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Purpose: The purpose of this study is to assess the dose-dependent immunohistopathological effects of intradermal microneedle-delivered 5-fluorouracil (5-FU) for postincisional wound healing in a murine model., Methods: A prospective experimental study was performed. Twelve hairless mice were randomized into 4 treatment groups for postincisional wound treatment: microneedling with topical saline, or microneeding with topically-applied 5-FU at concentrations of 25 mg/ml, 50 mg/ml, or 100 mg/ml. Two surgical wounds were created on each animal. Combination wound treatments were performed on postoperative days 14 and 28, and cutaneous biopsies were obtained on day 56. Specimens were analyzed by a dermatopathologist, blinded to the treatment group, for collagen thickness, lymphocytic infiltration, histiocytic response, sub-epidermal basement membrane zone thickness, and myofibroblast density., Results: Histopathologic evaluation showed increased collagen thickness, lymphocyte infiltration, and granuloma density in the groups undergoing microneedling treatment with 5-FU, compared to saline. Immunohistochemical analysis revealed a trend toward thicker basement membranes with higher concentrations of 5-FU used, reaching statistical significance between controls and those treated with 100 mg/ml 5-FU ( p = 0.0493). A trend toward decreasing myofibroblast density with increasing doses of 5-FU was noted. No postincisional or treatment complications were observed., Conclusions: Our results demonstrate that microneedling is an effective topical subepithelial drug delivery system, and further suggest a beneficial dose-dependent immunomodulatory effect of 5-FU on intermediate wound healing when used in combination with microneedling. We recommend a 5-FU dose at the mid-range 50 mg/ml concentration to simultaneously maximize efficacy and minimize complication risk., Competing Interests: N.A.H.: consultant for Pulse Biosciences. V.D.D.: consultant for Stryker and Genentech and Speaker for Horizon Therapeutics. T.N.: shareholder, AVYA Skincare. Other authors have no conflict of interest to disclose., (Copyright © 2022 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: In March 2020, the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) advised the suspension of all non-emergent oculofacial patient care, imparting unprecedented interruptions in fellowship training., Methods: ASOPRS fellows and program directors were asked to complete an anonymous survey regarding their perceived impact of the COVID-19 crisis., Results: Forty ASOPRS fellows (70.2%) participated, including 20 first-year and 20 second-year trainees, from all country regions. During the social distancing restrictions, 100% of fellows continued to participate in surgical procedures, including orbital biopsy (77.5%), abscess drainage (55.0%), fracture repair (45.6%), eyelid lesion excision (70.0%) and temporal artery biopsy (57.5%). ASOPRS fellows evaluated patients, including in emergency room (84.6%) and inpatient hospital (76.9%) settings, wearing surgical (85.0%) or N-95 (40.0%) masks, gloves (80.0%) and eye protection (62.5%).Most ASOPRS fellows (87.5%) participated in virtual interinstitutional education sessions and indicated a desire to continue this curriculum. Fellows also used available time for research (85.0%), independent study (77.5%), personal health (70.0%) and social interaction (60.0%).ASOPRS fellows reported COVID-19 restrictions to have a mild (72.5%) to moderate (27.5%) impact on their overall training, and most (75.0%) felt their surgical confidence to decline. Fellowship program directors also asserted a mild (72.2%), moderate (19.4%) or significant (5.6%) impact on subspecialty training, and 94.4% predict adverse effects on graduation case logs., Conclusions: During the COVID-19 restrictions most ASOPRS fellows participated in emergent clinical activities and novel telemedicine curriculum. Most fellows and program directors expressed concern regarding a negative impact on overall subspecialty education and surgical confidence.

Primary mucinous adenocarcinoma of the skin is an uncommon malignancy in clinical practice, but multicentric presentation of the malignancy is considered even more rare. In this case report, the authors present a 70-year-old woman with multicentric primary mucinous adenocarcinoma of the skin manifesting with 2 separate lesions located on the right eyelid and cheek. Lesion removal and immunohistochemical staining ruled out mucinous adenocarcinoma of the skin secondary to lung or thyroid carcinoma, however, was inconclusive for breast carcinoma. A negative breast examination and mammography determined the lesions were primary mucinous adenocarcinoma of the skin. Lesion removal resulted in a large defect, which was repaired using a tarsoconjunctival flap and right cheek rotational/advancement flap. Six months postoperatively, the patient's vision returned to baseline with excellent eyelid position and no evidence of local recurrence. Oral consent for the report and photographs was obtained from the patient and filed.

