The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery.

PURPOSE: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery. METHODS: An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain. RESULTS: The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity. CONCLUSIONS: The OSCAR for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

Orbital and Periorbital Extension of Congenital Dacryocystoceles: Suggested Mechanism and Management.

Orbital and periorbital extension of congenital dacryocystoceles is rarely observed in neonatal infants. The authors describe 4 cases of congenital dacryocystocele that presented with extension to the orbital and periorbital regions. The first 3 newborns underwent marsupialization of the orbital and periorbital dacryocystoceles with aspiration of the purulent material followed by nasolacrimal duct probing after radiographic evidence of diffuse orbital or periorbital expansion. The fourth patient was successfully treated with an external dacryocystorhinostomy with excision of the enlarged cystic walls. Transconjunctival orbitotomy with sac marsupialization followed by nasolacrimal intubation can provide immediate and permanent resolutions of this unusual complication in most instances. External dacryocystorhinostomy may be required, however, when the orbital or periorbital dacryocystocele is complicated by acute or recurrent dacryocystitis.

Long-term efficacy and safety of botulinum toxin A injections to treat blepharospasm and hemifacial spasm.

BACKGROUND: To evaluate efficacy and safety of botulinum toxin A injections after more than 10 consecutive years of treatment for benign essential blepharospasm and hemifacial spasm. DESIGN: Retrospective chart review at university-affiliated hospital. PARTICIPANTS: Study consisted of 64 patients treated with botulinum toxin A injections between October 2005 and May 2006. METHODS: Inclusion criteria included patients treated with at least one annual botulinum toxin-A injection for more than 10 consecutive years. Data collected included diagnoses and patient characteristics, injection dates, doses administered at each visit, response scores, duration of effect, and adverse events. MAIN OUTCOME MEASURES: Included changes in doses, response scores, duration of effects, and adverse events between the first and last botulinum toxin A injections. RESULTS: Thirty-two of 64 patients (mean age at first injection, 57.2 ± 12.4 years; 25 women) met the inclusion criteria. The mean duration of follow up was 14.1 ± 3.1 years (range 10-20 years; mean total visits 44.4 ± 19). A higher mean injection dose per visit was administered during the last year compared with the first year (26.8 ± 10.3 vs. 22.5 ± 7.5 units, respectively) (P = 0.003). The mean durations of effect during the first and last years were 12.4 ± 7.1 and 14.6 ± 7.0 weeks, respectively (P = 0.076). There were no significant differences between genders or between benign essential blepharospasm and hemifacial spasm subgroups. The most common adverse events were ptosis, lagophthalmos and dry eye. CONCLUSIONS: Botulinum toxin A is an effective, safe, long-term treatment for patients with benign essential blepharospasm and hemifacial spasm. Sustained treatment efficacy required higher doses; however, fewer adverse reactions developed.

Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags.

PURPOSE: To describe the authors experience with calcium hydroxyl-apatite (CaHa) injections for the aesthetic correction of tear trough, infraorbital hollows, deep upper sulcus, dark circles and lower eyelid bags. METHODS: The records of 63 patients (127 eyelids) injected with CaHa for aesthetic rejuvenation of the periocular region between March 2012 and March 2013 were retrospectively evaluated. All injections were carried out using a 25-gauge cannula after adding 0.5 ml of 2% lidocaine to 1.5 ml vials of the original product. Postoperative visits were scheduled at 1 week and 1 month. Any previous treatment was recorded, and necessity of retreatments and side effects was evaluated. Patient satisfaction was recorded at 1 month with self-evaluation of the treatment result as "worsened," "unchanged," or "improved." Standard pre- and postinjection photographs were taken and compared to analyze the success of the procedure. Pictures were retrospectively graded by the authors on a similar improvement scale of 1 (worse), 2 (no change), and 3 (improvement). RESULTS: Fifty-eight/sixty-three patients were women (92%), with an average age of 42 years (range; 18-57 years). Chief complaints were "hollows" in 94% of patients, "dark circles" in 33%, lower eyelid "bags" in 17%, and deep upper sulcus in 4.7%. Twenty-three patients (36.5%) required an additional correction 1 month after the primary treatment. Satisfaction was as high as 98% among patients treated primarily for hollowness, and the overall satisfaction rate was 92%. Associated dark circles were satisfactorily treated in 68% of the patients. Temporary side effects involved mild erythema and swelling for 2 to 3 days and pseudoxanthalesma effect in 22 eyelids (17.4%) lasting <6 weeks. In 2 patients, erythema lasted longer than 4 weeks. The 2 worse complications in this series were migration of the product above the medial canthal tendon in 1 patient and overcorrection in another patient. These complications were all managed conservatively and resolved spontaneously within 6 to 8 weeks. No case of irregular contour, palpable lumpiness, or unevenness were encountered. In the end, only 1 patient thought she was worsened after the treatment. CONCLUSIONS: Treatment of the periocular region with CaHa injections is a safe and effective treatment with high patient satisfaction and low complication rate. Advanced technical skills may have to be acquired for the specific treatment of this area using this particulate material.

