The Effect of Ptosis Surgery on Meibomian Glands and Dry Eye Syndrome.

PURPOSE: To investigate the effect of ptosis surgery on dry eye disease as measured by dry eye parameters and meibomian gland function. METHODS: This prospective, case series study included patients with involutional ptosis with no prior history of dry eye disease who were scheduled for a levator aponeurosis advancement procedure. Dry eye evaluation included the ocular surface disease index (OSDI) questionnaire as well as objective measurements, which included meibomian gland loss measured by meibography, meibomian gland disease grading, tear breakup time (TBUT), corneal and conjunctival fluorescein staining, tear meniscus height, and Schirmer testing. All dry eye measurements were recorded preoperatively and repeated 21-28 days postoperatively. RESULTS: A total of 30 eyes were included with a mean age of 65.6 ± 11.9 years. There was a significant improvement in margin reflex distance1 (MRD1) postoperatively ( p < 0.001) and a significant decrease in upper lid margin thickening ( p = 0.022). There were no significant differences between the pre- and postoperative measurements in meibomian gland loss, TBUT, corneal and conjunctival fluorescein staining, tear meniscus height, and the Schirmer test. OSDI was increased nonsignificantly postoperatively (16.094 vs. 24.296, respectively, p = 0.107). CONCLUSION: The levator aponeurosis advancement procedure does not affect the eyelid meibomian glands, nor does it cause an increase in dry eye signs and symptoms, according to the measured parameters.

Influence of COVID-19 mRNA vaccination on the efficacy and safety of Botulinum toxin type A injections.

BACKGROUND: Concerns have been raised recently regarding the efficacy and safety of Botulinum toxin type A (BTA) injections following COVID-19 vaccination. AIMS: To assess the influence of BNT162b2 mRNA vaccine on the safety and efficacy of BTA injections performed for aesthetic indications. METHODS: A retrospective cohort study followed patients undergoing periodic BTA treatments who completed two doses of BNT162b2 vaccine. The latency between BTA injections before and after getting vaccinated was assessed for all study participants. Efficacy and longevity of BTA was reflected and evaluated by the latency between BTA injections. Patients were longitudinally monitored for the development of adverse events. RESULTS: Forty-five patients were eligible for inclusion in the current study. The mean (standard deviation [SD]) age of patients was 48.3 (8.9) years and 40 (88.9%) patients were females. The mean (SD) number of pre- and post-COVID-19 vaccination BTA injections was 5.1 (2.6) and 3.1 (0.4), respectively. The average (SD) interval between BTA injections after COVID-19 vaccination (96.0 [12.3] days) was significantly shorter than before it (118.6 [22.7]; p < 0.001). No severe BTA-associated adverse events were registered after the administration of BNT162b2 vaccine. CONCLUSIONS: Our findings indicate that BTA might be less effective after COVID-19 vaccination. Further research is required to delineate the pathomechanism underlying this observation.

Rituximab for thyroid-associated ophthalmopathy.

