The Spiral of Tillaux: dead on accurate; a cadaveric study.

INTRODUCTION: The Spiral of Tillaux describes the historically accepted insertion distances of the medial rectus, inferior rectus, lateral rectus, and superior rectus from the limbus: 5.5 mm, 6.5 mm, 6.9 mm, and 7.7 mm, respectively. The corneal diameters are historically accepted to be 11.7 mm horizontally and 10.6 mm vertically in adults. We investigated the variability of the insertion distances of the extraocular rectus muscles from the limbus as well as the corneal diameters using eyes from human cadavers and compared our measurements to these historically accepted measurements. METHODS: A sample of 60 eyes were included. For each eye, a 360 peritomy was conducted and the conjunctiva bluntly dissected to view the sclera. Muscle hooks were utilized to isolate the extraocular rectus muscles. Calipers were used to measure the insertion distances of the rectus muscles as well as the corneal diameters. RESULTS: The mean rectus muscle insertions distances from the limbus were medial 5.28 mm, inferior 5.72 mm, lateral 6.40 mm, and superior 6.78 mm. These insertion distances were shorter than the historical benchmarks (p < .01). However, observed maximum distances of the rectus muscles were all greater than the historically accepted benchmarks, with the medial, inferior, lateral, and superior rectus muscles being 6.4 mm, 7.3 mm, 7.4 mm, and 7.8 m from the limbus, respectively. The mean width and height of the cornea were 11.7 mm and 10.7 mm, respectively, and similar to the expected ranges. CONCLUSION: This study concludes that variability does exist from the historically accepted Spiral of Tillaux measurements. In addition, significant variation exists between male and female rectus muscle insertions. However, we did confirm that the rectus muscles followed the same spiral pattern described by the Spiral of Tillaux and concluded that the corneal diameters are consistent with previously accepted values.

Analysis of Uveal Melanoma 5-Year Survival Rates by Medicaid Status: A Nationwide Analysis.

PURPOSE: The survival outcomes of patients with primary uveal melanomas based on Medicaid status have not been previously discussed in the literature. METHODS: The Surveillance, Epidemiology, and End Results Medicaid database were utilized to identify patients with primary uveal melanomas diagnosed between 2006 and 2013. The Kaplan-Meier method was utilized to construct 5-year survival curves in adult, non-elderly patients. Log-rank testing was used to determine differences in survival rates, and multivariate Cox proportional hazards modeling was utilized to perform adjusted survival analysis. RESULTS: A total of 1,765 patients were included (Medicaid: 81, non-Medicaid: 1684). A total of 1683 (95.4%) were White. The average age was 51.75 years (SD = 9.5 years). Medicaid patients were more likely to be unmarried, live in a high poverty neighborhood, and live in a rural area (all p < .001). We observed no significant difference in 5-year survival rates between those enrolled in Medicaid (86.6%, 95% CI: 79.1%1-94.7%) and those not enrolled in Medicaid (85.5, 95% CI: 83.8%-87.2%) (p = .80). After controlling for socioeconomic and clinical factors, Medicaid enrollment was not associated with an increased risk of mortality compared to non-Medicaid enrollment. Age (aHR: 1.04, 95% CI: 1.02-1.06, p < .001) and tumor size >10 mm (aHR: 3.04, 95% CI: 1.49-6.21, p = .002) were associated with an increased risk of mortality. CONCLUSION: Medicaid enrollment was not associated with worse cancer-specific 5-year survival. Further research needs to be elicited to better understand the role of Medicaid enrollment in patients with primary uveal melanoma.

Pediatric Central Retinal Vein Occlusion Secondary to Concurrent Mechanisms of Optic Neuritis and Antiphospholipid Syndrome.

