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Purpose: Lower eyelid management is challenging. The conchal cartilage is often considered a spacer of choice for treating lower eyelid retraction. However, dermis graft has also recently been shown to be a viable spacer. The aim of this study was to compare the efficacy of dermis graft to that of conchal cartilage graft in this indication. Methods: A retrospective comparative study was conducted in patients who underwent lower eyelid lengthening with autologous dermis graft (group 1) or autologous conchal cartilage graft (group 2). The main outcome measure was the reduction in inferior scleral show (ISS) assessed by three independent masked surgeons. Secondary outcome measures was the assessment of lagophthalmos and corneal keratitis. Complications were also recorded. Results: Twenty-five eyelids of 23 patients were included: 11 and 14 eyelids, respectively in group 1 (dermis graft) and group 2 (conchal cartilage graft). Patient mean follow-up was 12.3 (±12.5) and 7.1 (±7.7) months, respectively. No statistical differences in postoperative ISS reduction, lagophthalmos and exposure keratitis was observed ( p = 0.540, p = 0.946, p = 0.934, respectively). Three patients experienced a grade I Clavien–Dindo complication in group 1 and one patient experienced a grade II complication in group 2 ( p = 0.540). Conclusion: Autologous dermis grafts and conchal cartilage grafts provide favorable outcomes without major complications.

AimPhantom eye syndrome is a poorly understood and underestimated complication of eye removal (ER). Seeing with the amputated eye, referred to as phantom vision (PV), is undoubtedly the most intriguing and confusing complication experienced by anophthalmic patients. The aim of the study was to assess PV prevalence, clinical features and risk factors after ER.MethodsA multicentric questionnaire-based study was conducted between April 2016 and July 2017. Patients >18 years who underwent ER >3 months ago had a socket examination before inclusion. Data recorded included patients’ demographics, and preoperative, surgical and postoperative features.ResultsOne hundred patients (53 men) with a mean age of 65.1 years (29–92; SD=13.0) were included. ER indications were: uveal melanoma (n=24, 24%), trauma (n=20, 20%), retinal detachment (n=20, 20%), glaucoma (n=14, 14%) and endophthalmitis (n=12, 12%). Thirty (30%) patients experienced PV. Elementary and complex visual hallucinations were experienced by 80% and 20% of patients, respectively. PV usually appeared within the first postoperative month and tended to decrease over time. Risk factors for PV were the preoperative use of proton beam therapy (p=0.006), uveal melanoma (p=0.014), enucleation (p=0.015), anxiety with a Hospital and Anxiety Depression (HAD) score ≥8 (p=0.042), depression with a HAD score ≥8 (p=0.030), phantom eye pain (p=0.044) and phantom eye sensations (p=0.002).ConclusionPV was reported by one-third of our patients. Despite being widely misunderstood, ophthalmologists and neurologists should be aware of this complication to adequately reassure patients.

Background: In the last decade, FDG-PET/CT has become routine practice in the management of lymphoma or autoimmune diseases. In the current study, we aimed to assess the usefulness of FDG-PET/CT as a potential diagnostic tool for detecting underlying systemic diseases (SD) in patients with orbital inflammatory disorders (OID).Methods: All consecutive patients managed for new-onset OID between 2011 and 2018 in a tertiary referral center for OID, who underwent FDG-PET/CT as part as the etiological diagnostic workup were enrolled. PET-FDG/CT scans were reviewed blindly and were considered as positive for SD detection if they showed lymphadenopathy and/or other visceral lesions with an uptake above blood pool background. We used the standard diagnostic workup (performed in all patients at presentation) as relevant comparator. To quantify the incremental value of FDG-PET/CT over the standard diagnostic workup, the Net Reclassification Index (NRI) and Integrated Discrimination Index (IDI) were used. The final diagnosis was based on international criteria for autoimmune diseases, or histological confirmation for lymphoma, xanthogranuloma, crystal storing histiocytosis (CSH), or idiopathic orbital inflammation syndrome (IOIS). Results: Among the 22 patients enrolled, 14 (63%) had underlying SD (granulomatosis with polyangiitis (GPA), n=1; IgG4-related disease (IgG4-RD), n=5; CSH, n=1; adult onset asthma and periocular xanthogranuloma (AAPOX), n=3; lymphoma, n=4) while the remaining 8 (37%) patients were diagnosed with IOIS. Eleven (50%) patients had a positive FDG-PET/CT. After clinicobiological evaluation, FDG-PET/CT correctly reclassified 29% of patients with SD (p=0.04) and 13% with IOIS (p=0.3), corresponding to an elevated NRI of 0.41±0.17 (p=0.03). The IDI test used to evaluate the improvement of FDG-PET/CT for SD detection was 0.38±0.08 (pConclusion: FDG-PET/CT enabled accurate reclassification of more than one quarter of patients with SD, suggesting its potential value for detecting SD (especially extraorbital lymphoma).

