Thursday 15 September
08:00 ESOPRS PRE-MEETING DAY

"Thursday 15 September"

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A10
08:00 - 08:30

Welcome Address

08:00 - 08:06 Introduction. Jacques LAGIER (local organiser ESOPRS 2022) (Pre-Course Speaker, NICE, France)
08:06 - 08:30 New developments in oculoplastic surgery in 2022. Jonathan ROOS (Surgeon) (Pre-Course Speaker, London, United Kingdom), Rachna MURTHY (Oculoplastic & Aesthetic Surgeon) (Pre-Course Speaker, London, United Kingdom), Dyonne HARTONG (oculoplastic and orbital specialist) (Pre-Course Speaker, Amsterdam, The Netherlands)
Room 1
08:30

"Thursday 15 September"

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A11
08:30 - 10:00

Eyelid Malposition Ptosis

Moderators: Dion PARIDAENS (Orbital Surgeon, Head of Department) (Rotterdam, The Netherlands), Francesco QUARANTA-LEONI (Rome, Italy)
08:30 - 08:45 Lower eyelid - Entropion and ectropion: The same entity? Philippe IMBERT (Oculoplastic Surgeon) (Pre-Course Speaker, TOULOUSE, France)
08:45 - 09:00 Lower eyelid - What is the ideal spacer for managing a lower eyelid retraction? Miguel GONZALEZ-CANDIAL (Chief) (Pre-Course Speaker, BARCELONA, Spain)
09:00 - 09:15 Upper eyelid - Ptosis surgery: do not forget the aesthetics. Isabelle LARRE (PH) (Pre-Course Speaker, Reims, France)
09:15 - 09:30 How performing a regional anesthesia in oculoplastics. Stéphane GINDRE (Pre-Course Speaker, Nice, France)
09:30 - 09:45 Inner canthus - Medial canthoplasty: a surgical challenge. Pierre-Vincent JACOMET (Deputy Head of Department) (Pre-Course Speaker, Paris, France)
09:45 - 10:00 Discussion.
Room 1
10:00 COFFEE BREAK & EXHIBITION AREA - VISIT OF THE EPOSTERS
10:30

"Thursday 15 September"

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A13
10:30 - 12:30

Eyelid and Conjunctival Malignancies

Moderators: Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Stockholm, Sweden), Jacques LASUDRY (Chef de clinique) (Brussels, Belgium), David H. VERITY (London, United Kingdom)
10:30 - 10:45 Conjunctival malignancies: what all oculoplastic surgeons should know ? Jean-Pierre CAUJOLLE (PH) (Pre-Course Speaker, NICE, France)
10:45 - 11:00 Locally advanced conjunctival malignancies: when the oculoplastic surgeon plays a role. Arnaud MARTEL (doctor) (Pre-Course Speaker, Nice, France)
11:00 - 11:15 Why should I manage benign eyelid tumors with Argon/532nm laser? Jean-Marc RUBAN (Senior Oculoplastic Surgeon) (Pre-Course Speaker, Lyon, France)
11:15 - 11:30 Intraoperative surgical margins assessment in eyelid malignancies. Ioannis LIOLIOS (Pre-Course Speaker, NICE, France)
11:30 - 11:45 Controversies in eyelid malignancies with anterior orbital involvement: Conservative surgery first. Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Pre-Course Speaker, Stockholm, Sweden)
11:45 - 12:00 Controversies in eyelid malignancies with anterior orbital involvement: Exenteration first. David H. VERITY (Pre-Course Speaker, London, United Kingdom)
12:00 - 12:15 Controversies in eyelid malignancies with anterior orbital involvement: New targeted therapies / immunotherapy first. Jacques LASUDRY (Chef de clinique) (Pre-Course Speaker, Brussels, Belgium)
12:15 - 12:30 Controversies in eyelid malignancies with anterior orbital involvement: Clinical case challenge. Arnaud MARTEL (doctor) (Pre-Course Speaker, Nice, France), Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Pre-Course Speaker, Stockholm, Sweden), Jacques LASUDRY (Chef de clinique) (Pre-Course Speaker, Brussels, Belgium)
Room 1
12:30 LUNCH IN THE EXHIBITION AREA
14:00

"Thursday 15 September"

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A15
14:00 - 15:15

Sockets and Orbit

Moderators: George CHARONIS (OCULOPLASTICS SURGEON) (KALLITHEA, Greece), Miguel GONZALEZ-CANDIAL (Chief) (BARCELONA, Spain)
14:00 - 14:15 Socket - Eye evisceration: personalized surgical technique. Dion PARIDAENS (Orbital Surgeon, Head of Department) (Pre-Course Speaker, Rotterdam, The Netherlands)
14:15 - 14:30 Socket - Orbital lipofilling: surgical technique and results. Olivier GALATOIRE (Pre-Course Speaker, PARIS, France)
14:30 - 14:45 Socket - Current management of orbital implant exposure. Eric LONGUEVILLE (Ophthalmologist/Plastic and reconstructive Surgeon) (Pre-Course Speaker, BORDEAUX, France)
14:45 - 15:00 Orbit - Management of tumors located at the orbital apex. Jacques LAGIER (local organiser ESOPRS 2022) (Pre-Course Speaker, NICE, France)
15:00 - 15:15 Orbit - Place of the optic nerve sheath fenestration in 2022. Diego STRIANESE (Pre-Course Speaker, Naples, Italy)
Room 1
15:15

"Thursday 15 September"

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A16
15:15 - 16:00

Lacrimal

Moderators: Daniel EZRA (United Kingdom), Ulrich SCHAUDIG (Chief) (HAMBURG, Germany)
15:15 - 15:25 Endonasal DCR: always first. Daniel EZRA (Pre-Course Speaker, United Kingdom)
15:25 - 15:35 External DCR: always first. Jacques LAGIER (local organiser ESOPRS 2022) (Pre-Course Speaker, NICE, France), Edouard FEVRIER (Interne) (Pre-Course Speaker, Nice, France)
15:35 - 15:45 Current indications of lacrimal stents. Jean-Marc RUBAN (Senior Oculoplastic Surgeon) (Pre-Course Speaker, Lyon, France)
15:45 - 15:55 Management of canalicular obstructions. Francesco QUARANTA-LEONI (Pre-Course Speaker, Rome, Italy)
15:55 - 16:00 Discussion.
Room 1
16:00 COFFEE BREAK & EXHIBITION AREA - VISIT OF THE EPOSTERS
16:30

"Thursday 15 September"

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A18
16:30 - 17:55

Aesthetic, Hyaluronic Acid And Toxin

Moderators: Thierry MALET (oculoplastic surgeon) (MARSEILLE, France), Eric SARFATI (Ophtalmologue) (TOULON, France)
16:30 - 16:45 Toxin in the periorbital area. Dan GEORGESCU (Pre-Course Speaker, Romania)
16:45 - 17:00 Upper blepharoplasty. Olivier GALATOIRE (Pre-Course Speaker, PARIS, France)
17:00 - 17:15 Lower blepharoplasty. Jérôme DELAS (Pre-Course Speaker, NICE, France)
17:15 - 17:30 Lipostructure of the periorbital area. Thierry MALET (oculoplastic surgeon) (Pre-Course Speaker, MARSEILLE, France)
17:30 - 17:45 Hyaluronic acid in the periorbital area. Frederic BRACCINI (Director) (Pre-Course Speaker, NICE, France)
17:45 - 17:55 Use of Botulinum Toxin for the Correction of Mild Ptosis. Eric SARFATI (Ophtalmologue) (Pre-Course Speaker, TOULON, France)
Room 1
18:30 WELCOME COCKTAIL IN THE EXHIBITION AREA Room 1
Friday 16 September
08:00 ESOPRS MAIN MEETING - DAY 1
08:15

"Friday 16 September"

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A20
08:15 - 08:30

Welcome Address and Opening

08:15 - 08:30 Welcome Address and Opening. Jacques LAGIER (local organiser ESOPRS 2022) (Congress Speaker, NICE, France), Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Congress Speaker, Stockholm, Sweden)
Mr Chemla (Nice, France)
Room 1
08:30

"Friday 16 September"

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A21
08:30 - 10:00

Oral Communications
Eyelid

Moderators: Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Stockholm, Sweden), Miguel GONZALEZ-CANDIAL (Chief) (BARCELONA, Spain)
08:30 - 10:00 #32098 - OP01 Quantitative volumetric study of different periocular tumor models.
OP01 Quantitative volumetric study of different periocular tumor models.

Background: Three-dimensional (3D) imaging is increasingly popular in surgical planning and postoperative evaluation. However, the volumetric changes in the periorbital region were rarely assessed, especially for tumors. Therefore, we measured the volume of customized tumor models using 3D stereophotogrammetry and evaluated their validity and reproducibility.

Methods: Sixty-eight healthy adult volunteers were enrolled, and five tumor models with different colors and sizes were chosen to be placed in the periocular area. Furthermore, 3D facial images were taken by a 3D imaging system. Lastly, we measured the tumor models' volume and assessed the intra-rater and inter-rater reliability.

 

Results: Highly reliable outcomes were demonstrated in both Caucasians and Asians for the gray model with a volume of 55.00 mm3. In Caucasians, the intra- and inter-rater intraclass correlation coefficient (ICC) were 0.981 and 0.899, mean absolute difference (MAD) 1.446 mm3 and 3.327 mm3, relative error measurement (REM) 3.497% and 8.120%, technical error of measurement (TEM) 1.450 mm3 and 3.105 mm3, and relative technical error of measurement (rTEM) 3.506% and 7.580%. In Asians, the intra- and inter-rater ICC, MAD, REM, TEM, and rTEM were respectively 0.968 and 0.844, 1.974 and 4.067 mm3, 4.772% and 9.526%, 2.100 and 4.302 mm3, as well as 5.076% and 10.076%. Besides, Caucasians have the highest reliability in the inner canthus with opening eyes, while Asians show the same trend with the eyes closed.

 

Conclusions: This is the first study to validate the reproducibility of three-dimensional volumetric measurements for periocular tumor models. Three-dimensional stereophotogrammetry might be more suitable to measure gray-pigmented masses' volume with a sizeable dimension, especially at the inner canthus.


Wanlin FAN (Cologne, Germany), Ludwig M. HEINDL
08:30 - 10:00 #30792 - OP02 Primary cemiplimab treatment for orbital squamous cell carcinoma is effective and may alleviate the need for orbital exenteration.
OP02 Primary cemiplimab treatment for orbital squamous cell carcinoma is effective and may alleviate the need for orbital exenteration.

   Purpose: To evaluate the effectiveness of cemiplimab, a Programmed cell death 1 (PD-1) protein inhibitor, for the treatment of periocular locally advanced squamous cell carcinoma (POLA-SCC) with orbital invasion.

   Design: Multicenter real-world retrospective study.

   Participants: Patients with biopsy-proven POLA-SCC (AJCC T4) with orbital invasion who were treated with cemiplimab at one of four tertiary medical centers in Israel in 2019-2022.

   Methods: Demographic, clinical, and outcome data were collected and analyzed from the patients’ electronic medical records.

   Main Outcome Measures: Rate and degree of patient response to treatment and rate of organ preservation.

   Results: The cohort included 13 patients, 8 males and 5 females, of median age 76 years (IQR 65-86). The median duration of treatment was 5.0 months (IQR 3.5-10.5) and the median follow-up time, 15.0 months (IQR 10.5-30). The overall response rate was 69.2%. Complete response was documented in seven patients (53.8%), partial response in two (15.4%), stable disease in one (7.7%), and progressive disease in two (15.4%); in one patient (7.7%), response was not evaluable. Six complete responders (46.1% of the cohort) received no further treatment and did not have a recurrence during an average follow-up of 6.14 (±6.9) months from treatment cessation. None of the patients underwent orbital exenteration. The majority of adverse events were mild (grade 1), except for a moderate increase in creatinine level (grade 2), severe bullous dermatitis (grade 3), and myocarditis (grade 5) in one patient each. Four patients (30.7%) died during the follow-up period, all of whom had an Eastern Cooperative Oncology Group score of 4 at presentation.

   Conclusions: To our knowledge, this is the largest study to date on cemiplimab therapy for POLA-SCC with orbital invasion. Treatment was shown to be effective, with an overall response rate of 69.2%. Cemiplimab holds promise for the treatment of patients with tumors invading the orbit as it may alleviate the need for orbital exenteration


Alon TIOSANO, Meydan BEN ISHAI (Tel Aviv, Israel), Yaccov CNAANY, Gal MARKEL, Noga KURMAN, Aron POPOVTZER, Gil BAR SELA, Guy BEN SIMON, Assaf GERSHONI, Iftach YASSUR
08:30 - 10:00 #32183 - OP03 Lower eyelid margin reconstruction: results of 5 different techniques.
OP03 Lower eyelid margin reconstruction: results of 5 different techniques.

Purpose:  While there are many reports describing eyelid reconstructive procedures, outcome measures are often inconsistent between studies. The literature contains little information regarding comparative results of different operations. In this project we used standardized criteria to evaluate five methods for repairing the lower eyelid margin.

 

Methods: The retrospective study included 178 patients undergoing surgery between 2005–2020. Outcomes were evaluated (photographic review) by 3 oculoplastic observers masked to procedure type, with and without knowledge of the eyelid defect.

 

Results:  All patients achieved a good-excellent functional result and 90.4% were asymptomatic after surgery. Tarsoconjunctival flaps were associated with greater a need for subsequent interventions (p<0.001) and anterior lamellar irregularity (p<0.001). Semicircular flaps had a higher incidence of lateral canthal deformity (p<0.001), but less eyelash disruption than other flap/graft techniques (p<0.001). Mean cosmetic scores were similar for dermal matrix grafts, semicircular, and sliding tarsal flaps; each rating higher than tarsoconjunctival flaps (p≤0.05). Comparing results for similarly sized defects (9-15mm), semicircular and sliding tarsal flaps graded better than dermal matrix grafts (p≤0.005) and tarsoconjunctival flaps (p≤0.02).  

 

Conclusions: Among all procedures, good-excellent functional (100%) and cosmetic (87.1%) outcomes were achieved in most patients. Semicircular flaps were effective for medium sized defects that could not be closed primarily, creating a continuous lash line, although with a higher incidence of canthal deformities. Sliding tarsal flaps were useful for shallow wounds of varying widths. Single-staged dermal matrix grafts provided similar results as tarsoconjunctival flaps. Subsequent interventions were more frequent after tarsoconjunctival flaps than other methods.


Philip CUSTER (St Louis, USA), Robi MAAMARI, Tiffany HO, Steven COUCH
08:30 - 10:00 #32331 - OP04 Periorbital reconstruction method by tunneled unipedicular orbicular flap, or "paddle flap”.
OP04 Periorbital reconstruction method by tunneled unipedicular orbicular flap, or "paddle flap”.

Background

Carcinological surgery of small palpebral tumors is most often performed using a myocutaneous flap composed of the orbicularis muscle and the overlying skin. This flap respects the nature of the tissues and has an excellent vascularization. It is most often uni or bi-pediculated and harvested from a dermatochalasis. 

The authors describe here a method of unipediculated and tunneled myocutaneous orbicularis flap, or "paddle flap”, allowing reconstruction of the tissues at a distance. 

 

Methods 

This is a pedicled flap, the proximal part of which (composed only of the orbicularis thanks to a shaving) is tunneled under the skin to reconstruct the defect at its distal end (composed of the orbicularis and the overlying skin). 

The analysis includes 40 patients over a period of 5 years, with various carcinological and post-traumatic periorbital reconstructions.

 

Results

During the entire follow-up period, the aesthetic and functional criteria were met. 

Only 2 complications were described: a necrosis of the flap due to its tension, and an edema of the flap by strangulation in its tunnel. 

 

Conclusion

This is the first time in the literature that this type of flap has been described. 

The myocutaneous orbicular “paddle flap” can be used in many palpebral and periorbital areas, and gives good results. 

The two key points to remember to avoid complications are its length and the diameter of the tunnel. 


Victor DESFEUX, Eric SARFATI, Victor DESFEUX (Marseille)
08:30 - 10:00 #31292 - OP05 Is there a metrical correspondence between surgical margins and histopathology clear peripheral margins on direct wide local excision (WLE) of periocular BCC?
OP05 Is there a metrical correspondence between surgical margins and histopathology clear peripheral margins on direct wide local excision (WLE) of periocular BCC?

Purpose: To assess the metrical correspondence between surgical margins in WLE on periocular BCC and metrical histopathology minimal clear peripheral margins.

Methods: 46 surgeries in 41 patients with periocular BCC treated with WLE during 5 months had histologically-metrical measured tumour clear margins compared with surgical margins.

Results: Mean patient’s age was 75, nearly equal gender representation. All patients were White British, skin Fitzpatrick type 1-2. Nodular subtype represented 67.4% of BCCs. All but one case reached peripheral clear margins greater than 1.2mm (mean 3.5mm). 

50% BCC located at lower eyelid, 15.2% at medial canthus and 8.7% at lateral canthus. Tumour sizes varied from 1-24mm (mean 9.24mm).

Mean surgical margins, histological peripheral margins, histological clear margins were (3.24mm, 3.5mm, 3.24mm)

Although the mean histological minimal clear margins and mean surgical margin were closer in metrical values (3.24mm, 3.5mm respectively) their correlation was no statistically significant (p=0.79) when analysed by Pearson correlation coefficient, “r” near to zero (r= 0.039).

A sample of 12 cases with tumour at the eyelid margin with tarsal plate involvement had a positive correlation with wider histological clear margins than surgical margins, proven to be statically significance (p=0.024), Pearson “r” of 0.64.

No correlation between the two variables was found when looking into subgroups: tumour macroscopic size, patient’s age, different pathologists reporting, tumour clinical edges demarcation or tumour subtype.

Conclusions: 

No metrical correlation between the two variables was found: surgical margins and histological minimal clear peripheral margins. 

Tumours at the lid margin involving the tarsal plate has a positive Pearson correlation, statistically significant, higher clear histological margins than the surgical margins, proven unnecessary excision of healthy tissue. 

WLE is safe and efficient in obtaining clear margins ( 93.47%). However 41.3% of cases had clear histological margins far wider than the surgical margins, proven to be a no spare healthy tissue procedure .

Tumour involving the lid margin/tarsal plate and cases with associated ectropion may benefit to have MMS as first surgical option as spare tissue technique.


Victor PAIUSCO (London, United Kingdom), Murta FABIOLA
08:30 - 10:00 #32403 - OP06 Sebaceous carcinoma treated with mohs micrographic surgery.
OP06 Sebaceous carcinoma treated with mohs micrographic surgery.

Sebaceous Carcinoma (SC) is a rare malignant tumor frequently affecting the head and neck region,  representing only 0.7% of skin cancers. It is the third most common eyelid malignancy and periorbital cases have a greater likelihood of regional metastasis. Surgical extirpation is the treatment of choice and may be achieved through conventional excision or Mohs micrographic surgery (MMS). 

This study aimed to characterize tumor characteristics and outcomes in SC patients treated with MMS at a single institution.Patients with biopsy-proven SC treated with MMS from January 1, 2005 through August 17, 2020 were identified. Clinical records were reviewed and data pertaining to demographics, tumor characteristics and treatment was collected. The primary outcomes were tumor recurrence and metastasis.  Secondary outcomes included tumor location, subclinical spread, number of stages required for clear margins and reconstruction techniques. 

Fourty-nine patients with a mean age of 67 years met the inclusion criteria. All had sebaceous carcinoma of the face and scalp. The majority (94%) identified as Caucasian, more than half  (59%) were male and tumor location varied with most common being the periorbital region, cheek, and nasal ala. 

The majority of the patients (68%) were classified as stage 1 and 94% were Breslow stage 2. No patients had metastatic recurrence and only one patient, with genetic predisposition for sebaceous lesions, experienced local recurrence. All tumors involving the eyelids required coordinated reconstruction by an oculoplastic surgeon. 

Our cohort of SC patients treated with MMS is one of the largest with longest follow-up that has been described from a single institution with only one episode of recurrence. The tissue-sparing approach of MMS may be especially beneficial for SC cases involving the face. Overall, our findings demonstrate that MMS is an effective treatment option for SC, with a lower risk of recurrence. 


Elana MEER, Gabriela LAHAIE LUNA (Philadelphia, USA), Jeremy ETZKORN, Christopher MILLER, Cesar BRICENO
08:30 - 10:00 #32508 - OP07 Periocular management and reconstruction of medial canthal chemical burns following assault.
OP07 Periocular management and reconstruction of medial canthal chemical burns following assault.

Methods: 

Retrospective chart review of all patients requiring medial canthal eyelid reconstruction following chemical burns at the largest specialist London burns unit, 2019-2022. 

 

Clinical record review, photograph analysis, managementprinciples, surgical technique, are presented with relevant illustrative clinical images and decision making flow charts

 

Results

Chemical burns represent 2.1%-6.5% of burn centre admissions.

Superficial second-degree eyelid burns were managed conservatively with lubricants and antibiotics.

Five medial canthal-eyelids of four patients, over a three year period required surgical intervention for deep secondary and third degree burns.

Interventions included debridement in 4/5 eyelids. Time to debridement was 10-22 days (mean 13 days). Split thickness grafts were used initially in three eyelids due to poor vascular donor bed. Mean number of surgical interventions was 2.5 (range 1-5). All patients had good functional eyelid opening/closure, healthy ocular surfaces and excellent visual acuity at most recent follow-up. 

 

 

Conclusions:

Medial canthal burns represent a specific challenge due to the dynamic eyelid function and junction of eyelid nasal and brow tissues. 

Early debridement and reconstruction is indicated in cases of deep second degree or third degree burns, to preserve anatomy and function of the eyelids and prevent severe cicatrising sequelae.

Concurrent corneal injury frequently co-exits requiring amniotic membrane grafting. Optimal outcomes can be achieved with effective multi-disciplinary management involving oculoplastic surgeons, corneal surgeons and burns plastic surgeons.


Aoife NAUGHTON (London, United Kingdom), Manvi SOBTI, Richard SCAWN
08:30 - 10:00 #32268 - OP08 Evaluating patient satisfaction of an oculoplastic nurse practitioner led minor surgery service.
OP08 Evaluating patient satisfaction of an oculoplastic nurse practitioner led minor surgery service.

Objective

To assess patient satisfaction of a nurse led minor surgery service.

Method

Retrospective audit of patient satisfaction with an oculoplastic nurse led minor surgery service over two-year period. 92 patients treated by a single oculoplastic nurse practitioner were sent a questionnaire to assess their level of satisfaction with having an ophthalmic operation performed by a nurse, and with their overall experience of the service.

Patients requiring minor surgery were all assessed and listed by a doctor. Procedures were all performed by the oculoplastic nurse practitioner in an outpatient setting. Procedures performed include incisional and excisional biopsies, incision and curettage of meibomian cysts, and insertion of Mini-Monoka® stents.

Results

Of 92 patients retrospectively sent a questionnaire to assess their level of satisfaction, there were 42 respondents.

The audit results show that 21% of these patients were satisfied and 79% were very satisfied with having received treatment by a nurse, and 100% would be happy to be treated by the oculoplastic nurse again. 21% were satisfied with their overall experience and the service they received, and 88% were very satisfied.

Discussion

Ophthalmology is significantly affected by rising demand due to demographic changes and this has been exacerbated by the COVID-19 pandemic, with a need for service transformation to address the lack of capacity and reduce patient waiting times. UK national recommendations underpin the importance of evolution in the role of non-medical health professionals such as nurses, orthoptists and optometrists, expanding to perform advanced roles.

We report high rates of patient satisfaction and acceptance of an oculoplastic nurse led minor surgery service. The introduction of this service has increased the capacity and reduced the waiting times for procedures undertaken in the oculoplastic service at Buckinghamshire NHS Trust. This audit shows evidence in support of nurse practitioners performing minor ophthalmic procedures.


Alice CRANSTON (Buckinghamshire, United Kingdom), Hazel NYACK-KASEKE, Fiona JAZAYERI
08:30 - 10:00 #32470 - OP09 Autologous Dermal Grafts in oculoplastic surgery.
Autologous Dermal Grafts in oculoplastic surgery.

Background: One of the greatest challenges in plastic and reconstructive surgery of the orbit and the periorbital region lies in the insufficiency of the orbital and/or periocular soft tissues, frequently requiring the use of a variety of grafts. Autologous dermal graft has been used in eyelid retraction, orbital implant expositions and paralytic eyelids. Only few series have been reported in literature.

Purpose: To report our experience in the use of autologous dermal graft in a variety of oculoplastic indications.

Methods: Retrospective cases serie.

The dermis graft was obtained from the para umbilical or the buttock region. We reviewed the indications and the surgical results of the use of dermis graft in oculoplastic surgery.

Results: Thirty-seven (37) patients were included. Dermis graft was used to treat thyroid-associated eyelid retraction in 5 cases, paralytic eyelid in 8 cases and as a spacer in retracted eyelid with orbital prostheses in 10 cases. In orbital indications, dermis graft was used to treat recent and  mild orbital implants expositions without infection in 12 cases. Finally, we also used the dermis as filler tissue for the treatment of dark circles in cosmetic surgery (2 cases). The cosmetics and functional results were good in all patients. In paralytic lagophthalmos, the occlusion was sufficient to protect the cornea in all cases. No donor site complications were encountered.

Conclusions: Autologous Dermis graft seems to be a safe, a good and a cheap option in a variety of oculoplastic applications. It may be useful in orbital and eyelid surgery. It provides an adequate rigidity with an excellent pliability to be a used as a spacing material in surgical correction of eyelid retraction. In orbital surgery, it effectively and definitively solves the exposure of non-infected balls and the retraction of dead ends. Finally, in aesthetics applications, the dermal graft seems to be a promising material for treating dark circles. Long term evaluation is required in this latter indication.


Narjess BEN RAYANA (Sousse - TUNISIA, Tunisia), Leila KNANI
08:30 - 10:00 #31618 - OP10 Triamcinolone Acetate injections for upper eyelid retraction in active Graves Orbitopathy.
OP10 Triamcinolone Acetate injections for upper eyelid retraction in active Graves Orbitopathy.

Triamcinolone acetate (TCA) injections have been described as an effective treatment for upper eyelid retraction in active Graves Orbitopathy (GO).

 

Methods

We performed a retrospective cohort study of consecutive GO patients undergoing upper eyelid TCA injection. Baseline information including patient demographics and thyroid diagnosis was ascertained. The change in eyelid position following TCA injection using Marginal Reflex Distance 1/Palpebral aperture (MRD1/PA ratio) was measured and the Clinical Activity Score (CAS), Gorman score and intra-operative and post-operative complications were recorded.

 

Results

16 patients (24 eyes) with a median age 44.5 years (range 26-68 years) were included. 82% (13/16) had Graves Hyperthyroidism. 47% (7/15) were either current or ex-smokers. 83% (14/16) had received selenium supplementation and 38% (6/16) had previous systemic immunosuppression. The mean CAS score reduced from 1.45 pre-treatment to 0.45 post-treatment.  The mean Gorman score remained unchanged at 0.4. The mean MRD1/PA ratio reduced from 0.45 pre-treatment to 0.43 post-treatment. There was no increase in IOP of more than 3mmHg post-treatment. 67% (10/15) reported improvement in appearance and ocular comfort post-treatment. There was 1 case (6.3%) of transient skin depigmentation.

 

Conclusion

Upper eyelid TCA injections for upper eyelid retraction appears to improve symptoms with minimal side effects in patients who have unstable GO and thyroid status when other rehabilitative surgical options are limited. The exact therapeutic effect is difficult to quantify in a real world setting of other concomitant therapy.


Simrun VIRDEE (London, United Kingdom), Arun KIRUPAKARAN, Ahmad AZIZ, Vickie LEE
08:30 - 10:00 #32158 - OP11 Lipostructure after orbital decompression in thyroid associated orbitopathy: Case series.
OP11 Lipostructure after orbital decompression in thyroid associated orbitopathy: Case series.

OBJECTIVE: 

The purpose of this study is to report our experience with the use of autologous fat grafting in aesthetic rehabilitation after orbital decompression for thyroid associated orbitopathy.   

 

MATERIAL AND METHOD: 

A retrospective study was conducted in our specialist centre in patients with thyroid associated orbitopathy (TAO)undergoing lipostructure following orbital decompression. The data collected included: the number of orbital walls previously decompressed, the volume and the site injected, the donor area, the operative protocol, the number of procedures required, any associated palpebral surgery, and postoperative complications. The aesthetic result before and after the operation was studied on photographs by an external consultant. 

RESULTS:

10 patients were selected, i.e. 17 orbital decompressions, 11 of which concerned the 3 orbital walls. The average age was 52 years. The surgical technique was identical for all patients. 6 patients required a single operation to obtain a satisfactory postoperative volume. 4 patients required further lipostructures. The average follow-up ranged from 2 to 5 years. The volumes injected varied from 1 to 4 cc depending on the area (supra tarsal crease, lower eyelid, and malar). The donor sites were mainly the posterior external aspect of the thigh (9 patients) or abdominal fat (1 patient).  No patient had a postoperative complication. Pre- and postoperative photos were taken for each patient. Aesthetic improvement was satisfactory in 80% of cases.  

DISCUSSION:

Orbito-palpebral lipostructure is a treatment of choice in the aesthetic rehabilitation of patients undergoing orbital decompression surgery. It can be associated with the correction of upper or lower palpebral retraction, and allows the treatment of the palpebral hollow frequently associated with fatty hypertrophy of the palpebral pockets in dysthyroid orbitopathy. In our experience, this autologous tissue graft is preferred to the injection of hyaluronic acid because of its longer lasting effects and better tolerance. 

 CONCLUSION:

Orbito-palpebral lipostructure is a tool of choice in the therapeutic arsenal of aesthetic rehabilitation of Thyroid associated orbitopathy after orbital decompression

 


Barbara MONJANEL (PARIS)
Dr Olivier Galatoire, Dr Pierre-Vincent Jacomet, Dr Mathieu Zmuda. Fondation Adolphe de Rothschild. Paris.
08:30 - 10:00 #32296 - OP12 To develop a protocol for the medical management of superior limbic keratoconjunctivitis.
OP12 To develop a protocol for the medical management of superior limbic keratoconjunctivitis.

Methods: A retrospective cohort study conducted at a tertiary ophthalmic center in Kochi, from 2011 to June 2022, identified patients with dysthyroid ophthalmopathy who had superior limbic keratoconjunctivitis (SLK). Patients were divided into 3 treatment groups – 1st episode cases, recurrent cases, and relapsed cases. Patients from all groups were started on topical steroids and lubricants. Bandage contact lenses were given to severe 1st episode cases and recurrent SLK cases. N-acetyl cysteine drops and Cyclosporine drops were added to the recurrent group. Patients were followed up for 1 month in first-episode cases and up to 1 year in recurrent/relapsed cases.  

Results: Of the 232 cases of dysthyroid ophthalmopathy identified, 7 (3.01%) were noted to have SLK. All 7 patients (100 %) showed complete remission. 3 (42.8 %) of 7 patients showed remission with the use of topical steroids and lubricants. 3 patients (42.8 %) showed recurrent SLK in whom treatment was reinitiated with additional cyclosporine drops, and N-acetyl cysteine drops. 1 patient (14.28 %) had relapsed SLK in whom topical steroids and lubricants were tapered off gradually. 

Discussion: Gradual tapering of steroids is the key to the complete remission of SLK. Bandage contact lenses are the second line of treatment as they reduce friction between the upper lid and superior limbus, and maintain a stable precorneal tear film. N-acetyl cysteine is an antioxidant and scavenger of free radicals. Topical Cyclosporine A is an immunomodulatory agent that acts as an adjuvant to steroids in controlling surface inflammation.

Conclusion: The mainstay of treatment is the gradual tapering off of topical steroids. The second line of treatment involves the insertion of a bandage contact lens in the affected eye. N-acetyl cysteine drops and Cyclosporine A drops comprise the final line of treatment.


Sarah GEORGE (Kochi, India), Marian PAULY
08:30 - 10:00 #32185 - OP13 Patient Satisfaction of Teleoculoplastics: a survey of 1215 patients over 2 years.
OP13 Patient Satisfaction of Teleoculoplastics: a survey of 1215 patients over 2 years.

Introduction

Teleoculoplastics has undergone rapid acceleration over the past year, archetyping the new normal of healthcare consultations. However, engagement and uptake are heavily reliant on patient experiences, which may inevitably be the limiting factor to achieving widespread adoption. We describe an analysis of a satisfaction survey assessing patients’ experience of teleoculoplastics in our ophthalmic tertiary centre. 

 

Methods

Video consultation was set up for follow-up and newly referred general adnexal patients using ‘Attend Anywhere’(Attend Anywhere Pty Ltd, Victoria, Australia). This platform was accessed via URL in a web browser on a device. After the consultation, patients were sent an online survey to complete. The survey was carried out over 2 years between 1st June 2020 and 10th June 2022.  

 

Results

1215 patients were included in the survey. Of these 61%(n=739) were female and 39%(n=476) were male. The mean age was 49.8 years (range1 month-101 years). 40%(n=494) were in current employment. Laptop device(43%) and Google Chrome browser(56%) were most commonly used followed by mobile phone(31%). 

 

The majority rated the video(86%) and sound quality(81%) positively as excellent or good with only 5%(n=56) rating the quality as poor. Patients reported high ease of accessibility with 88%(n=1170) agreeing they were able to access the consultation easily and 84%(n=1017) were satisfied with waiting times. 33%(n=396) preferred video to face-to-face consultations, 43%(n=524) were equivocal and only 24% preferred in-person. 72%(n=869) preferred video to telephone consultations. 

 

63% agreed that video consultations should continue even after social distancing measures ended and 72% would recommend video consultations to others.

 

Conclusion 

We have demonstrated that our video-based telemedicine consultations have a high satisfaction rate being easily accessible, for a wide-ranging age group with acceptable waiting times. Interestingly, there was preference for video over telephone consultations demonstrating that patients continue to value the personal aspect of seeing a clinician’s face during a consultation. 

 


Radhika Pooja PATEL (London, United Kingdom), Laura AH-KYE, Peter B. M. THOMAS, Swan KANG
08:30 - 10:00 Time for questions and discussion.
Room 1
10:00

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A22
10:00 - 10:20

Keynote Lecture I

10:00 - 10:20 Lower eyelid retractors: entropion ectropion. Hirohiko KAKIZAKI (Keynote Speaker, Aichi, Japan)
Dr. Hirohiko Kakizaki, MD, PhD, is a professor at Aichi Medical University (Japan), organizing the department of Oculoplastic, Orbital & Lacrimal Surgery.
He graduated from Osaka City University Medical School in 1996.
Prof. Kakizaki completed his fellowships in Eyelid, Orbital and Lacrimal Surgeries under Mr. Raman Malhotra at the Queen Victoria Hospital (UK, 2007 & 2008) and Prof. Dinesh Selva at the University of Adelaide (Australia, 2008).
He is a past president of the Asia-Pacific & Japanese Societies of Ophthalmic Plastic & Reconstructive Surgery, editorial board members of “OPRS (Journal of American Society of OPRS)”, and “Orbit (Journal of European society of OPRS)”.
He is enthusiastic in education, in which he has trained more than 10 domestic and 40 overseas fellows.
He has published more than 300 English peer reviewed articles, more than 150 Japanese articles and 7 Japanese textbooks.
Mainly its recent anatomical confirmation of two layers of lower eyelid retractors make it possible to conceive of the role of each of these layers in the stability of the two palpebral lamellae and their involvement in the pathogenesis of the age-related lower eyelid malpositions.
10:00 - 10:20 Introduced by:. Philippe IMBERT (Oculoplastic Surgeon) (Chairperson, TOULOUSE, France)
Room 1
10:20 COFFEE BREAK & EXHIBITION AREA - VISIT OF THE EPOSTERS
10:40

"Friday 16 September"

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A24
10:40 - 12:40

Oral Communications
Eyelid & Aesthetics

Moderators: Dion PARIDAENS (Orbital Surgeon, Head of Department) (Rotterdam, The Netherlands), Gustavo SAVINO (ophthalmology surgeon) (Rome, Italy)
10:40 - 12:40 #32438 - OP14 The posterior approach brow suspension in the treatment of congenital ptosis.
OP14 The posterior approach brow suspension in the treatment of congenital ptosis.

Introduction/purpose: Brow suspension typically takes an anterior approach to the eyelid with either stab incisions to the pre-tarsal skin or a skin crease incision. Here we present a novel approach to brow suspicion avoiding such incisions.

Methods: Over 60 paediatric patients with up to 17 years follow up have undertaken a posterior approach brow suspension technique with stab incisions to the conjunctiva, the use of the brow sling securing the tarsus to the brow with one skin incision to the brow. We present the results of numerous cases to show the efficacy and longevity of the procedure.

Results: The posterior approach brow suspension has been shown to be an effective technique in the treatment of congenital ptosis with excellent long term follow up results.

Conclusion: Posterior approach brow suspension negates the need for any pre-tarsal or skin crease incision and forms an excellent natural skin crease in most patients. It is a method that can be considered in the treatment of paediatric ptosis with only one small stage scar to the brow skin overall.


Hesham FOUAD (Cairo, Egypt), Ahmad AZIZ
10:40 - 12:40 #32173 - OP15 Frontal Eyelid Transmission: a new parameter in frontal suspension.
OP15 Frontal Eyelid Transmission: a new parameter in frontal suspension.

Frontal Eyelid Transmission:  a new parameter in frontal suspension.

OBJECTIVE: To define a new parameter in patients with severe ptosis treated with frontalis suspension.

MATERIAL AND METHOD: Retrospective analysis of medical records of patients with severe palpebral  ptosis and poor levator function operated with frontal is flap at IMO (Barcelona) between 2003 and 2019, with a minimum of 1 year follow-up. Preoperative baseline reflex distance to the margin (MRD1) without frontalis muscle action and maximal voluntary capacity of frontalis muscle function were measured. The patients were organized in grops: <1 year (Group 1), 1-2 years (Group 2), 3-5 years (Group 3), 6-10 years (Group 4), 11-18 years (Group 5) and > or = 20 years (Group 6).

Patients with previous indirect frontalis suspension, blepharophimosis syndrome and Marcus Gunn syndrome without levator muscle resection were excluded.

RESULTS: A total of 70 eyes, 55 patients, 41 male and 29 female, were analyzed. The most common etiology was levator muscle dysgenesis, followed by congenital or acquired paralysis. The global preoperative frontal function (FF) was 8 mm. The mean preoperative MRD1 was -0.35 mm (-0.73 – 0.03 mm). Six months postoperative baseline MRD1 was 3.1 mm (2.7-3.5mm), FF 8.1 mm (7.6-8.7mm) and FET (frontalis eyelid transmission) 32% (26-38%).  One year postoperative baseline MRD1 was 2.7mm (2.4-3.1mm), FF 8.4mm (8-9mm), and FET 35% (30%-40%). The FET showed a small reduction at 6 months, with an increase one year after surgery.

CONCLUSIONS: A high FET can be used as a new parameter to assess surgical effectiveness, as well as to avoid complications in both myogenic and neurogenic pathologies and allows us to obtain long-term follow-up and thus be able to assess the stability of surgery.


Medel RAMON, Vásquez LUZ MARÍA, Paños MARÍA INMACULADA, Cordero López CLAUDIA (Barcelona, Spain)
10:40 - 12:40 #32467 - OP16 Outcomes of single suture mueller’s muscle conjunctival resection: ethnic considerations.
OP16 Outcomes of single suture mueller’s muscle conjunctival resection: ethnic considerations.

Purpose

To compare outcomes of Mueller’s Muscle Conjunctival Resection (MMCR) between two groups of patients with different anatomy due to ethnic heritage.

Methods

The medical records of patients who underwent MMCR between 2013 and 2018 under local anesthesia were retrospectively reviewed. Patients who underwent additional procedures, such as upper blepharoplasty and browplasty were excluded from the study. Patients were divided into 2 groups based on self-identified ethnic groups (Asian and Caucasian). Image J software was used to calculate MRD1 from digital images. The improvement of MRD1 (net MRD1) after surgery was evaluated and compared between 2 groups.

Results

Eighty-three eyes of 68 patients were included in this study. The Asian group consisted of 41 eyelids from 28 patients. The Caucasian group consisted of 42 eyelids from 40 patients. The average age was 52.18 (SD 20.176) in the Asian group compared to the 66.45 years (SD 9.22, p<0.005) in the Caucasian group. The mean improvement of MRD1 was 1.96± 0.75 mm in Asian group and 2.05 ± 0.72 mm in Caucasian group which was not statistically significant (p=0.62). The incidence of ptosis over-correction and under-correction between the groups was also not statistically significant. 

Conclusions There was no statistically significant difference in the surgical outcomes among the two study groups. Despite differences in the anatomy of Caucasian and Asian eyelids, MMCR is a successful procedure in patients self-identified from both ethnic groups.

 


Zvi GUR (Jerusalem, Israel), Chang MINWOOK, Liu CATHERINE, Bobby KORN, Don KIKKAWA
10:40 - 12:40 #32412 - OP18 Clinical Value of Phenylephrine Testing in the Upper and Lower Eyelids of Patients with Aponeurotic and Congenital Eyelid Ptosis.
OP18 Clinical Value of Phenylephrine Testing in the Upper and Lower Eyelids of Patients with Aponeurotic and Congenital Eyelid Ptosis.

Aim: To characterize the phenylephrine test in aponeurotic and congenital eyelid ptosis, to determine the appropriate timing of the phenylephrine test, and to assess the responses of the upper and lower eyelids.

Methods: This was a retrospective analysis of 140 eyes of 87 patients (mean age 52.29±16.45 years; 22 males, 65 females) with upper eyelid ptosis. 88.6% had aponeurotic and 11.4% had congenital ptosis. For the evaluation of the responses of the upper and lower eyelids to topical 2.5% phenylephrine, the scleral show height, the marginal reflex distance between the inferior margin of the upper eyelid and pupillary light reflex (MRD1), and between the central portion of the lower eyelid and pupillary light reflex (MRD2) were measured at the 2nd, 5th, and 15th minutes (min). The changes of MRD1 and MRD2 with time (ΔMRD1 and ΔMRD2) were evaluated.

Results: The mean MRD1, MRD2, and scleral show heights increased within 5 min after testing, remaining largely stable between the 5th-15th min. The percentage of eyes with a greater response in MRD1 increased with increased severity of ptosis (p<0.05). Eyes with aponeurotic ptosis were more responsive to phenylephrine testing than congenital ptosis. The mild ptosis group had lower scleral show measurements and higher ΔMRD2 values. The ΔMRD1 and ΔMRD2 values were poorly correlated in all measurement times.

Conclusion: Performing the phenylephrine test 5 min after instilling the reagent is adequate to assess the maximum response of the upper and lower eyelids. The upper and lower eyelid responses in phenylephrine testing were poorly correlated. However, the ΔMRD2 was related with baseline scleral show degree that may be a postoperative predictive factor. Further studies are necessary to determine the relationship between the responses of the lower eyelids to phenylephrine testing.


Özgün Melike GEDAR (Istanbul, Turkey), Meltem Guzin ALTINEL, Ayse Yagmur KANRA, Umit AYKAN
10:40 - 12:40 #32284 - OP19 Evaluating Quality of Patient Generated Photographs in the Virtual Oculoplastics Clinic.
OP19 Evaluating Quality of Patient Generated Photographs in the Virtual Oculoplastics Clinic.

Introduction

To assess quality of patient generated photographs of presumed benign eyelid pathology in the oculoplastics clinic. Whilst oculoplastics is particularly amenable to video consultations given that examinations are primarily external, a significant barrier to implementation is visualising pathology. To alleviate this, we introduced patient generated photographs as a tool to supplement synchronous video appointments. Using this addition, our aim was to hone the quality of remote clinical assessments and clinicians’ diagnostic proficiency.  

Method

Prior to a virtual video consultation in the benign eyelid clinic new patients were asked to submit self-captured photographs to a designated email inbox. Photographs for 300 consecutive patients between 29th April and 6th May 2021 were reviewed by two independent observers GG and HK. Photographs emailed to the inbox for follow-up patients or those sent by a medical professional were excluded from this study. Photographs were assessed to see if there were of sufficient quality to allow for diagnosis.

Each patient’s submitted photographs were independently graded as either inadequate/adequate or excellent based of a previously agreed standard. Furthermore observers also noted whether the images were adequately focussed and well lit.

Results

A sample of 300 (n=300) patients submitted 895 photographs to the shared inbox in the time period. Females formed 57.3% (172) of participants and patient mean age was 42.49 years old (SD=16.37) ranging from 16 to 90. Each patient submitted a mean number of 2.98 (Sd = 1.84) ranging from 1 to 15 images. 84.5% of photographs were graded as excellent (40.5%) or adequate (44.0%). There was no statistical difference in the overall quality of images between different age groups (Chi-square test p-value=0.79) Inter-reader reliability score with Cohen’s Kappa overall was k=0.77 (P= <0.01) demonstrating good concordance between graders.

Conclusion 

Patients of all ages are able to provide photographs of adequate quality to allow for diagnostic assessment of benign eyelid lesions. Our study revealed that older age was not a barrier to the successful submission of adequate quality photographs of adequate quality. 80.8% of patients over 65 years were able to submit either adequate or excellent quality photographs with no statistically significant difference between different age groups. 

 


Gabriella GUEVARA (London, United Kingdom), Hardeep KANDOLA, Raja LAXMI, Swan KANG
10:40 - 12:40 #32228 - OP20 Digital analysis of eyelid contour changes in unilateral ptosis repair: External levator advancement vs Muller’s muscle conjunctival resection.
OP20 Digital analysis of eyelid contour changes in unilateral ptosis repair: External levator advancement vs Muller’s muscle conjunctival resection.

Purpose: Evaluation of lid contour changes and symmetricity analysis to compare outcomes of external levator advancement (ELA) and Muller’s muscle conjunctival resection (MMCR) surgeries in unilateral ptosis

Methods: The charts of unilateral ptosis patients who underwent ELA or MMCR were reviewed. Preoperative and postoperative 6th-month digital images were used for eyelid contour analysis. Digital analysis of eyelid contour was performed by a previously described technique, multiple MRD1, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals (Image 1). Marginal peak point changes were analyzed digitally by the coordinates of the peak point according to the pupil center. The mean distance at each position was compared pre-, post-operatively, and fellow eye.

Results: 16 patients had ELA and 16 patients had MMCR. The mean MRD1 improved by both techniques (1,46 vs 2,43 mm, and 1,12 vs 2,25 mm, p=0,008 and 0,0001 respectively), and became similar to fellow eye (2,43 vs 2,88 and 2,25 vs 2,58 mm, p=0,23 and p=0,19, respectively). However statistically significant lid margin elevation was limited between N6-T6 points in the ELA group, while this was achieved along the whole lid margin in the MMCR group (Image 2). A slight lateral shift of the marginal peak point was observed in the ELA group (p=0,11).

Conclusions: Both techniques provide effective lid elevation, however, the effect of ELA lessens towards canthi while MMCR provides more uniform elevation across the lid margin. MRD1 is not sufficient alone to reflect contour changes.


Serdar BILICI, Tomurcuk HARBIGIL-SEVER, Suat Hayri UGURBAS (Zonguldak, Turkey)
10:40 - 12:40 #32102 - OP21 Periocular asymmetry is increasing with age: a three-dimensional stereophotogrammetry study in Caucasians.
OP21 Periocular asymmetry is increasing with age: a three-dimensional stereophotogrammetry study in Caucasians.

Objective: To quantitatively assess the periocular asymmetry and investigate its sex and age-related differences in a Caucasian population using three-dimensional stereophotogrammetry.

Method: Three hundred and one volunteer Caucasians were recruited from May to December 2020. Three-dimensional periocular photos were taken for all subjects using the VECTRA M3 3D Imaging System. The 3D images were imported into the VECTRA Analysis Module software, and a coordinate system was established automatically. Subsequently, the periocular landmarks were localized, and a series of measurements were performed on these 3D images. All measurements were assessed with intraclass correlation coefficient (ICC) for inter-observer reliability, and both sides' absolute differences and asymmetry rates were calculated. Lastly, sex and age-related differences were evaluated.

Result: All 301 volunteers were German Caucasians, including 128 males (51.2 ± 19.2 years old) and 173 females (54.1 ± 19.5 years old). They were divided into the youth group (≤ 35 years old), middle-aged group (35 to 60 years old), and elderly group (> 60 years old). (1) Age variations: palpebral fissure height (PFH) asymmetry positively correlated with age (F = 7.616, p = 0.006). In the elderly group, marginal reflex distance (MRD) asymmetry positively correlated with age (F = 5.526, p = 0.0204). (2) Sex variations: absolute difference of tarsal platform show (TPS) was 0.65 ± 0.79mm for females and 0.90 ± 0.94 mm for males (p = 0.013). In the elderly group, the absolute difference of MRD was 0.664 ± 0.471 mm for males and 0.470±0.408 mm for females (p=0.001); the absolute difference of PFH was 0.619 ± 0.469 mm for males and 0.436±0.372 mm for females (p = 0.027). All measurements had an ICC between 0.668 and 0.943.

Conclusion: Asymmetry is prevalent in periocular appearance. Periocular asymmetry is more prominent in older people. The PFH asymmetry increases with age, and the MRD asymmetry is more evident in the elderly population. Meanwhile, the PFH and MRD asymmetry tend to be more significant in older men than women. Furthermore, three-dimensional photogrammetry might provide an accurate and effective reference and standard for periocular cosmetics and plastic surgery.


Xiaojun JU (Köln, Germany), Ludwig M. HEINDL
10:40 - 12:40 #32539 - OP22 Elaborated Analysis of Short and Long Term Results of Skin-Only versus Skin+Muscle Blepharoplasty.
OP22 Elaborated Analysis of Short and Long Term Results of Skin-Only versus Skin+Muscle Blepharoplasty.

Objective: It was aimed to evaluate the short and long-term effects of skin only and  skin+ muscle excision blepharoplasty on corneal nerves, dry eye parameters, meibomian glands, and eyebrow height.

 

Method: Twenty-four eyes (Group-S) of 12 patients who underwent skin excision and 24 eyes (Group-M) of 12 patients who underwent skin+muscle excision were included in the study. Preoperative, 1st week, 1st month, and 1st year Schirmer test, corneal confocal microscopy (CCM) parameters, non-invasive tear break-up time (NTBUT), meibomian gland area (MGA) analysis with infrared meibography, and lateral (LBH) and central (CBH) eyebrow heights were evaluated.

 

Results: There was no significant difference between the two groups regarding age, gender, and preoperatively evaluated parameters (p>0.05). According to the preoperative values, a significant decrease was observed in the CCM parameter of nerve branch density in Group-S at week 1 (19.50±7.88 vs. 16.70±7.72 branches/mm2, p=0.026), and a significant decrease was observed in nerve fiber density in Group-M (19.98 ±7.59 vs. 17.11±7.16 fibers/mm2, p=0.006). A non-significant increase was observed in corneal nerve parameters in the 1st month; however, there was a slight decrease in the 1st year compared to baseline in both groups (p>0.05). Regarding Schimmer and NTBUT, there was no significant change from baseline in all visits in both groups (p>0.05). According to preoperative MGA values, a significant increase was observed in Group-S (18.84±6.02 vs. 21.18± vs.6.10, p=0.005) and in Group-M (18.25±8.45 vs. 20.21±8.02, p=0.001) at 1 year. While no significant change was observed in eyebrow height in Group-S, a significant increase was observed in Group-M at 1 year in LBH (16.50±2.81 vs. 17.19±2.40 mm, p=0.007) and 1 month (17.31±2.77 vs. 18.00±2.50 mm, p=0.007) and 1 year (17.31±2.77 vs. 18.13±2.71 mm, p=0.001) in CBH compared to baseline.

 

Conclusion: Elaborated analysis of this cohort showed that both surgical methods had similar effects on corneal nerves and dry eye parameters. Both approaches provided a significant increase in MGA. In addition, including muscle excision in the routine blepharoplasty operation has been found to be a reliable method that will give a slight elevation in eyebrow position.


Volkan DERICIOĞLU (Istanbul, Turkey), Burçin ŞAN
10:40 - 12:40 #32544 - OP23 Popeye: Rejuvenation of the brow and upper eyelid volume, projection and contour using PDO threads.
OP23 Popeye: Rejuvenation of the brow and upper eyelid volume, projection and contour using PDO threads.

Objective: To describe the popeye procedure, evaluate clinical rejuvenation and patient satisfaction in patients with aging of the brow-upper eyelid continuum.

Methods: Experimental non-randomized prospective study. Pop eye was performed on two groups of patients with aging characterized by deflation or ptosis of periocular tissues. Each group was treated with an original designed standardized 3 step protocol using 3 types of polydioxanone  (PDO) threads: Biocannula for revolumization, mono double screw for projection and monofilament for fine lines and skin quality. All procedures were performed by the same doctor, duration, pain and complications were registered. Standardized digital and 3D photography was taken before and on follow up visits weeks 1, 6 and 12. Clinical outcomes: Brow fat pad volume, elasticity and shape; brow - eyelid linkage and dynamics, eyelid crease definition, skin quality and brow hair density. Patient satisfaction was assessed using face QTM 2013. 

Results: 7 women and 2 men, 45 years average underwent bilateral pop eye and completed follow up. The Popeye procedure took 30 minutes in average and patients reported pain ranging from 2 to 6 out of 10. 4 patients presented mild to severe hematomas during the procedure, all resolving within the first week. By week 6 all showed some degree of brow contour, skin quality and volume improvement, which increased significantly by week 12. The group with deflation aging showed higher satisfaction rates that the ptosic group. No severe complications were reported.

Discussion/Conclusion: Popeye is a minimally invasive safe in office procedure that rejuvenates the supero lateral periocular area. It targets multiple tissues achieving a natural and balanced restoration of the patients anatomy, thereby being highly accepted by patients. Because of the nature of PDO threads pop eye may be used in combination with other cosmetic treatments and as complement of surgery.


Jocelyne KOHN (Santiago., Chile), Geraldine KOHN
10:40 - 12:40 #32314 - OP24 Periorbital and peri ocular microfat grafting : Complications observed over a series of 262 personally performed procedures.
OP24 Periorbital and peri ocular microfat grafting : Complications observed over a series of 262 personally performed procedures.

Periorbital and periocular microfat grafting:


Complications observed over a series of 262 personally performed procedures

 

 

Objective:

 

Microfat grafting and lipostructure are becoming increasingly popular when it comes to achieving facial rejuvenation and socket reconstruction.

 

Very few papers concerning the complications encountered therein are available in the literature, and the follow-up periods are usually relatively short.

 

Considering that the potential complications and the benefit / risk ratio are critical when selecting the correct procedure, I thought it might be of interest to research the complications that arose in my personal series of consecutive patients who underwent these procedures between 2006 to 2021.

 

Method:

 

The series comprises 230 patients and 262 procedures, which concern the orbit (socket reconstruction) and the face (facial rejuvenation). These operations might have been associated with various other cosmetic procedures, such as blepharoplasty, ptosis repair, canthoplasty, etc.

 

Results:

 

I encountered the following issues:

 

 

Benign and temporary complications:

 

Facial pain
Thigh pain
Ecchymosis (thigh or face) 

 

More threatening complications:

 

Intermittent lymphatic oedema (2 cases) that did not improve over time
Cysts that appeared at 6 weeks post-surgery (2 cases)which cleared up spontaneously several weeks later
Accentuation of the pre-op pigmentation following post-op ecchymosis 
Infection (one caselymphangitis in the thigh) that required antibiotics 
Ptosis (3 cases) following orbital injections for socket reconstruction 

 

Discussion:

 

It must be emphasized that the following complications did not occur:

 

No orbital or palpebral hematoma 
No granuloma 
No embolization 
No surface irregularity
No excess of volume requiring surgical correction 

 

The precautions that were used to prevent these complications are outlined in the presentation.

 

Conclusion:

 

Microfat grafting and lipostructure in the periocular and orbital areas is a safe procedure in this series, wherein potential complications were anticipated and prevented with specific precautions.

 

 


Pierre ESCALAS (Saint Herblain)
10:40 - 12:40 #32402 - OP25 Lateral brow tail elevation using selective orbicularis muscle excision in upper blepharoplasty.
OP25 Lateral brow tail elevation using selective orbicularis muscle excision in upper blepharoplasty.

The Main lateral brow depressor, responsible for the unpleasant temporal hooding is the orbicularis muscle. Neurotoxin injections have proven efficient in weakening lateral orbicularis function & reducing this unwanted look, elevating the level of the brow, thereby delaying surgery for many.

This presentation is to show our results utilizing this concept to help elevate the tail of the brow in patients undergoing UL blepharoplasty in Magrabi Eye Hospital, Abu Dhabi UAE.

Patients:

30 female patients, 25-55 years old, undergoing UL blepharoplasty.

Inclusion criteria: 

Dermatochalasis with or without orbital fat prolapse

Exclusion criteria:

concomitant blepharoptosis

concomitant brow ptosis (below the orbital margin)

recent botox treatment or eyebrow filler (6months or less)

brow ptosis due to facial nerve paresis

history of previous surgeries

Assessment: Brow position is measured pre-op & 1 month post op, with the patient in seated position looking straight and with fully relaxed forehead, using a vertical line from lateral canthus to the bottom of the brow & another diagonal measurement from the lateral canthus to the tail of the brow (intersecting with the lateral ala of the nose)

Methods: (video will demonstrate the procedure) After skin incision, skin is dissected away from the orbicularis, lateral fibers of the orbital orbicularis is transected in a triangular incision & dissected away from the septum down to the periorbita of the lateral & superior orbital margin. The brow & sub-brow fat is dissected over the periosteumreleasing all tethering attachments. The rest of the surgery follows as a classic blepharoplasty, insuring intact lateral orbital septum, with added thermal treatment to tighten the lateral orbital septum & encourage post op adhesion.

Result: Overall satisfaction rate was almost 95% with no significant complications. Significant brow tail elevation (an average of 5mm) following this procedure, 1 month post-operative.  (due to elevation by take over action of the lateral fibers of the frontalis muscle)

Conclusion: The incorporation of selective orbicularis oculi muscle excision has been a safe & effective augmenting tool to produce elevation of the tail of the brow after UL blepharoplasty, providing a more pleasing result.


Riham AFIFI (Abu Dhabi, United Arab Emirates)
10:40 - 12:40 #32156 - OP26 Brow lifting using retro orbicularis oculi fat (ROOF) augmentation.
OP26 Brow lifting using retro orbicularis oculi fat (ROOF) augmentation.

Background

The eyebrow is a mobile structure, and some degree of brow ptosis occurs with age. Ptosis may be attributable to depletion of facial tissues, such as fat and ligaments, and gravitation. In assessing a patient for blepharoplasty or ptosis repair surgery, it is important to determine the eyebrow position. To date, numerous surgical techniques have been developed for brow lifting.

Methods

We introduce a new technique of repairing brow ptosis using retro orbicularis oculi fat (ROOF) augmentation. This surgery is performed through an upper eyelid crease incision. The procedure aims to reposition the preaponeurotic fat, which has two major roles. First, preaponeurotic fat supports the brow and soft tissues. Second, the volume added to the ROOF raises the eyebrow.

Results

By using ROOF augmentation we can raise the eyebrows and get a nice aesthetic result during blepharoplasty.

Conclusion

This is a new effective and easy technique for brow lifting.


Yanir KASSIF (Nahariya, Israel), Relli OVADIA, Dana COHEN
10:40 - 12:40 #32301 - OP27 Scar acceptability of the modified pear-shaped direct brow lift.
OP27 Scar acceptability of the modified pear-shaped direct brow lift.

Aims: The direct brow lift is a powerful method of raising the brow but can be associated with significant scarring. We describe a technique of raising the lateral brow to minimise visible scarring. 

 

Methods: Modifications to the direct brow lift included a lateral incision, incision close to the upper border of the brow hairs, counter-bevelling of the upper and lower incision and a pear-shaped excision. Patients who underwent direct brow lift by the senior author over a 5-year period were identified and asked to complete the validated Patient Scar Assessment Questionnaire.

 

Results:

76 patients were identified and 47 (62%) completed the questionnaire. Mean patient age was 57 years (range 26-79); 79% were female. 68% underwent concurrent upper eyelid blepharoplasty, 6% ptosis surgery and 30% lower eyelid blepharoplasty. 2 patients (4%) underwent revision of the brow lift; for a granuloma and residual brow ptosis.

The first component of the questionnaire is scar appearance and 70% of patients described the appearance as excellent, 11% as good, 15% as okay, 4% as poor and none as very poor. The scar was described as very well or well matched to surrounding skin in 92%, short or very short in 79%, thin or very thin in 94% and smooth or very smooth in 98%. 70% described the scar as flat and level, 11% as slightly raised, none as fairly or very raised, 15% as slightly sunken, 2% as fairly sunken and 2% as very sunken. In terms of symptoms, 96% reported that there were none, and 4% described symptoms as a little troublesome. Patients reported that itching was a feature in 8%, 2% reported numbness and odd sensations and no patients reported pain or discomfort. 96% were satisfied with the symptoms from the scar. Overall, 77% were not at all self-conscious about the scar, 13% slightly, 6% fairly and 4% very self-conscious.

 

Conclusion: The direct brow lift is associated with high levels of patient acceptance when the scar is hidden at the tail of the brow. 


Caroline WILDE (London, United Kingdom), Sherlock ALEXANDER, Tanaka ANNALISE, Blood AMBER, Daniel EZRA
10:40 - 12:40 #31962 - OP28 Periocular Fillers in Imaging - What can we learn?
OP28 Periocular Fillers in Imaging - What can we learn?

Introduction: Periocular fillers are commonly used. Usually they are ignored in imaging, although they have a specific well known appearance . Periocular fillers are usually incidental findings, but, they should be part of the differential diagnosis of every periorbital or orbital mass, swelling, inflammation or infection

The purpose of this presentation is to present all forms of fillers as expressed in CT MRI - in uncomplicated and complicated cases. It is important for the aesthetic surgeon/ Dermatologist or Oculoplastic surgeon to be aware of filler appearance in imaging in order to assist differential diagnosis, exact position of fillers, distribution and filler type 

In the presentation (depending on time ) 15 cases will be presented- each case adds to the understanding of fillers in imaging . MOreover - three main complications will be presented in imaging as well 

For summary- As we become more precise in fillers injections- imaging is a strong tool in understanding filler distribution differential diagnosis and complications. Understanding their appearance in imaging is mandatory for the aesthetic surgeon


Ayelet PRIEL (Ramat Gan, Israel), Gahl GREENBERG, Guy BEN SIMON
10:40 - 12:40 #32545 - OP29 In office high resolution ultrasound in the management of periocular filler related syndrome.
OP29 In office high resolution ultrasound in the management of periocular filler related syndrome.

Objective: To describe the applications, clinical and imagenological correlations of high resolution ultrasound in the diagnosis and treatment of patients presenting with periocular filler related syndrome.

Methods: 25 patients presented between June 2021 and June 2022 with at least one clinical feature of the syndrome: persistent edema, recurrent edema, persistent filler, discromia, filler migration, cutaneous expansion or contour abnormality. Complete and detailed medical history, clinical examination and standardized digital and 3D photography was complemented with high resolution doppler evaluation using a portable, cordless and simple to use devise (Clarius L20). Images and videos were recorded. 

Results: The most frequent signs of periocular filler related syndrome observed were edema and contour abnormalities. Ultrasound evaluation was key in identifying the presence and nature of the filler in all cases. The use of doppler ultrasound assessment was of great value, showing in vivo information on vessel anatomy and blood flow that correlates with edema and soft tissue changes. Direct visualization of the filler allowed to plan and tailor the treatment for each patient according to the findings. 15 patients underwhent treatment with hialuronidase. Only 2/3 of them required filler to be fully disolved, the rest were resolve with just partial dissolution. Patients were then treated subsequently with surgery, re-filled or with a combination of treatments. 

Discussion/Conclusion: Ultrasound is a useful and easy to use tool that may help the clinician confirm the diagnosis in complex cases of aesthetic filler complications. It is also a good ally to perform guided hialuronidase injection and then visualize no filler is left over. 


Jocelyne KOHN (Santiago., Chile), Geraldine KOHN
10:40 - 12:40 #32298 - OP30 Indications, outcomes and optimal dosing strategies for hyaluronidase injections in the treatment of filler related complications.
OP30 Indications, outcomes and optimal dosing strategies for hyaluronidase injections in the treatment of filler related complications.

Background: The presentation of patients with filler-related complications is increasing. Hyaluronidase is effective at dissolving hyaluronic acid fillers but concerns exist regarding post treatment hollowing, skin changes, wrinkling and pigmentation. This study aims to investigate the optimal dosing strategy for hyaluronidase and to identify predictors of poor outcomes.

 

Methods: Retrospective review of 157 orbits of 90 patients treated with hyaluronidase over a four year period. Demographic data, indication and details of hyaluronidase treatment were recorded. Patient outcomes were categorised as satisfactory result, insufficient treatment or adverse effects.

 

Results: The primary indication for dissolving filler was swelling in 52%, lumpiness in 20%, and prior to surgical blepharoplasty in 17%. The most frequently used hyaluronidase concentration was 150U/mL in 66%, followed by 75U/mL in 31%, 37.5mg/ml in 3% and 100mg/ml in 1%. Outcomes were characterised as: 59% with a satisfactory result; 24% as insufficient treatment requiring further hyaluronidase; and 18% complaining of facial changes such as hollowing, indicating a posthyalase syndrome. A significant correlation was identified between a hollow outcome and duration of filler in situ (p=0.00019) and volume of filler (p= 0.000017). There was no effect of concentration of hyaluronidase or total dose on outcomes.  There was no statistical difference in outcomes between the 75 and 150 U/mL dosage groups (p=0.625).

 

Conclusions: 30-40 units of hyaluronidase per 0.1ml of filler is associated with a high rate of success and low rate of complications. All patients should be consented about the risks of hyaluronidase; patients with longer histories of filler use and higher total volumes should be advised of the increased risk of complications. In patients with high total volumes of filler, clinicians should consider a gradual process of filler dissolving over multiple sessions in lower doses to cautiously reduce the volume of filler to prevent a post hyalase syndrome.


Caroline WILDE (London, United Kingdom), Kailun JIANG, Sieun LEE, Daniel EZRA
10:40 - 12:40 Time for questions and discussion.
Room 1
12:40

"Friday 16 September"

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A25
12:40 - 13:00

Keynote Lecture II

12:40 - 13:00 Peri Orbital neurofibromasis. How to manage it ? Naresh JOSHI (Keynote Speaker, Londres, United Kingdom)
Naresh Joshi is a founder member, and ex-president of the British Ophthalmic Plastic Surgical Society (BOPSS). He heads the BOPSS and the Royal College of Ophthalmologist’s aesthetics subcommittee. He is the UK representative on ESOPRS committee.
12:40 - 13:00 Introduced by:. Jacques LAGIER (local organiser ESOPRS 2022) (Chairperson, NICE, France)
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"Friday 16 September"

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A26
13:00 - 14:00

THEA LUNCH SYMPOSIUM
WHEN EYELID IS A PROBLEM

13:00 - 14:00 Peri-ocular skin problems. Lionel STORK (Ophthlamologist) (Presenter, NANTES, France)
13:00 - 14:00 The microbiotia of the eyelid skin. Marc LABETOULLE (Presenter, KREMLIN BICETRE, France)
13:00 - 14:00 Interlink between eyelid surgery and dry eye. Daniel EZRA (Presenter, United Kingdom)
LUNCH IN THE EXHIBITION AREA Room 1
14:00

"Friday 16 September"

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A27
14:00 - 15:40

Oral Communications
Orbit

Moderators: Francesco QUARANTA-LEONI (Rome, Italy), David H. VERITY (London, United Kingdom)
14:00 - 15:40 #30793 - OP31 Orbital fat density as a predictive value in orbital cellulitis.
OP31 Orbital fat density as a predictive value in orbital cellulitis.

Objective: To evaluate orbital fat density as a tool to differentiate peri-orbital  and orbital cellulitis at initial diagnosis.

Methods: Data regarding all patients with clinical diagnosis of orbital and peri-orbital cellulitis (OC, POC) in a 10-year period were collected and analyzed. Intra-conal orbital fat density was measured using Hounsfield units (HU) in 6 different delineated surfaces: nasal and temporal at the axial equator plane, one section above, and one below (Figure 1). Fat density was correlated with disease status (i.e. pre septal and orbital) both at presentation and at final diagnosis. 

Results: Seventy-seven patients were included, 59 males (77%), mean (SD) age of 17 (19) years [0-90]; 57 (74%) underwent CT scans with contrast and were included in statistical analysis. Average intraconal fat density (SD) measured -52 (18) HU on the involved side vs. -63 (13) on the non-involved side (P<0.001). There was a strong correlation between the HU of both orbits (R=0.42, p=0.001, Spearman’s correlation). The HU values were higher in cases of a final diagnosis of OC vs. POC in both eyes, (involved orbit: -68 POC vs. -46 OC, p<0.001, uninvolved orbit: -68 vs. -61, p=0.09, Independent samples t-test). This effect was mirrored when taking into account HU measurements from the nasal intraconal space only (involved nasal fat: -62 POC vs. -30 OC, p<0.001, uninvolved nasal fat: -66 vs. -55, p=0.05, Independent samples t-test). 

The HU values were significantly higher in the nasal vs. temporal locations of each orbit, and this was observed both on the involved and noninvolved orbit (P<0.001). 

When stratifying patients into four groups based on the initial and final diagnosis of orbital cellulitis (OC) and peri-orbital cellulitis (POC), a similar trend of higher fat density was observed in cases with final diagnosis of OC. These differences were significant in the involved side (p<0.001, ANOVA multivariable analysis) and more robust on the nasal side (p<0.001, ANOVA multivariable analysis) (Figure 2).

Conclusions: Intraconal orbital fat density, measured by HU can assist in primary assessment of orbital involvement in patients with orbital and pre-septal/periorbital cellulitis. The nasal intraconal fat may be more sensitive perhaps because of its close proximity to the ethmoidal sinus from which the disease evolves. This may aid in initial differentiating pre-septal and orbital cellulitis in cases of uncertainty, pertaining directly to best treatment options. 


Daphna LANDAU (Tel Aviv, Israel), Ella NISSAN, Ofira ZLOTO, Gahl GREENBERG, Guy J. BEN SIMON
14:00 - 15:40 #31979 - OP32 Peculiarities of primary surgical treatment of bullet eye periorbital region and orbit injuries.
OP32 Peculiarities of primary surgical treatment of bullet eye periorbital region and orbit injuries.

Relevance: Considering war actions in Ukraine, the incidence of combined eye injuries is constantly growing. 

Aim: To improve surgical treatment of bullet injuries of the periorbital region and orbit.

Materials and methods: A retrospective analysis of 69 patients’ cases during the period of 24.02.2022 till 24.05.2022with eye trauma, the patients were admitted in the Center of Eye Trauma, Oleksandrivska hospital, Kyiv.

Results: 14,5% patients from the group had combined eye injury due to the orbit gunshot woundsThe vision acuity in 60% of patients was no light perceptionin 20% - light projection, 10% - light perception, and 10% -  totally destroyed eyeball. In 3 cases an open eye injury was combined with the ethmoidal sinus trauma, in 2 cases – with the temporal pit trauma, and in 5 cases – with the maxillary sinus trauma. In 6 cases the injury was accompanied with the traumas and defects of the periorbital area of eyelids. In 6 cases computed tomography revealed foreign bodies in the wound canals. All cases were characterized by the orbit fractures. Primary surgical treatment included: removing foreign bodies and suturing the entry and exit eyeball wounds.  Under impossibility of organ-saving operation, the debris of the eye were removed and the stump was made using Dermo-fat Graft of the sciatic area and introducing temporary prosthesis. At the same time, upon the necessity, metallo- osteosynthesis of orbit fractures was performed, if the soft tissues were injured, a primary defect plastics was used, otherwise - free plastics.

Conclusion: Organ-saving and reconstructive operations on the primary stage are aimed at timely appropriate ophthalmologic service, in order to achieve best anatomic-functional and esthetic results.


Nataliia ROSUMIY, Tetiana PIVNEVA, Anna CHMIL (Kyiv, Ukraine)
14:00 - 15:40 #31973 - OP33 Optic nerve sheath fenestration: current status in France and comparison of 6 different surgical approaches.
OP33 Optic nerve sheath fenestration: current status in France and comparison of 6 different surgical approaches.

PURPOSE: Optic nerve sheath fenestration (ONSF) is a surgical procedure commonly performed in the Anglo-saxons countries for the treatment of medically refractory idiopathic intracranial hypertension (IIH). We aimed to compare 6 different trans-orbital surgical approaches to perform an ONSF. We also aimed to determine the number of optic nerve decompression procedures in 2019 and 2020 in France.

 

METHODS: Four fresh frozen orbits were dissected at the University anatomy laboratory of Nice. We performed the following surgical approaches: (i) eyelid crease, (ii) lid-split, (iii) medial transconjunctival with medial muscle disinsertion, (iv) medial transconjunctival without muscle disinsertion, (v) lateral transconjunctival and (vi) lateral orbitotomy. For each surgical approach, we measured the distance between the incision and the optic nerve dura mater. We also extracted data providing from the French National PMSI (Programme de Médicalisation des Systèmes d’ Information) database between January 2019 and December 2020 to determine the annual number of optic nerve decompression procedures.

 

RESULTS: The lid crease and medial transconjunctival approaches provided the shortest distance to the optic nerve (average 21 mm and 24 mm, respectively) and the lowest levels of difficulty compared to the other surgical routes. A total of 23 and 45 optic nerve decompressions were performed in France in 2019 and 2020, respectively. Among them, only 2 and 7 procedures were performed through a trans-orbital approach, respectively.

 

CONCLUSION: Upper lid crease incision and medial transconjunctival approaches are the most direct and easiest surgical routes when performing an ONSF. We found that ONSF was rarely performed in France. We claim for a rehabilitation of ONSF especially in patients with IIH with severe visual loss and advocate close cooperation between the ophthalmologists, the neurologists, the neurosurgeons and the interventional radiologists.


Ken MARTINI (NICE), Laura TRUCCHI, Jerome DELAS, Jacques LAGIER, Arnaud MARTEL
14:00 - 15:40 #32392 - OP34 Magnetic Oculomotor Prosthetic for Acquired Nystagmus: Safety and outcomes.
OP34 Magnetic Oculomotor Prosthetic for Acquired Nystagmus: Safety and outcomes.

Objective: Acquired nystagmus in adulthood results in debilitating oscillopsia and functional reduction in visual acuity, caused by heterogeneous pathology affecting the complex multiplicity of cerebral nuclei and neural pathways. Thereby, producing an effective pharmacological therapeutic agent is challenging. Alternatively, the endpoint of such pathology converges towards extraocular muscles - which has prompted the development of strabismic approaches - with limited success. More recently, our centre reported a novel technique using a magnetic oculomotor prosthesis to dampen the rhythmic oscillations in such patients. We report on the safety of this technique and interim outcomes. 

Methods: Case series of patients undergoing orbital magnetic prosthetic implants for acquired nystagmus at a single tertiary centre. We assessed visual acuity (VA), intraocular pressure (IOP), and colour vision (Ishihara) and perioperative complications. 

Results: Ten eyes of 5 patients underwent magnetic oculomotor prosthetic implantation at a mean age of 56 years (median 55, range 47-64). Patients were followed up on average for 44 months (median 30, range 16 - 112 months). On average, there was 1.7 line of Snellen acuity improvement in the operated eye (median 1.5, range 0-3), reflecting subjective dampening of nystagmus on primary gaze, with complete resolution in one patient. No patients had a significant change in intraocular pressure or reduction in colour vision. One patient had postoperative orbital inflammation, thought to be secondary to excess cyanoacrylate glue. No reaction is observed with conservative application in future cases. Change in oculo-motility was observed in 3 of 5 patients, of which one patient had symptomatic diplopia that was managed conservatively with head posture. 

Conclusions: Magnetic oculomotor prosthetic implantation is a novel technique for managing acquired nystagmus and overall safe with no detriment to patients' visual function. Such treatment offers a new management paradigm for patients that remain refractory to pharmacological and standard strabismus approaches. 


Mohsan MALIK (London, United Kingdom), David VERITY, Parashkev NACHEV, Geoff ROSE, Sanjay MANOHAR, Kelly MACKENZIE, Gill ADAMS, Maria THEODOROU, Quentin PANKHURST, Chris KENNARD
14:00 - 15:40 #31960 - OP35 Alterations in retrobulbar hemodynamics after orbital decompression surgery in inactive thyroid eye disease in Indian population - a prospective study.
OP35 Alterations in retrobulbar hemodynamics after orbital decompression surgery in inactive thyroid eye disease in Indian population - a prospective study.

PURPOSE:

Perfusion biomarkers in thyroid eye disease (TED) are an important predictor for the pathogenesis of dysthyroid optic neuropathy (DON). Inactive TED shows reduced orbital blood flow with an increased resistance index in the orbital arteries. We plan to evaluate the exact effects of orbital decompression surgery on arterial and venous beds in orbit.

METHOD:

24 euthyroid inactive moderate-to-severe TED patients underwent surgical orbital decompression. Colour Doppler imaging was used to image the ophthalmic artery (OA), central retinal artery (CRA), and superior ophthalmic vein (SOV). The parameters assessed were peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistivity index (RI) for the arteries, and the direction of blood flow for the vein. Optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) thickness was used to monitor for DON. All biomarkers were evaluated pre-surgery and 3 months post-surgery. 24 age and gender-matched cases of inactive TED, not requiring orbital decompression surgery, were used as disease controls along with 18 healthy controls.

RESULTS:

All cases had a significant reduction in proptosis after orbital decompression surgery. There was a reduction in SOV dilatation and a reduction in a reversal of blood flow from 8 to 3 TED orbits, post-surgery. The arterial velocities improved among all cases post-decompression. The improvement was significant (p<0.05) among CRA-PSV, OA-PSV, OA-EDV, and OA-RI. On dichotomously dividing the groups at the median duration of thyroid disease (48 months), the early and late groups showed significant improvement in CRA-PSV, CRA-EDV, OA-PSV, OA-EDV, and OA-RI. However, only the early group showed significant improvement in CRA-RI, suggesting the onset of irreversible changes in intra-ocular microvasculature with time. A thicker inferior RNFL rim at presentation, which declined in OCT RNFL values post-surgery was noted.

CONCLUSION: Orbital decompression surgery improves the orbital hemodynamics by resolving the orbital volume conflict. Long-standing TED cases may develop irreversible changes in the intraocular vasculature. A reduction in orbital perfusion parameters could herald the onset of ischemic DON. A timely intervention - early orbital decompression, can help reduce the visual morbidity in DON. 


Shalin SHAH (NEW DELHI, India), Ruchi GOEL
14:00 - 15:40 #32231 - OP36 Are we missing something in patients with Thyroid Eye Disease-Compressive Optic Neuropathy (TED-CON)?
OP36 Are we missing something in patients with Thyroid Eye Disease-Compressive Optic Neuropathy (TED-CON)?

Background: The aim of this research was to investigate the subclinical findings in patients with TED-CON and to present the tritan deficiency as an early indicator for the optic nerve compression in patients with Graves’ orbitopathy.

 

Patients and Methods: In this observational, retrospective study the medical charts of 24 patients (32 eyes) with a definitive diagnosis of TED-CON between 2008 and 2019 were included. Our goal was to identify potential pathological signs in patients prior to the TED-CON diagnosis. Therefore, our statistical analysis examined the data of the visits prior to the definitive diagnosis of TED-CON (subclinical phase) and at the time of the definitive diagnosis of TED-CON.

 

Results: We discovered that the earliest pathological sign in the subclinical cases was tritan deficiency of the color vision test. In all cases but one, regardless of the visual field defects, the tritan value was pathological (based on a threshold of  8%) in subclinical phase. The mean tritan value was 19.12% (range 6.9 – 80.8%) at the time of the subclinical phase and 32.16% (range 6.3 – 100.0%) at the time of the diagnosis of TED-CON. The sensitivity of the color vision test was 20% for protan and 96.67% for tritan in the subclinical phase. At the time of the definitive diagnosis of TED-CON, the sensitivity of protan was 48.15% and sensitivity for tritan was 96.30%.

 

Conclusion: In summary, we found in our retrospective analysis, that an early sign resulting from the compression of the optic nerve in patients with TED-CON involves changes to vision of blue-yellow (tritan) colors, even in patients with normal visual field tests. Our data suggest that, in cases suspected of TED-CON, a color vision test that can detect tritan deficiency is helpful in the subclinical phase, as well as for the confirmation of TED-CON diagnosis. 


Garip Kübler AYLIN (Munich, Germany), Kathrin HALFTER, Annemarie KLINGENSTEIN, Siegfried PRIGLINGER, Christoph HINTSCHICH
14:00 - 15:40 #31622 - OP37 Magnetic resonance imaging for dysthyroid optic neuropathy and moderate-to-severe Graves’ orbitopathy: an observational prospective cross-sectional study.
OP37 Magnetic resonance imaging for dysthyroid optic neuropathy and moderate-to-severe Graves’ orbitopathy: an observational prospective cross-sectional study.

