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.

A Review of Current Uses of Amniotic Membrane Transplantation in Ophthalmic Plastic and Reconstructive Surgery.

PURPOSE: To review and summarize the existing literature on the clinical applications of amniotic membrane transplantation (AMT) in ophthalmic plastic and reconstructive surgery. METHODS: A literature review was conducted on the PubMed database using the following search terms: "amniotic membrane" and "eyelid" or "orbit" or "fornix" or "socket" or "lacrimal". RESULTS: In total 516 articles resulted from the search, of which 62 were included. Numerous cases and case series have been published on the use of amniotic membrane transplantation for ocular surface reconstruction, eyelid and forniceal reconstruction, and cicatricial eyelid abnormalities. Surgical methods of securing the graft vary. Few comparative studies exist; some show a similar or improved result when compared to oral mucous membrane grafting for certain indications. CONCLUSIONS: Amniotic membrane transplantation can be a useful tool for the oculoplastic surgeon when faced with a case requiring reconstruction of the posterior lamellae, particularly in patients without other graft donor sites available, and uses of AMT continue to expand. Additional studies directly comparing AMT to other reconstructive techniques would be helpful in choosing between the available surgical techniques and standardizing best practices.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study.

PURPOSE: To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). METHODS: In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. RESULTS: Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. CONCLUSIONS: Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Oral Sedation Anesthesia Protocol for In-Office Oculoplastic Surgery.

PURPOSE: To present an oral anesthesia protocol for in-office oculoplastic surgery and to compare safety outcomes and patient and physician experiences to ambulatory surgery center (ASC)-based surgery with intravenous sedation or general anesthesia. METHODS: A prospective study was performed on consecutive patients undergoing surgery at an oculofacial plastic surgery practice. Surgery was performed in an in-office setting using our standardized oral sedation protocol or at an ASC with intravenous sedation or general anesthesia. Preoperative and postoperative surveys were conducted by patients and physicians to compare surgical experience, safety, and efficacy of our oral sedation protocol for in-office surgery in the ASC setting. RESULTS: Two hundred and fifty-three patients (167 in-office and 86 at ASC) underwent surgery between March and November 2022. There was no significant difference in how patients or physicians rated their experience between the 2 locations. A significantly higher proportion of ASC patients would have rather had surgery in-office (34.9% vs. 19.2%; p = 0.006). A significantly higher number of physicians in the office setting would have rather performed surgery at the ASC than the reverse (12.7% vs. 2.3%, respectfully; p = 0.007). There were no safety complications reported in either setting. CONCLUSIONS: Within our patient cohort, the presented oral sedation protocol provided safe and effective anesthesia for in-office oculoplastic surgery that is comparable to an ASC.

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.

Bilobed flap reconstruction after en-bloc removal of solitary fibrous tumor of the lacrimal sac.

Purpose: To report a rare case of a solitary fibrous tumor (SFT) of the lacrimal sac and discuss considerations for management of similar cases. Observations: We present the case of a 41-year-old woman who presented with a primary lacrimal sac SFT for which she underwent en-bloc surgical resection. We discuss management options for SFTs and our surgical approach for this case: bilobed flap reconstruction of the medial canthus and inferior orbit. Conclusions: We present an uncommon presentation of a rare tumor and a successful one-stage reconstruction with a bilobed flap.

Multiple Cases of Facial Disfigurement From Filler Use and One Injector.

PURPOSE: To present a case of facial disfigurement from an injectable permanent filler and describe the consequences to patients exposed to the same injector (common source outbreak). METHODS: Case report and discussion of a common source outbreak after a group of persons developed complications years after permanent filler given by one injector. RESULTS: A 39-year-old transgender model underwent polymethylmethacrylate (Artefill) facial filler injections to the lips, cheeks, and chin in 2018. A year later, the patient presented to the emergency room with severe facial swelling and difficulty breathing. Treatments have included 4 surgeries to remove filler and scar tissue and chronic low-dose oral steroid therapy. Upon questioning the patient, 6 additional people suffered from similar facial swelling years after injection by the same injector. The injector cannot be located. CONCLUSIONS: Care must be taken in giving all facial fillers, particularly permanent ones. When one source patient is identified, questioning the patient's knowledge of others affected is critical to help manage an epidemic problem and to report a rogue injector. Physicians have a duty to investigate and report such cases.

Carotid-Cavernous Sinus Fistula Masquerading as Thyroid Eye Disease.

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

Lateral Tarsoconjunctival Flap Suspension Treatment of Post Blepharoplasty Lower Eyelid Retraction.

