The Use of Hyaluronidase in Aesthetic Practice: A Comparative Study of Practitioner Usage in Elective and Emergency Situations.

BACKGROUND: Hyaluronic acids (HAs) continue to be the fillers of choice worldwide and their popularity is growing. Adverse events (AEs) are able to be resolved through the use of hyaluronidase (HYAL). However, routine HYAL use has been at issue due to perceived safety issues. OBJECTIVES: There are currently no guidelines on the use of HYAL in aesthetic practice, leading to variability in storage, preparation, skin testing, and beliefs concerning AEs. This manuscript interrogated the use of this agent in daily practice. METHODS: A 39-question survey concerning HYAL practice was completed by 264 healthcare practitioners: 244 from interrogated databases and 20 from the consensus panel. Answers from those in the database were compared to those of the consensus panel. RESULTS: Compared to the database group, the consensus group was more confident in the preparation of HYAL, kept reconstituted HYAL for longer, and was less likely to skin test for HYAL sensitivity and more likely to treat with HYAL in an emergency, even in those with a wasp or bee sting anaphylactic history. Ninety-two percent of all respondents had never observed an acute reaction to HYAL. Just over 1% of respondents had ever observed anaphylaxis. Five percent of practitioners reported longer-term adverse effects, including 3 respondents who reported loss of deep tissues. Consent before injecting HA for the possible requirement of HYAL was always obtained by 74% of practitioners. CONCLUSIONS: Hyaluronidase would appear to be an essential agent for anyone injecting hyaluronic acid filler. However, there is an absence of evidence-based recommendations with respect to the concentration, dosing, and treatment intervals of HYAL, and these should ideally be available.

Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections.

BACKGROUND: The pathogenesis of delayed-onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. OBJECTIVES: To formulate a rational theory for DTN development and their avoidance and treatment. METHODS: A multidisciplinary and multicountry DTN consensus panel was established, with 20 questions posed and consensus sought. Consensus was set at 75% agreement. RESULTS: Consensus was reached in 16 of 20 questions regarding the pathogenesis of DTNs, forming the basis for a classification and treatment guide. CONCLUSIONS: The group believes that filler, pathogens, and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen, if the skin barrier is altered. The initially high molecular weight HA filler is degraded to low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viremia or vaccination. Systemic pathogenic bacteremia may also interact with the filler peripheral LMWHA, activating Toll-like receptors that induce DTN formation. Given this scenario, attention to practitioner and patient hygiene and early systemic infection treatment deserve attention. Classification and treatment systems were devised by considering each of the 3 factors-filler, inflammation, and infection-separately.

Subbrow Blepharoplasty in Caucasians.

SUMMARY: Subbrow blepharoplasty is widely used in Asian patient populations to preserve the natural upper lid crease while addressing dermatochalasis with lateral hooding. The authors describe the first use of this technique in Caucasians with dermatochalasis and lateral hooding. This is a retrospective case series of Caucasian patients who underwent subbrow blepharoplasty for moderate to severe dermatochalasis with lateral hooding. Patients were included when the skin excess of the upper lid was noted predominantly as a lateral hooding over the lateral half of the upper lid. A modified subbrow blepharoplasty technique was used and will be described in detail. Fifty patients underwent the procedure from January of 2017 to June of 2018, 18 female and 32 male patients. The average age of the patients was 71.4 years (range, 59 to 84 years). Minimum patient follow-up was 3 months. An internal browpexy and a periosteal fixation were combined with subbrow blepharoplasty for 22 patients (14 men and eight women). Patient satisfaction with the result of the procedure and incision line were assessed. All 50 patients were satisfied with the surgical results. No patients noted any issues with the incision. No patients complained of incision problems, but the surgeon noted two patients with redness in the scar at 3 months that improved over a 12-month follow-up. Subbrow blepharoplasty may be an alternative to the classic upper lid blepharoplasty in older Caucasian patients, as it can address moderate to severe dermatochalasis with lateral hooding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparing the outcomes of severe versus mild/moderate ptosis using closed posterior levator advancement.

