A Case of Chronic Intranasal Cocaine Abuse Masquerading and Exacerbating Underlying Orbital IgG4-Related Disease.

Chronic cocaine use may lead to widespread intranasal inflammation and necrosis. Cases of cocaine use affecting the orbit have been reported in the literature with a clinical spectrum ranging from inflammation-induced p-anti-cytoplasmic neutrophil autoantibodies positive vasculitis to severe midline destructive lesions resulting in orbital apex syndrome. Here, we present a case of chronic intranasal cocaine abuse with midline destruction that initially obscured diagnosis of, and is hypothesized to have exacerbated, underlying IgG4-Related Disease (IgG4-RD) of the orbit over a 2-year period.

Management of periocular cutaneous squamous cell carcinoma with perineural invasion: a case series and literature review.

PURPOSE: To review and elucidate the complex, multimodal management of periocular cutaneous squamous cell carcinoma (SCC) with perineural invasion (PNI), and offer practical, evidence-based patient care recommendations. METHODS: Three exemplary cases of high-risk periocular cutaneous SCC with PNI were selected from a single surgeon's experience. The clinical courses, management, and clinical outcomes, with follow-up intervals of 19, 19, and 24 months after presentation, were reviewed. The English-language literature on PNI, with attention to the management of cutaneous SCC of the head and neck (SCCHN), was reviewed. RESULTS: PNI of cutaneous SCCHN portends aggressive tumor behavior and a worsened prognosis. Treatment is multimodal, with varied combinations of surgical excision, radiotherapy (RT), and systemic chemotherapy. Retrospective reports from multiple institutions involve heterogenous patient populations, treatment strategies, and confounding variables that preclude formulation of a standardized treatment paradigm. Newer, comparative studies of advanced RT techniques (e.g., hyper-fractionation), novel systemic chemotherapeutic agents (e.g., cetuximab, cemiplimab), and varied integrative regimens are providing additional insights. Prompt initiation of adjuvant therapies (within 6-8 weeks of surgery), and careful evaluation of lymphatic basins can increase oncologic control. Utilizing deep-tissue fixation of advancement flaps and eyelid stabilization can enhance functional and aesthetic results. CONCLUSIONS: Management of cutaneous SCC with PNI remains complex and in most cases requires combined-modality therapy directed by a multidisciplinary tumor board. With novel therapies and new treatment patterns, optimal combinations and intensities of individual modalities require further elucidation. The oculofacial plastic surgeon plays a pivotal role - in diagnosis, coordination of interdisciplinary management, thoughtful surgical reconstruction, and postoperative surveillance.

Aesthetic Eyelid Measurements of "Beautiful People": Gender Differences and Application for Thyroid Eye Disease Patients.

There remains a paucity of studies investigating measurements of periocular structures of people popularly seen as "beautiful." Such measurements may be helpful in establishing postoperative goals and measuring aesthetic outcomes. This study (1) identifies aesthetic measurements of the periocular structures in idealized celebrities, (2) determines gender differences in such measurements, and (3) compares these measurements to patients who underwent surgical repair of upper eyelid retraction associated with thyroid eye disease. METHODS: Digital analysis of 38 celebrity photographs in People's "Most Beautiful People" and "Sexiest Man Alive" was performed to measure image-derived (denoted with an "i") margin reflex distance (iMRD1), tarsal platform show (iTPS), brow fat span (iBFS), and iTPS:iBFS ratio. The same analysis was used for 35 women who underwent surgical repair for thyroid eye disease-related upper eyelid retraction. RESULTS: Significant gender differences (P < 0.05) were observed in celebrity metrics, with women having higher upper eyelids (longer iMRD1) (3.30 mm versus 2.50 mm), longer iTPS measurements (3.90 mm versus 2.50 mm), and larger iTPS:iBFS values (0.31 versus 0.20). Postoperative thyroid eye disease patients had significantly higher upper eyelids (longer iMRD1s) (4.80 mm versus 3.30 mm), longer iTPS (5.10 mm versus 3.90 mm), and larger iTPS:iBFS (0.37 versus 0.31) than celebrities. CONCLUSIONS: There are significant gender differences in the periocular metrics of "beautiful people." Optimal aesthetic outcomes may be more effectively obtained by achieving a preferred range of ratios than by relying on independent measurements. Although aesthetic outcomes are multi-factorial, measurements of "beautiful" people provide helpful guidelines to gauge aesthetic outcomes.

Intimate partner violence as a mechanism of traumatic ocular injury in women.

