of patients would have preferred local anesthetic before removal in the oral analgesia-only group. Only 2 patients experienced mild and localized side effects: mild bruising and temporary facial and eyelid swelling following regional scalp block. We conclude that regional supraorbital and supratrochlear nerve block is a simple, safe, and effective adjunct to minimizing discomfort during bolt removal and improving overall patient satisfaction of ICP monitoring.

Successful Management of Neonatal Orbital Cellulitis: A Rare Case Report

Objective: To report a rare case of neonatal orbital cellulitis along with the successful management. Introduction: Orbital cellulitis is a sight- and life-threatening infection of the post-septal tissues of the orbit, and is a considerably rare finding in neonates. Prompt diagnosis and treatment is essential, as 11-26% of cases of orbital cellulitis result in death and visual loss. Case Presentation: A one-month-old neonate presented with rapidly progressive swelling and redness of the right eyelid along with persistent subfebrile fever seven days before admission to the hospital. Blinking reaction to light stimulation was good on the left eye. Ocular motility was difficult to be evaluated. Conjunctival appearance on the right eye showed severe chemosis, while the other parts of both eyes were within normal limit. Orbital Computed Tomography (CT) scan revealed diffuse soft-tissue swelling at the superior and inferior palpebra of the right eye and partial erosion of the lateral wall of the right ethmoidal sinus, suggesting sino-orbital inflammation. Diagnosis of orbital cellulitis was confirmed on the right eye in this patient. Incision and drainage surgery of the right eyelids were done immediately as improvement was only seen on the upper eyelid after empirical intravenous (IV) antibiotic administration. Strain of Methicillin-Resistant Staphylococcus Aureus (MRSA) was found from the discharge’s culture. At one month follow up, the swelling of the right eyelid had markedly decreased with no signs of inflammation. Conclusion: This case highlights and showed a rare case and successful management of neonatal orbital cellulitis. Early diagnosis and prompt treatment of neonatal orbital cellulitis may benefit patient and prevent sight- and life-threatening condition.

Microphthalmos with Orbital Cyst: Case series with a review of literature

Microphthalmos with orbital cyst is a rare congenital abnormality of fetal fissure closure leading to a small eyeball associated with an orbital cyst. In this case series, we describe six such cases and discuss the clinical features, differential diagnosis, diagnostic modalities, and management in accordance with the existing literature. Out of the six cases, four were male and two were females. All the cases presented with a swelling in the lower eyelid of the involved eye, which was the right eye in all the male patients and the left eye in all the female cases. Other eye showed uveal coloboma in 50% of the cases. Microphthalmos with orbital cyst was diagnosed based on the clinical features and radiological findings (ultrasonography B-scan and/or Computed Tomography scan). Two patients from our case series underwent surgery (cyst excision with enucleation of microphthalmic eye with orbital implant and conformer) and, histopathology confirmed the diagnosis of microphthalmos with orbital cyst. Microphthalmos with orbital cyst presents as a swelling of the lower eyelid since birth in which a careful examination often reveals a microphthalmic eye. Two such cases in our case series were managed with orbital cyst excision and enucleation of microphthalmic eye followed by orbital implant and conformer, leading to good cosmetic results.