PURPOSE Phantom eye syndrome (PES) is an underestimated complication of eye amputation (EA) characterized by phantom eye pain (PEP), phantom visions and/or phantom sensations. The aim of this study was to assess PEP prevalence, features, risk factors, social and psychological consequences and associated quality of life. METHODS A questionnaire study was conducted in three oculoplastic departments between April 2016 and July 2017. Patients >18 years who had undergone EA ≥3 months earlier were included and asked to complete a prestamped questionnaire. Patient's characteristics, preoperative, surgical and postoperative data were collected. RESULTS Of the 185 questionnaires given, 115 (62%) were returned for analysis. Hundred patients with a mean age of 65.1 years (29-92; SD = 13.0) were included. Eye amputation (EA) indications were uveal melanoma (n = 24, 24%), trauma (n = 20, 20%), retinal detachment (n = 20, 20%), glaucoma (n = 14, 14%) and endophthalmitis (n = 12, 12%). Forty-seven (47%), 30 (30%) and 38 (38%) patients experienced PEP, phantom visions and phantom sensations, respectively. Anxiety and depression [Hospital Anxiety Depression scale (HADS) score ≥8 for both] were diagnosed in 34 (34%) and 42 (42%) patients, respectively. The mean EQ-5D-3L and EQ-5D visual analogue scale scores were 0.8 (0.06-1; SD = 0.2) and 68 (0-100; SD = 22), respectively. Preoperative eye pain (p = 0.031), glaucoma (p = 0.027), postoperative anxiety with HADS score ≥8 (p = 0.012) and ≥11 (p = 0.014), aesthetic discomfort (p = 0.002) and EQ-5D-3L score

There are requirements for long-term, objective comparisons of hyaluronic acid (HA) dermal fillers.To compare efficacy and tolerability of ART FILLER Universal (AFU) and ART FILLER Fine lines (AFFL) with the existing HA fillers for the treatment of nasolabial folds and crow's feet.Prospective, randomized, rater- and patient-blind, split-face comparison of AFU with JUVEDERM Ultra 3 (JUV) and AFFL with FIRST LINES PureSense (FLPS). The severity of nasolabial folds and crow's feet was assessed by independent blinded evaluators using the Lemperle scale at baseline, day (D) 30/D45, D90, and D180. Tolerability, Global Aesthetic Improvement Scale (GAIS), wrinkle volumes, and skin thickness and density were also measured at D30/D45, D90, and D180.At D30 and D180 respectively, 61 and 57 patients were assessed. Scores for nasolabial folds and crow's feet showed statistically significant improvements at D30, D90, and D180. AFU and AFFL were noninferior to JUV and FLPS, respectively. Most patients showed GAIS improvements, maintained until at least D180 and significant increases of collagen synthesis in crow's feet and nasolabial folds. Treatments were well tolerated.AFU and AFFL are noninferior to comparators. The methodology used represents a novel approach to augment existing clinical assessment of HA fillers.

A 7-day-old boy was referred from the maternity hospital to the eye care emergency for a right unilateral congenital upper eyelid eversion (Figure 1A). This is a rare condition, observed mainly in ...

The aim of this study is to describe the experience of 33 physicians, dermatologists and surgeons, with the use of a semi-cross-linked hyaluronic acid (HA) gel as a tear trough deformity filler within one month following injection, and to assess patient satisfaction with the procedure. This study is a case series conducted between February 2012 and December 2012 with the use of semi-cross-linked HA to correct tear trough deformity. The filler was administered in the preperiosteal tissues. The study involved case note review and a patient satisfaction survey. A total of 302 eyes of 151 patients were treated by 33 physicians, with a mean follow-up of 3 weeks. Patients were mainly female (86%), and middle-aged (mean age 48 years old). The gel was placed preperiosteally, deep to the orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.48 ml per eye to achieve correction. The injection procedure was performed without local anesthetic for 79% of the patients. No serious adverse event was recorded. Side effects reported by investigators immediately after injection included bruising (11%), swelling (12%), and redness (inflammation 12%). Very few transitional blue discolorations (2.6%) were observed. No patient required dissolution with hyaluronidase. According to our satisfaction survey, all patients had cosmetic improvement. Most patients (97%) described marked or moderate satisfaction with the treatment. At one month, 18% requested additional hyaluronic acid gel for a touch-up injection. This case series confirms the effective use of a semi-cross-linked HA gel in tear trough rejuvenation. It has excellent patient tolerability, minimal complications, and excellent patient satisfaction.

