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Anna Artymowicz,1 Christina Douglas,2 Kimberly Cockerham2,3 1West Coast Eye Institute, Bakersfield, CA, USA; 2Southeast Eye Specialists, Knoxville, TN, USA; 3Senta Clinic, San Diego, CA, USACorrespondence: Anna Artymowicz, West Coast Eye Institute, 215 China Grade Loop, Bakersfield, CA, 93308, USA, Tel +1 (661) 393-2331, Email artywcei@gmail.comAbstract: Advances in telemedicine have allowed physicians to provide care in areas that were previously geographically or practically inaccessible. Roughly 70% of all US hospital have less than 200 bed capacity and nearly 50% have fewer than 100 beds. These smaller hospitals often do not have specialists available for bedside patient care, making them potential beneficiaries of telemedicine medical specialty services. In 2005, the American Stroke Association proposed implementing telemedicine services in effort to increase access to acute stroke care in neurologically underserved areas such as small hospitals. Tele-stroke services have since become established across the country and are now utilized by approximately 30% of US hospitals. By reducing the time between presentation and evaluation by a stroke specialist, tele-stroke programs have successfully increased patient access to life-saving treatment with tissue-plasminogen activator (t-PA) treatments. This change has been especially profound remote and underserved community hospitals. However in the evaluation of acute vision loss, an area where ophthalmology and stroke care overlap, increased reliance on tele-stroke services has contributed to some unique challenges. Acute vision has a complex differential and is commonly a result of conditions other than stroke. When tele-stroke services are engaged for the evaluation of acute vision loss, the neurologist is asked to make medical decisions without complete information about the eye. This situation can expose patients to costly or inappropriate testing, unnecessary hospitalizations, or lead to delayed diagnosis and treatment of non-neurologic conditions of the eye. The goal of this paper is to provide an overview of the overlap between stroke and vision loss, highlight the challenges inherent in using tele-stroke in evaluating acute vision loss and to offer our comments on how increased communication between emergency medicine, ophthalmology, and neurology services can ensure that patients with vision loss receive the highest standard of care in all hospitals.Keywords: telemedicine, tele-stroke, acute vision loss, tele-neurology, CRAO

An apparatus was designed and constructed that quantitatively measures the number and size of poorly dispersed particles ( >3 μm diameter) that protrude above the surface of an extruded plastic ribbon (0.10–0.15 mm thick). Major components of the apparatus include a set of in-house fabricated dispensing and take-up wheels for guiding the ribbon’s path, a commercially available variable differential transducer, and custom-designed software based on National Instruments’ LABVIEW platform. The reproducibility and repeatability of the technique are presented, along with data comparing this approach to more conventional, albeit labor-intensive manual approaches. [ABSTRACT FROM AUTHOR]

Background: Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of acute and chronic thyroid eye disease (TED) related to hyperthyroidism. Given the lower incidence of TED associated with hypothyroidism / euthyroidism, there is a paucity of data regarding the efficacy of teprotumumab in this group., Methods: In this multicenter study, consecutive patients who had been diagnosed with TED, presenting with either hypothyroidism or euthyroidism as their baseline thyroid dysfunction and treated with teprotumumab were included. All patients had measurements of proptosis, clinical activity scores (CAS), diplopia scores and four-point strabismus scores before and after therapy., Results: Twenty-six patients met the inclusion criteria. Mean age was 48 ± 14 years old and mean duration of TED prior to treatment was 31 ± 43 months. All patients received 8 infusions. Mean (SD) reduction in proptosis for study orbits was 2.7 mm (1.8) (p < 0.05) and 1.8 mm (2.0) for the fellow orbit (p < 0.05). In the study orbit, mean (SD) CAS was 2.3 (1.3) before therapy and 1.0 (1.0) following therapy (p < 0.05). At baseline, mean (SD) diplopia score was 1.2 (1.1) and 0.9 (1.1) following therapy (p < 0.05)., Conclusion: Teprotumumab reduces proptosis and inflammation in patients presenting with TED associated with hypothyroidism and euthyroidism. The results of this study highlight the potential for teprotumumab therapy in this subgroup and also provide a unique insight into the potential role of the IGF-1R in these patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Traumatic optic neuropathy is classically described in up to 8% of patients with traumatic brain injury (TBI), but subclinical or undiagnosed optic nerve damage is much more common. When more sensitive testing is performed, at least half of patients with moderate to severe TBI demonstrate visual field defects or optic atrophy on examination with optical coherence tomography. Acute optic nerve compression and ischaemia in orbital compartment syndrome require urgent surgical and medical intervention to lower the intraocular pressure and diminish the risk of permanent optic nerve dysfunction. Other manifestations of traumatic optic neuropathy have more variable treatments in international practice., Methods: We conducted a systematic review of traumatic optic neuropathy treatments in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement., Results: We included three randomised controlled trials of intravenous methylprednisolone (IVMP), erythropoietin, and levodopa-carbidopa combination, with no evidence of benefit for any treatment. In addition, large studies in TBI have found strong evidence of increased mortality in patients treated with megadose IVMP., Conclusions: There is therefore no evidence of benefit for any medical treatment and strong evidence of harm from IVMP. There is also no evidence of benefit for optic canal decompression for traumatic optic neuropathy. Orbital compartment syndrome is a separate entity that requires both medical and surgical interventions to prevent visual loss., (© 2024. Crown.)

