Socioeconomic Disparities Associated with Access to Oculofacial Plastic Surgeons: A Cross-Sectional Analysis of US County Demographics.

PURPOSE: To compare population demographics with the geographic distribution of oculofacial plastic surgeons (OPSs) in the United States. DESIGN: A cross-sectional study design was used to investigate demographic differences between counties with 1 or more OPSs and counties with zero OPSs. PARTICIPANTS: The number of OPSs were identified in each US county using online public databases: American Society of Ophthalmic Plastic and Reconstructive Surgeons and American Academy of Ophthalmology. Counties were categorized into 2 groups: 1 or more OPSs and zero OPSs. Demographic characteristics at the county level were obtained from the 2021 US Census Bureau Population Estimates and the American Community Survey. Cost of living was collected from the 2022 Economic Policy Institute Family Budget Calculator. MAIN OUTCOME MEASURES: Socioeconomic demographics of the US population as related to geographic OPS distribution. RESULTS: A total of 1238 OPSs were identified. States with the most OPSs per million were Hawaii (6.2), D.C. (6.0), Connecticut (5.8), Utah (5.1), and Maryland (5.0). Among 3143 counties, 2725 (86.7%) had zero OPSs and 418 (13.3%) had 1 or more OPSs. Counties with 1 or more OPSs had a higher median (standard deviation) household income versus counties with zero OPSs ($72 471 [$19 152] vs. $56 152 [$13 675]; difference $16 319; 95% confidence interval [CI], $14 300-$18 338; P < 0.001). The annual cost of living per person (standard deviation) was higher in counties with 1 or more OPSs versus counties with zero OPSs ($39 238 [$6992] vs. $36 227 [$3516]; difference $3011; 95% CI, $2328-$3694; P < 0.001). Counties with zero OPSs versus counties with 1 or more OPSs had higher proportions of persons with only Medicaid (15.6% vs. 13.6%; difference 2.0%; 95% CI, 1.4%-2.5%; P < 0.001), no health insurance (9.9% vs. 8.0%; difference 1.9%; 95% CI, 1.5%-2.4%; P < 0.001), no household internet access (17.2% vs. 9.6%; difference 7.6%; 95% CI, 7.1%-8.0%; P < 0.001), and higher proportions of persons aged 65 years or older (20.0% vs. 17.0%; difference 3.0%; 95% CI, 2.5%-3.5%; P < 0.001). CONCLUSIONS: This cross-sectional analysis of all US counties revealed socioeconomic disparities associated with access to OPSs. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Tendon-Sparing Extraocular Muscle Enlargement Associated With Chronic Inflammatory Demyelinating Polyradiculoneuropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory, sensorimotor polyneuropathy. It has presented with a variety of orbital and neuro-ophthalmic manifestations, including cranial nerve hypertrophy and a single case of extraocular muscle enlargement. The authors present a second case of tendon-sparing, extraocular muscle enlargement, resulting in new-onset diplopia and strabismus in a teenager with CIDP. The workup ruled out alternative causes of extraocular muscle enlargement, such as hyperthyroidism, inflammation, or malignancy. As with other cases of CIDP, management involved a combination of immunoglobulin therapy and anti-inflammatory medications. The patient experienced resolution of his symptoms, and radiologic improvement was noted in the muscle enlargement. As many CIDP patients have a favorable treatment response and long-term prognosis, awareness of this rare disease with an early and accurate diagnosis is important.

Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial.

