Structural Limits of Orbital Compliance and Treatment Options for Pathologic Orbital Pressure.

PURPOSE: The integrity of the orbit has a finite structural limit due to the compliance of its tissue. The authors investigate these limits to quantify them and inform the treatment of heightened ocular and orbital pressure. METHODS: Cadaveric study with 12 orbits being volumized before randomization of treatment for pathologic levels of ocular and orbital pressure. First-line and second-line treatment was chosen randomly (lateral cantholysis, superior septolysis, inferior septolysis). Prior to treatment, IOP, orbital compartment pressure, and axial globe projection was measured after delivery of each 1cc aliquot and surgical treatment. RESULTS: Orbital compartment pressure and IOP were well correlated (r = 0.99). The average reduction in IOP after treatment averaged a 56.2 mm Hg reduction in IOP. All treatments were statistically equivalent ( p < 0.01). Loss of compliance (P LOC ) was determined when the mean plus 1 standard deviation of change in IOP/ml volume was achieved with simultaneous change in exophthalmometry of <0.5 mm change/ml added volume, indicating an acceleration in pressure in the face of a steady volume. This criteria was met for 11 of 12 orbits. The 12th orbit missed this threshold by 1 mm Hg in IOP. P LOC occurred at an average IOP of 43.0 mm Hg (±5.8 mm Hg, 90% CI) and after an average injection of 13 ml (±1.4 mm, 90% CI). Additionally, lateral cantholysis, superior septolysis, and inferior septolysis were statistically equivalent in reducing IOP after P LOC . CONCLUSIONS: IOP and orbital compartment pressure are excellent proxies for each other in the authors' model. Orbital compliance is a mathematic phenomenon that can be quantified, as evident in this investigation. P LOC can inform timing for orbital decompressions in the presence of heightened IOP. Multiple procedures can be used to extinguish dangerously high orbital compartment pressure.

Refuge-yeah or refuge-nah? Predicting locations of forest resistance and recruitment in a fiery world.

Climate warming, land use change, and altered fire regimes are driving ecological transformations that can have critical effects on Earth's biota. Fire refugia-locations that are burned less frequently or severely than their surroundings-may act as sites of relative stability during this period of rapid change by being resistant to fire and supporting post-fire recovery in adjacent areas. Because of their value to forest ecosystem persistence, there is an urgent need to anticipate where refugia are most likely to be found and where they align with environmental conditions that support post-fire tree recruitment. Using biophysical predictors and patterns of burn severity from 1180 recent fire events, we mapped the locations of potential fire refugia across upland conifer forests in the southwestern United States (US) (99,428 km2 of forest area), a region that is highly vulnerable to fire-driven transformation. We found that low pre-fire forest cover, flat slopes or topographic concavities, moderate weather conditions, spring-season burning, and areas affected by low- to moderate-severity fire within the previous 15 years were most commonly associated with refugia. Based on current (i.e., 2021) conditions, we predicted that 67.6% and 18.1% of conifer forests in our study area would contain refugia under moderate and extreme fire weather, respectively. However, potential refugia were 36.4% (moderate weather) and 31.2% (extreme weather) more common across forests that experienced recent fires, supporting the increased use of prescribed and resource objective fires during moderate weather conditions to promote fire-resistant landscapes. When overlaid with models of tree recruitment, 23.2% (moderate weather) and 6.4% (extreme weather) of forests were classified as refugia with a high potential to support post-fire recruitment in the surrounding landscape. These locations may be disproportionately valuable for ecosystem sustainability, providing habitat for fire-sensitive species and maintaining forest persistence in an increasingly fire-prone world.

Forest restoration treatments increased growth and did not change survival of ponderosa pines in severe drought, Arizona.