Aim: A survey of ophthalmic plastic and reconstructive surgeons as well as seven-year data regarding claims made to the Ophthalmic Mutual Insurance Company (OMIC) is used to discuss operating room fires in periocular surgery., Methods: A retrospective review of all closed claim operating room fires submitted to OMIC was performed. A survey soliciting personal experiences with operating room fires was distributed to all American Society of Oculoplastic and Reconstructive Surgeons., Results: Over the last 2 decades, OMIC managed 7 lawsuits resulting from an operating room fire during periocular surgery. The mean settlement per lawsuit was $145,285 (range $10,000-474,994). All six patients suffered burns to the face, and three required admission to a burn unit. One hundred and sixty-eight surgeons participated in the online survey. Approximately 44% of survey respondents have experienced at least one operating room fire. Supplemental oxygen was administered in 88% of these cases. Most surgical fires reported occurred in a hospital-based operating room (59%) under monitored anesthesia care (79%). Monopolar cautery (41%) and thermal, high-temperature cautery (41%) were most commonly reported as the inciting agents. Almost half of the patients involved in a surgical fire experienced a complication from the fire (48%). Sixty-nine percent of hospital operating rooms and 66% of ambulatory surgery centers maintain an operating room fire prevention policy., Conclusions: An intraoperative fire can be costly for both the patient and the surgeon. Ophthalmic surgeons operate in an oxygen rich and therefore flammable environment. Proactive measures can be undertaken to reduce the incidence of surgical fires periocular surgery; however, a fire can occur at any time and the entire operating room team must be constantly vigilant to prevent and manage operating room fires.

Purpose: To compare revision rates for ptosis surgery between posterior-approach and anterior-approach ptosis repair techniques., Methods: This is the retrospective, consecutive cohort study. All patients undergoing ptosis surgery at a high-volume oculofacial plastic surgery practice over a 4-year period. A retrospective chart review was conducted of all patients undergoing posterior-approach and anterior-approach ptosis surgery for all etiologies of ptosis between 2011 and 2014. Etiology of ptosis, concurrent oculofacial surgeries, revision, and complications were analyzed. The main outcome measure is the ptosis revision rate., Results: A total of 1519 patients were included in this study. The mean age was 63 ± 15.4 years. A total of 1056 (70%) of patients were female, 1451 (95%) had involutional ptosis, and 1129 (74.3%) had concurrent upper blepharoplasty. Five hundred thirteen (33.8%) underwent posterior-approach ptosis repair, and 1006 (66.2%) underwent anterior-approach ptosis repair. The degree of ptosis was greater in the anterior-approach ptosis repair group. The overall revision rate for all patients was 8.7%. Of the posterior group, 6.8% required ptosis revision; of the anterior group, 9.5% required revision surgery. The main reason for ptosis revision surgery was undercorrection of one or both eyelids. Concurrent brow lifting was associated with a decreased, but not statistically significant, rate of revision surgery. Patients who underwent unilateral ptosis surgery had a 5.1% rate of Hering's phenomenon requiring ptosis repair in the contralateral eyelid. Multivariable logistic regression for predictive factors show that, when adjusted for gender and concurrent blepharoplasty, the revision rate in anterior-approach ptosis surgery is higher than posterior-approach ptosis surgery (odds ratio = 2.08; p = 0.002)., Conclusions: The overall revision rate in patients undergoing ptosis repair via posterior-approach or anterior-approach techniques is 8.7%. There is a statistically higher rate of revision with anterior-approach ptosis repair.

Purpose: Loss of volume in the sub-brow fat pad with associated descent of the eyebrow is a common anatomical finding resulting in both functional and aesthetic consequences. A variety of techniques have been described to address brow position at the time of blepharoplasty. To our knowledge, none of these techniques treat the sub-brow fat pad as an isolated unit. Doing so enables the surgeon to stabilize and volumize the brow without resultant tension on the blepharoplasty wound. The authors describe a technique for addressing volume loss in the eyebrow with associated brow descent that treats the sub-brow fat pad as an isolated unit., Methods: A retrospective review of all patients undergoing brow ptosis repair by a single surgeon (J.W.S.) over an 11-month period was performed., Results: Eighteen patients and 33 brows underwent the technique described. Patients were followed for an average of 11 weeks (range: 4 weeks to 20 weeks). All patients preoperatively displayed both visually significant dermatochalasis and brow descent below the orbital rim. Evaluation of pre- and postoperative photos demonstrates successful volumization of the brow with skin redraping without focal dimpling or undue tension on the eyelid wound., Conclusions: Performing a dissection that allows the sub-brow fat pad to be elevated in isolation from the overlying orbicularis and underlying periosteum allows for volumization and of the brow without compromising closure. This technique is a safe and effective means of volumizing the brow and treating secondary brow descent.

Purpose: Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV., Methods: An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed., Results: Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively., Conclusion: Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.

Orbital floor fractures (OFF) with entrapment require prompt clinical and radiographic recognition for timely surgical correction. Correct CT radiographic interpretation of entrapped fractures can be subtle and thus missed. We reviewed the clinical, radiographic and intraoperative findings of 45 cases of entrapped OFF to correlate pre- and intraoperative findings with radiography. Retrospective review and statistical analysis of 45 patients with OFF using the chi squared and Kruskal-Wallis tests. Main outcome measures included patient demographics, clinical features, radiologic interpretation, intraoperative findings, and treatment outcomes. Twenty-one cases (47%) had radiologic evaluations of orbital CT scans that included commentary on possible entrapment. Intraoperatively, 16 (76%) of these patients had the inferior rectus muscle incarcerated in the fracture, while 5 (24%) patients had incarceration of the orbital fat. Possibility of entrapment was not commented on in the radiology reports of the remaining 24 (53%) cases. Intraoperatively, 13 (54%) of these patients had the inferior rectus muscle incarcerated in the fracture, while 11 (46%) patients had incarceration of the orbital fat. It is vital to assess the possibility of entrapment, especially in young patients, in the setting of OFF as a delay in diagnosis may lead to persistent diplopia, disfigurement, or bradycardia. Most radiology reports did not mention the possibility of entrapment in this cohort. A key concept is that entrapment occurs when any orbital tissue (muscle or fat) is trapped in the fracture site.

