A 66-year-old female with a past medical history of psoriasis and chronic sinusitis presented with left orbital pain, proptosis, ptosis, and blurry vision, concerning for orbital cellulitis. Imaging revealed an enhancing soft tissue mass centered in the left anterior ethmoid cavity with extension into the nasolacrimal duct, with associated osseous erosion and orbital inflammatory changes consistent with ipsilateral orbital cellulitis. Endoscopic surgical resection was performed, and histopathology confirmed inverted papilloma without high-grade dysplasia or carcinoma. While orbital involvement has been described in prior reports, presentation with secondary infectious complications such as orbital cellulitis is rare. This case expands the limited, yet growing, body of literature on the various clinical presentations of orbital inverted papilloma.

An 80-year-old male had undergone extensive left upper eyelid reconstruction. Over the following 14.5 years, he had mild, minimally symptomatic lagophthalmos. He was then started on topical prostaglandin analogues and developed progressive eyelid retraction, lagophthalmos, and ocular exposure. The medication was discontinued, and the findings improved over the following 4 months.

A 2-year-old male presented to ophthalmology following a short admission for dacryoadenitis, with a background of 6 months of bilateral fluctuating upper lid swelling, obstructive airway disease, and enlarged tonsils. He had been treated for an allergy-related disease with little effect and, post-hospital discharge, continued in a similar fashion as prior. Given the poor response to escalating allergy medication, a biopsy was taken from the right lacrimal gland. This demonstrated an eosinophil-rich small vessel vasculitis with extravascular eosinophilic granulomas, consistent with a diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome. The patient was placed on a tapering course of steroids and started on long-term mycophenolate immunosuppression. To our knowledge, this patient is the youngest case of EGPA with orbital involvement. The case and its heterogeneous presentation add to the growing knowledge of this rare condition.

Kikuchi-Fujimoto disease is a rare, benign, self-limited inflammatory disorder characterized by necrotizing lymphadenitis. Ocular manifestations are uncommon, and periocular involvement is rare. We report a 16-year-old male with a remote history of biopsy-proven Kikuchi-Fujimoto disease who presented with a 2-year history of recurrent left upper and lower eyelid lesions clinically diagnosed as chalazia. Despite multiple incision and drainage procedures, the lesions recurred and were associated with progressive eyelid thickening and mechanical ptosis. Magnetic resonance imaging demonstrated diffuse cervical, parotid, and supraclavicular lymphadenopathy with enhancement of the lacrimal glands and eyelids. Biopsy of the eyelid lesions demonstrated necrotizing lymphohistiocytic inflammation with characteristic histopathologic and immunohistochemical findings supporting extranodal Kikuchi-Fujimoto disease and excluding lymphoma, chalazia, or infection. Following incisional biopsy and intralesional corticosteroid injection, the patient demonstrated marked clinical improvement without recurrence at postoperative month 1. To our knowledge, this represents the first reported case of Kikuchi-Fujimoto disease presenting as chronic eyelid lesions mimicking chalazia and further expands the spectrum of ophthalmic manifestations associated with this uncommon disease.

Cerebrospinal fluid (CSF) leak during endonasal dacryocystorhinostomy is a rare, life-threatening, and underreported complication. We present 3 cases of 2 males and 1 female with an age range of 48 to 79 years. All cases involved patients with narrow nasal passages and were performed by early career surgeons. No intraoperative complications were noted in 2 cases, while severe epistaxis occurred in 1 case during superior osteotomy. All patients developed a headache within the first 48 hours, and cerebrospinal fluid rhinorrhea occurred in 1 case. Two patients developed bacterial meningitis and required intubation and ventilatory support, with 1 fatality. Imaging revealed pneumocephalus in all cases and a transverse venous sinus thrombosis in one. A break in the fovea ethmoidalis was identified in all cases, located posterior to the lacrimal sac. These defects were either at the vertical insertion of the middle turbinate or in association with an extended osteotomy superoposteriorly to the sac.

A 36-year-old woman at 36 weeks gestation presented with 5 months of pain on upgaze and 2 months of progressive vision loss in the right eye. Examination revealed 20/200 acuity, a relative afferent pupillary defect, proptosis, motility restriction, disc edema, and visual field loss. Noncontrast MRI showed a lobulated superolateral orbital apex mass, with differential diagnosis including an orbital vascular malformation enlarged by gestational hypervolemia versus a hormonally sensitive meningioma. Given severe vision loss and advanced gestational age, induced delivery was performed. Postpartum imaging and rapid partial visual recovery favored a vascular etiology. Because spontaneous resolution could not be reliably timed to prevent permanent damage, endoscopic transethmoidal posterior medial wall decompression was performed, restoring vision to 20/20-1 with subsequent lesion regression and normalization of examination findings by 4 months postpartum. Coordinated obstetric-ophthalmic management achieved excellent maternal and fetal outcomes.

Teprotumumab has demonstrated significant efficacy in active, moderate-to-severe thyroid eye disease; however, concerns remain regarding the durability of response, especially in high-risk patients with recalcitrant disease and risk of compressive optic neuropathy. Orbital radiation therapy has historically been shown to reduce the risk of vision loss from compressive optic neuropathy in muscle-predominant phenotypes, but its role in the biologic era remains unclear. We report a patient with recalcitrant, muscle-predominant thyroid eye disease with radiographic apical crowding who experienced repeated disease reactivations despite multiple courses of teprotumumab and immunomodulatory therapies. Following orbital radiation therapy, the patient demonstrated sustained orbital disease stabilization and resolution of compressive optic neuropathy despite recurrence of severe pretibial myxedema and elevated thyroid-stimulating antibodies. This case suggests that adjunctive orbital radiation therapy with teprotumumab may provide durable orbital disease control despite ongoing systemic reactivations and lower the risk of compressive optic neuropathy in high-risk recalcitrant thyroid eye disease, supporting its continued role as a disease-modifying adjunct in select patients.

Nodular fasciitis (NF) is a benign, rapidly growing myofibroblastic proliferation that can closely mimic sarcoma clinically, radiographically, and histologically, posing a significant diagnostic challenge. We report a case of an 11-year-old boy presenting with a painless but progressively enlarging periorbital mass initially suspected to be a dermoid cyst. Although his ultrasound was reassuring, MRI showed an enhancing lesion concerning for neoplasm, prompting surgical excision. Histopathologic evaluation revealed spindle-cell proliferation within a myxoid stroma consistent with NF. However, the USP6 fluorescence in situ hybridization analysis was negative. Further genomic analysis identified a rare USP6-PAFAH1B1 fusion. This case highlights a diagnostically challenging subset of NF in which conventional USP6 fluorescence in situ hybridization testing may be negative, necessitating next-generation sequencing for a definitive diagnosis. Increased awareness of NF and its clinical, histologic, genetic, and radiographic presentation is essential to avoid misdiagnosis and to guide appropriate management.