Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial.

PURPOSE: Pilot studies suggest that waiting 15 minutes after a subcutaneous tranexamic acid injection is associated with decreased intraoperative bleeding and postoperative ecchymosis in eyelid surgery. The outcomes of commencing eyelid surgery immediately after injection without a waiting period remain unexplored. METHODS: This prospective, randomized, multicenter, double-masked, controlled study examined bilateral symmetric upper and/or lower lid blepharoplasty or ptosis repair. Patients received tranexamic acid in 1 eyelid and control in the contralateral eyelid. The surgeon recorded the side with more intraoperative bleeding. Two masked graders evaluated periocular ecchymosis at postoperative day 0 and postoperative week 1 (POW 1) with a 5-point scale. At POW 1, patients reported subjective grading of bruising as increased on 1 side or similar on both sides. Results were analyzed with Wilcoxon signed-rank and sign tests. RESULTS: Of 130 patients, there was less eyelid ecchymosis on the tranexamic side at postoperative day 0 ( p = 0.001) and POW 1 ( p < 0.001). By surgery type, the 69 levator advancement surgeries had significantly less ecchymosis at postoperative day 0 ( p < 0.001) and POW 1 ( p = 0.001), while upper eyelid blepharoplasty, combined upper and lower lid blepharoplasty, and conjunctivomullerectomy trended toward significance. Of 68 patients reporting a POW 1 grading, 69% reported less bruising on the tranexamic side ( p < 0.001). Intraoperative bleeding was not significantly different between sides ( p = 0.930). CONCLUSIONS: Without a postinjection waiting period, subcutaneous tranexamic acid for eyelid surgery significantly decreased postoperative ecchymosis on postoperative day 0 and POW 1 but did not affect intraoperative bleeding. Subcutaneous tranexamic acid was not associated with any complications.

Pigmented Squamous Cell Carcinoma In Situ of the Eyelid.

This case report describes a diagnosis of pigmented squamous cell carcinoma in situ in a female patient aged 61 years who presented with a pigmented lesion on her medial canthus that had been growing over a 2-year period.

Tendon-Sparing Extraocular Muscle Enlargement Associated With Chronic Inflammatory Demyelinating Polyradiculoneuropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory, sensorimotor polyneuropathy. It has presented with a variety of orbital and neuro-ophthalmic manifestations, including cranial nerve hypertrophy and a single case of extraocular muscle enlargement. The authors present a second case of tendon-sparing, extraocular muscle enlargement, resulting in new-onset diplopia and strabismus in a teenager with CIDP. The workup ruled out alternative causes of extraocular muscle enlargement, such as hyperthyroidism, inflammation, or malignancy. As with other cases of CIDP, management involved a combination of immunoglobulin therapy and anti-inflammatory medications. The patient experienced resolution of his symptoms, and radiologic improvement was noted in the muscle enlargement. As many CIDP patients have a favorable treatment response and long-term prognosis, awareness of this rare disease with an early and accurate diagnosis is important.

Socioeconomic Disparities Associated with Access to Oculofacial Plastic Surgeons: A Cross-Sectional Analysis of US County Demographics.

