Congenital orbital respiratory epithelial cyst with anomalous maxillary antrum in the absence of bony defect.

A 23-year-old female symptomatic with unilateral proptosis with superior globe displacement and hypertropia was found to have a multiloculated cystic lesion with bony lining arising from the inferomedial orbit. The adjacent maxillary sinus was markedly smaller on the affected side, with no defect of the wall on radiographic or intraoperative examination. Surgical excision and histological analysis of the lesion demonstrated an orbital respiratory epithelial cyst. A literature review of congenital orbital respiratory epithelial cysts is presented. To our knowledge, this is the first published case of choristomatous orbital respiratory epithelial cyst associated with ossification, and a primary or secondary anomaly of the adjacent sinus without bony defect.

Oculoplastic Conditions in Covid-19 Patients: Case Series and Literature Review.

Purpose: To investigate oculoplastic conditions in patients diagnosed with coronavirus disease 2019 (COVID-19) seen at ophthalmology departments of three tertiary referral centers in the United Kingdom and the United States, and review of the literature. Methods: Retrospective multicenter case series studied over 18 months. Results: A total of four patients developed eyelid, orbital, or lacrimal gland pathology within four weeks of testing positive for COVID-19. All were male, and the mean age at presentation was 49 (range, 31-58 years). Suspected diagnoses included anterior idiopathic orbital inflammation, facial angioedema, dacryoadenitis, and anophthalmic socket inflammation. Three patients recovered fully and one patient recovered partially (mean 2.7 weeks) from ocular manifestations with steroids hastening recovery. Conclusion: Adnexal manifestations of COVID-19 include self-limiting orbital inflammation and eyelid lymphedema.

Topical Chloramphenicol in Ophthalmology: Old is Gold.

PURPOSE: Topical chloramphenicol is one of the most ubiquitous antibiotics used in ophthalmology and oculoplastic surgery globally. It shows broad-spectrum activity against a variety of different pathogenic organisms, is well tolerated on the ocular surface and displays excellent topical pharmacokinetics. Chloramphenicol has been available for purchase over the counter in the United Kingdom since 2005. Despite this, the largest health economy in the world, The United States has had a de-facto moratorium on its use for the past 30 years. In this review, we aim to evaluate topical chloramphenicol in ophthalmology and oculoplastic surgery and to determine whether its reputation within the US is warranted and justified. METHODS: We conducted a comprehensive literature review to evaluate the different facets of chloramphenicol, providing a detailed understanding of the drug, its historical context, the benefits and perceived risks, including safety concerns, and clinical perspectives of its use in clinical practice. RESULTS: The mechanism of chloramphenicol, the context around which the drug's use in the US declined, and the drug's evidence base and safety data, including published case reports of serious adverse events, were analysed. The perceived benefits of the drug, particularly in light of antimicrobial resistance and its economic impact, were reviewed. Finally, perspectives on its use in clinical practice in ophthalmology and associated allied specialities were presented. CONCLUSION: Chloramphenicol and its topical application have been misunderstood for many decades, particularly in the United States. Its demise across the Atlantic was due to an overzealous response to a dubious association with a weak evidence base. Numerous authors have since validated the safety profile of the and its safety has been borne out. The benefits of chloramphenicol, an effective broad-spectrum agent with a positive cost differential in the era of anti-microbial resistance and fiscal tightening, cannot be understated. Its likely effectiveness as a therapeutic topical agent in ophthalmic surgery makes it a valuable tool in the ophthalmic anti-microbial armoury. We would encourage the reinstatement of this valuable yet misunderstood drug as a first-line agent for simple ophthalmic infections.

The Effectiveness of Facial Exercise Therapy in Ophthalmic Complications of Facial Nerve Palsy and the CADS Grading Scale as an Ophthalmic-Specific Grading System.

PURPOSE: The effectiveness of facial exercise therapy in facial nerve palsy is well documented in the literature. However, there is no study examining its effect on ophthalmic manifestations of facial nerve palsy. The study reports its impact on the ophthalmic manifestations of facial nerve palsy using the ophthalmic-specific CADS grading system. METHODS: A retrospective case series of patients aged 18 years or older with facial nerve palsy was performed in a single specialist center between 2013 and 2019. Inclusion criteria were ophthalmic involvement, recorded CADS, and Sunnybrook grading scale pre- and post-treatment. RESULTS: A total of 73 patients were identified. There were 24 patients (M = 11, F = 13) who received facial exercise therapy only (group 1) and 49 patients (M = 17, F = 32) who received combined treatment of facial exercise therapy and eyelid surgery (group 2). The mean ages were 54.8 and 49.7 years, respectively. The groups were further subdivided into early (<3 months), intermediate (3-12 months), and late presenters (>12 months). In group 1, statistically significant improvements were seen in early (static asymmetry and dynamic function), intermediate (cornea), and late groups (cornea, static asymmetry, and dynamic function). The Sunnybrook grading scale was unable to detect changes in the ophthalmic features post-therapy or to report the corneal status. CONCLUSIONS: Facial exercise therapy is likely to improve ophthalmic manifestations of facial nerve palsy, in particular, those with static asymmetry and dynamic function of eye closure. The CADS grading scale is more suitable for the ophthalmic assessment.

