Adult Versus Pediatric Relapse and Recurrence in Orbital Inflammatory Syndrome.

PURPOSE: Orbital inflammatory syndrome (OIS) is a diagnosis of exclusion that has a variable presentation and unpredictable course. Many studies report incomplete or lack of OIS resolution with high recurrence and relapse rates. No studies to date have investigated the characteristics of both recurrence and relapse in OIS. We sought to determine this in both pediatric and adult patients. METHODS: A retrospective chart review of 56 patients with OIS was performed between 2004 and 2018. Forty-one patients were identified as adults greater than 18 years of age and 15 were identified as pediatric patients less than 18 years of age. RESULTS: Among 56 (41 adult and 15 pediatric) cases of OIS, 18 cases of recurrent disease (32.1%) were identified and 15 (26.8%) patients experienced relapses. All 6 (100%) pediatric patients that had recurrent disease initially suffered from relapses. In contrast, only 1 of the 12 (8.3%) recurrent adult cases initially experienced relapse. Of the 18 patients with recurrent disease, 9 (50%) had multiple recurrences. Underlying etiologies were confirmed in 5 of 18 recurrent cases (27.8%) and 5 of 38 (13.2%) non-recurrent cases. Of the 5 patients with recurrent OIS and an identified etiology, all 5 (100%) demonstrated multiple recurrences. CONCLUSIONS: In pediatric cases, relapse was more common and prior episodes of relapse were predictive of later recurrence. Recurrence was relatively common in both groups with half of the patients having multiple recurrences. Identifiable underlying etiologies were more common in patients with recurrent OIS and those cases all demonstrated multiple recurrences.

Effects of Aspirin on Postoperative Bruising and Bleeding Complications in Upper Eyelid Surgery.

PURPOSE: We evaluated the effects of aspirin versus placebo in patients undergoing upper eyelid blepharoplasty and/or levator advancement or plication blepharoptosis repair in this randomized, prospective study. METHODS: Patients who presented between October 2017 and April 2019 requiring blepharoptosis repair and/or upper eyelid blepharoplasty who were taking 81 mg aspirin were randomized to receive 1 week of aspirin tablets or 1 week of placebo tablets prior to surgery. Postoperative complications, such as bleeding, hematoma, or hemorrhage, were noted as well as perioperative thromboembolic complications. Photos were obtained at the patient's first postoperative visit and later judged on bruising severity. The 2 groups were subsequently compared. RESULTS: A total of 48 patients and 89 eyelids were evaluated in this study. Fifty-two eyelids were included in the aspirin group and 37 eyelids were included in the placebo group. There was no statistically significant difference in bruising rating between groups. There was no statistically significant difference in the number of patients who experienced mild postoperative bleeding. No patients experienced vision loss. No patients experienced a thromboembolic event. There were no patients who experienced hemorrhage, hematoma, or retrobulbar hemorrhage. CONCLUSIONS: Continuation of aspirin does not appear to effect outcomes with respect to postoperative bruising in patients undergoing upper eyelid blepharoplasty or blepharoptosis repair. The study was not powered to determine statistical significance with regard to bleeding complications and would require a significantly higher sample size. We suggest changing the current guidelines to recommend routine continuation of low dose 81 mg aspirin before upper eyelid surgery.

Ophthalmic Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome): A Systematic Review of the Literature.

PURPOSE: To review and summarize the clinical features, presentations, diagnostic modalities, and management of ophthalmic manifestations of eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss Syndrome). METHODS: A systematic PubMed search of all English articles on EGPA with ophthalmic involvement was performed. Emphasis was placed on English-language articles, but any article with an abstract translated into English was also included. Only those cases that satisfied the American Rheumatology criteria (1990) for diagnosis were included. Data examined included epidemiology, pathogenesis, presentations, diagnostic modalities, and management. RESULTS: There was a wide range in ophthalmic manifestations of EGPA. In order of most frequent presentation to least frequent, these include central retinal artery or vein occlusion, ischemic optic neuropathy, conjunctival nodules, orbital myositis, proptosis, dacryoadenitis, retinal vasculitis/infarcts/edema, cranial nerve palsy, and amaurosis. The 46 qualifying cases were divided into the categories of ischemic vasculitis versus idiopathic orbital inflammation due to prognostic significance. Ischemic vasculitis cases tended to be older patients (p = 0.03), unilateral (p = 0.006), require immunosuppressive therapy beyond steroids (p = 0.015), and were less likely to show improvement on therapy (p = 0.0003). CONCLUSIONS: Prompt diagnosis of EGPA by the ophthalmologist can decrease patient morbidity and mortality. This requires knowledge of likely ophthalmic EGPA presentations, as well as recommended workups and treatment.