Background: diagnosis of dysthyroid optic neuropathy (DON) is based on clinical criteria, but can be challenging in early or atypical cases. Imaging is often supportive. Magnetic resonance imaging (MRI) can evaluate the same parameters as computed tomography, but can additionally assess inflammatory activity. It may therefore be a valuable adjunct in the diagnosis of DON.

Objective: To evaluate MRI and clinical characteristics in patients with moderate-to-severe Graves orbitopathy (GO) and DON, to assess the diagnostic value of these factors for DON, and to correlate the MRI features with the clinical activity score (CAS).

Design: observational prospective cross-sectional study.

Participants: patients older than 18 years diagnosed with moderate-to-severe GO or DON who have never undergone surgical decompression and did not receive corticoid or radiotherapy within 6 months prior to participation.

Methods: nineteen patients with DON (34 orbits) and 29 patients with moderate-to-severe GO (58 orbits) were consecutively enrolled. Orbital MRI was performed according to a standardized imagistic protocol followed by clinical ophthalmic and orthoptic examination within 4 weeks. Multivariable logistic regression models were built to predict the presence of DON and correlations between the primary outcomes and CAS were calculated.

Main outcome measures: maximal radial diameter of the extraocular muscles (EOMs), signal intensity ratio of the EOMs (relative to the temporalis muscle), relative apparent diffusion coefficient (rADC) of the EOMs (relative to the temporalis muscle), apical crowding index, CAS, duction scores.

Results: in a univariable analysis, depression, adduction, abduction, CAS (both ordinal and dichotomized), all EOM diameters, medial, superior and inferior rectus rADC and apical crowding were significant predictors of the presence DON. However, in multivariable models only medial rectus diameter, superior and inferior rectus rADC and depression remained significant independent predictors. The strongest model combined medial rectus diameter and inferior rectus rADC. Apical crowding and optic nerve stretching were not independent preditors of DON.

Conclusion: MRI with diffusion-weighted imaging sequences can be a useful adjunct in the diagnosis of DON. Medial rectus diameter, inferior and superior rectus rADC and limitation of depression are independent predictors of DON. Apical crowding and optic nerve stretching may be less important in its pathogenesis.


Arnaud POTVIN (Amsterdam, The Netherlands), Maartje DE WIN, Peter BISSCHOP, Michael TANCK, Robert LOONTJENS, Hinke Marijke JELLEMA, Ioana IONESCU, Peerooz SAEED
14:00 - 15:40 #32199 - OP38 Comparative study on the efficacy of periocular methotrexate versus periocular triamcinolone injections in management of thyroid associated orbitopathy.
OP38 Comparative study on the efficacy of periocular methotrexate versus periocular triamcinolone injections in management of thyroid associated orbitopathy.

Aim:  To assess the efficacy and safety of periocular injections of methotrexate in management of active thyroid associated orbitopathy (TAO) in comparison to periocular injections of triamcinolone.

Methods: Prospective, double-blind, interventional randomized clinical trial in which eighteen patients with bilateral active, moderate to severe TAO were randomized such that an orbit received methotrexate (7.5mg) and the contralateral orbit received triamcinolone (20mg). Each orbit received three periocular injections at 3-weeks interval. 

Results:

In the methotrexate group, the mean clinical activity score (CAS) decreased significantly from 5.2± 0.89 at baseline to 0.9 ± 1.7 six months after last injection (p-value<0.001), mean proptosis also decreased from 25.2 ± 3.4 mm at baseline to 23.8 ± 3.7 mm at end of study (p-value=0.01). In the triamcinolone group, the mean CAS decreased significantly from 5.1± 0.9 at baseline to 1 ± 1.7 six months after last injection (p- value<0.001), mean proptosis also decreased from 24.27 ± 3.06 mm at baseline to 23.27 ± 3.3 mm at end of study (p-value=0.049). 

Statistically significant decline in lid aperture and soft tissue inflammatory score in each group was observed in all visits compared to baseline. BCVA in both groups remained stationary throughout the study. A statistically significant reduction in IOP was noted in the methotrexate but not in the triamcinolone group.

About 89% of patients in both groups had improvement in CAS at week 30, 33-50% of patients showed improvement in proptosis and lid aperture measurements and only 5.6% of patients had improvement in EOM function. No statistically significant difference was detected between both methotrexate and triamcinolone groups at any follow up visit. Both drugs were safe with minimal local complications and systemic adverse effects.

Conclusion: Periocular methotrexate injection is as effective as periocular triamcinolone injection and represents an effective and safe modality for management of active TAO.


Islam SWAIFY, Kareem ELESSAWY, Rania EL ESSAWY (Egypt, Egypt), Haytham NASR
14:00 - 15:40 #32064 - OP39 Pediatric Graves’ orbitopathy: a multicentre study.
OP39 Pediatric Graves’ orbitopathy: a multicentre study.

Purpose: Graves' orbitopathy (GO) is a rare condition in children and often considered to be milder than at an older age. The aim of our study was to analyze the characteristics of pediatric GO population in order add more data on how to assess and manage pediatric GO.

Methods: A retrospective analysis of 115 pediatric patients with GO seen at our university medical centers in the Netherlands and Iran was performed between 2003 and 2019. Patients were submitted for complete ophthalmological examinations, serological testing and/or orbital imaging. Main outcome measures were: the natural course of the disease, clinical picture and both medical and surgical treatment in pediatric GO.

Results: The median age at diagnosis and first presentation was 15 years (range 0–18) and 81% of the patients’ population were girls. Clinical findings included proptosis (84.3%), eyelid retraction (67%) and diplopia (11.3%). Eighty percent presented with mild disease, 18.3% with moderate-severe disease and around 2% with severe GO. Two patients experienced reactivation of the disease. Five patients underwent intravenous glucocorticoids and 25 patients underwent orbital decompression surgery. Overall, rehabilitative surgical treatment was performed in 26.9% of patients with inactive disease.

Conclusion: Although pediatric and adult GO are considered two separate entities, they might be the same disease with two different clinical phenotypes. Pediatric GO has a comparable clinical picture in relation to both soft tissue involvement and proptosis, which may require surgical rehabilitation.


Ioana Catalina LACRARU (BUCHAREST, Romania), Dion PARIDAENS, Eliane CAGIENARD, Rachel KALKMANN, Farzad PAKDEL, Stijn VAN DER MEEREN, Peerooz SAEED
14:00 - 15:40 #32346 - OP40 89Zr-rituximab PET/CT in orbital inflammatory disease - an update.
OP40 89Zr-rituximab PET/CT in orbital inflammatory disease - an update.

Background: Orbital inflammatory diseases are a heterogenic group of conditions that often entail a difficult diagnostic process and many patients are treatment resistant. Inflammatory diseases can be visualized by Zirconium-89 labelled rituximab PET-CT (89Zr-rituximab PET/CT). In this study we update our experience and potential of the 89Zr-rituximab PET/CT for diagnostic and therapeutic management of refractory orbital inflammation.

 

Methods: Retrospectively, 89Zr-rituximab uptake was assessed and related to clinical data. The main outcome measures were the characteristics of the scan and the clinical relation of uptake with the diagnostic process and treatment effectivity.

 

Results: We included >40 patients that received the 89Zr-rituximab PET/CT and updated our previous records. A high 89Zr-rituximab uptake was seen in almost all patients. We found that patients with high uptake of 89Zr-rituximab had a good response to rituximab treatment. Differences in 89Zr-rituximab uptake were noted for diagnosis and lesion location. Correlation with disease activity was variable for diagnosis.  

 

Conclusion: 89Zr-rituximab PET/CT has the potential to be a powerful tool for the detection of B-cell mediated disease within the orbit and ocular adnexa. This technique can be a valuable addition for diagnosing diseases around the eye and can potentially predict rituximab treatment response in patients with refractory inflammation.


Kamil LABAN (Utrecht, The Netherlands), Mahdi AL SAADI, Bart DE KEIZER, Rachel KALMANN
14:00 - 15:40 #32319 - OP41 Reconstruction after orbital exenteration: interest of the Radial Forearm free flap.
OP41 Reconstruction after orbital exenteration: interest of the Radial Forearm free flap.

Orbital exenteration is a disfiguring surgical procedure classically reserved for malignant, locally advanced or recurrent orbital and eyelid pathologies. Surgical progress in facial reconstruction has changed our practices, notably with the use of the Radial Forearm free flap. The purpose of this study is to show the evolution of a specialized tertiary care center practices in the management of orbital cavities and to show the interest of reconstruction by Radial Forearm free flap.

This was a retrospective single-center study, including patients who underwent orbital exenteration between January 2004 and December 2021. Clinical, therapeutic and surgical data were collected retrospectively via the computerized file.

133 patients were included (59 women; 74 men). Three types of exenteration were performed, 16 (12.0%) subtotal, 75 (56.4%) total and 42 (31.6%) extended exenterations. The reconstruction methods used were: Temporalis muscle flap (34.6%), Latissimus Dorsi free flap (24.8%), Radial Forearm free flap (18.8%), spontaneous granulation (9.0% ), skin grafts (9.8%) and Direct Closure (3.0%). The median healing time was 7 days for the Radial Forearm flap, 60 days for the Latissimus Dorsi flap, 92 days for the Temporal Muscle flap and 242 days for spontaneous granulation; it was significantly lower in the “Radial Forearm free flap” group than in the other groups (p < 0.0001). No free flap loss was described.

The rate of prosthetic equipment in the “Radial Forearm flap” group was significantly higher than in the “Other flaps” group (46.67% vs 19.74%) (p = 0.0439) and substantially identical between the groups “Forearm Free Flap” and “Granulation”; (46.67% vs. 45.45%) (p>0.99999).

The technique of reconstruction after orbital exenteration is chosen according to the habits of the teams, the type of exenteration, the comorbidities and the wishes of the patient. The use of a Radial Forearm free flap could be proposed for the reconstruction of total or extended exenteration cavities in patients in general good condition. This allows early adjuvant irradiation, reduces the risk of sinus communication and allow an aesthetic result and a satisfactory rate of equipment.


Nathalie BADOIS (Paris), Maria LESNIK, Antoine DUBRAY-VAUTRIN, Baptiste SABRAN, Romain MILHEIRO, Olivier CHOUSSY, Nathalie CASSOUX
14:00 - 15:40 #32375 - OP42 Decompression and reconstruction of orbital bones in spheno-orbital meningioma: comparison of reconstruction techniques with titanium mesh and patient-specific polyetheretherketone (PEEK) implants.
OP42 Decompression and reconstruction of orbital bones in spheno-orbital meningioma: comparison of reconstruction techniques with titanium mesh and patient-specific polyetheretherketone (PEEK) implants.

Introduction

Spheno-orbital meningioma is often characterized by hyperostosis of the orbital bones, requiring multidisciplinary surgery and decompression with reconstruction of the lateral orbital wall. We assessed the feasibility of reconstruction with computer aided designed and manufactured (CAD/CAM) patient specific implants (PSIs) made from poly-ether-ether-ketone (PEEK) and compared outcomes with conventional reconstruction with titanium mesh. 

 

Methods

We compared consecutive patients with spheno-orbital meningioma who received reconstruction of the lateral orbital wall with PEEK PSI between 2019 and 2021 with an historical cohort of patients who received titanium mesh before 2019. Preoperatively a virtual 3D surgical planning was made and a CAD/CAM manufactured resection guide and a PEEK PSI were fabricated. Proptosis, visual acuity, visual fields, placement, cosmetic satisfaction and complications were compared.   

 

Results

Eleven patients, median age of 47 years, were operated. Reoperation with PEEK PSI was performed in two patients to resolve oscillopsia and temporal pain after previous surgery without reconstruction and titanium mesh reconstruction respectively. The periorbita was opened in 11 cases and intra-orbital tumor was resected in 7. In 3 cases the PEEK PSI was slightly refined intraoperatively. Median proptosis before surgery was 5.0mm (IQR: 3.0 to 6.0), which significantly improved to 1.5mm (IQR: 0 to 4.0) 1 year after surgery, p<0.01. Preoperative median visual acuity was 1.1 (IQR: 1.0 to 1.2), which remained stable after surgery (median 1.2, IQR: 0.9 to 1.2). Preoperative median visual field was -3.7dB (IQR: -12.4 to -1), which improved to -1.5dB (IQR: -4.3 to -0.2). All patients were satisfied with the cosmetic results. Compared with the titanium mesh cohort (n=14) with similar baseline values, PEEK PSI resulted in better proptosis reduction (mean PEEK: 2.7mm, mesh 1.0mm, p=0.04), with similar stable visual acuity (PEEK: 0.6, mesh: -0.3: p=0.12) and improvement of visual fields (PEEK: 4.0dB, mesh: 2.9dB, p=0.13). Complications in the PEEK cohort were new visual field defects and an epidural hematoma, requiring surgery. One patient received proton beam therapy one year after surgery.

 

Conclusions

CAD/CAM PEEK PSI results in satisfying reduction of proptosis in spheno-orbital meningioma with good visual outcomes compared with titanium mesh reconstruction with the additional benefit that it does not interfere with proton beam radiotherapy.  


Amir H. ZAMANIPOOR NAJAFABADI (Leiden, The Netherlands), Sarina E.c. PICHARDO, Wouter A. MOOJEN, Roy P.j. VAN DEN ENDE, Wouter R. VAN FURTH, Stijn W. VAN DER MEEREN
14:00 - 15:40 #31923 - OP43 Long-term outcomes after multidisciplinary treatment for pediatric orbital rhabdomyosarcoma.
OP43 Long-term outcomes after multidisciplinary treatment for pediatric orbital rhabdomyosarcoma.

Purpose: description of clinical presentation, imaging characteristics, prognostic factors, histopathology, and treatment outcomes of pediatric orbital rhabdomyosarcomas (RMS). 

 

 

Methods: institutional retrospective study with data from 39 patients (children aged 0-18) with primary orbital RMStreated between 1995 and 2016 at the Amsterdam University Medical Centers / Emma Children Hospital. We evaluated demographic characteristics, symptoms and signs, imaging characteristics, risk factors and treatment outcomes.

 

 

Outcome Measures: Medical records review for demographic information, clinical data history (including symptoms at presentation), imaging studies, histopathologic information, treatment received, and follow-up.

 

Results: The median age at presentation was 7 years (range, 9 months to 16 years). The median follow-up period was 9.4 years (range, 3 to 25 years). Eyelid swelling (in 45% of cases) was the most common presenting manifestation. The majority of orbital tumors were located in the superior medial quadrant of the orbit. Ninety-five percent of cases showed embryonal histology. Sixty-two percent of patients presented with Intergroup Rhabdomyosarcoma Study (IRS) group III disease. Of the 39 patients, 10 underwent chemotherapy and excision without additional radiotherapy. The 29 patients with additional local treatment received Ablative surgery, MOld technique with after loading brachytherapy and surgical REconstruction (AMORE) (N = 21), proton (N = 4) or external beam radiation treatment (EBRT; N = 4). We found 14 cases with recurrences, 9 of which underwent exenteration and two of them died. 

The 10-year overall survival was 95% and the EFS 63%. All 18 cooperative patients had functional decimal visual acuity (0.5 or better). Cataract was the most common adverse event of local treatments, present in 33% of survivors.

 

Conclusions: long term follow up with 10-year survival rate of orbital RMS in this series was 95% by achieving local tumor control and eye preservation in 77% of our study population. 

 


Nur KHATIB (Tel Aviv, Israel), Johannes MERKS, Jeroen MARKENSTEIN, Brian BALGOBIND, Cemile SAVCI-HEIJINK, Michele MORFOUACE, Bradley PIETERS, Peerooz SAEED
14:00 - 15:40 #32340 - OP44 Congenital Microphthalmia – Results of a conservative rehabilitation approach.
OP44 Congenital Microphthalmia – Results of a conservative rehabilitation approach.

Background: The importance of an early intervention in the rehabilitation of anophthalmic and microphthalmic patients for optimal aesthetic results is well established. However, minimize medical and surgical procedures at an early age is also important to reduce surgical scarring and sequelae in young children.

Methods: Retrospective review of consecutive cases of anophthalmia or microphthalmia referred to Centro Hospital e Universitário de Coimbra, between 2006 and 2020, submitted to a conservative rehabilitation with orbital conformers, progressively adapted to expand the orbital cavity and conjunctival fornixes. The final surgical rehabilitation was performed, when necessary, at a later age (usually at pre-school age).

Results: During the study time, 14 children were referred to our center: 10 males, with a mean age at initial follow up of 8.9 months (range 0.1 – 24) and including 3 cases of bilateral microphthalmia. All children had conformers  (augmented  every 2-3 months) adapted to their cavities by a specialized prosthetist. Seven children were thereafter submitted to surgery for rehabilitation of cavity volume (1 dermis-fat graft [DFG], 1 expandable hydrogel implant and 5 spherical porous implants) and 2 children were submitted to surgery for palpebral reconstruction due to associated colobomas/malformations. The mean age at first surgery 3.9 years (range 1,5 - 8).  Five children had to be submitted to second surgeries due to: overgrowth of DFG, insufficient expansion of hydrogel implant or exposure of orbital implants. The mean follow up was 10.7 years (range 4-14). Eleven (78.6%) children obtained a good or very good aesthetical result, with good facial symmetry. Children referred at an older age, bilateral cases and syndromic complex cases had poorer results. No children were lost to follow up.

Conclusions: Our series enlightens a valuable alternative to more invasive approaches for the rehabilitation of micro- and anophtalmic patients. Our conservative management, associated to individually selected surgical interventions performed at older ages, offers a good aesthetical result providing a progressive dilatation of the bone cavity and soft tissues accompanying children growth.


Joana PROVIDENCIA (Coimbra, Portugal), Margarida QUEIRÓS, Cecília RAMOS, Catarina PAIVA, Guilherme CASTELA
14:00 - 15:40 #31746 - OP45 Trametinib for orbital plexiform neurofibromas in young children with neurofibromatosis type 1.
OP45 Trametinib for orbital plexiform neurofibromas in young children with neurofibromatosis type 1.

Introduction: Plexiform neurofibromas (PNF) in neurofibromatosis type 1 (NF1) are usually diagnosed in childhood and can grow rapidly during this period. In 10% of patients, PNF involve the orbital-periorbital area and may cause visual problems including glaucoma, visual loss from amblyopia (deprivational, strabismic, or refractive), optic nerve compression, or keratopathy. Ptosis, proptosis, and facial disfigurement lead to social problems and decreased self-esteem. Complete surgical removal involves significant risks and mutilation, and regrowth after debulking is not uncommon. Inhibitors of the RAS/MAPK pathway have recently been investigated for their activity in PNF. We administered the oral MEK inhibitor trametinib to five young children with NF1 and PNF of the orbital area, with visual compromise and progressive tumor growth; and followed them clinically and by volumetric MRI.

Methods: Treatment was initiated at a mean age of 26.8 months (SD ± 12.8) and continued for a median 28 months (range 16-51). Doses were 0.025 mg/kg/day for children aged > 6 years and 0.032 mg/kg/day for those aged < 6 years.

Results: Volumetric MRI measurements showed a reduction of 2.9-33% at 1 year after treatment initiation, with maximal reductions of 44% and 49% in two patients, at 44 and 36 months, respectively. No change in visual function was recorded during treatment. One child reported decreased orbital pain after 2 weeks; and another, with involvement of the masseters, had increased ability to chew food. Toxicities were mostly to skin and nails, grades 1-2.

Conclusions: Trametinib can decrease tumor size in some young children with orbital PNF and may prevent progressive disfigurement.


Helen TOLEDANO, Meydan BEN ISHAI (Tel Aviv, Israel), Gad DOTAN, Rivka FRIDLAND, Rony COHEN, Iftach YASSUR, Hagit TOLEDANO-ALHADEF, Shlomi CONSTANTINI, Mika SHAPIRA ROOTMAN
14:00 - 15:40 #30965 - OP16b Multimodal approach to lateral canthotomy and cantholysis training using a low-fidelity model in combination with visual teaching: a study on a cohort of Emergency Medicine doctors.
OP16b Multimodal approach to lateral canthotomy and cantholysis training using a low-fidelity model in combination with visual teaching: a study on a cohort of Emergency Medicine doctors.

Background: Acute orbital compartment syndrome as a result of retrobulbar haemorrhage secondary to trauma is rare but has the potential to cause irreversible blindness. Lateral canthotomy and cantholysis (LCC) can be sight-saving but needs to be performed urgently upon arrival to the Emergency Department. 

 

Objectives: The purpose of this study was to evaluate a training session for junior Emergency Medicine doctors, which combined visual learning consisting of watching a video of a LCC being performed on an actual patient and an interactive demonstration of the lateral canthal area anatomy on a large-scale 3D model by an Oculoplastic surgeon, with hands-on experience on a low-fidelity model. 

 

Participants and Setting: 17 emergency medicine, non-consultant doctors from hospitals across South-East London (King’s College Hospital, Princess Royal Hospital, University Hospital Lewisham). 

 

Main outcomes measures: Participant self-reported using 3-point Likert Scales of their knowledge of the lateral canthal area, understanding the steps in performing a LCC and confidence in performing a LCC in a clinical indicated setting.

 

Results: 88.2% (15/17), had never performed a LCC even in simulation, while the remaining 11.8% (2/17) had only performed this procedure in simulation. Before training, the mean confidence level in understanding of the lateral canthal area anatomy was 1.12 and rose to 3.00 post-training (p<0.0001). Prior to training the mean confidence level in knowing the steps of an LCC was 1.29 and rose to 3.00 post-training (p<0.0001). Pre-training, the mean confidence level in performing a LCC when clinically required was 1.12 and improved to 2.76 post-training (p<0.0001). 

 

Conclusions: This study found that the cost of constructing such a model to be low-cost (£2.16 per model) and also easily replicable, allowing this procedure to be practiced regularly by clinicians. Unlike cadaveric simulation models, it is also safer; avoiding infection risk should a needle-stick injury occur and it is also not limited to human/animal dissection lab-based settings.  This in combination with the visual and interactive teaching programme as described above, resulted in a significant increase in the knowledge and confidence of EM clinicians in this essential, sight-saving procedure. 


Li Yen GOH (London, United Kingdom), Tahir FAROOQ
14:00 - 15:40 Time for questions and discussion.
Room 1
15:40

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A28
15:40 - 16:00

Keynote Lecture III

15:40 - 16:00 Teprotumumab in TED. Raymond DOUGLAS (Keynote Speaker, Beverly Hills, CA, USA)
What is the main medical revolution of the last decade? Undoubtedly the emergence of targeted therapies to fight against cancer allowing dedicated and personalized medicine. In recent years, personalized medicine has also become possible in thyroid eye diseases (TED).

In 2020, the insulin growth factor receptor 1 (IGF1R) inhibitor teprotumumab gained FDA approval for the first time for the treatment of patients with TED. This approval was based on 2 randomized, controlled trials published in the prestigious New England Journal of Medicine comparing teprotumumab with a placebo. Teprotumumab demonstrated superiority over placebo in terms of clinical activity score and reduction in proptosis.

Dr Raymond DOUGLAS is a worldwide recognized oculoplastic surgeon working in Beverly Hills, California. He is also a professor at Cedars Sinai Hospital in Los Angeles where he is head of the orbital and TED programs. Dr. DOUGLAS' lab was associated with the initial development of teprotumumab by investigating the role of IGF1R in TED. Dr DOUGLAS was respectively last and first author of the 2 clinical trials published in the New England Journal of Medicine. He treated the first patient and currently has the most experience with Teprotumumab.

Dr. DOUGLAS will tell us about his daily clinical experience with teprotumumab in TED. Most importantly, Dr. DOUGLAS will address the current challenges, questions and fears raised by the growing use of teprotumumab: Should teprotumumab be used in inactive TED? How common is hearing loss and how do you monitor it? What is the cost-benefit of teprotumumab? Will teprotumumab cause orbital decompression obsolete?

See you in Nice for the next ESOPRS congress with our special guest Dr Raymond DOUGLAS.
15:40 - 16:00 Introduced by:. Arnaud MARTEL (doctor) (Chairperson, Nice, France)
Room 1
16:00 COFFEE BREAK & EXHIBITION AREA - VISIT OF THE EPOSTERS
16:15

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A29.1
16:15 - 17:00

Oral Communications
Socket

Moderators: Olivier GALATOIRE (PARIS, France), Dan GEORGESCU (Romania)
16:15 - 17:00 #32174 - OP46 CT Volumetry Study of Micro Fat Graft survival from different donor sites in augmenting the Enophthalmic Socket.
OP46 CT Volumetry Study of Micro Fat Graft survival from different donor sites in augmenting the Enophthalmic Socket.

Purpose: The aim of the current study is to study autologous fat grafts harvested from the abdomen and thigh for treating the enophthalmic anophthalmic socket using CT volumetry.

Methods:  A randomized prospective interventional study including 20 patients suffering from unilateral enophthalmic socket. Pre-operative clinical assessment included photographs, exophthalmometry reading as well as CT volumetry for volume deficit calculations. The harvesting site was randomly allocated between patients (abdomen or thigh). Patients were followed up to 6 months post-operatively. Percentage of fat retained 1 and 2 (Percentage of fat remaining at the last follow up compared to pre-operative measurements of the enophthalmic socket with the globe and without the globe respectively) was calculated as well as exophthalmometry change.

Results: Mean percentage of retained fat 1 was 14.75 ± 17.06 %, while mean percentage of retained fat 2 was 25.31 ± 25.49 % A statistically significant difference was found between the post-operative increase in orbit soft tissue volume and the preoperative calculations in the volume of fat retained 2 (p <0.001) in every visit and volume of fat retained 1 (p= 0.001 at 6 months). No statistically significant correlation was found between the sex, age of the patients, donor site and the microfat graft survival. Difficulty of extraction and degree of atrophia correlated significantly with percentage of fat retained 2 and not 1. Exophthalmometer change correlated significantly with percentage of fat retained 1 and not 2.  Decline in the percentage of volume of fat retained continued up to 6 months post operatively.

Conclusion: Autologous fat grafting is a safe and effective technique for volume augmentation. CT volumetry has an important role to assess the volume deficit and measure the postoperative results accurately. No statistical significant difference was found in percentage of fat survival between the abdomen and thigh groups.  


Aliaa AHMED (Cairo, Egypt), Haythem E. NASR, Tamer I. GAWDAT, Rania A. ABDELSALAM, Kareem B. ELESSAWY
16:15 - 17:00 #32184 - OP47 Individualizing enucleation implant size: volumetric vs empirical methods.
OP47 Individualizing enucleation implant size: volumetric vs empirical methods.

Introduction

Individualization of enucleation implant size has been advocated to reduce the incidence of the anophthalmic socket syndrome. Implant size has been determined by preoperative ultrasound, intraoperative volume measurement, and sizing implants. We compared outcomes of the volumetric measurement (‘volume’) and sizing implant (‘empirical’) methods. Effects of preoperative and surgical findings on implant size were also investigated.

 

Methods: 

This retrospective study included 139 patients undergoing enucleation with insertion of spherical implants between 2007-2016. The ‘volume’ method was preferentially used in patients with symmetrically appearing globes, while the ‘empirical’ method was more commonly used in patients with apparent proptosis or enophthalmos. 

 

Results: 

Preoperative phthisis (p<0.0001) and conjunctival-Tenons fibrosis (p=0.001) were more common in the ‘empirical’ group. Mean implant size was larger in males (21.3mm) than females (20.7mm) (p=0.003), and in the ‘volume’ (21.4mm, n=55) than ‘empirical’ (20.8mm, n=84) cases (p=0.002). Spheres >21mm were placed in 46% of patients with and 63% without intraoperative fibrosis (p=0.047). Implants >20mm were more frequently used in patients with a wider exophthalmometry base (80% of males >95mm; 77% of females >97mm).

 

Postoperative mean implant (p=0.6562) and prosthetic (p=0.1990) enophthalmos, and the frequency of sulcus deformity (p=0.6394) were similar between the two methods. We estimate that 11% of patients could have accommodated a sphere >22mm. 

 

Conclusions: 

Previous studies have shown the advantages of individualizing enucleation implant size. While implants should not be intentionally oversized, larger spheres provide improved implant motility and reduce the incidence of the anophthalmic socket syndrome. Sizing implants can provide similar results as intraoperative volumetric measurement, as determined by postoperative superior sulcus depth, and prosthetic or implant enophthalmos. Preoperative exophthalmometry can guide selection of implant size. Preexisting conjunctival-Tenon fascial fibrosis often did not limit implant size and was not associated with a higher rate of wound breakdown or implant exposure. 


Philip CUSTER (St Louis, USA), Robi MAAMARI, Julia HUECKER, Mae GORDON
16:15 - 17:00 #31951 - OP48 Clinical Use of Cryopreserved Ultra-thick Human Amniotic Membrane for Anophthalmic Socket Contracture: A prospective study.
OP48 Clinical Use of Cryopreserved Ultra-thick Human Amniotic Membrane for Anophthalmic Socket Contracture: A prospective study.

Purpose

 

Anophthalmic socket contracture (ASC) refers to a decrease in fornix depth (FD) incited by prior surgery, trauma, inflammation, radiation, or infection. The traditional treatment is mucous membrane graft which offers the advantage of an autologous source and a low incidence of graft rejection, but the disadvantages include donor-site pain and morbidity, and additional harvesting time. This is the first prospective study that reports on the use of cryopreserved ultra-thick human amniotic membrane (CUT-hAM) in ASC treatment.

 

Methods

 

Patients with ASC caused by previous trauma, radiotherapy, congenital anophthalmia, anophthalmia 2ry to Enucleation/Evisceration, delay in the use of prosthesis, and post pyogenic granuloma excision were included. A thick amniotic membrane was taken from donor umbilical cord. Ultrasound biomicroscopy was used for standard thickness measurement. Fornix contracture grade ( using classification proposed by Tawfik et al. ) was used. Post-operative evaluation includes measurement of FD pre/post-surgery, prosthesis fitting, and complications such as infection and wound dehiscence in addition to the rate of re-operation were included.

 

Results

 

33 patients ( 42 fornices ) were involved from Dec 2020 until Dec 2021 with a mean follow up 10.5 months. Grade II fornix contracture was the most common type ( 54.8% ). The most common involved primary diagnosis was anophthalmia 2ry to Enucleation/Evisceration ( 31% ). The overall success rate was 85.7% when the fornix achieved a 70% increase in FD and/or prosthesis fit at the last visit. Overall median FD ( medially, centrally, and laterally )  before surgery and at the last visit was ( 3, 3, 2 ) and ( 5, 7, 6 ) mm respectively.

 

 

Conclusion

CUT-hAM is well tolerated and ideal for the treatment of ASC. It is effective to establish FD and improving prosthesis fit. It has the advantage of being easy to use, having a relatively short surgical duration, and avoidance of second-site surgery. The overall success rate is higher among patients with Anophthalmia 2ry to Enucleation/Evisceration compared to other causes.


Mohammad ALSEMARI (RIYADH, Saudi Arabia), Fatimah ALZAHRANI, Muhammad AHAD, Hailah ALHUSSAIN, Hamad ALSULAIMAN, Rawan ALTHAGIB, Diego STRIANESE, Osama ALSHEIKH
16:15 - 17:00 #31985 - OP49 Manus ex Machina; Can 3D Printing and Scanning Change Our Prosthesis Making Techniques?
OP49 Manus ex Machina; Can 3D Printing and Scanning Change Our Prosthesis Making Techniques?

Handmade objects have been historically associated with exclusivity, individuality, and elitism. While machine products have been identified with progress but also with dehumanization and homogenization.

In this presentation, I would like to discuss the possibility of a common practice of custom handmade and 3d printing and scanning in prosthesis making.

I would like to share two innovative prosthetic projects that became a common practice in treating congenital anophthalmic patients, and patients in need of a facial prosthesis, in my clinic. In both projects we designed prototypes that helped us refine the end prosthesis. 3D scanning and printing advantages as well as limitations will be discussed using clinical cases, in order to prove their benefit and judge their role in prosthesis making.

We have learned that incorporating 3D scanning and printing with manual production of ocular and facial prosthesis rather than replacing the production process seems to bring a better prosthetic outcome to this population of patients.


Yoav VARDIZER (Haifa, Israel)
16:15 - 17:00 #32057 - OP50 Congenital anophthalmia and microphthalmia with cyst:new concepts in management strategies.
OP50 Congenital anophthalmia and microphthalmia with cyst:new concepts in management strategies.

Microphthalmia and Anophthalmia (A/M) are rare conditions, which represent maldevelopment of the eye and may be associated with orbital cysts. Current literature recommends cyst retention to drive orbital growth during socket rehabilitation; this study aims to illustrate the long-term outcomes when other elements, such as forniceal and lid development, are considered alongside orbital bone growth, when forming bespoke treatment plans for patients.Retrospective case series from a single prosthetics clinic since 1988. Patient outcomes and natural history data are reported using clinical and surgical notes, radiological imaging, clinical photographs and patient/doctor satisfaction questionnaires.89 sockets of 78 patients (11 bilateral) were included; median age of presentation being 2.8 years (9 days-29.5 years). Cysts were clinically detected (48%) or were incidental findings (52%). The mean follow-up time was 7.2 years (6 months–28 years). 46 % of sockets had surgical excision of the cyst at the median age of 17 months (3 months–28 years); the rest were managed with customised cosmetic prosthesis only. Satisfaction surveys were obtained for 75 patients, with cosmetic outcomes rated as ‘excellent’ or ‘good’ in 90% of cases by physicians and 97% of cases by patients or guardians.The management of cysts in Anophthalmia /Microphthalmia (A/M) involves bespoke treatments whether or not surgical intervention is required.We define ‘regional orbital growth’ as an important concept to understand when looking after patients with A/M and cysts as it is possible for cysts to drive the growth of regions of the orbit disproportionately.The favourable long-term outcomes in this study have resulted from bespoke plans that consider periocular tissue development, regional orbital growth and orbital volume replacement. The authors consider early cyst excision if there is the risk of long-term periocular deformation.


Sri K GORE, Gustavo SAVINO, Collin RICHARD, Gabriela GRIMALDI, Alessandra MODUGNO (roma/italy, Italy)
16:15 - 17:00 #32473 - OP51 How to plan conformer treatment for congenital microphthalmia and anophthalmia?
OP51 How to plan conformer treatment for congenital microphthalmia and anophthalmia?

Background/aims To evaluate treatment with custom, three-dimensional (3D) printed conformers for socket expansion in congenital microphthalmia and anophthalmia (MICA).


Methods Retrospective analysis of prospective cohort from 2016 to 2020. All children received custom-made 3D-printed conformers increasing in size. We measured height, width, thickness, surface and volume of first and consecutive conformers, as well as horizontal palpebral fissure length (HPF) at start and follow-up visits. We analysed these parameters for severely (<45%) and moderately (>45%–75%) affected children, based on affected axial length on ultrasonography.

Results We included 18 cases (9 severe, 9 moderate) with a total of 174 conformers (88 severe, 86 moderate) and a mean follow-up of 2.8 years (range 1.3–4.8). The mean relative HPF increased from 77% to 93% with 16/17 cases reaching >80%, and 12/17 cases >90% symmetry. Horizontal and vertical conformer dimensions increased up to 10 months of treatment, with a steeper slope for the severe group (10.5% vs 5.5% for height and 9.0% vs 6.1% for width gain per treatment month, for severe and moderate MICA, respectively). After 10 months of treatment conformer height and width increased only slightly. No serious complications were observed.

Conclusion 3D-design and printing of solid conformers results in highly acceptable horizontal eyelid symmetry in the treatment of congenital MICA. The mean increase in conformer height and width in the first 10 months should be about 170% for moderate and about 200% for severe MICA. The presented conformer size formulas can aid ophthalmologists and ocularists to plan conformer treatment.

NB this work has recently been accepted for publication in British Journal of Ophthalmology, copyright by the authors: Groot ALW, et alBr J Ophthalmol 2022;0:1–7. doi:10.1136/bjophthalmol-2021-320882 1


Annabel GROOT (Nijmegen, The Netherlands), Jelmer REMMERS, Birgit LISSENBERG-WITTE, Simon DE MEULENAERE, Duygu TALAN, Niels LIBERTON, Pim DE GRAAF, Annette MOLL, Peerooz SAEED, Dyonne HARTONG
16:15 - 17:00 Time for questions and discussion.
Room 1
17:00

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A29.2
17:00 - 17:45

Full Member ESOPRS General Assembly

Room 1
20:00 CONGRESS DINNER Room 1
Saturday 17 September
08:00 ESOPRS MAIN MEETING - DAY 2
08:15

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A30
08:15 - 09:45

Oral Communications
Lacrymal

Moderators: Daniel EZRA (United Kingdom), Ulrich SCHAUDIG (Chief) (HAMBURG, Germany)
08:15 - 09:45 #30885 - OP52 Age-related changes in the lacrimal punctum morphology in a normal population: an update.
OP52 Age-related changes in the lacrimal punctum morphology in a normal population: an update.

Objective: To define the clinical and optical coherence tomography (OCT) morphology of the lacrimal punctum and assess the age-related changes across 8 decades of life in a normal population.
Methods: A total of 1310 high-magnification slit-lamp, Fourier-domain OCT (FD-OCT), and optical coherence tomography angiography (OCTA) images were obtained from 320 puncta of normal asymptomatic individuals representing the Indian population. The punctum and peri-punctal area were defined with the help of 2 rims (inner punctal rim and outer punctal rim ) and 3 zones (white zone [Wz], separation zone [Sz], and peri-punctal vascularity). FD-OCT images were used to measure the external punctal diameters and internal lacrimal punctal diameters and the reflectivity patterns of the 3 punctal layers. OCTA was used to assess the branching and extent of vascular networks.
Results: The upper puncta were narrower and more circular than the lower puncta across the decades. The elevation of the punctal papilla began in the upper puncta in the fifth decade, involved the lower puncta in the sixth decade, and gradually became exaggerated by the eighth decade. A typical punctal narrowing in previously wide puncta began to appear in the sixth decade of life, peaks in the seventh decade, and reverses gradually and spontaneously by the end of the eighth decade of life. The third and fourth decades saw a narrowing of the Sz with prominent vascularity crossing the Sz to reach the Wz. The Sz became indistinct in the fifth and sixth decades of life. The FD-OCT showed gradual thickening and dominance of the fibrous layer from the fifth to eighth decade of life. The clinical vascularity in the peri-punctal region increases from the third decade onwards, with vascular networks becoming increasingly dense, intricate, and branched as the age progresses.
Conclusion: The present study defined and characterized the involutional changes in a normal population’s first–eighth decades of life. Significant morphological changes were noticed across the different age groups with several clinical implications.


Nandini BOTHRA (India, India), Mohammad JAVED ALI
08:15 - 09:45 #32143 - OP53 Ultrasonic guidance of transcutaneous injection of stem cells into the lacrimal gland of patients with aqueous deficient dry eye disease.
OP53 Ultrasonic guidance of transcutaneous injection of stem cells into the lacrimal gland of patients with aqueous deficient dry eye disease.

Objective: To develop a method of injecting a volume of up to 50% of the lacrimal gland (LG) volume whilst minimizing patient discomfort and maximizing accurate delivery.This method was used in a randomized placebo-controlled trial aimed at elucidating the therapeutic effect of allogeneic stem cells in 40 patients with aqueous deficient dry eye disease (ADDE). These patients had a small LG, suffered from sensitivity to light and found lid eversion painful.Methods:Stem cells:The authors have recently conducted a safety study for injection of mesenchymal stem cells to the LG of 7 patients with ADDE. One transconjunctival injection of a volume of maximally 50% of the LG was well tolerated in all 7 patients (ref 1) Ultrasonography and injection into the LG:Traditionally injection into the LG is performed by everting the upper eyelid and aiming the needle towards the palpebral lobe (ref 2)Ultrasound can provide real-time images of the LG and can be used to safely guide the needle ensuring the correct placement within the gland capsule. This reduces the risk of injury to the eye and adjacent structures and enables transcutaneous injection.Ultrasound scans were performed using a GE Logiq E10 (Milwaukee, Wisconsin, USA) ultrasound machine with 5-16 ML and 6-24 MHz transducers. Ultrasound was performed by two expert rheumatological ultrasonographers. We recorded the injection and observed an enlargement of the LG ensuring delivery within the lacrimal gland before the needle was removed.Results:The position of the injection needle within the LG was documented in all 40 patients. Injection of the stem cells (N=20) or vehicle (N=20) led to an enlargement of the glandular structures in all cases.Conclusion:Ultrasound guidance of injection into the lacrimal gland enables injection on a closed eye causing minimum patient discomfort and maximum certainty of accurate “drug” delivery. No adverse reactions related to this injection procedure were observed.[LT1] 

References:1.      Møller-Hansen M et al. Safety and feasibility of mesenchymal stem cell therapy in patients with aqueous deficient dry eye disease. Ocul Surf. 2021 Jan;19:43-52. doi: 10.1016/j.jtos.2020.11.013. Epub 2020 Nov 28. PMID: 33253910.2.      Riemann R et al Successful treatment of crocodile tears by injection of botulinum toxin into the lacrimal gland: a case report. Ophthalmology 1999; 106: 2322–2324.

 

 [LT1]


Anne Katrine WIENCKE (Copenhagen, Denmark), Lene TERSLEV, Søren TORP-PEDERSEN, Ann-Cathrine LARSEN, Michael MØLLER-HANSEN, Steffen HEEGAARD
08:15 - 09:45 #30464 - OP54 Evaluating the effectiveness of lacrimal gland botulinum toxin using the TEARS score.
OP54 Evaluating the effectiveness of lacrimal gland botulinum toxin using the TEARS score.

Purpose:

To evaluate the effectiveness of lacrimal gland botulinum toxin injections for epiphora.

 

Methods:

Patients receiving incobotulinum toxin A injection (Xeomin 2.5 - 5 units) injected into the palpebral lobe of the lacrimal gland for epiphora of any cause were prospectively recruited. Epiphora was graded at baseline and at 2-6 months using the TEARS score. This is a validated measure of tearing frequency (T), clinical effects (E), activity limitation (A) and reflex tearing (R). The underlying aetiology was recorded, along with duration of treatment effect, complications and whether the patient went on to undergo further injections.

 

Results:

Thirty-four patients were recruited with a mean age of 62.2 (+/- 15.1) years. Of these, 23 (68%) had gustatory epiphora secondary to facial nerve synkinesis. Other aetiologies included eyelid malposition (18%) and canalicular or nasolacrimal obstruction (12%). There were no complications reported. The effect duration lasted a median 13 weeks (range 6 – 26). Over half (52%) saw a reduction in tearing frequency (T), with 33% gaining >= 2-point improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 48% and 55% of patients respectively, with 30% and 33% respectively gaining >= 2-point improvement. Improvements in R scores were observed in 42% with 24% seeing >= 2-point improvements. There was no significant difference in the proportion responding favourably when comparing gustatory and non-gustatory epiphora. Additional injections were sought in 91% of patients with gustatory epiphora vs 50% of those with other causes (p<0.01). 

 

Conclusion:

Incobotulinum toxin A administered to the lacrimal gland is a safe and effective treatment option for epiphora, with clinical improvements seen in most patients regardless of aetiology. Patients with gustatory epiphora secondary to facial nerve synkinesis are more likely to undergo repeat injections compared with other aetiologies. The TEARS score provides validated quantitative and qualitative outcome data that can be used to support treatment decisions and provide evidence of value for commissioners.


Samantha HUNT (East Grinstead, United Kingdom), Christopher SCHULZ, Raman MALHOTRA
08:15 - 09:45 #31966 - OP55 The role of dacryoscintigraphy in evaluation and management of patients with functional epiphora.
OP55 The role of dacryoscintigraphy in evaluation and management of patients with functional epiphora.

Abstract

Purpose: Many patients present with complaints of tearing but have a normal lacrimal outflow work up. To investigate how dacryoscintigraphy (DSG) may aid in their diagnosis and management.

Methods: A retrospective case series was performed on patients with symptomatic tearing despite no identified external cause and normal lacrimal probing and irrigation (i.e., functional epiphora). Many of these patients had been diagnosed by other providers with “dry eye”, but failed to improve with artificial tear supplementation. All patients with normal office evaluation underwent DSG testing.  If DSG demonstrated normal evacuation of tears into the nose no intervention was undertaken. We recommended surgery to enhance entry of tears through the puncta and canaliculi into the lacrimal sac for those with delayed tear flow prior to entering the lacrimal sac (pre-sac) and dacryocystorhinostomy for those with delayed tear flow after the lacrimal sac (post-sac). Surgical success was defined as epiphora being resolved or improved. Surgical failure was defined as epiphora being unchanged or worse when compared to the preoperative timepoint.

Results: Fifty five patients (86 sides) were identified for DSG testing. Of these, 96% (53 patients, 79 sides) had abnormal DSG findings indicating delayed clearance of tears through the lacrimal outflow system. A pre-sac delay was observed in 14 cases (18.2%) and post-sac delay in 63 (81.8%). Overall surgical success was 83.1% across the cohort. Success was 100% in the pre-sac group and 79.4% in the post-sac group (p = 0.06). Mean follow-up time was 22 months (Standard Deviation = 21 months).

Conclusion: Many patients present with complaints of tearing but have a normal lacrimal outflow work up. DSG revealed an anatomic location of impaired lacrimal outflow in 96% of cases. Surgery to correct the anatomic localization of outflow restriction allowed a better than 80% successful resolution of epiphora.

 


Evan KALIN-HADJU, Robert KERSTEN (San Francisco, USA), Mikaël BERNIER, Reza VAGEFI, Victoria LEUNG, Amanda MILLER
08:15 - 09:45 #30756 - OP58 Outcome of primary monocanalicular stent placement in pediatric Down’s syndrome patients with congenital nasolacrimal obstruction.
OP58 Outcome of primary monocanalicular stent placement in pediatric Down’s syndrome patients with congenital nasolacrimal obstruction.

Objective: Congenital Nasolacrimal duct obstruction (CNLDO) is a relatively common problem in children with Down Syndrome (DS). Probing and irrigation (PI) may be less successful with monocanalicular stent intubation (MSI), thus raising some concern regarding the preferred treatment in this population. Our purpose was to describe the surgical outcome of PI along with MSI in children with DS compared with non-DS patients.

Methods: A single-center retrospective medical chart review was performed for all children who underwent PI with MSI as primary treatment for congenital NLDO between 2009 and 2020. The diagnosis of NLDO was based on the history, ocular examination, and dye disappearance test. All procedures were performed by a single surgeon (WRK). Main outcome measure was surgical success defined as resolution of symptoms after surgery.

Results: A total of 1020 patients participated in the study, 1001 children without DS and 19 children with DS, 48.6% female and 52.4% male. A total of 1469 eyes were operated on the non-DS group and 35 eyes on the DS group. The mean age at procedure was 1.9±1.4 years (range: 0.1 – 18.1), the mean follow-up time was 35.0 months. No difference was found in age and gender between both groups.

A higher rate of right NLDO was observed in the DS group (100% vs. 73.2%, p=0.006). Patients with DS had more bilateral obstructions (84.2% vs. 46.8%, p=0.001) and had lower success rate (57.1% vs 92.4%,p<0.0001). No difference was found between nasolacrimal stenosis grade as appreciated during the procedure or rates of stent loss after the procedure. The median time to failure was 3.1 months in the DS group, and 5.2 months (range: 0.7-43.2) in the non-DS group. The hazard ratio comparing Down’s syndrome patients to Down’s syndrome-free patients was 6.6 (95% CI: 3.2-13.7, P<0.001).

Conclusions: CNLDO in DS has unique characteristics. It is more likely to be bilateral and to involve the right nasolacrimal system, and less likely to resolve after initial probing with monocanalicular stent intubation. However, in most patients, the procedure was successful, thus withholding the need for more aggressive primary treatment modalities such as balloon dacryoplasty or DCR. Therefore, we believe that probing with monocanalicular stent intubation remains a viable primary treatment option for DS patients.


Daphna LANDAU (Tel Aviv, Israel), Christiana E. MUNROE, Karen E. REVERE, Lama KHATIB, Peiying HUA, Gui-Shuang YING, Gil BINENBAUM, James A. KATOWITZ, William R. KATOWITZ
08:15 - 09:45 #32163 - OP59 Mid-term outcome of endoscopy-guided laser-assisted transcaruncular stoploss jones tube implantation for canalicular obstructions.
OP59 Mid-term outcome of endoscopy-guided laser-assisted transcaruncular stoploss jones tube implantation for canalicular obstructions.

Purpose: To assess mid-term outcomes of minimally-invasive endoscopy-guided transcaruncular laser-assisted StopLoss Jones tube (SLJT) implantation for severe canalicular obstructions in primary surgeries.

Method: We retrospectively identified patients who underwent an endoscopy-guided transcaruncular SLJT implantation as the primary surgery for complete canalicular dacryostenosis. The procedure was conducted under an 810-nm diode laser's assistance. Patients were followed up for a minimum of 1 year postoperatively. Surgical and functional success rates, intraoperative and postoperative complications, and the necessity for secondary surgery are evaluated.

Result:Thirty-two eyes in 32 patients were identified, including 19 (59%) of canalicular agenesis and 13 (41%) of acquired canalicular obstruction. Primary surgical success was achieved in 30 of the 32 cases (94%). Two patients (6%) required secondary surgery to replace an SLJT with a shorter one. Ultimately, all cases showed well-placed functioning tubes. Seven of the 32 cases (22%) presented conjunctival scarring, conjunctival granuloma tissue, with or without tube-associated irritation of the ocular surface. In the one-year follow-up of 32 patients, complete functional success was achieved in 84%, and five patients (16%) complained about ocular surface discomfort. In the two-year follow-up of 15 patients, complete functional success was achieved in 12 patients (80%), and three patients (20%) suffered from ocular surface discomfort. No sink-in, migration, extrusion, nor crack of the tube was observed during the follow-up.

Conclusion: Endoscopy-guided transcaruncular diode laser-assisted SLJT implantation appears to be a promising minimally invasive approach for the primary treatment of severe canalicular dacryostenosis. It has shown a high functional success rate and might avoid the risk of tube malposition and extrusion, septal and turbinate injury, nasal adhesion, drainage failure, ethmoiditis, postoperative bleeding, and cutaneous scars.


Ludwig M. HEINDL, Sitong JU (Koln, Germany), Yongwei GUO, Alexander C. ROKOHL
08:15 - 09:45 #30669 - OP60 Assessment of lacrijet monocanalicular intubation for congenital nasolacrimal duct obstruction.
OP60 Assessment of lacrijet monocanalicular intubation for congenital nasolacrimal duct obstruction.

     Background: Congenital nasolacrimal duct obstruction (CNLDO) is usually secondary to a blockage at the valve of Hasner by a membranous tissue. Silicone lacrimal intubation is indicated if conservative and/or probing treatments fail to resolve CNLDO. The purpose of this study is to assess the success rate and complications of Lacrijet monocanalicular stent (FCI S.A.S, Paris, France) intubation in children treated for CNLDO.

        Methods: Retrospective review study which included children with CNLDO that were intubated with Lacrijet monocanalucilar silicone tube.The Lacrijet tube remained in place for 11-15 weeks post operatively and was removed in the clinic with topical anesthesia. Operative time was recorded for each case. All children were evaluated using the following parameters preoperatively and postoperatively: tear meniscus height, Fluorescein dye disappearance test, and MUNK score. 

         Results: The study included 20 eyes with mean age of 26.25 ± 11.25 months. 17 eyes (85%) had undergone probing previously. Mean operation time of Lacrijet intubation was 8.5 minutes (95%CI 7.04 – 9.95). Mean follow-up period was 204.65 ± 105.27 days. Lacrijet intubation resulted in statistically significant improvements in tear meniscus height (P < .001), fluorescein dye disappearance test (P < .001), and MUNK score (P < .001) in all children. Two different sizes of Lacrijet intubations were used. Complete success was obtained in all cases. No complications were observed.

         Conclusions: Lacrijet lacrimal intubation has a high rate of success, shortens surgical time and has a low rate of complications in children with CNLDO.


Shirin HAMED AZZAM, Shirin HAMED AZZAM (Poriya, Israel), Morris HARTESTEIN, Angela DOLMETSCH, Abed MUKARI
08:15 - 09:45 #31950 - OP62 Chronic inflammation score of the lacrimal sac: Can it be a prognostic factor for external dacryocystorhinostomy outcomes?
OP62 Chronic inflammation score of the lacrimal sac: Can it be a prognostic factor for external dacryocystorhinostomy outcomes?

Aim:Many factors can affect external-Dacryocystorhinostomy (ex-DCR) success.It was reported that chronic inflammation score (CIS) can aid to determine the outcomes of endoscopic DCR.However, to date there is no study evaluating the relationship between ex-DCR outcomes and CIS.Therefore, this study was conducted to find out if there is an effect of CIS on the surgical outcomes of Ex-DCR.

Methods:Lacrimal sac specimens of the 30 naive ex-DCR patients were scored according to these 3 histopathological features:the intensity of inflammatory cell infiltration (IC), the density of fibrosis (F) and the degree of capillary proliferation (CP).Each features were scored as 1 for mild, 2 for moderate and 3 for severe.The total score was CIS.The surgical outcomes were assessed subjectively (+/- epiphora) and objectively (+/- syringing).Histopathological features and CIS were compared between successful and unsuccessful results.

Results:The subjective success rate was 86.7% and the objective rate was 90%.For both subjective and objective outcomes;IC, F and CP were significantly different between successful and unsuccessful patients(for subjective outcomes;p=0.02, 0.001 and 0.001; for objective outcomes;p=0.03, 0.01 and 0.007 respectively).Total mean CIS was 3.80±1.24 and it was higher in both objectively and subjectively unsuccessful cases than in successful cases(6.33±0.57 vs. 3.52±0.94, p=0.004 and 6.25±0.50 vs. 3.42±0.81, p<0.001;respectively).

Conclusion:CIS were found to be higher in unsuccessful ex-DCR than in successful.CIS can be a useful prognostic factor for ex-DCR outcomes.This study should be regarded as a pilot study and must be validated with a larger sample size.


Deniz KILIC (Ankara, Turkey), Ayşenur PAŞAOĞLU, Sefa ÜNAL, Bekir AYYILDIZ, Suat Hayri UGURBAS
08:15 - 09:45 #32502 - OP63 Comparing outcomes of standard silicone tube lacrimal intubation techniques with adaptations to reduce risk of Covid-19 transmission in Dacryocystorhinostomy surgery.
OP63 Comparing outcomes of standard silicone tube lacrimal intubation techniques with adaptations to reduce risk of Covid-19 transmission in Dacryocystorhinostomy surgery.

Introduction

During the Covid-19 pandemic, dacryocystorhinostomy (DCR) technique was modified to reduce risk of viral transmission through exposure to nasal mucosa during the tube removal and to reduce the number of post-operative visits.

Methods

We retrospectively reviewed case notes from patients who had DCR (external and endonasal) in 2020 at Moorfields Eye Hospital, comparing 2 groups:

Group A. Lacrimal intubation technique requiring post-operative removal via nasal cavity – tied bicanalicular silicone stents, or:

Group B. Lacrimal intubation not requiring post-operative manipulation via nasal cavity - self-retaining monocanalicular stents or untied bicanalicular silicone stent with intranasal silicone sleeve.

Exclusion criteria:

  • no lacrimal intubation

  • obstruction proximal to nasolacrimal duct

  • primary insertion of Lester Jones tubes

Primary outcome was success or failure, measured by symptomatic improvement (epiphora or discharge). Secondary outcomes include number of post-operative appointments, wound healing and complications. We compared outcomes between group A vs B, and whether outcomes differed in external DCR with suture vs glue skin closure. Chi-squared and T-test were used.

Results

114 DCR (61% external; 39% endonasal) were performed from 1st January to 31st December 2020 for nasolacrimal duct obstruction. Median age was 58 years (range 5-92; 26% male, 74% female). 19 (14%) patients met exclusion criteria. Group A (n=87) success was 87%; post-operative complications arose in 9% (most commonly cheesewiring (2%), hypertrophic scarring (2%) and epistaxis (2%)). 

In group B (n=27), neither success (92%, p=0.488) nor post-operative complications (4%, p=0.319; one case of mild infection) were significantly different to group A.

Success did not differ between patients who had skin closure with glue (95% success, 28% of patients) or sutures (88% success, 72% of patients, p=0.367) during external DCR. Average number of post-operative appointments was lower in patients who had skin closure with glue (1.89) compared to sutures (3.25, p<0.001). No wound healing issues or post-operative cellulitis were reported in either group.

Conclusions

Variations in lacrimal intubation and skin closure during DCR can avoid high-risk exposure to nasal mucosa and reduce post-operative appointments without compromising success or complication rates. These modifications in DCR developed during the pandemic may have a long-term value.


Otti VANESSA (London, United Kingdom), Maria MAS CASTELLS, Rishi RAMESSUR, Swan KANG
08:15 - 09:45 #32201 - OP64 Long-term outcomes of revision endoscopic dacryocystorhinostomy aided by 4-mm coronary balloon catheter dacryoplasty.
OP64 Long-term outcomes of revision endoscopic dacryocystorhinostomy aided by 4-mm coronary balloon catheter dacryoplasty.

Purpose: To assess the long-term efficacy of 4-mm coronary balloon catheter dacryoplasty in revision endoscopic dacryocystorhinostomy (RevEnDCR).

Methods: Retrospective interventional case-series of patients who underwent RevEnDCR aided by a 4-mm coronary balloon catheter (CBC) dacryoplasty. The indications for the surgery were previously failed DCRs by external or endoscopic approach where the ostium showed near total cicatrization with or without the presence of organized granuloma threatening the internal common opening (ICO). The coronary balloon (4 × 10 mm, SPALNO, Cardiomac, Haryana, India) with the guidewire was used and a minimum of >12 months of follow-up was considered for analysis.

Results:Ten lacrimal systems of eight patients with mean age of 48.8 years underwent CBC-assisted revision endoscopic DCR. Of the 10 failed DCRs, 6 had a previous external approach DCR and 4 were endoscopic DCRs. Grossly stenosed ostium with near total cicatricial closure were noted in half of the patients (50%, 5/10) while the remaining half, in addition, showed organized granulomas threatening the ICO. The surgical technique using CBC was found to be minimally invasive, easy to perform with multiple advantages like uniform clearance of the area in front of ICO and more predictable lacrimal sac flaps. At a mean follow-up of 20 months, anatomical and functional success were achieved in 90% (9/10) of the eyes.

Conclusion: The coronary balloon catheter-assisted revision endoscopic DCR is a minimally invasive and viable alternative in select group of patients of failed DCR with near total cicatrisation or organized granulomas threatening ICO.


Nandini BOTHRA (India, India), Mohammad JAVED ALI
08:15 - 09:45 Time for questions and discussion.
Room 1
09:45 COFFEE BREAK & EXHIBITION AREA - VISIT OF THE EPOSTERS
10:10

"Saturday 17 September"

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10:10 - 10:30

Keynote Lecture IV

10:10 - 10:30 Lacrimal endoscopy ; myth or reality in the management of epiphora. Karl-Heinz EMMERICH (Direktor der Klinik) (Keynote Speaker, Darmstadt, Germany)
To look inside the lacrimal was a long existing wish in the management of Epiphora.
The lacrimal system was still a myth, the diagnostic possibilities have covered the clinical examination and indirect procedures like Dacryocystographie.

Since 1995, microendoscopes with rather good quality of pictures and a maximum diameter of 1.1 mm have been presented by Storz company and Polydiagnost company. The results were first presented to the ESORPS by J. M. Piffaretti with the Storz system and by Karl-Heinz Emmerich and Hans Meyer-Rüsenberg by the Polydiagnost system. Microendoscopic procedures for recanalization of the lacrimal system like Microdrilldacryoplasty and Laserdacryoplasty have been introduced and have been developed as important tools managing epiphora.

Reality is the worldwide spreading of Dacryoendoscopy. Reality is, the experience of more than 30.000 Dacryoendoscopies by Hans Meyer-Rüsenberg an me in the last 28 years. Reality is, in most cases of PANDO microendoscopic procedures are the first step procedures and the rates of DCR in our patients could decrease from more then 30% to 10%. Reality is, DCR and Jones procedure are still keeping to be important in those cases, which are not giving the indication for micoendoscopic procedures.
So, in reality, Dacryoendoscopy has brought a lot of new insights of epiphora reasons for us and the possibility of a less traumatical, but successful treatment of Epiphora.
10:10 - 10:30 Introduced by:. Mehrad HAMEDANI (Médecin chef) (Chairperson, LAUSANNE, Switzerland)
Room 1
10:30

"Saturday 17 September"

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A33
10:30 - 12:00

Oral Communications
Flash

Moderators: Mehdi FENDRI (MEDECIN CONSULTANT) (TUNIS, Tunisia), Hirohiko KAKIZAKI (Aichi, Japan)
10:30 - 12:00 #32295 - OP65 The Lesser-known Lateral Fornix Orbitotomy.
OP65 The Lesser-known Lateral Fornix Orbitotomy.

In the array of lateral orbitotomy procedures, the lateral fornix approach is less well known. It involves a curvilinear conjunctival incision in the lateral fornix, situated behind the equator of the globe. Dissection remains posterior to the lateral orbital tubercle of Whitnall. The technique allows exposure of the lateral orbit for repair of orbitozygomatic fractures and defects, to access extra- and intraconal lesions, and to perform lateral orbital decompression. The advantage of the lateral fornix approach is wide access to the lateral orbit without severing the anatomy of the lateral canthal ligament. The secretory tear ducts of the lacrimal gland require identification to avoid injury. In this presentation, the technique and applications are described.


Ilse MOMBAERTS (Leuven, Belgium, Belgium)
10:30 - 12:00 #32441 - OP66 Development of endoscopic orbital surgery - the progression of a tertiary referral centre.
OP66 Development of endoscopic orbital surgery - the progression of a tertiary referral centre.

Abstract title: Development of endoscopic orbital surgery - the progression of a tertiary referral centre

Format: Oral

Authors: Ahmad Aziz, Vickie Lee, Rajni Jain, Catherine Rennie, William Grant

Affiliation: Imperial College Healthcare NHS Trust, UK

Introduction/purpose: Transorbital neuroendoscopic surgery is gaining in popularity with ENT and neurosurgeons as an approach with improved visualisation of the orbit. Here we present with pictures and videos the benefits of an endoscopic approach to the orbit.

Methods: An endoscopic approach has been used in the procedures of enucleation, orbital abscess drainage, orbital decompression, access to the orbital apex and biopsy of lesions in the medial orbit posterior to the globe. We present a sample of the techniques used and the examples of the visualisation achieved with this approach.

Results: An endoscopic approach to the orbit has been used successfully in a busy London tertiary referral centre. There is superior visibility compared to traditional anterior orbital approaches of the posterior orbit and optic nerve.

Conclusion: The use of an endoscope in the orbit has a learning curve but offers enhanced visualisation in what is a small operative field and improved access to posterior orbital lesions. We recommend the use of the endoscope in cases where access can be limited and visualisation poor.


Ahmad AZIZ (London, United Kingdom), Vickie LEE, Rajni JAIN, Catherine RENNIE, William GRANT
10:30 - 12:00 #32303 - OP67 Evaluation of Orbital lymphoproliferative and inflammatory diseases by Gene Expression Analysis.
OP67 Evaluation of Orbital lymphoproliferative and inflammatory diseases by Gene Expression Analysis.

Background: Non-specific orbital inflammation (NSOI) and IgG4-related-orbital-disease (IgG4-ROD) are often challenging to differentiate. Furthermore, it is still uncertain how chronic inflammation, like IgG4-ROD, can lead to Mucosa-associated lymphoid tissue (MALT) lymphoma. Therefore, we aimed to evaluate the diagnostic value of gene expression analysis to differentiate orbital autoimmune diseases and elucidate genetic overlaps.

Methods: First, we established a database of NSOI, IgG4 ROD and MALT patients of our orbital center (2000-2019). In a consensus process, three typical patients of the above mentioned three groups (mean age 56.4±17y) at similar locations were selected. Afterwards, RNA was isolated using the RNeasy-FFPE-kit (Qiagen) from archived paraffin-embedded tissues. The RNA was then subjected to gene expression analysis (NanoString nCounter®) including a total of 1364 target genes. The most significantly up- and downregulated genes were used for a machine learning algorithm to distinguish entities. All statistical analyses were calculated using the Ri386 statistical programming environment (v4.0.3).

Results:

Using a set of marker genes the decision-tree-based algorithm could distinguish between the three entities with a high probability (p<0.0001). Interestingly, gene expression patterns showed a characteristic overlap of lymphoma with IgG4-ROD and NSOI. In contrast, IgG4-ROD shared only altered expression of one gene regarding NSOI.

Conclusion: Genetic expression analysis has the potential for faster and more secure differentiation between NSOI and IgG4-ROD. After this screening process for marker genes, a validation in a larger cohort is undergoing to verify the results. MALT-lymphoma and IgG4-ROD showed markedly more genetic similarities, which points towards the possible progression to lymphoma.


Michael OEVERHAUS (Essen, Germany), Karim AL-GHAZZAWI, Fabian MAIRINGER, Anja ECKSTEIN
10:30 - 12:00 #32144 - OP68 Orbital solitary fibrous tumours: a single-centre case series.
OP68 Orbital solitary fibrous tumours: a single-centre case series.

Background: Solitary fibrous tumours (SFT) are rare tumours with an intermediate malignant potential. The risk factors for aggressive behaviour of these tumours are still poorly understood. We detail a series of orbital SFT managed in a specialised centre in order to contribute to a better understanding of these rare tumours.

Patients and methods: 15 patients with orbital SFT treated in our centre between 01/01/2013 and 30/11/2021 have been selected. Clinical, radiological and histo-pathological characteristics are described and analysed.

Results: On the 15 lesions included, 4 lesions are secondary addressed recurrences with infiltration of surrounding tissue. These 4 lesions have been treated with a further surgical resection: 2/4 with preservation of the globe, the optic nerve and/or the oculomotor muscles with remaining tumour tissue controlled by adjuvant treatments (1/4 gamma-knife, 1/4 proton therapy), and 2/4 with exenteration up to the vital neurosurgical structures with later recurrence from the intracranial tumour tissue and metastasis in spite of adjuvant treatment.

On the 11 primary lesions managed in our centre, 8/11 lesions have been completely removed with no recurrence. 3/11 lesions have been near-totally removed due to infiltration of the surrounding noble tissues. Radiological and histo-pathological considerations are detailed.

Discussion: Orbital SFT are rare tumours with a potential malignancy with still poorly understood prognostic criteria. Our single-centre series of orbital cases is one of the largest series described in the literature. Discussion and comparison with recent studies pinpoint the need of meta-analysis.

Conclusion: Considering the rarity of orbital SFT, our additional data should contribute to a better understanding of these tumours with malignant potential.


Natasha MAMBOUR, Natasha MAMBOUR (Paris), Mathieu ZMUDA, Augustin LECLER, Marc PUTTERMAN, Pierre-Vincent JACOMET, Olivier GALATOIRE
10:30 - 12:00 #32501 - OP69 Orbital Apex Exenteration.
OP69 Orbital Apex Exenteration.

Background:

Orbital exentration is a standard treatment for severe orbital involvement in mucormycosis when it has its indications in addition to other medical remedies.

Normally, Orbital exenteration removes the entire contents of the bony orbit, including the globe, extraocular muscles and periorbital fat, and many times includes the eyelids.

It leads to several functional, esthetic and psychological problems for the patients.

In many cases of orbital mucormycosis, only orbital apex is involved and the anterior orbit including the globe and eyelids are not necrotic and logically and potentially do not need debridment.

If there is any technique not to debride the uninvolved tissues including the globe and eyelids, we will be able to avoid the devastating effects of a total or subtotal orbital exentration.

In this presentation, we introduce a technique to remove and debride the necrotic tissues behind the globe including the orbital apex but sparing the uninvolved orbital tissues including the globe and eyelids.

 

 Methods:

 Case series, Endoscopic endonasal orbital surgery approach

 

Results:

The surgery was done in 4 proved sino-orbito-nasal post-covid mucormycosis patients with severe orbital apex necrosis that were given indications of orbital exentration by at least 2 oculoplastic surgeons.All eyes had no light perception with frozen movements.

The technique was endoscopically and endonasally removal of the necrotic tissues of the whole orbital apex including the medial and lateral necrotic bony wall and apex necrotic soft tissues. We will show the technique and all cases one by one. In all of four patients, globe,eyelids and anterior orbital tissues were saved. We followed up them between 4 to 8 months until we were sure there was not any sign of the infection recurrence.
Conclusion:

Many cases of severe mucormycosis have already lost their vision due to orbital apex involvement, and frozen eye is observed in many; hence, the surgeon needs not to worry about vision loss perioperatively and can remove even the optic nerve in the case of involvement.

Sparing the globe and uninvolved tissue with the aid of endoscopic-power-assisted surgeries can bring the feasibility of avoiding a rather disfiguring and catastrophic procedure and eliciting the need for further complex reconstruction.


Abolfazl RAHIMI (Tehran, Islamic Republic of Iran), S Hadi SAMIMI
10:30 - 12:00 #32244 - OP70 The change of fusion area after Bilateral microscopic extra/intraconal Orbital fat Decompression for Thyroid Eye Disease.
OP70 The change of fusion area after Bilateral microscopic extra/intraconal Orbital fat Decompression for Thyroid Eye Disease.

Indroduction; Exophthalmos caused by thyroid eye disease is usually treated by orbital decompression, which involves resection of orbital fat and bone. The most common postoperative complication of orbital decompression is new-onset diplopia (NOD). However, almost reports concern diplopia in the primary position, and there are no reports showing changes in the entire visual field. In this study, we investigated how the fusion image area (FIA) changes after orbital decompression surgery, which mainly involves microscopic resection of the orbital intra/extraconal fat, using the binocular single vision (BSV) test.

Methods: Of 76 patients (150 eyes) with thyroid eye disease who underwent bilateral orbital fat decompression under general anesthesia at Oculofacial Clinic Tokyo between January and December 2021, 29 (58 eyes) who were available for a 6-month follow-up were enrolled. Patient age and sex, postoperative changes in Hertel exophthalmometer measurements, amount of orbital fat removed, and BSV were recorded. FIA was defined as the average of the four locations from the primary position at which diplopia was felt, which were measured using the BSV test.

 

The surgery was performed through a conjunctival incision in the inferior fornix, excising the anterior orbital fat, extraconal fat and then intraconal fat entering between the lateral and inferior rectus muscles and between the medial and inferior rectus muscles, being careful to avoid nerves and blood vessels. The excised fat was placed in an empty syringe without air to measure the volume after blood was removed with gauze.

 

Results: The 31 patients (28 women, three men) had a mean age of 43.4±13.2 years (range, 19–72). Mean ocular protrusion decreased 3.6mm from 20.0±3.2 mm preoperatively to 16.4±3.0 mm postoperatively. The average amount of fat removed was 3.8±1.6 mL; accordingly, the volume of orbital fat needed to improve the exophthalmos by 1 mm was 1.1 mL. FIA was changed  from 43.7° preoperatively to 44.2° (P=0.38), 44.5° (P=0.31), and 44.4° (P=0.34) at 1, 3, and 6 months, respectively, after surgery. At 6 months postoperatively, none of 30 patients without preoperative diplopia in the primary position developed NOD in the primary position. One patient had all field diplopia throughout follow up duration.

 

Conclusion: The fusion area was not decreased significantly at 1,3 months and 6 months after  orbital fat decompression. There were no cases of residual NOD postoperatively.


Tomoyuki KASHIMA (Tokyo, Japan), Masashi MIMURA
10:30 - 12:00 #32151 - OP72 The role of thyroid stimulating immunoglobulin (TSI) in evaluating Thyroid Eye Disease.
OP72 The role of thyroid stimulating immunoglobulin (TSI) in evaluating Thyroid Eye Disease.

Background: The most common blood tests to evaluate patients with Thyroid Eye Disease (TED) are: Thyroid Stimulating Hormone (TSH), T3, T4. However, it is known that those blood tests are not correlated with the severity of TED. In recent years, a new blood test for Thyroid Stimulating Immunoglobulins (TSI) is in use. However, there is not enough evidence about the correlation between the TSI level to Thyroid Eye Disease (TED). Therefore, the purpose of this current study was to evaluate the correlation between TSI and TED and to examine if TSI is a good predictor for the severity of the disease. 

Methods:  A retrospective review of medical records of all patients who attended the TED clinic at Sheba Medical Center, Israel from January 2020 to April 2022 and had a TSI results was performed. The retrieved data included: demographics, comprehensive ophthalmic examination findings, orbital and eyelids evaluation, clinical activity scores (CAS) and laboratory test results.

 Results: 60 patients (43 females) had a known TED and had a documented TSI result.

The mean TSI  at presentation was 1171.35 while at the end of follow up,it was 517.98 (P=0.012). TSI values were found to be positively correlated with IOP (P=0.01) and eyelids measurements of PF (P=0<0.01) and MRD1 (P<0.01) while negatively correlated with Pattern Standard Deviation result (P=0.05).

TSI values > 500 were also found positively correlated with the clinical activity score (CAS) (P=0.02) and eyelids measurements of PF (P=0.02), MRD1 (P=0.01) and MRD2 (P=0.003) while negatively correlation with Pattern Standard Seviation result (P=0.015).

TSI values > 500 were found to be significantly correlated with medical treatment- high dose steroids (P=0.05), steroid treatment according to the European Group on Graves’ Orbitopathy protocol (P=0.02) and Radioactive iodine (P=0.03).

Conclusions: TSI value is correlated with the presentation of the clinical features of TED. TSI can be considered as a good predictor factor for the activity of the disease as well as the number of surgical and medical interventions. Therefore, It is recommended to add this blood test to the panel of blood tests for patients with TED. 


Shiran MADGAR (Tel Aviv, Israel), Guy BEN SIMON, Ayelet PRIEL, Ofira ZLOTO
10:30 - 12:00 #30874 - OP73 Porous orbital implants: is it time to close this chapter?
OP73 Porous orbital implants: is it time to close this chapter?

Abstract: A new era in anophthalmic socket surgery began with the introduction of coralline hydroxyapatite (HA) in the late 1980’s. The HA implant represented a new generation of buried spherical implant with an interconnecting system of pores that allowed host fibrovascular ingrowth. By drilling into the HA implant and inserting a peg, the orbital implant could be directly coupled to the overlying prosthetic eye, producing life-like movement of the prosthesis. Although HA implants significantly increased the cost of rehabilitating the anophthalmic socket (e.g., higher implant costs, wrapping material costs, additional surgeries to implant a peg, confirmatory bone scan etc.), the proposed advantages of a lower migration rate, lower extrusion rate, resistance to infection, and enhanced motility were used to justify the added expense. The author reviews his 30-year experience with a variety of these porous implants as well as the literature and reports that there is no evidence to corroborate a lower migration rate, a lower extrusion rate, and a lower infection rate. With respect to enhanced motility, there is no difference from that of a non-porous implant unless a coupling peg has been used. As with innovative implant designs from the past (e.g., Mules, Rudemann, Cutler), the initial wave of enthusiasm with porous implants has been tempered as an increasing number of surgeons recognize the touted advantages have little scientific data to support them and the implants associated with numerous risks and complications that may be difficult to manage. They are not the gold standard as some once thought.


David JORDAN (Ottawa, Canada)
10:30 - 12:00 #32225 - OP74 Patient Satisfaction and Long-Term Volumetric Measurements after Transcutaneous Restylane Injection for Anophthalmic Socket Syndrome.
OP74 Patient Satisfaction and Long-Term Volumetric Measurements after Transcutaneous Restylane Injection for Anophthalmic Socket Syndrome.

Purpose: To evaluate the outcomes of transcutaneous Restylane injection in patients with anophthalmic socket syndrome.

Methods: Twenty-six patients with anophthalmic socket syndrome were treated with transcutaneous injections of Restylane. Patient satisfaction was evaluated using the validated Face-Q scale. A subset of patients (n=12) was followed for ultrasound filler dimensions over time. Three-dimensional images (Figure 1) were also acquired in 11 cases to evaluate both changes in filler volume and upper eyelid crease height (UECH) symmetry. Follow-up was scheduled at 3 months and annually after surgery.

Results: One year post-injection, significant improvement was observed on the FACE-Q scales for psychological well-being (p=0.04), social functioning (p=0.02), satisfaction with facial appearance (p=0.04) and satisfaction with eyes (p=0.02) in the ‘Restylane-only’ group (n=19). Based on echography, no significant differences were observed in the axial, anteroposterior and craniocaudal filler dimensions over 4 years. Compared to baseline, median filler volume based on 3-D imaging significantly increased one year after a single injection (3.35 mm3, IQR: 2.76-4.48 mm3) (p=0.003) and remained stable up to 4 years (p=0.392). Median UECH difference between the prosthetic and the healthy fellow eye significantly decreased from baseline (4.9mm, IQR:1.6-8.6mm) to final follow-up (0.33mm, IQR: 0.16-1.21mm) (p<0.001).

Conclusions: Transcutaneous injection of Restylane improved significantly patient satisfaction scores, lid crease symmetry and superior sulcus volume in patients with anophthalmic socket syndrome. Volumetric measurements remained stable up to at least 4 years after injection. This represents a long-lasting feasible nonsurgical alternative for the management of upper eyelid crease asymmetry and superior sulcus deformity. 


Linda Marie Louise BUSIN (Milan, Italy), Humeyra AYDIN, Steffi J E ROMBOUTS, Emiel ROMEIN, Jelmer REMMERS, Pim DE GRAAF, Dyonne T HARTONG
10:30 - 12:00 #32325 - OP75 Non-surgical treatment for reshaping fornices in contracted sockets.
OP75 Non-surgical treatment for reshaping fornices in contracted sockets.

Purpose: To describe a non-surgical method to reshape shallow fornices in contracted sockets that cannot be adequately fitted with a prosthesis, and to prevent fornices’contraction following socket surgery.Methods: Thirty-two patients unable to retain the prosthesis due to a contracted socket were retrospectively reviewed. Ten patients had a moderately contracted socket and preferred to avoid surgery; in 8 patients the surgery was contraindicated for medical reasons; 14 patients had previously been submitted to mucous-membrane graft or dermis-fat graft. In all cases the socket was fitted with a customised conformer; a mark was made on the conformer at the centre of the eyelid opening. The conformer was then removed from the socket and a cylindrically shaped handle was glued onto the previously marked area to form the so-called compressor. This device was inserted into the socket with two patches positioned on the top of the handle to keep the compressor stable. In 14 patients who underwent reconstructive surgery, the device was positioned immediately after removal of the temporary tarsorrhaphy in order to avoid graft retraction. The compressor is kept 24 hours a day for a week, and afterwards it is alternated with a prosthesis or a conformer during the daytime, until a customized prosthesis can be properly retained into the socket .Results: The use of the compressor allowed the deepening of the fornices in non-surgical patients, and reduced graft contraction and stabilised the fornices after reconstructive surgery. After the treatment, all patients were able to wear a prosthesis.Conclusion: This procedure is effective in permitting the reshaping of shallow fornices in contracted sockets. It is very beneficial in patients who are unfit for surgery. By reducing socket contraction, the compressor increases the success rate of surgery, with good patient satisfaction and the advantage of reducing the chances to having to undergo further interventions.


Alessandra MODUGNO (roma/italy, Italy), Elia FRANZOLIN, Francesco QUARANTA-LEONI
10:30 - 12:00 #32259 - OP76 Manchester eye removal study: 15 years of real-world eye removal experience in a tertiary centre.
OP76 Manchester eye removal study: 15 years of real-world eye removal experience in a tertiary centre.

Introduction

To assess patient demographics, clinical indications, over a fifteen-years period in Manchester (United Kingdom) and to investigate the systemic co-morbidities associated with orbital implant exposure in patients with anophthalmic sockets.

 

Methods:

Retrospective review of patients who underwent enucleation or evisceration at a single tertiary oculoplastic centre between January 1, 2007 and January 1, 2022. The data collected included patient demographics, surgical indication, implant size, implant exposure rate and other postoperative complications. Medical comorbidities, including peripheral or coronary vascular disease, inflammatory conditions, diabetes, malignancy, history of smoking or substance abuses were also recorded. Univariate and multivariate analysis was used to determine clinical and demographic factors that have impact on post-operative outcomes.

 

Results:

After excluding patients with incomplete data, two hundred and seventy patients underwent eye removal surgery over a fifteen-year period. Implant exposure was seen in 21 (7.8%) patients. The most common indication for eye removal surgery was painful blind eye (147, 54.4%), followed by trauma (31, 11.5%), severe infection (30, 11.1%) and malignancy (29, 10.7%). Significantly more patients with the following clinical or demographic factors experienced implant exposure: malignancy (29.4% vs 4.7%, p=0.002), substance addiction (50.0% vs 5.6%, p=0.021) and smoking (37.5% vs 4.3%, p=0.001). Multivariate logistic regression model revealed that history of smoking, secondary implant, and use of porous implant materials were significant predictors of implant exposure (p=0.017, 0.008, 0.045, respectively).

