Search

To investigate and quantitatively analyze preoperative and postoperative photographs posted on social media by oculoplastic surgeons.Pre- and postoperative blepharoplasty photographs posted by oculoplastic surgeons on the social media platform Instagram were identified over a 4-month period. Photographs demonstrating a frontal pose of the periocular region were selected, and image analysis was performed to compare the preoperative and postoperative photographs. Quantitative image analysis was performed with a semiautomated script using ImageJ (v1.52k) software. Image analysis compared magnification, patient position, luminosity, relative color profiles, and edge detection/sharpness. Three oculoplastic surgeons graded these imaging metrics for the same photoset and the consensus grade was assigned to each category. Finally, the quantitative calculations were then compared with the consensus grades to develop receiver operating characteristic curves for further analysis.The study included 104 posts from 35 members of ASOPRS. Regarding patient positioning, 9 postings were 5%-10% offset from the patients' center, and 6 postings were more than 10% from the patients' center. The majority of photosets demonstrated less than or equal to 2.5% difference in magnification (69/104), with 7 postings demonstrating a greater than 5% difference, and 3 postings exhibiting greater than 10% difference in magnification. In the periocular region, 17.3% (18/104) of postings were found to have a greater than 10% difference in luminosity (25.5 pixel-value). A more than 5% difference (12.75 pixel-value) in pre- and postoperative edge-detection measurements was identified in 12 of 104 postings. In 22 of 104 photosets, the mean absolute deviation in color channel ratios was more than 0.01 and 15 of 104 photosets were found to have a mean absolute deviation more than 0.05.Numerous quantifiable photographic inconsistencies were identified in surgical photographs posted on social media by members of ASOPRS. Adoption of an automated image analysis tool that compares before-and-after surgical photographs could promote standardized oculoplastic surgery photography on social media.

In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen.This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events.The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS (P0.01) and reduction in ocular motility restriction (P0.01) were maintained during interruption.Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

Purpose: To report the influence of unilateral upper eyelid retraction repair on the upper eyelid position of the contralateral, non-operative side.Methods: An IRB-approved retrospective chart review was performed to identify patients who underwent unilateral upper eyelid retraction repair. Patient demographics, etiology of upper eyelid retraction, previous surgeries, and periocular measurements from pre-operative and follow-up visits were reviewed.Results: Thirteen patients who underwent unilateral upper eyelid retraction repair due to thyroid eye disease or iatrogenic retraction secondary to ptosis repair demonstrated an elevation in contralateral eyelid height post-operatively. The mean pre-operative MRD-1 was 6.6 mm in the operative eye and 2.6 mm in the contralateral eye. All patients demonstrated a decreased MRD-1 in the operative eye (mean change: -2.6 mm [-38.4%]; standard deviation [SD]: 1.2 mm) and an increased MRD-1 in the contralateral eye (mean change: +1.3 mm [+62.4%]; SD: 0.6 mm) following unilateral upper eyelid retraction repair. The mean post-operative MRD-1 measurements were 4.0 mm ± 0.5 mm and 3.9 mm ± 0.6 mm in the operative and contralateral eyes, respectively.Conclusions: Unilateral upper eyelid retraction repair may induce an elevation of the contralateral upper eyelid position in some patients. The findings in this report may support unilateral intervention in patients with upper lid retraction, especially in the setting of contralateral blepharoptosis.

This retrospective study was performed to examine surgical results of five different techniques for lower eyelid margin reconstruction after Mohs surgery: primary closure, semicircular flap, dermal matrix graft, sliding tarsal flap, and tarsoconjunctival flap.Medical records were reviewed in 178 patients undergoing surgery between 2005 and 2020. Outcomes were evaluated (photographic review) by three oculoplastic observers masked to procedure type, both with and without knowledge of the eyelid defect.All patients achieved a good-excellent functional result and 90.4% were asymptomatic after surgery. Tarsoconjunctival flaps were associated with greater need for subsequent interventions (All patients achieved a good-excellent functional result and 87.1% a good-excellent cosmetic result. The semicircular flap was effective for repairing medium sized wounds that could not be closed primarily, creating a continuous lash line, although with a higher incidence of lateral canthal deformities. The sliding tarsal flap was effective for shallow wounds of varying widths. The single-staged dermal matrix graft provided similar results as the tarsoconjunctival flap. Subsequent interventions were more frequent after the tarsoconjunctival flap than other methods.