BACKGROUND: Thyroid-associated ophthalmopathy (TAO) is the most frequent extrathyroidal manifestation of Graves' disease, affecting up to 50% of patients. It has a great impact on quality of life. Rituximab (RTX) is a human/murine chimeric monoclonal antibody that targets the CD20 receptor on B-lymphocytes. Preliminary work has shown that blocking this CD20 receptor with RTX may affect the clinical course of TAO by reducing inflammation and the degree of proptosis.  OBJECTIVES: This review update, originally published in 2013, assesses the efficacy and safety of using RTX for the treatment of TAO. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 2), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, Latin American and Caribbean Health Science Information database (LILACS), the ISRCTN registry, clinicaltrials.gov and the WHO International Clinical Trials Registry Platform (WHO ICTRP). There were no language restrictions in the electronic search for trials. We last searched the electronic databases on 22 February 2022.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of RTX administered by intravenous infusion using any dosage regimen for the treatment of active TAO in adults, compared to placebo or glucocorticoids treatment.  DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently scanned titles and abstracts, and screened full-text reports of potentially relevant studies. The outcomes of interest in this review were: clinical activity score (CAS), NOSPECS severity scale, proptosis (mm), palpebral aperture (mm), extraocular motility (degrees or diplopia rating scale), quality of life and adverse effects. MAIN RESULTS: We identified two studies that met the inclusion criteria in this updated review. Across both studies, the mean age of participants was 55 years and 77% were women. RTX compared to intravenous methylprednisolone (IVMP) One study, conducted in Italy, compared RTX (n = 15 after one participant withdrew) with IVMP (n = 16) for active TAO (CAS ≥ 3 out of 7 or 4 out of 10). We judged this study to be at low risk of bias in most domains, but it was stopped early because of disease reactivation in the comparator group (5/16 participants). This study provided low-certainty evidence that RTX may result in CAS improvement at 24 weeks compared to IVMP (15/15 versus 12/16 improved by ≥ 2 points; risk ratio (RR) 1.32, 95% confidence interval (CI) 0.98 to 1.78). Only very low-certainty evidence was available for the other outcomes: NOSPECS improvement by 2 or more classes (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); proptosis improvement by 2 mm or more (0/15 versus 1/16; RR 0.35, 95% CI 0.02 to 8.08); palpebral aperture improvement by 3 mm or more (2/15 versus 0/16; RR 5.31, 95% CI 0.28 to 102.38); motility improvement by 1 class or more (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); and improvement on the Graves' ophthalmopathy QoL scale by at least 6 points for "functioning" (5/14 versus 8/13; RR 0.58, 95% CI 0.25 to 1.32), and "appearance" (9/14 versus 6/13; RR 1.39, 95% CI 0.69 to 2.82). Adverse events were more common in the RTX group (RR 1.39, 95% CI 0.90 to 2.13; low-certainty evidence). Minor adverse effects (mild infusion reactions) were observed in most people receiving RTX at first infusion. Two participants experienced a major infusion reaction, likely cytokine release syndrome. RTX compared to placebo One study, conducted in the USA, enrolled 25 participants with active TAO (CAS ≥ 4 out of 7), comparing RTX (13 participants) to placebo. We judged this study to be at low risk of bias in most domains, but it was stopped early due to recruitment issues. It provided very low-certainty evidence on the following outcomes at 24 weeks: CAS improvement by 2 or more points (4/13 RTX versus 3/12 placebo; RR 1.23, 95% CI 0.34 to 4.40); NOSPECS improvement by 2 or more classes (2/13 versus 2/12; RR 0.92, 95% CI 0.15 to 5.56); proptosis improvement by 2 mm or more (2/13 versus 4/12; RR 0.46, 95% CI 0.10 to 2.08); palpebral aperture median change (0 mm in RTX group, in both eyes separately, versus -0.5 mm and 0.5 mm in placebo group right and left eye, respectively); motility median diplopia score (3 versus 2.5); SF-12 physical component median score (45.9 versus 40.3) and mental component median score (52.8 versus 46.1). More participants in the RTX group experienced adverse effects (8/13 versus 3/12; RR 2.46, 95% CI 0.84 to 7.18).  AUTHORS' CONCLUSIONS: There is currently insufficient evidence to support the use of RTX in people with TAO. Future studies investigating RTX in people with active TAO may need to be multi-centre in order to recruit enough participants to make an adequate judgement on the efficacy and safety of this novel therapy.

Global improvement in meibomian glands after chalazion surgery demonstrated by meibography.

PURPOSE: To evaluate the use of meibography as an objective measure of the effects of incision & curettage (I&C) chalazion surgery on meibomian gland loss and morphology as well as dry eye syndrome. METHODS: This prospective, interventional clinical study included adult patients with a primary chalazion which persisted despite conservative treatment. All patients underwent I&C surgery. The following parameters were compared both preoperatively and 21 days postoperatively: meibography, tear breakup time (TBUT), Schirmer test, meibum expression, tear meniscus height, meibomian gland dysfunction (MGD) grading, and the Ocular Surface Disease Index (OSDI). RESULTS: Thirty eyelids were enrolled in the study. The mean age ± SD was 40.56 ± 13.94 years. Meibography demonstrated a significant decrease in meibomian gland loss (P = 0.00) and improvement in morphology. The most common meibomian gland pathology preoperatively noted was morphological signs of atrophy that included fluffy areas and tortuous glands. Both of these findings improved postoperatively (P = 0.04 and P = 0.02, respectively). There were a significant change in MGD grading and a significant decrease in meibum expression score postoperatively (P = 0.00). TBUT and tear meniscus height also improved significantly (P = 0.00 and P = 0.003, respectively). The OSDI score improved significantly as well (P = 0.00). CONCLUSION: While incision and drainage surgery is a time-honored, standard treatment for chalazion, meibography now demonstrates a global improvement in the meibomian glands, not just the ones involved with the chalazion. In addition to the improvements in the clinical and dry eye syndrome parameters improvements, meibography findings demonstrate that early I&C surgery restores the meibomian glands architecture significantly.

Assessment of Lacrijet monocanalicular intubation for congenital nasolacrimal duct obstruction.