Objective: In thyroid eye disease (TED), inflammation and expansion of orbital muscle and periorbital fat result in diplopia and proptosis, severely impacting patient quality of life (QOL). The reported health state utility (HSU) scores, which are QOL measures, allow quantification of TED impact and improvement with therapies; however, no current QOL instrument has been validated with HSU scores for TED. Here, we used the disease-specific Graves Ophthalmopathy Quality of Life (GO-QOL) questionnaire and HSU scores to validate QOL impact., Methods: The GO-QOL scores from patients in 2 randomized, masked, placebo-controlled teprotumumab trials (N=171) were compared with 6 HSU values based on severity of proptosis/diplopia in those studies. Patient GO-QOL and HSU scores were compared at baseline and after 6-month treatment via regression analyses. GO-QOL and HSU scores were correlated for validation and quantification of QOL impact by severity state and to estimate quality-adjusted life year improvement., Results: GO-QOL scores were correlated with TED severity, indicating that worse severity was associated with lower (worse) GO-QOL scores. Less severe health states were represented by higher (better) GO-QOL scores. Importantly, GO-QOL scores were positively correlated with utility scores of the 6 health states, allowing for conversion of the GO-QOL scores to utility scores. A positive (improved) 0.013 utility change was found for each 1-point (positive) improvement in GO-QOL score produced by teprotumumab versus placebo., Conclusion: Patients with moderate-to-severe active TED health states demonstrate increasing TED severity associated with declining utility values and worsening GO-QOL scores. These results indicate that the GO-QOL scores can be used to bridge to the HSU scores for benefit quantification., Competing Interests: Disclosure T.J. Smith was issued US patents covering the use of IGF-1 receptor inhibitors in TED which are held by UCLA and the Lundquist Institute and is a consultant for Amgen (formerly Horizon), Viridian, Minghui and Lundbeck. K. Cockerham is a consultant for Amgen Inc (formerly Horizon) and Viridian. N. Barretto and R.J. Holt are employees and hold stock in Amgen (formerly Horizon). S. Taylor is a former employee and stockholder of Horizon. A. Hirst, L. Oliver, A. Enstone, and G. Brandolini are employees of Adelphi Values PROVE (Adelphi Values received budgetary compensation from Horizon [now Amgen] for conduct of the study)., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Purpose: Teprotumumab, an insulin-like growth factor 1 receptor monoclonal antibody, is FDA-approved to treat thyroid eye disease (TED). The initial clinical trials excluded patients with previous orbital irradiation, surgery, glucocorticoid use (cumulative dose >1 gm), or prior biologic treatment. Information on the use of teprotumumab for patients who failed prior therapy is limited. Our purpose is to characterize the efficacy of teprotumumab for the treatment of recalcitrant TED., Methods: This is a multicenter retrospective study of all patients treated with teprotumumab for moderate-to-severe TED after failing conventional therapy with corticosteroids, orbital radiation, surgical decompression, biologics, or other steroid-sparing medications. Treatment failure was defined as an incomplete response to or reactivation after previous treatment. Only patients who received at least 4 infusions of teprotumumab were included in the analysis. Primary outcome measures comprised proptosis response (≥2 mm reduction in the study eye without a similar increase in the other eye), clinical activity score (CAS) response (≥2-point reduction in CAS), and diplopia response (≥1 point improvement in Gorman diplopia score in patients with baseline diplopia) following treatment. Adverse events and risk factors for recalcitrant disease were also evaluated., Results: Sixty-six patients were included in this study, 46 females and 20 males. Average age was 59.3 years (range 29-93). The mean duration of disease from TED diagnosis to first infusion was 57.8 months. The proptosis, CAS, and diplopia responses in this recalcitrant patient population were 85.9%, 93.8%, and 69.1%, respectively. Patients experienced a mean reduction in proptosis of 3.1 ± 2.4 mm and a mean improvement in CAS of 3.8 ± 1.6. Patients who underwent prior decompression surgery experienced a statistically significant decrease in diplopia response (46.7% vs. 77.5%, p = 0.014) and proptosis response (75.0% vs. 90.9%, p = 0.045) when compared with nondecompression patients. Additionally, there were no significant differences in proptosis, CAS, and diplopia responses between patients with acute (defined as disease duration <1 year) versus chronic (disease duration ≥1 year) TED. While most adverse events were mild to moderate, 4 patients reported serious adverse events related to persistent hearing loss., Conclusions: Patients with recalcitrant TED demonstrated a significant improvement after teprotumumab in each of the primary study outcomes. The degree of proptosis reduction, diplopia response, and CAS improvement in the recalcitrant group were similar to those of treatment-naïve patients from the pivotal clinical trials. Patients with a prior history of orbital decompression, however, demonstrated poor improvement in diplopia and less reduction in proptosis than surgery naïve patients. These results indicate that teprotumumab is a treatment option for the treatment of patients with TED recalcitrant to prior medical therapies., Competing Interests: Wendy W. Lee is a consultant for Allergan, Galderma, Horizon, RVL, Tarsus, RoC, Revance, and Evolus. Andrea L. Kossler is a consultant for Horizon, Immunovant, Argenx, Genentech, Acelyrin, and Axogen. Andrea L. Kossler is engaged in independent research with Horizon, Sling Therapeutics, Viridian, and Kriya Therapeutics. The remaining authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background: Dry eye syndrome occurs in up to 85% of patients with thyroid eye disease (TED). Lacrimal gland enlargement correlates with subjective tearing and a reduction in quality of life in patients with TED., Methods: In this prospective longitudinal study, patients presenting for the treatment of TED were considered for eligible. Primary outcomes included a change in the volume of the lacrimal gland and the production of tears following treatment with teprotumumab. The volume of lacrimal glands and proptosis was calculated using 3D volumetric analysis. Tear production was measured by Schirmer's test and associated symptoms were assessed using the VLSQ-8. The orbit with the most proptosis was designated the study orbit and the contralateral orbit was designated the fellow orbit., Results: Twenty patients were included. Mean (SD) age was 61 (18) and mean duration of TED prior to therapy was 48 months (47). Lacrimal gland volume in the study orbit decreased from 768 mm 3 (288) to 486 mm 3 (173) (p < 0.01) following therapy. For the fellow orbit, volume reduced from 637 mm 3 (261) to 379 mm 3 (147) (p < 0.01). Schirmer's test reading (STR) in the study orbit increased from 14.5 mm (8.2) to 23 mm (10) (p < 0.01) (59%) following treatment. In the fellow orbit, STR increased from 12.7 mm (7) to 21 mm (9) post therapy (69%) (p < 0.01). There was a significant improvement on all parts of the VLSQ-8., Conclusion: Teprotumumab significantly reduces TED related expansion of the lacrimal gland, increases tear production, and improves dry eye symptoms., (© 2023 Royal Australian and New Zealand College of Ophthalmologists.)

