Superior Ophthalmic Vein Thrombosis Associated With Asymptomatic COVID-19 Infection.

Superior ophthalmic vein thrombosis is a rare condition scarcely described in clinical literature with potentially severe consequences including permanent vision loss. This report details the case of a 70-year-old woman who presented with acute binocular horizontal diplopia, relative proptosis of the OD by 4 mm, and pain OD. On exam, visual acuity was 20/20 OD and 20/30 OS with full extraocular movements. CT revealed proptosis OD with a thrombosed superior ophthalmic varix. Evaluation for etiology of hypercoagulability was unremarkable, although the patient did have an asymptomatic COVID-19 infection 1 month prior. To the authors' knowledge, this is the first reported case of superior ophthalmic vein thrombosis secondary to an asymptomatic COVID-19 infection.

Efficacy of the Buried Temporary Suture Tarsorrhaphy: A Novel Technique.

PURPOSE: To describe a buried variation of the temporary suture tarsorrhaphy and determine its efficacy period. METHODS: This retrospective case review includes 11 patients needing corneal protection. Six patients had lagophthalmos from facial nerve palsy, 4 had cicatricial ectropion, and 1 had neurotrophic keratopathy. A total of 14 buried temporary suture tarsorrhaphies (BTSTs) were placed. The duration of the BTST was the main outcome. The corneal status before and throughout the BTST was monitored. The eyelids were examined for any undesired changes from the BTST. RESULTS: The mean duration of the BTST was 97.5 days, with a maximum of 273 days. Aside from one spontaneous dehiscence 5 days after placement, all BTSTs held until intentional removal. Five BTSTs were removed for a more definitive surgical procedure, 6 were removed after resolution of the initial indication, and 2 are still in place as the patient awaits surgery. All cases of keratopathy improved after BTST placement. There were no complications and no undesired eyelid changes. CONCLUSIONS: The BTST is a simple, fast, safe, and effective procedure that can be performed in the clinic or inpatient to immediately improve ocular surface coverage. As a minimally invasive procedure that can easily last several months, the BTST is an excellent option for patients who require more intense intervention than medical management alone. It can also securely bridge patients to a permanent solution such as lateral canthal resuspension.

Recurrent Retrobulbar Hemorrhage Associated With CPAP Use After Orbital Fracture Repair.

We present a patient who underwent orbital fracture repair complicated by retrobulbar hemorrhages twice within the first postoperative week. The suspected cause is continuous positive airway pressure (CPAP) use with inappropriate patient-modified settings. The most likely mechanism of action was venous congestion from the extrinsic positive pressure, similar to Valsalva maneuvers increasing orbital vasculature pressure. In our patient, because his orbital blood vessels had recently been cauterized, they were too fragile to handle the engorgement and bled, leading to a retrobulbar hemorrhage. It is possible that at a lower CPAP setting, the vascular congestion would not have been as severe and caused bleeding. We recommend routinely asking patients about CPAP use before orbital surgeries and instructing patients to stop CPAP usage for 1 week after any orbital surgeries if medically cleared.

Metastatic Merkel cell carcinoma presenting as an orbital mass.

A 67-year-old female presented with 2 weeks of right eye pain, redness, and diplopia. An orbital mass was found on magnetic resonance imaging (MRI), and biopsy revealed Merkel cell carcinoma (MCC). She had no primary head or neck lesion and no previous history of MCC. Positron emission tomography (PET) scan showed hypermetabolic subcutaneous lesions of the lower extremity andmultiple osseous lesions of the axial and appendicular skeleton. She received palliative external radiation of 20 Gy in 5 fractions to the orbit. After discussing immunotherapy, she opted for comfort care and expired 1 month later. To the best of our knowledge, this is only the third case of MCC with distant metastasis to the orbit and the first case in which the patient had no previous diagnosis of MCC and no known primary tumor.

Anatomical Description of Zygomatic Foramina in African American Skulls.