To describe a unique ocular presentation of Cat Eye Syndrome and review the ocular and systemic findings associated with the syndrome.Case report with multimodal imaging.A newborn female presented with a unilateral Peters anomaly with contralateral microphthalmia with cyst. The patient's other systemic findings included a hypoplastic right heart, persistent ductus arteriosus, intrauterine growth retardation, bilateral anotia, preauricular ear pits and skin tags, micrognathia, hypoplastic female genitalia, and unilateral cranial nerve VII palsy. Chromosomal microarray testing showed tetrasomy of chromosome 22 in the q11.1-q11.21 region consistent with Cat Eye Syndrome. The patient ultimately underwent a successful optical iridectomy on one side and orbitotomy with excision of the cystic mass on the other.The co-occurrence of unilateral Peters anomaly with contralateral microphthalmia with cyst in Cat Eye Syndrome is rare and demonstrative of the syndrome's phenotypic variability. The medical and surgical management of these patients may require a multidisciplinary approach and must be tailored to the individual findings and overall systemic health of the patient.

Purpose Well-differentiated neuroendocrine or carcinoid tumors are found most commonly in the gastrointestinal tract. When metastatic to the orbit, they tend to have a propensity for the extraocular muscles. The purpose of this study was to better understand the diversity in presentation of orbital carcinoid disease and to determine predictors for survival. Methods In this observational cross-sectional cohort study, data from 8 tertiary orbital practices were compiled. Demographic, clinical, pathologic, American Joint Committee on Cancer stage and grade, imaging, and management data were extracted for all the patients. Descriptive statistics were calculated. Subgroups were compared utilizing analysis of variance analyses and Kaplan-Meier curves. Time to progression and disease-specific and overall mortality were calculated. Comparisons were performed for the following a priori pairs: unknown versus known primary tumor, single versus multiple extraocular muscle involvement, unilateral versus bilateral orbital disease, extraocular muscle versus other orbital involvement, and excisional versus incisional surgery. Results A total of 28 patients with carcinoid tumors of the orbit were identified. Of these, 57.1% of patients were female, the mean age at diagnosis of the primary tumor was 58.8 years and the mean age at diagnosis of orbital disease was 62.6 years. At primary presentation, all patients were American Joint Committee on Cancer stage III or IV and 21.4% demonstrated carcinoid syndrome. Muscle involvement was noted in 78.6% of patients, and of these, 72% were noted to have single muscle disease. Eight patients had no primary tumor identified; 3 of these 8 demonstrated disseminated disease at the time of diagnosis. The overall 5-year survival rate was 81.8% from diagnosis of primary tumor and 50% from diagnosis of orbital disease. Subgroup analysis revealed that patients with unilateral orbital disease when compared with bilateral orbital disease had a longer progression-free survival and time to death from all causes (p = 0.025). Patients with disease localized to the orbit at presentation had longer time to death than those with disseminated disease. Treatment with surgery, radiation, or octreotide did not appear to affect survival. Patients managed with systemic chemotherapy had a shorter time of survival than the rest of the group. All other subgroup comparisons were not found to be statistically significant. Conclusions Neuroendocrine tumors of the orbit represent a wide spectrum of disease, with some cases being part of disseminated disease, while others being localized presentations. This heterogeneity may be responsible for the slightly higher overall survival in these patients than others with metastatic carcinoid tumors in other locations.

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a rare, low-grade adnexal neoplasm with predilection for the periorbital skin of older women. Histologically and immunophenotypically, EMPSGC is analogous to another neoplasm with neuroendocrine differentiation, solid papillary carcinoma of the breast. Both lesions are spatially associated with neuroendocrine mucinous adenocarcinomas of the skin and breast, respectively. EMPSGC is ostensibly a precursor of neuroendocrine-type mucinous sweat gland adenocarcinoma (MSC), a lesion of uncertain prognosis. Non-neuroendocrine MSC has been deemed locally aggressive with metastatic potential, and previous works speculated that EMPSGC-associated (neuroendocrine-type) MSC had similar recurrence and metastatic potential with implications for patient follow-up. Only 96 cases of EMPSGC have been reported (12 cases in the largest case series). Herein, we present 63 cases diagnosed as "EMPSGC" in comparison with aggregated results from known published EMPSGC cases. We aim to clarify the clinicopathologic features and prognostic significance of the neuroendocrine differentiation of EMPSGC and its associated adenocarcinoma and to determine the nosological relevance of EMPSGC association in the spectrum of MSC histopathogenesis. Results established an overall female predominance (66.7%) and average presenting age of 64 years. EMPSGC lesions were associated with adjacent MSC in 33.3% of cases. The recurrence rate for neuroendocrine-type MSC was ~21%, less than the reported 30% for non-neuroendocrine MSC. There were no cases of metastasis. EMPSGC and neuroendocrine-type MSC are distinct entities with more indolent behavior than previously reported, supporting a favorable prognosis for patients.

Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED).Methods: A multi-center retrospective case series of patients with TED who develope...

Purpose Piezosurgical tools utilize high-frequency ultrasonic oscillations to selectively cut mineralized bone and minimize damage to soft tissue and mucosa. The purpose of this study was to directly compare outcomes in external dacryocystorhinostomy (DCR) using a piezoelectric ultrasonic bone aspirator (UBA) versus a high-speed electric drill with a diamond burr. Methods A retrospective chart review was conducted on 145 consecutive patients who underwent external DCR by a single oculoplastic surgeon between 2012 and 2017. Collected data included baseline patient characteristics, presenting symptoms, operative details and complications, and postoperative symptoms. Results One hundred and seventy-three primary external DCRs performed on 145 patients were included in this study. In total, 61.3% of cases were performed with the UBA and 38.7% with the high-speed drill. Most patients were white (92.4%) and female (67.6%), with a mean age of 57.6 years (range 1-93). Surgical success was achieved in 94.3% of patients in the UBA group and 94.0% in the drill group, with no significant differences between the two arms (p=0.36). Patients who experienced persistent nasolacrimal duct obstruction after surgery underwent endoscopic revision. Operative time was shortened for cases utilizing the UBA (38.9 mins) instead of the high-speed drill (44.7 mins; p=0.01). No significant intraoperative complications occurred in either group. Conclusion The UBA offers comparable outcomes and complication rates to more conventional surgical tools for external DCR. Excellent outcomes, ease of adoption, and potential surgical time savings make the UBA an appealing option for both novice and experienced surgeons.

Purpose: To describe the demographic and clinical characteristics of patients with thyroid eye disease (TED) who present with predominate superior rectus/levator complex involvement.Methods...

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

Purpose Periocular inverted papilloma (IP) is a rare, locally aggressive tumor with a propensity for recurrence and malignant transformation. Historically treated via wide excision, this study examines the characteristics and management of periocular IP, comparing those confined to the nasolacrimal system with those invading the orbit. Methods An Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective, comparative case series was conducted in patients with IP of the orbit or nasolacrimal system across 15 clinical sites. Results Of 25 patients, 22 met inclusion criteria with 9 limited to the nasolacrimal system and 13 invading the orbit. Mean age was 60.4 years, 55% were women, all were unilateral. Mean follow-up was 48 months. Rates of smoking, dust and/or aerosol exposure, human papillomavirus (HPV) status, and inflammatory polyps were elevated compared to rates in the general population (45%, 18%, 18%, and 14%, respectively). Bony erosion on computed tomography scans was statistically significantly associated with orbit-invading IP (p = 0.002). Treatment involved all confined IP undergoing surgery alone while 39% of orbit-invading IP also received radiation therapy and/or chemotherapy (p = 0.054). Orbit-invading IP was more likely to be excised with wide margins than IP confined to the nasolacrimal system (85% vs. 22%, p = 0.007). Overall rates of malignancy, recurrence, and patient mortality from IP were found to be 27%, 23%, and 9%, respectively. Conclusions IP invading the orbit typically requires aggressive therapy, while IP confined to the nasolacrimal system may be treated more conservatively. Using risk factors, characteristics, and outcomes, a treatment algorithm was created to guide management.

Medical therapy is the mainstay of initial treatment for periocular xanthogranulomas. Here we depict surgical management of biopsy-proven adult-onset asthma and periocular xanthogranuloma (AAPOX). This 27-year-old female presented with seven years of progressive bilateral periorbital swelling, weight gain, and severe asthma refractory to immunosuppressive therapy including methotrexate, rituximab, and cyclophosphamide. Pre-operative and post-operative photos show excellent resolution of lesions. Orbitotomy with excision involved an upper eyelid crease incision marked at 9 mm centrally. A flap was dissected between the skin and orbicularis-involving xanthogranuloma, extended superiorly to orbital rim and laterally and medially until normal orbicularis was encountered. The xanthogranuloma was excised en-bloc. Infiltrated preaponeurotic fat and portions of the orbital lobe of the lacrimal gland were resected. After achieving hemostasis, the skin was closed with 6-0 polypropylene suture. Surgical pathology was consistent with the diagnosis of AAPOX.

