Upper eyelid reconstruction using an advancement tarso-conjunctival flap.

PURPOSE AND CONTEXT: Upper eyelid reconstruction is particularly complex due to its functional and aesthetic importance. We aim to assess the outcomes/ complications of patients who undergo upper eyelid reconstruction of the posterior lamellae with an advancing tarsonconjunctival flap from the same affected eyelid, following excision of a periocular malignancy by Mohs Micrographic Surgery. METHOD: A retrospective consecutive case note review of all eight patients who underwent the procedure between May 2016 and Jan 2021 were included. Patient demographics and factors influencing outcomes (smoking status, use of blood thinners, past medical/ drug history, size/location of the defect), follow up duration and complications were recorded. KEY RESULTS: Minor post-operative complications included an eyelid notch and retraction. There was one patient with lagophthalmos, but no exposure keratopathy. Two patients had misdirected lashes, one requiring electrolysis. Both monocular patients, who required the procedure in their only seeing eye, and were unable to tolerate a compressive dressing, had wound dehiscence. One patient was on steroids and the other on warfarin and a diabetic. No vision loss ensued and no-one underwent surgical revision. Follow up ranged from 4-52 months. CONCLUSIONS: An advancing tarso-conjunctival flap is an expedient single-stage reconstructive technique that can be used to reform up to two- thirds of the posterior lamellae in full thickness upper eyelid defects involving the lid margin. Complications are minor. It is of particular benefit in patients where occlusion of the visual axis is unacceptable, although the risk of wound dehiscence is high. This technique forms a valuable part of the systematic reconstructive algorithm.

Orbital metastasis from neuroendocrine tumour: Case report and literature review.

Orbital metastases from neuroendocrine tumour are rare entities. An incidental finding of orbital metastasis originating from neuroendocrine tumour is presented in the context of a comprehensive review of all case reports and series published to date. Demographics, clinical features, diagnostic work-up, treatment and prognostic data from the published literature are discussed. Ninety-five patients with orbital metastases from neuroendocrine tumours have been reported so far. Average age at presentation is 63.8 years (range 25-86), with no significant gender predominance. Gastrointestinal tract is the most common site of primary neuroendocrine tumours (62-85%). Typical presentation includes proptosis (80-85%) and diplopia (27-62%) in patients with known primary neuroendocrine tumour elsewhere. Histological subtype and presence of metastases seem to be important prognostic factors. Incidental finding of neuroendocrine tumour mestastases in asymptomatic patients with unknown primary disease is uncommon. In such cases, orbital biopsy and structural and functional imaging are essential to establish a diagnosis and stage the disease.

Modified cheek advancement flap for medial lower eyelid, nasal sidewall and infraorbital cheek reconstruction: a case series.

Aim: To describe and evaluate surgical outcomes of the Modified Cheek Advancement Flap (MCAF) to reconstruct defects involving medial lower eyelid, nasal sidewall and infraorbital cheek following Mohs micrographic surgery for basal cell carcinoma (BCC).Materials and Methods: All patients who underwent MCAF between 2012 and 2018 under the care of a single surgeon (LCA) were identified. The technique described in this report is a significant modification of the traditional cheek advancement flap. The MCAF was undertaken without subciliary or infraorbital incisions, less extensive dissection and use of flap advancement rather than rotation. A retrospective chart review was completed using a pro-forma which included risk factors for flap failure, early and late complications and additional reconstructive procedures. Patient satisfaction was rated using a five-point Likert-type scale.Results: 42 patients underwent the MCAF. Mean follow up was 28.4 months (±19.9 months). Early complications were found in 11.9% of the patients and resolved completely within the first four post-operative weeks. There were no long term complications secondary to the reconstruction. No lower eyelid ectropion was noted. 78.6% of the patients cited they were 'extremely satisfied' with the final cosmetic outcome.Conclusion: The MCAF proves a valuable and safe option in periocular reconstructive surgery with excellent cosmetic results and no post-operative ectropion. The necessity for eyelid tightening as part of the reconstructive process should encourage oculoplastic surgeons to use the MCAF when reconstructing defects involving medial lower eyelid, infraorbital cheek and nasal sidewall.

Orbital infantile haemangioma: radiological features and treatment - case series and literature review.

