Abstract Listings for export (Regular oral)

Resolution rates in congenital nasolacrimal duct obstruction managed with massage or antibiotics compared to observation alone

Author: Brian Mohney

Purpose

Although digital massage and topical antibiotics are commonly recommended for the management of congenital nasolacrimal duct obstruction (CNLDO), there is very little data describing their effect on spontaneous resolution. The purpose of this study was to determine if the use of nasolacrimal massage or topical antibiotics is associated with higher rates of spontaneous resolution compared to observation alone.

Methods

The medical records of all children < 5 years diagnosed with CNLDO over a 10-year period were retrospectively reviewed. Patients were, at the discretion of their care provider, prescribed the administration of digital massage, topical antibiotics, both, or neither (observation).

Results

Among 1958 infants diagnosed with CNLDO, 516 (26.4 %) were merely observed, 506 (25.8 %) were prescribed massage alone, 485 (24. 8%) were prescribed at least one course of topical antibiotics, 397 (20.3 %) were prescribed both topical antibiotics and massage, and 54 (2.8 %) had no documented therapy. Non-surgical resolution, occurring in 1669 (85.2%) during a median follow-up of 3.1 months (range, 1 week to 248 months), was 74.6 % for the merely observed, 89.7 % for those prescribed digital massage, 87.0 % for those prescribed antibiotics, and 90.7 % for those treated with both. This comparison was significant in unadjusted (p<0.001) and multivariable comparisons (p,0.001).

Conclusion

Prescribing topical antibiotics or digital massage for infants with CNLDO, individually or in combination, is associated with a higher rate of resolution than observation alone.

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Lacrimal Sac Fungal Microbiome and Virome in PANDO

Author: Mohammad Javed Ali

Purpose

To assess the fungal microbiome (mycobiome) and the virome of the lacrimal sacs in patients with PANDO .

Methods

A prospective study was performed on 10 consecutive samples of the lacrimal sac contents obtained from patients with PANDO. The samples were obtained from the lacrimal sacs under endoscopy guidance and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform (NOVASEQ 6000). The fungal internal transcript spacer analysis was performed using the PIPITS v2.7 . The viral taxonomy profiling was performed using Kraken2 against the virus database.

Results

The taxonomic hit distribution across the lacrimal sac samples showed rich fungal diversity (4 phyla, 12 classed, 21 families and 26 genera). The major phyla were Ascomycota and Basidiomycota, and the key genera identified were Alternaria, Hyphopichia, Malassezia, Aspergillus and Epicoccum. The virome analysis identified 13 phyla, 15 classes and 27 families. The viruses were commonly from the families Poxviridae, Retroviridae, Siphoviridae and Myoviridae, Poxviridae being the most prevalent family. The BeAn 58058 virus, a member of the Poxviridae family, was the most abundant in all the samples.

Conclusion

The present study is the first whole metagenome sequencing exclusively of the fungal microbiome and virome from the lacrimal sacs of patients with PANDO. The lacrimal sacs harbour diverse fungal and viral communities with distinct ecosystem dynamics. Further studies of their functions and interactions with the hosts would provide valuable insights.

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In Vitro Pharmacology and Phase 1/2 Results of VRDN-001, a Full Antagonist Antibody to IGF-1 Receptor for Thyroid Eye Disease (TED)

Author: Raymond Douglas

Purpose

IGF-1 receptor (IGF-1R) antagonism reduces TED-related inflammation and proptosis. VRDN-001, a high-affinity antagonist antibody to IGF-1R, has distinct pharmacological properties that may enable differentiated dosing and better efficacy than other antibodies. We assessed VRDN-001 in vitro pharmacology compared with teprotumumab and VRDN-001 clinical proof of concept in a phase 1/2 RCT (NCT05176639).

Methods

Inhibition of biotinylated IGF-1 binding to IGF-1R expressing FreeStyle™ 293-F cells was assessed by flow cytometry; inhibition of IGF-1 mediated signaling (phosphorylation of IGF-1R and AKT) was assessed in primary human ocular choroidal fibroblasts. In the phase 1/2 trial, adults with active moderate-to-severe TED and clinical activity score (CAS) ≥4 were randomized to 2 infusions 3 weeks apart of either 3, 10, or 20 mg/kg VRDN-001 or placebo (PBO). Safety and efficacy through 6 weeks were assessed.

Results

In vitro, VRDN-001 provided near-complete inhibition of IGF-1 binding and signaling at ≥50 nM; in contrast, teprotumumab provided only partial inhibition. Phase 1/2 baseline characteristics were similar between VRDN-001 (n=21) and PBO (n=6). All 3 doses of VRDN-001 showed similar reductions in proptosis and clinical activity at 6 weeks. Across all doses, the overall responder rate (% of patients with ≥2-mm reduction in proptosis and ≥2-point reduction in CAS) was 67% (14/21; VRDN-001) vs 20% (1/5; placebo). Mean reduction in CAS was 4.1 (VRDN-001) vs 1.8 (placebo), and CAS decreased to 0 or 1 for 62% (13/21; VRDN-001) vs 20% (1/5; placebo). Complete resolution of diplopia occurred for 54% (7/13; VRDN-001) vs 0% (0/3; PBO). AEs were mostly mild, with no severe or serious AEs.

Conclusion

VRDN-001’s near-complete inhibition of IGF-1 binding and signaling may explain the rapid, marked reductions in proptosis and clinical activity observed in patients with TED in our trial. The potential efficacy and safety of VRDN-001 in TED are being further assessed in the THRIVE phase 3 RCT.

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Comparison of Patients Satisfaction after Botulinum Toxin A Injection in Lacrimal Gland and Conjunctivodacryocystorhinostomy (CDCR) with John’s Tube in a Tertiary Eye Hospital.

Author: Osama AlSheikh

Purpose

Tearing due to upper lacrimal system obstruction could affect the patient’s quality of life and satisfaction, the options available for patient with upper lacrimal obstruction would be either surgical, like Conjunctivodacryocystorhinostomy (CDCR) with a Jones tube placement, or non-surgical like injection of the lacrimal gland with botulinum toxin A. The aim of this study is to investigate and compare both procedures in term of patient’s satisfaction and psycho-social effects.

Methods

A total of 206 charts have been reviewed, 24 patients were included those who underwent CDCR, and 24 patients who underwent Botox injection met the inclusion criteria and were investigated. Data were manually collected and recorded from patients’ electronic medical records. Then, all patients were individually interviewed, study methods and objective were explained and consent was obtained before starting the interview, each interview had 2 sections, first section is composed of Munk score, the five questions related to ‘social and lifestyle impact of tear duct problem’ from the Lac-Q questionnaire, and second section was the GBI questionnaire. Data were entered in a Microsoft Access (Microsoft Corporation, Redmond, WA) database and analysed using Stata 17.0 (Stata Corporation, College Station, Texas).

Results

Patients in the two groups were comparable with regard to demographic and past medical and surgical history. Munk score , Lac-Q questionnaire and the the Glascow Benefit Inventory (GBI) questionnaires showed no statistical significance between cDCR and Botox groups.

Conclusion

To the best of our knowledge, there are no studies have compared patient satisfaction after botulinum toxin injection and CDCR. Lacrimal gland injection with botulinum toxin has several potential advantages over CDCR since it is less invasive and associated with less and milder complications The satisfaction of all patients in both groups showed no statistical difference.

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Use of 2 Octyl Cyanoacrylate skin adhesive (Dermabond®) in pediatric eyelid surgery

Author: Jisang Han

Purpose

To investigate the effect of 2 octyl cyanoacrylate skin adhesive (Dermabond®) to replace fast absorbing surgical gut suture material in pediatric eyelid surgery.

Methods

We retrospectively reviewed the medical records of 10 pediatric patients and 20 eyes who underwent epiblepharon repair using 2 octyl cyanoacrylate skin adhesive. After subciliary incision, 3 to 4 points of buried sutures were done between the tarsal plate and the subcutaneous tissue of the upper skin flap of lower lid or the lower skin flap of upper lid with 6-0 nylon. Temporary skin suture with 6-0 prolene with Connell pattern was done before applying 2 octyl cyanoacrylate skin adhesive. 6-0 prolene was removed after 2 minutes after applying 2 octyl cyanoacrylate skin adhesive. The dry 2 octyl cyanoacrylate skin adhesive was left on until it falls off on its own. No ointment was applied on dry Dermabond®.

Results

The average age was 8.9 years. The average follow-up period after surgery was 3.7 months. In all patients, and there was no complication such as wound dehiscence, contact dermatitis, infection or inflammation after surgery. There were no complaints from the patient regarding scarring. There was no recurrence of epiblepharon after surgery.

Conclusion

Suturing the skin using 2 Octyl Cyanoacrylate skin adhesive is a safe and effective method when performing epiblepharon repair and eliminates the inconvenience of removing suture materials in pediatric patients. This skin closure method can also be used in other eyelid surgeries.

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Meibomian Gland Dysfunction in Mild versus Moderate-Severe Thyroid Eye Disease

Author: Mohsen Kashkouli

Purpose

to compare the meibomian gland (MG) structure (meibography) and function (lipid layer thickness, LLT) in mild versus moderate-severe Thyroid eye disease (TED) using the SBM Sistemi Ocular Surface analyzer.

Methods

This is a prospective observational comparative study evaluating the severity and frequency of MG dysfunction in 40 eyes (> 18 years of age) with mild (19 eyes) and moderate-severe (21 eyes) TED. Right eye was included in bilateral TED. Patients with any evidence of ocular surface disease were excluded. The ocular surface disease index (OSDI), tear secretion test without anesthesia (using Strip Meniscometry Tube), non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), lipid layer thickness (LLT), and meiboscore were assessed. Meiboscore is defined as the MG drop-out in relation to total tarsal plate area and divided into 4 grades: grade 1 (0-25% loss), grade 2 (26-50% loss), grade 3 (51-75% loss), and grade 4 (>75% loss).

Results

Moderate-severe TED group had a higher frequency of smoking (P<0.01) and clinical activity score (P<0.01) and showed a higher tear film osmolality (P=0.02), total meiboscores (P=0.01), and a lower LLT (P=0.03). Lower eyelid meiboscore (P=0.1), OSDI (P=0.1), tear secretion (P=0.2), NITBUT (P=0.09) and, TMH (P=0.75) were not significantly different between the two groups. Smokers were significantly more likely to have higher meiboscores (OR [95%CI], 30.00 [4.71-190.93]; P<0.01). In fact, multivariable logistic regression with conditioning for smoking showed no TED related variable to significantly affect the meiboscore. Directed acyclic graph (DAG) is provided to show confounding variable of smoking which requires conditioning when estimating causal effect of other TED related variables on MG.