We report on survival and growth of ponderosa pines (Pinus ponderosa Douglas ex P. Lawson & C. Lawson) 2 decades after forest restoration treatments in the G. A. Pearson Natural Area, northern Arizona. Despite protection from harvest that conserved old trees, a dense forest susceptible to uncharacteristically severe disturbance had developed during more than a century of exclusion of the previous frequent surface-fire regime that ceased upon Euro-American settlement in approximately 1876. Trees were thinned in 1993 to emulate prefire-exclusion forest conditions, accumulated forest floor was removed, and surface fire was re-introduced at 4-years intervals (full restoration). There was also a partial restoration treatment consisting of thinning alone. Compared with untreated controls, mortality of old trees (mean age 243 years, maximum 462 years) differed by <1 tree ha-1 and old-tree survival was statistically indistinguishable between treatments (90.5% control, 92.3% full, 82.6% partial). Post-treatment growth as measured by basal area increment of both old (pre-1876) and young (post-1876) pines was significantly higher in both treatments than counterpart control trees for more than 2 decades following thinning. Drought meeting the definition of megadrought affected the region almost all the time since the onset of the experiment, including 3 years that were severely dry. Growth of all trees declined in the driest 3 years, but old and young treated trees had significantly less decline. Association of tree growth with temperature (negative correlation) and precipitation (positive correlation) was much weaker in treated trees, indicating that they may experience less growth decline from warmer, drier conditions predicted in future decades. Overall, tree responses after the first 2 decades following treatment suggest that forest restoration treatments have led to substantial, sustained improvement in the growth of old and young ponderosa pines without affecting old-tree survival, thereby improving resilience to a warming climate.

Lower Eyelid Ectropion Secondary to Over-the-Counter Treatment of Xanthelasma.

Xanthelasmas are localized accumulations of lipids, mainly cholesterol, that can occur in the epidermis, dermis, and muscle of the eyelids. They are the most common cutaneous presentation of xanthoma and occur most commonly on the upper eyelid near the inner canthus. Despite their benign presence, xanthelasmas can be cosmetically concerning. With this in mind, several treatment modalities have been described to eliminate the appearance. We report the first case to describe a cicatricial ectropion from the topical treatment, "Glycolic acid, Lactic acid, Mandelic acid, Salicylic acid, Resorcinol, Jessners peel" (XanthelR, 483 Green Lanes, London, N13 4BS).

Effect of Premature Tube Extrusion for Simple Congenital Nasolacrimal Duct Obstruction: A Comparison of Monocanalicular and Bicanalicular Intubation.

ABSTRACT: The objective of this article is to compare the incidence of premature dislocation of silicone tubes and the effect on treatment success between monocanalicular (MCI) and bicanalicular (BCI) intubation in pediatric patients with simple congenital nasolacrimal duct obstruction. Retrospective comparative case series of 108 eyes of 78 pediatric patients with simple congenital nasolacrimal duct obstruction who underwent probing with either BCI (n = 38 eyes) or MCI (n = 70 eyes) from 2017 to 2020. Premature tube extrusion was defined as any tube removed prior to the 3 month postoperative appointment. Success was defined as resolution of tearing 3 months post tube removal. Ages ranged from 10 months to 5.35 years (mean, 1.95 years; Standard deviation (SD), 0.91). Premature tube extrusion occurred in 15 eyes with BCI and 29 eyes with MCI. Success rates were not significantly different regardless of intubation type between the planned tube removal (90.6%) and the premature tube extrusion cohorts (84.1%), P = 0.89. There was no significant difference in treatment success between the planned tube removal (92.7% MCI, 87% BCI) and the premature tube extrusion cohorts (86.2% MCI, 80% BCI). Complications included 2 infections (1 MCI, 1 BCI) and 2 cases of tube related keratopathy (1 MCI, 1 BCI) that all resolved with tube removal. There were 2 BCI patients that presented to the emergency department for premature tube extrusion. Silicone intubation regardless of stent type is an effective treatment for simple congenital nasolacrimal duct obstruction. There was no significant difference in treatment success between tubes that extrude prematurely, and tubes removed at term based on type of intubation.

Long-acting opioid prescribing patterns of ophthalmic plastic surgeons in the medicare Part D database.