PURPOSE: Pilot studies suggest that waiting 15 minutes after a subcutaneous tranexamic acid injection is associated with decreased intraoperative bleeding and postoperative ecchymosis in eyelid surgery. The outcomes of commencing eyelid surgery immediately after injection without a waiting period remain unexplored. METHODS: This prospective, randomized, multicenter, double-masked, controlled study examined bilateral symmetric upper and/or lower lid blepharoplasty or ptosis repair. Patients received tranexamic acid in 1 eyelid and control in the contralateral eyelid. The surgeon recorded the side with more intraoperative bleeding. Two masked graders evaluated periocular ecchymosis at postoperative day 0 and postoperative week 1 (POW 1) with a 5-point scale. At POW 1, patients reported subjective grading of bruising as increased on 1 side or similar on both sides. Results were analyzed with Wilcoxon signed-rank and sign tests. RESULTS: Of 130 patients, there was less eyelid ecchymosis on the tranexamic side at postoperative day 0 ( p = 0.001) and POW 1 ( p < 0.001). By surgery type, the 69 levator advancement surgeries had significantly less ecchymosis at postoperative day 0 ( p < 0.001) and POW 1 ( p = 0.001), while upper eyelid blepharoplasty, combined upper and lower lid blepharoplasty, and conjunctivomullerectomy trended toward significance. Of 68 patients reporting a POW 1 grading, 69% reported less bruising on the tranexamic side ( p < 0.001). Intraoperative bleeding was not significantly different between sides ( p = 0.930). CONCLUSIONS: Without a postinjection waiting period, subcutaneous tranexamic acid for eyelid surgery significantly decreased postoperative ecchymosis on postoperative day 0 and POW 1 but did not affect intraoperative bleeding. Subcutaneous tranexamic acid was not associated with any complications.

Implantable Electronic Cardiovascular Device Complications Related to Electrocautery During Ophthalmology Surgery: A Systematic Review.

PURPOSE: Implantable electronic cardiovascular device such as cardiac pacemakers and implantable defibrillators are common life-saving devices. Device-related complications can arise when undergoing surgical interventions with electrosurgical tools due to electromagnetic interference, based on electrocautery type, implantable electronic cardiovascular device type, electrocautery location, and a number of other factors. The risk of device-related complications due to electrocautery in oculoplastic surgery has not been established. This systematic literature review assesses prevalence, risk factors, and outcomes of electrocautery-related device complications in oculoplastic surgery. METHODS: Systematic literature review followed Preferred Reporting Items for Systematic and Meta-Analysis guidelines and used the search terms "pacemaker," "implantable cardioverter defibrillator," "electrocautery," "cautery," and "electrosurgery" through June 2022. Inclusion criteria were full-text articles, discussing ocular, oculoplastic, or other facial surgery. Exclusion criteria were non-English language or surgery focused on other parts of the body. Full-text manuscripts of identified articles were reviewed and relevant data were extracted. RESULTS: Twelve studies met inclusion criteria. Two studies were level I and II evidence, while 10 studies were level III or IV. There were no reports of electromagnetic interference with bipolar cautery use. With monopolar cautery use, cases of electromagnetic interference were reported, but without related significant morbidity or mortality. Safety recommendations to minimize electrical flow through the implantable electronic cardiovascular device are described. CONCLUSIONS: There were no reports of implantable electronic cardiovascular device-related complications from bipolar or thermocautery use in ophthalmic or oculoplastic surgeries. Monopolar have been associated with electromagnetic interference, but additional preoperative and perioperative measures can be taken to mitigate this risk.

Pseudocholinesterase deficiency in ophthalmology: a systematic review.

PURPOSE: Unexpected anesthesia-related complications are among the most feared outcomes of ambulatory surgery. One potential culprit is pseudocholinesterase deficiency, which most commonly presents with protracted apnea, necessitating prolonged mechanical ventilation. We report the first case of pseudocholinesterase deficiency in a Bengali person and the first systematic review of pseudocholinesterase deficiency in ophthalmology. This review analyzed the epidemiology, etiologies, presentation, evaluation, and treatment of pseudocholinesterase deficiency. METHODS: Searches were conducted in PubMed, Embase, and Medline through August of 2022 for publications related to pseudocholinesterase deficiency in ophthalmology. In total, 689 studies were screened by two independent reviewers with 26 full-text articles examined for inclusion eligibility. Nineteen studies were eligible and included in the final analysis. RESULTS: Of the 16 identified cases of pseudocholinesterase deficiency, nine (56%) were drug-induced, four (25%) were inherited deficiencies, and in one (6%) of the cases, the cause could not be determined. In two (13%) cases, pseudocholinesterase deficiency could not be confirmed or ruled out. The duration of post-operative apnea ranged from 10 minutes to 14 hours. Continued ventilatory support was the main treatment for all cases and all patients made a full recovery. CONCLUSIONS: Pseudocholinesterase deficiency is a rare, but potentially fatal, anesthetic complication that results in prolonged apnea, respiratory distress, and dependency on ventilators. Ophthalmologists should remain aware of this condition, especially when planning outpatient procedures, as ambulatory centers may have limited resources for managing prolonged post-operative complications.

