Incidence of Sympathetic Ophthalmia after Intraocular Surgery: A Systematic Review and Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a rare bilateral granulomatous panuveitis that can present after trauma or intraocular surgery (IOS). The incidence of SO after IOS varies among studies. The purpose of this review was to determine the incidence proportion of SO after IOS. CLINICAL RELEVANCE: The incidence proportion of SO after IOS can provide physicians and patients with information on the risk of SO during the consent process before surgery. METHODS: In this systematic review and meta-analysis, MEDLINE, EMBASE, and Cochrane databases were searched from inception to January 1, 2023 for population-based studies of SO after IOS. Two reviewers independently screened the results. Random-effects meta-analyses calculated incidence proportion. Subgroup analysis assessed SO incidence based on IOS type and technological advancements. Study quality and bias were assessed using the Newcastle-Ottawa scale and the Grades of Recommendation, Assessment, Development, and Evaluation framework. RESULTS: The final meta-analyses included 19 studies, with 118 cases of SO occurring after 505 178 inciting events. The estimated overall incidence proportion of SO after IOS was 0.061% (95% confidence interval [CI], 0.033%-0.111%; I2 = 83%), and the estimated incidence rate was 9.24 cases per 100 000 person-years (95% CI, 4.03-21.19; I2 = 88%). The average study duration across these studies was 10.8 years. Within the reviewed literature, SO after glaucoma and vitreoretinal IOS was studied most, with 9 and 6 studies, respectively. Observed differences in incidence between glaucoma (0.098%; 95% CI, 0.042%-0.232%; I2 = 40%) and vitreoretinal (0.043%; 95% CI, 0.022%-0.085%; I2 = 88%) IOS were not statistically significant (P = 0.14). Also, no significant difference was found in the incidence proportion before and after 1975, when modern intraocular surgical techniques emerged (0.060% vs. 0.058%; P = 0.98). The outcome measures showed low-certainty Grades of Recommendation, Assessment, Development, and Evaluation evidence. DISCUSSION: Sympathetic ophthalmia after IOS is rare and might not have changed over the past 5 decades. The estimated incidence proportion of SO may be useful during the consent process before surgery. Also, no significant difference may exist in the incidence of SO between glaucoma and vitreoretinal IOS, based on low-certainty evidence. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The Role of Denosumab Treatment in Recurrent Giant Cell Bone Tumor of the Orbit.

Giant cell tumor of the bone (GCTB) is a rare primary bone neoplasm, representing about 5% of all primary bone tumors. Most GCTBs are found in the epiphysis of long bones, with only 2% of GCTBs involving the skull. In recent years, the receptor activator of nuclear factor Kappa ligand monoclonal antibody denosumab has been demonstrated as a promising therapeutic option for GCTB; however, this is an evolving field. We present a case of a 57-year-old female with a rare GCTB in the right orbit and sinuses, originally thought to be an aneurysmal bone cyst. Her symptoms included proptosis, intermittent blurry vision, sinus congestion, and frontal headaches. After excision, the tumor recurred within 18 months. Upon repeat excision, a diagnosis of GCTB was made. The patient started denosumab therapy and had no tumor growth over the ensuing 2 years, with stability of symptoms and clinical signs on follow-up.

Evaluating ChatGPT on Orbital and Oculofacial Disorders: Accuracy and Readability Insights.

PURPOSE: To assess the accuracy and readability of responses generated by the artificial intelligence model, ChatGPT (version 4.0), to questions related to 10 essential domains of orbital and oculofacial disease. METHODS: A set of 100 questions related to the diagnosis, treatment, and interpretation of orbital and oculofacial diseases was posed to ChatGPT 4.0. Responses were evaluated by a panel of 7 experts based on appropriateness and accuracy, with performance scores measured on a 7-item Likert scale. Inter-rater reliability was determined via the intraclass correlation coefficient. RESULTS: The artificial intelligence model demonstrated accurate and consistent performance across all 10 domains of orbital and oculofacial disease, with an average appropriateness score of 5.3/6.0 ("mostly appropriate" to "completely appropriate"). Domains of cavernous sinus fistula, retrobulbar hemorrhage, and blepharospasm had the highest domain scores (average scores of 5.5 to 5.6), while the proptosis domain had the lowest (average score of 5.0/6.0). The intraclass correlation coefficient was 0.64 (95% CI: 0.52 to 0.74), reflecting moderate inter-rater reliability. The responses exhibited a high reading-level complexity, representing the comprehension levels of a college or graduate education. CONCLUSIONS: This study demonstrates the potential of ChatGPT 4.0 to provide accurate information in the field of ophthalmology, specifically orbital and oculofacial disease. However, challenges remain in ensuring accurate and comprehensive responses across all disease domains. Future improvements should focus on refining the model's correctness and eventually expanding the scope to visual data interpretation. Our results highlight the vast potential for artificial intelligence in educational and clinical ophthalmology contexts.

