Session 138 Oculoplastics

Transcription

ARVO 2016 Annual Meeting Abstracts
138 Oculoplastics
Sunday, May 01, 2016 1:30 PM–3:15 PM
Exhibit/Poster Hall Poster Session
Program #/Board # Range: 676–722/B0175–B0221
Organizing Section: Eye Movements/Strabismus/Amblyopia/NeuroOphthalmology
Program Number: 676 Poster Board Number: B0175
Presentation Time: 1:30 PM–3:15 PM
Transient Dry Eye Following the Fasanella-Servat Operation in
the Early Postoperative Period
Christopher Lo1, 2, Carisa Petris1, 3, Richard Lisman1, 3. 1Department
of Ophthalmology, NYU, New York, NY; 2Department of
Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, New York,
NY; 3Institute of Reconstructive Plastic Surgery, NYU, New York,
NY.
Purpose: The Fasanella-Servat levator resection is a popular, less
invasive ptosis repair that involves excision of tarsus and conjunctiva
from a posterior approach. The aim is to identify if the amount of
tissue excised during a Fasanella-Servat procedure correlates with
increased early postoperative dry eye.
Methods: An IRB approved retrospective review of a surgeon’s
experience over a five-year period was performed. Data from pre
and postoperative photographs, operative reports, and postoperative
visits was analyzed. Small excision was defined as less than 2 mm
tarsus removed, moderate excision was between 2 and 4 mm, and
large excision was 4 mm or more removed. Postoperative dry eye
was defined as subjective complaints, excessive tearing, foreign
body sensation, or use of supplemental lubrication during the first
postoperative month with sutures removed and the tarsoconjunctival
incision well healed.
Results: In total, 51 patients and 99 eyes were included. Thirty-six
(70.5%) of patients were female. Mean age was 68, SD 15.5.
Forty-six (90.3%) patients were Caucasian. Average follow up
time was 6.9 months, SD 1.4. Forty-one (41.4%) eyes had small,
41 (41.4%) had moderate, and 17 (17.2%) had large corrections.
In the group undergoing small excision, dry eye increased
from 31.7% to 46.3% in the first postoperative month, without
significance (p=0.085). Eyes with moderate correction had increased
postoperative dry eye from 12.2% to 51.2% (p<0.05). Eyes
undergoing large corrections had increased dry eye from 11.8% to
58.8% (p<0.05). Despite transient increases, only 3 (5.9%) patients
had significant dry eye requiring use of ocular lubricants after the
early postoperative period.
Conclusions: Dry eye following ptosis repair may be caused by
increased evaporative losses, alteration of blink, incomplete closure,
injury to accessory lacrimal glands, or decrease of meibomian
glands or mucin-secreting conjunctiva. Despite these risks, there
was not a significant correlation with dry eye with small corrections.
In moderate and large ptosis corrections, there was increased
early postoperative dry eye, which was managed with short-term
lubricants. Changes in palpebral height, tear composition, and
hyperawareness of symptoms may play a role in the transient increase
of dry eye symptoms, which resolved after orbicularis contraction
frequency and excursion returned by the third postoperative month.
Commercial Relationships: Christopher Lo, None; Carisa Petris;
Richard Lisman, None
Comparative Ocular Effects of Topical Epinephrine Versus
Phenylephrine in Ptotic and Non-ptotic Subjects
Philip Ngai, Jeremiah Tao. Gavin Herbert Eye Institute, University of
California, Irvine, Irvine, CA.
Purpose: Injected 1% lidocaine with epinephrine 1:100,000 (LE100),
commonly used in blepharoptosis surgery, may elevate the upper
eyelid through sympathetic effects on Müller’s muscle (Trans
Am Ophthalmol Soc. 1996;94:165-73) and can also induce pupil
dilatation. Such stimulation of sympathetic pathways may affect
intraoperative assessment during ptosis surgery. Exposure of the
ocular surface to LE100 can occur during ptosis repair, though the
effects have not been described. Herein we compare the effect of
topical LE100 and phenylephrine on upper eyelid position and pupil
size.
Methods: Upper eyelid margin reflex distance (MRD-1) and pupil
diameter were measured at baseline and 5 minutes after application
of topical LE100 in one eye of 14 non-ptotic and 10 ptotic patients.
Measurements were obtained by digital photography with each
subject’s head and eyes in primary position. After >48 hours each
eye was exposed to topical phenylephrine 2.5% and the same
measurements were obtained.
Results: Topical LE100 did not produce an increase in mean
MRD-1 (p>0.05). Conversely, 19/24 eyes (13 non-ptotic, 6 ptotic)
exhibited a significant increase (p<0.01) in MRD-1 (mean 0.59
mm) after application of phenylephrine. Change in MRD-1 was
significantly greater (p<0.01) after exposure to phenylephrine
than to LE100. 5/24 eyes (1 non-ptotic, 4 ptotic) did not exhibit an
increase in MRD-1 in response to phenylephrine; these eyelids also
did not elevate in response to LE100. Average pupil size increased
0.24 mm (p=0.013) after exposure to phenylephrine, and 0.27 mm
(p<0.01) after instillation of LE100. The effect on pupil diameter was
statistically similar between the two solutions (p>0.05).
Conclusions: Topical LE100 and topical phenylephrine had similar
effects on pupil size, but not on MRD-1. The measurable response of
the iris dilator muscle was not coupled with a statistically significant
response of Müller’s muscle. These data may have implications
on intraoperative measurements recorded during ptosis surgery.
Importantly, a surgeon should not presume there is elevation of the
upper eyelid when pupil dilatation is noted after eye exposure to
LE100.
Commercial Relationships: Philip Ngai, None; Jeremiah Tao,
None
Tarsal switch to correct severe neurogenic or myogenic ptosis
Roberta L. Meneghim1, Lucieni C. Ferraz2, Alicia Galindo3, 4,
Rajiv Khandekar3, Silvana A. Schellini3, 1. 1Ophthalmology
Department, Universidade Estadual Paulista - UNESP, BOTUCATU,
Brazil; 2Hospital Estadual de Bauru, FAMESP, Bauru, Brazil; 3King
Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; 4Department
of Ophthalmology, Complejo Asistencial de Palencia, Palencia,
Spain.
Purpose: To report the tarsal switch procedure to correct severe
neurogenic or myogenic ptosis with poor levator function (< 4mm)
and Bell’s phenomenon absent.
Methods: Eleven patients (seven male and four female) with
myopathic or neurogenic ptosis treated at the Faculty of Medicine
of Botucatu – UNESP - Brazil and at King Khaled Eye Specialist
Hospital – Riyadh – Saudi Arabia underwent to surgery to correct
palpebral ptosis using the tarsal switch procedure between the years
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2012 to 2015. Complete eye examination was performed, including
margin reflex distance (MRD), palpebral fissure, levator function,
extraocular motility and Bell’s phenomenon.
Results: Surgeries were performed in 18 lids of 11 patients.
Median age of the patients at the time of the surgery was 57 years
(Minimum=29; Maximum=86). Seven (64%) were males and four
(36%) females; four had unilateral ptosis and seven, bilateral; nine
patients had myogenic and two neurogenic ptosis. All patients
showed improvement of head position after surgery. The MRD before
surgery was 0 mm and after surgery was 1.0mm, with significance
(Wilcoxon p = 0.001). The median of palpebral fissure before surgery
was 2 mm and after surgery, 7 mm with significance (Wilcoxon p <
0.001).
Conclusions: Tarsal switch procedure constitutes an efficient
alternative proposition to correct severe ptosis with poor levator
function and negative Bell’s phenomenon and can be performed
decreasing the eye exposure risk.
Commercial Relationships: Roberta L. Meneghim, None;
Lucieni C. Ferraz, None; Alicia Galindo, None; Rajiv Khandekar,
None; Silvana A. Schellini, None
Amyloidosis Masquerading as Unilateral Ptosis
Maria M. Choudhary, Rao Chundury, Priyanka Kumar, Julian Perry.
Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH.
Purpose: We report 2 cases of amyloidosis masquerading as
unilateral ptosis. To the author’s knowledge these are the first 2
cases in which a diagnosis of amyloidosis was made from isolated
unilateral ptosis without any other clinical signs.
Methods: Case 1 is a 34 year old woman with a history of
monocular strabismus surgery of the left eye combined with left
upper blepharoplasty and external ptosis repair 4 years prior to her
presentation for persistent droopy left upper eyelid (Figure 1). MRD
was 4mm on the right and 2mm on the left. Levator function was
12mm on both sides and there were no conjunctival abnormalities on
slit lamp examination. During a modified conjunctivo-mullerectomy
ptosis repair, the posterior superior palpebral conjunctival tissue was
found to be necrotic and friable upon double eversion. The tissue was
biopsied and demonstrated amyloid deposition with positive congo
red staining (Figure 2). Systemic work up was negative. Case 2 is
a 74-year old man with a history of right upper eyelid ptosis with
MRD of 2mm on the right and 3.5mm on the left. Just as in case 1
the patient had no other periorbital or conjunctival abnormalities.
During double eversion for right conjunctivo-mullerectomy a friable
mass was noted deep within the superior conjunctival fornix. Biopsy
revealed amyloid dispersed throughout the tissue, with a positive
Thioflavin stain. Systemic work up was negative for other systematic
disease.
Results: Only 4% of head and neck amyloid involve the orbit and
the vast majority of periorbital cases involve the conjunctiva and
eyelid. Periorbital signs commonly seen include conjunctival deposits
or soft tissue nodular deposits. Classically, eyelid amyloid implies
systemic disease, while conjunctival amyloid suggests no systemic
involvement. Ptosis can be a presenting sign of amyloidosis but it is
almost always associated with other signs or symptoms. Myogenic
infiltration of the levator muscle has been reported in one patient with
amyloid who underwent a levator resection. Our patients underwent
mullerectomy hence no levator specimens were available for review.
Conclusions: These are the first two cases to describe amyloidosis
masquerading as isolated ptosis without any other signs. Eyelid
eversion during pre-op evaluation and careful examination during
double eversion at the time of mullerectomy surgery may help in
detecting any unusual entities such as amyloidosis.
Commercial Relationships: Maria M. Choudhary, None;
Rao Chundury, None; Priyanka Kumar, None; Julian Perry,
None
Entropion and Ectropion Patient Characteristics and Outcomes:
A Retrospective Chart Review
Annie Wu1, Connie Wu1, Philip R. Rizzuto2. 1Ophthalmology, Warren
Alpert Medical School of Brown University, Providence, RI;
2
Ophthalmic Plastic Surgery, Warren Alpert Medical School of Brown
University, Providence, RI.
Purpose: To describe patient characteristics and outcomes after
entropion and ectropion surgical repair.
Methods: A retrospective chart review was performed of all
patients who underwent entropion and/or ectropion repair within a
2-year interval (2013-2015) in the practice of one surgeon (PRR).
Data included patient’s age, gender, surgical indication, medical
comorbidities, diagnosis, procedure(s) performed, time interval from
surgery to follow-up appointment, and postoperative complications.
Results: A total of 61 entropion repairs and 112 ectropion repairs
were performed on 122 patients. The patients included 61 women and
61 men. Average age was 76.49 years (women 77.33, men 75.65).
Of the 50 patients with entropions, 38% were men and 62% were
women; average age was 77.72; 12 patients (24%) had bilateral
entropions. Of the 80 patients with ectropions, 58.75% were men and
41.25% were women; average age was 76.35; 33 patients (41.25%)
had bilateral ectropions. Entropion was more common in women and
ectropion was more common in men (p=0.02). Bilateral ectropion
was more commonly observed than bilateral entropion (p=0.04).
There was no statistical difference in age between the entropion
and ectropion groups (p=0.52). A total of 8 patients (6.56%) had
entropion of one eye and ectropion of the other. No intraoperative
complications were reported. Average postoperative follow-up was
48 days. Over the 2 year period, recurrent ectropion was noted in 6
cases. No recurrences were reported in patients receiving entropion
repair. Recurrence occurred less frequently in patients receiving
entropion repair (p=0.03).
Conclusions: Entropion was found to be more common in women
and ectropion more common in men. Bilateral disease was observed
more frequently in patients with ectropion. A considerable proportion
of patients had a diagnosis of entropion of one eye and ectropion of
the other. Recurrence was more common among patients undergoing
ectropion repair.
Commercial Relationships: Annie Wu, None; Connie Wu, None;
Philip R. Rizzuto, None
Quality of life assessment after entropion repair
Yan Tong Koh1, Philemon Keqin Huang1, Eugenie Wei Ting Poh1,
Chee Chew Yip2, 1. 1Ophthalmology, Tan Tock Seng Hospital,
Singapore, Singapore; 2Ophthalmology and Visual Sciences, Khoo
Teck Puat Hospital, Singapore, Singapore.
Purpose: Lower lid involutional entropion is a common eyelid
malposition. Few studies have analysed the quality of life (QOL) in
patients after lower lid entropion surgery (LLES). We thus studied the
effect of LLES on the QOL as well as factors associated with a poorer
post-operative QOL.
Methods: Consecutive patients from 2 centers who underwent LLES
by a single surgeon in 2004 – 2007 were recruited. LLES was defined
as lower eyelid retractor repair alone or with additional lateral tarsal
strip (LTS). The EuroQol-5 Dimension (EQ-5D), EuroQol-Visual
Analogue Scale (EQ-VAS) and Utility Value (UV) questionnaires
were administered via a phone interview by a single interviewer after
the patient underwent LLES. The UV score were derived using the
time tradeoff (TTO) and standard gamble (SG). TTO was based on
two hypothetical questions: how long they expected to live (x years)
and how much time they would be willing to trade off (y years) in
return for improvement in their pre-operative lower eyelid position
and symptoms. The value was derived by 1-y/x. SG was based on the
patient’s perception of the highest risk of blindness (z) they would be
willing to accept if there was another technology that could possibly
permanently improve pre-operative eyelid conditions and symptoms,
but which success of the technology was not guaranteed. The value
was derived by 1-z.
