Adnexal squamous cell carcinoma: incidence of eyelid margin involvement.

PURPOSE: We aimed to perform a review of facial and periorbital squamous cell carcinoma (SCC) cases to assess the relative incidence of eyelid margin involvement. METHODS: This is a retrospective review of all patients with biopsy-proven SCC who were evaluated at a single oculoplastic surgery practice from 2007 to 2019. The charts were reviewed for the anatomical location of the malignancy, and those involving the eyelid were further divided into marginal and non-marginal lesions. Statistical analysis was performed using a one proportion z-test. RESULTS: A total of 76 patients with a diagnosis of biopsy-proven periorbital and facial SCC were identified, 67 involved the ocular adnexa. Thirty-nine (58.2%) patients had lesions located on the eyelid. Of these, 33 (84.6% p < 0.0001, 95% CI 69.45-94.13) had lesions located at the margin, six of the 39 lesions were non-marginal. The remaining lesions were present within the brow (n = 10, 14.9%), medial canthus (n = 10, 14.9%), palpebral conjunctiva (n = 1, 1.5%), or orbit (n = 1, 1.5%). In six patients (8.9%) lesions involved multiple anatomic subunits. CONCLUSION: We present our investigation of the incidence of SCC of the marginal vs. non-marginal eyelid, revealing a statistically significant increased involvement of the eyelid margin. Future investigations are necessary to further elucidate the vulnerability of the eyelid margin to the development of SCC in particular in regards to the role of the unique genetic expression profile of eyelash follicular stem cells.

5-Fluorouracil With Microneedling Modulates Wound Healing in a Murine Model: An Immunohistochemical Analysis of Mechanism and Dose Efficacy.

PURPOSE: The purpose of this study is to assess the dose-dependent immunohistopathological effects of intradermal microneedle-delivered 5-fluorouracil (5-FU) for postincisional wound healing in a murine model. METHODS: A prospective experimental study was performed. Twelve hairless mice were randomized into 4 treatment groups for postincisional wound treatment: microneedling with topical saline, or microneeding with topically-applied 5-FU at concentrations of 25 mg/ml, 50 mg/ml, or 100 mg/ml. Two surgical wounds were created on each animal. Combination wound treatments were performed on postoperative days 14 and 28, and cutaneous biopsies were obtained on day 56. Specimens were analyzed by a dermatopathologist, blinded to the treatment group, for collagen thickness, lymphocytic infiltration, histiocytic response, sub-epidermal basement membrane zone thickness, and myofibroblast density. RESULTS: Histopathologic evaluation showed increased collagen thickness, lymphocyte infiltration, and granuloma density in the groups undergoing microneedling treatment with 5-FU, compared to saline. Immunohistochemical analysis revealed a trend toward thicker basement membranes with higher concentrations of 5-FU used, reaching statistical significance between controls and those treated with 100 mg/ml 5-FU ( p = 0.0493). A trend toward decreasing myofibroblast density with increasing doses of 5-FU was noted. No postincisional or treatment complications were observed. CONCLUSIONS: Our results demonstrate that microneedling is an effective topical subepithelial drug delivery system, and further suggest a beneficial dose-dependent immunomodulatory effect of 5-FU on intermediate wound healing when used in combination with microneedling. We recommend a 5-FU dose at the mid-range 50 mg/ml concentration to simultaneously maximize efficacy and minimize complication risk.

Isolated globe rupture without concomitant eyelid laceration or orbital trauma following facial dog bite injury in a child.

PURPOSE: Facial dog bites often cause periorbital trauma; however, the globe is rarely damaged. Most globe injury following dog bites results from unusual circumstances and typically presents with concomitant periorbital and ocular adnexal injuries. OBSERVATIONS: The case presented is a rare presentation of isolated globe rupture without orbital trauma following facial dog bite in a child without history or evidence of decreased blink reflex, mental deficiency, or substance use. CONCLUSIONS AND IMPORTANCE: Ophthalmic investigation is warranted in all pediatric periorbital dog bite injuries, even in the setting of minimal or absent periorbital trauma. As additional blunt trauma to the globe in the immediate recovery period resulted in a second open globe injury, the critical importance of protective eyewear, activity restriction, and judicious corneal suture removal postoperatively following repair of open globe injury is discussed.

Traumatic intrachoroidal nail implantation.

Penetrating globe injury can lead to serious vision loss and even loss of the eye. Intraocular foreign bodies (IOFBs) are a major cause of traumatic globe injury commonly seen in work-related accidents. We present a unique case of a large IOFB that was fully embedded within the choroid, where enucleation was pursued due to inability to safely remove the IOFB.

