The Hatchet Flap for Eyelid and Midfacial Reconstruction: Experience From 70 Cases.

PURPOSE: To describe surgical variations of the hatchet flap and a large series of patients in which this procedure was used for eyelid and midfacial reconstruction. METHODS: A retrospective review was performed on patients treated with a hatchet flap between March 2016 and March 2023. Patient demographics, defect characteristics, surgical techniques, and outcomes were investigated. RESULTS: The hatchet flap was used to repair 70 defects in 69 patients, aged 41.6 to 90.0 years (mean, 66.1). Defects measured 0.6 to 23.6 cm 2 (mean, 4.8) and resulted from Mohs surgery (n = 62), exenteration (n = 2), benign lesion excision (n = 3), or cicatricial ectropion/fistula repair (n = 3). The flap tail was managed with 3 techniques: V-Y plasty (n = 26), transposition (n = 34), and excision (n = 10). Ancillary procedures were often used during reconstructions (skin grafts: 29; double hatchet flap: 2; additional skin flaps: 26; tarsoconjunctival flaps: 6; and other grafts: 7). Small distal eschars healed in 7 flaps without necrosis. Four patients with subcutaneous thickening improved after steroid injections. Mild hatchet flap contracture may have contributed to postoperative cicatricial ectropion in 1 patient. There were no other flap related complications. CONCLUSIONS: In selected patients, the hatchet flap is a versatile technique to mobilize vascularized tissue into eyelid/midfacial defects resulting from the excision of lesions or treatment of cicatricial ectropion/fistulas. Individuals without laxity in the plane perpendicular to the flap base may not be good candidates for this procedure. The hatchet flap can be modified by advancing, transposing, or excising the flap tail. Reconstruction is often combined with other flaps/grafts. Few complications were associated with the hatchet flap.

Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab.

PURPOSE: In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen. METHODS: This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events. RESULTS: The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption. CONCLUSIONS: Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

Lower eyelid margin reconstruction: results of five different techniques.

PURPOSE: This retrospective study was performed to examine surgical results of five different techniques for lower eyelid margin reconstruction after Mohs surgery: primary closure, semicircular flap, dermal matrix graft, sliding tarsal flap, and tarsoconjunctival flap. METHODS: Medical records were reviewed in 178 patients undergoing surgery between 2005 and 2020. Outcomes were evaluated (photographic review) by three oculoplastic observers masked to procedure type, both with and without knowledge of the eyelid defect. RESULTS: All patients achieved a good-excellent functional result and 90.4% were asymptomatic after surgery. Tarsoconjunctival flaps were associated with greater need for subsequent interventions (p < .001) and anterior lamellar deformities (p < .001). Semicircular flaps had a higher incidence of lateral canthal deformity (p < .001), but less eyelash disruption than other flap/graft techniques (p < .001). Mean cosmetic ratings (defect masked) were similar for dermal matrix grafts, semicircular, and sliding tarsal flaps; with each grading higher than tarsoconjunctival flaps (p ≤ .05). Among patients with 9-15 mm wide defects, results were better for semicircular and sliding tarsalflaps, than dermal matrix grafts (p ≤ .005) and tarsoconjunctival flaps (p ≤ .02). CONCLUSIONS: All patients achieved a good-excellent functional result and 87.1% a good-excellent cosmetic result. The semicircular flap was effective for repairing medium sized wounds that could not be closed primarily, creating a continuous lash line, although with a higher incidence of lateral canthal deformities. The sliding tarsal flap was effective for shallow wounds of varying widths. The single-staged dermal matrix graft provided similar results as the tarsoconjunctival flap. Subsequent interventions were more frequent after the tarsoconjunctival flap than other methods.

The Köllner Tarsoconjunctival Flap for Lower Eyelid Reconstruction: Historical Perspective and Surgical Outcomes of 140 Cases.

