Search

Samuel A Cohen,1 Nikhita Yadlapalli,2 Jonathan D Tijerina,3 Chrisfouad R Alabiad,3 Jessica R Chang,4 Benyam Kinde,5 Nicholas R Mahoney,6 Kelsey A Roelofs,1 Julie A Woodward,7 Andrea L Kossler5 1Department of Ophthalmology, Stein Eye Institute at University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA; 2Department of Ophthalmology, FIU Herbert Wertheim College of Medicine, Miami, FL, USA; 3Department of Ophthalmology, Bascom Palmer Eye Institute at University of Miami Miller School of Medicine, Miami, FL, USA; 4Department of Ophthalmology, USC Roski Eye Institute at University of Southern California Keck School of Medicine, Los Angeles, CA, USA; 5Department of Ophthalmology, Byers Eye Institute at Stanford University School of Medicine, Palo Alto, CA, USA; 6Department of Ophthalmology, Wilmer Eye Institute at Johns Hopkins University School of Medicine, Baltimore, MD, USA; 7Department of Ophthalmology, Duke Eye Center at Duke University School of Medicine, Durham, NC, USACorrespondence: Andrea L Kossler, Department of Ophthalmology, Byers Eye Institute at Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, USA, Email akossler@stanford.eduPurpose: To compare the accuracy and readability of responses to oculoplastics patient questions provided by Google and ChatGPT. Additionally, to assess the ability of ChatGPT to create customized patient education materials.Methods: We executed a Google search to identify the 3 most frequently asked patient questions (FAQs) related to 10 oculoplastics conditions. FAQs were entered into both the Google search engine and the ChatGPT tool and responses were recorded. Responses were graded for readability using five validated readability indices and for accuracy by six oculoplastics surgeons. ChatGPT was instructed to create patient education materials at various reading levels for 8 oculoplastics procedures. The accuracy and readability of ChatGPT-generated procedural explanations were assessed.Results: ChatGPT responses to patient FAQs were written at a significantly higher average grade level than Google responses (grade 15.6 vs 10.0, p < 0.001). ChatGPT responses (93% accuracy) were significantly more accurate (p < 0.001) than Google responses (78% accuracy) and were preferred by expert panelists (79%). ChatGPT accurately explained oculoplastics procedures at an above average reading level. When instructed to rewrite patient education materials at a lower reading level, grade level was reduced by approximately 4 (15.7 vs 11.7, respectively, p < 0.001) without sacrificing accuracy.Conclusion: ChatGPT has the potential to provide patients with accurate information regarding their oculoplastics conditions. ChatGPT may also be utilized by oculoplastic surgeons as an accurate tool to provide customizable patient education for patients with varying health literacy. A better understanding of oculoplastics conditions and procedures amongst patients can lead to informed eye care decisions.Keywords: oculoplastics, google, ChatGPT, readability, accuracy

The development of methods for public health surveillance in Medicaid populations is an important goal for public health practice. In Oregon, we developed approaches to case finding using claims and self-reported data obtained from the Medicaid beneficiary population. Disease rosters, derived from claims data, form the basis for analyses pertaining to particular health conditions. Selfreported information obtained through a telephone survey forms the basis for analyses pertaining to behavioral risk factors, disease history, and other information not available in claims data. We also describe some projects in which we plan to use combined claims and survey data. We describe our experiences with using these techniques and provide examples from projects in progress or planned. Our initial experiences suggest that these approaches enhance our ability to conduct public health surveillance in Oregon's Medicaid population. [ABSTRACT FROM AUTHOR]

Recent trends in Oregon indicated that diabetes is on the rise. Medicaid self-reported data estimated about 11 percent are affected by diabetes, which is twice the prevalence of the general population in Oregon. Little is known about the agreement between self-reported information and medical claims data in the Medicaid population. This study provides an opportunity to compare prevalence of diabetes when the estimates are computed from the two different data sources. A sample of 2,154 Medicaid adults in Oregon (18 to 64 years old) were identified in both the Medicaid claims and self-report survey. The result reported a strong agreement of diabetes definition between the Medicaid claim data and the self-reported survey. [ABSTRACT FROM AUTHOR]

Periocular and orbital myiasis are rare, vision-threatening conditions characterized by the infestation of dipterous fly larvae into periorbital and orbital tissues. While it has been primarily reported in tropical and subtropical regions where the climate is ideal for fly larval breeding, any patient with inadequate wound care regardless of geography may be predisposed. Infestations can progress rapidly over the course of several days with significant risk of life-threatening intracranial extension. Despite this, there is a paucity of oculoplastic literature describing protocols to treat periocular and orbital myiasis in the acute setting. Here, the authors present a case of periocular and orbital myiasis seen at the Duke University Hospital in Durham, North Carolina (U.S.A.), and describe a protocol that was effective in the eradication of the infestation without surgical tissue debridement., Competing Interests: JAW is a speaker and consultant for Allergan (Irvine, CA), Galderma (Lausanne, Switzerland), and SkinCeuticals (New York, NY); a speaker for Prollenium (Ontario, Canada); and a consultant for Merz (Frankfurt, Germany) and Tarsus (Irvine, CA). The other authors have no financial disclosures or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Competing Interests: J.A.W. has the following disclosures: Allergan—speaker consultant; Galderma—speaker consultant; Merz—consultant; Prollenium—speaker consultant; SkinCeuticals—speaker consultant; Stroma Medical—investor. S.M.K. has no conflicts of interest to disclose.

