Abstract Listings (ePosters) 2023

Analysis of Nano-Structure of Raising Rabbit Skin Enhancing Effect of Collagenase before Radiofrequency Treatment

Author: Yoo Jin Kim

Purpose

To morphologically investigate the enhancement of radiofrequency treatment effect through collagenase pre-injection in the rabbit dermal collagen fibrillary matrix.

Methods

Coupling mono-polar radiofrequency energy was administered to four limb regions of 25 New Zealand white rabbits by a non-ablative skin tightening handpiece using a Surgitron Dual Frequency Radiofrequency Device (Ellman International Inc., USA) under anesthesia. Each rabbit was treated with a power of 10, 20, and 30 W and a pulse duration of 1200 msec, receiving single and multiple passes. A total of 100 skin punch biopsies (Ø 4 mm) were harvested from all four limbs of a single control rabbit (n = 4), and 24 radiofrequency-treated rabbits (n = 96) at postoperative days 0, 2, 7, and 30. Fixed and paraffin-embedded tissues were undergone standard hematoxylin-eosin and Masson’s trichrome staining and were evaluated by two pathologists using atomic force microscopy.

Results

After the collagenase injection, the collagen layer showed initial breakdown, and after radiofrequency treatment, the collagen rearrangement was shown. In the collagenase injection group, the collagen structure was rearranged earlier, and denser and more ordered collagen structure rearrangement was shown than in the group treated with radiofrequency alone. Also, collagen diameter increased earlier in the collagenase injection group than high frequency-only group, and a larger change in collagenase injection was observed in the low energy 10 W group and single treatment group.

Conclusion

Collagenase successfully enhanced the effect of radifrequency in rabbit dermal collagen. This combination therapy can improve skin wrinkles and restore skin tightness. Using radiofrequency and collagenase simultaneously, the therapeutic effect of radiofrequency will be enhanced and less power and treatment number will be needed.

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Comparison of Efficacy between Three-Dimensional Printing and Manual-Bending Implants for Inferomedial Orbital Fracture: A Retrospective Study

Author: Jun Hyeok Kim

Purpose

The purpose of reconstruction of an orbital fracture is restoration of normal structure and volume without visible or functional complications. In a previous study, orbital implants were created using three-dimensional (3D) printing technology to restore orbital fractures. In the present study, the authors compared the efficacy of the conventional manual-bending implant and the 3D-printed standardized implant in order to verify the clinical utility of the fabricated 3D printed orbital implant.

Methods

In this single-center, retrospective study, the authors evaluated medical records and 3D-CT scans of patients with inferomedial orbital fracture. Selected patients were divided into two groups. Group A underwent surgery with the 3D-printed standardized implant, while group B was treated using a manual technique to mold and trim the implant.

Results

A total of 32 patients was included in this study, 16 in each group. The volume of the preoperative lesion side was significantly different from that of the normal side or postoperative lesion side within each group. The volume of the postoperative lesion side was not statistically different from that of the normal side in Group A, but this volume was significantly different from that of the normal side in Group B.

Conclusion

The 3D-printed standardized implant provides surgical efficacy to restore inferomedial orbital fracture and has superior surgical outcomes to the manual-bending implant.

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Restoration of the inferomedial orbital strut using a standardized three-dimensional printing implant

Author: Jun Hyeok Kim

Purpose

The inferomedial orbital strut (IOS) is the thin bony junction of the orbital medial wall and floor. Its fracture is common and leads to serious complications, including enophthalmos, globe dystopia and diplopia. However, anatomical restoration of the IOS is challenging owing to reduced structural support; sound anatomical background and accurate implants are therefore essential. The aim of the present study was to incorporate data from cadaveric orbit anatomy into three-dimensional (3D) printing technology and to reconstruct the complex orbital fracture elaborately.

Methods

After averaging the data from computed tomography (CT) images of 100 adult cadavers, the dimensions of the IOS were extracted, and a tangent sphere was created using a computeraided design program. The curves were compared with the CT data of 10 adult patients from the simulation test. Based on these data, a standardized 3D implant, 1.15 mm thick, was designed using polycaprolactone. The implant was placed in five patients with complex orbital fractures.

Results

The radius of the sphere in contact with the orbit, measuring 33.54 mm, was confirmed to be appropriate. A comparison between the normal side volume (V0) and the postoperative volume (Vpost) showed that they were statistically similar. Furthermore, a comparison between V0 and the preoperative volume (Vpre), and Vpost compared with Vpre also showed a statistically significant difference (P < 0.05). On follow-up, the preoperative ocular symptoms were resolved.

Conclusion

The orbital data obtained from 100 cadavers provided standardized orbital anatomy, and 3D printed implants were created. The implants were anatomically accurate with regard to the orbital cavity and adequately covered the simulation model. The implant also showed satisfactory results when applied clinically in actual patients.

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Müller’s Muscle-Conjunctival Resection for Treatment of Contralateral Ptosis Following Unilateral External Levator Advancement

Author: Mehmet Serhat Mangan

Purpose

One of the main causes of unsatisfactory outcomes after unilateral blepharoptosis surgery is asymmetry of the upper eyelid height, which occurs as a result of a contralateral eyelid droop. Therefore, we evaluated the efficacy of Müller’s muscle-conjunctival resection (MMCR) for the treatment of contralateral ptosis following unilateral external levator advancement (ELA).

Methods

This study analyzed 26 eyelids of 26 patients with upper eyelid height asymmetry following unilateral ELA who underwent contralateral MMCR retrospectively. Asymmetric or unilateral ptosis was defined as with MRD1 of ≥1.5 mm lower than the contralateral eyelid and more ptotic eyelid MRD1 value was equal to or less than ≤ 1 mm. The phenylephrine test was performed before ELA and before MMCR. The main outcome measures were symmetry outcomes and clinical outcomes.

Results

The mean patient age was 55.81 ± 7.98 years (range, 44–70 years); 15 were (57.7%) female. Hering’s dependency was observed in 13 (50%) of the patients before ELA. An adequate response to phenylephrine was observed before MMCR but not before ELA. Symmetry outcomes after MMCR were perfect (<0.5 mm), good (≥0.5 mm, <1 mm), and fair (≥1 mm) in 7, 17, and 2 patients, respectively. An optimal upper eyelid height was noted in 47 of the 52 eyelids after the MMCR, while three of the 52 eyelids had minimal overcorrection, and two eyelids had undercorrection. The mean change in MRD1 of the contralateral eyelid droop was greater for patients with than without Hering dependency (p < .0001) after ELA but not after MMCR. Two patients (7.6%) underwent revisional ELA surgery.

Conclusion

To the authors’ knowledge, this is the first study to evaluate the efficacy of the MMCR procedure for the management of contralateral eyelid ptosis following unilateral ELA. MMCR and use of the phenylephrine test to predict the eyelid position may represent an alternative approach in patients who require management of contralateral ptosis following unilateral ELA.

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Simultaneous posterior eyelid ptosis repair and strabismus surgery: a single-stage approach

Author: Mehmet Serhat Mangan

Purpose

Blepharoptosis with coexisting strabismus can be observed in adults, and both these conditions affect cosmetic appearance and have psychosocial effects. Both also commonly require surgery, which is typically performed using a sequential approach. A preoperative phenylephrine test can be used to predict the final eyelid position, thereby eliminating the need for intraoperative eyelid adjustments achieved with Müller’s muscle-conjunctival resection with or without tarsectomy. This study aimed to evaluate the efficacy of simultaneous Müller’s muscle-conjunctival resection with or without tarsectomy and strabismus surgery in adult patients with ptosis and coexisting strabismus.

Methods

Patients with ptosis and coexisting strabismus who underwent simultaneous Müller’s muscle-conjunctival resection with or without tarsectomy and horizontal strabismus surgery were retrospectively evaluated. Analysis included measurement of the angle of deviation in prism diopters, margin reflex distance, eyelid height asymmetry, and complications following surgery. Success of Müller’s muscle-conjunctival resection with or without tarsectomy was defined as a margin reflex distance of ≥3.5 and ≤5 mm with a difference between the two upper eyelids of <1 mm. Strabismus success was defined as alignment with ±10 prism diopters of orthotropia.

Results

The patients comprised three women and five men with a mean age of 37.1 years (range, 22-62 years). The strabismus stage of the surgery was performed first in all patients. Upper eyelid symmetry outcomes were assessed as perfect (<0.5 mm) in four patients and good (≥0.5, <1 mm) in four patients. Success of Müller's muscle-conjunctival resection with or without tarsectomy was achieved in six of eight patients (75%), and strabismus success was achieved in all patients. No revision eyelid or strabismus surgery was required following simultaneous surgery in any of the patients.

Conclusion

Müller’s muscle-conjunctival resection with or without tarsectomy combined with strabismus surgery may be an alternative approach for use in patients with ptosis and coexisting strabismus.

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IgG4-related disease of the skull base

Author: S.E. Detiger

Purpose

IgG4-related disease (IgG4-RD) is an immune-mediated, systemic, fibroinflammatory disease. IgG4-RD may manifest in almost every part of the human body. IgG4-RD of the skull base is rare and my mimic malignancy, infection or inflammation.
The objective is to describe skull base manifestation of IgG4-RD, illustrated by four cases.

Methods

Four patients with skull base IgG4-RD are presented with a literary summary.

Results

Patient 1, a 73-year-old male, presented with a mass in the left nasopharynx and clivus. Patient 2, a 73-year-old male, presented with a mass in the left petrous bone and clivus with involvement of the left jaw joint. Patient 3, a 50-year-old male, presented with a lytic lesion of the clivus and sphenoid bone. Patient 4, a 19-year-old male, presented with a mucocele. All patients complained of headache. Serum IgG4 was normal or elevated, and imaging did not show systemic manifestation. Histology established the diagnosis of IgG4-RD. Two patients were treated successfully with prednisone, hydroxychloroquine, and radiotherapy. One patient is monitored without treatment. One patient was therapy resistant to prednisone and rituximab and required multiple surgeries. Unfortunately, this patient lost vision in the left eye.

Conclusion

IgG4-RD may affect the skull base and diagnostic workup may be challenging. Careful histopathologic examination is essential for proper diagnosis. A multidisciplinary approach in the management of IgG4-RD of the skull base is warranted.

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High Double Eyelid Fold Correction Composite Using Fat Strip Transplantation and Pretarsal Orbicularis Oculi Flap

Author: Haihua Chen

Purpose

As the growing amount of unnatural-appearing upper eyelid after blepharoplasty, it’s necessary to find suitable methods for secondary revision. This study aimed to evaluate aesthetic outcomes of surgical correction of the high fold using a pretarsal orbicularis oculi flap with fat strip transplantation.

Methods

From January 2018 to September 2022, 50 patients with high and deep double eyelid folds underwent our fold-lowering procedure. All of these patients underwent surgical correction of high folds composite using fat strip transplantation and pretarsal orbicularis oculi flap, with postoperative follow-up ranging from 6 months to 2 years. All the Postoperative outcomes were recorded and reviewed.

Results

Using the composite technique, unnatural, high, and deep double eyelid folds were converted to lower and relative natural folds. Although prior high fold incision scars could be seen postoperatively on close examination, they were not easily visible. Complications included fold height asymmetry in 5 cases, persistence of the prior fold in 6 cases, and redundant upper flap skin that needed further excision in 3 cases.

Conclusion

Secondary blepharoplasty revision to correct the high fold is a challenging procedure for plastic surgeons. Using fat strip transplantation and pretarsal orbicularis oculi flap for correction of the high fold is relatively safe and effective. This provides a new treatment option in secondary revision techniques.

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Prevalence and clinical features of orbital vascular anomalies in children

Author: Gregory Griepentrog

Purpose

While vascular anomalies have been reported systemically in up to 1% of children, there are, to our knowledge, no population-based studies describing the prevalence of orbital vascular anomalies. Broadly divided into vascular tumors and vascular malformations, orbital vascular anomalies are a heterogeneous group of potentially vision threatening lesions. Herein, we present the birth prevalence, demographics, types, and ocular sequelae of orbital vascular anomalies in a pediatric patient population over 50 years.

Methods

Medical records of all children (<19 years) diagnosed with an orbital (post-septal involvement) vascular anomaly from January 1, 1966 through December 31, 2015, were retrospectively reviewed. Each diagnosis was confirmed with imaging, and when available, histopathology. A birth prevalence was calculated using the county-specific annual birth incidence of the US Census for congenital cases of patients living in Olmsted County, Minnesota, USA at the time of birth.

Results

A total of 109 children were diagnosed with an orbital vascular anomaly, including 25 from Olmsted County, yielding a birth prevalence of 1 in 4305 births. The median age at diagnosis was 1.2 (0 to 17.9) years, and 67 (61.5%) were female. There were 55 (50.5%) cases of vascular malformations [50 (91%) low-flow lymphatic malformations, 3 (5.5%) high-flow arteriovenous malformations, and 2 (3.5%) low flow venous malformations] and 54 (49.5%) cases of vascular tumors [53 (98%) orbital hemangiomas and 1 (2%) case of kaposiform hemangioendothelioma]. During a mean follow-up of 5.95 years (range 0-27.7 years), amblyopia and/or strabismus were diagnosed in 46 (43.4%) patients.

Conclusion

Within this largest series to date, we present the previously unknown birth prevalence of pediatric orbital vascular anomalies as approximately 1 in 4300 births. Hemangiomas and low-flow lymphatic malformations comprised more than 90% of the orbital vascular anomalies and significant ocular sequelae, including amblyopia and strabismus, were prominent.

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Bilateral conjunctival lymphoma revealed by chronic tearing: a case report

Author: Rihab DAAJI

Purpose

Conjunctival lymphoma is characterised by a slow and insidious development with aspecific symptoms that may be confused with those of conjunctivitis: this results in a delay in diagnosis.

Methods

This is a 75 year old man referred by his ophthalmologist for bilateral chronic tearing, for one year.

Results

The clinical examination revealed bilaterally: a white eye, a fluorescein-negative cornea, a calm anterior segment and good palpebral static. The inferior palpebral eversion revealed large pinkish conjunctival follicles, firm to palpation.There was no orbital syndrome, no enlargement of the lacrimal glands and the fundus examination was normal. A conjunctival biopsy was performed and the histological examination concluded to be a low-grade follicular B lymphoma. The extension work-up carried out in haematology found oropharyngeal and digestive dissemination. In terms of treatment, given the indolence of this subtype of lymphoma , it was decided in a multidisciplinary consultation meeting to carry out biological, clinical and radiological monitoring, and to start treatment only in the event of signs of progression.

Conclusion

When a patient over 60 years of age presents with chronic tearing, it is important to think of conjunctival lymphoma and examine the conjunctiva carefully.

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Palpebral tuberculosis : atypical presentation

Author: Rihab DAAJI

Purpose

Ocular manifestations of tuberculosis are varied. The disease may affect all ocular and orbital tissues. Eyelid infection as a primary site is unusual and can lead to delayed diagnosis, and therefore to poor management.
We report a rare case of eyelid nodules revealing ocular tuberculosis.

Methods

A rare case of eyelid nodules revealing ocular tuberculosis.

Results

A 69-year-old, otherwise healthy female presented with a painless swelling of left upper eyelid for the past 6 months. The slit lamp examination revealed firm, mildly erythematic, non-tender swelling in left upper eyelid. Examination of the anterior segment was unremarkable and visual acuity was preserved. The fundus examination was also normal. Furthermore, right eye examination showed no abnormalities. Systemic physical examination including respiratory system was normal. Laboratory work up was unremarkable. Thoraco-abdominopelvic examination revealed no abnormalities. The biopsy with histopathological examination of the lesion showed epithelioid cell granulomas in the background of dense lymphocytic infiltration of the stroma. There was nocollection of inspissated material. Instead, there was lot of friable granulation tissue. A diagnosis of upper eyelid tuberculosis was made. The patient was started on 9-month course of antituberculosis therapy (ATT), after ruling out systemic involvement. There was no recurrence at 1 year of follow-up.

Conclusion

Primary eyelid tuberculosis is extremely rare and it can mimic tumoral lesions. Biopsy helps in confirming the diagnosis in cases with clinical doubts. It is mandatory to evoke the diagnosis of tuberculosis in any ocular or orbital inflammation, because of its clinical polymorphism.

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The Effect of Ptosis Surgery on Meibomian Glands and Dry Eye Syndrome

Author: Shirin Hamed Azzam

Purpose

To investigate the effect of ptosis surgery on dry eye disease as measured by dry eye parameters and meibomian gland function.

Methods

This prospective, case series study included patients with involutional ptosis with no prior history of dry eye disease who were scheduled for levator aponeurosis advancement procedure. Dry eye evaluation included the ocular surface disease index questionnaire (OSDI) as well as objective measurements which included meibomian gland loss (MGL) measured by meibography, meibomian gland disease grading, tear break up time (TBUT), corneal and conjunctival fluorescein staining, tear meniscus height, and Schirmer testing. All dry eye measurements were recorded preoperatively and repeated 21-28 days postoperatively.

Results

A total of thirty eyes were included with mean age of 65.6 11.9 years old. There was a significant improvement in margin reflex distance1 (MRD1) postoperatively (p<0.001) and a significant decrease in upper lid margin thickening (p=0.022). There were no significant differences between the pre- and post- operative measurements in MGL, TBUT, corneal and conjunctival fluorescein staining, tear meniscus height, and Schirmer test. OSDI was increased non-significantly postoperatively (16.094 vs. 24.296, respectively, p=0.107).

Conclusion

The aim of this study was to evaluate whether anterior approach ptosis surgery affects meibomian glands and dry eye symptoms using objective and subjective measurements. The results demonstrated that although there was a significant improvement in MRD1, there was no significant alteration in the objective dry eye measurements postoperatively including meibography, nor in the patients’ subjective assessment of dry eye.Our initial results suggest that anterior approach ptosis repair does not have an effect on dry eye syndrome. Of course, the risk of dry eye is always present after manipulation of the eyelid. However, our findings can be encouraging for both patient and surgeon that the postoperative risk for dry eye is minimal.

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White apex and cicatricial active thyroid eye phenotypes: What are they and How do they behave?

Author: Shirin Hamed Azzam

Purpose

In this retrospective study we aimed to describe the clinical features, photographic, orbital imaging and the treatment of unusual phenotypes of Thyroid eye disease (TED): white apex and cicatricial active.

Methods

A retrospective review was conducted and included cases of TED with white apex and cicatricial active phenotypes between January 2020- January 2022. We analyzed the demographics data, clinical features, response to treatment and the prognosis.

Results

17 patients were analyzed. All patients were in active phase of TED despite a low overt CAS score. There were 8 patients with white apex phenotype who presented with optic neuropathy, moderate motility problems and minimal conjunctival injection. They responded poorly to immunosuppression but well to apical orbital decompression. There were 9 patients with Cicatricial active phenotype and had marked motility problems with restriction of eye movement, mild conjunctival injection with mild to moderate propotsis. Imaging revealed predominant muscle expansion. They were resistant to steroid treatment and responded better to second line immunosuppression such as Tocilizumab and Teprotumumab.

Conclusion

TED is a heterogeneous disease in its clinical manifestations and response to medical and surgical treatment. The white apex and cicatricial active phenotypes can mislead clinicians as the clinical activity score is low, but they do have active disease. These phenotypes behave differently clinically and respond to treatment modalities differently. Therefore, it is important to differentiate the phentyopes of TED to offer tailored individual management.

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Superficial temporal artery pseudoaneurysm post blepharoplasty: Case report

Author: Asaad Alhabsi

Purpose

Reporting 83 years old man with history of left upper eyelid swelling post 4-lids blepharoplasty diagnosed based on clinical presentation and Radiological imaging with pseudoaneurysm of frontal branch of Superficial Temporal Artery post blepharoplasty.

Methods

83 years old who presented to a Tertiary ophthalmic center with painless left upper eyelids swelling for 2 months post 4-lids blepharoplasty. Left subcutaneous, sub-brow lesion, in the supertemporal pre-septal area, large mass found and excised surgically. Then he developed recurrent larger mass twice first time treated with aspiration of blood, second time diagnosed with superficial temporal artery (STA) pseudoaneurysm of frontal branch treated with endovascular embolization.

Results

Pseudoaneurysm of superficial temporal artery (STA) is a rare , presenting usual post head or face trauma .literature reported few cases of such conditions post operatively, and no reported cases post blepharoplasty.

Conclusion

Surgical intervention is the gold standard of treatment either directly by dissecting the aneurysmal sac and ligate both ends, or endovascular method of injecting thrombin or embolization which was done in this patient by interventional radiologist

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Role of Doppler perfusion biomarkers in severity grading of Thyroid Eye Disease.

Author: SHALIN SHAH

Purpose

The severity of thyroid eye disease (TED) is currently decided per EUGOGO guidelines, based on clinical examination findings. TED also shows progressive retrobulbar hemodynamic changes, which may lead to orbital ischemia. The role of optic nerve head ischemia is well documented in the occurrence of dysthyroid optic neuropathy (DON). Serial orbital perfusion scans using color doppler imaging (CDI) can provide accurate disease monitoring and help predict the onset of DON.

Methods

33 eyes of moderate-to-severe TED, 15 eyes of mild TED, and 18 eyes of healthy controls were enrolled in the study. Each case underwent detailed clinical examination, CAS scoring, radiological evaluation for Barret’s index (BI), and color doppler imaging of the ophthalmic artery (OA) and central retinal artery (CRA). The peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) were evaluated. Area under the curve (AUC) analysis was done between the healthy vs TED orbits, mild vs moderate-to-severe TED orbits, and high BI vs normal BI orbits. Youden’s ratio was calculated and used to predict the potential cutoffs for discrimination.

Results

The groups were age and gender-matched. AUC analysis showed the maximum discrimination power (AUROC = 0.986) of OA-PSV to discriminate healthy vs TED orbits with a proposed cutoff of 25.4 cm/s. However, the severity of the disease was better predicted (AUROC = 0.881) by OA-EDV at the cutoff of 3.23 cm/s. OA – EDV (0.728) and OA – PSV (0.770) also showed higher discriminatory potential for high BI orbits.OA-RI and CRA-RI had little role in predicting the severity of TED.

Conclusion

Arterial velocities alter with the progression of TED. The resultant orbital ischemia can lead to DON. Serial monitoring of orbital perfusion using CDI may help early prediction of DON.

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Bilateral closed frontalis suspension Fox method with silicone rod for apraxia of eyelid opening with blepharospasm – a case report

Author: Biljana Kuzmanović Elabjer

Purpose

To present bilateral closed frontalis suspension Fox method with silicone rod for treatment of apraxia of eyelid with blepharospasm.

Methods

A 78-year-old female with apraxia of eyelid opening and blepharospasm presented with a Jankovic rating scale (JRS) frequency of 4 and JRS severity of 4. She got no relief from Botulinum toxin treatment as well as from orbicularis oculi myectomy. Bilateral closed frontalis suspension Fox method with silicone rod was performed the same day as a “day surgery”, in local anesthesia. A silicone rod was introduced through the lumen of the 18 G syringe needle (1.2×40 mm). The position of the eyelid was set to give a 3 mm wide palpebral aperture at the end of surgery. Only the central incision on the forehead was sutured. No patching was applied.

Results

On the first check-up seven days after the surgery, JRS frequency was 0 and JRS severity 1. The patient was able to go back to her regular daily activities.

Conclusion

In the patient with apraxia of eyelid opening and blepharospasm, where other established techniques of treatment yielded no improvement, bilateral closed frontalis suspension Fox method with silicone rod offered an instant relief, that lasts for months now. It was performed safely and efficiently as day surgery with local anesthesia.

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A Treatment Protocol (STS) and Long-term Results of Oral Propranolol in Peri-orbital Infantile Hemangioma

Author: Mohsen Kashkouli

Purpose

Although oral propranolol (OP) has been introduced as the gold standard treatment of peri-orbital infantile hemangioma (IH), there is no standard treatment protocol in terms of treatment duration and its tapering. Aim of this study is to report the long-term results of STS (Start, Taper, Stop) treatment protocol.

Methods

Children with IH, OP treatment, and the last follow-up (FU) age of ≥24 months + ≥4 months FU after stopping the OP (December 2008- April 2018) were included in the chart review. STS protocol was commenced regardless of age and type of IH. Main outcome was change in IH size on the photographs by 3 masked observers using Visual Analog Scale (VAS) of -100 (increased by two folds) to +100 (no IH). VAS values were also presented in 4 categories: “Excellent” (≥ 50% reduction), “Good” (1- 49% reduction), “Fair ” (no change), and “Failure” (increased by -1.00 to -100%).

Results

Orbital involvement was observed in 49% and ptosis in 58%. Amblyopia treatment was deemed necessary in 63%. Mean treatment, tapering, and FU duration were 37, 13, and 74 months, respectively. Mean age at presentation, start of OP, tapering, stop of P, and last FU were 1.5, 5, 29, 42, and 78 months, respectively. Twenty-seven patients received 2, seven 2.5, and nine 3 mg/kg/day. FUs (months) were divided into: FU1 (1-2), FU2 (2.1-6), FU3 (6.1-12), FU4 (12.1-24), FU5 (24.1-48), and FU6 (>48). Three observers’ ratings were highly and significantly correlated. Mean VAS at FU1 (43.5%) significantly (p=0.002) increased at all FUs to reach 92% at the FU6 when 97.6% of patients showed an excellent response. While a higher dose resulted in a sooner excellent response, the difference was not statistically significant. Residual skin lesion was observed in 35%. Older age at presentation was significantly correlated to the residual skin appearance. No patient ended up with amblyopia and no OP side effect was reported.

Conclusion

Long-term (mean: 74 months) results of the STS protocol, regardless of the age and lesion characteristics, showed an excellent response in 97.6% of patients with no side effect, even though 1/3 of patients ended up with residual skin lesions.

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Müller’s Muscle as a Sensory Proprioceptive Organ: Histological and Histochemical Analysis

Author: Daphna Landau

Purpose

Upper eyelid retraction is believed to be maintained solely by contraction of the levator palpebrae superioris (LPS) and frontalis muscles, together with contraction of the sympathetically innervated Müller’s muscle (MM). Several studies have suggested that the LPS also undergoes reflexive contractions, and that a visual stimulus may not be the only trigger for retractor muscles contractions. MM has also been hypothesized to contain proprioceptive neuronal structures, which elicit LPS muscle contraction by the mesencephalic trigeminal nucleus via a stretch reflex. However, these studies did not distinguish between myelinated sensory proprioceptive and large motor axons. Our aim was to identify proprioceptive structures in MM by means of histological examinations and immunofluorescent labeling.

Methods

This was a prospective cohort study in which histologic and immunofluorescence analyses of excised Müller’s muscle specimens were performed. Twenty fresh Müller’s muscle’s specimens from patients undergoing posterior approach ptosis surgery in one center between 2017-2018 were evaluated by histologic and immunofluorescent analysis. Axonal types were determined by measuring axon diameter in methylene blue stained plastic sections and by immunofluorescence of frozen sections.

Results

We identified large (greater than 10 microns) and small myelinated fibers in the Müller’s muscle, with 6.4% of these fibers being large. Immunofluorescent labeling with choline acetyltransferase showed no evidence of motor axons in the samples, rendering large axons as sensory A-beta fibers, likely proprioceptive. In addition, we identified C-fibers using double labeling with peripherin and neural cell adhesion molecule.

Conclusion

Overall, large myelinated sensory fibers are present in the Müller’s muscle, likely serving proprioceptive innervation. This therefore suggests that proprioception may have a role in eyelid spatial positioning, in addition to visual deprivation, as a stimulus to retractor activation. This finding sheds new light on our understating of this complex mechanism.

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Müller’s Muscle as a Sensory Proprioceptive Organ: Histological and Histochemical Analysis

Author: Daphna Landau

Purpose

Upper eyelid retraction is believed to be maintained solely by contraction of the levator palpebrae superioris (LPS) and frontalis muscles, together with contraction of the sympathetically innervated Müller’s muscle (MM). Several studies have suggested that the LPS also undergoes reflexive contractions, and that a visual stimulus may not be the only trigger for retractor muscles contractions. MM has also been hypothesized to contain proprioceptive neuronal structures, which elicit LPS muscle contraction by the mesencephalic trigeminal nucleus via a stretch reflex. However, these studies did not distinguish between myelinated sensory proprioceptive and large motor axons. Our aim was to identify proprioceptive structures in MM by means of histological examinations and immunofluorescent labeling.

Methods

This was a prospective cohort study in which histologic and immunofluorescence analyses of excised Müller’s muscle specimens were performed. Twenty fresh Müller’s muscle’s specimens from patients undergoing posterior approach ptosis surgery in one center between 2017-2018 were evaluated by histologic and immunofluorescent analysis. Axonal types were determined by measuring axon diameter in methylene blue stained plastic sections and by immunofluorescence of frozen sections.

Results

We identified large (greater than 10 microns) and small myelinated fibers in the Müller’s muscle, with 6.4% of these fibers being large. Immunofluorescent labeling with choline acetyltransferase showed no evidence of motor axons in the samples, rendering large axons as sensory A-beta fibers, likely proprioceptive. In addition, we identified C-fibers using double labeling with peripherin and neural cell adhesion molecule.

Conclusion

Large myelinated sensory fibers are present in the Müller’s muscle, likely serving proprioceptive innervation. This therefore suggests that proprioception may have a role in eyelid spatial positioning, in addition to visual deprivation, as a stimulus to retractor activation. This finding sheds new light on our understating of this complex mechanism.

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An Unusual Tumor of the Eyelid: Childhood Pilomatricoma

Author: Asma ZAGHDOUDI

Purpose

To report a case of childhood eyelid pilomatricoma masquerading as Chalazion.

Methods

A single case report

Results

A 14–year-old healthy boy, with a history of surgical excision of a chalazion of the right upper eyelid six months ago, presented to our department for slowly growing, painless nodular mass of the right upper eyelid. Ocular examination showed the presence of a large mass of the outer portion of the upper right eyelid measuring 10*1 mm. The mass was nontender, hard in consistency, and could not be moved over the underlying structures. Ultrasonography showed a subcutaneous ovoid mass with heterogeneous echo structure tissue and mixed blood supply. Total surgical excision was performed. Histopathological examination concludes to the diagnosis of pilomatricoma. After a follow-up period of 6 months, there was no evidence of local recurrence.

Conclusion

Pilomatricoma is a benign skin neoplasm arising from the matrix cells at the base of hair. It uncommonly manifests on the eyelid areas, and when it does, it is often mistaken clinically for chalazion. Treatment consists of surgical excision, and recurrence is rare after complete resection.

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Eyelid non-melanoma malignancies – always quite challenging

Author: Zuzana Prídavková

Purpose

Basal cell carcinoma (BCC) is the most common skin cancer of the eyelids. Surgery is the first line treatment of the BCC. The integrity of the eyelids and its function is important for protecting and preserving the function of the eye globe. The shape of the tumour, the distance from the eyelid margin and its diameter are important to choose the best surgical technique. The histopathological examination is essential as well as prognostic biomarkers of biological behaviour of the cancer.

Methods

We analysed data of patients clinically diagnosed with BCC of the eyelids between 2019 and 2023. Data on epidemiological parameters, localization, size, clinical type of lesion, size of resection margins were collected and analysed. We evaluated selected prognostic markers in relation to biological behaviour of tumour, development of recurrence and metastases.

Results

We found 28 BCCs of the eyelids (n=28) in 27 patients, median age was 66 years (range from 14 to 90 years). The male/female ratio was 1:0,93. More than 39 % of all BCC’s were located on the lower lid. The nodular BCC was the most frequent type (60,7 %), followed by the nodular-cystic (14,3 %), infundibulocystic (10,7 %), cystic (7,2 %) and morphoeic (7,2 %) types. Surgical margins less than 2 mm were taken in 39 %. Aggressive type of BCC occurred in 5 eyes (17,8 %). Tumour size more than 0,5 cm was noted in all aggressive types. The smaller size of the tumour (stage T1) simplifies the surgical reconstruction and better functional and cosmetic results can be achieved. We excided the suspected tumour using flaps in 2 cases. R1 resection was observed in 2 cases (7,1%). Expression of Bcl-2 and apoptotic index were evaluated as prognostic markers of biological behaviour of BCC. Adjuvant radiotherapy was not indicated. There were no cases of the recurrence.

Conclusion

Functional and aesthetic outcome in patients is important after clear excisions and reconstruction should be carefully considered. The prevention of BCC is based on the knowledge of risk factors, early diagnosis and treatment.

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Dermoscopy Demonstrates Excellent Results for Examining Eyelid Lesions

Author: Hanna Barinova

Purpose

To define if a dermatoscope, an essential hand-held device used by dermatologists for diagnosing skin lesions, can be particularly useful for examining the surface and subsurface structures of periorbital, eyelid, and conjunctival lesions.

Methods

A 10x dermatoscope was used to take pictures of lesions with enhancing light features. The instrument was attached to a standard cell phone camera. Written informed consent was obtained from each participant prior to participation. The images were assessed for diagnostic utility by a team of one oculoplastic surgeon and two dermatologists.

Results

120 patients were enrolled prospectively from July 2021 to March 2023. Of those, 98 patients (117 lesions) had high quality dermoscopic pictures to assess the extent and depth of the lesion under tenfold magnification. 81 of the lesions were biopsied with 53 being benign and 28 malignant. There were 91 skin lesions, 24 conjunctival lesions and 2 iris lesions.

Conclusion

Dermoscopy demonstrated the high number of lesions that could be photographed for analysis and possible diagnosis. The use of dermoscopy is painless and safe. The dermatoscope is a powerful diagnostic tool producing high quality images due to its polarizing and pigment-enhancing light. The potential use for study of eyelid and conjunctival neoplasm is great and can provide important information about the lesion’s structure, vascular patterns, and potential aggressiveness.

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Orbital Extramedullary Plasmacytoma masquerading as Lacrimal Gland tumor: a Case Report

Author: Konstantin Gushansky

Purpose

To report an unusual case of Orbital Extramedullary Plasmacytoma and to discuss various clinical manifestations of this condition in recent literature

Methods

Extramedullary plasmacytomas are solitary tumors consisting of neoplastic plasma cell proliferations that occur in locations other than bone. Most extramedullary lesions occur in the upper respiratory tract. Orbital involvement, although uncommon, poses great risks to both vision and life.

Results

A 66-year-old man presented with worsening left upper eyelid swelling and redness for a week, as well as new onset diplopia and weight loss. Unilateral proptosis and hypoglobus were noted, and extraocular movements were limited.Imaging showed an extraconal mass with globe displacement and bone destruction. The mass was first suspected lacrinal gland tumor. However, when biopsy results returned normal, a sub-periosteal origin was determined following a radiology consult.An urgent biopsy was performed, with notable intraoperative bleeding from the lesion and eroded infiltrated bone. Pathology results were consistent with extramedullary plasmacytoma, and hematological workup was diagnostic of Multiple Myeloma. The patient was started on systemic chemotherapy.The disease course was complicated by a pathologic humeral fracture, which was treated after patient stabilization. After two cycles of systemic chemotherapy, there was significant improvement in pain, proptosis and extraocular movements.

Conclusion

[A discussion of recent literature follows]The clinical presentation of orbital plasmacytoma is highly versatile and clinically challenging. The most common presentation is subacute progressive unilateral proptosis in a middle-aged man. Variable amounts of pain, diplopia and visual loss might be present. Additional signs, including palpable orbital masses, epistaxis, and cranial nerve palsies, may also be found. Orbital plasmacytoma may be the first manifestation of systemic disease. A high index of suspicion and a multidisciplinary approach are needed to diagnose and manage this potentially devastating, albeit rare, condition.

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Management of a Rare Case of Adult-Onset Asthma and Periocular Xanthogranuloma (AAPOX)

Author: Arshi Kabir Baig

Purpose

We present a rare case of AAPOX and discuss the challenges involved in managing this complex condition, given the limited evidence base for current treatment options.

Methods

We conducted a literature review to identify various treatment modalities for AAPOX. We describe the management of a 38-year-old patient with AAPOX-related periocular swelling, including the use of intralesional steroid injections (triamcinolone). The triamcinolone was delivered via a 25-gauge needle with 40mg given into each side.

