Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study.

PURPOSE: To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). METHODS: In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. RESULTS: Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. CONCLUSIONS: Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Use of a nasolacrimal stent to treat air regurgitation after dacryocystorhinostomy in a patient using a continuous positive airway pressure device.

The dacryocystorhinostomy procedure creates a direct passageway between the lacrimal sac and nasal cavity, bypassing any nasolacrimal duct obstruction. Use of a continuous positive airway pressure device after dacryocystorhinostomy can cause nasolacrimal air regurgitation. Here, we report a case of air regurgitation after dacryocystorhinostomy that was successfully treated with placement of a Mini Monoka device, a silicone stent used in nasolacrimal surgery to prevent closure of the passageway, in a patient using a continuous positive airway pressure machine. Following the procedure, the patient was able to resume use of her continuous positive airway pressure device. CITATION: Srivatsan S, Mirza M, Imayama I, Setabutr P, Mahoney NR. Use of a nasolacrimal stent to treat air regurgitation after dacryocystorhinostomy in a patient using a continuous positive airway pressure device. J Clin Sleep Med. 2023;19(12):2123-2124.

Predictability of the Phenylephrine Test in Congenital Ptosis: Ten Years of Experience.

PURPOSE: To assess the predictability of phenylephrine testing for congenital ptosis and review outcomes of Müller's Muscle-conjunctival resection (MMCR) for congenital ptosis across ten years of follow-up. METHODS: In this retrospective case series, all patients who underwent MMCR for congenital ptosis at a single institution between 2010 and 2020 were identified. Exclusion criteria included patients who had not undergone preoperative testing with 2.5% phenylephrine in the superior fornix; patients who underwent revision surgery; and patients who had a broken suture in the early postoperative period. Demographics, margin-reflex distance 1 (MRD1) values pre- and postphenylephrine, millimeters of tissue resected intraoperatively, and final postoperative MRD1 were recorded. RESULTS: A total of 28 patients were included; 19 patients received MMCR and 9 patients received a combined MMCR plus tarsectomy. The amount of tissue resected ranged from 5 to 11 mm. There was no significant difference between median postphenylephrine MRD1 and median final postoperative MRD1 in either surgical group. Neither patient age nor levator function was significantly associated with a change in MRD1 in either group. The addition of a tarsectomy had no bearing on the final MRD1 value. CONCLUSIONS: MMCR is a viable option for patients with congenital ptosis and moderate levator function with a response to phenylephrine. In these patients, MRD1 after 2.5% phenylephrine testing correlates to the final postoperative MRD1 outcome within 0.5 mm.

Lacrimal gland botulinum toxin injection for epiphora management.

PURPOSE: Epiphora remains an often difficult to manage ocular complaint for ophthalmologists in all subspecialties. This review seeks to examine the safety and efficacy of botulinum toxin injection for management of chronic epiphora. METHODS: The authors conducted a Pubmed search for studies on the use of lacrimal and transplanted salivary gland botulinum toxin injections for the management of epiphora within the past 20 years. Studies included had a minimum of four glandular injections. RESULTS: The authors identified 14 studies and divided them by indication for injection; either functional epiphora, non-functional epiphora, or mixed studies. Seven studies examined injections for cases of functional epiphora, four for non-functional epiphora, and four for mixed cases. The number of glandular injections reported ranged from 4 to 65. Side effects reported were limited to diplopia, eyelid or lacrimal gland hematoma, papillary conjunctivitis, dry eye, ptosis, and bleeding. CONCLUSIONS: Glandular botulinum toxin injection should be considered as a viable treatment strategy for both functional and nonfunctional epiphora. From the studies reviewed, botulinum toxin injection was shown to be effective in both children and adults. Injection can be performed in the outpatient setting, is minimally invasive, technically easy to administer, has a favorable side effect profile, and good efficacy. Furthermore, repeat injections can be performed with similar efficacy.

Single-stage repair of large full thickness lower eyelid defects using free tarsoconjunctival graft and transposition flap: experience and outcomes.