Importance: Thyroid eye disease (TED) results in varying degrees of proptosis and diplopia negatively affecting quality of life (QoL), producing possibly substantial visual changes, disfigurement, and disability., Objective: To determine the association of varying TED severities with QoL in a non-TED population by assessing health state utility scores., Design, Setting, and Participants: This qualitative study, conducted from April 20, 2020, to April 29, 2021, assessed health states for active, moderate-severe TED, and values were elicited using time trade-off methods. Six health states of varying severity were determined from 2 placebo-controlled clinical trials (171 patients with TED and clinical activity score ≥4, ±diplopia/proptosis) and refined using interviews with US patients with TED (n = 6). Each health state description was validated by interviews with additional TED patient advocates (n = 3) and physician experts (n = 3). Health state descriptions and a QOL questionnaire were piloted and administered to a general population. Visual analog scales (VASs) were also administered to detect concurrence of the findings., Main Outcomes and Measures: TED health state utility scores and whether they differ from one another were assessed using Shapiro-Wilk, Kruskal-Wallis, pairwise Wilcoxon rank sum, and paired t tests., Results: A total of 111 participants completed time trade-off interviews. The mean (SD) utility value was 0.44 (0.34). The lowest (worse) mean utility value was observed in the most severe disease state (constant diplopia/large proptosis) with 0.30 (95% CI, 0.24-0.36), followed by constant diplopia/small proptosis (0.34; 95% CI, 0.29-0.40), intermittent or inconstant diplopia/large proptosis (0.43; 95% CI, 0.36-0.49), no diplopia/large proptosis (0.46; 95% CI, 0.40-0.52), and intermittent or inconstant diplopia/small proptosis (0.52; 95% CI, 0.45-0.58). The highest (best) mean value, 0.60 (95% CI, 0.54-0.67), was observed for the least severe disease state (no diplopia/small proptosis)., Conclusions and Relevance: These findings suggest that patients with active, moderate-severe TED may have substantial disutility, with increasing severity of proptosis/diplopia more likely to have detrimental associations with QoL. These health state scores may provide a baseline for determining QoL improvement in these TED health states (utility gains) treated with new therapies.

