Symposium - American Society of Ophthalmic Plastic and

Transcription

SYLLABUS
ASOPRS 45TH
FALL SCIENTIFIC
Symposium
OCTOBER 16-17, 2014
SHERATON, CHICAGO, IL
Oculofacial Insights
from the
Windy City
Relevant Financial Disclosures
In accordance with the guidelines of the Accreditation Council for Continuing Medical Education (ACCME), ASOPRS requires
disclosure of any relevant interests or affiliations with corporate organizations of Faculty (F), Program Committee and
CME Subcommittee Members (PC), Program Abstract Reviewers (R), YASOPRS Committee Members (Y) and Awards Committee
Members (A). Relationships listed below belong to the author unless otherwise noted.
R. Rox Anderson . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Brian S. Biesman, MD . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Philip L. Custer, MD . . . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Dorris Day . . . . . . . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Steven Dayan . . . . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Zoe Draelos . . . . . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Vikram D. Durairaj, MD . . . . . . . . . . . (PC, Co-Author) . . . . . . . .
Bita Esmaeli, MD . . . . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Joseph Eviatar . . . . . . . . . . . . . . . . . . . (Co-author) . . . . . . . . . . .
Robert G. Fante, MD . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Patricia Farris . . . . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Jill A. Foster, MD, FACS . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Barbara Gilchrest . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Mark Glasgold, MD . . . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Robert A. Goldberg, MD, FACS . . . . . (Co-Author) . . . . . . . . . . .
Andrew R. Harrison, MD . . . . . . . . . . . (PC, Co-Author) . . . . . . . .
Marc J. Hirschbein, MD, FACS . . . . . . (R) . . . . . . . . . . . . . . . . . . .
Eric M. Hink, MD . . . . . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
John B. Holds, MD . . . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Catherine J. Hwang, MD . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Derek Jones . . . . . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Alon Kahana, MD, PhD . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Vladimir Kratky, MD . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
N. Grace Lee, MD . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Wendy W. Lee, MD . . . . . . . . . . . . . . . (R, Co-Author) . . . . . . . . .
Daniel R. Lefebvre, MD . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Guy G. Massry, MD . . . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Louise A. Mawn, MD . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Janet F. Neigel, MD, FACS . . . . . . . . . (Co-Author) . . . . . . . . . . .
John Ng, MD, MS, FACS . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Julian D. Perry, MD . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Fernanda Sakamoto . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Robert M. Schwarcz, MD . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Peter J. Sneed, MD . . . . . . . . . . . . . . . (PC) . . . . . . . . . . . . . . . . . .
Sara D. Tullis Wester, MD . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Edward J. Wladis, MD . . . . . . . . . . . . . (F) . . . . . . . . . . . . . . . . . . .
Ted H. Wojno, MD . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Michael T. Yen, MD . . . . . . . . . . . . . . . (PC, Co-Author) . . . . . . .
Betty Yu . . . . . . . . . . . . . . . . . . . . . . . . . (Co-Author) . . . . . . . . . . .
Living Proof, Inc. – Consultant
Allergan, Cytrellis, Kythera, Living Proof, Inc., Merz, Revance,
Syneron-Candela, Valeant, Zeltiq – Consultant; Allergan,
Living Proof, Inc., Tria Beauty, Valeant, Syneron-Candela –
Lecture Honoraria; Cytrellis, OnLight Sciences – Equity Owner;
Allergan, Evolus, Kythera, Myoscience, OnLight Science,
Syneron-Candela, Ulthera – Other
Pfizer, Johnson & Johnson – Equity Owner
Stryker, Matrix – Consultant; KLS Martin, AO Foundation –
Lecture Honoraria
Genetech, Roche – Consultant
ThermiRF – Consultant
OMIC – Consultant; Strathspey Crown – Equity Owner
Merz, Allergan – Consultant
Lippencott – Royalty
Merz, Valeant – Grant Support
Neuro-Ophthalmix, LLC – Equity Owner
Merz Pharmaceutical – Constultant
River Vision Development Corp – Grant Support;
AO Foundation – Lecture Honoraria
Merz Pharmaceuticals – Consultant; Allergan USA – Lecture Honoraria
Merz, Valeant – Grant Support
NIH, Genentech, Inc. – Grant Support
Research Initiation Grant – Grant Support
Heed Fellowship – Grant Support
Allergan Medical, Medicis Aesthetics, Elizabeth
Arden, Lumenis, Cutera, Ophthalmology Web,
Merz – Consultant; Solta Medical – Grant Support
XLibris Corporation – Royalty
Springer Publisher, Elsevier – Editor
Research to Prevent Blindness – Grant Support
Valeant, Allergan – Consultant
Bio Logic Aqua Research – Consultant, Equity Owner
Merz Pharmaceuticals – Consultant
Valeant – Consultant
Strathspey Crown/Alphaeon – Equity Owner
Cutera – Other
Lions Eye Foundation, National Rosacea Society –
Grant Support
Medical Director Solutions, Ethicon – Consultant;
Research to Prevent Blindness – Grant Support
Merz Pharmaceuticals – Consultant
Living Proof, Inc. – Employee
All other Faculty (F), Program Committee and CME Subcommittee Members (PC), Program Abstract Reviewers (R), YASOPRS
Committee Members (Y), and Awards Committee Members (A) have declared that they have no relevant financial disclosures.
ASOPRS Fall Scientific Symposium Syllabus 2
Program Snapshot
WEDNESDAY, OCTOBER 15, 2014
FRIDAY, OCTOBER 17, 2014
3 – 7 pm
6 am – 5 pm
Registration
6:45 am
ASOPRS Fellowship Program
Directors Committee Meeting
Mayfair Room
6:45 am
ASOPRS Foundation Board
of Trustees Meeting
Ohio Room
6:45 – 8 am
Breakfast with Exhibitors
7 – 8 am
YASOPRS Eye Openers:
Rapid Fire Cases
Registration
THURSDAY, OCTOBER 16, 2014
6 am – 5 pm
Registration
6:45 am
ASOPRS Education Committee Meeting
Superior Room
6:45 – 8 am
Breakfast with Exhibitors
7 – 8 am
YASOPRS Eye Openers: Rapid Fire Cases
8 am – 5 pm
General Session
8 – 8:50 am
Eyelid Session I
8 am – 5 pm
General Session
8:50 – 9:30 am
Volumization Session I
8 – 8:40 am
Oncology Session
9:30 – 10:15 am
Featured Speaker: Mark Glasgold, MD
Volumization in Facial Aesthetics
8:40 – 9:30 am
Henry Baylis Lecture Series
9:30 – 10 am
10:15 – 10:45 am
Break with Exhibitors and Poster Stand By Session
Break with Exhibitors and
Poster Stand By Session
10:45 – 11:25 am
Volumization Session II
10 – 10:40 am
Lacrimal Session
11:25 am – 12 pm
Featured Speaker: Mark Glasgold, MD
Techniques for Fat Transfer
10:40 – 11:15 am
Eyelid Session II
11:15 am – 12 pm
12 – 1 pm
Lunch
12 – 1 pm
YASOPRS LUNCH LECTURE:
How to Build and Grow a Successful Practice
(Ticketed Event)
Ohio Room
Featured Speaker: Andrew Jacono, MD
An Algorhythmic Multi-Modality
Approach to the Devolumized
Lower Eyelid
12 – 1 pm
Lunch
1 – 1:40 pm
Orbit Session II
1:40 – 2:20 pm
Featured Speaker: Suresh Mukherji, MD
Imaging of the Orbit and Globe
2:20 – 2:50 pm
Break with Exhibitors and
Poster Stand By Session
2:50 – 3:45 pm
Eyelid Session III
3:45 – 4:30 pm
Orbit Session III
4:30 – 5 pm
ASOPRS Thesis & Awards Session
5 pm
General Session Adjourns
5 – 6 pm
ASOPRS Business Meeting
(All ASOPRS Members are invited
to attend)
12 – 1 pm
Satellite Symposium: Creating the Most
Powerful Internet Presence to Attract and Convert
New Patients (sponsored by Advice Media)
Michigan Room
1 – 1:40 pm
Orbit Session I
1:40 – 2:20 pm
The Practice of Oculofacial Plastic Surgery Session
2:20 – 3 pm
ASOPRS Foundation Lecture
3 – 3:30 pm
3:30 – 3:55 pm
Neck and Facial Rejuvenation Session
3:55 – 4:30 pm
Featured Speaker: Andrew Jacono, MD
A Structured Anatomic Approach to Face and
Neck Lifting
4:30 – 5 pm
Pediatric Oculofacial Plastic Surgery
5 pm
General Session Adjourns
5 – 6:30 pm
Social Event: ASOPRS Reception (Ticketed Event)
Social Event — ASOPRS Reception
Thursday, October 16, 2014 | 5 – 6:30 pm Join colleagues and friends for a networking and social reception, immediately
following the General Session on Thursday, October 16 at the Sheraton. Start
your evening off by making new connections, catching up with old friends and
making dinner plans in Chicago!
Ticket Cost: $40 per person (tickets are non-refundable)
Ticket includes: Light snacks and a beverage
Visit Registration to purchase tickets onsite; space is limited.
Awards
The Bartley R. Frueh Award for Best YASOPRS Presentation
Wendell Hughes Lecture Award
Named in memory of ASOPRS Past President, Dr. Bartley Frueh,
the ASOPRS Foundation will award the Bartley R. Frueh Award for
Best YASOPRS Presentation to two presentations (one from each
morning’s session) given during the YASOPRS Eye Openers —
Rapid Fire Case Presentations.
The Wendell Hughes Lecture Award is given to an individual,
selected by the ASOPRS Wendell Hughes Committee, who delivers
the prestigious named lecture in honor of Dr. Hughes, ASOPRS
Inaugural President. An annual tradition since 1970, the lecture is
delivered at the joint ASOPRS-AAO Symposium during the
American Academy of Ophthalmology meeting each Fall.
The recipients of the Bartley R. Frueh Award for Best YASOPRS
Presentation will be announced during the Awards Session
on Friday, October 17, 2014.
Young ASOPRS (YASOPRS) are defined as ASOPRS members,
age 40 or less.
The recipient of this year’s Wendell Hughes Lecture Award is:
Philip L. Custer, MD
The award will be presented to Dr. Custer after presentation of the
Wendell Hughes Lecture on Monday, October 20, 2014 at 9:30 am
at McCormick Place Convention Center, Room E350.
Marvin H. Quickert Thesis Award
The Marvin H. Quickert Thesis Award is an honorary award given
annually for the most outstanding thesis chosen from those
submitted by candidates seeking membership in ASOPRS during
the current year.
The recipient of this year’s Marvin H. Quickert Thesis Award
will be announced during the Thesis Session on Friday,
October 17, 2014.
Merrill Reeh Pathology Award
The Merrill Reeh Pathology Award honors an outstanding
contribution to the study of pathology pertinent to the field of
ophthalmic plastic and reconstructive surgery. Papers are submitted
for consideration for this honorary award by members of ASOPRS
or anyone interested in the field of ophthalmic plastic and
reconstructive surgery. Theses from membership candidates are
also eligible. The Merrill Reeh Pathology Award is reserved for a
paper considered to represent a truly significant contribution
to the field of ophthalmic plastic and reconstructive surgery.
The recipient of this year’s Merrill Reeh Pathology Award is:
Francesco Quaranta-Leoni, MD for the paper: Management of
Porous Orbital Implants Requiring Explantation: A Clinical and
Histopathological Study. Quaranta-Leoni, Francesco M. Ophthalmic
Plastic and Reconstructive Surgery. 30(2):132-136, March/April 2014.
Lester T. Jones Surgical Anatomy Award
The Lester T. Jones Surgical Anatomy Award is given to an
individual who has made an outstanding contribution to ophthalmic
plastic and reconstructive surgery. The first award in 1974 was
awarded to Marvin H. Quickert, MD, for his application of anatomy
to surgical approaches.
The recipient of this year’s Lester T. Jones Anatomy Award
is: Petros Konofaos, MD for the paper: Suprathrochlear and
Supraorbital Nerves: An Anatomical Study and Applications in the
Head and Neck Area. Konofaos, Petros. Ophthalmic Plastic and
Reconstructive Surgery. 29(5):403-408, September/October 2013.
ASOPRS Outstanding Contribution Award
This award is given to an individual or individuals who make a
legendary single, or longstanding multiple contributions to ASOPRS.
The recipient of this year’s ASOPRS Outstanding Contribution
Award is: Richard L. Anderson, MD
ASOPRS Research Award
The ASOPRS Research Award is given annually to a member or
candidate for membership who submits the most outstanding paper
describing original research conducted in the field. Only papers
submitted to Ophthalmic Plastic and Reconstructive Surgery, the
official journal of the Society are considered.
The recipient of this year’s ASOPRS Research Award is:
David B. Samimi, MD for the paper: Microbiologic Trends and
Biofilm Growth on Explanted Periorbital Biomaterials: A 30-Year
Review. Samimi, David B. Ophthalmic Plastic and Reconstructive
Surgery. 29(5):376-381, September/October 2013.
Orkan G. Stasior Leadership Award
This award is given to an individual who has demonstrated
distinguished service in the field of ophthalmic plastic and
reconstructive surgery through education, research, humanitarian
activities and/or service to the Society. This award is presented in
recognition of the leadership of ASOPRS charter member,
Orkan G. Stasior, MD.
The recipient of this year’s Orkan G. Stasior Leadership Award
is: William R. Nunery, MD, FACS.
Henry I. Baylis Cosmetic Surgery Award
This award is given to an individual for longstanding contributions
in the field of cosmetic surgery. The recipient of this award presents
the Henry I. Baylis Lecture at the Fall Scientific Symposium.
The recipient of this year’s Henry I. Baylis Cosmetic Surgery
Award is: Guy G. Massry, MD
The award will be presented to Dr. Massry after presentation of the
Henry I. Baylis Lecture on Friday, October 17, 2014 at 8:40 am in the
Chicago Ballroom of the Sheraton, Chicago.
Robert H. Kennedy Presidential Award
Named in memory of ASOPRS’ 2007 President, Robert H. Kennedy,
MD, PhD, this award is presented to the Society’s Immediate Past
President in recognition of their devotion, leadership, and ongoing
service to the Society.
The recipient of this year’s Robert H. Kennedy Presidential
Award is: Michael E. Migliori, MD, FACS
Program at a Glance – Thursday, October 16, 2014
6 am – 5 pm
Registration (Chicago Promenade)
7 – 8 am
YASOPRS Eye Openers – Rapid Fire Cases and Presentations (Chicago Ballroom)
7 – 8 am
Breakfast with Exhibitors (River Exposition Hall)
7 am – 3:30 pm
Scientific Posters and Videos (River Exposition Hall)
YASOPRS Eye Openers — Rapid Fire Cases and Presentations
Sponsored by Young ASOPRS (YASOPRS). YASOPRS are defined as ASOPRS members, age 40 or less.
Moderators: Albert Ya-Po Wu, MD, PhD, Shu-Hong Chang, MD
7:00 am A Cyst You Don’t Want to Miss: Endocrine Mucin-Producing Sweat Gland Carcinoma of the Eyelid
Nada Farhat1, Rachel Sobel2,3, Avneet Sodhi1, Katrinka Heher1, Julia Schneider3, Mitesh Kapadia1, Nora Laver1. 1Department of Ophthalmology,
Tufts Medical Center, Boston, MA, United States, 2Department of Ophthalmology, Boston Medical Center, Boston, MA, United States, 3
Boston University School of Medicine, Boston, MA, United States
7:04 am Carcinoma ex Pleomorphic Adenoma of the Lacrimal Gland with Clear Cell and Myoepithelial Differentiation
Ema Avdagic 1, Nicholas Farber 1, Nora Katabi 2, Tanuj Nakra3, Roman Shinder 1,3. 1Ophthalmology, SUNY Downstate Medical Center, Brooklyn,
NY, United States, 2Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, United States, 3Texas Oculoplastic Consultants,
Austin, TX, United States
7:08 am Retrobulbar Hemorrhage: An Algorithm to Guide Canthotomy/Cantholysis By Non-Ophthalmologists
Benjamin Erickson, Wendy Lee, Nathan Blessing. Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States
7:12 am Metastatic Melanoma of the Lateral Rectus Misdiagnosed as Idiopathic Orbital Inflammation
Nicholas Farber1, Ai-Lin Shao1, Renelle Pointdujour1, Tanuj Nakra2, Roman Shinder1,2. 1Ophthalmology, SUNY Downstate Medical Center,
Brooklyn, NY, United States, 2Texas Oculoplastic Consultants, Austin, NY, United States
7:16 am Ophthalmic Manifestations and Outcomes of Cavernous Sinus Thrombosis in Children
Garett Frank1, Jesse Smith1, Brett Davies1, David Mirsky3, Eric Hink1, Vikram Durairaj1,2,4. 1Department of Ophthalmology, University
of Colorado Hospital, Aurora, CO, United States, 2Department of Otolaryngology, University of Colorado Hospital, Aurora, CO,
United States, 3Department of Radiology, Childrens Hospital Colorado, Aurora, CO, United States, 4Texas Oculoplastic Consultants,
7:20 am Lateral Canthoplasty Combined with “En-Glove” Placement of Acellular Porcine Dermis Graft for Correction
of Lower Eyelid Retraction
F. Lawson Grumbine, Robert Kersten, Sarah Deparis, M. Reza Vagefi. Ophthalmology, University of California, San Francisco,
San Francisco, CA, United States
7:24 am Orbital Fibroblastic and Myofibroblastic Proliferation Resembling Fibromatosis Colli
Audrey Ko1, Sophie Liao1, Benjamin Erickson1, Rebecca Shields1, J. Antonio Bermudez-Magner 1,2, Sander Dubovy1,2, Wendy Lee1.
1
Ophthalmology, University of Miami, Miami, FL, United States, 2Florida Lions Ocular Pathology Laboratory, Miami, FL, United States
7:28 am Outcomes of a Non-image-guided Injection Technique for Intralesional Bleomycin Injection for Orbital Lymphangiomas
Bradford Lee, Richard Scawn, Bobby Korn, Don Kikkawa. Division of Oculofacial Plastic and Reconstructive Surgery, University of California
San Diego Shiley Eye Center, La Jolla, CA, United States
7:32 am Blepharoptosis from Statin-induced Necrotizing Myopathy
Jessica Lin1, Juan Javier Servat2, Gary Lelli3, Flora Levin1. 1Ophthalmology and Visual Science, Yale University School of Medicine, New Haven,
CT, United States, 2Oculofacial Plastic Surgeons of Georgia, Atlanta, GA, United States, 3Ophthalmology, Weill Cornell Medical College,
New York, NY, United States
7:36 am Medial Orbital Wall Anatomic Landmarks
Milap Mehta1,2, Julian Perry1. 1Ophthalmology, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, United States, 2Surgery, Northshore
University, Evanston, IL, United States
Program at a Glance – Thursday, October 16, 2014, continued
7:40 am Hydrogel Expansion and Glue Tarsorrhaphy for Congenital Anophthalmia and Microphthalmia
Maryam Nazemzadeh1,2, Michael Sulewski, Jr.3, William Katowitz1,2, James A. Katowitz1,2. 1Department of Oculoplastic and Orbital Surgery,
The Children’s Hospital of Philadelphia, Philadelphia, PA, United States, 2Center for Human Appearance, University of Pennsylvania,
Philadelphia, PA, United States, 3University of Pennsylvania School of Medicine, Philadelphia, PA, United States
7:44 am Lateral Browlift Using Temporal (Pretrichial) Subcutaneous Approach Under Local Anesthesia
Mehryar Taban. Private Practice, Beverly Hills, CA, United States
7:48 am Osseointegrative Implants for Orbito-Facial Prostheses: Six Preoperative Planning Tips and Intraoperative Pearls
Leslie Wei, MD1, Julie Brown, CCA2, Dori Hosek, BCO3, Cathy Burkat, MD FACS1. 1Department of Ophthalmology, Oculoplastic,
Facial Cosmetic and Orbital Surgery Service, University of Wisconsin – Madison, Madison, WI, United States, 2
Medical Art Resources, Inc, Milwaukee, WI, United States, 3Global Prosthetics, Inc, Madison, WI, United States
7:52 am External Dacryocystorhinostomy Through a Midface Rhytidectomy Incision
Kate Xie, Swapna Vemuri, Jeremiah Tao. Department of Ophthalmology, Gavin Herbert Eye Institute, University of California - Irvine,
Irvine, CA, United States
7:56 am Questions and Discussion
GENERAL SESSION
8:00 am Welcome
Don O. Kikkawa, MD, FACS, ASOPRS President
Michael T. Yen, MD, ASOPRS Program Chair
Vikram D. Durairaj, MD, ASOPRS Fall Meeting Co-Chair
Eyelid Session
Moderator: Eric A. Steele, MD
8:05 am Reducing the Risk of Operating Room Fires in Eyelid Surgery with a Mixture of Medical Air and Oxygen via Nasal Cannula
Charles Rice1,2, Michael Twilley2. 1Lansing Ophthalmology, East Lansing, MI, United States, 2Michigan Surgical Center, East Lansing,
MI, United States
8:11 am Comparison of Revision Rates Between External Levator Advancement vs Muller’s Muscle-Conjunctival Resection
For Correction of Upper Eyelid Ptosis
Eva Chou1, Matthew Sniegowski2, Cathleen Seaworth1, Malena Amato1, Vikram Durairaj1, Tanuj Nakra1, John Shore1, Sean Blaydon1.
1
Texas Oculoplastic Consultants, Austin, TX, United States, 2Oculoplastic and Reconstructive Surgery, The University of Texas MD Anderson
Cancer Center, Houston, TX, United States
8:17 am The Impact of Ptosis on Driving Performance: Implications for Functional Surgery
Bobby Korn, Bradford Lee, Richard Scawn, Jane Kim, Don Kikkawa, Felipe Medeiros. Ophthalmology, University of California, San Diego,
La Jolla, CA, United States
8:23 am Levator Aponeurectomy
John Martin. John J. Martin, Jr., M.D., P.A., Coral Gables, FL, United States
8:29 am Worldwide Comparison of Prophylactic Antibiotic Use for Eyelid Surgery
Nambi Nallasamy1, Francesco Bernardini2, Aaron Fay3, Ted Wladis4. 1Ophthalmology, Duke University Eye Center, Durham, NC,
United States, 2Oculplastica Bernardini, Genova, Italy, 3Ophthalmology, Harvard Medical School, Boston, MA, United States, 4
Ophthalmology, Lions Eye Institute, Albany, NY, United States
8:35 am Questions and Panel Discussion
Panel: Charles Rice, MD, Eva Chou, MD, Bobby Korn, MD, John Martin, MD, Nambi Nallasamy, MD
Moderator: Michael McCracken, MD
8:50 am End-to-end Fat Pedicle Redraping for Improved Contour of the Lower Eyelid Mid-face Junction
Matthew Sniegowski1, Eva Chou2, Vikram Durairaj2, Malena Amato2, Sean Blaydon2, John Shore2, Tanuj Nakra2. 1Orbital Oncology and
Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, University of Texas MD Anderson, Houston, TX, United States, 2
Texas Oculoplastic Consultants, Austin, TX, United States
8:56 am The Role of Nitropaste in Ischemic Filler Complications: Should we use it? An Animal Model with ICG Imaging
Catherine Hwang1, Payam Morgan1, Shu-Hong Chang2, Aline Pimentel1, Gary Duckwiler3. 1Oculoplastics, Jules Stein Eye Institute, Los Angeles,
CA, United States, 2Oculoplastics, University of Washington, Seattle, WA, United States, 3Interventional Radiology, UCLA, Los Angeles, CA,
United States
9:02 am Initial Experience with Juvederm Volbella (Hyaluronic Acid) and Volift (Hyaluronic Acid) for Facial Volume Augmentation
Morris E. Hartstein1, Guy Ben Simon2, Oren Benyamini. 1Ophthalmology, Assaf Harofeh Medical Center, Zerifin, Israel, 2Ophthalmology, Sheba
Hospital, Tel Aviv, Israel
9:08 am Superficial Enhanced Fluid Fat Injection (SEFFI) for Aesthetic Enhancement on the Periocular Aesthetic Unit
Francesco Bernardini1, Alessandro Gennai2. 1Oculoplastica Bernardini, Genova, Italy, 2Gennai Chirurgia, Bologna, Italy
9:14 am Filling The PreJowl Sulcus To Streamline the Jawline
Robert Schwarcz. Oculoplastic Surgery, Albert Einstein College of Medicine, New York, NY, United States
Panel: Matthew Sniegowski, MD, Catherine Hwang, MD, Oren Benyamini, MD, Francesco Bernardini, MD, Robert Schwarcz, MD
Featured Speaker — Mark Glasgold, MD, FACS
9:30 am Introduction of Dr. Mark Glasgold
Michael T. Yen, MD
9:33 am Volumization in Facial Aesthetics
Mark Glasgold, MD, FACS
10:15 – 10:45 am
Moderator: John B. Holds, MD
10:45 am Lower Eyelid Position After Aesthetic Injection of Hyaluronic Acid Filler for Midface Augmentation
Eric Ahn, Roger Dailey. Ophthalmology, Oregon Health and Sciences University, Portland, OR, United States
10:51 am Use of Hyaluronic Acid Gel to Improve the Appearance of Lower Eyelid Fat Prolapse as an Alternative to Eyelid Surgery
Debra Kroll1,2, Mitesh Kapadia3, Janet Neigel4. 1Ophthalmic Plastic, Orbital and Reconstructive Surgery, The New York Eye and Ear Infirmary
of Mount Sinai, New York, NY, United States, 2Debra M. Kroll, M.D., New York, NY, United States, 3Division of Oculoplastic Surgery,
New England Eye Center, Tufts Medical Center, Boston, MA, United States, 4The Neigel Center for Cosmetic and Laser Surgery, PA,
New Jersey, NJ, United States
10:57 am Belotero Rescue for Patients with Complications from Restylane (Hyaluronic Acid) Treatment in the Lower Eyelids
Wenjing Liu, Catherine Hwang, Robert Goldberg. Division of Orbital and Oculoplastic Surgery, Jules Stein Eye Institute, Los Angeles, CA,
United States
11:03 am Prospective Evaluation of Three Different Hyaluronic Acid (HA) Gels to Varying Doses of Hyaluronidase
Sandy Zhang-Nunes1,2,3,4, Dan Straka1,2,4, Cameron Nabavi1,2,4, Kenneth Cahill1,2,4, Craig Czyz1,2,3,4, Jill Foster1,2,3,4. 1Plastic Surgery
Ohio/Eye Center of Columbus, Columbus, OH, United States, 2Ophthalmology, The Ohio State University, Columbus, OH,
United States, 3Oculofacial and Reconstructive Surgery, Ohio Health/Doctor’s Hospital, Columbus, OH, United States, 4
Ophthalmology, Mount Carmel Health System, Columbus, OH, United States
11:09 am Volumetric Rejuvenation of the Hollow Superior Sulcus-the Final Frontier
Morris E. Hartstein1, Guy G. Massry2. 1Ophthalmology, Assaf Harofeh Medical Center, Zerifin, Israel, 2Ophthalmology, Beverly Hills
Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills, CA, United States
Panel: Eric Ahn, MD, Debra Kroll, MD, Wenjing Liu, MD, Sandy Zhang-Nunes, MD, Guy Massry, MD
11:25 am Techniques for Fat Transfer
12 – 1 pm
Lunch (River Exposition Hall)
12 – 1 pm
YASOPRS LUNCH LECTURE (Ohio Room)
Brian S. Biesman, MD
YASOPRS** members are invited to an educational lunch with ASOPRS member Brian Biesman, MD.
Topics will include Practice Development and Marketing Strategies.
**YASOPRS are defined as ASOPRS members, age 40 or less. This event is open to YASOPRS
members only.
RSVP’s were required and space is limited; sorry, no entries will be allowed without a ticket.
Orbit Session I
Moderator: Jennifer A. Sivak-Callcott, MD
1:00 pm Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair
Jane S. Kim, Bradford W. Lee, Richard Scawn, Bobby S. Korn, Don O. Kikkawa. Division of Oculofacial Plastic and Reconstructive Surgery,
Department of Ophthalmology, Shiley Eye Center, UC San Diego, La Jolla, CA, United States
1:06 pm Subperiosteal Abscess Of The Orbit: Evolving Pathogens and the Therapeutic Protocol
Janice Liao, Gerald Harris. Ophthalmology, Medical College of Wisconsin, Milwaukee, WI, United States
1:12 pm Orbital Fractures in Emergency Departments: Discharge, Observation or Admission?
Lilly Wagner1,2, Scott Ketner1,2, Simeon Lauer1,2. 1Ophthalmology, Bronx-Lebanon Hospital Center, New York, NY, United States, 2
Ophthalmology, Albert Einstein College of Medicine, New York, NY, United States
1:18 pm Orbital Tumors: An Epidemiologic Survey at a Tertiary Referral Center
Jordan Thompson, Sophie Liao, Sander Dubovy, Thomas Johnson. Bascom Palmer Eye Institute, University of Miami Miller School of
Medicine, Miami, FL, United States
1:24 pm C-reactive Protein as a Marker for Initiating Steroid Treatment In Children with Orbital Cellulitis
Brett W. Davies1, Jesse M. Smith1, Eric M. Hink1, Vikram D. Durairaj2. 1Oculofacial Plastic Surgery, University of Colorado Hospital, Aurora, CO,
United States, 2Texas Oculoplastic Consultants, Austin, TX, United States
Orbit Session I, continued
1:30 pm Questions and Panel Discussion
Panel: Jane S. Kim, MD, Janice Liao, MD, Lilly Wagner, MD, Jordan Thompson, MD, Eric M. Hink, MD
The Practice of Oculofacial Plastic Surgery
Moderator: John D. McCann, MD, PhD
1:40 pm Oculoplastic Hospital Call Coverage Utilization: A Prospective Study
Craig Czyz1,2, Adam Strittmatter1, Kenneth Cahill2, Jill Foster1,2. 1Oculofacial Plastic and Reconstructive Surgery, Ohio University,
Columbus, OH, United States, 2Ophthalmology, Oral and Maxillofacial Surgery, Grant Medical Center, Columbus, OH, United States
1:46 pm A Modified Action Camera for High-Quality, Cost-Effective Oculofacial Surgical Videography
Robi Maamari, Swapna Vemuri, Jeremiah Tao. Gavin Herbert Eye Institute, University of California, Irvine, Irvine, CA, United States
1:52 pm ASOPRS Atlas: Does the Distribution of the Over-65 Population Account for Uneven Access to ASOPRS Specialists
in Metropolitan Statistical Areas?
Rachel Sobel1, David Whelan2, Richard Allen3,4. 1Ophthalmology, Boston Medical Center/Boston University School of Medicine,
Boston, MA, United States, 2Office of Strategy and Business Development, Beth Isreal Deaconness Medical Center, Boston, MA,
United States, 3Ophthalmology and Visual Sciences, University of Iowa Hospital and Clinics, Iowa City, IA, United States, 4
Otolaryngology—Head and Neck Surgery, University of Iowa Hospital and Clincis, Iowa City, IA, United States
1:58 pm Oculoplastic and Orbital Surgery: Millennia in the Making
George Bartley. Mayo Clinic, Rochester, MN, United States
Panel: Craig Czyz, MD, Robi Maamari, MD, Rachel Sobel, MD, George Bartley, MD
ASOPRS Foundation Update & Michael J. Hawes Lecture Series
2:20 pm ASOPRS Foundation Update and Foundation Service Award
Ralph E. Wesley, MD
2:25 pm ASOPRS Foundation Lecture Dedication to John N. Harrington, MD
James C. Fleming, MD
2:30 pm Introduction of ASOPRS Foundation Michael J. Hawes Lecturer
Mark J. Lucarelli, MD, FACS
2:35 pm Thyroid Eye Disease 25 Years of Progress — What’s Next?
Michael Kazim, MD
2:55 pm Questions and Discussion
3 – 3:30 pm
Break with Exhibitors and Poster Stand By Session ASOPRS Fall Scientific Symposium Syllabus 9
Moderator: Robert G. Fante, MD, FACS
3:30 pm Direct Submentoplasty Combined with Limited-Incision Facelift for Male Lower Facial Rejuvenation
Tanuj Nakra1, Brett Kotlus2, Robert Schwarcz3, Jonathan Hoenig4. 1Texas Oculoplastic Consultants/ Toccare Medical Spa, Austin, TX,
United States, 2Allure Medical Spa, Shelby Township, MI, United States, 3Private Practice, New York, NY, United States, 4
Jules Stein Eye Institute/UCLA, Los Angeles, CA, United States
3:36 pm A Definitive Surgical Approach to Festoons
Bhupendra Patel. Facial Plastic Surgery, University of Utah, Salt Lake City, UT, United States
3:42 pm Central Platysmaplasty with a Bidirectional, Barbed Suture
Brett Kotlus1, Robert Schwarcz2, Tanuj Nakra3. 1Private practice, Shelby Twp, MI, United States, 2Private practice, NY, NY, United States, 3
Panel: Tanuj Nakra, MD, Bhupendra Patel, MD, Brett Kotlus, MD
Featured Speaker — Andrew Jacono, MD
3:55 pm Introduction of Dr. Andrew Jacono
Guy G. Massry, MD
3:58 pm A Structured Anatomic Approach to Face and Necklifting
Andrew Jacono, MD
Moderator: Eric M. Hink, MD
4:30 pm Trends in Pediatric Idiopathic Intracranial Hypertension (IIH): A Multicenter Study of Treatment Outcomes
Rebecca Shields1, Roberto Warman2, Wendy Lee1, Kara Cavuoto1. 1Ophthalmology, Bascom Palmer Eye Institute, Miami, FL,
United States, 2Ophthalmology, Miami Children’s Hospital, Miami, FL, United States
4:36 pm Surgical Outcomes in Pediatric Orbital Cellulitis
Jesse Smith1, M. Leslie Pfeiffer2, Brett Davies1, Emily Bratton1, Eric Hink1, Vikram Durairaj3. 1Ophthalmology, University of Colorado, Denver,
CO, United States, 2Ophthalmology, University of Texas, Houston, TX, United States, 3Oculofacial Plastic Surgery, Texas Oculoplastic
Consultants, Austin, TX, United States
4:42 pm Characteristics and Management of Tessier #3 Clefts
Peter Bin-yu Xie1, Bradford W. Lee2, Dongmei Li1, Jane S. Kim2, Bobby S. Korn2, Don O. Kikkawa2. 1Capital Medical University and Beijing
Ophthalmology Visual Science Key Lab, Beijing Tongren Eye Center, Beijing, China, 2Division of Ophthalmic Plastic and Reconstructive
Surgery, Department of Ophthalmology, UC San Diego Shiley Eye Center, La Jolla, CA, United States
4:48 pm Use of a Double Triangle Silicone Sling for Early Repair in Congenital Ptosis
Karen Revere, Maryam Nazemzadeh, William Katowitz, James Katowitz. Ophthalmology, The Children’s Hospital of Philadelphia,
Philadelphia, PA, United States
Panel: Rebecca Shields, MD, Jesse Smith, MD, Peter Bin-yu Xie, MD, Karen Revere, MD
5 pm
Adjourn
5 pm
Program at a Glance – Friday, October 17, 2014
6 am – 5 pm
Registration (Chicago Promenade)
7 – 8 am
YASOPRS Eye Openers – Rapid Fire Cases and Presentations (Chicago Ballroom)
7 – 8 am
Breakfast with Exhibitors (River Exposition Hall)
7 am – 2:50 pm
Scientific Posters and Videos (River Exposition Hall)
YASOPRS Eye Openers – Rapid Fire Cases and Presentations
Sponsored By: Young ASOPRS (YASOPRS). YASOPRS are defined as ASOPRS members, age 40 or less.
Moderators: Pete Setabutr, MD, Christina Choe, MD
7:00 am Intralesional Rituximab: An Effective Therapeutic Alternative for Recurrent Orbital Lymphoma in a Patient with
Severe Dry Eye
Courtney Kauh, Victor Elner, Hakan Demirci. Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center,
Ann Arbor, MI, United States
7:04 am Quantified Incision Placement for Transconjunctival Blepharoplasty with Retroseptal Fat Entry
Cesar Briceno1, Satyen Undavia2, Guy Massry3. 1Ophthalmology, Kellogg Eye Center, Ann Arbor, MI, United States, 2Facial Plastic Surgery,
Spalding Drive Cosmetic Surgery and Dermatology, Beverly Hills, CA, United States, 3Ophthalmic Plastic Surgery, Beverly Hills Ophthalmic
Plastic Surgery, Beverly Hills, CA, United States
7:08 am Combined Endoscopic Endonasal Transorbital Approach with Transconjunctival Medial Orbitotomy for Orbital Tumor
Excision: Our Experience and Technique
Lisa Chen, Tarek El-Sawy, Andrea Kossler. Ophthalmology, Byers Eye Institute at Stanford, Palo Alto, CA, United States
7:12 am One Stage Hughes Flap
Erin Lessner1, Alexander Blandford2, Anthony Greer2, Alan Lessner2. 1Ophthalmology, University of South Carolina, Columbia, SC,
United States, 2Ophthalmology, University of Florida, Gainesville, FL, United States
7:16 am Acellular Dermal Matrix-supported Modified Tenzel Flap for Reconstruction of Large Lower Eyelid Defects
Pradeep Mettu1,3, Andrew Munro2,3, Parag Gandhi2,3. 1Duke Eye Center, Durham, NC, United States, 2Duke Eye Center of Winston-Salem,
Winston-Salem, NC, United States, 3Duke University School of Medicine, Durham, NC, United States
7:20 am Granulocytic Sarcoma of the Orbit Presenting as a Fulminant Orbitopathy in an Adult with Acute Myeloid Leukemia
Ali Mokhtarzadeh1, Andrew Harrison1,2. 1Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN,
United States, 2Otolaryngology, University of Minnesota, Minneapolis, MN, United States
7:24 am Intralesional Clindamycin Injections for the Treatment of Necrotizing Fasciitis
Payam Morgan, Catherine Hwang, Robert A. Goldberg. Ophthalmology, UCLA, Los Angeles, CA, United States
7:28 am MRI Findings of Non-Specific Orbital Inflammation (NSOI) of the Optic Nerve in a Child
Carisa Petris, Payal Patel, Michael Kazim. Ophthalmology, Columbia University College of Physicians and Surgeons, New York, NY,
United States
7:32 am Cosmetic Hyaluronic Acid Injection: Delayed Periocular Edema as an Uncommon Complication
Sherveen Salek, Jessica Chang, Jordan Piluek, Charles Eberhart, Timothy McCulley. Wilmer Eye Institute, Johns Hopkins Hospital,
Baltimore, MD, United States
7:36 am Mutational Landscape of Lacrimal Gland Carcinomas and Implications for Treatment
Matthew Sniegowski1, Diana Bell2, Khalida Wani1, Michael Tetzlaff2, Kenneth Aldape2, Bita Esmaeli1. 1Orbital Oncology and Ophthalmic Plastic
Surgery Program, Department of Plastic Surgery, University of Texas MD Anderson, Houston, TX, United States, 2Department of Pathology,
University of Texas MD Anderson, Houston, TX, United States
7:40 am Impaled Orbital Taser Injury
Jenny Temnogorod1, Frank Tsai1, Tanuj Nakra2, Roman Shinder1,2. 1Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY,
Program at a Glance – Friday, October 17, 2014, continued
7:44 am Changes in Intracocular Pressure During Orbital Floor Fracture Repair
Preeti Thyparampil1, Michael Yen1, Phillip Freeman2, John Ng3, Jeremiah Tao4, Douglas Marx1. 1Ophthalmology, Baylor College of Medicine,
Houston, TX, United States, 2Oromaxillofacial Surgery, UT Houston Dental Branch, Houston, TX, United States, 3Ophthalmology, Oregon
Health & Sciences University, Portland, OR, United States, 4Ophthalmology, University of California Irvine, Irvine, CA, United States
7:48 am Differential Expression of Micrornas in Sebaceous Carcinoma of Eyelid Compared with Sebaceous Adenoma
Vivian T. Yin1, Michael T. Tetzlaff2, Jonathan Curry2, Khalida Wani2, Ganiraju C. Manyam3, Diana Bell2, Li Zhang3, Kenneth Aldape2, Bita
Esmaeli1. 1Orbital Oncology & Ophthalmic Plastic Surgery, Department of Plastic Surgery, University of Texas MD Anderson Cancer
Center, Houston, TX, United States, 2Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, United
States, 3Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
7:52 am Neuroendocrine (Carcinoid) Tumor Metastasis to the Extraocular Muscles: Variability in Presentation and Primary
Location
Sara Alshaker, Nariman Nassiri, Dan Rootman, Robert Goldberg. Division of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute,
David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, United States
GENERAL SESSION
8:00 am Welcome
Vikram D. Durairaj, MD, ASOPRS Program Co-Chair
Oncology Session
Moderator: Jonathan W. Kim, MD
8:02 am Globe Sparing Surgery and Post-operative high-dose Radiation Therapy for Lacrimal Gland Carcinoma
Bita Esmaeli1, Vivian Yin1, Ehab Hanna2, Merrill Kies3, William William3, Diana Bell4, Steven Frank5. 1Orbital Oncology & Ophthalmic Plastic
Surgery Program, MD Anderson Cancer Center, Houston, TX, United States, 2Head and Neck Surgery Department, MD Anderson Cancer
Center, Houston, TX, United States, 3Head and Neck Medical Oncology Department, MD Anderson Cancer Center, Houston, TX, United
States, 4Radiation Oncology Department, MD Anderson Cancer Center, Houston, TX, United States
8:08 am Systemic Rituximab Therapy for Ocular Adnexal Mucosal-Associated Lymphoid Tissue (MALT) Lymphoma
Hakan Demirci1, Brian Marr2, Victor Elner1. 1Ophthalmology and Visual Sciences, University of Michigan, W.K. Kellogg Eye Center, Ann
Arbor, MI, United States, 2Ophthalmic Oncology, Memorial Sloan-Kettering, New York, NY, United States
8:14 am Primary Periocular Sweat-Gland Carcinomas: Epidemiology and Prognosis
Meredith Baker1, Vivian Yin2, Doina Ivan3, Bita Esmaeli2, Erin Shriver1. 1Department of Ophthalmology, University of Iowa, Iowa City, IA,
United States, 2Orbital Oncology & Ophthalmic Plastic Surgery, Department of Plastic Surgery, University of Texas MD Anderson Cancer
Center, Houston, TX, United States, 3Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
8:20 am Periocular Melanoma in-situ Treated with Imiquimod
Maxwell Elia1, Sara Lally2, Krishna Kalyam1, Shabnam Pakneshan1, Mark Fisher3, Caleb Ho4, John Sinard1,4, Allison Hanlon5, Jennifer Choi5,
Gary Lelli6, Juan Servat7, Jerry Shields2, Carol Shields2, Flora Levin1. 1Ophthalmology and Visual Sciences, Yale University School
of Medicine, New Haven, CT, United States, 2Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, United States, 3School of
Medicine, Johns Hopkins University, Baltimore, MD, United States, 4Pathology, Yale University School of Medicine, New Haven, CT,
United States, 5Dermatology, Yale University School of Medicine, New Haven, CT, United States, 6Ophthalmology, Weill Cornell Medical
College, New York, NY, United States, 7Oculofacial Plastic Surgeons of Georgia, Atlanta, GA, United States
8:26 am Targeting the Hedgehog Pathway in Patients with Periorbital Locally Advanced Basal Cell Carcinoma or Basal Cell
Nevus Syndrome
Bita Esmaeli1, Viivan Yin1, Eva Chou1, William William2, Merrill Kies2, Michael Migden3. 1Orbital Oncology & Ophthalmic Plastic Surgery
Program, MD Anderson Cancer Center, Houston, TX, United States, 2Head and Neck Medical Oncology Department, MD Anderson Cancer
Center, Houston, TX, United States, 3Dermatology Department, MD Anderson Cancer Center, Houston, TX, United States
Panel: Bita Esmaeli, MD, Hakan Demirci, MD, Meredith Baker, MD, Maxwell Elia, MD
Henry Baylis Cosmetic Surgery Award Lecture
8:40 am Introduction of the Henry I. Baylis Award Lecturer: Dr. Guy Massy
Roberta E. Gausas, MD
8:45 am A Personal Perspective on Treating the Eyelids and Periorbita with Injectable Hyaluronic Acid Gels
Guy G. Massry, MD
9:25 am Henry I. Baylis Award Presentation
9:30 – 10 AM
Break with Exhibitors and Poster Stand By Session Lacrimal Session
Moderator: John D. Ng, MD, MS, FACS
10:00 am Surgical and Epidemiologic Factors Affecting Canalicular Laceration Repair with the Mini Monoka Monocanalicular Stent
Blair Armstrong1, Michael Rabinowitz2, Brianna Kenney3, Robert Penne2. 1Ophthalmology Residency, Wills Eye Hospital, Philadelphia, PA,
United States, 2Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, PA, United States, 3Department of Research,
Wills Eye Hospital, Philadelphia, PA, United States
10:06 am Bicanalicular Silicone Intubation with Intra-Lacrimal Sac Fixation Suture For Punctal and Canalicular Stenosis
Kasra Eliasieh, Jessica Chang, Nicholas Mahoney, Michael Grant, Shannath Merbs. Ophthalmology, Wilmer Eye Institute, Johns Hopkins
Hospital, Baltimore, MD, United States
10:12 am Computed Tomographic Findings Can Discriminate Lacrimal Sac Malignancies from Dacryocystitis
Pimkwan Jaru-ampornpan1, Tabassum Kennedy2, Cat Burkat1, Mark Lucarelli1. 1Ophthalmology and Visual Sciences, University of Wisconsin,
Madison, WI, United States, 2Radiology, University of Wisconsin, Madison, WI, United States
10:18 am Technique and Success Rate of Transcanalicular Endoscopic Lacrimal Duct Recanalization (TELDR) with
Silicone Intubation
Reynaldo M. Javate, M.D., F.I.C.S., Armida L. Suller, M.D., Kathleen Faye N. Buyucan, M.D., Elise Estelle T. Ma. Guerrero, M.D.,
Kristina C. Teope, M.D. Department of Ophthalmology, University of Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines
10:24 am Tear Trough Incision for External Dacryocystorhinostomy
Brett W. Davies1, Michael S. McCracken2, Michael J. Hawes3, Eric M. Hink1, Vikram D. Durairaj1, 4, Ron W. Pelton5. 1Ophthalmology,
1
Oculofacial Plastic and Orbital Surgery, Aurora, CO, United States, 2McCracken Eye and Face Institute, Parker, CO, United States, 3
Michael J. Hawes, MD, Denver, CO, United States, 4Texas Oculoplastic Consultants, Austin, TX, United States, 5Ronald W. Pelton, MD,
Colorado Springs, CO, United States
Panel: Blair Armstrong, MD, Kasra Eliasieh, MD, Pimkwan Jaru-ampornpan, MD, Reynaldo M.Javate, MD, FICS, Ron W. Pelton, MD
Eyelid Session II
Moderator: Tanuj Nakra, MD
10:40 am Anatomy and Histology of the Frontalis Muscle
Bryan Costin1, Thomas Plesec2, Natta Sakolsatayadorn3, Tal Rubinstein1, Jennifer McBride4, Julian Perry1. 1Cole Eye Institute,
Cleveland Clinic, Cleveland, OH, United States, 2Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, United
States, 3Department of Ophthalmology, Medicine Siriraj Hospital, Bangkok, Thailand, 4Department of Anatomy, Cleveland Clinic,
Cleveland, OH, United States
10:46 am Stop Blaming the Septum
Robert Schwarcz1, John Fezza2, Andrew Jacono3, Guy Massry4. 1Ophthalmic Plastic Surgery, Robert Schwarcz MD, New York, NY,
United States, 2Ophthlamic Plastic Surgery, Center For Sight, Venice, FL, United States, 3Facial Plastic Surgery, New York Center For Facial
Plastic And Laser Surgery, New York, NY, United States, 4Ophthalmic Plastic Surgery, Beverly Hills Ophthalmic Plastic Surgery, Beverly Hills,
CA, United States
10:52 am The Beauty of the Crease: Cosmetic Eyelid Crease Elevation to Enhance the Aesthetics of the Brow-Eyelid Continuum
Abraham Gomez1, Geoffrey Gladstone1,2. 1Consultants in Ophthalmic and Facial Plastic Surgery, Southfield, MI, United States,
2
Ophthalmology, Oakland University, Beaumont Hospital, Royal Oak, MI, United States
10:58 am A Novel At-Home Procedure Providing Marked Improvements for Lower Lid Aesthetics Utilizing a Tensile, Elastic,
Non-Invasive Polymer System with In-Situ Cross-Linking Functionality
Brian Biesman1, Zoe Draelos2, R. Rox Anderson3, Patricia Farris4, Derek Jones5, Doris Day6, Steven Dayan7, Fernanda Sakamoto3,
Soo-young Kang8, Barbara Gilchrest9, Betty Yu8. 1Nashville Centre for Laser and Facial Surgery, Nashville, TN, United States, 2
Dermatology, Duke University Medical Center, Durham, NC, United States, 3Dermatology, Harvard Medical School, Boston, MA,
United States, 4Dermatology, Tulane University Medical Center, New Orleans, LA, United States, 5Dermatology, David Geffen School of
Medicine, University of California, Los Angeles, Los Angeles, CA, United States, 6Dermatology, New York University Medical Center,
New York, NY, United States, 7Otolaryngology, University of Illinois Hospital and Clinics, Chicago, IL, United States, 8LivingProof, Inc,
Cambridge, MA, United States, 9Dermatology, Boston University School of Medicine, Boston, MA, United States
Panel: Bryan Costin, MD, Robert Schwarcz, MD, Abraham Gomez, MD, Brian Biesman, MD
11:15 am An Algorhythmic Multi-Modality Approach to the Devolumized Lower Eyelid
Andrew Jacono, MD
12 – 1 pm Lunch (River Exposition Hall)
Orbit Session II
Moderator: Suzanne K. Freitag, MD
1:00 pm Symmetry of the Angle of the Orbital Strut (AOS) – A Radiological Study
Raghuraj Hegde1, Gangadhara Sundar1, Eric Ting2, Thiam Chye Lim3, Michael Grant4. 1Ophthalmology, National University Hospital,
Singapore, Singapore, 2Radiology, National University Hospital, Singapore, Singapore, 3Plastic and Aesthetic Surgery, National University
Hospital, Singapore, Singapore, 4Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, United States
1:06 pm Axial Globe Position Measurement: A Prospective Multi-center Study Sponsored by the International Thyroid Eye
Disease Society
Chad Bingham1, Jennifer Sivak-Callcott1, Mathew Gurka2, John Nguyen1, Steve Feldon3, Aaron Fay4, Lay-Leng Seah5, Diego Strianese6,
Vikram Durairaj7, Jimmy Uddin8, Martin Devoto9, Matheson Harris1, Justin Saunders1, Audrey Looi5, Livia Teo5, Michale Kazim10.
1
West Virginia University, Morgantown, WV, United States, 2Biostatistics, West Virginia University, Morgantown, WV, United States, 3
Univ of Rochester, Rochester, NY, United States, 4Harvard University, Boston, MA, United States, 5Singapore National Eye Centre,
Singapore, Singapore, 6Univeristy Federico II, Naples, Italy, 7Texas Oculoplastic Consultants, Austin, TX, United States, 8
Moorefields Eye Hospital, London, United Kingdom, 9Consultores Oftalmologicos, Buenos Aires, Argentina, 10Columbia University,
1:12 pm Lateral Rectus Muscle Expands More than Medial Rectus Following Maximal Deep Balanced Orbital Decompression
Sara Alshaker1, Alex Nobori1, Dan Rootman1, Robert Goldberg1, Yi Wang2. 1Department of Orbital and Ophthalmic Plastic Surgery, Jules Stein
Eye Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, United States, 2Institute of Orbital
Diseases, Armed Police General Hospital, Beijing, China
1:18 pm Dilated Superior Ophthalmic Vein: Features of 113 Cases
Jenny Temnogorod1, Christopher Adam1, Carol Shields2, Joon Kim3, Brent Hayek3, Flora Levin4, Bryan Winn5, Ivan Vrcek6, Craig
Linden7, Christina Choe8, Mithra Gonzalez9, Johanna Fifi10, Alejandro Berenstein10, Vikram Durairaj11, Tanuj Nakra11, Roman Shinder1,11.
1
Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, United States, 2Ocular Oncology, Wills Eye Institute, Philadelphia, PA,
United States, 3Ophthalmology, Emory University Hospital, Atlanta, GA, United States, 4Yale University School of Medicine, New Haven,
CT, United States, 5Columbia University Harkness Eye Institute, New York, NY, United States, 6UT Southwestern Medical Center, Dallas, TX,
United States, 7Radiology, SUNY Downstate Medical Center, Brooklyn, NY, United States, 8Carolina Ophthalmology, Asheville, NC, United
States, 9University of Rochester Flaum Eye Institute, Rochester, NY, United States, 10Hyman Newman Institute for Neurology and Neurosurgery,
Mt. Sinai-Roosevelt Hospital, New York, NY, United States, 11Texas Oculoplastic Consultants, Austin, TX, United States
1:24 pm Intracranial Hypotension Related Skull Remodeling With Enophthalmos and Sphenoid Sinus Expansion
Timthy McCulley1, Jordan Piluek1, Jesica Chang1, Thomas Hwang2. 1Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD,
United States, 2Ophthalmology, Stanford University School of Medicine, Stanford, CA, United States
Panel: Raghuraj Hegde, MD, Chad Bingham, MD, Sara Alshaker, MD, Jenny Temnogorod, MD, Timothy McCulley, MD
Featured Speaker — Suresh Mukherji, MD, MBA, FACR
1:40 pm Introduction of Dr. Suresh Mukherji
Alon Kahana, MD
1:43 pm Imaging of the Orbit and Globe
Suresh Mukherji, MD, MBA, FACR
2:20 – 2:50 pm
Break with Exhibitors and Poster Stand By Session Eyelid Session III
Moderator: Sean M. Blaydon, MD, FACS
2:50 pm The Abbreviated National Eye Institute Visual Function Questionnaire (NEI VFQ 9) is a Sensitive and Time Efficient
Method for Detecting the Changes in Visual Function Caused by Blepharoptosis and Dermatochalasis and Their Surgical
Correction
César A. Briceño1, Molly L. Fuller2, Elizabeth A. Bradley2, Christine C. Nelson1. 1Ophthalmology, Kellogg Eye Center, University of Michigan,
Ann Arbor, MI, United States, 2Ophthalmology, Mayo Clinic, Rochester, MN, United States
2:56 pm Lid Crease Approach for Margin Rotation in Upper Cicatricial Entropion
Antonio Cruz1,2,3, Patricia Akaishi1,2, Mohammed Dufaileej2, Alicia Galindo2. 1Ophthalmology, School of Medicine of Ribeirao Preto,
RIBEIRAO PRETO, Brazil, 2King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, 3Wilmer Institute, Johns Hopkins University,
3:02 pm Upper Eyelid Myectomy for Essential Blepharospasm: Cost Benefit Analysis to the US Medicare System
Tiffany Kent1,2, Carisa Petris3, John Holds2,4. 1Ophthalmology, Washington University School of Medicine, St. Louis, MO, United
States, 2Ophthalmic Plastic and Cosmetic Surgery, Inc., Des Peres, MO, United States, 3Ophthalmology, Columbia university College of
Physicians and Surgeons, New York, NY, United States, 4Ophthalmology and Otolaryngology/Head and Neck surgery, Saint Louis University
School of Medicine, St. Louis, MO, United States
3:08 pm Conjunctiva-Sparing Modification to Posterior Approach Ptosis Repair
Ivan Vrcek, Ronald Mancini. Department of Ophthalmology, UT Southwestern Medical Center at Dallas, Dallas, TX, United States
3:14 pm The Versatility of the Lateral Tarsoconjunctival Onlay Flap
Swapna Vemuri, Amy Patel, Jeremiah Tao. University of California - Irvine, Gavin Herbert Eye Institute, University of California - Irvine,
3:20 pm Medial Anchoring of the Upper Eyelid Skin During Blepharoplasty
Fatemeh Rajaii, Victor Elner. Kellogg Eye Center, University of Michigan, Ann Arbor, MI, United States
3:26 pm Upper Eyelid Skin Contracture in Facial Paralysis
Kimia Ziahosseini1, Vanessa Venables 2, Charles Nduka3, Raman Malhotra1. 1Corneoplastic Unit, Queen Victoria Hospital, East Grinstead,
United Kingdom, 2Department of Physiotherapy, Queen Victoria Hospital, East Grinstead, United Kingdom, 3Department of Plastic Surgery,
Queen Victoria Hospital, East Grinstead, United Kingdom
Panel: César A. Briceño, MD, Antonio Cruz, MD, Tiffany Kent, MD, Ivan Vrcek, MD, Swapna Vemuri, MD, Fatemeh Rajaii, MD,
Kimia Ziahosseini, MD
Orbit Session III
Moderator: Timothy J. McCulley, MD
3:45 pm Orbital and Periorbital Extension of Congenital Dacryocystoceles
Francesco Bernardini1, Altug Cetinkaya2, James Katowitz3, Pelin Kaynak4. 1Oculoplastica Bernardini, Genova, Italy, 2
Ophthalmology, Dunyagoz Ankara Hastanesi, Ankara, Turkey, 3Ophthalmology, The Children’s Hospital of Philadelphia,
Philadelphia, PA, United States, 4Ophthalmology, Istanbul Beyoğlu Eye Research Hospital, Istanbul, Turkey
3:51 pm Radiation Exposure from Orbital CT Scans – Spiral vs Traditional Scans
Tiffany Kent, Philip Custer. Ophthalmology, Washington University, St. Louis, MO, United States
3:57 pm Efficacy of Intravenous Mannitol as an Adjunct to Lateral Canthotomy and Cantholysis in the Management of Orbital
Compartment Syndrome; A Non-Human Primate Model
Davin Johnson1, Andrew Winterborn2, Vladimir Kratky1. 1Department of Ophthalmology, Queen’s University, Kingston, ON, Canada, 2
Office of the University Veterinarian, Queen’s University, Kingston, ON, Canada
4:03 pm A Four Year Retrospective Review of Space Occupying Lesions of the Orbit
Alina V Dumitrescu1, Anna W Berry1, William R Nunery2, Jason A Sokol1. 1Department of Ophthalmology, Kansas University Medical Center,
Kansas City, KS, United States, 2Department of Ophthalmology, University of Louisville, Louisville, KY, United States
4:09 pm Orbital Exenteration: The 10-year Massachusetts Eye and Ear Infirmary Experience
Sonali Nagendran1, N. Grace Lee2, Aaron Fay2, Daniel Lefebvre2, Francis Sutula2, Suzanne Freitag2. 1Department of Ophthalmology, Frimley
Park Hospital, Frimley, United Kingdom, 2Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
4:15 pm ITEDS Update
Mark J. Lucarelli, MD, Peter Dolman, MD
Panel: Francesco Bernardini, MD, Tiffany Kent, MD, Davin Johnson, MD, Alina Dumitrescu, MD, Sonali Nagendran, MD,
Mark J. Lucarelli, MD
Moderators: Michael T. Yen, MD, Roberta E. Gausas, MD
4:30 pm Clinical and Immunohistochemical Features of Conjunctival Melanocytic Lesions
Harsha S. Reddy, MD
4:35 pm Patterns of Strabismus Following Orbital Decompression in Thyroid Eye Disease
Katherine M. Whipple, MD
4:40 pm In Vivo Imaging of a Novel Mouse Model of Filler Induced Tissue Necrosis
Michael C. Chappell, MD
Moderator: Michael T. Yen, MD
Panel: Harsha S. Reddy, MD, Katherine M. Whipple, MD, Michael C. Chappell, MD
4:50 pm Marvin H. Quickert Thesis Award Presentation
Michael T. Yen, MD
4:55 pm ASOPRS Awards Presentations
Roberta E. Gausas, MD, Chair, ASOPRS Awards Committee
Bartley R. Frueh Award for Best YASOPRS Presentation
Robert H. Kennedy Presidential Award (presented by Don O. Kikkawa, MD, FACS, ASOPRS President)
5 pm
Adjourn
5 – 6 pm
ASOPRS Business Meeting & International Associate New Member Inductions
Chicago Ballroom
(All members are invited and encouraged to attend the Business Meeting)
Thank you for joining us!
Program at a Glance – Thursday Posters
NEW THIS YEAR: ASOPRS Poster Stand By Sessions Please be sure to take the opportunity to visit the posters
during the morning and afternoon breaks (even numbered posters in the morning, odd numbered posters in the afternoon) to
meet the authors, ask questions and get more information about their research. The Poster Stand By Sessions will be held in River
Exposition Hall and posters are unique each day so be sure to visit during both sessions on Thursday and Friday.
T1
A Novel Modification to the Hughes Tarsoconjunctival
Flap for a Challenging Case of Recurrent Lower Eyelid Retraction
Andrew Anzeljc, Justin Saunders, Ted Wojno. Department of Ophthalmology,
Emory University School of Medicine, Atlanta, GA, United States
T2
Retrospective Chart Review of the Use of Imaging and Biopsy
in the Diagnosis of Optic Nerve Sheath Meningiomas and Nerve
Involving Orbital Lymphomas
Anna Berry1, Alina Dumitrescu1, William Nunery2, Jason Sokol1.
1
Ophthalmology, KUMC, Prairie Village, KS, United States, 2
Ophthalmology, University of Louisville, Louisville, KY, United States
T3
Deep Lateral Wall Orbital Decompression Following Strabismus
Surgery in Patients with Type II Graves Orbitopathy
Emily Broxterman1, Alan Hromas1, Jason Sokol1, William Nunery2, Thomas
Whittaker1. 1Dept of Ophthalmology, University of Kansas Medical Center,
Kansas City, KS, United States, 2Dept of Ophthalmology, University of
Louisville, Louisville, KY, United States
T4
Malignant Rhabdoid Tumor of the Orbit
Alison Callahan, Frederick Jakobiec, Grace Lee, Arthur Grove, Suzanne
Freitag. Ophthalmology, Harvard Medical School, Boston, MA, United States
T5
Demographics, Etiology, and Management of Allergic Blepharitis
Smith Ann Chisholm, Steven Couch, Philip Custer. Ophthalmology,
Washington University in St. Louis, Saint Louis, MO, United States
T6
Primary Signet Ring Cell Carcinoma of the Eyelid: A Case
Report and Review of Literature
Rao Chundury MD MBA, Alexander D’Angelo MS, Gabriela Espinoza MD.
Ophthalmology, St. Louis University, St. Louis, MO, United States
T7
Recession and Extirpation of the Lower Lid Retractors
for Paralytic Lagophthalmos
Christopher Compton1,2, Hui Bae Lee2. 1Ophthalmology, Oculofacial
Plastic and Orbital Surgery, University of Louisville, Louisville, KY,
United States, 2Ophthalmology, Oculofacial Plastic and Orbital Surgery,
Indiana University, Indianapolis, IN, United States
T8
Treating Buccinator with Botulinum Toxin in Patients
with Facial Synkinesis — A Previously Overlooked Target
Jacqueline Diels, OT1, Leslie A Wei, MD2, Mark J Lucarelli, MD, FACS2.
1
Neuromuscular Retraining Clinic, University of Wisconsin - Madison,
Madison, WI, United States, 2Oculoplastic, Facial Cosmetic, & Orbital
Surgery, University of Wisconsin - Madison, Madison,
WI, United States
T9
Anesthetic Device Reduces Pain Perception for Subcutaneous
Injections and Ophthalmologic Lasers
Shenoda Elmaseh1, Ed Siu1, Mike Song1, Trisa Palmares2, Julia Song2,
Alice Song1. 1Ophthalmology, Long Beach Memorial Hospital, Long
Beach, CA, United States, 2Ophthalmology, Huntington Memorial Hospital,
Pasadena, CA, United States
T10
A Low Cost Ocular Prosthesis Using 3-Dimensional Printing
Benjamin Erickson1, Daniel Chao1, Landon Grace2, Mauro Fittipaldi2,
Wendy Lee1. 1Bascom Palmer Eye Institute, University of Miami, Miami,
FL, United States, 2Mechanical and Aerospace Engineering Department,
University of Miami, Coral Gables, FL, United States
T11
The J-Curve for Navigating the Nasolacrimal Outflow Tract
Katie Finnerty1, Ronald Mancini2. 1Ophthalmology, University of Texas
Southwestern, Dallas, TX, United States, 2Ophthalmology, University
of Texas Southwestern, Dallas, TX, United States
T12
Tangent Visual Fields are a Precise, Time and Cost Efficient
Method for Detecting the Changes in Superior Visual Field
Caused By Blepharoptosis and Dermatochalasis and Their
Surgical Correction
Molly Fuller1,2, César Briceño1, Elizabeth Bradley2, Christine Nelson1.
1
Ophthalmology, Kellogg Eye Center, University of Michigan,
Ann Arbor, MI, United States, 2Ophthalmology, Mayo Clinic,
Rochester, MN, United States
T13
Eccrine Porocarcinoma of the Eyelid Masquerading
as Basal Cell Carcinoma
Laura Gadzala MD, Allison Bardes MD, John Nguyen MD,
Jennifer Sivak-Callcott MD. Ophthalmology, West Virginia
University, Morgantown, WV, United States
T14
A Newly Identified Syndrome of Multiple Facial Clefts
Ron Gutmark, W Jordan Piluek, Timothy J. McCulley.
Ophthalmology, The Wilmer Eye Institute, Johns Hopkins
University School of Medicine, Baltimore, MD, United States
T15
A Unique Presentation of Adult-Onset Xanthogranuloma
Cristos Ifantides1, Alan Friedman1, James Strauchen2, Albert Wu1.
1
Ophthalmology, Icahn School of Medicine at Mount Sinai, New York,
NY, United States, 2Pathology, Icahn School of Medicine at Mount Sinai,
T16
Canalicular Injury Associated with Dog Bites in the
Pediatric Population
Krishna Kalyam1, Javier Servat2, Roman Shinder3, Reshma Mehendale3,
Gary Lelli5, Jose-Luis Tovilla4, Flora Levin1. 1Ophthalmology, Department
of Ophthalmology and Visual Science, Yale University School of Medicine,
New Haven, CT, United States, 2Ophthalmology, Oculofacial Plastic Surgeons,
Macon, GA, United States, 3Ophthalmology, SUNY Downstate Medical Center,
Brooklyn, NY, United States, 4Ophthalmology, Institute of Ophthalmology,
Mexico City, Mexico, 5Ophthalmology, New York-Presbyterian Hospital,
Weill Cornell Medical College, New York, United States
T17
Periocular Changes associated with Six Months of Topical
Bimatoprost in the Rabbit
Tiffany Kent, Philip Custer. Ophthalmology, Washington University,
St. Louis, MO, United States
T18
Sling Revision for Undercorrection after Frontalis Sling Operation
Ju-Hyang Lee, Jisang Han, Yoon-Duck Kim, Kyung In Woo. Ophthalmology,
Samsung Medical Center, Sungkyunkwan University School of Medicine,
Seoul, Korea
Program at a Glance – Thursday Posters, continued
T19
The Orbital Strut Revisited: Anatomic Definition and
Computer-Assisted Volumetric Analysis of Boney Volume
Jennifer Lira, Carisa Petris, Joyce Khandji, Alexander Khandji, Michael
Kazim. Department of Ophthalmology, Columbia University Medical Center,
New York-Presbyterian Hospital, New York, NY, United States
T20
Spindle Cell Lipoma of the Orbit
Amina Malik1, Jeffrey Nerad2. 1Cincinnati Eye Institute, Cincinnati, OH,
United States, 2Ophthalmology, University of Cincinnati, Cincinnati, OH,
United States
T21
Corneal Topography With Upper Eyelid Platinum Chain
Implantation Using The Pretarsal Fixation Technique
Ioannis Mavrikakis1, Efstathios Detorakis2, Stefanos Baltatzis3,
Ioannis Yiotakis 4, Dimitrios Kandiloros4. 1Athens Eye Hospital,
Athens, Greece, 2Department of Ophthalmology, University Hospital
of Heraklion, Heraklion, Greece, 3Department of Ophthalmology,
University of Athens, Athens, Greece, 4Department of Otolaryngology,
University of Athens, Athens, Greece
T22
T23
T24
T29
Ocular Trauma from Dog Bites: Characterization, Associations
and Treatment Patterns at a Regional Level I Trauma Center
Mark Prendes, Arash Jian-Amadi, Shu-Hong Chang, Solomon Shaftel.
Ophthalmology, University of Washington, Seattle, WA, United States
T30
Lower Lid Position Following Transconjunctival Incision
Kira Segal1, Payal Patel1, Ben Levine1, Richard Lisman2, Gary Lelli, Jr.1.
1
Ophthalmology, Weill Cornell Medical Center, New York, NY,
United States, 2Ophthalmology, NYU Langone Medical Center,
T31
Final Diagnosis in Headache Patients Following Temporal
Artery Biopsy
Marie Somogyi, Sarah Hale, David Yoo, Yasmin Shayesteh.