PURPOSE: The zygomaticofacial/temporal/orbital nerve is a terminal branch of the zygomatic nerve and exits the orbit through zygomatic foramina. The nomenclature in the literature varies with some studies identifying all 3 foramina on the malar surface of the zygoma, while others describe each along different aspects of the zygoma. In this study, foramen on the malar surface of the zygoma is termed zygomatic foramen, and the authors describe anatomical variations in the position and number of these foramina in an African American population. METHODS: Sixty-two African American skulls from the Hamann-Todd collection of the Cleveland Museum of Natural History were studied. The primary outcome was the number of zygomatic foramina on the malar surface of the zygomatic bone. Secondary outcomes included the location of foramina relative to the orbital rim and the frontozygomatic suture. Mean and standard deviation were used to describe measurements. Chi-squared and Wilcoxon signed rank tests were used to analyze measurements between left and right hemicrania. RESULTS: The average number of foramina was 1.98 ± 0.93. More foramina were found on the right (2.13 ± 0.98) when compared with the left (1.68 ± 0.79; p = 0.001). The average distance between the lateral-most and medial-most foramina was 9.7 ± 5.0 mm. The distance from the orbital rim to the lateral foramen was 8.4 ± 4.2 mm, and distance from the orbital rim to the medial foramen was 7.7 ± 2.1 mm. The frontozygomatic suture was 22.9 ± 3.9 mm from the lateral foramen and 27.9 ± 3.6 mm from the medial foramen. CONCLUSION: The locations of the foramina in relation to the frontozygomatic suture and orbital rim were consistent with other populations. However, in this African American population, more zygomatic foramina were noted compared with previously published results in Korean, Indian, Brazilian, and West Anatolian populations. Surgeons should be cognizant of zygomatic foramina in this population to reduce potential neurovascular complications.

Relationship between ocular dominance and brow position in patients with blepharoptosis.

PURPOSE: This study aims to determine if ocular dominance plays a role in predicting compensatory eyebrow elevation in cases of ptosis. METHODS: This retrospective observational cohort study screened all individuals presenting to two tertiary oculoplastics practices with complaints of ptosis for entry. Primary position photographs were obtained. Ocular dominance was assessed via a modified Porta test. Ptosis was defined in bilateral cases as marginal reflex distance of <2.5 mm in both eyes and in unilateral cases as either an MRD1 < 2.5 mm or MRD1 of >1 mm lower on one side. Asymmetry in brow height was defined as a difference of >1 mm. Chi square and t-tests were performed. RESULTS: Sixty-eight patients from the both tertiary practices met inclusion criteria (37 male, 31 female). Concordance between the higher brow and the dominant side was 50.0% (n = 22, p > 0.05). Mean brow height on the dominant side (15.5 mm) was not statistically different than brow height on the non-dominant side (15.3 mm, p > 0.05). The concordance between the higher brow and the lower MRD1 eyelid was not significant (45.5%, n = 20, p > 0.05). The difference in mean brow height between the lower and higher MRD1 eyes was not significantly different (-0.11 mm; p > 0.05). This also held true when restricted to unilateral cases (0.28; p > 0.05). CONCLUSIONS: Although asymmetric brow elevation can be noted in patients with ptosis, ocular dominance does not appear to be concordant with this asymmetry. Additionally, brow height does not appear to be concordant with MRD1 in cases of ptosis.

Online Ratings of ASOPRS Surgeons: What Do Your Patients Really Think of You?

