Long-Term Results of Oral Propranolol Treatment Protocol for Periocular Infantile Hemangioma: Should There Be Any Contraindication?

PURPOSE: The authors report long-term results of the oral propranolol treatment protocol for periocular infantile hemangioma regardless of conventional indications. METHODS: This is a retrospective study (2008-2018) on children with propranolol treatment protocol for periocular infantile hemangioma and last follow-up (FU) of ≥4 months after treatment and age of >24 months. After systemic evaluation, it was started with 0.5 and increased by 0.5 every 3 days to reach 2 mg/kg/day. If there was no good response, it would be gradually increased up to 3 mg/kg/day. Tapering (0.5 mg/kg/day every 4 weeks) was started when patients were on treatment for ≥6 months and ≥12 months old and there was no change in the infantile hemangioma size for ≥3 months. Rebound growth was based on the parents' report and would be treated by increasing the dose to at least 2 mg/kg/day for 3 months. FU was either in-person or via social media. Change in periocular infantile hemangioma size on the photos was scored by 3 masked observers (visual analog scale) and presented as excellent (≥50% reduction), good (1%-49%), fair (no change), and failure (enlarged). RESULTS: Forty-three patients were included. Orbital involvement was in 49%, ptosis in 58%, and risk of amblyopia in 63%. Mean treatment, tapering, and FU duration were 37, 13, and 74 months, respectively. Mean age at presentation, start of propranolol treatment protocol, tapering, stop, and last FU were 1.5, 5, 29, 42, and 78 months, respectively. Twenty-seven patients received 2, seven 2.5, and nine 3 mg/kg/day. Mean visual analog scale significantly increased from 43% (FU1) to 92% (last FU) when 97.6% of patients showed an excellent response. The remaining skin lesions were observed in 35%. No side effect was reported. CONCLUSIONS: Long-term results of the propranolol treatment protocol for periocular infantile hemangioma showed an excellent response in 97.6% of patients with no side effects. A residual skin lesion was observed in 1/3 of the patient.

Lower Eyelid Position Changes Following Müller's Muscle-Conjunctival Resection Blepharoptosis Surgery.

BACKGROUND: Asymmetry of the lower eyelids and a lower position of the lower eyelid on the ptotic side are common issues in patients with upper lid ptosis. Understanding the relationship between upper lid ptosis correction and lower eyelid position will facilitate better treatment strategies for ptosis. OBJECTIVES: To assess the lower eyelid position before and after Müller's muscle-conjunctival resection (MMCR) in unilateral myogenic ptosis (MP) and aponeurotic ptosis (AP). METHODS: This prospective interventional before-and-after study, included adults with blepharoptosis. Measurements were taken before and 6 months after the surgery. RESULTS: A total of 47 patients included, with 29 having MP and 18 having AP. The mean ages were 31.55 ± 5.30 years and 50.11 ± 6.45 years, respectively. In MP group, there was a significant association between baseline MRD2 and the severity of ptosis (MRD1) (ß= -0.739, p=0.004, multivariate regression analysis). After MMCR, significant decreases were observed in MRD2 for both MP (-0.38 ± 0.48 mm, p<0.001) and AP (-0.39 ± 0.47 mm, p=0.003). The symmetry of MRD2 remained stable at 41.4% in the MP, while it decreased from 44.4% to 16.7% in the AP. The baseline MRD2 was the only factor associated with postoperative MRD2 in the MP. CONCLUSIONS: Patients with myogenic and aponeurotic ptosis often exhibit a lower position of the lower eyelid, which typically elevates after posterior upper lid ptosis surgery. In myogenic cases, the severity of preoperative lower eyelid position correlates with the severity of upper lid ptosis and predicts postoperative elevation of the lower lid.

Endoscopic-assisted Orbitotomy for Obliteration of Orbital Arteriovenous Fistula Refractory to Endovascular Techniques.

Orbital arteriovenous fistula is a rare acquired disorder. The coincidence of arteriovenous fistula with lymphaticovenous malformation is even rarer. The optimal treatment, thus, is controversial. Surgical approaches vary widely, with associated pros and cons. The purpose of this case report is to describe an orbital arteriovenous fistula in a 25-year-old man with congenital fronto-orbital lymphaticovenous malformation, refractory to endovascular techniques, which was later successfully ablated by a direct endoscopic-assisted orbital approach.

Anaplastic Large Cell Lymphoma With Intraocular or Ocular Adnexal Involvement: A Case Report and Systematic Review.

