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Tomoyuki Kashima,1 Robert A Goldberg,1 Jocelyne C Kohn,2 Daniel B Rootman1 1Division of Orbital and Oculoplastic Surgery, Stein Eye Institute, University of California, Los Angeles, CA, USA; 2Pasteur Ophthalmology Clinic, Oculoplastic, Orbit and Lacrimal Service, Santiago, Vitacura, Santiago Metropolitan Region, Chile Purpose: Chronic maxillary atelectasis is characterized by unilateral spontaneous enophthalmos and hypoglobus due to increased orbital volume secondary to maxillary sinus inward deformation. Reformation of the sinus architecture and reconstruction of the orbit are key to a successful outcome. Here, we introduce a one-staged surgery that addresses both these goals.Patients and methods: We retrospectively reviewed 11 patients treated with one-stage orbital and sinus surgery. A transconjunctival subperiosteal approach was used to create slats in the thinned orbital floor. A nasal endoscopic approach was utilized to access the maxillary sinus and place a modified Foley catheter balloon through the enlarged maxillary ostium. A bridge graft of nasal septal, ear cartilage, or LactSorb was placed on the reconstructed and balloon-supported orbital floor. The balloon was deflated and removed at 10–14 days. All patients underwent complete ophthalmic and orbital evaluation, including standardized photography and radiologic imaging.Results: Eleven patients, mean age 39.5 years, presented with diplopia in upgaze, superior sulcus deformity, and at least 2 mm of relative enophthalmos. After initial overcorrection, enophthalmos improved in all cases. Symmetry within 1 mm was accomplished in 10 of 11 cases. Follow-up time was 259±320 days. Full motility was recovered in all patients.Conclusion: We describe a one-staged surgery consisting of cutting slats in the orbital floor, dilating the maxillary sinus with a balloon, and stabilizing the orbital floor with a cartilage graft placement. Our anecdotal experience suggests that this surgical approach can safely achieve normalization of the pathologic sinus outflow and restoration of the orbit anatomy. The balloon ensures orbital floor stability during the healing process, and it may act to stent open the sinus ostium during early mucosal healing. Keywords: silent sinus syndrome cartilage graft, orbital floor, remodeling

Roger A Goldberg,1,2 Sabri Raza,1 Eric Walford,1 William J Feuer,1 Jeffrey L Goldberg1,3 1Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA; 2Tufts-New England Eye Center/Ophthalmic Consultants of Boston, Boston, MA, USA; 3Shiley Eye Center, University of California San Diego, San Diego, CA, USA Purpose: To review the patient and clinical characteristics of patients with Fuchs endothelial corneal dystrophy (FECD). Methods: Review of records for every patient who presented to the Bascom Palmer Eye Institute between 2003 and 2009 whose visit was coded for endothelial corneal dystrophy (International Classification of Diseases, Ninth Revision [ICD9] 371.57), bullous keratopathy (ICD9 371.23), or who underwent a corneal surgery with or without cataract extraction. Demographic, clinical, and ancillary testing data were collected from the time of presentation, diagnosis, and follow-up, and the use, timing, and type of surgical interventions was documented, with 6-month and final visual acuities recorded. Results: A total of 2,370 charts were included in this study, of which 966 patients had a diagnosis of FECD. Of these, 197 patients (21%) received a corneal transplantation procedure. The surgery most often performed was penetrating keratoplasty with or without cataract extraction (66%), followed by endothelial keratoplasty with or without cataract extraction (34%). The risk factors for surgery include worse visual acuity at presentation (20/60 Snellen visual acuity in surgical patients versus 20/40 Snellen visual acuity in nonsurgical patients, P

Nitish Mehta,1 Roger A Goldberg,2 Chirag P Shah21University of Massachusetts Medical School, Worcester, MA, USA; 2Department of Retina, Ophthalmic Consultants of Boston, Boston, Massachusetts, USAPurpose: Dense, vision-obscuring calcification on the posterior aspect of silicone intraocular lenses (IOLs) is often not amenable to neodymium:yttrium-aluminum-garnet capsulotomy, and, in prior reports, has required IOL exchange. We report the successful removal of dense calcium deposition on the posterior surface of a three-piece silicone lens using pars plana vitrectomy (PPV).Materials and methods: A 23-gauge PPV was performed using the Stellaris® vitrectomy system. A light pipe was used to retroilluminate the IOL, and a dense fibrous tissue setting with a low cut-rate and high aspiration rate was able to clear the visual axis of the dystrophic calcification without damaging the IOL optic.Results: Visual acuity improved from 20/100 to 20/25.Conclusion: Small-gauge PPV may be utilized to remove dense dystrophic calcium deposits on the lens surface in lieu of IOL exchange. Keywords: cataract surgery, technique, Nd:YAG capsulotomy, IOL exchange

Importance: The involvement of chronic inflammation in the pathogenesis of age-related macular degeneration (AMD) opens therapeutic possibilities to AMD management., Objective: To determine whether Janus kinase inhibitors (JAKis) are associated with a reduced risk of AMD development in patients with autoimmune diseases., Design, Setting, and Participants: This retrospective observational cohort study used administrative claims data from Merative MarketScan research databases (Commercial and Medicare Supplemental) and Optum Clinformatics Data Mart databases between January 1, 2010, and January 31, 2022. Patients with autoimmune diseases satisfying study eligibility criteria and who received JAKi treatment (9126 in MarketScan and 5667 in Optum) were propensity score matched (1:1) to identical numbers of study-eligible patients who received non-JAKi-based immunotherapy., Exposure: Treatment duration of 6 months or longer., Main Outcomes and Measures: Incidence rates of AMD (exudative and nonexudative) over the first 6 to 18 months of treatment were determined, and bayesian Poisson regression models were used to estimate incidence rate ratios, 95% CIs, and posterior probabilities of AMD., Results: After matching, female sex represented the majority of the patient population in both MarketScan and Optum (14 019/18 252 [76.6%] and 8563/3364 [75.2%], respectively in the JAKi patient population). More than 60% of the patient population was older than 55 years of age in both cohorts. Over the specified treatment period, a 49% relative reduction in incidence of AMD was observed among patients who received JAKi therapy (10/9126 events; adjusted incidence rate ratio [AIRR], 0.51; 95% CI, 0.19-0.90) vs those who received non-JAKi therapy (43/9126 events; AIRR, 1 [reference]) in MarketScan, and a 73% relative reduction in incidence of AMD was observed among patients who received JAKi therapy (3/5667 events; AIRR, 0.27; 95% CI, 0.03-0.74) vs those who received non-JAKi therapy (21/5667 events; AIRR, 1 [reference]) in Optum. The absolute percentage reductions were 0.36% (MarketScan) and 0.32% (Optum), favoring patients who received JAKi therapy. Posterior probabilities of the adjusted risk being less than unity were 97.6% (MarketScan) and 98.9% (Optum) for those who received JAKi therapy vs those who received non-JAKi therapy in MarketScan and Optum, respectively., Conclusions and Relevance: JAKi use may be associated with a reduced risk of incident AMD in US adults with major autoimmune diseases. The absolute percentage reduction is consistent with a potential role for JAKi in this population. Future studies with long-term follow-up are recommended to investigate the association between JAKi use and incident AMD in other disease indications. Investigation into the role of systemic inflammation and JAK-signal transducers and activators of transcription signaling in AMD may improve understanding of the pathophysiology of AMD and lead to new treatment options.

