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Purpose: The purpose of this study was to review the long history of entropion, with emphasis on its significance to the specialty of ophthalmology, and the numerous methods developed to treat cicatricial and involutional forms of the condition., Methods: An extensive medical literature review was performed, identifying publications containing information on entropion and associated conditions. Foreign language manuscripts were translated using online resources., Results: A total of 920 manuscripts published between 1505 and 2023 were reviewed. While the majority were written in English, 38.5% were foreign language works. For much of history, both cicatricial and involutional entropion were managed by shortening the anterior lamella. Horizontal eyelid margin or posterior tarsal incisions were often added for cicatricial disease. Later, different tissues were grafted into the defects created by these incisions. A variety of measures were used to temporize in patients with involutional entropion. Surgical treatment of this condition evolved to include methods of suture rotation, orbicularis weakening or redirection, tarsal stabilization, lid margin shortening, and eyelid retractor repair., Conclusions: Entropion and its management are described throughout recorded history. For much of this time, cicatricial entropion was the most common form of the disease, in great part secondary to the prevalence of trachoma. The social impact of these conditions was a primary factor in the establishment of ophthalmology as a medical specialty and the creation of dedicated eye hospitals. Publications describing the treatment of involutional entropion appear with increasing frequency after the mid-19th century. Arguably, more procedures have been described for entropion than for any other ophthalmic condition., Competing Interests: The author has no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To report the observation that the efficacy of topical glaucoma treatment improved after surgical correction of ectropion in a 71-year-old male with a known history of glaucoma., Observations: The patient initially presented for tearing and lid malposition and was found to have bilateral elevated intraocular pressures (IOP) in addition to bilateral lower eyelid ectropion. IOP control was initially prioritized over ectropion repair, with IOP remaining elevated despite topical glaucoma treatment and selective laser trabeculoplasty. Sequential unilateral ectropion repair was then carried out, with topical glaucoma treatment resumed after the first repair. It was observed that the IOP improved with topical glaucoma treatment on each side after ectropion repair, despite no changes to medications nor dosing., Conclusions and Importance: The efficacy of topical glaucoma treatment is dependent on drop availability and absorption. While recent efforts to increase drop efficacy have been focused on engineering formulations that increase retention or corneal penetration, our case highlights that in selected glaucoma patients, correction of lid malposition may serve as an effective way to improve drop efficacy., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Inc.)

Purpose: Acquired melanocytic nevi are common eyelid lesions; however, their clinical presentation is not well documented., Methods: In this retrospective study, clinical records were reviewed in patients evaluated between 2005 and 2022., Results: Eyelid margin nevi ( n  = 150) were more commonly excised in female (78%) and Caucasian (86%) patients. Change in appearance/size were frequent presenting complaints, and 17% experienced ocular symptoms. Referring diagnosis included other benign lesions (11.3%), and concern for malignancy (16.7%). Many individuals (38.7%) noted their lesion for ≤5 years. Nevi were distributed across the 4 margins (9% peripunctal), and 88% had a regular base. Visible pigmentation was more common in non-Caucasians (95.2%) than Caucasians (41.1%). Lashes grew through 60.7% of nevi and were often misdirected.Nevi were treated with superficial excision and cauterization. Histologic subtypes included: dermal (86.6%), compound (9.4%), blue (2.7%), junctional (0.7%), lentiginous dysplastic (0.7%). An irregular base ( p =0.042) and pigmentation ( p =0.056) were more common in compound than dermal nevi. Lash line quality and appearance were improved in the majority of patients returning for follow-up, although postoperative trichiasis, marginal erythema, and residual pigmentation were observed., Conclusions: Melanocytic nevi commonly involve the eyelid margins and have a variety of presentations and appearances. Existing nevi can change, and new lesions appear throughout adulthood. Stable, benign appearing nevi can be observed. Shave excision provides a diagnosis and improved appearance for symptomatic or suspicious lesions, with few serious complications. Malignant transformation is rare, although evidence for recurrence warrants further evaluation.

Purpose: To describe surgical variations of the hatchet flap and a large series of patients in which this procedure was used for eyelid and midfacial reconstruction., Methods: A retrospective review was performed on patients treated with a hatchet flap between March 2016 and March 2023. Patient demographics, defect characteristics, surgical techniques, and outcomes were investigated., Results: The hatchet flap was used to repair 70 defects in 69 patients, aged 41.6 to 90.0 years (mean, 66.1). Defects measured 0.6 to 23.6 cm 2 (mean, 4.8) and resulted from Mohs surgery (n = 62), exenteration (n = 2), benign lesion excision (n = 3), or cicatricial ectropion/fistula repair (n = 3). The flap tail was managed with 3 techniques: V-Y plasty (n = 26), transposition (n = 34), and excision (n = 10). Ancillary procedures were often used during reconstructions (skin grafts: 29; double hatchet flap: 2; additional skin flaps: 26; tarsoconjunctival flaps: 6; and other grafts: 7). Small distal eschars healed in 7 flaps without necrosis. Four patients with subcutaneous thickening improved after steroid injections. Mild hatchet flap contracture may have contributed to postoperative cicatricial ectropion in 1 patient. There were no other flap related complications., Conclusions: In selected patients, the hatchet flap is a versatile technique to mobilize vascularized tissue into eyelid/midfacial defects resulting from the excision of lesions or treatment of cicatricial ectropion/fistulas. Individuals without laxity in the plane perpendicular to the flap base may not be good candidates for this procedure. The hatchet flap can be modified by advancing, transposing, or excising the flap tail. Reconstruction is often combined with other flaps/grafts. Few complications were associated with the hatchet flap., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: This retrospective study was performed to examine surgical results of five different techniques for lower eyelid margin reconstruction after Mohs surgery: primary closure, semicircular flap, dermal matrix graft, sliding tarsal flap, and tarsoconjunctival flap., Methods: Medical records were reviewed in 178 patients undergoing surgery between 2005 and 2020. Outcomes were evaluated (photographic review) by three oculoplastic observers masked to procedure type, both with and without knowledge of the eyelid defect., Results: All patients achieved a good-excellent functional result and 90.4% were asymptomatic after surgery. Tarsoconjunctival flaps were associated with greater need for subsequent interventions ( p  < .001) and anterior lamellar deformities ( p  < .001). Semicircular flaps had a higher incidence of lateral canthal deformity ( p  < .001), but less eyelash disruption than other flap/graft techniques ( p  < .001). Mean cosmetic ratings (defect masked) were similar for dermal matrix grafts, semicircular, and sliding tarsal flaps; with each grading higher than tarsoconjunctival flaps ( p  ≤ .05). Among patients with 9-15 mm wide defects, results were better for semicircular and sliding tarsalflaps, than dermal matrix grafts ( p  ≤ .005) and tarsoconjunctival flaps ( p  ≤ .02)., Conclusions: All patients achieved a good-excellent functional result and 87.1% a good-excellent cosmetic result. The semicircular flap was effective for repairing medium sized wounds that could not be closed primarily, creating a continuous lash line, although with a higher incidence of lateral canthal deformities. The sliding tarsal flap was effective for shallow wounds of varying widths. The single-staged dermal matrix graft provided similar results as the tarsoconjunctival flap. Subsequent interventions were more frequent after the tarsoconjunctival flap than other methods.