Purpose: To report a pediatric case of optic neuritis with subsequent development of central retinal vein occlusion (CRVO). Methods: A case and its findings were analyzed. Results: A 16-year-old boy presented with painful vision loss in the left eye, an afferent pupillary defect, and optic disc edema. Magnetic resonance imaging showed optic nerve enhancement and contrast-enhancing cerebral white-matter lesions, consistent with optic neuritis and demyelinating disease. He received intravenous methylprednisolone followed by a prednisone taper. At the 3-week follow-up, the visual acuity (VA) in the left eye had worsened and fundoscopic examination showed a new CRVO. A hypercoagulable workup showed antiphospholipid syndrome, which was treated with warfarin. He received intravitreal antivascular endothelial growth factor treatment with subsequent improvement in VA and resolution of the macular edema. Conclusions: This case describes an unusual mechanism for CRVO via a combination of optic disc edema from optic neuritis and hypercoagulability from antiphospholipid syndrome. It is important to recognize this complication of optic disc edema and the necessary workup for a pediatric CRVO.

Impact of individual counseling on the knowledge and attitudes of type 2 diabetics regarding diabetic retinopathy: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study - Report 3.

Purpose: Baseline knowledge and attitudes regarding diabetic retinopathy (DR) have not been previously reported for type 2 diabetes mellitus adults (T2DM) in Dharavi, one of the largest slums in Mumbai. Furthermore, a pre- and post-intervention survey study regarding this topic has not been conducted to date in Dharavi. This pre- and post-intervention survey study analyzes the impacts of DR counseling sessions administered individually on the knowledge and attitudes of T2DM participants recruited from Dharavi. Methods: Potential subjects (>30 years old) from Dharavi were enrolled by community workers and screened for T2DM. Those with confirmed T2DM were each registered for an individual DR counseling session. A survey was distributed to participants before the counseling session to determine their baseline knowledge and attitudes. The same survey was distributed after the counseling session, and changes in pre- and post-survey responses were analyzed. Results: Exactly 1718 T2DM study participants were given pre- and post-surveys. Before the counseling, T2DM participants showed low baseline knowledge and attitudes regarding DR, with only 30.8% (530/1718) participants being aware that diabetes can affect the eye. Participants showed significant improvements after the counseling session, with more participants showing willingness to attend DR screenings (pre: 38.3.%, post: 56.8%; P < 0.0001) and more becoming aware that diabetes can affect the eye (90.4%, 1553/1718; P < 0.0001). Conclusion: Targeted educational interventions for T2DM individuals from the slums of western India, such as Dharavi, can lead to significant improvements in knowledge and attitudes, representing a promising avenue in tackling the burden of avoidable blindness caused by DR in India.

Longitudinal trends in volume of oculoplastic procedures without ACGME minimum requirements among United States ophthalmology residents: an ACGME case log analysis.

PURPOSE: To our knowledge, there have been no previous reports that investigate trends in ophthalmology residents' exposure to oculoplastic procedures without Accreditation Council for Graduate Medical Education (ACGME) minimum requirements. To fill this knowledge gap, we investigated publicly available ACGME ophthalmology residency case logs from 2009 to 2021. METHODS: National resident averages and standard deviations were collected for the following oculoplastic procedures without minimum ACGME requirements: eye removal and implant, lacrimal surgery, other orbital surgery (e.g. orbitotomy), tarsorrhaphy, entropion/ectropion repair, temporal artery biopsy, and other oculoplastic surgery. We also collated average yearly surgical volumes of all oculoplastic procedures, "Total Oculoplastic Surgery," which includes procedures with minimum requirements and procedures without requirements. Finally, we collected the average yearly volumes of all ophthalmic procedures. Linear regressions were used to characterize trends in resident oculoplastic surgical volume. RESULTS: We provide evidence that the average yearly volumes of all but one oculoplastic procedure without ACGME minimum requirements have been decreasing. The decreases in volume for these procedures are driven by residents having fewer cases both as primary surgeon and as assistant. In addition, while the total number of ophthalmic procedures logged by residents on average increased (ß = 7.519, p = 0.0163), the average volume of total oculoplastic procedures did not demonstrate any statistically significant trends. CONCLUSIONS: Volumes of oculoplastic procedures without ACGME minimum requirements between 2009 and 2021 have been decreasing among ophthalmology residents.

