Correction of Tear Trough Deformity with Minced Orbital Fat Grafts During Transconjunctival Lower Blepharoplasty.

BACKGROUND: The correction of tear trough deformity poses a significant challenge in the context of facial rejuvenation. Our aim was to introduce a technique that corrects tear trough deformity during transconjunctival lower blepharoplasty using minced orbital fat grafts. METHODS: The medical records of patients who underwent lower blepharoplasty from January 2019 to December 2021 were reviewed. The study included patients with various grades of tear trough deformity, who underwent lower blepharoplasty using minced orbital fat grafts and followed up for at least 6 months. Modified Barton's grading for tear trough depression, patient satisfaction, and postoperative complications were evaluated. RESULTS: A total of ninety-eight patients, with a mean age of 48.07 ± 9.72 years, consisting of 93 (94.9%) females were included in the study. The average duration of follow-up was 7.2 months, ranging from 6 to 13 months. Tear trough depression significantly improved after the operation (preoperative tear trough depression grade mean (SD): 3.11 (0.60); postoperative tear trough depression grade mean (SD): 0.87 (0.66); P < 0.001). 78.5% of the participants reported their outcome as excellent or good, 20.4% reported as fair, and 1.0% (only one patient) reported as no improvement. None of the participants rated their outcome as worsening. No major complication was observed during the follow-up period. CONCLUSION: Minced orbital fat grafting during transconjunctival lower eyelid blepharoplasty has good effectiveness for correcting tear trough deformity without the risk of major complications. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Diagnosis and Treatment of Lacrimal Gland Prolapse: A Narrative Review.

BACKGROUND: Lacrimal gland prolapse (LGP) is considered to be one of the causes for upper eyelid contour abnormality that should be recognized and treated properly to yield satisfactory outcomes in blepharoplasty. To describe current findings about the prevalence, pre- and intraoperative diagnosis of LGP and its treatment options. METHODS: PubMed and Google Scholar were thoroughly searched for articles published describing the diagnosis and treatment of LGP. RESULTS: The reported prevalence of LGP by various authors varies between 10 and 60% based on their preoperative or intraoperative reports. Techniques such as dacryoadenopexy, modified dacryoadenopexy, and dacryoplasty have been described to secure the prolapsed lacrimal gland back into its original position. Additionally, creating a Whitnall's barrier has also been suggested as a method to reposition the gland. While all these surgical procedures have shown promising immediate results, there is a lack of published data on their long-term outcomes. CONCLUSION: Diagnosis and proper treatment of LGP could enhance the cosmetic results of upper eyelid blepharoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lower eyelid position after ptosis repair in patients with blepharoptosis.

PURPOSE: To determine the changes in the lower eyelid position, following ptosis surgery of the upper eyelid of the same eye in blepharoptosis patients. METHODS: This prospective interventional before and after study included patients aged more than 5 years with blepharoptosis. Margin reflex distance one (MRD-1), MRD two (MRD-2), and levator function were measured before and the 6 months after the surgery. RESULTS: Sixty patients with blepharoptosis (33 congenital and 27 acquired) were recruited. The mean age was 21.61 ± 10.82 and 59.8 ± 13.73 years in congenital and acquired groups, respectively. The mean MRD-1 improved from 1.95 ± 0.99 before treatment to 4.47 ± 0.47 after treatment (p < 0.001). The mean MRD-2 improved from 5.57 ± 0.63 before treatment to 4.95 ± 0.51 after treatment (p < 0.001). There was no statistically significant difference in MRD-1 and MRD-2 changes between the two groups (p > 0.05) There was no statistically significant correlation between MRD-2 changes and LF (r = -0.03. p = 0.83). CONCLUSION: Present study showed a significant improvement in the condition of the lower eyelid improved after upper eyelid ptosis surgery.

Assessing the success rate of treatment in simple and complex congenital nasolacrimal duct obstruction: a systematic review and meta-analysis.

PURPOSE: To assess and compare the success rate (SR) of probing and intubation in patients with congenital nasolacrimal duct obstruction (CNLDO). METHODS: We conducted a literature search for identifying relevant studies published in English using PubMed, Google Scholar, Scopus, and Web of Science databases from the date of inception to Feb 2023. After extracting data, the SR was compared between the study groups: simple and complex CNLDO. To compare the treatment outcome, the mean difference of the SR was considered as the effect size. Random effects model or fixed effects model were performed for statistical inferences. RESULTS: A total of 21 studies were eligible to be analyzed. The pooled SR of treatment was 88% in simple, and 57% in complex CNLDO. Exerting intubation in increased the SR from 87% (SR of probing) to 92% in simple CNLDO which was not significant. However, compared to probing, intubation has a significantly higher SR in complex CNLDO (46 to 82%). While the SR of probing was significantly lower in complex CNLDO, the difference between the SR of intubation was not significant between groups. Although increasing the age does not have an adverse effect on the SR in simple CNDLO, it causes a significant decrease in the SR of complex group. CONCLUSION: This study revealed that even though the addition of NLD intubation does not provide significant benefits beyond probing alone for patients with simple CNLDO, in children with complex CNLDO, NLD intubation should be considered as a primary treatment due to its substantial increase in surgical success rates. Delaying the treatment would increase its success in patients with complex but not the simple CNLDO.

