Opioid Usage Following Oculoplastic Procedures.

BACKGROUND: With the rising toll of the opioid crisis, oculoplastic surgeons have been looking at methods to decrease opioid prescription. OBJECTIVES: The aim of this study was to identify factors that correlate with opioid usage after oculoplastic surgery. METHODS: This was a prospective study conducted at University of Texas Southwestern. All patients who underwent an oculoplastic procedure were eligible for inclusion. Patients enrolled were provided 20 tablets of tramadol 50 mg, to take 1 tablet every 6 hours as needed for pain. At their postoperative week 1 appointment, participants had the remaining number of unused opioid tablets counted. The number of tablets taken were calculated by subtracting the remaining number of tablets from the original prescribed amount. RESULTS: A total of 310 patients were enrolled in our study. Of these, 129 patients met the inclusion criteria. There was a statistically significant difference in the number of tramadol tablets taken between procedures for upper eyelids, lower eyelids, and both eyelids (P < .01). There were no statistically significant differences in tramadol usage when comparing procedures on eyelids with orbit procedures(P = .30), cosmetic with noncosmetic procedures (P = .52), males with females (P = .87), or patients naive to oculoplastic procedures with those undergoing reoperation (P = .58). Longer procedures were correlated with greater tramadol usage (R = 0.28, P < .01). CONCLUSIONS: This is the first study in the literature that has objectively quantified opioid usage after oculoplastic surgery in a prospective manner. Procedures that involve both upper and lower eyelids simultaneously and longer procedures resulted in higher opioid use. Orbital procedures, cosmetic procedures, sex, and procedural naivety were not found to be associated with higher opioid usage.

Sarcoid-like reaction of the orbit in diffuse large B-cell lymphoma.

Sarcoid-like reaction (SLR) has been reported in patients with solid tumor malignancies, lymphomas, and patients receiving immunotherapy. SLR is often incidentally found during positron emission tomography/computed tomography scans as hilar and/or mediastinal lymphadenopathy. SLR has also been found in the lung, spleen, bone marrow, and skin. Biopsy of these lesions shows noncaseating granulomas. When systemic criteria are not met for sarcoidosis, these noncaseating granulomas are termed SLR. We present the first case in the literature of a case of orbital SLR in a patient with concomitant diffuse large B-cell lymphoma and inverted papilloma of the maxillary sinus. This case highlights the importance of including malignancy in the differential for the presence of a noncaseating granuloma in the orbit.

The Effect of Optic Nerve Sheath Fenestration on Intraocular Pressure in Patients With Idiopathic Intracranial Hypertension.

BACKGROUND: To evaluate the change in intraocular pressure (IOP) in patients with idiopathic intracranial hypertension (IIH) who underwent optic nerve sheath fenestration (ONSF) and to determine if radiographic evidence of posterior scleral or globe indentation influenced IOP. METHODS: This is a retrospective analysis of IOP in IIH patients who underwent ONSF. The study included all patients from September 2010 to March 2018 operated on by a single surgeon (R.M.). IOPs preoperatively and postoperatively were recorded along with the acetazolamide dosage and whether there was evidence of posterior scleral or globe indentation on preoperative MRI. RESULTS: A total of 29 patients (35 eyes) with IIH underwent ONSF. The average reduction in IOP among all patients was 1.24 mm Hg (P = 0.0218), but this increased to 2.69 mm Hg (P = 0.004) in patients who were maintained on the same dosage of acetazolamide in the preoperative and postoperative period. Furthermore, the reduction in IOP in those with posterior scleral or globe indentation was 2.5 mm Hg (P = 0.0095). When the perioperative period was evaluated, the mean decrease in IOP was 1.83 mm Hg (P = 0.0217). CONCLUSIONS: Reducing the cerebral spinal fluid pressure (CSFP) at the level of the intraorbital optic nerve through an ONSF can slightly reduce the IOP. In those with evidence of posterior globe or scleral indentation/flattening, the reduction in IOP was higher, which supports the theory that CSF pressure indents the globe and leads to an increase in IOP. Although these changes in IOP are small, this study provides further evidence for a connection between IOP and CSFP.

Surgical Treatment of Proptosis due to High-axial Myopia During Lower Eyelid Blepharoplasty in Identical Twins.