Purpose: Non-traumatic orbital hemorrhage without underlying vascular malformations or predisposing conditions is uncommon, and particularly rare in the context of maternal labor. This study combines a novel case report and retrospective review to analyze reported cases and propose insights., Methods: This study is both a unique case report and literature review examining PubMed publications with articles traced back to original sources through citations for inclusion. Analysis included clinical presentation, visual examination, hematoma characteristics, neuroimaging, management strategies, and outcomes., Results: We present a 37-year-old multigravida woman at 40 weeks gestation who developed acute right-sided proptosis, diplopia, retrobulbar pain, and periorbital edema during the second stage of labor. Computed tomography (CT) revealed a subperiosteal hemorrhage, with subsequent magnetic resonance imaging (MRI) excluding vascular anomalies. Symptoms resolved within two months. Only 14 cases of maternal orbital hematoma associated with labor have been reported. The average age was 28 with 42% (6/14) being primigravid. Including our case, forty percent (6/15) developed symptoms during the second stage of labor, 40% (6/15) immediately postpartum, and 20% (3/15) over 24 hours postpartum. Overall, 33% (5/15) had potentially contributing conditions including coagulopathies, delivery complications, or vascular malformations. Unilateral orbital hemorrhage occurred in 87% (13/15). Surgical intervention was necessary in 13% (2/15). Most (87%, 13/15) underwent observation or medical management with full recovery of symptoms., Conclusions: Non-traumatic orbital hematomas associated with maternal labor are rare and likely related to increased valsalva during delivery and heightened blood volume in pregnancy. Neuro-imaging and systemic workup are recommended to assess for vascular anomalies or underlying coagulopathies. The overall prognosis is favorable with most having full recovery., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Organelles form membrane contact sites between each other, allowing for the transfer of molecules and signals. Mitochondria-endoplasmic reticulum (ER) contact sites (MERCS) are cellular subdomains characterized by close apposition of mitochondria and ER membranes. They have been implicated in many diseases, including neurodegenerative, metabolic, and cardiac diseases. Although MERCS have been extensively studied, much remains to be explored. To uncover novel regulators of MERCS, we conducted a genome-wide, flow cytometry-based screen using an engineered MERCS reporter cell line. We found 410 genes whose downregulation promotes MERCS and 230 genes whose downregulation decreases MERCS. From these, 29 genes were selected from each population for arrayed screening and 25 were validated from the high population and 13 from the low population. GET4 and BAG6 were highlighted as the top 2 genes that upon suppression increased MERCS from both the pooled and arrayed screens, and these were subjected to further investigation. Multiple microscopy analyses confirmed that loss of GET4 or BAG6 increased MERCS. GET4 and BAG6 were also observed to interact with the known MERCS proteins, inositol 1,4,5-trisphosphate receptors (IP3R) and glucose-regulated protein 75 (GRP75). In addition, we found that loss of GET4 increased mitochondrial calcium uptake upon ER-Ca 2+ release and mitochondrial respiration. Finally, we show that loss of GET4 rescues motor ability, improves lifespan and prevents neurodegeneration in a Drosophila model of Alzheimer's disease (Aβ42Arc). Together, these results suggest that GET4 is involved in decreasing MERCS and that its loss is neuroprotective., (© 2024. The Author(s).)