Periocular fat grafting: indications and techniques.

PURPOSE OF REVIEW: Autologous fat transfer (AFT) is gaining popularity in periorbital and facial rejuvenation as well as structural reconstruction because of the advantages of fat over other fillers and implants. RECENT FINDINGS: As the technique and instruments were refined over the years, the incidence of AFT morbidity decreased; however, there is still no consensus on the standardization of the procedure. Several studies have failed to demonstrate superiority of any routine technique; however, various suggestions provided by these investigations have had significant impact on the outcome of surgery. New insights are mainly focused on improving the survival of the grafted tissue, mainly through enhancing cell differentiation and angiogenesis. Clinical applications of adipose-derived stem cell (ADSC) transfer with or without other enhancers were proven to be successful; however, there is not enough human research on this topic yet. Experts made a clear distinction between AFT and ADSC transfer, and the details can be found in this report. Management of hard-to-treat maxillofacial conditions including orbital disorders evolved from AFT techniques, the so-called structural fat grafting. SUMMARY: Harvesting methods to obtain stem cells have proven helpful in many studies. The future of fat grafting relies on the basic research that includes using additive agents, enhancers, or scaffolds to fat for increased survival of the graft.

Treatment of unilateral congenital ptosis: putting the debate to rest.

PURPOSE OF REVIEW: Frontalis suspension for the surgical correction of poor levator function congenital ptosis has been a matter of debate in the last decade, but recently progress has been made. This study highlights the relevant keystones regarding sling material, surgical steps, and approach that can improve functional and esthetic results, while minimizing risk to the eye. RECENT FINDINGS: The incidence and demographics of ptosis in children have been reported by two recent studies confirming that unilateral, poor levator function congenital ptosis is the most common form, the left eye is most commonly affected, and frontalis suspension is the most commonly performed technique. Significant progress has been made concerning the sling material and the surgical technique of frontalis suspension. Although different surgical designs for sling suspension have proven to have no effect on the final result, a recent study has shown the importance of direct fixation with sutures of the sling material to the tarsal plate to increase the success rate Autologous fascia lata has been found to be an excellent sling material with the lowest complication rate and should be considered the preferred material for long-term correction. A review of the recent literature suggests that unilateral surgery is the preferred approach. SUMMARY: Although the surgical treatment of simple congenital ptosis has not radically changed through the years, recent reports have established some keystones that can positively affect the esthetic outcomes and safety of frontalis suspension.

Bilobed flap in the reconstruction of inferior and/or lateral periorbital defects.

