Reverse Lid Swinging Approach: A Case Series.

In this report, the authors describe the reverse lid swinging approach, which comprises lateral canthotomy, superior lateral cantholysis to free the upper eyelid, and an incision at the superonasal conjunctival fornix for orbital exposure. Four patients underwent orbitotomy using the reverse lid swinging approach for orbital tumor removal (n = 3) or orbital abscess drainage (n = 1). All 4 operations were uneventful, with no optic nerve dysfunction or extraocular dysmotility over the follow-up period. Satisfactory cosmesis was achieved with no visible external scar in all cases. The reverse lid swinging approach provides easy access to medial orbital lesions as demonstrated in the present case series.

Survey of ptosis practice patterns among surgeons in Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS).

OBJECTIVE: To characterize the preferred ptosis practice patterns and variations among oculoplastic surgeons in the Asia-Pacific region. METHODS: A web-based questionnaire was sent to both members and non-members registered under the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS)'s email database. The survey included preoperative testing practices, surgical preferences for adult aponeurotic and congenital ptosis, various surgical techniques (anterior and posterior approach ptosis procedures, and frontalis sling procedures) and postoperative practices. RESULTS: A total of 386 survey invitations were sent. There was a response rate of 68.7% from respondents from 20 countries in the Asia-Pacific region. There was variation in the preoperative evaluation and management of ptosis. Anterior approach ptosis surgery (96.6%) and frontalis sling procedures (86.8%) were performed by more surgeons than posterior approach ptosis surgery (47.2%). There was a deviation from the traditional frontalis sling procedures for patients with poor levator function. CONCLUSIONS: Our survey results provide insight into the variation in the assessment and management of ptosis amongst oculoplastic surgeons in the Asia-Pacific region. It also demonstrates some differences between practice patterns in Asia-Pacific and America.

Atypical mycobacterium infection following upper eyelid Müller's muscle-conjunctival resection - case report.

Periorbital non-tuberculous mycobacterium (NTM) infections are uncommon. To the best of our knowledge, NTM infection as a complication following Müller's muscle-conjunctival resection (MMCR) surgery has not been reported before. We report a case of left upper lid M. Chelonae infection following MMCR surgery. A 61-year-old lady presented with left upper lid swelling and nodular mass 4 weeks after bilateral MMCR surgery for aponeurotic ptosis. Past medical and ocular history include systemic lupus erythematosus (SLE), chronic hepatitis B infection, bilateral cataract operation done 14 years ago and right eye Fuch's dystrophy with Descemet stripping automated endothelial keratoplasty done 3 years ago. She was initially treated with topical and oral antibiotics, as well as repeated incision and curettage and intralesional steroid injection with limited improvement. Seven months post-MMCR, repeated biopsy and nodule debulking were performed. Biopsy revealed granulomatous inflammation with mycobacterial infection and PCR identified M. Chelonae. A total of 6 months course of combination systemic antibiotics were given, with good response. Limited blepharoplasty with repeat nodular excision was performed 15 months after the initial MMCR surgery, and biopsy culture and PCR were both negative. No relapse of symptoms was noted and good lid height was maintained at 30 months of follow-up. Management of periorbital NTM infections can be challenging. Clinicians should consider early diagnostic workup with mycobacterial culture and PCR in suspicious cases, followed by prompt initiation of empiric treatment with systemic macrolides. A combination of surgical excision of nodules and prolonged systemic antimicrobial treatment is needed for complete organism eradication.

Giant Fornix Syndrome: How Much Conjunctiva Should Be Resected?