Simultaneous presentation of orbital mantle cell lymphoma and endocrine mucin-producing sweat gland carcinoma.

Mantle cell lymphoma is a rare malignancy to present in the orbit, comprising only 1-5% adnexal lymphomas. Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is an equally uncommon adnexal tumor of sweat gland origin that may present on the eyelid. Herein we present a case of a 77-year old man with no previous cancer history who presented with painless progressive left globe proptosis and an enlarging left upper lid margin lesion, ultimately determined upon biopsy to be simultaneous orbital mantle cell lymphoma with systemic involvement and isolated eyelid EMPSGC. The pathogenesis, clinical manifestation, and management for each rare disease entity are reviewed and concept of collision tumors is discussed.

Autologous Fat Transfer Harvest-site Complications: Incidence, Risk Factors, and Management.

PURPOSE: Autologous fat transfer is an effective tool for volume restoration to the aging face. Although numerous reports exist regarding injection site complications, there is limited data on donor-site morbidity in the cosmetic surgery literature. METHODS: This study is a large-scale retrospective review to determine incidence of fat harvest-site complications, identify risk factors, and describe management strategies. Records of all patients who underwent autologous fat harvesting and facial grafting at a single oculofacial plastic surgery practice from 2010 to 2019 were reviewed. Patient demographics and clinical data were collected and assessed. A statistical analysis was performed using a two-tailed T-test with p values of <0.05 considered significant. RESULTS: Four-hundred sixteen patients were followed for an average of 6.2 months postoperatively. There was an overall 5.5% harvest-site complication rate. There was no correlation of harvest-site complications with gender (p = 0.249) or age (p = 0.881). Harvest location did not significantly correlate with complication rate. The most common complications were contour irregularities, prolonged induration, and prolonged erythema. Low body mass index was associated with higher complication rate (p = 0.003), even when excluding those patients with contour irregularities (p = 0.001). Various treatment modalities were used to manage donor-site morbidity with consistent improvement. CONCLUSIONS: Autologous fat transfer used for facial volume augmentation has low donor-site morbidity. Minor harvest-site complications occur more commonly in patients with low body mass index, irrespective of age, gender, or fat source.

Rifle Blast Exacerbating Hearing Loss in a Patient Treated With Teprotumumab for Thyroid Eye Disease.

Teprotumumab is a promising new immunomodulatory therapy for thyroid eye disease. One unique adverse effect observed in clinical trials was hearing impairment; however, all adverse auditory effects in prior clinical trials resolved spontaneously after completion of teprotumumab therapy. The authors present a case of a patient on teprotumumab for thyroid eye disease who experienced sustained hearing loss secondary to shooting a rifle without ear protection. In this case, it is suspected the teprotumumab infusions resulted in increased susceptibility of the inner ear hair cells to noise-induced trauma secondary to IGF-IR inhibition. Specific ear protection protocols may need to be implemented in the future for patients on teprotumumab therapy to prevent sustained hearing loss, especially for susceptible patient populations.

Case Report of Conjunctival Melanoacanthoma.

PURPOSE: The purpose of this study was to describe a case of conjunctival melanoacanthoma, an exceedingly rare condition that has yet to be fully described in the literature. METHODS: Melanoacanthomas are most commonly seen on the skin or oral mucosa and are believed to result from local irritation or trauma. A 34-year-old Hispanic man presented with a painless, solitary, pigmented conjunctival lesion, in addition to bilateral pterygia suggesting chronic solar damage. The lesion was excised and sent for analysis. RESULTS: Histopathologic analysis of tissue samples demonstrated melanocyte proliferation and epithelial dysplasia, yielding a final pathologic diagnosis of conjunctival melanoacanthoma with dysplastic and acantholytic-type features. The patient is being closely followed and has not had recurrence of the lesion. CONCLUSIONS: Only 1 prior case of conjunctival melanoacanthoma has been documented. As such, there is no standard of care regarding appropriate management.

Disseminated Coccidioidomycosis With Orbital Osteomyelitis and Periorbital Abscess.

Coccidioidomycosis osteomyelitis involving the orbital bones is exceedingly rare and is often misdiagnosed initially as other inflammatory or infectious conditions. No clear guidelines currently exist regarding appropriate management. The authors present an atypical presentation of disseminated coccidioidomycosis in an immunocompetent child with frontal bone superotemporal orbital rim osteomyelitis and associated periorbital abscess, successfully managed with surgical debridement through an upper eyelid crease incision.

Wound Dehiscence Following Upper Blepharoplasty: A Review of 2,376 Cases.