PURPOSE: To review the existing literature on patients with anaplastic large cell lymphoma (ALCL) affecting the globe and/or ocular adnexa, and to present a report documenting the clinical course of a patient with ALCL that involved their globe and ocular adnexa. METHODS: PubMed, Scopus, and Google scholar were systematically searched for all cases of ALCL involving intraocular or adnexal ocular structures from inception to May 2023. Moreover, a new reported case added to the cases found in searches. RESULTS: The review identified 1680 studies, with 8 meeting inclusion criteria. A total of 9 patients were included with a mean age of 29.7 years (median: 30.0, range: 1.3-48). Primary ALCL was present in 5/9 (55.6%) patients. The most common ophthalmic manifestations included periorbital swelling (5/8), chemosis (5.8), and decreased vision (5/7). Misdiagnoses were initially made in 3 patients, and the lag time to correct diagnosis from 3 weeks to 3 months. CD30 expression was positive in all cases, and 6/9 patients were positive for anaplastic lymphoma kinase, resulting in 6/9 patients being diagnosed with anaplastic lymphoma kinase-positive ALCL. In terms of management modalities, chemotherapy was administered in 8/9 patients, while radiation therapy was utilized in 4/9 patients, and 2 underwent autologous stem cell transplantation. Five (55.6%) patients succumbed to ALCL while 4 (44.4%) were alive and disease-free at the last follow-up. The median times from the initial presentation of ALCL to death, ophthalmic presentation to death, and diagnosis to death were 4.12 months (range: 1.1-168.0), 2.62 months (range: 1.1-144), and 4.00 months (range: 0.10-168), respectively. The median follow-up duration was 21.0 months (range: 1.1-168.0). CONCLUSIONS: ALCL involving the globe and ocular adnexa is a rare and highly malignant tumor that can mimic benign clinical conditions. Early biopsy and aggressive treatment with chemotherapy regimens such as CHOP and radiation therapy may be useful.

Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty.

BACKGROUND: Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique for preventing postoperative tear trough deformity. Its drawbacks include retraction, limited volume, transcutaneous fixation, and a complex insertion technique. The minced lower eyelid fat graft was introduced to overcome these drawbacks. OBJECTIVES: The aim of this study was to compare the outcome of preperiosteal pedicle fat flaps with minced free fat graft in TCLB. METHODS: Participants who underwent the pedicle fat flap procedure from April 2019 to April 2020 (Group A) and the minced free fat graft from May 2020 to May 2021 (Group B) with at least 6 months of follow-up were included. Subjective (pain, infraorbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes, satisfaction (visual analogue scale score) at the last follow-up, and reoperation rates were compared. RESULTS: There were 142 participants (94% females) with a mean age of 48.4 years (range: 21-71) and a follow-up of 8.2 months (range: 6-36). There were 73 participants in Group A and 69 in Group B, with no significant differences in age (P = .6), sex (P = .7), or follow-up (P = .3). In addition to TCLB, Groups A and B had simultaneous upper eyelid and eyebrow procedures (53% vs 49%, P = .2), lateral canthal plication (77% vs 83%, P = .4), and pinch skin excision (82% vs 88%, P = .3). Groups A and B did not have significant differences in postoperative numbness (6.8% vs 1.4%, P = .2), chemosis (11% vs 10%, P = 1), skin wrinkles (12.3% vs 8.7%, P = .6), hyperpigmentation (1.4% in both groups), bumps (2.7% vs 7.2%, P = .3), tear trough deformity (0.0% in both groups), satisfaction score (97.7% vs 98.1%, P = .4), or reoperation rate (12.3% vs 5.8%, P = .2). CONCLUSIONS: The desired aim of fat redistribution in TCLB seems to be equally achievable with minced fat graft and pedicle fat flap techniques.

Management of refractory Acanthamoeba keratitis, two cases.

Acanthamoeba keratitis is a serious infection of the eye that can result in permanent visual impairment or blindness, caused by free-living amoebae of the genus Acanthamoeba. Early diagnosis is necessary for effective treatment of Acanthamoeba keratitis. Acanthamoeba is abundant in nature and can be found in water, soil, and air. Acanthamoeba keratitis is usually diagnosed by culture from a scraping of the eye or by confocal microscopy. In this paper, two complicated Acanthamoeba keratitis cases are reported.

Effect of phenytoin on retinal ganglion cells in acute isolated optic neuritis.