 

Conclusion:

This report shed novel insights in the impact of medical comorbidities on patients with orbital implant exposure. Understanding the pathophysiology of implant exposure and taking a holistic approach are crucial to preoperative planning and postoperative care.


Siyin LIU (Manchester, United Kingdom), Daisy MORGAN, Laura CHAN, James LAYBOURNE, Anne COOK, Paul CANNON, Sajid ATAULLAH
10:30 - 12:00 #30461 - OP77 Phantom vision after eye amputation: prevalence, features and related risk factors.
OP77 Phantom vision after eye amputation: prevalence, features and related risk factors.

Aim: Phantom eye syndrome (PES) is a poorly understood and underestimated complication of eye amputation (EA). Seeing with the amputated eye, referred to as phantom vision (PV), is undoubtedly the most intriguing and confusing complication experienced by anophthalmic patients. The aim of the study was to assess PV prevalence, clinical features and risk factors after EA.

Methods: A multicentric questionnaire-based study was conducted between April 2016 and July 2017. Patients >18 years who underwent EA >3 months ago had a socket examination before inclusion. Data recorded included patients’ demographics, and preoperative, surgical and postoperative features.

Results: One hundred patients (53 men) with a mean age of 65.1 years (29-92; SD=13.0) were included. EA indications were: uveal melanoma (n=24, 24%), trauma (n=20, 20%), retinal detachment (n=20, 20%), glaucoma (n=14, 14%) and endophthalmitis (n=12, 12%). Thirty (30%) patients experienced PV. Elementary and complex visual hallucinations were experienced by 80% and 20% of patients, respectively. PV usually appeared within the first postoperative month and tended to decrease over time. Risk factors for PV were the preoperative use of proton beam therapy (p=0.006), uveal melanoma (p=0.014), enucleation (p=0.015), anxiety with a HAD score ≥8 (p=0.042), depression with a HAD score ≥8 (p=0.030), phantom eye pain (p=0.044) and phantom eye sensations (p=0.002).

Conclusion: PV was reported by one third of our patients. Despite being widely misunderstood, ophthalmologists and neurologists should be aware of this complication to adequately reassure patients.


Ken MARTINI (NICE), Jacques LAGIER, Jerome DELAS, Olivier GALATOIRE, Mehrad HAMEDANI, Arnaud MARTEL
10:30 - 12:00 #32287 - OP79 Analysis of Earlier Failed Probing without Endoscopy Guidance in Congenital Nasolacrimal Duct Obstructions.
OP79 Analysis of Earlier Failed Probing without Endoscopy Guidance in Congenital Nasolacrimal Duct Obstructions.

Aim: The purpose of this study was to report the profile and outcomes of children with an earlier failed probing that was performed without endoscopy guidance.

Methods: Retrospective interventional case study was performed on all the patients who were referred with a diagnosis of a single or multiple failed probing from Jan 2016 to June 2019 to a tertiary care Dacryology center. All the patients had a blind probing without an endoscopy assistance before referral. The parameters evaluated were patient demographics, number of earlier probings, prior operative notes, clinical presentation, findings of endoscopy guidance during the repeat procedure, simple vs complex CNLDO, types of complex CNLDO, management, complications and outcomes.

Results: One hundred eyes of 82 children had a failed probing experience without endoscopic guidance elsewhere. The mean age of the children was 55.7 months (range: 9-168 months). Of these, 63 eyes underwent repeat probing under endoscopic guidance, 35 eyes being simple CNLDO (35/63, 55.5%), and 28 eyes (28/63, 44.5%) being complex CNLDO. Among the complex subset, balloon dacryoplasty was performed for five cases and monoka-Crawford stents for eight cases under direct endoscopy visualization. Buried probes were managed successfully by standard protocols of probe exteriorization. The two cases of misdirected probes were re-directed under endoscopy guidance for appropriate recanalization and the single case of granuloma at the NLD opening was excised followed by intubation without any recurrence.

Conclusion: Endoscopy guidance plays a crucial role in the management of CNLDO with an earlier failed probing.


Nandini BOTHRA (India, India), Mohammad JAVED ALI
10:30 - 12:00 #32382 - OP80 Post-operative epiphora in patients who have undergone marsupialisation for the management of canaliculitis.
OP80 Post-operative epiphora in patients who have undergone marsupialisation for the management of canaliculitis.

Canaliculitis is described as inflammation of the lacrimal canaliculus, most caused by infection. Of the symptoms, epiphora is common and can have significant impact on patients’ quality of life. Conservative management alone is often trialled but is rarely curative. In comparison, various forms of surgical techniques have been described for more definitive management. Marsupialisation involves incising into the canalicular space and suturing the edges to form a surface extending from the interior to exterior, allowing the space to remain open and drain. This study aims to evaluate the effectiveness of marsupialisation in the treatment of canaliculitis and specifically, the impact on pre-existing and post-operative epiphora.

 

A retrospective, single centre study was conducted. Patients treated for canaliculitis via marsupialisation between years 2006 to 2021 in a tertiary hospital ophthalmology unit were included. 45 patients were identified through electronic patient records (EPR). Data was collected via EPR, physical notes, and telephone surveys. Data collected included demographics, presenting complaints, presence of pre- and post-operative epiphora, Munk scale classification of epiphora, and postoperative complications. The presenting complaints investigated included redness, epiphora, discharge, pain, and swelling. Post-operative complications reviewed included redness, lid malposition, exposure of conjunctiva, and non-resolution.

 

68% of the patients were found to have pre-operative epiphora with an average Munk scale grading of five, indicating constant epiphora. Of these patients, 86% of patients experienced an improvement or resolution of epiphora post-operatively, 9% had a similar severity of epiphora post-operatively, and 5% had worsening of epiphora. Of the 32% of patients who did not suffer from epiphora pre-operatively, none developed new epiphora post-operatively.

 

Epiphora is a debilitating symptom for those with canaliculitis and was found in a large proportion of canaliculitis patients prior to treatment. This retrospective study suggests marsupialisation to be an effective and safe surgical technique in managing epiphora in such patients.


Tracie LIU (Sheffield, United Kingdom), Jennifer TAN
10:30 - 12:00 #32538 - OP81 Results of Simultaneous Bilateral Endoscopic Dacryocystorhinostomy: Duration of Surgery, and Evaluation of Success and Complications.
OP81 Results of Simultaneous Bilateral Endoscopic Dacryocystorhinostomy: Duration of Surgery, and Evaluation of Success and Complications.

Purpose: It was aimed to evaluate the results of simultaneous bilateral endoscopic dacryocystorhinostomy (DCR).

 

Method: Simultaneous bilateral endoscopic DCR was applied to patients with bilateral acquired nasolacrimal duct obstruction who applied to Marmara University, Department of Ophthalmology between 2020-2022. Patients with punctal - canaliculi occlusion and a history of previous DCR were excluded from the study. Only Kerrison punch and curettes were used for bone excision in all cases, and lacrimal intubation was applied to all eyes. History of dacryocystitis, duration of symptoms and surgery, complications, and functional and anatomical success parameters were evaluated.

 

Results: Twenty-four eyes of 12 patients were included in the study. The female ratio was 4/12 (33.3%), and the mean age of the patients was 50.9±9.1 years. Six eyes (25%) had a history of dacryocystitis. The mean time to development of symptoms was 9.21±4.14 months. The mean operation time per eye was 37.08±6.41 (min:25-max:50) minutes. The functional and anatomical success rates at 3 months were 91.7% (n=22) and 95.8% (n=23), respectively; and 6 months success rates were 87.5% (n=21) and 91.7% (n=22), respectively. While no perioperative complication was observed, the hematoma was seen in 4 eyes (16.6%), and intranasal bleeding occurred in 2 eyes (8.3%) postoperatively. In one of the anatomically unsuccessful eyes, the lacrimal intubation tube extruded on the 3rd postoperative day, and another eye had a history of dacryocystitis.

 

Conclusion: Simultaneous endoscopic DCR can be applied as a useful method in bilateral acquired nasolacrimal duct obstructions with its high anatomical and functional success rate, short operation time, and low complication rates.


Volkan DERICIOĞLU (Istanbul, Turkey)
10:30 - 12:00 #32389 - OP82 Periorbital Injectable 5-fluorouracil for Teatment and Prevention of Cicatricial Lagophthalmos After Eyelid Surgery.
OP82 Periorbital Injectable 5-fluorouracil for Teatment and Prevention of Cicatricial Lagophthalmos After Eyelid Surgery.

Purpose: The authors describe their experience with the treatment of postoperative subcutaneous injections of 5-fluorouracil (5-FU) in a subset of patients that underwent different eyelid surgeries, to treat or prevent cicatricial sequela. 

Methods: A retrospective case series review of patients with post-operative eyelid cicatricial changes treated with a series of subcutaneous 5-FU injections to the area of the scar. 

Results: We present 5 cases (in 4 patients) of cicatricial changes after eyelid surgery treated with a series of 4 weekly injections of 0.3ml 5-FU in a concentration of 50mg/ml. Two patents after eyelid reconstruction secondary to eyelid trauma, one patient after upper and lower eyelid aesthetic blepharoplasty, and one patient after bilateral cicatricial ectropion repair, combined with basal cell carcinoma excision. All patients presented with lagophthalmos and secondary corneal changes. All patient showed resolution of lagophthamos corneal dryness. None of the patient required secondary revision and no drug side effects were notes. 

Conclusions: The use of post-operative injectable 5-FU for the treatment and prevention of cicatricial changes after eyelid surgery appears to be both effective and safe.


Zvi GUR (Jerusalem, Israel), Pablo GALARZA
10:30 - 12:00 #32547 - OP83 Levator palpebrae superioris tuck with small incision.
OP83 Levator palpebrae superioris tuck with small incision.

Background:

The direction is always towards interventions that are more conservative preserving as much of the normal tissues as possible.

And so, levator palpebrae superioris tucking is to be considered in correcting ptosis of the upper eyelids.

Since 2017, this has been the sole technique for correction of ptosis to the eyelids with levator palpebrae superioris muscle function ranging between moderate to good.

Method:

135 eyelids with moderate to good LPS function were done.

The incision to the skin is only 20 - 25 mm.

The LPS was tucked to the tarsus after freeing it from the orbital septum and fats.

Postoperative outcome measures included: level of the eyelid, contour of the eyelid and postoperative lagophthalmos.

The follow up was done at 1 week and then monthly along 6 months from the surgery.

Results: 

The position of the upper eyelid was good in 75% of the cases after 6 months from surgery. Eyelid contour was normal in 70% of the cases. Postoperative lagopthalmos was not seen in any case with proper closure of the eyelids.

Conclusion:

The LPS tucking preserves the normal fibers of the muscle, in case there is any recurrence later on that makes it much easier. Doesn't affect the closure of the eyelids and minimizes the possibility of any lagophthalmos. The small incision on the skin in the crease preserves the cosmetic aspect.


Bassem MORSHED, Bassem MORSHED (Cairo, Egypt)
10:30 - 12:00 #32462 - OP84 Replacing “like to like” - a modified approach for lower eyelid reconstruction following tumor resection.
OP84 Replacing “like to like” - a modified approach for lower eyelid reconstruction following tumor resection.

Purpose:  To describe a modified approach for the anterior lamella reconstruction during full thickness reconstruction with a tarsoconjunctival flap or free tarsal graft.

 

Methods:  This is a retrospective review of 6 patients with greater than 80%, full-thickness eyelid defects after tumor resection requiring reconstruction. For lower eyelid defects, a traditional tarsoconjunctival flap from the upper eyelid was used to rebuild the posterior lamella.  For upper eyelid defects, a free tarsal graft from the contralateral eyelid was used.  In all cases, the anterior lamella was supplied from an adjacent myocutaneous flap in a bucket handle configuration.  To prevent anterior lamellar shortening, a full thickness skin graft is placed in the resulting defect after mobilization of the bucket handle. Data collection included: tumor type and location, size of eyelid defect, presence of canalicular involvement, post-operative eyelid position, patient satisfaction, and complication rates.

 

Results:  Six eyelids in 6 patients underwent Mohs micrographic excision of basal cell carcinoma followed by reconstruction with a bucket handle flap. There was one male and 5 females, with the age ranging from 68 to 96 years old (mean of 81 years). Five patients presented with lower eyelid involvement and 1 with upper eyelid involvement. The defect size ranged from 80% to 100% of the eyelid. Four patients had canalicular involvement and required bicanalicular nasolacrimal stent placement. After reconstruction, all patients showed good eyelid apposition to the globe. No eyelid malposition, lagophthalmos, corneal decompensation, or epiphora was noted postoperatively. All patients expressed satisfaction with their results. Average follow up time was 12 months (range of 5 to 21 months).

 

Conclusion:  The bucket handle flap for full-thickness eyelid reconstruction is a simple technique that allows for preservation of all anatomical layers of the anterior lamella. This technique shows promising functional and aesthetic outcomes

 

 


Zvi GUR (Jerusalem, Israel), Liu CATHERINE, Don KIKKAWA, Bobby KORN
10:30 - 12:00 #32245 - OP85 Long-term outcome of hyaluronic acid in dark under-eye circles.
OP85 Long-term outcome of hyaluronic acid in dark under-eye circles.

Introduction:

The injection of hyaluronic acid is an aesthetic medicine procedure that is very commonly used, particularly for dark under-eye circles. We know a lot about the immediate complications. What about the complications when the product ages?

Materials and Methods:

The authors reviewed the files of about fifty patients injected in the dark under-eye circles with a 10-year follow-up and tried to highlight the aging of the product by comparing the different photos.

Results:

There are still late complications related to the aging of the product. We often find a progressive swelling linked to an increase in hydrophilicity and a hyperpigmentation of the area related to a probable chronic inflammatory reaction, as well as a migration of the product.

Conclusion:

Hyaluronic acid injections in dark circles are not harmless. We know very well the short-term complications, but we don’t know as much the late complications. Should we continue to inject dark circles with hyaluronic acid?

Keywords: Dark under-eye circles, hyaluronic acid, complications.


Arthur AULANIER (Marseille), Thierry MALET, Eric SARFATI
10:30 - 12:00 #32150 - OP86 Surface electromyography of the orbicularis oculi muscle with pretarsal electrode placement.
OP86 Surface electromyography of the orbicularis oculi muscle with pretarsal electrode placement.

Introduction:

Surface electromyography is being widely used in skeletal muscles function assessment. However, in eyelid muscles examination, surface electromyography is used only in experimental studies, mainly regarding developing the blinking periorbital prothesis. Nevertheless, surface electromyography has a potential to be used in monitoring of the orbicularis oculi muscle recovery after eyelid surgery, trauma, paralysis or planning the best surgical approach. Developing reliable technique may increase the feasibility of surface electromyography in clinical practice. One of the main limitations is crosstalk with adjacent muscles. We propose placing the electrode in the mid-pretarsal area of the upper eyelid.  

Material and methods: 126 surface electromyography examinations in 39 controls and 29 ptotic patients were conducted. Silver-chloride electrodes with the dimensions of 5x8 mm were used. The electrode was placed in the central portion of the upper eyelid horizontally, 5mm above the lash line. The orbicularis oculi muscle function was assessed in the primary gaze and while performing maximal eyelid closure using Root Mean Square in controls and ptotic patients before and after ptosis surgery.

Results: We found significantly lower Root Mean Square values of the maximal contraction of the orbicularis oculi muscle 2 weeks after surgery (p<0.05). After 6 months there were no statistically significant differences in Root Mean Square values compared to the preoperative results. No technical difficulties in the electrode instillation, performing the examination and interpretation of the results was observed.

Conclusions: By placing the electrode in the mid-pretarsal area of the upper eyelid, one can easily perform fast examination and achieve repeatable results, which may enhance the feasibility of surface electromyography in clinical practice. Eyelid surface electromyography may be an useful diagnostic tool in an objective and quantitative post-operative orbicularis oculi muscle recovery monitoring.

 


Larysa KRAJEWSKA-WĘGLEWICZ (Warsaw, Poland), Marta BANACH, Ewa FILIPIAK, Joanna SEMPIŃSKA-SZEWCZYK, Piotr SKOPIŃSKI, Małgorzata DOROBEK
10:30 - 12:00 #32390 - OP87 Oculoplastic video clinics in the real world.
OP87 Oculoplastic video clinics in the real world.

Background

 

During the COVID pandemic, we conducted oculoplastic teleclinics via Attend Anywhere, a virtual consultation platform provided by the National Health Service (NHS), due to reduced clinic capacity and social distancing requirements.

 

Purpose

The aim of this study is to to assess the efficacy of Attend Anywhere clinics for the oculoplastic service and identify the cohort of patients suitable for virtual consultations by analyzing the outcome patterns.

 

Methods

100 consecutive patients seen over 5 weeks were included in study.

 

Results

Patients ranged from 6-93y, 67% of patients were >60 years old, 17% were >80 years old.

There were 46 video consultations, 36 phone consultations and 12 face to face consultations. 6 patients did not attend.

There were 46 new and 54 follow up patients (29 post-operative patients).

 

We were able to offer definitive treatment for 25%, discharge 34%; 37% required face to face consultation, 4 further video consultations.

Of the 9 patients listed for surgery, 5 were listed from video consultation, for lower lid malpositions and dermatochalasis, 4 patients had a biopsy prior to  definitive surgery. All the patients listed for minor operations were able to be listed following video consultation.  27patients had to be brought back face to face for assessment such as ptosis measurements, syringing and lid lesion malignancy before further decision on surgery could be made.

25% of patients had technical difficulties, including not having internet connection or video enabled devices.  Despite these problems consultation was successfully supplemented with telephone consultation.

 

Conclusions

Video consultation is effective for oculoplastic clinics despite real-world difficulties and can be adapted to a hybrid model of consultation to reduce departmental footfall, limit the exposure of the elderly to COVID risk and save on costs related to multiple hospital visits.

 


Lee Teak TAN (Chelmsford, United Kingdom), Seyed GHAZI-NOURI
10:30 - 12:00 #31976 - OP88 Oculoplastic Surgeries in Patients Older than 90 Years of Age.
OP88 Oculoplastic Surgeries in Patients Older than 90 Years of Age.

Purpose: To report the epidemiology, indications and surgical outcomes of oculoplastic surgeries in very old patients (≥ 90 years old).

Methods: A retrospective, tertiary single center study was carried out on the medical charts of 114 patients aged 90 years old and older who underwent oculoplastic procedures from 2010 to 2019. Data retrieved from the medical records included: past medical and ocular history, indication for surgery, type of surgery, intra and post-operative complications, pathological analysis for removed tissues, and surgical outcome in the last follow-up.

Results: 128 surgeries were performed in 114 patients (male: female = 1:1). The mean age was 92.95 years old (± 3.12 SD). Six patients (5.2%) were older than 100 years old. The most common indication for surgery was lower lid malpositioning (32%). Mass/lesion excision was performed in 34 procedures (25%). 43 biopsies were analyzed. Basal cell carcinoma was the most common pathological diagnosis (32%). 20% of the patients had glaucoma and 15% had neovascular age related macular degeneration. Hypertension was the most common associated systemic comorbidity (79 patients, 69%). 80% of the surgeries were done under local anesthesia. In seven patients (5.2%) - surgical revision was required. One patient suffered from minor stroke one day postoperatively. The same patient had orbital-skin fistulas after orbital exenteration

Conclusion: In our experience, oculoplastic surgeries in the elderly population are safe without significant complications and can usually be performed under local anesthesia. Advanced age should not prevent surgery, especially if the procedure may improve vision and quality of life.


Muhammad ABUMANHAL (Tel Aviv, Israel), Ran BEN CNAAN, Igal LEIBOVITCH
10:30 - 12:00 #32383 - OP89 Addressing digital exclusion in Oculoplastic Outpatient Clinics.
OP89 Addressing digital exclusion in Oculoplastic Outpatient Clinics.

Background

Our previous study of 92 outpatients identified lack of digital skills, access to technology and low confidence in digital healthcare as contributors to digital exclusion. Patients expressed interest in digital skills workshops and schemes to enhance access to internet and devices.

Methods

Oculoplastic outpatients at Moorfields Eye Hospital who had previously declined video consultations (VC) - and those attending parallel clinics eager to improve digital skills - were invited for training to use our VC platform, take ‘selfie’ photos, and send them via email – using departmental laptops, tablets and patients’ devices. We secured internet data packs to donate to patients who lack internet access and require frequent telemedicine access.

Pre- and post-workshop surveys explored patients’ confidence with online services, inclination to use VC and perceived utility of the workshop using a 10-point Likert scale (0 ‘extremely unlikely’ à 10 ‘extremely likely’). Two-tailed paired T-test was used to assess significance of rating differences before and after the workshop. Qualitative feedback was analysed thematically.

 

Results

Feedback was obtained from 38 of 51 (75%) patients (average age 66 years - 47% male, 53% female).

Patients reported greater inclination to use (mean rating 6.9/10 vs 5.5/10, p=0.002) – and felt more confident with (mean rating 6.7/10 vs 5.3/10, p=0.0002) – VCs after attending the workshop compared to before.

Patients found the workshop useful (mean rating 7.6/10) and were likely to recommend it to family and friends (mean rating 7.9/10). Most common suggestions were for interpreters for patients with limited command of English.

Preliminary findings suggest that loaning SIM cards to patients who frequently need telemedicine has improved healthcare accessibility.

 

Conclusion

Patients consider digital skills workshops useful to improve confidence and motivation with using Oculoplastic online services. Scaling these and aiding internet (data and device) connectivity may help address increasing issues of exclusion as services become more reliant on teleophthalmology.


Rishi RAMESSUR (London, United Kingdom), Juwairiya REHMAN, Hardeep KANDOLA, Claus GRUBER, Swan KANG
10:30 - 12:00 #32525 - OP90 Role of Oculoplastic fellow in facial trauma pathway.
OP90 Role of Oculoplastic fellow in facial trauma pathway.

Aim - We describe a unique one of a kind setup at Royal London Hospital which is a tertiary trauma referral center with oculoplastic fellow as part of weekly maxillofacial trauma clinic.

Methods- Role of the fellow is to examine patients with orbital fractures presenting to the maxillofacial clinic. Assessments include- visual acuity, pupil reaction, ocular motility (performed by specialist orthoptist) and exophthalmometry. Additionally screen for signs of retinal detachment and acute ophthalmic concerns. If red flags are noted from the above, the patient is streamed to a same urgent ophthalmology clinic for detailed assessment including dilated fundus examination. The fellow is also regularly involved in maxillofacial theaters for repair of orbital fractures, complex eyelid laceration, canthal repair, etc. 


Results- We present a cross section of patients seen from March 2022 to May 2022 (3 months). The average number of patients seen with orbital fractures 9.6 (range 7 - 15); median 9. A total of 61 patients were seen with orbital fracture during this period. Out of these, 16 patients (26.2%) were streamed for urgent same day ophthalmology review, 9 patients (14.7%) required further orthoptic assessment (including Hess chart). 3 patients (4.9%) were referred to specialist ophthalmic clinic and 4 patients (6.5%) were planned for either a joint surgical procedure with oculoplastics or required further multidisciplinary (MDT) discussion


Conclusion- We highlight a scope for collaboration and multidisciplinary input in improving patient outcomes. The presence of oculoplastic fellow in maxillofacial trauma clinics helps streamline patient flow and improve patient experience. This also offers a unique training opportunity and a framework for designing facial trauma service.


Radhika DASHPUTRA, Nikhil CASCONE (London, United Kingdom), Andrew COOMBES
10:30 - 12:00 Time for questions and discussion.
Room 1
12:00

"Saturday 17 September"

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A34
12:00 - 12:35

Mustardé Lecture

12:00 - 12:35 Grave's Orbitopathy a disease known for 2500 years. Lelio BALDESCHI (Keynote Speaker, BRUXELLES, Belgium)
He qualified in Medicine cum laude at the University of Pisa, graduated in Ophthalmology cum laude at the University of Florence, became PhD at the University of Amsterdam and Fellow of the European Board of Ophthalmology (FEBO) (international recognition of the title of specialist in ophthalmology) in Paris. He sub-specialized in oculoplastic and orbital surgery first under the guide of Richard Collin and Geoffrey Rose at Moorfields Eye Hospital in London and then with Leo Koornneef at the Orbital Centre, University of Amsterdam.
He is Professor of Ophthalmology (“Chargé de Cours”), Director to the “Orbita and Ocular Adnexal service” and President to the PhD Council “Oculoplastic, Orbital, Lacrimal Diseases and Surgery” at the Department of Ophthalmology, Catholic University of Louvain, at the Saint Luc Academic Hospital of Brussels, member of the Examining Commission of the European Board of Ophthalmology (EBO) which grant the international recognized title of specialist in ophthalmology.
He is member of the Italian Society of Ophthalmology (SOI), European Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS), European Association for Vision and Eye Research (EVER), has been elected among the three honorary members of the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS), has been Secretary (2011-2014) and President (2014-2017) of the International Society of Dacryology and Dry Eye (ISD&DE), President for two terms (2010-2012 and 2013-2015) of the Italian Society of Ophthalmic Plastic Surgery (SICOP), Secretary for two terms (2014-2017 and 2018-2021) of the European Group on Graves’ Orbitopathy (EUGOGO).
Currently he is the President of the European Group on Graves’ Orbitopathy (EUGOGO), Associated Editor of Frontiers in Endocrinology and Associated Editor for orbit, oculoplastic and adult strabismus of the European Journal of Ophthalmology.
12:00 - 12:35 Introduced by:. Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Chairperson, Stockholm, Sweden)
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12:35 - 14:15

LUNCH - LIVE SURGERY - LIVE INJECTIONS
Live broadcast from the Clinique du Parc Imperial

Moderators: Philippe BERROS (Chirurgien) (Monaco, Monaco), Arnaud MARTEL (doctor) (Nice, France), Fabrice SERRA (1501299138006 88) (ANTIBES, France)
12:35 - 14:15 Hyaluronic Acid Injections - TEOXANE. Cyrielle BELA (MD) (Keynote Speaker, Geneve, Switzerland)
12:35 - 14:15 Botulic Toxin and Hyaluronic Acid Injections - MERZ AESTHETIC. Frederic BRACCINI (Director) (Keynote Speaker, NICE, France), Eric SARFATI (Ophtalmologue) (Delegate, TOULON, France)
12:35 - 14:15 Aesthetic Rejuvenation - DELEO INNOVATION.
12:35 - 14:15 Live Surgery. Jacques LAGIER (local organiser ESOPRS 2022) (Keynote Speaker, NICE, France), Jean-Marc RUBAN (Senior Oculoplastic Surgeon) (Keynote Speaker, Lyon, France)
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A37
14:15 - 15:00

Orbital Tumor Session

Moderators: Mehdi FENDRI (MEDECIN CONSULTANT) (TUNIS, Tunisia), Mehrad HAMEDANI (Médecin chef) (LAUSANNE, Switzerland)
14:15 - 14:25 Lacrimal gland masses. 10 years experience in diagnosis and management. Ismail Gawdat TAMER (Congress Speaker, Egypt), Hesham KAMEL (Congress Speaker, Le Caire, Egypt)
(Cairo University, EGYPT)
14:25 - 14:35 Management of Orbital Cavernous Hemangioma. Abed CHARIF CHEFCHAOUNI (Medecin interne) (Congress Speaker, Rabat, Morocco)
Mohamed El Belhadji, Iatissam El Belhadji (Morrocco)
14:35 - 14:45 Low Pressure and Multimodality image guided Sclerotherapy for Vascular Orbital Lesions. Mehdi FENDRI (MEDECIN CONSULTANT) (Congress Speaker, TUNIS, Tunisia)
K. Hamza, H. Kamoun (Tunisia)
14:45 - 14:55 Orbital inflammatory disease: biopsy first or steroids first? Pierre-Vincent JACOMET (Deputy Head of Department) (Congress Speaker, Paris, France)
14:55 - 15:00 Discussion.
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A38
15:00 - 15:45

Eyelid Tumor Session

Moderators: Michele BEACONSFIELD (Consultant Surgeon) (LONDON, United Kingdom), Jean MAALOUF (resident) (Nancy, France)
15:00 - 15:10 Malignant eyelid tumors : Study Of 520 Cases. Amel SAIDANI (DIU 2015) (Congress Speaker, Alger, Algeria)
15:10 - 15:20 Management of concomitant full upper and lower eyelid defect. Eric SARFATI (Ophtalmologue) (Congress Speaker, TOULON, France)
15:20 - 15:30 Eyelid reconstruction: is the equation graft + graft = necrosis still true? Johanna V. BERGGREN (MD, PhD) (Congress Speaker, Lund, Sweden)
15:30 - 15:40 Multidisciplinary team management in ocular oncology: unexpected opportunities with the Covid-19 crisis. Sacha NAHON (Ophthalmologist) (Congress Speaker, Nice, France)
15:40 - 15:45 Discussion.
Room 1
15:45 COFFEE BREAK & EXHIBITION AREA - VISIT OF THE EPOSTERS
16:15

"Saturday 17 September"

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A39.1
16:15 - 17:15

European Oculoplasty: the past, the future

Moderators: Michele BEACONSFIELD (Consultant Surgeon) (LONDON, United Kingdom), Francesco QUARANTA-LEONI (Rome, Italy)
16:15 - 16:16 Current challenges in young oculoplastic surgeon formation in Europe: the YESOPRS point of view.
16:15 - 16:25 In France. Arnaud MARTEL (doctor) (Congress Speaker, Nice, France)
16:25 - 16:35 In Spain. Santiago ORTIZ-PEREZ (Head of the department) (Congress Speaker, Granada, Spain)
16:35 - 16:45 In Italy. Matteo DI MARINO (medical doctor, ophthalmologist) (Congress Speaker, Rome, Italy)
16:45 - 16:55 In Germany. Christina MILLER (Consultant) (Congress Speaker, Ulm, Germany)
16:55 - 17:05 The History of ESOPRS: Introduction. Francesco QUARANTA-LEONI (Congress Speaker, Rome, Italy)
17:05 - 17:15 History of the ESOPRS. Jean-Paul ADENIS (Congress Speaker, LIMOGES, France), Richard COLLIN (Oculoplastic Surgeon) (Congress Speaker, London, United Kingdom)
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17:15

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A39.2
17:15 - 18:00

ESOPRS AWARDS

Moderators: Michele BEACONSFIELD (Consultant Surgeon) (LONDON, United Kingdom), Francesco QUARANTA-LEONI (Rome, Italy)
17:15 - 17:30 The EBO-ESOPRS. Michele BEACONSFIELD (Consultant Surgeon) (Congress Speaker, LONDON, United Kingdom)
17:30 - 17:40 Peter Eustace medal Award to Dr M. Beaconsfield. Renata IVEKOVIC (prof) (Congress Speaker, Zagreb, Croatia)
President of the EBO
17:40 - 17:50 Presentation of the 2021 RICHARD COLLIN AWARD – Junior Award of ESOPRS: Developing a Radiological Activity Score for the diagnosis and surveillance of Graves’ Orbitopathy. Nicole GEORGE (Congress Speaker, United Kingdom)
What I did with the award price?
17:50 - 18:00 The RICHARD COLLIN AWARD – Junior Award of ESOPRS 2022. Eva DAFGARD KOPP (Associate Professor, Karolinska Institutet , Consultant Oculoplastic and Orbital Surgeon) (Congress Speaker, Stockholm, Sweden)
Room 1
18:00 CONGRESS ADJOURNMENT Room 1
00:00
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EP01
00:00 - 00:00

Eposters
01 -Aesthetic & Eyelid

00:00 - 00:00 #32125 - "Woody" plaques in the eye, a dangerous disease.
"Woody" plaques in the eye, a dangerous disease.

We present a case of Ligneous conjunctivitis due to inhered Congenital plasminogen deficiency. Debut as 2-3 years old with recurrent, bilateral pseudomembranes in the conjunctiva. Referred to us when she was 12 years old, with an interactable chronic conjunctivitis. 

The patient was born with congenital hydrocephalus, with multiple (>30) shunt revisions due to thrombosis in the shunts.  No other diseases. The father and mother were consanguine in several generations.

Histopathological biopsy confirmed ligneous conjunctivitis, systemic disease was suspected, and the patient was referred to systemic workup and genetic counseling and genetic investigation. The plaques are composed of fibrinogen, granulation tissue, and inflammatory cells.

One month after she was diagnosed with bladder thrombosis, and acute oliguric renal failure and sepsis. Multiorgan influence and cardiac obstructive shock due to thrombosis of the shunt and the heart valves. The patient was hospitalized for 11 months and was restored cardiovascular. The recurrent thrombosis in the bladder developed a chronic renal failure. Her cerebral shunt has been revised 8 times over the last year. Due to high pressure in the brain between all the shunt revisions her vision field have been affected creating an incomplete left sided homonym hemianopsia.

Currently the patient is treated with plasma infusion IV every 3 days (cryodeplated plasma). One month after the plasma infusions her conjunctiva normalized completely. The patient is now back at school and thrives apart form her renal impairment, where she is waiting for a renal transplant.   

Ligneous conjunctivitis is an important or though rare differential diagnosis in chronic conjunctivitis characterized by wood-like pseudomembranes developing on the ocular conjunctiva and can be associated to congenital plasminogen deficiency. In this case the eye symptoms led to the right diagnosis.


Marie Louise RASMUSSEN (Copenhagen, Denmark), Anne Kathrine WIENCKE, Peter Kristian RASMUSSEN
00:00 - 00:00 #32179 - 'Slow Mohs' surgery for periocular non-melanomatous skin cancer: 5 year follow-up data on recurrence, histology, functional outcome and patient satisfaction.
'Slow Mohs' surgery for periocular non-melanomatous skin cancer: 5 year follow-up data on recurrence, histology, functional outcome and patient satisfaction.

‘Slow Mohs’ surgery offers an alternative to traditional Mohs surgery for the treatment of periocular non-melanomatous skin cancer (PO-NMSC) facilitating en-face evaluation of the entire peripheral tumour margin without the need for dedicated Mohs equipment and expertise. It avoids freeze artefact and unpredictable operating time. 

 

This single-centre evaluation of Slow Mohs surgery to treat PO-NMSC assesses long-term (>5 years) rates of recurrence, functional outcomes and patient satisfaction. 92 patients underwent Slow Mohs for PO-NMSC prior to 2016 and were invited for long-term follow-up. In total, 45 had follow-up >5 years with long-term functional outcomes and satisfaction evaluated in 38.

 

40/45 cases were for BCC, 4 for SCC and 1 for basosquamous carcinoma. Nodular BCC was the most common growth pattern, followed by superficial and infiltrative BCC. 2/45 patients (4.4%) had recurrence of PO-NMSC within 5 years. An additional 2/45 (4.4%) had recurrence more than 5 years after surgery (73 and 101 months). All recurrences had an initial histological diagnosis of superficial BCC with 3/4 also demonstrating nodular growth patterns. In cases that recurred, the median minimum peripheral margin at closure was 2mm (range 0.5-3mm). All had clear margins at closure. This compares with a median minimum peripheral margin of 1.6mm (range 0-2.2mm) in cases without recurrence.

 

When assessed more than 5 years post-surgery, the rates of lagophthalmos, ectropion and ocular surface symptoms were 10%, 22.5% and 20%, respectively. Satisfaction regarding surgical experience, eyelid function and cosmesis was reported as good or excellent in 97.2%, 91.7% and 94.4%, respectively.

Slow Mohs surgery for PO-NMSC is a well-tolerated procedure with an acceptable 5-year recurrence rate making it a non-inferior option for oculoplastic services without access to Mohs surgery. Superficial growth patterns may confer an increased risk of recurrence.


Thomas Rp TAYLOR (Portsmouth, UK, United Kingdom), Christopher B SCHULZ, Simon ROGERS, Sarith MAKULOLUWE
00:00 - 00:00 #32146 - 3 x 5 cm palpebral neurofibroma and our surgical approach: a case report.
3 x 5 cm palpebral neurofibroma and our surgical approach: a case report.

Introduction

Type I neurofibromatosis involves development of neurofibromas with cafe au lait macules. Neurofibromas of the orbit and palpebra are relatively uncommon. Surgical resection is the treatment of choice however is a complex procedure. Here we present our surgical approach to a 27 year old male presenting with 3 x 5 cm superior palpebral neurofibroma. 

 

Case Illustration 

A 27 year old male presents with a right superior palpebral mass from 5 years ago. The mass was painless, lobulated and soft on palpation with indistinct borders and recurring. The mass was suspected to be neurofibroma which was later confirmed by histopathology. A 3 x 5 cm hyper -vascularized and lobulated mass was undermined under the orbicularis muscle, and the lateral periorbita was freed to debulk tumor as much as possible. Debulking was also done in the inferior palpebra. Palpebral reconstruction involved inferior palpebral lateral tarsal strip and direct closure of the superior palpebra, with the palpebral margin slightly everted.

Discussion

Tumor removal by surgical resection was done in this case, along with direct closure as it involved small margin defects with lateral cantholysis. Through the signs obtained from our patient and difficulties faced during surgical procedure, it is more likely that the patient had Plexiform type neurofibroma. 

Conclusion 

Orbital/palpebral neurofibroma is uncommon. Tumor removal remains the main treatment choice. Mass debulking was done to our patient, as complete removal was not favorable. Direct closure was then done to reconstruct palpebra. 


Josiah IRMA, Erna KRISTIANTI, Cheryll YUDAKUSUMA, Saraswati Anindita RIZKI, Patricia BUDIMULIA (Jakarta, Indonesia), Celine CHRYSTELLE, Regan ELBERT
00:00 - 00:00 #32394 - 5-year survival outcomes for Ocular Surface Squamous Neoplasia in specialist ocular oncology Center in a Temperate Climate.
5-year survival outcomes for Ocular Surface Squamous Neoplasia in specialist ocular oncology Center in a Temperate Climate.

ObjectiveThere is an established association between human immunodeficiency virus (HIV), sunlight exposure and development of OSSN, which reflects geographic variation in incidence – high as 35 cases/ million/ year in tropical environments with poor access to antiretroviral therapy. However, clinical outcomes following treatment remain less established due to loss of follow-up, thereby difficulties in assessing the effectiveness of treatment. We aimed to evaluate epidemiological risk factors and survival outcomes in patients with ocular surface squamous neoplasia in temperate climates.

 

MethodsRetrospective chart review for patients seen in a specialist oncology service between 2005 and 2017, with the review of patient demographics, co-morbidity, histology and outcomes after treatment.

 

ResultsSeventy-eight patients (46 males; 59%) presented at a mean age of 62 (median 64, range 3-92 years). Seventy-Seven (88%) patients had unilateral disease, whereas 11 had bilateral involvement. Predominant histological findings conjunctival squamous cell carcinoma (SCC in situ) and Conjunctival intraepithelial neoplasia (CIN) grade 3 was the most predominant presentation, 48% and 28%, respectively.

Overall 12, month and 5-year survival were found to be 96% and 79%. Disease recurrence was found in 63 (72%) patients, of which 27 were found to have progression of the disease, with progression-free survival found to be 91% and 67% at 12 and 60 months. None of the CIN 1 patients was found to have progression in the five years, whereas CIN 3 had the highest rate, 11% in 1 year and 34% in 5 years. Nine patients required exenteration for invasive SCC during the study period.

Concurrent inflammatory ocular surface disease, immunodeficiency and significant sun exposure were noted in 13% (11/88), 19% (17/88) and 26% (23/88), respectively, associated with a higher risk of recurrence, whereas the former, was found to be associated with a higher risk of progression (p=0.03)

ConclusionOcular Surface Squamous Neoplasia is a spectrum of ocular surface tumours that offers favourable outcomes with the current management regime, with 26% of patients progressing to require orbital exenteration for locally advanced disease. In the UK, ocular surface disease appears to be a risk factor for disease progression; however, other factors such as HPV remain to be examined.


Mohsan MALIK (London, United Kingdom), Periklis GIANNAKIS, Safa AYKAC, Jeannon JEAN-PIERRE, Claire DANIEL
00:00 - 00:00 #32453 - A case of combined periocular merkel cell carcinoma and eyelid basal cell carcinoma.
A case of combined periocular merkel cell carcinoma and eyelid basal cell carcinoma.

Purpose: To describe the case of a patient diagnosed simultaneously with periocular Merkel cell carcinoma (MCC) and eyelid basal cell carcinoma (BCC).

Material and Methods: Medical records of a patient with periocular MCC and eyelid BCC were reviewed. 

Results: A 66-year-old caucasian female with a history of frequent, unprotected solar exposition and a slowly growing eyelid lesion was referred for ophthalmic evaluation. Eyelid and periocular examination revealed a pink-coloured, pearly-edge, ulcerated skin lesion occupying most of the left inferior eyelid margin, suggestive of BCC. An additional small, ‘‘violaceous’’ cutaneous lesion was present near the left lateral cantus, with vascularization and superficial ulceration. Surgical excision of both lesions was proposed, but the patient declined surgery. Two months later, the patient returned to the Ophthalmology department because of rapid growing of the periocular lesion. Tarsoconjunctival flap advancement and superior eyelid skin graft were undertaken following the excision of the eyelid margin lesion. The periocular lesion was removed by simple excision with wide margins and undermining for adequate wound closure. Histopathological analysis was compatible with nodular type BCC for the eyelid margin lesion and MCC for the lateral cantus lesion. Both biopsy specimens showed negative margins. The patient maintained regular follow-up visits and was referred to the oncology department for systemic evaluation and decision on further treatments.

Conclusion: This is a rare case of a patient presenting with both eyelid BCC and periocular MCC, possibly explained by older age and history of ultra-violate radiation exposure. BCC is a common malignancy of the eyelid, with a relatively good prognosis when adequately treated. Conversely, MCC is a rare, highly aggressive skin malignancy whose prognosis is often poor given the potential for recurrence, lymph node metastasis, and distant dissemination. Prompt and aggressive treatment with ongoing clinical surveillance are needed for MCC management.


Catarina FERREIRA (Vila Nova de Gaia, Portugal, Portugal), David JOÃO, Agostinho SANCHES, Renata ROTHWELL, Sandra PRAZERES
00:00 - 00:00 #32338 - A case of dupilumab associated conjunctivitis and the importance of specialist ophthalmology involvement.
A case of dupilumab associated conjunctivitis and the importance of specialist ophthalmology involvement.

Dupilumab is the first biologic drug licensed for the treatment of moderate to severe atopic dermatitis (AD). It works on Interleukin (IL)-4 receptors, disrupting the IL-4, IL-13 pathway. It is used widely in the UK, Europe and the US and has shown high efficacy in difficult to manage AD. The use of dupilumab is becoming more prevalent and has recently been approved for the treatment asthma. It’s role in the management of other allergic conditions is also being researched.

 

This poster presents the case of a 22-year-old with long-standing and severe AD. Shortly after commencing a course of dupilumab, he presented to our service suffering from conjunctivitis with right lower lid cicatricial ectropion. He had associated reduction in visual acuity. This is a known complication of treatment with dupilumab, and severity of ocular surface disease can vary from mild and self-limiting in most cases to severe, with cicatrisation, madarosis and reduction in visual acuity. 

 

The development of severe conjunctivitis is often difficult to manage and places significant burden on patients. It is therefore important to raise awareness of this association. Firstly, to encourage screening and identification of those at greater risk for development of ocular surface disease and secondly, to promote adequate counselling of patients commencing treatment with dupilumab. We suggest a closer liaison with ophthalmology services prior to starting therapy in those at high risk and in those who are symptomatic. 


Mark AWAD (Southampton, United Kingdom), Elizabeth JAMES, John AWAD
00:00 - 00:00 #32505 - A case of extensive linear basal cell carcinoma (BCC) with secondary cicatricial ectropion.
A case of extensive linear basal cell carcinoma (BCC) with secondary cicatricial ectropion.

Introduction

Linear BCC is a very rare variant, in part due to misdiagnosis and under-recognition of its morphological phenotype. This can lead to substantial delay in treatment and hence progression of the primary lesion. Here we illustrate the features of Linear BCC with an extensive archetypal clinical case with photos. 

Case

A 96 year old woman with a background of previous breast cancer and no other ocular or facial surgery presented to a specialist oculoplastic clinic in the UK, having been referred by the optician who noted a scab-like lesion under the right lower lid. The patient stated that the lesion had been present and increasingly painful for over two years; the general practitioner had dismissed it and given topical ointment.

Examination revealed a long, curvilinear, telangiectatic pearlescent lesion, 2-3mm wide and 40mm in length, extending from the right lateral canthus downwards and curving medially towards the nasal bridge along the intraocular relaxed skin tension lines (RSTLs). She had total loss of lower lid skin laxity with overt cicatricial ectropion. By contrast the fellow eye (Left)showed pronounced skin laxity and ballooned anterior fat prolapse under the lower lid. Biopsies of the lesion have been arranged and she has been listed for cryoablation. 

Discussion

This patient is the oldest documented case of Linear BCC. The size of the lesion is also remarkable, and likely to be one of the largest documented due to the delay in diagnosis. Like other documented cases, this linear lesion also appears to track along RSTLs as the path of least resistance. As illustrated by this case, linear BCCs are often misdiagnosed as scabs or scars, with significant secondary complications such as cicatricial ectropion from retraction of the surrounding tissue. Therefore it is an important phenomenon to recognise in an oculoplastic clinic.


Lizzie ROSEN (Bristol, United Kingdom), Harry ROSEN, Annette BACON
00:00 - 00:00 #31984 - A comparison of the clinical outcomes of anterior levator resection, simple levator plication, and modified deep levator plication for the treatment of congenital ptosis based on five years of experience.
A comparison of the clinical outcomes of anterior levator resection, simple levator plication, and modified deep levator plication for the treatment of congenital ptosis based on five years of experience.

Purpose

To compare the outcomes of levator resection and simple and deep levator plication techniques for correcting congenital ptosis.

Methods

In this prospective, comparative, and interventional case series, 45 lids were divided into three groups. The study included 45 patients older than five years with mild to moderate congenital ptosis and good to fair levator function. Levator resection was performed in group I, simple levator plication in group II, and modified deep levator plication in group III. The final assessment was conducted six months postoperatively. A successful outcome was defined as a marginal reflex distance 1 (MRD1) between 3 and 5 mm, an interlid MRD1 difference of less than 1 mm, and a symmetrical lid contour.

Results 

For group I, the mean improvement of MRD1 was  2.56±0.24 mm, and the success rate was 93.3%. One patient experienced overcorrection immediately after the surgery (Figure 1). One patient had conjunctival prolapse (Figure 2). Only one case (6.7%) of early minimal undercorrection was accepted by the patient with no more progression. For group II, the mean improvement was 1.10±0.11 mm, and the success rate was 53.3%. Three patients were scheduled for reoperation due to recurrence, with a failure rate of 20%. For group III, the mean improvement was 1.37±0.14 mm, and the success rate was 73.3%. One lid was scheduled for reoperation because of recurrence (failure rate, 6.7%) (Table1).

 Conclusion

Levator resection is the most effective and stable option for correcting congenital ptosis. Simple levator plication is not recommended for correction of congenital ptosis because it has the highest failure rate. Recurrence, the main drawback of levator plication, can be reduced using the deep plication technique.


Hossameldeen Elsayed Awad ELBARBARY (Alexandria, Egypt, Egypt)
00:00 - 00:00 #31975 - A Long Cut: Emergency and long-term management of a severe and complex traumatic ocular injury involving a long vertical eyelid wound and a penetrating corneo-scleral laceration.
A Long Cut: Emergency and long-term management of a severe and complex traumatic ocular injury involving a long vertical eyelid wound and a penetrating corneo-scleral laceration.

A 41-year-old Chinese man sustained a left-sided penetrating ocular injury from an angle-grinder resulting in a corneo-scleral laceration and an extensive vertical upper and lower eyelid defect. Left visual acuity (VA) was light perception, right eye VA 6/5 (Snellen). Computerised tomography showed a deformed globe, no intra-ocular/-orbital foreign-bodies and a stable orbital floor fracture. Exploration and primary repair under general anaesthesia revealed a V-shaped, full-thickness corneal defect, which extended inferiorly to transect the inferior-rectus. Total anterior iris loss and an intact lens were noted. The corneal, then scleral laceration were closed first and followed by inferior rectus repair. The vertical eyelid wound measured 15cm; sub-brow to the nasolabial fold. There was <25% eyelid tissue loss and direct closure in layers was achieved methodically. Limited skin Z-plasty and deep fornix sutures were performed to minimise scarring and cicatrisation. Horizontal lid tightening was not undertaken to minimise pressure on the globe. Post-operative regime included antibiotics (moxifloxacin orally and guttae) and topical steroid (dexamethasone 0.1% guttae) application to the left eye and eyelid wounds (dexamethasone 0.1%/neomycin ointment three times daily (t.d.s.)).

Post-operatively, the globe was comfortable and sealed. VA was counting fingers and intraocular pressure 14. Corneal oedema limited fundal view but ultrasound B-scanning showed a flat retina. Four weeks post-operatively, eyelid wound contraction ensued, with 1mm lagophthalmos. This resolved with high concentration steroid (hydrocortisone 0.1% t.d.s. cream) application and wound massage for six months. 16 months post-operatively, the globe was well-formed with no appreciable volume loss. Corneal scarring and a white cataract were evident. Optical coherence tomography showed good corneal alignment and intact zonules. Following phacoemulsification surgery with intra-capsular lens implantation, VA improved to 6/60 (Snellen).

Traumatic ocular injuries are common and variable, and can significantly impact physical functionality and mental health. It is imperative to adapt the primary repair to the presenting injury, while prioritising the globe for best overall outcomes. Despite a severe and complex ocular injury, this patient achieved stable globe integrity with visual potential, and recovered excellent eyelid functional and cosmesis, which he reported was fundamental in regaining confidence. 


Li Yen GOH (London, United Kingdom), Tahir FAROOQ
00:00 - 00:00 #32393 - A novel multi-modal approach to managing severe paralytic ectropion with periocular lymphoedema secondary to infiltrative squamous cell carcinoma.
A novel multi-modal approach to managing severe paralytic ectropion with periocular lymphoedema secondary to infiltrative squamous cell carcinoma.

Introduction

 

A 74 year old male developed gross unilateral periocular lymphoedema and grade V facial nerve palsy secondary to infiltrative squamous cell carcinoma. We describe management with cemiplimab immunotherapy, Endolift® (EUFOTON S.R.L. Italy) laser and extensive lower eyelid surgery. This challenging problem and management approach adopted has not been previously reported.

 

Methods

 

Patient initially presented with unilateral painful, erythematous periocular swelling 1 month prior to developing a grade V facial nerve palsy. He had loss of infraorbital nerve sensation with cheek and temple skin induration and ulceration. MRI revealed sphenoid, temporal fossa and infraorbital malignant subcutaneous lesions with periorbital inflammation. Histology confirmed moderately differentiated squamous cell carcinoma with perineural invasion. He was given a very guarded prognosis and commenced cemiplimab palliative immunotherapy. This treatment yielded an excellent response. Quality of life was limited by severe left ocular pain due to gross lower lid paralytic and mechanical ectropion. Endolift® laser reduced gross lymphoedema significantly with sustained improvement. Subsequent lower lid surgery with retractor recession, donor fascia lata sling with drill hole fixation, subcutaneous debulking of all involved tissues of lower lid and upper cheek down to periosteum and Tisseel glue dermadesis was performed. Patient is delighted with improvement thus far and reports complete pain resolution.

 

Discussion

 

A multi-modal approach in managing this complex condition was crucial in addressing multiple issues affecting patient’s quality of life. Cemiplimab is a human immunoglobulin G4 monoclonal antibody, which potentiates an immune response to squamous carcinoma cells. Endolift® is a minimally invasive 1470 nm laser that remodels both deep and superficial layers of the skin by stimulating neocollagenesis and lipolysis. Extensive lower lid surgery as described above improved lid malposition and ocular surface protection and relieved his severe ocular pain. Through this novel multi-modal approach, the patient has achieved a very satisfactory outcome.


Michael Yoon Tze LAI (Leicester, United Kingdom), Sabrina SHAH-DESAI, Sajid ATAULLAH
00:00 - 00:00 #30741 - A theory of unified pathogenesis for tarsal ectropion and involutional entropion.
A theory of unified pathogenesis for tarsal ectropion and involutional entropion.

Introduction

Tarsal ectropion and involutional entropion are two frequent age-related lower eyelid malpositions characterized by their "mirrored" clinical presentation, respectively external rotation and internal rotation of the lid margin.

Several pathogenic factors have been recognized in both conditions: involutional weakness of lower lid retractors responsible for tarsal instability, tarso-tendinous laxity, and specifically for entropion the ascent of the preseptal orbicularis, and even some degree of enophthalmos. However, no study links these two malpositions pathologically nor describes an overarching mechanism by which the lower eyelid would rotate in one direction or another. 

Material and Method

A recent anatomical description of retractors confirms the existence of two layers, anterior and posterior, and their close relationship with the anterior and posterior palpebral lamellae. This description has focused our attention on the function of retractors in lamellar stability ensuring the normal position of the lower eyelid. Moreover, the clinical study of these malpositions, the surgical interventions on the retractors, the postoperative results and the data in the literature lead us to suggest a greater role of the retractors in these malpositions.

This study excludes the involutional hypotonic ectropion, where tarso-tendinous hyperlaxity is predominant.     

Results

This study describes two new clinico-anatomical entities and proposes a unified pathogenesis placing the retractors at the origin of the mechanism leading to tarsal ectropion or involutional entropion


Philippe IMBERT (TOULOUSE)
00:00 - 00:00 #32433 - A variety of flap techniques for upper eyelid reconstruction after surgical resection of eyelid tumors.
A variety of flap techniques for upper eyelid reconstruction after surgical resection of eyelid tumors.

 

 Reconstruction of the upper eyelid is one of the greatest challenges facing the orbitofacial surgeon.

we are presenting 5 cases with a different techniques for upper eyelid reconstruction after tumor excision :

  1st case: the inverted semicircular flap for reconstruction of upper lateral 1/3 of the eyelid after basal cell carcinoma excision 

2nd  case:   the Cutler-Beard bridge flap from the lower eyelid,two stage procedure flap for recontruction of 90 % of upper eyelid after Merckel Cell Carcinoma excision

3d case : Revisited FRICKE flap, the flap donor site is situated immediatly superior to the brow cilia, one stage procedure, with contralateral tarsal graft for total superior upper eyelid reconstruction after sebaceous cell carcinoma excision

4th case : ABBE MUSTARDE lower transposition eyelid flap for 2/3 upper eyelid reconstruction, two stage procedure flap after sebaceous cell carcinoma excision

5th case : Glabellar flap for upper 1/3 medial reconstruction after Basal Cell Carcinoma excision 

 

the determination of which lamella of the eyelid is involved in the defect is a crucial part of the evaluation.

Since the anterior and posterior lamellae contain different tissues, the surgeon should consider a different graft or flap for each portion.

any tissue that replaces the posterior lamella must have a stable lid margin, closely approximate the cornea and globe, but does not abrade the cornea by hair follicules or epethelium.

the survival of the flap depends on its design, with the flap length as measured from the medal end of the defect to the base or rotation point of the flap. The length: width ratio of the flap must not exceed of 4:1 


Edgard FARAH (PARIS)
00:00 - 00:00 #30728 - Adopting the CADS scoring system; perspectives of a new user.
Adopting the CADS scoring system; perspectives of a new user.

AIM: Several grading instruments exist for assessing the severity of facial nerve palsy, with associated prognostic indications, including House-Brackmann, Yanagihara, and Sunnybrook gradings. However, these have been criticised for inadequately assessing the periocular region, and the associated consequences on ocular function. These instruments are unable to identify all patients at risk of, or experiencing, ocular complications. Similarly, they cannot adequately track changes over time, particularly important after interventions. The CADS score was developed to address these shortfalls and provide a periocular-specific, comprehensive, objective assessment. Despite previous oculoplastic experience, enough to feel I could identify which patients with a facial nerve palsy required surgical intervention, I previously relied on subjective descriptions to communicate the clinical situation with colleagues and determine the most appropriate intervention for them. CADS may appear onerous to incorporate into daily practice. This study highlights the learning curve for an experienced fellow in oculoplastics beginning to use the CADS score in daily practice.

METHODS: A retrospective study highlighting my experience and learning curve in using the CADS score. Aspects of usefulness and weakness, difficulties in using the score in a busy practice are outlined.

RESULTS: Approximately 70 patients examined over 6 months. Use of the CADS score necessitated routine evaluation of all relevant parameters every consultation, rather than focusing specifically on patient concerns or overt pathology. I developed an appreciation for the impact of lid-to-brow-margin distance, blink lagophthalmos, brow movement and evidence of synkinesis, which now form conscious parts of my assessments. My evaluations became more objective and repeatable, particularly for corneal disease, which is notoriously subjective. I recognised that patients with high C scores required the most urgent intervention though those with high scores elsewhere likely have high disease burden too. CADS enabled me to develop consistent decision-making, addressing each scoring parameter for a comprehensive intervention. 


Samantha HUNT (East Grinstead, United Kingdom), Raman MALHOTRA
00:00 - 00:00 #32251 - An insidious infection that creates a mass effect in the nasojugal groove.
An insidious infection that creates a mass effect in the nasojugal groove.

Purpose: To present a case with skin and soft tissue involvement in the periorbital region and isolated staphylococcus lugdunensis.Case presentation: A 44-year-old female patient was admitted to our clinic with complaints of swelling under the eyes and narrowing of the visual field in downward gaze, which had been present for 6 months. It was learned from the patient's history that she was examined in another center in the hematology and oncology department for the preliminary diagnoses of idiopathic thrombocytopenic purpura, iron deficiency anemia and lymphoma. In her ophthalmological examination, her vision was bilaterally 20/20, anterior segment, intraocular pressure and fundus examinations were normal. In the external examination, it was observed that there was swelling matching the tear trough area and xanthelasma on it (Figure 1A). MRI radiographs showed hypodense lesions on T1-weighted images and hyperdense lesions on T2-weighted images in the nasojugal groove and premaxillary area (Figure 2). During excisional biopsy performed bilaterally from xanthelasma and subcutaneous tissues in this region, it was observed that there was a collection of white colored, creamy fluid (Figure 1C,D). Pathological examination of the removed skin and subcutaneous tissues revealed xanthelasma and fibrolipomatous tissues. Staphylococcus lugdunensis was grown in culture as a result of microbiological examination of the fluid. Antibiotic therapy was administered to the patient for 10 days, as she was sensitive to amoxicillin-clavulanic acid in the culture antibiogram. There was no re-collection of fluid in the patient's controls (Figure 1B).Conclusion: Staphylococcus lugdunensis is a coagulase negative, Gr (+) bacterium that is most commonly present in the normal skin flora between the axilla, groin and toe. It has been reported to cause skin and soft tissue inflammation, osteomyelitis, septic arthritis, prosthetic joint infections, endocarditis, and endophthalmitis infections. This is a rare case in which this infection was detected in the periocular region.   


Gamze OZTURK KARABULUT, Zehra KARAAGAC, Korhan FAZIL, Kubra SEREFOGLU CABUK (istanbul, Turkey), Senay ASIK NACAROGLU
00:00 - 00:00 #32424 - Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide.
Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide.

Background Currently, botulinum toxin (BoNT) injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face. The therapeutic use of botulinum toxin has generally been safe and well tolerated. Adverse effects are considered mild, transient, and self-limited. However, as with all other injectable procedures, this one is also susceptible to adverse events and complications. When the safety zones are respected, the chance of any of these complications is practically null. Thus, this review aims to describe the main complications of treatment with BoNT on the upper face and to present a practical guide based on current evidence on how to avoid them. Methods The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. Results The main complications secondary to BoNT injections on the upper face are: ptosis of eyelid or eyebrow, eyebrow asymmetry, diplopia, Lagophthalmos, ectropion, and prominence of the palpebral bags. To avoid such complications, it is necessary to have knowledge of the anatomy of this region and adequate and individualized planning based on the existing patterns of the frontalis muscle, glabella, and crow’s feet. This review presents the specificities of each of these regions and practical suggestions to obtain satisfactory results, avoiding complications. Conclusion Particularly on the upper face treatment with BoNT offers predictable results, has few adverse effects, and is associated with high patient satisfaction. However, it is suggested that the commented parameters and safety areas be incorporated into daily practice so that the possibilities of complications are minimized as much as possible. 


André Luis BORBA DA SILVA (SAO PAULO, Portugal)
00:00 - 00:00 #32203 - Awareness of Periocular Sun Exposure Risk in Patients Attending the Adnexal Clinic.
Awareness of Periocular Sun Exposure Risk in Patients Attending the Adnexal Clinic.

Purpose

The incidence of skin cancer in the UK is set to soar, with between 5-10% of all types of skin cancer occurring in the eyelid: an area commonly missed when adopting sun-protection measures. We investigated awareness of sun exposure to the periocular area for patients attending the Adnexal clinic.

Methods

Patients over 16 years presenting to the Adnexal clinic at Moorfields Eye Hospital were invited to complete a survey consisting of 29 multiple choice questions assessing 1) Patient demographics, 2) Risk factors for skin cancer, 3) Subjective awareness of skin cancer, 4) Objective awareness of skin cancer, 5) Level of advice received.

Results

50 patients (18 male, 32 female) responded. Only 34% (n=17) patients were aware that sun exposure can cause cancer on the eyelid. Patients 2 years of higher education showing more consistent sunscreen use and greater ability to list the consequences of unprotected sun exposure.

Only 24% of respondents (n=12) applied sunscreen around the periocular area, compared to 74% (n=37) who applied it to the cheeks. Only 6 individuals received sun protection advice from their ophthalmologist, 3 of them being lid oncology patients. Those who were aware of the risk to the eyelids were more likely to have been given advice from their ophthalmologist (P < 0.05) and were more likely to apply sunscreen to the periocular area (P < 0.001).

Conclusions

Our study shows patients attending the adnexal clinic at Moorfields Eye Hospital are not sufficiently aware of periocular sun exposure risks; demonstrating the need for improved patient education in this area. Studies with a larger number of participants are warranted to explore this further.


Sara MEMON (London, United Kingdom), Maria MAS CASTELLS, Swan KANG
00:00 - 00:00 #32274 - Bilateral upper and lower eyelid conjunctival extranodal marginal zone lymphoma.
Bilateral upper and lower eyelid conjunctival extranodal marginal zone lymphoma.

Lymphoma is a malignant lymphoproliferative tumor that can involve the conjunctiva. Ocular adnexal lymphoma (OAL) represents 5% to 15% of all extranodal non-Hodgkin lymphomas and 55% of all orbital malignancies. Extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT) is the most common tumor diagnosed in these organs (80%). One third of OALs primarily arise in the conjunctiva and usually presents a unilateral salmon-colored patch and patients discomfort. Bilateral as well as upper and lower tarsal conjunctiva involvement, as we presented in this case, is an extremely rare disease.

Patient 77-year-old woman refered with a lesion in the lower tarsal conjunctiva of the right eye (RE) of several months of evolution. Ophthalmologic examination showed a salmon patch lesion that extended into the lower and upper tarsal conjunctiva of the RE. A lesion with the same characteristics was found in the lower and upper tarsal conjunctiva of the left eye. Incisional biopsy of the lower conjunctiva of the RE was performed showing a EMZL. She was referred to the hematology-oncology service. Chest and abdomen CT showed no extension of the disease to other organs and in the cerebral MRI no invasion of the eyeball or brain was found. Treatment was started with intravenous Rituximab, after six months a clinical complete response was observed.

Orbital involvement and primary bilateral conjunctival lymphoma is not frequent. The gold standard of treatment for isolated conjunctival lymphoma is radiotherapy but systemic treatment is preferred in cases of bilateral OAL. While most conjunctival lymphomas are localized to the ocular adnexa at the time of presentation, the 31% of conjunctival lymphomas have systemic involvement so systemic examination and management are of key importance in the long-term care of the patient.


Julia PEREZ-MARTINEZ (Valencia, Spain), Amparo LANUZA-GARCIA, Sergio MAUGARD TEPPER, Javier GARULO NICOLÁS, Gemma ORTEGA PRADES, Raul MARTINEZ-BELDA, Antonio DUCH SAMPER
00:00 - 00:00 #31634 - Bioinformatics analyses of miR-424/503 in the pathogenesis of basal cell carcinoma.
Bioinformatics analyses of miR-424/503 in the pathogenesis of basal cell carcinoma.

Objective: MicroRNAs (miRNAs) exert vital functions in the occurrence and development of various tumors.

Aim: The aim of this study is to reveal the molecular mechanism of miRNA in the pathogenesis of basal cell carcinoma (BCC) by bioinformatics analyses.

Methods: The microarray data of BCC were downloaded from the Gene Expression Omnibus (GEO) database to screen differentially expressed miRNA. Based on the differentially expressed miRNAs, we predicted the target gene and transcription factors (TFs) by using Targetscan, miRanda, and mirSVR. Then we performed functional enrichment analysis to analyze the functions of target genes. In addition, we used String and Cytoscape to analyze the interaction of its targeted regulatory proteins and screened its core regulatory genes

Results: The miRNA expression profiles in BCC tumor tissues were significantly different from those in adjacent tissues, among which miRNA gene clusters (miR-424, miR-542-5p, miR-503) were highly expressed in BCC tumor tissues. A total of 1349 miR-424 targeted regulatory genes and 380 miR-503 targeted regulatory genes were obtained from the analysis, and 312 overlapping genes were further analyzed. The function of miR-424 was mainly enriched in the MAPK, mTOR, and Hippo pathway, and CDC42, CCND1, VEGFA, and PIK3R1 were the core factors of targeted regulatory genes of miR-424. The function of miR-503 was mainly enriched in the MAPK, PI3K-Akt, Hippo, and Rap1 pathways, and CCND1VEGFAPIK3R1 were the core factors of targeted regulatory genes of miR-503.

Conclusions: The expression of miR-424, miR-542-5p, and miR-503 clusters were significantly different in BCC. The target gene of CCND1, VEGFA, and PIK3R1 may play important roles in the development of BCC, serving as a potential therapeutic target.


Xiaoyi HOU (Chengdu, China)
00:00 - 00:00 #32205 - Botulinum Treatment patterns in Spasmodic Entropion.
Botulinum Treatment patterns in Spasmodic Entropion.

Introduction

While surgical procedure has been considered as the golden standard treatment of spasmodic entropion, Botulinum Neurotoxin A is indicated for fragile elderly patients. 

Current literature, however, is week about this subject, and many practitioners administered BT with irregular dosage and variable location of injection

 

The intent of the present study was to describe an alternative outdoor treatment, to precise the Botulinum Neurotoxin (BT) treatment pattern, the superiority of one of the three main botulinum toxin A, the dosage of BT needed, the frequency of re-injection, the efficiency and the complications encountered. 

 

Methods:  
A study from 2002 to 2020, including 50 outdoor patients treated for spasmodic entropion, for whom palpebral surgery was recused. 

 

Results:   

We have treated 50 patients, 87.9 years old in average (± 14,3). 

The average total dosage of BT is 7,62 ± 1,38 units of Incobotulinum, 10,2 ± 1,03 units of Onabotulinum and 17,2 ± 1,33 Speywood-units of abobobotilinum

Spasmodic entropion resolved in 3 days ± 2 after the BT injection. 

The average of re-injection is every 4.25 months ± 1.30. 

By adjusting age and total dose, we have not been able to show any statistically significant relationship between time needed for re-injection and type of botulinum toxin A (p = 0.46). 

 

Discussion :

Surgical treatment of senile entropion is more reliable and persistent and must remain the golden standard treatment. 

However, botulinum toxin A has the advantage to be easy to use and it’s a very secured process, which can be given at the initial consultation and may have a role to play for patients where there is a long waiting list for surgery, or in those unable or unwilling to have an operation, and in the few cases where temporary relief of the spasmodic entropion is needed. 

 

Conclusion 

Patients with spasmodic entropion responded significantly to Botulinum treatment. No systemic complications had been reported in this study. BT injection is safe and effective for fragile elderly patients with spasmodic entropion and can be proposed instead of surgery or while waiting for their procedure. 


Rayan MEKOUI (Paris), Bahram BODAGHI, Frédéric TANKERE, Brigitte GIRARD
00:00 - 00:00 #32283 - Caruncle lesions: demographics, clinical presentation and histopathology.
Caruncle lesions: demographics, clinical presentation and histopathology.

Purpose

 

Caruncular lesions are rare making their diagnosis more challenging. We present the demographics, clinical presentation and histology of patients presenting to our service. 

 

Methods 

 

This is a retrospective case note review of all patients presenting to our tertiary referral service with a caruncular lesion between December 2016 and February 2022. All patients were identified through the histopathology electronic database. Patient records were reviewed. Patient demographics, clinical presentation and histological diagnosis were documented. 

 

Results 

 

In total 30 patients with a caruncle lesion were identified, of which 57% were females. Mean age was 64 years (range 18-87 years). All patients underwent an excision biopsy with no intraoperative complications. Post-operatively one patient had a mild restrictive motility defect on abduction due to a symblepharon/scar that occurred in the early months after surgery. The majority of lesions were benign with the most common pathology in our cohort identified as pigmented naevi ( 23%) and oxyphilic adenomas (23%). Malignancy was confirmed in 7 lesions (12%) to include melanomas and lymphomas. 

 

Conclusion 

 

Lesions of the caruncle are uncommon and mostly benign. However due to the diverse components of the caruncle including hair follicles, sebaceous glands and sweat glands, diagnosis can be difficult on clinical examination alone. Excision with histopathological confirmation of the lesion is recommended to ascertain the diagnosis and to make an adequate management plan.


Awad MARY (Leicester, United Kingdom), Christina LIM, Hardeep Singh MUDHAR, Joyce BURNS, Raghavan SAMPATH, Antonella BERRY-BRINCAT
00:00 - 00:00 #32029 - CO2 laser use for an oculoplastic surgeon.
CO2 laser use for an oculoplastic surgeon.

CO2 laser is a wide known technology used in plastic surgery for both surgical and non surgical procedures, with the advantage of its versatility to treat many lesions.

In ophthalmology its applications is mostly known as cutting tool in blepharoplasty, decreasing the surgical time and improving the postoperative period, but this use can be extended to any kind of surgery. On the other hand, many skin problems, such as xantelasmas, syringomas, nevus, among many others, can be also addressed with Co2 laser, in a minimal invasive way.

Learn about the laser, its application, its indications, as well as the management of the pre and post intervention treatment is crucial to obtain all the benefits from it and to avoid complications or bad outcomes.

The aim of this talk is to show the versatility of the CO2 laser by showing some of the conditions that can be treated in an oculoplastics practice.


Luz María VÁSQUEZ, María Inmaculada PAÑOS (Barcelona, Spain), Claudia CORDERO LÓPEZ, Ramon MEDEL
00:00 - 00:00 #31989 - Complications of lower eyelid blepharoplasty: prevention and management.
Complications of lower eyelid blepharoplasty: prevention and management.

Blepharoplasty has become a very popular surgery procedure lately. Lots of women want to improve their appearance, get rid of wrinkles and/or fat pads within lower eyelids and regain youthful look.  The eye area heals good with very small scarring and the outcomes can be spectacular, that is why more doctors decide to perform lid blepharoplasty. As upper lid blepharoplasty may forgive some mistakes of the beginners, lower blepharoplasty is very demanding and will reveal all mistakes made during the surgery or assessment. The more procedures are being performed the more complications we should expect.  I searched for the articles about this topic and found out there were only few of them. Probably the reason of this situation is that luckily major complications are rare, and it is not easy to write articles when having only few of them. I made a summary of complications, prevention and management from available articles as well as my clinical experience.

The purpose of this speech is to present most common complications after lower eyelid plastic surgery and known procedures for avoiding or dealing with them.  I hope this topic will be interesting and helpful for the beginners as well as experienced eyelid surgeons.

 

Keywords: lower eyelid blepharoplasty, complications and management of lower eyelid blepharoplasty, blepharoplasty complications.

 


Agnieszka JASZCZUK (Gdansk, Poland)
00:00 - 00:00 #32124 - Correlation between patients’ satisfaction and clinical presentation after lid reconstruction using Hughes flap.
Correlation between patients’ satisfaction and clinical presentation after lid reconstruction using Hughes flap.

Tarsoconjunctival or Hughes flap is a technique of choice primarily but not exclusively used for the reconstruction of large lower eyelid defects. We aimed to examine and quantify patients’ satisfaction with the Hughes flap reconstruction and correlate it with the objective clinical presentation.

A combined retrospective-prospective two centers case series generated results of 17 patients who underwent a two-stage modified Hughes flap surgical procedure from January 2019 until January 2021 to repair a lower eyelid defect caused by epithelial cancer was conducted. It included patients from oculoplastic centers in tertiary and secondary clinical levels facilities in BiH and Croatia. All patients were operated on by two oculoplastic surgeons. All patients were followed up for a minimum of six months prospectively. Photos before and after surgery (one, three, and six months) were taken for independent reviewer evaluation. A patient macroscopic evaluation of redness, lid position, retraction, trichiasis, conjunctival overgrowth, tissue inflammation/infection, and hypertrophic scarring was obtained by a surgeon, and findings were graded on a scale of 1 to 3 or yes/no dichotomized. A patient satisfaction questionnaire after 6-month follow-up via telephone interview or in-person visit using a Likert-type scale was obtained asking five questions.

Pearson correlation coefficient between patients’ satisfaction and objective clinical presentation was 0.53. Out of the 510 (the highest summed score for patients’ satisfaction on the Likert score scale), the total score in the case series was 479, which was 93.9% of optimal satisfaction. Out of 187 (the highest summed score for clinical presentation graded by two reviewers), the total score in the case series was 162, which was 86.6% of assigned optimal results.   

Although both scores were very high which advocates for Hughes flap as a superior procedure in selected cases, the low correlation coefficient, and higher satisfaction score can be explained by more realistic expectations in oncological patients compared to cosmetic ones.


Nina JOVANOVIC (Zenica, Bosnia and Herzegovina), Patricia REISZ-MAJIC
00:00 - 00:00 #31987 - Cosmetic bilateral orbital fat decompression for naturally protruding eyes.
Cosmetic bilateral orbital fat decompression for naturally protruding eyes.

Objective.

Orbital decompression is originally intended as a radical treatment for ocular protrusion in thyroid eye disease. When the palpebral fissure is naturally large, and the eye appears as thyroid eye protrusion, some patients suffer psychologically because of their appearance. We report the results of an orbital fat decompression procedure performed at our clinic for such patients.

 

Methods.

The subjects underwent orbital fat decompression during a 27-month period from January 2019 to March 2021. Forty-three eyes in 22 patients were included in this study. The patients’ mean age was 36.5 ± 7.1 years, and there were 8 males and 14 females. The surgery was performed after confirming the absence of hyperthyroidism and no history of the development of thyroid ophthalmopathy. All patients underwent outpatient general anesthesia, and improvement in exophthalmos was obtained by resecting both intraconal and extraconal orbital fat through a conjunctival incision. The volume of the excised fat was measured by placing the fat into a syringe after removing the blood with gauze. The volume of the excised fat, degree of Hertel ocular protrusion before and after surgery, and the presence of serious complications were investigated.

 

Results.

The degree of ocular protrusion decreased by 2.8 mm from an average of 19.0 mm preoperatively to 16.2 mm postoperatively. The orbital fat resection volume averaged 2.6 ± 0.9. Pupillary discrepancy occurred in one eye in the early postoperative period; however, this improved during the 3-month follow-up. There were no cases of ocular motility disorder, loss of visual acuity, or diminished visual field.

 

Conclusion.

Orbital fat decompression is a newly developed treatment for thyroid eye disease that is also effective in the treatment of naturally protruding eyes.


Tomoyuki KASHIMA (Tokyo, Japan), Masashi MIMURA
00:00 - 00:00 #30480 - Cosmetic Outcomes of Epicanthoplasty for Epicanthus Tarsalis.
Cosmetic Outcomes of Epicanthoplasty for Epicanthus Tarsalis.

Background: Epicanthus is a term that refers to the semilunar eyelid skin fold over the medial aspect covering the medial canthal angle. Epicanthus tarsalis is the most common type and is most evident in Asian population with a prevalence of 40% as opposed to 2-5% in non-Asian population. Epicanthoplasty has not been studied in patients of a population of heavier skin pigmentation

Methods: A retrospective review of patients that underwent Park’s modified Z-Epicanthoplasty from January 2018 to August 2020. They were categorized based on their Fitzpatrick skin type. Their pre-operative and post-operative pictures were analyzed for epicanthal fold correction with focus on scar visibility, pigmentation and elevation. The patients were contacted over the phone for a questionnaire about their subjective scar assessment and satisfaction rate.

Results: A total of 35 patients with mild epicanthus tarsalis were included in this study. 22 patients had Fitzpatrick skin type 3, 7 patients had type 4 and 6 had type 5. Normal post-operative scar pigmentation was reported 37.1% (n=13) patients. Scar hypopigmentation was reported in 28.6% (n=10) and scar hyperpigmentation was reported in 34.3% (n=12). The final cosmetic satisfaction rate score was a median of 9/10 on the 1-10 scale with 40% recording 10/10 satisfaction. On the scar visibility scale the median was 3/10. 82.9% (n=29) had no scar elevation or hypertrophy. Only one patient had scar hypertrophy and elevation and 3 patients had a vertical depression scar. No clinical or statistical significance was found when correlating scar visibility and pigmentation with Fitzpatrick skin type.

Conclusion: Epicanthoplasty is a commonly performed surgery specially in China and South Korea. In our popularion, Z-Epicanthoplasty has proven to be effective in epicanthus tarsalis with high cosmetic satisfaction rate, low scar visibility and acceptable scar pigmentation.


Dalal FATANI (Riyadh, Saudi Arabia)
00:00 - 00:00 #32104 - Dosimetry for laser canthoplasty as a therapy for horizontal lid laxity and meibomian gland dysfunction.
Dosimetry for laser canthoplasty as a therapy for horizontal lid laxity and meibomian gland dysfunction.

Introduction

Dry eye disease is one of the most common diagnoses in ophthalmology. Clinical data have already demonstrated a correlation between horizontal lower lid laxity and meibomian gland dysfunction. In this project, appropriate laser parameters for minimally invasive irradiation to increase lower eyelid tension as an alternative to surgery (lateral tarsal strip, wedge excision) were evaluated.

Methodology

Different settings of a laser system (Asclepion GmbH) were compared ex vivo on porcine lower eyelid tissue (n=6 per group): Group 1 1940nm/2.5W/2s/5J, Group 2 1940nm/1W/5s/5J and Group 3 1470nm/2.5W/2s/5J. Three laser coagulations were performed per lid at a distance of 5mm and an interval of 30s transconjunctivally in the temporal lid. The shortening of the lower lid after laser application and the lower lid tension at a defined time were investigated using a force sensor (LD Didactic GmbH). The coagulation foci were assessed morphologically and histologically (hematoxylin/eosin; picro-Sirius red) and evaluated with the program ImageJ (Wayne Rasband) using a grading system.

Results

After irradiation, the greatest longitudinal shortening resulted in the 1470nm group (15.1 ± 3.7% 2.5 ± 0.6mm; p<0.0001). Compared to the untreated sample, the largest significant increase in lower eyelid tension occurred after the 3rd coagulation (1: p=0.01; 2: p=0.04; 3: p=0.004). Group 3 showed significantly deeper coagulation than groups 1 and 2 at 1071.8 ± 70.8µm (p<0.0001). In addition, coagulation foci were largest in group 3 with 2910.8 ± 220.6µm epithelial side (2vs.3 p=0.007) and total coagulation area was 25.6 ± 3.8% and 59.1 ± 8.3% in group 3 respectively. In the grading of epithelial and tissue changes, group 3 showed less destruction (grade 0.8 ± 1.2).

Conclusion

Laser coagulation of the posterior lamella results in lower eyelid shortening and increase of lower eyelid tension. The strongest and most gentle result was obtained at a total energy of 5 J with a wavelength of 1470nm. A longer-term effect of the increase in lower eyelid tension as well as potential adverse effects need to be tested in vivo.


Christoph HOLTMANN (Duesseldorf, Germany), Alexandra SCHILCHER, Amir AVDAKOVIC, Alessa HUTFILZ, Katharina WIEBE-BEN ZAKOUR, Dirk THEISEN-KUNDE, Erich KNOP, Gerd GEERLING, Joana WITT
00:00 - 00:00 #32108 - Epiblepharon- a case report.
Epiblepharon- a case report.

The study aims to evaluate epiblepharon as a rare condition, but also in some cases disturbing and damaging for the anterior segment, and its treatment possibilities. Epiblepharon is a condition in which the eyelid pretarsal muscle and skin ride above the eyelid margin to form a horizontal fold of tissue that causes the cilia to assume a vertical position. It can involve either the upper or lower eyelid but is most commonly seen as involving the lower eyelid.