Traditionally, posterior eyelid surgical approaches such as Müller's muscle-conjunctival resection (MMCR) have been utilised with great success for mild cases of ptosis, with external levator approaches having been used for more severe cases of ptosis. We present a new technique which we label closed posterior levator advancement (CPLA) for the correction of all grades of ptosis. This article is a retrospective cohort study reviewing patients with mild, moderate, and severe ptosis over a 6-year period, treated by a single surgeon using CPLA. Minimum follow-up was 3 months. Patients with good levator function (levator palpebrae superioris (LPS) function >10 mm) without concomitant procedures were subdivided based on margin-to-reflex-distance-1 (MRD1) into mild-to-moderate ptosis (MRD1 > 1.5 mm) and severe ptosis (MRD1 ≤ 1.5 mm) cohorts. The outcome measures were preoperative and postoperative MRD1, lid contour, intereye symmetry, complications, and revision rates. 393 eyes of 313 patients were identified. 91 eyes in the mild-to-moderate cohort had a preoperative MRD1 of 2.38 mm, and 302 eyes in the severe cohort had a preoperative MRD1 of 0.27 mm. Postoperatively, MRD1 was 3.86 mm and 3.49 mm, respectively. There were no significant complications in both cohorts, and revision rates were 3.3% (3 of 91 eyes) in the mild-to-moderate and 2% (6 of 302 eyes) in the severe cohorts. Upper-eyelid contour was satisfactory in 98.2% of eyes, and 97.5% intereye symmetry within 1 mm was observed. Our results show an effective correction of all ptosis grades with satisfactory cosmetic outcomes and low complication and revision rates.

Closed Posterior Levator Advancement in Severe Ptosis.

BACKGROUND: Repair of blepharoptosis from the posterior eyelid approach has usually been done utilizing a Müller's muscle-conjuctival resection (MMCR) or an "open sky" technique. We present a new technique to advance the levator muscle from the posterior-approach in a closed fashion that can be used in patients with severe involutional ptosis. METHODS: A retrospective chart review was performed for consecutive patients with severe involutional blepharoptosis during a 6-year period treated by a single surgeon with a Closed Posterior Levator Advancement. The inclusion criteria were good levator function (≥ 10 mm), graded response to phenylephrine (change in lid height, 0-5 mm), and no concomitant procedures. Severe involutional blepharoptosis was defined as a margin-to-reflex-distance-1 (MRD1) of ≤ 1.5 mm. Follow-up for all patients was a minimum of 9 months. The main outcome variables were MRD1, upper eyelid contour, intereye symmetry, and reoperation rates. RESULTS: Three hundred three eyes from 192 patients, with severe ptosis were identified. The average age was 65 years, and the mean preoperative MRD1 was 0.3 mm. Postoperatively, mean MRD1 was 3.5 mm with a median improvement of 3.2 mm. The upper eyelid contour was deemed to be satisfactory by patient and surgeon in 98.3% of eyes. Intereye symmetry was excellent in 96% of our cohort. An overall revision rate of 1.8% was found. CONCLUSIONS: We present a new technique that involves an advancement of the levator muscle in a closed posterior eyelid approach. The technique has produced satisfactory outcomes in our cohort of patients with severe ptosis with a low revision rate.

Association of Polymorphisms in MACRO Domain Containing 2 With Thyroid-Associated Orbitopathy.