Background: Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of active Thyroid eye disease (TED). The current study reviews its efficacy in chronic TED., Methods: In this retrospective review, consecutive patients with chronic stable TED (>2 years), who had received ≥3 infusions of teprotumumab were included. All patients had measurements of proptosis, and calculation of the CAS and diplopia scores before and after therapy. Five-point strabismus scores were also calculated. Patients who had imaging within 4 months prior to therapy and 6 weeks post therapy underwent orbital 3D volumetric analysis., Results: Thirty-one patients met the inclusion criteria. The mean (SD) duration of TED was 81 months (56) and the mean (SD) number of infusions received by each patient was 7 (2). Mean (SD) reduction in proptosis for each study orbit was 3.5 mm (0.4) and 3 mm (0.3) for the fellow orbit. The CAS response was 90% for the study orbit and 87% for the fellow orbit. Of the 15 patients who had diplopia at baseline, 67% had a clinically significant response, while 47% had complete resolution following treatment. Following teprotumumab, mean (SD) reduction of muscle tissue was 2011 mm 3 (1847) in the study orbit and 1620 mm 3 (1759) in the fellow orbit. The mean (SD) reduction of fat volume was 2101 mm 3 (1681) in the study orbit and 1370 mm 3 (1181) in the fellow orbit., Conclusion: Teprotumumab significantly reduces proptosis, inflammation, diplopia, strabismus and orbital soft tissue volume in patients with chronic TED., (© 2021. The Author(s).)

Competing Interests: The authors report no conflicts of interest.

Background: Teprotumumab, a monoclonal antibody that blocks the insulin-like growth factor-1 receptor, has recently been approved by the US Food and Drug Administration (FDA) for the treatment of thyroid eye disease (TED). Since its approval, aside from data on the safety and clinical efficacy of teprotumumab from Phase-2 and Phase-3 trials, only a handful of reports have been published regarding its use in the wider population. In this review, we briefly describe the mechanism of action of teprotumumab and review the literature to provide an overview of published clinical experience. This information was used to provide recommendations for patient selection, management of patient expectations, infusion details and site options, tips to optimize the authorization process, and how to monitor and mitigate side effects., Evidence Acquisition: A systemic review of the literature was performed regarding teprotumumab, focusing on its mechanisms of action and published reports on its use on patients with TED. A review of Embase, Medline (PubMed), Web of Science, and Google Scholar was conducted., Results: Clinical experience following the approval of teprotumumab has confirmed its efficacy in reducing inflammation and proptosis in patients with acute TED (<2 years). The reduction in proptosis occurs due to a reduction in orbital fat and muscle volume. Furthermore, there is evidence for its use in patients with compressive optic neuropathy. There are also reports that show its efficacy in reducing proptosis, inflammation, and diplopia in patients with chronic TED (>2 years). Teprotumumab was associated with side effects, such as muscle spasm, hearing loss, and hyperglycemia. To date, 2 case reports have shown a possible association with flares of inflammatory bowel disease., Conclusions: Teprotumumab is a powerful therapeutic option for the treatment of TED. Clinical experience following FDA approval has demonstrated efficacy in treating patients with acute and chronic TED. It is the only therapeutic option that has been shown to reduce orbital soft tissue expansion in TED. However, it is expensive, and sometimes, obtaining insurance authorization can be time consuming and difficult. Further work will reveal its full side effect profile and help to establish its role in the armamentarium used to treat TED., Competing Interests: A. L. Kossler: Horizon Therapeutics, Osmotica; R. Douglas: Horizon Therapeutics, Osmotica, ValenzaBio, Viridian; K. Cockerham: Horizon Therapeutics, Viridian. The remaining author reports no conflict of interest., (Copyright © 2022 by North American Neuro-Ophthalmology Society.)

