Supraorbital Neuralgia Associated With Thyroid Eye Disease.

PURPOSE: To identify the relationship between thyroid eye disease (TED) and supraorbital neuralgia (SON) and establish a reliable approach to the diagnosis and management of TED-associated SON. METHODS: This retrospective study included 1,126 patients. Demographics, active and inactive phase status and duration, and reactivation rate were noted. TED clinical activity was determined using the vision, inflammation, strabismus, and appearance assessment system, and TED severity was classified using the European Group of Graves' Orbitopathy system. Subtypes of periorbital pain were identified, and suspected SON was confirmed by supraorbital nerve block. RESULTS: Of the study's 1,126 patients, 935 (83%) were deemed "active" at some point during the follow up and 34 (3%) remained "active" at the study's conclusion. Of the 2,251 eyes studied, 1,193 (53%) underwent orbital decompression. Of the 1,126 patients, 946 (84%) reported a retrobulbar "pressure" or "aching," but a distinct, more debilitating pain suggestive of SON was reported in 91 (8%). All 91 patients were given a supraorbital nerve block, and all had complete pain resolution lasting from hours to weeks. Eighty-eight (97%) of the 91 patients with SON-type pain underwent orbital decompression compared to 496 (48%) of the 1,035 without SON-type pain (p < 0.00001). A difference was found in the rate of TED reactivation between those with SON-type symptoms (8%) as compared to those without (2%), p = 0.01. CONCLUSIONS: SON of uncertain etiology appears to be a previously underreported but significant pain associated with TED. Paradoxically, although the SON does not appear to be related to the type or severity of TED on standard rating scales, the presence of SON was found to be associated with increased likelihood of both orbital decompression and TED reactivation.

Traumatic optic neuropathy and second optic nerve injuries.

IMPORTANCE: Current controversy about the primary treatment of traumatic optic neuropathy (TON) has anchored on final vision following injury, but, to our knowledge, no study has examined the effect of different treatments on regaining and protecting optic nerve reserve or on the outcome of second optic nerve injuries. OBJECTIVE: To assess vision improvement in patients treated by various methods who have a second incidence of TON. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review of 12 patients with a second TON seen in an 18-year period (mean follow-up, 11.3 months) at a single tertiary care oculoplastic practice. INTERVENTIONS: Observation, high-dose corticosteroids, optic nerve decompression, or high-dose corticosteroids plus optic nerve decompression. MAIN OUTCOMES AND MEASURES: Change in vision on the Snellen eye chart. RESULTS All second TON events involved the same-side optic nerve as initially injured, and with observation alone, corticosteroids, or corticosteroids and partial optic canal decompression, all patients had vision improvement after their initial injury (P = .004). However, following the second optic nerve injury, most patients' vision fell to the pretreatment level of the first injury, and subsequent management of the second injury with corticosteroids and/or optic canal decompression provided little or no vision return (P = .05). In contrast, optic canal decompressions performed for 91 primary TON injuries resulted in 82.4% having some degree of vision improvement. CONCLUSIONS AND RELEVANCE: Patients with TON may have a second optic nerve insult, and vision recovery from the second event may be limited regardless of primary treatment choice.

Management of the 'tight orbit' and associated visual loss.

PURPOSE OF REVIEW: To review the most recent literature on the management of the orbit under high pressure (the tight orbit) with threatened visual loss. RECENT FINDINGS: Definitive management of traumatic optic neuropathy remains unclear, lacking randomized head-to-head treatment option trials. Instead, numerous case series and anecdotal reports show benefit in each of the four treatment modalities currently in use, but a multitude of variables confound cross-study comparison. In contrast, the management of orbital hemorrhage and orbital emphysema is well known. A number of immunomodulatory protocols have recently arisen for the medical suppression of Graves' ophthalmopathy, but when surgical decompression is required, most authors currently favor a combined transconjunctival and endoscopic endonasal approach. SUMMARY: This article reviews the anatomy, pathophysiology, diagnosis, and intervention of the 'tight orbit' with associated visual loss. Guidelines for the intervention are given.