Results

The most common initial treatment approach involves systemic treatment with high-dose steroid therapy, followed by either an anti-metabolite or an immunosuppressant. Orbital radiotherapy, intralesional steroid injections and debulking surgery has been reported to manage periorbital swelling. In this patient’s case, systemic steroid therapy had a good effect in reducing the size of the lesions but unfortunately resulted in steroid induced diabetes. The patient was reluctant to undergo debulking surgery and as had responded well to systemic steroids elected to trial intralesional steroid injections of triamcinolone. We initiated a course of 6-weekly intralesional triamcinolone therapy, resulting in reduction and softening of periocular swelling.

Conclusion

This case demonstrates that intralesional triamcinolone therapy may offer a less invasive alternative with fewer systemic side effects for treatment of periocular inflammatory disease, such as AAPOX. This approach may be considered in other orbital inflammatory conditions before attempting more invasive treatment options such as orbital surgery.

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Diagnosis of orbital lesions: strengths and pitfalls of fine needle aspiration cytology

Author: Margarida Baptista

Purpose

Fine-Needle Aspiration Cytology (FNAC) has been gaining relevance in our clinical practice in the diagnostic workup of orbital and adnexal lesions. The aim of this study was to describe the results of FNAC performed as a primary approach in the diagnosis of orbital lesions, in a tertiary cancer center.

Methods

Retrospective observational study conducted at Instituto Português de Oncologia de Lisboa Francisco Gentil through review of clinical charts and anatomopathological reports of patients who underwent FNAC of orbital lesions between 2011-2021.

Results

Twenty-two FNAC samples of orbital tissues were performed in 21 patients/lesions (mean age 60.9 ± 24.1 years). Three lesions (14.3%) were in the lacrimal gland, 1 (4.8%) in the lacrimal sac and the remaining 17 (81.0%) lesions were located elsewhere in the orbit. Only 5 (23.8%) patients underwent incisional biopsy after FNAC to confirm diagnosis, and the remaining were directly referred for definitive medical or surgical treatment. There were no complications. Concerning the final diagnosis, 1 case (7.7%) had a benign etiology and the remaining 12 (92.3%) were malignant. There were no discordant results between FNAC and subsequent incisional/excisional biopsy. Three (14.3%) FNAC procedures were inconclusive. The main limitation of FNAC was collecting sufficient tissue to provide a diagnosis.

Conclusion

FNAC should be considered in the initial approach of orbital and adnexal lesions in selected cases, since it is a fast, safe and reliable technique. The current study describes its utility as a tool for initial screening, allowing a prompt and adequate therapeutic referral.

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Eye Rate it! Patient satisfaction with the new ‘one stop’ Minor Operations Service (MOPS) at Milton Keynes University Hospital (MKUH)

Author: Arshi Kabir Baig

Purpose

A new ‘one stop’ minor operations service (MOPS) was recently introduced for patients with oculoplastic conditions at MKUH. Patients requiring minor eyelid procedures, such as eyelid lesion biopsies and chalazion incision and curettage, were previously initially assessed in an outpatient clinic, and if listed for surgical intervention, placed on waiting list for the procedure to be performed in surgical theatres. This resulted in an extended waiting times and multiple hospital visits. Since the introduction of the MOPS service, new suitable referrals have been booked directly to MOPS clinic, achieving a one-stop service with assessment and surgery performed at the same visit. This led to reduced number of patient visits, thus providing a more efficient and cost-effective service. This study aims to evaluate the patients’ perspective with the new MOPS clinic, an important aspect in the implementation of any service change.

Methods

We used an anonymous validated questionnaire, the Visit-Specific Satisfaction Questionnaire (VSQ-9), to assess patient experience. The questionnaire measures 9 outcomes on a 5-point scale, which was converted to a 100-point scale for analysis. We also conducted a thematic analysis of the comments section.

Results

Over the first 4 months of the introduction of this service, we had high response rate of 100% to the questionnaire (93 responses). 76% of patients rated the overall visit “Excellent”, with technical skills and personal manner receiving 88% and 91% of excellent ratings, respectively. The sections of the questionnaire pertaining to the clinician’s skill and manner were rated highly. However, those relating to administrative issues (waiting times, scheduling of appointment) scored poorly, also congruous with our findings in the thematic analysis of the comments. The waiting time from referral to minor procedure was reduced from 12 to 3 months.

Conclusion

We found our new ‘one-stop’ MOPS clinic achieving high patient satisfaction, in addition to providing more effective service. We aim to maintain this high standard of care and make necessary changes based on patient feedback.

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Functional outcome and patient satisfaction for involutional ptosis repair 2017-2022

Author: Christine Safieh

Purpose

Reviewing outcomes of aponeurotic ptosis repair in a tertiary referral centre. Comparing results with Quality Standards for Oculoplastic Surgery Services (2021) and British Oculoplastic Surgery Society: National Ptosis Survey (2008).

Methods

Retrospective analysis of 108 patients who underwent anterior approach aponeurotic ptosis repair for involutional ptosis at University Hospitals, UK, between Jan 2017 to October 2022. Data collected included: demographics, pre and post upper marginal reflex distance, revisions cause and time, type of suture, complications and patients satisfaction

Results

Patients age range 21-92 yrs with average 66.5 yrs. F:M ratio 64:44. Ptosis Severity: Severe 29.32 %, Moderate: 39.85%, Mild 30.83%. Average pre-op MRD1: 1.157 mm, and post-op 3.311 mm. Mean MRD1 improvement 2.124 mm. Success rate: 76.7% full success, 6.76% partial success, failure 16.54%. Revisions: 5.88% unilateral ptosis, 38.46% BE ptosis corrected at 2 stages, 27.27% BE ptosis corrected at one stage . 83 eyes were operated by trainees with success rate of 76% and 51 eyes were operated by consultants with success rate of 76.5%. Patient satisfaction: 85% happy, 15% unhappy. Complications: Infection, swelling, overcorrection, dry eye, lid show asymmetry and eyelid hematoma

Conclusion

Majority of aponeurotic repairs have good outcomes with high patient satisfaction rates. Documentation of pre and post-op MRDs, LF and patient satisfaction needs to be improved. Authors suggest several options for faster and standardized measurements including preprinted chart, clinical photography or artificial intelligence. Further studies to reassess efficacy of such tools, are needed. Bilateral ptosis correction outcome is a tricky due to low numbers of patients, yet there is a trend towards high revisions. Both trainees and consultants had similar success rate despite of the severity and complicity of the ptosis. There was a high rate of 9.6% re do compared to BOPSS study, yet the success rate was 76.7% vs BOPSS <60%.

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5 Years outcome of DCR surgery in tertiary referral Centre.

Author: Christine Safieh

Purpose

Reviewing outcomes from external and endonasal DCR surgeries performed at tertiary referral centre before and after Covid -19 pandemia. Understanding seasonal variation in numbers of DCR surgeries performed and its effect on listing for surgery and success.

Methods

Retrospective study of 241 patients who underwent DCR surgery at University Hospital, UK, between Jan 2017 to April 2022. All surgeries performed by consultant surgeon or senior oculoplastic fellow. Data collected: demographics, presenting symptoms, time between presenting and treatment, type of procedure, revisions, complications, and patients’ satisfaction.

Results

241 patients were admitted for 270 surgeries. Mean age 73, F:M ratio 2:1. 25 patients underwent more than one DCR, 14 had re-do on the same eye, 11 on other eye. 91.5% were endonasal DCR, and 7.5% external. No seasonal variation in DCR operations numbers noted, but December month had the least numbers performed. Most common presenting symptoms epiphora and dacryocystities. 25 patients had previous ponctuplasty, 8 intubation and punctoplasty, 22 only intubation, 31 had previous DCR and 175 had no previous procedures trailed. Average waiting time from listing to operation increased from 3.7 months (pre-covid) to 10.7 months. No increase of surgery complicity was noted due to the delay, nor recovery or success rate. However, patients reported reduced life quality and prolonging of their suffering. Majority of patients had no post-operative complications (76%). Most common complications were failure and infection. Overall DCR surgery satisfaction rates were >95%, endonasal and external DCR combined

Conclusion

Endonasal has become more common than external DCR with high success and satisfaction rate. Revisions mainly due to unresolving epiphora. Complications were minor and reversible. No statistically significant seasonal variation found but winter months noted least numbers performed. Covid pandemia had highly affected waiting time for the surgery and highly affected the patients life quality and daily life.

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Diagnosis of orbital mass lesions: clinical, neuroradiological and pathological recommendations

Author: Christine Safieh

Purpose

Determining the pathology types seen in a tertiary referral centre in the UK.

· Comparing accuracy of clinical and radiological diagnoses of orbital tumours versus Histological diagnoses.

Methods

Retrospective analysis of 93 patients who underwent lacrimal gland or orbital biopsy at Leeds Teaching Hospitals, UK, between Jan 2017 to December 2022. Data collected included: demographics, presenting symptoms, systemic medical history, clinical diagnosis, imaging type and report, time from referral to surgery. Clinical and radiological diagnosis were compared to the histopathological diagnosis to determine their accuracy.

Results

93 patients underwent orbital or lacrimal gland biopsy within the 5 year time period. Female to male ratio was 56:37 with an average age being 45 years old. Radiological reports were available in 92 cases. The most common imaging was MRI in 46 patients with 33 patients having CT. 13 patients had both MRI and CT.

Radiological diagnoses was not offered in 15% of cases. Clinical diagnosis was not suggested in 12.3% of cases.

Histological diagnosis confirmed 26 cases of lymphoma, 11 chronic inflammation, 9 dermoid, 9 nonconclusive, 5 metastasis, 5 normal histology, 3 dacryoadinitis, 3 cavernous hemangioma, 4 lipoma, 2 solitary fibrous tumours and 1 IgG4 Rd.

Concordance between clinical, histology and neuroradiology reports was found only in 38 cases (40.86%).

One patient had a per-operative complication of a dilated pupil due to the surgery but this did not affect his vision afterwards. Postoperative complications included: 3 cases of ptosis, 2

cases of persistent eyelid swelling, one patient having a pyogenic granuloma with one case of post-op entropion.

Conclusion

Concordance was found in approximately 41%. 73.07% of lymphoma cases were correctly diagnosed by neuro- imaging prior to biopsy. Having 2 types of imaging done did not improve accuracy of diagnosis. Histological diagnosis remains the gold standard to determine orbital lesions of unknown cause

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Outcomes of patients with orbital lymphoma at a tertiary referral centre 2017-2022

Author: Christine Safieh

Purpose

Reviewing incidence of orbital lymphoma in orbital biopsies taken at tertiary referral centre. Comparing pathology versus HMDS diagnosis. Understanding clinical presentation, treatment and long term sequala of lymphoma orbital patients.

Methods

Retrospective study of 93 patients underwent lacrimal gland or orbital biopsy at University Hospital, UK, between Jan 2017 to December 2022. Data collected: demographics, presenting symptoms, time between referral and surgery, type of surgery, Histopathology and HMDS reports, systemic medical history, treatment, recurrence and long term sequelae.

Results

26 patients were diagnosed with lymphoma, 4 cases had discrepancy between histopathology and HMDS results. Female to male ratio 1:1. 15 patients had local disease and 11 had systemic. Only 2 patients had bilateral findings. Presenting symptoms included: Eyelid swelling, Proptosis, Ptosis, diplopia, Persistent LG swelling, Epiphora and conjuctival mass. Average time between referral and surgery was 80 days. Average time between biopsy and pathology result was 26 days. Treatment was coordinated with haematology team and according to the extent of the disease. 17 diagnosed with DLBCL, 3 follicular and 6 marginal B cell lymphoma. 16 patients treated with radiation, 6 with chemotherapy and 4 with immunotherapy. Only one patient with local disease had recurrence and is still under monitoring. Long term follow up showed improvement under proper treatment in most local disease patients, only minority has persistence symptoms. 4 patients with systemic disease died within 2-3 years.

Conclusion

: Lymphoma incidence among orbital biopsies was found to be 27.98%, with most common site anterior orbit and lacrimal gland. Equal incidence among both genders. 42.3% had systemic involvement and mortality rate in our series was 15.38%.
There was 16% discrepancy in initial Histopathology and immunophenotype studies. Advanced diagnostic test results are mandatory prior to informing the patient of the results and refer for treatment, though it causes delay by few days.

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Granular cell tumour mimicking a chronic dacrocystitis

Author: Priya Bhatt

Purpose

Granular cell tumour is a rare soft-tissue tumour which is usually benign. The most common location is the skin and subcutaneous tissue of the head and neck, with only 3% arising in the orbit. The most frequently reported symptoms of orbital granular cell tumours are diplopia and proptosis, with 79% presenting with an ocular motility issue. The most common location is within the inferior half of the orbit. We present an unusual case of granular cell tumour mimicking a chronic dacrocystitis.

Methods

A 57 year old female was referred to the Oculoplastic clinic with epiphora and a left medial canthal swelling which had been present for several months. She reported that the lesion fluctuated in size. She had no past ocular history and a past medical history of chronic obstructive pulmonary disease and arthritis of the knee. On examination she was found to have a mass in the medial canthal region. The mass felt firm and fixed with no posterior extent palpable and extended above the medial canthal tendon. A sac washout through the inferior punctum showed patency with no regurgitation. In view of the findings, a possible maligancy was suspected and an urgent CT orbits was arranged. CT imaging showed a 10mm, round, solid and contrast-enhancing (extraconal) mass medially to the globe and distal tendon of the medial rectus. An MRI orbit was recommended which showed a small left medial orbital extraconal rounded lesion attached to the subcutaneous tissues and inferior-medial aspect of the left globe. An orbital incision biopsy was performed followed by an en bloc excision biopsy.

Results

We present our case with a discussion regarding differential diagnosis, our operative finding and the post-operative outcome. We consider the pathogenesis, imaging, histopathology results, and best management for granular cell tumours.

Conclusion

Granular cell tumour is rare within the orbit, but should be considered as a differential in patients presenting with an orbital or medial canthal mass and epiphora when a discreet soft tissue lesion isodense relative to extraocular muscles and brain tissue can be seen on imaging.

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Recurrent Chalazion in the young and the elderly – Thinking beyond sebaceous gland carcinoma!

Author: SHALIN SHAH

Purpose

A recurrent chalazion is a red flag for malignancy, classically sebaceous gland carcinoma (SGC). Elderly and immunocompromised cases are primarily predisposed to ocular adnexal malignancies. We present two cases, with a recurrent upper eyelid chalazion, suspected to have SGC.

Methods

Case 1: 75-year female came with recurrent swelling of the right upper lid for 8 months. A 10 x 6 mm firm nodular, yellowish lesion with dilated vessels, loss of eyelashes & ulceration on lateral one-third of the right upper eyelid suggested possible SGC. No palpable lymph nodes and negative systemic metastatic workup. A wide excision was done, followed by lid and lateral canthus reconstruction were done using a periosteal flap and Tenzel skin flap.
Case 2: 35-year female came with recurrent swelling on her left upper eyelid for 2 years. A 15 x 10 mm firm, nodular mass was palpated on the medial one-third of the upper eyelid, with symblepharon formation underneath the swelling. No palpable lymph nodes, negative systemic metastatic workup, and negative workup for immunocompromised status. A wide excision was followed by lid and medial canthus reconstruction were done using a periosteal flap and Cutler-Beard advancement flap.

Results

Case 1: Histopathology confirmed atypical cells with palisading and separation artifacts, suggestive of nodular basal cell carcinoma (nBCC). 3 mm margins were clear. The final diagnosis was BCC T1c N0 M0. The patient has no recurrence and a satisfactory cosmetic outcome at 16-month follow-up.
Case 2: Histopathology confirmed atypical small blue round cells with immunohistochemistry markers positive for synaptophysin, chromogranin, TTF – 1, CK20, and CAM 5.2. This was suggestive of Merkel cell carcinoma (MCC). 4 mm margins were clear. The final diagnosis was MCC T2 N0 M0. The patient has no recurrence and a satisfactory cosmetic outcome at 5-month follow-up.

Conclusion

The atypical presentation of eyelid malignancies is well documented. BCC and MCC can be potential mimickers of SGC, in the form of recurrent chalazia. Hence, these rare diagnoses can be missed. Detailed histopathology of every lid mass is essential.

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Surgical outcome of Trachoma related eyelid and adnexal pathologies in tertiary eye hospital for the past 30 years

Author: Mohammad AlSemari

Purpose

Trachoma is considered one of the most common causes of preventable blindness worldwide. This infection can lead to multiple ocular sequelae affecting the eyelids, lacrimal system, and conjunctiva. Our aim is to evaluate the surgical outcomes of Trachoma related eyelid and adnexal pathologies for the past 30 years.

Methods

A retrospective study was conducted at King Khaled Eye Specialist Hospital in Riyadh, SA. All reported cases of trachoma in the period of January 1990 to January 2022 were included. Different surgical interventions for entropion, punctal stenosis/obstruction, trichiasis and their outcome were documented.

Results

542 patients with Trachoma underwent surgical interventions as the primary management for their clinical presentation. The most common presenting sign was eyelid malposition (entropion) in 315 patients and tarsotomy was the most common surgical procedure performed with a success rate of 90.8%. Punctuplasty, was the most common surgical intervention among patients who presented with punctal stenosis with a success rate reaching 85%.

Conclusion

Trachoma used to be a public health problem in certain countries worldwide affecting a large number of patients. There is no gold standard surgery for trachomatous ocular consequences and it is usually tailored toward patient presentation, and surgeon experience. Tarsotomy, punctoplasty, and electrolysis in this study showed to be effective in treating trachomatous sequelae with satisfactory outcomes.

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Adult xanthogranulomas of the orbit and IgG4-related disease: case reports and literature review

Author: Ana Duarte

Purpose

To present two cases of adult xanthogranulomatous diseases of the orbit (AXGDO) with clinical and histological manifestations overlapped with features of IgG4-related disease (IgG4-RD). A literature review of AXGDO associated with IgG4-RD is also performed.

Methods

Two case reports are presented with a review of existing English literature on AXGDO association with IgG4-RD.

Results

We present 2 cases of progressive yellow eyelid swelling. In the first case, imaging showed proptosis and bilateral enlargement of the extraocular muscles. An eyelid biopsy was compatible with a xanthogranuloma with increased IgG4+ plasma cells. In the second case, the histopathological examination was similar to case 1. However, the patient developed other features compatible with systemic IgG4 RD. Since 2007, 32 cases of AXGDO with increased IgG4+ plasma cells in xanthogranuloma biopsies have been reported. Of these, 18 were adult-onset asthma and periocular xanthogranuloma, five were necrobiotic xanthogranuloma, and nine were adult-onset xanthogranuloma.

Conclusion

AXGDO is a group of rare infiltrative diseases of the eyelids and orbits that share histological features. A possible association with IgG4-RD was recently suggested and remains controversial.Considering the most recent diagnostic criteria of IgG4-RD, only 6 of the 32 reported cases could fulfill the required features. In 5 other cases, IgG4 RD is highly questionable, and in the remaining 21 cases, this relationship cannot be established. Considering these data, our first patient can be viewed as an AOX with increased IgG4+ plasma cells on eyelid biopsy, and the second case AOX with IgG4-RD.IgG4 is a non-inflammatory and tolerance-inducing antibody that can be increased in biopsies of several inflammatory non-IgG4-RD orbital disorders. Authors should be cautious about drawing definitive conclusions about the co-existence of AXGDO and IgG4-RD. Future research on genetic aspects, management, and prognosis of IgG4 increase in AXGDO and other orbital conditions is recommended.

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The Difference between Nasal and Temporal Intraconal Orbital Fat Density on Computerized Tomography

Author: Daphna Landau

Purpose

The evaluation of orbital pathologies typically includes imaging studies, such as computed tomography (CT) scans. The density of the intraconal orbital fat can vary with different orbital pathologies. This study aimed to investigate the potential difference between nasal and temporal orbital fat density.

Methods

The data of 54 patients who underwent orbit CT scans at the Sheba Medical Center in 2022 were analyzed. Intraconal orbital fat density was measured using Hounsfield units (HU) in six areas consisting of nasal and temporal sites. Patients with abnormal findings on imaging in any orbit were excluded.

Results

Fifty-four patients were included, 29 females (54%), mean ± standard deviation (SD) age 45.3±25.5 years. Non-contrast-enhanced (NCE) CT was available in 36 patients (67%), and contrast-enhanced (CE) CT in 31 patients (57%), 13 of the patients had both CE and NCE scans. HU values were significantly higher in the nasal orbit compared to the temporal orbit on both NCE-CT (-75.8±7.5 nasal vs. -78.1±8.4 temporal, P < 0.001) and CE-CT (-72.7±6.7 nasal vs. -74.6±8.6 temporal, p=0.02). Age, gender, and laterality had no effect on HU values.

Conclusion

Nasal intraconal fat is denser than temporal intraconal fat as observed both on CE and NCE-CT. These results may suggest anatomical variance between these tissues and may have important clinical implications in diagnosing various orbital pathologies.

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Surgical reconstruction of medial defects with eyelid margin transposition, tarsal graft, and periosteal strip

Author: Georgi Balchev

Purpose

Medial lower eyelid defects and medial canthus defects were challenging for surgical reconstruction due to the uneven terrain in the nasal region, lacrimal puncta, and the frontal facial location of the surgical defect, which became part of the patient’s appearance. The possibilities for reconstruction of large medial lower eyelid defects were many, but most of them leave a reconstructed medial eyelid margin without eyelashes in the frontal face area. The absence of eyelashes in the medial part of the eyelid was frontal to the face, making it visible and leading to a compromised cosmetic result. The objective is to show the cosmetic results of surgical reconstruction after tumour excision of the lower eyelid in the nasal part in patients treated at the Eye clinic – Medical University Pleven, Bulgaria.

Methods

After the excision of the tumour, a reconstruction was made, with medial transposition of the intact temporal part of the eyelid. After the healthy eyelid was transpositioned and medially sutured, a new temporal defect was formed, which must be addressed. The posterior lamella of this temporal defect was reconstructed with a tarsal graft sutured to a periosteum strip and the anterior with a skin-muscle flap or free skin graft for larger defects.

Results

As seen in the pictures, medial transposition shows a much better cosmetic result than only covering the temporal defect.

Conclusion

The absence of eyelashes and normal eyelid margin was more tolerated when it was temporary from a cosmetic point of view, since it was not a direct part of the frontal view of the face. The medially transposed lateral part of the lower eyelid provided good aesthetic and functional results. Taking a rectangular tarsal graft was limited in width by the crescent shape of the upper tarsus. This, on the one hand, necessitated compensating the missing length by preparing a periosteum strip, and on the other hand, this periosteum strip provided firm fixation of the donor tarsus and formation of an intact posterior lamella. The combination of several primary surgical procedures provided us with a wonderfully functional and cosmetic result.

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A novel biomarker for early detection of eyelid basal cell carcinoma risk

Author: Wanlin Fan

Purpose

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. The identification of new biomarkers for early BCC detection, recurrence and progression is urgently needed. The main objective of this research project is to assess whether micronuclei (MN) frequencies detected by cell division block micronuclei (CBMN) can be used as a potential molecular biomarker to identify individuals at increased risk for basal cell carcinoma.

Methods

Chromosomal damage (expressed as frequencies of MN, nucleoplasmic bridges (NPB), and nuclear buds (NBUD)) was evaluated by CBMN assay in cryopreserved lymphocytes from 102 age/smoking-matched pairs of cases and controls in relation to BCC risk, recurrence, and progression. Moreover, these results are then correlated with sociodemographic parameters such as age, gender, origin, occupation, and income, as well as UV radiation exposure.

Results

Cases had a mean MN frequency of 34.70±10.15 compared with 16.05±6.15 of controls. The mean NPB frequency in cases was 15.30±7.80 compared with 7.30±3.04 of controls. The mean NBUD frequency in cases was 5.06±3.36 compared with 3.99±2.44 of controls. MN, NPB, and NBUD frequencies were significantly higher in BCC cases than in controls (P <0.0001, P <0,0001, and P <0,0001, respectively).

Conclusion

The findings of this study suggest that the MN, NPB, and BUD frequency may serve as a promising biomarker for the diagnosis, evaluation of recurrence, and progression in patients with BCC.

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Traction Applying Technique on Bicanalicular Crawford Silicone Tube to Overcome the Notching Deformity After Lacrimal Canalicular Repair

Author: Sang Oon Baek

Purpose

Lower eyelid avulsion injury with lower canalicular laceration generally occur just medial to the punctum with insuffcient skin remnant for repair causing tension on repair margins. The inevitable blinking force, along with the tension widens the repair margin, resulting in an aesthetically challenging notch at the medial lower lid. The authors attempted to minimize this notching deformity with a traction applying technique on bicanalicular silicone tube.

Methods

Fifteen patients were enrolled and divided into 2 groups: the experimental group with 10 patients which received the traction technique, and the control group with 5 patients which the traction technique was omitted. Each end of the bicanalicular silicone tube was intubated through both puncta and the lacerated canaliculus. No canalicular anastomosis was performed. The tube ends were retrieved through the nostril, followed by medial canthal tendon, orbicularis oculi muscle, and skin repair. The tube ends were pulled to create a tension on the loop, until upper and lower puncta apposed each other, creating a dimple in the medial canthal area. The tube ends were tied and anchored at internal valve of the nostril to maintain the traction tension. Medial lower lid notching (>2 mm width), epiphora, and conjunctival injection were evaluated and compared in the 2 groups.

Results

Patients with traction technique showed symmetric medial canthal angle and minimized lower lid notching deformity when compared with the control group (P = 0.025). No conjunctival injections and epiphora were observed in either group.

Conclusion

Symmetric and aesthetically satisfactory results were achieved by traction applying technique on bicanalicular silicone tube.

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Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction

Author: Hui Hyung Jeon

Purpose

Neurogenic blepharoptosis after orbital wall reconstruction is a rare complication. It can either present as an isolated blepharoptosis, or accompany with other ocular symptoms. The authors introduce 4 cases of post-operative neurogenic blepharoptosis after reconstruction of medial orbital wall via transcaruncular approach.

Methods

Immediately after the surgery, 2 adolescent patients experienced unilateral islolated complete blepharoptosis with no other ocular symptoms. The other 2 adult patients presented unilateral complete blepharoptosis accompanied by lateral displacement of the globe and evident extraocular movement limitations. The 2 adolescent patients were observed with no particular treatment, whereas the other 2 adult patients were treated with intravenous systemic steroids.

Results

The blepharoptosis symptom began to improve at 2 weeks post-operatively and completely recovered within 3 to 4 months in all patients, while the globe displacement and extraocular movement limitation started to improve at 4 weeks after the surgery and fully recovered within 6 months.

Conclusion

Although neurogenic blepharoptosis after medial orbital wall reconstruction is a very rare complication, it can be critical once it occurs. According to the author’s experience, it fortunately shows a favorable clinical course of spontaneous recovery. Postoperative neurogenic blepharoptosis usually recovers between 2 weeks and 4 months and other ocular symptoms related to oculomotor nerve injury recovers within 6 months after the surgery.

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The treatment of anophthalmic socket syndrome

Author: Ryo Kikuhi

Purpose

Anophthalmic Socket Syndrome (ASS) refers to problems after prosthetic eye insertion, such as eyelid drooping, upper eyelid sulcus, eyelid retraction, and entropion. It is well known that apparent facial asymmetry can significantly impair a patient’s quality of life and cause emotional distress. We report cases of ASS treated at our clinic with excellent results.

Methods

A retrospective study was conducted on 17 patients (5 males and 12 females), mean age of 46.0 ± 23.0 years (18-85), who visited our clinic. The period covered is three years and three months, from March 2019 to June 2022. The mean postoperative follow-up period was 334 (32-860) days. We inserted implants in all cases. If an implant was already in place, it was removed, and a larger implant was inserted. All patients underwent general anesthesia. We added postoperative procedures and surgeries as needed.

Results

The causes of anophthalmia were rupture of the eyeball due to trauma in 6 cases, retinoblastoma in 5 cases, endophthalmitis in 1 case, scleritis in 1 case, uveitis in 1 case, cellulitis in 1 case, retinal detachment in 1 case, and unknown cause in 1 case. The clinical presentation of patients with AS syndrome at initial presentation included 11 cases of ptosis, 8 cases of enophthalmos, 5 cases of lower eyelid laxity, 5 cases of eyelid entropion, 3 cases of upper eyelid sulcus, 1 case of downward deviation of prosthetic eye, and 1 case of implant exposure. Our treatment included 17 cases of implant replacement, 10 cases of ptosis surgery, 4 cases of entropion surgery, 4 cases of filler injection, 2 cases of implant position correction, and 1 case of conjunctival sac formation. In all cases, patients showed an improvement in terms of patient’s cosmetic appearance.

Conclusion

The treatment of ASS has resulted in cosmetic improvement. The patient’s quality of life can be improved with appropriate treatment rather than becoming a “finished eye” after removing the eyeball. We recommend aggressive therapeutic intervention for patients with ASS.

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SUCCESSFUL MANAGEMENT WITH A COMBINATION OF EMERGENCY EYEBALL REPOSITION AND SENSITIVE ANTIBIOTICS FOR INFECTIOUS ORIGIN ORBITAL APEX SYNDROME

Author: Junely Jaury

Purpose

This case report aimed to demonstrate the successful management of infectious origin orbital apex syndrome with emergency eyeball repositioning through canthotomy, cantholysis, and tarsorrhaphy followed by intravenous antibiotics and corticosteroid medication

Methods

A 24-year-old man was referred to an ophthalmologist with sudden proptosis in his right eye associated with ocular pain and redness one day before admission. His upper eyelid was edema and itchy one week before, so he rubbed it forcefully. An ophthalmology examination reveals light perception on the right eye, periorbital edema, and hard swelling with ptosis and proptosis eyeball anteriorly. Lagophthalmos, chemosis, and subconjunctival hemorrhage were also found. His cornea was severely dry and cloudy half inferior quadrant, standard anterior chamber with dilated pupil and no light reflex. There was a restriction of eye movements in all directions. Leukositosis and high C-Reactive Protein (CRP) were found in his laboratory test. Computed tomography showed thickening and edema of extraocular muscles consistent with post-septal orbital cellulitis. Emergency canthotomy, cantholysis, and tarsorrhaphy were performed on the same day to reduce proptosis and gain eyeball repositioning

Results

Normal eyeball positions without limitation on eye movement were achieved after one month of treatment and reduced 8mm Hertel exophthalmometer from 26 to 18. A combination of 500mg meropenem and 160mg gentamycin was used intravenously for one week based on microbiological culture and sensitive results. To reduce CRP, 5mg dexamethasone has also been given intravenously. Tarsorrhaphy was released after one week of hospitalization

Conclusion

Orbital apex syndrome can be a rare but severe complication of an orbital cellulitis infection in late cases. A combination of emergency eyeball repositioning and cultured-sensitive antibiotic plus corticosteroid intravenously could be considered in an infectious origin orbital apex syndrome for the promising cosmetic result, although vision loss was irreversible

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Systemic lead poisoning secondary to retained facial and orbital foreign bodies

Author: Alexander Mitchell

Purpose

Systemic lead poisoning from intra-orbital lead foreign bodies has not been previously described. Decisions as to whether retained lead foreign bodies are removed depend on the resting location of the projectile and associated functional deficits related to the injury.

Methods

We present a case of a 23 year old man who sustained an injury to the face and right globe at close range by a homemade shotgun.

Results

The patient sustained a right perforating globe injury and underwent primary globe repair and subsequent further retinopexy and cryotherapy. Multiple (>60) metallic pellets 1.5-2mm in diameter were embedded across the forehead, within the posterior right orbit, and within the anterior left orbit, adjacent to superior rectus. Vision was initially CF in the right eye, 6/6 in the left eye. Approximately 10 of these metallic pellets were removed at presentation. Analysis showed the presence of lead in the pellets, and at presentation serum lead was raised at 0.94 mmol/L (normal <0.48). Another 11 superficial pellets were removed, and serum lead levels reduced to 0.82 mmol/L.

Conclusion

Systemic lead poisoning typically presents with non specific symptoms, with toxicity related to serum lead levels. Lead pellets are considered largely insoluble. Previous studies suggesting that soft tissue injuries do not lead to systemic absorption. We describe a case with a large number of retained periocular and orbital foreign bodies and raised serum lead levels.

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Middle turbinectomy in orbital decompression: a new dimension to consider.

Author: Alexander Mitchell

Purpose

We present a case of 47 year old man who was referred with asymmetric thyroid eye disease with a right relative proptosis of 11 mm.

Methods

After a 3-wall orbital decompression (with 0.75 ml fat excision), his surgical result was disappointing with only 2mm reduction in proptosis. A post-op CT orbits showed that the right periorbita was being splinted by the right middle turbinate preventing maximal decompression.

Results

After a right (endoscopic, endonasal) middle turbinectomy and freeing of the periorbita maximal decompression was achieved. Final exophthalmometry measurements 8 months later were 21.5 mm right and 21 mm left: full orbital decompression achieved.

Conclusion

Consider middle turbinectomy pre-emptively as an adjunct to orbital decompression surgery when maximal decompression is required or subsequently if sub-optimal orbital decompression achieved after a 3-wall orbital decompression.

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Orbital Hidrocystoma: case reports and review of the literature

Author: Matteo Di Marino

Purpose

To report the clinical features and the management of two cases of orbital hidrocystoma.

Methods

Retrospective review of two patients with orbital hydrocystoma referred to a single tertiary institution. The first patient presented with a mass in the upper medial orbital quadrant, firmly attached to the supraorbital incisure. The other patient had a well demarcated lesion in the upper lateral orbital quadrant adherent to the lacrimal gland, that appeared prolapsed. Clinical data included visual acuity, ocular motility, orbital CT scan, clinical photographs, and management undertaken. The patients were operated on with an anterior orbitotomy.

Results

Following complete excision, histopathology confirmed a diagnosis of apocrine hidrocystoma, identified by an outer layer of flattened vacuolated myoepithelial cells and an inner layer of elongated, columnar, eosinophilic cells with apical snouts and decapitation secretions.
After surgery, the first patient complained of mild hypoesthesia in the area of the supraorbital nerve that resolved spontaneously within 3 weeks. Surgery was uneventful in the second patient. No later complications were seen in both patients. The patients were followed up for 20 and 22 months with no recurrence.

Conclusion

Although uncommon, orbital hidrocystomas should be considered in the differential diagnosis of orbital cystic masses. Apocrine hidrocystomas are rarely seen in the orbit with very few adult cases published in literature. Hidrocystomas are usually located in the upper medial orbital quadrant, are benign tumors and are cured with surgical excision with rare recurrence.

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Dacryocystoplasty: a long-term experience with balloon dilation and stenting

Author: Elske Bak

Purpose

To evaluate the long-term results of dacryocystoplasty by balloon dilation with or without stenting by outcome differences in the Munk score, whilst also assessing the level and severity of the obstruction. Additional objectives were to study patient satisfaction after dacryocystoplasty and complication rates of the procedure.

Methods

This is a retrospective, questionnaire-based study. Patients who underwent dacryocystoplasty at the Tjongerschans Hospital in the Netherlands between January 2011 and May 2021 were included. Munk score differences were compared using a Wilcoxon signed-rank test. Associations were checked between the duration of the epiphora before DCP, the level and severity of the obstruction and the change in the Munk score after the intervention using a Pearson chi-square test.

Results

385 patients (63 years +/-14, 294 women) were included in whom dacryocystoplasty was performed in 515 eyes. Munk scores before and after dacryocystoplasty showed an improvement of epiphora (p-value <0.001). Duration of epiphora before the procedure showed that if the complaint exists longer, the chances of improvement are lesser (phi 0.292, p-value <0.001). The severity nor the level of the obstruction showed an influence on the outcome of dacryocystoplasty. 76.1% of patients experienced improvement of epiphora symptoms after dacryocystoplasty.

Conclusion

This study shows that a DCP is a safe (2.1% complications) and minimal invasive procedure. Most patients with epiphora benefit significantly from DCP, especially if the procedure is performed within two years of onset of complaints, therefore it seems an adequate first step in treatment of epiphora prior to or preventing a DCR-operation.