Purpose: To delineate specific imaging characteristics of solitary fibrous tumors, schwannomas, cavernous venous malformations, and well-circumscribed orbital lymphoma., Methods: Patients undergoing excisional biopsy of solitary fibrous tumor, schwannomas, cavernous venous malformations, or well-circumscribed orbital lymphoma with preoperative MRIs available for review were identified at 3 academic centers in the United States and Australia. An exploratory statistical analysis was performed to identify important radiologic features, which were subsequently included in a random forest model. Histopathologic correlates were evaluated in representative cases., Results: A total of 91 cases were included with a mean age of 52.9 ± 17.2 years. Nearly all solitary fibrous tumors were located in the anterior or mid orbit (87.5%) and they more commonly demonstrated intralesional heterogeneity on T2-weighted imaging (45.5%) ( p < 0.01). Compared with the other tumors, schwannomas tended to be intraconal (66.7%) and were often in the mid or posterior orbit (83.4%) ( p < 0.01). Cavernous venous malformations characteristically demonstrated progressive contrast enhancement (93.9%; p < 0.01). Most lesions in all 4 groups were hypointense on T1-weighted imaging (80%-100%; p = 0.14) and only well-circumscribed orbital lymphoma tended to also be hypointense on T2 (81.8%) ( p < 0.01). Finally, cases of lymphoma had significantly lower apparent diffusion coefficient ratios (0.9 ± 0.2) ( p < 0.001), while the other 3 groups were not significantly different from one another (cavernous venous malformations: 1.8 ± 0.4; schwannomas: 1.8 ± 0.5; and solitary fibrous tumor: 1.6 ± 0.6) ( p = 0.739)., Conclusions: Key features that aid in the differentiation of these 4 tumors from one another include T2 intensity and homogeneity, early contrast-enhancement pattern, and ADC ratio., Competing Interests: D.B.R. has acted as a marketing consultant for Horizon pharmaceuticals and is a member of the speaker’s bureau. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence., Methods: Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects., Results: One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up ( p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone., Conclusions: Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone., Competing Interests: D.B.R. is a consultant for Horizon Therapeutics. The other authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

A previously healthy adult male presented with a slowly enlarging orbital mass associated with 5 mm of non-pulsatile proptosis. On imaging, a soft tissue lesion with avid contrast enhancement and associated bony hyperostosis was noted. The lesion and hyperostotic bone were surgically debulked, and significant arterial bleeding was noted intraoperatively consistent with an arteriovenous malformation. Histopathologic analysis revealed a vascular malformation with enhanced microvasculature infiltrating the periosteum. While vascular lesions elsewhere in the body can be associated with skeletal changes, bony hyperostosis is a rare feature of orbital vascular malformations.

Purpose: The purpose of this article and accompanying video is to demonstrate a transorbital endoscopic approach for accessing the pterygopalatine fossa (PPF). This technique does not require a skin incision, avoids dissection of critical neurovascular structures, and utilizes a comparatively small osteotomy. The 2 cases presented in this article highlight the utility of a transorbital endoscopic approach for accessing an anatomic region that has traditionally required more invasive techniques to reach., Methods: Description of surgical technique with 2 illustrative clinical cases and accompanying surgical video., Results: Surgical technique: A trans-conjunctival approach is taken to the inferior orbital rim, and a subperiosteal dissection is propagated posteriorly. The bone of the posterior orbital floor is then deroofed, and the superior portion of the posterior wall of the maxillary sinus is removed, allowing access to the PPF for an incisional biopsy., Case: A 76-year-old male with a history of left cheek squamous cell carcinoma presented with progressive V2 paresthesia and an abnormally enhancing lesion in the left PPF on MRI., Case: A 58-year-old male with no significant medical history presented with left facial numbness (V1-V3), ptosis, an abduction deficit, and decreased hearing. Contrast-enhanced MRI demonstrated an abnormally enhanced lesion in the left PPF extending to Meckel's cave.The transorbital approach described was used to successfully obtain a diagnostic biopsy in both cases., Conclusions: These cases highlight the utility of a transorbital endoscopic approach to the PPF as a less morbid alternative to traditional access. Patient selection is key to identifying appropriate cases., 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: To report a case of a globular primary optic nerve sheath meningioma managed surgically with improvement in vision and review the literature for outcomes of purely intraorbital exophytic-globular primary optic nerve sheath meningiomas managed surgically., Methods: A literature review was conducted using Google Scholar and PubMed with the search terms "primary optic nerve sheath meningioma," "surgery," "exophytic," and "globular." Articles were included if they were available in English. Individual cases from the reviewed articles were included if the tumor was purely intraorbital with a globular or exophytic morphology, was managed with total or subtotal surgical excision, and visual outcomes were reported. Cases were excluded if the tumor extended intracanalicularly or intracranially, tumor morphology was unknown, or surgical management consisted of biopsy, optic nerve sheath decompression, or optic canal decompression rather than tumor debulking., Results: A total of 28 patients with intraorbital globular-exophytic primary optic nerve sheath meningiomas managed surgically have been reported in the literature. Vision improved in 29% (n = 8/28) and remained stable in 43% (n = 12/28) of patients. Furthermore, patients with good (Snellen notation ≥ 0.5) vision (n = 10) typically retained good vision postoperatively and at follow-up, with 1 patient experiencing a decline to poor (Snellen ≤0.1) vision at the last follow-up (92 months postoperatively). Similarly, patients with fair (Snellen notation >0.1 and <0.5) vision (n = 5) often improved to good vision (n = 3) or stayed at fair vision (n = 1), with 1 declining to poor vision at postoperative hospital discharge., Conclusions: Surgical management of exophytic or globular optic nerve meningiomas does not universally lead to vision loss and may be appropriate in select patients., 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: To review the advances in the surgical techniques of orbital decompression., Methods: A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression., Results: In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed., Conclusion: A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms., 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: One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease., Methods: In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved., Results: The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) ( p  < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow ( p  < .001)., Conclusions: ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.

