Marginal Full Thickness Blepharotomy for Management of Orbital Compartment Syndrome.

PURPOSE: To assess the utility of a marginal full thickness blepharotomy (MFTB) for the treatment of orbital compartment syndrome. METHODS: An experimental study design employing a cadaver model for orbital compartment syndrome was used to assess the efficacy of an MFTB. Elevated orbital compartment pressures were created in 12 orbits of 6 fresh cadaver heads. Intraocular pressure, as an analog of orbital pressure, was measured before and after inferior and superior MFTBs were performed. Statistical analysis was performed on the collected data to assess the efficacy of the procedure. RESULTS: Both procedures were found to significantly lower the orbital compartment pressure. MFTB of the inferior lateral eyelid decreased orbital compartment pressure by an average of 62.2 mm Hg (95% CI, 56.9-67.5). MFTB of the superior lateral eyelid following MFTB of the inferior lateral eyelid decreased the orbital compartment pressure by an additional average of 10.3 mm Hg (total average reduction of 72.5 mm Hg; 95% CI, 68.1-76.9). CONCLUSIONS: Orbital compartment syndrome is a time-sensitive vision-threatening emergency that requires prompt diagnosis and intervention to prevent irreversible vision loss. The authors describe the MTFB, a simple one-step procedure that when performed correctly results in a significant decrease in orbital compartment pressure, making it a viable option when canthotomy and cantholysis fails or is unable to be performed.

Side Effects and Adverse Events After Treatment With Teprotumumab for Thyroid Eye Disease: A Retrospective Observational Case Series.

As the use of teprotumumab for thyroid eye disease (TED) becomes more prolific, there remains a scarcity of literature regarding the associated side effects and adverse events of teprotumumab use. The authors present a single-center retrospective, observational case review of TED patients who received at least a single dose of teprotumumab infusion at the oculofacial plastic surgery service between February 2020 and July 2023. The most predominant recollected side effects were fatigue, brittle nails, dry eye symptoms, hair loss, muscle spasms, and dry mouth. Significant adverse events were limited to two cases of a blood clot and a single case of pulmonary embolism. This is the first retrospective study of patient-reported side effects and adverse events experienced by a cohort of teprotumumab users.

Longitudinal Comparison of Orbital Volumes from Enucleated Eyes with Hydroxyapatite Orbital Implant in Unilateral Retinoblastoma Patients.

PURPOSE: To compare the orbital volume between enucleated and contralateral, uninvolved orbits over a 5-year period in patients with unilateral retinoblastoma who underwent enucleation with hydroxyapatite (HA) implant placement by a single surgeon. METHODS: A retrospective review was performed on the clinical records and radiographic images of unilateral retinoblastoma patients who underwent enucleation with primary HA implantation from 2003 to 2020 at a single institution. Bilateral orbital volume measurements were taken from the initial postoperative MRI scan and again at 1- and 5-years postenucleation. The main outcome measure was the longitudinal change in volume difference (∆𝑉). The implant size, age at enucleation, and sex were also evaluated. A linear mixed-effect model was used for analysis. RESULTS: A total of 124 patients (73 males) with HA implants following enucleation were included. Overall, the unaffected orbit trended toward having a greater volume compared with the enucleated orbit, but this was not statistically significant (ß = 0.003; p = 0.122). The mean age at enucleation was 2.4 years. The median time between enucleation and the initial, 1-year, and 5-year postoperative MRIs was 6 months, 17 months, and 55 months, respectively. There was no statistical correlation between age at enucleation, gender, implant size, or orbital volume at any time points (p > 0.05). CONCLUSIONS: Patients treated with enucleation and primary HA implant placement for unilateral retinoblastoma did not display significant asymmetry in orbital volume on 5-year postenucleation MRIs, suggesting that HA implants promote orbital growth comparable to a nonenucleated orbit in the pediatric population.

The posterior auricular muscle complex graft as a porous orbital implant wrap: long-term follow-up over a 31-year period.

