The Dysmorphic Concern Questionnaire: Is It Possible to Predict a Satisfactory Result After Cosmetic Eyelid Surgery?

PURPOSE: As oculofacial surgeons performing esthetic surgery, the most valuable result is a satisfied patient. It can be extremely frustrating to have an unhappy patient with, what we believe is, a satisfactory result. Therefore, the ability to predict satisfaction is of extreme importance. We studied our cosmetic eyelid surgery patients to try to find factors that can predict satisfaction. METHODS: We retrospectively studied 454 consecutive patients, who underwent any combination of 7 cosmetic surgical procedures. Patients answered the Dysmorphic Concern Questionnaire (DCQ) before surgery. We studied age, gender, type and number of procedures performed, DCQ score, presence of complications, and history of previous fillers. At the 3-month follow-up visit, patients were given an outcome report survey to graduate their surgical results on a scale from 1 to 5. Results were evaluated using a model of binary logistic regression in which the outcome variable was divided into 2 groups. RESULTS: Three hundred eighty-six patients (85%) were female and the median age was 54.8 years old. The median for the number of procedures was 2 (range, 1-5). Two hundred two of the 454 patients (44.5%) had a history of fillers. Twenty-five patients had complications. DCQ score was significantly lower in the satisfied group (median score, 3) versus the unsatisfied group (median, 6), p = 0.007. In the multiple binary logistical model, the variables age, male gender, DCQ, presence of complications, and upper eyelid blepharoplasty resulted as significant. CONCLUSIONS: We found a significant positive association with upper lid blepharoplasty and a negative association with increasing age, male gender, occurrence of complications, and DCQ score, as predictors of patient satisfaction. We routinely administer the DCQ to all cosmetic patients: It is a brief, sensitive, and specific screening instrument for body dysmorphic disorder.

The Ophthalmology Surgical Competency Assessment Rubric for External Dacryocystorhinostomy Surgery.

PURPOSE: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tool for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for external dacryocystorhinostomy (ExDCR). METHODS: An international panel of content experts, representing Argentina, India, U.A.E., United Kingdom, and the U.S.A. was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardized OSCAR template as a baseline, developing explicit behavioral descriptors (the behavior and performance expected for each step) that were reviewed and modified with successive models. Learners were scored on a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain. The tool was then reviewed by a secondary panel of international content experts, representing Brazil, India, Iran, Singapore, United Kingdom, and the U.S.A. RESULTS: The final OSCAR ExDCR tool was developed in alignment with the ICO-OSCAR standard. Nineteen agreed and weighted stems were produced. Specific comments with regards to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity. CONCLUSIONS: The OSCAR ExDCR is skill and behavior based, has ICO agreed standards for assessment, and provides learners with specific targets for improvement. Although the OSCAR tool has face and content validity, further development could better elucidate its precise role.

Simultaneous Aesthetic Eyelid Surgery and Orbital Decompression for Rehabilitation of Thyroid Eye Disease: The One-Stage Approach.

BACKGROUND: Aesthetic rehabilitation of thyroid orbitopathy includes orbital decompression, correction of eyelid retraction, and aesthetic blepharoplasty, performed traditionally in separate stages. OBJECTIVES: To report the results of orbital decompression surgery associated with aesthetic eyelid surgery in one stage for aesthetic rehabilitation of patients affected by thyroid eye disease. METHODS: Retrospective, multicentric study including 40 consecutive patients, who underwent orbital decompression surgery associated with aesthetic eyelid surgery in two centers: Genova (group 1) + Buenos Aires (group 2). Surgical techniques are described in detail. RESULTS: Mean patient age in the study group was 41.2, 85% of the patients were female, and minimum follow-up time was 12 months, with average follow up of 27 months. All patients underwent orbital decompression; at the same time, 26 patients (65%) underwent bilateral upper blepharoplasty and 32 patients (80%) underwent transconjunctival lower blepharoplasty. Associated upper eyelid procedures included 23 patients (58%) undergoing upper eyelid retraction repair, 9 patients (23%) undergoing associated inferior retractor recession, and 12 patients (30%) closed transcanthal lateral canthopexy. Seven patients (17%) needed strabismus surgery for the treatment of new-onset diplopia and none required further revision eyelid surgery. CONCLUSIONS: Shorr and Seiff suggested 4 stages of surgical rehabilitation: (1) orbital decompression; (2) eye muscle surgery; (3) correction of eyelid retraction; and (4) removal of excess fat and skin. This is the first study to suggest single-stage aesthetic rehabilitation consisting of combined orbital decompression and aesthetic eyelid surgery. This approach has high patient satisfaction and significant reduction in direct and indirect healthcare costs.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags.

