Trace Elements in Tears: Comparison of Rural and Urban Populations Using Particle Induced X-ray Emission

We aimed to evaluate the types and concentrations of trace elements in tears of individuals living in urban and rural environments using particle induced X-ray emission (PIXE) and the possible association with exposure to air pollution and suggest a novel method for tear-based biomonitoring studies. This cross-sectional pilot study comprised 42 healthy subjects, 28 living in a rural area and 14 in an industrial city. Tears were collected with Schirmer paper and characterized by PIXE. Trace element concentrations from both eyes were averaged together with environmental pollution data. Main outcome measures were between-group differences in types and concentrations of trace elements in tears and comparison to environmental data. The rural group included 12/28 men, mean age 45.2 ± 14.8 years. The urban group consisted of 11/14 men of mean age 27 ± 5.9 years. Six rural and all urban were active smokers. Air pollution data showed more toxic elements in the rural environment. On PIXE analysis, chlorine, sodium, and potassium were found in similar concentrations in all samples. Normalizing to chlorine yielded higher values of aluminum, iron, copper, and titanium in the rural group; aluminum was found only in the rural group. The higher levels of certain trace elements in the rural group may, in part, be a consequence of exposure to specific environmental conditions. No direct association was found with air pollution data. PIXE is useful to analyze trace elements in tears, which might serve as a marker for individual exposure to environmental pollutants in biomonitoring studies.

The Management of Congenital Microphthalmia With Orbital Cyst: A Case Series

PURPOSE

To describe a series of patients treated for congenital microphthalmia associated with orbital cyst and recommend a management protocol.

METHODS

This retrospective case series comprised 6 patients (7 eyes) who attended an oculoplastic tertiary medical center from 2001 to 2018. Clinical, treatment, and outcome data were collected from the electronic files. Main outcome measures were preservation of vision and cosmetic appearance.

RESULTS

Four patients were diagnosed at birth. Six cysts were located inferiorly and one superiorly. Two patients had a visual potential of light perception or better in the affected eye. In 4 eyes, the cyst was initially retained and the eye was fitted with a custom-made conformer. In 1 eye, the fornices were too shallow for a conformer, warranting fornix reconstruction and cyst excision. Early surgery was required in 1 eye for an expanded cyst and large orbit volume, and in another eye the cyst had overgrown the orbit, causing bone erosion and remodeling. Cosmetic results were good in 3 of the eyes in which the cyst was retained in early childhood, stimulating orbital growth.

CONCLUSIONS

Congenital microphthalmia with orbital cyst is rare. Management should focus on preserving visual potential, especially in unilateral cyst cases when the other eye is also microphthalmic. Otherwise cosmetic symmetry is the main concern; cyst retention combined with ocular conformers may stimulate socket expansion. The authors found that, in most cases, if treated early, enucleation was avoidable during cyst excision. Early assessment, meticulous follow-up, and individually tailored treatment are warranted. [J Pediatr Ophthalmol Strabismus. 2022;59(3):192-199.].

Assessing the results of anophthalmic prostheses

Purpose

Anophthalmic sockets cause disfigurement that may result in emotional and social distress. The choice of procedure and implant is based upon the surgeon's experience. There remains no standardization of cosmetic result. We sought to identify quantifiable anatomical features and functional properties related to a successful cosmetic result in patients with ocular prosthesis and to determine correlations between self-reported and third-party assessment of cosmetic success.

Methods

This was a prospective observational study, which included 107 adult patients (50.1% female; age 53.08 ± 18.64 years, range 18-89) with acquired anophthalmia following prosthesis fitting. Patients completed a self-assessment questionnaire on self-perception of body image and ocular properties. Three independent examiners assessed cosmetic score. Assessed variables included prosthesis movement, eyelid symmetry, prosthesis stability, and socket fullness.

Results

The general cosmetic result was 8.1 ± 2.19 (on a predetermined scale of 1-10) as perceived by the patients and 7.2 ± 0.19 by the examiners. Interexaminer correlation was high for all variables (P < 0.05). A good cosmetic result was correlated with prosthesis movement (P = 0.02), eyelid symmetry (P = 0.001), and prosthesis stability (P = 0.01). Factors that correlated with a good cosmetic result on multivariate analysis were prosthesis movement (odds ratio [OR] 4.95, P = 0.004), eyelid symmetry (OR 4.51, P = 0.006), and socket fullness (OR 3.56, P = 0.005). No correlation was observed between patients' perceptions of the overall cosmetic result and those of the examiners.

