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Facelift and midface lifts are performed to give a more youthful appearance to the face. While this type of surgery is mostly performed on the aging face, it can also be used for patients with facial paralysis. Overall, aging involves gradual thinning of the epidermis, flattening of the epidermal-dermal border, loss of collagen and thickness in the dermis, decrease in collagen type I to type III ratio, and reduction in the skin cellular and protein components. Sun damage can worsen and accelerate this process. Lax skin with decreased collagen manifests through sagging and increased propensity to be wrinkled and furrowed. In addition, muscle laxity and atrophy can add to sagging tissues and lack of face, mandibular, and neck definition. This can be seen in the increase in the cervicomental angle of the neck, and jowling, which is sagging of tissues along the mandibular line. These particular effects of aging can be amenable to a facelift or midface lift.

Striae distensae (SD) are linear dermal scars that arise from progressive stretching or tearing of the dermal layer. This study tests the safety and efficacy of a topical formulation of silicone-based scar cream containing selective synthetic recombinant human growth factors, hyaluronic acid, and vitamin C to improve overall appearance and texture of SD. Twenty-two subjects with SD alba were recruited and randomized to apply the topical formula to half of their SD laterally twice a day for 1 month. Patient surveys were obtained at 1 month for overall appearance, texture, and tolerability. Three-dimensional imaging was obtained at baseline and at 1 month and submitted to independent evaluators for grading on overall appearance. Subjects reported improved texture and appearance in 86.4% of SD. Subjects reported 100% of untreated SD to have no change in overall appearance or texture. 90.9% of subjects reported no tolerability issues. 9.1% of the treated group reported mild issues such as slight itching or redness the first day of application, which subsided in 2 days for all patients. Independent evaluators indicated improvement in 72.7% of SD in comparison to improvement in 36.3% of untreated SD. This study demonstrates that the investigated topical formulation is safe and effective to use for SD.

Background: In contrast to fetal scar tissue, adult scar tissue presents with visible scarring. Topical silicone creams have been shown to improve the appearance of scars. This case series compares the genetic expression of post-surgical scar tissues that received topical scar treatment with silicone cream, SKN2017B, or no treatment. SKN2017B is a recently formulated silicone-based scar cream that contains selective synthetic recombinant human growth factors, hyaluronic acid, and vitamin C. We hypothesise that scars treated with silicone-based scar creams have a more favourable genetic expression resembling a well-healing scar. Methods: Women who had undergone an abdominoplasty were included in this investigation and randomly assigned to treat part of the scar with topical silicone, another part with SKN2017B, and to leave a third part untreated. After four weeks, punch biopsies were taken and the RNA sequenced. Healthy abdominal skin was biopsied as baseline data. Genes of interest were identified and median values were calculated for the samples. Results: SKN2107B-treated scars demonstrated the lowest collagen type I to collagen type III ratio. Other key genes of interest in wound healing showed the lowest (favourable) expression of fibroblast activation protein alpha, lysyl oxidase and cartilage oligomeric matrix protein; the highest (favourable) expression of fibronectin type III domain containing 1 and matrix metallopeptidase 9 were found in scars treated with SKN2017B. Conclusion: The results of this small case series demonstrate a trend that those scars treated with topical silicone cream, notably SKN2017B, display the most favourable gene expression for wound healing., Lay Summary Silicone scar creams have been shown to improve the appearance of scars. In this case series, we evaluated the genetic expression of post surgical scars that were treated with SKN2017B (a silicone-based cream incorporating novel growth factors and ingredients), silicone scar cream or skin left untreated. We hypothesised that scars treated with a silicone-based scar cream would demonstrate a more favourable genetic expression trending toward the profile of a well-healing scar, as seen in fetal scar tissue, which undergoes scarless healing. For this case series, we included women who had undergone an abdominoplasty. They were instructed to treat part of the scar with silicone cream, another part with SKN2017B and to leave a third part untreated. After four weeks, punch biopsies were taken and the RNA sequenced. The genes of interest for the samples were identified due to their roles in wound healing based on peer-reviewed literature. The median expression levels of the genes of interest were calculated and compared between the 3 patients. The results of this case series demonstrate a trend that those scars treated with silicone cream, notably SKN2017B, display the most favourable gene expression for wound healing. Future studies should employ larger samples of scar tissues for gene expression analysis with longer followup period time.