Aims: Orbital extraocular extension of choroidal melanoma is very rare with small melanomas. We report the case of a patient whose small choroidal melanoma was initially overlooked and was revealed by a large extrascleral extension. Methods: A 48-year-old Caucasian woman presented with sudden total visual loss in the right eye. Multicolor imaging of the fundus showed right optic disc edema and an orange and green lesion near the optic disc. The diagnosis of unilateral optic neuritis was made. Magnetic resonance imaging showed an extraocular mass adjacent to the optic nerve; on ultrasound, this mass was acoustically hollow and a small intraocular component was visible. Results: Choroidal melanoma with a large extrascleral extension was diagnosed (T4eN0M0, stage IIIC according to the AJCC 7th TNM classification, 2010). The size of the extraocular nodule was 13 × 5 mm. Treatment consisted of enucleation followed by adjuvant external beam orbital radiotherapy. Tumor analysis showed a mixed cell type melanoma with monosomy 3. The patient developed liver metastasis 10 months after local treatment. Conclusion: Extraocular extension of choroidal melanoma can occur with small lesions. Prognosis is generally poor according to AJCC TNM. This case is a reminder that fundus examination may reveal the nature of the mass in some patients with orbital tumors.

A woman in her early fifties had regular follow-up for a medium-sized divided nevus of the eyelids which had undergone several surgical excisions during childhood for functional and esthetic reasons. Malignant transformation of the nevus occurred in the inferior eyelid, with the appearance of a new pigmented flat lesion. Histology showed in situ melanoma, and an NRAS activating mutation was found. A full-thickness excision of the inferior eyelid was performed, followed by reconstruction. Local recurrence of the melanoma occurred 1 year after surgery. Lifelong follow-up of divided nevi of the eyelids is recommended, even if very few cases of malignant transformation have been reported so far.

Aims To evaluate retrospectively the prevalence of positive IgG4-immunostaining in orbital tissue of patients with idiopathic orbital inflammation and to compare the clinical, radiographic and pathologic features among patients with and without IgG4-positive cells. Patients and methods 25 patients with biopsy-proven idiopathic orbital inflammation examined from January 2006 through December 2011 were included. Immunohistochemistry with IgG and IgG4 immunostaining from biopsy specimens of all patients was performed. Tissue with more than 10 IgG4-positive plasma cells per high-power field and with a ratio of IgG4+/IgG+ plasma cells of more than 40% was scored as positive. Histopathologic features, demographic and clinical data, radiologic findings, treatment and follow-up information for each patient were analysed. Results Immunohistochemical staining showed 10 cases (40%) were IgG4 positive. The symptoms and signs included eyelid or periocular swelling/mass in all, pain (3/10), extraocular muscle restriction (3/10), proptosis (5/10) and/or decreased vision (4/10). Demographic and clinical findings of these patients did not differ from those with IgG4-negative cells. The presence of positive IgG4-immunostaining in orbital tissue was significantly associated with characteristic pathological features (more background fibrosis, lymphoid hyperplasia, plasma cells and phlebitis). Conclusions Finally, 40% of patients with biopsy-proven orbital inflammation were classified as IgG4-RD, with typical histological features, but without specific clinical or radiological findings.

Adenoid cystic carcinoma (ACC) is the most common malignant epithelial cancer of the lacrimal gland. Despite a slow rate of growth, ACCs are ultimately associated with poor clinical outcome. Given the rarity of this disease, most recommendations regarding therapy are guided by expert opinion and retrospective data rather than level 1 evidence. Surgery and postoperative radiation therapy are commonly used as initial local treatment. In patients at high risk of recurrence, concomitant platinum-based chemotherapy may be added to postoperative radiotherapy in an attempt to enhance radio-sensitivity. While encouraging responses have been reported with intra-arterial neoadjuvant chemotherapy, this strategy is associated with substantial toxicity and should be considered investigational. For patients with metastatic disease not amenable to surgery or radiotherapy, chemotherapy may have a role based on its modest efficacy in non-lacrimal ACC. Similarly, molecular targeted agents may have a role, although the agents tested to date in non-lacrimal ACC have been disappointing. A better understanding of the biology of ACC will be crucial to the future success of developing targeted agents for this disease.

