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Medial lacrimal sac excision versus conventional H-shaped lacrimal sac opening in external dacryocystorhinostomy: a comparative cohort study

Author: Suzanna Roohé

Purpose

The external dacryocystorhinostomy (Ex-DCR) is a reliable but surgically challenging procedure to overcome a nasolacrimal duct obstruction (NLDO). The aim of this study is to describe the outcomes of a modified technique of lacrimal sac opening and to compare it with the conventional Ex-DCR.

Methods

This comparative cohort study included adult patients undergoing Ex-DCR for primary acquired NLDO by or under supervision of one surgeon. Group 1 (conventional Ex-DCR including H-shaped incision, anastomosis of the anterior mucosal flap to nasal mucosal flap and resection of the posterior sac flap) was compared with Group 2 (modified Ex-DCR including excision of the medial lacrimal sac and anastomosis of remaining anterior sac flap to nasal mucosal flap). Outcome measures included the success rate (defined as complete symptom relief or patent irrigation after three months), reoperation rate, redo-free survival within five years, and occurrence of postoperative bleeding and postoperative infection.

Results

138 patients were included. The success rates were 94.7% (54/57 cases) for Group 1 and 96.3% (78/81) for Group 2 (p-value = 0.658). The redo-rate was 5.3% (3/75) in Group 1 and 2.5% (2/81) in Group 2 (p = 0.331). Two-year redo-free survival probability estimates were 89.8% for Group 1 and 96.3% for Group 2, respectively. No complications occurred in Group 2, whereas in Group 1, one patient (1.8%) suffered from postoperative bleeding and one (1.8%) from postoperative infection.

Conclusion

This study showed that our modified Ex-DCR technique is equally efficacious compared with the conventional Ex-DCR technique in adult patients with NLDO.

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Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty

Author: Nasser Karimi

Purpose

Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique to prevent postoperative tear trough deformity. Its retraction, limited volume, trans-cutaneous fixation, and complex technique of insertion are the drawbacks. Minced lower eyelid fat graft was introduced to overcome the drawbacks. The aim of this study is to compare the outcomes of pre-periosteal pedicle fat flap vs. minced free fat graft in TCLB.

Methods

Participants with pedicle fat flap from April 2019 to April 2020 and minced free fat graft from May 2020 to May 2021 with at least 6 months follow up were included. Subjective (pain, infra-orbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes as well as satisfaction (visual analogue scale score) at the last follow up and re-operation rates were compared.

Results

There were 142 participants (94% women) with the mean age of 48.4 years (Range: 21-71) and follow up of 8.2 months (Range: 6-36). There were 73 participants in the group A and 69 in the group B with no significant difference in terms of age (p = 0.6), sex (p = 0.7) and follow up (p = 0.3). In addition to TCLB, Group A and B had simultaneous upper eyelid and eyebrow procedures (53 vs 49%, p = 0.2), lateral canthal plication (77 vs 83%, p = 0.4), and pinch skin excision (82 vs 88%, p = 0.3). Group A and B were not significantly different in terms of postoperative numbness (6.8 vs 1.4%, p = 0.21), chemosis (11 vs 10%, p = 1), skin wrinkles (12.3 vs 8.7%, p = 0.59), hyperpigmentation (1.4% in both), bumps (2.7 vs 7.2%, p = 0.2), tear trough deformity (0.0 % in both), satisfaction score (97.7 vs 98.1%, p = 0.4), and re-operation rate (12.3 vs 5.8%, p = 0.25).

Conclusion

The pursued aims of fat redistribution in TCLB seem to be equivalently achievable by either minced fat graft or pedicle fat flap technique.

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HOOK ATROCITIES–‘THE CURVED CURSES’

Author: Asma Khan

Purpose

To report a case series of 21 patients with lid lacerations involving canaliculi, due to injury with various kind of hooks used in daily lives, such as-2 wheeler handle bar hook, cradle hook, blouse hook etc. and to evaluate the surgical outcomes of these repairs with self retaining monocanalicular intubation system.

Methods

This was a retrospective study. All data was collected from hospital records including patients’ demographic details, mode of trauma, associated ocular injuries, time interval between injury and surgical intervention, postoperative complications, and follow up period.
A total of 21 patients ranging from 2-45 years of age were included in the series between a period of March 2019 and March 2022 . All repairs were done with monocanalicular stent placements within 24-48 hours of injury .
The follow up period was up to 6 months . Patency of canaliculus was assessed by syringing.

Results

The mean age of the patients was 17 years, ranging from 2–45 years of age . Out of 21 patients, 14 (66%) were male and 7(33%) were female . The most common type of hook injury was with 2 wheeler handle bar hook. Others were cradle hook, blouse hook,4-wheeler seat belt hook and cement bag metal hook . In most cases ,upper canaliculus was involved. Other associated ocular injuries were- tarsal plate fracture , conjunctival tear, LPS(Levator palpebral superioris ) tear and extraocular muscles injury.
Post operative complications included punctal eversion in 1 case and wound site granuloma in 2 cases.1 patient lost to follow up and in 2 cases stent extrusion was found after 1 month. In 19 patients, lacrimal system was found to be patent.

Conclusion

Canalicular lacerations are the most common injury of lacrimal drainage system because of their exposed position in lids where tarsal plate is deficient.
The monocanalicular stents are easy to insert and remove and yield excellent outcomes if repaired in time.
The hooks that we come across in day to day lives, although small in size, are becoming major culprits for such mishaps but fortunately we can prevent these atrocious consequences with little awareness and alerteness.

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Update on the Long Term Outcomes Following theManagement of Incomplete Punctal Canalization

Author: Pragya Saini

Purpose

To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC).

Methods

Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship’s punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes.

Results

Ninety eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization external membrane variant was seen in 62% (61/98)and internal membrane variant in 38% (37/98). Seventy eight puncta(78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship’s punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean followup of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively.

Conclusion

The long-term outcomes of membranotomyfor IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC.

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Comparison of External vs Endoscopic Dacryocystorhinostomy in Congenital Nasolacrimal Duct Obstruction: A single-center experience

Author: Mohammad AlSemari

Purpose

Most of the congenital nasolacrimal duct obstruction (CNLDO) in children spontaneously resolved during the first year of life in 80-96%. Dacryocystorhinostomy (DCR) in children is reserved for refractory cases to conservative treatment. We compare the outcome of external vs endoscopic DCR in the pediatric age group.

Methods

A retrospective study was done at King Khaled Eye Specialist Hospital, Riyadh, SA. Medical records of all pediatric patients (0-17 years) who underwent external or endoscopic DCR from January 2014 – July 2022 with a minimum follow-up of 12 months were involved.The main outcome measures were patients’ demographics, clinical presentation, surgical success, complications, and resolution of epiphora.

Results

A total of 52 patients with primary CNLDO were included. 58 eyes underwent Dacryocystorhinostomy with stent intubation (27 external vs 31 endoscopic). The success rate of external DCR was (88.9%) while endoscopic DCR was (93.5%), Fluorescein dye disappearance test was used to assess the lacrimal system patency at the last follow-up visit which showed a delay in 5 eyes (8.6%) (3 external vs 2 endoscopic).

Conclusion

Our study demonstrates that both external and endoscopic DCR are effective methods for the treatment of CNLDO in children, with comparable functional and anatomical success rates. However, the choice between these techniques may depend on the surgeon’s preference, the patient’s clinical presentation, and the availability of resources.

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Angiolymphoid hyperplasia with eosinophilia: a case series and literature review

Author: Humoud AlOtaibi

Purpose

Angiolymphoid hyperplasia with eosinophilia is an uncommon chronic inflammatory condition of unknown etiology. Orbital and adnexal involvement findings are variable and often non-specific.

Methods

We report six patients with angiolymphoid hyperplasia of the orbit, their clinical and histopathological characteristics, and a review of previously published literature with this diagnosis between 1980 and 2021.

Results

We report six patients with angiolymphoid hyperplasia of the orbit, their clinical and histopathological characteristics, and a review of previously published literature with this diagnosis between 1980 and 2021.

Conclusion

ALHE has definite histopathologic features but inconclusive radiological studies. The ophthalmologic findings of this entity overlap significantly with other similar variants and may be thought as equivalent lesions.

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Advanced ocular surface squamous cell carcinoma (OSSC): long-term follow-up

Author: Giovanni Cuffaro

Purpose

To analyze the clinical characteristics and long-term follow-up of patients with advanced ocular surface squamous cell carcinoma (OSSC) involving periocular tissues and/or orbit. Primary outcomes were overall survival (OS), disease-free survival (DFS), and overall recurrence rate (RR). Secondary outcomes were a correlation between primary outcomes and tumor location, American Joint Committee on Cancer Classification (AJCC) staging system, histological results, surgical margins, and type of treatment.

Methods

The medical records of patients affected by OSSC involving periocular tissues and/or orbit referring, from 01/2011 to 01/2020, to our tertiary referral center were reviewed. Patients initially received either surgical or topical treatment for their ocular surface disease, followed by subsequent therapies for persistent or recurrent disease. Patients previously medically or surgically treated or with a follow-up period of less than 6 months and or those with missing or incomplete records were excluded.

Results

Thirty-six eyes of 36 patients were included. The mean age was 68.2 years; 18 (50%) patients were males. The mean follow-up was 40 months. The RR was 64%. The OS at 12, 24, 36, and 60 months was respectively 97.1%, 92.7%, 92.7%, and 92.7%. The DFS at 12, 24, 36, and 60 months was respectively 62.9%, 50.8%, 41.6%, and 29.7%. Multicentric disease (p = 0.0039), inferior tarsus localization (p = 0.0428), histological diagnosis of high-risk SSCs (p = 0.0264), positive surgical margins (p = 0.0434), and excisional biopsy (EB) alone (p = 0.0005) were associated with an increased risk of recurrence. A shorter OS was observed in patients who underwent EB alone (p = 0.0049).

Conclusion

OSCC involving periocular tissues and/or orbit is an aggressive disease with a high recurrence rate. Multicentric disease, positive surgical margins, inferior tarsus localization, and surgery without adjuvant therapies are strong predictors of recurrence and are the main factors affecting prognosis.

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The effect of Hughes Procedure on eyelids evaluated with three-dimensional image

Author: Sitong Ju

Purpose

The Hughes procedure is used to repair full-thickness lower eyelid defects with a high functional and aesthetic success rate. This study aimed to evaluate its effect on the eyelid and its laxity using 3D-images.

Methods

Patients who underwent Hughes procedure in the Department of Ophthalmology, University of Cologne, between January 2015 and May 2019 were retrospectively identified. In the healthy and operated eyes of all patients, the lower eyelid was pulled down respectively with a finger and a 15.9-g weighted eyelid hook. Three-dimensional images were acquired with a VECTRA M3 stereophotogrammetry device in the neutral position without a hook, and distracted position with the eyelid hook and finger pulling down. After landmarks were localized, the inter-landmark linear distances of the operated and the healthy eye were measured and compared.

Results

17 patients (17 eyes) were retrospectively identified, primarily female (71%), and basal cell carcinoma was the most common pathology (76%). The mean age of the patients was 74 years (SD 9.01, range 56-86) and the mean follow-up time was 44.65 months (SD 24.16, range 19-106). The height of the temporal palpebral fissure was increased in the operated eye with/without the hook, showing a statistically significant difference compared to the healthy eye (P-value 0.004, 0.015,0.016 and 0.013), and more obvious in patients with over 50% lower eyelid defects (P-value 0.012). The lower eyelid length changes more in the operated eye than in the healthy eye with the hook (P-value 0.013). No significant differences were observed with the finger pulling-down.

Conclusion

Laxity of the lower eyelid increased after Hughes procedure and was more significant on the temporal side and in patients with large eyelid defects. The surgical procedure could be improved accordingly.

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Change in Eyelid Parameters After Uncomplicated Cataract Surgery and Effects of Local Anesthetic Administration Methods

Author: Sibel Ahmet

Purpose

To investigate the effect of local anesthesia method on postoperative eyelid parameters in patients who underwent standard phacoemulsification and intraocular lens implantation surgery.

Methods

This study included 160 eyes of 80 patients. Between December 2022 and March 2023, only one eye of each patient underwent cataract surgery by the same surgeon. Patients with any previous ocular surgery and eyelid pathology excluded. The decision of topical (group 1,n=37) or subtenon anesthesia (group 2,n=43) was randomized. For topical anaesthesia, 0.1 ml of a solution containing 5 cc lidocaine (20 mg/ml) + 1 cc adrenaline (0.25 mg/ml) + 4 cc balanced salt solution (BSS) was applied to the anterior chamber. Two cc of a solution containing lidocaine 20 mg/ml and epinephrine 0.125 mg/ml was injected into the subtenon space. The duration of the surgery was recorded. Preoperative and postoperative 1st month eyelid margin reflex distance-1 (MRD-1) and levator function (LF) measurements were measured by another ophthalmologist.

Results

The mean age was 69.38±8.59 years in group 1(19F/18M) and 65.19±7.53 years in group 2(20F/23M) (p=0.023). In both groups, preoperative MRD-1 and LF were similar in both eyes (p=0.46, 0.69, respectively). In eyes that underwent surgery preoperative MRD-1 was 3.11±0.90 mm and LF was 15.41±2.0 mm in group 1, whereas MRD-1 was 3.56±1.24 mm and LF was 14.91±2.2 mm in group 2 (p=0.06, 0.29, respectively). At the first postoperative month, MRD-1 was 2.81±0.61 mm and LF was 14.78±2.01 mm in group 1 and MRD-1 was 3.0±1.0 mm and LF was 14.56±2.11 mm in group 2 (p=0.32, 0.62, respectively). The mean duration of surgery was 16.1±4.7 min in group 1 and 20±5.9 min in group 2 (p=0.006). There was no correlation between the duration of surgery and MRD-1 and LF values at 1st month postoperatively (each value p>0.05).

Conclusion

The effect of the local anesthesia method in uncomplicated cataract surgery on postoperative MRD-1 and LF could not be demonstrated in this current study. In the light of these results, local anesthetic methods used in standard phacoemulsification surgery do not seem to be associated with eyelid ptosis.

