Utility of the Glabellar Flap in the Reconstruction of Medial Canthal Tumors after Mohs Surgery

The goals of periorbital region reconstruction are to obtain both functional and esthetic results. Medial canthus is the second most common periorbital location for basal cell carcinoma. If left untreated, it is locally destructive but rarely metastasizes. Incompletely resected medial canthal tumors recur or penetrate along the lacrimal path and expand to wider lesions. A safety margin is necessary to ensure a complete lesion resection. Since it was introduced in 1941, Mohs surgery has been promoted as an efficient method of dealing with infiltrative periorbital skin tumors. It has been shown to have high rates of complete cancer removal during surgery, minimizing the amount of normal tissue loss and securing better functional and cosmetic outcomes. Due to its concave contour and convergence of skin units with variable thickness, texture and mobility, reconstruction of the medial canthal region (MCR) remains challenging. Reconstructive methods such as free full-thickness skin grafts and glabellar flaps have been used alone or in combination with other techniques. The concavity of the canthus must be achieved, but the maintenance of the normal contour and symmetry of the surrounding tissue is critical. The glabellar flap (GF) is a triangular advancement flap that adequately restores the volume in deeper defects, guaranteeing sufficient vascular support without complex or undesirable scars. We present two cases of basal cell carcinoma affecting the MCR that was successfully reconstructed using a GF alone in one case and together with a cheek advancement flap in the second one. In both cases, tumor excision was performed using Mohs surgery.

Locking Y Lateral Canthopexy as a Treatment for Dry Eye Disease Caused by Eyelid Malposition.

PURPOSE: The signs and symptoms of dry eye disease (DED) can affect the quality of life of patients. This study analyzes whether locking Y lateral canthopexy improves patients' quality of life and in what way it does so (based on the ocular surface disease index questionnaire) and DED signs (measured by the fluorescein breakup time, tear osmolarity, Schirmer test, and corneal staining) in patients with DED caused by a eyelid malposition or impaired blink dynamics. METHODS: This was a case-control study. Forty eyes of 20 patients with DED and lateral canthal disinsertion examined at the University Hospital La Ribera during a 1-year period from November 2016 to November 2017. The 40 eyes were divided into 2 groups: Group 1 eyes that underwent locking Y lateral canthopexy (i.e., a plication of the superficial lateral canthal tendon to the lateral orbital rim periosteum); and group 2 eyes that underwent observational treatment, without surgery. Symptoms and signs in OU were recorded separately at baseline and 1 month after surgery. RESULTS: One month after surgery, the ocular surface disease index reduced in group 1 eyes when compared with those of group 2 (p = 0.001), fluorescein breakup time showed an improvement in the operated eyes (group 1) (p < 0.001) and corneal staining was reduced in group 1 after surgery (p = 0.012). The osmolarity results did not change when compared with eyes from group 2 (p < 0.001). CONCLUSIONS: Locking Y lateral canthopexy is an effective surgical technique for treating patients with evaporative dry eye caused by a lateral canthal tendón disinsertion by restoring proper eyelid closure and improving blinking dynamics. It improves DED signs and symptoms, thereby enhancing the quality of life of patients.

Aflibercept in the management of acute retinal necrosis syndrome-related macular edema.

PURPOSE: Acute retinal necrosis (ARN) is a panuveitis syndrome that may lead to severe complications such as cystoid macular edema (CME). There is no consensus about the best treatment. We report one case of CME secondary to ARN managed with intravitreal aflibercept. CASE REPORT: A 41-year-old woman with a history of successfully treated varicella-zoster virus-associated ARN developed an epiretinal membrane (ERM) and underwent pars plana vitrectomy, ERM removal, inner limiting membrane peel, and lensectomy. After surgery, the retinal architecture improved and the visual acuity returned to 20/20. Six months later, she developed nontractional CME, which was treated monthly with triple-dose intravitreal aflibercept (2 mg). She gained 3 lines of vision and CME resolution was achieved. DISCUSSION: Cystoid macular edema is a late complication of ARN that may affect vision. Some off-label therapies have been reported to be useful in CME secondary to ARN, including pegaptanib and interferon-α-2. Since interferon-α-2a is not currently available for ophthalmic use in Spain, aflibercept was the first choice. This soluble protein blocks the placental growth factor and all isoforms of vascular endothelial growth factor (VEGF); its half-life is prolonged and its affinity to VEGF-A is more than 100-fold greater than bevacizumab, pegaptanib, or ranibizumab. After each injection, macular thickness decreased consistently and visual acuity improved 3 lines after the treatment. CONCLUSIONS: Intravitreal aflibercept is effective in the management of acute nontractional CME secondary to ARN.

