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Sarah Guo,1 Mark S Borchert,2,3 Melinda Chang,2,3 Sudha Nallasamy,1– 3 Mark W Reid,2,3 Sandy Zhang-Nunes,1,3 Jessica R Chang,1,3 Angeline M Nguyen1– 3 1Keck School of Medicine of University of Southern California, Los Angeles, CA, USA; 2The Vision Center at Children’s Hospital Los Angeles, Los Angeles, CA, USA; 3Roski Eye Institute at the University of Southern California, Department of Ophthalmology, Los Angeles, CA, USACorrespondence: Angeline M Nguyen, Tel +1 323-361-2347, Fax +1 323-361-9812, Email angnguyen@chla.usc.eduPurpose: To evaluate the effectiveness, tolerability, and safety of the Nictavi Tarsus Patch™ (NTP) in inducing temporary eyelid closure for the management of lagophthalmos in the pediatric and young adult population.Methods: We prospectively enrolled 20 patients < 21 years of age who had previously been managed for lagophthalmos to trial the NTP in clinic. Inter-palpebral fissure distance (IPFD) was compared before and after the placement of the NTP in the eyes-closed position using paired t-tests. Subjects then underwent a 3-night home trial with the NTP, and parent and subject perceptions of effectiveness, comfort, and complications with the patch were analyzed using Likert scale survey questions.Results: Twenty subjects ages 2– 20 years with paralytic (65%) and non-paralytic (35%) lagophthalmos were enrolled. The NTP improved lagophthalmos from a mean pre-placement IPFD of 3.3 mm to post-placement IPFD of 0.4 mm (p < 0.01). Overall, 80% of subjects achieved successful eyelid closure defined as ≤ 1 mm of post-placement IPFD. When stratified by subtype, 100% of subjects with paralytic lagophthalmos achieved successful eyelid closure compared to 71% of subjects with non-paralytic lagophthalmos. On a scale of 1 (worst) to 5 (best), parents rated the NTP at 4.3± 0.7 for comfort while wearing, 4.3± 1.0 for comfort in removing, 4.6± 0.7 for ease of use, and 4.3± 0.9 for effectiveness. Ninety-three percent of parents reported preferring NTP to other eyelid closure methods previously tried and indicated that they would use it again.Conclusion: The NTP is an effective, tolerable, and safe method of eyelid closure for children and young adults.Keywords: lagophthalmos, eyelid closure, Nictavi Tarsus Patch, pediatric

Purpose: Severe postoperative edema after eyelid surgery can have negative clinical and psychological effects. In this study, the authors investigated whether surgical factors, including surgical techniques and suture type, were associated with clinically significant eyelid edema (CSEE)., Methods: A chart review was performed on 269 patients who underwent upper eyelid blepharoplasty with or without external levator advancement by 2 surgeons at a single institution between January 2021 and December 2022. Postoperative photos were graded by 2 physicians for eyelid edema using a standardized grading scale ranging from 0 (no edema) to 3 (severe edema). CSEE was defined either as having a grade of 3 at any point postoperatively or any grade that was 1 or greater after 90 days postoperatively. Logistic regression controlling for race was used for analysis; the statistical significance level was defined as p < 0.05., Results: Of 269 patients, 56 developed CSEE. Of those who underwent blepharoplasty with mini crease enhancement (closure with every other bite incorporating levator aponeurosis), 40.5% developed CSEE versus 12.5% of those without ( p < 0.001). Patients with lid crease formation using buried interrupted sutures had greater CSEE than those with externalized interrupted sutures removed at 1 week (43.8% versus 11.5%, p < 0.01). There was no increased risk of CSEE with additional procedures performed versus blepharoplasty alone., Conclusions: Patients who underwent blepharoplasty with mini crease enhancement, where more than 4 sutures are placed from skin to levator, and/or had buried suture lid crease formation had greater rates of CSEE., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To present a modification of the reversible tarsorrhaphy that can be opened and reclosed as necessary by caretakers and the patient., Methods: Retrospective case series of patients who underwent the reversible tarsorrhaphy. Materials included intravenous (IV) tubing as bolsters and 4-0 polypropylene suture. The 4-0 suture is first passed through and through one end of IV tubing approximately 20 mm in length. Starting on the lateral upper lid and approximately 4 mm above the lash line, the suture is placed through the skin and into the tarsus. The suture exits through the eyelid gray line. These steps through the eyelid are repeated in the opposite direction. An air knot is tied above the upper eyelid near the base of IV tubing. A second air knot can be tied higher to provide a handle easily allowing the caretaker to close the eyelid., Results: Included were 13 patients (ages 21-95-yeas), indications included lagophthalmos secondary to cicatricial changes from burns (2), keratouveitis (1), neurogenic palsy (3), neurotrophic ulcer (6), and cicatricial changes from skin cancer (1). There were no reported difficulties in maintaining the tarsorrhaphy by either family members or healthcare providers. The first tarsorrhaphy for each patient lasted between 3-19 weeks, with an average of 8 weeks. All were well tolerated., Conclusions: The caretaker-reversible tarsorrhaphy can be used as a temporizing measure. The technique balances the need for ocular protection with the need for examination/treatment by health care professionals and, equally importantly, the patients and caretakers., (© 2024. The Author(s).)