PURPOSE: To assess the success rate and complications of Lacrijet monocanalicular stent (FCI S.A.S, Paris, France) intubation in children treated for congenital nasolacrimal duct obstruction (CNLDO). METHODS: Retrospective review study which included children with CNLDO that were intubated with Lacrijet monocanalucilar silicone tube.The Lacrijet tube remained in place for 11-15 weeks post operatively and was removed in the clinic with topical anesthesia. Operative time was recorded for each case. All children were evaluated using the following parameters preoperatively and postoperatively: tear meniscus height, Fluorescein dye disappearance test (FDDT), and MUNK score. RESULTS: The study included 20 eyes with mean age of 26.25 ± 11.25 months. 17 eyes (85%) had undergone probing previously. Mean operation time of Lacrijet intubation was 8.5 min (95% CI 7.04-9.95). Mean follow-up period was 204.65 ± 105.27 days. Lacrijet intubation resulted in statistically significant improvements in tear meniscus height (P < .001), FDDT (P < 0.001), and MUNK score (P < 0.001) in all children. Two different sizes of Lacrijet intubations were used. Complete success was obtained in all cases. No complications were observed. CONCLUSIONS: Lacrijet lacrimal intubation has a high rate of success, shortens surgical time and has a low rate of complications in children with CNLDO.

Role of oncogenic viruses in the development ocular surface squamous neoplasia.

PURPOSE: The pathogenesis of ocular surface squamous neoplasia is not fully understood. Therefore, we evaluated the role of oncogenic viruses in the pathogenesis of ocular surface squamous neoplasia in Israel. METHODS: Patients with ocular surface squamous neoplasia were enrolled in this retrospective study. The specimens were taken during 2004-2015 from two big centers: Emek Medical Center, Afula and the Hadassah Medical Center, Jerusalem. All the specimens (totally 26) were analyzed by immunohistochemistry for evidence of oncogenic viruses that included Human Papilloma virus, Herpes Simplex virus and Cytomegalovirus infection and 14 samples were examined by polymerase chain reaction. In addition, all the samples were examined for Epstein Barr virus infection by immunohistochemistry and Epstein Barr encoding region test. RESULTS: Twenty-six patients were included with a mean age of 61.81 [Formula: see text] 3.83 years (mean [Formula: see text]. Immunohistochemistry staining and Epstein Barr encoding region test did not detect any of the oncogenic viruses in the 26 samples. Human Papilloma virus-16 and -18, and Herpes Simplex virus were detected by polymerase chain reaction in 14.2%, 7% and 7%, respectively. CONCLUSION: We conclude from our study that oncogenic viruses may play a role in the pathogenesis of ocular surface squamous neoplasia in Israel.

Filler Migration to the Orbit.

BACKGROUND: Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications. OBJECTIVES: We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed. METHODS: A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections. RESULTS: Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively. CONCLUSIONS: Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

The first UK national blepharospasm patient and public involvement day; identifying priorities.

PURPOSE: We describe the planning and outcomes of the first 'Blepharospasm Day' in the UK. Blepharospasm is a distressing condition for patients and carers. Our 'patient and public involvement' event aimed to: cultivate a more informed patient group via active dialogue, help clinicians more effectively prioritise research and to facilitate peer-to-peer support for affected patients and public. DESIGN: A national one-day event was organised by the oculoplastics department at Moorfields Eye Hospital. The event was divided into informative lectures delivered by professionals and a patient panel, during which patients shared their experiences and expectations. METHODS: Data were collected from a variety of sources including: an interactive voting "LiveWall" poster, a pre-event questionnaire; "living with Blepharospasm", transcripts from patient panel discussions; and a feedback questionnaire. RESULTS: The event was well-received with 100% of respondents rating it good or excellent. Four research themes were identified: "aetiology", "alternative treatments", "faster, more accurate diagnosis", and "symptom control". Delegates' self-reported knowledge of blepharospasm increased significantly after the event. Limitations of the BdSI severity-assessment tool were noted with 22% of respondents failing to utilise it appropriately. CONCLUSION: Through our innovative "Blepharospasm Day", patient's priorities for research were identified, delegates understanding of blepharospasm increased and an independent blepharospasm patients-representatives' group was established; a first in the UK. Furthermore, short-fallings identified in the BdSI tool highlight the need for better severity-assessment tools. We demonstrate the benefits of the 'patient and public involvement' approach in the management of complex conditions such as blepharospasm. ABBREVIATIONS: PPI: Patient and public involvement; SLV-PSP: sight loss and vision sector - priority setting partnership; BRC: Biomedical Research Centre; NIHR: National Institute for Health Research; BsDI: Blepharospasm Disability Index.

Tocilizumab for thyroid eye disease.

