Patient Preferences for Physician Attire in Ophthalmology Practices.

IMPORTANCE: Interest is growing in targeting physician attire to improve the patient experience. Few studies in ophthalmology have examined patient preferences for physician attire. OBJECTIVE: To understand patient preferences for physician attire in ophthalmology practices in the United States. DESIGN: Survey-based, cohort study. SETTING: Two private and two academic ophthalmology practices. PARTICIPANTS: A convenience sample of patients receiving ophthalmic care between June 1, 2015 and October 31, 2016. METHODS: A questionnaire containing 22 questions and photographs of a male and female physician in seven forms of attire were presented to patients; 14 unique questionnaires were randomly distributed. Patient preference for physician attire was the primary outcome determined by summing ratings of how knowledgeable, trustworthy, caring, approachable, and comfortable the pictured physician made the respondent feel. One-way ANOVA assessed differences in mean composite scores. Comparisons between respondent demographics, practice type, and attire preferences were assessed by chi-square tests. Patient satisfaction was assessed by agreement with questions about importance of physician attire and whether this influences happiness with care. RESULTS: In total, 1,297 of 1,826 (71.0%) questionnaires were completed. Physician attire was rated as "important" by 62.9% of participants. A total of 43.6% of participants indicated that physician attire influenced how happy they were with their care. Overall, formal attire with white coat was preferred to casual, formal, and business attire (all comparisons, p < 0.05). No differences in composite scores between formal attire with white coat, scrubs alone, scrubs with white coat, or casual attire with white coat were observed. However, compared with formal attire with white coat, physicians wearing scrubs without white coat appeared less knowledgeable (mean [standard deviation]: 8.2 [1.8] vs. 7.4 [2.1]; p < 0.05) and trustworthy (8.3 [1.8] vs. 7.6 [2.1]; p < 0.05). Additionally, casual attire with white coat was rated as less knowledgeable compared with formal attire with white coat (7.4 [2.0] vs. 8.2 [1.8]; p < 0.05). Preferences for attire varied by clinical setting: patients preferred surgeons (45.2%) and physicians in emergency rooms (41.7%) in scrubs rather than formal attire with white coat. CONCLUSIONS: Physician attire is important to patients receiving ophthalmic care. Policies aimed at physician attire in ophthalmology practices should be considered.

Refractive changes following corrective surgery for thyroid-related orbitopathy.

Thyroid-related orbitopathy (TRO) is a common and recognizable manifestation of Graves' disease, caused by an increase in orbital fat volume, increased extraocular muscle diameter, and fibrosis. Together, within the bony confines of the orbit, these changes might alter the shape and position of the globe, potentially inducing refractive shifts. These refractive changes may then be affected by corrective surgical interventions for TRO such as orbital decompression and strabismus surgery. We studied refractive changes in patients with TRO who underwent strabismus surgery with or without orbital decompression. Manifest refraction was performed preoperatively and postoperatively in 33 patients who met inclusion criteria. Statistically significant postoperative refractive changes were found for cylinder, axis, and spherical equivalent.

Glomuvenous Malformation: A Rare Periorbital Lesion of the Thermoregulatory Apparatus.

Glomuvenous malformations (GVMs), previously referred to as glomus tumors or glomangiomas, are benign, mesenchymal venous malformations arising from glomus bodies. Glomus bodies are modified smooth muscle neuromyoarterial structures involved in temperature regulation via blood shunting. These classically occur in the digits but can occur in other locations. The authors present a case of a periorbital GVM presented following blunt trauma to the area.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury.

PURPOSE: Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described. METHODS: This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded. RESULTS: Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25-80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1-5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively. CONCLUSION: Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Recognizing and managing complications in blepharoplasty.

The goal of this article is to enhance the surgical precision and accuracy of surgeons performing upper and lower eyelid blepharoplasty. The most common blepharoplasty complications are described and how to avoid them is discussed in detail. Complications range from mild to severe and for each, preoperative measures to prevent, perioperative measures to avoid, and postoperative measures to minimize complications are detailed. After reading this article the surgeon should have a greater understanding of blepharoplasty complications and how to best manage and avoid them.

Mastication induced retrobulbar hemorrhage.

Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.

A 55-mm object inside a 40-mm orbit.

A 43-year-old man was struck in the left orbit with his board while surfing and sustained a 3-cm laceration above his left eyebrow. The laceration was sutured closed primarily at a local emergency room. When he presented to UCSD oculoplastics for suture removal, he complained of diplopia with upgaze and was found to have hypoglobus on clinical exam. An orbital CT demonstrated a hyperintense linear signal within the orbit. The patient underwent surgical exploration. A 55-mm-length piece of fiberglass from the patient's surfboard was removed from his orbit. This case demonstrates the importance of having a high index of suspicion for retained orbital foreign bodies, regardless of the size of the object inflicting the injury.