Background and Objectives: It is commonly taught that thyroid eye disease (TED) causes enlargement of the extraocular muscles (EOMs) in the following descending order: inferior rectus (IR), medial rectus (MR), superior rectus (SR), lateral rectus (LR), superior oblique (SO) and inferior oblique (IO). However, with recent literature challenging this notion, we aimed to compare EOM volumes in our cohort of TED patients.  Methods: We conducted a retrospective, non-randomized case-control study. Twenty-eight orbits from 28 unique patients with TED who had high-resolution CT scans were compared to 31 normal orbits, all from a single academic institution. Orbital soft tissues were manually segmented using ITK-SNAP 3.8.0 (http://itksnap.org), and soft tissue volumes of the control and TED orbits were compared using independent-sample t-tests., Results: Of the TED orbits, 54% of SR/levator palpebrae superioris complex volumes (SRC) and 50% of IR volumes were greater than two standard deviations above the normal orbit average. Compared to controls, the mean SRC volume in TED subjects was 2.3 times enlarged, followed by the IR (2.1 times), SO (1.8 times), MR (1.7 times), LR (1.6 times), IO (1.6 times), and orbital fat (1.4 times) ( p < 0.01 for all).  Conclusions: Our findings suggest that contrary to previous teaching, the SRC may be the most severely affected in TED., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board (IRB) of the University of Southern California issued approval (HS-20-00911). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: Unrestricted grant to the Department of Ophthalmology from Research to Prevent Blindness, New York, NY. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Park et al.)

Intense pulsed light has a growing body of research supporting its use in skin rejuvenation, dermatologic conditions, as well as ocular rosacea, dry eyes and meibomian gland dysfunction. This paper will start with the conception of one protocol for treating dry eyes, blepharitis and styes using broad band light, a version of intense pulsed light, and its evolution into a life-changing in-office procedure for many patients. The approach for optimizing the settings, considerations during the consultation, the procedure in detail, after treatment care, and potential complications to avoid are all explained. Periocular and facial rejuvenation treatment protocols are discussed as well. This should be a useful guide for clinicians looking to add intense pulsed light to their in-office treatment armamentarium to significantly improve the lives of their patients., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose The purpose of this study is to assess the accuracy of and bias in recommendations for oculoplastic surgeons from three artificial intelligence (AI) chatbot systems. Methods ChatGPT, Microsoft Bing Balanced, and Google Bard were asked for recommendations for oculoplastic surgeons practicing in 20 cities with the highest population in the United States. Three prompts were used: "can you help me find (an oculoplastic surgeon)/(a doctor who does eyelid lifts)/(an oculofacial plastic surgeon) in (city)." Results A total of 672 suggestions were made between (oculoplastic surgeon; doctor who does eyelid lifts; oculofacial plastic surgeon); 19.8% suggestions were excluded, leaving 539 suggested physicians. Of these, 64.1% were oculoplastics specialists (of which 70.1% were American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members); 16.1% were general plastic surgery trained, 9.0% were ENT trained, 8.8% were ophthalmology but not oculoplastics trained, and 1.9% were trained in another specialty. 27.7% of recommendations across all AI systems were female. Conclusions Among the chatbot systems tested, there were high rates of inaccuracy: up to 38% of recommended surgeons were nonexistent or not practicing in the city requested, and 35.9% of those recommended as oculoplastic/oculofacial plastic surgeons were not oculoplastics specialists. Choice of prompt affected the result, with requests for "a doctor who does eyelid lifts" resulting in more plastic surgeons and ENTs and fewer oculoplastic surgeons. It is important to identify inaccuracies and biases in recommendations provided by AI systems as more patients may start using them to choose a surgeon., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Parikh et al.)

