Trends in horizontal periocular asymmetry.

OBJECTIVE: To determine whether there is laterality predominance in the horizontal dimensions of the periocular region. DESIGN: Retrospective study. PARTICIPANTS: Patients >18 years of age who presented to a single academic ophthalmology department. Exclusion criteria included history of facial trauma or surgery, aesthetic injections, or other periocular-altering processes. METHODS: Standardized digital photographs were obtained, and periocular structures were measured with Image J software. The midline was defined as the midpoint between the medial canthi, and the distances measured include midline to medial canthus, pupil centre, lateral canthus, and lateral zygoma. The palpebral fissure width was calculated as the distance between the lateral canthus and medial canthus. Data analysis was done for the full cohort and subsequently according to patient-identified gender. RESULTS: Periocular structures were measured in 83 patients (50 female and 33 male) with a mean age of 57.0 ± 16.2 years (range, 22-84 years). Right-sided predominance was found to be increasingly significant for the following variables: midline to pupil centre (31.34 mm vs 31.08 mm, p < 0.01), midline to lateral canthus (42.57 mm vs 42.23 mm, p < 0.005), and midline to lateral zygoma (65.70 mm vs 64.01 mm, p < 0.001). CONCLUSIONS: Photographic analysis of adults with no periocular-altering history demonstrates that there is a right-sided predominance in the horizontal dimension of the midline to the pupil, lateral canthus, and zygoma with increasing significance. Asymmetry of horizontal periocular measurements was more prevalent in males.

The Effect of Sleep Position Preference on Eyelid and Eyebrow Symmetry.

PURPOSE: To investigate the relationship between sleep position preference and eyebrow and eyelid position and degree of upper eyelid dermatochalasis. METHODS: A prospective study evaluating the impact of sleep position on facial asymmetry was conducted at an academic ophthalmology department. Eligibility criteria included the absence of periocular-altering trauma or surgery, contact lens use, or other periorbital disease processes. Patients reported their sleep position preference on a questionnaire. Standardized digital photographs of patients were obtained, and Image J software was used for measurements and converted into millimeters based on a standard corneal limbus-to-limbus ratio. Upper and lower eyelid position, upper eyelid dermatochalasis, and eyebrow position were assessed by the following image-derived measurements: marginal reflex distance 1 (iMRD1), marginal reflex distance 2 (iMRD2), tarsal platform show (iTPS), and central brow position (iBP). These results were compared with the patient reported sleep position preference to determine correlation. RESULTS: Seventy-one patients were enrolled and reported the following sleep position preferences: 28 (right), 24 (left), 13 (both), and 6 (supine). Patients with a right- or left-sided preference demonstrated lower iMRD1 measurements for the preferred sleep side (p < 0.0004) with no other significant difference in periorbital measurements. A larger degree of upper eyelid height (iMRD1) asymmetry was observed among patients with a sleep side preference. CONCLUSION: Patients with a predominant sleep side preference demonstrate a significant increase in ipsilateral upper eyelid asymmetry and an inferior upper eyelid position on the sleep side. There were no differences noted in lower eyelid position, central eyebrow position, or amount of upper eyelid dermatochalasis.

Lateral Wall Implant as an Adjunct to Lateral Wall Orbital Decompression in Severe Thyroid Eye Disease.