Orbital involvement in acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) is well-described in children but is uncommon in adults. This series reports 2 adult patients with orbital leukemic involvement and summarizes the existing literature. A 37-year-old male with recently diagnosed AML underwent induction therapy and subsequently developed a tan-pink colored sub-conjunctival lesion in the left eye. Incisional biopsy confirmed AML. A 35-year-old male with history of ALL presented with left-sided orbital mass. Fine needle aspiration biopsy confirmed ALL. Literature review of adult-onset orbital leukemia yielded 29 cases of AML and 3 cases of ALL. Orbital involvement of acute adult-onset leukemia tends to be unilateral, presents in the extraconal space and can occur at any point during systemic leukemic disease. Chemotherapy is the mainstay of treatment, often in combination with radiation and/or hematopoietic stem cell transplant., Competing Interests: Dr Rootman has a consulting relationship with Horizon. The other authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

A 28-year-old female with congenital left-sided ptosis presented after 3 prior surgeries elsewhere. Although centrally her margin to reflex distance1 was 3 mm, persistent ptosis was noted laterally. In an effort to improve the symmetry of her eyelid contour, a lateral tarsectomy was performed. As the authors worried this might worsen her dryness, the decision was made to bank the excised tarso-conjunctival tissue in case additional revision surgery is required at a later date. To accomplish this, a conjunctival incision was created at the inferior tarsal margin in the ipsilateral lower lateral eyelid and the excised upper eyelid tarso-conjunctival tissue was secured in this pocket. Four months postoperatively, the banked tissue appeared healthy and the upper eyelid contour was improved. This technique may be most helpful in multi-operated situations, where the chance of future revision is not insignificant., 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.)

Competing Interests: The author has no financial or conflicts of interest to disclose.

Background/objectives: The purpose of this study is to report cases of choroidal melanoma that developed extrascleral tumour recurrence after treatment with iodine-125 brachytherapy., Subjects/methods: In this single-institution retrospective observational case series, all instances of biopsy-confirmed orbital melanoma after known intraocular melanoma were reviewed. Tumour characteristics, clinical course, time to recurrence, cytogenetics of initial tumour and recurrence, and presence of intraocular recurrence were documented., Results: Five cases of orbital melanoma following treatment with plaque radiotherapy are described. Tumour staging was Ia (1), IIa (2), and IIb (2). The primary lesion in four of the five appeared to have undergone complete regression for an average of 2 years, with the orbital melanoma developing after this interval. Recurrence of the intraocular tumour was seen in conjunction with an extrascleral component in two cases. Four cases ultimately underwent enucleation or exenteration; three had evidence of direct extension of tumour through the sclera. Four cases in this series had molecular characteristics associated with high metastatic risk (three patients with monosomy 3, one with BAP1 mutation)., Conclusions: High-risk tumour biology may predispose to late appearance of extrascleral melanoma despite optimal treatment and adequate control of the intraocular tumour. Extended follow-up with detailed orbital examination and imaging is recommended for this population., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: The purpose of this study was to compare the efficacy of 3 resection algorithms in the management of patients with asymmetric ptosis., Methods: Patients undergoing bilateral Muller's muscle-conjunctival resection (MMCR) were identified. Standardized preoperative clinical photographs were examined and margin reflex distance 1 (MRD1) was measured using ImageJ. Patients presenting with ≥1 mm of asymmetry in MRD1 were included. Three groups were identified: variable (4:1 ratio, with the lower side receiving a greater resection), fixed (7 mm resection bilaterally), and tarsectomy (7 mm bilaterally + 1 mm of tarsus resected on the lower preoperative side). Postoperative MRD1 was measured from photographs obtained 3 months after surgery. The primary outcome was postoperative asymmetry., Results: A total of 95 patients with a mean age of 71.0 ± 11.0 years were included. There was no significant difference in age ( p = 0.277) or length of follow-up ( p = 0.782) between the groups. Although the fixed tarsectomy group had significantly greater preoperative asymmetry ( p = 0.001), there was no significant difference in postoperative asymmetry ( p = 0.166). On multivariate analysis, preoperative asymmetry was the only significant predictor of postoperative asymmetry ( p < 0.001). Specifically, the surgical group was not a predictor of the primary outcome ( p = 0.723)., Conclusions: Resection amount and technique did not predict postoperative outcomes in cases of asymmetric ptosis. This may support the hypothesis that changes in eyelid position and symmetry following MMCR is due to a dynamic system, rather than as a result of purely mechanical forces., Competing Interests: D.B.R. has acted as a marketing consultant for Horizon Pharmaceuticals and is a member of the speaker’s bureau. Other authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Spheno-orbital meningiomas are rare tumors, accounting for up to 9% of all intracranial meningiomas. Patients commonly present with proptosis, and visual deficits. These slow growing tumors are hard to resect due to extension into several anatomical compartments, resulting in recurrence rates as high as 35-50%. Although open surgical approaches have been historically used for resection, a handful of endoscopic approaches have been reported in recent years. We aimed to review the literature and describe a case of spheno-orbital meningioma with severe vision loss which was resected with an endoscopic endonasal approach achieving complete resolution of visual symptoms., Methods: A systematic review of literature was conducted in accordance with the PRISMA guidelines. PubMed, Cochrane, and Web of Science databases were queried for spheno-orbital meningiomas resected via an endoscopic endonasal approach. Furthermore, the presentation, surgical management, and post-operative outcomes of a 53-year-old female with a recurrent spheno-orbital meningioma are described., Results: The search yielded 26 articles, of which 8 were included, yielding 19 cases. Average age at presentation was 60.5 years (range: 44-82), and 68.4% of patients were female. More than half of the cases achieved subtotal resection. Common complications associated with endoscopic endonasal surgery included CN V2 or CN V2/V3 hypoesthesia. Following surgical intervention, visual acuity and visual field remained stable or improved in the majority of the patients., Conclusion: Endoscopic approaches are slowly gaining momentum for treatment of spheno-orbital meningiomas. Further studies on the clinical benefits of this approach on patient outcomes and post-operative complications is warranted., (© 2022. The Author(s).)