Introduction: AI chatbots are being increasingly used in healthcare settings. There is growing interest in using AI to assist in patient education. Currently, extensive healthcare information is found online but is often too complex to understand. Our objective is to determine if physicians can recommend the free version of ChatGPT version 3.5 (OpenAI, San Francisco, CA, USA) for patients to simplify text from the American Academy of Ophthalmology (AAO) in English and Spanish. This version of ChatGPT was assessed in this study due to its increased accessibility across various patient populations., Methods: Fifteen articles were chosen from AAO in both languages and simplified with ChatGPT 10 times each. The readability of original and simplified articles was assessed with the Flesch Reading Ease and Gunning Fog Index for English and Fernández Huerta, Gutiérrez, Szigriszt-Pazo, INFLESZ, and Legibilidad-µ for Spanish. Grade levels to assess readability were calculated with Flesch Kincaid Grade Level and Crawford Nivel-de-Grado. Mean, standard deviation, and two-tailed t-tests were performed to assess differences before and after simplification., Results: Average grade levels before and after simplification were as follows: English 8.43±1.17 to 8.9±2.1 (p=0.41) and Spanish 5.3±0.34 to 4.1±1.1 (p=0.0001). Spanish articles were significantly simplified per Legibilidad-µ (p=0.003). No significant difference was noted for other scales., Conclusions: The readability of AAO articles in English worsened without significance but significantly improved in Spanish. This may result from simpler syllable structures and a lesser overall vocabulary in Spanish. With increased testing, physicians can recommend ChatGPT for Spanish-speaking patients to improve health literacy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Sudharshan et al.)

Introduction: Point-of-care ultrasound is becoming increasingly popular, and we sought to examine its role in evaluating ocular and periocular structures and facial vasculature. With the large number of point-of-care ultrasound devices available, it is difficult to determine which devices may be best suited for ophthalmic and facial aesthetic applications. This study compares five popular handheld point-of-care ultrasound devices to help guide clinicians in choosing the device best suited for their needs., Methods: We compared five point-of-care ultrasound devices: Butterfly IQ+ (Butterfly, Burlington, MA), L15 (Clarius Mobile Health, Vancouver, British Columbia, Canada), L20 (Clarius Mobile Health, Vancouver, British Columbia, Canada), Lumify (Philips, Amsterdam, Netherlands) and Vscan Air (GE, Boston, MA). Three ophthalmologists obtained the following views on three volunteers: eight arteries, four ocular and periocular structures and areas of filler injections. The image quality of each view was graded on a four-point Likert-type scale. In addition, graders filled out a survey. The data were analysed using analysis of variance tests with the significance level set to p  < 0.05., Results: In terms of overall image quality, the L20 received the highest mean rating, followed by the L15, Vscan Air, Butterfly IQ+ and the Lumify ( p  < 0.05). With further stratification for structure type, the L20 was ranked first for filler, artery and orbital imaging ( p  < 0.05)., Conclusions: The L20 received the highest image quality rankings. While image quality is an important aspect of point-of-care ultrasound device selection, other factors such as cost, wireless capabilities, range of presets and battery life should also be considered., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