Clinical Profile and Long-Term Outcomes in Pediatric Cavernous Sinus Thrombosis

BackgroundPediatric cavernous sinus thrombosis (CST) is a rare condition with limited data regarding its clinical characteristics and long-term outcomes. The objective of this study was to describe the clinical and radiologic features, diagnostic evaluation, management, and long-term prognosis and to identify clinical variables associated with long-term outcomes in pediatric CST. MethodsA retrospective chart review of patients younger than 18 years diagnosed with a CST between 2004 and 2018 at a single center was conducted. ResultsWe identified 16 (M:F = 10:6) children with CST with a mean age of 7.6 years (10 days to 15 years) and average follow-up duration of 29 months (3 weeks to 144 months). The most common symptom and examination finding at presentation was eyelid swelling (n = 8). Six patients had bilateral CST. The most common etiologies were sinusitis (n = 5) and orbital cellulitis (n = 5). Treatments included antibiotics (n = 14), anticoagulation (n = 11), and surgery (n = 5). Only one patient died due to intracranial complications. Twelve patients had a normal examination at follow-up. None of the clinical variables including age (P = 0.14), gender (P = 0.09), use of antibiotics (P = 1.00) or anticoagulation (P = 1.00), surgery (P = 0.28), parenchymal abnormalities (P = 0.30), additional cerebral venous thrombosis (P = 0.28), and early versus late commencing of anticoagulation (P = 1.00) were significant when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging. ConclusionsOur study is one of the largest cohorts with the longest follow-up data for the pediatric CST. Most of our patients had favorable outcomes at follow-up. We found no statistical difference between clinical variables when comparing patients with full/partial resolution versus those with no resolution of thrombosis on follow-up neuroimaging.

Congenital Orbital Glial Heterotopia Associated with Clinicopathological Anophthalmia: A Case Report.

Glial heterotopia (GH) is the presence of glial tissue outside the cranial cavity, without communication with the brain. The orbital location usually presents as eyelid swelling, strabismus, and proptosis. This is considered a congenital location that usually presents at birth. Its association with anophthalmia is uncommon. We report the case of a 2-day-old male neonate with left congenital intraorbital lesion presenting with massive proptosis. No eyeball could be seen. Preoperative magnetic resonance imaging disclosed a large and predominantly cystic mass occupying and protruding from the left orbit without intracranial extension. In the operating theatre, a large amount of fluid was aspirated prior to total resection of the mass. Chemical analysis of the fluid was compatible with cerebrospinal fluid. Histologically, the tumor was composed of mature neuroglial tissue and ependymal cells. Despite multiple sections, no choroid plexus or intraocular content was found. The diagnosis of GH with anophthalmia was made.

Effect of low-level light therapy in patients with dry eye: a prospective, randomized, observer-masked trial

To evaluate the efficacy of low-level light therapy (LLLT) with near-infrared light-emitting diodes (LED-LLLT) for the treatment of dry eye. 40 patients were randomly assigned with a 1:1 allocation ratio to receive LED-LLLT (LLLT group, n = 20) or placebo treatment (placebo group, n = 20). Patients in the LLLT group received LLLT twice a week for 3 weeks, for a total of 6 treatment sessions. The primary endpoint was the changes in the fluorescein corneal staining (FCS) score. The secondary endpoints were the changes in the ocular surface disease index (OSDI) score, lissamine green conjunctival staining (LGCS) scores, tear film break-up time (TBUT), Schirmer test, and the meibomian gland dysfunction (MGD) index. These were evaluated before treatment and 4 weeks after start of treatment. The mean difference of score change in primary endpoint revealed significant improvement in the LLLT group, compared to the placebo. Among secondary endpoints, LGCS, Schirmer's test, upper meibography scores showed significant improvements, while TBUT, lid debris, lid swelling, lid telangiectasia, meibomian gland secretion and expressibility scores had slight improvement without significant differences. No serious adverse events were observed. The use of LED-LLLT for the treatment of dry eye and MGD appears to be safe and beneficial.

Atypical lymphoid proliferation of the orbit.