Bilateral, sequential orbital inflammatory syndrome associated with ruxolitinib.

Ruxolitinib is an oral Janus associated kinase (JAK) inhibitor commonly used in the treatment of primary myelofibrosis. We describe a case of an 86-year-old woman on ruxolitinib for primary myelofibrosis who presented with a three-day history of worsening left eyelid swelling, pain, and decreased vision. Her exam was notable for left upper lid ptosis, periorbital edema, and nearly complete external ophthalmoplegia along with diffuse conjunctival injection and microcystic corneal edema. An orbital computed tomography demonstrated left proptosis accompanied by extensive inflammatory changes of the preseptal and orbital soft tissues. She was diagnosed with acute left orbital inflammatory syndrome (OIS) and treated with intravenous methylprednisolone, one gram over 48 hours followed by an oral steroid taper as well as discontinuation of her ruxolitinib. Complete recovery was noted at her one-week follow-up visit and ruxolitinib was restarted. However, 3 weeks later, she presented with new right periorbital swelling and pain and was found to have a sequential right OIS for which she was again treated with methylprednisolone and discontinuation of ruxolitinib with the goal of transitioning to an alternative biologic agent. Although there are no previous documented cases of ruxolitinib associated orbital inflammatory syndrome, a similar JAK inhibitor medication, Fedratinib, has been reported to cause a similar side effect. We propose that her ruxolitinib paradoxically lead to a pro-inflammatory state leading to bilateral, sequential orbital inflammatory syndrome.

A 20-year nationwide analysis of golf-associated eye injuries in the United States.

PURPOSE: Existing knowledge regarding golf-associated eye injuries (GEIs) is sparse. The purpose of this study was to characterize the types of GEIs, examine the mechanisms of injury, describe the characteristics of GEI victims, and determine the incidence of GEIs during the 2002-2021 period using the National Electronic Injury Surveillance System (NEISS) database. METHODS: Deidentified patient records were analyzed. Each GEI was assigned into a specific category of diagnosis, and the mechanism of injury was determined. National estimates were collected for each year, and simple linear regression modeling was used to determine trends over time. Furthermore, patient variables for sex, race, and age were analyzed. RESULTS: The NEISS query provided a total of 379 GEIs for analysis. GEIs were most common in adult males, with a decreasing, although not statistically significant, trend during this period (ß = -17.88, p = 0.110). Children were more likely to have a GEI caused by a golf club while adults were more likely to have one caused by the surrounding environment. Across all age groups, contusions and corneal abrasions were the most common GEIs, constituting 50.4% (190/377) of all eye injuries, followed by foreign body injuries (9%, 34/377) and then irritation/inflammation of the eye (8%, 30/377). The most common mechanism of injury among all players involved adverse interactions with the environment (37.7%, 142/377). CONCLUSION: Contradictory to existing literature, we show that minor GEIs are more common than severe ones. Rather than golf clubs or balls, environmental elements are the leading cause of GEIs.

Reliability of Time Domain AS-OCT in Measuring the Extraocular Rectus Muscle Insertion-Limbus Distances: A Systematic Review and Meta-Analysis.

Purpose: The insertion-limbus distances of the extraocular muscles are clinically relevant in the preoperative planning of strabismus surgeries, especially in reoperations when information regarding insertion sites is not accessible to the surgeon. In this systematic review, we assess the reliability of time-domain anterior segment optical coherence tomography (TD AS-OCT) in determining insertion-limbus distances preoperatively by investigating prior studies that compare preoperative TD AS-OCT measurements of the insertion-limbus distances to those of calipers, which are assumed to be the gold standard. Methods: Systematically reviewing EMBASE, PubMed, Google Scholar, Science Direct, and Web of Science, 2 members screened for studies that compared preoperative TD AS-OCT measurements to those of intraoperative calipers, the gold standard. To assess the risk of bias for individual studies, the reviewers utilized the ROBINS-I tool, a Cochrane's collaboration tool used to assess bias in studies that are not randomized. For the meta-analysis, parallel forms reliability was examined and estimated as the Pearson product-moment correlation between TD AS-OCT measurements and surgical caliper measurements. Results: Six out of the seven eligible studies provided measures of reliability that were >0.7. These six records were eligible for meta-analysis. There was no evidence of a difference between means of TD AS-OCT and caliper measurements ( = 6.81, 95% CI [6.41, 7.22]; = 6.73, 95% CI [6.18, 7.29]; = 0.08, 95% CI [-0.44, 0.61]). Reliability was estimated to be good ( = 0.91) though the lower limit was slightly below the recommended minimum acceptable level of 0.70 (95% CI [0.65, >0.99]). Conclusion: In the setting of primary surgeries, TD AS-OCT has an acceptable reliability. However, there is insufficient data to conclude whether TD AS-OCT has an acceptable reliability in the setting of reoperations.

