Simple Incisionless Temporary Stabilization: An Adjunct to Lower Blepharoplasty.

Background: Lateral canthal tightening is indicated for patients undergoing lower eyelid blepharoplasty who have preexisting lower eyelid laxity or ectropion. A canthoplasty or canthopexy is indicated at the time of lower blepharoplasty to avoid postoperative complications, such as eyelid retraction or ectropion. Various surgical techniques are described to accomplish this goal, including canthopexy procedures, which usually access the lateral canthal tendon through an upper eyelid blepharoplasty or lateral canthal incision. Objectives: To describe an incisionless technique adjunctive to lower blepharoplasty, which stabilizes the lower eyelid in the week following blepharoplasty. Methods: This operative technique description and retrospective case series includes 15 patients who underwent a simple incisionless temporary stabilization (SITS) during lower eyelid blepharoplasty. The procedures were performed at the same outpatient office-based surgery center and were performed by the author surgeons. Patients were followed from 3 to 6 months postoperatively. Results: The SITS procedure during lower eyelid blepharoplasty successfully maintained a desirable functional and aesthetic eyelid position with minimal complications. One patient reported tearing postoperatively which was determined to be unrelated to the SITS and resolved by the 1-month follow-up visit. No patient had any other complications during the follow-up period. Conclusions: The SITS procedure was successfully utilized in patients with mild-to-moderate lower eyelid laxity and/or a negative vector to prevent postoperative ectropion and eyelid retraction. It is a more favorable alternative to temporary tarsorrhaphy, as it does not obstruct vision during healing and better secures the eyelid. It should not be used in patients with significant lower eyelid laxity that would place the patient at significant risk of ectropion and lower eyelid retraction related to swelling and inappropriate eyelid position during the early postoperative course.

Spontaneous orbital hemorrhage in a case of acute liver failure.

Purpose: To report an unusual case of spontaneous orbital hemorrhage in the setting of DIC and hepatic failure. Observations: A 33-year-old female presented to the Emergency Department (ED) with acute liver failure. During the first week of her hospital admission, she developed unilateral eyelid swelling and proptosis, prompting a consult to ophthalmology. Additional physical examination revealed significantly decreased visual acuity, extraocular muscle restriction, afferent pupillary defect, and increased intraocular pressure. Computed tomography (CT) and ultrasound confirmed the diagnosis of intraorbital hemorrhage. Aggressive management in the form of lateral canthotomy, cantholysis, and septolysis was unable to be performed due to the patient's multiple comorbidities outweighing the potential benefits. Conclusions and importance: This rare phenomenon is unique from previous existing literature in that the timing of the incident limited the therapeutic options for this patient, additional imaging in the form of ultrasound was utilized in the work-up, and to our knowledge this is the second case of spontaneous orbital hemorrhage as a complication of disseminated intravascular coagulation (DIC) caused by hepatic failure.

Long-acting opioid prescribing patterns of ophthalmic plastic surgeons in the medicare Part D database.

PURPOSE: To assess extended release/long acting (ER/LA) opioid prescribing patterns among ophthalmic plastic surgeons in the Centers for Medicare and Medicaid Services (CMS) Part D database. METHODS: A retrospective observational cohort study was conducted on oculoplastic surgeons in the CMS Part D database who prescribed ER/LA opioids from 2013 to 2017. American Society of Ophthalmic Plastics and Reconstructive Surgery (ASOPRS) and non-ASOPRS surgeons were analyzed as groups. Prescribers were also analyzed based on gender and practice experience. RESULTS: Oculoplastic surgeons (64 ASOPRS and 78 non-ASOPRS) were responsible for 1,177 ER/LA opioid prescriptions from 2013 to 2017. ASOPRS members accounted for 4.6% and non-ASOPRS members accounted for 7.5% of all ER/LA opioids prescribed by ophthalmologists over the study period (p= .02). The total number of ASOPRS and non-ASOPRS members prescribing ER/LA opioids decreased by 52% (p= .10) and 58% (p= .07) from 2013 to 2017 respectively. CONCLUSION: ER/LA opioids are indicated for treatment of chronic pain and may be appropriately prescribed by the oculoplastic surgeon in certain circumstances, however due to the higher risk of overdose injury, those circumstances must be defined and justified. While a relatively small number of oculoplastic surgeons (10.6% ASOPRS and 19.6% non-ASOPRS) prescribed ER/LA opioids from 2013 to 2017, non-ASOPRS oculoplastic surgeons wrote 23.5% more ER/LA opioid prescriptions over the study period. Over the 5-year study period there was a general decline in the prescribing of ER/LA opioids by oculoplastic surgeons. Reviewing the prescribing practices of oculoplastic specialists, regardless of professional affiliation, is necessary to understand the role of ER/LA opioids for all of ophthalmology.

The sensitivity and specificity of retinal and choroidal folds to distinguish between mild papilloedema and pseudopapilledema.

