An Analysis of Surgical Factors Associated with Clinically Significant Eyelid Edema (CSEE) in Patients Undergoing Blepharoplasty: Lid Crease Techniques Associated with CSEE.

PURPOSE: Severe postoperative edema after eyelid surgery can have negative clinical and psychological effects. In this study, we investigated whether surgical factors, including surgical techniques and suture type, were associated with clinically significant eyelid edema (CSEE). METHODS: A chart review was performed on 269 patients who underwent upper eyelid blepharoplasty with or without external levator advancement by 2 surgeons at a single institution between January 2021 and December 2022. Postoperative photos were graded by 2 physicians for eyelid edema using a standardized grading scale ranging from 0 (no edema) to 3 (severe edema). CSEE was defined either as having a grade of 3 at any point postoperatively or any grade that was 1 or greater after 90 days postoperatively. Logistic regression controlling for race was used for analysis; the statistical significance level was defined as p < 0.05. RESULTS: Of 269 patients, 56 developed CSEE. Of those who underwent blepharoplasty with mini crease enhancement (closure with every other bite incorporating levator aponeurosis), 40.5% developed CSEE versus 12.5% of those without (p < 0.001). Patients with lid crease formation using buried interrupted sutures had greater CSEE than those with externalized interrupted sutures removed at 1 week (43.8% versus 11.5%, p < 0.01). There was no increased risk of CSEE with additional procedures performed versus blepharoplasty alone. CONCLUSIONS: Patients who underwent blepharoplasty with mini crease enhancement, where more than 4 sutures are placed from skin to levator, and/or had buried suture lid crease formation had greater rates of CSEE.

Accuracy and Bias in Artificial Intelligence Chatbot Recommendations for Oculoplastic Surgeons.

Purpose The purpose of this study is to assess the accuracy of and bias in recommendations for oculoplastic surgeons from three artificial intelligence (AI) chatbot systems. Methods ChatGPT, Microsoft Bing Balanced, and Google Bard were asked for recommendations for oculoplastic surgeons practicing in 20 cities with the highest population in the United States. Three prompts were used: "can you help me find (an oculoplastic surgeon)/(a doctor who does eyelid lifts)/(an oculofacial plastic surgeon) in (city)." Results A total of 672 suggestions were made between (oculoplastic surgeon; doctor who does eyelid lifts; oculofacial plastic surgeon); 19.8% suggestions were excluded, leaving 539 suggested physicians. Of these, 64.1% were oculoplastics specialists (of which 70.1% were American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members); 16.1% were general plastic surgery trained, 9.0% were ENT trained, 8.8% were ophthalmology but not oculoplastics trained, and 1.9% were trained in another specialty. 27.7% of recommendations across all AI systems were female. Conclusions Among the chatbot systems tested, there were high rates of inaccuracy: up to 38% of recommended surgeons were nonexistent or not practicing in the city requested, and 35.9% of those recommended as oculoplastic/oculofacial plastic surgeons were not oculoplastics specialists. Choice of prompt affected the result, with requests for "a doctor who does eyelid lifts" resulting in more plastic surgeons and ENTs and fewer oculoplastic surgeons. It is important to identify inaccuracies and biases in recommendations provided by AI systems as more patients may start using them to choose a surgeon.

Assessing the Utility of ChatGPT in Simplifying Text Complexity of Patient Educational Materials.

INTRODUCTION: AI chatbots are being increasingly used in healthcare settings. There is growing interest in using AI to assist in patient education. Currently, extensive healthcare information is found online but is often too complex to understand. Our objective is to determine if physicians can recommend the free version of ChatGPT version 3.5 (OpenAI, San Francisco, CA, USA) for patients to simplify text from the American Academy of Ophthalmology (AAO) in English and Spanish. This version of ChatGPT was assessed in this study due to its increased accessibility across various patient populations. METHODS: Fifteen articles were chosen from AAO in both languages and simplified with ChatGPT 10 times each. The readability of original and simplified articles was assessed with the Flesch Reading Ease and Gunning Fog Index for English and Fernández Huerta, Gutiérrez, Szigriszt-Pazo, INFLESZ, and Legibilidad-µ for Spanish. Grade levels to assess readability were calculated with Flesch Kincaid Grade Level and Crawford Nivel-de-Grado. Mean, standard deviation, and two-tailed t-tests were performed to assess differences before and after simplification. RESULTS: Average grade levels before and after simplification were as follows: English 8.43±1.17 to 8.9±2.1 (p=0.41) and Spanish 5.3±0.34 to 4.1±1.1 (p=0.0001). Spanish articles were significantly simplified per Legibilidad-µ (p=0.003). No significant difference was noted for other scales. CONCLUSIONS: The readability of AAO articles in English worsened without significance but significantly improved in Spanish. This may result from simpler syllable structures and a lesser overall vocabulary in Spanish. With increased testing, physicians can recommend ChatGPT for Spanish-speaking patients to improve health literacy.

