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Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

Punctal agenesis and other nasolacrimal abnormalities have been infrequently reported in CHARGE syndrome-a constellation of findings affecting the eyes, heart, choana, and ears-which generally presents at birth. We present a rare case of punctal agenesis with delayed-onset dacryocystocele/lacrimal sac mucocele in a teenager with CHARGE syndrome.

Introduction: Facial trauma can often lead to functionally significant fractures of the orbital bones. A significant challenge inthe repair these injuries is to resolve the restriction of prolapsed orbital soft tissue without inducing iatrogenic impingementat the time of implant placement. Forced duction testing, consisting of grasping the conjunctiva with forceps and manuallymanipulating the globe, is the current gold standard for assessing mechanical restriction of eye movement. However, forcedductions result in binary designations of positive or negative, as determined by an individual surgeon's subjectiveperception, which is highly variable and experience-dependent. Here, we present a device to determine quantitative and reproducible measurements of orbital compliance and orbital soft tissue restriction. Method: The device consists of stacked rotational and horizontal translational piezoelectric motor stages, attached to avertical translational motor stage via a load cell that senses vertical resistance ([ Fig. 1 ]). The horizontal translational stageis coupled to a load cell that senses horizontal resistance, with a custom 3D-printed rail and shuttle interface system thatcreates a curvilinear motion for appropriate globe manipulation. The ocular surface is engaged via vacuum-assisted suction([ Fig. 2 ]). The apparatus is mounted on a locking gooseneck arm that can be fastened to the operating table, allowing quickintraoperative positioning, neutralizing recoil force from motor motion, and eliminating user movement interference. Inaddition, we have devised a component for sensing resistance to cyclotorsion ([ Fig. 3 ]), to be affixed between the rotational and horizontal translational motor stages. We designed the device to automate scanning of resistance to translation alongeach orbit clock hour, of force applied normal to the ocular surface, and of globe torque;this enables rapid mapping of softtissue resistance and range of motion with respect to translation, cyclotorsion, and retropulsion. [ Fig. 4 ] depicts a proposedcolor-coded system for visualizing data on translational range of motion and resistance. Results: We had performed cadaveric testing of a previous handheld iteration of the device, consisting of stackedtranslational and rotational motor stages. We demonstrated the feasibility of manipulating the globe through the suctionmechanism and the ability of the load cell to measure resistance to translational force, distinguishing the entrapped state ina cadaveric fracture model. The need to gauge soft-tissue resistance across greater ranges of motion, and to remove usererror stemming from the handheld operation of the previous iteration, led to the creation of the present version. Though wehave constructed a fully functioning prototype, cadaveric and animal testing have not been performed due to COVID-19restrictions. Conclusion: Our device allows for the quantitative characterization of all extraocular muscles and resistance to retropulsion,which can assist in the evaluation not only of soft tissue entrapment secondary to orbital fractures, but also otherpathologies involving mechanical restriction of ocular motion including thyroid eye disease, orbital tumors, and iatrogenicinjury. We envision this device to be used for both preoperative and intraoperative assessment of these conditions and the irsurgical correction.

Patients should have been evaluated and deemed appropriate for such surgical intervention. Temporary suture tarsorrhaphy is used as a temporizing measure for the treatment of decompensated ocular surface disorders, neurotrophic ulcers, or infectious corneal ulcers in convalescent phase, nonhealing corneal epithelial defects, and cases of transient ocular exposure. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Blepharoptosis is an unpleasant complaint of the patients referring to oculoplastic clinics. Following a thorough medical and neurologic work-up, the surgical correction is the main treatment strategy in many cases. Levator muscle function is a measure of maximal lid excursion and crucial for selecting the best surgical approach. Once the levator muscle function is measured as reasonable, along with a good Bell’s phenomenon, the strengthening of the muscle by the shortening or resection techniques through an external approach can favorably elevate the eyelid.

