Publications by authors named "Brittany A Simmons"

11 Publications

  • Page 1 of 1

Misdiagnosis of fungal infections of the orbit.

Can J Ophthalmol 2022 May 4. Epub 2022 May 4.

From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Electronic address:

Objective: To evaluate the accuracy of the initial diagnosis in the case of fungal infections of the orbit and identify factors that may influence patient outcomes.

Methods: An institutional review board-approved retrospective chart review was conducted across 2 large academic centres to identify cases of fungal infections involving the orbit from January 1, 1998, to November 15, 2019. Data collected included patient demographics, past medical history, examination findings, diagnosis, treatment, imaging, and outcomes.

Results: Fifty cases of fungal infection involving the orbit were identified. Of these, 33 (66.0%) were initially misdiagnosed as nonfungal diagnoses. Sixteen patients (32.0%) received multiple initial diagnoses. The most common diagnoses on presentation were bacterial cellulitis (n = 12 of 50; 24.0%) and bacterial sinusitis (n = 12 of 50; 24.0%). These were followed by vascular and orbital inflammatory conditions (n = 9 of 50; 18.0%): 5 patients (10.0%) were clinically diagnosed with giant cell arteritis, 3 (6.0%) with nonspecific orbital inflammation, and 1 (2.0%) with optic neuritis. In this subset of patients, 77.8% (n = 7 of 9) were treated initially with systemic steroids. Additional initial diagnoses included neoplastic mass lesions, mucocele, dacryocystitis, cavernous sinus thrombosis, hemorrhage, tick-borne illness, allergic rhinitis, and allergic conjunctivitis. Misdiagnosis was significantly correlated with involvement of the masticator space on imaging (p = 0.04).

Conclusion: Fungal infections of the orbit are misdiagnosed in 2 of 3 cases. Nearly 15% of patients who are later diagnosed with fungal disease of the orbit were initially treated with systemic steroids. Misdiagnosis is more frequent when the masticator space is involved.
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http://dx.doi.org/10.1016/j.jcjo.2022.04.007DOI Listing
May 2022

The Effect of Teprotumumab on Eyelid Position in Patients with Thyroid Eye Disease.

Plast Reconstr Surg Glob Open 2022 Apr 22;10(4):e4287. Epub 2022 Apr 22.

Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Teprotumumab has been shown to improve proptosis and clinical activity scores (CAS) in patients with thyroid eye disease, but little has been published regarding its effects on eyelid retraction. The purpose of this work was to evaluate changes in eyelid position in thyroid eye disease patients after teprotumumab. Eight patients completed eight cycles of teprotumumab. Data collected included exophthalmometry; clinical activity scores; margin reflex distance (MRD) 1; MRD2; and pre-, during, and posttreatment photographs. ImageJ analysis was also used to evaluate eyelid position in photographs. Proptosis significantly improved in 15 of 16 orbits [mean 4.75 ± 2.07 mm reduction ( = 0.0001) in study orbits and mean 3.00 ± 2.14 mm reduction ( = 0.0048) in nonstudy orbits]. CAS was significantly reduced (pretreatment mean 4.88 mm and posttreatment mean 1.88 mm, 0.006). MRD1 decreased in 11 of 16 orbits and increased in five orbits ( 0.18 in study orbits and 0.22 in nonstudy orbits). MRD2 decreased in six of 16 orbits and increased in eight orbits ( 0.49 in study orbits and 0.43 in nonstudy orbits). Patients exhibited variable changes in eyelid position with teprotumumab. There was a statistically insignificant decrease in MRD1 after teprotumumab. Proptosis reduction led to unpredictable changes in MRD1 and MRD2. Severity of eyelid retraction did not correlate with clinical activity score response to teprotumumab. There are inherent difficulties in evaluating eyelid position in thyroid eye disease, which may necessitate a paradigm shift in how patients are examined, measured, and photographed.
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http://dx.doi.org/10.1097/GOX.0000000000004287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9029877PMC
April 2022

The role of teprotumumab in chronic, clinically active thyroid eye disease.

Eye (Lond) 2022 Jul 4;36(7):1500-1501. Epub 2022 Jan 4.

University of Iowa Hospital and Clinics, Department of Ophthalmology and Visual Sciences, Iowa City, IA, 52240, USA.