Background: One benefit of hyaluronic acid fillers is the ability to dissolve them using hyaluronidase. With the increasing number of fillers entering the market, it is crucial to understand each of these fillers' responsiveness to hyaluronidase., Methods: Twenty-one hyaluronic acid fillers of 0.2 mL aliquots each were placed on slides. Twenty units of recombinant human hyaluronidase were injected into the aliquots every 30 minutes for a total of 120 units recombinant human hyaluronidase injected over 3 hours. With each injection, videos and photographs were taken from bird's eye and lateral views to measure aliquot height. Stirring videos were graded by three oculoplastic surgeons, and these grades were used to categorize each filler's responsiveness., Results: Restylane Lyft, Restylane-L/Eyelight, and Resilient Hyaluronic Acid (RHA) 1/Redensity were the least resistant. The moderately resistant group comprised of Restylane Silk, Juvéderm Volbella, Revanesse Versa/Lips, and Belotero Balance on the less resistant side to Juvéderm Vollure, RHA 2, Restylane Contour, Juvéderm Ultra, Restylane Refyne, Belotero Intense, Restylane Kysse, RHA 3, Juvéderm Ultra Plus, and Restylane Defyne on the more resistant side. The most resistant were RHA 4, Juvéderm Voluma, Belotero Volume, and Juvéderm Volux. The most resistant fillers required 120 units of hyaluronidase per 0.2 mL filler to dissolve., Conclusions: With the increasing popularity of fillers comes the increasing need to dissolve them for both ischemic and nonischemic complications. The majority of hyaluronic acid fillers available on the market are very resistant to hyaluronidase, which must be considered when determining the amount of hyaluronidase to dissolve a particular filler., Competing Interests: Dr. Woodward: Allergan (speaker and consultant), Galderma (speaker and consultant), Prollenium (speaker and consultant), Merz (speaker and consultant), SkinCenticals (consultant). Dr. Lee: Allergan, Galderma, Revance, Evolus, RoC, Tarsus, RVL, Horizon, NovaBay. Dr. Kherani: Abbvie, Horizon, Santen, SunPharma, Tarsus. Dr. Foster: Horizon, Tarsus. Dr. Zhang-Nunes: Horizon Therapeutics, Tarsus Pharmaceuticals, Bruder, Sciton. Drs. Park and Mehta have nothing to disclose., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Purpose: To describe postoperative management following ablative carbon dioxide laser resurfacing of the lower eyelids., Methods: A retrospective review of patients who consecutively underwent bilateral lower eyelid ablative carbon dioxide laser resurfacing by a single experienced oculoplastic surgeon over a 6-year period was conducted. Patient satisfaction, aesthetic outcomes, and postoperative complications were evaluated as adjunctive or monotherapy., Results: Among 424 patients included in the study, most were female (n = 356, 84.0%) and Caucasian (n = 404, 95.3%), with Fitzpatrick skin types II-III (n = 381, 89.9%). Mean age was 62.8 years (standard deviation: 9.7 years). Most (n = 324, 76.4%) underwent fractional ablative carbon dioxide laser resurfacing of the lower eyelids, whereas 91 (21.5%) received traditional laser resurfacing and 9 (2.1%) had both fractional and traditional laser resurfacing during the same session. At the time of lower eyelid laser resurfacing, most patients also underwent concurrent procedures, including upper (n = 321, 75.7%) and lower blepharoplasty (n = 348, 82.1%); a small proportion of patients (n = 39, 9.2%) did not undergo any concurrent surgical procedure. In addition to ablative laser resurfacing of the lower eyelids, 25 (5.9%) had upper eyelid laser resurfacing, 60 (14.2%) had full-face laser resurfacing, 55 (13.0%) had neck laser resurfacing, and 42 (9.9%) had additional treatment of solar lentigines or dyschromias on the face. Median follow-up duration was 3.9 months (interquartile range: 2.0-11.0 months). In the immediate postoperative period, 22 patients (5.2%) developed contact dermatitis from topical antibiotic eye drops and/or ointment prescribed postblepharoplasty. Postinflammatory hyperpigmentation was observed in 40 patients (9.4%) despite topical prophylaxis; all were eventually successfully treated with a combination of topical nonprescription and prescription creams and/or oral tranexamic acid. A localized herpetic outbreak occurred in 3 (0.7%) who underwent full-face laser resurfacing and 1 (0.2%) who underwent periocular laser resurfacing only; all were successfully treated with oral antiviral therapy. Two (0.5%) developed culture-proven atypical mycobacterial infection of the resurfaced lower eyelid skin and were treated with combination antibiotic therapy for several months until resolution. A small scar was noted in 4 patients (0.9%), which resolved after local corticosteroid injections. No patient developed persistent scarring or ectropion. Patient satisfaction was overall high, with 363 (85.6%) very satisfied and 48 (11.3%) satisfied with the aesthetic outcome of lower eyelid laser resurfacing., Conclusions: Ablative carbon dioxide laser resurfacing of the lower eyelids can be a useful tool in the armamentarium of the experienced oculoplastic surgeon, with excellent aesthetic results, high patient satisfaction, and low complication rates as adjunctive or monotherapy. Proper and timely management of postoperative complications is essential to maximizing successful cosmetic outcomes., Competing Interests: J.A.W. is a consultant for Allergan, Galderma, Merz Aesthetics, Prollenium, Evolus, and L’Oréal U.S.A., For the remaining authors, there are no conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Aim: To evaluate the effectiveness of treating mimetic facial lines with an incobotulinumtoxinA (INCO) and Cohesive Polydensified Matrix ® hyaluronic acid (CPM-HA) combination., Methods: Subjects with moderate-to-severe lateral periorbital lines (LPL) and perioral lines at rest according to Merz Aesthetics Scales ™ received 10 U of INCO/eye and up to 10 U to the perioral area. This was followed by intradermal injection of 1-3 cc CPM-HA to the same lines. Primary outcomes were physician- and subject-rated improvement at 1 month using the Global Aesthetic Improvement Scale (GAIS) and changes in line severity using the Merz Aesthetics Scales ™ ., Results: The study included 10 women aged 42-74 years with moderate-to-severe LPL and perioral lines at baseline. At 1 month, treating physician GAIS scores indicated 45.0% of subjects were very much improved and 52.5% much improved; 75% remained at least improved at 6 months. Subject GAIS results indicated 7 women rated themselves as very much improved and 3 as much improved. For LPL, improvements of ≥1-point on the Merz Aesthetics Scales ™ compared with baseline were seen at 1, 3, and 6 months in 86.8%, 74.3%, and 65.8% of subjects, respectively. For perioral lines, improvements of ≥1-point were observed for 89.2%, 86.5%, and 73.0% at 1, 3, and 6 months, respectively. No treatment-related adverse events were observed., Conclusions: Combined INCO/CPM-HA filler in individuals with moderate-to-severe LPL and perioral lines was effective at improving overall appearance and reducing line severity in two highly mobile facial areas that are the first to show lines of aging., (© 2020 Wiley Periodicals LLC.)

