Search

Purpose To review the medical literature on the outcomes and complications of various Food and Drug Administration-approved botulinum toxins for benign essential blepharospasm (BEB) and hemifacial spasm (HFS). Methods Literature searches were last conducted in February 2017 in PubMed for articles published in English and in the Cochrane Library database without language limitations; studies published before 2000 were excluded. The combined searches yielded 127 citations. Of these, 13 articles were deemed appropriate for inclusion in this assessment, and the panel methodologist assigned ratings to them according to the level of evidence. Results A combined total of 1523 patients (1143 with BEB and 380 with HFS) were included in the 13 studies. Five studies provided level I evidence, 2 studies provided level II evidence, and 6 studies provided level III evidence. Pretarsal injections were more efficacious than preseptal injections (96% vs. 86%, respectively). Pretarsal injections also resulted in a higher response rate on clinical scales ( P Conclusions Level I evidence supports the efficacy of Botox (Allergan Corp., Irvine, CA), Meditoxin, and Xeomin (Merz Pharmaceuticals, Frankfurt am Main, Germany) for the treatment of BEB. Meditoxin and Botox have equivalent effectiveness and incidence of adverse events for BEB and HFS. Dysport (Ipsen Biopharmaceuticals, Inc, Paris, France) seems to have efficacy similar to Botox and Meditoxin for BEB and HFS, but any definitive conclusions from the 2 level II studies in this review are limited by differences in the methodologies used. Higher doses of Botox and Dysport result in more adverse events. Repeated treatments using Botox seem to maintain efficacy for treatment of facial dystonias over a follow-up period of at least 10 years, based on level III evidence.

Purpose To review the literature to determine the efficacy of available treatments for ocular adnexal lymphoma (OAL) and to evaluate the outcomes and complications of treatments in patients older than 13 years. Methods A literature search was conducted last in March 2017 in the PubMed and Cochrane Library databases for English-language original research investigations that evaluated treatment outcomes for OAL. The searches identified 307 unique citations, and 27 studies were selected according to the criteria outlined for this assessment. Results The 27 studies reviewed comprised 2009 patients. Seventy-five percent of the cases reported were extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT). Twenty-five studies reported results using radiotherapy with or without chemotherapy or surgery. The local control rate of MALT lymphomas with treatments involving radiotherapy averaged 95.9%. Distant and local relapses can occur, and in studies reporting only on MALT lymphomas (884 patients), the 5-year and 10-year disease-free survival rates were reported to be 86.4% and 78.7%, respectively. However, overall survival in patients receiving radiotherapy remained very good, with the 5-year and 10-year survival rates reported to be 93.8% and 84.9%, respectively. Studies that included data on multiple histologic subtypes of lymphoma or non-MALT lymphomas (988 patients) reported local control rates to be 93.1%; 5-year and 10-year disease-free survival rates to be 75.7% and 71.0%, respectively; and 5-year and 10-year overall survival rates to be 78.9% and 73.5%, respectively. Studies on the use of doxycycline for MALT lymphomas (137 patients) reported complete responses of between 4.4% and 13%. Complete and partial responses combined were between 26.7% and 65%. Disease-free survival was not reported for these 2 studies, although progression-free survival was reported to be between 55% and 60.9%. The most frequently reported complications of treatment were cataracts (12.1%) and dry eye (8.5%). Conclusions For MALT lymphomas, local control, disease-free survival, and overall survival are good with radiation treatment. The results of treatment of non-MALT lymphomas using radiotherapy also were good, but they were not as favorable as the treatment results of MALT lymphomas.