PURPOSE: Orbital implant exposures, infections, and extrusions can occur many years following enucleation or evisceration. This study analyzes complication rates following porous orbital implant wrapped with a posterior auricular muscle complex graft (PAMCG). METHODS: This is a retrospective study of patients who underwent orbital implantation following enucleation using this technique between 1992 and 2013. Only cases with a minimum of 18 months of follow-up were included. No patients underwent peg implantation. Patient's demographics, follow-up time, type of implant, complications including wound dehiscence, exposure, postoperative infection, and extrusion were recorded. RESULTS: This study included 36 orbits of 36 patients with a mean age of 39.3 ± 23.2 years (range, 3-84 years). Thirty patients had hydroxyapatite implants and six had porous polyethylene. The average follow-up time was 12.6 ± 5.6 years (range, 1.5-31.0 years). There were no implant extrusions, and only one exposure resulting in orbital infection that necessitated implant removal (2.8%). CONCLUSION: Wrapping porous orbital implants with PAMCG had favorable long-term outcomes over a thirty-one-year period.

Metastasis of Conjunctival Melanoma to the Cardiac Atrium: A Case Report.

The authors present an unreported case of malignant conjunctival melanoma with metastasis to the right cardiac atrium. A 67-year-old woman with history of conjunctival melanoma of the OS presented with asymptomatic recurrence with new extension to the fornix. Surgical management was planned; however, the patient was admitted to the hospital with symptoms of heart and respiratory failure. She was found to have a large mass in the right atrium. The mass was resected and was found to be metastatic conjunctival melanoma. The patient received chemotherapy and her symptoms have improved. This case highlights the high recurrence rate of conjunctival melanoma and the importance of tumor surveillance.

When the Cost of Vaping Is an Eye: A Case of an Open Globe and Superior Orbital Roof Fracture.

The authors report a penetrating orbitocerebral vape pen injury necessitating a primary enucleation and craniotomy to remove the foreign body fragments. A 31-year-old male presented with acute right vision loss after a modifiable vape pen explosion launched multiple projectile fragments into his right eye. CT revealed a deformed globe with multiple radiodense curvilinear fragments in the superior orbital roof and intracranial space. A right frontal craniotomy and orbitotomy with removal of vape pen fragments, reconstruction of the orbital roof, primary enucleation, and eyelid repair were performed in conjunction with neurosurgery. To the best of the authors' knowledge, this is the first reported penetrating globe injury from a vape pen explosion.

An Orbital Mystery: A Unique Case of an Obsolete Orbital Implant With a Review of Orbital Implant Materials.

Orbital implant materials have evolved greatly over the past century and include but are not limited to metal, ceramic, polymer, silicone, and glass. Knowledge of historically used materials is clinically relevant to patient care as certain materials carry a greater risk of migration, extrusion, infection, and limitations for imaging modalities utilized to visualize adjacent structures. We report an unusual case of an 80-year-old male who presented to our community hospital with seizure-like activity. CT imaging of the brain revealed several white matter and cortex lesions with the largest lesion measuring 2.5 × 2 × 1.9 cm. The patient had a history of enucleation with placement of an orbital implant following a penetrating injury to the left eye at four years of age. Hounsfield scale analysis was read by radiology as being most consistent with a thin metallic shell surrounding the orbital implant. The potential for metallic material was consistent with the implant's age and time of placement. Few reviews on ocular implant materials from this period exist in the current medical literature. A single case report discussing a hollow metal orbital implant with similar-appearing imaging was identified. Due to concern for possible metal implant materials, the patient underwent implant exchange so MRI imaging could safely be performed. Intraoperatively, the implant was identified as a clear, hollow, non-metallic, non-porous polymer sphere. Following surgery, the patient was able to undergo appropriate neuroimaging with subsequent diagnostic biopsy. Current literature reviewing CT or photographic imaging of ocular implant devices prior to the 1940s is limited. This case highlights the importance of detailing materials historically used in orbital implants, their effects on clinical decision-making, and the utility of Hounsfield scale values to identify a material's radiodensity on CT imaging.

Primary Malignant Orbital Tumors.