Objective: To evaluate for relative palpebral and orbital changes after long-term unilateral exposure to prostaglandin analogues (PGAs) in patients with childhood glaucoma., Design: Prospective cross-sectional cohort study., Participants: A total of 29 patients with history of childhood glaucoma, who were treated unilaterally with PGAs for at least 12 months., Methods: Based on 4 standardized clinical photographs (en face with eyes open, right and left side views with eyes open, and en face with eyes closed), 3 masked expert graders each independently selected the eye they perceived to have received unilateral PGA treatment by physical appearance alone and graded the following features relative to the other eye: (1) ocular (e.g., conjunctival hyperemia, iris heterochromia, and buphthalmos), (2) palpebral (e.g., eyelash trichomegaly, eyelash hypertrichosis, eyelid erythema, eyelid edema, eyelid hyperpigmentation, high upper eyelid crease, upper eyelid ptosis, upper and/or lower eyelid retraction, and eyelid skin atrophy with presence of telangiectasias), and (3) periorbital (e.g., superior sulcus hollowing, proptosis, enophthalmos, hypoglobus, and hyperglobus). An interrater reliability analysis was performed using the Fleiss kappa (κ) statistic to determine consistency among raters., Main Outcome Measures: Frequencies of each feature of prostaglandin-associated periorbitopathy (PAP); group consensus; interrater reliability of selected PGA-treatment laterality., Results: Median unilateral PGA exposure time was 31.7 months (interquartile range: 18.8-44.3 months). Eyelash trichomegaly and hypertrichosis (n = 22, 76%), high upper eyelid crease (n = 20, 69%), upper eyelid ptosis (n = 14, 52%), and superior sulcus hollowing (n = 15, 52%) were the most frequently observed features of PAP in PGA-treated eyes compared with untreated fellow eyes. Most of these changes were mild, but 20% to 30% of patients exhibited moderate eyelash and/or eyelid changes. One patient had severe PAP after long-term unilateral PGA exposure. Group consensus with correctly selected laterality was achieved in all patients. The inter-rater reliability was excellent (κ = 0.815, P < 0.001, 95% confidence interval [0.605, 1.000])., Conclusions: Mild-to-moderate changes in the ocular adnexa can develop in children and young adults with long-term PGA exposure. Patients and their families should be educated on the possibility of PAP, especially when initiating monocular PGA therapy., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the safety, efficacy, and patient satisfaction of a newly described technique for the treatment of mild to moderate lash ptosis performed as augmentation to upper eyelid blepharoplasty., Methods: Patient medical records for 27 consecutive cases of upper eyelid blepharoplasty between January 2016 and June 2017 and 19 consecutive cases of upper eyelid blepharoplasty with the laser lash tilt procedure between July 2016 and January 2017 performed by the senior author were retrospectively reviewed. Lash position in preoperative and postoperative photographs was graded in a randomized masked fashion on a 4-point scale by 5 oculoplastic surgeons., Results: There was a significant improvement in mean lash position scores for the control group (0.52 ± 0.34, p < 0.001) with mean lash score improving from 1.14 ± 0.46 before surgery to 0.62 ± 0.46 after blepharoplasty alone. There was also significant improvement in mean lash position scores for the laser lash group (0.98 ± 0.52, p < 0.01) with mean lash score improving from 1.66 ± 0.62 before surgery to 0.68 ± 0.50 after blepharoplasty with laser lash treatment. The improvement in lash position seen in the laser lash group was significantly greater than the improvement seen in the control group (p = 0.001). There were no complications and all patients were satisfied with their results., Conclusions: Compared with upper eyelid blepharoplasty alone, the addition of the CO2 laser lash tilt technique provides a significant improvement in the upward tilt of the eyelashes as they emerge from the eyelid margin.

Previous studies have demonstrated incomplete sunscreen self-application to various facial regions in cosmetic surgery patients, but there is no scientific research on the completeness of facial and periocular sunscreen self-application using ultraviolet (UV) photography for assessment. This prospective, cross-sectional, qualitative study aimed to assess completeness of facial application of sunscreen in oculofacial surgery patients at the Duke Eye Center (Durham, North Carolina). Forty-four participants were enrolled, and completeness of facial sunscreen self-application was assessed using UV photography.

Background: Embolia cutis medicamentosa (ECM) is a rare phenomenon attributed to intra-arterial drug injection. Glabellar filler injections can result in potentially devastating visual loss from inadvertent retrograde arteriolar embolization due to the extensive vasculature within the upper face. The minimum amount of filler necessary to potentiate this complication has not yet been reported., Objectives: We aim to determine the volume of filler necessary to occupy the supratrochlear artery from the glabella to the bifurcation of the ophthalmic and central retinal arteries. We specifically examine the volume of the supratrochlear artery from the glabella to orbital apex., Methods: The study was approved by Duke University Institutional Review Board and involved surgical dissection of six fresh tissue cadaver heads (12 hemifaces). The arterial system in each cadaver head was injected with latex for visualization. The supratrochlear arteries were isolated anteriorly from the glabella to the orbital apex posteriorly. Intra-orbital vessel radius and length were measured. The vessel volume was calculated by water displacement of the intra-arterial latex., Results: The vessel volumes ranged from 0.04 to 0.12 mL. The average vessel volume was calculated as 0.085 mL, the average length as 51.75 mm, and the average radius as 0.72 mm., Conclusions: Vascular occlusion from filler injections can lead to devastating visual consequences due to inadvertent retrograde intra-arterial embolization. Our findings indicate that the average entire volume of the supratrochlear artery from the glabella to the orbital apex is 0.085 mL. Injectors should be aware that a bolus of this critical volume may lead to a significant adverse outcome., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Effective antiseptic to reduce surgical site infections is a cornerstone of modern surgery. Chlorhexidine gluconate-based antiseptics are among the most effective of these products. Unfortunately, chlorhexidine solutions are toxic to the cornea and middle ear, and they pose a splash risk to both the patient and health care personnel., Objective: To examine the clinical evidence that led to the disavowal of chlorhexidine antiseptic solution for use on the face and head., Methods and Materials: Reference searches were performed using PubMed, Embase, and LexisNexis databases without restriction to the date of publication, language, or study setting., Results: The literature revealed 11 sentinel cases of severe chlorhexidine-related keratitis in the late 1980s. These cases are reviewed together with data on ototoxicity and alternative products to understand why chlorhexidine solution should not be used on the face and scalp., Conclusion: Chlorhexidine antiseptic solutions are highly effective. However, they pose a risk to the middle ear and have the potential to irreversibly damage the cornea with a minimal splash exposure. Povidone-iodine is a safe and effective alternative.