PURPOSE: To assess extended release/long acting (ER/LA) opioid prescribing patterns among ophthalmic plastic surgeons in the Centers for Medicare and Medicaid Services (CMS) Part D database. METHODS: A retrospective observational cohort study was conducted on oculoplastic surgeons in the CMS Part D database who prescribed ER/LA opioids from 2013 to 2017. American Society of Ophthalmic Plastics and Reconstructive Surgery (ASOPRS) and non-ASOPRS surgeons were analyzed as groups. Prescribers were also analyzed based on gender and practice experience. RESULTS: Oculoplastic surgeons (64 ASOPRS and 78 non-ASOPRS) were responsible for 1,177 ER/LA opioid prescriptions from 2013 to 2017. ASOPRS members accounted for 4.6% and non-ASOPRS members accounted for 7.5% of all ER/LA opioids prescribed by ophthalmologists over the study period (p= .02). The total number of ASOPRS and non-ASOPRS members prescribing ER/LA opioids decreased by 52% (p= .10) and 58% (p= .07) from 2013 to 2017 respectively. CONCLUSION: ER/LA opioids are indicated for treatment of chronic pain and may be appropriately prescribed by the oculoplastic surgeon in certain circumstances, however due to the higher risk of overdose injury, those circumstances must be defined and justified. While a relatively small number of oculoplastic surgeons (10.6% ASOPRS and 19.6% non-ASOPRS) prescribed ER/LA opioids from 2013 to 2017, non-ASOPRS oculoplastic surgeons wrote 23.5% more ER/LA opioid prescriptions over the study period. Over the 5-year study period there was a general decline in the prescribing of ER/LA opioids by oculoplastic surgeons. Reviewing the prescribing practices of oculoplastic specialists, regardless of professional affiliation, is necessary to understand the role of ER/LA opioids for all of ophthalmology.

Trends of forest and ecosystem services changes in the Mescalero Apache Tribal Lands.

Forests are critically important for the provision of ecosystem services. The Sacramento Mountains of New Mexico, USA, are a hotspot for conservation management and the Mescalero Apache Tribe's homeland. The multiple ecosystem services and functions and its high vulnerability to changes in climate conditions make their forests of ecological, cultural, and social importance. We used data from the Mescalero Apache Tribal Lands (MATL) Continuous Forest Inventory over 30 yr to analyze changes in the structure and composition of ecosystems as well as trends in ecosystem services. Many provisioning, regulating, cultural, and supporting services were shared among the MATL ecosystems and were tied to foundational species dominance, which could serve as a reliable indicator of ecosystem functioning. Our analysis indicates that the MATL are in an ongoing transition from conifer forests to woodlands with declines in two foundation species, quaking aspen and ponderosa pine, linked to past forest management and changing climate. In addition, we detected a decrease in species richness and tree size variability, amplifying the risk of forest loss in a rapid climatic change. Continuous permanent plots located on a dense grid (1 × 1 km) such as the ones monitored by the Bureau of Indian Affairs are the most detailed data available to estimate forests multiresource transitions over time. Native lands across the USA could serve as the leading edge of detecting decadal-scale forest changes and tracking climate impacts.

Primary Melanoma of the Lacrimal Sac Treated With Pembrolizumab.

Primary melanoma of the lacrimal sac is a rare entity, with high mortality and a propensity for recurrence. This report details a patient with widely metastatic melanoma discovered after biopsy of abnormal lacrimal sac tissue during routine dacryocystorhinostomy. The patient subsequently underwent local excision and treatment with pembrolizumab. At the time of this writing, it has been 24 months since the original diagnosis with resolution of his lacrimal and orbital lesions and improvement in all metastatic lesions. This case highlights the growing use of cancer genomics and immunotherapeutic agents in orbital aspects of oncology and reinforces the role of a multidisciplinary approach in the treatment of such diseases.

Diné kinship as a framework for conserving native tree species in climate change.