Unilateral high-axial myopia can be associated with amblyopia and relative proptosis due to elongation of the eye and staphyloma formation. It is important to consider addressing any relative proptosis at the time of a lower eyelid blepharoplasty as the proptotic eye often creates a significant negative vector and increases the likelihood of postoperative retraction and scleral show. We present twin sisters who presented for a lower eyelid blepharoplasty evaluation; each sister had unilateral proptosis with high-axial myopia. Both underwent bilateral lower eyelid blepharoplasty and unilateral fat decompression in the proptotic eye. One sister required additional medial wall bony decompression to resolve the proptosis at the time of the aforementioned surgery. Therefore, it is important to consider globe position and degree of proptosis at the time of lower eyelid blepharoplasty surgery to optimize surgical results.

Facial Asymmetry in Children With Unilateral Congenital Ptosis.

PURPOSE: To analyze facial asymmetry in children with unilateral congenital ptosis. METHODS: This is a retrospective review of pediatric patients undergoing ptosis repair between January 1, 2017, and December 31, 2020. Charts were reviewed to ensure a diagnosis of idiopathic unilateral congenital ptosis. Sex, age, laterality, margin to reflex distance 1, levator function, and surgical intervention were collected.Clear preoperative photos without head turn were included. Using the ImageJ software ( nih.gov ), landmarks of the periorbital region, midface, and lower face were marked, and measurements between these landmarks were taken.Two-tailed Student t tests were used to compare measurements between the ptotic and non-ptotic sides. Relationships between different measurements on the same side of the face were analyzed using paired-variable regressions. RESULTS: Forty-four patients with unilateral congenital ptosis were included. The surgical management consisted of Mullerectomy in 9 of 44 (20%), levator resection in 15 of 44 (34%), and frontalis suspension in 20 of 44 (46%) patients. The side of the face with blepharoptosis was found to more often have smaller margin to reflex distance 1 ( p < 0.001), smaller margin to reflex distance 2 ( p < 0.005), smaller horizontal palpebral fissure ( p < 0.05), shorter midface height ( p < 0.001), and a more inferiorly displaced lateral canthus (canthal angle, p < 0.001) relative to the non-ptotic side of the face. The mean head tilt of patients with right sided ptosis (1.37° right tilt) was statistically significantly different from those with left sided ptosis (0.85° left tilt; p = 0.04). CONCLUSIONS: In children with unilateral congenital ptosis, the ptotic side of the face was found to be the nondominant side of the face. Patients were also found to have ipsilateral head tilt.

Conjunctival changes following Muller's muscle conjunctival resection.

PURPOSE: To analyze the conjunctival changes, especially goblet cell populations, following Muller's muscle conjunctival resection (MMCR) by histologically evaluating pre and post-MMCR specimens. METHODS: This is a retrospective analysis of conjunctival samples sent for histologic evaluation from two patient populations: those who had previously undergone a MMCR and required repeat surgery and controls who underwent a MMCR surgery in a previously unoperated eyelid. Specimens underwent hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS) staining to accentuate goblet cell identification and were evaluated by two ocular pathologists to quantify goblet cell populations and note other anatomical changes. Statistical analysis of goblet cell populations was then performed. RESULTS: Four samples were identified for each group: (1) post-MMCR and (2) control. The mean age was 67 years in the post-MMCR group and 66 years in the control group. The mean goblet cell population was 7 ± 5 cells/mm in the post-MMCR conjunctiva and was 39 ± 16 cells/mm in the control group, which was statistically significant (p = 0.01). Samples from both groups demonstrated scarring and inflammatory cell infiltrate. CONCLUSIONS: While there was a relative loss of goblet cell populations in the conjunctiva overlying the region of surgery following MMCR, the lack of dry eye symptoms or changes in tear production reported in prior studies suggests that there may be enough goblet cell population reserve in the remaining accessory lacrimal glands and in the unaltered conjunctiva to provide sufficient lubrication and ocular protection.

Trochleaectomy: An Effective Treatment of Trochlear Pain in Monocular Patients.

BACKGROUND: Conventional treatment options for trochlear pain arising from trochleitis or primary trochlear headache include oral anti-inflammatory medications and/or local injection of corticosteroids and local anesthetic. Trochleaectomy is an additional option to consider for monocular patients with intractable trochlear pain. METHODS: We report 3 patients undergoing trochleaectomy for refractory trochlear pain syndromes. RESULTS: Trochleaectomy resulted in resolution of their periocular discomfort. CONCLUSIONS: Trochleaectomy is an effective procedure to treat trochlear pain syndrome in functionally monocular patients.