Aging of the periocular area involves changes of the skin, muscle, fat, and bones. Facial fillers can be helpful in minimizing these changes by restoring youthful fullness to periocular areas that have undergone volume loss or loss of support. Physicians should understand the complicated anatomy surrounding the eyes, both to understand the aging process and to minimize treatment complications.

Objective: Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection., Method & Results: Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described., Conclusion: Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.

Background: Microfocused ultrasound (MFU) and ablative fractionated laser (AFL) resurfacing techniques have been used separately to noninvasively improve skin laxity and rhytides on the face and neck. Simultaneous combination treatment would be anticipated to provide further improvement but has not previously studied., Methods: A retrospective analysis of 100 combination face and neck treatments from 3 centers was performed, including collective treatment protocols, postoperative recovery, side effect profile, and clinical results., Results: Skin laxity and photodamage (rhytides and texture) showed significant improvement with combination MFU + AFL treatment. Except for increased facial swelling in a small percentage of patients, postoperative recovery and side effects were comparable with those obtained after application of individual treatments., Conclusion: Combination MFU-AFL on the face and neck is a safe and effective method for targeting multiple facets of facial and neck skin aging and can be safely performed in a single treatment session.

Orofacial granulomatosis is a relapsing nonnecrotizing granulomatous syndrome that classically presents with lip and perioral swelling. Over the years, several patients have been referred to the Duke Eye Center Oculoplastics Department for severe, progressive, recurrent eyelid swelling interfering with both their functional vision and their appearance. In this IRB approved retrospective case series, we describe the clinical course of 5 such patients, including their presenting symptoms, diagnosis, and response to treatment. We hope that oculoplastics specialists will consider this entity in the differential diagnosis of periorbital edema and consider initiating localized anti-inflammatory treatment once the diagnosis has been made.

Background: Intense focused ultrasound is an FDA-approved noninvasive technology for facial/brow lifting procedures. During the course of our experience, several patients had complications with this technology, some of which have not been reported in the literature., Objective: The purpose of this study was to assess the spectrum and duration of complications associated with administering intense focused ultrasound at the Duke Aesthetic Center., Materials and Methods: This retrospective IRB-approved chart review evaluates all 39 patients treated at the Duke Aesthetic Center from November 4, 2011 to October 9, 2012. Thirty-eight patients had concurrent ablative fractionated laser skin resurfacing using the Lutronic eCO2 system over the neck. The charts and photograph archive were reviewed to determine the amount and location of treatment and complications experienced by each patient., Results: Overall, 23% of patients had a complication. These included mandibular ecchymosis, facial edema, transient lip and brow paralysis, and pseudofacial fat atrophy., Conclusion: Although most of the complications were transient in nature, 1 patient developed persistent facial edema that became a scar and another developed pseudomelolabial fat atrophy. Furthermore, 3 patients experienced previously unrecognized transient lip and/or brow paralysis. All patients tolerated concurrent neck ultrasound and ablative fractionated CO₂ laser resurfacing well.

Primary cutaneous signet-ring cell carcinoma (PCSRCC) is a rare but aggressive tumor. Our case highlights a 60-year-old man who presented with eyelid ptosis, for which he underwent multiple surgical procedures over a 3-year period prior to referral to our clinic. These procedures were complicated by scarring, delayed healing, and poor cosmetic outcome. In addition, the patient was noted to develop progressive enophthalmos. These concerning signs led to a CT scan and subsequent eyelid biopsy, which revealed a diagnosis of PCSRCC. Further management has involved an MRI and orbitotomy with biopsy revealing widespread extension of the carcinoma. Exenteration was performed to reduce the likelihood of metastasis. There are few documented case reports of PCSRCC of the eyelid in the literature. Of the 33 published cases of PCSRCC, 27 cases involve the eyelids and the other 6 cases involve the axilla. The unique clinical features of this case will be discussed, in particular the presentation as ptosis, an otherwise commonplace complaint in the oculoplastics clinic. The surgical course and histopathologic findings will be presented. The literature regarding PCSRCC will be reviewed including demographics, management, and prognosis. Although rare, PCSRCC follows an aggressive course with characteristically delayed diagnosis. Early identification and treatment likely offer a better prognosis. Thus, description of the clinical presentation of this rare tumor may aid in recognition and earlier treatment.