Thyroid-associated ophthalmopathy, a condition commonly associated with Graves' disease, remains inadequately treated. Current medical therapies, which primarily consist of glucocorticoids, have limited efficacy and present safety concerns. Inhibition of the insulin-like growth factor I receptor (IGF-IR) is a new therapeutic strategy to attenuate the underlying autoimmune pathogenesis of ophthalmopathy.We conducted a multicenter, double-masked, randomized, placebo-controlled trial to determine the efficacy and safety of teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, in patients with active, moderate-to-severe ophthalmopathy. A total of 88 patients were randomly assigned to receive placebo or active drug administered intravenously once every 3 weeks for a total of eight infusions. The primary end point was the response in the study eye. This response was defined as a reduction of 2 points or more in the Clinical Activity Score (scores range from 0 to 7, with a score of ≥3 indicating active thyroid-associated ophthalmopathy) and a reduction of 2 mm or more in proptosis at week 24. Secondary end points, measured as continuous variables, included proptosis, the Clinical Activity Score, and results on the Graves' ophthalmopathy-specific quality-of-life questionnaire. Adverse events were assessed.In the intention-to-treat population, 29 of 42 patients who received teprotumumab (69%), as compared with 9 of 45 patients who received placebo (20%), had a response at week 24 (P0.001). Therapeutic effects were rapid; at week 6, a total of 18 of 42 patients in the teprotumumab group (43%) and 2 of 45 patients in the placebo group (4%) had a response (P0.001). Differences between the groups increased at subsequent time points. The only drug-related adverse event was hyperglycemia in patients with diabetes; this event was controlled by adjusting medication for diabetes.In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. (Funded by River Vision Development and others; ClinicalTrials.gov number, NCT01868997 .).

In humans, midget and parasol ganglion cells account for most of the input from the eyes to the brain. Yet, how they encode visual information is unknown. Here, we perform large-scale multi-electrode array recordings from retinas of treatment-naive patients who underwent enucleation surgery for choroidal malignant melanomas. We identify robust differences in the function of midget and parasol ganglion cells, consistent asymmetries between their ON and OFF types (that signal light increments and decrements, respectively) and divergence in the function of human versus non-human primate retinas. Our computational analyses reveal that the receptive fields of human midget and parasol ganglion cells divide naturalistic movies into adjacent spatiotemporal frequency domains with equal stimulus power, while the asymmetric response functions of their ON and OFF types simultaneously maximize stimulus coverage and information transmission and minimize metabolic cost. Thus, midget and parasol ganglion cells in the human retina efficiently encode our visual environment.

Drs. Leyngold, Kossler, and Yen have composed a high yield, informative and innovative textbook that provides a comprehensive resource for corneal neurotization. This text explores this hot topic w...

PURPOSE To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation (FaCE) Scale Instrument outcomes when treating hemifacial spasm (HFS) with onabotulinumtoxinA. METHODS An Institutional Review Board-approved retrospective review of records of 66 HFS patients treated with onabotulinumtoxinA. SFGS and FaCE surveys were completed prior to onabotulinumtoxinA therapy and at 1 month follow up. Surveys were analyzed for differences using paired Student t tests, with statistical significance set at p < 0.05. Correlations were determined using Spearman correlation (rs), with coefficients of ≥0.40 or ≤-0.40 considered significant. RESULTS There were 22 complete data sets. SFGS composite score improved from mean, 56.9 (SD, 12.3) to 63.6 (SD, 12.3), p < 0.01. SFGS subdomain synkinesis score significantly improved (p < 0.01). The FaCE scale subdomain oral function significantly worsened (p = 0.05). The Δ pre-/post-SFGS composite score did not correlate with the Δ pre-/post-FaCE composite score (rs = 0.24). There was a significant positive correlation between SFGS composite score and FaCE social function score (rs = 0.462, p = 0.03) and between SFGS voluntary movement score and FaCE social function score (rs = 0.477, p = 0.03). Subgroup analysis of single FaCE questions demonstrated no statistical change in subjective dry eye (p = 0.30). CONCLUSIONS There was an improvement in social functioning in treated HFS patients, which positively correlated with improvement in overall objective voluntary facial movement. There was no statistical difference in subjective dry eye symptoms. The overall SFGS composite score improved following treatment of HFS with botulinum toxin. This information can be used when counseling expected outcomes in HFS patients treated with onabotulinumtoxinA.

