Dacryoscintigraphy as a guide for surgery in patients with functional epiphora.

OBJECTIVE: To investigate how dacryoscintigraphy (DSG) may benefit surgical planning for functional epiphora. METHODS: A retrospective multicenter case series was performed on patients with symptomatic tearing despite no identified external cause and normal lacrimal probing and irrigation (i.e., functional epiphora). All patients had preoperative DSG testing. Patients were excluded if DSG testing failed to detect a tear flow abnormality. Those with delayed tear flow prior to entering the lacrimal sac (presac) on DSG underwent surgery aimed at improving flow into the lacrimal sac. Those with delayed tear flow after the lacrimal sac (postsac) on DSG underwent dacryocystorhinostomy. Surgical success was defined as epiphora being completely resolved, significantly improved, or partially improved. Surgical failure was defined as epiphora being unchanged or worse than at the preoperative timepoint. RESULTS: A total of 77 cases (53 patients) of DSG-guided surgery were included. A presac delay was observed in 14 cases (18.2%) and post-sac delay in 63 (81.8%). Overall surgical success was 83.1% across the cohort. Success was 100% in the presac group and 79.4% in the postsac group (p = 0.06). Mean follow-up time was 22 months (SD = 21 months). CONCLUSION: A role was demonstrated for DSG in the planning of surgery for patients with functional epiphora. The DSG-guided approach, when compared with empirical lacrimal intubation or dacryocystorhinostomy, may be especially useful in cases of functional epiphora that are presac in nature.

Prevalence and Predictors of Hering's Response in Müller's Muscle-conjunctival Resection.

PURPOSE: Determine the prevalence and predictors of Hering's response following Muller's muscle-conjunctival resection (MMCR). METHODS: Seventy-five consecutive patients undergoing unilateral MMCR were recruited in this prospective, multicenter, cohort study. Margin-reflex distance-1 (MRD1) of both eyelids was recorded preoperatively and postoperatively. One hundred forty-three variables were investigated as potential predictors of a late postoperative (≥3 months) Hering's response using regression analyses. Main outcome measures were Hering's response (≥0.5 mm descent of the unoperated eyelid from baseline), and a clinically relevant Hering's response (descent of the unoperated from baseline to a MRD1 ≤ 2.0 mm, or descent from baseline such that the MRD1 of the unoperated eyelid became >1 mm lower than the operated eyelid). RESULTS: Twenty-four (32.0%) patients had a late postoperative Hering's response, but only 6 (8.0%) responses were clinically relevant. A Hering's response at the immediate (OR 16.24, p = 0.02) and 1-week postoperative (OR 8.94, p = 0.04) timepoints predicted a late postoperative response. However, the presence (OR 7.84, p = 0.07) and amplitude (OR 8.13, p = 0.06) of a preoperative phenylephrine Hering's response did not predict a late postoperative response. Of the 10 patients with a clinically relevant phenylephrine Hering's response, only 1 demonstrated a clinically relevant response late postoperatively. CONCLUSION: Unilateral MMCR induces a clinically relevant Hering's response in 8% of patients. A preoperative phenylephrine Hering's response does not predict a late postoperative Hering's response. Therefore, when unilateral phenylephrine testing unmasks contralateral blepharoptosis, only the side with blepharoptosis at baseline should be operated.

Müller Muscle Conjunctival Resection: A Multicentered Prospective Analysis of Surgical Success.

PURPOSE: This is a multicenter prospective cohort study investigating Müller muscle conjunctival resection success rates based on marginal reflex distance-1 (MRD1) and symmetry criteria. A secondary objective was to identify predictors of success. METHODS: One hundred fifty-two patients with unilateral or bilateral blepharoptosis (229 eyelids) undergoing Müller muscle conjunctival resection were consecutively recruited from 2015 to 2020 at the Université de Montréal and University of California San Francisco. Ptosis was defined as MRD1 ≤ 2.0 mm or MRD1 > 1 mm lower than the contralateral eyelid. Patients were selected for Müller muscle conjunctival resection surgery if they demonstrated significant eyelid elevation following phenylephrine 2.5% testing. MRD1 success (operated eyelid achieving MRD1 ≥ 2.5 mm) and symmetry success (patient achieving an intereyelid MRD1 difference ≤ 1 mm) were evaluated for the patient cohort. Predictors of MRD1 and symmetry success were analyzed using multivariate regression analysis. RESULTS: MRD1 success was achieved in 72.1% (n = 165) of 229 operated eyelids. Symmetry success was achieved in 75.7% (n = 115) of 152 patients. MRD1 before phenylephrine testing was the only statistically significant predictor of MRD1 success (odds ratio [OR] 2.69, p = 0.001). Symmetry following phenylephrine testing was the only variable associated with increased odds of symmetry success (OR 2.71, p = 0.024), and unilateral surgery (OR 0.21, p = 0.004), the only variable associated with reduced odds of symmetry success. CONCLUSIONS: Müller muscle conjunctival resection effectively achieves postoperative MRD1 and symmetry success. MRD1 before phenylephrine testing is the strongest determinant of MRD1 success. Neither a large rise in MRD1 with phenylephrine nor increasing tissue resection length adequately counterbalance the effect of a low MRD1 before phenylephrine. Unilateral surgery and the absence of symmetry following phenylephrine predict greater odds of symmetry failure.

Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis.

PURPOSE: To assess whether a modified treatment ladder algorithm incorporating transcutaneous retrobulbar amphotericin B (TRAMB) for invasive fungal rhino-orbital sinusitis can reduce the risk of exenteration without compromising survival. DESIGN: Retrospective, comparative clinical study with historical control subjects. METHODS: Fifty consecutive patients with biopsy-proven invasive fungal sinusitis and radiographic evidence of orbital involvement were evaluated at a single tertiary institution from 1999-2020. TRAMB was incorporated as part of the treatment algorithm in 2015. Demographics, underlying immune derangement, infective organism, ophthalmic examination, surgical care, and survival were compared in a quasiexperimental pre-post format, dividing patients into a pre-2015 group and a post-2015 group. Risk of exenteration and mortality were the primary outcomes. RESULTS: Baseline characteristics did not differ significantly between the 2 groups. Nearly all patients underwent a surgical intervention, most commonly functional endoscopic sinus surgery with debridement. TRAMB was administered to 72.7% of the post-2015 group. Exenteration was more common in the pre-2015 group (36.4% vs 9.1% [95% confidence interval {CI} 5.2-48.8]; P = .014), while mortality was similar (40.0% vs 36.7% [95% CI -22.1 to 29.3]; P = .816). After adjusting for potential confounders, patients treated after 2015 were found to have lower risk of exenteration (relative risk 0.28 [95% CI 0.08-0.99]; P = .049) and similar risk of mortality (relative risk 1.04 [95% CI 0.50-2.16]; P = .919). CONCLUSION: Compared with historical control subjects, patients with invasive fungal rhino-orbital sinusitis who were treated with a modified treatment ladder algorithm incorporating TRAMB had a lower risk of disfiguring exenteration without an apparent increase in the risk of mortality.

Personal protective equipment (PPE) during the COVID-19 pandemic for oculofacial plastic and orbital surgery.

Purpose: To review the current literature on Coronavirus Disease 2019 (COVID-19) virology and transmission; to present a decision tree for risk stratifying oculofacial plastic and orbital surgeries; and to generate personal protective equipment (PPE) recommendations by risk category.Methods: A comprehensive literature review on COVID-19 was conducted. A two-stage modified Delphi technique involving 18 oculofacial plastic and orbital surgeons across Canada was used to determine consensus risk-stratification criteria and PPE recommendations for surgeries performed in the North American context.Results: COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We summarize COVID-19 virology and transmission, as well as practice considerations for oculofacial plastic and orbital surgeons. Although SARS-CoV-2 is known to be transmitted predominantly by droplet mechanisms, some studies suggest that transmission is possible through aerosols. Among common procedures performed by oculofacial and plastic surgeons, some are likely to be considered aerosol-generating. Risk of transmission increases when manipulating structures known to harbor high viral loads. We present an algorithm for risk-stratification based on the nature of surgery and the anatomical sites involved and offer recommendations for PPE.Conclusions: Although universal droplet precautions are now recommended in most healthcare settings, some clinical situations require more stringent infection control measures. By highlighting high-risk scenarios specific to oculofacial plastic and orbital surgery, as well as PPE recommendations, we hope to enhance the safety of continued care during the COVID-19 pandemic.

Helicobacter pylori Infection of the Gastric Mucosa and Ocular Adnexa-Lack of Association With Ocular Adnexal Lymphoma.

PURPOSE: Helicobacter pylori could theoretically induce ocular adnexal lymphoma (OAL) via 2 mechanisms: the first is that of infection within the ocular adnexa and the second is that of infection within the gastric mucosa, leading to the malignant transformation of lymphocytes that migrate to the ocular adnexa, forming a primary "ectopic" cancer. This study investigated if an association exists between gastric H. pylori or ocular adnexal H. pylori and OAL. METHODS: Prospective case-control study including cases with OAL and controls with nonlymphomatous pathologies. Gastric H. pylori infection was assessed via serologic antibody testing. Ocular adnexal infection was assessed via polymerase chain reaction testing for H. pylori and Chlamydia psittaci within ocular adnexal samples. RESULTS: Seventy-two patients were enrolled, of whom 18 had lymphoma and 54 nonlymphomatous pathologies. H. pylori antibodies were present in 5 cases (28%) and 18 controls (33%) (95% CI, 0.24%-2.50%, p = 0.78). All ocular adnexal specimens were negative for H. pylori and C. psittaci infection. The only relevant statistically significant difference between cases and controls was a history of gastric ulcer (95% CI, 1.23%-44.80%, p = 0.03). CONCLUSIONS: In the study's population, infection of gastric mucosa with H. pylori does not appear to influence the development of OAL. Also, H. pylori or C. psittaci infection within the ocular adnexa does not appear to influence the development of OAL. In the study's practice, authors do not recommend antibiotic administration or routine gastroscopy for patients with OAL. The authors do recommend referral of OAL patients with gastric symptoms to a gastroenterologist.