Objective: Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity., Design: Case series., Participants: Ninety-seven patients with bilateral LG disease., Methods: Retrospective review and statistical analysis using analysis of variance and the Fisher exact test., Main Outcome Measures: Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment., Results: Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease., Conclusions: The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Subperiosteal orbital hemorrhage typically results from trauma. Spontaneous subperiosteal orbital hemorrhage (SSOH) is rare and has been reported with sudden elevation of cranial venous pressure, bleeding diathesis, and sinusitis. This article presents a series of 9 patients (11 orbits) with SSOH and review the associated systemic conditions. 10 out of 11 orbits (91%) underwent surgical intervention due to advanced orbital signs or poor vision.

Purpose: The aim of this article was to report the clinical presentation, radiography, culture results, treatment modalities, and outcomes of periocular abscesses associated with brow epilation., Methods: This was a retrospective case series including 26 patients referred for periocular abscess following brow epilation., Results: Twenty-six female patients with a median age of 20.5 (range, 12-73) years were referred for oculoplastic evaluation of periocular abscesses related to recent brow epilation. All patients were treated with incision and drainage along with systemic antibiotics. Culture results revealed 16 cases of methicillin-resistant Staphylococcus aureus, 3 of methicillin-sensitive Staphylococcus aureus, and 7 cultures that showed no growth. All patients had resolution of their abscesses at 1-month follow-up visits without progression to orbital cellulitis., Conclusions: Periocular abscess formation after brow epilation has been previously described in only a single case report in the literature. The authors believe this entity is underreported given their current report describing 26 such cases. Given the high prevalence of cosmetic brow epilation in females, the authors believe a careful history regarding brow epilation in any patient presenting with a periocular abscess or preseptal cellulitis is essential to explore the possible cause of their infection. The majority of patients in the current study's cohort had methicillin-resistant Staphylococcus aureus-related abscesses, and treatment with antibiotics with methicillin-resistant Staphylococcus aureus coverage may be a prudent first line choice in such patients.

Orbital malignancy can mimic thyroid associated orbitopathy (TAO) due to overlap of clinical and radiographic findings, which include proptosis, extraocular muscle (EOM) enlargement on imaging, and EOM restriction with diplopia. We report a case of primary orbital liposarcoma masquerading as TAO which required exenteration.

Purpose: To describe a technique of lower eyelid blepharoplasty and report observations on 274 consecutive surgeries., Methods: Retrospective, noncomparative case series of lower eyelid blepharoplasty by 2 surgeons from January 2004 through January 2006., Results: Two-hundred seventy-four eyelids of 137 patients underwent transcutaneous lower eyelid blepharoplasty for the treatment of steatoblepharon. There were 27 men and 110 women with an age range of 35 years to 85 years. Minimum length of follow-up was 6 months. Two-thirds of patients had simultaneous horizontal lower eyelid tightening. Four patients (3%) had surgical enhancement for retained lower eyelid fat., Conclusions: With appropriate patient selection, orbital septal excision is an effective aesthetic technique for lower eyelid blepharoplasty. It combines surgical simplicity with good cosmetic outcomes.

Purpose: To report the use of a modified frontalis suspension procedure for congenital ptosis patients with minimal to no levator function., Methods: Retrospective, non-comparative case series of frontalis suspension by 2 surgeons over a 21-year period., Results: Frontalis suspension with broad fascia fixation was performed on 48 eyelids of 25 patients. All patients had visual obscuration due to blepharoptosis with only 0 mm to 2 mm of measurable levator function. Age ranged from 3 to 13 years. Minimum length of follow-up was 6 months (range, 6-174 months). The palpebral fissure was increased in all patients, improving their head position and unmasking their visual axis in primary gaze. Postoperatively, all patients developed transient exposure symptoms. There were no migrations, extrusions, infections, or granulomas. All patients achieved a satisfactory postoperative result based on eyelid position, function, and contour., Conclusions: This modified frontalis suspension procedure maximizes frontalis muscle recruitment, creating powerful eyelid elevation with stable effect over time. The technique minimizes other procedures' pitfalls and advances in cosmesis are achieved with enhanced eyelid crease formation and adjustable eyelid contour.

Thyroid dysfunction, particularly hypothyroidism, following interferon-alpha therapy is not uncommon. To our knowledge, this is the first case report of exacerbation of Graves ophthalmopathy during treatment with interferon-alpha for chronic hepatitis C virus.

