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Thyroid eye disease (TED) is a rare disease that can lead to decreased quality of life, permanent disfigurement, and vision loss. Clinically, TED presents with exophthalmos, periorbital edema, extraocular muscle dysfunction, and eyelid retraction, and can lead to vision-threatening complications such as exposure to keratopathy and dysthyroid optic neuropathy (DON). Over the last several years, significant advancements have been made in the understanding of its pathophysiology as well as optimal management. Ethnic variations in the prevalence, clinical presentation, and risk of vision-threatening complications of TED are summarized, and risk factors associated with TED are discussed. Additionally, significant advances have been made in the management of TED. The management of TED traditionally included anti-inflammatory medications, orbital radiation therapy, orbital surgical decompression, and biologic therapies. Most recently, targeted therapies such as teprotumumab, an insulin-like growth factor-1 receptor antagonist, have been studied in the context of TED, with promising initial data. In this review, updates in the understanding and management of TED are presented with a focus on the international variations in presentation and management.

In the United States, women are at a higher risk of developing vision impairment or a serious eye disease (such as age-related macular degeneration, thyroid eye disease, or chronic dry eye disease) than men. Disparities in eye diseases due to biology widen even further when considering factors such as social determinants of health; gaps in research data, literature, and policy; insufficient provider and patient education; and limitations in screening and treatment options. Sex and gender disparities in eye health are clinically under-addressed and burdensome on both patient quality of life and the health care and economic systems, resulting in a pressing population health issue that negatively impacts women. The Society for Women's Health Research convened a working group of expert clinicians, researchers, and patient advocates to review the current state of science regarding sex and gender disparities in women's eye health, identify knowledge gaps and unmet needs, and explore better means to advance research, improve patient care, and raise awareness of key issues. The SWHR Women's Eye Health Working Group identified priority areas in research, clinical care, and education to reduce disparities and improve patient care in women's eye health. The working group recommends using a systems approach that incorporates a comprehensive research framework with a sex and gender lens to guide future work and that increases health care provider and public education, as well as engagement by expanding partnerships among ophthalmologic providers, researchers, and non-vision stakeholders.

In patients with thyroid-associated ophthalmopathy, responses to treatment are rare and usually minor. Teprotumumab, an antibody to the insulin-like growth factor I receptor, led to significant responses in 69% of patients and to decreased proptosis. Medical therapies for moderate-to-severe thyroid-associated ophthalmopathy (Graves’ orbitopathy) that have proved to be effective and safe in adequately powered, prospective, placebo-controlled trials are lacking. This unmet need is due to the incompletely understood pathogenesis of the disease. 1 Current treatments are inconsistently beneficial and often associated with side effects, and their modification of the ultimate disease outcome is uncertain. 1 – 3 Previous clinical trials, which were rarely placebo-controlled, suggest that high-dose glucocorticoids, alone 3 – 5 or with radiotherapy, 6 , 7 can reduce inflammation-related signs and symptoms in patients with active ophthalmopathy. However, glucocorticoids and orbital radiotherapy minimally affect proptosis and can cause dose-limiting adverse . . .

To identify cases of OCS, a query of the institution's electronic medical records and billing records was performed for ICD-9 codes (376.31, 376.32, 376.33, 921.2) and ICD-10 codes (H05.221, H05.222, H05.223, H05.232, H05.231, H05.233) related to OCS and for CPT® codes (67,715, 21,282) related to the LCC procedure. Participants were instructed to complete this self-directed study and pre-assessment (https://eyerounds.org/tutorials/ocs/), and subsequently, ophthalmology residents and an ophthalmology faculty member conducted a didactic session reviewing orbital anatomy, the clinical signs of OCS including instructions on how to measure intraocular pressure, and the management of OCS including a video of the LCC procedure. Participants were instructed to complete this self-directed study and pre-assessment (https://eyerounds.org/tutorials/ocs/), and subsequently, ophthalmology residents and an ophthalmology faculty member conducted a didactic session reviewing orbital anatomy, the clinical signs of OCS including instructions on how to measure intraocular pressure, and the management of OCS including a video of the LCC procedure. Pt # Age(yrs)/Sex Initial Intervention Final RAPD IOP (mmHg) Visual acuity Procedure Service(s) Performing Time from injury to LCC completion (minutes) IOP (mmHg) Visual acuity 1 70/M + 90 LP LCC & Superior lid splitting OSH ED, Level 1 ED, Ophtho 231 18 NLP 2 60/M + 87 NLP LCC Ophtho 600 30 LP 3 89/F + 86 NLP LCC Ophtho 450 46 NLP 4 44/M + 86 20/250 LCC Level 1 ED & Ophtho 390 24 20/15 5 83/F + 58 20/40 LCC Ophtho 335 21 20/30–2 6 92/F + Not checked CF at 1 ft LCC OSH ED & Ophtho 255 19 CF at 1 ft 7 46/F Not checked Not checked Not checked LCC Level 1 ED 120 29 20/25 8 53/M Minimally reactive 98 Unable LCC & Superior lid splitting Level 1 ED, ENT, Ophtho 220 26 20/25 9 56/F Fixed 49 Unable LCC Ophtho 225 19 Deceased 10 33/M Fixed 65 Unable LCC Level 1 ED & Ophtho 165 40 Deceased Table 1 Orbital compartment syndrome patients seen in the ED between 2016 and 2017 Key: RAPD: relative afferent pupillary defect; LCC: lateral canthotomy and cantholysis; M: male; F:

To describe 3 patients with chronic mucopurulent conjunctivitis found to have an unrecognized sequestration of bacteria within tarsoconjunctival crypts of the upper eyelid. Review of 3 noncomparative cases. settings_ Institutional. study population: Three consecutive patients with tarsoconjunctival crypts. intervention procedure: Marsupialization of the individual crypts. main outcome measures: Resolution of chronic discharge and resolution of signs and symptoms. One patient with Stevens-Johnson syndrome and 2 patients with floppy eyelids had chronic mucopurulent conjunctivitis that was refractory to multiple medical and surgical interventions. Retention of a yellowish coagulum within the fistulous tracts of the tarsal conjunctiva was the site of pathologic features in all patients. The diagnosis was confirmed by squeezing out of the coagulum from the fistulous tracts by pinching the eyelid horizontally. Pseudomonas aeruginosa was isolated in 1 patient and Staphylococcus aureus was isolated in the other 2 patients. A Bowman probe could be passed through the fistulous opening to unveil the full extent of the conjunctival tunnels on the epitarsal surface. Each tract was marsupialized, and no relapse was found during a follow-up period of 12 to 96 months. Patients with chronic, relapsing, purulent conjunctivitis should have their upper eyelid everted to search for tarsoconjunctival crypts as the source of bacteria-laden coagulum. The formation of the crypts is likely the result of tarsal conjunctiva trauma with lamellar de-epithelialization, followed by re-epithelialization to form an epithelialized tunnel as a potential space for harboring bacteria. Marsupialization of the crypts obliterates the potential space and is curative.

To evaluate the long-term effectiveness of improved ocular alignment using a suture/T-plate anchoring platform system. Retrospective, noncomparative, interventional case series. setting_ Institutional. study population: Seven consecutive patients with large angle deviations attributable to paralytic and/or restrictive strabismus managed jointly by orbital and strabismus surgeons. intervention procedure: The T-plate base is anchored to the orbital rim with the shaft projecting toward the orbital apex to simulate the origin of the affected muscle. A nonabsorbable suture serves as the coupling element linking the muscle insertion to the tip of the T-plate such that the suture coincides with the axis of the dysfunctional muscle and yields a pull vector to simulate the passive tensile force of the muscle. Information analyzed included patient demographics, etiology of strabismus and characteristics, prior muscle surgeries, secondary interventions, subjective appraisal of diplopia, and final ocular alignment measurements. main outcome measures: Subjective appraisal of diplopia, final ocular alignment in primary gaze, and late stability. All 7 patients showed marked reduction in ocular deviation with a median change of 33 prism diopters (PD) and a range of 7 to 72 PD. For the 6 patients with medial rectus dysfunction, the final ocular alignment ranged from 6 to 18 PD of residual exotropia in primary gaze. The patient with sixth nerve palsy had 5 PD of residual esotropia. There were no failures after an average of 59.4 months of follow-up. A globe tethering technique using a suture/titanium T-plate anchoring platform system effectively treats refractory cases of paralytic and restrictive strabismus with large angles of deviation.

The purpose of this study was to determine if patients with certain risk factors are more likely to harbor conjunctival bacterial flora resistant to multiple antibiotics. In this prospective study, detailed medical history and slit-lamp examination were performed on all patients prior to intraocular surgery. Patients with local risk factors were defined as those with chronic blepharitis, conjunctivitis or discharge. Those with systemic risk factors were patients with diabetes, autoimmune, immunodeficient or skin disorders, asthma and those taking immunosuppressant medications. Conjunctival cultures were obtained prior to preoperative antibiotics and povidone-iodine. Bacteria isolated were identified and antibiotic susceptibility was determined. Bacteria resistant to five or more antibiotics were defined as multi-resistant (MR). Among the 207 patients enrolled in the study, 73 patients had local risk factors. Of these patients, 32 patients (44%) carried MR organisms, compared to 32 of the 134 patients (24%) without local risk factors (P=0.0049). Thirty-two of 71 patients (45%) with systemic risk factors harbored MR organisms, compared to 32 of 136 patients (24%) without systemic risk factors (P=0.0025). Seventeen of 93 patients (18%) who had neither local nor systemic risk factors had MR organisms on their conjunctiva. In contrast, 17 of the 30 patients (57%) with both local and systemic risk factors (57%) carried MR bacteria (P=0.0001). Patients with local and/or systemic risk factors are more likely to harbor MR organisms. This may be one mechanism for the reported increased risk of postoperative endophthalmitis in this group of patients.

The article reports on a study to evaluate the safety and efficacy of teprotunumab as a form of treatment for patients with thyroid-associated ophthalmopathy. The results indicate that among these patients teprotunumab was found to be quite effective.

The range of a species is determined by the balance of its demographic rates across space. Population growth rates are widely hypothesized to be greatest at the geographic center of the species range, but indirect empirical support for this pattern using abundance as a proxy has been mixed, and demographic rates are rarely quantified on a large spatial scale. Therefore, the texture of how demographic rates of a species vary over its range remains an open question. We quantified seasonal fecundity of populations spanning the majority of the global range of a single species, the saltmarsh sparrow (Ammodramus caudacutus), which demonstrates a peak of abundance at the geographic center of its range. We used a novel, population projection method to estimate seasonal fecundity inclusive of seasonal and spatial variation in life history traits that contribute to seasonal fecundity. We replicated our study over 3 years, and compared seasonal fecundity to latitude and distance among plots. We observed large-scale patterns in some life history traits that contribute to seasonal fecundity, such as an increase in clutch size with latitude. However, we observed no relationship between latitude and seasonal fecundity. Instead, fecundity varied greatly among plots separated by as little as 1 km. Our results do not support the hypothesis that demographic rates are highest at the geographic and abundance center of a species range, but rather they suggest that local drivers strongly influence saltmarsh sparrow fecundity across their global range.