Climate change affects all ecosystems but despite increasing recognition for the needs to integrate Indigenous knowledge with modern climate science, the epistemological differences between the two make it challenging. In this study, we present how Indigenous belief and knowledge system can frame the application of a modeling tool (Climate-Forest Vegetation Simulator). We focus on managing forest ecosystem services of the Diné (Navajo) Nation as a case study. Most Diné tribal members depend directly on the land for their livelihoods and cultural traditions. The forest plays a vital role in Diné livelihoods through social, cultural, spiritual, subsistence, and economic factors. We simulated forest dynamics over time under alternative climate change scenarios and management strategies to identify forest management strategies that will maintain future ecosystem services. We initialized the Climate-Forest Vegetation Simulator model with data from permanent plots and site-specific growth models under multiple management systems (no-management, thinning, burning, and assisted migration planting) and different climate scenarios (no-climate-change, RCP 4.5, RCP 6.0). Projections of climate change show average losses of basal area by over 65% by 2105, a shift in tree species composition to drier-adapted species, and a decrease in species diversity. While substantial forest loss was inevitable under the warming climate scenarios, the modeling framework allowed us to evaluate the management treatments, including planting, for conserving multiple tree species in mixed conifer forests, thus providing an anchor for biodiversity. We presented the modeling results and management implications and discuss how they can complement Diné kinship concepts. Our approach is a useful step for framing modern science with Indigenous Knowledge and for developing improved strategies to sustain natural resources and livelihoods.

Simulating post-wildfire forest trajectories under alternative climate and management scenarios.

Post-fire predictions of forest recovery under future climate change and management actions are necessary for forest managers to make decisions about treatments. We applied the Climate-Forest Vegetation Simulator (Climate-FVS), a new version of a widely used forest management model, to compare alternative climate and management scenarios in a severely burned multispecies forest of Arizona, USA. The incorporation of seven combinations of General Circulation Models (GCM) and emissions scenarios altered long-term (100 years) predictions of future forest condition compared to a No Climate Change (NCC) scenario, which forecast a gradual increase to high levels of forest density and carbon stock. In contrast, emissions scenarios that included continued high greenhouse gas releases led to near-complete deforestation by 2111. GCM-emissions scenario combinations that were less severe reduced forest structure and carbon stock relative to NCC. Fuel reduction treatments that had been applied prior to the severe wildfire did have persistent effects, especially under NCC, but were overwhelmed by increasingly severe climate change. We tested six management strategies aimed at sustaining future forests: prescribed burning at 5, 10, or 20-year intervals, thinning 40% or 60% of stand basal area, and no treatment. Severe climate change led to deforestation under all management regimes, but important differences emerged under the moderate scenarios: treatments that included regular prescribed burning fostered low density, wildfire-resistant forests composed of the naturally dominant species, ponderosa pine. Non-fire treatments under moderate climate change were forecast to become dense and susceptible to severe wildfire, with a shift to dominance by sprouting species. Current U.S. forest management requires modeling of future scenarios but does not mandate consideration of climate change effects. However, this study showed substantial differences in model outputs depending on climate and management actions. Managers should incorporate climate change into the process of analyzing the environmental effects of alternative actions.

Pediatric Orbital Roof Fractures: A Ratio of Orbital Dimensions Correlated to Prevalence of Fracture.