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 and Design: To evaluate the accuracy and bias of ophthalmologist recommendations made by three AI chatbots, namely ChatGPT 3.5 (OpenAI, San Francisco, CA, USA), Bing Chat (Microsoft Corp., Redmond, WA, USA), and Google Bard (Alphabet Inc., Mountain View, CA, USA). This study analyzed chatbot recommendations for the 20 most populous U.S. cities., Methods: Each chatbot returned 80 total recommendations when given the prompt "Find me four good ophthalmologists in (city)." Characteristics of the physicians, including specialty, location, gender, practice type, and fellowship, were collected. A one-proportion z-test was performed to compare the proportion of female ophthalmologists recommended by each chatbot to the national average (27.2% per the Association of American Medical Colleges (AAMC)). Pearson's chi-squared test was performed to determine differences between the three chatbots in male versus female recommendations and recommendation accuracy., Results: Female ophthalmologists recommended by Bing Chat (1.61%) and Bard (8.0%) were significantly less than the national proportion of 27.2% practicing female ophthalmologists (p<0.001, p<0.01, respectively). ChatGPT recommended fewer female (29.5%) than male ophthalmologists (p<0.722). ChatGPT (73.8%), Bing Chat (67.5%), and Bard (62.5%) gave high rates of inaccurate recommendations. Compared to the national average of academic ophthalmologists (17%), the proportion of recommended ophthalmologists in academic medicine or in combined academic and private practice was significantly greater for all three chatbots., Conclusion: This study revealed substantial bias and inaccuracy in the AI chatbots' recommendations. They struggled to recommend ophthalmologists reliably and accurately, with most recommendations being physicians in specialties other than ophthalmology or not in or near the desired city. Bing Chat and Google Bard showed a significant tendency against recommending female ophthalmologists, and all chatbots favored recommending ophthalmologists in academic medicine., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Oca et al.)

Purpose: To investigate demographic and physiological variables associated with clinically significant edema after upper eyelid surgery., Methods: A retrospective chart review was performed on patients who underwent blepharoplasty or external levator advancement with or without lid crease formation between January 2018 and January 2021 at the University of Southern California. Age, sex, pertinent medical history (medications causing edema and comorbidities), and pertinent surgical procedures were all collected. Postoperative photos were graded by two independent physician graders on a newly developed photographic scale ranging from 0 (no edema) to 3 (severe edema). Clinically significant edema of the eyelids was defined as Grade 3 edema at any postoperative point or ≥ Grade 1 edema after 90 days post operation. Patients without postoperative photos were excluded. Mann-Whitney U test, Fisher's exact test, and χ2 test were used to compare groups with and without significant edema. All analyses were conducted using SAS version 9.4 (SAS Institute Inc.) with α=0.05., Results: Out of 217 patients, East Asian participants had higher odds of developing edema than White participants (odds ratio, 7.92; CI, 3.15-19.93, p < 0.0001) and Hispanic participants (odds ratio, 3.47; CI, 1.51-7.97, p = 0.003). Southeast Asian participants also had higher odds of developing CSEE than White participants (odds ratio, 6.19; CI, 1.71-22.43, p = 0.006). Fifty-four (24.9%) patients had clinically significant edema. Although BMI, medical comorbidities, medication use, and age did not affect edema, there was a statistically significant relationship between race and incidence of edema (p = 0.0001). Those in the CSEE group were also more likely to require reoperation (p = 0.0143)., Conclusions: There is a statistically significant relationship between Asian race and the incidence of clinically significant eyelid edema. CSEE is associated with a higher incidence of reoperation., (Copyright © 2022. Published by Elsevier Ltd.)

Competing Interests: The authors have no conflicts of interest to disclose.

Competing Interests: None disclosed.

An isolated defect in the lateral orbital wall is an uncommon occurrence, although cases of orbital floor, roof, and medial wall spontaneous dehiscence have been described in the literature. Here, we describe a lateral orbital wall defect in a patient with thyroid eye disease - which may be related to bony remodeling or may represent a rare congenital anomaly. Computed tomography (CT) prior to decompression surgery revealed a defect in the left lateral orbital wall. At the time of orbital decompression, prolapse of buccal fat into the orbit was noted once the subperiosteal plane was entered along the lateral orbital wall in the area of this bony defect. Literature review revealed only a few previous reports of lateral wall abnormalities, including two involving the inferior orbital fissure; one other case was associated with Down syndrome, and other reports consist of sphenoid hypoplasia associated with neurofibromatosis.