Patients should be evaluated and deemed appropriate for such surgical intervention. Smaller eyelid defects can be repaired using direct closure with or without canthotomy and cantholysis. Larger defects may require more elaborate surgical techniques such a Hughes tarsoconjunctival flap with an independently rotated myocutaneous flap for anterior lamellar reconstruction. Patients with moderate-sized upper or lower lid defects are ideal candidates for this procedure, though some surgeons extend the application to significantly larger defects, particularly in those who would not be good candidates for an eyelid sharing procedure (monocular patients and children at risk of amblyopia). An additional advantage of the Tenzel flap is that any remaining temporal eyelashes are transposed centrally, minimizing the potential cosmetic penalty of surgical madarosis. The choice of technique for eyelid reconstruction should be discussed with the patient once the size of the defect is known and the appropriate procedure tailored to the individual patient’s needs and anatomy. Patients should be educated about the risks and benefits of the procedure as well as about any alternatives.

Nasolacrimal duct obstruction is a common cause of chronic epiphora and may frequently lead to mucopurulent ocular discharges, chronic dacryocystitis, and acute dacryocystitis. External dacryocystorhinostomy is a standard surgery in which a new passageway is established to bypass the occluded or narrowed nasolacrimal duct for the tear drainage.

The authors report an unusual case of lung adenocarcinoma metastasis to the lacrimal sac. A 61-year-old woman with stage IV non-small cell lung cancer presented with left facial pain and epiphora. She was found to have an elevated tear meniscus associated with a firm, fixed medial canthal mass. Orbital imaging demonstrated nodular enlargement of the lacrimal drainage apparatus. Biopsy of the lacrimal sac was performed, and it revealed a metastatic lung adenocarcinoma. The patient received targeted radiation therapy to the lacrimal sac, and her dose of maintenance chemotherapy was increased. The patient's symptoms have since improved. This case of lung cancer involving the lacrimal sac highlights the importance of thorough oncologic surveillance, even with respect to locations atypical for metastatic spread.

Purpose Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous polyethylene-titanium implants (Medpor Titan 3D Orbital Floor Implant) are designed to reestablish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. This is the first study to report clinical outcomes with this implant. Methods This retrospective case series reviewed clinical data and outcomes for patients undergoing orbital reconstruction with a presized and precontoured porous polyethylene-titanium orbital implant from January 2016 to June 2018. Results A total of 34 orbits of 33 patients were identified (mean age: 43 ± 16 years, 70% men). Most bony defects were a result of trauma and included large orbital floor deformities (100%), medial wall defects (74%), disrupted inferomedial struts (68%), and broken posterior ledges (82%). Symptomatic diplopia (73%) and enophthalmos (89%, mean: 3.7 ± 2.1 mm) were common preoperatively. Many cases were revisions (44%). Mean follow up was 7.8 ± 6.7 months. All patients had improved globe positioning, enophthalmos, and hypoglobus. Seven patients had persistent postoperative diplopia: 6 responded to prism therapy and 1 required strabismus surgery. One patient required retrobulbar hematoma drainage and 1 patient required implant explantation due to chronic infection. Conclusions Commercially available presized and precon-toured porous polyethylene-titanium implants are useful for complex orbital bony defects and can achieve functional improvements in diplopia, enophthalmos, and extraocular motility with a low incidence of postoperative complications or revisional surgery.

PURPOSE: To assess whether exenteration specimens obtained after neoadjuvant intra-arterial cytoreductive chemotherapy (IACC) for adenoid cystic carcinoma of the lacrimal gland (ACC) demonstrate significant ocular histopathologic alterations that might preclude future pursuit of globe-preserving therapy. METHODS: Retrospective histopathologic analysis of globes in IACC-treated exenteration specimens among the same cohort of patients whose survival outcomes have been reported. RESULTS: Twenty patients had specimens available. Nineteen globes revealed no abnormalities of the iris, ciliary body, lens, retinal pigment epithelium, choroid, or chorioretinal vasculature. Eighteen globes showed no optic nerve abnormalities. One globe from a patient who refused exenteration until ACC recurrence supervened demonstrated optic nerve edema with a peripapillary hemorrhage and cotton wool spot, as well as hemorrhage and necrosis within an extraocular muscle. Eighteen globes showed no retinal abnormalities attributable to intra-arterial chemotherapy. Three globes showed incidental retinal findings: two globes contained one to two small peripheral retinal hemorrhages and one had a pigmented retinal hole. Seven demonstrated mild, chronic extraocular muscle inflammation, and thirteen had unremarkable musculature. The single patient who received IACC via the internal carotid rather than the external carotid artery developed ophthalmic artery occlusion with orbital apex syndrome prior to exenteration, and diffuse necrosis and hemorrhage were evident histopathologically. CONCLUSIONS: Neoadjuvant IACC does not cause significant histopathologic damage to key ocular structures or compromise visual function in patients receiving intra-arterial chemotherapy through the external carotid artery. However, delivering chemotherapy through the internal carotid artery may result in visually significant thrombotic vascular events. The generally benign histopathological findings in these exenteration specimens supports the concept of IACC delivery through the external carotid system as the cornerstone of a future globe-preserving strategy for lacrimal gland ACC. PRECIS: After delivery of neoadjuvant intra-arterial chemotherapy for lacrimal gland adenoid cystic carcinoma through the external carotid system, none of the studied eyes showed histopathologic changes that would portend loss of ocular function.