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http://dx.doi.org/10.1038/s41433-021-01904-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9232635PMC
July 2022

Echographic Assessment of Extraocular Muscle Response to Teprotumumab.

Ophthalmic Plast Reconstr Surg 2022 Jul-Aug 01;38(4):336-339. Epub 2022 Oct 13.

Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: To evaluate extraocular muscle response to teprotumumab using orbital echography in thyroid eye disease.

Methods: This retrospective study included adult thyroid eye disease patients with pre- and post-teprotumumab orbital echography. Data collected included: age, Hertel measurements, clinical activity score, Gorman diplopia scores, ocular motility, and recti muscle diameters measured by echography. The patient's more proptotic eye before treatment initiation was designated as the study orbit. Ocular motility was assessed by totaling the ductions in all 4 cardinal directions. Orbital echography was obtained pre- and post-treatment to assess response of extraocular muscle diameters.

Results: Six patients with a mean age of 67 years were included. There was a mean improvement in proptosis of 4.3 mm in the study eye with 11/12 orbits showing improvement in globe position ( p < 0.05). All patients had a decrease in clinical activity score with a mean reduction of 2.5. Four patients had an improvement in Gorman diplopia score. Ocular motility in the study orbits improved by a total mean of 26.9° ( p < 0.05). Mean total extraocular muscle diameter was reduced from 27.4 to 23.4 mm ( p < 0.001). On average, superior recti were largest pre- and post-treatment, followed by inferior, medial, then lateral recti. However, inferior recti showed the greatest reduction of 23% ( p < 0.02).

Conclusions: Orbital echography demonstrated extraocular muscle reduction in all patients after teprotumumab, correlating with improved clinical activity score, ocular motility, and proptosis. Orbital echography is a safe and cost-effective imaging alternative to monitor therapeutic response to teprotumumab.
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http://dx.doi.org/10.1097/IOP.0000000000002072DOI Listing
July 2022

Audiology findings in patients with teprotumumab associated otologic symptoms.

Am J Ophthalmol Case Rep 2021 Dec 16;24:101202. Epub 2021 Sep 16.

Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, USA.

Purpose: To report a case series of subjective and objective hearing function changes associated with teprotumumab treatment for thyroid eye disease.

Observations: A 74-year-old female with a history of Graves' disease with thyroid eye disease was treated with teprotumumab. She had a history of bilateral tinnitus and noticed a subjective improvement in her tinnitus after the second infusion. Audiology testing obtained before, during, and after completion of infusions showed symmetric and rapidly progressive worsening of the patient's sensorineural hearing loss. In contrast, a 42-year-old male with a history of Grave's disease endorsed worsening intermittent tinnitus and low-pitched hearing loss after initiation of teprotumumab. Audiology testing before, during, and after completion of infusions showed stable and normal hearing function bilaterally.

Conclusion And Importance: This case series highlights the importance of objective testing in patients prior to and after teprotumumab initiation as subjective hearing changes may not accurately reflect objective hearing function. In addition, this report suggests that teprotumumab may play a role in potentiating sensorineural hearing loss.
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http://dx.doi.org/10.1016/j.ajoc.2021.101202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8452766PMC
December 2021

Scleral Contact Lens as Initial Management in a Neonate With a Large Upper Eyelid Coloboma.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):e10-e13

From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.

A neonate presented with a large full-thickness upper eyelid coloboma with near-complete exposure of the cornea. After failing lubrication and a moisture chamber, he was fit with a customized scleral contact lens that protected the ocular surface. It was tolerated well, and ocular surface health was maintained for 13 months to permit the growth of eyelid tissue for future oculoplastic surgery. Delaying reconstruction by using scleral contact lenses as management for large eyelid colobomas has not been previously described. A temporizing measure such as this could be considered for large eyelid colobomas in neonates.
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http://dx.doi.org/10.1097/IOP.0000000000002057DOI Listing
January 2022

Association of Age-adjusted Charlson Comorbidity Index With Orbital Fungal Disease Outcomes.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):53-58

Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Purpose: To determine whether the age-adjusted Charlson comorbidity index (age-CCI) in sino-orbital fungal disease patients correlates with disease-specific mortality.