BACKGROUND: Thyroid eye disease (TED) is an autoimmune disorder that constitutes a major clinical and therapeutic challenge. Current treatment options for moderate-to-severe TED include immunotherapy, orbital radiotherapy and decompression surgery. Limited drugs of proven efficacy are available for the treatment of people with TED. Given the role in the pathogenesis of TED of interleukin (IL)-6 expression in adipocytes, fibroblasts and macrophages, the proposed theory is that inhibition of IL-6 by tocilizumab may be an effective treatment in TED by directly reducing the inflammatory response. In addition, there is an unmet need for a new treatment that can modify the natural course of the disease and reduce the incidence of late complications that can occur as a result of fibrosis following inflammation. OBJECTIVES: To investigate the efficacy and harms of tocilizumab for the treatment of people with TED. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); MEDLINE Ovid; Embase Ovid; LILACS BIREME; OpenGrey; the ISRCTN registry; ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the EU Clinical Trials Register. The date of the search was 31 July 2018. SELECTION CRITERIA: We searched for trials of tocilizumab administered by intravenous infusion using any dosage regimen, compared with placebo or intravenous glucocorticoid therapy for people with TED. DATA COLLECTION AND ANALYSIS: We planned to use standard methods recommended by Cochrane. The primary outcome was change in TED score (as defined by investigators). Secondary outcomes included measurement of the following parameters: change in proptosis, change in extraocular motility, change in palpebral aperture measurements, number of relapses, development of optic neuropathy and change in quality of life score. We planned to measure these outcomes at three months (range two to six months) and 12 months (range six to 18 months) post-treatment. Adverse outcomes included any adverse effects identified in the trials at any time point. MAIN RESULTS: No studies met the inclusion criteria of this review. We found one randomised, placebo-controlled, double masked study (NCT01297699). This study plans to evaluate the efficacy and harms of tocilizumab administration in people with moderate-to-severe or sight-threatening graves' ophthalmopathy (GO), that had not responded adequately to treatment with intravenous corticosteroid pulses. It was completed in December 2015 and will be assessed for inclusion in the review when data become available. AUTHORS' CONCLUSIONS: There is currently no evidence from randomised controlled trials evaluating the efficacy and harms of tocilizumab for the treatment of people with TED.

Phenotypes of Thyroid Eye Disease.

PURPOSE: To describe a new classification system of thyroid eye disease (TED) based on the phenotypic features (clinical and radiologic) of the disease. METHODS: Clinical features, photographic, and orbital imaging of TED patients were considered in relation to their natural history and treatment response in the experience of the author. Phenotypically distinct categories of patients were identified and described. RESULTS: Six phenotypes of TED are observed: 1) congestive (active inflammatory), 2) "white eye" expansion, 3) "hydraulic" apex, 4) "white eye" apex, 5) cicatricial active, and 6) cicatricial passive. CONCLUSIONS: The observable characteristics of TED are determined by the underlying pathophysiology of the disease. TED is heterogeneous in its underlying pathogenesis, clinical manifestations, and response to medical and surgical treatment modalities. Several previous categorizations of the clinical appearance of TED exist, but they are dichotomous and underrepresent the heterogeneity of the disease. The authors present clinical and radiologic features of 6 different classes or phenotypes of TED and their response to different treatments.

Common Orbital Infections ~ State of the Art ~ Part I.

Infections of the orbit and periorbita are relatively frequent, and can cause significant local and systemic morbidity. Loss of vision occurs in more than 10% of patients, and systemic sequelae can include meningitis, intracranial abscess, and death. Numerous organisms infect the orbit, but the most common are bacteria. There are many methods through which orbital infections occur, with infection from the neighboring ethmoid sinuses the most likely cause for all age groups. Prompt management is essential in suspected orbital cellulitis, and involves urgent intravenous antibiotics, rehydration, and treatment of any co-existent underlying systemic disease, e.g., diabetes, renal failure. This review summarizes the common infectious processes of the orbit in both pediatric and adult groups. We review pathophysiology, symptoms, signs, and treatment for infectious orbital processes.

Rare Orbital Infections ~ State of the Art ~ Part II.

Infections of the orbit and periorbita are relatively frequent. Identifying unusual organisms is crucial because they can cause severe local and systemic morbidity, despite their rarity. Opportunistic infections of the orbit should be considered mainly in debilitated or immunocompromised patients. The key to successful management includes a high index of suspicion, prompt diagnosis, and addressing the underlying systemic disease. This review summarizes unusual infectious processes of the orbit, including mycobacterial, fungal, and parasitic infections, as well as their pathophysiology, symptoms, signs, and treatment.