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Intraorbital Steroid Injection for Active Thyroid Ophthalmopathy

Author: Alice Cranston

Purpose

To evaluate the effect of orbital floor steroid injections as a first line treatment of active thyroid ophthalmopathy.

Methods

This retrospective case series includes 19 eyes of 12 patients, all who were treated with orbital floor steroids.
Intraorbital Triamcinolone injections (40mg/ml) were administered by a single injector to all the patients in this study.
Out of the 12 patients, 10 were patients with Graves’ disease, one with hyperthyroidism and one with hypothyroidism.
The clinical activity scores (CAS) and margin reflex distance 1 (MRD1) values were recorded before and after treatment.

Results

All patients received intraorbital steroid injections between 1 and 3 times, with two thirds of patients receiving only one injection.
The mean pre-injection CAS was 3.67 and improved to 1.42 after their final injection, showing a statistically significant mean improvement of CAS of -2.25 (P < 0.001).
There was an improvement in MRD1 in 60% of eyes. Mean pre-injection MRD1 was 4.78 and improved to 3.94 after their final injection, showing a statistically significant mean improvement of 0.84 (2dp) (P=0.0193).
None of the patients in this study had an intraocular pressure rise or displayed any side effects to the intraorbital steroid injections.

Conclusion

Orbital steroid injections can be used as a first line treatment of active thyroid ophthalmopathy. They can improve the clinical activity score and margin reflex distance and can be considered in patients wishing to avoid the effects of systemic steroids.

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Oculoplastic procedures in patients with adenoviral keratoconjunctivitis

Author: Niko Viskari

Purpose

Viral infections, including adenovirus, are known to cause conjunctival scarring and synechiae and acquired lacrimal system obstructions. However, the incidence of such complications is not well-known. This study was done to assess possible oculoplastic complications and need for surgical procedures in patients with adenoviral keratoconjunctivitis.

Methods

This retrospective study includes patients with adenoviral keratoconjunctivitis treated at HUS eye clinic during adenoviral epidemic in winter 2017-2018. Of these 161 patients 90 were female and 71 male, and mean age was 43,94 years (range 0-83 years). 128 patients presented with a bilateral and 33 with a unilateral disease. In viral cell culture both adenovirus serotypes 4 and 8 were found.These patients’ medical records were reviewed to assess possible oculoplastic complications and need for surgical procedures.

Results

Two patients with chronic tearing after adenoviral infection were diagnosed with a canalicular obstruction. One of them was treated with silicone tube intubation. After the removal of the tubing, the patient presented with tearing again but had no interest in further surgical interventions. With the other patient the obstruction was released by lacrimal irrigation only. On the follow up visit one month later the patient remained symptom free.No other oculoplastic complications were diagnosed.

Conclusion

Infections, including adenoviral keratoconjunctivitis, are known to cause conjunctival scarring and synechiae and lacrimal canalicular obstruction. Even in patients with severe inflammation of the anterior segment due to adenoviral keratoconjunctivitis oculoplastic complications requiring surgical interventions seem to be rare.

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The result and complication after Bilateral microscopic extra/intraconal Orbital fat Decompression for Thyroid Eye Disease

Author: Tomoyuki Kashima

Purpose

The fundamental treatment for exophthalmos caused by thyroid eye disease is orbital decompression, which involves resection of orbital fat and bone. We mainly choose orbital fat decompression for these patients. In this study, we investigated complication after bilateral microscopic orbital fat decompression surgery.

Methods

Two hundred and fifteen patients with thyroid eye disease who underwent bilateral orbital fat decompression at our two clinics between January and December 2021 were enrolled. Patient age and sex, postoperative changes in Hertel exophthalmometer measurements, amount of orbital fat removed, and BSV were recorded. Fusion image area (FIA) was defined as the average of the four locations from the primary position at which diplopia was felt, which were measured using the BSV from 130 patients who were available for a 3-month follow-up.

The surgery was performed through a conjunctival incision in the inferior fornix, excising the anterior and extraconal orbital fat, and entering muscle cone and excising the intraconal fat while relaxing it, being careful to avoid nerves and blood vessels. The excised fat was placed in an empty syringe without air and blood and measured.

Results

The patients had a mean age of 40.1±12.8 years. Mean ocular protrusion decreased 3.1mm from 19.8±2.9 mm preoperatively to 16.7±2.5 mm postoperatively. The average amount of fat removed was 3.5±1.5mL. Mean FIA was 44.2° preoperatively and 44.2° (P=0.06), 44.3° (P=0.35) at 1, 3months, respectively, after surgery. At 3 months postoperatively, 3 of 130 patients (2.3%) were developed diplopia in the primary position. None of 215 eyes developed visual field defect.

Conclusion

Bilateral microscopic orbital fat decompression seemed to be safe procedure with rare complication.

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Comparison of post operative habits in eyelid surgery in ophtalmologists, plastic surgeons and dermatologists

Author: Geraldine Chotard

Purpose

Eyelid surgery is shared by oculoplastic surgeons, whether they are ophthalmologists, plastic surgeons or dermatologists. These different specialties have a different approach and are not used to share their habits. The purpose of this study is to compare their practice, the suture threads used in the operating room, the treatments prescribed postoperatively, the use of antibiotics…

Methods

A multiple-choice questionnaire of about twenty questions was sent by email in January 2023 to experienced French surgeons (ophthalmologists, plastic surgeons and dermatologists) specialized in oculoplastic. Questions concerned the nature of the threads used for the skin sutures; the methods used for incision of the skin, the post-operative treatments used and its duration.

Results

We received 46 answers, including 73% of ophthalmologists, 13% of plastic surgeons and 13% of dermatologists. 40% had an activity in private practice and public hospital, 43% were in hospital and 17% only in private. In functional surgeries, 40% used prolene to suture the skin, 35% used silk. In esthetic surgeries, they were 57% to use prolene and only 22% to use silk. 80% used vitamin A oinment as post operative treatment in functional surgeries instead of 60% in esthetic surgeries. The use of dexaméthasone associated to oxytetracycline was more frequent in esthetic than in functional surgeries (45 vs 24%). Use of antibiotic oinment was more frequent in ophtalmologists (78%) than plastic surgeons (33%) or dermatologists(33%).

Conclusion

This observational study clearly shows that there are multiple possible options in terms of postoperative treatment. These differences depend, among other things, on the specialty of the surgeon, but there are significant variations within the same specialty. It is interesting to note that the use of postoperative antibiotic ointments is not systematic and is less frequent in dermatologists and plasticians and the surgeons concerned have not seen more postoperative infection in their patients. Routine use of prophylactic antibiotic agents in primarily closed surgical eyelid incisions does not adhere to international standards and may contribute to antimicrobial resistance. A study published by Hunt et al. in 2022 suggests that post operative infection is not significatively more important in patients receiving no antibiotics. Clinicians should consider withdrawing it from routine practice in suitable patients.

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Complications of facial dermal fillers imaged with 3-D Magnetic Resonance Imaging – A Cohort Study.

Author: Michelle Khan

Purpose

Facial rejuvenation is a rapidly evolving field in aesthetic oculoplastics. Dermal fillers are a popular modality used to restore volume loss and optimize facial proportions. In this retrospective cohort study, we report on the incidence and nature of complications post facial fillers using cutting-edge 3-dimensiomal magnetic resonance imaging (MRI) scanning technology.

Methods

A retrospective cohort study of 50 patients presenting to an aesthetic oculoplastics practice in London, United Kingdom between December 2021 and December 2022. All patients had 3D MRI scanning of the head and neck to quantify and visualize facial fillers upon clinical presentation.

Results

50 patients were included in this retrospective study. 88% of the cohort was female. The mean patient age was 47.5 years. The mean age within males was 38.6 years of age, compared to 48.8 years of age within females (p=0.05). The average total amount of facial filler on presentation, as measured on MRI, was 19.24ml across both subgroups. The average amount of facial filler in men was 10.5ml, compared to 20.45ml in females (p>0.05). The majority of complications were seen in tear trough fillers (72%), while forehead fillers presented the least amount of complications (12%). The most common complaint upon presentation was lower lid swelling (22%), while 16% presented with malar oedema, and 2% experienced a post -filler tyndall affect.

Conclusion

Facial dermal fillers are a common aesthetic tool in facial rejuvenation. This study analyses and describes the differences between males and females in terms of the nature and distribution of potential complications. 3-D MRI imaging is a useful adjunct to the diagnosis and management of dermal filler complications. A volumetric analysis of the 3-D MRI scans is recommended for future analysis of filler complications.

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Is Floppy Eyelid Syndrome a predictor of Intraoperative Floppy Iris Syndrome? A prospective translational study.

Author: thierry ferrete

Purpose

Floppy Iris Syndrome (IFIS) is defined as excessive undulation of the iris during cataract surgery. Floppy Eyelid Syndrome (FES) is defined as excessive eyelid hyperlaxity. Based on our daily experience, we suspected FES to be associated with IFIS. This association was investigated. The aim of this study was to explore whether FES was a predictor of IFIS.

Methods

Hospital, including 452 eyes operated on for cataract (312 patients) by 11 different surgeons between November 2019 and May 2021 and histological analysis from 2 fresh cadavers with Verhoeff histochemical staining to demonstrate the presence of elastin in both eyelid and iris. The primary endpoints were the presence of FES and/or IFIS during surgery

Results

Clinical study: 452 eyes (n=312 patients, 50.9% male) with a mean age of 71.73 years (+/- 11.4) were included. IFIS was diagnosed in 88 (19.5%) patients, of which 20 (4.4%) were grade 1, 34 (7.5%) were grade 2, and 33 (7.3%) were grade 3. FES was diagnosed in 35 (7.7%) patients. PEX was found in 23 (5.1%) patients.
In multivariate analysis, FES (<0.001), pseudoexfoliation (0.017), intracameral dilatation (p<0.004), senior surgeons (0.009) and α1-ARA (<0.001) were associated with IFIS.
Histological study: Verhoeff's stain identified a low elastin contingent in the tarsus of 2-5% in patient 1 and 1% in patient 2, the pathological study did not reveal any elastin in the iris of the patients.

Conclusion

In this study we found a significant association between FES and IFIS as well as between PEX and IFIS.
The prevalence of IFIS varies in the literature from 2% to 31.9% depending on the definition but also on the geographical origin of the studies as well as the type of alpha-blockers used and the proportion of patients on alpha-blockers. A pathophysiological hypothesis linking FES and IFIS is the involvement of elastic fibres, which are elastin in the tarsus for FES and microfibrils in the iris for IFIS. This hypothesis is supported by several pathological models.
In conclusion we found that FES was predictive of IFIS.

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Evaluation of the lower punctum structure with anterior segment oct before tube implantation and after explantation in dacryocystorhinostomy cases with bicanalicular silicone tube implantation

Author: Sibel Yavuz

Purpose

To record the structural changes in the lower punctum by performing spectral domain anterior segment OCT imaging of dacryocystorhinostomy cases who underwent bicanalicular silicone tube implantation.

Methods

Thirty eyes of 30 patients who underwent bicanalicular Crawford silicone tube implantation with dacryocystorhinostomy were included in the study. The lower punctum images of the cases were recorded with spectral domain anterior segment OCT before surgery and at the 1st day, 1st month and 6th month after silicone tube explantation. External punctum width (PW) and canaliculi depth (CD) measurements of the lower punctum were performed.

Results

The average PW and CD measurements of the cases in the preoperative period were 544.90±144.11µm and 451.70±197.45 µm respectively, 818.00±186.83 µm and 735.35±337.15 µm on the first day after silicone tube explantation, 665.95±142.12 µm and 619.30±212.11 µm in the first month and at the sixth month, it was found to be 530.30±150.29 µm and 558.45±254.37 µm. The average PW values were found to be higher on the first day after tube explantation compared to before surgery (p=0.001). There was no significant difference in the mean PW values at the first and sixth months after explantation compared to before surgery (p>0.05). The average CD values were higher on the first day, first month and sixth month after tube explantation compared to before surgery, but they were not statistically significant.

Conclusion

According to OCT imaging data of the lower punctum, silicone tube implantations applied to the canalicular system do not cause structurally significant differences in the lower punctum. The punctum opening gradually decreases slightly in the process after tube explantation. The decrease in PW values is more pronounced, but the decrease in CD values is less. Silicone tube implantation was more effective in maintaining canaliculi depth compared to external punctal width.

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Correction of posttraumatic enophthalmos with bone and cartilage grafts

Author: Dorukcan Akıncıoğlu

Purpose

Posttraumatic increased volume of the bony orbit is one of the most common causes of enophthalmos. My aim is to present the results of posttraumatic enophthalmos/hypophthalmos correction with bone and cartilage grafts and to compare the results in seeing eyes

Methods

The report is an interventional case series of 13 patients (13 eyes) with post-traumatic enophthalmos and hypophthalmos, who underwent reconstruction surgery to correct the enophthalmos and hypophthalmos using bone grafts or cartilage grafts based on the patient choice of donor area. The intraoperative surgical aim was overcorrection of 1mm compared to the other eye. Ophthalmologic examination, Hertel exophthalmometry, clinical photography, three-dimensional computed tomography (3D-CT), and orbital volume calculations using software on 3D-CT (ITK-SNAP, Insight Toolkit-SNAP) were performed preoperatively and postoperatively. Postoperative success was defined as the globe position within 1mm of the other eye. Improvement was defined as the globe position outside the success range of 1mm and failure was defined as no change in the amount of enophthalmos/hypophthalmos..

Results

Success, improvement, and failure of enophthalmos correction were: 76.92% (10/13), 23.08% (3/13), and 0 respectively. Success, improvement, and failure of hypophthalmos correction were: 61.53% (8/13), 30.76% (4/13), and 7.71% (1/13) respectively. Also, orbital volume measured by the ITK-SNAP program calculations was improved significantly compared with the preoperative baseline. The preoperative and postoperative average volumetric change was statistically significant, overcorrecting by an average of 5.29 cm3.

Conclusion

All cases showed satisfactory results for enophthalmos and hypophthalmos correction. But for the long term, bone grafts may be a better choice.

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Advantaged of Monocanalicular intubation over bicanalicular intubation for CNLDO

Author: Saamir Kharma

Purpose

To compare the two techniques in the following aspects:- Ease of insertion of tube.- Length of procedure. – incidence of failure to complete the surgery.-Incidence of nasal complications.- incidence of tube prolapse or loss during course of follow up.-compare ease of tube removal.

