Incidence and severity of asymptomatic ocular injury in adult and pediatric orbital fractures.

PURPOSE: To evaluate the incidence of severe ocular injury requiring emergent ophthalmic evaluation in visually asymptomatic patients presenting with orbital fractures. METHODS: We performed a retrospective chart review of all adult and pediatric orbital fractures between 2012-2022 at a level 1 trauma center. Ocular injuries were categorized into severe, moderate, and mild. We evaluated symptoms, mechanism of injury, visual acuity (VA), and severity of injuries using the Cochran-Armitage and linear-by-linear tests. RESULTS: Of the 2495 cases, 1534 had ophthalmology evaluation. The mean ± standard deviation age was 40.4 ± 20.4 years. Most patients were male (73.1%) and Caucasian (75.9%). The mean time to evaluation was 0.6 ± 2.5 days. 486 (31.7%) were visually symptomatic, 760 (49.5%) were asymptomatic, and 288 (18.8%) were unknown. Of the symptomatic, 135 (27.8%) had severe injuries, 108 (22.2%) had moderate injuries, 216 (44.4%) had mild injuries, and 27 (5.6%) had no injuries. Of the asymptomatic, 67 (8.8%) had severe injuries, 183 (24.1%) had moderate injuries, 468 (61.6%) had mild injuries, and 42 (5.5%) had no injuries. Symptoms correlated with injury severity (p-value <.001). The most common mechanism of injury were falls (24.0%), assaults (22.2%), and motor vehicle accidents (14.8%). CONCLUSIONS: Visually asymptomatic orbital fractures were less likely to have severe ocular injuries; however, many patients were unable to express symptoms. Emergent ophthalmology evaluation should be considered in all patients presenting with orbital fractures, especially patients with visual symptoms or are unable to report symptoms.

Ipilimumab-related orbitopathy: a case report.

Ipilimumab, an immune checkpoint inhibitor used in the treatment of metastatic melanoma, can cause immune-related adverse events including rare ocular-related inflammation. This is a case of a 54-year-old man with metastatic melanoma and bilateral orbital inflammation associated with ipilimumab that occurred after drug rechallenge 6 years after initial orbital inflammation with ipilimumab use. Imaging revealed tendon-involving myositis. He was managed with intravenous corticosteroid and intravenous immunoglobulin therapy with improvement in his orbital inflammation. This case demonstrates the potential ocular effects of ipilimumab use, differentiation of ipilimumab-associated orbital inflammation from thyroid orbitopathy and management considerations to effectively reduce orbital inflammation.

Interdisciplinary Protocol for the Management of Vision-Threatening Papilledema.

BACKGROUND: This study evaluates the effectiveness of a multidisciplinary protocol for management of patients with papilledema and vision loss secondary to increased intracranial pressure. METHODS: Retrospective record review of all adult patients who presented with vision-threatening papilledema (VTPE) and were treated under this protocol. Patients are admitted for lumbar drain placement and diuretics and followed daily to determine if they may be managed medically or require surgery (optic nerve sheath fenestration [ONSF] and/or cerebrospinal fluid [CSF] shunting). RESULTS: Nineteen patients were included. Twelve had body mass index in the obese range and 6 were morbidly obese. Fourteen had idiopathic intracranial hypertension. Five had secondary pseudotumor cerebri syndrome related to medication use, dural venous sinus thrombosis, hypothyroidism, end-stage renal disease, pulmonary disease, and diastolic heart failure. Three patients did not require surgery and were discharged on oral diuretics; 3 patients underwent unilateral ONSF, 9 underwent bilateral ONSF, and 4 underwent bilateral ONSF followed by ventriculoperitoneal shunt placement. The average follow-up was 10.1 months. The visual acuity improved bilaterally in 12 patients and unilaterally in 4 patients. The remaining 3 patients had worsened vision in both eyes. Fifteen patients had bilateral improvement in their visual fields. Five eyes in 3 patients showed further constriction of the visual field at follow-up. CONCLUSIONS: We demonstrate how a multidisciplinary complex care protocol for treating VTPE can expedite and streamline treatment and restore vision. We found that most patients had improved symptoms and signs, including visual acuity, visual fields, and papilledema. We encourage institutions that manage VTPE to adopt similar institutional protocols.

Adjunctive techniques to dacryocystorhinostomy: an evidence-based review with recommendations.

