Intraoperative Image Guidance in Orbital and Lacrimal Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the efficacy and safety of the use of intraoperative image guidance (IIG) in orbital and lacrimal surgery. METHODS: A literature search of the PubMed database was last conducted in November 2023 for English-language original research that assessed the use of any image guidance system in orbital and lacrimal surgery that included at least 5 patients. The search identified 524 articles; 94 were selected for full-text analysis by the panel. A total of 32 studies met inclusion criteria. The panel methodologist assigned a level II rating to 2 studies and a level III rating to 30 studies. No study met the criteria for level I evidence. RESULTS: Procedures reported on were as follows: fracture repair (n = 14), neoplasm and infiltrate biopsy or excision (n = 6), orbital decompression for Graves ophthalmopathy (n = 3), dacryocystorhinostomy (n = 1), and mixed etiology and procedures (n = 8). Four studies used more than one IIG system. One study that met level II evidence criteria compared the outcomes of orbital fracture repair with IIG (n = 29) and without IIG (n = 29). Borderline better outcomes were reported in the IIG group: 2% versus 10% with diplopia (P = 0.039) and 3% versus 10% with enophthalmos (P = 0.065). The other level II study compared the repair of fractures with navigation (n = 20) and without (n = 20). The group in which navigation was used had a measured mean volume reduction of 3.82 cm3 compared with 3.33 cm3 (P = 0.02), and there was a greater measured reduction in enophthalmos in the navigation group of 0.72 mm (P = 0.001). Although the remaining 30 assessed articles failed to meet level II criteria, all alleged a benefit from IIG. No complications were reported. CONCLUSIONS: A small number of comparative studies suggest that there are improved outcomes when IIG is used in orbital fracture repair, but each study suffers from various limitations. No high-quality comparative studies exist for the management of lacrimal surgery, neoplastic disease, or decompression. Complications attributable to the use of IIG have not been identified, and IIG has not been analyzed for cost savings. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

The role of oculoplastic surgeons in minimally invasive cosmetic injectables.

PURPOSE OF REVIEW: In recent years, the field of aesthetic medicine has witnessed a paradigm shift with an increasing demand for minimally invasive cosmetic procedures, including cosmetic injectables. This review aims to delineate the distinctive role played by oculoplastic surgeons in the administration of cosmetic injectables, comparing their expertise to that of nonphysician practitioners. RECENT FINDINGS: Complications arising from cosmetic injections are discussed, including skin discoloration, inflammation, necrosis, vision loss, retinal pathology, and central nervous system adverse effects. Injector expertise, patient factors, type of filler, location of injection, and management strategies are reviewed. Findings highlight diverse practitioner involvement, common adverse effects like skin necrosis and vision loss, with hyaluronic acid fillers being prominent. Areas at the highest risk for ocular complication include the glabella and nose with potential management involving dissolving fillers and reducing pressure. Emphasis is placed on expert injector selection and patient awareness. SUMMARY: The administration of cosmetic injectables requires a profound understanding of facial anatomy, vasculature, and potential complications. In contrast to nonphysician practitioners, oculoplastic and aesthetic surgeons bring a level of anatomical precision and clinical acumen that is essential for navigating the complexities of cosmetic injectables. Emphasis on training and collaboration among practitioners will be essential in advancing the field while prioritizing patient safety and satisfaction.

Bilateral Facial Palsy: A Rare Presenting Symptom for Inclusion Body Myositis.

Inclusion body myositis is a common type of inflammatory myopathy among populations over the age of 50 years, classically presenting with weakness and atrophy of the forearms and quadriceps. While a third of patients may eventually present with mild facial weakness, findings of ptosis, facial palsy, or involvement of extraocular muscles are rarely, if ever, seen. The authors describe a unique case of inclusion body myositis in which a patient initially presented with bilateral severe facial palsy and exposure keratitis but minimal limb weakness. While midface weakness, unilateral lagophthalmos, and ptosis have been documented in one reported case, key presenting symptoms of bilateral facial palsy and symmetric paralytic lagophthalmos with corneal exposure have not been presented before. Therefore, this case serves as an important reminder to consider the inclusion body myositis in the differential diagnosis of bilateral facial palsy.