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The Cutler-Beard bridge flap: old but gold

Author: Elia Franzolin

Purpose

To present the long-term clinical outcome of the Cutler-Beard 2-stage technique in patients with large full-thickness upper eyelid defects after tumour excision.

Methods

The medical records of 24 patients with large full-thickness upper eyelid defects following tumour removal reconstructed with the Cutler-Beard technique from January 2000 to January 2021 were retrospectively reviewed. All the defects involved ≥ 60% of the horizontal length of the upper eyelid and extended vertically for at least 15 mm from the lid margin. Patients with follow-up < 24 months were excluded. Long-term postoperative complications, functional outcome, and patient’s satisfaction at the end of the follow-up were evaluated.

Results

Patients’ age ranged from 36 to 88 (mean 66.0 ± 10.7 years), and 58.3% were females. Seven patients (29.2%) had previous eyelid surgeries. The most common diagnosis was basal cell carcinoma (62.5%), followed by sebaceous gland carcinoma (12.5%), squamous cell carcinoma (8.3%), and Merkel carcinoma (8.3%). The mean duration of follow-up was 50.9 ± 18.9 months. Eleven patients (45.8%) developed upper eyelid entropion: 9 were treated conservatively with a therapeutic contact lens for variable time, 2 patients required a third operating stage. All patients achieved satisfactory functional and aesthetical outcomes at the end of the follow-up.

Conclusion

The Cutler-Beard bridge flap is a valuable technique to reconstruct patients with large full-thickness upper eyelid defects where the vertical gap is greater than 15 mm. It usually allows to achieve a satisfactory outcome, and rarely further surgeries are necessary to manage post-operative complications.

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Effects of Hyaluronic Acid/Collagen Resorbable Gel Use in Endoscopic Dacryocystorhinostomy

Author: Hyungyu Lee

Purpose

The purpose of this study was to investigate whether the use of hyaluronic acid/collagen resorbable gel(Regenwel®) has an inhibitory effect on rhinostomy obstruction during endoscopic dacryocystorhinostomy (Endo DCR).

Methods

A total of 298 patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction from May 2017 to June 2021 who underwent Endo DCR was enrolled. The patients were divided into the Regenwel group (152 patients) and the Control group (146 patients) that did not use Regenwel during surgery, and the medical records were compared and analyzed retrospectively.

Results

The mean age of the Regenwel group was 65.8 years, and that of the Control group was 63.2 years. Regarding anatomical success as the primary outcome, the Regenwel group had a higher success rate than the Control group (96.7% vs. 86.3%, p=0.012), and the functional success result confirmed that the Regenwel group had a higher success rate than the Control group (94.1% vs. 84.3%, p=0.024). Among secondary outcomes, granulation formation occurred less frequently in the Regenwel group than in the Control group (9.2% vs. 32.2%, p <0.001), and there was no statistically significant difference in postoperative bleeding between the two groups (0% vs. 1.4%, p=0.478). The Regenwel group had fewer infections after surgery than the Control group (5.3% vs. 8.9%, p=0.012) and required less frequent revision surgery (2.0% vs. 15.8%, p <0.001).

Conclusion

In conclusion, Regenwel is a resorbable gel containing hyaluronic acid and collagen that is used during Endo DCR and is thought to contribute to the improvement of surgical success rate by preventing complications such as rhinostomy obstruction and bleeding after surgery.

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Cutaneous squamous cell carcinoma of the eyelid in northern Europe, a 25-year experience

Author: Paula Niinimäki

Purpose

To evaluate the incidence, clinical features, diagnostic challenges, management, and the prognosis of cutaneous squamous cell carcinoma SCC of the eyelid (ecSCC) in Finland, located in northern Europe, latitude 64°N.

Methods

Patients were identified from the Finnish Cancer Registry and the Helsinki University Hospital databases during the 25-year period (1998-2022). Age, sex, location, clinical and histopathologic diagnosis, treatment, and outcome were registered.

Results

Cutaneous squamous cell carcinoma of the eyelid (ecSCC) was diagnosed in 58 patients. The mean age-standardised incidence was 1,03 per 100,000. Median age at the time of histopathologic diagnosis was 79 (range 55-93) years, and 59% (34) of the patients were women. The clinical diagnosis in the referral letter was ecSCC only in three patients. Most frequent misdiagnose (38%) was basal cell carcinoma (BCC). One or more of the known risk factors (smoking, history of extensive sun exposure and systemic immunosuppression) were documented in 71% of the patients. More than one third (38 %) of the patients developed in situ SCC elsewhere on the skin. Three of them had more than ten in situ SCCs during the study period. Almost one third (31 %) of the patients with ecSCC had invasive cSCC elsewhere on the skin as well. During the median follow-up time of 24 months, three patients (5%) experienced local recurrence, four patients developed metastatic disease (median 19 months) and two patients died of metastatic ecSCC.

Conclusion

The estimated incidence of ecSCC in Finland in its predominantly white Caucasian population was higher than previous study from Europe. Male dominance was lower. The clinical diagnosis of ecSCC is difficult, often misdiagnosed as BCC. Recurrences of ecSCC, potentially lethal, were infrequent.

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Dynamic Measurements of Lower Eyelid using Ultrasound Biomicroscopy

Author: Xiaojun Ju

Purpose

To define the normal lower eyelid anatomy and their changes during dynamic motion using ultrasound biomicroscopy.

Methods

High-resolution ultrasound biomicroscopy (50MHz) was performed on 84 lower eyelids of 42 healthy volunteers without eyelid problems. The major structures of the lower eyelids, including the pre-tarsal orbicularis (PTO), pre-septal orbicularis (PSO), the tarsal plate, the capsulopalpebral fascia (CPF), and the conjunctiva complex were imaged. The thickness of these structures was measured by primary gaze and up-gaze.

Results

Eighty-four lower eyelid UBM images of 42 volunteers (age 40.3±19.9 years old) were collected and analyzed, including 40 males and 44 females. In the primary gaze position, the mean thickness of PTO and PSO were 0.50 ± 0.20 mm and 0.84 ± 0.19 mm, respectively. The tarsal plate measured 0.45 ± 0.16 mm, the CPF measured 0.56 ± 0.15 mm, and the mean thickness of the conjunctiva complex was 0.67±0.18 mm. In the up-gaze position, the mean thickness of PTO and PSO were 0.49 ± 0.19 mm and 0.78 ± 0.18 mm, respectively. The tarsal plate measured 0.45 ± 0.13 mm, the CPF measured 0.55 ± 0.15 mm, and the mean thickness of the conjunctiva complex was 0.67±0.19 mm. The measured profile thickness of the PSO during the movement of the globe from primary gaze to up-gaze decreased by 7.69% (p＜0.01). Meanwhile, the PSO’s thickness on the eyelid’s lateral is thicker than the inner (p＜0.01). For age and gender differences, the thickness of the PSO from the pupillary midline to the inner canthus was significantly positively correlated with age (p＜0.05), and the thickness of the CPF and the tarsal plate were also positively correlated with age (p＜0.05). The measured PTO, PSO, and CPF thicknesses of males are all thicker than females (p＜0.05).

Conclusion

Ultrasound biomicroscopy can be used non-invasively to visualize the morphology of the lower eyelid. Expanding its use in the eyelid region can help us understand the dynamics of eyelid physiological movement and aging, as well as in disease study populations and in evaluating surgical outcomes.

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An epidemiologic analysis of the association between eyelid disorders and ocular motility disorders in pediatric age

Author: Giovanni Cuffaro

Purpose

Aim of the study was to assess: (a) the prevalence and type of strabismus, ptosis and eyelid dynamic disorders features, (b) the prevalence of refractive errors, amblyopia and, (c) their association with ocular/systemic syndromes in a cohort of patients.

Methods

This is a retrospective observational multicenter cohort study. Patients, aged 6 to16 years old, with coexisting ocular motility disorders, comitant and incomitant strabismus, ptosis and dynamic eyelid disorders who have never undergone surgery were enrolled throughout a 3-years a study period.

Results

137 out of 19,089 patients were enrolled, of which 97 with uniocular and 40 with binocular disease. Isolated congenital ptosis was observed in 84 patients. A polymalformative syndrome was present in almost one third of cases, whilst among strabismus type, esotropia was slightly more prevalent. Most patients were hypermetropic. In monocular disease, myopia mainly affected older patients, who were characterized by a worse ptosis margin reflex distance and levator function, and significantly higher astigmatism. Amblyopia occurred in 67.4% of the study sub-population. Of note, in monocular disease this was mild in 25.8%, moderate in 24.2% and severe in 11.3% of cases, whilst in binocular disease it was mild in 25%, moderate in 41.7% and severe in 16.7%.

Conclusion

Eyelid static and dynamic disorders and ocular motility disorders are often related. Ocular motility evaluation and follow-up is especially important in congenital ptosis, where the ptotic lid may in fact precipitate strabismus and amblyopia. The high incidence of polymalformative syndromes in monocular disease should alert the specialist to a possible multidisciplinary assessment. Ultimately these patients thus need a careful ophthalmologic and systemic evaluation, due the high prevalence of amblyopia, refractive errors and systemic/ocular associated disorders.

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Review of glabellar flap technique in oculoplastic surgery

Author: Georgi Balchev

Purpose

Facial skin defect reconstruction in medial-canthal area of the lids can be a challenge even when performed by a skilled surgeon. The excision of large tumors in this area leads to significant surgical defects that cannot be repaired by merely closing the wound. The glabellar area provides a source of redundant skin with similar characteristics to that of the medial-canthal lid area. The purpose show the possibility of the glabellar flap technique surgery in patients after tumor excision in the medial canthal area with the formation of a large surgical defect and especially those with defect under the medial canthal tendon.

Methods

We selected 15 well-documented retrospective cases of patients operated over 2 years and followed up for a minimum of 36 months, who underwent surgery with a glabellar flap technique. Patients were operated with V-Y glabellar rotation, advancement, or combined transposition flap techniques.

Results

A satisfactory functional result was obtained in all the patients. In most of them, the cosmetic results were also good. No additional surgical procedures were required in any of the patients.

Conclusion

Our experience showed excellent results with the glabellar flap technique in all three types of lesions in the medial canthal zone-upper, medial, and especially lower which until recently was thought to be inappropriate.

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Managements of Conjunctival Prolapse Following Levator Muscle Resection for Ptosis Correction: A Report of Seven Cases

Author: Yeon Jeong Lee

Purpose

To report successfully managed cases of conjunctival prolapse following levator muscle resection for ptosis correction.

Methods

This retrospective study was conducted from July 2009 to December 2014 at the Oculoplastic Clinic, Kim’s Eye Hospital, Seoul, Korea. Medical records of patients of conjuntival prolapse following levator resection for ptosis correction surgery were reviewed. The operation was conducted by one surgeon. The outcomes of conjunctival prolapse and ptosis correction were reviewed.

Results

This report presents seven patients, 5 females, 2 males who had conjunctival prolpase after levator muscle resection. The mean age was 11 years old. One patient who showed only conjuncitval prolpase was treated with conservative care. One patients who showed only conjuncitval prolapse received full thickness mattress sutures at superior conjunctival fornix and fully recovered. Four patients showed only conjunctival prolapse, the adjustment of levator muscle after the dissecting the adhesion of conjunctiva-muller and levator muscle solved conjunctival prolapse. Two patients showed conjunctival prolapse with tarsal plate eversion. Frontalis suspension with fascia lata was performed because the tarsus eversion and conjunctival prolapse were not corrected even though the removal of adhesion.

Conclusion

Conjunctival prolapse could be developed after maximal levator muscle resection. This can be categorized two types, with or without tarsal plate malposition. The conjunctival prolapse without tarsal plate malposition can be treated according to the remained ptosis. (1) conservative treatment, steroid ointment with compressive eye patch, (2) full thick mattress suture like non-incisional blepharoplasty method, (3) the adjustment of levator muscle. Conjunctival prolapse with tarsal plate malposition can be treated by frontalis suspension combined with the removal of adhesion between conjunctiva-Muller muscle.

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The New Indication for Non-incisional Blepharoplasty: correction of loss of double folds after incisional blepharoplasty

Author: Yeon Jeong Lee

Purpose

The authors introduce outcomes of non-incisional blepharoplasty, continuous buried suture technique for correcting loss of double folds after incisional blepharoplasty.

Methods

This retrospective study was conducted from July 2010 to January 2023 at the Oculoplastic Clinic, Kim’s Eye Hospital, Seoul, Korea. Medical records of 24 patients(38 eyes) who underwent non- incisional blepharoplasty for double folds correction after incisional blepharoplasty were reviewed. Continuous buried suture technique was used for correction by one surgeon. After the surgery, the cosmesis and complications were reviewed.

Results

The 21 patients were composed of 17 females and 4 males. the loss of double folds occurred 8 unilateral eye, and 13 bilateral eyes. The age was from 13 to 65 years old, average age was 29±19 years old. The mean period from incisional blepharoplasty to non-incisional blepharoplasty was 34±43 months. Post operative complication, which was inflammation of skin occurred in 1 patient. Removal of suture material was done. Overall, all cases showed good cosmetic results without other complications.

Conclusion

It is known that if the double eyelids are lost or weakened after double eyelid surgery, the incisional double eyelid surgery should be performed again. However, if there is no redundant skin and no more soft tissue or fat to be removed, an incisional double eyelid surgery is not necessarily required. Non-incisional double eyelid surgery would be the simple and effective treatment option for loss or loosening of double folds after incisional blepharoplasty.

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An atypical Monkeypox presentation with a large right upper eyelid ulcerative mass

Author: Elise Steinberger

Purpose

To describe a unique case of ocular Monkeypox infection, which presents as an ulcerative upper eyelid mass and conjunctivitis.

Methods

Retrospective case report

Results

A 27-year-old male with a history of HIV (CD4+ 258), untreated hepatitis C, illicit drug use, and treated syphilis infection presented with multiple large (up to 7 x 8 cm) ulcerative, verrucous wounds on his face and body. He reported fevers, decreased appetite, and weight loss. His symptoms did not improve after multiple oral antibiotics and antifungals.
His exam was significant for a 5 x 5cm ulcerative mass (external photo) extending from the right eyebrow to the eyelid margin. The eye exam was normal, except for conjunctivitis and subtle HIV retinopathy. He also had ulcerated masses on his nose and right lower face.
A biopsy of the lesion demonstrated suppurative granulomas. The patient was treated for presumed disseminated fungal infection with itraconazole, and the disseminated masses continued to worsen. Monkeypox testing was positive via PCR (Karius test). He received IV tecovirimat and IV cidofovir with significant improvement.
Ocular Monkeypox is a rare infection caused by autoinoculation of the Monkeypox virus to the eye. The U.S. Centers for Disease Control and Prevention report 86,500 cases of Monkeypox in the world, with 30,262 of these in the U.S., 3,738 in the U.K., and 69 in the state of Oklahoma. It may present as conjunctivitis, blepharitis, keratitis, or facial rash. Monkeypox lesions are typically less than 2cm, though comorbid HIV is associated with more extensive lesions/masses.

Conclusion

In immunocompromised patients who present with disseminated ulcerated lesions refractory to treatment, Monkeypox should be considered.

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Non-invasive differentiation of xanthogranuloma and xanthelasma with reflectance confocal microscopy

Author: Larysa Krajewska-Węglewicz

Purpose

Adult xanthogranulomatous disease (AXD) involving the periocular region is a rare non‐Langerhans histiocytic disorder. Xanthelasma palpebrarum (XP) is the most common form of cutaneous xanthoma. The clinical differentiation of both conditions can pose a challenge. We decided to use reflectance confocal microscopy (RCM) to perform a noninvasive high-resolution imaging of AXD and XP.
We report a case of bilateral xanthogranulomas (XG) of the upper and lower eyelids coexisting with xanthelasmas (XL) of the upper eyelids diagnosed with RCM.

Methods

A 71-year-old woman presented with a 3 year history of progressively enlarging nodules of the upper and lower eyelids. There were no other associated symptoms or any relevant familial history. On examination, the lesions presented as yellowish, firm, immobile, and non-tender. The large, indurated nodules were accompanied by smaller, yellow, soft, plaque-like lesions located in the inner canthus.

Results

RCM of the inner canthal nodules displayed normal epidermis, round cells, rich in lipids with hyper-reflective cytoplasm corresponding to the foamy histiocytes. RCM of the firm lesions revealed the presence of a typical honeycomb pattern, multiple cells in the dermis and large round cells with hyper-refractile peripheral rings mimicking multinucleated giant cells called “Touton cells” when seen on histology. The fibrosis was also present. The biopsy of the smaller nodule in the inner canthus of the upper eyelid confirmed XL and the biopsy of the larger nodules confirmed the diagnosis of XG. The lesion was surgically excised and further histological study with HE staining was consistent with the results of the biopsy.

Conclusion

RCM can be beneficial in a non-invasive differential diagnosis of XL and XG.
To the best of our knowledge, this is the first report on the differential diagnosis of XG and XL with the use of RCM.

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Clinical presentation of different hair follicle tumours of eyelids in a tertiary eye care centre in Hungary

Author: Márton Magyar

Purpose

Tumours derived from the pilosebaceous unit are rare and frequently misdiagnosed in the periorbital area due to the misleading clinical appearance. The aim of our presentation is to demonstrate the wide range of clinical appearance and histological variations of benign and malignant hair follicle tumours of the eyelids.

Methods

This retrospective series of case reports included selected patients with histopathologically proven eyelid benign and malignant tumours of the pilosebaceous unit between 2010 and 2022 in a tertiary eye care centre in Hungary

Results

We demonstrate a variety of short case reports to present the clinical appearance of different tumours derived from hair follicles of the eyelids, namely: trichoepitelioma, trichilemmoma, benign trichoblastoma, pilomatricoma, malignant trichoblastoma (trichoblastic carcinoma), and transitional tumours.

Conclusion

Among periorbital lesions pilar tumours often pose diagnostic uncertainty, as the clinical appearance vary greatly and could mimic different eyelid malignancies. For this reason, clinicians should be aware of the possibility of different trichoid tumours during preoperative differential diagnosis.

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Extended Tenzel flap for the reconstruction of lower lid defects involving more than half of the lid margin: A case series.

Author: Norma Espinoza

Purpose

Reconstructing large eyelid defects may be extremely challenging. Although numerous procedures for reconstructing periorbital defects have been proposed, no method is universally used. The Tenzel semicircular flap is the most commonly used technique and is usually indicated to reconstruct eyelid defects involving less than 50% of the lower lid. In defects involving over 50%, the Hugh’s flap is usually utilized. This series of cases presents the Tenzel flap procedure for full-thickness defects of the lower lid, longer than 50% or even 75%.

Methods

Retrospective review of patients with lower lid malignant lesions who underwent a wide local excision with frozen sections which resulted in a lower lid defect involving more than 50%. All patients were reconstructed using a Tenzel semicircular flap.

Results

Four patients were included in the series, three males and one female, mean age 69 (range 61 to 77). All patients presented with a lower lid lesion suspected to be basal cell carcinoma (BCC), and they underwent incisional biopsy which proved the lesion was BCC. Following the diagnosis, a lower lid wide local excision with frozen sections was performed, which proved complete excision of the lesion. All patients had a lower lid defect of greater than 50%. In order to avoid eye closure with the Hugh’s flap, a decision was made to reconstruct using an extended Tenzel semicircular flap. On follow up all patients presented with a very good cosmetic outcome with no eyelid malposition, trichiasis or any other complications. Mean follow up was 6 months.

Conclusion

Compared to traditional Hugh’s flap used for large lower lid defects, the extended Tenzel flap achieves a good cosmetic and functional outcome with no eye closure, and no disruption of the upper eyelid’s anatomy. Primary closure with Tenzel flap can be used as first-line treatment to reconstruct most full-thickness defects of the lower lid, including subtotal defects.

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Evisceration: comparing 2 surgical techniques in a cohort from Rouen

Author: Dhyna THOREL

Purpose

Evisceration techniques have improved in order to implant larger volume implants to avoid the enucleated socket syndrome.
We have performed a “2 petal” technique and we want to evaluate its complications compared to the reference “4 petal” technique.

Methods

We present a retrospective study performed at Rouen hospital university including primary eviscerations performed between 2009 and 2018. The nature of the implant and its size are recorded as well as the complications.

Results

Ninety eyes were eviscerated, 81 were “4-petal” and 9 were “2-petal”.
Seven patients presented implant exposure, four cases in the first three years and three cases after five years. Five cases were “4-petal” and two were “2-petal”.
The risk factors for extrusion (size, nature of the implant) were studied.
There was no significant difference between the two groups regarding extrusions (p=0.14). Regarding extrusions, we did not find a significant difference between the 4-petal group and the 2-petal group for patients with Medpor (p=1), Hydroxyapatite HA (p=1), bioceramic (p=1) and the size of the implant (p=0.28).

Conclusion

The 2 and 4 petal techniques allow the implantation of a good volume implant with results similar to those found in the literature.

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Diffuse Weight Imaging (DWI) a Radiological Pattern-Based Approach in diagnosing Lacrimal Gland pathologies

Author: Meishar Meisel

Purpose

To investigate the diagnostic utility of diffusion-weighted magnetic resonance imaging (DW-MRI) for the differentiation between lymphoma and an inflammatory mass in the orbit. DW-MRI probes noninvasively the random microscopic motion of water molecules in the body, reflecting cellularity and cell membrane integrity. Because of their high cellularity lymphomas demonstrate restricted diffusion of water molecules on DW-MRI. There is a wide range of pathological entities that can affect the lacrimal glands ranging from inflammatory processes to neoplastic lesions. From a clinical standpoint Preoperative differentiation of orbital lymphoma and orbital inflammation is highly desirable since treatment strategies vary substantially. Standard MRI cannot permit the differentiation between orbital lymphoma and inflammation. Advances in MRI techniques, such as DW-MRI, have been used for preoperative diagnosis of space-occupying lesions in the orbit.

Methods

Retrospective review of 3 patients with lacrimal gland enlargement, with no clear diagnosis on CT and standard MRI. The patients underwent DW-MRI and open incisional lacrimal gland biopsy.

Results

Two female patients and one male patient (mean age- 32, range 21-40) presented with an upper lid lateral swelling, pain and enlarged lacrimal gland. The patients underwent DW-MRI demonstrated restricted diffusion in one patient but no restriction was observed in the other patients. In the former patient the histopathology diagnosis was lacrimal gland lymphoma while in the other patients it was non-specific non-IgG4 inflammation.

Conclusion

DWI is a radiological pattern-based approach that can aid in the differential diagnosis of lacrimal gland masses and can thus preclude the need for biopsy. In the presently described patients, restriction of diffusion on DWI indicated a malignant process whereas the no restriction suggests inflammation. DWI is a modality that can assist in the differentiation between orbital lymphoma and orbital inflammation. As a result, a biopsy can be avoided and proper treatment can be established.

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Anthropometric differences of the periocular region between younger and older patients in the Czech Republic

Author: Adam Kopecký

Purpose

To assess whether there are differences in periocular anthropometric measurement between two groups of Czech volunteers – one group with a mean age of 26, and the second group with a mean age of 70 years.

Methods

In 41 volunteers of the Czech Republic with a mean age of 70 years [38;88] and in 33 with a mean age of 26 years [23;31], stereophotography of their faces was acquired using Vectra 3D device. In every volunteer, the measurement was acquired twice for 6 months period. Volunteers who ever experienced craniofacial trauma or had any congenital facial abnormality were excluded from the study. On every acquired stereophotography, 52 anthropometric points were marked on every eye, and subsequently, 45 parameters on every eye and 4 parameters between both eyes were measured. Statistical analysis of mean measurements between both groups was made.

Results

Interpupillary Distance (PD), Outerintercantal Distance (ExD) are not statistically different between the two groups of volunteers. Inner intercantal distance (EnD), Canthal Tilt (CT) were significantly different between the two groups. Aspin-Welch test was used for statistical analysis. Among the right eyes, medians of 17 parameters were statistically different in older group of patients. Among left eyes, medians of 20 parameters were statistically different in the older group of patients.

Conclusion

There is a marked difference in the periocular region between older and younger volunteers. These differences can be attributed to the process of aging of the face. Further research on larger populations should be done

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Botulinum toxin injection for the treatment of epiphora in lacrimal outflow obstruction.

Author: Michael Yulish

Purpose

The lacrimal gland is innervated by the cholinergic fibers of seventh cranial nerve. Injection of botulinum toxin-A (BTA) in the lacrimal gland decreases tear production by blocking presynaptic release of acetylcholine into neuromuscular end plates of cholinergic nerve fibers. Is the Botulinum toxin injection effective for the treatment of epiphora in lacrimal outflow obstruction? Are there any serious complication of the procedure?

Methods

We retrospectively reviewed 11 consecutive cases of patients with epiphora due to lacrimal outflow obstruction (canalicular obstruction or functional epiphora), who chose to have injections of botulinum toxin into the palpebral lobe of the lacrimal gland instead of surgery.

Results

14 eyes of 11 patients were injected. 8 patients noted significant epiphora symptoms improvement, two patients noted partial improvement, and one patient reported no improvement at all. No hematoma, dry eye symptoms significant worsening or diplopia were noted.

Conclusion

Our results show favourable outcomes for Botox treatment of lacrimal outflow obstruction in the patients seeking non-surgical treatment.

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Case series of Alemtuzumab-induced thyroid eye disease (AI-TED)

Author: Alice Cranston

Purpose

To present two patients who developed thyroid eye disease following treatment with Alemtuzumab for Multiple Sclerosis (MS).

Methods

A retrospective case series of five patients with Alemtuzumab-induced Graves’ disease, two of whom developed thyroid eye disease. Chart review was evaluated for time course of onset of Graves’ disease, thyroid eye disease, clinical characteristics, imaging and management.

Results

All 5 cases in this series were given two infusions of Alemtuzumab (also known as lemtrada) to treat MS. In 2 of these 5 patients (40%), AI-TED developed. The two patients had different clinical phenotypes. One patient was female and one was male. Both patients had elevated TSH receptor antibody levels. Both patients were treated with medical interventions for their disease.

Conclusion

We report two cases of Alemtuzumab-induced thyroid eye disease (AI-TED).

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Recurrence Rates after Surgical Resection of Periocular Basal Cell Carcinoma

Author: Xincen Hou

Purpose

The incidence of periocular basal cell carcinoma (BCC) has significantly increased in the last decades. Tumor recurrence can be frequent and represents a primary clinical challenge for the surgeon. The aim of this study was to assess clinical and histologic features of primary basal cell carcinomas of the periocular region and to assess the rate of local recurrence of these tumors after surgical excision.

Methods

The study comprised a retrospective case note review of 330 patients who underwent surgical resection from 2017 to 2022 for periocular BCC. Patients were identified via hospital coding databases. Medical records were reviewed, and the parameters collected include age, gender, previous BCCs and treatment modality, postoperative complications and subsequent management, site, size of lesion, histological subtype, and recurrence following surgery.

Results

330 patients with 338 tumors were included in this study. The median follow-up time was 28 months (range, 3-72 months). The tumor was located at the lower eyelid, medial canthus, upper eyelid, and lateral canthus in 68.0%, 17.5%, 11.8%, and 2.7%, respectively. The nodular type (61.8%) was the most common histology followed by the infiltrative type (31.7%). Fifteen BCCs (4.4%) exhibited a surperficial subtype, whereas five (1.5%) were basosquamous and two(0.6%) were unknown. We detected 15 cases of BCC recurrence, the recurrence rate was 4.4%. Prognostic factors for recurrence are an aggressive histopathological subtype, young age, more than four Mohs’ stages, and a recurrent BCC.

Conclusion

For BCC in the periocular region, surgical microscopically controlled resection should be the treatment of choice for primary BCCs with an aggressive histopathological subtype and for recurrent BCCs. The increased recurrence rate, demonstrated by recurrent BCCs, highlights the need for a comprehensive follow-up, especially for younger patients.

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Identifying Meibomian Gland Dysfunction Biomarkers in a Cohort of Patients Affected by DM Type II

Author: Antonio Florido

Purpose

The purpose of this study is to identify clinical parameters and biomarkers useful to improve the follow-up and
the treatment of patients affected by diabetes mellitus type II with a meibomian glands dysfunction.

Methods

We have used an ocular surface disease index (OSDI) questionnaire, Schirmer test I/II, tear film break-up time (TF-BUT), fluorescein plus lissamine green staining, Marx’s line (ML), and meibomian gland (MGs) morphology using Sirius® Topographer (CSO, Costruzione Strumenti Oftalmici, Florence, Italy). Blood sample analysis included glucose, glycated hemoglobin, lipid profile, cortisol, dehydroepiandrosterone sulfate (DHEA-S), androstenedione (ASD) and testosterone

Results

Cortisol and ASD were positively correlated with an increase of MG tortuosity, and an Increased level of triglycerides was associated with a reduction of MGs length. DHEAS levels lowered with age and were associated with ocular surface staining

Conclusion

Future studies, perhaps including meibum lipid analysis and tear cytokine levels, may also further elucidate the
connection between these parameters, MG architecture and function.

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Reconstruction Management of Congenital Palpebra Coloboma Bilateral With Modifed Tenzel Semicircular Flap Technique For Upper Eyelid : a case series

Author: Pradistya Syifa Yudiasari

Purpose

To describe case series of reconstruction management in congenital palpebra coloboma bilateral with modified Tenzel semicircular flap technique

Methods

The first case, a 5-month-old girl patient with a deformity on both of her upper eyelids since birth. A full-thickness defect of the medial 1/3 of the upper eyelids without exposure keratitis. The second case, a 5-month-old boy with full-thickness asymmetrical defects on both of his upper lids. The ophthalmological examination revealed a nearly complete bilateral corneal exposure and mild symblepharon. The patient was diagnosed as Congenital Palpebra Coloboma Bilateral and underwent surgery using the Tenzel semicircular flap technique.

Results

The initial step was to draw the semicircular pattern inferiorly from the lateral canthus. Using number 15 blade, semicircular incisions were made in the skin and muscles. The superior lateral canthus tendon was cantholyzed using monopolar after a lateral canthotomy. The tissue dissected until a mucocutaneous flap formed. For second case the first step was to released the symblepharon using monopolar and made the same flap as the first case. Then the semicircular flap pushed medially. On the borders of the lids, tarsus, and skin, the two margins of the lid defect were stitched together using 6-0 Vicryl. By creating a horizontal incision 4 mm high from the lid edge or at the lid crease part, the Tenzel semicircular flap technique was modified to lessen horizontal force on the superior lid that be able to minimize the dog ear on the top of the vertical incision and performed lid crease in some cases. The 6-0 Vicryl suture was used in an interrupted suture technique to attach the semicircular flaps to the skin. After the surgery, the eyelid edge was accurately approximated and the eyelids were sufficiently closed.

Conclusion

Deciding the eyelid reconstruction technique for congenital eyelid coloboma repair needs numbers of considerations, including the size of the eyelid defect. The moderate eyelid deformity (33–50%) and pediatric cases could be treated with the Tenzel semicircular flap procedure without having second step procedure.

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CIELAB color space-based quantitative analysis of eyelid redness in idiopathic orbital inflammation and orbital cellulitis patients

Author: Hwa Lee

Purpose

To identify the differences of redness of the eyelids and disease-specific characteristics in idiopathic orbital inflammation and orbital cellulitis by using the CIELAB color space-based quantitative image analysis technique.

Methods

Using the Matlab® program, RGB images were changed to CIELAB images of facial images of patients with histologically confirmed idiopathic orbital inflammation and orbital cellulitis at Korea University Ansan Hospital. The values of the channels of the affected and non-lesioned facial areas were averaged. The difference (Δa*) between the lesion and non-lesional partitions was calculated and statistically analyzed to determine whether classification for each group was possible.

Results

Nineteen patients with idiopathic orbital inflammation and 12 patients with orbital cellulitis were included. The △a* values of the orbital cellulitis group was higher than that of the idiopathic orbital inflammation group, and the difference was statistically significant (1.130 vs 5.948, p < 0.0001 by unpaired t test).

Conclusion

Quantitative analysis of the amount of change in the value of a* channel for the affected eyelid is considered to be a good tool for artificial intelligence-based diagnosis between idiopathic orbital inflammation and orbital cellulitis.

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Early rehabilitation of modified cutler beard procedure,Novel silicone plate use as tarsal plate replacement

Author: SALIL MANDAL

Purpose

To evaluate the safety, surgical outcome, and efficacy of early rehabilitation of modified cutler beard(CTB) eyelid reconstruction utilizing a Novel silicone plate for tarsal plate replacement in the repair of 70-100% eyelid defects following excision of large malignant tumors.

Methods

Prospective, non-comparative, interventional case study of twenty patients over a period of eighteen months.2nd Stage of CTB was done at 2-3wk for early lid rehabilitation for vision. The created defect and Pre, post-operative measurement of (MRD1) were also noted

Results

The follow-up period ranged from six months to one year. Pre-operative MRD1 ranged from -4 mm to -1 mm, while post-operative MRD1 at 1st wk +1 ,at 1month +3 and after one year +4 -+ 4.5mm

Conclusion

Early rehabilitation of lid opening within 2wk using a novel silicone plate is effective. Visual rehabilitation is faster within 2wk in comparison to the 6th wk conventional Novel silicone plate to maintain the architectural support with excellent aesthetic appearance.

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Impacted wooden foreign body in the deep orbit without damage to the eyeball and vision in child : a case series

Author: SALIL MANDAL

Purpose

Impaction of foreign body in the orbit is a common civilian injury. Longstanding impaction of FB in the orbital wall as well as in the soft tissue of the orbit may cause risk of damage to the eyeball, muscle and cranial nerves which may cause movement disorder, vision loss. FBs can be difficult to detect and, if missed, may have devastating clinical consequences. If an orbital FB is detected, it is critical to determine the type of material, which significantly affects management and potential complications. We have attempted to study the nature of injury, mode of presentation and subsequent post-operative outcome with this case series

Methods

This study shows a series of 8 cases all of which had accidental impacted nonmetallic FB with preserved vision in the affected eye. 4 cases had discharging sinuses and orbital cellulitis with abscess formation. Possibility of metallic FB was excluded by meticulous history taking, and its absence was confirmed by CT scan with thin axial and coronal slices which was the initial imaging modality of choice. Once metallic FBs were ruled out, MRI with T2-weighted and/or contrast and fat suppression protocols of the orbit done for confirmation, better delineation, location, extension of the FB. It provided better visualization and resolution of soft tissues. Minimally invasive orbitotomies through different approaches were undertaken for their removal.

Results

FBs were removed from the eyes of all 8 patients, following which all patients had complete resolution of symptoms and eom restriction within one week to 3 months postoperatively

Conclusion

Orbital foreign bodies pose difficult diagnostic and therapeutic challenges. Organic foreign bodies can cause significant inflammation and carry a higher risk of subsequent infection compared with inorganic materials. Inorganic nonmetallic foreign bodies are many a times, inert. However, some metallic foreign bodies, particularly iron, copper, and lead, can cause specific complications such as retinopathy, siderosis, chalcosis, or systemic toxicity. Organic FBs are poorly tolerated, hence should be removed

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Surgical approaches for the correction of ptosis with low levator function

Author: Ayşe Çetin Efe

Purpose

To review the surgical results of patients who underwent maximal levator resection (MLR) and frontal sling (FS) for the correction of moderate to severe ptosis.

Methods

The files of the patients who underwent ptosis surgery between 2019-2022 were reviewed retrospectively. Patient age-gender, levator functions (LF), previous-after MRD-1, postoperative corneal staining and location, lagophthalmos values,follow-up time were recorded.