Orbital Inflammation as a Presenting Sign for CREST Syndrome.

A 61-year-old male was referred with a week's history of a painful and swollen left eye. Examination revealed normal visual acuities, left proptosis and global restriction of ocular ductions, and subretinal fluid at the macula. CT imaging confirmed thickening of the posterior scleral coat, with an associated choroidal effusion. Serology revealed positive antinuclear antibodies with a centromere staining pattern; subsequent rheumatology review revealed extensive telangiectasia with digital ulceration in both hands, and a diagnosis of limited cutaneous systemic sclerosis was made. Orbital inflammatory disease is often the initial presentation of systemic diseases such as sarcoidosis, granulomatosis with polyangiitis, and IgG4 disease. Limited cutaneous systemic sclerosis is rarely encountered in the context of orbital inflammation, but is a further systemic association, reminding the clinician of the diagnostic importance of peripheral symptoms and serological markers in patients presenting with orbital inflammation and scleritis.

Identification of human papillomavirus in pterygium.

PURPOSE: The purpose of this study was to evaluate the involvement of human papillomavirus in the pathogenesis of primary and recurrent pterygium in northern Israel. METHODS: A retrospective study examined 100 randomly chosen pterygium specimens with solar elastosis, from 100 patients who underwent pterygium surgery during 2012-2013 at the Emek Medical Center. All the specimens were analysed for evidence of human papillomavirus infection by immunohistochemistry. RESULTS: Human papillomavirus was not detected in any of the 100 pterygia samples by immunohistochemistry. These used samples were taken from 100 patients with mean age of 51.5 years and a primary: recurrent ratio of 8.09:1. CONCLUSION: We conclude from our study that human papillomavirus infection does not appear to be an important pathogenic factor of pterygium in Israel.

Fornix triamcinolone injection for thyroid orbitopathy.

PURPOSE: In this pilot study we aimed to examine the association between eyelid fornices triamcinolone injections and clinical activity score in patients with active thyroid orbitopathy. METHODS: Adult patients aged 18 years or older, diagnosed with active thyroid orbitopathy and a clinical activity score ≥ 3 were recruited to this interventional prospective pilot study between 2010 and 2013. Three upper and lower fornices injections of triamcinolone acetate 20 mg (40 mg/ml) were administered at 4-week intervals. Each patient included was followed up for a period of 6 months. Clinical activity score was estimated at each monthly visit. Extraocular muscle thickness was measured by ultrasound examination at entrance and at the last visit. RESULTS: Eleven eyes of seven patients were included in our study. Initial clinical activity score was 3.81 ± 1.80 and fell to 0.63 ± 0.72 during a 6-month follow-up. There was a significant difference in clinical activity score between the baseline examination and the following visits (p-value < 0.0001). Ultrasound examination showed a significant decrease in medial and lateral rectus muscle thickness following treatment; median difference -0.93 and -0.58, respectively (p-value < 0.005). Lid retraction was reduced by the treatment. Side effects included a transitory increase in intraocular pressure in one patient, which was controlled with topical medication. CONCLUSIONS: In this pilot study a series of three separate triamcinolone fornix injections at 4-week intervals reduces the inflammatory effects of thyroid orbitopathy, as measured by clinical activity score. The treatment was simple, effective, and safe eliminating the side effects associated with systemic corticosteroid use.

Evaluation of intraocular pressure according to corneal thickness before and after excimer laser corneal ablation for myopia.

Intraocular pressure is affected by corneal thickness and biomechanics. Following ablative corneal refractive surgery, corneal structural changes occur. The purpose of the study is to determine the relationship between the mean central corneal thickness (CCT) and the change in intraocular pressure measurements following various corneal ablation techniques, using different measurement methods. Two hundred myopic eyes undergoing laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) were enrolled into a prospective, non-randomized study. Corneal parameters examined included full ocular examination, measurement of CCT, corneal topography, corneal curvature and ocular refractivity. Intraocular pressure measurements were obtained using three different instruments-non-contact tonometer, Goldmann applanation tonometer and TonoPen XL (TonoPen-Central and TonoPen-Peripheral). All measurements were performed pre-operatively and 4 months post-operatively. Post-operative intraocular pressure was significantly lower than pre-operative values, with all instruments (p value < 0.001, Student's t-test). The post-operative intraocular pressure decrease was smallest using the Tonopen-XL compared to the Goldmann applanation tonometer and non-contact tonometer (p value < 0.001, ANOVA). Intraocular pressure readings are significantly reduced following corneal ablation surgery. We determined in our myopic patient cohort that the TonoPen XL intraocular pressure measurement method is the least affected following PRK and LASIK as compared to other techniques.