Results: 61 eyelids of 61 patients were evaluated. The mean age
was 76.9 ±10.1 years old. The mean EQ-5D, EQ-VAS and TTO
and SG scores are 90.8 ± 16.7, 74.8 ± 14.2, 0.8 ± 0.2 and 0.9 ± 0.07
respectively. There were no significant factors on univariate analysis
of EQ-5D scores. Multivariate analysis showed the mean EQ-VAS
score for patients who underwent additional LTS was 10.2 (95%
CI=3.4-17.1, p=0.004) lower than patients who underwent isolated
retractor repair. The mean EQ VAS score for patients with bilateral
and recurrent entropion was 10.8 (95% CI=3.8-17.9, p=0.005) and
27.1 (95% CI=8.4-45.7, p=0.01) lower compared to those with
unilateral entropion and no recurrence respectively. Patients with a
positive family history had a 0.2 (95% CI=0.02-0.3, p=0.03) lower
mean TTO score compared to those without. Male gender and higher
education level were statistically associated with a lower SG mean
score.
Conclusions: Significant factors associated with poorer QOL include
male gender, higher education level, positive family history, bilateral
entropion, recurrent entropion and additional LTS.
Commercial Relationships: Yan Tong Koh, None;
Philemon Keqin Huang, None; Eugenie Wei Ting Poh, None;
Chee Chew Yip, None
Reversible Cicatricial-like Ectropion Related to Epidermal
Growth Factor Receptor (EGFR) Inhibitors
Stacy Scofield-Kaplan, Bryan Winn. Ophthalmology, Columbia
University, Harkness Eye Institute, New York, NY.
Purpose: The management of cicatricial-like ectropion resulting
from epidermal growth factor receptor (EGFR) inhibitors is unclear.
In the few published case reports, the offending EGFR inhibitor
has been stopped and the patient has either been maintained off that
medication or has undergone surgical repair with resumption of the
same EGFR inhibitor.
Methods: We retrospectively reviewed one physicians private
practice and found two patients who developed bilateral cicatriciallike ectropion following use of an EGFR inhibitor.
Results: The first case involves bilateral ectropion of the
lower eyelids with anterior lamellar contraction and bilateral
keratoconjunctivitis following panitumumab infusions. The patient
was treated with temporary suspension of panitumumab infusions
with concomitant medical management with oral doxycycline
100mg twice daily, maxitrol ophthalmic ointment twice daily to
the eyelids, and artificial tears four times a day to both eyes. The
bilateral ectropions resolved and the patient subsequently restarted
panitumumab infusions without ophthalmic complications (Figure
1AB). The second case involves the development of bilateral
ectropion of the lower eyelids in the setting of cituximab infusions
for recurrent squamous cell carcinoma of the mandible. She was
maintained on cituximab at the same infusion frequency of every
two weeks with institution of doxycycline 100mg twice daily,
fluorometholone ointment to the eyelids four times a day, and
artificial tears four times a day. Four months later she had complete
resolution of the right lower lid ectropion and almost complete
resolution of the left lower lid ectropion (Figure 2AB).
Conclusions: It is still unclear what the optimal treatment regimen
is for lower lid ectropion related to EGFR inhibitors. While the first
case had resolution of the bilateral lower lid ectropion, it is unclear
whether this was from discontinuation of the panitumumab infusions
or from use of oral doxycycline with steroid ointment to the lower
eyelids. However, the second case may provide support for the
use of oral doxycycline and steroid ointment to the eyelids prior to
discontinuation of the offending EGFR inhibitor, given the successful
outcome without alteration of the cituximab infusions. Additional
cases are necessary to determine if this is a successful means of
treating bilateral lower lid ectropion from EGFR inhibitors.
Purpose: Ectropion of the eyelid can lead to skin retraction, stenosis
of lacrimal point, chronic watering, visual discomfort or low visual
acuity, mostly when it occurs with ectropion of lacrimal point. The
objective of the study is to compare two surgical strategies for eyelid
ectropion combined with ectropion of the lacrimal point.
Methods: We included all consecutive patients who underwent eyelid
ectropion surgery in our department from Oct 2014 to Oct 2015. The
first procedure is lateral tarsal strip alone (group 1); the second one is
lateral tarsal strip with three snips with or without diamond-shaped
resection (group 2). The authors focused on the alteration of the
quality of life related to watering, before and after operation. Quality
of life related to discomfort due to watering was evaluated before and
after surgery using a questionnaire. Informations have been gathered
via phone with a ten items questionnaire, each item is worth 0 (no or
minim discomfort due to watering) or 1 (discomfort due to more than
moderated watering).
Results: Twenty-two eyelids from eighteen patients were included,
eleven in group 1 and eleven in group 2. Average age was 79 ± 11
year-old in group 1 and 80 ± 9 in group 2. The five more relevant
items were: reading capacity, watching TV, outdoor activities,
social interaction and general well being. For reading: respectively
in group 1 and 2, 82 % and 91 % of the patients were discomfort
before surgery while 18 % and 0 % after surgery. For watching TV:
82 % and 91 % before surgery while 9 % and 9 % after. For outdoor
activities: 91 % and 100 % before surgery while 0 % and 0 % after.
For social interaction: 80 % and 90 % before surgery while 0% and
0% after surgery. For global well being, respectively 90 % and 70 %
before surgery, while 0 % and 0% after surgery.
Conclusions: Our study proves effectiveness of both surgery
strategies to improve patients’ discomfort due to watering. Contrary
to our initial assumption, both strategies lead to similar results, which
would be in favor of a surgery as little invasive as possible. A larger
sample size will be necessary to demonstrate any superiority of
lacrimal point surgery.
Commercial Relationships: Alix EHRHARDT, None;
Oualid Guechi, None; Mohamed Zaidi, None; Louis Lhuillier,
None; Naïla Houmad, None; Maxime SOT, None; adina agapie,
None; piotr krawczyk, None; Huong Duong Nguyen Viet, None;
Jean-Marc Perone, None; Nadia OUAMARA, None
Commercial Relationships: Stacy Scofield-Kaplan, None;
Bryan Winn, None
Presentation Time: 1:30 PM–3:15 PMComparison between two
surgical methods for eyelid ectropion: tarsal strip alone versus
tarsal strip with punctoplasty (three snips with or without diamondshaped resection).
Alix EHRHARDT1, Oualid Guechi1, Mohamed Zaidi1,
Louis Lhuillier1, Naïla Houmad1, Maxime SOT1, Adina Agapie1,
Piotr Krawczyk1, Huong Duong Nguyen Viet2, Jean-Marc Perone1,
Nadia OUAMARA1. 1ophthalmology, Regional hospital center, Mercy
hospital, METZ cedex 03, France; 2University of Medicine and
Pharmacy of Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
SURGICAL OUTCOMES OF PORCINE ACELLULAR
DERMIS GRAFT IN SOCKET AND EYELID
RECONSTRUCTION: A COMPARISON WITH ORAL
MUCOSAL GRAFT
Livia Teo1, 2, Chang Yeom Kim2, Dong Kyu Kim2, Jin Sook Yoon2.
1
Singapore National Eye Centre, Singapore, Singapore; 2Yonsei
University, Severance Hospital, Seoul, Korea (the Republic of).
Purpose: To compare the efficacy of the Permacol™ graft with
autologous buccal mucosal graft in socket and eyelid reconstruction,
with emphasis on the postoperative vascularization and fibrosis of
each graft.
Methods: This was a retrospective comparative study. Ten patients
underwent Permacol™ graft reconstruction and 44 patients
underwent buccal mucosal graft reconstruction. The time necessary
for the graft surface to be completely vascularized and the fornix
depth of the conjunctival sac in anophthalmic patients was measured.
Results: All ten patients in the Permacol group had unilateral
contracted anophthalmic sockets. Seven eyelids (70%) in the
anophthalmic socket group had a good outcome with improvement
in lower eyelid position and prosthesis retention. Nine out of ten
eyelids (90%) in this group showed complete vascularization of
the graft with minimal fibrosis at 2.6± 1.9 months postoperatively,
while the grafted buccal mucosa was fully vascularized at 1.1± 0.3
months postoperatively (P< 0.01). Postoperative fornix depth in the
Permacol™ group was 9.1 ± 2.2 mm compared to14.9 ± 4.5 mm in
the buccal mucosal graft group (P< 0.01).
Conclusions: The Permacol™ graft can be a useful spacer graft
material in anophthalmic socket and eyelid patients. It takes longer
to vascularize and undergoes greater graft shrinkage with time when
compared to buccal mucosal graft.
Commercial Relationships: Livia Teo, None; Chang Yeom Kim,
None; Dong Kyu Kim, None; Jin Sook Yoon, None
Geometry of the Blepharoplasty Incision
Sagar Y. Patel, Ronald Mancini. Ophthalmology, University of Texas
Southwestern Medical Center, Dallas, TX.
Purpose: Our study evaluted the affects of the blepharoplasty
incision and its result on eyelid aesthetics, specifically eyebrow and
eyelid positioning, which both play a pivotal role in facial beauty,
perception of aging, and patient satisfaction.
Methods: This was a prospective study that included individuals
undergoing upper lid blepharoplasty. Patients were excluded if they
had eyelid ptosis and/or brow ptosis repair. Standard frontal plane full
face digital photographs before and after surgery were obtained of
the subjects with eyes open and closed. Patients were analyzed in two
cohorts depending on timing of post-operative evaluation, 6-weeks or
3-months. Every patient had an operative photograph with their eyes
closed outlining the blepharoplasty incision. Images were processed
using ImageJ software (v1.48) developed by the National Institute of
Health. The measurements examined before and after surgery were
Brow Position Index (Image 1), Palpebral Fissure, Margin-Reflex
Distance-1, Margin-Reflex Distance-2, and Eyelid Skin Surface
Area (Image 2). The measurements examined at the time of surgery
were Operative Skin Surface Area, Operative Superior Distance, and
Operative Inferior Distance. A paired t-test of each measurement was
performed to evaluate differences before and after surgery in each
cohort.
Results: The average age was 67.4 years. The 6-week cohort
revealed a statistically significant increase in margin fold distance
and decrease in eyelid surface area as would be anticipated. The
differences in the margin fold distance and eyelid surface area
remained statistically significant in the 3-month cohort. The 3-month
cohort also revealed statistically significant increases in MRD1
and lowering of brow position. Statistical analysis evaluating the
blepharoplasty incision and its distance from superior and inferior
eyelid landmarks yielded no statistically significant differences
between pre- and post-operative measurements at 6 weeks or 3
months.
Conclusions: At 3 months, we found statistically significant changes
in brow position, MRD1, margin fold distance, and eyelid surface
area. Minor changes in the blepharoplasty incision did not affect the
eyelid or eyebrow position. These findings will help in educating
patients and setting expectations, particularly regarding lowering
of brow position and increase in MRD1. Minor adjustments can be
made to the shape of the blepharoplasty incision without significantly
impacting eyelid or eyebrow position.
Commercial Relationships: Sagar Y. Patel, None;
Ronald Mancini, None
Immortalization of Human Lacrimal Epithelial Cells
Marwan Ali, Dhara Shah, Zeeshan Pasha, Vinay K. Aakalu.
Department of Ophthalmology, University of Illinois at Chicago,
Chicago, IL.
Purpose: Purpose: Study of human lacrimal epithelial cell biology
is limited by poor access to tissue and difficulty with maintaining
primary cultures. A better understanding of lacrimal epithelial biology
would advance efforts to develop treatments for dry eye disease and
other lacrimal gland diseases. In this study, we utilized viral vectors
expressing hTERT to develop an immortalized human lacrimal
epithelial cell line.
Methods: Methods: Primary human Lacrimal Epithelial (hLE) cells
from passage 3 to 5 were immortalized using Lentiviral vectors
expressing GFP-tagged hTERT gene. Cultured primary hLE cells
were transfected with pLenti-GIII-CMV-hTERT-GFP-2A-Purovirus
at Multiplicity Of Infection (MOI) of 1, 1.5 and 2 in the presence
of 0.8ug/ml Polybrene. The next day, the viral supernatant was
removed and replaced with fresh complete HepatoStim growth
medium. After three days, 10ug/ml Puromycin Dihydrochloride
was added to medium for selection of immortalized hLE cells.
Immortalized hLE cells were then viewed using bright field and
fluorescent microscopies to detect GFP signal of transfected hLE
cells. Successful transfection of different hLE cells from the different
passages was analyzed using RT-PCR and fluorescence microscopy.
GFP labeled cells were selected using FACS and subcultured.
Isolated cells were passaged and followed for a period of 100 days.
RT-PCR and immunofluorescence analysis were conducted to
evaluate lacrimal epithelial phenotype and telomerase activity for 20
passages.
Results: Results: Successful immortalization of human lacrimal
epithelial cells using a lentiviral hTERT vector with GFP reporting
was demonstrated through maintenance of epithelial cells through
multiple passages, evidence of integration of the viral vector, stable
expression of GFP and maintenance of lacrimal epithelial gene
expression patterns and immunophenotyping.
Conclusions: Conclusion: We have successfully developed an
immortalized human lacrimal epithelial cell line which can be
used for future study in developing cell based therapies for dry eye
disease.
Immortalized Human Lacrimal Epithelial Cells Passage5 (MOI 1)
Immortalized Human Lacrimal Epithelial Cells Passage3 (MOI 1.6)
Commercial Relationships: Marwan Ali, None; Dhara Shah,
None; Zeeshan Pasha, None; Vinay K. Aakalu, None
Support: NIH—NEI Grant (K08EY024339), a seed grant from
Illinois Society to Prevent Blindness, a Research Grant from Midwest
Eye Banks, a Grant-in-Aid from Fight for Sight and Departmental
Support through an NIH-NEI Core grant (2P30EY001792-36A1) and
an Unrestricted Grant from Research to Prevent Blindness (NY,NY).
Targeted Endoscopic Dacryocystorhinostomy for Acquired
Nasolacrimal Duct Obstruction
Paul Petrakos1, Ashutosh Kacker2, Joshua I. Levinger2, Gary Lelli1.
1
University Eye Clinic, Weill Cornell Medical College, New York,
NY; 2Otolaryngology, Weill Cornell Medical College, New York, NY.
Purpose: To evaluate the improvement in epiphora in patients with
acquired nasolacrimal duct obstruction (NLDO) following targeted
(inferior meatal) endoscopic dacryocystorhinostomy (EndoDCR).