Conclusion

While older age, male gender, smoking, and eyes with moderate-severe TED showed a significantly higher meiboscore (greater MG drop-out) in univariate analysis, smoking was the only one remained statistically significant in multivariate analysis to which DAG is provided.

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Comparison of systemic inflammatory markers in patients with different types of lacrimal drainage system obstruction

Author: Husna Topcu

Purpose

To evaluate of systemic markers of inflammation in patients with different types of lacrimal drainage system (LDS) obstruction.

Methods

This retrospective study reviewed patients who were diagnosed with LSD obstruction between 2021-2023. Patients with a canalicular obstruction and “soft stop” during the irrigation test were included in group 1 (n=26), patients with complete obstruction accompanied by “hard stop” during the irrigation test were included in group 2 (n= 20). In group 1, 20 patients underwent probing and bicanalicular intubation following initial punctal dilatation, other 6 patients did not prefer surgery. All patients underwent external dacryocystorhinostomy (DSR) in group 2. From the preoperative blood samples, the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and the mean platelet volume (MPV), which are systemic inflammatory markers, were obtained. The systemic immune inflammation index (SII) based on neutrophil (N), lymphocyte (L) and platelet (P) counts (NxP/L) was assessed as a biomarker.

Results

The mean age of the patients in group 1 52.3±9.4 years (18 females, 8 males); in group 2 it was 47.1±9.0 years (15 females, 5 males). The gender distribution and mean age were similar in both groups (p>0.05). In group 1, neutrophil count was 4.98±2.36 10^3/uL, NLR 2.25±1.19, and PLR 114.7±29.2. These values were 3.91±0.85 10^3/uL, 1.57±0.48, 95.5±27.9 in group 2, respectively (each p value<0.05). Statistically significantly higher SII values were found in Group 1 (p=0.004). In the ROC-Curve analysis, the optimal cut-off values for NLR, PLR and SII were 1.61, 109.59 and 432.51, respectively. The post-operative LDS patency was found to be higher in group 2 (p<0.001).

Conclusion

Systemic inflammatory markers were significantly elevated in patients with canalicular obstruction in our study. Local inflammation at the ocular surface may be the cause of the increased neutrophil count and activity. Alternatively, canalicular obstruction may be associated with low-grade chronic systemic inflammation. Inflammatory markers may be predictive of surgical success.

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Gender- and Age-Related Variations in Periocular Dermatochalasis

Author: Xueting Li

Purpose

The objective of this study was to analyze gender- and age-related characteristics of periocular dermatochalasis patients.

Methods

We recruited 100 patients with periocular dermatochalasis, aged between 35 and 73, for this prospective study. The patients were classified into two groups: the middle-aged group (35-55 years old) and the older group (older than 55). We used a 3D Imaging system, the VECTRA M3, to take standardized three-dimensional facial photos. We measured and analyzed periocular parameters, including palpebral fissure height (PFH), palpebral fissure width (PFW), upper lid fold-palpebral margin distance (FPD), upper palpebral margin length (UPML), lower palpebral margin length (LPML), canthal tilt (CT), palpebral fissure index (PFI), upper eyelid area, and ocular surface area.

Results

We found statistically significant differences in specific parameters between genders, except for PFI. In the middle-aged group, males had a significantly higher CT (172.739˚ ± 3.145) compared to females’ 169.568˚ ± 4.406 (P=0.009). Additionally, males had a significantly smaller upper eyelid area (5.096 mm2 ± 1.104) than females (6.157 mm2 ± 1.416) (P=0.008). In the older group, male PFH and PFW measurements (1.77 ± 0.27 mm, 27.37 ± 2.61 mm) were significantly larger than those in females (1.38 ± 0.15 mm, 25.25 ± 2.59 mm, both P < 0.001). However, old males had a shorter FPD (1.94 ± 1.67 mm) compared to old females with 2.74 ± 1.83 mm. The old male group also had longer eyelid lengths, including 36.01 ± 4.26 mm of UPML and 29.91 ± 3.41 mm of LPML, while the measurements for old females were 32.57 ± 4.36 mm and 27.49 ± 3.16 mm, respectively. Moreover, old males’ ocular area was more exposed than old females' (2.12 ± 0.52 mm2 and 1.85 ± 0.46 mm2, respectively).

Conclusion

There are notable differences in periocular morphology between men and women, particularly with increasing age. However, the PFI value did not differ between men and women, regardless of the age group.

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Eyelid patching after ptosis surgery – is it worth it?

Author: Anna Schuh

Purpose

To investigate the effect of compression dressing on postoperative edema, hematoma, scar formation, pain, and ocular surface irritation after ptosis surgery.

Methods

Ptosis correction was performed by anterior levator reinsertion/resection (ALR) in cases of involutional ptosis, if necessary combined with additional blepharoplasty. Degree of edema and hematoma was scored at a four-point rating scale by a blinded observer at the first postoperative day (D1), after one week (D7) and after 8 (D56) weeks. Aesthetic outcome was ranked by the patient and a blinded observer using the Global aesthetic improvement score (GAIS) at D1, D7 and D56. Postoperative pain was scored by the patients using a visual analogue scale (0 to 10) at D1. Impairment after surgery by dressing or cover was evaluated at D1. At D7 and D56 the scar was evaluated regarding redness and bulging by a blinded observer. Best corrected visual acuity (BCVA) was tested pre-operatively and at D1, D7 and D56.

Results

Hematoma and edema did not differ between the group with compression dressing and cover at D1, D7 and D56 (p>0.005). Aesthetic outcome ranked by the patient and blinded observer did not differ between both groups at D1, D7 and D56 (p>0.005). Postoperative pain and impairment were the same in both groups (p>0.005). Scar formation was the same in both groups at D7 and D56 (p>0.005). One case of corneal erosion occurred in the group of compression dressing at D1 (p=0.342). At D7 corneal staining was increased in the group without compression dressing (p=0.930).

Conclusion

Compression dressing after ALR does not reduce hematoma, edema, postoperative pain, or impairment and has no effect on scar formation or aesthetic results. To prevent corneal erosion caused by the dressing it can be omitted after ALR surgery without inferiority for the postoperative results.

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Traumatic Optic Neuropathy Treatment Trial 2 (TONTT-2); Efficacy and Safety of different Doses of Erythropoietin A Multicenter, Randomized, Double-blind, Phase 3 Trial

Author: Mohsen Kashkouli

Purpose

Despite safety and efficacy of a fixed dose (10,000 and 20,000 IU/day for 3 days) of intravenous erythropoietin (EPO) in patients with indirect traumatic optic neuropathy (TON) in prior trials, neither weight-adjusted dose nor different doses have been tested. The aim was to compare the efficacy and safety of 3 EPO doses in patients with TON (NCT03308448).

Methods

Naïve patients ≥ 7 years of age and TON of ≤3 weeks were randomly allocated into 3 groups (G): G1: 3-day of 300 IU/kg/day (G1), G2: 3-day of 600 IU/kg/day, G3: 2x 3-day of 600 IU/kg/day one month apart. Follow-up visits were set at 1, 2, 3, 7, 30, and at least 90 days. Primary outcome measure was change in the best corrected visual acuity (BCVA). Secondary outcomes included change in color vision and relative afferent pupillary defect (RAPD). EPO side effects were documented.

Results

Of 118, 31 patients at each group were completed the trial (Jan.2018- Aug.2022). There was no significant difference between the groups in regard to baseline characteristics. Mean trauma-treatment and follow-up time were 10 and 147 days, respectively. One-third were <25 years old and 47% had posterior orbital fracture. BCVA was NLP in 45%, LP/HM in 23%, and ≥20/200 in 15%. Mean LogMAR significantly improved from 2.2 to 1.7 in G1, 2.4 to 2.1 in G2, and 2.1 to 1.8 in G3 with no significant difference between the groups. None except one in G3 showed worsening of BCVA. Considering ≤-0.30 LogMAR change at the last FU; 64% of G1, 39% of G2, and 48% of G3 ended up with a better BCVA. Age ≥ 25 years (OR=3), initial NLP (OR=14), and posterior orbital fracture (OR=2.5) negatively impacted the visual improvement. Improvement of NLP vision was in 50%, 0%, and 7% of the patients in G1,2, and 3, respectively (P=0.03). Mean RAPD significantly improved in 3 groups without a significant difference between the groups. Color vision improvement was only significant in G3. No serious adverse event was observed.

Conclusion

Significant improvement of BCVA and RAPD was not different between the 3 doses of EPO during the follow-up times. Older age, initial NLP, and posterior orbital fractures were associated with worse visual outcomes.

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Chasing the objective upper eyelid symmetry formula; R-Squared, RMS, MAE, MSE

Author: Kubra Serefoglu Cabuk

Purpose

Investigating for the most appropriate mathematical formula to objectively express upper eyelid contour symmetry.

Methods

64 eyes of 32 patients were included in the study. Upper eyelid contour symmetry of the patients was classified subjectively (independent of MRD1) as poor, acceptable and good by 3 oculoplasty specialists (senior, expert and junior surgeon). Bézier curves of the upper lid contour were drawn with ImageJ software (NIH, Bethesda, MA, USA) based on the patient photographs. The mid-pupil was marked manually. We transferred the data to the Spyder (Python 3.7.9.). Using the algorithms created by Author SKC, the symmetry of the Bézier curves of the left eyelids are obtained according to the y-axis and mid-pupils of both eyes are superimposed. The lower curve moved vertically to the equal height of the other curve (for independence of MRD1). RMS (Root-mean-square error), MAE (Mean absolute error), R-Squared (Coefficient of determination) were calculated. We evaluated the correlation between subjective grading and objective formulas.