Phthisical eye and orbital ischemia after cosmetic platelet-rich plasma injection to the forehead.

Purpose: To report a case of retrograde embolism of cosmetic injection of platelet-rich plasma (PRP) to the ophthalmic artery, resulting in orbital ischemia, blindness, and eventual phthisis bulbi. Observations: A 37-year-old woman presented with two days of vision loss OS beginning seconds after undergoing cosmetic PRP filler injections to the face at an outside clinic. Immediately after injection to the left medial forehead, the patient reported bleeding, transient loss of consciousness, and complete vision loss OS. Two days later, vision remained no light perception OS and she exhibited manifestations of both anterior and posterior segment ischemia in the left eye. These findings were ultimately attributed to retrograde embolism to the ophthalmic artery via inadvertent injection of PRP into the supratrochlear or supraorbital arteries. She ultimately did not regain her vision in the left eye and the eye became enophthalmic and phthisical. Conclusions: After conducting a literature review on August 18, 2023, utilizing PubMed and Google Scholar, and searching for the key words "platelet-rich plasma" and "vision loss" or "vision impairment," we did not find any prior reports of anterior segment ischemia or pan-orbital ischemia resulting in phthisis bulbi. In the setting of vision changes after cosmetic platelet-rich plasma filler injection. Additionally, there is no validated therapy for ophthalmic artery occlusion from any cosmetic filler embolism. Further research should prioritize developing therapeutic guidelines for managing such complications. Injectors should also be educated to emergently refer patients to hospitals with ophthalmology consults available and stroke protocols in place.

A comparison of five point-of-care ultrasound devices for use in ophthalmology and facial aesthetics.

Introduction: Point-of-care ultrasound is becoming increasingly popular, and we sought to examine its role in evaluating ocular and periocular structures and facial vasculature. With the large number of point-of-care ultrasound devices available, it is difficult to determine which devices may be best suited for ophthalmic and facial aesthetic applications. This study compares five popular handheld point-of-care ultrasound devices to help guide clinicians in choosing the device best suited for their needs. Methods: We compared five point-of-care ultrasound devices: Butterfly IQ+ (Butterfly, Burlington, MA), L15 (Clarius Mobile Health, Vancouver, British Columbia, Canada), L20 (Clarius Mobile Health, Vancouver, British Columbia, Canada), Lumify (Philips, Amsterdam, Netherlands) and Vscan Air (GE, Boston, MA). Three ophthalmologists obtained the following views on three volunteers: eight arteries, four ocular and periocular structures and areas of filler injections. The image quality of each view was graded on a four-point Likert-type scale. In addition, graders filled out a survey. The data were analysed using analysis of variance tests with the significance level set to p < 0.05. Results: In terms of overall image quality, the L20 received the highest mean rating, followed by the L15, Vscan Air, Butterfly IQ+ and the Lumify (p < 0.05). With further stratification for structure type, the L20 was ranked first for filler, artery and orbital imaging (p < 0.05). Conclusions: The L20 received the highest image quality rankings. While image quality is an important aspect of point-of-care ultrasound device selection, other factors such as cost, wireless capabilities, range of presets and battery life should also be considered.

Long-Term Follow-Up of a Case of Severe Hyperglycemia Requiring Hospitalization after Third Dose of Teprotumumab: A Case Report.