Background: The effect of perceived facial blanching with neurotoxin therapy has been described in the literature and has been used to treat the undesirable facial flushing of Frey's syndrome. Patients rarely report it as a complication after cosmetic injection, but it can be distressing., Objectives: To elucidate the proposed mechanism(s) of this unusual vasculocutaneous phenomenon, we reviewed normal physiologic responses to heat stress and the role of cholinergic neurotransmission in modulating cutaneous vascular tone in the context of the literature., Materials/methods: We report a case of a 32-year-old woman who complained of white patches on her forehead at sites of abobotulinumtoxinA injections administered 2 weeks before presentation., Results: Acetylcholine is a primary mediator of cutaneous vasodilatation; certain co-transmitters modulate its effect. Chemical denervation by botulinum toxin (BoNT) appears to interfere with these normal signaling pathways and can provide symptomatic relief to patients with undesirable facial flushing. Conversely, it may create an unwanted cosmetic effect in patients who desire isolated muscle paresis., Conclusions: Skin sites injected with BoNT type A may not experience the expected decrease in cutaneous vessel tone associated with higher body temperature. The exact mechanism remains unclear., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

The authors report a 30-year-old Caucasian woman with nodular fasciitis presenting as a nontender lesion to right temporal area. The lesion was removed by en bloc excision and the base was cauterized. Six months later, the patient returned to the clinic for possible recurrence of lesion or for residual lesion; the patient was then injected with a total of 1 cc of kenalog at 20 mg/kg. Two weeks later, the lesion had greatly subsided and the patient was satisfied with the esthetic appearance. Nodular fasciitis is a rare reactive growth with even fewer cases of recurrence. In young patients, steroid injection is an alternative to repeat resection.

Chemodervation with abobotulinum toxin A (Dysport) and botulinum toxin type A (Botox) is finding an expanding role in functional and cosmetic cases. We describe the use of chemodenervation with abobotulinum toxin A for functional corneal protection in two cases and botulinum toxin type A for facial symmetry after Bell's palsy in one patient. The first case is a 75-year-old female with a nonhealing corneal erosion in her right eye secondary to epithelial basement membrane corneal dystrophy who underwent injection of 24 units of abobotulinum toxin A to the right Muller's muscle and levator palpebrae superioris to induce a protective ptosis. The second case is a 40-year-old male with corneal decompensation in the right eye after penetrating keratoplasty who underwent similar injection at both sites. The third case is a 46-year-old Asian female with history of Bell's palsty affecting her right side and causing mild left eyelid retraction who was injected 3 units of botulinum toxin type A to her Muller's muscle for lid positioning. Chemodenervation is used in these cases to purposefully induce ptosis by careful injection to Muller's muscle and the levator palpebrae superioris for functional and cosmetic purposes.

Angiosarcomas involving the head and neck are malignant tumors which tend to involve multiple anatomical structures with an overall dismal prognosis. Reports of primary, isolated eyelid involvement are rare. We report 4 cases of angiosarcoma involving the eyelid as either an isolated tumor or as part of a more diffuse malignant process and compare the features of these 2 tumor types to cases reported in the literature. The mean age at which patients develop angiosarcoma involving the eyelid was 72. Patients with isolated tumors most often presented complaining of a discrete mass clinically resembling a stye. Patients with isolated eyelid involvement had better survival (100% at 3.2 years) compared with patients with diffuse disease (57% at 3.3 years). Those with isolated eyelid involvement have an average tumor size of 2.08 cm with no distant metastasis. Patients who have eyelid angiosarcoma with extrapalpebral involvement have tumors ranging between 5 and 10 cm on average and 21% develop metastases. True isolated angiosarcoma of the eyelid is rare. When extrapalpebral involvement is ruled out by clinical and radiographic examination, patients with isolated involvement seem to fare better compared with patients with eyelid involvement secondary to more regionally extensive tumors.

This study investigates the effects of specularly and diffusely reflected CO2 laser energy on operative field materials. The CO2 laser was reflected off the sandblasted and polished surfaces of an eyelid plate and a wet cotton gauze pad. The laser was aimed at a surgical glove, operative gown, laser safety goggles, and endotracheal tube, each positioned 5 cm, 10 cm, and 15 cm from the plate. Primary outcomes were time to initial effect and description of result. There was no reflection off wet gauze and no effect on the gauze itself. When reflected off sandblasted and polished surfaces, the laser created a hole in the glove and a flame in the surgical gown. When targeting safety goggles and an endotracheal tube, the laser created a surface divot at short distances and surface irregularity at 15 cm. While the CO2 laser is an excellent surgical instrument, reflected laser energy can affect operative field materials.

Purpose: To determine whether there is an objective benefit to prescribing Ritalin for patients with uncontrolled blepharospasm exists., Methods: Seven subjects with benign essential blepharospasm, who were being treated with botulinum toxin injections and Ritalin LA, were recruited for this pilot study. Patients were asked to participate during the period of time when symptoms were beginning to return. Subjects underwent video and surface electromyography (sEMG) monitoring before and 2 hours after the administration of Ritalin. Mean sEMG potential for each eye was compared before and after the administration of Ritalin. Subjects also rated their disability based on a previously developed and reproducible blepharospasm functional disability scale. Functional Disability Scores were compared, and post-Ritalin treatment benefit was determined., Results: The mean voltage of the sEMG was lower in 13 of 14 eyes after the administration of Ritalin. For the right eye, the voltage decreased by 50% (106.4 ± 13.6 mV to 52.7 ± 7.1 mV, p = 0.015), and for the left eye, by 31% (81.9 ± 9.7 mV to 56.6 ± 6.1 mV, p = 0.031). The Functional Disability Scores were also lower after the administration of Ritalin than before (p = 0.016)., Conclusions: A significant decrease in mean voltage after the administration of Ritalin was found in this preselected group of patients. Subjective improvement with decreased disability and increased functional benefit was also found in all subjects. Based on the results of this study, a randomized, controlled study comparing Ritalin versus placebo is needed to determine whether Ritalin should be routinely prescribed for benign essential blepharospasm during the symptomatic window period.