PURPOSE: To describe the use of a lateral wall implant as an adjunct in lateral orbital wall decompression in severe thyroid eye disease. METHODS: This study is a retrospective review of 6 patients who underwent prior orbital decompression but had persistent proptosis. These patients underwent lateral wall decompression with adjunct lateral wall implant placement with a manually vaulted 0.6-mm polyethylene-coated titanium mesh implant. Data collection included: visual acuity, intraocular pressure, exophthalmometry, ocular motility, eyelid position, and complication rates. RESULTS: Eight orbits in 6 patients underwent maximal lateral wall decompression and reconstruction using the polyethylene-coated titanium implant. Four males and 2 females were included with ages ranging from 25 to 73 years. Visual acuity improved an average of 2.4 lines (range 0-5 lines). Intraocular pressure improved an average of 7.5 mm Hg (2-13 mm Hg). There was reduction of proptosis by 3.4 mm on average (1-7 mm). Upper eyelid retraction improved on average by 1.8 mm (0-5 mm). Horizontal eye movements improved by 11% on average (-3.1% to +25%). Excellent cosmesis was achieved with no visible temple deformity, trismus, conjunctival scarring, orbital hemorrhage, or vision loss. CONCLUSIONS: The amount of volume created in lateral wall decompression is limited by the amount of native bone present and the temporalis muscle. In severe or recalcitrant cases, the authors propose the placement of a lateral wall implant as an adjunct to laterally displace the temporalis muscle and create additional volume. This technique accomplishes further reduction of proptosis in patients who have undergone prior orbital decompression.

Eyelid and Periorbital Soft Tissue Trauma.

Facial trauma often involves injuries to the eyelid and periorbital region. Management of these injuries can be challenging due to the involvement of multiple complex anatomic structures that are in close proximity. Restoration of normal anatomic relationships of the eyelids and periocular structures is essential for optimum functional and aesthetic outcome after trauma. This review provides an overview of the current literature involving soft tissue trauma of the eyelid and periorbital tissue, and highlights key steps in patient evaluation and management with various types of injuries.

Canalicular laceration repair using a self-retaining, bicanalicular, hydrophilic nasolacrimal stent.

Purpose: To evaluate outcomes of primary eyelid and canalicular laceration repair using a self-retaining bicanalicular hydrophilic nasolacrimal stent.Methods: This study is a retrospective review of seven patients with canalicular laceration primarily repaired with a self-retaining bicanalicular nasolacrimal stent within 72 hours of initial injury. After lacrimal intubation, repair was performed by reapproximation of the lacerated tissues. Data collection included ophthalmic examination, mechanism of injury, involvement of upper/lower/common canaliculi, symptoms of epiphora, operative time, stent extrusion and canalicular irrigation.Results: Seven patients with monocanalicular laceration were repaired using the self-retaining bicanalicular nasolacrimal stent. The stent was left in place an average of 5 months. The average operative time was 29.3 minutes. None of the stents extruded prior to removal. After 5 months, the stent was removed successfully without difficulty. All patients reported subjective improvement in epiphora, with complete resolution of symptoms. Anatomic success was confirmed with irrigation in all cases. There were no complications associated with usage of the self-retaining bicanalicular nasolacrimal stent.Conclusions: Primary repair of canalicular lacerations can be successfully performed with a self-retaining bicanalicular nasolacrimal stent. This stent has several advantages, including potentially faster operative times, no need for intranasal fixation or retrieval, easier intubation in the lacrimal system, and improved anatomic reapproximation of lacerated tissues.

The Effect of Photographic Visual Aids in Preoperative Patient Counseling in Oculoplastic Surgery.

PURPOSE: To investigate the effect of visual supplementation and its mode of delivery in preoperative counseling of patients undergoing oculoplastic surgery. METHODS: A prospective randomized controlled trial of consecutive patients undergoing oculoplastic eyebrow and eyelid surgery was conducted. Patients were randomized to an "oral only" group receiving routine preoperative oral counseling or an "oral and visual" group receiving identical counseling visually supplemented with photographs demonstrating common postoperative physical findings. Patients in the "oral and visual" group were further randomized to receive education from the medical team in person versus prerecorded video. Patient emotions and expectations regarding postoperative healing were assessed preoperatively and at 1 week and 2 months postoperatively. RESULTS: 103 patients were included: 32 received in-person oral education, 33 received in-person oral education with photographs, and 38 received education with photographs via video. There were no significant differences in demographics or preoperative patient fear, anxiety, or preparedness. The "oral and visual" group expected more severe postsurgical discomfort and physical findings at postoperative day 1 and week 1. There were no significant differences between groups in surgery signup, cancellation, or triage call rates; patient expectations of postoperative months 2 and 4; or in anxiety, preparedness, or satisfaction. CONCLUSIONS: Visual supplementation in preoperative counseling increases patient expectations of postoperative physical findings without escalating fear or anxiety, and has no significant impact on patient emotions, triage call rates, and satisfaction throughout their surgical experience. Preoperative education via video is perceived by patients to be equivalent to counseling in person by the surgeon.