OBJECTIVE: Determine the prevalence of intimate partner violence (IPV) as a mechanism of traumatic ocular injury in women, typical injury patterns, and the clinical course of affected patients. Encourage IPV screening and safety assessment in patients presenting with characteristic ocular trauma. METHODS: Medical records of 211 female patients with traumatic ocular injuries evaluated at the University of Iowa Hospitals and Clinics between January 1995 and January 2015 were reviewed to determine the rate of IPV as a mechanism of ocular trauma. Twenty-one patients were excluded due to no documented trauma. RESULTS: Leading causes of traumatic ocular injuries in the 190 female patients included were accidental trauma with an inanimate object (n = 70/190, 36.8%), falls (n = 52/190, 27.4%), motor vehicle collisions (n = 21/190, 11.1%), and assault (n = 16/190, 8.4%). In 2.1% of cases (n = 4/190), no mechanism of traumatic injury was documented. Assault was the fourth leading mechanism of injury accounting for 8.4% of cases (n = 16/190), with IPV accounting for more than one third of cases with a documented perpetrator (n = 5/13). No perpetrator was documented in 18.8% (n = 3/16). All 5 patients with IPV-related injuries sustained scleral laceration or rupture; 4 out of 5 patients had no light perception vision and ultimately required enucleation. CONCLUSION: IPV is an important mechanism of traumatic ocular injury. IPV-associated injuries tend to be severe in nature, as demonstrated by the high rate of globe laceration or rupture and subsequent enucleation in the study population. By appropriate screening and referral, ophthalmologists have an opportunity to redirect a potentially devastating course.

Effect of iris show on perceived upper eyelid height.

OBJECTIVE: To introduce "iris show," the amount of visible iris tissue between the superior pupil border and the upper eyelid margin, to evaluate the effect of iris show on perceived upper eyelid height, and to discuss potential nonsurgical treatment options for mild blepharoptosis. METHODS: Participants completed a survey containing 4 subject photographs. These photographs depicted images of varying iris colouration (blue, green, light brown, and dark brown) with identical upper eyelid marginal reflex distance (MRD1) values, but asymmetric pupil size/amount of visible iris show. Study participants were asked to select the eyelid that appeared "droopier," or choose "same height." Statistical analyses used 1-tailed and 2-tailed t tests. RESULTS: 390 participants completed the survey. In photographs of blue and green irides, both eyelids had equal MRD1s, but the eyelid with less iris show was perceived as more ptotic (p = 0.002 and 0.03, respectively). In patients with dark brown irides, eyelid heights were perceived as identical despite differences in iris show (p = 0.002). CONCLUSIONS: Decreased iris show corresponds to perceived lowering of the upper eyelid in light-coloured irides (e.g., blue and green), but may be less impactful in brown and/or dark brown irides where the iris tissue is less distinguishable from the pupil. Topical instillation of apraclonidine may represent a nonsurgical option for treatment of mild blepharoptosis in patients with light irides as it both elevates the upper eyelid margin and induces miosis, resulting in an increase in iris show and corresponding enhanced perception of upper eyelid elevation.

Upper Eyelid Response to Topical 0.5% Apraclonidine.

PURPOSE: To describe the change in upper eyelid position in a self-reportedly normal population after the administration of topical 0.5% apraclonidine in each eye. METHODS: One hundred self-reportedly normal subjects received a 1-time administration of topical 0.5% apraclonidine in each eye. Digital photographs were taken at baseline and then 30 and 45 minutes following apraclonidine instillation. Marginal reflex distance 1 was determined via image analysis of acquired digital photographs (image-derived measurements are given the prefix "i" in this study). The horizontal corneal diameter was used as a constant measurement scale in each photograph. RESULTS: The mean increase in i-marginal reflex distance 1 post-administration of 0.5% apraclonidine was +0.70 ± 0.60 mm (range, -0.94 to +2.66 mm) after 30 minutes and +0.68 ± 0.59 mm (range, -0.69 to +2.54 mm) after 45 minutes. Of the 200 total eyelids in 100 subjects, 181 (90.5%) had an increase in i-marginal reflex distance 1 at 30 minutes. Of the 100 subjects, 85 (85%) had a bilateral increase in i-marginal reflex distance 1, 4 (4%) had a bilateral decrease, and 11 (11%) had a unilateral increase with a contralateral decrease. CONCLUSIONS: Given its predominant small-amplitude upper eyelid elevating effect, topical apraclonidine may be a useful off-label alternative treatment for mild upper eyelid ptosis and in eyelid asymmetry due to eyelid retraction through use in the contralateral eye.

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

PURPOSE: To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. METHODS: A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. RESULTS: In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. CONCLUSIONS: Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.

Rethinking Our Definition of Postoperative Success: A Comparative Analysis of Three Upper Eyelid Retraction Repair Techniques Using Novel Metrics to Capture Functional and Aesthetic Outcomes.