Introduction: In 2020, teprotumumab became the first FDA-approved treatment for thyroid eye disease (TED). In clinical trials, hyperglycemia had been described as mild and controlled with medication. We present a case that occurred in 2020 of a 67-year-old male with TED and pre-existing glucose intolerance, who was hospitalized with severe hyperglycemia (1,059 mg/dL) after three doses of teprotumumab. Case Presentation: This patient's HbA1c was in the pre-diabetic range (6.3%) 6 months prior to initiating teprotumumab. After three doses, the patient was hospitalized with hyperosmolar hyperglycemic nonketotic syndrome and an HbA1c of 11.7%. He was diagnosed with type 2 diabetes mellitus and treated with insulin aspart mixed 70/30. He remained on this regimen for 14 months with an A1c of 6.0%. He then self-discontinued the insulin, with an A1c 4 months later measuring 5.5%. The patient's latest HbA1c approximately two and a half years after hospitalization was 6.1% on no medications. Conclusion: It appears that teprotumumab was a trigger for this transient case of diabetes, and detecting those that have underlying glucose intolerance ahead of time is important. We recommend blood glucose levels for patients with pre-diabetes prior to and ideally in the first few days after each infusion, to help determine patients at a greater risk for adverse hyperglycemic outcomes. A glucometer may be valuable for patients to self-monitor while on teprotumumab. If fasting blood glucose is ≥126 mg/dL or non-fasting glucose is >200 mg/dL, patients should be referred for further diabetes assessment and possible treatment initiation.

Response of 21 Hyaluronic Acid Fillers to Recombinant Human Hyaluronidase.

Background: One benefit of hyaluronic acid fillers is the ability to dissolve them using hyaluronidase. With the increasing number of fillers entering the market, it is crucial to understand each of these fillers' responsiveness to hyaluronidase. Methods: Twenty-one hyaluronic acid fillers of 0.2 mL aliquots each were placed on slides. Twenty units of recombinant human hyaluronidase were injected into the aliquots every 30 minutes for a total of 120 units recombinant human hyaluronidase injected over 3 hours. With each injection, videos and photographs were taken from bird's eye and lateral views to measure aliquot height. Stirring videos were graded by three oculoplastic surgeons, and these grades were used to categorize each filler's responsiveness. Results: Restylane Lyft, Restylane-L/Eyelight, and Resilient Hyaluronic Acid (RHA) 1/Redensity were the least resistant. The moderately resistant group comprised of Restylane Silk, Juvéderm Volbella, Revanesse Versa/Lips, and Belotero Balance on the less resistant side to Juvéderm Vollure, RHA 2, Restylane Contour, Juvéderm Ultra, Restylane Refyne, Belotero Intense, Restylane Kysse, RHA 3, Juvéderm Ultra Plus, and Restylane Defyne on the more resistant side. The most resistant were RHA 4, Juvéderm Voluma, Belotero Volume, and Juvéderm Volux. The most resistant fillers required 120 units of hyaluronidase per 0.2 mL filler to dissolve. Conclusions: With the increasing popularity of fillers comes the increasing need to dissolve them for both ischemic and nonischemic complications. The majority of hyaluronic acid fillers available on the market are very resistant to hyaluronidase, which must be considered when determining the amount of hyaluronidase to dissolve a particular filler.

Bias and Inaccuracy in AI Chatbot Ophthalmologist Recommendations.