The Prevalence of Undiagnosed Ptosis Among Candidates for Upper Eyelid Blepharoplasty.

Background: Because upper eyelid blepharoplasty has become a popular aesthetic facial surgery, surgeons should be aware that age-related changes in the eyelid are not confined to skin laxity and orbital fat prolapse. Objectives: This study was designed to assess the prevalence of undiagnosed ptosis among blepharoplasty candidates as one of the causes of unsatisfactory surgical results. Methods: From December 2018 to December 2022, blepharoplasty candidates were meticulously assessed for their upper eyelid and eyebrow position. Patients who were aware of their ptosis were excluded, and the other patients were classified as mild, moderate, or severe ptotic based on margin reflex distance 1. The eyebrow height was also assessed in the mid-pupillary line to assess the relationship between the severity of ptosis and eyebrow asymmetry. Results: The authors found that 13.7% of the 2530 blepharoplasty candidates in this study had undiagnosed ptosis. Most of these patients had mild ptosis (85.5%), and they were significantly older than nonptotic patients. The rate of prevalence of ptosis was significantly higher in patients with eyebrow asymmetry (75.3% vs 3.7%); however, the severity of ptosis was not associated with the severity of eyebrow asymmetry. Conclusions: Ptosis should be cautiously looked for and addressed for treatment in candidates for upper blepharoplasty. In most patients with masked ptosis, the severity of eyelid drooping is mild and could remain undiagnosed until after the surgery and cause unsatisfactory aesthetic results. The presence of eyebrow asymmetry could be a key feature to unmask an undiagnosed ptosis.

A comparison between bilateral and unilateral thyroid eye disease.

PURPOSE: To compare characteristics of unilateral vs. bilateral thyroid eye disease (TED). METHODS: This retrospective analytical cross-sectional study was conducted on patients with TED who were evaluated at an academic referral center over a 6-year period. We compared demographics, activity (clinical activity score) and severity (EUGOGO classification) of TED, thyroid disease duration, TED duration, the time interval between thyroid and eye involvement, thyroid function status, and clinical signs between bilateral and unilateral TED. RESULTS: Three hundred eighty-three patients including 213 females (55.6%), who had a mean age of 40.23 ± 13.72 years, were enrolled. Active TED was seen in 8.8% of bilateral and none of unilateral cases (P = 0.04). Bilateral TED patients had more severe disease (P = 0.001). The distribution of hyperthyroidism, hypothyroidism, and euthyroidism was significantly different between unilateral and bilateral groups (P = 0.001). Abnormal ocular motility was present in 26.3% versus 2.3% of bilateral and unilateral ones, respectively (P = 0.001). Proptosis was more prevalent in bilateral than unilateral cases (P = 0.001). We did not observe any statistically significant difference between the two groups in others variables. CONCLUSION: Bilateral TED patients present with more severity, activity, movement abnormality, proptosis, and hyperthyroidism.

Hypo vs. hyperthyroid eye disease: is there any difference?

BACKGROUND: Thyroid-eye disease (TED) is the most common extra-thyroidal presentation of graves' disease. We performed this study to compare clinical characteristics of TED in hypothyroid vs. hyperthyroid patients. METHODS: This was a retrospective analytical cross-sectional study in which we compared demographics, severity (EUGOGO classification) and activity (clinical activity score) of TED, thyroid disease duration, TED duration and clinical signs between hypothyroid eye disease (Ho-TED) and hyperthyroid eye disease (Hr-TED). To minimize the effect of selection bias and potential confounders, 1:1 propensity score matching (PSM) was also performed. RESULTS: Three hundred and seventy-four patients (341 Hr-TED and 33 Ho-TED) with a female to male ratio of 1.4:1 were identified in our study. Female to male ratio was 1.3:1 in hyperthyroid and 4.5:1 in hypothyroid group (P = 0.005). The duration of thyroid disease was longer in Ho-TED (P = 0.002) while the duration of eye disease was not significantly different between the Hr-TED (mean = 24.33 ± 41.69, median = 8) and Ho-TED (mean = 19.06 ± 33.60, median = 12) (P = 0.923). Most of the patients in hypothyroid group developed eye involvement after thyroid disease (80.0% in hypo vs. 48.1% in hyper, P = 0.003). Severity (P = 0.13) and activity (P = 0.11) was not different between Hr-TED and Ho-TED patients. After PSM analysis, no clinical characteristics were significantly different between the two groups (P > 0.05). CONCLUSION: The results of our study showed several differences between the Hr/Ho TED patients including sex, duration of thyroid disease and pattern of eye involvement. After matching the two groups with statistical methods, no clinical characteristics were different between Hr-TED and Ho-TED patients.

