Eye pain is a common presentation in outpatient, urgent care, and emergency settings. Causes range from benign to vision-threatening. Family physicians should promptly identify red-flag features that require urgent or emergent ophthalmology referral. A painful eye with vision loss, severe photophobia, proptosis, hyphema, or corneal ulceration is a medical emergency. Patient history should include onset, associated vision changes, contact lens use, trauma, chemical exposure, systemic symptoms, and rheumatologic disease. Physical examination should include evaluation of visual acuity (eg, using a Snellen or Rosenbaum chart), pupillary reactions, and extraocular movements. The eyes should be inspected for redness, discharge, and corneal lesions with fluorescein, if available. Findings of significant photophobia, anisocoria, dendritic corneal lesions, or restricted eye movement should prompt immediate referral. Common emergent causes of eye pain include acute angle-closure glaucoma, orbital cellulitis, infectious keratitis, scleritis, and anterior uveitis. An algorithmic approach that distinguishes urgent vs nonurgent etiologies and ophthalmic vs nonophthalmic causes of eye pain can direct next steps.

Metastatic spread of invasive lobular carcinoma (ILC) to the eyelid is exceedingly rare and may masquerade as benign disease. We describe a woman in her 60s with a history of multifocal, estrogen receptor-positive ILC who presented with progressive, painless right periorbital swelling mimicking cellulitis. She was initially managed for presumed hordeolum and preseptal cellulitis without response over 4 months. Orbital MRI demonstrated non-specific preseptal thickening without a discrete mass. Given persistent symptoms, biopsy was pursued and revealed poorly differentiated carcinoma with immunohistochemical features consistent with breast origin. A repeat biopsy confirmed metastatic ILC with histiocytoid and signet ring cell morphology. This case highlights that orbital or eyelid metastasis from ILC can closely mimic inflammatory conditions and imaging may be non-diagnostic, delaying diagnosis. Clinicians should maintain suspicion for metastatic disease in patients with a history of breast cancer who develop unexplained orbital or eyelid changes to enable timely recognition and management.

Objective: To analyze the clinical characteristics, causative pathogens, complications, and treatment outcomes of orbital cellulitis in children. Methods: A retrospective cohort study was performed. Clinical data including clinical characteristics, laboratory tests, pathogen profiles, and treatment were analyzed for 175 pediatric patients with orbital cellulitis admitted to Beijing Children's Hospital, Capital Medical University from January 2016 to December 2023. Patients were categorized by lesion location into periorbital cellulitis (PC) and orbital cellulitis (OC) groups; by complication status into with and without complications. Intergroup comparisons were performed using the chi-square test and Mann-Whitney U test. Logistic regression analysis was used to identify risk factors for complications. Results: Of the 175 patients, 116 were male and 59 were female, with an age at presentation of 3.6 (2.1, 6.7) years. There were 81 patients in the PC group and 94 in the OC group. All patients presented with eyelid and periorbital erythema and edema. The OC group demonstrated higher proportions of males, sinusitis, proptosis, ocular motility disorders, bulbar conjunctival edema, and decreased visual acuity compared to the PC group, C-reactive protein levels, neutrophil counts, and platelet counts in the acute phase were also significantly higher in the OC group (all P<0.05). A definitive microbiological diagnosis was established in 74 cases (42.3%), and a total of 76 pathogenic strains were isolated. The most common pathogen was Staphylococcus aureus, accounting for 47 strains (61.8%), including 33 strains (43.4%) of methicillin-susceptible Staphylococcus aureus, and 14 strains (18.4%) of methicillin-resistant Staphylococcus aureus, followed by Streptococcus intermedius and Streptococcus constellatus with 6 strains each (7.9%), and Streptococcus pneumoniae and Pseudomonas aeruginosa with 4 strainss each (5.3%). Complications developed in 47 cases (26.8%), most commonly orbital abscesses in 29 cases (16.6%), followed by purulent meningitis in 14 cases (8.0%). Multivariate logistic regression analysis identified proptosis (OR=3.56, 95%CI 1.49-8.49), decreased visual acuity (OR=4.45, 95%CI 1.27-15.66), and headache (OR=2.76, 95%CI 1.01-7.57) as independent risk factors for complications (all P<0.05). Conclusions: Orbital cellulitis in children commonly presents with eyelid and periorbital redness and swelling. Male sex, sinusitis, proptosis, ocular motility disorders, bulbar conjunctival edema, and decreased vision acuity serve as high-risk indicators for orbital cellulitis. Elevated C-reactive protein, neutrophil count, and platelet counts in the acute phase are laboratory makers closely associated with orbital cellulitis. Staphylococcus aureus is the most common causative pathogen. Decreased vision acuity, proptosis, and headache suggest the presence of complications.