Methods

Files of all children with cnldo who underwent intubation duration the last 10 years were studied and data analysed, comparing the two techniques

Results

Monocanalicular intubation has less operating time,easier insertion, less nasal annihilation, less risk of prolapse, easier removal.

Conclusion

Monocanalicular intubation is far more superior in every aspect of comparison, and is Relatively considered the next generation of nldo intubation.And should be aimed at when intubation is indicated.

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Periocular Neurofibromas-Long Term Follow Up

Author: Matthew Gillam

Purpose

Neurofibromas may be isolated or occur as part of the genetic condition neurofibromatosis. A proportion of these can be found around the orbit and can lead to ptosis, globe malposition and amblyopia in children. The literature relating specifically to periocular neurofibromas is mostly single case reports and so we aimed to assess the effect and management of these over time in a series of patients from a single centre.

Methods

The electronic patient record system at Chelsea and Westminster Hospitals NHS Foundation Trust, a tertiary craniofacial centre was searched for patients with the ICD10 diagnostic code Q85.0 representing neurofibromatosis to create a patient database. These records were supplemented by review of the craniofacial MDT patient lists where management of such patients are discussed. Data on patient demographics, symptoms and surgical interventions and follow up time periods were calculated.

Results

31 patients were identified from both sources with a mean age of 32.2 years. 21 (66%) were female. All patients had a diagnosis of neurofibromatosis type 1. The most common documented symptom was a dissatisfaction with facial symmetry in 58% of patients. Over a mean follow up of 6.75 years, patients had an average of 2 surgical procedures with the majority being debulking of neurofibroma tissue (68% of surgeries performed), other surgeries include canthopexies/canthal reformation (14%), ptosis repair (8%) and brow procedures (6%) and sphenoid wing reconstruction (5%). 10 patients (30%) had 2 or more debulk procedures on the same neurofibroma for regrowth.

Conclusion

We believe this is one of the largest case series specifically on periocular neurofibromas. Facial asymmetry is the main concern for patients and they require surgical intervention on average every 3 years, mostly to debulk neurofibroma tissue.

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Clinical & Radiological findings of a cohort of Euthyroid thyroid eye disease patients attending a multi-disciplinary Thyroid Eye Disease (MDTED) service.

Author: Ourania Fydanaki

Purpose

Euthyroid thyroid eye disease (ETED) is a rare entity (5% in most TED case series) and can represent a diagnostic and management challenge.

Methods

Consecutive ETED patients were included. Prospective collection of TSH receptor (TSH-R) status, Clinical activity score (CAS), ETED severity, Gorman score and Graves Orbitopathy Quality of Score (GOQOL) scores and ETED management at each clinic visit. Retrospective collection of radiological parameters, treatment outcomes and TED reactivation.

Results

14 patients (3.1% of all TED patients) with no present or past thyroid clinical or biochemical abnormalities without any antithyroid treatment were included. Mean age 46.8 (31- 63) years, female to male ratio 5:2. 8 patients were never smokers (57.1%), 4 ex- and 2 active smokers. 6 patients were TSH-R positive and 3 presented TPO Ab positive.

On Presentation: 10 patients (71.4%) presented with CAS 0 or 1. One patient presented with bilateral dysthyroid optic neuropathy (DON). Mean presentation GOQOL score 80.24 (VF) and 60.6 (A). 4 (28.5%) had severe proptosis with mean 24.62 mm (range 23-26mm) in the more affected eye. 2 of the patients presented with eyelid retraction (ER) as only symptom.

Radiologically: 6 patients (42.8%) had moderate or severe radiological inflammation on baseline MRI with elevated ADC values > 1000 (mean 1383, range 1000-1710).

Outcome: 4 patients (28.5%) required Intravenous steroids and second line treatment, while 2 required urgent orbital decompression for DON. 2 patients had local eyelid steroid injection for lid retraction. 7 (50%) did not require TED specific treatment. None had TED reactivation on follow up.

Conclusion

Our incidence of ETED patients requiring systemic immunosuppression (28.5% vs 33.3%) and DON (14.3 vs 19.1%) was not dissimilar compared to our overall TED cohort. A TSH R titre, radiological and endocrine input may help confirm the ETED diagnosis but vigilance essential to exclude other causes of myositis and need for timely disease modifying treatment.

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Ocular and Orbital Manifestations in VEXAS Syndrome

Author: Muhammad Abumanhal

Purpose

Background VEXAS (V- vacuoles, E- E1 enzyme, X- X-linked, A- autoinflammatory, S- somatic) is an adult onset hematoinflammatory disease, resulting from somatic mutation of the E1 ubiquitin conjugating enzyme encoded by the UBA1 gene, and it primarily affects older males. It is frequently accompanied by myelodysplastic syndrome. Systemic inflammatory involvement includes alveolitis and pulmonary infiltrates, recurrent fever, ear and nose relapsing chondritis and skin lesions
Purpose to describe the ocular and orbital manifestations of VEXAS patients in a case series in our medical center

Methods

A retrospective chart review was performed for all patients who were diagnosed with VEXAS syndrome in a tertiary medical center over two years.

Results

Eight patients were identified with VEXAS syndrome. In six patients, the diagnosis was confirmed by genomic sequencing. Two patients, were identified from a database based on their phenotype. All patients were males. The mean age at diagnosis was 78.7 years ± 5.3 years. Two patients (25%) were firstly presented with ocular symptoms. Seven patients (87.5%) had history of MDS. Systemic inflammation manifestations include: skin rash (n=5), recurrent fevers (n=2), relapsing polychondritis (n=2), pleuritis and pleural effusion (n=2), poly arthritis nodosa- PAN (n=1) and thrombophlebitis (n=1).
Seven (87%) patients were presented with periorbital edema. Three patients (37.5%) showed orbital inflammation. Dacryoadenitis was observed in two patients (25%), and extraocular muscle (EOM) myositis was detected in two patients (25%). Four patients (50%) demonstrated ocular inflammation such as: episcleritis, scleritis and anterior uveitis.

Conclusion

ocular and orbital manifestations in VEXAS including orbital inflammation, dacryoadenitis, myositis, uveitis, scleritis, episcleritis and periorbital edema. We suppose that in old male patients, with history of hematological disorder, presenting with ocular symptom, VEXAS investigation should be taken into consideration.

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Evaluation of intraocular inflammation with aqueous flare meter in Graves’ ophthalmopathy and its relationship with ophthalmopathy severity

Author: Husna Topcu

Purpose

To examine aqueous flare in Graves’ ophthalmopathy (GO) and investigate the relationship between aqueous flare and disease severity and clinical activity score (CAS).

Methods

Eighty eyes of 40 cases (29 females,11 males) with GO were included in the study. Cases were divided into two groups based on the severity of GO; mild (group 1, n=26) and moderate-to-severe (group 2, n=14). The laser flare meter (FC-700, Kowa Co. Ltd, Tokyo, Japan) was used to measure flare of aqueous humor. Laser flare meter and clinical evaluation were performed at the same visit. Ocular findings, thyroid hormone and antibody levels of each patient were also recorded.

Results

The mean age of cases was 46.8±11.7 years in group 1 and 44.5±12.5 years in group 2 (p=0.56). The mean CAS was 0.8±0.6 in group 1 and 3.0±1.3 in group 2 (p0.05). The mean Anti-TPO level was higher in group 2 (p=0.006). Restricted eye movements were found in 6 cases in group 1 and 9 cases in group 2 (p=0.041). Diplopia was found in 2 cases in group 1 and 6 cases in group 2 (p=0.008). Thyroid hormone levels were found to be dysregulated in 13 cases in group 1 and 11 cases in group 2 (p=0.10). There was no correlation between aqueous flare value and CAS, Hertel exophthalmometry, IOP, thyroid hormone and antibody levels (each p-value>0.05).

Conclusion

Graves’ ophthalmopathy is a clinical entity characterized by different signs of periocular inflammation depending on the severity of the disease. Normal flare values observed in mild and moderate to severe GO may be evidence that intraocular inflammation is not increased in these patients. This suggests that the damage to the blood-aqueous barrier in these cases is not great enough to increase intraocular inflammation.

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The portrayal of periocular ageing changes in renaissance art, a comparison of Northern and Southern schools

Author: Oshin Bansal

Purpose

The 15th and 16th centuries in Europe were marked by a resurgence of focus on the arts and humanities and hearkened back to ancient cultures with new allusions and influences. This period was called the Renaissance, and while the Renaissance is often thought of as an Italian phenomenon, the entirety of Europe experienced a parallel shift marked by varying characteristics. In comparison, Italy’s and Northern Europe’s Renaissances differ in their approach to the newly burgeoning sense of representation in the art world. Despite the shared interest in classical cultures of antiquity, the Northern Renaissance differed from the Italian Renaissance in subject matter and formal interests. While the Italian Renaissance focused on idealized subject matter and subjects that veered away from classic religious concepts, the Northern Renaissance explored altarpieces and realistic daily portraits of everyday life. Italian Renaissance artists focused on the science of perspective and anatomy while Northern Renaissance artists focused on brushwork and the development of printmaking.
We studied the periocular ageing changes using standard published grading systems to understand which school of art had a more ideal view of facial ageing.

Methods

Its a cohort study conducted at a eye institute in collaboration with an art historians. 10 paintings of each school of art were studied and graded for tear trough – eyelid bag complex (ABL classification). The two schools of art were compared.

Results

Tear trough scores (p=0.0159), Bulging scores (p=0.022) and Lid laxity scores (p=0.05029) showed higher values and therefore more realistic ageing changes in the Northern European renaissance paintings compared to Italian paintings.

Conclusion

The Italian school of art had a more idealised and less realistic approach compared to Northern European school during the renaissance period which is proved by the scientific and more anatomically accurate periocular ageing changes noted in Northern European art.

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The addition of a conjunctival flap to a posterior lamella auricular cartilage graft: a technique to avoid corneal complications.

Author: Constanza Barrancos

Purpose

To present the benefits of adding a conjunctival flap when correcting lower eyelid retraction by means of an auricular cartilage graft.

Methods

An auricular cartilage graft was obtained from either the concha or the scaphoid fossa. When preparing the recipient bed, the conjunctival incision was made 2-3 mm below the lower edge of the lower palpebral tarsus, thus obtaining a conjunctival flap arising from the lower edge of the tarsus. The cartilage graft was placed in the lower eyelid. The lower edge of the graft was sutured to the retractors and the conjunctiva with absorbable sutures. The upper edge was sutured to the lower tarsus so that the conjunctival flap covered the upper portion of the graft.

Results

22 patients underwent the surgical technique. No corneal complications were observed in the early or late postoperative period. No donor site complications were found.

Conclusion

A conjunctival flap overlying the upper portion of a lower eyelid auricular cartilage graft provides protection against corneal postoperative complications until the graft is epithelialized.

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Assessment of the reported outcomes and impact on the quality of life of patients undergoing a Lester Jones tube

Author: Emma Samia-Aly

Purpose

To assess the subjective impact Lester Jones tube (LJT) surgery has on patients’ quality of life and symptoms.

Methods

A prospective questionnaire-based study was undertaken involving all patients who underwent a LJT in the last year at Moorfields Eye Hospital. We assessed the severity of epiphora using the Munk score pre-operatively and at three to six months postoperatively. The Lac-Q questionnaire was also used pre-operatively and post-operatively, with the ‘medical impact score’ giving further evaluation of epiphora and the “social impact score’ exploring quality of life. The Glasgow Benefit Inventory (GBI) score ranging from -100, maximal detrimental, to +100, maximal benefit, was used to post-operatively to assess the impact surgery had on quality of life.

Results

In total 22 patients underwent Lester Jones tube surgery in the last year. The Munk score improved from an average of 4.3 (epiphora that requires dabbing ten or more times a day to constant dabbing) to 2.7 post operatively (epiphora requiring dabbing two to four times to a maximum of ten times). The Lac-Q social average score went from 2.9 (out of a total score of 5) pre-operatively to 3.2 post-operatively which seemed to suggest the surgery had not improved their quality of life, despite a statistically significant improvement in symptoms based on the Lac-Q medical score (p=0.064). The overall GBI however was +15.6 which would suggest an improvement in the quality of life of patients following surgery.

Conclusion

Patients derived a significant improvement in epiphora following LJT surgery, however had limited change in their quality of life according to the LAC-Q social impact score compared to the improvement noted on the GBI score. We plan to repeat the questionnaires a year post-operatively to ascertain the longer term impact.

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Botox in management of mild ptosis and orbicularis hypertrophy

Author: Bassem Morshed

Purpose

Mild eyelid margin asymmetry makes many cases seek any sort of treatment. In many cases, surgical intervention might not be the best option and in other cases patients may try to look for an alternative solution other than surgery. Another frequent complaint is the puffiness found just beneath the lash line in the lower eyelids along with the narrowing of the palpebral fissure during laughing or smiling due to orbicularis hypertrophy.
Botulinum toxin injection is a useful tool in correction of both cases.

Methods

A case series of 6 cases was organized to illustrate the use of botulinum toxin for the correction of very mild degree of ptosis. Another case series of 7 cases was organized to illustrate the use of botulinum toxin for the correction of orbicularis hypertrophy.
In the first case series, injection of three units at three sites along the eyelid at the pre-tarsal orbicularis was done.
In the second case series, injection of three units in the lower eyelid at three sites along with one to two units in the upper eyelid according to the case.
Imaging pre and post injections were taken to asses the impact of the procedure.

Results

In the first case series, 4 out of the 6 cases showed a good response from the first session. 2 cases had to be re-injected after two weeks to show a satisfactory result.
In the second case series, 3 out of 7 cases showed a good response from the first session. 4 cases had to be re-injected after 2 weeks to show a satisfactory result.
In all cases there were no adverse effects to the procedure except some tearing in 2 cases in the second case series.
Results lasted for an average duration of 12 to 18 months.
All cases were documented with photos.

Conclusion

Botulinum toxin is a useful relatively safe tool in aesthetic correction of very mild asymmetrical eyelid margins as well as orbicularis hypertrophy.

