Transitioning from a gold weight to an "enhanced" palpebral spring in the management of paralytic lagophthalmos secondary to facial nerve palsy.

PURPOSE: To analyze the outcomes of patients who transitioned from a weight to a spring. METHODS: Case series original investigation. Five consecutive patients undergoing "enhanced" palpebral spring insertion status post gold weight insertion were identified. Outcome measures included visual acuity, lagophthalmos, margin reflex distance 1, and corneal epithelial defects. Subjective outcomes included need for eye lubrication, closure and rapid blink, and symptoms of discomfort and dryness. This study was reviewed by an accredited Institutional Review Board (IRB) and granted exempt status according to federal regulations. RESULTS: Mean visual acuity post weight versus spring was 20/200 (logMAR 1.0, Std Dev. -0.6) and 20/25 (logMAR 0.1, Std Dev. -0.1), respectively (p = 0.0214, CI 0.231 to 1.670). Mean lagophthalmos post weight (3.5 mm, Std Dev. -2.8) versus post spring (0.2 mm, Std Dev. -0.5). Margin reflex distance 1 improved by a mean of 1.4 mm (gold wt -0.6, Std Dev. -0.5/spring -2.0, Std Dev. -0.4) (p = 0.0016, CI -1.773 to -0.977). Superficial punctate keratopathy was present in all patients with weights and present in no patients post transition (p = 0.0079). Post transition, three of five patients rarely required lubrication and experienced a more satisfactory blink rate. CONCLUSION: Patients with lagophthalmos due to cranial nerve seven palsy who have undergone gold weight placement but continue to exhibit objective and subjective corneal symptoms may have symptomatic improvement with the transition to a palpebral spring.

Ophthalmic Plastic Surgery in Patients 100 Years and Older.

PURPOSE: The centenarian population is growing and ophthalmic plastic surgeons are providing care to an increasing number of elderly patients. Outcomes of centenarians have not been previously studied in the ophthalmic plastic surgery literature. The goal of the current review was to examine the baseline characteristics, surgical problems, and outcomes of this select group of patients. METHODS: A retrospective chart review was performed. Patients who underwent ophthalmic plastic surgery at age 100 or older between January 2000 and June 2016 by a member of the New England Oculoplastics Society were included in the study. RESULTS: Fifteen patients met inclusion criteria. The majority (66%) were female. More than half (60%) presented with a surgical problem of an urgent nature. Most disorders involved the lacrimal system or eyelids, and many were the result of trauma or infection. There were no cases of orbital tumor or thyroid eye disease. There were no surgical or anesthesia-related complications. Most patients (80%) had no documented history of dementia, and only 1 was diabetic. Notably, 33% of patients presented with no light perception vision in at least 1 eye. CONCLUSIONS: Ophthalmic plastic surgery can be performed safely in select patients 100 years of age and older. Formal prospective studies are needed to improve surgical care in this group.

Orbital Myxofibrosarcoma: Case Report and Review of Literature.

Myxofibrosarcoma is rarely found in the orbit, let alone as a primary orbital tumor. With this having only been previously reported 5 times in the literature, there is a very limited understanding of its presentation and course. Typical management involves surgical excision with or without postoperative radiotherapy. Low-grade malignancy, although rare to metastasize, still has a high rate of local recurrence and with each recurrence increases the risk of metastatic potential. With this in mind, analysis of each case is critical in better understanding the disease, and this case adds to the current literature.

Diagnosis of optic nerve sheath meningioma during optic nerve sheath decompression.

Optic nerve sheath meningioma (ONSM) is typically diagnosed based on clinical suspicion and imaging characteristics and is most often treated with radiation. Historically, biopsy, optic nerve sheath decompression, and debulking surgeries have been avoided for fear of optic nerve vascular disruption and tumor spread into the orbit. This is a case of a 48-year-old man who presented with unilateral optic disc edema, declining visual acuity, and a visual field defect. Despite an initial improvement with acetazolamide, his vision subsequently worsened. With an elevated lumbar puncture opening pressure and imaging showing right optic nerve sheath enhancement, the differential diagnosis included ONSM, perineuritis and idiopathic intracranial hypertension (IIH). Optic nerve sheath decompression (ONSD) with biopsy was performed, simultaneously decompressing the nerve and yielding a sample for pathologic analysis. A pathologic diagnosis of ONSM was made and treatment with radiation was subsequently initiated, but vision began to improve after the surgical decompression alone.

Pediatric and adult vision restoration after optic nerve sheath decompression for idiopathic intracranial hypertension.