Summary: Thyroid dermopathy is an uncommon manifestation of thyroid disease that impairs the quality of life in certain cases. Currently, the available treatments offer limited results and a chance of recurrence. Teprotumumab, a novel medication that results in the regression of thyroid ophthalmopathy, may have similar effects on dermopathy. We describe four patients treated with teprotumumab for their thyroid ophthalmopathy who concomitantly had dermatopathy upon initiation of their infusions. Patients improved after two to three infusions and three out of the four patients have not suffered a recurrence.Teprotumumab is a monoclonal antibody (MAB) that attenuates an inflammatory response, resulting in decreased edema and tissue expansion. Given the similarities of their pathophysiology, we believe that the resolution of thyroid dermatopathy and regression of thyroid eye disease occurs via the same mechanism. We encourage further investigation utilizing teprotumumab for patients whose dermopathy is associated with impaired quality of life., Learning Points: Thyroid dermopathy (TD), an uncommon manifestation of thyroid disease, may occasionally impair function and quality of life. There are only a few treatments for TD, with limited results and high rates of recurrence. Teprotumumab is a Food and Drug Administration-approved medication used for thyroid eye disease (TED). Our patients treated with teprotumumab for TED showed improvement of TD, which demonstrates its potential use for this condition.

Teprotumumab was the first and only medication approved by the US Food and Drug Administration for the treatment of thyroid eye disease in January 2020. Thyroid eye disease is a complex autoimmune inflammatory disease that can be sight-threatening, debilitating, and disfiguring to affected patients. Although biologic therapies are a preferred treatment option for many complex immunologic and oncologic conditions, their use in ophthalmology and endocrinology may be more novel. The goals of this article are to introduce this new therapeutic option; discuss its mechanism of action, indications for use, administration protocol, infusion precautions, and informed consent; and review common side effects and management., Competing Interests: K. Cockerham and R. Douglas are on the Horizon Therapeutics Medical Advisory Board. A. Kossler is a consultant for Horizon Therapeutics. J. Kang, M. Lechuga, and J. Braun have no conflicts of interest to disclose., (Copyright © 2021 Infusion Nurses Society.)

Objective  Primary orbital malignancy is rare. Awareness of the characteristic clinical and imaging features is imperative for timely identification and management. Surgery remains an important diagnostic and treatment modality for primary orbital malignancy, but determining the optimal surgical approach can be challenging. The purpose of this article is to explore recent advances in the diagnosis, management, and surgical approaches for primary orbital malignancies. Design  In this review, the clinical presentation, imaging features, and medical and surgical management of primary orbital malignancies with representative cases will be discussed. Setting  Outpatient and inpatient hospital settings. Participants  Patients with diagnosed primary orbital malignancies. Main Outcome Measures  Descriptive outcomes. Results  Advancements in orbital imaging, microsurgical techniques, and multimodal therapy have improved the diagnosis and management of primary orbital malignancies. Special considerations for biopsy or resection are made based on the tumor's location, characteristics, nearby orbital structures, and goals of surgery. Minimally invasive techniques are supplanting traditional approaches to orbital surgery with less morbidity. Conclusions  Advances in imaging technologies and surgical techniques have facilitated the diagnosis and management of primary orbital malignancies. Evolution toward less invasive orbital surgery with focus on preservation and restoration of function is underway., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objectives  To describe medical and surgical options and techniques for functional and aesthetic abnormalities after orbital surgery and multidisciplinary approaches that include the orbit. Design  A review of current management options in outpatient clinics and ambulatory surgery centers with selected illustrative cases. The rationale for choosing specific medical and surgical interventions will be discussed with a focus on eyelid malposition and double vision. Setting  Outpatient clinics and ambulatory surgery centers. Participants  Patients with eyelid, orbital, eye muscle, and scalp contour abnormalities as a result of medical and surgical interventions for brain and/or orbital tumors. Main Outcome Measures  Descriptive outcomes. Results  A variety of medical and surgical options are available to optimize eyelid, orbit, extraocular muscle, and scalp structure and function., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Purpose: Intravenous antibiotic prophylaxis is used for many clean-contaminated surgeries or clean surgeries with an implant, but its value for clean orbital surgery has not been determined. This study investigated infection risks and adverse effects related to antibiotics in patients undergoing orbital surgery., Methods: A prospective, nonrandomized comparative case series of all patients undergoing orbital surgery with participating surgeons between October 1, 2013, and March 1, 2015. Types of surgery, antibiotic regimens, corticosteroid use, antibiotic side effects, and surgical site infections (SSIs) were entered into an electronic database and subsequently analyzed. Cases in which patients received postoperative oral antibiotics were analyzed separately., Results: Of 1,250 consecutive orbital surgeries, 1,225 met inclusion criteria. A total of 1208 patients were included in the primary analysis: 603 received no antibiotic prophylaxis (group A), and 605 received a single dose of intravenous antibiotic (group B). Five patients (0.42%) developed an SSI, 3 in group A and 2 in group B. The difference in SSI rates was not statistically significant between the 2 groups (p = 0.66). Antibiotic prophylaxis, alloplastic implants, paranasal sinus entry, and corticosteroid use were not associated with differences in SSI rates. All SSIs resolved on a single course of oral antibiotics; an implant was removed in 1 case. There were no complications associated with a single dose of intravenous prophylaxis. However, 12% of 17 patients (group C) who received 1 week of oral postoperative prophylactic antibiotics developed antibiotic-related complications (diarrhea, renal injury), yielding a number needed to harm of 8.5., Conclusions: In this large series, antibiotic prophylaxis does not appear to have reduced the already low incidence of SSI following orbital surgery. Given the detriments of systemic antibiotics, the rarity of infections related to orbital surgery, and the efficacy of treating such infections should they occur, patients undergoing orbital surgery should be educated to the early symptoms of postoperative infection and followed closely, but do not routinely require perioperative antibiotics.