Background: Previous studies have attempted to explain age-related changes to the orbit in isolation, often producing conflicting results. The authors used highly accurate imaging software to analyze computed tomographic scans to characterize changes related to age objectively., Methods: In this case-control study, patients seen in an ear, nose, and throat clinic were screened for study entry. Male and female participants were divided into two age groups (20 to 30 years and 60 to 75 years). Primary outcomes included measurement of bony orbital dimensions, volume of soft tissues (muscle and fat volume), and anterior globe position. Three-dimensional reconstructions were created of each orbit allowing these measurements. The generalized estimating equation was used so that both orbits from each patient could be included without any bias., Results: The final sample included 240 orbits from 120 patients. There were 30 patients in each age group. Among female participants, the bony orbital volume ( p < 0.05), fat volume ( p < 0.01), and central width ( p < 0.001) of the bony orbit increased with age. The anterior globe position was significantly greater in older female participants ( p < 0.01). For male participants, the fat volume ( p < 0.0001) and central height ( p < 0.03) increased with age; the lateral rim moved posteriorly with age ( p < 0.007). The anterior globe position was not different between the age groups in male participants ( p = 0.56)., Conclusion: The female bony orbit expands with age and is associated with a more anterior position of the globe; the male bony orbital volume remains the same and the lateral rim moves posteriorly., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Purpose: To assess the effect of various lighting conditions and photograph exposures on perceived attractiveness., Methods: In the first experiment, 5 variably exposed photographs were taken of 10 subjects using a consistent lighting condition (45° superior box light). In the second experiment, 10 subjects were photographed under variable lighting conditions with consistent exposure: 1) 90° overhead box light, 2) ring light, 3) 45° superior box light, 4) built-in camera flash, 5) 2 straight on box lights, each 45° from midline, and 6) natural light. Participants were instructed to maintain a neutral expression, were placed in front of a standardized blue-gray background, and were photographed during a single session. Photographs were imported into an online survey platform (Qualtrics 2020) and displayed in random order. Volunteer survey respondents were instructed to rate the subject's attractiveness on a scale of 0 to 10. Between the two experiments, a total of 22,000 scored photographs were included in the analysis. Mixed ANOVA and pairwise comparisons with Bonferroni correction were used to compare between- and within-subject ratings., Results: Lighting condition had a significant impact on perceived attractiveness ( p < 0.001), with the 90° overhead box light achieving lower scores and the 45° superior box light yielding greater scores of attractiveness relative to the other conditions. Photograph exposure did not have a significant impact on subjective attractiveness ( p = 1.000)., Conclusions: Our findings suggest that perceived attractiveness is enhanced when a 45° superior box light is used for illumination, and attractiveness is reduced when 90° overhead exposure is utilized. Exposure did not play a prominent role in perceived attractiveness., Competing Interests: Dr Rootman has served as a marketing consultant for Horizon Pharmaceuticals. The other authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Objective: To evaluate factors associated with Diabetic Retinopathy Severity Scale (DRSS) changes with less frequent ranibizumab after induction therapy., Methods and Analysis: Post hoc analyses of RIDE/RISE and their open-label extension (OLE). Analyses included patients with diabetic retinopathy (DR)/diabetic macular oedema who completed the OLE. Comparisons were made between patients with improved/maintained (≥0 step decrease from OLE baseline (month 36) to month 48) versus worsened (≥1 step increase) DRSS during the OLE. DRSS changes over 12 months were compared between patients randomised to ranibizumab at RIDE/RISE baseline who improved to DRSS score ≤43 at OLE baseline (induced) versus those randomised to sham with DRSS score ≤43 at RIDE/RISE baseline (native)., Results: From OLE baseline to month 48, 72% (263/367) of patients improved/maintained DRSS scores. These patients had similar mean best-corrected visual acuity at RIDE/RISE (56.4 letters) and OLE baseline (68.6 letters) versus patients with worsened scores (58.2 and 70.8 letters). Patients who improved/maintained DRSS scores had similar mean central foveal thickness at RIDE/RISE (492 µm) and OLE baseline (196 µm) versus patients with worsened scores (441 and 167 µm). Patients who improved/maintained DRSS scores received a significantly higher (p<0.0001) mean number of pro re nata (PRN) injections (4.4) between OLE baseline and month 48 versus those with worsened scores (2.3). Patients with more severe DR at baseline who achieved mild-to-moderate non-proliferative DR (NPDR) induced by monthly ranibizumab injections were significantly more likely to worsen (p<0.0001) than those with mild-to-moderate NPDR at baseline randomised to sham injections (1.0-step versus 0.1-step worsening)., Conclusions: Most patients improved/maintained DRSS scores with less-than-monthly PRN ranibizumab. Some minimum treatment/monitoring may be necessary to maintain improvements after induction therapy., Trial Registration Numbers: NCT00473382/NCT00473330., Competing Interests: Competing interests: RAG reports being a consultant for Allergan, Carl Zeiss Meditec, Genentech, Inc., Novartis and Regeneron; receiving lecture fees from Allergan, Carl Zeiss Meditec, Genentech Inc., and Novartis; and receiving grant support from Carl Zeiss Meditec, Genentech, Inc., Novartis and Santen. LH reports being a consultant for Alimera, Genentech, Inc., PolyPhotonix and Recens Medical. TD was an employee of Genentech at the time of the study, and is a current employee of NGM Biopharmaceuticals. IS an employee of Genentech, Inc., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the effect of orbital decompression on the upper eyelid contour., Methods: A paired cross-sectional analysis of the upper eyelid contour was performed for 103 eyes of 66 patients who underwent orbital decompression. A control group of 26 normal subjects was also included. The eyelid contour of all participants were measured with Bézier lines adjusted to the eyelid contour and 9 midpupil eyelid margin (MPD) distances from a horizontal line bisecting the pupil. One central, corresponding to the margin reflex distance (MRD 1), and 8 equally distributed medially and laterally at 20% of the interval between the lines. Patients were classified as with flare if the height of the most lateral MPD relative to the MRD 1 was above the upper limit of the controls., Results: Preoperatively 63 of the 103 contours were classified as flare + (F+). After decompression MRD1 showed a mean decrease of 0.4 mm and the location of the contour shifted 0.8 mm medially. These changes were not correlated with proptosis reduction. Orbital decompression decreased the lateral curvature of the contours especially for the F+ lids. In 40% of the F+ eyelids the flare sign disappeared after decompression., Conclusions: Orbital decompression affects the lateral eyelid contour and diminishes the amount of lateral eyelid retraction surgery necessary to correct the flare sign. In 40% of the patients, the eyelid contour is normalized with proptosis reduction only., Competing Interests: D.B.R. has acted as a consultant to Horizon Pharmaceuticals. The remaining authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Treatment for orbital venolymphatic malformations (VLMs) commonly includes 3 major options: sclerotherapy, surgery, and embolization followed by surgical excision. Each has certain advantages, although it is not clear whether all are effective. The authors characterize the clinical course for a series of patients with distensible orbital venous-dominant VLM treated with sclerotherapy and/or embolization with excision., Methods: In this cross-sectional cohort study, patients affected by distensible orbital venous-dominant VLM presenting to the orbital and ophthalmic plastic surgery service from 2014 to 2020 were identified. Patients were included if they presented with a moderate-flow, distensible venous-dominant malformation associated with Valsalva-related symptoms (e.g., pain, proptosis, and diplopia)., Results: Six cases were treated with sclerotherapy. Four underwent multiple treatments, with a mean ± SD of 3.5 ± 2.3 (range 1-7). All patients in this group failed to improve or experienced recurrence of symptoms after sclerotherapy. Twelve cases were treated with embolization and excision. Resolution of symptoms in all 12 cases was noted and maintained for a mean of 3.4 ± 2.1 years. There have been no cases of recurrence. Patients treated with sclerotherapy were more likely to experience recurrence of symptoms compared to those treated with embolization and excision (p < 0.001)., Conclusions: Treatment of distensible venous-dominant moderate-flow orbital VLM with sclerotherapy may provide temporary improvement in some cases. However, in the medium to long term, recurrence was universal in this series. Embolization with excision appears to provide more definitive management, avoiding recurrence in all cases for a mean follow-up of 3 years., Competing Interests: The authors have no financial or conflicts of interest to disclose. The authors alone are responsible for the content and writing of the paper., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To present a case of pneumatic retinal detachment repair that did not require retinal pexy., Methods: Report of a case and review of the literature., Results: Pneumatic retinopexy was performed with a plan for photocoagulation of the retinal tear once the retina was reattached. During postoperative evaluation, the superotemporal retinal tear had operculated and the retina was reattached. No laser or cryopexy was performed, and the retina remained attached during long-term follow-up., Discussion: Addressing traction on the retina and intraocular microcurrents that allow subretinal fluid accumulation is the core principle of detachment repair; if the traction is released, pexy may not be necessary.