Methods: A retrospective study of 9 eyes in 8 patients (n=9) who
were surgically treated for acquired NLDO using targeted (inferior
meatal) EndoDCR. Patients were included in the study if they had at
least 3 months of follow-up. Their final visit was used to determine
success. Patients were classified as having full success (complete
absence of tearing in normal conditions, no recurrence of infection
and absence or minimal reflux on lacrimal irrigation), partial success
(improved tearing compared with preoperative tearing, but not
resolved with partial or complete irrigation), or complete failure
(anatomical failure with persistent/recurrent tearing).
Results: Mean follow-up time for the 9 subjects was 8.8 months
(SD 6.6). At least partial success was achieved in 7 of 9 subjects
(78%). Full success was found in three eyes, partial success in four
eyes, and complete failure in two eyes. There were no incidences of
dacryocystitis, punctal erosion from silicone tubing, or canalicular
obstruction. One of the complete failure patients had previous
EndoDCR. The other complete failure patient underwent septoplasty
at the time of the targeted EndoDCR and had a history of recurrent
sinus inflammatory disease.
Conclusions: Targeted (inferior meatal) EndoDCR is a less invasive
and efficacious modality in the treatment of acquired NLDO in
patients that are suffering from epiphora and may be useful in cases
of early diagnosis, where the inferior nasolacrimal duct can still be
utilized in the repair.
Commercial Relationships: Paul Petrakos, None;
Ashutosh Kacker, None; Joshua I. Levinger, None; Gary Lelli,
None
Effect of Nunchaku-Style Silicon Tube Intubation in Patients with
Lacrimal Duct Obstruction Associated with S-1
Kazuyoshi Ohtomo. Ophthalmology, The University of Tokyo
Hospital, Tokyo, Japan.
Purpose: To investigate clinical features of lacrimal duct obstruction
associated with S-1 (LDOAS) and the prognostic factors of direct
silicon tube intubation (DSI) with Nunchaku-style silicon tube.
Methods: Of 26 patients (15 males and 11 females), 52 eyes with
a LDOAS who had an operation between 2008 and 2014 were
evaluated retrospectively. The severity of canalicular obstruction
was assigned as a degree of canalicular obstruction. Patients were
categorized into an effective group defined as disappearance of
epiphora and improvement of lacrimal passage and an ineffective
group including re-occlusions and insertion failures which were not
able to insert the NST.
Results: The mean age was 64.5±7.1(mean±SD). Average
followed-up period was 18.1±21.2 months. The mean duration
of S-1 administration was 14.0±11.8months. The mean period
until symptom appearance was 4.9±3.5 months. The frequency of
epithelial disorder of cornea before the treatment was 42%. The S-1
administration was 58%. The obstructed parts including duplication
were found in punctum (19%), canaliculous (65%), common
canaliculous (13%), lacrimal suc (4%), and nasolacrimal duct (15%).
The mean severity of canaliculous obstruction was 3.6±2.3.
DSI was effective in 29 eyes (56%). There were significant
differences on followed-up period (p=0.0007, Mann-Whitney U test),
the duration of S-1 administration (p=0.0041, Mann-Whitney U test),
the period until symptom appearance (p=0.0032, Mann-Whitney
U test), and the frequency of corneal epithelial disorder (p=0.0240,
Fisher’s Exact test) between the effective and the ineffective
groups. In the obstructed parts, there were significant differences on
canaliculous (p<0.0001, Fisher’s Exact test), common canaliculous
(p=0.0064, Fisher’s Exact test), nasolacrimal duct (p=0.0064, Fisher’s
Exact test). In the severity of canaliculous, the ineffective group
was more severe obstruction than the effective group (p<0.0001,
Mann-Whitney U test). In the multiple regression analysis, there was
a significant difference on the severity of canaliculous (OR=5.69,
p=0.0006, 95%CI=2.5412-18.998).
Conclusions:
Patients with a LDOAS had mainly canaliculous obstruction
(65%). DSI was effective in 29 eyes (56%). Our findings showed that
the severity of canaliculous obstruction became the prognostic factor
of DSI.
Commercial Relationships: Kazuyoshi Ohtomo, Japan society for
the promotion of science (F)
Support: JSPS KAKENHI grant Number 15K20249
Lacrimal tubes in external dacryocystorhinostomy: a method for
placement and removal and the incidence of prolapse
Seanna R. Grob, Michael Yoon. Ophthalmology, Massachusetts Eye
and Ear Infirmary, Boston, MA.
Purpose: To report a method of lacrimal tube placement and
removal, and the incidence of lacrimal tube extrusion after external
dacryocystorhinostomy (DCR).
Methods: A retrospective review of 88 patients (96 eyes) that
underwent external DCR from 2011-2015 by one surgeon at
Massachusetts Eye and Ear Infirmary was conducted. For placement,
the Crawford tube was secured using 20 square knots and replaced in
the nose. For removal, a 50:50 mix of 0.05% oxymetoxalone and 4%
lidocaine was sprayed into the nose and the stent was cut between the
puncta. After 5 minutes, the patient blew the affected side of the nose,
while occluding the contralateral nare. Endonasal forceps were used
to remove the stent if this was unsuccessful.
Results: 88 patients (96 eyes) were identified (mean 61 years,
54 female). 15 eyes had one or more episodes of tube extrusion
(15.6%). Two eyes had two episodes and three eyes had 3 episodes of
extrusion. The mean time after surgery until the first tube extrusion
was 34.2 days (median 17 days). The tube was unable to be replaced
after extrusion in 4 patients after the first extrusion, 1 patient after the
second, and 2 patients after the third extrusion. A total of 21 patients
had their tubes removed prior to the usual 3-month period (only 6
were from tube extrusion or 6.2%). Of the six patients whose tubes
were out before the 3 months from tube extrusion, only 1 patient did
not have post-operative symptom relief.
Forty patients were observed using the nose blowing technique. 83%
achieved success using this technique with a mean of 1.6 attempts. Of
these patients, 30 of them exerted adequate effort with nose blowing.
The remainder required forceps for removal, either due to poor effort
or failure of the technique. There were no instances of slit puncta or
inability to locate/remove the stent.
Conclusions: Our method of tube placement and removal showed
successful results. Although lacrimal tube extrusion occurred, over
half of the displaced tubes were replaced without requiring early
tube removal. The success rate of surgery was still high despite tube
extrusion and early removal. Forceps and endoscope tube removal
was avoided in the majority of patients and no damage to the puncta
occurred.
Commercial Relationships: Seanna R. Grob; Michael Yoon, None
The success rate of simultaneous and asynchronous approach of
bilateral external dacryocystorhinostomy
Silvana A. Schellini, Alberto Galvez, Mohamed Dufaileej,
Rajiv Khandekar, Alicia Galindo. Oculoplastic, King Khaled
Specialist Eye Hospital, Riyadh, Saudi Arabia.
Purpose: Purpose: to determine the success rate of bilateral
dacryocystorhinostomies (DCR) using simultaneous and
asynchronous approach.
Methods: Methods: this retrospective study included patients who
underwent bilateral external DCR between January 2010 and August
2015 at King Khaled Eye Specialist hospital. Postoperative success
defined as absolute if no tearing bilaterally or partial if tearing in
one side only was assessed by subjective (symptoms of tearing) and
objective (fluorescein dye disappearance test - FDDT) methods.
Statistical analysis was performed applying the Fisher exact test.
Results: Results: of 57 patients undergoing DCR 32 (56%) had
simultaneous surgeries on both sides while in 25 patients, the surgery
was asynchronous. The median duration of follow up was 7 months.
The absolute success and partial rate based on subjective method
was 43/55 [(78.2% (67.3 – 89.1)]. Partial success was noted in 5/55
(9.1%). Seven (12.7%) patients persisted with tearing on both sides.
The objective method (n = 40) showed similar results in patients
undergoing simultaneous (71.9%) and asynchronous (80%) DCR
(p=0.4).
Conclusions: Conclusions: bilateral DCR surgery is useful in
patients who have bilateral symptoms of lacrimal obstruction due to
blockage of tear ducts and gives promising outcomes. By performing
the DCR simultaneously, the success rate is not compromised, and
one can rehabilitate patient sooner.
Commercial Relationships: Silvana A. Schellini, None;
Alberto Galvez, None; Mohamed Dufaileej, None;
Rajiv Khandekar, None; Alicia Galindo, None
Clinical presentation and bacteriology of eyebrow infections: the
Massachusetts Eye and Ear experience (2008-2015)
Anaïs Carniciu, Ilya Leskov, Jonathan Chou, Suzanne K. Freitag.
Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA.
Purpose: Characterization of preseptal cellulitis and abscesses of
the eyebrow remains limited. A retrospective study was performed
to elucidate the clinical history, precipitating human behaviors, and
bacteriology of eyebrow infections.
Methods: A retrospective chart review was conducted to identify
patients with preseptal cellulitis or abscess involving the eyebrow
who were treated at Massachusetts Eye and Ear Infirmary between
2008 and 2015. Patient history, ophthalmic examination, and culture
results were reviewed to identify characteristics and trends in the
clinical presentation and bacteriology of eyebrow infections.
Results: 80 patients with eyebrow infections were identified. The
median age of patients was 37 years (range 14-67). 49 patients
(61.3%) were female, and 31 (38.7%) were male. Of all eyebrow
infections, 26 cases (32.5%) were limited to preseptal cellulitis
without abscess formation, while the remaining 54 cases (67.5%)
presented with eyebrow abscess. Of cases presenting with abscess,
20 were positive for methicillin-resistant Staphylococcus aureus
(MRSA); this comprised 39.2% of all culture results. Twelve cases
had cultures positive for methicillin-sensitive Staphylococcus aureus
(MSSA), which comprised 23.5% of all culture results. Coagulase
negative staphylococci (CoNS) were present in 7 eyebrow abscesses,
corresponding to 13.7% of culture results. Three patients had a
medical history of previous MRSA infection, while 4 patients had
prior history of recurrent skin infections (with organisms unknown)
elsewhere in the body. Two patients presented with recurrent eyebrow
abscess after previous incision and draining. Clinical history was
remarkable for eyebrow hair removal (tweezing, waxing, threading,
or shaving) in 17 cases (21.3%), manipulation of acne lesions
(“popping,” “picking,” or “squeezing”) in 6 cases (7.5%), and both
brow hair removal and acne manipulation in 1 case (1.3%).
Conclusions: The most frequently isolated organisms in eyebrow
infections are MRSA, MSSA, and CoNS, respectively. Human
behaviors associated with presentation of preseptal cellulitis
and abscesses of the eyebrow include eyebrow hair removal and
manual manipulation of eyebrow-localized acne lesions. Given the
prevalence of MRSA in the bacteriology of eyebrow infections,
empiric antibiotic coverage for MRSA should be strongly considered
in any patient with an eyebrow area infection.
Commercial Relationships: Anaïs Carniciu, None; Ilya Leskov,
None; Jonathan Chou, None; Suzanne K. Freitag, None
Outcomes of revision conjunctivodacryocystorhinostomy with
Jones tubes
Bryce Radmall1, Eric Ahn3, Eric Steele2, Roger Dailey2.
1
Ophthalmology, Casey Eye Institute, Beaverton, OR; 2Division of
Oculoplastics, Casey Eye Institute, Portland, OR; 3Oculoplastics, Eye
Consultants of Northern Virginia, Springfield, VA.
Purpose: Determine the success rate of revision
conjunctivodacryocystorhinostomy (CDCR) with Jones tubes (JT).
Methods: A retrospective chart review was performed identifying
those undergoing external and endoscopic CDCR from January 1,
2006 to November 1, 2014. Only those patients having revision
CDCR (a patient’s second CDCR), and at least six months follow up
were included. The primary outcomes were time to failure of revision
CDCRs and the number of subsequent repeat CDCRs needed.
Results: A total of 18 eyes from 16 patients met the inclusion criteria.
Average patient age was 57.7 years, with nine females and seven
males all of whom were Caucasian. There were nine frosted and nine
non-frosted JTs placed at the time of each eye’s initial CDCR. 8/9
frosted JTs either migrated in too deeply or were lost in the nose by
history. 5/9 non-frosted JTs were lost having completely migrated
out, with the remaining 4/9 migrating too deep to replace. Revision
CDCR involved the use of fifteen frosted JTs and three non-frosted
JTs, with nine patients requiring lysis of scar tissue involving the
nasal ostium, three patients needing changes to the trajectory of the
CDCR tract, and eight requiring subtotal middle turbinectomy. Six
eyes required further CDCR, four requiring one more CDCR and
two each requiring three more CDCRs. Average time from revision
CDCR to repeat CDCR was 1604.8 (343-4773) days. Kaplan Meier
analysis showed 50% of revision CDCR functioning at 10 years
postoperatively.
Conclusions: Most patients undergoing revision CDCR required no
further surgery, although 33% needed at least one or more additional
CDCRs and this group as a whole over time may have a higher rate
of reoperation.
Commercial Relationships: Bryce Radmall, None; Eric Ahn,
None; Eric Steele, None; Roger Dailey, None
Support: This manuscript was supported in part by an unrestricted
grant to Casey Eye Institute from Research to Prevent Blindness,
New York, New York.
Dacryocystectomy: indications and results at tertiary eye hospital
of central Saudi Arabia
Laryssa K. Veloso3, Alicia Galindo1, 2, Mohamed Dufaileej1,
Alberto Galvez1, Rajiv Khandekar1, Silvana A. Schellini1, 3. 1King
Khaled Eye Specialist Hospital, Riyad, Saudi Arabia; 2Oftalmologia,
Complejo Asistencial de Palencia, Palencia, Spain; 3Oftalmologia,
Faculdade de Medicina de Botucatu- UNESP, Botucatu, Brazil.
Purpose: This study was done to give evidence about the indication
and success of dacryocystectomy (DCT) in a tertiary eye institute.
Methods: A retrospective review of all patients who underwent
DCT from the Oculoplastic Division of King Khaled Eye Specialist
Hospital, Saudi Arabia, from 2008 through July 2015 was done.
Demographic data of patients, symptoms related to the lacrimal
drainage system before and after surgery and complications were
observed. The data was transferred to spreadsheet of SPSS 16 and
univariate analysis using parametric and non-parametric methods was
done.
Results: 47 DCT surgeries were performed in the studied period. The
median age of patients was 58.2 years old, 63.8% were female, left
side was operated in 60% of patients and 8% undergone to bilateral
simultaneous DCT. All the indications for DCT for our patients was
chronic dacryocystitis and 23.5% of them had dry eye before surgery.