Hyaluronic acid (HA) dermal fillers are the most widely used injectables to augment facial volume without surgery. HA dermal fillers are popular because of their ease of administration, predictable effectiveness, good safety profile, and quick patient recovery. The most common patient complaint is pain. Our goal is to review the current literature on HA fillers and compare outcomes with and without lidocaine. We found adjunctive lidocaine significantly decreases pain during injection and postinjection with corresponding increased patient satisfaction. The efficacy and safety profile appears unchanged. Rare complications with HA fillers and those associated with constituents of the product, contaminants, and lidocaine are reviewed. The corrective effects of HA fillers are temporary; repeat treatment is required to maintain results. Minimizing pain is crucial to optimize patient satisfaction.

The demand for dermal fillers and the variety of dermal fillers available have evolved dramatically during the past 2 decades. Collagen was the first material to be approved by the U.S. Food and Drug Administration (FDA) for injection into facial scars, furrows, and lines. Bovine collagen (95% type I and 5% type III collagen) was approved in 1981; buffered collagen Zyderm I and Zyderm II followed by Zyplast were FDA approved and released shortly thereafter. This article will focus on the historical benefits and risks of collagen injections and the typical outcomes. With the advent of hyaluronic acid products and other options, the risks of collagen and limited benefit have caused a marked loss of market share. Specifically, allergy is a major concern. As a result, two rounds of skin testing are required adding inconvenience and delay for both the practitioner and patient. Furthermore, a negative skin test does not guarantee allergic reactions or other more serious side effects will not occur. Finally, the perceived clinical efficacy is often short lived despite histopathologic assessments showing that collagen persists at best 9 months.

Translational research may lead to development of micro-electromechanical system-based devices to treat muscle and nerve dysfunctions whose current treatments are inadequate and, at best, palliative. This paper discusses the development of engineered microsystems as a treatment option for palsies of the seventh cranial nerve and the potential application of these devices as a platform technology for treatment of other nervous dysfunctions. The engineering techniques for electrical and chemical stimulation of denervated muscle are discussed along with current caveats from clinical and engineering standpoints. As opposed to current treatments, miniaturized implants offer the possibility of the reduced toxicity and increased specificity of direct drug delivery. As with the increased miniaturization of other technologies, engineering of these increasingly small implantable microsystems holds great promise for the future development of yet smaller, even nanoscale, implantable devices.

Orbital tumors can be excised or biopsy samples obtained via transorbital approaches, especially those located in the anterior two thirds of the orbit. The indications and various surgical steps will be reviewed for the anterior, the anteromedial, and the lateral approaches. Some of these approaches can be combined or extended to accommodate large or deep-seated tumors.