Dysthyroid Optic Neuropathy (DON) can lead to irreversible visual loss. We report risk features correlated with poor visual recovery despite an intensive treatment in a series of patients with DON.Retrospective analysis of a non-comparative interventional series.Between 1997 and 2007, 300 consecutive patients with Graves' orbitopathy were seen at the Rothschild Foundation (Paris). Medical records of all consecutive patients who developed a DON were reviewed. Demographic, clinical features and visual function were collected at the time of the first onset, one month follow-up after medical and sometime surgical treatment and at the last examination. Statistical analysis (reflected as p values) gathered the significant observations into detrimental visual recovery prognostic factors for DON.Fifty-six eyes of 29 patients developed a DON. Sixteen eyes (28%) did not improve vision despite usual treatment (intravenous steroids and surgical decompression when necessary). An inferior altitudinal visual field defect (AVF, p=0.0004) and/or a lack of response to intravenous steroids boluses (p= 0.011) were related to a poor recovery.DON prognosis is highly variable. Our results suggest that a non-inflammatory element, probably vascular could be involved in atypical DONs. An earlier recognition could prompt to rapid surgical treatment for these patients.

Adult onset asthma and periocular xanthogranuloma (AAPOX) is a rare non-Langerhans histiocytosis characterized histopathologically by a periocular infiltration of foamy histiocytes and Touton giant cells. Benign hyperplasia with plasma cell infiltration is classically described in eyelids or lymph nodes of AAPOX patients. It is also a characteristic feature of IgG4-related disease (IgG4-RD), a new entity defined by an IgG4-bearing plasma cell infiltration of organs. To determine if AAPOX syndrome shares clinical, biological, and histopathological characteristics with IgG4-RD, we used the comprehensive clinical diagnostic criteria for IgG4-RD in a retrospective case series of three consecutive patients with histologically-proven AAPOX. Patients who were diagnosed with AAPOX at a French academic referral center for orbital inflammation between November 1996 and March 2013 were enrolled. Biopsies from ocular adnexa or other organs were systematically reexamined. For each patient, clinical and serological data, radiologic findings, and treatment were retrospectively analyzed. Two AAPOX patients fulfilled all of the diagnostic criteria for a definite IgG4-RD. One patient who lacked the serological criteria fulfilled the criteria of a probable IgG4-RD. These 3 cases of AAPOX patients fulfilled the IgG4-RD comprehensive clinical diagnostic criteria. To our knowledge, this is the first observational case report study to clearly show a strong relationship between IgG4-RD and AAPOX syndrome.

Tatjana Pavicic,1 Welf Prager,2 Markus Klöppel,3 Simon Ravichandran,4 Olivier Galatoire5 1Private Practice, Munich, Germany; 2Dr. Prager & Partner, Derma-Hamburg, Hamburg, Germany; 3Private Practice Clinic of Esthetic Surgery, MediCenter Munich-Solln, Munich, Germany; 4Clinetix Rejuvenation, Glasgow, Scotland, UK; 5Department of Ophthalmology, Adolphe Rothschild Ophthalmological Foundation, Paris, France Purpose: To characterize utilization patterns and treatment satisfaction with incobotulinumtoxinA for aesthetic indications and assess adherence to the Summary of Product Characteristics. Patients and methods: Data were collected retrospectively from physicians in Germany, France, and the UK regarding patients (n=638) treated with incobotulinumtoxinA for aesthetic indications. Data on indication, treatment interval, dose injected, physician and patient satisfaction, and adverse drug reactions were recorded according to routine daily practice. Results: Most patients (76.0%) received incobotulinumtoxinA for glabellar frown lines (GFL) and were given doses of ≤20 U. The majority of treatment intervals were 5 months or longer. Overall, 64.1% of patients were treated for off-label indications, sometimes in combination with treatment for GFL. The most frequently treated off-label indications were horizontal forehead lines (38.6%) and/or crow's feet (CF; 31.7%); for CF, >95% of injected doses were ≤24 U. In Germany, a smaller proportion of patients were given incobotulinumtoxinA treatment for CF (27.6%), compared with France (40.4%) and the UK (33.2%), although country-specific differences were less prominent when treatment cycle data for CF were examined. Treatment satisfaction among physicians and patients (overall, and for GFL specifically) was very high, with excellent tolerability and only one mild adverse drug reaction reported. Conclusion: In daily practice, incobotulinumtoxinA is mainly used for GFL; however, its use for CF and horizontal forehead lines (often in combination with GFL) is relatively common. Treatment satisfaction across aesthetic indications is high, and incobotulinumtoxinA is well tolerated, with time intervals of 5 months or longer between injections in the majority of cases. When considering factors such as dose and treatment interval, adherence to the Summary of Product Characteristics when treating GFL in daily practice is good. These results support previous reports that incobotulinumtoxinA is an effective treatment for GFL, with an excellent safety profile. Furthermore, incobotulinumtoxinA may display efficacy and tolerability in other indications. Keywords: incobotulinumtoxinA, Xeomin®/Xeomeen®/Bocouture®/XEOMIN Cosmetic™, NT 201; free from complexing proteins, retrospective, daily practice, glabellar frown lines, crow's feet