Purpose: To assess the sensitivity and specificity of lateral midpupil lid distances for the detection of upper lid lateral flare., Methods: Lateral lid flare was determined by unanimous agreement among six experienced oculoplastic surgeons in the grading of photographs obtained for patients with Graves orbitopathy (GO). Bézier lines were employed to extract the upper eyelid contours of the patients and a control group of age and sex matched subjects. Custom software was employed to determine 5 lateral midpupil eyelid distances. The sensitivity and specificity of each measurement in detecting lateral flare were estimated from receiver operating characteristic curves. The non-parametric Kruskal-Wallis one-way analysis of variance (ANOVA) with Dunn's posthoc test was used to compare the median values of the contour parameters between groups., Results: The degree of agreement between judges evaluated with the Fleiss' Kappa test was relatively high (K = 0.69, z = 16.6, p < .0001). The raters classified 12 lids with lateral lid flare (LLF) and 7 without LLF in patients with GO. There was no agreement on the presence or absence of LLF in 11 lids. In all eyes, lateral midpupil lid distances diminished from the center of the eyelid towards the lateral canthus. Receiver operating characteristic analysis for the midpupil distances revealed that the fourth distance from the center demonstrated high sensitivity and specificity in detecting flare. At this location (2.5 mm medial to the lateral canthus) a midpupil distance equal to or greater than 60% of the margin reflex distance (MRD 1 ) indicated the presence of flare., Conclusions: - A single measurement of a lateral midpupil eyelid distance 2.5 mm medial to the lateral canthus is a sensitive and specific measurement for the diagnosis of the LLF.

Purpose: To analyze a series of eyes with brolucizumab-associated intraocular inflammation (IOI) without retinal vasculitis reported to the American Society of Retina Specialists (ASRS)., Methods: The ASRS Research and Safety in Therapeutics (ReST) Committee analyzed clinical characteristics from submitted reports of IOI after brolucizumab. Eyes with retinal vasculitis or that received intraocular antibiotics were excluded., Results: Forty-nine eyes of 45 patients were collected. Mean visual acuity (VA) at baseline was 20/49 (range 20/20 - 5/200). Patients presented with IOI a mean of 24 (range 3-63) days after most recent brolucizumab injection; 61% presented for an unscheduled visit while 39% presented at routine follow-up. Mean VA at IOI presentation was 20/67 (range 20/20 - 3/200). Most common symptoms were floaters (78%) and blurry vision (76%). Pain (20%) and redness (16%) were less common; 3 (6%) eyes were asymptomatic. IOI was anterior only in 18%, posterior only in 31%, and both anterior and posterior in 51% of eyes. Treatment included topical steroids alone in 67% eyes, while 10% eyes received no treatment. Mean VA at last follow-up was 20/56 (range 20/20 - 1/200). Three (6%) eyes lost 3 or more lines and 1 (2%) eye lost 6 or more lines., Conclusions: Brolucizumab-associated IOI without retinal vasculitis typically presented with a delayed onset of a few weeks. Often, visual acuity decline was relatively mild. Most symptoms resolved and nearly all had a return to baseline VA, but a small percentage of patients had a significant decrease in VA at last follow-up., Competing Interests: Declaration of Conflicting Interests Relevant potential conflicts of interest are reported as follows: AJW: none; PH: Genentech (Consultant, Lecture Fees), Allergan (Consultant); TGM: none; JFA: Springer SBM LLC (Patents/Royalties), DORC International B.V. (Consultant, Lecture Fees), Allergan Inc. (Consultant, Lecture Fees), Bayer (Consultant, Lecture Fees), Mallinckrodt (Consultant), TOPCON (Grant support); KJB: Bausch&Lomb (Consultant, Lecture Fees), Allergan (Consultant, Lecture Fees), Regeneron (Consultant, Lecture Fees), Novartis (Consultant, Lecture Fees), Genentech (Consultant); NC: Allergan (Consultant), Bayer (Consultant), Novartis (Consultant); GGE: Novartis (stock), Regeneron (stock); RAG: Genentech (Research, Speaker, Advisory), Regeneron (Advisory), Novartis (Research, Speaker, Advisory), Allergan (Research, Speaker, Advisory), Aerie (Research), Santen (Research), Graybug (Research), NovoNordisk (Research); SJK: none; JP: none; EWS: none; HT: Alimera (stock); RWW: Novartis (Research)

Purpose: To determine orbital anatomical parameters that affect surgical outcome of deep lateral orbital wall decompression., Methods: Twenty orbits of 20 patients with moderate proptosis (maximum 25 mm) due to thyroid eye disease who were stable for at least 6 months were included in this prospective cohort study. Four parameters including lateral orbital wall distance (LOWD), removable surface area (RSA), removable surface length (RSL), and sphenoid door jamb thickness (SDJ) were evaluated by computed tomography (CT) scan prior to surgery in these patients. Deep lateral orbital wall decompression without fat removal was done in all patients. Relationship between all these factors and proptosis reduction, 6 months after surgery was assessed., Results: Mean proptosis before decompression surgery (mean ± SD) was 23.22 ± 1.19 mm and reduction in Hertel exophthalmometry (mean ± SD) was -3.27 ± 1.03 mm ( p  = 0.006). Pearson correlation showed that LOWD, RSL, and SDJ had statistically significant correlation with proptosis reduction ( p  = 0.017, 0.002, and 0.001, respectively.). Linear multivariate regression analysis showed SDJ as the only independent factor in predicting surgical outcome., Conclusion: several orbital anatomical factors have significant role in predicting surgical outcome following deep lateral wall orbital decompression. Among these parameters, SDJ is an independent factor, whereas LOWD and RSL are dependent factors. Preoperative assessment of the bony sphenoid anatomy may be helpful in predicting the amount of potential decompression.