A Novel Report of Suspected Prostate Adenocarcinoma to Orbital Roof Meningioma Metastasis.

: Tumor-to-meningioma metastasis (TTMM) is an uncommon phenomenon, in which a primary malignant tumor metastasizes to a recipient preexisting meningioma. Herein, the authors report a case of a 74-year-old man with a known history of metastatic prostate adenocarcinoma who with frontal headache and right orbital apex syndrome. Initial CT studies demonstrated a right orbital roof osseous lesion. Subsequent MRI was reported as characteristic of an intraosseous meningioma with intracranial and intraorbital extensions. A biopsy of the right orbital mass was obtained and returned a diagnosis of metastatic prostate cancer. The combination of imaging and pathologic findings suggested that the clinical scenario was overall most in keeping with a skull bone-based prostate adenocarcinoma metastasis infiltrating a preexisting meningioma. This is a rare case of TTMM in an orbit-based meningioma, presenting with an orbital apex syndrome.

Outcomes of Endonasal Dacryocystorhinostomy Performed for Functional Nasolacrimal Obstruction With Delay on Dacryoscintigraphy.

PURPOSE: To report the demographics and outcomes of endonasal dacryocystorhinostomy (DCR) following dacryoscintigraphy (DSG) performed for a series of patients with functional epiphora. METHODS: Case series of endonasal DCR outcomes in patients with symptomatic epiphora with no evidence of lacrimal hypersecretion or lacrimal pump failure, minimal regurgitation noted on syringing, and DSG-confirmed delayed drainage. A successful outcome was defined as 80% subjective improvement or resolution of tearing on the operated side. Patient charts, DSG results, and operative records were examined, and data were collected. Relevant literature was reviewed and discussed. RESULTS: The case series included 15 eyes of 10 patients. The mean age was 61.7 years at the time of surgery. Most cases (n=13) had post-sac obstruction, retention, or delay. One patient had pre and post-sac retention. A total of 12 cases had success after endonasal DCR, and 3 cases had failure. Follow-up for all operated patients was over 6 months. There were no reported complications by the surgeon or patients. CONCLUSIONS: Patients with functional epiphora confirmed by DSG seem to have a high success rate after endonasal DCR. In patients with symptomatic epiphora with subjective patency on syringing, the use of DSG in decision-making and outcome prediction may be supported. Further studies, including clinic-based tests, to demonstrate functional obstruction are warranted.

Influence of orbital decompression on upper eyelid retraction in Graves' orbitopathy: a systematic review and meta-analysis.

Graves'-associated upper eyelid retraction (GAUER) is the commonest manifestation of orbitopathy in adults. Surgical management typically follows a 3-step staged approach commencing with orbital decompression. The rationale behind this is that certain surgical interventions can influence the parameters and outcomes of subsequent procedures. We performed a systematic review and meta-analysis evaluating the effects of orbital decompression on GAUER in adult patients with Graves' orbitopathy. All original English, non-pediatric studies meeting the study inclusion criteria from the last 20 years were included. The characteristics of margin reflex distance 1 (MRD-1) pre- and post-orbital decompression of 688 orbits were collected, and a meta-analysis of 472 orbits was performed. The average reduction in MRD-1 across 688 orbits was found to be 0.40 mm. Meta-analysis of 6 applicable articles demonstrated that orbital decompression decreases MRD-1 by an average of 0.35 mm (n = 472, p = .007, 95% CI = [0.08, 0.63]). This study demonstrates that although statistically significant, orbital decompression does not appear to have a clinically significant effect on GAUER. This has implications for clinical practice, namely the likely requirement of eyelid surgery following or in combination with orbital decompression, and the importance of counselling patients on this preoperatively.