Purpose: The angular vein extends between the supraorbital and supratrochlear veins superiorly and the facial vein inferiorly. Rarely, this vessel can be involved by infections, vascular malformations, or benign tumors. In this study, we report both our experience and the published literature on angular vein disorders., Methods: A retrospective study was performed on patients seen between 2008 and 2022. The medical literature was searched for reports of conditions affecting the angular vein., Results: During the study period, we encountered 5 patients with angular vein disorders. Information from these patients was combined with 18 published cases. Among the 23 patients, the diagnosis was confused with lacrimal drainage abnormalities in 52%, and 57% underwent imaging. "Swelling" or a palpable, moveable mass were frequent findings. Pain or tenderness was experienced by 43.5% of patients. Five patients were observed, and 2 infections were treated with antibiotics. The remaining 16 lesions were successfully treated with excision (n = 15) or cauterization (n = 1), without complications. Final diagnosis included 14 vascular malformations (isolated varix: 7, thrombosis: 6, cavernous venous malformation: 1), 7 vascular tumors (intravenous pyogenic granulomas: 6, intravascular papillary endothelial hyperplasia: 1) and thrombophlebitis (n = 2)., Conclusions: Disorders of the angular vein are uncommon and frequently misdiagnosed as lacrimal abnormalities. While these lesions can frequently be identified on clinical findings, imaging can be helpful in some cases. Patients with suspected thrombophlebitis require urgent antibiotic therapy. Minimally symptomatic angular vein lesions can be observed. Surgical excision is effective in treating the different vascular malformations and tumors affecting this structure., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: The presence of eyebrow elevation in anophthalmic patients has been used as evidence to support a proprioceptive stimulus for frontalis innervation. In this study, we examined the frequency of brow elevation before and after enucleation and reviewed additional clinical findings to determine if any were associated with eyebrow position., Methods: A retrospective study was performed on 134 anophthalmic patients. Demographics, measurements, and photographs were reviewed. Reference photographs were used to subjectively grade brow position and sulcus depth., Results: Preoperative eyebrow elevation was present in 56.2% of patients without blepharospasm from a painful eye, of who 62% had chronic visual loss. Ipsilateral ptosis (p = 0.008), deep superior sulcus (p &lt; 0.001), and right-sided pathology (p = 0.045) were more common in patients with brow elevation. Symmetrically elevated brows were more frequent before right than left enucleation (p = 0.05). Brow position remained stable after 61.9% of procedures. While often mild, postoperative brow elevation was seen in 31.0% of patients without preoperative elevation. Deepening of the superior sulcus was more common in patients with new relative brow elevation (p = 0.031). Anophthalmic ptosis and right-left surgical side were not associated with new postoperative brow elevation., Conclusions: Eyebrow elevation was often present prior to enucleation and associated with an increased occurrence of ptosis, superior sulcus deepening, and right-sided pathology. Intact vision was not needed to maintain an elevated brow. Superior sulcus deepening, but not ptosis, was more common in patients developing new postoperative brow elevation. The findings support both proprioceptive and compensatory mechanisms for eyebrow elevation., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2022 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Psychogenic ptosis is a rare ophthalmic manifestation of conversion disorder. The aim of this study was to describe the clinical parameters, etiology, psychological, and clinical aspects of psychogenic ptosis., Methods: A retrospective case series was conducted of patients with psychogenic ptosis seen between 1990 to 2020. Medical records were reviewed for patient demographics, including psychiatric history, clinical findings, diagnostic studies, treatment, and resolution rates. A literature review was performed to identify cases of psychogenic ptosis previously published between 1990 and 2020., Results: Six female patients (aged 14-60 years) were diagnosed with unilateral psychogenic ptosis. Physical trauma preceded the onset of ptosis in all cases. Imaging studies had been previously obtained in all patients, none of who were correctly diagnosed at time of referral. Associated signs included concurrent brow ptosis, orbicularis oculi spasm, squint on upgaze, and variable levator function and eyelid margin measurements. Four patients had preexisting psychological conditions. Patients were primarily managed with reassurance., Conclusions: Psychogenic ptosis is an often delayed or misdiagnosed condition, resulting in unnecessary referrals and imaging. Psychogenic ptosis should be considered in patients with atypical findings of ptosis including ipsilateral brow depression, orbicularis oculi spasm, squint on upgaze, and variable eyelid measurements. A prior history of minor trauma and female sex were common in this series. Our experience suggests that psychogenic ptosis can often be treated with reassurance, leading to partial or complete resolution. Given the number of patients with comorbid psychiatric conditions, the authors recommend a low threshold for psychiatric or psychological evaluation., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2022 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: While Wendell Hughes popularized the tarsoconjunctival flap for lower eyelid reconstruction, most modern procedures are derived from the technique described by Köllner in 1911. This study reviews the history, techniques, and outcomes of a large series of patients treated with a modified Köllner flap., Methods: In this observational cohort study, medical records and photographs were reviewed in patients undergoing surgery between 2005 and 2020. Patient demographics, complications, secondary interventions, and outcomes were evaluated., Results: Marginal defect size ranged from 12 to 41 mm among the 140 study patients. Ancillary procedures included lower eyelid conjunctival flaps (n = 64) and septal orbicularis flaps (n = 68). The anterior lamella was reconstructed with skin grafts (n = 86), flaps (n = 10), or combined flaps/grafts (n = 44). Pedicle division was performed 23 to 84 days after primary repair. Subsequent interventions included steroid injection (n = 10), cryotherapy (n = 10), marginal erythema treatment (n = 9), and upper eyelid retraction repair (n = 6). Tearing (6.5%) and dryness (10%) were the most common postoperative symptoms, with most patients (78.6%) being asymptomatic. A good-excellent functional outcome was achieved in 94.3% and cosmetic outcome in 85.0% of cases. Defects <30 mm in width (P = 0.0001), defects not involving a canthus (P = 0.0158), and upper eyelid skin graft donor sites (P = 0.0001) were associated with better outcomes., Conclusions: The Köllner tarsoconjunctival flap is an effective technique to repair moderate-large lower eyelid defects, with the majority of patients achieving good-excellent cosmetic and functional outcomes. Factors associated with a poorer result include marginal eyelid defects ≥30 mm in width, defects involving a canthus, and non-upper eyelid skin graft donor sites. Most patients are asymptomatic after surgery., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Metabolic reprogramming has been shown to occur in uveal melanoma (UM), the most common intraocular tumor in adults. Mechanisms driving metabolic reprogramming in UM are poorly understood. Elucidation of these mechanisms could inform development of new therapeutic strategies for metastatic UM, which has poor prognosis because existing therapies are ineffective. Here, we determined whether metabolic reprogramming is driven by constitutively active mutant α-subunits of the heterotrimeric G proteins Gq or G11 (Gq/11), the oncogenic drivers in ∼90% of UM patients. Using PET-computed tomography imaging, microphysiometry, and GC/MS, we found that inhibition of oncogenic Gq/11 with the small molecule FR900359 (FR) attenuated glucose uptake by UM cells in vivo and in vitro, blunted glycolysis and mitochondrial respiration in UM cell lines and tumor cells isolated from patients, and reduced levels of several glycolytic and tricarboxylic acid cycle intermediates. FR acutely inhibited glycolysis and respiration and chronically attenuated expression of genes in both metabolic processes. UM therefore differs from other melanomas that exhibit a classic Warburg effect. Metabolic reprogramming in UM cell lines and patient samples involved protein kinase C and extracellular signal-regulated protein kinase 1/2 signaling downstream of oncogenic Gq/11. Chronic administration of FR upregulated expression of genes involved in metabolite scavenging and redox homeostasis, potentially as an adaptive mechanism explaining why FR does not efficiently kill UM tumor cells or regress UM tumor xenografts. These results establish that oncogenic Gq/11 signaling is a crucial driver of metabolic reprogramming in UM and lay a foundation for studies aimed at targeting metabolic reprogramming for therapeutic development., Competing Interests: Conflict of interest K. J. B. and M. D. O. are listed as coinventors on a provisional patent application on targeted pharmacological therapeutics in uveal melanoma that is owned by Washington University in St Louis. All other authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