Ophthalmology, Loyola University Medical Center, Maywood, IL,
United States
T32
Pseudomonas Aeruginosa Sinusitis Causing Orbital Apex
Syndrome: A Case Series
Marie Somogyi, Yasmin Shayesteh. Ophthalmology, Loyola
University Medical Center, Maywood, IL, United States
T33
Orbital Malignant Melanoma Arising in a Phthisical Eye
James Murphy, Valerie Elmalem. Ophthalmology, SUNY
Downstate Medical Center, Brooklyn, NY, United States
Use of Goniometer in Orbital Reconstruction
Gangadhara Sundar1, Thiam Chye Lim2, Raghuraj Hegde1,
Michael Grant3. 1Ophthalmology, National University Hospital,
Singapore, Singapore, 2Plastic and Aesthetic Surgery, National University
Hospital, Singapore, Singapore, 3Ophthalmology, Johns Hopkins School
of Medicine, Baltimore, MD, United States
T34
Surgical Management of Orbital Arteriovenous Malformation:
Case Report and Literature Review
David Myung, Andrea Kossler, Lisa Chen. Ophthalmology,
Byers Eye Institute at Stanford, Palo Alto, CA, United States
Evaluation of Non-Ablative Laser for Treatment of Direct
Brow Lift Scars
Phillip Tenzel, Ben Erickson, Wendy Lee, Sara Wester. Ophthalmology,
Bascom Palmer Eye Institute, Miami, FL, United States
T35
Unique Presentation of Periorbital Dermatomyositis
Swapna Vemuri1, Kenneth Feldman2. 1Department of Ophthalmology,
Gavin Herbert Eye Institute, University of California - Irvine, Irvine, CA,
United States, 2Department of Ophthalmology, Kaiser Permanente South
Bay, Harbor City, CA, United States
T36
The Role of the Cavitron Ultrasonic Surgical Aspirator in the
Resection Of Combined Intracranial And Orbital Neoplasms
Edward Wladis, Tyler Kenning. Lions Eye Institute, Department of
Ophthalmology, Albany Medical College, Ophthalmic Plastic Surgery,
Albany, NY, United States
T37
Suggestion of Optimal Response Criteria in Patients
with Ocular Adnexal Mucosa Associated Lymphoid
Tissue Lymphoma
Suk Woo Yang1, Won Mo Lee2, Su kyung Jung1. 1Ophthalmology,
St. Mary’s hospital, Seoul, South Korea, 2Ophthalmology,
St. Mary’s eye clinic, Daejon, South Korea
Demonstrating the Ischemic Effects of Intra-arterial
Hyaluronic Acid Gel Injection Using Indocyanine Green (ICG)
in An Animal Model
Payam Morgan1, Holly Chang2, Aline Pimentel1, Catherine Hwang1.
1
Ophthalmology, UCLA, Los Angeles, CA, United States, 2
Ophthalmology, UW, Seattle, WA, United States
T25
Recurrent Malignant Meningioma of the Ethmoid Sinus:
Case Study and Literature Review
Leslie Neems, Chambers Christopher. Ophthalmology,
Northwestern University, Chicago, IL, United States
T26
Imiquimod 5% Cream for the Treatment of Periocular Lesions:
Two Case Reports
Gamze Ozturk Karabulut1, Pelin Kaynak1, Can Ozturker1, Korhan Fazil1,
Altug Cetinkaya2, Ahmet Demirok1, Omer Faruk Yilmaz1. 1OPRS,
Beyoglu Eye Research And Training Hospital, Istanbul, Turkey, 2
OPRS, Dunyagoz Ankara Hospital, Ankara, Turkey
T27
T28
Face and Neck Rejuvenation Using a Novel Radiofrequency
Device (Thermi RF): Initial Treatment Guidelines to Maximize
Outcomes and Minimize Adverse Events
Payal Patel1, Carisa Petris1, Joseph Eviatar1,2. 1Ophthalmology,
New York University Langone Medical Center, New York, NY,
United States, 2Ophthalmology, Chelsea Eye & Cosmetic Surgery
Associates, New York, NY, United States
Acquired Brown Syndrome After Filler Injection: A Case Report
Aline Pimentel de Miranda1, Daniel Rootman1, Nariman Nassiri1,
Joseph Demer2, Robert Goldberg1. 1Ophthalmology, Division of Orbital
and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, UCLA,
Los Angeles, CA, United States, 2Ophthalmology, Division of Pediatric
Ophthalmology and Strabismus, Jules Stein Eye Institute, UCLA,
Los Angeles, CA, United States
T38
Estrogen Increases Aquaporin-1 Mediated Membrane
Permeability: A New Pathophysiologic Mechanism for
Idiopathic Intracranial Hypertension
Marc Yonkers MD/PhD, Sarah Farukhi MD, Jim Hall PhD, Robert Crow
MD, Jeremiah Tao MD. Department of Ophthalmology, University of
California Irvine Gavin Herbert Eye Institute, Irvine, CA, United States
Program at a Glance – Friday Posters
NEW THIS YEAR: ASOPRS Poster Stand By Sessions Please be sure to take the opportunity to visit the posters
during the morning and afternoon breaks (even numbered posters in the morning, odd numbered posters in the afternoon) to
meet the authors, ask questions and get more information about their research. The Poster Stand By Sessions will be held in River
Exposition Hall and posters are unique each day so be sure to visit during both sessions on Thursday and Friday.
F1
F2
Long Term Follow up for Conjunctival Benign Reactive
Lymphoid Hyperplasia in Children
Adel Alsuhaibani1, Adel Al Akeely1, Hisham Alkhalidi2, Deepak Edward3,
Hind Al-Katan3. 1Ophthalmology department, King Saud University, Riyadh,
Saudi Arabia, 2Pathology department, King Saud University, Riyadh, Saudi
Arabia, 3King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
Review of Acellular Human Dermis (AlloDerm) Regenerative
Tissue Matrix in Multiple Types of Oculofacial Plastic &
Reconstructive Surgery
Brock Alonzo2, Youn-Shen Bee1, John Ng2. 1Kaohsiung Veterans General
Hospital, Kaohsiung, Taiwan, 2Casey Eye Institute, Oregon Health and
Science University, Portland, OR, United States
F3
Automated Ptosis Measurements from Facial Photographs
Zachary Bodnar, John Holds. Ophthalmology, St. Louis University,
St. Louis, MO, United States
F4
A Survey Of Current Blepharospam Treatment Patterns Among
Oculoplastic Surgeons
Talmage Broadbent, Ralph Wesley, Louise Mawn. Ophthalmology,
Vanderbilt Eye Institute, Nashville, TN, United States
F5
F6
F7
Sentinel Lymph Node Biopsy for Ocular
Adnexal Melanomas
Mary Champion1, John Neis2, Yelizaveta Shnayder2, William R. Nunery3,
Jason A. Sokol1. 1Oculofacial Plastic and Orbital Surgery, University of
Kansas, Prairie Village, KS, United States, 2Department of Otolaryngology,
University of Kansas, Kansas City, KS, United States, 3Department of
Surgical Outcomes of Deep Superior Sulcus Augmentation
Using Acellular Human Dermal Matrix In Anophthalmic
or Phthisis Socket
Won-Kyung Cho1,4, Ji-Sun Paik2,4, Won-Mo Lee3,, Suk-Woo Yang2,4.
1
Ophthalmology and Visual Science, Daejeon St. Mary’s Hospital, Daejeon,
Korea, 2Ophthalmology and Visual Science, Seoul St. Mary’s Hospital,
Seoul, Korea, 3Seung-Mo Eye Clinic, Daejeon, Korea, 4College of Medicine,
The Catholic University of Korea, Seoul, Korea
Margin Reflex Distance: Differences Based on Camera
and Flash Position
Catherine Choi1,2, Daniel Lefebvre1,2, Michael Yoon1,2.
1
Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary,
Boston, MA, United States, 2Ophthalmology, Harvard Medical School,
Boston, MA, United States
F8
Eyelid Sensation Distribution
Betsy Colón-Acevedo, Julie Woodward. Ophthalmology,
Duke University Eye Center, Durham, NC, United States
F9
Inflammatory Myofibroblastic Tumor of the Orbit
Lorena Di Nisio1, Raisa Abraham1, Daniel Weil 1, Martín H. Devoto2.
1
Ophthalmology, Hospital de Clínicas José de San Martín, Buenos
Aires, Argentina, 2Ophthalmology, Consultores Oftalmológicos,
Buenos Aires, Argentina
F10
The Doughnut Revisited: A Novel Cerclage For
Canalicular Repair
Benjamin Erickson, Sophie Liao, Wendy Lee. Bascom Palmer
Eye Institute, University of Miami, Miami, FL, United States
F11
Outcomes of Conjunctivodacryocystorhinostomy with
Metaireau Tube
Korhan Fazil1, Pelin Kaynak1, Can Ozturker1, Gamze Ozturk Karabulut1,
Altug Cetinkaya2, Ahmet Demirok1, Omer Faruk Yilmaz1. 1OPRS,
Beyoglu Eye Research Hospital, Istanbul, Turkey, 2OPRS, Dunyagoz
Ankara Hospital, Ankara, Turkey
F12
Normal Parameters of the Superior Ophthalmic Vein
Based on CT and MRI
Katie Finnerty1, Ankur Gupta1, Ronald Mancini1. 1Ophthalmology,
University of Texas Southwestern, Dallas, TX, United States, 2
School of Medicine, University of Texas Southwestern, Dallas, TX,
United States, 3Ophthalmology, University of Texas Southwestern,
Dallas, TX, United States
F13
Silent Sinus Syndrome and its Relation to Nasolacrimal
Duct Obstruction
Larissa K. Ghadiali1, Peter G. Coombs 2, Ashutosh Kacker3,
Gary J. Lelli2. 1Ophthalmology, New York Medical College, Valhalla, NY,
United States, 2Ophthalmology, Weill Cornell Medical College, New York,
NY, United States, 3Otolaryngology, Weill Cornell Medical College,
F14
Rapid Fabrication of Nanoclay-Reinforced Custom Orbital
Prosthesis Via 3-Dimensional Printing
Landon Grace1, Mauro Fittipaldi1, Kristoffer Winks2, David Tse3.
1
Mechanical and Aerospace Engineering, University of Miami, Coral
Gables, FL, United States, 2Biomedical Engineering, University of Miami,
Coral Gables, FL, United States, 3Department of Ophthalmology, University
of Miami Miller School of Medicine, Bascom Palmer Eye Institute, Miami,
FL, United States
F15
Long Term Outcomes of Globe Preserving Surgery for
Adenoid Cystic Carcinoma of the Lacrimal Gland
Jisang Han, Ju-Hyang Lee, Kyung In Woo, Yoon-Duck Kim.
Ophthalmology, Samsung Medical Center, Sungkyunkwan
University School of Medicine, Seoul, Korea
F16
Risk Factors for the Development of Optic Neuropathy in
Thyroid-Associated Orbitopathy
Chaitanya Indukuri, Ronald Mancini. Ophthalmology, UT Southwestern
Medical Center, Dallas, TX, United States
F17
Observer Impression of Patient Appearance Following Various
Methods Of Reconstruction After Orbital Exenteration
Justin Kuiper1, M. Bridget Zimmerman2, Keith Carter1, Richard Allen1,
Erin Shriver1. 1Ophthalmology, University of Iowa Hospitals and Clinics,
Iowa City, IA, United States, 2Biostatistics, University
of Iowa Hospitals and Clinics, Iowa City, IA, United States
Program at a Glance – Friday Posters, continued
F18
Infraorbital Nerve Enlargement in Idiopathic Orbital
Inflammatory Disease
Ka Hyun Lee, Chang Yeom Kim, Sang Yeul Lee, Jin Sook Yoon. Department
of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
F19
Managing Extensive Facial Cutaneous Malignancies in
Xeroderma Pigmentosum: Staged, Sub-total Facial Resurfacing
using Combination Split- and Full-thickness Skin Grafting
Bradford W. Lee, Bobby S. Korn, Don O. Kikkawa. Division of Oculofacial
Plastic and Reconstructive Surgery, University of California San Diego Shiley
Eye Center, La Jolla, CA, United States
F20
Efficacy of Lateral Orbital Rim Decompression in Patients with
Prior Rim-sparing, Three-wall Orbital Decompression
Bradford W. Lee, Jane S. Kim, Richard Scawn, Don O. Kikkawa, Bobby S.
Korn. Division of Oculofacial Plastic and Reconstructive Surgery, University
of California San Diego Shiley Eye Center, La Jolla, CA, United States
F21
Novel Genetic Mutations in Orbitoblepharophimosis Phenotype
Flora Levin1, Gary Lelli2, Deepak Narayan3. 1Ophthalmology,
Yale School of Medicine, New Haven, CT, United States, 2Ophthalmology,
Weill Cornell Medical College, New York, NY, United States, 3Surgery,
Yale School of Medicine, New Haven, CT, United States
F22
Mucoepidermoid Carcinoma Arising in the Anophthalmic Socket
Ilya Leyngold, MD. Ophthalmology, University of South Florida Morsani
College of Medicine, Tampa, FL, United States
F23
Aneurysmal Bone Cysts of the Orbit: Unusual Presentations
of a Rare Lesion
Sophie Liao, Thomas Johnson. Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, FL, United States
F24
Frontoethmoidal Sinus Mucocele Associated with Osteoma —
Clinical Features of 3 Cases
Reshma Mehendale1, Tanuj Nakra2, Roman Shinder1,2. 1Ophthalmology,
SUNY Downstate Medical Center, Brooklyn, NY, United States, 2Texas
Oculoplastics Consultants, Austin, TX, United States
F25
F26
F27
Does Eyebrow Soft Tissue Expansion in Thyroid Eye Disease
Improve over Time?
Grant Moore, Amir Yeganeh, Daniel Rootman, Robert Goldberg.
Ophthalmology, University of California, Los Angeles, Los Angeles,
CA, United States
The Ophthalmologic Findings in Acute Orbital Wall Fractures
Leslie Neems, MD, Elisa Chiang, MD PhD, Lilly Saadat, BS, Jared Spitz, BS,
Paul Bryar, MD, Christopher Chambers, MD. Ophthalmology, Northwestern
University, Chicago, IL, United States
Epidemiology and Clinical Characteristics of Pediatric Eyelid
Retraction
Jessica Olayanju1, Gregory Griepentrog2, David Hodge1,
Brian Mohney3. 1Mayo Medical School, Rochester, MN,
United States, 22Division of Oculofacial and Orbital Surgery,
Department of Ophthalmology, Medical College of Wisconsin, Milwaukee,
WI, United States, 3Department of Ophthalmology, Mayo Clinic, Rochester,
MN, United States
F28
Reconstruction of Medial Upper Eyelid Defects Following
Excision of Large Xanthelasma Palpebrarum with
Blepharoplasty Island Rotation Flaps
Gamze Ozturk Karabulut1, Pelin Kaynak1, Can Ozturker1, Korhan Fazil1,
Altug Cetinkaya2, Ahmet Demirok1, Omer Faruk Yilmaz1. 1OPRS, Beyoglu Eye
Research And Training Hospital, Istanbul, Turkey, 2OPRS, Dunyagoz Ankara
Hospital, Istanbul, Turkey
F29
Obesity as a Potential Risk Factor for Blepharoptosis: The Korea
National Health and Nutrition Examination Survey 2008-2010
Ji-Sun Paik1, Su-Kyung Jung2, Won-Kyung Cho3, Suk-Woo Yang1.
1
Ophthalmology and visual science, Seoul St. Mary’s Hospital,
The Catholic University of Korea, Seoul, South Korea, 2Ophthalmology and
visual science, Bucheon St. Mary’s Hospital, The Catholic University of
Korea, Seoul, South Korea, 3Ophthalmology and visual science, Dae-Jeon
St. Mary’s Hospital, The Catholic University of Korea, Seoul, South Korea
F30
Primary Renal Carcinoid Metastatic to the Orbit
Deep Parikh1, Reshma Mehendale1, Tanuj Nakra2, Roman Shinder1,2.
1
Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn,
NY, United States, 2Texas Oculoplastic Consultants, Austin, TX, United States
F31
Endonasal vs. External Dacryocystorhinostomy: A Meta-Analysis
W. Jordan Piluek, Timothy McCulley. Ophthalmology,
The Wilmer Eye Institute, Johns Hopkins University School
F32
The Role of Prophylactic Antibiotic Use in Orbital Fractures
Lamise Rajjoub, Benjamin Reiss, Craig Geist, Tamer Mansour.
Ophthalmology, The George Washington University, Washington, DC,
United States
F33
Dynamic Analysis of Muller’s Muscle Response to Phenylephrine
Sathyadeepak Ramesh, Ronald Mancini. Ophthalmology, University of Texas
Southwestern Medical Center, Dallas, TX, United States
F34
Chronic Anophthalmic Socket Pain Treated by Implant Removal
and Dermis Fat Graft
Pari Shams1, Meredith Baker1, Eva dafgard-kopp2, Elin Bohman 2, Richard
Allen1. 1Department of Ophthalmology and Visual Sciences, University of
Iowa Hospitals and Clinics, Iowa City, IA, United States, 2Oculoplastic and
Orbital services, St. Erik Eye Hospital, Stockholm, Sweden
F35
A Case of Dual Organism Canaliculitis
Janhavi Shirali, Alan Friedman, Albert Wu. Ophthalmology, Icahn School
of Medicine at Mount Sinai, New York, NY, United States
F36
Outcomes of Strabismus Surgery in Thyroid Eye
Disease Using the Technique of Tenon Recession
Gregory Stein, Carisa Petris, Michael Kazim. Ophthalmology,
Columbia University Medical Center, New York, NY, United States
F37
Retinoblastoma: A Surveillance, Epidemiology, and
End Results Dataset Evaluation for Treatment Patterns,
Second Malignant Neoplasms, and Overall Survival
Diana Tamboli1, Alan Topham2, Nakul Singh3, Vivek Patel4,
Julian Perry5, Arun Singh5. 1Ophthalmology, Loyola University Chicago
Stritch School of Medicine, Chicago, IL, United States, 2Coalition of Cancer
Cooperative Groups, Philadelphia, PA, United States, 3Biostatistics, Harvard
School of Public Health, Boston, MA, United States, 4Vanderbilt University,
Nashville, TN, United States, 5Ophthalmology, Cole Eye Institute, Cleveland
Clinic Foundation, Cleveland, OH, United States
F38
Acquired Socket Contracture. The Role of the
Yofibroblast Revisited
Hatem Tawfik1, Yousef Fouad2, Wesam Osman3, Hazem Rashed1,
Mohamed Abdulhafez1, Sameh Abdelrahman1. 1Ophthalmology,
Ain Shams University, Cairo, Egypt, 2Medical Student, Ain Shams
University, Cairo, Egypt, 3Pathology, Ain Shams University,
Cairo, Egypt
F39
Congenital Ptosis with Poor Levator Function:
The Role of Conjunctival-Müllerectomy Repair
Leslie Wei, MD, Cathy Burkat, MD FACS. Department of
Ophthalmology, Oculoplastic, Facial Cosmetic and Orbital
Surgery Service, University of Wisconsin – Madison, Madison,
WI, United States
F40
Traumatic Orbital Encephalocele: Presentation
and Imaging
Leslie Wei, MD1, Tabassum Kennedy, MD2, Sean Paul, MD3,
Greg Griepentrog, MD3, Timothy Wells, MD3, Mark Lucarelli, MD1.
1
Department of Ophthalmology, Oculoplastic, Facial Cosmetic
and Orbital Surgery Service, University of Wisconsin – Madison,
Madison, WI, United States, 2Department of Radiology, University
of Wisconsin – Madison, Madison, WI, United States, 3Division
of Oculofacial and Orbital Surgery, Department of Ophthalmology,
Medical College of Wisconsin, Milwaukee, WI, United States
Videos
1
Point of view (POV) Video Surgical Training: The use of
Consumer Electronics to Record and Teach Oculoplastic
Surgery Procedures from the Surgeon’s Perspective
Jonathan Hurst, Paul Huang, Vladimir Kratky. Ophthalmology,
Queen’s University, Kingston, ON, Canada
2
Permanent Punctal Closure for Dry Eye Disease
with the Slit-lamp 532nm Diode Laser
Charles Rice1,2. 1Lansing Ophthalmology, East Lansing, MI,
United States, 2Ophthalmology, Michigan State University,
East Lansing, MI, United States
3
Recurrent Bone Formation in a Complex
Grade III Choristoma of the Anterior Segment
Jeremy Tan1, P. Lloyd Hildebrand1, Annie Moreau1,
Hans Grossniklaus2. 1Ophthalmology, Dean McGee Eye
Institute, Oklahoma City, OK, United States, 2Ophthalmology,
Emory Eye Center, Atlanta, GA, United States
4
Trans-nasal, Trans-caruncular Orbitotomy for
Inferomedial Tumors of the Orbital Apex
Grant Moore, Alexander Nobori, Daniel Rootman,
Robert Goldberg. Ophthalmology, University of California,
Los Angeles, Los Angeles, CA, United States
Detailed Program — Thursday, October 16, 2014
YASOPRS Eye Openers — Rapid Fire Cases and Presentations
Sponsored by Young ASOPRS (YASOPRS). YASOPRS are defined as ASOPRS members, age 40 or less.
7:00 am A Cyst You Don’t Want to Miss: Endocrine Mucin-Producing Sweat Gland
Carcinoma of the Eyelid
Nada Farhat1, Rachel Sobel2,3, Avneet Sodhi1, Katrinka Heher1, Julia Schneider3, Mitesh Kapadia1, Nora Laver1. 1Department of
Ophthalmology, Tufts Medical Center, Boston, MA, United States, 2Department of Ophthalmology, Boston Medical Center, Boston, MA,
United States, 3Boston University School of Medicine, Boston, MA, United States
Introduction: Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is an uncommon slow growing intradermal tumor that
can occur in the eyelid. This low-grade tumor has been reported in other anatomic sites including the breast and vulva. Due to limited
number of case reports, clinical and histopathological diagnosis of this tumor may be under recognized. This study aims to report the
clinical presentation and outcomes of patients with EMPSGC and discuss the best treatment strategies for clinicians.
Methods: In-depth retrospective review of clinical and pathologic information was performed on 16 cases of EMPSGC, from
2000-2014, the largest case series to date. Immunohistochemistry for synaptophysin, chromogranin, estrogen receptor (ER),
progesterone receptor (PR) and e-cadherin stains were performed on formalin-fixed paraffin-embedded tissue. Mucicarmine stain
was also performed in all cases.
Results: The majority of patients (69%) presented with a slow growing cystic eyelid lesion. Other presentations included a nodular,
papular or elevated erythematous lesion. It most commonly occurred in females (81% of cases) and in the lower eyelid (62% of
lesions). Other sites included the medial canthus (6 % of cases) and the upper eyelid (32% of cases). Seventy-five percent of cases
required excision. After the initial biopsy; one case required re-excision with clear margins due to recurrence three years later; none
of the cases showed metastases. Invasive carcinoma infiltrating the reticular dermis was found in 2 cases. Of interest, 2 patients
were also diagnosed with ductal carcinoma of the breast. Histopathology of all eyelid tumors showed a cyst with solid, papillary,
and micropapillary tumor growth patterns. All eyelid tumors showed mucin production, with immunoreactivity with neuroendocrine
markers (synaptophysin and chromogranin) and ER/PR positivity.
Conclusions: Surgeons should biopsy cystic appearing lesions of the eyelid despite their benign appearance in order to identify
occult EMPSGC. Complete excision of EMPSGC with clear margins is recommended to avoid recurrences and transformation to
invasive mucinous carcinoma. The relationship between EMPSGC and breast carcinoma deserves further investigation, given the
analogous histopathology and presence of concomitant disease.
References: Hoguet A, Warrow D, Milite J, McCormick SA, Maher E, Della Rocca R, Della Rocca D, Goldbaum A, Milman T.
Mucin-producing sweat gland carcinoma of the eyelid: diagnostic and prognostic considerations. Am J Ophthalmol. 2013
Mar;155(3):585-592.
Shimizu I, Dufresne R, Robinson-Bostom L. Endocrine mucin-producing sweat gland carcinoma. Cutis. 2014 Jan;93(1):47-9.
Bulliard C, Murali R, Maloof A, Adams S. Endocrine mucin-producing sweat gland carcinoma: report of a case and review of the
literature. J Cutan Pathol. 2006 Dec;33(12):812-6.
Dhaliwal CA, Torgersen A, Ross JJ, Ironside JW, Biswas A. Endocrine
mucin-producing sweat gland carcinoma: report of two cases of an under-recognized malignant neoplasm and review of the
literature. Am J Dermatopathol. 2013 Feb;35(1):117-24.
7:04 am Carcinoma ex Pleomorphic Adenoma of the Lacrimal Gland with Clear Cell and
Myoepithelial Differentiation
Ema Avdagic 1, Nicholas Farber 1, Nora Katabi 2, Tanuj Nakra3, Roman Shinder 1,3. 1Ophthalmology, SUNY Downstate Medical Center,
Brooklyn, NY, United States, 2Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, United States, 3Texas Oculoplastic
Consultants, Austin, TX, United States
Introduction: Carcinoma ex pleomorphic adenoma with clear cell and myoepithelial differentiation is an exceptionally rare tumor of
the lacrimal gland.1,2 These malignant tumors are more commonly seen in the salivary glands, with only four previous cases described
in the lacrimal gland (Table 1). 2 We report the presentation, radiography, histopathology and treatment of one such patient. Methods: The medical record of a patient with a lacrimal gland malignant mixed tumor with clear cell and myoepithelial
differentiation was reviewed. Results: A 53-year old female presented with a one month history of left sided decreased vision and painful progressive periorbital
fullness. On exam visual acuity was 20/400 OS without RAPD. There was inferomedial globe dystopia with 2mm of proptosis on
exophthalmometry from a palpable nontender lacrimal fossa mass (Fig 2A,B). There was limitation of supra- and adduction OS.
Fundoscopy revealed optic disc edema (Fig 2C) and choroidal folds, and automated perimetry disclosed an inferomedial defect
(Fig 2D). Orbital CT revealed a 2 x 2.5 cm enhancing, well circumscribed lacrimal gland mass causing mass effect on the globe and
optic nerve without bony erosion (Fig 3). A lateral orbitotomy with excisonal biopsy was performed on the encapsulated mass (Fig
4A). Histopathology including immunohistochemistry confirmed an intermediate grade carcinoma ex pleomorphic adenoma with clear
cell and myoepithelial differentiation (Fig 4B,C), necrosis, perineural invasion, and tumor capsule violation. After a negative systemic
workup the patient was recently started on Intensity-modulated radiation therapy for a target dose of 60 Gy. Conclusions: This case represents a rare example of a carcinoma ex pleomorphic adenoma with clear cell and myoepithelial
differentiation of the lacrimal gland. There are only four prior cases described in the literature with one receiving exenteration, while
three received globe salvage tumor resection. Two of the globe salvage cases had postoperative radiotherapy, while 1 patient refused.
The exenterated patient was not offered radiation. None of the cases reported metastases, disease recurrence, or death from disease
with follow up ranging from several months to two and a half years. There is sparse knowledge with respect to the staging, treatment
and prognosis of this rare malignancy. Recruitment of a multidisciplinary team to include an ophthalmologist, oncologist, and radiation
oncologist is vital to tailor a treatment plan for such cases.
References: 1. Ostrowski ML, Font RL, Halpern J, et al. Clear cell epithelial- myoepithelial carcinoma arising in pleomorphic
adenoma of the lacrimal gland. Ophthalmology 1994;101:925-30.
2. Singh G, Sharma MC, Agarwal S, et al. Epithelial- myoepithelial carcinoma of the lacrimal gland: a rare case. Ann Diagn Pathol
2012;16: 292-7.
7:04 am Carcinoma ex Pleomorphic Adenoma of the Lacrimal Gland with Clear Cell and Myoepithelial
Differentiation, continued
7:08 am Retrobulbar Hemorrhage: An Algorithm to Guide Canthotomy/Cantholysis
By Non-Ophthalmologists
Benjamin Erickson, Wendy Lee, Nathan Blessing. Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States
Introduction: Retrobulbar hemorrhage (RBH) is a potentially blinding consequence of craniofacial trauma. Timely ophthalmic
evaluation is difficult to obtain in some settings and concrete standards for performing canthotomy/cantholysis are lacking. Our goal
was therefore to develop a simple experience-based algorithm to help emergency personnel and non-ophthalmic specialists identify
and treat vision-threatening RBH.
Methods: Data from 42 consecutive emergency department consults for retrobulbar hemorrhage in a level one trauma center
were reviewed.
Results: The majority of patients were male (83.3%). The most common mechanisms in descending order were blunt trauma
(45.2%), falls (21.4%), motor vehicle accidents (16.7%), and motorcycle crashes (17.1%). Other mechanisms accounting for less
than 5% of cases included pedestrian injuries, gunshot wounds, and stabbing. 52.4% of patients were observed, 25.9% were treated
pharmacologically, and 16.7% received emergent canthotomy/cantholysis. Among those observed, mean IOP was 21.1 ± 9.4 mmHg.
Among those requiring pharmacologic and surgical intervention, mean pressures were 33.3 ± 6.8 and 51.0 ± 13.2 mmHg. Following
intervention, IOP fell to 24.3 ± 6.0 mmHg in the pharmacologic group and 22.2 ± 3.3 mmHg in the canthotomy/cantholysis group.
Comparing the three groups, there were no differences in GCS, trauma score, pain score at intake, loss of consciousness, need for
intubation, degree of concomitant maxillofacial trauma, or presence of bodily trauma. Edema, ecchymosis, chemosis, subconjunctival
hemorrhage, and ocular motility also failed to correlate with the need for surgical intervention. ‘Tight’ eyelids, unilateral proptosis, and
afferent pupillary defect (APD), however, all related to the need for canthotomy/cantholysis (P ≤ 0.02). Globe ‘tenting’ was the only
radiographic finding to predict the need for surgery, but was seen in just 26.8% of these cases. Nearly one third of surgical patients
had significantly displaced fractures, suggesting that this does not protect against compartment syndrome. No association between
location of bleeding and need for intervention was detected.
Conclusions: Many traditionally emphasized clinical signs fail to identify cases of RBH requiring immediate treatment. Our data
support a simple 3-factor decision tool. The factors are: (1) relative proptosis, (2) eyelids that are difficult to open with finger pressure,
and (3) presence of an APD. If all three factors are noted or if the patient has proptosis and tight lids in the absence of a large
preseptal hematoma on CT scan, he/she likely needs surgical decompression. Globe tenting, while a relatively rare finding, should
also alert the physician of the need for prompt intervention.
References: 1. Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic
surgical emergency. Surv Ophthalmol. 2009 Jul-Aug;54(4):441-9.
2. McClenaghan FC, Ezra DG, Holmes SB. Mechanisms and management of vision loss following orbital and facial trauma.
Curr Opin Ophthalmol. 2011 Sep;22(5):426-31.
3. Yung CW, Moorthy RS, Lindley D, Ringle M, Nunery WR. Efficacy of lateral canthotomy and cantholysis in orbital hemorrhage.
Ophthal Plast Reconstr Surg. 1994 Jun;10(2):137-41.
7:12 am Metastatic Melanoma of the Lateral Rectus Misdiagnosed as Idiopathic
Orbital Inflammation
Nicholas Farber1, Ai-Lin Shao1, Renelle Pointdujour1, Tanuj Nakra2, Roman Shinder1,2. 1Ophthalmology, SUNY Downstate Medical
Center, Brooklyn, NY, United States, 2Texas Oculoplastic Consultants, Austin, NY, United States
Introduction: Melanomas most commonly metastasize to the lung, bone, and liver. Survival of patients with metastatic orbital
disease is poor, with life expectancy ranging from 5-17 months. We present a case of misdiagnosed metastatic melanoma to the
left lateral rectus muscle without known primary originally diagnosed and treated as idiopathic orbital inflammation (IOI).
Methods: Presentation, radiography, histopathology, and treatment of a patient with metastatic orbital melanoma were reviewed.
Results: A 62 year-old male presented to the ER with altered mental status and left hemiparesis. Five months earlier the patient
presented to an outside institution with acute left periorbital pain, proptosis, and limited ductions. Orbital CT at that time showed a
focal mass in the left lateral rectus muscle. Incisional biopsy showed a mild inflammatory infiltrate of the lacrimal gland, confirmed
by a second pathologist. The patient was diagnosed with IOI and given prednisone with symptomatic relief. A few weeks later his
orbital symptoms returned and was treated again with steroids for preseumptive recurrent IOI. Five months from initial presentation,
our initial exam revealed left proptosis (Fig 1) and a sentinel vessel at the lateral rectus insertion (Fig 2). Orbital CT revealed a large
lobular mass within the left lateral rectus muscle unchanged from original radiography (Fig 3A,B). Brain CT revealed multiple bilateral
high-attenuation lesions suspicious for metastases (Fig 3C). Systemic workup revealed metastatic disease of the liver, lungs, and
vertebrae. Incisional biopsy through an extended lid crease approach revealed a pigmented orbital mass. Histopathology was positive
for HMB45, S100, Malan A, and CD45, confirming metastatic melanoma (Fig 4). Full body skin exam by dermatology did not reveal a
primary site. Palliative brain radiation was administered, however, the patient expired 3 weeks after the biopsy.
Conclusions: Orbital metastasis of any type occurs in only 2% to 3% of patients with a history of malignancy. Those from melanoma
are even less common. Clinical presentation of orbital metastasis typically involves an acute orbital syndrome with blurred vision,
proptosis, dismotility, diplopia, and periorbital pain. Survival of patients with orbital metastasis is generally poor, averaging 19-25
months. The described case was suspicious for malignancy given the presentation & radiographic findings. The initial surgeon
attempted a confirmatory biopsy, however, the lesion was likely not sampled as two separate pathology reports proved only nearby
lacrimal gland was present. A definitive diagnosis at presentation would have allowed treatment to begin earlier and end of life
planning such as hospice could have been explored. Physicians should always consider metastatic disease when evaluating a patient
presenting with acute orbital syndrome especially with a focally enlarged rectus muscle.
References: 1. Rosenberg C, Finger PT.
Cutaneous Malignant Melanoma Metastatic
to the Eye, Lids, and Orbit. Surv Ophthalmol
2008;53:187-202.
2. Greene D, et al. Cutaneous Melanoma
Metastatic to the Orbit: Review of 15 Cases.
Ophthal Plast Reconstr Surg. 2014: 30
(3): 233-237
7:16 am Ophthalmic Manifestations and Outcomes of Cavernous Sinus Thrombosis
in Children
Garett Frank1, Jesse Smith1, Brett Davies1, David Mirsky3, Eric Hink1, Vikram Durairaj1,2,4. 1Department of Ophthalmology, University
of Colorado Hospital, Aurora, CO, United States, 2Department of Otolaryngology, University of Colorado Hospital, Aurora, CO,
United States, 3Department of Radiology, Childrens Hospital Colorado, Aurora, CO, United States, 4Texas Oculoplastic Consultants,
Introduction: To review the causes, treatment, and outcomes of all children diagnosed with cavernous sinus thrombosis at
Children’s Hospital Colorado in Aurora, CO from January 2000 through January 2013.
Methods: This is an observational, retrospective chart review. Electronic health records of all children under the age of 18 diagnosed
with thrombophlebitis of an intracranial venous sinus were reviewed to find cases of cavernous sinus thrombosis. These cases were
evaluated for etiology, symptoms, treatment, and outcomes.
Results: One hundred and ten children had a thrombus on an intracranial sinus. Nine of these had cavernous sinus thrombosis. In all
cases, the diagnosis was confirmed by magnetic resonance imaging. All cases involved sinusitis, five cases had orbital involvement,
and one case resulted from a nasal septal abscess. All but one patient presented with ophthalmoplegia, and five patients presented
with decreased vision. Every patient underwent sinus surgery, five underwent orbitotomy for abscess drainage, and one patient
required bilateral exenteration to control the infection. Cultures were inconclusive in two cases, while rhino-orbital mucormycosis and
Methicillin-resistant Staphylococcus aureus (MRSA) were identified in two cases and one case respectively. Four cases returned to
normal vision and motility, while five cases resulted in permanent ophthalmoplegia and vision loss. There were no cases of mortality.
Conclusions: In the modern era, cavernous sinus thrombosis is a rare complication of orbital and sinus disease. This disease
is poorly described in children. Based on our results, a high clinical suspicion, early neurologic imaging, and a multi-disciplinary
approach to management are key factors in reducing morbidity and mortality from cavernous sinus thrombosis in children.
References: 1. Odabasi, A.O. and A. Akgul, Cavernous sinus thrombosis: a rare complication of sinusitis. Int J Pediatr
Otorhinolaryngol, 1997. 39(1): p. 77-83.
2. Yarington, C.T., Jr., Cavernous sinus thrombosis revisited. Proc R Soc Med, 1977. 70(7): p. 456-9.
3. Yarington, C.T., Jr., The prognosis and treatment of cavernous sinus thrombosis. Review of 878 cases in the literature.
Ann Otol Rhinol Laryngol, 1961. 70: p. 263-7.
4. Absoud, M., et al., Bilateral cavernous sinus thrombosis complicating sinusitis. J R Soc Med, 2006. 99(9): p. 474-6.
5. Cannon, M.L., et al., Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med, 2004. 5(1): p. 86-8.
6. Parikh, V., V. Tucci, and S. Galwankar, Infections of the nervous system. Int J Crit Illn Inj Sci, 2012. 2(2): p. 82-97.
7. Desa, V. and R. Green, Cavernous sinus thrombosis: current therapy. J Oral Maxillofac Surg, 2012. 70(9): p. 2085-91.
7:20 am Lateral Canthoplasty Combined with “En-Glove” Placement of Acellular Porcine
Dermis Graft for Correction of Lower Eyelid Retraction
F. Lawson Grumbine, Robert Kersten, Sarah Deparis, M. Reza Vagefi. Ophthalmology, University of California, San Francisco,
San Francisco, CA, United States
Introduction: The purpose of this study is to describe the authors’ experience with a minimally invasive surgical technique for
repairing lower eyelid retraction in which a lateral tarsal strip is combined with “en-glove” placement of an alloplastic acellular dermal
spacer graft and to assess the post-operative change in lid position as measured by the MRD2.
Methods: A retrospective review of the charts of 8 concecutive patients who underwent surgical correction of lower eyelid retraction
by the senior author (MRV) was performed. Charts were reviewed for patient age, symptoms, etiology of eyelid retraction, pre and
post-operative MRD2, duration of follow-up and complications. A complication was defined as need for revision within the 90 day
global period or failure to improve MRD2 at last followup. The opertaive technique first involved performing a lateral canthotomy,
cantholysis and formation of a lateral tarsal strip. Blunt dissection is then performed with tenotomy scissors in the subconjunctival
space along the length of the lower lid. During blunt dissection, the scissors are repeatedly opened widely to stretch the lower eyelid
retractors. An acellular porcine dermis graft (ENDURAGen; Stryker, Kalamazoo, MI) is then inserted into the subconjunctival space
and secured to the inferior border of tarsus, taking care to make sure that the entire graft is covered by conjunctiva. The tarsal strip
is then secured in standard fashion and the skin of the canthotomy incision closed. The final step is to place the lower eyelid on
superior traction with a frost suture using the brow as a bolster. This is left in place for 1 week.
Results: Eight patients representing 12 eyelids underwent surgical correction of lower eyelid retraction using the described
technique. Mean age was 74 (range, 63-86). Etiologies of lower lid retraction included atopic disease, rosacea, prior facelifting
and/or lower eyelid blepharoplasty and anatomically shallow orbits with a negative vector. Symptoms included tearing, foreign body
sensation, burning and light sensitivity. The mean preoperative MRD2 was 8.6 mm (range, 7.5-10 mm). The mean improvement
in MRD2 was 2.6 mm (range, 1.5-3 mm) at last follow-up. Mean follow-up was 12 weeks (range, 4-52 weeks). There was one
complication in one eyelid in which the graft scrolled, necessitating repositioning in the office at the post-op week 1 visit.
Conclusions: Combining a lateral tarsal strip procedure with “en-glove” placement of an alloplastic acellular dermis graft in the
subconjunctival space allows for successful correction of lower eyelid retraction. This is a minimally invasive technique that permits
horizontal tightening of the lid with placement of a posterior spacer graft that is completely covered by intact conjunctiva.
References: Chang HS, Lee D, Taban M et al. “En-Glove” lysis of lower eyelid retractors with AlloDerm and dermis-fat grafts in lower
eyelid retraction surgery. Ophthal Plast Reconstr Surg 2011; 27:137-41.
McCord C, Nahai FR, Codner MA et al. Use of acellular dermal matrix (Enduragen) grafts in eyelids: a review of 69 patients and
129 eyelids. Plast and Reconstr Surg 2008; 122:1206-13.
7:24 am Orbital Fibroblastic and Myofibroblastic Proliferation Resembling
Fibromatosis Colli
Audrey Ko1, Sophie Liao1, Benjamin Erickson1, Rebecca Shields1, J. Antonio Bermudez-Magner 1,2, Sander Dubovy1,2, Wendy Lee1.
1
Ophthalmology, University of Miami, Miami, FL, United States, 2Florida Lions Ocular Pathology Laboratory, Miami, FL, United States
Introduction: In the pediatric population, a delay in diagnosis and treatment of an orbital mass can lead to vision loss and
deformity. However, overly aggressive treatment of benign lesions may also lead to undesired outcomes. We describe a case of an
intra- and extra-conal orbital mass present since birth that caused proptosis without ocular compromise. Biopsy results showed
histopathological characteristics consist with fibromatosis colli, which typically presents as a self-resolving mass found in the
sternocleidomastoid muscle in infants.
Methods: A four-month-old male presented with a history of right orbital fullness since birth that had remained stable in size. He
had an unremarkable delivery at 36 weeks gestation, and was otherwise healthy and without any family history of ocular or orbital
disease. His exam was remarkable for right proptosis and right lower lid entropion(Figure 1). He grimaced to light bilaterally, the
globes were equally soft to palpation, and there was no afferent pupillary defect. Motility was full bilaterally. Anterior segment and
dilated fundus exams were unremarkable. A CT and MRI of the orbits showed a poorly-defined right orbital mass with intraconal and
extraconal extension, isodense on CT scan to muscle. A well-circumscribed portion of the mass was adjacent to and indistinguishable
from the medial rectus muscle. An orbital ultrasound(Figure 2) showed a vascular lesion involving the belly of the medial rectus
muscle with intraconal and extraconal extension superotemporally.
Results: A biopsy was performed, which showed a grey and firm intra- and extra-conal lesion. Intraoperative frozen sections showed
a spindle cell lesion. Histopathology of fixed tissue specimen (Figure 3) showed striated muscle fibers that were focally atrophied and
replaced by scar-like fibroblastic-myofibroblastic proliferation, which resembled fibromatosis colli morphologically. The patient’s six
month follow-up exam and imaging is pending at the time of abstract submission(expected in October 2014).
Conclusions: We report a rare case of orbital skeletal muscle with fibrosis consistent with fibromatosis colli. This tumor is typically
found in the sternocleidomastoid but has not been reported in the orbit. Fibromatosis colli of the sternocleidomastoid muscle is a rare
but benign infantile condition with an incidence of 0.3-2% of live births. It typically has a unilateral presentation and is postulated
to be secondary to birth trauma, causing hematoma formation and subsequent endomysial fibrosis. They have a benign course and
typically resolve without intervention. In the evaluation of an orbital mass for an infant or young child, this fibroblastic/myofibroblastic
disease should be included on the differential as a rare but non-neoplastic orbital tumor that may be observed.
References: 1. Garetier M et al. Fibromatosis colli.Fresse Med.2012Feb;41(2):213-4.
2. Hayashi K et al. Clinicopathological study of three cases of infantile fibromatosis of the orbit. Int Ophthalmol.2014Feb15.
3. Mynatt CJ et al. Orbital infantile myofibroma: a case report and clinicopathologic review of 24 cases from the literature.
Head Neck Pathol.2011Sep;5(3):205-15.
7:28 am Outcomes of a Non-image-guided Injection Technique for Intralesional
Bleomycin Injection for Orbital Lymphangiomas
Bradford Lee, Richard Scawn, Bobby Korn, Don Kikkawa. Division of Oculofacial Plastic and Reconstructive Surgery, University of
California San Diego Shiley Eye Center, La Jolla, CA, United States
Introduction: Traditional management of orbital lymphangiomas with surgical excision has gradually evolved to include sclerosing
agents administered by a variety of techniques. This paper describes a non-image-guided protocol and technique for intralesional
bleomycin injection in orbital lymphangiomas refractory to surgery and/or other sclerosing therapies, and reports on clinical outcomes
associated with this technique.
Methods: A retrospective review was performed for all orbital lymphangiomas treated with non-image-guided intralesional
bleomycin injections (IBI) at a single institution. Injections were performed under general anesthesia using a solution of 4 units/ml
bleomycin with a total injection volume of up to 2 ml. A 27-gauge needle was used to inject intraorbitally either transcutaneously or
transconjunctivally based on anatomical landmarks and pre-procedure CT or MRI scans. Multiple retrograde injection passes were
performed throughout the lesion. Pain, proptosis, extraocular motility, and cosmesis were assessed both before and after treatment,
along with adverse outcomes and patient satisfaction with treatment.
Results: Four patients with orbital lymphangiomas underwent IBI and all had undergone prior debulking surgery, embolization
procedures, and/or sclerosing therapy with limited objective and subjective improvement. IBI resulted in significant improvement
in pain and superficial soft tissue swelling in all cases. Among the three cases with pre-existing proptosis, a single IBI resulted in
a mean reduction in proptosis of 6.7 mm (Range 5 to 10 mm). Of the two cases with pre-existing spontaneous bleeding from the
lesions, both had resolution of bleeding following IBI. Of the three cases with pre-existing limitation in extraocular motility, IBI resulted
in improvement in all cases. Cosmesis, both by patient and provider estimation, was significantly improved in all cases, and patients
were uniformly highly satisfied with clinical outcomes. There were no systemic, visual, or ophthalmic adverse outcomes associated
with the procedure, and uncorrected visual acuity improved in two cases following IBI.
Conclusions: Intralesional bleomycin can be administered safely and effectively in the treatment of orbital lymphangiomas refractory
to other treatments with a non-image-guided injection technique. All patients treated had improvement in pain, proptosis, extraocular
motility, and cosmesis with high patient satisfaction and no ophthalmic or systemic outcomes. Rather than a treatment of last resort,
IBI may be considered as a first-line option in the treatment of orbital lymphangiomas.
References: 1. Gooding C, Meyer D. Intralesional bleomycin: a potential treatment for refractory orbital lymphangiomas.
Ophthal Plast Reconstr Surg. 2014 May-Jun;30(3)e65-7.
2. Yue H. Qian J, Elner VM, Guo J, Yuan YF, Zhang R, Ge Q. Treatment of orbital vascular malformations with intralesional injection of
pingyangmycin. Br J Ophthalmol. 2013 Jun;97(6):739-45.
3. Sainsbury DC, Kessell G, Fall AJ, Hampton FJ, Guhan A, Muir T. Intralesional bleomycin injection treatment for vascular birthmarks:
a 5-year experience at a single United Kingdom unit. Plast Reconstr Surg. 2011 May;127(5):2031-44.
7:32 am Blepharoptosis from Statin-induced Necrotizing Myopathy
Jessica Lin1, Juan Javier Servat2, Gary Lelli3, Flora Levin1. 1Ophthalmology and Visual Science, Yale University School of Medicine,
New Haven, CT, United States, 2Oculofacial Plastic Surgeons of Georgia, Atlanta, GA, United States, 3Ophthalmology, Weill Cornell
Medical College, New York, NY, United States
Introduction: We describe severe bilateral blepharoptosis resulting from statin-induced necrotizing myopathy in an HIV-positive
patient that did not improve after stopping the statin or with immunosuppressive therapy.
Methods: A 61-year-old HIV-positive man presented with bilateral upper eyelid ptosis and proximal muscle weakness for one year
that began after starting low-dose statin therapy. Patient denied diplopia. The patient took Atripla, which includes tenofovir, a protease
inhibitor. Serologic evaluation showed normal electrolytes and ESR. Acetylcholine receptor antibody titer, ANA and paraneoplastic
panel were negative. Total creatinine kinase (CK) was 1650 U/L (normal range: 24-125 U/L). Urinanalysis was normal. Genetic testing
for oculopharyngeal dystrophy was negative. Muscle biopsy (Figure 1) demonstrated necrotizing muscle fibers and lymphohistiocytic
inflammatory cell infiltrates, including CD45+ CD3+ T cells with CD68+ macrophages. Diagnosis was made of statin-induced
necrotizing myositis.
Results: Ophthalmologic examination showed severe bilateral ptosis (MRD1= -1mm OD, -2mm OS) with diminished levator function
(8mm OU), poor orbicularis function with lagophthalmos, bilateral lower eyelid retraction, and poor Bell’s reflex (Figure 2). Extraocular
movements were full. While cessation of the statin and immunosuppressive therapy improved the patient’s systemic symptoms, his
periocular myopathy remained unchanged. The patient underwent surgical intervention with bilateral external levator advancement
and lower eyelid retraction repair. Despite immediate post-operative success, ptosis recurred shortly thereafter.
Conclusions: Statin-induced necrotizing myositis, a rare but significant complication of statin therapy1, can affect the periocular
muscles. Statin-induced necrotizing myositis is associated with an autoantibody to 3-hydroxy-3-methylglutaryl-coenzyme-A
reductase, the enzyme target of statins2. Statin-induced necrotizing myositis is diagnosed clinically. Patients have significantly
elevated CK and severe, symmetric proximal muscle weakness1. Muscle biopsy typically reveals necrosis and inflammatory cell
infiltrate, predominantly macrophages, with an absence of CD8+ T-cells1.
There have only been two reported cases of statin-induced myopathies causing blepharoptosis. In both cases, the ptosis resolved
completely after cessation of the statin. One report described unilateral ptosis in a patient taking Atorvastin for two years3. Another
report described bilateral ptosis in a patient on Simvastatin who developed rhabdomyolysis triggered by strenuous exercise4.
Protease-inhibitors, which have been previously known to increase risk for statin-induced myopathies, may also increase the risk of
statin-induced necrotizing myositis in HIV-positive patients.
References: 1. Hamann PDH, Cooper RG, McHugh NJ, Chinoy H. Review: Statin-induced necrotizing myositis - A discrete
autoimmune entity within the “statin-induced myopathy spectrum”. Autoimmunity Reviews. Jul 2013;12:1177-1181.
2. Mammen AL, Chung T, Christopher-Stine L, Rosen P, Rosen A, Doering KR, et al. Autoantibodies against 3-hydroxy3-methylglutaryl-coenzyme-A reductase in patients with statin-associated autoimmune myopathy. Arthritis Rheum.
2011;63(3):713-21.
3. Ertas FS et al. Unrecognized Side Effect of
Statin Treatment: Unilateral Blepharoptosis.
Ophthal Plast Reconstr Surg May/June
2006;22(3):222-224.
4. Finsterer J, Zuntner G. Rhabdomyolysis
from simvastatin triggered by infection
and muscle exertion. South Med J.
2005;98:827-9.
7:36 am Medial Orbital Wall Anatomic Landmarks
Milap Mehta1,2, Julian Perry1. 1Ophthalmology, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, United States, 2Surgery, Northshore
University, Evanston, IL, United States
Introduction: We sought to describe the medial orbital wall foramina in two previously unstudied populations, to describe a concavity
distinct from the frontoethmoidal suture line, and to validate the use of a new coordinate measurement device within the orbit.
Methods: Dried, well-preserved human skulls belonging to the Hamann-Todd osteological collection were studied. Incomplete
specimens and skulls with any bony defects were excluded. Age, gender, birthplace, ethnicity, and laterality of the orbit were recorded
for each skull. Photography was performed and a ray was drawn on orbit photographs extending through the center of the anterior
and posterior ethmoidal foramina toward the optic canal. Each orbit was inspected for the presence of supranumerary ethmoidal
foramina and the presence of a frontoethmoidal groove. All landmarks were confirmed by two independent examiners. The distances
between the anterior lacrimal crest (ALC) - anterior ethmoidal foramen (AEF), AEF - posterior ethmoidal foramen (PEF), and PEF optic canal (OC) were measured first by surgical rule and wire and then by the Microscribe coordinate measurement device.
Results: One hundred forty-six orbits (76 skulls) were studied. There were 45 male skulls, 30 female skulls, and one with no gender
information. Thirty-one skulls (57 orbits) were of European or Caucasian descent, 34 skulls (68 orbits) were of African American
descent, 1 skull (2 orbits) was of West African descent, 6 skulls (11 orbits) were of Eskimo descent, and 4 skulls (8 orbits) were of
unknown origin. No significant differences existed between the manual and Microscribe measurements for the ALC-AEF, AEF-PEF,
and PEF-OF distances (p <0.0001). A significant frontoethmoidal groove was observed in 27/146 (19%) orbits in 17/76 (22%)
skulls. A significant groove was identified in 6/57 (11%) Caucasian orbits, 17/70 (24%) of African American orbits, and 4/11 (36%)
Eskimo orbits. Supranumerary ethmoidal foramina were found in 50/146 orbits (34.2%) and in 17/27 (63%) orbits with a significant
frontoethmoidal grooves. The AEF-PEF ray extended superior (12/66), through (53/66), and inferior (1/66) to the optic canal.
Conclusions: The Microscribe coordinate measurement system represents a valid tool to measure distances within the orbit.
No significant differences in medial wall foramina distances exist in African Americans and Caucasian orbits; however, a
frontoethmoidal groove occurs more commonly in African American orbits (approximately one-quarter) than in Caucasian orbits
(approximately one-tenth). This groove often occurs in the presence of supernumerary ethmoidal foramina. The AEF-PEF line
accurately predicts the superior aspect of the optic canal. This information should help guide medial orbital wall surgery.
References: Bibliography:
1. Rene C. Update on Orbital Anatomy. Eye (Lond)
2006;10:1119-29.
2. Rootman J, Stewart B, Goldberg RA. Orbital
Surgery: A Conceptual Approach. 1 Baltimore:
Williams & Wilkins; 1995; 79-131.
3. Kirchner JA, Yanagisawa E, Crelin ES. Surgical
anatomy of the ethmoidal arteries. A laboratory
study of 150 orbits. Arch Otolaryngol. 1961
Oct;74:382-6.
7:40 am Hydrogel Expansion and Glue Tarsorrhaphy for Congenital Anophthalmia
and Microphthalmia
Maryam Nazemzadeh1,2, Michael Sulewski, Jr.3, William Katowitz1,2, James A. Katowitz1,2. 1Department of Oculoplastic and Orbital
Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States, 2Center for Human Appearance, University of
Pennsylvania, Philadelphia, PA, United States, 3University of Pennsylvania School of Medicine, Philadelphia, PA, United States
Introduction: To evaluate the efficacy of using hydrogel expanders placed anteriorly within the socket and secured with a glue
tarsorrhaphy in an outpatient clinic setting.
Methods: Retrospective review of 50 patients (51 eyes) with microphthalmia who underwent insertion of osmotic hydrogel expanders
(Osmed). All expanders were placed in the anterior socket with a cyanoacrylate glue tarsorrhaphy. All procedures were done in clinic
without local or general anesthesia. Orbital volumes were estimated by measurements taken from pre and post-operative CT and MR
scans in 16 patients (17 eyes). Horizontal fissure lengths were sequentially recorded at follow-up visits in all 50 patients (51 eyes).
Orbital growth in the affected eye was compared to that of the contralateral, non-affected eye, except for one case in which both eyes
received hydrogel expanders. Follow-up scans were grouped into the following time points after placement: <6 months, 6 months 1 year, 1-2 years, 2 - 5 years, 5 - 10 years.
Results: The pre-implanted volumes of the microphthalmic eye were estimated to be 3.6 mL as compared to 5.7 mL for the
contralateral non-microphthalmic. Follow-up imaging at <6 months, 6 mo - 1yr, 1 - 2 yrs, 2 - 5 yrs, and 5 - 10 yrs revealed interval
increases in orbital volumes of 32%, 7%, 23%, 6%, and 1%, respectively. These changes to orbital volume were comparable to
normal growth occurring in the non-affected eyes, which measured 19%, 10%, 24%, 1%, and 1%, respectively. Horizontal fissure
lengths demonstrated similar growth patterns. All the patients tolerated the procedure well in clinic without complication.
Conclusions: Insertion of osmotic hydrogel expanders in the anterior socket of anophthalmic and microphthalmic patients is an
efficacious, safe, and non-invasive technique for orbital and eyelid expansion. The procedure can be done easily in the office without
concern for complication. The hydrogel expanders allow for symmetric orbital and horizontal palpebral fissure growth, thus allowing
for eventual prosthesis placement with favorable aesthetic results.
References: 1) Dunaway DJ, David DJ. Intraorbital tissue expansion in the management of congenital anophthalmos. Br J Plast Surg.
1996 Dec;49(8):529-35. 2) Schittkowski MP, Katowitz JA, Gundlach KKH, Guthoff RF. Chapter 16: Self-inflating hydrogel expanders
for the treatment of congenital anophthalmos. Essentials in Ophthalmology: Oculoplastics and Orbit, Springer, 2005. 3) Hou Z1, Yang
Q, Chen T, Hao L, Li Y, Li D. The use of self-inflating hydrogel expanders in pediatric patients with congenital microphthalmia in China.
J AAPOS. 2012 Oct;16(5):458-63.
7:44 am Lateral Browlift Using Temporal (Pretrichial) Subcutaneous Approach
Under Local Anesthesia
Mehryar Taban. Private Practice, Beverly Hills, CA, United States
Introduction: Lateral brow ptosis is a common aging phenomenon, contributing to the lateral upper eyelid hooding, in addition to
dermatochalasis. Lateral brow lift complements upper blepharoplasty in achieving a youthful periorbital appearance. In this study,
the author reports his experience in utilizing a temporal (pretrichial) subcutaneous lateral brow lift technique, under local anesthesia.
Methods: Retrospective analysis of all patients undergoing the proposed technique by one surgeon, from 2009-2013. Additional
procedures were recorded. Preoperative and postoperative photographs at longest follow-up visit were used for analysis. Operation
was performed under local anesthesia. Surgical technique included a temporal (pretrichial) incision with subcutaneous dissection
towards the lateral brow, with superolateral lift and closure.
Results: Total of 45 patients (44 females, 1 male; mean age 58 years old) underwent temporal (pretrichial) subcutaneous lateral
brow lift technique, under local anesthesia, in office setting. The procedure was unilateral in 4 cases. Additional procedures included
upper blepharoplasty (38), ptosis surgery (16), and lower blepharoplasty (24). Minimum follow up time was 4 months (range,
4 months to 1 year). All patients were satisfied with the eyebrow contour and scar appearance. One patient required additional
brow lift on one side for asymmetry. There were no cases of frontal nerve paralysis.
Conclusions: Temporal (pretrichial) subcutaneous approach is an effective, safe technique for lateral brow lift/contouring, which can
be performed under local anesthesia. It is ideal for women. Additional advantages include ease of operation, cost, and shortening the
hairline (if necessary).
References: 1. Bidros RS, Salazar-Reyes H, Friedman JD. Subcutaneous temporal browlift under local anesthesia: a useful technique
for periorbital rejuvenation. Aesthet Surg J. 2010 Nov-Dec;30(6):783-8.
2. Passot RL. Chirurgie esthetique pure: techniques et resultats. Paris: Gaston Dorn et Cie; 1930.
3. Gonzalez-Ulloa M. Facial wrinkles—integral elimination. Plast Reconstr Surg 1962;29:658-673.
4. Marten FW, et al. Aging defects in the male: a regional approach to treatment. In: Marten FW, Lewis JR, eds. Symposium on
Aesthetic Surgery of the Face, Eyelids, and Breast. St Louis, MO: Mosby; 1972.
5. Gleason MC. Brow-lift through a temporal scalp approach. Plast Reconstr Surg 1973;52:141.
6. Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg
1996;97:1334.
7. Core GB, Vasconez LO, Askren C. Coronal face lift with endoscopic techniques. Plast Surg Forum XV 1992;15:227-228.
8. Fogli AL. Temporal lift by galeapexy: a review of 270 cases. Aesth Plast Surg 2003;27:159-165.
9. Guyuron B, Davies B. Subcutaneous anterior hairline forehead rhytidectomy. Aesth Plast Surg 1988;12:77.
10. Miller TA, et al. Lateral subcutaneous brow lift and interbrow muscle resection: clinical experience and anatomic studies.
Plast Reconstr Surg 2000;105:1120-1127.
11. Tonnard P, Verpaele A. Short-Scar Face Lift: Operative Strategies and Techniques. St Louis, MO: Quality Medical Publishing;
2007:271-295.
7:48 am Osseointegrative Implants for Orbito-Facial Prostheses: Six Preoperative
Planning Tips and Intraoperative Pearls
Leslie Wei, MD1, Julie Brown, CCA2, Dori Hosek, BCO3, Cathy Burkat, MD FACS1. 1Department of Ophthalmology, Oculoplastic,
Facial Cosmetic and Orbital Surgery Service, University of Wisconsin – Madison, Madison, WI, United States, 2
Medical Art Resources, Inc, Milwaukee, WI, United States, 3Global Prosthetics, Inc, Madison, WI, United States
Introduction: Implant-retained facial prostheses are becoming increasingly sophisticated. We describe guidelines for successful
preoperative preparation and intraoperative implant placement for orbito-facial prostheses.
Methods: Retrospective case series. Patients with severe unilateral orbital deformity who underwent socket reconstruction with
placement of orbital implants were identified from one surgeon’s practice (CNB). Prior to surgery, all patients were seen by an
oculoplastic surgeon, anaplastologist, and ocularist for examination, surgical planning, and orbital casting. Data on patient age,
gender, mechanism of eye, soft tissue, and bone loss, prior reconstructive surgeries and radiation, and orbital imaging were
collected and analyzed.
Results: Four patients between 2010 and 2014 who had osseointegrative implants placed for orbito-facial prostheses were
identified (9 total implants). Three were male, one female. Average age was 59 years (range 34-86). Reason for eye loss was
trauma in two patients, exenteration with radiation for recurrent rhabdomyosarcoma in one patient, and enucleation and radiation
for retinoblastoma with severe orbital hypoplasia in one patient. All patients had Vistafix (Gothenburg, Sweden) osseointegrative
titanium implants (4 mm) placed in a 2-stage procedure over a span of 3-6 months with subsequent successful prosthesis fitting.
Complications included poor angulation of inferior implant rendering it unusable for fixation in one patient. There were no cases of
infection or implant failure.
Conclusions: Implant-retained orbito-facial prostheses are safe, easy, and reliable. The ideal socket has minimal dead space,
robust bone, and soft tissue 4-5 mm in depth. Preoperative planning should consist of: 1) orbit CT, 2) careful clinical exam of the
orbital deformity by the surgeon and anaplastologist with particular attention paid to soft tissue mobility, and 3) analysis of socket
topography to ensure adequate depth and space for the implants and ocular component of the prosthesis. Operative tips for
successful implant placement include: 1) three points of fixation, although two will suffice if proper angulation cannot be achieved,
2) placement of implants in bone of adequate thickness (superior and inferior rims), and 3) implant placement as a 2-stage rather
than 1-stage procedure with soft tissue closure after the first stage to minimize interim maintenance. There appears to be no
difference in outcome in irradiated and non-irradiated sockets in this series.
References: 1) Karakoca Nemli S, Aydin C, Yilmaz H, et al. Retrospective study of implant-retained orbital prostheses: Implant
survival and patient satisfaction. J Craniofac Surg 2010;21:1178-83. 2) de Mello R, Guedes JAP, de Oliveira VA, et al. Extraoral
implants for orbit rehabilitation:
A comparison between one-stage
and two-stage surgeries. Int J Oral
Maxillofac Surg 2014;43:3417. 3) Guedes R, Pires de Mello
MM, Piras de Oliveira JA, et al.
Orbit rehabilitation with extraoral
implants: impant of radiotherapy.
Clin Implant Dent Relat Res. 2014.
Epub ahead of print.
7:52 am External Dacryocystorhinostomy Through a Midface Rhytidectomy Incision
Kate Xie, Swapna Vemuri, Jeremiah Tao. Department of Ophthalmology, Gavin Herbert Eye Institute, University of California - Irvine,
Introduction: We describe a technique of external dacryocystorhinostomy (DCR) using a continuous lateral canthal and subciliary
incision through which a cosmetic midface rhytidectomy was performed at the same surgical setting.
Methods: We review the surgical approach and assess the results in a series of 4 patients.
Results: A lateral canthal and subciliary incision with lateral canthotomy and inferior cantholysis allowed access to the inferior
orbital rim up to the naso-maxillary suture (Figure 1A). In all cases, a large (1.0-1.5 cm) osteotomy (Figure 1B) with sutured anterior
and posterior mucosal flaps (Figure 1C) was achieved. The cosmetic midface lift, including repositioning of inferomedial orbital fat
across the anterior mucosal flaps (Figure 2), achieved excellent correction of the nasojugal fold and midface rhytids. At 3 months
post-operatively, all patients were epiphora free with no cutaneous scars and showed significant aesthetic improvement of the
palpebromalar zone.
Conclusions: Many surgical techniques have been described to minimize a transcutaneous scar associated with an external DCR.1-4
A lateral canthal and subciliary external midface rhytidectomy incision provided appropriate access for a large osteotomy, dual flap
external DCR in this series. This approach is an excellent option for patients in need of DCR and desiring aesthetic improvement of
their midfacial zone.
References: 1. Akaishi PM, Mano JB, Pereira IC, Cruz AA. Functional and cosmetic results of a lower eyelid crease approach for
external dacryocystorhinostomy. Arq Bras Oftalmol. 2011;74(4):283-5.
2. Dave TV, Javed ali M, Sravani P, Naik MN. Subciliary incision for external dacryocystorhinostomy. Ophthal Plast Reconstr Surg.
2012;28(5):341-5.
3. Kim JH, Woo KI, Chang HR. Eyelid incision for dacryocystorhinostomy in Asians. Korean J Ophthalmol. 2005;19(4):243-6.
4. Ekinci M, Cağatay HH, Gokce G, et al. Comparison of the effect of W-shaped and linear skin incisions on scar visibility in bilateral
external dacryocystorhinostomy. Clin Ophthalmol. 2014;8:415-9.
General Session
8:00 am
Welcome
Vikram D. Durairaj, MD, ASOPRS Fall Meeting Co-Chair
Eyelid Session
8:05 am Reducing the Risk of Operating Room Fires in Eyelid Surgery with a Mixture of
Medical Air and Oxygen via Nasal Cannula
Charles Rice1,2, Michael Twilley2. 1Lansing Ophthalmology, East Lansing, MI, United States, 2Michigan Surgical Center, East Lansing,
MI, United States
Introduction: This study applies research of major disasters towards the prevention of operating room fires and offers a method to
reduce the oxygen level delivered at the nasal cannula.
Methods: Ten adult patients undergoing functional eyelid surgery under conscious sedation were included in the study. The standard
3-gas (air, nitrous oxide, and oxygen) anesthesia machine was modified with adapters to deliver a mixture of oxygen and medical
air via a Salter style nasal cannula to maintain a delivered oxygen level below 30% during the surgical period. The nasal cannula
delivered 25% oxygen concentration with medical air set at 4 liters/min. and oxygen at 50ml/min. (minimum flow). Patient’s oxygen
saturation and oxygen level at the nasal cannula were recorded during surgery.
Results: There were 7 males and 3 females ranging from 59 to 88 years of age (average 64 years of age). The oxygen concentration
delivery from the start to the end of surgery ranged from 22-26% (average 23% ) with oxygen saturations between 94-98% (average
96%). Anesthesia communicated the levels of oxygen delivery at the start of surgery and during the case. The surgeon reported when
there was cautery activation and cessation.
Conclusions: The study of catastrophes such as airline crashes, nuclear accidents, and space shuttle disasters demonstrate
that a series of mechanical and human errors lead to the tragic event rather than a single isolated factor.1,2 Comparably, oxygen
operating room fires occur from multiple factors such as lack of communication between anesthesia and surgeons as well as
failure to recognize risks of oxygen levels, heat of ignition source, and fuel sources. Rather than accountable members functioning
independently, the team approach involves the responsibility and communication between surgeons, anesthesia providers, nursing,
and technical staff.3 Most oculoplastic procedures are at an increased risk of operating room fire due to the proximity of cautery
near nasal cannula oxygen delivery.4,5 Oxygen concentrations above 25% increase the rate of combustion over room air. If oxygen
concentration at the nasal cannula can be measured, communicated, and maintained below 25% while providing adequate
oxygenation, then one of the major risks of operating room fires can be diminished.
References: 1. Perrow, C. Normal Accidents:Living with
High Risk Technologies. New York. Basic Books. 1984
2. Gladwell, M. Outliers, The Story of Success. New York.
Little, Brown, and Co. 2008
3. American Society of Anesthesiologists: Practice Advisory
for the prevention and management of operating room fires.