PURPOSE: Silicone cream has been shown to improve the appearance of postoperative scars. Nevertheless, surgeons may incorporate intralesional wound modulators such as a triamcinolone and/or 5-fluorouracil (5-FU) for scars that do not completely heal well or those that do not completely respond to other treatment options such as silicone cream. This study sought to determine whether a silicone-based topical scar cream that incorporates selective growth factors can help reduce the incidence of postoperative cicatricial and hypertrophic changes in upper eyelid blepharoplasty incisions. METHODS: This is a single-surgeon, retrospective chart review of patients that underwent a cosmetic upper eyelid blepharoplasty. Subjects were divided into two cohorts depending on whether they received postoperative topical scar cream (SKN2017B) twice daily for 3 months versus no topical scar treatment. Using a modified Vancouver Scar Study Scale for treatment criteria, the incidence of focal intralesional injections of triamcinolone and 5-FU to targeted areas of cicatricial and hypertrophic changes was compared between the two groups. RESULTS: 272 eyelids were identified, of those, 132 eyelids received no treatment and 140 were treated with SKN2017B. 43.9% of eyelids that did not receive treatment underwent intralesional injections of triamcinolone and 5-FU, and 22.9% of eyelids treated with SKN2017B underwent intralesional injections of triamcinolone and 5-FU. The difference between the two groups was found to be statistically significant (P less than 0.05). No adverse reactions were reported from either group. CONCLUSION: The use of a topical silicone-based scar cream has been shown to be safe and effective in decreasing the incidence of intralesional injections of triamcinolone and 5-FU for postoperative cicatricial and hypertrophic changes in upper eyelid blepharoplasty incisions. J Drugs Dermatol. 2019;18(5):440-446.

Background Several growth factors and hyaluronic acid are implicated in fetal scarless healing. Whether these factors can be applied to an adult scar to improve scar characteristics is unknown. Objectives This study compared the efficacy and safety of SKN2017B, a proprietary topical cream consisting of selective synthetic recombinant human growth factors and hyaluronic acid in a silicone base containing a specifically formulated silicone cream for postsurgical scar treatment. Methods In this prospective, randomized, controlled, double-blinded study, unilateral or bilateral facial or truncal scars in adult surgical patients were randomly treated with SKN2017B or silicone cream. Study investigators, study patients, and 2 independent reviewers assessed improvement in scar characteristics after 4 and 12 weeks of treatment. Results Forty-nine bilateral and 12 unilateral scars in 45 patients were treated with SKN2017B or silicone. At 12 weeks, investigators rated 74% of scars treated with SKN2017B as showing overall improvement vs 54% of silicone-treated scars, a 73% relative improvement with SKN2017B (P < 0.0001). Patients rated a moderate-to-significant improvement in 85% of SKN2017B-treated scars vs 51% of silicone-treated scars, a 67% relative improvement with SKN2017B (P < 0.001). Independent reviewers rated 87% of scars treated with SKN2017B to be better overall vs 1% of scars treated with silicone (P < 0.0001). There were no tolerability issues or adverse reactions with either cream. Conclusions SKN2017B consists of highly selective growth factors within a silicone cream matrix and is well tolerated and effective for surgical scar management. Level of Evidence: 1

Hyaluronic acid (HA) fillers are extensively used in periocular volume augmentation. Although they have an excellent safety profile, filler-related issues such as visibility/palpability, contour abnormalities, malar edema, and blue-gray dyschromia can occur. Recognition and management of filler-related issues are critical prior to subsequent procedures. The clinical course of patients who had periocular HA filler-related issues and subsequently underwent lower eyelid blepharoplasty is described. HA filler was dissolved with hyaluronidase (15–30 U/cm2) treatment. Visible lower eyelid fat prolapse after filler removal was corrected with transconjunctival blepharoplasty with fat repositioning and skin resurfacing. Complications and outcome were assessed and recorded. Twenty-three patients (46 eyelids) were treated. All presented with contour abnormalities, 19 with contour abnormalities and malar edema, and seven with blue-gray dyschromia. In 15 patients, one session of hyaluronidase completely dissolved the filler, and in eight patients, two sessions were required. Of these eight patients, edema resolved after the second hyaluronidase injection in four; in the remaining four, mild edema persisted despite absence of visible/palpable filler. Postblepharoplasty, 19 patients had an acceptable outcome with no complications (82.6%). Four patients had prolonged edema postoperatively; three had a resolution by 6 months. In 23 patients who had skin resurfacing procedures, there was no incidence of postinflammatory hyperpigmentation. HA filler-related issues need to be identified and managed prior to further intervention. Hyaluronidase treatment effectively dissolves the filler, but mild malar edema can persist. Outcomes are acceptable after subsequent blepharoplasty, but adequate patient counseling is necessary about expectations and limitations. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Scar formation is the body's natural healing response to reestablish dermal integrity following an injury. Excessive scarring, however, can cause significant cosmetic, functional, and psychological problems. A wide variety of topical creams, lotions, and oils are available for scar treatment or wound healing. Sieving through the options and selecting the best option for their patients can be challenging for clinicians, especially given that clinical evidence for many of the active agents in commonly used topical treatments is lacking. The goal of this review is to provide an overview of topical treatments utilized for scar management, including their mechanism of action and evidence of efficacy. As knowledge of the wound healing process is critical to understanding the effects of topical treatments, the pathophysiology of wound healing is also reviewed.pemJ Drugs Dermatol. 2018;17(4):421-425./em/p.

