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PURPOSE: To compare subjective and objective dry eye syndrome (DES) metrics preoperatively and postoperatively in patients undergoing bilateral upper eyelid blepharoplasty (ULB) using orbicularis-sparing versus orbicularis-excising techniques. METHODS: A double-blind, randomized clinical trial was conducted on patients without prior DES or other severe conditions who presented to our institution between 2017 and 2019 for routine functional ULB. Patients were randomized into two treatment arms: bilateral ULB using the orbicularis-sparing technique or bilateral ULB using the orbicularis-excising technique. One subjective and seven objective DES assessments were performed on all patients preoperatively and 1 month and 1 year after surgery. RESULTS: A total of 63 patients were recruited for the study. Standard Patient Evaluation of Eye Dryness (SPEED) scores decreased in both treatment groups at 1 month and 1 year postoperatively. This change did not significantly vary based on surgical technique. Objective DES assessments were not significantly changed at both postoperative time points for either group. There was a correlation between the severity of preoperative DES symptoms and the subjective improvement of DES symptoms postoperatively in both groups. CONCLUSIONS: ULB with an orbicularis-sparing or orbicularis-excising technique does not worsen subjective or objective DES metrics and so, surgeons may confidently use either surgical technique. These findings may impact postoperative expectations for surgeons and patients alike.
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Blefaroplastia , Síndromes de Ojo Seco , Humanos , Blefaroplastia/métodos , Síndromes de Ojo Seco/diagnóstico , Síndromes de Ojo Seco/cirugía , Párpados/cirugía , Resultado del Tratamiento , Método Doble CiegoRESUMEN
Operative repair of orbital fractures utilizes implants constructed of a plethora of materials that vary in cost. Surgeon preference as well as fracture complexity may dictate the implant chosen. In this study, we retrospectively compared the complication rates of the four most common types of implants utilized at our institution. We found no significant difference in complication rates in our sample of 88 patients. Additionally, the least expensive implant was as effective as the most expensive implant in addressing isolated orbital blowout fractures. This situation is not unique to the field of oculoplastics. As evidenced from published literature in other areas of surgery, from orthopaedics to orthodontics, cheaper alternatives often afford similar outcomes as more expensive options. We herein argue that a cost-effective approach should be considered while still allowing for high quality of care, in the face of rising health care costs and health disparities in America.
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Implantes Dentales , Fracturas Orbitales , Implantes Orbitales , Análisis Costo-Beneficio , Costos de la Atención en Salud , Humanos , Fracturas Orbitales/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Severe, permanent vision loss is a feared sequela of untreated or refractory idiopathic intracranial hypertension (IIH). For patients with progressive vision loss despite maximally tolerated medical treatment, optic nerve sheath decompression (ONSD) remains a viable and effective option to protect vision. Our objective is to introduce a modified transconjunctival technique for ONSD and determine its safety, efficacy, and efficiency in patients with IIH. METHODS: We performed analyses for a retrospective case series of consecutive patients with IIH by modified dandy criteria who underwent isolated superonasal transconjunctival optic nerve sheath decompression (stOND) at single eye institute in a large academic center from January 2013 to February 2017. Sixty-six patients were identified who met these criteria with at least 6 weeks of follow-up data. Primary outcome measures were visual field mean deviation, grading of papilledema by the modified Frisen scale, and best-corrected visual acuity. Secondary outcome measures were presence of postoperative diplopia and operative time. RESULTS: One hundred thirty-two eyes of 66 patients were identified; 58 were female (88%), and 8 were male (12%). The mean age was 30 years (range 13-55) with an average lumbar puncture opening pressure of 38 cm H2O. Participants mean body mass index was 36 (range 20-59) with Grade 3 papilledema on average by the modified Frisen scale. No patients experienced operative complications, postoperative diplopia, or worse visual acuity at 1 week after surgery. Average operative time was 50 minutes (range: 25-89). The median decrease in papilledema grading was 3 grades on the Frisen scale (95% confidence interval [CI], 2-3, P < 0.0001). Snellen visual acuity changes did not meet statistical significance. The average Humphrey Visual Field mean deviation change was +1.91 (95% CI, 0.58-3.24, P = 0.0052). Despite successful bilateral decompressions, 4 patients (6.1%) progressed in their visual loss. CONCLUSIONS: The superonasal transconjunctival approach to ONSD is a safe, efficient and effective surgical treatment for patients with deteriorating visual function due to IIH. Although additional study is required to further clarify the best timing and indications for ONSD among other treatment options for refractory IIH, providers should be aware of the reduced complication rates and efficacy of the stOND technique.