PURPOSE: To report the outcome of bilobed flap (BF) reconstruction of inferior and/or lateral periorbital defects following tumor excision. METHODS: Records of 20 patients who underwent inferior and/or lateral periorbital reconstruction with the BF were reviewed. The surgery was performed with local anesthesia in 18 patients and with general anesthesia in 2. Malignant tumors were excised together with a 4- to 5-mm margin of surrounding skin. Superolaterally based BFs were created from the malar or zygomatic region to cover the defects. RESULTS: Patients ranged in age from 48 to 86 years (mean, 67 years). Nineteen patients had epithelial carcinoma and 1 had pilomatrixoma. Mean tumor diameter was 16 mm (range, 7-42 mm). Skin defects were located in the inferior (n = 14), lateral (n = 4), or inferolateral (n = 2) periorbital region. The BF was used in combination with the posterior lamella and/or canthus reconstruction techniques in 9 patients. For skin defects, BF was used alone in 17 patients, together with other flaps in 3. Primary closure of the skin defect with the flaps was achieved in 19 patients (95%). Three patients (15%) developed major complications requiring revision surgery (2 canthal webbings, 1 permanent pin-cushion deformity, and 1 ptosis) and 6 patients developed minor temporary complications. Mean follow-up duration was 34 months (range, 9-75 months). CONCLUSIONS: The BF is a valuable alternative for reconstruction of inferior and/or lateral periorbital defects alone or in combination with other eyelid reconstruction methods to achieve good functional and aesthetic outcome.

Embolization of dural carotid-cavernous fistulas via the thrombosed superior ophthalmic vein.

PURPOSE: To present the authors' experience treating dural carotid-cavernous sinus fistulas (CCF) with retrograde embolization via the thrombosed superior ophthalmic vein (SOV). METHODS: The medical records of 4 patients with dural CCFs treated via the thrombosed SOV were reviewed. All procedures were performed unilaterally in the interventional radiology unit with the administration of general anesthesia. The SOV was exposed via an eyelid crease incision, and then an angiocatheter was inserted in the vein and advanced through the segment with thrombosis to the cavernous sinus, where embolizing agents were deposited. After the procedure, the patients were followed up and evaluated clinically. RESULTS: Three patients had unilateral CCFs, and 1 had a bilateral CCF (3 women and 1 man; age range, 58-68 years). The CCFs were Barrow type B (n=2) and Barrow type D (n=2). All patients had severe venous congestive orbital symptoms, chorioretinopathy, increased intraocular pressure, and visual loss. In all cases, the SOV appeared as a pale, thin, tortuous vessel adherent to the surrounding tissues during the surgical procedure. In 3 patients, the cavernous sinus was successfully embolized, and all symptoms were completely resolved without recurrence during follow up (3, 15, and 24 months). In the patient in whom the SOV could not be catheterized, the symptoms regressed slowly, but visual acuity remained unchanged during follow up (64 months). CONCLUSIONS: Dural CCFs can be successfully treated through the SOV, even when the vein is thrombosed. Identification and catheterization of the thrombosed SOV may be difficult because of the tiny and fibrotic structure of the vein.

Unilateral superior ophthalmic vein thrombosis in a neonate.

A 10-month-old boy was referred for drooping and intermittent swelling in his right upper eyelid. Careful evaluation of his MRI findings along with the clinical presentation established the diagnosis of superior ophthalmic vein (SOV) thrombosis. History, old photographs, and imaging studies showed that the symptoms and signs were already present possibly since birth; however, further workup failed to reveal an underlying hematologic disorder or a congenital causative pathology. The patient was put on low-dose aspirin while waiting for the coagulation panel and genetic testing, which was stopped after 1 month of use with respect to normal test results. The symptoms except for ptosis resolved and did not recur during 6 months of follow up. To the authors' knowledge, this is the first reported case of unilateral isolated SOV thrombosis in the neonatal period.

Surgical outcomes in patients with bilateral ptosis and Hering's dependence.

