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Objective The management of advanced basal cell carcinoma (BCC) in the periocular region remains a clinical challenge. Vismodegib (ErivedgeTM) has been approved in 2013 by Health Canada for adult patients with “histologically confirmed metastatic BCC or locally advanced BCC inappropriate for surgery or radiation.” An expert consensus was sought to create a standardised approach in the use of this novel treatment. Methods Fourteen practicing oculoplastic surgeons across Canada were involved in formulating and reviewing guidelines until consensus was reached. A consultancy meeting was followed by further ratification of guidelines over email. Two voting surveys were performed of the group to objectively assess agreement over each statement within the guidelines. Ratification continued until at least two-thirds of the group agreed on every guideline statement. Results The guidelines summarize 21 statements in a major and minor criteria format. A multidisciplinary team review is suggested for each patient with the involvement of recommended specialists. The internal survey revealed 100% agreement over 9 statements, 91.7% agreement over 8 statements, 83.3% agreement over 4 statements, and 2 statements had 66.7% and 58.7% agreement each. All statements with less than 91.7% agreement were surveyed again, and they were kept, modified, or removed on the basis of a consensus of over 66.7%. Conclusions These guidelines serve to act as a framework for physicians considering vismodegib for the medical management of patients with advanced or metastatic periocular BCC. Future applications, including neoadjuvant uses of the drug, may become apparent through further research.

Study Design Case Report. Objective Paranasal osteomas are rare, benign bony tumors of the craniofacial skeleton and most are treated endoscopically without the need for reconstruction. In rare cases, open traditional craniofacial approaches are required with a paucity of literature describing extirpative maneuvers in this setting. We present a unique case of a rapidly growing, paranasal bony tumor in a pediatric patient and describe our surgical technique for resection and reconstruction. Methods A 13-year old male presented with eight months of progressive, painless right periorbital swelling and proptosis. Trans-nasal biopsy confirmed an osteoma of the right ethmoid sinus and endoscopic resection was recommended. Due to interval tumor growth, there was worsening visual acuity that precluded a minimally invasive approach. Pre-operative and post-operative 3D computed tomography (CT) scans were completed, and a 3D printed skull model was produced to aid in surgical planning. A multi-disciplinary team of Otolaryngology, Neurosurgery, and Plastic Surgery was employed. The majority of the extirpation was performed with a highspeed carbide burr. Results Post-operative course was unremarkable and CT scan demonstrated a complete resection. Pathology confirmed the diagnosis of an osteoma. Six-month follow-up demonstrated normal ophthalmologic function and visual acuity with excellent aesthetic results. Conclusions This is a rare, complex presentation of a paranasal osteoma that was successfully managed with an open, multi-disciplinary approach. We highlight pearls gleaned from this extirpative and reconstructive technique. Due to the tumor density and location, a multidisciplinary team, Stealth navigation, an open, intra- and extra-cranial approach and use of a highspeed carbide burr were essential.

Histiocytic Sarcoma is a rare malignant hematopoietic neoplasm that can present in extranodal sites including lymph nodes, skin, gastrointestinal tract, and the central nervous system. Only 10% of cases manifest as skin lesions and very few are reported in the head and neck. The authors report a case of histiocytic sarcoma of the eyelid in a 72-year-old male that was clinically diagnosed as a chalazion. Initial excision was not sent for routine histopathological assessment and the patient was subsequently lost to follow up. Recurrence occurred at the eyelid site and additional lesions were found on the forearms, abdomen, and right knee. Histopathological assessment of one of these other sites confirmed the diagnosis of histiocytic sarcoma. To our knowledge, this is the first reported case of disseminated histiocytic sarcoma that originally presented in the ocular adnexa (eyelid). And, as the initial lesion was not sent to Pathology and therefore potentially missed, this case highlights the importance of submitting tissue, including chalazia, for pathologic evaluation. Keywords: Histiocytic sarcoma, Chalazion, Immunohistochemistry, Diagnosis

PURPOSE To report the efficacy of intravenous mannitol in the treatment of orbital compartment syndrome. METHODS An experimental study was conducted on 4 nonhuman primates (8 orbits). Orbital compartment syndrome was simulated by injecting autologous blood into both orbits of each nonhuman primate until a pressure of 80 mm Hg was reached (time 0). After 10 minutes, nonhuman primates were randomized to receive an infusion of either mannitol or saline, given over 15 minutes. Five minutes after the infusion was complete, lateral canthotomy and cantholysis was performed on both orbits in isolated steps every 5 minutes. During the study protocol, orbital and intraocular pressures were recorded every 5 minutes, with a final set of measurements at 60 minutes. The primary outcome measures were the mean change in pressure from time 0 to 60 minutes, as well as the mean change in pressure during the infusion period. RESULTS There was no statistically significant difference in the mean changes in orbital or intraocular pressure from time 0 to 60 minutes of the protocol. However, during the infusion period there was significantly greater decrease in both orbital and intraocular pressure in the mannitol compared with saline group (-34.0 vs. -9.3 mm Hg for orbital pressure [p = 0.03]; -34.8 vs. -9.7 mm Hg for intraocular pressure [p = 0.04]). CONCLUSIONS While the definitive treatment of orbital compartment syndrome is lateral canthotomy and cantholysis, mannitol results in a rapid and clinically meaningful drop in orbital and intraocular pressure. The authors believe that their data support the routine use of mannitol in orbital compartment syndrome, especially when there is a delay in timely surgical management.