Rhino-orbital mucormycosis is a rare, life-threatening opportunistic fungal infection, typically affecting immunocompromised patients. During the COVID-19 pandemic, increased cases were mainly linked to SARS-CoV-2 infection, diabetes, and corticosteroid exposure. We report a severe case in a previously healthy 44-year-old immunocompetent man who developed acute left-sided exophthalmos, ophthalmoplegia, severe visual loss, and systemic deterioration 10 days after AZD1222 COVID-19 vaccination. Clinical and radiologic findings suggested invasive rhino-orbital fungal disease, prompting immediate liposomal amphotericin B, broad-spectrum antibiotics, urgent endoscopic sinus surgery, and repeated orbital-sinonasal debridements with amphotericin B irrigation. Histopathological examination demonstrated broad aseptate hyphae with tissue necrosis, consistent with mucormycosis, while fungal culture and ITS sequencing identified Rhizopus arrhizus as the causative species. Therapy was later adjusted to include isavuconazole and antibacterial coverage for persistent inflammation and secondary colonization. Orbital and systemic improvement occurred within the first week, with globe preservation and marked proptosis reduction at 6 months, despite persistent ophthalmoplegia and residual light perception. Isavuconazole was continued for 2 years, with no recurrence during 3 years of follow-up. Although causality with vaccination cannot be established, the temporal association and biological plausibility warrant further investigation. Early suspicion and prompt combined medical-surgical management are essential in rapidly progressive orbital cellulitis.

Endophthalmitis is a rare but sight-threatening ophthalmic emergency that may occur following trauma, surgery, or hematogenous spread of infection. Diagnosis may be particularly challenging in critically ill or sedated patients unable to report visual symptoms. A Caucasian male in his 50s was admitted to the ICU following a motor vehicle collision. During admission, progressive erythematous changes developed around the right eye in the absence of clinically identified ocular trauma, systemic infectious features, or subjective visual symptoms due to ongoing sedation. Computed tomography demonstrated orbital cellulitis with probable endophthalmitis and lens dislocation. Despite urgent ophthalmological intervention, systemic and intravitreal antimicrobial therapy, and orbital decompression, disease progression resulted in corneal perforation requiring enucleation. Early lens dislocation was considered a poor prognostic feature. This case highlights the diagnostic challenge of rapidly progressive endophthalmitis in sedated critically ill patients and emphasizes the importance of vigilant ocular assessment, early specialist involvement, and prompt treatment to minimize irreversible complications.

No regulatory agency-approved nucleic acid amplification tests (NAATs) exist for detecting Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (NG) in conjunctival samples, necessitating validation, including performance analysis. This is challenging due to case rarity and the absence of a gold standard. This retrospective case series evaluated the performance of the Roche cobas CT/NG NAAT on conjunctival samples using microbiological and clinical data. Clinical records of patients with positive CT/NG NAAT conjunctival samples processed in our laboratory between 2013 and 2023 were reviewed, along with matched negative controls. Positive results were confirmed using a stepwise algorithm: (i) positive NG culture (NG only); (ii) confirmatory CT/NG NAAT performed at the Laboratoire de santé publique du Québec (LSPQ); (iii) CT/NG NAAT from other anatomical sites; or (iv) clinical presentation compatible with CT/NG conjunctivitis. Negative controls were confirmed based on clinical information. Sixty-five positive conjunctival samples were included (53 CT-positive, 12 NG-positive). Of the 53 CT-positive samples, 52 were confirmed (21 by LSPQ testing, five by a concomitant genital sample, and 26 by a compatible presentation). Of 53 CT-negative controls, 45 were clinically confirmed as true negatives. Among the 12 NG-positive samples, 11 were confirmed (seven by culture, four by LSPQ testing). Of 12 NG-negative controls, 11 were clinically confirmed. Sensitivity and specificity were 87% and 98% for CT, and both were 92% for NG. Given sufficient data, the Roche cobas CT NAAT assay on conjunctival samples does not require confirmatory testing. However, confirmation of NG-positive results should continue until more data are available.