Blepharoplasty remains one of the most common aesthetic procedures performed today. Its popularity stems partly from the ability to consistently make significant improvements in facial aesthetics with a relatively short operation that carries an acceptable risk profile. In this article, the authors attempt to simplify the approach to both upper and lower lid blepharoplasty and provide an algorithm based on the individual findings for any given patient. The recent trend with both upper and lower lid blepharoplasty has been toward greater volume preservation and at times volume augmentation. A simplified approach to upper lid blepharoplasty focuses on removal of excess skin and judicious removal of periorbital fat. Avoidance of a hollow upper sulcus has been emphasized and the addition of volume with either fat grafting or fillers can be considered. Lower lid blepharoplasty can use a transcutaneous or a transconjunctival approach to address herniated fat pads while blending the lid-cheek junction through release of the orbitomalar ligament and volume augmentation with fat (by repositioning and/or grafting) or injectable fillers. Complications with upper lid blepharoplasty are typically minimal, particularly with conservative skin removal and volume preservation techniques. Lower lid blepharoplasty, conversely, can lead to more serious complications, including lid malposition, and therefore should be approached with great caution. Nevertheless, through an algorithmic approach that meets the needs of each individual patient, the approach to blepharoplasty may be simplified with consistent and predictable results.

The Cutler-Beard procedure is indicated in reconstruction of large defects of the upper eyelid. Typically, defects of more than 60% of the eyelid require repair with this two-stage reconstruction using full-thickness tissue from the lower eyelid. In the first stage, a full-thickness flap from the lower eyelid is advanced posterior to an intact lower eyelid margin. This includes the conjunctiva of the lower fornix, deep tissue of the lower eyelid, and skin. It attains collateral vascularization and lengthens over a period of 3–8 weeks. In the second-stage, the flap is divided at the level of the palpebral fissure, and the lower eyelid is reconstructed. The fornices are moderately foreshortened after this procedure.

PURPOSE Upper eyelid retraction is the most common sign of thyroid eye disease (TED). The results of traditional surgical procedures to correct upper eyelid retraction have been limited by unreliable postoperative eyelid height and contour. We investigate the outcome of the surgical correction of upper eyelid retraction using a modification of the full-thickness blepharotomy technique initially described by Elner et al. METHODS Fifty-three patients (78 eyelids) underwent a modified full-thickness blepharotomy. RESULTS Symmetry (within 1 mm) was achieved in 40 patients (75.5%) and symmetry (within 2 mm) was achieved in 43 cases (81.1%). Of the 53 patients, 8 (15.1%) required reoperation. CONCLUSIONS Our surgical approach can be performed efficiently and produces predictably satisfactory eyelid height even in severely retracted eyelids.