The delayed cost of treatment.

A 78-year-old woman presented with acute decreased vision in both eyes. She had been treated for a pituitary mass with a total of 4,500 centigray of external beam radiation 8 months prior to presentation. She was diagnosed with radiation optic neuropathy. Treatment with hyperbaric oxygen and intravenous steroids were initiated but vision remained poor.

Conjunctival-orbital fistula from extensive facial trauma.

A 31-year-old man with a history of severe facial trauma and multiple reconstructive operations presented with a conjunctival-orbital fistula in the OS. Successful treatment required a vascularized orbicularis oculi flap with a temporalis fascia overlay. Risk factors for fistula formation included extensive orbital trauma, devascularized tissue from previous operations and infection, and prior strabismus surgery using the fornix-based approach.

Blepharoplasty complications: prevention and management.

This article presents common and rare complications following blepharoplasty, with discussion of avoidance of these complications through presurgical planning and review. Management of the complications is provided, with surgical details supported by images and advice for the best approaches. The complications discussed include hemorrhage, infection, corneal abrasion, ptosis, lacrimal gland injury, and residual excess skin.

Use of antimetabolites in the reconstruction of severe anophthalmic socket contraction.

PURPOSE: The use of antimetabolites is well established in ophthalmology with expanded uses still being defined. We describe our experience of antimetabolite use in the reconstruction of severe anophthalmic socket contraction. METHODS: Nonrandomized, retrospective case series. The medical records and clinical photographs of 5 patients with severe socket contraction were reviewed. Either 5-Fluorouracil (5-FU) (50 mg/ml) or Mitomycin C (MMC) (0.4 mg/ml) was used during the course of the surgery via direct injection into the operative bed in the area of scarring. In addition, in 3 cases, 5-FU was also applied after surgery, in the clinic setting. Variables examined included: number of previous socket operations; preoperative ability to retain a prosthesis; type of socket reconstruction; type, amount, and location of antimetabolite injected; number of postoperative injections; average follow-up; and the postoperative ability to retain a prosthesis. RESULTS: All 5 patients had multiple operations previously. After surgery, all 5 were able to retain an ocular prosthesis. We did not observe any delay in wound healing, implant exposure, or extrusion, and no significant side effects were noted. CONCLUSION: The use of adjunct antimetabolite in severe anophthalmic socket reconstruction is an effective option that is well tolerated with minimal side effects.

Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy.

Reconstruction of periocular defects following excision of cutaneous malignancy can present difficulties for oculofacial and reconstructive surgeons. The intricate anatomy of the eyelids and face requires precise restoration in order to avoid postoperative functional anesthetic concerns. Various reconstructive procedures based on common principles, location and size of the defect, can be applied to achieve restoration with the best possible functional and aesthetic outcomes.

Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers.

BACKGROUND: Preliminary experience with the use of hyaluronic acid fillers as a nonsurgical alternative in the management of upper eyelid crease asymmetry and superior sulcus hollowing in Asian patients has proven promising. METHODS: This retrospective, interventional case series included seven patients (11 eyes) of various Asian ancestries. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. Upper eyelid crease asymmetry and hollowing of the superior sulcus were assessed before and after treatment. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juvéderm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Pretreatment and posttreatment photographs were taken. Outcomes were assessed by the total volume injected; masked, independent assessment using preoperative and postoperative photographs; and the subjective assessment of results by the patient. RESULTS: The average age was 43.1 years. The average volume of hyaluronic acid filler injected was 0.61 cc per eye. All seven patients were satisfied with the cosmetic improvement after hyaluronic acid filler injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 18 months. CONCLUSIONS: Hyaluronic acid filler injections into the upper eyelid and superior sulcus are effective in providing volume to recreate the fullness natively present in the Asian upper eyelid. Furthermore, this fullness lowers the surgically created eyelid crease in those patients with eyelid asymmetry following cosmetic blepharoplasty. It should be considered in Asian patients presenting with upper eyelid hollowing or asymmetric eyelid creases.

Three carcinomas in one eyelid.

A 90-year-old woman presented with 2 masses on the right lower eyelid. Excisional biopsy revealed 1 lesion to be Merkel cell carcinoma and the other to be invasive squamous cell carcinoma. The patient also had a prior history of basal cell carcinoma in the same eyelid. This case emphasizes the importance of careful pathologic examination of all eyelid lesions regardless of previous history.