Father-Son COVID-19-associated mucormycosis: Important role of genetic susceptibility in combination with environmental factors.

In this report, a father with a history of diabetes mellitus and his son without a remarkable past medical history, both got COVID-19- associated mucormycosis (CAM) as evidenced by their clinical and radiological findings. This suggests the possible role of genetics in combination with the environment in susceptibility to CAM.

From Bilateral Periorbital Necrotic Wound to Fungal Brain Abscess: A Complicated Case of COVID-19-Associated Mucormycosis.

COVID-19-associated mucormycosis (CAM) is categorized as rhinocerebral-orbital (RCOM), pulmonary, gastrointestinal, cutaneous, and disseminated mucormycosis. An alarming surge in morbidity and mortality attributed to mucormycosis concurrent with coronavirus disease 2019 (COVID-19) has emerged as a cause for concern during the current outbreak of COVID-19. The global incidence of CAM has been attributed to environmental, host, and iatrogenic factors. Further, Mucorales interacting with epithelial cells followed by endothelium invasion are pivotal in developing mucormycosis in patients with COVID-19. In essence, CAM is an emerging condition that requires increased vigilance in all COVID-19 patients, including those who have recovered. In this case report, we describe a rare case of CAM in a 33-year-old immunocompetent man who developed bilateral periocular pain and a small area of cutaneous necrosis in both medial canthi associated with impaired vision, which progressed into a fungal brain abscess formation in the post-COVID period. Furthermore, this case aims to illustrate the potential underlying risk factors of CAM other than known risk factors, especially in immunocompetent individuals.

Atypical intraorbital dermoid and epidermoid cyst: A single institution cross-sectional retrospective study.

Purpose: Intraorbital epidermoid and dermoid cyst (DC) has been reported in the literature rarely. The current study evaluates clinicopathologic, radiologic, and management of intraorbital DC cases over ten years. Methods: In this cross-sectional study, the medical records of patients with intraorbital DC treated at the academic referral center for ocular surgery were retrospectively reviewed. Data reviewed included the patient's demographic characteristics, clinical features, imaging, surgical technique, and pathology report. Results: Nine patients with a rare presentation of intraorbital DC were reviewed within the study period in five presentations (five intraosseous, one intraconal, one dumbbell-shaped with a large part in anterior orbit, one juxta levator palpebral muscle, and one recurrent case with intracranial extension). They ranged from 8 to 53 years of age, with a median of 29 years, and five (55.6%) were female. Histopathological evaluation revealed two cysts were epidermoid. Conclusion: The current study provides more clinical and radiologic manifestations of rare presentations of DC that highlight the importance of high clinical suspicion in the approach to atypical DC.

Outcome of monocanalicular intubation for complex congenital nasolacrimal duct obstruction: the role of age.

Objective: Complex congenital nasolacrimal duct obstruction (CNLDO) is caused by pathologies other than the typical incomplete perforation of the thin membrane in the distal end of the nasolacrimal duct (NLD). Our purpose was to determine the success of silicone tube insertion for such complex CNLDO cases. Methods: Children who met the defined criteria for complex CNLDO and underwent monocanalicular silicone tube insertion between April 2016 and December 2020 were included. The tube was retained for 6-8 weeks and the final outcome was measured 3-4 months after tube removal. If the patients were totally symptom free, the outcome was recorded as complete success. Acceptable outcome was defined as Munk score ≤ 1 (requiring less than twice daily dabbing) and others were classified as failed. Results: Initially, 147 eyes of 132 patients underwent NLD intubation. However, after exclusion of the 11 cases with spontaneous tube extrusion (7.48%), 136 eyes of 121 patients entered the final analysis. The mean age was 23.9 ± 13.0 months (range 8-73 months). The outcome was complete success in 100 eyes (73.5%), acceptable in 16 (11.8%), and failure in 20 eyes (14.7%). The differences in the outcome of the procedure for the eyes based on history of previous probing and age was not statistically significant. Conclusions: NLD intubation with monocanalicular stent is effective in the resolution of complex CNLDO in 85% of cases. This procedure is associated with infrequent complications, like tube loss. The success is not negatively affected by older age and previously failed probing history. Abbreviations: CNLDO = congenital nasolacrimal duct obstruction, NLD = nasolacrimal duct.