#Oculoplastics: An Analysis of TikTok's Top Oculoplastics Content.

PURPOSE: To analyze the source and quality of oculoplastics-related content on TikTok, a popular social media platform. METHODS: Twenty-five oculoplastics-related hashtags were queried. The top 20 videos for each hashtag were included. The number of views, likes, comments, and shares were recorded for each video. Each video was also categorized by the account owner and by video content characteristics. A subanalysis of the educational videos was conducted using the mDISCERN, Patient Education Materials Assessment Tool, and modified MICI scores to assess video quality, understandability and actionability, and medical accuracy, respectively. RESULTS: The included 386 videos amassed 218,997,134 views, 15,033,220 likes, 148,099 comments, and 276,445 shares. Patients were the leading content creators (38.1%), followed by nonophthalmology MDs/DOs (25.6%), and oculoplastic surgeons/ophthalmologists (16.3%). Physician-created videos received more visibility than nonphysician-created videos (median of 23,600 views and 22 shares), though this did not reach statistical significance. However, oculoplastic surgeon-posted content received the lowest median views and shares. The video category that amassed the most views was "live procedure/surgeries," followed by "educational" and "patient experience." Subanalysis of 46 educational videos revealed physicians were the chief creators, accounting for 67.4% of all educational videos. Physician-created content demonstrated statistically significant better understandability and actionability, as measured by the Patient Education Materials Assessment Tool ( p = 0.0053). CONCLUSION: Physicians play an important role in disseminating evidence-based medicine on social media. While oculoplastics-related TikTok videos are gaining traction, additional research is needed to improve the visibility of oculoplastic-surgeon posted content.

Impact of the COVID-19 Pandemic on Quantity and Characteristics of Ophthalmology Consults.

Purpose: To assess the COVID-19 exposure risk to consulting ophthalmologists and the pandemic effect on consultations at one of the most impacted hospital systems in New York. Methods: In a retrospective, cross-sectional study, ophthalmology consult notes and COVID-19 test results were collected from the electronic medical record from February to May in 2019 and 2020. Results: Of 2,215 total notes analyzed, consults decreased from 1,374 to 841 between years (p = 0.0002). In 2020, 22.5% of all consults were COVID tested and 2.4% were positive within 2 weeks of in-person evaluation. In 2020, 1.8% of consults were electronic. Ventilated patients increased between years (7.5% to 10.8%; p = 0.04). Conclusions: Although consultations decreased during the Spring 2020 peak, the majority (98.2%) remained as in-person evaluations. While few patients tested COVID positive, this likely reflects the limited availability of testing early in the pandemic. Consulting ophthalmologists remained at high risk of COVID-19 exposure during the pandemic peak.

#OculoplasticsandSocialMedia: a review of social media in oculoplastics and relevant subspecialties.

The permeation of social media into life almost goes without bounds and medicine is no exception. While social media holds great potential for physicians and medicine, it also comes with concurrent spread of disinformation. This increases the importance of evidence-based information from qualified physicians on social media.Although the definition of social media is broad, in general, it refers to the use of web-based platforms to connect one human to another. In oculoplastic surgery, these relationships can be physician to physician, physician to patient, patient to patient, and vendor to physician. These relationships mostly involve education, social support, and advertising, but can also include research and government advocacy. The purpose of this review is to evaluate the current utilization of social media in oculoplastic surgery and relevant subspecialties.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports.

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

Vision Loss Secondary to Facial and Periorbital Steroid Injection: A Systematic Review.