PURPOSE: To describe the authors experience with calcium hydroxyl-apatite (CaHa) injections for the aesthetic correction of tear trough, infraorbital hollows, deep upper sulcus, dark circles and lower eyelid bags. METHODS: The records of 63 patients (127 eyelids) injected with CaHa for aesthetic rejuvenation of the periocular region between March 2012 and March 2013 were retrospectively evaluated. All injections were carried out using a 25-gauge cannula after adding 0.5 ml of 2% lidocaine to 1.5 ml vials of the original product. Postoperative visits were scheduled at 1 week and 1 month. Any previous treatment was recorded, and necessity of retreatments and side effects was evaluated. Patient satisfaction was recorded at 1 month with self-evaluation of the treatment result as "worsened," "unchanged," or "improved." Standard pre- and postinjection photographs were taken and compared to analyze the success of the procedure. Pictures were retrospectively graded by the authors on a similar improvement scale of 1 (worse), 2 (no change), and 3 (improvement). RESULTS: Fifty-eight/sixty-three patients were women (92%), with an average age of 42 years (range; 18-57 years). Chief complaints were "hollows" in 94% of patients, "dark circles" in 33%, lower eyelid "bags" in 17%, and deep upper sulcus in 4.7%. Twenty-three patients (36.5%) required an additional correction 1 month after the primary treatment. Satisfaction was as high as 98% among patients treated primarily for hollowness, and the overall satisfaction rate was 92%. Associated dark circles were satisfactorily treated in 68% of the patients. Temporary side effects involved mild erythema and swelling for 2 to 3 days and pseudoxanthalesma effect in 22 eyelids (17.4%) lasting <6 weeks. In 2 patients, erythema lasted longer than 4 weeks. The 2 worse complications in this series were migration of the product above the medial canthal tendon in 1 patient and overcorrection in another patient. These complications were all managed conservatively and resolved spontaneously within 6 to 8 weeks. No case of irregular contour, palpable lumpiness, or unevenness were encountered. In the end, only 1 patient thought she was worsened after the treatment. CONCLUSIONS: Treatment of the periocular region with CaHa injections is a safe and effective treatment with high patient satisfaction and low complication rate. Advanced technical skills may have to be acquired for the specific treatment of this area using this particulate material.

Periocular fat grafting: indications and techniques.

PURPOSE OF REVIEW: Autologous fat transfer (AFT) is gaining popularity in periorbital and facial rejuvenation as well as structural reconstruction because of the advantages of fat over other fillers and implants. RECENT FINDINGS: As the technique and instruments were refined over the years, the incidence of AFT morbidity decreased; however, there is still no consensus on the standardization of the procedure. Several studies have failed to demonstrate superiority of any routine technique; however, various suggestions provided by these investigations have had significant impact on the outcome of surgery. New insights are mainly focused on improving the survival of the grafted tissue, mainly through enhancing cell differentiation and angiogenesis. Clinical applications of adipose-derived stem cell (ADSC) transfer with or without other enhancers were proven to be successful; however, there is not enough human research on this topic yet. Experts made a clear distinction between AFT and ADSC transfer, and the details can be found in this report. Management of hard-to-treat maxillofacial conditions including orbital disorders evolved from AFT techniques, the so-called structural fat grafting. SUMMARY: Harvesting methods to obtain stem cells have proven helpful in many studies. The future of fat grafting relies on the basic research that includes using additive agents, enhancers, or scaffolds to fat for increased survival of the graft.

Minimal incisions vertical endoscopic lifting and fat grafting as a systematic approach to the rejuvenation of the periocular esthetic unit.

PURPOSE: The forehead/brow complex, the temporal region, the upper eyelid, the zygomatic area, the lower eyelid, and the cheek comprise the periocular esthetic unit. The combination of variable degrees of tissue descent and fat deflation of the component parts of the unit determine its appearance with age. The authors report the results of tissue repositioning through a minimal incisions vertical endoscopic lift and volume restoration used in combination to restore the natural youthful appearance of the periocular esthetic unit. METHODS: The authors retrospectively reviewed the charts of patients who underwent minimal incisions vertical endoscopic lift and fat grafting over a 12-year period in 3 different centers. Patients results were evaluated with standardized pre- and postoperative pictures graded by masked observers in a scale from poor, fair, satisfactory, to very satisfactory results. Patient satisfaction was self-graded in the same manner. RESULTS: The study consists of 400 patients, of whom 337 (85%) were women and 63 (14.8%) were men, with a mean age of 46 years (range 38-67) for women and mean age of 53 years (range 48-65) for men. Mean follow up was 16 months (range 6 months-8 years); in 180 patients follow up was 2 years or longer. Additional procedures included lower blepharoplasty in 205 patients (51%), neck lift in 102 patients (26%), upper blepharoplasty in 63 patients (15.7%), lateral canthoplasty in 9 patients (2.3%), and upper eyelid ptosis in 6 patients (1.5%). The results were graded as satisfactory or very satisfactory by 95% of patients and by 91% of observers. CONCLUSIONS: On the basis of the anatomical changes that occur in the periocular esthetic unit, tissue repositioning is indicated to address the descent of the superior complex and in minor part of the inferior complex, while volume restoration is indicated to address the volume depletion of the inferior and the lateral complexes and for refinements of the superior complex. The authors propose a systematic combination of lifting and filling to naturally restore the youthful appearance of the periocular esthetic unit. Conservative blepharoplasty can be associated in selected cases for result optimization.