Effect of dietary zinc and phytase supplementation on botulinum toxin treatments.

PURPOSE: To determine whether oral zinc supplementation might affect the efficacy and duration of botulinum toxin treatments. METHODS: In a double-blind, placebo-controlled, crossover pilot study, we examined the efficacy of three botulinum toxin preparations (onabotulinumtoxinA, abobotulinumtoxinA, and rimabotulinumtoxinB) following oral supplementation with zinc citrate 50 mg and phytase 3,000 PU, zinc gluconate 10 mg, or lactulose placebo in individuals treated for cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm. RESULTS: In seventy-seven patients, 92% of subjects supplemented with zinc 50 mg and phytase experienced an average increase in toxin effect duration of nearly 30%, and 84% of participants reported a subjective increase in toxin effect, whereas no significant increase in duration or effect was reported by patients following supplementation with lactulose placebo or 10 mg of zinc gluconate. The dramatic impact of the zinc/phytase supplementation on some patients' lives clinically unmasked the study and prompted an early termination. CONCLUSIONS: This study suggests a potentially meaningful role for zinc and/or phytase supplementation in increasing the degree and duration of botulinum toxin effect in the treatment of cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm.

The diagnosis and treatment of thyroid-associated ophthalmopathy.

BACKGROUND: Little is written in the plastic surgery literature about thyroid-associated ophthalmopathy (TAO), a condition that is separate from Graves-Basedow disease and may not be accompanied by hyperthyroidism. Many patients with this disease frequently seek periocular aesthetic reconstruction prior to medical workup. METHODS: This study presents a comprehensive review of the literature surrounding TAO in order to better understand the prevalence, diagnosis, pathophysiology, and appropriate management of TAO. RESULTS: TAO is frequently under- or misdiagnosed by health-care providers. Patients seeking blepharoplasty or other oculoplastic procedures may have underlying TAO, and the prevalence of TAO in patients who have had a blepharoplasty is approximately 3%. This condition occurs five times more often in women than in men. As a product of the relatively high prevalence of this disease and its underdiagnosis, TAO patients may experience perioperative and late complications due to surgery. CONCLUSION: Blepharoplasties performed on TAO patients must be undertaken with care and insight to avoid cosmetic and functional complications.

Metaplastic bone formation in the orbit.

Osseous or cartilaginous metaplasia in the orbit are both rare phenomena. The authors describe a unique case of combined primary orbital osseous and cartilaginous metaplasia presenting with orbital pain and ocular dysmotility and discuss the radiologic, histopathologic, and clinical features. This entity should be considered in the differential diagnosis of an orbital mass showing similar radiographic features of calcification.

Pearls of orbital trauma management.

Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.

The eye examination in facial trauma for the plastic surgeon.

Fifteen to 20 percent of patients with major facial trauma suffer vision-threatening injuries. Not only does the early identification and management of such ophthalmic insults frequently carry a better visual prognosis, but manipulations during facial fracture repair may exacerbate unrecognized eye trauma. In addition, ophthalmic problems not documented before facial reconstruction may be interpreted as direct complications of surgery. Thus, all physicians who treat patients with trauma above the mandible should appreciate the fundamentals of ophthalmic evaluation and emergency management. This article strives to provide a simplified, practical guide, but it should not be viewed as a substitute for consultation by a qualified eye care provider when an ocular injury is strongly suspected.

Perspectives on periocular asymmetry.

Eyelid, orbit, and eye position asymmetry may adversely affect overall facial aesthetics. Armed with the knowledge of important periocular measures and landmarks, asymmetries can be easily identified and consideration may be given to correction or camouflage.

Eyelid edema.

Facial aesthetic surgeons are sometimes challenged by the predicament of diagnosing and managing patients with chronic eyelid edema. Herein we provide a brief review of some of the more common causes of pre- and postoperative eyelid edema, many of which have important systemic implications, and offer management suggestions.

Periocular anesthesia in aesthetic surgery.