AIM: The aim of this study is to report a retrospective case series on orbital infantile haemangiomas (OIH). Radiological features and treatment with oral propranolol (OP) are illustrated along with an updated literature review. METHODS: A retrospective chart review of six children, diagnosed with OIH from November 2015 to October 2016, was carried out. Only children with deep documented orbital involvement were included. All patients underwent magnetic resonance imaging (MRI) under general anaesthesia. OP was administered to the infants according to the Nottingham Children's Hospital guideline. As per the guideline, a preliminary paediatric assessment was performed and a 1 mg/kg test dose was administered, followed by definitive treatment at a dosage of 2 mg/kg in three divided doses. RESULTS: Average age at presentation was within the first 3 weeks of life. T1 hypointensity, T2 hyperintensity, avid enhancement with contrast, and the presence of flow-voids appear a fixed pattern of OIH on MRI. Response to treatment was noticed within 4 weeks in all children, and two of them (33.3%) responded within the first 7 days. In two children (33.3%), the haemangioma became clinically undetectable by the seventh month of treatment, while the other four (66.6%) experienced an almost complete regression of the OIH by the last follow-up. No complications were found. CONCLUSIONS: Our series strengthens the understanding that MRI is the preferred imaging modality in the investigation of OIH, showing vascular features, detailed orbital extension, and possible associated malformations. OP is the treatment of choice for OIH, and our study confirms its safety and effectiveness.

Effectiveness of 0.1% topical salicylic acid on blepharoconjunctivitis affecting glaucoma patients treated with topical prostaglandin analogues: a prospective randomized trial.

AIM: To evaluate the efficacy of 0.1% topical salicylic acid (TSA) to treat iatrogenic chronic blepharoconjunctivitis in patients with primary open angle glaucoma (POAG), treated with topical prostaglandin analogues (TPAs). METHODS: Totally 60 patients were randomly distributed into 3 equal size groups, two of which treated with 0.1% TSA (OMKASA®) and 0.1% topical clobetasone butyrate (TCB; VISUCLOBEN®) respectively, and one consisting of untreated controls. The parameters taken into account at baseline (T0) and after 30d (T1) of therapy were: conjunctival hyperemia, lacrimal function tests [Schirmer I test and break up time (BUT)] and intraocular pressure (IOP). RESULTS: Conjunctival hyperemia showed a substantial improvement in both treated groups (P<0.001) but not among controls. Similarly, lacrimal function tests displayed an improvement of Schirmer I test in both treated groups (P<0.05) and an extension of BUT only in the group treated with 0.1% TSA (P<0.05). The IOP increase was statistically significant only in those patients treated with 0.1% TCB (P<0.001). CONCLUSION: The 0.1% TSA has proved to be an effective anti-inflammatory treatment of blepharoconjunctivitis affecting glaucoma patients on therapy with TPAs, leading to a sizeable decrease of inflammation as well as both quantitative and qualitative improvement of tear film. Furthermore, differently from 0.1% TCB, it does not induce any significant IOP increase.

Long-term outcomes after cosmetic customized prostheses and dermis fat graft in congenital anophthalmia: a retrospective multicentre study.

PURPOSE: To evaluate long-term outcomes of progressively enlarging cosmetic customized prostheses (CCP) early after birth followed by dermis fat graft (DFG), as a strategy of socket rehabilitation in children with clinical congenital anophthalmia (CCA). METHODS: Twenty patients with unilateral and two patients with bilateral CCA were enrolled. All patients were treated by inserting a CCP at the time of their first assessment which was then enlarged. Subsequently they underwent DFG. Differences in vertical palpebral aperture (VPA) and horizontal palpebral length (HPL), between affected and unaffected sides, were recorded at the first CCP fitting as well as before and after DFG. Satisfaction with cosmetic results, prosthetic retention, and complications rate were assessed. Magnetic resonance imaging of the orbit was performed in all patients before and after surgery. RESULTS: A significant decrease in the difference between the normal and the anophthalmic side of both PA and HPL was found over follow-up. Both VPA and HPL differences decreased by 47.6% (10.5 mm, range 1-28 mm) and by 7.1% (5.8 mm, range 0-18 mm), respectively. Satisfaction in terms of cosmetic outcomes proved to be very positive, being "very satisfied" for families and "satisfied" for physicians. Excellent retention of prostheses was observed in all cases. CONCLUSIONS: A rehabilitating strategy combining early CCP and further DFG proved to be a valuable approach in children with CCA, offering significant benefits in terms of socket expansion, prosthetic retention, psychological impact, and cosmetic outcomes.