PURPOSE: To characterize clinical profiles of Chinese patients with giant fornix syndrome (GFS), compare surgical outcomes with amount of Müller's muscle-conjunctival resection (MMCR), and elicit risk factors for those who have prolonged recovery after MMCR. METHODS: Retrospective, observational, interventional cohort study on GFS eyes. Two treatment groups were established: limited MMCR-as defined by 8 mm or less resection; maximal MMCR-as defined by 10-12 mm resection. Good responders were defined as eyes exhibiting disease resolution within 3 months after surgery. Primary outcome was disease resolution, secondary outcome was ptosis improvement. RESULTS: Mean age was 81.9 years old (range, 76-89), with 6 (75%) females and 2 (25%) males. All 10 eyes presented with discharge, partial ptosis, and conjunctival injection. In the limited MMCR group, time to symptom resolution was longer at 5.56 months, while maximal MMCR group was 2.02 months (p = 0.004). Limited MMCR group also had lower primary surgical success and required additional surgery compared with maximal MMCR group (p = 0.008). At mean follow up of 34.4 months (range, 11-65 months), all eyes achieved disease resolution, no recurrence, and ptosis improvement. CONCLUSIONS: In the largest series on Chinese eyes with GFS to date, GFS is mainly a disease in elderly females. Maximal MMCR has a higher rate of surgical success with no additional complications. For those who underwent MMCR, additional treatment such as topical steroids and fortified antibiotics do not affect time to recovery. These findings may help ophthalmologists consider maximal MMCR as a definitive surgical treatment in GFS eyes.

Oculoplastic surgical simulation using goat sockets.

PURPOSE: To describe a reproducible and easily available goat socket model for training of various oculoplastic operations, and to evaluate trainees' perception of this training model in terms of their learning progress and satisfaction. METHODS: Goat sockets including orbital rim and eye with eyelids were harvested in form of a split-head model. Ophthalmology residents underwent individual surgical training using the goat socket model, supervised by an oculoplastic attending. Participants completed a questionnaire in form of a 5-point Likert Scale to evaluate their learning progress and satisfaction. OUTCOME MEASURES: Types of oculoplastic operations performed using the goat socket models, and participants' rating of their learning progress and satisfaction were reported. RESULTS: A wide range of oculoplastic operations including both eyelid and orbital operations could be simulated because of similarities of the goat eye model to the human eye anatomy. Fifteen ophthalmic trainees participated in surgical training using the goat eye model. All (100%) participants agreed that surgical simulation using the goat socket model increased their skills in surgical instrumentation and carrying out surgical steps, and their confidence in operating on patients. Most (87%) agreed the model resembled reasonably well compared to surgeries in human, and 93% would recommend training with the model to fellow resident ophthalmologists before operating on human patients. CONCLUSIONS: Oculoplastic surgical training using goat sockets is simple, readily available, and inexpensive. Trainee users showed promising feedback and positive learning progress using the goat socket model.

Transnasal Endoscopic Sclerotherapy for Orbital Apex Lymphatic Malformation.

Orbital lymphatic malformations are benign, slowly progressive vascular malformations. Management of these malformations is challenging due to their infiltrative and diffuse nature. The authors present a case with orbital apex lymphatic malformation treated with transnasal endoscopic sclerotherapy.

Extraocular silicone oil migration to orbit and retrolaminar region: case report and systematic review.

BACKGROUND: Silicone oil insertion is a common modality in vitreoretinal surgeries. The purpose of this study is to conduct a systematic review to summarize the uncommon complication of extraocular silicone oil migration. METHODS: Following the PRISMA guidelines, a systematic review of the literature was performed on January 11, 2020, using PubMed and EMBASE with the following terms: "silicone oil," "eye," and "migrat*." RESULTS: A total of 69 patients-68 patients from 59 articles and one case from our institution-were included in the final analysis. The median age was 54 years (range, 9-92) and 40 patients (57.9%) were men. Orbital migration was reported in 34 patients, and retrolaminar migration (including optic nerve, optic chiasm, suprasellar, subarachnoid space, intraventricular spaces) was reported in 35 patients. Orbital migration group had more aphakics (p = 0.007), implanted glaucoma drainage device (p = 0.005), scleral buckle (p = 0.000), history of trauma-related indications for pars plana vitrectomy (p = 0.000), shorter silicone oil endotamponade time (p = 0.008), more symptomatic (p = 0.000), and requiring surgical intervention (p = 0.000). Retrolaminar migration group had older patients (p = 0.016) and more diabetics (p = 0.041). CONCLUSION: Systematic review sheds light on plausible risk factors on site of silicone oil migration. Majority of orbital cases are symptomatic and require intervention while retrolaminar cases are incidental and can be managed conservatively. Awareness of this complication can help guide clinicians predict which patients would likely need surgical intervention. Graphical abstract.