BACKGROUND: Corneal denervation can lead to opacification and blindness. A new treatment technique, surgical corneal neurotization, transfers healthy donor nerve, (most commonly contralateral supratrochlear or supraorbital) to the affected limbus to prevent corneal destruction and improve healing potential of the cornea following insult. We examine gross and histomorphometric anatomy of the supratrochlear and supraorbital nerves relevant to their use in corneal neurotization. METHODS: For each of nine adult cadaver heads, bilateral supraorbital and supratrochlear nerves were dissected from the supraorbital rim to the anterior hairline. The following data were recorded for each nerve: exit from the orbit through a notch versus foramen; horizontal distance from midline at the supraorbital rim; and distance from orbital exit to first branching point. Samples of all left supraorbital and supratrochlear nerves were obtained at the level of the supraorbital rim and at points 3 cm and 6 cm distally for histomorphometric analysis. Myelinated axon counts were determined for each sample. RESULTS: Four supraorbital foramina, 14 supraorbital notches, two supratrochlear foramina, and 15 supratrochlear notches were identified. Average supraorbital and supratrochlear distances to midline were 26.5 mm and 21 mm respectively. Average myelinated axon counts for both nerves were greater at the orbital rim (supraorbital: 6018, supratrochlear: 2533) than at 6 cm distally (supraorbital: 1621, supratrochlear: 1112). CONCLUSIONS: Anatomic dissection shows relative close approximation of the supraorbital and supratrochlear nerves, with a high proportion of both nerves exiting the orbit through foramina. The supraorbital nerve at the orbital rim contains the greatest number of myelinated axons.

Purpose Vascular lesions of the orbit, although not malignant, can cause morbidity because of their location near critical structures in the orbit. For the same reason, they can be challenging to remove surgically. Anti-vascular endothelial growth factor (VEGF) drugs are increasingly being used to treat diseases with prominent angiogenesis. Our study aimed to determine to what extent VEGF receptors and their subtypes are expressed on selected vascular lesions of the orbit. Design Retrospective case series of all orbital vascular lesions removed by one of the authors (JAG) at the Mayo Clinic. Participants A total of 52 patients who underwent removal of vascular orbital lesions. Methods The pathology specimens from the patients were retrieved, their pathologic diagnosis was confirmed, demographic and clinical information were gathered, and sections from vascular tumors were stained with vascular endothelial growth factor receptor (VEGFR), vascular endothelial growth factor receptor type 1 (VEGFR1), vascular endothelial growth factor receptor type 2 (VEGFR2), and vascular endothelial growth factor receptor type 3 (VEGFR3). Main Outcome Measures The existence and pattern of staining with VEGF and its subtypes on these lesions. Results There were 28 specimens of venous malformations, 4 capillary hemangiomas, 7 lymphatic malformations, and 6 lymphaticovenous malformations. All samples stained with VEGF, 55% stained with VEGFR1, 98% stained with VEGFR2, and 96% stained with VEGFR3. Most (94%) of the VEGFR2 staining was diffuse. Conclusions Most orbital vascular lesions express VEGF receptors, which may suggest a future target for nonsurgical treatment.

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

We investigated operative course and post-operative findings of patients undergoing primary enucleation for uveal melanoma versus those requiring secondary enucleation after brachytherapy. A retrospective chart review was performed with IRB approval on patients receiving treatment for uveal melanoma. Patients with enucleation as initial treatment and patients enucleated after plaque brachytherapy were analyzed for demographic data, operative course, and post-enucleation outcome. Further cause analysis for secondary enucleations was investigated. No significant difference was seen in age, laterality, or gender between the primarily enucleated (n = 54) and secondarily enucleated (n = 34) groups. Greater difficulty with surgery was noted in 28/32 (87.5%) of secondary enucleations compared to 1/54 (1.8%) of primary enucleations (p0.0001). Operative time was2 hours in 3/51 (6%) of primary enucleations (vs. 8 of 32, 25%, p = 0.02). Average implant size was similar in the 2 groups (20.6 mm), however 2/34 (6%) of secondary enucleations required dermis fat grafting. Post-enucleation anophthalmic ptosis occurred after 8/49 (16%) of primary cases (vs. 13/30, 43%, p = 0.02) and prosthetic enophthalmos after none (0%) of primary cases (vs. 5/30, 17%, p = 0.006). Class 2 gene expression profile was found in 6/8 (60%) of eyes enucleated for treatment failure. Secondary enucleation performed after plaque brachytherapy was technically more difficult, and had more anophthalmic socket and eyelid complications compared to primary enucleation for uveal melanoma. Primary enucleation may avoid additional surgery and morbidity in a subset of patients with contraindications to plaque brachytherapy.