PURPOSE: Thyroid-associated orbitopathy (TO) is an autoimmune-mediated orbital inflammation that can lead to disfigurement and blindness. Multiple genetic loci have been associated with Graves' disease, but the genetic basis for TO is largely unknown. This study aimed to identify loci associated with TO in individuals with Graves' disease, using a genome-wide association scan (GWAS) for the first time to our knowledge in TO. METHODS: Genome-wide association scan was performed on pooled DNA from an Australian Caucasian discovery cohort of 265 participants with Graves' disease and TO (cases) and 147 patients with Graves' disease without TO (controls). Top-ranked single nucleotide polymorphisms (SNPs) then were genotyped in individual DNA samples from the discovery cohort, and two replication cohorts totaling 584 cases and 367 controls. RESULTS: In the GWAS of pooled DNA samples, several SNPs showed suggestive association with TO at genome-wide P ≤ 10-6; rs953128 located on chr10q21.1, rs2867161 on chr7q11.22, rs13360861 on chr5q12.3, rs7636326 on chr3q26.2, rs10266576 on chr 7q11.22, rs60457622 on chr3q23, and rs6110809 on chr20p12.1. However, the only SNP consistently associated with TO on individual genotyping in the discovery and replication cohorts was rs6110809, located within MACROD2 on chromosome 20p12.1. On combined analysis of discovery and replication cohorts, the minor A allele of rs6110809 was more frequent in TO than in Graves' disease controls without TO (P = 4.35 × 10-5; odds ratio [OR] = 1.77; 95% confidence interval [CI], 1.35-2.32) after adjusting for age, sex, duration of Graves' disease, and smoking. CONCLUSIONS: In patients with Graves' disease, a common genetic variant in MACROD2 may increase susceptibility for thyroid-associated orbitopathy. This association now requires confirmation in additional independent cohorts.

Bilateral lacrimal gland disease: clinical features of 97 cases.

OBJECTIVE: Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. DESIGN: Case series. PARTICIPANTS: Ninety-seven patients with bilateral LG disease. METHODS: Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. MAIN OUTCOME MEASURES: Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. RESULTS: Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease. CONCLUSIONS: The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%.

Oculofacial contour asymmetries: Management of combined treatment with hyalurostructure and botulinum toxin injections.

PURPOSE: To assess the long-term results of the treatment of oculofacial asymmetries using a combined injection schedule for injections of hyaluronic acid, with a specific micro cannula and botulinum toxin. METHOD: A retrospective study was conducted from January 2009 to January 2010. Patients were treated in the Alcazar Eye Clinic and Oculoplastic Department in Princess Grace Hospital, Monaco. We selected patients complaining of asymmetrical periorbital features who received treatment with hyalurostructure and botulinum toxin injection in one or more sessions. Nine patients were selected and presented with the following symptoms: asymmetry of eyebrow position (2 patients), superior orbital hollow (2 patients), tear trough (2 patients) and orbital volume (ocular prosthesis) (3 patients). The objective was to evaluate the efficiency of combined treatment in one or more sessions on these oculofacial asymmetries. Hyaluronic acid injections were done using hyalurostructure. Hyaluronic acid gel (Restylane Lidocaine) was used with a 25 gauge reinforced micro-cannula (pix'l +, Thiebaud). This was combined with injections of botulinum toxin (azzalure*) to areas of muscular hyperaction. Follow-up was done at 1 year by clinical examination, photography and patient satisfaction. Complications of this combined treatment have been identified. RESULTS: At 1-year follow-up, 88% of patients were satisfied or very satisfied with their results. There were no more complications secondary to both treatments in the same session. It was not noticed more hematomas and bruises than in classical injection method. The action of toxin is constant over time despite the association of hyaluronic acid injections. CONCLUSION: Combined treatments with toxin and hyaluronic acid in oculofacial asymmetries are efficient and can be proposed in the same session. These treatments must be repeated to maintain and optimize muscle contraction and volume loss. Use of hyalurostructure and botulinum toxin treatment in the same session is effective and safe.

Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series.