A 72-year-old man with history of chronic lymphocytic lymphoma presented with a tender, ulcerated cutaneous eyelid lesion. Excisional biopsy revealed a diagnosis of eosinophilic dermatosis of malignancy. This rare paraneoplastic eruption is associated with hematologic malignancies and characterized histopathologically by lymphocytic infiltration accompanied by numerous eosinophils. To our knowledge, eosinophilic dermatosis of malignancy involving the eyelid has not been previously reported., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background and Importance: Orbitocranial penetrating injury (OPI) is associated with neurological, infectious, and vascular sequalae. This report describes unique application of an orbitofrontal craniotomy through a supraciliary approach to remove a wooden stick penetrating through the orbit and frontal lobe, postoperative management, and antimicrobial therapy., Clinical Presentation: A 51-yr-old male presented after a tree branch penetrated beneath his eye. He had no loss of consciousness and was neurologically intact with preserved vision and ocular motility. Computed tomography (CT) and CT angiogram revealed an isodense hollow cylindrical object penetrating though the left orbit and left frontal lobe. The object extended into the right lateral ventricle, abutting the left anterior cerebral artery. There was minimal intraventricular hemorrhage without arterial injury. The patient was treated with broad-spectrum antimicrobial coverage. The foreign body was removed and the dural defect repaired via an orbitofrontal craniotomy through a supraciliary eyebrow incision. He was treated with an extended course of antimicrobial therapy, and after 18 mo remained neurologically intact., Conclusion: OPI are a subset of penetrating brain injuries with potential for immediate injury to neurovascular structures and delayed complications including cerebrospinal fluid leak and infection. Treatment includes attempted complete removal of the foreign body and antimicrobial therapy. An orbitofrontal craniotomy through a supraciliary eyebrow incision may be effective in selected patients., (© Congress of Neurological Surgeons 2021.)

Purpose: To compare the use of sizing implants versus intraoperative volume measurements for individualization of enucleation implant size, and to identify preoperative factors affecting the choice of implant., Methods: In this retrospective observational cohort study, 2 implant sizing methods were compared using clinical records and photographs in 139 patients who underwent enucleation between 2007 and 2016., Results: There was no difference in mean implant (p = 0.6562) or prosthetic (p = 0.1990) enophthalmos between the 2 methods, or when comparing patients with and without conjunctival-Tenons fibrosis. The incidence and severity of superior sulcus deformity was similar between the methods (p = 0.6394). Preoperative phthisis (p < 0.0001) and intraoperative conjunctival-Tenons fibrosis (p = 0.0010) were more common in the sizing implant group. Among all study patients, mean implant size was larger in males (21.3 mm, n = 80) than females (20.7 mm, n = 59) (p = 0.0027). Implants >20 mm were more frequently inserted in patients with a wider Hertel exophthalmometry base (80% of males >95 mm; 77% of females >97 mm). Approximately 21.0% of patients demonstrated ≥8 mm of implant enophthalmos, suggesting an undersized implant. The authors estimate that 11% of patients could have received a sphere larger than 22 mm., Conclusions: Individualization of enucleation implant size can reduce the incidence of anophthalmic socket syndrome. The empirical use of sizing implants provided similar results as intraoperative volumetric measurements, when evaluated by postoperative superior sulcus depth and prosthetic or implant enophthalmos. Preoperative exophthalmometry may facilitate selection of implant size. Preexisting conjunctival-Tenon fascial fibrosis often did not limit implant size and was not associated with a higher prevalence of wound breakdown or implant exposure., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To describe the incidence of anophthalmic ptosis, identify clinical factors associated with its development, and evaluate the effects of enucleation on eyelid mechanics., Methods: In this observational cohort study, measurements and photographs were reviewed in 139 patients who underwent enucleation between 2007 and 2016. Patient demographics, pre- and postoperative eyelid measurements, and exophthalmometry were used to assess the incidence of ptosis and effects of surgery on eyelid function., Results: Preoperative ptosis was common and more often present in patients with enophthalmos (p = 0.0305) or reactive blepharospasm (p < 0.0001). The incidence of new-onset ptosis and improvement of preexisting ptosis following enucleation were similar (40%). Surgical repair was performed in 7% of patients with ptosis. Contralateral levator function declined with age and was positively correlated with exophthalmometry (p < 0.0001). Anophthalmic levator function was greater with increased anterior projection of the implant (p < 0.0001) and prosthesis (p < 0.0001). Patients with larger implants had improved levator function, with (p = 0.0065) and without (p = 0.0007) the prosthesis. Superior sulcus deepening was associated with decreased levator activity, but not margin-reflex distance., Conclusions: Preoperative ptosis was common, and often related to reactive blepharospasm or enophthalmos. Levator function declined with age, and correlated to greater anterior projection of the implant and prosthesis following enucleation. The surgeon can counsel patients regarding the similar likelihood (40%) of preoperative ptosis improving and new ptosis developing after enucleation. The primary factor the surgeon can modify to improve postoperative eyelid function is to maximize implant size, which is associated with greater levator activity., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose : To report the clinical outcomes of porcine acellular dermal matrix implants sandwiched between skin and conjunctival flaps for lower eyelid reconstruction following Mohs surgery. Methods : A retrospective review was performed on patients with lower eyelid defects following Mohs surgery treated using a porcine acellular dermal matrix sandwich graft from 2013 to 2018. Patient demographics, defect size and characteristics, and collagen matrix implant dimensions were evaluated. Postoperative course and complications were also reviewed. Results : The dermal matrix sandwich graft was performed in 13 cases (12 patients). Average horizontal marginal defect width was 11.7 mm (range: 6-16 mm). Mean width of the implanted dermal matrix was 7.7 mm (range: 5-9 mm). There were no instances of infection or graft failure. The reconstructed lid had an excellent marginal contour in 11 cases (84.6%), while 2 had minimal irregularities. All patients had an excellent thickness of the reconstructed margin. One patient (7.7%) required cauterization of overgrown marginal conjunctiva after surgery. Two patients (15.4%) experienced symptomatic trichiasis, requiring electrolysis (n = 1) and epilation (n = 1). Conclusions : The dermal matrix sandwich graft is an effective method for marginal defect repair when the remaining conjunctiva and skin are sufficient to develop the necessary flaps. While the resolution of edema and erythema may take several months, an excellent final result is achieved in the majority of cases. Complications are mild, relatively uncommon, and similar to those encountered in other reconstructive procedures. This single-stage, tissue-sparing technique preserves the capability of performing future tarsoconjunctival flaps or lateral canthal procedures, should the need arise.