OBJECTIVE: Phenytoin has been shown to reduce the peripapillary retinal nerve fiber layer (pRNFL) loss in optic neuritis (ON). We evaluated the effects of phenytoin on retinal ganglion layers and visual outcomes of newly diagnosed acute ON. METHODS: A randomized, placebo-controlled trial was conducted in a tertiary referral eye hospital and patients with the first episode of typical demyelinating ON, without any history of multiple sclerosis were randomly assigned to phenytoin or placebo. The thickness of ganglion cell-inner plexiform layer (GCIPL) measured by optical coherence tomography (OCT) was considered as the primary outcome. RESULTS: One patient in the phenytoin group developed severe cutaneous rashes that progressed to Stevens-Johnson syndrome (SJS)/toxic epidermal necrosis (TEN), and further allocation of patients to the phenytoin group was stopped, and finally fifteen participants were included in the phenytoin group. Fifty-one patients were enrolled to the placebo group, from which four were excluded. Both visual acuity and field were not significantly different between the control and phenytoin groups after 1 and 6 months. Mean 3- and 6-mm macular GCIPL thicknesses decreased after 6 months to 73.6 ± 14.1 and 57.9 ± 7.5 µm, respectively, in the phenytoin group and to 71.6 ± 15.7 and 55.6 ± 6.6 µm, respectively, in the placebo group with no significant differences between the two groups (P = 0.77 and P = 0.26, respectively, linear multilevel model). CONCLUSION: Phenytoin is not probably safe and effective as neuroprotection after acute ON. Further investigation with other sodium channel inhibitors could be considered.

Cherry Red Spot Myoclonus Syndrome.

Cherry red spot is a known sign of retinal occlusive disease. However, when it occurs bilaterally in a young patient with neurological findings, a diagnosis of retinal occlusive disease becomes farfetched, and the possibility of a storage disorder is raised. We report multimodal retinal imaging findings in a case of cherry-red spot myoclonus syndrome. This form of imaging helps in the ophthalmological diagnosis and management of these patients.

Lacrimal Canalicular Bypass Surgery with Autologous Superficial Temporal Artery Graft.

Purpose: To describe superficial temporal artery graft as a new autologous tissue to reconstruct the upper lacrimal drainage system. Methods: We explain the history of a 30-year-old female with upper lacrimal drainage system obstruction, in whom conjunctivodacryocystorhinostomy (CDCR) failed to resolve epiphora. A superficial temporal artery graft was harvested, intubated with Masterka tube, and implanted between the conjunctiva and nasal cavity. Masterka was replaced with a thicker dummy tube 12 weeks postoperatively. The adequacy of the graft was checked with irrigation tests in follow-up visits from 1 to 26 months after the procedure. Results: Superficial temporal artery autograft successfully eliminated epiphora of the patient in whom (CDCR) with Jones tube failed to make her symptom free. Conclusion: Superficial temporal artery autograft as an autogenous tissue with adequate characteristics can be considered in selective patients of upper lacrimal obstruction to reconstruct the lacrimal drainage system.

A Systematic Review on the Role of Antioxidants in Thyroid Eye Disease.

Purpose: To systematically review the role of antioxidants in management of patients with thyroid eye disease (TED). Methods: A literature search of the electronic databases was performed without restrictions on the date of publication till the end of March 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical trials, case-control studies, cohorts, case series, case reports, and experimental (including in vitro) studies in the English language were included. The primary outcome in human studies was improvement in severity, activity scores, and/or quality of life scores. There was a decrease in the level of H2O2-dependent oxidative stress, Hyaluronic acid release, reactive oxygen species, cell proliferation, or antifibrotic/antiproliferative actions in the in vitro studies. Results: Out of 374 initially screened articles, 157 studies were selected, the full texts of 82 were reviewed, and 14 papers were finally included. There were 4 clinical and 10 in vitro studies from 1993 to 2018. While ß-carotene, retinol, Vitamin E, Vitamin C, melatonin, resveratrol, N-acetyl-l-cysteine, and quercetin showed some efficacy in in vitro studies; allopurinol, nicotinamide, pentoxifylline, and selenium (Se) were effective in both clinical and experimental reports. Se was the only recommended antioxidant based on one high-level randomized controlled trial. Conclusion: While different antioxidants could potentially be effective in the management of TED, no strong recommendation for any or combination of antioxidants could be made to be implemented in the daily practice.

Long-term Results of Palpebral Fissure Transfer With No Lower Eyelid Spacer in Chronic Progressive External Ophthalmoplegia.