PURPOSE The purpose of this study was to investigate the prevalence of a common canalicular entrance in the lacrimal sac and to investigate the anatomy of the canalicular/lacrimal sac junction with direct visualization using a novel cadaveric dissection technique. METHODS Preserved cadavers were dissected to allow direct visualization of the canalicular entrance(s) to the lumen of the lacrimal sac. The prevalence of a common canaliculus and the anatomical variations of the canalicular/lacrimal sac mucosal fold of tissue were recorded. RESULTS One hundred twenty-four lacrimal systems (95 cadavers; 43 female, 52 male) were included in the study analysis. Overall, 123 lacrimal systems demonstrated a common canaliculus entering the lacrimal sac. Only one demonstrated 2 separate orifices (right orbit; male) in the sac (0.08%; 95% confidence interval, 0.1%-4.4%). Seventy-four lacrimal systems had some variation of a canalicular/lacrimal sac mucosal fold (59.7%). The remaining 50 (40.3%) had no visible canalicular/lacrimal sac mucosal fold. CONCLUSIONS This study provides direct anatomical evidence that the prevalence of separate canalicular orifices in the lacrimal sac is lower than previously reported (

Purpose: Treatment of large-angle strabismus in thyroid eye disease has historically suffered from low success rates. The authors report a novel technique that adds Tenon recession without conjunctival recession to standard extraocular muscle surgery. Methods: Twenty-six patients with thyroid eye disease-associated strabismus with preoperative deviations of ≥25 prism diopters in horizontal or vertical deviations underwent strabismus surgery. The amount of recession for a given muscle was determined by a combined analysis of the preoperative versions, deviation in primary gaze and in gaze opposite the restricted muscle, and intraoperative forced duction testing. Before conjunctival closure, the underlying Tenon layer and associated orbital tissues were recessed and allowed to retract posteriorally. The overlying conjunctiva was subsequently reapproximated to its anatomic position without tension. Results: The average preoperative measurements for horizontal and vertical deviations were 39.2 ± 13.4 and 45.0 ± 18.9 prism diopters, respectively. Average postoperative measurements for horizontal and vertical deviations were 3.2 ± 6.0 and 11.1 ± 11.9 prism diopters, respectively. Overall, 22 of 26 patients (84.6%) were within 10 prism diopters of intended correction postoperatively and achieved binocular fusion with or without the use of prisms for both distance and near vision. Four had residual deviations that required reoperation, all of which successfully produced binocular vision without the use of prisms. Conclusions: In the authors' experience, Tenon recession improves outcomes in surgery for large-angle strabismus in thyroid eye disease.

A variety of inflammatory lesions and tumors can present within the lacrimal gland. Given the inconsistency in the preoperative differentiation of malignant from benign tumors, complete surgical resection and histological identification remain the only means for a correct diagnosis. Lacrimal tumors such as pleomorphic adenoma have a high rate of recurrence and can undergo malignant transformation if they are not completely removed. Lacrimal gland tumors should undergo complete excision (with preservation of its capsule) without a primary incisional biopsy. These excisions can be facilitated through a lateral orbitotomy, which can offer the surgeon an exceptional approach with optimal exposure with or without the use of bone window.

Purpose Sildenafil can cause transient, mild ERG changes in healthy individuals taking large single doses. Although the drug was originally intended for intermittent use in erectile dysfunction, it has now been approved for chronic use in subjects with pulmonary arterial hypertension (PAH). The purpose of our study is to investigate possible ERG changes in subjects using large doses of sildenafil on a chronic daily basis. Methods We examined five subjects with PAH taking sildenafil daily for 1–4 years. Full-field electroretinogram (ERG), multifocal ERG (mfERG), and color testing were performed. Three of the subjects returned on a later date for challenge off and on the medication. Results On chronic daily sildenafil, color vision testing was normal, and ERG and mfERG amplitudes were normal; however, cone implicit times on drug were modestly lengthened. There were no consistent full-field ERG changes when off the drug, but the mfERG showed a small amplitude increase and implicit time decrease, which returned 1 h after re-dosing. Conclusion There was a modest lengthening of cone implicit time on chronic daily doses of sildenafil and a hint that some of these changes may be reversible in the short term. It does not appear that chronic sildenafil usage at these dosage levels is seriously toxic or threatening to vision.