Purpose: To report the surgical technique and functional outcomes of the medial canthoplasty for the treatment of exposure keratopathy., Patients/methods: An IRB approved, retrospective review of patients who underwent medial canthoplasty for exposure keratopathy was performed. Patient demographics, reported symptoms, and clinical examination findings were collected and analyzed from pre-operative and follow-up visits., Results: The study included 73 consecutive cases in which the medial canthoplasty was performed in patients with exposure keratopathy. The average follow-up period was 7.9 months (median: 4.7 months; range: 1-150 months). Complete or partial improvement in ocular symptoms (dryness; pain/irritation; tearing) was achieved in 95% (69/73). Clinically, 85% (41/48) of patients demonstrated a post-operative reduction in lagophthalmos and 90% (60/67) showed improvement in ocular surface findings. Complications were rare (1/73) and reversal of medial canthoplasty was not required in any case., Conclusions: The medial canthoplasty appears to be a safe and effective technique to narrow the palpebral fissure, provide lower eyelid support, and improve keratopathy. It is an uncomplicated procedure that may be considered for the treatment of exposure keratopathy caused by facial paralysis and lower eyelid malposition.

Purpose: The purpose of this study is to report the surgical technique and functional outcomes of the hatchet flap with transposed nasal inset for midfacial defect repairs., Methods: An Institutional Review Board-approved, retrospective review was performed to identify patients treated using the hatchet flap with transposed nasal inset. Patient demographics, disease etiology, defect characteristics, and postoperative complications were collected from preoperative and follow-up visits., Results: The hatchet flap with transposed nasal inset was performed in 5 patients between March 2016 and April 2017. Two patients developed mild transient ischemia of the nasal inset flap tip without necrosis. A suture granuloma was removed in 1 patient. No additional surgical procedures were required after the nasal inset cheek flap., Conclusions: The hatchet flap with transposed nasal inset is an effective procedure to address defects involving the upper cheek, lower eyelid, and medial canthus. Incorporation of the nasal inset helps prevent distortion of the ala and facilitates closure of the flap donor site. This technique may be employed in certain patients as an acceptable alternative to more extensive Mustardé or paramedian forehead flaps.

Purpose: This study was performed to characterize the frequency, causes, and possible risk factors of operating room (OR) fires experienced by members of the American Society of Ophthalmic Plastic and Reconstructive Surgery., Methods: An online questionnaire was distributed to American Society of Ophthalmic Plastic and Reconstructive Surgery members, collecting data on surgical fires experienced by respondents throughout their careers. In addition, the questionnaire investigated viewpoints on OR fire safety, current practice patterns with oxygen delivery and surgical device usage, and management of patients referred after previous surgical fire exposure., Results: There were 258 participants in the survey. Eighty-three surgeons (32.2%) experienced at least 1 surgical fire in their careers. Most OR fires occurred during monitored sedation cases with oxygen delivered by nasal cannula underneath drapes completely covering the head and use of a monopolar or battery-operated device. Patient hair and skin were the most common fuel sources, and most of the injuries were limited to singing of facial hair. Regarding current practice patterns, monopolar, bipolar, and battery-powered disposable devices were the most frequently used electrosurgery and electrocautery tools. Patients seen after an OR fire with another surgeon generally experienced more severe burns requiring hospitalization and subsequent procedures., Conclusions: Many oculoplastic surgeons have experienced OR fires during their careers. Certain surgical and anesthetic techniques, particularly the delivery of supplemental oxygen underneath surgical drapes and the use of monopolar electrosurgery and battery-powered electrocautery, may be associated with increased fire risk. While most of the reported OR fires did not result in significant patient injury, caution must be taken to prevent these potentially devastating events.

We investigated operative course and post-operative findings of patients undergoing primary enucleation for uveal melanoma versus those requiring secondary enucleation after brachytherapy. A retrospective chart review was performed with IRB approval on patients receiving treatment for uveal melanoma. Patients with enucleation as initial treatment and patients enucleated after plaque brachytherapy were analyzed for demographic data, operative course, and post-enucleation outcome. Further cause analysis for secondary enucleations was investigated. No significant difference was seen in age, laterality, or gender between the primarily enucleated (n = 54) and secondarily enucleated (n = 34) groups. Greater difficulty with surgery was noted in 28/32 (87.5%) of secondary enucleations compared to 1/54 (1.8%) of primary enucleations (p < 0.0001). Operative time was >2 hours in 3/51 (6%) of primary enucleations (vs. 8 of 32, 25%, p = 0.02). Average implant size was similar in the 2 groups (20.6 mm), however 2/34 (6%) of secondary enucleations required dermis fat grafting. Post-enucleation anophthalmic ptosis occurred after 8/49 (16%) of primary cases (vs. 13/30, 43%, p = 0.02) and prosthetic enophthalmos after none (0%) of primary cases (vs. 5/30, 17%, p = 0.006). Class 2 gene expression profile was found in 6/8 (60%) of eyes enucleated for treatment failure. Secondary enucleation performed after plaque brachytherapy was technically more difficult, and had more anophthalmic socket and eyelid complications compared to primary enucleation for uveal melanoma. Primary enucleation may avoid additional surgery and morbidity in a subset of patients with contraindications to plaque brachytherapy.

Aim: To report a rare presentation of adenoid cystic carcinoma (ACC) of the lacrimal gland., Method: This is a case report presenting clinical, radiographic, and histopathologic findings., Results: A 72-year-old female with no reported ocular symptoms was found to have an incidental right orbital mass on imaging. Additional studies revealed multiple liver lesions, which were biopsied and found to be consistent with ACC. She was then referred to the ophthalmology service, where ocular examination demonstrated 2.5 mm of right proptosis with elevation and abduction deficits. Diplopia could be elicited in extreme upgaze and right lateral gaze. An excisional biopsy of the orbital mass was performed, with histopathology confirming the diagnosis of primary ACC of the lacrimal gland, thereby also supporting the initial suspicion that the hepatic ACC lesions represented metastases., Conclusion: The authors describe a rare presentation of ACC of the lacrimal gland, initially asymptomatic, with metastatic lesions restricted to the liver at the time of diagnosis. Three previous cases of ACC with isolated metastatic hepatic lesions at the time of diagnosis have been reported; all of these cases localized the primary tumor to the salivary glands.