Anesthesiology. 2013;118:1-20
4. Orhan-Sungur M, Komatsu R, Sherman A, et. al.
Effect of nasal cannula oxygen administration on oxygen
concentration at facial and adjacent landmarks. Anaesthesia
2009, 64: 521-526
5. Greco RJ, Gonzalez R, Johnson P, Scolieri M, et. al.
Potential dangers of oxygen supplementation during facial surgery.
Plastic and Reconstructive Surgery 1995:95:978-84
8:11 am Comparison of Revision Rates Between External Levator Advancement vs
Muller’s Muscle-Conjunctival Resection For Correction of Upper Eyelid Ptosis
Eva Chou1, Matthew Sniegowski2, Cathleen Seaworth1, Malena Amato1, Vikram Durairaj1, Tanuj Nakra1, John Shore1, Sean Blaydon1.
1
Texas Oculoplastic Consultants, Austin, TX, United States, 2Oculoplastic and Reconstructive Surgery, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
Introduction: Both external levator advancement (ELA) and Muller’s muscle-conjunctival resection (MMCR) are utilized to correct
upper eyelid ptosis of all etiologies. This study was performed to compare the rates of revision between the two approaches.
Methods: This is a retrospective chart review of consecutive patients undergoing blepharoptosis surgery via either ELA or MMCR
during a 21-month period (June 2012 - March 2014) at a high-volume oculoplastic surgery practice. All patients with at least one
postoperative follow-up evaluation were included.
Results: A total of 768 patients (241 men, 527 women) underwent 1371 ptosis correction procedures; 1022 were ELA and 349
were MMCR. The average age was 66 +/- 12.6 years in the ELA vs 58.2 +/- 17.8 years in the MMCR group. Average follow-up
time was 11.3 weeks in the ELA vs 13.4 weeks in the MMCR group. Involutional ptosis was the most common indication for surgery
overall (98.8% of ELA vs 94.2% of MMCR) with congenital being second (1.2% of ELA vs 4.6% of MCMR). MMCR, but not ELA, was
also performed for paralytic (n=3) and myogenic (n=1) ptosis. In almost all cases, a concurrent blepharoplasty was performed. In the
ELA group, there were 57 revisions out of 1022 procedures, a rate of 5.8%; the most common cause for revision was residual ptosis
(n=42), followed by overcorrection (n=9) and contralateral Herring’s response (n=4). In the MMCR group, there were 22 revisions out
of 349 procedures, a rate of 6.0%; the most common cause for revision was residual ptosis (n=9), followed by contralateral Herring’s
response (n=7) and overcorrection (n=3). There were no cases of repeat revisions.
Conclusions: Revision rates were similar between external levator advancement (5.8%) vs Muller’s muscle-conjunctival resection
(6.0%) for the correction of upper eyelid ptosis, suggesting similar reliability in achieving clinical success.
References: Baldwin HC, Bhagey J, Khooshabeh R. Open sky Muller muscle-conjunctival resection in phenylephrine test-negative
blepharoptosis patients. Ophthal Plast Reconstr Surg. 2005;21:276-80.
Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement vs Muller’s muscle-conjunctival resection for correction of
upper eyelid Involutional ptosis. Am J Ophthalmol. 2005;140:426-432.
Berlin AJ, Vestal KP. Levator aponeurosis surgery: A retrospective review. Ophthalmology 1989;96:1033-36.
Brown MS, Putterman AM. The effect of upper blepharoplasty on eyelid position when performed concomitantly with Muller
muscle-conjunctival resection. Ophthal Plast Reconstr Surg. 2000;16:94-100.
Lucarelli MJ, Lemke BN. Small incision external levator repair: Technique and early results. Am J Ophthalmol. 1991;127:637-644.
McCulley TJ, Kersten RC, Kulwin DR, et al. Outcome and influencing factors of external levator palpebrae superioris aponeurosis
advancement for blepharoptosis. Ophthal Plast Reconstr Surg. 2003;19:388-393.
Pang NK, Newson RW, Oestreicher JH, et al. Fasanella-Servat procedure: Indications, efficacy, and complications. Can J Ophthalmol.
2008;43:84-88.
8:17 am The Impact of Ptosis on Driving Performance: Implications for
Functional Surgery
Bobby Korn, Bradford Lee, Richard Scawn, Jane Kim, Don Kikkawa, Felipe Medeiros. Ophthalmology, University of California,
San Diego, La Jolla, CA, United States
Introduction: 40 million people in the U.S. are 65 years of age or older, of which 32 million are licensed drivers. Ptosis is a
common condition among senior citizens affecting 22% of those aged 60-69 years and 35% of those aged 70 years or older.
Ptosis causes limitation in patients’ visual fields, and many patients report improved driving facility and driving confidence following
ptosis repair surgery. Current approval for functional ptosis repair surgery are based on arbitrarily defined criteria that vary between
localities and third-party payors. These criteria do not reflect patients’ real-life impairment in their daily activities, such as driving.
As such, providers spend unnecessary time negotiating with insurance carriers to perform functional ptosis surgery that improves
patients’ abilities to complete activities of daily living and enhances quality of life. With national policy makers applying continual
pressure to reduce healthcare expenditures, one potential concern is the elimination of coverage for certain functional oculoplastic
procedures that could be construed as simply cosmetic in nature. This prospective study seeks to evaluate the impact of functional
ptosis on driving performance and quality of life using the useful field of view (UFOV) test and a high-fidelity driving simulator. This
study’s findings could lend objective evidence of functional impairment to patients’ subjective complaints about ptosis-related
morbidity and impairment.
Methods: Subjects enrolled in this study included patients with bilateral upper eyelid ptosis (MRD1)
Results: Patients with functional upper eyelid ptosis showed inferior performance on the UFOV and driving simulator tests as
compared to age-matched controls. This reduced driving performance was consistently noted with repeat testing.
Conclusions: This is the first study to show the impact of ptosis on a real-life activity of daily living as tested with a high-fidelity
driving simulator. In the next phase of this study, patients with functional upper eyelid ptosis will be reassessed after ptosis repair
with the UFOV and driving simulator to determine the degree of improvement in driving ability. Demonstrating the impact of
driving performance in patients with ptosis should help to justify why payors should continue to authorize treatment for functional
oculoplastic surgeries.
8:23 am Levator Aponeurectomy
John Martin. John J. Martin, Jr., M.D., P.A., Coral Gables, FL, United States
Introduction: There are many options available for repairing ptosis. A levator aponeurectomy is a technique that should simplify
ptosis repair, decrease contour abnormalities, and decrease surgical time. Traditional teaching recommends dissecting the
aponeurosis off of the tarsus and separating it from the underlying Muller’s muscle. It is then reattached to the tarsus with interrupted
sutures. While results with this technique can be excellent, it can be time consuming and can result in lid contour abnormalities.
A levator aponeurectomy entails a modified dissection of the aponeurosis. A segment of the aponeurosis is excised from the anterior
surface of the tarsus, and it is not separated from Muller’s muscle. The superior cut edge is advanced and hooked to the distal fibers
of aponeurosis under the pretarsal orbicularis. This aponeurectomy technique and the results using this procedure will be discussed.
This surgery was performed on 30 consecutive patients. Results will be discussed, including the amount of correction obtained,
the number of patients within 1mm of desired correction, and post-op complications. The anatomy of the repair will be described,
showing why this surgery is effective and results in fewer post-op complications and improved surgical time.
Methods: A retrospective chart review was done for 30 consecutive patients with bilateral ptosis who underwent levator
aponeurectomy with concurrent blepharoplasty. A segment of aponeurosis is removed from the anterior face of the tarsus, and is not
separated from Mueller’s muscle superiorly. The superior cut edge of aponeurosis is advance and hooked to the distal aponeurosis
fibers under the pretarsal orbicularis. Excess skin was removed at the same time. Age, pre and post-op marginal reflex distances
(MRD1), eyelid contour, need for reoperation, and complications (undercorrection and overcorrection) were recorded.
Results: The mean preoperative MRD was 1.25mm OU. The mean post-op MRD was 3.20mm OD and 3.23mm OS. The surgery had
an 87% success rate, with 52 of 60 lids with an MRD of > 3mm post-op. Of the 60 eyelids corrected with this procedure, there were
no overcorrections, and no contour abnormalities.
Conclusions: External ptosis repair by levator aponeurectomy gives excellent post-op results with few contour abnormalities and
decreased surgical time
References: 1. Massry G. Ptosis Repair for the Cosmetic Surgeon. Facial Plat Surg Clin N Am. 2005;Nov.13(4):533-539.2. Anderson
RL, Beard C. The Levator Aponeurosis - Attachments and Their Clinical Significance. Arch Ophthalmol. 1977 Aug; 95:1437-1441.
3. Azizzadeh B, Massry GG: Clinics in Plastic Surgery. 2013 Jan; Vol. 20. No.1. 4. Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck
DE, MArcet MM, Mawn LA. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery A report by the American
Adacemy of Ophthalmology. Ophthalmology. 2011 Dec;118(12):2510-7.5. Jones LT, Quickert MH, Wobig JL.The Cure of Ptosis
by Aponeurotic Repair. Arch Ophthalmol. 1975 Aug;93(8): 629-34.6. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch
Ophthalmol. 1979 Jun;97(6):1123-8.7. Lucarelli MJ, Lemke BN. Small Incision External Levator Repair: Technique and Early Results.
Am J Ophthalmol. 1999 Jun;127(6):637-44.
8:29 am Worldwide Comparison of Prophylactic Antibiotic Use for Eyelid Surgery
Nambi Nallasamy1, Francesco Bernardini2, Aaron Fay3, Ted Wladis4. 1Ophthalmology, Duke University Eye Center, Durham, NC,
United States, 2Oculplastica Bernardini, Genova, Italy, 3Ophthalmology, Harvard Medical School, Boston, MA, United States, 4
Ophthalmology, Lions Eye Institute, Albany, NY, United States
Introduction: PURPOSE: The practice of prescribing postoperative, prophylactic antibiotics has been under increasing scrutiny.
Some surgeons are reluctant to forego antibiotics after eyelid surgery for fear of violating standards of care. In order to determine
current standards of care and to assess factors influencing antibiotic prescription practices, a worldwide survey of oculoplastic
surgeons was undertaken.
Methods: METHODS: A multinational study group was convened and a survey developed. The primary aim of the survey was to
identify rates of antibiotic use in different countries. A second aim was to assess factors influencing surgeons’ practices. Factors
assessed included geographic location, clinical setting, infection rates, and adverse effect rates. Additional questions were included
to assess the usage of IV, oral, and topical antibiotics in the perioperative period. The survey was deployed electronically to members
of ophthalmic plastic and reconstructive surgery societies in fifteen different regions worldwide using Survey Monkey. Code was
written in Matlab (The Mathworks, Natick, MA) in order to analyze the survey responses statistically. Data were analyzed by practice
location and training location. A linear regression with logit link function was performed to identify the contributions of factors to the
prescription of oral postoperative antibiotics.
Results: RESULTS: 782 responses were obtained worldwide. Designated regions correlating with society membership included
North America (ASOPRS), Spanish-speaking South and Central America (Ojoplast), Brazil (SBCPO), United Kingdom (BOPSS),
Europe (ESOPRS), Australia/New Zealand (ANZSOPS), Philippines (PSOPRS), Asia (APSOPRS), India (OPAI), and Israel. 93% percent
of respondents practice in an urban environment. Half practice in an academic setting. Rates of postoperative, prophylactic oral
antibiotic utilization varied widely by practice location (e.g., 2.9% in the UK and 86.7% in India), with a worldwide mean of 24%.
In Europe, Italy had the highest rate at 41.7%, while France had the lowest at 0%. Among South and Central American Countries,
Venezuela had the highest rate at 83.3% and Chile the lowest at 0%. 14% percent of respondents use PERI-operative prophylactic
antibiotics for uncomplicated eyelid surgeries. Practice location was a statistically significant predictor of antibiotic prescribing
practices. In addition, surgeons’ concern for allergic reaction to antibiotics was inversely related with antibiotic use (coeff -1.07,
p <10^-7), while surgeons’ concern for infection in the absence of antibiotics was directly related with antibiotic use (coeff 0.60,
p <10^-6). Topical antibiotic use after surgery was common in all regions (~85% overall).
Conclusions: CONCLUSION: Antibiotic prescribing practices for routine eyelid surgeries vary widely throughout the world.
No standard of care has been established that would require the routine use of postoperative prophylactic antibiotics following
eyelid surgery.
Panel: Charles Rice, MD, Eva Chou, MD, Bobby Korn, MD, John Martin, MD, Nambi Nallasamy, MD
8:50 am End-to-end Fat Pedicle Redraping for Improved Contour of the Lower Eyelid
Mid-face Junction
Matthew Sniegowski1, Eva Chou2, Vikram Durairaj2, Malena Amato2, Sean Blaydon2, John Shore2, Tanuj Nakra2. 1Orbital Oncology and
Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, University of Texas MD Anderson, Houston, TX, United States, 2
Introduction: The youthful mid-face has a smooth single convexity. With age, the firm attachments of the orbital retaining ligament
along with prolapse of orbital fat through a diaphanous orbital septum and mid-facial volume loss, can lead to lower eyelid mid-face
contour irregularities Traditional fat transposition, while improving the overall aesthetics of the eyelid-midface junction, can still lead
to peaks and valleys due to the discontinuity of the transposed fat. We propose the end to end fat pedicle transposition as a novel
technique to improve lower eyelid contour and overall aesthetics.
Methods: A retrospective chart review was performed on all consecutive patients undergoing lower eyelid blepharoplasty with
end to end fat pedicle transposition by the senior surgeon (TN), from January 2013 through February 2014. The technique involves
fixating the following: the medial aspect of the medial fat pad in the medial canthal subperiosteal pocket, the lateral aspect of the
medial fat pad to the medial aspect of the central fat pad deep into the subperiosteal maxillary pocket, and the lateral aspect of
the central fat pad to the deep lateral subperiosteal maxillary pocket. The pre and post-operative photos were graded by three
oculoplastic surgeons on the overall aesthetic improvement as well as the contour of the lower eyelid-midface junction. Postoperative
photos were taken at least 3 months after surgery. A set of patients who had undergone standard monofixation fat pedicle
transposition were included as control patients.
Results: There were 22 patients included in the study; 14 patients who underwent end-to-end lower eyelid fat pedicle transposition
and 8 patients who underwent traditional fat transposition. Overall, there was an aesthetic improvement in all patients undergoing
lower eyelid blepharoplasty, however, the group of patients undergoing the end to end transposition were judged to have had the
smoothest contour of the lower eyelid-midface junction.
Conclusions: The end-to-end fat pedicle transposition lower blepharoplasty is safe and effective procedure to efface the tear trough
deformity in a smooth manner in comparison to the traditional monofixated fat pedicle.
References: Sullivan PK, Drolet BC. Extended lower lid blepharoplasty for eyelid and midface rejuvenation. Plast Reconstr Surg.
2013 Nov;132(5):1093-101.
Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr
Surg. 2000 Feb;105(2):743-8; discussion 749-51.
Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and lid/cheek junction: Anatomy and implications for surgical
correction. Plast Reconstr Surg. 2009;123:1332-1340; discussion 1341.
Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: Facial layers, spaces, and the midcheek segments. Clin Plast Surg.
2008;35:395-404; discussion 393.
8:56 am The Role of Nitropaste in Ischemic Filler Complications: Should we use it?
An Animal Model with ICG Imaging
Catherine Hwang1, Payam Morgan1, Shu-Hong Chang2, Aline Pimentel1, Gary Duckwiler3. 1Oculoplastics, Jules Stein Eye Institute,
Los Angeles, CA, United States, 2Oculoplastics, University of Washington, Seattle, WA, United States, 3Interventional Radiology, UCLA,
Introduction: Soft tissue dermal fillers, both temporary and permanent, are used frequently in facial rejuvenation. As the use of
fillers increases, ischemic complications including skin necrosis are becoming more prevalent. In the literature, topical nitropaste has
been recommended in the early treatment of patients. The purpose of our study was to evaluate the vascular perfusion effects of
topical nitropaste in an animal model using ICG imaging.
Methods: After Animal Research Committee approval, a rabbit ear model was used to create filler skin ischemia (total of 4 rabbits,
8 ears). Two commonly used HAG fillers around the periorbital area were injected intra-arterially, Restylane® and Belotero® (0.1
cc). Thirty minutes after occlusion, nitropaste (Nitro-Bid 2%) was applied topically to 4 experimental ears (2 rabbits) for 5 minutes.
Vascular perfusion was evaluated with the SPY System (Novadaq Inc.) using ICG imaging. Perfusion images were obtained at
baseline, following intra-arterial filler injection, and at 5, 30, 60 minutes post application of nitropaste.
Results: No perfusion improvement was noted after topical application of nitropaste. Control ears not treated with nitropaste
appeared to have fewer areas of capillary dropout and ischemia. In addition, systemic effects on the rabbit could be seen including
increased heart rate and more bluish discoloration of the ear skin.
Conclusions: Ischemic filler complications are becoming increasingly prevalent. Practitioners often treat these complications
with topical nitropaste, based on the knowledge that topical nitropaste causes vasodilation to enhance flap survival. In filler-induced
tissue ischemia, however, filler particles present within arterioles may be further propagated into the capillary bed with the application
of topical nitropaste, thereby worsening malperfusion and ischemia. In addition, nitropaste has systemic effects including hypotension
and tachycardia, which may not be tolerated by some patients. We caution the use of topical nitropaste in patients presenting
with filler complications. The best treatment algorithm for patients presenting with ischemic complications still needs to be
better elucidated.
References: 1. DeLorenzi C. Complications
of injectable fillers, part 2: vascular
complications. Aesthet Surg J. 2014 May 1;
34(4):584-600.Epub 2014 Apr 1.
2. Kim DW, Yoon ES, Ji YH, Park SH,
Lee BI, Dhong ES. Vascular complications
of hyaluronic acid fillers and the role
of hyaluronidase in management. J
Plast Reconstr Aesthet Surg. 2011
Dec;64(12):1590-5. Epub 2011 Jul 31.
3. Kleydman K1, Cohen JL, Marmur E.
Nitroglycerin: a review of its use in the
treatment of vascular occlusion after soft
tissue augmentation. Dermatol Surg.
2012 Dec;38(12):1889-97.
9:02 am Initial Experience with Juvederm Volbella (Hyaluronic Acid) and Volift
(Hyaluronic Acid) for Facial Volume Augmentation
Morris E. Hartstein1, Guy Ben Simon2, Oren Benyamini. 1Ophthalmology, Assaf Harofeh Medical Center, Zerifin, Israel, 2
Ophthalmology, Sheba Hospital, Tel Aviv, Israel
Introduction: Juvederm (Allergan) Volbella and Volift are smooth, non-particle hyaluraonic acid (HA) gel using the same Vycross
technology as Voluma. We present our experience using Volbella and Volift for facial volume augmentation.
Methods: A retrospective review of 20 patients who underwent facial volume augmentation using Volbella and Volift. There
18 females and 2 males, with an age range of 28-67. Areas of the face injected included the tear trough, cheek, nasolabial fold,
perioral, prejowl,and lips.
Results: All patients had a successful fill of the treated areas, were pleased with the results and reported minimal discomfort
during the procedure. There were no complications. Follow-up ranged from three to seven months.
Conclusions: The Vycross technology in Juvederm allows for the incorporation of short and long chain HA, which in turn produces
more cross-linking. This distinguishes this product from Juvederm Ultra which only contains long chain HA. The increased
crosslinking produces a higher viscosity gel with greater lift capacity. Most significant is the lower concentration of HA which make
the products less hydrophilic and less likely to cause swelling. Volbella and Volift had a high rate of patient satisfaction, as a result of
ease and comfort of injection, the smooth gel producing a natural look, as well as excellent longevity.
References: Eccleston D, Murphy DK. Juevderm Volbela in the peri-oral area: a multicenter,open-label study. Clin Cosmet Invest
Dermatol. 2012;5:167-172
9:08 am Superficial Enhanced Fluid Fat Injection (SEFFI) for Aesthetic Enhancement
on the Periocular Aesthetic Unit
Francesco Bernardini1, Alessandro Gennai2. 1Oculoplastica Bernardini, Genova, Italy, 2Gennai Chirurgia, Bologna, Italy
Introduction: To report the results of superficial enhanced fluid fat injection for the correction of volume defects and
three-dimensional improvement of the periocular region.
Methods: A standardized protocol for fat preparation and harvesting was established between the two authors. The fat was manually
aspirated using two different hole-size cannulas, one with side holes of 0,5mm diameter and the other 0,8mm diameter. The fat was
centrifuged and a Plated Rich Plasma (PRP) solution was added in respect of a 10% compared to the total fat harvested. Finally,
1U of fast acting insulin per kg of fat was added. The finer 0,5mm SEFFI was then injected with multiple 1cc syringe mounted with a
23G syringe needle, while the 0,8mm SEFFI was injected using 3cc syringes mounted with 21G syringe needles.
Results: The charts of 84 consecutive patients that were treated between January 2013 and January 2014 were retrospectively
reviewed. The fat harvested with three different size cannulas (0,5mm, 0,8mm and 3 mm cannulas) was examined. The adipocytes
were all comparable to those originating from normal fat specimen. The main histological difference consisted in the rate of
adipocytes/stromal component in the three specimens collected. The larger the cannula the more dense was the cellularity and the
less the stromal component.
Conclusions: We believe that the advantages of the SEFFI technique are unique compared to the existing techniques. Viable fat
cells organized in fine and homogenous lobules allow superficial placement with a needle without risks of visible lumpiness or
irregularities. This superficial plane allows safe and precise fat placement in association with simultaneous surgical dissection in
the same area, restoring volume deficiencies in the periocular area and can be used as a stand alone technique or associated with
other aesthetic procedures. Mixing the fine fat with PRP renders our fat fluid allowing easy injection through fine needles and at the
same time it offers a combination of adipocyte derived stem cells with platelet rich plasma making the SEFFI potentially the most
effective autologous potion in regenerative medicine today. The volume effect offers a three dimensional projection in treated areas
like the brow and upper sulcus, the tear trough and the malar mound and the temporal and it is therefore indicated in association
with MIVEL or isolated upper or lower blepharoplasty. The regenerative effects may result especially useful in revision blepharoplasty
surgery, where the SEFFI acts as scaffold to elevate the eyelid, regenerates the scarred tissues and corrects the volume depletion
that invariably accompanies overly generous respective blepharoplasty.
References: Zeltzer AA, Tonnard PL and Verpaele AM. Sharp-needle intradermal fat grafting (SNIF). Aesthet Surg J
2012;32:554-561.
Correction of infraorbital dark circles using collagenase-digested fat cell grafts. S Youn, JI Shin, JD Kim et al. Dermatol Surg
2013:39;766-772.
9:14 am Filling The PreJowl Sulcus To Streamline the Jawline
Robert Schwarcz. Oculoplastic Surgery, Albert Einstein College of Medicine, New York, NY, United States
Introduction: The defining feature of the lower face is a straight jawline. With the aging face the depression noted just anterior to
the jowl could be filled to help streamline the jawline.
Methods: A non surgical technique of filling the pre jowl suclus is described and how this can provide immediate cosmetic correction
and providing a smooth straight jawline. The technique is shown with various filers used to fill this area and the injection technique
that is described is easily reproducible.
Results: After filling the prejowl sulcus with either the filler of choice the marionette lines are softened and the pre jowl sulcus is
filled and the jowls appear less profound at this point. The jawline appears smoother and more streamlined.
Conclusions: The most common complaint the aging face patients present with are usually jowling. A facelift is usually the
appropriate procedure toa address this concern. After non surgical filling of this area is performed significant correction can be
achieved. The pre jowl sulcus or antigonion notch can be from soft tissue descent or bone resorption of the anterior mandible below
the mental foramen. Once the problem is identified, the appropriate filler is chosen and the problem can easily be addressed and the
solution easily reproduced.
References: Mittelman H. The anatomy of the aging mandible and its importance to facelift surgery. Facial Plast Surg Clin North
Am 1994;2(3): 301-9.
Shire J. The importance of the pre jowl notch in facelifting. Facial Plast Surg Clin North Am 2008;16: 87-97.
Panel: Matthew Sniegowski, MD, Catherine Hwang, MD, Oren Benyamini, MD, Francesco Bernardini, MD, Robert Schwarcz, MD
9:30 am Introduction of Dr. Mark Glasgold
Michael T. Yen, MD
9:33 am Volumization in Facial Aesthetics
Volumetric techniques are now standard practice in facial rejuvenation. However, the misconception that volume is a goal rather than a
tool has resulted in a whole new spectrum of patients, balloonheads, bearing the stigmata of the cosmetic practitioner. Understanding
the role of volume loss in facial aging and more importantly what the visual cues we are responding to, is the basis for using volume
as a tool in creating subtle natural rejuvenation. This analysis can most effectively be understood by examining facial shadows and
highlights. Our perception of the dominant features of the face, the eyes and the mouth as well as the face itself is strongly influenced
by how light and shadows frame these structures. A detailed examination of the shadows of aging will naturally lead into a plan for
volumetric treatment.
10:15 – 10:45 am
10:45 am Lower Eyelid Position After Aesthetic Injection of Hyaluronic Acid Filler
for Midface Augmentation
Eric Ahn, Roger Dailey. Ophthalmology, Oregon Health and Sciences University, Portland, OR, United States
Introduction: To assess for changes in the position of the lower eyelid after injection of JUVÉDERM VOLUMATM XC (Allergan, Inc,
Irvine, California) into the midface.
Methods: A retrospective review of all patients receiving JUVÉDERM VOLUMATM XC (XC) from 12/13/2013 - 5/9/2014 was
performed. Patient demographics, location and amount of XC used, and pre and post-procedure marginal reflex distance (MRD2)
were reviewed. The latter was obtained through the analysis of frontal photographs using FACE-gram software (Massachusetts Eye
and Ear Infirmary). The primary outcome measure was a change in MRD2. Patients were excluded if XC was diluted or injected
outside of the midface, follow up photographs were not available, or if other filler and/or surgery had been done between facial
measurements. A one-sample t test was used for statistical analysis.
Results: Eight otherwise healthy patients (16 eyelids) received XC for midface volume augmentation, consisting of 7 females and
1 male, with an average age of 56.4 years. Half the patients received a total of 2ml of XC bilaterally, with the remaining receiving
1ml total bilaterally. The 2ml group showed an increase in MRD2 of 0.58mm, which was statistically significant having a P value of
0.0035. Similarly, the 1ml group showed an increased MRD2 of 0.13mm although this was not statistically significant. When both
groups were combined, MRD2 was noted to increase by 0.35mm, with P = 0.008.
Conclusions: Although hyaluronic acid filler injection into the midface can be helpful in correcting volumetric defects, it does not
seem to help recruit tissue into the lower eyelid, and, in fact, may increase retraction.
References: None.
10:51 am Use of Hyaluronic Acid Gel to Improve the Appearance of Lower Eyelid Fat
Prolapse as an Alternative to Eyelid Surgery
Debra Kroll1,2, Mitesh Kapadia3, Janet Neigel4. 1Ophthalmic Plastic, Orbital and Reconstructive Surgery, The New York Eye and Ear
Infirmary of Mount Sinai, New York, NY, United States, 2Debra M. Kroll, M.D., New York, NY, United States, 3Division of Oculoplastic
Surgery, New England Eye Center, Tufts Medical Center, Boston, MA, United States, 4The Neigel Center for Cosmetic and Laser Surgery,
PA, New Jersey, NJ, United States
Introduction: To describe the outcomes of patients with varying degrees of prolapsed inferior orbital fat who underwent minimally
invasive lower eyelid rejuvenation with a hyaluronic acid gel (Restylane).
Methods: A retrospective case series was performed on the charts of 11 patients (22 eyelids) with fat prolapse in the lower
eyelids who were treated with periorbital injections of hyaluronic acid gel from December 2009 through March 2013. Injections
were performed with serial puncture and threading techniques in the preperiosteal tissues at and slightly caudal to the inferior
orbital rim. Inferior orbital fat prolapse was graded by four independent raters (0=none to 4=severe) before and after treatment.
Demographics, total volume of hyaluronic acid gel utilized, months of follow up and patient satisfaction were recorded. Statistical
analysis was performed.
Results: Mean age was 47 years, (range 29-65). There were 8 females and 3 males, Mean (S.D.) fat prolapse rating on a 0-4 scale
pre treatment was 2.51 (0.76) and post treatment rating was 0.85 (0.49), p <.0005. All eyelids with prolapsed inferior orbital fat
showed an improvement of contour. Total quantity of hyaluronic acid gel used on both sides was mean 1.01 cc’s (range 0.3-2.1
cc’s). Follow up was mean 10.04 months (range 6-25 months). All patients were satisfied and none of the patients pursued surgical
blepharoplasty.
Conclusions: Hyaluronic acid gel injected preperiosteally at and caudal to the inferior orbital rim significantly improves the
appearance of fat prolapse in the lower eyelids. This procedure may serve as a useful alternative to lower blepharoplasty surgery in
selected patients.
References: Airan LE, Born TM. Nonsurgical lower eyelid lift. Plast Reconstr Surg 2005;116:1785-92.Goldberg RA, Fiaschetti
DF. Filling the periorbital hollows with hyaluronic acid gel: Initial experience with 244 injections. Ophthal Plast Reconstr Surg
2006;22:335-341. Steinsapir KD, Steinsapir SM. Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove:
a report of 303 consecutive treatments. Ophthal Plast Reconstr Surg 2006;22:344-8.Goldberg RA, McCann JD, Fiaschetti D, Ben
Simon GJ. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 2005 Apr 15;115(5):1395-402;
discussion 1403-4.
10:57 am Belotero Rescue for Patients with Complications from Restylane (Hyaluronic
Acid) Treatment in the Lower Eyelids
Wenjing Liu, Catherine Hwang, Robert Goldberg. Division of Orbital and Oculoplastic Surgery, Jules Stein Eye Institute, Los Angeles,
CA, United States
Introduction: The purpose of this study was to observe if patients with unsatisfactory results from treatment in the lower eyelids
from one hyaluronic acid gel, Restylane, would benefit from treatment with another hyaluronic acid gel with different biophysical
properties, Belotero.
Methods: A retrospective chart review was conducted for 60 patients who received both Belotero and Restylane treatment to
the lower eyelids at the Oculoplastic and Reconstructive Surgery Clinic at the Jules Stein Eye Institute between December 2004
and March 2014. All patients with unsatisfactory results from Restylane were identified and the following data was collected:
demographics, past medical and surgical history, distribution and amount of injections, description of the complication, hyaluronidase
use, and whether there were any complications from subsequent Belotero treatment. Standardized clinical photographs were
analyzed after both Restylane and Belotero treatments.
Results: 15 patients reported complications with Restylane treatment to the lower eyelids including swelling, lumps, ridge or
indentation formation, darkness or Tyndall effect. 7 of these patients did not report complications from subsequent Belotero treatment
(Figure 1) and 8 of these patients reported complications from both Restylane and Belotero treatments (Figure 2). 6 patients received
hyaluronidase to dissolve the Restylane treatment and 2 patients received hyaluronidase to dissolve the Belotero treatment. Patients
with more severe complications typically had adverse effects with both Restylane and Belotero treatments.
Conclusions: In our experience, approximately half of patients who have unsatisfactory results from Restylane treatment of the lower
eyelids can be rescued with a different hyaluronic acid gel, Belotero. Patients with more severe complications tend to experience
them regardless of the type of hyaluronic acid gel treatment.
11:03 am Prospective Evaluation of Three Different Hyaluronic Acid (HA) Gels to
Varying Doses of Hyaluronidase
Sandy Zhang-Nunes1,2,3,4, Dan Straka1,2,4, Cameron Nabavi1,2,4, Kenneth Cahill1,2,4, Craig Czyz1,2,3,4, Jill Foster1,2,3,4. 1Plastic Surgery
Ohio/Eye Center of Columbus, Columbus, OH, United States, 2Ophthalmology, The Ohio State University, Columbus, OH,
United States, 3Oculofacial and Reconstructive Surgery, Ohio Health/Doctor’s Hospital, Columbus, OH, United States, 4
Ophthalmology, Mount Carmel Health System, Columbus, OH, United States
Introduction: Hyaluronic acid (HA) gel has achieved widespread use for facial rejuvenation. Its advantage over other fillers is its
reversibility by commercially available hyaluronidase. Not much is known, however, about the dose response of different HA gels to
hyaluronidase. We sought to determine if there are differences among three currently available products in response to recombinant
human hyaluronidase (Hylenex).
Methods: Nine subjects had each forearm randomized for injection of a HA gel (Restylane, Juvederm, or Voluma) for a total of 18
arms, 6 for each type of HA. Each forearm had 7 sites randomized, all 5 cm apart. Six sites were first injected with 0.2 mL of one HA
gel intradermally [Figure 1 - Center], then one week later, each location was randomly assigned to receive equal volumes (0.15 mL)
of 2.5 U, 5 U, 10 U, 20 U of hyaluronidase, saline, or nothing, with the seventh site being a control for 10 U of hyaluronidase only.
The diameter was measured, and the elevation and firmness of each site was graded immediately after injection of HA gel, one week
later, immediately prior to hyaluronidase injection, immediately after hyaluronidase injection, then at time points: 15, 30 minutes, 1, 2,
3, 5, 8 hours, days 1, 2, 3, weeks 1 and 2. All subjects and graders were masked. Grading for firmness and elevation was rated “3”
for most elevated or firm, “2” for moderate, “1” for minimal, and “0” for none.
Results: The most dramatic changes for all fillers after hyaluronidase injection occurred starting at the 30 minute time point
through hour 3, with continued gradual degradation up to day 3, then minimal change through week 2. Although many Juvederm
and Restylane spots disappeared completely with 2.5 to 20 units of hyaluronidase, several spots, especially Voluma, still remained
partially undissolved even with 20 Units. No significant dose response was found for Juvederm or Restylane; however, a slight dose
response from 2.5 to 10 Units was seen for Voluma with 2.5 Units behaving more like controls for diameter [Figure 2-Left], elevation
[Figure 3-Center], and firmness [Figure 4-Right]. There were no allergic reactions to the recombinant Hylenex, although 3 people had
significant erythema and irritation at the HA gel sites starting 5 hours after initial intradermal HA implantation, lasting up to 1-2 days,
most significant in arms with Restylane. Some mild post-inflammatory hyperpigmentation was seen.
Conclusions: Majority of dissolution occurred 30 min to 3 hours post hyaluronidase injection of intradermally placed hyaluronic acid
gel. Although there was no significant dose response for Juvederm and Restylane to Hylenex, 2.5 Units of hyaluronidase was not
enough to dissolve 0.2 mL of Voluma.
11:03 am Prospective Evaluation of Three Different Hyaluronic Acid (HA) Gels to Varying Doses
of Hyaluronidase, continued
11:09 am Volumetric Rejuvenation of the Hollow Superior Sulcus-the Final Frontier
Morris E. Hartstein1, Guy G. Massry2. 1Ophthalmology, Assaf Harofeh Medical Center, Zerifin, Israel, 2Ophthalmology, Beverly Hills
Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills, CA, United States
Introduction: Much attention is given to restoring volume in the lower lid and cheek. The superior sulcus undergoes aging changes
as well. Loss of volume in the upper lid leads to unmasking of the superior orbital rim and a visible concavity between the brow and
the upper eyelid fold. When there is greater loss medially, this results in the A-frame deformity. These changes are a result of normal
aging, overaggressive blepharoplasty, or from an anophthalmic socket. A small percentage of patients have a natural concavity
beneath the brow but this too can become more pronounced with age. By volumizing the superior sulcus in a specific fashion, we can
restore the youthful superior sulcus. We describe our technique of unfolding the orbital hollow using hyaluronic acid (HA) fillers.
Methods: 45 patients underwent treatment for a hollow superior sulcus with HA filler injection. 15 underwent primary correction,
20 patients had prior blepharoplasty surgery, 10 patients had an anophthalmic socket. The ages ranged from 16 to 62. Filler was
injected, beginning deep along the superior rim and then gradually “unfolding” the concavity by progressing inferiorly in a superficial
plane. In most patients, the treatment goal was to restore fullness in the superior sulcus. In patients with a natural concavity, the goal
was to mask the superior orbital rim.
Results: All patients had significant improvement in effacing the superior orbital hollow and restoring the youthful superior sulcus.
There were no complications although 11 of the patients requested additional touch-up volume augmentation.
Conclusions: Volume augmentation is now a standard part of periorbital rejuvenation, but the hollow superior sulcus has been given
less attention. A hollow sulcus may result from a variety of factors, but when present it signifies an aged appearance. Filling the
hollow superior sulcus with HA fillers is a safe and effective method of restoring a youthful appearance to the patient.
References: Glasgold RA, Lam SM, Glasgold MJ. Periorbital fat grafting. In:Master Techniques in Blepharoplasty and Periorbital
Rejuvenation, Massry GG, Murphy MR, Azizzadeh B, eds. Springer:New York, 2011
Panel: Eric Ahn, MD, Debra Kroll, MD, Wenjing Liu, MD, Sandy Zhang-Nunes, MD, Guy Massry, MD
11:25 am Techniques for Fat Transfer
Autologous fat transfer is often thought of as an unpredictable, highly artistic and technically difficult procedure. Our experience over
the past 15 years has supported the belief that autologous fat transfer can be taught as highly algorithmic and easily approachable
procedure. Defining standardized injections based on surface and bony landmarks allows the creation of a Volumetric Foundation
which is the basis for learning the techniques. Once the Volumetric Foundation is appreciated, further individualized refinements can
be introduced. Standardized injections and fat processing reduce the unpredictability of the procedure and allow for high levels of
long term patient satisfaction.
12 – 1 pm
Lunch
(River Exposition Hall)
12 – 1 pm
YASOPRS Lunch Lecture
(Ohio Room)
Brian S. Biesman, MD
This session will explore a variety of factors and strategies to consider when starting a practice as well as measures that can be
taken to help an established practice grow. Some of the topics that will be discussed include the following:
•
•
•
•
Developing a professional identity
Legal aspects
Selection of office location and space
Personnel and human capital
• Acquisition of software and medical equipment
• Marketing: internal, external
• Social media
As each of these topics is explored, associated costs a various options will be considered. Time will be allotted for questions
and discussion.
YASOPRS** members are invited to an educational lunch with ASOPRS member Brian Biesman, MD.
Topics will include Practice Development and Marketing Strategies.
**YASOPRS are defined as ASOPRS members, age 40 or less. This event is open to YASOPRS
members only.
RSVP’s were required and space is limited; sorry, no entries will be allowed without a ticket.
Orbit Session I
1:00 pm Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair
Jane S. Kim, Bradford W. Lee, Richard Scawn, Bobby S. Korn, Don O. Kikkawa. Division of Oculofacial Plastic and Reconstructive
Surgery, Department of Ophthalmology, Shiley Eye Center, UC San Diego, La Jolla, CA, United States
Introduction: Performing secondary orbital reconstruction on inadequately repaired orbital fractures is challenging, and controversy
exists regarding the wisdom of further surgical intervention. Nonetheless, patients may have debilitating functional and cosmetic
deficits, which if addressed could result in significant improvements in quality of life. This study evaluates clinical characteristics and
post-operative outcomes of secondary orbital reconstruction in patients who underwent suboptimal primary orbital fracture repair.
Methods: A retrospective review yielded 14 patients who underwent secondary orbital reconstruction following suboptimal primary
orbital fracture repair. Indications for secondary surgery, interval between primary and secondary surgery, and complications of
secondary surgery were analyzed. Primary outcomes included post-operative changes in enophthalmos, hypo- or hyperglobus,
superior sulcus deformity, extraocular motility (scale: 0 to -4), and compressive optic neuropathy. Patient-reported functional and
cosmetic outcomes were also assessed on a five-point analog scale (very satisfied, satisfied, neutral, dissatisfied, very dissatisfied).
Globe position and motility were compared pre- and post-operatively using paired t-tests for statistical analysis.
Results: Indications for secondary surgery included enophthalmos, hypo- or hyperglobus, superior sulcus deformity, restrictive
strabismus, pain with extraocular movements, and compressive optic neuropathy. Prior to secondary orbital reconstruction, 13/14
cases had enophthalmos, 11/14 had hypoglobus, 1/14 had hyperglobus, 10/14 had a superior sulcus deformity, 13/14 had
restricted supraduction, and 7/14 had restricted infraduction. Mean pre-operative enophthalmos was 4.3 +/- 2.5 mm, and mean
pre-operative hypoglobus was 3.1 +/- 1.5 mm. Secondary reconstruction resulted in mean enophthalmos reduction of 3.39 +/1.4 mm (p<0.001), mean hypoglobus reduction of 2.86 +/- 1.4 mm (p<0.001), and hyperglobus reduction of 1 mm (n=1). All ten
patients had resolution of their superior sulcus deformity. Of 13 cases with restricted ocular motility, six had complete resolution, and
seven had partial resolution following secondary orbital reconstruction. Mean improvement in supraduction and infraduction was
1.77 points (p<0.001) and 1.43 points (p=0.025), respectively. Subjectively, 64% of patients reported being “very satisfied,”
29% were “satisfied,” and one patient was “neutral” regarding both functional and aesthetic post-operative outcomes. Complications
included persistent mydriasis (1/14) and prolonged chemosis which resolved (1/14). 5/14 patients had infraorbital hypesthesia
pre-operatively, but this did not worsen after secondary surgery.
Conclusions: Secondary orbital reconstruction following
suboptimal primary orbital fracture repair presents
numerous challenges due to implant malposition, scarring,
and tissue injury. This study demonstrates that secondary
orbital reconstruction can achieve excellent functional and
cosmetic outcomes with minimal complications and high
patient satisfaction. Statistically significant improvements
in enophthalmos, hypoglobus, superior sulcus deformity,
and restrictive strabismus were observed and positively
correlated with patient-reported outcomes. Secondary
orbital reconstruction of orbital fractures should be strongly
considered as a treatment option when clinically indicated.
References: Jordan DR, Mawn L. Blowout fractures of
the orbit. In: Black EH, Nesi FA, Calvano CJ, Gladstone GJ, Levine MR, ed. Smith and Nesi’s Ophthalmic Plastic and Reconstructive
Surgery. 3rd ed. New York: Springer, 2012:243-63.
1:06 pm Subperiosteal Abscess Of The Orbit: Evolving Pathogens and the
Therapeutic Protocol
Janice Liao, Gerald Harris. Ophthalmology, Medical College of Wisconsin, Milwaukee, WI, United States
Introduction: The objective of the study is to determine changes over time in the bacteriology of sinusitis-related subperiosteal
abscess (SPA) of the orbit and their impact on patient outcomes under a uniform management protocol.
Methods: This is a comparative case series, involving patients ≤18 years of age with sinusitis-related SPA treated from 2002-2012.
Investigation includes analysis of culture results and outcomes in surgical cases, comparison of overall and age-specific results to
those in a 1977-1992 patient series, and comparison of the proportion of patients <9 years old requiring surgery among current,
1988-1998, and 1999-2008 cohorts.
Results: Ninety-four patients met inclusion criteria: 53 of 94 (56%) recovered with medical therapy alone; 41 of 94 (44%)
underwent surgical drainage. Compared to a 1977-1992 cohort, there was increased representation of Streptococcus anginosus
group (24% v. 12%), Staphylococcus aureus (17% v. 12%), and group A β-streptococci (12% v. 4%). Methicillin-resistant S. aureus
(MRSA) accounted for 4 of 7 S. aureus isolates in the current series. Seventy-four of 94 patients (79%) were <9 years of age:
53 of 74 (72%) recovered without surgery; 21 of 74 (28%) underwent drainage. Comparable figures were 67.5% v. 32.5% and
85% v. 15% in 1988-1998 and 1999-2008 cohorts, respectively. Whereas patients ≥9 years old in the 1977-1992 cohort had a
higher proportion of positive cultures and more varied pathogens than younger patients, in the current series both age groups had
similar culture yields and aerobic constituencies. Anaerobes were isolated from only patients ≥9 years old in both series. In cases
positive for MRSA and other aggressive aerobes, initial findings prompted early drainage and outcomes were not compromised by
adherence to the treatment protocol (Figs. 1 and 2).
1:06 pm Subperiosteal Abscess Of The Orbit: Evolving Pathogens and the Therapeutic Protocol,
continued
Conclusions: The proportion of children <9 years of age requiring surgery for sinusitis-related SPA has remained a minority
(15%-32.5%) and without a clearly upward trend over 25 years. Anaerobes continue not to factor in the younger subgroup, but more
aggressive aerobic pathogens, including MRSA, have emerged. In such cases, surgical criteria that supersede age are triggered
under the current treatment algorithm, and modification is not recommended.
References: 1. Harris GJ. Age as a factor in the bacteriology and response to treatment of subperiosteal abscess of the orbit.
Trans Am Ophthalmol Soc 1993;91:441-516.
2. Garcia GH, Harris GJ. Criteria for nonsurgical management of the subperiosteal abscess of the orbit: analysis of outcomes
1988-1998. Ophthalmology 2000;107:1454-6.
3. Hurley PE, Harris GJ. Subperiosteal abscess of the orbit: duration of intravenous antibiotic therapy in nonsurgical cases.
Ophthal Plast Reconstr Surg 2012;28:22-6.
1:12 pm Orbital Fractures in Emergency Departments: Discharge, Observation
or Admission?
Lilly Wagner1,2, Scott Ketner1,2, Simeon Lauer1,2. 1Ophthalmology, Bronx-Lebanon Hospital Center, New York, NY, United States, 2
Ophthalmology, Albert Einstein College of Medicine, New York, NY, United States
Introduction: Current clinical recommendations for conservative management of orbital fractures presume patient compliance with
outpatient follow-up appointments. Patient and visit specific variables evident on first presentation in the emergency department
(ED) may mitigate the expectation for follow-up compliance, necessitating observation or admission status, without specific medical
indication. However, data on predictors of follow-up behavior are lacking and objective alternative management criteria are needed.
Methods: The ED and outpatient records of adult patients (>18 years) who presented with an acute orbital fracture at our inner city
hospital between January 2012 and December 2013 were retrospectively reviewed. Patients who underwent immediate repair were
excluded. Outpatient compliance was measured against patient and visit related variables, using bivariate and multivariate analysis to
identify associations between case specific factors and follow-up behavior.
Results: A total of N=92 patients were included. The overall rate of compliance with initial follow-up was 58.7%. There was a
significantly higher risk for non-compliance in patients who presented between 10PM and 5AM (p=0.008), patients who were
intoxicated at the time of presentation (p=0.001), patients who had no prior outpatient visit in the ophthalmology or OMFS
department (p=0.005) and patients who were admitted for other medical reasons (p=0.043). Other factors such as patient age,
sex, mechanism of trauma and presence of other injuries did not show a significant association with follow-up behavior.
Conclusions: In orbital fracture cases managed with delayed repair, patient compliance with follow-up appointments is essential.
In our patient population the follow-up rate is overall moderate, however time of presentation to the ED, presence of intoxication and
lack of prior outpatient visits to the ophthalmology service are variables associated with significantly higher risk of non-compliance
with follow-up. These objective findings are crucial to define criteria for new management categories such as observation or extended
recovery status.
1:18 pm Orbital Tumors: An Epidemiologic Survey at a Tertiary Referral Center
Jordan Thompson, Sophie Liao, Sander Dubovy, Thomas Johnson. Bascom Palmer Eye Institute, University of Miami Miller School
of Medicine, Miami, FL, United States
Introduction: Orbital tumors and simulating masses can present in any age group and comprise a range of benign and malignant
disease. Clinical evaluation with or without orbital imaging is often insufficient, and may require histopathologic confirmation.
Knowledge of the true incidence of subtypes of orbital masses remains difficult, as patients who are clinically stable and functionally
asymptomatic may be monitored without a biopsy. Several authors have reported orbital tumor frequencies based on clinical or
radiographic data, but the majority of these reports lack complete histopathologic correlation. An analysis of the orbital lesions that
cause either functional symptoms or present a diagnostic dilemma, both situations that prompt an orbital mass biopsy, would be
informative 1,2 3. The purpose of this study was to analyze the incidence of histopathologically-confirmed orbital tumors and simulating
masses over the period 1997-2014 that presented to a single tertiary referral eye institute.
Methods: Retrospective, observational case series. The Florida Lions Ocular Pathology Laboratory database at the Bascom Palmer
Eye Institute was searched for all orbital masses and simulating lesions that were biopsied between 1997 and May of 2014. The
diagnosis was established by the histopathologic findings in each case. The number and percentage of each subtype of neoplastic
and nonneoplastic disease were calculated.
Results: 727 neoplastic and nonneoplastic orbital masses with histopathologic data were analyzed. There were 347 lymphocytic
and leukocytic lesions (47.7%), 74 vasculogenic lesions (10.2%), 53 neurogenic masses (7.3%), 35 metastatic masses (4.8%),
21 fibrocytic masses (2.9%), 13 cystic masses (1.9%), 12 histiocytic lesions (1.6%), 10 myogenic tumors (1.4%), 10 osseus and
fibro-osseus lesions (1.4%), 8 orbital amyloidosis (1.1%), 4 lipoid/myxoid lesions (0.5%), 7 lacrimal sac tumors (0.9%),
24 inflammatory and infectious masses (3.3%), 56 secondary tumors (7.7%), and 63 lacrimal gland masses (8.7%). The most
common benign diagnoses were benign lymphocytic infiltrate (25.4% overall and 53.3% of all lymphocytic/leukemic lesions) and
cavernous hemangioma (7.6% overall and 74.3% of all vasculogenic lesions). The most common malignancy was extranodal
marginal zone lymphoma (16.4% overall, 34.3% of all lymphocytic/leukemic lesions).
Conclusions: We report the incidences of subtypes of orbital tumors and simulating lesions over 17 years. Evaluation and analysis of
these masses presenting to a large tertiary referral center can help to inform the ophthalmologist when presented with a patient with
a new orbital mass.
References: 1. Khandekar RB, Al-Towerki AA, Al-Katan H, et al. Ocular malignant tumors. Review of the Tumor Registry at a tertiary
eye hospital in central Saudi Arabia. Saudi medical journal. Apr 2014;35(4):377-384.
2. Bonavolonta G, Strianese D, Grassi P, et al. An analysis of 2,480 space-occupying lesions of the orbit from 1976 to 2011.
Ophthalmic plastic and reconstructive surgery. Mar-Apr 2013;29(2):79-86.
3. Shields JA, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: The 2002 Montgomery
Lecture, part 1. Ophthalmology. May 2004;111(5):997-1008.
1:24 pm C-reactive Protein as a Marker for Initiating Steroid Treatment In Children
with Orbital Cellulitis
Brett W. Davies1, Jesse M. Smith1, Eric M. Hink1, Vikram D. Durairaj2. 1Oculofacial Plastic Surgery, University of Colorado Hospital,
Aurora, CO, United States, 2Texas Oculoplastic Consultants, Austin, TX, United States
Introduction: To assess the usefulness of C-reactive protein (CRP) levels as a marker for starting steroids in pediatric patients
with orbital cellulitis.
Methods: Prospective, comparative interventional study. Pediatric patients aged 1-18 years old admitted to a tertiary care children’s
hospital with a diagnosis of orbital cellulitis from October 2012 to March 2014 were included in the study. All patients received IV
antibiotics, and those with subperiosteal abscess were treated as per previous published criteria. CRP was measured daily as a
biomarker of inflammation, and when below 4 mg/dL, patients were started on oral prednisone 1mg/kg per day for 7 days. Patients
whose families did not consent to steroid treatment served as the control group. Patients were followed after discharge until
symptoms resolved and all medications were discontinued.
Results: Thirty one children were diagnosed with orbital cellulitis during the study period. Of these 31 children, 24 received oral
steroids (77%) and 7 did not (23%). The average CRP at the onset of steroid treatment was 2.8 mg/dL (range 0.5-4). Patients who
received oral steroids were admitted for an average of 3.96 days. In comparison, patients who did not receive steroids were admitted
for an average of 7.17 days (p <0.05). Once CRP was <4mg/dL, patients treated with steroids remained in the hospital for another
1.1 days, while patients who did not receive steroids remained hospitalized for another 4.9 days (p <0.01). Average follow up time
was 2.4 months in the treatment group and 2 months in the non-treatment group (p = 0.996). At last visit, all patients returned to
their baseline ophthalmic exam. There were no cases of vision loss or permanent ocular disability in either group.
Conclusions: Our results give further evidence of the safety and benefit of systemic steroids in children with orbital cellulitis.
Futhermore, this is the first study to suggest a standardized starting point (CRP <4 mg/dL) and dosing schedule (oral prednisone
1mg/kg for 7 days) for children with orbital cellulitis.
References: 1. Yen MT, Yen KG. Effect of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal
abscess. Ophthal Plast Reconstr Surg. 2005 Sep;21(5):363-62. Holds JB. Commentary on the effect of corticosteroids in the acute
management of pediatric orbital cellulitis with subperiosteal abscess. Ophthal Plast Reconstr Surg. 2005 Sep;21(5):366-73. Jaye
DL, Waites KB. Clinical applications of C-reactive protein in pediatrics. The Pediatric Infectious Disease Journal Issue: Volume 16(8),
August 1997, pp 735-7474. Arnold JC, Cannavino CR, Ross MK, Westley B, Miller TC, Riffenburgh RH, Bradley J. Acute bacterial
osteoarticular infections: eight-year analysis of C-reactive protein for oral step-down therapy. Pediatrics. 2012 Oct;130(4):e821-85.
Pushker N, Tejwani LK, Bajaj MS, Khurana S, Velpandian T, Chandra M. Role of oral corticosteroids in orbital cellulitis. Am J
Ophthalmol. 2013 Jul;156(1):178-183
Panel: Jane S. Kim, MD, Janice Liao, MD, Lilly Wagner, MD, Jordan Thompson, MD, Eric M. Hink, MD
The Practice of Oculofacial Plastic Surgery
1:40 pm Oculoplastic Hospital Call Coverage Utilization: A Prospective Study
Craig Czyz1,2, Adam Strittmatter1, Kenneth Cahill2, Jill Foster1,2. 1Oculofacial Plastic and Reconstructive Surgery, Ohio University,
Columbus, OH, United States, 2Ophthalmology, Oral and Maxillofacial Surgery, Grant Medical Center, Columbus, OH, United States
Introduction: According to a recent survey, the amount of physicians compensated for call coverage has increased 25% in the past
year to 60% overall1. While the study did report on “surgical subspecialists” there was no breakdown for specific subspecialties.
Further, the study did not comment on the patient volume or resources and time required to meet the on-call duties. While most
institutions have ophthalmology call coverage, oculoplastic subspecialists are routinely requested for “subspecialty” consultation,
especially at higher-level trauma centers.
Methods: Prospective study of hospital on-call coverage where oculoplastic evaluation and/or treatment was requested. Data was
collected over a consecutive one-year period at the following sites: 1. (1) Level 1 Trauma Center; 2. (1) Level 2 Trauma Center;
3. (3) Community Hospitals with no trauma rating. None of the sites had institutionally employed ophthalmologists or oculoplastic
surgeons. Data was aggregated based on trauma level rating. Consults were reviewed to determine if they were appropriate to
require oculoplastic evaluation, rather than general ophthalmology. Those not meeting inclusion criteria were excluded from the study.
Results: The Level 1 Trauma Center had the highest average number of consults per week (1.0), follow by the Level 2 center (0.47),
and community hospitals (0.27). The majority of consults at the Level 1 center were for inpatients (63%) versus the Emergency
Department (37%). The opposite trend was found at the Level 2 and community hospitals where Emergency Department consults
were significantly higher (69% Level 2 and 79% community). The consults that required surgical intervention were highest at the
Level 1 center (96%), followed by the community hospitals (71%), and Level 2 (62%). Approximately half the patients requiring
surgery at the Level 1 (42%) and Level 2 (50%) centers were uninsured versus 10% at the community hospitals. Overall, 42% of all
Level 1 patients encountered were uninsured, compared to 35% for Level 2, and 15% for the community hospitals.
Conclusions: The data indicates that oculoplastic surgeons providing on-call hospital coverage are most frequently summoned to
higher trauma rated centers, where surgical intervention is routinely required. While the amount and complexity of service provided is
highest at Level 1 centers, nearly half the patients treated are uninsured. The nationwide trend for paid hospital call coverage should
include oculoplastic surgeons who provide a complex level of care often without compensation for their services. These factors should
be part of the conversation when negotiating call coverage contracts.
References: Kearns, Madelyn. “On-call compensation is on the uptick.” Medical Practice Insider. 14 May 2014. Accessed 31 May
2014. http://www.medicalpracticeinsider.com/news/call-compensation-trending-upward-mgma-finds
1:46 pm A Modified Action Camera for High-Quality, Cost-Effective Oculofacial
Surgical Videography
Robi Maamari, Swapna Vemuri, Jeremiah Tao. Gavin Herbert Eye Institute, University of California, Irvine, Irvine, CA, United States
Introduction: High-resolution, mounted digital operating room video systems can be costly — in the tens of thousands of USD.1,2
We describe and evaluate a modified, commercially available, high-definition action camera for capturing high-quality oculofacial
surgical video footage.
Methods: A GoPro Hero3+ camera (GoPro, Inc., San Mateo, CA) was set up in the operating room using standard mounting
hardware (Figure 1). Two lens configurations were tested: the standard lens and a modified setup using a 16mm lens (RageCams,
Inc., Sparta, MI). We assessed image resolution (using ImageJ software; National Institute of Health, USA), field-of-view,
implementation cost, ease-of-use, and limitations.
Results: The standard (out-of-box) GoPro lens system was easy to mount and position with the Jaws: Flex Clamp™, but produced
a wide-angle view that was suboptimal for surgery (98.0 x 65.7 degrees; Figure 2A). Increasing magnification by positioning the
camera closer to the surgical field was impractical, as the setup interfered with the surgical space. Reconfiguration with a 16mm lens
presented technical challenges, however it achieved an appropriate field-of-view (19.9 x 11.2 degrees; Figure 2B) with the camera
at an appropriate distance from the surgical workspace. Resolution was excellent with the resolution grid showing a resolution greater
than 50 line pairs per inch (Figure 3). The total cost of the system was less than $800 USD. The system was highly user friendly; the
GoPro App adds further functionality, including mobile phone- or tablet-based control and monitoring, although the preview picture is
poorer quality than the actual video. High-resolution, real-time display required an HD monitor, but was easy to configure.
Conclusions: The modified action camera with the 16mm lens was effective in capturing high-resolution digital video recordings
with a suitable field-of-view at a fraction of the cost of marketed operating room video systems.
References: (1) Berchtold, Inc. (2014) ChromoVision HD Camera System [Price Quote Brochure]. Charleston, SC. Received January
15, 2014. (2) Paragon Medical Supply, Inc (2014). System Two Operating Room Lights. Retrieved on http://www.paragonmed.com/
systemonelighting.shtml
1:52 pm ASOPRS Atlas: Does the Distribution of the Over-65 Population Account for
Uneven Access to ASOPRS Specialists in Metropolitan Statistical Areas?
Rachel Sobel1, David Whelan2, Richard Allen3,4. 1Ophthalmology, Boston Medical Center/Boston University School of Medicine,
Boston, MA, United States, 2Office of Strategy and Business Development, Beth Isreal Deaconness Medical Center, Boston, MA,
United States, 3Ophthalmology and Visual Sciences, University of Iowa Hospital and Clinics, Iowa City, IA, United States, 4
Otolaryngology—Head and Neck Surgery, University of Iowa Hospital and Clincis, Iowa City, IA, United States
Introduction: The purpose of this abstract is to follow up on a 2012 study[i] which showed that access to ASOPRS specialists
across the 100 largest metropolitan areas were uneven. This study seeks to update those findings while also testing whether the age
distribution of populations in metropolitan areas might explain geographic access disparities.
Methods: Five-hundred eighty-two ASOPRS members currently practice in the U.S. Of those, 572 practice in defined Metropolitan
Statistical Areas. Each of those ASOPRS members was assigned by zip code to one of the 381 MSAs as defined by the U.S. Census
Bureau. For each MSA a per million persons ratio was calculated.
The number of persons 65 years old and above was assigned to each MSA using U.S. Census age distribution data. Another ratio,
comparing the number of ASOPRS in a given MSA to the number of individuals of Medicare age (65+), was calculated and compared
to overall access ratio.
Results: 510 of 581 U.S. ASOPRS members practice in the 100 largest markets, up from 451 reported in 2012. The largest clusters
of members were in the largest markets such as New York (#1 MSA, 46 ASOPRS) and Los Angeles (#2 MSA, 38 ASOPRS). In 2012,
18 of the top 100 MSAs lacked an ASOPRS specialist. In 2014 that number had fallen to 12. Those large metropolitan areas lacking
access to ASOPRS include Virginia Beach (#37) and Tulsa (#55).
Most MSAs lack access to ASOPRS specialists: only 135 out of 381 MSAs have an ASOPRS specialist. Within those 135 MSAs, the
range of access varies. Riverside had the least, at 0.7 ASOPRS per million while Ann Arbor had the most, at 19.8 ASOPRS per million.
A regression of the ASOPRS to general population ratio and the share of the population over 65 found an R-squared of only 0.017.
Age explains virtually none of the variability in access. Where markets offered substantial access to the general population they also
offered similar access to the Medicare population.
Conclusions: This study reiterates findings that access to ASOPRS specialists is uneven. Further, it found that age distributions
do not account for those differences. Limitations include inability to account for non-ASOPRS practice and not accounting for local
practice patterns of related specialties that overlap with oculoplastics.
References: [i] Sobel R, Whelan D, Allen R. Mapping disparities in access to ASOPRS specialists in metropolitan statistical areas.
43rd American Society of Ophthalmic Plastic & Reconstructive Surgery 2012 Annual Meeting, Chicago, IL. 2012 November 8.
1:58 pm Oculoplastic and Orbital Surgery: Millennia in the Making
George Bartley. Mayo Clinic, Rochester, MN, United States
Introduction: Founded in 1864 during the Civil War, the American Ophthalmological Society is the oldest medical society in the
United States. As part of the AOS’s sesquicentennial meeting earlier this year, a representative from each ophthalmic subspecialty
provided an overview of the discipline’s past, present, and future. This presentation reviews five milestones relevant to oculoplastic
and orbital surgery from antiquity until 1864, five milestones from 1864 to the present, and identifies five challenges for our future.
Panel: Craig Czyz, MD, Robi Maamari, MD, Rachel Sobel, MD, George Bartley, MD
ASOPRS Foundation Update & Michael J. Hawes
Lecture Series
2:20 pm ASOPRS Foundation Update and Foundation Service Award
Ralph E. Wesley, MD
2:25 pm ASOPRS Foundation Lecture Dedication to John N. Harrington, MD
James C. Fleming, MD
2:30 pm Introduction of ASOPRS Foundation Michael J. Hawes Lecturer
Mark J. Lucarelli, MD, FACS
2:35 pm Thyroid Eye Disease 25 Years of Progress — What’s Next?
Michael Kazim, MD
3 – 3:30 pm
Break with Exhibitors and Poster Stand By Session ASOPRS Fall Scientific Symposium Syllabus 67
3:30 pm Direct Submentoplasty Combined with Limited-Incision Facelift for Male
Lower Facial Rejuvenation
Tanuj Nakra1, Brett Kotlus2, Robert Schwarcz3, Jonathan Hoenig4. 1Texas Oculoplastic Consultants/ Toccare Medical Spa, Austin, TX,
United States, 2Allure Medical Spa, Shelby Township, MI, United States, 3Private Practice, New York, NY, United States, 4
Jules Stein Eye Institute/UCLA, Los Angeles, CA, United States
Introduction: Rejuvenation of the lower face for men by standard faclifting techniques is limited by the potential unwanted migration
of hair bearing skin, in contrast to female patients. In patients with significant skin laxity of the neck, the need for neck skin redraping
into the postauricular space can be dramatic. There is another procedure that has historically been useful for submental skin excess:
the direct necklift. In this study, we present a previously undescribed approach to male lower facial rejuvenation: limited facelifting
plus direct necklifting
Methods: This is a retrospective review of consecutive combined limited facelifts with direct necklifts performed in 4 private
practices over 5 years. Pre and postoperative photographic results were reviewed by blinded observers and compared. The overall
aesthetic outcome, the location of hair bearing skin, and appearance of the skin scars were reviewed. In addition, the charts were
reviewed for complications, subjective satisfaction, and safety of the procedure.
Results: A total of 18 patients met the inclusion criteria. The minimum follow up time was 4 months. 18 out of 18 patients were
judged to have excellent to very good overall results. 3 out of 18 patients were judged to have hair bearing skin posterior to the
lobule. 16 out of 18 patients were judged to have excellent to very good healing of the incisions- the remaining 2 patients underwent
additional scar revision to achieve optimal final results. There were no serious complications encountered in the series. 2 patients had
suture granulomas that were addressed with simple excision. 1 patient had a same day postoperative hematoma that was evacuated;
he undewent a normal postoperative healing phase thereafter.
Conclusions: The combined direct neck lift and limited lower facelift is a safe and effective procedure for achieving lower facial
rejuvenation in male patients. This combined procedure has a strong ability to limit the migration of the hair bearing skin. The long
term healing of the direct necklift is excellent due to its location and the ability of routine shaving manoevers in remodeling the scar
over the long run.
References: Bitner JB1, Friedman O, Farrior RT, Cook TA. Direct submentoplasty for neck rejuvenation. Arch Facial Plast Surg. 2007
May-Jun;9(3):194-200.
Perkins SW1, Gibson FB. Use of submentoplasty to enhance cervical recontouring in face-lift surgery. Arch Otolaryngol Head Neck
Surg. 1993 Feb;119(2):179-83.
3:36 pm A Definitive Surgical Approach to Festoons
Bhupendra Patel. Facial Plastic Surgery, University of Utah, Salt Lake City, UT, United States
Introduction: Malar festoons are the bane of an oculofacial surgeon’s life: ther has been no definitive surgical approach that has
been shown to work reliably. Indeed, many techniques that have been described seem to address only a part of the presenting
problem. These techniques include:
• Microsuction in the subcutaneous plane: excess fat in the subdermal plane can be suctioned using a small-caliber liposuction
cannula. The aim is to suction until the bulge has been removed and the fat is no longer palpable. May be useful if combined
with lateral suspension of the orbicularis oculi muscle to the temporalis muscle (Liapakis and Paschalis).
• Skin-Muscle Flap: Furnas described skin-muscle flaps and skin-only flaps with supero-lateral fixation.
• Midface lift: several authors have suggested subperiosteal midface lifts.
• Direct excision: this technique is usually used when there is a significant degree of skin excess with cascading skin hammocks.
• Laser resurfacing.
Based upon anatomic studies, we have established a surgical approach we would like to present, based upon 18 patients who have
had surgery using this technique.
Methods: As the anatomical basis of festoons includes laxity of the orbitomalar ligament, presence of a zygomaticocutaneous
ligaments, subcutaneous edema, skin laxity, skin festooning and midfacial ptosis, our approach includes the surgical intervention
of each of these. The patient with festoons is analyzed systemically, as presented in our paper.
The surgical technique includes the following steps:
• a trans-temporal approach to the midface in a pre-preiosteal plane.
• a lateral canthotomy and cantholysis with release of the orbitomalar ligament and dissection over the lateral and
anterior zygoma.
• a superficial skin only flap down to BELOW the mid-facial groove
• a sub-orbicularis dissection with elevation in a supero-temporal direction.
• manipulation of the malar edema with direct cautery and/or laser
• elevation in a supero-temporal direction with resection of excess skin.
• a firm cheek dressing for five days.
Results: We present our results and also our technique based upon 18 patients
who have undergone our technique. The results were judged as very good to excellent
in all cases. We also present some provisos that apply to this surgical approach.
Conclusions: Our method of analysis of festoons and the methodical surgical approach
gives the surgeon a reasonable chance of achieving success in the management of this
difficult problem.
References: Hester TR Codner MA McCord CA
The “centrofacial” approach to correction of facial aging using the transblepharoplasty
subperiosteal cheek lift
Aesthetic Surgery J. 16:51, 1996
Hester TR the transblepharoplasty approach to lower lid and midface rejuvenation
revisited: the role and techjnique of canthoplasty. Aesthetic Surgery J. 18:372,1998.
3:42 pm Central Platysmaplasty with a Bidirectional, Barbed Suture
Brett Kotlus1, Robert Schwarcz2, Tanuj Nakra3. 1Private practice, Shelby Twp, MI, United States, 2Private practice, NY, NY, United States, 3
Introduction: Corset platysmaplasty consolidates the submentum with centrally-directed suture plication of the platysma muscle.
We describe a method of platysma plication using an absorbable, bidirectional, barbed suture.
Methods: After exposure of the platysma muscle through a submental crease incision, a 2-0 gauge polydioxanone, double-armed,
bidirectionally barbed suture is used to approximate and then overlap the central muscles edges in conjunction with a deep plane or
SMASectomy facelift. The corset is performed in two layers and the suture ends are secured by reversing direction without tying a
knot. The platysma is horizontally transected below the level of the thyroid cartilage. 38 cases over a 12-month period were reviewed
with an average follow-up of 6 months.