PURPOSE: While Wendell Hughes popularized the tarsoconjunctival flap for lower eyelid reconstruction, most modern procedures are derived from the technique described by Köllner in 1911. This study reviews the history, techniques, and outcomes of a large series of patients treated with a modified Köllner flap. METHODS: In this observational cohort study, medical records and photographs were reviewed in patients undergoing surgery between 2005 and 2020. Patient demographics, complications, secondary interventions, and outcomes were evaluated. RESULTS: Marginal defect size ranged from 12 to 41 mm among the 140 study patients. Ancillary procedures included lower eyelid conjunctival flaps (n = 64) and septal orbicularis flaps (n = 68). The anterior lamella was reconstructed with skin grafts (n = 86), flaps (n = 10), or combined flaps/grafts (n = 44). Pedicle division was performed 23 to 84 days after primary repair. Subsequent interventions included steroid injection (n = 10), cryotherapy (n = 10), marginal erythema treatment (n = 9), and upper eyelid retraction repair (n = 6). Tearing (6.5%) and dryness (10%) were the most common postoperative symptoms, with most patients (78.6%) being asymptomatic. A good-excellent functional outcome was achieved in 94.3% and cosmetic outcome in 85.0% of cases. Defects <30 mm in width (P = 0.0001), defects not involving a canthus (P = 0.0158), and upper eyelid skin graft donor sites (P = 0.0001) were associated with better outcomes. CONCLUSIONS: The Köllner tarsoconjunctival flap is an effective technique to repair moderate-large lower eyelid defects, with the majority of patients achieving good-excellent cosmetic and functional outcomes. Factors associated with a poorer result include marginal eyelid defects ≥30 mm in width, defects involving a canthus, and non-upper eyelid skin graft donor sites. Most patients are asymptomatic after surgery.

Eyebrow Position Before and After Enucleation.

PURPOSE: The presence of eyebrow elevation in anophthalmic patients has been used as evidence to support a proprioceptive stimulus for frontalis innervation. In this study, we examined the frequency of brow elevation before and after enucleation and reviewed additional clinical findings to determine if any were associated with eyebrow position. METHODS: A retrospective study was performed on 134 anophthalmic patients. Demographics, measurements, and photographs were reviewed. Reference photographs were used to subjectively grade brow position and sulcus depth. RESULTS: Preoperative eyebrow elevation was present in 56.2% of patients without blepharospasm from a painful eye, of who 62% had chronic visual loss. Ipsilateral ptosis (p = 0.008), deep superior sulcus (p < 0.001), and right-sided pathology (p = 0.045) were more common in patients with brow elevation. Symmetrically elevated brows were more frequent before right than left enucleation (p = 0.05). Brow position remained stable after 61.9% of procedures. While often mild, postoperative brow elevation was seen in 31.0% of patients without preoperative elevation. Deepening of the superior sulcus was more common in patients with new relative brow elevation (p = 0.031). Anophthalmic ptosis and right-left surgical side were not associated with new postoperative brow elevation. CONCLUSIONS: Eyebrow elevation was often present prior to enucleation and associated with an increased occurrence of ptosis, superior sulcus deepening, and right-sided pathology. Intact vision was not needed to maintain an elevated brow. Superior sulcus deepening, but not ptosis, was more common in patients developing new postoperative brow elevation. The findings support both proprioceptive and compensatory mechanisms for eyebrow elevation.

Quantitative Analysis of Preoperative and Postoperative Photographs Posted on Social Media by Oculoplastic Surgeons.