Results

There was a strong positive correlation (spearman’s rho: 0.818, p<0.001) between senior surgeon’s subjective scoring (N; poor=8, fair=16, good=8) and R-Squared, and a negative moderate correlation between MSE, MAE, and RMS (r:-0.684, p<0.001; r:-0.684, p<0.001; r:-0.680, p<0.001, respectively). We found a moderate correlation between the expert surgeon’s subjective scoring (n poor=9, fair=13, good:10) and R-Squared, MSE, MAE, and RMS (r:-0.781, p<0.001; r:-0.644, p<0.001; r: -0.644, p<0.001; r:-0.623, p<0.001, respectively). We found a moderate correlation between Junior surgeon’s subjective scoring (N; poor=6, fair=18, good=8) and R-Squared, MSE, MAE, and RMS (r:-0.791, p<0.001; r:-0.709, p<0.001; r: -0.709, p<0.001; r:-0.695, p<0.001, respectively).

Conclusion

RMS, MSE, MAE, and especially R-Squared, may quantitatively express upper eyelid symmetry, comparable with a senior surgeon.

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Caruncle and Plica Hypertrophy causing Mechanical Secondary Acquired Lacrimal Duct Obstruction

Author: Nandini Bothra

Purpose

To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy.

Methods

Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora.

Results

The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma.

Conclusion

The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

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Acute versus late endoscopic dacryocystorhinostomy in the treatment of acute dacryocystitis: A prospective randomized trial

Author: Marita Uusitalo

Purpose

To compare long-term symptom resolution and use of resources of endoscopic dacryocystorhinostomy (enDCR) in acute or delayed phase in patients with acute dacryocystitis.

Methods

In this prospective, randomized controlled trial 50 adult patients with acute dacryocystitis at Helsinki University Eye and Ear hospital were randomized to acute (1 week) or delayed (3-4 months) enDCR surgery groups. Follow-up time was 18 months. Outcome measures were subjective epiphora, lacrimal symptoms, Visual Analog Scale (VAS) pain scores, number of hospitalized and unhealthy days, use of medication and openness in lacrimal syringing and dye test.

Results

EnDCR was performed on 24 patients in the acute and on 19 patients in the delayed group. There were no significant differences in lacrimal symptoms, syringing or use of resources. At 18 months follow-up 21/23 (91,3%) in acute and 12/13 (92,3%) in delayed group had no disturbing lacrimal symptoms. When reoperations and dropouts are considered, success was 22/24 (91,7%) in the acute and 12/16 (75%) (p=0,195) in the delayed group. Acute group had significantly fewer pain medication days 3 versus 10,5 in the delayed group (p=0,03).

Conclusion

Acute enDCR within one week after the diagnosis of acute dacryocystitis is equally effective and safe with similar resolution of lacrimal symptoms and use of hospital resources than traditional delayed surgery 3-4 months after acute dacryocystitis. Patients treated with acute enDCR need less pain medication.

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Teprotumumab for the treatment of thyroid eye disease (TED): the Holy grail, really?

Author: Arnaud Martel

Purpose

Since 2017, teprotumumab has been considered a “game changer” in TED. In 2022 at the last ESOPRS congress in Nice, it was announced that teprotumab would replace orbital decompression in the near future.
Here the author aims:
1. Present a critical review of teprotumumab in TED in 10 points
2. Highlight 2 different philosophies in TED. The American philosophy of “blockbuster” versus the European philosophy of “Reconditioning” carried by the EUGOGO consortium

Methods

Critical review of the teprotumumab litterature up to august 2022.

Results

1. The primary endpoint of the 2nd randomized trial was not clinically useful
2. The FDA has approved teprotumab for “the treatment of TED”. It is very surprising that the term “active TED” was not mentioned because the 2 randomized clinical trials only included patients with CAS > 3
3. In 2022, a retrospective study suggests that teprotumumab could be indicated in chronic TED. Interestingly, 15 of the 31 patients had a CAS=3
4. Teprotumab has never been compared to IV steroids.
5. The price of teprotumumab is high: $45,000 per infusion ($350,000 for 8 infusions)
6. Conflicts of interest cannot be excluded. Most of the articles are written by consultant ophthalmologists from the laboratory (Horizon Therapeutics)
7. Hearing impairments are increasingly reported. An audiogram must be systematically prescribed at the start and during the follow-up
8. Relapse data are scarce
9. Teprotumumab is not easily accessible in Europe
10. Teprotumumab in 2023 is still “has been”. New anti-IGF1R molecules are being studied (VRDN 001 study) with “better” preliminary results compared to teprotumumab (according to the VIRIDIAN laboratory)

Conclusion

Teprotumab illustrates 2 radically opposed philosophies: the American philosophy based on the “Blockbuster strategy” (new drug, in monotherapy, expansive, supported by key opinion leaders) versus the European philosophy based on the “Reconditioning strategy” (use of “old” and “well-known” drugs such as steroids, sometimes in combination, not expansive, based on a multidisciplinary consortium such as EUGOGO)

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Patient Experience of Living with Benign Essential Blepharospasm

Author: Nicola Dunlop

Purpose

To explore the impact of BEB outpatient treatment and care on patients’ lives and offered health professionals a model guide on how to improve services.

Methods

Study data was collected between 8th January and 31st October 2019 from 10 individual interviews and one focus group discussion. Interpretative phenomenological analysis (IPA) provided a deeper understanding of BEB lived experience.

Results

Five themes emerged; no knowledge, an incredibly debilitating state, loss of social richness, fleeting normality, and a battle for adequate care.

Conclusion

Discussion: The fundamental rights of people with benign essential blepharospasm (BEB) to access timely care and treatment is significantly challenged in the United Kingdom and across the world. Untimely care at a time of acute relapse resulted in eyelid spasms, temporary blindness, facial contortion, social stigma. A meta-synthesis of text and opinions papers across the UK, the United States of America (USA), Australia and Canada dystonia websites found poor treatment, care and quality of life. Utilisation of NHS Quality Framework (2016) and IPA to assess the patient experience bridged the gap between policy, theory and practice. It marked a move away from studying the condition as a biomedical model of disease and illness in recognition of its complex construct of patient self-reflection and the researcher interpretation to improve services. Conclusion: The introduction of electronic treatment records, NHS Attend Anywhere video severity assessment, patient-initiated booking, online focus group discussion, uniform practitioners’ training, introduction of more injectors and nurse-led clinics reduced geographical disparity configured and improve access.

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Impaired Orbital Development in Pediatric Retinoblastoma Patients: A Retrospective MRI-based Study

Author: Daphna Landau

Purpose

The presence of normal ocular tissue is essential for normal orbital development. Children with retinoblastoma (Rb), after medical treatment or enucleation, may present a violation of this delicate balance and show interrupted orbital growth. Our aim was to examine whether children who were treated for retinoblastoma have impaired orbital development.

Methods

Data from medical records of all Rb patients treated at a single center in 2000-2020 and who had at least two successive MR scans were collected and analyzed. Orbital volumes and measurements were assessed using 3D image processing software based on MR scans. In unilateral cases, the contralateral side served as control. Main outcome measures were the difference in orbital growth taken at last follow-up between diseased and healthy cases.

Results

Forty-four patients were included, 22 males (50%), mean age at diagnosis of 16.09±18.01 months. A positive correlation was calculated between age and orbital volume at diagnosis, both in healthy and affected eyes (P=0.003, P<0.001, respectively). At last follow-up, this relationship however remained in healthy eyes only (P=0.03), possibly suggesting interference with orbital growth in the group of affected eyes. In unilateral cases, orbital growth in the horizontal, vertical, and deep plains was smaller in the affected compared to the healthy eyes (P<0.05). Orbits with enucleated eyes showed decreased growth over time compared to orbits with medically treated eyes (P=0.017).

Conclusion

Orbital growth rate is slower in children who recovered from retinoblastoma. This may originate in the disease itself or its treatment effect on the globe and surrounding tissues. Enucleation negatively affects orbital growth. We presume that decreased globe volume or prosthesis volume directly affects normal orbital growth.

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The role of biomaterials in posterior lamellar eyelid defects: a systematic review and meta-analysis

Author: Umar Rehman

Purpose

Eyelid defects can occur secondary to tumours, trauma, burns and congenital factors. Among the most challenging aspects of eyelid reconstruction is the rebuilding of a tarsal substitute due to its delicate and multi-layered tissue composition. Attempts to use biomaterials for posterior lamellar reconstruction provide an alternative to traditional autograft reconstructions. This review aimed to assess the types of biomaterials used for the reconstruction of the posterior lamellar associated with eyelid defects and the associated clinical outcomes.

Methods

A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE and COCHRANE databases.

Results

A total of 15 articles fulfilled the inclusion criteria with 129 patients and 142 eyelids reconstructed using artificial grafts were included in the review were. Acellular Dermis Allograft (Alloderm) (n=49) was the most common artificial graft used. A meta-analysis was performed which demonstrated a pooled success rate of artificial grafts of 99% (95% CI 96-100, p=0.05; I2 = 40%, total complications seen 39%(95% CI 96-100, p=0.05; I2 = 40%) and re-operation rates of 5.6% (n= 8).

Conclusion

Biomaterials used demonstrated an overall success rate of 99% which is similar if not greater than that reported with the use of traditional autograft reconstruction techniques, with similar complications and fewer reoperations compared to autografts. This suggests clinicians consider the clinical use of artificial grafts for posterior lamellar reconstruction.

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Factors affecting the need for silicon tube implantation in cases of congenital dacriostenosis: Time of delivery, type of delivery and age of operation

Author: Sibel Yavuz

Purpose

To evaluate the delivery time, type of delivery, age at the time of operation, and surgical methods applied in cases of congenital nasolacrimal duct obstruction (CNLDO).

Methods

This study retrospectively included a total of 207 eyes of 160 cases who underwent surgery for CNLDO between February 2012 and April 2021. According to their age at the time of operation, the cases were divided into 0-12, 12-24, 24-36, 36-48 and >48 months groups. The cases were evaluated as term/preterm according to the delivery time and cesarean section/vaginal delivery according to the type of delivery. The surgical methods applied were examined as probing alone and probing plus silicone tube implantation.

Results

Of the cases, 146 (91,2%) were born at term and 14 (8,7%) were born preterm, and there was no statistically significant difference in the silicone tube implantation rates according to the time of delivery. The rate of silicone tube implantation was statistically significantly higher in the vaginal delivery group than in the cesarean section group (p=0.001; p<0.01). The rate of silicone tube implantation was higher in those who were older than the age of the operation.

Conclusion

Although the rate of those who were born by cesarean section was higher in probing cases, those who required silicone intubation were more common in those who were born vaginally. This suggests that dacryostenosis in the vaginally born cases resulted from a persistent structural and anatomical obstruction despite the presence of a high intrauterine pressure increase and enzymatic lysis.