Conjunctival Lymphoma With Nasal Spread Through the Nasolacrimal Duct.

Conjunctival mucosa-associated lymphoid tissue lymphoma classically presents as a subconjunctival mass, most often in the fornix. The presence of conjunctival mucosa-associated lymphoid tissue lymphoma with spread down the nasolacrimal duct has only been reported once previously. The authors present a case of a 35-year-old woman with a right conjunctival mass in the inferior fornix along with sinus congestion and fullness. A biopsy of the conjunctival mass and the nasal turbinate revealed a conjunctival mucosa-associated lymphoid tissue lymphoma. Therefore, it is important to consider spread down the nasolacrimal duct in patients with conjunctival lymphoma also presenting with difficulty breathing or nasal congestion.

Endoscopic dacryocystorhinostomy as an option for symptomatic epiphora in isolated monocanalicular obstruction.

Epiphora from monocanalicular obstruction is commonly treated with canaliculoplasty, with or without dacryocystorhinostomy, or with conjunctivodacryocystorhinostomy with Jones tube placement. We describe two patients with epiphora due to isolated monocanalicular obstruction without concurrent nasolacrimal duct obstruction who underwent endoscopic dacryocystorhinostomy; both cases had previously failed canaliculoplasty, and both reported significant improvement in epiphora postoperatively. We hypothesize this is due to decreased resistance through the lacrimal drainage system allowing for increased flow through the patent canaliculus and shortened lacrimal apparatus. In patients presenting with epiphora secondary to isolated monocanalicular obstruction, endoscopic dacryocystorhinostomy may be considered in the absence of nasolacrimal duct obstruction before proceeding to conjunctivodacryocystorhinostomy and Jones tube placement.

Change in Lower Eyelid Contour Following Ectropion Repair With Lateral Tarsal Strip.

PURPOSE: To evaluate the change in lateral canthal angle (LCA), inferior ocular surface exposed (IOSE), lower eyelid curvature, and margin-to-reflex distance 2 in those undergoing lower eyelid ectropion repair using a lateral tarsal strip technique. METHODS: This is an Institutional Review Board-approved retrospective analysis of patients undergoing lower eyelid ectropion repair. This study included all patients from 2012 to 2018 operated on by a single surgeon at the University of Texas Southwestern Medical Center. For each patient, LCA, IOSE, and eyelid curvature were measured on preoperative and postoperative photographs using NIH Image J photographic analysis. These measurements were compared using paired 1-tail t-tests for LCA and IOSE and paired 2-tail t-tests for eyelid curvature. This study was Health Insurance Portability and Accountability Act-compliant with protection of individually identifiable information. RESULTS: Fifty-one patients with lower eyelid ectropion underwent lower eyelid ectropion repair using a lateral tarsal strip technique. Forty-three of the patients underwent a bilateral lower eyelid ectropion repair. There was no statistically significant difference in the LCA. There was a reduction in IOSE among both cohorts. The fourth degree polynomial trendlines generated to assess eyelid curvature demonstrated statistical significance, suggesting a flattening of eyelid curvature. margin-to-reflex distance 2 also had a statistically significant decrease postoperatively. CONCLUSIONS: Lower eyelid ectropion repair using a lateral tarsal strip approach causes a reduction in IOSE, a more gradual lower eyelid curvature, and a decrease in margin-to-reflex distance 2 without causing a statistically significant change in LCA.

The Mathematical Analysis of the Aesthetically Pleasing Eyelid.

PURPOSE: To analyze and quantify the characteristics and parameters of the eyelid and adnexa of males and females and correlate these findings to an aesthetically pleasing score. METHODS: This is an Institutional Review Board approved study involving healthy male and female volunteers. The margin-to-reflex distance, palpebral fissure, inferior scleral show, tarsal platform show, and brow fat span were measured using Image J digital photographic analysis and the images were scored by 110 non-ophthalmologists. The eyelid parameters were compared between the groups with Student t tests and the total aesthetic score was correlated to the measured parameters with Pearson's correlation coefficients (r). This study was HIPAA-compliant with protection of individually identifiable information. RESULTS: Twenty male and 22 female participants were included and divided into 2 groups based on the aesthetic score. The average aesthetic score was 3.06 for males and 3.36 for females. None of the eyelid parameters were found to be significantly significant between the 2 male groups. In females, both inferior scleral show and tarsal platform show were significantly lower in the more aesthetic group. A greater margin-to-reflex distance correlated with increased aesthetic appeal. The ratio of brow fat span/tarsal platform show was not significantly different between the 2 female groups. CONCLUSIONS: Quantifying goals are important for the surgical and nonsurgical management of the eyelid and periorbita. Beauty is considered to be subjective and is comprised of various criteria. However, this study reveals that the female sex may have certain quantifiable goals for eyelid parameters that are considered more aesthetically pleasing.