PURPOSE: To determine if the presence or absence of retinal and choroidal folds on SD-OCT imaging can distinguish between mild papilloedema and pseudopapilledema. DESIGN: Cross-sectional cohort study METHODS: Subjects with optic disc elevation (Frisen grades 1 and 2 only) were eligible to be enrolled prospectively. Pseudopapilledema was defined as a lack of change in optic disc appearance between two visits <6 months apart, and papilloedema was defined as change in optic disc appearance between two visits <6 months apart determined by review of fundus photographs by a masked neuro-ophthalmologist. Three masked neuro-ophthalmologists independently reviewed en face and axial optical coherence tomography (OCT) images of the optic nerve of the study subjects for the presence or absence of retinal and choroidal folds. Concordance was determined when there was agreement between at least 2 of the 3 observers. RESULTS: Forty-five subjects (78 eyes) met inclusion criteria. There were 32 eyes with papilloedema and 46 eyes with pseudopapilledema. Choroidal and/or retinal folds were detected in 38% of eyes (12/32) with papilloedema and 19.6% of eyes (9/46) with pseudopapilledema. Post-hoc analyses eliminated six questionable cases of pseudopapilledema that had ancillary testing suggestive of elevated intracranial pressure and resulted in one remaining eye (2%) with more certain pseudopapilledema that was found to have folds. En face OCT imaging was more sensitive (71%) in detection of folds than axial OCT imaging (57%). CONCLUSIONS: Choroidal and/or retinal folds on OCT are commonly observed in patients with mild papilloedema and are uncommon in those with pseudopapilledema. The presence of folds on OCT in patients presenting with disc elevation suggests papilloedema.

Laughter-Induced Transient Vision Loss in a Patient With Silent Sinus Syndrome.

BACKGROUND: To report a patient with silent sinus syndrome (SSS) who experienced transient ipsilateral monocular vision loss during intense laughter. METHODS: Case report. RESULTS: Our patient's transient vision loss completely resolved after maxillary sinus decompression and during 7 months of follow-up. CONCLUSIONS: Although the precise mechanism of our patient's vision loss remains undetermined, we suspect that the vascular supply to the eye and/or the optic nerve was compromised as the result of the combination of laughter (causing Valsalva maneuver and increased intrathoracic pressure) and SSS.

Sleep-Induced Apraxia of Eyelid Opening.

BACKGROUND: Apraxia of eyelid opening (AEO) primarily has been described as bilateral loss of volitional ability to open the eyes at certain times and often associated with neurodegenerative disease. Rarely, it can occur in isolation and as an idiopathic phenomenon. There are a few reports of unilateral AEO only on awakening from sleep. We report an additional 11 patients with this unusual variation of AEO. METHODS: Retrospective, observational case series of patients collected from 3 separate neuro-ophthalmology practices. RESULTS: All 11 patients were Caucasian women with a mean age of 59 years (range 35-80 years). All experienced AEO on awakening from sleep. Eight patients had unilateral AEO, and 3 had bilateral symptoms. The duration of episodes ranged from 3 weeks to several years. Ten of the patients reported manually elevating the eyelid to open it, while 1 patient waited for the eyelid to open spontaneously. After initial manual elevation, all patients reported normal function and position of the eyelids for the remainder of the day. Seven patients had a history of autoimmune disease. Slit-lamp and fundus examinations were negative for ocular pathology to explain the patients' symptoms, and 9 patients had unremarkable brain imaging. CONCLUSIONS: AEO occurring only on awakening from sleep is a rare entity. Neuroimaging and extensive laboratory testing are not indicated without associated neurologic or ocular findings. There may be a Caucasian female preponderance and autoimmune link in patients with AEO, but further studies are required.

The Role of Surgeon Technique in Current Practice Patterns for Combined Ptosis and Dermatochalasis.

PURPOSE: The goal of this study is to identify and describe the role of surgical incision preference, insurance reimbursement, and geographical location on the current ptosis repair practice patterns of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members. METHODS: A 9-question survey was designed with surveymonkey.com and a participation link was emailed to all active ASOPRS members' email addresses in February 2015. After a reminder email, the survey was closed and the results were analyzed. There are 3 major questions the survey data is to be used answer: 1) Surgical approach preference: The first question established preferred surgical technique (internal vs. external approach) for ptosis repair. This result was/is used to stratify the remaining responses into 2 groups. 2) Functional versus cosmetic surgical indication: Three clinical scenarios were presented for a functional versus cosmetic patient for ptosis repair and blepharoplasty. 3) Location: The responses were analyzed based on location to determine any geographic bias for surgical preference. For this analysis, the US was separated into 4 regions (West, Midwest, North, and South), as defined by the United States Census Bureau; all international respondents were grouped together. RESULTS: Three hundred and ten responses were included and analyzed; 61% preferred the internal surgical approach, there was no statistical significance to geographic location (p = 0.17). Surgeons who prefer the external surgical approach (76.1%) were more likely than internal (62.5%) to include a bundled (nonreimbursed) blepharoplasty at no additional charge in the setting of functional ptosis repair (p = 0.015). Treatment plans differed significantly in both groups between functional and cosmetic patients with visually significant ptosis (Margin Reflex Distance < 1.5) and moderate dermatochalasis; with both the internal and external group electing combined surgery at a higher rate in cosmetic patients (p < 0.01 for functional vs. cosmetic within each group, and internal vs. external repair). There was no statistical difference in the timeframe for adjusting external ptosis for functional or cosmetic patients (p = 0.79). More surgeons use nonabsorbable closure for cosmetic blepharoplasty patients (68.7%) than for functional (54.1%) surgery patients (p < 0.01). CONCLUSION: Previous studies have documented the immediate effect of Medicare reimbursement changes on the management of concurrent ptosis and dermatochalasis. This study illustrates current practice patterns for ptosis repair and blepharoplasty. The necessity of creating a separate surgical site for surgeons who prefer the internal approach to ptosis surgery to perform a functional blepharoplasty has a significant influence on surgeon's willingness to perform concurrent blepharoplasty as a nonreimbursed bundled procedure.