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Blepharoptosis and Cognitive Function among 1.4 Million Adolescents: More than Meets the Eye

Author: Ofira Zloto

Purpose

To examine the association between blepharoptosis and cognitive function in late adolescence.

Methods

Population-based, retrospective, cross-sectional study.
1,411,570 Israeli-born adolescents (620,107 women, 43.9%) aged 16-19 years who were medically examined before compulsory military service between 1993 and 2017.
The diagnosis of blepharoptosis was verified by an ophthalmologist. Cognitive function was evaluated by a validated 4-domain assessment (problem-solving, verbal abstraction and categorization, verbal comprehension, and mathematical abilities). Cognitive Z-scores were calculated and categorized as high (≥1 standard deviation [SD]), medium (−1 to <1 SD), and low (<−1 SD). Relationships were analyzed using regression models adjusted for sociodemographic variables including sex, year of birth, residential socioeconomic status, education level, body mass index, and familial country of origin.

Results

A total of 577 (41 per 100,000, 32.2% women) participants had blepharoptosis. The proportions of unilateral and bilateral visual impairment among participants with blepharoptosis were 13.0% and 3.5%, respectively. In a multivariable analysis, blepharoptosis was associated with a 0.18 SD reduction in cognitive Z-score (P < 0.001). The adjusted odds ratios for low and high cognitive Z-scores in participants with blepharoptosis were 1.54 (1.25-1.89) and 0.80 (0.62-1.04), respectively. This relationship persisted when participants with normal visual acuity or unimpaired health status were analyzed separately.

Conclusion

Blepharoptosis is associated with reduced cognitive function determined in late adolescence. Future prospective studies should investigate the causes of this link and its underlying mechanisms.

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IMPROVEMENT IN EPIPHORA USING TEARS GRADING FOLLOWING SURGICAL TREATMENT OF MEIBOMIAN GLAND INVERSION IN PATIENTS WITH FACIAL NERVE PALSY

Author: Camille Yvon

Purpose

Upper eyelid meibomian gland inversion (MGI) is a condition often overlooked in clinical practice leading to tarsal curling in the absence of obvious entropion. It is commonly found in patients with facial nerve palsy (FNP) and may aggravate ocular surface symptoms and epiphora.

OBJECTIVE
To assess epiphora outcomes using the TEARS grading score in patients with concomitant MGI and FNP undergoing correction of MGI.

Methods

Retrospective, 5-year, non-comparative, single-center study of patients with MGI and FNP, treated with MGI correction, under the supervision of a single surgeon. A validated ‘TEAR’ score was used to assess changes in epiphora.

Results

160 patients with FNP underwent surgery to correct MGI over the study period. 11% (18/160) had bothersome symptoms of epiphora, and ten fulfilled the inclusion criteria. The mean age at surgery was 50 (range 13–76) years.

T, E, and A scores significantly improved (p<0.05). 80% of patients saw a reduction in tearing frequency (T), with 60% gaining ≥ 2-grade improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 80% of patients, with 40% and 50% gaining ≥ 2-grade improvement, respectively. R scores (related to symptoms suggestive of evaporative dry eye and reflex tearing) improved by 60%, with 40% seeing ≥ 2-grade improvement. Nine (90%) patients improved symptomatically with an average improvement “S” score of 65% over a mean follow-up period of 30 months. All patients demonstrated restoration of the normal anatomical position of the meibomian glands.

Conclusion

MGI can cause epiphora in patients with FNP and may explain cases where symptoms persist despite standard surgical intervention. This study provides proof of concept that MGI correction can improve epiphora and that identifying MGI may be considered a critical step in the treatment algorithm for epiphora in patients with FNP.

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BUFFERED VERSUS NON-BUFFERED LOCAL ANESTHETICS AND LOCAL PAIN SCORES IN UPPER EYELID BLEPHAROPLASTY

Author: Dolika Vasovic, MD

Purpose

This study aimed to see if different types of local anesthetics (LAs) or their buffered/ non-buffered combinations produce lower pain scores in upper eyelid blepharoplasty.

Methods

The study involved 285 patients, randomly divided into nine groups: 1. 2% lidocaine with epinephrine ‒ Lid+Epi; 2. 2% lidocaine with epinephrine and 0,5% bupivacaine (1:1) ‒ Lid+Epi+Bupi; 3. 2% lidocaine with 0,5% bupivacaine (1:1) ‒ Lid+Bupi; 4. 0,5% bupivacaine ‒ Bupi; 5. 2% lidocaine ‒ Lid; 6. 4% articaine hydrochloride with epinephrine ‒ Art+Epi; 7. buffered 2% lidocaine/ epinephrine with sodium bicarbonate (SB) in a 3:1 ratio ‒ Lid+Epi+SB; 8. buffered 2% lidocaine with SB in a 3:1 ratio ‒ Lid+SB; 9. buffered 4% articaine hydrochloride/ epinephrine with SB in a 3:1 ratio ‒ Art+Epi+SB. Following injection of the first eyelid and a 5 minute period of soft pressure on the injection site, patients were asked to rate their pain level on the Wong-Baker Face Pain Rating Visual Analogue Scale. Rating of the pain level was repeated 15 and 30 minutes following anesthetic administration.

Results

The lowest pain scores at the first time point were observed in Lid+SB when compared to all of the other groups (p<0.05). At the final time point, significantly lower scores were also observed in Lid+SB, Lid+Epi+SB and Art+Epi+SB when compared to the Lid+Epi group (p<0.05).

Conclusion

These findings could help surgeons select an appropriate combination of LAs particularly in patients with lower pain threshold and tolerance since buffered combinations of LAs produce significantly lower pain scores compared to non-buffered solutions.

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Non-surgical facial reanimation using Hyaluronic Acid fillers in chronic CN VII palsy

Author: Ofira Zloto

Purpose

Chronic facial nerve palsy causes a weakness or paralysis of the movement of the affected side of the face. It impacts the patient’s quality of life, functionality and self- esteem.
This current study aims to describe the effect of Hyaluronic Acid (HA) filler on static and dynamic facial reanimation in chronic CN palsy.

Methods

Prospective interventional study.
Patients with long standing CN VII palsy were treated with HA fillers injections to improve both static and dynamic facial mimicry. Patients were evaluated using still photographs, non-contact facial Electromyography, Nerve Conduction Tests and questionnaires (before injection, one month after first injection, 3 months and 6 months after first injection).

Results

Six patients with chronic cranial nerve palsy (medical and surgical) were treated, two males, four females, mean age of 50 years. All patients underwent HA fillers injections to deep facial and superficial fascial tissues in an attempt to achieve lifting effect along with filling effect. All patients experienced good to excellent improvement in static and dynamic facial mimicry (as measured in pictures before vs 6 months after injections), and were highly satisfied with aesthetic (9.16/10) and functional outcome (8.33/10). Contact EMG showed increased muscle activity (6/6) likely secondary to mechanical weakening effect of their antagonists. Blink EMG showed significant improvement (3.88 before vs. 0.600 at 6 months, p=0.043)

Conclusion

Deep and superficial HA injections provide good static and dynamic facial improvement in chronic facial nerve palsy, and may be an excellent alternative to surgical rehabilitation.

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Surgical Options for Severe and Complex Lower Eyelid Retraction in Children- The Use of Pericranial Periosteal Flap To Achieve Eyelid Elevation

Author: Christina Lim

Purpose

To describe the use of pericranial periosteal flap in treating severe lower eyelid retraction in children where the surgical options are limited due to complex craniofacial and surgical history.

Methods

A retrospective, single-centre, case series of three consecutive paediatric cases are performed where a pericranial periosteal flap was used with a skin graft to treat severe lower eyelid retraction. Outcome measures include the extent of lower eyelid elevation (mm) and complications in the follow-up visits.

Results

Three children with severe lower eyelid retraction and previous craniofacial and complex surgical history underwent the surgery. The cohort consisted of two boys and one girl with the mean age of 6.7 years, ranging between 5-8 years. Their diagnoses included congenital ocular surface stem cell deficiency with previously failed corneal grafts with perforation, crypophthalmos with coloboma and ankyloblepharon, possible Tessier type 4 craniofacial cleft with microphthalmia. The improvement of lower eyelid retraction was 3,3,6 mm at 28, 24, 6 months respectively. No peri- or post-operative complications occurred.

Conclusion

Treating children with severe lower eyelid retraction is challenging due to the limited tissue availability arising from complex craniofacial and surgical history and smaller surface areas of potential harvest. Our case series presents the successful use of pericranial flap in treating severe lower eyelid retraction in children. We recommend its utility in children where traditional options have either failed or are not applicable.

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Outcomes after multidisciplinary treatment for pediatric and adult orbital rhabdomyosarcoma

Author: nur khatib

Purpose

To describe and compare the clinical presentation, imaging characteristics, prognostic factors, histopathology, and treatment outcomes of pediatric and adult orbital rhabdomyosarcomas (RMS).

Methods

We conducted an institutional retrospective study with data from 39 patients with primary orbital pediatric RMS and three cases of adults primary orbital RMS treated between 1995 and 2016 at the Amsterdam University Medical Centers / Emma Children Hospital. We evaluated demographic characteristics, symptoms and signs, imaging characteristics, risk factors and treatment outcomes.

Results

The median follow-up period was 9.4 years (range, 3 to 25 years). In terms of prognostic factors that affect survival rate of adult RMS are similar to children including age, para-meningeal involvement, TNM staging, Intergroup RMS Study Group (IRSG) stage, and histological subtype. The staging of RMS in our cases were in accordance with the staging system for children, which was based on the IRSG and TNM staging system.
Of the 39 children, 10 underwent chemotherapy and excision without additional radiotherapy. The 29 patients with additional local treatment received.
The treatment principles of adults were according to children treatment protocol at our center; patients were required to begin therapy including chemotherapy, radiation and /or surgery once the diagnosis is confirmed. Delayed surgery was recommended, after chemotherapy (ideally after 3-4 courses) if tumor was resectable.
Among children group the 10-year overall survival was 95% and the EFS 63% with functional decimal visual acuity (0.5 or better). Among adults two cases had long term complete remission with no recurrence episodes the 3rd case Although chemotherapy or palliative radiotherapy were offered, the patient refused treatment and died a month after the diagnosis because of metastasis.