Eye Trauma in Mixed Martial Arts and Boxing.

PURPOSE: To evaluate and compare eye and face trauma in mixed martial arts (MMA) and boxing. DESIGN: Retrospective cohort study. METHODS: Data from boxing and MMA competitions were extracted from the Nevada Athletic Commission (NAC) between 2000 and 2020. Details of competitions, contestants, outcomes, and injuries were extracted. RESULTS: In total 1539 boxing injuries (from 4313 contests) and 1442 MMA injuries (from 2704 contests) were identified. Boxing had higher eye injury rates compared to MMA ( p < 0.0001), with an odds ratio of 1.268 (95% CI, 1.114-1.444). Eye trauma represented 47.63% of boxing injuries and 25.59% of MMA injuries, with periocular lacerations being the most common eye injury in both. Orbital fractures represented 17.62% of eye injuries in MMA and 3.14% in boxing contests. However, 2%-3% were retinal in both sports, and 3.27% were glaucomatous in boxing. MMA contestants had an odds ratio of 1.823 (95% CI, 1.408-2.359) for requiring physician evaluation following an eye injury compared with boxing. MMA contestants also had a higher rate of face ( p < 0.0001) and body ( p < 0.0001) injuries. For both sports, an increased number of rounds and being the losing fighter were associated with increased odds of eye and face injury. CONCLUSION: Although boxing has a higher rate of eye injuries, MMA eye injuries are more likely to require physician evaluation. MMA contestants also have a higher rate of orbital fractures and face and body trauma. A detailed postfight examination and long-term follow-up of ocular injury in combat sports will be vital in proposing reforms to prevent eye trauma.

Cutaneous Mucormycosis of the Eyelid Treated With Subcutaneous Liposomal Amphotericin B Injections.

Cutaneous mucormycosis is a rare, opportunistic fungal infection that typically affects immunocompromised hosts. Current treatment consists of systemic antifungal therapy, surgical debridement, and when applicable, restoration of immune function. Despite intervention, the morbidity and mortality of invasive fungal disease remains high. There are few reports of primary or secondary cutaneous mucormycosis involving the ocular adnexa. The authors describe the course of 2 children with cutaneous mucormycosis of the eyelid treated with subcutaneous liposomal amphotericin B (LAmB) injections (3.5 mg/ml) in an off-label application as an adjunct to debridement and systemic antifungal therapy. To the authors' knowledge, these are the first 2 cases of invasive fungal disease involving the eyelid treated with subcutaneous LAmB injections, and the first reported case of disseminated fungal infection with secondary cutaneous involvement of the eyelid.

Outcomes for expanded polytetrafluoroethylene strip in frontalis suspension surgery.

PURPOSE: This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE). METHODS: This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized. RESULTS: Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period. CONCLUSION: An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high.

Augmentation of telemedicine post-operative follow-up after oculofacial plastic surgery with a self-guided patient tool.

PURPOSE: This study evaluates a web-based tool designed to augment telemedicine post-operative visits after periocular surgery. METHODS: Adult, English-speaking patients undergoing periocular surgery with telemedicine follow-up were studied prospectively in this interventional case series. Participants submitted visual acuity measurements and photographs via a web-based tool prior to routine telemedicine post-operative visits. An after-visit survey assessed patient perceptions. Surgeons rated photographs and live video for quality and blurriness; external raters also evaluated photographs. Images were analyzed for facial centration, resolution, and algorithmically detected blur. Complications were recorded and graded for severity and relation to telemedicine. RESULTS: Seventy-nine patients were recruited. Surgeons requested an in-person assessment for six patients (7.6%) due to inadequate evaluation by telemedicine. Surgeons rated patient-provided photographs to be of higher quality than live video at the time of the post-operative visit (p < 0.001). Image blur and resolution had moderate and weak correlation with photograph quality, respectively. A photograph blur detection algorithm demonstrated sensitivity of 85.5% and specificity of 75.1%. One patient experienced a wound dehiscence with a possible relationship to inadequate evaluation during telemedicine follow-up. Patients rated the telemedicine experience and their comfort with the structure of the visit highly. CONCLUSIONS: Augmented telemedicine follow-up after oculofacial plastic surgery is associated with high patient satisfaction, rare conversion to clinic evaluation, and few related post-operative complications. Automated detection of image resolution and blur may play a role in screening photographs for subsequent iterations of the web-based tool.

Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis.

PURPOSE: To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS). DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020. METHODS: A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality. MAIN OUTCOME MEASURE: Identification of initial, preintervention MRI findings associated with visual and mortality outcomes. RESULTS: The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001). CONCLUSIONS: Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality.

Efficacy of Care and Antibiotic Use for Chalazia and Hordeola.

OBJECTIVES: To evaluate whether use of an antibiotic improves the efficacy of care for a chalazion or hordeolum. METHODS: A cross-sectional retrospective review was performed. All patients treated for a newly diagnosed chalazion or hordeolum at the University of California, San Francisco from 2012 to 2018 were identified. Patients were excluded when clinical notes were inaccessible or there was inadequate documentation of treatment modality or outcome. Patient demographics, setting of initial presentation, treatment modalities, antibiotic use, and outcomes were analyzed. RESULTS: A total of 2,712 patients met inclusion criteria. Management with an antibiotic was observed in 36.5% of patients. An antibiotic was 1.53 times (95% confidence interval [CI], 1.06-2.22, P=0.025) more likely to be prescribed in emergency or acute care setting for a chalazion. Older age was associated with a higher risk of receiving an antibiotic for a hordeolum (adjusted RR 1.07 per decade, 95% CI, 1.05-1.11, P<0.001). The addition of an antibiotic to conservative measures for a chalazion (adjusted RR, 0.97, 95% CI, 0.89-1.04, P=0.393) or hordeolum (adjusted RR, 0.99, 95% CI, 0.96-1.02, P=0.489) was not associated with an increased likelihood of treatment success. CONCLUSION: Although frequently prescribed, an antibiotic is unlikely to improve the resolution of a chalazion or hordeolum.

Combined Endonasal and Orbital Approach for Resection of Orbital Apical Tumors.

PURPOSE: Tumors of the medial orbital apex can be challenging to resect. Primary endonasal resection can be limited by requirements for fat retraction and poor angulation for lateral orbital dissection. Orbital resection alone can have space limitations and a limited view for dissection of the posterior aspect of the tumor. The combined transorbital transnasal approach integrates the retraction and instrumentation advantages of the transorbital approach with the optical and space advantages of the transnasal approach. METHODS: In this cross-sectional cohort study, patients who underwent surgical resection of an apical orbital tumor via a combined endoscopic and orbital approach from 2014 to 2019 were identified. Clinical history, examination findings, imaging, surgical technique, histopathology, and complications were reviewed. RESULTS: Six patients were included. Patients presented with proptosis (5), optic neuropathy (3), and motility restriction (2). Surgery involved a medial orbitotomy and endoscopic ethmoidectomy ± sphenoidotomy, medial wall removal, and periosteum opening. The lesion was prolapsed into the sinus, dissected at the apex via the orbital approach, and removed through the nasal cavity. Pathologic diagnoses were cavernous venous malformation (4), venolymphatic malformation (1), and metastatic carcinoid (1). Improvement in pain (2/2), optic neuropathy (2/3), and proptosis (5/5) were noted. Complications included ethmoid mucocele and nasal polyps. CONCLUSIONS: The combined endonasal and orbital approach involves prolapsing the lesion into the nasal cavity to aid in dissection on the lateral and posterior aspects, maximizing visibility of the tight intraconal space. This technique can be performed by a team of orbital surgeons experienced in both orbital and endonasal surgery.