Development and validation of a convolutional neural network to identify blepharoptosis.

Blepharoptosis is a recognized cause of reversible vision loss and a non-specific indicator of neurological issues, occasionally heralding life-threatening conditions. Currently, diagnosis relies on human expertise and eyelid examination, with most existing Artificial Intelligence algorithms focusing on eyelid positioning under specialized settings. This study introduces a deep learning model with convolutional neural networks to detect blepharoptosis in more realistic conditions. Our model was trained and tested using high quality periocular images from patients with blepharoptosis as well as those with other eyelid conditions. The model achieved an area under the receiver operating characteristic curve of 0.918. For validation, we compared the model's performance against nine medical experts-oculoplastic surgeons, general ophthalmologists, and general practitioners-with varied expertise. When tested on a new dataset with varied image quality, the model's performance remained statistically comparable to that of human graders. Our findings underscore the potential to enhance telemedicine services for blepharoptosis detection.

[Systemic treatment of ocular cicatricial pemphigoid]. / Tratamiento sistémico del penfigoide cicatrizal ocular.

Ocular cicatricial pemphigoid (OCP) is a blistering autoimmune disease that can produce severe conjunctival damage. Its response to immunosuppressive treatment is poorly known. We describe a group of 76 patients, 62 women and 14 men. Mean age at diagnosis was 67±14 years old, with a delay to diagnosis of 7.5±10 years. Sixty patients continued their follow up in our services for 19±21 months. Nineteen out of 51 had mild disease, 19 moderate, 5 severe and 8 very severe at onset of treatment. The more frequently prescribed drugs were dapsone, in 35 (23 discontinued it because of adverse effects), and methotrexate in 42 patients, nine of them stopped it. Other patients received azathioprine, cyclophosphamide and ciclosporine. Seventeen received oral steroids in addition to immunosuppressive drugs. Four patients combined two immunosuppressive drugs to control their disease. In three refractory cases IV immunoglobulin (Ig) was administered with good response. From 48 evaluated patients, 39 improved with treatment, eight remained stable and one progressed. In our experience, methotrexate and azathioprine were effective drugs, with low toxicity. Dapsone was useful in mild cases, with frequent adverse effects. IVIg was effective for refractory cases.

Epithelial tumors of the lacrimal gland: an update.

PURPOSE OF REVIEW: The goal of this article is to offer an update on the treatment and prognosis of the most common epithelial tumors of the lacrimal gland, report on new pathological entities and offer a review of the classification of lacrimal gland tumors. RECENT FINDINGS: Improvements have been made in the understanding of lacrimal gland lesions with the knowledge that lacrimal gland tumors compare to the more common counterparts of the major salivary glands. Therefore, the WHO's classification of salivary gland tumors has been adapted to the lacrimal gland pathology. Until recently, primary adenocarcinomas of the lacrimal gland were not further subclassified, but they can now be divided into low-grade and high-grade malignancies. The adjunctive use of intra-arterial cytoreductive chemotherapy for the management of adenoid cystic carcinoma is one of the most important advancements on the management of these aggressive tumors. Another important step forward has been taken on carcinoma ex pleomorphic adenoma of the lacrimal gland, which is subclassified into noninvasive carcinoma, with an excellent prognosis after complete excision and invasive carcinoma for which the prognosis is still guarded despite adjunctive radiotherapy. SUMMARY: This article offers an update on diagnosis, classification and treatment of common and rare epithelial lacrimal gland tumors.

Consensus on Diagnostic Criteria of Idiopathic Orbital Inflammation Using a Modified Delphi Approach.