OBJECTIVE: To present our experience of early endonasal DCR (endoDCR) in the treatment of acute dacryocystitis (AD). Methods. International multicenter non-comparative retrospective study. RESULTS: Eighteen patients were identified. All were treated with antibiotics prior to surgery with a median of time from referral to endoDCR surgeon to surgery of 3 days (range 1-7). Surgery was performed using mechanical powered endoDCR (MENDCR) in 15/18 (83.3%) cases; mitomycin C was used in 5/18 (27.8%) and all cases underwent bicanalicular intubation. An increase in perioperative bleeding was noted in 5/18 (27.8%), causing interference in surgical technique in one (5.6%). Resolution of AD was seen in all cases, with no recurrences. 17/18 (94.4%) cases were free of epiphora at median follow-up of 12 months (range 2-36), with nasal endoscopy revealing free flow of fluorescein through the ostium in 17/18 (94.4%) of cases. The median total length of stay was 1 night (range 0-3). CONCLUSIONS: EndoDCR surgery performed early in AD led to rapid resolution of the condition in all cases and was associated with subsequent anatomical and functional success in 94.4% of cases. Early endoDCR surgery in the context of AD and the potential associated health economic benefits are worth further consideration and study.

Rare dural arteriovenous fistula of the lesser sphenoid wing sinus.

A fistula of the lesser sphenoid wing sinus is a rare dural arteriovenous fistula resulting from a connection between the middle meningeal artery and recipient vein in the sinus of the lesser sphenoid wing. In this report, MRI/magnetic resonance angiography of a 54-year-old man who presented with sudden-onset glaucoma and proptosis revealed a fistula in this anatomic location. Drainage patterns here may account for the absence of serious complications and optimistic prognosis following embolization. Care in diagnosis is required to avoid superfluous procedures, because classic signs of the more common carotid-cavernous fistula are absent.

Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique.

OBJECTIVE: To identify components of a provisional clinical response index for thyroid eye disease using a modified Delphi technique. METHODS: The International Thyroid Eye Disease Society conducted a structured, 3-round Delphi exercise establishing consensus for a core set of measures for clinical trials in thyroid eye disease. The steering committee discussed the results in a face-to-face meeting (nominal group technique) and evaluated each criterion with respect to its feasibility, reliability, redundancy, and validity. Redundant measures were consolidated or excluded. RESULTS: Criteria were parsed into 11 domains for the Delphi surveys. Eighty-four respondents participated in the Delphi 1 survey, providing 220 unique items. Ninety-two members (100% of the respondents from Delphi 1 plus 8 new participants) responded in Delphi 2 and rated the same 220 items. Sixty-four members (76% of participants) rated 153 criteria in Delphi 3 (67 criteria were excluded because of redundancy). Criteria with a mean greater than 6 (1 = least appropriate to 9 = most appropriate) were further evaluated by the nominal group technique and provisional core measures were chosen. CONCLUSIONS: Using a Delphi exercise, we developed provisional core measures for assessing disease activity and severity in clinical trials of therapies for thyroid eye disease. These measures will be iteratively refined for use in multicenter clinical trials.

Nonsurgical management of congenital eyelid malpositions using hyaluronic Acid gel.

PURPOSE: To report our preliminary experience using hyaluronic acid gel fillers as a nonsurgical alternative in the management of congenital eyelid malpositions. METHODS: In this retrospective interventional case series, 5 patients (10 eyes) with congenital eyelid malpositions, including eyelid retraction, ectropion, euryblepharon, epiblepharon, and abnormalities associated with a shallow orbit, with resultant lagophthalmos and/or keratopathy and tearing were evaluated before and after injection with hyaluronic acid gel (Restylane) in the pretarsal and/or septal regions of the affected eyelid(s). Pretreatment, posttreatment, and follow-up photographs were analyzed for eyelid position and degree of eyelid closure and lagophthalmos, and slit-lamp evaluation of the degree of keratopathy. RESULTS: All 5 patients demonstrated significant improvement of eyelid position and degree of keratopathy. The mean improvement in lagophthalmos was 4.5 mm (range, 2-7 mm). The average volume of hyaluronic acid gel used was 0.5 ml per eyelid. Complications were minor, including transient edema and ecchymosis at the sites of injection. Of the 10 eyelids injected, only one had increased astigmatism after injection. CONCLUSIONS: Hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of certain eyelid malpositions, disorders traditionally requiring surgical intervention if aggressive ocular lubrication fails. This treatment is particularly useful in such patients who are commonly premature with poor general health and serves as a temporizing measure by allowing the much needed tissue expansion to take effect over time.