PURPOSE: To assess whether sequential or simultaneous ptosis repair yields a better postoperative outcome in patients with documented preoperative Hering's dependency. DESIGN: Retrospective, case-control study. PARTICIPANTS AND CONTROLS: Of the 216 patients who underwent bilateral ptosis surgery, 109 patients with documented Hering's dependency constituted the study group and the 107 patients with no Hering's dependency constituted the control group. METHODS: The charts of patients who underwent levator advancement ptosis surgery between April 2002 and December 2004 by the same surgeon (R.C.K.) were reviewed retrospectively. Data regarding patient demographics, preoperative and postoperative margin-reflex distance values, levator function, presence of Hering's dependency, side of the initial operation, and reoperation status were collected from the charts. Patients demonstrating preoperative Hering's dependency of eyelid position operated simultaneously and sequentially were compared for postoperative symmetry and reoperation rates. Postoperative asymmetry was defined as a more than 1-mm difference between upper eyelid heights. MAIN OUTCOME MEASURES: Postoperative asymmetry and reoperation rates. RESULTS: In the Hering's dependency group (n = 109), 64 sequential surgeries that yielded 15 asymmetric results (23.4%) and 7 reoperations (10.9%) compared with the 45 simultaneous operations, which revealed 1 case of asymmetry (2.2%; P = 0.002) and 1 case of reoperation (2.2%; P = 0.137). Compared with the control group, sequentially operated Hering's dependency patients still showed higher postoperative asymmetry (P = 0.011), and the reoperation rate was similar (P = 0.134). Hering's dependency patients who had the initial operation on the left side demonstrated a significantly higher rate of postoperative asymmetry (42.3% vs. 10.5%; P = 0.006). CONCLUSIONS: Bilateral ptosis cases with documented Hering's dependency yield better results when both eyes are operated in the same session, rather than delaying surgery for the second eyelid. Ocular dominance probably has a significant impact on Hering's dependency and postoperative outcome after unilateral operations.

Cicatricial entropion following docetaxel (Taxotere) therapy.

We report eyelid margin changes in 3 patients after docetaxel treatment for breast cancer. These patients were referred to Cincinnati Eye Institute for eyelash abnormalities and/or epiphora and all had been treated with docetaxel in the near past. The ophthalmic complaints started soon after chemotherapy. All 3 cases showed varying degrees of palpebral mucosal inflammation and cicatricial changes leading to marginal entropion. The first patient exhibited very prominent eyelid margin inflammation and diffuse trichiasis without madarosis. The second patient had extensive madarosis and abnormally curved, thin eyelashes with punctal and canalicular obstruction. Her marginal entropion was most prominent at the medial lower eyelids. The last patient showed significant lash misdirection in a scattered distribution and patchy madarosis along with pseudomembranes blocking the puncta. All of these eyelid abnormalities occurred soon after docetaxel treatment for advanced breast cancer. Such changes in the absence of questioning for previous docetaxel use in history taking.

Ciliary body toxicity of subconjunctival suramin compared with mitomycin-C in the rabbit eye: determining the toxic concentration.

BACKGROUND/AIMS: To evaluate the safety of suramin compared with mitomycin-C (MMC) as an adjunctive agent in trabeculectomy by determining its ciliary body toxicity at predetermined effective dosages in rabbit eyes. METHODS: Thirty-two New Zealand albino rabbits received either suramin (200, 300, 400, or 800 mg/ml) or MMC (0.2, 0.3, 0.4, or 0.8 mg/ml) injections subconjunctivally in the right eye. Enucleations were performed on the 1st, 3rd, 7th and 28th day. Untreated left eyes were injected with balanced salt solution and served as controls. The injection-exposed ciliary body specimens were processed to be investigated under the light microscope and transmission electron microscope. RESULTS: There was no pathologic abnormality in specimens under light microscopy. The morphologic evaluation with transmission electron microscopy showed severe changes in structure, except for eyes treated with 200 mg/ml suramin and 0.2 mg/ml of MMC. These changes were more prominent in eyes exposed to MMC, and appeared earlier compared to suramin-treated eyes. CONCLUSIONS: Suramin 200 mg/ml and MMC 0.2 mg/ml seem to be comparatively nontoxic to the ciliary body of the rabbit eye. Concentrations higher than these values caused severe damage.

Solitary orbital plasmacytoma associated with chronic hepatitis C: a case report.