PURPOSE: To characterize patient evaluations of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) surgeons on a popular online physician rating website in an effort to determine which factors play a role in determining the likelihood of a patient recommending an ASOPRS surgeon to family and friends. METHODS: After obtaining approval and access from Healthgrades.com, the website database was searched for 612 U.S.-based ASOPRS members using their name as published on http://www.asoprs.org/ as of May 2015. For each surgeon, the total number of ratings and average ratings were recorded under each category. The evaluator recommendation, defined as the response to the questions of "likelihood of recommending Dr. X to family and friends," constituted the main outcome measure. Variables from each surgeon were compared using unpaired t tests, with statistical significance set at p < 0.05. Correlations were analyzed using Spearman correlation (rs), with coefficients of greater than or equal to 0.40 or less than or equal to -0.40 considered significant. RESULTS: Five-hundred nineteen members (85%) had at least 1 rating while 222 members (36%) had 10 or more ratings. The mean number of ratings for all rated members was 11.4 (range, 1-77; standard deviation [SD] = 11.1) and mean evaluator recommendation score was 4.16 (range, 1-5; SD = 0.79). There was a strong negative correlation between total wait time and evaluator recommendation score (rs = -0.409, p < 0.001). The average number of ratings and rating scores for all categories were not significantly different when comparing male with female members. University-employed members had significantly fewer ratings (8.46; range, 1-52; SD = 9.3) compared with other members (11.9; range, 1-77; SD = 11.3) (p < 0.016). There were no differences in any other rating score when comparing those university-employed members with other members. CONCLUSION: Online patient-reported evaluations of ASOPRS surgeons appear high in many categories. Long wait times correlate strongly with lower recommendation scores. Further study is required to determine how online patient reviews correlate to objective outcome measures, and how these reviews affect surgeon selection by patients.

Comparison of the FaroArm Laser Scanner With the MicroScribe Digitizer Using Basicranial Measurements.

PURPOSE: To compare the results of a mechanical 3-dimensional laser scanner for craniofacial measurements of the basicranium to a validated coordinate device. METHODS: Access was granted by the Cleveland Natural History Museum to evaluate the Hamann-Todd Human Osteological Collection for this study. The MicroScribe and the FaroArm were used to gather coordinate data of various bony landmarks measurements including the prosthion, staphylion, hormion, and basion. Seventy-three human skulls were measured and scanned. Distances calculated from the coordinates were tested for agreement using the Bland-Altman test. RESULTS: There were no significant differences in the bias or slope measures between the MicroScribe and the FaroArm. In addition to the univariate test for slope significance, multivariable analysis using age, gender, and race as additional predictors showed no significant difference in any variable (P < 0.05). CONCLUSION: This is the first study demonstrating agreement of the FaroArm in any human skull measurement with the validated MicroScribe digitizer. Compared with the MicroScribe digitizer, the FaroArm allows for 3-dimensional imaging and the ability to store, handle, and view data digitally. Future use of real-time facial measurements using the FaroArm offers potential for improved surgical planning and outcomes.

Periocular Skin Cancer in Solid Organ Transplant Recipients.

PURPOSE: To determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients. DESIGN: Cohort study. PARTICIPANTS: Consecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 and 2008. METHODS: The charts of all patients receiving a solid organ transplant from 1990-2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair. MAIN OUTCOME MEASURES: Primary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC. RESULTS: A total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies). CONCLUSIONS: Squamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.

Safety and Effectiveness of a Small Incision Lateral Eyebrow Ptosis Repair Technique Using a Frontalis Muscle Transposition Flap.

PURPOSE: To evaluate the safety and effectiveness of a frontalis muscle transposition flap for treatment of lateral eyebrow ptosis. METHODS: The charts of all patients undergoing frontalis muscle transposition flap eyebrow ptosis repair from December 2013 to September 2014 were reviewed. Charts with inadequate photographs were excluded. Charts were reviewed for demographics, preoperative and postoperative photographs, surgical technique, and complications. The following parameters were assessed on preoperative and postoperative photographs: corneal diameter, central brow height, and lateral brow height. Measurements were normalized to a standard corneal diameter of 11.5 mm. Statistical analysis was performed in conjunction with the Cleveland Health Institute Biostatistics Department. RESULTS: Forty-six total patients underwent frontalis muscle transposition flap eyebrow ptosis repair and the charts of 31 patients (53 cases) were reviewed. There were 20 female and 11 male patients. Average age was 69.1 ± 7.7 years (range: 50 - 86 years). There were 9 unilateral and 22 bilateral cases. Concomitant surgeries included upper blepharoplasty (33 cases), conjunctival-Mullerectomy blepharoptosis repair (3 cases), and intralesional tetracycline injection for festoons (3 cases). Average follow-up interval between surgery and the final postoperative photograph was 10.2 weeks (range: 6-26 weeks). Overall, lateral brow height increased postoperatively by 1.78 mm (p < 0.05). In patients that underwent frontalis muscle transposition flap alone, lateral brow height increased by 2.86 mm (p < 0.05). Scalp hypesthesia was documented in 10/31 patients, and resolved in 8/10 patients at last follow up. CONCLUSIONS: A frontalis muscle transposition flap effectively addresses lateral eyebrow ptosis repair through a small, relatively concealed incision. It produces temporary scalp hypesthesia in a significant number of patients, and long-term results remain unknown.

