Periocular Granuloma Annulare: A Case Report of a Rare Childhood Disease in an Adult.

A 21-year-old female presented to the oculoplastic clinic with a 2-year history of raised lesions in the right upper eyelid and lateral canthus area. Due to their unusual appearance, the patient underwent an excisional biopsy of the lateral canthus lesion. A diagnosis of granuloma annulare was made after histopathology demonstrated palisading epithelioid granulomas with central fibrinoid necrosis and Alician blue positive acid mucin. Granuloma annulare is a benign inflammatory skin condition characterized by firm discolored papules or nodules classically arranged in an annular pattern. Periocular involvement is extremely rare in adults and may pose a diagnostic challenge to ophthalmologists unfamiliar with its presentation and management.

Acute Bilateral Orbital Myositis Following Covid 19 Vaccination.

The authors present a case of acute bilateral orbital myositis occurring 24 hours after the administration of the mRNA1273 vaccination for COVID 19. The patient was presented with right proptosis, with orbital imaging demonstrating bilateral enlargement of all the extraocular muscles. Serological investigation did not reveal a precipitating cause or underlying disease process. The presenting features resolved entirely following treatment with methylprednisolone and the patient remains asymptomatic.

Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures.

PURPOSE: The study reports the correlation between surgical timing and postoperative ocular motility in orbital blowout fractures. METHODS: This was a retrospective study of 191 patients that underwent surgical repair for unilateral orbital fractures. All patients included in the study had symptomatic diplopia from the fracture. Patients were classified into one of three groups according to the time of surgery after injury: (1) Early (within 14 days of surgery), (2) intermediate (between 15 and 30 days), and (3) late (greater than 30 days). Ocular motility was measured presurgery and at 3 and 6 months postsurgery by Hess chart with calculation of the Hess area ratio (HAR%). RESULTS: Surgery was conducted at a mean of 24.7 ± 45.0 days (range: 1-283 days) postinjury. There were 120 patients in the early surgery group (surgery at 6.8 ± 3.8 days), 38 in the intermediate surgery group (20.7 ± 4.1 days), and 33 in the late surgery group (95.1 ± 75.0 days). Overall the HAR% improved significantly from a mean of 74.2% preoperatively to 90.8% at 6 months postoperatively (p < 0.01). In the early and intermediate groups, the postoperative HAR% improved significantly with all fracture regions (orbital floor, medial wall, and combined orbital medial wall and floor) (p < 0.05). However, in the late groups, the postoperative HAR% only improved significantly with orbital floor fractures. CONCLUSION: Pre- and postoperative the HAR% give objective evidence of ocular motility improvement with early orbital floor fracture repair surgery. However, observation can be deployed, as a significant improvement in ocular motility can also be achieved with reconstructive surgery conducted 30 days or more after depressed floor-fragment fractures. Early intervention should be prioritized for symptomatic medial wall fractures, as late surgery does not improve motility.

Healthcare worker protection against epidemic viral respiratory disease.

Lower respiratory infections are often caused or precipitated by viruses and are a leading cause of global morbidity and mortality. Mutations in these viral genomes can produce highly infectious strains that transmit across species and have the potential to initiate epidemic, or pandemic, human viral respiratory disease. Transmission between humans primarily occurs via the airborne route and is accelerated by our increasingly interconnected and globalised society. To this date, there have been four major human viral respiratory outbreaks in the 21st century. Healthcare workers (HCWs) are at particular risk during respiratory epidemics or pandemics. This is due to crowded working environments where social distancing, or wearing respiratory personal protective equipment for prolonged periods, might prove difficult, or performing medical procedures that increase exposure to virus-laden aerosols, or bodily fluids. This review aims to summarise the evidence and approaches to occupational risk and protection of HCWs during epidemic or pandemic respiratory viral disease.

The Management of Orbital Roof Fractures and Defects: A Review.