A case report of a girl with congenital epiblepharon, from birth to age of five, presents her symptoms, conservative and operative treatment, and results.

We will discuss conservative and operative treatment of our patient, according to her symptoms, and results of our treatment, compering to other authors.  

Congenital epiblepharon is self-limited in most cases, at around 2 years of age. Symptomatic conservative treatment is sufficient in such a case. Persistent epiblepharon with symptoms at anterior segment and keratopathy is an indication for surgical intervention.


Maja NOVAK-STROLIGO (Rijeka, Croatia), Tamara MIŠLJENOVIĆ-VUČERIĆ, Tea ČALJKUŠIĆ-MANCE
00:00 - 00:00 #32208 - Everting sutures for entropion repair: recurrence rate and quality of life metrics.
Everting sutures for entropion repair: recurrence rate and quality of life metrics.

Introduction

Entropion is defined as an inward turning of the eyelid margin. Pathophysiology of entropion is predominantly two-fold: horizontal and vertical lid laxity. Everting sutures address the vertical laxity by tightening the lower lid retractors. Everting sutures are an attractive option as it is quick and relatively easy to perform. We wanted to know how efficacious this procedure was. For this reason, we conducted this retrospective study where we looked at the recurrence rate, surgical outcome, and the quality of life of patients following the surgery.

 

Method

 

We identified all the patients who had everting sutures between April 2019 and March 2020. Patients who had everting sutures combined with another procedure were excluded from the study. 58 patients were identified and their data were collected using their electronic letters. 42 patients were phoned to complete The European Quality of Life questionnaire.

 

Results

Quality of life was improved in 80.9% of patients post-op. Recurrence rate of 26.7% was noted within 12 months. Good lid position was reported in 94.8% soon after the surgery with 1.7% noting a partial correction and 3.4% noting no correction . With regards to entropion symptom improvement, 62.9% had complete resolution of epiphora, 72.7% reported resolution of irritation and 86.3% no longer reported redness.

 

Conclusion

 

Everting sutures is a quick and minimally invasive procedure with extremely low complication rate and high short-term success rate. Due to these aforementioned characteristics, with prudent patient selection, we feel this procedure is a valuable tool in the armamentarium against entropion.


Mohamad BABA, Deji AJANAKU (Liverpool, United Kingdom), Halliwell MARK
00:00 - 00:00 #32223 - Extranodal NK/T-cell lymphoma, nasal type, presenting as a primary upper eyelid tumor.
Extranodal NK/T-cell lymphoma, nasal type, presenting as a primary upper eyelid tumor.

We present a rare case of primary extranodal natural-killer (NK)/T-cell lymphoma, nasal type involving the upper eyelid.

A 83-years-old male presented with a localized tumor measuring 18 mm x 14 mm involving the right upper eyelid with no other clinical findings. A biopsy of the tumor was performed. Histopathological examination showed benign seborrheic keratosis.

One month later, the patient returned with an enlarging diffuse hyperemic eyelid mass and pain, interpreted as a chalazion. Incision and curettage was performed. Excised tissue was sent for histopathological examination that showed granulomatous inflammation with no signs of malignancy. One and a half month after first visit the patient reappeared with a large ulcerating tumor of the right upper eyelid. A third incisional biopsy was performed revealing a gelatinous tumor mass profound of the ulceration. The specimen showed fragmented tissue with sections of well-differentiated epidermis, connective tissue, and numerous lymphocytic tumor cells. The lymphocytic cells were positive for CD2, CD3, CD56, perforin and EBV and negative for CD20, CD45, CD79α, CD4, CD5, CD7, CD8, CD10 and PD1. No reaction was seen for the pan B-cell marker PAX-5. Polymerase chain reaction (PCR) assessment of T-cell-receptor clonality was unsuccessfully performed due to unsuitable material. On the basis of these findings an extranodal NK/T-cell lymphoma, nasal type was diagnosed.

A systemic work-up was performed with no signs of systemic lymphoma. Treatment consisted of radiotherapy with a total dose of 50 Gray (Gy) delivered in 2 Gy x 25 fractions, 5 F/W with complete regression of the tumor.

Two months after radiotherapy the patient develop a severe radiation related keratopathy that resulted in evisceration of the eye. No signs of malignancy or infection was found in the resection. However, the patients’ health was slowly declining, and the patient succumbed 15 months after the time of diagnosis.


Peter Kristian RASMUSSEN (Copenhagen, Denmark), Daniel KANDEL, Steffen HEEGAARD, Anne Kathrine WIENCKE, Marie Louise Roed RASMUSSEN
00:00 - 00:00 #32193 - Eyelid coloboma in Goldenhar syndrome : a case report.
Eyelid coloboma in Goldenhar syndrome : a case report.

Introduction :

Eyelid coloboma, a rare congenital defect of the eyelid margin affecting its full thickness, can be associated with other eye structures defects, and can also be classified within various congenital syndromes such as Goldenhar syndrome. The aim of our study is to report a rare case of eyelid coloboma with challenging surgical management.

Observation

We report the case of a 40 days old male infant, who was addressed to the ophthalmology clinic for multiple congenital oculofacial malformations. Upon examination, the infant presented with a unilateral upper eyelid coloboma on the medial half. The cornea was exposed with an inferior punctate keratitis, and the exam showed no other associated ocular defects. He presented with facial and auricular sessile tags. The contralateral eye assessment was unremarkable. Complementary exams were ordered like ultrasonography and spinal X-ray. Nightly eye bandaging associated to artificial tears and lubrificating gel were prescribed. Surgical reconstruction of the eyelid is planned after a full malformative assessment.

Discussion

It is a rare hereditary disease that results from abnormal development of the branchial arches. It has a classical triad of facial malformations : ocular or auricular malformations and periauricular tags; mandibular hypoplasia ; and vertebral anomalies ( scoliosis, hemivertebra).

Ocular manifestations can range from eyelid coloboma to an epibulbar choristoma , dermolipoma, microphtalmos. Surgical treatment is indicated without delay in order to prevent amblyopia and regain eye function.

Conclusion

Goldenhar syndrome is a rare condition that associates multiple malformations, including eyelid coloboma that can be therapeutically challenging depending on the extent of the defect. It is a surgical emergency to preserve corneal surface and prevent amblyopia.

Multiple reconstruction techniques can be used, and a multidisciplinary approach coordinating between paediatricians, maxillofacial surgeons and ophthalmologists is required.


Iatissam EL BELHADJI, Selma CHIGUER, Adil MCHACHI, Laila BENHMIDOUNE, Rayad RACHID, Mohamed ELBELHADJI (, Morocco)
00:00 - 00:00 #32256 - Eyelid Kaposi sarcoma as initial symptom leading to AIDS diagnosis.
Eyelid Kaposi sarcoma as initial symptom leading to AIDS diagnosis.

Kaposi sarcoma is a neoplastic disorder of vascular origin related to Human Herpes Virus 8 (HHV-8) that occurs in patients with immunodeficiency. In most cases it involves skin, mucous membranes and lymph nodes, however it can occur in other localization.

A 36-year-old man with no medical history presented to an ophthalmologist with painless, purplish red, elevated lesion of the left lower eyelid. The patient had a 2-month history of enlarging lesion despite antibiotics treatment. Surgical incision biopsy of the lesion revealed Kaposi sarcoma and the patient was subsequently diagnosed with human immunodeficiency virus.

This case confirmed that Kaposi sarcoma in the eyelid region can be the first presentation of human immunodeficiency virus even in patient without other symptoms of the disease.


Radosław RÓŻYCKI (Warsaw, Poland), Dominika BIAŁAS, Katarzyna PACZWA, Ewa KULPECKA
00:00 - 00:00 #32527 - Eyelid swelling and facial pain associated with late onset filler migration.
Eyelid swelling and facial pain associated with late onset filler migration.

A 63 year old woman developed right sided facial pain quickly followed by swelling of the right upper eyelid. She saw her family doctor who prescribed topical antibiotic drops and analgesics followed by oral antibiotics and lastly oral corticosteroids. These treatments did not improve her symptoms. The patient was referred to our department, four months after the initial presentation. On examination, there was a firm, smooth, oblong, subcutaneous  swelling measuring 25mm long by 10 mm in height, situated at the upper boarder of the right upper eyelid. The lesion displayed transillumination and the overlying skin was mildly erythematous. The lesion was non tender and not tethered to the deeper tissues. A mild upper lid ptosis was caused by the lesion but the vision was normal at 6/6 in both eyes. Colour vision and pupil responses were normal. The extraocular eye movements were normal. The rest of the ocular examination of both eyes was unremarkable. On questioning, the patient denied any past ophthalmic history of note or any treatment with fillers. 

In view of the presence of facial pain associated with this lesion, blood tests were requested ( including IgG levels, auto antibody screen, serum angiotensin converting enzyme level, protein electrophoresis, thyroid function tests and C1 esterase level) and an MRI scan of the orbits and sinuses. 

The MRI scan report concluded that there was a soft tissue swelling over the right upper eyelid with increased signal on T2 and low signal on T1. The scan was otherwise normal. 

A biopsy of the lump was undertaken six weeks after the initial presentation. A linear incision was made along the length of the lesion, on deepening the incision it was possible to see that the lump was composed of a solid, transparent gel.

The post operative recovery was quick and uneventful. The facial pain subsided within a few day after surgery. The histology report described an ellipse of skin measuring 28mm by 7mm with underlying tissue to a depth of 5mm, which had a gelatinous appearance. The dermis and underlying tissue included some structurelesss mucin like material which extended down to underlying striated muscle. On further questioning, the patient remebered having filler injections to both cheeks four year prior. 

This case is unusual in the late presentation of the filler migration and the movement of the filler from the cheek to the upper eyelid


Konstantina SORKOU, Chris MCLEAN (Guildofrd, United Kingdom)
00:00 - 00:00 #30670 - Filler migration to the orbit.
Filler migration to the orbit.

Background: Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. With this increase in the number of injections, comes an increasing number of types of filler-related complications. 

 

Objective: We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

 

Methods: A retrospective, multi-center analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

 

Results: Seven patients presented with orbital symptoms after filler injection, and were subsequently found to have dermal filler in the orbit.

There were six females and one male, with an age range of 45-64. Four out of seven patients underwent orbitotomy surgery, one patient underwent lacrimal surgery, one patient had strabismus surgery and one patient was treated with hyalurodinase injections.   All patients have remained stable postoperatively.

 

Conclusion:

Orbital complications secondary to migrated filler   may occur long after the initial procedure.   Since the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Thus, dermal fillers should be considered in the differential diagnosis of patients presenting with a new onset orbital masses.


Shirin HAMED AZZAM (Poriya, Israel), Cat BURKAT, Abed MUKARI, Daniel BRISCOE, Narish JOSHI, Richard SCAWN, Morris HARTESTEIN
00:00 - 00:00 #32171 - Frontalis flap in fair to good levator function.
Frontalis flap in fair to good levator function.

Ptosis repair require an accurate evaluation of levator muscle function which is used to determine the surgical approach. In case of good levator function, the surgical options use the levator muscle to elevate the eyelid. When the function is poor, usually a frontalis muscle suspension is recommended. Based in our own experience, frontalis flap is the elected technique for frontalis suspension.

 

This is a retrospective chart review of patients with levator function over 4 mm who underwent frontalis flap surgery between 2012 and 2021 by Dr XXX.

 

The results showed levator dysgenesis as the most frequent cause of ptosis. A slightly predominance on male patients was found and most frequently the surgery was bilateral. Amblyopia was studied and was present on almost 30% of patients. Re-intervention was needed in 11.5 % of surgeries. The most common indication was as first option with a mean increase on MRD1 of 3.5mm.

 

We present frontalis flap as a secure and useful technique for eyelid ptosis, even in fair to good levator function cases.


Ramon MEDEL, María Inmaculada PAÑOS (Barcelona, Spain), Luz María VÁSQUEZ, Claudia CORDERO LÓPEZ
00:00 - 00:00 #31974 - Functional and Aesthethic Results of Medial Canthal Area and Large Full Thickness Eyelid Defect Reconstruction.
Functional and Aesthethic Results of Medial Canthal Area and Large Full Thickness Eyelid Defect Reconstruction.

Purpose: The purpose of this study was to present surgical techniques for the reconstruction of medial canthal defect with large full-thickness eyelid involvement. 

Methods: This study included 8 patients (6 women, 2 men) who underwent medial canthal defect reconstruction with large full-thicness eyelid involvement after tumor excision between January 2017-March 2022. Data regarding patient demographics, defect size, tumor pathology, surgery techniques, functional and cosmetic outcomes, and complications were recorded. 

Results: Mean age was 62±16.04 years and mean followup time was 18±3 month. Histopathological diagnosis were basal cell carsinoma (BCC) in 6 patients, sebaceous carsinoma in 1 patient and squamous cell carsinoma (SCC) in 1 patient.  Methods used for anterior lamella reconstruction of eyelids were myocutaneous advancement flap, Tenzel flap, Mustarde cheek rotation flap and with or without mid-face-lift; for medial canthal area reconstruction were designed glabella or forehead flaps; and for posterior lamella reconstruction and stabilization of eyelids were tarso-conjunctival flaps/grafts, medial canthal tendon flap, medial/lateral periosteal flaps, and retractor recession. Postoperative complications included epifora in one patient and mild pitozis in another. The functional outcome was regarded as normal in all patients and cosmetic outcomes were satisfactory in all patients.

Conclusions: The use of designed reconstructive approaches and multiple flaps for medial canthal area and different subunits of large eyelid tissue defects are effective methods to achieve superior functional and cosmetic outcomes.

 




Demet YOLCU (Ankara, Turkey)
00:00 - 00:00 #32416 - Fungal Parinaud oculoglandular syndrome: A dilemma in a tuberculosis endemic region.
Fungal Parinaud oculoglandular syndrome: A dilemma in a tuberculosis endemic region.

Human Sporotrichosis is caused by a dimorphic fungus, Sporothrix Schenkii. It is rare in non-endemic area thus misdiagnosis is common leading to delayed treatment.

We report on a case of a 22-year-old, otherwise healthy lady who had a painful right eyelid swelling for 4 weeks which gradually spread to right pre and post auricular as well as submandibular regions. She had intermittent bilateral allergic conjunctivitis for the past 4 years with no complete resolution albeit treatments. There was no preceding trauma, but she had 10 cats at home. On examination, right sided lower motor neuron facial nerve palsy was evident. Her right eyelids were swollen with crusted ulceration, involving medial canthus and lacrimal sac. Multiple firm nodules felt, some were discharging thick pus. There were bulbar granulomatous conjunctivitis and cornea scarring. Blood tests and multiple biopsies were suggestive of chronic granulomatous inflammation but nothing was confirmative, with fungal, acid fast bacilli and bartonella tests being negative. Neither antibiotics nor steroid were proven to be effective. Additional biopsies performed were tested positive for fungal PCR and histopathology examinations isolated fungal elements which were confirmed as Sporothrix Schenkii. Hence, oral Itraconazole 200mg OD commenced and clinical improvement was immediate. The lesions worsened refractorily following a trial of anti-tuberculosis agents by another attending physician but improved tremendously after the discontinuation. After 3 months of treatment, all the lesions resolved leaving her with cicatricial upper eyelid ectropion pending corrective surgery.

Clinical similarities with other types of conjunctivitis may misled ophthalmologist to undertreat cases of ocular sporotrichosis. A high suspicion index is warranted as not to confuse it with different granulomatous inflammation-inducing pathogens. Treatment delay could lead to complicated eyelid and ocular sequelae.


Hanida HANAFI (Sabah, Malaysia, Malaysia), Caroline BINSON, Stephanie FONG, Kwok Hoong CHAN
00:00 - 00:00 #32204 - Gliding brow lift in facial palsy.
Gliding brow lift in facial palsy.

Background: None of brow lift surgical techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. 

The aim of this study was to test a new technique: The Gliding brow lift (GBL), described by Viterbo and al, on patient who suffered from peripheral facial palsy. 

 

Methods:  One patient with peripheral facial flask palsy who underwent GBL technique in January 2022, was evaluated. Eyebrow height on paralyzed side was measured in preoperative time, on a standing patient. There was a 15 mm height differential between each side. The aim of this surgery was to obtain, a symmetry of the eyebrows but also to treat forehead wrinkles, without modifying the insertion zone of the scalp on paralyzed side. With one minimal incision in the fronto-temporal area, the skin of the upper third of the face was freed from the underlying muscles according to the Viterbo technique.

The eyebrow was, then, repositioned and fixed to the deep plane with a hemostatic net which was left in place 3 days to avoid any unacceptable scare according dermatologist recommendation. 

 

Results:  The follow-up period was 8 months. No recurrence of ptosis of the brow was shown. There was no more difference in height between the two eyebrows (measurements at the head and body of eyebrow). Forehead wrinkles has diminished. 

There was no incidence of unacceptable scare, hematoma, infection, permanent sensory changes, skin necrosis. 

The patient has recovered eyebrow symmetry and his satisfaction was rated at 80/100 on a scale of 0 to 100, 8 months after the surgery. 

 

Conclusion:  The gliding brow lift seems to be a good surgical alternative to treat the upper third of the face in facial palsy compared to endoscopic and coronal technique. 

It seems to allows effective, long-lasting results with less complications and better results. 

Nevertheless, these conclusions should be taken with caution.

A future study is needed on more patient, with a greater follow-up over the time to totally agreed this technique on patient with facial unilateral paralysis.

 


Rayan MEKOUI (Paris), Bahram BODAGHI, Frédéric TANKERE, Nathalie BUTEL, Claire FOIREST
00:00 - 00:00 #32324 - Horizontal shortening of the lower eyelid in facial nerve palsy.
Horizontal shortening of the lower eyelid in facial nerve palsy.

Background: Following an initial paralytic phase, patients with facial nerve palsy (FNP) enter a ‘contraction phase’ (as early as three months after onset), during which they can develop anterior lamellar (skin/muscle) contraction.

Purpose: To determine whether horizontal lower eyelid length changes following FNP. 

Methods: A single-centre retrospective audit of lower eyelid horizontal length measurements (‘PC distance’: measuring from lower lacrimal punctum to lateral canthal angle with a clear plastic ruler, with eyelid on gentle stretch) recorded in all FNP patients reviewed in July-September 2021. Affected and fellow eyes were compared using non-parametric testing.

Results: Forty-one patients were reviewed. Seventeen were excluded as they had previously undergone surgery that would lengthen (e.g. periosteal flap) or shorten (e.g. lateral tarsal strip) the lower eyelid. Of the remaining 24, mean age was 52.5 years (range, 27-79) and 54% were female. FNP aetiology was pre-ganglionic in 75%: 12.5% post-ganglionic; 12.5% idiopathic. Mean PC distance was significantly shorter in affected eyes (26.0mm, range: 22-34mm) than fellow eyes (27.5mm, 24-35mm) (Wilcoxon signed-rank test, Z-value -3.6214, p=0.0002). Mean difference between both eyes’ PC distance was 1.5mm (0-4mm). Only three patients were still in the ‘paralytic phase’ (i.e., <1 year since FNP onset), and the difference in PC distance was 0mm in all three. 

Conclusions: The lower eyelid appears to shorten horizontally following FNP. PC distance adds an additional tool for the overall assessment of soft tissue contraction following FNP, and may help identify patients likely to require eyelid lengthening, such as a lateral periosteal flap.


Aaron JAMISON (Glasgow, United Kingdom), Bhupendra PATEL, Raman MALHOTRA
00:00 - 00:00 #32241 - Impact of Teprotumumab on Periocular Appearance in Thyroid Eye Disease.
Impact of Teprotumumab on Periocular Appearance in Thyroid Eye Disease.

Purpose:

Teprotumumab is a monoclonal antibody that decreases periorbital inflammation in thyroid eye disease (TED) patients.  This study aimed to analyze periocular photographs of TED patients before and after teprotumumab therapy using a standardized grading scheme to identify changes in eyelid edema and fullness as a result of inflammation and/or fat hypertrophy. 

 Methods:

A retrospective cross-sectional study was performed. TED patients > 18 years old who completed 8 teprotumumab treatments and had external, forward-facing photographs taken pre- and post- treatment between 2020 and 2022 were included. Two masked graders scored eyelid appearance using a grading scheme developed from a library of photographs of TED patients. The primary outcome was the change in scores before and after teprotumumab treatment averaged across all four eyelids. The secondary outcome was the analysis of upper and lower eyelids separately. Statistical analysis was performed with two-sided Wilcoxon signed rank tests. 

 Results:

A total of 50 patients (39 females; average age 59.5 years) were included, resulting in 200 eyelids (100 upper and 100 lower; 400 total when including pre- and post-treatment). Forty-three patients (86%) had improvement in average scores across all four eyelids after treatment (Figure 1). The average change in score after treatment per eyelid ranged from -3.0 to +0.75 points, with a median of -0.75 points (95% confidence interval of -1.00 to -0.749, p<0.001). Sub-analysis of the upper and lower eyelids separately showed significant (p<0.001) improvement in eyelid scores post-treatment. 

 Conclusions:

Standardized grading of periocular photographs of TED patients demonstrated statistically significant improvement in eyelid fat hypertrophy and edema after treatment with teprotumumab. 


Lisa Y LIN, Jonathan E LU (Boston, USA), Edith R RESHEF, Carolina A CHIOU, Nahyoung Grace LEE, Natalie WOLKOW, Suzanne K FREITAG
00:00 - 00:00 #31978 - Just an entropion - or is it?
Just an entropion - or is it?

We here report a rare case of Mantle Cell Lymphoma (MCL) of the conjunctiva, as the first clinical presentation of advanced-stage MCL with extraocular lymph node involvement(neck and axilla) and bone marrow involvement.

An 83 year old lady presented to our department with history of dry eyes & foreign body sensation. She was seen earlier this year & had electrolysis for distichiasis ( 2 sittings). She was also using lubricants regularly for symptomatic relief. When we saw her, we noted that she has some fullness of her left lower eyelid along with entropion. She also had conjunctival mass in both eyes (left>right) with symblepharon in left eye & some scarring.

Blood tests were requested in view of the conjunctival changes & she was noted to have increased WBC count with some lymphoblastic cells. Urgent referral was done to haematology for further investigations and management . This case highlights the importance of examining seemingly simple cases carefully,as rarely they have something else lurking underneath.

Seen by haematology and diagnosed as B-cell lymphoproliferative disorder on peripheral blood. Results attached. This patient then underwent left eye conjunctival biopsy and everting sutures to correct the entropion. She also had cryotherapy for distichiasis of right upper eyelid. 

Ocular adnexal lymphomas (OAL) account for 2% of all non-Hodgkin lymphomas, and about 6-8% of extranodal lymphomas. The primary involvement of the conjunctiva by lymphoma, comprises about one third of ocular adnexal lymphoma, and 1.5% of all conjunctival tumors. Like other primary ocular adnexal lymphomas, most of the primary conjunctival lymphomas are low-grade extranodal marginal zone B-cell lymphomas of MALT . Mantle cell lymphoma (MCL) is a relatively rare lymphoma, accounting for less than 10% of all lymphomas. In the ocular adnexal region, including rare cases of conjunctiva, MCL accounts for between 1-5%. MCL in the ocular adnexal region is associated with poorer prognosis.

According to the largest published series (n=21) of ocular adnexal MCL, patients with involvement of the orbital and adnexal region as first presenting symptom (n=14) had more frequently bilateral eye and bone marrow involvement, and inferior overall survival as opposed to patients with secondary ocular adnexal MCL . The majority of patients in this series presented with stage IV disease with nodal- and bone-marrow involvement. The median overall survival has been reported to be only 57 months.


Rashmi RAO (Worthing, United Kingdom), Cornelia POITELEA
00:00 - 00:00 #32408 - Laissez faire – how far can we still go - meanwhile?
Laissez faire – how far can we still go - meanwhile?

Defects on the lid after removal of different tumors are usually restored by reconstruction. An alternative to a surgical repair is wound healing by secondary intention. We want to present two cases to evaluate cosmetic and functional outcome of large defects treated by the Laissez-faire technique in situations where primary closure would not have been possible or suitable. 

One is a 83 year old female patient who had an excision of a basalioma with consequent full skin graft transplantation three years before. She presented herself with a secondary basalioma at the right medial nose angle with ulceration of the upper and lower eyelid. After resection she underwent various operations for correction of the eyelids while the primary excision site was left open for consecutive granulation.

The second patient was a 59 year old female with a basalioma on her left medial lid crease. Due to its localization very close to the bulbus and tear ducts after excision the site was left open for healing by secondary intention.

Even in large defects or in places with challenging reconstructive circumstances following excision of peri-ocular tumors healing by secondary intention can be an effective alternative to reconstructive surgery.


David LUECHT (Hamburg, Germany), Ulrich SCHAUDIG
00:00 - 00:00 #32265 - Lengthening the upper eyelid by means of an autologous transplant of the levator eyelid fascia - case report.
Lengthening the upper eyelid by means of an autologous transplant of the levator eyelid fascia - case report.

The elevator palpebral superiors muscle is responsible for the opening of the palpebral fissure, acting in opposition to the orbiculares oculi muscle, which ensures the correct field of view. In the presented case report of a 59-year-old woman, there was a narrowing of the eyelid fissure as a result of chronic inflammation within the eyelids and orbit due to S. aureus infection. The infection resulted in resorption of the nasal septum, nasal conchae, infiltration of the sphenoid and frontal sinuses, as well as the meninges of the base of the frontal lobes. In surgical treatment, the adhesions were released and the upper eyelid was lengthened by means of an autologous transplant of the levator eyelid fascia, which resulted in anatomical, functional and aesthetic improvement.


Dorota POJDA-WILCZEK, Rafal WOS (Katowice, Poland)
00:00 - 00:00 #32344 - Lower eyelid conjunctival amyloidosis: a case report.
Lower eyelid conjunctival amyloidosis: a case report.

Case report

A 37-year-old female of Bangladeshi origin, referred to the oculoplastic clinic from local optician with the suspicion of conjunctival lesion. The right lower lid superior fornix and tarsal conjuctiva were affected, without any sign of orbital involvement. The lesion’s colour was yellow, pink, the associated features were intrinsic vascularization. Systemic evaluation revealed no related systemic abnormalities. Incisional biopsy performed was suggestive of AL (lambda sub-type) amyloid. Further investigation regarding systemic amyloidosis and neoplastic plasma cells disease have been performed which have shown negative results. Blood test results show increased levels of Serum IgA 4.85, Ser Kappa light ch23.4. The patient has been referred to the National Amyloidosis Centre (UCL Hospital, London) and diagnosed with Amyloidosis Type A1 localised. The patient remains stable over the last 9 months under conservative treatment.The family history was no contributory although the patient has suffered from chronic plaque psoriasis for the last 10 years, received and completed phototherapy on October 2020 with good response.A few rare cases of secondary amyloidosis complicating psoriasis have been reported.

Recommended treatmentThis case has been managed so far conservatively using artificial tears. Management modalities include observation, judicious use of artificial tears, excision, liquid nitrogen cryotherapy or low dose external beam therapy for localized conjunctival amyloidosis. For patients with systemic manifestations, stem cell transplant, chemotherapy and steroids may be considered depending on the extend of the disease. Surgical debulking remains the standard treatment, but because complete excision isn’t always possible, the disease may occur. Demirci and Leibovitch report a recurrence rate of 21-27% after surgical debulking of localized orbital amyloidosis. Newer therapies such as cryotherapy may further decrease recurrence rate by decreasing blood supply to the surrounding tissue, but more research is needed. Radiotherapy for localized amyloidosis has also been reported but is not considered the standard of care. For patients with recurrent amyloidosis, treatment varies depending on the disease manifestations.


Anna GKOUNTELIA, Wessam MINA (London, United Kingdom)
00:00 - 00:00 #32282 - Lower eyelid marginal entropion repair using a grey line split and absorbable everting sutures: 12-month clinical and patient-reported outcomes.
Lower eyelid marginal entropion repair using a grey line split and absorbable everting sutures: 12-month clinical and patient-reported outcomes.

Background

Marginal entropion of the lower lid is a frequently overlooked malposition secondary to chronic lid margin disease and leads to abrasive contact between the eyelashes and ocular surface. This study evaluates clinical and patient reported outcomes of surgical correction using localised grey line split with everting sutures (GLSES).

 

Methods

Consecutive patients with marginal entropion undergoing GLSES were reviewed to evaluate surgical success at a minimum of 12 months. Complete surgical success was defined as an absence of corneal staining and lashes touching the globe. Partial success was defined as fewer lashes touching the globe and reduced staining (vs pre-operatively). Failure was defined as no change in corneal staining or the number of lashes touching the globe or the need for further surgery. Patients were invited to complete the Glasgow Benefit Inventory (GBI) to assess self-reported benefit in 5 domains: Quality of life(QOL), self-confidence, support, general health and social involvement.

 

Results

Seventeen eyes of 14 patients underwent surgery for lower lid marginal entropion between July 2018 and July 2021(mean age 76.6 years). Pre-operatively, all patients had lashes touching the globe with corneal staining. Four patients (5 eyes) were lost to follow up before 12 months. Complete success occurred in 9 eyes (75.0%) with a median follow-up of 21 months (range 13-30). Partial success was observed in 2 eyes (16.7%), with 1 surgical failure who subsequently underwent tarsal fracture. Eleven patients completed the GBI. Overall, results of the surgery positively affected patients’ QOL (median 50 IQR (50–100)) but no positive or negative change was found in the remaining GBI domains.

 

Conclusion

GLSES was found to be a successful and acceptable treatment of marginal entropion of the lower eyelid. Patients report improved QOL and avoid repeated trichoablation which might exacerbate the underlying disease process.


Suzannah BELL (Portsmouth, United Kingdom), Christopher SCHULZ, Simon ROGERS
00:00 - 00:00 #32196 - Lower eyelid reconstruction by minimal and marginal approach to releasing the lid with closure handling technique (March technique).
Lower eyelid reconstruction by minimal and marginal approach to releasing the lid with closure handling technique (March technique).

Skin cancer is especially harmful due to local invasion and surgical iatrogenic morbidity. The recurrence may be high, implying challenging surgical management depending on the prior surgery, which in eyelids may mean sacrificing periosteum or tarsus. To avoid this, in cases where the defect involves up to 66% of the lower eyelid with at least around 17% of remnant lateral lower margin respected, the MARCH technique would be a more conservative approach, with minimal damage to perilesional healthy tissues, which provides good resources for the future. Here is described the surgical procedure and is presented different clinical cases that underwent this technique, with very promising results that would encourage us to use it as the first surgical step. The authors declare having no conflicts of interest. 


Anna MARCH DE RIBOT (BARCELONA, Spain), Francesc MARCH DE RIBOT
00:00 - 00:00 #32175 - Lupus pernio of the eyelid as the presenting sign of systemic sarcoidosis.
Lupus pernio of the eyelid as the presenting sign of systemic sarcoidosis.

Background: Sarcoidosis is a chronic multisystemic disease of unknown aetiology characterised by non-caseating granulomas. Ocular involvement rate ranges from 30% to 60% among individuals with sarcoidosis, and can vary widely, making the diagnosis a challenge to the ophthalmologist. Most common presentation is anterior or posterior uveitis.  Cutaneous manifestations occur in about 22% of cases, but eyelid involvement is rare. Millet seed nodules, ulcerated nodules, plaques, swelling, anterior and posterior lamella scarring with entropion and lid notching, have all been previously reported.

 Case:  A 60 years old female came to the outpatient department complaining of hyperemic scaly plaque on the upper eyelid and back of the neck which was mistaken for psoriasis. During the follow up, she began developing indurated violaceous plaque on the right upper eyelid that was characteristic for lupus pernio. Biopsy revealed the presence of non caseating granulomatous infiltration characteristic of sarcoidosis. CBC, ACE and high resolution chest CT were done.  Bi-hilar lymphadenopathy was noted on CT chest. Patient was prescribed systemic and potent topical steroids with marked improvement of the eyelid lesion and stability of the general condition.

Conclusion: Lupus pernio is the most characteristic skin lesion in systemic sarcoidosis. Although eyelid involvement is rare, its identification is important as it strongly suggests lung involvement. Systemic as well as topical steroid treatment can improve the cosmetic outcome of such lesions.


Aliaa AHMED (Cairo, Egypt), Rania A. ABDELSALAM
00:00 - 00:00 #30702 - Malignant neoplasms of the eyelid; excision-reconstruction results in tertial referral center.
Malignant neoplasms of the eyelid; excision-reconstruction results in tertial referral center.

Objective: To analyze the demographic data, pathological diagnoses, and eyelid reconstruction techniques of cases who underwent surgery for malignant neoplastic lesions of the eyelid in a tertial referral center.

 

Methods: The files of the cases who were operated on for malignant neoplastic lesion of the eyelid between 2003-2021 were reviewed retrospectively. 110 cases were included in the study. The demographic data of the cases, the location of the lesion, the surgical procedure performed, the pathological diagnosis of the lesion, and the eyelid reconstruction performed when necessary were recorded.

 

Results: Fifty-five of the cases were female (50%) and 55 were male (50%), mean age was 62.54±13.88 years (23-87). The mean time between the development of the eyelid lesion and the admission to hospitals of the cases was 18.66±22.91 months (1-120). The right eye was affected in 56 (50.9%) cases and the left eye was affected in 54 (49.1%) cases. The neoplastic lesion was located on the lower lid in 84 cases (76.4%), on the upper lid in 17 cases (15.5%), and on the medial cantus in 9 cases (8.2%). Reported pathological diagnosis of lesions; basal cell carcinoma in 90 cases (81.8%), squamous cell carcinoma in 13 cases (11.8%), sebaceous gland carcinoma in 2 cases (1.8%), mucinous carcinoma in 1 case (0.9%), neurofibroma in 1 case (0.9%), metastatic adenocarcinoma in 1 case (0.9%), nodular hidradenoma (0.9%) in 1 case, severe dysplasia in 1 case (0.9%). Post-excision eyelid deformity was corrected with primary repair in 45 cases (40.9%), graft combined with flap in 20 cases (18.2%), only graft in 9 cases (8.2%), and only flap in 36 cases (32.7%). The flap-type was Hughes tarsoconjunctival flap (50%) in 26 cases, Tenzel semicircular flap (30.8%) in 16 cases, Tenzel flap combined with Hughes flap (5.8%) in 3 cases, and skin sliding (13.5%) in 7 cases. The mean opening time of the flap was 4.37±1.75 weeks (2-8). Upper lid skin tissue (16 cases, 64%) was used as a graft most frequently. Additional surgical intervention for complications was performed in 13 cases (11.8%) in the postoperative period.

 

Discussion/Conclusion: Basal cell carcinoma is the most common malignant neoplastic lesion of the eyelid in our clinic, and the most common location is the lower eyelid. Primary repair is the most used reconstruction technique.


Ali Safa BALCI, Husna TOPCU, Ayse CETIN EFE, Mehmet Goksel ULAS, Kubra SEREFOGLU CABUK (istanbul, Turkey)
00:00 - 00:00 #30610 - Mapping of Perfusion During Full-thickness Blepharotomy Using Laser Speckle Contrast Imaging.
Mapping of Perfusion During Full-thickness Blepharotomy Using Laser Speckle Contrast Imaging.

Purpose: The aim of this study was to monitor how the blood perfusion in human upper eyelids is affected during full-thickness blepharotomy.

Methods: Seven eyelids in five patients with upper lid retraction due to Graves’ disease underwent full-thickness blepharotomy. Perfusion was measured using laser speckle contrast imaging (LSCI) in the eyelid margin and in the conjunctival pedicle.

Results: Immediately following the procedure, a non-significant reduction in perfusion was observed in the skin of the pretarsal eyelid margin, being 66% of the initial value (p=n.s.). However, a statistically significant decrease in perfusion, to 53% of the initial value (p<0.01), was seen in the central pedicle of the conjunctiva. There were no surgical complications such as infection, signs of ischemia or bleeding.

Conclusions: In this study, eyelid perfusion was mapped during full-thickness blepharotomy for the first time using LSCI. The results showed that perfusion is sufficiently preserved during surgery, probably due to the rich vascular supply in the periocular region, which may explain the low risk of postoperative complications such as ischemia and infection.


Anna WIKTORIN (Stockholm, Sweden), Johanna BERGGREN, Malin MALMSJÖ, Sandra LINDSTEDT, Rafi SHEIKH, Elin BOHMAN
00:00 - 00:00 #32365 - Marcus-Gunn syndrome: case series study and management algorithm.
Marcus-Gunn syndrome: case series study and management algorithm.

Purpose: Long-term surgical outcomes of a series of patients with Marcus Gunn jaw winking syndrome (MGJWS) with moderate to severe ptosis.

 

Methods: Retrospective review of 34 consecutive patients with MGJWS who presented at a tertiary referral centre from 2000 to 2020.

 

Results: Ipsilateral hypotropia and refractive errors were seen in 62% of patients. Eight cases with mild ptosis were managed conservatively. Eight cases with various degrees of ptosis and moderate synkinetic movement were submitted to levator advancement or resection. Seven patients underwent unilateral levator excision (LE) and unilateral frontalis suspension (FS); five were submitted to unilateral LE and bilateral FS; three underwent bilateral LE and bilateral FS; three were submitted to bilateral FS without LE. Seven cases had FS with autogenous fascia lata, 9 with donor fascia, 2 with expanded Polytetrafluoroethylene. Jaw winking was temporary resolved in all patients who were submitted to LE but recurred in 4 patients with severe preoperative jaw winking. Levator advancement was successful in case of moderate ptosis and negligible synkynetic movement; levator resection in severe ptosis was associated with unpredictable results.

 

Conclusion: If only mild ptosis and mild jaw winking are present, no intervention is recommended; if moderate ptosis is the main problem, it can be corrected with levator advancement, but success is not related to levator function and patients should be warned that the aberrant movement may get worse. Levator resection appears to be ineffective in severe cases. If there is severe ptosis and the aberrant movement is evident, LE and FS is recommended. Severe unilateral ptosis with moderate jaw winking may be treated with a bilateral FS without LE.  Severe preoperative jaw winking has an increased risk of postoperative residual synkinesis compared with moderate jaw winking. Unilateral frontalis flap with or without unilateral LE may be an alternative to FS.


Matteo DI MARINO (Rome, Italy), Francesco Maria QUARANTA-LEONI
00:00 - 00:00 #31712 - Merckell cell carcinoma of the eyelid- case report and current therapy options.
Merckell cell carcinoma of the eyelid- case report and current therapy options.

Aim: To highlight the importance of early recognition and treatment of this rare but serious type of cancer and updates on current treatment options

Methods: We present the case of an 88 year old patient that presented with rapidly enlarging upper eyelid tumour and the management of this case.

Results: The patient initially presented with small tumour of the right upper lid, consistent with a chalazion, that starting rapidly enlarging within 2 weeks. He had a performance status of 2, with previous history of atrial fibrillation and prostate cancer in remission, on Apixaban. Clinically Merckell cell carcinoma was diagnosed and patient underwent excision biopsy with 5mm margins clearance and delayed reconstruction initially with Cutler Beard technique. He underwent comprehensive tests including blood tests and imaging. The imaging raised question about possible nasopharyngeal and colon lesions. Patient underwent specialist biopsy of the area, which were deemed to be unrelated and benign. 

Patient had further eyelid surgery as there was ocular surface exposure post residual flap snapping, and significant skin scarring for upper and lower eyelid. 3 months into the first diagnosis recurrent tumour in the medial aspect of the reconstructed lid extending to the anterior medial orbit was noted, as well as preauricular node involvement. Repeated imaging showed no other extension. Patient was discussed with tertiary centre MDT who advised Avelumab treatment locally. Patient underwent local debridement of the tumour (biopsy confirming high grade carcinoma in keeping with Merckell carcinoma)  and after referral to local oncology team started 2 weekly infusions with Avelumab. 

8 infusions later and 8 months after initial presentation, patient retains good visual acuity and corneal surface and unaltered quality of life. There have been no significant side effects from current treatment.

Discussion: Merckell cell carcinoma is a very rare, agressive tumour that with a high mortality. Risk factors have been described: immunosupression, sun dammage or polyoma virus. Wide local excision with or without radiotherapy is the first line treatment. Avelumab is a check point inhibitor with promising results. Despite advanced age, the patient was keen to undergo all possible treatment.

Conclusion: Early recognition and treatment of Merckell cell carcinoma is essential in preventing recurrences and life expectancy.


Cornelia POITELEA, Roshni SAWH (SHOREHAM-BY-SEA, United Kingdom), Rashmi RAO
00:00 - 00:00 #32219 - Merkel cell carcinoma of the eyelids, a diagnosis to never forget.
Merkel cell carcinoma of the eyelids, a diagnosis to never forget.

Merkel cell carcinoma (MCC) is an aggressive and extremely rare malignancy in the and periocular area. It is commonly diagnosed in the seventh decade with a slightly higher prevalence in women.

57-year-old woman was referred to our clinic presenting a rapid growing lobulated painless upper eyelid lesion with partial eyelash loss and telangiectasia of her left eye, the visual function was preserved. Incisional biopsy was reported as MCC. A 13 mm long lesion was removed leaving 5 mm surgical margins. We performed a Cutler-Beard flap to reconstruct the superior eyelid. Sentinel lymph node biopsy (SLNB) of the cervical region was reported as negative and the patient was not prescribed any further treatment, only follow-up.

After a 2-month period, the patient presented a preauricular nodule on her left side, a fine-needle aspiration biopsy was performed and reported as MCC metastasis. The patient received 56.25 Gy in the periocular region and 50 Gy in the cervical area. At present, after1 year follow-up, the patient remains disease free with optimal ocular function.

The tumor size at presentation is a very important prognostic factor for the periocular MCC. Duo to frequent regional lymph node involvement, SLNB is suggested to improve overall disease survival. Adjuvant radiotherapy to the surgical bed and/or to the regional lymph node remains controversial. Due to reported risk of 20-60% of nodal metastasis at the time of diagnosis, adjuant radiotherapy may be justified as a prophylactic measure to all patients. The only statistically significant factor associated with a decrease disease free survival is nodal metastasis at presesntation.

Diagnosis and treatment timing in MCC is crucial. These lesions are frequently misdiagnosed as cyst, chalazion or basal cell carcinomas. About 20% of these patients will present metastasis by the time of the diagnosis. 


Grethel RIVAS DANGEL (A CORUNA, Spain), Sofia ALMAGRO SOTELO, Vivian PÉREZ VARELA
00:00 - 00:00 #32471 - New algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis.
New algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis.

Posterior approach is recommended for correction of mild to moderate upper eyelid ptosis. The aim of the study is to present a new algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis in adults.

Materials and methods:

This pilot study included 97 eyes of 60 patients aged on average 69 (range 47-87) years with involutional ptosis and upper eyelid margin reflex distance (MRD) <2 mm. In the years 2019-2022, all patients underwent ptosis correction from posterior approach using an algorithm based on the degree of ptosis, the function of the levator palpebrae superioris muscle and the 10% phenylephrine test result. There was minimum 3-month follow-up. Outcomes were assessed based on pre- and postoperative MRD1 changes, inter-eyelid height symmetry, cosmetic effect, and complications.

Results:

MRD1 changed statistically significant from 0.2±1.6 mm before to 4.1±1mm after surgery. The function of the levator palpebrae superioris muscle was 10.2±3.4 (range 5-17) mm. Upper eyelid lifted by an average of 1.8± 0.7mm after the installation of 10% phenylephrine. An average of 8.5±0.8 (range 8-10) mm of conjunctiva and Mueller's muscle and 2.2±0.9 (range 1-4) mm of the upper eyelid tarsus were resected during the procedure. There was no inter-eyelid height asymmetry>1mm. Significant blepharochalasis appeared in 23% eyes after surgery.

Conclusion:

The algorithm used in this study seems to be useful to achieve repeatable satisfactory outcomes of the transconjunctival correction of moderate to severe upper eyelid ptosis in adults.


Izabela NOWAK-GOSPODAROWICZ (Warszawa, Poland), Marek RĘKAS
00:00 - 00:00 #32229 - NTRK rearranged mesenchymal eyelid neoplasm.
NTRK rearranged mesenchymal eyelid neoplasm.

The aim of this report is to present girl diagnosed with eyelid neoplasm of mesenchymal origin in whom  NTRK inhibitor entrectinib was successfully administrated.

She presented at age of  15 months as recurrent chalazion. After clinical and radiological follow-up a diagnosis of right upper eyelid tumour was made. After surgery histopathological analysis confirmed the diagnosis of NTRK-rearranged spindle cell neoplasm according to the new 2020 WHO classification of soft tissue tumours. The possibility of an aggressive clinical course could not be excluded. Entrectinib therapy was initiated. Patient tolerated the medication very well and is without the radiological signs of eventual local relapse.


Renata IVEKOVIC (Zagreb, Croatia), Ognjen ZRINSCAK, Leo PZANIN, Jasminka STEPAN GILJEVIC
00:00 - 00:00 #32452 - Ocular findings in tangier disease: a case report.
Ocular findings in tangier disease: a case report.

Purpose: To report the case of a patient with Tangier disease, a genetic disorder characterized by severe deficiency or absence of high-density lipoprotein (HDL)-cholesterol presenting with distinctive ocular findings.

Material and Methods: A retrospective review of medical records from a patient diagnosed with Tangier disease was performed. 

Results: A 45-year-old female was referred to ophthalmic evaluation for bilateral eyelid abnormalities. Her medical history included a recent diagnosis of coronary disease and large vessels stenosis, attributed to accelerated atherogenicity, peripheral polyneuropathy affecting predominantly the upper limbs, and facial diplegia. At ophthalmological examination, the patient presented bilateral lagophthalmos with incomplete eyelid closure, enlarged eyelids with apparent yellowish deposits, and bilateral mild corneal opacities. Visual acuity was 20/25 bilaterally. No other alterations were noted at anterior segment examination or fundoscopy. Extensive systemic work-up was performed, revealing an undetectable level of HDL-cholesterol and low levels of apolipoprotein A-1. Eyelid biopsy was compatible with xanthoma. Genetic testing with ATP-binding cassette transporter A1 (ABCA1) molecular gene sequencing was conducted, showing a compound heterozygotic mutation in the ABCA1 gene. The definite diagnosis of Tangier disease was established based on clinical, laboratory, and genetic findings.

Conclusion: Tangier disease is an extremely rare genetic disorder caused by an autosomal recessive mutation in the ABCA1 gene, necessary for the generation of HDL particles from cellular cholesterol and phospholipids. Deposition of cholesterol esters occurs in various tissues, including ocular structures, resulting in characteristic ocular findings. Recognition of these abnormalities may raise the suspicion of Tangier disease, assisting in early diagnosis and accurate management of these patients.


Catarina FERREIRA (Vila Nova de Gaia, Portugal, Portugal), Dália MEIRA, Sandra PRAZERES
00:00 - 00:00 #32164 - Ocular surface and tear film function changes following hughes procedure.
Ocular surface and tear film function changes following hughes procedure.

Purpose:The Hughes procedure has been frequently used to repair full-thickness lower eyelid defects with a high functional and aesthetic success rate. This study aimed to evaluate its effect on the ocular surface and tear film function postoperatively.
Methods:We retrospectively identified patients who underwent Hughes's procedure in the Department of Ophthalmology, University of Cologne, between January 2015 and May 2019. Data were collected on patient demographics, defect size, adjuvant surgical procedures required for reconstruction, as well as surgical and postoperative complications. Meanwhile, postoperative ocular surface function indicators were evaluated by ocular surface disease index (OSDI),tear film osmolarity, matrix metalloproteinase 9 (MMP-9), in vivo confocal microscopy examination,slit-lamp microscopy examination (including tear film break-up time (TBUT),corneal fluorescein staining, conjunctival fluorescein staining),and Schirmer's I test.
Results:Seventeen patients (17 eyes) were retrospectively identified. They were primarily female (71%), and basal cell carcinoma was the most common pathology (76%). Their mean age was 74 years (SD 9.01 years, range 56 - 86 years), and the mean follow-up time was 44.65 months (SD 24.16 months, range 19 - 106 months). MMP-9 values were significantly higher in the operated eye than in the healthy eye (P = 0.006). They were more significantly raised in patients with defects of more than 50% lower eyelid (P = 0.034). Furthermore, lower eyelid laxity was more evident in patients with defects of more than 50% lower eyelid  (P = 0.009). More visible fluorescein staining was observed on the inferior central conjunctiva of operated eyes. There were no statistical differences in the TBUT, Schirmer I test, and tear osmolarity (P = 0.146, 0.108, and 0.234, respectively).
Conclusions:Hughes procedure is suitable for various defect sizes and results in excellent functional and cosmetic outcomes. Although complications are relatively infrequent, postoperative inflammatory factors and ocular surface function changes can still be detected.


Sitong JU (Koln, Germany), Senmao LI, Ludwig M. HEINDL
00:00 - 00:00 #32484 - Oculoplastic, reconstructive and prosthetic treatment of post-traumatic lesions of the orbital region.
Oculoplastic, reconstructive and prosthetic treatment of post-traumatic lesions of the orbital region.

AIM: To present five cases of treatment of post-traumatic lesions of the orbital region treated with oculoplastic, reconstructive and prosthetic methods.

PATIENTS AND METHODS: The functional and aesthetic results of complete oculoplastic, reconstructive and prosthetic treatment were analyzed in 5 representative patients. The anatomical structures of orbital regions were with prominent post-traumatic lesions due to which prosthetic treatment was very difficult or impossible.

RESULTS: Analyzed patients were surgically and prosthetically treated on several occasions. Various oculoplastic, reconstructive and prosthetic procedures were conducted depending on the required correction of the existing lesions of orbital regions. The required oculoplastic procedures included: substitution of the missing oribtal tissue volume with various types of implants and fillers, as well as correction of deformities of orbital bone structures, correction of eyelid deformity and position, mucosal graft transplantation, correction of conjunctival fornices. Satisfactory results have been achieved from both functional and aesthetic aspect.

CONCLUSION: In cases where prosthetic rehabilitation was impossible or very difficult, the administration of necessary oculoplastic and reconstructive procedures accompanied by complementary prosthetic treatment achieved satisfactory functional esthetic effects of prosthetic treatment and correction of deformity facilitating socialization of such patients.


Djoko OBUCINA, Miroljub BOGDANOVIC, Vladimir BOGDANOVIC (Belgrade, Serbia), Milica BOGDANOVIC
00:00 - 00:00 #32162 - Onwards and upwards: intra-palpebral migration of a rigid gas-permeable contact lens.
Onwards and upwards: intra-palpebral migration of a rigid gas-permeable contact lens.

Objective

To describe an unexpected finding of a rigid gas-permeable contact lens (RGP-CL) within levator muscle during routine ptosis surgery.

Method

Clinical and photographic findings are presented, along with literature search results of reports of intra-palpebral migration of RGP-CL.

Results

A 64 year old lady was referred to clinic with bilateral upper lid ptosis. She had a history of RGP-CL wear and had stopped wearing them 5 years prior to presentation. Clinically she had features consistent with aponeurotic ptosis, with no lid lumps or swelling. Levator function was normal on assessment. She denied any history of previous lid surgery. Risks and benefits of surgery were discussed and after some time to consider these, she agreed to proceed with left upper lid ptosis surgery under local anaesthetic. During surgery, there was noted to be significant fibrosis between levator and tarsus. The levator complex was found to be bulky and on further exploration a firm, cystic lesion was found within the levator muscle. Further dissection revealed a retained RGP-CL surrounded by a fibrous capsule. The lens was removed intact and sent to microbiology. The fibrous capsule was excised and sent to histopathology. Levator advancement was performed but the patient was advised the outcome may be sub-optimal due to levator fibrosis. However, at post-operative review she was very happy with the result and showed an improvement in palpebral aperture. Lab results showed no growth from the RGP-CL. Histopathological analysis reported chronic papillary and follicular conjunctivitis, with no evidence of epithelial atypia. She went on to have uneventful right upper lid ptosis repair.

Discussion

It is possible the RGP-CL migrated to the fornix and slowly eroded through the forniceal conjunctiva into the eyelid. Although previous case reports detail similar findings, these all report preceding lid lump/swelling; neither were present in this case.


Harpreet KAUR (Sheffield, United Kingdom), Sarju ATHWAL
00:00 - 00:00 #30757 - Outcome of silicone sling frontalis suspension in isolated uncomplicated congenital ptosis vs. complicated ptosis.
Outcome of silicone sling frontalis suspension in isolated uncomplicated congenital ptosis vs. complicated ptosis.

Objective: Our purpose was to compare the outcome of silicone sling frontalis suspension (FS) surgery in children with isolated uncomplicated congenital ptosis (IUCP) vs. children with complicated ptosis.

Methods: A retrospective medical chart review of all pediatric patients who underwent double-triangle silicone sling FS surgery between 2009-2020 at a single center. Patients were divided according to ptosis type: IUCP vs. complicated ptosis.  Pre-and post-operative margin to reflex distance (MRD1) measurements were determined from clinical photographs using ImageJ Software. Main outcome measures were differences in improvement in eyelid height, reoperation rate and timing between the groups.

Results: Two-hundred and eight children were included: 139 IUCP and 69 complicated cases, 83 females (40%), mean (±SD) age at intervention was 1.9±2.9 years. Complicated cases included: blepharophimosis epicanthus inversus syndrome (BPES, n=35), Marcus Gunn jaw winking (MGJW, n=12), oculomotor palsy (n=8), congenital fibrosis of extraocular muscles (CFEOM, n=3), chronic progressive external ophthalmoplegia (CPEO, n=3), and others (n=8). A history of previous ptosis repair surgery at presentation was more common in the complicated group (n=21,30% vs. n=16,11% respectively, p=0.002,  χ2). Complicated ptosis cases were operated at an older age:  3.1 vs. 1.4 years (P=0.002). 74 (36%) children underwent bilateral surgery, and this was more common in the complicated cases (25% vs. 56%, p<0.001, χ2). Mean MRD1 improved by an average of 1.6 mm in both groups. Repeat ptosis repair was performed in 50/171 (29%) patients without a history of a failed ptosis procedure, and this rate was similar between IUCP and complicated cases (p=0.8). Overall, repeat ptosis repair was performed in 64 (31%) patients, 31.2±20.9 months after the initial procedure. Patients under 3 years of age were more likely to undergo a repeated repair (34% vs. 15%, p=0.03, χ2). Cases of MGJW had a shorter period until repeated procedure.

Conclusions: Double silicone sling FS has a favorable outcome in 70% of pediatric patients and this includes both IUCP and complicated cases. Preoperative and final MRD, reoperation rate and parental satisfaction were similar between both groups, suggesting that despite the higher complexity in atypical cases, the outcome is similar. These encouraging findings support the use of double triangle FS in complicated cases.


Daphna LANDAU (Tel Aviv, Israel), Cindy ZHAO, Meera RAMAKRISHNAN, Karen E. REVERE, William R. KATOWITZ, James A. KATOWITZ
00:00 - 00:00 #32349 - Outcomes of peri-ocular non-melanoma skin cancer following MOHS surgery over 5 year period– Retrospective, Single centre experience.
Outcomes of peri-ocular non-melanoma skin cancer following MOHS surgery over 5 year period– Retrospective, Single centre experience.

Purpose

Our objective was to report our experience following Mohs micrographic surgery for high risk head and neck basal cell carcinomas (BCC)

Methods

This retrospective cohort study reviewed patients who underwent Mohs micrographic surgery for periocular skin tumours during January 1st, 2013 and December 31st, 2017 in a single ophthalmic unit. We recorded patient demographics, maximum clinical tumour size, histopathology, reoccurrence and survival.

Results

169 patients underwent Mohs micrographic surgery (MMS) for suspected basal cell carcinoma (BCC), median age at diagnosis was 73 years IQR 17 (63-80), of which 161 were primary MMS excisions and 8 secondary excisions following reoccurrences. Nodular BCC was the predominant histological subtype (n=88, 52%), infiltrative (n=17, 10%), and mixed nodular histological subtypes (n=52, 30%). Majority of the tumours were noted on the lower eyelid (n=70, 41%) and medical canthus (n=55, 32%). Median pre-operative lesion diameter (maximal) was 10 mm that increased to 15.5mm defect following MMS. Less than <1% were found to have reoccurrence in the previous site of surgery following MMS during the minimum 3-year follow-up period.

Conclusion

Very few studies have reported on long term outcome of “high risk” basal cell carcinomas (ill-defined lesions, periocular, median maximal diameter 10mm), following Mohs micrographic surgery. Our review found a low reoccurrence rate <1% over a minimum 3-year follow-up period, supporting Mohs micrographic surgery as a treatment for choice for such cases.


Ibtesham HOSSAIN, Marta GARCIA-VILARO (London, United Kingdom), Anna GKOUNTELIA, Ioulios PALAMARAS, Mohsan MALIK, Priyanka SANGHI, Wessam MINA, Linda BLACKWELL
00:00 - 00:00 #30791 - Outcomes of vismodegib for periocular locally advanced basal cell carcinoma from an open-label trial.
Outcomes of vismodegib for periocular locally advanced basal cell carcinoma from an open-label trial.

Importance  The outcomes of vismodegib treatment in a relatively large cohort of study participants with periocular locally advanced basal cell carcinoma (POLA-BCC) may guide physicians when considering this treatment.

Objective  To report the outcomes of vismodegib treatment in patients with POLA-BCC in the Safety Events in Vismodegib (STEVIE) study.

Design, Setting, and Participants  This post hoc subgroup analysis from the STEVIE single-arm, multicenter, open-label cohort study screened all 1215 participants for ocular or periocular involvement and identified 244 participants with POLA-BCC or metastatic BCC. Data for the first STEVIE trial were collected from 167 treatment locations in 36 countries from June 30, 2011, to June 14, 2017. This post hoc analysis was performed from April 1 to August 31, 2019.

Main Outcomes and Measures  Response to treatment and adverse events.

Results  Ocular or periocular involvement was found in 244 of 1215 STEVIE participants (20.1%), who constituted the analytic sample. The median age of the study participants was 72.0 (interquartile range [IQR], 60.0-82.0]) years, and they included 143 men (58.6%). Locally advanced BCC was diagnosed in 238 of the 244 participants (97.5%) and metastatic BCC, in 6 (2.5%). The median duration of exposure to vismodegib was 40.0 (IQR, 20.0-78.0) weeks, specifically 39.7 (IQR, 19.9-76.0) weeks for POLA-BCC and 92.4 (IQR, 53.2-163.0) weeks for metastatic BCC. Sixty-nine participants (28.3%) sustained serious adverse events (alopecia, muscle spasms, dysgeusia, weight loss, decreased appetite, asthenia, ageusia, nausea, fatigue, and diarrhea). Two hundred thirty-two study participants (95.1%) sustained more than 1 adverse effect. The overall mean (SD) number of drug-related adverse effects per study participant by first adverse event, regardless of the severity, was 5.48 (3.84). Discontinuation of vismodegib treatment owing to an adverse event was recorded in 58 participants (23.8%). During the study, 22 participants (9.0%) died, 70 (28.7%) achieved complete response, and 94 (38.5%) achieved partial response.

Conclusions and Relevance  Vismodegib was well tolerated by the study participants with POLA-BCC. The safety of vismodegib treatment according to the STEVIE trial findings is consistent with that reported in previous studies. These data may be helpful when considering vismodegib for patients with POLA-BCC.


Meydan BEN ISHAI (Tel Aviv, Israel), Alon TIOSANO, Eyal FENIG, Guy BEN SIMON, Iftach YASSUR
00:00 - 00:00 #31620 - Outcomes on the utilization of lipodermoid skin for anterior lamella reconstruction in severe lipodermoids with eyelid coloboma: a case series.
Outcomes on the utilization of lipodermoid skin for anterior lamella reconstruction in severe lipodermoids with eyelid coloboma: a case series.

We describe a retrospective case series involving two patients describing the clinical presentation, surgical management and clinical progress following anterior lamellar reconstruction using lipodermoid skin as a skin graft. An 8 month-old girl presented with a lipodermoid at the lateral canthus and a medial upper lid coloboma with the fornix absent superomedially in this location. A large medial epicorneal lipodermoid was present extending nasally into the medial fornix and obliterating the superomedial fornix and caruncle. The medial and lateral lipodermoids were partially excised, preserving all skin. Fornix defects were reconstructed with a buccal mucous membrane graft. The anterior lamella of the medial upper eyelid was reconstructed using the medial lipodermoid skin. A levator recession was performed and a full-thickness skin graft was placed using the defatted skin of the lipodermoid of the lateral canthal cleft. A retractor recession was performed and a full thickness skin graft taken from the medial lipodermoid skin placed. The lateral canthus lipodermoid was debulked and lateral canthal angle reformed. Due to an upper eyelid notch causing focal lagophthalmos, revision surgery with superior fornix reconstruction with repeat buccal graft and post-auricular skin graft to the pre-tarsal upper eyelid was performed. A newborn male presented with a large right upper lid coloboma, medial lower lid coloboma, a microphthalmic right eye and a large lipodermoid lesion in the inferior cul de sac. Lipodermoid transposition was performed followed by cheek expansion, and subsequent lower lid repair with a rotating cheek flap. The upper lid coloboma was repaired using the lipodermoid skin as a transposition flap with good cosmesis. This case series provides evidence by proof of concept that the utilization of lipodermoid skin in the primary reconstruction of the eyelid anterior lamella may be considered a useful option, thereby avoiding use of conventional skin grafts in children.


Islam MERIAM (London, United Kingdom), Raman MALHOTRA, Danny MORRISON, Samer HAMADA, James KATOWITZ
00:00 - 00:00 #32148 - Overview of various technique of reconstruction after tumor removal. Our 2 years experience in 176 operated cases.
Overview of various technique of reconstruction after tumor removal. Our 2 years experience in 176 operated cases.

Topic:Overview of various surgical techniques of reconstruction of  the eyelid after tumor removal.Our 2 years  experience in 176 operated cases.Objectives:To present the surgical techniques of palpebral reconstruction after removal of tumor, to select and adapt the technique to each patient taken in the study.Methods and Study:176 cases of patients with eyelid tumors over the period from 2018 to 2020 at the University Ophthalmology Clinic in Tirana were studied.All patients underwent surgical removal of the tumor and subsequent reconstruction of the eyelid.The choice of surgical technique is made depending on the size and position of the tumor.All removed samples have undergone histopathological evaluation and follow up 18 months from the removal of the primary tumor.All cases presented that have undergone eyelid reconstruction interventions are classified into inferior eyelid reconstruction, medial angle, superior eyelid reconstruction. The most used techniques are direct closure, lateral canthotomy, Hughes flap, Cutler -Beard technique, Tenzel ”rotational flap,Glabellar flaps, eyelid sharing, flap advanced into defect, Mustard cheek rotation flap, tarsal graft, nasojugal transposition flap, rhombic flap. Only the 4mm surgical removal technique was used in sound borders and not radiotherapy.Results:For defects smaller than 2/3 of  the eyelid more often lateral advancement flap.For defects more than 2/3 of  the eyelid was used Hughes tarsoconjuctival flap technique was used more often. In cases of medial angle reconstruction after tumor removal the most commonly used technique was glabella v and y flap.The most commonly used technique in the reconstruction of the upper eyelid is the Cutler – Beard flap  technique.Conclusion:The eyelids are complex and dynamic structures at the same time, therefore their reconstruction is not easy.The selection and application of the technique rigorously makes the patient have a satisfactory functional and aesthetic result after surgery.Basal cell carcinoma is the most common tumor of the eyelids and is located mainly in the inferior eyelid.Reconstruction and selection of surgical technique depends on the dimensions and position of tumor.Large tumors creates greater difficulty in reconstruction of  the eyelid also functionally and aesthetically creates unsatisfactory results.One of the major problems in Albania is late diagnosis. Patients consult a specialist when the eyelid tomor is very l


Alda SHYQYRIU ZANI (Tirana, Albania), Eglantina BULICA
00:00 - 00:00 #31731 - Periocular basal cell carcinoma recurrence following surgical treatment: safe surveillance time.
Periocular basal cell carcinoma recurrence following surgical treatment: safe surveillance time.

Purpose: To report the rate of primary periocular BCC recurrence following surgical excision in low-risk and high-risk BCCs, and to propose long term follow up guidelines.

Design: Retrospective case series.

Participants: Patients with primary BCC treated with surgical excision (Mohs micrographic surgery [MMS], wide local excision [WLE] or fast paraffin excision) who have histologically-confirmed BCC subtype and histologically-measured tumour clearance margins, and were followed up for a minimum of 12 months following surgery for low-risk BCC, or minimum of 36 months following surgery for high-risk BCC.

Methods: Retrospective review and statistical analyses.

Main outcome measures: Patient demographics, location of tumour, surgical excision type, histological subtype, tumour clearance, further treatment, recurrence rate and follow up duration.

Results: 77 patients (78 eyelids) were included. Their ages ranged from 29 to 90 (mean 72 years) with a female predominance (42, 54.5%). The most common histological BCC subtype was nodular (39, 50.0%). 44 (56.47.1%) patients underwent MMS.

Tumour clearance was achieved in 59 (75.6%) eyelids after one surgery. 9 had further surgery to achieve tumour clearance while 10 were monitored. There was no statistical significance between recurrence rates in patients who had tumour clearance compared with patients with incomplete tumour clearance after initial surgery (p=0.15). In patients with incomplete tumour clearance, there was no statistical significance between recurrence rates in those who underwent further surgery versus those who were monitored (p=0.47).

The average follow up duration was 37.9±17.2 months. Three (3.9%) cases had recurrent BCC. All three cases had high-risk BCC features (infiltrative subtypes and/or incomplete tumour excision after initial surgery).

 

Conclusions:

There was no evidence of recurrence of completely excised, low-risk BCCs at three years, regardless of type of surgical excision. We recommend patients with completely excised, primary BCCs without high-risk features be monitored for one year. Patients with any high-risk BCC features, such as incompletely excised tumours or high-risk histological subtypes, should be monitored for five years.

 


Prachi SHAH (LONDON, United Kingdom), Valerie JUNIAT, Oana VONICA, Claire DANIEL, Fabiola MURTA
00:00 - 00:00 #30754 - Periocular Mohs micrographic surgery in a UK centre 2012-2019; a retrospective cohort study.
Periocular Mohs micrographic surgery in a UK centre 2012-2019; a retrospective cohort study.

Introduction

Mohs Micrographic surgery (MMS) is the gold standard treatment for periocular non-melanoma skin cancers. Periocular tissues are critical both functionally in maintaining the ocular surface and visual function, and aesthetically. Long-term follow up data is limited for periocular MMS and reconstruction. We aim to describe our outcomes across an 8-year period.

 

Methods

A single-centre retrospective cohort study was carried out including all patients who underwent MMS to the periocular region between 1st January 2012 and 31st December 2019.

 

Results

244 cases were treated with MMS and reconstruction to the periocular region between 1st January 2012 and 31st December 2019 at Buckinghamshire NHS Trust. 92.2% of the cases involved BCCs (n= 225), 3.3% were SCCs (n=8). The majority of the tumours were located on the lower lid and medial canthus (n=215, 88.1%). The majority of tumours were excised within 2 stages of MMS (n=125, 92.3%). The majority of cases were reconstructed on the same day (n=211, 86.5%).

 

At 3 months post-surgery, the functional and cosmetic outcome from patient and healthcare professional perspective was noted. The majority of patients gained both good functional (n=223,91.4%) and cosmetic outcome (patient perspective n=220, 90.2%, healthcare professional perspective n=218, 89.3%).

 

Our cohort had a median follow up time of 27 months (interquartile range 13-36 months). Overall we encountered 3 recurrences in our cohort (1.2%), with 2 cases (0.82%) of recurrence occurring within 2 years and 1 case of recurrence within 5 years (0.41%).

 

 

Discussion

 

We present a relatively large, retrospective cohort study of patients with periocular keratinocyte carcinomas treated with MMS, by a dedicated multidisciplinary service involving dermatology and oculoplastics. The majority of patients gained good functional and cosmetic outcome under the care of the service, demonstrating the effectiveness of multi-disciplinary working on periocular keratinocyte carcinomas. The recurrence rate in our cohort was low (overall 1.2%), supports the effectiveness of MMS.

 

We conclude that MMS is an excellent treatment option for periocular keratinocyte carcinomas, and that multidisciplinary working between dermatology and oculoplastic services ensures the best chance of tumour clearance, alongside restoration of function and cosmesis to the periocular area. It is imperative for MOHS centres to collect outcome data in order to justify the gold-standard status of MMS.


Jennifer DOYLE (Buckinghamshire, United Kingdom), Dev SHAH, Richard SCAWN
00:00 - 00:00 #32428 - Periorbital Filling With The MD Codes™ Algorithm: A Narrative Review and a Practical Guide.
Periorbital Filling With The MD Codes™ Algorithm: A Narrative Review and a Practical Guide.

Introduction: The hyaluronic acid dermal fillers are employed to bring balance and facial harmony, improving the proportions and asymmetries of the structures, besides acting to reverse the signs of facial aging. The periorbital region is one of the first to show the signs of aging with periocular wrinkles, deepening of the nasojugal and palpebromalar folds, prolapse of the fat bags, excess palpebral skin, ptosis of the eyelashes, disappearance of the upper eyelid crease due to excess skin and hollowing of the upper eyelid. Aims: To describe the lines and grooves of the periorbital region and present a practical guide to the MD CODES™ algorithm for filling this region based on a narrative review of the literature. Methods: The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. Results: MD CODES™ algorithm maps anatomical points of the face (anatomical codes) that, when treated with fillers, promote instantaneous lifting and rejuvenation. In addition to defining the points for treatment, this method identified the order of the points to be treated, that is, which points should be prioritized to cause greater aesthetic impact. The MD CODES aim to standardize facial rejuvenation and is of particular interest for young as well as more experienced physicians. Conclusion: Was presented in detail the regions, the aesthetic effects of the application, the technique, the volume, and the target structure undertaken in the remodeling of the tear trough, periorbital, temporal, brow, and frontal regions.


André Luis BORBA DA SILVA (SAO PAULO, Portugal)
00:00 - 00:00 #32206 - Polynucleotides: Biostimulation in periocular rejuvenation.
Polynucleotides: Biostimulation in periocular rejuvenation.

Introduction: Periocular rejuvenation is one of the most sought-after aesthetic treatments, yet one of the most challenging areas to address with traditional injectable modalities. We present the results of an alternative treatment based on biostimulation rather than volumization.  

Methods: Review of three cases in which polynucleotides have successfully been used to treat three different age-related concerns affecting the periocular area. 

Results: Polynucleotides are a safe injectable treatment which can help enhance the appearance of the infraorbital region with natural results. 

Conclusion: Periocular skin concerns such as skin laxity, prominence of the tear trough deformity and poor skin quality can be improved with polynucleotides. This type of biostimulation, as opposed to cross linked hyaluronic acid is suitable for a larger cohort of patients, as its mechanism of action, does not allow for post-treatment issues such as Tyndall effect, overtreatment, persistent oedema or vascular occlusions. Patient selection however remains key to obtain best results. 


Sara NUNEZ MARQUEZ (Bournemouth, United Kingdom), Madalina CHIHAIA, Ran STEIN
00:00 - 00:00 #32260 - Portable Next-Generation Three-dimensional Anthropometry Imaging Systems for Eyelid Area and Volume Assessment.
Portable Next-Generation Three-dimensional Anthropometry Imaging Systems for Eyelid Area and Volume Assessment.

Portable Next-Generation Three-dimensional Anthropometry Imaging Systems for Eyelid Area and Volume Assessment

 

Purpose: Portable three-dimensional imaging systems H2 and M3 are becoming increasingly common for facial measurement analysis. However, it is uncertain about the reliability of eyelid area and volume measurements with portable devices H2 and M3. The purpose of this study was to evaluate the effectiveness of portable devices Vectra H2 and M3 for assessing the area and volume of eyelid. 

 

Methods: In 81 Caucasian volunteers (162 eyes), four facial scans (twice for each instrument) using the portable VECTRA H2 and static VECTRA M3 devices were performed; patients’ heads were kept straight, looking ahead, with a neutral facial expression. Two assessor assessed intra- and inter-device reliability by comparing two within-device measurements and one between-device measurement, respectively.

 

Results: Regarding the measurement of the eyelid area, the intraclass correlation coefficient (ICC) (0.92, 0.98) showed good intra-rater reliability for M3 and H2; ICC (0.88, 0.96) indicated that inter-device reliability deteriorated compared to intra-device reliability; ICC (0.91, 0.97) showed good inter-rater reliability for M3 and H2. For the measurement of the eyelid volume, ICC( 0,0 ) exhibits low intra-rater, intra-device, and inter-rater reliability for M3.For H2,ICC(0.27,0.60) and 0.200.50showed moderate reliability in intra-rater and inter-rater.

 

Conclusions: The portable VECTRA H2 and M3 devices seemed to be reliable in assessing area of eyelidbut in assessing volume of eyelid, neither device is very accurate, but the H2 is relatively more accurate than the M3. Therefore, H2 can replace M3 in area measurement, even more accurate than M3 in volume measurement, and also has the advantage of portability.

Key words:Three-dimensional anthropometry, portable stereophotogrammetry devices, validity, reliability, 

periocular morphology


Xincen HOU, Wanlin FAN (Cologne, Germany), Ludwig M. HEINDL
00:00 - 00:00 #32238 - Posterior approach of medial tarsorrhaphy. A new technique.
Posterior approach of medial tarsorrhaphy. A new technique.

Purpose: Traditional medial tarsorrhaphy involved tissue removal and closure of anterior and posterior lamella in layers. We would like to present a new technique 

for medial tarsorrhaphy with posterior approach without tissue removal. 

 

Methods: We performed posterior approach medial tarsorrhaphy in two patients with facial palsy. In one of our patients we performed ectropion repair at the same time. After the instillation of local anaesthetic, Bowman probe is inserted in the canaliculi for protection. Upper and lower eyelids were everted and incision and made 2mm below the canaliculi to the conjunctiva horizontally and parallel to the lid margin medially to the punctums. Vicryl stitches are then placed through our incision full thickness to the superior and inferior limp of the medial canthus, respectively, and tied. Patient were reviewed 2 week, 4 and 6 months post-operatively and photos included.

 

Results: Both of our patients had nice and quick healing with no wound dehiscence. The cornea exposure improved significantly in both patients. 

 

Conclusion:  Posterior approach of medial tarsorrhaphy is a simple, quicker and effective technique to address medial lagophthalmos, especially in patients with facial palsy, with improved cosmetic outcome and long-term results, without the need of tissue removal.


Ourania FYDANAKI (London, United Kingdom), Lee VICKIE, Rajni JAIN, Aziz AHMAD
00:00 - 00:00 #31661 - Posterior-approach 'levatorpexy' in congenital ptosis repair- comparison between local and general anesthesia.
Posterior-approach 'levatorpexy' in congenital ptosis repair- comparison between local and general anesthesia.

Background: The authors report their experience with posterior approach levator plications ('levatorpexy') in children and young adults with congenital ptosis. Additionally, we compared the results between general anesthesia and local anesthesia during our surgeries. 

Materials and methods: This was a retrospective review of 21 consecutive patient (23 eyes). Posterior approach levatorpexy was performed for congenital ptosis under general or local anesthesia. This surgical procedure involves exposing the posterior surface of the levator muscle through a transconjunctival approach. The levator muscle is advanced and plicated using a suture passed through its posterior surface, partial-thickness, to tarsal plate and tied on the skin. No tissue (conjunctiva, Muller's muscle, levator) are excised during this procedure.

Data collected included margin reflex distance (MRD1) before and after the surgery, symmetry of eyelid height, contour, and complications. Surgery was considered successful if the following three criteria were simultaneously met: A postoperative MRD1 of ≥2 mm and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour. Due to the relative unpredictability of the final result in general anesthesia as a result of an unresponsive patient, we also compared the results of general anesthesia and local anesthesia. 

Results: Mean age was 24.1 years (range 8-47 years). Preoperative phenylephrine test was positive in 57% of patients. Mean levator function was 11.2 mm (range 7-15 mm). Mean preoperative MRD1 was 1.05 mm and 1.41 for general and local anesthesia respectively (p-value=0.195) Mean postoperative MRD1 was 3.33 mm and 3.37 mm for general and local anesthesia respectively (p-value=0.85). Eighteen patients (85%) achieved the desired eyelid height and fulfilled our criteria set for success. There were no complications in any of the patients.

Conclusion: Posterior approach levatorpexy appears to be a safe and effective procedure for correction of congenital ptosis particularly with moderate or better levator function. Since the results of local anesthesia and general anesthesia are not significantly different, this technique is also suitable for young patients as well as those who are unable to undergo local anesthesia alone.  


Meydan BEN ISHAI (Tel Aviv, Israel), Karny SHOUCHANE-BLUM, Inbal AVISAR
00:00 - 00:00 #31698 - Practice pattern in periocular rejuvenation.
Practice pattern in periocular rejuvenation.

Objective: To describe the treatment paradigm for periocular rejuvenation - brow ptosis, eyelid excess skin and ptosis, and lower eyelid bags.

 

Periocular rejuvenation involves surgical removal of excess skin, fat debulking or transfer with or without eyelid ptosis repair, brow ptosis repair, or lateral canthal resuspension. Periocular injectables have changed the way we treat these complex aesthetic problems, and in some instances have gradually replaced surgical treatment.

 

Methods: Retrospective data analysis of all patients treated for periocular rejuvenation - upper / lower eyelids in a 6-year period were collected and analyzed to treatment type and outcome. All patients were treated at a single private center by a single surgeon  (GBS).

 

Results: 1741 patients treated for upper eyelid/brow rejuvenation,  and 435 for lower eyelid rejuvenation.  Upper eyelid blepharoplasty was the most common procedure, followed by aesthetic ptosis surgery  (muller muscle conjunctival resection) in 34%. Trans-conjunctival fat debulking was the most common procedure for lower eyelid rejuvenation followed by midface and tear trough filler injections, canthopexy and fat injection. Botulinum toxin injections for crow's feet and glabellar lines were common independent of surgical procedure. Endoscopic brow-lift was performed in only 5% of patients.

 

Conclusions: Upper eyelid/brow rejuvenation commonly involves surgical blepharoplasty with or without cosmetic ptosis. In cases of deep superior sulcus, HA injection provides a better aesthetic outcome. Periocular fillers in selected cases may be preferable to conventional lower eyelid blepharoplasty.


Guy J. BEN SIMON (Tel Aviv, Israel)
00:00 - 00:00 #32020 - Ptosis correction with adjustable silicon rod.
Ptosis correction with adjustable silicon rod.

Poster abstract for ESOPRS 2022, 15-17 September 2022, Nice France.

Title: Ptosis correction with adjustable silicon rod.

Authors: Ritika Gupta, MD & Dag Krohn-Hansen, MD, PhD.

Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.

Purpose: To evaluate the efficacy of the silicone ptosis sling set from FCI S.A.S (Ref.1000, 75015 Paris-France) on a series of children suffering from severe congenital eyelid ptosis and operated on with frontalis suspension surgery.

Methods: Thirty-three patients (37 eyes) with ptosis between 0 and 7 years old (median age 18 months) with poor function of the levator muscle were operated on between January 2017 and December 2020. All patients underwent general anesthesia and were operated on with the silicone tube passed in a single triangle suspension and adjusted and closed via a short silicone sleeve. Median follow-up time was 7 months (range 1 to 10 months). Pre- and postoperative examinations included eyelid height measured as MRD1 (marginal reflex distance in primary position of gaze) and complications such as infections, marked lagophthalmos, exposure keratitis and exposure of sling material were registered.

Results: Overall, the final results were evaluated as satisfactory in 27 of the cases (30 eyes) whereas 6 cases (7 eyes) needed a second surgery for adjusting the eyelid height. No cases of serious complications were registered.

Conclusion: For the youngest children, or when temporary eyelid elevations are needed, the FCI silicone sling system offers a safe and effective alternative for suspension material. The silicone tubes are secured solely via the silicon sleeve without knots or necessity for additional fixation sutures. This allows for adjustment if necessary or for later removal of the silicon system if a permanent correction of the ptosis by autogenous fascia lata is performed.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the responsible for the content and writing of the poster abstract.

Correspondence:    

Postal address: Ritika Gupta. Oslo University Hospital. P.Box 4950. 0424 Oslo, Norway

E-Mail: rgau@ous-hf.no


Ritika GUPTA (Oslo, Norway), Dag KROHN-HANSEN
00:00 - 00:00 #32191 - Ptosis treatment by injection of botulinum toxin: a prospective study of 31 cases.
Ptosis treatment by injection of botulinum toxin: a prospective study of 31 cases.

Objective

Evaluate efficacy and tolerance of a medical treatment for ptosis by botulinum toxin injection

into the orbicularis muscle, a technique that is already used in the treatment of

blepharospasm. To our knowledge, this is the first description of this approach, common

treatment being surgery.

Methods:

In this prospective study, 31 eyelids from 25 patients are analyzed. Treatment consists of

injection of botulinum toxin (5 UI) into the pretarsal orbicularis, weakening this muscle.