Orbital Inflammatory Complications of Crohn's Disease: A Rare Case Series.

Orbital inflammatory disease is a rare ophthalmic manifestation of Crohn's disease. Inflammation is characteristically nonspecific, involving one or multiple structures of the orbit. Mechanisms of disease and optimal methods of treatment are poorly understood. The aim of this report is to present 3 cases of orbital involvement in Crohn's disease. A retrospective case note review of patients with orbital inflammatory disease and Crohn's disease was performed at our academic center to determine the clinical, imaging, and histopathologic features of this condition and its relationship to intestinal Crohn's disease. Three patients were identified with orbital inflammatory manifestations complicating Crohn's disease. All patients described were women with active intestinal disease and had a history of treatment with immunosuppressive therapies. Similarities were observed in clinical presentations with variance noted in radiologic and histopathologic findings. In all cases, symptoms improved with oral corticosteroids or nonsteroidal drugs in combination with anti-tumor necrosis factor agents. Inflammatory bowel disease-related orbital complications are rare but potentially vision-threatening. It is important to consider mimics of orbital inflammatory disease such as systemic inflammatory disease, malignancy, congenital malformations, infection, and trauma when formulating a comprehensive differential diagnosis. Therapeutic intervention is directed toward preservation of vision and orbital function and reducing the acute inflammatory process. Corticosteroids are typically the initial treatment of choice for moderate-to-severe disease, although several classes of immunomodulatory agents have been variably useful in treating this condition. Heightened awareness and close cooperation between gastroenterologists and ophthalmologists are mandatory.

Periocular Amyloidosis Manifesting as Pseudopemphigoid Treated With Mitomycin C.

PURPOSE: To describe an unusual cicatrizing manifestation of periocular amyloid and the utility of adjuvant antimetabolite therapy. METHODS: This is a case report of a 49-year old woman with progressive bilateral upper lid ptosis, who was found to have bilateral inferior forniceal masses with thickening of the conjunctiva. Conjunctival and eyelid biopsies showed evidence of amyloid deposition. Systemic evaluation did not reveal any evidence of systemic amyloidosis. Her blepharoptosis continued to deteriorate, and she underwent bilateral sequential upper lid ptosis correction surgery and debulking procedures. Subsequently, she developed severe and progressive cicatricial conjunctivitis with extensive symblepharon formation in all 4 fornices and restriction of ocular motility, simulating a clinical picture of ocular mucous membrane pemphigoid. RESULTS: She was treated surgically by division of symblepharon augmented with application of topical mitomycin C intraoperatively. This has been partially successful in freeing up differential movement between her lid and her eye and consequently improving eye protection and lubrication. CONCLUSIONS: Pseudopemphigoid represents a rare manifestation of periocular amyloid. Risks and benefits of surgical procedures in this context need to be carefully weighed to minimize the risk of secondary complications. Topical mitomycin C may be considered as a relatively safe adjunct in managing the cicatricial component of the disease.

Neurofibromatosis: an update of ophthalmic characteristics and applications of optical coherence tomography.

Neurofibromatosis (NF) is a multisystem disorder and tumor predisposition syndrome caused by genetic mutation on chromosome 17-17q11.2 in NF type 1 (NF1), and on chromosome 22-22q12.2 in NF type 2. The disorder is characterized by considerable heterogeneity of clinical expression. NF1 is the form with the most characteristic ocular manifestations. Lisch nodules of the iris are among the well-known diagnostic criteria for the disease. Glaucoma and associated globe enlargement have been described in a significant proportion of patients with NF1 and orbital-facial involvement. Optic nerve glioma may cause strabismus and proptosis, and palpebral neurofibroma may reach considerable size and occasionally show malignant transformation. Near infrared reflectance has greatly contributed to enhancing our knowledge on choroidal alterations in NF1. Indeed, some authors have proposed to include these among the diagnostic criteria. Optical coherence tomography has given new insight on retinal alterations and is a noninvasive tool in the management of optic nerve gliomas in children. Ocular manifestations in NF type 2 can range from early-onset cataracts in up to 80% of cases to optic nerve hamartomas and combined pigment epithelial and retinal hamartomas.