PURPOSE: To compare population demographics with the geographic distribution of oculofacial plastic surgeons (OPSs) in the United States. DESIGN: A cross-sectional study design was used to investigate demographic differences between counties with 1 or more OPSs and counties with zero OPSs. PARTICIPANTS: The number of OPSs were identified in each US county using online public databases: American Society of Ophthalmic Plastic and Reconstructive Surgeons and American Academy of Ophthalmology. Counties were categorized into 2 groups: 1 or more OPSs and zero OPSs. Demographic characteristics at the county level were obtained from the 2021 US Census Bureau Population Estimates and the American Community Survey. Cost of living was collected from the 2022 Economic Policy Institute Family Budget Calculator. MAIN OUTCOME MEASURES: Socioeconomic demographics of the US population as related to geographic OPS distribution. RESULTS: A total of 1238 OPSs were identified. States with the most OPSs per million were Hawaii (6.2), D.C. (6.0), Connecticut (5.8), Utah (5.1), and Maryland (5.0). Among 3143 counties, 2725 (86.7%) had zero OPSs and 418 (13.3%) had 1 or more OPSs. Counties with 1 or more OPSs had a higher median (standard deviation) household income versus counties with zero OPSs ($72 471 [$19 152] vs. $56 152 [$13 675]; difference $16 319; 95% confidence interval [CI], $14 300-$18 338; P < 0.001). The annual cost of living per person (standard deviation) was higher in counties with 1 or more OPSs versus counties with zero OPSs ($39 238 [$6992] vs. $36 227 [$3516]; difference $3011; 95% CI, $2328-$3694; P < 0.001). Counties with zero OPSs versus counties with 1 or more OPSs had higher proportions of persons with only Medicaid (15.6% vs. 13.6%; difference 2.0%; 95% CI, 1.4%-2.5%; P < 0.001), no health insurance (9.9% vs. 8.0%; difference 1.9%; 95% CI, 1.5%-2.4%; P < 0.001), no household internet access (17.2% vs. 9.6%; difference 7.6%; 95% CI, 7.1%-8.0%; P < 0.001), and higher proportions of persons aged 65 years or older (20.0% vs. 17.0%; difference 3.0%; 95% CI, 2.5%-3.5%; P < 0.001). CONCLUSIONS: This cross-sectional analysis of all US counties revealed socioeconomic disparities associated with access to OPSs. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Pseudocholinesterase deficiency in ophthalmology: a systematic review.

PURPOSE: Unexpected anesthesia-related complications are among the most feared outcomes of ambulatory surgery. One potential culprit is pseudocholinesterase deficiency, which most commonly presents with protracted apnea, necessitating prolonged mechanical ventilation. We report the first case of pseudocholinesterase deficiency in a Bengali person and the first systematic review of pseudocholinesterase deficiency in ophthalmology. This review analyzed the epidemiology, etiologies, presentation, evaluation, and treatment of pseudocholinesterase deficiency. METHODS: Searches were conducted in PubMed, Embase, and Medline through August of 2022 for publications related to pseudocholinesterase deficiency in ophthalmology. In total, 689 studies were screened by two independent reviewers with 26 full-text articles examined for inclusion eligibility. Nineteen studies were eligible and included in the final analysis. RESULTS: Of the 16 identified cases of pseudocholinesterase deficiency, nine (56%) were drug-induced, four (25%) were inherited deficiencies, and in one (6%) of the cases, the cause could not be determined. In two (13%) cases, pseudocholinesterase deficiency could not be confirmed or ruled out. The duration of post-operative apnea ranged from 10 minutes to 14 hours. Continued ventilatory support was the main treatment for all cases and all patients made a full recovery. CONCLUSIONS: Pseudocholinesterase deficiency is a rare, but potentially fatal, anesthetic complication that results in prolonged apnea, respiratory distress, and dependency on ventilators. Ophthalmologists should remain aware of this condition, especially when planning outpatient procedures, as ambulatory centers may have limited resources for managing prolonged post-operative complications.

Implantable Electronic Cardiovascular Device Complications Related to Electrocautery During Ophthalmology Surgery: A Systematic Review.

PURPOSE: Implantable electronic cardiovascular device such as cardiac pacemakers and implantable defibrillators are common life-saving devices. Device-related complications can arise when undergoing surgical interventions with electrosurgical tools due to electromagnetic interference, based on electrocautery type, implantable electronic cardiovascular device type, electrocautery location, and a number of other factors. The risk of device-related complications due to electrocautery in oculoplastic surgery has not been established. This systematic literature review assesses prevalence, risk factors, and outcomes of electrocautery-related device complications in oculoplastic surgery. METHODS: Systematic literature review followed Preferred Reporting Items for Systematic and Meta-Analysis guidelines and used the search terms "pacemaker," "implantable cardioverter defibrillator," "electrocautery," "cautery," and "electrosurgery" through June 2022. Inclusion criteria were full-text articles, discussing ocular, oculoplastic, or other facial surgery. Exclusion criteria were non-English language or surgery focused on other parts of the body. Full-text manuscripts of identified articles were reviewed and relevant data were extracted. RESULTS: Twelve studies met inclusion criteria. Two studies were level I and II evidence, while 10 studies were level III or IV. There were no reports of electromagnetic interference with bipolar cautery use. With monopolar cautery use, cases of electromagnetic interference were reported, but without related significant morbidity or mortality. Safety recommendations to minimize electrical flow through the implantable electronic cardiovascular device are described. CONCLUSIONS: There were no reports of implantable electronic cardiovascular device-related complications from bipolar or thermocautery use in ophthalmic or oculoplastic surgeries. Monopolar have been associated with electromagnetic interference, but additional preoperative and perioperative measures can be taken to mitigate this risk.