BACKGROUND: Many adjunctive techniques exist for dacryocystorhinostomy (DCR), with varying levels of supportive evidence. METHODS: Literature from PubMed, EMBASE, and Cochrane Databases was reviewed between January 1990 and January 2020 to examine evidence regarding the utility of adjunctive techniques to DCR, including mucosal flap preservation, concurrent septoplasty, stenting, topical mitomycin C (MMC), and 5-fluorouracil (5-FU), as well as perioperative antibiotics and steroids. Recommendations were made based on the evidence found. RESULTS: Seven adjunctive techniques used in DCR were examined. The literature supported concurrent septoplasty when septal deviation is present. Silicone stents are recommended for external DCR approaches. MMC use is optional in external DCR and revision cases. The literature does not support the routine use of silicone stents or MMC in primary endoscopic DCR. Mucosal flap preservation is optional, with evidence showing comparable results with or without utilization. The level of evidence is limited for topical 5-FU, as well as perioperative antibiotic and steroid use. CONCLUSION: Recommendations for adjunctive techniques to external and endoscopic DCR surgeries can be made based on the current literature. Higher-level studies are needed to better optimize perioperative approaches to DCR.

Face Mask-Associated Ocular Irritation and Dryness.

During the current coronavirus disease 2019 (COVID-19) epidemic, the concern for reducing disease transmission has led to a worldwide increase in face mask utilization. During this period, we have observed a corresponding increase in ocular irritation and dryness among regular mask users. This finding has not been previously described in the literature but has important implications on eye health and infection prevention, as mask use is likely to continue for the foreseeable future.

Ocular Adnexal Reconstruction for Cutaneous Periocular Malignancies.

Although the majority of lesions present in the periocular region are benign, periocular cutaneous malignancies are certainly not uncommon and must be considered. The management of nonmelanoma cutaneous malignancies is predominately surgical with Mohs micrographic surgery or excision with frozen sections. The approach to reconstruction of the resulting defects depends on the defect location and size. When able, it is preferable to close lesions directly or with the recruitment of adjacent tissue in an effort to preserve the inherent anatomy. The eyelid's dynamic function is thus maintained, which is essential for optimal ocular surface protection. However, larger and more extensive defects will require complex reconstructions that are able to restore the necessary structural integrity to the eyelids. The authors review the various reconstruction approaches for defects of all sizes involving the periocular area including nonmarginal defects and defects of the lower and upper eyelids, as well as those of the medial canthal region.

Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions.

Aponeurotic ptosis accounts for the majority of acquired ptosis encountered in clinical practice. Other types of ptosis include traumatic, mechanical, neurogenic, and myogenic. In addition to true ptosis, some patients present with pseudoptosis caused by globe dystopia, globe asymmetry, ocular misalignment, or retraction of the contralateral lid. It is particularly important for the clinician to rule out neurologic causes of ptosis such as dysfunction of the third cranial nerve, Horner's syndrome, and myasthenia gravis, as these conditions can be associated with significant systemic morbidity and mortality. A thorough history and physical examination is necessary to evaluate each patient presenting with a complaint of ptosis. Correctly identifying the cause of the patient's complaint allows the ptosis surgeon to plan for appropriate surgical repair when indicated and to defer surgery when observation or additional clinical evaluation is warranted.

Orbital Decompression for Thyroid Eye Disease.

Although most cases of thyroid eye disease (TED) can be managed medically, some refractory or severe cases are treated surgically with orbital decompression. Due to a lack of randomized controlled trials comparing surgical techniques for orbital decompression, none have been deemed superior. Thus, each case of TED is managed based on patient characteristics and surgeon experience. Surgical considerations include the extent of bony wall removal, the surgical approach, the choice of incision, and the use of fat decompression. Outcomes vary based on surgical indications and techniques; hence, vision can improve or worsen after the surgery.

An Update on Lower Lid Blepharoplasty.

Aging changes to the lower eyelids and midface include pseudoherniated orbital fat, tear trough deformity, lid laxity, and dermatochalasis. Surgical repair often aims at treating redundant skin or orbital fat malposition with a lower eyelid blepharoplasty. Either a transcutaneous or transconjunctival approach may be used, though recent trends have favored the transconjunctival technique if procedures require more than simple skin excision. In manipulating the inferior orbital fat pads, a surgeon has many options including excision, repositioning, or augmentation with synthetic dermal filler, autologous fat grafts, or acellular dermal allografts. The authors review and detail indications, preoperative evaluation, techniques, and complications of lower lid blepharoplasty.

Pediatric Blepharoptosis.

Congenital blepharoptosis, caused by levator muscle dysgenesis, presents at birth and may lead to disturbed visual development and function. Other causes of ptosis in pediatric patients can be myogenic, neurogenic, mechanical, or traumatic. Timely correction is, therefore, critical, and careful preoperative planning and intraoperative considerations are crucial to achieve optimal outcomes and minimize potential complications. The various surgical techniques, including the frontalis suspension or sling, levator resection and advancement, Müller's muscle conjunctival resection (the Putterman procedure), and modified Fasanella-Servat procedure are each associated with distinct indications, benefits, and drawbacks, necessitating a unique tailored approach to each surgical candidate.

Multimodality Image-Guided Sclerotherapy of Low-Flow Orbital Vascular Malformations: Report of Single-Center Experience.