Objective Orbital roof fractures are more likely to occur in younger children, specifically younger than 7 years. Cranium to face ratio decreases with age; however, there is no definition for measurement of the neurocranium or face. We propose using the length of the orbital roof as a measurement of the neurocranium and length of the orbital floor as a tool to estimate midface size. The purpose of this study is to test this measurement as a correlation rate of orbital roof fractures within the pediatric population. Design This is a retrospective study. Setting This study was done at the LeBonheur Children's Hospital. Participants Sixty-six patients with orbital roof fractures were identified and stratified by gender and age, specifically younger than 7 years and 7 years or older. Main Outcome Measures The main outcome measures were orbital roof length, floor length, and ratio thereof. Results Mean orbital roof length was 43.4 ± 3.06 and 45.1 ± 3.94 mm for patients <7 and ≥7 years, respectively ( p = 0.02). Mean orbital floor length was 41.3 ± 2.99 and 47.7 ± 4.19 for patients <7 and ≥7 years, respectively ( p < 0.00001). The mean roof to floor ratio (RTFR) for patients <7 years was 1.051 ± 0.039 and for patients ≥ 7 years was 0.947 ± 0.031 ( p < 0.00001). Conclusion As children age, the relative length of the orbital roof decreases when compared with the orbital floor. The RTFR was more than 1.0 in children younger than 7 years. These differences were statistically significant when compared with children 7 years and older. This measurement shift follows the differences noted in orbital fracture patterns during childhood.

Western Spruce Budworm Effects on Forest Resilience.

Western spruce budworm (Choristoneura freemani Razowski) is the most destructive defoliator of forests in the western US. Forests in northern New Mexico experienced high levels of WSBW-caused defoliation and subsequent mortality between the 1980s and 2010s. The effects of severe western spruce budworm outbreaks on stand dynamics in the US Southwest are still relatively unknown, but understanding the impacts is important to the management and resilience of these forests. To begin addressing this knowledge gap, we conducted a study along two gradients: an elevational gradient from mixed-conifer to spruce-fir forests and a gradient of WSBW-caused defoliation intensity. We recorded overstory and understory stand conditions (size structure, species composition, damaging agents). Western spruce budworm was the primary damaging agent of host trees in all stands andcaused host tree mortality across all size classes, particularly in spruce-fir stands. Results indicate an unsustainable level of mortality in spruce-fir stands and a transition towards non-host species in mixed-conifer stands. Low levels of regeneration coupled with high overstory mortality rates indicate a potential lack of resilience in spruce-fir stands, whereas resilience to future western spruce budworm defoliation events may have increased in mixed-conifer stands affected by these outbreaks.

A Case of Orbital Granuloma Secondary to Dermal Filler Injection.

A foreign body granulomatous reaction is a rare complication of the subcutaneous injection of fillers. We describe a 57-year-old female that presented with a six-month history of a non-painful, right lower eyelid mass. She had a dermal filler in the zygomatic region several months before the onset of her symptoms. Anterior orbitotomy and pathology revealed multinuclear giant cells consistent with a hyaluronic acid-based filler. This case describes the clinical presentation, histopathologic features, and treatment of an orbital granuloma secondary to dermal filler injection. Our case was uncommon because the zygomatic filler migrated across the orbital septum. Additionally, transconjunctival orbitotomy was used instead of a hyaluronidase injection due to the inferior location of the granuloma.

Intravascular Papillary Endothelial Hyperplasia of the Orbit: A Case of Masson's Tumor.

Herein, we present a case of a 64-year-old male presenting with diplopia that was found to have a left orbital Masson's tumor. It is necessary to differentiate it from malignant angiosarcoma as complete excision is often curative. The following case emphasizes the modalities that can be used for diagnosis as well as the appropriate treatments.

Fire regime on a cultural landscape: Navajo Nation.

Fire has played an important role in the evolutionary environment of global ecosystems, and Indigenous peoples have long managed natural resources in these fire-prone environments. We worked with the Navajo Nation Forestry Department to evaluate the historical role of fire on a 50 km2 landscape bisected by a natural mountain pass. We used fifty 5-ha circular plots to collect proxy fire history data on fire-scarred trees, stumps, logs, and snags in a coniferous forest centered on a key mountain pass. The fire history data were categorized into three groups: All (all 50 plots), Corridor (25 plots closest to Buffalo Pass drainage), and Outer (remaining 25 plots, farther from pass). We assessed spatial and temporal patterns of fire recurrence and fire-climate relationships. The landscape experienced frequent fires from 1644, the earliest fire date with sufficient sample depth, to 1920, after which fire occurrence was interrupted. The mean fire interval (MFI) for fire dates scarring 10% or more of the samples was 6.25 years; there were 13 large-scale fires identified with the 25% filter with an MFI of 22.6 years. Fire regimes varied over the landscape, with an early reduction in fire occurrence after 1829, likely associated with pastoralism, in the outer uplands away from the pass. In contrast, the pass corridor had continuing fire occurrence until the early 20th century.Synthesis. Fires were synchronized with large-scale top-down climatic oscillations (drought and La Niña), but the spatially explicit landscape sampling design allowed us to detect bottom-up factors of topography, livestock grazing, and human movement patterns that interacted in complex ways to influence the fire regime at fine scales. Since the early 20th century, however, fires have been completely excluded. Fuel accumulation in the absence of fire and warming climate present challenges for future management.