Diode Laser-Assisted Endocanalicular Dacryocystorhinostomy: A Prospective Study.

PURPOSE: To evaluate the efficacy of the diode laser in endocanalicular dacryocystorhinostomy. METHODS: A prospective, noncomparative, interventional case series using the diode laser for endocanalicular dacryocystorhinostomy in patients with tearing and nasolacrimal duct obstruction. Outcome measures included subjective tearing complaints and objective patency of the nasolacrimal system. Success was defined as improvement of symptoms with patency of nasolacrimal drainage. Patients were followed for 12 months. Institutional review board approval was obtained. RESULTS: Forty eyes (28 unilateral, 6 bilateral) underwent surgery. Five cases were excluded because of inadequate follow-up. Patients ranged in age from 27 to 88 years (66.7 ± 15.7). Seventy-seven percent were female and 23% were male. At 1 week, 88% had improvement in tearing, 12% had no change or worsening of symptoms, and all patients were patent on irrigation. At 1 month, 86% had improvement, 14% had no change, and all patients were patent on irrigation. At 3 months, 83% had improvement and were patent on irrigation. Seventeen percent had no change or worsening with reflux and were considered failures. At 6 months, 77% had improvement and were patent on irrigation. Five additional patients had no change, reflux on exam and were failed surgeries. At 12 months, 74% had complete resolution and were patent. One additional patient failed. Nine surgeries in 35 cases were considered failures by 12 months. CONCLUSIONS: Subjective complaints of tearing correlated with patency of the nasolacrimal system after 3 months. A success rate of 74.3% (26 out of 35 cases) was observed by 12 months.

Granular cell tumor masquerading as a chalazion: a case report.

Granular cell tumors were first described in the 1920s and since then have been commonly found throughout the body. They are rarely found in periorbital, orbital, and ocular structures. The authors present a patient with a 2-year history of a lesion that had been previously excised as a presumed chalazion without pathologic analysis. The lesion recurred, and histopathological analysis following complete resection revealed a granular cell tumor. This case is an example of a rare periocular tumor. Although only an isolated case, it provides support for the recommendation that excised lesions be sent to pathologic study, particularly those with an atypical clinical course.

Thyroid Eye Disease With Significant Levator Involvement and Ptosis: A Case Report.

A case of an 87-year-old woman with a history of Graves disease presenting with a 5-year history of severe ptosis and very poor levator function of the left side is presented. MRI revealed marked enlargement of all extraocular muscles and significant enlargement of the left levator muscle. Given the patient's age and atypical presentation of thyroid eye disease (TED), she was taken to the operating room for biopsy and ptosis repair with frontalis suspension. Histopathological analysis revealed chronic inflammation and fibrosis consistent with Graves disease.

Electromagnetic image-guided orbital decompression: technique, principles, and preliminary experience with 6 consecutive cases.

PURPOSE: To assess the feasibility of routine use of electromagnetic image guidance systems in orbital decompression. METHODS: Six consecutive patients underwent stereotactic-guided three wall orbital decompression using the novel Fusion ENT Navigation System (Medtronic), a portable and expandable electromagnetic guidance system with multi-instrument tracking capabilities. The system consists of the Medtronic LandmarX System software-enabled computer station, signal generator, field-generating magnet, head-mounted marker coil, and surgical tracking instruments. In preparation for use of the LandmarX/Fusion protocol, all patients underwent preoperative non-contrast CT scan from the superior aspect of the frontal sinuses to the inferior aspect of the maxillary sinuses that includes the nasal tip. RESULTS: The Fusion ENT Navigation System (Medtronic™) was used in 6 patients undergoing maximal 3-wall orbital decompression for Graves' orbitopthy after a minimum of six months of disease inactivity. Preoperative Hertel exophthalmometry measured more than 27 mm in all patients. The navigation system proved to be no more difficult technically than the traditional orbital decompression approach. CONCLUSION: Electromagnetic image guidance is a stereotactic surgical navigation system that provides additional intraoperative flexibility in orbital surgery. Electromagnetic image-guidance offers the ability to perform more aggressive orbital decompressions with reduced risk.