PURPOSE: To evaluate the role of multimodality imaging tools for intraprocedural guidance and outcome evaluation during sclerotherapy of low-flow orbital vascular malformations. MATERIALS AND METHODS: A retrospective review was performed of 17 consecutive patients with low-flow orbital malformations (14 lymphatic, two venous, and one venolymphatic) who underwent multimodality image-guided sclerotherapy between November 2012 and May 2015. Sclerotherapy technique, image guidance tools, and complications were recorded. Sclerotherapy outcome was evaluated using clinical response, magnetic resonance (MR) image-based lesion volumetry, and proptosis quantification. RESULTS: There were 22 sclerotherapy sessions performed. Intraprocedural ultrasound (US), fluoroscopy, cone-beam computed tomography (CT) and MR image fusion were used for image guidance with 100% technical success. Resolution of presenting symptoms was observed in all patients at 1-month follow-up. Four major sclerotherapy complications were successfully managed. Statistically significant reduction in lesion volume (P = .001) and proptosis (P = .0117) by MR image analysis was achieved in all patients in whom 3-month follow-up MR imaging was available (n = 13/17). There was no lesion recurrence at a median follow-up of 18 months (range, 8-38 mo). CONCLUSIONS: Multimodality imaging tools, including US, fluoroscopy, cone-beam CT, and MR fusion, during sclerotherapy of low-flow orbital malformations provide intraprocedural guidance and quantitative image-based evaluation of treatment outcome.

The Emergence of Zoonotic Onchocerca lupi Infection in the United States--A Case-Series.

This case-series describes the 6 human infections with Onchocerca lupi, a parasite known to infect cats and dogs, that have been identified in the United States since 2013. Unlike cases reported outside the country, the American patients have not had subconjunctival nodules but have manifested more invasive disease (eg, spinal, orbital, and subdermal nodules). Diagnosis remains challenging in the absence of a serologic test. Treatment should be guided by what is done for Onchocerca volvulus as there are no data for O. lupi. Available evidence suggests that there may be transmission in southwestern United States, but the risk of transmission to humans is not known. Research is needed to better define the burden of disease in the United States and develop appropriately-targeted prevention strategies.

Angiosarcoma of the Eyelid With Superimposed Enterobacter Infection.

Angiosarcoma is a rare, aggressive, malignant endothelial neoplasm with a variable clinical presentation. The authors describe a case of angiosarcoma involving the eyelid that was complicated by a superimposed Enterobacter infection. Following positive cultures for E. aerogenes and multiple biopsies suspicious but not definitive for angiosarcoma, a final biopsy was consistent with angiosarcoma.

Proptosis Caused by Rhabdomyomatous Mesenchymal Hamartomata Occurring in the Orbit.

Two infants were referred for progressive orbital proptosis. MRI in both cases demonstrated a homogenous mass in the orbit adherent to and isointense with a rectus muscle. Histopathology in both cases demonstrated a bland proliferation of spindle cells with entrapped skeletal muscle. Immunochemistry demonstrated that the abnormal tissue was of skeletal muscle origin, consistent with rhabdomyomatous mesenchymal hamartoma (RMH). Observation was elected due to the reported benign nature of RMH. In contrast to RMH of the cutaneous tissues that typically follows a benign course, RMH of the orbit may present with rapid growth.

Porcine dermal collagen in lower eyelid retraction repair.

PURPOSE: To describe clinical outcomes of patients receiving porcine dermal matrix implants for lower eyelid retraction repair. METHODS: A retrospective review of all patients who underwent lower eyelid retraction repair with porcine dermal matrix implantation between June 2007 and July 2013 at a tertiary care center was conducted. Patient demographics, procedure(s) performed, preoperative and postoperative marginal reflex distance, inferior scleral show, and complications were reviewed. Patients with a prior history of lower eyelid surgery were excluded. The study is Health Insurance Portability and Accountability Act compliant, institutional review board approved, and adherent to the Declaration of Helsinki. RESULTS: One hundred patients (160 eyelids) received porcine dermal collagen implants. Fifty-six patients had thyroid eye disease, 23 had midface descent, 10 had seventh nerve palsies, and 11 had other etiologies of retraction. The average preoperative marginal reflex distance was 7.64 mm in the OD and 7.17 mm in the OS, compared with 6.40 mm in the OD and 6.22 mm in the OS postoperatively. The average preoperative inferior scleral show was 2.04 in the OD and 1.70 in the OS compared with 0.81 mm in the OD and 0.65 mm in the OS postoperatively. Follow up ranged from 1.46 to 66.04 months, with an average of 14.06 months and median of 8.84 months. Nineteen eyelids had implant-related complications: 7 with cyst formation, 7 with exposure/rejection, 2 with long-term pain, 2 with transient inflammation, and 3 with irregular implant contour. CONCLUSIONS: Porcine dermal matrix implants provide reliable support, integration, and function in lower eyelid retraction repair without significant resorption or complications in the majority of patients.