To compare presentations of idiopathic intracranial hypertension and efficacy of optic nerve sheath decompression between adult and pediatric patients, a retrospective cohort study was completed All idiopathic intracranial hypertension patients undergoing optic nerve sheath decompression by one surgeon between 1991 and 2012 were included. Pre-operative and post-operative visual fields, visual acuity, color vision, and optic nerve appearance were compared between adult and pediatric (<18 years) populations. Outcome measures included percentage of patients with complications or requiring subsequent interventions. Thirty-one adults (46 eyes) and eleven pediatric patients (18 eyes) underwent optic nerve sheath decompression for vision loss from idiopathic intracranial hypertension. Mean deviation on visual field, visual acuity, color vision, and optic nerve appearance significantly improved across all subjects. Pre-operative mean deviation was significantly worse in children compared to adults (p=0.043); there was no difference in mean deviation post-operatively (p=0.838). Significantly more pediatric eyes (6) presented with light perception only or no light perception than adult eyes (0) (p=0.001). Pre-operative color vision performance in children (19%) was significantly worse than in adults (46%) (p=0.026). Percentage of patients with complications or requiring subsequent interventions did not differ between groups. The consistent improvement after surgery and low rate of complications suggest optic nerve sheath decompression is safe and effective in managing vision loss due to adult and pediatric idiopathic intracranial hypertension. Given the advanced pre-operative visual deficits seen in children, one might consider a higher index of suspicion in diagnosing, and earlier surgical intervention in treating pediatric idiopathic intracranial hypertension.

Regression of a paraganglioma tumor of the orbit.

PURPOSE: To describe a clinical case of an orbital paraganglioma that displayed regression after biopsy alone. METHODS: Case report. RESULTS: A 75-year-old female was examined for a right orbital tumor suspected to be metastatic breast carcinoma. An orbital biopsy was performed with significant hemorrhage encountered requiring extensive cautery. There was apparent clinical regression of the tumor with no signs of proptosis or eye movement restriction two years after this patient's biopsy. Histology was consistent with paraganglioma (glomus tumor). CONCLUSION: Although we cannot rule out spontaneous regression of this unique tumor, we postulate that tissue necrosis caused by the use of cautery induced regression. Unless encapsulated and easily accessible, we suggest that the best management of this rare tumor is that of observation after being found negative for malignancy by biopsy given their propensity for slow progression and in rare cases, regression.

Transcaruncular medial wall orbital decompression: an effective approach for patients with unilateral graves ophthalmopathy.

PURPOSE: To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. METHODS: Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. RESULTS: The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). CONCLUSIONS: Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results.

Visual improvement after optic nerve sheath decompression in a case of congenital hydrocephalus and persistent visual loss despite intracranial pressure correction via shunting.

Among the sequelae of persistent raised intracranial pressure (ICP) are ophthalmologic signs and symptoms, including cranial nerve palsies, visual field deficits, papilledema, and vision loss. Elevated pressure within the optic nerve sheath may not be relieved by shunt procedures, which can decrease generalized ICP. The authors present a case of acute visual loss in the setting of chronic hydrocephalus and multiple shunt revisions. Despite shunt correction resolving systemic symptoms of raised ICP, this child had persistent visual loss. Bilateral optic nerve sheath decompression was performed, and the visual acuity improved over the next 3 days. This case highlights the importance of routine ophthalmologic examination in patients with hydrocephalus and shunts and demonstrates the utility of optic nerve sheath decompression as a surgical intervention when shunting alone does not resolve visual loss.

Prevalence of canaliculitis requiring removal of SmartPlugs.

PURPOSE: To report the first accurate prevalence of canaliculitis associated with the use of the SmartPlug. METHODS: All patients from a single private ophthalmology practice who received SmartPlugs from 2002 to 2007 were identified. All patients from the private ophthalmology practice that developed canaliculitis secondary to SmartPlug insertion were referred to a single private ophthalmic plastic and reconstructive surgery office. A retrospective review of those 17 patients was performed. RESULTS: From 2002 to 2007, a total of 235 patients were identified from a single private ophthalmology practice with a total of 402 SmartPlugs inserted. Of those 235 patients, 17 developed canaliculitis and were referred to a single private ophthalmic plastic and reconstructive surgery office. The prevalence of canaliculitis per patient was 7.23%. The prevalence of canaliculitis per SmartPlug inserted was 4.73%. The average time from SmartPlugs insertion to onset of symptoms was 3 years. All affected patients required canaliculotomy and plug removal. CONCLUSIONS: This is the first study reporting the prevalence of canaliculitis associated with the use of the SmartPlug. All affected patients required surgical intervention, after which many continued to have dry eye and one required bilateral Jones tubes. Ophthalmologists using the SmartPlug for the treatment of dry eye syndrome should carefully weigh the risks and benefits of their use.

Bulbar conjunctival autograft with rectus muscle transeyelid traction suture for diplopia due to bulbar conjunctival scarring.

Cases of bulbar conjunctival fibrosis from pterygium surgery, strabismus surgery, trauma, chemical exposure, and inflammatory conditions can be difficult to manage. Despite surgical approaches entailing autografts, amniotic membranes, and antimetabolites, preventing postoperative scarring and contracture can be difficult, particularly in patients with susceptibility to scarring. The authors present a case of a 39-year-old man with diplopia secondary to subconjunctival scarring and fibrosis after multiple pterygium surgeries. The authors describe a unique surgical approach using a medial rectus transeyelid traction suture as a means of preventing postoperative conjunctival graft contracture and functional disability.