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Determining the degree of perceptible static eyelid asymmetry and effect of face inversion: a cross-sectional pilot study

Author: Ziyaad Sultan

Purpose

This study aimed to determine the degree of static eyelid asymmetry required to be perceptible and whether this is affected by image inversion.

Methods

To test asymmetry perception, images of three volunteers were digitally manipulated to have varying degrees of eyelid asymmetry (0.5 mm, 1 mm, and 1.5 mm) of three different types (upper lid ptosis, upper lid retraction, and lower lid retraction). Laypersons stated whether the images were symmetrical or asymmetrical. A separate inversion survey, completed by clinicians, consisted of symmetrical images and 1 mm asymmetrical images, with half being inverted.

Results

The eyelid asymmetries upper lid ptosis, upper lid retraction and lower lid retraction are detectable to most laypeople at 1 mm of severity (68.3%, 63.3%, 53.3%, respectively), unlike at 0.5 mm of severity (25.9%, 13.0%, 20.4%, respectively). In the inversion survey, a significant drop of 19.5% (p=0.00000004) was seen between correctly identified asymmetrical faces and inverted asymmetrical faces (79.8% and 59.3%, respectively).

Conclusion

This study provides research to counsel patients with varying degrees of eyelid asymmetry. Image inversion decreases a clinician’s ability to detect a 1 mm asymmetry, indicating an impaired asymmetry perception in the intraoperative view.

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Lacrimal Obstruction in Craniosynostosis: Anatomical and Genetic Risk Factors

Author: Daphna Landau

Purpose

Craniosynostosis can cause oculofacial issues like strabismus, refractive errors, shallow orbits, proptosis, lid abnormalities, and papilledema. It may also impact the lacrimal drainage system due to orbital and nasal anatomical abnormalities. Our study aimed to determine if patients with craniosynostosis have higher rates of nasolacrimal duct obstruction (NLDO) and identify potential associated anatomical and syndromic/genetic risk factors.

Methods

A retrospective review was conducted for craniosynostosis patients treated at CHOP’s Divisions of Ophthalmology and Plastic and Reconstructive Surgery from 2009-2020. Variables examined were suture type, number, genetic variants, and syndromes. The main outcomes assessed were NLDO rate and associations with anatomy and genetics.

Results

767 patients were included, 465 (60.6%) males, mean age 2.8±3.8 years, median follow-up length 25.2 months. 485 patients (63.2%) had no known genetic or syndromic association; 631 patients (82.3%) had one major suture involved, while 128 (17%) had involvement of 2 to 4 major sutures; 429 (55.9%) underwent craniofacial surgical intervention.
Out of the 767 patients, 51 (6.6%) were diagnosed with NLDO. This was more prevalent in the genetic/syndromic group (12.1% vs. 3.5%, p<0.001), with the highest prevalence in Apert (5/13, 38.5%) and the lowest in Muenke syndrome (1/15, 6.3%). When considering genes, NLDO was most prevalent with variations in EFNB1, FGFR2, FGFR3, and TWIST1 (p<0.001). When examining the sutures involved, NLDO was more common when the coronal suture was affected (p=0.001), and less frequent in the sagittal group (p=0.02). There was no association observed between NLDO and other sutures or the number of sutures involved.

Conclusion

NLDO is more common in patients with craniosynostosis, especially those with involvement of the coronal suture, compared to the general population. It is also more prevalent in patients with syndromic craniosynostosis. Therefore, it is recommended to conduct ophthalmic evaluations for all craniosynostosis patients and carefully assess any symptoms of tearing.

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A Closer Look at Periocular Necrotizing Fasciitis: A review of four cases.

Author: David Oliver-Gutierrez

Purpose

The objective of this study is to provide a comprehensive visual understanding of four cases of periocular necrotizing fasciitis (NF) through the use of high-resolution images.

Methods

This study focuses on necrotizing fasciitis (NF), a severe infection that rapidly affects the fascia and subcutaneous tissue, resulting in skin necrosis. While periocular involvement is uncommon, the infection typically starts as cellulitis and progresses swiftly to blisters and necrosis. The primary prognostic factor is rapid and aggressive debridement. The study conducted a clinical and photographic follow-up of cases over the past two years.

Results

We present four cases involving three women and one man, all averaging 65 years of age with no relevant prior medical history. One case was secondary to sinusitis, another to a skin wound, and the remaining two were idiopathic. Three cases required debridement within the first few days, with two of them needing a second debridement after 4 and 16 days. One patient showed good progression with antibiotics, not requiring debridement until after two weeks. Only one case exhibited crepitus and air in imaging. In three cases, S. Pyogenes was isolated, one also showed S. Aureus, while the last case yielded mixed anaerobic flora. Outcomes varied, from minimal aesthetic sequelae, to visual acuity of Counting Fingers at 1 meter due to corneal haze from lagophthalmos, necessitating reconstructive surgery.

Conclusion

Periocular NF is a very rare entity. Its suspicion should be high in cases exhibiting edema and induration beyond the erythematous zone, crepitus or air in imaging, or necrotic blisters/eschar. Early recognition, coupled with aggressive debridement and appropriate intravenous antibiotic therapy, is the most important prognostic factor. Nevertheless, even with proper treatment, aesthetic sequelae are common, and serious complications including vision loss or even death from septic shock may occur.

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The anatomical challenges of using the rongeur on the frontal process of the maxilla in endoscopic dacryocystorhinostomy.

Author: Hannah Beck

Purpose

A critical step in dacryocystorhinostomy (DCR) is creating an osteotomy in the frontal process of the maxilla (FPM) and lacrimal bones. Inadequate bone removal is a major cause of DCR failure. In endoscopic surgery it may result from challenges in using a rongeur on the frontal process of the maxilla. Understanding the endonasal angulation and thickness of the FPM will help to optimise endoscopic techniques and instrumentation.

Methods

CT volumes were obtained from patients at a single centre. For each, the FPM was digitally segmented and modelled in 3D space. A line vector was drawn from a point at the level of the nostril in the mid-sagittal plane and passed iteratively through every voxel of the FPM model to simulate endoscopic surgery. The thickness of the FPM was calculated for each vector. Each vector creates an angle (α) with the surface of the bone it enters and an angle (β) with the surface it exits. These, along with the absolute difference (Δ) between α and β were calculated for each vector. Optimal rongeur efficiency will occur when α and β approach the rongeur’s jaw angle (e.g. 90º or 130º), and when Δ approaches 0º.

Results

Scans in 94 patients were analysed (mean age of 55±23 years; 59% male). Mean bone thickness was 7.1±2.5mm; average maximum thickness was 11.5±3.7mm, with thicknesses up to 20.8mm encountered. The posterosuperior FPM was thicker than all other regions (p=0.002). The average Δ of the anterosuperior bone was significantly further from 0º than all other regions (25.0 vs 21.5º; p = 0.001). Average α and β were 34.5±12º and 36.2±12º, respectively, with no significant difference between regions.

Conclusion

The thickness and angulation of the FPM makes complete bony removal challenging during unpowered endo-DCR, and significantly more so superiorly. The typical bite width of existing rongeurs means that in 12% of patients, over 1/3 of the FPM bone cannot be removed. These findings may explain why the bony ostium is sometimes inadequate in endoscopic DCR and will help refine both surgical technique and the development of better instrumentation.

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Risk factors for bleeding and perioperative bleeding complications in oculoplastic surgery – a prospective pilot study

Author: Nike Annika Christensen

Purpose

Guidelines for managing patients taking antiplatelet agents (AP) or anticoagulants (AC) in oculoplastic surgery are lacking. We evaluated risk factors for bleeding complications and tested a standardized bleeding risk assessment in extraocular surgery.

Methods

In this prospective study, a standardized questionnaire (SQ) was used to obtain the patient’s bleeding history. The role of AP and AC, herbal supplements, pre-existing conditions, blood pressure, surgery type, use of bone wax or nasal packing, primary and revision surgery, anesthesia type, surgery duration and postoperative pain medication were examined. A scoring system was used to quantify bleeding severity.

Results

324 patients (18 to 92 years) were included between 2018 and 2020. 252 patients underwent eyelid, 55 orbital, and 17 nasolacrimal surgery. 87 patients were taking AP, AC and/or herbal supplements. 35 patients had severe bleeding complications, and four patients required revision surgery. None experienced permanent damage.
Bleeding complications were associated with a higher SQ score (p = .044), patients with eyelid surgery taking ASA (p = .038), diabetes mellitus (p = .016), renal diseases (p = .044), nasal packing (p = .036), general anesthesia (p = .001), and an increased duration of surgery (p = .007). Local anesthesia, AC and systolic hypertension were not significantly associated with an increased bleeding risk.

Conclusion

Surgeons should be aware of the risk of larger hematomas after eyelid operations in patients taking ASA. The SQ is useful in assessing the bleeding risk of oculoplastic patients. Based on these methods multicenter studies can be conducted to define guidelines.

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The VEXAS syndrome- a new disease entity causing orbital inflammation

Author: Peter Kristian Rasmussen

Purpose

VEXAS (Vacuoles, E1 enzyme, X-Linked, Autoinflammatory, Somatic) syndrome is a newly recognized multisystem autoinflammatory disease.

Methods

Case presentation of the first Danish VEXAS patient with severe orbital inflammation.

Results

A 76-year-old male present with a history of reduced kidney function, leucopenia, and recent C-reactive protein (CPR) increase in combination with thrombophlebitis. He presented with left peri-ocular swelling and worsening of a pre-existing ipsilateral facial nerve palsy. Initially he responded well to treatment with prednisolone and antihistamine.Two months later he developed anemia in addition to his leucopenia and recurrence of his thrombophlebitis. Myelodysplastic syndrome (MDS) was ruled out and he was diagnosed with Clonal cytopenia of undetermined significance (CCUS).Seven months following initial presentation he presented with severe pre- and post-septal cellulitis with cystoid macula edema, hot disc and vitritis. CRP elevation, anemia and leucopenia were still present. The response to intravenous antibiotics was limited. Orbital biopsy showed chronic inflammation. There was a prompt response to systemic prednisolone, and an underlying rheumatologic or paraneoplastic disease was suspected. A PET-CT showed no signs of cancer. Right-sided pleural effusion and discrete pericardial effusion was found. Rheumatologists suspected VEXAS syndrome and chromosomal sanger sequencing confirmed the diagnosis.

Conclusion

VEXAS syndrome is a new multisystem autoinflammatory disease that may present with orbital cellulitis. The disease is caused by somatic mutations of the UBA1 gene in the blood cells precursers creating severe systemic inflammation and a spectrum of hematological problems including risk of MDS.

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VACTREL associations (VACTRELA) with right congenital ptosis and bilateral corneal anesthesia (CA); A case report and review of the literature.

Author: Fadi F Hassanin

Purpose

To present a rare case of none healing corneal epithelial defect (CED) after congenital ptosis repair in a child with VACTRELA.

Methods

A literature review was done through the web to find and review all the reported cases of VACTRELA with ophthalmic manifestations.

Results

This is the first case of unilateral congenital ptosis and bilateral (CA) in a patient with VACTRELA.

Conclusion

VACTREL association involves the co-occurrence of a group of congenital malformations including vertebral anomalies (V), anal atresia (A), esophageal atresia, and, or tracheoesophageal fistula (TE), renal (R), cardiovascular (C) and limb (L) anomalies or defects.
Case presentation: A 2-year-old girl was diagnosed with a non-healing CED four weeks after a frontalis sling procedure in her right eye and bilateral CA. Amniotic membrane (AMT) grafted over the CED combined with frontalis sling release and small temporary lateral tarsorrhaphy. Complete healing is achieved by 6 weeks of follow-up.
Discussion: It reported that VACTERL patients have eye defects; The ophthalmic findings include ptosis, myopia, amblyopia, congenital CA, and lacrimal system abnormalities, and none of them reported co-occurrence of both congenital ptosis and CA in VACTRELA as in ours. Frontalis suspension is a popular surgical option for cases with severe congenital ptosis and poor levator muscle function. It carries a high risk of exposure keratopathy and lagophthalmos. Patients with poor corneal sensation were at a higher risk. The best treatment option for them is to do frontalis suspension aiming for under-correction and intensive lubrication with a low threshold of sling release. AMT grafting is a well-established treatment for non-healing CED with successful outcomes reported in the literature.
Conclusion: Ophthalmic manifestations, CA, in particular, need to be considered as a part of VACTERL. The corneal sensation should be tested in all children with congenital anomalies. CA can be predicted in children with a lack of distress during eye exams or drops instillation. Under-correction should be considered in all patients with CA and severe ptosis.

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The use of botulinum neurotoxins (BoNT) for the treatment of BoNT induced eyelid ptosis.

Author: Fadi F Hassanin

Purpose

To evaluate the effect of BoNT injection in reversing the eyelid ptosis induced by miss-injected BoNT used for periocular aesthetics.

Methods

1-2 units of BoNT “Botox in our series” is injected at 2 areas, 1-2 mm above the lid margin in a series of 4 patients presented to our service after developing eyelid ptosis post-BoNT injection in the periocular area for aesthetic purposes. All cases presented to us within 2 weeks of injection. and followed for 8 to 10 weeks.

Results

All patients were females. Age ranged from 23-45 years. Have mild to moderate unilateral eyelid ptosis (1-3 mm difference in MRD1 measurements) with good levator function. 2 cases showed improvement in MRD measurements from 1-3 mm with good symmetry, 1 case showed no effect, and 1 case lost follow-up. None of them showed worsening or contra-lateral ptosis. 1 case developed mild overcorrection after 8 weeks of the 1st BoNT injection.

Conclusion

Discussion: BoNT injections for facial rejuvenation and brow lifting are a common practice. The complications are rare and mostly temporary. Eyelid ptosis is one of the complications seen commonly in oculoplastic clinics. Many drops were used to reverse the ptotic effect such as brimonidine, apraclonidine, and oxymetazoline. It has its limitations as needing frequent applications, not being available, not effective at all, or having some side effects. BoNT is used as the main treatment for decades to treat varieties of facial dystonia such as blepharospasm, apraxia of eyelid opening, and hemifacial spasm. Injecting botox at the pre-tarsal orbicularis muscle blocks some of its small protraction effects, leading to a reduction in its antagonizing effect on the weakened levator muscle. Results in improving the eyelid’s height. The late over-correction in our case could be explained by the resolved side effect of the previously injected BoNT which usually takes 4-8 weeks.
Conclusion: Our preliminary report showed that BoNT could be a well-tolerated alternative treatment for BoNT-induced eyelid ptosis with few side effects. However more cases and longer follow up are needed for further evaluation of its efficacy and safety.