PURPOSE: To explore the anatomy, etiopathogenesis, diagnosis and classification, current evidence on intervention and the surgical management of orbital roof fractures and defects (ORFD) for oculoplastic surgeons presented with such cases. METHODS: A review of the current literature through the MEDLINE database using the following search terms: "orbital roof fracture (+treatment/management)," "orbital roof defect (+treatment/management)," "orbital roof erosion (+treatment/management)," "orbital roof repair," "orbital roof," "orbital fracture," "pediatric orbital roof (defect/fracture/erosion)," "orbital anatomy," and "orbital roof anatomy" was conducted. As relatively little has been published on this topic, inclusion criteria were broad and peer-reviewed articles judged to be of clinical importance, relevant to the aims of this review, were included. Non-English abstracts were also included if relevant. Year of publication was not a strict exclusion criterion, and older articles were judged for their suitability based on clinical importance and relevance to current practice. Additional references were obtained from citations in key articles and recommendations from the coauthors based on their areas of expertise. RESULTS: The etiopathogenesis of ORFD varies. Classification systems have been formulated to guide management decisions and can range from conservative management to complex neurosurgery. Eyelid approaches have also been described. This review provides a summary of the evidence for each and a management framework oculoplastic surgeons can use when presented with ORFD. CONCLUSION: Oculoplastic surgeons can be involved, either alone or as part of a multidisciplinary team, in the management of ORFD, and for some, conduct orbital approach reconstructive surgery.

Probable IGG4 related ophthalmic disease presenting with uveitis.

We present a case of an uncommon presentation of IgG4-related ophthalmic disease (ROD). A 58-year-old female presented with unilateral acute anterior uveitis of the right eye, which progressed to scleritis with the development of an associated orbital mass despite treatment with oral glucocorticoid. Initial histopathology of an orbital biopsy was non-diagnostic and continued progression of the disease lead to complete loss of vision in the right eye. The development of uveitis in the previously unaffected left eye led to the decision for enucleation of the right globe and further orbital biopsy. Histopathology revealed features supporting IgG4-related ophthalmic disease. Oral glucocorticoid therapy failed to induce remission, and rituximab therapy was initiated, leading to a rapid resolution in her symptoms. Other cases with a similar presentation report a poor visual prognosis, highlighting the need for prompt diagnosis and treatment of uveitis associated with signs of orbital or scleral involvement.

Assessment of a Consecutive Series of Orbital Floor Fracture Repairs With the Hess Area Ratio and the Use of Unsintered Hydroxyapatite Particles/Poly l-Lactide Composite Sheets for Orbital Fracture Reconstruction.

PURPOSE: The purpose of this study is to report the outcomes of a series of orbital fracture repairs, their assessment with the Hess area ratio (HAR%), and the use of unsintered hydroxyapatite (HA) implants for reconstruction. METHODS: This study involved 207 consecutive unilateral orbital fractures with symptomatic diplopia that underwent surgical repair within 28 days of injury. Ocular movement was measured presurgery and at 3 and 6 months postsurgery by Hess chart with calculation of the HAR%. RESULTS: Surgery was conducted on 207 patients (161 males and 46 females; mean age, 27.8 years) at a mean of 9.9 days postinjury and with a mean follow-up of 8.6 months. There were 160 patients with orbital floor fractures, 27 with medial wall fractures, and 20 with combined orbital medial wall and floor fractures, 135 of 207 patients had orbital blowout fractures, and 72 had orbital trap-door fractures. The HAR% improved significantly from a mean of 73.8% preoperatively to 92.7% postoperatively (P < .01). Orbital fractures were reconstructed with either unsintered HA particles/poly l-lactide composite sheet (133 patients), a silicone silastic sheet (47 patients), a combination of sheets (15 patients), or without an implant (12 patients). There was no significant difference in the HAR% improvement between the different implants. CONCLUSIONS: Very good outcomes can be achieved with early orbital floor fracture repair surgery, which can be assessed preoperatively and postoperatively by HAR%. Unsintered HA/poly l-lactide composite sheets are an effective absorbable material for orbital floor fracture reconstruction.