PURPOSE: To evaluate the long-term outcomes of the palpebral fissure transfer (PFT) technique without lower eyelid spacer in patients with chronic progressive external ophthalmoplegia (CPEO). DESIGN: Retrospective interventional case series. METHODS: Consecutive patients with CPEO with PFT surgery (2006-2017) and a minimum follow-up of 24 months were included. The PFT included simultaneous levator resection or frontalis sling (based on the levator function and Bell's phenomenon) and lower eyelid retractor recession without spacer. Primary outcome measures included the change in margin reflex distance 1 (MRD-1), MRD-2, and palpebral fissure height (PFH) in the course of time. Potential predictors of keratopathy were also explored. RESULTS: There were 32 patients (64 eyelids) with the mean age and follow-up of 34.1 years (range 15-56 years) and 37.9 months (range 24-72 months), respectively. Mean MRD-1 significantly increased from -0.9 mm to 3.4 mm in postoperative weeks 1 and 2 and 1.8 mm at the last follow-up. Mean MRD-2 significantly decreased from 5.6 mm to 3.7 mm in postoperative weeks 1 and 2 and 5 mm at the last follow-up. Eyes with frank lower eyelid retraction (MRD-2 >5 mm) gained more reduction in MRD-2 compared with those with no sclera show (-0.9 mm vs -0.3 mm, P < .001). Reoperation was performed in 9 eyelids for under- (n = 5) and overcorrection (n = 4). Persistent keratopathy was observed in 3 eyes (4.5%). CONCLUSION: Lower eyelid retractor recession without spacer yields significant protective corneal coverage at the critical early postoperative period when the risk of keratopathy is highest.

Lateral rectus advancement versus medial rectus recession for consecutive esotropia.

PURPOSE: To compare lateral rectus advancement with medial rectus recession for patients with consecutive esotropia without abduction limitation. METHODS: Forty-three patients who developed consecutive esotropia following bilateral lateral rectus recession for intermittent exotropia were reviewed retrospectively. Twenty-two patients underwent lateral rectus advancement (lateral rectus advancement group) and medial rectus recession was performed in 21 patients (medial rectus recession group). Success rate of the surgery was based on the percentage of postoperative esophoria or exophoria of less than 8 PD, which did not require a third surgery. Mean follow-up after second surgery was 23.5 ± 8.7 months. RESULTS: Mean consecutive esotropia in the lateral rectus advancement group was 24.8 ± 9.0 PD. Eight patients were orthophoric after second surgery; mean postoperative esophoria and exophoria/tropia was 5.4 ± 3.4 PD and 6.5 ± 5 PD, respectively. Postoperative success rate in this group was 90.9%. Mean consecutive esotropia in the medial rectus recession group was 21 ± 98.4 PD. Three patients were orthophoric after second surgery; mean postoperative esotropia/phoria and exophoria was 9.5 ± 5.0 PD and 5.2 ± 1.3 PD, respectively. Postoperative success rate in this group was 71.4%. Postoperative undercorrection rate of 4.5% in lateral rectus advancement group was significantly less than the similar measure of 28.6% in medial rectus recession group (chi-square, P = 0.03). CONCLUSION: Advancement of the previously recessed lateral rectus has improved consecutive esotropia better than medial rectus recession.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series.

PURPOSE: To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis). METHODS: Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4-14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded. RESULTS: Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively (p=0.29). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation (p=0.07). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p=0.75). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications. CONCLUSION: Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Pneumocephalus after Orbital Decompression Surgery for Thyroid Eye Disease.

A cerebrospinal fluid (CSF) leak is a rare complication after orbital surgery. We reported a 49-year-old man who presented with CSF leakage after transcaruncular medial wall decompression for proptosis due to thyroid eye disease. He underwent an endoscopic endonasal approach to surgical repair of the defect with nasoseptal flap. Rhinorrhea was stopped immediately after endoscopic repair.

Photoreceptor outer nuclear layer thickness changes in optic neuritis follow up.

BACKGROUND: Ganglion cell inner plexiform (GCIP) layer thinning following acute optic neuritis (ON) is well-known. However, the onset of changes in the outer retinal layers needs further study. In this study, we determine longitudinal changes in retinal layer thickness in ON. METHODS: Thirty ON patients underwent optical coherence tomography (OCT) and visual function testing at baseline, one month, and 6 months. RESULTS: Mean GCIPL thickness decreased at one month relative to baseline from 63.6 ± 7.5 µm to 57.3 ± 6.8 µm in 3 mm ring (P < 0.001). There were no significant changes in GCIPL thickness between one and 6 months (P = 0.42). Outer nuclear layer (ONL) thickness in the 6 mm macular area increased from 58.9 ± 5.8 µm to 63.2 ± 6.8 µm at one month (P < 0.001) and then decreased at six month (58.8 ± 5.8 µm) relative to one month, reaching the baseline thickness. While GCIPL thinning at 1 month correlated with baseline visual acuity, change in the central ONL thickness from baseline to month 1 predicted visual outcome at month 6 (r = 0.6, P = 0.001). CONCLUSIONS: Following ON, transient changes occur in the photoreceptor nuclei layer and then revert to baseline. This finding could predict 6 month visual acuity after ON.