Skin Color Representation in Ophthalmology Textbooks.

Objective: Inadequate diversity in dermatologic images has been associated with diagnostic delays and poorer health outcomes. This underrepresentation of darker skin tones has also been demonstrated across various fields of medicine, including rheumatology, urology, and in the COVID-19 pandemic. The distribution of skin tones has not been examined in educational ophthalmology texts. The authors aimed to quantify the representation of skin tones across three leading ophthalmology textbooks. Methods: Two independent investigators utilized the Fitzpatrick's skin phototype scale to code images containing skin as either "light" (Fitz. I-IV) or "dark" (Fitz. V-VI) in three fundamental ophthalmology textbooks: Clinical Ophthalmology (Salmon and Kanski), Ophthalmology (Yanoff and Duker), and the 13 Basic and Clinical Science Course texts by the American Academy of Ophthalmology. Images without discernible skin color were excluded. Results: Of the 9766 images reviewed, 2305 images met inclusion criteria. The three textbooks combined were found to have 2123 (92.1%) images of light skin tones and 182 images (7.9%) of dark skin tones. When compared to national data that found 12.6% of individuals to have dark skin tones, the proportion of images with darker skin tones in ophthalmology textbooks was statistically significantly lower (χ 2 corr(1, N = 4996) = 211.7, p < 0.001). Conclusions: Darker skin tones are statistically significantly underrepresented in textbooks that are central to education of trainees in ophthalmology. Acknowledgement and inclusion of skin tone diversity in ophthalmology educational materials are necessary to ensure that physicians in the field are equipped with the knowledge and training to provide the highest level of care to all patients. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01636-4.

Orbital Index: A Novel Comprehensive Quantitative Tool for Prediction of Delayed Enophthalmos in Orbital Floor Fracture Management.

SUMMARY: Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. However, identifying those at risk for delayed enophthalmos and requiring subsequent repair has remained a challenge. This study aimed to validate the Orbital Index, a prediction tool using computed tomography to stratify risk for delayed enophthalmos and establish a threshold for repair. The Orbital Index stratifies fractures by size, location, and inferior rectus rounding (a surrogate for fascioligamentous sling disruption) on a scale 0 to 6. A 22-year (1998 to 2020) multi-institution analysis of unilateral isolated orbital floor fractures was performed. Index scores were assigned to each scan, unoperated patients invited for blinded Hertel exophthalmometry assessment, and enophthalmos measurements correlated with Index scores. Interobserver scoring reproducibility was assessed with weighted Cohen kappa. Preintervention and postintervention Likert scale surveys were administered to determine whether this tool improved understanding and communication. The Orbital Index demonstrated high fidelity and interobserver reproducibility and identified a score of four or greater as a surgical threshold. Of 1769 computed tomography scans, 395 met criteria and were included for analysis. Eighty of 395 were managed operatively (operative rate, 20.3 percent). Of 315 patients managed nonoperatively, 41 (13.0 percent) agreed to follow-up evaluation and 28 (68.3 percent) were found to have enophthalmos. Unoperated patients with an Orbital Index score of 4 or higher were more likely to have enophthalmos than those with a score of 3 or less ( p = 0.001). The mean weighted Cohen kappa was 0.73, corroborating reproducibility. Communication ( p = 0.0003) and ability to correctly identify surgical need ( p = 0.01) were improved with use of this tool. The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.

#Oculoplastics: An Analysis of TikTok's Top Oculoplastics Content.