Conclusion

Even though the absence of controlled, prospective trials, which is due to extreme rarity of the disease among adults our treatment approach for adults was according to pediatric protocols.

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DCR Preferences Among Oculoplastic Surgeons: Barriers and Facilitators to adoption of Endoscopic DCR

Author: Walaa Alturkistany

Purpose

To determine the preference for dacryocystorhinostomy (DCR), patient selection criteria for endoscopic DCR, endoscopic DCR technique, and barriers to adoption of endoscopic DCR.

Methods

Cross-sectional study conducted from May-December 2021. A survey was sent to oculoplastic surgeons. Questions on demographic characteristics, type of clinical practice, technique preferences, barriers and facilitators to adoption of endoscopic DCR were included.

Results

245 participants completed the survey. Most respondents were located at an urban site (84%), were in private practice (66%), and had been in practice for more than 10 years (58.9%). Sixty one percent perform external DCR as the first line procedure for treating primary nasolacrimal duct obstruction. The most common factor influencing the surgeon’s decision to perform endoscopic DCR was the patient’s request (37%) followed by endonasal exam (32%). The most common barrier for not performing endoscopic DCR was the lack of experience and lack of training during fellowship (42%). The most worrisome complication for most respondents was failure of the procedure (48%), followed by bleeding (30.3%). Eighty one percent believe surgical mentorship and supervision during initial cases would facilitate endoscopic DCR learning.

Conclusion

External Dacryocystorhinostomy is the preferred technique for treating primary acquired nasolacrimal duct obstruction. Learning endoscopic DCR early during fellowship training and high surgical volume to improve the learning curve dramatically impacts the adoption of the procedure.

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Two-year retrospective analysis in two clinics on orbital decompression for congenital, non-thyroid, proptosis.

Author: Sawa Minohara

Purpose

Eye prominence is a source of cosmetic “deformity” for many patientswho worried about congenital bulging eyes without Graves. We have applied orbital fat decompression for them, making use of our experience on patients with Graves. We would like to report our two-year experience in our two institutions of purely aesthetic surgeries to reduce eye prominence in non-thyroid patients.

Methods

In this study, we retrospectively reviewed patients undergoingcosmetic orbital fat decompression in our two institutions for two years. Surgical technique is an orbital fat removal via lower lid conjunctival incisions. Patients with Graves or other diseases affected to ocular area and patients treated unilaterally were excluded. Patients treated by combination of fat and bone decompression were also excluded. Preoperative and postoperative dates at longest follow-up, at least one month, were used for analysis.

Results

Operation was performed on 58 orbits of 29 patients. Mean patient age was 28.6 years. The mean amount of removed fat was 2.87ml on the right eye,and 2.81 on the left. The mean decrease of Hertelmeasurement was 2.45mm and 2.36mm respectively. No patients suffered from significant decreasing visual acuity (p=0.45 on the right, p=0.19 on the left in Student t-test). In the Hess chart, only 3 patients had slight change, with diplopia in small range of upper field. No case gained intraocular pressure (more than 21mmHg) after surgery even on the first postoperative day.

Conclusion

Orbital fat decompression could be helpful option for patients with congenital bulging eyes. Smaller change rather than cases of Graves would be effective enough for congenital proptosis. Moreover, less inflammatory change in fat can be seen, fat decompression itself is easier than for patients with Graves.On the other hand, the risk of severe visual impairment is still existed. In this study we cannot find out the relation between the diplopia and the amount of fat removed. Regarding the orbital anatomy, greater caution should be exercised in its medication and the amount of fat to remove.

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The Status of the Lacrimal Drainage System in cases with Punctal Agenesis: Clinical and Histopathological evidence

Author: Nandini Bothra

Purpose

To understand the development of the lacrimal drainage system (LDS) in cases with punctal agenesis

Methods

A prospective interventional case series involving 10 cases of punctal agenesis (PA) with absent lacrimal sac (LS) swelling and 10 cases of PA with LS mucocele. Exclusion criteria included cases with punctal dysgenesis or incomplete punctal canalization, acquired cases of punctal effacement, or any prior interventions. For cases without LS mucocele, following the exploration, the entire specimen of the tissue from the expected punctal opening to the medial canthus (length = 8 mm and depth = 3 mm) was sent for histopathological analysis to ascertain the presence and extent of the canalicular tissue. In cases with LS mucocele, exploration was done to look for the presence of common canalicular opening, the general status of the LS and NLD.

Results

Canalicular exploration: The mean age of the patients at the time of exploration was 7.5 years (range 6-10 years). Histopathological analysis showed tissue surfaces lined with stratified squamous epithelium with occasional interspersed goblets cells (conjunctival epithelium), a few chronic inflammatory cells, and muscle fragments. Epithelium suggestive of proximal LDS was absent
LS and NLD exploration: Mean age of the patients was 23.83 years (range: 6-39 years). Clinically, the LS was extremely thinned out with absence of common canalicular opening with a dilated bony NLD with a blind end distally. Histopathologically, irregularly folded thinned columnar epithelium with few goblet cells was seen. Underlying stroma showed gross fibrosis, congested and thin capillary blood vessels to thick hyalinized blood vessels. Deep stroma showed smooth muscle bundles with minimal inflammation.

Conclusion

The present series did not find any histological or clinical evidence of canalicular tissues or common canaliculus in cases of punctal agenesis with extremely thinned out LS and NLD. The findings of this study do not support retrograde approaches in cases of punctal agenesis, while procedures like canaliculodacryocystorhinostomy should be undertaken with extreme caution

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Improving the Outcomes of Brow Suspension in Congenital Ptosis: A Pilot Study

Author: Mena Al Whouhayb

Purpose

This study aims to explore the strength and longevity of silicone threads and and their different fixation methods (horizontal vs. vertical).

Methods

This is an experimental laboratory study involving 8 experiments comparing 2 fixing designs in 4 conditions. Sutures and lard were incorporated to alter the conditions. A silicone-extending rig was designed and built to simulate normal physiology of an eyelid and brow. Each extension (‘cycle’) of the silicone on the rig represented one brow elevation and depression. Cycles were repeated 50 times for each experiment. The force of the sling was measured at equidistant intervals along a fixed scale. The force difference (ΔF) between elevation and depression was calculated. The results were analysed using Factorial ANOVA 4-Way statistical design.

Results

Statistical analysis indicated that fixing design type has a statistically significant influence on sling performance (p=0.000). In 75% of cases, the horizontal sleeve performed better through maintaining a higher mean force after 50 cycles. The remaining 25% showed that when sutures and lard were combined, the vertical sleeve performed better. Adding sutures and/or lard influenced the results as they reduced ΔF; these factor-interactions were statistically significant (p= 0.000).

Conclusion

Vertical fixation of silicone is more widely practised but this study indicates surgeons should consider horizontal fixation. Surgeons should be aware that the presence of grease around the sling, which may replicate in vivo fatty tissue, weakens the silicone sling fixation. Additional research is needed which could incorporate in vivo conditions, alternative materials and larger sample sizes to further guide surgical practice.

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May the Force be with Two

Author: Ilse Mombaerts

Purpose

Both the ophthalmologist and endocrinologist are involved in the management of patients with thyroid eye disease (TED). With the introduction of novel therapies, a concise and timely consensus for treatment is required.

Methods

The American and European Thyroid Association assigned a Task Force, consisting of physicians with expertise in thyroidology and TED, to review and discuss international knowledge and practices on the management of TED until a consensus was reached.Therapies were categorized as following: (1) ‘preferred’, if >2 randomized controlled studies (RCT) have shown efficacy against standard of care or placebo with concordant results; (2) ‘acceptable’, when there exists >2 RCTs with discordant results likely due to differing inclusion criteria, or only one single RCT is available and shows efficacy; and (3) ‘may be considered’, based on a collective interpretation of the available evidence. The recommendations are listed as key points.

Results

Clinical disease heterogeneity and insufficient published evidence with scarce rigorous RCTs challenge robust recommendations on first- and second-line treatment. With the assessment of disease severity and activity, and quality of life, treatment is tailored to goals, patient age, and comorbidities, and, to availability and relative costs. The preferred therapy for mild TED is watchful waiting and selenium supplementation, and for moderate-to-severe TED includes intravenous glucocorticoids, teprotumumab, and radiation therapy with or without intravenous or oral glucocorticoids.

Conclusion

While primarily aimed at endocrinologists, the consensus statement includes salient key points for ophthalmologists too.
Reference: Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J. 20228;11(6):e220189.

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Hatchet Flap Update: Lessons learned after 70 cases of eyelid and midfacial reconstruction.

Author: Philip Custer

Purpose

In 2018 we reported a series of 5 patients in which we used the hatchet flap for periocular reconstruction. We have since gained extensive experience with this technique. In this presentation we describe patient selection, surgical variations, and hatchet flap design. Results from a large series of patients undergoing eyelid and midfacial reconstruction will be presented.

Methods

A retrospective review was performed on patients treated with a hatchet flap between March 2016 – March 2023. Demographics, defect characteristics, surgical techniques, and outcomes were investigated.

Results

The hatchet flap was used to repair 70 defects in 69 patients, aged 41.6-90.0 yr (mean 66.1). In 2 patients a “double hatchet flap” was utilized. Defects resulted from Mohs surgery (n=62), exenteration (n=2), benign lesion excision (n=3), or cicatricial ectropion/fistula repair (n=3). Largest dimension of the defect was ≥30mm in 42% of cases. The flap tail was managed with 3 methods: V-Y plasty (n=26), transposition (n=34), and excision (n=10). Ancillary procedures were often used during reconstructions (skin grafts: 29, additional skin flaps: 26, tarsoconjunctival flaps: 6, other grafts: 7). Small eschars of the peripheral flap were observed in 7 patients. All healed without necrosis or scarring. Four patients with subcutaneous flap thickening improved after steroid injections. Mild flap contracture likely contributed to postoperative ectropion in 1 patient. There were no other flap related complications.

Conclusion

The hatchet flap has features of both rotational and advancement flaps. Its ability to mobilize tissue relies upon laxity in the plane perpendicular to the flap base. Developing the flap on mobile tissue, such as the cheek, greatly enhances the ability to rotate tissue into the defect. Individuals without sufficient tissue laxity are not good candidates for this procedure. The hatchet flap is modified by advancing, transposing, or excising the flap tail. In this large series, the hatchet flap proved to be a versatile technique for repairing eyelid/midfacial defects or treatment of cicatricial ectropion/fistulas.