Persistent Basal Cell Carcinoma Following Self-Treatment With a "Natural Cure," Sanguinaria canadensis.

A 65-year-old woman presented with a 6-week history of redness, eyelid swelling, and discharge in the right eye. Slit lamp examination revealed right medial canthal erythema with cicatricial lower lid ectropion, retraction, and inferior punctal obliteration. The patient was previously diagnosed with a medial canthal basal cell carcinoma 1.5 years ago, but opted for self-treatment with black salve, a commonly used naturopathic "cure" for skin cancer. Each application resulted in increasingly severe periorbital inflammation with eventual eschar formation. Over time, this led to cicatricial band formation over the medial canthus. After biopsy confirmation of residual basal cell carcinoma within the cicatricial tissues, the patient underwent Mohs surgery followed by multistaged reconstruction. Herein, we report a case of patient whose use of an unproven naturopathic "cure" led to persistent periorbital inflammation, persistence of malignancy, and significant tissue destruction.

Newly Designed Universal Trans-punctal Rigid Lacrimal Microendoscope.

PURPOSE: To report the development and clinical findings of a universal trans-punctal lacrimal microendoscope design. METHODS: In this study, we examined a unique and original "2-bend" (i.e., double-angle) rigid lacrimal microendoscope designed for universal applications for anatomical variations. The shape of endoscope was initially evaluated in 6 lacrimal systems of cadavers (4 Caucasian-cadaver lacrimal systems and 2 Asian-cadaver lacrimal systems). Second, a prospective clinical study involving 45 consecutive cases of nasolacrimal duct obstruction in Japanese patients was conducted to compare the facility and ease of use between the conventional single-bend type and our original 2-bend type trans-punctal lacrimal microendoscope for examination of the lacrimal drainage system. RESULTS: The findings in the cadaver study revealed that original 2-bend lacrimal microendoscope, which was designed double-angled 20°-30° at 10 and 30 mm from the tip of the scope, could more easily used to insert and image all lacrimal systems, while the conventional single-bent lacrimal microendoscope was difficult to insert in subset of patients with a prominent nasal process of the frontal bone. In the clinical trial, our findings showed that 26.7% of lacrimal systems could not be passed using the conventional single-bend design, while using the 2-bend design, all cases could successfully be investigated. CONCLUSIONS: The original 2-bend-design microendoscope was found to be effective and valuable for universal use in examination and evaluation of the lacrimal passage.

Orbital Actinomyces Masquerading as Meningioma.

Orbital actinomyces is a rare diagnosis with only a few cases reported in the literature. It can be difficult to diagnose due to its slow, indolent course, and nonspecific findings on imaging and clinical examination, and frequently it can masquerade as other pathologies such as neoplasm and inflammatory disease. The authors present a case of actinomyces masquerading as meningioma with findings of hyperostosis and a superior orbital roof interosseous tract on imaging.

Analysis of Periorbital Soft Tissue in Thyroid Eye Disease.