Mesenchymal chondrosarcoma of the orbit masquerading as a hemophilic pseudotumor.

An 11-year-old boy presented with a lesion of the right orbit that was thought to be a hemophilic pseudotumor. Excisional biopsy revealed an unexpected diagnosis of mesenchymal chondrosarcoma. Both mesenchymal chondrosarcoma and hemophilic pseudotumor of the orbit are exceedingly rare. To the best of our knowledge, this is the first reported case of orbital mesenchymal chondrosarcoma masquerading as hemophilic pseudotumor.

Nasolacrimal Obstruction Following the Placement of Maxillofacial Hardware.

PURPOSE: This article reviews cases of nasolacrimal obstruction (NLO) secondary to maxillofacial hardware placement. METHODS: A retrospective review was performed at a single institution from 2012 to 2017 of patients with NLO following maxillofacial reconstruction. The study was approved by the Institutional Review Board of the University of California, San Francisco, adhered to the tenets of the Declaration of Helsinki, and was Health Insurance Portability and Accountability Act compliant. Patients were included if external dacryocystorhinostomy (DCR) confirmed previously placed maxillofacial hardware as the primary contributor to lacrimal outflow obstruction and had at least 3 months of follow-up. RESULTS: Of 420 patients who underwent external DCR, 6 cases of implant-related NLO were identified. The mean age was 47.3 ± 9.6 years and 66.7% of patients were male. All patients presented with epiphora and 50% also had chronic dacryocystitis. Patients had prior maxillofacial hardware placement for paranasal sinus tumors (66.7%) or facial fractures (33.3%). In addition to external DCR, all patients had revision or removal of implants that were impeding lacrimal outflow by 2 mechanisms: (1) an orbital implant impinging the lacrimal sac or nasolacrimal duct (NLD) and/or (2) maxillofacial screws placed into the bony NLD or nasolacrimal fossa. Five of the 6 patients (83.3%) had complete resolution of symptoms and patency of the nasolacrimal system at their last follow-up visit (range 3-30 months). CONCLUSION: NLO secondary to hardware placement, though infrequent, is underreported. Two mechanisms of hardware-induced NLO were encountered in this case series. Specific attention to nasolacrimal anatomy at the time of maxillofacial reconstruction may help minimize implant-induced NLO.

Regression of Sebaceous Carcinoma of the Eyelid after a Small Incisional Biopsy: Report of Two Cases.

PURPOSE: To report 2 cases of regression of sebaceous carcinoma of the eyelid after a small incisional biopsy. METHODS: Clinical, imaging, and histopathological findings are presented, with a literature review on regressing ocular tumors. RESULTS: Our first patient was a 79-year-old man who presented with a 10-month history of progressive left upper eyelid ptosis caused by an eyelid tumor with orbital involvement and confirmed on magnetic resonance imaging. Our second patient was a 70-year-old woman who presented with ptosis with a left upper eyelid mass. Both patients underwent a small incisional biopsy of their lesion. The histopathological diagnoses in both cases were consistent with sebaceous carcinoma. Both patients refused exenteration. Follow-up clinical examination and imaging disclosed total regression of the ptosis and of the neoplasm with no sign of recurrence in both patients over a 4-year period for Case 1 and a 7-year period for Case 2. CONCLUSION: Regression following incisional biopsy of basal cell, squamous cell, and Merkel cell carcinoma, including of the eyelid, is well documented. To the best of our knowledge, our 2 cases of sebaceous carcinoma are the first to be reported with total involution clinically and on imaging of the tumor following partial incisional biopsy.

Invasive Fungal Sinusitis: Risk Factors for Visual Acuity Outcomes and Mortality.

