Association of topical glaucoma medications with lacrimal drainage obstruction and eyelid malposition.

BACKGROUND/OBJECTIVES: Adverse effects of topical glaucoma medications (TGMs) may include development of ocular adnexal disorders. We undertook a study to determine the effect of TGMs on the risk of developing lacrimal drainage obstruction (LDO) and eyelid malposition. SUBJECTS/METHODS: All patients 66 years of age and older in Ontario, Canada initiating TGM and all patients diagnosed with glaucoma/suspected glaucoma but not receiving TGM from 2002 to 2018 were eligible for inclusion in this retrospective cohort study. Using validated healthcare administrative databases, cohorts were identified with TGM and no TGM patients matched 1:2 on sex and birth year. The effect of TGM treatment on risk of surgery for LDO and lid malpositions was estimated using Kaplan-Meier and Cox proportional hazards models. RESULTS: Cohorts included 122,582 patients in the TGM cohort and 232,336 patients in the no TGM cohort. Among the TGM cohort there was decreased event-free survival for entropion (log-rank P < 0.001), trichiasis (P < 0.001), and LDO (P = 0.006), and increased ectropion-free survival (P = 0.007). No difference in ptosis-free survival was detected (P = 0.78). For the TGM cohort there were increased hazards for entropion (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.12-1.37; P < 0.001), trichiasis (HR 1.74, 95% CI 1.57-1.94; P < 0.001), and LDO (at 15 years: HR 2.39, 95% CI 1.49-3.85; P = 0.004), and a decreased hazard for ectropion (HR 0.89, 95% CI 0.81-0.97; P = 0.008). No association between TGM treatment and ptosis hazard was detected (HR 0.99, 95% CI 0.89-1.09; P = 0.78). CONCLUSIONS: TGMs are associated with an increased risk of undergoing surgery for LDO, entropion, and trichiasis.

Myopic Correction with Iris-Fixated Phakic Intraocular Lenses: Twelve-Year Results.

PURPOSE: To evaluate a 12-year follow-up of myopic patients after iris-fixated phakic intraocular lenses (IF pIOLs) implantation. Setting. Ophthalmology Department, Military University Hospital in Prague (Czech Republic). DESIGN: Single-center retrospective cohort study. METHODS: We describe the results of a cohort study that included 85 eyes of 46 myopic patients who underwent implantation of Verisyse myopia, Veriflex, and Verisyse myopia toric (all Abbott Medical Optics, Inc.) intraocular lenses. Refractive functions and adverse events were assessed preoperatively, at 6 months, and 1, 2, 5, and 12 years after IF pIOL implantation. RESULTS: Mean spherical equivalent was measured as -9.37 ± 2.87 D, 0.14 ± 0.61 D, and -0.42 ± 1.08 D, preoperatively, at 6 months and 12 years postoperatively, respectively. There was a significant reduction in the cylinder after surgery. At 12 years postoperatively, 90% of eyes had uncorrected distance visual acuity (UDVA) of 20/40 and 64% of 20/20. The safety index was 1.10 for the whole postoperative follow-up period. We found cataract formation in 3 eyes (3.5%). The endothelial cells loss (EC loss) directly caused by IF pIOL implantation was 6.0%, 8.10%, 12.8%, and 11.9%, at 1, 2, 5, and 12 years, respectively. In our cohort, 95% of eyes lost a higher percentage of EC than would be expected from a physiological loss at 12 years postoperatively. We found a significant negative interaction between preoperative pachymetry and EC loss, indicating that the lower pachymetry leads to a faster decline in endothelial cells density (ECD). IF pIOL re-enclavation was found in 28% of eyes. 7% of subluxations were caused by trauma. The mean time of nontraumatic re-enclavation was 6 years postoperatively. CONCLUSIONS: The study confirmed the advantages of IF pIOL implantation due to rapid visual recovery and stable visual function over the 12-year follow-up and also showed the influence of lower corneal pachymetry regarding EC loss.

Guidelines for vismodegib in the management of periocular basal cell carcinoma.

OBJECTIVE: The management of advanced basal cell carcinoma (BCC) in the periocular region remains a clinical challenge. Vismodegib (ErivedgeTM) has been approved in 2013 by Health Canada for adult patients with "histologically confirmed metastatic BCC or locally advanced BCC inappropriate for surgery or radiation." An expert consensus was sought to create a standardised approach in the use of this novel treatment. METHODS: Fourteen practicing oculoplastic surgeons across Canada were involved in formulating and reviewing guidelines until consensus was reached. A consultancy meeting was followed by further ratification of guidelines over email. Two voting surveys were performed of the group to objectively assess agreement over each statement within the guidelines. Ratification continued until at least two-thirds of the group agreed on every guideline statement. RESULTS: The guidelines summarize 21 statements in a major and minor criteria format. A multidisciplinary team review is suggested for each patient with the involvement of recommended specialists. The internal survey revealed 100% agreement over 9 statements, 91.7% agreement over 8 statements, 83.3% agreement over 4 statements, and 2 statements had 66.7% and 58.7% agreement each. All statements with less than 91.7% agreement were surveyed again, and they were kept, modified, or removed on the basis of a consensus of over 66.7%. CONCLUSIONS: These guidelines serve to act as a framework for physicians considering vismodegib for the medical management of patients with advanced or metastatic periocular BCC. Future applications, including neoadjuvant uses of the drug, may become apparent through further research.