Objective To review the existing medical literature on the role of oral antibiotics in the management of ocular surface disease (OSD) that arises from disorders of the meibomian glands and to assess the efficacy of oral antibiotics in the management of this common ocular disease. Methods A literature search was last conducted on August 12, 2015, in the PubMed and Cochrane databases for English-language original research investigations that evaluated the role of doxycycline, minocycline, and azithromycin in OSD among adult patients. The searches identified 87 articles, and 8 studies ultimately met the criteria outlined for this assessment. Results The 8 studies identified in the search documented an improvement in meibomian gland-related OSD after treatment with these agents, although side effects were common. This search identified only 1 randomized, controlled trial to assess the efficacy of these medications. Conclusions Although oral antibiotics are used commonly in the management of OSD, there is no level I evidence to support their use. There are only a few studies that have assessed the efficacy of oral antibiotics in clinically meaningful ways in the management of OSD that arises from disorders of the meibomian glands. The current level of evidence is insufficient to conclude that antibiotics are useful in managing OSD arising from disorders of the meibomian glands. The few existing studies on the topic indicate that oral antibiotics may be an effective treatment for OSD that results from meibomian gland disease.

To review the medical literature on the outcomes and complications of various Food and Drug Administration-approved botulinum toxins for benign essential blepharospasm (BEB) and hemifacial spasm (HFS).Literature searches were last conducted in February 2017 in PubMed for articles published in English and in the Cochrane Library database without language limitations; studies published before 2000 were excluded. The combined searches yielded 127 citations. Of these, 13 articles were deemed appropriate for inclusion in this assessment, and the panel methodologist assigned ratings to them according to the level of evidence.A combined total of 1523 patients (1143 with BEB and 380 with HFS) were included in the 13 studies. Five studies provided level I evidence, 2 studies provided level II evidence, and 6 studies provided level III evidence. Pretarsal injections were more efficacious than preseptal injections (96% vs. 86%, respectively). Pretarsal injections also resulted in a higher response rate on clinical scales (P0.05) and a longer duration of maximum response for both HFS and BEB. Patients with HFS require lower overall doses of onabotulinumtoxinA than patients with BEB for a similar duration of effect. Adverse events were dose related, and they occurred more frequently in patients who were given more units.Level I evidence supports the efficacy of Botox (Allergan Corp., Irvine, CA), Meditoxin, and Xeomin (Merz Pharmaceuticals, Frankfurt am Main, Germany) for the treatment of BEB. Meditoxin and Botox have equivalent effectiveness and incidence of adverse events for BEB and HFS. Dysport (Ipsen Biopharmaceuticals, Inc, Paris, France) seems to have efficacy similar to Botox and Meditoxin for BEB and HFS, but any definitive conclusions from the 2 level II studies in this review are limited by differences in the methodologies used. Higher doses of Botox and Dysport result in more adverse events. Repeated treatments using Botox seem to maintain efficacy for treatment of facial dystonias over a follow-up period of at least 10 years, based on level III evidence.

Objective To review the published literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults. Methods Literature searches of the PubMed and Cochrane Library databases were last conducted on March 9, 2015, without date restrictions and were limited to English language abstracts. The searches retrieved 309 unique citations. The primary authors reviewed the titles and abstracts. Inclusion criteria specified reports that provided original data on plugs for the treatment of dry eyes in at least 25 patients. Fifty-three studies of potential relevance were assigned to full-text review. The 27 studies that met the inclusion criteria underwent data abstraction by the panels. Abstracted data included study characteristics, patient characteristics, plug type, insertion technique, treatment response, and safety information. All studies were observational and rated by a methodologist as level II or III evidence. Results The plugs included punctal, intracanalicular, and dissolving types. Fifteen studies reported metrics of improvement in dry eye symptoms, ocular-surface status, artificial tear use, contact lens comfort, and tear break-up time. Twenty-five studies included safety data. Plug placement resulted in ≥50% improvement of symptoms, improvement in ocular-surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Serious complications from plugs were infrequent. Plug loss was the most commonly reported problem with punctal plugs, occurring on average in 40% of patients. Overall, among all plug types, approximately 9% of patients experienced epiphora and 10% required removal because of irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs and occurred in approximately 8% of patients. Other complications were reported in less than 4% of patients on average and included tearing, discomfort, pyogenic granuloma, and dacryocystitis. Conclusions On the basis of level II and III evidence in these studies, plugs improve the signs and symptoms of moderate dry eye that are not improved with topical lubrication, and they are well tolerated. There are no level I studies that describe the efficacy or safety of lacrimal drainage system plugs.