Purpose: Allergic dermatitis is a common but often misdiagnosed condition that can present with a variety of findings including inflammation, eyelid malposition, and tearing. This study was performed to identify likely etiologies, along with presenting findings and treatment strategies for allergic dermatitis., Methods: A retrospective review of clinical records was performed of patients diagnosed with allergic dermatitis in academic oculoplastics practices from 2002 to 2014. Initial consultation included review of medications and cosmeceuticals. Suspected allergens were discontinued and an ophthalmic steroid was applied. Persistent allergic dermatitis led to further medication changes or formal allergy testing in an effort to identify the causative agent., Results: Sixty-one patients were identified; average age was 66 years old (range: 33-94), and 45 of the patients were women (74%). Average follow up was 7 months (range: 1-60 months). Reasons for referral included epiphora (31.2%), ectropion (24.6%), blepharitis/dermatitis (18.0%), and "droopy" eyelid (14.8%). Presenting symptoms included irritation (77.1%) and tearing (50.8%). Average duration of symptoms was 16.5 months (range: 2 days-8 years). The 3 most common etiologies were eye drops (54.2%), creams/lotions (24.6%), and cosmetics (13.1%). Rubbing/manipulation was also thought to be a significant factor in 30% of the patients. Overall, the initial treatment regimen led to at least partial resolution in 88% of patients and 66% experienced complete resolution. Patients resistant to therapy were referred for patch testing. At follow up, 98% of patients had improvement in their symptoms and 90% of patients had complete resolution of their symptoms., Conclusions: Allergic eyelid dermatitis is commonly related to eye drops and topical cosmetics or skin care products. Identification and elimination of causative agents is the mainstay of management. Topical corticosteroids often facilitate resolution of the associated inflammation. Therapy resistant patients may benefit from formal allergy testing.

Purpose: To determine the periorbital effects of daily 0.03% bimatoprost in New Zealand white (NZW) rabbits., Materials and Methods: NZW rabbits were treated with daily 0.03% bimatoprost, artificial tears, or left untreated. Following 3 and 6 months of treatment, eyelid measurements were obtained for both upper and lower eyelid distraction, as well as canthus-to-canthus measurements. Once complete, subjects were humanely euthanized and eyelid tissue was utilized for histology. Hematoxylin and eosin staining, along with Verhoeff Van Giesen staining was performed on paraffin-embedded sections. Tissue was also stained with mActin antibodies as a marker for fibroblast activity., Results: Daily, topical 0.03% bimatoprost induced eyelid tightening and shortening the NZW rabbit. These findings were most striking at the 6-month timepoint, suggesting a temporal component to these induced changes. Histologically, eyelid tissue demonstrated thinning in bimatoprost-treated eyelids compared with those receiving artificial tears. Slightly increased mActin and Verhoeff Van Giesen staining was observed, suggesting increased fibroblast activity and elastin production in prostaglandin analogs-treated eyelids., Conclusions: These findings suggest that eyelid tissue thins and tightens over time, following daily administration of 0.03% bimatoprost in the NZW rabbit. These findings are similar to what has been observed in human patients.

Purpose: To evaluate the frequency of protective lens wear by anophthalmic patients and identify factors that influence compliance., Methods: An IRB approved descriptive retrospective chart review of patients undergoing surgery with the senior author (PLC) with an anophthalmic orbit and one remaining sighted eye. Results were tabulated and analyzed using age, indication for procedure, duration of visual symptoms, safety glasses wear, number of postoperative visits, and evidence of new trauma to the remaining eye. All patients underwent counseling on the importance of protective lens wear preoperatively and each subsequent visit., Results: Etiologies for loss of the eye in the 132 study patients included trauma (33.3%), blind painful eye (33.3%), congenital disorders (14.4%), adult-onset malignancy (14.4%), and retinoblastoma (4.5%). At the final visit, protective lenses were worn in the following patterns: full-time (55.3%), frequently (11.4%), occasional (6%), and never (28.8%). The regular use of protective eyewear at last visit was more common in patients wearing glasses at presentation (79.7%), than in those who did not (32.9%; p ≤ 0.001). Increased number of office encounters correlated with more frequent use of protective eyewear (p ≤ 0.01). Patient age (p = 0.95), indication for surgery (p = 0.97), and duration of visual loss (p = 0.85) were not predictive of safety glasses wear. Three patients had evidence of subsequent ocular trauma to the remaining eye, with 2 having resultant decrease in acuity; none of these 3 patients wore safety glasses full-time., Conclusions: A significant number of anopthalmic patients were not wearing protective lenses at presentation. Overall compliance was poor; but repeated education on the importance of safety glasses appears to improve compliance. Educating referring providers and primary care physicians about the importance of early and repeated counseling is vital to increasing compliance.

Patient safety focused on a reduction in both procedural and diagnostic error is the number one concern of the United States healthcare system in the 21st century. The American Board of Ophthalmology has a longstanding interest in patient safety, and in 2015, teamed with the American Academy of Ophthalmology to convene all ophthalmology subspecialties and other prominent national organizations to address patient safety in ophthalmology. This article reviews the topic and highlights concerns for ophthalmologists., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report results in patients undergoing lower eyelid reconstruction following Mohs surgery using a combination of surgical techniques, the rhomboid skin flap and a sliding tarsal flap., Methods: An IRB approved, retrospective case series of patients undergoing surgery between April 2007 and October 2014. Outcomes include establishment of a functional eyelid, quality of postoperative eyelid margin contour, and postoperative complications., Results: During the study period, sliding tarsal flaps were used to repair marginal lower eyelid defects in 32 patients. Coexisting anterior lamellar defects were repaired with a modified rhomboid skin flap in 24 patients, a full thickness skin graft in 4 patients, and combined skin graft and rhomboid flaps in 4 patients. The average width of the marginal defects was 11.3 mm (range: 7-19 mm). Reconstruction resulted in a functional lower eyelid in all patients, the majority having an excellent cosmetic result (n = 20). Minimal contour abnormalities were present in 9 patients, while 3 patients developed a noticeable notch following surgery. Patients repaired with a rhomboid flap were more likely to have isolated postoperative misdirected lashes (5/24) than those repaired using a skin graft with or without a flap (0/8)., Conclusion: Combined sliding tarsal and modified rhomboid skin flaps are an effective method of repairing superficial defects of the lower eyelid margin. This tissue-preserving technique maintains the ability to perform subsequent upper eyelid tarsoconjunctival flaps and lateral canthal procedures should a future need arise. Isolated misdirected lashes and minor contour abnormalities are the most common complications of the procedure.

Purpose: To present the various orbital soft-tissue changes that can result from the use of topical prostaglandin analogs., Methods: A case series of patients seen in a referral oculoplastic practice with presumed prostaglandin orbitopathy., Results: Thirty-five patients were found to have a variety of disorders, including deepening of the superior sulci (24/35), hypertrichosis (32/35), periocular erythema (24/35), and meibomian gland dysfunction (18/35). Marginal eyelid thinning with posterior migration of the lash line was commonly present (34/35). Increased eyelid margin tension with horizontal eyelid shortening (32/35) was often associated with lateral canthal deformity or displacement (15/35). Lower eyelid retraction (18/35) seemed to contribute to ptosis in some patients, secondary to apparent tethering at the lateral canthus. Functional conditions resulting from the above structural abnormalities included tractional ptosis (n = 4), cicatricial entropion (n = 3), cicatricial ectropion (n = 2), trichiasis (n = 2), eyelid subluxation (n = 1), and chalazia (n = 1)., Conclusions: While topical prostaglandin analogs are well-tolerated by many patients with glaucoma, some individuals using these medications develop structural changes of the orbital soft tissue resulting in a variety of cosmetic and functional eyelid disorders. The eyelid margins can thin, causing posterior migration of the lashes. Increased horizontal tension of the eyelids may result in acquired blepharophimosis and upper or lower eyelid malposition. These orbital changes may be partially reversible in some patients. When possible, it is reasonable to withhold the prostaglandin and allow a period of observation before proceeding with surgical correction.