Periocular invasive melanoma manifestation in a patient using bimatoprost: case report and literature review.

Prostaglandin F2a analogs (PGAs) are considered efficacious in the first-line treatment of glaucoma. They have however been associated with a number of periocular side effects. We present a case of periocular hyperpigmentation and progression to lentigo maligna melanoma (LMM) in a patient using bimatoprost eye drops. We conducted a literature review regarding the etiology and pathophysiology of periocular pigmentation in this setting.A 71-year-old female Caucasian patient with open-angle glaucoma using bimatoprost exclusively in her right eye noticed an ipsilateral lower eyelid/upper cheek area dark lesion after commencing treatment. Examination demonstrated a heterogeneously pigmented lesion. Excisional biopsy demonstrated extensive lentigo maligna (melanoma in situ) with superficially invasive malignant melanoma in the lesion center. The patient underwent successful staged excision and reconstruction. Literature review has demonstrated case reports supporting periocular hyperpigmentation; however, there has been no description of progression to periocular lentigo maligna and melanoma in a patient using bimatoprost.

Congenital Aberrant Lacrimal Gland Ductules Presenting as a Nonhealing Upper Eyelid Lesion.

A 2-year-old girl presented with a history of a recurrent painless red and swollen lesion on the right upper eyelid. Examination demonstrated an 8.0-mm erythematous papule with overlying crusting skin in the lateral aspect of the right upper eyelid. Probing under general anesthesia revealed openings in the right temporal brow region and upper eyelid that led to aberrant ductules traveling toward the lacrimal gland. The temporal ductule was surgically excised, whilst the eyelid ductule was redirected to the fornix.

Outcomes of conjunctival-Müller's muscle resection surgery with and without epinephrine in local anesthetic.

PURPOSE: To determine the effect of epinephrine as an anesthetic adjunct on outcomes of conjunctival-Müller's muscle resection (CMMR) ptosis surgery. METHODS: A retrospective cohort study of patients having undergone CMMR with plain local anesthetic (LA) and local anesthetic combined with epinephrine (LA+Epi). Two measures of success were investigated: margin to reflex distance 1 (MRD1) success and overall success. MRD1 success was defined as a postoperative MRD1 between 2-4 mm. Overall success was defined as all of i) MRD1 success, ii) a ≤ 1 mm difference between the eyelid height following the preoperative phenylephrine test and post-operative MRD1 (PE-MRD1 Δ), and iii) symmetrical postoperative contour between both upper eyelids. Study inclusion criteria included blepharoptosis from levator aponeurotic dehiscence and satisfactory response to the phenylephrine test. Exclusion criteria included congenital ptosis, ptosis secondary to another cause, previous ipsilateral eyelid surgery, or a medical condition that may have impacted surgery. RESULTS: There were 26 eyelids in the LA+Epi group, and 19 eyelids in the LA group. There was no difference in the two groups in age (P =0.28), pre-operative MRD1 (P =0.37), levator function (P =0.27), intraoperative tissue resection amount (P =0.27), number of weeks postoperatively at final MRD1 measurement (P =0.99), and PE-MRD1 Δ (P =0.08). All patients achieved a symmetrical post-operative eyelid contour. The LA+Epi group had a higher attainment of MRD1 success (P =0.04) and overall success (P =0.045). CONCLUSIONS: Epinephrine as an anesthetic adjunct improves CMMR outcome. This suggests its use can be considered the standard of care.

Eyelid-Cheek Junction Soft-Tissue Perineurioma: Case Report and Controversies.