PURPOSE: To investigate and quantitatively analyze preoperative and postoperative photographs posted on social media by oculoplastic surgeons. METHODS: Pre- and postoperative blepharoplasty photographs posted by oculoplastic surgeons on the social media platform Instagram were identified over a 4-month period. Photographs demonstrating a frontal pose of the periocular region were selected, and image analysis was performed to compare the preoperative and postoperative photographs. Quantitative image analysis was performed with a semiautomated script using ImageJ (v1.52k) software. Image analysis compared magnification, patient position, luminosity, relative color profiles, and edge detection/sharpness. Three oculoplastic surgeons graded these imaging metrics for the same photoset and the consensus grade was assigned to each category. Finally, the quantitative calculations were then compared with the consensus grades to develop receiver operating characteristic curves for further analysis. RESULTS: The study included 104 posts from 35 members of ASOPRS. Regarding patient positioning, 9 postings were 5%-10% offset from the patients' center, and 6 postings were more than 10% from the patients' center. The majority of photosets demonstrated less than or equal to 2.5% difference in magnification (69/104), with 7 postings demonstrating a greater than 5% difference, and 3 postings exhibiting greater than 10% difference in magnification. In the periocular region, 17.3% (18/104) of postings were found to have a greater than 10% difference in luminosity (>25.5 pixel-value). A more than 5% difference (>12.75 pixel-value) in pre- and postoperative edge-detection measurements was identified in 12 of 104 postings. In 22 of 104 photosets, the mean absolute deviation in color channel ratios was more than 0.01 and 15 of 104 photosets were found to have a mean absolute deviation more than 0.05. CONCLUSIONS: Numerous quantifiable photographic inconsistencies were identified in surgical photographs posted on social media by members of ASOPRS. Adoption of an automated image analysis tool that compares before-and-after surgical photographs could promote standardized oculoplastic surgery photography on social media.

Contralateral eyelid elevation following unilateral upper eyelid retraction repair.

PURPOSE: To report the influence of unilateral upper eyelid retraction repair on the upper eyelid position of the contralateral, non-operative side. METHODS: An IRB-approved retrospective chart review was performed to identify patients who underwent unilateral upper eyelid retraction repair. Patient demographics, etiology of upper eyelid retraction, previous surgeries, and periocular measurements from pre-operative and follow-up visits were reviewed. RESULTS: Thirteen patients who underwent unilateral upper eyelid retraction repair due to thyroid eye disease or iatrogenic retraction secondary to ptosis repair demonstrated an elevation in contralateral eyelid height post-operatively. The mean pre-operative MRD-1 was 6.6 mm in the operative eye and 2.6 mm in the contralateral eye. All patients demonstrated a decreased MRD-1 in the operative eye (mean change: -2.6 mm [-38.4%]; standard deviation [SD]: 1.2 mm) and an increased MRD-1 in the contralateral eye (mean change: +1.3 mm [+62.4%]; SD: 0.6 mm) following unilateral upper eyelid retraction repair. The mean post-operative MRD-1 measurements were 4.0 mm ± 0.5 mm and 3.9 mm ± 0.6 mm in the operative and contralateral eyes, respectively. CONCLUSIONS: Unilateral upper eyelid retraction repair may induce an elevation of the contralateral upper eyelid position in some patients. The findings in this report may support unilateral intervention in patients with upper lid retraction, especially in the setting of contralateral blepharoptosis.

Anophthalmic Ptosis and the Effects of Enucleation on Upper Eyelid Function.

PURPOSE: To describe the incidence of anophthalmic ptosis, identify clinical factors associated with its development, and evaluate the effects of enucleation on eyelid mechanics. METHODS: In this observational cohort study, measurements and photographs were reviewed in 139 patients who underwent enucleation between 2007 and 2016. Patient demographics, pre- and postoperative eyelid measurements, and exophthalmometry were used to assess the incidence of ptosis and effects of surgery on eyelid function. RESULTS: Preoperative ptosis was common and more often present in patients with enophthalmos (p = 0.0305) or reactive blepharospasm (p < 0.0001). The incidence of new-onset ptosis and improvement of preexisting ptosis following enucleation were similar (40%). Surgical repair was performed in 7% of patients with ptosis. Contralateral levator function declined with age and was positively correlated with exophthalmometry (p < 0.0001). Anophthalmic levator function was greater with increased anterior projection of the implant (p < 0.0001) and prosthesis (p < 0.0001). Patients with larger implants had improved levator function, with (p = 0.0065) and without (p = 0.0007) the prosthesis. Superior sulcus deepening was associated with decreased levator activity, but not margin-reflex distance. CONCLUSIONS: Preoperative ptosis was common, and often related to reactive blepharospasm or enophthalmos. Levator function declined with age, and correlated to greater anterior projection of the implant and prosthesis following enucleation. The surgeon can counsel patients regarding the similar likelihood (40%) of preoperative ptosis improving and new ptosis developing after enucleation. The primary factor the surgeon can modify to improve postoperative eyelid function is to maximize implant size, which is associated with greater levator activity.