PURPOSE: To report a rare case of solitary orbital plasmacytoma associated with chronic hepatitis C. METHODS: We have reviewed the case of a man who presented with soft tissue mass in the superolateral orbit. Biopsy demonstrated immunohistochemical positivity of plasma cells for lambda light chains and CD56. Systemic evaluation was negative for multiple myeloma, and the diagnosis of solitary orbital plasmacytoma was made. RESULTS: We comment on the rarity of the case according to the reviewed literature. CONCLUSIONS: Given the correlation between hepatitis C and other lymphoproliferative disorders, we conclude hepatitis C may also be associated with solitary plasmacytomas.

Ptosis repair options and algorithm.

PURPOSE OF REVIEW: The treatment options for ptosis are strictly surgical. Each patient needs to be individually assessed and treated. A surgeon needs to be familiar with all types of surgical repair to choose the best possible option for his/her particular patient. RECENT FINDINGS: There are certain established surgeries in ptosis repair; however, there is no ideal surgical technique to treat every patient without any drawbacks. Several modifications of known techniques have been described to address the weaknesses of original applications. Also, new techniques such as orbicularis plication, levator readaptation, and new approaches in frontalis suspension surgery were presented. An algorithm showing the appropriate/most preferred ptosis surgery techniques is prepared based on the traditional knowledge and the latest publications. SUMMARY: There have been many modifications and new proposals in the management of ptosis. The surgeon needs to be familiar with an algorithm for the appropriate surgical method.

Intraoperative predictability of temporal artery biopsy results.

PURPOSE: To determine whether inflammatory/granulomatous changes of giant cell arteritis can be grossly identified by the surgeon during temporal artery biopsy to allow institution or discontinuation of steroid therapy without delay. METHODS: The records of 113 consecutive patients operated on by the same surgeon (R.C.K.) between November 2002 and June 2007 were reviewed. Demographic characteristics, date and site of the surgeries, surgical complications, surgeon's intraoperative presumption about the outcome (based on his assessment of the thickness, nodularity, tortuosity, and color/pallor of the arterial wall, blood flow, and the lumen size), and histopathologic biopsy results were collected from the chart review. The main outcome measure was the correspondence of the surgeon's intraoperative impression expressed in the operative note to the ultimate histopathologic diagnosis. RESULTS: After exclusion of 5 cases with incomplete data, the study consisted of 108 patients (78 females and 30 males) with an average age of 72.4 +/- 11.4 years (range, 45-93 years). There were no complications during or after surgery. The surgeon's comment was "grossly positive" in 17 cases, and 15 of these cases were pathologically positive. For all of the cases that the surgeon's impression was negative, the pathology was negative as well (100% negative predictive value). Overall, the surgeon's intraoperative comments had a 100% sensitivity to detect giant cell arteritis. The specificity and accuracy values were 97.9% and 98.2%, respectively. CONCLUSION: The surgeon's intraoperative evaluation of the temporal artery may be extremely valuable in predicting the biopsy result and may allow the surgeon to determine whether steroids could be discontinued in patients in whom the clinical history is not highly suggestive of giant cell arteritis.

Pediatric ocular acne rosacea: long-term treatment with systemic antibiotics.

PURPOSE: To report our experience with four cases of pediatric ocular acne rosacea, including responses to long-term systemic treatment. DESIGN: Retrospective interventional case series. METHODS: The medical records of four consecutive cases diagnosed with pediatric ocular acne rosacea over a period of 36 months were reviewed. Diagnostic criteria were meibomian gland dysfunction, blepharitis, lid margin telangiectasia, punctate superficial keratopathy, and conjunctival hyperemia with or without inferior corneal vascularization. RESULTS: The patients, aged between four and 12, were all females with bilateral disease. Meibomitis, blepharitis, conjunctival hyperemia, and punctuate epitheliopathy was evident in each case. Cutaneous involvement was seen in two cases (50%), and limbal vascularization with subepithelial or stromal infiltrates was present in three cases (75%). One case showed corneal ulceration at presentation. All four children received systemic doxycycline or erythromycin for at least 12 months and showed considerable improvement within the first month of therapy. No recurrence was noted within the mean 25.5 months of follow-up. None of the girls experienced any side effects during the long treatment duration. CONCLUSIONS: Ophthalmologists should consider acne rosacea as a potential diagnosis for any child who has any combination of meibomian disease, chronic blepharitis, recurrent chalazia, and chronic symptoms of photophobia, ocular irritation, and redness that does not respond to routine medical treatment. Such patients respond very well to long-term treatment with systemic erythromycin/doxycycline.