Orbital Floor and Rim Reconstruction With a Titanium Orbital Implant and Acellular Dermis.

Reconstruction of the orbital rim and floor following tumor excision is traditionally performed with bone grafts, vascularized grafts, or free flaps. The authors describe a case of an osteosarcoma of the maxillary sinus and a second case of an ossifying fibroma of the orbital floor, both of which required reconstruction of the orbital floor and rim. In both of these cases, reconstruction of the orbital floor and rim was performed with a titanium implant whose anterior portion was bent inferiorly to recreate the orbital rim. Acellular dermis was sutured over the anterior portion of the orbital implant to act as a barrier between the implant and the overlying eyelid tissues.

Predictive Value of Preoperative Periocular Skin Cancer Measurements for Final Mohs Defect Size.

PURPOSE: To evaluate the relationship between pre-Mohs skin cancer lesion measurements with the post-Mohs defect size in order to most accurately estimate post-Mohs defect size. METHODS: This is a retrospective analysis of patients who underwent Mohs excision by one of 3 Mohs surgeons followed by reconstruction for basal cell carcinoma or squamous cell carcinoma of the eyelid. The study included all patients from January 2011 to May 2018 operated on by a single oculoplastic surgeon (R.M.) at the University of Texas Southwestern Medical Center. Maximum horizontal and vertical (H/V) dimensions were determined clinically by Mohs surgeons at the time of excision and photographs of the lesion and defect size were analyzed in order to determine the total area of the lesion preoperatively and the defect postoperatively with Image J using H/V dimensions and the area tracing function. RESULTS: Forty-two patients with periocular skin cancers underwent Mohs resection followed by reconstruction. The Mohs defect was overall 4.88 times the size of the preoperative skin cancer measurement using maximum H/V dimensions by Mohs surgeons (p < 0.0001). When using Image J, the area of the Mohs defect was 6.5 times the size of the preoperative lesion (p < 0.0001) using both the maximum H/V dimensions and the area tracing function. There was a statistically significant difference between the Image J area tracing and area determined with H/V dimensions by both the Mohs surgeon and Image J. CONCLUSIONS: Postoperative Mohs defect size can be estimated based on maximum H/V dimensions clinically or with Image J technology. Image J digital photograph analysis using the area tracing function more accurately determines the pre-Mohs lesion size and the post-Mohs defect area when compared with standard maximum H/V measurements and digital photographic analysis of maximum H/V measurements with Image J.The preoperative periocular skin cancer measurements can assist in determining the post-Mohs defect size.

Foreign-Body Granulomata Caused by Injected Permanent Filler Masquerading as Cutaneous Sarcoidosis.

Foreign-body granuloma formation following filler injections is most commonly seen with permanent fillers; these reactions can occur years following the injections and often require either an intralesional steroid injection or surgical excision. The authors present a case of a 75-year-old woman with a history of systemic sarcoidosis previously treated with numerous immunosuppressive medications who was examined for bilateral infraorbital nodules and swelling that were unresponsive to treatment. She underwent a bilateral anterior orbitotomy through a transconjunctival approach with mass excision. The histologic analysis was consistent with foreign-body granulomata juxtaposed to implantable material, specifically ArteFill, which was injected many years prior. There were no separate noncaseating granulomas to suggest sarcoidosis as the underlying etiology. It is important to consider prior filler injections in patients with sarcoidosis who present with subcutaneous nodules as this changes management and may prevent the need for more aggressive immunosuppressive treatment.

A rare case of atypical pleomorphic adenoma arising from periocular ectopic lacrimal gland.