Epidemiology of cutaneous sebaceous carcinoma.

There has been uncertainty about the demographics and anatomical distribution of cutaneous sebaceous carcinoma. This study aims to investigate these uncertainties by analysing data from various countries. Data were obtained from cancer registries of the United States, England, Norway and Taiwan, and incidence rates were calculated with uniform age-adjustment. sebaceous carcinoma was more commonly reported in males than females in white populations, whereas the inverse was true in Taiwan. Ocular sebaceous carcinoma was more commonly reported in females than males in all populations, despite male predominance in white populations. The majority (approx. 70-90%) occurred on head and neck in Asians and whites. Age-adjusted incidence rate (to the 2000-2025 WHO World Standard Population) ranged from 0.07 to 0.18 per 100 000 person-years and was not higher in Taiwanese than in white populations.

Positional Variation of the Infraorbital Foramen in Caucasians and Black Africans from Britain: Surgical Relevance and Comparison to the Existing Literature.

BACKGROUND: Midface augmentation and orbital surgery carry an inherent risk of injury to the infraorbital vascular bundle, especially the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity for the patient, including paresthesia and neuralgia. Studies report significant heterogeneity in IOF position according to gender, ethnicity, and laterality. A knowledge of the relationship of the IOF to regional soft tissue, bony landmarks, and its variation among ethnicities is likely to reduce iatrogenic injuries. METHODS: A single-center retrospective computed tomography (CT)-based study was conducted. Twenty Caucasians and 20 Black Africans patients were selected from an existing radiologic database at Moorfields Eye Hospital, London, UK. DICOM image viewing software (Syngo, Siemens Healthineers) was used to record the position of the IOF using standardized sagittal and axial views. RESULTS: There was a statistically significant difference in the horizontal position of the IOF in the 2 races (P = 0.00). The combined measurements were used to derive a rectangular zone of variability measuring 14.30 mm by 10.60 mm. This zone was found to lie 3.50 mm below the infraorbital rim, 7.10 mm medial to the piriform aperture, and 11.60 mm from the lateral orbital rim. CONCLUSION: A sound knowledge of key facial landmarks is necessitated when performing midface augmentation and orbital surgery. An anatomical safe zone depicting the variation of the IOF will help reduce iatrogenic injury to the infraorbital nerve and prevent patient morbidity.

Cutaneous sebaceous carcinoma.

Cutaneous sebaceous carcinoma occurs almost exclusively on the head and neck and has a significant propensity for recurrence and metastasis. It is easily mistaken for benign conditions, resulting in inappropriate management. Thus, it is important to maintain a high index of suspicion. Despite previous reports, sebaceous carcinoma may occur with similar frequency in Asians and whites. Recent genetic data suggest there are multiple mutational groups of sebaceous carcinoma, paving the way for targeted treatment. After a diagnosis, investigations for staging and for Muir-Torre syndrome should be considered. The available evidence on the treatment options for sebaceous carcinoma is discussed, and specific recommendations for management are made.

New Onset Alacrima as a Presenting Feature of a Skull Base Chondrosarcoma.

Acquired unilateral alacrima as a presenting sign of an intracranial tumor is exceptionally rare, and only described once previously in a case of nasopharyngeal carcinoma. The authors present a 32-year-old female patient who presents with a year-long history of alacrima and arhinorrhea. She was subsequently diagnosed with a petroclival chondrosarcoma extending into Meckel's cave and the cavernous sinus and underwent surgical debulking. To the authors' knowledge, this is the first reported case of acquired unilateral alacrima as a presenting feature of a skull base chondrosarcoma. This case serves to remind general ophthalmologists and oculoplastic surgeons alike that acquired alacrima may be the presenting feature of serious intracranial disease.

Morbihan Syndrome, a UK Case Series.