Histiocytic sarcoma of the eyelid.

Histiocytic Sarcoma is a rare malignant hematopoietic neoplasm that can present in extranodal sites including lymph nodes, skin, gastrointestinal tract, and the central nervous system. Only 10% of cases manifest as skin lesions and very few are reported in the head and neck. The authors report a case of histiocytic sarcoma of the eyelid in a 72-year-old male that was clinically diagnosed as a chalazion. Initial excision was not sent for routine histopathological assessment and the patient was subsequently lost to follow up. Recurrence occurred at the eyelid site and additional lesions were found on the forearms, abdomen, and right knee. Histopathological assessment of one of these other sites confirmed the diagnosis of histiocytic sarcoma. To our knowledge, this is the first reported case of disseminated histiocytic sarcoma that originally presented in the ocular adnexa (eyelid). And, as the initial lesion was not sent to Pathology and therefore potentially missed, this case highlights the importance of submitting tissue, including chalazia, for pathologic evaluation.

Novel taste test for nasolacrimal duct obstruction using denatonium benzoate: a randomized controlled pilot study.

OBJECTIVE: To evaluate a novel, simple, noninvasive method (known as the "bitter taste test") of establishing nasolacrimal duct patency in healthy asymptomatic eyes. DESIGN: Double-blind, randomized controlled pilot study. PARTICIPANTS: Healthy asymptomatic medical students, residents, and allied health staff at our institution. METHODS: Participants, aged 18-35 years (n = 28) with assumed normal lacrimal function, were randomized to the interventional group (100 parts per million denatonium benzoate in sterile water, n = 14) or to the control group (sterile water only, n = 14). All participants were pretreated with topical tetracaine in their right conjunctival cul-de sac, followed by 3 drops of the experimental solution spaced 1 minute apart. The primary outcome was whether participants reported a strong, persistent bitter taste. The secondary outcome was the time-to-taste. All participants received lacrimal irrigation. The Fisher's exact test was done using GraphPad online software. RESULTS: All participants in the interventional group reported the presence of the bitter solution. None of the participants in the control group reported bitterness (p < 0.001, Fisher's exact test). Time-to-taste was within 15 minutes for 71% of the intervention group (n = 10); within 30 minutes for 79% (n = 11); and within 2 hours for 100% (n = 14). The bitterness typically persisted for 1-2 hours. All participants had normal lacrimal systems to irrigation. No adverse events were reported. CONCLUSIONS: The bitter taste test demonstrates a promising ability to assess nasolacrimal duct patency under physiologic conditions in healthy participants. Further research is needed to validate this method in a clinical sample of patients with nasolacrimal duct obstruction.

Efficacy of Intravenous Mannitol in the Management of Orbital Compartment Syndrome: A Nonhuman Primate Model.

PURPOSE: To report the efficacy of intravenous mannitol in the treatment of orbital compartment syndrome. METHODS: An experimental study was conducted on 4 nonhuman primates (8 orbits). Orbital compartment syndrome was simulated by injecting autologous blood into both orbits of each nonhuman primate until a pressure of 80 mm Hg was reached (time 0). After 10 minutes, nonhuman primates were randomized to receive an infusion of either mannitol or saline, given over 15 minutes. Five minutes after the infusion was complete, lateral canthotomy and cantholysis was performed on both orbits in isolated steps every 5 minutes. During the study protocol, orbital and intraocular pressures were recorded every 5 minutes, with a final set of measurements at 60 minutes. The primary outcome measures were the mean change in pressure from time 0 to 60 minutes, as well as the mean change in pressure during the infusion period. RESULTS: There was no statistically significant difference in the mean changes in orbital or intraocular pressure from time 0 to 60 minutes of the protocol. However, during the infusion period there was significantly greater decrease in both orbital and intraocular pressure in the mannitol compared with saline group (-34.0 vs. -9.3 mm Hg for orbital pressure [p = 0.03]; -34.8 vs. -9.7 mm Hg for intraocular pressure [p = 0.04]). CONCLUSIONS: While the definitive treatment of orbital compartment syndrome is lateral canthotomy and cantholysis, mannitol results in a rapid and clinically meaningful drop in orbital and intraocular pressure. The authors believe that their data support the routine use of mannitol in orbital compartment syndrome, especially when there is a delay in timely surgical management.

Identifying predictive morphologic features of malignancy in eyelid lesions.