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Conjuntiva/cirugía , Descompresión Quirúrgica/métodos , Procedimientos Quirúrgicos Oftalmológicos , Nervio Óptico/cirugía , Seudotumor Cerebral/cirugía , Adolescente , Adulto , Femenino , Humanos , Presión Intracraneal/fisiología , Masculino , Persona de Mediana Edad , Nariz/cirugía , Seudotumor Cerebral/fisiopatología , Estudios Retrospectivos , Punción Espinal , Resultado del Tratamiento , Trastornos de la Visión/fisiopatología , Agudeza Visual/fisiología , Pruebas del Campo Visual , Campos Visuales/fisiología , Adulto JovenRESUMEN
BACKGROUND: To our knowledge, there are no studies of patients with idiopathic intracranial hypertension (IIH) that address the relationship between level of intracranial pressure (ICP) and likelihood of progressive visual loss despite uncomplicated optic nerve sheath decompression (ONSD). This study investigated whether patients with IIH undergoing ONSD had a higher risk of surgical failure if opening pressure (OP) on lumbar puncture was ≥50 cm H2O compared to those with OP <50 cm H2O. METHODS: We conducted a retrospective chart review of consecutive patients with IIH who failed maximal medical therapy and underwent ONSD between January, 1992 and November, 2014, and were followed at least 3 months postoperatively. The main outcome measure was the relationship between OP on lumbar puncture and ONSD failure. We also investigated the relationship of OP with visual acuity, visual fields, age, and gender. RESULTS: During this period, 174 patients met inclusion criteria. Of the 40 patients who had an OP ≥50 cm H2O, 6 (15%) had progressive visual loss after uncomplicated ONSD, vs 6 (4.5%) of 134 patients with an OP <50 cm H2O (P = 0.032, Fisher exact test). Patients with worse visual acuity at presentation also had a higher risk of progressive visual loss after ONSD (P < 0.001, Cochran-Armitage trend test), as did men (P = 0.048, Fisher exact test). CONCLUSIONS: Patients with IIH and an OP ≥50 cm H2O had a 3-fold increased risk of failure of ONSD to prevent progressive visual loss, requiring a shunting procedure when compared to those with OP <50 cm H2O. Visual acuity at presentation and male sex also were associated with progressive visual decline after ONSD. These risk factors merit closer follow-up in the postoperative period when signs of further visual deterioration would indicate an urgent need for neurosurgical shunting.
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Descompresión Quirúrgica/métodos , Presión Intracraneal/fisiología , Enfermedades del Nervio Óptico/cirugía , Seudotumor Cerebral/cirugía , Punción Espinal , Baja Visión/etiología , Adulto , Femenino , Humanos , Masculino , Nervio Óptico/patología , Enfermedades del Nervio Óptico/complicaciones , Enfermedades del Nervio Óptico/fisiopatología , Seudotumor Cerebral/complicaciones , Seudotumor Cerebral/fisiopatología , Estudios Retrospectivos , Insuficiencia del Tratamiento , Baja Visión/fisiopatología , Agudeza Visual , Campos VisualesRESUMEN
BACKGROUND: The purpose of this study was to determine the safety and efficacy of optic nerve sheath decompression (ONSD) with a medial transconjunctival approach for a variety of indications in a larger population of patients than has previously been reported. METHODS: A retrospective chart review was performed on consecutive patients who underwent ONSD between January 1992 and December 2010. Before ONSD, all patients had documented evidence of progressive loss of visual acuity or visual field, or both. Postoperative follow-up visits were scheduled at 1 week, 1 month, and then every 3-6 months. Main outcome measures were visual acuity, visual fields, and surgical complications. RESULTS: Five hundred seventy-eight eyes of 331 patients underwent ONSD for progressive vision loss due to various indications, which included but were not limited to idiopathic intracranial hypertension (IIH), progressive nonarteritic ischemic optic neuropathy, and optic nerve drusen (OND). During a mean follow-up of 18.7 months (range, 1 week to 10 years), postoperative visual acuity remained stable or improved in 536 of 568 eyes (94.4%) and progressively worsened in 32 of 568 eyes (5.6%). Visual fields remained stable or improved in 257 of 268 eyes (95.9%) and progressive visual field loss occurred in 11 of 268 eyes (4.1%). There were no reported intraoperative complications. The most common postoperative complication was diplopia (6.0%). CONCLUSIONS: To our knowledge, this review represents the largest series of patients who have undergone ONSD for any indication. Our data are consistent with current literature supporting ONSD as a safe and effective procedure for IIH. Other indications for ONSD, such as progressive visual field loss associated with OND, warrant further study. Regardless of the indication, complications following ONSD with the technique described in this report are infrequent.