Volumetric Versus Empirical Determination of Enucleation Implant Size.

PURPOSE: To compare the use of sizing implants versus intraoperative volume measurements for individualization of enucleation implant size, and to identify preoperative factors affecting the choice of implant. METHODS: In this retrospective observational cohort study, 2 implant sizing methods were compared using clinical records and photographs in 139 patients who underwent enucleation between 2007 and 2016. RESULTS: There was no difference in mean implant (p = 0.6562) or prosthetic (p = 0.1990) enophthalmos between the 2 methods, or when comparing patients with and without conjunctival-Tenons fibrosis. The incidence and severity of superior sulcus deformity was similar between the methods (p = 0.6394). Preoperative phthisis (p < 0.0001) and intraoperative conjunctival-Tenons fibrosis (p = 0.0010) were more common in the sizing implant group. Among all study patients, mean implant size was larger in males (21.3 mm, n = 80) than females (20.7 mm, n = 59) (p = 0.0027). Implants >20 mm were more frequently inserted in patients with a wider Hertel exophthalmometry base (80% of males >95 mm; 77% of females >97 mm). Approximately 21.0% of patients demonstrated ≥8 mm of implant enophthalmos, suggesting an undersized implant. The authors estimate that 11% of patients could have received a sphere larger than 22 mm. CONCLUSIONS: Individualization of enucleation implant size can reduce the incidence of anophthalmic socket syndrome. The empirical use of sizing implants provided similar results as intraoperative volumetric measurements, when evaluated by postoperative superior sulcus depth and prosthetic or implant enophthalmos. Preoperative exophthalmometry may facilitate selection of implant size. Preexisting conjunctival-Tenon fascial fibrosis often did not limit implant size and was not associated with a higher prevalence of wound breakdown or implant exposure.

Porcine dermal matrix sandwich graft for lower eyelid reconstruction.

Purpose: To report the clinical outcomes of porcine acellular dermal matrix implants sandwiched between skin and conjunctival flaps for lower eyelid reconstruction following Mohs surgery. Methods: A retrospective review was performed on patients with lower eyelid defects following Mohs surgery treated using a porcine acellular dermal matrix sandwich graft from 2013 to 2018. Patient demographics, defect size and characteristics, and collagen matrix implant dimensions were evaluated. Postoperative course and complications were also reviewed. Results: The dermal matrix sandwich graft was performed in 13 cases (12 patients). Average horizontal marginal defect width was 11.7 mm (range: 6-16 mm). Mean width of the implanted dermal matrix was 7.7 mm (range: 5-9 mm). There were no instances of infection or graft failure. The reconstructed lid had an excellent marginal contour in 11 cases (84.6%), while 2 had minimal irregularities. All patients had an excellent thickness of the reconstructed margin. One patient (7.7%) required cauterization of overgrown marginal conjunctiva after surgery. Two patients (15.4%) experienced symptomatic trichiasis, requiring electrolysis (n = 1) and epilation (n = 1). Conclusions: The dermal matrix sandwich graft is an effective method for marginal defect repair when the remaining conjunctiva and skin are sufficient to develop the necessary flaps. While the resolution of edema and erythema may take several months, an excellent final result is achieved in the majority of cases. Complications are mild, relatively uncommon, and similar to those encountered in other reconstructive procedures. This single-stage, tissue-sparing technique preserves the capability of performing future tarsoconjunctival flaps or lateral canthal procedures, should the need arise.