A 73 years old woman presented with 10 months history of inferior eyelid nodule, the biopsy revealed at the time a grade 2 leiomyosarcoma without metastasis, the excision was considered inappropriate and radiotherapy was performed. The patient was addressed for resistant ocular pain management grade 3 and persistence of the lesion despite all the treatments. The mass is now measuring 8 cm in maximal diameter. The MRI showed lesions that affect mainly the median extra orbital part. An embolization of the main artery that vascularise the lesion was performed, proceeded by wide exenteration. The patient died 4 months later of local recurrence in the orbital cavity and metastases. Leiomyosarcoma as a highly malignant character showed a furious resistance to chemotherapy, radiotherapy and embolization so wide radical exenteration from the beginning might give better chance at long term survival.

Botulinum neurotoxins are the most popular non-surgical treatments for aesthetic indications, but there is uncertainty about whether certain formulations are comparable in efficacy and safety and can be substituted for one another by a simple one to one dose conversion ratio. An expert panel of French practitioners was convened to establish a consensus on the clinical equivalence in efficacy and safety of OnabotulinumtoxinA (900 KDa) and IncobotulinumtoxinA (neurotoxin free from complexing proteins - 150 KDa). The consensus was divided into three sections incorporating a biological, bibliographic and clinical analysis of the two toxins. This included a review of the published data that have directly compared the two toxins for aesthetic indications and a survey of the panel's extensive clinical experience with the two toxins in terms of efficacy and safety. All panel members reviewed and endorsed the content of each section. Among this expert panel of French aesthetic physicians and biologists there was consensus that OnabotulinumtoxinA and IncobotulinumtoxinA are clinically equivalent in terms of efficacy and safety, and that a switch from one drug to the other can be made using a simple 1:1 conversion ratio.

PURPOSE To report some novel findings concerning the systemic manifestations and treatment of adult-onset asthma and periocular xanthogranuloma, a rare type of non-Langerhans histiocytosis that can lead to important visual dysfunction. METHODS A retrospective case series of 2 patients was evaluated for orbital and systemic manifestations using fluorodeoxyglucose positron emission tomography/CT and/or orbital MRI. Histological specimens were reviewed in all patients. Oral prednisone was initiated at 1 mg/kg daily and gradually tapered to a minimum effective dose. Efficacy was assessed on the basis of an objective observation of decreased swelling. RESULTS One patient displayed original uptake foci involving intrathoracic lymphadenopathies, the trajectory of the paraumbilical vein and perirectal fat. Low-dose prednisone was able to induce a durable response in the authors' patients. CONCLUSIONS Fluorodeoxyglucose positron emission tomography/CT may be useful for the diagnostic workup and follow-up assessment of patients with adult-onset asthma and periocular xanthogranuloma. Oral corticosteroids can be used successfully as first-line treatment in such patients.