Outcomes are the variation of interpalpebral distance (IPD) and MRD-1 (or Marginal Reflex

Distance 1) during the follow-up.

Results:

31 eyelids were analyzed (23 female and 8 male) with an average age of 68.5 years. Ptosis

was secondary to an ophthalmologic pathology in 11 cases, senile in 9 cases, asymmetry

after ptosis surgery in 7 cases, secondary to a diffusion of toxin after cosmetic injection in the

frontal muscle in 2 cases, and secondary to another etiology in 2 cases (one secondary to an

undetermined cause and the other secondary to a stroke). On average, DIP measurement

increases by 1.77 mm and MRD-1 by 1.32 mm after injections (p<0.001). Benign

complications are observed in 6 cases: 3 cases of keratitis, 1 case of chalazion, 1 case of

palpebral hematoma, and 1 case of increased ptosis, with spontaneous favorable outcomes.

Conclusion:

Treatment of ptosis by injection of toxin into the pretarsal orbicularis significantly reduces its

intensity. It could be considered in some well-defined cases as an alternative to surgery.

Best results seem to be observed with secondary ptosis.


Charles Henry REMIGNON, Francesco ESPOSITO (Toulon), Eric SARFATI
00:00 - 00:00 #30909 - Re-surgery for Congenital ptosis: characteristics, success rates and predictor factors.
Re-surgery for Congenital ptosis: characteristics, success rates and predictor factors.

Purpose: Congenital ptosis can cause occlusion amblyopia, astigmatism, ocular torticollis and cosmetic problems. The treatment for most of those patients is ptosis correction surgery. However, the success rates of those ptosis surgeries are unknown as well as the predictors factors for re-surgery. Therefore, the purpose of this current study was to examine the risk for second ptosis surgery in patients with congenital ptosis as well as to find predictors factors for re-surgery.

Methods: This is a retrospective, cohortstudy. Analysis of all patients with  congenital ptosis  who underwent their first ptosis correction surgery between 2010 to 2020 in Sheba Medical Center was done. Their demographic data, clinical data and surgeries data were retrieved. 

Results: Sixty patients (36 male and 24 female) underwent ptosis surgery for congenital ptosisFrom them,29 patients (48.33%) underwent frontalis sling (FS) surgery, 13 patients (21.67%) underwent levator aponeurosis advancement (LAA) surgery and 18 patients (30%) underwent Müller’s Muscle-Conjunctival Resection (MMCR) surgery for their first surgery. 

Eighteen patients (30%) underwent second ptosis surgery (14 male and 4 female). The proportion of re-surgery to each of the surgeries were: FS- 34.48%, LAA- 23.07% and MMCR- 27.78%. 

The unadjusted risk of second ptosis surgery was almost fourfold higher among male with ptosis relative to female with ptosis (HR, 3.90; 95% CI, 3.67-547; P=0.032) and higher among younger individuals (HR, 4.23; 95% CI, 3.33-5.62; P=0.042). Older age (>3years) was proved protective against the risk of second ptosis surgery (adjusted OR, 0.50; 95% CI, 0.21-0.60; P<0.001), whereas a male sex was associated with an increased likelihood of second ptosis surgery (adjusted OR, 3.33; 95% CI, 1.64-3.98; P<0.001) as well as lower MRD1 (adjusted OR, 2.43; 95% CI, 1.32-2.88; P=0.04).

Conclusions: There is a risk for re-surgery in congenital ptosis for almost a third of the cases.An increased risk of second ptosis was found among male patients, patients younger than 3 years old and patients with low MRD1 at first surgery. Awareness of those factors is of benefit for clinicians as well as for the parents of those patients. Both of them should be aware of the high risk for  re-surgery as well as the long term follow up that those patients need.

 

 

 


Ofri BERAR (Ramat Gan, Israel), Abergel EDEN, Ben Simon GUY, Zloto OFIRA
00:00 - 00:00 #32358 - Reconstruction of a complete upper eyelid thermal burn using serial skin grafts with preservation of vision, eyelid function & aesthetics.
Reconstruction of a complete upper eyelid thermal burn using serial skin grafts with preservation of vision, eyelid function & aesthetics.

Purpose

To present a successful reconstruction for a complete upper lid burn

 

Methods

A 70-year-old man suffered an upper eyelid thermal burn on collapsing over a radiator following a syncopal attack. Complete upper lid burn involving full-thickness skin, orbicularis and central third of tarsus was seen. Systemic co-morbidities limited surgical options under local anaesthetic. Stage one (day 7) involved eschar debridement, temporary allograft placement and insertion of a bandage contact lens (BCL). Stage two (week 3) involved replacement of the allograft with a split-skin graft. Six-weeks later, posterior lamellar deficiency was apparent as a wide notch and upper lid contracture lifted the lid away from the globe, making it impossible to retain the BCL. Stage three involved release of contracture, placement of a full-thickness skin graft & a glabellar flap to cover the sub-brow canthal area. Tarsus was not replaced. The BCL was removed and dryness managed with lubricants.

 

Results

Two years post-injury, the patient has excellent aesthetic results despite a vertical lid deficiency. The cornea is well protected & vision is preserved.

 

Conclusion

This demonstrates successful reconstruction of a complete upper lid loss from a burn injury with serial skin grafts, without the use of bulky & immobile flaps.


Manvi SOBTI (London, United Kingdom), Isabel JONES, Jorge LEON-VILLAPALOS, Aoife NAUGHTON, Richard SCAWN
00:00 - 00:00 #32190 - Reconstruction of periocular defects following excision of large cutaneous malignancy- a case series.
Reconstruction of periocular defects following excision of large cutaneous malignancy- a case series.

Reconstruction of periocular defects following excision of cutaneous malignancy can present difficulties for oculoplastic surgeons. The  anatomy of the periocular area requires precise restoration in order to avoid postoperative functional and aesthetic problems. 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. Reconstructive surgical planning is determined by several factors including the nature of the defect, the health and age of the patient, the availability of surrounding tissue and the surgeons experience. We present a case series of reconstruction of six callenging cases with diferent size, location and diagnosis of the malignancy. 


Artur KLETT (Tallinn, Estonia)
00:00 - 00:00 #32348 - Reconstruction of the medial canthus following Mohs micrographic surgery.
Reconstruction of the medial canthus following Mohs micrographic surgery.

Purpose

Our objective was to review post-Mohs micrographic surgery (MMS) medial canthus defects and propose a local algorithm for reconstruction of the defect.

Methods

This retrospective cohort study reviewed patients who underwent MMS for peri-ocular skin tumours from January 1st, 2013 to December 31st, 2017 in a single institution. We recorded patient demographics, maximum clinical tumour size, maximum post-Mohs margins, and complications of note.

Results

55 patients underwent MMS for suspected basal cell carcinoma (BCC) in the medial canthus region. Median age at diagnosis was 73 years (IQR 16). Nodular BCC was the predominant histological subtype (n=29, 52%), with infiltrative (n=5, 9%), and mixed nodular histological subtypes (n=16, 29%) also recorded. Median pre-operative (maximum) lesion diameter was 9 mm (IQR 7) that increased to a 15 mm (IQR 8) defect following MMS. Most defects were reconstructed using local flaps (n=44, 80%), of which 34% were transpositional, 33% rotational and 33% advancement. One patient developed flap necrosis which was managed conservatively. Other cases underwent reconstruction with direct closure (10%), use of a skin graft (6%) or using a laissez faire (4%) approach.

Conclusion

Reconstruction of medial canthal defects are challenging due to the variety of adnexal structures that may be involved with the primary tumour, in particular the lacrimal apparatus, as well as the unique contouring in the aesthetic sensitive region. The primary aim of reconstruction is therefore to reduce morbidity and dysfunction. We found functionally satisfactory outcomes are achievable following review of various closure techniques. We propose an algorithm to guide reconstruction based on location and size of the defect at the medial canthus.


Mohsan MALIK (London, United Kingdom), Marta GARCIA-VILARO, Anna GKOUNTELIA, Linda BLACKWELL, Ibtesham HOSSAIN, Wessam MINA, Ioulios PALAMARAS, Priyanka SANGHI
00:00 - 00:00 #32167 - Reconstruction of Upper Eyelid Defects Using an Acellular Dermal Matrix Graft Combined with a Tipped Flap.
Reconstruction of Upper Eyelid Defects Using an Acellular Dermal Matrix Graft Combined with a Tipped Flap.

a tipped flap to reconstruct large full-thickness upper eyelid defects.

Method: en patients were enrolled. Among them, nine (nine eyes) resulted from eyelid carcinoma, and one (one eye) had an upper eyelid full-thickness defect after trauma. The tarsal plate defects were repaired using an acellular dermal matrix graft that was 1 mm wider than the defects. A skin-orbicularis muscle flap was glided or transferred over the acellular dermal matrix graft according to the dimensions of the defect.

Results: After cancer removal, the nine patients had full-thickness upper eyelid defects 50% of the eyelids margin. The patient with an eyelid defect due to trauma had a full-thickness upper eyelid defect ranging 70% of the eyelid margin. All ten patients showed satisfactory cosmetic and functional results after a median follow-up of 4.5 months (range 1 - 8 months). No infection and rejection were detected. The palpebral conjunctiva completely migrated to cover the defect without scarring at one month postoperatively. At the last follow-up, there was no tumor recurrence, exposure keratopathy, eyelid entropion, blepharoplasty, or continuous use of bandage contact lens.

Conclusions: Acellular dermal matrix graft might be an effective tarsal substitute to reconstruct sizeable upper eyelid defects when combined with a tipped flap. The graft with a 1 mm larger area than the defects might avoid postoperative scar contraction.


Danning LIU (Germany, Germany), Yan XU, Alexander C. ROKOHL, Ludwig M. HEINDL
00:00 - 00:00 #31959 - Recurrent Upper eye-lid Chalazion in an elderly female - thinking beyond Sebaceous Cell Carcinoma !
Recurrent Upper eye-lid Chalazion in an elderly female - thinking beyond Sebaceous Cell Carcinoma !

Purpose - Recurrent chalazion in the elderly is a known red flag for malignancy, classically sebaceous gland carcinoma (SGC). Few masquerades are also known to have a similar presentation. Here, we present a novel case of a recurrent chalazion in the right upper eyelid in an old female patient, who underwent a wide excision biopsy with lid reconstruction. The histopathology proved a nodular basal cell carcinoma (BCC).

Methods - A 75-year-old female, presented with recurrent swelling of the lateral aspect of the right upper lid for eight months. She had undergone repeated incision and curettage at a local hospital before being referred to us. On examination, a solitary 10 x 6 mm firm nodular lesion was noted on lateral one-third of the right upper eyelid. A yellowish lesion with dilated vessels, loss of eyelashes, areas of ulceration, and blood clots suggested a possible diagnosis of SGC. No palpable lymph nodes were noted. Systemic metastatic workup was negative. A wide excision was performed with clear margins noted on the frozen section. Lid and lateral canthus reconstruction were done using a periosteal flap and Tenzel skin flap.

Results - Histopathology confirmed atypical cells with palisading - the definitive features suggestive of nodular BCC. The margins were clear for 3 mm. The patient is being followed up for six months, with no recurrence and a satisfactory cosmetic outcome.

Conclusion - An atypical presentation of nodular BCC in the upper eyelid, mimicking chalazion or SGC may be missed on preliminary clinical examination. Detailed histopathology of every lid mass is essential for ruling out the masquerades.


Shalin SHAH (NEW DELHI, India), Nutan SHAH, Khushboo SHAH
00:00 - 00:00 #32065 - Resolution of Pityriasis rubra piliaris induced cicatricial ectropion with Oral Dexamethasone. A case report.
Resolution of Pityriasis rubra piliaris induced cicatricial ectropion with Oral Dexamethasone. A case report.

Purpose

To present a case of bilateral lower lid ectropion induced by Pityriasis rubra piliaris (PRP) completely resolved with oral Dexamethasone treatment.

 

Methods

Retrospective review of clinical notes and photos of a patient with cicatricial ectropion caused by PRP. 

 

Results

An 82-year-old male presented with bilateral cicatricial lower lid ectropion in a background of Pityriasis rubra piliaris skin disease. The patient did not respond well to treatment with Acitretin and topical steroid cream, while Methotrexate was added in the regime. A head injury resulting in subacute subdural haematoma, which managed with two-weekly course of low dose oral Dexamethasone, resulted in the improvement of his skin condition and complete resolution of the cicatricial ectropion within few weeks.

 

Conclusion

Systemic treatment of PRP, with a short course of oral Dexamethasone, alone or combined with other medication, may be beneficial in reversing cicatricial ectropion changes in PRP patients resistant to medical treatment. To our knowledge, this is the first case report with complete resolution of cicatricial ectropion in the background of PRP disease with a short course of oral steroid.


Ourania FYDANAKI (London, United Kingdom), Haytham REZQ, Sepetis ANASTASIOS, Varajini JOGANATHAN
00:00 - 00:00 #32142 - Results of Mohs’ micrographic surgery of periocular basal cell carcinoma. The Swedish experience.
Results of Mohs’ micrographic surgery of periocular basal cell carcinoma. The Swedish experience.

Purpose: The Department of Ophthalmology at Sahlgrenska University Hospital has until recently been the only eye clinic in the Nordic countries to perform Mohs’ micrographic surgery (MMC) of basal cell carcinoma (BCC). This fact has led to the practice of only the most complicated BCCs being operated with this technique. The purpose of this study was to present our results of these surgeries in patients with at least five years follow up, with focus on recurrences and postoperative complications.

Methods: A retrospective study of all patients operated upon 2010-2015 was performed. Data was gathered from the medical records. Main outcome was recurrence of BCC and time to recurrence. Information on age, gender, side of tumour, location of tumour periocularly, type of BCC, number of resections and postoperative complications were also noted.

Results: 167 patients were operated on during the period, spread out over the five years. MMC was used for tumours that were judged as highly aggressive on preoperative biopsy, had ill-defined borders, had recurred after previous excisional surgery or cryosurgery, or a combination of these factors. Nine recurring tumours (5.4% of all radical MMCs) were diagnosed after a mean post-operative time of 37 months (4-84 months). An interesting finding was that all of these nine recurrences after MMCs were in patients who had an MMC because of a recurrent BCC to start with.

Conclusion: Despite the fact that the most difficult BCCs were operated upon with MCC our results regarding recurrences were comparable to previously published reports. Special care has to be to ensure radical borders when operating recurring BCCs.

 


Karin SVEDBERG, Daniel PAUSSEN, Kalliopi ERRIPI (Gothenburg, Sweden)
00:00 - 00:00 #32347 - Retrospective review of non-melanoma skin cancer’s in the peri-ocular region: A single institution’s experience of cases treated with wide surgical excision over a 5 year period.
Retrospective review of non-melanoma skin cancer’s in the peri-ocular region: A single institution’s experience of cases treated with wide surgical excision over a 5 year period.

Purpose

Surgical excision with pre-determined margins for non-melanoma skin cancers has proved reliable in achieving complete histological clearance and low recurrence rates. The purpose of this study is to evaluate the efficacy of wide surgical excision for peri-ocular basal cell carcinoma’s (BCC’s) and squamous cell carcinoma’s (SCC’s) over 5 years at a single institution.

Methods

A retrospective analysis was conducted for all patients who underwent surgical excision of peri-ocular non-melanoma skin cancers from 2013 to 2017. Patient demographics, tumour size, anatomical location, histological differentiation, surgical margins excised around the macroscopic tumour and margins of clearance post-excision were reviewed. The rate of recurrence was examined over a 3 to 5 year close follow-up period. Similarly, data was collected for non-melanoma skin cancers referred for Moh’s micrographic surgery (MMS), to compare the efficacy of wide surgical excision and MMS in our unit.

Results

BCC’s comprised over 90% of cases. Per United Kingdom National Multidisciplinary Guidelines, average margins of 4 mm were used for non-infiltrative basal cell carcinoma’s and low-risk SCC’s, with wider margins of 5-6 mm for high-risk SCC’s and large morphoeic BCC’s. Complete excision achieved recurrence rates found in previous studies of <2%. Peripheral or deep margins of less than 0.5 mm post-excision were either referred for radiotherapy or underwent close monitoring, with no recurrence noted.

Conclusion

MMS is considered generally more effective than wide excision in achieving complete clearance of tumour and reducing recurrence; however it is time-consuming, expensive and unavailable in all ophthalmology units. Our data suggests wide excision with predetermined surgical margins is as efficacious as MMS in our institution, with comparable recurrence rates in both groups.


Mohsan MALIK (London, United Kingdom), Marta GARCIA-VILARO, Anna GKOUNTELIA, Wessam MINA, Linda BLACKWELL, Priyanka SANGHI
00:00 - 00:00 #32444 - Review of non invasive optical imaging, innovative tools for peri-ocular neoplasm.
Review of non invasive optical imaging, innovative tools for peri-ocular neoplasm.

Purpose Dermatologists are working with new imaging tools that optimized the management of skin neoplasm whereas ophthalmologists still work with standard photography and slit lamp.

Objectives: To show images of periocular lesions of innovative non invasive imaging and assess the interest for ophthalmologists in consultation.

Methods: We used a high (x400) magnification dermoscopy D400, In vivo Confocal microscopy and a Line-Field Optical Cohérence Tomography (LC-OCT ) that allowed histological scale imaging. This was performed by 3 skilled dermatologists.  Imaging results were compared with histopathology. We evaluated practical using, interest for practicians and new perspective of development.

Results: Consultation can be improved by these devices, allowing pseudo histologic images, useful in diagnosis, delimitation of the infraclinical lesions before surgery, postoperative surveillance and image ranking and comparison. Limits were the size of the device applied on the skin or conjonctiva and the cost of these devices.

Conclusions Using standard photography seems archaic in the current area of dermatological tools, management of periocular neoplasm can be improved by these innovative devices, and it opens the field of analysis by artificial intelligence.


Marine ESPINASSE, Marine ESPINASSE (Lyon), Eric BAGGIO, Jeremie BARBIER, Damien GRIVET, Jean Luc PERROT
00:00 - 00:00 #32363 - Sparing the upper eyelid in the reconstruction of lower eyelid defects: a ten-year review of Mohs surgery for periocular malignancies.
Sparing the upper eyelid in the reconstruction of lower eyelid defects: a ten-year review of Mohs surgery for periocular malignancies.

Purpose

Upper lid tarsoconjunctival flap (Hughes flap) is widely utilised for reconstructing large lower lid defects following tumour excision. The upper lid however has a vital function of globe protection & tear distribution. Techniques that spare the upper lid to reconstruct the less vital lower lid need to be explored.

 

Methods

A retrospective analysis of lower lid tumours (basal and squamous cell carcinoma) following underwent Mohs micrographic surgery followed by reconstruction at Chelsea & Westminster Hospital from March 2011-October 2021.

 

Results

60 patients had lower lid margin involving tumors. Complete reconstructive data was available for 42 patients. 26 patients had lost less than 50% of the horizontal lid length. These were reconstructed with direct closure (n=14), Tenzel flap (n=6), laissez-faire (n=3), periosteal flap (n=2) & skin graft (n=1). The remaining 16 patients had lost more than 50% of the lower lid. Tarsoconjunctival flap was used in 8 patients. Some of the defects (n=4) also included medial and/or lateral canthal or upper lid structures & one needed an additional forehead flap with complex craniofacial reconstruction. In the remaining eight patients, upper lid was spared. Techniques used included laissez-faire for long shallow defects (n=3), cheek advancement (n=1), a combination of a periosteal flap, mucosal graft & skin graft (n=1), a combination of a forehead flap & buccal mucosal graft (n=1), anterior lamella repair only with skin graft (n=1) & anterior lamellar repair only with a Trepier flap (n=1).

 

Conclusion

Hughes flaps were reserved for defects involving surrounding structures. Techniques including buccal mucosa for tarsal support, laissez-faire for long shallow defects & repairing only the anterior lamella were successfully used. Sparing the upper lid not only preserves its anatomy, aesthetics & function but also avoids temporary eyelid closure, a procedure to divide the flap and complications from the procedure.


Laura HUGHES, Naresh JOSHI, Richard SCAWN, Sheeva RABIEE, Adriana KOVACOVA, James SHELLEY, Manvi SOBTI (London, United Kingdom)
00:00 - 00:00 #32322 - Surgical management of acquired cryptophthalmos secondary to thermal injury.
Surgical management of acquired cryptophthalmos secondary to thermal injury.

Purpose: To present a small case series of patients in whom thermal injury led to acquired cryptophthalmos - total ankyloblepharon (complete fusion of the eyelids) and total symblepharon (complete fusion of the palpebral conjunctiva to the globe surface), such that the corneal epithelium had been replaced by skin - and to highlight a surgical technique that allowed the restoration of both a palpebral fissure and conjunctival fornices.

Methods: A two-centre retrospective, non-comparative case series of all patients who developed acquired cryptophthalmos secondary to thermal injury over the course of the two senior author’s practice (RM & BP, no time period specified).

Results: Three cases are reported, in whom the use of face-down buccal mucous membrane grafts (MMG) made it possible to restore both the palpebral fissure and conjunctival fornices. A suggested surgical technique is outlined.

Conclusions : We report a technique of repeated face-down buccal MMG which enables the reconstruction of both the palpebral fissure and conjunctival fornices in patients with acquired cryptophthalmos following thermal injury. The management of such cases requires close collaboration with corneal colleagues and patients should be carefully counselled to expect their treatment to take place in numerous stages.


Aaron JAMISON (Glasgow, United Kingdom), Bhupendra PATEL, Raman MALHOTRA
00:00 - 00:00 #32379 - Temporalis fascial sling for lower lid paralytic ectropion repair.
Temporalis fascial sling for lower lid paralytic ectropion repair.

Introduction: Correction of paralytic ectropion poses a challenge due to loss of muscle tone and effect of gravity.  Various materials such as silicone tubing, autologous facia lata, temporalis fascia and palmaris longus have been used as a sling to support the lower lid.  Problems with slippage, extrusion and erosion documented in silicone tubing are less common with autologous material that are well-integrated into the tissue.

Purpose: We provide a photographic description of a surgical technique for paralytic ectropion correction with temporalis fascia suspension.

Method: Case study, description of surgical technique

 Results: Ipsilateral temporalis fascia is harvested and trimmed to required size.  The temporalis fascia strip is passed suborbicularis with a Wright’s needle under the lid margin via skin incisions on the central, medial and lateral aspect of the lower lid and secured to the media canthal tendon and periosteum of the lateral orbital rim.  There is good functional and cosmetic result.  The lower lid is well-apposed to the globe, with improvement in exposure keratopathy and epiphora.

Conclusion: Temporalis fascia suspension provides a valuable alternative for correction of paralytic ectropion and is a useful tool in the armamentarium of the oculoplastic surgeon.


Lee Teak TAN (Chelmsford, United Kingdom), Kalliroi TZAFETTA, Seyed GHAZI-NOURI
00:00 - 00:00 #31946 - The correlation between chronic usage of topical anti-glaucoma eye drops and lower eyelid increased laxity.
The correlation between chronic usage of topical anti-glaucoma eye drops and lower eyelid increased laxity.

Background: Ectropion in elderly patients is often assumed to be involutional, due to an increased horizontal and vertical lid laxity.

The first line of treatment in glaucoma patients is topical anti-glaucoma eye-drops.

 In order to put those drops the patients stretch the lower eyelid. We hypothesis that this stretching may cause an ectropion. To the best of our knowledge this is the first time that this assumption is examined.

 

Method: A prospective, case-control comparison between glaucoma patients who use anti-glaucoma eye-drops vs. patients without glaucoma and that are not use eyedrops was done. All participants had gone through slit lamp examination and lower eyelid laxity tests and measurements. 

Results: Fifty-six patients (29 men, 27 woman) were included in this study, with a mean age of 66 years. Out of those, 26 (46%) are glaucoma patients and 30 (54%) without glaucoma.

 In their clinical examination, glaucoma patients demonstrated a variety of eyelid abnormalities: they demonstrated increased lower-eyelid laxity in both the Horizontal Laxity-Eyelid Distraction test (2.85 mm vs. 2.00 mm, accordingly, p=0.002) and in Eyelid Distraction Test-Snap Back test when compared to the control group (4.65 mm vs. 2.38 mm accordingly, p=0.005). They were also presented with a higher rate of eyelid pathology (6 patients among glaucoma group and none in the control group, p>0.01) and 65% of them presented poor orbicularis muscle strength (p>0.01).

Another finding in the eye exam was the presence of Punctate Epithelial Erosions (PEE), that was significantly higher in the glaucoma group compared to the control group (1.6 vs. 0.06 accordingly, p<0.01). In the study, 21.4% (12 patients) use alpha agonist eye drops, 41.1% (23 patients) use prostaglandin eye drops, 33.9% (19 patients) uses beta blocker (BB) eye drops and 11% (19.6%) uses carbonic anhydrase inhibitor (CAI) eye drops.

We found a strong correlation between the use of eye drops and an increased horizontal laxity in the eyelid, with the strongest correlation showing in patients who use prostaglandin eye drops (p=0.043). The presence of PEEs was found to be strongly correlated to the use of all eye drops (prostaglandin p=0.00, BB p=0.00 CAI p=0.011).

Conclusions: In this study we found correlation between chronic usage of topical anti-glaucoma eye drops and increased lower eyelid laxity. Therefore, patients may need to be instructed to put the drops without stretching the lower eyelid.


Lital SMADAR (Tel Aviv, Israel), Ofira ZLOTO, Noa KAPELUSHNIK, Alon WEISSMAN, Alon SKAAT, Singer REUT, Ben Simon GUY, Mordechai ROSNER
00:00 - 00:00 #32362 - The Gliding Midface lift - a novel technique for the treatment of lower lid skin deficiency.
The Gliding Midface lift - a novel technique for the treatment of lower lid skin deficiency.

Introduction/purpose: Lower eyelid ectropion with skin deficiency can be challenging and has typically been treated with skin flaps/grafts, mid face lift and mucosal grafts with varying results. Here we present a new technique with photographs and videos of a simplified skin mid face lift to successfully treat lower eyelid ectropion due to deficiency of skin.

Methods: A patient with previous extensive BCC treated with local grafts developed cicatricial lower eyelid ectropion. A subciliary incision was made and the skin was dissected from the orbicularis beyond the arcus marginalis and off the zygoma to release the mid face skin from its attachments. The skin was advanced and repositioned. The eyelid was tightened with a lateral wedge and the skin was supported with running skin to subcutaneous fat supporting sutures across the mid face. A frost suture was placed in a new technique through the sporting mid face sutures and not through the skin or the eyelid. The patient was reviewed at 2 days, 1 week, 2 weeks and 2 months post operatively

Results: Efficient skin advancement can be achieved with this new technique sparing the need for the use of more complex surgical techniques or grafts and flaps that can lead to additional facial scarring.

Conclusion: The gliding mid face lift may be an effective method for treating lower eyelid skin deficiency caused by previous cosmetic and reconstructive surgery with an enhanced cosmetic outcome and lower surgical complexity compared to traditional methods. 


Ahmad AZIZ (London, United Kingdom), Ourania FYDNAKI, Vickie LEE, Rajni JAIN
00:00 - 00:00 #32059 - The new face of the switch flap in the reconstruction of a large upper eyelid defect.
The new face of the switch flap in the reconstruction of a large upper eyelid defect.

Reconstruction of a large defect after the removal of a massive malignant upper lid tumor is still a challenge in oculoplastic surgery. Our method of choice is Mustardé switch flap. Due to the lack of Mohs micrographic surgery and frozen section technique as well as waiting time of two weeks for histopathological results, we made modifications enabling us to re-excise in case of positive margins: the width of the pedicle of the flap was 7 mm allowing the length of the flap to be increased if needed, the lids were closed with temporary lateral tarsorrhaphy to protect the eye and the lower lid is finally reconstructed in the second stage of the procedure (Figure 1).

In three patients with malignant upper lid tumors, this method of reconstruction proved to be safe and effective with favorable long-term results.

The only complication we experienced was a prolonged Mustardé switch flap edema in one case that resolved in four weeks (Figure 2).



Biljana KUZMANOVIĆ ELABJER (ZAGREB, Croatia), Mladen BUŠIĆ, Daliborka MILETIĆ, Andrej PLEŠE, Mirjana BJELOŠ
00:00 - 00:00 #32066 - The outcomes of Lid Malposition Surgeries in one tertiary center.
The outcomes of Lid Malposition Surgeries in one tertiary center.

Purpose:To report the surgical outcome of primary aponeurosis-disinsertion-ptosis, senile-ectropion and senile-entropion in one tertiary center comparing to the outcomes of those surgeries to the known in the literature. 

Design:Retrospective review of series of annual audits 

Methods:Operations for aponeurosis-ptosis,  senile-ectropion and senile-entropion performed at Moorfields-Eye-hospital (MEH) between 1/2015-12/2016 and 1/2018-12/2019 and a sample of consecutive surgeries performed in 2014 were included. The following data were collected: number of surgeries per year, number of patients, demographics data, success-rate, complications-rate and redo-rate. 

Results:During the study years 1944 eyelid malposition surgeries were included: 1049  ptosis-correction, 397ectropion-correction and 498entropion-correction. The mean success rates of those surgeries were 94.91%, 95.28%, 96.04%, respectively. The success rates were higher than those published by the BOPSS for ptosis surgery as well as higher than the current published literature for ectropion correction, as it was for the known literature on entropion surgical correction. The mean complication rates were 5% for ptosis surgery, 5.57% for ectropion surgery and 4.56% for entropion surgery. 

Conclusions: Beside the fact of MEH being one of the biggest training center to junior doctors in the UK, the success rates of all primary lid malposition surgeries are around 95%. The complications rates were around 5% and similar for those surgeries when comparing with the literature. To the best of our knowledge, this is the largest study over the last 20 years that collected and examined the results of the core surgical outcome of lid malposition covering such a long period.


Zloto OFIRA (Tel Aviv, Israel), Kang SWAN, Bharpoor SINGH, Victor PAIUSCO, David VERITY, Fabiola MURTA
00:00 - 00:00 #31756 - The surgical management and outcomes of kissing nevi of the eyelids.
The surgical management and outcomes of kissing nevi of the eyelids.

Purpose: A kissing nevus is a rare congenital melanocytic lesion, located in adjacent areas on the upper and lower lids. Literature regarding surgical management is limited. Our aim was to describe the surgical management and outcomes in patients with kissing nevi.

Methods:Medical chart review was conducted for all patients who underwent kissing nevi surgical repair in Moorfields Eye Hospital, London and The Children's Hospital of Philadelphia between 2006 and 2021. Demographics, ocular and medical history, lesion characteristics, surgical intervention, and outcomes were collected and analyzed. Main outcome measures were surgical interventions as well as functional and cosmetic outcomes. 

Results:Thirteen patients were included, median age at presentation was 16.93 years (±20.07, 4-61). The most common indication for surgery was cosmetic. None of the patients had a family history of kissing nevi. The mean number of surgeries per patients during the follow up period was1.9 (±1.3, 1-5). Initial procedure included incisional biopsy in 3 cases (23%) and complete excision and reconstruction in 10 cases (77%). Surgery involved the upper and lower anterior lamella in all cases, the upper posterior lamella in 4 patients (31%), and the lower posterior lamella in 2 patients (15%). Local flaps were utilized in 3 cases and grafts in 5 cases. Complications included: trichiasis (n=2, 15%), lower eyelid ectropion (n=2, 15%), mild ptosis (n=1, 8%), and upper/lower punctal ectropion (n=1, 8%).  Twelve patients (92%) were satisfied with the final functional and cosmetic outcome. No recurrences or malignant transformations were observed.

Conclusion:Surgical management of kissing nevi can be challenging, and commonly includes the use of local flaps or grafts, often requiring multiple interventions. The surgical approach should be personalized based on lesion size and location, proximity to and involvement of eyelids’ anatomical landmarks, and individual facial characteristics. Surgical management has a favorable functional and cosmetic outcome in the majority of patients.


Zloto OFIRA (Tel Aviv, Israel), Landau Prat DAPHNA, Katowitz JAMES A, Katowitz WILLIAM R, Ben Simon GUY, Verity DAVID H
00:00 - 00:00 #32434 - The use of the swinging lower lid for medial canthal lesions.
The use of the swinging lower lid for medial canthal lesions.

Introduction/purpose: Lower swinging eyelid approach is a well documented approach to the lateral orbital wall and the orbital floor. Here we present the use of this approach with photographs with a trans-conjunctival approach to medial canthal lesions avoiding the need for a medial canthal scar.

Methods: A patient with a medial canthal lesion thought to be in communication with the lacrimal apparatus required a biopsy to determine the nature of the lesion. To avoid a medial canthal scar and the associated morbidity and swinging lower eyelid approach was taken entering through the inferior conjunctiva to completely excise the medial canthal lesion without any scar to the medial canthal skin.

Results: The patient had excision of the lesion with a good cosmetic outcome compared to traditional approaches to pathology in this area.

Conclusion: The swinging lower eyelid approach is a useful method for the biopsy of medial canthal pathology and can be considered along with traditional methods. 


Ahmad AZIZ (London, United Kingdom), Rajni JAIN, Vickie LEE, Branka MARJANOVIC
00:00 - 00:00 #30910 - The very long term effect of Muller Muscle Conjunctival Resection on dry eye syndrome.
The very long term effect of Muller Muscle Conjunctival Resection on dry eye syndrome.

Introduction: Our previous study has reported that Muller Muscle Conjunctival Resection (MMCR) surgery causes dry eye syndrome, three months after surgery.1However, it is unknown if this effect stays after a long term post-operative period. Therefore, the purpose of this current study was to examine the very long term effect of MMCR on dry eye syndrome as well as to examine the long term success rates of MMCR.

Methods: This is a prospective, comparative clinical study. It was suggested, to all patients that underwent MMCR surgery and participated in our previous study,1to re-evaluate for dry eye syndrome as well as for eyelids position. The following parameters were compared, for all patients, before the procedure (baseline) and on postoperative long term period: MRD1, Schirmer’s-test-2, Tear-break-up-time (TBUT), Fluorescein-staining, Lissamine-green-staining (LG).

Results: Among 31 patients who were evaluated for dry eye after MMCR in the previous study, 20 patients were available. The mean time after surgery was 62.28 months (±0.72, 46.88-76.56 months). There was  a significant improvement in MRD1 long time after the surgery vs. before surgery (3.73 vs. 1.53, paired t-test, P<0.01). None of the patients underwent second ptosis surgery during this period of time. There was a significant increase in the long term postoperative period in LG score, fluorescein staining as well as a decrease in TBUT compared to the preoperative values (paired t-test, P<0.01,P<0.01, P<0.01,respectively). There was a decrease in Schirmer test values in the long term postoperative period compared to preoperative. However, it is not significant (paired t-test, P=0.076).

Conclusions:The long term success rates of MMCR surgery are high and patients did not need re-surgery, even 5 years after the surgery. However, MMCR can cause an increase in the signs of dry eye, not just in the short term period after the surgery, but also after a long term. Physicians should discuss with patients, who are candidates for MMCR surgery, about the significant advantage of the surgery- that repairs the ptosis even after a very long time as well as the disadvantage of the surgery- the risk for dry eye.


Zloto OFIRA (Tel Aviv, Israel), Alcalay IDAN, Matani ADHAM, Ben Simon GUY
00:00 - 00:00 #32300 - Three point tangent technique for filler injection; results and predictors of poor outcomes.
Three point tangent technique for filler injection; results and predictors of poor outcomes.

Purpose: To describe the three point tangent technique for tear trough filler and to identify predictors of poor outcomes.

Methods: Examination of the patient includes assessment of the extent of the nasojugal fold medially, palpebromalar groove laterally and presence of fat herniation. Hyaluronic acid filler is injected using a blunt cannula using a novel three point tangent method. A retrospective case review was performed of all patients who underwent tear trough filler from 2016 to 2020. Patient demographics, volume ranges and complications were recorded.

Results: 1514 applications of tear trough filler to the orbits of 586 patients were recorded. The mean patient age was 42 years (range 19-77) and 85% were female. 21% of patients had previous filler to the tear trough and this was dissolved pre-treatment in 13%. 16% of patients had previous eyelid surgery and filler was injected at the time of surgery in 1.7%. The mean dose of filler was 0.34ml to each orbit (range 0.1 – 1.5) and 96% were treated with Teosyal redensity 2. 83% reported no complication; 14% reported swelling with a mean duration of 11 weeks (range 1-52), 4% experienced bruising, 4% reported lumps and 3% experienced a Tyndall effect. Retrobulbar haemorrhage occurred in 1 patient (0.07%) which was managed immediately with no lasting visual compromise. A volume over 0.3ml was significantly associated with swelling (p<0.0001). Filler was dissolved in 2% of orbits.

Conclusion: The three point tangent technique is a safe and effective method for tear trough filler. Swelling is the most common complication and is more likely when volumes over 0.3ml are injected. Even with a very low incidence, the risk of retrobulbar haemorrhage suggests that tear trough filler application should occur in a unit which can manage this potentially devastating complication.


Caroline WILDE (London, United Kingdom), Ankur GUPTA, Sieun LEE, Daniel EZRA
00:00 - 00:00 #32178 - three-dimensional measurements of patients with different stages of upper eyelid dermatochalasis.
three-dimensional measurements of patients with different stages of upper eyelid dermatochalasis.

Purpose: To evaluate different stages of upper eyelid dermatochalasis patients’  three-dimensional facial morphology.

 

Methods: We enrolled patients with symmetrical bilateral dermatochalasis who underwent bilateral blepharoplasty from Nov 2021 to June 2022. Furthermore, three-dimensional (3D) photos were taken preoperatively by the 3D VECTRA M3 imaging system. Lastly, we measured and evaluated the margin reflex distance (MRD), upper lid length, ocular surface-exposed area, as well as the upper eyelids area.

 

Results: 

Forty-five patients between 47 and 86 years of age (69.0 ±12.0 years) were included. The upper lid length and ocular surface-exposed area were negatively correlated with age (r=0.699, 0.683 respectively, p<0.001). There is no significant difference between left and right eyes, except for MRD1 measurements (-0.99± 1.73 mm, p <0.05). There were also significant correlations between the left and right eyes’ upper lid length, ocular surface-exposed area, and the upper eyelids area (r= 0.755, 0.731, and 0.928, respectively, p<0.001). 

Conclusions: 

The upper lid length and ocular surface-exposed area tend to decrease with age. Three-dimensional stereophotogrammetry might be suitable for periocular assessment and planning oculoplastic surgeries.

 


Xueting LI (Köln (Lindenthal), Germany), Ludwig M. HEINDL, Alexander C. ROKOHL
00:00 - 00:00 #32224 - Topical tacrolimus treatment for adult-onset xanthogranulomatous disease.
Topical tacrolimus treatment for adult-onset xanthogranulomatous disease.

Purpose: To present a case with an  adult onset  orbital xanthogranulomatous disease  with preseptal lesion who was treated with topical tacrolimus.

Case presentation: A 43-year-old female patient presented with swelling and redness in her right upper eyelid that had persisted for a year. She had received topical medicines and complementary treatments. She had limitation of upgaze in the right eye. Visual acuity of right eye  was 16/20  and left eye was 20/20. The  anterior and posterior segment examinations were normal.  She had no known disease other than hypothyroidism and uterine myoma. Orbital MRI revealed a cutaneous-subcutaneous soft tissue mass suspected of malignancy in the preseptal region. Punch biopsies were performed. Histopathology showed infiltration with intensive T lymphoid cells, polytypic plasma cells, histiocytes without significant granuloma formation and a few multinucleated giant cells. Systemic investigations for lymphoid hyperplasia, malignancy and infection were negative. The diagnosis of adult-onset xanthogranulomatous disease was made by evaluating the patient's clinic and histopathology. Topical and high dose systemic steroid treatment were administered. After a month, steroid ointment was discontinued and topical tacrolimus was started. Meanwhile systemic steroid was tapered off and stopped within 3 months. Topical tacrolimus was continued for 6 months. The symptoms resolved and the lesion healed. No relapse was observed in the one-year follow-up after tacrolimus withdrawal.

Conclusion: This case report showed that topical tacrolimus can be an effective treatment in xanthogranulomatous disease with preseptal lesions and may be helpful in avoiding side effects of systemic treatment and topical steroids.


Zeynep Zahide GÜLLÜLÜ (Tokat, Turkey), Sertaç Argun KIVANÇ, Berna AKOVA
00:00 - 00:00 #32427 - Transcutaneous Eyebrow Tail Lift: A Simplified Approach.
Transcutaneous Eyebrow Tail Lift: A Simplified Approach.

The eyebrow position is a determining factor related to facial expression, especially concerning the anatomical relationship of the eyebrow with the eyelid. The changing position of the eyebrows with aging influences the individual’s expression and can give negative emotions such as loss of vitality, sadness, and tiredness, and influence facial beauty. Numerous procedures are available to the surgeon to prevent the eyebrows from falling after upper blepharoplasty or lift them in isolation. Despite the various surgical techniques undertaken to manage the eyebrow, conventional approaches are usually more aggressive procedures involving extensive skin resection at the hairline or scalp, endoscopic elevation, and temporal and coronal approaches. Given the growing search for less aggressive procedures that patients better tolerate, this study aims to describe a less invasive variation of the Castañares technique, focused on the elevation of the eyebrow’s tail, which may or may not be associated with blepharoplasty, the Surgical Fox Eye. The technique removes an ellipse of skin above the distal third of the eyebrow close to the hair bulbs and then sutures with a direct elevation of the eyebrow tail. The technique described is ideal for several cases, as it presents predictable and satisfactory clinical outcomes as to the patients’ expectations. It also presents easy healing with extensive durability with minimal chance of complications.


André Luis BORBA DA SILVA (SAO PAULO, Portugal)
00:00 - 00:00 #32120 - Treatment of involutional ectropions and entropions by laser.
Treatment of involutional ectropions and entropions by laser.

Introduction :

Involutional entropions and ectropions of the lower eyelid are disabling pathologies whose prevalence is high in patients over 60 years of age. The reference treatment is surgery, but it is often decided to abstain from treatment in elderly patients with comorbidities. We present a new management of ectropions and entropions by laser.

 

Materials and methods :

 

Patients included presented involutional ectropions or entropions. Cicatricial ectropions were excluded.

The 2 types of laser used were a CO2 laser and an Argon laser (ophthalmic laser for the retina). The treatment was carried out by 2 operators (one operator used the CO2 laser and the other operator the Argon laser).

 

Results :

 

The technique for treating ectropions and entropions by laser consists of making a deep horizontal incision in the middle 2/3 of the tarsus. In the case of ectropions, the laser is performed on the inner side of the eyelid, and in the case of entropions, it is performed on the outer side of the eyelid. During the healing process, fibrosis and shrinkage of the treated area appear. This technique is practiced after performing local anesthesia with xylocaine in the practitioner's office.

In the case of ectropions, there is a shortening of the posterior lamella induced by fibrosis and in the case of entropions, an eversion of the eyelashes.

 

Conclusion :

 

Surgical treatment of ectropions and entropions remains the gold standard. However, this surgical treatment is not accessible to patients with significant comorbidities.

Laser treatment is then an alternative to surgical treatment and allows a reduction in discomfort in a few weeks for patients. The technique is particularly interesting where a surgical operation presented an unfavorable benefit/risk ratio.


Francesco ESPOSITO (Toulon), Eric SARFATI
00:00 - 00:00 #30887 - Tumour resolution following diagnostic punch biopsy: Is surveillance an option?
Tumour resolution following diagnostic punch biopsy: Is surveillance an option?

Purpose

Many surgeons perform diagnostic punch biopsies to confirm the diagnosis of BCC before proceeding with further excision and reconstruction. Some studies have suggested that there is up to a 25% cure rate of BCCs following an initial diagnostic biopsy. The purpose of this study was to determine the incidence of tumour resolution following a punch biopsy in a United Kingdom cohort and the rate of subsequent recurrence if left under surveillance.

 

Methods

Retrospective continuous comparative case note review, looking at all patients who underwent a 4mm punch biopsy, at the University Hospital Coventry between 2005 and 2019. Patients who had a resolution of their lesion were then further analysed in terms of their demographics, size of lesion at presentation, rate of recurrence and need for further treatment.

 

Results

392 patients were diagnosed with a BCC over this 14-year period. Of these patients, 14 had a complete resolution of their lesion following the punch biopsy. This accounts for an incidence in our population of 3.6%. None of these patients with tumour resolution opted for or needed further treatment. No BCC recurrences occurred at a mean follow up of 4 years, with the range being 1 to 8 years. 

 

Conclusion

The incidence of complete BCC resolution is low following a diagnostic punch biopsy. However, our study suggests that surveillance is a reasonable option to present to patients particularly if they want to avoid further­­­­­­­ surgery.


Emma SAMIA-ALY (London, United Kingdom), Harpreet AHLUWALIA
00:00 - 00:00 #32216 - Unusual eyelid and periocular malignancies.
Unusual eyelid and periocular malignancies.

Background: Most eyelid malignancies are of epidermal origin. Basal cell carcinoma is the most common neoplasm of the eyelid and the periocular region. It represents 90% of eyelid malignancies. Some unusual types of tumors may occur in the eyelids. They often arise from other components than the epidermis and may have a poor prognosis.

Purpose: To report clinical, histological features and prognosis of unusual non epithelial eyelid and periocular malignancies.

Methods: We retrospectively reviewed a serie of non epithelial eyelid and periocular malignancies, confirmed histopathologically, from a single institute in Tunisia.

Results: A total of 26 Tumors were identified, accounting for 8% of all eyelid tumors during the study period (n=322). The mean age of the patients was 69,3 years. The commonest lesion was adnexal lymphoma (n=12), followed by sebaceous carcinoma (n= 5), melanoma (n=3), kaposi sarcoma (n=2), eyelid metastases (n= 2), Merkel cell carcinoma (n=1) and mucinous carcinoma arising from sweat glands (n= 1). Two adnexal lymphomas were misdiagnosed as benign lymphoid hyperplasia (pseudolymphoma).  The two metastases originated from pancreatic adenocarcinoma (n=1) and osteoid osteoma (n=1). Kaposi sarcoma was related to a classic form in one case and to acquired immune deficiency syndrome in the other case. In the latter, the tumor has completely regressed under highly active antiretroviral therapy. One patient with eyelid melanoma (1/3) already had bone metastases at the time of diagnosis. The overall mortality rate was 42% (n= 11/26).

Conclusions: Given the importance of functional and aesthetic role of the eyelids, some unusual tumors, although uncommon, should be considered by ophthalmologists. These rare presentations may lead to misdiagnosis and poor prognosis with a high mortality rate. Thus, ophthalmologists should recognize them early, based on clinical features and history. Patients have to be addressed promptly to oculoplastic surgeons. Biopsy is required for an early accurate diagnosis and an adequate treatment.


Leila KNANI (Sousse, Tunisia), Mehdi OUESLATI, Mohamed GHACHEM, Fehmi TOUZANI, Narjess BEN RAYANA
00:00 - 00:00 #32321 - Upper eyelid reconstruction after resection of a large verrucous tumor.
Upper eyelid reconstruction after resection of a large verrucous tumor.

Purpose: A 66-year-old patient with massive expansion of a verrucous tumor infiltrating the whole right upper eye lid presented with beginning damage of the ocular surface after multiple surgical procedures out of house beforehand. In 2020 a small number of biopsies from the tumor were obtained, which showed no signs of malignancy. The decision to debulk the anterior lamella and to perform cryotherapy on lesions infiltrating the posterior lamella in the marginal lid region was made. Discharged from hospital with clinical improvement and a lack of symptoms the patient missed the following control examinations due to the Covid-19 pandemic. Two years later symptoms such as corneal pain and beginning corneal damage reoccurred caused by the expansive regrowth of the tumor, that infiltrated approximately the whole tarsal plate.

Methods: We decided to perform a subtotal upper eyelid resection in general anesthesia, involving all of the altered tissue and including the resection of the whole tarsal plate. The posterior lamella was reconstructed with a free graft of the hard palate. The anterior lamella was reconstructed by creating a modified flap of the glabella in addition to a Cutler-beard flap to support the mucosal graft. A small wound dehiscence between the glabella flap and the flap from the lower lid was closed one week after surgery using a randomised flap from the lateral temporal region.

Results: After three weeks the new eyelid fissure was created by dividing the flap pedunculated in the lower lid. Postoperatively the patient did not report any pain or discomfort. No tissue necrosis or infection were found after opening the skin bridge three weeks later. Additionally a satisfying cosmetic and functional result was provided and by saving the levator aponeurosis during the resection a sufficient upper eyelid mobility was preserved. During the follow up time no recurrences could be found.

Conclusion: In cases of benign, circumscribed verrucous tumors infiltrating the lids local resection, combined with cryotherapy, could be a useful tool in preventing recurrences. Dealing with large tumors, which also infiltrate the posterior lid lamella, a prompt full thickness lid resection is indicated to prevent corneal damage. In this case of subtotal upper eyelid resection an adequate cosmetic and functional result was reached using a graft from the hard palate in combination with a modified glabella flap and a Cutler-Beard flap for reconstruction.


Martin EMESZ (Zell am See, Austria), Paul EMESZ, Christian GINZEL, Ulrike HÖLLER, Anna-Lena LAUSCH
00:00 - 00:00 #32368 - Use of Hughes flap for entire eyelid reconstruction in combination with other reconstructive procedures of face and neck.
Use of Hughes flap for entire eyelid reconstruction in combination with other reconstructive procedures of face and neck.

Tarsoconjunctival/Hughes flap is a gold standard technique primarily but not exclusively used for the reconstruction of large lower eyelid defects.This is a case report of using a Hughes flap for the reconstruction defect of the entire lower eyelid caused by locally advanced Squamous Cell Carcinoma ( SCC) infraorbital, zygomatic et periocular region and for the first time reconstuctive teamwork of the ENT and the oculoplastic surgeon at University Hospital Centre Osijek, Croatia.The 85-year-old patient came due to locally advanced tumor formation of her right cheek, wich has been growing several years, and has been bleeding for 2 months( photo), making it difficult for her to close and open her right eye. The imaging has been done( photo) and biopsy confirmed SCC. The operation was perfomed under general anesthesiain the first act: extirpation of the tumor, lymph nodes (preauricular, submandibular, neck) and the right parothid gland.For reconstraction of facial and periocular region (photo) rotation neck flap and Hughes flap( photo)were used. Patohistological analysis of the lymph nodes and the parotid gland were negative. Postoperatively, the patient was monitored and sutured were removed( foto) but due to comorbidity, the second act of Hughes procedure was postponed to the 74th day. The control was done 2 weeks after the act of separation flap( photo). The patient was reffered for  futher monitoring and sistemic treatment to an oncologist.


Patricia REISZ-MAJIĆ (Osijek, Croatia), Nina JOVANOVIĆ, Dubravka BIUK, Dario ŠOŠ, Tihana MENDEŠ
00:00 - 00:00 #32309 - Use of pericranial periosteal flap and anterior lamellar graft to correct severe lower lid retraction in children with complex eyelid retraction.
Use of pericranial periosteal flap and anterior lamellar graft to correct severe lower lid retraction in children with complex eyelid retraction.

Purpose

We describe the surgical approach of a forehead pericranial periosteal flap and skin graft to correct severe lower eyelid retraction in children in whom tarso-conjunctival flaps or free grafts alone were not feasible due to previous complex surgical history.

Methods

A full-thickness horizontal lower eyelid blepharotomy is performed, canthus-to-canthus and the retracted lid margin is raised to the level of the pupil or above. A vertical paramedian glabella skin incision is made and forehead dissection achieved to the sub-frontalis plane without breaching the pericranium. The desired size of periosteal flap is raised and reflected through a subcutaneous tunnel between the base of the flap to the blepharotomy defect and sutured to adjacent conjunctiva. An anterior lamellar skin graft is secured over it. The lower eyelid is placed on traction with suture tarsorrhaphy.

Results

Three paediatric patients underwent lower eyelid elevation using pericranial flaps and anterior lamellar grafts. A 5-year-old male with cryptophthalmos. The eye closure was poor with lower lid retraction with short inferior fornix despite previous surgeries. A 7-year-old male with congenital stem cell deficiency and lagophthalmos. The third, an 8-year-old female with Tessier type 4 craniofacial cleft, bilateral lower eyelid coloboma and maxillary hypoplasia. She had lagophthalmos of her left only eye due to severe lower lid retraction despite multiple surgeries involving skin grafts. All three patients underwent lower lid reconstruction with a pericranial periosteal flap and anterior lamellar skin graft. Lower eyelids were successfully elevated to achieve better closure.

Conclusions

The pericranial periosteal flap is an excellent middle and posterior lamella substitute which can provide vascular support for anterior lamellar grafts. It can be safely used in children to produce good functional and cosmetic outcomes.


Christina LIM (East Grinstead, United Kingdom), Raman MALHOTRA
00:00 - 00:00 #32004 - Wedge resection and retractor plication using 8-0 vicryl for lower eyelid involutional entropion repair: long term follow-up across two centres.
Wedge resection and retractor plication using 8-0 vicryl for lower eyelid involutional entropion repair: long term follow-up across two centres.

Purpose:  Larger gauge absorbable sutures are known to illicit a greater inflammatory response, which has implications in wound strength, scar formation, and risk of post-operative infection.  Typically, entropion repair is done with 6-0 sutures.  We aim to assess the long-term outcome of entropion repair using 8-0 Vicryl sutures, with specific focus on rates of recurrence, wound dehiscence, infection, and scarring.

 

Methods: This retrospective case series is comprised of consecutive patients from two centres in the UK who underwent entropion repair using a subciliary incision and lateral wedge resection approach.   Eligible patients were invited for review.  Patient demographics, rates of complications and overall patient satisfaction were recorded.

 

Results:  84 eyes of 77 patients were included.  The median follow-up time from surgery was 48 months (range 20-100).  5 cases of entropion recurrence (5.9%) occurred between 5 months to 4 years after surgery, two of which required further surgery while three were conservatively treated.  There was no case of wound dehiscence.   Two cases (2.4%) of mild superficial wound infections occurred, which were successfully treated with topical antibiotics with no sequelae.  1 case (1.2%) of mild lid notching, and 1 case (1.2%) of visible scarring were recorded.  Overall, 97% of patients reported to be satisfied with their surgical outcome.

 

Conclusions:  Entropion repair using 8-0 vicryl sutures provided good aesthetic and functional outcomes for this cohort of patients.  Rates of recurrence and other complications were low.  No case of wound dehiscence occurred, suggesting this gauge of suture provided adequate tensile strength to facilitate wound closure and healing.


Yingjia YANG (Oxford, United Kingdom), Madalina CHIHAIA, Christopher SCHULZ, Alexandra KENCHINGTON, Ben PARKIN, Hunter MACLEAN
00:00 - 00:00 #32302 -  Safety and Efficacy of subcutaneous diode laser (EndoLift®) as a novel treatment in the management of malar oedema.
 Safety and Efficacy of subcutaneous diode laser (EndoLift®) as a novel treatment in the management of malar oedema.

Purpose: Facial ageing can lead to the formation of malar oedema. There are a variety of minimally invasive and surgical treatment options with variable efficacy. This study examines the effectiveness of Endolift® laser resurfacing in the management of malar oedema.

Methods: All patients from a single specialist clinic who received Endolift® laser treatment for malar oedema between August 2020 and May 2021 were included. Effectiveness of the treatment was determined using clinical photographs, 3-dimensional imaging and a novel anatomical grading system.

Results: 9 patients were identified, all female with a median age of 51 (39-62). The mean total energy delivered was 75J (36-152). Of the 18 malar regions, malar oedema severity was Grade 1 (mild) in 10 cases, Grade 2 (moderate) in 8 cases, and Grade 3 (severe) in none of the cases. Most patients had improvement following Endolift® treatment. 50% of grade 1 malar oedema regions had a significant response whilst 50% had a partial response. There were 5 malar regions with Grade 1 malar oedema versus 3 regions with Grade 2 malar oedema that had a significant response. There was no difference in response between patients with Grade 1 (mild) versus Grade 2 (moderate) malar oedema.

Conclusion: Endolift® provides a safe and minimally invasive laser method of treating mild-moderate malar oedema.


Caroline WILDE (London, United Kingdom), Megha KAUSHIK, Inga NEUMANN, Daniel EZRA
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02 -Lacrimal

00:00 - 00:00 #32435 - 1998 - 2018 Lacrimal surgery at the department of Ophthalmology Darmstadt.
1998 - 2018 Lacrimal surgery at the department of Ophthalmology Darmstadt.

Background:

Initial approach in therapy of lacrimal stenosis was external dacryocystorhinostomy (DCR) first described in 1750 before Christ. 

In the past century, treatment methods underwent significant development. The first steps of the endoscopic procedure were developed as early as 1990. However, in the beginning optical quality and imaging was very poor. 

Since 1995 microendoscopes with good quality are available and therefore rates of microendoscopic surgeries increased while the rate of DCR relatively decreased. 

Very little information is available on the epidemiology of lacrimal stenosis, and it is difficult to determine the incidence of this problem. 

The aim of this study was to identify age- and gender incidence of lacrimal stenosis and changes in surgical approach.

Methods

The department of ophthalmology, Klinikum Darmstadt GmbH, one of the largest clinics specialized in lacrimal surgery in Germany. Between 1998 and 2018 in total 15701 lacrimal surgeries have been performed in this department. These cases were divided as follows:

- 10412 (66.3%) endoscopic procedures with intubation of a silicone tube

- 1806 (11.5 % of endoscopic procedures) Laser dacryoplasty 

- 6975 (44.4 % of endoscopic procedures) microdrill and - 193 balloon dilatations (1.23 %)

Procedures without endoscopic approach were divided to Laser-DCR 39 (0.25 %), DCR 1842 (11.7 %), Conjunctivorhinostomy with tube 132 (0.84 %) and revisions of them 159 (1.01 %) and ringingubations mostly after traumata 275 (1.75 %). 

All surgical procedures where evaluated about age and gender of the patients. 

Results

15701 surgical procedures of 12233 patients have been evaluated. 

There was a marked increase in the incidence of diagnosis for all forms of lacrimal duct stenosis and surgical procedures, particularly in microendoscopic procedures.  

The incidence of all forms of lacrimal obstruction was higher in females (63.9 %) than in male patients (36.1 %). 

Rates of lacrimal stenosis increased slowly beginning at age of 40 with highest rates in age group 50 and 60. 

Conclusions 

This evaluation confirms the frequently made statement that lacrimal obstructions is most commonly in female and middle-aged to older patients. 

In this regard, rates of minimally invasive procedures increased during the search period due to the development of better microendoscopes.


Monica LANG (Darmstadt, Germany), Liana Virginia HECK, Karl-Heinz EMMERICH
00:00 - 00:00 #31646 - A canaliculus wire.
A canaliculus wire.

Lacrimal duct trauma Represents 1% of traumas in ophthalmology..Eyelid trauma 36% associated.Men. 10-30 years..50-70% lower canaliculus. 20% upper canaliculus..10-15% bicanalicular.Intubation techniques to repair the canaliculus Intubation. The bicanalicular and CLN such as: the Crawford catheter and repair using the "pig tail".The monocanalicular ones of siliconeBut when we do not have any prosthesis for different reasons: economic, health permits, or they are simply not on their guard. Dr. Johnson described the making of a handmade monocanalicular prosthesis. Using a Bowman tube. In Brazil, the use of the Johnson wire using a No. 24 serum guide, a forceps and a needle holder has been described. When this material was found in the nursery and it is really cheap, its use becomes fundamental when reconstructing a canaliculus and not having the most used commercial prostheses.


Fernando PERCHES (São Paulo, Brazil), Alejandra Raquel BILLAGRA, Simone BISON
00:00 - 00:00 #32388 - A case of Lacrimal sac malignant melanoma.
A case of Lacrimal sac malignant melanoma.

To present the case of a 60-year-old male presented with a 9 month history of lesion on the right medial canthus- lacrimal sac area.

CT scan performed demonstartes a well defined 2x2cm cystic lesion on the lacrimal sac area involving the lacrimal fossa.. This has well defined walls and homogenous density. There is no bony erosion, those signs are in keeping with benign lesion. Interestingly the patient doesn't report any discharge symptoms but reports watery eye symptoms. The visual acuities are full,, extraocular movements are full  and there is no proptosis.  Excsision of the cyst has been planned. During surgery lacrimal duct tumour has been observed and therefore instwad of excision of the lesion as planned right lacrimal duct tunour endoscopic biopsy has been performed. Urgent full body CT PET requested.

Histology from biopsy has reported as malignant melanoma with necrosis present and inavading the bone. CT of orbit is suggestive of a dacryocystocele involving the right lacrimal sac. There is another heterogeneously enhancing lesion in the right inferior meatus at the terminal end of the nasolacrimal duct. Posibility of a neoplastic process arising from the nasolacrimal duct is raised. Case has been discussed at the Head and Neck MDT and Skin SSMDT. PET CT reviewed and lesions noted in liver, left lobe, suspicious in nature. Liver MRI reports that liver is clear.

Full body examination confirmed that there was no evidence of a primary cutaneous melanoma, neither any evidence of lymphadenopathy. 

Care plan: surgery, excision of the lacrimal sac and possibly wider surgery with lateral rhinostomy. Craniofacial resection of nasal cavity nad local flap has been performed, including partial maxillectomy and tarsoraphy.

Histology from right orbital tumour excision reports malignant melanoma extending to deep margin, right anterior maxillary wall reports malignant melanoma. Right frontal sinus reports no malignancy. Cannot confirm definite origin from samples. Pt4a type. After discussion at skin MDT decision made for close clinical surveillance and follow up with PET imaging.


Wessam MINA (London, United Kingdom), Marta GARCIA-VILARO, Anna GKOUNTELIA
00:00 - 00:00 #30681 - A Comparison between Placement of Three Interrupted sutures after Triangular Three-snip Punctoplasty versus Conventional Triangular Three-snip Punctoplasty.
A Comparison between Placement of Three Interrupted sutures after Triangular Three-snip Punctoplasty versus Conventional Triangular Three-snip Punctoplasty.

Aim

To  evaluate surgical outcome of Triangular Three-snip Punctoplasty (TSP) with addition od three interrupted sutures and to compare it with conventional Triangular Three-snip Punctoplasty (TSP) in treatment of acquired lower punctal stenosis.

Methods

This was a prospective study included 40 eyelids of 24 patients with acquired lower punctal stenosis grade 1 or 2. Patients were enrolled in two groups; group A patients were treated by triangular 3-snip punctoplasty of the lower punctum followed by three interrupted sutures at the posterior ampulla and group B patients were treated by conventional triangular 3-snip punctoplasty of the lower punctum. Grade of epiphora and grade of Flourescein Dye Disappearance Test (FDDT) were measured preoperative, and then post-operative after 1 week, 1 month, 3 months and 6 months.

Success was defined as postoperative improvement of epiphora and FDDT grading with no restenosis occurred.

Results

from 20 eyelids in group A, 16 cases showed success (80%) with patent puncta, 2 cases (10%) showed no change and 2 cases (10%) showed failure with restenosis. While from 20 eyelids in group B, 14 cases showed success (60%) with patent puncta, 4 cases (20%) showed no change and 4 cases (20%) showed failure with restenosis.

Conclusion

Triangular 3-snip punctoplasty of the lower punctum followed by three interrupted sutures seems to have better results compared to conventional triangular 3-snip punctoplasty of the lower punctum in treatment of grade 1 or 2 lower punctal stenosis.


Hesham ABDULHADY, Sameh MANDOUR (Cairo, Egypt), Hany KHAIRY, Awara AMR
00:00 - 00:00 #32374 - A Rare Case of Acute Dacryoadenitis in Adult-Onset Still's Disease.
A Rare Case of Acute Dacryoadenitis in Adult-Onset Still's Disease.

Purpose

Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disease of unknown aetiology characterised by four cardinal signs: high spiking fever, arthralgia, skin rash and leucocytosis with neutrophilia. A wide range of inflammatory episodes can occur during the condition.  Here, we report a case of acute dacryoadenitis as a rare clinical manifestation of the disease.

Methods

A 32-year-old female of African descent, born and raised in the UK, presented to the ophthalmology emergency department with a 15-day history of non-tender left upper lid oedema, with no other systemic symptoms. She was diagnosed with AOSD in October 2021 and successfully treated with oral prednisolone.

On suspicion of dacryoadenitis, she received a 1-week course of Ibuprofen 400mg TDS. The swelling continued to worsen and progressed to bilateral involvement with restricted motility. Consequentially, her regular 10mg daily prednisolone dose was doubled for a few weeks until symptoms improved. She was referred to her rheumatologist to assess long-term treatment with sparing-steroid agents.

Results

CT orbit showed significant bilateral lacrimal gland enlargement. Bloods were negative for ANA/ANCA and ACE, but positive for Quantiferon.

Chest X-ray was unremarkable showing normal cardiomediastinal contour with clear lungs and pleural spaces. Lacrimal gland biopsy demonstrated non-specific chronic inflammation and perivascular reaction. No granulomas nor hypercellularity were noted, making sarcoidosis, tuberculosis, and malignancy unlikely diagnoses.

Conclusion

Only a handful of cases of dacryoadenitis in the context of AOSD have been reported. Our case did not respond to oral NSAIDs but was successfully managed with higher doses of oral steroids. The positive Quantiferon blood test was likely to be incidental finding, as it didn´t correlate with the clinico-radiological picture or the pathology findings. This case highlights the importance of careful rheumatology and ophthalmology co-management of systemic conditions with ocular involvement, in order to maintain remission and prevent further flare-ups.


Maria MAS CASTELLS, Sara MEMON (London, United Kingdom)
00:00 - 00:00 #32536 - Acquired lacrimal canaliculus obstruction treated by silicone stent insertion – a retrospective study.
Acquired lacrimal canaliculus obstruction treated by silicone stent insertion – a retrospective study.

Purpose: To investigate the outcomes of acquired lacrimal canaliculus obstruction treated by silicone stent insertion with or without intranasal endoscopic visualisation.

Methods: A retrospective study included 46 patients with acquired canalicular obstruction treated from October 2017 to March 2022 at Eye Hospital, University Medical Centre Ljubljana, Slovenia. Patients conducted in the study had symptomatic epiphora with upper and lower canalicular or common canalicular obstruction. They were diagnosed by probing and irrigation where soft stop and absence of mucopurulent discharge differ them from patients with nasolacrimal duct stenosis. The procedure was performed mostly in local anesthesia (1 patient in general) by dilating the canaliculi using a Nettleship dilatator and a Bowman probe. Before silicone stent insertion (Minimonoka or Nunchaku stent - FCI Ophthalmics) the lacrimal system was irrigated to check for patency.

Statistical analysis included demographic data, location of obstruction, silicone stent type and time of removal, anatomical and functional success rate. The anatomical success was assessed by probing and irrigation including complete patency without reflux, patency with some reflux and complete obstruction, while the postoperative subjective outcomes were assessed by questionnaire including complete success without tearing, partial success with occasional tearing and no success.

Results: The average age of patients was 59+/-17 years with female predominance (74%). 39 patients had common canaliculus and 7 upper and lower canaliculus obstruction. In 7 patients Minimonoka and in 39 patients Nunchaku stent was used. Average time of stent removal was 6 months after procedure, 10 patients were without symptoms and did not want the stent to be removed. The complete anatomical success rate was achieved in 71.7%, partial anatomical success in 19.6% and no anatomical success in 4.3% of patients. Subjectively complete success was achieved in 67.4%, partial success in 19.6% and no success in 8.7%.

Conclusion: The relatively high anatomical success rates and positive subjective scores with improved tearing symptoms indicate that mono or even more bicanalicular silicone stent insertion is a good minimally invasive method to treat acquired lacrimal canaliculus obstructionProcedure could be performed in local anesthesia and reduce the need for more invasive dacryocystorhinostomy with retrograde intubation preformed under general anesthesia.


Gregor HAWLINA (Ljubljana, Slovenia)
00:00 - 00:00 #32377 - Assessment of quality of life through Glasgow Benefit Inventory (GBI) Score in post punctoplasty patients.
Assessment of quality of life through Glasgow Benefit Inventory (GBI) Score in post punctoplasty patients.

Purpose-Measuring quality of life (QoL) improvement for patients post intervention can be a good way of demonstrating benefit to the patient and functional success of procedure. Many studies have assessed QoL improvement following Dacryocystorhinostomy (DCR) surgery mostly using Glasgow Benefit Inventory (GBI). So far there is only one study that  assessed quality of life in patients who had punctoplasty.
Methods-This is a retrospective analysis of adult patients that underwent Punctoplasty for epiphora between 1st January 2020 and 30th June 2021. We used the audit suite in Medisoft to derive the patients that underwent Punctoplasty during this period. Exclusion criteria included previous lacrimal surgery, canalicular obstruction and adjuvant surgery like DCR, lacrimal intubation and ectropion surgery.We conducted telephone interviews and used GBI which is a post-interventional questionnaire, consisting of 18 questions with responses scored on a five-point Likert scale  ranging from −100 (maximal detriment) to +100 (maximal benefit).
Results-The GBI questionnaires were analysed as recommended by the GBI manual. There were a total of 77 patients who underwent Punctoplasty during this period. After excluding the patients according to our criteria we had 30 patients in total. We were able to complete the telephone survey for 21 patient. About 90% of patients underwent Kellys punch Punctoplasty compared to 10% who had 3 snip procedure.The GBI score ranged from -30 to 50. 
Conclusion-Results suggest that in majority of patients the intial benefit obtained after Kellys punch Punctoplasty doesnt last long and need further repetition of punctoplasty or combine with other type of intervention. Further studies are required if a combined punctoplasty with intubation or balloon punctoplasty gives better long term satisfaction to patients.

Saadia CHAUDHRY (Leeds, United Kingdom), Faizan TAHIR, Christine SAFIEH, Sreedhar JYOTHI
00:00 - 00:00 #32345 - Bilateral Dacryoadenitis as the initial presentation of Granulomatosis with Polyangiitis after COVID-19.
Bilateral Dacryoadenitis as the initial presentation of Granulomatosis with Polyangiitis after COVID-19.

SARS-CoV-2 has been found to potentially trigger autoimmunity. This case reports a previously healthy female with new onset of aggressive bilateral subacute dacryoadenitis due to Granulomatosis with polyangiitis (GPA) two weeks after COVID-19 infection.A 23 year old Asian female presented with a 10 day history of significant periocular swelling of the lacrimal gland area with pain and limitation of extra-ocular movements and a right sided proptosis. The remainder of the ocular examination was normal and she was afebrile. Antibiotics were commenced for a possible infectious orbital cellulitis, with no improvement.Blood tests revealed elevated inflammatory markers (WCC 12 800/µL with neutrophilia, CRP 40 mg/L) and PR3-ANCA positivity.Orbital CT scan demonstrated enlarged well defined lacrimal glands causing displacement of extra-ocular muscles and compression of the right globe. Mucosal thickening of maxillary and ethmoidal sinuses was noted.Biopsy of the right lacrimal gland showed a chronic non granulomatous inflammatory infiltrate with lymphocytosis, necrosis and the presence of macrophages.The above findings and c-ANCA positivity supported the diagnosis of bilateral dacryoadenitis suggestive of limited GPA. Oral prednisolone was started. She responded rapidly but experienced aggressive recurrent ophthalmological relapses on dose reduction. She subsequently developed upper respiratory symptoms. Chest CT demonstrated two pulmonary nodules. Biopsy confirmed granulomatous inflammation and diagnosis of GPA. The patient commenced rituximab treatment with clinical improvement.Orbital GPA is a challenging “simulator” disease with a wide range of differential diagnosis. Our patient presented with aggressive symptoms limited to the orbit, refractive to treatment and only developed systemic symptoms later in the course of the disease. Treatment requires a collaborative multidisciplinary approach. The temporal association between COVID-19 infection and new onset of GPA vasculitis in this case suggests SARS-CoV-2 as a potential trigger.


Marta GARCIA-VILARO (London, United Kingdom), Anna GKOUNTELIA, Wessam MINA, Charlotte Louise GODFREY
00:00 - 00:00 #32049 - Biofilm in the lacrimal sac as a prerequisite for chronic dacryocystitis.
Biofilm in the lacrimal sac as a prerequisite for chronic dacryocystitis.

Biofilm in the lacrimal sac as a prerequisite for chronic dacryocystitis

Objective: Chronic dacryocystitis is known to be refractory to treatment with local and general antibiotics. Presence of biofilm in the lacrimal sac could be an explanation for the lack of response to antibiotics in these patients. In this study we wanted to examine the presence of biofilm in the lacrimal sac of patients with chronic dacryocystitis as well as patients with epiphora but without discharge.

Methods: Patients with ductus stenosis without dacryocystitis (n=2) and with dacryocystitis refractory to antibiotics (n=2) were operated with external dacryocystorhinostomy. Upon opening the sac during the operations bacterial cultures were taken from the lumen of the sac to analyze possible bacterial growth including resistance pattern. Biopsies (4 x 4 mm) were taken from all lacrimal sacs and prepared for light and scanning electron microscopy.

Results: Cultures from three of the sacs did not display any growth of bacteria. In one patient with chronic dacryocystitis, Haemophilus influenzae and Streptococcus intermedius were identified.

Scanning electron microscopy of lacrimal sacs revealed structures consistent with bacterial colonies and extracellular material adjacent to the bacterial colonies, indicating biofilm formation. This was most prominent in one of the patients with chronic dacryocystitis. Bacteria were not only located on the luminal surface of the sacs, but also found within the tissue of the sac.

Conclusions: Lack of passage in the lacrimal duct predisposes to bacterial growth and even in patients with no clinically proven infection of the lacrimal sacs we found bacteria in their lacrimal sacs. These findings of biofilm in patients with chronic dacryocystitis may explain the lack of efficiency on dacryocystitis by antibiotic in concentrations used in clinical practise as bacterial biofilms are 10-1000 times more resistant to antibiotic treatment compared to planktonic bacteria.

 

 

 

 


Karl ENGELSBERG (Lund, Sweden), Johanna BERGGREN, Maria BAUMGARTNER, Ravi BONGHIR, Malin MALMSJÖ, Andreas SONESSON
00:00 - 00:00 #32386 - Conjunctivodacryocystorhinostomy (CDCR) with preparatory carunculectomy.
Conjunctivodacryocystorhinostomy (CDCR) with preparatory carunculectomy.

Background: Conjunctivodacryocystorhinostomy (CDCR) with a Lester Jones Tube is indicated for the treatment of epiphora when traditional dacryocystorhynostomy (DCR) would fail due to presence of canalicular disease, thus necessitating a bypass of obstructed canaliculus. Due to high rates of tube extrusion and sub-conjunctival displacement, various surgical modifications have been proposed however limited data exists on their success rates. One such technique is the minimally invasive CDCR (MICDCR) where a direct communication between the conjunctiva and middle meatus is created.

 

Aim: We propose an additional step to this procedure; an initial carunculectomy followed by a MICDCR. The added benefit of a carunculectomy would induce conjunctival scarring to secure the tube and reduce conjunctival overgrowth, thus minimizing movement of the tube and improving continued patency.

 

Results: We analysed data of the Lester Jones tube insertion between 2008 and 2019 (11 year period) at our tertiary unit. There were 26 patient in total, and 13 who underwent prior carunculectomy when our local practice has changed. We specifically report our results of 4 patients who underwent this 2 step procedure in a prior carunculectomy with MICDCR. Only 1 patient developed extrusion of the tube with the rest having successful cessation of epiphora and no untoward complications. A further 9 patients underwent a carunclectomy and a standard CDCR with a Jones tube. There were no reports of tube extrusion although 3 tubes were electively removed for various reasons. Data comparing our results to those previously, before the additional carunculectomy step for both MICDCR and CDCR was added, demonstrated inferior results.

 

Conclusion: This highlights the addition of prior carunculectomy as a strong adjunct to maximise results in those patient who require Lester Jones tube. Although a promising start, additional numbers are necessary to determine the efficacy of an added carunculectomy.

 


Yahya KHEDR, Bryan ATIENZA, Mousindha ARJUNAN, Egle ROSTRON, Colin VIZE (Hull, United Kingdom)
00:00 - 00:00 #32110 - Diagnosis of a lacrimal sac diverticulum through lacrimal endoscopy: A case report.
Diagnosis of a lacrimal sac diverticulum through lacrimal endoscopy: A case report.

Objective

Lacrimal sac diverticula are outpouchings of the lacrimal drainage system. They are rare conditions, and often undetected due to their asymptomatic appearance. This case report shows lacrimal system endoscopy as a possible diagnostic tool in the case of lacrimal sac diverticulum and patent lacrimal system.

 

Methods & Results: Case Report

A 38-year-old female presented with a subcutaneous swelling lateral from the lacrimal sac region of the left eye since a few months. Irrigation showed a free passage of fluid to the nose without changes in the appearance of the swelling. In the history, oral antibiotics have showed insufficient results and the mass, diagnosed as an abscess, had been repeatedly drained without conclusive effects. Imaging showed a 6-8mm subcutaneous process near the medio-caudal part of the orbital rim. A diagnostical lacrimal endoscopy was carried out and revealed the opening of a lacrimal sac diverticulum. A diverticulectomy was performed and the histopathological report confirmed the diagnosis. The follow-up until now did not show any sign of complication or recurrence and patent lachrymal drainage system.

Discussion

The diagnosis of lacrimal sac diverticulum should be considered in case of intermittent or persistent swelling near the lacrimal sac with or without a patent lacrimal system. The most useful diagnostic tool described in the literature is the dacryocystography, which can demonstrate the presence of a cavity connected to the lacrimal system after contrast injection. A lacrimal system endoscopy, as shown in this case report, is a less known diagnostical technique but can directly demonstrate the opening of the diverticulum in the wall of the lacrimal sac.  As for the other diagnostic options, the endoscopy has a limited sensitivity and requires expertise.


Maria BORRELLI (Düsseldorf, Germany), Celine TRIGAUX, Christoph HOLTMANN, Gerd GEERLING
00:00 - 00:00 #30747 - Effectiveness of punctocanaliculoplasty with mini-monoka stent placement for epiphora.
Effectiveness of punctocanaliculoplasty with mini-monoka stent placement for epiphora.

Introduction: Punctocanaliculoplasty with mini-Monoka stent placement is a minimally invasive procedure performed with intra-canalicular anaesthetic (tetracaine) or local anaesthetic infiltration that can relieve symptoms of epiphora due to punctual stenosis, punctual occlusion or canalicular stenosis or obstruction. Here we analyse the effectiveness of this procedure.

Methods: A retrospective analysis of patients who underwent punctocanaliculoplasty with mini-Monoka stent placement in the years 2017-2019 inclusive.

Results: There were 18 patients with operations on 24 eyes. 72% of patients (n=13) were female while 28% were male, and their average age was 63.5 years. Surgery was performed on the right side alone in 39% of cases, bilateral in 33%, and left side alone in 28%. The most common indication was punctual stenosis.There were no post-operative complications. 83% of operations (20/24) were successful without any further intervention required. Stents were dislodged prior to post-operative clinic visit in 3 cases; the lacrimal system remained patent in 2 of these and 1 required revision. 4 patients had ongoing symptoms, 3 of which required dacrocystorhinostomy within one year (with one declining) while 1 was listed for lid tightening. Average time to post-operative clinic was 59 days.

Conclusion: Punctocanaliculoplasty with mini-Monoka stent placement is a safe and effective management option for canalicular and punctual stenosis. Close monitoring and follow up ensures that complications are detected in a timely manner and allows planning for appropriate further intervention. As punctocanaliculoplasty is minimally invasive it can be used to treat elements of outflow obstruction in the context of co-existing lacrimal pump failure, which can be addressed later with lid tightening if symptoms persist.


Vinod EDIRISINGHE (Northampton, United Kingdom), Tristan MCMULLAN
00:00 - 00:00 #32540 - Efficacy of the nasal septum mucosa flap for revision external dacryocystorhinostomy.
Efficacy of the nasal septum mucosa flap for revision external dacryocystorhinostomy.

Purpose: To evaluate the effectiveness of the nasal septum mucosa flap in revision external dacryocystorhinostomy (rE-DCR).

Design: A prospective longitudinal and interventional study, for assessment of a novel surgical technique, wich consists in harvesting a pedunculated mucosa flap in the nasal septum and suture it to the  remanent mucosa flap of the lacrimal sac, in patients with prior history of failed DCR. Wilcoxon test was performed for statical evaluation with a  P value <0.05.

Results: Nine patients underwent re-DCR with nasal septum mucosa flap. Patient´s had a mean age of 51.22 years (IR 9-74 years). Eight patients had anatomical and functional success outcome. A statistically significant postsurgical improvement in epiphora (p=0.0039), lacrimal meniscus height (p=0.0042) and regurgitation test (p=0.0098) was found when compare with presurgical measurements. Mean follow-up was 15.66 months (IR 12-25 months). Non-appropriate osteotomy size and fibrotic tissue blockage at the osteotomy were the main trans-surgical findings associated to failure in the primary DCR.

