More Than Under-Eye Bags: Treatment of Formidable Festoons.

A 64-year-old male with no medical care over the last decade was transferred from his local emergency room to a level 1 trauma center following an unwitnessed fall. Upon ophthalmic evaluation, he was noted to have significant lethargy and bilateral large festoons with secondary ectropion. Laboratory workup revealed severe hypothyroidism, consistent with myxedema coma, and his lethargy improved with medical treatment. The festoons were surgically removed to address the ectropion, and the patient was satisfied with the results following a single procedure. This case report features the largest reported festoons to date in the literature and emphasizes the importance of balancing cosmesis with function during surgical excision and correction of ectropion.

Primary Gouty Tophi Involving the Eyelid.

A 51-year-old male with no known history of gout was referred by his optometrist for bilateral lower eyelid cysts near the puncta. The lesions were not painful but were cosmetically concerning and excision was desired. Utilizing local anesthesia, the lesions were excised and sent to pathology for review. Pathology noted lesions to be "gouty tophus." Given that our patient had no history of gout, this is the first case report of gouty tophus on the eyelid being the initial manifestation of gout.

Nose-Ocomial Pulmonary Edema: A Rare Complication of Oxymetazoline.

A 72-year-old female with epiphora presented for outpatient punctoplasty with probing and lacrimal stent placement. Oxymetazoline was administered intranasally and the case was completed in standard fashion. Postoperatively, the patient desaturated with a workup revealing elevated cardiac enzymes, pulmonary congestion, and sinus bradycardia. However, the final cardiac testing was noncontributory, suggesting flash pulmonary edema secondary to intranasal oxymetazoline. This case highlights a rare presentation of pulmonary compromise secondary to oxymetazoline, emphasizing the importance of intraoperative and postoperative vigilance in simple outpatient procedures.

Effects of Smoking on Outcomes of Thyroid Eye Disease Treated with Teprotumumab: A Retrospective Cohort Study.

Introduction: Smoking has been demonstrated to worsen the disease process and conventional treatment outcomes of thyroid eye disease. However, the effects of smoking on outcomes of thyroid eye disease treated with the novel therapeutic teprotumumab are currently unknown. Our study compares response to teprotumumab treatment between smokers and non-smokers with thyroid eye disease. Methods: A single-center, retrospective cohort study was conducted. Inclusion criteria were patients diagnosed with thyroid eye disease who had started or completed therapy with teprotumumab at the time of our data collection. Main outcome measures included reduction in clinical activity score, diplopia, and proptosis. Results: All smokers had type 2 thyroid eye disease prior to treatment and demonstrated less improvement in diplopia, proptosis, and overall clinical activity score compared to non-smokers with thyroid eye disease. There was no significant difference between smokers and non-smokers in baseline variables (sex, thyroid stimulating hormone (TSH), thyroxine (T4), triiodothyronine (T3), number of infusions completed). Data analysis revealed a statistically significant difference in proptosis reduction between non-smokers and smokers. Conclusions: Smoking is a modifiable risk factor which portends a worse response to treatment of thyroid eye disease with teprotumumab.

Bell's palsy following COVID-19 vaccine administration in HIV+ patient.