PURPOSE: There have been limited studies evaluating specifically the incidence of wound dehiscence following isolated upper blepharoplasty. This is a large-scale upper blepharoplasty review to evaluate the rate of wound dehiscence, to assess risk factors, and to analyze management outcomes. METHODS: A retrospective review was performed of all patients who underwent upper blepharoplasty at a single surgery center. All incisions were closed using either 6-0 fast-absorbing plain gut or polypropylene suture in a running fashion, with an additional interrupted suture near the lateral wound edge. Incidence of wound dehiscence was determined and further assessed by patient age (≤67 or >67 years), gender, preexisting medical conditions, smoking history, and suture type. RESULTS: A total of 1,190 patients (2,376 eyelids) met inclusion criteria. In total, there were 34 instances (1.4%) of wound dehiscence in 32 patients at an average 9 days (range, 0-30 days) following surgery. Evaluation of wound dehiscence rates by demographic factors revealed male gender to be a significant predictor of wound dehiscence (p = 0.0062). Age, hypertension, heart disease, and diabetes were not predictors of wound dehiscence. Lifetime smoking history increased risk for wound dehiscence (p < 0.0001). Use of fast-absorbing plain gut suture was also significantly associated with dehiscence, when compared with polypropylene (p = 0.0025). Multivariate analysis revealed male gender and fast-absorbing plain gut suture to be independent risk factors for wound dehiscence. Seventeen eyelids with wound separation were observed for second-intention healing, 1 underwent delayed scar revision. Fourteen eyelids were repaired primarily using suture and 3 with cyanoacrylate surgical skin adhesive. All patients reported satisfaction with their final outcome, and objective final healing was deemed satisfactory. CONCLUSIONS: Wound dehiscence following isolated upper blepharoplasty is rare and associated with male gender and fast-absorbing plain gut suture. Patients with wound separation may be successfully managed with individualized care.

Atypical acute presentation of an optic nerve sheath meningioma.

PURPOSE: Primary optic nerve sheath meningiomas (ONSM) are benign lesions that typically present with findings of painless proptosis (59%), optic nerve pallor (55%), and decreased peripheral vision (35%). Herein we share an atypical case of a patient who presented acutely with periorbital pain and optic nerve head edema, and was ultimately determined to have a low-grade optic nerve meningioma. OBSERVATIONS: A 36-year-old healthy woman presented with acute onset of left periorbital discomfort. She was found to have intact visual acuity, full peripheral vision, and ipsilateral optic nerve edema. MRI imaging revealed a large intraconal mass partially encircling the left optic nerve. Incisional biopsy revealed a diagnosis of meningioma, WHO grade 1. CONCLUSIONS: Low-grade optic nerve sheath meningiomas may uncommonly present with acute pain and optic nerve head swelling, and absence of classic disease features.

Acute post-partum vision loss due to pilocytic astrocytoma.

PURPOSE: We report an unusual case of a thirty-three-year-old woman who presented with acute unilateral vision loss following pregnancy and was ultimately discovered to have a pilocytic astrocytoma of the optic nerve. OBSERVATIONS: A thirty-three-year-old previously healthy female presented one month following Caesarean section with unilateral vision loss. She was found to have significantly decreased visual acuity, an afferent pupil deficit, proptosis, optic nerve edema and choroidal folds. Imaging revealed a large lesion of the optic nerve. Biopsy was performed and pathologic analysis revealed a pilocytic astrocytoma, WHO grade 1. The patient opted for close observation without further management and demonstrated mild improvement in visual function. CONCLUSIONS/IMPORTANCE: Optic pathway gliomas (OPG) most commonly present in the pediatric patient population with painless proptosis, slowly progressive vision loss, and clinical findings of chronic optic neuropathy.( Farazdaghi et al., 2019 Sep) 1 Acute presentations of this disease in adulthood are rare. This case demonstrates a rare case of acute optic nerve glioma presentation during the post-partum period.

Long-term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation.