To assess the long-term results of the treatment of oculofacial asymmetries using a combined injection schedule for injections of hyaluronic acid, with a specific micro cannula and botulinum toxin.A retrospective study was conducted from January 2009 to January 2010. Patients were treated in the Alcazar Eye Clinic and Oculoplastic Department in Princess Grace Hospital, Monaco. We selected patients complaining of asymmetrical periorbital features who received treatment with hyalurostructure and botulinum toxin injection in one or more sessions. Nine patients were selected and presented with the following symptoms: asymmetry of eyebrow position (2 patients), superior orbital hollow (2 patients), tear trough (2 patients) and orbital volume (ocular prosthesis) (3 patients). The objective was to evaluate the efficiency of combined treatment in one or more sessions on these oculofacial asymmetries. Hyaluronic acid injections were done using hyalurostructure. Hyaluronic acid gel (Restylane Lidocaine) was used with a 25 gauge reinforced micro-cannula (pix'l +, Thiebaud). This was combined with injections of botulinum toxin (azzalure*) to areas of muscular hyperaction. Follow-up was done at 1 year by clinical examination, photography and patient satisfaction. Complications of this combined treatment have been identified.At 1-year follow-up, 88% of patients were satisfied or very satisfied with their results. There were no more complications secondary to both treatments in the same session. It was not noticed more hematomas and bruises than in classical injection method. The action of toxin is constant over time despite the association of hyaluronic acid injections.Combined treatments with toxin and hyaluronic acid in oculofacial asymmetries are efficient and can be proposed in the same session. These treatments must be repeated to maintain and optimize muscle contraction and volume loss. Use of hyalurostructure and botulinum toxin treatment in the same session is effective and safe.

The objective of this paper is to provide an expert consensus regarding facial rejuvenation using a combination of volume replacement (Juvederm(®) VOLUMA(®)), filling products (Juvederm(®) Ultra product line) and botulinum toxin. The Juvederm product line exploits innovative 3-D technology, producing a range of cohesive, homogenous gels that produce predictable, long-lasting and natural results. The products are easy to use by practitioners and are well-tolerated by patients, and used in combination can provide additional benefits not achieved with one product alone. An assessment of facial anatomy and consideration of the aging process, as well as available treatment options, are also addressed in determining the best combination of products to use. Outcomes from a questionnaire and workshop sessions focusing on specific aspects of use of the Juvederm product line and botulinum toxin in daily clinical practice are discussed, and recommendations for product use following debate amongst the experts are provided.

The position and appearance of the upper eyelid crease is one of the challenges in eyelid surgery. The aim of this study was to compare the clinical appearance of the upper eyelid crease with its anatomy, including the position of the levator, the septum, and the orbital fat as determined by Magnetic Resonance Imaging (MRI).Oculoplastic examination was performed in normal volunteers of the same age with different appearances of the upper eyelid. MRI (Intera 1.5 T, Philips, the Netherlands) was carried out with both head and surface coils in all volunteers. Subjects were asked to keep their eyes closed during the whole procedure, thus reducing artefacts due to eyeball movements. The protocol lasted 8 minutes and included a multiplanar scout to obtain T1-weighted 3D-images. Thin sagittal T2 sequences were obtained along the plane of the optic nerve and focused on both orbits, allowing a precise analysis of the orbital content and eyelid anatomy.Six volunteers were included in this prospective study, three of Caucasian origin and three of North African, Central African and Asian origin, respectively. We distinguished two appearances of the crease: in some cases, the superior eyelid sulcus was convex, while in other cases it was concave. The superior eyelid fold was either high or low. Two Caucasian subjects had a deep, concave superior eyelid sulcus with a high crease. This crease appearance was correlated with a short concave appearance of the septum, which pulled back the pre-aponeurotic fat. The non-Caucasian volunteers all had a convex superior eyelid sulcus. The orbital septum insertion was low on the levator aponeurosis, and the orbital fat pad drooped onto the levator muscle, accounting for the convexity of the upper eyelid sulcus. A skin fold was formed by redundant skin over the crease.MRI provides excellent images and allows a good analysis of the upper eyelid components. It permits a detailed analysis of the architecture for a better understanding of its appearance and of the crease position, although further investigation with a larger number of volunteers is required.

A 54-year-old man had a 5-year history of painless bilateral eyelid swelling, proptosis, and diplopia. MRI showed enlargement of extraocular muscles, lacrimal gland, and divisions of the trigeminal nerve (figure 1). Biopsy from the left infraorbital canal demonstrated lymphoplasmacytic infiltrate and fibrosis. Mean number of immunoglobulin G (IgG)4+ cells was 155 per high-power field and ratio of IgG4+/IgG+ cells was 89% (figure 2). Serum IgG4 concentration was 878 mg/dL (normal range 4–86 mg/dL). Symptoms resolved with steroids. The patient relapsed during tapering and azathioprine was added. IgG4-related disease is characterized by IgG4-positive cells and lymphocyte infiltration into various organs, including orbital tissues. Thickening of branches of the trigeminal nerve is highly suggestive of IgG4-related disease.1,2