Results

The mean age of 29 cases included in the study ranged from 3-68 years.MLR was performed in 13 patients, FS was performed in 16 patients. Follow-up period ranged from 3 to 24 months (mean:11.45±6.55 months). Six of the patients who underwent MLR (46.2%) and FS (53.8%) were girls. The mean age was 12.77±8.59years in the MLR and 21.00±20.58years in the FS. In the preoperative evaluations of the patients, in order of the MRD-1 value was 0.08±1.03mm in MLR, -0.44±1.15mm in FS. The LF was 4.85±1.86mm in MLR; 4.27±2.18mm in FS. Postoperative MRD-1 was 2.77±1.58mm in MLR; 1.62±1.50mm in FS. Lagophthalmus was 1.23±0.43mm in MLR; 0.69±1.10mm in FS. Punctate was not observed in 5 cases(38.5%) in MLR, in 7 cases(43.8%) in FS. The punctate was mildly detected in the cases with signs. When both groups were compared, lagophthalmus was found to be lower in the FS compared to the MLR cases (p=0.015).

Conclusion

In patients with ptosis with moderate to severe, MLR in addition to FS is a physiological and effective option that provides a more cosmetic lid contour and prevents eyebrow scars.

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Management of paediatric dacryocystitis following graft versus host disease

Author: Nazanin NOSRATI

Purpose

Presentation of a rare case of paediatric dacryocystitis secondary to ocular graft versus host disease

Methods

Case report and literature review

Results

An 8 year old boy presented with recurrent right sided dacryocystitis. He suffered from Hunters syndrome and developed chronic ocular Graft Versus Host Disease (GVHD) following an allogenic cord blood transplant aged 7 weeks. Previously he had undergone right eye amniotic membrane graft and subsequent allogenic stem cell transplant (COMET) surgery during his infancy. Right endoscopic dacryocystorhinostomy (DCR) and lacrimal intubation with silicone tubes was performed. Recovery was rapid, with resolution of the nasolacrimal duct swelling.

Conclusion

There are only 2 previously published case reports of dacryocystitis secondary to GVHD. We describe a third case, managed successfully with endoscopic DCR.

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Bilateral eyelid oedema as the first extrathyroidal manifestation of thyroid disease: About two cases

Author: Asma ZAGHDOUDI

Purpose

To report two cases of patients who presented with bilateral eyelid edema as the first sign of dysthyroidism.

Methods

Two Cases reports

Results

Case 1: A 53-year male presented to our department for persistent upper eyelid edema of the left eye without pain or redness, with a normal ophthalmological examination. He was diagnosed with hyperthyroidism and treated with synthetic antithyroid medication (SAM). The course of the disease was marked by recurrence of palpebral edema, which worsened and became bilateral. So that, the patient received oral prednisone with progressive tapering. After 4 months, thyroid function was clearly improved.
Despite a return to normal thyroid function, the palpebral edema was refractory and resolved only after radioactive treatment of the thyroid gland.
Case 2: A 23-year female presented with bilateral eyelid edema with no history of pain or redness over several months. The ophthalmic examination was normal. Hypothyroidism was diagnosed and she was started on thyroid hormone replacement therapy with levothyroxine. The evolution was marked by the disappearance of the eyelid edema.

Conclusion

Thyroid disorders should be a consideration in the setting of refractory eyelid edema. It can be the first sign of the disease.

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Nineteen Years of Clinical Experience of Ocular Sebaceous Gland Carcinoma in a Tertiary Medical Center in Taiwan

Author: Ming-Hsuan Chiang

Purpose

Sebaceous Gland Carcinoma(SGC) is more common in Chinese, followed by Indian population, than in Caucasians. The study aims to describe histopathological features and outcomes of patients with ocular sebaceous gland carcinoma in Linkou Chang Gung Memorial Hospital.

Methods

Retrospective study of reviewing patients with ocular sebaceous gland carcinoma from May 2000 to December 2019. Parameters include demographic data, histopathological features, surgical outcomes, complications and adjunct treatment. The outcome measures included local recurrence, lymph node and distant metastasis and death. All patients had over six months follow-up.

Results

Totally seventy-five patients were included in the study. The mean age was 67.3 years, with female predominant. (49 patients, 65.3%) At a mean follow-up time of 46.2 months, local recurrence occurred in 10 patients (13.3 %), while 2 and 5 patients had lymph node and distant metastasis, respectively. Five patients(6.67%) received orbital exenteration, which had no evidence of recurrence at a mean follow-up time of 20.4 months. There were two (2.67%) tumor-related death and another two (2.67%) non -tumor-related death.

Conclusion

Sebaceous gland carcinoma is a great mimicker, thus early detection for diagnosis is necessary. The crucial goal of treatment of ocular sebaceous gland carcinoma is complete surgical removal with negative histological margins for malignancy. Closely monitor and appropriate management to patients with advanced stage had benefit on overall survival.

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Pericardium patch graft (Tutoplast) use for reconstruction in orbital implant exposure

Author: Fatma Poslu Karademir

Purpose

To present the technique of using pericardium patch graft in implant exposure treatment

Methods

A 48-year-old male patient applied to our clinic with a complaint of pain in his left eye. The patient had a history of evisceration surgery due to a painful blind eye in the left eye in 2015. On examination, the best corrected visual acuity was found to be complete in the right eye, anterior segment findings, and fundus findings were normal in the right eye. In the left eye, hydroxyapatite implant exposure was observed in the conjunctival center, and no signs of infection or discharge were observed. Surgical technique: The surgery was performed under general anesthesia under standard aseptic conditions. The entire defect was exposed by separating the conjunctiva surrounding the defect from the anterior implant surface. After shaving the surface of the hydroxyapatite implant, the Tutoplast® patch graft was covered over the defect and sclera. The Tutoplast® graft was then secured in place with interrupted 6-0 vicryl sutures to the sclera, followed by tenon and conjunctiva closure with 7-0 vicryl. A conformer was then placed, followed by antibiotic ointment, and then the eye was buffered. The patient has been prescribed analgesics, oral antibiotics, topical steroids, and antibiotic ointments.

Results

There were no complications following the surgery, he remained asymptomatic in the 1-month follow-up and was in good cosmetic condition.

Conclusion

We consider that the use of Tutoplast® patch graft for the repair of exposed ocular implants is a safe and effective alternative with the advantage of a shorter operative time compared to other autograft techniques.

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Sub-total upper eyelid defects: reconstruction with a myocutaneous bipedicled flap, a free conjuctivotarsal graft and a free skin graft

Author: Tomislav Sarenac

Purpose

The purpose is to examine and demonstrate the outcomes of a single-step approach that utilizes a free tarsal plate graft and a myocutaneous bipedicled flap, in addition to a free skin graft, to repair significant upper eyelid defects resulting from tumor removal surgery.

Methods

This study retrospectively analyzed a series of 4 cases in which patients underwent upper eyelid reconstruction following tumor removal. The horizontal defect affected more than 75% of the lid, and in one instance, the lateral canthus was also affected. To reconstruct the posterior lamella, the contralateral upper eyelid tarsal plate and conjunctiva were used and attached to the remaining m. levator palpebrae superioris. For the anterior lamella, a bipedicled myocutaneous flap was employed, based laterally and medially, resulting in a raw surface beneath the brow, which was covered with a free skin graft. In one case, the lateral canthal tendon was reconstructed using a periosteal flap.

Results

None of the patients experienced necrosis or lagophthalmos, and all of them achieved satisfactory cosmetic results. The margin to reflex distance was almost symmetrical to the unaffected eye, and levator function was maintained. After 3 months, all patients were free of complications and did not require lubrication. However, at the 6-month mark, two patients needed an anterior lamellar resection at the margin due to pseudotrichiasis of skin cilia. After 12 months, all patients remained stable in terms of lid position and function, and did not experience any eye discomfort.

Conclusion

Reconstruction of sub-total upper eyelid defects can be achieved using a free tarsal plate graft, a bipedicled myocutaneous flap, and a free skin graft. It is essential to ensure that the flap is placed at an appropriate height to prevent pseudotrichiasis. By using this approach, two-step procedures can likely be avoided in the majority of cases.

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Umbilical Amniotic Membrane use in socket and conjunctival surface reconstruction

Author: Kubra Serefoglu Cabuk

Purpose

To present the results of patients used umbilical amniotic membrane (UAM) in socket and conjunctival surface reconstruction

Methods

Umbilical Amniotic Membrane (UAM) is prepared in collaboration with Beyoglu Corneal Banking with cryopreservation method and placed at -80°C until needed. UAM is used in 5 eyes of 5 patients; anophthalmic socket fornix reconstruction in contracted sockets (n:2, 49-year-old male, 60-year-old-female), patch graft for symblepharon surgery (n:1, 42-year-old-female) and patch graft for conjunctival defect secondary to scleral buckle exposure (n:1, 49-year-old-female respectively), and sclera-conjunctival tissue reconstruction in surgically induced necrotizing scleritis (n:1, 59-year-old-male). The primary outcome measure was the success rate of the surgery.

Results

Primary outcome measures were met in all patients. None of the patients needed additional surgical intervention.

Conclusion

UAM is an ideal biomaterial for socket, fornix, and ocular surface reconstruction.

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Changes in tear meniscus after levator muscle resection in ptosis patients

Author: Ming-Hsuan Chiang

Purpose

In this study, we aimed to quantitatively evaluate changes in tear measurements and dry eye tests following levator muscle resection in ptosis patients. This study highlights the importance of understanding the potential effects of this procedure on tear production and dry eye symptoms, and the need for appropriate management of these symptoms in patients undergoing levator muscle resection.

Methods

This comparative prospective clinical study comprised adults undergoing blepharoplasty and anterior levator resection procedures. Ocular Surface Disease Index, tear film break-up time, corneal staining, and Schirmer test values were recorded at one month postoperatively.

Results

This study comprised fourteen patients, including six males and eight females. Increased severities were found in the corneal staining postoperatively. Schirmer test values were significantly decreased compared to those preoperatively. (P= 0.043). The changes of tear film break-up time did not significantly change postoperatively.

Conclusion

Significant changes in Schirmer test and corneal staining were found in patients following levator muscle resection procedure. All patients receiving anterior levator muscle resection should be followed up carefully and treated for dry eye symptoms.

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Low-fidelity simulation models for teaching lateral canthotomy/cantholysis: a cut above the rest.

Author: Haider Zaki

Purpose

To evaluate validity of low-fidelity simulation models for teaching lateral canthotomy/cantholysis.

Methods

Trainee self-reported confidence levels performing emergency canthotomy/cantholysis were evaluated pre- and post-training session using Likert scales (-2 to 2). Training was delivered incorporating six simulation models identified via literature review and author experience. Trainees evaluated face and construct validity by rating realism of anatomy, pathology and procedure simulation via Likert scales (0 to 10) and ranking models in order of preference. A weighted scoring system was used to compare ranks. Model 1: Foam manikin with foam tapeModel 2: Cardboard with eggsModel 3: Balloon and flower potModel 4: Halloween masksModel 5: Tupperware pot with ping pong ballModel 6: Toilet roll with eggs

Results

Median reported confidence was 1 +/- 0.97, improving to 2 +/- 0.85 (p=0.0001). Cumulative model scores were 1277, 814, 1396, 578, 1438 and 1030 for models 1-6 respectively. Model 5 scored statistically higher than all bar model 3 (p=0.42) and model 3 was statistically different to all bar models 5 and 1 (p=0.42, p=0.070). Adjusted ranking scores were 59, 34, 69, 17, 72 and 32 for models 1-6 respectively. Models 5 and 3 scored statistically higher than models 2,6 and 4, but not than each other (p=0.78) or model 1 (p=0.22 model 5 compared with 1, p=0.35 model 3 compared with 1).

Conclusion

Low fidelity models offer low-cost, logistically-straightforward simulation options compared with high-fidelity or organic-tissue-based models. Model 5 (tupperware pot with ping pong ball) scored highest both in construct validity scores and trainee-rankings, but was not statistically different to model 3 (balloon and flower pot). Further research could explore improving construct validity further, and exploring sustainability and higher levels of simulation validity. New models should be compared to these established levels of validity.

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Bilateral small cell lung cancer metastasis to the extraocular muscles.

Author: João Ponces Ramalhão

Purpose

To report a unusual presentation of orbital metastasis.

Methods

Retrospective case report.

Results

A 46-year-old-male with a past medical history of smoking and stage IV small cell lung carcinoma present with loss of vision and pain on the left eye. Examination revealed bilateral proptosis, left afferent pupillary defect (APD) and visual acuity was hand motion on the left eye. An orbital computed tomography (CT) scan showed a compression of the optic nerve between the extraocular muscles at the apex and a lateral canthotomy was performed for a new onset compressive optic neuropathy, with residual visual improvement. The patient was maintained in palliative treatment with both chemotherapy and local medical and surgical (amniotic membrane cover for exposure keratopathy) ophthalmological treatments.

Conclusion

Orbital metastases limited to the extraocular muscles is a rare presentation of small cell lung carcinoma.

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Outcomes of immunosuppression & orbital radiotherapy in a metropolitan multi ethnic Graves Orbitopathy (GO) cohort

Author: Vickie Lee

Purpose

To describe the ‘real world’ outcomes of using the EUGOGO GO treatment guidance in a multiethnic patient cohort with moderate/ severe and sight threatening GO in a multidisciplinary GO service

Methods

Parameters prospectively collected for consecutive GO patients >18 years who received immunosuppression– age gender, ethnicity smoking status; thyroid diagnosis and status, TSH- receptor antibody (TSHR) titre and endocrine and GO management. Outcome measures: Clinical Activity Score Gorman & GOQOL score changes post treatment, incidence and risk factors for GO reactivation

Results

146/438 (33.3%) of all GO patients received immunosuppression. 115 (80.4%) had moderate to severe GO and 28 (19.6%) had sight threatening GO (STGO). 113 (77.4%) female, median age of 50 (IQR 18-59), >57 patients (39%) non-white. 132 (90.4%) had Graves hyperthyroidism, 28 (19.1%) were current smokers. 24 (16.4%) had prior radio iodine treatment. Median maximum CAS prior to immunosuppression was 3 (2-4). All received first line intravenous methylprednisolone (IVMP) and 38(26.0%) received second line mycophenolate mofetil (MMF) 36 (24.7%) orbital radiotherapy (ORT) and 13 (8.9%) had both MMF and ORT. 14/28 (50%) STGO underwent orbital decompression. Outcomes: Reduction in maximum CAS score (from 3 to 0) (p<0.0001) and Gorman score from 1.2 (SD+/-1.1) to 0.9(+/- 1.1) )(p=0.01) and improvement in GOQOL scores (visual function 60.4+/-27.1 to 68.6+/- 29.3 appearance (46.6+/-34.0 to 55.8=+/- 29.3). 38 (26.0%) had TED reactivation: 16 (29.0%) were only treated with IVMP and 22 (24%) had received second line treatments. Initial TSHR titres were found to be significantly higher (p=0.0039) in the reactivation cohort (median 8.7, IQR 4.7–25.3) compared to the quiescent cohort (median 3.4, IQR 1.6–9.7).

Conclusion

Conventional immunosuppression improves CAS and Gorman scores significantly but GOQOL scores improved only modestly. There was a 26% TED reactivation rate in our cohort. Initial TSHR titres may guide targeted treatment at patients at higher risk of relapse.

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5-year review of Basal Cell Carcinoma(BCC) – Pre (2017 – 19) and Covid (2020 -21) Eras.

Author: Mariam Doctor

Purpose

We determine incidence, effects of incomplete lesion excision, analyze overall recurrences of BCC and plan follow-up recommendations at a single hospital center offering services to a sun exposed beach county in England during the pre (2017-19) and covid (2020-21) era’s.

Methods

Retrospective analysis of clinical notes and histopathology reports of 160 patients with ocular BCC, based on complete/incomplete excision and classifying them according to location and histological characteristics.

Results

160 patients (pre: ~36/year | covid: ~25/year) with median age 75 years and male/female ratio ~0.85 during both era’s were studied. Average reference time ratio (pre / covid) from general practitioner to clinic was ~0.45 days and from clinic to biopsy was ~0.71 days. Location of occurrences (pre% | covid%) were Lower Lid (47 % | 37 %), Upper Lid (16 % | 22 %), M-Canthus (25 % | 19%), L-Canthus (2 % | 4 %), Eyebrow (2 % | 2 %) and Multiple locations (8 % | 16 %). Histology findings (pre% | covid%) were nodular BCC (65 % | 61 %), superficial (6 % | 5 %), Morpheaform (11 % | 10 %), Micronodular (4 % | 1 %) and mixed pattern (14 % | 23 %). Complete excision was in 80 % and majority of the repeat biopsy were required for morpheaform (6 (18 %)) patients. Overall true recurrence was 1.83 % and that of morpheaform histology was 9 %.

Conclusion

Incidence is higher in our study mainly attributed to a beach town with more sun exposure activities in the serving population. The study concludes that true recurrence is extremely low in BCC and occurs mainly in morpheaform and infiltrative histology and hence we suggest that:
1) r-BCC, morpheaform, infiltrative histologies need to be followed for atleast 5 years.
2) Primary nodular BCC can be discharged for self-monitoring after satisfactory 6 monthly post-op review.
The recommendations from this study will help to utilize limited and precious health care resources efficiently, but without compromising on patient safety.

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Idiopathic orbital inflammation with myositis after eyebrow waxing

Author: Hong Kai Lim

Purpose

Idiopathic orbital inflammation (IOI) is a benign, non-infective, inflammatory condition of the orbit without a specific identifiable cause. The clinical presentation variably includes signs of inflammation, infiltration and coincidental rheumatologic disease. Immune reactions to exogenous or endogenous factors are implicated as possible aetiologies but it remains a diagnosis of exclusion. We report a case of IOI with myositis that followed eyebrow waxing and discuss the multidisciplinary approach to the diagnosis and management.

Methods

Case report

Results

A 67-year-old Caucasian female with prior vestibular neurectomy for Meniere’s disease presented initially with severe right temple pain worse on eye movement. Symptoms began one week after waxing her eyebrows for the first time. Inflammatory markers, thyroid function tests and microbial cultures were unremarkable. In the next week, her right eye developed choroidal folds, abduction limitation, as well as lid and conjunctival oedema with proptosis, which was refractory to empirical antimicrobials. IOI with myositis was subsequently determined on MRI, which demonstrated abnormal thickening and enhancement of the right intraorbital space, sclera and both inferior and lateral recti. Following a joint oculoplastics-rheumatology discussion, regular enteral diclofenac was commenced to a favourable outcome. Significant resolution of inflammatory signs and symptoms was observed at two weeks. Pre- and post-treatment best corrected visual acuity was 6/5 and 6/6-2 respectively. Her pre-treatment IOP was 12mmHg and post-treatment was 16mmHg. NSAIDs were continued to maintain remission.

Conclusion

IOI is an uncommon but important orbitopathy and the approach to a case that developed after minor periorbital cutaneous trauma is discussed. Although the definitive aetiology is unknown, infective and immune-related mechanisms are suggested. Suspected cases require detailed ophthalmic and systemic workup as well as consideration for prompt anti-inflammatory therapy to prevent visual morbidity.

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Necrotizing fasciitis: rising incidence?

Author: Leonie Keidel

Purpose

Necrotizing Fasciitis (NF) is a rare severe infection of subcutaneous tissues, characterized by a rapid progression to extensive skin necrosis and systemic toxicity with a mortality rate up to 10-14% for periorbital NF. This case series documents an unexpected accumulation of NF and its presentation and is intended to raise awareness for NF and its early recognition.

Methods

Five patients with periorbital NF who presented to a tertiary eye department during February/March 2023 are presented. Past medical history, course of disease, pathogen profile and outcome are analyzed. All patients were male with a mean age of 76.7 years (65-83 years).

Results

Onset of symptoms was below three days in all patients, always with unilateral presentation focused to the nasal periorbital region. Eyelid swelling, tenderness and incipient gangrenous areas could be noted, deteriorating within hours. No triggering incidents could be documented. In the patients’ medical history, coronary artery disease (4/5), chronic renal failure (2/5), obstructive pulmonary disease (2/5), type 2 diabetes mellitus (1/5) and rheumatoid arthritis (1/5) were reported. All patients developed septicemia. An immediate start on i.v. antibiotics and prompt surgical debridement followed by hydrogen peroxide irrigation allowed survival of all patients and preservation of good vision. All bacterial cultures showed Gram-positive hemolytic streptococci group A beta; further DNA-analysis was initiated.

Conclusion

Occurrence of five cases of NF within two months within one center raises the question of raising incidence (known incidence 0.24/million/year), maybe due to altered pathogenity of the bacteria. Awareness of the disease and early treatment increases the chance for surviving and preserved visual function.

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Difficulties in endoscopic endonasal DCR

Author: Zoran Zikic

Purpose

To present four (4) cases in which endoscopic endonasal DCR (endo DCR) had a more difficult course of surgery.

Methods

In two of the four cases, the preoperative exam showed a less than favourable setting. In the first case the nasal passage was very narrow, so a submucosal resesction of the septal cartilage was performed. In the second case, an enlarged ager nasi encompassed the lacrimal fossa, thus an ethmoidectomy had to be done to expose the lacrimal sac. In the rest of the cases, the difficulties were encountered intraoperatively. In the third case, after incising the lacrimal sac, the Bowman probe could not pass, due to a dacryolyth, which was curreted out. In the fourth case, after incising the lacrimal sac, an orbital fat prolapse was encountered.
In all cases a bicanalicular nasal silicone stent was inserted and removed in four to eight weeks.
All the postoperative follow ups included nasal endoscopy and crust removal.

Results

In all four cases the surgery was completed successfully, and the patients were symptom free during a follow up period of six months.

Conclusion

In addition to a standard lacrimal system assessment, a preoperative endonasal endoscopic exam is important in the planning of an endo DCR. This enables the surgeon to take into account the potential difficulties. However, some complications arise during surgery, and cannot be planned for.

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Melanocytoma of the Eyelid: Novel Cutaneous Melanocytic Neoplasm Nomenclature

Author: Natalie Homer

Purpose

Cutaneous melanocytic lesions have historically been stratified into benign nevus and malignant melanoma categories. The term melanocytoma was recently proposed for intermediate-stage melanocytic lesions (1).

Methods

Herein is presented a case of a young patient with a recurrent right lower eyelid pigmented lesion, deemed histopathologically to be a melanocytoma, to bring awareness to this novel nomenclature.

Results

A 28-year-old male presented with a recurrent right lower eyelid lesion, previously biopsied 10 years prior with benign pathology. He noted subsequent increase in size of the non-pigmented anterior portion of the lesion, and increased darkening of the pigmented patch on the palpebral conjunctiva (Figure 1). He was found to have a 2.5 mm x 3.5 mm non-pigmented elevated lesion abutting the inferior punctum, with contiguous palpebral conjunctival pigmentation. Subtotal resection was performed. Histopathology demonstrated a combined compound melanocytic nevus and deep penetrating nevus, with nevocellular and deep penetrating nevus components and positive nuclear beta catenin staining in deeper melanocytes, consistent with melanocytoma designation (Figure 2). Repeat excision was recommended, along with full-body dermatologic surveillance. Upon 11-month follow-up there were no signs of recurrence.

Conclusion

Melanocytic proliferations are historically challenging to characterize. The 2018 World Health Organization (WHO) skin classification system has recognized a new intermediate melanocytic tumor, termed melanocytoma (2). Nevi most commonly arise from a BRAF V600E mutation, which ultimately activates the MAPK pathway (3). Melanocytic tumors that harbor additional mutations, such as those of the B-catenin signaling pathway, carry a higher risk of malignant transformation and now fall into this new intermediate classification category (2,4,5). Preliminary evidence has suggested potential for these lesions to spread to regional lymph nodes, with low likelihood for distant spread (1). Oculoplastic surgeons should be aware of this new histopathologic classification system.

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Ocular myasthenia gravis: Diagnosis and therapeutic challenge

Author: Fendouli Ines

Purpose

Myasthenia gravis is a serious auto-immune disease, affecting the neuro-muscular junction. Classic symptoms include muscular weakness, fatigability and oculomotor paralysis. The polymorphic clinical picture and the severity of the disease are variable from one patient to another and within the same patient. This pathology can be associated with other autoimmune diseases.
We report a case series of ten patients affected by myasthenia gravis and discuss the diagnostic and therapeutic approach of this condition.

Methods

We conducted a retrospective study of ten patients affected by ocular myasthenia gravis, between January 2020 and July 2022. The diagnosis of myasthenia was established, based on intermittent or non-systematic oculomotor disorders. All patients had a neurological examination, a thoracic CT and/or an orbital-cerebral MRI, an electromyogram (EMG), a muscle biopsy and immunological ancillary tests.

Results

The average age of our patients was 33 years old, with a female predominance. Clinical picture was variable: 70 %of patients had diplopia, 30% had intermittent ptosis, 10% had palpebral retraction and 10% had internuclear ophthalmoplegia. The ice test was positive in 40% of the cases, the Lancaster test found a fluctuation of OM disorders. Anti-acetylcholine receptor antibodies (antiRACh) were significant in 65% of cases. EMG revealed neuromuscular block in 40% of cases. The thoracic CT scan showed a thymoma in one patient.

Conclusion

Myasthenia gravis is a rare disease, with polymorphous clinical picture. Fatigability and intermittent character of diplopia and ptosis are characteristic features, that could help recognize this disease. Biological tests in isolated ocular forms have low specificty. Generalized forms can be life-threatening and represent a therapeutic emergency.
Collaboration between ophthalmologists and neurologists is essential to ensure follow-up of these patients. Ophthalmologists play an important role in early diagnosis, aggressive and adequate management of the patient, allowing better prognosis.

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Kaposi Sarcoma of the cunjonctiva revealing human immunodeficiency virus infection

Author: Fendouli Ines

Purpose

Kaposi’s sarcoma is a rare condition due to HHV8 viral infection, which is common in patients affected by human immunodeficiency virus , hematological disorders or in case of organ transplantation. Ocular location is rare. Conjunctival forms represent 7 to 18% of ocular lesions. We report a case of a woman with a Kaposi’s sarcoma of the bulbar conjunctiva that revealed infection with human immunodeficiency virus.

Methods

A case report

Results

A 38 year old woman, without any particular clinical history, presented to our department with a lesion in the bulbar conjunctiva at the level of the inferior fornix, of purple color without scleral invasion nor orbital extension. The lesion was dependent of the conjunctival tissue and mobile. General examination and the rest of his ophthalmologic examination were without abnormalities. Biopsy and pathology examination showed double spindle cell and vascular tumor proliferation with extravasation of red blood cells and nuclear labeling of tumor cells with HHV8 in relation to Kaposi’s syndrome. An etiologic workup revealed lymphopenia and positive human immunodeficiency virus serology. She received antiretroviral treatment with a favorable evolution.

Conclusion

Kaposi’s sarcoma with conjunctival origin is exceptional. It usually occurs in the context of a multicentre disease. Isolated ocular involvement is extremely rare. Pathological examination of biopsy specimens helps establish the diagnosis. Clinicians should be able to make the diagnosis even in the absence of skin manifestations. Treatment is mainly based on surgery, chemotherapy and radiotherapy.

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Diplopia Incidence Rate Post Balanced Orbital Decompression for Thyroid-Associated Orbitopathy

Author: Ahmed Dawood

Purpose

To evaluate the incidence of new-onset or increased pre-existing diplopia after balanced orbital decompression (BOD) in patients with Graves’ orbitopathy, and to possibly identify any associated risk factors.

Methods

A retrospective review of patients who had undergone medial & lateral orbital wall decompression for thyroid-associated orbitopathy by one orbital surgeon between 2019 and 2022 in our unit. A total of 45 orbits in 27 patients were reviewed. Diplopia was essentially based on subjective reporting by the patient at the time of the one-month follow-up visit, either in the primary position or gaze-evoked. Orthoptic assessments were performed for all patients with pre-existing diplopia and those who reported postoperative diplopia.

Results

The Review showed that eight patients had preoperative diplopia, of whom one (2.2%) had complete resolution after decompression and seven (15.6%) reported no new diplopia. Amongst these patients two had increased prism measurements on postoperative orthoptic assessment, however they did not report any new diplopia or required change of preoperative correcting prisms.
The incidence of new-onset diplopia was 4.4% (n=2). Diplopia spontaneously resolved in one patient after 6 months and the other patient required a referral for extraocular muscle surgery.
The main indication for orbital decompression was exophthalmos. The postoperative reduction of proptosis ranged between 4-7 mm (20-22%).

Conclusion

In general, diplopia is less likely after BOD because of the preservation of the inferomedial strut and the symmetrical relief of orbital space around both medial and lateral rectus muscles. The incidence of post BOD diplopia (new-onset or increased) in this case series was 4.4%, below previously literature-reported rates of 5.8% and 7%.
We noted resolution of pre-existing diplopia in one patient and spontaneous recovery of surgically induced diplopia in another one. As the incidence was low, we could not statistically identify any associated preoperative risks for post decompression diplopia in this series.

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Polymerase Chain Reaction Based Characterization of Nasal and Ocular Flora Microbiome in Congenital Nasolacrimal Duct Obstruction and Functional Analysis of Microbiome-Related Metabolic Pathways

Author: hazal bircan

Purpose

To characterize Streptococcus pneumonia, Staphylococcus aureus, Hemophilus influenza, Serratia marcescens, and Moraxella catarrhalis in the nasal and ocular surface flora of children with unilateral congenital nasolacrimal duct obstruction (CNLDO) using polymerase chain reaction (PCR)-based methods, and to identify the bioactivity and enzymes of these bacteria, and to compare age- and sex-matched healthy children.

Methods

Before probing, the swab samples were taken from the bilateral inferior meatus and ocular surfaces of 26 patients with unilateral CNLDO. Also, samples taken from the contralateral ocular surface and inferior meatus of the children who underwent unilateral strabismus or ptosis surgery constituted the control group. The presence and quantity of bacteria in the samples were analyzed by using primers specific to the bacteria. The cycle threshold (ct) value was used to determine the amount of bacteria. The lower ct value means there was more bacteria DNA/RNA in the sample.

Results

Streptococcus pneumonia in nasal flora, Staphylococcus aureus in the ocular surface flora, and Hemophilus influenza, Serratia marcescens in both the nasal and ocular surface flora were more abundant on the CNLDO side than the control group (p<0.05). The ct value for all bacteria was lower on the CNLDO side in both nasal and ocular flora compared to controls (p<0.05). The difference was the most remarkable for Serratia marcescens. When the obstructed and patent sides of the children with CNLDO were compared, Moraxella catarrhalis was found to be higher in the ocular surface, and Streptococcus pneumoniae, Staphylococcus aureus, Serratia marcescens, Moraxella catarrhalis were found to be higher in the nasal flora (p<0.05). The metabolite analysis of these bacteria revealed that betaine, L-carnitine, L-leucine, and L-alanine were negatively regulated in the presence of these bacteria.

Conclusion

CNLDO seems to be associated with some bacteria or alterations in their amounts in the ocular surface and nasal flora. These microbiological differences may be a risk factor for or a result of CNLDO.

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A modified Hughes procedure using the Tutopatch® and the Mini-Monoka® in a patient with a significant lower eyelid defect following a tumor resection – a case report.

Author: Sylwia Konarska

Purpose

The Hughes procedure is a frequently utilized prominent technique to reconstruct a large full-thickness defect of a lower eyelid after tumor resection. The purpose of this study is to present a possible modification of the Hughes procedure in the case of post-operative lack of the lateral part of a tarsal plate and the proximal part of a lacrimal duct.

Methods

A 77-year-old female patient underwent full-thickness resection of a lower eyelid tumor with a 3 mm clear margin after histopathological diagnosis of Basal Cell Carcinoma. The excision involved the proximal part of the lacrimal duct and the lateral part of the tarsus. The tarsoconjunctival flap from the upper eyelid for posterior lamella, and a full-thickness skin graft from the preauricular area for anterior lamella, were used for reconstruction. Due to an insufficient orbital periosteal flap, lyophilized bovine pericardium (Tutopatch®) was attached to the periosteum as a base for tarsoconjunctival flap. The laceration of the lacrimal duct was rebuilt using the Mini-Monoka® artificial tube.

Results

In this case, the modified Hughes technique with the use of Tutopatch® and Mini-Monoka® brought favorable functional and cosmetic outcomes.

Conclusion

The Tutopatch® implant can be an alternative material for a periosteal flap to anchor the tarsoconjunctival flap. Canaliculoplasty with the Mini-Monoka® stenting prevents post-operative epiphora.
In conclusion, the modified Hughes procedure with the use of Tutopatch® and Mini-Monoka® can be the technique of choice in challenging lower eyelid defects.

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Conjunctivochalasis and epiphora improvement after fornix deepening with retractor recession and repositioning

Author: Camille Yvon

Purpose

To evaluate outcomes of fornix deepening with retractor recession and repositioning for conjunctivochalasis (CCh) on improvement of conjunctival folds and ocular surface symptoms, particularly epiphora and symptoms that may be related to evaporative dry eye and reflex tearing.

Methods

Retrospective, single-centre, observational case series of patients with refractory CCh who underwent fornix deepening and retractor recession. CCh was graded using the Hoh classification (grades 0 to 3 depending on the number and height of folds). Epiphora, reflex tearing and dry eye symptoms were assessed using the validated ‘TEAR’ score pre- and post-CCh correction.

Results

18 eyes of 11 patients with conjunctivochalasis (average age 68, range 46-82 years) were treated with fornix deepening and retractor recession. All had shallow fornices pre-operatively with a mean CCh grade of 1.7 (typically lower than the tear meniscus). Locations of the folds were variable: diffuse/middle (n=6), nasal (n=3), and temporal (n=2). At 15-months mean follow-up, conjunctival redundancy was absent in 10 of 11 patients postoperatively, resulting in a restored tear meniscus and reservoir.

91% saw a reduction in tearing frequency (T), with 73% gaining ≥ 2-point improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 82% and 91% of patients, respectively, with 36% and 64% gaining ≥ 2-point improvement. R scores (related to reflex tearing) improved in 73%, with 64% seeing ≥ 2-point gains. (P<0.05 for all).

Conclusion

Restoration of the tear reservoir by inferior fornix deepening with retractor recession and repositioning can result in improvement of CCh and epiphora.

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Orbital schwannoma:a case report,the challenge of diagnosis and management

Author: Lilit Arustamyan

Purpose

To present a case of orbital schwannoma and highlight the challenge of its diagnosis and treatment.

Methods

A case report of 68 year old woman,who was diagnosed orbital schwannoma.Patient had a painless palpable mass on inferolateral wall of right orbit,which was getting bigger,swollen eyelids,proptosis 5 mm from right side for over 3 months.CT scan examination found out a mass with exact boundaries,with 16*17 mm sizes,without erosion of the bone.The decision was made to do an operation:inferior-anterior orbitotomy by transcutaneous incision,total excision of the tumor.The operation was done with local anesthesia,because of systemic problems of the patient.A tumor was fully removed from retrobulbar space.It was homogenous,encapsulated,had 27*27 mm sizes,exact boundaries,didn’t grow into the eyeball,optic nerve,extraocular muscles.The tumor was sent to histopathological examination.The answer was orbital schwannoma

Results

Orbital schwannoma(neurilemoma)is a very rare type of benign neural orbital tumors.During 2022 year,in S.V. Malayan eye clinic,Oculoplastic and Neuro-ophthalmology department,178 cases of tumors were examined and operated.129 of them(72.5%)were benign by histopathological examination,49 of them(27.5%)were malignant.During 20 years of experience,in S.V.Malayan eye clinic this was the first case of orbital schwannoma.Orbital schwannoma occurs from myelin producing schwann cells,has slow growing,usually involves head and neck,not common location is superior quadrant of the orbit.In our case schwannoma had not typical location,including infero-lateral quadrant.They occur usually from sensory nerves,in our case,relying on location,it presumably occurred from 3rd nerve(nervus oculomotorius),so,in this form, it is also very rare.Now the patient is under our control,without any complication.

Conclusion

Orbital schwannoma is a very rare orbital neoplasm.Therefore,it should be considered in the differential diagnosis of slow growing orbital masses. As experience shows,total excision of the tumor and clear boundaries have low risk of recurrence of the tumor.