 Conclusions: The functional and anatomical success rate of the nasal septum mucosa flap in patients who underwent a rE-DCR was achieved in 88.88% cases. These results suggest that the nasal septum mucosa flap could be considered as a very good option for patients undergoing re-DCR.


Rubén LÓPEZ OLIVER (Mexico City, Mexico), Cristina PLATA PALAZUELOS, Verónica ESCALANTE GÓMEZ, Gerardo GRAUE MORENO
00:00 - 00:00 #32440 - Epidemiologic, anatomical, and functional outcomes of lacrimal canalicular injuries repair in a French tertiary center.
Epidemiologic, anatomical, and functional outcomes of lacrimal canalicular injuries repair in a French tertiary center.

Purpose:

 

This study was designed to identify the demographic and clinical features of canalicular injuries and to determine the control of epiphora after stent removal.

 

Methods:

 

From January 2005 to May 2022, all patients who underwent canalicular laceration repair at Limoges University Hospital were retrospectively reviewed. Demographic information, cause/mechanism of injury, clinical data, surgical management, and its outcome were analyzed.

 

Results:

 

The mean age of the 90 patients included was 33.5 (range 1-86) years old. 67 patients (72.5%) were male.

The most common cause of canalicular laceration was home accidents (29%), followed by animal injuries (17%), falls (16%) and fight injuries (11%).

Lower canaliculus was involved for 53 patients (58.9%), upper for 28 (31.1%), both for 8 (8.9%), and union canaliculus for 1 (1,1%).

79 patients (88%) underwent canalicular repair with Mini-monoka® silicone stent, 5 (5.5%) with Fayet-Bernard Monoka® silicone stent, 5 (5.5%) didn’t have intubation and 1 (1%) with Bicanaliculonasal Ritleng lacrimal intubation®.

After arrival at the hospital, the average time to management was 8 hours and the average operating time was 103 minutes. Stents were removed at an average of 12.4 weeks (range 4-84).

At 3 months after stent removal, 91% of patients had functional success and 89% anatomical success. For 5 patients, surgical revision was necessary because of persistent epiphora and for 3 patients for a better anatomic result.

 

Conclusion:

 

Canalicular injuries frequently occurred in children and young male adult with high rates of anatomical and functional success after surgery. Our findings shown equivalent results to the published literature. The Mini-monoka stent was the most used device, it is known as easy and safe, but we noticed that the procedure without intubation didn’t have more epiphora. The stent removal time ? remains controversial, and our results reflect those of a recent American research review. Further studies will be necessary to determine this optimal time and to compare canalicular repair with and without stent.


Rodolphe POULENARD, Juliette DELMAS (Limoges), Odile VERNAT-TABARLY, Pierre-Yves ROBERT
00:00 - 00:00 #32207 - How accurate is the lacrimal examination performed for the evaluation of epiphora in an outpatient clinic?
How accurate is the lacrimal examination performed for the evaluation of epiphora in an outpatient clinic?

Purpose: To evaluate the accuracy of the diagnostic probing and lacrimal irrigation test for the patients with epiphora through lacrimal micro-endoscopic evaluation(LEE) of lacrimal drainage system(LDS)

Method: from January 2020 to December 2021, the charts of patients with epiphora chosen to undergo diagnostic probing, lacrimal irrigation and LEE of LDS were reviewed retrospectively. We compared the results of the probing and the lacrimal irrigation test with the results of LEE. In probing, the soft stop was diagnosed as canalicular or common canalicular obstruction. In the lacrimal irrigation test, passage was defined to no nasolacrimal duct stenosis, partial regurgitation was regarded as nasolacrimal duct stenosis, and total regurgitation was diagnosed as nasolacrimal duct obstruction. It was judged to be accurate if it was consistent with the LEE findings. Patients with soft stop or false hard stop in the diagnostic probing were excluded from the evaluation of lacrimal irrigation test results.

RESULTS: The accuracy of the diagnostic probing was 84%, false soft stop 17.6% and false hard stop 15.7%. Among the false soft stop cases, two cases were CLS-MFs and the other case was lacrimal sac concretion. In all the cases of false hard stop, common canalicular obstruction was found by LEE. The accuracy of lacrimal irrigation test was 68% overall, 36.4% for passage, 69% for partial regurgitation, and 81.8% for total regurgitation. The accuracy of lacrimal irrigation test was lower than that of the diagnostic probing, and especially, the accuracy of passage was the lowest.

Conclusions: Although the diagnostic probing, a representative lacrimal examination performed in an outpatient clinic for the evaluation of patient with epiphora, has relatively accurate, it should be considered that there is a possibility of a false hard stop. On the other hand, the lacrimal irrigation test had relatively low accuracy, and especially the result of passage was not reliable. Therefore, it should be kept in mind that the nasolacrimal duct may not be patent even if the lacrimal irrigation test shows passage without regurgitation.


Jihyun PARK (none, Korea), Minwook CHANG
00:00 - 00:00 #32378 - How to stop losing "e;stop loss LJ tube"e;.
How to stop losing "e;stop loss LJ tube"e;.

Purpose-The aim of this surgical modification is to apply a stitch to fix the Lester Jones tube and prevent its post operative displacement in order to avoid a redo surgery for this particular complication.

 

Methods-Lester Jones tube repositing surgery was performed on 12 eyes, of patients of both genders, as a redo procedure after failure of previous surgery. Some of these patients had the tube migrated down and others had it expelled out spontaneously. The Lester Jones tube was either repositioned or a new one was used.

 

A double ended non-absorbable prolene 6/0 suture was used to secure the neck of the tube with caruncle stump and with the anterior limb of medial canthal tendon. The suture ends were then brought out through the eyelid and the knot was buried in a subciliary incision beneath the lower punctum.

 

Results-This resulted in a well-positioned and stable Lester Jones tube in 100% of the cases.
 There were 2 cases that had conjunctival overgrowth across the tube opening but the tube still stayed where it was fixed.
This issue would be addressed by using an antimetabolite (Mitomycin C) during the next procedure while exposing the tube opening.

 

Conclusion-This non absorbable prolene 6/0 stitch did not cause any significant discomfort to the patient, kept the tube in place and prevented the downwards migration and expulsion in 100% cases. Hence it could be safely used in every primary StopLoss Lester Jones tube surgery.

 


Saadia CHAUDHRY (Leeds, United Kingdom), Faizan TAHIR, Christine SAFIEH, Bryan ATIENZA, Sreedhar JYOTHI
00:00 - 00:00 #32384 - Imaging of the lower punctum with anterior segment OCT in patients with dacryocystorhinostomy who underwent bicanalicular silicone tube implantation.
Imaging of the lower punctum with anterior segment OCT in patients with dacryocystorhinostomy who underwent bicanalicular silicone tube implantation.

Purpose: To record the structural changes developing in the lower punctum using spectral domain anterior segment OCT imaging of dacryocystorhinostomy patients who underwent bicanalicular silicone tube implantation.

Materials and Methods: The study included 29 eyes of 29 patients who underwent bicanalicular Crawford silicone tube implantation together with dacryocystorhinostomy. The mean age of the cases was 53 (24-72). Of the cases, 19 were female and 10 were male, 18 right eyes and 11 left eyes were operated. The lower punctum images of the cases were recorded with spectral domain anterior segment OCT before surgery and at the 1st day, 1st month and 6th month after silicone tube explantation. External punctum width (PW) and canaliculus depth (CD) measurements of the lower punctum were performed.

Results: Preoperative mean external PW and CD measurements of the cases, respectively; It is 545 µm and 451.7 µm, after silicone tube explantation it is 818 µm and 735.3 µm on the 1st day, 665.9 µm and 619.3 µm in the 1st month and 530.3 µm and 558.4 µm in the 6th month seen. While the mean PW values were significantly higher on the 1st day after tube explantation than before the surgery, there was no significant difference between the 1st and 6th month measurements. In the mean CD values, there was no significant difference between the 1st day, 1st month and 6th month measurements after tube explantation compared to preoperatively.

Conclusions: Since PW and CD measurements were found to be close to preoperative values at 6 months after silicone tube explantation, we think that the effects of silicone intubations applied to the canalicular system in punctal stenosis in providing punctal openness will decrease over time after tube explantation.


Sibel YAVUZ, Sibel YAVUZ (Antalya, Turkey), Hatice Deniz İLHAN, Olgar ÖCAL
00:00 - 00:00 #32262 - Lacrimal puncta stenosis. Investigation of viral implication as an etiological factor.
Lacrimal puncta stenosis. Investigation of viral implication as an etiological factor.

Objective: Various etiological factors have been studied for the stenosis or obstruction of lacrimal puncta (LPS). Scarce studies have researched the potential interference of viruses in the LPS. The aim of this study is to investigate the implication of viral infection of the lacrimal puncti as a risk factor for LPS.

Methods: We present early data of a prospective study. The tissue removed during a 3-snip procedure in cases of LPS, is collected and subjected to Polymerase Chain Reaction (PCR) for HSV1, HSV2, CMV, EBV, HHV6 and chlamydia trachomatis. Up to present, 48 specimens have been received from 26 patients (bilateral surgery was performed at 22 patients and unilateral at 4).

Results: HHV6 was detected in 12 specimens (25%), CMV in 9 specimens (18,75%) and EBV in 2 (4,17% of total specimens). HSV and chlamydia trachomatis were not found in any case.

Conclusion: Our preliminary results show an increased probability of viral implication for LPS. Additional data need to be examined, as well as comparison with normal population.


Phoebos PAPADOPOULOS, Theodora TSIROUKI, Ioannis ASPROUDIS, Ioannis NTOUNTAS (ATHINA, Greece)
00:00 - 00:00 #31977 - Lacrimal Sac Diverticulum: Clinical Presentation and Endoscopic Management.
Lacrimal Sac Diverticulum: Clinical Presentation and Endoscopic Management.

Background To describe the clinical presentation, surgical intervention and clinical outcomes of patients with a lacrimal sac diverticulum.

Methods Retrospective chart review of all patients who underwent endonasal endoscopic DCR in a single medical center from January 2010 to May 2022. The diagnosis of a lacrimal sac diverticulum was based upon intraoperative findings.

Results In total, 492 patients underwent endonasal endoscopic DCR during the study period. eleven female patients (mean age 37 years) were diagnosed with a lacrimal diverticulum and underwent DCR by an endonasal endoscopic approach. The mean follow-up period was 11.5 months. All eleven patients had cystic findings at the lacrimal fossa on imaging studies prior to surgery. Seven patients had a history of dacryocystitis. The main presenting symptoms were epiphora and/or medial canthal swelling. The diverticulum was identified on the inferior wall in ten cases. A dacryolith in the lacrimal sac was identified intraoperatively in three patients. All patients showed full resolution of symptoms after surgery. There were no intraoperative or postoperative complications.

Conclusion Lacrimal sac diverticulum is a rare entity with female predominance. It may be the underlying etiology of epiphora and/or dacryocystitis. The diagnosis is based upon identifying the presence of a diverticulum intraoperatively. Endoscopic DCR is an effective approach for integrating both the lacrimal sac and diverticulum cavities into a single space, leading to resolution of symptoms.


Ran BEN CNAAN, Muhammad ABUMANHAL (Tel Aviv, Israel), Igal LEIBOVITCH, Avraham ABERGEL
00:00 - 00:00 #32480 - Novel sustainable bicanalicular intubation technique for lacrimal canalicular laceration: Prolene suture assisted annular silicon tube intubation with adjustable silicon sleeve -Kıvanç’s Loop.
Novel sustainable bicanalicular intubation technique for lacrimal canalicular laceration: Prolene suture assisted annular silicon tube intubation with adjustable silicon sleeve -Kıvanç’s Loop.

Objective: Monocanalicular intubation is one of the methods frequently used in lacrimal canaliculi injuries. MiniMonoka silicone tube can be used for this purpose. Another method is bicanalicular silicone tube intubation using a pig tail probe. However, in circumstances like  pandemic or war, there may be difficulties in accessing these equipments, and there are also difficulties and complications caused by the implementation of these procedures. Here we describe a new bicanalicular intubation technique and we believe that we also contribute to sustainability with the new technique we describe.

 

Methods: During the pandemic period and after pandemic, at the time of Ukranian war that took place at the  north of Turkey, the prices of health equipment have increased a lot and there has been a limited amount of some medical supplies  available to our clinic. Our department is the tertiary center serving nearly 10 million people in the South Marmara region in terms of Ocular Traumas. In our clinic, the pig tail probe is not preferred  in case  it may cause  damage to the lacrimal canaliculi. We  developed  a novel loop technic which  we called “Prolene suture assisted annular silicon tube intubation with adjustable silicone sleeve -Kıvanç’s Loop”. Best of our knowledge this technique has not been presented previously.

Results: This technique was used  in 5 cases successfully. It is much more effective for lower canalicular laceration,  bicanalicular laceration, and punctum laceration. No complication was observed. Removal of the silicone tube was very easy.  It is easy to arrange size of annular ring with adjustable silicon sleeve. It is also possible to suture eachother both ends of silicone tube. Objective: Monocanalicular intubation is one of the methods frequently used in lacrimal canaliculi injuries. Lacrimal canaliculus is patent in all patients and no epiphora has been noted.

Conclusion: This new technique is an alternative, inexpensive and sustainable method that can be used if there is shortage for lacrimal surgery equipments.


Sertac Argun KIVANC (Bursa, Turkey), Berna AKOVA
00:00 - 00:00 #32192 - Ochrobactrum anthropi chronical dacryocystitis.
Ochrobactrum anthropi chronical dacryocystitis.

Purpose: To describe an unusual case of chronical dacryocystitis caused by Ochrobactrum anthropi and its particularities (clinical, bacteriological, surgical).

Methods: Case report

Results: The patient was a 79-year-old immunosuppressed woman with frank hypogammaglobulinemia, contaminated during a thalassotherapy cure few weeks ago. The surgery was performed without biomaterials after the failure of a medical treatment using usual antibiotics (oral amoxicilline and clavulanique acid and topical rifamycine). Bacteriological samples pre op et per op grew a non-fermenting gram-negative bacteria Ochrobactrum anthropi with multidrug resistance. By using systemic ciprofloxacine per op, then oral and topical ciprofloxacine for two weeks, the outcome was good.

Conclusion: Ochrobactrum anthropi is an emerging ocular pathogen that has not been previously reported in case of dacryocystitis. It’s important to think about this pathogen in case of chronical and drug resistant dacryocystitis with a water exposition in an immunosuppressed old person. Using biomaterial during the surgery is prohibited because of the well-known risk of chronical contamination with this type of bacteria.


Herve CHENAL (NANCY), Lucas MASTRANGELO, Sebastien FOUGNOT
00:00 - 00:00 #32418 - Outcomes of conjunctivochalasis treatment after fornix deepening and retractor recession.
Outcomes of conjunctivochalasis treatment after fornix deepening and retractor recession.

Title:

Outcomes of conjunctivochalasis treatment after fornix deepening and retractor recession

 

Purpose:

To evaluate outcomes of fornix reconstruction and retractor recession for conjunctivochalasis (CCh), particularly ocular surface symptoms (epiphora and dry eye) and improvement of conjunctival folds.

 

Methods:

Retrospective, 4-year, non-comparative, single-centre study of patients with refractory CCh who underwent fornix deepening and retractor recession. CCh was graded using the Hoh classification (grade 0 - no persistent fold; grade 1 - a single, small fold; grade 2 - two or more folds but not higher than the tear meniscus; grade 3 - multiple folds and higher than the tear meniscus). Epiphora and dry eye symptoms were assessed using a validated ‘TEAR’ score pre- and post-CCh correction.

 

Results:

18 eyes of 11 patients with conjunctivochalasis (average age 68, range, 46-82 years) were treated with fornix deepening and retractor recession. All had shallow fornices pre-operatively with a mean CCh grade of 1.7 (typically lower than the tear meniscus). The location of the folds was variable (n=6 diffuse; n=3 medial and n=2 lateral). For a mean follow-up of 15 months, conjunctival redundancy was absent in 10 of 11 patients post-operatively, resulting in a restored tear meniscus and reservoir.

91% saw a reduction in tearing frequency (T), with 73% gaining >= 2-point improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 82% and 91% of patients, respectively, with 36% and 64% gaining >= 2-point improvement. R scores (which relates to dry eye disease) improved in 73%, with 64% seeing >= 2-point gains. (P<0.05 for all). Complications included one case of temporary focal conjunctival inflammation due to a persistent suture and one conjunctival cyst that required deroofing.

Conclusion:

Restoration of the tear reservoir by fornix deepening and retractor recession results in improvement of CCh, epiphora, and dry eye symptoms.


Camille YVON (East Grinstead, United Kingdom), Raman MALHOTRA
00:00 - 00:00 #32357 - Postoperative infection rate after DCR – is selective antibiotic use enough?
Postoperative infection rate after DCR – is selective antibiotic use enough?

Purpose:

Antimicrobial resistance is a critical health issue today. Many recent papers show that DCR surgery can be safely performed without systemic antibiotic prophylaxis and argue that routine use may not be justified. However, antibiotic drugs continue to be widely used in DCR surgery  and vary between and within countries depending on institutional guidelines, medicolegal reasons etc.

In a survey among ESOPRS full members ski WhatsApp group, did 5 of 12 (42%) 2018 and (5 of 19) 26% 2022 use systemic antibiotic routinely on all DCR. In our institution we give antibiotic ointment postop in all patients but use systemic antibiotics just in patients with signs of infection in the lacrimal sac undergoing external DCR and this study evaluates the success of this strategy.

Methods:

Retrospective review of case notes of 107 patients who underwent 110 external DCR from January 2016 to September 2018. Notes of preoperative dacryocystitis and mucous discharge,  pre-, per- and postoperative given systemic antibiotics, peroperative infection or mucous material in the sac and postoperative infection rates in forms of wound infection and related complications one week after surgery were evaluated.

Results:

None of the 110 cases showed any signs of wound infection one week after surgery. Systemic antibiotics were given in 6 cases (5%), either before, intraoperative or after surgery.  104 patients (95%) received no systemic antibiotics at all. 21 patients had a history of dacryocystitis, 20 patients had mucous discharge before surgery and 10 patients had pus in the sac during surgery.

Conclusion:

To prevent soft tissue infection after external DCR, selective use of systemic antibiotics limited to patients with signs of active lacrimal sac inflammation appears to be sufficient. 

 


Eva DAFGÅRD KOPP (Stockholm, Sweden)
00:00 - 00:00 #32200 - Radiofrequency-Assisted Endofistulectomy: Treating Coexisting Lacrimal Fistulae During Endoscopic Dacryocystorhinostomy.
Radiofrequency-Assisted Endofistulectomy: Treating Coexisting Lacrimal Fistulae During Endoscopic Dacryocystorhinostomy.

Purpose: To assess the efficacy of radiofrequency-assisted endofistulectomy in patients with lacrimal fistulae communicating with the lacrimal sac.
Methods: Retrospective interventional case series of patients undergoing endoscopic dacryocystorhinostomy with endofistulectomy from June 2016 to January 2020 were studied. The indications of endoscopic dacryocystorhinostomy were associated refractory complex congenital nasolacrimal duct obstructions and primary-acquired nasolacrimal duct obstruction. The communication of the fistulae with the lacrimal sac was ascertained. Specific surgical parameters and technique were used, and the variables assessed include patient demographics, clinical presentation, indications, surgical technique, recurrences, and outcomes.
Results: Six eyes of 6 patients with mean age of 23.33 years underwent radiofrequency-assisted endofistulectomy. The surgical technique was found to be minimally invasive, easy to perform with multiple advantages like absence of a skin incision, targeting of the complete extent of the fistula, and complete closure of the external and internal openings of the fistulae. At 4 weeks, dacryocystorhinostomy ostium was well mucosalized and patent with a dynamic common canalicular opening. The fistula site had healed well with no epiphora or discharge or residual scarring.
Conclusion: Radiofrequency-assisted endofistulectomy is a minimally invasive and viable alternative to incisional fistulectomy in select group of patients of congenital or acquired fistulae which communicate with the lacrimal sac.


Nandini BOTHRA (India, India), Mohammad JAVED ALI
00:00 - 00:00 #32236 - Retrospective radiological analysis to establish anatomical variation in angulation between medial canthus and the middle turbinate, for optimal positioning of lester jones tubes in treatment of epiphora.
Retrospective radiological analysis to establish anatomical variation in angulation between medial canthus and the middle turbinate, for optimal positioning of lester jones tubes in treatment of epiphora.

Purpose: To determine the optimum angle for placement of Lester Jones lacrimal bypass tube using fixed radiological markers on CT scan head with axial and coronal cuts, as well as analysing the anatomical variation and range of angulation between individuals within our local population.

Methods: A retrospective radiological study conducted on a randomly selected sample of 384 adult patients in a UK Teaching Hospital. The angle between the medial canthus and the middle turbinate was measured on CT scans of the head using fixed radiological anatomical landmarks and analysed using the IMPAX software. Patients with orbital or nasal fractures, as well as those with history of surgical procedures involving the facial bones, were excluded. The accuracy of our measurements was validated using three dimensional (3D) CT head reconstruction technology.

Results: Analysis of the results showed a range of angulation between 28-45 degrees, with a mean angle of 36.99 ± 4.78 SD. There was no significant correlation found when comparing the different age groups using the One Way ANOVA test. Furthermore, a non-significant correlation was found between males and females when their mean angles were compared using the independent t-test.

Conclusion: Our data showed that the ideal angle for insertion of Lester Jones tube would be between 30-45 degrees, with a mean of 37 degrees. No significant correlation was found between the age of the patient and the ideal angle of insertion of Lester Jones tube. Moreover, no significant difference was found in the angle measurements between males and females.


Yahya KHEDR, Egle ROSTRON, Colin VIZE (Hull, United Kingdom)
00:00 - 00:00 #32446 - Should we perform a biopsy of the lacrimal sac during dacryocystorhinostomy?
Should we perform a biopsy of the lacrimal sac during dacryocystorhinostomy?

Introduction : Biopsy of the lacrimal sac in dcr is still a controversial issue. Some authors (3) think that a biopsy should be performed only if there is a reason to suspect a pathology other than a chronic infection while some others think (1) it should be performed routinely. We retrospectively reviewed the histological specimens obtained during 157 surgical consecutive procedures performed in Nantes between 2016 and 2019. 

Material and Methods : 157 external DCR were performed (93% under local anesthesia and 7% under general anesthesia) in 143 patients : 105 women (75%) and 36 men (25%). During the procedure the posterior flap of the lacrimal sac was resected and sent for histological examination in 126 cases (80% of the procedures).

Results : in 114 cases (90%) a non granulomatous inflammation was found. But we also found 4 vascular lesions, 3 lymphoplasmacytic infiltrates, 1 sarcoidosis, 2 leukemic infiltrate, 1 malt lymphoma and one indifferenciated carcinoma whose primary or secondary nature couldn’t be assessed. 

Discussion : There is a real risk of not diagnosing a neoplasm causing a primary acquired nasolacrimal duct obstruction (one personal case) due to the lack of obvious macroscopic lesion of the mucosa of the lacrimal sac at the time of surgery. The rate of 3.5% of neoplasms found  in the histological specimens of this series is the same than what is usually described in the medical literature (2).

Conclusion : We recommend routine biopsy of the lacrimal sac during dacryocystorhinostomy to avoid the misdiagnosis of neoplasms causing nasolacrimal duct obstructions.

Bibliography : 

  1. Anderson NG, Wojno TH, Grossniklaus HE. Clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2003;19:173-6.
  2. Koturovic Z, Knezevic M, Rasic DM. Clinical significance of routine lacrimal sac biopsy during dacryocystorhinostomy :  A comprehensive review of literature. Bons J Basic Med Sci 2017;19:1-8.
  3. Merkonidis C, Brewis C, Yung M, Nussbaumer M. Is routine of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review. Br J Ophthalmol 2005;89:1589-91.

Lionel STORK (NANTES)
00:00 - 00:00 #30888 - Softacort eyedrops following lacrimal surgery:is it safe and effective?
Softacort eyedrops following lacrimal surgery:is it safe and effective?

Purpose

Post-operative treatment regimes for external and endonasal Dacryocystorhinostomy (DCR) vary greatly with some surgeons using topical steroid eyedrops post operatively to reduce the risk of scarring and ensuring a successful outcome. In our service, patients undergoing both external or endonasal DCR were being given 4 weeks of Maxitrol drops (Neomycin-Polymyxin B-Dexamethasone) four times a day in the operated side followed by 6 weeks at twice a day. In January 2020, we changed to Softacort drops (hydrocortisone sodium phosphate) eyedrops using the same frequency regime. The rationale for the change was that the lack of intraocular penetration would minimise risks associated with conventional topical steroids like raised intraocular pressure (IOP), whilst offering the same benefits. We looked at the safety and efficacy of postoperative Softacort eyedrops as an alternative to conventional steroid eyedrops in patients undergoing DCR surgery.

 

Methods

Retrospective continuous comparative case note review, looking at all patients who underwent external or endonasal DCR surgery, at the University Hospital Coventry. Patients treated with Softacort post operatively, between January 2020 to January 2022 were compared with those treated with M­­­axitrol postoperatively between January 2019 and January 2020. Post-operative intraocular pressure, success of surgery (defined as resolution of symptoms of epiphora) and any complications were included in the outcome measures.

 

Results

None of the patients in the Softacort group    had raised intraocular pressure at any time point postoperatively. In contrast, 13% of patients treated with Maxitrol following external DCR experienced a temporary intraocular pressure spike which resolved once the steroid drop was discontinued. Interestingly none of the patients treated with Maxitrol following endonasal DCR experienced raised intraocular pressure. Both groups, had a similar success rates of surgery with no significant difference between the Softacort and Maxitrol groups.  

 

Conclusion

Our study suggests that Softacort eyedrops provide a safe and effective alternative to conventional topical steroid drops in this group of patients. The lack of intraocular penetration minimises the risks of raised IOP whilst offering an adequate anti-inflammatory response.


Emma SAMIA-ALY (London, United Kingdom), Harpreet AHLUWALIA
00:00 - 00:00 #32463 - Solitary fibrous tumor of the lacrimal sac in a pediatric patient.
Solitary fibrous tumor of the lacrimal sac in a pediatric patient.

 

INTRODUCTORY SENTENCE

To report the clinical features, radiographic studies and histopathology of a solitary fibrous tumor of the lacrimal sac in a pediatric patient with local recurrence. 

 

Methods:

Case report of a pediatric patient with solitary fibrous tumor.  Data studied included: clinical history, radiographic studies, histopathology and genetic analysis. 

 

Results:

This 16 year old female presented with tearing and a progressively enlarging mass along the right medial canthus over the past 5 years.  On examination, a large inferomedial mass was noted on to displace the right globe superolaterally (Figure 1A).  MR imaging of the orbit showed a 3.4 x 3.3 x 2.6 cm mass arising from the lacrimal sac with a smaller secondary lobe extending superiorly with rapid contrast washout (Figure 1B).  An orbitotomy was performed to remove the lesion with its capsule.  Histopathology demonstrated bland spindle cell neoplasm consistent with solitary fibrous tumor and the superior extent of the excision positive for tumor cells at resection margin.  DNA microarray analysis showed that the tumor was positive for the NAB2-STAT6 gene fusion.  Owing to the potential for malignant degeneration, the residual focus of tumor was excised with negative margins.  At 12 months surveillance imaging, there is no residual tumor. 

 

CONCLUSION: 

Solitary fibrous tumor (SFT) is a rare neoplasm in the pediatric population.  SFT can present in any location in the orbit and may causing epiphora when involving the lacrimal system.  Although considered benign, incomplete SFT excision can result in malignant degeneration, necessitating margin clearance and long term surveillance.  Lacrimal bypass surgery should be delayed by at least 1 year to ensure no tumor recurrence. 


Zvi GUR (Jerusalem, Israel), Liu CATHERINE, Don KIKKAWA, Bobby KORN
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00:00 - 00:00 #32215 - A 3 year review of the outcomes of orbital decompression surgery in patients with thyroid eye disease.
A 3 year review of the outcomes of orbital decompression surgery in patients with thyroid eye disease.

Purpose

Since the Covid-19 pandemic orbital decompressions for thyroid eye disease (TED) have decreased 33% at our unit as compared to the same period two years before. Conversely, there has been a 200% increase in the number of orbital decompressions performed for dysthyroid optic neuropathy (DON). We report the surgical outcomes for the past three years.

Methods

A retrospective analysis of orbital decompressions for TED between January 2019 to February 2022 at the Royal Victoria Infirmary.

Results

Data from 30 orbital decompressions (17 patients) was analysed; of these 53% were female, the mean age was 51.9 years, 20% (n=6) were performed for DON and 80% (n=24) for proptosis in inactive stable TED. Decompressions included 14 (46.7%) balanced two walls, 11 (36.7%) lateral single walls, 3 (10%) medial single walls, and 2 (6.7%) two-and-a-half walls. The mean orbital fat extracted was 0.87mL.

All patients maintained or had improvement in their visual acuity (VA) post decompression. Mean logMAR VA before and after surgery for DON was 0.54+/-0.37 (standard deviation) and 0.16+/-0.14 respectively. Similarly, decompression for inactive TED showed improved VA pre and post decompression at 0.22+/-0.52 and 0.15+/-0.47 respectively. Mean time to achieve optimum VA post-surgery in the DON group was 49.7+/-60.5 days, and 54.9+/-68.2 days in the inactive TED group.

The mean reduction in proptosis was 3.6+/-1.3mm for balanced two wall surgeries, 3.1+/-0.7mm for lateral single walls, 3.0+/-1.7mm for medial single walls, and 6.0+/-1.4mm for two-and-a-half walls. 

Post-operative complications included new diplopia (27%), orbital inflammation (3%), numbness (3%), subconjunctival haemorrhage (3%), and dellen (3%).

Conclusions

 

There has been a significant increase in DON since the Covid-19 pandemic. Orbital decompressions are beneficial for reducing proptosis in TED and for significantly improving the VA in DON. New diplopia was the most common complication of decompression surgery and this should be counselled for pre-preoperatively


Tejaswi BOMMIREDDY (Newcastle, United Kingdom), Reinold GOETZ, Romeela RANA-RAHMAN, Lucy CLARKE
00:00 - 00:00 #32522 - A case of conjuntival squamous carcinoma and its interdisciplinary management.
A case of conjuntival squamous carcinoma and its interdisciplinary management.

INTRODUCTION: 

Squamous carcinoma of the conjunctiva has an incidence of around 0.02-3.5 cases per 100,000 inhabitants.

The average time of revolution is around 5 years, although more aggressive cases are found.

 

Next, we will present the report of a case in Valme and Virgen Macarena University Hospitals

 

OBJECTIVES:

Describe a squamous carcinoma of the conjunctiva case in our environment and what it took to propose a treatment taking into account other concomitant pathologies present in the patient and its surgical approach given its extension and evolution.

 

METHODOLOGY:

A 69-years-old patient goes to the emergency service due to pain and loss of vision in the RE after trauma in the previous weeks. He is diagnosed and treated for a self-sealing central perforation., and in addition to this, a mass with a variegated appearance was found, multilobulated and vascularized, affecting the bulbar, fornitial and tarsal conjunctiva of the lower eyelid.

 

After completing the anamnesis, the patient reported presenting this tumor for at least a year ago, and when performing TC with intravenous contrast bilateral orbit, a tumor at lower palpebral level contacting the conjunctiva was confirmed (size: 21x12x11mm in its transverse, anteroposterior and longitudinal axes respectively) of neoproliferative origin as the first possibility.

Pathological anatomy confirms locally advanced squamous carcinoma of the conjunctival mucosa, with infiltration of the lower eyelid and bulbar conjunctiva: therefore, extended evisceration is proposed and contact is made with a reference center for orbital pathology.

Assessed at Hospital Virgen Macarena, complete right orbital exenteration was decided due to tumor advancement, but prior to IQ, a hepatic LOE of 8cm with peripheral enhancement was found, so surgery was postponed until the etiology of the mass was determined.

After a radiological and pathological study, a hepatic mass was characterized as intrahepatic cholangiocarcinoma, unresectable so orbital exenteration surgery was paralyzed. After 6 months of Gemcitabine and Cisplatin therapy, the conjunctival injury was growing.

Finally, we decided to do palliative total right orbital exenteration of 7x6x5.5cm is performed. 

CONCLUSION: 

 

Conjunctival squamous carcinoma, must always be taken into account when performing a routine ophthalmological examination as it could require different specialist  interventions.


Cristina ESCORIAL ALBENDIZ, Antonio Manuel GARRIDO HERMOSILLA, Aitor Joaquín CASTILLA LAZPITA, Jose Luis BASURTE (SEVILLA, Spain)
00:00 - 00:00 #30758 - A case of IgG4 related ophthalmic disease exacerbated by chronic intranasal cocaine abuse.
A case of IgG4 related ophthalmic disease exacerbated by chronic intranasal cocaine abuse.

Intranasal cocaine abuse can cause a destructive, inflammatory disease process mimicking neoplastic, infectious, or inflammatory etiologies, including IgG4 Related Disease (RD). Herein, we present a patient with orbital IgG4-RD with exacerbation of the underlying auto-immune process from extensive long-term cocaine use. 

 

A 61 year old, Caucasian, male with past medical history significant for chronic intranasal cocaine abuse presented with acute painless vision loss in the right eye. Exam revealed a right optic neuropathy with disc edema. In addition to the optic neuropathy, imaging (Figure 1A and 1B) demonstrated extensive chronic sinus destruction, along with a diffuse, infiltrative, enhancing, soft-tissue process involving the infraorbital fissures, bilateral pterygopalatine fossae, and lateral cavernous sinuses, right greater than left optic nerve sheath dilation (Figure 1B arrow) along with linear dural enhancement (Figure 1B double arrow) of the anterior and middle cranial fossae. Nasal tissue biopsy that revealed polypoid chronic sinusitis with focal squamous metaplasia. Additional neurosurgical workup with potential biopsy of the meningeal/cavernous sinus process was recommended, however, the patient was lost to follow up. Two years later he presented with left eye pain, lower lid swelling, and binocular diplopia. Ophthalmologic testing revealed decreased visual acuity in both eyes, a relative afferent pupillary defect of the right eye, dysmotility, and 3 mm left proptosis. Imaging (Figures 1C and 1D) revealed infiltrative masses involving the left greater than right orbits. Biopsy was performed on the left orbital mass and histologic analysis revealed fibrous connective tissue with mixed inflammatory infiltrate with IgG increased to up to 100 IgG4 cells per high powered field (HPF). Laboratory testing for serum IgG4 was 135 mg/dl and titers for cytoplasmic neutrophil antibody (c-ANCA) were positive at 1:640. He was started on IV solumedrol inpatient and discharged on a long steroid taper with both ophthalmologic and rheumatologic follow-up. Mitigative strategies to help stop cocaine use have thus far been unsuccessful despite strong medical system and familial support.

 

Chronic cocaine use may lead independently to destructive orbital disease and/or exacerbate underlying auto-immune disorders such as IgG4-RD, while additionally making diagnosis of concurrent disease with biopsy more difficult due to widespread soft-tissue and bony destruction.

 


Gregory GRIEPENTROG (Milwaukee, USA), Carleigh BRUCE, Andrea STAHULAK
00:00 - 00:00 #32343 - A case report of recurrent episodes of periorbital cellulitis (RPOC) and facial inflammation on a background of 1E nasal extranodal NKT cell Lymphoma in remission.
A case report of recurrent episodes of periorbital cellulitis (RPOC) and facial inflammation on a background of 1E nasal extranodal NKT cell Lymphoma in remission.

Case report

A 53-year‐old male presented to the emergency eye clinic with a history of recurrent episodes of progressive swelling around his right eye, treated with oral antibiotics. At the time of admission, he reported photophobia and a right‐sided headache but denied diplopia, sinus tenderness, or oral pain. He was diagnosed with periorbital cellulitis and was admitted for intravenous antibiotics. The patient had had at least seven prior episodes of periorbital cellulitis of the right eye within the previous five months and had also had milder episodes of bilateral eyelid swelling which had resolved spontaneously. The patient's past medical history was significant for multiple medical problems, including stage 1E nasal extra nodal NKT cell lymphoma treated with chemoradiotherapy and consolidative therapy in March 2016 and multiple sinus surgeries and chemoradiotherapy, remained in remission since. On exam, the patient was afebrile, other vital signs were stable, had marked erythema and swelling around his right eye, particularly superiorly with marked tenderness over the area of his maxillary sinus,vision and extraocular movements were intact and did not elicit pain. He reports getting thick nasal discharge regularly. On examination there are atrophic changes in his nasal mucosa secondary to the radiotherapy.MRI/nasendoscopies and biopsies performed showed no recurrent tumour but likely post radiotherapy opacified and stenosed frontal sinuses bilaterally with a mucocele in the right supraorbital cell and osteosis of the drainage pathway of that particular cell, causing recurrent episodes of periorbital cellulitisThe following options on treatment have been discussed:1.Conservative treatment with regular saline douches although, this kind of treatment is unable to prevent the continuous orbital infections.2.Sinus surgery. Any form of surgery unfortunately doesn’t guarantee prevention of orbital infections in the future as the patient has a high chance of scarring due to the radiotherapy which may affect the result of any surgery performed and result in reclosure of the sinus drainage pathways.The patient had the modified Lothrop procedure, posterior part of the nasal septum completely taken down and the frontal sinus drainage pathways opened up into the nasal cavity. This created wide frontal sinusotomies. The patient remains asymptomatic 10 months postoperatively.


Anna GKOUNTELIA (London, United Kingdom), Wessam MINA
00:00 - 00:00 #32356 - A live-time demonstration of how we perform a bilateral endoscopic, endonasal orbital decompression(ENOD) for dysthyroid optic neuropathy (DON).
A live-time demonstration of how we perform a bilateral endoscopic, endonasal orbital decompression(ENOD) for dysthyroid optic neuropathy (DON).

Introduction

Sight threatening DON occurs in 2-8% of patients with GO. When best medical treatment is insufficient, patients benefit from timely orbital decompression. The surgical approach can vary. Our multidisciplinary GO pathway for ENOD allows for a safe and direct decompression of the optic canal to increase the efficacy of immunosuppressive treatment. In this video we illustrate the key steps of the surgical technique.

 

Case

This patient presented with bilateral acute DON with rapid deterioration of visual acuity and severe visual field loss, following a partial response to medical treatment. The MDT decision was to proceed with ENOD.

 

Procedure

Following standard preparation of the nasal cavity, diligent endoscopic sinus surgery with a wide middle meatal antrostomy (MMA), total spheno-ethmoidectomy and frontal sinusotomy were performed. A generous MMA is important to ensure that the maxillary sinus remains patent, as orbital fat protrudes into the nasal cavity after decompression, similarly frontal sinusotomy with preservation of the adjacent lamina prevents obstruction of the frontal sinus. The lamina papyracea was then removed exposing the periorbita. 

Three incisions were made into the periorbita to expose the orbital fat. A middle band of periorbita was preserved to provide stability to the medial aspect of the orbit,  preventing complete collapse into the nasal cavity, which could worsen diplopia. Given clinical evidence of orbital apex crowding, the optico-carotid recess was delineated and the canalicular component of the optic nerve identified, the overlying bone was thinned using a diamond bur drill, decompressing the optic nerve.

 

Conclusions

This case and video recording illustrates the surgical technique for ENOD. We propose that ENOD provides superior direct visualisation of the posterior orbit, allows for direct decompression of the optic canal without need of retraction of the inflamed orbital tissues and is an effective and safe approach for surgical DON treatment.


Faaizah CHISHTY, Harry ROSEN (Henley-on-Thames, United Kingdom), Yadsan DEVABALAN, Acharya VIKAS, Vickie LEE, Catherine RENNIE
00:00 - 00:00 #31097 - A neurofibroma enigma.
A neurofibroma enigma.

Purpose: To report a rare case of rapidly progressive unilateral proptosis in a patient with known Neurofibromatosis Type 1 with concurrent inflammatory pathology (IgG4 mediated inflammatory response), in addition to markedly abnormal thyroid parameters. 



Methods: Case review, with photo series, radiological images & histopathological correlation



Results: A 41-year-old male (smoker) had a background of Neurofibromatosis Type 1 with a left optic nerve glioma, right sphenoidal wind dysplasia and extensive orbital neurofibroma (NF). He presented with right pulsatile proptosis that had rapidly progressed over 4 months. Optic nerve function was closely monitored, the right being his dominant eye and was preserved. Incidentally, he also developed Graves' disease concurrently, but had no thyroid eye disease/inflammatory signs. Radiology showed doubling of the intraconal NF & expansion of the extraconal NF component. The recti muscles were normal on MRI. In view of the rapidity of the expansion, and secondary lagopthalmos, debulking surgery was undertaken (to rule out presence of a sarcoma) via a combined lid crease and bicoronal approach. A 20 mm diameter intraconal NF was removed. In addition, medial and lateral wall decompression and insertion of a titanium sphenoid wing implant was performed. Histology ruled out malignant transformation and reported NF tissue with lymphocytic infiltration. There was no evidence of IgG4 disease. Despite radical surgery, over the following six months, the proptosis recurred and the upper eyelid neurofibroma continued to grow, causing marked displacement of the globe. Further debulking was undertaken. Histopathological analysis identified features of IgG4 disease (up to 50 IgG4+ plasma cells /HPF & ratio between IgG4 + and total (CD138+) plasma cells at least 20%). Post-operative steroids contributed to marked shrinkage of the residual NF tissue & the patient is now being further investigated for systemic features of IgG4 disease.  

 

Conclusions: Rapid progression of orbital NF lesions is atypical and in such cases, histopathological analysis is indicated to outrule malignant transformation. Dual pathology of neurofibromatosis and IgG4 disease is extremely rare. The concurrent diagnosis of Grave’s Disease in a smoker adds some uncertainty to the final diagnosis. Multidisciplinary management of this complex case was essential in effective management.


Aoife NAUGHTON (London, United Kingdom), Manvi SOBTI, Christopher ABELA, Kevin TSANG, Richard SCAWN
00:00 - 00:00 #32258 - A rare case of bilateral carotid cavernous fistula managed with sequential retrograde endovascular coiling via direct cannulation of the superior ophthalmic veins.
A rare case of bilateral carotid cavernous fistula managed with sequential retrograde endovascular coiling via direct cannulation of the superior ophthalmic veins.

BACKGROUND
Bilateral carotid cavernous fistulas (CCF) are rare, with most cases caused by trauma but some may be secondary to cavernous sinus thrombosis.  Though some may resolve spontaneously, many do not and require treatment. A retrograde venous approach via the inferior petrosal sinus utilising a trans-jugular venous access is often used to reach the CCF and perform coil embolization. If atypical vascular anatomy precludes this route, alternative approaches may be required.


DISCUSSION
We report the case of a seventy-four year old female with bilateral CCF presenting as a two-week history of headaches and diplopia. After a thorough workup, she underwent a cerebral digital subtraction angiography (DSA), a partial trans-arterial liquid embolic embolization of the extensive indirect cavernous sinus dural arteriovenous fistula (AVF).  Intra-operatively, both inferior petrosal sinuses appeared occluded and persistence of thrombus in the cavernous sinuses suggested a hypercoagulable state, confirmed by haematology. The contributory factors may have been her co morbidities such as hypertension, type 2 diabetes but we felt that it was most likely due to Letrozole treatment for previous breast cancer. She was anticoagulated on advice from haematology and the neurovascular multidisciplinary team meeting (MDT) agreed on an anterior cutdown by Ophthalmology to gain access to the left super ophthalmic vein for direct cannulation and coiling. Clinical improvement followed successful occlusion of the left sided CCF but enlargement of the right superior ophthalmic vein persisted with worsening symptoms on the right. She subsequently underwent the same operation on the right side several weeks later with a successful outcome.


CONCLUSION
Bilateral CCFs are rare and lack of vascular access to treat the CCF may pose a challenge to the interventional neuroradiologists. The ability to obtain a more direct, per orbital access to the superior ophthalmic vein is still a skill that should be maintained by orbit surgeons for similar situations (however infrequently), requiring an astute knowledge of anatomy and careful, meticulous dissection.


Bryan Jason ATIENZA, Colin VIZE (Hull, United Kingdom), Egle ROSTRON, Paul MALIAKAL, Raghuram LAKSHMINARAYAN, Saira SAYEED
00:00 - 00:00 #30916 - A Rare Orbital IgG4-Related Disease: Eosinophilic Angiocentric Fibrosis.
A Rare Orbital IgG4-Related Disease: Eosinophilic Angiocentric Fibrosis.

Objective: To present the pre- and postoperative findings of a patient with orbital eosinophilic angiocentric fibrosis.

Methods: The preoperative and postoperative findings of the patient were recorded retrospectively from the patient file.

Results: A Thirty-seven-year-old female patient presented with a subcutaneous mass with irregular borders, 3-4 cm in diameter, completely involving the left lower eyelid and pushing the globe upwards (Fig.1 A, B, C). The skin over the mass was hyperemic, outward gaze was limited and intraocular pressure was 33 mmHg in the left eye. The serum IgG4 level was 195 mg/dL. Incisional biopsy was reported as an inflammatory reaction and fibrosis, rich in eosinophils and plasma cells around the vascular structures, with a high suspicion of Eosinophilic Angiocentric Fibrosis (EAF) although IgG4/IgG ratio was less than 25%. Because she was unresponsive to high dose IV methylprednisolone infusion, immediate surgical debulking was performed. Two masses with a diameter of 3.5x2.5x1 cm and 3x5x1 cm were excised and triamcinolone injection was administered for the remaining subcutaneous infiltration (Fig. 1 D). Marked angiocentric fibrosis, intense eosinophilic infiltration, and 40% IgG4/IgG ratio was reported in histopathology. Oral prednisolone (in tapering doses), methotrexate, and IV Rituximab were given following surgery. No activation or recurrence was observed during the sixth-month follow-up (Fig. 1 E, F, G).

Discussion/Conclusion: EAF is a rare subtype of IgG4-related diseases. Histopathology is the key factor in diagnosis. Eosinophilic infiltration and fibrosis around the vascular structures, and a >40% ratio of IgG4/IgG. When there is no response to anti-inflammatory therapy, surgical debulking may be a good option. Oral prednisolone in tapering doses, methotrexate and Rituximab may prevent recurrence as in our case.  


Kubra SEREFOGLU CABUK (istanbul, Turkey), Ali Safa BALCI, Senay ASIK NACAROGLU, Husna TOPCU, Ayse CETIN EFE, Mehmet Goksel ULAS, Safak KARSLIOGLU, İsmail Bilgin GULEC, Nesimi BUYUKBABANI, Sabriye GUNER, Emire SEYAHI
00:00 - 00:00 #32261 - A unique incidence of a confined unilateral orbital metastasis of adenocarcinoma in a patient with history of cured breast cancer.
A unique incidence of a confined unilateral orbital metastasis of adenocarcinoma in a patient with history of cured breast cancer.

Introduction:  

Orbital metastasis is a rare condition that accounts for 1-13 % of all orbital tumors. Most common primary source is breast cancer, accounting for 30-70% of cases. It occurs typically 3-6 years after the diagnosis of the cancer. Here we report a presentation of an orbital metastasis 18 years after the diagnosis of breast cancer. 

 

Case presentation:  

A 71 years old female with a past medical history of a cured breast cancer, diagnosed 18 years earlier. She presented complaining of left eye pain, decrease of visual acuity (VA), ptosis, diplopia and complete Ophthalmoplegia. Imaging studies revealed unilateral confined intra-orbital infiltration of the fat and extraocular muscles of the left eye without any bony or intracranial invasion. Biopsy was compatible with mammary adenocarcinoma. Histopathological markers of estrogen and progesterone receptors (ER, PR) were positive and HER2 was negative. PET scan and mammogram were unremarkable. Due to the well localization of the mass and its histopathological aspects, surgical exenteration followed by hormonal therapy (HT) were advised but patient decided to adhere to the HT only. Follow up visits and MRIs, of a 20 months period, showed improvement of VA and ocular symptoms with partial regression of the intra-orbital infiltration without any other metastasis.  

 

Discussion:  

Orbital metastasis from breast cancer is usually considered as an advanced sign of a widespread disease and the aim of treatment is primarily palliative, unlike our patient. Here we present a case of a well localized unilateral orbital metastasis as a recurrent distant metastatic breast cancer that is only confined to the left orbit without any other organ involvement. Hence, local surgical intervention combined with HT, as ER and PR positive HER2 negative protocol, are supposed to be sufficient.

 

Conclusion: 

Ophthalmological exam and further imaging studies should be considered for patients with active or history of breast cancer who present with ocular symptoms. Early detection and appropriate prompt intervention is the goal to ensure a better outcome and to enhance the quality of life of the patients. 


Abdulaziz ALKAHTANI (Limoges), Juliette DELMAS, Pierre-Yves ROBERT
00:00 - 00:00 #32105 - Acute dacryoadenitis secondary to COVID-19.
Acute dacryoadenitis secondary to COVID-19.

We describe a case of dacryoadenitis associated with orbital disease in a patient with confirmed COVID-19 infection. A 53-year-old patient presented to their general practitioner with left worsening periorbital swelling and pain on ocular movement on the background of upper respiratory tract symptoms and pyrexia in the past few days. Examination noted a restriction of ocular movement particularly in lateral and superior gaze of the left eye associated with diplopia. There was also a demonstratable proptosis of 2mm on exophthalmometry. Based on clinical findings, the patient was initially diagnosed with orbital cellulitis and admitted for intravenous antibiotics. The patient underwent COVID-19 PCR testing on admission and was found to be positive. A laboratory workup including serum angiotensin converting enzyme were unremarkable. Multimodal imaging during admission demonstrated a soft tissue mass in the left superolateral orbit which exerted a mass effect on the left globe suggestive of an inflammatory lacrimal gland pathology. The diagnosis was revised to be acute dacryoadenitis secondary to SARS-CoV-2 and the patient was treated with intravenous pulsed methylprednisolone. The patient made a remarkable recovery and was followed up a week after discharge with a resolution of symptoms. There is growing evidence that COVID-19 can manifest ocularly but orbital involvement remains uncommon and causal relationship have yet to be fully elucidated.


Kareem ALSAFFARINI, Han Xern KHOO (Hull, United Kingdom), Colin VIZE
00:00 - 00:00 #32320 - Advanced primary Histiocytoid/ Signet Ring Carcinoma of the orbit in a 53-year-old man requiring radical exenteration and craniectomy.
Advanced primary Histiocytoid/ Signet Ring Carcinoma of the orbit in a 53-year-old man requiring radical exenteration and craniectomy.

Background

Histiocytoid carcinoma, also described as signet ring carcinoma is a rare malignant eccrine tumour, which can present in the orbit. The tumour is locally invasive but distant metastases can also occur.  We present an advanced case in a 53-year-old man who required radical exenteration and craniectomy performed as a joint case between maxillofacial surgery, neurosurgery and ophthalmology. 

The case is presented with pre-operative, intraoperative and post-operative photographs with the written consent of the patient.

 

History and Clinical Findings

A 53-year-old man presented to the eye clinic with a 4-year history of a slowly evolving right proptosis and partial lid ptosis associated with discomfort and occasional diplopia. The patient was an ex smoker with an unremarkable past medical history and no systemic symptoms.

On examination there was proptosis with inferior displacement of the globe and 3 mm of ptosis with reduced levator function. Extraocular motility demonstrated restricted elevation in the right eye. Visual acuity in the right eye was slightly reduced at 6/18 in spite of otherwise normal optic nerve function tests.

 

Investigations

Orbital MRI revealed a large superior orbital mass infiltrating the superior rectus, levator palpabrae muscles and the lacrimal gland. Distant metastases were excluded with PET/CT.  Transcutaneous biopsy performed with histopathology demonstrating an unusual infiltrative carcinoma with the appearances and immunophenotype in keeping with a primary cutaneous histiocytoid/signet ring cell carcinoma.

 

Management

The case was discussed at the regional orbital multidisciplinary team meeting. It was decided that radical evisceration and craniectomy with adjuvant radiotherapy would provide the best chance of remission without recurrence.  Surgery was performed as collaboration between maxillofacial surgery, neurosurgery and ophthalmology.

 

Conclusion

Hystiocystoid/ Signet ring carcinoma is a rare malignancy requiring aggressive surgical management. We present an unusual case of advanced pathology with orbital infiltration requiring a multidisciplinary surgical approach.


Mark HUGHES, Daniel BECK (Edinburgh, United Kingdom), Robert PEDEN, Chee THUM, James MORRISON
00:00 - 00:00 #32221 - An example of when Ockham's razor is not fulfilled in a patient with graves' orbitopathy.
An example of when Ockham's razor is not fulfilled in a patient with graves' orbitopathy.

AN EXAMPLE OF WHEN OCKHAM'S RAZOR IS NOT FULFILLED IN A PATIENT WITH GRAVES' ORBITOPATHY

A 76-year-old female patient who began follow-up by our service 5 years ago. She was a patient with Graves Basedow disease, for which at that time she had already undergone a thyroidectomy. She was assessed in 2017 by our service for discomfort and tearing. Her examination revealed an asymmetric right eye exophthalmos with palpebral retraction and optic atrophy that was thought to be secondary to her disease. Visual acuity was lump vision. The patient had an MRI that reported residual changes consistent with Graves' disease in the lateral lateral rectus and superior rectus without compression of the optic nerve at that time. The left eye had no pathological findings. She continued in follow-up and in 2019 she went to the emergency room for a dislocation of the right eyeball that the patient was able to reduce manually. A CT scan with contrast was requested. The CT scan revealed a bony expansion of the greater wing of the sphenoid and ethmoid bones compatible with fibrous dysplasia. These findings caused a stenosis of the optic nerve orifice and its atrophy. The stenosis caused a thickening of the superior and lateral rectum and of the orbital fat due to venous compression. Reviewing the imaging tests, she was already present at the previous MRI. In this case, it was not a new outbreak of her thyroid disease. It was a totally different type of orbital affectation. She was assessed by the neurology and maxillofacial surgery service, agreeing with the patient on conservative management. For our part, a tarsorrhaphy was successfully performed to reduce the exposure, obtaining a good palpebral position. Currently the patient undergoes treatment with tears and night gels without discomfort and is very satisfied.


Cristina ESCORIAL ALBENDIZ (Seville, Spain), José Luis BASURTE BAUTISTA, Aitor Joaquín CASTILLA LAZPITA, Nahed EL ABDELLAH HAJJI
00:00 - 00:00 #32075 - Application of surgical cutting guides for orbital decompression in a Graves’s disease treatment: a preliminary study.
Application of surgical cutting guides for orbital decompression in a Graves’s disease treatment: a preliminary study.

Objectives: The main surgical treatment modality of endocrine ophthalmopathy (EOP) is orbital decompression. Bone decompression of the orbit currently remains the most predictable surgery. However, numerous studies reported about incidence of complications. Therefore, the development of ways to prevent complications during bone decompression of the orbit is an actual task of EOP management. The aim of the study was to evaluate the results of treatment and determine the frequency of complications during orbital decompression using surgical cutting guides for management of EOP.

Materials and methods: 17 patients with EOP, who underwent orbital decompression with surgical cutting guides at Kyiv Regional Hospital were analyzed. The design and manufacture of surgical cutting guides were carried out according to CT data using CAD/CAM technology after simulating bone decompression within the "safe zones" in relation to the anatomical structures of the orbit and its soft tissue contents.

Results. According to preoperative exophthalmometry the average value of exophthalmos in the right and left eye was 23,75±3,07 and 24,27±3,26 mm respectively. In the postoperative period the average value of exophthalmos for the right eye was 18,88±2,18 mm, for the left -19,47±3,01 mm (р ˃ 0,05). The average reduction in exophthalmos in the study group was 4,84±0,27mm (p <0,01). Postoperative complications (observation period 3 months): diplopia was noted only in one patient and unilateral hypoesthesia of the infraorbital nerve were detected in tree cases. However, cases of such threatening postoperative complication as liquorrhea were not observed. At the same time, the improvement of visual acuity was noted in 8 cases after treatment: the average value of visual acuity before treatment was 0.74 ± 0.35 and after surgery 0.82 ± 0.27 (р ˃ 0,05).

Conclusion: The use of CAD/CAM technology in the treatment of patients with EOP allows to improve the planning stage of surgery due to the possibility of virtual simulation of bone decompression of the orbit in the preoperative stage. The use of surgical cutting guides during osteotomy allows to achieve a significant reduction in exophthalmos (4.84 ± 0.27 mm) (p <0,01) against the background of reducing the area of bone resection, which can potentially reduce the risk of postoperative complications.


Alina SLOBODIANIUK, Olha PRUSAK (Kyiv, Ukraine), Yurii CHEPURNYI, Andrii KOPCHAK, Oksana PETRENKO, Sergiy RYKOV, Olga DENISIUK
00:00 - 00:00 #31922 - Case report: Primary Orbital Rhabdomyosarcoma in Adults.
Case report: Primary Orbital Rhabdomyosarcoma in Adults.

Purpose: Description of clinical presentation, report and emphasize the treatment approach of this rare tumor among adults.

 

Methods: Institutional case report study and review of two adult patients with primary orbital RMS treated at the Amsterdam University Medical Centers. We evaluated demographic characteristics, symptoms and signs, imaging characteristics, and treatment approach.

 

 

Outcome Measures: Medical records review for demographic information, clinical data history (including symptoms at presentation), imaging studies, treatment received, and follow-up.

 

Results: We reported two cases of primary RMS in adults. RMS is a rare adult disease and considered as a disease of young children, which occur at mean age of 8 years. Several large retrospective studies, have reported the prognosis of adult RMS, but the treatment approach outcome of adult HNRMS (AHNRMS) is still unclear because of its rarity. The low rate of prognosis among adults can be related to different facts; less experience, histological subtype, no consensus on treatment approach, chemotherapy effect is less among adults’ etiology aggressive clinical feature among adults.

 

Conclusions: Even though the absence of controlled, prospective trials, which is due to extreme rarity of the disease our treatment approach was according to pediatric protocols. From our children RMS experience, orbital RMS are usually incompletely resected (group III) in the majority of cases, therefore it is necessary to treat with postoperative chemotherapy and radiotherapy. We consequently believe that adult RMS patients should always be considered at higher risk even in localized disease and the adult age per se should be seen as an important prognostic factor.

A more appropriate use of standard therapies (pediatric protocols) may improve their outcome to some degree, but new adult tailored therapy needed, and a better understanding of the biology of the disease will be crucial to improve the treatment outcome, therefore prospective studies are needed to test this idea. 


Nur KHATIB (Tel Aviv, Israel), Bradley PIETERS, Jacqueline TROMP
00:00 - 00:00 #32152 - Characterization of VRDN-001, a high affinity and potent anti-insulin-like growth factor-1 receptor (IGF-1R) inhibitory antibody for the treatment of Thyroid Eye Disease (TED).
Characterization of VRDN-001, a high affinity and potent anti-insulin-like growth factor-1 receptor (IGF-1R) inhibitory antibody for the treatment of Thyroid Eye Disease (TED).

       Purpose: VRDN-001 is an antagonist antibody to IGF-1R under development by Viridian Therapeutics for treatment of patients with TED. Blockade of IGF-1R has been shown to improve TED symptoms in randomized clinical trials.  We evaluated the binding characteristics of VRDN-001 to IGF-1R and its potency for inhibition of IGF-1R phosphorylation.

       Methods: Surface plasmon resonance was used to determine kinetic parameters and affinity. Binding to cell-surface IGF-1R was assessed by flow cytometry. Inhibition of receptor autophosphorylation was determined using a commercial ELISA after stimulating primary human ocular choroid fibroblasts (HOCF) and A549 carcinoma cells with IGF-1 in the presence of inhibitory antibodies.

       Results: VRDN-001 bound IGF-1R ECD with 0.57 nM affinity and exhibited slow dissociation. These results were consistent with cell binding studies. In IGF-1 stimulated HOCFs and A549 cells, VRDN-001 inhibited IGF-1R phosphorylation with an IC50 of ~0.1 nM and >95% inhibition was observed at concentrations in the 1-10 nM range.

       Conclusions: VRDN-001 bound IGF-1R with high affinity and inhibited IGF-1R signaling with high potency. VRDN-001 shut down IGF-1R signaling at clinically achievable concentrations. This in vitro profile suggests favorable characteristics for treatment of TED patients. A phase 1/2 trial for VRDN-001 in healthy volunteers and TED patients is underway (NCT050176639).


Vahe BEDIAN, Rachel NEWELL, Angela SHE, Linda PESTANO, Robert HENDERSON (Boston, USA), Barrett KATZ
00:00 - 00:00 #32286 - Checkpoint inhibitor induced orbital myositis.
Checkpoint inhibitor induced orbital myositis.

Background:

Checkpoint inhibitors are a class of cancer immunotherapeutic agents. They target immune checkpoints which are key regulators of the immune system. Some cancers protect themselves from attack by stimulating immune checkpoint targets; thus evading immune destruction. Checkpoint therapy can block inhibitory checkpoints thus restoring immune function. They have been associated with multiple immune-related adverse events; although orbital toxicity is not common.

 

Case:

A 58-year-old man presented with binocular diagonal diplopia in all extremes of gaze and left proptosis. This occurred post completion of a course of pembrolizumab. This was a treatment for right pulmonary squamous cell carcinoma – treated initially with chemo radiation (carboplatin and vinorelbine). After a relapse he underwent chemotherapy (carboplatin and paclitaxel – discontinued due to peripheral neuropathy) and immunotherapy (pembrolizumab). He has a background of hypothyroidism and is an ex-smoker – 25 pack year history prior. On initial examination: VA both eyes 6/5, Colour perception full, Intraocular pressures: R: 14mmHg; L: 13mmHg, Hertel exophthalmometry: 18--117—19, mild bilateral reduced elevation, adduction and abduction with normal pericocular sensation. A CT of his orbits showed subtle extraocular muscle enlargement and granular intramuscular changes. He received a course oral dexamethasone by his oncologist and subsequently he was started on oral prednisolone as he developed myocarditis

 

 

Conclusion and significance:

Pembrolizumab is a therapeutic antibody that binds to and blocks PD-1 located on lymphocytes. It is a member of this new class of cancer immunotherapeutic agents termed checkpoint inhibitors. It was felt that the clinical course of this case of orbital myositis indicated that this drug was the cause. Most of these immune-related adverse events are transient and usually resolve by stopping the treatment combined with immunosuppression with corticosteroids or other immune modulators. With increasing use of these agents so more cases likely to present.


Ankur GUPTA, Kaveh VAHDANI (London, United Kingdom)
00:00 - 00:00 #32165 - Complex surgical reconstruction of the eye, eyelids, lacrimal ducts and orbit after a severe concomitant injury (clinical case).
Complex surgical reconstruction of the eye, eyelids, lacrimal ducts and orbit after a severe concomitant injury (clinical case).

Purpose. Demonstration of the clinical result of complex surgical rehabilitation of a patient with combined traumatic injury to the eye, its accessory apparatus of the lacrimal ducts and orbit.

Material and methods.  Patient M., 14 years old, was admitted with complaints of lack of vision in the right eye, multiple sutured wounds of the eyelids of the face on the right (Fig. 1). It is known that she was injured on the right half of her face during an accident. Visual acuity of the right eye - 0 (zero). On examination, sutured wounds of the eyelids, face, forehead skin. In the projection of the upper eyelid, the coloboma is 15x20 mm in size. The inner corner of the eye is deformed. The lacrimal ways are not passable. The eye is hypotonic. Sutured corneoscleral wound 12 mm long. Hyphema in the anterior chamber of the eye. Optical media are not visible.

B-scanning of the right eye revealed hemophthalmos, retinal detachment. Anterior-posterior axis of the eye - 15.3 mm. CT scan of the orbits shows a fracture and defects in the medial and inferior bone walls.

The first stage included plasty of bone defects in the medial and inferior orbital walls with a porous polytetrafluoroethylene implant, followed by external dacryocystorhinostomy and reconstruction of the medial eyelid ligament. Upper eyelid coloboma plasty with local tissues and a free skin flap.

The second stage was evisceration with plasty of the musculoskeletal stump with an allograft and temporary ocular prosthetics.

The third stage was the correction of cicatricial dystopia of the medial angle using skin Z-plasty.

 

Results. 14 months after the injury, the width, length, and shape of the palpebral fissure had no obvious differences from the healthy side. The shape and mobility of the upper eyelid was restored. The function of lacrimation is preserved. There is a normal position and good mobility of the ocular prosthesis (Fig. 2).

Conclusion. Complex specialized surgical care using the achievements of modern reconstructive ophthalmic surgery makes it possible to carry out cosmetic, functional and social rehabilitation of the patient in a short time.


Pavel BANSHCHIKOV (Khabarovsk, Russia)
00:00 - 00:00 #31645 - Complication: prolonged use of corticoids.
Complication: prolonged use of corticoids.

PATIENT WITH ORBIT TUMOR OF 1 AND A HALF YEAR OF EVOLUTION, WITHOUT BIOPSY. WHO WAS TREATED WITH REPEATED DOSES OF CORTICOIDS, IN ADDITION, THE PATIENT SELF-MEDICATED WITH CORTICOIDS. I PRESENT INSUFFICIENCY OF THE ADRENAL GLANDS AND THE ORBIT BIOSPIA RESULTED IN LYMPHOMA

. PATIENT IS REFERRED FOR A TUMOR OF THE ORBIT, WHICH WAS INTERPRETED AS A PSEUDOTUMOR IN THE LEFT ORBIT. IM AND INTRAORBITAL CORTICOID TREATMENT WAS PERFORMED FOR 1 AND A HALF YEAR. BEFORE NO IMPROVEMENT, THERE WAS REFERRED TO PERFORM A BIOPSY. DUE TO THE IMPORTANT QUANTITY OF CORTICOIDS RECEIVED, THE PATIENT IS EVALUATED WITH ENDOCRINOLOGY THAT DETERMINES ADRENAL INSUFFICIENCY. TREATMENT WITH HYDROCORTISONE STARTS. IT IS STABILIZED AND A BIOPSY IS PERFORMED, WHICH SHOWS PRIMARY LYMPHOMA OF THE ORBIT AS A RESULT.

DECORTICOID DOSES IN THE LONG TERM AND IN HIGH DOSES CAN BRING MANY COMPLICATIONS. SUCH AS: CATARACTS, GLAUCOMA, HYPERGLYCEMIA, OSTEOSPOROSIS, REDUCED PRODUCTION OF HORMONES BY THE ADRENAL GLANDS. IN THE EVENT OF NO TOTAL RESPONSE TO TREATMENT WITH CORTICOIDS, DO NOT DELAY A BIOPSY. AND IF WE HAVE THE SURGICAL POSSIBILITY, THAT THE BIOPSY IS THE FIRST OPTION IN THE FACE OF AN ORBIT INJURY.


Alejandra Raquel BILLAGRA (Ciudad Autonoma de Buenos Aires, Argentina), Victoria ARIASGAGO, Felicitas LACOSTE
00:00 - 00:00 #32038 - Conjunctival mass as initial symptom of athypical EBV infectious mononucleose.
Conjunctival mass as initial symptom of athypical EBV infectious mononucleose.

We present  a case of a 10 years old girl who came to emergency service after a light accidental right eye trauma with unespecific foreing body sensation. He got COVID-19 one month ago and referred asthenia and suffered headache the last days. Besides, she had started snorring recently. At the exploration we discover an internal-superior pink salmon mass. We detect  high levels of lynhocites, uric acid and LDH and we decided to intern the patient to continuate the study. ORL detect  growing oropharingeal mass and the patient starts with fever and worse breathing so we managed it in critical cares to keep the airways preserved.  Nuclear Resonance shows eyelid   and lynph nodes severe inflamation but non intraorbital occupation.  Biopse of bonenarrow, orofarigeal mass and lynph nodes did not show any sign of malignancy and inmunohitology tests just showed signs of lynphoproliferative unespcific cronical proces. EVB was positive for IgM and IgG serology  and PCR of the eye mass and the rest of the masses. Tonsils were surgically removed and general illness was treated with intravenous corticosteroids having a positve evolution of the systemic and eye lesions. . She still under surveillance at ophtalmology regular controls.  EBV is an ubiquous virus who usually does not produce clinically illness but sometimes can produce several complications as infectious mononucleose, linfoproliferative processes or even malignant malalties as burkit lynphoma or non hodgkin lynphomas. EVB can affect to any segment of the eye being well known posterior segment affliction. Conjunctival masses can be the first symptom or a posterior presentation of infectious mononucleose and is crucial to do a concious differential diagnosis to reject  malignant disorders and to choose the correct treatment


Manuel GARCÍA MARTÍNEZ (Seville/Barcelone, Spain), Hugo GONZÁLEZ, Joan PRAT, Ester CASAS
00:00 - 00:00 #32353 - Conjunctival tumor and cavernous sinus syndrome revealing sarcoidosis with orbital involvement.
Conjunctival tumor and cavernous sinus syndrome revealing sarcoidosis with orbital involvement.

Introduction

Ophtalmic involvement in sarcoidosis most commonly manifests as uveitis, but it can also involve the conjunctiva and extraocular muscles, which can be confusing especially when revealing the disease. In this observation we report the case of an orbital tumor associated with a cavernous sinus syndrome as a revealing sign of sarcoidosis.

Purpose:

Identify and characterize clinical and imaging findings of orbital and visual pathways sarcoidosis.

Observation

We report the case of a 56 years-old man, with a history of type II diabetes and systemic hypertension, who presented with a growing mass in the right eye concurring with remitting episodes of painless ophtalmoplegia and general fatigue. On physical examination, a conjunctival mass was found at the right eye, extending from the superotemporal fornix further deep into the orbit, as well as anisocoria with a reduced direct pupillary reflex at the right eye but conserved consensual reflex, and a VIth  and Vth nerve paralysis. Neurological examination concluded to multiple mononeuropathy and parotidomegaly. Orbitocerebral MRI found a tissular mass extending anteriorly from the anterior orbit and lateral rectus muscle of the right eye to the cavernous sinus, which itself had a wall thickening and enhancement, as well as an extended IIIrd and Vth nerve thickening. Lumbar puncture showed a lymphocytosis and proteinorachia. Neurosarcoidosis was the retained diagnosis and treatment with intravenous steroids was administered followed by immunosuppressants, with progressive improvement.

Discussion

Sarcoidosis is a granulomatous systemic disease affecting the eye in 20-50% of cases, typically as uveitis, optic neuritis, it less frequently involves retrobulbar fat, lacrimal gland, ophthalmic pathways, ocular muscles or conjunctiva. Very rare cases of orbital sarcoid mass have been described, even less with an extended cranial nerve infiltration. Its superoanterior localization in this reported case has made the mass palpable and visible through conjunctiva. Pathologic exam confirms the diagnosis as it typically shows a gigantocellular epitheloid granuloma without caseous necrosis. Treatment consists of systemic steroids and immunosuppressants in severe cases with a generally marked improvement without resorting to surgical excision.

Conclusion

Although rare, orbital sarcoidosis must be investigated in orbital tumors. A full systemic work up must be undertaken and appropriate therapy should be administered rapidly.


Iatissam EL BELHADJI, Selma CHIGUER, Adil MCHACHI, Laila BENHMIDOUNE, Rayad RACHID, Mohamed ELBELHADJI (, Morocco)
00:00 - 00:00 #32405 - Covid Related Multisystem inflammatory syndrome in Children (MIS-C) Masquerading as Paediatric Orbital Cellulitis.
Covid Related Multisystem inflammatory syndrome in Children (MIS-C) Masquerading as Paediatric Orbital Cellulitis.

Multisystem inflammatory syndrome (MIS-C) or pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in children is a serious sequela of SARS-CoV-2 infection and continues to be a worldwide phenomenon. The clinical signs and symptoms vary widely and may involve virtually any organ system. Supplementing this, the United States Center of Disease Control (CDC) and the World Health Organization (WHO) outlined separate but overlapping criteria for diagnosis of MIS-C. Though cited as a rare and uncommon complication of COVID-19 infection, the mortality rate is high, especially in cases of delayed treatment. A critical problem clinicians face is disentangling MIS-C from infection—the diagnostic conundrum at first presentation is whether the patient is suffering from severe infection or an autoimmune reaction. Here we present a case of MIS-C masquerading as orbital cellulitis. 


Kailing YONG (Singapore, Singapore)
00:00 - 00:00 #30860 - Diagnostic challenges in atypical orbital myositis.
Diagnostic challenges in atypical orbital myositis.

Purpose: To present a case series of five bilateral orbital myositis patients with radiological and clinical findings atypical for TED accompanied by history of clinical and/or biochemical thyroid dysfunction.

 

Methods: Retrospective medial record review including patient demographics, medial diagnoses, thyroid status, ocular examination and motility, imaging, treatment and outcomes.

 

Results:  Five females with age range 29-58 years old were included.

 

Patient 1, with background of Hashimoto’s thyroiditis, was diagnosed with paraneoplastic orbital myositis following previously treated breast cancer. She was euthyroid with positive TPOAb. MRI imaging revealed unilateral proptosis and muscles’ enlargement, ipsilaterally. The patient improved with local steroids and chemotherapy.

 

Patient 2 &3 were diagnosed with concurrent TED, in the background of Grave’s Disease, and Myasthenia Gravis. MRI showed bilateral proptosis and severe muscle enlargement for patient 2, while no proptosis or discrete extraocular muscles thickening for patient 3. Both were hyperthyroid at the time of diagnosis with positive TRAbs, with positive AChR antibodies or positive repetitive stimulation testing. Both improved clinically with intravenous immunoglobulin, oral prednisolone and pyridostigmine.

 

Patients 4 & 5 with known hypothyroidism and negative TRAbs and TPOAbs, were diagnosed with orbital myositis and infective myositis, accordingly. Patient 4 presented with left-sided proptosis with inferior and lateral recti enlargement in the MRI and treated only with intravenous steroids with complete resolution of symptoms. Patient 5, presented with asymmetrical extraocular muscle enlargement, was treated with intravenous steroids and immunoglobulin. Unfortunately, the patient 5 died few months later due to spontaneous infection.

 

Conclusion: Thyroid dysfunction with myositis involving multiple extraocular muscles may present a significant diagnostic conundrum and a multi-disciplinary approach is, therefore, helpful.


Ourania FYDANAKI (London, United Kingdom), Nicole QUAH QIN XIAN, Bhatia KUNWAR, Lee VICKIE
00:00 - 00:00 #32350 - Diffuse large B-Cell lymphoma of the orbit: Clinical features and outcome for 28 cases during a ten-year period.
Diffuse large B-Cell lymphoma of the orbit: Clinical features and outcome for 28 cases during a ten-year period.

PurposeTo characterize clinical features and outcome for patients with diffuse large B cell lymphoma (DLBCL) of the orbit, treatment success, and recurrence rate.

Patients and MethodsRetrospective case-note analysis for 30 orbital biopsy-proven DLBCL in 28 patients, treated at Moorfields Eye Hospital (MEH) between 2005 and 2015.

Results: The mean age at presentation was 73 years (+13; range 37-92). Two patients (7%) had bilateral disease.  Orbital symptoms were the presenting issue in 82% of cases. Proptosis (24/30), palpable mass (23/30), dystopia (22/30), and motility restriction (21/30) were the commonest signs, but 30% of orbits had optic neuropathy and half of patients had ache or pain. 53% showed rapid disease-progression within 6 weeks.  

In 28 orbits the extraconal space was affected, 30% including lacrimal gland, and one-third of cases extended intraconally.  Extraorbital spread occurred in 7 orbits: to the cavernous sinus, supraorbital nerve, superior orbital fissure and sinuses.

Two patients died before starting treatment: the remaining 26 patients (28 orbits) had a mean follow-up of 4.3 years (median 3.95; range 0-13.5), 17 being followed up at MEH. Eight orbits (29%) had solely radiotherapy, 3 unilateral cases (11%) received chemotherapy alone, and 13 orbits (46%) of 12 patients had chemotherapy plus radiotherapy.  Local treatment response was high, with only one patient with widespread disease being unresponsive to radiotherapy, R-CHOP and methotrexate, and dying within 5 months of diagnosis.  Local recurrence rates were low: one orbit (1/17; 6%) had ipsilateral recurrence at 4.5 years after previous radiotherapy.  Recurrence elsewhere was documented in 4 patients (16%): one involved the contralateralorbital rim and systemically, and the others had systemic spread. 

Overall recurrence (orbital and systemic) rate was 23% at a mean interval of 4.4 years and the overall rate of lymphoma-related death was 8/28 (29%).  10/28 had other cause of death or uncertain cause.  

Conclusion: Orbital DLBCL is relatively rare and regarded as “high-risk” malignancy. Overall survival rate was 68% at 5 years and 30% at 10, and 29% had confirmed lymphoma-related death. Orbital disease progressed rapidly in 53% of patients, 30% had optic neuropathy, and there was a fairly high rate of systemic involvement.  Local treatment response was very good and ipsilateral orbital recurrence occurred in 1/17 cases followed at MEH.


Inga NEUMANN (London, United Kingdom), Amrita SAWHNEY, Kaveh VAHDANI, Geoffrey E. ROSE, Fabiola MURTA
00:00 - 00:00 #32044 - Duration of healing by secondary intention after orbital exenteration.
Duration of healing by secondary intention after orbital exenteration.

Jesper Skovlund Jørgensen and Peter Bjerre Toft

Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Denmark

Duration of healing by secondary intention after orbital exenteration

Objective: To determine the duration of healing by secondary intention after orbital exenteration in cases where primary closure of remaining eyelid skin was not possible. 

Methods: 15 patients underwent unilateral orbital exenteration at the Department of Ophthalmology, Rigshospitalet, from February 2018 until January 2022. The medical records and clinical photographs of these patients were retrospectively reviewed. Indication for orbital exenteration, surgical technique, and complications were noted. In cases with healing by secondary intention the time until a remaining skin defect was small i.e., less than 3 mm was noted.  

Results:  In 12 patients primary closure was possible by using the remaining skin of the eyelids. In three patients primary closure was not possible and these three patients underwent healing by secondary intention. They were one woman (84 years of age) with orbital invasion of basal cell carcinoma in the eyelids, and two men (55 and 81 years of age) with orbital invasion of squamous cell carcinoma from the eyelids. In these three patients the surgical procedure included complete removal of the orbital content and the periorbita, and excision of the eyelids to a degree that made direct closure impossible. The surgical defect was left for granulation and was packed with dressings with antibiotic ointment and a saline soaked bandage with compression. The dressings were changed 1-2 times weekly until acceptable skin coverage of the orbit was achieved. The duration to archive healing with only small skin defects was 13, 15 and 32 weeks in the three patients. Necrosis or infection were not observed. One patient developed a sino-orbital fistula.

Conclusion: Healing by secondary intention after orbital exenteration is possible, but acceptable healing may last more than half a year. A major advance is the absence of donor site morbidity.

 


Jesper Skovlund JØRGENSEN (Copenhagen, Denmark), Peter Bjerre TOFT
00:00 - 00:00 #32214 - Elevated serum thyroid stimulating immunoglobulin is associated with failure of first-line intravenous methylprednisolone treatment in patients with thyroid eye disease.
Elevated serum thyroid stimulating immunoglobulin is associated with failure of first-line intravenous methylprednisolone treatment in patients with thyroid eye disease.

Purpose: There is little information on which patients with thyroid eye disease (TED) might benefit from the addition of mycophenolate mofetil (MMF) to the traditional intravenous methylprednisolone (IVMP) as first-line of treatment. In this study we sought to assess factors associated with failure of IVMP alone as the first-line treatment.

Methods: In this is a retrospective cohort study we analyzed data for all patients with TED who were treated with IVMP according to the EUGOGO protocol between 2016 to 2021 in our center.

Results: Forty-seven patients (27 females) with a mean age of 51.32±14 years were treated with IVMP according to the EUGOGO protocol for TED. Mean time from first reported symptoms to first IVMP treatment was 12.1 months (±25.59, 0-120). The mean CAS before treatment and at a mean time of 5 weeks and 12.2 weeks after the initiation of treatment was 6.00, 2.96 (p<0.01), and 1.81 (p<0.01), respectively. Twenty-one patients (44.68%) were recommended to receive a second-line treatment for the following reasons: no response or worsening of CAS (9, 19.14%), partial response (6, 12.75%), good response with early relapse after completion of treatment (4, 8.51%) or late relapse (1, 2.12%). Eighteen patients (18/21, 85.71%) received a second-line treatment which included: rituximab (7, 38.89%), MMF (6, 33.33%), a second course of IVMP (4, 22.22%), and tocilizumab (1,5.55%). Thyroid stimulating immunoglobulin (TSI) serum levels were higher in patients who were given the second-line treatment compared with patients who responded well to first-line IVMP alone at presentation (2135 vs 1159, p=0.056) and after completion of first-line treatment (2201 vs. 986, p=0.043).

Discussion: Patients who required a second-line treatment after first-line treatment with IVMP alone had higher baseline and post-first-line treatment serum TSI. Patients with elevated TSI may benefit from dual therapy (IVMP and MMF) and require closer monitoring.