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Novel GATA3 Biomarker and Sarcomatoid Differentiation in Primary Ductal Adenocarcinoma of the Lacrimal Gland: Indicators of Differential Growth Patterns?

Author: Harshvardhan Chawla

Purpose

We describe a case of primary ductal adenocarcinoma of the lacrimal gland with novel histopathological characteristics corresponding to a biphasic growth course. Furthermore, we present a comprehensive genomic profile of this rare malignancy using next-generation sequencing technology.

Methods

A 39-year-old male with a 15-year history of slowly progressive unilateral proptosis and hypoglobus presented after one month of hyperacute symptom exacerbation. Orbital imaging revealed a 7.1 x 4.6 x 3.9 cm superior orbital mass with osseous erosion of the lateral orbital wall and greater sphenoid wing. The patient underwent orbital exploration and excisional biopsy of the mass via lateral orbitotomy. Permanent section histopathology was performed on the sample, along with hybrid-capture next-generation sequencing against a testing panel of 648 genes.

Results

Histopathology demonstrated high-grade adenocarcinoma with a well-differentiated glandular component alongside a poorly-differentiated sarcomatoid region. The glandular section was immunopositive for Her-2, CK7, GATA3, and androgen receptor. Genomic profiling identified a high variant allele fraction in the KDM5C, ATM, FLCN, NCOR1, TSC1, NF1, and TP53 genes. Tumor recurrence necessitated en-bloc exenteration with dural resection alongside adjuvant radiotherapy and chemotherapy. The patient died of unrelated causes five months after the initial surgery.

Conclusion

Despite previous reports of pleomorphic adenoma undergoing malignant transformation, the absence of a chondromyxoid stroma suggests that this tumor was a primary ductal adenocarcinoma with a uniquely biphasic growth phase. This represents the first report of sarcomatoid differentiation in primary ductal adenocarcinoma of the lacrimal gland, which may incite hyperacute progression as experienced by our patient. Conversely, the heretofore undescribed GATA3 biomarker in this case may correlate with an indolent growth phase. Genomic variants such as the SEMA3C oncogene illustrate potential therapeutic targets for this condition as further molecular data becomes available.

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Orbital Solitary Fibrous Tumour Versus Non-Orbital Solitary Fibrous Tumour

Author: mary awad

Purpose

To report the clinical and oncological outcomes of Orbital Solitary Fibrous Tumour compared to Non-Orbital Solitary Fibrous Tumour

Methods

A retrospective case notes review of 7 patients with Orbital Solitary Fibrous Tumour (SFT) was analysed and compared to the clinical and oncological outcomes of 138 patients presenting with Non-Orbital SFT.

Results

7 patients presented with primary Orbital SFT, of which 4 were males and 3 were females. The age ranged from 24 to 80 years. The most common presenting symptom was painless non- axial proptosis with restricted ocular movements. All patient had routine orbital work up including optic function, neuro-orbital imaging and underwent de-bulk orbital excision biopsy. 4 patients had local orbital recurrence who then went on to have further excision biopsy. 1 patient had adjuvant radiotherapy. No malignant transformation was noted in our study group. 138 patients with non-orbital SFT were analysed by the East Midlands Sarcoma Service. The age group ranged from 10-87 years. The most commonly involved anatomical site was thorax followed by head and neck, abdomen then extremities. 10 patients had recurrence of SFT and 3 had malignant transformation of which 2 patients had distant metastasis. All patients were treated with surgical excision.

Conclusion

Solitary fibrous tumour is a rare mescenchymal tumour commonly involves the lung but rarely involves the orbit. It generally follows an indolent course but does have malignant potential. Orbital SFT has a higher recurrence but lower malignant transformation rate compared to non orbital SFT.

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A shift in the management of orbital schwannomas, to operate or not? A population-based case series.

Author: Elin Bohman

Purpose

This study aims to review the national Swedish experience regarding management, both surgical and conservative, of orbital schwannomas.

Methods

The study centre is the primary referral centre for multidisciplinary evaluation, discussion, and management of orbital tumors, including schwannomas, in Sweden. During the period of 2005-2010, 16 patients with an orbital schwannoma diagnosis were identified and managed at the centre.

Results

Four patients underwent immediate surgery due to globe displacement or optic neuropathy. Gross total resection was achieved in three cases and subtotal resection in one case. The remaining 12 patients, with minimal/no symptoms or contraindications for surgery, were treated conservatively by watchful waiting and re-evaluation. Surgery with subtotal resection was later performed after an average of 17 months in three of these patients. No recurrences were detected on radiographic follow-up (mean 50 months), and all patients experienced postoperative improvement at clinical follow-up (mean 65 months). The remainder of the conservatively treated patients (n=9) experienced no clinical progression (mean 30 months). A slight radiological tumor progression was detected in one patient after 17 months.

Conclusion

This study report on the largest cohort of conservatively treated orbital schwannomas. The results suggest that surgery may safely be avoided in a selected number of patients, typically those presenting with few to no symptoms. In these cases, a conservative approach with watchful waiting may safely be initiated. If surgery is needed, subtotal resection may be utilised as an equally safe and effective alternative to gross total resection for surgically challenging tumors, reducing the risk of unnecessary operative complications.

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Functional and anatomical success of canalicular trephination and bicanalicular intubation in patient undergoing Dacryocystorhinostomy with proximal and distal canalicular obstruction

Author: Pari Shams

Purpose

To determine the functional and anatomical success of canalicular trephination and bicanalicular intubation in patient undergoing DC) with proximal and distal canalicular obstruction

Methods

Retrospective, consecutive interventional case series of patients with canalicular obstruction undergoing DCR endoscopically or externally with trephination and bicanalicular silicone intubation for 3 months. The functional, and anatomic outcomes of surgery are presented.

Results

22 patients (mean age, 65 yrs) in 5-year period underwent endoscopic (45.5%) or external (54.5%) DCR for management of epiphora (monk score of 4) secondary to canalicular obstruction +/- co-exiting nasolacrimal duct obstruction (NLDO). 59% had known canalicular obstruction prior to surgery, 41% were diagnosed per-operatively. 50% involved one canaliculus and 50% both canaliculi or the common canaliculus. 32% were redo-DCR surgery of which 71% performed endoscopically. 4 cases of lower canalicular obstruction (18%) had undergone previous trephination only and mono-canalicular stent, in 3 cases the stent was lost prematurely. 64% were distal and 36% proximal canalicular obstructions. 68% solid and 32% membranous obstructions. 57% of distal obstructions were solid and 1 membranous was proximal. 2 patients did not attend after removal of stent at 3 months, both had a monk score of 4 and offered Lester Jones tubes. 20 cases followed up for a minimum 6 months with Monk score of 0 in 80% (n=16) (p=0.001). All 20 patients had good functional success at 6 months (resolution or improvement of epiphora) and anatomical success (dye disappearance test 100%, lacrimal irrigation in 80%)

Conclusion

Canalicular trephination and bicanalicular lacrimal intubation performed at the time of DCR, for management of canalicular obstruction, diagnosed pre or per-operatively, achieved a high rate of functional and anatomical success and may prevent the need for future bypass surgery using a Lester Jones type tube in a significant proportion of patients. Bicanalicular stenting prevents premature stent extrusion and should be left in situ for at least 3 months.

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Robotic Assisted Orbital Surgery for resection of advanced periocular tumours

Author: Mohsan Malik

Purpose

Orbital surgery benefits from well-designed instrumentation that offers gentle tissue manipulation, high manoeuvrability and control. Nevertheless, tissue manipulation must be accomplished in confined spaces with exceptionally high accuracy and precision. This is where robotic surgery offers an advantage. We aimed to evaluate a robotic-assisted surgical system’s feasibility, safety and outcome in assisting tumour clearance.

Methods

A case series of patients with advanced periocular tumours undergoing robotic-assisted globe-sparing resection was performed using the DaVinci XI system (intuitive surgical, inc). Institutional ethics and multidisciplinary approval were sought in all cases.

Results

Four patients underwent robotic-assisted orbital surgery at a mean age of 63 years (range 42-86). Two patients were diagnosed with UICC T3 squamous cell carcinoma, and two had UICC T3 basal cell carcinoma. One patient was found to have positive lymph nodes at the time of surgery and underwent simultaneous parotidectomy and lymph node clearance. Clear resection of the primary tumour was achieved in all patients.

Patients were followed-up for at least one year, and three remained disease-free. One patient with pre-existing extra-orbital disease developed metastatic disease five months post-op. All patients preserved vision peri-operatively, with no complaints of diplopia. Moderate ocular surface disease was noted in two patients; one was associated with a neuropathic cornea, and the second required medial tarsorrhaphy to reduce exposure. Limitation: tissue dissection was limited to a sizeable monopolar dissection tool for soft tissue. Due to limited haptic feedback, an assistant was required to retract the soft tissue and globe.

Conclusion

Our series highlights the potential advantage of three-dimensional optics, multi-directional instrumentation and motion scaling technology to achieve globe-sparing tumour resection in advanced periocular tumours. However, further robotic instrumentation development is required for orbital surgery.

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Oculoplastic-led immunosuppressive therapy for Thyroid Eye Disease.

Author: Ahmed Magid Wanas

Purpose

To share our early experience of using mycophenolate mofetil (MMF) alongside IV methylprednisolone (IVMP) per EUGOGO Guidelines 2021.

Methods

Prospective data collection for patients seen from September 2021. Mycophenolate commenced and monitored by the Oculoplastics team according to the Shared Care Protocol issued by Rheumatology Department while IVMP administered in Day Therapies Unit/Ambulatory Care Unit.

Results

9 patients with moderate-severe Thyroid Eye Disease (TED) and two with Dysthyroid Optic Neuropathy (DON) were treated with IVMP and MMF. Age range was 34-80 (median 61, mean 58). Male: female was 1:5. Dose of MMF 1-2g per day. Duration of MMF treatment was ≤6 months in 46% of patients, and >6 months in 55%. In one DON patient, VA improved from HM to 6/9, and in the other from 6/24 to 6/7.5 with treatment. There was partial improvement of extraocular dysmotility and proptosis of 0-2mm. In terms of side effects 1 patient stopped MMF within a week due to intolerance of gastrointestinal symptoms, 1 patient had deranged liver function at week 8 of IVMP with MMF 500mg BD and 1 patient developed steroid-induced hypermetabolic periodic hypokalaemic paralysis with ECG changes 24 hours after the 1st dose of IVMP with MMF 500mg OD. He recovered uneventfully following potassium infusion. 2 patients had orbital radiotherapy and 2 were referred to tertiary units during the course of treatment. No patient required emergent orbital decompression.

