Severe Upper Lid Fornix Prolapse After a Ptosis Repair in Floppy Eyelid Syndrome: A Case Report.

ABSTRACT: Patients with profound floppy eyelid syndrome (FES) may experience challenges achieving eyelid and tarsal stability in the setting of severe ptosis. A 43-year-old woman with sleep apnea presented to clinic with difficulties driving because of droopy eyelids. She also experienced chronic tearing, crusting, and discharge of the eyes. She was diagnosed with severe FES and significant ptosis. She underwent a wedge excision of the upper lid in the medial and lateral aspect of the upper lid. This was followed by a ptosis repair that resulted in complete upper lid fornix obliteration causing the conjunctiva to obstruct the patient's pupils. The patient's symptoms ultimately improved after a definitive fornix reconstruction. Her visual field symptoms were improved with 1-year follow-up. To our knowledge, this is the first report in the literature of a prolapsed fornix resulting in vision obstruction after floppy eyelid repair via a wedge excision followed by a ptosis repair via an external levator advancement. Given these unusual findings for the patient's age, further investigations into treatment management may be necessary to mitigate eyelid reconstruction complications in younger patients with FES.

Subciliary Rotating Sutures Combined With Modified Hotz Procedure for Correction of Congenital Lower Eyelid Entropion.

PURPOSE: Standard techniques for the treatment of congenital lower eyelid entropion may not yield suitable outcomes or may result in overcorrection if disinsertion of the lower eyelid retractors is not the primary cause. Herein, we propose and evaluate a technique using subciliary rotating sutures combined with a modified Hotz procedure for repair of lower eyelid congenital entropion that addresses these concerns. METHODS: A retrospective chart review was conducted of all patients who underwent lower eyelid congenital entropion repair by a single surgeon using subciliary rotating sutures combined with a modified Hotz procedure between 2016 and 2020. Study variables included patient demographics, follow-up period, postoperative complications, operative success, and recurrence. RESULTS: Twelve patients (19 eyelids) met the study inclusion criteria. The mean patient age was 7.1 ± 6.1 years (range, 0.2-22 years). Nine of the patients were female (75%) and 3 were male (25%). The distribution of eyelids was 8 right (42%) and 11 left (58%). The mean follow-up time was 19.5 ± 15 (range 2.5-45) months. There were two eyelids (11%) that had entropion recurrence after initial repair in patients with concomitant compound disease processes. Repeated repair resulted in success with no recurrence at last follow-up. Overall, the described entropion repair technique was successful and without recurrence in 17 eyelids (89%). There were no cases of ectropion, lid retraction, or other complications. CONCLUSIONS: Subciliary rotating sutures combined with a modified Hotz procedure are effective for correction of congenital lower eyelid entropion. As the technique does not manipulate the posterior layer of the lower eyelid retractors, it may be useful for when retractor reinsertion does not yield adequate improvement and may also reduce the risk of eyelid retraction and overcorrection in particular cases.

A 10-Year Review of the Management of Ocular Mucous Membrane Pemphigoid: A Private Practice Experience.

PURPOSE: Ocular mucous membrane pemphigoid (OcMMP) is a rare and potentially blinding condition for which consensus treatment guidelines do not exist. The purpose of this study was to assess the effectiveness and safety of various immunomodulatory agents in the treatment of OcMMP in a private practice setting. METHODS: We conducted a 10-year retrospective chart review of patients managed with OcMMP (n = 22). The median age at diagnosis was 73 (range: 35-91) years, and 59% (13/22) of patients were female. Visual acuity, Foster stage, and adverse effects (AEs) were documented. Treatment outcomes for each treatment episode were qualified at 3 months as complete response (CR), response (R), or failure (F). After 3 months, CR was then further subqualified as sustained CR, reactivation after initial CR, or AE after initial CR. The Fisher exact test P values were calculated for each outcome in comparison with mycophenolate. RESULTS: Twenty patients were treated with an immunomodulatory agent for a total of 55 treatment episodes. In comparison to dapsone, mycophenolate was more likely to achieve sustained CR (50% vs. 0%, P = 0.022) and R (100% vs. 50%, P = 0.007), and less likely to fail (0% vs. 50%, P = 0.007). Dapsone was also more likely to be discontinued because of AEs than mycophenolate (40% vs. 6%, P = 0.041). CONCLUSIONS: Mycophenolate is a superior first-line agent to dapsone in the treatment of OcMMP. Although not statistically significant, mycophenolate trends toward superiority over methotrexate as well. Mycophenolate is very effective when used in combination with rituximab. Azathioprine remains a reasonable second-line agent.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Retrobulbar hemorrhage decompression with paracanthal "one-snip" method: Time to retire lateral canthotomy?