Response to Hypoglossal Nerve Stimulation Changes With Body Mass Index and Supine Sleep.

Importance: Hypoglossal nerve stimulation (HGNS) is a potential alternative therapy for obstructive sleep apnea (OSA), but its efficacy in a clinical setting and the impact of body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) on treatment response remain unclear. Objective: To investigate whether HGNS therapy is effective for patients with OSA, whether HGNS can treat supine OSA, and whether there are associations between BMI and treatment response. Design, Setting, and Participants: In this cohort study, adult patients with OSA implanted with HGNS at the Washington University Medical Center in St Louis from April 2019 to January 2023 were included. Data were analyzed from January 2023 to January 2024. Exposure: HGNS. Main Outcomes and Measures: Multivariable logistic regression was performed to assess associations between HGNS treatment response and both BMI and supine sleep. Treatment response was defined as 50% reduction or greater in preimplantation Apnea-Hypopnea Index (AHI) score and postimplantation AHI of less than 15 events per hour. Results: Of 76 included patients, 57 (75%) were male, and the median (IQR) age was 61 (51-68) years. A total of 59 patients (78%) achieved a treatment response. There was a clinically meaningful reduction in median (IQR) AHI, from 29.3 (23.1-42.8) events per hour preimplantation to 5.3 (2.6-12.3) events per hour postimplantation (Hodges-Lehman difference of 23.0; 95% CI, 22.6-23.4). In adjusted analyses, patients with BMI of 32 to 35 had 75% lower odds of responding to HGNS compared with those with a BMI of 32 or less (odds ratio, 0.25; 95% CI, 0.07-0.94). Of 44 patients who slept in a supine position, 17 (39%) achieved a treatment response, with a clinically meaningful reduction in median (IQR) supine AHI from 46.3 (33.6-63.2) events per hour preimplantation to 21.8 (4.30-42.6) events per hour postimplantation (Hodges-Lehman difference of 24.6; 95% CI, 23.1-26.5). In adjusted analysis, BMI was associated with lower odds of responding to HGNS with supine AHI treatment response (odds ratio, 0.39; 95% CI, 0.04-2.59), but the imprecision of the estimate prevents making a definitive conclusion. Conclusions and Relevance: This study adds to the growing body of literature supporting the use of HGNS for OSA treatment. Sleep medicine clinicians should consider informing patients that higher BMI and supine sleeping position may decrease therapeutic response to HGNS. Future research is needed to replicate these findings in larger, more diverse cohorts, which would facilitate the optimization of treatment strategies and patient counseling for HGNS therapy.

Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy.

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Evaluating the Effectiveness of Lacrimal Gland Botulinum Toxin Using the TEARS Score.

PURPOSE: Botulinum toxin (BoNTA) lacrimal gland injections are one treatment option for managing epiphora. Outcomes for epiphora in existing studies are subjective and lack grading. This study utilized validated grading instruments to evaluate the efficacy of BoNTA lacrimal gland injections. METHODS: Prospective study evaluating the TEARS score and quality of life in patients receiving incobotulinum toxin (Xeomin) lacrimal gland injections for epiphora. Epiphora was graded using the TEARS score. Quality of life was evaluated using the watery eye quality of life score. Etiology, benefit duration, complications and additional injections were recorded. RESULTS: Of the 28 patients, (median age 67.5 years), 19 (68%) had facial palsy gustatory epiphora (GE). Median effect duration was 13 weeks. Improvements in tearing frequency (T), clinical effects (E), and activity limitation (A) were seen in 57%, 57%, and 71% of patients, respectively. Median watery eye quality of life score improved from 42.4/100 ± 10.1 to 10.6 ± 15.5 (p < 0.001). Alongside crocodile tears, reflex tearing R-scores improved in 68% of patients with GE vs. 11% with non-GE causes (p = 0.004618). In total 89% of patients with GE and 56% with non-GE requested repeat injections. Self-reported percentage improvement ranged from 0% to 100% (median 60%, interquartile range 10%-76.25%). CONCLUSIONS: This is the first study reporting the outcomes of BoNTA lacrimal gland injections using validated TEARS and watery eye quality of life scores. Clinical and quality of life improvements are seen in most patients. Patients with GE achieve an additional improvement in dry eye-related reflex tearing alongside crocodile tears which both improve with BoNTA. TEARS data supports using BoNTA in these patients and is a useful validated grading instrument for epiphora.