Conclusion

IVMP and MMF has been shown in the literature to be safe and effective within the recommended dosage, however patients should be closely monitored for side effects while on therapy. It is essential to work closely with the local rheumatology and medical unit, as a formal MDT with co-location of rheumatologist and endocrinologist may not always be feasible.

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Navigation system assisted surgical management of orbital portion of spheno-orbital meningiomas

Author: Saadia Chaudhry

Purpose

Spheno-orbital meningiomas (SOM) present a surgical challenge because of involvement of important structures in the orbit, cavernous sinus, superior orbital fissure, and optic canal. Therefore resection focuses on maximum safe resection while preserving neurovascular structures and is usually performed by neuro-surgery teams. In rare instances, extensive orbital involvement causes sight threatening optic nerve compression or cosmetically disfiguring proptosis, trans-orbital surgery may be required. We present our experience in the surgical management of this complex disease with assistance of navigation system.

Methods

We identified 4 patients in the last 5 years with extensive orbital involvement from Grade 1 SOM requiring orbital surgery. 4 patients had spheno-orbital meningiomas debulked through the lateral orbitotomy approach while 1 patient had lateral wall decompression. .
Patient 1- 55 year old female patient with a secondary SOM from radiotherapy for retinoblastomas presenting with sight threatening disease in her only seeing eye underwent successful debulking.
Patient 2- 51 year old female with proptosis.
Patient 3- 21 year old male with Right SOM with previous orbital debulking biopsy, bicoronal approach debulking under neurosurgery and significant orbital recurrence causing severe globe dystopia.
Patient 4- 41 year old male patient with recurrent left SOM causing severe proptosis.

Results

All patients had successful debulking of the meningioma performed trans-orbitally aided by navigation system and cusa aspirator. Patient 1 maintains stable vision 3 years after surgery. Patients 2, 3 and 4 had significant improvement in proptosis. Patients 3 and 4 required adjuvant IMRT for extensive disease after surgery.

Conclusion

Trans-orbital debulking of SOM’s may be required in select patients. Lateral orbitotomy approach, use of the navigation system 3D printing of skull and use of Cusa aspirator helps carry out this surgery safely and effectively. Patients may require long term follow up and agressive meningioma’s may require post surgical adjuvant IMRT to stabilise disease.

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Nasolacrimal duct mucosectomy

Author: Masashi Mimura

Purpose

Surgical removal of the nasolacrimal duct mucosa is challenging because it is embedded in the maxillary bone. The previously reported procedures for the removal are invasive in that resection of the bony nasolacrimal wall or sharp dissection of the mucosa using a chisel is required. This report introduces a new, less-invasive procedure to remove nasolacrimal duct mucosa completely.

Methods

This procedure illustrates a surgical rescue in the case of the lacrimal-sac tumor patients who underwent dacryocystectomy, with the progression of the tumor to nasolacrimal duct mucosa. After the conservative dacryocystectomy, the cut-end of the nasolacrimal duct mucosa was held with Nishihata`s small cup forceps, which has a diameter of 3mm and is angled upward. Next, withholding the tissue, the forceps is inserted downward through the bony nasolacrimal duct to the inferior meatus of the nose, to strip the nasolacrimal mucosa down. Then, under nasal endoscopic view, the nasolacrimal mucosa was removed conjointly with nasal mucosa of inferior meatus as much as possible to complete an excisional biopsy to send for further histopathological evaluation.

Results

The histopathological study of the resected mucosa revealed that the procedure removed all layers of the mucosal nasolacrimal duct except the periosteum. Dacryoendoscopic evaluation showed that the nasolacrimal canal was wide open after the surgery. No complication was observed.

Conclusion

This procedure provides the easy and low-invasive total mucosectomy of the lacrimal sac and nasolacrimal duct with preserving the bony nasolacrimal canal.

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Long-term surgical outcomes of levator resection in patients with Marcus-Gunn jaw-winking ptosis

Author: Rawan Althaqib

Purpose

To report long-term surgical outcomes of a series of MGJWS patients with moderate ptosis who underwent levator resection

Methods

A retrospective review of medical records of 10 MGJWS patients with moderate ptosis who underwent levator resection was performed in two major eye centers in Riyadh, Saudi Arabia from January 1987 to December 2019. Clinical features, pre-operative and post-operative data of the 10 patients were recorded

Results

The mean patient age at presentation was 5.4 years. Seven patients were female and three were male. All patients had moderate ptosis with marginal reflex distance ranged from 1 to 2 mm. The mean age at surgery was 9.5 years. After initial good ptosis correction for all patients, seven of them had a recurrence of ptosis several months after levator resection

Conclusion

Levator resection in MGJWS patients with moderate ptosis and good levator function is associated with a high rate of ptosis recurrence and less predictable surgical results

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A valuable approach to tarsal reconstruction: the tongue-and-groove joint

Author: Peter Martin

Purpose

To demonstrate an effective approach to tarsal reconstruction, in order to add to the armemantarium of reconstructive techniques. Translating into surgical practice a traditional carpentry technique, the tongue-and-groove joint, to optimise alignment and mechanical strength of adjoining panels.

Methods

Schematic diagrams demonstrating the technique. Three cases outlining the varied indications for this technique in Hughes tarsonconjuctival flaps, Hewes tarsonconjuctival flaps, and free tarsoconjunctival grafts. Review of the frequency of application of this technique in a quaternary referral centre.

Results

A tongue-and-groove joint is an interlocking edge joint. The edge of one board has a groove, which matches the tongue formed on the edge of the adjoining board.

The three cases demonstrate this technique being applied to Hughes tarsonconjuctival flaps, Hewes tarsonconjuctival flaps, and free tarsoconjunctival grafts.

A 10 year analysis of periocular malignancies at the quaternary referral centre noted 487 periocular cancers. 77/487 underwent a Hughes flap for defects greater than half the lid width. 19/487 underwent a Hewes flap for lateral defects between one third to one half lid width.

Conclusion

From this single centre experience, we find that the anatomically correct realignment of the posterior lamellar creates a strong mechanical support for the reconstruction. And this in turn appears to reduce wound dehiscence and edge misalignment, while improving the cosmetic outcomes. Further research is required to formally compare this approach with other common tarsal reconstructive techniques with respect to surgical outcomes.

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A randomized clinical trial evaluating allogeneic Adipose-derived MesenchymAl stem cells as a treatment of dry eye disease in patients with Sjögren’s Syndrome (AMASS)

Author: Michael Møller-Hansen

Purpose

This randomized clinical trial aimed at evaluating the therapeutic efficacy of injecting allogeneic adipose-derived mesenchymal stem cells (ASCs) into the lacrimal gland (LG) in patients with dry eye disease (DED) due to Sjögren’s syndrome (SS)

Methods

Subjects who met all inclusion criteria and no exclusion criteria were randomly assigned to injection of either ASCs or vehicle into the LG in one eye. Subjects who met all inclusion criteria, but any exclusion criteria were allocated to an observation group. The primary endpoint was change in subjective DED symptoms on the ocular surface disease index (OSDI)-score, and secondary endpoints were changes in various homeostasis markers of DED. The follow-up period was 12 months.

Results

A total of 54 subjects were included in the ASCs (n=20), vehicle (n=20), and observation (n=14) groups. Baseline characteristics were similar among the three groups. A significant reduction of approximately 40% in OSDI-score was observed in both intervention groups. This change presented at the one-week follow-up and was sustained at 12-months. The observation group exhibited no change in OSDI-score. The ASCs group demonstrated a mean increase in non-invasive tear break-up time (NIKBUT) of 6.48 seconds (149%), which was significantly higher than in the vehicle group (p=0.04) at the four-weeks follow-up. Further, a significant increase in Schirmer test scores in both the ASCs (3.6 mm, 125%, p=0.01) and vehicle (3.8 mm, 115%, p=0.01) group was sustained from the four-months follow-up.

Conclusion

Injection of ASCs improved subjective and objective measures of DED due to SS, suggesting the potential of this treatment as a therapeutic option for managing DED.

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Post enucleation socket syndrome; can facial scanning and the “Orbit Asymmetry Application” help us understand PESS better

Author: yoav vardizer

Purpose

To describe the new “Orbit Asymmetry Application”, we have created, the way it works and share our experience using this application to investigate the orbits asymmetry of 28 post enucleation patients for childhood retinoblastoma.

Methods

28 post enucleation patients were interviewed for their perspective on facial asymmetry due to their anophthalmic state. Patient’s faces were scanned by a portable face scanner (Einscan pro scanner 2X). Face scans were simplified in order to enable their analysis by the application. Flipping and super positioning the right over the left side of the patients scans produced a colored 3D graph and volumetric analysis of the orbital difference between the two sides

Results

28 patients after enucleation for retinoblastoma were enrolled. Age was 2-56. Time from enucleation was 1-55 years. Age at enucleation 1-6. 13/28 had either a primary or secondary orbital implants. 19/28 patients were aware of the assymetry caused by the prosthesis. Patients used the frases: Suncken orbit, droopy eyebrow or eyelid, and deep superior eyelid sulcus. Typical scans are to be presented and described.The application succeeded diagnosing the anophthalmic side in all cases. Mathematical new tools to evaluate the asymmetry in the two orbits (total score, score percentage from scale and times the cost) will be explained and demonstrated in chosen cases. The application was not able to differentiate orbits with an implant from those without in up to 42% of cases (while wearing the prosthesis on).

Conclusion

Since PESS was introduced by Tyers and collin in 1982, and smith’s causative description (1991), little insight was added to our understanding of PESS’s phenotype. We created a new application that is capable of analyzing the asymmetry between the two sides of facial scans. This application enables to graphically see the topographic discrepancy between the two sides of the face, once mathematically superimposed, and to calculate the missing volume.The “Orbit Asymmetry Application” is an effective and easy to use tool to graphically demonstrate and volumetrically calculate the asymmetry between the two orbits of anophthalmic patients. oIt helps describe and define the surface changes in PESS.oIt helps to better evaluate the volumetric problem by comparing the two sides of the face.oIt focusses on specific orbital area that could be treated in order to achieve symmetry.oIt helps to evaluate implant size before secondary implantation of ball implants We are sure that it will enable analysis of other causes of facial asymmetry as well.