Background: The current standard of care for moderate to severe thyroid eye disease (TED) is intravenous methylprednisolone (IVMP), though alternative immunosuppressive options are emerging. In a recent randomized trial, Tocilizumab (TCZ), an anti-IL-6 receptor antibody, demonstrated improved efficacy for corticosteroid-resistant TED compared to placebo. Clinical response to TCZ retreatment, however, has not been previously reported. Clinical case: A 64-year old man presented with progressive diplopia, eyelid retraction and edema and retrobulbar pain. Initial labs revealed TSH 0.221 uIU/mL, free thyroxine (FT4) 1.11 ng/dL, total T3 172 ng/dL and a thyroid stimulating immunoglobulin (TSI) index of 329 (normal < 140). The patient was a former cigarette smoker who had recently transitioned to e-cigarettes. He was treated with 12 weeks of IVMP with improvement in ocular redness and swelling. Three months following completion of treatment, he presented with worsening left sided proptosis, restrictive strabismus, and compressive optic neuropathy (CON) evidenced by deteriorating central acuity and color vision. He underwent urgent surgical decompression for CON with full restoration of visual acuity. He then received a second 12-week course of IVMP with concomitant orbital radiation. Of note, his hyperthyroidism was well controlled with methimazole. Two months after his second IVMP course, he had a third flare of ophthalmic symptoms. He was then treated with TCZ 8 mg/kg (800mg) IV monthly for six months. The patient’s Clinical Activity Score (CAS) improved from 4 to 2 and TSI index decreased from 610 to 92 (normal). He had significant improvement in periorbital edema, caruncle/plica swelling, and conjunctival injection. However, ten months following completion of the TCZ course he again complained of worsening diplopia and left proptosis. Of note, relapse of his TED symptoms was preceded by an increase in TSI from 92 to 300 two months prior. Orbital CT demonstrated progression of left orbitopathy and increased orbital apex crowding. Following these CT findings he was restarted on TCZ, of which he has now completed 5 additional infusions. His CAS has improved from 3 to 2 and TSI index has decreased from 284 to 100. Conclusion: This is the first reported case of response to successive courses of TCZ in relapsing, severe, corticosteroid-resistant TED. TCZ can be an effective option for refractory TED though retreatment may be necessary for recurrent inflammation. Further study of TCZ is required to determine its role in relapsing TED and the optimal duration of therapy needed. References: Perez-Moreiras et al., 2018. Efficacy of Tocilizumab in patients with moderate to severe corticosteroid resistant Graves’ orbitopathy: a randomized controlled trial. Am J Ophthalmol 195:181

Purpose: To highlight the presentation and management of a patient with eyelid, orbital and nasopharyngeal silicone oil migration through a glaucoma drainage implant presenting as pseudo-xanthelasma and ptosis. Observations: A 68-year male presented with unilateral ptosis and presumed xanthelasma. He had a history of glaucoma drainage implant surgery, pseudophakia, and multiple retinal detachment repairs with silicone oil. During ptosis repair it was discovered that his presumed xanthelasma was in fact an eyelid silicone granuloma. Additional work up revealed silicone infiltration of the eyelids, orbits, and nasopharynx, resulting from emulsified silicone oil leakage through his glaucoma valve implant. Conclusions and Importance: Silicone oil may emulsify with time, with potential egress via a glaucoma filtration device. Clinicians should be alert for eyelid, orbital and sinonasal findings that may indicate occult migration. Keywords: Silicone oil, Xanthelasma, Orbit, Foreign body granuloma, Baerveldt, Glaucoma drainage implant