Objective: Lymphoproliferative disorders are a group of lesions characterized by abnormal proliferation of lymphocytes. In the orbit, they can occur in the ocular adnexae. These neoplasms have defined clinical and pathologic characteristics and account for more than 20% of all orbital tumors. Several types of lymphoproliferative lesions have been described in the orbit. One example is lymphoid hyperplasia, which commonly involves the lacrimal gland. A benign lesion like lymphoid hyperplasia will show a general normal archetype of the tissues-involved lacrimal gland. We expect a polyclonal group of cells with more or less normal architecture of a follicle. On the other hand, lymphoma will show less organized arrangement of cells, and we expect them to be of monoclonal lineage.Methods: This is a case report of a 55-year-old Filipino female who came in for blurring of vision of both eyes. During her assessment, there was an incidental finding of bilateral upper eyelid swelling, and a 30x15 mm palpable firm mass under the right superior orbital rim and a 30x10 mm mass under the left were noted. The right globe was displaced inferiorly, but no proptosis was seen on exophthalmometry. On plain CT scan, we noted a homogenous mass with molding or contouring around the orbital structures. On coronal view, we noted homogenous masses that mold around the globe and recti, and this also confirmed on axial cuts. A section biopsy was done via anterior orbitotomy.Results: Our patient’s histopath had features of both. On scanning magnification, we noted a very cellular round cell tumor. The round cell lesion seemed to be reminiscent of a germinal center of a lymph node. Around it we noticed the glandular structures, which were expected, since this specimen was from the lacrimal gland. A closer view of the lesion on high power showed these lymphocytes within a germinal center. These are large macrophages that actively phagocytose apoptotic lymphoid cells in germinal centers. We expect to see a lot of them in benign hyperplasia, but only a few will be present in malignancies. In summary, our patient had both benign and malignant features, resulting in a histopath result of atypical lymphoid proliferation.Conclusion: Atypical lymphoid proliferation is a rare orbital tumor with benign and malignant features. There is no standard protocol for treatment, and proper multi-specialty coordination is important. External beam radiation therapy with linear accelerator (LINAC) appears to be an effective treatment, with no recurrence in our patient after 5 months.

Removal of Autogenous Fat Filling in Double Eyelid Operation by Artificial Intelligence (AI) Algorithm-Based Computerized Tomography (CT) Image Features

The effect of autogenous fat filling was evaluated by computerized tomography (CT) image features based on the symmetric extended convolutional residual network image denoising algorithm in this research, and the pathological examination was conducted for the lesions of patients with complications. The examination provided more valid research basis for the clinical application of autogenous fat filling. 60 patients who received double eyelid operation were selected as the research objects, and the patients were randomly divided into the control group and the experimental group, where each group included 30 cases. The conventional double eyelid operation was adopted in treating the cases in the control group, while autogenous fat filling was adopted in the treatment of the cases in the experimental group. All patients in two groups were examined by CT images based on the symmetric extended convolutional residual network image denoising algorithm, and the therapeutic effects on patients in two groups and the evaluation of complications were compared. Next, the lesions of the complications of patients in the experimental group were examined pathologically. Besides, the efficacy and security of the pathological examination were assessed. The result showed that the values of peak signal-to-noise ratio (PSNR) and structural similarity (SSIM) (σ (noise level) = 60 : 24.78 dB, 0.7022) in different noise images of the artificial intelligence algorithm adopted in the research were obviously higher than those obtained by the convolutional neural network (CNN) and deep convolutional neural network (DCNN) algorithms (P &lt; 0.05). The therapeutic efficacy of patients in the experimental group was higher than that in the control group (68.67% vs 60%). In addition, eyelid swelling scoring, double eyelid line width, and upper eyelid muscle strength of patients in the experimental group were all better than those of patients in the control group (P &lt; 0.05). Besides, the incidence of complications (10%) of patients in the experimental group was significantly lower than that (30%) of patients in the control group. The pathological results of patients in the experimental group demonstrated that the lesion tissues might denature in future. As a result, the CT image processing of the algorithm adopted in this research could denoise effectively, and PSNR and SSIM values were high. In terms of the treatment by double eyelid operation, autogenous fat filling was effective, noninvasive, simple and resulted in low incidence of complications with a certain degree of security.