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Emerging trend of Secondary Acquired Lacrimal Duct Obstruction (SALDO) in Sino-Orbital Mucormycosis Treated Patients in the post COVID-19 pandemic era

Author: Nandini Bothra

Purpose

To describe and prepare for the emergence of SALDO in the Sino-orbital Mucormycosis treated patients during the COVID-19 pandemic

Methods

A prospective interventional case series involving 5 consecutive eyes with SALDO presenting months or years after the treatment of orbito-sino-nasal mucormycosis post COVID-19 pandemic were enrolled in the study. Lacrimal irrigation, endoscopic examination of the nasal cavity and computed tomography dacryocystography scans were done prior to initiating surgical management. All patients underwent external dacryocystorhinostomy (DCR). Primary outcome measures were demonstrable resolution of epiphora with patent irrigation and the secondary outcome measure was the subjective improvement of the epiphora.

Results

The mean age of the patients was 45.6 years (range: 41-62 years). Right sided SALDO was present in 4 patients and left sided in 1 patient. All the patients had completed sino-orbital mucormycosis treatment atleast 6-months prior to development to epiphora. Lacrimal irrigation confirmed the nasolacrimal duct obstruction and CT-DCG confirmed the site of obstruction at the sac-duct junction. Endoscopic examination showed loss of nasal architecture with no visible landmarks. All patients underwent external dacryocystorhinostomy (DCR). Anatomical and functional success was 100% at an average follow-up of 3.8 months.

Conclusion

SALDO is one of the emerging sequels of post COVID-19 Rhino-Orbital mucormycosis which can account to further morbidity in patients who survived. Invasive fungal sinusitis is likely to cause SALDO by various possible mechanisms like involvement of bony nasolacrimal duct secondary to erosion within maxillary sinus and chronic inflammation related scarring and narrowing of distal nasolacrimal duct. Iatrogenic damage to the nasolacrimal duct during the extensive debridement could be a possible etiology. CT DCG was a useful tool to identify the exact site of obstruction in these patients, also to see integrity of surrounding bones for creation of bony ostium and to plan further management of the patient.

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Role of nasal endoscopic medial wall decompression in orbital thyroid decompression

Author: Saamir Kharma

Purpose

To analyse the endonasal medial orbital wall decompression and compare it to the conventional transconjunctival approach.
Comparing the duration, decompresive effect and morbidly of the two approaches.

Methods

Analysis of the last 10 cases of thyroid Ophthalmopathy who needed medial orbital wall decompression,

Results

Endoscopic medial orbital wall decompression gives a more comprehensive tool in performing decompression.
It needs less operative time and gives more decimpressive effect.

Conclusion

Endoscopic medial orbital wall decompression is probably a better way in performing this goal, as it is done by ENT surgeons who are trained to do endonasal surgery and are fully oriented in this technique

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Why is Trapdoor orbital floor fracture is a different floor fracture

Author: Saamir Kharma

Purpose

To highlight the pathophysiology, and mechanisms of trapdoor orbital floor fracture.To clarify that it’s management is totally different from other more common orbital floor fractures.

Methods

Files of all patients diagnosed with orbital floor fractures seen at our unit during the last 10 years where analysed.

Results

9 cases out of 30 orbital floor fractures where found to be of Trapdoor pattern.This require timely management, and surgery to be done in a particular way, with less need to place floor spacer, and goal being to release entrapped tissue and normalize the forced duction test

Conclusion

Identifying that the fracture we are dealing with is a trapdoor type, makes its management more accurate, more predictable and carry less morbidty.

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Congenital blepharoptosis: Comparison of two surgical approach results- ongoing study

Author: nur khatib

Purpose

Congenital blepharoptosis presents within the first year of life either in isolation or as a part of many different ocular or systemic disorders. Surgical repair is challenging, and recurrence necessitating more than one operation is not uncommon. Not all patients with congenital ptosis require surgery, but children with amblyopia due to astigmatic anisometropia or visual deprivation may benefit from early surgical correction. A variety of surgical procedures to correct congenital ptosis have been described.

Methods

Primary results of a retrospective clinical analysis of 48 out of 62 patients with congenital blepharoptosis aged from 0 to 17, who underwent surgical corrections at the Department of ophthalmology, HaEmek Medical Center, between 2020 and 2023, were reviewed.
Included cases were analysed on the base of the type of primary defect, degree of ptosis, and surgical method.
The aim of this study was to estimate esthetic and functional results of different surgical treatments in 36 patients corrected by Levator resection method, and 12 by frontalis suspension.

Results

The median age at presentation was 6 years (range,0 months to 17 years). The median follow-up period was 1.4 years (range, 6 months to 3years). No statistically difference in ptosis rate between genders. 60.4% of ptosis cases were among Arabs ethnic origin in comparison to Jews 39.6%.
In comparison between the levator resection and frontalis suspension surgical approach no statically significant difference in MRD1 at final follow up (median; 3.25 versus 2, mean; 2.81 versus 1.83 respectively). The two surgical approach has no difference in MRD1 improvement after the surgery. The ptosis recurrence rate among frontalis suspension group was higher than in levator resection group (25% versus 11.11%).

Conclusion

Comparable acceptable results of levator resection and frontalis suspension surgical approaches were achieved regardless of levator function and ptosis severity prior to surgery.

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Botulinum toxin A injection with anatomical landmarks: an alternative upper face approach

Author: Ana Drumond Cassimiro

Purpose

To present the practical association of two injection techniques developed to treat upper third of the face’s wrinkles, one targeting the frontalis muscle (ONE21 technique, described by Pecora et al., 2020), and the other concerning the frontalis antagonists glabellar muscles: corrugator supercillii and procerus (refined 3-point injection technique, described by Cotofana et al., 2021).

Methods

We describe each technique separately in order to proper introduce 4 cases illustrating their association regarding 4 different frontal and glabellar patterns of contraction and their results after 30 days.
Anatomical landmarks and functional evaluation of frontalis muscle provide 21 intersection points. These points should be clearly marked on the patient, although subsequently erased if desired and the dosing of each point can be tailored accordingly, for a fully customized approach.
The glabellar approach is based on 3 points of injection targeting the anatomic origin of the procerus and the corrugator supercilii muscles to minimize the risk of medial brow and eyelid ptosis.
For both techniques, to assist in defining the proper dose, it is important to gently palpate the region in contraction in order to feel the presence or absence of the muscle in each particular area, as well as the strength of the muscle.
We used abobotulinumA (Dysport®) in all cases.
All patients provided their consent for image use.

Results

The association of these techniques seems to be effective with good patient’s satisfaction and predictable results despite diferent frontal and glabellar muscles contraction patterns.

Conclusion

Treatment protocols based on common patient scenarios may lack practicability for most physicians, as they may not be accurate to classify certain faces and so they fail to provide the best treatment outcome. Here, we present the association of two published techniques dedicated to aesthetical treatment of upper third face’s wrinkles considering anatomical and functional landmarks for a customized approach appliable to all different patients’ upper third faces regardless of gender, age or ethnicity.

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Lower Eyelid Retraction Repair Using Autologous Auricular Scapha Cartilage

Author: Ayse Dolar Bilge

Purpose

To evaluate lower eyelid retraction surgery using autologous auricular scapha cartilage (anterior surface groove between helix and anti helix) and present its surgical results in a group of patients.

Methods

Medical records of 21 patients who underwent lower eyelid retraction surgery using scapha cartilage were reviewed. Retractions were longstanding (6 months to 20 years) and with 1 mm or more inferior scleral show, due to previous lower eyelid blepharoplasty, facial palsy or congenital retraction. Lateral canthotomy, cantholysis, subtarsal conjunctiva-lower eyelid retractors incision, lower eyelid retractor lysis and suturing of the cartilage graft to the defect area without conjunctival cover were performed in all patients.

Results

Twenty nine eyelids in 21 patients were operated. There were no per-operative complications. During the follow-up period (mean, 11 months; range, 6-30 months). Lower lid retraction improved (better than before) %96,5 of eyelids. Four patients were revised because of canthal problems (cantus sutures loosening and eyelid apposition). The graft was visible in two patients but revision was not required. One patient had donor area mild helix deformity that did not require futher intervention. One patient had punctate epitheliopathy following surgery which healed following bandage contact lens placement for 1week.

Conclusion

Auricular scapha cartilage may be an useful spacer graft for lower eyelid retraction caused by middle/posterior lamellar shortening. Many lower lid retractions that have no middle lamellar shortening can be corrected without grafting). It can be accepted as an ideal spacer graft because it is a very stable material, does not shrinkage, its concavity is compatible with the concavity of the globe, it is soft compared to other cartilages, it is easy to harvest, the donor site and ocular surface complications are very low and it is autologous.

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Posterior scleritis and orbital inflammatory pseudotumor: Case report.

Author: Felicitas Lacoste

Purpose

Report of a clinical case of unilateral posterior scleritis associated with an inflammatory pseudotumor

Methods

Description of the clinical case and bibliographic review of the subject

Results

A 66 year old female patient with a diagnosis of left inflammatory pseudotumor attended referring a 5 day history of decreased vision. At the time of consultation, far visual acuity of the right eye (RE) was verified: 20/20; left eye (LE): 20/200; eye movements: limited in supraduction, abduction and infraduction. LE biomicroscopy: conjunctival injection, pigment in the anterior chamber, posterior synechiae at hs 12, anterior vitreitis. LE funduscopy: papilla with raised edges, inferior bullous retinal detachment. On computed tomography (CT): extensive scleral thickening with choroidal detachment. Given the urgency, the patient was admitted for study by general physicians and treatment began with 3 cycles of pulse therapy of methylprednisolone 1 gr.

Conclusion

Orbital inflammatory pseudotumor is a non-specific, non-infectious, benign inflammatory condition that it usually affects the orbit. It can present as an acute, subacute or chronic, unilateral or bilateral condition. The physiopathogenesis is not yet identified but it has been associated with systemic autoimmune diseases. It can affect the eyeball, conjunctiva, eyelids and muscular structures. The most common form of presentation is pain and periorbital inflammation. Other frequent presentations include: chemosis, limitation of eye movements and proptosis. Rarer: uveitis and papillitis or exudative retinal detachment. It represents 8-10% of orbital lesions. For the diagnosis, a detailed clinical history, physical examination, complementary images (eg, CT or MRI) are necessary. An incisional biopsy should be performed in those lesions that are occupying the orbit. As for the main differential diagnoses to take into account in these cases are granulomatosis with polyangiitis, IgG4 disease and sarcoidosis. The main treatment consists of the systemic administration of corticosteroids associated with immunomodulatory therapy.

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Managing “Botox failures” in Blepharospasm- Improving Outcomes by Treatment of Meibomian Gland Inversion

Author: Christina Lim

Purpose

Benign essential blepharospasm is a movement disorder characterised by repetitive involuntary contractions of periocular muscles. Unfortunately, available treatment options for blepharospasm are limited, including incobotulinum toxin (BoNTA) injections and myectomy of eyelid protractors. However, the effect of BoNTA is temporary and myectomy may be considered excessive for milder cases. Refractory cases persist despite these treatments. We report the importance of recognising meibomian gland inversion (MGI) in blepharospasm and its treatment as an alternative option in improving its symptoms.

Methods

A retrospective, case series of patients with blepharospasm receiving BoNTA injections in a single centre was performed between 2018-2022. In this cohort, those with the concurrent diagnosis of MGI who underwent anterior lamellar repositioning surgery have been identified. The outcomes include pre- and post-surgery Jankovic rating score, blepharospasm functional disability scale (FDS) and number of units of BoNTA injections.

Results

A total of 8 patients have been identified (M=4, F=4, mean age 68 years, range 52-78 years). There were no intra- or post-operative surgical complications. The mean reduction in Jankovic severity and frequency scores were 0.88 (p<0.05) and 1.25 (p<0.05) respectively. The mean reduction in the blepharospasm FDS were reading (1.125, p<0.05), watching television (0.5, p0.05), driving (2.5, p<0.05). No patients reported worsening of their symptoms.

Conclusion

Refractory blepharospasm poses challenges due to limited treatment options. Our case series highlights the importance of identifying MGI as a significant factor in the treatment of blepharospasm, particularly in patients where BoNTA fails to give adequate relief. Anterior lamellar repositioning surgery has shown to be effective in improving the Jankovic score and blepharospasm FDS and can reduce the required BoNTA injection doses. We recommend considering MGI treatment as an alternative treatment option when traditional methods are inadequate or less invasive surgery is desired.

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Reconstructive surgery on eyelids and orbits in facial cleft patients in a facial cleft surgery centre in Assam

Author: Anne Wiencke

Purpose

To share experience from “the difficult cases week” with Second Chance Medical in Northeast India in October 2022 and to invite a discussion on planning reconstructive surgery in children with facial clefts.

Methods

Using the Tessier Classification for facial clefts I will go through 10 patients that were managed by a cleft specialist plastic surgeon and myself during the five days spent in the operating theatre

Results

Patients with facial clefts will be demonstrated in pre- and postop photos and oculoplastic procedures will be discussed.
There were patients who had had primary procedures performed years previously and some were primary cases.
The staging of procedures and the possible late complications of procedures will be discussed.

Conclusion

Patients with facial clefts are very rare. Gaining maximum experience from each patient is important as is knowledge of changes over time following reconstructive surgery.

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DERMOID CYST: OUTCOME ANALYSIS IN A PEDIATRIC REFERRAL HOSPITAL

Author: Hugo Gonzalez Valdivia

Purpose

To describe the management of dermoid cysts in a pediatric referral hospital.

Methods

Retrospective review of 142 patients with pathological diagnosis of dermoid cyst in a pediatric referral hospital between 2013 and 2023.

Results

One hundred forty two patients, 44.3% males, and 55.7% females were retrospectively reviewed. There were 44.3% right eyes and 55.7% left eyes. Mean age at surgery was 39.15 months (5.6 months–16.4 years). 90.4% lesions were superficial, and 9.6% were deep. Quadrant location was 54.8% superiortemporal, 39.1% superior-nasal, 3.5% inferior-temporal, and 1.7% in the nasal inferior quadrant. Most patients only had aesthetic concerns, but 2.61% showed lacrimal drainage obstruction symptoms, 1.74% had proptosis, and 1 case spontaneously drained to the cutaneous surface. Imaging was performed in 44.3% patients. Regarding to their radiodensity, 71.9% had low density content, 28.1% high density, and only 1 patient showed full liquid content; 10.9% showed heterogeneous content; 53.1% showed bone remodeling. Every patient but 1 underwent surgery for a barely accessible asymptomatic retrobulbar cyst. 7.8% of the cysts were breached during surgery. 2,6% recurrences were found, but only 1 was related to intraoperative breach.

Conclusion

Dermoid cysts are the most common benign orbital/periorbital tumors in the pediatric population. Imaging is required for evaluation of lesions in atypical locations, deep or fixed to underlying tissue. Surgical removal is the gold standard of treatment. Multidisciplinary approach may be required in the most complex cases. After surgery, few complications and recurrences were found in our series.

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Orbital Compression and Ocular Dystopia Secondary to Maxillary Dentigerous Cyst. Literature Review.

Author: Hugo Gonzalez Valdivia

Purpose

The aim of this work is to present an infrequent clinical case and to review the available literatura, with an emphasis on ophthalmological symptoms.

Methods

We present the case of a 4-year-old girl with a large dentigerous cyst on the maxillary bone, who had long-standing unilateral epiphora associated with progressive ocular dystopia, facial asymmetry and ipsilateral amblyopia. A multidisciplinary approach was taken by the maxillofacial surgery, ophthalmology and optometry teams. This included systemic antibiotic administration, surgical cyst drainage and amblyopia treatment. The literature review was carried out in the MEDLINE database through the free electronic access to PubMed in March 2020.

Results

At the 6-month follow-up, the patient was asymptomatic. The most common symptoms of dentigerous cysts are epiphora 36.8%, ocular dystopia 31.2%, diplopia 21.1%, proptosis, nasolacrimal duct obstruction and blurred vision at 10.5%. Amblyopia has not been reported.

Conclusion

Dentigerous cysts are benign odontogenic cysts, which can be found in the jaw and less frequently on the maxillary bone. They are usually asymptomatic, and the occurrence of ophthalmic complications is very infrequent. Multidisciplinary management is essential to avoiding long-term morbidity of maxillary dentigerous cysts and should include an ophthalmologist.

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Clinical and radiological findings of a cohort of patients with hypothyroid thyroid eye disease (Ho-TED) attending a multi-disciplinary thyroid eye disease service

Author: Ken Kawamoto

Purpose

Ho-TED is a rare entity and can represent a challenge in diagnosis and management.

Methods

Consecutive Ho-TED patients were included. Prospective collection of thyroid stimulating hormone receptor antibody (TSHR-Ab) and thyroid peroxidase antibody (TPO-Ab) status, Clinical Activity Score (CAS), Gorman score, disease severity and Graves Orbitopathy Quality of Life (QO-QOL) score at each visit. Radiological parameters, management, and outcomes were collected retrospectively.

Results

10 patients with Ho-TED with no history of hyperthyroidism were included. Mean age at presentation was 44.2 years (range 27-72), with a female to male ratio of 4:1. Three patients (30%) were current smokers. Three patients (30%) were positive for TSHR-Ab and four (40%) for TPO-Ab. On initial presentation, CAS score was 0 or 1 in four patients (40%), 3 in two patients (20%) and 4 in two patients (20%). One patient presented with unilateral dysthyroid optic neuropathy. Mean GO-QOL score was 83.1 (VF) and 61.5 (A). Two patients (20%) had severe proptosis with a mean of 24.5mm. All patients had a known diagnosis of hypothyroidism and were taking levothyroxine at the time of initial presentation. Two patients (20%) had moderate to severe radiological inflammation on baseline MRI with mean ADC value of 1260 (range 1100-1421). Two patients (20%) required intravenous steroids, one patient (10%) required bilateral medial wall decompression, and one patient (10%) had orbital floor steroid injection. No patient had TED reactivation on follow-up.

Conclusion

Our incidence of Ho-TED patients requiring systemic immunosuppression was 20% compared to 33.3% in our overall TED cohort. Patients presenting with dysthyroid optic neuropathy was 10% compared to 19.1% in the overall TED cohort. The clinical presentation of Ho-TED can range from mild ocular surface disease to sight threatening dysthyroid optic neuropathy. Whilst rare, clinicians must consider the possibility of TED in hypothyroid patients.

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Lateral tarsal strip with everting suture and inferior retractor plication for correction of entropion

Author: Nazanin NOSRATI

Purpose

To describe a surgical technique that involves combining a lateral tarsal strip with one everting suture and one inferior retractor plication suture for correction of lower eyelid involutional entropion.

Methods

Retrospective review of patients that underwent correction of lower eyelid entropion with a combination of lateral tarsal strip, everting suture and inferior retractor plication were conducted.

Results

66 patients underwent this surgical procedure between December 2020 and October 2022.42 males and 24 females underwent this surgical procedure.Complete resolution of eyelid malposition was noted in all patients at 1 month follow up. No recurrences were noted in the follow up period extending up to 22 months after surgery. One patient developed suture granuloma at the lateral canthus, which resolved with conservative management with topical steroids. One patient developed a bleed at 4 days post-operatively, which resolved spontaneously.No other intra-operative or postoperative complications were noted

Conclusion

Combination of lateral tarsal strip with everting suture and inferior retractor plication suture achieved good surgical success rate in correcting involutional lower eyelid entropion.

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The glabellar “flap-graft”: how to maximize the result of a glabellar flap avoiding the formation of a “unibrow”.

Author: Constanza Barrancos

Purpose

In the conformation of a glabellar flap, it is common that after rotating the flap to adapt it to the skin defect that is to be covered, there may be fragments of the flap that are resected. These skin fragments can function as useful free skin grafts that help us complete the “puzzle” of tissue reconstruction.

Methods

We present three cases in which a glabellar flap was performed to reconstruct skin defects in the medial canthal region secondary to resection of basal cell carcinomas with the Mohs technique. After rotation of the flap to cover the recipient area, a triangular fragment of the flap was excised, corresponding to the “upper peak” of the flap. Said fragment was used as a free graft to cover the glabellar donor area, so as to avoid excessive approximation of the heads of the eyebrows or the formation of a “unibrow”.

Results

The three cases presented a favorable evolution avoiding unsightly monobrow.

Conclusion

The carving of skin flaps can lead to the formation of free skin grafts that can be useful to complete the reconstruction.

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Periorbital skin graft outcomes and donor site morbidity: Does grade of surgeon matter?

Author: Hetvi Bhatt

Purpose

Skin grafts are frequently used in periorbital reconstructive surgery. Harvesting of the graft is often performed by the primary surgeon. However, the presence of a surgical assistant able to harvest the graft from a remote surgical site, such as the arm, significantly reduces surgical time and improves the patient experience. Clinical Nurse Specialists (CNS) may fulfil this role. We aim to compare the impact of the grade of surgeon harvesting the graft on surgical outcomes and donor site complications.

Methods

This is a retrospective study of all patients who underwent periorbital reconstruction involving a skin graft under a single consultant oculoplastic surgeon at a tertiary referral centre. Using the electronic theatre logbook, we identified all patients who underwent a skin graft from January 2013 to December 2022. Case notes were reviewed to identify primary diagnosis, site of surgery, grade of surgeon harvesting graft, donor site morbidity and host site complications. This study was registered as an audit with the hospital quality improvement team.

Results

78 patients who had reconstruction involving skin grafts from the arm were included. There were 40 female and 38 male patients, mean age was 75. The most common diagnosis was BCC (n=63). Other diagnoses included SCC (n=9), lentigo maligna (n=3), Cicatricial ectropion (n=1), seborrhoeic keratosis (n=1) and Merkle Cell Carcinoma (n=1). 38 grafts were harvested by a doctor, and 40 by a CNS. There was no significant difference in the donor site dehiscence rates between grafts harvested by doctor or CNS (p= 0.36, chi-squared test). 87% of grafts had a good colour match. Mean follow up duration was 28 months (range 1-93).

Conclusion

We concluded that with appropriate training CNS’s can actively undertake more complex surgical tasks like harvesting skin grafts, thereby almost halving the surgical time and improving the patient experience. We demonstrated that there was no statistically significant difference in donor site morbidity or surgical outcomes whether the grafts were harvested by a doctor or CNS.

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A novel surgical technique involving bone fixation canthoplasty in treating patients with euryblepharon

Author: Emma Samia-Aly

Purpose

Euryblepharon is a rare congenital eyelid malformation characterised by symmetrical horizontal enlargement of the palpebral fissure. The eyelid is shortened vertically compared with the horizontal dimension, with the lateral canthus most commonly affected. They can be isolated or associated with other anomalies and it is unclear what causes this appearance, however several theories have been reported. Conservative treatment is the mainstay however in some severe cases surgery is necessary, which have been reported to varying degrees of success. Either they have not resolved the functional element or improved the cosmesis or both.

Methods

In total 6 patients were identified with euryblepharon. Some had mild changes and were asymptomatic with no concerns regarding the appearance of their eyelids, whilst others suffered from ocular irritation and dry eyes and were bothered by the cosmesis. These symptomatic patients, on examination, had inferior punctate staining, inferior scleral show and lagophthalmos and two opted to go ahead with surgery as they found conservative measures to be unsatisfactory.

Results

For those patients that opted for surgery, we performed lower eyelid bone fixation canthoplasty, with excellent results. This technique corrected both their functional and cosmetic elements, with a follow up period of up to 7 months, when they were discharged. This technique uses a 5-0 prolene suture to anchor the lower eyelid tarsus tissue to two bone drilled fixation points on the lateral orbital rim, with the suture allowing for adjustment in height and tension to ensure a good position of the lower eyelid.

Conclusion

This new technique corrects both the functional and aesthetic issues that some patients with euryblepharon experience. This new technique does not compromise on either element which has been the case in some previous studies. It is also tissue sparing and can be done as a day case procedure, either under a general anaesthetic or with local and sedation and has been beneficial in this rare group of patients with euryblepharon that require surgery.

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Lacrimal gland volume measurements in normal and thyroid orbitopathy patients using Magnetic Resonance Imaging

Author: nur khatib

Purpose

In different orbital diseases such as thyroid orbitopathy, structural and inflammatory changes occur in the lacrimal gland. Previous studies using computed tomography imaging have demonstrated that the lacrimal gland volume is larger among patients with thyroid orbitopathy.

Methods

On going retrospective study (now on) 22 lacrimal glands in 11 normal patients and 28 lacrimal glands in 14 thyroid orbitopathy patients from July 2015 to November 2021. This research was performed according to the institutional declaration of Helsinki. Normal patients were recruited from a subset of patients hospitalized in the Ophthalmology department with optic neuritis, optic neuropathy, or other neurological cause of visual disturbance unrelated to the lacrimal gland. Patients with thyroid orbitopathy were diagnosed in the Oculoplastic Clinic at Emek Medical Center. All patients underwent a Magentic Resonance Imaging of the brain and orbit. All patients with thyroid orbitopathy underwent endocrinological evaluation, ocular evaluation and orbital MRI examination. Lacrimal glands were evaluated on T2-weighted images using a simple method of volume measurement with Siemens’ Synovis imaging software.

Results

The mean volumes for normal and thyroid orbitopathy patients were 0.62 ± 0.11 cm3 and 0.70 ± 0.13 cm3, respectively. Mean lacrimal gland volumes in normal female vs. male patients were 0.66 ± 0.10 vs. 0.58 ± 0.11, whereas in the thyroid group female vs. male patients had volumes of 0.71 ± 0.09 cm3 vs. 0.69 ± 0.15 cm3. Female predominance in the normal group was 45% (5/11) vs. 57% (8/14) in the thyroid orbitopathy group.

Conclusion

these are primary results of on going study: the mean volumes for normal and thyroid orbitopathy patients were 0.62 ± 0.11 cm3 and 0.70 ± 0.13 cm3, respectively. Mean lacrimal gland volumes in normal female vs. male patients were 0.66 ± 0.10 vs. 0.58 ± 0.11, whereas in the thyroid group female vs. male patients had volumes of 0.71 ± 0.09 cm3 vs. 0.69 ± 0.15 cm3. Female predominance in the normal group was 45% (5/11) vs. 57% (8/14) in the thyroid orbitopathy group.

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Frontal bone Osteoma Growth in Pregnancy

Author: Akruti Desai

Purpose

To describe a case of frontal bone osteoma presenting only as ptosis and its progression during pregnancy and its management

Methods

Study of Computed tomography imaging of bony lesion of superior orbital rim
Post delivery excision of osteoma was done through an aesthetic eyelid crease incision
Histopathological study was done and to evaluate the co-relation with growth in pregnancy, Estrogen Receptor and Progesterone receptor study was done.
Over expression of Estrogen Receptor beta inhibits E2-mediated proliferation and gene expression in breast while in prostrate estrogen receptor alpha promotes cell proliferation and survival.By immunohistochemistry, ERβ is expressed at higher levels in cancellous bone than in compact bone, while ERα is detected higher in compact bone than in cancellous bone.

Results

Histopathological Diagnosis confirmed Mature osteoma of bone
Immunohistochemical studies for Estrogen Receptor and Progesterone receptor study was negative for both

Conclusion

Emphasises the importance of palpation in cases presenting with ptosis.
Growth of osteoma in pregnancy needs further study. There could be a role Human chorionic gonadotropin-beta and human placental lactose immunohistochemical marker to co-relate growth during pregnancy.
Eyelid crease incision: Aesthetic approach for in-toto excision of moderate size frontal bone osteoma

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Management of ocular complications after injection of hyaluronic acid at the face level : The French consensus.

Author: SARFATI ERIC

Purpose

The French consensus

Methods

Material and method :The authors propose the fruit of several work sessions corrobirated by a rewiew

Results

Discussion : The implementation protocol for the management of ocular vascular complications after injection of hyaluronic acid at the face level was the subject of a national consensus. The treatment must be renewed in a referent center.These centers are currently set up throughout the francais territoryPeribular hyaluronidase associated with the hyperbaric caisson must be instituted very quickly after confirmation of the diagnosis in order to have a reversibility of the phenomenon.

Conclusion

Conclusion : There is currently a French consensusof vascular ocular complications after injection of hyaluronic acid but for the moment the protocol comes up against the establishment of a referent center.

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Eyelid Atypical Fibroxanthoma: An Insight into a Rarely Encountered Tumor

Author: David Oliver-Gutierrez

Purpose

This study aims to provide a comprehensive analysis of a rare mesenchymal tumor, Atypical Fibroxanthoma (AFX), which accounts for only 0.2% of skin tumors, with a particular focus on a rare periocular case.

Methods

A 63-year-old female patient presented with a one-year progressive growth of a tumor in her right upper eyelid. The lesion started as a soft, reddish growth and eventually reached 2.5 cm with a 1 cm base. Surgical excision was performed with safety margins, and glabelar flap reconstruction was applied.

Results

Histopathological examination revealed a well-defined, bilobular dermal proliferation, separated from the epidermis by the Grenz zone and featuring abundant cellular atypia and pleomorphism. Epithelioid giant cells, histiocytic cells, and multinucleated Lagerhas giant cells were identified, forming nodules around thin-walled vessels. Some cholesterol crystals and mitotic figures were also observed. No necrosis or vascular or neural invasion was seen. Immunohistochemical staining showed positivity for vimentin, CD10, and CD99. The patient was diagnosed with atypical fibroxanthoma and is under surveillance with no recurrences to date.

Conclusion

Atypical fibroxanthoma is an extremely rare tumor, with few cases reported in the periocular region. Despite its benign appearance and rare recurrence or metastasis, it requires cautious management. Mohs micrographic surgery should be considered as the first-line treatment, and at least two years of follow-up is recommended. Diagnosis necessitates microscopic examination of the tissue and an immunohistochemical panel. Ophthalmologists, particularly oculoplastic specialists, should be aware of this rare tumor’s benign appearance but potentially malignant nature.

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Switch Flap Technique for Upper Eyelid Reconstruction – An Underused Art?

Author: Holly Clarke

Purpose

To describe our approach to reconstructing large full thickness upper lid defects whilst achieving a functional upper lid with preservation of lashes.

Methods

We describe 4 cases with near-total upper eyelid defects following tumour excision. The defect was closed using a rotational switch flap based on the lower lid and sutured into the end of the upper lid defect containing the largest remnant, including reattachment of as much of the residual levator complex as possible; the remainder was tagged and secured to the forehead to aid second stage reconstruction. The lower lid flap was sized at approximately ¾ of the reduced defect size to minimize tissue loss and flap tension. The second stage was carried out approximately 4 weeks later. The flap with base still attached to the lower lid was divided and sutured to the tagged levator complex and other end of the upper lid defect. The subsequent lower lid defect was either left to heal laissez-faire or closed directly.

Results

Four patients underwent the procedure between 2018 and 2022. Patient age ranged from 27-60 years. The histological diagnoses were Bowen’s disease (n = 1), conjunctival squamous carcinoma in-situ (n = 1), and sebaceous gland carcinoma (n = 2). The mean width of full thickness reduced upper eyelid defect was 21mm (17-25mm) and height was 8.5mm (6-10mm). The mean time between the first and second stage was 35 days (range 29-43 days). Duration of post-operative follow-up ranges from 3 months to 4 years. No patient has recurrence of their malignancy. 3 patients have achieved a good functional outcome and are being managed with topical lubricants only. 1 patient has suffered lateral upper lid retraction with exposure keratopathy requiring tarsorrhaphy and subsequent upper lid lowering.

Conclusion

Optimal functional and cosmetic results, with the presence of upper lid lashes, can be achieved with lower lid switch flaps to reconstruct extensive upper lid defects. It should be particularly considered in young patients. In our experience, upper lid retraction occurred with large reduced vertical defects > 8mm, and may be addressed by overcorrection of the anterior lamella.

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Epiphora Related Quality of Life in Patients Following Traumatic Canalicular Laceration Repair

Author: Holly Clarke

Purpose

To evaluate long term functional outcomes, as defined by epiphora related quality of life (QoL), in patients undergoing canalicular trauma repair with monocanalicular stenting.

Methods

A retrospective review of all patients undergoing monocanalicular stenting for trauma at a single unit over the last 10 years, with a minimum of 12 months follow-up. Medical records were used to record demographics, timing of surgery and stent removal, and stent related complications. Patients were contacted via telephone to complete a Watery Eye Quality of Life (WEQOL) questionnaire to assess their epiphora-related QoL after 12 months post-operatively.

Results

21 patients underwent monocanalicular stenting for traumatic canalicular lacerations between 2011 and 2021. 13 were male. The mean age at time of surgery was 50 years (range 9-93). 17 patients damaged the lower canaliculus, 1 the upper, and 3 damaged both canaliculi. The mean time from injury to repair was 2.4 days (range 0-6). The mean interval to stent removal was 18 weeks (range 2-103). The mean duration of outpatient clinic follow-up was 7.5 months (range 1.4 – 28). There were 2 stent-related complications; 1 patient developed a canalicular fistula, the other suffered protrusion of the stent. 11 patients (or parents on behalf of patients) completed the WEQOL questionnaire via telephone at a median time of 54 months post-operatively (range 18-122). 81% reported a score of 15 or less out of 100 (adjusted), suggesting minimal impact on QoL. 2 patients reported higher scores of 35 and 49. The patient scoring 35 damaged both upper and lower canaliculi, and the patient scoring 49 developed a canalicular fistula.

Conclusion

Reporting of functional success after canalicular trauma is variable and often defined by surrogate markers for epiphora. Scores from the WEQOL questionnaire suggest that post-operative epiphora had minimal impact on QoL in 81% of patients at least 18 months after surgery. In those with more significant post-operative epiphora, the WEQOL questionnaire may be helpful in defining specific patient-centred goals for ongoing management.

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A novel and fully virtual lateral canthotomy and cantholysis (LCC) telesimulation training programme using a low-fidelity model

Author: Li Yen Goh

Purpose

Acute orbital compartment syndrome due to retrobulbar haemorrhage secondary to trauma is rare but can cause irreversible blindness. LCC is a sight-saving procedure but must be performed very urgently. The purpose of this study was to evaluate an entirely virtual telesimulation training session in LCC for junior Emergency Medicine doctors and ophthalmologists.

Methods

The session included short lectures on the lateral canthal anatomy, indications for undertaking a LCC and the steps in performing a LCC, followed by participant construction of the low-fidelity model and then supervised execution of the procedure. Two separate sessions were carried out, there was one trainer to every four participants. In total, 12 participants from across world, including the UK, Australia, Singapore and Malaysia attended. Simulation kits were provided to UK participants before the course, while overseas attendees were given a list of materials needed. Participants self-reported using 5-point Likert scales; knowledge of the lateral canthal area, steps in performing a LCC and confidence in performing a LCC in a clinical setting. Data was analysed using two sample paired T-testing.

Results

This online programme resulted in statistically significant increases in the participant reported knowledge of the lateral canthal area anatomy, steps in LCC and confidence in performing the procedure if clinically indicated. These findings were comparable to the outcomes of a similar face-to-face course using the same low-fidelity model by the same trainers.

Conclusion

Admittedly not as many participants could be taught online at the same time as an in-person course. This study found the cost of the low-fidelity model to be low at £2.16 and easily replicable allowing this procedure to be practiced regularly by clinician later on, though the cost of surgical instruments, packaging and postage of the simulation kit resulted in an overall cost of £13.46 per kit. However, a physical venue was not needed including any specific cadaver laboratory settings and there was no infection risk with this training session.

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Orbito-Zygomatic Osteoblastoma: Unusual lesion, Unusual location

Author: Bhavna Sharma

Purpose

To present a case of an unusually located orbito-zygomatic osteoblastoma and the diagnostic, surgical and reconstructive challenges encountered with emphasis upon the value of a multi-disciplinary approach in the management of such a unique presentation. A descriptive clinico-pathological and radiological review of the literature is also explored and discussed.

Methods

This is a surgical case report and literature review detailing the imaging, clinical and histopathological findings of an orbital osteoblastoma.

Results

We present a rare case of an osteoblastoma within the right orbit of a healthy 25-year-old male. He presented with eye pain, proptosis and superior globe displacement over 3 months. Imaging with CT and MRI revealed an enlarging mass invading the right lateral orbital floor, zygoma and maxillary antrum. OCT images and fundoscopy showed unilateral choroidal and retinal folds with a healthy optic nerve. Differential diagnoses included a neural-based tumour, histiocytic tumour, lymphoma, osteosarcoma, osteo-fibroma or metastasis. Two endoscopic biopsies were inconclusive, and the diagnosis was subsequently established via excision biopsy with a joint maxillo-facial and orbital approach and simultaneous reconstruction with a custom-made titanium plate.
At four months post-excision, our patient has had an excellent aesthetic outcome with no evidence of early recurrence.