Background/Aims: Our study aims to better characterize the clinical and histopathologic features of eyes with extrascleral uveal melanoma associated with scleral melt following brachytherapy. Methods: A retrospective review was performed on patients who had undergone 125I (iodine-125) brachytherapy for uveal melanoma at our institution between 1992 and 2015. Patients with postradiation scleral necrosis who required enucleation were identified, and an analysis including a review of histopathology results was performed on those cases. Results: A total of 301 patients underwent plaque brachytherapy for uveal melanoma, of whom 31 required eventual enucleation. The histologic analysis showed extraocular extension through full-thickness scleral discontinuities in 6 cases. All but 1 (5 of 6) of these eyes exhibited either mitotic figures or Ki-67 positivity. Mitotic figures were noted in 4 specimens, including 3 eyes exhibiting mitoses within or adjacent to the extrascleral portion of the tumor. Two eyes exhibiting mitoses, as well as the case with Ki-67 positivity, also had clinical evidence of tumor regrowth. Conclusion: We found evidence of mitotic activity at the area of scleral discontinuity in some eyes with and in some without clinical evidence of tumor regrowth. Protruding pigmented material in areas of scleral necrosis after plaque brachytherapy may represent actively proliferating tumors even without internal evidence of tumor regrowth.

Gold hypersensitivity is a cause of periorbital dermatitis that often presents as a diagnostic challenge for many ophthalmologists. Six female patients are described as presenting with isolated bilateral periorbital dermatitis. Main symptoms included itching (3/6), eyelid redness (3/6), and drooping eyelids (3/6) for an average duration of 16.8 months prior to referral. All 6 patients failed conservative management. Recurrence of symptoms necessitated allergic patch testing, revealing a severe hypersensitivity reaction to gold in all cases. By discontinuing contact with gold, specifically gold jewelry, the allergic periorbital dermatitis completely resolved. No patients required surgical intervention for eyelid malposition. Increased awareness of this reversible cause of allergic periorbital dermatitis may improve patient outcomes.

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

Upper lid blepharoplasty is a common procedure for restoration and rejuvenation of the upper eyelids that can be performed safely and reliably. Understanding the anatomy and aging process of the brow-upper lid aesthetic unit along with properly assessing the excesses and deficiencies of the periorbital region helps to formulate an appropriate surgical plan. Volume deficiency in the aging upper lid may require corrective augmentation. Preexisting asymmetries and ptosis need to be identified and discussed before surgery. Standardized photography along with a candid discussion regarding patients' desired outcomes and realistic expectations are essential to a successful outcome.

Upper eyelid ptosis and crease abnormalities can lead to significant cosmetic deformity. An intimate knowledge of the anatomic structures responsible for eyelid height, contour, and pretarsal show will allow precise surgical correction.

PURPOSE The goal of this study is to identify and describe the role of surgical incision preference, insurance reimbursement, and geographical location on the current ptosis repair practice patterns of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members. METHODS A 9-question survey was designed with surveymonkey.com and a participation link was emailed to all active ASOPRS members' email addresses in February 2015. After a reminder email, the survey was closed and the results were analyzed. There are 3 major questions the survey data is to be used answer: 1) Surgical approach preference: The first question established preferred surgical technique (internal vs. external approach) for ptosis repair. This result was/is used to stratify the remaining responses into 2 groups. 2) Functional versus cosmetic surgical indication: Three clinical scenarios were presented for a functional versus cosmetic patient for ptosis repair and blepharoplasty. 3) Location: The responses were analyzed based on location to determine any geographic bias for surgical preference. For this analysis, the US was separated into 4 regions (West, Midwest, North, and South), as defined by the United States Census Bureau; all international respondents were grouped together. RESULTS Three hundred and ten responses were included and analyzed; 61% preferred the internal surgical approach, there was no statistical significance to geographic location (p = 0.17). Surgeons who prefer the external surgical approach (76.1%) were more likely than internal (62.5%) to include a bundled (nonreimbursed) blepharoplasty at no additional charge in the setting of functional ptosis repair (p = 0.015). Treatment plans differed significantly in both groups between functional and cosmetic patients with visually significant ptosis (Margin Reflex Distance < 1.5) and moderate dermatochalasis; with both the internal and external group electing combined surgery at a higher rate in cosmetic patients (p < 0.01 for functional vs. cosmetic within each group, and internal vs. external repair). There was no statistical difference in the timeframe for adjusting external ptosis for functional or cosmetic patients (p = 0.79). More surgeons use nonabsorbable closure for cosmetic blepharoplasty patients (68.7%) than for functional (54.1%) surgery patients (p < 0.01). CONCLUSION Previous studies have documented the immediate effect of Medicare reimbursement changes on the management of concurrent ptosis and dermatochalasis. This study illustrates current practice patterns for ptosis repair and blepharoplasty. The necessity of creating a separate surgical site for surgeons who prefer the internal approach to ptosis surgery to perform a functional blepharoplasty has a significant influence on surgeon's willingness to perform concurrent blepharoplasty as a nonreimbursed bundled procedure.