Purpose: Diagnosis of carotid cavernous fistula (CCF) relies on clinical findings, such as proptosis, chemosis, and pulsatile tinnitus, plus imaging features including enlargement of the superior ophthalmic vein (SOV). This study reviewed patients with CCF, with a focus on those who were clinically symptomatic but had a normal-appearing SOV on routine scans., Methods: Retrospective review was conducted on the clinical records of patients with CCF seen by ophthalmology or interventional neuroradiology, with attention to clinical and imaging features, angiography findings, management, and outcomes., Results: Forty patients presented with CCF. History of head trauma was present in 13 (average age 43.8 years; all direct or complex), while the remainder occurred spontaneously (average 66 years; 85% indirect). The most common presenting ophthalmologic signs or symptoms were proptosis (65%), binocular diplopia (60%), redness (57.5%), and chemosis (47.5%). After diagnosis, 36 underwent endovascular treatment, with successful occlusion achieved in 90% of cases for whom follow-up data was available (n = 21). Notably, 3 patients with CCF did not have SOV enlargement on any imaging modality including catheter angiography., Conclusions: In this series of patients with clinical signs of CCF, there was no radiologic evidence of enlarged SOV in 26% of patients on noninvasive imaging and in 8% on catheter angiography. To avoid inappropriate interventions or delays in diagnosis and care, it is important to recognize that CCF can exist without SOV enlargement. Patients with clinical features suspicious for CCF should undergo catheter angiography if treatment is being considered. Endovascular treatment can produce clinical improvement or resolution.

Purpose of Review: Ophthalmologists are dependent on computed tomography (CT) and MRI to aid in the diagnosis and management of patients with orbital and visual conditions. Pitfalls in the imaging process can lead to inefficient care or patient harm. This review summarizes these problems and provides methods to reduce imaging errors., Recent Findings: There has been exponential growth in the number of radiographic scans performed, resulting in increased awareness of the risks from medical radiation. Strategies to minimize radiation exposure include reducing the need for sequential scans, using appropriate technology, and substituting MRI for CT. Contrast administration can be associated with systemic reactions, renal disease, and thyroid dysfunction. Scan interpretation errors are reduced by the ophthalmologist reviewing the study and communication with the radiologist., Summary: Medical radiation exposure can be reduced by initially ordering the appropriate scan and substituting MRI for CT when possible. MRI is contraindicated in patients with certain implants and metallic foreign bodies. Noncontrast studies are adequate to evaluate many conditions and some patients should not receive contrast. Imaging errors can be reduced by the ophthalmologist personally reviewing the orbital scans and correlating the results with the clinical findings.

Purpose: To describe a method for staged partial resection of congenital divided eyelid nevus. The rationale, technique, and outcomes for this approach are described., Design: Retrospective chart review of a case series., Methods: Clinical records of 12 patients with divided eyelid nevus were reviewed with attention to presenting features, surgical management, histopathology, and follow-up course. Surgical approach involved the use of bipolar and thermal cautery to ablate the eyelid margin component, skin excision for cutaneous lesions, and then repair with advancement flaps or skin grafting., Results: Eight patients with divided nevus were treated with a staged surgical approach: 5 primarily and 3 as revision cases. Average age was 16.3 years at primary presentation (range, 2-36 years), 16.5 years at initial surgery (range 2-36 years), and 36.0 years at presentation for revision (range, 12-72 years). Primary patients required 1 (n = 3) or 2 (n = 2) surgeries. Revision patients required 2 (n = 1) or 3 (n = 2) procedures in addition to those they had already undergone. Anterior lamellar repair was by granulation (n = 2), local skin flaps (n = 3), or skin grafts (n = 3). Average follow-up was 21.6 months (range, 0-98 months). No adverse effects or malignant transformations were seen., Conclusions: Patients with divided eyelid nevi often present for surgical management because of cosmetic and functional concerns. Because small-to-medium congenital nevi have a low risk of malignant transformation, total excision may not be necessary. A staged surgical approach with cautery ablation and contouring of the eyelid margin component and surgical resection of the anterior lamellar portion may be a reasonable treatment strategy for these patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: This study was performed to ascertain the incidence of anticoagulant use in oculoplastic surgical patients and the reliability of patient medication disclosure. Differences in perioperative bleeding complications among patients continuing anticoagulants, those who withheld the medications, and those not anticoagulated were investigated., Methods: Following institutional review board approval, a retrospective chart review was conducted (January 1, 2008, to June 30, 2010). Anticoagulant medications and their management during the perioperative period were reviewed. Type of surgical procedure and perioperative complications were documented., Results: Charts were reviewed for 1130 surgeries in 1015 patients. Eighteen percent of patients failed to accurately disclose their medication use. Aspirin use was not reported in 12% of patients. There were no intraoperative complications and a single postoperative orbital hematoma among 682 patients not using anticoagulants. There were 3 intraoperative complications and 1 postoperative hemorrhage in the 207 patients whose anticoagulants were withheld. In the 145 patients who continued their anticoagulation therapy throughout the surgical period, there were no intraoperative bleeding complications, and one postoperative hemorrhage. None of the study patients sustained permanent visual deficit or deformity related to hemorrhage., Conclusions: Forty percent of patients undergoing oculoplastic procedures were using anticoagulants; yet, many patients failed to disclose their medication usage. The decision to operate and whether to discontinue these medications must be individualized considering the nature of the procedure and the patient's medical condition. It may be appropriate to continue anticoagulants in certain patients at increased risk for a vascular event, ensuring adequate hemostasis throughout the procedure.

Purpose: To evaluate the efficacy and safety of topical 5% fluorouracil (5-FU) cream in the treatment of periocular actinic keratosis and squamous cell carcinoma in situ., Methods: A retrospective case series including 14 patients treated with topical 5-FU cream, 13 patients with actinic keratosis and 1 patient with squamous cell carcinoma in situ. All patients were treated with an initial 2-week course of twice-daily 5-FU application followed by mild ophthalmic antibiotic ointment applied until the epithelium healed. Additional 14-day courses of therapy were prescribed as clinically indicated if residual lesion was present or recurrence occurred. Charts were reviewed for location of lesion, marginal involvement, residual lesion at follow up, recurrence, and ocular adverse events., Results: Six patients had upper eyelid lesions and 8 patients' lesions involved the lower eyelid. Marginal involvement was seen in 9 patients. All patients completed an initial 14-day course of twice-daily therapy. Five patients with actinic keratosis required a second 14-day course of therapy, 3 for residual lesion and 2 for recurrence at follow-up visits. The patient with squamous cell carcinoma in situ was treated with 3 courses. Average follow up was 38 months with a range of 4 to 142 months. No clinically detectable lesion was seen in any patient at final follow up. Two patients experienced transient ocular adverse effects, including 1 patient with mild keratopathy and another with chemosis., Conclusions: The use of 5% 5-FU has been described in the treatment of noninvasive squamous neoplasia. This article describes the authors experience with lesions involving the eyelid, including the eyelid margin. Expected dermatologic inflammation occurred following treatment regimens, and mild transient ocular adverse effects were seen in 2 patients. Topical 5-FU may be useful in the treatment of periocular actinic keratoses and squamous cell carcinoma in situ.