Despite advances in orbital implant design and refinements in technique, exposure and extrusion remain both relatively common and challenging to manage. The increased popularity of porous implants confers a number of significant advantages, which are in turn counterbalanced by well-characterized and distinctive drawbacks when compared to solid spheres. A thorough understanding of implant sizing and material properties, wrapping options, and surgical technique is critical to minimizing the incidence of exposure. When it does arise, rescue techniques with patch grafts or vascularized flaps are used in conjunction with removal of any clearly avascular portion of the implant. Should implant removal be required, thoughtful management of conjunctival and forniceal deficits is essential to permit successful future prosthesis wear.

In comparison to their adult counterparts, congenital and early acquired pediatric anophthalmia require distinctive management strategies, as orbital volume plays a substantial role in the development of the bony socket and surrounding facial structures. Strategies for soft tissue and orbital expansion typically proceed in two stages. The first aim is to promote periocular soft tissue development of the eyelids and fornices via staged or progressive tissue expansion with acrylic or hydrogel conformers. The second aim is to promote bony orbital and midfacial growth with serial implant exchange, tissue expansion with saline or hydrogel implants, or dermis fat grafting. Given the high incidence of concomitant ocular and systemic developmental disorders, careful multidisciplinary evaluation management is also paramount.

A 20-year-old woman presented with loss of vision in her right eye and a "black nose" after receiving hyaluronic acid filler injections in her right glabella 1 month prior. Her vision was no light perception, and external examination revealed resolving skin necrosis at the nasal tip. A dilated fundus exam showed a fibrotic membrane emanating from a pale optic nerve and a diffusely atrophic retina with sclerotic vessels. An MRI demonstrated scattered right-sided parietal lobe infarcts. These findings were consistent with inadvertent cannulation of the supraorbital artery, followed by injection of filler into the internal carotid circulation. The product traveled in a retrograde fashion, occluding the right ophthalmic artery, right dorsal nasal artery, and arterial segments to the Circle of Willis. This case highlights the importance of understanding the complex vascular architecture of the periorbita and the mechanism by which such occlusions occur.

Purpose: To report a case of disseminated silicone granulomatosis presenting with ptosis, proptosis and vision loss. Observations: A 56-year-old female presented with ptosis, proptosis, and vision loss and was noted to have palpable, erythematous masses involving the orbit, face, trunk, and body. She had a history of bilateral silicone breast implants and cosmetic facial filler injections. Orbital biopsy demonstrated non-caseating granulomas with foreign-body giant cells and vacuoles containing material consistent with silicone. Removal of the patient's breast implants and systemic immunosuppression led to dramatic granuloma regression. Conclusions: Silicone can induce a severe, systemic inflammatory response and should be considered in the differential for facial and periorbital granulomas in patients with a history of silicone breast implants. Management of disseminated silicone granulomatosis is challenging and requires multimodal treatment with silicone removal and systemic immunomodulation. Keywords: Silicone, Disseminated, Silicone granulomatosis, Orbit, Breast implants, Autoimmune/inflammatory syndrome

Purpose: To report a case of orbital cholesterol granuloma and discuss the orbital findings seen in this entity. Observation: A 38-year-old male presented with an 8-month history of progressive left upper lid ptosis and hypoglobus. Clinical examination was significant for 3 mm of hypoglobus and restricted supraduction in the left eye. Contrasted computed tomography imaging revealed a well-circumscribed lesion in the superotemporal orbit causing extensive bone erosion that appeared to arise from the lacrimal gland. An incisional biopsy was performed, and histopathological evaluation demonstrated fibrovascular tissue surrounding a mixture of histiocytes and cholesterol clefts, consistent with a cholesterol granuloma. Conclusions and importance: Orbital cholesterol granulomas are rare lesions that are predominantly found in the superotemporal orbit. These lesions can be associated with marked bony changes in the superotemporal fossa that can be mistaken for a lacrimal gland neoplasm; however, bony erosion is a hallmark of this lesion and should be considered on the differential diagnosis of any lacrimal gland mass with extensive bony erosion. Keywords: Blood cyst, Hematocele, Xanthomatosis of the orbit, Cholesteatoma, Hematic cyst, Orbitofrontal choletesterol granuloma