To review the literature to determine the efficacy of available treatments for ocular adnexal lymphoma (OAL) and to evaluate the outcomes and complications of treatments in patients older than 13 years.A literature search was conducted last in March 2017 in the PubMed and Cochrane Library databases for English-language original research investigations that evaluated treatment outcomes for OAL. The searches identified 307 unique citations, and 27 studies were selected according to the criteria outlined for this assessment.The 27 studies reviewed comprised 2009 patients. Seventy-five percent of the cases reported were extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT). Twenty-five studies reported results using radiotherapy with or without chemotherapy or surgery. The local control rate of MALT lymphomas with treatments involving radiotherapy averaged 95.9%. Distant and local relapses can occur, and in studies reporting only on MALT lymphomas (884 patients), the 5-year and 10-year disease-free survival rates were reported to be 86.4% and 78.7%, respectively. However, overall survival in patients receiving radiotherapy remained very good, with the 5-year and 10-year survival rates reported to be 93.8% and 84.9%, respectively. Studies that included data on multiple histologic subtypes of lymphoma or non-MALT lymphomas (988 patients) reported local control rates to be 93.1%; 5-year and 10-year disease-free survival rates to be 75.7% and 71.0%, respectively; and 5-year and 10-year overall survival rates to be 78.9% and 73.5%, respectively. Studies on the use of doxycycline for MALT lymphomas (137 patients) reported complete responses of between 4.4% and 13%. Complete and partial responses combined were between 26.7% and 65%. Disease-free survival was not reported for these 2 studies, although progression-free survival was reported to be between 55% and 60.9%. The most frequently reported complications of treatment were cataracts (12.1%) and dry eye (8.5%).For MALT lymphomas, local control, disease-free survival, and overall survival are good with radiation treatment. The results of treatment of non-MALT lymphomas using radiotherapy also were good, but they were not as favorable as the treatment results of MALT lymphomas.

Objective To describe patient preferences regarding payment for blepharoplasty and blepharoptosis repair and physician practices before and after the 2009 change in reimbursement for these 2 procedures by the Centers for Medicare and Medicaid Services (CMS). Design Cross-sectional study. Participants Fifty patients presenting for functional blepharoplasty and blepharoptosis repair at an academic oculoplastic practice and 198 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. Methods A 5-question paper survey was administered to patients, and a 5-question web-based survey was distributed to 510 unique physician e-mail addresses obtained from the American Society of Ophthalmic Plastic and Reconstructive Surgery mailing list server in 2010. Main Outcome Measures The surveys elicited patient knowledge and attitudes regarding the reimbursement policy of the CMS and physician knowledge and behaviors before and after the reimbursement policy change. Results Ninety-one percent of patients would be opposed to having to pay out of pocket for blepharoplasty or having to wait at least 3 months after ptosis repair to have a blepharoplasty. When asked to choose between these options, 62% of the patients would rather have the 2 surgeries performed separately than pay out-of-pocket. Before the reimbursement policy change by the CMS, 77% of oculoplastic surgeons performed blepharoplasty and blepharoptosis repair in the same sitting, whereas 37% did so after the policy change ( P P P = 0.009). Conclusions Our study suggests that oculoplastic surgeons have made a change in the delivery of ptosis and blepharoplasty surgical services after the reimbursement policy change for these procedures by the CMS in 2009. This change, in which patients undergo separate surgical visits for ptosis repair and blepharoplasty, is not desirable to most patients.