Orbital lesions are variable in nature and location. Their management can be challenging, and surgical intervention is often needed. Although a significant percentage of these tumors are treated by the ophthalmologist alone, collaboration with a neurosurgeon is often required, especially for tumors that are located deep within the orbit, are large, or have an intracranial extension. Technical advances and modifications in surgical technique have decreased surgery-related morbidity and increased its success. The authors describe their rationale in the choice of a surgical approach, the surgical techniques for extraorbital approaches, and the new surgical adjuvants.

Objective: To define the clinicopathologic features of eyelid involvement in Melkersson-Rosenthal syndrome (MRS)., Methods: Four patients with eyelid edema consistent with MRS were evaluated clinically, including diagnostic imaging in 2 patients. Eyelid tissue from these patients was examined by light microscopy and immunohistochemistry. Polymerase chain reaction for herpes simplex virus was performed in 1 case., Results: The 3 men and 1 woman ranged in age from 33 to 74 years. All patients had insidious, painless, nonpitting eyelid edema. Three patients had unilateral edema; one had bilateral, asymmetric involvement. Ipsilateral lip edema was present in 1 case. Computed tomography demonstrated periorbital heterogeneous thickening that corresponded to the microscopic finding of scattered granulomas. All 4 patients demonstrated epithelioid granulomas inside and adjacent to dilated lymphatic vessels. Polymerase chain reaction testing was negative for herpes simplex virus., Conclusions: Isolated eyelid swelling that mimics thyroid-associated ophthalmopathy may occur in MRS. Computed tomography may be useful in the diagnosis. Biopsy should be performed in all cases of unexplained nonpitting eyelid edema. In the eyelid, MRS is characterized histopathologically by a granulomatous lymphangitis, a finding that seems to be unique to this condition.

Schwannomas (neurilemomas) are benign tumors that arise from Schwann cells in the peripheral nervous system. The most commonly involved nerves that cause neuro-ophthalmic manifestations are cranial nerves V and VIII. In this series of three women, schwannomas presented as intraconal masses that mimicked a cavernous hemangioma, a superior orbital mass transgressing the superior orbital fissure, and an expansive frontal lobe mass with clinical symptoms and signs of increased intracranial pressure. Although all three complained of visual blurring, none of our patients presented with Vth or VIIIth cranial nerve dysfunction. Histopathologic studies demonstrated well-circumscribed, encapsulated spindle-cell lesions with classic Antoni A and B patterns. Histopathologic examination is essential to confirm the diagnosis of a schwannoma that may be otherwise clinically confusing. Direct optic nerve compression, globe indentation with induced hyperopia, or increased intracranial pressure with optic nerve compromise may be responsible for visual symptoms. A multidisciplinary approach is often required because of the size and location of schwannomas.

Objective: To highlight a troubling cause of dacryocystorhinostomy (DCR) failure and to alert ophthalmologists to the potential problems that can result when stenting material is not removed and becomes retained after DCR., Design: Consecutive noncomparative case series., Participants: Twelve patients who underwent revision DCR from February 1994 to January 1997., Intervention: Endoscopic DCR, pre- and postoperative nasal endoscopy, preoperative computerized tomography (CT), and pre- and postoperative Jones testing., Results: Fourteen revision endoscopic procedures were performed on 12 patients with recurrent epiphora following DCR. Failure was due to retained stenting material in six patients, a small bony rhinostomy in three patients, excessive scar formation within the rhinostomy in two patients, and improper location of the rhinostomy in one patient. Preoperative endoscopy and CT scan each correctly identified the retained sponge or tubing in four of six patients., Conclusions: Fastening a small sponge to Silastic tubing and positioning it within the DCR site in an attempt to retard DCR stenosis can be associated with a poor outcome and should be avoided. The nasal endoscope provided excellent visualization of pathology within the lacrimal sac and was a valuable tool. Retained stenting material should be considered in patients with persistent epiphora following DCR or intubation prior to any decision to commit a patient to permanent Jones tube placement.

A previously healthy 35-year-old man experiencing slowly progressive, painless proptosis of the right eye. Visual function was normal, but supraduction was limited. Computed tomography revealed a superior, extraconal orbital mass. Subtotal excision was performed, and a diagnosis of liposarcoma was rendered only with expert analysis. Despite subsequent orbital exenteration and postoperative radiation, a local recurrence developed 5 years later. The clinical features that predict recurrence, and management options that may promote longevity, are discussed.