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Treatment of periocular cutaneous melanoma in situ with Imiquimod

Author: Brett O’Donnell

Purpose

To report the safety and efficacy of a 12 week course of Imiquimod cream to periocular melanoma in situ.

Methods

Patients underwent pretreatment confocal microscopy and biopsy routinely and a 12 week course of topical Imiquimod, usually with topical fluorometholone steroid eye drops.

Results

16 patients over a three year period were treated: 13 females, 3 males, average age 77 years. Nine patients had recurrent lesions following previous radiotherapy or surgery with the number of previous excisions ranging from 1 to 12. Nine patients were successfully treated with no recurrence clinically or on follow up confocal microscopy. Five patients have ongoing treatment.

Conclusion

There were no serious complications during the 12 week treatments with no post treatment morbidity. Patient reaction to Imiquimod was variable and sometimes required retreatment with more frequent applications to achieve a result. Imiquimod is an alternative treatment for melanoma in situ, especially in cases that have failed other treatments, those with extensive lesions wishing to avoid surgery, and elderly patients.

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Optical Frequency Domain Imaging: A Novel Technique for Diagnosing Giant Cell Arteritis

Author: Laurence Cox

Purpose

Giant cell arteritis (GCA) is a systemic inflammatory disease with a risk of blindness, stroke, and aortic aneurysm; prompt and accurate diagnosis is critical. The gold standard test is temporal artery biopsy (TAB), although its sensitivity is limited by the length of specimen that is available for analysis, and a delay in histological analysis and reporting. This first-in-man ex-vivo study aims to assess the accuracy of optical frequency domain imaging (OFDI) as an alternative diagnostic modality.

Methods

TAB samples of patients with suspected GCA were submerged in 0.9% sodium chloride. An OFDI catheter was passed through the lumen of the specimens to create two-dimensional cross-sectional images before undergoing histological analysis. Histological evidence of GCA was used as the gold standard. The following features were assessed on OFDI and compared with histological assessment: Mean intimal thickness (MIT) and the presence or absence of both giant cells (GCs) and fragmentation of the internal elastic lamina (FIEL).

Results

A total of 29 patients were recruited, 12 of whom had histological evidence of arteritis. MIT in patients with no histological evidence of GCA was 0.13mm (±0.06) on histology vs 0.14mm (±0.07) on OFDI. MIT among arteritis patients was 0.59mm (±0.46) on histology vs 0.21mm (±0.09) on OFDI. MIT as measured by OFDI was significantly higher in those patients with histologically diagnosed arteritis (p = 0.02). For detecting FIEL, OFDI had a sensitivity of 75% and a specificity of 100%. For detecting GCs, OFDI had a sensitivity of 28.6% and a specificity of 77.3%. Applying diagnostic criteria of MIT > 0.20mm, or the presence of GCs or FIEL, the sensitivity of detecting histological arteritis using OFDI was 91.4% and the specificity 94.1%.

Conclusion

OFDI provided rapid imaging of TAB specimens with a diagnostic accuracy approaching that of histological examination. In-vivo, OFDI might permit a longer sample of artery to be examined than is typically available for histology.

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Topical Mitomycin chemiotherapy for conjunctival tumors: 10 years’ experience

Author: Maria Grazia Sammarco

Purpose

To report our experience with topical mitomycin chemotherapy for diffuse and multifocal conjunctival tumors such as primary acquired melanosis (PAM) with atypia, conjunctival melanoma and ocular surface squamous neoplasia (OSSN).

Methods

Chemotherapy with topical mitomycin, 0.02% 4 times daily, was administered 1 month as primary treatment and as adjuvant therapy to excision and cryotherapy.

Results

All patients who received adjuvant therapy after surgery achieved disease resolution without recurrence one year after one cicle of mitomycin C. Side effects were managed with topical anti-inflammatory therapy.

Conclusion

Conjunctival tumors responded to mitomycin 0.02% topical chemotherapy, as primary and adjuvant therapy. Treatment-related complications were acceptable.

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Dysmorphic Tendencies among Diasporic Asians considering Cosmetic Facial Procedures

Author: Cat Burkat, MD FACS Professor

Purpose

Asians, especially diasporic Asians, have unique cultural contexts that warrant closer study. Given the highly context-dependent life experience of Asian individuals residing in Asian countries versus Asian individuals in non-Asian countries, our study includes only responses from individuals identifying themselves as with Asian heritage while living in a predominantly non-Asian society, termed “diasporic Asians”. At present, there is no specific facial dysmorphia validated tool.

Methods

Body Dysmorphic Disorder Questionnaire was adapted to focus on facial dysmorphic tendencies and consisted of three sections: Demographic Survey, Cosmetic Procedure Survey, Dysmorphic Concern Questionnaire. Participants were also asked about their age group, immigrant generation, ethnic identity, country of origin, country where raised, comfort with being known to have undergone a cosmetic facial procedure, and preference on types of procedures. Over 100 survey responses were collected.

Results

Survey data revealed that respondents primarily represented the “18 to 24” or “25-34” (years old) age groups, which reflects these demographics’ high participation in internet-based activity and a specific subset of diasporic Asians who may consider cosmetic procedures. Most respondents were 2nd generation immigrants, did not have a history of cosmetic procedures, and had described being previously criticized for a physical feature. The most desired change to facial characteristics was nose shape/size, eye shape/size, followed by jawline.
Correlation was noted between higher scores on adapted dysmorphia questionnaire and self-reported desires for cosmetic procedures.

Conclusion

This study explores the unique perceptions and motivations underlying the increasing demand for cosmetic facial procedures among diasporic Asians. Additionally, the adapted dysmorphic concern questionnaire specifically focused on facial dysmorphic tendencies holds promise as a valuable tool in facial-type body dysmorphia research. Psychometric validation of the adapted questionnaire is currently underway.

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Oral Propanolol for the Treatment of Ocular Adnexal Hemangioma: a case series

Author: STEFANO MALVINDI

Purpose

Infantile hemangioma is the most common vascular tumor in childhood, it can lead to significant complications when located in the orbital region such as astigmatism, visual axis obstruction, nasolacrimal duct obstruction, ptosis, amblyopia, and strabismus.
The aim of our study is to add evidence to the management, effectiveness and safety of the oral Propanolol therapy.

Methods

Twenty-four children with periocular and orbital IH referred to ‘Santobono’ Pediatric Hospital in Naples between January 2011 and December 2021 were reviewed. The diagnosis of IH was confirmed by radiological tests in all patients
All patients underwent a complete ophthalmic and orbital examination, cardiac evaluation, allergies tests for asthma, blood tests for glycaemia and measurement of blood pressure.
Periocular and orbital lesions were identified by radiological methods of contrast enhancement ultrasound (CEUS) and magnetic resonance imaging (MRI).
All 24 children with IH started treatment with Propanolol with an initial orally dose of 1 mg/kg in two daily doses and after 7 days. If there were no side effects, the dose was increased to 2mg/kg of Propanolol divided in 2 times a day for 1 year.
Therapy was started for 23/24 patients at 5 weeks old 1/24 started at 9 weeks old

Results

The mean age of presentation was 4±1 weeks and 8 were pre-term babies. Out of the 24 patients, 17 were females (71%) and 7 were males (29%). The average follow-up time was 18±3 months.
Clinical manifestations were: eyelid swelling, telangectasie, proptosis and strabismus.
After 12 months in 95% of patients the mass has decreased completely. In 1 case (5%) there was only a 40% of mass reduction after 1 year of treatment so the dose was increased to 3mg/kg until 18 months old and in that case there was a 60% mass reduction so we stopped the treatment.

Conclusion

This study confirms that oral propranolol therapy for ocular adnexal hemangioma is a safe and effective sparing surgery treatment regimen, espacially in those cases a timely treatment is mandatory to avoid serious consequences. Early treatment is recommended for optimal results.

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Outcomes from the London NHS 2-week wait referral pathway for peri-ocular cancer: a case-control analysis of 170 patients.

Author: Periklis Giannakis

Purpose

To investigate the London NHS 2-week wait (2WW) referral pathway for peri-ocular cancers.

Methods

Clinicodemographic data available on our electronic health records were extracted for patients being referred to Moorfields Eye Hospital under the 2WW pathway between July 2019 to May 2022. Fisher exact test was used to determine statistical significance.

Results

From the 306 individuals extracted, 174 (56.86%) were eligible for inclusion. The mean (± standard deviation) age was 60.84 ± 18.04 years, 104 (61.18%) female, 62 (36.47%) White, and 46 (27.06%) as not specified. The majority, 96 (56.47%), lived in inner London, with the second biggest region being Greater London, 51 (30.00%). Most were referred using the Pan-London Suspected Ocular surface/orbital/intraocular/retinoblastoma 113 (66.47%). Many of our patients were referred by GPs, 112 (65.88%). The average time to be first seen at our service from the initial referral was 11.02 days (±5.28). 97 biopsies were performed, representing 57.06% of the referrals yielding a cancer diagnosis in 21 cases (12.35%). The most common cancer diagnosis was basal cell carcinoma representing 8.82% (15 cases) of all biopsy-proven diagnoses. No statistical significance was observed between the grade of referring clinician and referral form type with biopsy-requiring and biopsy-proved cancer diagnosis referral rates.

Conclusion

Simplified and peri-ocular cancer-specific referral forms should be designed and used for the 2WW referral pathway. More education is required for referring clinicians to ensure they are aware of benign eyelid diseases.

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Evolving TED Management: Measuring Horizontal Saccades in TED Patients using a Novel VR Eye-Tracker

Author: Ali Al-Hussaini

Purpose

The objective of this study is to assess the efficacy of Bulbicam (BCAM), a novel virtual reality (VR) eye-tracker, in measuring horizontal saccades in patients with thyroid eye disease (TED). Specifically, we aim to evaluate the accuracy and reliability of BCAM by comparing measurements of horizontal saccades in TED patients and normal individuals with a controlled saccadic protocol.

Methods

A total of 20 participants were included in this study, divided into two groups: 10 normal individuals and 10 patients diagnosed with TED. BCAM was employed to measure horizontal saccades during a standardised eye movement task. Participants were instructed to fixate on a central target and then to controlled stimuli at 10 degrees laterally either side, whilst BCAM recorded their eye movements. Stimuli size was constant and duration was controlled with a degree of randomness to work against patient anticipation. Data obtained by BCAM was subjected to further mathematical analysis to detect differences between the groups.

Results

Preliminary analysis revealed promising results for the use of BCAM in measuring horizontal saccades in both normal individuals and patients with TED. In the normal group, BCAM demonstrated high accuracy and consistency in measuring horizontal saccades with the saccadic protocol. In the TED group, BCAM effectively captured and quantified the deviations in horizontal saccades, providing valuable insights into the oculomotor abnormalities associated with the disease.

Conclusion

The findings suggest that BCAM is a promising method for evaluating horizontal saccades in TED patients. The device exhibited accurate and reliable measurements of horizontal saccades, both in normal individuals and in those with TED, when tested with the same saccadic protocol. The application of BCAM in assessing oculomotor abnormalities in TED may aid in the diagnosis, monitoring, and treatment evaluation of the disease. However, further research with larger sample sizes and comparisons to traditional assessment methods are warranted to establish BCAM’s full potential.

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Fixation of High-Density Porous Polyethylene Implant with Cyanoacrylate Tissue Adhesive in Orbital Floor Fracture. Eighteen years’ Experience.

Author: Hamad Alsulaiman

Purpose

cyanoacrylate tissue adhesives have been in used with success in different branches of the medical field. the purpose of this study to assess the safety and efficacy of fixation of porous polyethylene implant N-butyl cyanoacrylate tissue adhesive.

Methods

A retrospective chart review of all patients with orbital floor fracture who underwent surgical repair with high density porous polyethylene (Medpor®) implant and fixated with N-butyl-2-cyanoacrylate tissue adhesive glue from January 2000 till December 2018.

Results

Thirty-seven patients were included. Median age was 7 months (IQR 0.7-24 months). median duration of follow up was 7 months (IQR 0.7-24 months). Reason for surgery was diplopia in 19 (51.3%) patients, enophthalmos in 22 (59.5%) patients limited ocular motility in 12 (29.7%) patients and combined canalicular laceration with orbital floor fracture in 1 (2.7%) patient. Thirty-five (94.6%) had either partial or complete improvement in their symptoms after the surgery, either subjectively or objectively after the first operation, regardless of the presence of subsequent operations. No patient had implant displacement or implant related infection.

Conclusion

After 18 years’ experience, fixation of high-density porous polyethylene (Medpor®) with N-butyl-2-cyanoacrylate in orbital floor fracture seems to be safe, fast, cheap and effective.

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Orbital metastases in the immunotherapy era: thoughts on the management approach

Author: Joseph Yap

Purpose

Translational research and subsequent clinical uptake of immunotherapy in oncology is rapidly progressing. And although orbital metastases are generally infrequent they may result in significant morbidity such as vision loss and potential mortality from extension intracranially. We present a striking case of complete radiological and clinical resolution following immunotherapy of an extensive renal cell carcinoma metastasis to the orbit and frontal sinus and draw inferences for orbital metastasis management in the era of immunotherapy.

Methods

Case report.

Results

A 61-year-old gentleman with previously excised renal clear cell carcinoma (T1NXMX, Grade 1 disease) presented with left globe inferior displacement and double vision. Examination revealed left sided 3mm exophthalmos and 2mm ptosis, although ocular motility was full and visual acuity was 20/20 bilaterally. Magnetic resonance imaging demonstrated a large osteolytic lesion measuring 2.8×3.4×3.7cm (APxLxT) involving the left frontal calvarium, frontal sinus and superior orbit. Computer tomography revealed a recurrent lesion at the left lateral partial nephrectomy site. A fine needle aspiration biopsy of the orbital lesion confirmed recurrence with metastases. Neoadjuvant treatment with immune checkpoint inhibitors, nivolumab and ipilimumab, was given according to the CheckMate 214 clinical trial protocol with follow up extending from six to twelve weeks.6

Literature search showed instances of complete radiological and histological response, between 6weeks and 6months, of renal cell carcinoma metastases to the lung and choroid. Close observation was undertaken. Visual acuity remained 20/20 bilaterally. Serial neuroimaging demonstrated complete resolution at one year after treatment commencement.