PURPOSE: To investigate periorbital tissue enlargement in thyroid eye disease (TED) by 3-dimensional CT volumetric analysis. METHODS: Twenty-four adult subjects, 16 with TED and 8 controls, were studied. Three-dimensional volumetric calculations were performed on CT imaging of the orbit and face, focusing on the retroorbicularis oculi fat, suborbicularis oculi fat, facial muscles in periorbital region, orbital fat, extraocular muscles, and orbital volume. Analysis was performed using JMP version 12 software. Each measure was compared between the TED and control groups using Wilcoxon rank sum test. Correlations were investigated between periorbital and orbital tissue using the Spearman's correlation coefficient method. RESULTS: A statistically significant increase in volume was measured in TED patients in the superior and inferior periorbital fat tissue (p = 0.0044, p = 0.047), including the retroorbicularis oculi fat (p = 0.0011), suborbicularis oculi fat (p = 0.0093), and a decrease in facial muscle of superior periorbital region (p = 0.035). Strong positive correlation was noted between the muscles of superior and inferior periorbital region (rs = 0.65; p = 0.0006), and between the suborbicularis oculi fat and retroorbicularis oculi fat (rs = 0.50; p = 0.013). No correlation was observed between orbital and periorbital tissue, except between the orbital fat and the inferior periorbital fat tissue (p = 0.047). CONCLUSIONS: Facial fat in the periorbital region is enlarged in TED, with the superior component correlating with orbital fat tissue expansion. These findings may assist in the clinical evaluation and management of disfigurement in TED patients.Superior and inferior periorbital fat is enlarged in thyroid eye disease with the superior periorbital fat expansion correlating with orbital fat expansion.

Resolution of self-injurious behavior in a nonverbal and developmentally delayed patient after surgical treatment of a blind painful eye.

Changes in behavioral patterns can be the only indication of the presence of pain in nonverbal patients. Phthisis bulbi results in shrinking, disorganization, and sometimes severe inflammation of the ocular globe and can occur after eye injury or multiple eye surgeries. Chronic tearing, frequent eye rubbing, and self-injurious behavior focused around the eye and periocular region may indicate ocular discomfort in nonverbal patients. In eyes that become painful and refractory to medical treatment, ocular evisceration or enucleation can provide immediate pain relief. An ocular prosthesis provides excellent cosmetic results to restore normal facial appearance after surgery.

Dog bite injuries of the eye and ocular adnexa.

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.

Incidence of diplopia after division and reattachment of the inferior oblique muscle during orbital fracture repair.

BACKGROUND: Wide surgical access to the orbital floor and medial wall is often impaired by the course of the inferior oblique muscle. There is no current consensus on the optimal surgical approach for exposure, and techniques involving inferior oblique division are generally shunned for concern of possible complications. OBJECTIVE: To determine the safety and outcomes of inferior oblique division and reattachment for surgical access to the orbital floor and medial wall during orbital fracture repair. METHODS: Retrospective, single-center, review of 85 patients that underwent orbital floor, medial wall or combined fracture repair with division and reattachment of the inferior oblique near its origin. Measured characteristics include surgical approach, type of surgery, time to surgery, pre- and post-operative diplopia, enophthalmos, and complications. RESULTS: Forty-five patients (52.9%) with no pre-operative diplopia were followed up for a mean of six months. Of these, six patients (13.3%) developed post-operative binocular diplopia that resolved in all patients on an average of three months (range 2-6 months). No patients developed torsional diplopia. One patient developed a hematoma two years later attributable to capsular contraction around the implant. CONCLUSION: Division and reattachment of the inferior oblique muscle is a safe method that allows for panoramic surgical visualization of the inferior and medial orbit.

Transcriptome Analysis of Orbital Adipose Tissue in Active Thyroid Eye Disease Using Next Generation RNA Sequencing Technology.