After surgery 8.5% of our patients complains of tearing and only
6.4% complaint about dry eye.
Conclusions: The main indication for DCT in our hospital is chronic
dacryocystitis. DCT still seems to be a good procedure to treat select
patients, mainly elderly with dry eyes.
Commercial Relationships: Laryssa K. Veloso, None;
Alicia Galindo, None; Mohamed Dufaileej, None; Alberto Galvez,
None; Rajiv Khandekar, None; Silvana A. Schellini, None
Modified canaliculotomy with suture-fixed stent for treatment of
canaliculitis
Tina H. Chen1, Milap Mehta2. 1Ophthalmology, University of
Chicago, Chicago, IL; 2Eye and Vision, Northshore University,
Chicago, IL.
Purpose: The gold standard surgical treatment of canaliculitis is
punctal dilatation and curettage, but may lead to recurrent disease if
dacryoliths remain. Canaliculotomy allows direct access, but can lead
to scarring, strictures, or dilatation of the canaliculi or punctum. In
our study, we conducted a restrospective chart review of 2 patients
undergoing modified canaliculotomy with suture-fixed stenting to
evaluate its efficacy and ability to maintain patency of the lacrimal
system.
Methods: Inclusion criteria included chronic canaliculitis with
canalicular stenosis proven on probing and irrigation without
nasolacrimal duct involvement. Patients with punctal plugs were
excluded from the study. Our cohort included 2 patients (2 puncta),
including 1 male (Patient 1) and 1 female (Patient 2), ages 71 and
22 years, respectively. Both presented with tearing and purulent
discharge which failed conservative treatment. Intraoperatively, each
patient received upper and lower punctal dilatation of the affected
eyelid. A bowman probe #2 was then placed into the left lower
punctum and canalicular system until a “hard stop” was engaged.
A #11 blade was used to incise the canaliculus from the punctum
towards the common canaliculus. A chalazion curette was then used
to express any dacryoliths or foreign bodies. A chalazion clamp was
used in a “milking” fashion to ensure no additional foreign bodies
remained. Both patients had a lacrimal stent fixed into the punctum
with a 6-0 prolene suture and externalized. The stent was then
directed along the path of the previously incised canaliculus into the
lacrimal sac. The skin was closed with 6-0 chromic sutures over the
stent and re-formed canaliculus. The stents were removed after 6
weeks.
Results: Both patients underwent uncomplicated stent removal
after 6 weeks. Both (100%) had complete resolution of symptoms
and maintained patency of the lacrimal system. One patient
(50%) developed a small pyogenic granuloma that resolved with
conservative treatment. There were no cases of disease recurrence 6
weeks post-operatively.
Conclusions: The modified canaliculotomy with suture fixation of
a lacrimal stent provides excellent surgical exposure and allows for
easy removal of lacrimal foreign bodies. The suture-fixated lacrimal
stent is easily placed with the wide surgical exposure. Fixation
sutures prevent premature extrusion.
Modified canaliculotomy
Post op week 6
Commercial Relationships: Tina H. Chen, None; Milap Mehta,
None
Critical exam findings and culture results that correlate with
inpatient hospitalization in the setting of Acute Infectious
Dacryoadenitis
Matthew Zhang2, 1, Sarah Tanaka2, Matthew Hollar2, Viraj Mehta2,
Behin Barahimi2. 1Ophthalmology and Visual Sciences, Vanderbilt
University, Nashville, TN; 2Ophthalmology, Vanderbilt Eye Institute,
Nashville, TN.
Purpose: Acute Infectious Dacryoadenitis (AID) is a potentially lifethreatening ophthalmic condition that is understudied. We performed
a retrospective, observational clinical study that identified culture
results and critical signs on physical examination which correlated
with whether patients did or did not require inpatient hospitalization
in the setting of AID.
Methods: A retrospective chart review was performed of Vanderbilt
Hospital records for patients of all ages who carried an ICD9 code of
375.01 (acute dacryoadenitis) between the years 1998 and 2015, and
in whom at least 1 year of ophthalmology follow-up was available.
A total of 20 patients met entry criteria. Twelve patients with
inpatient hospitalization and eight patients treated as outpatients were
reviewed. The two-tailed Fisher’s exact test and Chi-squared test
were used to draw statistical comparisons between categories of this
study.
Results: A total of 20 patients with AID were identified. Twelve
patients with AID were admitted for inpatient management and
intravenous antibiotics. Eight patients were managed on an outpatient
basis. Fornix cultures were obtained in thirteen AID subjects. There
were six patients that had culture-confirmed Staphylococcus aureus
(SA), and another seven patients had mixed flora or no growth. All
six SA-positive patients presented with critical signs on examination,
defined as purulent discharge and/or extraocular movement deficits.
SA culture-positivity correlated with the presence of purulent
discharge (p=0.006) and extraocular movement deficits (p=0.02).
The likelihood of inpatient hospitalization also correlated positively
with the presence of purulent discharge (p=0.0009) and extraocular
movement deficits (p=0.0004). Finally, SA culture-positivity
correlated with likelihood of inpatient hospitalization (p=0.0419)
Conclusions: In patients with AID, our findings suggest that the
presence of purulent discharge and extraocular movement deficits
correlated with SA culture-positivity. Also, SA culture-positivity,
presence of purulent discharge, and extraocular movement deficits
each separately correlated strongly with the likelihood of inpatient
hospitalization. This is the first study that correlates culture results
and critical signs on examination with likelihood of inpatient
hospitalization in the setting of AID.
Commercial Relationships: Matthew Zhang, None;
Sarah Tanaka; Matthew Hollar, None; Viraj Mehta, None;
Behin Barahimi, None
Support: Research to Prevent Blindness Grant
Long-term Efficacy of Aluminum Foil Draping Technique in
Oculoplastic Surgical Procedures
Lauren Cournoyer, Philip R. Rizzuto. Ophthalmic Plastic Surgery,
Warren Alpert Medical School Brown University, Providence, RI.
Purpose: A retrospective case review, presented at ARVO in 2012, of
294 consecutive patients concluded that an aluminum foil drape was
as effective as a standard surgical paper drape at minimizing the risk
of wound infection in oculoplastic surgical procedures. The purpose
of this retrospective case review is to compare the long-term efficacy
of aluminum foil draping technique versus standard surgical paper
draping technique at minimizing the risk of wound infection in select
oculoplastic surgeries using a larger sample size. The cost of each
drape is reported as well.
Methods: A retrospective case series of 991 consecutive patients,
between the ages 30 and 90, who underwent ectropion or entropion
repair, levator resection or advancement, or blepharoplasty by a
single surgeon using either an aluminum foil drape (n=748) in an
office-based surgery suite or a standard surgical paper drape (n=243)
in a hospital-based ambulatory surgery center was performed. The
rate of wound infection in the two groups at postoperative days 1, 7,
and 10 was evaluated. Statistical analysis (2-sample t test) could not
be applied due to the absence of any difference in the data from the
two groups. A cost analysis was also performed comparing the two
draping techniques.
Results: Seven hundred and forty-eight cases (334 blepharoplasty,
283 levator repair/advancement, 14 ectropion repair, 117 entropion
repair) were performed in an office-based surgery suite using
an aluminum foil drape. Two hundred and forty-three cases (71
blepharoplasty, 48 levator repair/advancement, 73 ectropion repair,
51 entropion repair) were performed in a hospital-based ambulatory
surgery center using a standard surgical paper drape. There was
no incident (0) of wound infection in the 991 cases reviewed at
postoperative day 1, 7, or 10. There was no difference in the rate
of wound infection between the two groups. The cost per surgical
procedure was $0.63 for the aluminum foil drape and $28.25 for the
standard surgical drape.
Conclusions: Aluminum foil draping technique continues to be as
effective as standard surgical draping technique at minimizing the
risk of wound infection in oculoplastic surgical procedures in the
outpatient setting. The cost per surgical procedure of the aluminum
foil drape is significantly less than the cost of the standard surgical
paper drape.
Commercial Relationships: Lauren Cournoyer, None;
Philip R. Rizzuto, None
BI-INSTITUTIONAL RETROSPECTIVE REVIEW ON THE
DEMOGRAPHICS AND BASIC CLINICAL PRESENTATION
OF HIDROCYSTOMAS
Michelle M. Chang1, Paul Petrakos2, Mei Zhou1, Benjamin Levine2,
Gary Lelli2, Pete Setabutr1. 1University of Illinois at Chicago,
Chicago, IL; 2Weill Cornell Medical College, New York, NY.
Purpose: Hidrocystomas are benign, cystic lesions of eccrine and
apocrine sweat glands. The literature on hidrocystomas is sparse,
consisting of a handful of case reports and limited retrospective
reviews. This is the first known bi-institutional, retrospective, chart
review aimed to elucidate the demographics and basic clinical
presentation of hidrocystomas.
Methods: Medical records of adult patients with a pathological
diagnosis of hidrocystoma from September 1, 2008 to August 1, 2015
in the Oculoplastic and Reconstructive Surgery Service at the Illinois
Eye and Ear Infirmary (UIC) and Department of Ophthalmology of
Weill Cornell Medical College (Cornell) were reviewed. Children
under the age of 18 were not included. Data collection included:
gender, race, age at diagnosis, laterality, location, total number of
lesions, and recurrence. Results from both institutions were compared
against each other and as a whole.
Results: A total of 107 patients were diagnosed with hidrocystoma
on pathology. The mean age of diagnosis was 56 years (22-85).
Hidrocystomas were diagnosed in 69 (64.4%) females and 38
(35.5%) males. Lesions were most commonly found in African
American (37.4%), Caucasian (30.8%), and Hispanic (16.8%)
patients combined across the two institutions with different patient
populations. Lesions were largely unilateral (74.8%) and found on
the lower lid (38.6%), lateral canthus (31.2%), upper lid (17.7%), and
medial canthus (12.6%). Recurrences were seen in 2.3% of lesions.
The majority of recurrences occurred in patients who identified their
race as Hispanic (2/5) and Caucasian (3/5). Recurrences were seen in
2 males and 3 females.
Conclusions: Apocrine and ecccrine hydrocystomas may be more
common in female, African American, Caucasian, and Hispanic
patients, presenting most commonly in adults in their mid-fifties.
Lesions tend to be unilateral with lower lid lesions being the most
prevalent location and medial canthus lesions being the least
prevalent location for lesion growth. Recurrences may be most
common in Hispanics and Caucasians and less common in African
Americans. Although a precise recurrence rate cannot be determined
at this time, our data suggests that the recurrence rate is low with
current excisional methods.
Commercial Relationships: Michelle M. Chang, None;
Paul Petrakos, None; Mei Zhou, None; Benjamin Levine;
Gary Lelli, None; Pete Setabutr, None
Support: Unrestricted departmental grant from the Research to
Prevent Blindness
The Efficacy of Primary Pentagonal Wedge Resection in
Achieving Negative Margins in Eyelid Basal Cell Carcinoma
Christine V. Nguyen, Giancarlo A. Garcia, Marc Yonkers,
Jeremiah Tao. Gavin Herbert Eye Institute, University of California,
Irvine, Irvine, CA.
Purpose: Typical treatment protocols for eyelid basal cell carcinoma
(BCC) include two or more surgical procedures: biopsy for diagnosis
followed by tumor resection with intraoperative frozen section or
Mohs margin control and then defect reconstruction. Full thickness
eyelid sampling obviates the deep margin concern and when gross
medial and lateral margins are obtained, we hypothesize a high
incidence of complete BCC (negative histologic margins) is achieved
on primary resection. We evaluate the efficacy of pentagonal wedge
gross tumor resection in achieving negative histopathologic margins
on primary resection of small eyelid BCC.
Methods: Retrospective review of consecutive nodular eyelid BCC
managed with full thickness eyelid excisional biopsy with immediate
reconstruction. In all cases, the eyelid was incised in a pentagonal
wedge technique with grossly visible full thickness margins around
the lesion. Specimen margin status was evaluated on permanent
histopathology sections. Charts were reviewed for any adverse events
and subsequent related surgical interventions.
Results: 36 cases of histopathology-confirmed eyelid BCC were
identified (mean age 67.3 ± 2.5 years). The majority (94.4%,
p<0.001, Chi square) were completely excised with negative margins
on permanent histopathology of the primary resection sample.
Eyelid repair was completed immediately after excision in all cases
that had short total duration. Incomplete excision with positive
margins occurred in two cases (5.6%). These were managed with
further tumor resection with intraoperative frozen section margin
control and immediate eyelid reconstruction. Mean postoperative
follow-up duration was 361 ± 109 days. In the majority of cases with
complete excision there was no recurrence (97.1% p<0.001, Chi
square). There was one case of recurrence (2.9%) among those with
complete excision; this was the only case that required a secondary
surgical procedure. There were no intraoperative or postoperative
complications.
Conclusions: Pentagonal wedge resection of eyelid BCC was
associated with a high incidence of negative primary histologic
margins and definitive management in one short surgical setting.
There was a low rate of recurrence at a mean of 1 year. Primary full
thickness gross eyelid resection of lesions highly suspicious for BCC
may obviate a need for additional procedures required with incisional
biopsy techniques.
Commercial Relationships: Christine V. Nguyen, None;
Giancarlo A. Garcia, None; Marc Yonkers, None; Jeremiah Tao,
None
Retrospective Chart Review of Vascular Tumors at a Single
Academic Institution
Anjulie Quick, Thomas Whittaker, Jason Sokol. Ophthalmology,
University of Kansas Medical Center, Prairie Village, KS.
Purpose: Vascular lesions and malformations of the orbit are
a benign but important group of space occupying lesions in the
population. In the literature, the incidence of vascular lesions is
reported as 13-25% of all orbital tumors with the most common being
capillary hemangiomas in children and cavernous hemangiomas in
adults. Our goal was to compare the incidence of biopsy confirmed
vascular tumors reported in the literature to those at our academic
institution and to review the demographics and clinical presentation.
Methods: A retrospective, descriptive, chart review was performed
after IRB approval. All biopsied/surgically removed orbital lesions
treated in our department between 2010 and 2015 were identified by
surgical CPT codes. Those patients with vascular tumors were then
selected for our study. In each case gender and age of the patients,
pathological diagnosis, number of reinterventions and laterality were
registered.