Conclusion

The cosmetic result of prosthesis use among anophthalmic patients is generally good, as perceived by both patients and examiners. Good eyelid position and symmetry, orbital fullness, and prosthesis motility were associated with a better cosmetic result.

Proptosis due to intraorbital space-occupying lesions in children

PURPOSE

To report the 10-year experience of two tertiary medical centers with children presenting with proptosis due to an intraorbital space-occupying lesion.

METHODS

Patients were identified by file review. Data were collected on demographics, findings on ophthalmologic and imaging evaluations, etiology, treatment, and outcome.

RESULTS

Nineteen children (7 male) were included. Eleven patients had optic nerve glioma, including 9 with substantially decreased visual acuity. Treatment consisted of chemotherapy alone or with radiation, resection or anti-VEGF agents, MEK inhibitor, or observation only (n = 1). Visual and cosmetic outcomes were poor in all cases. Outcome for arteriovenous malformations was good following corticosteroid treatment (n = 1), but catheterization led to persistent proptosis and fluctuating visual acuity (n = 1). Compound capillary hemangioma (n = 1) was treated with laser and systemic beta blockers with satisfactory results. Rhabdomyosarcoma had a good prognosis in one patient treated with resection and radiation but was fatal in another even after chemotherapy. Juvenile xanthogranuloma, frontal bone osteoma, and localized hypertrophic neuropathy of the supraorbital nerve (n = 1 each) were treated by resection with good visual and cosmetic outcomes.

CONCLUSIONS

Proptosis accompanied by visual loss is an uncommon presentation in children and suggests an orbital tumor. We found that visual outcome was better when the nerve was not involved by tumor. Optic nerve glioma was the most common cause and failed to respond to various treatments. Catheterization for arteriovenous malformation did not prevent proptosis, and final visual acuity fluctuated. Surgery for rhabdomyosarcoma and xanthogranuloma led to remission with preservation of vision in 2 of 3 cases.

Gene-Related Response of Basal Cell Carcinoma to Biologic Treatment with Vismodegib

We aimed to characterise the response of locally advanced basal cell carcinoma (BCC) to systemic treatment with Vismodegib, a Hedgehog pathway inhibitor, by changes in the expression levels of Hedgehog pathway genes. Data were collected prospectively on 12 patients treated systemically for locally advanced BCC. Biopsy samples taken on admission and after treatment cessation were analysed pathologically and with the NanoString nCounter system to quantify the expression of 40 Hedgehog signaling pathway genes. Findings were compared before and after treatment, between complete and partial responders, and with localised BCC samples from 22 patients. Sixteen Hedgehog pathway genes changed significantly from before to after treatment. GAS1 was the only gene with a significantly different expression at baseline between complete responders (6 patients) and partial responders (4 patients) to Vismodegib (P = 0.014). GAS, GLIS2 and PRKACG1 showed different expression before treatment between the locally advanced and localised BCCs. The baseline expression level of GAS1 appears to be predictive of the response of locally advanced BCC to systemic Vismodegib treatment. A change in expression of many Hedgehog pathway genes, albeit expected by the known activity of Vismodegib, may nevertheless serve as an indicator of the response potential of the tumour.

Clinical assessment of thyroid related orbitopathy: a review

This review follows the process of evaluation of thyroid related orbitopathy (TRO) patients from diagnosis to treatment decision. We will attempt to define the criteria for referring TRO patients to the ophthalmologist and establish a common basis for orbital examination and TRO patient assessment. This should help classify TRO patients and achieve the best treatment regime. Thyroid related orbitopathy (TRO) is an endocrine disorder with orbital manifestations. Though most patients are first seen by an endocrinologist because of thyroid function disturbance symptoms, approximately 10% will first be seen by an ophthalmologist due to orbitopathy symptoms and signs (1). In the majority of cases the time interval between the appearance of dysthyroid symptomatology and orbital signs is less than a year. Among patients with thyroid endocrine dysfunction, 25% to 50% will gradually develop TRO. Most will have mild orbital manifestations, 28% will develop moderate to severe signs and only 3-5% will have the severe form (2). In this review we will follow the TRO patient through his first steps in the orbital clinic and emphasize the importance of clinical assessment as a crucial phase in determining the appropriate therapeutic approach.