PURPOSE: To describe 10 patients with Morbihan syndrome, a rare condition characterized by the slow appearance of erythema and solid edema on the upper portion of the face, and review the literature. METHODS: Retrospective case series and review. RESULTS: The majority of patients were male (80%), and the mean age at presentation was 67 years (range, 48-88 years); 60% had asymmetrical disease (affecting mainly the right side). All subjects underwent a lid biopsy to support the diagnosis of Morbihan syndrome, which showed features of inflammation and vascular dysfunction, highly suggestive of a rosacea histological picture complicated by chronic lymphoedema. A range of medical and surgical treatment were used with variable success. The most effective ones included oral isotretinoin, intralesional triamcinolone injections, and debulking surgery. CONCLUSIONS: Morbihan syndrome is a rare and chronic condition. It can be difficult to treat and may require a range of interventions.

Time-resolved three-dimensional technique for dynamic magnetic resonance dacryocystography.

IMPORTANCE: This study introduces a new technique in the assessment of nasolacrimal drainage with magnetic resonance imaging. BACKGROUND: To describe a new dynamic magnetic resonance dacryocystography (MRDCG) protocol and report normative findings on asymptomatic lacrimal drainage systems. DESIGN: A prospective observational study at the Royal Adelaide Hospital. PARTICIPANTS: Seventeen patients with unilateral epiphora were prospectively recruited. METHODS: Patients underwent dynamic MRDCG. The time-resolved angiography with interleaved stochastic trajectories (TWIST) sequence was used to visualise contrast flow through the lacrimal drainage system. MAIN OUTCOME MEASURES: Tear transit times and anatomical dimensions were measured. RESULTS: Dynamic MRDCG with TWIST sequence reliably demonstrated contrast flow. Tear transit times and anatomical dimensions were comparable to previously reported values in other imaging modalities. CONCLUSIONS AND RELEVANCE: Dynamic MRDCG provides good structural and temporal resolution to the assessment of lacrimal outflow obstructions. The physiological nature of this modality allows potential assessment for functional obstruction and future research on tear flow assessment.

Endoscopic Orbital Decompression by Oculoplastic Surgeons for Proptosis in Thyroid Eye Disease.

PURPOSE: Orbital decompression is an established surgical treatment option for a range of orbital conditions. Traditionally, Ear, Nose and Throat surgeons have adopted the endoscopic route while ophthalmologists operate via an external approach. The authors report the outcomes of endonasal decompression performed by oculoplastic surgeons experienced in endonasal techniques. METHODS: This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to thyroid eye disease across 2 hospital sites between January 2011 and July 2018. Inclusion criteria were patients who had endoscopic decompression for proptosis in inactive thyroid eye disease or active disease without dysthyroid optic neuropathy. Information collected includes patient demographics, diagnosis, surgical details, preoperative and postoperative clinical findings (including, visual acuity, color vision, exophthalmometry readings, palpebral aperture, intraocular pressure, ocular motility, diplopia, and visual field), complications, and further treatment. RESULTS: There were 70 cases of endoscopic decompression. The majority of patients had endoscopic medial and posterior medial wall/floor decompression (44.3%; 31/70 cases). Visual acuity remained stable in 98.6% (69/70). There was an average reduction in proptosis of 3.5 ± 1.2 mm (standard deviation [SD]) in the endoscopic medial wall only group, 3.9 ± 0.9 mm (SD) in endoscopic medial wall and posterior medial portion of the floor group, and 7.6 ± 2.1 mm (SD) in the 3-wall decompression group. Motility improved in 11.4% (8/70) and worsened in 2.9% (2/70). There were no significant intraoperative or postoperative complications associated with endoscopic surgery. CONCLUSIONS: Oculoplastic surgeons experienced in endonasal techniques can perform endoscopic orbital decompression with outcomes comparable to the literature.The authors report the outcomes of a series of endonasal orbital decompression carried out by oculoplastic surgeons.

The 'over-the-top' modified Cutler-Beard procedure for complete upper eyelid defect reconstruction.