Results: Two hundred and one biopsied confirmed orbital tumors
were identified over a 5-year period. Sixteen cases were identified
as vascular tumors constituting 8% of all orbital tumors in this
review. The age ranged from 2-65 years old with a median age of 43.
The majority (75%) of all vascular tumors were women. The most
common presenting complaint was proptosis (56%). The breakdown
of the vascular tumors includes: 6 cavernous hemangiomas (37.5%),
2 lymphangiomas (12/5%), 2 solitary fibrous tumors (12.5%),
2 arteriovenous malformations (12.5%), 1 hemangiopericytoma
(6.25%), 1 orbital varix (6.25%), 1 capillary hemangioma (6.5%) and
1 Masson’s vegetant intravascular hemangioendothelioma (6.25%).
The two most common reasons for surgical intervention were
diplopia (31%) and optic nerve compression (31%).
Conclusions: Although our study shows that the incidence of
vascular tumors is lower than the number reported in the literature,
this may be related to the broad and diverse patient population seen
at a referral center. It is possible that common tumors are managed
in the community or observed for a longer period of time due to their
charaterization as benign tumors.
Commercial Relationships: Anjulie Quick, None;
Thomas Whittaker; Jason Sokol, None
Outcomes of two surgical techniques for major trichiasis
Lucieni C. Ferraz1, Roberta L. Meneghim3, 1, Alicia Galindo2,
Ana C. Wanzeler5, Michelli Saruwatari5, Larissa Satto5,
Carlos R. Padovani4, Silvana A. Schellini2. 1FAMESP, Bauru,
Brazil; 2King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia;
3
Faculdade de Medicina de Botucatu, Botucatu, Brazil; 4Instituto de
Biociências, Botucatu, Brazil; 5Faculdade de Medicina de BotucatuUNESP, Botucatu, Brazil.
Purpose: To analyze the patient outcomes of two surgical techniques
for major trichiasis.
Methods: A retrospective chart review was performed of 67 patients
(89 eyelids) with major trichiasis who underwent surgical treatment
using one of two techniques: Van Millingen (intermarginal split
with graft; ISG group) technique or lid anterior lamella resection
(ALR group). There were 30 eyelids in the ISG group with mean
patient age of 71.8 years and 63.3% were females. There were 59
eyelids in the ALR group with mean patient age of 72.5 years and
52.5% were female. The minimum postoperative follow up was 6
months. Statistical analysis included descriptive measures, Goodman
association test for contrasts between and within multinomial
populations and non-parametric Mann Whitney test for comparison
between groups. P<0.05 was considered statistically significant.
Results: The underlying causes of trichiasis were, blepharitis
(37.07%), chronic meibomitis (21.3%), multiple causes (20.2%),
ectropion (11.2%), actinic keratosis (6.7%) or prior ocular surgery
(3.3%). Postoperatively, in the ISG group, there were 20% eyelids
with complete success, 50% underwent laser or electrolysis,
16.7% required further surgery and 13.3% were unsuccessful.
Postoperatively, in the ALR group there were 47.5% eyelids with
complete success, 46.7% underwent laser or electrolysis, 6.8%
required further surgery and 5.1% were unsuccessful. There was a
higher statistical chance of complete success with ALR (P<0.05).
Conclusions: ALR is superior than ISG surgery for major trichiasis.
There is a greater chance of success with ALR and it is technically
simpler.
Commercial Relationships: Lucieni C. Ferraz, None;
Roberta L. Meneghim, None; Alicia Galindo, None;
Ana C. Wanzeler, None; Michelli Saruwatari, None;
Larissa Satto, None; Carlos R. Padovani, None;
Silvana A. Schellini, None
Clinical Features of Graves Orbitopathy Patients with Recurred
Orbital Inflammation after Decompression
Young Jun Woo, Do Wook Kim, Ji Won Kim, Jin Sook Yoon.
Ophthalomology, Yonsei college of medicine, Seoul, Korea (the
Republic of).
Purpose: To investigate clinical features of Graves orbitopathy (GO)
patients with recurred orbital inflammation after decompression.
Methods: Ninety-seven patients who underwent orbital
decompression because of disfiguring proptosis (n = 60) or orbital
congestion including compressive optic neuropathy (ON) (n = 37)
were evaluated. Demographics, ophthalmic manifestations, and
biochemical parameters were reviewed. Preoperative factors affecting
occurrence of orbital inflammation after decompression were
investigated with logistic regression analyses.
Results: Seventeen patients experienced recurred inflammation of
GO after orbital decompression. All had undergone surgery because
of orbital congestion or ON. Univariate logistic regression analysis
identified current smoking (P = 0.042), modified NOSPECS score
(P = 0.013), and presence of ON (P = 0.019) as significant factors
for recurred inflammation of GO. Multivariate logistic regression
analysis revealed that current smoking (P = 0.022) and presence
of ON (P = 0.011) were associated with postoperative recurred
inflammation of GO.
Conclusions: Orbital inflammation after decompression tends to
occur in GO patients with preoperative orbital congestion or ON.
The presence of ON and smoking status at the time of surgery were
significant positive, independent factors for recurred inflammation of
GO in group of orbital congestion or ON. Patients with these factors
should be carefully observed for recurrence of orbital inflammation
even if GO became inactive after orbital decompression.
Commercial Relationships: Young Jun Woo, None;
Do Wook Kim, None; Ji Won Kim, None; Jin Sook Yoon, None
Characterization of patients receiving evisceration in a major
metropolitan hospital in Mexico City
Miriam G. Arellano, Francisca Zuazo, Martin Gonzalez,
ALBERTO ABDALA, Angel Nava, OSIRIS OLVERA-MORALES,
JOSE L. TOVILLA CANALES. instituto de oftalmologia conde de
valenciana, Mexico, Mexico.
Purpose: Currently, evisceration is becoming a useful technique
for the removal of the eye content in cases of endophthalmitis,
painful blind eye, ocular trauma, among others. We performed a
retrospective, observational clinical study to describe and analyze the
causes, results and complications of evisceration surgery.
Methods: Clinical records of patients undergoing evisceration
at Instituto de Oftalmología Conde de Valenciana IAP, between
January 2008 and July 2015 were reviewed. Patients who underwent
enucleation surgery or evisceration surgery performed in other
institution, were excluded. We analyzed gender, age, operative eye,
cause of evisceration, preoperative visual acuity, implant used, and
complications.
Results: A total of 186 eyes were eviscerated during the study period.
53% of the patients undergoing evisceration surgery, were men. The
average age was 54 ± 23 years. The right eye was affected in 53% of
cases. 79.2% of patients had a vision of No Light Perception in the
affected eye and 92% of patients had preoperative pain.
The mean preoperative intraocular pressure was 22.17 ± 15.6 mmHg.
The most common diagnosis for which evisceration was performed,
was endophthalmitis (28%), followed by ocular trauma in 23.12%.
10.8% of the operated eyes were reported to be in phthisis bulbi.
In 86.8% of cases, a primary implant was placed. Of these, 34.1%
were porous polyethylene. In 7.5% cases, a secondary implant was
placed, approximately a month after evisceration surgery in cases
of endophthalmitis. 4% of cases had implant extrusion, 75% of
them being porous polyethylene. The ocular prosthesis was well
tolerated in 91% of cases. Complications were present in 7.5%,
being postoperative pain the most common. No cases of sympathetic
ophthalmia were reported.
Conclusions: In our series, most of eviscerations were performed
on the right eyes of men, with a vision of no light perception and
preoperative pain. The main causes were endophthalmitis and ocular
trauma. Most patients received a primary porous polyethylene
implant, achieving good tolerance of the ocular prosthesis.
Evisceration is shown as an alternative to enucleation in cases where
the sclera can be preserved, showing low incidence of sympathetic
ophthalmia. The importance of descriptive studies is that this data can
serve as a prognostic indicator for patients that are candidates for this
surgery.
Commercial Relationships: Miriam G. Arellano,
None; Francisca Zuazo, None; Martin Gonzalez,
None; ALBERTO ABDALA, None; Angel Nava,
None; OSIRIS OLVERA-MORALES, None;
JOSE L. TOVILLA CANALES, None
A new orbital implant model of high density porous polyethylene:
First animal model using OMNIPOR
Francisco J Rodriguez, Mariana Cabrera, Marcela Lonngi,
Cristina Gabela, Maria Teresa Daza. Fundacion Oftalmologica
Nacional, Bogota, DC, Colombia.
Purpose: Medpor ® is an orbital implant for anophthalmic cavities
made of high density porous polyethylene (HDPP), which is safe and
has good biocompatibility. Omnipor ® is a new HDPP implant, with
similar characteristics to Medpor®, which has not been studied in
vivo.
The purpose of this study was to compare the results obtained
with Medpor® versus Omnipor® in an animal model in terms
of vascularization of the device after two and four weeks of
implantation. Vascularization is the main measurement for
biocompatibility.
Methods: Sixteen New Zealand rabbits were randomized into four
groups: Group 1: Medpor for 2 weeks, 2: Omnipor for 2 weeks, 3:
Medpor for 4 weeks, 4: Omnipor for 4 weeks. All rabbits underwent
enucleation of the right eye with implantation of a sphere of 12 mm
of either Omnipor or Medpor according to the initial randomization.
Two weeks after implantation, 8 rabbits (4 from each group) were
sacrificed with sodium thiopental. Implants were extracted and
fixated with 10% formaldehyde and parafin. The process was
repeated at 4 weeks with the remaining rabbits.
Three plaques (3 microns thick) were obtained at the equator of the
implant which were stained with hematoxilin-eosin. The plaques
were divided into quadrants and the deepest point of fibrovascular
growth was measured from the external border in mm. This process
was done by two independent pathologists obtaining 24 values for
each rabbit. Other characteristics of the implant were reported such
as: encapsulation, foreign body granulomatous reaction, infection,
etc.
Results: Fourteen rabbits were included in the final report (2 rabbits
died soon after surgery). Seven in the Medpor group and 7 in the
Omnipor group. The results are summarized in table 1. There
were no complications related to the implants. Vascularization was
significantly higher at week four compared to week two in both
Medpor and Omnipor (p<0.0001). There was no statistical difference
between the vascularization with Medpor vs. Omnipor at two and
four weeks (p>0.05).
Conclusions: There was no difference in the degree of
vascularization between the two implants. There were no
complications related to the implants. None of the implants showed
complete vascularization. More studies are needed to confirm the
safety and biocompatibility of the new implant.
Commercial Relationships: Francisco J Rodriguez, None;
Mariana Cabrera, None; Marcela Lonngi, None; Cristina Gabela,
None; Maria Teresa Daza, None
Evisceration with autogenous scleral graft and implantation by
posterior way with ceramic implants: a seventeen-year study of
134 case reports
Jeremy NADAL, Vincent Daien, Jacques Jerome, Frederic MURA,
Didier HOA, Max Villain. france, chu gui de chauliac montpellier,
CODOGNAN, France.
Purpose: To present long-term follow-up data on eviscerations
performed with autogenous scleral graft and a ceramic implantation
by posterior way.
Methods: This study is a retrospective analysis of all eviscerations
performed in the department of ophthalmology, Montpellier, France,
between February 1998 and October 2015. The technic used was
a conventional anterior evisceration with a total keratectomy, a
disinsertion of the medial rectus muscle, a sectioning of the optic
nerve and a taking of sclera centered on the papilla. The scleral graft
was sutured just behind the suture of keratectomy, and the bioceramic
implant carried out by posterior way. Demographic characteristics,
implant size and type, cosmetics and complications were recorded.
Results: In total, 134 patients were included. The female to male
ratio was 1/ 1,71. The median (interquartile range) size of implant
was 17.32mm (1.84mm, [14-20]). The median follow-up after
evisceration was 53.5 [2-138] months. Two cases of implant exposure
(1.49%) were recorded during the study period. For 24 patients
(17.9%), additional surgeries were performed for ptosis, conjunctival
cyst or anophthalmic socket syndrome. Cosmetics results were
recorded as good or excellent in 82.71% of cases.
Conclusions: Evisceration with autogenous scleral graft and
implantation by posterior way suggest a high volume restoration,
high rate of good mobility and low risks of exposure of the implant.
Commercial Relationships: Jeremy NADAL, None;
Vincent Daien, None; Jacques jerome, None; Frederic MURA,
None; Didier HOA, None; Max Villain, None
Retrospective Review of Indication of Evisceration, Enucleation
or Exenteration at One Academic Institution
Derek Horkey, Isabella Herrera, Jason Sokol. Ophthalmology,
University of Kansas, Lenexa, KS.
Purpose: Purpose: At times in ophthalmology instead of visionenhancing or vision-preserving procedures, it is necessary to perform
eye destructive procedures, including evisceration, enucleation, and
exenteration. The purpose of this study was to analyze over a five
year period the number of eye destructive procedures and investigate
the most common indication for said procedures.
Methods: Methods: After obtaining IRB approval all medical records
from August of 2010-February of 2015 from patients having eye
destructive procedures performed by one surgeon at one academic
tertiary care facility were reviewed investigating clinical indication
for the procedure.
Results: Results: There were 103 eye destructive procedures
performed on 101 patients at one institution over the roughly 5 year
period. Of these 103, 69% of the procedures were enucleations,
27% were exenterations, and 4% were eviscerations. The two
most common indications for procedure were trauma (40%) and
malignancy (34%). The other noted indications were blind painful
eye (15%), infection (10%), and ruptured cornea (1%).
Conclusions: Discussion: As one might imagine more complicated
cases were very common indications for eye destructive procedures
at a tertiary care center. The hospital is a level I trauma which
would account for a high volume of trauma cases. Also given that
there is a large cancer center the high incidence of malignancy is
accounted for as well. There were also five exenterations performed
because of invasive mucormycosis. In these five patients, four had
known malignancies and one had immunodeficiency secondary to
unknown reason which was being worked up at the patients time of
death. These numbers suggest that often complicated orbital trauma
and malignancies are transferred or referred to tertiary care centers
for definitive management and treatment. Our institution has a
large cancer center, which contributes to our significant number of
procedures secondary to those malignancy as well as malignancy
related infections.