Purpose To evaluate the efficacy, predictability, and safety of wavefront-guided laser in situ keratomileusis (LASIK) using the Visx CustomVue excimer laser (Advanced Medical Optics) in eyes with consecutive hyperopia and compound hyperopic astigmatism after LASIK. Setting Stanford University School of Medicine, Department of Ophthalmology, Stanford, California, USA. Methods This retrospective analysis included 19 eyes of 16 patients who had wavefront-guided LASIK for consecutive hyperopia and compound hyperopic astigmatism after initial LASIK surgery. Primary outcome variables, including uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), higher-order aberration (HOA) analysis, and spherical equivalence, were evaluated at 1 and 3 months. Nine eyes of 7 patients were available for all visits. Results The mean patient age was 51.7 years ± 3.77 (SD) (range 44 to 55 years). The mean preoperative manifest refractive spherical equivalent (MRSE) was 0.99 ± 0.32 diopters (D) (range 0.50 to 1.50 D) and the mean 3-month postoperative MRSE, −0.04 ± 0.66 D (range −1.50 to 0.75 D). At 1 month, 57.9% of eyes had a UCVA of 20/20 or better and 78.9% of 20/25 or better; 84.2% were within ±1.00 D of emmetropia. At 3 months, 66.7% of eyes had a UCVA of 20/20 or better and 88.9% of 20/25 or better; 88.9% were within ±1.00 D of emmetropia. No eye lost 2 or more lines of BSCVA at 1 or 3 months. Conclusion Wavefront-guided LASIK was an effective, predictable, and safe procedure for consecutive hyperopia and compound hyperopic astigmatism after LASIK.

Blepharoplasty has traditionally been one of the most common aesthetic procedures performed and remains so today. Blepharoplasty is performed by a variety of surgeons with different training levels of experience including plastic surgeons, ophthalmologists, otolaryngologists, cosmetic surgeons, and dermatologists. Although relatively straightforward, complications ranging from mild skin blemishes to vision-threatening emergencies can arise postoperatively. Many of these complications can be prevented with careful preoperative evaluation and proper surgical technique. When complications do arise, their significance can be diminished by appropriate treatment and/or referral consultation when necessary.

Thyroid Eye Disease (TED, Graves ophthalmopathy, thyroid ophthalmopathy) is the most common cause of orbital inflammation and proptosis in adults. There is no agreement on its management although corticosteroids and external beam orbital radiation (XRT) have traditionally been believed to provide benefit in active inflammation. Our review of the published literature in English disclosed an overall corticosteroid-mediated treatment response of 66.9% in a total of 834 treated patients who had moderate or severe TED. Intravenous corticosteroids used in repeated weekly pulses were more effective (overall favorable response = 74.6%, n = 177) and had fewer side effects than daily oral corticosteroids (overall favorable response = 55.5%, n = 265). A combination of corticosteroid and radiation therapy seemed to be more effective than corticosteroids alone. Our conclusions are tempered by a notable lack of standardization within and between study designs, treatment protocols, and outcome measures. Accordingly, the North American Neuro-Ophthalmology Society (NANOS), American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and the Orbital Society, in conjunction with Neuro-Ophthalmology Research and Development Consortium (NORDIC), will investigate the design and funding of a multi-center controlled trial.

Purpose Canalicular stenosis is a frequent cause of epiphora. Patients with canalicular stenosis often require timely insertion of bicanalicular silicone stents to prevent permanent and complete closure of the canaliculi. This study reports the use of balloon canaliculoplasty in conjunction with silicone tube intubation in selected cases of canalicular stenosis. Methods Patients with canalicular stenosis noted upon probing of the upper and lower lacrimal systems were included in the study. Patients with punctal stenosis underwent concurrent punctoplasty. Patients with complete canalicular obstruction were excluded from the study. The procedure was as follows. Canalicular dilation was achieved with 2 successive dilations of 90 seconds with a 2-mm-diameter balloon dilator, followed by probing and intubation of the lacrimal system with bicanalicular Crawford tubes. Results Twenty-one eyes (41 canaliculi) of 12 patients (10 females, 2 males) with canalicular stenosis were included in this study. The average age was 64.5 ± 7.5 years. Silicone tubes were left in place for an average 5.5 ± 2.6 (range: 2 to 12) months. Mean follow up after tube removal was 6.2 ± 1.1 months. Improvement within 1 week of the procedure was recorded in 20 out of 21 canaliculi (95.2%). Final clinical outcomes were successful or acceptable in 16 out of 21 eyes (76.2%). Conclusions Balloon canaliculoplasty with silicone tube intubation is simple and safe and appears to be an effective alternative treatment in patients with canalicular stenosis.

Intraorbital foreign body (IoFB) presents an interesting therapeutic dilemma when located posterior in the orbit. Factors such as foreign body composition, inflammation, infection, functional deficit, and potential for iatrogenic damage are considered when choosing the appropriate treatment.