Purpose: The authors report the use of a tarsal switch levator resection procedure that opens the palpebral fissure while reducing the risk of postoperative exposure in ptosis patients with poor eye protective mechanisms., Design: Retrospective noncomparative case series., Participants: Fifteen consecutive patients of 2 surgeons at Texas Oculoplastic Consultants from July 1997 through July 2005., Intervention: A composite tarsal-levator-conjunctival graft was taken from the upper eyelid and was transferred to the lower eyelid., Main Outcome Measures: Clinical assessment of postoperative exposure keratopathy and position of palpebral fissure relative to visual axis., Results: A composite tarsal-levator-conjunctival graft was taken from the upper eyelid and was transferred to the lower eyelid in 26 eyelids of 15 patients. One patient was excluded because of lack of follow-up. There were 7 men and 7 women; the age ranged from 20 months to 74 years. The average duration of follow-up was 34 months, with a range of 3 to 85 months. The palpebral fissure was moved cephalad in all patients, improving their head position and unmasking their visual axis in primary gaze. One patient experienced exposure symptoms after surgery and required recession of the levator aponeurosis of both upper eyelids. Overall patient satisfaction was excellent., Conclusions: The tarsal switch levator resection procedure elevates both the upper and lower eyelids a predetermined amount. This displaces the palpebral fissure superiorly, effectively opening the visual axis in primary gaze and decreasing the risk of postoperative exposure problems in patients with diminished eye protective mechanisms.

Purpose: To describe a technique of canalicular ligation and report observations on 59 consecutive surgeries., Methods: Retrospective, non-comparative case series of canalicular ligation by 3 surgeons over a 7-year period., Results: Fifty-nine eyelids of 29 patients (2 men and 27 women) underwent canalicular ligation for the treatment of severe dry eyes. Patient age ranged from 34 to 90 years. Average length of follow-up was 20 months. There were no complications. Ninety-one percent of patients noted an improvement in their symptoms. Two patients developed symptomatic epiphora more than 1 year postoperatively and both underwent successful reversal., Conclusions: Canalicular ligation is an effective technique for punctal occlusion in patients with severe dry eyes. It combines surgical ease with excellent cosmetic outcomes.

Purpose: To determine whether the tyrosine kinase epidermal growth factor receptor (EGFR) is expressed in squamous cell carcinoma of the conjunctiva., Methods: A retrospective, observational case series of 5 patients with biopsy-proven conjunctival squamous cell carcinoma treated at one institution between January 1996 and April 2004. Medical records and tissue specimens from the 5 patients were reviewed. A control specimen of normal conjunctiva was also obtained from one of the 5 patients. Immunohistochemical analysis was performed using antibodies against EGFR., Results: Immunohistochemical staining showed that EGFR expression was moderate to strong in all tissue specimens, both in the normal mucosa and in the in situ and invasive components of the conjunctival squamous cell carcinomas., Conclusions: An intense expression of EGFR occurs in squamous cell carcinoma of the conjunctiva. Further study is needed to determine whether an EGFR inhibitor that targets this expression would have potential therapeutic benefit in treating squamous cell carcinoma of the conjunctiva.

Background and Objective: To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant., Patients and Methods: Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility)., Results: Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8., Conclusion: The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.

Purpose: To investigate the clinical and histologic response of Novabone-C/M as an osteoproductive alloplastic implant for volume augmentation in the orbit in the treatment of enophthalmos and to compare its outcome alone versus its use in combination with autogenous bone or Medpor granules., Methods: Novabone-C/M, a bioactive silicone glass material, was implanted in the subperiosteal space of the left orbit of 12 New Zealand White rabbits. The animals were divided into 3 groups, each with 4 animals, based on the material implanted in the orbit: group 1, Novabone alone; group 2, Novabone plus Medpor granules; and group 3, Novabone plus autogenous bone fragments. All rabbits were studied clinically, radiographically, and histologically at 1-, 3-, and 6-month intervals. Animals underwent preoperative and postoperative computed tomography (CT) with 3-dimensional reconstruction, proptosis measurements, and volumetric analysis. Orbit specimens were studied histologically with mineralized bone stain (MIBS) to look for bone formation, reactivity, infection, implant resorption, and migration., Results: There were no signs of significant inflammation or infection. Subcutaneous migration of the implant was seen radiographically but not clinically in groups 1 and 3. Induced proptosis averaged 2.5 mm (at 1 month) and showed regression in all groups over a 6-month period but was not statistically significant. Implant volume was markedly reduced in all groups, averaging 69% in group 1, 37% in group 2, and 59% in group 3 at 6 months. New bone formation and bone remodeling was present in all 3 groups at 3 months and only in group 2 at 6 months. The rate and amount of implant remodeling and bone formation was greatest in the Novabone/Medpor group (group 2)., Conclusions: Bioglass particulate is biocompatible, easy to use in the orbit, and stimulates bone growth. Bioglass is associated with volume loss and migration over 6 months and may not provide adequate volume augmentation in the orbit when used alone for the treatment of enophthalmos. The duration and amount of bone formation may be enhanced when Novabone is used in conjunction with Medpor.

