Intraoperative Image Guidance in Orbital and Lacrimal Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the efficacy and safety of the use of intraoperative image guidance (IIG) in orbital and lacrimal surgery. METHODS: A literature search of the PubMed database was last conducted in November 2023 for English-language original research that assessed the use of any image guidance system in orbital and lacrimal surgery that included at least 5 patients. The search identified 524 articles; 94 were selected for full-text analysis by the panel. A total of 32 studies met inclusion criteria. The panel methodologist assigned a level II rating to 2 studies and a level III rating to 30 studies. No study met the criteria for level I evidence. RESULTS: Procedures reported on were as follows: fracture repair (n = 14), neoplasm and infiltrate biopsy or excision (n = 6), orbital decompression for Graves ophthalmopathy (n = 3), dacryocystorhinostomy (n = 1), and mixed etiology and procedures (n = 8). Four studies used more than one IIG system. One study that met level II evidence criteria compared the outcomes of orbital fracture repair with IIG (n = 29) and without IIG (n = 29). Borderline better outcomes were reported in the IIG group: 2% versus 10% with diplopia (P = 0.039) and 3% versus 10% with enophthalmos (P = 0.065). The other level II study compared the repair of fractures with navigation (n = 20) and without (n = 20). The group in which navigation was used had a measured mean volume reduction of 3.82 cm3 compared with 3.33 cm3 (P = 0.02), and there was a greater measured reduction in enophthalmos in the navigation group of 0.72 mm (P = 0.001). Although the remaining 30 assessed articles failed to meet level II criteria, all alleged a benefit from IIG. No complications were reported. CONCLUSIONS: A small number of comparative studies suggest that there are improved outcomes when IIG is used in orbital fracture repair, but each study suffers from various limitations. No high-quality comparative studies exist for the management of lacrimal surgery, neoplastic disease, or decompression. Complications attributable to the use of IIG have not been identified, and IIG has not been analyzed for cost savings. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Perceptions of Parental Leave Among Ophthalmologists.

Importance: Benchmarking attitudes surrounding parental leave among posttraining North American ophthalmologists may reveal possible areas for intervention. Objective: To evaluate perceptions of current parental leave policy and culture among posttraining North American ophthalmologists. Design, Setting, and Participants: This nonvalidated survey used a 19-item online questionnaire. A convenience sample of 186 self-identified North American-based ophthalmologists who had completed training was obtained using listservs, residency program coordinators, and social media. Data collection occurred from May to July 2022. Main Outcomes and Measures: Descriptive analysis demonstrated response frequencies. Pearson χ2 comparison of means was performed for categorical variables. Two-tailed t tests were performed for continuous variables. Results: Among the 186 surveys completed, 105 respondents (56.5%) identified as female, 76 (40.9%) worked in academia, 133 (71.5%) were 1 to 20 years out of training, and 156 (83.9%) had children. Attitudes toward stop-the-clock policies, or delays in tenure/promotion/partnership review when taking leave, were mixed. Of 171 respondents, 78 (45.6%) thought that stop-the-clock policies should be optional, 39 (22.8%) thought that they should be required, and 31 (18.1%) thought that they should be removed. Of 76 academicians responding, 56 (73.7%) and 49 (64.5%) were unaware if their institution had a stop-the-clock policy for tenure review or promotion review, respectively. Male and female respondents differed in feeling comfortable with taking leave (36 of 66 [54.5%] vs 67 of 90 [74.4%], respectively; P = .04), as well as in their ratings of stress about peer perception on a scale of 0 to 10 (3.70 vs 4.81, respectively; P = .05). Private practitioners and academicians differed in confirmation of leave options for both parents (52 of 101 [51.5%] vs 49 of 69 [71.0%], respectively; P = .02) and ratings of financial stress (7.10 vs 5.43, respectively; P = .004) and research considerations (1.60 vs 3.85, respectively; P < .001). Conclusions and Relevance: Results of this survey study support the hypothesis that demographic factors affect attitudes toward parental leave among posttraining ophthalmologists; policies could be better publicized. Feelings regarding policies and leave were mixed. These findings should be viewed as hypothesis generating because the survey was not validated and the associations provided could be due to confounding factors.

Orbital tuberculosis: a case report and update on the role of imaging in treatment.

Orbital tuberculosis is a manifestation of extra-pulmonary tuberculosis that is challenging to diagnose and treat. Here, we describe the pivotal role of serial imaging in the diagnosis and treatment of orbital tuberculosis. A 28-year-old male presented with recurrent right upper eyelid swelling and a supraduction deficit associated with a firm painless orbital mass, seen on initial computed tomography to be an extensive superomedial lesion producing mass effect. Biopsy revealed a tuberculosis-like granulomatous inflammation, which, coupled with a positive QuantiFERON gold test, led to empiric anti-tuberculin treatment. Serial radiologic imaging following initiation of treatment showed progressive reduction in mass size, supporting the diagnosis and determining the length of treatment. This rare case demonstrates the utility of serial radiologic exams in the diagnosis and treatment of orbital tuberculosis.