Objective: To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results., Methods: Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis., Results: The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty., Conclusions: Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Traumatic, nonaneurysmal subarachnoid hemorrhage (SAH) is common after closed head injury and most often results from ruptured cortical microvessels. Here, the authors present the case of a 60-year-old woman who fell and struck her head, causing traumatic enucleation and avulsion of both the optic nerve and ophthalmic artery. The arterial avulsion caused a Fisher Grade 3 SAH. During her stay in the intensive care unit, hydrocephalus and vasospasm developed, clinical conditions commonly observed after aneurysmal SAH. Epileptiform activity also developed, although this may have been related to concurrent Pantoea agglomerans ventriculitis. It is reasonable to suggest that intracerebral arterial avulsion with profuse arterial bleeding may be more likely than traditional traumatic SAH to result in clinical events similar to that of aneurysmal SAH. Special consideration should be given to the acute care of patients with intracranial arterial avulsions (conservative management vs surgical exploration or endovascular treatment), as well as long-term follow-up for vascular or other neurosurgical complications.

Purpose: To present the experience and outcomes of orbital fracture repair using Lorenz titanium orbital implants in one tertiary care center., Methods: Five-year retrospective chart review of 55 patients who underwent orbital fracture repair with Lorenz titanium orbital implants since 2002. The following data were recorded: age; gender; mechanism of injury; prior fracture repair; concomitant ocular injuries; time elapsed between injury and surgery; and preoperative and postoperative visual acuity, diplopia, extraocular motility, and Hertel exophthalmometry. All patients underwent preoperative CT. Operative data included surgical approach, type of Lorenz implant used, duration of surgery, and presence of extraocular muscle entrapment. Length of follow-up and complications were also recorded., Results: Of those undergoing primary repair, diplopia in primary gaze was present in 29.3% of patients preoperatively and 0% postoperatively. Severe, moderate, and mild motility restriction in any gaze direction were 5.5%, 14.5%, and 34.5% preoperatively and decreased to 0%, 1.8%, and 7.3% postoperatively. Although only 14.3% of primary repair patients had full extraocular motility prior to surgery, this number increased to 80% after surgical repair. More than 80% of patients achieved symmetry within 1 mm by Hertel exophthalmometry. The authors did not encounter instances of implant extrusion, infection, or eyelid malposition during follow-up., Conclusions: Orbital fracture repair using Lorenz titanium orbital implants provides reliable and reproducible stabilization of orbital wall defects, while offering outstanding functional and cosmetic results comparable with other alloplastic materials.

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

Purpose: To identify what factors may predispose patients to exposure of porous anophthalmic implants and to determine the outcome of exposed porous implants., Methods: Examination of pooled data obtained through a PubMed literature search of English-language publications from 1989 through 2004 using the key words enucleation, evisceration, and socket reconstruction., Results: Porous implants were inserted in 80% (3012 of 3777) of the cases identified from 49 publications. The difference in exposure rate between coralline hydroxyapatite (4.9%) and porous polyethylene (8.1%) implants is primarily related to a higher reported complication rate of uncovered porous polyethylene implants, particularly in retinoblastoma patients. Other techniques associated with increased exposures include wrapping implants with bovine pericardium or polyglactin mesh. Evisceration and secondary procedures did not have statistically different complication rates compared with enucleation. There are more late exposures of porous polyethylene than coralline hydroxyapatite implants. Spontaneous healing of exposures occurred in 13% (19 of 145) of cases. Covering exposures with patch grafts underneath vascularized conjunctival flaps was the most successful method of surgical repair. Implant removal was necessary after 29% (42 of 145) of exposures., Conclusions: Although the published literature between 1989 and 2004 reports higher complication rates for uncovered porous implants and implants wrapped with bovine pericardium or polyglactin mesh, pooling data from different studies may mask very good or poor results obtained by individual surgeons. Spontaneous healing of exposed porous implants is relatively uncommon. However, many exposed porous implants can be salvaged with secondary repair.

Purpose: To determine the incidence of complications associated with the use of donor human sclera to cover porous and nonporous enucleation implants., Methods: A retrospective case series of 207 patients receiving donor scleral-covered implants during a standardized enucleation procedure., Results: There was a single case of exposure among the 112 patients (0.9%) receiving nonporous implants. None of the 95 porous implants (0%) demonstrated primary exposure. Conditions leading to the removal of 3 of the 207 (1.4%) implants included primary exposure (n = 1), secondary exposure after peg insertion (n = 1), and postoperative pain (n = 1). Two patients (1%) required postoperative tarsorrhaphies to control chemosis. Conjunctival granulomas developed in 2 patients (1%). Asymptomatic implant rotation was observed in 31% (5/16) of patients receiving flattened porous implants. There were no cases of implant migration or prolonged inflammation related to the covering material., Conclusions: Donor sclera covering of both porous and nonporous enucleation implants appears to be a successful surgical technique associated with few serious complications. The potential benefits of this technique must be balanced by the increased cost of the wrapping material and the rare but potential risk of transmitting infectious disease.

Purpose: To report our experience using interrupted 7-0 chromic sutures to close marginal eyelid defects., Methods: A retrospective case series of patients undergoing upper or lower eyelid repair with two 7-0 chromic marginal sutures., Results: Nine upper and 22 lower eyelid defects were closed with the described technique. Elective removal was performed 9 to 27 days after surgery in 5 patients in whom the sutures either were no longer needed or had not spontaneously absorbed. There were no cases of suture-related corneal abrasion. Minimal notching was observed in 2 eyelids after surgery., Conclusions: Closure of marginal eyelid defects with 7-0 chromic sutures simplified postoperative care. There are few complications associated with this procedure, which overall provided excellent wound healing and cosmesis.

Purpose: To describe the spectrum and treatment of orbital Rosai-Dorfman disease and to review previously documented cases., Methods: Retrospective, interventional case series of seven patients and literature review., Results: Each patient with Rosai-Dorfman disease had unique disease expression requiring aggressive therapy, such as chemotherapy, radiation, and/or surgical excision. One systemically aggressive case presented with intraocular and choroidal invasion, a previously unreported finding. Response to therapy was variable and unpredictable., Conclusions: Rosai-Dorfman disease, although historically described as benign and self-limiting, may cause significant morbidity and mortality involving multiple organ systems. Available treatment options may not control the disease. Further research and long-term clinical correlation is necessary.