Orbital compartment syndrome is a rare but serious condition most commonly as a result of traumatic retrobulbar hemorrhage and must be treated quickly to avoid ischemic damage to the optic nerve and retina. While the previously accepted standard of care for management of this condition has been lateral canthotomy with inferior cantholysis, this procedure can be challenging for physicians to perform given the rarity of the condition and that patients are frequently in significant pain often with significant periocular edema. In this case, orbital compartment syndrome was effectively treated with a paracanthal "one-snip" incision quickly and efficiently in the ED. This procedure offers a more manageable alternative treatment which has been found to produce a satisfactory intraocular pressure reduction in both cadaver models and now a patient with confirmed retrobulbar hemorrhage and resultant orbital compartment syndrome.

Changes in perception of pitch during vocal performance after three- and two-wall orbital decompression surgery.

This case series presents 2 Caucasian females that underwent orbital decompression surgery for symptomatic exophthalmos and postoperatively developed a change in their perception of pitch during vocal performance. One patient went as far as to undergo voice lessons in attempt to regain her pre-operative pitch perception; however, the attempt was unsuccessful. We propose the etiology of this complication is anatomic changes within the ethmoid sinus. Temporary changes in nasalance have previously been reported with functional endoscopic sinus surgery literature, but this specific complication of change in pitch perception has not.

Age-matched, case-controlled comparison of clinical indicators for development of entropion and ectropion.

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a "white line," occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test.

Efficacy of pulsed electromagnetic energy in postoperative recovery from blepharoplasty.

BACKGROUND: A novel medical device that has been approved by the Food and Drug Administration is available for treatment of postsurgical edema. The device emits a low-level, pulsed electromagnetic energy field, which modulates resting cell membrane potential, allowing a return to physiologic resting membrane potential. OBJECTIVE: To investigate the benefits of electromagnetic energy in eyelid wound healing. METHODS: Fifty-seven individuals participated in this randomized, double-blinded study. All patients underwent upper blepharoplasty. At the postoperative visit, patients rated pain, edema, and ecchymosis, and the physician rated edema, ecchymosis, and erythema. RESULTS: There was no difference (p = .76) in patient pain rating when comparing placebo (1.6) with the patch (1.3). Patients reported 6% less edema (p = .11) and 10% less ecchymosis (p = .17) with the active patch eye than in control eye. The physician-graded edema, ecchymosis, and erythema had a mean Likert-type scale difference between placebo and active eyes of -0.3 (p = .12), -0.3 (p = .17), and -0.2 (p = .004) respectively. CONCLUSION: The use of pulsed electromagnetic energy did not have an effect on postoperative pain, edema, or ecchymosis as rated by patients and physicians. There was a statistically significant reduction in physician-graded erythema for active patch eyes versus placebo.

Reconstructive options for the medial canthus and eyelids following tumor excision.

General principles provide the framework for eyelid and periorbital reconstruction following tumor excision. Eyelid tumors involving the medial canthus region and/or lacrimal system add to the complexity of reconstructive planning. The nature of the tumor, patient and tissue factors, and surgeon preference guide repair design choices. Reconstructive considerations and options following medial canthal tumor resection are described.

Transvenous embolization of a dural carotid-cavernous sinus fistula via the inferior ophthalmic vein.

A 76-year-old woman presented with an acute onset of right periocular pain, diplopia, ocular injection, progressive proptosis, and periocular swelling. She had an unremarkable past medical history, and the erythrocyte sedimentation rate and complete blood count were normal. A carotid-cavernous sinus fistula was suspected, and an MRI demonstrated enlargement of the superior ophthalmic vein posterior to the globe and enlargement of the inferior ophthalmic vein throughout its entire course. Cerebral arteriography demonstrated a dural cavernous sinus fistula. The inferior ophthalmic vein was accessed via the inferonasal orbital space and was catheterized for delivery of multiple platinum coils to the cavernous sinus fistula. Follow-up venograms demonstrated occlusion of the fistula. At 2-month follow-up, there was a residual sixth nerve palsy and resolution of symptoms, including proptosis and periocular swelling.

Müller muscle-conjunctiva resection to correct ptosis in high-risk patients.