Real or MADE-up: Investigating Mask-Associated Dry Eye (MADE) as an emerging syndrome.

Mask-Associated Dry Eye (MADE) has emerged as a consequence of widespread face mask usage during the Covid-19 pandemic. This review critically assesses the available evidence. A comprehensive search on PUBMED and EMBASE was conducted to identify studies on MADE, which were then categorized based on their design. A total of 26 studies were critically appraised, with the majority exhibiting poor study design quality. Investigating the impact of mask use on ocular surface irritation faced challenges due to global mask mandates, pandemic-related behavioural changes, and a lack of validated methods to measure the response to mask wear. Among the 15 studies, 12 reported a statistically significant reduction in TBUT associated with mask wear; however, the median decrease of 1.3 s was considered clinically insignificant. Results from Schirmer's test in 8 studies varied, with 5 studies reporting a decrease, contradicting the hypothesis of misdirected airflow. Out of 7 studies on corneal and conjunctival staining, 6 indicated a worsening associated with mask wear. Five studies investigating OSDI scores reported an increase following mask wear, but 3 studies repeated the survey too soon. Limited evidence suggests that masks may cause mild ocular surface irritation, but the quality and certainty of this evidence remain low. Methodological limitations were prevalent across the majority of studies, and the observed changes were minimal. Therefore, it is unlikely that significant ocular surface pathology will develop in the majority of mask wearers. Currently, there is insufficient data to support the establishment of a new syndrome.

Horizontal shortening of the lower eyelid margin in facial nerve palsy.

BACKGROUND/OBJECTIVES: To determine whether horizontal lower eyelid margin length shortens following facial nerve palsy (FNP). SUBJECTS/METHODS: A single-centre retrospective audit of lower eyelid margin horizontal length, measuring from the lower lacrimal punctum to lateral canthal angle with a straight plastic ruler, with the eyelid on gentle stretch ('punctum-to-canthus (PC) distance'), recorded in all FNP patients reviewed in July-September 2021. Affected and fellow eyes were compared using parametric testing. RESULTS: Forty-one patients were reviewed. Seventeen were excluded due to previous surgery that would lengthen (e.g., periosteal flap) or shorten (e.g., lateral tarsal strip) the lower eyelid margin. Of the remaining 24, mean age was 52.5 years (range, 27-79) and 54% were female. Mean PC distance was significantly shorter in affected eyes (26.0 mm, range: 22-34 mm) compared to fellow eyes (27.5 mm, 24-35 mm) (paired t-test, T(23) = 6.06, p < 0.00001). Mean difference between both eyes' PC distance was 1.5 mm (0-4 mm). Only three patients were still in the 'paralytic phase' (i.e., <1 year since FNP onset), and difference in PC distance was 0 mm in all three. A reduction in lower eyelid PC distance was weakly associated with a reduction in upper eyelid lid-margin-to-brow distance (R = 0.4775, p = 0.0286). CONCLUSIONS: The lower eyelid margin appears to shorten horizontally following FNP. This study provides proof-of-concept for the use of measuring PC distance in patients with FNP as an additional tool for the overall assessment of soft tissue contraction following FNP. It may help identify patients in whom further lower eyelid margin shortening should be avoided and in whom eyelid lengthening may be required.

Lower eyelid lengthening in facial nerve palsy: when is a periosteal flap required?