Orbital Radiation Therapy in Thyroid Eye Disease.

PURPOSE: To review the current literature summarizing the state of knowledge on the use of orbital radiation therapy (ORT) in thyroid eye disease. METHODS: A systematic review and analysis of the literature were performed. MEDLINE/PubMed, Cochrane Library databases, SCOPUS, and recent relevant journal articles were searched. RESULTS: Thyroid eye disease is an autoimmune disorder that has the propensity to affect multiple orbital tissues and can cause permanent vision loss. In moderate to severe disease, treatment may be warranted and can include multiple therapeutic modalities. Orbital radiation therapy is frequently used in this setting and may act to break the inflammatory cycle of glycosaminoglycan production and deposition. There has been a wealth of data regarding the effectiveness of ORT in thyroid eye disease resulting in the publication of treatment algorithms and management guidelines; however, there continues to be a lack of conformity among experts on the exact role of ORT in thyroid eye disease. CONCLUSION: The multiple different thyroid eye disease classification schemes and the concurrent use of other therapeutic modalities challenge the interpretation of studies evaluating the effectiveness of thyroid eye disease. Despite these limitations, the current literature indicates that ORT is generally safe and well tolerated. Orbital radiation therapy may have a modest effect on motility and proptosis early in the disease process. It is unclear whether ORT leads to improved quality of life. There are some data to support the use of ORT to prevent compressive optic neuropathy.

Subjective and Objective Measures in the Treatment of Hemifacial Spasm With OnabotulinumtoxinA.

PURPOSE: To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation (FaCE) Scale Instrument outcomes when treating hemifacial spasm (HFS) with onabotulinumtoxinA. METHODS: An Institutional Review Board-approved retrospective review of records of 66 HFS patients treated with onabotulinumtoxinA. SFGS and FaCE surveys were completed prior to onabotulinumtoxinA therapy and at 1 month follow up. Surveys were analyzed for differences using paired Student t tests, with statistical significance set at p < 0.05. Correlations were determined using Spearman correlation (rs), with coefficients of ≥0.40 or ≤-0.40 considered significant. RESULTS: There were 22 complete data sets. SFGS composite score improved from mean, 56.9 (SD, 12.3) to 63.6 (SD, 12.3), p < 0.01. SFGS subdomain synkinesis score significantly improved (p < 0.01). The FaCE scale subdomain oral function significantly worsened (p = 0.05). The Δ pre-/post-SFGS composite score did not correlate with the Δ pre-/post-FaCE composite score (rs = 0.24). There was a significant positive correlation between SFGS composite score and FaCE social function score (rs = 0.462, p = 0.03) and between SFGS voluntary movement score and FaCE social function score (rs = 0.477, p = 0.03). Subgroup analysis of single FaCE questions demonstrated no statistical change in subjective dry eye (p = 0.30). CONCLUSIONS: There was an improvement in social functioning in treated HFS patients, which positively correlated with improvement in overall objective voluntary facial movement. There was no statistical difference in subjective dry eye symptoms. The overall SFGS composite score improved following treatment of HFS with botulinum toxin. This information can be used when counseling expected outcomes in HFS patients treated with onabotulinumtoxinA.

Predictability of Optic Foramen Location From a Ray Through the Ethmoidal Foramina.