Conclusion

Osteoblastomas are unique, benign, bone-forming neoplasms commonly found in the spine, sacrum or long tubular bones. Their presentation can range from indolent to aggressive radiologically and thus are capable of local anatomical destruction. An orbital location, particularly inferolateral, is highly unusual with only a handful of case reports published detailing similar presentations.
Diagnosis can be challenging, and this case illustrates the importance and value of a cohesive multi-disciplinary approach involving ENT, Maxillofacial, Radiology, Pathology and Ophthalmology in providing optimum patient care.

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The effect of intranasal steroid inhalation on intraocular pressure after dacryocystorhinostomy

Author: Ju-Hyang Lee

Purpose

Several studies have been controversial on the relationship between nasal steroid use and intraocular pressure (IOP). Endonasal dacryocystorhinostomy (DCR) is a surgical procedure that allows the bypass of the orbital space and nasal cavity. IOP would be vulnerable to intranasal steroid use after DCR, but there have been no previous studies. We examined the effects of intranasal steroid inhalation on IOP after DCR.

Methods

A retrospective chart review was conducted in patients who underwent DCR and were then administered intranasal steroid spray for three months. IOP　was measured preoperative and one week, one month, two months, three months, and six months after the surgery using a rebound tonometer. We compared the difference between preoperative and postoperative IOP. The difference was analyzed in glaucoma patients and individuals who received intralesional steroid injections on granulation formation around the ostium.

Results

A total of 101 patients (136 eyes) were included with a mean age of 60.6. Twenty eyes (14.7%) were included in the glaucoma group, and 22 (16.2%) were in the intralesional steroid injection group. The surgical success rate was 96.3% (131 eyes). There was no significant difference in IOP between preoperative and postoperative in the use of nasal steroids spray after DCR (p>0.05). In the intralesional steroid injection group, there was no significant increase in IOP (p=0.47 by repeated measures ANOVA). There was no significant difference between the normal and the glaucoma groups in the change of IOP at each postoperative period (p=0.92 by repeated measures ANOVA).

Conclusion

Intranasal steroid inhalation after DCR is considered safe on IOP. Its safety can be ensured even in patients with glaucoma.

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A rare case of orbital cellulitis complicated by haemophagocytic lymphohistiocytosis

Author: Matthew Fenech

Purpose

We cover a rare case presentation of haemophagocytic lymphohistiocytosis (HLH). A large study by Wang et al.2023 showed that 39% of HLH patients had ocular abnormalities. We describe a rare case of unilateral orbital cellulitis complicating HLH

Methods

The patient was followed up as an in-patient for a few weeks:
– At presentation, ophthalmic assessment of both the anterior and posterior segment was unremarkable, bar for evidence of pre-septal cellulitis
– The clinical picture progressed dramatically over a 2 week period, despite oral antibiotic treatment. The eye was now proptosed and injected. Visual acuity, ocular motility, pupillary light reflexes and fundal examination remained unremarkable. The patient developed a new blanching macular rash involving his limbs and trunk, associated with cervical lymphadenopathy and night sweats. No orbital collection was seen on CT.

An “H-score” to calculate the probability of HLH, initially was <1% initially. Furthermore, multiple blood cultures were negative and screening for HIV, Syphilis and Hepatitis B & C was also unsuccessful. The patient was managed as an orbital cellulitis with IV antibiotics. The patient's clinical condition worsened. A subsequent orbital biopsy showed lymphoplasmacytic infiltrations admixed with histiocytes

A repeat H-score was undertaken, now scoring 171 points, indicating a 54-70% probability of HLH

Results

Guided by the H-score, the patient was started on IV Anakinra at 2mg/kg in 2 split doses and oral dexamethasone. Serology significantly improved, mirroring the improvement in his ocular findings.

Conclusion

The diagnosis of HLH can be delayed as the findings are non-specific. There are no tests pathognomonic for HLH but the H-score has a diagnostic sensitivity and specificity of 90% and 79% respectively. HLH is potentially a life-threatening condition with a median survival of 1-2 months if untreated. Furthermore, the investigations can result in false negatives or may take several days to be reported. Hence if clinical suspicion is high, treatment with IV Anakinra should be started without further delay.

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Ocular Adnexal Lymphomas: Exploring Diverse Presentations and Optimal Management Strategies

Author: Kristin Cowan-Lyn

Purpose

Ocular adnexal lymphomas, although rare, represent the most prevalent malignancy of the orbit. This study aims to illustrate the diverse presentations of ocular adnexal lymphoma, emphasising uncommon manifestations, and provide insights into the practical decision-making process for their management.

Methods

We conducted a retrospective case series of six patients between 2014 and 2023. Diagnosis was established through patient history, ocular findings, diagnostic imaging, and histopathological analysis. The authors analysed the patients’ case notes, focusing on clinical presentation, histopathology, treatment modalities, treatment responses and recurrence rates.

Results

Median age was 79 years (range: 67-88); male and female patients were equally represented. 17% had pre-existing lymphoma, while 83% presented with primary ocular adnexal lymphoma, of which 67% had localized disease.

50% presented with conjunctival masses, 33% with brow/upper lid masses, and 17% with lower lid entropion. Bilateral involvement was seen in 33% of cases. Histological analysis revealed high-grade lymphomas in 33%, including mantle cell and diffuse large B-cell lymphomas, while 67% had low-grade lymphomas (follicular and extra-nodal marginal zone lymphomas).

Treatment modalities varied, with 33% undergoing radiotherapy alone, one case receiving single-modality rituximab chemotherapy, and the remaining cases receiving combination radiotherapy with chemotherapy. During a median follow-up of 34 months (range: 5 to 96 months), 50% of patients achieved complete remission, with one patient experiencing a relapse. Two patients succumbed during the study period, one of whom had a lymphoma-related death.

Conclusion

Ocular adnexal lymphomas exhibit a broad spectrum of presentations beyond the classic salmon patch lesion. It is crucial to consider ocular adnexal lymphoma in cases of entropion, periorbital masses, and lid masses. Optimal management strategies vary, relying on factors such as patients’ general fitness, bilateral or unilateral involvement, and histological classification.

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Lacrimal gland biopsies—results from a tertiary centre in the UK

Author: mary awad

Purpose

To report the histopathological results of lacrimal gland biopsies over a 21-year period in a tertiary referral centre in the United Kingdom. To the best of our knowledge, this represents the largest series to be published in the United Kingdom.

Methods

A retrospective observational review was carried out for patients who underwent lacrimal gland biopsies in a tertiary referral centre at the University Hospitals of Leicester, United Kingdom between the years of 2000 and 2021.

Results

Lacrimal gland biopsies were performed on 248 patients during the specified 21-year period. They comprised 157 (63.3%) females and 91 (36.7%) males. The mean age at presentation was 50.8 years (range 15–94 years). The majority of patients were Caucasian (69.4%, n = 172) followed by Asians (25.0%, n = 62), African/Afro-Caribbean (4.8%, n = 12) and other ethnicities (0.8%, n = 2). The most common histopathological diagnosis was chronic inflammation dacryoadenitis (69.0%, n = 171) followed by lymphomas (15.3%, n = 38).

Conclusion

Our study shows that chronic inflammation accounts for the majority of histopathological diagnosis followed by lymphoproliferative disorders.

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Efficacy and Safety of Intra-operative Triamcinolone in Primary and Re-do Dacryocystorhinostomy

Author: mary awad

Purpose

The precise role of steroids in dacryocystorhinostomy (DCR) is controversial with no clear evidence or consensus on the optimal dose or delivery. We aim to evaluate the safety, functional and anatomical success of primary/re-do DCR’s, with and without intra-operative triamcinolone, to give clinicians a better indication of which patients benefit most.

Methods

A retrospective consecutive case note review of 286 patients undergoing 312 DCR’s performed between January 2013 and 2017 at a tertiary centre. Age, gender, average duration of symptoms, follow-up, insertion of tubes, reason for DCR, laterality, co-morbidities, change in intraocular pressure (IOP) and scar appearance were documented. Functional and anatomical success of primary and re-do, external /endonasal DCR’s, with and without intra-operative triamcinolone were assessed.

Results

There was no difference in patient demographics. Primary DCR’s have a similar success in the triamcinolone (TAG) and non-triamcinolone groups (N-TAG). In re-do endonasal DCR functional (50% N-TAG vs 100% TAG; p=0.11) and anatomical (75% N-TAG vs 100% TAG; p=0.36) success and in re-do external DCR functional (83% N-TAG vs 100% TAG; p=0.56) and anatomical success (96% N-TAG vs 100% TAG; p=1.00) increased in the TAG, but did not reach a level of statistical significance.There were no cases of failure in re-do operations where intraoperative triamcinolone was used and no cases of raised IOP warranting treatment.

Conclusion

Triamcinolone does not increase surgical success in primary DCR but has shown a trend towards increased success in re-do DCR. It is safe with no complications noted in our cohort.

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MiniMonoka Stent for the treatment of severe punctal stenosis

Author: Muhammad Asif

Purpose

Epiphora resulting from sever punctal stenosis can be very symptomatic and annoying. Traditional treatment with 3 snip punctoplasty is invasive, not always successful and at times can result in scarring causing complete and irreversible stenosis of punctum requiring major surgical procedure to correct it. Three is a need to find a solution for this by a procedure which is simple, non invasive, and reversible.

Methods

Prospective study of 156 MiniMonaka stent insertion in 82 consecutive patients over last 36 months.

Results

The technique is highly successful and results will be discussed in the presentation in a detailed manner.

Conclusion

The technique is highly successful and well tolerated by the patients and should be the first treatment of choice in cases of epiphora resulting due to severe punctal stenosis.

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Association between Visual Impairment and Suicide: A Systematic Review and Meta-Analysis

Author: Marie Louise Roed Rasmussen

Purpose

Visual impairment severely impacts the life of the patients. In this study, we systematically reviewed studies on the potential relationship between visual impairment and suicidal behavior and conducted meta-analyses on the risk estimates.

Methods

We searched 11 literature databases on 20 October 2022 and identified a total of 10 eligible studies with 5.8 million participants. Suicide behavior was investigated according to three domains: suicide ideation, suicide attempt, and suicide death. In the 10 eligible studies, seven reported data on suicide ideation, five reported data on suicide attempt, and three reported data on suicide death. All summary estimates extracted for use in the meta-analyses were adjusted estimates of association since we acknowledged that depression as well as other confounding factors may play an important role.

Results

We found that visual impairment was a significant risk factor of suicide ideation (OR 1.83; 95 % CI: 1.40–2.40; P=0.000012), suicide attempt (OR 2.62; 95 % CI: 1.29–5.31; P=0.0077), and suicide death (OR 7.00; 95 % CI: 2.30–21.4; P=0. 000063).

Conclusion

These high increases in risk of suicide from visual impairment underscore the importance of eye health on the overall mental health, and the potential devastating consequences of insufficient access to eye care, lack of treatment possibilities for any reason, or low political priority of eye care.

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REVISTING THE CHANNEL IMPLANT IN REVISION ORBITAL FRACTURES

Author: Hatem A Tawfik

Purpose

To investigate the role of the Channel Implant in the repair of complex, or revision orbital fractures.

Methods

A retrospective chart review was performed for all patients who underwent implantation of the Channel implant over a 16-year period from 2007-2023.

Results

Twenty-eight patients underwent the procedure. The indications for surgery included revision fractures, neglected fractures, rim + floor fractures, anophthalmic orbits with extensive fractures, and patients with post-floor orbital decompression (for thyroid eye disease). All patients had a substantial cosmetic improvement.

Conclusion

The primary aim of orbital fracture repair is to replicate the contour of the orbital floor and the slope of the medial wall using thin implants. Although newer implants facilitate close-to-original anatomical reconstruction, there may still be a place for the Channel Implant in complex and revision orbital trauma cases.

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Central retinal artery occlusion and ischemic oculomotor nerve palsy after aesthetic facial filler with Hyaluronic Acid

Author: Amparo Lanuza Garcia

Purpose

Hyaluronic acid (HA) filler is the most widely used filler for facial aesthetic procedures and the only one that has a solution: hyaluronidase enzyme. But it is not exempt from serious complications both at the ocular and cerebral level.

Methods

Case Report: A 49-year-old woman presented with sudden vision loss and left eye pain after injection of HA in the back of the nose. In the ocular examination, she presented central retinal artery occlusion. Anterior chamber paracentesis was performed and she was treated with aspirin, antibiotic therapy, sodium enoxaparin, and cortisone, and hyaluronidase injections were applied in the area. at 4 hours she did not recover her vision and ptosis and DPAR were observed in the left eye, ophthalmoplegia, conjunctival chemosis, and corneal edema. The computed tomography was normal. Subsequently, she developed necrotic and hemorrhagic skin, lagophthalmos, anterior and posterior segment ischemia, as well as de-epithelialization and the appearance of a corneal ulcera. The magnetic resonance showed frontal ischemic lesions, posterior parietal subarachnoid hemorrhage. Angiography shows attenuation of the left choroidal blush and poorer definition of the short posterior ciliary arteries and the central retina.

Results

After three weeks, the patient recovered ocular motility but started ischemia of the ocular globe.

Conclusion

We present this case to learn how to better manage the adverse effects of aesthetic treatments. Although available skin treatments have improved, the incidence should be reduced and, where possible, these serious complications minimized. We must be aware of the urgent and interdisciplinary measures and strategies for the appropriate medical treatment of these patients, usually young women.

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Lung metastases from primary conjunctival squamous cell carcinoma.

Author: Amparo Lanuza Garcia

Purpose

Regional metastases of mucoepidermoid carcinoma of the conjunctiva are rare, but distant metastases are unusual. We present a case of a conjunctival carcinoma that metastasized to the lung.

Methods

Clinical case: An 88-year-old male with a personal history of cord squamous cell carcinoma 30 years ago, stage IE2 gastric MALT lymphoma with three recurrences with annual controls by the Digestive Service. Recurrent bladder tumor and 10 years without recurrence. He attended due to a suspect lesion of lymphoma in the upper conjunctiva of the left eye. After a biopsy with negative results, the evolution was torpid until exeresis of the entire upper conjunctiva and amniotic membrane graft was performed, diagnosing mucoepidermoid carcinoma of the conjunctiva. MRI showed invasion of the medial rectum and upper eyelid. Oncology carried out a systemic study, evidencing pulmonary metastases, which did not exist in the previous examination carried out by Digestive.

Results

Orbital exenteration was performed, resulting in adenosquamous carcinoma of the bulbar and tarsal conjunctiva, and immunohistochemistry was positive for CK7. Lung biopsy revealed a non-small cell carcinoma compatible with mucoepidermoid carcinoma and c. squamous cells of the same type as the primary conjunctiva. The patient died as a result of lung metastases.

Conclusion

Squamous cell carcinoma of the conjunctiva is unusual. The most aggressive variant is mucoepidermoid or adenosquamous carcinoma. Systemic metastases are a rare complication, with very few cases described in the literature. It is important to screen for suspect conjunctival lesions by performing deep biopsies to reduce sampling bias in conjunctival lesions and avoid underdiagnosis of aggressive mixed histological subtypes, as well as performing thoracoabdominal imaging tests for screening of metastatic lesions.

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Idiopathic orbital inflammatory syndrome treated initially as orbital cellulitis

Author: Matthew Azzopardi

Purpose

The diagnosis of acute unilateral orbitopathy can be challenging and includes infective, inflammatory and neoplastic causes. We present here a case of idiopathic orbital inflammatory syndrome (IOIS) treated initially as orbital cellulitis.

Methods

A case report.

Results

A 76-year-old previously healthy male was referred to a tertiary centre after a diagnosis of ‘periorbital cellulitis’, not improving with oral antibiotics. Examination findings showed unilateral lid oedema, proptosis, reduced ocular motility, and chemosis, with an acuity of 6/9.5. CT-scan revealed inflammatory stranding in the post-septal orbital fat, in keeping with orbital cellulitis. Despite broad-spectrum intravenous antibiotics the clinical signs worsened. Although inflammatory markers were raised, he remained afebrile with a normal white cell count. 3 days post-presentation he developed complete ophthalmoplegia with worsening proptosis and ocular pain. A repeat CT-scan showed left-sided myositis of the extraocular muscles, with inflammatory change extending to the orbital apex, in keeping with orbital inflammatory disease. Inflammatory markers were now highly raised and he was started on high-dose intravenous methylprednisolone. The ophthalmoplegia resolved completely within 2 days whilst his proptosis and chemosis gradually improved. IgG-4 levels were within normal limits along with negative autoimmune and infective screens. 5 days later antibiotics were stopped and he was discharged on oral steroids.

Conclusion

This case highlights the importance of an exhaustive work-up, inclusive of systemic investigations, in order to differentiate between infective and inflammatory aetiology. Failure to respond to initial treatment (such as antibiotics) should prompt re-evaluation and consideration of other diagnoses, such as severe IOIS, which whilst potentially sight-threatening is highly responsive to high-dose systemic steroids.

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Evaluation of Eyelid Morphology using Neural Network-based Automated Eyelid Measurement System

Author: Jeong Kyu Lee

Purpose

The purpose of this study was to evaluate the clinical usefulness and reliability of a neural network (NN)-based automatic eyelid measurement system and to find objective measurement parameter that can detect eyelid abnormalities.

Methods

Digital images of the eyelids of a total of 300 subjects, including 100 patients with Graves orbitopathy (GO), 100 patients with ptosis, and 100 controls, were taken. A specific type of neural network was developed to measure Margin reflex distance (MRD) 1 and 2, upper and lower eyelid lengths, and then the results were compared with values measured using the image J software. The length from the corneal light reflex to the eyelid margin was measured by dividing the eyelid margin by 360 degrees. In order to obtain an appropriate number of eyelid divisions that can detect eyelid disease, the number of patients whose measurement length according to each number of divisions deviated from the mean by ±2σ was analyzed.

Results

Automated MRD1, MRD2, upper eyelid length, and lower eyelid length measurements were strongly correlated with manual measurements (r = 0.92, 0.93, 0.90 and 0.91, respectively). Automated MRD1, MRD2, upper eyelid length, and lower eyelid length measurements showed a high agreement with manual measurements. As a result of confirming the number of patients outside the mean ±2σ range according to the number of divisions, there was no change in the number of patients outside the mean value from the 16th division.

Conclusion

An automated, NN-based system could provide a simple and accurate means for obtaining the MRD 1 and 2 and other eyelid morphometric data. The best performance was to analyze the shape of the eyelid by dividing it into 16 equal parts.

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Basal cell carcinoma of the inner eyelids’ cantus: therapeutic challenge

Author: Samah Mbarek

Purpose

The aim of this study is to present a therapeutic approach for the treatment of basal cell carcinoma (BCC) on the inner eyelid canthus.

Methods

We included 25 cases of inner canthal BCC. Tumor resection was performed under local or general anesthesia.

Results

There were 18 Men and 7 Women. The tumor size ranged from 1 cm to 4 cm. In 11 patients with tumors larger than 1 cm an ophthalmological examination was performed. Four cases of scleroderma BCC were identified. In one case the disease recurred after 2 years and this was the only case of recurrence after incomplete resection. Reconstruction which was performed immediately, consisted of loco-regional plasty in all cases.

Conclusion

BCC accounts 80% of malignant eyelid tumors. The infero-internal region of the inner canthus is the predilection site. The diagnosis is clinical, expect the misleading forms in which, it was made by extemporaneous examination. Metastases of BCC are uncommon, ranging from 0.0028% to 0.1 % of cases. Nevertheless, ophthalmological examination is necessary to detect conjunctival, orbital, bony or lacrymal extension. further imaging was warranted if deep or locoregional invasion were suspected. The treatment is based on surgery with or without reconstruction. Adjuvant radiotherapy is indicated in cases of incomplete resection, perineural invasion or recurrence. The prognosis depends essentially on the risk of recurrence.

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Anophthalmic ptosis: Considerations in tailoring the right treatment

Author: Dana Cohen

Purpose

To discuss the different mechanisms of ptosis in anophthalmic socket and to share the specific considerations that could help us choose the right ptosis surgical approach

Methods

Taking a glance at our experience and literature review

Results

There are a number of mechanisms causing ptosis in anophthalmia: Post Enucleation Socket Syndrome, Superior migration of orbital implants, Tarsal papillary conjunctivitis, and Levator dehiscence. Collaborating with a good ocularist helps minimize ptosis and therefore prevent surgery in selected patients . The oculoplastic surgeon job starts when the best prosthesis is not satisfactory. Mullerectomy, levator surgeries and volume augmentations are all eligible techniques for such ptosis repair, and should be tailored specifically. When surgery ends, results can still be improved by improving the prosthesis.

Conclusion

Anophthalmic ptosis is a common diagnosis in the oculoplastic clinic, yet its causes are diverse and therefore deserve special attention and treatment tailoring.

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Eyelid reconstruction for extensive palpebral substance loss: Which techniques?

Author: Samah Mbarek

Purpose

The aim of this study is to report our contribution to the management of extensive eyelid defects.

Methods

Clinical cases.

Results

Several illustrated clinical cases of eyelid defects and different surgical techniques with grafts used for reconstruction. Fibromucosa palatine and conqual cartilage grafts were, in our experience, the most adaptable for repairing the tarsoconjunctival plane.

Conclusion

Eyelid reconstruction procedures are numerous. They are often combined to reconstruct the posterior and anterior lamella, which is the only guarantee for satisfactory functional and aesthetic results. In the case of defects, the surface, thickness and individual anatomical characteristics determine the surgical technique. Reconstruction of the skin depends on the situation of substance loss and the eyelid involved.

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Superior orbital fissure syndrome: a case report

Author: Hajer Touil

Purpose

To report the case of a patient admitted to the Department of Maxillofacial Surgery of the University Hospital of Mahdia for diplopia associated with exophthalmos, total ophthalmoplegia and post-traumatic ptosis

Methods

A case report.

Results

The 35-year-old female patient presented to the emergency department after a craniofacial trauma caused by a blow from a cow horn. She complained of diplopia and examination of the left eye revealed: periorbital oedema, exophthalmos, ptosis, complete ophthalmoplegia and an areflexic semi-mydriatic pupil. The emergency CT scan showed: a left maxillary hemosinus, a fracture of the floor of the left orbit with detachment of an intrasinus bone fragment and incarceration of the right inferior muscle, a fracture of the medial wall of the orbit and a left pneumo-orbit. The initial Lancaster test showed paralysis of all oculomotor muscles on the homolateral side and hyperstimulation of the oculomotor muscles on the contralateral side. The patient was treated with antibiotics and corticosteroids. Transconjunctival disimpaction of the inferior rectus muscle was performed with a Mercylene plate. On the eighteenth day after the trauma, the patient still had diplopia, partial improvement of oculomotor and photomotor reflexes, and marked improvement of ptosis and exophthalmos.

Conclusion

Post-traumatic superior orbital fissure syndrome is a rare complication, clinically diagnosed, CT scan is essential to make a complete assessment of the lesion and to exclude other emergencies, as in our case, incarceration of the inferior rectus muscle. Treatment is medical-surgical and recovery is usually partial.

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Persistent post-traumatic diplopia: Should surgery be performed?

Author: Hajer Touil

Purpose

To report the improvement of ocular motility in a case of persistent post-traumatic diplopia operated on late.

Methods

A case report.

Results

We present the case of a 30-year-old patient who, two months after a direct impact on the right eye following a sports accident, presented with persistent diplopia which he had initially neglected. Clinical examination revealed subtle limitation of abduction of the right eye with vertical and lateral diplopia, without loss of visual acuity, enophthalmos or sensory disturbances. A CT scan of the face showed a fracture of the floor of the right orbit with fat herniation and muscle entrapment, and a fracture of the medial wall with the presence of a bone fragment in contact with the medial rectus muscle. A Lancaster test was performed and confirmed the clinically observed oculomotor dysfunction. The patient underwent transconjunctival surgery under endoscopic guidance. The herniated periorbital tissues were released. Orthoptic rehabilitation was started on the seventh day.
The evolution was marked by improvement of ocular motility and diplopia as assessed by Lancaster test three weeks after surgery.

Conclusion

Oculomotor disturbances after orbital floor and medial wall fractures have a highly variable outcome. The earlier the onset of diplopia, the higher the risk of fixation. Persistent oculomotor dysfunction is an indication for surgery in this type of fracture. With the exception of trapdoor fractures, surgery is indicated between 4 and 10 days, depending on the team.
According to several authors, late treatment of these fractures is pointless because of the operative difficulties and the often very incomplete results. With this work, we show that even at a late stage, surgical exploration to restore oculomotricity in orbital fractures retains all its interest.

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Orbitopathy due to Cocaine-Levamisole-Induced Vasculitis: A rare presentation.

Author: Mustafa Franka

Purpose

To describe a case of visual loss secondary to cocaine-levamisole-induced vasculitis presenting as orbitopathy.

Methods

Observational case report.

Results

A 53-year-old man presented with a 3-day history of diplopia and ptosis of the left eye on a background of 6-month history of headaches, significant weight loss and numbness over the left cheek. Ophthalmic examination revealed left sided ptosis and global restriction of extraocular movements. Visual acuity and pupil reactions were normal with no relative afferent pupillary defect. Magnetic resonance imaging showed extensive destructive sinonasal disease with enhancing soft tissue mass with orbital invasion and involvement of both pterygopalatine fossae. Biopsies and histological examination showed chronic inflammation, fibrosis, and necrosis with features supportive of vasculitis. Base of skull multi-disciplinary team (MDT) suggested a likely diagnosis of levamisole induced vasculitis related to cocaine use resulting in a cocaine induced midline destructive lesion as the main differential. Blood immunology tests showed weakly positive Antineutrophil Cytoplasmic Antibody (ANCA) Proteinase 3 antibody. Drug and alcohol team advised complete cessation of cocaine use as the definitive management. Unfortunately, he represented 2 months later with headache and subacute vision loss of the left eye followed by the right eye. Urine toxicology was in keeping with ongoing cocaine use.

Conclusion

Levamisole is a synthetic imidazathiazole antihelminthic agent once used medically for its immunomodulatory effects. Although its medical use has been discontinued, up to 70% of street cocaine is contaminated with levamisole. Only one case of Levamisole induced vasculitis with orbital involvement have been reported previously. MDT input is invaluable in diagnosis and management.

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Comparative analysis of the volumetric characteristics of the soft tissue content of the orbit in patients with endocrine orbitopathy using computer modeling methods

Author: Olha Prusak

Purpose

To conduct a comparative analysis of the area of the bone surface of the orbit, the total volume of soft tissue content, extraocular muscles, fat compartments of the orbit by CM methods in patients without pathology and with endocrine orbitopathy(EO).

Methods

An analysis of computed tomography (CT) scans of 22 patients with OE, who were treated at the department’s clinical facilities in 2016-2022, was performed. with a control group of patients without orbital pathology in the number of 178 people. CT data in Dicom format were loaded into Mimics Medical 21.0 software (Materialise, Belgium), where orbitovolumetric analysis was performed by segmentation and computer modeling.

Results

The area of the orbit in the main group was 59.73±5.24 cm2, in the control group – 53.07±4.90 cm2, the average volume of the orbit was 26.29±3.5 cm3 and 26.50±2.90 cm3, respectively (р= 0.73 and р= 0.72, respectively). The average volume of muscles in the group of patients with EO- 7.63±3.02 cm3, in control group – 3.86±0.56 cm3 (р= 0.0003). The volume of adipose tissue in the main group was -18.75±4.25 cm3, in the comparison group – 22.13±2.81 cm3 (р= 0.0081).

Conclusion

The study showed no correlation in the volume and area of the orbit, and its presence between the volume of muscle and adipose tissue in patients with EO and in the control group. It is also interesting that the ratio of fat to muscle in the main group was 2.5:1, and in the control group it was 5.7:1. The use of this approach can become a promising method in the differential diagnosis of EO, in particular in the aspect of evaluating its various forms and when planning decompression of the orbit as the main method of its treatment.

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Functional and anatomical success of bicanalicular intubation in lacrimal system reconstruction following eyelid tumor removal

Author: Pari Shams

Purpose

To determine the functional and anatomical success of two types of bicanalicular intubation in reconstruction of the lacrimal system following eyelid tumor removal

Methods

Retrospective, consecutive interventional case series of patients undergoing eyelid reconstruction following Mohs Microsurgical excision of eyelid malignancy involving the lacrimal and canalicular system. Reconstruction of the canalicular system was performed using bicanalicular intubation with Crawford stents retrieved under the inferior meatus or an annular stent inserted using a pigtail probe. The functional, and anatomic outcomes of surgery are presented.

Results

24 patients (mean age, 62 years) over and 8-year period underwent eyelid and canalicular repair by a single surgeon. In 4 cases where the lacrimal system had been sacrificed no repair of the canaliculi or sac was possible. In 20 cases (83%) canaliculi were repaired by inserting an annular silicone stent guided by 6-0 Prolene with Pigtail Probe, and in 4 (17%) cases a bicanalicular Crawford stent was retrieved and tried within the inferior meatus. 18 cases (75%) involved the lower canaliculus only and 6 cases (25%) the upper and lower canaliculus. Mean follow‑up 18 months (range 12–24 months). Intubation tubes were removed at 3 months post op. 29% had complaints of epiphora in the first 3 months post op and 8% between 3- 6 months and 0% after 6 months. All the patients had good anatomic success (normal alignment of the eyelids and symmetric dye disappearance test with or without lacrimal irrigation), and functional success, (Munk score or 0 or 1 and no further surgery needed).

Conclusion

Bicanalicular lacrimal intubation achieved a high rate of functional and anatomical success in patients undergoing lacrimal system repair post tumor removal. Bicanalicular stenting eliminates the risk of stent extrusion or loss, helps to maintain the anatomic alignment of the canaliculi and helps to align and medialise the medial reconstructed eyelid(s). The use of an annular stent and Pigtail probe is valuable if the surgeon prefers not to retrieve the stents within the nasal cavity.

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A multi-centre retrospective study of the relationship between radioactive iodine (RAI) therapy and Graves Orbitopathy (GO)

Author: John Vekinis

Purpose

RAI frequently used in the treatment of Grave’s Hyperthyroidism (GH) is often cited as a major risk factor by GO specialists in the development & exacerbation of GO. We aim to identify the incidence and any risk factors associated with RAI and GO in our multicentre RAI treated cohort.

Methods

From four endocrine centres, we collected the following parameters from patients over 18-years-old who underwent RAI therapy over an 8-year period: Demographics (age, gender and ethnicity), thyroid diagnosis and pre-treatment status, pre-existing GO, TSHR-Ab status, smoking status, RAI dose and number of treatments, ophthalmology assessment and use of steroid prophylaxis. Outcomes measured included: Development of a reoccurrence/new GO and the severity/activity of GO during their follow up period.

Results

159 patients met the inclusion criteria with 119 (75%) female patients, an average age of 44 at RAI and white British as the most common ethnicity. Pre-treatment diagnosis was most frequently GH (131, 82%), thyroid status at RAI was most frequently euthyroid (100, 63%) and TSH-R Ab was positive in 141 (88.6%) patients. 22 (18.8%) patients were smokers at the time of RAI. 15 (9.5%) patients had a pre -RAI diagnosis of GO and 7 (5%) had oral steroid prophylaxis.

The median follow up post RAI was 13.5 (1-52) months. RAI dose ranged from 448 to 857 mCi with a median of 583 mCi.

Following RAI, 2 (1.3%) patients developed new or worsening GO. One was an exacerbation of existing and the other was a new diagnosis of mild GO. Both did not require immunosuppression or rehabilitation GO treatment. Both were TSHR-Ab positive non-smokers and did not have oral steroid prophylaxis.

Conclusion

We did not observe a significantly increased risk in development/exacerbation of GO following RAI in our cohort. This may reflect judicious identification of at-risk patients who are given prophylactic oral steroid cover and meticulous prevention of hypothyroidism post treatment.

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Oculoplastic side effects of molecular targeted therapies. Four case reports and review of literature.

Author: Inbal Man Peles

Purpose

Presenting four cases of oculoplastic side effects of biologic therapeutic, and addressing the subject of rapidly growing use of these drugs and, as a consequence, the increasing number of patients presenting with oculoplastic side effects.

Methods

Four short case reports and literature review (pubmed search) of the oculoplastic side effects of molecular targeted therapy.

Results

Case number 1: 41 years old female, treated with Alemtuzumab for relapsing Multiple sclerosis (MS), developed both Thyroid orbitopathy and ocular Myasthenia gravis.
Case number 2: 72 years old male, treated with Imatinib for chronic myelogenous leukemia (CML) suffered from periorbital edema.
Case number 3: 75 years old male, treated with Ipilimumab and Nivolumab for metastatic Melanoma, developed Myasthenia gravis.
Case number 4: 50 years old female suffering from nonspecific orbital inflammation, developed a new periorbital edema after receiving Rituximab infusion.

Conclusion

Molecular targeted therapies, including monoclonal antibodies and small molecule inhibitors, are now widely used to treat oncologic and inflammatory diseases. The number of such agents and it’s approved indications is rapidly increasing. Reports of orbital, lacrimal and eyelid adverse effects, associated with Molecular targeted therapies, are also rising. Oculoplastic surgeons should be aware of those effects and learn to recognize it.

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Orbital aspergillosis: a differential diagnosis plot-twist.

Author: Alejandra Herranz-Cabarcos

Purpose

Space-occupying diseases of the orbit present similar symptoms, regardless of etiology. The causes can be neoplastic, inflammatory and infectious. The differential diagnosis is based on pathological studies.

Methods

An 81-year-old woman presented with ocular pain in the right eye, associated with binocular diplopia. On examination, limited adduction and supraversion in the right eye with 2mm ptosis of the upper eyelid were observed. A CT scan showed an hyperdense and heterogeneous lesion, occupying the ethmoid and maxillary sinuses and apical orbit. MRI confirmed a hypointense and heterogeneous lesion on T1 and T2, with marked contrast uptake. Inverted papilloma and orbital lymphoma were established as differential diagnosis. Three weeks after the endoscopic biopsy, the cultures showed growth of Aspergillus fumigatus. Neuronavigator-assisted endoscopic debridement was performed in conjunction with the otolaryngology department.

Results

Orbital aspergillosis spreads to the orbit normally from the paranasal sinuses. It affects immunosuppressed and immunocompetent patients, especially with environmental risk factors. It can be invasive, with a behavior similar to a neoplasia, or non-invasive. Diagnosis is made with Gomori Methanamine silver and periodic acid Schiff stains and can be confirmed by culture. Treatment is medical, including orbital infiltration of Amphotericin B in cases of apical involvement, and surgical. Neuronavigation-assisted surgery, represents an advance in orienting the surgical procedures. Aspergillosis should be treated as an emergency.

Conclusion

In the case of orbital space-occupying lesions that extend from the paranasal sinuses, it is essential to systematically obtain fungal cultures, even in immunocompetent patients.

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Joint management of preseptal and orbital cellulitis between ENT and orbital surgeons: a six-year study in a tertiary hospital in London

Author: Reem Farwana

Purpose

Preseptal and orbital cellulitis often presents in the paediatric population. We present our six-year experience from a London Tertiary Centre.

Methods

Electronic health records of children admitted with preseptal or orbital cellulitis between December 2016 and August 2022 were analysed retrospectively. Data collected included clinical, laboratory, microbiology and radiology results as well as management and length of stay.

Results

201 children were included; 152 (76%) had preseptal and 49 (24%) had orbital cellulitis. Patients with orbital cellulitis had higher rates of fever compared to cases of preseptal cellulitis. The majority of patients with orbital cellulitis had a subperiosteal abscess (SPA) (78%). 82% of SPA cases had a medial component, while 29% had superior component. 61% of orbital cellulitis cases were managed surgically. Surgical intervention was carried out by otolaryngologists in 77% of cases, jointly between otolaryngologists and orbital surgeons in 17% of cases and by orbital surgeons alone in 7% of cases. Of the 11 SPA involving the orbital roof, all were surgical managed and orbital surgeons were involved in 55% of cases. When SPA involved the medial wall, orbital surgeons were only involved in 6% of cases.