Oculoplastic surgery practice during the COVID-19 novel coronavirus pandemic: experience sharing from Hong Kong.

At present, all parts of the world are hit hard by COVID-19. The first confirmed case of COVID-19 in the territory of Hong Kong was announced on January 23, 2020. Since then, oculoplastic surgeons in Hong Kong have been taking every measure to protect all healthcare workers and patients from contracting the disease. This paper aims to share the experiences of and measures taken by local oculoplastic surgeons in combating COVID-19. Three main aspects are discussed, namely clinical, administrative, and training and educational. We hope our experiences would provide reference to fellow oculoplastic colleagues in other parts of the world in fighting this COVID-19 pandemic.

Medical and sclerosing agents in the treatment of orbital lymphatic malformations: what's new?

PURPOSE OF REVIEW: Currently, there is no ideal management for orbital lymphatic malformations. Significant advances have been made since the discovery of new agents in the treatment. The purpose of this manuscript is to review the recent evidence on new sclerotherapy agents and systemic medications. RECENT FINDINGS: Traditional sclerosants are OK-432, sodium tetradecyl sulphate and ethanol. More recent developments are the use of doxycycline, bleomycin, and pingyangmycin. Sirolimus as a systemic medication has revolutionized the medical management of lymphatic malformations. Other oral drugs such as propranolol and sildenafil are controversial. Future treatment involves targeting lymphangiogenic pathways including inhibition of vascular endothelial growth factors and the phosphatidylinositol 4,5-bisphosphate 3-kinase catalytic subunit. SUMMARY: The development of new agents allows multimodal management either as monotherapy or combined therapy to achieve better outcomes in this difficult to manage disease.

Unilateral Eyelid Swelling as a Sign of Antimelanoma Differentiation-Associated Gene 5 (Anti-MDA5)-Antibody-Positive Dermatomyositis.

The authors describe a 40-year-old woman who presented with unilateral eyelid swelling, and later on developed heliotrope rash, extensive oral and cutaneous ulcers, and muscle weakness. She was diagnosed with dermatomyositis associated with antimelanoma differentiation-associated gene 5 antibody. Even after combination of immunosupressants including a corticosteroid, tacrolimus, and rituximab, her eyelid swelling and oral ulcers progressively worsened. Administration of loading and then monthly intravenous immunoglobulin resulted in clinical remission, suggesting that intravenous immunoglobulin could be a useful remedy in cases refractory to conventional immunosuppressive agents, especially those with antimelanoma differentiation-associated gene 5 antibody-dermatomyositis.

Preferred practice patterns in endoscopic dacryocystorhinostomy among oculoplastic surgeons in Asia-Pacific region.

PURPOSE: The aim of this study is to report the preferred practice patterns in endoscopic dacryocystorhinostomy (EnDCR) among oculoplastic surgeons practicing in the Asia-Pacific region. METHODS: A detailed survey with 40 questions was electronically disseminated among oculoplastic surgeons practicing in Asia-Pacific region. The mailing list included targeted members of the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery and nonmembers from the contact directories of the two senior authors. Data collected include demographics, training, surgical techniques, postoperative care, and outcomes. RESULTS: The majority of surgeons performed a preoperative nasal endoscopy (76.2%, total respondents (n) = 122), and most preferred a general anesthesia for endoscopic DCRs (51.9%, n = 104). The majority of surgeons believed in preserving nasal mucosal and the lacrimal sac flaps and adjunctive endoscopic procedures were performed when required (58.4%, n = 101). Routine lacrimal sac wall biopsy for histopathology was not a preferred practice. The practice of routine silicone intubation was more common than the use of topical adjunctive. The majority of surgeons (52.6%, n = 97) took 31-60 minutes to complete a unilateral endoscopic DCR. Postoperative routine nasal douching and ostium cleaning were not widespread practices. The self-reported outcomes were good. CONCLUSION: A significantly high percentage of oculoplastic surgeons from Asia-Pacific perform endoscopic DCR. Although the range of practice patterns is wide, there is increasing uniformity in surgical techniques with regard to endoscopic DCR as compared to the previous surveys.