Purpose To present a novel myocutaneous flap for anterior lamellar reconstruction. Methods Retrospective interventional case series of consecutive patients who underwent Mohs reconstruction using the flip-back flap. Operations were performed by a single surgeon (DTT) between January 2012 and May 2016. For lower eyelid defects, an extended subciliary incision was made and a skin-muscle flap developed and suspended in the manner of lower eyelid blepharoplasty. A back-cut was used to develop a pedicle from the overlapping tissue, which was then rotated 180 degrees into the defect. A similar method was employed in an inverted manner for upper eyelid defects. Postoperative eyelid function, cosmesis, complications, and need for further interventions were assessed. Results Ten patients-8 with lower and 2 with upper eyelid defects-were reconstructed using this method. Mean follow up was 18.3 ± 15.5 months with a minimum interval of 4 months. Despite the 180-degree rotation of a relatively narrow pedicle, none of the patients experienced flap necrosis. Postoperative function and cosmesis was satisfactory, with no tissue puckering, notching, or symptomatic retraction. No antimetabolite/steroid injection or surgical revision was required. Conclusions The flip-back flap expands the armamentarium of the periocular reconstructive surgeon. Its particular forte is in addressing broad and relatively shallow anterior lamellar defects where sufficient tissues are not available for transposition via a uni- or bipedicle flap. By leveraging the robust periocular vascular plexus and defying traditional guidelines governing pedicle formation and rotation, it permits creation of a local flap in cases where skin grafts or extensive Mustarde-style flaps might otherwise be required.The flip-back myocutaneous flap offers a novel alternative to skin grafting or more extensive cheek rotational flaps for reconstruction of challenging anterior lamellar defects involving the eyelids and adjacent periocular tissues.

PURPOSE To highlight features of lateral canthal tendon disinsertion (LCTD), provide an algorithm for systematic assessment, and describe the anatomic genesis of signs and symptoms. METHODS Retrospective case series of consecutive patients with lateral canthal tendon disinsertion, who underwent lateral canthal tendon fixation by a single surgeon (DTT) between 2004 and 2011. RESULTS One hundred and seventeen eyes in 90 patients underwent lateral canthal tendon fixation. Average age was 69.3 ± 17.9 years. Twenty-three percentage of eyes had undergone lower eyelid blepharoplasty and 52% had undergone lateral canthal tightening; 35% had no previous periocular surgery. Patients with purely involutional lateral canthal tendon disinsertion were significantly older (76.1 ± 7.8 years of age; p < 0.03). Six key features associated with lateral canthal tendon disinsertion were identified. On static evaluation: 1) a blunted or vertically displaced lateral canthal angle; 2) a narrow horizontal fissure with reduced temporal scleral triangle; and 3) pseudo eyelid retraction. On dynamic evaluation with attempted closure: 4) medial and inferior movement of the lateral commissure; 5) incomplete apposition of the eyelid margins in the absence of anterior lamellar shortage; and 6) temporal eyelid imbrication. Improved blink dynamics with manual lateral canthal tendon complex repositioning ("the thumb test") predicted a favorable outcome with surgical tightening in 95.7% of cases. CONCLUSIONS Lateral canthal tendon disinsertion results in altered eyelid fissure symmetry, blink dynamics, and lacrimal pump function. The authors recommend the mnemonic-A.B.C.: for Aperture configuration, Blink dynamics, and eyelid Closure-to structure the examination of all symptomatic patients. Manual restoration of the disinserted lateral canthal tendon with the "thumb test" predicts favorable outcomes with surgical fixation.