Conclusion

This study showed a relatively high proportion of patients with orbital cellulitis having surgical management. This could reflect a higher proportion of patients presenting with more severe disease from peripheral hospitals after a trial of conservative management or a lower threshold for surgery from having orbital surgeons and otolaryngologists available. We recommend all patients with superior SPA be treated at a centre with an orbital surgeon as these may not be amenable to drainage by an otolaryngologist.

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A conjunctival mysterious lesion with an unexpected pathology results

Author: Dana Cohen

Purpose

To report clinical and histopathologic findings of a conjunctival juvenile xanthogranuloma in an adolescent and to review the literature regarding such a diagnosis.

Methods

Case report and literature review.

Results

Case presentation: 11 Years old boy with no relevant past medical or ocular history, presented with red-yellowish lesion located on medial bulbar conjunctiva of the left eye, not involving the limbus. Topical steroids were initiated with no lesion response. Anterior segment OCT revealed a well-defined mass, however, sclera underneath was not observed well. The lesion was carefully removed sparing ajacent tissue and pathology results demonstrated a histiocytic lesion. 6 months after excision, the patient returned with a red mass located on the same medial bulbar conjunctiva of his left eye. The lesion clinically infiltrated the left medial rectus muscle, so only debulking was done with mitomycin C infiltration into the lesion bed. Pathology report was juvenile xanthogranuloma.
Ocular Juvenile xanthogranuloma is a rare entity. Usually, it is presented during the first years of life and has some skin manifestations, which our patient did not demonstrate. Ocular subconjunctival lesions are even rarer and usually involve the limbus. Only 3 cases are found in the literature of juvenile xanthogranuloma underneath the conjunctiva as mentioned above. Treatments in all reported cases were surgical excision with or without the use of cryotherapy. The patient was followed for 2 years with no recurrence.

Conclusion

Surgical debulking with an additional mitomycin C could be a reasonable treatment for conjunctival juvenile xanthogranuloma

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Thyroid Eye Disease after Total Thyroidectomy

Author: Catarina Mota

Purpose

Thyroid eye disease (TED) is a complex autoimmune condition generally associated with Graves’ Disease (GD). Surgical thyroidectomy is a definitive treatment for GD and it is usually considered beneficial for TED as well, as it reduces the antigenic stimulus and thereby contributes to the reversal of autoimmune manifestations. However, the natural history of TED is highly variable and unpredictable, with a progression often independent of the clinical course of thyroid dysfunction. Our purpose is to describe 2 cases of TED developed after total thyroidectomy (TT).

Methods

Case-report.

Results

A 51 years-old female with previously diagnosed GD presented with new-onset active TED with periocular inflammatory signs, strabismus and left proptosis, and was treated with IV methylprednisolone (IVMP) with clinical improvement. Six months later, due to persistently uncontrolled thyroid parameters despite medical treatment, she underwent TT. Four months after surgery, with a TRAb level of 0.96IU/L (normal range<2IU/L), she reported a severe exacerbation of the orbital inflammatory signs, for which she was again treated with IVMP and mofetil mycophenolate (MMP), with no improvement, and later tocilizumab (TCZ), with good response.
A 57 years-old female with GD, poorly controlled thyroid function and TRAb elevated to 29.22IU/L, despite treatment, was submitted to TT. Two months later she presented with new-onset eyelid edema, diplopia and bilateral proptosis. At that time, TRAb level was 14.1IU/L. IVMP and MMP were indicated, with no improvement, and then switched to TCZ, with good response.

Conclusion

Reactivation or new-onset TED following TT is extremely rare and its pathogenesis is unclear. Several mechanisms have been hypothesized, such as the release of antigens during surgery, the persistence of minimal residual thyroid tissue, and the early occurrence of hypothyroidism that may confer an increased risk for the development/deterioration of TED. Both patients and clinicians should be aware of this possibility, and maintain a close surveillance of thyroid function and periorbital inflammatory signs.

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Application of the Hughes Procedure for Patients with Basal Cell Carcinoma and Other Lower Eyelid Lesions – Case Studies

Author: Joanna Aleksandra Pyzia

Purpose

Basal cell carcinoma (BCC) is the most prevalent malignant skin neoplasm. BCC treatment encompasses surgical and/or physical modalities (cryo-, radio-, laser-, and chemotherapy). The selection of a treatment approach depends on factors such as the lesion’s location, size, and type, adjacent tissue vascularization, and the patient’s age and overall health. The study is to present the Hughes procedure for excising basal cell carcinoma lesions and non-neoplastic abnormalities from the lower eyelid while concurrently reconstructing and maintaining the lower eyelid’s functionality.

Methods

This study reviews patients with BCC who underwent a modified Hughes flap for reconstruction of lower eyelids after tumor excision. Patients were evaluated and treated with appropriate modalities and the outcome was analyzed. Cosmetic, functional, and postoperative results were analyzed.

Results

We analyzed tumoral lesions in three patients aged 74-79 years, including two females and one male. The tumor size range was 7–14 mm. Tumor excision was performed with a 3-4 mm margin beyond the clinically visible tumor stratification. Reconstruction was also performed, using a modified Hughes conjunctivo-tarsal flap – a two-stage method of reconstructing centrally located lower eyelid defects. No complications occurred during the procedures. Continuity of the lower eyelid was restored in all patients. Basal cell carcinoma was confirmed in all patients based on histopathological examination of the material collected during the surgery.

Conclusion

The reconstruction of the lower eyelid using the Hughes conjunctival-tarsal flap technique presents both advantages and disadvantages. The drawbacks encompass the two-stage nature of the procedure and the employment of the upper eyelid tarsal plate for reconstructing the lower eyelid, resulting in the temporary inability to use the operated eye by the patient. Notwithstanding these limitations, this surgical method proves to be beneficial due to the satisfactory cosmetic and functional outcomes of the lower eyelid following the procedure.

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Temporary Severe Oculomotor Nerve Palsy After Reconstruction of Orbital Medial Wall Fracture: A Case Report of Nonfamiliar Complication

Author: TAE YOON LA

Purpose

Commonly known complications following reconstruction of an orbital fracture include diplopia, hemorrhage, and displacement or infection of the orbital implant, and some studies have reported ptosis caused by temporary or permanent oculomotor nerve palsy after operation. However, no study has reported a case of both medial and superior rectus palsy with ptosis. Ptosis and medial and superior rectus palsy are hypothesized to have a neurogenic origin of reversible or irreversible impairment of the oculomotor nerve branch that connects to the muscle, rather than by direct damage of the levator muscle or extraocular muscle. However, it is difficult to identify which part of the nerve branch was damaged and which manipulation during or after surgery caused the damage. We experienced a case of temporary severe oculomotor nerve palsy which showed both complete ptosis and medial and superior rectus palsy that developed immediately after a successful reconstruction of an orbital medial wall fracture. We present this nonfamiliar complication of orbital medial wall fracture repair.

Methods

A 21-year-old female patient underwent successful reconstruction of an orbital medial wall fracture. However, immediately after the operation, the patient was unable to open her eyes or perform any ocular movement in medial and upward directions. We immediately administered high-dose oral steroids under suspicion of compressive oculomotor nerve palsy.

Results

The patient was able to slightly open her eye and perform limited ocular movements on one week after operation. After three months, the patient’s lid returned to the preoperative position, and the range of eye movement was fully recovered.

Conclusion

After reconstruction of orbital medial wall fracture, ptosis and medial and superior rectus palsy may be caused by ischemic injury of the oculomotor nerve due to excessive compression or traction during operation. Although rare and temporary, these unfamiliar complications may occur unpredictably following a successful operation. Therefore, they should be considered important complications by both surgeons and patients.

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A Case of Unsuspected Trans-Orbital-Cranial Penetrating Injury by a Wooden Chopstick in a One-Year-Old Infant

Author: TAE YOON LA

Purpose

To report a case of early detection and successful treatment of brain abscess caused by an unsuspected trans-orbital- cranial penetrating injury by a wooden chopstick in a one-year-old infant who initially presented with pre-septal cellulitis.

Methods

A one-year-old male infant was brought to the hospital by their guardian who found the infant with a wooden chopstick stuck in his eye and pulled it out. The upper eyelid was slightly swollen, but no wounds were observed on the skin or eyeball. On orbital CT, pre-septal cellulitis was suspected and there were no intraorbital foreign bodies. Systemic antibiotics were administered; however, lid swelling worsened and fever developed. Orbital MRI on the fourth day of hospitalization showed an abscess that had spread out through the orbit to the frontal lobe. The orbital CT taken on the first visit was thoroughly rechecked, and a small hole in the orbital roof was found on only one cross-section of the scan. Abscess drainage was immediately performed, and the superior conjunctival fornix, the presumed site of chopstick penetration, was checked, but no wound was found. On culture, no bacteria were identified.

Results

The infant improved rapidly after the operation and recovered completely without any sequelae after additional antibiotic treatment for brain abscess in the neurosurgery department.

Conclusion

Infant injuries not witnessed by guardians are often difficult to evaluate due to communication and cooperation problems, which make it hard to identify details of the accident. This case of trans-orbital-cranial penetrating injury, which showed a very rare route of injury, demonstrated the importance of a full understanding of injury details, accurate identification of the wound, thorough examination of imaging study results, and prompt surgical treatment (when needed) in infant injuries.

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A longitudinal study at a multi-disciplinary Grave’s Orbitopathy (GO) service in patient Graves Orbitopathy Quality of life outcome (GOQOL) visual function (VF) and appearance (AP) scores following treatment with systemic immunosuppression

Author: John Vekinis

Purpose

GO can have a significant adverse impact on the QOL & the effect is related to the severity & activity of GO. A reasonable QOL is compatible with score of 75 in the vision/appearance subscales.

Methods

Parameters prospectively collected for consecutive GO patients >18 years who received immunosuppression at each visit – Demographics, smoking status; thyroid diagnosis, TSH- receptor antibody (TSHR) status and endocrine and GO management; clinical activity score (CAS), disease severity, Gorman diplopia score and GOQOL scores. Outcome measures: Response to Immunosuppressive treatment, orbital radiotherapy, orbital decompression and incidence of GO reactivation and post treatment GOQOL scores.

Results

161/ 533 (30.2%) patients were in the immunosuppression group with mean CAS scores improving by 2.5 to 0.8 (p<0.001), with a mean pre treatment CAS of 3.3. 37 (23%) patients had GOQOL scores recorded pre & post immunosuppression. The mean pretreatment GOQOL scores for appearance was 41.1 & function 54.2. There was an increase in mean GOQOL VF & AP scores by 3.2 & 5.0 pre and post treatment (p=0.01). Median post immunosuppression GOQOL recorded in 37 patients for AP was 78.6 (range 16.67 -100) and VF 68.8 (range 12.5 -100). Correlation between the CAS and GOQOL VF scores (rs= -0.4, 95% CI -0.652 to -0.096) but none between CAS & AP scores in this cohort.

In the 372 patients in the non-immunosuppression group the mean CAS scores improved from 1.0 to 0.4 (p<0.001) with a baseline CAS of 1.1 during follow up. The mean GOQOL scores AP 70.7 & VF 83.9 & mean Gorman score was 0.3.

Conclusion

Immunosuppression appears to significantly improve the VF and AP GOQOL scores. The CAS statistically correlated with GOQOL VF but with not the AP scores.

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Aetiology & Associated Ocular Injuries in 599 Orbital Fractures Across Different Age Groups

Author: Kailing Yong

Purpose

The purpose of the present study was to investigate the causes of trauma and resulting orbital fractures and associated severe ocular injuries across different age groups.

Methods

This is a retrospective study which included 599 subjects who sustained orbital fractures in a single centre in Singapore. All patients had radiological confirmation of orbital fractures on computed tomography scans. The subjects were divided into elderly (>65 years, n=194), middle-aged (41 to 65 years, n=191) and young (≤40 years, n=214).

Results

Majority (71.1%) of our study population were male and the mean age (standard deviation, SD) was 51.9 (21.2) years. The mean number of orbital walls fractured was 1.7 (0.43), and the most common wall fractured was the floor (74.5%), followed by lateral wall (42.6%), medial wall (39.1%) and roof (14.5%). Forty-one percent of the injuries were associated with a zygomatico-maxillary complex (ZMC) fracture, and 15.2% of subjects had a concomitant intracranial haemorrhage. About a quarter of patients (25.4%) had surgical intervention. The mechanisms of injury were significantly different across the three age groups (p<0.001); The most common cause of fracture in the elderly was falls (82.5%), while for the young age group the most common causes were road traffic accident (32.7%) and assault (30.8%). For the middle-aged group, falls accounted for 36.6% of the injuries, road traffic accident 25.7% and assault 23%. There were no significant differences between the age groups and number of orbital walls fractured (p=0.70) and intracranial haemorrhage (p=0.06). The elderly group were more likely to have associated ZMC fractures (p=0.001). Three patients had globe rupture, 4 had traumatic optic neuropathy and 5 patients had significant retrobulbar haemorrhage requiring immediate cantholysis.

Conclusion

The elderly is predisposed to fall and associated orbital fractures. There were a significant proportion of associated intracranial haemorrhage and morbidity, hence orbital fractures should be strongly suspected in the elderly and a low threshold for performing a scan in these patients.

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THE LID SPLIT SHUFFLE TECHNIQUE FOR THE REPAIR OF FULL THICKNESS MEDIAL LOWER EYELID DEFECTS

Author: Rob van der Veen

Purpose

The goal of this study is to describe the advantages and limitations of a new combined technique for the correction of full thickness medial lower eyelid defects in patients with little or no lid laxity.

Methods

In the lid split shuffle technique, we perform a combined intervention consisting of: 1. Standard lateral canthotomy; 2. Vertical eyelid split through a subciliairy incision, hence separating the lower eyelid into a posterior lamella consisting of the full thickness remnant of eyelid border attached to the posterior lamella consisting of conjunctiva, lower eyelid retractors and septum, and, in an anterior lamella that is void of eyelid border and solely consists of skin and orbicularis muscle; 3. Medial tarsal strip fashioning of the medial cut edge and subsequent medial canthopexy; 4. Lateral canthal defect reconstruction (i.e. small Tenzel and/or periosteal flap); 5. Redraping of the anterior skin-muscle lamella into a natural position, with or without the use of a skin advancement flap.

Results

This technique was designed for the first patient we present in this study and executed successfully. Afterwards it was applied in 4 more patients. Of the five cases, two had a (suspected) basal cell carcinoma and one had a squamous cell carcinoma, all have had at least 6 months of follow up after the reconstruction and are recurrence-free. One patient had a benign lesion of the eyelid border and the last patient had a naso-dermal fistula after unsuccessful DCR surgery that needed closing. In one case, however, due to previous tumor surgery, there was not enough tissue to close the gap created laterally in the described fashion and we resorted to the use of a Hughes flap instead. All patients are happy with the final aesthetic result.

Conclusion

This combined technique for a single-stage closure of a full thickness medial eyelid defect in patients without eyelid laxity, can offer the surgeon an extra tool that can lead to very good functional and cosmetic results, especially of the medial canthus and medial third of the lower eyelid. We believe that the technique can be useful for defects of maximally one third of the eyelid length.

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Treating a Congenital Melanocytic Nevus of Upper Eyelid with Blepharoplasty and Full-Thickness Skin Graft

Author: Leonor Caixeiro

Purpose

To present a case of late excision of a Congenital Melanocytic Nevus of Upper Eyelid and reconstruction with Blepharoplasty and Full-Thickness Skin Graft

Methods

We describe the case of a 48-year old woman that presented us with a pigmented lesions with regular margins over the left upper eyelid present since birth. She elected to remove at this time because it was limiting her visual fields, causing a hooded/drooping eyelid. The markings of bilateral upper blepharoplasty were made at a standing position. We excised the skin as usual in the right upper eyelid and then removed the left upper eyelid skin which partially included the nevus.The remaining of the nevus was then removed with a 1mm margins and the defect in the left upper eyelid was then covered with full-thickness skin graft obtained from right upper eyelid.

Results

The graft take-up over the recipient site was 100% with excellent colour match. A final diagnosis of congenital melanocytic nevus was made.

Conclusion

There was a good aesthetic outcome after 6 monyhd, with no impairment of the function of the eyelids and relief in eye fatigue.

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Characterising the Cohort of Thyroid Eye Disease Patients at a Tertiary Oculoplastic Unit

Author: Sabah Janjua

Purpose

To characterise patient demographics and trends in elective surgery of a cohort of thyroid eye disease patients at a tertiary oculoplastic unit over a 15-year study period.

Methods

All patients with a clinically coded ICD-10 diagnosis (H06.2) for thyroid eye disease were identified from April 2008 – April 2023 on our electronic patient database. Data was analysed for demographic features and type and number of surgeries performed by year.

Results

1568 thyroid eye disease patients were identified during the study period who had undergone elective surgery. Of these, 1194 were female (76%) and 374 were male (24%). Average age of the cohort was 49 years (range 16-90). In terms of ethnicity, the majority of patients were White (45%), followed by Any other ethnic group (9.3%), Black or Black British (8.7%), Asian or Asian British (5.9%), Chinese (1.5%) and Mixed (1.5%). 24.8% of patients chose not to state their ethnicity and data was unknown for the remaining 3.4% of patients. A total of 2752 surgical procedures were performed on this cohort over the 15-year period, with the commonest categories being lid 1198 (43.5%), strabismus 355 (12.9%) and orbital 302 (10.9%). Average number of surgeries per patient was 1.55 (range 0-9). When analysed by gender, average number of surgeries was 1.65 for male patients and 1.52 for female patients. 667 (25.7%) patients underwent medical management with drug transfusions. Number of procedures performed per year was fairly consistent, with a decline across all categories in 2020 due to the COVID-19 pandemic. Whilst total number of surgeries performed increased in 2021-22, they did not return to pre-pandemic volume.

Conclusion

Management of thyroid eye disease often requires long-lasting and multiple medical and surgical therapies. Our study provides large cohort data on patient factors implicated in disease severity and treatment, including gender, age and ethnicity. Better understanding surgical trends and the burden of disease on the healthcare system will facilitate service planning in the context of post-pandemic recovery and an increasingly available number of targeted therapies.

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Effectiveness of See-and-Treat approach for Oculoplastics Procedures

Author: Awais Rauf

Purpose

To evaluate the effectiveness of same-day examination and treatment approach when dealing with Minor Oculoplastics procedure in a UK District General Hospital.

Methods

4 months data for same day see and treat clinic in Royal Gwent Hospital was analyzed. Agreement of the diagnosis inferred from the referral to the diagnosis made in clinic was analyzed. Patient discharge rate after single appointment was assessed to evaluate the effectiveness of the same day see and treat approach for minor oculoplastic conditions.

Results

37/43 (84%) had agreement of diagnosis inferred from the referral to the diagnosis made in clinic. There was a 53% (23/43) discharge rate for patients seen in see and treat clinic. 8/43 (18%) patients needed referral to main theatre following their appointment in see and treat clinic.

Conclusion

See and Treat oculoplastic clinics are a useful resource in providing prompt patient care at the first point of contact with secondary care. It can help in reducing the oculoplastics procedure waiting time.

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Dynamic magnetic resonance dacryocystography using a continuous infusion of topical gadolinium as a diagnostic modality for functional and partial nasolacrimal duct obstruction.

Author: Christopher Schulz

Purpose

Dacryocystography (DCG) and dacryoscintigraphy (DSG) have major limitations in the functional and anatomical information they provide. Magnetic resonance dacryocystography (MRDCG) is a viable alternative to conventional DCG and DSG with the potential to offer improved delineation of surrounding soft tissue anatomy and functional outflow. This study aimed to develop a new custom and reproducible dynamic MRDCG protocol with real-world testing in routine clinical practice.

Methods

Patients with clinical evidence of functional or partial nasolacrimal duct obstruction underwent MRDCG using T1- and T2-weighted dynamic turbo spin-echo (TSE) sequences on a 1.5-Tesla magnetic resonance (1.5-T) scanner. During the imaging protocol, dilute (1:100 with saline) gadolinium drops were instilled into the medial corner of both eyes simultaneously using an infusion pump at a rate of 15ml/hour, with dynamic sequences captured with a frame rate of 1.8 seconds. One radiologist and two lacrimal specialists assessed the MRDCG images for image quality and resolution, visualisation of anatomical structures and flow of contrast.

Results

The described MRDCG protocol was performed in 7 patients and reliably demonstrated bilateral lacrimal sacs and nasolacrimal ducts. Dynamic sequences facilitated direct visualisation of lacrimal outflow and any resistance, narrowing or hold up to flow. The topical administration of dilute gadolinium was well tolerated in all patients. Unilateral functional nasolacrimal duct obstruction (FNLDO) was diagnosed in 3 cases, and bilateral asymmetric FNLDO in 2 cases. Functional or anatomical obstruction of the proximal outflow pathway was identified in two cases.

Conclusion

This protocol for dynamic MRDCG is a simple and reproducible method of obtaining detailed structural and functional information on lacrimal drainage. It is less invasive than standard DCG as it requires no canalicular cannulation and provides better functional information. The resolution afforded and volumetric imaging outperforms that of both DCG and DSG.

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Endoscopic medial orbital wall decompression in thyroid-associated orbitopathy and the rate of post-operative diplopia

Author: Saul Rajak

Purpose

Endoscopic medial orbital wall decompression is an effective surgical management strategy for thyroid-associated orbitopathy (TAO). It facilitates good visualisation and decompression of the bony orbital apex with modest reductions in proptosis. It is not clear whether one-wall (medial) decompression is associated with an unacceptable rate of post-operative diplopia.

Methods

This was a retrospective review of all patients undergoing endoscopic medial 1-wall orbital decompression surgery for TAO at a single centre. Pre- and post-operative diplopia rates, along with prism cover test (PCT) and horizontal fusion range measurements at near and distance were evaluated.

Results

20 TAO patients underwent endoscopic 1-wall medial orbital decompression. 13/20 (65%) were bilateral. 90% (n=18) of patients reported no pre-op diplopia. The majority (75%) of patients had a small exophoria pre-operatively. Post-operatively, all patients saw an eso shift in their PCT. Post-op diplopia was reported in 3 (15%) patients, 2 of whom had pre-existing diplopia. Both of these reported post-op improvement in diplopia. In the one patient with new-onset diplopia, they had a small pre-op exophoria (6Δ at near; 2Δ at distance) and the base-in extent of their horizontal fusion range was 4Δ pre-operatively. This was significantly less than the cohort mean of 10.5Δ (p=0.015).

Conclusion

The rate of new-onset diplopia in endoscopic 1-wall medial orbital decompression was 5% in this series. A surgically-induced eso shift is universally seen. In this series, it may be that pre-operative exophoria may be protective against post-op diplopia. Reduced pre-operative base-in fusion range might confer greater risk of new-onset post-operative diplopia following 1-wall medial orbital decompression. The findings of this study will help to inform pre-operative orthoptic evaluation, surgical decision-making and patient counselling.

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Small Incision Levator Resection for Correction of Congenital Ptosis

Author: Gizem Kardaş

Purpose

To report the results of levator aponeurosis surgery performed with small incision and single suture technique in the correction of congenital ptosis.

Methods

The files of patients who were operated for congenital ptosis between 2000 and 2020 were reviewed retrospectively. Inclusion criterias were evaluated as margin reflex distance (MRD-1), palpebral fissure height, and levator function before and after surgery. Eye movements, bell’s phenomenon and phenylephrine test were also performed.Those with involutional aponeurotic ptosis, had any previous lid surgery, and those levator function below 5 were not included in the study. The cases were followed for at least 6 months.

Results

70 eyes of 70 congenital ptosis cases (40 males and 30 females) were included in the study. The mean age was 21.7 ‡ 9.7 years (range, 3-44 years). Preoperative mean levator function and MRD-1 were 13‡1.5 and 3 mm, respectively, while postoperative MRD-1 increased to 2 mm. Insufficient correction in 25 patients and good results in 45 patients. A 10-12 mm incision was made in the upper eyelid crease. After resection of the levator muscle of sufficient length, a single suture was used to fix it to the tarsal plate. Shifting the incision to the medial and lateral sides provided a greater reach to allow the surgeon to place the sutures over the nasal and temporal borders of the limbus. Success was defined as margin reflex distance-1 (MRD-1) ≥ 3 mm and the difference between the eyelids of MRD-1 less than 1 mm; this was considered excellent if the difference between the eyelids was <0.5 mm, and good if between 0.5 and 1 mm.

Conclusion

Small-incision levator resection has been previously studied for the correction of aponeurotic ptosis and has proven to be successful. The findings of this study suggest that the small incision technique can also be used effectively in the correction of congenital ptosis.

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Teprotumumab in Thyroid Eye Disease – Beyond the Eyes?

Author: Mohsan Malik

Purpose

Thyroid eye disease (TED) is an autoimmune disorder that results in the expansion of muscles and soft tissue of the orbit resulting in facial disfigurement and notable psycho-social impact on patient’s quality of life.

Current therapy is targeted to reduce the severity of the expansion that can result in optic neuropathy and corneal exposure. Although facial changes in thyroid disorders are well recognised, resulting in functional and aesthetic changes, there is no effective therapy to resolve this. Teprotumumb, a monoclonal antibody, has been shown to reduce proptosis in patients with thyroid eye disease. We sought to evaluate facial changes following teprotumumab.

Methods

We performed an observational evaluation of all patients undergoing teprotumumab therapy. All patients had 3D facial imaging using the Vectra M3. Soft-tissue volume changes in the face were quantified and evaluated at baseline and following the fourth intravenous infusion.

Results

Eight patients were included in the study, 7 female, 1 male. All patients had chronic inactive TED (mean 3, Range 1-4 years), median clinical activity score was (1, range 0-2). Following teprotumumab therapy, we noted 2mm reduction in proptosis (range 0-5). The mean decrease in global facial volume was 1.3 ml (0 – 5.5ml) after four infusions of teprotumumab, which largely contributed by changes in the malar and periocular areas. All patients noted a subjective improvement in facial appearance following infusion.

Conclusion

One millilitre dermal filler has been used in aesthetic practice to transform the face, in our cohort, a 1 ml global reduction was subjectively associated with facial improvement. Our study found variable measurable responses in patients with chronic thyroid disease, with a wide distribution of responses to teprotumumab. Nevertheless, malar and periocular areas demonstrated the greatest effect noted in mid-face and periocular subunits. Further work is required to ascertain biomarkers in predicting patients with the greatest responses.

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Clinical analysis of congenital Microphthalmos

Author: Suk-Woo Yang

Purpose

To report clinical outcomes of non-surgical treatments in patients with congenital microphthalmia.

Methods

We retrospective reviewed the medical records of 20 patients, 21 eyes who has been diagnosed with congenital microphthalmos from May 2008 to December 2022 at Seoul St. Mary’s Hospital, Korea

Results

Total 20 patients were composed of 12 male and 8 female, average age at the time of diagnosis was 4 months. Other ophthalmic anomaly found were 2 congenital cataract, 1 posterior embryotoxon, 1 corneo-iris strand, 4 iris coloboma, 5 central corneal opacity, 1 Peter’s anomaly and 1 retrobulbar cyst. Systemic abnormalities accompanied were lateral ventricle atrophy, corpus callosum atrophy, patent ductus arteriosus, atrial septal defect, and developmental disorder of language. Genetic abnormalities detected were Anti SS-A/Ro Ab positive, Anti-nuclear antibody 1:100 positive, and Next generation sequencing PAX6 mutation(c.188C>G). There was no unusual history of family or during pregnancy among all patients. Average corneal diameter was 4.6mm, average axial length of eye was 17.44mm, and average artificial eye replacement period was 22 months, at least 4 moths and the most 5 year 8 months.

Conclusion

We used non-surgical methods of gradually expanding the artificial eye with proper size and interval. Most patients were satisfied cosmetically and emotionally.

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Evaluation of the arm as a donor site for skin grafts reconstructing the periocular region

Author: Ian Reekie

Purpose

Skin grafts are a key technique for periocular reconstructive surgery. Several graft donor sites have been described, including upper lid, postauricular and supraclavicular and more distal sites such as the upper arm. A concern when using the arm is colour match and cosmesis. Here, we present 10-year data on using the upper arm as a donor site for full thickness skin grafts.

Methods

A retrospective study was undertaken of all patients who underwent periorbital reconstruction involving a skin graft under a single consultant oculoplastic surgeon at a tertiary referral centre between January 2013 and December 2022. All patients who underwent a procedure involving a skin graft in this time were identified, case notes were reviewed to identify primary diagnosis, site of surgery, grade of surgeon harvesting graft, donor site morbidity and host site complications.

Results

78 patients who underwent skin graft with the arm as donor site were included. There were 40 female and 38 male patients, mean age was 75. The most common diagnosis was BCC (n=63) followed by SCC (n=9), lentigo maligna (n=3), cicatricial ectropion (n=1), seborrhoeic keratosis (n=1) and Merkle Cell Carcinoma (n=1). Based on review of the medical notes, 87% of grafts had a good colour match, 12% fair and 1% poor. Cosmesis was good or fair in 99% of patients. 32 patients had rosacea or actinic type skin, and 37.5% of those developed mild ectropion compared to 11% of those who did not have rosacea or actinic type skin (p=0.005). One patient required subsequent ectropion correction. This patient also underwent ectropion correction with retractor reattachment on the non-reconstructed side, possibly indicating a predisposition to ectropion.

Conclusion

Taking a full thickness skin graft from the upper arm as donor site is an excellent alternative to more traditional donor sites. Surgical times can be significantly shorter for this donor site as an assistant can harvest the graft concurrently with the primary surgeon preparing the host site. There is a low rate of cicatricial sequelae and cosmesis is good. Risk of cicatricial ectropion is higher in actinic skin types.

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Beyond Steroids for Moderate-Severe Thyroid Eye Disease – What’s Next?

Author: Kate Reed

Purpose

In the emerging world of novel use of current and new immunotherapies, we aim to review the evidence-base for their safety and efficacy for improved patient outcomes in thyroid eye disease (TED) phenotypes.

Methods

PUBMED database search was performed with the search criteria “(methotrexate OR azathioprine OR cyclosporine OR cyclophosphamide OR rituximab OR etanercept OR adalimumab OR tocilizumab OR teprotumumab OR infliximab OR mycophenolate) AND (Thyroid Eye Disease OR Graves Eye Disease OR Thyroid Orbitopathy). Papers published in English, adults, and primary procedures for TED were assessed using the Oxford Centre for Evidence Based Medicine (OCEBM) levels 1 to 5.

Results

24 articles matched our inclusion criteria. 10 were evidence level 1b, 1 was evidence level 1c, 11 were evidence level 2b and 2 were evidence level 4. TED results from an autoimmune response targeting orbital tissues. Inflammatory cytokines such as IL-1, IL-6, IL-12, and TNF-α play a crucial role, making biologics a logical choice. Tocilizumab, rituximab teprotumumab and Adalimumab have shown efficacy in reducing ocular manifestations and disease severity. There may also be a role for etanercept and a combination of immunosuppressive agents with orbital radiotherapy.

Conclusion

Multidisciplinary care, early intervention, and combined therapies are crucial in TED management. Challenges include access, cost, and biomarker identification. Biologics offer potential for improved outcomes, but further research is needed for optimal use in TED.

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Assessing the safety of eyelid surgery in patients on anticoagulant and antiplatelet medications: empirical evidence supporting favourable outcomes.

Author: Clarice Giacuzzo

Purpose

To evaluate the incidence of bleeding complications in patients who continued taking antithrombotic medication before oculoplastic surgery.

Methods

This was a prospective study of patients undergoing pre-septal and post-septal oculoplastic procedures under local anesthesia over a 7 months period. The type of antithrombotic, details of surgery, intra and post-operative complications were documented.

Results

214 patients were included, age range 26-98 years (median 70.5 years). 49 patients (23%) on antithrombotics were advised not to stop their medication prior to surgery. The study did not include high bleeding–risk procedures, such as orbital surgery and dacryocystorhinostomy. The types of antithrombotics taken by patients at the time of surgery were 59% antiplatelets, 33% anticoagulants and 8% combination therapy. Amongst patients who continued taking their oral antitrombotic medications there was no major intraoperative or peri operative bleeding complications, and no patients required additional surgical or medical reintervention.

Conclusion

Currently, there are no established guidelines for perioperative antithrombotic agents in oculoplastic surgery, leading to a broad range of practice patterns among clinicians. Our study shows that it is generally safe to continue anticoagulants and antiplatelets perioperatively for certain oculoplastic procedures. This allows simplification of instructions to patients; particularly where pre-operative assessment is no longer supported on the perioperative pathway. Moreover, it reduces the risk of a thromboembolic event as a consequence of anticoagulants and antiplatelet cessation. Clinicians should prioritise meticulous haemostasis over cessation of antithrombotic agents wherever possible.

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Dermis Fat Graft in congenital anophtalmia: surgical tips and prosthetic tricks

Author: alessandra modugno

Purpose

To evaluate long-term outcomes in thirty-six children born with Clinical Congenital Anophthalmia(CCA) treated with progressively enlarging Cosmetic Customized Prostheses (CCP) soon after birth followed by Dermis Fat Graft (DFG), as a strategy of socket rehabilitation and to show surgical tips to facilitate the removal of the graft and its insertion in the socket.

Methods

Thirtysix patients born with Clincal Congenital Anophthalmia were enrolled :30 unilateral and 6 patients with bilateral CCA. All patients were treated by inserting a CCP at the time of their first assessment.Progressively larger CCPs were then changed .The prosthetic strategy was customised according to the clinical case. Subsequently they underwent DFG . The DFG was fixed with four sutures before being harvested from the upper outer quadrant of the gluteal region to easy its removal. After the opening of the socket conjunctiva four sutures were passed through its edges to make easier to suture the conjunctiva and the edge of the dermis and vice versa to the graft. Magnetic Resonance Imaging (MRI) of the orbit was performed before and after surgery.

Results

in all cases the fornices were deepened and the prosthesis was retained better in the socket. The best cosmetic outcomes were achieved when DFG was performed between 12 and 24 months after birth. In four cases an inferior entropion was noted in the immediate post-op stage, the post-op MRI demonstrated the DFG shifting to the upper quadrant of the orbit: a second DFG placed below the former one recovered the inferior eyelid position. Satisfaction in terms of cosmetic outcomes proved to be very positive.

Conclusion

In Clinical Congenital Anophthalmia the main goals are : to allow retention of a suitable prosthesis and to maximize facial symmetry. To achieve the best cosmetic outcome early expansion of the socket is essential before any surgical treatment. DFG is then the key in order to fill the socket homogeneously, to increase the conjunctival lining and deepen the fornices. Pre and post-op MRI are mandatory to assess the positions of both the prosthesis and the graft in the orbit.

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Preliminary study results of high frequency skin ultrasound, shear wave and strain elastography in patients with floppy eyelid syndrome

Author: Vasileios Batis

Purpose

This study will investigate the use of high frequency ultrasound imaging techniques including high frequency skin ultrasound, strain elastography and shear wave elastography of the superior eyelid and in the diagnosis and follow-up of patients with floppy eyelid syndrome.

Methods

We used the GE LOGIQ E9 machine along with the 18MHz high frequency skin ultrasound head, the strain elastography 12 MHz head and shear wave elastography 9MHz head to perform the measurements. 29 eyelids of 15 patients diagnosed with floppy eyelid syndrome have so far been registered as part of the disease group while 14 eyelids of 11 normal patients have been registered so far as the control group. For each parameter that we measured we took the average value of 3 measurements. All the ultrasounds were performed by an expert radiology consultant.