Conclusion

Lessons learned from this specific case, such as time to radiological resolution and frequency of clinic review, will add to an increasing body of literature. Over time this may help form guiding principles for management approaches to orbital metastases in the era of immunotherapy.

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Transconjunctival Botulinum toxin injection as an alternative treatment for structural, functional and reflex tearing

Author: Vladimir Kratky

Purpose

To investigate the use of transconjunctival botulinum toxin for the treatment of symptomatic epiphora due to various etiologies

Methods

In this prospective double-arm interventional study, two groups of patients presenting with epiphora were randomized into receiving a transconjunctival injection of 0.1mL of Botox® (10U) or placebo saline (0.9% NaCl) into the lacrimal gland.
Nineteen patients were recruited for this study (29 eyes; 19 Botox® arm, 10 placebo arm, mean age 70.3, 9 males and 10 females). Patients were evaluated at four different time intervals: before injection (V0), one-week post-injection (V1), after 4 weeks (V2), and 13 weeks post-injection (V3). A Schirmer I test score was measured to assess the tear production (in mm). Validated questionnaires including MUNK and Lac-Q (Lacrimal Symptom Questionnaire) were used to quantify the efficacy of the transconjunctival treatment. Three-way ANOVA, independent t-tests, and Mann-Whitney U test were performed for each outcome on SPSS.

Results

The Schirmer’s I. score (mean 15.05 mm, SD 7.670) in the treatment group at V2 (4 weeks post-injection) was found to be significantly different (P<0.001 three-way ANOVA) compared to the placebo group (mean 21.70, SD 6.111). The mean MUNK score at V2 in the Botox® arm (1.95, stdev 1.026) was not found to be statistically significant compared to the placebo arm (mean 2.30, SD 1.337, P=0.062). Finally, the mean social component of Lac-Q scores at V2 in the Botox® arm (5.32, SD 2.405) was found to be statistically significant after treatment (mean 5.70, SD 2.459 P=0.031).

Conclusion

Our results provide evidence for the efficacy of transconjunctival Botox® for the temporary relief of symptomatic epiphora, as shown by the reduction in their Schirmer I score after four weeks post-injection. Overall, patient satisfaction was greater in the Botox® arm with all patients which is also reflected in post-treatment questionnaires. Botulinum toxin injection should be considered a viable treatment strategy for symptomatic epiphora. Furthermore, repeated injections can be performed with similar efficacy.

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Combination of Triamcinolone/5FU with multiple Z-Plasty: A powerful duo to combat cicatricial ectropion

Author: Andi Pratiwi

Purpose

This case report aimed to demonstrate the promising outcome of multimodal management using mixture of Triamcinolone with 5FU prior to Multiple Z-Plasty procedure to succeed a severe cicatricial ectropion

Methods

A 43 year-old male referred to our hospital with chief complaint of imperfect right eyelid closure for 1 month prior after a car crash injured the same side of his face. The patient was undergoing an emergency eyelid and facial reconstruction with miniplate implantation at the superior orbital rim at the time. Recently he experienced redness and watery in the affecting eye. Physical examination revealed pthisical globe with no light perception. A marked keloid traction of the upper eyelid margin was found, and an extensive hypertrophic scar on lower eyelid extending to cheek area, causing severe cicatricial ectropion, leading to chemosis, corneal scarring and leukoma. The fellow eye was remained normal. A mixture of 5FU and Triamcinolone Acetonide (TA) 10% (3:1) was administered intralesional in both superior and inferior palpebra for 4 cycles with one month interval each. Multiple Z-plasty for lower eyelid was performed as the first step of reconstruction plan.

Results

The reduction of scar height was achieved after 4 cycles of TA and 5FU injection. Surgical correction released the tension along the inferior margin and anterior lamella. Postoperatively, there was no residual lower lid ectropion, with a promising cosmetic result. The patient was followed up for 5 months and planned to correct the upper lid ectropion.

Conclusion

Despite the myriad choices of managements, hypertrophic scar leading to severe ectropion remained challenging to conquer. Combination of TA and 5FU followed by excision has been reported to be more beneficial in terms of reduction in size, vascularity, and pliability and offer the faster and more efficacious result with fewer unwanted side effects. Thus, this technique is a potential alternative to skin grafting in similar cases.

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Orbital compartment syndrome following transcutaneous retrobulbar amphotericin B (TRAMB): Factors affecting occurrence and visual implications

Author: tarjani dave

Purpose

We report the demographic and clinical features and treatment outcomes in patients of rhino-orbital-cerebral-mucormycosis (ROCM) developing orbital compartment syndrome following treatment with TRAMB

Methods

Retrospective study of patients with OCS diagnosed based on clinical signs and symptoms and radiology. The demographic and clinical features of the subset that developed OCS are compared with those that did not. Risk factors for the development of OCS have been elicited.

Results

Forty-six orbits of 44 patients were included. Mean age at presentation was 50.13±12.93 years (median 49). Fifteen (32.6%) developed compartment syndrome (OCS) and 31(67.39%) did not (NOCS). The interval between TRAMB injection and the development of OCS was 4.46±6.68 days (median 3). The mean number of injections preceding the development of OCS was 4.26±2.12 injections (median 5). Forty percent in the OCS group lost vision during treatment as compared to the NOCS group (p=0.005, 95% C.I. 8.84% to 58.24%). A prominent difference along the management of the ROCM in the two groups was the number of orbits that underwent decompression, 7% in OCS and 61% in NOCS respectively (p=0.0006, 95% C.I. 24.9% to 70.1%). On both bivariate and multivariate analysis a sinus debridement without a medial orbital wall decompression had an odds of 22.16 (p=0.004, 95% C.I. 2.57 to 190.99) in favour of developing an OCS. The number needed to harm by not performing a medial wall decompression was 2 (95% C.I. 3.93 to 1.38). For every two patients who are treated with TRAMB but do not undergo a medial orbital wall decompression, 1 patient is at a risk of OCS. The number needed to harm for occurrence of vision loss due to OCS was 2.98 (95% C.I. 8.13 to 1.82). For every 3 patients that develop OCS, 1 patient is at the risk of vision loss.

Conclusion

Any inflammatory changes that occur following repeated injections of TRAMB should be closely watched for the development of OCS. If missed this could lead to vision loss that may be wrongly attributed to the primary disease process. This risk reduces though if a simultaneous medial wall orbital decompression is performed.

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EFFICACY OF INTRALESIONAL BLEOMYCIN IN TREATMENT OF ORBITAL LYMPHANGIOMA

Author: Sindhuja Murugesan

Purpose

To study the effectiveness of intralesional bleomycin injection in orbital lymphangiomas

Methods

16 patients diagnosed with orbital lymphangiomas were included in this prospective study. Patients with hypersensitivity to bleomycin, impaired renal function test, pulmonary problems, pregnant or lactating women, and patients who lost to follow-up were excluded from study. All of them received intralesional bleomycin injection at a dose of 0.5mg/kg body weight (maximum 15mg) along with 2% lignocaine. The volume injected into lesion was proportional to volume of the aspirate from the lesion (preferably 20%) did not exceed 5 ml at a session. Pupillary reactions & visual acuity were checked after couple of hours following injection. Patients who required repeat injections were based on the documentation of serial clinical & radiological response to treatment. Repeat injections were given once in every 4 weeks. Patients were under follow-up upto 1 year after completion of the treatment course. Informed consent was taken from all patients.

Results

Proptosis & lid swelling was common presenting sign. Patients were treated with 2-4 injections of bleomycin. The follow up period ranged from 6-18 months. 11 patients had complete resolution, 3 patients had poor response & required surgical excision, remaining 2 patients had recurrence. In our study immediate postoperative complications were pain at injection site, lid edema, ecchymosis and transient increase in proptosis. No long-term or systemic complications were noted.

Conclusion

Lymphangiomas are benign lymphatic tumors, characterized by proliferation of anomalous dilated lymphatic vessels lined by normal endothelial cells. Ideally surgical excision is the main stay of treatment but due to extensive infiltrative nature of the lesion, complete surgical excision is dangerous due to risk of damage to adjacent vital structures & recurrence is very common in case of incomplete removal of lesion. Hence, intralesional bleomycin therapy is an effective & safe treatment method of orbital lymphangioma without any significant ophthalmic or systemic side effects.

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Assessment of Clinical Features, Treatment and Outcomes in Sebaceous Gland Carcinoma of the Eyelid: A Retrospective Analysis

Author: Upasana Pokal

Purpose

To assess and analyse the clinical features, treatment and outcomes of confirmed sebaceous gland carcinoma (SGC) of the eyelid, with the goal of enhancing our understanding of this condition

Methods

A retrospective study was conducted involving 511 patients with confirmed SGC who underwent management for the disease.

Results

Histopathology confirmed SGC in all 511 patients, with 509 cases presenting unilaterally. Common presenting symptoms included eyelid mass (88.8%), eyelid deformity (26.22%), irritation (22.11%), tearing (21.5%), pain (23%) and redness (16.27%). Regional lymphadenopathy was observed in 15.2% of patients at presentation, and 18.3% demonstrated contiguous spread of the tumor. The primary treatment of choice for SGC was wide excision biopsy (69.5%). Of the cases, 71.37% underwent reconstruction for eyelid defects while 28.63% did not require reconstruction. Among the 460 patients who required secondary treatment, the most common interventions included excision biopsy (5.43%), cryotherapy (2.82%), external beam radiotherapy (3.47%), and exenteration (3.91%). Of the 135 patients with residual tumors after primary treatment, 102 required secondary treatment. A third-line treatment was necessary for 11.31% of cases. Locoregional metastases were found in 51 patients, while 20 had systemic metastases. Unfortunately, 12 patients did not survive due to metastatic progression during follow-up. Treatment outcomes varied, with 36.2% of cases achieving normal eyelid appearance. The most common outcomes included notched eyelids (9.6%), empty socket (15.9%), and ptosis (5.87%).

Conclusion

SGC typically presents as a unilateral eyelid mass and is associated with pagetoid and locoregional spread. Wide excision biopsy with eyelid reconstruction is the primary treatment of choice. Secondary treatment is required for approximately one-third of the cases. Although metastases occur less frequently, they contribute significantly to morbidity in SGC. Timely primary treatment and diligent follow-up are essential for reducing morbidity associated with this condition.

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Use of Donor Sclera to Correct Lower Eyelid Retraction in Thyroid Eye Disease

Author: Annette Morwena Hope

Purpose

The optimal spacer for use in procedures to correct lower eyelid retraction still remains to be identified. Donor sclera has been used in several studies in the past. As part of our ongoing work on procedures for correcting eyelid retraction in thyroid eye disease (TED), we have evaluated outcome of donor sclera in correction of lower eyelid retraction.

Methods

All TED patients operated with the use of donor sclera to correct lower eyelid retraction at the Department of Ophthalmology, Haukeland University Hospital in the period 1999-2023 were identified and included in this retrospective study. Preoperative and postoperative data were obtained from hospital records. Wilcoxon signed-rank test was used to evaluate changes in pre- and postoperative data.

Results

Thirty-six patients (30 females) with a median (range) age of 55 years (29-79) at surgery were included. Operation was performed unilaterally in 29 and bilaterally in seven individuals. Median time from debut of eyelid retraction to surgery was 120 (12-516) months. Median time to follow-up was 15 (1-240) months. A significant (P<0.05) improvement in lower scleral show was observed from a preoperative value of 2 mm (1-6) mm to 0 mm (0-6) after surgery. Median vertical eyelid aperture was 12 (9-22) mm preoperatively and 10 (0-17) mm postoperatively. Median size of the scleral graft used was 10 (6.5-14) mm in height and 20 (15-30) mm in width. Out of 36 patients, 31 (86%) patients were satisfied with the postoperative result. Postoperative complications consisting of graft shrinkage, bacterial infection, cosmetic deformation, double vision, and wound dehiscence were seen in 5 patients.

Conclusion

Use of donor sclera as a spacer is effective and safe in correction of lower eyelid retraction in patients with TED. Further prospective comparative studies on scleral grafts in correction of lower eyelid retraction is needed.

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Thyroid stimulating immunoglobulin levels, but not soluble interleukin-2 receptor levels, predict disease activity and response to treatment with methylprednisolone in patients with Graves’ orbitopathy

Author: Gijsbert Hötte

Purpose

To investigate soluble interleukin-2 receptor (sIL-2R) levels in relation to thyroid function and to explore the potential of sIL-2R and thyroid stimulating immunoglobulin (TSI) as biomarkers for disease characteristics and response to treatment with intravenous methylprednisolone (IVMP) in patients with Graves’ orbitopathy (GO).

Methods

TSH, fT4, TSI and sIL-2R levels were measured in biobank serum samples from 111 GO patients and 25 healthy controls. Clinical characteristics (activity, severity, response to treatment with IVMP) were recorded.

Results

Higher sIL-2R levels were observed in GO patients compared to controls (418 IU/mL vs. 286 IU/mL; p<0.001). sIL-2R correlated with fT4 (r=0.26; p= 0.0072), TSH (r=-0.40; p<0.001) and TSI (r=0.21; p=0.035). sIL-2R and TSI concentrations were higher in patients with active compared to inactive GO (457 IU/mL vs. 387 IU/mL, p=0.012 and 6.80 IU/L vs. 2.53 IU/L, p<0.001, respectively). Both sIL-2R and TSI correlated with total clinical activity score (CAS) (r=0.28, p=0.027 and r=0.33, p<0.001, respectively) and with several individual CAS items. Cut-off levels for predicting active GO were 428 IU/mL for sIl-2R (AUC = 0.64, sensitivity 62%, specificity 62%) and 2.62 IU/L for TSI (AUC = 0.71, sensitivity 69%, specificity 69%). In multivariate testing TSI (CI 2.20 – 52.7; p=0.0051), age (CI 1.05 – 1.16; p<0.001) and disease duration (CI 0.992 – 0.999; p=0.0023) predicted disease activity. sIL-2R levels did not differ between responders and non-responders to intravenous methylprednisolone (IVMP), but TSI levels were significantly lower in responders (3.36 IU/L vs. 14.2 IU/L; p=0.048). TSI cut-off for predicting steroid response was 19.4 IU/L (AUC = 0.69, sensitivity 50%, specificity 91%). In multivariate analysis TSI was the only independent predictor of response to treatment (CI 1.97 – 171.2; p=0.017).

