Cheeklift With and Without Posterior Lamellar Spacer Grafts for Treatment of Lower Eyelid Retraction.

BACKGROUND: To compare outcomes of lower eyelid retraction repair using a subperiosteal midface lifting technique with and without posterior lamellar grafts. METHODS: Charts of patients undergoing a sub-periosteal midface lift for treatment of lower eyelid retraction using 4 techniques for posterior lamellar reconstruction were reviewed. Thirty patients were included in each of the groups: midface with hard palate graft (HPG), midface lift with acellular cadaveric graft (ADG), midface lift with retractor disinsertion (RD) and midface lift alone (NG). Measurements of distance from pupil center to lower lid margin (MRD2) and from lateral limbus to lower lid margin (MRD2limbus) were taken from pre- and postoperative photographs and compared. Secondary outcomes included rates of reoperation, major and minor complications, resolution of symptoms and keratopathy. RESULTS: One hundred twenty operations were assessed (n = 30 for each surgical group). The average follow-up time was 20 weeks. The median MRD2 elevation was 0.95 mm (NG), 0.85 mm (HPG), 1.59 mm (ADG) and 1.02 mm (RD). The median MRD2limbus elevation was 1.06 mm (NG), 0.92 mm (HPG), 1.45 mm (ADG) and 1.12 mm (RD). There were no significant differences in MRD2 or MRD2limbus between the 4 groups (p = 0.06 and 0.29, respectively). Reoperation rates were highest with in the hard palate graft group (33%) compared to other techniques (p = 0.0006). CONCLUSIONS: Similar degrees of lower eyelid elevation were achieved with all the midface lifting techniques, and complication rates did not significantly differ between techniques. However, the higher reoperation rates with the use of spacer grafts suggest that a no-graft technique may be preferable. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reactivation After Teprotumumab Treatment for Active Thyroid Eye Disease.

PURPOSE: To determine the recurrence and reactivation rates after teprotumumab therapy for active thyroid eye disease. DESIGN: Retrospective consecutive case series. METHODS: This was a study of all patients followed for active thyroid eye disease at the Cole Eye Institute, Cleveland Clinic, treated with teprotumumab between May 2020 and May 2021. Patients with less than 6 months follow-up after completion of infusions were excluded. The primary outcome measure was reactivation, defined as a regression in proptosis (increase of ≥2 mm in either eye and to within ≤2 mm of pre-treatment level and Clinical Activity Score [CAS] worsening of 2 points or greater). Secondary outcome was diplopia response. RESULTS: A total of 21 patients were included in the study. The average long-term improvement in proptosis in the eye with more proptosis after teprotumumab was 1.57mm (range, -3 to 4 mm). Of the 17 initial responders, there were 8 reactivations (47%) and 2 isolated proptosis regressions (12%); Overall, 7 of 21 patients (33%) responded throughout the study period. Average time to regression was 12.25 months (range, 2-22.5 months). There was no statistically significant change in diplopia at final visit in any subgroup (P = 0.68 to >.99). CONCLUSIONS: At most, 33% of patients demonstrate continued response 2 years after teprotumumab treatment. The proptosis and CAS regression occurs in the setting of disease reactivation in 80% of regressions. Teprotumumab treatment appears to offer minimal long-term improvement in diplopia.

Metastatic gastric carcinoma to the eyelids masquerading as a chalazion: A case report.

Purpose: To describe an unusual case of metastatic gastric adenocarcinoma involving the eyelids and anterior orbit. Observations: An 82-year-old female with prior diagnosis of locally metastatic gastric adenocarcinoma developed eyelid edema. Initial ophthalmic assessment suggested presence of a chalazion that did not resolve with medical management. A few weeks after initial evaluation, the eyelid and facial edema worsened. Eyelid skin biopsy showed only inflammatory changes, but inflammatory work up was unrevealing and there was poor response to steroid therapy. Orbitotomy with biopsy ultimately revealed involvement of eyelid skin by a signet ring cell metastatic gastric carcinoma. Conclusions and importance: Eyelid and orbital metastasis from gastric adenocarcinoma may present mainly with inflammatory signs and symptoms masquerading as a chalazion. This case highlights the spectrum of presentation of this rare periocular metastasis.

Enucleations, Eviscerations, and Exenterations at a Supratertiary-care Hospital in Puerto Rico: A Retrospective Study.

OBJECTIVE: To provide a descriptive analysis of the indications and the intraoperative and postoperative complications of eye enucleations and eviscerations, and orbital exenterations performed at the only academic institution in Puerto Rico providing supratertiary care. METHODS: A retrospective medical record review of patients who underwent enucleations, eviscerations, and exenterations from January 2015 through June 2020 was conducted. The data were analyzed to generate a descriptive profile of the demographic characteristics of the patients, their clinical indications and surgical complications, and a histopathological diagnosis per type of eye-removal procedure. RESULTS: A total of 118 eyes were removed via enucleation, evisceration, or exenteration over the 66-month study period. The average patient age was 64 (±17.5) years and 63.8% of the patients were male. The most frequently performed eye-removal procedure was enucleation (73.7%), followed by evisceration (18.6%) and exenteration (7.6%). The main clinical indications for enucleations and eviscerations were infectious processes, namely panophthalmitis, endophthalmitis, and/or perforated corneal ulcers, that failed medical management. In our sample, squamous cell carcinoma was the most common diagnosis (both clinically and histopathologically) leading to exenteration. Postoperative complications in our patient cohort were minimal. CONCLUSION: At our institution, enucleations predominate over eviscerations. Retrospective reviews published in recent years indicate that the rate of eviscerations at our institution is comparatively low. The results of this study, the first of its kind at our institution, may encourage a re-evaluation of the indications for evisceration versus enucleation in our patient population.

Longitudinal Observations on the Mineral Metabolism of Dialysis Patients at the University Hospital.

A retrospective review was performed from November 2011 through June 2012 in 49 stable patients receiving ambulatory hemodialysis at the dialysis unit of the University Hospital in San Juan. Measurements of serum phosphate, serum calcium (corrected to albumin levels), intact parathyroid hormone (PTH), and pulse pressure were obtained at 3-month intervals over the course of a 9-month observation period. These longitudinal observations assessed the efficiency of treatment, with the objective being to determine the nature of and then implement such changes as would improve the patients' outcomes. Thirty-three of the 49 patients appeared to have fairly good control of their PTH levels during the observation period. Sixteen patients had levels over 300 pg/ml, and, using Stata data analysis software, a linear relationship with phosphate levels was obtained (p = 0.021, R2 = 0.1037, adjusted R2 = 0.0855). Pulse pressure (PP) measurements obtained at each observation interval showed the following increases: 69% at 3 months, 65% at 6 months, and 57% at 9 months. Calcium-containing phosphate binders were used in one third of the population and vitamin D analogs in 50%. A trend towards a rise in PP was observed as calcium levels increased over 9.5 mg/dl. It is concluded that those patients experiencing that rise need close supervision to avoid the increasing morbidity and mortality associated with mineral metabolism derangement. Wide PPs were observed in these patients during the 9 months of observation, denoting persistent arterial stiffness suggestive of an increase in calcium balance.