Objective Primary orbital malignancy is rare. Awareness of the characteristic clinical and imaging features is imperative for timely identification and management. Surgery remains an important diagnostic and treatment modality for primary orbital malignancy, but determining the optimal surgical approach can be challenging. The purpose of this article is to explore recent advances in the diagnosis, management, and surgical approaches for primary orbital malignancies. Design In this review, the clinical presentation, imaging features, and medical and surgical management of primary orbital malignancies with representative cases will be discussed. Setting Outpatient and inpatient hospital settings. Participants Patients with diagnosed primary orbital malignancies. Main Outcome Measures Descriptive outcomes. Results Advancements in orbital imaging, microsurgical techniques, and multimodal therapy have improved the diagnosis and management of primary orbital malignancies. Special considerations for biopsy or resection are made based on the tumor's location, characteristics, nearby orbital structures, and goals of surgery. Minimally invasive techniques are supplanting traditional approaches to orbital surgery with less morbidity. Conclusions Advances in imaging technologies and surgical techniques have facilitated the diagnosis and management of primary orbital malignancies. Evolution toward less invasive orbital surgery with focus on preservation and restoration of function is underway.

Putting the Pieces Back Together: Optimizing Function and Appearance after Orbital Surgery.

Objectives To describe medical and surgical options and techniques for functional and aesthetic abnormalities after orbital surgery and multidisciplinary approaches that include the orbit. Design A review of current management options in outpatient clinics and ambulatory surgery centers with selected illustrative cases. The rationale for choosing specific medical and surgical interventions will be discussed with a focus on eyelid malposition and double vision. Setting Outpatient clinics and ambulatory surgery centers. Participants Patients with eyelid, orbital, eye muscle, and scalp contour abnormalities as a result of medical and surgical interventions for brain and/or orbital tumors. Main Outcome Measures Descriptive outcomes. Results A variety of medical and surgical options are available to optimize eyelid, orbit, extraocular muscle, and scalp structure and function.

Transvenous embolization of bilateral indirect carotid-cavernous fistulas via a unilateral transorbital approach.

A 73-year-old man with a complex ophthalmologic history presented with several weeks of worsening diplopia, visual acuity, and proptosis bilaterally. Cerebral angiography demonstrated bilateral indirect Barrow type B carotid-cavernous fistulas (CCFs). Transarterial embolization was not attempted due to small arterial diameter and risk of stroke. Multiple attempts were made to access the fistula via a transfemoral venous approach and were unsuccessful. A transorbital puncture was performed, which allowed access to both cavernous sinuses via a unilateral approach. After embolization with Onyx, there was no residual fistula. The patient had a left-sided retrobulbar hematoma from the access. Right eye vision improved postoperatively.

Practice Patterns in the Management of Amblyopia: A Survey Study.

PURPOSE: To characterize current practice preferences of pediatric ophthalmologists in the management of amblyopia and whether these are influenced by demographic variables. METHODS: A 10-question survey was distributed to all pediatric ophthalmologists and fellows attending the Annual Joseph H. Calhoun Pediatric Ophthalmology Forum at Wills Eye Hospital in 2016. The questionnaire consisted of demographic information and clinical management of amblyopia using clinical scenarios commonly encountered in pediatric ophthalmology practice. RESULTS: Of the 133 pediatric ophthalmologists who attended, 74 completed the survey, all of which were included in the data analysis. Seventy-six percent of respondents prescribed refractive correction to a 3 year old with untreated anisometropic amblyopia prior to initiating occlusion therapy. For a child with coexisting exotropia, 57% recommended refractive and occlusion therapy until significant visual improvement, then surgery; however, 30% would perform surgery earlier. Fifty-seven percent stopped occlusion therapy at 10 years of age or older. Sixty-four percent estimated a patient patching compliance rate of 50% to 75%. There was no significant relationship (P < .05) between any of the demographic variables, indicating that no group was more or less likely to respond to the question in any way. CONCLUSIONS: This study highlights the lack of a unified approach to certain aspects of amblyopia management. Physician-related demographic variables did not significantly affect clinical decision-making; however, variation did exist among respondents, a finding that warrants further investigation. [J Pediatr Ophthalmol Strabismus. 2018;55(2):100-106.].