Efficacy of Preoperative Risk Stratification on Resident Phacoemulsification Surgeries.

Purpose: To evaluate efficacy of a novel risk stratification system in minimizing resident surgical complications and to evaluate whether the system could be used to safely introduce cataract surgery to earlier levels of training. Materials and Methods: This is a retrospective cross-sectional study on 530 non-consecutive cataract cases performed by residents at Columbia University. Risk scores, preoperative best corrected visual acuity (BCVA), intraoperative complications, postoperative day 1 (POD1), and month 1 (POM1) exam findings were tabulated. The relationship between risk scores and POD1 and POM1 BCVA was modeled using linear regression. The relationship between risk scores and complication rates was modeled using logistic regression. Logistic regression was used to model the rates of complications across different levels of training. Rates of complications were compared between diabetic versus non-diabetic patients using t-tests. Results: Risk scores did not have significant association with intraoperative complications. Risk scores were predictive of corneal edema (OR = 1.36, p = 0.0032) and having any POM1 complication (OR = 1.20, p = 0.034). Risk scores were predictive of POD1 (ß = 0.13, p < 0.0001) and POM1 (ß = 0.057, p = 0.00048) visual acuity. There was no significant association between level of training and rates of intraoperative (p = 0.9) or postoperative complications (p = 0.06). Rates of intraoperative complication trended higher among diabetic patients but was not statistically significant (p = 0.2). Conclusion: Higher risk scores were predictive of prolonged corneal edema but not risk of intraoperative complications. Our risk stratification system allowed us to safely introduce earlier phacoemulsification surgery.

The Arched Rainbow Brow in Thyroid Eye Disease.

PURPOSE: To morphologically describe and mathematically quantify a novel clinical feature of thyroid eye disease (TED). METHODS: A retrospective study was conducted of TED patients and age-sex-matched normal controls. The arched Rainbow Brow appearance in TED patients was determined by unanimous agreement of 3 oculoplastic surgeons. Eyebrow curvature was assessed by plotting 15 points along the eyebrow in ImageJ. The fourth-degree polynomial ( y = ax4 + bx3 + cx2 + dx + e ) was fitted to each eyebrow. RESULTS: Two hundred seventy-one eyes were analyzed (200 TED and 71 age-sex-matched normal controls). A Rainbow Brow was identified in 42% of TED patients. A unilateral Rainbow Brow was seen in 15% of patients. The fourth-degree polynomial coefficients yielded significant differences between Rainbow Brow patients and age-sex-matched normal controls for the coefficients a, b, c , and d . Similar analysis of TED patients with and without a Rainbow Brow showed differences in coefficients a and b . Age >50 years ( p = 0.009) and the presence of brow fat expansion ( p < 0.001) were associated with the presence of a Rainbow Brow. Proptosis >24 mm showed a trend toward association with the presence of a Rainbow Brow ( p = 0.057). When considering the contribution of these features in a multivariable analysis, only brow fat expansion was a significant contributing factor ( p = 0.009). CONCLUSIONS: The Rainbow Brow is a distinct entity in TED and is likely consequent to brow fat pad expansion. Patients with a Rainbow Brow have different eyebrow curvature as compared to both normal age-sex-matched controls and TED patients without a Rainbow Brow.

Ophthalmology Medical Student Directors, Associate Residency Program Directors, and Program Directors: A Benchmarking Study of Work and Life Metrics.

Introduction During a time of increased interest in physician well-being, this study benchmarks current work life, home life, and burnout scores for ophthalmology medical student directors (MSD), associate program directors (APD), and program directors (PD). Methods An anonymous cross-sectional survey was disseminated through the Association of University Professors of Ophthalmology (AUPO) listserve, with queries regarding leadership positions, work time allotment, extracurricular activities, family life, and burnout. Answers were analyzed descriptively through Fisher's exact test, Kruskal-Wallis test, and Poisson regression models. Results Nineteen percent of listed MSD, 15% of APD, and 29% of PD queried responded to the survey. MSD, APD, and PD are statistically similar in terms of work and home life, with the exception of time spent performing administrative tasks for the position. PD spend more time on administrative tasks, and are paid more. All groups score positively on burnout surveys. Conclusion This benchmarking survey demonstrates that MSD, APD, and PD are intensively involved in both their work and home lives, with a seemingly high correlation of sense of worth both personally and in their careers.

Teprotumumab and Hearing Loss: Case Series and Proposal for Audiologic Monitoring.

PURPOSE: To present a protocol for audiologic monitoring in the setting of teprotumumab treatment of thyroid eye disease, motivated by 4 cases of significant hearing loss, and review the relevant literature. METHODS: Cases of hearing loss in the setting of teprotumumab were retrospectively elicited as part of a multi-institutional focus group, including oculoplastic surgeons, a neurotologist and an endocrinologist. A literature review was performed. RESULTS: An aggregate of 4 cases of teprotumumab-associated hearing loss documented by formal audiologic testing were identified among 3 clinicians who had treated 28 patients. CONCLUSIONS: Teprotumumab may cause a spectrum of potentially irreversible hearing loss ranging from mild to severe, likely resulting from the inhibition of the insulin-like growth factor-1 and the insulin-like growth factor-1 receptor pathway. Due to the novelty of teprotumumab and the lack of a comprehensive understanding of its effect on hearing, the authors endorse prospective investigations of hearing loss in the setting of teprotumumab treatment. Until the results of such studies are available, the authors think it prudent to adopt a surveillance protocol to include an audiogram and tympanometry before, during and after infusion, and when prompted by new symptoms of hearing dysfunction.