Diagnostic clues of IOP pulsation on applanation tonometry in carotid-cavernous fistula patients

BackgroundCarotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system and exhibits typical symptoms of red eye, diplopia, blurred vision, headache, and murmur. However, the symptoms for CCF may vary and can lead to misdiagnosis. IOP pulsations provide a hint leading to suspicion of CCF. We report three cases related to CCF differential diagnosis: two cases of CCF patients and one case of conjunctivitis with corkscrew conjunctival vessels.Case presentationThe case 1 patient, with a typical unilateral CCF, exhibited significant IOP pulsation in Goldmann tonometry measurements in the affected eye. The case 2 patient did not show typical symptoms of CCF except asymmetric upper eyelid swelling (right > left). In clinical evaluation, IOP elevation in the right eye and IOP pulsation in both eyes were noted. Based on radiology, the patient was diagnosed with bilateral CCF. The case 3 patient was referred to our institution for differential diagnosis of CCF. The patient had corkscrew conjunctival vessels in both eyes, which had appeared after he had been revived through CPR (cardiopulmonary resuscitation) 25 years prior. IOP pulsation was not observed in Goldmann tonometry. Radiology test result for arterio-venous fistula was negative in the case 3 patient.ConclusionFor diagnosis of CCF, IOP pulsation by Goldmann applanation tonometry exhibits a good correlation with the disease in our cases and provides useful diagnostic clues.

Presenting features for developmental cysts of the orbit.

To evaluate the clinical features of developmental cysts of the orbit. Retrospective study of patients who had excision of cysts between 1992 and 2020. Three hundred and 58 patients (189 male; 53%) with orbital developmental cysts were identified, all being unilateral. Age at surgery varied from birth to 77 years (mean 17, median 18 years) and the average symptom duration was 5 years (median 18 months; range 1 day-50 years). The commonest presenting features were a peribulbar lump or upper lid swelling, followed by proptosis, pain, diplopia and reduced vision. Most patients (82%) had a palpable mass, with epidermoids, sebaceous dermoids and keratinised dermoids commonly affecting the superotemporal quadrant, and conjunctiva-containing cysts usually being biased to a medial location. Cysts were lined by keratinised epithelium with dermal structures (224/358; 63%), non-keratinised epithelium with dermal structures (69/358; 19%), epidermis without identifiable dermal structures (19/358 'epidermoids'; 5%), conjunctiva (12/358; 3%), respiratory epithelium (4/358; 1%), or mixed dermal and conjunctival epithelia (30/358 'dermo-conjunctival' cysts; 8%). Overall, two-thirds (242/358; 66%) had histological evidence of chronic intramural inflammation, and a half of cysts showed granuloma formation (178/358 cysts). Chronic inflammation was less common with conjunctival cysts (54%, 7/12 patients) and none showed granuloma formation. Developmental cysts of the orbit vary from the relatively common dermoid cysts to the extremely rare respiratory epithelial-lined cysts. Respiratory cysts, being deeper, may present late in life and cysts containing conjunctival epithelium tend to be less inflamed and typically favour the superonasal quadrant.

Case of an Infant with Intermittent Eye Swelling.

Case PresentationAn eight-week-old infant presented to the emergency department with two weeks of fluctuating swelling and erythema of her right upper eyelid. On examination, she had swelling of the right upper eyelid with ptosis and proptosis as well as a nevus simplex on the upper eyelid. Orbital magnetic resonance imaging demonstrated a proliferating orbital hemangioma.DiscussionPeriorbital erythema and swelling are often infectious or allergic, but in infants with a fluctuating course, underlying vascular malformation must be considered. Without early provider recognition, periocular hemangiomas have the potential to cause vision-related complications.

Multiple Cranial Neuropathies as the Initial Presentation of Primary Ductal Adenocarcinoma of the Lacrimal Gland.