This article focuses on the administration of anesthesia for periocular aesthetic procedures. Special emphasis is given to office-based procedures, most often without any systemic sedation, highlighting the importance of open communication with patients. Finally, attention is given to potential pitfalls including anesthetic systemic toxicity, ocular injuries, and orbicularis myotoxicity.

Periocular laser complications.

Laser periocular surgery has achieved an increased popularity, particularly since the widespread use of CO(2) and erbium:yttrium aluminum garnet laser and more recently with the development of nonablative laser technology. The main target of these techniques is to treat photoaging changes to obtain a rejuvenated skin. Despite the relatively safety of these procedures on experienced hands, postoperative complications affecting the periocular region, and the eye itself, may follow laser surgery. More common complications include persistent erythema, hyper- and hypopigmentation, and hypertrophic scarring. Viral, bacterial, or fungal skin infections may also jeopardize the postoperative period after periocular laser treatment. Severe burns, transitory or permanent lower lid ectropion, and even corneal injuries or ocular perforation are among the most severe hazards. The majority of these complications are related to the use of ablative technologies. A thoughtful preoperative evaluation, conscientious patient selection, comprehensive informed consent, adequate training, and a cautious and conservative approach are reinforced to minimize moderate or even severe aesthetic and functional periocular complications. Nonablative laser therapies are notably safer; however, their ability to significantly improve photoaged skin characteristics is still limited.

Efficacy of botulinum toxin type a after topical anesthesia.

PURPOSE: To determine whether the use of topical anesthesia has an impact on botulinum toxin type A (BTX-A) efficacy. METHODS: Forty patients (20 receiving BTX-A for facial cosmetic rhytid reduction and 20 for benign essential blepharospasm) were evaluated in a double-blind, randomized, triple-crossover study at 2.5- to 4.5-month intervals. The discomfort and efficacy of BTX-A injections after betacaine application to half the face (random assignment) were compared against the discomfort and efficacy of a placebo ointment on the other half of the face. This was followed by cryoanalgesia to the entire face. RESULTS: Patients ranged from 27 to 81 years of age (mean, 53 years), and 34 were female. Of the 120 total injection comparisons, a better BTX-A effect on one side of the face was reliably identified by 80% and 77% of blepharospasm and cosmetic patients, respectively, with the placebo-treated side providing better BTX-A effect approximately 90% of the time (p < 0.001). Patients reported a more painful side during injection in just 18 of the 120 trials, and only 1 of 40 patients believed the administration of analgesia was worth the trouble. CONCLUSIONS: Pretreatment with topical betacaine followed by skin cooling seems to have a deleterious impact on BTX-A effect without a significantly beneficial patient-perceived reduction in injection discomfort.

Cold urticaria: an under-recognized cause of postsurgical periorbital swelling.

PURPOSE: To report cold urticaria as an under-recognized cause of potential periorbital and facial edema after elective oculofacial plastic surgery. METHODS: Retrospective case series of three patients with primary acquired cold urticaria with review of the clinical aspects of each of the cases. RESULTS: Two of the patients had significant postoperative swelling attributed to primary acquired cold urticaria after the routine use of cool compresses to their surgical sites. The third patient had known primary acquired cold urticaria and required special perioperative management. All three patients ultimately had a good surgical outcome with no long-term sequelae. CONCLUSIONS: Although primary acquired cold urticaria is generally not a serious condition, it can be easily overlooked and misdiagnosed as a localized adverse reaction to injected anesthetic, topical antibiotic ointments, or early preseptal cellulitis after eyelid or facial surgery. Rarely, this condition can be fatal and should be recognized by the surgeon to ensure both optimal surgical results and general medical management. Three simple screening questions should identify most patients with this disorder.

Managing inflammatory reaction to restylane.

A 62-year-old woman received injections of Restylane, cross-linked hyaluronic acid, for the cosmetic filling of facial rhytids and developed a severe dermal inflammatory reaction. Hyaluronidase administered directly in the inflammatory nodules resulted in rapid resolution of pain, palpable nodularity, and visible induration possibly due to dissolution of the hyaluronic acid.