BACKGROUND/AIMS: To present a case series of patients with facial nerve palsy (FNP) undergoing lower eyelid surgery where inadequate horizontal tarsal length was encountered and managed with a periosteal flap. METHODS: A two-centre retrospective, non-comparative case series of all patients with FNP who underwent lower eyelid periosteal flap procedures. Theatre records identified all such procedures performed by, or under the supervision of, one of two surgeons (RM, BCP) between November 2018 and November 2020. Outcome measures, including the Cornea, static Asymmetry, Dynamic function, Synkinesis grading score, were measured preoperatively and postoperatively. RESULTS: All 17 patients had undergone medial canthal tendon (MCT) plication. Six had previously undergone MCT plication then were listed for further lower eyelid surgery. In 11 cases, horizontal deficiency was encountered intraoperatively, immediately following MCT plication. Four patients were surgery-naïve. 94% were within the 'contraction phase' of FNP (ie, greater than 1-year duration); eight (45%) had previously undergone lower eyelid shortening procedures (such as lateral tarsal strip procedure, LTS). All patients had improved lower eyelid position postoperatively, although at 1-year postoperation, four patients require redo lower eyelid surgery. CONCLUSIONS: MCT plication and stabilisation appear to be closely linked to the need for lower eyelid lengthening procedures, particularly in patients who have also undergone LTS and/or those within the 'contraction phase' of FNP. Unnecessary loss of horizontal tarsal length (particularly during LTS procedures) must be avoided in patients with FNP. Surgeons managing such patients should take care to identify inadvertent eyelid shortening early and be prepared to perform a lateral periosteal flap when required.

Improvement in Epiphora Using TEARS Grading Following Surgical Treatment of Meibomian Gland Inversion in Patients With Facial Nerve Palsy.

PURPOSE: To assess epiphora outcomes using the TEARS grading score in patients with concomitant meibomian gland inversion (MGI) and facial nerve palsy (FNP) undergoing correction of MGI. METHODS: Retrospective, 5-year, noncomparative, single-center study of patients with MGI and FNP, treated with MGI correction, under the supervision of a single surgeon. A validated "TEAR" score was used to assess changes in epiphora. RESULTS: Ten patients with FNP, MGI, and epiphora were analyzed from a group of 160 patients with FNP who underwent MGI surgery between 2017 and 2022. The mean age at surgery was 50 years (range, 13-76 years). T, E, and A scores significantly improved (p < 0.05). Eighty percent of patients saw a reduction in tearing frequency (T), with 60% gaining ≥ 2-grade improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 80% of patients, with 40% and 50% gaining ≥ 2-grade improvement, respectively. R scores (related to reflex tearing) improved by 60%, with 40% seeing ≥ 2-grade improvement. Nine patients (90%) improved symptomatically with an average improvement "S" score of 65% over a mean follow-up period of 30 months. All patients demonstrated restoration of the normal anatomical position of the meibomian glands. CONCLUSIONS: MGI can cause epiphora in patients with FNP and may explain cases where symptoms persist despite standard surgical intervention. This study provides proof of concept that MGI correction can improve epiphora and that identifying MGI may be considered a critical step in the treatment algorithm for epiphora in patients with FNP.

Perifolliculitis mimicking basal cell carcinoma.

We present a case of a periocular painless perifolliculitis clinically mimicking basal cell carcinoma (BCC), excised by margin-controlled excision. This case reminds readers that perifolliculitis as a response to rosacea can mimic BCC. The value of diagnostic biopsy and dermoscopy to support management planning and avoid unnecessary surgery is discussed.

The Use of the Pericranial Periosteal Flap in Children for Treating Severe Lower Eyelid Retraction.

PURPOSE: To describe a surgical technique that can achieve significant lower eyelid elevation in severe retraction in children using a pericranial periosteal flap with skin graft. METHODS: A retrospective, single-center, case series of 3 consecutive pediatric cases are performed where a pericranial periosteal flap was used with a skin graft to manage severe lower eyelid retraction. Outcome measures include the extent of lower eyelid elevation (mm) and complications in the follow-up visits. RESULTS: Three children with severe lower eyelid retraction underwent the surgery. There were 2 boys and 1 girl with the mean age of 6.7 years (range, 5-8 years). The improvement of lower eyelid retraction was 3, 3, and 7 mm at 28, 24, and 6 months, respectively. No perioperative or postoperative complications occurred. CONCLUSIONS: Children with severe lower eyelid retraction often have a complex craniofacial and surgical history, and its surgical correction can be challenging. This case series present the successful use of pericranial flaps in treating severe lower eyelid retraction in children. The authors recommend this flap in children where traditional options have either failed or are not applicable.

Mucous membrane grafting for cicatricial entropion repair: review of surgical techniques and outcomes.