OBJECTIVE: To determine features of eyelid lesions most predictive of malignancy, and to design a key to assist general practitioners in the triaging of such lesions. DESIGN: Prospective observational study. SETTING: Department of Ophthalmology at Queen's University in Kingston, Ont. PARTICIPANTS: A total of 199 consecutive periocular lesions requiring biopsy or excision were included. MAIN OUTCOME MEASURES: First, potential features suggestive of malignancy for eyelid lesions were identified based on a survey sent to Canadian oculoplastic surgeons. The sensitivity, specificity, and odds ratios (ORs) of these features were then determined using 199 consecutive photographed eyelid lesions of patients who presented to the Department of Ophthalmology and underwent biopsy or excision. A triage key was then created based on the features with the highest ORs, and it was pilot-tested by a group of medical students. RESULTS: Of the 199 lesions included, 161 (80.9%) were benign and 38 (19.1%) were malignant. The 3 features with the highest ORs in predicting malignancy were infiltration (OR = 18.2, P < .01), ulceration (OR = 14.7, P < .01), and loss of eyelashes (OR = 6.0, P < .01). The acronym LUI (loss of eyelashes, ulceration, infiltration) was created to assist in memory recall. After watching a video describing the LUI triage key, the mean total score of a group of medical students for correctly identifying malignant lesions increased from 46% to 70% (P < .001). CONCLUSION: Differentiating benign from malignant eyelid lesions can be difficult even for experienced physicians. The LUI triage key provides physicians with an evidence-based, easy-to-remember system for assisting in the triaging of these lesions.

Fixation of Extraocular Muscles to Porous Orbital Implants Using 2-Ocetyl-Cyanoacrylate Glue.

PURPOSE: To assess the efficacy of recti muscle fixation with 2-ocetyl-cyanoacrylate tissue glue to porous orbital implants in human subjects undergoing enucleation. METHODS: This was a prospective interventional study with a historical control group. Over a 1-year period, patients who received orbital implant fixation using 2-ocetyl-cyanoacrylate tissue glue were enrolled in the study. Functional assessment was carried out by measurement of implant motility at the 6-month postoperative period, which was compared with a historical control group of patients with sutured implants. Structural assessment was carried out with a random sample of orbital MRIs. RESULTS: Twelve patients received the glue-fixation technique. There were no intraoperative or immediate postoperative complications. There was no statistically significant difference between the glued and sutured groups' horizontal implant movement (7.0 mm ± 1.5 mm vs. 6.8 mm ± 1.8 mm, respectively; p = 0.85) or vertical implant movement (5.6 mm ± 1.7 mm vs. 5.0 mm ± 1.4 mm, respectively; p = 0.39). Sample orbital MRI demonstrated good muscle approximation to the implants as well as contrast enhancement suggestive of successful fibrovascular proliferation. CONCLUSIONS: Recti muscle fixation using 2-ocetyl-cyanoacrylate tissue glue to porous orbital implants appeared safe and produced good functional and structural results in this proof-of-concept study. This novel technique of implant fixation may offer benefits in terms of reduced operating room time and cost savings.

Orbital compartment syndrome in a burn patient without aggressive fluid resuscitation.

INTRODUCTION: Orbital compartment syndrome may rarely occur in the setting of burns where therapy includes aggressive fluid resuscitation. CASE: We report a case of bilateral orbital compartment syndrome in a 13-year-old male, with superficial facial burns secondary to hydrobromic acid, who did not receive aggressive fluid resuscitation. The patient was treated successfully with bilateral lateral canthotomy and cantholysis. COMMENT: Facial burns may lead to orbital compartment syndrome without aggressive fluid resuscitation, likely due to excessive leakage of fluid and protein into the orbit combined with an inflammatory reaction.

Patterns and causes of epiphora referrals to a tertiary oculoplastic practice.

OBJECTIVE: To report the causative factors and surgical candidacy of patients referred to an oculoplastic surgery clinic for the complaint of epiphora. DESIGN: Prospective observational study. PARTICIPANTS: Consecutive patients (n = 159) referred to a tertiary care oculoplastic surgery clinic over a 12-month period for the complaint of epiphora. METHODS: The causative factor most responsible for tearing was determined based on clinical examination by the principal investigator, who was blinded to referral source. Patients were considered surgical candidates with a diagnosis of significant nasolacrimal duct obstruction, lid malposition, or pump dysfunction. The primary outcome was the percentage of referrals that were surgical candidates, classified by referral source. RESULTS: The most common cause of tearing was nasolacrimal duct obstruction, occurring in 53 of 159 (33%) patients. The percentage of surgical candidates was highest in referrals from ophthalmologists (82%), followed by optometrists (67%) and family physicians (55%; p = 0.011 for difference between ophthalmologists and family physicians). CONCLUSIONS: Epiphora may be because of a variety of causes, some of which are amendable to surgical treatment. In the absence of an obvious cause, a trial of lubrication by the family physician is warranted before referral being made to an oculoplastic surgeon.