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.

   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. 

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.

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. 

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.

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. 

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.

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.

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.

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.

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. 

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.

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 10^th 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. 

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.

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.

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.

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 2^nd, 5^th, and 15^th 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 5^th-15^th 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.

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 29^th April and 6^th 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. 

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.

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.

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.

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.

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:

More threatening complications:

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.

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.

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. 

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

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. 

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.

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. 

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 wounds. The vision acuity in 60% of patients was no light perception, in 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.

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.

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. 

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. 

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. 

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.

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.

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.

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.

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.

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.  

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. 

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.

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.

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.