Comparison of non-absorbable silk and absorbable polyglactin sutures for external ptosis repair.

Purpose: The authors compare the outcomes and revision rates for external levator aponeurotic advancement for the treatment of involutional ptosis using non-absorbable silk and absorbable polyglactin sutures.Methods: An IRB-approved retrospective chart review identified 121 patients who underwent external levator advancement for involutional ptosis between 2015 and 2016 by the senior author (JBH).  All patients underwent ptosis repair using either 5-0 polyglactin 910 on a S-14 spatulated needle or 6-0 silk on a G-1 reverse cutting needle for the aponeurotic advancement. Ptosis etiologies other than involutional ptosis were excluded. Patients with >0.5 mm of upper lid height asymmetry post-operatively underwent surgical adjustment. Demographics, clinical findings and revision rates were collected and analyzed from follow-up visits.Results: 116 patients (190 eyelids) met inclusion criteria. Fewer ptosis repairs performed using silk sutures necessitated adjustment when compared to those using polyglactin (1/73 [1.4%] vs. 14/117 [12.0%], p = 0.010). Silk direct connection sutures had no better stability than polyglactin direct connection sutures (p = 0.16), but silk hang-back sutures were significantly superior to polyglactin hang-back sutures (p = 0.035).  Thirteen out of fifteen (86.7%) revisions were advancements to raise the eyelid, while two (13.3%) were recessions.Conclusion: Non-absorbable silk suture may be superior to absorbable polyglactin, necessitating fewer surgical revisions. Silk demonstrated superiority to polyglactin when a hang-back suture was employed. Since the need to place direct or hang-back sutures cannot be made pre-operatively, the authors modified their technique to utilize silk sutures for external aponeurotic ptosis repair.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Complicated by Fatal Cerebral Vasculitis.

A 21-year-old man experienced unilateral vision loss associated with multiple atrophic chorioretinal lesions. He was treated for a presumptive diagnosis of acute retinal necrosis, but his vision did not improve with antiviral therapy. Over the course of several weeks, his symptoms progressed to involve both eyes. The fellow eye showed characteristic yellow-white placoid lesions, prompting treatment with oral corticosteroids for acute posterior multifocal placoid pigment epitheliopathy (APMPPE). Despite high-dose therapy with prednisone 80 mg daily, the patient developed the acute onset of mental status changes within the next several days. Neuroimaging revealed multifocal large-vessel strokes associated with cerebral edema; these infarcts led to herniation and death. Postmortem histopathologic examination confirmed granulomatous inflammation in both ocular and cerebral vasculatures. Together with findings from multimodal imaging obtained throughout this patient's clinical course, our findings support the notion that granulomatous choroiditis is the mechanism of the ocular lesions seen in APMPPE. This granulomatous inflammation can also affect cerebral vessels, leading to strokes.

Hatchet Flap With Transposed Nasal Inset for Midfacial Reconstruction.

PURPOSE: The purpose of this study is to report the surgical technique and functional outcomes of the hatchet flap with transposed nasal inset for midfacial defect repairs. METHODS: An Institutional Review Board-approved, retrospective review was performed to identify patients treated using the hatchet flap with transposed nasal inset. Patient demographics, disease etiology, defect characteristics, and postoperative complications were collected from preoperative and follow-up visits. RESULTS: The hatchet flap with transposed nasal inset was performed in 5 patients between March 2016 and April 2017. Two patients developed mild transient ischemia of the nasal inset flap tip without necrosis. A suture granuloma was removed in 1 patient. No additional surgical procedures were required after the nasal inset cheek flap. CONCLUSIONS: The hatchet flap with transposed nasal inset is an effective procedure to address defects involving the upper cheek, lower eyelid, and medial canthus. Incorporation of the nasal inset helps prevent distortion of the ala and facilitates closure of the flap donor site. This technique may be employed in certain patients as an acceptable alternative to more extensive Mustardé or paramedian forehead flaps.