Objective: To evaluate a bimatoprost gel for enhancing eyelash growth, adverse effects, and change in intraocular pressure (IOP)., Methods: Prospective, double-masked, randomized controlled study. Fifty-two patients without ocular disease were assigned a control or bimatoprost 0.03% gel to apply to the eyelid margin once a day., Results: The adjusted mean change in eyelash length from baseline to 6 months was 0.77 mm in the bimatoprost group and -0.12 mm in the control group (P = 0.004). Adverse effects were experienced by 2 of 16 patients (12.5%) in the control group and 9 of 36 patients (25%) in the bimatoprost gel group. Mean change in IOP from baseline to 6 months was 0.685 mmHg in the control group and -2.04 mmHg in the bimatoprost group (P = 0.009)., Conclusions: Bimatoprost gel was effective in enhancing eyelash growth. The most common adverse effect for the bimatoprost gel was conjunctival and eyelid hyperemia, while the most severe was recurrent anterior uveitis. Mean IOP was reduced in subjects using the bimatoprost gel.

Background: Transduction with recombinant HIV-1 derived lentivirus vectors is a multi-step process initiated by surface attachment and subsequent receptor-directed uptake into the target cell. We previously reported the retention of vesicular stomatitis virus G protein pseudotyped particles on murine progenitor cells and their delayed cell-cell transfer., Methods: To examine the underlying mechanism in more detail, we used a combination of approaches focused on investigating the role of receptor-independent factors in modulating attachment., Results: The investigation of synchronized transduction reveals cell-type specific rates of vector particle clearance with substantial delays during particle entry into murine hematopoietic progenitor cells. The observed uptake kinetics from the surface of the 1 degrees cell correlate inversely with the magnitude of transfer to 2 degrees targets, corresponding with our initial observation of preferential cell-cell transfer in the context of brief vector exposures. We further demonstrate that vector particle entry into cells is associated with the cell-type specific abundance of extracellular matrix fibronectin. Residual particle-extracellular fibronectin matrix binding and 2 degrees transfer can be competitively disrupted by heparin exposure without affecting murine progenitor homing and repopulation., Conclusions: Although cellular attachment factors, including fibronectin, aid gene transfer by colocalizing particles to cells and disfavoring early dissociation from targets, they also appear to stabilize particles on the cell surface. The present study highlights the inadvertent consequences for cell entry and cell-cell transfer., (Copyright (c) 2010 John Wiley & Sons, Ltd.)

Purpose: To examine the current cosmetic practices of American Society of Oculoplastic and Reconstructive Surgery members using a survey and compare those results with a similar survey that was performed 6 years prior, and to determine the types and breadth of cosmetic procedures that are currently performed within the field of ophthalmic plastic and reconstructive surgery., Methods: A 49-question survey was sent to members of American Society of Oculoplastic and Reconstructive Surgery by post mail and/or electronic mail in 2007. The questions covered surgeon demographics, cosmetic practice design, and preferences for aesthetic procedures and commercial equipment and products. Frequencies and percentages of responses were obtained for each question individually. Responses to similar questions in a 2001 survey were compared with those in the current survey., Results: Two hundred fifty-seven members of 488 responded (53%). Eighty-two percent of respondents (208 of 253) performed some type of cosmetic procedure. Fifty-five percent of respondents reported that less than 25% of their practice consisted of cosmetic procedures and services. Thirty-one percent of respondents reported that 25% to 75% of their practice was cosmetic., Conclusions: A slightly higher percentage of respondents reported that more of their practice consisted of cosmetic procedures and services compared with 6 years ago; however, the difference did not reach statistical significance (p = 0.895). A lower percentage of respondents injected Botox cosmetic (p = 0.02), offered ablative laser skin resurfacing (p < 0.001), and performed rhytidectomy (p < 0.001) in 2007 compared with 2001.

Acquired eyelash hypertrichosis is associated with medications, systemic diseases, and ocular inflammation. The authors present a study showing that eyelash length is significantly longer following enucleation and evisceration surgery compared with the contralateral side. This may be related to factors involved in postoperative conjunctival and orbital inflammation and healing.

Background: Patients often complain of pain and bruising from needle injections. Some clinicians believe smaller gauge needles cause less pain. Thirty-gauge needles are currently the standard needles employed for administering botulinum toxin type A (BTX-A)., Objective: This study sought to determine whether patients receiving BTX-A have a preference for 30-gauge or 32-gauge needles based on the amount of pain and bruising experienced., Methods: Thirty-seven subjects received BTX-A on the right side of the face using a 30-gauge needle and on the left side using a 32-gauge needle. Subjects were masked to needle size. They were then asked to rate injection pain on an 11-point numerical rating scale and to note any bruising. Physician preference was also evaluated., Results: There were no statistically significant differences in the amount of intra-procedural pain (p=.37) or the level of post-procedural pain and discomfort (p=.76) experienced. Twenty-seven percent of subjects reported greater bruising with the 32-gauge needle, versus 29.7% with the 30-gauge needle. The physician injector did not have a preference. Lastly, 83.8% of subjects did not detect a difference in BTX-A paralysis effect., Conclusion: We do not recommend using 32-gauge needles in place of 30-gauge needles for administering BTX-A.