PURPOSE: The risk of ophthalmic and retinal artery occlusions following facial and periorbital steroid injection has not been explored. This systematic review examines the prevalence, risk factors, and treatment outcomes of steroid-induced vision losses. METHODS: A literature search in Evidence Based Medicine Reviews, MEDLINE, Embase, Pubmed, ClinicalTrials, and WHO ICTRP was performed for vision loss following facial and periorbital corticosteroid injections through July 2020. RESULTS: Of 35 case reports, series, and reviews, 49 patients (56 eyes) with steroid-induced vision loss were analyzed. Injection sites predominantly involved the nose (45%) and periocular regions (10%). The most common type of steroid is triamcinolone (54%). Most cases were unilateral, except 7 cases of bilateral vision losses, 4 of which resulted from unilateral steroid injection. Symptoms were reported during or immediately after injections in 49% of cases. Most occlusions occurred in the ophthalmic (53%) or central retinal artery (33%). Vision most commonly presented as no light perception (37%), and 90% were 20/200 or worse. Final visual outcomes varied from 20/200 or worse (56%), 20/40 or better (30%), to in between (13%). CONCLUSION: Most vision losses resulted from steroid injections in the nasal and periorbital area. Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation. Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.

Inverted Papilloma of the Orbit and Nasolacrimal System.

PURPOSE: Periocular inverted papilloma (IP) is a rare, locally aggressive tumor with a propensity for recurrence and malignant transformation. Historically treated via wide excision, this study examines the characteristics and management of periocular IP, comparing those confined to the nasolacrimal system with those invading the orbit. METHODS: An Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective, comparative case series was conducted in patients with IP of the orbit or nasolacrimal system across 15 clinical sites. RESULTS: Of 25 patients, 22 met inclusion criteria with 9 limited to the nasolacrimal system and 13 invading the orbit. Mean age was 60.4 years, 55% were women, all were unilateral. Mean follow-up was 48 months. Rates of smoking, dust and/or aerosol exposure, human papillomavirus (HPV) status, and inflammatory polyps were elevated compared to rates in the general population (45%, 18%, 18%, and 14%, respectively). Bony erosion on computed tomography scans was statistically significantly associated with orbit-invading IP (p = 0.002). Treatment involved all confined IP undergoing surgery alone while 39% of orbit-invading IP also received radiation therapy and/or chemotherapy (p = 0.054). Orbit-invading IP was more likely to be excised with wide margins than IP confined to the nasolacrimal system (85% vs. 22%, p = 0.007). Overall rates of malignancy, recurrence, and patient mortality from IP were found to be 27%, 23%, and 9%, respectively. CONCLUSIONS: IP invading the orbit typically requires aggressive therapy, while IP confined to the nasolacrimal system may be treated more conservatively. Using risk factors, characteristics, and outcomes, a treatment algorithm was created to guide management.

Oculoplastic considerations for refractive procedures.

PURPOSE OF REVIEW: Refractive surgery is one of the most popular elective procedures performed in the world. Given that dry eye is a common complaint following keratorefractive surgery, evaluation, and treatment of periocular conditions that further predispose the patient to dry eye symptoms is an important part of the presurgical assessment. Periocular conditions and surgeries can also affect the ocular surface and keratometry, and should be addressed. For example, ptosis, orbital fat herniation, ectropion, and eyelid masses have been shown to induce corneal topography changes and astigmatism. The oculoplastic considerations for refractive surgery include both the contribution of eyelid position on dry eye, ocular surface damage, refractive error, and outcomes, as well as the timing of oculoplastic surgery in relation to the refractive surgery. In this review, the recently published literature on eyelid and orbital surgery in relation to keratorefractive surgery is reviewed to elucidate the relationship of periocular factors with refractive surgery outcomes and complications. To improve keratorefractive surgery outcomes, a literature review is presented, discussing evaluation, management, and timing of management of oculoplastics conditions. RECENT FINDINGS: Dry eye syndrome is a well known complication of keratorefractive procedures. This is exacerbated with concurrent eyelid or orbital disorders, such as ectropion, lagophthalmos, and thyroid eye disease. In addition to impacting dry eye and ocular surface damage, eyelid surgeries can also affect corneal topography and refraction. Studies have found that patients with ptosis have topographic corneal aberrations from the eyelid exerting pressure on the cornea, while ptosis repair and blepharoplasty patients may undergo an astigmatic change postoperatively. Finally, the corneal flap created in laser-assisted in situ keratomileusis may be at risk for displacement or damage postoperatively with this risk changing, depending on method of flap creation, and time elapsed since keratorefractive surgery. SUMMARY: Eyelid and orbital conditions that predispose to dry eye syndrome and refractive changes should be evaluated and optimized prior to keratorefractive surgery. Patients electing to have oculoplastic surgery, like ptosis repair, should be fully healed prior to any refractive surgery to allow both refractive changes and eyelid positions to stabilize prior to the refractive surgery.