Conclusion

TSI level is an independent predictor of disease activity and response to treatment with IVMP in GO patients. While sIL-2R correlates with disease activity, it is also influenced by thyroid function, making it less useful as a biomarker in GO.

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Autostable un-knotted bicanalicular tubes in dacryocystorhinostomy: does it work ?

Author: Sylvie Vandelanotte

Purpose

To evaluate the efficacy of unknotted autostable bicanalicular tubes (Ritleng plus tubes) in dacryocystorhinostomy. These tubes art autostable because of the 2 separate widenings, meant to be situated behind the opening of the canaliculus communis.

Methods

Retrospective case serie of 500 patients in 2 lacrimal centers.
Review of patiens who underwent a dacryocystorhinostomy (endonasal and external) with placement of bicanalicular autostable unknotted tubes.The tubes were left in place for 6 weeks – 3 months, depending on location of the stenosis and / or revision surgery.
Patients were evaluated at week 1 / week 6 after surgery or at removal of the tubes.
Nasal endoscopy was used to inspect the nasal cavity after the DCR. Mean follow-up period of 10 months. Complications (cheese wiring, keratopathy, early extrusions, granuloma formation) and problems in stent removal were evaluated.

Results

There was no cheese-wiring. In the first 200 patients, the extrusion rate was about 10%, in the next 300 patients this percentage lowered.
Less granuloma formation (5%) on the nasal mucosa comparing to the knotted or clipped tubes (20%).

Conclusion

The unknotted autostable bicanalicular lacrimal tubes (Ritleng plus) are promising in use per- en postoperatively after DCR.
They have a slightly higher spontaneous extrusion rate comparing to knotted or clipped tubes, but there is no risk for cheese-wiring on the lacrimal punctae. Absence of a knot causes less friction during blinking which results in reduced granuloma formation on the nasal mucosa and consequently better results.

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The light switch and the dimmer: Qualitative observations to improve diagnostic lacrimal syringing.

Author: Irene Bermudez-Castellanos

Purpose

To propose additional qualitative “soft” observations during lacrimal syringing (LS) that can help to identify stenosis or nasolacrimal duct (NLD) outflow dysfunction in patients with epiphora and ≤20% fluid reflux and assess the success of dacryocystorhinostomy (DCR).

Methods

Retrospective, observational study in patients undergoing DCR for NLD dysfunction between March 2021-October 2022. Patients with 80+% patency and ≤20% reflux of saline during LS were identified and a comparative analysis of percentage reflux of saline (RFX), initial mucus in reflux (IMR), transit time of saline (TTS), and resistance (RES) during syringing was performed. Validated TEAR score was used. Subjective success was defined as minimum 2-point improvement in the T subscale of TEAR score. Objective success, as a decrease in RFX, RES, TTS and absence of IMR after DCR.

Results

288 eyes of 253 patients underwent DCR of which 51 met the inclusion criteria. Out of these, 43 were excluded due to the change of practice after COVID-19 pandemic: if symptomatically improved, patients were invited to be followed up by video consult.

Full data was available in 8 patients: 6 right eyes (75%) and 6 females (75%). All patients were T4 indoors and outdoors.
Compared to less symptomatic side: pre-operative RFX was 11.88±7% vs 2.50±3.7%. IMR 37.5% vs 12.5%, RES was greater in 66.7%, and TTS was slower in 100%.

Improvement of TEAR score after DCR was a reduction of T=2.62, E=1.63 and A=1.35 (p<0.05) with no significant change in R scores (p=0.10). A reduction in RFX of 11.75±6.74% (p<0.01) was observed with an improvement of TTS (p<0.01) and RES (p<0.05).
Subjective and objective success 100% and 96.87% respectively. From the 43 excluded patients, 28 showed an improvement of T=2.93±1.3 (p<0,05), while in the other 15 patients, subjective success was reported but not classified in TEARS score.

Conclusion

This study is the first to combine “soft” observations during LS to identify NLD dysfunction and reduce complementary tests. These parameters were greater in the more symptomatic side and successfully improved after DCR. A video will be presented.

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Oculo palpebral and facial synkinesis associated with ptosis: From clinical classification to treatment

Author: Narjess BEN RAYANA

Purpose

Oculo palpebral and facial synkinesis are abnormal and involuntary movement of the upper eyelid after an energetic movement of the eye or another part of the face. No consensus is admitted due to their clinical polymorphism. We propose a clinical classification and a treatment plan.

Methods

35 patients presenting a pathological association “ptosis – synkinesis” were collected and operated. Marcus Gunn phenomenon was observed in 27 cases, the Pseudo-Graefe’s sign in 2 cases and was associated to a congenital paralysis of the 3rd nerve and Marin Amat synkinesis was observed in only one case. Finally, it was noted an unusual synkinesis which, to our knowledge, is not described in the literature in 4 cases. According to the importance of the synkinesis and the degree of the ptosis we have classified the patients in 4 groups. The surgery consisted on a simple resection of the levator muscle or on unilateral section-denervation of the levator muscle with one-sided suspension of the eyelid to frontalis muscle or on unilateral section-denervation of the levator in the side of ptosis with a bilateral suspension of the eyelids.

Results

The results were satisfactory when the synkinesis was minim and insufficient when the synkinesis was moderate. A lid lag phenomenon was observed when the associated ptosis was moderate or major and it was the major drawback of the operating technique.

Conclusion

The resection of the levator upper eyelid muscle can be satisfactory for minimal synkinesis when the ptosis is minim or moderate. The unilateral or bilateral section denervation of the levator muscle with suspension of the two eyelids gives a better static and dynamic symmetry with disappearance of the synkinesis but presents the disadvantage to mutilate definitively the healthy side.

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The value of 68Ga-DOTA-TATE PET/CT-imaging in diagnosis of Orbital Meningiomas

Author: Nara Badalova

Purpose

To investigate the value of 68Ga-DOTA-TATE PET/CT imaging in detection and differential diagnosis of orbital meningioma’s.

Methods

Electronic patient files of all patients referred to the Orbital center of Amsterdam UMC between July 5, 2016, and September 6, 2022, were evaluated. Patients with untreated orbital lesions requiring diagnostic evaluation using 68Ga-DOTA-TATE PET/CT imaging (i.e. radio-labeled somatostatin receptor analog, which has been used as PET tracer to evaluate somatostatin expressing meningioma’s) were included. Data regarding imaging, histopathology, clinical follow up was collected for all patients. Patients were divided into three groups according to orbital lesion types: ONSM, secondary orbital meningioma’s and other lesions. Standardized maximum uptake value (SUVmax) of all three groups were determined by two assessors. The Kruskal Wallis test was performed to determine statistical difference in SUVmax between different tumor groups.

Results

Total of 31 untreated orbital lesions were included, consisting of 11 optic nerve sheath meningioma’s (ONSM), 12 secondary orbital meningioma’s and 8 other lesions (i.e. cavernous venous malformations, lymphomas, idiopathic orbital inflammation and sarcoidosis). The sensitivity and specificity of 68Ga-DOTA-TATE PET/CT in detecting optic nerve sheath meningioma’s were 92% and 100%, respectively. For secondary orbital meningioma’s both sensitivity and specificity were 100%. There was a significantly lower 68Ga-DOTA-TATE uptake in the subgroup consisting of lesions other than meningioma’s in comparison with the groups consisting of ONSM and secondary orbital meningioma’s (p < 0.05). Receiver operating characteristic (ROC) curve analysis revealed an optimal SUVmax cutoff value of 3.28 to differentiate ONSMs from the non-meningioma subgroup, corresponding with a sensitivity of 83.3% and a specificity of 100%.

Conclusion

68Ga-DOTA-TATE PET/CT imaging is a valuable imaging technique in diagnosing and differentiating orbital meningioma’s from other lesions with a sensitivity of 83% and specifity of 100%.

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THE IMPACT OF EYEBROW MICROPIGMENTATION TO SOFTEN THE SCAR FROM THE DIRECT BROW LIFT TECHNIQUE

Author: nathalia kassis

Purpose

The purpose of this study was to evaluate patient satisfaction regarding the scar from the direct brow lift, as well as the choice and/or need for eyebrow micropigmentation after surgery.

Methods

The research was developed at the Doctor Nathalia Kassis Clinic. The approach of this research was qualitative and is characterized as applied research. As for the data collection instrument, a semi-structured questionnaire was chosen. The questionnaire was applied to the patients via WhatsApp. All participants signed the informed consent form agreeing to participate.

Results

In this study 13 patients participated. women from 45 to 76 years old who had the direct brow lift more than 3 months ago. Of the 13 patients who were interviewed, all said they were satisfied with the final result of the surgery. Five had undergone micropigmentation for different reasons: to mark the shape of the eyebrow more, one to darken the eyebrow which was too light, one to camouflage the scar from the surgery, and two because they believed the result of the surgery would be improved. The other 8 patients did not undergo micropigmentation yet, with four having no desire to do it and four due to lack of time.The traditional open approach for the brow lift remains a fundamental skill in the arsenal of the oculoplastic surgeon, because it has several positive points such as: presenting a low rate of complications, providing the highest degree of precision in relation to the repositioning of the eyebrow, promoting a satisfactory arching of the eyebrow and a satisfactory post-operative period. The negative point of the surgery would be the scar, which was proven in this study that when necessary can be quietly camouflaged with eyebrow micropigmentation with satisfied patients.

Conclusion

It is extremely important that the surgeon talk and inform the patient before surgery, about the possible scar and the possibility of performing micropigmentation for it to be camouflaged to not cause discomfort to women.

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Comparative Evaluation of Two Medical Treatment Modalities for Membranous Punctal Stenosis: A Prospective Study with Anterior Segment OCT

Author: Volkan Dericioglu

Purpose

Previous histopathological studies have shown the presence of inflammation in the different types of punctal stenosis, especially in the membranous form. This study investigates the early and mid-long-term effects of two medical treatment modalities on membranous punctal stenosis.

Methods

This prospective, comparative study included 23 eyes of 13 patients treated with topical dexamethasone (1 month) and cyclosporin for 9 months (Group-Cyc) and 25 eyes of 14 patients treated with topical steroids (1-month dexamethasone and 3 months loteprednol [Group-Str]). For treatment efficacy, the tear meniscus surface area (TMSA) and the external punctal diameter (EPD) were evaluated with anterior segment optical coherence tomography (AS-OCT) at baseline and months 1, 3, 6, and 9. In addition, the Munk score and fluorescein dye disappear test (FDDT) were evaluated for the subjective and objective complete and partial success rates, respectively.

Results

The mean age of the patients was 54,5 ± 13,5 years, and the female ratio was %66.6 (18/9). No statistical difference was found between the two groups regarding age and sex (p>0.05). The mean baseline TMSA was significantly decreased only at month 6 in Group-Cyc (0.075 ± 0.038 vs. 0.039 ± 0.021mm2, p=0.040) and at month 1 in Group-Str (0.056 ± 0.037 vs. 0.031 ± 0.018mm2, p=0.010). Compared to baseline, the mean EPD was significantly increased at month 9 in Group-Cyc (280.78 ± 85.73 vs. 367.47 ± 92.46µm, p=0.013) and at month 6 and 9 in Group-Str (296.52 ± 68.17 vs. 342.14 ± 75.97µm at month 6, p=0.009; and 333.67 ± 94.92µm at month 9, p=0.018, respectively). There was a significant difference in the subjective and objective partial success rates between Group-Cyc and Group-Str only at month 1 (33.3 vs. 75%, and 50 vs. 81%, respectively).

Conclusion

This study showed that both medical treatment modalities could effectively address membranous punctal stenosis, providing clinicians with viable options for managing this condition. Long-term follow-up studies are warranted to validate these results and optimize treatment strategies.

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Novel Indications & Outcomes of Shave Excision of Posterior Tarsal Mucosa & Oral Mucous Membrane Tarsal Patch Grafting

Author: Raman Malhotra

Purpose

To report the outcomes of Oral Mucous Membrane Tarsal Patch Grafting (OMMTPG) for recalcitrant giant papillae & novel indications: tarsal conjunctival keratinization in Ocular Cicatricial Pemphigoid (OCP) & posterior tarsal scarring in advanced meibomian gland dysfunction (MGD)

Methods

A retrospective review of patients who underwent the procedure in a single centre are included, data collected from electronic hospital records. Outcome measures: corneal surface improvement, shield ulcer resolution, visual acuity (VA), and symptomatic improvement. Indications for intervention: rosacea blepharoconjunctivitis with advanced MGD, OCP with tarsal keratinization as well as more traditional recalcitrant giant papillae in Vernal Keratoconjunctivitis (VKC).

Results

4 eyes of 4 patients who underwent the intervention are included. Patient 1 had rosacea blepharoconjunctivitis with advanced MGD in the right upper lid. Patient 2 had keratinization of the right lower lid tarsal surface due to OCP. Patient 3 had recalcitrant giant papillae of VKC and patient 4 had microphthalmos and giant papillae due to acrylic prosthesis allergy. Patient 3 had shield ulcers with an average of once per eye per year prior to the procedure. Corneal surface improved in all three patients and shield ulcer resolved in the patient with VKC. There were no recurrences of epithelial defects or shield ulcers over a mean follow-up period of 58 (range 2 – 90) months. Patient 4 discontinued steroids and subjectively was asymptomatic for the first time since 15 years. Two patients showed significant improvement of vision: patient 1 – 6/48 to 6/18 & patient 3 – counting fingers VA to 6/7.5, while VA of patient 2 remained unchanged due to corneal scarring from recurrent epithelial defects and background dry age related macular degeneration.

Conclusion

This case series provides a novel insight to the successful use of OMMTPG in tarsal conjunctival keratinization in OCP, posterior tarsal scarring in advanced MGD and giant papillae for improving vision, ocular surface and symptoms.