Use of hyaluronic Acid gel in the management of paralytic lagophthalmos: the hyaluronic Acid gel "gold weight".

PURPOSE: To evaluate the safety and efficacy of injecting hyaluronic acid gel in the upper eyelid as a nonsurgical alternative in the treatment of paralytic lagophthalmos. METHODS: This is a retrospective study of 9 patients (10 eyelids) with paralytic lagophthalmos treated with hyaluronic acid gel in the prelevator aponeurosis region and/or pretarsal region of the paralytic upper eyelid. Pretreatment, posttreatment, and follow-up photographs were digitized, and overall outcomes assessed. Measurements of lagophthalmos were standardized and compared. Slit-lamp examination was used to evaluate the degree of exposure keratopathy. ImageJ was used for photographic analysis. RESULTS: Ten eyelids (9 patients, 7 men; mean age 69.2 years; range, 31-90 years) with paralytic lagophthalmos were treated with hyaluronic acid gel. The average amount of injected hyaluronic acid gel was 0.9 ml (range, 0.2-1.2 ml). All patients demonstrated significant improvement in lagophthalmos and exposure keratopathy. The mean improvement in lagophthalmos was 4.8 mm (range, 0.9-11.9 mm; p = 0.001). Of the 5 patients with follow-up, the mean follow-up period was 3.6 months (range, 2-5 months). Of these, 2 had no change in lagophthalmos (both maintained 0 mm at 5 months), one had a slight decrease in lagophthalmos (4.8-4.6 mm at 2 months), one had a slight increase in lagophthalmos (0.3-0.5 mm at 2 months), and one had a more significant increase in lagophthalmos (1.9-4.3 mm at 4 months). The latter patient underwent a second treatment with further reduction of lagophthalmos to 0.4 mm. Overall, there was a decrease in margin reflex distance from the upper eyelid margin to the corneal light reflex (MRD1) but it was not statistically significant. Complications were minor and included transient ecchymosis, edema, and tenderness at the injection sites. CONCLUSIONS: On the basis of these preliminary results, hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of paralytic lagophthalmos. This treatment may be particularly useful in patients who are poor surgical candidates and/or as a temporizing measure in patients in whom return of facial nerve function is anticipated, given the hyaluronic acid gel's properties of slow resorption and reversibility with hyaluronidase.

Reactivation of thyroid-associated orbitopathy after cataract surgery.

BACKGROUND: We describe an episode of thyroid-associated orbitopathy (TAO) following sequential bilateral cataract surgery. CASE: We report the case of an 80-year-old woman who developed TAO in 2000. OBSERVATIONS: After an episode of mild TAO, the patient's condition was stable and quiescent for 4 years. Following cataract surgery on her right eye in 2004, there was rapid worsening of the TAO bilaterally that lasted approximately 12 months. Her condition then stabilized for 2 years. In 2007, she had cataract surgery on the left eye and the TAO again worsened bilaterally. CONCLUSION: Cataract surgery may lead to recrudescence of TAO in predisposed individuals.

Biologic therapeutics in thyroid-associated ophthalmopathy: translating disease mechanism into therapy.

Graves' disease (GD) is a systemic autoimmune disease which targets the thyroid, orbit, and skin. Thyroid-associated ophthalmopathy (TAO) refers specifically to the orbital and periorbital manifestations of GD. Several important concepts have emerged from our enhanced understanding of the molecular mechanisms of the disease. Considerable debate remains concerning the specific identity and roles of inflammatory T-cell subsets, soluble and contact-mediated signalling, and autoantigens driving TAO. However B and T lymphocytes appear central in the process through production of disease mediators including activating autoantibodies to the thyrotropin receptor and insulin-like growth factor-1 receptor; cytokines including IL-1beta, IL-6, and IL-16; and chemokines including RANTES. Many of these molecules appear central to the inflammation, accumulation of extracellular matrix macromolecules, and fibrosis in the disease. Novel therapeutics targeting other autoimmune diseases may provide an opportunity for disrupting disease pathogenesis. It is imperative that agents targeting B-and T-cell functions be further evaluated in the treatment of aggressive forms of TAO utilizing multicenter clinical trials that allow adequate statistical power and sample size.