Purpose: To evaluate complications and risk factors associated with the placement of wrapped and unwrapped porous polyethylene (PP) spherical implants after evisceration, enucleation, or secondary implantation., Methods: A retrospective, interventional, noncomparative case series of consecutive cases of PP implant placement after anophthalmic socket surgery performed by three surgeons over a 5-year period. A PP spherical implant was placed in 133 patients, 61 women (2 bilaterally) and 72 men (1 bilaterally). There were 91 enucleations, 30 eviscerations, and 15 secondary implant placements. Sixty-six (48.5%) implants were wrapped prior to placement. Parameters evaluated included: age, sex, prior ocular surgery or radiation treatment, indications for surgery, procedure performed, size of PP sphere, material used to wrap the implant, and complications., Results: A total of 17 of 136 (12.5%) cases had documented postoperative complications, with implant exposure being the most common. In 5 patients (3.7%), implant exposure developed: 1 after evisceration and 4 after primary enucleation. Three of the five exposures were small and resolved with either observation alone or in one case with surgical revision of the socket. In two cases, the exposures were large enough that removal of the implant was indicated, one after evisceration and the other after enucleation with placement of a wrapped PP sphere., Conclusions: Our series revealed no significant difference in exposure rate between wrapped and unwrapped PP sphere implants, nor was the exposure rate affected by whether an eye was eviscerated or enucleated.

Objective: To report a rare presentation of metastatic orbital rhabdomyosarcoma and the corresponding findings on magnetic resonance imaging (MRI)., Design: Interventional case report., Results: A 29-year-old white man was diagnosed with rhabdomyosarcoma of the left sinus and orbit for which he was treated with chemotherapy and radiation. Eighteen months after diagnosis, he returned with subacute right eye pain and dysmotility of his extraocular muscles. MRI revealed solitary enlargement of the right medial rectus muscle, and thyroidopathy was suspected. Over the next 2 months, symptoms progressed, and proptosis developed. MRI showed infiltration of seven extraocular muscles. A biopsy of right orbital tissues and the right medial rectus muscle was performed. Special tissue typing confirmed metastatic alveolar rhabdomyosarcoma. The patient underwent palliative radiation therapy and chemotherapy, but he ultimately died of disseminated disease., Conclusions: Rhabdomyosarcoma can rarely metastasize to the extraocular muscles. Earlier recognition of orbital metastasis through radiographic and biopsy findings, along with prompt and aggressive treatment, may prevent fulminant spread of rhabdomyosarcoma.

Purpose: To verify if a Medpor porous polyethylene orbital implant (PPOI) (Porex Surgical, Atlanta, GA, U.S.A.), once vascularized, will tolerate a partially exposed titanium screw on its anterior surface., Methods: Ten New Zealand white rabbits were enucleated and given Medpor PPOIs. Eight weeks postoperatively, Medpor Motility Coupling Posts (MCPs) (Porex Surgical) were placed into the orbital implants. Clinical tissue tolerance and histologic response to the new device were noted., Results: The titanium screws were well tolerated by the animals. No case of post-operative infection, conjunctival inflammation, conjunctival erosion, MCP dislocation, or PPOI fragmentation was noted. A fibrous tissue growth over the titanium head was noted in all screws with a head height of 2.5 mm. The fibrous tissue overgrowth was not observed in screws with a head height of 4 mm or more., Conclusion: During the 6-month observation period, all implanted Medpor MCPs demonstrated favorable tissue tolerance and stable interfaces between the MCP and the conjunctiva and between the MCP and the PPOI.

Purpose: To report the ophthalmic manifestations of hypertrophic discoid lupus erythematosus of the conjunctiva., Method: Case report and review of biopsy results., Results: A 58-year-old woman with a history of chronic blepharoconjunctivitis presented with an unusual raised conjunctival lesion. Previous biopsy slides were reviewed and interpreted as diagnostic of discoid lupus erythematosus, hypertrophic or verrucous type. Both blepharoconjunctivitis and the raised conjunctival lesion resolved with hydroxychloroquine therapy., Conclusions: A raised conjunctival mass in the context of refractory blepharoconjunctivitis should elicit suspicion for discoid lupus erythematosus. The hypertrophic variant of this disease can affect the conjunctiva.

Purpose: To evaluate the effectiveness of a modified porous polyethylene implant in orbital fracture repair. A porous polyethylene channel implant (PPCI) has internal channels that accept mini- or microplates from conventional plating systems, facilitating fixation to bone in the reconstruction of large, complex orbital fractures., Methods: The authors used 29 PPCIs to repair 25 orbits. Seventeen cases involved repair of an acute (less than two weeks after injury) fracture of one or more orbital walls. Eight cases represented delayed reconstruction of orbital walls for late enophthalmos or for residual defects after previous operations., Results: A PPCI provides a stable platform for orbital soft tissue. Excellent results were obtained in all patients with acute orbital fractures, whereas good or excellent corrections of enophthalmos and hypoglobus were achieved in all patients who underwent late repair. There were no instances of orbital infection, implant exposure or migration, worsening diplopia, visual loss, or loss of structural support during 31 months of follow-up., Conclusions: A PPCI allows controlled placement of a porous polyethylene sheet with secure fixation to stable bone. The implant design allows it to be cantilevered from the orbital rim to serve as a stable platform when fractures are too large to support the implant in the posterior orbit. PPCIs are ideally suited for reconstruction of defects resulting from displacement of orbital walls and for repair of posterior floor fractures, medial wall fractures, and combined floor and medial wall defects.