Results: Successful improvement of the cervicomental contour was achieved in all patients without instances of early platysmal band
recurrence. The authors all reported reduced operative times and easy skill acquisition.
Conclusions: Barbed sutures in platysmaplasty aid in maintaining uniform suture tension and in eliminating bulk caused by knots.
They provide protection against slippage, even in the theoretical setting of disrupted sutures.
References: Paul MD. Barbed sutures in aesthetic plastic surgery: evolution of thought and process. Aesthet Surg J 2013; 33(3):
17S-31S.
Panel: Tanuj Nakra, MD, Bhupendra Patel, MD, Brett Kotlus, MD
3:55 pm Introduction of Dr. Andrew Jacono
Guy G. Massry, MD
3:58 pm A Structured Anatomic Approach to Face and Necklifting
Andrew Jacono, MD
There are many approaches in rhytidectomy from small incision, short skin flap SMAS plication techniques to long flap deep plane
techniques, with no consensus amongst surgeons which is the gold standard. Recently, their has been a greater understanding of
the anatomy of the face and neck, including the midface’s fat compartments, ligaments and musculature as well as the platysma
muscle’s ligamentous attachments. This course will explore incorporating these anatomic understandings into rhytidectomy. Areas
of focus will include deep plane dissection of the midface, complete platysma dissection and release, the vectors of suspension
applied to the SMAS, platysma and skin, and the indications for short incision approaches. Quantitative data will be presented to
describe the vectors of maximal rejuvenation in suspending the rhytidectomy. Results from a cohort of over 600 consecutive facelifts
with this approach will be presented, including complications and the need for tuck up surgery.
4:30 pm Trends in Pediatric Idiopathic Intracranial Hypertension (IIH):
A Multicenter Study of Treatment Outcomes
Rebecca Shields1, Roberto Warman2, Wendy Lee1, Kara Cavuoto1. 1Ophthalmology, Bascom Palmer Eye Institute, Miami, FL,
United States, 2Ophthalmology, Miami Children’s Hospital, Miami, FL, United States
Introduction: Idiopathic intracranial hypertension (IIH) commonly presents in obese females of child-bearing age. Our multi-center
study investigates current disease treatment and outcomes in children.
Methods: A retrospective multi-center chart review identified children (4-17 years) diagnosed with IIH from 2002-2012. Gender, age,
body mass index (BMI), optic nerve head (ONH) edema, treatment and outcomes were identified.
Results: Fifty-four patients were divided into group 1 (4-8 years), group 2 (9-12 years) and group 3 (13-17 years). The average
age was 11.5 years, differing significantly between males and females (9.7 versus 13.3 years, p=0.001). ONH edema was most
severe in group 3 and higher in females (median grade 4). Thirteen children underwent surgical intervention, of which 70% were
female (9/13). In the surgical group, the average grade of ONH edema was grade 3 (p=0.04) with median visual acuity of 20/70
pre-intervention and 20/25 post-intervention. The median ONH edema post-intervention in the surgical group was grade 1. Medical
treatment, however, was the predominant management method (41/54). In the medical group, the average ONH edema was grade 2
(p=0.04) with median visual acuity of 20/25 pre-intervention and 20/20 post-intervention. ONH edema post-intervention revealed a
median of grade 0.
Conclusions: Both medical and surgical treatment groups demonstrated overall improvement; however, the medical treatment group
demonstrated better outcomes. This is likely due to the severity of ONH edema in the surgical group. Pubescent female patients were
also found to require more invasive treatment methods and have worse visual prognosis.
References: Babikian, et al. “Idiopathic intracranial hypertension in children: the Iowa experience.” J Child Neurol 9:144-9, 1994.
Balcer, LJ., et al. “Idiopathic intracranial hypertension: relation of age and obesity in children.” Neurology 52: 870-872, 1999
Baryshnik, DB., et al. “Changes in the appearances of venous sinuses after treatment of disordered intracranial pressure.” Neurology
62:1445-6, 2004.
Cinciripini., et al. “Idiopathic Intracranial Hypertension in Prepubertal Pediatric Patients: Characterstics, Treatment, and Outcome.”
American Journal of Ophthalmology. Vol 127 (2): 178-182, 1999.
Friedman, DI., et al. “Diagnostic criteria for idiopathic intracranial hypertension.” Neurology 59: 1492-5, 2002.
Karahalios, DG., et al. “Elevated intracranial venous pressure as universal mechanism in pseudotumor cerebri of varying etiologies.”
Neurology 46:198-202, 1996
Liu, GT, et al. Neuro-ophthalmology: Diagnosis and management. Philadelphia, PA. Saunders, 2001.
Rangwala, Lubiana., et al. “Pediatric Idiopathic Intracranial Hypertension.” Survey of Ophthalmology. 52 (6) 597-617, 2007.
Rowe, FJ. “The relationship between obesity and idiopathic intracranial hypertension.” Int J Obes Relat Metab Disord 23:
54-59, 1999
Smith JL. “Whence pseudotumor cerebri?” J Clin Neuro-ophthalmol. 5:55-56, 1985.
Victorio, M. Cristina and Rothner, A. “Diagnosis and Treatment of Idiopathic Intracranial Hypertension (IIH) in Children and
Adolescents.” Curr Neurology and Neurosci Reports. 2013
Wall, M. “Idiopathic intracranial hypertension” Neurol Clin. 9:73-95, 1991.
4:36 pm Surgical Outcomes in Pediatric Orbital Cellulitis
Jesse Smith1, M. Leslie Pfeiffer2, Brett Davies1, Emily Bratton1, Eric Hink1, Vikram Durairaj3. 1Ophthalmology, University of Colorado,
Denver, CO, United States, 2Ophthalmology, University of Texas, Houston, TX, United States, 3Oculofacial Plastic Surgery, Texas
Oculoplastic Consultants, Austin, TX, United States
Introduction: Orbital cellulitis with subperiosteal abscess in pediatric patients can be a vision or life threatening condition if
not managed properly, and timely surgical intervention is often necessary to control the infection. Surgical approaches include
endoscopic sinus surgery with transnasal drainage of subperiosteal abscess, external orbitotomy, or a combined endoscopic and
external approach. Recent literature indicates a preference for an endoscopic approach, particularly for medially located abscesses.1,2
Our goal is to better characterize the clinical course of patients with surgical complications, focusing on the relationship between
surgical approach, microbiology, complication rate, and clinical outcomes.
Methods: This is a retrospective chart review of all patients presenting to Children’s Hospital Colorado 18 years of age and younger
between January 1, 2004 and November 1, 2012 with orbital cellulitis who underwent surgery as part of their treatment. Patients
were identified using diagnosis codes. Complications were defined as readmission within one month of discharge for recurrent
orbital cellulitis, recurrence of abscess, progressive cellulitis post-operatively, re-operation, prolonged hospitalization (>10 days) with
insertion of a peripherally inserted central catheter (PICC) line and home intravenous (IV) antibiotics, loss of vision, and death. Surgical
approaches were categorized as functional endoscopic sinus surgery (FESS) with or without transnasal drainage of abscess, external
orbitotomy, or combined endoscopic and external approaches.
Results: Fifty-eight patients underwent surgery. The initial surgeries performed were FESS alone (30 patients), external
orbitotomy alone (4 patients), and combined FESS and external orbitotomy (24 patients). Fifteen patients (26%) had complicated
postoperative courses as defined above, with re-operation (n=10) and prolonged hospital stay with PICC line and home IV antibiotics
(n=8) being the most common. Two patients lost all light perception by discharge, one patient developed orbital osteomyelitis
and underwent five orbitotomies, and one patient died from intracranial extension of infection. Fewer postoperative complications
occurred in cases where the initial surgery was a combined external and endoscopic approach versus an endoscopic-only approach
(8.3% vs. 36.7%, p=0.05). Patients with medial abscesses had lower complication rates than patients with non-medial abscesses
(12% vs. 50%, p<0.05). There were more anaerobic organisms cultured in patients who experienced postoperative complications
versus patients who did not (63.6% vs. 5.7%, p <0.05). Of the 15 children with complications, five (33.3%) had cultures that grew
Propionibacterium acnes.
Conclusions: A combined external and endoscopic approach to pediatric subperiosteal abscess is superior to either approach
alone. The combined approach leads to better outcomes and fewer complications with minimal added risk. Other risk factors for
complicated postoperative courses are non-medial location of an abscess and anaerobic infection.
References: 1. Pereira KD, Mitchell RB, Younis RT, Lazar RH. Management of medial subperiosteal abscess of the orbit in
children—a 5 year experience. Int J Pediatr Otorhinolaryngol 1997;38(3):247-54.
2. Fakhri S, Pereira K. Endoscopic management of orbital abscesses. Otolaryngol Clin North Am 2006;39(5):1037-47, viii.
4:42 pm Characteristics and Management of Tessier #3 Clefts
Peter Bin-yu Xie1, Bradford W. Lee2, Dongmei Li1, Jane S. Kim2, Bobby S. Korn2, Don O. Kikkawa2. 1Capital Medical University and
Beijing Ophthalmology Visual Science Key Lab, Beijing Tongren Eye Center, Beijing, China, 2Division of Ophthalmic Plastic and
Reconstructive Surgery, Department of Ophthalmology, UC San Diego Shiley Eye Center, La Jolla, CA, United States
Introduction: Embryonic facial development in the midline involves fusion of the medial nasal and maxillary processes. Arrested
growth leads to malunion, giving rise to complete or incomplete clefts. A classification scheme has been described by Tessier. Tessier
#3 clefts involving the medial canthus, lacrimal system, eyelid, and globe present a unique reconstructive challenge to oculoplastic
surgeons. We present a series of ten patients with Tessier #3 clefts.
Methods: This was a retrospective study involving two tertiary care centers. Medical records and pre- and post-operative
photographs of ten patients were reviewed. Age, gender, globe status, and lacrimal and canthal involvement were examined. Type of
reconstruction and operative sessions were also recorded. Primary outcome measures included final canthal position, globe status
and/or position, and degree of lacrimal system development.
Results: All patients had clefting present at birth. However, the presenting age ranged from 3 months to 13 years (average
3.9 years). All patients had clefts involving the medial canthus. 10/10 had lacrimal system involvement with either atresia or
obstruction of the lower canaliculus. One patient presented with dacryocystitis. 5/10 had cleft upper lips. In 6/10, the clefting
extended to the globe causing microphthalmos. 6/10 patients underwent Z-pasty of the medial canthus to elevate the dystonic
canthus. 2/10 underwent bone grafting to reconstruct the maxillary bone defect. Four of ten patients had dermis fat grafting for
soft tissue augmentation.
Conclusions: Lack of fusion of facial processes during embryonic development creates clefts involving the medial canthus, lacrimal
system, globe, cheek, and lip. Reconstruction of facial clefts involving the medial canthus typically involves rebuilding of the bony
structure if necessary, followed by soft tissue reconstruction and augmentation. The medial canthus position is elevated by Z-plasty
with dacryocystorhinostomy being performed simultaneously if necessary. Ptosis repair and socket reconstruction are performed
in the final stage if indicated. Tessier #3 clefts are uncommon, and full thickness clefts are the most challenging to treat. Good
functional and aesthetic results can be obtained even in severe cases.
References: 1. Wu D, Wang G, Yang Y, Chen Y, Wan T. Severe bilateral Tessier 3 clefts in a Uighur girl: the significance and surgical
repair. J Craniomaxillofac Surg. 2013;41(7):598-602.
2. Chen PK, Chang FC, Chan FC, Chen YR, Noordhoff MS. Repair of Tessier no. 3 and no. 4 craniofacial clefts with facial unit and
muscle repositioning by midface rotation advancement without Z-plasties. Plast Reconstr Surg. 2012;129(6):1337-44.
3. Allam KA, Wan DC, Kawamoto HK, Bradley JP, Sedano HO, Saied S. The spectrum of median craniofacial dysplasia. Plast Reconstr
Surg. 2011;127(2):812-21.
4. Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg. 1976;4(2):69-92.
4:48 pm Use of a Double Triangle Silicone Sling for Early Repair in Congenital Ptosis
Karen Revere, Maryam Nazemzadeh, William Katowitz, James Katowitz. Ophthalmology, The Children’s Hospital of Philadelphia,
Philadelphia, PA, United States
Introduction: To evaluate the efficacy and safety of a novel surgical approach for congenital ptosis repair using a double triangle
silicone sling.
Methods: A consecutive, retrospective case series of 38 children (48 eyes), aged 3 years or less (average 20 months), undergoing
congenital ptosis repair between April 2013 and June 2014 at The Children’s Hospital of Philadelphia. In all cases, a double triangle
silicone configuration (FCI Ophthalmics) was employed. This technique differs from single or double rhomboid approaches, as two
slings are used to create separate triangles extending from the medial and lateral tarsus, through frontalis with only two suprabrow
stab wounds. This approach was possible, even in the newborn eyelid, because of the thin and elastic silicone material, which is
easily secured with multiple surgical knots, rather than a bulky silicone cuff. Outcomes were based upon review of photographs and
medical charts. Functional success was defined as improvement of eyelid position above the pupillary margin (MRD1 ≥ 2.0mm)
without recurrence or serious complications. Cosmetic success was scored using the algorithm from Rizvi et al. by comparing
postoperative MRD1 between eyes, scored as good if inter-eye difference ≤ 1.0 mm; fair if 1.5-2.0 mm; and poor if > 2.0 mm.
Results: Follow-up ranged from 1 week to 24 weeks, with an average of 7.8 weeks. Five cases were excluded due to loss of
follow-up. There were no reported intraoperative complications. Functional success was (31/33 cases) 93.9% at last follow-up.
Cosmetic success was (24/33) 72.7% fair or good lid symmetry at last follow-up. Four unilateral cases (12.1%) needed a reoperation
due to functionally or cosmetically unacceptable recurrent ptosis, one of which involved a broken sling. No other complications were
noted; there were no corneal abrasions.
Conclusions: In this series, the double triangle technique using FCI Ophthalmics silicone sling appears to be a safe technique for the
correction of congenital ptosis. Functional success is comparable to other approaches for congenital ptosis repair. A longer follow-up
is needed to determine cosmetic efficacy.
References: 1. Rizvi SA et al. Evaluation of safety and efficacy of silicone rod in tarsofrontalis sling surgery for severe congenital
ptosis. Ophthal Plast Reconstr Surg. 2014; 30: 11-14.
2. Heher KL, Katowitz JA: Pediatric Ptosis. Katowitz JA; Pediatric Oculoplastic Surgery. New York, NY: Springer-Verlag. 2002:
262-280.
3. Katowitz J. Frontalis Suspension in Congenital Ptosis Using a Polyfilament, cable-type suture. Arch Ophthalmol. 1979; 97:
1659-1663.
Panel: Rebecca Shields, MD, Jesse Smith, MD, Peter Bin-yu Xie, MD, Karen Revere, MD
5 pm
Adjourn
5 pm
Detailed Program — Friday, October 17, 2014
YASOPRS Eye Openers – Rapid Fire Cases and Presentations
Sponsored By: Young ASOPRS (YASOPRS). YASOPRS are defined as ASOPRS members, age 40 or less.
7:00 am Intralesional Rituximab: An Effective Therapeutic Alternative for Recurrent
Orbital Lymphoma in a Patient with Severe Dry Eye
Courtney Kauh, Victor Elner, Hakan Demirci. Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center,
Ann Arbor, MI, United States
Introduction: Mucosa associated lymphoid tissue (MALT) lymphoma is the most common primary ocular adnexal lymphomas
(OAL).1 Radiation therapy is the mainstay treatment for primary OAL but it might have substantial ocular side effects.2 Systemic
rituximab has been used as an alternative therapy for CD20 positive OAL in selected cases. However, it is less effective in relapsing
patients.3 Recent literature has reported the use of intralesional rituximab for treatment of primary OAL.4,5 We herein report the use of
intralesional rituximab for recurrent MALT OAL in a patient with severe dry eye secondary to Sjogren syndrome.
Methods: Case report and literature review
Results: A 41- year old female with Sjogren’s syndrome presented with a 5-month history of bilateral upper eyelid swelling.
Incisional biopsy of the left lacrimal gland revealed MALT lymphoma. Due to bilateral severe dry eyes, the patient declined external
beam radiotherapy and systemic rituximab was initiated. The patient responded well to intravenous rituximab and the follow-up CT
scan revealed decrease in size of both lacrimal glands. Eleven months after systemic rituximab therapy, the patient had bilateral
lacrimal gland recurrence. The patient again declined external beam radiotherapy. Intralesional rituximab (50mg /1 ml) was injected
into the left lacrimal gland, followed by injection in the right lacrimal gland 7 months later. Eighteen months follow-up after injection
into left lacrimal gland and 10 months after injection into right lacrimal gland, there was significant interval decrease in size of
bilateral lacrimal glands.
Conclusions: This case highlights the use of intralesional rituximab as an alternative therapy for recurrent orbital MALT lymphoma in
selected cases.
References: 1. Coupland SE, Hummel M, Stein H. Ocular adnexal lymphomas: five case presentations and a review of the literature.
Surv Ophthalmol. 2002;47(5):470-490.
2. Tsang RW, Gospodarowicz MK, Pintilie M, et al. Localized mucosa-associated lymphoid tissue lymphoma treated with radiation
therapy has excellent clinical outcome. J Clin Oncol. 2003;21(22):4157-4164. doi:10.1200/JCO.2003.06.085.
3. Ferreri AJM, Ponzoni M, Martinelli G, et al. Rituximab in patients with mucosal-associated lymphoid tissue-type lymphoma of the
ocular adnexa. Haematologica. 2005;90(11):1578-1579.
4. Savino G, Battendieri R, Balia L, et al. Evaluation of intraorbital injection of rituximab for treatment of primary ocular adnexal
lymphoma: a pilot study. Cancer Sci. 2011;102(8):1565-1567. doi:10.1111/j.1349-7006.2011.01976.x.
5. Laurenti L, De Padua L, Battendieri R, et al. Intralesional administration of rituximab for treatment of CD20 positive orbital
lymphoma: safety and efficacy evaluation. Leuk Res. 2011;35(5):682-684. doi:10.1016/j.leukres.2011.01.030.
7:04 am Quantified Incision Placement for Transconjunctival Blepharoplasty with
Retroseptal Fat Entry
Cesar Briceno1, Satyen Undavia2, Guy Massry3. 1Ophthalmology, Kellogg Eye Center, Ann Arbor, MI, United States, 2Facial Plastic
Surgery, Spalding Drive Cosmetic Surgery and Dermatology, Beverly Hills, CA, United States, 3Ophthalmic Plastic Surgery, Beverly
Hills Ophthalmic Plastic Surgery, Beverly Hills, CA, United States
Introduction: Eyelid/orbital fat can be accessed in transconjunctival lower blepharoplasty (TCB) via a preseptal or retroseptal
approach. Retrospetal surgery is a direct approach to fat which proceeds through an incision below the fusion point of the lower
eyelid retractors and the orbital septum. The literature states that the conjunctival incision in this approach should be placed 3-5 mm
below the tarsus, at the inferior vascular arcade, or in the fornix. There has been no quantitative study evaluating location of incision
placement and the associated incidence of accessing fat directly.
Methods: A retrospective chart review of patients undergoing TCB by one of us from January 2013 to January 2014 was
performed. Patients with a history of previous eyelid surgery, eyelid trauma, thryroid eyelid/orbital disease, or with eyelid malposition
on presentation were excluded. Simultaneous globe retropuslion and lower eyelid inferior displacement was used to balloon the
conjunctiva forward for better exposure of anatomy. This maneuver allowed clear view of the relevant subconjunctival posterior eyelid
landmarks of importance: the tarsus, lower eyelid retractors, and the eyelid/orbital fat. A caliper was used to measure the distance
in millimeters from the inferior tarsus to the most superior projection of fat. The conjunctival entry was made just posterior to this
measurement in each case. For each procedure it was noted whether the retrospetal (direct fat exposure) or preseptal (requiring
septal division) plane was entered.
Results: Sixty-six patients (132 eyelids) were assessed. Fifty patients were woman and 16 patients were men. The mean patient
age was 54 years (range 36-71 years). The mean distance from the tarsus to the visualized anterior tip of fat was 6.03 mm (range
5-7 mm) and the mean incision placement was 6.53 mm (range 5.5-7.5 mm). The retroseptal space (direct access to fat) was
entered in 82% of cases. In many cases the inferior vascular arcade was above our incision placement. There were 5 cases (7.6%) of
postoperative chemosis which all resolved within 2 months with conservative measures. There were no healing issue or complications
related to the conjunctival incision.
Conclusions: Placing the transonjunctival incision for blepharoplasty just posterior to the most anterior projection of clinically visible
fat accesses the retrospetal space directly in 82% of cases. Previously suggested incision placement above this level may lower this
percentage.
References: 1. Tomlinson FB, Hovey LM: Transconjucntival lower blepharoplasty for fat removal. Plast Reconst Surg 1975;56:
314-18. 2. Baylis HI, Long JA, Groth MJ: Transconjunctival lower lid blepharoplasty. Technique and complications. Ophthalmology
1989;96;7:1027
7:08 am Combined Endoscopic Endonasal Transorbital Approach with Transconjunctival
Medial Orbitotomy for Orbital Tumor Excision: Our Experience and Technique
Lisa Chen, Tarek El-Sawy, Andrea Kossler. Ophthalmology, Byers Eye Institute at Stanford, Palo Alto, CA, United States
Introduction: A variety of approaches have been described and used in the management of orbital lesions. Traditionally, tumors
of the medial orbit have been removed by an external approach through the skin, conjunctiva, or caruncle. Significant advances in
endoscopic surgery have led to the more recent use of endoscopic techniques as an alternative approach to resecting orbital lesions.
The purpose of this study is to review the authors’ experience with a combined endoscopic endonasal transorbital approach with
transconjunctival medial orbitotomy for the removal of posterior medial orbital tumors in order to evaluate and present the utility of
this approach in Oculoplastic surgery.
Methods: In this retrospective case series, three patients with medial orbital tumors were treated with endoscopic transconjunctival
orbitotomy. Charts were reviewed for patient demographics as well as pre-operative and post-operative variables including orbital
imaging, tumor size and location, tissue diagnosis on pathology, intraoperative complications, post-operative time to recovery, and
patient satisfaction. Additionally, the surgical technique is described in detail.
Results: The study group consisted of 3 patients, two females and one male, with a mean age of 52 years (range 48-54 years).
Proptosis was the most common pre-operative finding and was present in all patients. Mean pre-operative exophthalmometry was
23 mm (range 21-25 mm), with an average difference of 5mm (range 2-9 mm) between the affected and unaffected eye. Evidence
of optic neuropathy was present in 2 out of 3 patients. All tumors were located in the posterior medial orbit. Mean tumor size was
1.4 cm (range 1.3-1.5 cm) in maximal dimension in two patients with measurable, discrete lesions on orbital imaging. The third
patient had a large, invasive right orbital tumor circumferentially encompassing the optic nerve with extension through the orbital
apex into the cavernous sinus and partial extension into the right ethmoid and sphenoid sinuses. Histopathology was consistent
with vascular malformation in two patients and meningioma (WHO grade 1) in the third. There were no significant intra-operative
or post-operative complications. By post-operative week one, all patients were doing well with stable to improved visual acuity and
visually significant improvement in proptosis. Moreover, all patients were satisfied with their post-operative results at mean
follow-up time of 6.3 months (range 1-10 months).
Conclusions: Combined endoscopic transconjunctival orbitotomy for medial tumor excision is a promising treatment option that
offers several advantages over a traditional external approach, including improved cosmesis and absence of cutaneous scarring,
enhanced surgical visualization and access to the posterior medial orbit, decreased orbital compression during surgical manipulation,
improved post-operative recovery time, and excellent patient satisfaction. This approach, in particular, should be considered
for posterior medial orbital tumors in patients at risk for compressive optic neuropathy or excessive bleeding due to abnormal
vasculature. As endoscopic technology continues to advance, the applicability of this approach to managing orbital tumors may
continue to expand.
7:12 am One Stage Hughes Flap
Erin Lessner1, Alexander Blandford2, Anthony Greer2, Alan Lessner2. 1Ophthalmology, University of South Carolina, Columbia, SC,
United States, 2Ophthalmology, University of Florida, Gainesville, FL, United States
Introduction: The purpose of this project is to identify an efficient one stage Hughes flap approach with optimal lower eyelid contour.
Methods: This prospective surgical trial included three patients with lower eyelid defects from basal cell carcinoma. The first patient
had a lower eyelid defect measuring 60% after Mohs surgery. The other two patients had lower eyelid defects measuring 40-50%
after frozen section removal. The same surgeon performed each reconstruction. In each case, a Hughes flap in standard fashion was
transposed into the lower eyelid defect. A musculocutaneous advancement flap was recruited from the respective lower eyelid and
advanced over the Hughes flap in the area of the reconstructed defect. A combination of 7-0 vicryl and 6-0 silk sutures were used for
cutaneous closure. Sharp wescott scissors were then used to transect the Hughes flap to create the new eyelid margin.
Results: The three patients had excellent graft survival and contour of their reconstructed eyelid. Patients were seen two weeks after
surgery and seen post operatively through month six. There was no eyelid retraction or flap compromise. No revisions were required.
Each patient was pleased with the surgical outcome. None of the patients experienced significant post-operative swelling or bruising.
There were no post-operative infections.
Conclusions: The Hughes flap is a well-established procedure to reconstruct significant lower eyelid defects. The Hughes flap is
subsequently released as a staged secondary procedure with the rationale that it requires a period of time for the distal portion
of the Hughes flap to achieve vascularity and integration into the new lower eyelid defect. The length of time between stage one
and two procedures has ranged from three months to approximately one week. We propose the Hughes flap in conjunction with
a musculocutaneous advancement flap can be released as a one -stage procedure without posterior lamellar compromise. This
technique provides all the advantages of the Hughes flap while eliminating obstruction of vision and need for a second procedure.
References: 1. Leibovitch, I, Selva, D. Modified Hughes flap. Ophthalmology 2004;111:2164-2167.
2. Paridaens, D, van den Bosch, W. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts.
Ophthalmology 2008;115:189-194.
7:16 am Acellular Dermal Matrix-supported Modified Tenzel Flap for Reconstruction of
Large Lower Eyelid Defects
Pradeep Mettu1,3, Andrew Munro2,3, Parag Gandhi2,3. 1Duke Eye Center, Durham, NC, United States, 2Duke Eye Center of Winston-Salem,
Winston-Salem, NC, United States, 3Duke University School of Medicine, Durham, NC, United States
Introduction: The Tenzel myocutaneous flap is a method to reconstruct medium-sized full-thickness lower eyelid defects. Larger
lower lid defects are reconstructed with a lid-sharing procedure from the upper to the lower lid, usually a Hughes tarsoconjunctival
flap. This necessitates closure of the involved eye for many weeks until the lids can be separated. The staged procedure lengthens
the patient’s overall healing time, increasing morbidity. To avoid this, we developed a new technique to reconstruct large lower eyelid
defects utilizing a modified Tenzel myocutaneous flap with a lateral segment of acellular dermal matrix.
Methods: We present a case series of two patients with large full-thickness lower eyelid defects who successfully underwent
reconstruction using our technique. The first patient is a 77-year old woman who presented with a nodular mass on the central
right lower eyelid margin for over one year. A biopsy-confirmed basal cell carcinoma was excised via frozen section technique,
yielding a full-thickness defect of the eyelid just over one-half of the total eyelid length (Figure 1). The second patient is 67-year
old man who presented with an ulcerated tumor of the left lower eyelid margin for over six months. A biopsy-confirmed basal cell
carcinoma was resected from this location by Mohs surgery, yielding a full-thickness defect of the eyelid approximately three-fifths
of the total eyelid length.
Description of technique: After lateral canthotomy and inferior cantholysis is performed, followed by release of the lateral
retinaculum from the orbital rim, the lateral lower eyelid becomes completely mobile from the lateral canthus. A traditional Tenzel flap
with an inverted semicircular incision is performed mobilizing the lateral myocutaneous tissue. A large segment of the reconstructed
lateral lower eyelid is composed of the myocutaneous flap with skin and muscle anteriorly. While there is conjunctiva posteriorly,
there is no tarsal support in this segment of the eyelid. A 1mm-thickness acellular dermal matrix graft is secured between the lateral
aspect of the tarsal stump and the lateral orbital rim filling this void and adequately supporting the eyelid for proper healing, function,
and aesthetics (Figure 2).
Results: Both patients in this series had successful eyelid reconstruction with the described technique. Post-operatively, the patients
had immediate use of the eye and healed with excellent symmetry and full support of the lower eyelid without malposition (Figure 3).
Conclusions: An acellular dermal matrix-supported Tenzel myocutaneous flap can be used to reconstruct large lower eyelid defects
in lieu of a Hughes tarsoconjunctival flap thereby reducing patient recovery time and preventing functional impairment imposed by
ocular occlusion.
7:20 am Granulocytic Sarcoma of the Orbit Presenting as a Fulminant Orbitopathy in an
Adult with Acute Myeloid Leukemia
Ali Mokhtarzadeh1, Andrew Harrison1,2. 1Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN,
United States, 2Otolaryngology, University of Minnesota, Minneapolis, MN, United States
Introduction: We present an unusual manifestation of orbital granulocytic sarcoma as a fulminant orbital process in a 64 year old
with acute myeloid leukemia (AML), presenting with double vision, rapid proptosis, and ultimately dramatic optic neuropathy and
vision loss, all over several hours.
Methods: Case Report
Results: A 64 year old with relapsed AML undergoing salvage chemotherapy with mitoxantrone and etoposide developed rapid onset
of right sided ophthalmoplegia, proptosis, optic neuropathy and vision loss from 20/30 to hand motions over a three hour period on
day four of her treatment. CT scan of her orbits revealed a markedly enlarged lacrimal gland and periocular edema (Figure 1). She
underwent immediate canthotomy and cantholysis (Figure 2), and a lateral orbitotomy later the same day. Despite her pancytopenia,
little bleeding was encountered and the hard, white mass was debulked. Bacterial and fungal cultures and stains were negative.
Pathology and flow cytometery revealed lacrimal gland infiltration by aggregates of myeloid blasts.
Conclusions: Orbital granulocytic sarcoma is a rare condition often concurrent with AML, typically in the pediatric population, and
rarely in adults. Presentation as a fulminant orbitopathy with rapidly progressive optic neuropathy and vision loss over several hours
has not been previously reported in the literature.
7:24 am Intralesional Clindamycin Injections for the Treatment of Necrotizing Fasciitis
Payam Morgan, Catherine Hwang, Robert A. Goldberg. Ophthalmology, UCLA, Los Angeles, CA, United States
Introduction: Necrotizing fasciitis (NF) is aa necrotizing soft tissue infection that spreads along fascial planes with or without
overlying cellulitis. It has also been described as a rapidly progressing necrotizing process accompanied by severe systemic toxicity.
Secondary to the necrotizing properties of this disease, surgical debridement along with systemic antibiotics have been the primary
treatment. This is one of the most challenging surgical diseases. This is even more real when the disease involves any part of the
face, since the open real estate is sparse for surgical debridement. Surgical debulking of the necrotic tissue typically occurs on
multiple occasions through out the course of the disease. However, on the face, this may leave the patient with significant morbidity
afterwards. Here we describe a case in which the addition of intralesional Clindamycin injection into the infected sites may have
reduced the need for further debridement by providing the ischemic tissues with direct access to the antibiotic. To our knowledge,
there are no reports of tissue injections of Clindamycin for the treatment of necrotizing fasciitis.
Methods: This is a case of a 73 y.o. female with a history of Diabetes Mellitus, Atrial Fibrillation, who presented with rapidly
spreading pre-septal cellulitis (figure 1) after being stabbed with a sharp branch on her right eyelid while gardening 2 days ago.
She initially noticed some mild redness, edema, warmth and pain rapidly spreading across her right eye. She presented to an outside
hospital, where her cultures grew group A streptococcus. She was then transferred to Ronald Reagan, UCLA hospital for higher level
of care. She initially underwent surgical debridement of the Right eyelid. She was started on systemic antibiotics, daily hyperbaric
oxygen therapy and daily intralesional clindamycin injections of 1.2mg/ml were injected diffusely into the infected sites for one week.
Everyday, she underwent bedside debridement. She was discharged after 14 days (figure 2).
Results: The patient had significantly less necrosis after the second day of injections. The cultures grew Streptococcus Pyogenes
sensitive to Clindamycin. The patient developed mild hyperammonemia during her stay that may have been secondary to her
underlying hepatic disease and Clindamycin. This was corrected after the Clindamycin injections and intravenous were stopped.
Conclusions: Intralesional Clindamycin injections did not result in any further tissue toxicity. The intralesional injections may have
reduced the amount of tissue necrosis by bypassing the circulatory system and directly infiltrating the ischemic tissues. It may be
used in other patients with necrotizing fasciitis who have no contraindications to Clindamycin. Further studies are needed.
References: Necrotizing Fasciitis, Sadasivan J, Maroju NK, Balasubramaniam A.
Indian J Plast Surg. 2013 Sep;46(3):472-478.
7:28 am MRI Findings of Non-Specific Orbital Inflammation (NSOI) of the Optic Nerve
in a Child
Carisa Petris, Payal Patel, Michael Kazim. Ophthalmology, Columbia University College of Physicians and Surgeons, New York, NY,
United States
Introduction: Non-specific orbital inflammation (NSOI) is a noninfectious, inflammatory disorder which may affect all orbital tissues,
namely, the posterior sclera, extraocular muscles, trochlea, lacrimal gland, optic nerve sheath, and orbital apex. We present an
unusual and very rare case of IOI affecting the optic nerve in a pediatric patient.
Methods: The medical records, radiography and pathologic reports of one patient were reviewed.
Results: A 20 month-old male presented with a 1-month history of progressive right proptosis (Figure 1). The diagnosis of
optic nerve glioma was entertained at an outside hospital and an MRI and CT with contrast were consistent with the diagnosis.
Corticosteroids were begun and a transcranial optic nerve resection was recommended. On presentation, he was found to have
a fixed right pupil, neovascular glaucoma, and an intraocular pressure of 50. There were diffuse intra-retinal and pre-retinal
hemorrhages. While the optic nerve was poorly visualized due to vitreous hemorrhage there appeared to be papilledema. Signs of
venous stasis and choroidal thickening were evident on B scan. A second MRI (Figure 2a) showed abnormal optic nerve enlargement
extending into the optic canal and to the optic chiasm; however, there was additionally noted significant restriction of diffusion
more consistent with an infiltrative leukemic/lymphomatous process than an optic glioma. There was resolution of post-contrast
enhancement thought secondary to steroid therapy. A biopsy of the optic nerve lesion identified fibroconnective tissue with mixed
inflammatory and reactive glial cells consistent with the diagnosis of NSOI. In this case the restricted diffusion may have been the
result of posterior ischemic optic neuropathy secondary to the inflammatory mass. The child was treated with oral corticosteroids
for one month. After withdrawal of the corticosteroids a follow-up MRI showed near complete resolution of the optic nerve
enlargement (Figure 2b).
Conclusions: NSOI is rarely seen in the pediatric population and even more rarely found to affect the optic nerve[1]. This is an
unusual presentation of a presumed glioma in a pediatric patient who was ultimately found to have NSOI affecting the optic nerve on
biopsy. We believe this represents, the first reported case of MRI findings of optic nerve glioma which highglights the importance of
DWI restriction to distinguishing optic glioma from that of a lymphoid infiltrate.
References: Winterkorn, J.M., J.G. Odel, M.M. Behrens, and S. Hilal, Large optic nerve with central retinal artery and vein occlusions
from optic neuritis/perineuritis rather than tumor. J Neuroophthalmol, 1994. 14(3): p. 157-9.
7:32 am Cosmetic Hyaluronic Acid Injection: Delayed Periocular Edema as an
Uncommon Complication
Sherveen Salek, Jessica Chang, Jordan Piluek, Charles Eberhart, Timothy McCulley. Wilmer Eye Institute, Johns Hopkins Hospital,
Introduction: Inflammatory reaction, occurring within weeks to months following, cosmetic hyaluronic acid injection, is a known and
well-described potential complication. In this report, we describe two patients who presented with periocular edema over three years
following treatment. We are unaware of any previously described similar cases.
Methods: Interventional case report
Results: Case 1: A 53 year-old man was referred for evaluation of bilateral lower eyelid edema of four months duration. Five years
prior, he reported uncomplicated cosmetic hyaluronic acid injection to the glabella and tear troughs bilaterally. Examination was
normal with the exception of bilateral swelling at the junction of both lower eyelids and the cheeks, oriented similar to and overlying
the “tear trough”. MRI demonstrated diffuse enhancement of the involved subcutaneous tissue. Surgical exploration with excision of
copious amounts of gelatinous material was performed. Microscopic evaluation demonstrated abundant amorphous and acellular
gray material dissecting through the soft tissues, highlighted by colloidal iron stains, consistent with retained hyaluronic acid. Residual
swelling was successfully managed with hyaluronidase injection.
Case 2: A 47 year-old female presented with one year duration of chronic bilateral periorbital edema. She had undergone cosmetic
hyaluronic acid injection of four years prior. Ophthalmologic exam was notable for bilateral periocular fullness. On surgical exploration
similar gelatinous material was excised. Microscopy demonstrated muscular fibers surrounded by an amorphous, acellular gray
material that highlighted with colloidal iron and Alcian blue stains, consistent with retained hyaluronic acid.
Conclusions: We describe two patients who presented with periocular swelling several years following cosmetic hyaluronic acid
injection. In both cases, they were symptom-free for three or four years before developing periocular edema. This is notable for two
reasons. First, hyaluronic acid is not expected to persist for years following injection. Secondly, the presumed immune-mediated
response was markedly delayed, contrary to previously described cases with onset weeks to months following injection. Knowledge of
this potential complication is important to avoid delay in diagnosis and treatment.
References: Owosho AA, Bilodeau EA, Vu J, Summersgill KF. Orofacial dermal fillers: foreign body reactions, histopathologic features,
and spectrometric studies. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 May;117(5):617-25.
Requena L, Requena C, Christensen L, Zimmermann US, Kutzner H, Cerroni L. Adverse reactions to injectable soft tissue fillers.
J Am Acad Dermatol. 2011;64:1-34.
Andre P, Lowe NJ, Parc A, Clerici TH, Zimmermann U. Adverse reactions to dermal fillers: a review of European experiences.
J Cosmet Laser Ther. 2005 Dec;7(3-4):171-6.
7:36 am Mutational Landscape of Lacrimal Gland Carcinomas and Implications
for Treatment
Matthew Sniegowski1, Diana Bell2, Khalida Wani1, Michael Tetzlaff2, Kenneth Aldape2, Bita Esmaeli1. 1Orbital Oncology and Ophthalmic
Plastic Surgery Program, Department of Plastic Surgery, University of Texas MD Anderson, Houston, TX, United States, 2Department of
Pathology, University of Texas MD Anderson, Houston, TX, United States
Introduction: Lacrimal gland carcinomas are rare. Identification of molecular abnormalities underlying lacrimal gland carcinogenesis
is critical to the development of new targeted therapies for lacrimal gland carcinomas. The purpose of our study was to look for
mutations that can be targeted as new treatments for lacrimal gland carcinomas.
Methods: Genomic DNA from patients with lacrimal gland epithelial neoplasms was analyzed. The Sequenom MALDI TOF mass
ARRAY platform was used to profile 168 common oncogenic point mutations in 40 genes. Mutation frequency was assessed overall
and by histologic diagnosis. These genetic mutations were then correlated with clinical outcomes in the patients.
Results: The study included 14 males and 10 females with a median age of 45 years (range, 17-75 years). The histologic diagnoses
were as follows: adenoid cystic carcinoma (n=16), low-grade carcinoma ex pleomorphic adenoma (n=2), high-grade carcinoma
ex pleomorphic adenoma (n=2), squamous carcinoma (n=1), and pleomorphic adenoma (n=3). Analysis revealed 18 oncogenic
mutations in 13 patients: KRAS mutations in 10 patients (46%), NRAS mutations in 2 patients (8%), MET mutations in 3 patients
(13%), PIK3CA mutation in 1 patient (4%), and BRAF mutation in no patients. About half of the patients with adenoid cystic carcinoma
had oncogenic mutations (7 out of 16, 44%). Of the 16 patients with adenoid cystic carcinoma, 5 had KRAS mutations, 1 had MET
mutations, and 1 had an NRAS mutation.
Conclusions: KRAS, NRAS, and MET mutations are frequent in epithelial neoplasms of the lacrimal gland, with the highest
rate of mutations found in adenoid cystic carcinoma. Therapies targeting these genes may be effective treatments for lacrimal
gland carcinomas.
References: 1. Shields JA, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: the 2002
Montgomery Lecture, part 1. Ophthalmology. 2004;111(5):997-1008.
2. von Holstein SL, Therkildsen MH, Prause JU, Stenman G, Siersma VD, Heegaard S. Lacrimal gland lesions in Denmark between
1974 and 2007. Acta Ophthalmol. 2013;91(4):349-354.
3. Shields CL, Shields JA, Eagle RC, Rathmell JP. Clinicopathologic review of 142 cases of lacrimal gland lesions. Ophthalmology.
1989;96(4):431-435.
4. Wang XN, Qian J, Yuan YF, Zhang R, Zhang YQ. Space-occupying lesions of the lacrimal gland at one tertiary eye center in China: a
retrospective clinical study of 95 patients. Int J Ophthalmol. 2012;5(2):208-211.
5. Batsakis JG, Regezi JA, Luna MA, el-Naggar A. Histogenesis of salivary gland neoplasms: a postulate with prognostic implications.
J Laryngol Otol. 1989;103(10):939-944.
Mutational Landscape of Lacrimal Gland Carcinomas and Implications for Treatment,
continued
7:40 am Impaled Orbital Taser Injury
Jenny Temnogorod1, Frank Tsai1, Tanuj Nakra2, Roman Shinder1,2. 1Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY,
Introduction: When fired, the Taser (Thomas A Swift’s Electric Rifle, Taser International, Scottsdale, AZ, USA) releases two
harpoon-like barbed electrode darts at a speed of 18.3 m/s1. It has been increasingly used by law enforcement agencies as a way
to avoid lethal force, and its potential for penetrating and perforating globe injury has been documented1-5 [Fig1]. Teymoorian et al
described a 26 year-old male who sustained perforating globe trauma from a Taser that was repaired, but eventually progressed to
a blind painful eye that required enucleation4. We report what may be the first case of an impaled orbital Taser that required primary
enucleation for globe perforation.
Methods: The chart of a patient who sustained ocular and orbital trauma from a Taser was reviewed.
Results: A 24 year-old schizophrenic male was involved in an altercation with police officers and sustained a Taser injury to the left
globe and orbit [Fig2A]. On presentation he was NLP in the left eye. The end of the dart with attached wire was impaled in the nasal
globe [Fig2B]. Pupils were 3mm in the right eye, 6mm in the left eye with peaking superiorly. Fundus examination was without view
in the left eye due to hemorrhage. CT revealed a large dart-like metallic foreign body traversing the left globe from the superomedial
to inferolateral aspect impaling into the greater wing of sphenoid [Fig3]. The patient was taken to the operating room emergently for
exploration and removal of the foreign body. A 35mm dart with wire was removed from the left globe and orbit [Fig2C]. Due to the
extent of globe trauma primary enucleation was undertaken.
Conclusions: Though an effective non-lethal means of immobilizing criminal suspects, the Taser has the potential to cause
catastrophic ocular and orbital trauma. Periocular injuries from Taser may include globe penetration or perforation, electrical injury,
optic nerve damage, and orbital wall trauma. This case may represent the first report of an impaled Taser in an orbital wall that
required primary enucleation. Furthermore, this case highlights the importance of a multidisciplinary team approach including
ophthalmology, radiology, and trauma surgery in evaluating the extent of injury and formulating an appropriate treatment plan for
such patients.
References: 1. Chen SL, Richard CK, Murthy RC, Lauer AK. Perforating ocular injury by Taser. Clin Experiment Ophthalmol. 2006
May-Jun;34(4):378-80.
2. Li JY, Hamill MB. Catastrophic globe disruption as a result of a TASER injury. J Emerg Med. 2013 Jan;44(1):65-7.
3. Sayegh RR, Madsen KA, Adler JD, Johnson MA, Mathews MK. Diffuse retinal injury from a non-penetrating TASER dart. Doc
Ophthalmol. 2011 Oct;123(2):135-9.
4. Teymoorian S, San Filippo AN, Poulose AK, Lyon DB. Perforating globe injury from Taser trauma. Ophthal Plast Reconstr Surg. 2010
Jul-Aug;26(4):306-8.
5. Ng W, Chehade M. Taser penetrating ocular injury. Am J Ophthalmol. 2005 Apr;139(4):713-5.
7:40 am Impaled Orbital Taser Injury, continued
7:44 am Changes in Intracocular Pressure During Orbital Floor Fracture Repair
Preeti Thyparampil1, Michael Yen1, Phillip Freeman2, John Ng3, Jeremiah Tao4, Douglas Marx1. 1Ophthalmology, Baylor
College of Medicine, Houston, TX, United States, 2Oromaxillofacial Surgery, UT Houston Dental Branch, Houston, TX, United
States, 3Ophthalmology, Oregon Health & Sciences University, Portland, OR, United States, 4Ophthalmology, University of California
Irvine, Irvine, CA, United States
Introduction: Hypothesis: There is a decrease in intraocular pressure during orbital floor fracture repair due to intraoperative
manipulation of the globe.
Methods: Intraocular pressure was checked, using a tonopen, in patients undergoing orbital floor fracture repair. Measurements
were taken immediately after induction of anesthesia, immediately after orbital floor implant placement, and on postoperative
day one.
Results: Nine patients who underwent orbital floor fracture repair were examined. There was a mean decrease of 4.66 mmHg in
intraocular pressure from preoperative evaluation to immediately after implant placement. There was a mean increase in intraocular
pressure of 4.33 mmHg at postoperative day one compared to preoperatively. There was a statistically significant difference (p
<0.05) in intraocular pressures between preoperative evaluation and post-implant placement, between post-implant placement and
postoperative day one, and between preoperative evaluation and postoperative day one.
Conclusions: All patients undergoing orbital floor fracture repair in this study had a decrease in intraocular pressure during orbital
floor fracture repair. This may be due to intraoperative manipulation of the globe. Intraocular pressure was increased at postoperative
day one compared to preoperative evaluation in all patients. This may be due to postoperative edema and due to the loss of the
decompressive effect of the orbital floor fracture.
7:48 am Differential Expression of Micrornas in Sebaceous Carcinoma of Eyelid
Compared with Sebaceous Adenoma
Vivian T. Yin1, Michael T. Tetzlaff2, Jonathan Curry2, Khalida Wani2, Ganiraju C. Manyam3, Diana Bell2, Li Zhang3, Kenneth Aldape2, Bita
Esmaeli1. 1Orbital Oncology & Ophthalmic Plastic Surgery, Department of Plastic Surgery, University of Texas MD Anderson Cancer
Center, Houston, TX, United States, 2Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, United
States, 3Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
Introduction: Sebaceous carcinoma (SebCa) is a rare and aggressive tumor of eyelid with high morbidity and mortality. The
molecular basis of SebCa is poorly understood. Micro-RNAs (miRNA) are highly conserved, 20-24 nucleotide, non-coding RNAs that
function in complex gene regulatory pathways. With more than 800 miRNAs in the human genome, it comprises the largest classes
of gene regulators.[1] Alterations in miRNA expression have been described in virtually all human cancer types.[2] These differences
provide a window to those mechanism central to tumorigenesis and metastasis. Furthermore, miRNA signatures serve as molecular
surrogates that can be exploited to distinguish benign from malignant and to predict clinical outcome in cancer. We describe
differentially expressed miRNAs in a series of eyelid SebCa compared to sebaceous adenomas (SebA).
Methods: Eleven eyelid SebCa from 9 patients and 10 SebA from 10 patients were selected. Total RNA was extracted from
formain-fixed paraffin embedded tissue using Epicentre RNA isolation kit (Epicentre Biotechnologies, Madison, WI). Quality of RNA
was assessed and a real-time PCR based micro fluidics card (Applied Biosystems Foster City, CA) containing 378 unique miRNAs
was used. Using the reference probe “RNU48-001006” fold-change for each miRNA was determined using the ∆∆Ct method.
Median centering within samples was used to normalize the data. Cluster analysis was performed using Hierarchical clustering and
Principal Component Analysis. Differentially expressed miRNAs were identified using t-test and corrected for false discovery rate by
beta-uniform mixture method.
Results: In the SebCa group, there were 7 females and 2 males with a mean age at presentation of 67 years-old (range: 48 to
82). The most common location for SebCa was in the upper eyelids (6/9 patients). In the SebA group, there were 3 females and
7 males with a mean age at presentation of 68 years-old (range: 52 to 88). We identified statistically significant overexpression in
SebCa compared to SebA in miR-18a (p=0.014) and miR133a (p=0.014). Furthermore, reduced expression was noted in miR-196b
(p=0.0059), miR-193b (p=0.0050), miR-152 (p=0.038), and miR-199a (p=0.031).
Conclusions: Sebaceous carcinoma of of eyelid exhibits a distinctive miRNA expression profile compared to sebaceous adenoma.
This difference in miRNA signature may help predict outcome and determine possible targets for therapy in the future.
References: 1. Bentwich I, Avniel A, Karov Y et al. Identification of hundreds of conserved and nonconserved human microRNAs.
Nat Genet 2005;37:766-770.
2. Esquela-Kerscher A, Slack FJ. Oncomirs-microRNAs with a role in cancer. Nat Rev Cancer 2006;6:259-269.
3. Calin GA, Sevignani C, Dumitru CD et al. Human microRNA genes are frequently located at fragile sites and genomic regions
involved in cancers. PNAS 2004;101:2999-3004.
7:52 am Neuroendocrine (Carcinoid) Tumor Metastasis to the Extraocular Muscles:
Variability in Presentation and Primary Location
Sara Alshaker, Nariman Nassiri, Dan Rootman, Robert Goldberg. Division of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye
Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, United States
Introduction: Carcinoid (neuroendocrine) tumors are known to rarely metastasize to the orbit1. Typically, orbital disease occurs in
the presence of diffuse metastatic disease. Here, we describe three patients who presented to our clinic with carcinoid tumor without
diffuse metastatic disease.
Methods: The medical records of three patients who were referred to the Ophthalmic and Orbital Surgery Clinic at Jules Stein Eye
Institute were reviewed.
Results: There were two females aged 75 and 58 years, and one male aged 64 years. In one case the primary site of the tumor was
known to be in the ileocecal region. The other two cases did not have a known primary at presentation. One presented with carcinoid
syndrome, and was found on octreotide scanning to have disease in the orbit alone. The final case was found after an episode of
falling, and no primary was noted after extensive systemic investigation.
All patients had involvement of a single EOM; the involved muscles were the inferior rectus, superior oblique and medial rectus.
None of the patients presented with EOM dysfunction or associated diplopia. Vision, optic nerve function and ocular examinations
were all normal. A small amount of proptosis (2-4 mm) was noted in each case.
Two of the three patients underwent excision of the tumor, the first en-block with the superior oblique and the second as a
lumpectomy excised from the medial rectus. The final patient was followed for clinical change and remained stable without surgery.
All patients did not progress during mean follow up of 7 months.
Conclusions: Carcinoid tumor metastasis to the orbit is a rare occurrence overall. However, when evident, this tumor tends to
hone to the extraocular muscles. As demonstrated in our cases, presentation can be in the context of known disseminated disease,
carcinoid syndrome or ‘incidentally’. It is not completely uncommon to find the primary site of origin difficult to detect.
References: 1. Gupta a, Chazen JL, Phillips CD. Carcinoid tumor metastases to the extraocular muscles: MR imaging and CT
findings and review of the literature. AJNR Am J Neuroradiol. 2011;32(7):1208-11.
General Session
8:00 am Welcome
Vikram D. Durairaj, MD, ASOPRS Program Co-Chair
Oncology Session
8:02 am Globe Sparing Surgery and Post-operative high-dose Radiation Therapy for
Lacrimal Gland Carcinoma
Bita Esmaeli1, Vivian Yin1, Ehab Hanna2, Merrill Kies3, William William3, Diana Bell4, Steven Frank5. 1Orbital Oncology & Ophthalmic
Plastic Surgery Program, MD Anderson Cancer Center, Houston, TX, United States, 2Head and Neck Surgery Department, MD Anderson
Cancer Center, Houston, TX, United States, 3Head and Neck Medical Oncology Department, MD Anderson Cancer Center, Houston, TX,
United States, 4Radiation Oncology Department, MD Anderson Cancer Center, Houston, TX, United States
Introduction: The standard treatment for lacrimal gland carcinoma has historically entailed orbital exenteration . We herein describe
11 patients who underwent globe sparing surgical resection of lacrimal gland carcinoma followed by high dose radiotherapy (RT).
We report on early ocular toxicity and local control rates.
Methods: The medical records of all consecutive patients with a diagnosis of lacrimal gland carcinoma treated at a tertiary cancer
center between 2007 and 2014 were retrospectively reviewed. Primary endpoints included the histologic type, type and dose of
radiation, ocular toxicity from RT, local and regional control rates, and disease free survival.
Results: Eleven of 20 patients with a diagnosis of lacrimal gland carcinoma during the study period had globe-sparing surgery
followed by high dose RT. These 11 patients were further studied in detail. Six male and 5 female patients had a median age of
55 yrs (range: 17-65 yrs). The histologic diagnosis was adenoid cystic carcinoma (n=7), carcinoma ex-pleomorphic adenoma (n=2),
high grade adenocarcinoma (n=1), and low-grade adenocarcinoma (n=1). The AJCC 7th edition “T” category was: T1 (n=1), T2
(n=6 ), T3 (n=1),T4b (n=2 ), and T4c (n=1 ). All 11 patients underwent globe-sparing surgical resection of lacrimal gland carcinoma;
all but 3 had negative surgical margins. Postoperative RT was carried out in 10 patients; one patient refused postoperative radiation
therapy. Three patients had concurrent adjuvant chemotherapy during radiation. The radiation modality was protons (IMPT) in 8
patients, photons (IMRT) in two patients, and gamma knife in one patient. The total radiation dose ranged from 50 to 64 Gy
(or CGE for protons); median dose = 62 Gy. With a median follow-up time after radiation therapy of 19 months (range: 6- 64
months), ocular toxicity included dry eye syndrome in all 11 patients, and severe corneal and conjunctival toxicity leading to eventual
enucleation in one patient (very first patient in cohort) treated with IMRT. All 11 patients were disease-free at last contact (median:
12 months after treatments). Only the one patient who refused postoperative RT experienced local recurrence; she later had gamma
knife for her recurrent lesion.
Conclusions: Globe sparing surgery followed by high dose radiation therapy is feasible and is associated with mild and acceptable
ocular toxicity. Although the follow-up time for this cohort is relatively short, there seems to be reasonable local control achieved with
this combined modality approach.
References: Esmaeli B, Golio D, Kies M, etal. Surgical management of locally advanced adenoid cystic carcinoma of the lacrimal
gland. Ophthal Plast Reconstr Surg 2006;22:366-70.
Ahmad SM, Esmaeli, B, Williams M,etal.. AJCC predicts outcome of patients with lacrimal-gland adenoid cystic carcinoma.
Ophthalmology, 116(6):1210-5, 2009.
8:08 am Systemic Rituximab Therapy for Ocular Adnexal Mucosal-Associated Lymphoid
Tissue (MALT) Lymphoma
Hakan Demirci1, Brian Marr2, Victor Elner1. 1Ophthalmology and Visual Sciences, University of Michigan, W.K. Kellogg Eye Center,
Ann Arbor, MI, United States, 2Ophthalmic Oncology, Memorial Sloan-Kettering, New York, NY, United States
Introduction: The main treatment option of mucosal-associated lymphoid tissue (MALT) lymphoma is external beam radiotherapy.
Although external beam radiotherapy is an effective therapy, it may have substantial ocular side effects. Systemic rituximab therapy
could be an alternative therapy in selected cases. We report our experience with ocular adnexal MALT patients who were treated with
systemic Rituximab therapy.
Methods: Six patients with ocular adnexal MALT lymphoma who had been treated with systemic Rituximab were retrospectively
reviewed. The patients received 4 weekly injections of Rituximab (375 mg/m2). Response to treatment, side effects and systemic
follow-up are evaluated.
Results: All patients responded to treatment by showing progressive in tumor size. All patients tolerated treatment well without
any complications. One patient developed recurrence 12 months following therapy. After a mean follow-up of 18 months following
treatment, there was no recurrence in the other 5 patients. None of the patients developed systemic involvement.
Conclusions: Systemic rituximab therapy seems to be an effective therapy in selected cases. There was no recurrence in most
patients, but they require close follow-up.
References: 1. Coupland SE, Hummel M, Stein H. Ocular adnexal lymphomas: five case presentations and a review of the literature.
Surv Ophthalmol. 2002;47(5):470–490.2. Tsang RW, Gospodarowicz MK, Pintilie M, et al. Localized mucosa-associated lymphoid
tissue lymphoma treated with radiation therapy has excellent clinical outcome. J Clin Oncol. 2003;21(22):4157–4164. doi:10.1200/
JCO.2003.06.085.3. Ferreri AJM, Ponzoni M, Martinelli G, et al. Rituximab in patients with mucosal-associated lymphoid tissue-type
lymphoma of the ocular adnexa. Haematologica. 2005;90(11):1578–1579.
8:14 am Primary Periocular Sweat-Gland Carcinomas: Epidemiology and Prognosis
Meredith Baker1, Vivian Yin2, Doina Ivan3, Bita Esmaeli2, Erin Shriver1. 1Department of Ophthalmology, University of Iowa, Iowa City,
IA, United States, 2Orbital Oncology & Ophthalmic Plastic Surgery, Department of Plastic Surgery, University of Texas MD Anderson
Cancer Center, Houston, TX, United States, 3Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX,
United States
Introduction: Sweat-gland carcinomas (SGC) consist of a variety of adnexal tumors including eccrine carcinoma, mucinous
carcinoma, and microcystic adnexal carcinoma. Primary periocular SGC are rare and reports to date are limited to single case
reports or small case series.[1-3] There are conflicting classification schemes in the literature and there is little guidance regarding
appropriate management of these lesions, especially in the periocular region. The purpose of this study is to retrospectively review
the clinical presentation, histologic features, management, and outcomes of patients with SGC of the periocular region in order to
better classify and characterize these rare tumors.
Methods: A retrospective review of consecutive patients seen at two tertiary institutions from 1990 to present with periocular SGC
tumors including eccrine carcinoma, mucinous carcinoma, microcystic adnexal carcinoma, poorly differentiated adnexal carcinoma,
apocrine carcinoma, and hidradenocarcinoma. Baseline demographic, treatment, and follow-up information were collected.
Results: Twenty patients (12 women and 8 men) with a mean age of 64.9 years were identified. Nineteen of the 20 patients were
white. The most common location was the lower lid (10 patients), followed by medial canthus, and upper lid. The median largest
tumor dimension was 13.0 mm. Perineural invasion was identified in 5 patients (25.0%). At presentation, 1 patient had lymph
node metastasis. Two patients presented with locally advanced (T4) disease and were treated with palliative surgery. The remaining
patients were treated with definitive surgery; local recurrence occurred in 1 of 18 patients (5.6%). Six patients had adjuvant radiation.
At last follow-up (median= 23.2 months) no patients experienced nodal or distant metastasis following treatment. Seventeen patients
were alive without evidence of disease and 3 patients were alive with disease. No patients died of disease or other causes during the
follow up period.
Conclusions: SGC of the eyelid can be locally aggressive with a relatively high rate of perineural invasion (25%); however distant
metastasis were not observed. Clarification of the classification system of SGCs and further characterization of these rare tumors will
lead to improved treatment outcomes.
References: 1. Zhang L, Ge S, Fan X. A brief review of different types of sweat-gland carcinomas in the eyelid and orbit. Onco
Targets Ther. 2013 Apr 9;6:331-40.
2. Durairaj VD, Hink EM, Kahook MY, Hawes MJ, Paniker PU, Esmaeli B.Mucinous eccrine adenocarcinoma of the periocular region.
Ophthal Plast Reconstr Surg. 2006 Jan-Feb;22(1):30-5.
3. Kramer TR, Grossniklaus HE, McLean IW, Orcutt J, Green WR, Iliff NT, Tressera F. Histiocytoid variant of eccrine sweat gland
carcinoma of the eyelid and orbit: report of five cases. Ophthalmology. 2002 Mar;109(3):553-9.
8:20 am Periocular Melanoma in-situ Treated with Imiquimod
Maxwell Elia1, Sara Lally2, Krishna Kalyam1, Shabnam Pakneshan1, Mark Fisher3, Caleb Ho4, John Sinard1,4, Allison Hanlon5,
Jennifer Choi5, Gary Lelli6, Juan Servat7, Jerry Shields2, Carol Shields2, Flora Levin1. 1Ophthalmology and Visual Sciences,
Yale University School of Medicine, New Haven, CT, United States, 2Ocular Oncology Service, Wills Eye Hospital, Philadelphia,
PA, United States, 3School of Medicine, Johns Hopkins University, Baltimore, MD, United States, 4Pathology, Yale University
School of Medicine, New Haven, CT, United States, 5Dermatology, Yale University School of Medicine, New Haven, CT,
United States, 6Ophthalmology, Weill Cornell Medical College, New York, NY, United States, 7Oculofacial Plastic Surgeons
of Georgia, Atlanta, GA, United States
Introduction: To evaluate the efficacy of topical 5% imiquimod cream in the treatment of periocular melanoma in-situ
(lentigo maligna).
Methods: Twelve patients with periocular melanoma in-situ were treated with topical 5% imiquimod cream. The clinical features
of the patients and the responses to treatment were evaluated in a retrospective case series.
Results: Twelve patients with a mean age of 77 years were included in this study. The anatomic locations were the lower eyelid
(n=5), upper and lower eyelids (n=4), lower eyelid including the eyelid margin (n=1), brow (n=1), and the medial canthus (n=1).
Topical 5% imiquimod cream was used as a primary treatment (n=6) or as an adjunctive therapy following local excision (n=2),
cryotherapy (n=2), or excisional biopsy with cryotherapy (n=2). Patients applied 5% imiquimod cream daily for a mean treatment
period of 3.9 months. Eleven patients achieved complete histologic clearance of atypical melanocytes on post-treatment biopsy. One
patient could not tolerate therapy due to local irritation and stopped in the first month with residual disease. The mean follow-up time
was 2.1 years. Among patients who completed the treatment, there have been no recurrences during follow-up. Side effects included
redness (n=12), discomfort (n=6), swelling (n=4), ectropion (n=1), and conjunctival chemosis (n=1). The patients experienced no
systemic side effects from the treatment.
Conclusions: Topical 5% imiquimod cream is an effective option as primary or adjunct therapy in the treatment of periocular
melanoma in-situ.
References: 1. O’Neill J, Ayers D, Kenealy J. Periocular lentigo maligna treated with imiquimod. J Dermatolog Treat. 2011 Apr;22:
109-12.
2. Demirci H, Shields CL, Bianciotto CG, Shields JA. Topical imiquimod for periocular lentigo maligna. Ophthalmology. 2010 Dec; 117:
2424-9.
Figure Legend: A) Melanoma in situ, pretreatment B) 2 weeks after 6 week course of daily Imiquimod C) Pretreatment biopsy
revealing melanoma in situ characterized by an atypical melanocytic proliferation at the dermoepidermal junction (Hematoxylin and
eosin staining, magnification x200). D) Post-treatment biopsy demonstrating histologic clearance (Hematoxylin and eosin staining,
magnification x200).
8:26 am Targeting the Hedgehog Pathway in Patients with Periorbital Locally Advanced
Basal Cell Carcinoma or Basal Cell Nevus Syndrome
Bita Esmaeli1, Viivan Yin1, Eva Chou1, William William2, Merrill Kies2, Michael Migden3. 1Orbital Oncology & Ophthalmic Plastic
Surgery Program, MD Anderson Cancer Center, Houston, TX, United States, 2Head and Neck Medical Oncology Department, MD
Anderson Cancer Center, Houston, TX, United States, 3Dermatology Department, MD Anderson Cancer Center, Houston, TX,
United States
Introduction: The most common type of eyelid carcinoma is basal cell carcinoma (BCC).Vismodegib (GDC-0449, Erivedge) is a firstin-class small molecule oral Hedgehog pathway inhibitor approved in the U.S. in January 2012 for the treatment of locally advanced
or metastatic BCC. We herein present our observations in 14 patients with locally advanced periorbital basal cell carcinoma or
symptomatic basal cell nevus syndrome who were treated with daily vismodegib.
Methods: The medical records of 14 consecutive patients with locally advanced periorbital BCC or basal cell nevus syndrome in
the periorbital region treated at a single institution were reviewed retrospectively. Tumor size at presentation, response to treatment,
duration of treatment, and adverse events were recorded.
Results: 12 men and 2 women had a median age of 65 years (range: 51 to 86 years). In each case, the decision to start treatment
with vismodegib was made with direct input from the senior treating oculoplastic surgeon and only if it was felt that complete surgical
excision of the locally advanced periorbital lesion was not possible without removal of the eye (i.e, an orbital exenteration) or in the
case of 3 patients with basal cell nevus syndrome to avoid multiple surgeries in the periorbital region. Each patient received 150 mg
of vismodegib daily. Eight patients experienced complete or partial response that was sustained at last contact, 3 patients had stable
disease, and 2 patients progressed after initial response that was sustained for 11 months and 19 months, respectively. One patient
developed a hypersensitivity reaction and discontinued treatment after one week. Median duration of treatment was 11 months
(range: 5-40 months). Similar to previous reports the most common adverse events included dysguesia, weight loss, hair loss, muscle
spasms, and diarrhea.
Conclusions: Vismodegib is a promising non-surgical option for patients with locally advanced periorbital BCC that would otherwise
need an orbital exenteration or in patients with basal cell nevus syndrome with symptomatic periocular lesions. The benefits of this
treatment should be weighed against side effects and cost; vismodegib should be reserved only for patients whose lesions are
advanced enough for which surgery would mean sacrifice of the eye or would render significant orbitofacial morbidity.
References: Sekulic A, Mangold AR, Northfelt DW, LoRusso PM. Advanced basal cell carcinoma of the skin: Targeting the hedgehog
pathway. Curr Opin Oncol 2013;25:218-223.
Yin VT, Pfeiffer ML, Esmaeli B. Targeted therapy for orbital and periocular basal cell carcinoma and squamous cell carcinoma.
Sekulic A, Migden MR, Oro AE, et al. Efficacy and safety of vismodegib in advanced basal-cell carcinoma. N Engl J Med
2012;366:2171-9.
Panel: Bita Esmaeli, MD, Hakan Demirci, MD, Meredith Baker, MD, Maxwell Elia, MD
Henry Baylis Cosmetic Surgery Award Lecture
8:40 am Introduction of the Henry I. Baylis Award Lecturer: Dr. Guy Massy
8:45 am A Personal Perspective on Treating the Eyelids and Periorbita with Injectable
Hyaluronic Acid Gels
Guy G. Massry, MD
The use of eyelid and periorbital fillers has evolved significantly over the last decade. A heightened awareness and understanding of
filler type and category, specific biochemical composition, flow characteristics, and potential for adverse outcomes has allowed better
clinical selection criteria based on desired result. As with many “newer” or “novel” aesthetic interventions, an initial general euphoria
with applicability becomes appropriately replaced with realistic expectations of outcome form both the physician (injector) and the
patient, as meaningful experience is gained. Overall there has been a healthy advancement in thought from indiscriminant filling of
lines and folds of the face, to a more sophisticated realization of appropriate product selection and placement. Nowhere has this
been truer than with the use of fillers in the “high risk” periorbital area. This shift has been based on clinical experience, research,
and shared knowledge amongst core specialties involved in treatment of this delicate and often unforgiving area. With this in mind, I
generalize the important issues, and lessons learned, with the use of fillers to the eyelids and periorbita as follows
1.
2.
3.
4.
5.
6.
7.
Awareness of the current economic trends with regard to aesthetic revenue generation and market share of fillers
Knowledge of the relevant literature, anatomic nuances and product information available to improve treatment/results
A thorough understanding of Hyaluronic Acid Gels (HAG) – the only product I use to fill in this area.
Familiarization with appropriate injection technique
Identification of appropriate clinical indications/expected outcomes
Understanding the realm of potential complications – non-vascular/vascular
Being realistic with patients.
The overview presented will bring a personal, yet contemporary perspective regarding HAG filling of the periorbital area.