Objective To evaluate intraoperative changes in the position of the orbicularis muscle edge, which defines the tear trough during lower eyelid blepharoplasty with supraperiosteal fat repositioning. Methods Thirty consecutive patients undergoing transconjunctival lower eyelid blepharoplasty with a supraperiosteal fat repositioning technique underwent intraoperative measurement of the elevation of the released orbicularis muscle edge. Using a “dipstick” method, the distance between the midinferior orbital rim and the inferior orbicularis muscle edge, which was previously located below the orbital rim, was measured after fixation of the repositioned orbital fat. Age, associated procedures, length of follow-up, and complications were noted. Results The released orbicularis muscle edge was elevated between 6 and 12 mm above the orbital rim (average elevation, 8.8 mm). All measurements were within 2 mm between the 2 sides for a given patient, with 24 of the cases being within 1 mm. No apparent difference was seen between the muscle elevation achieved with externalized suture fixation of repositioned fat (22 patients) and that achieved with internal suture fixation (8 patients). Conclusions The orbicularis oculi muscle fusion to the maxilla below the arcus marginalis defines the junction between the eyelid and the cheek, and it provides an anchor for the tear trough. The eyelid-cheek interface is significantly elevated with our surgical technique of fat repositioning in the supraperiosteal plane. Elevation of the orbicularis muscle edge may contribute to improved blepharoplasty results in treating the aging midface.

Vascular lesions of the orbit, although not malignant, can cause morbidity because of their location near critical structures in the orbit. For the same reason, they can be challenging to remove surgically. Anti-vascular endothelial growth factor (VEGF) drugs are increasingly being used to treat diseases with prominent angiogenesis. Our study aimed to determine to what extent VEGF receptors and their subtypes are expressed on selected vascular lesions of the orbit.Retrospective case series of all orbital vascular lesions removed by one of the authors (JAG) at the Mayo Clinic.A total of 52 patients who underwent removal of vascular orbital lesions.The pathology specimens from the patients were retrieved, their pathologic diagnosis was confirmed, demographic and clinical information were gathered, and sections from vascular tumors were stained with vascular endothelial growth factor receptor (VEGFR), vascular endothelial growth factor receptor type 1 (VEGFR1), vascular endothelial growth factor receptor type 2 (VEGFR2), and vascular endothelial growth factor receptor type 3 (VEGFR3).The existence and pattern of staining with VEGF and its subtypes on these lesions.There were 28 specimens of venous malformations, 4 capillary hemangiomas, 7 lymphatic malformations, and 6 lymphaticovenous malformations. All samples stained with VEGF, 55% stained with VEGFR1, 98% stained with VEGFR2, and 96% stained with VEGFR3. Most (94%) of the VEGFR2 staining was diffuse.Most orbital vascular lesions express VEGF receptors, which may suggest a future target for nonsurgical treatment.

Purpose To evaluate subjective outcomes and preferences in patients with benign essential blepharospasm (BEB) treated with both onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin). Methods An institutional review board approved retrospective review of 128 patients treated with onabotulinumtoxinA for BEB by 1 author (J.B.H.). Fifty of these patients were switched to incobotulinumtoxinA as an alternate drug. At scheduled follow up, patients decided to continue with incobotulinumtoxinA or switch to onabotulinumtoxinA. Patient preferences regarding treatment with onabotulinumtoxinA versus incobotulinumtoxinA were recorded. The preference groups were analyzed using unpaired Student t test, with statistical significance set at p Results Of the 50 incobotulinumtoxinA patients, the mean age was 64.9 years; 39 (78%) were women and 11 (22%) were men. In all, 26 (52%) preferred incobotulinumtoxinA and 24 (48%) preferred onabotulinumtoxinA. Most frequently, those who preferred incobotulinumtoxinA believed that it was "more effective" (N = 10, 29%), whereas those who preferred onabotulinumtoxinA concluded that it had a "longer duration" (N = 11, 37%). The mean treatment interval was 13.0 weeks (standard deviation [SD] = 6.39) in those who preferred onabotulinumtoxinA, whereas it was 10.2 weeks (SD = 2.15) in those who preferred incobotulinumtoxinA (p = 0.017). There was no statistical difference when comparing mean disease duration, number of total treatments, and number of units/treatment between the 2 preference groups. Conclusions This study demonstrates that patients who prefer incobotulinumtoxinA over onabotulinumtoxinA had a statistically significant shorter treatment interval. In addition, those who preferred incobotulinumtoxinA thought it was more effective, whereas those patients who preferred onabotulinumtoxinA thought it had a longer duration. This information can be used when counseling both newly diagnosed and long-standing BEB patients regarding their therapeutic options.