Objective: To discuss the multidisciplinary management of psammomatoid ossifying fibroma (POF) of the orbit and to clarify the clinicopathologic terminology., Design: The authors present a cohort of cases of POF involving the frontal and ethmoid sinuses and the orbit and discuss the nomenclature and literature., Participants: Three patients with POF and their treatment are discussed., Intervention: Patients were worked up and treated by a multidisciplinary team using imaging studies and histopathologic analysis. Reconstruction, if necessary, was carried out at the time of excision or in a second-stage procedure., Main Outcome Measures: In each case, the lesion was completely excised and has not recurred., Results: The diagnosis of POF was made in each case, and the patient underwent successful resection of the tumor., Conclusion: The authors' experience suggests that a multidisciplinary approach, including a radiologist, pathologist, neurosurgeon, otolaryngologist, craniofacial surgeon, and orbital specialist, may be useful in the evaluation and management of these lesions.

Soft tissue adhesion to the porous polyethylene sheet implant (PPSI) raises the concern of postoperative extraocular motility disturbance after orbital blowout fracture repairs using PPSI. A PPSI with a barrier surface (PPSI-B) has been developed to reduce adhesion between soft tissue and the implant. Six PPSI-B and six conventional PPSI were implanted under the scalps of three New Zealand white rabbits. The implants were harvested at 2-, 4-, and 20-week intervals. Clinical and histologic comparisons were made between PPSI-B and PPSI with regard to adhesion at the soft tissue-implant interface. Clinically, PPSI-B demonstrated less adhesion between soft tissue and implant compared with the conventional PPSI. Both types of implants demonstrated a complete fibrovascular ingrowth by 2 weeks. Because PPSI-B causes less adhesion at the soft tissue-implant interface, consideration should be given to the use of PPSI-B in repairs of orbital blowout fractures in which extraocular muscle is exposed to the implant surface.

Our purpose was to determine the efficacy of botulinum A toxin (BOTOX) in promoting wound immobilization and preventing wound dehiscence in patients at risk of wound-healing complications following eyelid reconstruction. In 11 patients at risk of postoperative wound complications, we injected BOTOX into the periocular musculature in addition to standard suture tarsorrhaphy. Each patient experienced excellent wound immobilization and wound healing. There were no complications. Adjuvant use of BOTOX, in conjunction with suture tarsorrhaphy, immobilizes the eyelids and promotes wound healing in patients at risk of wound complications following eyelid reconstruction.

Orbital aspergillosis is an uncommon but serious infection that may first present to the ophthalmologist. Usually arising from the paranasal sinuses, it may present in manifold ways within the orbit. Some presentations, such as optic nerve involvement, can respond to systemic corticosteroids, leading to delays in diagnosis and possibly iatrogenic potentiation of the infectious process. In this review, pertinent clinical and radiographic findings are discussed, and the literature is summarized. Classic approaches to therapy include local treatment, debridement, and systemic amphotericin B. We review novel approaches to treating orbital aspergillosis and detail a flow-chart for its management. Four patients from the spectrum of orbital aspergillosis are also described: initially presenting as an infection of an exenteration socket, a complex dacryocystitis, and optic nerve tumor, and post-operative periorbital swelling. Physicians should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of invasive aspergillosis. In the neutropenic or otherwise immunocompromised patient, a high index of suspicion must be maintained as delays in diagnosis of fulminant aspergillosis may lead to overwhelming and rapidly progressive infection. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly itraconazole and liposomal amphotericin B, may be beneficial in selected patients.

Purpose: The proximity of the paranasal sinuses to the orbit puts the anterior visual pathways at risk during sinus surgery. Although the ophthalmic complications of sinus surgery are well known to the otolaryngologist, they are rarely encountered in clinical practice. Several recommendations will help the surgeon performing intranasal sinus surgery., Materials and Methods: To study the incidence of orbital complications of intranasal ethmoid surgery, a retrospective review of 372 cases, most of them bilateral, was performed., Results: Our series of 372 patients who underwent endoscopic sinus surgery showed five orbital complications., Conclusion: several recommendations may help the surgeon to avoid any ophthalmic complication. When orbital wall dehiscence is suspected, either by CT scan or at surgery, especially in a previously operated case, extreme care should be taken not to penetrate the periorbita. If orbital fat protrudes into the operative field, it should not be pulled or twisted in an attempt to remove it. The surgeon should seek the cooperation of the anesthesiologist working the case. A knowledge of the variable anatomy is essential to avoid iatrogenic injury. The surgeon should be aware of the different complications for early recognition and management.

Conventional strabismus surgery employs a conjunctival incision to gain access to Tenon's space where a wide variety of procedures are routinely performed on the tendon and anterior aspect of the extraocular muscles. Recently, transnasal endoscopic surgical techniques have gained acceptance as effective means of decompressing the medial wall and floor of the orbit in patients with thyroid-related orbitopathy. The orbital surface of the medial rectus and inferior rectus are exposed from the annulus of Zinn to a position close to where the muscles penetrate Tenon's capsule. In theory, this technique also provides the exposure necessary to locate and retrieve a "lost" medial rectus when the usual sub-Tenon's approach fails to recover the muscle. Cadaver studies demonstrate the feasibility of exposure and suture placement in the stump of a lost medial rectus with passage of the suture through Tenon's capsule to transmit the force of the muscle to the globe, provided that the lost muscle is retrieved before severe contracture develops.