Introduction: Dysthyroid optic neuropathy (DON) is a rare complication (3 to 5% of dysthyroid orbitopathies) that rapidly involves the visual prognosis and requires urgent management. The most commonly used treatment currently involves intravenous corticosteroid therapy combined with decompression surgery of one or more of the orbital walls to relieve congestion at the apex. The objective of this study is to evaluate the visual, anatomical and psychosocial outcome of patients undergoing orbital decompression for DON. Methods and materials: In this retrospective and prospective unicentric study, patients with unilateral or bilateral DON were included for surgery. The primary endpoint was visual acuity. We assessed global visual function (severity of DON evaluated by CON-Score, visual field, color vision, OCT, fundus, contrast vision, intraocular pressure) and parameters associated with dysthyroid orbitopathy (degree of exophthalmia, CAS disease activity score, volume and orbital morphology, diplopia) and the risk factors associated with optic neuropathy. A subgroup analysis focused on visual recovery and the severity of DON.Results: 20 patients were included (29 orbits) with an average follow-up of 18 months. Orbital decompression surgery has significantly improved the visual acuity of 0.79 log MAR +/- 0.27 (p = 0.01), has lowered the intraocular pressure levels of 3 +/- 1.7 mmHg on average (p = 0.032), decreased proptosis of 3.7 mm +/- 2.83 (p = 0.0025), and improved quality of life with a significantly gain of GO-QOL score of 43,7 +/- 25.88 (p = 0.004). The visual field was improved in 85% of cases; 8% found a strictly normalised visual field in the long term. The colour vision was improved postoperatively in 100% of cases. Postoperatively, dyschromatopsia (minimal to moderate) persisted in 24% of cases.The surgery has increased the global orbital volume (average 2,169 cm3) mostly attributed to the medial rectus muscle (+12.8%) and the orbital fat (+ 19.41%). We did not find a correlation between the decrease in CAS and better visual recovery (p = 0.15) or between the severity of DON and CAS. We observed greater severity, poorer recovery, and decreased quality of life in less advantaged socio-economic groups compared to those in the more advantaged social class. The overall complication rate was 41%, most of which was transient and resolutive. After decompression, the rate of constant diplopia decreased by 20%. We found a degree of de novo diplopia of 42 %( including gaze-evoked intermittent diplopia). In addition, 50% of patients will require additional muscle surgery for long-term strabismus. Patients with late evolution orbitopathy (> 4 years) older age, a restrictive pattern with a significant diplopia and reduced ocular motility, a high rate of TRAK, active smoking have a lower increase in postoperative orbital volumes which implies less compliance of the orbital tissues.The analysis of contrast perception showed that 100% of patients who recovered a complete visual function nevertheless retained alterations in contrast sensitivity. This item is felt by patients as handicapping in everyday life and causing an impairment of the quality of life, despite the normalization of the visual field, colour vision and visual acuity.At a distance from surgery, however, 40% of patients maintained ocular hypertension, the main risk factor of which was the male sex and a long duration of evolution of the orbital inflammation.Discussion: Our results are consistent in terms of effectiveness and tolerance with the data of the literature. Patients can maintain subclinical sequelae that should be investigated by extensive analysis that can significantly affect quality of life. This study confirms the effectiveness of orbital decompression surgery for the treatment of DON. The surgical results are closely related to orbital compliance, a notion that we introduce in the study : it implies that the plasticity of fatty and muscular orbital tissues plays a key role in anatomical and functional recovery. The concept of compliance could be explored on a larger scale by the analysis of orbital volumes after decompression surgery without DON and could lead to inform the surgeon on the subtype of orbitopathy and guide a customised surgical procedure based on each patient’s presentation of OD.; Introduction : la neuropathie optique dysthyroïdienne (DON) est une complication rare (3 à 5 % des orbitopathies dysthyroïdiennes) mettant rapidement en jeu le pronostic visuel et nécessitant une prise en charge urgente. Le traitement le plus utilisé actuellement comporte une corticothérapie intraveineuse associée