Purpose The incidence of acquired nasolacrimal duct obstruction (NLDO) increases with age. Dacryocystorhinostomy, the definitive treatment for NLDO, has a high success rate (80%–100%) with a low complication rate (1%–6%), but surgical outcomes have not been reported previously specifically for an elderly population, in which there may be increased risk for intraoperative and postoperative complications. The purpose of this study was to examine surgical outcomes and complication rates of dacryocystorhinostomy in an elderly population. Design Retrospective cohort study. Participants Patients 80 years of age or older undergoing external dacryocystorhinostomy at the Mayo Clinic between January 1, 1990, and December 31, 2010, were compared with a matched control group of younger patients (40–79 years of age) undergoing external dacryocystorhinostomy by the same surgeons. Methods We reviewed the medical charts for patients as described above. Data abstracted from patient medical records included symptomatic relief and complications such as tube protrusion, infection, persistent bleeding, and return to operating room. Statistical analysis included a 2-sample t test to compare continuous variables, chi-square testing for categorical comparisons, and the generalized estimating equation model to control for nonindependence. Main Outcome Measures Primary end point was symptomatic improvement at last follow-up. Secondary end points included anatomic patency, adverse event rate, and return to operating room within 1 month of surgery. Results Forty-two dacryocystorhinostomies (32 patients) were performed in the elderly group. The control group comprised 73 dacryocystorhinostomies in 63 patients. Resolution of symptom rate at last follow-up was 64% in the elderly group versus 86% in the younger cohort ( P = 0.02). Although there was no difference between groups with respect to common postoperative complications, there was a higher rate of predefined serious complications in the elderly group (5 events vs. 1 event; P = 0.01). There was no difference between groups regarding need for additional eyelid surgery ( P = 0.30). Conclusions Although most elderly patients experience symptom resolution after dacryocystorhinostomy, the rate of symptom resolution was lower than that of younger patients. The risk of routine complications was similar between the groups. The risk of serious complications was higher in the elderly group.

Objective To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. Methods Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis. Results The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Muller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty. Conclusions Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD 1 ) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective To investigate whether orbital radiation offers effective and safe treatment for Graves ophthalmopathy. Methods Medical literature databases were searched to identify all published reports relating to orbital radiation treatment for Graves ophthalmopathy. To be included in the technology assessment, reports had to provide original data, to report on a case series or uncontrolled trial of at least 100 subjects or a randomized clinical trial of any size, to focus on orbital radiation for the treatment of Graves ophthalmopathy, and to follow-up patients for at least 3 months. Abstracted data included study characteristics, patient characteristics, treatment response, and safety information. Results Fourteen studies were included in the technology assessment: 5 observational studies and 9 randomized controlled trials. Three of the observational studies report on treatment response, with overall favorable outcomes for 40% to 97% of patients. Three of the observational studies provided intermediate-term safety data. The risk of definite radiation retinopathy is 1% to 2% within 10 years after treatment. Patients treated with orbital radiation did not have an increased risk of secondary malignancy or premature death. The 9 randomized trials were qualitatively heterogeneous. Patients with optic neuropathy generally were excluded from participating in the randomized trials. Three of the randomized trials were sham controlled. None of these studies showed that orbital radiation was more efficacious than sham irradiation for improving proptosis, lid fissure, or soft tissue changes such as eyelid swelling. Two of the 3 sham-controlled randomized trials demonstrated improved vertical range of motion in radiation-treated subjects compared with controls. Conclusions Systematic review of the effect of orbital radiation on Graves ophthalmopathy is limited by the lack of standardization and variable quality of published reports. Extraocular motility impairment may improve with radiotherapy, although the evidence of a treatment effect is mixed in clinical trials. Future studies are needed to determine if a potentially beneficial motility effect results in improved patient function and quality of life. Level I evidence indicates that proptosis, eyelid retraction, and soft tissue changes do not improve with radiation treatment. The efficacy of orbital radiation for compressive optic neuropathy resulting from Graves ophthalmopathy has not been investigated in clinical trials and merits further study. Radiation retinopathy, although rare, is a risk of orbital radiation, even in patients without diabetes who receive appropriate radiation dose and delivery.