Purpose To report the success rate of endoscopically assisted balloon dacryoplasty (EADCP) for treatment of acquired incomplete nasolacrimal duct obstructions (NLDOs). Design Retrospective, noncomparative case series. Participants Records of patients treated for incomplete NLDOs with EADCP by one of the authors (WLW) were reviewed. Diagnosis of incomplete NLDO was based upon subjective complaints of tearing, dye disappearance testing, clinical evidence of epiphora, and nasolacrimal duct irrigation. Endoscopically assisted balloon dacryoplasty was performed for incomplete obstructions identified. Methods One hundred forty-two nasolacrimal systems in 103 patients with incomplete NLDOs underwent EADCP for treatment of incomplete obstructions. A 3×15-mm balloon was utilized in all procedures, with silicone lacrimal tubes placed in 131 systems. Patients received postoperative topical antibiotic–steroid drops for 2 weeks and a 1-week tapering dosage of systemic methylprednisolone. Main outcome measures Patients were assessed at their last postoperative visit by nasolacrimal system irrigation, dye disappearance testing, and subjective complaints of epiphora. Results Eighty systems (56%) experienced complete resolution of symptoms after surgery. Forty-eight additional systems (34%) showed improvement but still experienced periodic epiphora. Fourteen systems (10%) showed no improvement. The average time before follow-up was 7.5 months. Conclusion Endoscopically assisted balloon dacryoplasty as a treatment for incomplete NLDOs provides complete relief or substantial improvement in a significant percentage of patients. Nasal videoendoscopy adds significantly to the understanding of this procedure and its potential for success. Endoscopically assisted balloon dacryoplasty should be considered an appropriate treatment option for selected patients with incomplete NLDOs.

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

Botulinum toxin therapy is commonly used for cosmetic treatment of glabellar, forehead, lateral periocular, and other facial rhytids. Many providers have familiarity with onobotulinum toxin A (Botox®) and are accustomed to the dosing, diffusion, onset, and duration of action. Patients also commonly refer to all botulinum toxins as “Botulinum toxin” and are not familiar with other variations of the toxin. While some patients are loyal to Botulinum toxin either from past use, patient recommendation, or even media, many patients would like to try other similar medications including incobotulinum toxin A (Xeomin®) and abobotulinum toxin A (Dysport®); this chapter will focus on the former.

PURPOSE To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation Scale (FaCE Scale) instrument outcome measures pre- and 30-day posttreatment of facial nerve synkinesis with botulinum toxin with attempts to correlate the 2 scales. METHODS An IRB approved retrospective review of 22 patients with facial nerve synkinesis where the surgeon completed the SFGS and the patient completed the FaCE prior to receiving onabotulinumtoxinA therapy, the SFGS, and FaCE scales were completed again 1 month later. RESULTS Of the 22 patients, 9 complete datasets were analyzed. Mean patient age was 59.8; 8 (89%) women and 1 (11%) men. Overall SFGS composite score decreased from 57.6 ± 20.9 to 45.2 ± 13.5, (p = 0.001). SFGS subdomain synkinesis significantly improved (p < 0.001), while voluntary movement significantly decreased (p = 0.002). A difference in the resting symmetry was not statistically significant (p = 0.08). The FaCE scale composite score significantly improved from 40.9 ± 9.5 to 47.6 ± 11.9, (p = 0.03). FaCE subdomains facial comfort (p = 0.005) and social function (p = 0.009) significantly improved, while oral function, eye comfort, facial movement, and lacrimal control did not. The Δ pre/post-SFGS composite score did not correlate with the Δ pre/post-FaCE composite score (rs= -0.318). Subdomain analysis demonstrated significant negative correlation between Δ pre/post-SFGS synkinesis score and Δ pre/post-FaCE eye comfort score (rs = -0.826, p < 0.01). CONCLUSIONS Significant improvement was seen in objectively reported synkinesis following botulinum toxin therapy. An improvement was noted in the overall subjective facial nerve functioning following therapy along with improvement in social functioning and facial comfort. A meaningful negative correlation was noted when comparing the SFGS "synkinesis" subdomain with the FaCE scale subdomain "eye comfort", implying improvement in eye comfort with control of synkinesis.

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