Background: Sight-threatening complications from retained orbital and intraocular foreign bodies are frequently reported in literature. Delays in diagnosis can result in severe complications, including choroidal neovascularization, infection, and irreversible vision loss. Therefore, it is imperative that emergency physicians consider the possibility of orbital and intraocular foreign bodies when evaluating patients with acute facial trauma., Case Report: A 91-year-old woman with a history of laser-treated glaucoma and cataracts presented to an outside emergency department after a ground-level fall. A maxillofacial noncontrast computed tomography scan showed no facial fractures or hemorrhage, but a 41 mm × 4 mm foreign body within the intraconal compartment of the right orbit was identified. The object was presumed to be an implanted glaucoma drainage device, and the patient was discharged without antibiotics. One day after discharge, the patient developed right periorbital swelling and erythema with increasing purulent discharge and skin thickening, ultimately requiring transfer to our facility for management of complex right orbital cellulitis, orbital compartment syndrome, and surgical foreign body removal. Despite globe exploration and surgical intervention, the patient developed a frozen globe with no light perception in the right eye. Why Should an Emergency Physician Be Aware of This? Subtle ophthalmologic emergencies such as sight-threatening foreign bodies can be challenging to diagnose on imaging, particularly with the advent of implantable ocular technology. When an orbital foreign body is discovered in the context of facial trauma, early ophthalmology consultation should be considered., (Copyright © 2022. Published by Elsevier Inc.)