PURPOSE: Invasive fungal sinusitis is a rare but potentially lethal disease that primarily affects immunocompromised patients. The purpose of this study was to review an academic medical center's experience in the presentation, diagnosis, and treatment of invasive fungal sinusitis. METHODS: A retrospective chart review was performed at a single institution over a 17-year period. Medical records, radiographic imaging, and operative reports were analyzed. Bivariate and multivariable analyses were performed to determine factors that affected visual acuity outcomes and mortality. RESULTS: Fifty-five patients with histopathologically confirmed invasive fungal sinusitis were included. The average duration of follow up was 1.8 ± 2.6 years (range: 1 week to 10 years). The most common causes of immunosuppression were hematologic malignancy (45%), diabetes (31%), and organ transplantation (9%). At presentation, 35% of individuals were neutropenic (absolute neutrophil count < 500/µl). All patients received systemic antifungal treatment. A surgical intervention was performed on 50 patients (91%), and all but one had functional endoscopic sinus surgery. Nine (16%) patients underwent orbital exenteration. Multivariable analysis of visual acuity outcomes demonstrated that individuals infected with Zygomycota had 6-7 lines worse vision than those infected with Ascomycota (mean difference in logMAR 0.66, 95% confidence interval 0.27 to 1.06, p = 0.001). Patients who had functional endoscopic sinus surgery had 7-8 lines better visual acuity than those without functional endoscopic sinus surgery (mean difference in logMAR -0.76, 95% confidence interval -1.13 to -0.38, p < 0.001). The overall death rate due to infection was 24%. Bivariate models demonstrated no difference in mortality in patients receiving exenteration versus those who did not (p = 0.14). Multivariable analysis of mortality demonstrated that neutropenia increased mortality (adjusted odds ratio 10.05, 95% confidence interval 1.49 to 67.67, p = 0.02). Having a greater number of surgeries was associated with an increased rate of survival (adjusted odds ratio 0.39, 95% confidence interval 0.15 to 0.96, p = 0.04). CONCLUSIONS: Invasive fungal sinusitis is an aggressive disease with significant mortality. Patients with neutropenia had a lower rate of survival, and infection with Zygomycota was associated with worse visual acuity outcomes. Those having functional endoscopic sinus surgery had better final visual acuity, and an increased number of surgeries was associated with a decreased chance of death. Exenteration yielded no observed survival benefit.Endoscopic sinus debridement portends better visual acuity outcomes in patients with invasive fungal sinusitis, whereas exenteration yields no difference in survival benefit.

Mixed cranial neuropathies due to occult perineural invasion of basal cell carcinoma.

PURPOSE: To report a diagnostically challenging case of cranial neuropathy due to perineural invasion by a basal cell carcinoma presenting 7.5 years after treatment of the primary tumor with Mohs micrographic surgery. OBSERVATIONS: A 62-year-old male with a history of Mohs micrographic surgery for basal cell carcinoma (BCC) of the left brow presented with insidious onset of diplopia and paresthesia localizing to the ipsilateral cranial nerves V1, V2, and VI. He had no evidence of recurrent cutaneous BCC. Magnetic resonance imaging of the orbits and skull base identified equivocal, subtle abnormalities in the ipsilateral superior orbital fissure and cavernous sinus, with normal appearance of the clinically involved nerve branches. A radiographically normal branch of cranial nerve V was biopsied and histopathology identified perineural invasion by recurrent basal cell carcinoma. CONCLUSIONS AND IMPORTANCE: The diagnosis of perineural invasion by BCC can pose several challenges, including subtle to absent imaging findings of clinically involved nerves and a lengthy latent period following primary tumor treatment. This case represents, to our knowledge, the longest reported interval between primary treatment and biopsy-proven recurrence with perineural invasion by BCC.

Zoledronic acid-induced orbital inflammation in a patient with multiple myeloma.

Multiple myeloma is a cancer of malignant plasma cells which stimulates osteoclasts and is associated with increased bone turnover and osteolysis. Bisphosphonates including zolendronic acid are used to prevent skeletal complications in patients with multiple myeloma. Orbital inflammation is a rare but serious complication following use of bisphosphonates. The diagnosis is made by excluding other possible causes in patients with myeloma and rapid initiation of therapy is required. Corticosteroids are the mainstay of therapy but the ideal treatment course has not been delineated. This report describes a case of this rare complication and provides a review of the literature.

Efficacy of Care for Blind Painful Eyes.

PURPOSE: Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions. METHODS: A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed. RESULTS: Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure. CONCLUSIONS: Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

Nasolacrimal Duct Obstruction Following Hyaluronic Acid Rejuvenation of the Tear Trough.

Although generally safe, hyaluronic acid rejuvenation of periorbital tissue has been reported to cause minor and major adverse events. The authors document a case of nasolacrimal duct obstruction due to hyaluronic acid rejuvenation of the tear trough. Nasolacrimal duct obstruction immediately resolved following irrigation of hyaluronidase into the affected lacrimal system. To the authors' knowledge, this is the first reported case of nasolacrimal duct obstruction due to filler injection.