9:25 am Henry I. Baylis Award Presentation
9:30 – 10 am
Break with Exhibitors and Poster Stand By Session Lacrimal Session
10:00 am Surgical and Epidemiologic Factors Affecting Canalicular Laceration Repair with
the Mini Monoka Monocanalicular Stent
Blair Armstrong1, Michael Rabinowitz2, Brianna Kenney3, Robert Penne2. 1Ophthalmology Residency, Wills Eye Hospital, Philadelphia,
PA, United States, 2Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, PA, United States, 3Department of
Research, Wills Eye Hospital, Philadelphia, PA, United States
Introduction: The purpose of this study is to review the epidemiologic and clinical characteristics of canalicular involving eyelid
lacerations surgically reconstructed with the Mini Monoka monocanalicular stent (FCI Ophthalmics, France) to identify individual and
surgical factors leading to complications or poor outcomes.
Methods: Retrospective analysis with survey component. Patients were identified through emergency department discharge log and
electronic billing records. Paper charts were reviewed for demographic data, injury details, operative report, and visit information.
All patients were contacted via telephone survey. Variables were quantified using means, medians, standard deviation, and ranges
for continuous variables and frequencies and percentages for categorical variables. All analysis was performed using SAS 9.3 (SAS
Institute, Cary, NC).
Results: 95 canalicular lacerations in 89 patients were identified. 18 patients responded to the telephone survey and 28 (31.5%)
of patients did not maintain follow up appointments. The mean age was 34.6 (range 0-91 years). 69.4% of patients were male and
30.6% were female; 51.5% were Caucasian, 30.9% Black, 14.7% Hispanic, and 2.9% Asian. Canalicular lacerations were most
commonly caused by blunt accidental trauma (31.3%), animal bite (22.5%), or sharp accidental trauma (16.3%). Lower lid (60.7%)
was more often affected than upper (32.1%) or both lids (7.1%). Associated ocular injuries included non-canalicular eyelid lacerations
(n=19), hyphema (n=16), and ruptured globe (n=4).
72.3% of patients underwent canalicular repair in the operating room under general anesthesia and 27.7% in a minor procedure
room with local anesthesia. 27.3% underwent repair <12 hours from sustaining injury, 36.4% within 12-24 hours, 24.2% at 25-48
hours, and 10.6% at greater than 48 hours. Stents were removed at a mean value of 21.77 weeks (range: 6 -152). 57.1% did not
have documented stent removal at last follow up visit.
Complications included early extrusion (n=15 patients) and infection (n=4 patients). Outcome measures included presence of tearing
(31.7%) or absence (68.3%). Tearing and epiphora were more common in patients with >24 hours between injury and repair (p =
0.029). There was a higher incidence of tearing in patients sustaining lower lid canalicular lacerations (p = 0.024).
Conclusions: Canalicular lacerations are most common in young males and often secondary to blunt or sharp accidental trauma.
Delayed repair and lacerations involving the lower lid result in higher incidence of tearing and epiphora.
10:06 am Bicanalicular Silicone Intubation with Intra-Lacrimal Sac Fixation Suture For
Punctal and Canalicular Stenosis
Kasra Eliasieh, Jessica Chang, Nicholas Mahoney, Michael Grant, Shannath Merbs. Ophthalmology, Wilmer Eye Institute,
Johns Hopkins Hospital, Baltimore, MD, United States
Introduction: Bicanalicular silicone intubation is a commonly used method of treatment for punctal and/or canalicular stenosis.
We present over 10 years of experience with the intra-lacrimal sac fixation suture technique, a modification of bicanalicular intubation
in which a knot is indirectly placed in the lacrimal sac, preventing prolapse as well as excess tension.
Methods: We performed a retrospective analysis of patient records on 186 consecutive adults (age 18 years and older) who
underwent bicanalicular silicone intubation with intra-lacrimal sac fixation for punctal and/or canalicular stenosis without evidence
of nasolacrimal duct obstruction (NLDO) at the Wilmer Eye Institute from January 2000 to October 2013. Postoperative tearing
symptoms were categorized as resolution, significant improvement (rare tearing), moderate improvement (occasional tearing),
minimal improvement, or no improvement.
Results: 41 patients (68 eyes) met inclusion criteria. The average age was 60 years (range 18-87). Average length of follow up
was 2.4 years (range 6 months to 8 years). 16 eyes (24%) required subsequent dacryocystorhinostomy (DCR) for NLDO and were
excluded from the study. Of the remaining 52 eyes, 27 (52%) had complete resolution of epiphora and 87% had at least moderate
improvement. 8% had no improvement. Silicone tubes remained in for the duration of follow-up in 29 eyes an average of 20 months
and up to 4 years. Of these eyes, 25 (86%) had at least moderate improvement. In the remaining 23 eyes, the tube was removed
(18 eyes) or prolapsed (5 eyes). Reasons for tube removal in the clinic included bacterial colonization of the tube, patient preference,
recurrence of tearing, or foreign body sensation. Of these eyes, 20 (87%) had at least moderate improvement. Although there was no
statistical difference in outcomes between eyes in which the tube stayed in and eyes in which the tube was removed, in those eyes
in which the tube was removed, a statistically higher number had worsening of tearing than in those in which the tube was left in
(p=0.011). Prolapse of the silicone tube occurred in 5 eyes (9.6%). There were no cases of punctal erosion due to excess tension.
Conclusions: Bicanalicular intubation is an ideal treatment for punctal and canalicular stenosis because it is highly successful and
preserves the architecture of the eyelid and lacrimal system. Placement of an intra-lacrimal sac suture is a simple modification of this
technique that reduces much of the associated morbidity of this procedure by allowing the surgeon to carefully adjust the tension and
size of the loop, reducing prolapse, and allowing the tube to stay in for long periods of time.
References: Merbs SL1, Harris LL, Iwamoto MA, Iliff NT. Prevention of prolapsed silicone stents in lacrimal intubation using an
intrasac fixation suture. Arch Ophthalmol. 1999 Aug;117(8):1092-5.
10:12 am Computed Tomographic Findings Can Discriminate Lacrimal Sac
Malignancies from Dacryocystitis
Pimkwan Jaru-ampornpan1, Tabassum Kennedy2, Cat Burkat1, Mark Lucarelli1. 1Ophthalmology and Visual Sciences,
University of Wisconsin, Madison, WI, United States, 2Radiology, University of Wisconsin, Madison, WI, United States
Introduction: Lacrimal sac malignant tumors are rare with high morbidity and recurrence. Their presentation can mimic chronic
dacryocystitis, sometimes delaying diagnosis. The main purpose of this study was to compare the radiologic findings of malignant
lacrimal sac tumors with cases of dacryocystitis. Understanding the radiologic characteristics of these two entities may improve our
ability to accurately diagnose lacrimal sac malignancies.
Methods: This was an IRB-approved retrospective medical records review. Patients with diagnoses of malignant lacrimal
sac lesions between July 1997 and 2013 who had computed tomography (CT) scans were identified from the University of
Wisconsin School of Medicine and Public Health’s database. Imaging studies from these cases were compared with imaging
from patients with dacryocystitis. Data on patient age, imaging indication, histological diagnosis, and radiologic findings including
lacrimal duct enlargement, bone erosion, soft tissue enhancement, soft tissue inflammation, and sinus mucosal disease were
collected and analyzed.
Results: Six patients with lacrimal sac malignancy and six patients with dacryocystitis who had CT scans were identified.
The histologic diagnoses of lacrimal sac malignancies included squamous cell carcinoma (2), adenoid cystic carcinoma, inverted
squamous papilloma, transitional cell carcinoma, and lymphoma. The mean age was 62 years in the tumor group (TG) and
18 years in the dacryocystitis group (DG). The main indication for imaging in the TG was chronic epiphora and lacrimal sac swelling.
The primary indication for imaging in the DG group was to assess for extent of cellulitis (5/6).
The presence of bony erosion was common in both groups (83% TG; 100% DG). Smooth osseous scalloping was seen in both groups
at similar rates (67% TG vs. 67% DG). Frank bone destruction, however, was seen only in TG (50%). Lacrimal duct enlargement was
present in all case of TG and in 67% of DG, but was more apparent in the TG. A cystic mass was seen commonly in DG (100%), but
not in TG (0%). Adjacent inflammatory signs (including fat stranding and mucosal thickening in the sinuses) were minimally present in
the TG (33%), but present in varying degrees in the DG (83%).
Conclusions: Malignant lacrimal sac tumors and dacryocystitis shared overlapping radiologic features of bone erosion and lacrimal
duct enlargement on CT scans. Useful discriminating features that favored tumor included frank bone destruction, whereas features
that were more suggestive of dacryocystitis included the presence of a cystic mass and associated inflammation.
References: Weber AL, et al. Normal anatomy and lesions of the lacrimal sac and duct: evaluated by dacryocystography, computed
tomography, and MR imaging. Neuroimaging Clin N Am. 1996; 6: 199-217.
Francis IC, et al. Computed Tomography of the Lacrimal Drainage System. OPRS.15: 217-226.
Russell EJ, et al. CT of the Inferomedial Orbit and the Lacrimal Drainage Apparatus. AJR. 1985; 145: 1147-54.
10:12 am Computed Tomographic Findings Can Discriminate Lacrimal Sac Malignancies from
Dacryocystitis, continued
10:18 am Technique and Success Rate of Transcanalicular Endoscopic Lacrimal Duct
Recanalization (TELDR) with Silicone Intubation
Reynaldo M. Javate, M.D., F.I.C.S., Armida L. Suller, M.D., Kathleen Faye N. Buyucan, M.D., Elise Estelle T. Ma. Guerrero, M.D.,
Kristina C. Teope, M.D. Department of Ophthalmology, University of Santo Tomas Hospital, University of Santo Tomas,
Manila, Philippines
Introduction: To determine the success rate of Transcanalicular Endoscopic Lacrimal Duct Recanalization (TELDR) with silicone
intubation in patients with complete primary acquired nasolacrimal duct obstruction (PANDO) and compare its efficacy to the
Standard External Dacryocystorhinostomy (SE-DCR).
Methods: This study was a randomized controlled trial consisting of 70 patients resulting to 90 cases diagnosed with complete
primary acquired nasolacrimal duct obstruction (PANDO) at the Javate Lacrimal, Orbital and Oculofacial Plastic Surgery Clinic,
University of Santo Tomas Hospital, University of Santo Tomas, Espana, Manila, Philippines between February 2010 to December
2013. Patients underwent either Standard External Dacryocystorhinostomy or Transcanalicular Endoscopic Lacrimal Duct
Recanalization with silicone intubation under topical or general anesthesia regardless of them having bilateral or unilateral
obstruction. Follow-up were conducted until December 2013 and each case were evaluated for anatomical and functional
patency every visit.
Results: A total of thirty-five (35) patients giving 45 cases underwent SE-DCR and thirty-five (35) patients resulting to 45 cases
underwent TELDR, all of whom had complete PANDO. The authors displayed that the success rate of TELDR (96.3%, CI 95%,
p value >0.05) was not statistically different from that of SE-DCR (98.4%, CI 95%, p value >0.05).
Conclusions: TELDR with silicone intubation is equally effective as SE-DCR, in the treatment of complete PANDO without the
later’s associated major convolutions and disadvantages.
References: 1. Javate RM, Pamintuan FG, Cruz RT. Efficacy of endoscopic lacrimal duct recanalization using microendoscope.
OphthalPlastReconstrSurg 2010; 26:330-33.
2. Hartikainen J, Grenman R, Puukka P, Seppä H. Prospective randomized comparison of external dacryocystorhinostomy and
endonasal laser dacryocystorhinostomy. Ophthalmology 1998; 105:1106-13.
3. Javate RM. Refinements in surgical technique of external dacryocystorhinostomy. OperTech in Oculoplast Orbit and Reconstr
Surg 1998; 2:93-97.
4. Meyer-Rüsenberg HW, Emmerich KH. Modern lacrimal duct surgery from the ophthalmological perspective. Dtsch Arztebl Int
2010; 107(14): 254-8.
5. Aritürk N, Oüge Đ, Ӧge F, et al. Silicone intubation for obstruction of the nasolacrimal duct in adults. Acta Ophthalmol Scan 1999;
77:481-2.
6. Haefliger IO, Piffaretti JM. Lacrimal drainage system endoscopic examination and surgery through the lacrimal punctum.
Klin Monatsbl Augenheilkd 2001; 218:384-87.
7. Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction: A clinicopathologic report and biopsy technique.
Ophthalmology 1986; 93:1055-63.
8. Moscato EE, Dolmetsch AM, Silkiss RZ, Seiff SR. Silicone intubation for the treatment of epiphora in adults with presumed
functional nasolacrimal duct obstruction. OphthalPlastReconstrSurg 2012; 28:35-39.
9. Khoubian JF, Kikkawa DO, Gonnering GS. Trephination and silicone stent intubation for the treatment of canalicular obstruction:
effect on the level of obstruction. OphthalPlastReconstrSurg 2006; 22:248-52.
10. Javate RM, Pamintuan FG. Endoscopic radiofrequency assisted DCR (ERA-DCR) with double stent: a personal experience.
Orbit 2005; 24:15-22.
10:24 am Tear Trough Incision for External Dacryocystorhinostomy
Brett W. Davies1, Michael S. McCracken2, Michael J. Hawes3, Eric M. Hink1, Vikram D. Durairaj1, 4, Ron W. Pelton5. 1Ophthalmology,
1
Oculofacial Plastic and Orbital Surgery, Aurora, CO, United States, 2McCracken Eye and Face Institute, Parker, CO, United States, 3
Michael J. Hawes, MD, Denver, CO, United States, 4Texas Oculoplastic Consultants, Austin, TX, United States, 5Ronald W. Pelton, MD,
Colorado Springs, CO, United States
Introduction: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this
study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough.
Methods: Multi-center, prospective, non-comparative interventional study approved by the University of Colorado Institutional Review
Board. Patients undergoing exDCR from February 2013 through January 2014 were included in the study, and surgeries were
performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended infero-laterally
into the tear trough for 10-15 mm. ExDCR was performed in the usual manner, and the incision was closed in a single layer using
absorbable sutures. At three months post op, all patients were asked to rate their scar on the following grading scale: 0, invisible
incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was
also determined by asking the patient if their symptoms resolved, improved, or did not change. External photographs taken at three
months after surgery were graded by three independent facial plastic surgeons using the same grading scale.
Results: Seventy two surgeries were performed in 68 consecutive patients with nasolacrimal duct obstruction during the study
period. Sixty nine out of 72 patients reported improved or resolved symptoms (95.8%). Average patient scar grade was 0.21, while
the average surgeon scar grade was 0.99 (p <0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only
3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades,
55 were graded as invisible (25.5%), while 8 were graded as very visible (3.7%).
Conclusions: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more
importantly, nearly invisible to patients.
References: 1. Caesar RH, Fernando G, Scott K, et al. Scarring in external dacryo¬cystorhinostomy: fact or fiction? Orbit
2005;24:83–62. Sharma V, Martin PA, Benger R, et al. Evaluation of the cosmet¬ic significance of external dacryocystorhinostomy
scars. Am J Ophthalmol 2005;140:359–623. Devoto MH, Zaffaroni MC, Bernardini FP, et al. Postoperative eval¬uation of skin
incision in external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2004;20:358–614. Harris GJ, Sakol PJ, Beatty RL. Relaxed
skin tension line incision for dacryocystorhinostomy. Am J Ophthalmol 1989;108:742–35. Dave TV, Javed Ali M, Sravani P, et al.
Subciliary incision for external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2012;28:341–5. 6. Olver JM. Tips on how to
avoid the DCR scar. Orbit 2005;24:63–6.
Panel: Blair Armstrong, MD, Kasra Eliasieh, MD, Pimkwan Jaru-ampornpan, MD, Reynaldo M.Javate, MD, FICS, Ron W. Pelton, MD
Eyelid Session II
10:40 am Anatomy and Histology of the Frontalis Muscle
Bryan Costin1, Thomas Plesec2, Natta Sakolsatayadorn3, Tal Rubinstein1, Jennifer McBride4, Julian Perry1. 1Cole Eye Institute,
Cleveland Clinic, Cleveland, OH, United States, 2Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, United
States, 3Department of Ophthalmology, Medicine Siriraj Hospital, Bangkok, Thailand, 4Department of Anatomy, Cleveland Clinic,
Cleveland, OH, United States
Introduction: The occipitofrontalis muscle represents the only muscle capable of elevating the eyebrow and critically determines
the structure, function, and cosmesis of the forehead, eyebrow, and eyelid.1-5 Despite its importance, a PubMed search in December
2013 using the search parameters ‘frontalis,’ ‘eyebrow position,’ ‘eyebrow ptosis,’ ‘brow position,’ and ‘brow ptosis’ yielded only
7 reports on the anatomy of this region. We sought to determine the gross and histological configurations of the medial and lateral
frontalis muscle to improve our understanding and treatment of forehead and periocular aging changes.
Methods: After making a mid-coronal incision and bluntly dissecting to the orbital rim, the frontalis muscle was marked and
measured. A protractor was used to measure the frontalis-orbicularis angle (FOA) (Figure 1,2) and, when present, the angle of central
bifurcation (AOB) (Figure 3). Three strips of full thickness forehead soft tissue 0.5 cm x 8 cm were excised 3 cm, 4.5 cm, and 6 cm
above the supraorbital notch and analyzed histologically for the presence of skeletal muscle fibers (Figure 4). Data were analyzed
using two-sample t-tests, paired t-tests, Pearson correlations, and mixed effect models. A p-value of ≤ 0.05 was considered
statistically significant.
Results: Sixty-four hemifaces of 32 cadavers (16 male) were dissected. All specimens were Caucasian. Average age was 78.2 years
(range, 56 - 102 years). Average FOA was 88.7° (13.0°) and average AOB was 90.0° (26.4°). A visible midline bifurcation occurred
in 28/32 (88%) subjects at an average height of 4.7 cm (range, 2.4 - 7.2 cm) superior to the supraorbital notch. Continuous skeletal
muscle fibers were present within the midline bifurcation histologically in 89%, 75%, and 11% of specimens 3.5, 5.0, and 6.5 cm
above the supraorbital notch, respectively. In 46% of individuals, skeletal muscle fibers were continuously present microscopically
within the gross bifurcation.
Conclusions: While a medial frontalis muscle bifurcation
occurs grossly in most senescent Caucasians, muscle
fibers exist microscopically within this zone in nearly half
of individuals. The frontalis orbicularis angle (FOA) and
insertion (FOI) display polymorphism and variations in
these structures may explain eyebrow position and contour
as well as eyebrow malpositions and rhytides.
References: 1. Matarasso A, Terino EO. Forehead-brow
rhytidoplasty: reassessing the goals. Plast Reconstr Surg
1994;93:1378-91.
2. Paul MD, The evolution of the brow lift in aesthetic
plastic surgery. Plast Reconstr Surg. 2001;108:1409-24.
3. Presti P, Yalamanchii H, Honrade CP. Rejuvenation
of the aging upper third of the face. Facial Plast Surg
2006;22:91-6.
4. Hetzler L, Sykes J. The brow and forehead periocular rejuvenation. Facial Plast Surg Clin N Am 2010;18:375-384.
5. Lorenc ZP, Smith S, Nestor M, et al. Understanding the functional anatomy of the frontalis and glabellar complex for optimal
aesthetic botulinum toxin type A therapy. Aesth Plast Surg 2013;37:975-983.
10:46 am Stop Blaming the Septum
Robert Schwarcz1, John Fezza2, Andrew Jacono3, Guy Massry4. 1Ophthalmic Plastic Surgery, Robert Schwarcz MD, New York, NY,
United States, 2Ophthlamic Plastic Surgery, Center For Sight, Venice, FL, United States, 3Facial Plastic Surgery, New York Center For
Facial Plastic And Laser Surgery, New York, NY, United States, 4Ophthalmic Plastic Surgery, Beverly Hills Ophthalmic Plastic Surgery,
Beverly Hills, CA, United States
Introduction: Traditional thought is that one of the critical factors leading to post-blepharoplasty lower eyelid retraction (PBLER) is
scarring of the “middle lamella” of the eyelid. In the literature the middle lamella is defined as the orbital septum. The authors believe,
in isolation, the orbital septum does not lead to lower eyelid retraction.
Methods: A retrospective chart review of patients undergoing transconjunctival blepharoplasty (TCB) by the authors from January
2012 to January 2014 was performed. All patients underwent isolated TCB with or without fat transposition. Patients who underwent
adjunctive canthal or orbicularis suspension, skin excision, cutaneous laser, or had a history of trauma, thryroid or other eyelid
inflammatory disease, or previous surgery, were excluded. Two of us performed all surgery in the preseptal plane (between the
orbicularis and orbital septum), requiring division of the septum to access eyelid/orbital fat, and the other two of us, in the retroseptal
plane, allowing direct entry to fat and leaving the septum undisturbed. Patients were evaluated postoperatively for eyelid malposition
(retraction, ectropion) and other complications.
Results: Two-hundred and eighty-eight patients (576 eyelids) were assessed. Two hundred and seventeen patients were woman
(75%) and 71 (25%) patients were men. The mean patient age was 55 years (range 32- 90 years). One-hundred and fifty eight
patients (55%) had TCB performed with a retroseptal approach, and 130 patients (45%) with a preseptal approach. There were no
cases of postoperative eyelid retraction. Seventeen patients (6%) had transient post-operative chemosis, 2 of which (11%) had selflimiting mechanical ectropion resolving in each case within 2 weeks. No patient developed clinically significant reduction in forced
upwards displacement of their eyelids postoperatively.
Conclusions: In this series no patient demonstrated lower eyelid retraction or limitation of forced superior lower lid excursion after
standalone TCB whether the surgical approach was preseptal or retroseptal. This suggests that violation of the orbital septum in
isolation does not lead to a clinically relevant eyelid scar or eyelid retraction. The term “middle lamellar scar” (defined in the literature)
as a cause of PBLER is incorrect and should be changed to reflect the true pathology leading to PBLER, which is a multilayered deficit
consisting of some combination of a skin, muscle and septal violation.
References: 1. Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg
2000;106:438-453. 2. Patel BCK, Patipa M, Anderson RL, McLeish W. Management of postblepharoplasty lower eyelid retraction
with hard palate spacer grafts and lateral tarsal strip. Plast Reconstr Surg 1997;99:1251-1260.
10:52 am The Beauty of the Crease: Cosmetic Eyelid Crease Elevation to Enhance the
Aesthetics of the Brow-Eyelid Continuum
Abraham Gomez1, Geoffrey Gladstone1,2. 1Consultants in Ophthalmic and Facial Plastic Surgery, Southfield, MI, United States,
2
Ophthalmology, Oakland University, Beaumont Hospital, Royal Oak, MI, United States
Introduction: In contemplating the issue of a crowded upper eyelid it becomes essential to increase the distance between the ciliary
margin and the overhanging skin fold. The traditional approaches addressing this goal have typically been related to the removal of
excess eyelid skin or the elevation of a ptotic eyebrow; however, a substantial group of patients have no excess skin and raising a
droopy brow might not be economically feasible. Less frequently considered is the position of the upper eyelid crease and it’s role
in the management of these patients. The purpose of this paper is to present surgeons with an alternative to conventional upper
blepharoplasty in patients with low supratarsal creases who seek aesthetic enhancement of the brow-eyelid continuum.
Methods: We conducted a prospective, interventional study in patients undergoing cosmetic eyelid crease elevation (CCE)
through an anterior approach at Consultants in Ophthalmic and Facial Plastic Surgery between September 2012- April 2014.
Patients on whom simultaneous upper eyelid skin excision, brow elevation, or additional concurrent surgery to the upper eyelids or
eyebrows was performed were excluded from our study. Parameters measured included the margin fold distance (MFD), margin
crease distance (MCD), margin fold rise (MFR), symmetry of MFD (FS), and patient-reported satisfaction using a 3-category
questionnaire. Preoperative and postoperative FS measurements at the longest follow-up visit were analyzed and correlated with
patient-reported outcomes.
Results: Fifty-two eyelids of 31 patients (mean age 62.3 ± 18.6 years, range 39-78 years, 6 men and 25 women) were included.
The mean follow up was 9.1 ± 5.3 (range 1.2-18.3) months. Mean preoperative MFD increased from 0.2 mm (standard deviation,
1.7 mm) to 2.9 mm (standard deviation, 1.3 mm; p <.0001), for a mean MFR of 2.6 mm ± 1.6 mm (range 0 mm to 6.0 mm). The
mean MCD increased from 5.9 mm (standard deviation, 1.7 mm) to 9.1 mm (standard deviation, 1.3 mm; p <.0001). Postoperatively,
21 patients (67.7%) achieved FS (<0.5 mm of asymmetry in MFD). A total of 27 patients (87%) were very satisfied with the
postoperative appearance, 3 patients (9.7%) noticed only a slight improvement, and 1 patient (3.2%) was unsatisfied with the final
result. There was no statistically significant correlation between the level of patient satisfaction and FS (p = 0.39).
Conclusions: The CCE is a safe and effective way to restore the aesthetic features of the youthful upper eyelid in the appropriate
clinical scenario. This elegant technique takes on an essential role in the context of upper eyelid crowding in patients who do not
have excess eyelid skin and in those who are not good candidates for a conventional brow-lifting procedure.
References: Sheen JH. A change in the technique of supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg. 1977;
59(6):831-4.
10:58 am A Novel At-Home Procedure Providing Marked Improvements for Lower
Lid Aesthetics Utilizing a Tensile, Elastic, Non-Invasive Polymer System with
In-Situ Cross-Linking Functionality
Brian Biesman1, Zoe Draelos2, R. Rox Anderson3, Patricia Farris4, Derek Jones5, Doris Day6, Steven Dayan7, Fernanda Sakamoto3,
Soo-young Kang8, Barbara Gilchrest9, Betty Yu8. 1Nashville Centre for Laser and Facial Surgery, Nashville, TN, United States, 2
Dermatology, Duke University Medical Center, Durham, NC, United States, 3Dermatology, Harvard Medical School, Boston, MA,
United States, 4Dermatology, Tulane University Medical Center, New Orleans, LA, United States, 5Dermatology, David Geffen School of
Medicine, University of California, Los Angeles, Los Angeles, CA, United States, 6Dermatology, New York University Medical Center,
New York, NY, United States, 7Otolaryngology, University of Illinois Hospital and Clinics, Chicago, IL, United States, 8LivingProof, Inc,
Cambridge, MA, United States, 9Dermatology, Boston University School of Medicine, Boston, MA, United States
Introduction: The aesthetic performance of Strateris®, a novel, topical skin conforming, cross-linked polymer layer (XPL) was
evaluated in an open label, single exposure, multi-site trial. Based on a tunable materials technology platform, the XPL is created in
situ, where a flowable, reactive polysiloxane blend is applied at the target skin site. When the polysiloxane is exposed to a catalyst,
a cross-linking reaction is initiated, forming a network that contracts over the course of one hour to mechanically reshape and
compress the appearance of lower lid wrinkles and fullness.
Methods: A total of 95 women, ages 30 to 77, were enrolled across 5 sites. A 9 point photo-numeric lower lid fullness scale was
developed to help assess product performance. The XPL was applied to each subject using a two-step procedure. Physician live
assessment of lower lid fullness, wrinkle severity and Global Aesthetic Improvement Score (GAIS) was conducted at baseline and
3 hours following XPL application. For wrinkle evaluation, a 4-grade scale was used to assess lower lid wrinkling and a standard
seven point GAIS was used. Standardized photographs were taken at baseline and 3 hours post treatment.
Results: Following XPL application to the target lower lid skin site, 99% of the patients demonstrated an overall global aesthetic
improvement, with 83% demonstrating marked or optimal GAIS (scores of 2 and 3). Average lower lid puffiness scores demonstrated
a 2.4 grade(p<0.0001), with 94% of subject demonstrating at least a 1 grade response. The lower lid wrinkle severity score
demonstrated an average improvement of 1.35 (p<0.0001) with 87% of the patients demonstrated at least a 1 grade response.
No adverse events were reported for any subject.
Conclusions: The XPL polymer film technology offers a first in class, noninvasive solution to address lower eyelid aesthetic needs.
In this multi-site clinical study, the performance benefits of the XPL product extend beyond visible improvements to the lower lid bag
and wrinkle severity scores. The improvements observed at the lower lid application site translated to an improvement in the global
facial aesthetic appearance, with 99% of the patients showing visible improvement in GAIS score 3 hours after XPL application.
Panel: Bryan Costin, MD, Robert Schwarcz, MD, Abraham Gomez, MD, Brian Biesman, MD
11:15 am An Algorhythmic Multi-Modality Approach to the Devolumized Lower Eyelid
Andrew Jacono, MD
Lower Eyelid Rejuvenation can be accomplished with many techniques which includes both non-surgical and surgical approaches.
In surgery, the approaches range from transconjunctival to transcutaneous approaches, from fat excision to fat repositioning/
preservation or fat transfer, and with no, some or aggressive manipulation of the orbicularis oculi muscle. We present a classification
of lower eyelid aging which incorporates consideration of the devolumized periorbital region, degree of orbicularis laxity, and quantity
of skin excess in order to better direct treatment. Procedures discussed include hyaluronic acid injections, autologous fat transfer,
extended lower blepharoplasty with orbital fat transposition, limited incision transconjunctical approaches, orbicularis redraping, and
skin excision versus skin redraping. An algorithm and decision making tree for lower eyelid rejuvenation is presented with special
attention to volumizing the nasojugal and infraorbital regions, which are undertreated in traditional approaches.Technical details of
surgical approaches are discussed in detail.
12 – 1 pm Lunch
(River Exposition Hall)
Orbit Session II
1:00 pm Symmetry of the Angle of the Orbital Strut (AOS) – A Radiological Study
Raghuraj Hegde1, Gangadhara Sundar1, Eric Ting2, Thiam Chye Lim3, Michael Grant4. 1Ophthalmology, National University Hospital,
Singapore, Singapore, 2Radiology, National University Hospital, Singapore, Singapore, 3Plastic and Aesthetic Surgery, National
University Hospital, Singapore, Singapore, 4Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD, United States
Introduction: Introduction: Reconstruction and restoration of the orbital strut is an integral part of anatomical correction in complex
orbital fractures. The orbital strut plays an important role in globe position and extraocular muscle function. In complex orbital trauma
the orbital strut is often poorly reconstructed or not even paid attention to, but just repairing an reconstructing the floor and the
medial wall alone. Awareness, recognition and measurement of the Angles of orbital strut preoperatively on the contralateral side is
a useful guide to intraoperative reconstruction., helps guide intraoperative reconstruction thereby translating into good postoperative
globe position and ocular motility. Even when prefabricated implants are available, refashioning the angles prior to insertion helps
restore this symmetry and makes it easy by avoiding unnecessary or undesirable intraoperative intraorbital manipulation. This may be
a reasonable alternative especially Intraoperative Navigation is not readily available, as in most centres in the world.
Methods: Retrospective review of 162 consequtive CT scan orbits(max.3mm cuts) with intact bilateral orbits measuring angle
between orbital floor and medial wallAOS measured at 3 standard locations:
1. Rim-Rim AOS(RAOS)
2. 9mm behind the RAOS-MiddleAOS(MAOS)
3. 18mm behind the RAOS-Posterior AOS(PAOS)
Statistical analysis(unpaired t-test and Mann-Whitney U) was done taking race into account.
Figure 1: Symmetry at Rim Angle of the Orbital Strut
Figure 2: Symmetry at Middle Angle of the Orbital Strut
Figure 3: Symmetry at Posterior Angle of the Orbital Strut
Results: 324orbits (162 patients) studied.Analysis showed significant symmetry of AOS at all the above locations irrespective
of race(p>0.05).Average AOS:East Asians-127.6°,South Asians 126.7°& Caucasians-127.3°
Conclusions: Variations of AOS between the right and left orbits are small indicating real world applications in repair of
orbital fractures.
References: Cho RI, Davies BW.Combined orbital floor and medial wall fractures involving the inferomedial strut: repair technique
and case series using preshaped porous polyethylene/titanium implants.Craniomaxillofac Trauma Reconstr. 2013 Sep;6(3):161-70.
1:06 pm Axial Globe Position Measurement: A Prospective Multi-center Study
Sponsored by the International Thyroid Eye Disease Society
Chad Bingham1, Jennifer Sivak-Callcott1, Mathew Gurka2, John Nguyen1, Steve Feldon3, Aaron Fay4, Lay-Leng Seah5, Diego Strianese6,
Vikram Durairaj7, Jimmy Uddin8, Martin Devoto9, Matheson Harris1, Justin Saunders1, Audrey Looi5, Livia Teo5, Michale Kazim10.
1
West Virginia University, Morgantown, WV, United States, 2Biostatistics, West Virginia University, Morgantown, WV, United States, 3
Univ of Rochester, Rochester, NY, United States, 4Harvard University, Boston, MA, United States, 5Singapore National Eye Centre,
Singapore, Singapore, 6Univeristy Federico II, Naples, Italy, 7Texas Oculoplastic Consultants, Austin, TX, United States, 8
Moorefields Eye Hospital, London, United Kingdom, 9Consultores Oftalmologicos, Buenos Aires, Argentina, 10Columbia University,
Introduction: There is no gold standard for measuring axial globe position (AGP). Hertel exophthalmometry is most commonly used/
studied, but has inherent errors.1 Our purpose was not to determine a gold standard, but to identify a reproducible method of AGP
measurement that allows valid comparison between patient visits, clinicians, and centers, for use in future multi-institutional studies.
Methods: Prospective, international, 7 institution study. Three measurement types were investigated: Clinical (ExophthalmometryHertel, Oculus, Mourits), radiologic (CT), and photographic. Horizontal and vertical palpebral fissure correlation with AGP was
investigated. Three clinicians at each site made 3 nonconsecutive measurements with each instrument with the patient upright and
supine and measured horizontal palpebral fissure width 3 nonconsecutive times. Same-day photographs were read by 3 readers,
3 nonconsecutive times for AGP, horizontal and vertical fissure (Univeristy of Rochester). All standardized orbital CTs were read by
3 oculoplastic surgeons (WVU) within 1 week.
CT was the standard to which all measurements were compared. Right and left sides were analyzed separately. Agreement with CT,
and within and between all clinicians/readers was assessed with intraclass correlation coefficients (ICC). ICC >0.9 was considered
ideal, 0.85-0.9 nearly ideal. Mean measures for each patient, graphs of individual pairs of estimates, and Bland-Altman figures
were generated. Means and standard deviation of difference values and 95% confidence intervals (those not containing 0 were
considered significant at α=0.05) were calculated., Paired t-tests evaluated patient position. Pearons correlations evaluated
Indirect measures of AGP.
Results: Figures 1-4. Sixty-eight patients participated. Intraclinician agreement was ideal across all exophthalmometers.
Interclinician agreement was ideal for Hertel, nearly ideal for Oculus. Right sided measurements agreed better with CT and had
better intra and interclinician agreement. CT and photography, intra and inter reader agreement was ideal. Supine Mourits and
Left-sided supine Hertel measurements were statisticially significantly different from CT. All exophthalmometry 95% confidence
intervals fell within 1mm. Oculus was the best estimate of CT, Hertel was nearly ideal. Oculus was the most precise. Patient position
and magnitude of proptosis had no clinically meaningful effect. Photography is not a good estimate of CT. Vertical and Horizontal
palpebral fissures do not correlate with AGP (r=0.19 - 0.58).
Conclusions: Exophthalmometry is a reliable with Oculus being the most precise. Future protocols should employ standardized
technique, constant base, same instrument, and clinician(s).
References: 1. Frueh WT, Frueh BR. Errors of single-mirror or prism Hertel exophthalmometers and recommendations for minimizing
the errors. Ophthal Plast Reconstr Surg. 2007 May-June;23(3):197-201
1:06 pm Axial Globe Position Measurement: A Prospective Multi-center Study Sponsored by the
International Thyroid Eye Disease Society, continued
1:12 pm Lateral Rectus Muscle Expands More than Medial Rectus Following Maximal
Deep Balanced Orbital Decompression
Sara Alshaker1, Alex Nobori1, Dan Rootman1, Robert Goldberg1, Yi Wang2. 1Department of Orbital and Ophthalmic Plastic Surgery,
Jules Stein Eye Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA,
United States, 2Institute of Orbital Diseases, Armed Police General Hospital, Beijing, China
Introduction: It has been reported that extraocular muscles can enlarge following orbital decompression in thyroid eye disease
(TED) 1,2,3. It has also been suggested that the medial rectus enlarges more2,3. However, these reports focused on medial wall
decompression with conservative or no lateral decompression. In this paper, we studied the changes in extraocular muscle size
following balanced maximal deep lateral and medial decompression in a large sample of TED patients (Figures 1 and 2).
Methods: Pre- and post-operative CT images of 48 consecutive balanced deep lateral and medial orbital decompressions (75 orbits)
were reviewed. Radiologic proptosis was assessed. Maximal axial muscle widths of the medial and lateral recti were measured for
each scan.
Results: There was a significant increase in the width of both the lateral and medial recti after decompression (p<0.01). The mean
[SD] change was less for the medial rectus (0.7mm [1.0]) than for the lateral (2.7mm [3.0]). This difference was significant (p<0.01).
For the lateral rectus, 80% of all decompressions were associated with an increase in width of >1mm. The same was true for 50%
of medial recti. There was a small significant negative association between lateral rectus width preoperatively and lateral rectus
expansion postoperatvely (r=-0.27, p<0.05). No such association was noted for the medial rectus. Mean (SD) proptosis reduction
was 8.2mm (3.4mm). There was a weak negative correlation (r=-0.26, p<0.05) between proptosis reduction and lateral rectus
enlargement. No such association was noted for the medial rectus.
Conclusions: In previous reports, after orbital decompression the medial rectus muscle expanded more than the lateral rectus, but
in these cases the primary wall removed was medial. In this series of aggressive lateral decompression, the lateral rectus muscle
expanded more than the medial. It may be that pressure reduction in decompression is compartmentalized based on the direction of
bony expansion. Additionally, expansion of the rectus muscles may negatively affect overall proptosis reduction.
Figure 1. Pre (left) and postoperative (right) CT scans of the orbits.
References:
1. Wenz R, Levine M, Putterman A, Bersani T, Feldman K. Extraocular Muscle Enlargement After Orbital Decompression for Graves’
Ophthalmopathy. Ophthalmic Plast Reconstr Surg. 1994;10(1):34-41.
2. Hu WD, Annunziata CC, Chokthaweesak W, et al. Radiographic analysis of extraocular muscle volumetric changes in thyroid-related
orbitopathy following orbital decompression. Ophthal Plast Reconstr Surg. 2010;26(1):1-6.
3. Alsuhaibani AH, Carter KD, Policeni B, Nerad J a. Effect of orbital bony decompression for Graves’ orbitopathy on the volume of
extraocular muscles. Br J Ophthalmol. 2011;95(9):1255-1258.
1:18 pm Dilated Superior Ophthalmic Vein: Features of 113 Cases
Jenny Temnogorod1, Christopher Adam1, Carol Shields2, Joon Kim3, Brent Hayek3, Flora Levin4, Bryan Winn5, Ivan Vrcek6, Craig
Linden7, Christina Choe8, Mithra Gonzalez9, Johanna Fifi10, Alejandro Berenstein10, Vikram Durairaj11, Tanuj Nakra11, Roman Shinder1,11.
1
Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, United States, 2Ocular Oncology, Wills Eye Institute, Philadelphia, PA,
United States, 3Ophthalmology, Emory University Hospital, Atlanta, GA, United States, 4Yale University School of Medicine, New Haven,
CT, United States, 5Columbia University Harkness Eye Institute, New York, NY, United States, 6UT Southwestern Medical Center, Dallas,
TX, United States, 7Radiology, SUNY Downstate Medical Center, Brooklyn, NY, United States, 8Carolina Ophthalmology, Asheville, NC,
United States, 9University of Rochester Flaum Eye Institute, Rochester, NY, United States, 10Hyman Newman Institute for Neurology and
Neurosurgery, Mt. Sinai-Roosevelt Hospital, New York, NY, United States, 11Texas Oculoplastic Consultants, Austin, TX, United States
Introduction: A dilated superior ophthalmic vein (SOV) is a rare radiographic finding (Figs 1-3) with a range of etiologies from the
benign to the life threatening1,2,3. The literature describing dilated SOV is scarce with only a few prior case reports1,2,3. We herein
present a series of 113 patients noted to have a dilated SOV on orbital imaging.
Methods: Clinical records of 113 patients with a dilated SOV on radiography were reviewed.
Results: 113 patients with a dilated SOV on radiography were evaluated (Fig 4). 75 women and 38 men had a median age of
49 years (range 0.4 - 90). The most common etiology found was cerebrovascular malformation (80 cases, 71%). Within this group,
dural cavernous fistulas (50 cases, 44%) and direct carotid cavernous fistulas (21 cases, 19%) predominated. The imaging modalities
utilized included CT, MRI, US, and angiography. Visual deficit observed at presentation and last-follow-up across all cases was
59% and 52%, respectively. Treatment was tailored based on the etiology, & clinical and radiographic findings with a median
follow-up of 18 months (range 0-180). Status at last follow-up included 57 patients with no evidence of disease, 53 alive with
disease, and 3 patients who expired.
Conclusions: This report to our knowledge represents the largest series of patients noted to have a dilated SOV on radiography
to date. A dilated SOV is a rare finding that can be the result of a variety of disorders, and careful review of orbital imaging is often
needed not to miss this critical entity1,2,3. A thorough understanding of its differential diagnosis is paramount in rendering proper
medical management. Various orbital imaging modalities (CT, MRI, MRV, US, angiography) have complimentary roles in diagnosing
a dilated SOV3. AV fistulas represented the most common cause of a dilated SOV in our cohort. Recognition of a dilated SOV is
important to clinicians as it can be the initial finding of a potentially vision or life threatening condition.
References: 1. Carrim ZI, Ahmed TY, Wykes WN. Isolated superior ophthalmic vein thrombosis with orbital congestion: a variant of
idiopathic orbital inflammatory disease? Eye. 2007 May21(5):665-6.
2. Somer D, Ozkan SB, Ozdemir H, et al. Colour Doppler imaging of superior ophthalmic vein in thyroid-associated eye disease. Jpn J Ophthalmol. 2002 May-Jun46(3):341-5.
1:18 pm Dilated Superior Ophthalmic Vein: Features of 113 Cases, continued
1:24 pm Intracranial Hypotension Related Skull Remodeling With Enophthalmos and
Sphenoid Sinus Expansion
Timthy McCulley1, Jordan Piluek1, Jesica Chang1, Thomas Hwang2. 1Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD,
United States, 2Ophthalmology, Stanford University School of Medicine, Stanford, CA, United States
Introduction: Previously, we investigated bony skull changes in patient presenting with enophthalmos following ventriculoperitoneal
shunting. 1,2 Here we collate volumetric analyses of the orbits and sphenoid sinuses in a cohort with enophthalmos secondary to
intracranial hypotension related skull remodeling.
Methods: In this retrospective case controlled study five patients (3 males, 2 females, mean age 24.8 years, range 16 to 38 years)
were identified with enophthalmos related to chronic intracranial hypotension. For two patients with adequate computed tomography
(CT) imaging, orbit volumes were calculated using ImageJ software (v1.40g, National Institute of Health). For four patients with
adequate CT imaging, three sphenoid sinus measurements were taken: the distance between the orbital apices, the posterior
extension of the sphenoid sinus posterior to the orbital apices and the maximal horizontal width. The mean of each was determined
and compared to that of the control group (5 males, 5 females, mean age 35.6 years old, range 23 to 45 years).
Results: Orbital volumes were significantly greater in enophthalmic patients than controls (33.3 + 1.7cm3 vs . 24.3 ± 3.3cm³,
P = 0.03, Wilcoxon rank-sum test). Sphenoid sinus posterior extension (26.3+4.1mm vs. 13.4+6.3 mm, p=0.0015, student’s t-test),
and width of the sphenoid sinus width (39.2+8.7mm vs. 25.1+6.9mm, p=0.0035, student’s t-test) were markedly larger in the
enophthalmic than the control group. Mean distance between the orbital apices was slightly greater (36.3+1.7mm vs. 34.1+2.1mm,
p=0.047, student’s t-test).
Conclusions: Our recognition of the relationship between skull remodeling and intracranial pressure is just beginning. In extreme
cases marked enophthalmos results from orbit volume expansion. Bony changes are not limited to the orbits, as demonstrated in this
cohort with documented sphenoid sinus expansion.These findings are of clinical, diagnostic and pathophysiologic importance.
References: 1) Hwang TN1, Rofagha S, McDermott MW, Hoyt WF, Horton JC, McCulley TJ. Sunken eyes, sagging brain syndrome:
bilateral enophthalmos from chronic intracranial hypotension. Ophthalmology. 2011 Nov;118(11):2286-95.
2) McCulley TJ. Sphenoid sinus expansion: a radiographic sign of intracranial hypotension and the sunken eyes, sagging brain
syndrome (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013 Sep;111:145-54.
Panel: Raghuraj Hegde, MD, Chad Bingham, MD, Sara Alshaker, MD, Jenny Temnogorod, MD, Timothy McCulley, MD
Featured Speaker — Suresh Mukherji, MD, MBA, FACR
1:40 pm Introduction of Dr. Suresh Mukherji
Alon Kahana, MD
1:43 pm 8/19/2014
Imaging of the Orbit and Globe
Suresh Mukherji, MD, MBA, FACR
The Orbit & Globe
Suresh K. Mukherji, M.D., M.B.A., F.A.C.R.
Professor and Chairman
Michigan State University Department of Radiology
W. F. Patenge Endowed Chair
Department of Radiology
Chief Medical Officer & Director of Health Care Planning
Michigan State University Health Team
Differential Diagnosis
Optic Nerve
• Intraconal versus extraconal
• Relationship to the Optic nerve
Optic Neuritis
Optic Neuritis
Acute
Subacute
Chronic
8/19/2014
Imaging of the Orbit and Globe, continued
Radiation-Associated Optic Neuritis
Optic Nerve Glioma
Cavernoma
Meningioma
Sarcoidosis
Clinical Presentation
Leukokoria
2
8/19/2014
Retinoblastoma
Retinoblastoma
• Majority of patients < 3 y.o
• Calcified intraoccular mass
• Heritable form:
• Chromosome 13/Rb
gene
• Bilateral
• “two hit” model
Retinoblastoma
Coat’s Disease
(Exudative Retinitis, Retinal Telangiectasis)
Unilateral
Males > females
6-8y.o.
Leaky Blood vessels
Persistent Hyperplastic Primary Vitreous
(PHPV)
Persistent Hyperplastic Primary Vitreous
(PHPV)
• Failure of the embryonic primary vitreous
and hyaloid vasculature to regress
• “Anterior” vs “Posterior”
• “Cloquet’s Canal”: Perivascular shealth
surrounding embryonic hyaloid artery
3
8/19/2014
Toxocariasis
Endopthalmitis
Toxocariasis
• Toxocara Canis or
Cati
• Unilateral
• Children or young
adults
• Posterior pole
granuloma: 50%
• Enopthalmitis: 25%
• Variety of medical
therapies
Posterior Pole Granuloma
Case Courtesy Feliza Restrepo, MD
Detached Retina
Detached Retina
• Diabetes, smoking,
trauma, etc
• Flashes of light, vision
loss, blindness
• Diagnosis: Fundoscopy
• Surgical emergency
Retinopathy of Prematurity
“Retrolental Fibroplasia”
• Pre-mature infants
• Oxygen toxicity, relative
hypoxia
• <31 wks gestation, low
birth weight
• Disorganized retinal
neovascularization leads
to scarring and retinal
detachment
• Tx: Peripheral retinal
ablation
Leukokoria
Anophthalmia/ Microphthalmia
4
8/19/2014
Anophthalmia
Anophthalmia
• Rare. 3/100,000 births
• Accounts for 3-11% of congenital blindness
• SOX 2 mutation that prevents formation of SOX 2
protein; OTX2, CHX10, RAX
Microphthalmia
Coloboma
Coloboma
Staphyloma
• Abnormal protrusion of
uveal tissue due to
weakening of the
cornea or sclera
• Inflammatory or
degenerative condition
• 5 types
• “bupthalmos: bulging
eyes: clinical diagnosis
5
8/19/2014
Leukokoria
Anophthalmia/ Microphthalmia
Infection
Pre-septal Cellulitis
Post-septal Cellulitis
Subperiosteal Abscess
Orbital Abscess
6
8/19/2014
Cavernous Sinus Thrombosis
Abducens Nerve
Cavernous Sinus
Thrombosis
Leukokoria
Anophthalmos/ Microphthalmos
Infection
Proptosis
Thyroid Ophthalmopathy
7
8/19/2014
Pseudotumor
6 Types based on location
Myositic
Sclertic
Lacrimal
Diffuse
Pseudotumor
Peri-neuritic
Tolosa-Hunt
Hemangioma
Hemangioma
Lymphatic Malformation
Schwannoma
8
8/19/2014
Lymphoma
Lymphoma
Sphenoid Wing Dysplasia
C-C Fistula
Lacrimal Gland & Sac
Bony Orbit
Dermoid
Sarcoid
Adenoidcystic Carcinoma
Lymphoma
Fibrous Dysplasia
Pott’s Puffy Tumor
Osteopetrosis
Metastases
9
8/19/2014
Primary Tumor and Metastases
Melanoma
Conjunctival Melanoma
Rhabdomyosarcoma
Differential Diagnosis
Leukocoria
Anophthalmia/Microphthalmia
Infection
Proptosis
Breast Metastases*
Which of the following usually
presents with proptosis?
A.
B.
C.
D.
Summary
Coloboma
PHPV
Thyroid opthalmopathy
Optic neuritis
Which of the following statements is true?
A. Cloquet’s canal is associated with persistent
hyperplastic primary vitreous
B. PHPV usually presents as a calcified
intraocular mass in a child
C. Patients with Coat’s disease usually presents
with an enlarged eye
D. Coloboma is a traumatic defect in the uveal
tract an usually presents in adults
Which of the following statements is true?
A. Cavernous sinus thrombosis (CST) is always
fatal
B. Radiologists must be familiar with early
findings of CST since early diagnosis could
prevent long term morbidity
C. CST is associated with enophthalmos
D. Cranial neuropathies are typically not
associated with CST
10
2:20 – 2:50 pm
Eyelid Session III
2:50 pm The Abbreviated National Eye Institute Visual Function Questionnaire
(NEI VFQ 9) is a Sensitive and Time Efficient Method for Detecting the Changes
in Visual Function Caused by Blepharoptosis and Dermatochalasis and Their
Surgical Correction
César A. Briceño1, Molly L. Fuller2, Elizabeth A. Bradley2, Christine C. Nelson1. 1Ophthalmology, Kellogg Eye Center,
University of Michigan, Ann Arbor, MI, United States, 2Ophthalmology, Mayo Clinic, Rochester, MN, United States
Introduction: The quality of life implications of functional blepharoplasty and ptosis surgery have been studied, but existing surveys
may be impractical to administer in a busy clinical setting1-3. The abbreviated National Eye Institute Visual Function Questionnaire (NEI
VFQ 9) is an established tool for quickly assessing visual function in a variety of eye conditions. We hypothesized that the NEI VFQ 9
would be a sensitive and efficient way to assess visual function in patients with blepharoptosis and dermatochalasis.
Methods: In this prospective study, patients referred to a single surgeon were evaluated with margin-to-reflex distance (MRD1), and
the NEI VFQ 9 survey. Patients were included in the study if their evaluation led to surgical correction by blepharoplasty, blepharoptosis
repair, or a combination. Patients with other simultaneous eyelid surgery were excluded. Testing was repeated at a post-operative visit.
Survey duration was timed in a subset of patients. Pre- and post-operative composite scores were compared with the Student’s T-test.
Results: Twenty-nine blepharoplasty-only patients, eleven ptosis surgery-only patients, and six combination patients were included in
the study. In the blepharoplasty-only group, the mean pre-operative NEI VFQ 9 composite score was 74.9/100, and the mean postoperative score was 86.8/100 (p<0.0001).The mean pre-operative composite score for the ptosis surgery-only patients was 72.07,
and the post-operative mean composite score was 86.41 (p=0.004). In the combination group, the pre-operative mean composite
score was 75.8, and the mean post-operative composite score was 87.2 (p=0.022). No correlation was found between the gain in
composite score and the change in MRD1. Twenty-five patients were timed filling out the survey, and the mean was 7.1 minutes.
Conclusions: The NEI VFQ 9 consistently demonstrates an increase in visual function for blepharoptosis and dermatochalasis patients.
This is in keeping with previously published reports, but the NEI VFQ 9 is a more efficient and more readily available tool, that has been
vetted in a number of common eye conditions. With further study, this may allow for comparisons of visual function impairment in eyelid
malpositions versus other conditions, and to further understand the role that eyelid malposition plays in diminishing visual function in
the patient with multiple eye comorbidities.
References: 1Sanchez-Castellanos A, Nelson CC, Musch D. Impact of Lid Position Surgery on Social and Emotional Aspects of Quality
of Life in Adults. ASOPRS Fall Symposium 2010
2
Federici TJ, Meyer DR, Lininger LL. Correlation of the vision-related functional impairment associated with blepharoptosis and the
impact of blepharoptosis surgery. Ophthalmology. 1999 Sep;106(9):1705-12.
3
Battu VK, Meyer DR, Wobig JL. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis
surgery. Am J Ophthalmol. 1996 Jun;121(6):677-86.
2:56 pm Lid Crease Approach for Margin Rotation in Upper Cicatricial Entropion
Antonio Cruz1,2,3, Patricia Akaishi1,2, Mohammed Dufaileej2, Alicia Galindo2. 1Ophthalmology, School of Medicine of Ribeirao Preto,
RIBEIRAO PRETO, Brazil, 2King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, 3Wilmer Institute, Johns Hopkins University,
Introduction: Upper eyelid cicatricial entropion is a common cause of trichiasis. This condition is caused by any pathological process
that provokes scarring of the tarsal plate and consequent inward rotation of the lid margin. In several regions of the Middle East and
Africa, trachoma is the most common cause of cicatricial upper eyelid entropion.1 The purpose of this work is to describe the lid
crease approach with internal absorbable sutures for upper lid margin rotation
Methods: Fifty-seven upper lids of 38 consecutive patients (22 women, 16
men with a mean age of 69.4 years ± 14.95 SD) with trachomatous cicatricial
entropion were operated in the King Khaled Eye Specialist Hospital (Riyadh,
Saudi Arabia) through anterior approach with a lid crease incision. Preoperatively
all lids were rotated inwards with trichiasis and the typical conjunctivalization of
the margin. After surgery lid rotation was evaluated and any residual trichiasis
was registered. Follow-up ranged from 1 to 12 months (mean = 2.8 ± 2.7 SD).
Surgical technique: a standard lid crease incision is used to create a pretarsal
skin muscle flap (Fig1 A,b) exposing the whole tarsal plate until the lash roots
are seen (Fig1 C). The eyelid is everted over a cotton-tipped applicator (Fig1 D)
and held in position with a traction suture. Using a No.15 Bard-Parker scalpel
blade and Westcott scissors, a curved incision paralleling lid margin is made
through the full thickness of the tarsus 3 mm posteriorly to the margin (Fig 1 E).
The lid is returned to its natural position. Three double-armed 6-0 polyglactin
(Vicryl) sutures are then passed through the central, medial and lateral aspects
of the distal cut edge of tarsus and attached to the orbicularis near the lash line
(Fig 1 F). As the sutures are tied, the distal portion of the tarsus is advanced over
the marginal tarsus, and the marginal orbicularis is pushed backwards rotating
outwards both lamellae of the lid margin (Fig 1G). The sutures remain within the
lid and no bolsters are used (Fig 1 H).
Results: Lid margin rotation was obtained in all operated lids. Trichiasis
was corrected in all lids but one that showed two lashes touching the
cornea medially.
Conclusions: Upper lid margin rotation can be achieved using a lid crease
incision and internal sutures. The operation is versatile and can be used to
simultaneously correct cicatricial entropion, dermatochalasis, aponeurotic ptosis or lid retraction.
References: 1- Polack S, Brooker S, Kuper H, Mariotti S, Mabey D, Foster A. Mapping the global distribution of trachoma.
Bull World Health Organ. 2005;83:913-9
3:02 pm Upper Eyelid Myectomy for Essential Blepharospasm: Cost Benefit Analysis to
the US Medicare System
Tiffany Kent1,2, Carisa Petris3, John Holds2,4. 1Ophthalmology, Washington University School of Medicine, St. Louis, MO, United
States, 2Ophthalmic Plastic and Cosmetic Surgery, Inc., Des Peres, MO, United States, 3Ophthalmology, Columbia university College
of Physicians and Surgeons, New York, NY, United States, 4Ophthalmology and Otolaryngology/Head and Neck surgery, Saint Louis
University School of Medicine, St. Louis, MO, United States
Introduction: Some patients with essential blepharospasm achieve suboptimal results with botulinum toxin injection alone and
require myectomy surgery. The authors hypothesized that myectomy provides a significant decrease in botulinum toxin dose and
increase in treatment interval with substantial savings in healthcare costs in the long-term treatment, even after subtracting the cost
of the myectomy.
Methods: Retrospective chart review of 27 patients undergoing myectomy for the treatment of refractory BEB. The frequency and
dosage of botulinum toxin were compared between pre-operative and post-operative treatments. Medicare allowables for surgery
and subsequent botulinum toxin treatment were examined. Mean postoperative follow up was 6.3 years.
Results: The mean interval between botulinum treatments was 10.1 weeks pre-operatively and 15.7 weeks post-operatively
(p<0.001). The mean quantity of botulinum toxin administered was 68 units prior to myectomy and 64.9 units post-operatively
(p=0.227). Utilizing Medicare system total allowable charges (facility, surgeon and anesthesia) for the myectomy of $1724 and
allowable charges for subsequent botulinum treatment of the study’s 27 patients with myectomy vs. without, each patient undergoing
myectomy surgery yielded a projected savings to the Medicare system of $11,505 over a 10-year postoperative period.
Conclusions: Myectomy for blepharospasm results in a lower postoperative botulinum A toxin treatment dose and a longer
treatment interval. This increased interval is associated with increased functional ability and patient satisfaction with treatment.
Clinicians treating blepharospasm should consider myectomy as an adjunct in the treatment of patients with clinically refractory
blepharospasm. The Medicare system and private healthcare carriers should recognize the medical benefits and long-term cost
savings associated with this surgery.
References: Holds, J.B., S.G. Fogg, and R.L. Anderson, Botulinum A toxin injection. Failures in clinical practice and a biomechanical
system for the study of toxin-induced paralysis. Ophthal Plast Reconstr Surg, 1990. 6(4): p. 252-9. Anderson, R.L., et al.,
Blepharospasm: past, present, and future. Ophthal Plast Reconstr Surg, 1998. 14(5): p. 305-17.
Gillum, W.N. and R.L. Anderson, Blepharospasm surgery. An anatomical approach. Arch Ophthalmol, 1981. 99(6): p. 1056-62.
Czyz, C.N., et al., Long-term botulinum toxin treatment of benign essential blepharospasm, hemifacial spasm, and Meige syndrome.
Am J Ophthalmol, 2013. 156(1): p. 173-177 e2.
Dressler, D., Complete secondary botulinum toxin therapy failure in blepharospasm. J Neurol, 2000. 247(10): p. 809-10.
3:08 pm Conjunctiva-Sparing Modification to Posterior Approach Ptosis Repair
Ivan Vrcek, Ronald Mancini. Department of Ophthalmology, UT Southwestern Medical Center at Dallas, Dallas, TX, United States
Introduction: Müller›s muscle conjunctiva resection (MMCR) is a well-established means of correcting blepharoptosis.
The primary objective of this prospective study was to determine if modifying MMCR by sparing the conjunctiva would accomplish
successful repair while allowing patients to retain their conjunctiva. The potential advantages of preserving conjunctiva are
significant and include: conservation of an anatomically normal tissue, retention of goblet cells, reduction of suture-related
complications such as corneal irritation or abrasion, and preservation of conjunctiva for potential future surgical procedures
such as glaucoma filtering surgery.
Methods: Following informed consent, patients with mild to moderate ptosis with a positive response to phenylephrine and good
levator function who met inclusion criteria were invited to participate in this prospective study.
At the time of surgery, the eyelid was everted and local anesthesia was injected into the supratarsal palpebral conjunctiva.
A supratarsal incision was created and a window pane conjunctival dissection carried out superior to the tarsus (figure 1). The
conjunctiva was reflected and markings were made on Müller’s muscle at a distance determined preoperatively depending on the
desired effect. A ptosis clamp was placed in position with the conjunctival flap reflected inferiorly (figure 2). The surgery was then
performed as described by Putterman and Urist with the exception that Müller’s muscle alone was excised and the conjunctival flap
was preserved1. The conjunctiva was then re-draped in position over the sutured Müller’s muscle without sutured closure of the
conjunctiva (figure 3).
Patients were followed at one week, one month, and three months where a complete ophthalmic exam including photographs and
measurement of MRD1 was performed.
Results: Thus far, this procedure has been performed on 10 patients and 16 eyelids. Follow-up at one week revealed adequate
healing with expected post-operative changes. Notably, all patients were free of any corneal abrasion or irritation. Follow-up at one
and three months revealed that all patients had satisfactory correction of their blepharoptosis with expected symmetry, MRD1, and
palpebral fissure height. Average improvement in MRD1 at one month was 4.04mm and all patients were satisfied with cosmesis.
Microscopic analysis of the surgical specimens confirmed that the excised tissue was composed of smooth muscle only (figure 4).
Additional operative time was minimal. There were no complications and none of the participants required a bandage contact lens
following surgery.
Conclusions: This modification to MMCR provides effective correction of blepharoptosis with no complications noted thus far, with
the advantage of preserving conjunctiva. There are numerous types of patients who may benefit from a conjunctiva-sparing surgery,
including those with anophthalmic socket, glaucoma, post-corneal transplant, contact lens use, and concern for dry eye. In such
patients, this conjunctiva-sparing modification to MMCR may be a preferred option to traditional surgery.
References: 1. Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis.
Archives of Ophthalmology 1975 Aug;93(8):619-23.
3:08 pm Conjunctiva-Sparing Modification to Posterior Approach Ptosis Repair, continued
3:14 pm The Versatility of the Lateral Tarsoconjunctival Onlay Flap
Swapna Vemuri, Amy Patel, Jeremiah Tao. University of California - Irvine, Gavin Herbert Eye Institute, University of California - Irvine,
Introduction: We evaluate the efficacy of a lateral tarsoconjunctival onlay flap (TaO flap) procedure1 to improve lower eyelid
malposition in a variety of complex lower eyelid retraction or ectropion scenarios.
Methods: Retrospective chart review of consecutive patients between 2008 and 2014 with lower eyelid malposition treated with
a far lateral tarsoconjunctival flap sutured to the lateral lower eyelid in an onlay fashion (Figure 1). Etiology of eyelid malposition, lid
position, lagophthalmos, ocular surface disease, patient satisfaction, and cosmesis were recorded. Post-operative complications and
subsequent management were also recorded.
Results: A total of 131 patients (147 eyelids) were identified with the following lower eyelid retraction or ectropion vectors: paralytic
(90 patients), cicatricial (15 patients), negative vector (25 patients, 50 eyelids), and congenital in association with Kabuki syndrome
(1 patient, 2 eyelids). Ocular surface exposure, ectropion, and/or eyelid retraction improved in all cases. Figure 2: representative
images in the treatment of paralytic retraction. Figure 3: the use in cicatricial ectropion combined with skin grafting and canthoplasty.
Figure 4: the use in congenital ectropion. All patients described an improvement in exposure symptoms and cosmesis. 3 eyelids
(2%) had flap dehiscence successfully treated with repeat suturing. 8 patients (8 eyelids, 5%) had symptomatic temporal peripheral
vision restriction requiring partial or complete flap takedown. 5 eyelids (3%) had pyogenic granulomas excised. 5 flaccid facial nerve
paralysis patients required a subsequent medial intermarginal adhesion tarsorrhaphy to treat medial lagophthalmos.
Conclusions: The lateral TaO flap was effective in achieving an aesthetically and functionally sound treatment for lower eyelid
malposition in a variety of difficult scenarios. In some multi-vector or pronounced vector cases, the TaO flap was a useful adjunct to
other procedures including canthoplasty, skin grafting, or both. Temporal vision obstruction was an infrequent side effect and flap
dehiscence and granulomas were rare complications.
References: 1. Tao J, Vemuri S, Patel A, et al. Lateral tarsoconjunctival onlay flap lower eyelid suspension in facial nerve paresis.
Manuscript pending publication in Ophthal Plast Reconstr Surg.
3:20 pm Medial Anchoring of the Upper Eyelid Skin During Blepharoplasty
Fatemeh Rajaii, Victor Elner. Kellogg Eye Center, University of Michigan, Ann Arbor, MI, United States
Introduction: This is a description of a novel technique, used during blepharoplasty to address the common post-operative issue
of prominent medial upper eyelid fullness by creating the natural concave medial upper eyelid contour.
Methods: We performed anchoring of the upper eyelid skin during blepharoplasty in 150 patients who were then followed for at
least 6 months post-operatively. Photographs were taken pre-operatively and post-operatively to document the results. Charts were
reviewed to assess for complications, patient satisfaction, and medial upper eyelid deformity. Step-by-step details of the technique
will be provided at the presentation.
Results: The senior author has used this technique for the past 10 years, with excellent post-operative outcomes in more than
90% of patients as shown in figure 1 (pre-operative (A, C) and post-operative (B, D) photographs of two representative patients
who underwent blepharoplasty using this technique). There have been no blepharoplasty-associated complications to date.
Conclusions: We describe a technique that anchors the medial skin during blepharoplasty to recreate the concave contour of
the medial upper eyelid, achieving excellent results in a high percentage of the cases. The technique is applicable in all races and
various eyelid/brow configurations.
3:26 pm Upper Eyelid Skin Contracture in Facial Paralysis
Kimia Ziahosseini1, Vanessa Venables 2, Charles Nduka3, Raman Malhotra1. 1Corneoplastic Unit, Queen Victoria Hospital,
East Grinstead, United Kingdom, 2Department of Physiotherapy, Queen Victoria Hospital, East Grinstead, United Kingdom, 3
Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, United Kingdom
Introduction: Clinicians and facial therapists are anecdotally aware of the shortening that can occur of the upper eyelid skin,
presumably due to the unopposed action of upper lid retractors. Muscle pump paralysis also reduces the venous tone and can lead
to raised hydrostatic pressure of the venous system leading to oedema. This can lead to fibrosis of the subcutis and trophic skin
changes. There is currently no quantitative evidence of this sequala in the literature. We report the occurrence and severity of this
complication and explore its correlation with various factors.
Methods: We carried out a prospective cross-sectional study on patients with unilateral facial paralysis during a five-month period
(december 2013- april 2014). Patients with previous upper eyelid surgery on either side were excluded. We developed a standardised
technique to measure the distance between the upper eyelid margin and the lower border of brow (LMBD). Facial paralysis was
graded using the Sunnybrook grading scale. Its aetiology, duration and treatment were noted.
Results: Forty-three patients (mean age 49.2, range: 10-79 years) were identified. The mean duration of the paralysis was
61.6 (range: 2 months to 29 years). LMBD on the paralytic side was shorter than the normal contralateral side in 26 (60%) patients.
The mean contracture was 3.4mm (range: 1-12), 6 (14%) patients showed 5mm or more of skin contracture. The mean LMBD on the
paralytic side in all patients was significantly smaller than the contralateral side; 30.8mm (95% CI, 29.6 to 32.1) compared to
32.7 mm (95% CI, 31.5 to 33.9), p<0.0001. LMBD reduction was associated with younger age (r=-0.33,n=43, p=0.02) and
lower MRD (r=0.32, n=43, p=0.03) suggesting that the lower eyelid skin also undergoes the same process.
Conclusions: This finding is valuable in directing optimal management in the acute phase to minimise skin contracture,
to reinforce the principles of avoiding skin excision in these patients and potentially to augment skin in selected patients.
References: 1. Trettin H. Neurologic principles of edema in inactivity Z Lymphol. 1992 Dec;16(1):14-6.
2. Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg;1996
Mar;114(3):380-6.
3. Hashemi H, Khabaz Khoob M, Yazdani K, et al. White- to-white corneal diameter in the Tehran Eye Study. Cornea 2010;29(1):9-12
4. Bladen JC, Norris JH, Malhotra R. Indications and outcomes for revision of
gold weight implants in upper eyelid loading. Br J Ophthalmol. 2012 Apr;96(4):485-9.
5. Kanerva M, Poussa T, Pitkaranta A. Sunnybrook and House-Brackmann Facial Grading Systems: intrarater repeatability and
interrater agreement. Otolaryngol Head Neck Surg; 2006 Dec;135(6):865-71.
6. Hu WL, Ross B, Nedzelski J. Reliability of the Sunnybrook Facial Grading System by novice users. J Otolaryngol;
2001 Aug;30(4): 208-11.
7. Kayhan FT, Zurakowski D, Rauch SD. Toronto Facial Grading System: interobserver reliability. Otolaryngol Head Neck Surg;
2000;122: 212-15.