Lanosterol reverses protein aggregation in cataracts.

The human lens is comprised largely of crystallin proteins assembled into a highly ordered, interactive macro-structure essential for lens transparency and refractive index. Any disruption of intra- or inter-protein interactions will alter this delicate structure, exposing hydrophobic surfaces, with consequent protein aggregation and cataract formation. Cataracts are the most common cause of blindness worldwide, affecting tens of millions of people, and currently the only treatment is surgical removal of cataractous lenses. The precise mechanisms by which lens proteins both prevent aggregation and maintain lens transparency are largely unknown. Lanosterol is an amphipathic molecule enriched in the lens. It is synthesized by lanosterol synthase (LSS) in a key cyclization reaction of a cholesterol synthesis pathway. Here we identify two distinct homozygous LSS missense mutations (W581R and G588S) in two families with extensive congenital cataracts. Both of these mutations affect highly conserved amino acid residues and impair key catalytic functions of LSS. Engineered expression of wild-type, but not mutant, LSS prevents intracellular protein aggregation of various cataract-causing mutant crystallins. Treatment by lanosterol, but not cholesterol, significantly decreased preformed protein aggregates both in vitro and in cell-transfection experiments. We further show that lanosterol treatment could reduce cataract severity and increase transparency in dissected rabbit cataractous lenses in vitro and cataract severity in vivo in dogs. Our study identifies lanosterol as a key molecule in the prevention of lens protein aggregation and points to a novel strategy for cataract prevention and treatment.

Opioid Use After Orbital, Eyelid, or Lacrimal Surgery.

PURPOSE: Opioids may be indicated to mitigate pain after oculofacial surgery. The opioid crisis prompted attention to how these medications are dispensed and disposed. This study aims to characterize opioid usage and handling of patients undergoing oculofacial plastic surgery. METHODS: Eighty-nine adult patients were surveyed on their opioid usage after undergoing orbital, lacrimal, or eyelid (including esthetic) surgery at a tertiary oculofacial plastic surgery practice. Each patient was prescribed 10 tablets of hydrocodone/acetaminophen 5 mg/325 mg; one tablet taken orally as needed every 6 hours for pain not relieved by acetaminophen. Subset analysis was performed for type of surgery, age, and gender. RESULTS: Patients consumed an average of 3 ± 0.4 tablets. In the subsets, the averages were 2.1 ± 0.5 (n = 38) tablets after eyelid surgery, 1.6 ± 0.6 (n = 24) after lacrimal surgery, and 5.6 ± 0.9 (n = 27) after orbital surgery. Greater opioid usage was observed after orbital versus eyelid surgery (p = 0.0007) and orbital versus lacrimal surgery (p = 0.0005) but not eyelid versus lacrimal surgery (p = 0.8604). Forty-six patients (51.7%) used no opioids. Over half (57.3%; n = 51) filled their prescription. Thirty-three patients (37.1%) had unused medications, of which 21 patients did not properly dispose of their medications. The mean age of patients who used opioids was less than the mean age of those who needed no opioids (p = 0.024). There were no gender differences in opioid usage use versus not (p = 0.62). CONCLUSIONS: Opioid needs after oculofacial plastic surgeries, especially eyelid and lacrimal, were minimal in this cohort. For most patients, the prescription exceeded needs. Younger age but not gender was associated with opioid use versus not. Most did not properly discard these medications. Quality improvement in both the dispensing and disposal of opioids in oculofacial surgical practice may be warranted.

Acute Invasive Rhino-Orbital Mucormycosis in a Patient With COVID-19-Associated Acute Respiratory Distress Syndrome.