DFG is usually performed under general anesthesia, and the donor site of the graft may be the lower abdomen, thigh, or inferomedial buttocks, depending on the surgeon’s preference. Local anesthesia is given to the orbit and the donor site. In cases of an extruding implant or one which has severe contractures, the conjunctiva is incised and the implant, if present, is removed. Muscle remnants within the socket should be identified if possible. This allows for greater graft survival (due to the vacularity the muscles provide to the graft) and motility of the socket. An approximate 20–25 mm diameter DFG is harvested from the donor site first by removing the epithelium. A sharp blade is then used to incise subcutaneous tissue and fat to a depth of 15–20 mm in a circular fashion. The graft is then sutured into the socket onto a vascularized source (i.e., extraocular muscles or orbital fat). The dermis is left bare to epithelialize from the surrounding conjunctiva. A temporary conformer is placed. Full epithelialization of the dermis occurs in approximately one month. An ocular prosthesis can be fitted in 2–3 months (Stewart 1995).

The use of proper instrumentation in ophthalmic plastic surgery is an essential element to successful surgical outcomes. However, the surgeon must be aware that without proper adherence to the basic surgical principles, surgical outcomes will be suboptimal. The surgeon must have an intimate knowledge of the eyelid, orbital, and facial anatomy. Furthermore, an understanding of the anatomy and the natural tissue planes allows the surgeon to surgically dissect the tissue planes as atraumatically as possible with the aid of appropriate and adequate instrumentation.

Ophthalmic plastic and reconstructive surgery combines the precision of ophthalmic microsurgery with plastic and reconstructive surgical principles, allowing for subspecialized care of the eyelid, orbital, and lacrimal system. A foundation in ophthalmology allows the oculoplastic surgeon the knowledge and skills to safely and successfully protect the globe while achieving functional and aesthetic results. Certain basic ophthalmic and plastic surgical considerations form the necessary framework for the successful practice of oculoplastic surgery.

A 45-year-old patient presented with bilateral orbital abscesses. He was found to have Lemierre syndrome, a condition involving septic thrombophlebitis of the internal jugular vein. The patient developed severe proptosis, sepsis, and cavernous sinus thrombosis. Despite aggressive antibiotic and anticoagulation therapy, visual loss was rapid, and the patient ultimately died. Lemierre syndrome, previously thought to be rare, is now becoming more commonly reported. Its prompt diagnosis and treatment are essential for patient survival.

PURPOSE Evaluate the relationship between extraocular muscle (EOM) size, measured by computed tomography, and ocular motility in thyroid eye disease (TED). METHODS This case series is based on a retrospective review of the records of 54 patients (108 orbits) with TED. Main outcome measures included EOM size and degree of motility restriction. The average diameter of each rectus muscle was compared with published norms. Four subpopulations based on Age (< 40 or ≥ 40 years) and State of thyroid eye disease (active or stable) were studied. Versions were measured by the corneal light reflex method. The trend of muscle diameter versus motility restriction was evaluated. RESULTS The average EOM diameter was greater than the norm in the study cohort and 4 subpopulations. The average diameter was largest in the Older and Active TED subpopulations. The inferior rectus and medial rectus were most frequently restricted in the study cohort and 4 subpopulations. The medial rectus had the strongest trend between increasing diameter and motility restriction, followed by the inferior rectus and the superior muscle group (comprised of the superior rectus and levator palpebrae superioris). However, there was a general lack of strong correlation between the diameter of the rectus muscles and their respective motility, especially in the Younger subpopulation. CONCLUSION EOM diameters are larger and have more restricted motility in the Older and Active TED subpopulations. Contrary to prior publications, the correlation between EOM diameters and motility was weak, especially in the Younger subpopulation. These findings suggest that the pathophysiology of EOM enlargement is different based upon the age of the patient and the activity of the orbitopathy.

A 24-year-old man developed abdominal carcinomatosis from signet cell carcinoma of the rectum. His only distal metastasis involved the superior orbit. Orbital pathology showed signet cells with a characteristic immunopathologic pattern. No hereditary syndrome was found. The authors identified only 5 cases in the literature describing colorectal adenocarcinoma metastatic to the orbit, with 2 showing histopathology. The authors believe that this rare case represents the first illustrating bona fide signet cell colorectal cancer involving the orbit.