Operating Room Fires in Oculoplastic Surgery.

PURPOSE: This study was performed to characterize the frequency, causes, and possible risk factors of operating room (OR) fires experienced by members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. METHODS: An online questionnaire was distributed to American Society of Ophthalmic Plastic and Reconstructive Surgery members, collecting data on surgical fires experienced by respondents throughout their careers. In addition, the questionnaire investigated viewpoints on OR fire safety, current practice patterns with oxygen delivery and surgical device usage, and management of patients referred after previous surgical fire exposure. RESULTS: There were 258 participants in the survey. Eighty-three surgeons (32.2%) experienced at least 1 surgical fire in their careers. Most OR fires occurred during monitored sedation cases with oxygen delivered by nasal cannula underneath drapes completely covering the head and use of a monopolar or battery-operated device. Patient hair and skin were the most common fuel sources, and most of the injuries were limited to singing of facial hair. Regarding current practice patterns, monopolar, bipolar, and battery-powered disposable devices were the most frequently used electrosurgery and electrocautery tools. Patients seen after an OR fire with another surgeon generally experienced more severe burns requiring hospitalization and subsequent procedures. CONCLUSIONS: Many oculoplastic surgeons have experienced OR fires during their careers. Certain surgical and anesthetic techniques, particularly the delivery of supplemental oxygen underneath surgical drapes and the use of monopolar electrosurgery and battery-powered electrocautery, may be associated with increased fire risk. While most of the reported OR fires did not result in significant patient injury, caution must be taken to prevent these potentially devastating events.

The efficacy of a novel mobile phone application for goldmann ptosis visual field interpretation.

PURPOSE: To evaluate the efficacy of a novel mobile phone application that calculates superior visual field defects on Goldmann visual field charts. METHODS: Experimental study in which the mobile phone application and 14 oculoplastic surgeons interpreted the superior visual field defect in 10 Goldmann charts. Percent error of the mobile phone application and the oculoplastic surgeons' estimates were calculated compared with computer software computation of the actual defects. Precision and time efficiency of the application were evaluated by processing the same Goldmann visual field chart 10 repeated times. RESULTS: The mobile phone application was associated with a mean percent error of 1.98% (95% confidence interval[CI], 0.87%-3.10%) in superior visual field defect calculation. The average mean percent error of the oculoplastic surgeons' visual estimates was 19.75% (95% CI, 14.39%-25.11%). Oculoplastic surgeons, on average, underestimated the defect in all 10 Goldmann charts. There was high interobserver variance among oculoplastic surgeons. The percent error of the 10 repeated measurements on a single chart was 0.93% (95% CI, 0.40%-1.46%). The average time to process 1 chart was 12.9 seconds (95% CI, 10.9-15.0 seconds). CONCLUSIONS: The mobile phone application was highly accurate, precise, and time-efficient in calculating the percent superior visual field defect using Goldmann charts. Oculoplastic surgeon visual interpretations were highly inaccurate, highly variable, and usually underestimated the field vision loss.

Tattoo-associated lacrimal gland enlargement and sarcoidosis.

Purpose: To describe a case of tattoo-associated sarcoidosis presenting with cutaneous findings of tattoo granulomas and ophthalmic manifestation of isolated bilateral lacrimal gland enlargement. Observations: A 35-year-old female presented with bilateral upper eyelid swelling for over a year. She reported no associated episodes of ocular pain or visual decline since onset of eyelid edema. On examination, the lacrimal glands were firm and enlarged bilaterally. Slit-lamp examination demonstrated no evidence of active or prior ocular inflammation. Further systemic examination revealed multiple raised papules within a 4-year-old chest/shoulder tattoo. Histopathology from a lacrimal gland biopsy showed non-caseating granulomas consistent with sarcoidosis. Conclusions and importance: The authors report a rare case of a 35-year-old presenting with isolated dacryoadenitis and tattoo granulomas found to be a tattoo-associated sarcoidosis. Although uveitis is a commonly described ocular manifestation in tattoo-associated sarcoidosis, few reports have described lacrimal gland enlargement as a presenting ophthalmic feature in tattoo-associated sarcoidosis.