To review the existing medical literature on the role of oral antibiotics in the management of ocular surface disease (OSD) that arises from disorders of the meibomian glands and to assess the efficacy of oral antibiotics in the management of this common ocular disease.A literature search was last conducted on August 12, 2015, in the PubMed and Cochrane databases for English-language original research investigations that evaluated the role of doxycycline, minocycline, and azithromycin in OSD among adult patients. The searches identified 87 articles, and 8 studies ultimately met the criteria outlined for this assessment.The 8 studies identified in the search documented an improvement in meibomian gland-related OSD after treatment with these agents, although side effects were common. This search identified only 1 randomized, controlled trial to assess the efficacy of these medications.Although oral antibiotics are used commonly in the management of OSD, there is no level I evidence to support their use. There are only a few studies that have assessed the efficacy of oral antibiotics in clinically meaningful ways in the management of OSD that arises from disorders of the meibomian glands. The current level of evidence is insufficient to conclude that antibiotics are useful in managing OSD arising from disorders of the meibomian glands. The few existing studies on the topic indicate that oral antibiotics may be an effective treatment for OSD that results from meibomian gland disease.

To review the published literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults.Literature searches of the PubMed and Cochrane Library databases were last conducted on March 9, 2015, without date restrictions and were limited to English language abstracts. The searches retrieved 309 unique citations. The primary authors reviewed the titles and abstracts. Inclusion criteria specified reports that provided original data on plugs for the treatment of dry eyes in at least 25 patients. Fifty-three studies of potential relevance were assigned to full-text review. The 27 studies that met the inclusion criteria underwent data abstraction by the panels. Abstracted data included study characteristics, patient characteristics, plug type, insertion technique, treatment response, and safety information. All studies were observational and rated by a methodologist as level II or III evidence.The plugs included punctal, intracanalicular, and dissolving types. Fifteen studies reported metrics of improvement in dry eye symptoms, ocular-surface status, artificial tear use, contact lens comfort, and tear break-up time. Twenty-five studies included safety data. Plug placement resulted in ≥50% improvement of symptoms, improvement in ocular-surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Serious complications from plugs were infrequent. Plug loss was the most commonly reported problem with punctal plugs, occurring on average in 40% of patients. Overall, among all plug types, approximately 9% of patients experienced epiphora and 10% required removal because of irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs and occurred in approximately 8% of patients. Other complications were reported in less than 4% of patients on average and included tearing, discomfort, pyogenic granuloma, and dacryocystitis.On the basis of level II and III evidence in these studies, plugs improve the signs and symptoms of moderate dry eye that are not improved with topical lubrication, and they are well tolerated. There are no level I studies that describe the efficacy or safety of lacrimal drainage system plugs.

Purpose To determine the potential suitability of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) for measuring health-related quality of life (HRQL) in patients with Graves' ophthalmopathy. Design Cross-sectional study. Participants Thirty adult patients with mild to severe Graves' ophthalmopathy. Methods Participants self-administered the NEI VFQ-25 and completed a semistructured interview to provide feedback about the questionnaire. The percentage of responses at the maximum and minimum value was calculated to assess ceiling and floor effects, respectively, for the 12 subscales of the NEI VFQ-25. The NEI VFQ-25 scores were compared for Graves' ophthalmopathy patients who reported symptomatic diplopia and those who did not report diplopia using univariate and multivariate linear regression models. Main Outcome Measures The NEI VFQ-25 subscale and composite scores. Results Health-related quality of life in those with Graves' ophthalmopathy was moderately impaired, with median composite score of 69. The greatest impairment was measured in the Mental Health (median, 50) and the Role Difficulties (median, 50) subscales. Significant ceiling effects were seen in 7 of the 12 subscales. More than two thirds of Graves' ophthalmopathy patients perceived that the NEI VFQ-25 lacked items relevant to their disease. The NEI VFQ-25 scores were lower for those with diplopia symptoms (composite score, 61) compared with those without diplopia (composite score, 90). Comparing these 2 groups, the largest differences were measured in the Driving and Peripheral Vision subscales. Conclusions The NEI VFQ-25 includes many items that are applicable to Graves' ophthalmopathy patients. However, it shows significant ceiling effects in more than half of the subscales and it lacks items on issues that are important to Graves' ophthalmopathy patients, such as altered appearance and ocular discomfort. Efforts to develop an HRQL instrument that adds Graves' ophthalmopathy-specific items to relevant aspects of the NEI VFQ-25 are warranted.