PURPOSE: To analyze the source and quality of oculoplastics-related content on TikTok, a popular social media platform. METHODS: Twenty-five oculoplastics-related hashtags were queried. The top 20 videos for each hashtag were included. The number of views, likes, comments, and shares were recorded for each video. Each video was also categorized by the account owner and by video content characteristics. A subanalysis of the educational videos was conducted using the mDISCERN, Patient Education Materials Assessment Tool, and modified MICI scores to assess video quality, understandability and actionability, and medical accuracy, respectively. RESULTS: The included 386 videos amassed 218,997,134 views, 15,033,220 likes, 148,099 comments, and 276,445 shares. Patients were the leading content creators (38.1%), followed by nonophthalmology MDs/DOs (25.6%), and oculoplastic surgeons/ophthalmologists (16.3%). Physician-created videos received more visibility than nonphysician-created videos (median of 23,600 views and 22 shares), though this did not reach statistical significance. However, oculoplastic surgeon-posted content received the lowest median views and shares. The video category that amassed the most views was "live procedure/surgeries," followed by "educational" and "patient experience." Subanalysis of 46 educational videos revealed physicians were the chief creators, accounting for 67.4% of all educational videos. Physician-created content demonstrated statistically significant better understandability and actionability, as measured by the Patient Education Materials Assessment Tool ( p = 0.0053). CONCLUSION: Physicians play an important role in disseminating evidence-based medicine on social media. While oculoplastics-related TikTok videos are gaining traction, additional research is needed to improve the visibility of oculoplastic-surgeon posted content.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports.

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

Impact of the COVID-19 Pandemic on Quantity and Characteristics of Ophthalmology Consults.

Purpose: To assess the COVID-19 exposure risk to consulting ophthalmologists and the pandemic effect on consultations at one of the most impacted hospital systems in New York. Methods: In a retrospective, cross-sectional study, ophthalmology consult notes and COVID-19 test results were collected from the electronic medical record from February to May in 2019 and 2020. Results: Of 2,215 total notes analyzed, consults decreased from 1,374 to 841 between years (p = 0.0002). In 2020, 22.5% of all consults were COVID tested and 2.4% were positive within 2 weeks of in-person evaluation. In 2020, 1.8% of consults were electronic. Ventilated patients increased between years (7.5% to 10.8%; p = 0.04). Conclusions: Although consultations decreased during the Spring 2020 peak, the majority (98.2%) remained as in-person evaluations. While few patients tested COVID positive, this likely reflects the limited availability of testing early in the pandemic. Consulting ophthalmologists remained at high risk of COVID-19 exposure during the pandemic peak.

#OculoplasticsandSocialMedia: a review of social media in oculoplastics and relevant subspecialties.

The permeation of social media into life almost goes without bounds and medicine is no exception. While social media holds great potential for physicians and medicine, it also comes with concurrent spread of disinformation. This increases the importance of evidence-based information from qualified physicians on social media.Although the definition of social media is broad, in general, it refers to the use of web-based platforms to connect one human to another. In oculoplastic surgery, these relationships can be physician to physician, physician to patient, patient to patient, and vendor to physician. These relationships mostly involve education, social support, and advertising, but can also include research and government advocacy. The purpose of this review is to evaluate the current utilization of social media in oculoplastic surgery and relevant subspecialties.

Shared Decision Making in Ophthalmology: A Scoping Review.

PURPOSE: Shared decision making (SDM) has been associated with improved patient satisfaction and outcomes in both medical and surgical specialties, but its role in ophthalmology has not been systematically examined. Using a scoping review of the literature, the purpose of this study was to explore the characteristics, implementation, and outcomes of SDM in ophthalmology. DESIGN: Scoping review of the literature. METHODS: Searches were conducted in PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through August 2021 for SDM in ophthalmology. The resulting 1602 studies were screened by 2 independent reviewers with 57 full-text articles examined for inclusion of an ophthalmologic diagnosis, as well as discussion of SDM or patient decision aids. Nineteen studies were eligible and qualitatively coded for 11 predetermined codes, which included patient outcomes, patient and physician requests for SDM, and methods of implementation. RESULTS: Of 19 included studies, all emphasized the value of SDM for ophthalmology and 2 studies reported improved patient outcomes. The most commonly examined topics were chronic ophthalmic diseases, such as cataracts and glaucoma. Limitations to SDM implementation were also universally discussed, including patients' lack of disease knowledge, communication barriers, and time restrictions. Although patient decision aids are an effective tool to mitigate these limitations, these have only been established for the subjects of cataracts and glaucoma. CONCLUSION: SDM is a methodology for patient-centered care that is regarded as a potentially useful tool in the field of ophthalmology. However, significant barriers exist to its effective implementation. Evidence-based research on if and how these barriers should be attenuated, as well as the development of additional patient decision aids for different ophthalmic diseases, are needed.