Panel: César A. Briceño, MD, Antonio Cruz, MD, Tiffany Kent, MD, Ivan Vrcek, MD, Swapna Vemuri, MD, Fatemeh Rajaii, MD,
Kimia Ziahosseini, MD
Orbit Session III
3:45 pm Orbital and Periorbital Extension of Congenital Dacryocystoceles
Francesco Bernardini1, Altug Cetinkaya2, James Katowitz3, Pelin Kaynak4. 1Oculoplastica Bernardini, Genova, Italy, 2
Ophthalmology, Dunyagoz Ankara Hastanesi, Ankara, Turkey, 3Ophthalmology, The Children’s Hospital of Philadelphia,
Philadelphia, PA, United States, 4Ophthalmology, Istanbul Beyoğlu Eye Research Hospital, Istanbul, Turkey
Introduction: To describe the clinical presentation and successful surgical management of four cases of congenital dacryocystocele
that presented with extension to the orbital and periorbital regions.
Methods: Retrospective chart review of four cases that were diagnosed and surgically treated for orbital and/or periorbital
dacryocystocele extensions. The first case was a 12 day-old newborn presenting with acute proptosis of the left eye secondary
to complete orbital invasion of a congenital dacryocystocele. The second case was a 40 days old female with an anterior
dacryocystocele that showed initial signs of orbital expansion and globe compression. The third case was a 9 day-old girl newborn
with a prominent dacryocystocele of the lacrimal sac that developed into an acute cystic expansion and infection of the anterior lower
orbit, lower eyelid and upper cheek immediately following overly forceful sac massage by the primary care physician. The fourth
patient was a 7-month-old infant with a history of recurrent episodes of acute dacryocystitis that began several weeks after birth and
on presentation demonstrated a large dacryocystocele extending toward the orbit and ethmoid sinus.
Results: The first three newborns were brought immediately to the surgical theater after radiographic evidence of diffuse orbital or
periorbital expansion. Prompt surgical intervention with marsupialization of the orbital and periorbital dacryocystocele with aspiration
of the purulent material followed by nasolacrimal duct probing resulted in complete resolution of the clinical picture in both patients.
No cyst recurrence or lacrimal drainage problems were seen during follow-up. The fourth patient was successfully treated with an
external dacryocystorhinostomy (DCR) with excision of the enlarged cystic walls.
Conclusions: Orbital and periorbital extension of congenital dacryocystoceles is rarely observed in neonatal infants. Transconjunctival orbitotomy with sac marsupialization followed by naso-lacrimal intubation can provide immediate and permanent
resolution of this unusual complication in most instances. External DCR may be required, however, when the orbital or periorbital
dacryocystocele is complicated by acute or recurrent dacryocystitis.
References: 1. Sevel D. Development and congenital abnormalities of the nasolacrimal apparatus. J Pediatr Ophthalmol Strabismus
1981; 18:13-9.
2. Harris GJ, DiClementi D. Congenital dacryocystocele. Arch Ophthalmol 1982; 100:1763-5.
3. Becker BB. The treatment of congenital dacryocystocele. Am J Ophthalmol 2006; 142:835-8.
4. Shekunov J, Griepentrog GJ, Diehl NN, Mohney BG. J AAPOS 2010; 14:417-20
5. Wong RK, VanderVeen DK. Presentation and management of congenital dacryocystocele. Pediatrics 2008; 122:e1108-12.
6. Schnall BM, Christian CJ. Conservative treatment of congenital dacryocystocele. J Pediatr Ophthalmol Strabismus 1996;
33:219-22.
3:45 pm Orbital and Periorbital Extension of Congenital Dacryocystoceles, continued
3:51 pm Radiation Exposure from Orbital CT Scans – Spiral vs Traditional Scans
Introduction: There is an increasing awareness of the medical risks of CT scan-related radiation1. Strategies to reduce radiation
exposure include substituting MRI for CT when possible and minimizing the dosage of radiation administered with each scan. The
amount of radiation delivered during a scan is determined by patient size, the region studied, desired resolution, scan technique,
and technology. Traditionally, high quality orbital scans in different planes required performing independent direct axial and coronal
studies. Newer “spiral” scanners acquire a 3-D image database, from which axial, coronal, and sagittal images can be reconstructed.
Previously, an oral surgery study has shown that spiral CT yielded a lower radiation dose than traditional imaging2. There is little
published information available for the relative radiation exposure for orbital CT scans. We performed a retrospective study to
determine if there was a difference in the amount of radiation delivered during orbital CT between traditional and spiral scanners.
Methods: Following institutional IRB approval, data from orbital CT scans at one institution were reviewed from 2011-2013.
Radiation doses (dose-length product, DLP, mGy*cm) from spiral orbital CT scans with reconstructions and “traditional” direct
coronal and axial orbital scans were reviewed and compared. Mean radiation doses were calculated, and statistical significance
was determined.
Results: Data from 55 spiral and 19 traditional (axial and direct coronal) scans were analyzed. The mean DLP from spiral orbital CT
scans was significantly lower than those scans utilizing traditional scanning techniques (547 ± 245 vs 810 ± 167, p<0.001). There
was also no significant difference between the different spiral scanners in the outpatient radiology department (DLP = 584 ± 150,
n=19) and the emergency room (528 ± 283, p=0.427) (p<0.001).
We looked at the subset of scans performed for a single diagnosis, dysthyroid ophthalmopathy. Again, combined direct coronal and
axial studies (DLP = 803 ± 218) had a higher radiation exposure than spiral scans with reconstructions (DLP = 587±73, p=0.026).
Conclusions: Patient radiation exposure from CT scans can be minimized by substituting MRI when possible, and only obtaining
contrast enhanced studies if necessary. Additionally, this study confirms that newer, spiral orbital CT scanning technology delivers
less radiation than the traditional method of direct axial and coronal studies. Ophthalmologists should insure their imaging center has
spiral technology available and specify that such scanners be used when performing orbital imaging.
References: 1) Miglioretti et al., (2013). “The use of computed tomography in pediatrics and the associated radiation exposure and
estimated cancer risk.” JAMA Pediatr 167(8):700-7.
2) Bianchi, J., et al. (2000). “In vivo, thyroid and lens surface exposure with spiral and conventional computed tomography in dental
implant radiography.” Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90(2): 249-253.
3:57 pm Efficacy of Intravenous Mannitol as an Adjunct to Lateral Canthotomy
and Cantholysis in the Management of Orbital Compartment Syndrome;
A Non-Human Primate Model
Davin Johnson1, Andrew Winterborn2, Vladimir Kratky1. 1Department of Ophthalmology, Queen’s University, Kingston, ON, Canada, 2
Office of the University Veterinarian, Queen’s University, Kingston, ON, Canada
Introduction: To report the efficacy of intravenous mannitol as an adjunct to lateral canthotomy and cantholysis in the treatment
of orbital compartment syndrome using a non-human primate (NHP) model.
Methods: An experimental study was conducted on 4 NHPs (8 orbits). Orbital compartment syndrome was simulated by injecting
fresh autologous blood into both orbits of each NHP until an orbital pressure of 80 mmHg was reached (time 0). After 10 minutes
NHPs were randomized to receive an infusion of either mannitol (1g/kg) or equal volume saline, given over 15 minutes. 5 minutes
after the infusion was complete, lateral canthotomy and inferior/superior cantholysis was performed on both orbits in isolated steps
every 5 minutes. During the study period, measurements of orbital and intraocular pressure were recorded every 5 minutes, with a
final set of measurements at 60 minutes. The primary outcome measures were the mean change in orbital and intraocular pressure
from time 0 to 60 minutes, as well as the mean change in pressure during the infusion period prior to lateral canthotomy. Secondary
outcome measures included mean changes in pressure after each isolated step of the canthotomy/cantholysis, as well as the
correlation between orbital and intraocular pressure during the study period.
Results: The mean orbital and intraocular pressures at each time point during the study protocol are displayed in figures 1 and figure
2, respectively (LC lateral canthotomy; IC inferior cantholysis; SC superior cantholysis). There was no statistically significant difference
in the mean changes in either orbital or intraocular pressure from time 0 to 60 minutes of the protocol. However, during the infusion
period there was significantly greater decrease in both orbital and intraocular pressure in the mannitol compared to saline group
(-34.0 vs. -9.3 mmHg for orbital pressure [p=0.03]; -34.8 vs. -9.7 mmHg for intraocular pressure [p=0.04]). For the isolated steps
of the canthotomy and cantholysis, the greatest decrease in pressure occurred after the inferior cantholysis. During the study period,
a high correlation was found between orbital and intraocular pressure (Pearson correlation coefficient 0.94).
Conclusions: While the definitive treatment of orbital compartment syndrome is lateral canthotomy and cantholysis, intravenous
mannitol results in a rapid and clinically meaningful drop in orbital and intraocular pressure. As single doses of mannitol are generally
safe and well tolerated, we believe our data supports the routine use of intravenous mannitol in orbital compartment syndrome,
especially when there is a delay in timely surgical management.
4:03 pm A Four Year Retrospective Review of Space Occupying Lesions of the Orbit
Alina V Dumitrescu1, Anna W Berry1, William R Nunery2, Jason A Sokol1. 1Department of Ophthalmology, Kansas University Medical
Center, Kansas City, KS, United States, 2Department of Ophthalmology, University of Louisville, Louisville, KY, United States
Introduction: A wide variety of processes can produce space-occupying lesions in and around the orbit. These include benign
neoplasms, malignant neoplasms (primary or metastatic), vascular lesions, inflammatory disease, congenital lesions and infection,
among other causes. The purpose of this study is to determine the demographics, the frequency, the distribution according to
diagnosis, the recurrence frequency of orbital space-occupying lesions in our population of patients at a single academic center.
Methods: A retrospective, descriptive, chart review was performed under IRB approval. All biopsied/surgically removed orbital lesions
treated in our department between 2010 and 2014 were identified by surgical orbital CPT codes. In each case gender and age of the
patients, pathological diagnosis, number of reinterventions and laterality were registered.
Results: We identified 157 procedures performed on 133 patients by a single surgeon over 4 year period. There was a slight
predominance of male patients. Average age at the time of the procedure was 54 (the youngest patient was 6 mo and the oldest 98).
Out of 157 procedures 46 (29.3%) were orbitotomy with bone flap, 16 (10.2%) were orbital exenteration, 12 (7.7%) were orbitotomy
with drainage, 51 (32.5%) were orbitotomy with removal of the lesion, 32(20.4%) were orbitotomy without bone flap and 2 (1.3%)
were exploratory orbitotomy.
Pathological characteristic of the lesions showed:
24 patients (18%) had invasive carcinomas including squamous cell, basal cell, metastatic adenocarcinoma, lacrimal gland
carcinoma and other malign tumors including sarcoma, spindle cell, solitary fibrous tumor
20 patients (15%) had benign lesions including lipoma, papilloma and granuloma and other benign tumors including schwannoma,
neurofibroma, adenoma
16 patients (12%) had infectious orbital cellulites, 6 of which (37.5%) were mucormycosis and 1 (6.3%) aspergillosis
16 patients (12%) had inflammatory disease including sarcoidosis and IgG4 related disease
13 patients (9.8%) had lymphomas
11 patients (8.3%) had cystic lesions including dermoid
8 patients (6%) had vascular malformations including cavernous hemagioma, AVM and lymphangioma
6 patients (4.5%) had trauma related complications
5 patients (3.8%) had melanoma
4:03 pm A Four Year Retrospective Review of Space Occupying Lesions of the Orbit, continued
5 patients (3.8%) had meningioma
9 patients (6.8%) had no abnormal findings on pathology exam
There were 16 reinterventions on 13 patients representing 10.2% of the procedures and 9.8% of the patients, respectively.
A larger number of the procedures involved the right orbit.
Conclusions: Orbital space-occupying lesions represent an important part in our practice. They carry a significant morbidity and
mortality. Our center has a referral population that covers a large geographic area. Despite the use of MRI and CT scanning, the
histological examination remains necessary for final diagnosis.
4:09 pm Orbital Exenteration: The 10-year Massachusetts Eye and Ear
Infirmary Experience
Sonali Nagendran1, N. Grace Lee2, Aaron Fay2, Daniel Lefebvre2, Francis Sutula2, Suzanne Freitag2. 1Department of Ophthalmology,
Frimley Park Hospital, Frimley, United Kingdom, 2Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA,
United States
Introduction: The authors report their experience with orbital exenteration surgery at one academic institution over a 10-year period.
Methods: This is a retrospective review of 25 eyes of 25 patients undergoing orbital exenteration at Massachusetts Eye and Ear
Infirmary between 2003 and 2013. Appropriate institutional review board approval was obtained. Patients with no follow-up data
or survival data were excluded from the study. Extracted data from paper and electronic medical records included demographics,
medical history including diagnosis and previous treatment, surgical details and outcome. Outcome measures included surgical
complications, disease status of surgical margins, need for adjuvant treatment, local recurrence, metastases and survival.
Statistical analysis was performed to create Kaplan Meier curves and calculate p-values.
Results: Twenty three patients with malignancy and 2 with mucormycosis met inclusion criteria for the study. Surgical procedures
included non-lid sparing total exenteration (44%), lid-sparing total exenteration (32%), non-lid sparing partial exenteration (8%)
and lid-sparing partial exenteration (16%) and 44% underwent additional extra-orbital procedures. Survival rates from the diseases
leading to exenteration were 72% at 1 year, 48% at 3 years, and 37% at 5 years (Figure 1). Of patients with malignancies, 48%
had clear margins after exenteration. There was no statistically significant difference in survival between patients with clear surgical
margins compared to those with tumor-involved margins (p=0.12) (Figure 2). Mortality was highest from the disease leading to
exenteration in patients with melanoma (85.7%) and squamous cell carcinoma (SCC, 42.9%) and lowest in patients with non-SCC
eyelid malignancies with minimal orbital invasion (0%).
Conclusions: Orbital exenteration is often a palliative measure in diseases with extremely poor prognoses but this radically
disfiguring surgery may aid long-term survival in a certain patients with orbital malignancy.
References: Ben Simon GJ, Schwarcz RM, Douglas R, Fiaschetti D, McCann JD, Goldberg RA. Orbital exenteration: one size does not
fit all. Am J Ophthalmol. 2005;139(1):11-17.
Shields JA, Shields CL, Demirci H, Honavar SG, Singh AD. Experience with eyelid-sparing orbital exenteration: the 2000 Tullos O.
Coston Lecture. Ophthal Plast Reconstr Surg. 2001;17(5):355-361.
Rahman I, Maino A, Cook AE, Leatherbarrow B. Mortality following exenteration for malignant tumours of the orbit. Br J Ophthalmol.
2005;89(11):1445-1448.
Hargrove RN, Wesley RE, Klippenstein KA Fleming JC, Haik BG. Indications for orbital exenteration in mucormycosis. Ophthal Plast
Reconstr Surg. 2006;22(4):286-291.
4:15 pm ITEDS Update
Mark J. Lucarelli, MD, Peter Dolman, MD
Panel: Francesco Bernardini, MD, Tiffany Kent, MD, Davin Johnson, MD, Alina Dumitrescu, MD, Sonali Nagendran, MD,
Mark J. Lucarelli, MD
Moderators: Michael T. Yen, MD, Roberta E. Gausas, MD
4:30 pm Clinical and Immunohistochemical Features of Conjunctival Melanocytic Lesions
Harsha S. Reddy, MD
Introduction: Melanocytic conjunctival lesions may overlap in clinical presentation and histopathology but vary widely in clinical
course and prognosis. Immunohistochemistry (IHC) has been used to distinguish between these lesions. This study evaluates IHC
differences between conjunctival nevi, primary acquired melanosis (PAM), and conjunctival melanomas using the markers HMB-45,
Ki-67, Melan-A and a novel marker, beta-catenin, a protein of the Wnt signaling pathway. In cutaneous melanomas, loss of
beta-catenin expression is associated with more aggressive molecular and clinical disease.
Methods: 11 conjunctival nevi, 10 PAM lesions, and 10 conjunctival melanomas were identified using a retrospective review
by ICD code and the institutional pathology database between the dates of 1/2000 and 1/2010. Each specimen was sectioned and
stained for the 4 IHC markers noted above. Three 3 independent graders trained in ocular pathology and blinded to the diagnosis
scored each slide for staining uniformity (0=no staining, 1=focally positive, 2=variably positive, 3=uniformly positive) and intensity
(0=no staining, 1=weak, 2=intermediate, 3=uniformly positive). The 3 groups’ IHC staining patterns were statistically compared.
Results: There was good inter-rater reliability (Kappa 0.53). HMB-45 and Ki-67 had higher staining intensity and distribution scores
in conjunctival melanomas than in PAM and conjunctival nevi (p< 0.001). Melan-A was highly expressed in all 3 groups and did not
distinguish between groups. Beta-catenin was more strongly expressed in melanomas and nevi than in PAM (p < 0.001).
Conclusion: IHC labeling of HMB-45 and Ki-67 is stronger in conjunctival melanomas than in PAM or conjunctival nevi.
Beta-catenin, an IHC marker previously unstudied in conjunctival melanocytic lesions, is not preferentially expressed in benign lesions
and may play a different role in conjunctival atypia than it does in cutaneous melanoma.
References: 1. Shields CL, Markowitz JS, Belinsky I et al. Conjunctival melanoma: outcomes based on tumor origin in
382 consecutive cases. Ophthalmol 2011; 118:389-95. 2. Jakobiec FA, Bhat P, Colby KA. Immunohistochemical studies of
Conjunctival nevi and melanomas. Arch Ophthal 2010; 128(2):174-183. 3. Sharara NA, Alexander RA, Luthert PJ, et al. Differential
immunoreactivity of melanocytic lesions of the conjunctiva. Histopathology. 20001; 39(40):426-431. 4. Keijser S, Missotten GS,
Bonfrer JM et al. Immunophenotypic markers to differentiate between benign and malignant melanocytic lesions. BJO 2006; 90:213217. 5. Lebe B, Pabuccuoglu U, Ozer E. The significance of Ki-67 proliferative index and cyclin D1 expression of dysplastic nevi in
the biologic spectrum of melanocytic lesions. Appl Immunohistochem Mol Morphol 2007; 15(2):160-164. 6.Chien AJ, Moore EC,
Lonsdorf AS, et al. Activated Wnt/betacatenin signaling in melanoma is associated with decreased proliferation in patient tumors and
a murine melanoma model. Proc Natl Acad Sci USA 2009; 106:1193–1198. 7.Kageshita T, Hamby CV, Ishihara T, et al. Loss of betacatenin expression associated with disease progression in malignant melanoma. Br J Dermatol 2001; 145:210–216.
4:35 pm Patterns of Strabismus Following Orbital Decompression in Thyroid Eye Disease
Katherine M. Whipple, MD
Patterns of Strabismus Following
Orbital Decompression in Thyroid
Eye Disease
Katherine M. Whipple, M.D.
Reed Eye Associates
Pittsford, NY
University of California San Diego
Shiley Eye Center, La Jolla, CA
October 17, 2014
Thyroid Eye Disease
• Affects 16/100,000 women and 3/100,000
men in America
• 30% will develop clinically apparent
strabismus
• Double vision is one of the most debilitating
symptoms of TED
• Incidence of strabismus following orbital
decompression is 10-60%
Can we do better?
The Goal
The Predictable
The Unpredictable
Patterns of Strabismus Following Orbital Decompression in Thyroid Eye Disease, continued
Can we do better?
Objective
• 10-60% is a huge range
• To qualify further the patterns of strabismus
that occur following orbital decompression for
thyroid eye disease
• What kind of double vision is it?
• Is it possible to examine to predict which patients
will get double vision after orbital
decompression?
• Can we predict the pattern of diplopia patients
will develop based up preoperative data?
Methods
Results
• Consecutive, clinical follow up study of all
patients undergoing orbital decompression for
TED
• July 2009 – December 2012
• Exclusion criteria:
• 113 patient charts reviewed
– 17 patient excluded
– 96 patients (169 orbits) enrolled
– 71 female, 25 male
– Previous orbital or strabismus surgery
– Insufficient follow up/chart data
• Followed from time of orbital decompression to at
least 6 months following decompression
TABLE1. Descriptive Characteristics of Participants by Eye
Variables
TABLE 2. Descriptive Characteristics of Participants by Subject
Variables
Incomitant
(subjects,
n= 30)
Mean±SD
56.4±13.9
Mean±SD
52.7±13.1
Clinical Activity Score
2.7±2.2
2.5±2.4
Time to Decompression
6.1±7.3
5.2±6.3
N(%)
N(%)
Age, years
PValue*
No Strabismus
(subjects,
n= 33)
PValue**
0.28
Mean±SD
47.0±13.6
0.01
0.77
2.2±1.1
0.40
0.67
8.2±7.0
0.18
N(%)
Gender:
Female
Male
Ethnicity:
25(76)
8(24)
18(60)
12(40)
0.18
European Descent
African Descent & Other
Pre-Decompression Diplopia
28(85)
5(15)
9(28)
26(87)
4(13)
13(45)
0.84
Pre-Decompression Radiation
28(85)
5(15)
0.18
20(61)
13(39)
n/a
18(72)
13(54)
0.20
14(64)
Botox at Decompression
4(13)
5(19)
0.59
n/a
Clinical Activity Score <4
27(82)
23(77)
0.61
27(82)
Straight Post Strabismus Surgery
25(78)
17(59)
0.1
3(30)
3(21)
0.63
Comitant Pre-Decompression
Walls Decompressed
** Comitant vs Incomitant
** Strabismus vs No Strabismus
Incomitant
(eyes, n=60)
Pvalue*
No Strabismus
(eyes, n=66)
Pvalue**
Pre-Decompression Medial Rectus muscle, mm
Mean±SD
59.5±17.0
Mean±SD
57.6±18.6
0.62
Mean±SD
46.8±16.7
<0.001
Pre-Decompression Lateral Rectus muscle, mm
43.2±13.3
40.2±13.2
0.29
35.4±9.1
0.002
Pre-Decompression Superior Rectus Complex
muscle, mm
Pre-Decompression Inferior Rectus muscle, mm
59.6±15.1
62.0±19.2
0.50
49.9±14.8
<0.001
62.9±2.4
63.3±20.6
0.93
54.1±23.3
0.01
Pre-Decompression Margin To Reflex Distance 1
6.0±2.1
5.7±1.8
0.47
5.5±1.8
0.19
Pre-Decompression Margin To Reflex Distance 2
6.7±1.7
6.4±1.3
0.43
6.7±1.4
0.44
Pre-Decompression Lag
0.5±1.2
0.9±1.2
0.19
0.6±0.9
Post Decompression Strabismus
Comitant
(subjects,
n= 33)
1 or 2
3 or 4
8(14)
50(86)
18(34)
35(66)
0.012
0.08
0.005
0.98
Post-Decompression Strabismus
Comitant
(eyes, n=65)
0.62
Pre-Decompression Naugle
23.2±3.5
23.2±3.0
0.92
23.9±2.7
0.16
Post-Decompression ABDUCTION
-1.1±0.9
-1.3±1.1
0.14
-0.08±0.3
<0.001
Post-Decompression ADDUCTION
-0.11±0.4
-0.14±0.4
0.64
0.0±0.0
0.006
<0.001
Post-Decompression SUPRADUCTION
-1.2±1.1
-0.9±1.1
0.18
-0.06±0.4
Post-Decompression INFRADUCTION
-0.2±0.5
-0.09±0.3
0.30
-0.02±0.09
0.03
Post-Decompression Margin To Reflex Distance 1
5.3±1.9
4.6±1.4
0.03
4.3±1.3
0.004
n/a
Post-Decompression Margin To Reflex Distance 2
5.7±1.5
5.5±1.5
0.59
5.0±1.7
0.39
n/a
Post-Decompression Lag
0.7±1.5
1.5±2.4
0.051
1.4±2.3
0.29
19.1±2.8
19.5±2.8
0.42
19.5±2.8
0.58
26(23)
85(77)
0.77
Post-Decompression Naugle
<0.001
* Comitant vs Incomitant
**Strabismus vs No Strabismus
Comitant Strabismus
Table 3. Univariable and Multivariable Logistic Model Evaluating the Relationship Between
Ocular and Non-Ocular Factors and Risk of Development of Comitant versus Incomitant
Strabismus Post Decompression Surgery
Risk Factors
Demographic
Odds Ratios (95% CI)
Univariable
Multivariable
Older Age per year
Male Gender
0.84 (0.20-3.54)
0.98 (0.95-1.02)
2.04 (0.69-6.07)
0.97 (0.93-1.01)
2.35 (0.71-7.84)
Pre-Decompression Medial Rectus
muscle increase width per mm
0.99 (0 .97-1.02)
-
Pre-Decompression Lateral Rectus
Pre-Decompression Superior Rectus
Pre-Decompression Inferior Rectus
Pre-Decompression Margin To Reflex
Distance 1 increase per mm
0.98 (0 .95-1.02)
-
1.01 (0 .98-1.04)
-
1.00 (0 .98-1.03)
-
0.93 (0.73-1.19)
-
0.90 (0.66-1.25)
-
1.25 (0.74-2.08)
0.99 (0.86-1.15)
0.76 (0.49-1.19)
0.79 (0 .21-2.98)
1.25 (0.82-1.89)
1.68 (0.58-4.92)
0.77 (0 .60-1.01)
0.80 (0.59-1.09)
0.93 (0 .65-1.32)
-
1.21 (0.95-1.53)
1.06 (0.88-1.27)
-
3.21 (0.99-10.42)
3.54 (1.11-11.26)
0.97 (0.75-1.24)
-
0.63 (0 .17-2.41)
1.97 (0.69—5.58)
0.39 (0 .12-4.78)
1.74 (0.43-7.05)
2.47 (0.80-7.63)
0.64 (0.095-4.25)
-
Ocular
Post-Decompression Margin To
Reflex Distance 1
Post-Decompression Margin To
Reflex Distance 2
Less Walls Decompressed
(1 or 2 vs 3 or 4)
Clinical Activity Score
(<4 vs ≥4)
Longer Time to Decompression
Botox at Decompression
Straight Post Strabismus Surgery
Comitant Pre-Decompression
Incomitant Strabismus
Table 4. Univariable and Multivariable Logistic Model Evaluating the Relationship Between
Ocular and Non-Ocular Factors and Risk of Development of Strabismus Post Decompression
Surgery.
Risk Factors
Odds Ratios (95% CI)
Univariable
Multivariable
Demographic
0.26 (0.095-0.702)
0.067 (0.008-0.57)
Older Age per year
1.04 (1.01-1.07)
1.04 (0.99-1.10)
Male Gender
2.64 (0.88-7.88)
3.28 (0.23-46.39)
0.96 (0.92-1.009)
Ocular
Pre-Decompression Medial Rectus
1.05 (1.00-1.09)
Pre-Decompression Lateral Rectus
1.05 (1.01-1.09)
1.09(1.02-1.17)
Pre-Decompression Superior Rectus
1.04 (1.01-1.07)
1.05 (1.01-1.11)
Pre-Decompression Inferior Rectus
1.03 (0 .99-1.06)
1.11 (0.91-1.36)
0.92 (0.70-1.22)
Post-Decompression Margin To Reflex
Distance 1
Post-Decompression Margin To Reflex
Distance 2
1.08 (0.74-1.58)
0.93 (0.82-1.05)
0.02 (0.002-0.13)
0.02 (0 .0005-0.55)
0.05 (0.002-1.15)
0.18 (0.035-0.89)
1.35 (1.05-1.73)
1.13 (0 .86-1.48)
0.93 (0.76-1.13)
0.96 (0.83-1.12)
Less Walls Decompressed
(1 or 2 vs 3 or 4)
Less Clinical Activity Score
(<4 vs ≥4)
Longer Time to Decompression
0.28 (0.12-0.66)
0.02 (0.003-0.17)
0.002 (0.00002-0.16)
0.12(0.02-0.66)
1.37 (0.87-2.15)
0.34 (0.07-1.62)
1.12 (0.92-1.35)
0.95 (0 .88-1.03)
1.97 (0.69—5.58)
0.95 (0 .34-2.73)
Critique
• Not randomized
• Tertiary eye care center
– Refractory, more extreme cases?
– Differences in surgical technique
• Is 6 months long enough? 3 months after
strabismus surgery?
Conclusions
In Conclusion?
• Further assessment of preoperative double
vision status is important
• EOM size and age are most important to
determine who will get diplopia following
orbital decompression
• Risk of incomitant diplopia development is
decreased 3.5-fold by performing a larger
orbital decompression
References
Thank you.
•
•
•
•
Don O. Kikkawa, MD, FACS
Bobby S. Korn, MD, PhD, FACS
David Granet, MD
Leah Levi, MBBS
•
•
•
•
Naira Khachatryan, MD, DrPh
Preamjit Saonanon, MD
Richard Scawn, MBBS, FRCOphth
LeeHooi Lim, MD
1.
Bartley GB. The epidemiologic characteristics and clinical course of ophthalmopathy associated with
autoimmune thyroid disease in Olmsted County, Minnesota. Transactions of the American Ophthalmological
Society 1994;92:477-588.
2.
Bahn RS, Heufelder AE. Pathogenesis of Graves' ophthalmopathy. The New England journal of medicine
1993;329:1468-75.
3.
Nishikawa M, Yoshimura M, Toyoda N, et al. Correlation of orbital muscle changes evaluated by
magnetic resonance imaging and thyroid-stimulating antibody in patients with Graves' ophthalmopathy. Acta
endocrinologica 1993;129:213-9.
4.
Farid M, Roch-Levecq AC, Levi L, Brody BL, Granet DB, Kikkawa DO. Psychological disturbance in graves
ophthalmopathy. Archives of ophthalmology 2005;123:491-6.
5.
Nunery WR, Nunery CW, Martin RT, Truong TV, Osborn DR. The risk of diplopia following orbital floor
and medial wall decompression in subtypes of ophthalmic Graves' disease. Ophthalmic plastic and
reconstructive surgery 1997;13:153-60.
6.
Paridaens D, Hans K, van Buitenen S, Mourits MP. The incidence of diplopia following coronal and
translid orbital decompression in Graves' orbitopathy. Eye 1998;12 ( Pt 5):800-5.
7.
Paridaens DA, Verhoeff K, Bouwens D, van Den Bosch WA. Transconjunctival orbital decompression in
Graves' ophthalmopathy: lateral wall approach ab interno. The British journal of ophthalmology 2000;84:77581.
8.
Garrity JA, Fatourechi V, Bergstralh EJ, et al. Results of transantral orbital decompression in 428 patients
with severe Graves' ophthalmopathy. American journal of ophthalmology 1993;116:533-47.
9.
McCord CD, Jr. Current trends in orbital decompression. Ophthalmology 1985;92:21-33.
10. Fatourechi V, Bergstralh EJ, Garrity JA, et al. Predictors of response to transantral orbital decompression
in severe Graves' ophthalmopathy. Mayo Clinic proceedings Mayo Clinic 1994;69:841-8.
11. Abramoff MD, Kalmann R, de Graaf ME, Stilma JS, Mourits MP. Rectus extraocular muscle paths and
decompression surgery for Graves orbitopathy: mechanism of motility disturbances. Investigative
ophthalmology & visual science 2002;43:300-7.
• ASOPRS Thesis Committee
References (cont)
12. Miller JM. Functional anatomy of normal human rectus muscles. Vision research 1989;29:223-40.
13. Ozgen A, Ariyurek M. Normative measurements of orbital structures using CT. AJR American journal of
roentgenology 1998;170:1093-6.
14. Dagi LR, Zoumalan CI, Konrad H, Trokel SL, Kazim M. Correlation between extraocular muscle size and motility
restriction in thyroid eye disease. Ophthalmic plastic and reconstructive surgery 2011;27:102-10.
15. Kikkawa DO, Pornpanich K, Cruz RC, Jr., Levi L, Granet DB. Graded orbital decompression based on severity of
proptosis. Ophthalmology 2002;109:1219-24.
16. Shorr N, Seiff SR. The four stages of surgical rehabilitation of the patient with dysthyroid ophthalmopathy.
Ophthalmology 1986;93:476-83.
17. Lyons CJ, Rootman J. Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy. Ophthalmology
1994;101:223-30.
18. Shepard KG, Levin PS, Terris DJ. Balanced orbital decompression for Graves' ophthalmopathy. The Laryngoscope
1998;108:1648-53.
19. Goldberg RA, Perry JD, Hortaleza V, Tong JT. Strabismus after balanced medial plus lateral wall versus lateral wall
only orbital decompression for dysthyroid orbitopathy. Ophthalmic plastic and reconstructive surgery 2000;16:271-7.
20. Eing F, Abbud CM, Velasco e Cruz AA. Cosmetic orbital inferomedial decompression: quantifying the risk of
diplopia associated with extraocular muscle dimensions. Ophthalmic plastic and reconstructive surgery 2012;28:204-7.
21. Shorr N, Neuhaus RW, Baylis HI. Ocular motility problems after orbital decompression for dysthyroid
ophthalmopathy. Ophthalmology 1982;89:323-8.
22. Garrity JA, Saggau DD, Gorman CA, et al. Torsional diplopia after transantral orbital decompression and
extraocular muscle surgery associated with Graves' orbitopathy. American journal of ophthalmology 1992;113:363-73.
23. Koornneef L. Orbital septa: anatomy and function. Ophthalmology 1979;86:876-80.
24. Demer JL, Miller JM, Poukens V, Vinters HV, Glasgow BJ. Evidence for fibromuscular pulleys of the recti
extraocular muscles. Investigative ophthalmology & visual science 1995;36:1125-36.
25. Seiff SR, Tovilla JL, Carter SR, Choo PH. Modified orbital decompression for dysthyroid orbitopathy. Ophthalmic
plastic and reconstructive surgery 2000;16:62-6.
26. Goldberg RA. Advances in surgical rehabilitation in thyroid eye disease. Thyroid : official journal of the American
Thyroid Association 2008;18:989-95.
27. Nardi M. Squint surgery in TED -- hints and fints, or why Graves' patients are difficult patients. Orbit
2009;28:245-50.
4:40 pm In Vivo Imaging of a Novel Mouse Model of Filler Induced Tissue Necrosis
Michael C. Chappell, MD
In Vivo Imaging of a Novel Mouse Model of Filler Induced Tissue Necrosis, continued
Moderator: Michael T. Yen, MD
Panel: Harsha S. Reddy, MD, Katherine M. Whipple, MD, Michael C. Chappell, MD
4:50 pm Marvin H. Quickert Thesis Award Presentation
Michael T. Yen, MD
4:55 pm ASOPRS Awards Presentations
Roberta E. Gausas, MD, Chair, ASOPRS Awards Committee
Bartley R. Frueh Award for Best YASOPRS Presentation
Robert H. Kennedy Presidential Award (presented by Don O. Kikkawa, MD, FACS, ASOPRS President)
5 pm
Adjourn
5 – 6 pm
ASOPRS Business Meeting & International Associate New Member Inductions
Chicago Ballroom
(All members are invited and encouraged to attend the Business Meeting)
POSTERS
T1
A Novel Modification to the Hughes Tarsoconjunctival Flap for a Challenging
Case of Recurrent Lower Eyelid Retraction
Andrew Anzeljc, Justin Saunders, Ted Wojno. Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA,
United States
Introduction: Severe cicatricial lower lid retraction is often difficult to manage.
Methods: The authors present a new modification of the Hughes tarsoconjunctival flap combined with a full-thickness
blepharotomy to correct a case of refractory lower eyelid retraction.
Results: A 49-year-old man with cicatricial right lower lid retraction that failed multiple surgical interventions including ear
cartilage grafts to the posterior lamella, tarsal strip, alloplastic implant and SOOF lift presented with exposure keratopathy and
inadequate cosmesis.
A modified Hughes tarsoconjunctival flap was used for repair of a full-thickness blepharotomy at the inferior border of the tarsus that
compensated for the amount of lower eyelid retraction. The posterior lamellar defect was filled with the tarsoconjunctival-Muller’s flap
and the anterior lamella defect covered with a full-thickness retroauricular skin graft.
Muller’s muscle was included in the flap to increase the vascular supply to the reconstructed lid. Likewise, we waited nine weeks
to divide the flap because of concerns that the vascular supply of the surrounding lid might be compromised from multiple previous
surgeries. A single case of cicatricial right lower lid retraction status post multiple failed surgical interventions successfully completed
a full-thickness blepharotomy with a modified Hughes tarsoconjunctival flap. Two months after the procedure, the patient had good
cosmesis and function with resolution of his signs and symptoms of exposure keratopathy.
POSTERS
T1
A Novel Modification to the Hughes Tarsoconjunctival Flap for a Challenging Case of
Recurrent Lower Eyelid Retraction, continued
Conclusions: The Hughes tarsoconjunctival flap combined with a full-thickness blepharotomy may be a useful technique in
selected patients for repair of non-marginal defects of the lower lid when other standard techniques have failed.
References: 1. Hughes WL. A new method for rebuilding a lower lid: Report of a case. Archives of ophthalmology. 1937;
17(6):1008-1017.
2. Bartley GB, Putterman AM. A minor modification of the Hughes’ operation for lower eyelid reconstruction. American Journal of
Ophthalmology. Jan 1995;119(1):96-97.
3. Cies WA, Bartlett RE. Modification of the Mustarde and Hughes methods of reconstructing the lower lid. Annals of ophthalmology.
Nov 1975;7(11):1497-1502.
4. Doxanas MT. Orbicularis muscle mobilization in eyelid reconstruction. Archives of ophthalmology. Jun 1986;104(6):910-914.
5. Hughes WL. Total lower lid reconstruction: technical details. Transactions of the American Ophthalmological Society.
1976;74:321-329.
6. Macomber WB, Wang MK, Gottlieb E. Epithelial tumors of the eyelids. Surgery, gynecology & obstetrics. Mar 1954;98(3):331-342.
7. Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a
1-stage sandwich technique for eyelid reconstruction. Ophthalmology. Jan 2008;115(1):189-194.
8. Pollock WJ, Colon GA, Ryan RF. Reconstruction of the lower eyelid by a different lid-splitting operation: case report. Plastic and
reconstructive surgery. Aug 1972;50(2):184-187.
9. Rohrich RJ, Zbar RI. The evolution of the Hughes tarsoconjunctival flap for the lower eyelid reconstruction. Plastic and
reconstructive surgery. Aug 1999;104(2):518-522; quiz 523; discussion 524-516.
POSTERS
T2
Retrospective Chart Review of the Use of Imaging and Biopsy in the Diagnosis
of Optic Nerve Sheath Meningiomas and Nerve Involving Orbital Lymphomas
Anna Berry1, Alina Dumitrescu1, William Nunery2, Jason Sokol1. 1Ophthalmology, KUMC, Prairie Village, KS, United States, 2
Introduction: To compare the pre-surgical diagnosis, based on clinical presentation and neuroimaging, to the surgical pathology
results of orbital lymphomas and optic nerve sheath meningiomas (ONSM).
Methods: This is an IRB approved retrospective chart review of orbital lymphomas and optic nerve sheath meningiomas
biopsied by a single surgeon over a 4 year period at a single institution. Cases were identified by surgeon name and CPT codes
67420 (orbitotomy with bone flap), 67400 (orbitotomy without bone flap), and 67450 (orbitotomy with bone flap with or without
biopsy) within the specified four year period. Physical exam and neuro-imaging was reviewed for each case identified. Orbital
lymphomas not involving the optic nerve on neuroimaging were excluded from the study. Pre-surgical diagnosis and surgical
pathology were compared.
Results: Fifteen cases of orbital lymphoma were identified. Fourteen were excluded based on lack of involvement of the optic
nerve. The single histologically confirmed orbital lymphoma had a pre-surgical diagnosis of ONSM. Four cases of optic nerve sheath
meningioma were identified. Three of the four cases of histologically confirmed ONSM had a pre-surgical diagnosis of ONSM. One of
the four had a pre-surgical diagnosis of lymphoma.
Conclusions: Diagnosis based on surgical pathology differed from the pre-surgical diagnosis in two out of five cases. While both
diseases are typically managed with radiation therapy, the treatment dosage and systemic disease implications are very different.
These findings emphasis the importance of biopsy in the diagnosis of orbital lesions surrounding the optic nerve.
References: Berman D, Miller NR: New concepts in the management of optic nerve sheath meningiomas. Ann Acad Med Singapore
35:168-174, 2006
Dutton JJ: Optic nerve sheath meningiomas. Surv Ophthalmol 37:167-183, 1992
Yadav BS, Sharma SC: Orbital lymphoma: Role of radiation. Indian J Ophthalmol 57(2): 91-97, 2009
POSTERS
T3
Deep Lateral Wall Orbital Decompression Following Strabismus Surgery in
Patients with Type II Graves Orbitopathy
Emily Broxterman1, Alan Hromas1, Jason Sokol1, William Nunery2, Thomas Whittaker1. 1Dept of Ophthalmology, University of Kansas
Medical Center, Kansas City, KS, United States, 2Dept of Ophthalmology, University of Louisville, Louisville, KY, United States
Introduction: We propose that deep lateral wall decompression appears to have a low rate of post-operative primary-gaze diplopia
for patients with type II ophthalmic Graves’ disease who require additional intervention after medial wall and floor decompression and
strabismus surgery.
Methods: We present a case series of five type II ophthalmic Grave’s disease patients, all of whom had already undergone
decompression and strabismus surgery, or strabismus surgery alone, and went on to develop worsening proptosis or optic nerve
compression necessitating further decompression thereafter. In all cases, patients were treated with deep lateral wall decompression.
Results: None of the five patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus
surgery following deep lateral wall decompression.
Conclusions: While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic
Grave’s disease, deep lateral wall decompression for those patients who develop worsening proptosis or optic nerve compression
following consecutive strabismus surgery appears to be effective with a low rate of recurrent primary-gaze diplopia.
References: 1. Shorr N. The four stages of surgical rehabilitation of the patient with dysthyroid ophthalmopathy. Ophthalmology
(Rochester, Minn.). 1986-04;93:476-83.
2. Nunery W. The association of cigarette smoking with clinical subtypes of ophthalmic Graves’ disease. Ophthalmic plastic and
reconstructive surgery. 1993-06;9:77-82.
3. Nunery W. The risk of diplopia following orbital floor and medial wall decompression in subtypes of ophthalmic Graves’ disease.
Ophthalmic plastic and reconstructive surgery. 1997-09;13:153-60.
4. Gomi C. Change in proptosis following extraocular muscle surgery: effects of muscle recession in thyroid-associated orbitopathy.
Journal of AAPOS. 2007-08;11:377-80.
POSTERS
T4
Malignant Rhabdoid Tumor of the Orbit
Alison Callahan, Frederick Jakobiec, Grace Lee, Arthur Grove, Suzanne Freitag. Ophthalmology, Harvard Medical School, Boston, MA,
United States
Introduction: Extrarenal rhabdoid tumors are rare neoplastic entities that have only twice previously been described in the
adult orbit.
Methods: We describe a rhabdoid tumor of the adult orbit, which arose within an initially benign, but locally aggressive myxoid tumor.
Results: An 80 year old woman has now been followed for over a decade for a previously benign, but locally aggressive myxoid
tumor of the left orbit that has required serial debulking procedures at 1-2 year intervals. In 2012, the tumor began behaving in a
more locally aggressive manner, growing with increasing rapidity (Figure 1A-1D). In addition to progressive limitation of extraocular
movement and severe (>35mm proptosis), new afferent visual dysfunction began at that time and rapidly progressed to no light
perception in the left eye. Despite an aggressive surgical debulking, the tumor re-amassed within months necessitating permanent
tarsorrhaphy. After lengthy consideration and discussions, the patient decided to proceed with exenteration and planned prosthetic
reconstruction. Microscopically, the bulk of the exenterated specimen demonstrated an infiltrative, hypocellular, myxoid character
consistent with earlier specimens (Figure 1E). However, there was additionally a focus of mitotically active large round tumor cells
with prominent central nucleoli and intensely eosinophilic cytoplasm with round pseudoinclusions (Figure 1F). This area stained
positively for calponin and weakly positive for smooth muscle actin, but was myogenin, myosin, myoglobin, muscle specific actin,
desmin, INI1, GFAP, S100 and Keratin 14 negative. The inclusions were vimentin positive. Ki67 proliferation index increased in the
final three specimens from 7% to 17% to 20-25%. The new focus of malignant cells were interpreted as rhabdoid. Subsequent
imaging revealed metastases to the lymph nodes and lungs.
Conclusions: Since their initial description in the kidneys in 19781, rhabdoid tumors occurring in extrarenal locations have been
reported in the literature. Uncommon orbital occurrences are more frequently reported in the pediatric population,2,3 while its
occurrence in the adult orbit has only been described twice: in the lacrimal gland4 and intraconal space.5 We report a third incidence
of a rhabdoid tumor in the adult orbit which evolved over the course of greater than a decade. The escalating clinical behavior of this
locally aggressive orbital tumor was paralleled by increasing proliferative indices until the previously benign myxoid tumor assumed
the phenotype and charactersitics of an orbital rhabdoid tumor.
References: 1. Beckwith JB, Palmer NF. Histopathology and
prognosis of Wilms tumor: results of the First National Wilms’
Tumor Study. Cancer 1978;41:1937-48.
2. Rootman J, Damji KF, Dimmick JE. Malignant rhabdoid tumor
of the orbit. Ophthalmology. 1989 Nov;96(11):1650-4.
3. Gündüz K, Shields JA, Eagle RC Jr, Shields CL, De Potter P,
Klombers L. Malignant rhabdoid tumor of the orbit. Arch
Ophthalmol. 1998 Feb;116(2):243-6. Review.
4. Niffenegger JH, Jakobiec FA, Shore JW, Albert DM. Adult
extrarenal rhabdoid tumor of the lacrimal gland.
Ophthalmology. 1992 Apr;99(4):567-74.
5. Johnson LN, Sexton FM, Goldberg SH. Poorly differentiated
primary orbital sarcoma (presumed malignant rhabdoid tumor).
Radiologic and histopathologic correlation. Arch Ophthalmol.
1991 Sep;109(9):1275-8.
POSTERS
T5
Demographics, Etiology, and Management of Allergic Blepharitis
Smith Ann Chisholm, Steven Couch, Philip Custer. Ophthalmology, Washington University in St. Louis, Saint Louis, MO, United States
Introduction: While blepharitis is a condition commonly encountered in ophthalmic practice, in our experience allergic blepharitis
is frequently under diagnosed. Patients may be referred to oculoplastic specialists when the resulting eyelid inflammation contributes
to a variety of secondary conditions including tearing, ectropion, ptosis, and exacerbation of dermatochalasis. As there is a paucity
of information in the literature regarding allergic blepharitis, we performed a retrospective study to better characterize the nature
of this condition.
Methods: After obtaining institutional IRB approval, a retrospective chart review was performed to identify patients seen in academic
oculoplastic practices with a diagnosis of allergic blepharitis. We attempted to identify presenting symptoms and findings, presumed
inciting agent, management, and outcomes. Statistical analysis was performed using Excel software.
Results: The chart review identified 50 patients with presumed allergic blepharitis. Average age was 65 years old (range: 33-94)
and 76% were female. The most common reasons for referral to an oculoplastics specialist were epiphora (26.92%), blepharitis/
dermatitis (21.15%), ptosis/dermatochalasis (17.31%), and ectropion (15.38%). Presenting symptoms included irritation (19.69%),
tearing (16.54%), and itching (11.81%). A coesixting conjunctival reaction was present in 56% of cases. Duration of symptoms
ranged from 2 days to 8 years, with 66% reporting over 6 months of symptoms attributable to the blepharitis. The most common
probable etiologies were facial creams/lotions (28.79%), eyelid cosmetics (18.18%), topical glaucoma medications (18.18%), and
other topical ophthalmic products (15.15%). Rubbing or manipulation of the lids was thought to be a compounding factor in 30%
of the patients. Management typically involved discontinuation of the offending agent(s) and topical ophthalmic steroid ointment.
This treatment scheme resulted in complete resolution of blepharitis in 66% of patients and partial improvement in 22% of patients.
Successful treatment of the allergic blepharitis led to resolution of ectropion in 68.75% of the patients who presented with ectropion.
The patients who did not adequately respond were referred to a dermatologist or allergist for further work-up including patch testing.
By the time of final follow-up, 98% of patients had reduction in their symptoms.
Conclusions: The development of allergic blepharitis is frequently not recognized by primary eye care providers. Left untreated, the
condition can contribute to a variety of other symptoms and findings. Topical glaucoma medications are a common cause of allergic
blepharitis. Fortunately, the eyelid inflammation and associated findings typically improve after the inciting agent is discontinued in
conjunction with a brief course of topical steroids. Isolated patients benefit from formal allergy testing.
References: 1. Bernardes TF, Bonfioli AA. Blepharitis. Seminars in Ophthalmology. 2010;25(3):79-83.
2. Wolf R, Orion E, Tuzun Y. Periorbital (eyelid) dermatides. Clinics in Dermatology. 2014;32:131-140.
3. Landeck L, Schalock PC, et al. Periorbital contact sensitization. Am J Ophthalmol. 2010;150:366-370.
POSTERS
T6
Primary Signet Ring Cell Carcinoma of the Eyelid: A Case Report and
Review of Literature
Rao Chundury MD MBA, Alexander D’Angelo MS, Gabriela Espinoza MD. Ophthalmology, St. Louis University, St. Louis, MO,
United States
Introduction: Signet-ring histiocytoid carcinomas of the eyelid (SRCA) are exceedingly rare and aggressive neoplasms. They are
found predominantly in elderly men and can be mistaken for chalazion or blepharitis. We report the 29th case and to the authors’
knowledge, the youngest male patient reported to have SRCA.
Methods: Of the 28 reported cases in the literature of SRCA only five have involved female patients, aged between 33-73 years.
Of the remaining male patients, the age at diagnosis ranged from 47-87 years, not including this case.1 The mass can eventually
progress to involve both upper and lower eyelids, prompting some clinicians to refer to it as the “monocle-like tumor”. Treatment
usually entails a multidisciplinary approach. Therapeutic modalities typically involve surgery (wide excision or orbital exenteration)
with or without adjuvant radiotherapy when complete excision is not possible. Antiestrogen agents and 5-fluorouracil have also
been used with varying success.2 The post-treatment refractory period has ranged from 5 months to 8 years.1
Results: A 45-year old man presented with left upper eyelid swelling (Figure 1) s/p biopsy and presumed lacrimal gland epitheloid
carcinoma. MRI orbits demonstrated a mass involving the entire central fat pad, the orbital lobe of the lacrimal gland and medial
orbital fat. Repeat biopsy showed histopathology consistent of primary SRCA with markers GCDFP-15 and CD15 positive for apocrine
tissue. CDX-2, ER, and PR were negative ruling out stomach, breast and prostate primary, respectively. All margins were widely
positive for carcinoma. PET-CT was also negative for metastasis or non-orbital primary neoplasm. The patient underwent complete
ocular exenteration (Figure 2 - Infiltration of orbital fat) with free margins followed by radiation therapy 60Gy in 30 fractions with a
post-treatment refractory period of 14 months and counting.
Conclusions: It remains the recommendation of these authors to perform careful clinical and histopathologic assessment of
suspicious eyelid lesions in order to hasten the accurate diagnosis of SRCA and to limit its progression. The potential for wide
surgical excision should be appropriately assessed, and orbital exenteration may be ultimately necessary. Depending on the extent
of the tumor, the degree to which surgery is able to relieve disease burden, and the immunochemical profile of the tumor, adjuvant
radiotherapy and chemotherapy may aid in treatment. As always, patients should be thoroughly evaluated for their ability to tolerate
these various treatment avenues.
References: 1. Tanboon J,
Uiprasertkul M, Luemsamran
P. Signet-Ring Cell/Histiocytoid
Carcinoma of the Eyelid: A Case
Report and Review of the Literature.
AM J Dermatopathol. 2013;35:e1-e5
2. Nazareth MR, Bogner P, Mansour
N, Raghu P, Mansour TN, Zeitouni NC.
Primary Adenocarcinoma of the Eyelid
with Signet Ring Cell and Histiocytoid
Features. Dermatol Surg. 2012;1-4
POSTERS
T7
Recession and Extirpation of the Lower Lid Retractors for
Paralytic Lagophthalmos
Christopher Compton1,2, Hui Bae Lee2. 1Ophthalmology, Oculofacial Plastic and Orbital Surgery, University of Louisville, Louisville, KY,
United States, 2Ophthalmology, Oculofacial Plastic and Orbital Surgery, Indiana University, Indianapolis, IN, United States
Introduction: We describe a useful surgical technique to address lower eyelid malposition and paralytic lagophthalmos due to
facial nerve paralysis.
Methods: A retrospective chart review was performed and identified 10 patients with facial nerve palsy who presented with
paralytic eyelid malposition and were treated with recession and extirpation of the lower lid retractors between September 2012
and March 2014 by one surgeon (HBL). Two patients were excluded due to less than 1 month of follow up. Inclusion criteria
were patients who underwent this procedure alone or in conjunction with other procedures including: modified tarsal strip, lateral
tarsoconjunctival flap tarsorraphy, or upper eyelid gold weight placement. Patient age, etiology of facial nerve paralysis, lower eyelid
position, lagophthalmos, ocular surface disease, and patient satisfaction were recorded before and after surgery. Post-operative
complications and subsequent need for treatment were also recorded.
Results: A total of 9 eyelids in 8 patients were identified. The patients’ age ranged from 24 years to 79 years. The follow-up period
ranged from 5 weeks to 19 months. All patients also had concurrent upper lid retraction repair with gold weight placement. In 2 of 9
cases, recession and extirpation of the lower lid retractors w/ modified tarsal strip was the only lower lid procedure performed. In 7 of
9 patients, the procedure was performed in conjunction with a lateral tarsoconjunctival flap tarsorraphy.
Recession and extirpation of the lower lid retractors with or without lateral tarsoconjunctival flap tarsorraphy was associated with
positive outcomes and there were no complications. Lower eyelid malposition, lagophthalmos, ocular surface exposure, and exposure
keratopathy improved in all patients.
There were no complications encountered in our 8 patients. None of the patients required subsequent eyelid procedures to further
correct ocular surface exposure and keratopathy. All patients had a subjective improvement in ocular comfort.
Conclusions: The authors’ surgical technique is effective in addressing lower eyelid malposition and ocular surface disease in
paralytic lagophthalmos. All patients had significant improvement in lagophthalmos, lower eyelid position, and subjective ocular
complaints.
References: 1. Seiff SR, Chang JS. The staged management of ophthalmic complications of facial nerve palsy. Ophthal Plast
Reconst Surg. 1993;9(4):241-49.
2. Lisman RD, Smith B, Baker D, et al. Efficacy of surgical treatment for paralytic ectropion. Ophthalmology. 1987;94(6):671-81.
3. Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch of Ophthalmol. 1989;107:604-6.
4. Sufyan AS, Lee HB, Shah H, et al. Single-stage repair of paralytic ectropion usuing a novel modification of the tarsoconjunctival
flap. JAMA Facial Plast Surg. 2014;16(2):151-52.
5. Chang L, Olver J. A useful augmented lateral tarsal strip tarsorraphy for paralytic ectropion. Ophthalmology. 2006 Jan;
113(1):84-91.
6. Patel A, Tao JP, et al. Lateral tarsoconjunctival flap lower eyelid suspension in facial nerve paresis. Ophthal Plast Reconst Surg.
2014;[Published ahead of print]
POSTERS
T8
Treating Buccinator with Botulinum Toxin in Patients with Facial Synkinesis —
A Previously Overlooked Target
Jacqueline Diels, OT1, Leslie A Wei, MD2, Mark J Lucarelli, MD, FACS2. 1Neuromuscular Retraining Clinic, University of Wisconsin Madison, Madison, WI, United States, 2Oculoplastic, Facial Cosmetic, & Orbital Surgery, University of Wisconsin - Madison,
Madison, WI, United States
Introduction: Synkinesis after facial nerve injury produces functional and cosmetic concerns for patients. The purpose of this study
is to review our experience of treating buccinator synkinesis with botulinum toxin.
Methods: This was a retrospective medical records review. All patients seen at the University of Wisconsin Neuromuscular Retraining
Clinic who were treated with botulinum injections to the buccinator muscle were included. After a period of neuromuscular retraining
lasting 6-12 months, botulinum injections were administered to the mid and/or posterior aspect of buccinator by the senior author
via an intra-oral approach. The sites and dosage of the injections depended substantially on input from the therapist (JD) overseeing
the patient’s neuromuscular retraining therapy. Data on patient age, gender, indication for treatment, location and dose of botulinum
administration, and outcome were collected and analyzed. The Synkinesis Assessment Questionnaire (SAQ) was utilized as a patientreported outcome measure. Descriptive statistics were computed for all recorded variables.
Results: A total of 40 patients with synkinesis involving buccinator were treated. Female to male ratio was 9:1. The indications
for treatment included: significant retraction and immobility of the affected oral commissure at rest and during volitional and
spontaneous facial expressions, difficulty manipulating food during mastication, and biting the inside of the affected cheek. Average
age at first treatment was 53 years old (range 18-83). Mean total dose of botulinum administered per session was 2.0 units (range
1.25- 2.5 units). Follow-up ranged from 1 to 18 months. SAQ scores improved from mean of 66.3 (33-88.8) preinjection to 49.5
(28.8-71.1) post injection. Two patients were bothered by temporary increased flaccidity of the cheek. In general, patient satisfaction
with the procedure was high.
Conclusions: To our knowledge, this is the first report of treatment of buccinator synkinesis with botulinum toxin. This treatment has
become a valuable adjunct in our comprehensive management of patients with facial synkinesis.
References: 1. Couch SM, Chundury RV, Holds JB. Subjective and objective outcome measures in treatment of facial nerve
synkinesis with onabotulinumtoxin A (Botox). Ophthal Plast Reconstr Surg. 2014; 30: 246-250.
2. Lindsay RW. Robinson M, and Hadlock TA. Comprehensive facial rehabilitation improves facial function in patients with facial
paralysis. Physical Ther. 2010, 90: 391-397.
3. Mehta RP, WernickRobinson M, Hadlock TA. Validation of the Synkinesis Assessment Questionnaire. Laryngoscope. 2007;
117: 923-6.
4. Laskawi R, Damenz W, Roggenkämper P, Baetz A. Botulinum toxin treatment in patients with facial synkinesis. Eur Arch
Otorhinolaryngol. 1994:S195-9.
POSTERS
T9
Anesthetic Device Reduces Pain Perception for Subcutaneous Injections and
Ophthalmologic Lasers
Shenoda Elmaseh1, Ed Siu1, Mike Song1, Trisa Palmares2, Julia Song2, Alice Song1. 1Ophthalmology, Long Beach Memorial Hospital,
Long Beach, CA, United States, 2Ophthalmology, Huntington Memorial Hospital, Pasadena, CA, United States
Introduction: Local anesthetic injections and botulinum toxins injections are painful. There have been anesthetics and distractors
utilized such as ethyl chloride, lidocaine gel, ear pulling, coughing during the injection, and massaging to lessen the discomfort or
the perception of discomfort. However, there are limitations including potential toxicity, cost, and patient movement. There is a new
device, the Vibration Anesthetic Device (VAD, Blaine Labs)1 which works on the Gate theory to reduce the transmission of noxious
stimuli by stimulating the large nerve fibers. Inhibitory cells are stimulated simultaneously so that the gates for pain are closed, and
the transmission of pain to the thalamus is decreased. The purpose of this study was to determine the efficacy of the VAD in reducing
the amount of pain perceived by patients during local anesthetic injection and botulinum toxin injections.
Methods: Prospective study with survey of 130 patients receiving the VAD.
Results: 101/130 patients received local anesthetic of 2% lidocaine with epinephrine, 0.75% Marcaine, 0.01% sodium bicarbonate
to the lids prior to eyelid surgery in the office setting with no intravenous sedation. 29 patients received botulinum toxin injections to
the periocular region. 92/101 (91%) stated that the pain perceived was decreased by >60%, 8/101 by 25%, and 1 no difference.
In those receiving botulinum injections, 26/29 (90%) reported >75% reduction in pain, 2 reported minimal reduction in pain, and 1
noted no difference. One patient refused the VAD as she felt it was too distracting during injections. The injector noted that the depth
of injection should be monitored carefully as is done without the VAD.
Conclusions: The VAD is a safe and effective method in reducing discomfort and perceived pain during injections. Care must be
taken to show the patient in advance of what the vibration device feels and sounds prior to injection. Depth of needle penetration
needs to be monitored by the injector as the device has an anesthetic effect.
References: 1 Fayers T1, Morris DS, Dolman PJ.Ophthalmology. Vibration-assisted anesthesia in eyelid surgery. 2010
Jul;117(7):1453-7.
POSTERS
T10
A Low Cost Ocular Prosthesis Using 3-Dimensional Printing
Benjamin Erickson1, Daniel Chao1, Landon Grace2, Mauro Fittipaldi2, Wendy Lee1. 1Bascom Palmer Eye Institute, University of Miami,
Miami, FL, United States, 2Mechanical and Aerospace Engineering Department, University of Miami, Coral Gables, FL, United States
Introduction: Hand painted, custom fit prostheses crafted by a well-trained ocularist are widely agreed to offer the best functional
and cosmetic rehabilitation for patients with anophthalmic sockets. Unfortunately, many of the indigent patients we serve cannot
afford a custom prosthesis and only a small number are able to obtain one via charitable consideration. Inadequate projection and
poor color matching limit the utility of available stock prostheses. Accordingly, we partnered with our department of engineering to
design and produce a semi-custom prosthesis that can be produced at low cost using digital photography and three-dimensional
(3D) printing.
Methods: Our design consists of a clear front plate, a replica of the patient’s healthy contralateral iris, and an off white back
plate that snap together to produce a comfortable and cosmetically acceptable prosthesis (Figure 1). The front plate is molded in
acrylic from a template created using computer assisted design and 3D printing. The patient’s healthy iris is photographed with a
slit lamp camera, miniaturized to 11.5 mm in diameter, and printed on photo paper. This iris replica fits into a recessed circle on
the anterior surface of the back plate. In order to minimize the need for specialized expertise and materials, our design does not
involve taking a custom impression of the anophthalmic socket. Rather, the back plate, which is 3D printed from a FDA approved
biocompatible material, is available in several different sizes based on the projection patterns of a wide range of custom prostheses
that we analyzed.
Results: To date, we have produced the following prototype and are in the process of obtaining institutional approval to initiate
clinical use (Figure 2).
Conclusions: Loss of an eye is a traumatizing experience; psychological wellbeing and social integration depend on the availability
of a prosthesis that replicates the patients’ pre-morbid appearance as closely as possible. Many of our indigent patients are currently
unable to achieve these goals, even though we can fund and perform their surgery. While our design is not intended to replicate or
replace the art of the ocularist, we believe that it will provide a safe, and reliable tool for rehabilitation of patients with lesser means.
References: 1. Artopoulou II, Montgomery PC,
Wesley PJ, Lemon JC. Digital imaging in the
fabrication of ocular prostheses. J Prosthet Dent.
2006 Apr;95(4):327-30.
2. Kumar P, Aggrawal H, Singh RD, Chand P, Jurel SK,
Alvi HA, Gupta SK. A simplified approach for placing
the iris disc on a custom made ocular prosthesis:
report of four cases. J Indian Prosthodont Soc. 2014
Mar;14(1):124-7.
3. Goiato MC, Bannwart LC, Haddad MF, Dos
Santos DM, Pesqueira AA, Miyahara GI. Fabrication
techniques for ocular prostheses – an overview.
Orbit. 2014 Jun;33(3):229-33.
POSTERS
T11
The J-Curve for Navigating the Nasolacrimal Outflow Tract
Katie Finnerty1, Ronald Mancini2. 1Ophthalmology, University of Texas Southwestern, Dallas, TX, United States, 2Ophthalmology,
University of Texas Southwestern, Dallas, TX, United States
Introduction: To describe the technique of J-shaped manipulation of the metallic stent for instrument-free intubation of the
nasolacrimal outflow tract after dacryocystorhinostomy.
Methods: The internal diameter of the J-shaped curve placed in the intubation stents was measured and the technique of intubation
of the nasolacrimal outflow tract and out the external naris is described. Additionally, the anatomic relationships of the nasolacrimal
system are illustrated and videographed in relation to the described procedure.
Results: This technique has been used successfully on 50 endoscopic dacryocystorhinostomy cases. After completion of bony
osteotomy and opening of the nasolacrimal sac, the metallic portion of the stent is bent into a J-shaped curved with an average
internal diameter of 4 cm (Image 1). The punctum is then canulated with the metallic stent and directed 2mm vertically then 8-10mm
medially along the path of the canalicular system. Upon entering the osteotomy the stent is directed inferior and slightly medial in the
direction of the external naris (Image 2). Gentle advancement with small angle redirection of the stent as needed allows exit through
the external naris without using additional instrumentation in the nose (Video 1).
Conclusions: The authors present a technique of J-shaped manipulation of the intubation stent allowing navigation of the
nasolacrimal outflow tract and exit through the external naris without additional instrumentation. This technique offers advantages
over instrument-assisted retrieval of the intubation tube. First, the J-Curve technique is faster than multi-instrument retrieval. Second,
less damage is incurred to the mucosa of the lateral nasal wall and/or septum secondary to blind placement of a Crawford hook,
hemostat, or grooved director.
POSTERS
T12
Tangent Visual Fields are a Precise, Time and Cost Efficient Method for
Detecting the Changes in Superior Visual Field Caused By Blepharoptosis
and Dermatochalasis and Their Surgical Correction
Molly Fuller1,2, César Briceño1, Elizabeth Bradley2, Christine Nelson1. 1Ophthalmology, Kellogg Eye Center, University of Michigan,
Ann Arbor, MI, United States, 2Ophthalmology, Mayo Clinic, Rochester, MN, United States
Introduction: Superior visual field testing is a common practice during the evaluation of blepharoptosis and dermatochalasis, but
studies show the use of Humphrey and Goldmann visual field testing predominates1 with manual testing preferred by patients2. We
hypothesized that tangent visual fields (TVFs) are more time and cost efficient, while maintaining good correlation with clinical exam
and surgical outcomes.
Methods: In this prospective study, patients referred to a single surgeon for upper eyelid malposition were evaluated with visual
acuity testing, superior margin-to-reflex distance measurements (MRD1), and TVFs. Patients were included in the study if evaluation
led to surgical correction by blepharoplasty, blepharoptosis repair, or a combination of both. Clinical testing was repeated at a
postoperative visit. TVF duration was timed, and superior visual fields (SVFs) were analyzed for intact vision in the superior vertical
meridian and area under the curve of the TVF tracing. Pre- and postoperative SVFs and MRD1 were compared with paired t-tests.
Duration and cost of the TVF exam was also compared to historical data.
Results: One hundred nine eyes from 57 patients were included in the study. The average time to complete TVFs in one eye
was 3:11, while the average time to complete testing of both eyes was 6:03. This was significantly less than published times for
Humphrey or Goldmann testing. SVF loss measured in the vertical meridian was extremely well correlated with measurement by
area under the curve (r=0.87). Both preoperative taped-eyelid SVFs and postoperative SVFs showed significantly greater intact
visual field (p<0.001) with surgery providing an average 12.9 degree improvement in the vertical meridian. Surgery induced a
significant increase in MRD1 consistent with the preoperative diagnosis: 0.6mm for blepharoplasty and 2.8mm for blepharoptosis
repair or combination surgery (p<0.001 for all 3 surgeries). A tangent screen is the most inexpensive form of testing equipment
available today.
Conclusions: We show that tangent visual fields are a time and cost efficient method of testing superior visual fields. TVF testing
is the quickest and most economical method of testing in common clinical use today. Additionally, post-operative testing shows
an increase in degrees of vision in the vertical meridian, area of superior visual field, and surgically appropriate margin-to-reflex
distance, supporting the high success rate of these surgical interventions. There is excellent correlation between SVF changes
measured by degrees in the vertical meridian and area under the curve.
References: 1. Aakalu VK, Setabutr P. Current ptosis management: a national survey of ASOPRS members. Ophthal Plast Reconstr
Surg. 2011 Jul-Aug;27(4):270-6.
2. Alniemi ST, Pang NK, Woog JJ, Bradley EA. Comparison of automated and manual perimetry in patients with blepharoptosis.
Ophthal Plast Reconstr Surg. 2013 Sep-Oct;29(5):361-3.
POSTERS
T13
Eccrine Porocarcinoma of the Eyelid Masquerading as Basal Cell Carcinoma
Laura Gadzala MD, Allison Bardes MD, John Nguyen MD, Jennifer Sivak-Callcott MD. Ophthalmology, West Virginia
University, Morgantown, WV, United States
Introduction: Eccrine porocarcinoma (EPC) of the eyelid is extremely rare, with only five cases reported. This neoplasm has
the potential for local nodal spread and metastasis. We report a case of porocarcinoma of the eyelid that presented with
features suspicious for basal cell carcinoma (BCCA).
Methods: Case report and literature review. The clinical presentation, histopathologic characteristics and management
are presented.