Periorbital masses are often referred to oculoplastic surgeons. We report a 20-year-old patient presenting with a tender supertemporal mass that on gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated a prominent dural enhancement adjacent to the mass, the so-called "dural tail sign." This sign has been reported to be highly specific for a meningioma; however recent literature challenges this view. In this case as well, the "dural tail sign" was not produced by a meningioma.

Purpose: The authors determined the prevalence of ocular hypertension and its association with progression to glaucomatous damage in patients with thyroid-associated orbitopathy (TAO)., Methods: The charts of 500 consecutive patients with TAO seen at the Allegheny General Hospital (Pittsburgh, PA) between 1985 and 1995 were analyzed. The amount of proptosis, degree and duration of myopathy, exposure to corticosteroids, prior glaucoma treatment, and family history of glaucoma were evaluated., Results: One hundred twenty (24%) patients with TAO were noted to have an intraocular pressure (IOP) greater than 22 mmHg but less than 30 mmHg. This ocular hypertensive group was composed of 34 men and 86 women with a mean age of 55 years and mean follow-up of 4 years. Seven patients were defined as glaucoma suspects, based on increased but nonprogressive cup-to-disc ratios or nonprogressive, atypical visual field changes in the presence of increased IOP. Two patients demonstrated progressive visual field abnormalities and cupping. Of the factors evaluated, only the duration of active orbital involvement was statistically associated with progression to glaucomatous damage. The mean duration of TAO was 3, 8, and 12 years for ocular hypertensives, glaucoma suspects, and glaucomatous damage, respectively., Conclusions: Only a prolonged duration of active TAO in association with ocular hypertension correlated with progression to glaucomatous damage. These patients with chronic TAO deserve special attention and close follow-up to prevent optic nerve damage.

Although the legitimate clinical use of amphetamine and amphetamine congeners is declining, the illicit use of these drugs remains high. There is a need for a rapid and conclusive method for detecting these compounds in routine urine drug testing, drug screening in drug rehabilitation centers, and as an aid in the diagnosis and treatment of potential overdoses. The Abbott ADx Amphetamine/Methamphetamine II assay (A/M II), a fluorescence polarization Immunoassay (FPIA), was compared to the Abbott TDx Amphetamine/Methamphetamine II assay (FPIA), the Syva enzyme-multiplied immunoassay technique (EMIT) and a gas chromatograph/mass spectrometry (GC/MS) method. Precision of the A/M II assay was evaluated on the ADx analyzer over a 14-day period in each of three modes of operation (batch, combination, and panel) and was based on within-run and between-run coefficients of variation (CVs). Within-run CVs for all three controls (low [L], medium [M], and high [H]) ranged from 0.40% to 10.60% and between run CVs ranged from 3.96% to 7.92%. Data indicated that the calibration curve was stable for 16 days. Each of the six calibrators and three controls were within 10% of their labeled concentrations when analyzed by GC/MS. Fifty routine clinical specimens from our laboratory and 74 specimens screened as positive for amphetamine or related compounds from a rehabilitation center were screened by ADx, TDx, and EMIT. Any specimen yielding a positive result by any of these three methods was confirmed by GC/MS. In-house controls, as well as clinical samples, which contained both amphetamine and methamphetamine in the same sample produced results greater than two times the expected response on the ADx and TDx.(ABSTRACT TRUNCATED AT 250 WORDS)

A modification of two commercially available enzymatic ethanol urine assays for use with the Monarch 2000 Chemistry System (Instrumentation Laboratory) is described. Both the Syva EMIT st Urine Ethyl Alcohol Assay and the Sigma Diagnostics Alcohol in Urine Assay, which utilize the reduction of nicotinamide adenine dinucleotide (NAD) to NADH associated with the oxidation of ethanol in the presence of alcohol dehydrogenase (ADH), were adapted to spectrophotometrically determine ethanol concentration. Precision was evaluated over a 3-day period. Within-day (n = 9) and total (n = 27) coefficients of variation (CV) were less than 7% for the controls greater than or equal to 200 mg/L (20 mg/dL). Enzymatic assay results utilizing the Monarch procedure were compared to a gas chromatographic (GC) reference method (n = 100 samples). Regression analysis of assay data with each reagent compared to the reference method resulted in correlation coefficients r = 0.972 (Syva) and 0.948 (Sigma). Both methods exhibited nonlinear results and therefore quantitative applications cannot be made. No false positive or negative results were encountered with either reagent, indicating that the assay is acceptable as a positive/negative screen for urine ethanol for a threshold less than or equal to 20 mg/dL.