OBJECTIVE: A growing body of evidence demonstrates that endonasal endoscopic dacryocystorhinostomy (eDCR) techniques provide comparable results to conventional external techniques. The purpose of this study was to evaluate long-term outcomes after powered endoscopic DCR without preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction performed by a single surgical team. METHODS: A retrospective review was performed of patients with epiphora secondary to acquired nasolacrimal duct obstruction who underwent eDCR without mucosal flap preservation from May 2003 to April 2013 at a tertiary referral medical center. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation and endoscopic evaluation. RESULTS: Eighty patients (69 primary and 11 revision) totaling 103 procedures (87 primary, 16 revision) were available for analysis at a mean follow-up of 28.7 (range 6-114) months. At the most recent follow-up, 92 of 103 (89.3%) procedures had complete resolution of epiphora, and 10 of 103 procedures achieved mild intermittent epiphora. Complete resolution of epiphora was noted in 93.1% (81 of 87) of primary procedures and 68.8% (11 of 16) of revision procedures. Objective anatomic patency was confirmed in 98% (101 of 103). A revision procedure was required in 5.8% (6 of 103). CONCLUSION: Outcomes of powered eDCR without the preservation of mucosal flaps compare favorably to previously reported results in the literature. These long-term results suggest that mucosal flap preservation is not required to achieve successful outcomes with eDCR. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:12-17, 2020.

Histologic Evaluation of Nonvisual Afferent Sensory Upper Eyelid Proprioception.

PURPOSE: Recent research has suggested a possible role for proprioception in ipsilateral frontalis activation in the setting of ptosis; however, there has not been any robust histologic or anatomic evidence to support this theory. To further elucidate proprioceptive structures in the eyelid, this investigation uses validated histologic techniques to explore the presence of proprioceptive structures or afferent neural networks in the Levator Palpebrae Superioris (LPS) and Müller muscle. METHODS: Müller muscle and LPS samples were evaluated by a laboratory with extensive experience with the histology of extraocular muscle proprioception. Immunofluorescence and confocal laser scanning microscopy were used to analyze the tissue samples. RESULTS: Thirty-four Müller muscle samples and 10 LPS samples were analyzed. Golgi tendon bodies and muscle spindles were not identified in the Müller muscle and LPS samples. This result is expected in the Müller muscle given that these structures are not typically present in smooth muscle, but noteworthy in the skeletal muscle of the LPS. Previously undescribed synaptophysin-positive free nerve terminals within the intermuscular connective tissue of the Müller muscle were identified. CONCLUSIONS: The nerve terminals identified are anatomically consistent with free nerve endings present in the extraocular muscles that have been implicated in proprioception. These findings advance our current knowledge of the ultrastructure of Müller muscle and the LPS and suggest a possible mechanism for proprioception in the upper eyelid that may have a role in ipsilateral brow elevation in the setting of ptosis.The authors describe proprioception in the upper eyelid: A histologic analysis.

Contemporary management of orbital blowout fractures.

PURPOSE OF REVIEW: Orbital floor blowout fractures may lead to significant morbidity, including debilitating double vision and globe malposition. Thorough evaluation and timely surgical intervention may prevent long-term sequelae. RECENT FINDINGS: New studies have demonstrated certain patients with orbital floor fractures to do well when managed conservatively. In those necessitating operative repair, precise surgical dissection and adequate fracture reduction are essential to restoring orbital anatomy and function. Novel surgical techniques and orbital floor reconstruction materials, described in this review, will further optimize patient outcomes. SUMMARY: A knowledgeable evaluation, thoughtful management strategy and modernized surgical technique can prevent long-term disability in patients with orbital floor blowout fractures.

Ophthalmic Manifestations of Facial Dog Bites in Children.

PURPOSE: To characterize ophthalmic manifestations and periocular injuries of pediatric facial dog bites. METHODS: A retrospective review of all children younger than 18 years who sought medical attention after a dog bite to the face between January 1, 2003 and May 22, 2014 was performed at a large tertiary pediatric hospital. Data on type and location of injury, surgical intervention, and complications were collected. RESULTS: A total of 1,989 children aged 0.19 to 17 years were identified with dog bites. Dog bites to the face occurred in most patients (n = 1, 414 [71%]). Of those children with facial dog bite injuries, 230 (16%) suffered ophthalmic manifestations. The average age was 4.3 years. Eyelid injuries occurred in 227 (99%) of children, 47 (20%) sustained canalicular system injuries, 3 (1.3%) suffered corneal abrasions, and 2 patients sustained facial nerve injury resulting in lagophthalmos. No patients suffered vision loss. Complications occurred in 32 patients (14%), with the most common being epiphora in 9 patients (28%), upper eyelid ptosis in 8 (25%), and prominent scar formation in 4 patients (13%). Thirteen children (5.7%) needed one or more secondary procedure to correct complications. CONCLUSIONS: The authors report the clinical features and management on the largest series of ophthalmic and periocular injuries associated with pediatric facial dog bites. These injuries occur in about 1 in 6 dog bites to the face and primarily involve the ocular adnexa. Despite early and appropriate surgical management, complications and the need for revision surgery are relatively common.