A rare variant of adenoid cystic carcinoma is the dedifferentiated sarcomatoid form, which has previously been reported in the hard and soft palate, maxillary sinus, submandibular glands, and nasal cavity. The authors report the first case of a dedifferentiated sarcomatoid adenoid cystic carcinoma occurring in the lacrimal gland, that of a 52-year-old man. The patient presented with a 4-month history of diplopia, decreased vision, and right upper eyelid swelling. Radiographic imaging showed a soft tissue mass in the extraconal compartment superolateral to the right eye. The patient subsequently underwent surgical debulking. Histologic examination of the tissue revealed classic cribiform adenoid cystic carcinoma and a sarcomatous component consisting of malignant spindle cells and fusiform cells arranged in whorls. Dedifferentiation is a well-established phenomenon in salivary gland tumors that is associated with aggressive behavior and poor prognosis; however, the exact nature of such dedifferentiated neoplasms remains unclear.

Radioimmunotherapy with yttrium-90-ibritumomab tiuxetan may result in hemorrhagic tumor necrosis with acute orbital and intracranial inflammation.

Objective To evaluate changes in lower eyelid position using digital image analysis in patients who have undergone an orbicularis suspension flap combined with blepharoplasty. Methods A total of 68 patients (136 eyes) underwent a lower eyelid orbicularis oculi suspension flap combined with blepharoplasty. Digital image analysis was used to standardize each patient's preoperative and postoperative photographs for accurate objective comparison. The photographs were analyzed for lower eyelid position. Results The mean (SD) preoperative standardized distance from the center of the pupil to the lower eyelid margin (MRD2) in all procedures was 5.53 (0.74) mm. The mean (SD) postoperative standardized MRD2 was 5.22 (1.0) mm. There was a statistically significant difference in MRD2 position such that the postoperative MRD2 position decreased or the lower eyelid position was elevated by an average of 0.31 mm in comparison to the preoperative position ( P Conclusions A well-performed suspension flap can elevate the lower eyelid position to a more natural and anatomically appropriate position. By resuspending the ptotic orbicularis muscle, the suspension flap also reinforces the underlying attenuated orbital septum. Such cases may not achieve the optimum level of rejuvenation if isolated lower eyelid blepharoplasty is performed.

A 40-year-old man presented with bradycardia, left eye pain, and intermittent nausea 1 day after blunt trauma to the left orbit. Imaging revealed a large orbital floor fracture with significant herniation of orbital contents but no obvious extraocualar muscle entrapment. Oculocardiac reflex was suspected, and the fracture was repaired surgically within 24 hours of presentation. His bradycardia resolved immediately postoperatively. This case is a unique presentation of the oculocardiac reflex in a large orbital floor fracture with significant herniation of orbital contents but without extraocualar muscle entrapment.

Objective To evaluate orbital pressure (OP), intraocular pressure (IOP), and the effectiveness of canthotomy, cantholysis, and septolysis using an experimental orbital hemorrhage model. Methods Expired whole blood was injected into the retrobulbar space of 10 human cadaver orbits. At 1-mL increments, OP, IOP, and globe position were documented. The mean (SD) time interval between the injections was 84 (36) seconds. Following injection of 22 mL, lateral canthotomy, cantholysis, and septolysis were performed. An additional 10 mL of blood was then injected. Results After injecting 22 mL of whole blood, mean (SD) OP and IOP were 68.4 (32.2) and 71.5 (19.1) mm Hg, respectively. The OP and IOP correlated closely throughout the experiment, with a mean (SD) difference of 11.4 (4.9) mm Hg (Pearson coefficient, 0.97). Following canthotomy, cantholysis, and septolysis, there was a mean (SD) decrease of 48.0 (27.2) mm Hg (70%) and 50.0 (18.1) mm Hg (59%) in OP and IOP, respectively. With additional injection of 10 mL of blood, OP and IOP increased rapidly. Conclusions The IOP and OP rose in direct proportion to the volume of whole blood injected; OP lagged behind IOP by 11 mm Hg, and surgical release of the orbit reduced OP by 70%. This effect was short-lived in the setting of continued simulated hemorrhage.

Giant cell angiofibroma has recently been hypothesized to be a clinicopathologic variant of solitary fibrous tumor. The authors report a case of an orbital giant cell angiofibroma that recurred as a solitary fibrous tumor 4 years later. The report strongly supports the hypothesis that giant cell angiofibroma and solitary fibrous tumor are related.