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Descompresión Quirúrgica/métodos , Procedimientos Quirúrgicos Oftalmológicos/métodos , Nervio Óptico/cirugía , Neuropatía Óptica Isquémica/cirugía , Complicaciones Posoperatorias/epidemiología , Seudotumor Cerebral/complicaciones , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neuropatía Óptica Isquémica/etiología , Neuropatía Óptica Isquémica/fisiopatología , Seudotumor Cerebral/diagnóstico , Seudotumor Cerebral/cirugía , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Agudeza Visual , Campos VisualesAsunto(s)
Anilidas/uso terapéutico , Antineoplásicos/uso terapéutico , Compuestos de Bifenilo/uso terapéutico , Carcinoma Basocelular/tratamiento farmacológico , Piridinas/uso terapéutico , Neoplasias Cutáneas/tratamiento farmacológico , Receptor Smoothened/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs. METHODS: Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi-squared or Fisher's exact tests. The Cochrane-Armitage test for trend was used to analyze outcomes by class. RESULTS: Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p < 0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate postoperative cranial nerve palsy (p < 0.05). CONCLUSION: Endoscopic treatment of PBOTs is an effective approach, with favorable short-term and long-term postoperative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic-based framework that effectively facilitates high-quality outcomes reporting for all PBOTs.
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Hemangioma Cavernoso , Neoplasias Orbitales , Humanos , Femenino , Adulto , Persona de Mediana Edad , Masculino , Neoplasias Orbitales/cirugía , Neoplasias Orbitales/patología , Estudios Retrospectivos , Resultado del Tratamiento , Nariz/cirugía , Endoscopía , Hemangioma Cavernoso/cirugíaRESUMEN
PURPOSE: To provide an update on different management approaches for Nontuberculous Mycobacterial (NTM) infections of the eye and orbit. OBSERVATIONS: A total of 9 eyes from 8 patients were found to meet study criteria. Of these 9 eyes, 6 eyes (66%) involved Mycobacterium abscessus, 2 (22%) involved M. chelonae, and 1 (11%) involved M. fortuitum. In 8 (88%) eyes, NTM infection was treated with a combination of antibiotics and removal of involved foreign body or tissue (e.g. scleral buckle, intraocular lens, orbital implant, or granuloma). One case was observed on topical therapy alone due to low suspicion for clinically significant infection. In 1 patient, a second culture-positive infection was found in the contralateral eye requiring treatment. CONCLUSIONS AND IMPORTANCE: Depending on the clinical presentation, optimal treatment of ocular and orbital NTM infections may require combination anti-mycobacterial antibiotics (topical and systemic), surgical removal of implanted material or tissue, or both.
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This case report describes a diagnosis of neuroendocrine carcinoma metastasis in the eyelid of an immune-competent patient.