Clinical Spectrum and Treatment Approaches in Corneal Burns.

OBJECTIVES: To evaluate the clinical findings, treatment modalities and long-term prognosis of chemical and thermal burns of the cornea. MATERIALS AND METHODS: Twenty-one patients (27 eyes) who were followed at two centers for corneal chemical and thermal burns between 2001 and 2013 were included. Eyes were grouped into four grades according to the severity of burn using Roper-Hall classification. Age, gender, type of burn, follow-up duration, corrected visual acuity before and after treatment, treatment modalities and complications were recorded. Patients received medical treatment or combined surgical treatment including amniotic membrane transplantation (AMT), conjunctivolimbal autograft/allograft (CLAU/CLAL) transplantation, keratolimbal allograft (KLAL) or penetrating keratoplasty (PKP). RESULTS: Patients had a mean age of 27.1±15.5 years (range, 6 months-56 years) and were followed for a mean 63.2±58.6 weeks (4-160 weeks). Significant improvement was achieved with medical treatment alone in patients with grade I (4 eyes) and 2 burns (8 eyes). Patients with grade III burns (11 eyes) underwent CLAU (6 eyes), combined AMT/CLAU (3 eyes), AMT/CLAL (1 eye), or CLAL+PKP (1 eye), while patients with grade IV burns (4 eyes) had keratectomy+CLAL/AMT (1 eye), keratectomy+CLAL+PKP after recurrence with CLAU/AMT (1 eye), CLAU+PKP (1 eye), and AMT/KLAL+PKP (1 eye). All patients except the latter showed ocular surface stabilization with these procedures. CONCLUSION: Ocular burns cause severe impairment of the ocular surface. It is possible to achieve good results with appropriate medical treatment and surgeries including ocular surface reconstruction.

Effect of topical brinzolamide 1% and brimonidine 0.2% on intraocular pressure after phacoemulsification.

PURPOSE: To compare the effectiveness of brinzolamide 1% (Azopt) and brimonidine 0.2% (Alphagan) with a placebo in preventing an early increase in intraocular pressure (IOP) after phacoemulsification. SETTING: Department of Ophthalmology, Baskent University, School of Medicine, Ankara, Turkey. METHODS: In this prospective double-masked study, 90 eyes of 90 patients having clear corneal phacoemulsification were randomly divided into 3 groups of 30 eyes each. One hour before surgery, 1 group received 1 drop of brinzolamide 1%, another received 1 drop of brimonidine 0.2%, and the third received 1 drop of a balanced saline solution (placebo). The IOP was measured preoperatively and 3 and 16 to 20 hours postoperatively. RESULTS: Three hours postoperatively, the mean IOP increased by 4.2 mm Hg +/- 7.0 (SD), 3.2 +/- 6.4 mm Hg, and 5.3 +/- 4.2 mm Hg in the brinzolamide, brimonidine, and placebo groups, respectively. The IOP increase from baseline was significant in all 3 groups (all P<.01), with no difference between the groups (P>.05). The change in IOP at 16 to 20 hours was 0.2 +/- 2.8 mm Hg, 0.2 +/- 2.4 mm Hg, and -0.8 +/- 2.4 mm Hg, respectively. The changes were not significant compared to baseline (all P>.05). Six eyes (20%) in the brinzolamide group, 5 eyes (16.7%) in the brimonidine group, and 7 eyes (23.3%) in the placebo group had an IOP higher than 25 mm Hg 3 hours postoperatively; the difference between groups was not significant (P =.8). CONCLUSION: Prophylactic use of 1 drop of brinzolamide or brimonidine was not more effective than a placebo in controlling early postoperative IOP elevations after clear corneal phacoemulsification.