PURPOSE: COVID-19 immunizations are novel and there is widespread public concern for the lack of data on their potential adverse effects. Cases of Bell's palsy following COVID-19 vaccination were reported disproportionately in the vaccine group during phase 3 clinical trials and have now been reported multiple times post-licensure. The U.S. Food and Drug Administration has stated the frequency of Bell's palsy in the vaccine group is consistent with the expected background rate of Bell's palsy in the population but recommends "surveillance for cases of Bell's palsy with deployment of the vaccine into larger populations."1 Here we present a case of Bell's palsy following Pfizer/BioNTech BNT162b2 COVID-19 vaccine administration in an HIV+ patient as a potential adverse event following immunization. OBSERVATIONS: A 60-year-old male with HIV presented to the emergency department for evaluation of left facial droop. He had received the first dose of Pfizer/BioNTech BNT162b2 vaccination approximately 42 hours prior to symptom onset. Physical examination in the ED revealed left-sided facial weakness with involvement of the forehead, inability to raise left eyebrow, and inability to close left eye with sensation and strength intact in bilateral upper and lower extremities. Physical examination in our outpatient ophthalmology clinic on day 2 following symptom onset was revealing for mild exposure keratopathy, 5 mm lagophthalmos and very poor Bell's reflex in the left eye with otherwise normal exam findings. These findings were judged to be consistent with uncomplicated Bell's palsy. He was provided ophthalmic lubricating ointment to use hourly, artificial tears as needed, moisture goggles and suggested to tape eyelids nightly in addition to standard systemic glucocorticoid and antiviral therapy. The patient's facial weakness and exposure keratopathy were completely resolved at approximately 90 days following symptom onset. CONCLUSIONS: Though there is insufficient evidence at this time to support any causal association between COVID-19 vaccines and Bell's palsy, the temporal relationship between vaccination and classic clinical features of Bell's palsy in our patient certainly raises suspicion for association with Pfizer/BioNTech BNT162b2 COVID-19 vaccination. It will be important to monitor for cases of Bell's palsy following COVID-19 immunization as an increasing percentage of the global population receives vaccination.

Unilateral retinopathy post perilesional interferon α2b injections for ocular surface squamous cell carcinoma.

PURPOSE: To describe the clinical course of a patient presenting with unilateral retinopathy after perilesional interferon alpha injections for treatment of ocular surface squamous cell carcinoma. OBSERVATIONS: A patient, who was being treated with interferon alpha for ocular squamous cell carcinoma, presented with new onset decreased vision in her left eye. Upon examination, she was found to have cotton wool spots and retinal hemorrhages in the affected eye. CONCLUSIONS AND IMPORTANCE: Retinopathy is a well-documented side effect of systemic usage of interferon alpha. However, retinopathy has not been well discussed in the scenario of perilesional injections of interferon. It is important for clinicians to monitor for such pathology when using interferon alpha not only systemically, but also locally.

Early Experience With Nonporous Polyethylene Barrier Sheet in Orbital Fracture Repair.

PURPOSE: The aim of this study was to evaluate the efficacy of the nonporous polyethylene barrier sheet as an alternative for nylon foil (SupraFOIL) implants in repair of orbital fractures. METHODS: This is a prospective, case series using the Stryker 0.4-mm-thick nonporous polyethylene barrier sheet in all patients over the age of 18 years presenting with orbital fractures from December 2014 to June 2015. Patient's age, location of fracture, etiology of injury, presence of preoperative restriction and diplopia, and postoperative diplopia and/or enophthalmos was recorded. Institutional review board approval was received, and consent was obtained from all participants. Patients were followed for at least 6 months when possible. Scanning electron microscopy was used to compare the thickness, surface characteristics, and porosity of the nonporous polyethylene barrier and nylon foil implants. Beam deflection testing was also performed to compare the biomechanical properties of each implant. RESULTS: Forty-six patients who underwent repair of orbital fractures with the nonporous polyethylene barrier sheet were included in this series. Average age was 43.3 years (range: 18-84 years). Twenty-six of 46 patients (56.5%) were males, and 20 (43.4%) were females. The most common causes of injuries were assault (38.3%), falls (25.5%), motor vehicle accident (14.9%), and sports related (10.5%). Twenty of 46 patients (43.4%) had isolated orbital floor, and 2 patients (4.3%) had isolated medial wall fractures. Fifteen patients (32.6%) had combined floor and medial wall fractures involving the inferomedial orbital strut, and 9 (19.6%) had floor fractures associated with zygomaticomaxillary complex or lateral wall fractures. Twenty-eight patients (60.9%) had preoperative diplopia. Timing of surgery was between 3 and 55 days, with the median of 11.5 days. Five of 46 patients (10.8%) had residual diplopia at their 1-week postoperative visit, 4 of those patients' diplopia had resolved at 2 months postoperatively. One patient had residual diplopia at 6-month follow up. Electron microscopy showed that the 0.4-mm nonporous polyethylene barrier implant was thinner (0.33 mm) than expected and thinner than 0.4-mm SupraFOIL (0.38 mm). Scanning electron microscopy exhibited that the surface of the nonporous polyethylene barrier was smooth and nonporous. Beam deflection testing showed that for small forces (<100 mN), the 2 materials behaved nearly identically, but at higher forces, the nonporous polyethylene implant exhibited less stiffness. CONCLUSIONS: The use of nonporous polyethylene barrier sheet implant for orbital fracture repair is a safe and effective alternative to nonporous nylon foil implants. There were no complications and one case of residual diplopia (2.1%) in this case series.