Background: Syringes containing anti-vascular endothelial growth factor drugs to treat retinal diseases are prepared in different ways by various parties with syringe selection, preparation, and storage conditions affecting the risk of injecting particles into the vitreous. This study examines particle loads from various syringes over time., Methods: Four syringes were studied: two plastic transfer syringes lubricated with silicone oil or oleamide, a glass syringe with baked-on silicone, and a lubricant-free polymer syringe. Syringes were rinsed with water or filled with buffer and analyzed over time; particles were quantified by flow imaging. Particle formation in a bevacizumab formulation was also characterized., Results: Insulin syringes consistently showed very high particle counts. Oleamide-lubricated syringes had substantially fewer particles, but showed appreciable increases over time (leading to visible particles). Baked-on silicone glass syringes and lubricant-free polymer syringes both showed low particle levels ≥10 μm. Lubricant-free syringes showed the lowest particle levels ≥1 μm and the lowest particle levels with bevacizumab agitation., Conclusion: Syringes have different intrinsic particle loads which can contribute to particle loads in the delivered drug. Oleamide-lubricated transfer syringes, commonly used for bevacizumab repackaging, have time-dependent particle loads and are associated with the formation of visible particles beyond 30 days of storage., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Purpose: To investigate the associations between systemic medical conditions and types of ocular surgery and the development of aponeurotic ptosis., Methods: In this case-control observational cohort study, the relative prevalence of involutional ptosis in a large population of adult patients was assessed. Deidentified patient data from a 10-year time period was obtained from the electronic medical records of 5 large academic medical centers. Patients were selected based on ICD9 and ICD10 codes for involutional ptosis. Control patients were age and gender matched and randomly selected from a general adult population. Systemic comorbidities were determined based on ICD9 and ICD10 codes, and prior ocular surgeries based on CPT codes. The influence of systemic comorbidities and ocular surgery was examined utilizing logistic regression analysis., Results: The study cohort consisted of 8297 adult patients with involutional blepharoptosis and 13,128 matched controls. The average age was 65 years. The 3 significant risk factors for developing ptosis were ocular surgery, hyperthyroidism, and type II diabetes with odds ratios of 4.2, 2.5, and 1.45, respectively (p < 0.05). Strabismus, cornea, and glaucoma surgeries were more highly associated with developing ptosis (p < 0.05). Strabismus surgery had the greatest odds ratio of 3.37, followed by cornea surgery at 2.31, and glaucoma surgery at 1.56., Conclusions: Involutional ptosis is likely a multifactorial process. This study demonstrates that risk factors for the development of ptosis include ocular surgery, specifically strabismus, cornea, and glaucoma surgery, as well as hyperthyroidism and type II diabetes., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2020 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background and Objective: To determine the potential impact on visual outcomes of delayed treatment initiation in patients with neovascular age-related macular degeneration (nAMD)., Patients and Methods: Post hoc analysis of anti-vascular endothelial growth factor treatment-naïve patients with nAMD from HARBOR. Time to treatment was defined as first ranibizumab injection date minus screening date. Comparisons were made between the prompt (≤ 6 days) versus delayed (> 10 days) treatment groups. Main outcome measures were best-corrected visual acuity (BCVA) change over time, BCVA, number of ranibizumab injections, and proportion of 3-line gainers/losers., Results: In HARBOR, more than 50% of patients received their first injection within 7 days of screening, with mean (median) time to treatment of 4.6 (5) and 15.9 (14) days for the prompt and delayed treatment groups, respectively. Mean (95% confidence interval [CI]) BCVA change from baseline to Month 24 was 9.1 (7.4-10.8) and 8.8 (6.7-10.8) Early Treatment Diabetic Retinopathy Study letters in the prompt (n = 395) and delayed (n = 230) treatment groups, respectively. Mean (95% CI) total number of ranibizumab injections for the as-needed arms was 12.4 (11.6-13.3) and 11.4 (10.3-12.4) for the prompt and delayed treatment groups, respectively., Conclusion: In HARBOR, time from screening to first ranibizumab injection did not seem to significantly affect mean BCVA change or number of injections. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:62-69.]., (Copyright 2021, SLACK Incorporated.)

Background: Intra-arterial injection of fillers can lead to occlusion of the ophthalmic artery or its branches supplying the retina or the optic nerve. The mechanism through which this occurs is incompletely understood. We investigated the possibility of generating microparticles after injecting commercially available fillers into a flowing system in vitro., Methods: Three hyaluronic acid fillers and one calcium hydroxylapatite filler were injected into an artificial saline flow system mimicking arterial systolic blood pressure and corresponding to the diameter of the facial artery. All the saline at the end of the tube was collected, centrifuged, and inspected for filler particles., Results: After injection into the system, all fillers immediately disintegrated into small particles that were carried downstream with the flow of the saline. The saline at the end of the tube contained collections of filler., Conclusion: Hyaluronic acid and hydroxylapatite fillers break up into small particles immediately after injection into a flowing system, generating emboli rather than a column of filler. The results of this study lead us to hypothesize another potential mechanism leading to filler-related blindness., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The floppy eyelid syndrome describes an eyelid disorder characterized by floppy tarsal plates that may be caused by a loss of elastin. The authors attempted to create floppy eyelids by digesting elastin from cadaveric tarsus and then treated them with cross-linking using ultraviolet A and riboflavin., Methods: Nine right and 9 left upper eyelids were excised from cadavers. Four vertical strips of central tarsus were removed from each eyelid. One strip of tarsus from each eyelid was treated with 10 units/ml of elastase for 2 hours. Another tarsal strip from each eyelid was immersed in normal saline for 2 hours (control). A third strip from the same eyelid was cross-linked using ultraviolet A at 6 mW/cm for 18 minutes. Finally, a fourth strip of tarsus was cross-linked in the same manner following treatment with elastase for 2 hours. A microtensile load cell was used to measure the Young modulus (stiffness) of each tissue., Results: Mean (standard deviation) Young modulus for controls (18.9 ± 3.6 MPa) was significantly higher than samples treated with elastase alone (6.6 ± 3.8 MPa, p <0.01). Samples that were treated with cross-linking after elastase had a mean (standard deviation) Young modulus of 26 ± 2.3 MPa, while those treated with cross-linking alone had a mean (standard deviation) Young modulus of 34 ± 0.15 MPa. The differences in stiffness between all groups were significant (p <0.01)., Discussion: Treatment with elastase significantly reduces the stiffness of tarsal plates. This effect is reversed by cross-linking, raising the possibility of using this modality for the treatment of FES.

