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Edsel B Ing,1 Neil R Miller,2 Angeline Nguyen,2 Wanhua Su,3 Lulu LCD Bursztyn,4 Meredith Poole,5 Vinay Kansal,6 Andrew Toren,7 Dana Albreki,8 Jack G Mouhanna,9 Alla Muladzanov,10 Mikaël Bernier,11 Mark Gans,10 Dongho Lee,12 Colten Wendel,13 Claire Sheldon,13 Marc Shields,14 Lorne Bellan,15 Matthew Lee-Wing,15 Yasaman Mohadjer,16 Navdeep Nijhawan,1 Felix Tyndel,17 Arun NE Sundaram,17 Martin W ten Hove,18 John J Chen,19 Amadeo R Rodriguez,20 Angela Hu,21 Nader Khalidi,21 Royce Ing,22 Samuel WK Wong,23 Nurhan Torun24 1Ophthalmology, University of Toronto, Toronto, ON, Canada; 2Ophthalmology, Johns Hopkins University, Baltimore, MD, USA; 3Statistics, MacEwan University, Edmonton, AB, Canada; 4Ophthalmology, Western University, London, ON, Canada; 5Queens University, Kingston, ON, Canada; 6Ophthalmology, University of Saskatchewan, Saskatoon, SK, Canada; 7Laval University, Quebec, QC, Canada; 8Ophthalmology, University of Ottawa, Ottawa, ON, Canada; 9University of Ottawa, Ottawa, ON, Canada; 10Ophthalmology, McGill University, Montreal, QC, Canada; 11University of Sherbrooke, QC, Canada; 12University of British Columbia, Vancouver, BC, Canada; 13Ophthalmology, University of British Columbia, Vancouver, BC, Canada; 14Ophthalmology, University of Virginia, Fisherville, VA, USA; 15Ophthalmology, University of Manitoba, Winnipeg, MB, Canada; 16Ophthalmology, Eye Institute of West Florida, Tampa, FL, USA; 17Neurology, University of Toronto, Toronto, ON, Canada; 18Ophthalmology, Queens University, Toronto, ON, Canada; 19Ophthalmology & Neurology, Mayo Clinic, Rochester, MN, USA; 20Ophthalmology, McMaster University, Hamilton, ON, Canada; 21Rheumatology, McMaster University, Hamilton, ON, Canada; 22Undergraduate Science, Ryerson University, Toronto, ON, Canada; 23Statistics, University of Waterloo, Waterloo, ON, Canada; 24Ophthalmology, Harvard University, Boston, MA, USA Purpose: To develop and validate neural network (NN) vs logistic regression (LR) diagnostic prediction models in patients with suspected giant cell arteritis (GCA). Design: Multicenter retrospective chart review.Methods: An audit of consecutive patients undergoing temporal artery biopsy (TABx) for suspected GCA was conducted at 14 international medical centers. The outcome variable was biopsy-proven GCA. The predictor variables were age, gender, headache, clinical temporal artery abnormality, jaw claudication, vision loss, diplopia, erythrocyte sedimentation rate, C-reactive protein, and platelet level. The data were divided into three groups to train, validate, and test the models. The NN model with the lowest false-negative rate was chosen. Internal and external validations were performed.Results: Of 1,833 patients who underwent TABx, there was complete information on 1,201 patients, 300 (25%) of whom had a positive TABx. On multivariable LR age, platelets, jaw claudication, vision loss, log C-reactive protein, log erythrocyte sedimentation rate, headache, and clinical temporal artery abnormality were statistically significant predictors of a positive TABx (P≤0.05). The area under the receiver operating characteristic curve/Hosmer–Lemeshow P for LR was 0.867 (95% CI, 0.794, 0.917)/0.119 vs NN 0.860 (95% CI, 0.786, 0.911)/0.805, with no statistically significant difference of the area under the curves (P=0.316). The misclassification rate/false-negative rate of LR was 20.6%/47.5% vs 18.1%/30.5% for NN. Missing data analysis did not change the results.Conclusion: Statistical models can aid in the triage of patients with suspected GCA. Misclassification remains a concern, but cutoff values for 95% and 99% sensitivities are provided (https://goo.gl/THCnuU). Keywords: giant cell arteritis, temporal artery biopsy, neural network, logistic regression, prediction models, ophthalmology, rheumatology

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.

Purpose: To describe a rare case of Mucor endophthalmitis that occurred in well-controlled diabetes after cataract surgery., Design: Interventional case report., Methods: Description of case and review of literature., Results/conclusion: Mucor endophthalmitis may occur after cataract surgery and should be considered in the differential for patients with unresolving postoperative uveitis.

Purpose: To describe a novel surgical technique for lower eyelid blepharoplasty with fat repositioning in an intrasuborbicularis oculi fat (intra-SOOF) plane., Methods: Description of surgical technique and outcome of a retrospective, interventional case series of 66 consecutive patients who underwent surgery., Results: Sixty-six patients with an average age of 56 years underwent bilateral transconjunctival lower eyelid blepharoplasty with fat repositioning in an intra-SOOF plane. Surgery was most commonly done in an office-based operating or procedure room under local anesthetic only. Patients were observed for an average of 6 months. Complications and revisions were few. Surgical outcomes and subjective patient satisfaction rate were excellent., Conclusions: Lower eyelid fat repositioning blepharoplasty in an intra-SOOF plane is an alternative technique to address the tear trough deformity. This technique provides excellent surgical results and high patient satisfaction. Convenient for both patient and surgeon, this technique is readily performed in an office-based procedure room under local anesthetic. Further follow-up will determine long-term outcomes.

Orbital fractures involving the middle or posterior third of the orbital floor are difficult to visualize with traditional surgical approaches. The authors describe their method of combining a transconjunctival incision with an endonasal endoscopic approach in the repair of orbital fractures. In their experience, this technique is especially useful in the treatment of posterior fractures or secondary repairs for residual enophthalmos. Besides better visualization, advantages include increased illumination; video projection for the rest of the surgical team and for documentation and recording; confirmation of correct implant placement; and, most importantly, precise and complete reduction of herniated orbital soft tissues.

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.

A 50-year-old woman with a clinically negative breast examination was diagnosed with metastatic breast cancer only after pathologic evidence of an orbital metastasis. She presented with pressure and pain above the right eye associated with enophthalmos and pseudo-Brown syndrome. The diagnosis of breast cancer based on initial ophthalmic findings requires a strong level of suspicion. Multiple reports show that survival in these cases is limited, usually only 1 year after diagnosis. We present a case of 10-year survival after the diagnosis of breast cancer presenting as an orbital mass. These new findings provoke us to continue aggressive systemic and ophthalmic treatment for such patients.

We report a case of a 23-year-old man with primary pelvic telangiectatic osteosarcoma metastatic to both orbits. The patient had proptosis with optic neuropathies and intermittent third nerve palsies. His disease was unresponsive to chemotherapy or radiotherapy, and extensive craniofacial involvement precluded surgical resection. The patient died of his disease. Telangiectatic osteosarcoma, a rare variant of osteosarcoma that is distinguished by blood-filled cystic spaces, may metastasize to the orbit and skull base. Because telangiectatic osteosarcoma may radiographically resemble other benign and malignant lesions, biopsy is essential for accurate diagnosis that will ultimately dictate clinical therapy. However, patients with this disease have a poor prognosis.