Indications for eye destructive procedures
Distribution of malignancies and eye destructive procedures
Commercial Relationships: Derek Horkey, None;
Isabella Herrera, None; Jason Sokol, None
Characterization of the preservative effects of UW cold storage
solution on mouse eyes harvested for whole eye transplants
Robert W. Nickells1, Cassandra Schlamp1, Heather M. Schmitt1,
Bikash R. Pattnaik2. 1Ophthalmology and Visual Sciences, University
of Wisconsin-Madison, Madison, WI; 2Pediatrics, University of
Wisconsin-Madison, Madison, WI.
Purpose: A principal obstacle preventing successful whole eye
transplantation (WET) is the preservation of retinal neurons,
particularly retinal ganglion cells (RGCs). Preservation of other
organs used in a majority of transplants has been achieved using
University of Wisconsin cold storage solution (UWS). The efficacy of
UW solution in preserving CNS tissue, including retina, has not been
evaluated.
Methods: Whole eyes were enucleated from mice and injected with
either PBS or UWS. Some eyes were injected with UWS modified
with BaCl2 and valproic acid, in order to counter early changes in
RGCs caused by axotomy. Globes were then immersed in PBS or
UWS and stored for up to 24 hrs at 4°C. Globes were evaluated by
H&E staining, NFκB reporter transgene expression as an indicator
of ischemia, and TUNEL. Retinal cell types were evaluated for
abundance of cell-specific transcripts by qPCR. Whole retina
electrophysiology experiments are planned.
Results: Injection of both solutions prior to storage was critical
to enhanced retinal preservation. PBS eyes exhibited edematous
changes to all ocular compartments within 6 hrs, but particularly
photoreceptor outer segments and the nerve fiber layer. Limbal scleral
fibroblasts also exhibited NFκB activation. UWS eyes exhibited
nearly pristine histology of all ocular compartments, including the
retina, as late as 24 hrs. Neither solution elicited TUNEL staining or a
change in lens opacity. Gross total RNA appeared intact in both PBS
and UWS retinas (24 hrs), but PBS eyes exhibited a decrease in RNA
amount as a function of wet tissue weight. Transcript abundance,
relative to freshly prepared retina, showed an overall decrease in
levels in eyes stored in both solutions, although UWS levels were
statistically higher across the board. Amacrine cells faired the best in
storage, while bipolar cells appeared most adversely affected. Some
RGC-select genes (Sncg and Gap43) were the same or greater than
levels in fresh retinal tissue.
Conclusions: Baseline studies using UWS to preserve mouse eyes in
preparation for WET prevented edema of ocular tissues. Molecular
studies of retina, as a function of transcript levels, indicate significant
beneficial effects on multiple cell types, including RGCs. This latter
finding may facilitate increased regenerative potential of these cells.
Functional testing is currently ongoing.
Commercial Relationships: Robert W. Nickells, None;
Cassandra Schlamp, None; Heather M. Schmitt, None;
Bikash R. Pattnaik, None
Support: NEI R01 EY012223, P30 EY016665, Lions Eye Bank of
Wisconsin, Research to Prevent Blindness
Total Human Eye Allotransplantation (THEA): Preclincal
Cadaveric Studies
Maxine R. Miller1, 2, Edward H. Davidson1, Eric W. Wang3,
Jenny Y. Yu2, Juan C. Fernandez-Miranda4, Dawn J. Wang1,
Joel S. Schuman2, 5, Kia M. Washington1, 6. 1Department of Plastic
Surgery, University of Pittsburgh, Pittsburgh, PA; 2Department
of Ophthalmology, University of Pittsburgh, Pittsburgh, PA;
3
Department of Otolaryngology, University of Pittsburgh, Pittsburgh,
PA; 4Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, PA; 5Department of Bioengineering, Swanson School of
Engineering, University of Pittsburgh, Pittsburgh, PA; 6VA Pittsburgh
Healtcare System, Pittsburgh, PA.
Purpose: It is estimated that approximately 40 million suffer from
blindness globally. Whole eye transplantation offers the opportunity
to provide viable retinal ganglion cells and an entire optical
system to recipients with vision loss. Our group has established
the first orthotopic model for eye transplantation in the rat. With
advancements in immunomodulation strategies together with new
therapies in neuroregeneration, parallel development of human
surgical protocols is vital in ensuring momentum towards eye
transplantation in patients.
Methods: Preserved injected human cadaveric heads (n=8)
underwent donor and recipient procedures. Bilateral transplants
were performed between two cadavers in each surgical session, for
a total of 4 transplants between 2 cadavers. A globe and periorbita
model was adopted. Donor procurement required orbital exenteration
with combined endonasal and transcranial approach to decompress
the orbital apex. Transection of cranial nerves II-VI and superior
ophthalmic vein was performed at the cavernous sinus transcranially
and the ophthalmic artery with carotid artery stem was ligated in the
paraclival space to deliver the donor specimen. Candidate recipient
vessels (superficial temporal, internal maxillary and facial artery and
superficial temporal and facial vein) were exposed. All required vein
grafting. Donor tissue was secured in recipient orbits followed by
sequential arterial and venous anastomoses and nerve coaptation with
standard microsurgical techniques. Pedicle lengths and calibers were
measured. All steps were timed, photographed, video recorded and
analyzed after each operative session.
Results: Technical feasibility of cadaveric donor procurement and
transplantation to cadaveric recipient was established. Mean donor
ophthalmic artery pedicle length and caliber were 13.5 and 1mm but
with a stem of paraclival internal carotid artery were 33 and 2mm.
Mean optic nerve was 25mm from orbital apex to annulus of Zinn
and 14 mm from annulus of Zinn to optic chiasm. Cranial nerves
III-VI had mobile pedicle lengths of 10-14mm. Candidate recipient
vessels required vein grafting.
Conclusions: This surgical protocol serves as a benchmark for
optimization of technique, large animal model development,
and ultimately potentiating the possibility of vision restoration
transplantation surgery.
Commercial Relationships: Maxine R. Miller, None;
Edward H. Davidson, None; Eric W. Wang, None; Jenny Y. Yu,
None; Juan C. Fernandez-Miranda, None; Dawn J. Wang, None;
Joel S. Schuman; Kia M. Washington, None
Support: 5T32 EY017271-07
Characteristics of Graves’ Orbitopathy Patients Requiring
Strabismus Surgery After Orbital Decompression
Michelle Boyce, Isabella Herrera, Thomas Whittaker, Jason Sokol.
Ophthalmology, University of Kansas, Shawnee, KS.
Purpose: Post-decompression strabismus and diplopia are not
uncommon in Graves’ orbitopathy patients and most require either
prisms or strabismus surgery to correct their vision. We sought to
determine whether there are characteristics that make it more likely
for patients to undergo strabismus surgery after decompression.
Methods: We performed a retrospective review of Graves’
orbitopathy patients who underwent orbital decompression in our
institution from 2010 to 2015 (IRB approved). The preoperative
characteristics examined were: age, gender, disease duration,
smoking history, presence of optic neuropathy, history of steroid
therapy, radioactive thyroid ablation, and prior history of strabismus
surgery and/or decompression. Patients were classified either as type
1 or type 2 Graves’ orbitopathy subtype as described by Nunery et
al. Only patients who reported diplopia after decompression and
required either prisms or strabismus surgery were included in the
final analysis.
Results: In the 63 patients that underwent orbital decompression, ten
type 1 patients were identified and none of these patients reported
post-decompression diplopia in primary gaze. In the 53 Type 2
patients that were identified, 19 patients required strabismus surgery
while seven required prisms to treat their post-decompression
diplopia. In the assessed parameters, there were no significant
differences between the strabismus and prism groups within the Type
2 patients except for the prism group having more former smokers
(p=.0026) and the surgery group having more patients with optic
neuropathy (p=.0394)
Conclusions: While we are limited by the retrospective nature of
our study, our data suggests that Type 2 patients are more likely
to require strabismus surgery especially those with compressive
optic neuropathy. We hypothesize that this could be secondary to
larger, scarred muscles and apex crowding that required more bony
decompression and orbital strut removal resulting in strabismus too
great to be corrected by prisms. Larger EOMs and strut removal
have been implicated in literature to contribute to the development of
post-decompression diplopia. Smoking cessation may prevent further
EOM damage and reduce the need for strabismus surgery as smoking
has been linked to mediate restrictive myopathy in Graves’ patients.
Table 1. Comparison of the strabismus surgery group and the prism
group.
Commercial Relationships: Michelle Boyce, None;
Isabella Herrera, None; Thomas Whittaker, None; Jason Sokol
Orbital Decompression in Thyroid Eye Disease, A 5 year review
in a reference center in Mexico City
NAYELI ALCARAZ LARES, ALBERTO ABDALA,
OSIRIS OLVERA-MORALES, JOSE L. TOVILLA CANALES.
INSTITUTO DE OFTALMOLOGIA CONDE DE VALENCIANA,
DISTRITO FEDERAL, Mexico.
Purpose: Thyroid eye disease (TED) is a form of autoimmune orbital
inflammation which during its active inflammatory phase, leads to
infiltration of muscles, lacrimal glands and orbital fat by lymphocytes
and glycosaminoglycans. Decompression can be utilized to treat
these cases and different approaches can be chosen such as a bone or
fat removal. We performed a retrospective study to describe the initial
presenting characteristics, surgical approaches and outcomes during
our 5 year experience.
Methods: A total of 19 patients were selected, for a total of 38 orbits.
Gender 12 females and 7 males. A retrospective review of all patients
undergoing orbital decompression for TED associated criteria
between 2010 and 2015. Clinical outcome measures included were
demographic data, Hertel exophthalmometry pre and post op, surgical
technique elected and preoperative thyroid status. Patients who did
not meet the criteria were excluded. T student test was applied to all
variables.
Results: Median age for males was 45 and 51 years for females
with no statistical significant difference between genders. Technique
chosen was bony decompression in 15 cases (78.9%) and fat
decompression in 4 cases (21.1%). In bony decompression the
most common option was inferior plus medial walls in 68.4% of
cases, followed by 3 walls (lateral, medial and inferior) in 10.5%.
The most common indication for surgery was disthyroid optic
neuropathy (52.6%), followed by cosmetic (31.6%) and intractable
IOP (15.8%). 57.9% of patients received steroid treatment prior to
surgery and 94.7% received steroids post op. Thyroid status prior
to surgery showed hyperthyroidism in 17 cases (89.5%). Hertel
exophthalmometry post op showed a medium decrease of 3mm in
both eyes with a bony decompression and a medium of 4.5mm with a
fat decompression.
Conclusions: Our findings correlate to previous published data
except the result that fat decompression provides a greater decrease
in post exophthalmometry. Our study is limited by several factors
particularly its retrospective nature and small cohort of patients which
is inherent due to the rare nature of this procedure. We believe more
prospective studies are needed to verify our findings and to provide
clear guidelines with which to choose the most appropriate conduct.
Commercial Relationships: NAYELI ALCARAZ LARES, None;
ALBERTO ABDALA, None; OSIRIS OLVERA-MORALES,
None; JOSE L. TOVILLA CANALES, None
Early Experience with Medpor Nonporous Barrier Sheet In
Orbital Fracture Repair
Lillian Yang1, Chris Compton2, Manuel Ochoa3, Babak Ziaie3,
Jason Sokol1, Michelle Boyce1. 1Department of Ophthalmology,
University of Kansas, Prairie Village, KS; 2Department of
Ophthalmology, University of Louisville, Louisville, KY; 3Birck
Nanotechnology Center, Purdue University, West Lafayette, IN.
Purpose: To evaluate the efficacy of the Medpor nonporous barrier
sheet as a substitute for supraFOIL in orbital fracture repairs.
Methods: A prospective, case series using the Stryker 0.4mm thick
medpor nonporous barrier sheet in patients presenting with orbital
fractures. Patient age, type of fracture, etiology of injury, presence
of pre-operative restriction and diplopia, and post-op diplopia and/
or enophthalmos were recorded. Patients were followed or will be
followed for 6 months. Scanning electron microscopy was used to
compare the thickness, smoothness, and porosity of the Medpor
nonporous barrier and SupraFOIL implants. Beam deflection testing
was performed to compare the biomechanical properties of each
implant.
Results: 47 patients underwent repair of orbital fractures with the
Medpor nonporous barrier sheet. Average age was 43.3 years (range
18-84). 27 of 47 patients (57.4%) were males and 20 (42.6%) were
females. The most common cause of injuries were: Assault (38.3%),
MVA (14.9%), falls (25.5%), and sports-related (10.5%). 20 of 47
patients (42.6%) had isolated orbital floor and 2 patients (4.3%) had
isolated medial wall fractures. 15 patients (31.9%) had combined
floor and medial wall fractures involving the inferomedial orbital
strut. 28 patients (59.6%) had pre-operative diplopia. Timing of
surgery was between 3 and 55 days, with the median of 11.5 days.
5 of 47 patients (10.6%) has residual diplopia at their 1 week post
operative visit, each had resolved at 2 months post op. Electron
microscopy showed that the 0.4mm Medpor nonporous barrier
implant was thinner (0.33mm) than reported and thinner than
0.4mm SupraFOIL (0.38mm). SEM also showed that the surface of
the Medpor nonporous barrier was smooth and nonporous. Beam
deflection testing showed that for small forces (< 100 mN) the
two materials behaved nearly identically, but at higher forces the
nonporous Medpor implant was weaker.
Conclusions: The use of Medpor nonporous barrier sheet implant
for orbital fracture repair is a safe and effective alternative. There
were no complications and no residual diplopia or restriction. The
“0.4mm” Medpor nonporous barrier was thinner (0.33mm) than
SupraFOIL implant (0.38mm). The Medpor nonporous barrier was
also weaker when compared to SupraFOIL at higher forces >100
mN. This may require thicker implants (~0.5 -0.6 mm) for combined
orbital floor and medial wall fractures where the orbital strut is
involved.
Commercial Relationships: Lillian Yang, None; Chris Compton,
None; Manuel Ochoa, None; Babak Ziaie, None; Jason Sokol,
None; Michelle Boyce, None
Distinguishing orbital and preseptal cellulitis: how useful are
clinical history and physical exam?
Alexander Port, Benjamin Levine. Ophthalmology, Weill Cornell
Medical College, New York, NY.
Purpose: Preseptal and orbital (post-septal) cellulitis often
present similarly, but must be distinguished to ensure appropriate
management. This study seeks to determine whether clinical history
and physical examination alone provide an accurate diagnosis of
orbital cellulitis as compared to imaging findings.