Surgical Outcome of Epicanthus and Telecanthus Correction by Double Z-Plasty and Trans-Nasal Fixation with Prolene Suture in Blepharophimosis Syndrome.

INTRODUCTION: Blepharophimosis Syndrome (BPES) is a complex and rare disease characterized by epicanthus inversus, telecanthus, lateral ectropion, narrowed or shortened inter-palpebral fissure distance and ptosis. It is mostly bilateral and may or may not be symmetrical. It is typically inherited as an autosomal dominant trait. In sporadic cases, the disease may occur without a prior family history as a genetic mutation from a deletion or translocation of the FOXL2 gene, which maps to chromosome 3q23. Surgical treatment of this disease poses an oculoplastic challenge due to multiple complex eyelid deformities. AIM: To evaluate the functional and cosmetic outcome of telecanthus and epicanthus correction by a Mustarde's rectangular double Z-Plasty and trans-nasal fixation using 1-0 prolene suture in BPES. MATERIALS AND METHODS: This was prospective, interventional study of 16 patients over a period of three years. In this study, all patients had BPES with prominent epicanthus and telecanthus. Mustarde's double Z-plasty and trans-nasal fixation with 1-0 prolene suture was performed in the first of a two-stage operation. If ectropion was present, the lateral ectropion was corrected by a base-out flap transfer from the upper eyelid to the lower eyelid. After three months, a 2nd stage was undertaken, involving a lateral canthoplasty for horizontal widening of a short palpebral fissure and a tarso frontalis sling with silicone rod for correction of moderate to severe ptosis. Patients were followed up for six months to one year with postoperative ophthalmologic examinations and photographs. RESULTS: Out of 16 patients, 10 were females and six were males. All the patients had bilateral involvement. In this study preoperative Inner Intercanthal Distance (IICD) ranged from 38 mm to 42 mm and the mean IICD was 41.2±0.57 mm. Postoperative IICD ranged from 31 mm to 34 mm. Horizontal Palpebral Fissure Length (HPFL) ranged from 20 mm to 23 mm and the mean value of HPFL was 21.50 mm preoperatively. Postoperative HPFL ranged from 26 mm to 29 mm and had a mean value of 28.50 mm, which was much improved after a combined correction of telecanthus and lateral canthoplasty. The mean preoperative IICD and HPFL ratio was 1.77 and was reduced to a postoperative value of 1.2. The Marginal Reflex Distance1 (MRD-1) test value improved from +1.25 mm to +3.50 mm postoperatively after placement of a tarsofrontalis sling with silicone rod using the Fox's Pentagon technique. In this study, two eyes had minimal unequal correction but were cosmetically and functionally acceptable. Correction of IICD is possible up to 6 mm. No major complication e.g., CSF rhinorrhea was noted in this series and preoperative prominent epicanthal folds were abolished. CONCLUSION: Here we propose a two-staged procedure involving a combined Mustarde's double Z-plasty with transnasal fixation using a 1-0 prolene suture with a flap transfer from the upper lid to the lower lid in the first stage and a lateral canthoplasty with a tarsofrontalis sling and silicone rod in the second stage. This technique is effective to correct epicanthus, telecanthus, ptosis and lateral ectropion in BPES with good cosmetic and functional outcome.