Changing in a GIF (Graphics Interchange Format): Innovations in Before and After Photography.

PURPOSE: Before and after images are an important part of aesthetic counseling, but no studies have examined ways to optimize change detection through the layout of displayed images. This study compares 3 different image layouts to determine which presentation style improves perception of postprocedure changes. METHODS: In this prospective, randomized study, participants viewed sequential images of patients who either had or had not undergone upper eyelid blepharoptosis repair or blepharoplasty ("change" and "no-change," respectively). These paired images were randomly presented in 1 of 3 formats: side-by-side, up-and-down, or alternation flicker (in which 2 images are superimposed and alternated in a graphics interchange format). Participants were asked if a procedure had been performed based on the 2 photographs. Paired t tests were used to compare response times and change detection rates between individual-level pairs of presentation modes. RESULTS: Of 299 recruited patients, 286 completed the study. Rate of change detection trended toward increased sensitivity for alternation flicker over static images. This became statistically significant for patients less than 45 years old. Detection rates did not differ significantly between the 2 static layouts (side-by-side and up-and down). CONCLUSIONS: Enhancing and customizing aesthetics counseling for different ages can improve patient understanding, expectations, and advertising. When using static photography, the layout, whether side-by-side or up-and-down, can be chosen to fit the mode of presentation with no statistically significant difference. To optimize detection of changes in before and after photography in a demographic less than 45 years old, the animated, alternation flicker format was statistically significantly more effective.

Building Your Brand: Analysis of Successful Oculoplastic Surgeons on Social Media.

PURPOSE: To determine the impact of social media content from oculoplastic surgeon-held accounts on public engagement. METHODS: This study analyzed successful Instagram accounts (defined by >500 followers as of May 2019) held by American Society of Ophthalmic Plastic Reconstruction Surgery members. Each account's 20 most and 20 least successful posts (based on number of likes) were characterized by the post's subject, location, media type, and tag usage. Posts were then analyzed using a web-based application that calculates the engagement level of Instagram users with the selected post. RESULTS: A total of 4,812 posts were analyzed from 37 Instagram accounts. Of these American Society of Ophthalmic Plastic Reconstruction Surgery members, the majority were men (67.6%, n = 25) in private practice solely (70.3%, n = 26). Numerous post characteristics, like content and media type, impacted success in a statistically significant manner; for example, public engagement rose when featuring the posting doctor, especially when smiling and wearing a white coat. Meanwhile, posts featuring an office procedure had a negative effect. Formatting was also found to contribute to success. For example, photographs were preferred over videos, while multiple images were best presented sequentially as a carousel (with the viewer swiping through the series) rather than in a large collage. Use of tags (hashtags, accounts, and locations) were associated with increased engagement. CONCLUSIONS: Social media is an important communication and marketing tool, especially in esthetic fields like oculoplastics. Guidelines for success are presented in this study; content, location, subject, media type, and tags statistically significantly impact public engagement.The influence of social media is rapidly growing and can be strategically harnessed by oculoplastic surgeons to educate both patients and healthcare providers, collaborate with colleagues, and for referrals and marketing.Supplemental Digital Content is available in the text.

The influence of social media is rapidly growing and can be strategically harnessed by oculoplastic surgeons to educate both patients and healthcare providers, collaborate with colleagues, and for referrals and marketing. Supplemental Digital Content is available in the text.

A human cadaveric model for effective instruction of lateral canthotomy and cantholysis.