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Carcinoma Neuroendocrino , Neoplasias de los Párpados , Humanos , Glándula Parótida , Carcinoma Neuroendocrino/patología , Párpados/patología , Neoplasias de los Párpados/patologíaRESUMEN
IMPORTANCE: Periocular necrotizing fasciitis is a rare but potentially devastating disease, accompanied by high rates of morbidity and mortality. OBSERVATIONS: We report 5 cases of periocular necrotizing fasciitis resulting in severe vision loss, 3 of which required exenteration to contain the disease and only 1 of which recovered vision. Three cases were caused by group A streptococcus; 1, by methicillin-resistant Staphylococcus aureus; and 1, by Streptococcus anginosus constellatus. CONCLUSIONS AND RELEVANCE: Providers should maintain a high clinical suspicion for necrotizing fasciitis and distinguish it from more common forms of cellulitis. As seen in these 5 cases, periocular necrotizing fasciitis may cause severe visual loss more often than previously recognized. To our knowledge, this is also the first report of Streptococcus anginosus constellatus causing necrotizing fasciitis.
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Ceguera/microbiología , Infecciones Bacterianas del Ojo/microbiología , Enfermedades de los Párpados/microbiología , Fascitis Necrotizante/microbiología , Enfermedades Orbitales/microbiología , Adulto , Antibacterianos/uso terapéutico , Ceguera/diagnóstico , Ceguera/terapia , Terapia Combinada , Desbridamiento , Infecciones Bacterianas del Ojo/diagnóstico , Infecciones Bacterianas del Ojo/terapia , Enfermedades de los Párpados/diagnóstico , Enfermedades de los Párpados/terapia , Fascitis Necrotizante/diagnóstico , Fascitis Necrotizante/terapia , Femenino , Humanos , Masculino , Staphylococcus aureus Resistente a Meticilina , Persona de Mediana Edad , Enfermedades Orbitales/diagnóstico , Enfermedades Orbitales/terapia , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/terapia , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/microbiología , Infecciones Estreptocócicas/terapiaRESUMEN
A 12-year-old girl presented with painless decreased vision in the left eye. Dilated fundus examination was consistent with Wyburn-Mason syndrome, and subsequent neuroimaging demonstrated a retro-orbital arteriovenous malformation. The etiology of the vision loss is discussed, as well as management options of Wyburn-Mason syndrome.
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Fístula Arteriovenosa/diagnóstico , Malformaciones Arteriovenosas/diagnóstico , Síndromes Neurocutáneos/diagnóstico , Arteria Retiniana/anomalías , Vena Retiniana/anomalías , Trastornos de la Visión/diagnóstico , Fístula Arteriovenosa/terapia , Malformaciones Arteriovenosas/terapia , Angiografía Cerebral , Niño , Femenino , Humanos , Imagen por Resonancia Magnética , Síndromes Neurocutáneos/terapia , Tomografía de Coherencia Óptica , Trastornos de la Visión/rehabilitación , Agudeza Visual/fisiología , Campos Visuales/fisiologíaRESUMEN
PURPOSE: To determine the effect of intraperitoneal and intravitreal D-penicillamine (DPA) on retinal neovascularization in a murine model of oxygen-induced retinopathy. METHODS: On postnatal day 7, 16 mice were injected intraperitoneally with 300 mg/kg/day DPA for 3 days followed by 50 mg/kg/day for 7 days. A different group of 7 mice were injected intraperitoneally with 600 mg/kg/day DPA for 3 days followed by 100 mg/kg/day for 7 days. A third group of 14 mice were injected with 1,500 mg/kg/day DPA for 2 days; a control cohort of 17 mice received intraperitoneal phosphate-buffered saline (PBS). An additional 15 mice underwent intravitreal injection of 1 µL of 100 mg/mL DPA in the right eye and 1 µL PBS intravitreally in the left eye as a control. All groups were placed in a 75% oxygen chamber for 7 days then room air for 3 days before being sacrificed and enucleated. The retinas were stained and flat-mounted to determine the severity of retinal neovascularization by quantifying neovascular buds. RESULTS: After intraperitoneal injection, the mean number of glomeruli and tubules was similar in the DPA and PBS groups (P = 1.0), regardless of DPA dosage. The dosage of 1,500 mg/kg/day proved to be uniformly lethal. After intravitreal injections, the mean number of glomeruli (P = 0.16) and tubules (P = 0.7) were similar in the DPA and PBS groups. CONCLUSIONS: Neither intraperitoneal nor intravitreal injection of DPA inhibits retinal neovascularization in a murine model of oxygen-induced retinopathy.