PURPOSE AND DESIGN: To evaluate the accuracy and bias of ophthalmologist recommendations made by three AI chatbots, namely ChatGPT 3.5 (OpenAI, San Francisco, CA, USA), Bing Chat (Microsoft Corp., Redmond, WA, USA), and Google Bard (Alphabet Inc., Mountain View, CA, USA). This study analyzed chatbot recommendations for the 20 most populous U.S. cities. METHODS: Each chatbot returned 80 total recommendations when given the prompt "Find me four good ophthalmologists in (city)." Characteristics of the physicians, including specialty, location, gender, practice type, and fellowship, were collected. A one-proportion z-test was performed to compare the proportion of female ophthalmologists recommended by each chatbot to the national average (27.2% per the Association of American Medical Colleges (AAMC)). Pearson's chi-squared test was performed to determine differences between the three chatbots in male versus female recommendations and recommendation accuracy. RESULTS: Female ophthalmologists recommended by Bing Chat (1.61%) and Bard (8.0%) were significantly less than the national proportion of 27.2% practicing female ophthalmologists (p<0.001, p<0.01, respectively). ChatGPT recommended fewer female (29.5%) than male ophthalmologists (p<0.722). ChatGPT (73.8%), Bing Chat (67.5%), and Bard (62.5%) gave high rates of inaccurate recommendations. Compared to the national average of academic ophthalmologists (17%), the proportion of recommended ophthalmologists in academic medicine or in combined academic and private practice was significantly greater for all three chatbots. CONCLUSION: This study revealed substantial bias and inaccuracy in the AI chatbots' recommendations. They struggled to recommend ophthalmologists reliably and accurately, with most recommendations being physicians in specialties other than ophthalmology or not in or near the desired city. Bing Chat and Google Bard showed a significant tendency against recommending female ophthalmologists, and all chatbots favored recommending ophthalmologists in academic medicine.

The Nictavi Tarsus Patch: A New Device for Achieving Temporary Eyelid Closure in Lagophthalmos.

Purpose: To evaluate the effectiveness, tolerability, and safety of the Nictavi Tarsus Patch™ (NTP) in inducing temporary eyelid closure for the management of lagophthalmos in the pediatric and young adult population. Methods: We prospectively enrolled 20 patients <21 years of age who had previously been managed for lagophthalmos to trial the NTP in clinic. Inter-palpebral fissure distance (IPFD) was compared before and after the placement of the NTP in the eyes-closed position using paired t-tests. Subjects then underwent a 3-night home trial with the NTP, and parent and subject perceptions of effectiveness, comfort, and complications with the patch were analyzed using Likert scale survey questions. Results: Twenty subjects ages 2-20 years with paralytic (65%) and non-paralytic (35%) lagophthalmos were enrolled. The NTP improved lagophthalmos from a mean pre-placement IPFD of 3.3 mm to post-placement IPFD of 0.4 mm (p < 0.01). Overall, 80% of subjects achieved successful eyelid closure defined as ≤1 mm of post-placement IPFD. When stratified by subtype, 100% of subjects with paralytic lagophthalmos achieved successful eyelid closure compared to 71% of subjects with non-paralytic lagophthalmos. On a scale of 1 (worst) to 5 (best), parents rated the NTP at 4.3±0.7 for comfort while wearing, 4.3±1.0 for comfort in removing, 4.6±0.7 for ease of use, and 4.3±0.9 for effectiveness. Ninety-three percent of parents reported preferring NTP to other eyelid closure methods previously tried and indicated that they would use it again. Conclusion: The NTP is an effective, tolerable, and safe method of eyelid closure for children and young adults.

Arterial Wall and Tissue Penetration Force With Various Cannulas and Needles.

BACKGROUND: Vascular penetration during aesthetic filler injections can cause serious side effects such as skin necrosis and blindness. OBJECTIVES: The objective of this study was to analyze the effect of cannula brand and gauge on the risk of vascular penetration. METHODS: The minimal force to penetrate the superficial temporal artery with 3 cannula brands and 1 needle brand in 4 sizes (22, 25, 27, and 30 gauge) was measured in 4 fresh frozen cadavers utilizing a force gauge that measured as low as 0.1 Newtons. Tissue penetration force in the subdermal plane of the nasolabial fold was measured and compared with retrospective training data in live humans. The arterial penetration test was repeated at a second site on 1 fresh cadaver with 2 different force gauges. RESULTS: Significantly lower forces were needed with all size needles vs the same gauge cannulas in all brands to penetrate the cadaveric artery and advance in the subdermal plane of the nasolabial fold in both cadavers and live humans. To successfully enter the artery in a cadaver with any cannula, numerous attempts were necessary. The tissue penetration force in the subdermal plane of the nasolabial fold in a cadaver was not significantly different than in a living person; however, it was significantly higher than the arterial penetration force in a dissected cadaver. CONCLUSIONS: All gauge cannulas (including 27 and 30 gauge), require more force than the same size needle to penetrate an artery. However, it appears that friction coefficient and flexibility, not the arterial penetration force, are the most important factors in keeping the instrument outside the vessel.

