Anaplastic Thyroid Carcinoma with Ocular Then Orbital Metastases.

A 52-year-old Hispanic woman with a history of metastatic thyroid carcinoma presented with left eye degeneration and a choroidal mass without evidence of orbital disease on neuroimaging. She underwent enucleation for a blind, painful eye. Histopathology demonstrated choroidal metastasis of thyroid carcinoma with a well-circumscribed episcleral nodule, consistent with extraocular tumor extension. The interdisciplinary team recommended expectant management. Three months later, she developed periorbital edema and discomfort with poor ocular prosthesis fit. Neuroimaging revealed a mass in the anophthalmic socket that proved to be thyroid carcinoma. The patient subsequently underwent exenteration for pain control and local tumor burden reduction. At 12-month follow-up, there was no evidence of residual orbital disease, and she remains in remission. While the orbit involvement likely represents direct extraocular extension, a discrete orbital metastasis remains a possibility. In either scenario, this is the only known case of anaplastic thyroid carcinoma metastatic to the choroid then orbit.

Carotid-Cavernous Sinus Fistula Masquerading as Thyroid Eye Disease.

A 29-year-old man with a medical and social history notable for smoking presented with progressive orbital congestion, conjunctival injection, and extraocular muscle enlargement consistent with thyroid eye disease (TED). On ophthalmologic examination, tortuous episcleral vessels and blood in Schlemm's canal on gonioscopy clued an alternative diagnosis. Cavernous sinus enhancement on computed tomography also suggested a retro-orbital process. Digital subtraction angiography confirmed a low-flow indirect carotid-cavernous fistula (CCF). He subsequently underwent endovascular embolization treatment. Ocular symptoms resolved by seven weeks, and he remained ocular symptom free at six months. Eye redness and proptosis frequently cause patients to seek medical attention. In the absence of a mass or signs of infection, TED is high on the differential, especially with a smoking history and even with normal thyroid parameters. However, CCF may lurk; the authors describe key diagnostic features and management.

Orbital Microscopic Polyangiitis With Secondary Angle Closure Due to Uveal Effusion.

A 63 year-old man presented with 3 weeks of worsening, painless left-sided proptosis, ptosis, and diplopia. Examination of the affected eye revealed normal visual acuity, normal intraocular pressure in the presence of a shallow anterior chamber, grade 1 relative afferent pupillary defect, restricted motility in all directions of gaze, and 6 mm of proptosis. Ultrasound biomicroscopy revealed uveal effusions with anterior rotation of the ciliary body causing appositional angle closure. B-scan ultrasonography and MRI demonstrated enhancement of the posterior globe and an infiltrative mass involving the lacrimal gland and multiple extraocular muscles. Laboratory studies revealed positive perinuclear antineutrophil cytoplasmic antibody with elevated myeloperoxidase antibodies, consistent with a diagnosis of microscopic polyangiitis. Biopsy showed nonspecific dacryoadenitis. Intravenous and oral corticosteroids were associated with rapid improvement of all examination findings. The patient was later switched to rituximab steroid-sparing therapy and has shown no recurrence of disease at 3-months follow-up.

Oculofacial plastic surgery-related online search trends including the impact of the COVID-19 pandemic.

Purpose: The authors aim to characterize oculofacial plastic surgery-related online interest that may be useful in forecasting demand and in designing patient-directed online resources. Methods: The authors queried Google Trends for over 100 oculofacial plastic surgery terms. The main outcome measure was the top 50 oculofacial plastic surgery-related search terms from 2004 to 2020. Secondary outcomes were trends, including seasonality, and search volume changes during the COVID-19 lockdown (March-May 2020) compared to 2018-2019. Terms were analyzed individually and in thematic categories; controlled against generic search terms to account for general internet traffic. Results: Between 2004 and 2020, searches for oculofacial plastic surgery altogether increased, surpassing the rate of internet traffic growth. One thematic category - eyelid malpositions - decreased month-over-month. The top five terms were "face lift," "Bell's palsy," "puffy eyes," "dark circles under eyes," and "chalazion." Eyelid neoplasms searches peaked in summer (R2  = 0.880) whereas cosmetic (R2  = 0.862), symptoms (R 2 = 0.907), and surgeries (R 2 = 0.140) peaked in winter. Overall, oculofacial-related searches decreased during the COVID-19 lockdown, although thyroid eye disease interest increased compared to 2018 or 2019 (+68.6%; adj. p = .005). Oculofacial plastic surgery interest in 2020 was inversely correlated to "COVID-19" searches (r = -0.76, p < .001). Conclusions: Oculofacial plastic surgery searches increased since 2004 at a pace greater than that ascribed to internet traffic growth. The most searched terms were "face lift," "Bell's palsy," "puffy eyes," "dark circles under eyes," and "chalazion." Almost all oculofacial-related searches decreased during the COVID-19 lockdown.