Depth Transitions of the Frontal Branch of the Facial Nerve: Implications in SMAS rhytidectomy.

BACKGROUND: Anatomy of the frontal branch of the facial nerve relative to the zygomatic arch and the superficial musculoaponeurotic system (SMAS) has been well described. The variability centers on the location where the frontal branch traverses from a deeper to more superficial plane in the SMAS. The goal of this study is to examine the depth transition of the frontal branch of the facial nerve relative to the zygomatic arch with hopes of pinpointing a caution zone for dissection to avoid nerve injury. METHODS: The frontal branch of the facial nerve was dissected in 36 hemifacial fresh cadaver specimens. Pitanguy's line, the zygomatic arch, and temporal crest were marked. Measurements were taken from the zygomatic arch to the location where the frontal branch pierced the temporoparietal fascia. Locations of the superficial temporal artery (STA), the frontal branch cross relative to the lateral orbital rim and frontalis muscle were also measured. RESULTS: In 94.4% (n = 36) of the specimens, the frontal branch was found to transition to an intra-SMAS plane approximately 9.6 mm above the zygomatic arch. In all specimens, the frontal branch transitioned to an intra-SMAS plane approximately 12.2 mm posterior to Pitanguy's line. CONCLUSIONS: This study describes a surgical "caution zone" centered on a point 9.6 mm above the arch and 12.2 mm posterior to Pitanguy's line, and related to the anterior branch of the STA. We hope this anatomical detail will help to decrease the likelihood of intraoperative injury to the frontal branch of the facial nerve.

Effect of phenylephrine 1.0%-ketorolac 0.3% injection on tamsulosin-associated intraoperative floppy-iris syndrome.

PURPOSE: To determine the effect of phenylephrine 1.0%-ketorolac 0.3% injection (Omidria) on different components of intraoperative floppy-iris syndrome (IFIS). SETTING: Silverstein Eye Centers, Kansas City, Missouri, USA. DESIGN: Prospective case series. METHODS: Men treated with tamsulosin having standard cataract extraction surgery were placed in a treatment group that received phenylephrine 1.0%-ketorolac 0.3% injection in the irrigation solution and a control group) that received basic saline solution. Every procedure was video recorded using an endocyclophotocoagulation (ECP) probe and microscopic view. Pupil dilation, iris billowing, and iris prolapse were measured using a micrometer, ECP recording grading scale, and microscopic recordings, respectively. RESULTS: Each group (treatment and control) comprised 25 eyes of 25 patients. Although both groups had a decrease in pupil diameter before and after cataract extraction and before cataract extraction and after intraocular lens implantation, the changes were statistically significantly greater in the treatment group. Iris prolapse occurred in 3 patients (12.0%) in the treatment group and 14 patients (56.0%) in the control group (P < .001). Stage 3 (severe) pupil billowing occurred in 1 eye (4.0%) in the treatment group and 10 eyes (40.0%) in the control group (P < .001). CONCLUSIONS: The use of the phenylephrine 1.0%-ketorolac 0.3% injection combination added to the irrigating solution during cataract surgery in patients at risk for IFIS led to significantly better prevention of miosis, less pupil billowing, and a reduced incidence of iris prolapse. A new grading scale for intraoperative iris abnormalities might be used for future evaluation.