The hydrogel lacrimal stent for dacryocystorhinostomy: preliminary experience.

PURPOSE: To present the results of dacryocystorhinostomy with the use of a newly designed hydrogel lacrimal stent for repair of acquired nasolacrimal duct obstruction. METHODS: Noncomparative interventional case series. Twenty-three cases of acquired nasolacrimal duct obstruction confirmed by probing and irrigation underwent dacryocystorhinostomy using the hydrogel lacrimal stent. Tearing symptoms, functional endoscopic dye test, and anatomic appearance of ostia were noted at follow-up. RESULTS: Five of 23 ostia closed during the postoperative period (1-3 months), translating to a late success rate of 78.3%. The 5 failed cases were treated successfully with ostium revision, 1 case requiring 2 revisions. All patients had endoscopic follow-up with a minimum follow-up of 6 months after stent removal. In the successful cases we noted a large, quiet ostium with good separation of the nasal septum and middle turbinate. Eleven cases (47.8%) had history of previously failed dacryocystorhinostomy surgery, chronic sinusitis, deviated septum, or maxillofacial surgery. There were no complications or reports of unusual pain or symptoms associated with the stent itself. CONCLUSIONS: Early experience suggests the hydrogel lacrimal stent is a well-tolerated, effective tool for dacryocystorhinostomy surgery after acquired nasolacrimal duct obstruction. The device may serve as a useful surgical tool by holding open the ostium, maintaining apposition of the mucosal edges, and decreasing the incidence of nasal adhesions.

Feasibility study of intraocular robotic surgery with the da Vinci surgical system.

PURPOSE: To assess the feasibility of performing intraocular robotic surgery with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). METHODS: Using modified robotic instruments, 25-gauge pars plana vitrectomy, intraocular foreign body removal, and anterior capsulorhexis were performed with the da Vinci system on porcine eyes. We assessed the surgical system's ability to provide the control, dexterity, maneuverability, and visualization necessary for intraocular surgery. RESULTS: Control of the robotic wristlike instruments allowed for full range of movement. The dexterity of the robotic arms was excellent, with steady instrument motion. Controlling the robotic arms was not as intuitive as moving the wrist. A high stable point of rotation induced motion-related stress at the site of instrument insertion. Visualization of the external operative field during intraocular procedures required camera realignment, and absent retroillumination made anterior segment surgery hard to perform. CONCLUSIONS: The da Vinci Surgical System provided adequate dexterity for performing delicate intraocular manipulations. In the current design, the kinematics of the robotic arms was found to be insufficient for standard intraocular surgery. The system's endoscope did not did not yield the same detail acquired by an ophthalmic microscope.

Autologous dermis graft at the time of evisceration or enucleation.

AIM: To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised. METHODS: A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications. RESULTS: Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site. CONCLUSIONS: This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.

Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic Acid gel.

PURPOSE: To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel. METHODS: Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared. RESULTS: Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection. CONCLUSIONS: Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.

Thiazolidinedione induced thyroid associated orbitopathy.

BACKGROUND: To describe an episode of thyroid associated orbitopathy (TAO) following the initiation of thiazolidinedione (TZD). CASE PRESENTATION: We report a female patient with a history of Graves' disease and stabilised thyroid associated orbitopathy for 2.5 years, who experienced rapid progression of TAO after the initiation of thiazolidinedione for glycemic control. Following the discontinuation of TZD, the patient experienced subsequent stabilisation of disease and normalization of vision. The medical history, ophthalmic findings, and clinical course are discussed. CONCLUSION: Thiazolidinediones may exacerbate TAO, and this should be taken into consideration when selecting treatment for diabetic patients with a history of autoimmune thyroid disorders.