Epidemiological Status of Thyroid Eye Disease in Central Iran.

Purpose: To focus on clinical manifestations and epidemiology of thyroid eye disease (TED) in Central Iran's population. Methods: In this retrospective case study, we analyzed all patients with TED who were referred to our oculoplastic clinic from 2015 to 2019. The patients' epidemiological characteristics and clinical presentation were compared between different thyroid disease groups and genders. Results: Overall, 383 patients (155 male; 40.5% and 228 female; 59.5%) were included. The mean age was 39.55 years (standard deviation ± 13.45, range 10-72). Most patients (89%) were hyperthyroid with the highest duration of ocular involvement among all categories (25.6 months). The most common signs on ophthalmic examinations were proptosis (80.4%), followed by eyelid retraction (72.3.0%). TED was classified as mild in 24.5%, moderate to severe in 67.6%, and sight-threatening in 7.9%. Thirty patients (7.8%) had active TED. Conclusions: This series with a relatively more significant number of TED cases in Central Iran found similar epidemiological and clinical characteristics of TED compared to other studies from Iran. Most of our patients were hyperthyroid, with more females compared to males. Proptosis and eyelid retraction were the most common manifestations. Most TED patients were classified as moderate to severe.

Mycophenolate Mofetil (CellCept®) in Combination With Low Dose Prednisolone in Moderate to Severe Graves' Orbitopathy.

Although corticosteroids are currently the first-choice drug for thyroid eye disease (TED), in 20-30% of cases, patients show poor or non-existent responses, and when the drug is withdrawn, 10-20% of patients relapse. Thus, in this study, we aimed to investigate the efficacy of the combined use of mycophenolate mofetil (CellCept®) and low dose oral prednisolone in patients with moderate to severe Graves' orbitopathy (GO). For the first time, we investigated the relationship between TED-related parameters and proptosis reduction. In a prospective, non-randomized, interventional case series, 242 patients with moderate-to-severe GO were, assigned to receive oral prednisolone (5 mg/ d) and mycophenolate mofetil (CellCept®) (one 500 mg tablet twice per day according to the therapeutic response). The patients were monitored regularly during the 3rd, 6th, 12th, and 18th month of treatment. The main outcome measures were the clinical activity score (CAS), intraocular pressure (IOP), diplopia, proptosis and visual acuity. We also assessed the relationship between the main outcomes with proptosis changes and time to improvement (months). Adverse effects were recorded during each visit. The clinical response rate increased from 67.7% on the third month to 89.2% on the sixth month, and 94.2% on the 12th month. This therapeutic response continued until the 18th month of follow-up. The CAS responses [disease inactivation (CAS <3)] improved during our study: 70.6% on the third month, 90.0% on the sixth month, and 92.5% at 12th month. These conditions continued until the 18th month of follow-up. Proptosis improvement was 52% on the third month, 71% on the sixth month, 83% on the 12th month, and 87.1% on the 18th month. Changes in IOP and visual acuity were not significant (P = 0.568 and 0.668, respectively). The patient showed significant improvement in the Gorman score. A Shorter duration of treatment was seen in patients with earlier onset of intervention, younger age, and lack of all extraocular muscle (EOM) enlargement on computed tomography (CT) scan (p < 0.05). In addition, a better response (more reduction) in proptosis was related to: younger age at disease, earlier treatment intervention (less interval from the time the diagnosis of moderate-to-severe GO was made until medication initiation), shorter treatment time (less time to improvement), less IOP, lack of EOM enlargement on CT scan, and lack of diplopia (P < 0.05). Adverse events occurred in six patients. Findings show that mycophenolate mofetil (CellCept®) plus low-dose prednisolone can be introduced as a new optimal dosing regimen in GO due to its better effect on chronic complications such as proptosis and diplopia.

Decreased Bell's phenomenon after inferior and medial orbital wall decompression in thyroid-associated ophthalmopathy: a double-edged sword in management of the patients.