Orbital decompression for Graves' disease has traditionally been performed with the patient under general anesthesia. Endoscopic instrumentation allows for removal of the medial orbital wall and floor through an intranasal approach with local anesthetic techniques. Twelve endoscopic orbital decompressions were performed on awake patients with uncovered eyes so that vision could be monitored throughout the procedure. Simultaneous lateral decompressions were performed in 11 cases. No intraoperative or postoperative complications occurred. Visual acuity remained stable or improved in all cases. Proptosis was reduced an average of 5.5 +/- 1.6 mm. In a comparable series of 29 endoscopic decompressions performed with patients under general anesthesia, proptosis was reduced an average of 4.8 +/- 2.0 mm. Endoscopic orbital decompression with patients under local anesthesia appears to be an effective technique that may provide an additional margin of safety in prevention of injury to the optic nerve.

Short-term and intermediate-term results from clinical use of high-density porous polyethylene implants for reconstructive orbital surgery have been encouraging. This article presents an intermediate-term result from one institution with a comprehensive comparative analysis of other available alloplastic materials. A patient survey of 32 cases of orbital reconstruction using porous polyethylene sheet implants was performed, with a mean follow-up period of 32 months (range 15 to 67). All cases were trauma-related injuries. The result was compared with that of published reports of other alloplastic materials with specific emphasis on complication rates. Complication rate following the use of porous polyethylene sheet implants was 6%. This finding was consistent with those of other reports on porous polyethylene sheet implants. A consistent, satisfactory surgical outcome and low complication rate were observed. In the authors' review, the porous polyethylene implants compared favorably in a comparative analysis of other alloplastic materials.

The contiguous spread of inflammation from infected ethmoid sinuses to the surrounding tissues of the lacrimal drainage system can produce symptoms easily confused with acute dacryocystitis. We report the cases of two patients with presumed dacryocystitis whose patency of the lacrimal apparatus was established by probing, irrigation, and dacryocystography. Computerized tomography and magnetic resonance imaging demonstrated opacification of anterior ethmoid air cells adjacent to the region of the lacrimal sac. A greater awareness of this diagnostic possibility of pseudodacryocystitis arising from anterior ethmoiditis, together with improved noninvasive imaging techniques, will likely increase the observed incidence of this disease. This distinction is important since anterior ethmoidectomy, rather than dacryocystorhinostomy, is the treatment of choice when such pseudodacryocystitis proves unresponsive to antibiotic therapy. In misdiagnosed patients who undergo dacryocystorhinostomy, it is the coincidental limited anterior ethmoidectomy and not the lacrimal-nasal fistula that provides the cure.

Aneurysmal bone cyst is a rare but recognized osseous lesion of the orbit. We report the presentation, treatment, and postoperative course of an orbital aneurysmal bone cyst in a patient with McCune-Albright syndrome. To our knowledge, this report represents the first description of aneurysmal bone cyst of the orbit in a patient with fibrous dysplasia. Although visual loss in patients with fibrous dysplasia is most commonly due to narrowing of the optic canal, aneurysmal bone cyst should be considered in a patient with fibrous dysplasia who presents with decreasing vision in the face of a rapidly expanding orbital mass. The treatment in this case was drainage and debridement with prompt resolution. Although not necessary in this case, an alternative treatment includes packing with bone chips. Radiation is usually avoided because of the risk of iatrogenically induced sarcoma.

Purpose/methods: Over the past six years, we have used ordinary radiographic film as a template for sizing alloplastic implants for orbital fracture repair in over 60 patients. The implants are made of such materials as titanium, Vitallium, and porous high-density polyethylene. Autoclaved 9.5 x 4.5-cm rectangles of radiographic film are easily trimmed, held by nontoothed forceps, inserted, and removed from the orbital cavity., Results/conclusions: We have found this simple and inexpensive technique to be superior to using aluminum templates that are supplied in commercially available plating sets.

Purpose: To determine the complications observed with using porous spherical orbital implants (hydroxyapatite and porous polyethylene) and the factors leading to their occurrence., Methods: A total of 101 cases of porous spherical orbital implantation by five ophthalmic surgeons were reviewed retrospectively. The demographic data, diagnosis, prior surgery, type and technique of surgery, implant characteristics and prosthesis fitting were described in patients with complications., Results: Eleven of the 101 patients had implant exposure. There were six male (1 with bilateral involvement) and four female patients, ranging in age from 2 to 71 years. Preoperative diagnosis included trauma in five patients, nontrauma in five, and tumor in one. Seven had prior eye surgeries. Three patients underwent evisceration, whereas eight underwent enucleation. Eight hydroxyapatite and three porous polyethylene implants were used with diameters of 16 to 20 mm. Three were unwrapped, six were wrapped in sclera, and two were wrapped in preserved fascia. Exposures, which generally occurred within 1 year, were grouped into small (1-5 mm), medium (6-10 mm), and large (> 10 mm). One delayed case occurred after drilling. Small stable exposures were managed conservatively. Larger exposures were managed either by implant revision or replacement. All patients were fit ultimately with a prosthesis. Histopathologic findings of explanted spheres showed fibrovascularization limited to the periphery with moderate inflammatory reaction., Conclusion: Complications were significantly higher in cases of eviscerations than enucleations. Complications occurred in implants either unwrapped or wrapped in homologous grafts. None of the autologous wrapping had exposure. Secondary procedures may initiate exposure when fibrovascular status of implant is inadequate.