Results: A 38 year-old Caucasian female presented with a slowly growing, painless, pruritic, left lower eyelid lesion, present for
8 months. She had mattering with occasional bleeding. Visual acuity was 20/25 right and 20/40 left. Slit lamp examination revealed
a 7.5mm x 3.5mm marginal lesion with focal ulceration, notching, madarosis and telangiectasia. She had a left posterior
subcapsular cataract; the rest of the examination was normal. The patient underwent full thickness wedge resection with frozen
section control. Histopathology showed numerous EMA-positive ducts consistent with EPC and negative margins.
EPC is a rare cancer that metastasizes to regional nodes and distant sites. It may arise
as a primary sweat gland tumor or malignant transformation of an eccrine poroma. Given
the rarity of the disease, there is no standard therapy. Most treatment recommendations
are based on case reports. Our patient had negative surgical margins, but in the literature
20% develop regional nodal involvement and 10% distant metastases despite negative
margins. Mortality in the setting of nodal metastases is nearly 70%, and some advocate
sentinel lymph node biopsy (SLNB). Adjuvant radiation and/or chemotherapy have
variable success. Staging PET CT is recommended to rule out nodal disease and distant
metastases. Of the five cases of eyelid EPC reported, none had metastatic disease at the
time of diagnosis, and no deaths were reported.
Conclusions: EPC is rare, but can occur in the eyelid masquerading as BCCA. Unlike
BCCA, management includes systemic evaluation with PET CT and possible SLNB due to
its metastatic potential.
References: 1. Chua PY, Comish KS, Stenhouse G, Barras CW. A rare case of eccrine
porocarcinoma of the eyelid. Semin Ophthalmol. 2013 Feb 27.
2. Jain R, Prabhakarn VC, Huilgol SC, Gehling N, James CL, Selva D. Eccrine porocarcinoma of the upper eyelid. Ophthal Plast
Reconstr Surg. 2008 May-Jun;24(3):221-3.
3. Kim Y, Scolyer RA, Chia EM, Steven D, Ghabriel R. Eccrine porocarcinoma of the upper eyelid. Australas J Dermatol. 2005
Nov;46(4):278-81.
4. D’Ambrosia RA, Ward H, Parry E. Eccrine porocarcinoma of the eyelid treated with Mohs micrographic surgery. Darmatol Surg.
2004 Apr;30(4 pt 1):570-1.
5. Boynton JR, Markowitch W Jr. Porocarcinoma of the eyelid. Ophthalmology. 1997 Oct;104(10):1626-8.
POSTERS
T14
A Newly Identified Syndrome of Multiple Facial Clefts
Ron Gutmark, W Jordan Piluek, Timothy J. McCulley. Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of
Medicine, Baltimore, MD, United States
Introduction: To describe the occurrence of multiple facial clefts involving all four eyelids, bilateral brows and the nose in a series
of Arabian patients.
Methods: In this observational case series, five patients from four families were identified during consultation with the Oculoplastics
Division at King Khaled Eye Specialists Hospital and the King Abdulaziz University Hospital, in Riyadh, Saudi Arabia. In each case,
photographs and head imaging were obtained, and charts were reviewed. Each patient was also interviewed for a history of
consanguinity and similar findings in other family members.
Results: 5 patients were identified, 3 males and 2 females, with ages ranging from 3 months to 22 years. Four of these patients had
bilateral upper and lower eyelid colobomas, and all five patients had incomplete brow development and central fusional defects of the
nose. These patients had normal head imaging and no known neurologic abnormalities. There is an admitted history of consanguinity
in the families, suggesting a heritable syndrome. One of the patients has a deceased sibling with a similar facial appearance, and two
of the patients presented here are siblings.
Conclusions: Four separate families were found in Saudi Arabia with at least one member affected by what appears to be the
same congenital syndrome consisting of bilateral upper and lower eyelid colobomas and clefts of the nose and brows. Such a
constellation of findings has not previously been described and it is proposed that an autosomal recessive inheritance pattern is
the most likely etiology.
References: 1. Tessier, P. Anatomical classification
of facial, cranio-facial and latero-facial clefts.
J Maxillofac Surg. 1976. 4(2):69-92.
2. Suresh BN, Raviprakash D, Kumar R.
Nasopalpebral lipoma coloboma syndrome.
Indian J Ophthalmol. 2011. 59(5):379-380.
3. Bock-Kunz AL, Lyon DB, Singhal VK, Grin TR,
Park O. Nasopalpebral lipoma-coloboma syndrome.
Arch Ophthalmol. 2000;118:1699-701.
4. Seah LL, Choo CT, Fong KS. Congenital upper
lid colobomas: Management and visual outcome.
Ophthal Plast Reconstr Surg. 2002;18:190-195
5. Penchaszadeh VBVelasquez DArrivillaga R The
nasopalpebral lipoma-coloboma syndrome: a
new autosomal dominant dysplasia-malformation
syndrome with congenital nasopalpebral lipomas,
eyelid colobomas, telecanthus, and maxillary
hypoplasia. Am J Med Genet. 1982;11397- 410
6. Marchac D, Arnaud E. Midface surgery from Tessier to distraction. Child’s Nerv Syst. 1999;15:681-694
7. Online Mendelian Inheritance in Man, OMIM®. Johns Hopkins University, Baltimore, MD. MIM Number: 167730: 07/16/2012:
World Wide Web URL: http://omim.org/
8. Online Mendelian Inheritance in Man, OMIM®. Johns Hopkins University, Baltimore, MD. MIM Number: 600251: 09/06/2011:
World Wide Web URL: http://omim.org/
9. Gregory-Evans CY, Williams MJ, Halford S, Gregory-Evans K. Ocular coloboma: a reassessment in the age of molecular
neuroscience. J Med Genet. 2004;41:881-891
POSTERS
T15
A Unique Presentation of Adult-Onset Xanthogranuloma
Cristos Ifantides1, Alan Friedman1, James Strauchen2, Albert Wu1. 1Ophthalmology, Icahn School of Medicine at Mount Sinai, New York,
NY, United States, 2Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
Introduction: Juvenile xanthogranuloma (JXG) is a relatively rare benign cutaneous fibrohistiocytic lesion. JXG usually presents as
an orange-yellow nodule before the age of 2. The skin of the head, neck, and upper trunk are commonly involved.1-3 Solitary lesions
of the eyelid area have been described, as well.4
Ocular JXG can also occur, involving the ocular surface or uvea. These lesions are typically self-limited and regress by age 5.
JXG represents approximately 0.5% of all pediatric tumors, with ocular JXG representing an estimated 0.3% of all JXG cases. 5,6
Adult xanthogranuloma can be similar in histology and appearance to JXG. However, adult xanthogranuloma tends to be less benign
and commonly displays systemic manifestations.
Results: A 38-year-old man presents with a 6-month history of a left upper lid lesion. He reported increasing irritation over this time
and denied discharge, history of trauma, or changes in visual acuity. He denied any constitutional symptoms and review of systems
was otherwise negative. His complete eye exam was normal except for a left upper lid lesion (Figure 1). Shave biopsies of the lesion
were taken and surgical pathology showed many foam-laden histiocytes along with Touton giant cells within the dermis (Figure 2,
H&E 400x). Immunohistochemical stains found CD1a weakly positive and CD163 and Factor XIIIa to be strongly positive. The final
diagnosis given was Juvenile Xanthogranuloma.
Conclusions: This case reinforces the idea that xanthogranuloma need not be limited to the pediatric population. It is important to
recognize an unusual presentation of xanthogranuloma in adults.
References: 1. Shields CL,
Shields JA, Buchanon HW.
Solitary orbital involvement
with juvenile xanthogranuloma.
Arch Ophthalmol 1990;
108(11): 1587-1589.
Kaur H, Cameron JD, Mohney
BG. Severe astigmatic
amblyopia secondary to
subcutaneous juvenile
xanthogranuloma of the eyelid. JAAPOS 2006; 10(3): 277-278.
2. Chaudhry IA, Al-Jishi Z, Shamsi FA, Riley F. Juvenile xanthogranuloma of the corneoscleral limbus: case report and review of the
literature. Surv Ophthalmol 2004; 49(6): 608-614.
3. Lim LT, McLaughlin S, Lavy T, Penman D, Dutton GN. Juvenile xanthogranuloma: an unusual eyelid presentation. Eye 2010; 24:
1425-1426.
4. Janssen D, Harms D. Juvenile xanthogranuloma in childhood and adolescence: a clinicopathologic study of 129 patients from the
kiel pediatric tumor registry. Am J Surg Pathol 2005; 29:21.
5. Chang MW, Frieden IJ, Good W. The risk intraocular juvenile xanthogranuloma: survey of current practices and assessment of risk.
J Am Acad Dermatol 1996; 34:445.
6. Chantranuwat C. Systemic form of juvenile xanthogranuloma: report of a case with liver and bone marrow involvement. Pediatr Dev
Pathol 2004; 7(6): 646-648.
POSTERS
T16
Canalicular Injury Associated with Dog Bites in the Pediatric Population
Krishna Kalyam1, Javier Servat2, Roman Shinder3, Reshma Mehendale3, Gary Lelli5, Jose-Luis Tovilla4, Flora Levin1.
1
Ophthalmology, Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, CT,
United States, 2Ophthalmology, Oculofacial Plastic Surgeons, Macon, GA, United States, 3Ophthalmology, SUNY Downstate
Medical Center, Brooklyn, NY, United States, 4Ophthalmology, Institute of Ophthalmology, Mexico City, Mexico, 5Ophthalmology,
New York-Presbyterian Hospital, Weill Cornell Medical College, New York, United States
Introduction: The purpose of this retrospective study is to report a series of pediatric canalicular lacerations associated
with dog bites.
Methods: Retrospective review of all canalicular lacerations in children associated with dog bites at three tertiary oculoplastic
surgery services between 2000 and 2013. The data collected included patient demographics, location of injuries, animal breed,
clinical course, treatment, complications and duration of follow-up. The data was analyzed using standard statistical methods.
Results: Seventy-two children with an average age of 6.4 years (1.5- 16 years) were included in the study. Sixty percent were
male. Pit-bull (20%) and labrador (20%) were most common breeds but others include golden retriever (11%), chihuahua (11%)
french poodle (11%), schnauzer (11%), doberman (5%) and others (11%). Injuries were incurred by patients own dog in 58%, most
commonly during play (55%). Twenty-two percent were unprovoked. The inferior canaliculus was most commonly affected (60%),
followed by involvement of both superior and inferior canaliculi in 30% and the superior canaliculus alone in 10%. The average time
from injury to repair was 30.5 hours (4-96 hours). Most patients (75%) underwent bicanalicular stenting with Crawford tubes. The
stents were left in place for an average of 5.4 months. Complications developed in 14 patients (19%). These included cicatricial
ectropion, stent extrusion, dacryocystitis and pyogenic granuloma. The average follow-up was 33 months (1week- 9 years) with
continued epiphora in only 3 paitents requiring Jones tubes for treatment of epiphora.
Conclusions: This report documents the largest series of canalicular injury related to dog bites in pediatric population. Canalicular
injury from dog bites in this age group can occur from any type of dog although Pit-bull and Labrador were the most common breeds
in this series. Dog bite injuries in children mostly occur during playtime and most often from their own pet. Surgical repair provides
good outcome.
References: 1. Savar A, Kirszrot J, Rubin PA. Canalicular involvement in dog bite related eyelid lacerations. Ophthal Plast Reconstr
Surg 2008; Jul-Aug;24(4):296-8
POSTERS
T17
Periocular Changes associated with Six Months of Topical Bimatoprost
in the Rabbit
Introduction: Topical prostaglandin analogues (PGAs) are frequently used for both primary and secondary treatment of glaucoma.
Physicians are becoming increasingly aware that isolated patients can develop prostaglandin associated orbitopathy, characterized
by deepening of the superior sulcus, reduction of dermatochalasis, enophthalmos, and ptosis. There have also been isolated reports
of increased tension of the eyelid margins.1-4 We performed a prospective animal study to both confirm the causal relationship and to
better characterize the nature of these eyelid changes.
Methods: Following institutional approval, female New Zealand White rabbits were separated into three treatment groups
(n=3 rabbits/group): Group 1: artificial tears OU, Group 2: 0.3% bimatoprost OU, Group 3: untreated. At the end of both 3-month and
6-month treatment periods, animals were sedated and measurements taken of both horizontal length and eyelid distraction from the
globe. Subsequently, the animals were euthanized and the eyelids examined histologically with hemotoxalin and eosin (H&E) staining.
Statistically analysis was performed using SPSS, with a significance 0.05, using ANOVA and post-hoc analysis with the leastsignificant difference test.
Results: Following both 3 and 6 months of treatment (Table 1), animals that received topical PGA drops demonstrated significantly
smaller eyelid fissure widths, than those treated with ATs (p=0.007 for 3 months, p<0.001 for 6 months) or untreated controls
(p<0.001 for both 3 and 6 months). Similarly,eyelid distraction data demonstrated a similar trend, with PGA treated eyelids having
significantly less distractibility than ATs treated eyelids (p=0.002 for uppers at 3 months, p<0.001 for uppers at 6 months, p<0.001
for lowers at both 3 and 6 months) or untreated controls (p<0.001 for uppers at both 3 and 6 months and P<0.001 for lowers at
3 months and p=0.008 for lowers at 6 months). Histological anayslis of H&E sections of all tissues did not reveal any notable
difference between groups.
Conclusions: Daily topical PGA drops in New Zealand White rabbits resulted in horizontal shortening of the eyelids and acquired
blepharophimosis. There was increased horizontal tension of the treated eyelids on the eyelid distraction test. These eyelid changes
are similar to those observed in human patients on PGA therapy.
References: 1) “Deepening of the Upper Eyelid Sulcus Caused by 5 Types of Prostaglandin Analogs”, Inoue, et al., J Glaucoma
2013 Oct-Nov;22(8):626-31
2) “Eyelid and Eyelash Changes Due To Prostaglandin Analog Therapy in Unilateral Treatment Cases”, Yoshino et al, Jpn J Ophthalmol
2013 Mar;57(2):172-8
3) “Adverse Periocular Reactions to Five Types of Prostaglandin Analogs”, Inogue, et al., Eye 2012 Nov;26(11):1465-72
4) “Iris and Periocular Adverse Reactions to bimatoprost in Japanese patients with glaucoma or ocular hypertension”, Inoue, et al.,
Clinical Ophthalmology 2012;6:111-6
POSTERS
T18
Sling Revision for Undercorrection after Frontalis Sling Operation
Ju-Hyang Lee, Jisang Han, Yoon-Duck Kim, Kyung In Woo. Ophthalmology, Samsung Medical Center, Sungkyunkwan University
School of Medicine, Seoul, Korea
Introduction: Undercorrection of blepharoptosis after frontalis sling operation using autologous or preserved fascia lata (AFL or PFL)
can be encountered and reoperation using new sling material has been tried. We described a new surgical technique to correct this
complication with reattachment of existing fascia.
Methods: This was a retrospective interventional case series of patients undergoing sling revision between November 2008 and
February 2014. Skin incision was made 2mm from the lid margin or on the previous incision line. Careful dissection was performed
superiorly and existing fascia was identified. Fascia was reattached to the tarsal plate using non-absorbable sutures for adjusting the
eyelid level and contour. The success of the procedure was defined as less than 1mm of difference in MRD1 of both eyes without
contour deformity.
Results: Eleven eyelids in ten patients were included with a mean follow-up of 18.9 months (range, 4-54 months). There were
8 male and 2 female patients, ranging from 3 to 35 years of age (mean, 11.9 years). Of these, 10 eyelids (9 patients) had undergone
frontalis sling with AFL, one eyelid with PFL for congenital ptosis. The mean time interval between previous frontalis sling operation
and sling revision was 6.2 years (range, 1-20 years). Undercorrections were seen as recurrence of ptosis in 3 eyelids and contour
deformity such as temporal ptosis in 8 eyelids. In case of nasal peaking, temporal sling revision was performed with concurrent
recession of existing fascia. Combined surgery included upper entropion repair in 5 eyelids (4 patients), upper blepharoplasty in
one, and medial canthoplasty in one eyelid respectively. All patients (100%) achieved surgical success and cosmetically acceptable
appearance without recurrence.
Conclusions: Sling revision is a simple and effective method, leading to short period of recovery and low perioperative morbidity,
for the treatment of undercorrection or contour deformity following frontalis sling operation even after a long time.
References: Orlando F, Weiss JS, Beyer-Machule CK, et al. Histopathologic condition of fascia lata implant 42 years after ptosis
repair. Arch Ophthalmol. 1985;103:1518-9
Beyer CK, Albert DM. The use and fate of fascia lata and sclera in ophthalmic plastic and reconstructive surgery. Ophthalmology
1981;88:869-86
Callahan M and Beard C, BEARD’S PTOSIS, 4th, 1990
Dortzbach RK. Ophthalmic plastic surgery: prevention and management of complications, 1994
POSTERS
T19
The Orbital Strut Revisited: Anatomic Definition and Computer-Assisted
Volumetric Analysis of Boney Volume
Jennifer Lira, Carisa Petris, Joyce Khandji, Alexander Khandji, Michael Kazim. Department of Ophthalmology, Columbia University
Medical Center, New York-Presbyterian Hospital, New York, NY, United States
Introduction: The portion of the bony orbit known as the inferior-orbital strut (IOS) is of particular interest to orbital surgeons
performing bony decompression. The orbital strut has been previously described as the bony thickening at the junction of the
maxillary and ethmoid bones beginning at the inferior orbital rim, extending to the posterior palatine bone[1]. Using volumetric
software, we were able to delineate the portion of the orbital strut that is safely removed during boney decompression for maximal
expansion of the orbit. This includes bone between the posterior lacrimal crest to the most posterior ethmoid air cell, anterior to the
palatine bone.
Methods: A retrospective IRB-approved radiographic study in which the IOS was analyzed with high resolution CT scans selected
from over 9000 scans performed at NYPH from 2008-14. All scans were high resolution and <1.6mm thickness. Scans were
excluded in patients with orbital surgery or trauma, craniofacial abnormalities, or orbital tumors. Volumetric analysis was performed
with VitreaWorkstation™Version6.5.3. by Vital Images, Inc. The IOS was outlined at the junction of the medial and inferior orbital
walls. Outlines were made in the coronal view while simultaneously visualizing the points on sagittal, axial, and 3D reconstruction
planes. The junction of the posterior lacrimal crest, maxillary floor, and ethmoid bone served as the anterior margin. The posterior
margin was located just anterior to the posterior aspect of the palatine bone. The software yielded volume measurements and 3D
reconstructions of the orbital strut.
Results: Twenty-one scans (41 orbits) were studied to determine variance and power of the available data. The strut was found
to be triangular in shape in coronal views. The anterior-most portion was easily identified at the junction of the ethmoid and maxillary
bones just posterior to the nasolacrimal canal. The strut ended posteriorly to the junction of the ethmoid and palatine bones.
The bony strut was thickest anteriorly and posteriorly. A mean IOS volume (mm3) of 385.0 OD and 405.2 OS (SD=131.6 OD,
141.7 OS) was calculated.
Conclusions: This study provides radiographic characterization of the dimensions of the orbital strut with emphasis on volumetric
analysis. Although the volume occupied by the IOS as defined is small, and if removed, adds only 1% to the total orbital boney
volume, we believe IOS removal produces a more significant increase in orbital volume as a consequence of the expansion of orbital
soft-tissues beyond the volume occupied by the IOS into the adjacent sinuses after the periorbita is opened. We suggest that the
most posterior ethmoid air cell should be removed in all cases to maximize volume expansion but does not constitute a portion of the
strut. Conversely, removal of the palatine bone does not significantly increase volume and carries additional operative risk.
References: Kim JW, et al. The Inferomedial Orbital Strut: An Anatomic and Radiographic Study.OPRS.2002;18:355-364
POSTERS
T20
Spindle Cell Lipoma of the Orbit
Amina Malik1, Jeffrey Nerad2. 1Cincinnati Eye Institute, Cincinnati, OH, United States, 2Ophthalmology, University of Cincinnati,
Cincinnati, OH, United States
Introduction: Lipomas are one of the most common mesenchymal neoplasms and can arise in any location in which fat is present.
In 1975, a specific variant of lipoma termed “spindle cell lipoma,” was first described. Cases of these unusual spindle cell lipomas
of the orbit are rarely seen, despite the abundance of fat in the orbit, with only four previous case reports described in the literature.
Here we describe a case of a recurrent spindle cell lipoma of the orbit, which to our knowledge, has not been previously described.
Methods: The clinical presentation, management, and outcome of a case of a recurrent spindle cell lipoma of the orbit is reported.
A literature search was performed on spindle cell lipoma of the orbit and is described.
Results: A 60 year old Caucasian male presented with complaints of worsening diplopia and protrusion of his left eye. His past
medical history was significant for Hepatitis C and squamous cell carcinoma of the tonsils, for which he was treated with radiation
three months prior to presentation. On examination he was noted to have 4 mm of left proptosis with ptosis (Figure 1) and limitation
of abduction and infraduction. Imaging disclosed a large, homogenous, well circumscribed mass in the left inferomedial orbit (Figures
2, 3). Surgical excision was performed and pathology was positive for spindle cell lipoma (Figure 3). Two years postoperatively, patient
presented with recurrence of symptoms, and on imaging was found to have a large orbital mass again in the left inferomedial orbit.
Repeat excisional biopsy was performed, with pathology positive for spindle cell lipoma. Postoperatively patient’s symptoms resolved,
and he remained stable over a two year follow up period.
Conclusions: Spindle cell lipoma of the orbit, though rare, should be considered in the differential diagnosis for an orbital
mass. Treatment is primarily via surgical excision, but patients should have long-term follow-up to check for development of
tumor recurrence.
References: 1. Enzinger FM, Harvey DA. Spindle cell lipoma. Cancer 197; 36:1852.
Shields JA, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: The 2002 Montgomery
Lecture, Part 1. Ophthalmol May 2004; 111(5):997-1008.
2. Johnson BL, Linn JG. Spindle cell lipoma of the orbit. Arch Ophthalmol Jan 1979; 97:133-134.
3. Bartley GB, Yeatts RP, Garrity JA, et al. Spindle cell lipoma of the orbit. Am J Ophthalmol Oct 1985; 100:605-609.
4. Uliveri S, Olieri G, Motolese PA, et al. Spindle cell lipoma of the orbit: a case report of an unusual orbital pathology.
Neurologia I Neurochirugia Polska 2010; 44:419-423.
5. Pardhe N, Singh N, Bharadwaj G, et al. Spindle cell lipoma. BMJ Case Rep Aug 2013; 2013.
6. Mawn LA, Jordan DR, Olberg B. Spindle cell lipoma. Ophthal Plastic Recons Surg May 1998; 14(3):174-177.
POSTERS
T21
Corneal Topography With Upper Eyelid Platinum Chain Implantation Using
The Pretarsal Fixation Technique
Ioannis Mavrikakis1, Efstathios Detorakis2, Stefanos Baltatzis3, Ioannis Yiotakis 4, Dimitrios Kandiloros4. 1Athens Eye Hospital,
Athens, Greece, 2Department of Ophthalmology, University Hospital of Heraklion, Heraklion, Greece, 3Department of Ophthalmology,
University of Athens, Athens, Greece, 4Department of Otolaryngology, University of Athens, Athens, Greece
Introduction: To determine the effect of upper eyelid platinum chain implantation, with the pretarsal fixation technique,
on corneal astigmatism.
Methods: This is a prospective, cohort study. Fifteen eyes of 15 patients underwent upper eyelid platinum chain implantation, with
the pretarsal fixation technique, for facial nerve palsy. Information recorded included patient demographics, etiology for facial palsy,
weight of the implant, time from onset of paresis to upper eyelid platinum chain implantation, associated surgical procedures, and
preoperative and postoperative keratometry measurements.
Results: Of the 15 patients studied, 10 were male and 5 were female. The mean age was 55.9 ± 13.8 years (range, 33-87 years).
The most common etiology for facial palsy was acoustic neuroma. The weight of the implant ranged from 0.6 to 1.6gr (median
1.2gr). The time from onset of paresis to upper eyelid platinum chain implantation varied from 1 week to 3 months (median 1 month).
Four patients had an associated procedure to correct the effect of paralytic ectropion. There was no statistically significant difference
in with the rule astigmatism before and after platinum chain implantation.
Conclusions: Upper eyelid platinum chain implantation, with the pretarsal fixation technique, does not appear to cause significant
change in corneal astigmatism. This is contrary to data for pretarsal gold weight implantation, which does induce significant with the
rule astigmatism.
References: Berghaus A, Neumann K, Schrom T. The platinum chain: a new upper-lid implant for facial palsy. Arch Facial Plast Surg
2003;5(2):166-70.
Mavrikakis I, Beckingsale P, Lee E, Riaz Y, Brittain P. Changes in Corneal Topography With Upper Eyelid Gold Weight Implants. Ophthal
Plast Reconstr Surg 2006;22(5):331-4.
Caesar RH, Friebel J, McNab AA. Upper lid loading with gold weights in paralytic lagophthalmos: a modified technique to maximize
the long-term functional and cosmetic success. Orbit 2004;23(1):27-32.
POSTERS
T22
Demonstrating the Ischemic Effects of Intra-arterial Hyaluronic Acid Gel
Injection Using Indocyanine Green (ICG) in An Animal Model
Payam Morgan1, Holly Chang2, Aline Pimentel1, Catherine Hwang1. 1Ophthalmology, UCLA, Los Angeles, CA, United States, 2
Ophthalmology, UW, Seattle, WA, United States
Introduction: As aesthetic fillers have become more popular, the reports of ischemic complications from their use have also
populated the literature. There have been different pathophysiologies proposed, such as intra-arterial injection versus compression of
the vessels. The purpose of our study is to introduce a new way of evaluating capillary beds after intra-arterial injections of hyaluronic
acid gel (HAG) injections using Indocyanine Green (ICG) angiography.
Methods: After Animal Research Committee approval, a rabbit ear model was used to create filler skin ischemia (total of 4 rabbits,
8 ears). The posterior branch of the postauricular artery was ligated on all four ears. Three commonly used HAG fillers around the
periorbital area, Restylane®, Belotero®, JUVÉDERM™ Ultra Plus (0.1-0.25 cc), were injected intra-arterially into the anterior branch of
the postauricular artery while the fourth ear was used as a control. Capillary perfusion was evaluated pre (figure 1), immediately post
(figure 2), 30, and 60 minutes after occlusion with the SPY System (Novadaq Inc.) using ICG imaging.
Results: Intra-arterial injection of HAG shows significant capillary drop out in the rabbit ears with no apparent reversal at 1 hour.
The ear injected with Belotero® seemed to retain better perfusion that the other three HAGs.
Conclusions: Use of the ICG SPY system is an effective way of evaluating the perfusion status of the capillary bed. With this animal
model the theory of intra-arterial injections of HAGs causing ischemia is further supported. Some HAGs may have less of an occlusive
property due to their cross-linking and particle size; however, further studies are needed.
References: 1. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014 May
1;34(4):584-600.Epub 2014 Apr 1.
2. Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dhong ES.
Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plast Reconstr Aesthet Surg. 2011
Dec;64(12):1590-5. Epub 2011 Jul 31.
POSTERS
T23
Orbital Malignant Melanoma Arising in a Phthisical Eye
James Murphy, Valerie Elmalem. Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, United States
Introduction: Case report of a patient with orbital malignant melanoma associated with phthisis bulbi.
Methods: Standard clinical oculoplastic evaluation techniques.
Results: Patient underwent advanced imaging and orbital biopsy with histopathological diagnosis of malignant melanoma.
Conclusions: The patient is currently undergoing metastatic work-up with hematology-oncology.
References: Tellada M, et al. Primary orbital melanomas. Ophthalmology.1996 Jun;103(6):929-32.
Zografos L, et al. Metastatic melanoma in the eye and orbit. Ophthalmology. 2003 Nov;110(11):2245-56.
POSTERS
T24
Surgical Management of Orbital Arteriovenous Malformation: Case Report
and Literature Review
David Myung, Andrea Kossler, Lisa Chen. Ophthalmology, Byers Eye Institute at Stanford, Palo Alto, CA, United States
Introduction: Arteriovenous malformations (AVMs) of the orbit are progressively enlarging, abnormal connections that bypass normal
capillaries between the arterial and venous circulation. They differ from AV fistulas in that AVMs are congenital, have a central nidus,
and both numerous feeding and draining vessels. The risk of hemorrhage, occlusion, and damage to surrounding structures makes
surgical management of orbital AVMs extremely challenging. Herein we describe the successful treatment of a rapidly growing, left
orbital AVM in a 46 year old woman by surgical excision alone. A multidisciplinary approach to management was taken in the context
of a literature review on reported management by excision versus chemoembolization.
Methods: The patient initially presented with several months of progressive pain proptosis, and ophthalmoplegia. Vision at initial
presentation was 20/20 but she was experiencing 10/10 pain and significant limitation in abduction, supraduction, and infraduction.
Hertel measurements revealed 5 mm proptosis of the left eye. Slit lamp examination revealed engorged episcleral vessels of the
left eye but an otherwise unremarkable exam and visual field testing was normal. The patient underwent an MRI which revealed an
enhancing, left intraconal oval heterogenous 2.6 x 1.8 x 1.9 cm mass with significant mass effect on left optic nerve, stretched and
medially displaced, with dilated veins coursing into the mass anteriorly and posteriorly, peripheral rim enhancement and enhancing
vessels extending towards and away from the mass, and a T1 hyperintense and T2 hypointense consistent with thrombus. CT
angiogram followed by cerebral angiogram revealed that the mass to be an AVM proximal to the central retinal artery that was
causing significant engorgement of the angular and inferior ophthalmic veins. Over the course of three months, the mass was found
to have increased in size and proptosis had progressed from 5 mm to 10 mm, and visually acuity had declined to 20/40. Discussions
with both neuroradiology, neurointerventional radiology, and neurosurgery services at Stanford led to the conclusion that endovascular
intervention via chemoembolization was not possible without significant circulatory compromise to the optic nerve and retina, that
Cyberknife therapy was unlikely to provide substantial benefit, and that surgical excision was the only viable treatment option. The
patient then underwent microscope-assisted resection of the AVM via an anterolateral craniotomy approach, followed by superior and
lateral wall reconstruction with titanium plate and medpore implant, and intraoperative angiography.
Results: The patient at post-operative month 1, the patients vision had returned to 20/20, her proptosis had reduced from 10 mm
to 1.5 mm, and her ophthalmoplegia had improved to only a small abduction deficit. Cerebral angiography at that time revealed no
recurrence of the AVM lesion and patent retrobulbar circulation.
A review of 25 cases in the literature revealed the following. Eight out of 25 cases led to improvement of which 4 underwent surgical
excision alone, 1 underwent embolization and surgical excision, 1 underwent embolization alone, 1 underwent ligation of feeder
vessels, and 1 underwent spontaneous thrombosis. Seven out of the 25 cases led to NLP vision; of these cases, two that underwent
embolization ended with exenteration, one underwent attempted surgical excision alone leading to massive hemorrhage and
enucleation, one underwent gamma knife radiosurgery, one underwent observation with steroids and another underwent observation
alone. Of the remaining 10 cases, two refused intervention, two underwent observation alone and another surgical excision without
change, one underwent partial surgical excision with recurrence. There were four cases in which no post-operative result was
mentioned, of which one underwent partial excision, one underwent embolization, one underwent observation alone, and one
underwent ligation of feeder vessels.
In contrast to arteriovenous fistulas (AVFs), AVMs are congenital lesions with multiple large feeding arteries, a central nidus, and
numerous dilated draining veins. Management of AVMs of the orbit may be difficult due to the threat of hemorrhage, vascular
occlusion during treatment, and collateral damage to surrounding organs. We managed AVM of the orbit and periorbital tissues
in four patients. Neuroimaging studies, clinical decision making, operative experience, and long-term postoperative results were
retrospectively reviewed. Four cases of AVM of the orbit and periorbital tissues were successfully treated with preoperative
POSTERS
T24
Surgical Management of Orbital Arteriovenous Malformation: Case Report and Literature
Review, continued
embolization and subsequent excision of the central nidus of the AVM. There was no evidence of recurrence in any of the cases over
follow up ranging from 2 to 5 years. We conclude that identification of all arterial feeders, from both internal and external carotid
systems, is critical in developing a therapeutic plan. AVMs may be treated by surgical excision alone, or embolization alone.
Conclusions: Management of orbital AVMs is a clinical challenge due to the high risk of postoperative vision loss. In the case
presented here, a careful, interdisciplinary approach was taken to determine the best course of action and surgical excision alone
was undertaken with a good post-operative result. However, a review of the literature reveals that all options—observation, surgical
excision, embolization with or without surgical excision, and radiotherapy—all come with the risk of NLP vision and possible
enucleation or exenteration. These results suggest that the management of orbital AVMs carries significant risk no matter what
approach is taken, and that the input of neurointerventionalists, neurosurgeons,and neuroradiologists should be sought early in the
clinical course, and if surgical excision is carried out, a combined surgical team involving both neurosurgery to provide anatomical
access along with neuroradiologists to provide intraoperative angiography is highly recommended.
POSTERS
T25
Recurrent Malignant Meningioma of the Ethmoid Sinus: Case Study and
Literature Review
Leslie Neems, Chambers Christopher. Ophthalmology, Northwestern University, Chicago, IL, United States
Introduction: This case report is to presents a patient with recurrent malignant meningioma of the ethmoid sinus invading
the inferior medial orbit. This patient’s course is that of a highly aggressive tumor, and poses a significant challenge to current
treatment options.
Methods: Review of literature via PubMED and Ovid. Chart review using Northwestern’s electronic medical records.
Results: 55 year old male presented for a mass adjacent to the left medial canthus with associated tearing for three months.
He had a history of malignant sinonasal meningioma status post wide excision and external beam radiation four years prior.
Exam revealed a raised 1 cm mass between the left medial canthus and the bridge of the nose. MRI showed a 1.5 cm mass
involving the inferior medial orbit. Biopsy demonstrated recurrent grade III malignant meningioma. ENT performed a radical resection
with free flap reconstruction. Oculoplastics performed a left orbitotomy, removal of the medial wall and floor with placement of
implants, and stenting of the nasolacrimal system. Pathology report showed disease free margins. The patient is healing well.
Conclusions: Intracranial meningiomas are common, accounting for 30% of all intracranial tumors. Extracranial meningiomas are
rare, comprising only 1-2 % of all meningiomas.This case report joins a limited body of knowledge of meningiomas of the sinonasal
tract. To date, four cases of sinonasal meningiomas presented primarily for ocular complaints. These complaints included blindness
in one case, secondary to invasion and compression of the orbit. This patient’s primary complaint was tearing from the mass
compressing the nasolacrimal system.
These tumors are diagnosed and graded histologically, according to the WHO criteria. The overwhelming majority of tumors are grade
I, and have a benign course. This case is a grade III malignant meningioma. It has recurred and infiltrated surrounding structures.
Secondary to prior intervention, surgical planning was complicated. Overall, the prognosis for such tumors is poor. This case
demonstrates the aggressive nature of this tumor, the complexity of treatment, and how optimal treatment is given with collaboration
between subspecialties.
References: M., Petrulionis, Valeviciene N., Paulauskiene I., and Bruzaite J. “Primary Extracranial Meningioma of the Sinonasal
Tract.” Acta Radiologica 46.4 (2005): 415-18. Print.
Thompson, Lester, and Kymberly Gyure. “Extracranial Sinonasal Tract Meningiomas.” The American Journal of Surgical Pathology
24.5 (2000): 640-50. Print.
Mnejja, M., B. Hammami, and L. Bougacha. “Primary Sinonasal Meningioma.” Eur Ann Otorhinolaryngol Head Neck Dis 129.1
(2012): 47-50. Print
Whittle, Ian R., Colin Smith, Parthiban Navoo, and Donald Collie. “Meningiomas.” The Lancet 363 (2004): 1536-543. Print
POSTERS
T26
Imiquimod 5% Cream for the Treatment of Periocular Lesions: Two Case Reports
Gamze Ozturk Karabulut1, Pelin Kaynak1, Can Ozturker1, Korhan Fazil1, Altug Cetinkaya2, Ahmet Demirok1, Omer Faruk Yilmaz1. 1OPRS,
Beyoglu Eye Research And Training Hospital, Istanbul, Turkey, 2OPRS, Dunyagoz Ankara Hospital, Ankara, Turkey
Introduction: Imiquimod is an immunomodulatory and antitumorigenic agent. It augments both innate and cell-mediated
immunity and stimulates cytotoxic T-cells, Langerhans cells and natural killer cells to produce interferon-alpha and other cytokines.
Two patients, one with basal cell carcinoma and another patient with actinic keratosis are presented in this study.
Methods: Case 1: A fifty-year-old male patient with a 10mm nodular lesion in the medial canthal area, diagnosed as basal cell
carcinoma by incisional biopsy, underwent local treatment with Imiquimod 5% cream once a day at bedtime, 5 times a week, for
6 weeks. Case 2: A sixty one-year-old male with a 20mm x 15mm diffuse, hyperpigmentated lesion covering the right upper eyelid
was diagnosed as actinic keratosis by incisional biopsy. This patient underwent the same dosing regimen for 5 weeks.
Results: In the follow-up period of case 1 the lesion size decreased to 1mm. In case 2 the lesion reduced half of the previous size
at the last follow-up and treatment still continues in both patients.They had local reactions such as erythema, crusting, ulceration,
punctate keratitis, the ophthalmic side effects could be managed by topical lubricating eye drops and both patients could continue
the treatment.
Conclusions: Surgical treatment is the standard treatment for periocular carcinoma and actinic keratosis. However, topical
5% imiquimod cream may become an alternative treatment whenever surgery is precluded, especially in elderly, in patients on
anticoagulant treatment, in diffuse and multiple lesions.
References: 1) Prokosch V, Thanos S, Spaniol K, Stupp T. Longterm outcome after treatment with 5% topical imiquimod cream in
patients with basal cell carcinoma of the eyelids. Graefes Arch Clin
Exp Ophthalmol. 2011 Jan;249(1):121-5.
2) Garcia-Martin E, Idoipe M, Gil LM, Pueyo V, Alfaro J, Pablo LE,
Zubiri ML, Fernandez J. Efficacy and tolerability of imiquimod
5% cream to treat periocular basal cell carcinomas.
J Ocul Pharmacol Ther. 2010 Aug;26(4):373-9.
3) Choontanom R, Thanos S, Busse H, Stupp T. Treatment of
basal cell carcinoma of the eyelids with 5% topical imiquimod: a
3-year follow-up study. Graefes Arch Clin Exp Ophthalmol. 2007
Aug;245(8):1217-20.
4) Leppälä J, Kaarniranta K, Uusitalo H, Kontkanen M. Imiquimod in
the treatment of eyelid basal cell carcinoma. Acta Ophthalmol Scand. 2007 Aug;85(5):566-8.
5) Blasi MA, Giammaria D, Balestrazzi E. Immunotherapy with imiquimod 5% cream for eyelid nodular basal cell carcinoma.
Am J Ophthalmol. 2005 Dec;140(6):1136-9.
6) Garcia-Martin E, Gil-Arribas LM, Idoipe M, Alfaro J, Pueyo V, Pablo LE, Fernandez FJ. Comparison of imiquimod 5% cream versus
radiotherapy as treatment for eyelid basal cell carcinoma. Br J Ophthalmol. 2011 Oct;95(10):1393-6.
7) Cannon PS, O’Donnell B, Huilgol SC, Selva D. The ophthalmic side-effects of imiquimod therapy in the management of periocular
skin lesions. Br J Ophthalmol. 2011 Dec;95(12):1682-5.
8) Demirci H, Shields CL, Bianciotto CG, Shields JA.Topical imiquimod for periocular lentigo maligna. Ophthalmology. 2010
Dec;117(12):2424-9.
POSTERS
T27
Face and Neck Rejuvenation Using a Novel Radiofrequency Device
(Thermi RF): Initial Treatment Guidelines to Maximize Outcomes and
Minimize Adverse Events
Payal Patel1, Carisa Petris1, Joseph Eviatar1,2. 1Ophthalmology, New York University Langone Medical Center, New York, NY,
United States, 2Ophthalmology, Chelsea Eye & Cosmetic Surgery Associates, New York, NY, United States
Introduction: There is a rising demand for facial and neck rejuvenation without the prolonged recovery time, expense and potential
adverse events of surgery. There is a paucity of truly effective non-surgical options. Thermi RF is a novel radiofrequency device
that allows for delivery of thermal energy subcutaneously into deep tissue planes for soft tissue and dermal tightening. The heat is
delivered precisely with a temperature sensitive probe to enable the surgeon to deliver varying temperatures to each tissue layer
while an external camera measures the surface skin temperature to protect from thermal injury. Skin and soft tissue tightening results
from collagen formation over the following months. Thermo-lipolysis can be achieved for contouring where desired. The purpose of
this study is to describe the technique and review the outcome and patient satisfaction of Thermi RF.
Methods: This is a chart review of the first consecutive 30 patients treated with Thermi RF for facial and neck rejuvenation in a
private practice setting. We excluded patients having liposuction or other surgical procedures along with Thermi RF. For each patient,
the following information is collected: 1) treatment area, 2) anesthesia 3) treatment times and thermal temperature settings in each
area 4) evaluation of patient satisfaction, procedure comfort and downtime as determined by questionnaire at 1 month, 5) adverse
events and 6) degree of improvement from baseline at 1, 3, 6 months and 1 year as graded by the patient and blinded a observer
using standardized photography.
Results: 30 patients will undergo ThermiRF to various treatment areas. These include lower eyelid fat pockets, malar festoons, facial
rhytids, periorbital region for brow elevation, and the lower face/jawline/neck. To date, patients have an average of 2-3 days of post
treatment bruising and mild swelling with no discomfort. Some improvement is noted by most patients at one month, but improves
significantly over the ensuing 6 months. Thus far, no significant adverse events have been recorded.
Conclusions: Unlike surface devices, Thermi RF is a minimally invasive device that expects to produce results more similar to those
of invasive surgery while minimizing downtime and adverse events. It allows for delivery of radiofrequency thermal energy using a
novel approach to both deep tissues and dermis for collagenosis and thermal lipolysis resulting in soft tissue and skin tightening and
facial contour improvement. Currently, there are no established guidelines for treatment that maximizes the potential of the device.
We hope this study will begin to identify how to optimize treatment to satisfy patient and physician expectations.
References: Sherber NS, Rad AN. Future directions in facial rejuvenation. Facial Plast Surg. 2014 Feb;30(1):72-5.
Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the upper eyelid and brow. Clin Plast Surg. 2013 Jan;40(1):55-76.
POSTERS
T28
Acquired Brown Syndrome After Filler Injection: A Case Report
Aline Pimentel de Miranda1, Daniel Rootman1, Nariman Nassiri1, Joseph Demer2, Robert Goldberg1. 1Ophthalmology, Division of Orbital
and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, UCLA, Los Angeles, CA, United States, 2Ophthalmology, Division of Pediatric
Ophthalmology and Strabismus, Jules Stein Eye Institute, UCLA, Los Angeles, CA, United States
Introduction: We present a case of acute acquired Brown syndrome following Hyaluronic acid (Juvéderm®) injection into
the superior sulcus.
Methods: A case report.
Results: A 54-year-old Caucasian female was referred to our clinic with the chief compliant of double vision in upgaze that occurred
immediately after injection of 1 ml hyaluronic acid in the upper and lower lids of both eyes six days earlier. She did not report pain
or change in acuity following the injections. Hyaluronidase injected in several sessions to remove the filler from the upper orbit on
the right side decreased the fullness related to the filler, but did not improve the motility. We noted a deep superior sulcus (Figure
1) on the right side with slight fullness of the medial fat; the left side was fuller, presumably due to the filler injection. Visual acuity,
color and pupillary examinations were normal. Eye movements on the right side showed striking limitation of upgaze, particularly
in adduction (Figure 1). In abduction, the eye moved slightly above the midline. Forced duction testing on the right side showed
complete positive forced ductions, with inability to manually move the eye above the midline with attempted upgaze. There was
no afferent defect or color desaturation. The double Maddox rod test demonstrated 10 degree of incyclotorsion. On the contrast
MR scan, the trochlea area on the right side enhanced (Figure 2), although the non-contrast scans did not show any anatomic
asymmetry. On high-resolution MR scan with Demer protocol,1 there was a T2 weighted images showed a bright signal (arrow) in
the tendon and trochlea of the superior oblique muscle on the right side, and the left trochlea (Figure 3). The patient underwent three
injections of Hyaluronidase (0.3 ml) and Triamcinolone acetonide (0.1 ml) into the superior oblique tendon and trochlea on the right
side with the aim to reduce any inflammation and dissolve the residual filler, in three different visits over two weeks. During this time,
patient’s symptoms and clinical examination improved gradually. At the last visit (4 months later), the patient reported significant
improvement in the double vision. Measurements clearly showed considerable improvement in the tight Brown’s restriction (Figure 4).
There was a mild remaining upgaze restriction (-1) in both eyes.
Conclusions: The clinical and MR data in this case suggested direct injection of hyaluronic acid gel into the trochlea, causing
acute Brown’s syndrome.
References: 1. Demer JL, Kono R, Wright W. Magnetic resonance imaging of human extraocular muscles in convergence.
J Neurophysiol. 2003 Apr;89(4):2072-85.
POSTERS
T28
Acquired Brown Syndrome After Filler Injection: A Case Report, continued
POSTERS
T29
Ocular Trauma from Dog Bites: Characterization, Associations and Treatment
Patterns at a Regional Level I Trauma Center
Mark Prendes, Arash Jian-Amadi, Shu-Hong Chang, Solomon Shaftel. Ophthalmology, University of Washington, Seattle, WA,
United States
Introduction: Canine bites frequently result in periocular injury1. The aim of this study was to further characterize the types of
injuries and dogs involved in the largest data set published to date.
Methods: All dog bites recorded in the University of Washington trauma registry from 2003-2013 were reviewed retrospectively.
Ppatient demographics, canine demographics, circumstances of injury, and structures involved were recorded. Cases that involved
periocular injury were further investigated to identify ocular tissues affected, vision, treatment patterns and outcomes.
Results: 341 patients were identified in the trauma registry of which 90 patients sustained ocular trauma (26.4%). The mean age of
patients with ocular injuries was significantly lower than those without (13.7 versus 29.2 years, respectively). Ocular injuries occurred
mostly in the pediatric population (68.9%). The most common breed of dog identified at the time of injury was the Pit bull (26%)
followed by mixed breeds (13.2%) and German Shepherds (11.4%). Assessment of patient-dog relationships revealed that pets were
most often responsible (27.0%), followed by a friend’s pet (17.6%) and neighbor’s pet (15.3%). Forty percent of patients sustained
canalicular laceration, with 3 being bilateral (3.3%). Physician preference largely determined the type of silicone stenting used for
canalicular repair, with excellent outcomes achieved in the large majority of patients. Two patients (2.2%) sustained ruptured globes,
and 5 patients (5.5%) suffered facial fractures. Infections were rare and only affected 2 patients (2.2%).
Conclusions: Our study is the largest to date to report on the incidence and characteristics of ocular injuries sustained from dog
bites. We report that ocular injuries from dog bites are disproportionately more common in the pediatric age group than in adults
and have a high incidence of canalicular laceration. Repair with either bicanalicular or monocanalicular stents have a high success
rate. Though rarely reported, this study documents globe injuries and orbital fractures in this population, highlighting the importance
of a thorough ophthalmic exam. Importantly, this study establishes for the first time that Pit bulls are the most frequent breed to be
associated with ocular injuries.
References: 1. Weiss HB, Friedman DI, Coben JH. Incidence of Dog Bite Injuries Treated in Emergency Departments. JAMA. 1998
Jan 7;279(1):51-3.
2. Savar A1, Kirszrot J, Rubin PA. Canalicular involvement in dog bite related eyelid lacerations. Ophthal Plast Reconstr Surg. 2008
Jul-Aug;24(4):296-8.
POSTERS
T30
Lower Lid Position Following Transconjunctival Incision
Kira Segal1, Payal Patel1, Ben Levine1, Richard Lisman2, Gary Lelli, Jr.1. 1Ophthalmology, Weill Cornell Medical Center, New York, NY,
United States, 2Ophthalmology, NYU Langone Medical Center, New York, NY, United States
Introduction: Transconjunctival approach offers access to the inferior orbital contents while limiting cutaneous scaring. Many
suggest that transconjunctival surgery does not alter lower eyelid position, but this has not yet been examined in the literature.
Our purpose is to study lower eyelid position following transconjunctival incision.
Methods: Retrospective review of patients who underwent lower eyelid blepharoplasty via transconjunctival approach.
Patients with front facing pre- and post-operative photos were included. Patients were excluded if they underwent any upper lid
procedure. Pre- and post-operative photos were measured for MRD1, MRD2, and a standardization measurement (P-L1) by two
oculoplastic surgeons. The change in the ratios of MRD1/P-L1 & MRD2/P-L1 pre- and post- operatively were compared to
determine final eyelid position.
Results: A total of 8 patients underwent 14 lower eyelid blepharoplasties via the transconjunctival approach. MRD2 decreased
post-operatively — as measured by delta MRD2/P-L1 (average delta MRD2/P-L1 = 0.005). When compared to the upper lid
(average delta MRD1/P-L1 = 0.006), the decrease in MRD2/P-L1 approached but did not reach significance (P = 0.06).
Subjectively, lower lid appeared elevated post-operatively in 64% and 50% of patients as per rater 1 and rater 2, respectively.
Conclusions: Transconjunctival incision is a safe and effective approach for accessing inferior structures in orbital surgery.
Though cicatricial ectropion and eyelid retraction are feared complications of transconjunctival approach, in a number of patients,
the lower lid is position is elevated from baseline post-operatively. In patients with baseline lower lid retraction or inferior scleral
show, transconjunctival incision may provide further cosmetic advantage.
References: Appling WD, Patrinely JR, Salzer TA. Transconjunctival approach vs subciliary skin-muscle falp approach for orbital
fracture repair. Archives of Otolaryngology-Head & Neck surgery. 1993;119:1000-7.
Baumann A, Ewers R. Use of the preseptal transconjunctival approach in orbit reconstruction surgery. Journal of Oral and Maxillofacial
Surgery. 2001;59:287-91.
Goldberg RA, Lessner AM, Shorr N, Baylis HI. The Transconjunctival Approach to the Orbital floor and Orbital Fat: A prospective Study.
Ophthal Plast Reconst Surg 1990;6:214-6.
Kashkouli MB, Pakdel F, Kiavash V, et al. Transconjunctival Lower Blepharoplasty: A 2-Sided Assessment of Results and Subjects’
satisfaction. Ophthalmic Plastic and Reconstructive Surgery. 2013;29:249-55.
Raschke GR, Rieger UM, rolf-Dieter Bader. Transconjunctival versus subciliary approach for orbital fracture repair-an anthropometric
evaluation of 221 cases. Clinical oral Investigations. 2013;17:933-42
Westfall CT, Shore JW, Nunery WR, et al. Operative complications of the transconjunctival inferior fornix approach. Ophthalmology.
1991;10:1525-8.
POSTERS
T31
Final Diagnosis in Headache Patients Following Temporal Artery Biopsy
Marie Somogyi, Sarah Hale, David Yoo, Yasmin Shayesteh. Ophthalmology, Loyola University Medical Center, Maywood, IL,
United States
Introduction: Giant cell arteritis (GCA) is a diagnosis made based on a combination of signs, symptoms and laboratory evidence
(1). Temporal artery biopsy is the gold standard for the diagnosis of GCA and a referral for biopsy is commonly encountered entity
in oculoplastic surgery practice (2). Our review investigates the final diagnosis and clinical course of headache patients undergoing
temporal artery biopsy with the suspicion of giant cell arteritis (GCA). To our knowledge, this series of 143 patients is the largest study
to date evaluating the final diagnosis in temporal artery biopsy patients from a single institution.
Methods: Retrospective chart review of 143 patients who underwent a temporal artery biopsy from January 2006 to April 2014 by
vascular surgery, plastic surgery and oculoplastic surgery at our institution. These patients were identified using the CPT code 37609.
Results: Of 143 patients, 15 had positive biopsies (10.5%) and 128 had negative biopsies. Among the patients with negative
biopsies, 41 patients (28.7%) ultimately were given the diagnosis of a benign headache. Biopsy-negative GCA was diagnosed
when the American College of Rheumatology classification (7) criteria were met, symptoms improved within 3 days of corticosteroid
therapy and no other diagnosis relevant to the patient’s presenting symptoms was diagnosed. 30 patients (20.9%) were ultimately
diagnosed with biopsy-negative GCA. Of the remaining negative biopsies, 7 (4.9%) were found to have non-arteritic anterior
ischemic optic neuropathy, 3 (2.1%) had isolated polymyalgia rheumatic, 3 (2.1%) with systemic vasculitis, 3 (2.1%) with acute
angle closure, 3 (2.1%) with hypertensive urgency, 2 (1.4%) with posterior ischemic optic neuropathy, and 2 (1.4%) with
granulomatosis with polyangiitis.
Conclusions: Although only 15 patients (10.5%) had positive temporal artery biopsies, a total of 45 patients (31.5%) were ultimately
treated for giant cell arteritis. Despite that the majority of patients (41 patients or 28.7%) undergoing temporal artery biopsy were
diagnosed with benign headache, it is important to consider other vision and life threatening entities when presented with a patient
with suspected GCA.
References: Villa-Forte A. “Giant cell arteritis: Suspect it, treat it promptly.” Cleve Clin J Med. 2011 Apr;78(4):265-70.
Jennette JC, Falk RJ. The role of pathology in the diagnosis of systemic vasculitis.Clin Exp Rheumatol 2007; 25 (Suppl. 44):S52-6.
Hedges TR, Gieger GL, Albert DM: The clinical value of negative temporal artery biopsy specimens. Arch Ophthalmol 1983;
101: 1251-4.
Roth AM, Milsow L, Keltner JL: The ultimate diagnoses of patients undergoing temporal artery biopsies. Arch Ophthalmol 1984;
102: 901-3.
Chmelewski WL, McKnight KM, Agudelo CA, Wise CM: Presenting features and outcome in patients undergoing temporal artery
biopsy. Arch Intern Med 1992; 152: 1690-5.
Breuer GS, Nesher R, Nesher G. Negative temporal artery biopsies: eventual diagnoses and features of patients with biopsy-negative
giant cell arteritis compared to patients without arteritis.Clin Exp Rheumatol. 2008 Nov-Dec;26(6):1103-6.
Hunder GG, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum
1990;33:1122-8
POSTERS
T32
Pseudomonas Aeruginosa Sinusitis Causing Orbital Apex Syndrome:
A Case Series
Marie Somogyi, Yasmin Shayesteh. Ophthalmology, Loyola University Medical Center, Maywood, IL, United States
Introduction: Orbital apex syndrome is a rare complication of sinusitis seen most often in diabetics and immunocompromised
patients. It is known to have a poor prognosis and typically described in conjunction with a paranasal sinus mycosis (1-4). There are
only 4 case reports (5-8) of an orbital apex syndrome due to Pseudomonas aeruginosa and only one in which Pseudomonas was the
sole pathogen (5). We encountered two patients with an orbital apex syndrome secondary to infection with Pseudomonas aeruginosa
as the sole pathogen.
Methods: Two patients with orbital apex syndrome secondary to sinusitis were identified based on a constellation of clinical
findings consistent with the involvement of the optic nerve and structures found in the apex of the orbit. Following the results of an
intraoperative biopsy, bacterial cultures and pathologic examination, these patients were diagnosed with Pseudomonas aeruginosa
as the sole pathogen.
Results: Our first patient was immunocompromised which is consistent with patient characteristics from previous case reports.
In contrast, our second patient is the first known case to be presented who was otherwise immunocompetent and presented with
an orbital apex syndrome following initial endoscopic sinus surgery with ethmoidectomy and sphenoidectomy. In both patients,
Pseudomonas aeruginosa was confirmed to be the sole infecting pathogen by intraoperative biopsy and cultures.
Conclusions: In patients presenting with an orbital apex syndrome secondary to sinusitis, it is important to expand our differential
beyond mycosis in the immunocompromised population to include bacterial infection, namely, Pseudomonas aeruginosa as a
sole pathogen. Furthermore, our second case illustrates that infection with Pseudomonas aeruginosa alone can be seen in the
immunocompetent population presenting with an orbital apex syndrome.
References: Hedges TR, Leung LS. Parasellar and orbital apex syndrome caused by aspergillosis. Neurology 1976; 26:117-20.
Luna JD, Ponssa XS, Rodriguez SD, et al. Intraconal amphotericin B for the treatment of rhino-orbital mucormycosis. Ophthalmic
Surg Lasers 1996; 27:706-8.
Pillsbury HC, Fischer ND. Rhinocerebral mucormycosis. Arch Otolaryngol 1977;103: 600-4.
Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature. Thurtell MJ, Chiu AL,
Goold LA, et al. Clin Experiment Ophthalmol. 2013 Aug;41(6):567-76. doi: 10.1111/ceo.12055. Epub 2013 Jan 24.
Kusunoki T, Kase K,IkedaK. A case of orbital apex syndrome due to Pseudomonas aeruginosa infection. Clinics And Practice,
2011;1(4), e127.
Scully RE, Mark EJ, McNeely WF, et al. Case records of the Massachusetts general hospital. New Eng J Med 1993;328:266- 75.
Colson AE, Daily JP. Orbital apex syndrome and cavernous sinus thrombosis due to infection with staphylococcus aureus and
Pseudomonas aeruginosa. Clin Infect Dis 1999;29:701-2.
Chua JLL, Cullen JF. Fungal Pan-sinusitis with severe visual loss in uncontrolled diabetes. Ann Acad Singapore 2008;37:964- 7.
POSTERS
T33
Use of Goniometer in Orbital Reconstruction
Gangadhara Sundar1, Thiam Chye Lim2, Raghuraj Hegde1, Michael Grant3. 1Ophthalmology, National University Hospital,
Singapore, Singapore, 2Plastic and Aesthetic Surgery, National University Hospital, Singapore, Singapore, 3Ophthalmology, Johns
Hopkins School of Medicine, Baltimore, MD, United States
Introduction: Reconstruction of the inferomedial orbital strut is a major challengeof orbital reconstruction as it is acurately
performed with intraoperative judgement, image guided navigational surgery with intraoperative verification, or postoperative CT
scan verification. A Goniometer is a device used to measure angles of rotation and adequacy of reduction of orthopedic (hand and
spinal) fractures. We herewith describe a technique of preoperative determination of the Angle of the Orbital Strut (AOS) based on the
contralateral orbit, prebending a ‘prefabricated anatomical orbital plate’ and intraoperative placement and fixation.
Methods: Prospective study of 25 orbits of 25 patients who sustained a complex blow out fracture (floor and medial wall) or
extensive zygomatico-maxillary complex (ZMC) fracture with medial wall involvement. Operative team consisted of either an Orbital
team alone or with a Facial Plastic & Reconstructive Surgeon. All patients underwent surgery under General Anesthesia through a
swinging eyelid approach’ with fixation of the ‘ prefabricated anatomical (Synthes) implant to the inferior orbital rim. When necessary
a retrocaruncular incision was utilized to access the medial wall. Preoperative determination of the angle of the orbital strut (AOS)
at the midlevel of the coronal section of the orbit was performed on the contralateral side. A Goniometer was used to prebend the
prefabricated anatomical Titanium plate (Small (purple) and large (gold) plates. 12 of 25 patients had intraoperative verification of
the superior, posterior extent of the orbital implants using Navigational Image guided technique (Brain Lab or Fusion system).
2 patients had a 3-D model fabricated based on the mirrored image of the unaffected side to be used as a template. All patients
had postoperative CT scan image to confirm accuracy of orbital content reduction and position of the orbital implant including the
angle of the orbital plate.
Results: 23 of 25 orbits had accurate correction of the inferomedial orbital strut with adequate coverage of both walls of the orbit.
2 of 25 patients had a suboptimal correction owing to varying contours of the extent of the floor and medial wall of the orbit. All
patients had good postoperative recovery with no diplopia in primary and within 30 degrees of primary gaze of fixation. None of the
patients required additional orbital plate repositioning or surgical intervention for diplopia or eyelid malposition. There were no cases
of visual loss
Figure 1: Goniometer being used to fashion a gold titanium implant
Figure 2: Pre-operative assesment of the angle of the orbital strut
Conclusions: Prebending a prefabricated titanium mesh, based on angles measured on preoperative CT scans of the unaffected
orbit with the guidance of a Goniometer, helps both an accurate and fast reconstruction of the inferiomedial angle with good
outcomes and minimizing complications.
References: Kim JW, Goldberg RA, Shorr N.The inferomedial orbital strut: an anatomic and radiographic study.Ophthal Plast
Reconstr Surg. 2002 Sep;18(5):355-64.
POSTERS
T34
Evaluation of Non-Ablative Laser for Treatment of Direct Brow Lift Scars
Phillip Tenzel, Ben Erickson, Wendy Lee, Sara Wester. Ophthalmology, Bascom Palmer Eye Institute, Miami, FL, United States
Introduction: The purpose of this study is to determine the efficacy of a non-ablative microsecond 1064nm Nd:YAG laser (Laser
Genesis, Cutera, Brisbane, CA) in the treatment of surgical scars after direct brow-lift. The presence of prominent, unsightly scars
currently limits the acceptance of this technique, which is otherwise ideal in many patients who are poor candidates for coronal,
pretricial or endoscopic brow procedures.
Methods: After baseline characteristics were documented, patients who underwent direct brow lifts were randomized to unilateral
laser treatment at 2-4 week intervals for a total of 6 treatments. The opposite scar was not treated and was used as a control.
Standardized photographs were taken at each visit, en face and 45 degree view. Before each treatment and one- and three- months
following the final treatment, scars were assessed for overall cosmesis by the subject using a 1-10 scale. Subjects also graded each
treatment with regard to discomfort, swelling, redness, hair loss, and any other symptoms to monitor for side effects.
The initial parameters were pulse duration of 300 microseconds, energy density of 14J/cm2, a spot size of 5mm, pulse rate of
7-10Hz, and 500 pulses, taking breaks as needed for patient comfort. Sunscreen with SPF 30 or higher was applied in office after
treatment, and subjects were instructed to use sunscreen with SPF of 30 or greater every day for the duration of the study.
Results: Follow-up data is being collected and analyzed at the time of submission.
Data presented previously showed statistically significant improvement in the treated brow scar before the 6th treatment as compared
to the control scar (p<0.05) and to the treatment scar before the first treatment (p<0.10) by paired t-tests. Early data also showed
5 patients reporting improvement, 1 remaining the same, and 1 worsening. Improvement did not appear to lessen with increasing
time between surgery and treatment.
Conclusions: To be presented.
References: 1. Alexiades-Armenakas MR DJ, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional,
and ablative laser resurfacing. J Am Acad Dermatol 2008; 58: 719-37.
2. Liu A, Moy RL, Ozog DM. Current methods employed in the prevention and minimization of surgical scars. Dermatol Surg 2011;
37: 1740-6.
3. Schmults CD, Phelps R, Goldberg DJ. Nonablative facial remodeling: erythema reduction and histologic evidence of new collagen
formation using a 300-microsecond 1064-nm Nd:YAG laser. Arch Dermatol 2004; 140: 1373-6.
4. Trelles MA, Alvarez X, Martin-Vasquez MJ, Trelles O, Velez M, Levy JL, Allones I. Assessment of the efficacy of non-ablative
long-pulsed 1064nm Nd:YAG laser treatment of wrinkles compared at 2, 4, and 6 months.
5. Verebelyi D. Case Study: Comprehensive Treatment for Severe Rosacea using Intense Pulse Light and a Novel Non-Ablative
1064Nd:YAG.
6. Booth AJ, Murray A, Tyers AG. The direct brow lift: efficacy, complications, and patient satisfaction. Br J Ophthalmol 2004;
88: 688-91.
POSTERS
T35
Unique Presentation of Periorbital Dermatomyositis
Swapna Vemuri1, Kenneth Feldman2. 1Department of Ophthalmology, Gavin Herbert Eye Institute, University of California - Irvine, Irvine,
CA, United States, 2Department of Ophthalmology, Kaiser Permanente South Bay, Harbor City, CA, United States
Introduction: We describe the presentation and subsequent management of a patient with dermatomyositis who presented
with diffuse, bilateral, firm upper eyelid nodules resulting in ptosis.
Methods: Case report.
Results: A 61-year-old African American woman with dermatomyositis presented with a several year history of progressively
increasing bilateral upper eyelid heaviness and discomfort as well as ptosis. On examination, she had diffuse, firm subcutaneous
nodules of both upper eyelids measuring 2cm x 1.5cm on the right and 3cm x 1.8cm on the left (Figure 1A). She had similar firm,
pre-auricular and elbow nodules (Figure 1B). Computed tomography (CT) showed dense lobulated calcified lesions of bilateral
superior orbits (Figure 1C). Bilateral anterior orbitotomy was performed to debulk the masses in order to improve the visually
significant ptosis and eyelid discomfort. Intra-operative findings included pseudoencapsulated, calcified, subcutaneous masses that
were also adherent to the periosteum of the superior orbital rim (Figures 2A and 2B) but were able to be resected (Figures 2C and
2D). Pathology confirmed calcified lesions. 4 months post-operatively, the patient describes an improvement in visual impairment
and decreased periorbital discomfort (Figure 3).
Conclusions: Calcinosis has been described to occur in a variety of settings, including in association with autoimmune connective
tissue diseases.1-3 With regards to calcified lesions in the periorbital region, small, subepidermal calcified nodules (SCN) of the eyelid,
most commonly in children,4-7 and hypercalcemic states with lid margin or ocular surface calcium deposits8 have been previously
described; however, extensive calcinosis of the eyelid, including in a patient with dermatomyositis, has not been previously reported.
Management of calcification found in other parts of the body may include the use of systemic medications such as colchicine or
bisphosphanates, laser therapy, intralesional steroid injections, or surgical excision.1,2,9 In our patient, surgical excision improved
ptosis and eyelid discomfort.
References: 1. Boulman N, Slobodin G, Rozenbaum M, and
Rosner I. Calcinosis in rheumatic disease. Seminars in Arthritis
and Rheumatism. 2005;34:805-812.
2. Gutierrez A and Wetter D. Calcinosis cutis in autoimmune
connective tissue diseases. Dermatologic Therapy. 2012;
25:195-206.
3. Ladizinski B, Khan A, Sankey C. Calcinosis in adult-onset
dermatomyositis: Metastatic or dystrophic? J Gen Intern Med 2013.
4. Doxanas MT, Green WT, Arentsen JJ, Elsas FJ. Lid lesions of
childhood: a histopathologic survey at the Wilmer Institute
(1923-1974). J Pediatr Ophthalmol 1976;13:7-39.
5. Ferry AP. Subepidermal calcified nodules of the eyelid.
Am J Ophthalmol 1990;109:85-8.
6. Nico MM, Bergonse FN. Subepidermal calcified nodule:
report of two cases and review of the literature.
Pediatr Dermatol 2001;18:227-9.
7. Nguyen J, Jakobiec F, Hanna E, Fay A. Subepidermal calcified nodule of the eyelid. Ophthal Plast Reconstr Surg 2008;24:494-95.
8. Lee DK, Eiferman RA. Ocular calcifications in primary hyperparathyroidism. Arch Ophthalmol 2006;124:136-7.
9. Reiter N, El-Shabrawi L, Leinweber B, et al. Calcinosis cutis: Part II. Treatment options. J Am Acad Dermatol 2011.65:15-22.
POSTERS
T36
The Role of the Cavitron Ultrasonic Surgical Aspirator in the Resection Of
Combined Intracranial And Orbital Neoplasms
Edward Wladis, Tyler Kenning. Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Ophthalmic Plastic Surgery,
Albany, NY, United States
Introduction: Surgical management of combined intracranial and orbital neoplasms provides a unique challenge, and reported
complications have included infection, hemorrhage, incomplete resection, and persistent diplopia and vision loss1,2. The cavitron
ultrasonic surgical aspirator (CUSA) provides constant irrigation, dissection, and aspiration and oscillates at a frequency which is
selective for tissue with high water and low collagen content, and thus resects tumors with minimal trauma to the surrounding soft
tissue and vasculature. While this instrument has been employed in neurosurgical resections for decades3, its use has not been
extensively described in the orbital surgery literature. This report was designed to provide the largest depiction of the use of the
CUSA in the resection of orbital tumors.
Methods: Retrospective review of resections of combined intracranial and orbital neoplasms. Cases in which the CUSA was utilized
were compared to previous resections performed by the same surgical team at the same institution, and statistical analyses were
performed to compare operative time and estimated blood loss. Analyses of post-operative results and complications were assessed.
Results: Six patients (4 females, two males, mean age = 30.2 years) underwent surgical resection of combined intracranial
and orbital tumors with the CUSA. As compared to historical controls, the operating time was significantly shorter (p <0.05) and
the estimated blood loss was significantly reduced (p <0.05) with the use of the CUSA. Postoperatively, all patients experienced
significant reduction in proptosis, diplopia resolved in all patients that presented with this chief complaint, and all patients that
presented with optic neuropathy developed improvement in their vision and resolution of optic nerve edema.