PURPOSE: To evaluate the changes in Bell's phenomenon after inferior and medial orbital wall decompression in patients with thyroid-associated ophthalmopathy (TAO). METHODS: This prospective interventional study included patients with moderate to severe non-active TAO, who underwent inferior and medial wall orbital decompression. Bell's phenomenon and adjusted Bell's phenomenon were evaluated at baseline and six months after surgery. Bell's phenomenon was assessed by holding the upper lid open during forced eyelid closure. Afterwards, the upward excursion, the distance between lower eyelid margin and lower corneal limbus, was measured. Adjusted Bell's phenomenon distance is defined as the difference between margin reflex distance two (MRD2) and Bell's phenomenon distance. RESULTS: Thirty TAO patients, including 15 males (50%), with a mean age of 43.6 ± 11.6 years, were enrolled. The distance of Bell's phenomenon significantly decreased after surgery by an average of 3.25 ± 1.57 mm (P < 0.001). In addition, the difference between pre- and post-operative distance of adjusted Bell's phenomenon was - 1.58 ± 2.13 (P < 0.001) corresponding to the worsening in the adjusted Bell's phenomenon. CONCLUSION: The result of our study demonstrated that Bell's phenomenon decreases significantly after inferior and medial wall decompression, which could be considered a complication of this form of orbital wall decompression in TAO.

Efficacy of probing adjunctive with low-dose mitomycin-C irrigation for the treatment of epiphora in adults with nasolacrimal duct stenosis.

PURPOSE: The purpose of the study was to investigate the efficacy of adjunctive low-dose mitomycin-C (MMC) during successful lacrimal duct probing in adults with nasolacrimal ducts (NLDs) stenosis. MATERIALS AND METHODS: This is a prospective case-control study on patients with NLD stenosis who were randomized into two groups. All patients underwent probing without or with an application of MMC. Former group received 0.2 mg/ml MMC irrigation for 5 min. The main outcome measures were objective evaluation of patency with irrigation, as well as patients' subjective assessment of improvement. RESULTS: There were 73 eyes in 58 consecutive patients; patient mean age ranged from 19 to 78 years (mean 44 years). Female included larger group of patients (63%) and mean duration of the symptoms was 26.1 months (range, 2-120 months). After mean follow-up of 11 months (range, 9-14 months), 23 (60%) of the 38 eyes in the MMC groups and 8 (22%) of the 35 eyes in control group had complete response and remained symptom free. This difference was statistically significant (P = 0.005). According to the patient's satisfaction, epiphora was partially improved in 6 (17%) eyes of control group and 4 (10%) eyes in MMC group. Application of MMC has a better outcome in patients with severe stenosis (P = 0.007); patients who had symptoms more than 12 months (P = 0.02) and patients with constant epiphora were compared with intermittent symptoms (P = 0.001). No complications were detected during patients follow-up. CONCLUSION: This study suggests acceptable long-term results for probing adjunctive with MMC irrigation for adults with NLD stenosis that can be recommended as a simple and effective procedure for these patients.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series.

PURPOSE: To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). METHODS: Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4-14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. RESULTS: Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively (p=0.29). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation (p=0.07). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p=0.75). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. CONCLUSION: Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Nonspecific orbital inflammation and thyroid eye disease, a rare comorbidity: report of two cases and review of literature.

BACKGROUND: To present the very rare comorbidity of developing non-specific orbital inflammation (NSOI) in two patients with histories of definite thyroid eye disease (TED). CASE PRESENTATION: Both patients complained of new-onset progressive proptosis although their thyroid disease was controlled and computed tomography scan revealed an intraorbital inflammatory mass. The pathological assessment indicated that both patients had developed fibrosing NSOI. Therefore, intravenous corticosteroids were administered. The mass regressed and the amount of proptosis was decreased in both patients. CONCLUSIONS: We reviewed all related cases in the literature and extracted their clinical and radiological characteristics for this paper. Ophthalmologists should consider TED and NSOI in patients with a new-onset complaint of proptosis. Despite rare comorbidity of TED and NSOI, it should be considered especially in patients with refractory proptosis, and lead to its further evaluation and prompt management.

Monocanalicular Intubation in Children with Incomplete Complex Congenital Nasolacrimal Duct Obstruction Older Than Five Years of Age.

PURPOSE: To evaluate the role of monocanalicular intubation (MCI) in congenital nasolacrimal duct obstruction (CNLDO) in children older than 5 years of age. METHODS: A retrospective case series study was done on children over 5 years of age diagnosed with CNLDO who underwent MCI. Success rates were evaluated subjectively by asking their parents about persistent symptoms and objectively using the dye disappearance test in clinical examination. RESULTS: A total of 43 eyes of 37 patients with a mean age of 7.42 ± 2.33 (range, 5-15 years of age) were included. The success rate was 60.46%, and the rate of secondary surgical intervention was 25% of all cases (61.11% of failed cases). CONCLUSION: Primary MCI maintains a reasonable success rate in incomplete complicated CNLDO regardless of age.