Safety and efficacy of adjunctive intranasal mitomycin C and triamcinolone in endonasal endoscopic dacryocystorhinostomy.

One of the common causes of failure in dacryocystorhinostomy for nasolacrimal duct obstruction (NLDO) is mucosal scarring and fibrosis around the ostium. Steroid and mitomycin C (MMC) can potentially reduce scarring by their action on the inflammatory and proliferative phase of wound healing, respectively. The purpose of this study is to evaluate the safety and efficacy of combined usage of adjunctive MMC and intranasal triamcinolone (TA) in endonasal endoscopic dacryocystorhinostomy (EE-DCR). This is a retrospective interventional case series. All patients underwent mechanical EE-DCR in two regional hospitals in Hong Kong from January 2005 to December 2006 were included. All received intraoperative MMC application for 5 min and gelfoam soaked with TA onto the ostium. Main outcome measures include the anatomical and functional success rate at follow-up at least 6 months after operation. Other outcomes include complications occurred during and after operation. A total of 73 EE-DCR were performed in 69 patients. Three patients had simultaneous bilateral DCR; one had sequential DCRs for both sides. At the last follow-up, anatomical success was achieved in 68 cases (93 %) and both anatomical with functional success in 67 cases (92 %). No major complication was observed. Minor complications included asymptomatic mucosal adhesion between the nasal septum and lateral nasal wall in one patient and moderate secondary hemorrhage in another. EE-DCR with adjunctive MMC and TA is a safe and successful procedure for the treatment of NLDO.

A survey of perceived training differences between ophthalmology residents in Hong Kong and China.

BACKGROUND: To study the differences in ophthalmology resident training between China and the Hong Kong Special Administrative Region (HKSAR). METHODS: Training programs were selected from among the largest and best-known teaching hospitals. Ophthalmology residents were sent an anonymous 48-item questionnaire by mail. Work satisfaction, time allocation between training activities and volume of surgery performed were determined. RESULTS: 50/75 residents (66.7 %) from China and 20/26 (76.9 %) from HKSAR completed the survey. Age (28.9 ± 2.5 vs. 30.2 ± 2.9 years, p = 0.15) and number of years in training (3.4 ± 1.6 vs. 2.8 ± 1.5, p = 0.19) were comparable between groups. The number of cataract procedures performed by HKSAR trainees (extra-capsular, median 80.0, quartile range: 30.0, 100.0; phacoemulsification, median: 20.0, quartile range: 0.0, 100.0) exceeded that for Chinese residents (extra-capsular: median = 0, p < 0.0001; phacoemulsification: median = 0, p < 0.0001). Chinese trainees spent more time completing medical charts (>50 % of time on charts: 62.5 % versus 5.3 %, p < 0.0001) and received less supervision (≥90 % of training supervised: 4.4 % versus 65 %, p < 0.0001). Chinese residents were more likely to feel underpaid (96.0 % vs. 31.6 %, p < 0.0001) and hoped their children would not practice medicine (69.4 % vs. 5.0 %, p = 0.0001) compared HKSAR residents. CONCLUSIONS: In this study, ophthalmology residents in China report strikingly less surgical experience and supervision, and lower satisfaction than HKSAR residents. The HKSAR model of hands-on resident training might be useful in improving the low cataract surgical rate in China.

Fat-removal orbital decompression for disfiguring proptosis associated with Graves' ophthalmopathy: safety, efficacy and predictability of outcomes.

The objective of this study was to analyse clinical outcomes of patient who underwent fat-removal orbital decompression (FROD) for disfiguring proptosis associated with Graves' ophthalmopathy. This is a retrospective review of 21 eyes of 11 patients who have received transforniceal FROD for disfiguring Graves' exophthalmos at the Hong Kong Eye Hospital from January 2009 to March 2012. The amount of orbital fat removed and proptosis reduction in terms of Hertel value and complications were evaluated. The mean volume of orbital fat removed was 4.0 ± 1.1 ml (range 1.6-5.5 ml), and the mean change of Hertel value was 4.2 ± 1.3 (range 1-6, p < 0.000). None has visual loss or new-onset diplopia at primary gaze after FROD. No complications such as retrobulbar haemorrhage, meningitis, sinusitis, tissue necrosis, infraorbital paraesthesia or unsightly scar were observed. FROD could achieve reasonable proptosis reduction. It had a good safety profile, and results were predictable.