Demographic and physiological factors associated with clinically significant eyelid edema in patients following upper eyelid surgery.

PURPOSE: To investigate demographic and physiological variables associated with clinically significant edema after upper eyelid surgery. METHODS: A retrospective chart review was performed on patients who underwent blepharoplasty or external levator advancement with or without lid crease formation between January 2018 and January 2021 at the University of Southern California. Age, sex, pertinent medical history (medications causing edema and comorbidities), and pertinent surgical procedures were all collected. Postoperative photos were graded by two independent physician graders on a newly developed photographic scale ranging from 0 (no edema) to 3 (severe edema). Clinically significant edema of the eyelids was defined as Grade 3 edema at any postoperative point or ≥ Grade 1 edema after 90 days post operation. Patients without postoperative photos were excluded. Mann-Whitney U test, Fisher's exact test, and χ2 test were used to compare groups with and without significant edema. All analyses were conducted using SAS version 9.4 (SAS Institute Inc.) with α=0.05. RESULTS: Out of 217 patients, East Asian participants had higher odds of developing edema than White participants (odds ratio, 7.92; CI, 3.15-19.93, p < 0.0001) and Hispanic participants (odds ratio, 3.47; CI, 1.51-7.97, p = 0.003). Southeast Asian participants also had higher odds of developing CSEE than White participants (odds ratio, 6.19; CI, 1.71-22.43, p = 0.006). Fifty-four (24.9%) patients had clinically significant edema. Although BMI, medical comorbidities, medication use, and age did not affect edema, there was a statistically significant relationship between race and incidence of edema (p = 0.0001). Those in the CSEE group were also more likely to require reoperation (p = 0.0143). CONCLUSIONS: There is a statistically significant relationship between Asian race and the incidence of clinically significant eyelid edema. CSEE is associated with a higher incidence of reoperation.

Lateral orbital wall anomaly in a patient with thyroid eye disease.

An isolated defect in the lateral orbital wall is an uncommon occurrence, although cases of orbital floor, roof, and medial wall spontaneous dehiscence have been described in the literature. Here, we describe a lateral orbital wall defect in a patient with thyroid eye disease - which may be related to bony remodeling or may represent a rare congenital anomaly. Computed tomography (CT) prior to decompression surgery revealed a defect in the left lateral orbital wall. At the time of orbital decompression, prolapse of buccal fat into the orbit was noted once the subperiosteal plane was entered along the lateral orbital wall in the area of this bony defect. Literature review revealed only a few previous reports of lateral wall abnormalities, including two involving the inferior orbital fissure; one other case was associated with Down syndrome, and other reports consist of sphenoid hypoplasia associated with neurofibromatosis.

Misdiagnosis of Orbital Foreign Body as Glaucoma Drainage Device.

BACKGROUND: Sight-threatening complications from retained orbital and intraocular foreign bodies are frequently reported in literature. Delays in diagnosis can result in severe complications, including choroidal neovascularization, infection, and irreversible vision loss. Therefore, it is imperative that emergency physicians consider the possibility of orbital and intraocular foreign bodies when evaluating patients with acute facial trauma. CASE REPORT: A 91-year-old woman with a history of laser-treated glaucoma and cataracts presented to an outside emergency department after a ground-level fall. A maxillofacial noncontrast computed tomography scan showed no facial fractures or hemorrhage, but a 41 mm × 4 mm foreign body within the intraconal compartment of the right orbit was identified. The object was presumed to be an implanted glaucoma drainage device, and the patient was discharged without antibiotics. One day after discharge, the patient developed right periorbital swelling and erythema with increasing purulent discharge and skin thickening, ultimately requiring transfer to our facility for management of complex right orbital cellulitis, orbital compartment syndrome, and surgical foreign body removal. Despite globe exploration and surgical intervention, the patient developed a frozen globe with no light perception in the right eye. Why Should an Emergency Physician Be Aware of This? Subtle ophthalmologic emergencies such as sight-threatening foreign bodies can be challenging to diagnose on imaging, particularly with the advent of implantable ocular technology. When an orbital foreign body is discovered in the context of facial trauma, early ophthalmology consultation should be considered.