BACKGROUND: Lid-sharing approaches are often advocated for repair of large full thickness lower eyelid defects, however result in temporary visual obstruction and the need for a second-stage procedure. The authors describe and report outcomes using a one-stage technique utilizing a free tarsoconjunctival graft (TCG) and musculocutaneous transposition flap (MCT) to repair defects up to 90% of the lower eyelid. METHODS: A retrospective chart review on patients that had undergone full thickness lower eyelid reconstruction using a TCG and MCT between the dates of 1/1/2015 to 3/1/2020 was performed. Demographic and clinical information including indication for repair, size of defect, post-operative complications, and outcomes were recorded and analyzed. RESULTS: Six cases of lower eyelid reconstruction using this technique were identified. Fifty percent were male, average age was 61.3 years (range 36-91, SD = 18.9), and follow up was 36.7 weeks (range 3-129, SD = 48.1). All defects were due to malignancy (4/6 for basal cell carcinoma, 1/6 each for sebaceous cell carcinoma and merkel cell carcinoma). Average horizontal defect size was 80% of lower eyelid width (range 57%-90%, SD = 12.3), while average vertical defect size was 8 mm (range 5-10 mm, SD = 1.7). There were no instances of post-operative infection, lid malposition, or dehiscence. A pyogenic granuloma was noted in one case and was managed with excision. CONCLUSION: A single-stage procedure using a TCG and MCT can be used to repair laterally based full-thickness lower eyelid defects up to 90% with satisfactory outcomes and few complications.

Malignant Conversion of Eyelid Capillary Hemangioma to Cutaneous Angiosarcoma.

Angiosarcomas represent a rare aggressive malignancy of endothelial cell origin that carry a poor prognosis. Here, the authors report the case of a 71-year-old male presenting with a well-differentiated angiosarcoma of the right upper eyelid which arose at the site of a congenital eyelid hemangioma. The patient had undergone multiple surgical resections of the hemangioma previously without adjunctive radiation therapy. This lends evidence to the potential for malignant transformation of benign hemangiomas, and long-term monitoring of benign cutaneous vascular lesions should be considered.

Patient-Specific Implants in Oculofacial Plastic Surgery.

PURPOSE: To investigate how patient-specific implants (PSIs) are being utilized for periocular facial skeletal reconstruction. Specifically, to characterize indications for custom implants, areas of reconstruction, intraoperative variables impacting implant placement, as well as to report on postoperative outcomes. MATERIALS AND METHODS: A retrospective chart review was performed for patients who received a PSI for periocular skeletal reconstruction between 2015 and 2019. Three independent academic centers were included in this study, which encompassed 4 different primary surgeons. Medical records, radiographic imaging, and operative reports were reviewed. RESULTS: Eleven patients, 8 females and 3 males, ages ranging from 15 to 63 years old received PSIs. The average duration of follow up was 16 months ± 6.6 months (range: 9-30 months). The most common underlying etiology for reconstruction was prior trauma (54.5%) followed by benign tumor resection (18.2%). The most frequent area of reconstruction involved the inferior orbital rim and adjacent maxilla (63.6%). Implant materials included porous polyethylene, polyetheretherketone, and titanium. Six implants required intraoperative modification, most commonly accommodate critical neurovascular structures (66.6%) or improve contour (33.3%). Two postoperative complications were noted, both in the form of infection with 1 implant requiring removal. CONCLUSIONS: Reconstruction of complex facial skeletal defects can be achieved by utilizing computer-assisted design software and 3D printing techniques to create PSIs. These implants represent the most customizable option for symmetric restoration of the facial skeleton by not only addressing structural deficits but also volumetric loss. This was particularly apparent in reconstruction of the orbital rim and midface. PSIs were found to be of most benefit in patients with prior trauma or complex skeletal defects after tumor resection.

Scleral lens for severe dry eye status post lacrimal gland resection for adenoid cystic carcinoma.

PURPOSE: Scleral contact lenses (SCLs) are devices that allow a fluid reservoir between the contact lens and the cornea, providing both improved lubrication and refraction. Consequently, SCLs have been used for significant refractive error in addition to a wide range of ocular surface diseases. We present the first case of a woman who complained of severe dryness and pain following resection of an adenoid cystic carcinoma of her lacrimal gland with complete resolution of her symptoms with a SCL. OBSERVATIONS: A woman who complained of severe dryness and pain following resection of an adenoid cystic carcinoma of her lacrimal gland presented to the ophthalmology clinic. She had no subsequent lacrimal function without relief from conventional dry eye treatments. However, early treatment with a SCL successfully preserved her ocular surface, improved her corneal staining pattern, and improved her vision. CONCLUSIONS AND IMPORTANCE: While other options exist, including permanent tarsorrhaphy, lid taping, or moisture goggles, the SCL allowed the combination of cosmesis, visual function, and ocular surface rehabilitation.

Loss of Pacer Spikes as electrocardiographic (EKG) Artifact Due to Microdebrider Use During Endoscopic Dacryocystorhinostomy.