Background: Basal cell carcinoma (BCC) is the most common malignancy worldwide, yet the management of patients with advanced or metastatic disease is challenging, with limited treatment options. Recently, programmed death receptor 1 (PD-1) inhibition has demonstrated activity in BCC after prior Hedgehog inhibitor treatment., Methods: We conducted a multicenter, retrospective analysis of BCC patients treated with PD-1 inhibitor therapy. We examined the efficacy and safety of PD-1 therapy, as well as clinical and pathological variables in association with outcomes. Progression-free survival (PFS), overall survival (OS) and duration of response (DOR) were calculated using Kaplan-Meier methodology. Toxicity was graded per Common Terminology Criteria for Adverse Events V.5.0., Results: A total of 29 patients with BCC who were treated with PD-1 inhibition were included for analysis, including 20 (69.0%) with locally advanced and 9 (31.0%) with metastatic disease. The objective response rate was 31.0%, with five partial responses (17.2%), and four complete responses (13.8%). Nine patients had stable disease (31.0%), with a disease control rate of 62.1%. The median DOR was not reached. Median PFS was 12.2 months (95% CI 0.0 to 27.4). Median OS was 32.4 months (95% CI 18.1 to 46.7). Two patients (6.9%) developed grade 3 or higher toxicity, while four patients (13.8%) discontinued PD-1 inhibition because of toxicity. Higher platelets (p=0.022) and any grade toxicity (p=0.024) were significantly associated with disease control rate., Conclusions: The clinical efficacy of PD-1 inhibition among patients with advanced or metastatic BCC in this real-world cohort were comparable to published trial data. Further investigation of PD-1 inhibition is needed to define its optimal role for patients with this disease., Competing Interests: Competing interests: GKI reports having consulting/advisory board roles with Boehringer-Ingelheim, Novartis, BMS, Castle Biosciences, Regeneron, Sanofi; receiving research support from Regeneron, Array, Idera, Roche/Genentech, Replimune, Xencor, InstilBio, and having speaker roles for Merck. DYR reports having consulting/advisory board roles with Castle Biosciences. JCH reports having consulting/advisory board roles with Regeneron. All other authors have nothing to disclose., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Dedicated post-operative radiological evaluation following ophthalmologic procedures is relatively uncommon. However, given the ever-growing ophthalmologic procedural advancements and the increasing utilization of neuroimaging for myriad indications, the orbits are often imaged incidentally in a delayed post-procedural state. Regardless of the clinical scenario, it is important for neuroradiologists and other specialists commonly exposed to orbital imaging to be aware of both expected and abnormal post-operative imaging findings because misinterpreted normal features or unrecognized complications can result in vision-threatening delays in treatment or mismanagement. In this review article, we discuss many common ophthalmologic procedures, their indications, and most likely complications. We also provide illustrative operative photographs and radiological imaging examples. By understanding the surgical intent, recognizing the devices that are commonly used, and developing familiarity with the appearance of post-operative complications, pitfalls in interpretation can be avoided and patient outcomes ultimately improved., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: Several injectable hyaluronic acid dermal fillers exist in the market, each with different rheologic and cross-linking properties. Their reversibility is useful for managing complications. We sought to determine the response of three different hyaluronic acid gels to varying doses of hyaluronidase., Methods: Each of 18 arms of nine subjects were prospectively randomized to receive intradermal injections of hyaluronic acid gel (Restylane-L, Juvéderm Ultra, Juvéderm Voluma). Seven sites on each arm were randomized to receive 0.2 mL of hyaluronic acid gel in anticipation of dissolution 1 week later with varying doses of hyaluronidase (Hylenex), 2.5, 5, 10, or 20 units or to be a control site. The outcome measures of diameter, elevation, and firmness were measured pre-injection and at varying time points to beyond 4 years. Subjects, graders, and injectors were masked., Results: The most dramatic changes for all fillers occurred starting at the 30-min time point through 3 h time point, with continued gradual degradation through week 2. A mild dose response was found for Juvéderm and Restylane; however, a clear dose response was seen from 2.5 to 10 units for Voluma, with 2.5 units showing features more like those of saline only or no hyaluronidase control. One Restylane arm had controls lasting four years., Conclusions: All fillers had a dose response, with Voluma exhibiting it most clearly. Voluma required higher doses of hyaluronidase for dissolution, i.e., more than 20 units per 0.2 mL of filler. Restylane appeared to respond most readily to hyaluronidase, at the dose of even 2.5 units, but it also was fastest to dissolve on its own., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: Hyaluronic acid (HA) fillers can be reversed with hyaluronidase, but their dose responses are not well-characterized. We evaluated 12 fillers' in vitro responses to varying doses of recombinant human hyaluronidase (RHH)., Methods: For the 12 HA gels, 0.2 mL aliquots were placed on six slides. Samples received no injection, saline injection, or RHH (2.5, 5, 10, or 20 units). The most resistant gels received 40 units of RHH on a seventh slide. Photos of gels were taken from bird's-eye and lateral views with a ruler at multiple time points., Results: Restylane-L and Restylane Lyft were the most easily dissolvable HA fillers. Both demonstrated a significant response to 2.5 units RHH/0.2 mL. Juvéderm Ultra, Belotero, Restylane Silk, and Restylane Defyne had moderate resistance to RHH. Restylane Refyne, Juvéderm Ultra Plus, Vollure, Versa, and Voluma were most resistant, requiring more than 20 units RHH/0.2 mL for complete dissolution. Volbella was moderately resistant up to 20 units RHH but demonstrated pronounced dissolution with 40 units RHH., Conclusions: This study visually and objectively demonstrates the in vitro response of HA to dissolution by hyaluronidase. Fillers were categorized into least, moderate, and most resistant to RHH. Interesting findings include markedly different degrees of liquefaction for products used for similar indications (such as Restylane Lyft being more liquefied than Voluma), and Belotero easily flattening but retaining texture. Combined with in vivo data, this may help calculate hyaluronidase doses needed for controlled, partial reversal of commercially available HA gels., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: We evaluated the safety and efficacy of an augmented BroadBand Light (BBL™) protocol on the upper and lower eyelids in improving meibomian gland dysfunction (MGD) and/or dry eye disease (DED). Background: DED, often associated with MGD, can cause significant morbidity and accounts for 3.54 billion U.S. dollars of health care spending yearly. Intense pulsed light (IPL) has been used to treat MGD DED with some success. BBL therapy, a high-quality IPL machine, shows much promise for decreasing inflammation and redness in rosacea, as well as hyperpigmentation from sun damage. Methods: A retrospective medical chart review was performed for MGD DED and/or hyperpigmentation patients who received BBL therapy between January 1, 2015, and February 28, 2020. Inclusion criteria included patients who underwent at least one BBL treatment. Each treatment involved the upper and lower eyelids, as well as cheeks, nose, and face. Each MGD DED subject completed the Ocular Surface Disease Index (OSDI) and underwent pre- and post-treatment standard clinical examinations. Results: Forty-seven patients had treatment without significant adverse effects; all patients with MGD DED reported improvement in their dry eye or blepharitis. BBL was determined to be a safe and effective treatment. There were no changes in visual acuity ( p  = 0.555) and OSDI scores were improved ( p  = 0.016). There was one case each of mild corneal/conjunctival abrasion, temporary hyperpigmentation, and two of temporary eyelash thinning. Patients with MGD also showed significant improvement in blepharitis and reduced hordeolum frequency after BBL treatment. Conclusions: This novel IPL/BBL protocol appears safe and effective for treating dry eye and blepharitis.