Balloon dacryoplasty in internal ostium stenosis after endoscopic dacryocystorhinostomy.

PURPOSE: To determine the effectiveness of balloon dacryoplasty in the treatment of internal ostium stenosis after endoscopic dacryocystorhinostomy (EnDCR). METHODS: A retrospective, noncomparative interventional case series of patients who underwent balloon dacryoplasty for post-EnDCR internal ostium stenosis were included. A balloon catheter was used in all procedures, with bicanalicular silicone intubation. Patient records were reviewed and data analyzed. Anatomical success was defined by functional endoscopic dye test, and functional success was defined as a subjective improvement in symptoms at last follow up. RESULTS: Nineteen lacrimal systems of 18 consecutive patients were studied between July 2007 and September 2012. At a mean follow up of 20 months (range, 3-53 months), anatomical success rate was 84% (16/19 systems), whereas functional success was 74% (14/19 systems). No major complication was observed. CONCLUSIONS: Balloon dacryoplasty is a minimally invasive procedure in the treatment of post-EnDCR internal ostium stenosis. It is a simple, safe procedure and can provide symptomatic relief to some of these patients. It can be considered as a treatment option for patients demonstrated with internal ostium stenosis after EnDCR.

DCR preferences among oculoplastic surgeons: Barriers and facilitators to adoption of endoscopic DCR.

OBJECTIVE: To determine the preference for dacryocystorhinostomy (DCR), patient selection criteria for endoscopic DCR, endoscopic DCR technique, and barriers to adoption of endoscopic DCR. METHOD: Cross-sectional study conducted from May-December 2021. A survey was sent to oculoplastic surgeons. Questions on demographic characteristics, type of clinical practice, technique preferences, barriers and facilitators to adoption of endoscopic DCR were included. RESULTS: 245 participants completed the survey. Most respondents were located at an urban site (84%), were in private practice (66%), and had been in practice for more than 10 years (58.9%). Sixty one percent perform external DCR as the first line procedure for treating primary nasolacrimal duct obstruction. The most common factor influencing the surgeon's decision to perform endoscopic DCR was the patient's request (37%) followed by endonasal exam (32%). The most common barrier for not performing endoscopic DCR was the lack of experience and lack of training during fellowship (42%). The most worrisome complication for most respondents was failure of the procedure (48%), followed by bleeding (30.3%). Eighty one percent believe surgical mentorship and supervision during initial cases would facilitate endoscopic DCR learning. CONCLUSIONS: External Dacryocystorhinostomy is the preferred technique for treating primary acquired nasolacrimal duct obstruction. Learning endoscopic DCR early during fellowship training and high surgical volume to improve the learning curve dramatically impacts the adoption of the procedure.

Advances in understanding and management of IgG4-related ophthalmic disease.

Immunoglobulin G4-related ophthalmic disease (IgG4-ROD) is an emerging, immune-mediated fibroinflammatory orbital disease, characterized by tumefactive lesions with noticeable IgG4+ plasma cell infiltration and distinctive pathohistological features. This disease is often associated with elevated serum IgG4 concentrations. IgG4-ROD may affect any ophthalmic tissues, particularly the lacrimal gland, extraocular muscles, and trigeminal nerves. Although the exact pathogenic role of IgG4 antibodies remains unclear, B-cell depleting agents have been reported to be an effective treatment. The diverse clinical manifestations of IgG4-ROD complicate diagnosis, and without prompt treatment, visual-threatening complications such as optic neuropathy may arise. Recent advances in understanding and managing IgG4-ROD have revolutionized the diagnosis and treatment of this emerging disease. This review article aims to provide a comprehensive overview of the latest advancements in the field of IgG4-ROD.