Mucous membrane graft (MMG) is used for moderate-to-severe cicatricial entropion repair either in primary or recurrent cases. We conducted a review to comprehensively summarize the various surgical techniques, outcomes, and complications of using MMG for cicatricial entropion. Though the comparison between different techniques is limited by multiple factors like small numbers of cicatricial entgropion patients, variable severity and success criteria across studies, and different underlying cicatricial entropion etiologies, the author has brought forth the nuances of the use of MMG for cicatricial entropion repair along with its outcomes and complications. MMG use in moderate-to-severe cicatricial entropion gives favourable outcomes. The shortened tarsoconjunctiva is lengthened using MMG, which is used either with terminal tarsal rotation or anterior lamellar recession (ALR) or tarsotomy alone. Non-trachomatous entropion has poor outcomes compared to trachomatous entropion. The most common source of MMG is labial or buccal mucosa and the exact size of MMG harvested is variable according to the defect, and very few prefer oversizing the graft by 10-30%. The outcomes of ALR+MMG appear similar to tarsal rotation and MMG for severe cicatricial entropion. The recurrences of trichiasis or entropion can occur for up to one year after surgery, irrespective of the technique used. Factors affecting the outcomes of cicatricial entropion repair are not well known. There is a non-uniformity in data reporting across literature; hence, future studies with details on severity of entropion, ocular surface changes, forniceal depth and ocular surface inflammation, and the degree of dry eye disease would be informative.

Delayed Optic Neuropathy Caused by Orbital Hyaluronic Filler Injection and Recovery Following Hyaluronidase Treatment.

A 26-year-old female presented with left enophthalmos following orbital floor and medial wall fracture despite surgical repair. She underwent further exploration and surgical repair but the enophthalmos persisted at 3-4 mm. Following discussion, she received 2 ml of hyaluronic acid filler injection into the posterior orbit and intraconal space. There were no immediate postoperative complications with normal optic nerve function, and the enophthalmos improved by 2 mm. The optic nerve function remained normal at the 4-week review. She returned 30 months following the injection with left periorbital edema, subjective red desaturation, and reduced peripheral visual field. On examination, there was a left relative afferent pupillary defect, disc pallor, and reduced visual field defect on automated visual field test. Following transcutaneous orbital injection of hyaluronidase, there was a subjective improvement in red desaturation with an improved peripheral visual field. Here the authors present a case of compressive optic neuropathy of delayed onset following orbital hyaluronic acid filler injection.

Pneumatization of the Greater Wing of Sphenoid Utilization for Lateral Wall Decompression.

The goal of orbital decompression for thyroid orbitopathy is to expand the orbital space for the contents with various techniques described. Deep lateral wall decompression is a procedure that expands the orbit by removing bone from the greater wing of sphenoid however its effectiveness is dependent on the volume of bone removed. Pneumatization of the greater wing of sphenoid is defined as an extension of the sinus beyond the VR line (a straight line crossing the medial edges of the vidian canal and the foramen rotundum) which is a demarcation between the sphenoid body and the lateral parts of the sphenoid bone, including the greater wings and pterygoid process. We present a case of complete pneumatization of the greater wing of sphenoid affording a greater volume of bony decompression in a patient with significant proptosis and globe subluxation as a result of thyroid eye disease.

Long-term outcomes of margin-controlled excision for eyelid melanoma.

OBJECTIVES: To provide evidence for long-term outcomes for margin-controlled excision of eyelid melanoma. METHODS: Retrospective single-centre observational case series of patients treated for eyelid melanoma between 2007 and 2016, with a minimum of 5-year follow-up. Tumour excision involved rush-paraffin en face horizontal sections and delayed repair (Slow Mohs; SM). RESULTS: Twenty-two cases were seen with a survival of 91% (two deaths from nodular and lentigo maligna melanoma) and seven with melanoma in situ (MIS). Invasive melanoma includes eight lentigo maligna melanoma, four nodular, two amelanotic and one desmoplastic. Mean Breslow thickness was 6 mm for invasive (range 0.5-26). Mean excision margin for MIS was 3 mm (range 2-5 mm) and for invasive was 5 mm (range 2-10). Further excisions were performed in nine (41%); two went on to recur. Local recurrence was 36%; six invasive (27%) at a mean of 24 months (range 1.5-5 years) and two for MIS at a mean of 15 months (range 1-1.5 years). Imaging occurred for suspected advanced disease. Sentinel node biopsy was not performed. Advanced melanoma therapy was performed in two cases. No vitamin D testing occurred. CONCLUSIONS: Survival rates are in line with 90% overall survival in the UK. Prescriptive excision margins are not applicable in the periocular region and margin-controlled excision with a delayed repair is recommended, but patients need to know further excision may be needed to obtain clearance. Evidence recommending vitamin D therapy needs to be put into clinical practice. In addition, upstaging of MIS occurred advocating excision rather than observation of MIS. More studies are needed to determine the best management of eyelid melanoma.