Perineurioma is a rare soft-tissue tumor with characteristic histologic and immunohistochemical features. The diagnosis; however, can be met with certain challenges. A 71-year-old woman presented with an enlarging painless mass in the right lower eyelid-cheek junction. The lesion presented as a raised overhanging trunk-shaped mass. An excisional biopsy and local reconstruction were performed. The overall morphology and immunohistochemical findings were most supportive of a cellular soft-tissue perineurioma, with differential diagnoses including dermatofibroma. To the authors' knowledge, this is the first histopathologically reported case of a superficially occurring soft-tissue perineurioma in the eyelid-cheek junction. The authors discuss the presentation, relevant literature, and controversies associated with this diagnosis.

Terminology and Etymology in Oculoplastic Surgery.

PURPOSE: To provide a collection of important terms in oculoplastic surgery, their etymology, current usage, and clarification of terms with overlapping or often misconstrued definitions. METHODS: Commonly employed terms in oculoplastic surgery were collected, and their etymologies were determined. The authors then examined how these terms are being currently used in the published literature to determine how closely their usage matched the origin of the terms, if any terms had developed multiple meanings, or if multiple terms were being used to describe the same concept. RESULTS: This article assembles in one area much of the important terms in oculoplastic surgery, highlighting how the etymology of the terms both links to their meanings as well as clarifies the appropriate usage of terms that have evolved to develop several different definitions. Special attention is placed on clarifying the correct definitions of closely related but distinct terms. CONCLUSIONS: Most terms in ophthalmology are used in a uniform manner across the literature with definitions closely matching their etymology, but some terms in oculoplastic surgery are being used in a potentially confusing overlapping manner and warrant clarification.

A Systematic Review and Meta-analysis of Methods for Reducing Local Anesthetic Injection Pain Among Patients Undergoing Periocular Surgery.

PURPOSE: Various factors help minimize pain during the injection of local anesthetic. The majority of current evidence involves nonspecific injection sites. The objective of this review was to provide a comprehensive summary of all existing evidence for methods used to reduce injection pain specifically in the context of periocular procedures. METHODS: A literature search of the MEDLINE, EMBASE, and Scopus databases was conducted to identify all relevant experimental and observational studies from 1946 to 2018. Studies were included of patients undergoing periocular surgery under subcutaneous local anesthesia whereby outcomes were reported following a specific intervention intended to help reduce pain. Risk of bias was assessed using recognized tools. A subgroup meta-analysis was performed to indirectly compare pooled intervention-versus-control differences for various pain reduction interventions. RESULTS: Following the review of 2089 search results, 23 articles representing 1135 patients were included. The methods assessed in the studies included choice of anesthetic agent, buffering, warming, dilution, needle type, administration of an inhalational anesthetic, application of topical anesthetics, iontophoresis, skin cooling with ice, tactile distraction with vibration, and decreasing the rate of injection. CONCLUSIONS: Methods demonstrating best efficacy included solution modification (buffering, dilution, warming), skin cooling with ice, vibration, transconjunctival topical anesthetic before injection, and decreased rate of injection. Further study is warranted for modification of equipment factors, topical anesthetics, and strategies to reduce pain because of anesthetic infiltration.

Perceptions and use of computer-assisted surgery (CAS) in the orbit.

Computer-assisted surgery (CAS) plays a prominent role in certain surgical disciplines. We investigated the current perceptions and use of this technology for orbital surgery. An online survey was emailed to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Society of Oculoplastic Surgery, and British Oculoplastic Surgery Society. Respondents were asked to describe their practice type and seniority, their frequency of orbital surgery, experience, use, and accessibility of CAS, and their opinion on the technology. There were a total of 151 responses across the societies. 105 respondents (69.5%) had been in attending/consultant practice for over 10 years, with over half (54.7%) working in academic/teaching hospitals. The majority (66.7%) had superficial or no experience with CAS. In total, 84.8% of respondents rarely or never use CAS for orbital surgery (n = 128). Posterior orbital surgery (64.2%) and orbital decompression (49.0%) were the two most useful reasons to implement CAS. Longer operating time (58.3%) and cost (54.8%) were the two most selected weaknesses for CAS, whereas improved accuracy in attaining surgical end point(s) (80.8%) and patient safety (63.6%) were the principal advantages. Type of practice was significantly associated with CAS availability/accessibility (p < 0.05). Proportion of orbital surgery performed in practice was significantly associated with both CAS experience and use (p < 0.05). Our study confirms an expected variation in the perception and use of CAS for orbital surgery. Demonstrated patient benefit and integration of refined and cost-effective CAS systems into operating room environments may influence its future role.