Purpose: To evaluate a human cadaveric model in improving knowledge and comfort of ophthalmology residents performing a lateral canthotomy/cantholysis.Methods: A prospective study was conducted in ophthalmology residents, who participated in a workshop including an interactive lecture followed by hands-on training on a human cadaver. The lecture consisted of the indications and techniques of lateral canthotomy/cantholysis, along with video-demonstration of proper technique. Residents practiced the procedure on cadavers under faculty supervision. Knowledge and comfort level of conducting the procedure was assessed pre- and post-workshop.Results: Post-workshop, the residents showed a significant improvement in general knowledge regarding the technique of the procedure. Pre-workshop, the average knowledge score was 9 points out of 18 and this improved post-workshop to 12 points out of 18 (p < 0.0001). Residents showed a significant improvement in comfort levels performing the procedure. Using a Likert scale, the average comfort level of performing the procedure rose from 2.5 (Fair) prior to the workshop to 4 (Very Good) post-workshop (p = <0.01). All participants reported an average score of 4.91 (1 = Strongly Disagree, 5 = Strongly Agree) that the human model workshop was clinically applicable to their training and would impact the quality and safety of patient care.Conclusion: The study demonstrated an increase in knowledge and comfort in performing lateral canthotomy and cantholysis using a cadaver model. With the time-sensitive nature of orbital compartment syndrome, it is imperative that physicians are comfortable in performing this procedure to prevent permanent vision loss.

Sinus pericranii in the upper eyelid: diagnosis and management guidelines.

Sinus pericranii (SP) is a rare malformation involving aberrant connections between the dural venous sinuses and extracranial veins. Classically considered congenital pathology, there are reported instances of post-traumatic SP in adults. Very rarely, the upper eyelid is involved and the resulting ptosis can obstruct the visual axis. In these cases, surgical removal may be warranted. Because of the high risk of massive intraoperative hemorrhage, careful preoperative identification and diagnostic workup is essential. The authors report a patient with new onset, asymmetric eyelid ptosis referred for evaluation, and subsequently diagnosed with SP. Through a multi-disciplinary assessment, deferring surgical intervention was determined to be appropriate management. The lesion was monitored clinically, and at 6 months follow-up, there were no noted adverse outcomes.

Types of materials for frontalis sling surgery for congenital ptosis.

BACKGROUND: Congenital ptosis is a drooping of one or both eyelids at birth, often due to poor development of the levator palpebrae superioris muscle. This can result in amblyopia, astigmatism, and ocular torticollis and therefore may necessitate surgical intervention in early childhood if visual development is compromised. Patients may have varied levels of levator function. Those with moderate to good function may elect to first attempt ptosis repair with external levator advancement or mullerectomy/Fasanella-Servat procedures. For those with poor function, those procedures are less likely to be effective, so they may undergo frontalis sling surgery, in which the tarsal plate is coupled to the frontalis muscle, so that movement of the brow and forehead result in movement of the eyelid. The optimal material to use in this surgery is unknown. OBJECTIVES: To evaluate the comparative effectiveness and safety of various materials used in frontalis sling surgery for congenital ptosis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (June 2018), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid Medline In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 20 June 2018), Embase (January 1947 to 20 June 2018), PubMed (1948 to 20 June 2018), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 20 June 2018), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 20 June 2018. SELECTION CRITERIA: We included randomized trials that compared one material to another for the treatment of congenital ptosis. DATA COLLECTION AND ANALYSIS: Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. MAIN RESULTS: We identified three randomized trials that had compared four different materials, two materials in each trial. The studies included a total of 160 participants. The surgical procedures compared were polytetrafluoroethylene (Gore-Tex), Ethibond suture, Mersilene mesh, and autogenous fascia lata.We judged all studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Because the three included studies compared different types of implants, we were unable to combine data in a meta-analysis. The limited data preclude any conclusion regarding the optimal implant for frontalis sling surgery.In terms of the primary outcome of functional success, this was defined as widening of the opening between eyelids, assessed either by grade or by millimeter measurement. Bajaj 2004 showed that 93% of the Gore-Tex group and 83% of the Ethibond group had a good or satisfactory outcome (as defined by investigators). Elsamkary 2016 reported that 78.1% of the autogenous fascia group and 61.8% of the Gore-Tex group had a very good or good outcome. Salour 2008 did not include this type of grading system; they showed that the lid fissure increased 4.0 mm ± 1.46 mm in the Mersilene group and 3.13 mm ± 1.72 mm in the fascia lata group.In terms of adverse events, Bajaj 2004, which included 15 patients per group, showed no recurrence in the Gore-Tex group and 1 in the Ethibond group; no need for removal in the Gore-Tex group and 1 in the Ethibond group; and no infections in the Gore-Tex group and 1 in the Ethibond group. Elsamkary 2016, which included 55 patients per group, had 3 recurrences in the fascia group and 6 in the Gore-Tex group; no need for removal in either group; and 1 infection in the fascia group and 2 in the Gore-Tex group. Salour 2008, which included 10 patients per group, had no recurrence, removals, or infections in either the Mersilene or the fascia group. AUTHORS' CONCLUSIONS: The three trials included in this review evaluated four materials for frontalis sling surgery. Assessment of these three studies does not allow us to identify the optimal material. Future randomized trials should be rigorously designed so as to identify the best treatment for this condition.