Methods: Hospital billing systems at 2 academic institutions were queried for patients with ICD-9, ICD-10, and CPT codes used in fungal disease who also had orbital disease and significant visual loss. Thirty-two patients at Institution A and 18 patients at Institution B met the inclusion criteria of microbiologic or pathologic confirmation of fungal infection and completion of inpatient ophthalmology evaluation. Patients without radiographic abnormality in the sinus or orbit were excluded. Demographic, diagnostic, treatment, and outcome variables were recorded. Our primary outcome was death due to fungal disease.

Results: Of the 50 medical records examined, 44 patients met the criteria for fungal-related death outcome on multivariate analysis. The regression coefficient for age-CCI and fungal-related mortality was 0.242 (95% CI, 0.012-0.779) with a p value of 0.038.

Conclusions: Age-CCI is significantly associated with fungal-related mortality. This relationship remains significant when controlling for 5 covariates of fungal organism phylum, presence or absence of CNS disease, exenteration, local treatment use, and presence or absence of an immunosuppressive diagnosis. Age-CCI shows promise as a clinical and research tool in the evaluation of invasive fungal disease involving the orbit.
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http://dx.doi.org/10.1097/IOP.0000000000001987DOI Listing
January 2022

A direct transcutaneous approach to infraorbital nerve biopsy.

Orbit 2022 Feb 6;41(1):130-137. Epub 2021 May 6.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, USA.

Purpose: To describe a novel transcutaneous infraorbital nerve biopsy technique which can be performed to aid in the diagnosis of perineural invasion (PNI) of facial cutaneous squamous cell carcinoma (SCC).

Methods: A single-center retrospective chart review was performed. Patients diagnosed with SCC with PNI via an infraorbital nerve biopsy between February 2019 and February 2020 were included. Data collected consisted of patient demographics, medical history, clinical presentation and exam, histologic and radiographic findings, treatment, and outcomes.

Results: Four patients (3 male, 1 female) met inclusion criteria. The mean age at diagnosis was 79.5 years (range 66-85 years). Three of the four patients had a history of facial skin lesions, including actinic keratosis and SCC, involving the nose, cheek, or ear. One patient had no history of cutaneous malignancy. All patients presented with cranial neuropathies, including total V2 hypoesthesia. The most common presenting symptom was facial pain, followed by diplopia, unilateral facial weakness, and hypoesthesia in the V1 and/or V2 distribution. Transcutaneous infraorbital nerve biopsy in all patients revealed squamous cell carcinoma with no biopsy complications.

Conclusion: Definitive diagnosis of PNI can be challenging but is important to minimize tumor-related morbidity. Infraorbital nerve biopsy can establish this diagnosis, especially in the context of negative or indeterminate imaging findings. This work comprises the first description of a transcutaneous approach to infraorbital nerve biopsy, which is a minimally invasive technique that can be performed in an outpatient procedure suite with limited to no sedation.
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http://dx.doi.org/10.1080/01676830.2021.1920041DOI Listing
February 2022

Biliary obstruction-induced coagulopathy with subperiosteal orbital hemorrhage after endoscopic retrograde cholangiopancreatography.

Can J Ophthalmol 2021 12 1;56(6):e179-e180. Epub 2021 May 1.

Carver College of Medicine, University of Iowa, Iowa City, Iowa. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2021.03.010DOI Listing
December 2021

Closure Technique and Antibiotics in Frontalis Sling Infection and Exposure.

Ophthalmology 2021 03 16;128(3):480-482. Epub 2020 Jul 16.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2020.06.066DOI Listing
March 2021

Orbital Actinomyces Masquerading as Meningioma.

Ophthalmic Plast Reconstr Surg 2020 Sep/Oct;36(5):e124-e126

Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa.

Orbital actinomyces is a rare diagnosis with only a few cases reported in the literature. It can be difficult to diagnose due to its slow, indolent course, and nonspecific findings on imaging and clinical examination, and frequently it can masquerade as other pathologies such as neoplasm and inflammatory disease. The authors present a case of actinomyces masquerading as meningioma with findings of hyperostosis and a superior orbital roof interosseous tract on imaging.
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http://dx.doi.org/10.1097/IOP.0000000000001626DOI Listing
March 2021
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