Graves' orbitopathy in a patient with adrenoleukodystrophy after bone marrow transplantation

OBJECTIVE

For many years, the treatment of X-linked childhood cerebral adrenoleukodystrophy (XALD) consisted of hydrocortisone replacement and a mixture of short chain-fatty acids, known as 'Lorenzo's oil'. Recently, bone marrow transplantation (BMT) has also been used.

CASE REPORT

We report the case of a patient affected by XALD who developed Graves' hyperthyroidism (GH) and Graves' orbitopathy (GO) after BMT and who we could follow-up for 6.5 years afterwards.

EVIDENCE SYNTHESIS

A boy affected by XALD was treated at the age of 6 years, with a whole BMT from his sister. One year after BMT, the transplanted patient presented TSH at the lower normal value and 3 years later he developed thyrotoxicosis. After a further 2 years, the patient developed GO, which showed clinical evidence of reactivation 5 years after its onset as a consequence of an attempt to treat thyrotoxicosis by means of I(131) (300 MBq). Seven years after BMT, the donor showed alterations of thyroid autoimmunity and 1 year thereafter she developed GH. She never presented GO during a subsequent 5 year follow-up.

CONCLUSIONS

This case illustrates that autoimmunity originating from a pre-symptomatic donor can be transferred into the host during allogeneic stem cell transplantation. In cases where autoimmune phenomena are recognized in the donor prior to donation, alternative donors or T-cell manipulation of the graft might be considered.

Unilateral blindness following septoplasty

Visual loss following routine nasal surgery is an extremely rare and devastating complication. We report a case of unilateral blindness due to orbital apex syndrome following septoplasty. We also review the literature and discuss probable causes. To the best of our knowledge, this is only the second published report of this complication.

Favorable effects of lacrimal plugs in patients with an anophthalmic socket

BACKGROUND

The use of punctal plugs in the treatment of dry eyes is well established. Anophthalmic patients have less tears in the anophthalmic socket in comparison to their normal side, due to an absent corneal reflex (Lee & Elsie, 1981a,b). Many of those patients complain of dry eye symptoms, even when they are treated with tear replacement therapy. The authors wished to examine whether they could improve their dry socket complaints with punctal plugs.

PURPOSE

To evaluate the clinical efficacy and tolerability of punctal plug (Smart Plugs) insertion in anophthalmic patients with symptoms of dry eye.

PATIENTS AND METHODS

Interventional case series. Fifteen anophthalmic patients with dry eye symptoms, a Schirmer test of less than 3 mm and an open lacrimal passage were examined before and after insertion of punctal plugs. The patients were asked for their subjective evaluation of the treatment and were examined to evaluate the change. Schirmer tests were compared. Bacterial cultures were taken at both visits.

RESULTS

Schirmer results of less than 3 mm in the anophthalmic socket were obtained in 75% of patients with dry eyes symptoms; 87% of patients in whom punctal plugs were inserted reported an improvement in dry eye sensation. More than half of the patients demonstrated less discharge (p < or = 0.05). Schirmer tests improved from 1.4 mm to 1.9 mm (p < or = 0.05). Patients with a Schirmer outcome of 2 mm or more tended to have less pathogenic bacterial cultures (p = 0.11).

CONCLUSION

Punctal plugs improve the symptoms and signs of dry socket. Punctal plugs seem to reduce the pathogenic bacterial growth in the anophthalmic socket.

Effect of Exophthalmometer Design on Its Accuracy

PURPOSE

To investigate the effect of the design of different exophthalmometers on their measurement accuracy.

METHODS

Eight different exophthalmometers were tested with a specially developed calibrator by experienced orbital surgeons.

RESULTS

Exophthalmometers with one mirror and a straight footplate were found to be more accurate than others. One-mirror exophthalmometers were less accurate when assessing low (< or =12 mm) and high (> or =23 mm) exophthalmometric values.

CONCLUSIONS

The design of an exophthalmometer affects its accuracy.

Interferon-?????Associated Bilateral Simultaneous Ischemic Optic Neuropathy

The authors describe one patient with essential thrombocytosis and one with chronic hepatitis C infection who developed bilateral simultaneous anterior ischemic optic neuropathy within 3 months of starting treatment with interferon-alpha. One patient had several typical risk factors for conventional AION; the other did not. These cases are the fourth and fifth reported examples of this phenomenon. Interferon-alpha treatment may cause or aggravate the risk of developing anterior ischemic optic neuropathy. Vulnerable patients should be advised of this potential complication, assisted in reducing risk factors, and monitored for optic nerve and retinal vascular complications.