Chronic Early-Stage Ocular Cicatricial Pemphigoid.

Ocular cicatricial pemphigoid (OCP) represents an insidious, autoimmune-mediated disease of the conjunctiva, initially presenting as chronic conjunctivitis and progressing to fibrosis, cicatrization, and eventually blindness secondary to corneal keratinization. This series reports 3 cases presenting with chronic conjunctivitis lasting an average of 10 years without cicatrix formation, ultimately diagnosed as OCP based on direct immunofluorescence of conjunctival biopsy samples. This chronic conjunctivitis without fibrosis suggests the possibility of an OCP subtype with a prolonged early stage or prodrome prior to cicatrization, which may benefit from early diagnosis and treatment to prevent complications of this disease.

Netarsudil-related Eyelid Wound Dehiscence.

An 81-year-old man with primary open-angle glaucoma on dorzolamide-timolol, bimatoprost and 0.02% netarsudil ophthalmic solution (Rhopressa), was found to have right lower lid basal cell carcinoma. The patient underwent Mohs surgery followed by repair of the right lower lid, with 3 episodes of wound dehiscence. When stopping netarsudil, appropriate granulation tissue was able to develop. While off netarsudil, the patient underwent Mohs resection of a left lower lid basal cell carcinoma, which was able to granulate well via secondary intention.

Thyroid Eye Disease, Teprotumumab, and Hearing Loss: An Evolving Role for Otolaryngologists.

Teprotumumab is a human monoclonal antibody and IGF-1R (insulin-like growth factor 1 receptor) inhibitor approved for treatment of thyroid eye disease in adults. Recent clinical trials have demonstrated side effects, notably hearing loss, in the treatment cohort as compared with the placebo cohort. These unexpected otologic side effects may be understood through a mechanistic understanding of IGF-1 (insulin-like growth factor 1). As otolaryngologists who historically play a significant role in the multidisciplinary treatment of thyroid disease and its associated complications, we should be aware of and monitor the otologic side effects of teprotumumab. Clinicians who prescribe teprotumumab should strongly consider monitoring patients' hearing with an audiologist and otolaryngologist.

Ultrasonographic Visualization of Bilaterally Fused Eyelids in a Premature Neonate.

In cases of significant prematurity, neonates born with eyelid fusion can undergo spontaneous eyelid disjunction. Here, the authors present such a case, along with ultrasound findings shortly before eyelid separation. All protected patient information extracted for this report was done so in accordance with the Health Insurance Portability and Accountability Act. This report was prepared in accordance with the tenants of the Declaration of Helsinki.

Punctal Congestion Syndrome: A Reversible, Functional Punctal Stenosis Causing Epiphora in the Setting of Chronic Pretarsal Conjunctivitis.

PURPOSE: To describe a reversible syndrome of epiphora, functional punctal stenosis, and chronic pretarsal conjunctivitis associated with corticosteroid or corticosteroid-antibiotic eyedrop use. METHODS: This is an Institutional Review Board-approved retrospective review of patients diagnosed with epiphora, punctal stenosis, and chronic conjunctivitis by a single surgeon (B.J.W.). These patients were subsequently invited to participate in a prospective study involving allergy skin patch testing for ophthalmic drops, common excipients, and active ingredients. RESULTS: Thirteen patients received a diagnosis of punctal congestion syndrome. The average age was 63 years (range, 41-93) and 69.2% were female. Findings were bilateral in 61.5%. All had used preserved drops in the affected eye(s). Various antecedent diagnoses resulted in treatment with preserved drops. Patients experienced epiphora for an average of 3.8 months (median, 3 months; mode, 3 months; range, 1-8 months) prior to presentation. Two patients had undergone punctoplasty which failed to resolve symptoms. 92.3% of patients had been taking tobramycin-dexamethasone drops, loteprednol drops, or a combination of both prior to presentation. All were taken off preserved drops. 69.2% were also treated with a preservative-free loteprednol etabonate 0.5% ophthalmic ointment taper. All improved. Partial relief of symptoms was achieved by an average of 1.6 months (median, 2 months; mode, 2 months; standard deviation, ±0.7 months) and resolution of symptoms by 2.5 months (median, 2 months; mode, 2 months; standard deviation, ±1.7 months). One patient underwent patch testing with strong positive reactions to formaldehyde and neomycin and a weak positive reaction to gentamicin. CONCLUSIONS: Functional punctal stenosis is associated with topical ophthalmic preparations, especially preserved corticosteroids and antibiotic-corticosteroid combinations. Treatment consists of removal of all preserved eyedrops. Symptoms often improve over several months.