PURPOSE: To describe features of atypical pleomorphic adenoma, a rare clinical entity, particularly when found in ectopic periocular lacrimal gland tissue. METHODS: Case report of biopsy-confirmed periocular atypical pleomorphic adenoma. RESULTS: A 35-year-old female presented with a unique orbital lesion found to be ectopic lacrimal gland demonstrating atypical pleomorphic adenoma on formal histopathologic review. Pleomorphic adenoma is pathologically characterized as an epithelial lesion intermixed with mesenchymal elements. It is further classified as atypical with the presence of features such as hypercellularity, regions of necrosis or hyalinization, cellular dysplasia, capsular violation, and malignant characteristics without frank local extension or distant metastases. CONCLUSIONS: Due to its rarity, the natural history and prognosis of atypical pleomorphic adenoma is unclear. Physicians need to recognize this entity, and complete surgical excision with strict follow-up regimens are likely warranted.

Reversible Charles Bonnet Syndrome After Oculoplastic Procedures.

Individuals with Charles Bonnet syndrome (CBS) typically have severe visual loss and experience visual hallucinations yet have no psychiatric disease. Visual impairment often is due to end-stage glaucoma or macular degeneration. We report 3 cases of CBS in patients who underwent an oculoplastic surgical procedure. One patient experienced binocular visual distortion due to excessive topical ophthalmic ointment, and 2 patients experienced monocular visual impairment from patching. Visual hallucinations resolved once vision returned to baseline. We highlight the possibility of transient CBS in postoperative patients who have temporary iatrogenic vision impairment in one or both eyes.

Frontalis Muscle Contraction and the Role of Visual Deprivation and Eyelid Proprioception.

PURPOSE: To determine if frontalis muscle contraction can be induced by manipulating visual and eyelid proprioceptive inputs through simulating visual deprivation and ptosis. METHODS: Volunteers without prior eyelid or forehead pathologic study were recruited for this nonrandomized, prospective study. Baseline and study phase brow positions were documented. The first phase was to simulate visual deprivation and the second to simulate ptosis. The dominant eye was used for each phase. As a proxy to simulate visual field deprivation, a black contact lens was placed on the eye, which reduced vision to light perception. As a proxy to simulate ptosis, an external eyelid weight was placed on the upper eyelid. Brow position ratios were calculated at various points along the brow and statistical analysis was performed. RESULTS: Fifteen subjects participated. The average brow position ratio was 1.00 ± 0.08 for the visual deprivation group, which was not different from baseline (p = 0.86). The average brow position ratio for the external eyelid weight group was 1.13 ± 0.07, which was statistically significant compared with baseline and the visual deprivation group (p < 0.001). CONCLUSIONS: Inducing visual deprivation with a black contact lens does not lead to a change in brow position. However, placing an external eyelid weight does lead brow elevation, with an average increase of 13% from baseline. This suggests a likely role for proprioceptive or sensory inputs in frontalis muscle contraction in the setting of eyelid ptosis.

Cosmetic Adolescent Filler: An Innovative Treatment of the "Selfie" Complex.

PURPOSE: "Selfie" photography is increasing among teenagers, accentuates congenital anomalies, and impacts self-confidence. Tear trough deformity is most commonly due to aging, but also occurs as a congenital anomaly and can be a major source of insecurity and embarrassment. OBJECTIVE: The purpose of this study is to show the efficacy and safety of hyaluronic acid gel filler in a teenage patient with congenital tear trough deformity. MATERIAL AND METHOD: We describe the case of a teenager who underwent hyaluronic acid gel filling to the tear trough deformity at age 14 years. Prospective follow up was assessed for 5 years. RESULTS: The patient improved clinical appearance and self confidence. Her satisfaction level was high, and no complication occurred during entire follow up. CONCLUSION: In this case, hyaluronic gel acid filler was safe and effective for augmentation of congenital tear trough. The patient was satisfied and experienced increased self-esteem.

Unusual Location for a Periorbital Dermoid Cyst.

Dermoid cysts in the orbit classically present in children as a mass in the superotemporal or superonasal orbit along the zygomatico-frontal or fronto-ethmoidal suture lines. The presence of a dermoid cyst in the superficial eyelid, not associated with the tarsus, has only been reported once previously. The authors present a case of a 60-year-old man with a painless right lower eyelid mass inferonasally that was completely excised and found to be a dermoid cyst. The presence of a dermoid cyst involving the superficial lower eyelid is very rare. Furthermore, dermoid cysts in adults typically present in the setting of trauma, which was absent in this case. Therefore, it is important to consider dermoid cysts in the differential diagnosis of eyelid lesions in adults.

Dilated Superior Ophthalmic Vein: Clinical and Radiographic Features of 113 Cases.

PURPOSE: Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV. METHODS: An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed. RESULTS: Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively. CONCLUSION: Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.