As intraoperative use of electronic equipment becomes more common, familiarity with the potential for electrocardiographic artifact generated by these instruments is increasingly important. The authors' patient underwent endoscopic dacryocystorhinostomy under general anesthesia for treatment of acute on chronic dacryocystitis secondary to acquired nasolacrimal duct obstruction. She had previously had pacemaker placement for treatment of sick sinus syndrome and low ejection fraction heart failure, and use of a microdebrider intraoperatively resulted in loss of pacer spikes and interference signal on electrocardiographic leading to placement of a magnet. Post-operatively, examination of the microdebrider cord revealed a tear that likely lead to the artifactual electrocardiographic signal influencing the decision for magnet placement. Although there were no long-term ill effects, placement of the magnet was an unnecessary intervention that may have been avoided by prompt recognition of artifactual changes that may be induced by intraoperative use of electronic instrumentation.

Solitary fibrous tumor of the orbit with growth during pregnancy: a case report.

We report the case of an anterior orbital tumor in a young woman that enlarged during pregnancy. The mass was excised and found to be a spindle cell tumor with immunohistochemical reactivity consistent with a solitary fibrous tumor, a rare entity in the spectrum of fibroblastic mesenchymal tumors. The tumor was strongly positive for the progesterone receptor, consistent with its clinical growth during the antenatal and postnatal periods. To our knowledge, a primary orbital tumor with these characteristics has rarely been reported in the literature.

Posterior auricular muscle patch graft for exposed orbital implant.

The purpose of this article is to describe a surgical technique to repair an exposed orbital implant by posterior auricular muscle autograft. A retrospective review was conducted of four patients with an exposed orbital implant that were treated with a posterior auricular muscle graft. Four patients received posterior auricular muscle patch graft to the exposed orbital implant. The donor site healed with minimal scarring and remained well hidden. The graft incorporated fully into surrounding orbital tissue with no recurrent exposure at average of 13 month follow-up. The posterior auricular muscle autograft is a viable technique for repairing an exposed orbital implant.

Self-insertion of foreign bodies into the orbit and periocular tissue.

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Blepharoptosis repair.

PURPOSE OF REVIEW: To review recent advances on the mechanisms and management of acquired aponeurotic blepharoptosis. RECENT FINDINGS: Recent advances over the past year have focused on refining well known methods of ptosis repair, expanding and modifying techniques to treat difficult and more severe conditions, and uncovering the biomechanical and neurostimulatory mechanisms of ptosis and its repair. SUMMARY: Innovations in ptosis repair are discussed in the context of current treatment paradigms.

Congenital cavitary optic disc anomaly and Axenfeld's anomaly in Wolf-Hirschhorn syndrome: A case report and review of the literature.

BACKGROUND: Wolf-Hirschhorn syndrome is a rare genetic syndrome caused by a heterozygous deletion on chromosome 4p16.3 and is characterized by a "Greek warrior helmet" facies, hypotonia, developmental delay, seizures, structural central nervous system defects, intrauterine growth restriction, sketelal anomalies, cardiac defects, abnormal tooth development, and hearing loss. A variety of ocular manifestations may occur in up to 40% of patients. MATERIALS/METHODS: We report the genetic testing results, systemic findings, and complete ophthalmologic examination findings in a patient with Wolf-Hirschhorn syndrome, including external photography, RetCam3 (Clarity Medical Systems, Pleasonton, CA) goniography, and fundus photography. In addition, we review the literature on ocular manifestations of Wolf-Hirschhorn syndrome. RESULTS: Microarray analysis revealed an unbalanced translocation between 4p16.3-15.3 and Xp22.33-p22.2. Systemic findings included "Greek warrior helmet" facies, hypotonia, cleft palate, neonatal tooth eruption, talipes equinovarus, bilateral clinodactyly, clitoromegaly, partial agenesis of the corpus callosum, bilateral renal hypoplasia, and two atrial septal defects. Ocular findings included normal intraocular pressures and corneal diameters, large-angle exotropia, downward slanting of the palpebral fissures, absent eyelid creases, upper and lower eyelid retraction with shortage of the anterior eyelid lamellae, euryblepharon, lagophthalmos with poor Bell's reflex and exposure keratopathy, hypertelorism, Axenfeld's anomaly, megalopapillae, and cavitary optic disc anomaly. CONCLUSIONS: We describe the ocular phenotype of a patient with Wolf-Hirschhorn syndrome, including the rare descriptions and photographs of Axenfeld's anomaly, megalopapilla, and cavitary optic disc anomaly in this condition.