American Journal of Ophthalmology Case Reports, 2021
Purpose To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) ... more Purpose To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) treated with teprotumumab. Observations In this multicenter observational Case series, patients with DON were treated with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with acute and chronic thyroid eye disease (TED) with DON who had failed conventional therapies and were not candidates for surgical decompression. Data collected included best corrected visual acuity (BCVA), color vision, RAPD when present, and orbital CT or MRI. Proptosis, clinical activity score (CAS), Gorman diplopia score (GDS), and Humphrey visual fields (HVF) were also evaluated. Ten patients (6 women, 4 men) with an average age 64 years old were included in this study. Mean follow up after completion of infusions was 15 weeks. Baseline visual acuity (VA) impairment ranged from hand motion (HM) to 20/25 in affected eyes. All patients had pre-treatment orbital CT or MRI that confirmed orbital apex compression. Seventy percent of patients had objective improvement in DON after 2 infusions of teprotumumab measured as significant improvement in visual acuity, resolution of RAPD, or both. After completion of treatment, affected eyes had a mean BCVA improvement of 0.87 logMAR (p=0.0207), proptosis reduction of 4.7 mm (p<0.00001), CAS improvement of 5.25 points (p<0.00001), and GDS improvement of 0.75 points (p=0.160). All 6 patients who presented with an RAPD had resolution or improvement of RAPD. All 7 patients who presented with color vision deficits had normalization or improvement of color vision. Conclusions and Importance Teprotumumab infusions resulted in medical decompression and objective resolution or improvement of dysthyroid optic neuropathy. Most patients had rapid improvement of visual acuity and reversal of RAPD. Post-infusion imaging demonstrated reduction in extraocular muscle size that correlated with improvement in visual dysfunction. However, patients who presented with longstanding severe visual loss had limited improvement. There was no recurrence of DON after completion of teprotumumab in our cohort.
Thyroid Eye Disease (TED, Graves ophthalmopathy, thyroid ophthalmopathy) is the most common cause... more Thyroid Eye Disease (TED, Graves ophthalmopathy, thyroid ophthalmopathy) is the most common cause of orbital inflammation and proptosis in adults. There is no agreement on its management although corticosteroids and external beam orbital radiation (XRT) have traditionally been believed to provide benefit in active inflammation. Our review of the published literature in English disclosed an overall corticosteroid-mediated treatment response of 66.9% in a total of 834 treated patients who had moderate or severe TED. Intravenous corticosteroids used in repeated weekly pulses were more effective (overall favorable response = 74.6%, n = 177) and had fewer side effects than daily oral corticosteroids (overall favorable response = 55.5%, n = 265). A combination of corticosteroid and radiation therapy seemed to be more effective than corticosteroids alone. Our conclusions are tempered by a notable lack of standardization within and between study designs, treatment protocols, and outcome measures. Accordingly, the North American Neuro-Ophthalmology Society (NANOS), American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and the Orbital Society, in conjunction with Neuro-Ophthalmology Research and Development Consortium (NORDIC), will investigate the design and funding of a multi-center controlled trial.
To describe our experience using acellular human dermal matrix (AlloDerm) as a full-thickness ski... more To describe our experience using acellular human dermal matrix (AlloDerm) as a full-thickness skin graft substitute for large periocular cutaneous defects. Retrospective review of the clinical records of all patients who received an acellular dermal allograft between 1997 and 2006 to reconstruct a large periocular cutaneous defect. Clinical outcomes, including graft viability, patient acceptance, and postoperative appearance, were assessed, and complications were noted. AlloDerm was used in 6 patients who were not ideal candidates for autologous skin grafts or local flap reconstruction. Four patients had severe comorbid conditions limiting the extent of surgery that could be performed safely. Four patients received AlloDerm following excision of extensive skin cancer. Two patients had extensive facial and periorbital trauma necessitating rapid defect closure at the time of primary repair. Follow-up ranged from 6 to 33 months.AlloDerm was easy to handle and shape, and it effectively covered the defects. Grafts were successfully epithelialized in all patients. One patient required a full-thickness skin graft 3 months following the original surgery for a cicatricial ectropion. No other postoperative complications were noted. Postoperative photographs demonstrated acceptable cosmetic appearance after epithelialization was complete. In patients for whom large full-thickness periorbital skin grafts or flaps are either inappropriate or extremely difficult to perform, the use of AlloDerm to cover a large cutaneous defect may be a viable option. Clinicians should consider covering large periorbital skin defects with AlloDerm in situations where autologous skin grafting or flap construction may be problematic or where extensive surgery may be hazardous to the patient.
Recent studies suggest an increasing incidence of gram-negative bacteria and methicillin-resistan... more Recent studies suggest an increasing incidence of gram-negative bacteria and methicillin-resistant Staphylococcus aureus in dacryocystitis. Since patients are often treated empirically without culture data, a changing microbiologic profile will markedly affect the success of oral treatment. To provide current guidelines for the treatment of this common condition, we investigated the microbiology and antibiogram of dacryocystitis seen at our institution. The charts of all patients presenting with acute and/or chronic dacryocystitis in University Hospital, Newark, from 2007 to 2015 were reviewed. Patient demographics, culture isolates, and in vitro antimicrobial susceptibility data were collected. Additional sensitivity data were obtained from the Sanford Guide to Antimicrobial Therapy. A total of 137 patients were included in the study. Of 205 samples collected, S. aureus was the most commonly isolated organism (46 of 156, 30%) followed by Pseudomonas species (19 of 156, 12%) and Pro...