Pharmaceutical and Supply Waste in Oculofacial Plastic Surgery at a Hospital-Based Outpatient Surgery Center.

PURPOSE: To investigate the financial and environmental waste burden of unused disposable surgical supplies and pharmaceutical products in oculofacial plastic surgery at a hospital-based outpatient surgery center. METHODS: This descriptive study was performed at a single academic hospital-based outpatient surgery center. Unused pharmaceuticals and disposable surgical materials were recorded for each of 34 consecutive oculofacial plastic surgeries performed by the same surgical team. Pharmaceutical products were grouped as local anesthetic (tetracaine, bupivacaine, lidocaine, and sodium bicarbonate), intraoperative (basic saline solution, methylene blue, and oxymetazoline hydrochloride), or antiseptic/antimicrobial (erythromycin ointment and hydrogen peroxide). Percentage of unused pharmaceutical product and disposable surgical material were calculated and extrapolated to direct costs to the institution and greenhouse gas emissions. RESULTS: The mean percentage of disposable surgical supply waste per case was 11.6% ($29.32). The mean percentage of pharmaceutical waste was 96.1% ($271.84) for local anesthetic, 71.0% ($163.47) for intraoperative medications, and 26.7% ($2.19) for antiseptic medication. The mean emissions per surgical case for unused disposable surgical equipment and unused pharmaceutical product were 10 and 103 kg of carbon equivalent gases (kg CO2-e), respectively. CONCLUSIONS: Surgical supply waste was nominal, but pharmaceutical waste was considerable in this single hospital-based outpatient surgery center study. There may exist opportunities for quality improvement in waste, especially pharmacologic burden, in oculofacial plastic surgery.

Clinical and Morphologic Outcomes of Minimally Invasive Direct Corneal Neurotization.

PURPOSE: To describe clinical outcomes of a minimally invasive technique for direct corneal neurotization to treat neurotrophic keratopathy. METHODS: All cases of corneal neurotization for neurotrophic keratopathy performed by a single surgeon using minimally invasive direct corneal neurotization were reviewed. The supraorbital donor nerve was directly transferred to the cornea through an upper eyelid crease incision using either a combination of endoscopic and direct visualization or direct visualization alone. Detailed ocular and adnexal examinations as well as Cochet-Bonnet esthesiometry of the affected cornea were performed. Corneal histopathology and in vivo confocal microscopy after minimally invasive direct corneal neurotization were reviewed in one patient who underwent simultaneous penetrating keratoplasty. RESULTS: Five consecutive cases in 4 patients were included, with a mean follow up of 15.8 months (range: 11-23 months). Average denervation time was 17.8 months (range: 6-24 months). Baseline corneal conditions were Mackie stage 1 (20%), Mackie stage 2 (40%), and Mackie stage 3 (40%). All patients demonstrated improvements in corneal sensibility and appearance postoperatively. All patients demonstrated stable or improved visual acuity. No patients developed persistent epithelial defects postoperatively, and all achieved return of tactile skin sensation in the donor nerve sensory distribution. In vivo confocal microscopy after minimally invasive direct corneal neurotization and simultaneous penetrating keratoplasty demonstrated regeneration of corneal nerves. Complications included an asymptomatic small bony excrescence lateral to the supraorbital notch in one patient and cataract progression in the patient who underwent penetrating keratoplasty. CONCLUSIONS: Minimally invasive direct corneal neurotization is a safe and effective treatment of neurotrophic keratopathy.

Facial and orbital asymmetry in oculofacial surgery patients.

Facial symmetry traditionally has been associated with beauty, and we typically strive for symmetry in surgery. However, the subtle degrees of asymmetry are natural and perhaps even more common than perfect symmetry. We retrospectively reviewed photographs of 100 oculofacial surgery patients without history of unilateral or orbital pathology or diplopia to describe the occurrence of facial asymmetries, including larger hemiface, hemiface with stronger seventh cranial nerve (measured by smile excursion and increased dynamic periocular rhytides during smile), hemiface with more pronounced rhytides at rest, difference in vertical globe height compared to interpupillary distance (IPD), higher earlobe, and higher lip. We found that most patients had static and dynamic facial asymmetry. Our data highlight the importance of counseling patients about preexisting facial asymmetry and establishing normative values for asymmetry.