Hyperpigmentation is a common concern of patients in aesthetic practice. There are various treatment options, but topical depigmenting agents such as hydroquinone (HQ) are usually a first-line option. Given HQ's side effects and potential controversy over its long-term use from prior animal studies, there is a consumer demand for non-HQ topical formulations that provide similar efficacy, but with a reduced adverse reaction profile to HQ. There is increasing evidence to support the use of selective growth factors, tranexamic acid, niacinamide, arbutin, and Vitamin C in improving hyperpigmentation. This study sought to determine whether a non-HQ topical formulation, composed of the aforementioned ingredients, could provide similar or improved efficacy to topical HQ, but with a reduced adverse reaction profile. This single-center, prospective, randomized, controlled split face study investigated the safety and efficacy of a proprietary product SKNB19 compared with hydroquinone 4% (HQ4%) in treating hyperpigmentation. Eighteen adult subjects with facial pigmentation were randomly assigned to have one side of their face treated with SKNB19 twice a day (morning and night application) and the other treated with HQ4% applied nightly. Patients used a 5-point scale to self-assess their overall appearance, and a 4-point scale to assess redness, irritation, and tolerability to the skin-brightening creams. A Wilcoxon signed-rank test was used to test whether there was a statistical difference between the two treatments. Three-dimensional imaging was performed before treatment was administered and again 1 month following treatment initiation using a Canfield Vectra 3D imaging system. Five independent reviewers comprising two dermatologists, two facial plastic surgeons, and one oculoplastic surgeon graded and performed a qualitative comparative assessment of each side of the face using the before and after images. A Wilcoxon signed-rank test was used to test whether there was a statistical difference in overall appearance between SKNB19- and HQ4%-treated sides. SKNB19-treated hyperpigmentation had a statistically significant improvement in the overall appearance of hyperpigmentation and was shown to be 28.5% better than HQ4%-treated skin in the patient self-assessment and 27% better than HQ4%-treated skin in the independent reviewer assessment. On pair-wise comparison, the independent reviewer assessment also showed that 88.2% of the SKNB19-treated sides appeared equal or better than the HQ4%-treated sides. One patient dropped out of the study because of severe intolerance to HQ4%. No patients experienced intolerance to SKNB19, and all were able to continue its use without adverse effects. SKNB19-treated hyperpigmentation also had a statistically significant reduction in irritation when compared with HQ4%-treated hyperpigmentation. Patients reported a reduction in redness when using SKNB19 as opposed to HQ4%, but these figures did not reach statistical significance. This study supports that SKNB19, a recently developed non-HQ proprietary product, is safe and effective in improving hyperpigmentation. SKNB19 significantly improved the appearance of hyperpigmentation when compared with HQ4% in both patient self-assessment and independent reviewer assessment. SKNB19 exhibited a lower adverse reaction profile and was significantly better tolerated than HQ4%. SKNB19 should be considered as a safe and effective non-HQ alternative for the management of hyperpigmentation.