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Systemic inflammation biomarkers in punctal stenosis

Author: Deniz Kilic

Purpose

Punctal Stenosis (PS) usually develops due to infectious/non-infectious local/systemic inflammatory processes. Various methods are available to determine the exact cause of the disease.In order to determine systemic inflammation, which is among the causes of various eye diseases other than PS, some parameters in routine whole blood analysis, which give rapid results and are low cost, are used. Platelet, Neutrophil/lymphocyte, platelet/lymphocyte, Neutrophil/monocyte levels are among these parameters that have been shown to be high in neovascular glaucoma, diabetic retinopathy and Behçet’s patients. In the literature, there is no study reporting systemic inflammation markers in PS patients. It was aimed to compare other markers of systemic inflammation in PS patients and healthy individuals in this study.

Methods

The medical records of the patients who underwent punctoplasty due to the diagnosis of chronic punctal stenosis in Kayseri City Hospital between January 2019 and May 2023 were retrospectively analyzed and those who underwent whole blood analysis were included in the study. Patients who underwent cataract surgery and routine whole blood analysis at the same time, without any additional disease, were determined as the control group. Total white blood cell count (WBC), neutrophil (NEU), lymphocyte (LYM), monocytes (MO) were recorded from whole blood parameters. In addition, NEU-LYM ratio (NLR), PLT-LYM ratio (PLR), MO-LYM ratio (MLR) were calculated and recorded. Values were compared between the two groups.

Results

While 57 cases were included in the PS group, a total of 48 patients were included in the control group. Age was similar in both groups (p=0.097). In addition, the two groups were found to be similar in terms of WBC, NEU, MO, LYM, PLT, NLR, PLR and MLR values (respectively p=0.121; p=0.131; p=0.268; p=097; p=0.226; p=0.150; p= 0.169; p=0.268).

Conclusion

Systemic inflammation parameters in PS patients were similar to the normal population. It can be considered as a pilot study for other studies that will better explain the place of cystmeic inflammation in the etiopathogenesis of PS.

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Transnasal canthopexy: a revisited personal technique

Author: Narjess BEN RAYANA

Purpose

Transnasal canthopexy is an effective technique to treat telecanthus in Blepharophimosis Ptosis Epicanthus Syndrome (BPES). We propose a personal technique using a bicanaliculo-nasal silicone probe and give a reflexion on this technique, based on our results.

Methods

Three patients with BPES had underwent a transnasal canthopexy using a bicanaliculo-nasal silicone probe to get the non-resorbable suture through the Lamina papyracea.

Results

The results were satisfactory with reduction of intercanthal distance. An acute dacryocystitis was noted in one case.

Conclusion

Transnasal canthopexy is an effective technique to treat telecanthus. Using a bicanalicular probe is an original technique which needs a deep reflexion on anatomy and relation with the lacrymal sac to minimize complications.

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Prognosis of orbit invasion from uveal melanoma: a retrospective monocentric study.

Author: Monica Maria Pagliara

Purpose

Uveal melanoma is the most common primary malignant tumour in adult population. The presence of extraocular extension is associated with an higher risk of metastasis and death. The aim of this study was to identify the prognostic value of extraocular spread and to correlate extraocular spread with clinical, morphological , genetic and histopathological characteristics of the tumor.

Methods

A retrospective study was carried out on patients diagnosed with uveal melanoma and treated by primary enucleation at the Ocular Oncology Unit of Fondazione Policlinico Gemelli between January 2008 and December 2018. Among all patients enucleated those with histopathological diagnosis of extraocular spread were included in the study.
Baseline variables considered were: age, gender, tumor location , largest basal diameter and thickness, tumor cell type, chromosomal aberration(monosomy 3 and chromosome 8q gain). Survival at five years after diagnosis was compared between patients with and without orbit invasion from uveal melanoma.

Results

Of the 320 patients treated with primary enucleation, 32(10%) presented extraocular extension at diagnosis confirmed with histopathological examination after enucleation.
Extraocular spread was correlated with large basal tumour diameter, epithelioid cells type and monosomy 3.

Conclusion

The presence of extraocular spread identifies patients at higher risk of metastatic disease that need personalized follow-up.

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Periorbital necrotizing infections : report of 3 cases and our experience in hyperbaric oxygen therapy

Author: Natasha MAMBOUR

Purpose

Necrotizing infections of the orbital region are rare and prompt appropriate management to reduce life-threatening, visual and aesthetic consequences. The place of hyperbaric oxygen therapy remains unclear. Objectives are to describe cases and report our experience with hyperbaric oxygen therapy.

Methods

We describe 3 cases of orbital necrotizing infections. 2/3 patients were managed with hyperbaric oxygen therapy, including one case of necrotizing fasciitis.

Results

The 2 patients treated with hyperbaric oxygen therapy were both intensive smokers, with uncontrolled ischemic wound bed after 2 weeks of appropriate systemic antimicrobial treatment and iterative surgical debridements. When introduced, hyperbaric oxygen therapy was concomitant with a drastic improvement of bed vascularisation for both cases.

Conclusion

We believe hyperbaric oxygen therapy is a key treatment to control poorly vascularised wound bed, and therefore improve functionnal results and duration of hospitalisation in these patients with compromised microvascularisation. Its use is discussed in the light of literature.  Besides we also discuss the possible interest of vacuum assisted closure (VAC) as an alternative when there is no access to hyperbaric oxygen therapy. VAC has never been used in the periorbital region but could be of increasing interest as infectious diseases are a growing concern all over the world.

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THE RESULTS OF NASAL ENDOSCOPIC CONTROLLED BICANALICULAR SILICONE STENT INTUBATION IN CONGENITAL LACRIMAL SYSTEM STENOSIS

Author: Gregor Hawlina

Purpose

Congenital lacrimal system stenosis is a common condition in children causing excessive tearing or mucoid discharge from the eyes. Spontaneous improvement in most cases (95%) occurs with conservative measures by the age of 1 year. If the problems persist initially probing and syringing is performed and in unsuccessful cases a silicone stent intubation is adviced.
The results of nasal endoscopic controlled bicanalicular silicone stent intubation for congenital lacrimal system stenosis that failed primary probing and syringing from tertiary centre in Slovenia are presented.

Methods

Retrospective analysis of consecutive cases performed at Eye hospital, University Medical Centre Ljubljana, from 1. 11. 2019 till 1. 4. 2023. All procedures were done in general anesthesia by the same surgical team. Bowman probe was used for trepanation followed by bicanalicular nasolacrimal silicone stent (Nunchaku, FCI Ophthalmics) insertion.

Results

A total of 18 children (median age 5.6, range 2.4 – 11.5 years) with congenital lacrimal system stenosis were included. 6 cases were done bilaterally. Mean follow-up time was 20 months (range 1-41). The mean silicone stent removal time was 4.5 months (range 1 – 8). In 4 children silicone stent is still inserted. During the follow-up successful outcome with complete resolution of previous lacrimal symptoms and signs were observed in all 18 children.

Conclusion

Bicanalicular silicone stent intubation using nasal endoscopic visualisation has high success rate for treating congenital lacrimal system stenosis that failed primary nasolacrimal probing and syringing.

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Orbital and facial measurements in microphthalmia and anophthalmia.

Author: Emiel J. Romein

Purpose

Congenital anophthalmia/microphthalmia are developmental eye disorders that result in a variable severity. The absence of a normal-sized eye can cause facial asymmetry. This study uses facial 3d scanning to assess the relationship between orbital size and facial asymmetry. Understanding these connections can guide interventions to improve quality of life.

Methods

In this retrospective study, 3D scans of 19 patients with microphthalmia were used. The scans were obtained using the Artec-Leo scanner, and measurements were taken using GOM inspect software. Various facial landmarks were identified, including the horizontal palpebral fissure (HPF), lower lid (LL), upper eyelid (UL), lid crease (CR), and inferior eyebrow margin (IEM). Ratios between affected and unaffected side were calculated from these measurements. Faces we also rated on degree of overall asymmetry on a scale from 1 to 3. These measurements and ratings were compared to orbital width, orbital height and axial eye length.

Results

No significant correlation was observed between orbital dimensions and objective facial asymmetry features. However, overall asymmetry judgement showed a significant association with orbital width(p=0.038) and HPF(p=0.037). With subjective judgement the shape of the eye and the lid crease seemed to be the most important factor. Axial eye length demonstrated a significant correlation with HPF (p=0.036).

Conclusion

The findings indicate no significant correlation between orbital dimensions and facial asymmetry features. Only axial eye length is showing an objective correlation with facial characteristics. These insights highlight the complex nature of facial asymmetry in microphthalmia patients.

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Eyelid Ptosis after botulinum toxin due to muscle anatomic variation documented by ultrasound images

Author: Janaina Brabo

Purpose

To describe corrugator supercili muscle anatomic variation, that caused four consecutive times eyelid ptosis in a patient after botulinum toxin injection in the glabellar area performed by three differents doctors.

Methods

Patient with the history of three episodes of eyelid ptosis after botulinum toxin injection by other practitioners came to our office after 6 months from the last one, to try one more injection. Botulinum toxin was injected in the head of corrugator supercilii, 1cm above the brow, deep and perpendicular to the skin, avoiding nerve or branches of the superior ophthalmic vein where the toxin could be spread to the elevator palpebral superioris muscle. After 15 days, the patient returned with eyelid ptosis.
An ultrasound exam was performed to find out if there was any anatomic variation that could result in this side effect.

Results

An anatomic variation of the corrugator supercilii was found after ultrasound exam performed. There was a fat pocket between the layers of the muscle connecting deep tissues with the orbital area. This findings probably was the cause of spreading the toxin causing eyelid ptosis in every injections time.

Conclusion

Botulinium toxin injections are commonly used for cosmetic purpose to reduce the appearance of wrinkles an fine lines. However, in some cases, these injections can cause unintended side effects, such as eyelid ptosis due to either inexperienced practitioners or anatomical factors. Nonetheles, the direct involvement of the corrugator superciliai muscle is less common. Ultrasound exam was extremely relevant to find out the reason of the sequential eyelid ptosis in this patient, showing this anatomies variation. It could be useful to help practitioners to avoid complications

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BOTULINUM TOXIN USE FOR THE TREATMENT OF EPIPHORA IN LACRIMAL TRACT OBSTRUCTION

Author: Janaina Brabo

Purpose

To evaluate the effectiveness of using botulinum toxin A as a treatment for epiphora secondary to obstruction of the lacrimal pathway.

Methods

A retrospective analysis of the medical records of patients who underwent botulinum toxin application in the lacrimal gland at HC-FMUSP was carried out.
Patients were treated with 100U and 500U botulinum toxin A (BTA).
Schirmer test was performed with topical anesthesia to measure basal tear secretion .

Results

Twenty-five patients with complaints of epiphora were included in the study, 4 with bilateral complaints. Altogether, we obtained a total of 31 eyes treated with BTA. The mean age was 65.18 years and female prevalence 58.06%.
In the subjective evaluation of the treatment, the application of 2.5U/7.5U of BTA in the lacrimal gland led to a total improvement of symptoms in 26 out of 31 eyes (83.87%) treated; partial improvement occurred in 5 of the 31 eyes (16.12%). In the case of partial improvement, we apply an additional dose of 2.5U/7.5U (totaling 5.0U/15U) in the reassessment of patients. All 5 cases showed complete improvement of symptoms after the second application.
In the Schirmer test, we found an average improvement of 5.19 mm (+/- 8.68 ; p < 0.005) from the moment of application (19.25mm) until the reassessment 14-21 days later (14.06mm). In the Milder test, we found an average improvement of 17.77% (+/- 18.33 ; p < 0.001) between the pre- and post-procedure lacrimal meniscus.
The only complication observed with the application was eyelid ptosis. Ptosis was observed in 7 (22.58%) of the treated eyes, it was transient, approximately 4 weeks, and presented complete resolution after 6 months.

Conclusion

The favorable results with the use of botulinum toxin for the treatment of epiphora, prove to be an alternative for patients who cannot or do not benefit from surgical treatment for obstruction of the lacrimal pathway.

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Histopathological Evaluation and Surgical Outcomes of Conjunctiva-Müller Resection in Ptosis

Author: Volkan Dericioglu

Purpose

This study aims to investigate the histopathological examination of excised tissue from eyelids undergoing conjunctiva-Müller muscle resection (CMMR) and its effects on surgical success.

Methods

This prospective study included 35 eyes of 29 patients with ptosis. Different amounts of CMMR with Putterman forceps were performed on the included eyes based on their response to 5% phenylephrine. The resected specimens were histopathologically examined using hematoxylin-eosin and Verhoeff-Masson trichrome stains. The total resected tissue area (TRTA) and muscle area (TRMA) were measured. The postoperative outcomes of the patients were compared with the muscle area ratios in the specimens.

Results

The mean age of the patients was 45.28 ± 20.78 years, and 15 (51.7%) were female. Twenty-three (65.7%) patients had right-sided dominant eyes. In total, 12 right eyes (34.3%) were operated on, and six patients underwent bilateral surgery. Fourteen eyes (40%) received 10mm, and 21 eyes (60%) received 8mm CMMR. The mean preoperative MRD1 of the eyes was 1.48±1.08 and increased to 1.60±1.29 at week 1 (p=0.50), 2.59±1.36 at week 2 (p<0.001), 2.99±1.23 mm at month 1 (p<0.001), and 2.82±1.13 mm at month 2 (p<0.001) postoperatively. The macroscopic average width of the resected tissue was 7.70±2.13 mm. The mean TRTA was 31.06±12.71 mm2, and TRMA was 11.93±5.85 mm2 upon histopathological examination. The increase in MRD1 at two-month correlated with the MRD1 measurement at preoperative, week 1, week 2, and month 1 MRD1 increase (p0.05). Inflammatory findings were observed in 18 eyes (51.4%) during the histopathological examination, while accessory glands were found in the excised tissue of 14 eyes (40%).

Conclusion

The elevation of MRD1 continued in the following weeks, and the increase rate of MRD1 elevation seems to be associated with the preoperative and follow-up MRD1 measurements. There was no correlation between the resected muscle area and the elevation in the eyelid. Evaluation of patients for the dry eye before surgery is essential due to the potential impact on accessory glands during surgery.

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