Purpose To describe a surgical technique to correct lateral canthal tendon disinsertion with a strabismus surgery-inspired locking capture of the tendon complex and osseous integration via drill holes. Methods Retrospective interventional case series including all patients with lateral canthal tendon disinsertion who underwent locking Y lateral canthopexy with drill hole reinforcement by 1 surgeon (D.T.T.) between 2006 and 2011. Outcome measures included resolution of presenting ocular symptoms, improved blink dynamics and lid closure, correction of lagophthalmos and exposure keratopathy, and need for further surgery. Results A total of 53 lateral canthopexies with osseous integration were performed in 42 patients who fulfilled clinical criteria for lateral canthal tendon disinsertion. The population was biased toward treatment failures; 81% of eyes (43/53) had a history of prior lateral canthal tightening, and of these 30.2% (16/53) had undergone 3 or more procedures. Postoperatively, all eyes demonstrated improved eyelid position and blink mechanics, and 83% (44/53) had subjective resolution of epiphora and ocular irritation. Lagophthalmos was fully corrected in 95% (19/20) of cases, and corneal staining resolved in 88% (14/16). With a mean follow-up period of 24 months, 3.7% of eyes (2/53) required additional lateral canthal tightening. Conclusions The locking Y lateral canthopexy is an effective and durable method for repositioning the lateral canthal tendon complex to improve blink dynamics, eyelid closure, and cosmesis. Even in a population heavily biased toward treatment failure, clinical results are excellent and the reoperation rate is low.

Aim: Marcus Gunn jaw-winking synkinesis (MGJWS) is characterized by congenital ptosis in conjunction with rapid and involuntary elevation of the affected upper eyelid upon contraction of the ipsilateral external pterygoid muscle. Selecting an approach to the surgical management of eyelid malposition in this syndrome is challenging and requires careful discussion with each patient’s family. In this systematic review, we describe reported surgical approaches, assess outcomes data, and attempt to identify areas of consensus in the management of MGJWS. Methods: Twenty-seven peer-reviewed studies were identified, describing a variety of interventions. Results: The most commonly-used surgical techniques included: bilateral levator excision with bilateral frontalis sling, unilateral levator excision with bilateral or unilateral frontalis sling, the Neuhaus/Lemagne method, and levator plication surgery. However, no clear outcomes-based consensus regarding choice of surgical approach was identified, highlighting the ongoing role of surgeon and family preference in the selection of management strategy. Further, there was considerable variability in the literature for reporting outcome measures, including grading schemes for ptosis and jaw-wink. Conclusion: The existing literature on management of MGJWS does not enable the development of an evidence-based consensus algorithm regarding the selection of an appropriate surgical technique. The disorder is treated according to a case-by-case approach governed by surgeon and family preference. Standardization of nomenclature and outcome measures is crucial for obtaining higher-quality, generalizable data in futures studies.

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.

A 71-year-old African American man presented with an indolent growth above the left medial canthus. CT of the orbits revealed a circumscribed, homogeneously enhancing 2.1 × 2.2 × 2.5 cm mass that appeared to extend into the medial orbit and proximal nasolacrimal duct without obstructing it. Intraoperatively, the mass was readily dissected free and excised in toto. Histopathology demonstrated spindle cells in a storiform pattern. Immunohistochemical staining was consistent with dermatofibrosarcoma protuberans (DFSP) although the t(17;22) translocation was absent. The patient underwent two-thirds of the recommended intensity-modulated radiation therapy dose before refusing further treatment. He declined additional interventions in favor of serial imaging. He remained recurrence free at 11 months. To the best of the authors' knowledge, this is the first case of recurrent DFSP invading the orbit managed with conservative resection and adjuvant therapy. A comprehensive review of the literature pertaining to DFSP of the orbit is presented.

Initially popularized for the treatment of strabismus and blepharospasm, injection of botulinum neurotoxin has become the most commonly performed cosmetic treatment in the United States. Injection techniques have been particularly well-studied in the midface and periocular region, and patient satisfaction tends to be very high. We review the salient differences among available neurotoxins, how to optimally reconstitute them, how to inject the forehead, glabella, lateral canthal lines ("crow's feet"), infralid region, and transverse nasal lines ("bunny lines"), how to sculpt the brow, and how to manage potential complications.