Deep lateral wall orbital decompression following strabismus surgery in patients with Type II ophthalmic Graves' disease.

PURPOSE: Surgical management of ophthalmic Graves' disease traditionally involves, in order, orbital decompression, followed by strabismus surgery and eyelid surgery. Nunery et al. previously described two distinct sub-types of patients with ophthalmic Graves' disease; Type I patients exhibit no restrictive myopathy (no diplopia) as opposed to Type II patients who do exhibit restrictive myopathy (diplopia) and are far more likely to develop new-onset worsening diplopia following medial wall and floor decompression. Strabismus surgery involving extra-ocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with Type II patients who have already undergone medial wall and floor decompression and strabismus surgery found, when additional decompression is necessary, deep lateral wall decompression (DLWD) appears to have a low rate of post-operative primary-gaze diplopia. METHODS: A case series of four Type II ophthalmic Graves' disease patients, all of whom had already undergone decompression and strabismus surgery, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with DLWD. Institutional Review Board approval was granted by the University of Kansas. RESULTS: None of the four patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following DLWD. CONCLUSIONS: While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Graves' disease, for proptosis following consecutive strabismus surgery, DLWD appears to be effective with a low rate of recurrent primary-gaze diplopia.

Retrospective chart review of the use of imaging and biopsy in the diagnosis of optic nerve sheath meningiomas and intra-conal orbital lymphomas at a single institution.

Optic nerve sheath meningiomas (ONSM) and intra-conal orbital lymphomas are common entities on the differential of a retrobulbar optic nerve involving space-occupying lesion. In this study, we compare the pre-surgical diagnosis, based on clinical presentation and neuroimaging, to the surgical pathology results of intra-conal orbital lymphomas and ONSM. This is an IRB approved retrospective chart review of orbital lymphomas and optic nerve sheath meningiomas biopsied by a single surgeon over a 4-year period at a single institution. Pre-surgical diagnosis and surgical pathology were compared. Fifteen cases of orbital lymphoma were identified. Fourteen were excluded based on extra-conal location. The single histologically confirmed intra-conal orbital lymphoma had a pre-surgical diagnosis of ONSM. Four cases of optic nerve sheath meningioma were identified. Three of the 4 cases of histologically confirmed ONSM had a pre-surgical diagnosis of ONSM. One of the 4 had a pre-surgical diagnosis of lymphoma. Diagnosis based on surgical pathology differed from the pre-surgical diagnosis in 2 out of 5 cases showing that clinical diagnosis does not always correlate with histologic diagnosis. Although both diseases are typically managed with radiation therapy, the treatment dosage and systemic disease implications are very different. These findings emphasis the importance of biopsy in the diagnosis of orbital lesions surrounding the optic nerve.

Metastatic prostate carcinoma to the orbit as the first presentation of disease.

Prostate carcinoma is a common tumor of the older adult male. It is associated with bony metastases, particularly to the axial skeleton. We present two case histories; in both cases, the patients had no prior history of prostate carcinoma. Both cases were diagnosed with CT imaging, elevated PSA, and biopsy. Additionally, they were treated with surgical resection and hormone modulation therapy. While bony metastases are frequently associated with advanced disease, they can also be a cause of presenting symptoms. The CT imaging in these two cases showed the classic hyperostotic findings of prostate cancer. Prostate cancer may cause osteoblastic lesions in contrast to other metastatic bone lesions, which cause destructive osteolytic lesions. During excisional surgery, the tumor was inspected and many stalactite-like lesions were present on the gross sample. We present these and compare them to the CT imaging.

Surgical approach to limiting skin contracture following protractor myectomy for essential blepharospasm.