Glaucoma surgeries, such as trabeculectomy, are performed to lower intraocular pressure to reduce risk of vision loss. These surgeries create a new passage in the eye that reroutes the aqueous humor outflow to the subconjunctival space, where the fluid is presumably absorbed by the conjunctival lymphatics. Here, we characterized the development and function of the ocular lymphatics using transgenic lymphatic reporter mice and rats. We found that the limbal and conjunctival lymphatic networks are progressively formed from a primary lymphatic vessel that grows from the nasal-side medial canthus region at birth. This primary lymphatic vessel immediately branches out, invades the limbus and conjunctiva, and bidirectionally encircles the cornea. As a result, the distribution of the ocular lymphatics is significantly polarized toward the nasal side, and the limbal lymphatics are directly connected to the conjunctival lymphatics. New lymphatic sprouts are produced mainly from the nasal-side limbal lymphatics, posing the nasal side of the eye as more responsive to fluid drainage and inflammatory stimuli. Consistent with this polarized distribution of the ocular lymphatics, a higher drainage efficiency was observed in the nasal side than the temporal side of the eye when injected with a fluorescent tracer. In contrast, blood vessels are evenly distributed at the anterior surface of the eyes. Also, we found that these distinct vascular distribution patterns were conserved in human eyes. Together, our study demonstrated that the ocular surface lymphatics are more densely present in the nasal side and uncovered the potential clinical benefits in selecting the nasal side as a glaucoma surgery site to improve fluid drainage.

A 70-year-old man presented with left-sided eye pain, impaired vision and restricted left ocular motility, later developing progressive visual decline with development of ataxia and incontinence. Fundoscopic examination revealed significant optic nerve head edema and hemorrhage on the left eye. Neuroimaging revealed an optic pathway mass, extending from the right optic nerve to the chiasm, which enlarged on serial imaging. After surgical excision of the mass, pathology showed a grade III astrocytoma. The patient died 16 months after presentation, which is longer than previously reported for late adult onset optic pathway astrocytoma. We believe that neuroimaging and pathological studies should be performed early in such patients to allow early diagnosis and intervention., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

We present a new clinical-radiological correlation method (AnaCOM) that aims at establishing structure-function relationships. We validated AnaCOM by assessing the location of lesions that are associated with altered performances in a well-studied task: the verbal fluency task. We retrospectively reviewed 64 brain-damaged patients who had focal lesions in a variety of cortical sites due to stroke, hemorrhage or tumor surgery. All patients were tested for verbal fluency at the time of the MRI examination. MRI volumes were normalized using a mask covering brain lesions and artifacts. The brain lesions were then segmented using the normalized MRI. In each patient, a verbal fluency score was assigned to each voxel in the segmented area. Subsequently, segmentations were superimposed and voxels were gathered in clusters defined by the overlap of the patients' lesion. For each cluster, the scores were statistically compared to those obtained by controls for the same task. This process allowed the construction of cluster-by-cluster statistical maps of anatomo-clinical correlations. As expected, the statistical map indicated that two regions were significantly associated with a deficit in the fluency task: one located in Broca's area and the other in the preSMA. AnaCOM does not require a priori selection of the location of lesions or task scores. The method complements the functional imaging techniques, as it tells which regions are necessary for a given function and it explores cortical regions as well as the white matter.

GABA transporter-1 (GAT1) plays a key role in GABA reuptake, and deletion of GAT1 leads to a largely increased GABA-induced tonic conductance in the GAT1(-/-) mice. We hypothesized that homeostatic plasticity of GABA(A) receptor-mediated inhibition takes place to balance the increased tonic inhibition and maintains stability of the nervous system. In this study, we employed the loss of righting reflex assay and compared the behavioral difference of three animal models, mice with acute, partial, and permanent GAT1 deficiency, to confirm our hypothesis. Our data demonstrated that both acute and partial block of GAT1 increased the sensitivity of mice to GABAergic sedative/hypnotic drugs, whereas permanent GAT1 dysfunction in the GAT1(-/-) mice decreased the sensitivity to some extent. These results confirmed our presumption about the down-regulation of phasic GABAergic transmission in the GAT1 knockout mice. Moreover, electrophysiological measurements performed on slices from motor cortex suggested that it was the reduced GABA release, but not change of postsynaptic GABA receptors, which led to the down-regulation of phasic inhibition in GAT1(-/-) mice.