à une chirurgie de décompression visant à décomprimer une ou plusieurs des parois orbitaires afin de soulager l’encombrement à l’apex. L’objectif de cette étude est d’évaluer le devenir des patients opérés de décompression orbitaire urgente pour DON sur le plan visuel, anatomique et psycho-social.Matériel et méthodes : au cours de cette étude rétrospective et prospective unicentrique, des patients opérés pour DON uni ou bilatérale étaient inclus. Le critère de jugement principal était le gain d’acuité visuelle. Nous avons évalué la fonction visuelle globale (sévérité de la DON par le CON-Score, champ visuel, vision des couleurs, OCT, fond d’œil, vision des contrastes, pression intra oculaire) et les paramètres associés à l’orbitopathie dysthyroïdienne (degré d’exophtalmie, score d’activité de la maladie CAS, volume et morphologie orbitaire au scanner, diplopie) ainsi que les facteurs de risques associés à la neuropathie optique. Une analyse en sous-groupe a porté sur la récupération visuelle et la sévérité de la DON.Résultats : 20 patients ont été inclus (29 orbites opérées) avec un suivi moyen de 18 mois. La chirurgie de décompression orbitaire a permis d’améliorer significativement l’acuité visuelle de 0,79 +/- 0,27 log MAR(p=0,01), de baisser les niveaux de pression intraoculaire de 3 +/- 1,7 mm Hg en moyenne (p=0,032), de diminuer l’exophtalmie de 3,7 +/- 2,83 mm (p=0,0025), et d’améliorer la qualité de vie avec un score GO-QOL moyen augmenté de 43,7 +/- 25,88 points de manière significative (p=0,004). Le champ visuel était amélioré dans 85% des cas ; 8% retrouvaient un champ visuel strictement normal à long terme. La vision des couleurs était améliorée en post opératoire dans 100% des cas. En post opératoire une dyschromatopsie (minime à modérée) persistait dans 24% des cas. La chirurgie a entraîné une augmentation du volume orbitaire d’en moyenne 2,169 cm3 au profit notamment du muscle droit médial (+12,8%) et de la graisse orbitaire (+19,41%). Nous n’avons pas retrouvé une corrélation entre la diminution du CAS et une meilleure récupération visuelle (p=0,15) ni entre la sévérité de la DON et le CAS. Nous avons observé une sévérité plus importante, une moins bonne récupération et une qualité de vie diminuée dans les groupes socio-économique moins favorisés comparés à ceux de classe sociale plus favorisées. Le taux de complication global était de 41% dont la plupart étaient transitoires et résolutives. Après décompression, le taux de diplopie constante a diminué de 20% passant de 38% à 18%. Nous avons retrouvé un taux de diplopie de novo de 42% (incluant les diplopies inconstantes dans les regards latéraux). En outre,50% des patients auront recours à une chirurgie musculaire supplémentaire du strabisme à long terme. Les patients présentant une orbitopathie d’évolution tardive ( > 4 ans) l’âge élevé, un syndrome restrictif avec une diplopie importante et une motilité oculaire réduite, un taux élevé de TRAK, un tabagisme actif présentent une augmentation moins importante des volumes orbitaires en postopératoire ce qui implique une moindre compliance des tissus orbitaires. L’analyse de la perception des contrastes a démontré que 100% des patients ayant récupéré une fonction visuelle complète conservaient néanmoins des altérations de la sensibilité aux contrastes. Ce critère est ressenti par les patients comme handicapant dans la vie quotidienne et à l’origine d’une altération de la qualité de vie et ce, malgré la normalisation du champ visuel, de la vision des couleurs et de l’acuité visuelle. A distance de la chirurgie,40% des patients conservaient cependant une hypertonie oculaire dont le facteur de risque principal était le sexe masculin et une longue durée d’évolution de l’inflammation orbitaire.Discussion : nos résultats sont cohérents en terme d’efficacité et de tolérance avec les données de la littérature. Les patients peuvent conserver des séquelles infra-cliniques qu’il convient de rechercher par une analyse étendue pouvant nuire considérablement à la qualité de vie. Cette étude confirme l’efficacité de la chirurgie de décompression orbitaire pour le traitement de la DON. Ses résultats sont étroitement liés à la compliance orbitaire, notion que nous introduisons selon laquelle la plasticité des tissus orbitaires graisseux et musculaires joue un rôle capital dans la récupération anatomique et fonctionnelle. La notion de compliance pourrait être explorée à plus grande échelle par l’analyse des volumes orbitaires après chirurgie de décompression hors DON et pourrait amener à renseigner le chirurgien sur le sous-type d’orbitopathie et guider un geste chirurgical sur mesure.