Methods: We reviewed all inpatient and ED ophthalmology
consultations for suspected orbital cellulitis over a 5-year period (Oct
2010-Oct 2015). Records were reviewed and analyzed with respect to
demographics, exam findings, imaging findings and outcomes.
Results: There were 139 consultations for suspected orbital cellulitis
with complete records available. Of these, 89 had preseptal cellulitis,
39 had orbital cellulitis, and 11 had other diagnoses. CT or MRI
imaging was available for 98 of 139 subjects (70.5%). Subjects with
preseptal and orbital cellulitis differed with respect to several factors
(see table 1). On forward stepwise logistic regression, a diagnosis of
orbital cellulitis was associated with proptosis (OR 33.4, 95% CI: 5.2,
68.6, p = 0.001) restricted extraocular movement (OR 29.5, 95% CI:
7.1, 123.1, p = 0.001) and afferent pupillary defect (OR 19.3, 95%
CI: 1.4, 68.9, p = 0.028).
36 patients had at least one “orbital sign” including ophthalmoplegia,
chemosis, proptosis, elevated IOP, RAPD, or dyschromatopsia. Of
these, 27 demonstrated radiographic evidence of orbital involvement
and 9 did not. 16 subjects were found to have 2 or more orbital signs
on examination, all of whom had orbital cellulitis. The presence
of at least 1 orbital sign on examination had a sensitivity of 69.2%
(95%CI: 52.4-83.0%) and a specificity of 89.9% (95%CI: 81.795.3%) for the diagnosis of orbital cellulitis. If 2 or more orbital signs
were found, examination findings had 41.0% sensitivity (95%CI
25.6-57.9%) and 100% specificity (95% CI: 95.9-100%) for orbital
cellulitis.
Conclusions: There were significant differences in clinical history
and examination findings of patients with preseptal and orbital
cellulitis. Clinical exam findings had moderate sensitivity and high
specificity for the presence of orbital cellulitis. In cases of suspected
orbital cellulitis where imaging is unavailable or deferred, the clinical
exam may reliably distinguish between patients with and without
post-septal involvement.
Results: 17 cases were identified for analysis: 8 patients (48%) were
male, with a mean age of 51.9 ± 11.1 years. Of these cases the largest
group showed non-specific inflammation; 15 (88%) of which 3 (18%)
displayed IgG4 expression. There was also 1 case of granulomatous
sarcoidosis and 1 case of granulomatosis with polyangiitis.
3 cases(18%) were managed without systemic corticosteroids
or other immunosuppressant medication. 11 cases (65%) were
managed with steroids alone; with an average cumulative dose of
2.8g over a mean course of 23.5 weeks. 3 patients (18%) required
other immunosuppressive treatment at different stages of their
management. Of the cases managed with steroids alone 6 had a single
course of treatment however 5 (45%) relapsed with 4 cases requiring
a further course of systemic steroids and 1 case methotrexate. Of
the 3 cases which displayed IgG4 expression 2 (67%) relapsed after
steroids were discontinued requiring a further course. 2 patients
(12%) are currently on long term systemic steroid treatment to
prevent relapse. Pain (71%) and proptosis (71%) were the most
common clinical features observed. 5 (29%) patients had a complete
resolution of all of their symptoms following treatment and all of the
remaining patients had a partial improvement.
Conclusions: The established management of orbital inflammatory
disease is with systemic steroids, this series highlights the need for a
significant course of tapering treatment. A large proportion of cases
treated with steroids relapse and require further courses of treatment.
These factors should be considered when counselling patients with
OID and deciding upon gastric and bone protection. In this case
series patients with IgG4 have a higher incidence of recurrence.
Commercial Relationships: Eric Spink, None; Darren Ting;
Lucy Clarke, None
Table 1: Preseptal vs orbital cellulitis. Significant differences
highlighted in bold.
Commercial Relationships: Alexander Port, None;
Benjamin Levine, None
Biopsy proven idiopathic orbital inflammatory disease - clinical
features, management and treatment outcomes
Eric Spink, Darren Ting, Lucy Clarke. Ophthalmology, Newcastle
upon tyne NHS trust, Newcastle upon Tyne, United Kingdom.
Purpose: We evaluated the clinical features, management and clinical
outcome of biopsy proven idiopathic orbital inflammatory disease
(IOID), from a UK tertiary referral centre. Our aim was to identify
prognostic factors that may be used to guide management.
Methods: This was a retrospective, clinical–pathological,
interventional, case series of biopsy proven IOID between 2006 and
2014 from the Newcastle Eye Centre (Newcastle upon Tyne, UK).
Data was collected from the patient notes, clinic letters and the local
patient database.
Clinical and radiographic characteristics of biopsy-proven adult
orbital lesions at an urban academic center
Hans Barron Heymann, Michael Mbagwu, Paul Bryar.
Ophthalmology, Northwestern Mcgaw Medical Center, Chicago, IL.
Purpose: To describe the clinical and radiographic characteristics of
biopsy-proven adult orbital lesions at a single academic center
Methods:
A retrospective chart review was conducted using the Northwestern
Enterprise Data Warehouse for all adult patients having undergone
orbital biopsies from January 2000 to October 2014. The database
was queried using CPT codes for all orbital biopsies. Patients under
age 18 years were excluded. 495 adults were identified using the
CPT coding for orbital biopsies. Of the 495, 381 patients were
excluded from study following chart review that did not demonstrate
biopsies of orbital lesions and 10 patients were excluded because
of incomplete records. 103 patients and 104 total cases fit inclusion
criteria into the study.
Results:
Clinical: Of 104 cases, 31.7% (n=33) were considered lymphoma
or lymphoid lesions (LLL) and 68.3% (n=71) were non-lymphoid
lesions (NLL). Of LLL, the most frequent were extranodal marginal
zone lymphoma (ENML) 48.5%, lymphoid hyperplasia 21.2%,
diffuse large B cell lymphoma 9.1% and IgG-4 disease 9.1%. Of
NLL, the most frequent were categorized as non-neoplastic benign
conditions 32.4% (n=23). Of these, amyloidosis and sarcoidosis (n=5
each) were most frequent. Of the remaining neoplastic NLL, the
most frequent were infiltrating basal cell carcinoma (BCC) (8.5%),
metastasis (8.5%), infiltrating squamous cell carcinoma (SCC)
(7.0%), pleomorphic adenoma (5.6%) and solitary fibrous tumor
(5.6%). Radiographic: Of 104 patients, 94.2% (n=98) of the patients
had imaging studies documented, 5.8% (n=6) had no imaging
recoded. Of the 98 patients with documented imaging 63 (64.3%)
had CT scans and 34 (34.7%) had MRI scans initially ordered.
One patient (1.0%) had an ultrasound performed. A radiologist
listed a clinical differential diagnosis in 80 of the 98 CT/MRI
reports (81.6%.) The ultimate histopathologic diagnosis was in the
radiologist’s differential diagnosis in 58 of the 80 reports (72.5%).
Conclusions: The majority of orbital biopsy diagnoses were NLL
(68%), with 32% being LLL. Of the NLL, the most common
diagnoses were non-neoplastic disorders, BCC, metastases, and SCC.
Of the primary orbital tumors, pleomorphic adenoma and solitary
fibrous tumor were the most common. For the lymphoid lesions,
approximately 70% were malignant lymphoma, with ENML being
most common. Radiologists predicted the histopathologic diagnosis
73% of the time.
Commercial Relationships: Hans Barron Heymann, None;
Michael Mbagwu; Paul Bryar, None
Support: Research to Prevent Blindness, New York, New York
Environmental Risk Factors for the Development of Concurrent
Involutional Lower Lid Entropion and Upper Lid Ptosis
Kendra Clemons1, 2, Michael E. Migliori1, 2. 1Ophthalmology, Brown
University, Providence, RI; 2Rhode Island Hospital, Providence, RI.
Purpose: To identify environmental risk factors associated with the
development of concurrent involutional lower lid entropion and upper
lid ptosis.
Methods: After receiving institutional review board approval from
Rhode Island Hospital, we reviewed the medical records of patients
referred to three oculoplastic surgeons for evaluation of involutional
entropion from January 2009 to Januarry 2014. We exckuded
oatuebts with previous eyelid or intraocular surgery, trauma, and
thyroid eye disease. We collected patient’s age, gender, ethnicity,
medical comorbidities, smoking history, alcohol use, and the
marginal distance reflex (MRD1). Visually significant ptosis was 2
millimeters (mm) or less. We analyzed the data using chi-square test,
t-test, and the factorial generalized estimating equation (p< 0.05).
Results: There were 181 records that met our inclusion criteria;
56 patients were exclided; 125 were entered into the study. The
prevalence of ptosis and involutional entropion was 30.6% (38); 18
(15%) patients had never used tobacco, 37 (29.7%) patients reported
tobacco use (p<0.05); 27 (22%) reported alcohol use and 28 (23%)
reported no alcohol use (p=0.9332). The mean MRD1 in patients that
reported neither alcohol nor tobacco use was 1.8 mm (p<0.05). The
mean MRD1 in patients that reported alcohol use was 2.9 mm (p<
0.05); the mean MRD1 in patients that reported tobacco use was 0.9
mm (p<0.05), which was visually significant ptosis. The mean MRD1
for patients that reported both tobacco and alcohol use was 1.3 mm
(p< 0.05).
Conclusions: Smoking may play a role in the development of
concurrent involutional lower lid entropion and upper lid ptosis.
Commercial Relationships: Kendra Clemons, None;
Michael E. Migliori
Preoperative levator function is a significant factor in
postoperative results of Muller’s muscle-conjunctival resection
Dan Yoon1, Rakesh Patel2, Vinay K. Aakalu1, Pete Setabutr1.
1
Ophthalmology, University of Illinois at Chicago, Chicago, IL;
2
Palmetto Health Ophthalmology Associates, Columbia, SC.
Purpose: How Muller’s muscle-conjunctival resection (MMCR)
improves ptosis is unclear. We conducted a retrospective,
observational clinical study to test the hypothesis that preoperative
levator function is associated with post-operative results of MMCR.
We also tested whether the length of resection and pre-operative
phenylephrine response are significant factors.
Methods: Fifty-eight eyes of 39 patients that underwent MMCR
were included in the study. Pre-operative levator function, postphenylephrine change in margin reflex distance 1 (MRD1), length
of resection, and post-operative MRD1 were measured (in mm).
Multiple linear regression was performed with post-operative MRD1
as the dependent variable.
Results: The regression model was statistically significant
(F(4, 53) = 3.12, p = .034), with an R2 of .15. There was a significant
association between preoperative levator function and post-operative
MRD1 (β = .35, t(57)= 2.6, p = .012). Post-phenylephrine MRD1
(β = .02) and length of resection (β = -.84) were not significantly
associated with post-operative MRD1 (ps > .05).
Conclusions: Preoperative levator function is a significant factor in
postoperative results of MMCR. Length of resection and preoperative
phenylephrine response are not significant factors.
Commercial Relationships: Dan Yoon; Rakesh Patel, None;
Vinay K. Aakalu, None; Pete Setabutr, None
Comparative Analysis of Eyelid Contour Changes in Müller’s
Muscle Conjunctival Resection and External Levator Resection
Ptosis Surgery
Daniel Rootman, Jennifer Danesh, Robert Goldberg. Ophthalmology,
UCLA, Los Angeles, CA.
Purpose: Although Müller’s Muscle Conjunctival Resection
(MMCR) and External Levator Resection (ELR) are widely utilized
to manage ptosis, there is little direct comparative data regarding
outcomes. Further, there is a dearth of available data concerning
objective or quantitative assessment of eyelid contour results. This
study aims to assess relative changes in upper eyelid contour for
patients undergoing MMCR and ELR surgery.
Methods: In this retrospective cohort study, 20 eyes of 10
patients who underwent MMCR and 20 eyes of 16 patients who
underwent ELR in a single center were included. Patients with
history of previous or concurrent eyelid surgery or orbital disease
were excluded. Primary position photographs were obtained
pre-operatively and >3 months postoperatively. Processing and
measurement of the digital photos with public domain NIH ImageJ
software proceeded as follows. Images were rotated in order that a
line intersecting the lateral canthi was made parallel to the horizontal
axis. The center of the pupil was then defined as the 0,0 coordinate.
Images were calibrated using a standard corneal diameter for males
and females respectively. Along the x-axis,10 points were defined:at
the center of the pupil and at 2mm intervals laterally to 10mm and
medially to 8mm(Figure 1). This was performed at baseline and
postoperative photographs. One-way and repeated measures ANOVA
were performed
Results: The overall main effect of position was significant(p<0.05)
indicating there is variation in vertical height across the eyelid.
The effect of time was also significant(p<0.05) indicating that the
vertical height of the eyelid changed with surgery. When assessing
individual point differences between groups, there was a significant
interaction effect of group on time at the nasal-most positions of 6
and 8mm(p<0.05), with a trend at 4mm(p<0.07), indicating a greater
change with MMCR at these positions(Figure 2a). Comparing change
in height at each point across the two groups revealed MMCR to have
greater change at positions N4, N6 and N8(p<0.05) (Figure 2b).
Conclusions: Both MMCR and ELR are effective in elevating the
eyelid. Relative to ELR, there is a small but significant bias towards
increased vertical elevation medial to the center of the pupil in the
MMCR group. This suggests that there may be a relative medial bias
with MMCR, or conversely a lateral bias with ELR.
Commercial Relationships: Daniel Rootman, None;
Jennifer Danesh, None; Robert Goldberg, None
Material breakage as an early complication of expanded
Polytetrafluoroethylene (ePTFE) usage in frontalis suspension
surgery for poor levator function blepharoptosis
John C. Zeyer, Hassan Shah. Ophthalmology and Visual Science,
University of Chicago, Chicago, IL.
Purpose: To report the results and complications of frontalis
suspension surgery using expanded polytetrafluoroethylene (ePTFE)
for poor levator function blepharoptosis over a 2-year period.
Methods: Retrospective chart review of all frontalis suspension
surgeries performed by a single surgeon over 2-years. All procedures
were performed using ePTFE of 2 or 3 mm width (Ptose-Up, FCI
Ophthalmics). Surgeries were performed through an eyelid crease
incision with a single pentagonal design involving suture fixation
of material to the tarsal plate. The material was then tied in a square
knot and buried just above the brow. Postoperative success was
defined as upper margin reflex distance (MRD1) of 2.5 mm or more,
a cosmetically acceptable eyelid contour, and lagophthalmos 1
mm or less. Complications included material breakage, granuloma
formation, unacceptable contour, lagophthalmos and ptosis
recurrence.