Purpose: To compare the surface electromyogram recordings between patients with benign essential blepharospasm and controls while maintaining primary gaze and reading in downgaze., Methods: A university-based, prospective case series of 7 benign essential blepharospasm patients and 7 normal patients. Bilateral lower eyelid preseptal orbicularis oculi muscle potentials were recorded via surface electromyogram and video while performing a standardized 60-second task that was divided in 3 equal 20-second subtasks. Specifically, patients were asked to maintain primary gaze for the first 20-second interval, to read quietly for the second interval, and again maintain primary gaze for the third 20-second interval. Fourteen trials capturing bilateral recordings were performed in each group; qualitative and quantitative analysis of the surface electromyogram recordings was performed and compared both between patient groups and between subtasks. Blepharospasm patients were also asked to describe the effect of reading on their spasms. Specifically, they were asked before the study if reading lessened or worsened their spasms and then were asked poststudy if their symptoms lessened or worsened during the reading task., Results: The mean surface electromyogram potential of the orbicularis muscle was significantly less in normal eyes when compared with blepharospasm eyes for each task. Furthermore, the mean surface electromyogram potential during the reading task was significantly reduced when compared with the primary gaze task in all eyes. Only blepharospasm patients noticed this reduction subjectively., Conclusions: Although conventional wisdom regarding blepharospasm suggests that reading is an exacerbating factor, short durations of reading seem to relieve spasms. This may be due to the effect of downgaze on the blink reflex and may offer possible areas of investigation for novel blepharospasm treatments.

Purpose: The bony skeleton serves as the scaffolding for the soft tissues of the face; however, age-related changes of bony morphology are not well defined. This study sought to compare the anatomic relationships of the facial skeleton and soft tissue structures between young and old men and women., Methods: A retrospective review of CT scans of 100 consecutive patients imaged at Duke University Medical Center between 2004 and 2007 was performed using the Vitrea software package. The study population included 25 younger women (aged 18-30 years), 25 younger men, 25 older women (aged 55-65 years), and 25 older men. Using a standardized reference line, the distances from the anterior corneal plane to the superior orbital rim, lateral orbital rim, lower eyelid fat pad, inferior orbital rim, anterior cheek mass, and pyriform aperture were measured. Three-dimensional bony reconstructions were used to record the angular measurements of 4 bony regions: glabellar, orbital, maxillary, and pyriform aperture., Results: The glabellar (p = 0.02), orbital (p = 0.0007), maxillary (p = 0.0001), and pyriform (p = 0.008) angles all decreased with age. The maxillary pyriform (p = 0.003) and infraorbital rim (p = 0.02) regressed with age. Anterior cheek mass became less prominent with age (p = 0.001), but the lower eyelid fat pad migrated anteriorly over time (p = 0.007)., Conclusions: The facial skeleton appears to remodel throughout adulthood. Relative to the globe, the facial skeleton appears to rotate such that the frontal bone moves anteriorly and inferiorly while the maxilla moves posteriorly and superiorly. This rotation causes bony angles to become more acute and likely has an effect on the position of overlying soft tissues. These changes appear to be more dramatic in women.

Background: Knowledge of the average dimensions of periocular features based on age, gender, and race is critical for surgeons so that complications can be avoided and ideal outcomes can be achieved. In this study, the authors sought to determine whether significant differences exist for certain eyelid and eyebrow dimensions between African American and white adults., Methods: Both eyes of 89 African American and 75 white subjects, aged 20 to 80 years, were evaluated. Subjects were divided by gender into three, 20-year age cohorts. Measurements of palpebral fissure height, palpebral fissure width, palpebral fissure inclination, pretarsal skin height, crease height, eyebrow height, eyebrow apex angle, and distance of the brow apex from the lateral corneal limbus were taken from standardized photographs. Mean values by race, age, and gender were compared using linear mixed modeling. Double-lid crease prevalence was also evaluated., Results: A significant difference was found between races for palpebral fissure width, pretarsal skin height, and crease height in men, and for eyebrow height in both men and women. A significant difference between genders was found for palpebral fissure height, palpebral fissure width, pretarsal skin height, and crease height in whites; for palpebral fissure inclination, eyebrow height, and distance of the brow apex from the lateral corneal limbus in both whites and blacks; and for eyebrow apex angle in blacks. Significant differences were also found between age cohorts for palpebral fissure height in black women and for eyebrow height in black men. Thirty-seven percent of African Americans had a double-lid crease versus 15 percent of whites., Conclusions: Race, gender, and age differences exist for certain eyelid and eyebrow positions. These factors can impact surgical decision-making and thus highlight the need for an individualized approach to patients.

Tick infestation of ocular tissues is not common. Tick inoculation of the skin can locally lead to granuloma and abscess formation. More concerning, however, is the potential systemic sequelae that can result from transmission of zoonoses such as Lyme disease, Rocky Mountain spotted fever, Ehrlichia, and tularemia. To avoid these complications, it is critical that the tick is completely removed. The authors present a case of tick infestation in the eyelid of a 55-year-old woman and review the management of such a case.

Pachydermoperiostosis is characterized by soft-tissue hyperplasia that gives patients a classic appearance of tarsitis leading to massively thickened tarsal plates and consequential ptosis. The authors describe a patient with the classic eyelid findings, the pathologic evaluation of the eyelid, and the presence of asymptomatic myelofibrosis.