Complete ophthalmoplegia in Ipilmumab and Nivolumab combination treatment for metastatic melanoma.

Ipilimumab and Nivolumab are novel monoclonal antibodies that have recently been used successfully for treatment of metastatic melanoma. Ipilimumab is a human monoclonal antibody against Cytotoxic T Lymphocyte Antigen 4 (CTLA4) receptor, which suppresses T-cell proliferation and stimulates an inflammatory response against cancer cells. Nivolumab is an IgG4 monoclonal antibody against the cytotoxic T lymphocyte associated programmed death 1 receptor (PD-1). Ipilimumab and Nivolumab combination treatment has been shown to induce remission and prolong survival in patients with metastatic melanoma. The side effect profile of these medications has not been well studied. One entity of the side effects reported in the literature is immune-related adverse events (irAEs). There have been few case reports where these events were serious and irreversible. In this case report, we describe a fatal and severe diffuse panmyositis that involved the cardiac, respiratory, and extraocular muscles in a patient with metastatic melanoma secondary to combination treatment with Ipilimumab/Nivolumab.

Is gastroesophageal reflux disease associated with primary acquired nasolacrimal duct obstruction?

PURPOSE: To determine if patients with primary acquired nasolacrimal duct obstruction (PANDO) have an increased prevalence of gastroesophageal reflux disease (GERD) compared to the general population. METHODS: Cross-sectional case-control study. The Mayo Clinic Reflux Disease Questionnaire (RDQ) is used to help physicians diagnose GERD. The retrospective group consisted of patients who previously had a dacryocystorhinostomy (DCR) over a 4-year period by one surgeon (JTH) at one institution. The prospective group included consecutive patients undergoing DCR over an 8-month period for PANDO. The control group consisted of patients at our institution who did not have complaints related to nasolacrimal duct obstruction (NLDO) or a known history of NLDO. The RDQ score or a previous diagnosis of GERD was recorded for each patient. The prevalence of patients with GERD in each of the groups was compared to that in the control group using the Fisher exact test. RESULTS: Nine (7.7%) of 117 patients in the control group were found to have GERD. Twenty-four of 65 (36.9%) patients in the retrospective cohort were found to have GERD. Twelve of 18 (66.7%) patients in the prospective cohort were found to have GERD. When the prospective and retrospective groups were compared to the control group, the presence of GERD was higher in patients with NLDO (p < .0001). CONCLUSION: Based on the results of this study and compared to the general population, GERD has an increased prevalence in patients with PANDO. GERD may have a role in the development of PANDO.

Endovascular Management of a Traumatic Infraorbital Pseudoaneurysm Causing Orbital Compartment Syndrome.

An 89-year-old woman presented after blunt injury to the left orbit from a fall. Examination findings were suggestive of left-sided orbital compartment syndrome, unresponsive to emergent lateral canthotomy and cantholysis. CT revealed a left-sided orbital floor blowout fracture involving the infraorbital canal, with a large maxillary and infraorbital hematoma. Angiography revealed a pseudoaneurysm supplied by the infraorbital artery. Interventional neuroradiology successfully achieved hemorrhage control by endovascular obliteration of the parent artery close to the pseudoaneurysm. To our knowledge, this is the first reported case of successfully managing active intraorbital hemorrhage causing orbital compartment syndrome by endovascular vessel sacrifice of an infraorbital artery pseudoaneurysm.

Bell's facial nerve palsy in pregnancy: a clinical review.

Bell's facial nerve palsy (FNP) during pregnancy and the puerperium can present significant challenges for the patient and clinician. Presentation and prognosis can be worse in this group of patients. This article reviews the background, manifestation and management options of FNP. In particular, it focuses on the controversies that exist regarding corticosteroid use during pregnancy and outlines approaches to diagnosis and treatment. Based on this review, we recommend an early evidence-based approach using guidelines derived from non-pregnant populations. This includes assessment for atypical causes, a multidisciplinary input and early introduction of corticosteroids to limit progression and improve prognosis.