PURPOSE: To determine how accurately a ray through the anterior and posterior ethmoidal foramina predicts the location of the optic foramen. METHODS: Dried, well-preserved, complete human skulls without bony defects belonging to the Hamann-Todd osteological collection of the Cleveland Museum of Natural History were examined. Photography was performed and a ray was drawn on orbit photographs extending through the center of the anterior and posterior ethmoidal foramina toward the optic canal. The location of the ray at the anterior aspect of the optic canal was recorded. RESULTS: Sixty-six total orbits were examined from 36 skulls with 6 skulls with only unilateral data. Thirty-eight orbits were of African descent and 28 were of European descent with an average age 45.25 years (range = 19-89 years). The anterior-posterior ethmoidal foramen ray extended superior (12/66), through (53/66), and inferior (1/66) to the optic canal. Of those rays passing through the optic canal, 32/53 (60%) passed through the upper one-third, 19/53 (36%) passed through the middle one-third, and 2/53 (4%) passed through the lower one-third of the optic canal. CONCLUSIONS: The anterior-posterior ethmoidal foramen ray highly predicts the superior aspect of the optic canal. This information can guide medial orbital wall surgery.

Frontalis Muscle Asymmetry and Lateral Landmarks.

PURPOSE: To investigate frontalis muscle asymmetry and characterize its lateral interdigitation with the orbicularis oculi muscle. METHODS: After making a mid-coronal incision and bluntly dissecting to the orbital rim, the frontalis muscle was exposed, marked, and photographed. The right and left muscle bellies were analyzed and compared in both pixels and cm ratios generated with NIH ImageJ software. A ratio of ≥1.5 was considered significantly asymmetric. The lateral interdigitation of the frontalis and orbicularis oculi muscles was measured from the supraorbital notch with a metric ruler. Data were analyzed using 2-sample t tests, paired t tests, log scales, and nonparametric tests were performed for sensitivity analyses. A p value of ≤0.05 was considered statistically significant. RESULTS: Fifty-eight hemifaces of 29 Caucasian cadavers were studied for muscle belly asymmetry. Thirty-six hemifaces of 18 Caucasian cadavers (9 males) were dissected for lateral landmarks and average age of these specimens was 73 years (range: 35-91 years). Significant asymmetry in muscle belly area was found in 6/29 (20%) specimens, with the right muscle belly larger in all 6 specimens. On average, the right muscle belly area was 1.23 times that of the left (p = <0.001). The average frontalis-orbicularis interdigitation occurred 3.4 cm lateral to the supraorbital notch. CONCLUSIONS: Significant frontalis muscle belly asymmetry exists in 20% of Caucasians cadavers. The right muscle belly was larger on average and in all cases of significant asymmetry. The frontalis muscle interdigitates with the orbicularis oculi on average 3.4 cm lateral to the supraorbital notch.

Comparison of Temporal Fossa Volume in Young Versus Senescent Human Skulls.

PURPOSE: To determine whether bony changes in the temporal fossa occur with age. METHODS: Human skulls within 2 age groups from the Hamann-Todd collection at the Cleveland Natural History Museum (Cleveland, Ohio, U.S.A.) were studied. The young group of skulls consisted of adults aged 18 to 30 years, and the senescent group of skulls consisted of individuals aged over 69 years. A modeling compound molded to each temporal fossa in an identical fashion was weighed as a proxy for volume. Calipers measured temporal fossa width and length, and the zygoma circumference was measured at 3 locations on each skull. A protractor determined the internal and external angles of the zygomatic bone for each skull. RESULTS: Each group contained 49 skulls. The average age was 23 years (range, 18-28 years) in the young skull group and 80 years (range, 72-96 years) in the senescent group. There were 62 (63%) African American skulls and 36 (37%) Caucasian skulls. There were 30 (31%) female skulls. Mean temporal fossa compound weight was 58.5 g in the young group and 59.5 g in the senescent group (p = 0.58). The differences in temporal fossa length and width were not statistically significant between the 2 age groups (p = 0.92 and p = 0.49, respectively). There were no significant differences in the bony dimensions of the zygoma or frontozygomatic suture between the 2 age groups, or in the internal or the external zygomatico-frontal angles (p = 0.76 and p = 0.96, respectively) between the 2 age groups. CONCLUSION: Temporal fossa bony anatomy remains stable with age, and expansion of this space does not contribute to temporal hollows. Current and future treatments for temporal hollows should be designed with these finding in mind.