Importance: Current practice to diagnose idiopathic orbital inflammation (IOI) is inconsistent, leading to frequent misdiagnosis of other orbital entities, including cancer. By specifying criteria, diagnosis of orbital inflammation will be improved. Objective: To define a set of criteria specific for the diagnosis of IOI. Design, Setting, and Participants: A 3-round modified Delphi process with an expert panel was conducted from June 8, 2015, to January 25, 2016. Fifty-three orbital scientist experts, identified through membership in the Orbital Society, were invited to participate in on online survey and they scored, using 5-point Likert scales, items that are eligible as diagnostic criteria from the literature and from personal experience. The items were clustered around the anatomic subtypes of IOI: idiopathic dacryoadenitis and idiopathic orbital fat inflammation (2 nonmyositic IOIs), and idiopathic orbital myositis (myositic IOI). Items with dissensus were rescored in the second round, and all items with consensus (median, ≥4; interquartile range, ≤1) were ranked by importance in the third round. Main Outcomes and Measures: Consensus on items to be included in the criteria. Results: Of the 53 experts invited to participate, a multinational panel of 35 (66%) individuals with a mean (SD) years of experience of 31 (11) years were included. Consensus was achieved on 7 of 14 clinical and radiologic items and 5 of 7 pathologic items related to diagnosis of nonmyositic IOI, and 11 of 14 clinical and radiologic items and 1 of 5 pathologic items for myositic IOI. There was agreement among panelists to focus on surgical tissue biopsy results in the diagnosis of nonmyositic IOI and on a trial with systemic corticosteroids in myositic IOI. Panelists agreed that a maximum number of 30 IgG4-positive plasma cells per high-power field in the orbital tissue is compatible with the diagnosis of IOI. Conclusions and Relevance: An international panel of experts endorsed consensus diagnostic criteria of IOI. These criteria define a level of exclusion suggested for diagnosis and include tissue biopsy for lesions not confined to the extraocular muscles. This consensus is a step toward developing guidelines for the management of IOI, which needs to be followed by validation studies of the criteria.

Multinational Comparison of Prophylactic Antibiotic Use for Eyelid Surgery.

IMPORTANCE: Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The literature regarding antibiotic use for eyelid surgery is lacking. OBJECTIVES: To determine standard care and assess factors influencing antibiotic prescribing practices for eyelid surgery. DESIGN, SETTING, AND PARTICIPANTS: A survey study was conducted from February 2, 2014, to March 24, 2014. The survey was distributed to 2397 oculoplastic surgeons in private and academic oculoplastic surgery practices in 43 countries. All surgeons were members of ophthalmic plastic and reconstructive surgery societies. Data were analyzed by geographic location. Linear regression was performed to quantify contributions to rates of prescribing postoperative antibiotics for routine eyelid surgical procedures. MAIN OUTCOMES AND MEASURES: Rates of prescribing prophylactic intravenous, oral, and topical antibiotics as well as factors that influence surgeons' prescribing practices. RESULTS: A total of 782 responses were received from 2397 surgeons (average response rate, 36.7%; 2.5% margin of error) from 43 countries. Topical antibiotic use was common in all regions (85.2%). Perioperative intravenous antibiotic use was uncommon in all regions (13.5%). Geographic location was the greatest predictor of antibiotic prescribing practices (range, 2.9% in the United Kingdom to 86.7% in India; mean, 24%). Within Europe, Italy had the highest rate of antibiotic prescriptions for eyelid surgery (41.7%) and the United Kingdom had the lowest rate (2.9%.) In South America, Venezuela had the highest rate of antibiotic prescriptions for eyelid surgery (83.3%) and Chile had the lowest rate (0%). The practice locations that were associated with routinely prescribing postoperative oral antibiotics were India (odds ratio [OR], 15.83; 95% CI, 4.85-51.68; P < .001), Venezuela (OR, 13.47; 95% CI, 1.43-127.19; P = .02), and Southeast Asia (OR, 2.80; 95% CI, 1.15-6.84; P = .02). Conversely, practice location in the United Kingdom (OR, 0.048; 95% CI, 0.0063-0.37; P = .004), Australia and New Zealand (OR, 0.15; 95% CI, 0.033-0.67; P = .01), and the United States and Canada (OR, 0.41; 95% CI, 0.23-0.72; P = .002) were associated with decreased rates of postoperative oral antibiotic use. Surgeons' concern for allergic reactions was associated with decreased rates of prescribing antibiotics (OR, 0.34; 95% CI, 0.23-0.49; P < .001), while surgeons' concern for infection was associated with increased rates of prescribing antibiotics (OR 1.80; 95% CI, 1.45-2.23; P < .001). CONCLUSIONS AND RELEVANCE: These results from members of ophthalmic plastic and reconstructive surgery societies confirm that antibiotic prescribing practices for routine eyelid surgical procedures vary widely throughout the world. No standard of care has been established that would require the routine use of postoperative prophylactic antibiotics following eyelid surgery.