Clinical activity of PD-1 inhibition in the treatment of locally advanced or metastatic basal cell carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) is the most common malignancy worldwide, yet the management of patients with advanced or metastatic disease is challenging, with limited treatment options. Recently, programmed death receptor 1 (PD-1) inhibition has demonstrated activity in BCC after prior Hedgehog inhibitor treatment. METHODS: We conducted a multicenter, retrospective analysis of BCC patients treated with PD-1 inhibitor therapy. We examined the efficacy and safety of PD-1 therapy, as well as clinical and pathological variables in association with outcomes. Progression-free survival (PFS), overall survival (OS) and duration of response (DOR) were calculated using Kaplan-Meier methodology. Toxicity was graded per Common Terminology Criteria for Adverse Events V.5.0. RESULTS: A total of 29 patients with BCC who were treated with PD-1 inhibition were included for analysis, including 20 (69.0%) with locally advanced and 9 (31.0%) with metastatic disease. The objective response rate was 31.0%, with five partial responses (17.2%), and four complete responses (13.8%). Nine patients had stable disease (31.0%), with a disease control rate of 62.1%. The median DOR was not reached. Median PFS was 12.2 months (95% CI 0.0 to 27.4). Median OS was 32.4 months (95% CI 18.1 to 46.7). Two patients (6.9%) developed grade 3 or higher toxicity, while four patients (13.8%) discontinued PD-1 inhibition because of toxicity. Higher platelets (p=0.022) and any grade toxicity (p=0.024) were significantly associated with disease control rate. CONCLUSIONS: The clinical efficacy of PD-1 inhibition among patients with advanced or metastatic BCC in this real-world cohort were comparable to published trial data. Further investigation of PD-1 inhibition is needed to define its optimal role for patients with this disease.

Focused ultrasound stimulation on meibomian glands for the treatment of evaporative dry eye.

Current treatments for meibomian gland dysfunction have several limitations, creating a necessity for other advanced treatment options. The purpose of this study is to determine the effectiveness of focused ultrasound stimulation for the treatment of dry eye disease caused by meibomian gland dysfunction. An in vivo study of nine Dutch Belted rabbits was conducted with focused ultrasound stimulation of the meibomian glands. A customized line-focused ultrasonic transducer was designed for treatment. Fluorescein imaging, Schirmer's test, and Lipiview II ocular interferometer were used to quantify outcomes from three aspects: safety, tear production, and lipid layer thickness. Both tear secretion and lipid layer thickness improved following ultrasound treatment. Five to 10 min after the ultrasound treatment, the mean values of lipid layer thickness increased from 55.33 ± 11.15 nm to 95.67 ± 22.77 nm (p < 0.05), while the mean values measured with the Schirmer's test increased from 2.0 ± 2.3 to 7.2 ± 4.3 (p < 0.05). Positive effects lasted more than three weeks. Adverse events such as redness, swelling, and mild burn, occurred in two rabbits in preliminary experiments when the eyelids sustained a temperature higher than 42°C. No serious adverse events were found. The results suggest that ultrasound stimulation of meibomian glands can improve both tear production and lipid secretion. Ultimately, ultrasound stimulation has the potential to be an option for the treatment of evaporative dry eye disease caused by meibomian gland dysfunction.

Imaging of the post-operative orbit and associated complications.

Dedicated post-operative radiological evaluation following ophthalmologic procedures is relatively uncommon. However, given the ever-growing ophthalmologic procedural advancements and the increasing utilization of neuroimaging for myriad indications, the orbits are often imaged incidentally in a delayed post-procedural state. Regardless of the clinical scenario, it is important for neuroradiologists and other specialists commonly exposed to orbital imaging to be aware of both expected and abnormal post-operative imaging findings because misinterpreted normal features or unrecognized complications can result in vision-threatening delays in treatment or mismanagement. In this review article, we discuss many common ophthalmologic procedures, their indications, and most likely complications. We also provide illustrative operative photographs and radiological imaging examples. By understanding the surgical intent, recognizing the devices that are commonly used, and developing familiarity with the appearance of post-operative complications, pitfalls in interpretation can be avoided and patient outcomes ultimately improved.