To evaluate a novel, simple, noninvasive method (known as the "bitter taste test") of establishing nasolacrimal duct patency in healthy asymptomatic eyes.Double-blind, randomized controlled pilot study.Healthy asymptomatic medical students, residents, and allied health staff at our institution.Participants, aged 18-35 years (n = 28) with assumed normal lacrimal function, were randomized to the interventional group (100 parts per million denatonium benzoate in sterile water, n = 14) or to the control group (sterile water only, n = 14). All participants were pretreated with topical tetracaine in their right conjunctival cul-de sac, followed by 3 drops of the experimental solution spaced 1 minute apart. The primary outcome was whether participants reported a strong, persistent bitter taste. The secondary outcome was the time-to-taste. All participants received lacrimal irrigation. The Fisher's exact test was done using GraphPad online software.All participants in the interventional group reported the presence of the bitter solution. None of the participants in the control group reported bitterness (p0.001, Fisher's exact test). Time-to-taste was within 15 minutes for 71% of the intervention group (n = 10); within 30 minutes for 79% (n = 11); and within 2 hours for 100% (n = 14). The bitterness typically persisted for 1-2 hours. All participants had normal lacrimal systems to irrigation. No adverse events were reported.The bitter taste test demonstrates a promising ability to assess nasolacrimal duct patency under physiologic conditions in healthy participants. Further research is needed to validate this method in a clinical sample of patients with nasolacrimal duct obstruction.

PURPOSE To assess the efficacy of recti muscle fixation with 2-ocetyl-cyanoacrylate tissue glue to porous orbital implants in human subjects undergoing enucleation. METHODS This was a prospective interventional study with a historical control group. Over a 1-year period, patients who received orbital implant fixation using 2-ocetyl-cyanoacrylate tissue glue were enrolled in the study. Functional assessment was carried out by measurement of implant motility at the 6-month postoperative period, which was compared with a historical control group of patients with sutured implants. Structural assessment was carried out with a random sample of orbital MRIs. RESULTS Twelve patients received the glue-fixation technique. There were no intraoperative or immediate postoperative complications. There was no statistically significant difference between the glued and sutured groups' horizontal implant movement (7.0 mm ± 1.5 mm vs. 6.8 mm ± 1.8 mm, respectively; p = 0.85) or vertical implant movement (5.6 mm ± 1.7 mm vs. 5.0 mm ± 1.4 mm, respectively; p = 0.39). Sample orbital MRI demonstrated good muscle approximation to the implants as well as contrast enhancement suggestive of successful fibrovascular proliferation. CONCLUSIONS Recti muscle fixation using 2-ocetyl-cyanoacrylate tissue glue to porous orbital implants appeared safe and produced good functional and structural results in this proof-of-concept study. This novel technique of implant fixation may offer benefits in terms of reduced operating room time and cost savings.

Introduction: Orbital compartment syndrome may rarely occur in the setting of burns where therapy includes aggressive fluid resuscitation.Case: We report a case of bilateral orbital compartment syndrome in a 13-year-old male, with superficial facial burns secondary to hydrobromic acid, who did not receive aggressive fluid resuscitation. The patient was treated successfully with bilateral lateral canthotomy and cantholysis.Comment: Facial burns may lead to orbital compartment syndrome without aggressive fluid resuscitation, likely due to excessive leakage of fluid and protein into the orbit combined with an inflammatory reaction.

Purpose To evaluate the efficacy of prophylactic administration of the topical nonsteroidal antiinflammatory drug (NSAID) ketorolac tromethamine 0.5% on acute (within 4 weeks of surgery) cystoid macular edema (CME) and total macular volume (TMV) in patients having phacoemulsification cataract surgery. Setting Department of Ophthalmology, Queen's University, Hotel Dieu Hospital, Kingston, Ontario, Canada. Methods This open-label nonmasked randomized (random number assignment) study comprised 106 eyes of 98 patients. Exclusion criteria included hypersensitivity to the NSAID drug class, aspirin/NSAID-induced asthma, and pregnancy in the third trimester. Ketorolac tromethamine 0.5% was administered starting 2 days before surgery and for 29 days after surgery for a total of 31 days. The outcome measure was macular swelling, which was quantified by the optical coherence tomography. Results At 1 month, there was a statistically significant difference in TMV between the control group (0.4420 mm 3 ) and the ketorolac group (0.2392 mm 3 ), with the ketorolac group having 45.8% less macular swelling ( P = .009). Multiple linear regression with backward selection indicated a 44.3% ( P = .013) and 46.1% ( P = .030) reduction in macular swelling in the ketorolac group at 1 week and 1 month, respectively. Conclusion Used prophylactically after cataract surgery, ketorolac 0.5% was efficacious in decreasing postoperative macular edema.