Purpose To evaluate intraobserver reliability and interobserver reliability of a computer-based digital image measurement of eyelid position in Graves' ophthalmopathy and to compare digital image measurement with clinical measurement. Design Cross-sectional study. Participants Eighty-four eyes of 42 patients with mild to moderate bilateral Graves' ophthalmopathy. Methods Digital images were created from 35-mm color slides of both eyes of participants and projected onto a 15-inch flat-screen computer monitor. Three observers (2 oculoplastic surgeons and 1 ophthalmology resident) independently recorded eyelid fissure height, margin–reflex distance, and inferior scleral show for each eye. Main outcome measures Intraobserver reliability and interobserver reliability of eyelid parameter measurements, as described by the intraclass correlation coefficient (ICC) and Bland–Altman plots. Agreement between digital image measurements of the investigators and clinical measurements taken on the same day as the photographs also was assessed. Results Excellent intraobserver agreement was found for the measurement of all eyelid parameters for all 3 investigators (ICC range, 0.93–0.99). Interobserver agreement for all eyelid parameters was also excellent for all investigators (ICC, 0.86–0.97). Agreement between the photographic and clinical measurements for eyelid parameters was fair to moderate (ICC range, 0.38–0.62). Conclusion Measurement of several eyelid parameters in Graves' ophthalmopathy patients from computer-based digital images is reliable. Associations between photographic and clinical measurements for all parameters are weaker. Relative to clinical measurements, the photographic technique offers the advantages of potential for masking and ease of transmission that might be useful in clinical trials.

To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis.The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty.Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment.The author(s) have no proprietary or commercial interest in any materials discussed in this article.

To investigate whether orbital radiation offers effective and safe treatment for Graves ophthalmopathy.Medical literature databases were searched to identify all published reports relating to orbital radiation treatment for Graves ophthalmopathy. To be included in the technology assessment, reports had to provide original data, to report on a case series or uncontrolled trial of at least 100 subjects or a randomized clinical trial of any size, to focus on orbital radiation for the treatment of Graves ophthalmopathy, and to follow-up patients for at least 3 months. Abstracted data included study characteristics, patient characteristics, treatment response, and safety information.Fourteen studies were included in the technology assessment: 5 observational studies and 9 randomized controlled trials. Three of the observational studies report on treatment response, with overall favorable outcomes for 40% to 97% of patients. Three of the observational studies provided intermediate-term safety data. The risk of definite radiation retinopathy is 1% to 2% within 10 years after treatment. Patients treated with orbital radiation did not have an increased risk of secondary malignancy or premature death. The 9 randomized trials were qualitatively heterogeneous. Patients with optic neuropathy generally were excluded from participating in the randomized trials. Three of the randomized trials were sham controlled. None of these studies showed that orbital radiation was more efficacious than sham irradiation for improving proptosis, lid fissure, or soft tissue changes such as eyelid swelling. Two of the 3 sham-controlled randomized trials demonstrated improved vertical range of motion in radiation-treated subjects compared with controls.Systematic review of the effect of orbital radiation on Graves ophthalmopathy is limited by the lack of standardization and variable quality of published reports. Extraocular motility impairment may improve with radiotherapy, although the evidence of a treatment effect is mixed in clinical trials. Future studies are needed to determine if a potentially beneficial motility effect results in improved patient function and quality of life. Level I evidence indicates that proptosis, eyelid retraction, and soft tissue changes do not improve with radiation treatment. The efficacy of orbital radiation for compressive optic neuropathy resulting from Graves ophthalmopathy has not been investigated in clinical trials and merits further study. Radiation retinopathy, although rare, is a risk of orbital radiation, even in patients without diabetes who receive appropriate radiation dose and delivery.