Primary ductal adenocarcinoma of the lacrimal gland is a rare, aggressive malignancy that clinically and histologically resembles salivary duct carcinoma. Similar to other malignant epithelial lacrimal gland tumors, ductal adenocarcinoma typically presents with unilateral proptosis, pain, upper eyelid swelling, palpable mass, diplopia, ptosis, and blurred or decreased vision. Rarely, primary malignant epithelial lacrimal gland tumors may first present with multiple cranial neuropathies due to occult spread to the cavernous sinus, as in this case. With such a vast differential diagnosis, a practical yet systematic approach to multiple cranial neuropathies, as guided by clinical history, exam, and neuroimaging, allows for a more targeted diagnostic evaluation, especially when multiple diagnostic tests and interventions return unrevealing. A repeat biopsy or complete excision of the lacrimal gland may be necessary to yield the correct diagnosis.

High-grade transformation of low-grade biphenotypic sinonasal sarcoma: Radiological, morphophenotypic variation and confirmatory molecular analysis

Biphenotypic sinonasal sarcoma (BSNS) is a recently described spindle cell sarcoma with neural and myogenic differentiation which arises exclusively in the sinonasal region.A man presented with swelling of left eyelid, and history of resection of a low-grade spindle cell mesenchymal tumor of left sinonasal cavity performed 15 years before. The original diagnosis was synovial sarcoma. Current MRI showed left supraorbital mass with intracranial extension. IR biopsy confirmed recurrence, and a left orbital craniotomy was done. NGS identified PAX3-MAML3 fusion in both, current and original tumor. The sarcoma was reclassified as BSNS, recurrent, with higher grade transformation. While the morphology, phenotype and molecular signature were in keeping with BSNS, the tumor showed biological progression towards a high-grade sarcoma.High-grade transformation of low-grade BSNS has not been described so far. High-grade transformation was not appreciated at the time of initial diagnosis, and it occurred in the local recurrence 15 years after.

Pain response and symptoms in photorefractive keratectomy: mechanical de-epithelization compared with transepithelial ablation.

To compare postoperative pain and discomfort between mechanical and transepithelial photorefractive keratectomies. This prospective comparative study included 190 eyes of 95 patients with hyperopia (up to +4.00 D), astigmatism (up to -5.00 D), and myopia (up to -8.00 D) who underwent mechanical photorefractive keratectomy in one eye and transepithelial photorefractive keratectomy in the contralateral eye using Wavelight Allegretto EX500 excimer laser. The patients were unaware of the side treated with each technique. The interval between operations in the same patient was 15-30 days. Both eyes had similar refraction before surgery, with a maximum of 15-µm difference in ablation. Postoperative questionnaires were administered on days 1 and 7 to assess the patients' level of discomfort (0=no discomfort to 5=extreme discomfort) with the following symptoms: pain, burning sensation, itchiness, tearing, photophobia, eye redness, foreign body sensation, and eyelid swelling. Patients were also asked about which method they preferred. The sample consisted of 61 women (64.21%) and 34 men (35.79%). The mean (SD) patient age was 31.66 (6.69) years (range, 22-54 years). On postoperative day 1, the patients reported significantly less discomfort in terms of pain (1.9 ± 1.74 vs 2.5 ± 1.83; p=0.017), burning sensation (1.8 ± 1.56 vs 2.5 ± 1.68; p=0.004), tearing (2.3 ± 1.71 vs 3.1 ± 1.69; p=0.001), and foreign body sensation (1.9 ± 1.77 vs 2.5 ± 1.86; p=0.024) in the eye that received mechanical photorefractive keratectomy than in the eye that received transepithelial photorefractive keratectomy. No significant differences were found between the mechanical and transepithelial photorefractive keratectomies on postoperative day 7. Fifty-nine patients (62.10%) preferred mechanical photorefractive keratectomy, while 32 (33.68%) preferred transepithelial photorefractive keratectomy. Four patients (4.22%) expressed no preference. Our results showed that pain scores were significantly lower in the mechanical photorefractive keratectomy-treated eyes than in the transepithelial photorefractive keratectomy-treated eyes on postoperative day 1, which may have provided greater patient comfort after surgery and led patients to prefer the mechanical photorefractive keratectomy technique.