PURPOSE: To describe and evaluate the use of a lateral tarsoconjunctival suspension flap (TCSF) for the management of post blepharoplasty lower eyelid retraction. METHODS: Two-center, retrospective chart review of patients who received a lateral TCSF between 2010 and 2018 for correction of post blepharoplasty lower eyelid retraction. The postoperative follow-up was a minimum of 3 months. Pre- and postoperative lower eyelid position (margin reflex distance 2 on standard photographs), degree of ocular surface disease, symptoms, complications, and need for further intervention were recorded. Pre- and postoperative photographs were scored using an objective grading system for cosmetic surgical results (MDACS). RESULTS: Forty-eight eyelids from 30 patients met inclusion criteria for this study. Twenty (67%) of the patients were female. Age ranged from 55 to 89 (mean, 73.2). After the TCSF, ocular surface exposure improved in all cases. Lower eyelid retraction (average margin reflex distance 2 pre- vs. postintervention) improved in 98% of cases. Objective scoring of appearance improved; the mean MDACS score was 8 pre- and 3 post-TCSFs (p < 0.0001). One patient required midface lift and lateral canthoplasty 7 months later for undercorrected eyelid retraction. Another case required partial resection due to visibility of the flap in the interpalpebral zone. Postoperative pyogenic granulomas were noted in 8% (4/48) of eyelids. CONCLUSIONS: The lateral TCSF was safe and effective in improving both functional and esthetic parameters in this series of post blepharoplasty eyelid retraction patients.

The Effect of a Screen Protector on Blue Light Intensity Emitted from Different Hand-held Devices.

PURPOSE: In response to growing concern about the effect of blue light on ocular tissue, companies have created mobile device screen protectors to block blue light. This project evaluates one of these screen protectors' ability to reduce blue light intensity. METHODS: The intensity of light at 450 nm from an iPhone 8, iPhone X, and iPad was measured in a dark room. The averages of three measurements were taken with and without the screen protector at different distances, settings of brightness, and Apple's night shift (NS) mode. Results were analyzed using paired t-tests. RESULTS: At 33 cm, 100% brightness, and 0% NS, the screen protector decreased intensity by 43.9%, 32.3%, and 34.9% for the iPhone 8, iPhone X, and iPad, respectively. At 33 cm and 100% brightness, increasing NS mode from 0% to 100% decreased intensity by 81.2%, 84.2%, and 86.5%. At 33 cm without NS, decreasing the brightness from 100% to 0% decreased intensity by 99.5%, 99.8%, and 97.8%. CONCLUSIONS: The screen protector decreased the intensity at 450 nm for every setting other than those at 0% brightness. Decreasing brightness and applying NS mode were more effective in reducing blue light. More research is needed to determine the benefits of decreasing blue light exposure from electronic devices.

Eccrine Porocarcinoma: A Rare Tumor of the Eyelid With a Novel Histopathological Finding of Free Tumor Cells in the Tear Film.

The authors present a case of an eyelid eccrine porocarcinoma, a very rare malignant sweat gland tumor characterized histopathologically by nests of atypical poromatous cells and the presence of duct-like lumina. Histopathologic analysis of this case also exhibited numerous loose tumor cells in the adjacent tear film, a finding that has not been previously described.

Embolization of cerebral arteriovenous malformations with silk suture particles prior to stereotactic radiosurgery.

We aimed to determine the long term durability of silk suture and polyvinyl alcohol (PVA) particle embolization (SPE) of arteriovenous malformations (AVM), and to evaluate the outcomes following multimodality management of AVM with combined SPE and stereotactic radiosurgery (SRS). A general supposition among neurointerventionalists is that embolization of cerebral AVM with silk sutures and PVA particles does not yield a durable occlusion. We performed a retrospective review of all AVM patients treated at our institution with combined SPE and SRS. After extracting the baseline, embolization and SRS data for each patient, the durability of SPE was determined by evaluating the postembolization recanalization between the last procedural angiogram and the most recent neuroimaging. Four AVM patients who underwent a total of nine SPE procedures through 21 arterial pedicles were included for the analyses. The nidus volumes were 5.8-75 cm(3) and the Spetzler-Martin grades were II and V in one patient and III in two patients. The median degree of devascularization per procedure was <25%. There were no procedural complications, with all patients maintaining functional independence after embolization (modified Rankin scale score 0-2). After a median follow-up duration of 27 months (range: 23-36), there were no patients with recanalization. SRS (marginal dose 13-18 Gy) resulted in 40 to >95% volume reduction. Following SRS, one patient remained asymptomatic, two patients improved, and one patient deteriorated due to a latency period AVM hemorrhage. In conclusion, SPE can safely provide durable AVM devascularization, therefore, appropriately selected nidi can be effectively treated with combined SPE and SRS.