To evaluate intraobserver reliability and interobserver reliability of a computer-based digital image measurement of eyelid position in Graves' ophthalmopathy and to compare digital image measurement with clinical measurement.Cross-sectional study.Eighty-four eyes of 42 patients with mild to moderate bilateral Graves' ophthalmopathy.Digital images were created from 35-mm color slides of both eyes of participants and projected onto a 15-inch flat-screen computer monitor. Three observers (2 oculoplastic surgeons and 1 ophthalmology resident) independently recorded eyelid fissure height, margin-reflex distance, and inferior scleral show for each eye.Intraobserver reliability and interobserver reliability of eyelid parameter measurements, as described by the intraclass correlation coefficient (ICC) and Bland-Altman plots. Agreement between digital image measurements of the investigators and clinical measurements taken on the same day as the photographs also was assessed.Excellent intraobserver agreement was found for the measurement of all eyelid parameters for all 3 investigators (ICC range, 0.93-0.99). Interobserver agreement for all eyelid parameters was also excellent for all investigators (ICC, 0.86-0.97). Agreement between the photographic and clinical measurements for eyelid parameters was fair to moderate (ICC range, 0.38-0.62).Measurement of several eyelid parameters in Graves' ophthalmopathy patients from computer-based digital images is reliable. Associations between photographic and clinical measurements for all parameters are weaker. Relative to clinical measurements, the photographic technique offers the advantages of potential for masking and ease of transmission that might be useful in clinical trials.

We report the development of a patient-derived, health-related quality-of-life (HRQOL) questionnaire for adults with strabismus.Cross-sectional study.Twenty-nine patients with strabismus in a first phase, and 32 patients with strabismus, 18 patients with other eye diseases, and 13 visually normal adults in a second phase.Individual patient interviews generated 181 questionnaire items. For item reduction, we asked 29 patients with strabismus to complete the 181-item questionnaire, analyzed responses, and performed factor analysis. Two prominent factors were identified, and the 10 items with the highest correlation with each factor were selected. The final 20-item questionnaire (10 psychosocial items and 10 function items) was administered to an additional 32 patients with strabismus (22 with diplopia, 10 without diplopia), 13 visually normal adults, and 18 patients with other eye diseases. A 5-point Likert-type scale was used for responses (never = 100, rarely = 75, sometimes = 50, often = 25, and always = 0). Median overall questionnaire scores and psychosocial and function subscale scores, ranging from 0 (worst HRQOL) to 100 (best HRQOL), were compared across groups.The HRQOL questionnaire response scores.Median overall scores were statistically significantly lower (worse quality of life) for patients with strabismus (56) compared with visually normal adults (95; P0.001) and patients with other eye diseases (86; P0.001). Median scores on the psychosocial subscale were significantly lower for strabismus patients (69) compared with visually normal adults (99; P0.001) and patients with other eye diseases (94; P0.001). For the function subscale, median scores were again significantly lower for strabismus patients (43) compared with visually normal adults (91; P0.001) and patients with other eye diseases (78; P0.001).We have developed a 20-item, patient-derived, HRQOL questionnaire specific for adults with strabismus, with subscales to assess psychosocial and function concerns. This 20-item, condition-specific questionnaire will be useful for assessing HRQOL in individual strabismus patients and also as an outcome measure for clinical trials.The authors have no proprietary or commercial interest in any materials discussed in this article.