To determine features of eyelid lesions most predictive of malignancy, and to design a key to assist general practitioners in the triaging of such lesions.Prospective observational study.Department of Ophthalmology at Queen’s University in Kingston, Ont.A total of 199 consecutive periocular lesions requiring biopsy or excision were included.First, potential features suggestive of malignancy for eyelid lesions were identified based on a survey sent to Canadian oculoplastic surgeons. The sensitivity, specificity, and odds ratios (ORs) of these features were then determined using 199 consecutive photographed eyelid lesions of patients who presented to the Department of Ophthalmology and underwent biopsy or excision. A triage key was then created based on the features with the highest ORs, and it was pilot-tested by a group of medical students.Of the 199 lesions included, 161 (80.9%) were benign and 38 (19.1%) were malignant. The 3 features with the highest ORs in predicting malignancy were infiltration (OR = 18.2, P.01), ulceration (OR = 14.7, P.01), and loss of eyelashes (OR = 6.0, P.01). The acronym LUI (loss of eyelashes, ulceration, infiltration) was created to assist in memory recall. After watching a video describing the LUI triage key, the mean total score of a group of medical students for correctly identifying malignant lesions increased from 46% to 70% (P.001).Differentiating benign from malignant eyelid lesions can be difficult even for experienced physicians. The LUI triage key provides physicians with an evidence-based, easy-to-remember system for assisting in the triaging of these lesions.

Pseudoretraction of the contralateral upper eyelid has long been recognized as a clinical phenomenon in certain patients with unilateral ptosis. In this prospective study of 30 patients with ptosis, we used two commonly used tests for pseudoretraction, the digital "lift" and "closure" tests. We also describe two new adaptations, the "lift and release" and "closure and release," which enhance these basic tests. The incidence of pseudoretraction in unilateral ptosis was found to be 66.7% and the test with the highest positive yield was the "closure test" (66.7%). The use of clinical tests for pseudoretraction, including the "release" maneuvers, are recommended as part of routine preoperative assessment of blepharoptosis.

We present a modification of the Tessier or orbitonasojugal flap for use in upper eyelid reconstruction. It is suitable for repairing full-thickness defects involving 60% or more of the lid margin and has the advantage of being a one-step procedure.

Background: The Hertel exophthalmometer is the most widely used instrument for the measurement of globe malposition, but an absent or damaged lateral orbital rim will preclude its application. To circumvent this shortcoming, the authors have developed a fixation adapter that attaches to a standard Hertel instrument and transfers fixation to the forehead and nasion from the lateral orbit. Methods: The adapter design is presented and discussed, along with illustrative clinical cases. A study of 30 healthy patients was performed to assess the validity of the adapter with respect to the Hertel standard. The agreement was then evaluated by comparing the Hertel adapter measurements from each patient with that of the adapter. A Wilcoxon statistic was performed to assess differences in the paired values from each patient for both techniques. Results: Analysis on a sample (n = 30) of a healthy adult population does not show a statistical difference between the Hertel adapter and the adapter data ( P > 0.05). In addition, more than 90% of the differences fall within ±1 mm (standard deviation=1.02 mm) of the means for both eyes, which is within the accepted variance for the Hertel instrument. Conclusion: The new fixation adapter promises to become useful in assessing trauma and surgical cases where the lateral orbital rim has been violated and will expand the application of Hertel exophthalmometry to these situations.

Avulsion of the common canaliculus from its attachment to the lacrimal sac should be suspected in cases involving either deep lacerations on the lateral side of the nose or traumatic telecanthus in midfacial trauma. Blunting of the canalicular angle and founding of the inner canthus are confirming signs. A canaliculodacryocystorhinostomy can be performed to reanastomize the lacrimal drainage pathways and relieve epiphora.

Satellite imagery produced by line scanners and vidicon cameras is radio-transmitted to ground stations and photoreproduced in computer controlled electron- or laser-beam devices. In mapping applications, the geometric distortion of images which inevitably results from these operations can be corrected by a polynomial transformation. A modification of its analytical formulation, which increases the solution efficiency is tested. It is found that the computation time can be significantly reduced and the accuracy of the solution improved.

• Goldmann's chronoscopy, a form of time-based photogrammetry of the optic disc, can be accomplished by repeated simultaneous stereophotography. The variations in centration and image orientation are nulled by azimuthal rotation and fusion of two pairs of stereophotographs taken at separate times.