There is a growing body of literature describing severe surfing-related ocular injuries that result in permanent vision loss. We describe three severe surfing-related ocular injuries that occurred on beaches in northern California. One particular case stresses the need to tailor treatment to the patient and injury because of the possibility of good outcomes despite severe injury. Attention should also be directed towards commercially available safety gear and providing additional safety measures to prevent other orbital and ocular injuries.

Purpose To evaluate the safety, efficacy, and clinical outcomes of wavefront-guided laser in situ keratomileusis (LASIK) surgery for the treatment of moderate to high myopia and compound myopic astigmatism. Setting Stanford University School of Medicine, Department of Ophthalmology, Stanford, California, USA. Methods This retrospective study included patients with moderate (−6.0 to −8.0 diopters [D]) and high (greater than −8.00) myopia treated with wavefront-guided LASIK using the WaveScan linked to the CustomVue system (AMO USA, Inc.). Eyes were analyzed preoperatively and 1, 3, and 12 months postoperatively. Results The mean patient age was 38.4 years ± 7.14 (SD). Eighty-nine eyes of 45 patients were evaluated at 3 months and 50 eyes of 25 patients at 12 months. No eye was retreated during the study. The mean manifest refraction spherical equivalent was −8.10 ± 0.98 D (range −6.00 to −10.63 D) preoperatively and −0.33 ± 0.55 D (range −1.625 to 1.375 D) 12 months postoperatively. Ninety percent of the eyes were within ±1.00 D of the intended correction and 64.0%, within ±0.50 D. For all eyes, the safety index was 1.00 and the efficacy index, 1.18. Conclusion The data support the safety and efficacy of correcting moderate to high myopia and compound myopic astigmatism using wavefront-guided LASIK.

To map and identify the pattern, in vivo, of axonal degeneration in ethambutol-induced optic neuropathy using optical coherence tomography (OCT). Ethambutol is an antimycobacterial agent often used to treat tuberculosis. A serious complication of ethambutol is an optic neuropathy that impairs visual acuity, contrast sensitivity, and color vision. However, early on, when the toxic optic neuropathy is mild and partly reversible, the funduscopic findings are often subtle and easy to miss.Three subjects with a history of ethambutol (EMB)-induced optic neuropathy of short-, intermediate-, and long-term visual deficits were administered a full neuro-ophthalmologic examination including visual acuity, color vision, contrast sensitivity, and fundus examination. In addition, OCT (OCT 3000, Humphrey-Zeiss, Dublin, CA) was performed on both eyes of each subject using the retinal nerve fiber layer (RNFL) analysis protocol. OCT interpolates data from 100 points around the optic nerve to effectively map out the RNFL.The results were compared to the calculated average RNFL of normal eyes accumulated from four prior studies using OCT, n=661. In all subjects with history of EMB-induced optic neuropathy, there was a mean loss of 72% nerve fiber layer thickness in the temporal quadrant (patient A, with eventual recovery of visual acuity and fields, 58% loss; patient B, with intermediate visual deficits, 68% loss; patient C, with chronic visual deficits, 90% loss), with an average mean optic nerve thickness of 26+/-16 microm. There was a combined mean loss of 46% of fibers from the superior, inferior, and nasal quadrants in the (six) eyes of all three subjects (mean average thickness of 55+/-29 microm). In both sets (four) of eyes of the subjects with persistent visual deficits (patients B and C), there was an average loss of 79% of nerve fiber thickness in the temporal quadrant.The OCT results in these patients with EMB-induced optic neuropathy show considerable loss especially of the temporal fibers. This is consistent with prior histopathological studies that show predominant loss of parvo-cellular axons (or small-caliber axons) within the papillo-macular bundle in toxic or hereditary optic neuropathies. OCT can be a valuable tool in the quantitative analysis of optic neuropathies. Additionally, in terms of management of EMB-induced optic neuropathy, it is important to properly manage ethambutol dosing in patients with renal impairment and to achieve proper transition to a maintenance dose once an appropriate loading dose has been reached.

In their article “Anthropometry of the Eyelid and Palpebral Fissure in an Indian Population,” Dr. Patil et al establish normal periorbital anthropometric values for a population that has not been studied to a great degree in the oculoplastic surgery literature. Their study included 216 male and female patients, 16 to 60 years old. Digital image analysis was prospectively performed to measure the following parameters: In choosing these measurements, the authors investigated parameters consistent with ranges published in current ophthalmic plastic surgery literature.1-4 The authors found that the mean intercanthal distance increased with age in both males and females, along with an increase in the palpebral fissure width …