Microanatomical Location of Hyaluronic Acid Gel Following Injection of the Temporal Hollows.

PURPOSE: To examine the microanatomical location of hyaluronic acid gel injected within the temporal hollows of cadaver specimens. METHODS: The temporal hollows were injected subcutaneously with hyaluronic acid gel in 6 fresh frozen human cadaver hemifaces. Temporal soft tissues were dissected to a preperiosteal plane and fixated in 95% alcohol. A soft tissue section extending from skin to temporal bone was obtained for each specimen. Histologic examination was performed using hematoxylin and eosin stain. RESULTS: In 5 of 6 specimens, at least 95% of the hyaluronic acid was located within the subcutaneous fat. In 1 of 6 specimens, approximately 35% of the material was located within the subcutaneous fat and 60% was located within the superficial temporal fascia. Two specimens had 5% located within the temporalis muscle. In 1 specimen, hyaluronic acid was found to encompass a superficial muscular artery within the superficial temporal fascia. CONCLUSIONS: This study elucidates the location of hyaluronic acid gel after subcutaneous injection within the temporal hollow. Histology confirmed consistent placement of the gel within the subcutaneous tissues, but it also showed that injection in this region may produce unintended deeper location of filler, and a significant perivascular collection of the material. The proximity of dense temporal fascial and muscle arterial networks in this region may pose risk for perivascular injection and associated complications.

Regional Variations in Orbicularis Oculi Histology.

PURPOSE: To investigate and compare the histologic compositions of the pretarsal, preseptal, and orbital orbicularis oculi muscle (OOM) using nonpreserved, fresh-frozen, human cadavers. METHODS: The OOM was exposed using sharp and blunt dissection. A metric ruler was used to measure and mark 0.5 cm × 1 cm samples from each portion of the right, superior OOM. Samples were excised, fixed in formalin, and completely embedded in paraffin. Five-micrometer-thick, hematoxylin- and eosin-stained sections were generated for each sample and analyzed by an anatomical pathologist. The relative percentages of the 4 main tissue types (skeletal muscle, fibrous tissue, adipose tissue, and neurovascular tissue) were quantified. RESULTS: Forty-two samples were obtained from 14 Caucasian cadavers. On average, the pretarsal samples were composed of 83.5% skeletal muscle, 0.0% adipose, 5.0% neurovascular, and 11.5% fibrous tissue. Average preseptal OOM was 46.5% skeletal muscle, 12.7% adipose, 9.2% neurovascular, and 31.5% fibrous tissue. The orbital OOM was, on average, 42.7% skeletal muscle, 32.7% adipose tissue, 6.9% neurovascular, and 17.7% fibrous tissue. CONCLUSIONS: The OOM represents a histologically heterogeneous structure.

Subjective and objective outcome measures in the treatment of facial nerve synkinesis with onabotulinumtoxinA (Botox).