Expanding Understanding of Thyroid Eye Disease Manifestations to Include Hispanic and Black Patients.

PURPOSE: Knowledge of thyroid eye disease (TED) is based on predominantly Caucasian populations. To date, no studies in the United States examine the presentation in Black and Hispanic patients. The purpose of this study is to introduce the presentation of TED in two previously undescribed populations. METHODS: This is a retrospective, cross-sectional, chart review study of patients with TED at a tertiary center using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. The main outcome measure for severity was the European Group on Graves' Orbitopathy 2016 Severity Scale. RESULTS: Of the 2905 charts reviewed, 99 met the inclusion criteria. The mean age was 51 (standard deviation 16) years with 78% women. Race was 49.4% Black, 39.1% Hispanic, 9.2% Caucasian, and 2.3% Asian. Smoking rates were 25% current smokers and 14% former smokers. Manifestations were proptosis (94% Hispanic and 91% Black), eyelid retraction (85% Hispanic and 79% Black), extraocular muscle (EOM) restriction (79% Hispanic and 63% Black), eyelid edema (41% Hispanic and 30% Black), chemosis (24% Hispanic and 14% Black), and optic neuropathy (18% Hispanic and 9% Black). Overall, disease severity was 22% mild, 65% moderate to severe, and 13% sight-threatening. Older patients had increased rates of optic neuropathy (P = 0.04). Younger patients had increased rates of proptosis (P = 0.02). Socioeconomic status was not associated with disease severity (P = 0.67). CONCLUSION: Hispanic and Black patients with TED presented with higher than previously established rates of proptosis, EOM restriction, and optic neuropathy. Including research of different races broadens understanding of presentation and management, improving patient outcomes.

Collagen Structural Changes in Rat Tarsus After Crosslinking.

Purpose: Surgery is the standard treatment for floppy eyelid syndrome, but crosslinking (CXL) tarsus has recently been proposed as an alternative. To the best of our knowledge, this study is the first to use second-harmonic generation (SHG) microscopy to examine tarsal collagen ex vivo before and after photo-activated crosslinking. To quantify crosslinking, this study examined fluorescence recovery after photobleaching (FRAP), which indirectly measures tissue stiffness. Methods: Upper eyelid tarsal plates were dissected from 21 Sprague-Dawley rats (total of 42 tarsal plates). Six normal plates were sent for histopathology and SHG imaging; the remaining 36 were crosslinked with phosphate-buffered saline (PBS) alone or riboflavin in PBS (concentrations of 0.1%, 0.3%, and 0.5%). Tissues were irradiated with 365-nm ultraviolet A light (power, 0.45 mW/cm2) for 30 minutes and immediately underwent SHG microscopy. Stiffness was indirectly measured with FRAP using fluorescein isothiocyanate (FITC)-dextran. Results: SHG imaging of normal tarsus showed that the organization of collagen bundles is complex and varies greatly depending on location. After crosslinking with high-concentration riboflavin (0.5%), collagen fibers showed clear structural changes, becoming more densely packed and wavier compared to control. FRAP half-time to fluorescence recovery was significantly increased (P < 0.05), indirectly indicating increased tissue stiffness. No structural changes were observed after crosslinking with lower riboflavin concentrations of 0.1% and 0.3%. Conclusions: This is the first report of SHG microscopy used to image tarsus collagen before and after crosslinking. These results highlight collagen structural changes, with effects on tissue stiffness indirectly confirmed by FRAP. Translational Relevance: Collagen fibers in the tarsus may be a therapeutic target for crosslinking in order to treat symptomatic floppy eyelid syndrome.