Purpose: To report an unusual case of multiple myeloma presenting with bilateral tearing secondary to lacrimal sac involvement., Design: Observational single case report., Methods: An 83-year-old woman presented with bilateral tearing secondary to infiltrative lesions of the lacrimal sacs. A biopsy was performed; findings confirmed the diagnosis of multiple myeloma., Results: The lacrimal sac fossa lesions responded to chemotherapy and local radiation. The patient subsequently developed multiple systemic recurrences, ultimately leading to her death., Conclusions: Multiple myeloma should be included in the differential diagnosis of lacrimal sac lesions.

Objective: To determine the safety and effectiveness of botulinum toxin for cosmetic oculofacial use., Methods: Literature searches for relevant citations were conducted in October 2003 for the years 1965 to 2003. The panel reviewed and rated the articles for study design, methods, and results., Results: Randomized double-masked controlled studies showed statistically significant improvement in glabellar, frontal, and lateral canthal rhytids (wrinkles) when injected with botulinum toxin. Standardized documentation using photographs and masked grading by the patient and physician support the efficacy of botulinum toxin for treatment of dynamic rhytids in the glabellar region, forehead, and lateral canthal area. Complications and adverse effects associated with treatment are infrequent and short lived., Conclusions: Botulinum toxin is safe in the short term and effective in the temporary treatment of glabellar, frontal, and lateral canthal rhytids. Potential functional complications should be discussed with patients who are seeking cosmetic rejuvenation of the periocular and facial region. Further research is needed to determine the ideal effective dose for particular anatomic areas, ideal concentration, applicable doses across the different serotypes of botulinum toxin, duration of effect, changes in efficacy (if any) over extended periods of treatment, and long-term safety.

The management of the ocular sequelae of facial palsy should be individualized for each patient. The patient's age, ocular motility, tear production, and corneal sensation are considered when developing a treatment plan. Individuals with transient weakness often require only therapy with topical lubricants. Permanent or chronic facial paralysis is usually associated with lagophthalmos, ectropion, and exposure keratitis. Both "static" and "dynamic" procedures can be performed to improve these conditions. Combined eyelid surgery and suspension of the midface often provides the best result. However, patients with permanent facial palsy usually suffer chronic ocular symptoms, requiring long-term follow-up and continued topical therapy.

Objective: To compare prosthetic and implant motility and the incidence of complications associated with porous and nonporous enucleation implants., Methods: Literature searches conducted in January 2002 for 1985 to 2001 and May 2002 for October 2001 to 2002 retrieved relevant citations. The searches were conducted in MEDLINE and limited to articles published in English with abstracts. Panel members reviewed the articles for relevance to the assessment questions, and those considered relevant were rated according to the strength of the evidence., Results: A randomized clinical trial and a longitudinal cohort study detected no difference in implant or prosthetic movement between nonpegged hydroxyapatite porous and spherical alloplastic nonporous implants. No controlled studies were retrieved that investigated whether pegging porous implants improves prosthetic movement. Several case series indicate that patients with pegged hydroxyapatite implants have some degree of improved prosthetic motility. Longitudinal cohort studies show that sclera-covered hydroxyapatite implants have higher exposure rates than sclera-covered silicone implants, and unwrapped porous polyethylene implants have higher exposure rates than unwrapped acrylic implants. There are numerous case series that document a wide range of implant exposure rates in patients with various enucleation implants. It is difficult to compare complication rates among implant types because patient populations vary, surgical techniques differ, and follow-up periods are often limited., Conclusions: Based on one randomized clinical trial, spherical alloplastic nonporous and nonpegged porous enucleation implants provide similar implant and prosthetic motility when they are implanted using similar surgical techniques. Coupling the prosthesis to a porous implant with a motility peg or post appears to improve prosthetic motility, but there are few available data in the literature that document the degree of the improvement. There is a widely variable incidence of porous implant exposure, but certain surgical techniques and the type of wrapping material seem to reduce the exposure rate. Additional research is needed to document the long-term incidence of complications related to porous enucleation implants and associated surgical techniques. This includes the use of wrapping materials and what procedural modifications, both surgical and prosthetic, are most effective in reducing these complications.

Purpose: To determine the incidence and risk factors of complications associated with Supramid orbital implants., Methods: A retrospective chart review was performed to document complications in a series of 41 patients receiving Supramid implants during orbital reconstruction or fracture repair. Implant size, duration of time between trauma and implant insertion, and history of prior orbital surgery were examined as possible risk factors for the development of complications., Results: Four patients had hemorrhage within the implant capsule. An orbital abscess developed in a single patient. All but one complication appeared 7.8 to 10 years after implant insertion. Patients who had complications had a longer duration of time between trauma and implant insertion than those in whom complications did not occur (P =0.0019). Complications were more frequent among patients with larger (>600 mm2) implants and a history of orbital surgery., Conclusions: Spontaneous infection or hemorrhage may occur within the capsules of Supramid orbital implants, even many years after surgery. The insertion of larger implants in the late repair of extensive bony orbital defects may predispose patients to these complications. Implant removal and marsupialization of the implant capsule to the maxillary sinus appears to be curative without causing significant postoperative enophthalmos.

Purpose: To determine the incidence and risk factors of hemorrhagic complications associated with selected oculoplastic procedures., Methods: A prospective study was performed to document the severity of intraoperative hemorrhage and postoperative bruising in patients undergoing oculoplastic procedures. The use of anticoagulant or platelet-inhibiting medications, systemic medical conditions, patient age, patient sex, and type of procedure were examined to identify risk factors for hemorrhagic complications., Results: Troublesome intraoperative bleeding prolonged surgery in 9.2% of cases. Severe bleeding with the potential to affect surgical outcome was encountered in 0.4% of procedures. There was little correlation between severity of bleeding and degree of postoperative bruising. Male sex, a history of heart disease, or age >60 years imparted a slightly greater risk of intraoperative bleeding. Age >60 years, hypertension, or recent cessation of aspirin may increase the risk of postoperative bruising. A history of previous stroke increased the risk of postoperative bleeding. There was no statistical difference in the incidence of hemorrhagic complications among patients currently treated with antiplatelet/anticoagulant agents, those who had stopped these medications before surgery, and those who were not treated with these agents. No patient had permanent sequelae related to hemorrhage. Two patients had postoperative systemic complications possibly attributable to withholding anticoagulant/antiplatelet medications in preparation for surgery., Conclusions: Although serious hemorrhagic complications may be associated with oculoplastic procedures, the incidence of these complications is low. The decision to withhold antiplatelet or anticoagulant medications before surgery should be individualized. Selected procedures can be safely performed without stopping these agents.

Purpose: To report the use of an Apligraf (Organogenesis, Inc., Canton, Massachusetts, USA) human skin equivalent for repair of cicatricial ectropion in a patient with harlequin ichthyosis., Design: Interventional case report., Methods: A 6-week-old male child with harlequin ichthyosis and severe bilateral upper eyelid cicatricial ectropion underwent repair with Apligraf grafts., Results: After the initial repair with Apligraf grafts, recurrent bilateral upper eyelid ectropion developed, requiring repeat Apligraf grafting at age 61 days. After the second graft, the eyelids remained well positioned until the child's sudden death from respiratory failure at age 6 months., Conclusion: Apligraf human skin equivalent facilitated the repair of cicatricial ectropion in a child with harlequin ichthyosis.