Background: We propose a technical variation of the minimally invasive suture suspension facelift., Methods: A novel variation of the minimally invasive facelift is proposed. The technique consists of two components. The anterior component addresses aging of the midface by anchoring the SMAS on to the sturdy retroauricular supra-helical deep temporal fascia using approximately 6-8 passes of a 4/0 Mersilene suture. The posterior component addresses cervical aging by securing the posterior edge of the platysma onto the sturdy mastoid fascia, using multiple loops of a 4/0 Mersilene suture. This technique was performed on 100 consecutive patients between 2005 and 2010., Results: The technique was found to be safe due to the plane of dissection remaining superficial to the parotid gland in the anterior component. There were no instances of facial nerve injury or sensory disturbance. None of the patients required a secondary procedure within the first 18 months following the procedure., Conclusions: This technique offers a safe and effective option for patients who seek a facelift, especially in combination with other procedures. It is envisaged that the use of multiple loops of suture to anchor mobile tissue onto fixed sturdy fascia will contribute to the longevity of the results. The limited skin undermining also makes this procedure a better choice for smokers., (© 2020 Wiley Periodicals, Inc.)

Purpose: The sagging eye syndrome (SES) describes a condition that presents with age-related distance esotropia, alone or in combination with cyclovertical strabismus. It has a high prevalence in those aged over age 40 years presenting with binocular diplopia. The authors aim to characterize the adnexal phenotype of those who have been diagnosed with SES., Methods: In this case-control study, patients were recruited from a prospectively maintained clinical and imaging database. The inclusion criteria required that subjects be above the age of 18 years and have a diagnosis of age-related distance esotropia or cyclovertical strabismus due to SES. Age-matched controls were selected from a validated database of normal faces that were not affected by any medical or surgical conditions. The margin to reflex distance from the upper eyelid, margin to reflex distance to the lower eyelid, the tarsal platform show, intracanthal distance, and inferior scleral bow were measured. Differences in the measurements between patients and controls were analyzed using a 2-tailed Student t tests., Results: Twenty-two patients and 22 age-matched controls (11 males and 11 females per group) were included for study. Females with SES had a significantly greater margin to reflex distance to the lower eyelid and inferior scleral bow, with a lower tarsal platform show and margin to reflex distance from the upper eyelid than controls. Male patients with SES had a significantly greater margin to reflex distance to the lower eyelid and inferior scleral bow with a significantly lower margin to reflex distance from the upper eyelid and tarsal platform show than controls., Discussion: This study supports the growing body of evidence which suggests that the SES represents age-related mechanical changes in the orbit that manifest as a specific adnexal phenotype.

Background: The tear trough is a prominent structure of the midface. Many surgical and nonsurgical techniques have been devised to efface this feature., Objectives: The aim of this study was to define an aesthetically pleasing tear trough and understand the effect of various surgical procedures on its appearance., Methods: We undertook a retrospective review of "ideal" subjects (ie, young men and women as well as male and female models) as well as surgical patients undergoing lower blepharoplasty with fat excision, fat transposition, erbium laser resurfacing of the eyelids and midface, or endoscopic midface lifting. Marginal reflex distance-2, lower eyelid length, and nasojugal fold depth were measured and analyzed for all patients., Results: The nasojugal fold was significantly less prominent in ideal female models than in all other groups (P < 0.0001). Lower eyelid length was significantly shorter after fat excisional lower blepharoplasty, laser resurfacing, and midface lift (P < 0.0001), and did not change after fat transpositional lower blepharoplasty. Postsurgical reduction in lower eyelid length was significantly less with fat transpositional lower blepharoplasty than in all other groups (P < 0.0001). The nasojugal fold was significantly effaced after all types of procedures (P < 0.0001), but was significantly more effaced after fat transpositional lower blepharoplasty (P < 0.01) than after all other procedures., Conclusions: A slight, medial tear trough is present in youth in many patients. The clinical tear trough is a virtual topographic structure distinct from the anatomic tear trough ligament and can be altered in a variety of ways., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Purpose: To analyze a case series of retinal vasculitis reported to the American Society of Retina Specialists (ASRS) following Food and Drug Administration approval of brolucizumab for treatment of neovascular age-related macular degeneration., Methods: The ASRS Research and Safety in Therapeutics Committee analyzed clinical and imaging characteristics from submitted reports of retinal vasculitis after brolucizumab., Results: Retinal vasculitis was reported in 26 eyes of 25 patients (22 [88%] female) after treatment with brolucizumab. Imaging studies were available for 24 of 26 eyes. Most cases (92%) were associated with intraocular inflammation, which presented at a mean of 25 days (range, 3-63 days) after the most recent brolucizumab injection. Mean visual acuity (VA) was 20/52 (range, 20/25-4/200) before the adverse event, 20/151 (range, 20/25-hand motion) at presentation of the adverse event, and 20/243 (range, 20/30-light perception) at last follow-up. Twelve eyes (46%) had a greater than 3-line decrease in VA at final follow-up, and 12 eyes (46%) had a final VA of 20/200 or worse. Analysis of retinal imaging identified vasculopathy that involved retinal arteries (91%), retinal veins (79%), and choroidal vessels (48%). Occlusive disease was apparent on imaging in 83% of eyes. Treatment approaches were varied., Conclusions: Retinal vasculitis has been identified in a series of eyes following brolucizumab. Although a few eyes in this series were asymptomatic or minimally symptomatic, some eyes had significant vision loss. A careful examination for signs of active inflammation prior to brolucizumab injection is recommended. Once vasculopathy is suspected, angiographic imaging may help define the spectrum of involvement. Optimal treatment strategies remain unknown., Competing Interests: Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Relevant potential conflicts of interest are reported as follows: A.J.W.: none; P.H.: Genentech (consultant, lecture fees) and Allergan (consultant); T.G.M.: none; J.F.A.: Springer SBM LLC (patents/royalties), DORC International B.V. (consultant, lecture fees), Allergan Inc (consultant, lecture fees), Bayer (consultant, lecture fees), Mallinckrodt (consultant), and TOPCON (grant support); K.J.B.: Bausch&Lomb (consultant, lecture fees), Allergan (consultant, lecture fees), Regeneron (consultant, lecture fees), Novartis (consultant, lecture fees), and Genentech (consultant); N.C.: Allergan (consultant), Bayer (consultant), Novartis (consultant); G.G.E.: Novartis (stock), and Regeneron (stock); R.A.G: Genentech (research, speaker, advisory), Regeneron (advisory), Novartis (research, speaker, advisory), Allergan (research, speaker, advisory), Aerie (research), Santen (research), Graybug (research), and NovoNordisk (research); S.J.K.: none; J.P.: none; E.W.S.: none; H.T.: Alimera (stock); R.W.W.: Novartis (research).