PURPOSE: To describe the 'Over-the-Top' Modified Cutler Beard Procedure (OTTMCB) for complete upper eyelid defect reconstruction Methods: This is retrospective case note review of four patients that underwent the OTTMCB procedure. This two-stage procedure comprises the replacement of the posterior lamella with a free tarsal graft from the contralateral upper eyelid, and the anterior lamella with a lower lid skin flap over the lower eyelid margin which is divided 2-4 weeks later. RESULTS: The procedure was undertaken for four patients with 75-90% upper eyelid defects from tumour excision surgery. One patient had post-operative dehiscence requiring debridement and resuturing and further reconstructive surgery 18 months later to improve the cosmesis and lagophthalmos. The other three patients had good functional and cosmetic outcomes. CONCLUSIONS: The OTTMCB procedure replaces the anterior and posterior lamellae of the upper eyelid with 'like-for-like' tissues. It avoids some of the drawbacks of the original and other variations of the Cutler-Beard procedure and achieves a good cosmetic outcome.

Intradiploic epidermoid cyst of the orbital roof: a case report.

Intradiploic epidermoid cysts are uncommon in the orbital walls and typically present with chronic headaches. We present the unusual presentation of a 46-year-old man where a long-standing intradiploic mass of the orbital roof led to acute onset of pain and mechanical ptosis. Computed tomography and magnetic resonance imaging revealed an intradiploic cystic mass within the orbital roof. The cystic mass was extirpated and histological examination confirmed the diagnosis of an epidermoid cyst. This case illustrates the potential of long-standing intradiploic epidermoid cysts in producing an acute presentation.

Biopsy of recurrent nasolacrimal duct obstruction using sheath-guided dacryoendoscopy.

PURPOSE: The purpose of this article is to present a novel technique, as well the histopathological findings, of dacryoendoscopic guided nasolacrimal duct (NLD) biopsy for recurrent nasolacrimal duct obstruction (NLDO). METHODS: This study involved subjects with recurrent NLDO. Direct endoscopic probing or sheath-guided endoscopic probing was used for the initial intubation in all treated eyes, and the stent had been removed at between 2 and 11 months (mean 3.5 months) post-intubation with dacryoendoscopic confirmation of patency and mucosal regeneration. Biopsy specimens were obtained by scraping the recurrent lesion by sheath advancement. Histopathological examination and immunohistochemical (IHC) staining were performed. RESULTS: In five patients (two males and three females, mean age: 71.2 ± 5.6 years [range: 61-78 years]) with recurrent NLDO, biopsy specimens were obtained from six ducts of six eyes, and stratified epithelium and a mixed inflammatory cell infiltrates were identified. IHC staining was positive for cytokeratin (CK)4 and CK13, and negative for paired box protein Pax-6. CONCLUSIONS: This novel technique enabled a minimally invasive biopsy of the NLD to be obtained, and IHC staining indicated the presence of mucus epithelium, thus suggesting squamous metaplasia of the usual respiratory epithelium which likely occurs secondary to chronic inflammation.

Primary replacement for the management of exposed orbital implant.

Purpose: We present a series of primary orbital implant replacement for cases of implant exposure to describe our experience of this one-staged surgical approach. Methods: This study reports on a one-stage technique which involved the removal of the exposed implant or dermis fat graft (DFG) and insertion of a secondary (replacement) in the same procedure, with a variety of materials, including autologous tissue. Re-exposure in a socket where a DFG was placed was defined as a new defect in the newly epithelialized conjunctiva or dehiscence of the dermis-conjunctiva junction. All cases of primary replacement for the management of exposed orbital implant, porous and non-porous, were included, even when there were clinical signs suggestive of infection. The primary outcome was the rate of re-exposure, requiring additional surgical procedures. Infection following primary replacement was a secondary outcome. Results: Seventy-eight patients had primary replacement for the management of an exposed orbital implant. 6.4% had re-exposure at a mean follow-up of 49.7 months (9.1% for ball implants and 4.5% for DFG). The rate of exposure was higher in those with prior signs of infection than those without (8% vs. 3.6%). Re-exposure occurred in 4.5% of cases with DFG implantation, 4.3% of cases with non-porous implants and in 20% of cases with porous implants. Conclusion: Primary replacement for management of exposed orbital implant, porous and non-porous, has a high rate of successful outcome even in cases with presumed or confirmed infection.