OBJECTIVE: This study utilized Next Generation Sequencing (NGS) to identify differentially expressed transcripts in orbital adipose tissue from patients with active Thyroid Eye Disease (TED) versus healthy controls. METHOD: This prospective, case-control study enrolled three patients with severe, active thyroid eye disease undergoing orbital decompression, and three healthy controls undergoing routine eyelid surgery with removal of orbital fat. RNA Sequencing (RNA-Seq) was performed on freshly obtained orbital adipose tissue from study patients to analyze the transcriptome. Bioinformatics analysis was performed to determine pathways and processes enriched for the differential expression profile. Quantitative Reverse Transcriptase-Polymerase Chain Reaction (qRT-PCR) was performed to validate the differential expression of selected genes identified by RNA-Seq. RESULTS: RNA-Seq identified 328 differentially expressed genes associated with active thyroid eye disease, many of which were responsible for mediating inflammation, cytokine signaling, adipogenesis, IGF-1 signaling, and glycosaminoglycan binding. The IL-5 and chemokine signaling pathways were highly enriched, and very-low-density-lipoprotein receptor activity and statin medications were implicated as having a potential role in TED. CONCLUSION: This study is the first to use RNA-Seq technology to elucidate differential gene expression associated with active, severe TED. This study suggests a transcriptional basis for the role of statins in modulating differentially expressed genes that mediate the pathogenesis of thyroid eye disease. Furthermore, the identification of genes with altered levels of expression in active, severe TED may inform the molecular pathways central to this clinical phenotype and guide the development of novel therapeutic agents.

Orbital fat regeneration following hormonal treatment of metastatic breast carcinoma.

Enophthalmos in the setting of breast cancer metastatic to the orbit results primarily from the disease pathogenesis, or secondary to treatment effects. Orbital volume restoration and fat regeneration following endocrine treatment monotherapy has not been previously reported. A 76- year-old previously healthy female presented with progressive right enophthalmos secondary to metastatic lobular breast carcinoma. Treatment with an aromatase inhibitor (letrozole) resulted in tumor regression and orbital fat restoration with a corresponding improvement in orbital volume and enophthalmos on clinical exam. The patient is alive on continued letrozole with no progressive disease ten years after diagnosis. This case illustrates the resilience of orbital soft tissues and ability of orbital fat to regenerate in face of breast cancer metastasis. We hypothesize that endocrine monotherapy, and avoidance of radiation therapy, allowed for differentiation of remaining orbital stem cells, and facilitated the fat regenerative process.

Ablative Fractional Laser Resurfacing With Laser-Assisted Delivery of 5-Fluorouracil for the Treatment of Cicatricial Ectropion and Periocular Scarring.

PURPOSE: Cicatricial ectropion and periocular scarring can cause significant functional and cosmetic deficits. Surgical treatments can be associated with recicatrization, donor site morbidity, and textural and pigmentary abnormalities. This case series reports on efficacy and safety of a novel nonsurgical approach to treating cicatricial ectropion using ablative fractional laser resurfacing and laser-assisted delivery of 5-fluorouracil. METHODS: A retrospective review was conducted of all patients at a single institution who received ≥3 rounds of ablative fractional laser resurfacing with laser-assisted delivery of 5-fluorouracil. Six patients with cicatricial ectropion and periocular scarring secondary to reconstructive surgery, traumatic lacerations, and facial burns were included. Aesthetic and functional improvement were evaluated via fluorescein staining, tear breakup time, external photography, questionnaires gauging dry eye symptoms, and scar appearance. RESULTS: All patients showed functional improvement based on fluorescein staining (mean improvement 6.0 ± 1.4; p = 0.0007) and other indicators of dry eye. All 4 patients with lagophthalmos improved and 2 showed complete resolution. All patients demonstrated significant cosmetic improvement based on a validated scar assessment questionnaire (mean improvement 37.5 ± 18.9; p = 0.004), and 5 of 6 patients reported improved satisfaction with scar appearance (mean improvement 19.3 ± 12.8; p = 0.014). There were no adverse effects reported. CONCLUSIONS: Ablative fractional laser resurfacing with laser-assisted delivery of 5-fluorouracil appears to be a safe and effective modality for treating the functional and aesthetic abnormalities associated with periocular scarring, yielding results that are difficult to attain through surgery alone. Optimal management of cicatricial ectropion and periocular scarring often requires multimodality treatment, and ablative fractional laser resurfacing with laser-assisted delivery of 5-fluorouracil may be considered as part of a comprehensive approach to managing periocular scars.