Acute invasive fungal rhinosinusitis is a rare, although highly morbid, infection primarily affecting immunosuppressed individuals. The same population is at particularly high risk of complications and mortality in the setting of SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome. The authors present a case of acute invasive fungal rhino-orbital mucormycosis in a patient with COVID-19 and discuss the prevalence, diagnosis, and treatment of fungal coinfections in COVID-19. Prompt recognition, initiation of therapy, and consideration of the challenges of rapidly evolving COVID-19 therapy guidelines are important for improving patient survival.

5-Fluorouracil Management of Oculofacial Scars: A Systematic Literature Review.

PURPOSE: To review the literature for the safety and efficacy of intralesional 5-fluorouracil (5-FU) in the management of oculofacial scars. METHODS: A literature search was performed in July 2019 in the PubMed database to identify reports of the use of 5-FU injections for modulating oculofacial cutaneous scars. The search yielded 152 articles, of which 15 met criteria outlined for assessment. Data were abstracted from these 15 relevant articles. RESULTS: While there were no high-level prospective randomized controlled trials, 8 were lower-quality randomized controlled trial, 3 were retrospective cohort studies, and 4 were case series. Most studies pooled results of facial and nonfacial cutaneous applications. Three studies focused solely on oculofacial applications, and these were all lower-level evidence studies. The study outcomes included scar dimension reduction, erythema, patient satisfaction score, observer assessment of scar improvement, and recurrence rates. 5-Fluorouracil was administered as monotherapy or as part of multimodality treatment with other agents (usually corticosteroids) or with CO2 laser, radiotherapy, or pulsed dye laser. 5-Fluorouracil was usually given as an intralesional injection, but in some studies, it was applied topically after micropuncture of the skin. The number and timing of treatments varied between studies. Overall, the level of safety of 5-FU was high. Pain with injection was the most common reported side effect. Other common adverse side effects included pruritus, telangiectasias, changes in pigmentation, and purpura, and 2 studies noted more serious events, such as ulceration, superficial necrosis, and local infection. There were no severe side effects such as anaphylaxis, immune suppression, secondary malignancy, systemic infection, blindness, or death. In all studies, 5-FU was associated with prophylaxis of oculofacial scars or improvement of keloids or hypertrophic scars in terms of reducing size, erythema, and pruritus. 5-Fluorouracil application was associated with favorable patient satisfaction and observer assessment scores especially compared with corticosteroid injections alone. CONCLUSIONS: High-quality randomized controlled trials are currently lacking, and the existing literature is predominately not specific to use of 5-FU on the face. These studies, however, suggest that intralesional 5-FU is safe and probably more effective than other options in the management of cutaneous scars in the oculofacial region. The delivery methods, timing, dosing, and concomitant therapies were highly variable. Further high-quality controlled studies specific to oculofacial scars may be indicated to assess the efficacy of 5-FU and to establish the best protocols for administering this medication.

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.

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.

Diagnosis and Management of Acute Thrombosis in Venous Dominant Orbital Venolymphatic Malformations.

PURPOSE: To report the characteristic clinical and imaging findings in a series of patients with thrombosed orbital venolymphatic malformations. METHODS: Patients affected by acute thrombosis of an orbital venolymphatic malformation were reviewed. Clinical findings including symptoms and signs of presentation, characteristic imaging features, and clinical course are presented. RESULTS: Ten patients were identified. The mean age at presentation was 56 years. All patients presented with acute pain or pressure sensation, with the most common additional presenting symptoms being proptosis (6/10) and diplopia (5/10). CT imaging typically demonstrated a nonspecific orbital mass. Nine patients underwent MRI which revealed a soft tissue mass with peripheral rim enhancement and a central, typically T2 hypointense, core. Seven out of 10 patients were observed and had improvement in symptoms and signs without surgical intervention. Two patients underwent surgical intervention for intractable pain. CONCLUSION: Patients with thrombosis of a venolymphatic malformation often present with acute pain, proptosis, and diplopia. Characteristic MRI findings of a peripheral rim enhancing mass with a T2 hypointense core can be noted. Careful observation is a reasonable management option for cases without visual compromise or intractable pain.