Results: 22 frontalis suspension surgeries were performed in 15
patients (14 children and 1 adult) from July 2013 to June 2015. The
etiology of ptosis was congenital in 13 patients, third nerve palsy in
1 patient, and traumatic ptosis in 1 patient. Mean age of the children
was 3 years (Range 1-5 years). Mean follow up time was 5 months.
13 procedures (60%) had successful results that did not require
reoperation. In 2 procedures (9%) the ePTFE broke intraoperatively
and the procedure was repeated immediately. In 5 procedures (23%)
the ePTFE broke in the postoperative period (range postoperative
day 1 to 44), which was confirmed during reoperation. 1 patient
(4%) developed a brow granuloma and abscess that required surgical
removal of the material. 1 eyelid (4%) had undesirable contour
requiring reoperation.
Conclusions: ePTFU has been reported as an excellent material
for frontalis suspension surgery with a low rate of ptosis recurrence
and complications. Our data concurs with other studies in terms of
achieving excellent eyelid height and contour with this material.
However, in our cohort there was a high incidence of material
breakage in the early postoperative period, as well as two cases
of intraoperative breakage. This is an important complication to
be aware of when using ePTFE. Factors such as material width
and thickness, surgical technique, handling of the material, and
postoperative care may all play a role.
Commercial Relationships: John C. Zeyer, None; Hassan Shah
Significance of Early Postoperative Eyelid Position on Late
Postoperative Result in Müller’s Muscle Conjunctival Resection
Surgery
Jennifer Danesh1, Shoaib Ugradar2, Robert Goldberg1, Naresh Joshi2,
Daniel Rootman1. 1Stein Eye Institute, UCLA, Beverly hills, CA;
2
Chelsea and Westminster Hospital, London, United Kingdom.
Purpose: External levator resection(ELR) and Müller’s muscle
conjunctival resection(MMCR) differ in the tissues dissected
during surgery. This study aims to determine if resection of purely
the levator aponeurosis or Müller’s muscle and conjunctiva has a
differential effect on variation in eyelid position after surgery.
Methods: In this retrospective observational cohort study, patients
from two practices undergoing surgery for involutional ptosis over
a 10-year period were screened. Exclusion criteria includes trauma,
ocular disease, or past orbital surgery. Patients underwent MMCR
surgery (RAG) or ELR (NJ). Marginal reflex distance (MRD) was
calculated on photos using NIH ImageJ software. Measurements
were made at baseline, 1 week postoperatively and at 3 to 12 months
follow up. The primary outcome measure was change in MRD over
time. The secondary outcome measure was the proportion of patients
with minimal early change in MRD (< 0.5 mm at 1 week). Repeated
measures ANOVA, T-test and Chi square tests were performed.
Results: Of 135 eyes, there were 101 in the MMCR group and
34 in the ELR group. Baseline mean MRD was 1.4mm in the
MMCR group and 1.0mm in the ELR group(p<0.05). At the early
postoperative visit, mean MRD was 2.3mm in the MMCR group and
2.8mm in the ELR group(p<0.05). At the late postoperative visit,
mean MRD was 3.0mm in the MMCR group and 3.0mm in the ELR
group(p>0.05). Change in MRD from baseline to early postoperative
visit was greater after ELR(1.81mm vs. 0.88mm, p<0.05). Change in
MRD from the early postoperative to the late postoperative visit was
greater with MMCR(0.75mm vs. 0.26mm, p<0.05).
Repeated measures ANOVA confirmed the interaction of group and
time(p<0.05), indicating that change over time was significantly
different for ELR vs. MMCR(Figure 1). For the secondary outcome,
the proportion of subjects with minimal(<0.05mm) change from the
baseline to early postoperative visit was significantly(p<0.05) lower
in the ELR group 11.8%) relative to the MMCR group(40.6%).
Conclusions: ELR and MMCR can effectively elevate the eyelid
and have similar late postoperative results. This study shows that
MMCR cases undergo greater change between the early and late
postoperative period, suggesting that the process of lid elevation in
MMCR is more dynamic than in ELR. This supports the contention
that MMCR and ELR surgery may act through different mechanisms.
Commercial Relationships: Jennifer Danesh, None;
Shoaib Ugradar; Robert Goldberg, None; Naresh Joshi, None;
Daniel Rootman, None
Bilateral ptosis due to mitochondrial cytopathy secondary to
antiretroviral treatment toxicity
Nilly Banayan1, Pascal Laforet3, Tanya Stojkovic3, Anthony Behin3,
Emmanuelle Salort-Campana2, Bahram Bodaghi1, Phuc Lehoang1,
Valérie Touitou1. 1Ophthalmology, Pitié-Salpétrière Hospital, Paris,
France; 2hopital La Timone, Marseille, France; 3Myology Institute,
Pitie Salpetriere Hospital, Paris, France.
Purpose: Progressive external ophthalmoplegia is the most common
clinical presentation of mitochondrial diseases, associated with
fatigability and muscular pain. These conditions are often hereditary
and diagnosed early in life. We report cases of isolated bilateral ptosis
due to acquired mitochondrial toxicity secondary to antiretroviral
treatment in HIV infected patients.
Methods: Medical records of patients treated with antiretroviral
drugs for HIV infection and presenting with acquired ptosis evocative
of mitochondrial cytopathy were retrospectively reviewed. Patients
were followed both in the Myology and Ophthalmology departments.
For all patients, differential diagnostics such as myasthenia, Melas,
Merrf and oculopharyngeal dystrophy syndroms were ruled out by
an etiologic work up. Muscular biopsy was performed in all cases to
histologically confirm the diagnosis of mitochondriopathy and for
genetic analysis purposes.
Results: Ten male patients were included. All patients presented
bilateral ptosis. Ptosis was initially bilateral and symetric in 4 patients
(40%) and secondarly bilatreal in 6 patients (60%). The average delay
between initiation of antiretroviral treatment and ptosis was 12 years.
The muscular biopsy demonstrated red ragged fibers in 9 patients
(90%) and a Cox1 deficit in all patients. Genetic analysis revealed
multiple deletions in 4 patients (40%) but no DNA depletion.
Conclusions: Mitochondrial toxicity secondary to antiretroviral
treatment is an unknown cause of ptosis in patients without other
muscular symptoms. Further genetic analysis remain necessary
to assess the responsible abnormalities. Modification of the
antiretroviral therapy does not seem to influence the evolution of the
disease which could result from a cumulative toxicity as suggested by
the 12-year delay before the onset of symptoms.
This entity is probably largely underestimated among HIV patients
and is important to detect because it can affect the therapeutic
strategy for these patients, in case of surgical correction of the ptosis.
Commercial Relationships: Nilly Banayan, None;
Pascal Laforet; Tanya Stojkovic, None; Anthony Behin, None;
Emmanuelle Salort-Campana, None; Bahram Bodaghi, None;
Phuc Lehoang, None; Valérie Touitou, None
Preferred methods of pediatric ophthalmologists for ptosis repair
in the pediatric population
Jennifer Murdock1, Radha Ram2, Evelyn A. Paysse2, 1, Michael T. Yen1,
Douglas P. Marx1. 1Baylor College of Medicine/ Cullen Eye Institute,
Houston, Afghanistan; 2Texas Childrens Hospital, Houston, TX.
Purpose: To investigate the most preferred materials used by
pediatric ophthalmologists for frontalis suspensions in the pediatric
population.
Methods: An online questionnaire was submitted to members of
American Association for Pediatric Ophthalmology and Strabismus
(AAPOS). Data was collected through an internet survey database.
Results: 85 respondents completed the survey. Most respondents
preferred silicone rod (36.11%), followed by autologous fascia lata
(19.44%), various suture types (18.06%), other materials (12.50%),
preserved fascia lata (8.33%), and Gore-tex (5.56%) (Figure 1). Most
respondents (82%) perform 10 or less frontalis suspensions each year,
and those surgeons prefer silicone rod. Silicone rod and suture are the
most preferred material in patients 3 years-old or younger. Along with
silicone rod, autologous fascia lata was also considered in patients
over 3 years of age (Figure 2). However, only 31% of respondents
reported that a patient’s specific age influences their decision about
which material to use in this population.
Conclusions: In general, silicone rod is the most preferred material
for frontalis slings in pediatric patients among AAPOS members.
Silicone rod remains the dominantly preferred material in all specific
age ranges for all surgeons, but autologous fascia lata becomes more
often considered in pediatric patients older than 3 years of age. While
small retrospective studies have investigated different methods for
frontalis suspensions, prospective studies directly comparing different
materials are suggested.
Figure 1. Percentages of AAPOS respondents’ preferred frontalis
sling material in pediatric patients.
Figure 2. Preferred materials preferred in specific age groups of
pediatric patients.
Commercial Relationships: Jennifer Murdock, None;
Radha Ram, None; Evelyn A. Paysse; Michael T. Yen, None;
Douglas P. Marx, None
Referral Patterns and Outcome Trends of Temporal Artery
Biopsies
Marie Somogyi, David Yoo, Yasmin Shayesteh. Loyola Univ Medical
Center, Maywood, IL.
Purpose: Giant cell arteritis (GCA) is diagnosed based on a
combination of signs, symptoms and laboratory evidence. Temporal
artery biopsy is the gold standard in diagnosis of GCA and referral
for biopsy is commonly encountered in ophthalmology practices. Our
review investigates referral patterns from various medical specialties
and the correlation to a positive biopsy. Additionally, we analyzed
outcome trends among various departments performing biopsies over
an eight-year period. To our knowledge, this series of 143 patients is
the largest to date evaluating outcomes based on referral source and
surgical trends among specialties.
Methods: IRB approved retrospective chart review of 143 patients
who underwent a temporal artery biopsy from January 2006 to April
2014 by all specialties at our tertiary care center.
Results: Of 143 patients, 15 had positive biopsies (10.5%) and 128
had negative biopsies. The departments performing the biopsies
primarily include ophthalmology, plastic surgery, and vascular
surgery. Ophthalmology performed 109 (76.2%) biopsies; however,
there was a significant decline over time. From 2006-2009,
ophthalmology performed an average of 90.1% of the biopsies,
which decreased to 54.6% from 2010-2013. Similarly, overall
biopsies performed decreased from 22 biopsies in 2006 to 11 in 2013.
Among the 15 positive biopsies, 11 (73.3%) were performed by
ophthalmology, 3 (20%) by vascular surgery, and 1 (6.6%) by plastic
surgery. Internal medicine accounted for the majority of the referrals
(51%) followed by ophthalmology (18.2%), rheumatology (13.3%),
neurology (10.5%), and others (7.0%). Neurology referrals resulted
in a 20% positive biopsy rate, followed by rheumatology (15.8%) and
internal medicine (12.3%). Ophthalmology referrals did not result in
any positive biopsies. Of the 15 positive biopsies, 60% were referred
from internal medicine, 20% from rheumatology, and 20% from
neurology.
Conclusions: Over time, we have witnessed a decrease in temporal
artery biopsies, as well as a decline in the proportion of biopsies
performed by the ophthalmology department. Internal medicine
provided the largest referral base for temporal artery biopsies.
However, neurology had the highest proportion of positive biopsies
per referral, suggesting they may have a better pretest probability
for the disease. Interestingly, none of the referrals from within the
ophthalmology department resulted in a positive biopsy.
Commercial Relationships: Marie Somogyi, None; David Yoo,
None; Yasmin Shayesteh, None
Proptosis and retrobulbar anesthesia: a technique to evaluate for
subclinical retrobulbar hemorrhage
Justin Spaulding, Therese Sassalos, Nitin Kumar, Aldo Fantin.
Department of Ophthalmology, Henry Ford Hospital System, Royal
Oak, MI.
Purpose: This is a prospective pilot study to quantify the
displacement of the globe and elevation in IOP from retrobulbar
anesthetic injections. There is no prior studying measuring this
phenomenon.
Methods: All patients were currently enrolled for PPV with a
retrobulbar block (5cc of equal parts 0.75% Marcaine and 4%
lidocaine) injected into the muscle cone. Baseline preoperative
measurements were taken in a supine position with Hertel (HR) and
Naugle (NU) exopthalmometers, IOP was measured using a tonopen.
The patient was then given the 5cc retrobulbar block and immediately
thereafter all measurements were repeated.
Using AEL, K radius, and ACD measurements (from IOL Master)
we will determine the location of the apex in relation to the lateral
canthi in the case of the HR or the frontal and maxillary bone in the
case of the NU. The increased exopthamomiters readings can then
be converted into a volume of forward displacement based off these
values.
A paired t-test was used for statistical analysis.
Results: From the 7 subjects enrolled to date, there are 5 males and
2 females, 4 OD and 3 OS eyes. All patients are Caucasian. The
difference of pre and post HR and NU measurements are statically
significant with a P=0.0008 and P=7.6E-5 respectively. The average
amount of proptosis is 3mm (HR) and 2.9mm (NU). There is not
enough data to compare across genders. Our goal is to enroll a total
of 15-20 patients for the study.
Justification for this goal is based on a conservative standard
deviation estimate of 3.75 (using a range of 15 divided by 4 -- this
is the range of millimeters of proptosis from 15-30mm) should be
appropriate. Using that standard deviation along with a 2-sided alpha
level of 0.05, the paired t-test would have a power of 0.80 to detect an
underlying mean measurement increase of 3 if a total of 15 patients
are used.
Conclusions: We hope in the end to have an average value of
proptosis associated with the volume of injection. This is directly
beneficial in the case of retrobulbar hemorrhage a rare complication
of such injections. Any displacement past this average change in
proptosis may indicate a subclinical retrobulbar hemorrhage.
Naugle exophthalmometer - uses fixation points above and below
the superior and inferior orbital rims to measure the distance of the
corneal apex.
Hertel exophthalmometer - measurement is taken from the lateral
orbital rim to the corneal apex.
Commercial Relationships: Justin Spaulding; Therese Sassalos,
None; Nitin Kumar, None; Aldo Fantin, None

Session 138 Oculoplastics

Transcription

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