Ofira ZLOTO (Tel Aviv, Israel), Arza ROSSET, Ayelet PRIEL, Daphna LANDAU-PRAT, Tali CUKIERMAN-YAFFE, Nancy AGMON-LEVIN, Guy BEN SIMON, Oded SAGIV
00:00 - 00:00 #30506 - Enucleation and evisceration at a tertiary care hospital in a developing country.
Enucleation and evisceration at a tertiary care hospital in a developing country.

To analyze the demographics, indications, and surgical outcomes of anophthalmic surgery (enucleation and evisceration) at Jordan University Hospital during a 5-year period.

We conducted a retrospective chart review of patients who had undergone evisceration or enucleation between August 2006 and June 2011. The data collected included age at the time of surgery, sex, affected eye, surgical indication, implant size, and postoperative complications.

Anophthalmic surgery was performed for 68 eyes of 67 patients during the study period (42 (62 %) eviscerations and 26 (38 %) enucleations). Forty-three patients (64 %) were men, and 40 (59 %) eyes were right eyes. Trauma was the leading cause for anophthalmic surgery in 40 % of cases followed by a blind painful eye secondary to glaucoma (19 %) in the enucleation group and endophthalmitis (28.6 %) in the evisceration group. The most common anophthalmic surgery complication was wound dehiscence in 11.5 % of patients in the enucleation and 9.5 % in the evisceration groups. The mean and median sizes of the implants for evisceration were 16.6 and 18.0 mm, respectively; for enucleation, both were 20 mm.

Evisceration was the preferred anophthalmic surgery in our series unless contraindicated. Trauma was the most common predisposing factor for evisceration and enucleation in our tertiary care center followed by blind painful eyes and endophthalmitis. The most common complication was wound dehiscence in both groups.


Ahmed ALAMER (HIDD, Bahrain), Osama ABABNEH, Eman ABOTALEB, Mohammad ABU AMEERH, Yacoub YOUSEF
00:00 - 00:00 #31701 - Erdheim-Chester disease with chorioretinal and orbital involvement: Case Report.
Erdheim-Chester disease with chorioretinal and orbital involvement: Case Report.

Erdheim-Chester disease with chorioretinal and orbital involvement: Case Report

Objective: We report a bilateral orbital, chorioretinal, and multi-organ involvement of an unusual Erdheim Chester disease (ECD).

Methods: The preoperative and postoperative findings of the patient were recorded retrospectively from the patient file.

Results: A 42-year-old female presented with bilateral proptosis and vision disturbances. The patient's medical history was significant for diabetes insipidus and auto-immune thyroiditis. Initial examination revealed conjunctival hyperemia and bilateral chemosis with proptosis. (Fig. 1A) Relative afferent pupil defect was positive in the left eye, and there is the blurring of the optic disc margins and choroidal folds at OD (Fig 1E). The patient was admitted to the orbital MRI with contrast. (Fig. 1C-D) Clinical, imaging and pathological findings were consistent with ECD. Bone marrow biopsy was performed, and BRAF mutation was found negative. The patient was started on interferon-alpha-2a (IFNα-2a). In the 3rd week, the patient's vision improved, and proptosis regressed. (Fig. 1B) Four months later, the patient presented with left visual loss and proptosis after cessation of interferon treatment. OCT image recordings are shown in figure 1-F. IFNα-2a started again with 1 mg/kg oral prednisolone. Proptosis regressed, vision OD improved, but the vision of OS did not improve on the 10th day of IFNα-2a.

Discussion/Conclusion

ECD is a rare chronic histiocytic proliferation disease with poor prognoses and delayed diagnosis. BRAF mutation is a crossroads in the treatment; If BRAF is negative, IFNα-2a is one of the first options in the treatment. 


Kubra SEREFOGLU CABUK (istanbul, Turkey), Adem TELLİOĞLU, Gamze ÖZTÜRK KARABULUT, Senay ASIK NACAROGLU, Korhan FAZIL, Tuğrul ELVERDİ, Muhittin TAŞKAPILI, Safak KARSLIOGLU
00:00 - 00:00 #32180 - Features of ocular injury of and their reconstruction in modern warfare.
Features of ocular injury of and their reconstruction in modern warfare.

Purpose - to analyze the features of ocular trauma and methods of their reconstruction during the war in Ukraine.

Result. The features of military injuries of the eye were the dominance of combined injuries (85 - 90%), bilateral open ocular trauma (70 - 80%) with multiple intraocular foreign bodies (45 - 80%) and damage to the auxiliary eye apparatus (77 - 85% ). Often, patients needed reconstruction of extensive defects of the eyelids, lacrimal organs and orbit with individualized patient-specific implants made using CAD/CAM technologies. In the absence of the globe and the impracticality of reconstructive operations in the periorbital zone due to extensive defects, the possibilities of modern endo- and ectoprosthesis with the involvement of ocularists and anaplastologists were used.

Conclusions. During the war in Ukraine, open combined and combined injuries of the organ of vision prevail, requiring a multidisciplinary team for the rehabilitation of patients, consisting of an oculoplastic, vitreoretinal, maxillofacial surgeon, an ophthalmologist, an anaplastologist.


Oksana PETRENKO, Olga DENISIUK (Kyiv, Ukraine), Serhiy RYKOV, Anriy KOPCHAK, Yuri CHEPURNYY
00:00 - 00:00 #32177 - Giant orbital cyst in an anophthalmic cavity: a case report.
Giant orbital cyst in an anophthalmic cavity: a case report.

Introduction: Orbital cysts can be congenital or acquired. Congenital cysts may be related to other malformations, such as microphthalmos, or appear alone, as the cystic globe. Acquired lesions may develop in the setting of surgical procedures. Our purpose is to report the case of a conjunctival cyst that mimicked a dysmorphic globe.  

 

Methods: Case report of a 25-years-old man observed at Centro Hospitalar Universitário do Porto, Portugal.

 

Results: A 25-years-old man, with previous history of retinoblastoma in the right eye was observed in the Department of Ophthalmology due to his inability to put on the eye prosthesis. On ophthalmological examination, the bulbar conjunctiva was thickened, with a central transparent and vascularized area that resembled a dysmorphic vascularized cornea. Additionally, there was a symblepharon in the lateral third of the inferior fornix. The patient could not detail to which treatments he had been previously submitted, which were performed in another institution. The orbital computerized tomography scan revealed a cystic lesion with 32x26 mm that projected anteriorly and posteriorly. This lesion had thin walls with apparently liquid content, that had density superior to that of the contralateral eye. The medial rectus and inferior oblique muscles could be identified near the medial wall of the lesion and an atrophic optic nerve was adjacent to the posterior wall. These aspects resembled a dysmorphic eyeball. The patient’s clinical information was requested, revealing that he was enucleated due to congenital retinoblastoma. Incisional biopsy of the lesion’s wall and aspiration of the liquid content were performed, showing a cystic structure lined by conjunctival epithelium, without evidence of dysplasia or malignant neoplasia, compatible with a benign conjunctival cyst. 

 

Conclusion: Giant conjunctival cysts are rare and due to their dimensions, can simulate dysmorphic eyeballs. The clinical history and information about previous treatments are fundamental for the diagnosis. 


Maria ARAÚJO (Porto, Portugal), Catarina CASTRO, Nuno LAMAS, Mafalda MACEDO
00:00 - 00:00 #32448 - Heterogenous orbital lymphoma management - One size does not fit all.
Heterogenous orbital lymphoma management - One size does not fit all.

Title

Heterogenous orbital lymphoma management - One size does not fit all

 

Objective

A prospective case series was carried out to evaluate and identify common and divergent themes in orbital lymphoma.

 

Methods

All orbital lymphoma presenting to a new hospital service over 4 years. Electronic patient records were reviewed; the pathway involved a multi-disciplinary team across ophthalmology, haematology, pathology, oncology and radiotherapy. Baseline investigations included MRI orbits, half-body PET-CT scan (whole body excluding limbs), FBC, U&E, Calcium, LDH LFT, ESR, HIV, Hepatitis B&C, open orbital biopsy and bone marrow biopsy. Patients were recorded under AJCC v8 TNM. All patients were discussed at weekly haematology-oncology MDT. Imaging response assessment occurred at 3 months with subsequent long-term follow-up under joint haematology and ophthalmology care.

 

Results

Twenty-two patients were identified (mean age 67; M:F 1:1); 1 patient was palliated prior to biopsy, 1 had a diagnostic pancreatic biopsy, 2 followed up elsewhere. Common presentation was ptosis (5), palpable mass (6), proptosis (3), conjunctival lesion (2) and epiphora (2). Two had contiguous, bilateral orbital disease. Histology: 11 extranodal marginal zone lymphoma (EMZL), 4 DLBCL, 2 Follicular, 2 SLL. Bone marrow involvement in 1 EMZL and 1 DLBCL.  Mean time from biopsy to treatment (radiotherapy or chemotherapy) 61 days.  Radiotherapy was given to 11 (4-30Gy). DBCL received 3 cycles of R-CHOP.  Fifteen had complete radiological remission; 1 had shrunken but residual lesion considered remission. Three EMZL patients had systemic recurrence at subsequent surveillance (neck, subplural and axillary locations) having had orbital radiotherapy only.

 

Conclusion

A multi-disciplinary approach is essential in managing orbital lymphoma.  Higher doses of radiotherapy was required in some EMZL. Patients can have asymptomatic radiological recurrence of EMZL highlighting its systemic nature and need for long-term follow-up; having expertise within each area provides a comprehensive patient experience.


Ziyaad SULTAN (London, United Kingdom), Jessica BRADY, George MIKHAEEL, Stella BOWCOCK, Jon SALISBURY, Steve CONNOR, John BLADEN
00:00 - 00:00 #32187 - HyperArc Stereotactic Radiotherapy for Thyroid Eye Disease.
HyperArc Stereotactic Radiotherapy for Thyroid Eye Disease.

Introduction:

 

Orbital radiotherapy is an effective treatment for active thyroid eye disease (TED), targeting fibroblasts and T lymphocytes. Standard treatment consists of two parallel opposed fields with lens sparing. The use of conventional Volumetric Modulated Arc Therapy (cVMAT) using co-planar arcs has been reported. HyperArc® (HA) is a form of VMAT using 4 non-co-planar arcs primarily designed to treat intracranial metastases. We assess the efficacy and safety of HA in patients with active TED. 

 

Methods:

 

Patients with active TED referred from the Oculoplastic service at NHS Greater Glasgow and Clyde to the Beatson West of Scotland Cancer Centre were enrolled. Non-contrast CT was used for delineating the Target Volume (TV) and the Organs at Risk (OAR). Prescription to the TV was 2004cGy in 12 fractions minimising the dose to the OAR. Patients were followed-up at 3, 6, 12 and 24 months. MRI orbits was performed at baseline, 3 and 6 months post radiotherapy. Radiological and patient reported outcomes were measured.

 

Results:

 

Between February 2018 and April 2022, 39 patients were treated, 37 with at least 3 months follow up. 67% of patients were female and 93% of patients had Graves’ disease. 90% of patients had steroids before or during radiotherapy. 10% had additional immunosuppression during or after radiotherapy.  Median follow up was 20 months. At 3 months, 67% of patients showed improvement in muscle appearance on MRI. At 6 months, 43% remained stable on imaging, 50% had further radiological improvement and 9% deteriorated. By 12 months, 33% of patients reported stable clinical symptoms and 67% reported improvement following radiotherapy. No radiotherapy-related toxicity was reported. 

 

Conclusions:

 

In this small cohort, HA appears to be a safe and effective way to deliver orbital radiotherapy for the management of TED. We plan to assess a larger number of patients and extend the follow-up period.


Matthew GILLAM (London, United Kingdom), Stefano SCHIPANI, Natalie ENTWISTLE, Kevin CROFTS, Paul CAUCHI
00:00 - 00:00 #32421 - Identification of novel imaging features of Thyroid Eye Disease using anterior segment optical coherence tomography angiography.
Identification of novel imaging features of Thyroid Eye Disease using anterior segment optical coherence tomography angiography.

Background:

Thyroid eye disease (TED) is an inflammatory condition that can lead to visual loss. Monitoring disease activity is pertinent to preventing sight-threatening complications. Given the qualitative nature of current grading systems including ‘Clinical Activity Score’ (CAS), there is a need for quantitative methods of assessment for reliable TED monitoring.  Anterior segment optical coherence tomography angiography (AS-OCTA) is a time-efficient and non-invasive imaging modality that has gained significant traction in the ophthalmic landscape. Its role in TED is a nascent field of study and this paper aims to explore the hypothesis that AS-OCTA can detect characteristic changes in anterior segment vasculature in TED. 

 

Methods:

A prospective comparative case series was conducted at Moorfields Eye Hospital. Patients diagnosed with TED and healthy controls were recruited. Demographic data, TED characteristics and CAS scores were collected. AS-OCTA images were captured using the AngioVue system. Masked image analysis was performed and two AS-OCTA derived vascular indices (vessel density index [VDI] and fractal dimension [FD]) were analysed.

 

Results:

13 controls (26 eyes) and 30 TED patients (60 eyes) were included, mean age 44.0 (± 17.4) and 52.3 (± 16.3) years respectively. 977 images were analysed (n=294 controls, n=683 TED). Overall mean VDI across all depths and quadrants was significantly lower at 20.7 for controls and 33.4 for TED subjects (p=0.008) (Figure 1). The highest VDI was seen in the episclera in both groups. The episcleral/sclera complex VDI was higher than the conjunctiva epithelium in TED patients; the inverse was observed in the controls. The overall mean FD was higher in TED patients vs. controls (p=0.22). VDI values for CAS sub-groups were 32.7, 30.7 and 34.5 for inactive, mildly active and moderately to severely active, respectively (p=0.44). 5 patients underwent decompression surgery, and a post-operative reduction in VDI and FD values were found (p=0.71, p=0.66).

 

Conclusion:

In this feasibility study, we demonstrate the role of AS-OCTA in quantifying anterior segment vasculature indices at different anatomical depths in normal and TED subjects. Moreover, this paper identifies AS-OCTA derived potential angiographic characteristics that may serve as surrogate biomarkers for TED. Further study with a larger cohort is warranted to further insights.


Swan KANG, Laxmi RAJA (Kenley, United Kingdom), Scott HAU, Victoria BARNETT, Pearse KEANE, Daniel EZRA
00:00 - 00:00 #32401 - Impact of optic nerve sheath fenestration on macular ganglion cell volume in idiopathic intracranial hypertension.
Impact of optic nerve sheath fenestration on macular ganglion cell volume in idiopathic intracranial hypertension.

Introduction

Optic nerve sheath fenestration (ONSF) is a decompressive surgical technique to preserve or recover vision in patients with papilledema in the setting of elevated intracranial pressure (ICP), most often seen with idiopathic intracranial hypertension (IIH). Recently, ganglion cell complex analysis has been found to be a sensitive proxy for early neuronal loss in IIH (Athappilly, et al). We aimed to evaluate the macular ganglion cell layer volume (mGCLv) using OCT before and after ONSF in patients with IIH.

 

Methods

A retrospective review of 25 patients with IIH who underwent ONSF (18 female, 7 male) in one (6 patients) or both eyes (19 patients) at an academic institution from 2018 to 2019 was performed. Charts were reviewed for preoperative data and 5-8 month postoperative data including best-corrected visual acuity (BCVA), Frisén stage of papilledema, perimetric mean deviation (PMD), retinal nerve fiber layer (RNFL) thickness, and mGCLv (volume measured on OCT raster B-scan of the macula). Statistics were performed to compare pre- and post- intervention metrics.

 

Results

There was no statistically significant difference in BCVA and PMD pre- and post-ONSF in either eye. Papilledema grade (p<0.001) and RNFL thickness (p<0.002) were improved after 6 months in both eyes. There was a small statistically significant mGCLv loss in both eyes 6 months after ONSF (p<0.003). Figure 1 shows the mean differences in the pre- and post- intervention metrics.

 

Conclusions

To our knowledge, we have compiled the largest sample size of patients with OCT data, including macular ganglion cell volume, pre- and post ONSF. Our results demonstrate that macular ganglion cell layer volume showed a small but statistically significant decrease 6 months after ONSF, but visual acuity did not have a statistically significant difference, suggesting that ONSF is a vision saving procedure with minimal damage to the macular ganglion cell complex. Especially in patients where no changes are seen in visual acuity or visual field testing, this may be a useful tool to guide management in patients with IIH who undergo ONSF. More analyses should be performed to determine the effect of surgical timing on perimetric testing and ganglion cell loss. More longitudinal data is needed to determine what effects are seen on this parameter with other methods of treatment such as ventriculo-peritoneal shunting or medication alone and how this compares to ONSF.


Paras VORA (Lexington, USA), Max BENNINGFIELD, Lalita GUPTA, Padmaja SUDHAKAR, Peter TIMONEY
00:00 - 00:00 #32154 - Incorporating adaptive design into clinical trials: VRDN-001: a novel monoclonal antibody for Thyroid Eye Disease (TED).
Incorporating adaptive design into clinical trials: VRDN-001: a novel monoclonal antibody for Thyroid Eye Disease (TED).

Background/Introduction: Drug development requires costly and time-consuming exploration of both effectiveness and safety. To increase efficiency and decrease participant burden, innovative trial designs different than those historically conducted are needed. 

Aims/Methods: Adaptive strategies are one such approach. They allow for prospectively planned modifications to aspects of the study based on accumulated data from subjects within the trial, as it is ongoing. Adaptations are prospectively specified before any comparative analyses of trial results are conducted, to protect trial integrity.

Results: VRDN-001 is a humanized IgG1κ monoclonal antibody that binds to human insulin-like growth factor-1 receptor (IGF-1R) and inhibits activation. A randomized, placebo-controlled multiple ascending dose (MAD) phase 1/2 trial evaluating safety and dose exploration is ongoing (NCT05176639). Driven by data from this trial, further exploration of VRDN-001 could include elements of adaptive design. These include a masked interim analysis in which the least promising dose cohort(s) would be stopped with no further recruitment into those cohorts; the trial would continue with the placebo arm and the surviving dose cohort(s) thus protecting statistical validity and sparing TED patients  least effective treatment arms.

Conclusion: Adaptive design permits trial adjustment to information not available at trial initiation. Advantages include statistical efficiency, number of arms brought forward and reduced sample size requirements. Our exploration of VRDN 001 seeks to protect patient interests and burdens; incorporating principles of adaptive design is a methodology to advance such interests.


Barrett KATZ (New York, USA), Denis O’SHAUGHNESSY, Elisabeth COART
00:00 - 00:00 #32186 - Initial presentation of systemic sarcoidosis as a Tolosa-Hunt syndrome.
Initial presentation of systemic sarcoidosis as a Tolosa-Hunt syndrome.

Tolosa-Hunt syndrome (THS), is described as severe and unilateral periorbital headaches associated associated with paralysis of one or more cranial nerves. Its etiology is varied and the diagnosis is clinical by exclusion. We present the clinical characteristics and management of a systemic sarcoidosis that presented as Tolosa-Hunt syndrome.

This is a 51 year-old female patient being investigated for left headache, blurred vision and diplopia of 7 days onset. She had proptosis of the left eye of 4 mm, diplopia and complete ophthalmoparesis on supraversion and abduction and partial on adduction. Magnetic resonance imaging showed probable orbital Tolosa-Hunt syndrome with involvement of the cavernous sinus, pachymeninges and diffuse thickening of the left superior rectus muscle. Chest X-ray showed no pathological findings and laboratory tests, thyroid profile, serology, IgG4, Mantoux, angiotensin converting enzyme and autoantibodies were negative.
Lumbar puncture showed normal opening pressure and analysis of cerebrospinal fluid levels were normal

The computed tomography (CT) showed pulmonary lesions compatible with stage III sarcoidosis. After the results of the imaging tests, it was decided to start treatment with a bolus of methylprednisolone for 5 days and then oral prednisone was started with clear clinical and radiological improvement. The mediastinal lymph node biopsy could not be performed due to the decrease in its size.

After two years of follow-up of the patient in treatment with descending corticosteroids, the patient showed total clinical and radiological improvement, with disappearance of the pulmonary and orbital radiological findings.

The presentation of sarcoidosis as a STH syndrome is rare. Despite this, we must take it into account in the differential diagnosis. In our case, the presentation of CT showing a pulmonary lesion compatible with sarcoidosis and the improvement with corticoid treatment made us reinforce the suspicion of a diagnosis of sarcoidosis. This can present itself in unusual ways.


Amparo LANUZA-GARCIA, Julia PEREZ-MARTINEZ (Valencia, Spain), Gemma ORTEGA PRADES, Francisca GARCIA-IBOR, Antonio DUCH SAMPER, Raul MARTINEZ-BELDA
00:00 - 00:00 #32006 - Intralesional injections of Bleomycin for Orbital Lymphatic and Lymphatic-Venous Malformations.
Intralesional injections of Bleomycin for Orbital Lymphatic and Lymphatic-Venous Malformations.

Purpose: Orbital lymphatic malformations and Orbital Lymphatic venous malformations causes disfigurement and ocular disorders, the purpose was to evaluate the efficiency of intralesional injections of Bleomycin

Methods: all patients received intralesional bleomycin injections for the treatement of Lymphatic and Lymphatic-venous malformations. a clinical examination with photography and orbital imaging are performed for all the patients

Results: 10 patients, 8 women and 2 men were injected. Mean units of bleomycin injected per session were 5 international units, 6 patients have received one injection, 3 patients have received 2 injections        (2 sessions), 1 patient have received 3 injections (3 sessions). 

The clinical response with radiologic regression was excellent in 8 patients, good in 1 patient and fair in 1 patient.

no side effects were noted after bleomycin injections

Conclusion: Intralesional injections of Bleomycin for Lymphatic and Lymphatic-Venous malformations of the orbit are effective with no side effects, it's a real and good option of management


Ahmed BEN SAID (Tunis, Tunisia)
00:00 - 00:00 #32263 - Is ‘Patient Initiated Follow Up’ the future for routine oculoplastic outpatient appointments?
Is ‘Patient Initiated Follow Up’ the future for routine oculoplastic outpatient appointments?

Objectives

Patient initiated follow up (PIFU) is an already established follow-up pathway in some specialties, such as Oncology, where it forms a part of patients personalised stratified follow-up. 

The COVID-19 pandemic brought about numerous positive changes to manage increasing outpatient care in busy sub-specialties including Ophthalmology and the PIFU pathway is rapidly becoming one such change. 

We performed a retrospective baseline review of all patients seen in orbit clinic in our tertiary centre over 3 months and identified those suitable for enrolment into the PIFU pathway and explored the patients' views on PIFU. 

Methods

 

We retrospectively collected data from electronic patient records (EPR) for patients seen in orbit clinic from January to March 2021 (n=100) and highlighted the patients with stable thyroid eye disease scheduled for routine follow up appointments. We analysed how many had their follow up appointments rescheduled. We gathered and analysed their views on the PIFU pathway.

 

Results

 

10% of 100 patients (n=10) were identified as meeting the above criteria and all these patients had their initial follow up rescheduled at an average of 1-2 times. 60% (n=6) of these patients were keen on the PIFU pathway and 10% (n=1) expressed more comfort with the traditional physician-initiated appointments. We were unable to contact the remaining 30% (n=3).

 

Conclusion

 

Our brief audit demonstrated clinical potential and patient willingness in the introduction of the PIFU pathway as a safe and logistically convenient way to review stable patients with thyroid eye disease in outpatient clinics. We aim to run an antecedent PIFU pathway to determine its effectiveness in reducing the number of secondary outpatient appointments, assessing patient satisfaction and clinical outcomes.


Anum BUTT, Kang SWAN, Periklis GIANNAKIS (London, United Kingdom)
00:00 - 00:00 #31647 - just a floor fracture.
just a floor fracture.

Presentation of a clinical case of a woman who presented to the emergency room due to a fracture of the orbital floor of three weeks of evolution. He was admitted to the operating room to repair surgery due to diplopia and hematoma that did not improve. She is undergoing surgery for an orbital tumor associated with a fracture of the psoo orbita. The pathological anatomy shows as a result Lymphoma. The patient died shortly after starting chemotherapy due to severe immunosuppression. Paranasal sinus tumors are very aggressive and can be associated with pathological fractures with invasion of contiguous areas, in this case the orbit.


Alejandra Raquel BILLAGRA (Ciudad Autonoma de Buenos Aires, Argentina), Virginia VITAR, Delfina ESTRADA
00:00 - 00:00 #32272 - Juvenile Xanthogranuloma: A rare orbital lesion.
Juvenile Xanthogranuloma: A rare orbital lesion.

Objective: to describe a case of orbital Juvenile Xanthogranuloma (JXG). Methods: Descriptive case report and literature review. Results: An 8-year-old female patient consulted for left palpebral ptosis and proptosis. Visual acuity was 20/20 in both eyes,and no diplopia was referred. Pupillary reflexes,slit lamp examination and fundoscopy were normal. Left eye proptosis of 4 mm was found with restriction to left supraversion. A hard lesion was palpated in the upper left orbit.CT-scan shows a hyperdense lesion in the superior left orbit displacing the globe,without bone erosion. An incisional biopsy was performed via eyelid crease incision. After surgery the patient presented left palpebral ptosis that resolved spontaneously in 3 months. The pathology showed an histiocytic infiltrate with Touton cells,lymphoid follicles ,plasma cells, and eosinophils. Immunohistochemical staining was positive for CD68, and Vimentin. The S100 protein was positive in isolated interstitial cells. CD1a, CD30, desmin, myogenin, and myoD1 were negative. CD20 and CD3 stains revealed a polymorphous lymphocytic inflammatory infiltrate. This findings were compatible with JXG of the orbit. Systemic screening for concomitant lesions was performed and expectant management with regular check-ups was decided. Eight months after surgery, a CT scan was performed showing almost total remission of the orbital lesion. Discussion: JXG is a rare entity of histiocytic cells. It is part of the Histiocytosis group, characterized by proliferation of cells from the mononuclear phagocytic system (monocytes, macrophages, dendritic cells) in different organs. It affects children and adolescents, but it has also been described in adults. The skin is the most frequent site of involvement, with single or multiple papules or nodules, from pink to yellow-brown. The most frequently extracutaneous sites are the nervous system, liver, spleen, lung, eyeball and periocular tissues. Clinical manifestations are variable and depends on the location and size of the lesions. The disease usually runs a benign course, with spontaneous regression of the lesions within 1 year,but they may persist for several years. There is no specific treatment for this entity. Complete surgical removal of the lesions has been performed as well as systemic corticosteroid treatments. As it is a very rare,benign, and self-limited pathology, management must be individualized on each patient, taking into account the affected structures.


Victoria ARIASGAGO, Alejandra BILLAGRA (Ciudad Autonoma de Buenos Aires, Argentina), Daniel WEIL, Felicitas LACOSTE, Lorena DI NISIO, Milagros AGUILAR, Soledad VALEIRAS, Jorge AVILA
00:00 - 00:00 #31935 - Lacrimal Gland Biopsy Results in a Tertiary Referral Centre.
Lacrimal Gland Biopsy Results in a Tertiary Referral Centre.

we describe results of lacrimal gland biopsies in a tertiary referral centrer


Segun AWOTESU (Leicester, United Kingdom), Mary AWAD, Ian DE SILVA, Raghavan SAMPATH
00:00 - 00:00 #32496 - Lateral Canthotomy and Cantholysis: A Low Cost, Simple and Anatomically Correct Simulation Model.
Lateral Canthotomy and Cantholysis: A Low Cost, Simple and Anatomically Correct Simulation Model.

Background

Lateral canthotomy and cantholysis is a procedure that ophthalmologists and emergency doctors must learn to rapidly treat orbital compartment syndrome. Our aim was to build a low-cost simulation model for this vision-saving procedure, using only materials available in the hospital.

Methods

Equipment to build the model includes 1 specimen pot, 1 elastic band, fabric dressing tape, micropore surgical tape, 5-6 sterile cotton swabs, 1 surgical glove, 1 sheet of gauze and scissors. The model was validated at ophthalmology and emergency department registrar teaching sessions using pre- and post-teaching questionnaires. Confidence level was gauged using a 5-point Likert scale from 1 (not at all confident), to 5 (extremely confident).

Results

Out of 34 participants, only 14.70% (n=5) had performed the procedure on a living patient. Prior to the teaching session, participants had a mean confidence level in carrying out the procedure of 1.88 which rose to 3.41 after teaching, resulting in a significant increase in confidence (p=<0.01, CI:1.08-1.97). Confidence in locating the required equipment also significantly improved following teaching by 1.59 (P=<0.01, CI:1.13-2.04).

Only 41.18% (n=14) of participants had received formal canthotomy and cantholysis teaching before. 23.53% (n=8) said they would require no further teaching following our session. Of those who wanted extra teaching, 73.08% (19/26) requested more simulation. 88.2% (n=30) of respondents found the model helpful in the anatomical understanding of canthotomy, as it allows the user to ‘strum’ the ‘inferior canthal tendon, without cutting the lower lid. The user can therefore appreciate the difference between canthotomy and cantholysis.

Conclusion

Our simulation model was effective in increasing confidence in a procedure which trainees have little prior experience or teaching opportunities in. Furthermore, it is the first model for this procedure to exclusively use materials from the hospital, making it accessible to all.


Sara MEMON, Caroline WILDE (London, United Kingdom), Laura AH-KYE, Alice MILLIGAN, Hannah TIMLIN
00:00 - 00:00 #32119 - Lateral decompression for fibrous dysplasia in the lateral orbital wall.
Lateral decompression for fibrous dysplasia in the lateral orbital wall.

Jesper Skovlund Jørgensen and Peter Bjerre Toft

Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Denmark

Lateral decompression for fibrous dysplasia in the lateral orbital wall

Objective: To report the use of lateral decompression as used in the treatment of Graves’ eye disease for surgical debulking of fibrous dysplasia in the lateral orbital wall.

Methods: Case report

Results:  A 51-year-old woman presented with proptosis of the right eye and double vision in upgaze for some months. Clinical examination revealed 7 mm proptosis of the right eye and normal visual acuity. An orbital CT imaging demonstrated thickened and sclerotic bone with “ground-glass” appearance in the lateral orbital wall and lateral part of the orbital roof consistent with fibrous dysplasia.

Surgical debulking was caried out as in lateral orbital decompression. The lateral orbital rim was exposed through an extended eyelid crease incision, and the periosteum of the lateral orbital rim was incised. Then the periorbita and periosteum was lifted of the bone on both sides of the lateral orbital wall. Rim sparing incisions in the lateral bony orbital wall were done with an osseoscalpel and part of the lateral wall and tumor were removed. With a cutting burr additional tumor in the deep lateral wall was removed. A piece of tumor was sent for pathology. The periorbita over the bony opening of the lateral orbital wall was incised and the orbital fat was released as in orbital decompression for Graves’ eye disease.

The surgery resulted in 4 mm reduction of the proptosis, but the double vision in upgaze was unchanged. Postoperative orbital CT showed marked reduction of the fibrous dysplasia but not complete removal. The pathology examination was consistent with fibrous dysplasia.

Conclusion: Patients with fibrous dysplasia in the lateral orbital wall giving rise to proptosis can benefit from a surgical procedure similar to lateral orbital decompression normally used in Graves’ eye disease.


Jesper Skovlund JØRGENSEN (Copenhagen, Denmark), Peter Bjerre TOFT
00:00 - 00:00 #32227 - Longitudinal Clinical Findings in Dysthyroid optic neuropathy in a single centre cohort.
Longitudinal Clinical Findings in Dysthyroid optic neuropathy in a single centre cohort.

Objective

To characterize the longitudinal clinical findings at presentation and follow up correlated with endocrine status, intervention and final visual outcome in patients with Dysthyroid Optic Neuropathy (DON).

Methods

A retrospective observational single centre study of the clinical characteristics of adult DON patients in a multidisciplinary TED clinic with a minimum follow up of 6 months after diagnosis.

Results

26 patients (52 eyes), mean age 57.8 years, 21 (80.8%) female. 4 (15.4%) unilateral, 22 (84.6%) bilateral; 7 (26.9%) Black, 5 (19.2%) Caucasian, 2 (7.7%) South Asian, 1(3.4%) South East Asian, 2 (7.7%) MENA and 3 (11.5%) mixed ethnicity were included. 14 (53.8%) were euthyroid status . Underlying thyroid diagnosis: 20 (76.9%) Graves disease, 4 (15.4%) Hashimotos, 1 (3.4%) Toxic Multinodular Goitre, 1 (3.4%) Hypothyroid. 15 (57.7%) patients positive TSH-receptor antibodies. 5 diabetic (19.2%) 11 (42.3%) were smokers.

Presenting visual acuity (VA) was worse than 0.3LogMar in 19 (36.5%) eyes.

25(96.2%) patients received the EUGOGO DON regimen of IVMP, 13 (50.0%) patients underwent emergency orbital decompression, 8 (30.8%) received subsequent Orbital radiotherapy , 1 (3.4%) patient underwent emergency thyroidectomy. 19 (73.1%) received further mycopheolated mofetil. 5 (19.2%) patients had a relapse during the follow up period requiring further salvage treatment.

Vision in 44 (84.6%) eyes stabilised or significantly improved at final follow up with 17 (65.4%) eyes worse than 0.2 LogMAR. Mean CAS score improved from mean 3.0 to 0.4 by final follow up. 10 (38.5%) still had intractable diplopia. Smokers more frequently presented with worse vision and were more likely to have severely reduced vision at final follow up.

Conclusions

Our patient cohort reflects the diverse population that our MDTED clinics serve, with majority non Caucasian patient cohort. 

Visual outcomes can vary significantly in patients with DON and patients have persistently reduced vision and intractable diplopia despite multimodal MDT Treatment.

Patients who were smokers appear to present with worse vision and have poorer outcomes, further underscoring the importance of smoking cessation in patients at risk of GO.


Gabriella GUEVARA (London, United Kingdom), Ourania FYDANAKI, Ahmed AL-NAHRAWY, Ahmad AZIZ, Rajni JAIN, Vickie LEE
00:00 - 00:00 #32436 - Malignant transformation of fibrous dysplasia into spindle cell sarcoma.
Malignant transformation of fibrous dysplasia into spindle cell sarcoma.

Introduction/purpose: Fibrous dysplasia is a benign fibro-osseous bone disease. We present an unusual case of fibrous dysplasia of the frontal sinus  transforming and becoming a locally advanced sarcoma 7 years after initial diagnosis. 

Methods: A 46 year old man presented to Eye Casualty with a 1 month history of a painful right eye and diplopia. Examination revealed significant hypoglobus, upper lid swelling and reduction in eye movements PMHx included well controlled schizophrenia and fibrous ddysplasia of the right frontal sinus diagnosed incidentally on imaging seven years prior Initial biochemistry was unremarkable and flexible nasal endoscopy revealed a tumour at the right middle meatus 

Results: Fibrous dysplasia is an uncommon bone disease with fibro-osseus material replaying bone caused by a mutation in the GNAS1 gene. Often diagnosed incidentally on imaging symptoms can include pain, fracture and deformity, Malignant transformation occurs in less than 1% and its factors include craniofacial disease and radiotherapy. Current guidance does not advocate regular imaging of asymptomatic adults.

Conclusion: Malignant transformation of fibrous dysplasia is rare but can be an aggressive disease process. Progression of symptoms in craniofacial disease should raise concern. This case highlights the need for a multidisciplinary approach to manage this rare and complex condition.


Ahmad AZIZ (London, United Kingdom), Vikas ACHARYA, Vickie LEE, Rajni JAIN, Catherine RENNIE
00:00 - 00:00 #32397 - Mature orbitary teratoma as a cause of congenital proptosis.
Mature orbitary teratoma as a cause of congenital proptosis.

 Mature teratoma is a tumor composed of cells derived from the three germ layers (ectoderm, mesoderm and endoderm) and has the highest incidence among all congenital tumors (1). Its orbital involvement, however, is quite rare and with few cases described in the literature (2). It usually presents as a single lesion that may extend to the intracranial space or remain restricted to the orbit. The primary objective of treatment is to preserve the affected eye and prevent optic nerve involvement. 

 M.B.M., a six-day-old female newborn, born at term and without gestational complications, had left eye proptosis (LE) since birth. His initial examination showed marked left axial proptosis. He had complete occlusion of the affected eye, a slightly lateralized look (Figure 1). In left fundoscopy, venous engorgement was observed without changes in the optic nerve. Computed tomography showed an intraconal cystic tumor lesion with regular borders. The cyst had heterogeneous content with an area of calcification that resembled a tooth root remnant (Figure 2). In the three-dimensional reconstruction of the tomography, it was possible to observe a slight asymmetry of the orbital continent, where the affected orbit was larger. Based on the clinical and radiological findings, we made the diagnostic hypothesis of orbital teratoma.

 Surgery was promptly scheduled as the tumor was rapidly growing. Tumor excision was performed through superolateral transpalpebral orbitotomy without osteotomy, preserving the affected eyeball. The anatomopathological study confirmed the clinical hypothesis of mature teratoma.

 After one year, we observed that the child had an adequate and symmetrical, cosmetically satisfactory orbitofacial development. Its main characteristic is the rapid growth after birth, which leads to severe unilateral proptosis of a morphologically normal eye (3).

 The ideal treatment consists of an early surgical approach, capable of preserving the eyeball and minimizing possible sequelae resulting from compression of the optic nerve. However, according to some articles in the literature, in few cases the visual function can be preserved, even in cases of small orbital teratomas in which isolated resection of the tumor is possible (4,5). In our case, the surgery anatomically preserved all orbital structures, but the patient's visual function could not yet be analyzed due to semiological difficulties at her age.


Allan PIERONI GONÇALVES, Carolina MENDES, Guilherme ARAUJO DE ABREU (São Sebastião / SP, Brazil)
00:00 - 00:00 #31639 - MicroRNA-155 acts as an anti-inflammatory factor in orbital fibroblasts from Graves’ orbitopathy by repressing interleukin-2-inducible T-cell kinase.
MicroRNA-155 acts as an anti-inflammatory factor in orbital fibroblasts from Graves’ orbitopathy by repressing interleukin-2-inducible T-cell kinase.

To investigate the role of microRNA (miR)-155 in inflammation in an in-vitro model of Graves’ orbitopathy (GO). The expression levels of miR-155 were compared between GO and non-GO orbital tissues. The effects of inflammatory stimulation of interleukin (IL)-1β and tumour necrosis factor alpha (TNF-α) on miR-155 expression on GO and non-GO orbital fibroblasts (OFs) were investigated. The effects of miR-155 mimics and inhibitors of inflammatory proteins and IL-2-inducible T-cell kinase (ITK) expression were examined, along with those related to the knockdown of ITK with siITK transfection on inflammatory proteins. We also examined how ITK inhibitors affect miR-155 expression in GO and non-GO OFs. The expression levels of miR-155 were higher in GO orbital tissues than in non-GO tissue. The overexpression of miR-155 was induced by IL-1β and TNF-α in OFs from GO and non-GO patients. IL-1β-induced IL-6 (ICAM1) protein production was significantly reduced (increased) by miR-155 mimics and inhibitors. The mRNA and protein levels of ITK were downregulated by overexpressed miR-155 via miR-155 mimics. Knockdown of ITK via siITK transfection induced a decrease in the expression levels of ITK, IL-17, IL-6, IL-1β, and TNF-α protein. The expression of miR-155 was significantly downregulated by treatment with ITK inhibitors and Bruton’s tyrosine kinase (BTK)/ITK dual inhibitors in a time-dependent manner. Our results indicated a potential relationship between miR-155 and ITK in the context of GO OFs. The overexpression of miR-155 repressed ITK expression and relieved inflammation. Thus, miR-155 appears to have anti-inflammatory effects in GO OFs. This discovery provides a new concept for developing GO treatment therapeutics.


Charm KIM, Yeon Jeong CHOI, Jong Jin JUNG, Jin Sook YOON, Sun Young JANG (Bucheon, Korea)
00:00 - 00:00 #32145 - Mortality and prognostic factors of patients with choroidal and ciliary body melanoma treated with enucleation in a single tertiary centre.
Mortality and prognostic factors of patients with choroidal and ciliary body melanoma treated with enucleation in a single tertiary centre.

Purpose: to determine the factors affecting mortality of patients with choroidal and ciliary body melanoma treated with enucleation.

Methods: Data on cases of choroidal or ciliary body melanoma treated with enucleation between 1996-2018 at Eye Hospital, University Medical Centre Ljubljana, were gathered from the National cancer registry. Statistical analysis included age, melanoma location, disease stage and cell type. Cancer-related mortality at 5 and 10-years was determined using Kaplan-Meier survival analysis. Log-Rank test and multiple regression were performed to determine the factors affecting mortality. For a subgroup of 45 patients treated between 2015-2017 additional morphological analysis was performed, including diameter, thickness and monosomy of chromosome 3.

Results: In the period of 22 years, 260 patients underwent enucleation due to choroidal or ciliary body melanoma; 51% male and 49% female; average age 63+/-14 years. Patients with ciliary body melanoma (6%; 16/260) were relatively older (avg. 66 years), however the difference was not significant. Cancer-related mortality was 36% at 5 years and 56% at 10 years. Significantly lower mortality was observed for choroidal (vs. ciliary body) melanoma (p<0.05), localized (vs. spread) melanoma (p<0.05) and age ≤55 years (p<0.001), however  on multiple regression only younger age remained significant (Exp(B)=1.03, p<0.01). Among patients with morphological analysis significantly lower mortality was observed for age ≤55 years (p<0.05) and diameter ≤6 mm (p<0.05), but not for thickness (p=0.33) or monosomy of chromosome 3 (p=0.13). On multiple regression including all significant factors from the univariate analysis, smaller diameter remained a positive predictive factor ((Exp(B) = 1.35, p<0.05) and ciliary body location became a negative predictive factor (Exp(B) = 20.56, p<0,05).

Conclusion: Among the studied parameters, younger age, smaller diameter and location in the choroid were the strongest predictive factors of lower mortality. Interestingly, although both, thickness and diameter are included in COMS melanoma classification, thickness had no effect on mortality in our cohort.


Fakin ANA, Janez BREGAR (Ljubljana, Slovenia), Jože PIŽEM, Brigita DRNOVŠEK OLUP
00:00 - 00:00 #31774 - Multiparametric radiological assessment in dysthyroid optic neuropathy patients.
Multiparametric radiological assessment in dysthyroid optic neuropathy patients.

Purpose: To analyse the radiological parameters of active dysthyroid optic neuropathy (DON) patients and correlate them with clinical elements.

 

Methods: A retrospective cohort MRI / CT analysis at DON diagnosis correlating recti maximum diameter, horizontal and vertical Barrett’s muscle index, proptosis and lacrimal gland prolapse against certain clinical parameters. 

 

Results:  26 patients, 5 males and 21 females, with mean age 57.85 (range 34-88) were included in the study. 3 presented with unilateral and 23 with bilateral DON. The mean maximum diameter of the recti muscles in the study eye was 6.539±2.011mm for medial rectus, 7.702±2.303mm for inferior rectus, 6.913±1.827mm for lateral rectus and 6.470±2.340mm for superior rectus. For each muscle, the strongest correlation and the highest significance was consistently with the fellow muscle in the contralateral eye (p = <0.001 for all recti muscles). Lacrimal gland prolapse appeared negatively correlated with the radiological proptosis in both study and fellow eyes (p = <0.001).

 

The horizontal Barrett’s muscle index was found negatively correlated with the timing from TED to DON presentation, (p=0.010 for study eye, p<0.001 for fellow eye). This was confirmed on group analysis with a higher mean index for presentation =< 6 months (0.556 ± 0.135 versus 0.451 ± 0.08, p = 0.017). In muscle analysis, lateral rectus was found negatively correlated with time from TED to DON (p<0.001in right eye and p=0.006 in left eye). In group analysis, medial rectus (p = 0.003), inferior rectus (p = 0.016) and lateral rectus (p = 0.032) were all negatively correlated with acuteness of presentation in the study eye.

 

Conclusion:  We found that horizontal muscle Barrett’s index appears to correlate with acute DON  =<6 months from TED diagnosis, which may be a useful adjunct to aid diagnosis and contribute to better understanding of the pathophysiology of the disease.

 

 


Ourania FYDANAKI (London, United Kingdom), Andy WANT, Gabriella GUEVARA, Alnalwary AHMED, Aziz AHMAD, Rajni JAIN, Claire FEENEY, Bhatia KUNWAR, Lee VICKIE
00:00 - 00:00 #32387 - OCT Analysis of Dysthyroid Optic Neuropathy.
OCT Analysis of Dysthyroid Optic Neuropathy.

Thyroid eye disease is the most common orbital disease, with up to half of patients with Graves disease affected with the condition. Dysthyroid optic neuropathy (DON) is one of the most severe complications of thyroid eye disease. DON can be accompanied by disc swelling in 30-33% of cases1 and with pallor in 4-20% of cases2. DON although potentially reversible can result in permanent visual loss if diagnosis or management is delayed. Studies have shown that this visual loss can be preceded by a decrease in retinal nerve fibre layer thickness. Optic coherence tomography (OCT) can be used to assess retinal nerve fibre layer anatomy and potentially detect early changes in DON. Our study aims to assess the OCT findings in patient with thyroid eye disease, we tried to identify characteristic distribution of decrease in nerve fibre layer thickness and changes in thickness following treatment with steroids, decompression surgery or radiotherapy. 

 

Twenty-one patients were retrospectively analysed. Heidelberg Eye Explorer was used to assess the retinal nerve fibre layer thickness. OCT scans of right and left eyes were assessed independently to look for defects pre- and post- treatment. A total of 42 eyes were analysed. Retinal nerve fibre layer thickness at one month, three months and six months post treatment was reviewed.

 

Results showed a decrease in nerve fibre layer thickness in all regions of the optic nerve. The inferior temporal and superior nasal bundle decreased significantly for all eyes. No significant reduction in retinal nerve fibre layer loss was seen following treatment. 

 

In conclusion, results showed that the inferior temporal and superior nasal aspect are regions of the retinal nerve fibre layer that are most significantly affected by thyroid eye disease. Limitations of the study are a small sample size and loss to follow-up of patients.

 


Syed AHMED, Mana RAHIMZADEH (London, United Kingdom), Minak BHALLA, Vickie LEE, Skanda RAJASUNDARAM
00:00 - 00:00 #32361 - Ocular adnexal lymphoma – a retrospective study of 24-year period.
Ocular adnexal lymphoma – a retrospective study of 24-year period.

Purpose: To review the characteristics of Slovenian patients with ocular adnexal lymphoma in the period of 24 years.

 

Methods: The study included 74 patients with ocular adnexal lymphoma diagnosed with biopsy between 1995-2019 at Eye Hospital, University Medical Centre Ljubljana, Slovenia, and treated at Institute of Oncology Ljubljana, Slovenia. Statistical analysis included demographic data, lymphoma location (orbital or conjunctival) and type, disease stage, treatment modality, local control rate and survival rate.

 

Results: The average age of patients was 68+/-13 years, 39% were male. The majority of lymphoma were of B-cell origin (97%, 72/74). Histological subtypes were extranodal marginal zone B-cell lymphoma (MALT) (70.3%), mantle cell lymphoma (MCL) (12.2%), follicular lymphoma (FL) (9.5%), diffuse large B-cell lymphoma (DLBCL) (5.4%), chronic lymphocytic leukemia (CLL) (1.4%) and peripheral T-cell lymphoma (TCL) (1.4%). MCL was found predominantly in males (67%) and all others predominantly in females (62%-100%). All subtypes were found in the orbit, most frequently MALT (63%) and MCL (16%), while only MALT (89%) and FL (11%) were identified in the conjunctiva. Patients with conjunctival lymphoma (N=18; avg. 60 years) were significantly younger than those with orbital lymphoma (N=56; avg. 67 years; p<0.05). Ocular manifestation was the first sign of the disease in 78.4% of patients and in 67.6% of patients ocular adnexa were the only location. Therapy included radiotherapy (69%), systemic treatment (9%), the combination of both (7%) or observation (15%). Local control of the disease was achieved in 96.8% of the treated patients (2/63), however, recurrence was observed during follow-up in 44% of the patients. Median overall survival was 169 months (range 1–280 months); 5-year overall survival rate was 78% and 5-year lymphoma specific survival rate was 86%. 

Conclusion: Ocular adnexal lymphoma is a group of heterogeneous diseases with variable outcomes. Treatment requires multidisciplinary collaboration. Radiotherapy is a very efficient treatment with excellent local control rate while systemic treatment is reserved for disseminated disease.


Ana FAKIN, Lučka BOLTEŽAR, Štrbac DANIJELA, Jože PIŽEM, Drnovšek Olup BRIGITA, Gregor HAWLINA (Ljubljana, Slovenia)
00:00 - 00:00 #32520 - Oculoplastic input in patients with orbital fracture repair.
Oculoplastic input in patients with orbital fracture repair.

Aim - To understand requirements for oculoplastic input in patients who have orbital fracture repair and utilise the data to guide service setup. 

Methods - Patients operated for orbital fracture from 1 Jan 2021 to 31 Dec 2021 (12 months) at Royal London Hospital which is a tertiary trauma referral center were included in the study. Patients who were later referred to the oculoplastic clinic for evaluation are considered for the study. We excluded patients who had diplopia or acute visual concerns which were managed by the orthoptic or emergency clinics.

Results- Number of orbital features operated during this period were 139. Average age of the patient was 37.4 years with male predominance (87%). Out of these, 57% were a single wall fracture of the orbit, 29% fractures involved 2 walls of the orbit and 14% were LeFort II/III or panfacial fractures. 29 patients (20.8%) were followed up or referred to the oculoplastic service for either canthal asymmetry (10%), lacrimal injury (4.2%), repaired globe injury or prosthesis (2.1%), ectropion (2.1) and 4.3% for other complaints (including facial nerve palsy, dry eye, etc).

Conclusion- We highlight a scope for collaboration and multidisciplinary input in improving patient care. The range of presentations are useful to understand long term outcomes and service design for trauma patients. 

Limitation - Services were impacted by the COVID 19 pandemic in early 2021




Radhika DASHPUTRA, Nikhil CASCONE (London, United Kingdom), Andrew COOMBES
00:00 - 00:00 #31694 - One orbital mass and a dozen puzzled doctors.
One orbital mass and a dozen puzzled doctors.

Background:

A detailed eye examination is crucial for diagnosing orbital diseases. Signs and symptoms may vary based on duration, severity and structures involved within the orbit. Presentation can be of inflammation, infection or enlarging mass. Moreover, it can be part of an underlying systemic condition.
Methods:

A 92 year old man with type 1 diabetes, presented with an 18-month history of right lower lid soreness. Initially, following virtual assessment due to Covid-19 pandemic, he was booked for entropion repair surgery, and discovered to have cicatricial changes, along with severe restricted eye movements on preoperative examination.  A conjunctival biopsy was performed and showed lipogranulomatosis inflammation. Initial blood investigations showed a negative autoantibody screening with no suggestive history of underlying connective tissue disease, vasculitis or malignancy. Orbital imaging showed diffused orbital inflammatory changes involving three recti muscles, with no optic nerve involvement. During the following few months the patient’s condition progressed with visual deterioration. Two further intraconal orbital biopsies from different sites were taken, with undefined results. Multi-disciplinary discussion suggested a slow infective process and a fourth biopsy was performed before initiating immunomodulatory treatment.

Results:

Initial histopathology findings suggested an infection-related mass. Haematologic Malignancy Diagnostic Service (HMDS) report ruled out lymphoma and any other neoplastic disease. There was no increase in IgG4 levels. Direct microscopy excluded a fungal infection and gram-stains were negative. Pan-fungal and bacterial PCR and cultures were negative as well. The fourth biopsy results showed an active chronic non-specific inflammation.

 

Conclusion:

Orbital disease assessment and evaluation occasionally require a multidisciplinary approach, yet diagnosis might still be challenging despite an adequate orbital biopsy. Treatment decisions necessitate consideration of disease burden, cost of treatment, and most importantly patient’s quality of life.

 


Christine SAFIEH (Leeds, United Kingdom), Faizan TAHIR, Sreedhar JYOTHI, George KALANTZIS, Bernard CHANG
00:00 - 00:00 #30886 - Orbital and ocular lymphoma – what can we tell our patients.
Orbital and ocular lymphoma – what can we tell our patients.

Purpose

Patients with ocular lymphoma may be asymptomatic or present with a range of signs and symptoms, including an orbital mass, axial and non- axial proptosis, diplopia and chemosis. Studies have focused on incidence, prognosis and best treatment options, with very few addressing the response to treatment in terms of their signs and symptoms. In clinic, patients are often concerned about this. Our study hopes to give some guidance on what they may expect.

 

Methods

This is a retrospective non-comparative case series, looking at all patients who were treated for orbital lymphoma, at Birmingham and Midland Eye Centre from January 2015 to January 2021. Biopsy specimens were sent to University College London Pathology department for analysis. Patients who were confirmed to have lymphoma were referred to our Haematology department where they were investigated and treated.  

 

Results

43% of patients had primary orbital lymphoma, and 57% had secondary orbital lymphoma. 71% of patients had complete resolution of symptoms following treatment. This included symptoms such as visible proptosis, swelling, mass, redness, diplopia and pain. 71% of patients also had a complete resolution of their examination findings namely proptosis, swelling or mass and restricted ocular motility. 43% of patients suffered treatment side effects, some of which were so called minor and temporary whilst a couple had more serious side effects.  

  

Conclusion

Our study shows that in patients diagnosed with either primary or secondary orbital lymphoma, on completion of treatment, all patients will have an improvement in their signs and symptoms. Almost all (71%) patients will also have a complete resolution of their symptoms and signs, including proptosis, pain, swelling and diplopia. This will aid in counselling patients who are newly diagnosed and address some of the more immediate concerns patients often express in clinic. 

 


Faye MELLINGTON, Emma SAMIA-ALY (London, United Kingdom)
00:00 - 00:00 #32367 - Orbital and Pulmonary MALT-Lymphoma presenting with unremitting red eye and ptosis - a case report.
Orbital and Pulmonary MALT-Lymphoma presenting with unremitting red eye and ptosis - a case report.

Extranodal marginal-zone-B-cell mucosa-associated lymphoid tissue (MALT) lymphomas correspond to the majority of the orbital lymphomas. Despite its tendency to remain confined to the orbit, a significant amount of cases present with disseminated disease. Therefore, a thorough systemic evaluation is recommended.

Here, we present a case of a 60 year-old-male with unremitting red right eye evolving for 5 months. 

Ophthalmological examination was notable for proptosis and a moderate ptosis of the right eye (OD). On biomicroscopy, hyperemia with a salmon coloured rubbery mass lesion on the superomedial aspect of his conjunctiva OD was observed. Orbital MRI showed a lesion on the superonasal portion of the anterior orbit. A thoraco-abdomino-pelvic computerized tomography (CT) scan revealed a 7mm solid nodule on his right lung.

A biopsy of the conjunctiva was performed and the anatomic pathology analysis revealed subepithelial connective tissue almost exclusively occupied by a nodular proliferating of small sized lymphocytes, with scarce cytoplasm and either dense chromatin or small nucleoli. There were a few mitotic figures and no necrosis was observed. The immunohistochemical study revealed a proliferation of CD20-positive and BCL2-positive lymphocytes. CD3, CD5 and CD43 were positive in reactive T lymphocytes in the background. The neoplastic B lymphocytes were negative for CD10, BCL6, LEF1, SOX11, Cyclin D1, CD21 and CD23. The proliferative index (% Ki-67) was lower than 1%. Flow cytometry analysis confirmed the presence of B-cell mature monoclonal lymphocytes with absent CD5 and CD10 expression and the diagnosis of a marginal zone extranodal MALT lymphoma was made.

The biopsy of the pulmonary nodule also revealed the presence of a lung MALT-lymphoma. It remains elusive whether lung and conjunctival MALT lymphomas are clonally related.

The patient is currently undergoing a complete lymphoma staging and a clonality analysis of both orbital and lung lymphomas to confirm disease dissemination before starting chemotherapy


João PONCES RAMALHÃO (Porto, Portugal), Francisca BRAGANÇA, Miguel AFONSO, Mafalda MACEDO, Nuno JORGE LAMAS, Maria ARAÚJO
00:00 - 00:00 #32285 - Orbital involvement of rhabdomyosarcoma in children – retrospective analysis of 77 cases.
Orbital involvement of rhabdomyosarcoma in children – retrospective analysis of 77 cases.

 

Introduction:

 

The purpose of the study was to describe orbital involvement of rhabdomyosarcoma (RMS) in a cohort of pediatric patients.

 

Methods:

 

Retrospective, single-center cohort study from a tertiary care pediatric hospital. The main outcome measures were the incidence, manifestations, and prognostic role of orbital involvement (primary and secondary) in pediatric RMS cases.

 

Results:

 

There were 77 patients with rhabdomyosarcoma. Orbital involvement was seen in 27 patients (35%) – 15 with primary orbital RMS and 12 with secondary orbital RMS. The most common ophthalmic manifestations in primary RMS were eyelid edema (60%), restriction of extraocular motility (60%), and proptosis (53%). The most common ophthalmic manifestations in secondary RMS were restriction of extraocular motility (83%), strabismus/diplopia (58%), and proptosis (58%). The most common ocular complications in both groups were bony hypoplasia/facial asymmetry (87% primary, 58% secondary) and keratopathy/dry eye (73% primary, 83% secondary).

 

In primary orbital RMS, visual acuity at final follow-up was ≥20/40 in 67%, 20/40-20/200 in 7%, and 27%. In secondary orbital RMS, visual acuity at final follow-up was ≥20/40 in 25%, 20/40-20/200 in 0%, and ≤20/200 in 75%. Visual acuity outcomes were significantly worse in the secondary orbital RMS group (p = 0.03). Survival was 100% in the primary orbital RMS group compared to the 42% in the secondary orbital RMS group (p = 0.0002). 

 

Discussion:

 

In this cohort of children with RMS, approximately 35% had primary or secondary orbital involvement. Visual outcomes and survival were worse in children who had secondary orbital RMS involvement compared to primary orbital RMS.  


Sybille GRAEF (Toronto, Canada), Dan DEANGELIS, Abha GUPTA, Michael J WAN
00:00 - 00:00 #32159 - Orbital lymphangioma in a girl treated with sirolimus.
Orbital lymphangioma in a girl treated with sirolimus.

Orbital lymphangiomas are vascular and lymphatic malformations. They appear in the first decade of life. In the orbit they present as ptosis, proptosis, alteration of ocular motility, and a compressive optic neuropathy may appear. The treatment is complex and varied: observation, sclerosing treatments of the lesion, systemic treatment and surgical excision. We present the results of treatment of an orbital lymphangioma with systemic Sirolimus, an immunosuppressive agent that inhibits mTOR. Patient 12-year-old girl, consulted for left exophthalmos of one week's evolution.She refers amblyopia of the left eye (LE) treated with occlusions in childhood. On examination, she presented hyperopia in both eyes and visual acuity (VA) 1 and 0.1 (+3 and +5), divergent strabismus in V, exophthalmos of 2 mm in LE. Motility preserved. Eye fundus: LE papilla edema. Magnetic resonance imaging (MRI) shows a polylobulated cystic lesion in the left orbit, intra and extraconal, with hemorrhagic complications, compatible with cystic lymphangioma. Oral treatment with Sirolimus is chosen. After 3 months of treatment, proptosis was reduced, LE VA 0.2 (amblyopia), and papilledema disappeared. MRI shows a decrease in the size of the lesion.After 18 months, monthly blood tests are normal, with no systemic side effects or increased damage. The diagnosis of lymphangioma is clinical and based on imaging techniques. It is difficult to perform a complete surgical resection and has a high risk of local recurrence and complications. Other therapeutic options have been proposed: sclerosing substances injected into the vascular walls of the lymphangioma: corticosteroids, tetracyclines, Bleomycin, OK-432 (Picibanil); and systemic medication to reduce the size in which the Siromilus used in this case is found. For now there here is no consensus on which is the best treatment for this pathology.


Amparo LANUZA-GARCIA, Alvaro OJEDA PAROT, Julia PEREZ-MARTINEZ (Valencia, Spain), Gemma ORTEGA PRADES, Raul MARTINEZ-BELDA, Antonio DUCH SAMPER
00:00 - 00:00 #32147 - Orbital phlegmon in a patient with COVID-19 - a case report.
Orbital phlegmon in a patient with COVID-19 - a case report.

Orbital soft tissue inflammation is a group of inflammatory conditions which the course, treatment and prognosis depend on the location of the inflammatory process - in front of or behind the orbital septum. The most common causes of orbital tissue inflammation are upper respiratory tract infections, especially sinusitis (Streptococcus penumoniae) and local skin infections (Staphylococcus aureus and Streptococcus pyogenes). The spectrum of symptoms is very wide and, depending on the localization of the process, includes: unilateral, painful, warm edema of the orbital tissues with accompanying narrowing of palpebral fissure, ophthalmoplegia, exophthalmos, conjunctival edema, epiphora, presence of purulent discharge in palpebral fissure, pain when moving the eyeball, diplopia, disorders of pupillary light reflex. The prognosis is good in most cases, but less frequent, untreated orbital cellulitis can result in permanent vision loss, cavernous sinus thrombosis, brain abscesses, and even death.

We present a case of severe orbital soft tissue inflammation complicated by the spread of inflammation through the soft tissues of the neck to the subcutaneous tissues of the chest in a 67-year-old man infected with COVID-19. The diagnostic process and therapy, in the presented case, were hampered by the sanitary regime related to the coronavirus infection. Clinical improvement was achieved due to the use of empiric antibiotic therapy with a broad spectrum of activity as well as surgical procedures - incision and drainage of the orbital tissues. As a consequence of the inflammation, the patient developed eyelid skin necrosis, complicated with upper eyelid ectropion and lagophthalmos, requiring consecutive surgical treatment.


Dominika BIAŁAS, Radosław RÓŻYCKI (Warsaw, Poland), Mateusz JACUŃSKI
00:00 - 00:00 #32327 - Orbital rhabdomyosarcoma in children – retrospective analysis for histologic spectrum and predisposing factors.
Orbital rhabdomyosarcoma in children – retrospective analysis for histologic spectrum and predisposing factors.

Introduction:

The purpose of the study was to describe the histologic subtypes and occurrence of predisposing factors in a cohort of pediatric patients presenting with head and neck rhabdomyosarcoma (RMS) compared to orbital RMS.

 

Methods:

Retrospective, single-center cohort study from a tertiary care pediatric hospital. The medical records of 77 patients with rhabdomyosarcoma in the head and neck region seen between 1997 and 2021 were analyzed. The main outcome measures were the distribution of histologic subtypes and incidence of predisposing factors and their prognostic role in orbital RMS cases compared to head and neck RMS.

 

Results:

There were 77 patients with rhabdomyosarcoma. Median age at diagnosis was 6.03 years and 54.5% were male. The histology was embryonal in 60 (77.9%) of cases, alveolar in 14 (18.2%) of cases, 2 cases (2.6%) had spindle cell and 1 case had epitheloid RMS (1.3%).  A total of 27 patients (35.1%) were found to have orbital involvement of rhabdomyosarcoma. 

In primary orbital cases, 11 (73.3%) patients had embryonal and 3 (20.0%) patients alveolar histology. There was one case (6.7%) with epitheloid RMS. In secondary orbital RMS 8 patients had embryonal and 4 had alveolar histopathology.

 

All primary orbital patients who had disease recurrence/progression and needed exenteration (4/15) had embryonal histology as well as one patient requiring exenteration in the group of secondary RMS (1/12).

On survival analysis, a favorable prognosis was found for cases with primary orbital RMS (0% deceased), in contrast to cases with secondary orbital involvement (66.7% deceased, 8/12 with 5 embryonal cases and 3 alveolar subtypes). The 2 patients with predisposing condition had embryonal pathology and ultimately died. From the non-orbital group only 2 patients with predisposing condition died of their disease.

 

Discussion:

In this cohort of children with RMS, approximately 78% had embryonal and 18.2% alveolar histology with one case of epitheloid and two cases of spindle cell RMS. The alveolar pathology which is deemed unfavourable was slightly higher in the orbital RMS cases. However, only cases with embryonal pathology needed exenteration. In about 15/77 cases 9 different predisposing conditions have been identified, either with increased genetic risk or developmental delay.


Sybille GRAEF (Toronto, Canada), Dan DEANGELIS, Abha GUPTA, Michael J WAN
00:00 - 00:00 #32278 - Orbital Silicone Mimicking Orbital Cellulitis.
Orbital Silicone Mimicking Orbital Cellulitis.

We present a case of a 23 year old male with longstanding diabetes who presented with severe eyelid swelling, pain, and chemosis. He was diagnosed with orbital cellulitis and started on intravenous antibiotics. Oculoplastics was consulted and notation was made of infiltrative conjunctival edema. Furter history revealed past vitrectomy with silicone oil. Imaging showed right proptosis and evidence of posterior scleral thinning with extrusion of oil into the orbit. Enucleation revealed extsnsive scleral necrosis and orbital siliconoma. Siliconoma should be included in the differential diagnosis of orbital and eyelid inflammation in the setting of prior vitrectomy.  


Adam DE LA GARZA (Atlanta, USA)
00:00 - 00:00 #32430 - Orbital Solitary Fibrous Tumour -a Case Series.
Orbital Solitary Fibrous Tumour -a Case Series.

To report the clinical and oncological outcomes of Orbital Solitary Fibrous Tumour in at tertiary centre


Segun AWOTESU (Leicester, United Kingdom), Evangelis LOKOVITIS, Raghavan SAMPATH
00:00 - 00:00 #30755 - Patient-specific orbital implants vs. pre-formed implants for internal orbital reconstruction.
Patient-specific orbital implants vs. pre-formed implants for internal orbital reconstruction.

Objective: To compare the outcome of orbital blowout fracture repair by means of pre-formed porous-polyethylene titanium implants (PFI) vs patient-specific porous-polyethylene implants (PSI).

Methods: Retrospective cohort study. Baseline characteristics, ophthalmic examination results, ocular motility, fracture type, timing of surgery, implant type, and final relative enophthalmos of all patients operated for blow-out fractures in a single center were collected and analyzed.

Results: Twenty-seven patients (mean age 39 years, 9 females) were enrolled. Sixteen underwent fracture repair with PFI and 11 with PSI, 11 months (median) post-trauma. Follow-up duration was 1.1 years (mean). Both groups showed significant postoperative improvement in primary or vertical gaze diplopia (P = .03, χ2). Relative enophthalmos improved from -3.2 preoperative PFI to -1.7 mm postoperative PFI, and from -3.0 mm preoperative PSI to -1.1 mm postoperative PSI (P = .1). PSI patients had non-significantly less postoperative enophthalmos and globe asymmetry than PFI patients. The outcome was not influenced by previous surgery, age, sex, number of orbital walls involved in the initial trauma, or medial wall involvement (linear regression). Both groups sustained severe complications unrelated to implant choice.

Conclusion: PSI may be a good alternative to PFI in primary or secondary orbital blowout fracture repair with less enophthalmos and globe asymmetry, in spite of the possible disadvantages of production time, a relatively larger design, and challenging insertion. Since it is a mirror-image of the uninjured orbit, it may be beneficial in extensive fractures or secondary repair.


Daphna LANDAU (Tel Aviv, Israel), Said MASSARWA, Ayelet PRIEL, Oded SAGIV, Ofira ZLOTO, Guy J. BEN SIMON
00:00 - 00:00 #32410 - Pediatric orbital dermoid cysts: two incarnations of one lesion.
Pediatric orbital dermoid cysts: two incarnations of one lesion.

Orbital dermoid cysts belong to choristomas – tumours, originated from aberrant primordial tissues, clinically could be present by preseptal and postseptal localization.

Purpose: To analyse the clinical, histopathological peculiarities and surgical treatment results of pediatric dermoid cysts.

Matherial and methods. 43 children aged 3-14 years were under observation. Preseptal localization was observed in 79,1 %,  postseptal - in 20,9 %. Superficial lesions characterized by rather small size (12-25 mm), upper eyelid deformation in some cases, no influence to visual functions. Deep orbital dermoid cysts distinguished by significantly bigger size, reached 35-45 mm, causing proptosis, eyeball and eye fissure displacement, visual acuity loss due to compressive neuropathy development.

CT and MRI visualizationn allowed to determine the topographic features of the cyst and changes of surrounding tissues. Eyelid deformation and progressive growth of superficial cysts, also visual functions worsening, expressed displacement of eyeball and eye fissure, proptosis - in deep localization, were the indications to surgical treatment. The technique of operation consists in total cyst removal with capsule integrity preservation.

Histopathological examination showed a similar structure of superficial and deep cysts. But preseptal dermoids were distinguished by a more quantity of skin appendages, determining the nature of the contents, and the signs of granulomatous inflammation with giant cells formation in some cases.     

Results. The presence of inflammation signs in preseptal dermoid cysts could be a result of traumatization due to constant touch of cysts by child. The same factor can be stimulating for skin appendages to produce more secret, which provokes to active cyst increase.

Good functional and cosmetic result of surgery was achieved in all cases. Improvement of visual functions was noted after postseptal dermoids removal as a result of orbital structures compression elimination.

          Conclusion. According to the clinical features preseptal dermoid cysts represent a more cosmetic problem and their removal aims to improve the appearance of the child. While deep dermoid cysts create a more serious medical problem, demand thorough preoperative examination with purpose of differential diagnosis with other orbital lesions, in distinction from superficial cysts, require performing “big” orbital surgery with individual approach for every case. 


Svitlana TRONINA (Odessa, Ukraine), Nadiia BOBROVA, Valeriy VIT
00:00 - 00:00 #32451 - Pediatric Orbital Fasciitis, two cases report and review of literature.
Pediatric Orbital Fasciitis, two cases report and review of literature.

Purpose: To report two consecutive cases of pediatric nodular fasciitis, a rare benign tumor with a potential aggressive behavior and malignant transformation.

 

Method: Two consecutive case report, literature review

 

Results: Patient I, a 10-month old girl who presented with a 3 weeks history of enlarging mass (15x15mm) in her right upper eyelid causing mechanical proptosis. patient II consists of a 2-year-old boy that presented with a rapid enlarging and extreme 30mm proptosis, lagophthalmos with corneal decompensation and low vision potential. Computer tomography and Magnetic resonance imaging disclosed enhancing, circumscribed, solid, soft-tissue mass in the orbit of both patients. Histopathologic and immunohistochemical studies revealed findings consistent with nodular fasciitis, a pseudoneoplastic lesion marked by a proliferation of myofibroblasts.

            

Conclusion: Although nodular fasciitis in the ocular region usually occurs in adults and older children, it should also be considered in the differential diagnosis of orbital or adnexal masses in infants and young children.


Zvi GUR (Jerusalem, Israel), Pablo GALARZA
00:00 - 00:00 #32497 - Rare case of necrobiotic xanthogranuloma (NXG) associated with IgG Lambda multiple myeloma presenting with intermittent left frontal headache associated with ptosis.
Rare case of necrobiotic xanthogranuloma (NXG) associated with IgG Lambda multiple myeloma presenting with intermittent left frontal headache associated with ptosis.

BACKGROUND

Necrobiotic xanthogranuloma (NXG) is a rare adult orbital xanthogranulomatous disease characterised histologically as a non-Langerhans cell histiocytosis and is typically associated with paraproteinaema. 

False positive anti-MuSK antibodies have only reported in one patient with multiple myeloma.

INTRODUCTION

A 66 years old female presented with a history of increasing frequency of left retro-orbital pain, with conjunctival injection, lid oedema and ptosis. She had bilateral medial upper eyelid orange plaques with a left ptosis. Remainder of examination was normal with full ocular motility. Medical history was significant for hyperlipidaemia and monoclonal gammopathy of undetermined significance (MGUS) with elevated Lambda light chain. 

INVESTIGATIONS

Acetylcholine receptor antibodies were negative while anti-MuSK antibodies were present. Single fibre EMG did not support myasthenia gravis and CT chest was negative for thymoma. She was treated for trigeminal cephalgic neuralgia with indomethacin by neurology, with good response. Ptosis surgery identified extension of orange plaque to deeper tissues and histology identified dense lymphohistiocytic infiltrate with foamy macrophages, Touton multinucleated giant cells and foci of necrobiosis. MRI imaging demonstrated bilateral high STIR signal of inflammatory intraconal soft tissue cuffing around both anterior orbits with effacement of the left globe. Patient progressed clinically over the next year, with a left superomedial orbital mass swelling regularly, and onset of diplopia with limitation of the left eye in all directions of gaze. Repeat imaging demonstrated progression with bilateral recti muscle involvement. 

MANAGEMENT

Left superomedial orbital stroid injection improved symptoms, however the patient progressed to smouldering myeloma under haematology with 10-15% plasma cells in the bone marrow, so plasma clone directed treatment was initiated. She had 6 cycles of VRD treatment (Velcade, Revlimid and dexamethasone) achieving biochemical remission and resoltion of eye symptoms. Repeat imaging demonstrated significant reduction of volume with only subtle enhancement post contrast. 

CONCLUSION

Patients with NXG may present to ophthalmology first. Given the potentially serious consequences, it is important for them to be considered in the differential and appropriately investigated.

This is the second reported case of fasle negative anti MuSK antibodies, and is also in a patient with multiple myeloma. 


Fiona JAZAYERI, Alice CRANSTON (Buckinghamshire, United Kingdom)
00:00 - 00:00 #32443 - Recurrence rate of orbital and periocular MALT Lymphoma: results using a 10-year surveillance period.
Recurrence rate of orbital and periocular MALT Lymphoma: results using a 10-year surveillance period.

Purpose: To evaluate the efficacy of 10-year surveillance period and recurrence rate of orbital/periocular mucosa-associated lymphoid tissue (MALT) lymphomas, an overview between 2002 to 2018. 

Methods: Retrospective review of 53 eyes in 45 patients with biopsy-proven orbital/periocular MALT lymphoma. Patient demographics, disease location, systemic involvement, treatment regime and recurrence rate were analysed. 

Results: Mean age at presentation 57 years (±17.6; median 58; range 19-92), no gender predilection. Most patients (41/45; 91%) presented with periocular symptoms/signs, bilateral in 8 cases (18%) and 9 orbits (17%) had optic neuropathy.In some cases more than one location was involved, orbit being the commonest(40/53;75.4%):extraconal(27/40;67.5%), intraconal 50% and extraocular muscles 22.5%. The lacrimal gland was involved in 7/53 orbits (13%), conjunctiva 15%, lacrimal sac 4%, eyelids 6%, and intraocular 3/53(6%);all intraocular cases had neighbouring intraconal lymphoma. 

The study comprised two groups:Group 1,37/45(82%) with orbital disease only and Group 2, 8/45(18%) with systemic involvement–4/8 having known systemic lymphoma prior to orbital diagnosis. Extra-orbital sites included lymphadenopathy 6/45patients(13%),bone marrow 4%,CNS 4%and spleen 2%. 

Radiotherapy was primary treatment in 31/53(58%) orbits, others received chemotherapy 7%,rituximab 10% and doxycycline 2%. 

The mean surveillance period 4.8 years (± 3.8; range 2 months – 14 years), during which 27% (12/45) patients had recurrence. The relapse rate was highest in Group 2, 4/8 patients recurring at a mean interval of 4 years (range 2-7); in contrast, 22% (8/37) Group 1 patients had relapse at mean interval of 4.6 years (range 1-9).

The probability of disease relapse for Group 1 was 15% at 5 years and 22% at 9 years, with bilateral disease being prone to earlier relapse. Group 2, the recurrence was nearly 40% at 5 years and 50% at 7years, without perceptible difference between bilateral and unilateral cases. 

The overall ten-year disease-free survival was 66.7%(22/34)

Conclusion: Most (91%)patients presenting with orbital/periocular MALT did not have systemic symptoms at presentation.Although MALT lymphoma is considered a “low-risk” lymphoma, the disease relapse was 27% during the surveillance period and those with systemic disease at the time of orbital diagnosis had more-than-twice the risk of relapse within the 10 year surveillance period. The ten-year relapse-free rate was 66.7%.


Amrita SAWHNEY, Inga NEUMANN (London, United Kingdom), Geoffrey E. ROSE, Fabiola MURTA
00:00 - 00:00 #30838 - Removal of an Incidental orbital metallic foreign body: MRI safety Controversies and considerations.
Removal of an Incidental orbital metallic foreign body: MRI safety Controversies and considerations.

A 77-year-old male plumber presented to emergency eye clinic for removal of foreign body from his right cornea. An incidental finding of a small metallic foreign body was found projected over the left medial orbit on plain film. The patient had no recollection of a specific event that could have resulted in this trauma.

 

A CT orbit demonstrated a 3mm hyperdense foreign body at the medial aspect of the left orbit. The patient was asymptomatic however after discussion regarding the risks and benefits of conservative versus surgical management, the patient decided to have the object removed. 

 

Discussion

 

Unexpected metallic foreign objects can pose a safety issue for future magnetic resonance imaging (MRI) scanning. The three principal considerations are (i)whether or not they are ferromagnetic, (ii) their location within the orbit and (iii) how long they have been in situ. The concern with ferromagnetic fragments is movement when exposed to a strong magnetic field such as that encountered in an MRI scanner. This is particularly the case for intraocular fragments. 

 

Extra-ocular orbital foreign bodies are thought less likely to cause significant harm if they have been in situ for a long period, as they tend to become enveloped in a fibrous capsule within the orbital tissue which prevents significant movement. They can however cause significant susceptibility artefact on MRI which may render an MRI non-diagnostic. The other consideration is that the patient may experience heating of the foreign body during MRI scanning.

 

There is some controversy with regards to the best screening protocol to ensure a patient with an undiagnosed metallic intra-orbital foreign body (IOFB) does not enter an MRI scanner. Some units advocate obtaining plain films of an orbit before MRI is carried out, in patients with potential occupational or recreational exposure to kinetic metal fragments. One study found that 0.65% of patients with such risk factors had evidence of incidental intraorbital metallic foreign bodies. Other studies have found that the rate of incidental IOFB did not warrant radiographic screening with plain film prior to MRI on a cost-effectiveness analysis. Instead clinical screening ie. asking the patient “did a doctor get it all out” is recommended for those with a history of previous ocular foreign body. Small, deeply seated IOFBs where access is a problem and risks subsequent morbidity are often managed conservatively and found to be well tolerated. 

 


Jennifer DOYLE (Buckinghamshire, United Kingdom), Kesh MISRA, Richard SCAWN
00:00 - 00:00 #32329 - Repair orbital implant exposure with donor scleral patch associated a double amniotic membrane layer: case report.
Repair orbital implant exposure with donor scleral patch associated a double amniotic membrane layer: case report.

Purpose: To show the use of the donor scleral patch associated to double amniotic membrane layer in orbital implant exposure: case report 

Clinical case: 71-years-old female patient with right eye ocular evisceration 11 years ago; who comes to our service with morning rheum and eye discomfortanophthalmic cavity examination revealed orbital implant exposure in central area of 8x8mm and in the upper area of 4x4mm, without signs of infection. Surgery with donor scleral patch coverage and double-layer amniotic membrane graft procedure was decided. One month after surgery, integration of the conjunctiva into the amniotic membrane upper layer was observed and at 6 months of follow-up, orbital implant exposure or rejection of the donor sclera graft were not observed. 

Discussion and Conclusion: The exposure of the orbital implant is the most frequent complication after ocular evisceration surgery, which requires adequate handling of the tissues and the implant depending on the clinical characteristics of how it is presented and the size of the exposure. The use of dermal fat grafting for repairing orbital implant exposures is widely known; in our case, the donor sclera patch associated with amniotic membrane has been useful demonstrating that it is a good alternative with good results, especially to facilitate tissue integration. 


Mora Botia GLADYS LORENA (TARRAGONA, Spain), Jordi COLOMÉ, Lucía LORAS QUEROL, F. Fabian RODRIGUEZ OLMEDO, Manuel CASTRO DÍAZ, María Cinta BAUBÍ
00:00 - 00:00 #31953 - Rhabdomyosarcoma of the orbit in an adult: a challenging diagnosis.
Rhabdomyosarcoma of the orbit in an adult: a challenging diagnosis.

Orbital rhabdomyosarcoma is a life-threatening and highly malignant tumor that usually presents first to the ophthalmologist. Although, the majority of cases occur in early childhood, its occurrence in the orbit remains rare and even rarer in adults.

We present a 41-year-old woman with rapidly progressive painful left upper lid swelling and proptosis, colour vision and motility deterioration, associated with weight loss.

MRI showed a T1 isointense, T2 iso- and hyperintense orbital mass arising from the left greater sphenoid ring, with significant compression of the orbital content and bone destruction. The lesion extended to the orbital apex, the infratemporal fossa and the dura. Radiological features were in favour of malignant tumor: sarcoma, metastasis, or lymphoma.  

Orbital biopsy was performed and frozen sections revealed possible malignant meningioma whereas definitive pathology report confirmed a spindle cell rhabdomyosarcoma.

PET scan showed metastases involving sternum and spine. Although chemotherapy or palliative radiotherapy were offered, the patient refused treatment. 