Resection of anterior orbital meningoencephalocele in a newborn infant.

An 11-day-old infant was referred for a large, fleshy swelling at the right medial canthus, which was noticed at birth. CT of the skull showed protrusion of brain tissue within the mass, from which a diagnosis of meningoencephalocele was made. The mass was subsequently resected by a team of physicians represented by ophthalmology, otolaryngology, and neurosurgery. Follow-up showed good cosmetic and functional results. Meningoencephaloceles usually need prompt attention to ensure a good visual and cosmetic result. Imaging before surgery and pathologic analysis are both necessary steps to successful management. Prognosis is excellent unless associated with other comorbid conditions such as Dandy-Walker syndrome, holoprosencephaly, or agenesis of the corpus callosum.

Multiple bilateral extraocular muscle metastases as the initial manifestation of breast cancer.

A 75-year-old woman had gradually progressive binocular diplopia and 2 months later had breast cancer diagnosed. Examination showed bilateral external ophthalmoplegia with lid retraction and lag and no pupillary abnormalities. Orbital magnetic resonance imaging showed enlargement and enhancement of all extraocular muscles bilaterally. A right orbital biopsy was consistent with metastatic breast carcinoma. Positron emission tomography, bone scan, and computed tomography of the chest, abdomen, and pelvis failed to disclose other evidence of breast cancer metastases. It is unusual to encounter metastatic breast cancer affecting every extraocular muscle before the diagnosis of the primary carcinoma.

Increased patient comfort utilizing botulinum toxin type a reconstituted with preserved versus nonpreserved saline.

PURPOSE: To demonstrate that injection of botulinum toxin type A is less painful when mixed with preserved saline compared with the suggested preservative-free saline reconstitution. METHODS: Two different injections were compared on 20 patients who had prior botulinum toxin type A treatments. Each side was injected with toxin reconstituted with either preserved or nonpreserved (0.9%) saline. The investigators and patients were blinded, and outcome was assessed with a verbal scale. Clinical outcome was subjectively and informally assessed by patient questioning and physician observation. RESULTS: Injection of botulinum toxin type A was noted to be less painful with the use of the preserved compared with the nonpreserved preparation (P<0.0001). The preserved reconstitution appeared to have no effect on clinical outcome. CONCLUSIONS: Injection of botulinum toxin reconstituted with preserved saline is less painful than nonpreserved saline preparations.

Medial rectus muscle injuries associated with functional endoscopic sinus surgery: characterization and management.

OBJECTIVE: To characterize and evaluate treatment options for medial rectus muscle (MR) injury associated with functional endoscopic sinus surgery (FESS). DESIGN: Retrospective interventional case series. PARTICIPANTS: A total of 30 cases were gathered from 10 centers. METHODS: Cases of orbital MR injury associated with FESS surgery were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) through an e-mail discussion group. MAIN OUTCOME MEASURES: Variables assessed included patient demographics, computerized tomography and operative findings, extent of MR injury and entrapment, secondary orbital/ocular injuries, initial and final ocular alignment and ductions, and interventions. RESULTS: A spectrum of MR injury ranging from simple contusion to complete MR transection, with and without entrapment, was observed. Four general patterns of presentation and corresponding injury were categorized. CONCLUSIONS: Medial rectus muscle injury as a complication of FESS can vary markedly. Proper characterization and treatment are important, particularly with reference to the degree of direct MR injury (muscle tissue loss) and entrapment. Patients with severe MR disruption can benefit from intervention but continue to show persistent limitation of ocular motility and functional impairment. Prevention and early recognition and treatment of these injuries are emphasized.

Radiotherapy for moderate-to-severe Graves' ophthalmopathy: improved outcomes with early treatment.

PURPOSE: The purpose of this review is to quantify the response to radiotherapy delivered early in the active inflammatory phase of moderate-to-severe Graves' ophthalmopathy. MATERIALS AND METHODS: A retrospective review of radiotherapy delivered early in the active phase of Graves' ophthalmopathy was performed. All 47 cases had moderate-to-severe ophthalmopathy, and 30 cases had optic neuropathy. Variables examined included exophthalmos, color vision, and resistance to retropulsion. Statistical analyses comparing these variables at presentation and at 3 and 6 months after radiotherapy were performed. Subset analyses comparing responses of patients with symptoms lasting longer or less than 6 months were also performed. RESULTS: At 6 months after radiotherapy, there was improvement in exophthalmos in 74.5% of cases and improvement in retropulsion in 83.0%, and all cases of previous color deficiency improved. The mean improvement in exophthalmos was 1.38 mm, color vision was two plates, and retropulsion was 1 grade. On subset analyses, there was a trend toward greater improvement in patients treated earlier in the course of their symptoms. CONCLUSIONS: Radiotherapy may play an important role in the treatment of Graves' ophthalmopathy, especially for patients with optic neuropathy. Early intervention (symptoms < 6 months) with radiotherapy may be the optimal timing for this treatment.