A comparison of surgical outcomes with the use of 2 different biodegradable multipoint fixation devices for endoscopic forehead elevation.

PURPOSE: To assess the efficacy and rates of inflammatory cyst formation with the use of 2 different biodegradable multipoint fixation devices, Endotine versus Ultratine, for endoscopic forehead elevation. METHODS: The charts of 138 patients who underwent endoscopic forehead elevation by the same surgeon (E.H.B.) were reviewed retrospectively. Data regarding patient demographics, type of biodegradable fixation device, loss of fixation in the immediate and late postoperative period, inflammatory cyst formation of the fixation device, additional complications, and reoperation status were collected from the charts. Patients implanted with Endotine and Ultratine were compared postoperatively for early and late loss of elevation (efficacy), inflammatory cyst formation, additional complications, and reoperation rates. RESULTS: Of the 276 fixation devices implanted (117 Endotine and 159 Ultratine), 11 inflammatory cysts were found, all of them in the Ultratine group (p = 0.0037). Four patients required reoperation due to early loss of fixation. Three of these cases were in the Endotine group, and 1 case was observed in the Ultratine group (p = 0.18). A total of 4 patients had late loss of fixation, all of them in the Ultratine group (p = 0.08). Scalp hypoesthesia and/or dysesthesia beyond the sixth postoperative month were observed in 3.62% of the cases. Postsurgical neuralgia was observed in 2.17%, and focal alopecia was seen in 1.44%. CONCLUSIONS: The presence of inflammatory cysts with the implantation of the Ultratine device is statistically higher than with Endotine. No statistical significant difference was found in either early or late fixation loss between the 2 groups.

A solution to the Jones tube continuous positive airway pressure (CPAP) dilemma?

A 49-year-old woman, who had previously undergone bilateral Jones tube placement, began nasal continuous positive airway pressure for obstructive sleep apnea. The patient's use of continuous positive airway pressure was limited by intolerance of the transfer of air through the Jones tube to her ocular surface resulting in irritation and discomfort. A change from nasal continuous positive airway pressure to a full face mask, including both Jones tubes in the pressure circuit, resolved the problem.

Biological agents for the treatment of uveitis.

INTRODUCTION: The conventional treatment of uveitis includes corticosteroids and immunosuppressive agents, which are highly efficacious, but can be associated with serious systemic side effects. Over the last two decades, advances in the understanding of the pathogenesis of inflammatory diseases, as well as improved biotechnology, have enabled selective targeting of the chemical mediators of diseases. Recently, a new class of drugs called biologics, that target the various mediators of the inflammation cascade, may potentially provide more effective and less toxic treatment. AREAS COVERED: This article is a review and summary of the peer-reviewed evidence for biologic agents in the treatment of various forms of ocular inflammation and it focuses on the potential use of other biologic agents that have been tested in experimental autoimmune uveitis. Pubmed was used as our main tool for our literature search. Some additional references were taken from books written on the subject. EXPERT OPINION: There are a wide variety of new and emerging biological agents currently being used in the treatment of uveitis which has expanded the therapeutic horizons far beyond previous limitations.

Phakomatous choristoma: a rare orbital tumor presenting as an eyelid mass with obstruction of the nasolacrimal duct.

We describe a case of phakomatous choristoma presenting as a lower eyelid mass with nasolacrimal duct obstruction. The literature is reviewed and the unique aspects of the case are discussed.

Botox: shaken, not stirred.