Poor prognoses of open globe injuries with concomitant orbital fractures.

PURPOSE: Orbital trauma, particularly with open globe injury, can have a wide range of visual outcomes, which can be difficult to predict at presentation. Clinical features on presentation may provide insight into visual prognosis. We hypothesized that patients with open globe injuries and concomitant orbital fractures have poorer visual outcomes than patients without orbital fractures. METHODS: We reviewed the charts of 77 patients with isolated open globe injuries (OG) and 76 patients with open globe injuries and concomitant orbital fractures (OGOF). Multivariate regression analysis was performed to assess the relative influence of individual presenting historical and clinical features on visual outcome. RESULTS: OGOF patients were more likely to have sustained blunt trauma than a sharp, penetrating injury compared to OG patients. Ocular wound locations were more posterior and likely to involve multiple zones in OGOF compared to OG patients. Among OGOF patients, orbital floor fractures were the most common and roof fractures were the least common, but the latter was associated with presenting NLP vision and multiple zone involvement. The presence of an orbital fracture independently increased the odds of subsequent evisceration/enucleation (OR: 4.6, 95% CI 1.3-20.1, p = .0246) and NLP vision (OR: 6.81, 95% CI 2.42-21.85, p = .0005) when controlling for zone, mechanism of injury, uveal prolapse and demographic variables. CONCLUSIONS: The presence of an orbital fracture independently confers a worse visual and ocular prognosis in patients with open globe injuries. Patients with open globe injuries in this category should be appropriately counseled.

Orbital Roof Reconstruction Using Nylon Foil Implants.

PURPOSE: To describe a surgical technique of orbital roof reconstruction with a thin nylon foil implant. METHODS: This study is a description of a surgical technique with a retrospective chart review of 3 consecutive patients treated with a nylon foil implant for a complete superior orbital defect after meningioma resection via craniotomy approach. RESULTS: The nylon foil reconstruction achieved an anatomically stable orbit without globe dystopia, pulsatile proptosis, cerebrospinal fluid leak, or other serious cranio-orbital problems, in all cases. Postoperative visual acuity, pain, extraocular motility, proptosis, and globe position remained stable or improved in each case. There were no complications related to the orbital roof reconstruction. CONCLUSIONS: Nylon foil implantation was an effective and inexpensive surgical technique for orbital roof reconstruction after tumor resection in this small series.

Opioid Prescribing Patterns Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members in the Medicare Part D Database.

PURPOSE: To assess opioid prescribing patterns among American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members. METHODS: An observational, retrospective, cohort study of ASOPRS members' prescribing patterns in the 2013-2016 Medicare Part D Prescriber database. These prescribers were stratified by years in practice, sex, and geography. The ASOPRS member cohort was compared with all ophthalmologists, as a group, and other surgeons. RESULTS: The authors identified 617 surgeons in the 2017 ASOPRS directory. Members wrote an average of 45 opioid prescriptions/year. Almost half (45%) wrote <10 prescriptions. Those with >10 prescriptions averaged 78 annually. A minority wrote >100 prescriptions per year (14.8%). Overall, opioids comprised 16.5% of all prescriptions written by ASOPRS members. Despite seeing a similar number of beneficiaries (p = 0.20), male members prescribed a greater number (p < 0.05) and a higher rate (p < 0.05) of opioids than female members. Older members had a lower opioid prescription rate (p < 0.0001). Many heavy opioid prescribers practiced in states with high opioid overdose deaths. CONCLUSIONS: American Society of Ophthalmic Plastic and Reconstructive Surgery members prescribe moderate amounts of opioids at a rate (16.5%) higher than all of ophthalmology (4%), above the national mean (6.8%), but lower than other surgical services (36.5%). Male gender, younger age, and practice in states with high opioid-related deaths were correlated to number of prescriptions. Prescribing patterns may naturally relate to the type of surgical intervention and population. Further research is warranted to understand opioid prescriptions and their role in the opioid epidemic.