Purpose/methods: A 72-year-old woman with antineutrophil cytoplasmic antibody-positive vasculitis had a combined detachment of the choroid and retina. This unique initial manifestation was also associated with systemic and orbital manifestations, including brow ptosis, dacryoadenitis, and pneumonitis., Results/conclusions: This patient underwent vitrectomy for removal of a dense vitreitis and responded well to systemic cyclophosphamide. This case demonstrates that antineutrophil cytoplasmic antibody testing is useful for the diagnosis and treatment of Wegener's granulomatosis and microscopic polyarteritis-associated scleritis. The distinction between these two entities is often difficult to make.

Background: Upper eyelid retraction in Graves disease may cause functional morbidity and aesthetic deformity. Surgery to correct thyroid-related upper eyelid retraction may result in temporal undercorrection with failure to eliminate lateral eyelid retraction, leading in turn to a poor eyelid contour postoperatively., Methods: In 1984, one of the authors developed a new procedure for correcting moderate to severe upper eyelid retraction associated with Graves disease. The surgical technique consists of a Müllerotomy and recession of the levator aponeurosis combined with medial transposition of the lateral horn of the levator aponeurosis. The procedure was performed on 37 patients (72 eyelids). Müller's muscle was used as the spacer to set the eyelid height. Transposition of the levator aponeurosis allowed adjustment of eyelid contour., Results: Thirty patients (58 eyelids) had excellent results, six (13 eyelids) had good results, and one (1 eyelid) had a poor result. No patient required re-operation for asymmetry, unacceptable contour, or malposition. Only one eyelid had significant overcorrection, and only one eyelid had significant undercorrection, requiring further surgery. The most frequent unwanted effects were high eyelid crease (24 eyelids) and residual temporal flare (6 eyelids); however, most of these were seen early in the series before the lateral levator transposition modification was added., Conclusion: This procedure allows successful and simultaneous correction of both eyelid position and contour in patients with moderate to severe thyroid-related upper eyelid retraction.

Arteriovenous malformations (AVMs) of the orbit are progressively enlarging communications between arteries and veins that bypass normal capillary beds. In contrast to arteriovenous fistulas (AVFs), AVMs are congenital lesions with multiple large feeding arteries, a central nidus, and numerous dilated draining veins. Management of AVMs of the orbit may be difficult due to the threat of hemorrhage, vascular occlusion during treatment, and collateral damage to surrounding organs. We managed AVM of the orbit and periorbital tissues in four patients. Neuroimaging studies, clinical decision making, operative experience, and long-term postoperative results were retrospectively reviewed. Four cases of AVM of the orbit and periorbital tissues were successfully treated with preoperative embolization and subsequent excision of the central nidus of the AVM. There was no evidence of recurrence in any of the cases over follow up ranging from 2 to 5 years. We conclude that identification of all arterial feeders, from both internal and external carotid systems, is critical in developing a therapeutic plan. AVMs may be treated by surgical excision alone, or embolization alone. However, in the hands of an experienced interventional neuroradiologist and an appropriately chosen surgical team, most AVMs can and should be treated by a combined approach of preoperative embolization followed by surgical excision of the vascular mass. The goal of therapy is closure of the low-resistance shunt.

Background: There has been growing interest in using porous alloplastic implants for reconstructive orbital surgery because of their perceived increased biocompatibility. One commercially available porous implant is high-density porous polyethylene (Medpor). It is made of pure particles of polyethylene that form interconnecting pores and have excellent handling characteristics., Methods: The authors performed 37 orbital reconstructions using 0.85-, 1.5-, or 3-mm porous polyethylene sheets to reconstruct internal orbital defects. Mean postoperative follow-up was 18.5 months. Four patients were treated for anophthalmic enophthalmos; there was one patient with spontaneous enophthalmos. In selected patients, other implants also were used, including miniplates or microplates, silastic sheets, autologous bone, or nasal septal cartilage. In patients with enophthalmos, the implants were stacked to reverse the malposition evident at surgery., Results: Preoperatively, 27 patients had symptomatic diplopia. Postoperatively, the diplopia resolved in 15 patients and decreased in 7. No patients had induced diplopia or exacerbation of preoperative diplopia. Enophthalmos resolved in 9 of 18 patients. Hypoglobus was normalized in nine of nine patients. There was one major complication of orbital infection requiring explantation 1 week postoperatively. Minor complications included undercorrection, a symptomatically palpable implant, and transient postoperative chemosis., Conclusion: Porous polyethylene sheets offer several distinct advantages when used for orbital reconstruction. They are easy to handle, shape, contour, position, fixate, and use with other autogenous and alloplastic implants. In this series, these sheets permitted predictable, stable results with few complications.