PURPOSE: Müller muscle-conjunctiva resection could be seen as a relative contraindication in patients with a prior history of a glaucoma filtering procedure, corneal disease, or corneal surgery. The concern centers around the theoretical risk of bleb-related complications or corneal damage from the palpebral conjunctival sutures. Our study aimed to determine whether any bleb- or cornea-related complications arose in patients who underwent Müller muscle-conjunctiva resection for ptosis correction. METHODS: A retrospective chart review was performed on 2 practices of oculofacial plastic surgeons from 2000 to 2006, including patients who had ptosis correction by Müller muscle-conjunctiva resection. Patients with a prior history of a glaucoma filtering procedure, corneal disease, or corneal surgery were identified. Each case was reviewed to determine whether any bleb- or cornea-related complications occurred. The postoperative improvement of ptosis measured by interpalpebral distance or margin reflex distance-1 also was noted. RESULTS: Forty-three patients and 55 eyes with a history of a glaucoma filtering procedure (13 patients/15 eyes), corneal disease (1 patient/1 eye), or corneal surgery (29 patients/39 eyes) who underwent Müller muscle-conjunctiva resection were identified. The average follow-up time was 212.4 days. No bleb-related complications occurred. One patient with a history of Reis-Bücklers dystrophy experienced a corneal abrasion. Fifty-two of 55 patients had objective improvement of their ptosis. CONCLUSIONS: Müller muscle-conjunctiva resection can provide an effective means for ptosis repair in patients with a prior history of a glaucoma filtering procedure, corneal disease, or corneal surgery. One temporary postoperative corneal complication occurred in our series.

A survey of desired skills to acquire in ophthalmology training: a descriptive statistical analysis.

BACKGROUND AND OBJECTIVE: To determine which skills are most important to clinicians and how they correlate with Accreditation Council for Graduate Medical Education (ACGME) competencies. PATIENTS AND METHODS: A descriptive analysis to test four hypotheses: specific skill sets are likely to be important/mandatory for residents to obtain during training; comprehensive and subspecialist ophthalmologists would likely value skills similarly; year of training would likely affect the ranking of skills; and surveying practicing ophthalmologist could help to modify the educational curriculum. RESULTS: Highest-ranked skill sets included interpersonal and communication skills (mean, 1.17 +/- 0.08), ocular trauma (mean, 1.28 +/- 0.26), and practice-based learning (mean, 1.37). Comprehensive ophthalmologists and subspecialists did not significantly differ in the ranking of skill sets. Year of graduation did not affect the ranking of skill sets. CONCLUSION: The ACGME core competencies of interpersonal and communication skills and practice-based learning were ranked as highly important to both comprehensive and subspecialty ophthalmologists. These are included in ACGME core competency requirements. These findings support ACGME core competencies and the need for continued evaluation of ophthalmology residents in all areas of medical training.

Bartonella henselae infection associated with neuroretinitis, central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss.

PURPOSE: To report a case of Bartonella henselae infection. DESIGN: Observational case report. METHODS: Review of the clinical, laboratory, photographic, and angiographic records of a patient with cat scratch disease associated with central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss. RESULTS: A 21-year-old man had no light perception in the left eye secondary to concurrent central retinal artery and vein occlusion believed to have resulted from infection with Bartonella henselae. Forty days later, he developed neovascular glaucoma in the left eye. CONCLUSION: Ocular complications associated with Bartonella henselae infection may include central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss.

Cytomegalovirus UL97 phosphotransferase mutations that affect susceptibility to ganciclovir.

Most ganciclovir (GCV)-resistant cytomegalovirus (CMV) isolates contain UL97 gene mutations at codon 460 or 520 or between codons 590 and 607, where an increasing variety of mutations have been detected, including deletions. To determine their phenotypic effect, 9 UL97 mutations not previously studied were transferred to drug-sensitive laboratory CMV strains that contained unique restriction sites developed for this purpose. Deletion of the entire codon range 591-607 conferred a 6-fold increase in GCV resistance, with little effect on viral replication. Some mutations found in clinical isolates, including C592G and A594T, conferred only 2-3-fold decreases in GCV susceptibility. For C592G, this phenotype was confirmed by transfer to different CMV strains and by restoration of full drug susceptibility after removal of the mutation. Low drug levels resulting from oral GCV therapy may predispose the virus to the initial selection of these low-grade UL97 resistance mutations and to later accumulation of other mutations and greater resistance.