Purpose: To accurately measure the vitreous chamber volume (VCV) in humans using high-resolution computed tomography (CT) scanning techniques combined with three-dimensional analysis software. Potential relationships between age, axial length, and VCVs were also explored., Methods: In this retrospective study, the eyes of 100 healthy individuals were studied. Scans were acquired during clinical care and did not show any signs of orbital pathology. Exclusion criteria included any ocular history. CT scans were acquired with a slice thickness of 0.7 mm, and volumetric analysis was carried out using the MIMICS image analysis software version 19.0 (Materialise, Leuven, Belgium)., Results: The final sample included 100 eyes from 50 patients (30 women, 20 men). The mean age was 48.67 ± 20.72 years, and the age range was 18 to 91 years. The mean VCV was 4.649.99 ± 0.426.54 mm 3 for women and 4.969.0 ± 0.465.20 mm 3 for men. We found a significant correlation between age and VCV ( P < 0.001), axial length and VCV ( P < 0.001), and age and axial length ( P < 0.005)., Conclusions: The VCV appears to be greater than the current consensus suggests. This work also suggests that the VCV is associated with age and axial length, indicating that it is dynamic and may change throughout adulthood., Translational Relevance: This information regarding the volume of the vitreous chamber is useful for our understanding of proper dosage and behavior of agents we commonly insert into the vitreous chamber., Competing Interests: Disclosure: A.M. Azhdam, None; R.A. Goldberg, None; S. Ugradar, None, (Copyright 2020 The Authors.)

Purpose: Hyaluronic acid gel (HAG) fillers provide a versatile and safe correction method for a sunken superior sulcus (SS) resulting from soft tissue volume loss occurring with aging, previous surgery, or enophthalmos related to trauma or phthisis bulbi. The purpose of this study was to report the long-term clinical outcomes of filler injection for soft-tissue augmentation in patients with a deep SS., Design: Retrospective, interventional case series METHODS:: The medical records of 27 patients (32 eyes) with deep superior sulci were reviewed. Twenty injections of hyaluronic acid fillers (Restylane; Q-med AB, Uppsala, Sweden) were performed in the retrobulbar (RB) area, and 15 injections were performed in the SS. Pre- and post-treatment photographs were taken., Main Outcomes Measures: Visual acuity for seeing eyes, intraocular pressure, exophthalmos measurement, marginal reflex distance 1, interpalpebral fissure, tarsal platform show, and SS hollowing depth grade RESULTS:: Enophthalmos corrections were 1.3 ± 0.8 mm (P < 0.001) and the SS hollowing grade decrease was 1.2 ± 0.9 (P < 0.01) after 1 month of RB injection. Enophthalmos corrections were 0.1 ± 0.4 mm (P = 0.317) and the SS sunkeness grade decrease was 1.7 ± 0.8 (P < 0.001) after 1 month of SS injection. The amount of filler to correct enophthalmos of 1 mm was 0.83 ± 0.53 mL using the RB injection. Using Kaplan-Meier survival analysis, the mean period of maintenance for deep SS correction was 9.1 months for RB injections and 8.5 months for SS injections., Conclusion: Retrobulbar (RB) hyaluronic acid gel (HAG) injections corrected enophthalmos and a deep SS, while SS injections corrected only a deep SS. These 2 techniques of RB and direct sulcus injection are safe and effective methods for the correction of a deep SS.

Purpose: To investigate the feasibility of increasing the stiffness of human tarsal tissue following treatment with riboflavin and ultraviolet A (UVA) to induce cross-linking of collagen fibers., Methods: In this case control study, 18 right and left upper eyelids were excised en bloc from 18 fresh-frozen cadavers. One side served as the control while the samples from the opposite side were cross-linked. Four 2 × 6-mm vertical strips of central tarsus were cut from the superior to inferior border of each tarsal plate. Sample tissue was irradiated with UVA at 6 mW/cm 2 for 18 minutes. A microtensile load cell and an optical coherence tomography scanner allowed calculation of stiffness (Young's modulus). Six cross-linked samples and corresponding controls were stained with hematoxylin and eosin (H&E) and Masson trichrome stains. Four controls and four cross-linked samples were also reviewed with a transmission electron microscope., Results: Mean Young's modulus in the linear region for controls was 28 ± 9 MPa and was much higher at 138 ± 8 MPa for cross-linked samples ( P < 0.001), yielding a 493% mean stiffness increase. Staining with H&E and Masson did not reveal any histologic changes. Transmission electron microscopy showed a decrease in average diameter of 50 randomly selected collagen fibers from 47.2 ± 1.9 nm prior to cross-linking to 34.2 ± 1.1 nm post cross-linking ( P < 0.001). Qualitatively, the collagen fibers appeared more closely packed following cross-linking., Conclusions: The findings of this study suggest that collagen cross-linking is a viable and effective modality for increasing the stiffness of human tarsal plates., Translational Relevance: This work provides proof that collagen cross-linking produces stiffening of the human tarsal plate and may be used in disorders that cause eyelid laxity., (Copyright 2019 The Authors.)

Purpose: Ptosis may occur in certain cases after upper blepharoplasty. The authors aim to characterize the incidence of postoperative marginal reflex distance (MRD1) reduction after upper blepharoplasty and surgical variables that may predict this occurrence., Methods: In this cross-sectional study, patients > 18 years old undergoing upper blepharoplasty were screened. Patients were excluded if they had any history of ptosis and brow surgery. Data regarding the excision of skin, muscle, fat, and brow fat as well as crease formation were documented. The distance in millimeter from the center of the pupil to the upper eyelid margin in the midpupillary line (MRD1) was measured digitally. The primary outcome measure was a postoperative reduction in MRD1 of >1 mm. Secondary outcome was overall mean change in MRD1 and the incidence of ptosis as defined by a final MRD1 ≤ 2.5 mm., Results: The final sample consisted of 100 patients (200 eyelids) and the mean age was 55.8 years. There were 65 patients with orbicularis muscle removal, 52 patients with postseptal fat removed, and 9 patients with crease formation. Overall 15 patients developed MRD1 decrease of greater than 1 mm (5 bilaterally and 10 unilaterally) with 7 eyes demonstrating a final MRD1 of ≤ 2.5 mm. In multivariate modeling, muscle removal was found to be the only variable with significant impact on the development of MRD1 reduction > 1 mm after upper blepharoplasty (p < 0.05, odds ratio = 8.2). The other variables did not significantly contribute. The overall mean (SD) MRD1 was 3.43 mm (1.1) preoperatively and 3.62 mm (1.1) postoperatively (p < 0.01)., Conclusions: Fifteen percent of patients demonstrated a reduction in MRD1 > 1 mm after upper eyelid blepharoplasty, and those with orbicularis resection were more likely to experience this change.The authors' study demonstrates a 15% incidence of postoperative MRD1 reduction after upper eyelid blepharoplasty. Orbicularis oculi muscle removal was significantly associated with this occurrence.