Although rhabdomyosarcoma in adults is very rare, it should be considered in any group of age in fast-growing orbital tumours. Its diagnosis can be challenging on presentation as imaging and clinical features may not be helpful in distinguishing it from other malignant lesions. Careful histopathological evaluation is key in determining the accurate diagnosis. 


Laura EID, Roel KLOOS, Peerooz SAEED, Laura EID (Bordeaux)
00:00 - 00:00 #32531 - Robotic assisted orbital surgery- a proof of concept using cadaveric specimens.
Robotic assisted orbital surgery- a proof of concept using cadaveric specimens.

The primary aim of this study was to ascertain the feasibility of robotic assisted orbital surgery (RAOS) to visualize adnexal structures and assist in common orbital surgical procedures. The study used the Da Vinci Robotics SI single port system provided by Intuitive Surgical Labs, Berlin, to perform orbital surgery on cadaveric specimens. The surgeons were able to use the robotic system to acurately perform various orbital procedures such as dissection of the lacrimal gland, enucleation and exenteration as well as providing an excellent stereoscopic magnified view and utilize precise robotic assisted instrumentation to dissect and visualise orbital adnexal structures.  Any advancement of RAOS would need to address the limitations of the current instrumentation size and variation of specialist instruments used in orbital surgery. With the advent of new robotic devices comes the opportunity to combine advanced digital techniques such as immunofluorecent tumour demarcation and spectral analysis technology to detect pathology within the orbit. Augmented reality platforms allow for imaging integration and guidance as well as enhanced training systems.The integration of a state-of-the-art surgical platform with advanced medical technology optimised for orbital surgery will expand boundaries and enhance the surgical capabilities within orbital surgery as it has already done in other specialities.

Patients with tumours in the periorbital region may benefit from robotic resections with superior access combined with image guidance and enhanced tumour detection systems may improve surgical resection margins and potentially limit more ablative resections. 


Jean Pierre JEANNON, Jimmy UDDIN, Asit ARORA, Hubert STEIN, Jack FAULKNER, Mohsan MALIK, Claire DANIEL (London, United Kingdom)
00:00 - 00:00 #32182 - Severe orbital cellulitis after hyaluronic acid filling of the lower lid.
Severe orbital cellulitis after hyaluronic acid filling of the lower lid.

We present the case of a 38 years old woman, who was admitted to our clinic due to massive  protrusion, decreased visual acuity, elevated intraocular pressure and constricted movements of the left eye. Urgent lateral cantothomy was needed to decrease the intraorbital pressure. In the background a cosmetic prodedure was suspected from 7 days earlier- the patient had a lower lid hyalouronic acid filling in a private institute. A long recovery started with more than 20 days hospital stay. There are case reports in the international literature about inflammation and preseptal pseudotumor formation of the lid after hyaluronic acid filling, but we have found this case unique, because it caused a serious pustulous preseptal cellulitis and abscess formation, as well as postseptal cellulitis with pseudotumor formation which reacted well to steroids after the acute phase.


Laszlo UJVARY (Budapest, Hungary), Balázs GEISZELHARDT, Katalin KORÁNYI, Márton MAGYAR, Zoltán Zsolt NAGY
00:00 - 00:00 #30801 - Spontaneously resolving, non- traumatic orbital encephalocele.
Spontaneously resolving, non- traumatic orbital encephalocele.

A 90-year old male was referred to the oculoplastic clinic for investigation of a right orbital mass. He was a glaucoma suspect and on g. Ganfort (0.35mg/ml + 5mg/ml bimatoprost & timolol) once a day to both eyes. He had a history of high myopia and dry age-related macular degeneration. He had a history of prostate carcinoma which had been previously treated. 

His visual fields showed a deterioration with central defects and bi-nasal change. It was felt this was due to his significant peri-papillary atrophy secondary to myopia and dry age-related macular degeneration. To ensure there was no neurological cause, routine MRI brain and orbits were ordered.

MRI orbits revealed a large ill-defined soft tissue signal mass within the superolateral aspect of the extraconal compartment of the right orbit, extending posteriorly towards the orbital apex. 

 

A high-resolution CT demonstrated a bony defect within the posterolateral aspect of the right orbital roof. The aetiology of the bony erosion was unclear, but given the history of prostate cancer a whole-body bone scan was recommended. The patient underwent blood tests which revealed a normal electrophoresis pattern, immunoglobulin screen and a stable PSA.  A nuclear medicine bone scan was performed which showed no osteoblastic activity along the roof of the right orbit or the rest of the skeleton to suggest skeletal metastatic disease.

A follow up MRI was performed. This demonstrated that the previously noted extraconal mass had resolved and there now appeared to be right enophthalmos. Further review of the previous study suggested that the mass was likely herniation of brain tissue through a right orbital roof defect.

 

His case was discussed at the skull base MDT and it was concluded he had an isolated orbital encephalocele. The finding would not correlate to his visual field defect which was most likely due to his peri-papillary atrophy and dry AMD and no further intervention was recommended.

 

 

Discussion:

Encephaloceles are rare lesions consisting of herniation of the intracranial contents. Intraorbital encephaloceles are most commonly encountered following trauma resulting in orbital roof fractures. Following trauma, one potential mechanism for orbital roof destruction is a “growing orbital floor fracture”. With no history of trauma, orbital roof encephaloceles may mimick destructive orbital neoplasms as in this case. Systemic conditions such as Gorham syndrome, the “disappearing bone disease” , may also be considered. 


Jennifer DOYLE (Buckinghamshire, United Kingdom), Kesh MISRA, Richard SCAWN
00:00 - 00:00 #31633 - Teprotumumab for thyroid eye disease.
Teprotumumab for thyroid eye disease.

Thyroid eye disease (TED) occurs in approximately 30-50% of individuals with Graves’ disease.  TED can result in disfigurement, discomfort, decreased quality of life, double vision and in about 5% of cases visual loss from compressive optic neuropathy.  Traditionally patients with mild disease were treated with comfort measures and those with more severe disease with any of the following or combinations of corticosteroid, biologics such as rituximab, external beam radiation therapy or surgery.  In January 2020, the United States Food and Drug Administration approved teprotumumab broadly for the treatment of moderate to severe TED.

Teprotumumab is a fully human monoclonal antibody that blocks the insulin-like growth factor-1 receptor.  It is delivered as an intravenous infusion and the currently recommended dosing regimen is every 3 weeks for a total of 8 doses.  Logistical issues include the very high cost of the drug requiring insurance approval, as well as arrangement of infusion center or home infusions.  

This presentation will review the author’s experience and lessons learned with use of this drug in over 125 patients.  Example cases will showcase teaching points on drug efficacy in acute and chronic patients and in compressive optic neuropathy, timing of surgery with relation to treatment, drug related adverse events, and efficacy in treating lower extremity Graves’ related dermopathy. 


Suzanne FREITAG (Boston, USA)
00:00 - 00:00 #32230 - TERT-Promotormutation in orbital solitary fibrous tumours – A case series.
TERT-Promotormutation in orbital solitary fibrous tumours – A case series.

Authors: Koca DS, Ihlow J, Von Laffert M, Erb-Eigner K, Herbst H, Schweizer L, Bertelmann E

Background: Orbital solitary fibrous tumours (oSFT) are rare neoplasms of the orbit. Increasing understanding of the molecular background brought us away from histologic diagnosis, but led to molecular pathology as diagnosis defining measure. Lately the oSFT is desireably considered as a fibroblastic tumour with typical histology (staghorn-like pattern) and NAB2-STAT6 fusion gene. TERT-promotormutations have been shown to play an important role in tumour dedifferentiation in different tumour entities and lately have been shown to also appear in solitary fibrous tumours.

Methods: Retrospective and descriptive analysis of 9 cases of pathologically confirmed cases of oSFTs between 2017 and 2019 among a collective of 469 cases of patients who underwent orbitotomy. Analysis considered clinical parameters, imaging modalities (sequences of CT and MRI) and pathology. Pathology included histology, immunohistochemistry (among others CD34, CD99, STAT6), DNA-analysis (NAB2-STAT6 fusion-gene) and Sanger-sequencing (TERT-Promotormutation).

Results: Parameters of 9 patients were reported (5 male, 4 female, age at initial presentation 23-83, median age : 56 years). A clinical hallmark was painless ipsilateral proptosis sometimes with diplopia or periocular swelling, BCVA was not altered by the tumour and ranged between 0,4 and 1,25, IOP 12-21mmHg. Imaging depicted a mostly solid tumour with tubular vascular structures and mostly ADC-reduction occurring in the intraconal, extraconal or periorbital space. Osseus infiltration occurred in 2 cases and was related to bad clinical outcome.  In histology we saw a spindle-cell configurated tissue with high cellularity without any sign of necrosis. IHC revealed in all cases CD34+, CD99+ and STAT6+. NAB2-STAT6 fusion gene was shown to be present in all cases, TERT-Promotormutation was shown in 1 case which showed clinically the most aggressive behaviour

Conclusion: Orbital neoplasms should be evaluated by multimodal MRI-imaging. In suspicious cases diagnosis should be evaluated by means of histology and DNA-analysis (NAB2-STAT6-fusion gene). TERT-Promotormutation can be associated with a bad prognosis.


David Sinan KOCA (Berlin, Germany), Jana IHLOW, Maximilian VON LAFFERT, Katharina ERB-EIGNER, Hermann HERBST, Leonille SCHWEIZER, Eckart BERTELMANN
00:00 - 00:00 #32217 - The relationship between the volume of posterior ethmoidal cell and the degree of decompression in endoscopic transnasal orbital decompression for thyroid associated ophthalmopathy patients.
The relationship between the volume of posterior ethmoidal cell and the degree of decompression in endoscopic transnasal orbital decompression for thyroid associated ophthalmopathy patients.

Purpose : Orbital decompression surgery is performed to solve functional and cosmetic problems in patients with thyroid ophthalmopathy who develop non-steroid responsive compressive optic neuropathy or have severe eye protrusion. Surgical methods for orbital decompression include an endoscopic transnasal approach and transconjunctival approach. The purpose of this study is to investigate the relation between posterior ethmoidal cell volume and subsequent decompression degree in patients with thyroid ophthalmopathy who underwent endoscopic transnasal orbital decompression.

Method : From December 2017 to February 2022, a retrospective study was conducted on thyroid ophthalmopathy patients (38 patients, 68 eyes) among patients who underwent endoscopic transnasal orbital decompression. We calculated posterior ethmoidal air cell volume in orbit CT before surgery, and measured the difference of orbital protrusion length by using pre-operation and post-operation orbit CT as a degree of decompression.

Result : The mean volume of the posterior ethmoidal air cell was 3315.33±1249.38 mm3, and the mean difference of ocular protrusion length before and after surgery was 2.72±1.61mm. The relationship between posterior ethmoidal air cell volume and degree of orbital decompression have no statistically significant. However the difference of decompression degree between right eye and left eye had correlation with difference of each side posterior ethmoidal air cell volume in patients who had bilateral surgery (p=0.02).

Conclusion :  There was a statistically significant relationship between the difference of the orbital decompression effect in right and left eye and the difference of each side posterior ethmoidal air cell volume in patients who had bilateral endoscopic transnasal orbital decompression.


Joonki MIN (Incheon, Korea), Sungmo KANG
00:00 - 00:00 #32328 - The walls are closing in again.
The walls are closing in again.

Purpose: To inform on a complex and rare disease entity and give an update on a case report 

Background: Excessive cranial bone formation in the rare Van Buchem disease leads to compression of cranial nerves and significant comorbidity.

Case: A patient with progressive headaches, retrobulbar pain and visual field loss, underwent bilateral medial wall orbital decompression in 2015, bilateral lateral wall decompression in 2018, endoscopic transsphenoidal decompression of the right optic nerve in 2021 in 2022 of the right optic nerve and orbital apex. Postoperatively the retrobulbar pain resolved, proptosis was reduced and visual fields recovered.

Conclusion: Surgical re-re-intervention based on clinical presentation and visual fields is helpful in preserving optic nerve function in patients with advanced Van Buchem disease.  


Peter UIJTTEWAAL (Leiden, The Netherlands), M.c. KLEIJWEGT, M.j.t. VERSTEGEN, Stijn VAN DER MEEREN
00:00 - 00:00 #32395 - The ‘real-world’ outcomes of immunosuppression for graves’ orbitopathy in a single centre multi-ethnic cohort.
The ‘real-world’ outcomes of immunosuppression for graves’ orbitopathy in a single centre multi-ethnic cohort.

Background/aims

Success of Graves’ orbitopathy (GO) immunosuppression treatment is highly variable; patients relapse and a debilitating residual disease burden often remains with current therapies. This study describes the outcomes of immunosuppression in a multi-ethnic GO cohort treated in accordance with the pre-2021 European Group on GO (EUGOGO) guidelines with first-line intravenous-methylprednisolone (IVMP). This study aims: (1) To evaluate the effect of first-line and additional immunosuppression on GO outcomes; (2) To assess the effect of immunosuppression on Graves-Orbitopathy-Quality-of-Life (GOQOL); (3) To determine the incidence of GO-relapse and predictive factors of relapse.

Methods

A retrospective study of patients who received IVMP first-line therapy at three MDT clinics between 2011-2021. Data was collected at the first, and most recent, clinic appointment. This included: (1) demographics; (2) endocrine parameters; (3) MDT-clinic data (Clinical Activity Score [CAS], Gorman Diplopia, GOQOL, GO-treatment, relapse). First-clinic appointment data was compared between relapse and non-relapse patients.

Results

146/438 (33%) patients were included; median age 50 (18-59) years. 77.4% were female; 42.8% Afro-Caribbean or Asian ethnicity. Fifty-four patients received IVMP alone; eighty-seven patients had additional immunosuppression with MMF or orbital radiotherapy (ORT). Median CAS was significantly reduced from 3(2.5-4.0) to 0(0.0-1.0) (p<0.0001). Mean Gorman demonstrated an insignificant decrease from 1.2(±1.1) to 0.9(±1.1); only twenty-seven (36.5%) patients achieved a clinically-significant diplopia response. Mean GOQOL visual-function and appearance scores increased by 8.3 and 9.2 (p=0.03) respectively. Thirty-eight (26.0%) patients relapsed. Baseline thyroid-stimulating hormone receptor antibodies (TRAb) levels were significantly higher with GO-relapse (p=0.0039). An antibody titre cut-off of 5.25 iu/L yielded a 73% sensitivity and 67% specificity to detect GO-relapse.

Conclusion

Our study shows that the pre-2021 EUGOGO immunosuppression regimen is effective in reducing orbital inflammation but limited in improving subjective diplopia and appearance, which is likely to hinder QOL improvement. Our study found higher TRAb levels were associated with disease relapse.

 



Ali KHALID (London, United Kingdom), Vickie LEE, Claire FEENEY
00:00 - 00:00 #30781 - Transorbital endoscopic-assisted management of intraorbital lesions: experience of 11 cases.
Transorbital endoscopic-assisted management of intraorbital lesions: experience of 11 cases.

Purpose: To present our experience in the management of selected extraconal orbital roof lesions utilizing the transorbital endoscopic approach.

Methods: A retrospective case series of patients who underwent transorbital endoscopic orbital surgery in a single medical center between 2015 to 2020.

Results: Eleven patients underwent transorbital endoscope assisted surgery for various indications. The mean age at surgery was 31.9 years (range, 6-73 years). Mean follow-up time was 10 months (range, 1-30). The aim of surgery was curative in 10 cases and diagnostic in the remaining one patient. Adequate specimen for tissue diagnosis was obtained from all patients. In all patients the procedure could be completed through small lid crease incision, in three patients a combined approach including functional endoscopic sinus surgery was used for achieving complete excision. None of the patients required conversion to an external wider orbital procedure. Intraoperative complication included cerebrospinal fluid leak in one case, which was addressed immediately; and postoperative complications included one case of pre-septal orbital cellulitis treated by intravenous antibiotics with complete resolution.

Conclusion: Endoscopic-assisted transorbital approach enabled safe removal of selected lesions involving the orbital roof and provided an effective and less invasive alternative to a traditional frontal craniotomy or lateral orbitotomy.


Ran BEN CNAAN (Tel Aviv, Israel), Dana BAREQUET, Igal LEIBOVITCH, Abergel AVRAHAM
00:00 - 00:00 #30974 - Traumatic globe avultion and complete optic nerve transection.
Traumatic globe avultion and complete optic nerve transection.

Traumatic globe avultion and complete optic nerve transection

PURPOSE:

The purpose of this study was to document clinical findings and management of a patient with unilateral globe avultion and complete nerve transection.

MATERIALS AND METHODS:

A 20 year-old male patient was admitted to the emergency department with unilateral traumatic globe avultion following a motor vehicle accident.

RESULTS:

On ophthalmolgy visit, he was conscious (GCS = 14). Severe facial soft tissue injury with Le Fort II maxillofacial fracture was noted.  The left globe was protruding out of the orbit and glob integrity is normal. The left extraocular muscles and optic nerve was cut.Orbital CT showed extensive facial and orbital fractures. The brain CT was normal.The left orbit was explored and the remaining conjunctiva

was repaired. Systemic antibiotics and corticostreoid were given postoperatively. Two weeks later the tarsorraphy was opened.

CONCLUSION:

We present a case of traumatic globe luxation and optic nerve transection. 

Complete protrusion of the eyeball from the orbita condition called globe avulsion or globe luxation is a clinical rarity. In fact, it is so rare that an ophthalmologist may encounter such a situation once in his lifetime. 

The patient was successfully treated using a multidisciplinary approach.

The challenges that the surgeons may encounter in such a case are discussed.

KEYWORDS:

Optic nerve avulsion; Optic nerve transection; Orbital trauma; Traumatic globe luxation


Nalan AYDIN (Antalya, Turkey)
00:00 - 00:00 #32311 - Treatment of bilateral orbital xanthogranuloma – part of Erdheim-Chester disease with BRAF targeted therapy.
Treatment of bilateral orbital xanthogranuloma – part of Erdheim-Chester disease with BRAF targeted therapy.

Background: A 57 year old man initially presented to ophthalmology clinic with a 2 month history of headache, temporal pain and occasional pain on mastication. Initial ocular examination was within normal limits but a raised CRP was noted and therefore was treated as giant cell arteritis with oral prednisolone. There was a partial response to steroid therapy but the patient subsequently worsened with development of a mild relative afferent pupillary defect and choroidal folds of the left macula. Multimodal imaging was performed demonstrating bilateral retro-orbital masses and the patient subsequently underwent orbital biopsies of the lesion which demonstrated bilateral orbital xanthogranulomaous lesions with a BRAF V600E mutation.

His presentation was in keeping with Erdheim-Chester disease after discussion with the National Histiocytosis Advisory Group. Initial treatment with oral steroid and bilateral periorbital steroid injections was followed with methotrexate. Despite maximal therapy, the lesions failed to respond and the lesions enlarged with the patient developing further ocular motility restrictions and choroidal folds in the other eye. Treatment with Dabrafenib was recommended and obtained on a compassionate basis following which the symptoms, signs and radiological features improved.

Discussion: Erdhiem-Chester disease is a rare non-Langerhans histiocytic multisystem disorder. A high prevalence of BRAF V600E mutations have been noted to be associated. Dabrafenib is a BRAF kinase inhibitor, usually used in the treatment of BRAF positive metastatic melanoma. Although the drug has gained the National Institute of Health and Care Excellence (NICE) approval for the treatment of unresectable metastatic melanoma, the use in orbital xanthogranuloma is rare.

Conclusion: We report a rare case of orbital xanthogranuloma associated with Erdheim-Chester disease which has been successfully treated with novel dabrafenib treatment.


Han Xern KHOO (Hull, United Kingdom), Egle ROSTRON, Colin VIZE, Bryan ATIENZA, Jireh ANN-BATAC
00:00 - 00:00 #32218 - Uncommon benign orbital tumors in adults.
Uncommon benign orbital tumors in adults.

Purpose: To describe the clinical features, imaging findings and surgical management of some rare benign orbital tumors in adults.

Methods: We reviewed clinical, imaging and pathological records of adult patients with rare benign orbital tumors. All patients had histologically proven diagnosis.

Results: Six patients (4 women and 2 men) were identified with rare benign orbital tumors including angiolymphoid hyperplasia with eosinophilia, orbital angiomyxoma, solitary fibrous tumor (2 cases), Rosai-Dorfman disease and primary orbital hydatid cyst. Tumors were unilateral in all cases except The Rosai-Dorfman disease. Magnetic resonance imaging was performed in all cases. It suggested cavernous angioma in both cases of angiomyxoma and angiolymphoid hyperplasia with esosinophilia.  All patients underwent surgical resection. The patient with orbital hydatic cyst had surgical excision followed by systemic use of albendazole. No recurrences occurred after a two-year follow up.

Conclusions: Although uncommon, angiolymphoid hyperplasia with eosinophilia, angiomyxoma, solitary fibrous tumor, Rosai-Dorfman disease and hydatid cyst should be considered in adult orbital tumors diagnosis.


Leila KNANI (Sousse, Tunisia), Mohamed GHACHEM, Mehdi OUESLATI, Narjess BEN RAYANA
00:00 - 00:00 #31640 - Upper eyelid crease incision for frontal sinus osteoma with orbital dystopia: An unconventional & aesthetic approach.
Upper eyelid crease incision for frontal sinus osteoma with orbital dystopia: An unconventional & aesthetic approach.

A 19-year-old Asian-Indian male presented with painless inferior displacement of right eye since 4 months. Examination revealed a gross inferior globe dystopia in right eye and a well-defined, non-tender, hard, irregular lesion was palpable in the superior orbit continuous with the superior rim. Visual acuity was 20/20 OU with intact ocular motility and rest of the ocular exam was unremarkable. Computed tomography scan revealed a hyperdense, sclerotic, globular lesion arising from the anterolateral aspect of the right frontal sinus, extending into the orbit and abutting the globe and superior rectus anteriorly suggestive of an osteoma. The inner table of the frontal sinus appeared intact. A surgical plan of approaching the lesion using eyelid crease incision with further dissection in the preseptal plane was contemplated and the same was performed. The entire bony lesion was sculpted and removed with a battery-powered mechanical drill (Stryker CoreTM  Console and a handpiece with 5mm diamond dusted tip). Frontal sinus was then opened up and the mucosal lining stripped off to avoid mucocele formation. Histopathological examination of excised lesion confirmed the diagnosis of osteoid osteoma. In view of known syndromic associations, a thorough systemic evaluation was performed including lower gastrointestinal endoscopy which was essentially normal. The surgical outcome of correction of dystopia with optimal aesthesis from a fine linear scar within the natural eyelid crease was gratifying to the young gentleman.


Oshin BANSAL (Gwalior, India, India)
00:00 - 00:00 #32153 - VRDN-002, a second-generation insulin like growth factor-1 receptor (IGF-1R) inhibitory antibody for Thyroid Eye Disease (TED): preclinical pharmacokinetics and clinical promise.
VRDN-002, a second-generation insulin like growth factor-1 receptor (IGF-1R) inhibitory antibody for Thyroid Eye Disease (TED): preclinical pharmacokinetics and clinical promise.

       Purpose: VRDN-002 is a novel anti-IGF-1R monoclonal antibody intended for treatment of TED. It is engineered to incorporate Fc modifications for half-life extension to enable convenient dosing. We sought to compare the pharmacokinetics of VRDN-002 in cynomolgus monkeys to the marketed IGF-1R antibody, teprotumumab, and to estimate potential human exposures.

       Methods: VRDN-002 was administered to cynomolgus monkeys at various doses by intravenous (IV) infusion and subcutaneous injection. Teprotumumab at 10 mg/kg was administered by IV infusion. Antibody levels were measured using a human IgG ELISA. Data were analyzed with WinNonlin software. A semi-mechanistic model was constructed to estimate human pharmacokinetics.

       Results: VRDN-002 pharmacokinetics by IV infusion was linear between 10 and 50 mg/kg. At 10 mg/kg, VRDN-002 half-life and AUCinf were 14 days and 2,300 µg.day/mL, respectively, vs. 6.4 days and 779 µg.day/mL for teprotumumab. Subcutaneous bioavailability of VRDN-002 was 62%. Human exposure estimates were generated from the semi-mechanistic model.

       Conclusions: VRDN-002 demonstrated a desirable pharmacokinetic profile in non-human primates, suggesting potential as a novel therapeutic monoclonal antibody for the treatment of TED. The prolonged half-life of VRDN-002 may enable lower frequency of IV infusion and/or low-volume subcutaneous injection; a clinical trial is underway to test these hypotheses. 


Vahe BEDIAN, Brent DICKINSON, Christian CLAUSEN, Linda PESTANO, Robert HENDERSON (Boston, USA), Barrett KATZ
00:00 - 00:00 #30505 - When Thyroid Orbitopathy Becomes a Nightmare.
When Thyroid Orbitopathy Becomes a Nightmare.

Thyroid-related eye disease is prevalent. It develops in any patient with a thyroid disease regardless of its status. Thyroid ablation and smoking can initiate and/or worsen thyroid orbitopathy. The following case shows a patient with a long follow-up period.

We reviewed the patient’s medical record, orbital images, and clinical photographs. In addition, articles regarding thyroid orbitopathy due to smoking and irradiation were reviewed for discussion.

A 75 years old single-eyed male patient was referred from a colleague for management of exophthalmos. He complained of itchiness and minimal drop of vision in the right eye,  which he suffers from glaucoma, and he had cataract surgery. Moreover, He lost his left eye in domestic violence. He is a known case of secondary hypothyroidism post-ablation, hypertensive, and COPD related to excessive smoking. Despite controlled thyroid function, the patient underwent multiple orbital and lids surgeries to overcome severe exposure keratopathy. Bevacizumab was given for corneal neovascularisation as subconjunctival injections or eye drops. During his follow-ups, he had good days and bad days. This fluctuance to his relapsing-remitting course was a matter of ours and his concerns. Fortunately, we are in a place where he is stable and satisfied. 

In conclusion, this case is, reasonably, seen in any oculoplastic clinic. Its detection and management are crucial for saving the organ.


Ahmed ALAMER (HIDD, Bahrain), Osama ABABNEH
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00:00 - 00:00 #32139 - 70 year old male with meige syndrome and response to lanbotulinumtoxin a injection: a case report.
70 year old male with meige syndrome and response to lanbotulinumtoxin a injection: a case report.

Introduction

Meige syndrome is a rare neurological disorder which presents as blepharospasm with oromandibular dystonia. Current accepted treatments for Meige Syndrome include GABA receptor agonists, anticholinergics and dopamine antagonists. Botulinum toxin A (BTXA) injection has shown promising results. This case report presents a 70 year old patient with Meige Syndrome treated with GABA receptor agonists and Lanbotulinum Toxin A (LANBTXA) Injection.

Case Illustration

A 70 year old male patient referred from Timor Leste with bilateral tonic clonic blepharospasm and mouth dystonia since 1 year ago, triggered by light and sunlight exposure. Treatment plan from the former hospital included Carbamazepine 3 x 200 mg tapered every 5 days, Vitamin B12 3 x 500 mcg parenterally and two doses of LANBTXA 50 U injection, done in two separate days. Improvement was noted however 3 weeks after initial injection, recurrence occurred with additional cervical dystonia. Subsequently, LANBTXA was injected three more times, each 100 U, focusing on the cervical muscles. Blepharospasm significantly improved as to oromandibular dystonia Hypersalivation was reported as an indirect side effect. 

Discussion

GABA Agonists and BTXA injection to affected muscles were done as both are current accepted treatments. LANBTXA was administered based on the dose conversion ratio 1:1 onabotulinum toxin A (ONABTXA) for Meige syndrome. In line with previous literature, our patient showed better blepharospasm improvement than his oromandibular dystonia. As with our patient, recurrence can still occur after BTXA injection. Our patient experienced recurrence quicker than the average duration (11 weeks).  Hypersalivation reported was an indirect side effect of BTXA due to paralysis and reduction of saliva removal. 

Conclusion

BTXA improves Meige Syndrome symptoms although recurrence may still occur. Further study regarding risk of recurrence should be done in order to minimize the recurrence rate. 


Josiah IRMA, Retno Jayantri KETAREN, Saraswati Anindita RIZKI (Jakarta, Indonesia), Serena ONASIS, Celine CHRYSTELLE, Regan ELBERT, Patricia BUDIMULIA
00:00 - 00:00 #32469 - A haemophilus influenzae subconjunctival abscess in an adult immunocompetent patient in the united kingdom.
A haemophilus influenzae subconjunctival abscess in an adult immunocompetent patient in the united kingdom.

Background:

Sub-conjunctival abscesses following a conjunctivitis are rare in adults, as few bacteria can penetrate the conjunctiva. We present a case of Haemophilus influenza sub-conjunctival abscess in an immunocompetent adult at a tertiary-care eye hospital in the United Kingdom.

 

Case Presentation:

A 47-year-old-woman of African descent presented to the eye emergency department with a 2-day history of unilateral mild left eye (LE) redness treated with over-the-counter Chloramphenicol 0.5% eye drops, which progressed to severe LE redness, discharge and periocular pain within 2 weeks.

She was not a contact lens wearer, had no previous eye surgeries and there was no history of ocular trauma or foreign body injury. Best corrected visual acuity on the right eye (RE) and 6/5 on the LE.

Slit lamp examination revealed a LE superior bulbar sub-conjunctival abscess with active mucopurulent discharge and associated perilesional conjunctival injection, chemosis, episcleritis and scleritis. There was pain on globe palpation and on eye movement.

Outcome:

She was empirically treated with a week's course of Co-Amoxiclav 625mg one tablet 3 times daily and Metronidazole 200mg one tablet 3 times daily, in addition to oc. Chloramphenicol 1% 4 times a day. Oral Ibuprofen and ocular lubricants were also prescribed for pain relief.

Conjunctival discharge swab microbiology revealed heavy Haemophilus influenzae growth sensitive to Chloramphenicol. An intermediate response to Co-Amoxiclav was observed. Blood tests were normal.

At the two-week follow-up, the abscess and conjunctival hyperaemia had notably reduced and at the four-week follow-up had completely resolved.

Conclusions:

This case demonstrates a case of HI subconjunctival abscess in an immunocompetent adult following a presumed bacterial conjunctivitis. To our knowledge, only three similar cases have been published internationally and this would be the fourth described case of HI subconjunctival abscess published in literature and the first one in the United Kingdom.


Hardeep KANDOLA (London, United Kingdom), Maria MAS-CASTELLS, Grace ENI, Christopher LEAK, Swan KANG, Periklis GIANNAKIS
00:00 - 00:00 #32461 - An assessment of general oculoplastic clinic presentations for referral quality, diagnostic agreement, and patient outcomes by referral source in the united kingdom.
An assessment of general oculoplastic clinic presentations for referral quality, diagnostic agreement, and patient outcomes by referral source in the united kingdom.

Background:

A paucity of literature exists exploring oculoplastic referral quality and patient presentations. We sought to review referrals to the oculoplastic department to support and direct the development of better pathways between primary and secondary care.

Methodology:

A sample of 100 new presentation referrals to a variety of oculoplastic clinics was sampled during March 2021. Patient referral documents were screened for diagnosis of referring clinician, referral source and referral date. Referral diagnosis was compared with first assessment diagnosis in oculoplastics. Outcomes and interventions were capture for first and second appointments within the hospital. Patients with incomplete or unavailable referral data were excluded.

Results:

A total of 76 patients were included, 47 were female. Internal ophthalmologist referral was most common (31), followed by 22 from community general practitioners (GP), 12 from optometrists via the patients GP, 7 external ophthalmologist referrals.

Median referral to clinic time was 40 days. Most common first assessment diagnosis were chalazion (12/76), ptosis (9/76) and blepharitis (5/76). Diagnosis concordance with referring clinician was 43/76. One patient did not attend first assessment and the remaining patients either had not been provided a diagnosis at referral or an incorrect diagnosis. GPs were concordant for 36% (8/22), internal ophthalmologists 66.6% (20/30), external ophthalmologists 85.7% (6/7) and optometrists 50.0% (6/12). Many patients (48/76) were followed up after first appointment with a second appointment. The remaining were discharged (26/76) after first assessment with a further two lost to follow-up. 8/12 patients referred by GP were discharged on first appointment, 11/30 internal ophthalmologist referrals, 5/12 optometrist and no external ophthalmologists.

Conclusions:

Referrals from ophthalmologists displayed high diagnostic accuracy and concordance with oculoplastic specialist first diagnosis. Enhanced referral criteria may be required for community practitioners such as GPs and optometrists since many patients are discharged after first assessment and some without any interventional outcome. 


Hardeep KANDOLA (London, United Kingdom), Anum BUTT, Swan KANG, Periklis GIANNAKIS
00:00 - 00:00 #32234 - Case report of a rare entity: syringoid eccrine carcinoma in the temple region.
Case report of a rare entity: syringoid eccrine carcinoma in the temple region.

Background

The syringoid eccrine carcinomas (SEC) are infiltrative, locally destructive, slowly growing tumors, derived from eccrine sweat glands. They rarely metastasize, but have high recurrence rates after conventional surgical excision. SEC usually involve the  centrofacial  region (approximately 85%), and under 300 cases have been reported overall in the literature, representing a diagnostic challenge, both clinically and histopathologically. 

Methods

We present a case report of a 77 year old Caucasian male, with a previous history of basal cell carcinoma of the right lower eyelid and the nose, who developed a lesion on the right temple, slowly growing over 8 months. At the time of the diagnosis, it measured 10 millimeter (mm) in diameter, was slightly raised and had a hyperkeratotic appearance. Regional lymph nodes were unremarkable on palpation.

Results

An excision/biopsy was carried out with 3 mm safety margins. Histology confirmed the diagnosis (SEC), however, describing a narrow deep margin (< 1 mm). A second excision/biopsy has been performed, with enlargement of previous margins, confirming clearance and staging (T1N0M0), with no further immunohistochemical investigations being requested. 

Discussion

Despite complete clearance, given the unusual location and the high risk of recurrence reported in the literature, the case has been discussed in a multidisciplinary team meeting. The management plan included 6 months follow-ups for 3 years. 

Conclusion

SEC are rare and locally invasive. The best  management is to obtain a complete excision with  clear  surgical margins, confirmed by microscopy. However, given the high risk of recurrence, close monitoring is indicated, even if no further systemic treatment is indicated.  


Sara NUNEZ-MARQUEZ (Bournemouth, United Kingdom), Madalina-Adriana CHIHAIA
00:00 - 00:00 #32537 - Comparison of the pre and post COVID-Lockdown histopathological specimens from a tertiary-referral oculoplastic service in Singapore.
Comparison of the pre and post COVID-Lockdown histopathological specimens from a tertiary-referral oculoplastic service in Singapore.

Background

The global pandemic of COVID-19 viral infection has resulted in the implementation of various social distancing measures, which arguably has been one of the largest social behavior changes in human history.  In Singapore, a strict social distancing measure that only allows its residents to leave the house for essential activities known as the “circuit-breaker” (CB) was implemented on the 7th of April 2020. During the CB, the Singaporean health system was closed except for emergency outpatient and surgeries. To understand how social-distancing measures affect oculoplastic service, we aim to look at histopathological data before and after the CB.

Method

Retrospective data review was conducted on the histopathological samples submitted by the oculoplastic department at the Singapore National Eye Centre (SNEC) between January 1st 2018 and 31st December 2021. Using the city’s COVID-19 pandemic lockdown date (7th April 2020) as a timeline divider, “pre-COVID” and “post-COVID” periods were analysed. The primary study outcome was malignant status of patient’s surgical specimen.

Results

The total histopathological sample numbers per day is less for before than after the COVID-19 lockdown. Pre-COVID (827 days) period had 0.78 samples per day, Post-COVID (634 days) period had 0.64 samples per day. Using multivariate logistic regression, samples during the post-COVID period are more likely to be malignant (OR=1.92, p=0.001) compared with samples received before the date, where sex, race and referral sources are adjusted. There is also a small risk of malignant samples in older patient. (OR=1.04, p<0.001). Using multinomial regression, none of the co-variates (age, gender, race or Pre/Post COVID status) appear to affect any of the tumour types. Linear regression did not show correlation of pre or post COVID status with tumour Maximal diameter. (R=0.172, p=0.276)

Conclusion

Ophthalmology service needs to adjust to the impact of social policies during a pandemic. Increased proportions of malignancy presentations is demonstrated by histopathological data analysis. Customized triage and follow up on tertiary referrals should be adopted by ophthalmology institutions.


Ming-Han (Hugo) LEE (Singapore), Shen Yu SUNNY, Anita CHAN
00:00 - 00:00 #32500 - Corneal neurotization utilizing the infraorbital nerve approach.
Corneal neurotization utilizing the infraorbital nerve approach.

Introduction:  Over the last 10 years, corneal neurotization has become a more popular method of reinnervating an insensate cornea. There are many techniques used for this purpose, including direct and indirect coaptation, ipsilateral or contralateral donor supply nerve, which could be either supratrochlear, supraorbital or infraorbital nerve and lastly the use of autologous vs alloplastic graft material. It appears that the use of infraorbital nerve for a donor supply is the least chosen approach.

Methods:  In our case, we present our technique of infraorbital nerve utilization for a patient with an insensate cornea after HZV keratitis with recurrent neurotropic ulcer.  The case involved an ipsilateral coaptation with a sural donor nerve and a side-to-end anastomosis.  The infraorbital nerve was approached through an inferior anterior orbitotomy. We will include a video of our technique to complement the presentation.

Results:  After one year post surgery, the denervated cornea has regained most sensation in all four quadrants as measured by an esthesiometer. The orbital would has healed without any consequences.

Conclusion:  The infraorbital nerve via an inferior orbitotomy is a valid alternative technique to the more common use of the supratrochlear and supraorbital nerves.


Vladimir KRATKY (Prague, Czech Republic), Davin JOHNSON, Michael HENDRY
00:00 - 00:00 #32242 - Hyperspectral imaging for non-invasive mapping of oxygen saturation in a forehead flap during reconstructive surgery.
Hyperspectral imaging for non-invasive mapping of oxygen saturation in a forehead flap during reconstructive surgery.

Objective: Understanding the vascular supply and the effect on oxygen saturation is crucial for successful design of flaps in reconstructive surgery. The aim of this study was to assess the effects on oxygen saturation in cutaneous forehead flaps in patients and to use a novel technique to monitor oxygen saturation never used in the periocular region before.    

Methods: Oxygen saturation was monitored using hyperspectral imaging during surgery in six patients undergoing direct brow lift. In order to mimic a cutaneous flap, the skin remained intact medially. Hyperspectral imaging is a non-invasive technique using a white light source (600–1700 nm). Since the absorbance properties of oxygenated and deoxygenated hemoglobin differ, it enables monitoring of oxygen saturation with high resolution after spectral unmixing. 

Results: A gradual decrease in oxygen saturation along the flap length was observed with a minimal value of 84% recorded at an average of 25 mm from the flap base. An increase in oxygen saturation along the excision was also observed, indicating a direct uptake of oxygen from the atmosphere. 

Discussion/Conclusion: Hyperspectral imaging in combination with spectral unmixing applied on a pixel-by-pixel basis provides a useful means of monitoring the oxygen saturation of periocular flaps during surgery. The results open up for investigating oxygen saturation in other flaps where necrosis is a frequent problem. The technique might also be combined with other techniques for perfusion monitoring such as laser speckle contrast imaging. The simultaneous use of hyperspectral imaging and laser speckle contrast imaging might be an advantage, since it allows direct comparison of oxygenation and perfusion in the same patient. 


Johanna V. BERGGREN (Lund, Sweden), Karl ENGELSBERG, Aboma MERDASA, Malin MALMSJÖ
00:00 - 00:00 #32460 - Leprosy mimicking delayed facial cosmetic filler reaction.
Leprosy mimicking delayed facial cosmetic filler reaction.

A 70-year female with a history of rheumatoid arthritis and presumed collagen vascular disease presented to a our oculoplastic service with a 6-week history of non-tender, firm, subcutaneous induration with associated madarosis and edema along her brows and nasolabial folds. 

Multiple biopsies revealed Xanthogranulomatous reaction of the subcutis and deep dermis with diffuse epithelioid histiocytes, scattered foamy histiocytes and rare multinucleated giant cells. Mycobacteria stains were negative and no lymphoproliferative disorder or foreign body material was noted. The working diagnoses includedxanthoma disseminatum, drug reaction, adult orbital xanthogranulomatous disease and necrobiotic xanthogranuloma.  

The patient then reported a history of dermal fillers performed 10 years ago in Oaxaca Mexico where she had spent winter months for the last 20 years, near small villages with endemic leprosy. A new working diagnosis of lepromatous multibacillary leprosy with early leonine facies was proposed by the infectious disease service. 

She developed bilateral lower limb erythema nodosum leprosum from treatment with Rifampin, Dapasone and Minocycline. Her facial deformity persisted and repeat biopsies showed lymphocytic inflammation with multinucleated giant cells in the dermis suggestive of an infectious etiology.

Infectious workups including HIV, Strongyloides stercoralis, Lyme and Tuberculosis were all negative.  Tissue biopsy for PCR was negative for Mycobacterium leprae.  After 4 months of the treatment regime, she had resolution of her facial lesions supporting a diagnosis of presumed paucibacillary lepromatous disease. 

This this is the first reported case of presumed leprosy following dermal filler injections. This patient presented with paucibacillary leprosy mimicking a delayed dermal filler complication.  Infection due to Mycobacterium lepra is a serious condition rarely encountered. The bacterium’s incubation period ranges from 9 months to 20 years. Diagnosis can be challenging with only 36% of tissue biopsies yielding detectable PCR amplification. Thus a thorough history, clinical assessment, and response to empiric treatment play an important role in its diagnosis. Despite decreasing global prevalence, with increasing immigration and global travel, unusual diseases such as leprosy should be considered on the differential of facial and periocular granulomatous inflammation.


Gabriela LAHAIE LUNA (Philadelphia, USA), Saerom YOUN, James FARMER, Vladimir KRATKY
00:00 - 00:00 #32432 - Long-term Changes of Thyroid-stimulating Antibody in Active, Moderate-to-severe Graves’ Orbitopathy after Intravenous Methylprednisolone Treatment.
Long-term Changes of Thyroid-stimulating Antibody in Active, Moderate-to-severe Graves’ Orbitopathy after Intravenous Methylprednisolone Treatment.

Aims: To evaluate the long-term changes of thyroid-stimulating antibody (TSAb) in active, moderate-to-severe graves’ orbitopathy (GO) after intravenous methylprednisolone (IVMP) treatment.  In addition, we investigated the factors associated with TSAb normalization.

Methods: The participants were newly diagnosed active, moderate-to-severe, GO patients who received intravenous methylprednisolone treatment for 12 weeks. We monitored TSAb at the time of the initial diagnosis, after treatment, and then every six months. At the time of initial diagnosis, ocular examination and laboratory tests were evaluated. Normalization of TSAb was defined as TS(survival of TSAb) if the level was below 140%. After IVMP administration, the treatment response was evaluated, and long-term changes were tracked for over 24 months.

Results: Thirty-six (43.4%) of 83 patients who were available for long-term analysis had their TSAb normalized after 2 years of IVMP treatment. Lower TSAb than 425%, no additional radiotherapy, and earlier treatment of GO allowed for higher TS (P = 0.035, P = 0.028, P < 0.001, respectively). Higher triglyceride (TG) level was associated with higher TS (P = 0.011). Initial TRAb and TSAb cutoff values for predicting TS in 24 months were 5.49 IU/L and 413%, respectively (P < 0.001 and P = 0.002, respectively).

Conclusion: Less than half of active, moderate-to-severe GO patients have normalized TSAb within 24 months of receiving IVMP treatment. Considering TSAb has a major role in GO, early diagnosis and treatment initiation are needed, especially in patients whose TSAb level is greater than approximately 413 percent at the time of initial diagnosis.


Park JUNGYUL (Busan, Korea), Choi HEE-YOUNG
00:00 - 00:00 #32542 - Mutational analysis of the pabpn1 gene in oculopharyngeal muscular dystrophy.
Mutational analysis of the pabpn1 gene in oculopharyngeal muscular dystrophy.

Purpose: To perform a molecular analysis of the PABPN1 gene in patients with oculopharyngeal muscular dystrophy of Mexican origin.

Design: Prospective, analytical and cross-sectional study was done in order to report the clinical and molecular characteristics in patients with a clinical diagnosis of oculopharyngeal muscular dystrophy, and to determine by nucleotide sequencing analysis mutations in the PABPN1 gene. Data concerning familial history of the disease, associated diseases, age of onset of major symptoms, presence of associated symptoms, past history of surgical eyelid procedures were collected for each subject. Genomic DNA was isolated from blood sample; PAPBPN1 gene was PCR-amplified using oligonucleotides and appropriate conditions; PCR products were analyzed by electrophoresis in agarose gel 1.5%, direct sequencing was achieved using the BigDye Terminator Cycle Sequencing kit and samples were analyzed in a 3130 Genetic Analyzer.  

Results: Clinical and genetic information was obtained from 17 subjects (patients and relatives). All subjects were of Mexican origin. Thirteen of the 17 patients (76%) had affected siblings and/or parents. The earliest symptom was ptosis and in four patients dysphagia was the first symptom followed by ptosis. By the time of the study twelve patients had undergone palpebral surgery and four of them with surgical re-operation with frontal muscle suspension. 

The most frequent mutation in our cohort was (GCN) 15 in five patients followed by (GCN) 13 in three patients. We did not find any mutation in asymptomatic relatives. 

Conclusions: There are different mutations for the PABPN1 gene in patients of Mexican origin. The most frequent mutation in our cohort was (GNC) 15 wich corresponds to another report of Mexican patients but differs from international literature.  


Cristina PLATA PALAZUELOS (Mexico City, Mexico), Humberto LÓPEZ GARCÍA, Mirena ASTIAZARÁN OSORNIO, Héctor PÉREZ CANO
00:00 - 00:00 #32323 - Patient-reported outcomes following a break in ophthalmic botulinum toxin therapy during the COVID-19 pandemic.
Patient-reported outcomes following a break in ophthalmic botulinum toxin therapy during the COVID-19 pandemic.

Background: Study to evaluate the impact of a break in botulinum toxin treatment, necessitated by the COVID-19 pandemic, on patients’ quality of life.

Methods: Prospective cohort study of all patients undergoing incobotulinumtoxinA treatment in our department - for benign essential blepharospasm (BEB), hemifacial spasm (HFS), aberrant facial regeneration (AFR) or crocodile tears - who were affected by the break in service (18/3/2020-17/6/2020). All patients who received treatment both before and after the break in service were included. Data gathered included subjective patient-reported measure of “time-till-treatment-failure”, and disease rating scale scores: Blepharospasm-Dystonia Functional Disability Assessment Scale (BDFDAS) (for BEB/HFS/AFR); Jankovic Rating Scale (JRS) (for BEB/HFS); TEARS Epiphora Grading Scale (for crocodile tears).

Results: Across 72 patients there was mean treatment delay of 3.9 (0-9.8) months. After a period of effect, treatment failed in all patients, with mean “time-to-treatment-failure” of 3.9 (0.5-12.0) months. All patient-reported outcome measurements increased, with greatest effect seen in AFR (178% increase in BDFDAS) and BEB (41% increase in JRS). At least two patients sought and underwent re-treatment elsewhere in the private sector due to their symptom severity.

Conclusions: Patients with AFR and BEB are likely to tolerate a break in service least, while patients with crocodile tears appear to be less affected. This “real-world” snapshot allows quantification of the harm caused by a break in botulinum toxin service or treatment delay. This study provides valuable information should further breaks in service or treatment delay be considered in future, due to a further wave of COVID-19 or other reasons.


Aaron JAMISON (Glasgow, United Kingdom), Maribel FAVOR, Raman MALHOTRA
00:00 - 00:00 #31936 - Self Sealing Scleral laceration manifesting as sympathetic ophthalmia.
Self Sealing Scleral laceration manifesting as sympathetic ophthalmia.

We describe a case of a patient presenting late  due to the COVID pandemic  following facial trauma.Sympathetic .Ophthalmia was noted in the contralateral eye and exploration under anaesthesia revealed a self sealing laceration and extensive ocular damage requiring enucleation.


Segun AWOTESU (Leicester, United Kingdom), Raghavan SAMPATH
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00:00 - 00:00 #32194 - Bone-like calcified orbital cavity following exenteration: a case report.
Bone-like calcified orbital cavity following exenteration: a case report.

Two cases of bone-like calcification in exenterated orbits are described. The first is a 77-year-old Asian female reporting a sensation of fluid in her left orbit several months after undergoing left orbit exenteration for recurrent sebaceous cell carcinoma. Magnetic resonance imaging (MRI) demonstrated a cyst-like cavity within the orbit with bright on T2 signal consistent with fluid. During surgical exploration a calcified, bone-like cavity was encountered. Histopathology revealed dense fibrous connective tissue with areas of calcification without osseous metaplasia suggestive of retained blood in the orbit that underwent dystrophic calcification (Figure 1). The second is a 58-year-old Caucasian female with sebaceous carcinoma of the left orbit. Exenteration was performed without reconstruction. At the first post-operative scan 3 months post-operatively, evidence of bony thickening was seen, primarily consisting of an apparent increase in trabecular bone (Figure 2). The latest scan at 36 months shows this continued. This case report illustrates a rare occurrence of a bone-like, calcified orbital cavity mimicking osseous metaplasia following exenteration. 


Naomi HASEGAWA, Jiawei ZHAO, Daniel GRENINGER, Jonathan E LU (Boston, USA), Michael YOON, Timothy MCCULLEY
00:00 - 00:00 #32176 - Determining asymmetry thresholds in microphthalmia using a 3d animated model.
Determining asymmetry thresholds in microphthalmia using a 3d animated model.

Purpose

Congenital microphthalmia and anophthalmia are rare development disorders with underdevelopment of the orbital region, resulting in asymmetry of the face. No clear guidelines exist to determine when these deviations are acceptable.

Methods

A face of a healthy 6-year-old child was three-dimensionally scanned. On this scan we modeled various incremental degrees of facial asymmetries using 3D modeling software. We modeled for smaller palpebral fissures, sunken eyes and downward displacement of the eye. We also looked if adjusting the vertical palpebral fissure height in ratio to the horizontal palpebral fissure wide  influenced perception. A total of 22 videos were created in which the model turned the head horizontal and vertical. We made a questionnaire where raters were asked how acceptable the face is, on a linear scale from 0 to 10.

Results

Results showed a correlation between the degree of asymmetry and the acceptability score of the raters. An enophthalmos of 6 mm or more, palpebral fissures length <80% compared to the other eye and more than 2mm downward displacement of the eye resulted in a significant different acceptability score. Desire for correction was strongly increased when these thresholds were crossed. Adjusting vertical palpebral fissure height to the horizontal palpebral fissure wide resulted in a worse score of acceptability.

Conclusion

A unilateral sunken eye (enophthalmos) of 6 mm or more, asymmetric horizontal palpebral fissure length of <80% and a lower position of one eye of more than 2 mm resulted in an unacceptable judgment. These data can be used to evaluate treatment outcome in children treated for congenital microphthalmia and anophthalmia.


Emiel ROMEIN (Amsterdam, The Netherlands)
00:00 - 00:00 #32160 - Enucleation in Iceland 2005-2018. Study in defined population.
Enucleation in Iceland 2005-2018. Study in defined population.

Purpose: To determine incidence rate for enucleation and causative diagnosis in Iceland in a defined population during the years 2005-2018.

Methods: A retrospective  population-based incidence study in Iceland. Medical records were reviewed of patients who were enucleated from January 2005 through December 2018. Annually updated Icelandic census was used as a denominator data.

Results: Fifty-five eyes were enucleated during 2005-2018. No eviscerations were performed and the eight exenterations were not included in the study. The mean annual age adjusted incidence rate was 1.23 enucleations per 100.000 population in comparison with 1.48 for the time period 1992-2004 (Geirsdottir et al. 2014) and 2.66 for the time period 1964-1991 (Sigurdsson et al. 1998). Compared to previous studies, a significant increasing linear regression was with advancing age (p=0.0002). The median age of enucleation was 66 years (mean 64±19 years; age span of 3-96 years). The most common indications for enucleation were ocular malignancy (54%), blind painful eye (42%) and acute trauma (4%). Choroidal melanoma was the most common ocular malignancy (80%).  The incidence of ocular malignant melanoma per 100.000 population was 1.26 and 25% of the patients died from the disease.

Conclusion: The mean annual incidence of enucleation in Iceland is decreasing compared to previous studies.  The median age has increased and the incidence for ocular malignancy has increased. Encucleation because of traumatic lesion has decreased.

References

Sigurdsson H, Thórisdóttir S & Björnsson J (1998): Enucleation and evisceration in Iceland 1964-1992. Study in a defined population. Acta Ophthalmol Scand 76: 103-107.

Geirsdottir A, Agnarsson BA, Helgadottir G, Sigurdsson H (2014): Enucleation in Iceland 1992-2004: study in a defined population. Acta Ophthalmol Scand 92: 121-125


Birna Sigurborg GUDMUNDSDOTTIR (Reykjavik, Iceland), Rannveig L. THORISDOTTIR, Olof Birna OLAFSDOTTIR, Bjarni A. AGNARSSON, Gudleif HELGADOTTIR, Haraldur SIGURDSSON
00:00 - 00:00 #30667 - Health Literacy in Patients Wearing Prosthetic Eyes: A Prospective Cross-Sectional Study.
Health Literacy in Patients Wearing Prosthetic Eyes: A Prospective Cross-Sectional Study.

Objectives: To investigate general and electronic health literacy (HL) levels in prosthetic eye wearing patients, to define factors associated with reduced HL, and to identify a potential healthcare gap.

Methods: In this prospective cross-sectional study 148 prosthetic eye wearers were screened using the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16) and the 8-item electronic Health Literacy Scale (eHEALS). HLS-EU-16 and eHEALS scores were correlated to health levels, vision functioning, and sociodemographic factors.

Results: 85 patients (57%) had adequate, 38 (26%) problematic, and 9 (6%) inadequate general HL, while 16 (11%) had no valid HLS-EU-Q16 score. General HL was positively correlated with physical health (p=0.009) and negatively with a migration background (p=0.023). There was a positive correlation between electronic HL and educational level (p<0.001), social status (p=0.048), and mental health (p=0.013). Higher age was associated with lower electronic HL (p<0.001).

Conclusions: More than 30% of the prosthetic eye wearers had problematic or even inadequate general HL, suggesting a significant health care gap. To identify patients with reduced HL, a standardized screening tool should be implemented as part of routine clinical care. Within integrated care, patients with insufficient HL should be offered barrier-free advisory services and information brochures in various languages.


Alexander C. ROKOHL (Cologne, Germany), Nicola S. PINE, Werner ADLER, Lisa A.k. BARTENSCHLAGER, Philomena A. WAWER MATOS, Marc TRESTER, Keith R. PINE, Timo-Kolja PFÖRTNER, Ludwig M. HEINDL
00:00 - 00:00 #30875 - localizing the lost rectus muscle using the connective tissue framework.
localizing the lost rectus muscle using the connective tissue framework.

Abstract: We describe and illustrate a simple and effective method to localize a lost rectus muscle based on knowledge of the orbital connective tissue framework. Adequate magnification with loupes and headlighting is required. The lost rectus muscle is identified and reattached to the globe by gently applying traction anteriorly at the conjunctiva/Tenon edge using double pronged skin hooks then following the path of the rectus muscle through its Tenon capsule tunnel where it remained attached by suspensory ligaments. Its imperative to avoid blind dissection into the orbital fat. There was no instance where orbital fat was obscuring or blocking the view of the lost rectus muscles with this technique. There were no other complications associated with the procedure


David JORDAN (Ottawa, Canada)
00:00 - 00:00 #32226 - Peri-ocular Autologous Fat Transfer Survival Outcomes Using Vectra 3D Imaging.
Peri-ocular Autologous Fat Transfer Survival Outcomes Using Vectra 3D Imaging.

Purpose:

To evaluate volume change and monitor the fat survival after autologous fat transfer (AFT) for volume augmentation in the peri-ocular and orbital area using sequential 3D imaging with the Vectra imaging system.

Methods:

A prospective cohort study of 13 consecutive patients who underwent AFT at a single institution with pre and post operative sequential imaging with the 3D Vectra imaging system. Facial Landmarks Tool and Surface Area Paint Tool allowed comparative volume analysis of images.

Results:

13 patients, 9 female vs 4 male, mean age at time of surgery 47.8. 9 Caucasian, 1 South Asian, 1 mixed ethnicity and 2 ethnicity not declared.

Aetiology of volume deficiency: PESS following trauma 6 patients (46.2%). Encucleation due to malignancy (30.7%) of which 3 had orbital (23.1% of total cohort). 2 patients enucleation due to orbital venous malformation, 1 orbital decompression due to Graves Orbitopathy. Follow up for patients ranged from 2 to 30 months.

Mean volume injected 2.73ml (1.0-5.5ml). Mean difference volume injected and immediate post-op -0.15ml (-1.48 to 1.2ml). At month 1 post op mean fat survival volume was 70%, however this had reduced to 55% by month 6.

Initially no statistically significant difference in residual injected volume with an unpaired t-test p value = 0.813 for donor site (abdomen vs thigh). At immediate post-operative follow up period difference in volume loss approached significance (unpaired t-test value of 0.096). Mean residual injected volume thigh donor 45.1 % vs 80.4% for abdominal donor site, suggesting abdominal fat may result in a longer duration of fat survival.

No difference in residual injected volume at any time point between patients who had a history of PESS following trauma vs history of orbital radiation, unpaired t-test p value of 0.639.

Conclusions:

Radiation did not appear to be risk factor for increased volume loss; suggesting AFT may be a good method of restoring volume in this cohort of patients. Abdominal fat transfer may result in longer fat survival.

3D VECTRA imaging allows quantifiable analysis of volume enhancement and long-term fat survival. By enabling quantifiable results from AFT the 3D Vectra system may also allow improved standardisation and refinement of surgical techniques.


Gabriella GUEVARA, Gabriella GUEVARA (London, United Kingdom), Fabiola MURTA, Jonathan HYER, Daniel EZRA
00:00 - 00:00 #31868 - Surgical management of orbital implant exposures after evisceration or enucleation: Retrospective study - Limoges University Hospital.
Surgical management of orbital implant exposures after evisceration or enucleation: Retrospective study - Limoges University Hospital.

Introduction: Implant exposure is the most frequent complication after evisceration or enucleation and multiple surgical techniques have been described. The aim of our study is to investigate the rate of success and the risk factors of failure of different surgical procedures. 

Methods: This is a retrospective study performed at the University Hospital of Limoges. We collected date from the files of every patient operated on for implant exposure between January 2005 and December 2020. The main criteria was the percentage of success whatever the procedure. Secondary objectives were to look for risk factors of failure in Müller's muscle flaps, and to study the incidence of post enucleation socket syndrome depending on orbital implant preservation. 

Results: 51 patients were included: 26 patients operated from Müller's muscle flap, 16 from dermis-fat graft, 3 from conjunctival flap, 2 from amniotic membrane graft, 1 from temporalis fascia graft, 1 from buccal mucosa graft, 1 from implant rotation, 1 from implant exchange. The dermis-fat grafts were more successful (87.5%) than the Müller's muscle flaps (52.2%) (p = 0.0213). The study highlighted the interest of a good vascularization of the implant (OR = 32.00, p-value = 0.0245) for the success of Müller’s muscle flap and we found no statistically significant difference between patient who kept their implant and patients who did not (p = 0,3865) on the incidence of post enucleation socket syndrome

Conclusion: Müller's muscle flap may remain a good indication in the management of medium-sized implant exposures on a well-vascularized implants confirmed on MRI, in patients with no systemic healing disorders. Dermis-fat graft remains the option of choice in the other cases, especially in large exposures or complicated orbits


Théa BREUIL (LIMOGES)
00:00 - 00:00 #30873 - The sleral cap technique for porous and non-porous orbital implants.
The sleral cap technique for porous and non-porous orbital implants.

Abstract: The author describes the results and potential benefit of a banked homologous donor scleral cap (1.5mm x 1.5mm ) over the anterior surface of polyglactin mesh wrapped porous and non-porous orbital implants during enucleation and secondary orbital implant surgery. This is a single center, retrospective, consecutive case series of 100 patients receiving a scleral capped, polyglactin mesh wrapped bioceramic or polymethylmethacrylate orbital implant (sphere or mounded) following enucleation or secondary implant surgery by one surgeon over a 10-year period.  A minimum of 1 year follow-up was required to be included in the study. Seventeen patients were either lost to follow-up or did not have at least a 1-year follow-up, leaving 83 patients (44 enucleations, 39 secondary implants) that were followed for 12- 120 months (average 60.7 months). There were no cases of implant exposure identified in either group of patients during this time period. This study suggests that a homologous donor scleral cap over the anterior orbital implant surface may help prevent implant exposure with porous or non-porous orbital implants. Patients with orbital implants should be followed on a long-term basis as exposure can occur at anytime post-surgery, even several years later.


David JORDAN (Ottawa, Canada)
00:00 - 00:00 #31990 - Uveal melanoma invasion into dermis fat graft.
Uveal melanoma invasion into dermis fat graft.

A 45-year-old female after enucleation of her left eye for choroidal melanoma (staging: pT3, no extrascleral invasion) presented progression despite primary radiotherapy without any signs of metastasis. A meshed silicone orbital implant was inserted primarily during the surgery.

Unfortunately, the orbital silicone implant was completely extruded 3 weeks after the surgery. Dermis fat graft surgery was performed. After initially normal healing, extremely fast growth and bleeding from the dermis fat graft occurred. Biopsy confirmed S100 positive, Melan-A immunopositive, HMB45 positive melanoma cells in the dermis fat graft. Exenteration of the left orbit was performed. Subsequently, metastasis occurred in the liver and brain.

There are no similar case reports, especially revealing a recurrent uveal melanoma invasion into a dermis fat graft after enucleation,  in the available literature so far. All clinicians should take this into account.


Adam KOPECKY (Ostrava / Olomouc, Czech Republic), Jan NEMCANSKY, Ludwig M HEINDL, Alexander C. ROKOHL
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VIDEOS

00:00 - 00:00 #32543 - 10 Top Tips to improve your technique in posterior ptosis surgery.
10 Top Tips to improve your technique in posterior ptosis surgery.

Objective: To teach key steps of the posterior approach ptosis surgery.

Methods: The surgery was recorded with 4k video. Sequential steps analyzed to determine potential omissions and errors that may lead to complications or poor outcome. Frequently used and novel variations of the technique were demonstrated and recommendations then formulated using simple concepts that could easily be learned by both young and experienced surgeons. The video was then edited to covey this findings in an educational format.

Results: 9 steps during surgery and the suture retrieval were considered key points to achieve successful results.  A conceptual image concept was developed  for each surgical tip and explained in detail during the video: Anesthesia injection, grasp with micro-hooks, clamp holding, suture passing, endpoints and glide checking; hemostatic knotting, cutting under the clamp and finally taking the sutures out one week later.

Discussion/Conclusion: The correct sequential performance of key steps during a surgical procedure will help the surgeon develop new skills. When reviewing surgical videos emphasizing on details, variations and unexpected situations in a systematic approach may lead to reveal valuable tips that can help flatten the learning curve of new surgeons in challenging surgical techniques like posterior ptosis surgery. 


Jocelyne KOHN (Santiago., Chile), Geraldine KOHN, Maria Jose MARIA JOSE HERNANDEZ
00:00 - 00:00 #32404 - A ' Four Flap' Six Layered Closure Technique Following Evisceration.
A ' Four Flap' Six Layered Closure Technique Following Evisceration.

Purpose: 

  

To determine the rate of implant exposure following evisceration using a four flap, six layered closure technique with vertical conjunctival closure. 

 

 

Methods   

  

Retrospective consecutive case-note review of all patients who underwent an evisceration by the supervising author over a 10-year period from August 2001 at the Leicester Royal Infirmary.  

 

Results   

 

Fifty-two patients were included of whom 65% were male. Mean age was 57 years (range 31-95 years). Trauma was the commonest cause for eye removal. Orbital implant size ranged from 16mm to 22mm (median 20 mm, n= 32). Mean follow up was 14 months (median 8 months). Two patients (3.8%) had conjunctival dehiscence within 3 months, all of whom resolved with conservative management. There were no cases of socket infection or implant exposure and no revision surgery required

 

Conclusion   

The technique described better maintains the depth of the inferior fornix which is essential for retaining a prosthesis, improved mobility and cosmesis. With extensive fibrosis within the socket, reconstruction can be extremely challenging. Multiple interventions may be required to restore adequate fornix depth and enable prosthetic wear. There has been a big shift towards evisceration, with enucleations being performed in infrequent cases of intraocular malignancy or significant trauma. 

 

 


Awad MARY (Leicester, United Kingdom), Segun AWOTESU, Antonella BERRY-BRINCAT, Raghavan SAMPATH
00:00 - 00:00 #32420 - Bloodless Blepharoplasty: The Use of Tranexamic Acid.
Bloodless Blepharoplasty: The Use of Tranexamic Acid.

Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize a safe indication, routes of administration, and highlight the clinical outcomes of TXA use in blepharoplasty. Given that eyelid surgeries may involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in trauma surgeries. In our service, we used TXA intravenously and locally in 1612 blepharoplasties from 2019 to 2022. Four vials of 250mg/5ml were administered intravenously starting 30 minutes before surgery by the anesthesiologist. In addition, during the preparation of the anesthetic solution, 1 vial of 250mg/5ml is added to the Klein solution. It is observed that blepharoplasty can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding and less edema. While most agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in oculoplastic surgery and therefore making the blepharoplasty postoperative journey more compatible with surgery for cosmetic purposes.




André Luis BORBA DA SILVA (SAO PAULO, Portugal), Mohamed KABAWA
00:00 - 00:00 CRANS" : CPAP-associated Retrograde Air escape via the Nasolacrimal System , a very recently described and rare phenomenon. Michelle TEO (Ophthalmology Trainee) (Poster Presenter, LONDON, United Kingdom)
00:00 - 00:00 #32398 - Four tips to improve the resulto f your blephatoplasty.
Four tips to improve the resulto f your blephatoplasty.

In this video I present four tips to improve the result of blepharoplasty.

1 - Upper fat transposition to A frame deformity;

2- Brassiere suture to increase the exposure of the tarsal platform;

3- Transcantal canthopexy to avoid complications such as eyelid retraction;

4- Inferior preseptal orbiculectomy to improve orbicularis muscle hypertrophy.

 

 


Nathalia KASSIS (Catanduva, Brazil)
00:00 - 00:00 #32359 - Full-thickness upper lid reconstruction: an alternative technique avoiding lid closure following Mohs micrographic surgery without tarsal replacement.
Full-thickness upper lid reconstruction: an alternative technique avoiding lid closure following Mohs micrographic surgery without tarsal replacement.

Purpose

Total upper eyelid reconstruction is challenging. Traditionally, Mustarde’s dictum of a three-layered approach has been followed: outer layer of skin; inner layer of mucosa; and a semi-rigid skeleton interposed between. This semi-rigid interface can be tarsus, hard palate or cartilaginous tissue. Repair often requires two stages and temporary obstruction of the visual axis as in a ‘switch’, ‘Cutler-Beard’, or ‘reverse’ ‘Hughes’ flap. We describe a case of total upper lid reconstruction by an ipsilateral sub-brow flap, pre-auricular skin graft and buccal mucosal membrane graft without the use of tarsal replacement.

Methods

A 70-year-old lady had a 3 x 1cm upper lid defect from a fully excised squamous cell carcinoma. An over-sized buccal mucosal graft was taken to allow for post-operative shrinkage. It was sutured epithelial side down to the posterior defect edge, replacing tarsus and conjunctiva. A sub-brow, bipedicle, bucket-handle flap was raised in a sub-orbicularis plane and transposed over the mucosal graft to provide vascularity and reform the anterior lamella. The mucosal graft was folded over the free edge of the skin flap to form the lid margin. The resultant sub-brow donor site defect was covered with a pre-auricular skin graft.

 

Results

Excellent post-operative aesthetic and functional outcomes were achieved. Mild ocular surface irritation, without corneal damage, was reported. Initially, lid margin vellus hairs were epilated but an anterior lamellar repositioning was undertaken 3 months later. In subsequent reviews over 6 months, all wounds have healed well and the flap and grafts have integrated fully.

Conclusion

Single-stage reconstruction in total upper lid loss prevented morbidity from vision obstruction. Placement of buccal mucosa with a bipedicle flap afforded the use of two grafts on separate vascular beds, achieving support and flexibility without surgical retrieval of a tarsal substitute.


Laura HUGHES, Manvi SOBTI (London, United Kingdom), Naresh JOSHI
00:00 - 00:00 #32494 - Lateral Canthotomy and Cantholysis: A Low Cost, Simple and Anatomically Correct Simulation Model.
Lateral Canthotomy and Cantholysis: A Low Cost, Simple and Anatomically Correct Simulation Model.

Background 

 

Lateral canthotomy and cantholysis is a procedure that ophthalmologists and emergency doctors must learn to rapidly treat orbital compartment syndrome. Our aim was to build a low-cost simulation model for this vision-saving procedure, using only materials available in the hospital. 

  

Methods 

 

Equipment to build the model includes 1 specimen pot, 1 elastic band, fabric dressing tape, micropore surgical tape, 5-6 sterile cotton swabs, 1 surgical glove, 1 sheet of gauze and scissors. Model simulation demonstrated in video.

 

The model was validated at ophthalmology and emergency department registrar teaching sessions using pre- and post-teaching questionnaires. Confidence level was gauged using a 5-point Likert scale from 1 (not at all confident), to 5 (extremely confident).

 

 

Results 

 

Out of 34 participants, only 14.70% (n=5) had performed the procedure on a living patient. Prior to the teaching session, participants had a mean confidence level in carrying out the procedure of 1.88 which rose to 3.41 after teaching, resulting in a significant increase in confidence (p=<0.01, CI:1.08-1.97). Confidence in locating the required equipment also significantly improved following teaching by 1.59 (P=<0.01, CI:1.13-2.04).

 

Only 41.18% (n=14) of participants had received formal canthotomy and cantholysis teaching before. 23.53% (n=8) said they would require no further teaching following our session. Of those who wanted extra teaching, 73.08% (19/26) requested more simulation. 88.2% (n=30) of respondents found the model helpful in the anatomical understanding of canthotomy, as it allows the user to ‘strum’ the ‘inferior canthal tendon, without cutting the lower lid. The user can therefore appreciate the difference between canthotomy and cantholysis.

 

 

Conclusion 

 

Our simulation model was effective in increasing confidence in a procedure which trainees have little prior experience or teaching opportunities in. Furthermore, it is the first model for this procedure to exclusively use materials from the hospital, making it accessible to all.  


Sara MEMON, Caroline WILDE (London, United Kingdom), Laura AH-KYE, Alice MILLIGAN, Hannah TIMLIN
00:00 - 00:00 #32198 - March technique step by step; a new lower eyelid reconstruction.
March technique step by step; a new lower eyelid reconstruction.

Skin cancer is especially harmful due to local invasion and surgical iatrogenic morbidity. The recurrence may be high, implying challenging surgical management depending on the prior surgery, which in eyelids may mean sacrificing periosteum or tarsus. To avoid this, in cases where the defect involves up to 66% of the lower eyelid with at least around 17% of remnant lateral lower margin respected, the MARCH technique would be a more conservative approach, with minimal damage to perilesional healthy tissues, which provides good resources for the future. The surgical procedure is shared step by step, with promising results that would encourage us to use it as the first surgical step. The authors declare having no conflicts of interest. 


Anna MARCH DE RIBOT (BARCELONA, Spain), Francesc MARCH DE RIBOT
00:00 - 00:00 #32529 - Non-surgical management of eyelid retraction in thyroid eye disease using hyaluronic acid gel filler.
Non-surgical management of eyelid retraction in thyroid eye disease using hyaluronic acid gel filler.

It is common practice for patients with active thyroid eye disease to suffer for months or years while awaiting inactivity of their disease process and then recovery from other rehabilitative surgical procedures such as orbital decompression and strabismus surgery prior to definitive surgical management of their eyelid retraction. Many individuals with an unacceptable appearance may experience significant psychological impact due to this prolonged delay to treatment. The video demonstrates a specific non-surgical technique for managing eyelid retraction in patients with thyroid eye disease. The procedure, involving the injection of hyaluronic acid gel filler, is cost-effective, well-tolerated, reversible and lead to significant patient satisfaction.


Angela RICHARDS (London, United Kingdom), Yun WONG
00:00 - 00:00 #32498 - Prolene suture assisted annular silicon tube intubation with adjustable silicon sleeve -Kıvanç’s Loop: A novel silicone tube intubation technique for lacrimal canalicular laceration:.
Prolene suture assisted annular silicon tube intubation with adjustable silicon sleeve -Kıvanç’s Loop: A novel silicone tube intubation technique for lacrimal canalicular laceration:.

Background: Monocanalicular intubation is one of the methods frequently used in lacrimal canaliculi injuries. MiniMonoka silicone tube can be used for this purpose. Another method is bicanalicular silicone tube intubation using a pig tail probe. Or  surgeon will need specific silicon tube sets for repairing lacrimal lacerations. However, in circumstances like  pandemic or war, there may be difficulties in accessing these equipments, and there are also difficulties and complications caused by the implementation of these procedures. During the pandemic period and after pandemic, at the time of Russia-Ukraine war that took place at the  North of the Turkey, the prices of health equipment have increased a lot and there has been a limited amount of some medical supplies  available to our Ophthalmology Department. 

Video Presentation: Our department is the tertiary center serving nearly 10 million people in the South Marmara region in terms of  Ocular Traumas. For repairing canalicular laceretions, we would prefer Mini-Monoka tube rather than  the pig tail probe.  The pig tail probe  may cause  damage to the lacrimal canaliculi.  Last few mounths we could not get access to the Mini-Monoka tube. Therefore, we developed  a novel technic which  we called “Prolene suture assisted annular silicon tube intubation with adjustable silicone sleeve -Kıvanç’s Loop”. Best of our knowledge this technique is not used previously. In this video you can find the steps of this technique, and removal of tube. 

Conclusion: This new technique is an alternative, inexpensive and sustainable method that can be used if there is shortage for lacrimal surgery equipments.


Sertac Argun KIVANC (Bursa, Turkey), Berna AKOVA
00:00 - 00:00 #32288 - Simplified endoscopy guided irrigation and probing.
Simplified endoscopy guided irrigation and probing.

This is a video presentation showing the correct and simplified technique of irrigation and probing and in turn explaining the improtance of endoscopy assistance during probing.


Nandini BOTHRA (India, India)
00:00 - 00:00 #32425 - Surgical Managament of Tarsal Buckling as a Complication of Congenital Ptosis Surgery.
Surgical Managament of Tarsal Buckling as a Complication of Congenital Ptosis Surgery.

Entropion is a rare complication of ptosis surgery following levator resection. In literature, there are four involutional ptosis cases of tarsal buckling complicated with entropion following anterior approach aponeurosis advancement surgery, and a case following Fasanella-Servat procedure. A 35-year-old Caucasian female underwent levator resection surgery for unilateral congenital ptosis in another clinic. Post-operatively she could not achieve good lid height, revision surgery had been performed. But subsequently, she developed entropion of the upper lid and was admitted to our clinic. When we performed further surgery to correct the entropion, we found the aponeurosis was inserted inferiorly onto the tarsus below the vertical midpoint and the tarsal plate was buckled. In this video, we showed how we managed this unexpected complication of ptosis surgery.


Özgün Melike GEDAR (Istanbul, Turkey)
00:00 - 00:00 #32372 - The use of a PHACO machine as an aid in endoscopic endonasal DCR.
The use of a PHACO machine as an aid in endoscopic endonasal DCR.

Introduction: The front lens of the rigid nasal endoscope easily becomes clouded, during endonasal endoscopic DCR (endo DCR). The main causes are fogging and blood from the surgical field. Fogging can be prevented by repeated application of an anti-fog solution, whereas blood needs to be wiped off with a wet gauze. In both cases, frequent exits and re-entries into the nasal cavity are required. An irrigation / aspiration machine, connected to a rigid endoscope sleeve, solves this problem, however, these machines are expensive and not always readily available in operating theatres and clinics which perform exclusively ophthalmic surgery. On the other hand, most every ophthalmic surgery clinic has a phaco machine, with which the lacrimal surgeron can control the irrigation of the endoscope and surgical field.

Methods: The irrigation line of the phaco machine is connected to a rigid endoscope sleeve. In our practice a metal, reusable sleeve is used. The aspiration line is free from any attachements, and the aspiration port of the sleeve is kept closed. The height of the saline bottle / irrigation pressure are adjusted to maximum. The phaco machine is kept in the irrigation / aspiration mode. The surgeon can activate irrigation by pressure on the pedal, while, at the same time, aspirating with the instrument in the dominant hand, which, in our practice, is the aspirating Freer periosteal elevator. This way, the endoscope is kept clean and the lens clear during the procedure, without the need to exit the nasal cavity.

Results: Seventeen (17) endo DCR procedures, performed with the aid of a phaco machine (group 1), were compared to twenty four (24) endo DCR procedures, without the aid of a phaco machine (group 2). Endo DCR-s in which adiuvant procedures, like submucosal nasal septum resection, were performed, were excluded. In comparrison, the average difference in surgical time was 12.5 minutes less in gropup 1. 

Conclusion: Depending on the experience of the surgeon, the reduction of the surgical time, with the use of this method, can be as much as 30%. With the presumtion that the operating theatre already has a phaco machine, the only investement is the rigid endoscope sleeve.


Zoran ZIKIC (Belgrade, Serbia), Enisa MEMIC
00:00 - 00:00 #32202 - Tissue preservation for horizontal lower lid laxity repair.
Tissue preservation for horizontal lower lid laxity repair.

Purpose–Lower lid horizontal laxity (LLHL) commonly occurs in involutional entropion. It is due to canthal ligament, orbicularis oculi weakening, or tarsal atrophic elongation. Numerous methods for LLHL correction have been described, e.g tarsal wedge resection, lateral tarsal strip procedure, or its modification. This video demonstrates tissue preservation technique and results in LLHL correction by transposition of orbicularis muscle together with tarsoligamentous shrinkage and lateral canthal suspension suture. 

Methods – 27 lower lid laxity with involutional entropion in 26 patients were corrected from May 2021 to June 2022 and were reviewed.

Technique – A subciliary skin incision over the temporal one-third of the lower lid and lateral canthal skin incision are made. Lateral one-third of orbicularis is undermined between skin and tarsus surface to connect tunneling between the subciliary incision and lateral canthal incision. A horizontal strip of orbicularis is fashioned and pulled through the tunnel to the lateral orbital rim. Incision over the lateral orbital rim is deepened to expose the lateral orbital rim. Tarsoligamentous tissue is shortened by cauterization. The lateral tarsal end and orbicularis strip are anchored to the lateral orbital rim with a 5-0 Maxon suture. The lower lid septum is then opened, the inferior lid retractor is identified, separated from the inferior tarsus muscles, and sutured to the inferior tarsal border with 2 Vicryl 6-0 sutures. Hemostasis is secured. Skin wounds are closed with one 6-0 silk on each site.

Results- Patients were followed up range from one to six months. All achieved stable lid margin position except one showed temporary postoperative ectropion, which resolved with lid massage, and another had residual entropion because of marginal cicatricial changes.

Conclusion- Tissue preservation in LLHL correction by transposition of orbicularis muscle tightening together with tarsoligamentous cauterization and lateral canthal suspension suture are practical and logical. It avoids disrupting the lateral canthal and lid margin tissue. 

References

Clinton DM. et al. Chapter 8, Oculoplastic Surgery (3rd ed 1995).

Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979 Nov;97(11):2192-6


Chaiteck CHOO (Singapore, Singapore), Hugo LEE
00:00 - 00:00 #32290 - Upper eyelid “Suture-less” Blepharoplasty.
Upper eyelid “Suture-less” Blepharoplasty.

Purpose: To present our surgical technique for performing “suture-less” upper lid blepharoplasty

Methods: Video presentation of the technique presented

Upper blepharoplasty can be conducted with a variety of techniques. One of the main factors that determine the outcome and patient satisfaction is the technique utilised to close the wound. This is a highly mobile thin skin structure susceptible to dehiscence, so the strength of closure is imperative.

The usual technique employs skin only suturing that requires the removal of these sutures at an early point to optimize scarring. It also requires the return of the patient at a set time frame.

We describe a “sutureless skin closure” technique. We have used this technique for a number of years with enhanced results in terms of skin scarring and reduction of early post-operative visits.

The video will clearly demonstrate our current favoured “suture-less” technique.

Conclusions: “Suture-less” upper lid blepharoplasty achieves excellent

post-operative scarring, and flexibility in patient follow-up, as the need for suture removal is precluded.


Manvi SOBTI, Naresh JOSHI, Aoife NAUGHTON (London, United Kingdom)