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Correlations between MRI and clinical findings in Graves’ orbitopathy

Author: Arnaud Potvin

Purpose

To assess the correlations between magnetic resonance imaging (MRI) and clinical parameters in patients with Graves’ orbitopathy (GO)

Methods

We retrospectively analyzed data from 225 patients (450 orbits) from our multidisciplinary GO clinic who were older than 18 years diagnosed GO, and who never underwent surgical decompression and did not receive steroids or radiotherapy within 3 months prior to their first visit. Clinical ophthalmic and orthoptic examination was performed within 4 weeks of the MRI. The main outcome measures included the maximal radial diameter of the extraocular muscles (EOMs), signal intensity ratio of the EOMs (relative to the temporalis muscle), relative apparent diffusion coefficient (rADC) of the EOMs (relative to the temporalis muscle), clinical activity score (CAS), ductions and best corrected visual acuity (BCVA). Spearman’s rank correlation coefficients were calculated.

Results

Mean SIR and mean rADC were correlated with the mean EOM diameter, severity, CAS, mean ductions and with each other. In the inactive group (CAS ≤ 3), mean SIR was correlated with the aforementioned measurements, mean rADC was correlated with mean SIR, mean EOM diameter, severity and mean ductions, and CAS was correlated with mean EOM diameter, severity, SIR and mean ductions. However, in the active group (CAS > 3), SIR was only correlated with severity, and rADC with BCA, severity and mean EOM diameter, but CAS was not correlated with any other parameter.

Conclusion

The MRI-specific inflammatory markers were significantly correlated with the CAS, mean EOM diameter, severity, mean ductions and with each other. However, in the active GO group inflammation seems to correlate less with EOM diameter and function.

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Analysis of Factors Related to Outcomes of Endoscopic Orbital Decompression Surgery

Author: Han Eul Lee

Purpose

To analyze factors associated with exophthalmos changes in patients undergoing endoscopic orbital decompression surgery using computed-tomography volumetric study.

Methods

In total, 116 eyes of 58 patients who underwent endoscopic orbital decompression surgery were included in this retrospective study. Data were collected before and 6 months after surgery. The degree of ocular decompression was measured using the Hertel exophthalmometer. Furthermore, orbital morphology parameters include preoperative orbit cone volume, fat volume, globe volume, other volumes (muscle, nerve and vessel) and postoperative orbital medial wall defect after semi-automated segmentation of computed tomography with 3D slicer software. Parameters associated with exophthalmos changes on univariate linear regression analysis were subjected to multivariate linear regression analyses.

Results

Univariate linear regression showed that the fat volume (β = 0.179, p = 0.041), fat volume to cone volume ratio (β = 0.129, p = 0.030), and orbital medial wall defect (β = 0.249, p = 0.004) were associated with exophthalmos reduction after endoscopic orbital decompression surgery. In addition, the multivariate linear regression of these three parameters showed significant results for the fat volume to cone volume ratio (β = 0.144, p = 0.034) and postoperative orbital wall defect (β = 0.249, p = 0.016).

Conclusion

The preoperative fat volume to orbit cone ratio and postoperative orbital medial wall defect were associated with exophthalmos reduction. When planning orbital decompression surgery, this association should be considered.

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Blepharotomy versus Levator Recession with Adjustable Sutures for Correction of Upper Eyelid Retraction in Thyroid Eye Disease

Author: Hans Olav Ueland

Purpose

To compare outcome and complications of blepharomtomy versus levator recession with adjustable sutures (LRWAS) for correction of upper eyelid retraction in thyroid eye disease (TED).

Methods

In the period 2019-2023, we performed a prospective randomized comparative study between blepharotomy and LRWAS. Patients were examined and photos obtained before and 1 week, 3 months and 6 months after surgery. Outcome was graded according to Mourits and Sasim`s classifications from 1999 (Prefect-acceptable-unacceptable).

Results

A total of 30 patients (25 women) with a median (range) age of 52 (28-74) years at surgery were included. Median time from operation to last examination was 6 (3-18) months. Fifteen (24 eyelids) were operated with blepharotomy and 15 (24 eyelids) with LRWAS.
Preoperative median MRD was 6.8 (4-8) mm for all patients, and at final visit, postoperative median MRD was 3.5 (3-4) mm after blepharotomy and 3.5 (2-5.5) mm after LRWAS. Reoperation was performed in nine eyelids, all due to overcorrection. Two reoperations were performed after blepharotomy and seven after LRWAS. At final examination, a perfect or acceptable result was found in 14 (93%) patients after blepharotomy and 13 (87%) after LRWAS. A significant different (P<0.05) median operation time was found between blepharotomy (41.5 (17-105) minutes) and LRWAS (69 (35-101) minutes).
Wound dehiscence occurred in one patient operated with blepharotomy, and one late postoperative infection was observed after LRWAS.

Conclusion

We demonstrate that LRWAS and blepharotomy are both effective methods for correcting upper eyelid retraction in TED. Blepharotomy is the fastest procedure to perform and might imply less reoperations due to overcorrection.

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Orbital inflammation: Idiopathic or IgG4-related?

Author: Leila Knani

Purpose

To identify the prevalence of Ig G4 related orbital disease among patients diagnosed with idiopathic orbital inflammation.

Methods

We retrospectively reviewed cases diagnosed with idiopathic orbital inflammation. We performed IgG4 immunostaining and identified the prevalence of Ig G4 related-disease according to the last diagnosis criteria.

Results

IgG4 positive cells were found in 30% of biopsies . Most of them were diagnosed with idiopathic bilateral dacryoadenitis. The mean age was 45 ans, with an IgG4 related disease in a 12 year-old girl.

Conclusion

Immunohistochemical analysis with IgG4 staining of previously diagnosed idiopathic orbital inflammation proved that Igg4-related orbital disease accounted for one third of idiopathic orbital inflammation. Immunohistochemistry study of orbital inflammation biopsies are recommended to rule out IgG4-related disease.

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CADS Grading Scale in Ophthalmic Management of Facial Nerve Palsy: Our Followup Experience

Author: Nirodha Jayawickrema

Purpose

Report the value of CADS grading scale guiding the management of ophthalmic manifestations of Facial Nerve Palsy (FNP).

Methods

A single centre, retrospective case series of patients with FNP. Inclusion criteria: patients with recorded CADS score in initial assessment & at 6 months follow-up. CADS grading scale assesses Cornea (C), static Asymmetry (A), Dynamic function (D) and Synkinesis (S) of periorbital structures in FNP.

Results

80 with documented followup CADS scores are included out of 328 patients with FNP seen in 8 years period (M=29, F=51, mean age 56.85, range 21 – 83 years). 79 had unilateral & 1 had bilateral weakness (Right = 35, Left = 44). 18 etiologies, preganglionic weakness in 60 & rest was postganglionic. The CADS scores of patients who were managed medically vs those who needed surgery shows a statistically significant difference (C, A & D ≤1, p = 1.26e-08, CI p<0.05). Patients needed subsequent surgery when presented with high first C & D values (C: p = 0.0161, D: p = 0.029) Patients who needed upper lid lowering surgery had significantly high C & D scores (C: p = 0.002, D: p = 7.53e-12) (i.e upper lid platinum chain placement, levator recession). Those who had lower lid elevation scored significantly high in A & D scores (A: p = 0.009, D: p = 0.0002) (i.e retractor recession, lower lid sling, lower lid full thickness skin graft with or without medial/lateral canthal reformation). Patients who underwent brow lift as a subsequent surgery had significantly high A scores (p = 1.90E-10). Chemodenervation (BTA) for synkinesis was always carried out in patients with ≥ 1 S score. BTA deferred till surgery in a group & of them 76% had ≥ 2 C & Ds.

Conclusion

When C, A & D values are individually 1 or less, it suggests considering medical over surgical management. High C & D values prompt to consider the need for upper lid lowering and high A & D suggest need for lower lid elevation. High A in subsequent visits, consider need for a brow lift. Need for BTA & timing was predictable with CADS score. According to our findings CADS scale well correlates with decisions made, hence is eligible as a highly specific and sensitive guide in ocular management in FNP.

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Changes in Lower Eyelid Position Following Transconjunctival Versus Transcutaneous Blepharoplasty: Measured by A Novel Method

Author: Demet Yolcu

Purpose

The autorefractometer was used to measure margin reflex distance, and, its validity and reliability was assessed before. The aim of the current study was to evaluate the effect of transconjunctival versus transcutaneous blepharoplasty on lower eyelid position by using the autorefractometer.

Methods

Subjects who underwent bilateral transconjunctival (with only sub-periosteal fat transposition without simultaneous canthoplasty, pinch skin excision, skin tightening procedures or fat grafting ) or transcutaneous (with sub-periosteal fat transposition, orbicularis flap suspension, lateral canthoplasty and skin excision procedures) blepharoplasty were analyzed. Autorefractometer front monitor images(AR-FMI) were obtained from all subjects both prior and after at least 3 months to the surgery. From the images MRD-2 was assessed by using the Image-J program and MRD- 2 difference both before and after surgery was analyzed.

Results

Out of 43 subjects, 28 underwent transconjunctival and 15 underwent transcutaneous blepharoplasty. Average follow-up time was 9.2  5 (3-24) months. Mean preoperative MRD-2 was 5.240.33mm for transconjunctival and 5.450.24mm for transcutaneous blepharoplasty. Mean postoperative MRD-2 was 5.010.13mm for transconjunctival blepharoplasty and 4.98  0.24 mm for transcutaneous blepharoplasty. The mean MRD-2 difference (the difference of MTD-2 before and after surgeries) was 0.21  0.18 mm for transconjunctival and 0.45  0.380.21mm for transcutaneous blepharoplasty (p: 0.23 for before and after transconjunctival surgery MRD-2 change, p: 0.12 for before and after transcutaneous surgery). There was no significant MRD-2 change among the groups ( p: 0.18).

Conclusion

Both transconjunctival and transcutaneous blepharoplasty resulted with elevation in lower eyelid height in majority of the cases. Elevation was much more prominent with transcutaneous approach; however, the difference was not significant. The autorefractometer is an easily evaluable device and can be achieved in every ophthalmic clinic to evaluate eyelid surgery results.

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