An 89-year-old woman presented with a canalicular-involving laceration/avulsion of the right lower eyelid after a fall. The inferior canaliculus was severed deep within the wound, and the ends were difficult to identify. Novel pigtail cannulas, designed by the authors, were used for lacrimal system intubation and suture passage. Satisfactory cosmetic and functional results were achieved. These cannulas facilitate repair by integrating multiple functionalities in a single instrument. Once a cannula has been inserted and rotated, the location of fluid egress provides important clues. If injected saline appears in the nasopharynx but not in the wound, absence of a common canaliculus can be suspected. Injection of viscoelastic, air or fluorescein-impregnated saline also permits easier identification of the cut end of the canaliculus within the wound and facilitates appropriate rotation of the pigtail.

Traumatic periocular injuries occasionally result in significant soft tissue loss, for which there are limited management options that provide satisfactory cosmetic and functional outcomes. The authors describe the use of a bioengineered dermal substitute (Integra® Dermal Regeneration Template [DRT], Integra LifeSciences, Plainsboro, NJ) as an alternative to immediate flap reconstruction or skin grafting.Retrospective interventional case series of patients who underwent DRT placement for periocular tissue loss at the time of trauma. In each case, primary closure or immediate flap reconstruction was deemed impractical or undesirable due to the size and location of the primary and associated secondary defects. One to four weeks later, the outer silicone layer was removed and healing assessed. Additional reconstructive techniques were performed as needed.Three patients were treated at Bascom Palmer Eye Institute and one at Byers Eye Institute at Stanford. The defects healed completely in two patients, and by 79.2% in a third, with no need for additional reconstructive surgery. In the remaining patient, the defect was significantly downsized by 56.1%, allowing for a simpler flap reconstruction.Bioengineered dermal substitutes should be considered as a viable alternative to traditional reconstructive techniques for large periocular defects resulting from trauma. The outer silicone layer prevents desiccation and serves as a protective barrier, while the inner collagen matrix organizes the growth of neo-dermis and minimizes wound contraction. The dimensions of cutaneous defects can therefore be reduced dramatically, potentially eliminating the need for skin grafting and/or reducing the ultimate complexity of flap reconstruction.

PURPOSE Cicatricial ectropion and periocular scarring can cause significant functional and cosmetic deficits. Surgical treatments can be associated with recicatrization, donor site morbidity, and textural and pigmentary abnormalities. This case series reports on efficacy and safety of a novel nonsurgical approach to treating cicatricial ectropion using ablative fractional laser resurfacing and laser-assisted delivery of 5-fluorouracil. METHODS A retrospective review was conducted of all patients at a single institution who received ≥3 rounds of ablative fractional laser resurfacing with laser-assisted delivery of 5-fluorouracil. Six patients with cicatricial ectropion and periocular scarring secondary to reconstructive surgery, traumatic lacerations, and facial burns were included. Aesthetic and functional improvement were evaluated via fluorescein staining, tear breakup time, external photography, questionnaires gauging dry eye symptoms, and scar appearance. RESULTS All patients showed functional improvement based on fluorescein staining (mean improvement 6.0 ± 1.4; p = 0.0007) and other indicators of dry eye. All 4 patients with lagophthalmos improved and 2 showed complete resolution. All patients demonstrated significant cosmetic improvement based on a validated scar assessment questionnaire (mean improvement 37.5 ± 18.9; p = 0.004), and 5 of 6 patients reported improved satisfaction with scar appearance (mean improvement 19.3 ± 12.8; p = 0.014). There were no adverse effects reported. CONCLUSIONS Ablative fractional laser resurfacing with laser-assisted delivery of 5-fluorouracil appears to be a safe and effective modality for treating the functional and aesthetic abnormalities associated with periocular scarring, yielding results that are difficult to attain through surgery alone. Optimal management of cicatricial ectropion and periocular scarring often requires multimodality treatment, and ablative fractional laser resurfacing with laser-assisted delivery of 5-fluorouracil may be considered as part of a comprehensive approach to managing periocular scars.