Persistent Diplopia in Primary Position after Pars Plana Vitrectomy with Encircling Band in Rhegmatogenous Retinal Detachment.

PURPOSE: To evaluate the incidence of persistent diplopia in primary position after encircling band procedures with pars plana vitrectomy (PPV) and to report the outcomes. DESIGN: Observational, retrospective study. PARTICIPANTS: One hundred sixteen patients who underwent successful rhegmatogenous retinal detachment (RRD) at our center from 2009 through 2014. METHODS: We studied all patients with RRD who underwent successful PPV with an encircling band. Patients reporting diplopia more than 2 months after retinal surgery were identified and evaluated by our strabismus colleagues. MAIN OUTCOME MEASURES: Outcome measures included near and far deviation in prism diopters, degree of anisometropia, and visual acuity. RESULTS: Six of 116 patients reported persistent diplopia in primary position (5.2%). The diplopia most often was related to vertical microdeviations from 3 to 5 prism diopters, and it was managed adequately with prisms. The deviation remained unchanged during the follow-up, except in 1 patient. CONCLUSIONS: Persistent diplopia associated to PPV with an encircling band has a low incidence and a small angle of deviation, and in our cases, it could be corrected successfully with prisms.

Keratitis due to Colletotrichu gloeosporioides and Herpesvirus reactivation / Queratiris por Colletotrichum gloeosporioides y reactivación de Herpesvirus

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Spontaneous globe luxation in iatrogenic Cushing syndrome.

PURPOSE: We report a rare case of spontaneous eyeball luxation associated with exophthalmos due to iatrogenic Cushing syndrome (CS). The normalization of serum hormones led to the regression of the picture. CASE: A 64-year-old man presented with spontaneous globe luxation of the left eye after a 6-month history of bilateral, painless, and slowly progressive exophthalmos. The patient had been receiving weekly infusions of methylprednisone over the previous 6 months. His best-corrected visual acuity (BCVA) at presentation was 20/40 in the right eye and 20/20 in the left eye. The patient demonstrated full extraocular motility. The intraocular pressure (IOP) was elevated in the right eye (24 mHg) and normal in the left eye (18 mmHg). Exophthalmometry demonstrated bilateral proptosis with measurements of 27 mm in the right eye and 28 mm in the left eye. Computed tomography scan of the brain and orbits revealed increased orbital and cervical fat. Clinical, radiographic and serologic findings ruled out potential diagnoses including orbital metastasis, thyroid orbitopathy, carotid-cavernous fistula, and idiopathic orbital pseudotumor. Clinical suspicion of iatrogenic CS was high, and additional serologic testing confirmed the diagnosis. CONCLUSION: Exophthalmos is an uncommon sign of CS, but to our knowledge, this is the first reported case of spontaneous globe luxation secondary to CS. In our case, normalization of cortisol was sufficient to resolve the clinical symptoms and eliminated the need for surgical intervention such as orbital decompression surgery.

Long-term effectiveness of vitrectomy in diabetic cystoid macular edema.

BACKGROUND: The aim of this study is to assess whether the outcome of pars plana vitrectomy for the treatment of cystoid non-tractional diabetic macular edema is stable and durable. METHODS: A prospective longitudinal analysis of central macular thickness and visual acuity was performed, using repeated-measures ANOVA, in 22 subjects with cystoid diabetic macular edema. RESULTS: Of the patients, 45.5 % met the criteria for surgical success at 6 months (achieving a reduction of central macular thickness of over 20 %, without associated loss of vision and central macular thickness less than 300 µm), of which 70 % remained stable at 1 year. A significant outcome of the intervention was found on central macular thickness (p < 0.01), but not on visual acuity (p = 0.159). This change occurred in the immediate postoperative period to remain stable thereafter. CONCLUSIONS: Vitreoretinal surgery can be an alternative treatment option in cases that do not respond to other types of treatment provided. Its expected benefit is observed in most cases in the immediate postoperative period, and is usually stable and sustained over 1-year follow-up.