PURPOSE: To determine whether the effect of botulinum toxin type A is maintained and has the same duration when it is reconstituted vigorously. METHODS: A prospective, double-blinded, randomized study was performed on 7 consecutive patients who underwent botulinum toxin type A injections to the forehead by one oculoplastic surgeon. Half of each patient's forehead was injected with botulinum toxin type A that had been gently reconstituted according to the package insert and the other half of the forehead was injected with botulinum toxin type A that had been reconstituted vigorously. Eyebrow excursion was measured in millimeters before injection, 1 week after injection, and every month after injection up to a total of 6 months. RESULTS: Seven consecutive patients with an average age of 39.9 +/- 2.8 years were evaluated. There was no statistically significant difference in eyebrow excursion between the side of the forehead that had been injected with gently reconstituted botulinum toxin type A and the side that had been injected with vigorously reconstituted botulinum toxin type A at every visit. CONCLUSION: The effect of botulinum toxin type A is maintained and has the same duration when it is reconstituted vigorously compared with when it is reconstituted gently.

Septic pulmonary embolism associated with orbital abscess and sinusitis.

A 13-year-old white boy was admitted to an outside institution for antibiotic treatment of right preseptal cellulitis. He subsequently developed a right orbital abscess, which could not be located on surgical exploration. On postoperative day 2, he developed acute chest pain and was transferred to Children's Hospital of Michigan for evaluation and treatment. CT of the thorax demonstrated multiple, bilateral lower lobe lesions consistent with septic pulmonary embolism. The right orbit was re-explored with successful drainage of an intraconal orbital abscess. He was treated with intravenous antibiotics with subsequent improvement of the orbital cellulitis and chest pain. He was discharged home on intravenous antibiotics. At 1 month, follow-up chest CT demonstrated near resolution of the lung lesions.

A prospective study assessing the utility of Cogan's lid twitch sign in patients with isolated unilateral or bilateral ptosis.

OBJECTIVE: Cogan's lid twitch is thought to suggest myasthenia gravis in patients with unexplained ptosis. The validity of this clinical test has not been established. We conducted a prospective study to ascertain the sensitivity and specificity of this finding. METHODS: 35 patients with isolated, symptomatic ptosis, referred to a neuro-ophthalmologist or oculoplastics specialist were enrolled. The presence or absence of Cogan's lid twitch was noted, according to standard technique. Further testing was performed, and the final diagnosis for each patient was recorded. RESULTS: Four patients were found to have a Cogan's lid twitch. Two patients had ocular myasthenia gravis as the final diagnosis, and of those, only one had a twitch. CONCLUSIONS: The sensitivity and specificity of Cogan's lid twitch is relatively low. Other conditions may cause a lid twitch as well. The presence of a Cogan's lid twitch may increase suspicion of myasthenia, but is not diagnostic, and does not exclude alternate etiologies of ptosis.

Choroidal melanoma with massive extrascleral extension in a young black man.

The reported incidence of choroidal melanoma is low among the general population and is especially low among blacks. Choroidal melanoma is seen most commonly in whites in the sixth to seventh decades. The tumor is complicated by orbital invasion in only a small percentage of cases. This report describes the case of a 38-year-old black man diagnosed with a choroidal melanoma of the right eye. The tumor exhibited extensive orbital invasion. Primary or metastatic disease elsewhere in the body was ruled out, and the patient underwent an eyelid-sparing orbital exenteration. Histopathologic examination of the orbital specimen confirmed the diagnosis of spindle cell-type choroidal melanoma. Orbital invasion by a primary choroidal melanoma in a black person under the age of 40 is highly unusual. To our knowledge, this represents the youngest reported case of choroidal melanoma with extrascleral extension in a black patient. Ophthalmologists should consider the possibility of this potentially deadly tumor, even in young, black patients.

Fundamentals of facelift surgery.

A multitude of techniques exists for facelift surgery (rhytidectomy). These techniques range from simple skin undermining to complex procedures involving superficial musculoaponeurotic system (SMAS) manipulation and subperiosteal dissection. Most surgeons agree that some type of modification of the SMAS is necessary to achieve an acceptable result. The technique presented herein involves developing a relatively large skin flap, tightening the SMAS, and redraping the skin.