PURPOSE: To compare 3 upper eyelid retraction repair techniques and introduce novel metrics, which enhance the analysis of postoperative aesthetic outcomes. METHODS: Retrospective review with Image J 1.48 digital analysis of patients who underwent repair of thyroid-related upper eyelid retraction at the University of Iowa from 1996 to 2014 via 1 of 3 surgical techniques, septum-opening levator recession with Muellerectomy, modified septum-preserving levator recession with Muellerectomy, and modified septum-preserving full-thickness blepharotomy, was conducted. Photographs were obtained preoperatively, 3 to 6 months postoperatively, and at last follow up (>6 months) and evaluated by digital image analysis (denoted by "i"). Outcome measures assessed were marginal reflex distance (iMRD1), temporal-to-nasal ratio, tarsal platform show (iTPS), pupil to visible eyelid crease, brow fat span (iBFS), tarsal platform show to brow fat span ratio (iTPS:iBFS), and tarsal platform show minimizing power (iTPS-minimizing power). RESULTS: A total of 121 eyelids (28 septum-opening levator recession with Muellerectomy, 66 septum-preserving levator recession with Muellerectomy, and 27 septum-preserving full-thickness blepharotomy) from 74 patients were evaluated with a mean follow up of 24.2 months. There were no statistically significant differences between techniques in terms of iMRD1 or temporal-to-nasal ratio reduction at either time point (intertechnique p values of 0.17 to >0.99). The percentage of eyelids from subjects undergoing bilateral intervention that achieved a final iMRD1 between 2.50 mm and 4.50 mm was similar (intertechnique p value of 0.23), with no difference regarding the number of subjects demonstrating iMRD1 symmetry within 1 mm (intertechnique p value of 0.15). Though iTPS elongation was greater at 3 to 6 months with septum-opening compared with the combined septum-preserving techniques (p value of 0.04), this difference was not maintained at final follow up (p value of >0.99). There was no difference in terms of iTPS symmetry at time of final follow up (intertechnique p value of 0.69). The pupil to visible eyelid crease was unchanged in all techniques (p values >0.99). Mean changes in iBFS at final follow up were -1.27 mm, -0.44 mm, and +0.55 mm for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy (p values of 0.01, 0.49, and >0.99, respectively). Mean iTPS:iBFS ratios at final follow up were not statistically different between techniques (intertechnique p value of 0.10) and no difference in symmetry was demonstrated (intertechnique p value of 0.47). Median values for iTPS-minimizing power were: -0.83, -0.93, and -1.01 for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy, respectively (intertechnique p value of 0.54). CONCLUSIONS: Each technique appropriately lowered the eyelid and improved contour without intertechnique variability. Septum-preserving techniques demonstrated less iTPS elongation initially, but this difference was not maintained. The visible eyelid crease height (pupil to visible eyelid crease) remained stable in all techniques, indicating that the iTPS elongation seen with each technique was secondary to reduction in iMRD1 and the iBFS reduction seen with septum-opening levator recession with Muellerectomy was due to brow descent. No intertechnique differences in the amount of iTPS elongation relative to iMRD1 reduction (i.e., the novel iTPS-minimizing power) were seen. Given that each procedure evaluated yielded similar results, technique selection may be guided by surgeon experience and preference.

A Vector Force Model of Upper Eyelid Position in the Setting of a Trabeculectomy Bleb.

PURPOSE: A vector force model for the determination of upper eyelid position in the setting of a trabeculectomy bleb is presented. The model is used to explain the clinical courses of 5 patients with bleb-induced upper eyelid malposition and the efficacy of modalities previously described for the treatment of bleb-induced upper eyelid retraction. The novel use of botulinum toxin in the treatment of bleb-induced eyelid retraction and unique surgical considerations in patients with trabeculectomy blebs undergoing upper eyelid surgery are discussed. METHODS: A vector force analysis was conducted and a force diagram constructed. The clinical and surgical courses of 5 patients with trabeculectomy blebs and upper eyelid malposition were reviewed. The vector force model was applied to these cases and the previously described treatment modalities for bleb-induced upper eyelid retraction. RESULTS: Vector force analysis demonstrates that in the case of trabeculectomy bleb-induced upper eyelid retraction, the net force vector, which represents the sum of all the individual forces acting on the eyelid, has a positive vertical component resulting in superior displacement of the eyelid. In contrast, bleb-induced ptosis results when the net force vector has a negative vertical component. In 3 patients, alterations in the bleb resulted in resolution of upper eyelid malposition. Botulinum toxin was used to achieve a normal upper eyelid position in 1 patient with lateral canthal tendon disinsertion and unilateral eyelid retraction and 1 patient with bilateral eyelid retraction. One patient developed unilateral ptosis in concert with the emergence of a large Tenon cyst that resolved with the treatment of the cyst via eyelid massage. One patient with unilateral ptosis and an ipsilateral bleb underwent external levator advancement but was unable to achieve the desired upper eyelid height as retraction over the bleb occurred with any attempt to elevate the eyelid above a marginal reflex distance of 1.5 mm. The efficacy of previously reported modalities for the treatment of trabeculectomy bleb-induced upper eyelid retraction can be explained by either a reduction in the positive vertical component of the net force vector or augmentation of the negative vertical component. CONCLUSIONS: A vector force model systematically accounts for the multiple determinants of upper eyelid position in the setting of a trabeculectomy bleb. This model provides a framework for the evaluation of bleb-induced upper eyelid malposition and offers a logical, mathematical explanation for the occurrence of bleb-induced upper eyelid retraction and the usefulness of previously reported treatment modalities for this clinical entity.