PURPOSE: To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation Scale (FaCE Scale) instrument outcome measures pre- and 30-day posttreatment of facial nerve synkinesis with botulinum toxin with attempts to correlate the 2 scales. METHODS: An IRB approved retrospective review of 22 patients with facial nerve synkinesis where the surgeon completed the SFGS and the patient completed the FaCE prior to receiving onabotulinumtoxinA therapy, the SFGS, and FaCE scales were completed again 1 month later. RESULTS: Of the 22 patients, 9 complete datasets were analyzed. Mean patient age was 59.8; 8 (89%) women and 1 (11%) men. Overall SFGS composite score decreased from 57.6 ± 20.9 to 45.2 ± 13.5, (p = 0.001). SFGS subdomain synkinesis significantly improved (p < 0.001), while voluntary movement significantly decreased (p = 0.002). A difference in the resting symmetry was not statistically significant (p = 0.08). The FaCE scale composite score significantly improved from 40.9 ± 9.5 to 47.6 ± 11.9, (p = 0.03). FaCE subdomains facial comfort (p = 0.005) and social function (p = 0.009) significantly improved, while oral function, eye comfort, facial movement, and lacrimal control did not. The Δ pre/post-SFGS composite score did not correlate with the Δ pre/post-FaCE composite score (rs= -0.318). Subdomain analysis demonstrated significant negative correlation between Δ pre/post-SFGS synkinesis score and Δ pre/post-FaCE eye comfort score (rs = -0.826, p < 0.01). CONCLUSIONS: Significant improvement was seen in objectively reported synkinesis following botulinum toxin therapy. An improvement was noted in the overall subjective facial nerve functioning following therapy along with improvement in social functioning and facial comfort. A meaningful negative correlation was noted when comparing the SFGS "synkinesis" subdomain with the FaCE scale subdomain "eye comfort", implying improvement in eye comfort with control of synkinesis.

Comparison of preferences between onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin) in the treatment of benign essential blepharospasm.

PURPOSE: To evaluate subjective outcomes and preferences in patients with benign essential blepharospasm (BEB) treated with both onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin). METHODS: An institutional review board approved retrospective review of 128 patients treated with onabotulinumtoxinA for BEB by 1 author (J.B.H.). Fifty of these patients were switched to incobotulinumtoxinA as an alternate drug. At scheduled follow up, patients decided to continue with incobotulinumtoxinA or switch to onabotulinumtoxinA. Patient preferences regarding treatment with onabotulinumtoxinA versus incobotulinumtoxinA were recorded. The preference groups were analyzed using unpaired Student t test, with statistical significance set at p < 0.05. RESULTS: Of the 50 incobotulinumtoxinA patients, the mean age was 64.9 years; 39 (78%) were women and 11 (22%) were men. In all, 26 (52%) preferred incobotulinumtoxinA and 24 (48%) preferred onabotulinumtoxinA. Most frequently, those who preferred incobotulinumtoxinA believed that it was "more effective" (N = 10, 29%), whereas those who preferred onabotulinumtoxinA concluded that it had a "longer duration" (N = 11, 37%). The mean treatment interval was 13.0 weeks (standard deviation [SD] = 6.39) in those who preferred onabotulinumtoxinA, whereas it was 10.2 weeks (SD = 2.15) in those who preferred incobotulinumtoxinA (p = 0.017). There was no statistical difference when comparing mean disease duration, number of total treatments, and number of units/treatment between the 2 preference groups. CONCLUSIONS: This study demonstrates that patients who prefer incobotulinumtoxinA over onabotulinumtoxinA had a statistically significant shorter treatment interval. In addition, those who preferred incobotulinumtoxinA thought it was more effective, whereas those patients who preferred onabotulinumtoxinA thought it had a longer duration. This information can be used when counseling both newly diagnosed and long-standing BEB patients regarding their therapeutic options.

Orbital Wall Fractures and Ocular Injury: Impact on Management.

Background: Orbital wall fractures are often associated with concomitant ocular injury. In some cases, detection and treatment of such injuries requires ophthalmology evaluation. Study Objective: To identify a change in ocular management as a result of ophthalmology evaluation in patients with orbital wall fractures. Materials and Methods: Retrospective cohort, patients >18 years of age with orbital wall fracture, and prompt evaluation by an ophthalmologist from 2012 to 2020 in a tertiary Level 1 trauma center. Results: Fifty percent of patients had a moderate and/or severe ocular injury. Ophthalmology evaluation led to an ocular management change in 27% of patients. Patients with eyelid laceration, extra-ocular motion (EOM) abnormality, and pupillary defect were more likely to have a change in management. There was no delay of surgical bony fracture management. Conclusion: In patients with midface trauma including orbital wall fractures those with eyelid laceration, EOM abnormality, and pupillary defect were likely to undergo ocular management change as a result of ophthalmology consultation.