Results

Using the high frequency skin ultrasound, we found that the mean epidermis/dermis layer thickness and the subcutaneous fat layer was increased in the disease group (0.13cm and 0.09cm respectively) in comparison to the control group (0.09cm and 0.07cm respectively). The ultrasonographic orbicularis muscle thickness was slightly increased in the disease group (0.10cm compared to 0.085cm) The ultrasonographic subepidermal low-echogenic band (SLEB) had the same thickness in both groups (0.06cm).With the strain elastography we measured an increased skin to subcutaneous fat and muscle to subcutaneous fat ratio in the disease group compared to the control group (1.2 and 0.97 compared to 0.94 and 0.79 respectively).With the shear wave elastography we measured significantly increased skin, subcutaneous fat and muscle KPa values in the disease group (11KPa, 9.8KPa and 10KPa) compared to the control group (6.6KPa, 7.2 KPa and 5KPa respectively).

Conclusion

These results indicate that floppy eyelid syndrome might present measurable differences using high frequency skin ultrasound, shear and strain elastography when performed in the superior eyelid of patients.

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Lower eyelid reconstruction using fascia lata and retro auricular skin graft in severe cicatricial ectropion secondary to burn injury.

Author: Alejandra Herranz-Cabarcos

Purpose

INTRODUCTION Eyelid reconstruction in cases of severe alteration of the anatomy might be complex. Support structures must be restored in addition to skin and conjunctiva. We herein describe an unusual surgical technique using fascia lata for replacing lower eyelid posterior lamella in a patient with keloid formation risk.

Methods

CLINICAL CASE We report a 72 y-o female who developed fungal keratitis on her right eye as a consequence of severe lower eyelid cicatricial ectropion secondary to burn injury. Complete eversion of lower tarsal plate associated with keloid scars were observed.. Surgical reconstruction using double folded fascia lata and retro auricular skin was proposed. Attachment to lateral orbital periosteum and to residual tarsal plate was performed, leaving a medial fold of fascia lata to be attached to medial canthal tendon in a second time, if needed.

Results

DISCUSSION The first use of a sling of fascia lata in reconstructive surgery of the lower eyelid was reported by Wiggs et al in 1982. Although there are not many subsequent publications in this regard,this procedure is included in most of the books on oculoplastic surgery, which points to its good results. We herein propose a variation of the technique in order to minimice the aggressiveness of the surgical procedure in order to prevent keloid formation.

Conclusion

The reconstruction technique with folded fascia lata allows, in patients who may need more than one eyelid reconstruction surgery, to minimize surgical aggression in the first stage. After assessing the results from the first surgery and only if the patient requires it, a second procedure can be planned.

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Periocular lesions: from clinical to histological diagnosis

Author: Clarice Giacuzzo

Purpose

To evaluate the accuracy of the clinical diagnosis of periocular lesions compared to the histopathologic diagnosis on biopsy and to determine the accuracy of diagnostic biopsies for malignant lesions compared to the definitive histology of the excised tumor

Methods

Retrospective analysis of periocular lesions treated in minor operation treatment room between April 2019 and October 2022. Patients with malignant lesions requiring further excision underwent surgery in the main theatre.

Results

276 biopsies were performed from 239 patients. Age range was 16-87 years (median 65 years), female:male was 51:49. 239 were benign lesions, 7 were premalignant, and 30 were malignant. Malignant lesions included 28 BCCs, 1 SCC, 1 melanoma-in-situ. The accuracy rate of clinical diagnosis was 100% for benign lesions, 86% for premalignant lesions, and 90% for malignant lesions i.e. 10% of the malignant lesions were not clinically suspected. Of the malignant tumours that underwent further excision, the overall correspondence of diagnostic biopsy with final definitive histology was 95% for tumour type but only 64% fully corresponded including the subtype. Tumour subtype was not able to be determined on 5 biopsies, 2 showed a different subtype to the final histology.

Conclusion

Our study highlights the importance of biopsy when there is clinical ambiguity, as clinical diagnosis alone is not 100% failsafe. Therefore, it is mandatory to keep accurate records of procedures performed and review all histology results in a timely manner. However, a diagnostic biopsy may not always be able to provide the desired details or add further information to a clinically diagnosed tumour.

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A 6-Year Retrospective Study of Periorbital Basal Cell Carcinoma at a Quaternary Referral Centre in Australia

Author: Ru Min Ong

Purpose

To analyse patient demographics, tumour profiles and surgical outcomes of patients with periorbital basal cell carcinoma (BCC) in a quaternary referral centre in Sydney, Australia.

Methods

Medical records of patients with periorbital BCC were reviewed from January 2014 to December 2019 at Sydney/Sydney Eye Hospital, Australia. Surgical excision with clinically clear margins of 2-4mm (SEM) or fresh frozen section (FFS) techniques were employed. Conventional reconstruction methods were utilised.

Results

A total of 157 periorbital BCC cases of 131 patients were recorded. Mean age was 71 with slight female predominance compared to males (1.06:1). 86% were primary BCCs. Most common histological subtype and tumour region were nodular BCC (30%) and lower lid (58.6%). 7% showed perineural, lymphovascular and/or orbital invasion.

38.2% underwent SEM and 61.9% underwent FFS. Additional management strategies of observation and radiotherapy were employed in selected cases due to patient preference and general health status. 1.9% had post-operative complications.

18.5% of cases had incomplete excision, with a higher rate seen in aggressive subtypes (p<0.05, Pearson's chi-squared test). Incomplete excision was higher in SEM (28.3%) than FFS (12.4%). Clearance was 93.3% and 100% for final SEM and FFS respectively. Recurrence rate was 5.7% and was related to aggressive subtypes. Incompletely excised BCC had a higher recurrence rate (13.8%). After incomplete excision, there was a higher recurrence rate in SEM than FFS (18.6% versus 7.7% respectively).

Conclusion

The main risk factors for recurrence are aggressive subtypes, medial canthal region and incomplete excision. FFS achieved better surgical outcomes than SEM in this study.

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Correlation of secondary glaucoma and High risk features on Histopathology in Asian Indian patients with retinoblastoma

Author: Komal Bakal

Purpose

To study the correlation of secondary glaucoma and high risk features(HRF) on histopathological Examination(HPE) in primary enucleated eyes with retinoblastoma in Asian Indian population and to compare with similar data in Caucasian population.

Methods

A retrospective study of 460 patients who underwent primary enucleation for retinoblastoma from April 2011 till March 2020 at a tertiary care centre in Hyderabad, India. Following details were noted-
-Demography
-Presence or absence of secondary glaucoma
-Stratification into groups based on IOP range
-Correlation of prevalence of HRF on HPE with the IOP groups
-Correlation of presence of NVI with high risk features
-Comparison with similar study in Caucasian population

Results

Out of 460 patients,169 eyes had secondary glaucoma(IOP>21 mmhg) on presentation. HRF on histopathological examination were observed in 112(66.27%) eyes out of these 169 eyes. On the other hand, 291 patients presented with normal IOP and out of them 107(36.76%) patients had high risk features on HPE. On further division of IOP scale, 84 patients had IOP between 21 to 30 mmhg and 46 (54.76%) out of them showed high risk features,57 patients had IOP between 31 to 40 mmhg and 45(78.94%) out of them showed high risk features, 28 patients had IOP of 41 mmhg and above and 21(75%) out of them showed high risk features. 101 patients showed presence of NVI out of which 70 (69.3%) had HRF. On analysing the HRF data it was found that 219 patients out of 460 had HRF, average IOP in these patients was 22.8 mmhg . 241 patients did not show HRF, average IOP in these patients was 15.68 mmhg. In comparison to a similar study by Kim et al in Caucasian population, it was noted that mean IOP in patients with or without HRF was lower in Asian Indian population as compared to Caucasian population.

Conclusion

Retinoblastoma patients with secondary glaucoma are more likely to have High risk features on HPE. The risk of HRF increases with increasing IOP and Secondary glaucoma is an independent risk factor regardless of presence of NVI. Asian Indian eyes show HRF on Histopathology at lower IOP as compared to Caucasian eyes.

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Lateral Tarsal Strip Procedure: comparison of absorbable sutures and non-absorbable polypropylene suture. Does the suture type matter?

Author: Malik Moledina

Purpose

To determine whether the success and complication rate of the Lateral Tarsal Strip (LTS) Procedure, when treating involutional ectropion or entropion, is influenced by the use of absorbable or non-absorbable suture when used to attach the tarsal strip to the periosteum

Methods

Multi-centre retrospective comparative study of re-operation and complication rates (Recurrence, Dehiscence, Suture Infection, Granuloma, Haemorrhage, Residual-Lid Laxity, Suture Extrusion and Repeat Procedure) in LTS for involutional ectropion/entropion using an absorbable polyglactin suture (vicryl) and non-absorbable polypropylene suture (prolene). The Medisoft and Saphire, data tools identified all patients between 01/01/2017 to 01/01/2022 who met the inclusion and exclusion criteria, at two NHS Trusts.

Results

1079 operations in 891 patients were performed within the study period, with an average follow-up of 1.785 years, that met the inclusion and exclusion criteria. 36% of patients were female, with an average age of 81.4 years. 588 operations in 475 patients were performed using non-absorbable prolene sutures whilst 491 procedures in 416 patients were performed using absorbable vicryl sutures. Of these, 61% were performed by a consultant surgeon in the prolene group compared to 49.7% in the vicryl group. Overall complication rates between prolene and vicryl were 24.7% and 29.7% (p=0.061) respectively. Higher complication rates for post-operative residual lid laxity, granuloma and suture infection were greater in the vicryl group compared to prolene. (2.65% and 0.51% p=0.004, 2.24% and 0.68% p=0.03, 1.83% and 0.17% p=0.007 respectively). No statistically significant difference was found for dehiscence or repeat procedures.

Conclusion

Both sutures are effective for the surgical correction of involutional ectropion/entropion with LTS. Long term dehiscence and redo rates were not found to show a statistically significant difference. Nevertheless, the use of absorbable Vicryl suture was found to be associated with a higher complication rate for: post-operative residual lid laxity, granuloma and suture infection.

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A rare case of multiple lacrimal gland ductal cysts.

Author: Edward Foo

Purpose

To present the clinical and histopathological features of a rare case involving multiple lacrimal gland ductal cysts.

Methods

A 57-year-old male presented with 15-year history of swelling in the right superotemporal orbit, with enlargement over recent months and fluctuation in size. Orbital CT and MRI showed bilateral orbital abnormalities in the region of the lacrimal glands, larger on the right. The lesions were composed of well-defined fluid signal spaces with a complex network of internal septations, extending posteriorly and anteriorly, with subtle right globe displacement medially. The patient underwent debulking and biopsy of the right lesion with concurrent blepharoplasties.

Results

Intra-operative and histopathology findings were consistent with large, multi-loculated lacrimal gland ductal cysts filled with clear fluid. Microscopy confirmed lacrimal gland ductal cysts lined with lacrimal ductal epithelium encased in a band of fibrous tissue, with chronic inflammation. IgG3 was elevated at 3.32 (normal 0.2-1.9), as was IgA at 4.75 (normal 0.8-4.0), suggestive of non-specific inflammation. Although the patient had recurrent cysts post-operatively, and no intervention was undertaken for the left cysts, the patient was pleased with the outcome and declined further treatment.

Conclusion

We present an unusual case of large, multi-loculated, bilateral lacrimal gland ductal cysts. Vasculitic screening is helpful to look for causes. In this case it was thought to be inflammatory in nature. Although small ductal cysts may be amenable to marsupialisation, large cysts causing globe displacement may warrant debulking. Patients may experience early recurrence and require further treatment.

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Ocular Manifestations of Pityriasis Rubra Pilaris: A Novel Case Report and Review of the Literature

Author: Malik Moledina

Purpose

Pityriasis Rubra Pilaris (PRP) is a rare dermatological condition which may present with ocular manifestations. We report a unique case of recurrent Cicatricial Ectropion(CE) associated with PRP which we postulate was triggered by the patient’s timolol eye drops. This is the third case of CE secondary to PRP reported in the literature a MEDLINE review was performed on the ocular manifestations of PRP.

Methods

The design of this study is an interventional case report and literature review. The intervention provided is surgery to correct CE which included the release of scar tissue, lateral tarsal strip and full thickness supra clavicular skin graft after immunosuppression with Methotrexate for a period of three months.

Results

A 86-year-old Caucasian woman was referred for a bilateral CE after a diagnosis of Type 1 PRP and Methotrexate immunosuppression for three months. After surgical intervention, the CE had subsequently resolved but reoccurred after eight weeks following the introduction of topical timolol drops with graft shrinkage and resumption of disease activity. The patient was referred for further immunosuppression and substitution of timolol drops prior to further surgery being considered.

Conclusion

PRP is a rare entity, manifesting a variety of ocular complications. Surgery should be carefully considered due to the high risk of recurrence, re-operation and residual disease. It should be performed when the disease is quiescent. Grafts should be oversized to reduce the risk of shrinkage. Surgery should be considered when drugs, that could trigger reactivation, have been substituted. These include: imatinib, ace-inhibitors, labetalol and as shown in our case report topical timolol. Finally, Herpes Simplex, PUK and Corneal Perforation is associated with PRP likely due to an increase in TNF-α associated inflammation. Careful corneal evaluation is also recommended.

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An easy-to-use screening tool for epiphora screening before cataract surgery: Munk’s scale

Author: Deniz Kilic

Purpose

Chronic dacryocystitis (CDC), a common reason of epihora, is a misdiagnosed and overlooked risk factor for post-cataract surgery endophtalmitis. Every country has their own screening tools for epiphora and CDC. In India all cataract patients are routinely undergo syringing before surgery to rule out CDC. However, in Turkey there is no routine screening method for epiphora before a cataract surgery. Hence, this study aimed to find out the usefulness of Munk’s scale in epiphora screening before a routine cataract surgery.

Methods

The scale consists of 6 grades of the epiphora evaluated by requiring dabbing times in a day:0 is for no epihora; 1 is for less than twice a day, 2 is for 2-4 times, 3 is for 5-10 times a day, 4 is for more than 10 times a day, 5 is for constant epihora. The scale is performed on 300 consecutive cataract patients. After the questionnaire patients underwent a syringing of the nasolacrimal ductus (NLD, test was + for patent NLD).Age, gender, laterality of the eye, Munk’s scale grade and syringing test results were recorded.

Results

The mean age of the patients were 68.11 ± 11 (24-92) years. There were more female patients than males (54%-46%). The right eyes were more than left eyes (53%- 47%). Munk’s scale was 0 in the majority of the patients; in 190 patients (63.3%). The score was 1 in 50 patients (16.7%), 2 in 32 (10.7%), 3 in 17 (5.7%), 4 in 8(2.7%) and 5 in only 3 patients (1%). The syringing test was positive in 296 (98.7%) patients. The punctums were normal in 292 patients (97.3%). The syringing was negative in 2 patients with a Munk’s scale of 5, in 1 patient with a Munk’s scale of 3 and in 1 patient with a Munk’s scale of 4. The – syringing test was found to be more in patients with higher Munk’s scale (p<0.001). There was a positive correlation with the negative syringing and Munk’s scale (r=0.211, p<0.001).

Conclusion

The study showed that a majority of included patients had a lower grade of Munk’s scale. The scale was found to be positively correlated with the negative syringing test. The scale is seem to be a cost-effective method in screening patients for epiphora especially screening the cataract patients preoperatively.

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Review of the management of nasolacrimal duct obstructions in a tertiary paediatric hospital in the United Kingdom

Author: Matthew Fenech

Purpose

Nasolacrimal duct obstruction (NLDO) may be congenital or acquired. Our aim was to assess the success of current practices in the management of NLDO by evaluating:
• Treatment modalities and their outcomes
• Discharge rates and symptom-free period

Methods

A retrospective, cross-sectional, case review of patients suffering from NLDO between January 2017 and January 2023 was undertaken in a tertiary paediatric hospital in the United Kingdom. Data pertinent to syringe and probe (S&P), NLD intubation (NLDI), dacryocystorhinostomy (DCR) and nasolacrimal tube removals was collected. Exclusion criteria included age <12 months at time of surgery, lack of follow up data, and those who received or were receiving treatment elsewhere

Results

62 NLDO patients were included; simple (65%), syndromic (24%) and acquired (11%). The primary management was S&P in 93% of patients (mean age at procedure 49.5 months). S&P was performed later in the syndromic congenital NLDO (57.2 months) and acquired NLDO (75.8 months) groups. Just under half (43.5%) required no further intervention. Of those who underwent NLDI, rates were lowest in the simple congenital NLDO group (51.5%) compared to the syndromic congenital (66.6%) and acquired NLDO (57.1%) groups. Stents were removed, on average, after 8.3 months;. Those with syndromic congenital NLDO had tubes in situ for longer (mean 14.6 months). Further treatment with DCR (endonasal or external) was required in 13.1% of the cohort. Disharge rates were higher in the simple congenital NLDO group (87.5%) compared to the syndromic NLDO group (66.7%). Over 92% of patients are currently symptom-free, with 37% of patients being symptom-free for >5 years in the simple congenital NLDO group compared to 13.3% in the syndromic NLDO group

Conclusion

Current treatment modalities for NLDO are effective in the resolution of symptoms. Those with syndromic congenital NLDO and acquired NLDO are more likely to require intubation for resolution of symptoms. Further data is needed to assess if intubation should be considered as the primary means of management in syndromic congenital and acquired NLDO rather than S&P

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Diagnostic Challenge of an orbital cellulitis

Author: Maria grazia Sammarco

Purpose

To describe a case of cilio-choroidal melanoma presenting as aseptic orbital cellulitis with massive conjunctival chemosis.

Methods

Case report

Results

A 51-year-old man with a left retro-iris pigmented lesion had acute lid edema, conjunctival chemosis, and extensive hyphema. Ultrasound revealed a large, lobulated, wide-base choroidal-starting lesion affecting the ciliary bodies and vitreous chamber. MRI revealed low-intermediate T2-signal and intermediate-high T1-signal, with substantial post-contrastographic enhancement. After one week of systemic corticosteroids, the chemosis reduced significantly, and the patient was referred for enucleation, even without histologic confirmation. Post-surgical histopathology found 90% necrotic tissue, few viable cells, and no scleral or vascular invasion, with genetic analysis showing monosomy of chromosome 3 and 8q gain.

Conclusion

Choroidal melanoma, particularly if necrotic, may occasionally present as aseptic orbital cellulitis, even without extraocular spread.

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Periorbital Necrotizing Fasciitis: 3 cases from presentation to reconstructive journey

Author: Kirupakaran Arun

Purpose

Periorbital necrotising fasciitis is a devastating bacterial infection associated with irreversible inflammatory destruction of soft tissues. Outcomes include disfigurement, vision loss, septic shock and death within hours to days. We describe three cases of periorbital necrotising fasciitis demonstrating the rapid progression of the disease and the need for prompt identification and decisive intervention.

Methods

All three patients were referred to our eye emergency department with suspected orbital cellulitis. A 52 year old male presented following a fall and hit to his left forehead 4 days prior. An 80 year old male presented with no history of trauma but was on immunosuppressive therapy for rheumatoid arthritis. A 65 year old female presented with recent coryzal symptoms and was undergoing concurrent chemotherapy for bladder cancer. All patients presented with similar signs: periorbital swelling, skin necrosis, fever and raised inflammatory markers. Patient 1 & 2 had left sided periorbital disease on presentation. Patient 3 had bilateral involvement on presentation.

Results

All 3 patients had positive cultures for Group A Streptococcus. Surgical debridement was performed within 12hours of presentation to the eye emergency department (mean 7.2 hours) and received intravenous antibiotic therapy based on sensitivities. Primary orbital reconstruction surgery was performed in all cases within 31 days of surgical debridement. (mean 19.6 days).

Conclusion

We report these 3 cases to highlight the key clinical features compatible with periorbital necrotising fasciitis. This disease is aggressive and both sight & life-threatening and should be managed with a combination of intravenous antibiotics and early surgical debridement in the acute setting followed by reconstruction once the acute infection has settled.

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Technique-specific success rates for correcting total and partial lower lid ectropion

Author: Jennifer Kwan

Purpose

Medial spindle is normally reserved for surgical correction of punctal ectropion, however, we reviewed cases of total and partial ectropion managed at a tertiary centre to determine the success rates of surgery managed with inverting sutures, medial spindle, or double medial spindle (DMS), which is two medial spindles in tandem.

Methods

A retrospective audit of all surgical cases of total or partial ectropion managed at a tertiary centre NHS Trust who were operated on between January 2017 and December 2019.

Results

98 operations for total ectropion (75.5% bilateral) and 120 for partial ectropion (81.7% bilateral) were performed. Additional procedures other than lid shortening methods were required in 81 (82.7%) of total ectropion and 87 (72.5%) of partial ectropion eyelids. Mean follow up was 30.7 (range 2-205) weeks.

Additional procedures for total ectropion included medial spindle, inverting sutures, or DMS, and were performed in 40 (40.8%), 22 (22.4%), and 15 (15.3%) eyelids, respectively. Functional success was obtained in 30/40 (75.0%), 12/22 (54.5%), and 12/15 (80.0%) of these procedures, respectively.

Partial ectropion was augmented with either medial spindle in 74 (61.7%) lids, or DMS in 6 (5.0%) lids. Functional success was seen in 63/74 (85.1%) lids corrected with medial spindle, and 3/6 (50%) lids that had DMS.

Pooled complication rates for all medial spindle operations, compared to inverting sutures, and DMS, were 9/114 (7.9%), 6/22 (27.3%), and 1/21 (4.8%), respectively, for over/under-correction. Granuloma accounted for 10/114 (8.8%) medial spindle cases compared to 4/22 (18.2%) inverting sutures cases and 3/21 (14.3%) DMS cases.

Conclusion

Over 70% of total and partial ectropion cases required additional procedures to enhance the degree of correction. In this audit medial spindle and DMS were more beneficial in improving functional and anatomical success than inverting sutures, and were not associated with increased rates of granuloma formation.

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Fatal Orbital Cellulitis with Orbital Apex Collection

Author: Kirupakaran Arun

Purpose

Orbital cellulitis is a potentially sight and life-threatening complication and often develops secondary to sinusitis. It Is seen more frequently in children and outcomes can include visual loss and even death within hours to days. We describe a case of orbital cellulitis complicated with an orbital apex collection.

Methods

A 15 year old boy presented to the Emergency Department with a 2-day history of coryzal symptoms, fever and headaches and a 1-day history of right periorbital swelling. Ocular examination showed significant right periorbital swelling, conjunctival chemosis with NPL vision, positive RAPD and minimal eye movements. He had no past medical history. He was admitted, bloods taken including blood cultures, started on intravenous antibiotics and CT head and orbits was performed. This demonstrated extensive right sided maxillary sinusitis with a collection in the right orbit of 2.7cm x 1cm x 3.5mm extending towards the orbital apex.

Results

Following the combined input of ophthalmology, ENT and paediatrics, surgical intervention was performed within 5 hours of presentation to the emergency department (functional endoscopic sinus surgery and external drainage of orbital abscess). Cultures from the collection were positive for Streptococcus anginosus and intravenous antibiotics were given based on sensitivities. Unfortunately, despite this vision did not improve and remained NPL.

Conclusion

This case represents the clinical features compatible with orbital cellulitis and the need for prompt examination, investigation and a lower threshold for more aggressive intervention when presenting in a child. In cases of advanced orbital cellulitis, multimodal imaging is critical to diagnose rare complications and a multidisciplinary approach is integral to managing these complicated cases.

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Intense Pulse Light therapy for Dry Eye Disease secondary to Rosacea associated Meibomian Gland Dysfunction in an Irish population

Author: Nikolina Budimlija

Purpose

To assess the safety and effectiveness of Intense Pulse Light (IPL) therapy for managing Meibomian Gland Dysfunction (MGD) – Rosacea related ocular surface disease in an Irish population over the 3 year period.

Methods

Patients with confirmed facial rosacea and dry eye disease diagnosis secondary to MGD, who underwent IPL from January 2020 to January 2023, were retrospectively enrolled into this study. All patients signed an informed consent for their anonymized data to be included in the study. The study outcome measures included Meibomian gland (MG) loss, Tear Meniscus Height (TMH), Non-Invasive Tear Film Breakup Time (NIBUT) test, and Best Corrected Visual Acuity (BCVA). All adverse events were also recorded

Results

A total of 272 eyes of 136 patients (comprising 44 males and 92 females) were treated with 4 IPL sessions 2 weeks apart. Following the IPL treatment, MG loss reduced from 40.38±17.77% at baseline to 27.21±12.79% (p<0.001) at the month-2 follow-up. Tear meniscus height increased from 0.24±0.10mm at baseline to 0.41±0.13mm (p<0.001). NIBUT also improved from 5.97±3.33s to 8.33±3.55s (p<0.001). BCVA (logMAR) improved significantly from 0.07±0.14 at baseline to 0.03±0.12 following IPL treatment (p<0.001). Of the 272 eyes treated, 250 (91.9%) reported improvement in their ocular surface discomfort at the month-2 follow-up visit. Of the 22 remaining dissatisfied eyes (11 patients), 1 patient discontinued treatment due to mild lid burns and 2 patients repeated the treatment 24 months from their initial procedures

Conclusion

The findings of the study indicate that IPL therapy improves rosacea MGD-related dry eye symptoms in patients who underwent the treatment. With a good treatment protocol and patient selection strategy, the rate of adverse events associated with IPL therapy is minimal.

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Automated Assessment of Eyelid Position using a Novel VR Eye-Tracking Device

Author: Ali Al-Hussaini

Purpose

The objective of this study is to evaluate the effectiveness of a Novel Virtual Reality (VR) Eye-Tracking Device, Bulbicam (BCAM) as a method for automated assessment of eyelid position. Specifically, we aim to assess the accuracy and reliability of the novel device in measuring lid position in a cohort of 10 normal patients, 10 patients with ptosis, and 10 patients with thyroid eye disease (TED).

Methods

A total of 30 participants were recruited for this study, including 10 normal patients, 10 patients with ptosis, and 10 patients with TED. BCAM was utilised to capture eye movements and record eyelid position in a standardised manner. The participants underwent a series of eye movement tasks and static lid position measurements whilst being measured by the device. Data collected were analysed using advanced computer vision algorithms to determine lid position.

Results

Preliminary analysis of the data revealed promising results regarding the automated assessment of eyelid position using the device. In the normal patient group, the novel device demonstrated high accuracy and consistency in measuring eyelid position during various eye movement tasks. In the ptosis group, BCAM successfully detected the abnormal lid position and provided quantitative measurements for further analysis. Similarly, in the TED group, BCAM accurately assessed the extent of lid retraction found in the disease.

Conclusion

The results suggest that the device is a valuable tool for automated assessment of eyelid position. Its ability to accurately track and record eye movements, combined with advanced computer vision algorithms, enables reliable measurement of lid position. The findings demonstrate the potential of BCAM as a non-invasive and user-friendly method for assessing eyelid position in different clinical scenarios, including normal individuals, ptosis patients, and TED patients. Further studies with larger

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Excision of periocular Basal cell carcinomas with 3 mm margins: 5-year recurrence rates

Author: Gabriele Quaranta

Purpose

The aim of this study was to determine the 5-year recurrence rate of periocular BCC treated with excision and delayed reconstruction at one institution.

Methods

This is a retrospective, non-comparative study of consecutive periocular BCC excisions performed at one institution between January 2013 and December 2017. 168 cases with at least 6 months follow-up were included in this study. 5-year follow-up was available for 95 cases.
BCC diagnosis was first confirmed histologically with a punch biopsy. The tumor was excised with 3 mm clearance margins and delayed reconstruction was undertaken following histology performed with formal paraffin sections. A further resection was performed in case of involved or narrow margins (<1mm). Data collected included demographic information, tumour site, histological subtype, number of excision, reconstruction technique and recurrence rate after 5 years

Results

47 out of 168 cases (28.0%) required more than one excision to achieve clear margins. The average follow-up time was 4.1 years and the median follow up was 4.8 years. 95 out of 168 cases (56.5%) were followed for at least 5 years. There were 2 recurrences out of the total 168 cases (1.2% recurrence rate), one patient had a recurrence after 1.5 years while the other after 5 years.

Conclusion

Excision with 3mm clearance margin and delayed reconstruction following histological clearance is a safe way of managing periocular BCC. Over a quarter of patients (28.0%) required further excision and highlighted the importance of delayed closure even with a 3mm clearance margin. Moreover, our late recurrence after 5 years underline the importance of a long follow-up time.The low recurrence rates compare well with Mohs surgery (1.2%). The standard formal paraffin sections are available in most centers, not labour intensive, cheap and arguably superior to frozen section techniques.

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Exploring Changes in the Incidence of Sympathetic Ophthalmia After Intraocular Surgery: A Meta-Analysis

Author: Mohamed Bondok

Purpose

Sympathetic ophthalmia (SO) is a rare form of bilateral granulomatous panuveitis that typically occurs following trauma or intraocular surgery (IOS). The reported incidence rate of SO following IOS varies in the literature. Therefore, the primary objective of the study was to determine the incidence proportion of SO following IOS, while the secondary objective was to investigate any potential decline in its occurrence over time. By addressing this research gap, the study provides new insights into the incidence proportion of SO following IOS and presents valuable information for consent discussions with patients.

Methods

A systematic literature search was performed using the MEDLINE, EMBASE, and Cochrane databases from inception to November 2021 for population-based studies on IOS and SO in adults. Two reviewers independently screened search results. Random-effects meta-analyses were performed to calculate the incidence proportion, and subgroup analyses were conducted to explore potential variations based on different study time periods. To assess changes in the incidence proportion of SO, a reference period was established using the median study year. This study was registered on PROSPERO with registration number CRD42020198920.

Results

The meta-analyses incorporated a total of 16 studies, published between 1947 and 2020. Following IOS, the overall estimated incidence proportion of SO was 0.058% (95% CI 0.035 % – 0.095%) with moderate heterogeneity (I2 = 55%). The reference period, represented by the median study year of included studies, was identified as 1999. Comparing the incidence proportion of SO between studies published before 1999 (0.053%, 95% CI 0.019% – 0.150%, I2 = 62%) and those published after 1999 (0.061%, 95% CI 0.037% – 0.101%, I2 = 38%), no statistically significant difference was found (p = 0.81).

Conclusion

SO after IOS is rare. The estimated incidence proportion of sympathetic ophthalmia may be useful in consent discussions preceding IOS. Notably, the study findings herein do not support the notion that the occurrence of SO following IOS has declined over the past two decades.

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Optic Nerve Assessment Using a Non-mydriatic Fundus Camera in a Tertiary Orbital Clinic

Author: Sabah Janjua

Purpose

We sought to assess the feasibility of using a non-mydriatric fundus camera to evaluate the optic nerve in an orbital clinic at a tertiary oculoplastic unit.

Methods

Images were captured with the Optomed Aurora handheld fundus camera following informed consent. Undilated optic nerve centred colour images were captured for 100 consecutive patients attending orbital clinic. All patients were reviewed in clinic as planned and received standard care. Time taken to capture a satisfactory image was recorded. Images were uploaded to the patient’s records and assessed.

Results

100 consecutive patients were imaged over a five-week period. 67 patients were female and 33 male. Patients had an average age of 51 years (range 19-80). 85 patients had both eyes imaged, whilst 8 had only the left eye imaged and 7 only the right eye. Reasons for not imaging the second eye included: prosthetic eye, post-operative swelling or pain, tarsorrhaphy, ptosis and poor vision or strabismus causing difficulty fixating. An average of 1.2 images (range 1-4) was required per patient with an average time of 48 seconds (range 9-420) taken to obtain a sufficient image. Image acquisition time decreased with use. 88% of images taken were of sufficient quality to assess the optic nerve adequately. Of the 185 eyes imaged, 13 were clinically known to have optic nerve pathology. In those patients where both an adequate fundus image and clinical assessment was available for comparative analysis, diagnostic concordance was 95%. There was one case of optic nerve pathology identified on fundus imaging which was not picked up in clinic and the patient was asked to re-attend for further review. Disc swelling and glaucoma were reliably identified on fundus images. Subtle optic disc pallor and drusen were less likely to be identified on imaging alone.

Conclusion

This study demonstrates that a handheld fundus camera can be used to produce adequate images to assess the optic nerve in the majority of patients in an orbital clinic, with a high degree of diagnostic concordance. There is a learning curve both for the patient and device operator, with improved efficiency with use.

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Changes in radiological proptosis following immunosuppression in a metropolitan multiethnic Graves Orbitopathy (GO) cohort

Author: Dengyi Zhou

Purpose

To describe the change in radiological proptosis in GO patients pre and post EUGOGO first and second line immunosuppression regimen in a multiethnic patient cohort in a metropolitan multidisciplinary GO service.

Methods

Parameters collected for consecutive GO immunosuppression patients >18 years: demographics (age, gender, ethnicity and smoking status), thyroid diagnosis and status, clinical activity score (CAS), disease severity, Gorman diplopia score, immunosuppression treatment, surgical orbital decompression and proptosis measurements on MRI imaging. Outcome measures: changes in radiological proptosis measurements in worse affected eye across the entire cohort, with or without orbital decompression surgery and differences between white and non-white populations. The Spearman’s Rank method was used to correlate changes in radiological proptosis with changes in CAS and Gorman scores.

Results

We included 91/143 (64%) of immunosuppression patients who had baseline and post immunosuppression MRI orbital imaging. 72 (80.0%) were female, median age of 51 (IQR 42-63) years. 46/72 patients (63.9%) with a recorded ethnicity were non-white. 16 (17.6%) had urgent orbital decompression for sight threatening disease. The change in proptosis across the entire non-decompression cohort from baseline to post immunosuppression was -1.25mm (95% CI, -4.74 to 2.26mm) in the worse affected eye and -2.75mm (95% CI, -7.52 to 2.92mm) in the post decompression cohort. In the non-white cohort, the change in proptosis in the non-decompression cohort was -1.22mm (95% CI, -5.27 to 2.82 mm) and -1.31mm (95% CI, -4.33 to 1.72 mm) in the white cohort. A significant correlation was observed between change in radiological proptosis in non-decompression cohort with improvement in Gorman scores (rs=0.303, p=0.0483) but not with change in CAS scores (rs=-0.0968, p=0.415).

Conclusion

A reduction in radiological proptosis from baseline was observed after the sole use of medical immunosuppression, which was more in white vs non-white cohort. As expected, a larger reduction was observed in the post decompression cohort.

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Effect of postoperative rebamipide ophthalmic suspension on lacrimal stent intubation outcome for primary acquired nasolacrimal duct obstruction complicated with chronic dacryocystitis

Author: Yohei Sato

Purpose

The outcome of lacrimal stent intubation (LSI) for primary acquired nasolacrimal duct obstruction (PANDO) complicated with chronic dacryocystitis is poor compared to that of dacryocystorhinostomy. The presence of chronic dacryocystitis induces inflammatory damage to the lacrimal mucosa, which can impede the recovery of obstructed mucosa, leading to lower success rates compared to cases without dacryocystitis. Rebamipide is known to possess anti-inflammatory properties and promote restoration of epithelial cells. In this study, we investigated the effect of postoperative rebamipide ophthalmic suspension on the outcome of LSI for the treatment of PANDO complicated with chronic dacryocystitis.

Methods

We enrolled a consecutive series of 77 patients who underwent LSI for the treatment of PANDO complicated with chronic dacryocystitis. Among them, 50 patients received postoperative rebamipide ophthalmic suspension four times per day during the 8-week tube placement term. Logistic regression analysis was performed to assess the influence of patient age, gender, laterality, and administration of rebamipide on the anatomical patency outcome at 12 months postoperatively.

Results

The study population had a mean age of 69 years, with a male-to-female ratio of 1:2.4 and a left-to-right ratio of 1:1.3. The anatomical success rates for patients with and without rebamipide ophthalmic suspension were 80.0% (40/50) and 51.9% (14/27), respectively. Patients who received rebamipide ophthalmic suspension demonstrated a significantly higher success rate compared to those without rebamipide ophthalmic suspension (Odds ratio = 4.15, 95% Confidence Intervals = 1.46-12.52). No adverse events related to the use of the suspension were observed.

Conclusion

The use of rebamipide ophthalmic suspension has the potential to enhance the success rate of recanalization LSI for PANDO complicated with dacryocystitis. The administration of rebamipide ophthalmic suspension appears to facilitate the recovery of the obstructed mucosa’s epithelium.

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