Patients should be evaluated and deemed appropriate for such surgical intervention. Patients with large margin-involving lower lid defects are candidates for this procedure. The choice of technique for eyelid reconstruction should be discussed with the patient and the appropriate procedure tailored to the individual patient’s needs and anatomy. Patients should be educated about the risks and benefits of the procedure and those pertaining to any appropriate alternatives. Hughes flaps result in functional closure of the eye for 3–6 weeks before a second stage is performed to sever the conjunctival flap. From a reconstructive perspective it is advantageous to have independent blood supplies to both the anterior and posterior eyelid lamella, but temporary closure may not be appropriate for monocular patients or children at risk of amblyopia. In such cases, consideration should be given to a Tenzel flap, a sliding tarsoconjunctival flap for smaller horizontal defects, or to a free tarsal graft for larger defects.

In patients presenting with ptosis, a complete exam, including eyelid measurements before and after instillation of 2.5 % phenylephrine, is integral in determining the optimal surgical procedure. Muller’s muscle is a sympathetically innervated smooth muscle capable of elevating the upper eyelid 2–3 mm under certain physiological conditions. Instillation of phenylephrine drops in the superior fornix will stimulate Muller’s muscle in many patients; those with mild to moderate ptosis who respond following instillation of phenylephrine may be suitable candidates for a conjunctival Muller’s muscle resection (CMMR). Patients should be educated about the risks and benefits of the procedure, including alternatives.

Patients should be evaluated and deemed appropriate for such surgical intervention. Brow ptosis that obstructs the visual axis, causes visual disability and affects activities of daily living, or cosmetically unacceptable appearance are candidates for this procedure. The choice of technique for brow lift should be discussed with the patient and the appropriate procedure tailored to the individual patient’s needs and preferences. Patients should be educated about the risks and benefits of the procedure, including alternatives.

Indications for the procedure include facial nerve palsy with poor upper eyelid excursion, lagophthalmos, and exposure keratopathy resulting in impaired visual acuity, visual disability, and/or affecting activities of daily living. Patients should be educated about the risks, benefits, and alternatives to the procedure, and informed consent obtained.

Patients should be evaluated and deemed appropriate for such surgical intervention. Patients with orbital compartment syndrome due to hemorrhage, pneumo-orbita, or other causes of increased intraorbital pressure, who are at risk for optic nerve compression or hypoperfusion, are candidates for this procedure. Experimental studies demonstrate that permanent ischemic changes can occur within 90 min, so this procedure is performed emergently in appropriate patients, without waiting for radiographic studies. Additional therapeutic measures, such as the administration of ocular hypotensive drops or systemic osmotic diuretics, may also be indicated. The technique can also be utilized on an elective basis in conjunction with other procedures for horizontal lid tightening or reconstruction. Patients should be educated about the risks and benefits of the procedure, including alternatives.

Ptosis that obstructs the visual axis, causes visual disability, affects activities of daily living, and/or causes cosmetically unacceptable appearance are indications for this procedure. Patients should be educated about the risks, benefits, and alternatives to the procedure prior to proceeding, and informed consent obtained.

Exenteration is surgical removal of the orbital contents, including the globe, ocular adnexa, and eyelids. The eyelids may be spared in certain circumstances and used to line the exenteration cavity. It is usually indicated for invasive or devastating orbital neoplasms (primary or secondary from adjacent structures) or the treatment of angioinvasive fungal infections. The exposed orbital walls may be left to heal spontaneously, by granulation tissue or covered with a split-thickness skin graft. Given the radical nature of exenteration with a significantly associated cosmetic penalty, patients must be extensively counseled preoperatively regarding the necessity of the procedure and its potential drawbacks.

Purpose Evaluation of the tearing patient is often distilled to a search for ocular surface problems causing reflex hypersecretion versus lacrimal drainage problems. The literature does not typically emphasize conditions affecting the function of the tear distribution system, but neglect of these important factors can lead to suboptimal treatment outcomes. The intent of this review is to provide a systemic evaluation of frequently overlooked conditions that can influence the distribution system and to offer a mnemonic to ensure an orderly sequence of inspection during clinical examination. Methods Review of clinical literature and experience from 1957 to 2014. Results Tearing complaints attributable to problems with the distribution system can be evaluated, classified, and managed according to the mnemonic BLICK, which stands for Blink dynamics, Lid malposition, Imbrication, Conjunctivochalasis, and Kissing puncta. Conclusion The BLICK mnemonic is a useful adjunct to the workup of epiphora.