Interventions for orbital lymphangioma.

BACKGROUND: Orbital lymphangiomas are a subset of localized vascular and lymphatic malformations, which most commonly occur in the head and neck region. Orbital lymphangiomas typically present in the first decade of life with signs of ptosis, proptosis, restriction of ocular motility, compressive optic neuropathy, and disfigurement. Therefore, early and effective treatment is crucial to preserving vision. Due to proximity to vital structures, such as the globe, optic nerve, and extraocular muscles, treatment for these lesions is complicated and includes a large array of approaches including observation, sclerotherapy, systemic therapy, and surgical excision. Of these options, there is no clear gold standard of treatment. OBJECTIVES: To assess the evidence supporting medical and surgical interventions for the reduction/treatment of orbital lymphangiomas in children and young adults. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 5); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 May 2018. SELECTION CRITERIA: We planned to include randomized controlled trials (RCTs) comparing at least two of the following interventions with each other for the treatment of orbital lymphangiomas: observation; sildenafil therapy; sirolimus therapy; sclerotherapy; surgery (partial or complete resection). We planned to include trials that enrolled children and adults up to 32 years of age, based on a prior clinical trial protocol. There were no restrictions regarding location or demographic factors. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles, abstracts, and full articles to assess their suitability for inclusion in this review. No risk of bias or data extraction was performed because we did not find any trials for inclusion. If there had been RCTs, two authors would have assessed the risk of bias and abstracted data independently with discrepancies being settled by consensus or consultation with a third review author. MAIN RESULTS: There were no RCTs that compared any two of the mentioned interventions (medical or surgical) for treating orbital lymphangiomas in children and young adults. AUTHORS' CONCLUSIONS: Currently, there are no published RCTs of orbital lymphangioma treatments. Without these types of studies, conclusions cannot be drawn regarding the effectiveness of the medical and surgical treatment options for patients with orbital lymphangiomas. The presence of only case reports and case series on orbital lymphangiomas makes it clear that RCTs are needed to address the differences between these options and help guide treatment plans. Such trials would ideally compare outcomes between individuals randomized to one of the following treatment options: observation, sclerotherapy, systemic sirolimus therapy, systemic sildenafil therapy, and surgical excision.

Lichenoid Dermatitis Development After Excision of Basal Cell Carcinoma.

This is the first reported case of lichenoid dermatitis erupting after surgical excision of basal cell carcinoma on the upper eyelid of an African-American woman. Lichenoid dermatitis is a common dermatologic diagnosis which may coexist with superficial malignancies, although the exact interaction between the 2 entities is not entirely known. The authors propose that successful treatment of basal cell carcinoma induces inflammation in the form of lichenoid dermatitis, which may play an adjunct role in eradication of the malignancy. The appearance of lichenoid dermatitis could theoretically represent a positive response to treatment; future studies are needed to establish this.