Efficacy and Safety of Teprotumumab in Patients With Thyroid Eye Disease of Long Duration and Low Disease Activity.

CONTEXT: Early inflammatory thyroid eye disease (TED) can lead to symptomatic chronic disease, including disabling proptosis. Teprotumumab, an insulin-like growth factor-1 receptor (IGF-1R) inhibitor, previously demonstrated efficacy in acute, high-inflammation TED trials. OBJECTIVE: We present data from the first placebo-controlled trial with teprotumumab in chronic/low disease activity TED. METHODS: This randomized double-masked, placebo-controlled trial, conducted at 11 US centers, enrolled adult participants with TED duration of 2 to 10 years, Clinical Activity Score (CAS) ≤ 1 or no additional inflammation or progression in proptosis/diplopia for ≥1 year, proptosis ≥3 mm from before TED and/or from normal, euthyroid/mildly hypo/hyperthyroid, no prior teprotumumab, and no steroids within 3 weeks of baseline. Patients received (2:1) intravenous teprotumumab or placebo once every 3 weeks (total 8 infusions). The primary endpoint was proptosis (mm) improvement at Week 24. Adverse events (AEs) were assessed. RESULTS: A total of 62 (42 teprotumumab and 20 placebo) patients were randomized. At Week 24, least squares mean (SE) proptosis improvement was greater with teprotumumab (-2.41 [0.228]) than with placebo (-0.92 [0.323]), difference -1.48 (95% CI -2.28, -0.69; P = .0004). Proportions of patients with AEs were similar between groups. Hyperglycemia was reported in 6 (15%) vs 2 (10%) and hearing impairment in 9 (22%) vs 2 (10%) with teprotumumab and placebo, respectively. AEs led to discontinuation in 1 teprotumumab (left ear conductive hearing loss with congenital anomaly) and 1 placebo patient (infusion-related). There were no deaths. CONCLUSION: Teprotumumab significantly improved proptosis vs placebo in longstanding/low inflammation TED, demonstrating efficacy regardless of disease duration/activity. The safety profile was comparable to that previously reported.

Smartphone-based Anterior Segment Imaging: A Comparative Diagnostic Accuracy Study of a Potential Tool for Blindness Prevalence Surveys.

PURPOSE: To determine if smartphone photography could be a useful adjunct to blindness prevalence surveys by providing an accurate diagnosis of corneal opacity. METHODS: A total of 174 patients with infectious keratitis who had undergone corneal culturing over the past 5 years were enrolled in a diagnostic accuracy study at an eye hospital in South India. Both eyes had an ophthalmologist-performed slit lamp examination, followed by anterior segment photography with a handheld digital single lens reflex (SLR) camera and a smartphone camera coupled to an external attachment that provided magnification and illumination. The diagnostic accuracy of photography was assessed relative to slit lamp examination. RESULTS: In total, 90 of 174 enrolled participants had a corneal opacity in the cultured eye and no opacity in the contralateral eye, and did not have a penetrating keratoplasty or missing photographs. Relative to slit lamp examination, the sensitivity of corneal opacity diagnosis was 68% (95%CI 58-77%) using the smartphone's default settings and 59% (95%CI 49-69%) using the SLR, and the specificity was 97% (95%CI 93-100%) for the smartphone and 97% (95%CI 92-100%) for the SLR. The sensitivity of smartphone-based corneal opacity diagnosis was higher for larger scars (81% for opacities 2 mm in diameter or larger), more visually significant scars (100% for eyes with visual acuity worse than 20/400), and more recent scars (85% for eyes cultured in the past 12 months). CONCLUSION: The diagnostic performance of a smartphone coupled to an external attachment, while somewhat variable, demonstrated high specificity and high sensitivity for all but the smallest opacities.