American Journal of Ophthalmology Case Reports, 2021
Purpose To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) ... more Purpose To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) treated with teprotumumab. Observations In this multicenter observational Case series, patients with DON were treated with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with acute and chronic thyroid eye disease (TED) with DON who had failed conventional therapies and were not candidates for surgical decompression. Data collected included best corrected visual acuity (BCVA), color vision, RAPD when present, and orbital CT or MRI. Proptosis, clinical activity score (CAS), Gorman diplopia score (GDS), and Humphrey visual fields (HVF) were also evaluated. Ten patients (6 women, 4 men) with an average age 64 years old were included in this study. Mean follow up after completion of infusions was 15 weeks. Baseline visual acuity (VA) impairment ranged from hand motion (HM) to 20/25 in affected eyes. All patients had pre-treatment orbital CT or MRI that confirmed orbital apex compression. Seventy percent of patients had objective improvement in DON after 2 infusions of teprotumumab measured as significant improvement in visual acuity, resolution of RAPD, or both. After completion of treatment, affected eyes had a mean BCVA improvement of 0.87 logMAR (p=0.0207), proptosis reduction of 4.7 mm (p<0.00001), CAS improvement of 5.25 points (p<0.00001), and GDS improvement of 0.75 points (p=0.160). All 6 patients who presented with an RAPD had resolution or improvement of RAPD. All 7 patients who presented with color vision deficits had normalization or improvement of color vision. Conclusions and Importance Teprotumumab infusions resulted in medical decompression and objective resolution or improvement of dysthyroid optic neuropathy. Most patients had rapid improvement of visual acuity and reversal of RAPD. Post-infusion imaging demonstrated reduction in extraocular muscle size that correlated with improvement in visual dysfunction. However, patients who presented with longstanding severe visual loss had limited improvement. There was no recurrence of DON after completion of teprotumumab in our cohort.
Thyroid Eye Disease (TED, Graves ophthalmopathy, thyroid ophthalmopathy) is the most common cause... more Thyroid Eye Disease (TED, Graves ophthalmopathy, thyroid ophthalmopathy) is the most common cause of orbital inflammation and proptosis in adults. There is no agreement on its management although corticosteroids and external beam orbital radiation (XRT) have traditionally been believed to provide benefit in active inflammation. Our review of the published literature in English disclosed an overall corticosteroid-mediated treatment response of 66.9% in a total of 834 treated patients who had moderate or severe TED. Intravenous corticosteroids used in repeated weekly pulses were more effective (overall favorable response = 74.6%, n = 177) and had fewer side effects than daily oral corticosteroids (overall favorable response = 55.5%, n = 265). A combination of corticosteroid and radiation therapy seemed to be more effective than corticosteroids alone. Our conclusions are tempered by a notable lack of standardization within and between study designs, treatment protocols, and outcome measures. Accordingly, the North American Neuro-Ophthalmology Society (NANOS), American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and the Orbital Society, in conjunction with Neuro-Ophthalmology Research and Development Consortium (NORDIC), will investigate the design and funding of a multi-center controlled trial.
To describe our experience using acellular human dermal matrix (AlloDerm) as a full-thickness ski... more To describe our experience using acellular human dermal matrix (AlloDerm) as a full-thickness skin graft substitute for large periocular cutaneous defects. Retrospective review of the clinical records of all patients who received an acellular dermal allograft between 1997 and 2006 to reconstruct a large periocular cutaneous defect. Clinical outcomes, including graft viability, patient acceptance, and postoperative appearance, were assessed, and complications were noted. AlloDerm was used in 6 patients who were not ideal candidates for autologous skin grafts or local flap reconstruction. Four patients had severe comorbid conditions limiting the extent of surgery that could be performed safely. Four patients received AlloDerm following excision of extensive skin cancer. Two patients had extensive facial and periorbital trauma necessitating rapid defect closure at the time of primary repair. Follow-up ranged from 6 to 33 months.AlloDerm was easy to handle and shape, and it effectively covered the defects. Grafts were successfully epithelialized in all patients. One patient required a full-thickness skin graft 3 months following the original surgery for a cicatricial ectropion. No other postoperative complications were noted. Postoperative photographs demonstrated acceptable cosmetic appearance after epithelialization was complete. In patients for whom large full-thickness periorbital skin grafts or flaps are either inappropriate or extremely difficult to perform, the use of AlloDerm to cover a large cutaneous defect may be a viable option. Clinicians should consider covering large periorbital skin defects with AlloDerm in situations where autologous skin grafting or flap construction may be problematic or where extensive surgery may be hazardous to the patient.
Recent studies suggest an increasing incidence of gram-negative bacteria and methicillin-resistan... more Recent studies suggest an increasing incidence of gram-negative bacteria and methicillin-resistant Staphylococcus aureus in dacryocystitis. Since patients are often treated empirically without culture data, a changing microbiologic profile will markedly affect the success of oral treatment. To provide current guidelines for the treatment of this common condition, we investigated the microbiology and antibiogram of dacryocystitis seen at our institution. The charts of all patients presenting with acute and/or chronic dacryocystitis in University Hospital, Newark, from 2007 to 2015 were reviewed. Patient demographics, culture isolates, and in vitro antimicrobial susceptibility data were collected. Additional sensitivity data were obtained from the Sanford Guide to Antimicrobial Therapy. A total of 137 patients were included in the study. Of 205 samples collected, S. aureus was the most commonly isolated organism (46 of 156, 30%) followed by Pseudomonas species (19 of 156, 12%) and Pro...
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