PURPOSE: To report our experience with protractor myectomy in patients with benign essential blepharospasm who did not respond to serial botulinum toxin injection, and to describe intra- and postoperative techniques that limited skin contracture while also providing excellent functional and cosmetic results. METHODS: The medical records of patients with isolated, benign, essential blepharospasm who underwent protractor myectomy from 2005 to 2008 by a single surgeon were reviewed retrospectively. The technique entailed operating on a single eyelid during each procedure, using a complete en bloc resection of all orbicularis tissue, leaving all eyelid skin intact at the time of surgery, and placing the lid under stretch with Frost suture and applying a pressure dressing for 5-7 days. RESULTS: Data from 28 eyelids in 7 patients were included. Average follow-up was 21.5 months (range, 4-76 months). Of the 28 eyelids, 20 (71.4%) showed postoperative resolution of spasm, with no further need for botulinum toxin injections. In the 8 eyelids requiring further injections, the average time to injection after surgery was 194 days (range, 78-323 days), and the average number of injections was 12 (range, 2-23 injections). All but one eyelid had excellent cosmetic results, without signs of contracture; one eyelid developed postoperative skin contracture following premature removal of the Frost suture and pressure dressing because of concerns over increased intraocular pressure. CONCLUSIONS: In our patient cohort, this modified technique resulted in excellent cosmetic and functional results and limited postoperative skin contracture.

Trends in Orbital Decompression Techniques of Surveyed American Society of Ophthalmic Plastic and Reconstructive Surgery Members.

PURPOSE: To assess current members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) regarding preference in surgical techniques for orbital decompression in Graves' disease. METHODS: A 10-question web-based, anonymous survey was distributed to oculoplastic surgeons utilizing the ASOPRS listserv. The questions addressed the number of years of experience performing orbital decompression surgery, preferred surgical techniques, and whether orbital decompression was performed in collaboration with an ENT surgeon. RESULTS: Ninety ASOPRS members participated in the study. Most that completed the survey have performed orbital decompression surgery for >15 years. The majority of responders preferred a combined approach of floor and medial wall decompression or balanced lateral and medial wall decompression; only a minority selected a technique limited to 1 wall. Those surgeons who perform fat decompression were more likely to operate in collaboration with ENT. Most surgeons rarely remove the orbital strut, citing risk of worsening diplopia or orbital dystopia except in cases of optic nerve compression or severe proptosis. The most common reason given for performing orbital decompression was exposure keratopathy. The majority of surgeons perform the surgery without ENT involvement, and number of years of experience did not correlate significantly with collaboration with ENT. CONCLUSIONS: The majority of surveyed ASOPRS surgeons prefer a combined wall approach over single wall approach to initial orbital decompression. Despite the technological advances made in the field of modern endoscopic surgery, no single approach has been adopted by the ASOPRS community as the gold standard.

Clinical and microbiologic features of dacryocystitis-related orbital cellulitis.

Dacryocystitis-related orbital cellulitis is a relatively rare condition, and large case series of this clinical entity have been reported. This study was undertaken to identify a larger cohort of patients with this ailment, with the intent of defining its clinical and microbiologic features. Case logs from four institutions were reviewed to identify patients that suffered from dacryocystitis-related orbital cellulitis. A retrospective chart review was then performed to identify clinical features, management strategies, microbiologic features, and outcomes. A dedicated statistical software package was utilized to identify correlations between these variables. 13 patients (7 females, 6 males; mean age = 57.2 years, range = 7-89 years) were identified. One patient carried a diagnosis of immunosuppressive disease. All patients underwent emergent surgical drainage and received intravenous antibiotics. Primary acquired nasolacrimal duct obstruction was found to be the underlying etiology in nine cases (69.2%), whereas four patients suffered from specific causes of their obstructions. An average of 1.07 organisms/patient (standard deviation = 0.49 organisms/patient) were recovered from microbiologic cultures, and Gram-positive bacteria represented the majority of cultured organisms. All patients experienced either stable or improved vision upon discharge. The relationships between a specific etiology and the possibility of vision loss or the number of organisms cultured, between the number of organisms cultured and vision loss, and immunosuppression and vision loss or the number of organisms cultured were all not statistically significant (p > 0.05). Dacryocystitis-related orbital cellulitis most commonly occurs in adult patients who do not carry immunosuppressive diagnoses and suffer from primary obstructions. Multiple microbiologic species may cause this problem, although Gram-positive organisms are most common. With appropriate management, stable or improved vision can be achieved.

Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene.

Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue. Foreign body reaction to porous polyethylene has been reported in facial tissue, but to our knowledge, not in the orbit. The authors report 2 cases of foreign body inflammatory giant cell reaction in patients who underwent orbital fracture repairs with porous polyethylene implants.

Farris-Tang retractor in optic nerve sheath decompression surgery.

PURPOSE: Our purpose is to introduce the use of the Farris-Tang retractor in optic nerve sheath decompression surgery. METHODS: The procedure of optic nerve sheath fenestration was reviewed at our tertiary care teaching hospital, including the use of the Farris-Tang retractor. RESULTS: Pseudotumor cerebri is a syndrome of increased intracranial pressure without a clear cause. Surgical treatment can be effective in cases in which medical therapy has failed and disc swelling with visual field loss progresses. Optic nerve sheath decompression surgery (ONDS) involves cutting slits or windows in the optic nerve sheath to allow cerebrospinal fluid to escape, reducing the pressure around the optic nerve. We introduce the Farris-Tang retractor, a retractor that allows for excellent visualization of the optic nerve sheath during this surgery, facilitating the fenestration of the sheath and visualization of the subsequent cerebrospinal fluid egress. Utilizing a medial conjunctival approach, the Farris-Tang retractor allows for easy retraction of the medial orbital tissue and reduces the incidence of orbital fat protrusion through Tenon's capsule. CONCLUSION: The Farris-Tang retractor allows safe, easy, and effective access to the optic nerve with good visualization in optic nerve sheath decompression surgery. This, in turn, allows for greater surgical efficiency and positive patient outcomes.

Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury.

OBJECTIVES/HYPOTHESIS: Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient's history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision. STUDY DESIGN: A retrospective clinical chart review was performed at a tertiary academic medical center. METHODS: Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test. RESULTS: In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P = 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P = 0.0029 and 0.0001, respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P = 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury. CONCLUSION: Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Subjects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment. LEVEL OF EVIDENCE: IV.

Radiographic evidence of prominent retro and suborbicularis oculi fat in thyroid-associated orbitopathy.

PURPOSE: To compare the radiological differences in retro-orbicularis oculi fat (ROOF) and suborbiculars oculi fat (SOOF) among patients with thyroid-associated orbitopathy (TAO) and normal subjects using computed tomography (CT). METHODS: A retrospective analysis of orbital CTs was performed in 39 consecutive patients, who were imaged between October 2005 and June 2009. Bilateral orbital CTs of 16 patients with a final report significant for thyroid orbitopathy and 23 normal subjects were evaluated. All of the CTs consisted of 0.75 mm thick axial slices with 1.5 mm coronal reconstructions. Using the axial soft tissue windows, the ROOF and SOOF tissues were identified. The maximum ROOF thickness was measured perpendicular to the frontal bone, immediately superior to the supraorbital rim. Similarly, the maximum SOOF thickness was measured perpendicular to the zygomatic bone, immediately inferolateral to the infraorbital rim. The radiologist was blinded to the CT reports while conducting the measurements. Multivariable analysis of the two groups was then performed for comparison. RESULTS: Seventy-eight ROOF and SOOF measurements were obtained from 16 TAO patients with and 23 patients without TAO. The female-to-male ratio was 6:1 in the TAO group and only 3:2 among the normal subjects. The mean axial ROOF thicknesses was 3.8 ± 1.9 for TAO patients and 2.8 ± 1.0 mm in patients without TAO, while the SOOF thickness was 4.4 ± 1.0 and 3.4 ± 1.0 mm in the 2 groups, respectively. To account for bilateral measurements, the mixed model analysis was used. After controlling for age, gender, and ethnicity, the mean TAO ROOF and SOOF thicknesses were 1.0 mm (p = 0.04) and 0.9 mm (p < 0.01) greater than the control group, respectively. CONCLUSION: Retro-orbicularis oculi fat (ROOF) and suborbicularis oculi fat (SOOF) hypertrophy are two additional radiologic CT measurements that may be valuable in establishing the diagnosis of thyroid-associated orbitopathy.