Primary orbital melanoma: a case series and literature review.

Primary orbital melanoma (POM) is a very rare condition. We report further four cases and review all previously reported cases. We present a multicentre retrospective review of patients with POM. Clinical, radiological, surgical, histological, and follow-up data is presented. Four patients with POM were identified between 2000 and 2013. All presented with proptosis and diplopia without reduced vision. Two had known pre-existing blue cell naevi. All were stage T1N0M0. All underwent exenteration with adjuvant radiotherapy. All are disease free at follow-up durations of 24-151 months. The present three cases and review of all cases in the literature suggest a higher likelihood of disease-free survival from primary exenteration (7/8 disease-free survival, 1/8 death from metastatic disease) than wide local excision (7/16 disease-free survival, 9 recurrence or metastasis of whom 4 died). Adjuvant radiotherapy may additionally improve outcomes.

Predictors of Trachomatous Trichiasis Surgery Outcome.

PURPOSE: Unfavorable outcomes after trachomatous trichiasis (TT) surgery are undermining the global trachoma elimination effort. This analysis investigates predictors of postoperative TT (PTT), eyelid contour abnormalities (ECAs), and granuloma in the 2 most common TT surgery procedures: posterior lamellar tarsal rotation (PLTR) and bilamellar tarsal rotation (BLTR). DESIGN: Secondary data analysis from a randomized, controlled, single-masked clinical trial. PARTICIPANTS: A total of 1000 patients with TT, with lashes touching the eye or evidence of epilation, in association with tarsal conjunctival scarring. METHODS: Participants were randomly allocated and received BLTR (n = 501) or PLTR (n = 499) surgery. Disease severity at baseline, surgical incisions, sutures, and corrections were graded during and immediately after surgery. Participants were examined at 6 and 12 months by assessors masked to allocation. MAIN OUTCOME MEASURES: Predictors of PTT, ECA, and granuloma. RESULTS: Data were available for 992 (99.2%) trial participants (496 in each arm). There was strong evidence that performing more peripheral dissection with scissors in PLTR (odd ratio [OR], 0.70; 95% confidence interval [CI], 0.54-0.91; P = 0.008) and BLTR (OR, 0.83; 95% CI, 0.72-0.96; P = 0.01) independently protected against PTT. Baseline major trichiasis and mixed location lashes and immediate postoperative central undercorrection independently predicted PTT in both surgical procedures. Peripheral lashes in PLTR (OR, 5.91; 95% CI, 1.48-23.5; P = 0.01) and external central incision height ≥4 mm in BLTR (OR, 2.89; 95% CI, 1.55-5.41; P = 0.001) were independently associated with PTT. Suture interval asymmetry of >2 mm (OR, 3.18; 95% CI, 1.31-7.70; P = 0.01) in PLTR and baseline conjunctival scarring in BLTR (OR, 1.72; 95% CI, 1.06-2.81; P = 0.03) were independently associated with ECA. Older age was independently associated with ECA in both PLTR (P value for trend < 0.0001) and BLTR (P value for trend = 0.03). There was substantial intersurgeon variability in ECA rates for both PLTR (range, 19.0%-36.2%) and BLTR (range, 6.1%-28.7%) procedures. In PLTR surgery, irregular posterior lamellar incision at the center of the eyelid (OR, 6.72; 95% CI, 1.55-29.04; P = 0.01) and ECA (OR, 3.08; 95% CI, 1.37-6.94; P = 0.007) resulted in granuloma formation. CONCLUSIONS: Poor postoperative outcomes in TT surgery were associated with inadequate peripheral dissection, irregular incision, asymmetric suture position and tension, inadequate correction, and lash location. Addressing these will improve TT surgical outcomes.