Conclusions: The CUSA dramatically reduced operative time, and, given its
ability to simultaneously irrigate and resect orbital neoplasms, afforded the
opportunity to retract soft tissue with a “free hand” and markedly enhanced
tumor resection. Furthermore, given the relative sparing of the tumor vasculature
associated with this device, the CUSA significantly estimated blood loss. The
CUSA utilizes technology and a handpiece that are similar to phacoemulsification
equipment, meaning that orbital surgeons can easily adopt this technique in the
management of this complex problem.
References: 1. Margalit N, Ezer H, Fliss DM, et al. J Neurosurg, 23: e11, 2007.
2. Kang JK, Lee IW, Jeun SS, et al. Childs Nerv Syst, 13: 536-41, 1997.
3. Jallo GI. Neurosurg, 47: 695-7, 2001.
POSTERS
T37
Suggestion of Optimal Response Criteria in Patients with Ocular Adnexal
Mucosa Associated Lymphoid Tissue Lymphoma
Suk Woo Yang1, Won Mo Lee2, Su kyung Jung1. 1Ophthalmology, St. Mary’s hospital, Seoul, South Korea, 2Ophthalmology,
St. Mary’s eye clinic, Daejon, South Korea
Introduction: Ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma (OAML) has been recognized as most common
primary orbital malignancy. However, little was known about the response criteria for OAML.
Methods: A retrospective chart review of 34 eyes from 30 patients diagnosed with nonconjunctival OAML was conducted, focusing
on the change in tumor size based on linear bi-dimensional, and three-dimensional methods in magnetic resonance imaging (MRI)
of the orbit. The maximum tumor response period of each case was investigated, and the expected optimal response period was
calculated using regression analysis.
Results: In 30 evaluable patients, the median time taken for the maximum tumor response was 6 months (range, 3-18). More than
75% of patients attained maximal tumor response in 6 months after initial therapy for follow up period, the median value of which
was 30 months (range, 15-77). Based on the regression analysis, it took 4.7 months for the maximum diameter (2r) of tumor to
decrease by fifty percent of initial lesion size.
Conclusions: We cautiously suggest that optimal response could be defined as fifty percent reduction of the maximum diameter in
6 months since the treatment was initiated, and that only observation without additional therapy is enough for nonconjunctival OAML,
if optimal response is achieved.
References: Cheson BD, Pfistner B, Juweid ME, et al. Revised response criteria for malignant lymphoma. J Clin Oncol 2007;
25:579-586.
James K, Eisenhauer E, Christian M, et al. Measuring response in solid tumors: unidimensional versus bidimensional measurement.
J Natl Cancer Inst 1999;91:523-528.
POSTERS
T38
Estrogen Increases Aquaporin-1 Mediated Membrane Permeability:
A New Pathophysiologic Mechanism for Idiopathic Intracranial Hypertension
Marc Yonkers MD/PhD, Sarah Farukhi MD, Jim Hall PhD, Robert Crow MD, Jeremiah Tao MD. Department of Ophthalmology,
University of California Irvine Gavin Herbert Eye Institute, Irvine, CA, United States
Introduction: We hypothesize that estrogen regulates aquaporin-1 (AQP1) function to increase membrane permeability as a
proposed pathophysiologic mechanism for idiopathic intracranial hypertension (IIH).
Methods: IIH primarily affects obese females of child bearing age, a population exposed to high concentrations of endogenous
estrogen. To assess the contribution of estrogen to increased cerebrospinal fluid (CSF) pressure, we examined the effect of estrogen
on AQP1, a water channel expressed in the choroid plexus1. To study the interaction of estrogen and AQP1, we injected AQP1
cRNA into xenopus oocytes and assessed aquaporin protein function via membrane permeability. Oocytes were exposed to control
solution or estrogen (10 µM) for an incubation period of two days, and then placed in a hypotonic solution to induce rapid swelling.
The increase in cross sectional area of the oocyte was measured over a period of two minutes to determine membrane permeability.
Permeability was compared between oocytes injected with AQP1 cRNA versus vehicle solution and both groups were exposed to
either estrogen or control solution during the incubation period.
Results: Oocytes injected with AQP1 and incubated in 10 µM estradiol showed a significantly higher permeability rate (95.42 ±
8.03 µm/s; n=5) compared to oocytes injected with AQP1 and incubated in control solution (68.89 ± 12.70 µm/s; n=4) (p <0.05).
Oocytes injected with vehicle alone showed no difference in permeability rate when incubated in control solution (7.35 ± 2.10 µm/s;
n=3) versus incubation in 10 µM estradiol (8.12 ± 2.03 µm/s; n=3).
Conclusions: Estrogen increases AQP1 mediated membrane permeability in xenopus oocytes. Given the widespread expression
of AQP1 in the choroid plexus, an estrogen induced increase in AQP1 function may contribute to increased CSF pressure and
clinical IIH. These data identify the estrogen-AQP1 interaction as a potential molecular target for improved drug development in IIH.
References: 1. Owler BK, Pitham, T, and Dongwei W. Aquaporins: relevance of cerebrospinal fluid physiology and therapeutic
potential in hydrocephalus. Cerebrospinal Fluid Res 2010 7: 1-12
POSTERS
F1
Long Term Follow up for Conjunctival Benign Reactive Lymphoid Hyperplasia
in Children
Adel Alsuhaibani1, Adel Al Akeely1, Hisham Alkhalidi2, Deepak Edward3, Hind Al-Katan3. 1Ophthalmology department, King Saud
University, Riyadh, Saudi Arabia, 2Pathology department, King Saud University, Riyadh, Saudi Arabia, 3King Khaled Eye Specialist
Hospital, Riyadh, Saudi Arabia
Introduction: To present the long term follow up for children with conjunctival Benign Reactive Lymphoid Hyperplasia (BRLH).
Methods: A retrospective case series including all children diagnosed with conjunctival Benign Reactive Lymphoid Hyperplasia
who presented to King Khaled Eye Specialist Hospital and King Abdulaziz University Hospital in Riyadh, Saudi Arabia from January
2000 to May 2014.
Results: Twenty three children were treated during the 14-year period of the study. The mean patient age at diagnosis was
11.6 years (median, 11 years; range, 7-17 years). 22 patients were males (96%). On average they presented to the hospital
3.75 months after they first noticed the lesion (range 1 week- 2 years with a median of 3 months). Regarding systemic associations,
3 had bronchial asthma, one patient was a known Down’s syndrome, one had generalized skeletal malformation and one had
gastritis. Surgical history revealed tonsillectomy/adenoidectomy in 5 patients (22%).
The bulbar conjunctival was involved in all the affected eyes. Nasal bulbar conjunctiva was involved in 22 (96%) of patients and
temporal bulbar conjuctiva in one (4%) patient. Carunclar involvement was present in 7 (30%) patients.
All patients eventually underwent complete excisional biopsy. Six (27%) patients were treated medically with no noticeable
improvement before excision. Follow up ranged from 13 months to 165 months (average 40 months) and recurrence occurred only in
one patient 1 year post-operatively. There was no evidence of malignant transformation.
Conclusions: BRLH of the conjunctiva in children differs from adults in its prevalence, gender predilection, site of involvement,
association with lymphoma, the need for extensive systemic investigation and options of treatment. This does not underestimate the
importance careful examination by pediatrician and thorough pathological evaluation of the specimen for any evidence of malignancy.
POSTERS
F2
Review of Acellular Human Dermis (AlloDerm) Regenerative Tissue Matrix in
Multiple Types of Oculofacial Plastic & Reconstructive Surgery
Brock Alonzo2, Youn-Shen Bee1, John Ng2. 1Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, 2Casey Eye Institute,
Oregon Health and Science University, Portland, OR, United States
Introduction: This study seeks to evaluate the efficacy and factors influencing surgical outcomes using acellular human dermis
(Alloderm) in multiple types of oculofacial plastic and reconstructive surgery.
Methods: Retrospective review of 84 patients who underwent surgical procedures using acellular human dermis. Preoperative
demographic data, comorbidities, tobacco use, clinical etiology, surgical methods, Alloderm thickness, and outcome (cosmetic and
functional) were evaluated.
Results: 84 patients were included in this study, accounting for a total of 98 procedures. Mean age was 52.5 years (3-93 years).
Etiology indications for surgery included malignancy (26), trauma (19), congenital lesions (15), and senile change (11). Surgical
procedures included lower lid posterior lamella elongation, socket and fornix reconstruction, scar repair, patch grafts, and filler.
Mean duration of follow up was 530 days. Overall, 92.8% of patients had successful outcomes. Factors associated with significantly
worse outcomes included smoking, congenital anomaly etiologies, and previous graft/flaps in the same area (p = 0.03, p = 0.029,
p = 0.007, respectively).
Conclusions: This study suggests that Alloderm acellular human dermis can be used safely and effectively in multiple types of
oculofacial procedures. Smoking, congenital anomaly etiologies, and previous graft/flap were associated with poor cosmetic and
functional outcomes.
References: 1. Chang HS, Lee D, Taban M, Douglas RS, Goldberg RA. “En-glove” lysis of lower eyelid retractors with AlloDerm and
dermis-fat grafts in lower eyelid retraction surgery. Ophthalmic plastic and reconstructive surgery 2011;27:137-41.
2. Dailey RA, Chavez MR. Lateral canthoplasty with acellular cadaveric dermal matrix graft (AlloDerm) reinforcement. Ophthalmic
plastic and reconstructive surgery 2012;28:e29-31.
3. Hayek B, Hatef E, Nguyen M, Ho V, Hsu A, Esmaeli B. Acellular dermal graft (AlloDerm) for upper eyelid reconstruction after cancer
removal. Ophthalmic plastic and reconstructive surgery 2009;25:426-9.
4. Lee EW, Berbos Z, Zaldivar RA, Lee MS, Harrison AR. Use of DermaMatrix graft in oculoplastic surgery. Ophthalmic plastic and
reconstructive surgery 2010;26:153-4.
5. Levin F, Turbin RE, Langer PD. Acellular human dermal matrix as a skin substitute for reconstruction of large periocular cutaneous
defects. Ophthalmic plastic and reconstructive surgery 2011;27:44-7.
6. Rinker B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Annals of plastic surgery 2013;
70:599-605.
7. Rubin PA, Fay AM, Remulla HD, Maus M. Ophthalmic plastic applications of acellular dermal allografts. Ophthalmology
1999;106:2091-7.
8. Shorr N, Perry JD, Goldberg RA, Hoenig J, Shorr J. The safety and applications of acellular human dermal allograft in ophthalmic
plastic and reconstructive surgery: a preliminary report. Ophthalmic plastic and reconstructive surgery 2000;16:223-30.
9. Sullivan SA, Dailey RA. Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery.
Ophthalmic plastic and reconstructive surgery 2003;19:14-24.
10. Taban M, Douglas R, Li T, Goldberg RA, Shorr N. Efficacy of “thick” acellular human dermis (AlloDerm) for lower eyelid
reconstruction: comparison with hard palate and thin AlloDerm grafts. Archives of facial plastic surgery 2005;7:38-44.
POSTERS
F3
Automated Ptosis Measurements from Facial Photographs
Zachary Bodnar, John Holds. Ophthalmology, St. Louis University, St. Louis, MO, United States
Introduction: Ptosis is objectively evaluated by manual measurements of the MRD1 and MRD2, as well as visual fields. However,
these methods are limited by operator dependence and variability, as well as patient factors such movement and the cognitive ability
to participate in testing.
We have developed software that can analyze photographs of patients face and identify features including the corneal light reflex and
lid margins. Using this software we can automatically extract the MRD1 and the MRD2 from a single photograph of a patient’s face
(see Figure 1 for sample output).
Methods: We obtained both manual measurements of the MRD1 and MRD2 of both normal and abnormal subjects. Photographs
of the subjects’ faces taken at the time of manual measurements were analyzed using our software to extract automated
measurements of the MRD1 and MRD2. Patients with surgically or pathologically altered eyelid margins, heterotropia of 4 vertical
or 8 horizontal prism diopters in primary gaze, nystagmus or abnormal corneal light reflexes were excluded. We used Bland-Altman
analysis to evaluate the agreement between the two measurement methods.
Results: Bland-Altman analysis showed good agreement between the two measurement methods with mean error of -0.06 mm
(standard deviation 0.32) in automated MRD1 measurements as compared to manual measurements and a mean error of 0.22 mm
(standard deviation 0.70) in automated MRD2 measurements as compared to manual measurements.
Conclusions: Our algorithm can extract accurate measurements of the MRD1 and MRD2 from patient photographs. This could
provide a rapid, highly reproducible method for determining ptosis measurements that could supplement manual measurements and
provide additional documentation for insurers. It could also be a more accurate way to measure ptosis in children or other patients
where manual measurements are difficult to obtain.
References: Burmann, T. G., & Valiatti, F. B. (2008). Medida da distância
reflexo margem por meio de processamento computadorizado de imagens
em usuários de lentes de contato rígidas, 71(1), 34-37. [Portuguese]
Han, S. J., Guo, Y., Granger-Donetti, B., Vicci, V. R., & Alvarez, T. L. (2010).
Quantification of heterophoria and phoria adaptation using an automated
objective system compared to clinical methods. Ophthalmic & Physiological
Optics : The Journal of the British College of Ophthalmic Opticians
(Optometrists), 30(1), 95-107. doi:10.1111/j.1475-1313.2009.00681.x
Hasebe, S., Ohtsuki, H., Tadokoro, Y., Okano, M., & Furuse, T. (1995).
The reliability of a video-enhanced Hirschberg test under clinical conditions.
Investigative Ophthalmology & Visual Science, 36(13), 2678-85. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7499090
Miller, J. M., Mellinger, M., Greivenkemp, J., & Simons, K. (1993). Videographic Hirschberg measurement of simulated strabismic
deviations. Investigative Ophthalmology & Visual Science, 34(11), 3220-9. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/8407230 Model, D., & Eizenman, M. (2011). An automated Hirschberg test for infants. IEEE Transactions on Bio-Medical
Engineering, 58(1), 103-9. doi:10.1109/TBME.2010.2085000 Schaeffel, F. (2002). Kappa and Hirschberg Ratio Measured with an,
79(5), 329-334. Yamanobe, S., Taira, S., Morizono, T., Yagi, T., & Kamio, T. (1990). Eye movement analysis system using computerized
image recognition. Archives of Otolaryngology--Head & Neck Surgery, 116(3), 338-41. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/2306353
POSTERS
F4
A Survey Of Current Blepharospam Treatment Patterns Among
Oculoplastic Surgeons
Talmage Broadbent, Ralph Wesley, Louise Mawn. Ophthalmology, Vanderbilt Eye Institute, Nashville, TN, United States
Introduction: Purpose: To determine the current practice pattern of ASOPRS members injecting onabotulinumtoxinA for
Blepharospasm.
Methods: An invitation to participate in a web-based, anonymous survey was sent to current members of American Society of
Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) via email. The survey consisted of 9 questions and used the Research
Electronic Data Capture (REDCap)1 online application. Vanderbilt Institutional Review board approval was obtained for this study.
Results: Forty-one percent of ASOPRS members invited responded to the survey. The mean initial dose of onabotulinumtoxinA used
was 22.5 units per side (standard deviation 9.6 units) and the most common number of injection sites was greater than 7 per side.
Only 12 of the 247 responding surgeons who treat BEB with onabotulinumtoxinA reported that their usual injection pattern consists
of 3 or fewer sites per side as the FDA recommends.
Conclusions: A survey of current trends in the management of blepharospam with onabotulinumtoxinA by ASOPRS members
revealed that there is wide variation in treatment dosing and injection patterns and that the majority of ASOPRS members do not
follow the FDA recommended dosing.
References: 1 Paul A. Harris, Robert Taylor, Robert Thielke, Jonathon Payne, Nathaniel Gonzalez, Jose G. Conde, Research electronic
data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics
support, J Biomed Inform. 2009 Apr;42(2):377-81.
POSTERS
F5
Sentinel Lymph Node Biopsy for Ocular Adnexal Melanomas
Mary Champion1, John Neis2, Yelizaveta Shnayder2, William R. Nunery3, Jason A. Sokol1. 1Oculofacial Plastic and Orbital Surgery,
University of Kansas, Prairie Village, KS, United States, 2Department of Otolaryngology, University of Kansas, Kansas City, KS,
United States, 3Department of Ophthalmology, University of Louisville, Louisville, KY, United States
Introduction: Sentinel lymph node biopsy (SNLB) in ocular adnexal melanomas can identify nodal micrometasasis, providing
important prognostic information and treatment guidance. We report five cases of ocular adnexal (conjunctiva or eyelid) melanomas
that underwent SNLB.
Methods: Medical charts of all patients with ocular adnexal melanoma who underwent SLNB at one institution between June 2011
and May 2014 were reviewed. The results of the SLNB and follow-up are the subject of this study.
Results: Five patients with ocular adnexal melanomas underwent excision and SNLB at our institution. Age ranged from 54 to 84
years. The mean follow-up time was 15 months. The tumor sites were: conjunctiva in 3 patients, medial canthus in one patient,
and medial canthus and conjunctiva in one patient. One out of the five patients had a positive SLNB. This patient had a conjunctival
melanoma Breslow thickness of 1.5 mm. SLNB revealed one intraparotid lymph node that was completely replaced by tumor. The
patient elected to have radiation and presented less than one year later with recurrence. She then underwent orbital exenteration
as she still had no evidence of distant metastasis. The patient was lost to follow-up and died less than 12 months later due to
complications from metastatic melanoma. The other four patients had negative SNLBs. A mean number of 3.2 lymph nodes was
biopsied. The Breslow thickness was indeterminable for two specimens; the mean thickness for the remaining three specimens was
2.7 mm. One patient with bulbar conjunctiva involvement underwent excision with cryotherapy and amniotic membrane grafting
followed by topical interferon therapy; she had local recurrence at 21 months. The other three patients underwent wide local excision,
radiation and/or chemotherapy with no recurrence or metastasis to date. No patient experienced complications related to the SNLB.
Conclusions: SLNB is effective for identifying nodal micrometastasis in patients with ocular adnexal melanoma and provides
important prognostic information which can guide treatment. In patients with only regional disease, survival of greater than 15 years
has been reported following local treatment, supporting the role of SNLB in the management of these tumors. SLNB is currently
indicated for conjunctival melanomas of ≥2 mm in histologic thickness and/or histologic ulceration. For cutaneous eyelid melanomas,
indications are for tumors ≥1 mm thick, those with >1 mitotic figures per high-power field, and/or those with histologic ulceration.
We recommend consideration of SLNB for patients with intermediate-thickness or indeterminable thickness ocular adnexal melanoma
and those with ulceration.
References: Pfeiffer ML, Savar A, Esmaeli B. Sentinel lymph node biopsy for eyelid and conjunctival tumors: what have we learned in
the past decade? Ophthal Plast Reconstr Surg. 2013 Jan;29(1):57-62.
Lim LA, Madigan MC, Conway RM. Conjunctival melanoma: a review of conceptual and treatment advances. Clin Ophthalmol.
2013;6:521-31.
POSTERS
F6
Surgical Outcomes of Deep Superior Sulcus Augmentation Using Acellular
Human Dermal Matrix In Anophthalmic or Phthisis Socket
Won-Kyung Cho1,4, Ji-Sun Paik2,4, Won-Mo Lee3,, Suk-Woo Yang2,4. 1Ophthalmology and Visual Science, Daejeon St. Mary’s Hospital,
Daejeon, Korea, 2Ophthalmology and Visual Science, Seoul St. Mary’s Hospital, Seoul, Korea, 3Seung-Mo Eye Clinic, Daejeon,
Korea, 4College of Medicine, The Catholic University of Korea, Seoul, Korea
Introduction: To evaluate the surgical outcomes of deep superior sulcus (DSS) augmentation using acellular dermal matrix in
patients with anophthalmic or phthisis socket.
Methods: We retrospectively reviewed anophthalmic or phthisis patients who underwent surgery for DSS augmentation using
acellular dermal matrix. To evaluate surgical outcomes, we focused on three aspects: the possibility of wearing contact prosthesis,
the degree of correction of the DSS, and any surgical complications. The degree of correction of DSS was classified as excellent:
restoration of superior sulcus enough to remove sunken sulcus shadow; fair: gain of correction effect but sunken shadow remained;
or fail: no effect of correction at all.
Results: Ten eyes of 10 patients were included. There was a mean 21.33±37.11-month period from evisceration or enucleation to
the operation for DSS augmentation. All patients could wear contact prosthesis after the operation (100%). The degree of correction
was excellent in eight patients (80%) and fair in two. Three of ten (30%) showed complications: eyelid entropion, upper eyelid
multiple creases, and spontaneous wound dehiscence followed by inflammation after stitch removal.
Conclusions: The overall surgical outcomes were favourable, showing an excellent degree of correction of DSS and low surgical
complication rates. This procedure is effective for patients who have DSS in the absence or atrophy of the eyeball. Uneven skin
surface and a tingling sensation in the forehead area of the affected eye may be observed after surgery.
References: 1. Choi HY, Lee DE, Lee JW, Park HJ, Lee HE, Jung JH: In vitro study of antiadipogenic profile of latanoprost, travoprost,
bimatoprost, and tafluprost in human orbital preadipocytes. J Ocul Pharmacol Ther 2012,28:146-152.
2. Wise JB, Greco T: Injectable treatments for the aging face. Facial Plast Surg 2006,22:140-146.
3. Paik JS, Cho WK, Park GS, Yang SW: Eyelid-associated complications after autogenous fat injection for cosmetic forehead
augmentation. BMC Opthalmol 2013,10:32.
4. Sa HS, Woo KI, Suh YL, Kim YD: Periorbital lipogranuloma: a previous unknown complication of autologous fat injections for
facial augmentation. Br J Ophthalmol 2011,95:1259-1263.
5. Van Gemert JV, Leone CR Jr: Correction of a deep superior sulcus with dermis-fat implantation. Arch Ophthalmol 1986,
104:604-607.
6. Pushpoth S, Tambe K, Sandramouli S: The use of AlloDerm in the reconstruction of full-thickness eyelid defects. Orbit
2008,27:337-340.
7. Lee EW, Berbos Z, Zaldivar RA, Lee MS, Harrison AR: Use of DermaMatrix in oculoplastic surgery. Ophthal Plast Reconstr
Surg 2010,26:153-154.
POSTERS
F6
Surgical Outcomes of Deep Superior Sulcus Augmentation Using Acellular Human Dermal
Matrix In Anophthalmic or Phthisis Socket, continued
POSTERS
F7
Margin Reflex Distance: Differences Based on Camera and Flash Position
Catherine Choi1,2, Daniel Lefebvre1,2, Michael Yoon1,2. 1Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary,
Boston, MA, United States, 2Ophthalmology, Harvard Medical School, Boston, MA, United States
Introduction: The margin reflex distance is a clinical measurement for recording the eyelid position. In this measurement, the
observer and the light source are nearly coaxial. In photographs, however, there may be a difference in the apparent MRD due to
the distance between the flash and the camera aperture. We therefore compared the clinical MRD to the values obtained with a
smartphone, point-and-shoot camera, a dSLR with lens-mounted ring flash, and a dSLR with the built-in pop-up flash.
Methods: Normal subjects were recruited for the study. Clinical measurements of MRD1 and inter-palpebral fissure (IPF) were
obtained for both eyes using a standard millimeter scale ruler and a muscle light. Photographs were then taken at a distance of
1 meter with a 15 cm ruler placed on the forehead in plane with the corneal surface. Four cameras were used: a digital single
lens reflex (dSLR) with built-in flash (dSLR-flash) (Nikon D3100, Nikon Corp, Japan), a dSLR with lens-mounted ring flash (dSLRring) (Canon 60D with 100mm macro lens, Canon Corp, Japan), a point-and-shoot camera (Fuji X10, Fujifilm Corp, Japan), and a
smartphone (iPhone 5s, Apple, USA). Photographs were taken with the camera upright, rotated 90 degrees right and left, as well
as 180 degrees. The images were then analyzed using ImageJ software (http://rsbweb.nih.gov/ij) to measure MRD1, IPF, horizontal
white-to-white (WTW), and distance from nasal limbus to corneal reflex. Statistical analysis was performed using repeated measure
one-way ANOVA with Newman-Keuls post-test and paired Student’s t-test using GraphPad Prism 5 (GraphPad Software, Inc).
Results: Thirty-two eyes of sixteen subjects between the ages of 27 and 65 were included. There was a statistically significant
difference between clinical MRD1 and photographic MRD1 in upright position with the dSLR-flash (mean difference 0.703,
σ = 0.984, p = 0.0008). Similar comparison for ring flash, point-and-shoot, and iPhone did not reach statistical significance.
For dSLR-flash, photographic MRD1 in upright versus inverted position differed significantly (mean difference -0.562, σ =0.348,
p <0.0001). Photographic MRD1 between dSLR-flash and dSLR-ring showed significant difference in upright position
(mean difference -0.572, σ = 0.701, p = 0.0002). There were no statistically significant differences between clinical IPF and
photographic IPF (p = 0.313, p = 0.953, p =0.946, p= 0.998) and between WTW measurements (p = 0.618, p = 0.0578,
p = 0.219, p = 0.312) in any position in all 4 cameras.
Conclusions: When using photographs for measurement of MRD1, cameras with a near-coaxial light source and aperture have
values that are similar to clinical measurements. However, when the light source is relatively distant, as with dSLR-flash, there are
statistically significant differences. When measuring the IPF, where the position of the corneal light reflex is not a feature of the
measurement, no difference exists.
POSTERS
F8
Eyelid Sensation Distribution
Betsy Colón-Acevedo, Julie Woodward. Ophthalmology, Duke University Eye Center, Durham, NC, United States
Introduction: Most surgeons who perform Oculofacial surgery have noticed that patients complaints more of pain when the
eyelid margin is infiltrated with local anesthesia when compared to the eyelid’s anterior lamella. Though, this is common
observation there is few or no investigation addressing the sensitivity of the eyelids. The primary purpose of this study is to
document the normal distribution of the eyelid sensation, and to identify if there is any difference in sensation between the
eyelid’s anterior lamella and margin.
Methods: Using a Cochet-Bonnet aesthesiometer (C-BA), with a 0.12mm nylon filament with a length of 30mm, the touch the
sensitivity of midline eyelid margin and anterior lamella was determined for both upper and lower lids in 33 patients. A pain scale
was given to patient to classified the degree of sensation. Statistical analysis was done using Wilcoxon Signed-Rank Test.
Results: A significantly higher touch sensitivity was found at the margin compared to the anterior lamella for both upper and lower
eyelids with a median value of 1 (p <0.0001). Although there was no statistical difference between upper and lower lid sensation,
we observed during testing that lower lid margin was more sensitive when compared to the upper lid.
Conclusions: The eyelids are shaped to warrant protection of the ocular surface in a addition to the production of tear film which is
essential for a satisfactory refractive surface. In our study we found that for both upper and lower lid a significantly higher sensitivity
was found at the eyelid margin. There was a reduced sensitivity over the lid’s anterior lamella of the eyelid. The high sensitivity at the
eyelid margin may be important to provide a mechanism for the detection of superficial foreign bodies and therefore a protective role
of the cornea. As described by Halata & Munger (1984) the human eyelid has a complex pattern of sensory innervation and each
of its landmarks having variety of sensory nerve terminals. These findings may guide us to understand our initial observation and
improve or facilitate mode of local anesthesia infiltration for eyelid surgery.
References: 1. Black, E. MD, Gladstone, G. MD, and Nesi, F. MD Eyelid sensation after supratarsal lid crease incision.
Ophthalmic Plastic and Reconstructive surgery. 2002;18:45-49.
2. Komiyama,O., Kawara,M., and De Laat, A. Ethnic differences regarding tactile and pain thresholds in the trigeminal region.
The Journal of Pain. 2007;8:363-369.
3. Costas, P., MD., Heatley, G., MS, Seckel, B., MD. Normal sensation of the human face and neck. Plastic and Reconstructive
surgery 1994;93:1141-1145.
4. McGowan D., Lawrenson, J. and Ruskell, G. Touch sensitivity of the eyelid margin and the palpebral cojunctiva. Acta
Ophthalmologica. 1994;72:57-60.
POSTERS
F9
Inflammatory Myofibroblastic Tumor of the Orbit
Lorena Di Nisio1, Raisa Abraham1, Daniel Weil 1, Martín H. Devoto2. 1Ophthalmology, Hospital de Clínicas José de San Martín, Buenos
Aires, Argentina, 2Ophthalmology, Consultores Oftalmológicos, Buenos Aires, Argentina
Introduction: Inflammatory myofibroblastic tumor (IMT) is a neoplasm of intermediate biologic potential that frequently recurs
and rarely metastasizes.(1,3,4) These tumors were considered benign and likely non-neoplastic until the early 1990s when Meis and
Enzinger published a series of 38 cases.(2, 3, 5) In the 2002 World Health Organization classification of soft tissue tumors, IMT is
defined as “a tumor composed of differentiated myofibroblastic spindle cells usually accompanied by numerous plasma cells and/
or lymphocytes.”(4, 6) Approximately half of IMTs harbor a clonal cytogenetic aberration that activates the anaplastic lymphoma kinase
(ALK)-receptor tyrosine kinase gene. The concept of IMT as a neoplasm was solidified with this discovery.(1,6) Immunohistochemical
staining is useful to confirm the myofibroblastic tumor phenotype, since they are positive for vimentin and smooth muscle actin
markers.(1,4) IMT are most commonly found in children and young adults. Although it was originally described in lungs and may occur
in the abdomen, pelvis and retroperitoneum.(1,2,4,5,6) The treatment of choice for IMT is total surgical excision of the tumor. Complete
resection leads to cure and good prognosis.(1,4,5)
Methods: We describe a case of a patient with a tumor in the left orbit. After evaluation with CT and MRI, surgical excision of the
lesion and pathological studies were performed.
Results: 19 years-old woman presented with superior orbital pain, decrease of visual acuity and proptosis in her left eye.
Orbital imaging showed a well-defined intraconal mass. Excisional surgery was performed. Histopathologic examination revealed a
proliferation of spindle-shaped cells with an infiltrate of inflammatory cells, inmunohistochemestry was positive for smooth muscle
actin and vimentin. After 2 years of follow-up the patient remains disease free.
Conclusions: IMT is a neoplastic process that can arise in many sites within the head and neck, but location in the orbit is extremely
rare. Only 11 cases of IMTs involving the eye and orbit have been previously reported in the literature. Total surgical excision of the
tumor is curative in most cases.
References: 1. Coffin, CM, Hornick JL, Fletcher, CD. Inflammatory Myofibroblastic Tumor: Comparison of Clinicopathologic,
Histologic, and Immunohistochemical Features Including ALK Expression in Atypical and Aggressive Cases. Am J Surg Pathol
2007;31:509-20.
2. Gleason BC, Hornick JL. Inflammatory myofibroblastic tumours: where are we now? J Clin Pathol 2008;61: 428-437.
3. Tawfik HA, Raslan AO. Infantile Inflammatory Myofibroblastic Tumor of the Orbit With Apical Bone Involvement. Ophthalmic Plastic
and Reconstructive Surgery 2013;29:e44-46.
4. Sa HS, Ji JY, Suh YL, et al. Inflammatory myofibroblastic tumor of the orbit presenting as a subconjunctival mass. Ophthal Plast
Reconstr Surg 2005;21:211-5.
5. Cramer SK, Skalet A, Mansoor A, Wilson DJ, Ng JD. Inflammatory Myofibroblastic Tumor of the Orbit: A Case Report. Ophthal Plast
Reconstr Surg 2014;20:e1-2.
6. Jeon YK, Chang KH, Suh YL, Jung HW, Park SH. Inflammatory Myofibroblastic Tumor of the Central Nervous System:
Clinicopathologic Analysis of 10 Cases. J Neuropathol Exp Neurol 2005;64:254-59.
F9
Inflammatory Myofibroblastic Tumor of the Orbit, continued
POSTERS
POSTERS
F10
The Doughnut Revisited: A Novel Cerclage For Canalicular Repair
Benjamin Erickson, Sophie Liao, Wendy Lee. Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States
Introduction: Canalicular compromise occurs in 16 to 37% of routine eyelid lacerations. Stenting the cut canaliculus with a
silicone ‘doughnut’ is a popular and effective technique for repair, and can be done under local anesthesia. One of the most difficult
and unpredictable steps, however, is rotating the silicone tube over a previously threaded monofilament suture. It tends to kink
and accordion, even with minimal resistance from the pericanalicular soft tissues. We present a novel cerclage, made from readily
available materials, that permits efficient stenting of the canalicular system.
Methods: A 2.4 cm segment of silicone tubing is obtained from a Crawford stent (FCI Ophthalmics, Marshall Hills, MA) or similar
source. A sterile dropper containing cyanoacrylate tissue adhesive (Glustitch Inc., Delta, British Columbia) is used to fill the lumen
of the tube via capillary action. A 5-0 silk tie is then slowly passed through the lumen to ensure even adhesive coverage. This is set
aside and permitted to dry while exploration is initiated. The superior and inferior puncta are dilated in the standard fashion. A pigtail
probe is passed into the superior punctum, rotated beneath the anterior limb of the medial canthal tendon, and out through the cut
end of the inferior canaliculus. The pigtail eyelet is then used to retrieve and pass the suture at one end of the cerclage. This process
is repeated with the inferior punctum and proximal canaliculus. The two suture ends are then grasped and tied. As the first loop of the
knot is tightened, this advances the cerclage within the canalicular system and out through the puncta. After completion, the resulting
‘doughnut’ is rotated so that the suture ends enter the common canaliculus/lacrimal sac.
Results: The cerclage is easily made from available materials, and can be passed efficiently in cases where a ‘doughnut’ is difficult
to create using standard techniques.
Conclusions: One of the most challenging steps in the ‘doughnut’ technique is rotating the silicone tube itself over a previously
threaded monofilament suture. Even minimal resistance from soft tissues causes the tube to kink and accordion, and multiple
attempts are often required to successfully rotate the stent. Our novel cerclage can be constructed rapidly from common materials.
Because the suture within the lumen is glued in place, the tube does not kink with attempted passage. Additionally, insertion through
the cut portion of the canaliculus results in automatic passage with tying of the suture ends.
References: 1. Jordan DR, Ziai S, Gilberg SM, Mawn LA. Pathogenesis of canalicular lacerations. Ophthal Plast Reconstr Surg.
2008 Sep-Oct;24(5):394-8.
2. Jordan DR, Gilberg S, Mawn LA. The round-tipped, eyed pigtail probe for canalicular intubation: a review of 228 patients.
Ophthal Plast Reconstr Surg. 2008 May-Jun;24(3):176-80.
3. McLeish WM, Bowman B, Anderson RL. The pigtail probe protected by silicone intubation: a combined approach to canalicular
reconstruction. Ophthalmic Surg. 1992 Apr;23(4):281-3.
POSTERS
F11
Outcomes of Conjunctivodacryocystorhinostomy with Metaireau Tube
Korhan Fazil1, Pelin Kaynak1, Can Ozturker1, Gamze Ozturk Karabulut1, Altug Cetinkaya2, Ahmet Demirok1, Omer Faruk Yilmaz1. 1OPRS,
Beyoglu Eye Research Hospital, Istanbul, Turkey, 2OPRS, Dunyagoz Ankara Hospital, Ankara, Turkey
Introduction: Purpose: To investigate the surgical outcome of conjunctivodacryocystorhinostomy (CDCR) operation with
Metaireau tube implantation.
Methods: Eighteen patients with epiphora due to upper lacrimal system obstructions who had undergone CDCR with Metairaeu tube
insertion between 2002-2012 were enrolled in this study where the diagnosis of upper lacrimal system obstructions were based on
lacrimal system irrigation to confirm complete obstruction or insufficient tissue to perform canalicular reconstruction. Data Patient
charts were reviewed retrospectively to obtain data. Preoperative and postoperative epiphora were evaluated and compared by using
Munk Epiphora Grading. Tube related complications were also recorded.
Results: Of the 18 patients, 7 were male and 11 were female and the mean age was 45,5 ±14,3. The most common etiology was
unsuccessful dacryocystorhinostomy (DCR) (9 eyes, 50%), followed by trauma (27.7%), lichen planus, herpetic infection and systemic
lupus erythematosus. After the surgery, the improvement of epiphora was statistically significant on each visit (p<0.0001 for all of the
controls, paired samples t test). At postoperative visits, tube dislocation was seen in 9 cases (%50) and obstruction of Metaireau tube
because of granuloma formation was seen in 4 cases (%22,2).
Conclusions: Conjuctivodacryocystorhynostomy with Metaireau tube reduces epiphora in patients with canalicular obstructions.
Tube complications such as tube loss and frequent obstruction with mucoid debris were prominent with Metaireau tubes.
References: 1) Goar EL. Congenital absence of the lacrimal puncta and canaliculi. Trans Am Ophthalmol Soc. 1931;29:91-9.
2) Athanasiov PA, Madge S, Kakizaki H, Selva D. A review of bypass tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol
2011;56:252-266.
3) Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages.
Trans Am Acad Ophthalmol Otolaryngol. 1962;66:506-24. 2001;5(3):76-8.
4) Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmol 1965;59:773-83.
5) Steele EA, Dailey RA. Conjunctivodacryocystorhinostomy with the frosted Jones Pyrex tube. Ophthal Plast Reconstruc Surg
2009;25:42-43.
6) Lim C, Martin P, Benger R, Kourt G, Ghabrial R. Lacrimal canalicular bypass surgery with the Lester Jones tube. Am J Ophthalmol
2004;137:101-108.
7) Rose GE, Welham RA. Jones’ lacrimal canalicular bypass tubes: twenty-five years’ experience. Eye 1991;5:13-9.
8) Sekhar GC, Dortzbach RK, Gonnering RS, Lemke BN. Problems associated with conjunctivodacryocystorhinostomy. Am J
Ophthalmol 1991;112:502-6.
9) Zilelioğlu G, Gunduz K. Conjunctivodacryocystorhinostomy with Jones tube. A 10-year study. Doc Opthalmol 1996;92:97-105.
10) Rosen N, Ashkenazi I, Rosner M. Patient dissatisfaction after functionally successful conjunctivodacryocystorhinostomy with Jones
Tube. Am J Ophthalmol 1994;117:636-42.
11) Gladstone GJ, Putterman AM. A modified glass tube for conjunctivodacryocystorhinostomy. Arch Ophthamol 1985;103:1229-30.
Dailey RA, Tower RN. Frosted Jones pyrex tubes. Ophthal Plast Reconstr Surg 2005;21:185-7.
12) Wojno T. Experience with a Medpor-coated tear drain. Ophthal Plast Reconstr Surg 2010;26:327-9.
13)Rosen N, Ashkenazi I, Rosner M. Patient dissatisfaction after functionally successful conjunctivodacryocystorhinostomy with Jones
Tube. Am J Ophthalmol 1994;117:636-42.
POSTERS
F12
Normal Parameters of the Superior Ophthalmic Vein Based on CT and MRI
Katie Finnerty1, Ankur Gupta1, Ronald Mancini1. 1Ophthalmology, University of Texas Southwestern, Dallas, TX, United States, 2
School of Medicine, University of Texas Southwestern, Dallas, TX, United States, 3Ophthalmology, University of Texas Southwestern,
Dallas, TX, United States
Introduction: The superior ophthalmic vein (SOV) provides the majority of venous drainage from the orbit and is affected in
disease states making the SOV diameter of particular diagnostic significance. Little information is published on normal parameters.
The current study sought to establish normal SOV dimensions based on current imaging techniques and ImageJ software to provide
a benchmark to which disease states may be compared.
Methods: A retrospective chart review evaluating CT and MRI head/orbit studies was done excluding diagnoses potentially affecting
the SOV. Axial and coronal measurements were assessed with ImageJ software.
Results: The mean axial CT SOV diameter was 1.94mm (SD=0.51, N=105) while coronal horizontal and vertical measurements
were 1.95mm (SD=0.51, N=90) and 1.96mm (SD=0.46, N=90; Table 1). Average axial MRI diameters were 1.57mm (SD=0.46,
N=114) and coronals measured 1.74mm horizontal (SD=0.46, N=84) and 1.66mm vertical (SD=0.56, N=84; Table 2). Interestingly,
all measurements demonstrated significant differences between CT and MRI groups (Axial, p=0.0001, t=5.61; Coronal horizontal,
p=0.006, t=2.81; Coronal vertical, p=0.0004, t=3.59).
Conclusions: This study provides normative parameters of the SOV from current imaging techniques to assist in accurate
diagnosis of disease states. A small but statistically significant overestimation of SOV diameter on CT as compared to MRI imaging.
POSTERS
F13
Silent Sinus Syndrome and its Relation to Nasolacrimal Duct Obstruction
Larissa K. Ghadiali1, Peter G. Coombs 2, Ashutosh Kacker3, Gary J. Lelli2. 1Ophthalmology, New York Medical College, Valhalla, NY,
United States, 2Ophthalmology, Weill Cornell Medical College, New York, NY, United States, 3Otolaryngology, Weill Cornell Medical
College, New York, NY, United States
Introduction: Silent sinus syndrome is a rare condition presenting with spontaneous enophthalmos secondary to collapse of the
maxillary sinus. In this study, the authors reviewed patients who were diagnosed with silent sinus syndrome and identified patients
with associated nasolacrimal duct obstruction. To the authors knowledge this association has not been previously described.
Methods: A retrospective chart review was performed on patients who were diagnosed with silent sinus syndrome between
6/1/08-6/1/14. Patients with associated nasolacrimal duct obstruction were identified and reviewed.
Results: Of the five patients who presented with silent sinus syndrome, two patients were found to have related nasolacrimal duct
obstruction. One patient underwent dacryocystorhinostomy for nasolacrimal duct obstruction in May 2011 and presented in April
2012 with symptoms and findings consistent with right sided silent sinus syndrome (figure 1). A second patient presented in March
2014 with symptoms and findings consistent with both right sided silent sinus syndrome and nasolacrimal duct obstruction (figure 2).
Conclusions: Due to their close anatomical relationship, it is plausible that trauma or chronic inflammation of the nasolacrimal duct
and canal may disrupt the maxillary sinus ostium. Currently, the most widely accepted theory of the pathophysiology of silent sinus
syndrome is that an inciting event causes occlusion of the ostiomeatal complex causing negative pressure resulting in the maxillary
sinus walls migrating inwards. In the two cases presented, a dacryocystorhinostomy and chronic nasolacrimal duct obstruction were
associated with silent sinus syndrome, raising the possibility that nasolacrimal duct obstruction may be more common in patients
with silent sinus syndrome than in the general population. Additional prospective multicenter data will likely be required to determine
the significance of this potential finding.
References: Rose GE, Sandy C, Hallberg L, et al. Clinical and Radiologic Characteristics of the Imploding Antrum, or “Silent Sinus”
Syndrome. Ophthalmology 2003; 110: 811-818.
Rose GE, Lund VJ. Clinical Features and Treatment of Late Enophthalmos after Orbital Decompression. A Condition Suggesting Cause
for Idiopathic “Imploding Antrum” (Silent Sinus) Syndrome. Ophthalmology 2003; 110: 819-826.
Soparkar CNS, Patrinely JR, Cuaycong MJ, et al. The Silent Sinus Syndrome. A Cause of Spontaneous Enophthalmos. Ophthalmology
1994; 101:772-8.
POSTERS
F14
Rapid Fabrication of Nanoclay-Reinforced Custom Orbital Prosthesis Via
3-Dimensional Printing
Landon Grace1, Mauro Fittipaldi1, Kristoffer Winks2, David Tse3. 1Mechanical and Aerospace Engineering, University of Miami,
Coral Gables, FL, United States, 2Biomedical Engineering, University of Miami, Coral Gables, FL, United States, 3Department of
Ophthalmology, University of Miami Miller School of Medicine, Bascom Palmer Eye Institute, Miami, FL, United States
Introduction: We propose an efficient, automated, low-cost, remotely-implemented method for fabrication of a custom orbital
prosthesis via 3D printing and a novel, skin-tone specific nanoclay-reinforced polymer.
Methods: A digital representation of an exenteration patient’s skin tone and facial topography, including the orbital defect, is
captured through an automated non-contact facial topography mapping technique. The resulting 3D model is as shown in Figure
1. Digital construction of the exterior surface of the orbital prosthesis is based on a mirrored version of the contralateral periorbital
region to ensure a cosmetically symmetric appearance. The posterior prosthesis contour is based on orbital defect geometry in
order to provide a comfortable, custom fit. The exterior and posterior details are then merged to form the digital version of the
prosthesis. To verify compatibility, the prosthesis is virtually inserted into the digital representation of the patient’s facial topography
as shown in Figure 2. The details of the digital representation of the prosthesis are then accurately reproduced via 3D printing and
injection molding of a novel biocompatible tri-block polymer (styrene-isobutylene-styrene) composite. Nanoscale phyllosilicates
(montmorillonite clay) are incorporated prior to injection molding in order to provide mechanical rigidity, prevent time-related
geometrical changes (creep), and enhance resistance to prosthesis degradation due to fluids and dirt. In addition, custom-colored
mixtures of titanium and zinc oxide nanoparticulates are incorporated into the polymer based on digital capture of the patient’s skin
tone. This automated method results in custom, consistent color through the depth of the prosthesis, thereby eliminating the effects
of surface wear over time and providing infinitely-adjustable prosthesis color.
Figure 1. Digital representation of exenteration patient’s facial topography.
Figure 2. Computer-assisted insertion of 3D prosthesis model into digital
representation of patient’s facial topography to ensure accurate fit.
POSTERS
F14
Rapid Fabrication of Nanoclay-Reinforced Custom Orbital Prosthesis Via 3-Dimensional
Printing, continued
Results: This technique was applied to the orbital defect of an exenteration patient with excellent cosmetic match and prosthesis fit.
Exterior and posterior views of the custom prosthesis are shown in Figure 3.
Figure 3. Custom injection-molded prosthesis, fabricated from biocompatible polymer
reinforced with nanoscale clay, titanium oxide, and zinc oxide.
Conclusions: Current custom orbital prosthesis fabrication methods require a skilled prosthetist in order to achieve a cosmetically
acceptable match to the patient’s facial anatomy. This process is time-consuming, requires multiple visits to a prosthetist, and is not
financially viable for most patients. The proposed method enables efficient, low-cost, standardized fabrication of a custom, wearresistant orbital prosthesis based on non-contact facial topography and skin-tone capture. This novel process does not require a
skilled prosthetist, and has the potential to provide an affordable solution to facial disfigurement associated with orbital exenteration
to patients in remote parts of the world.
References: None.
POSTERS
F15
Long Term Outcomes of Globe Preserving Surgery for Adenoid Cystic
Carcinoma of the Lacrimal Gland
Jisang Han, Ju-Hyang Lee, Kyung In Woo, Yoon-Duck Kim. Ophthalmology, Samsung Medical Center, Sungkyunkwan
University School of Medicine, Seoul, Korea
Introduction: The main purpose of this study was to identify the long term outcome of patients with globe-sparing surgery and
adjuvant radiotherapy for adenoid cystic carcinoma of lacrimal gland.
Methods: Patients who underwent globe-sparing surgery and adjuvant radiotherapy for adenoid cystic carcinoma at our
institution between March 1998 and November 2012 were included. Clinical records, radiographic findings, treatment modalities
and outcomes were reviewed.
Results: This study included 5 men and 4 women (mean age at diagnosis, 40.2 years). The 7th AJCC classification was as follows:
T2N0M0 6 patients, T3N0M0 2 patients, T4bN0M0 1 patient. All 9 patients underwent excision of tumor and postoperative adjuvant
radiotherapy with median dose of 6,000 cGy (Range, 5,940 to 6,600 cGy). Radiation treatment related complications include
radiation retinopathy in 3 patients, cataract in 3 patients, and keratitis in 1 patient.
Histopathologic examination demonstrated perineural invasion in 7 patients, bone invasion in 1 patient, and positive resection
margin in 8 patients.
At last follow-up, 7 patients were alive without evidence of disease and 1 patient died 58 months after the operation, due to
esophageal carcinoma which was unrelated to lacrimal gland tumor. The tumor recurred in medial orbit in one patient 52 months
after the surgery, and exenteration was performed. This patient was alive with no evidence of disease 72 months after the
exenteration. Follow-up duration was 14.1 to 195.6 months (median follow-up duration: 48.9 months). Systemic metastasis
did not occur in any patient.
Conclusions: Globe-sparing surgery and adjuvant radiotherapy showed favorable local control and long term survival outcomes
in the patients with adenoid cystic carcinoma of lacrimal gland. The eyeball preserving surgery with adjuvant radiotherapy can be
considered for locally confined adenoid cystic carcinoma of lacrimal gland.
References: 1. Ahmad SM, Esmaeli B, Williams M, et al. American Joint Committee on Cancer classification predicts outcome of
patients with lacrimal gland adenoid cystic carcinoma. Ophthalmology. 2009;116:1210-5.
2. Williams MD, Al-Zubidi N, Debnam JM, et al. Bone invasion by adenoid cystic carcinoma of the lacrimal gland: preoperative
imaging assessment and surgical considerations. Ophthal Plast Reconstr Surg. 2010;26:403-8.
3. Esmaeli B1, Ahmadi MA, Youssef A, et al. Outcomes in patients with adenoid cystic carcinoma of the lacrimal gland. Ophthal Plast
Reconstr Surg. 2004;20:22-6.
POSTERS
F16
Risk Factors for the Development of Optic Neuropathy in
Thyroid-Associated Orbitopathy
Chaitanya Indukuri, Ronald Mancini. Ophthalmology, UT Southwestern Medical Center, Dallas, TX, United States
Introduction: Previous studies have identified a positive smoking history as a risk factor for development of TAO. However,
studies have been unable to consistently identify any additional risk factors which may place patients with TAO at a higher risk of
developing optic neuropathy.
Methods: Enrollment was restricted to patients seen for TAO at our institution between 2008 and 2013. Subjects were excluded if
they have not followed up at least twice over a period of 6 months or if past medical history is incomplete such that smoking status
and presence of comorbid disease is unable to be ascertained. 107 patients were eligible for our study. This study complied with
polices of the local Institutional Review Board. A retrospective chart review of all eligible patients was undertaken and the patient’s
age; gender; past medical history including presence of type 2 diabetes mellitus, hypertension, and autoimmune disease; current
smoking status; ophthalmic medical notes; as well as relevant imaging was reviewed.
Optic neuropathy was diagnosed by the presence of any of the following clinical symptoms and signs not explained by other cause:
acutely decreased visual acuity, abnormal color vision, relative afferent pupillary defect, visual field defect on Humphrey visual field,
and disc edema.
Results: Out of a total of 107 patients with TAO who were eligible for analysis, 24 (22.4%) were diagnosed with optic neuropathy.
Mean age of patients without optic neuropathy (54.1 ± 14.6) was less than that of patients with optic neuropathy (62.5 ± 11.3);
this difference was statistically significant (p = 0.01). There was a greater percentage of female patients in the optic neuropathy
group (45.8%) compared to the group without optic neuropathy (25.3%); this difference was statistically significant (p = 0.05). There
was a greater percentage of patients with diabetes mellitus in the optic neuropathy group (16.7%) compared to the group without
optic neuropathy (10.8%); however, this difference was not statistically significant (p = 0.44). There was a greater percentage of
patients with hypertension in the optic neuropathy group (70.8%) compared to the group without optic neuropathy (36.1%); this
difference was statistically significant (p <0.01). There was a slightly greater percentage of patients with autoimmune diseases in the
optic neuropathy group (12.5%) compared to the group without optic neuropathy (9.6%); however, this difference was not statistically
significant (chi-square test, p = 0.68). There was a greater percentage of smokers in the optic neuropathy group (54.2%) compared
to the group without optic neuropathy (25.3%); this difference was statistically significant (p <0.01).
Conclusions: Our study showed an association that reached statistical significance between development of optic neuropathy in
patients with TAO and increased age, female sex, co-morbid diagnosis of hypertension, and positive smoking status.
References: 1. Lee JH, Lee SY, Yoon JS. Risk Factors Associated with the Severity of ThyroidAssociated Orbitopathy in Korean
Patients. Korean J Ophthalmol 2010; 24(5):267273.
POSTERS
F17
Observer Impression of Patient Appearance Following Various Methods
Of Reconstruction After Orbital Exenteration
Justin Kuiper1, M. Bridget Zimmerman2, Keith Carter1, Richard Allen1, Erin Shriver1. 1Ophthalmology, University of Iowa Hospitals
and Clinics, Iowa City, IA, United States, 2Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
Introduction: The purpose of this study is to compare the perception of health and beauty of patients after exenteration
reconstruction with either prosthesis, free flap, lid sparing, or split thickness skin grafting. Authors hypothesize a full exenteration
with placement of a split-thickness skin graft would be less aesthetic to the general public than other methods.
Methods: Images of 73 patients evaluated at a tertiary care center post-exenteration were reviewed to identify the image that
best demonstrated each of the reconstruction techniques selected for a survey. Objective evaluation of the images was determined
through questions based on a blepharoplasty scale from Alsarraf et Al.1 and included the following inquiries: Question 1 (Q1)
How comfortable would you be looking at this patient’s face during social interaction? Question 2 (Q2) How much does the postexenteration socket bother you? Question 3 (Q3) Do you feel like the appearance of the patient’s face makes them look unhealthy?
Question 4 (Q4) Do you feel the appearance of the patient’s face would limit their social or professional activities? These questions
and de-identified images of each method of repair were sent through anonymous survey to medical students at The University of
Iowa. Responses were scored from 0 (least visually appealing) to 4 (most visually appealing) for each method of reconstruction.
Friedman test was used to compare responses among reconstruction methods to each of the four questions, and if this was
significant, then post-hoc pairwise comparison was performed with p-values adjusted using Bonferroni’s method.
Results: 132 students responded to the survey and 125 completed all four multiple-choice questions. Favorable response for all
questions was highest for prosthesis and lowest for split-thickness skin graft. Repair with prosthesis had a significantly higher score
compared to each of the other 3 methods for all questions (p-value<0.0001). Second highest score was for the free flap which was
significantly higher compared to the split thickness skin graft (p-value: Q1 <0.0001; Q2 0.0005; Q3 0.006; and Q4 0.019). Q1 score
for free flap was higher than lid sparing but not was not significant (p-value=0.0.066). The score for Q2, Q3, and Q4 did not differ
between free flap and lid sparing (p-value 0.300, 1.0, and 0.460, respectively). Results are shown below.
POSTERS
F17
Observer Impression of Patient Appearance Following Various Methods Of Reconstruction
After Orbital Exenteration, continued
Conclusions: The facial prosthesis was the preferred post-operative appearance for the exenterated socket for each question.
Many people cannot obtain a facial prosthesis, however, so surgeons should be aware that not all reconstructive techniques are
equal aesthetically. For patients without a prosthesis, there was no significant difference between free flap vs. lid sparing. The splitthickness skin graft was significantly least preferred for every question.
References: Alsarraf, R. et Al. Measuring Cosmetic Facial Plastic Surgery Outcomes. Archives of Facial Plastic Surgery. Issue 3.
(July-Sept 2001): 198-201.
POSTERS
F18
Infraorbital Nerve Enlargement in Idiopathic Orbital Inflammatory Disease
Ka Hyun Lee, Chang Yeom Kim, Sang Yeul Lee, Jin Sook Yoon. Department of Ophthalmology, Yonsei University College of Medicine,
Seoul, Korea
Introduction: To investigate the clinical and histologic characteristics in patients with idiopathic orbital inflammatory disease (IOI)
with infraorbital nerve (ION) enlargement.
Methods: Consecutive patients with IOI were identified from our database (Severance Hospital, Seoul, Korea) from Jan 2009 until
Dec 2013, and retrospective review of the medical record and image was performed. We divided our patients into two groups;
patients with and without ION enlargement. We compared clinical manifestation, laboratory findings, radiology, histopathologic
findings, and treatment outcome between two groups.
Results: A total of 65 patients with IOI were found.19 (29.23%) patients were identified to have ION enlargement and 46 (70.77%)
patients did not have ION enlargement. Follow-up ranged from 4 to 40 months. Sex, age, duration of symptom between two groups
was not different. Elevation of immunoglobulin (Ig) G4 in pathologic specimen and serum showed no difference between two groups
(p=0.655 and 0.823, respectively). All patients received systemic steroid therapy for inflammation and patients with refractory
inflammation to steroid received systemic immunosuppressive agents. 2 of them received orbital radiotherapy (RT) for recurrent
orbital inflammation. The recurrence rate of inflammation during follow up period was significantly higher in patients with ION
enlargement (p=0.031).
Conclusions: IOI is often associated with ION enlargement. All cases with ION enlargement had higher recurrence rate after
steroid treatment and extension of inflammation into sinus along the infraorbital nerve complex.
References: Hardy TG MA, Rose GE. Enlargement of the Infraorbital Nerve: An Important Sign Associated with Orbital Reactive
Lymphoid Hyperplasia or Immunoglobulin G4-Related Disease. Ophthalmology 2014 Mar 7 (epub ahead of print).
Watanabe T, Fujinaga Y, Kawakami S, et al. Infraorbital nerve swelling associated with autoimmune pancreatitis. Japanese Journal
of Radiology 2011;29:194-201.
Ohshima K, Sogabe Y, Sato Y. The usefulness of infraorbital nerve enlargement on MRI imaging in clinical diagnosis of IgG4-related
orbital disease. Japanese Journal of Ophthalmology 2012;56:380-2.
POSTERS
F19
Managing Extensive Facial Cutaneous Malignancies in Xeroderma
Pigmentosum: Staged, Sub-total Facial Resurfacing using Combination
Split- and Full-thickness Skin Grafting
Bradford W. Lee, Bobby S. Korn, Don O. Kikkawa. Division of Oculofacial Plastic and Reconstructive Surgery, University of California
San Diego Shiley Eye Center, La Jolla, CA, United States
Introduction: Xeroderma pigmentosum (XP) is a rare autosomal recessive disease associated with defective DNA repair resulting
in hypersensitivity to ultraviolet radiation. Patients with XP develop numerous sun-induced facial cutaneous malignancies at an early
age that can cause functional eyelid malpositions, vision loss, severe disfigurement, and even death. Mainstays of treatment involve
sun avoidance and sun protection, and therapies include topical 5-fluorouracil, dermabrasion, chemical peels, MOHS micrographic
surgery, and either monobloc full-thickness skin grafting or split-thickness skin grafting. We describe an approach to managing
extensive facial cutaneous malignancies in XP patients with staged, sub-total facial resurfacing using a combination of split- and
full-thickness skin grafting that results in significant functional and cosmetic improvement.
Methods: A 10-year-old female of consanguineous parents presented with untreated XP with extensive basal and squamous
cell carcinomas throughout the eyelids and face, along with mechanical and cicatricial ectropion and exposure keratopathy.
The patient was treated with staged, sub-total facial resurfacing using a combination of a full-thickness skin grafting from her
upper extremity as well as split-thickness skin grafting from her abdominal region. Grafts were taken from sun-protected donor
sites and were placed such that they encompassed complete cosmetic subunits of the face. Temporary tarsorraphies were used to
help mitigate graft contraction.
Results: The patient was macroscopically cleared of the extensive facial cutaneous malignancies in the grafted area and had marked
improvement in her facial topography, skin texture, skin pigmentation, facial odor, and global facial aesthetics. The patient reported
extremely high satisfaction and improved quality of life with the management strategy. The patient had residual ectropion due to
contraction of skin grafts, which will require further grafting.
Conclusions: Extensive facial cutaneous malignancies in patients with XP represent a challenging clinical problem that can have
life- and vision-threatening consequences and result in severe facial disfigurement. We demonstrate a management approach using
staged, sub-total facial resurfacing using a combination of full- and split-thickness skin grafting that resulted in marked improvement
in global facial aesthetics and quality of life.
References: 1. Tayeb T, Laure B, Sury F, Lorette G, and
Goga D. Facial resurfacing with split-thickness skin grafts
in xeroderma pigmentosum variant. J Craniomaxillofac
Surg. 2001 Oct;39(7): 496-8.
2. Ozmen S, Uygur S, Eryilmaz T, and Ak B. Facial
resurfacing with a monoblock full-thickness skin graft
after multiple malignant melanomas excision in xeroderma
pigmentosum. J Craniofac Surg. 2012 Sep;23(5):1542-3.
3. Ergun SS, Cek DI, and Demirkesen C. Is facial
resurfacing with monobloc full-thickness skin graft a
remedy in xeroderma pigmentosum?
4. Agrawal K, Veliath AJ, Mishra S, and Panda KN.
Xeroderma pigmentosum: Resurfacing versus dermabrasion. Br J Plast Surg. 1992;45:311-314.
5. Kraemer KH, Lee MM, and Scotto J. Xeroderma pigmentosum: cutaneous, ocular, and neurologic abnormalities in 830 published
cases. Arch Dermatol. 1987;123:241-250.
POSTERS
F20
Efficacy of Lateral Orbital Rim Decompression in Patients with Prior
Rim-sparing, Three-wall Orbital Decompression
Bradford W. Lee, Jane S. Kim, Richard Scawn, Don O. Kikkawa, Bobby S. Korn. Division of Oculofacial Plastic and Reconstructive
Surgery, University of California San Diego Shiley Eye Center, La Jolla, CA, United States
Introduction: Orbital decompression is the treatment of choice for disfiguring exophthalmos secondary to thyroid-related orbitopathy
(TRO). A traditional rim-sparing, three-wall orbital decompression with fat removal may be adequate for many patients with severe
exophthalmos. However, some patients may have residual exophthalmos necessitating further decompression. Many surgeons do not
remove the lateral orbital rim due to concerns about functional impairment and cosmetic deformity. This study evaluated functional,
cosmetic, and patient satisfaction outcomes associated with lateral orbital rim decompression (LORD) in subjects who had undergone
previous three-wall, rim-sparing orbital decompression.
Methods: This retrospective, interventional case series included 8 subjects with severe TRO and prior three-wall, rim-sparing orbital
decompression who subsequently underwent lateral orbital rim removal for persistent exophthalmos. Using an upper eyelid crease
incision, the lateral orbital rim was accessed and removed from the level of the frontozygomatic suture line to the level of the orbital
floor using either an oscillating saw and/or diamond burr drill. Outcomes evaluated included change in exophthalmos, degree of
lagophthalmos, MRD1, MRD2, exposure keratopathy, and surgical complications. Post-operative cosmesis of the lateral canthal
region was evaluated by physician evaluators, and patient satisfaction was assessed post-operatively.
Results: Eleven orbits underwent secondary LORD surgery. Mean reduction in exophthalmos was 2.1 mm (Range: 0.5 to 4.0 mm,
p<0.001). There was no significant change in lagophthalmos, MRD1, MRD2, or exposure keratopathy. There were no instances of
worsened diplopia, decreased vision, pupillary abnormalities, or masticatory oscillopsia associated with LORD surgery, and no external
deformities of the lateral canthal region were appreciable. All subjects reported satisfaction with functional and cosmetic outcomes of
LRD, and none reported problems with external contour deformities of the lateral canthal region.
Conclusions: Lateral orbital rim decompression surgery serves as an effective technique for managing severe TRO with
persistent exophthalmos following rim-sparing, three-wall orbital decompression surgery. Despite concerns about functional or
cosmetic defects to the lateral canthal region, none of these were noted either by physicians or subjects using the LORD technique
described above. As such, it may be considered an option during primary lateral orbital decompression surgery to achieve maximal
decompressive effect.
References: 1. Mehta P, Durrani OM. Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated
orbitopathy: a new technique and results of a case series. Orbit. 2011 Dec;30(6):265-8.
2. Fichter N, Krentz H, Guthoff RF. Functional and esthetic outcome after bony lateral wall decompression with orbital rim removal
and additional fat resection in graves’ orbitopathy with regard to the configuration of the lateral canthal region. Orbit. 2013
Aug;32(4):239-46.
3. Fayers T, Barker LE, Verity DH, Rose GE. Oscillopsia after lateral wall orbital decompression. Ophthalmology. 2013
Sep;120(9):1920-3.
POSTERS
F21
Novel Genetic Mutations in Orbitoblepharophimosis Phenotype
Flora Levin1, Gary Lelli2, Deepak Narayan3. 1Ophthalmology, Yale School of Medicine, New Haven, CT, United States, 2Ophthalmology,
Weill Cornell Medical College, New York, NY, United States, 3Surgery, Yale School of Medicine, New Haven, CT, United States
Introduction: Blepharophimosis is a rare craniofacial disorder associated with clinical features of blepharophimosis, ptosis,
epicanthus inversus, and telecanthus (BPES). Although originally thought to be a purely soft tissue disorder, recent evidence suggests
that orbital dysmorphism is also part of the disease. The physical manifestations were originally described as a result of mutation
in the FOXL2 gene. However, despite the specificity of FOXL2 in BPES, additional gene mutations have been postulated to cause a
similar disorder. Here we investigate a novel, previously unreported pair of genes which result in BPES when mutated.
Methods: A patient with blepharophimosis was identified along with the parents and siblings who had similar facial morphology
(Figures 1 & 2). Physical features and anthropometric measurements were recorded. Whole blood samples were obtained and
genomic DNA extracted. Whole exome sequencing was performed and candidate mutations identified. Sanger sequencing was
performed with appropriate primers to confirm. The entire coding region of the FOXL2 gene was resquenced via the sanger method
to confirm the absence of FOXl2 mutations.
Results: Phenotypic features of this disease were found in 2 generations of living relatives. The inheritance demonstrated a
Mendelian autosomal dominant pattern.
Genetic analysis confirmed that a conserved mutation was responsible for the progression of disease. Whole exome sequencing
identified candidate genes ZC3H13, and RERE with a nonsense and missense mutation respectively. These are located on separate
chromosomes and loci from any previously reported BPES-mutation. A literature survey identified a mouse model of the defect for
the RERE gene.
Conclusions: We have identified a patient with orbitoblepharophimosis and together with the father, the subjects were found to have
a normal FOXL2 gene sequence. Whole exome sequencing confirmed that FOXL2 was normal. We report two previously undescribed
BPES mutations, ZC3H13 and RERE, which are evolutionarily conserved genes. These conserved mutations are true stop codon
mutations and this association may begin to highlight their importance in orbitofacial development and structure.
References: Brian C. Jackson, Christopher Carpenter, Daniel W. Nebert, Vasilis Vasiliou. Update of human and mouse forkhead box
(FOX) gene families. Human Genomics 4(5): 345-352. June 2010
Gijsbers AC, D’haene B, Hillhorst-Hofstee Y, Mannens M, Albrecht B, Seidel J, Will DR, Maisenbacher MK, Loeys B, van Essen T,
Bakker E, Hennekam R, Breuning MH, De Baere E, Ruivenkamp CA. Identification of copy number variants associated with BPES-like
phenotypes. Human Genetrics (2008) 124:489-498
Yanagisawa H, Bundo M, Miyashita T, Okamura-Oho Y, Tadokoro K, Tokunaga K, Yamada M. Protein binding of DRPLA family through
arginine-glutamic acid dipeptide repeats is enhanced by extended polyglutamine. Human Molecular Genetics, 2000 9(9): 1433-42
POSTERS
F22
Mucoepidermoid Carcinoma Arising in the Anophthalmic Socket
Ilya Leyngold, MD. Ophthalmology, University of South Florida Morsani College of Medicine, Tampa, FL, United States
Introduction: Mucoepidermoid carcinoma is the most common malignant salivary gland tumor in adults and children (1,2).
Mucoepidermod carcinoma arising from ocular adnexa is very rare, but has been reported in the presence of an intact globe (3,4).
The author describes the first case reported in literature of a mucoepidermoid carcinoma arising from an anophthalmic socket.
Methods: 48 year old previously healthy male was referred for evaluation of a large tumor of the anophthalmic socket. Patient
presented with an 8 week history of severe orbital pain, swelling, and difficulty wearing his ocular prosthesis. He was initially
treated empirically with antibiotics and steroids. On physical examination he was found to have a swollen orbit with erythematous,
indurated, and ulcerated mass involving the left lower eyelid, and an exposed porous orbital implant (Figure 1). Bilateral cervical and
submandibular lymphadenopathy was also present.
Results: Patient was admitted to the hospital for intravenous antibiotics, removal of the orbital implant, and orbital biopsy.
Histopathology revealed high grade mucoepidermoid carcinoma (Figure 2). Subsequent neuroimaging showed a left orbital mass
with intracranial extension of the tumor into the base of the skull (Figure 3). PET scan revealed hypermetabolic activity in the cervical
and submandibular lymph nodes and in the ascending colon. Patient underwent orbital exenteration and biopsy of the skull base
confirming intracranial extension of the tumor.
Ten days following his discharge, he presented to the outpatient clinic with inability to abduct his right eye and headaches. Repeat
MRI of the head revealed interval growth of the tumor to involve the right skull base. Despite aggressive external beam radiation
therapy the patient progressed to widely metastatic disease and expired 6 months later
Conclusions: To the author’s knowledge this is the first reported case of a mucoepidermoid carcinoma arising in the anophthalmic
socket. Since the patient presented with the advanced disease it is unclear which ocular structure gave origin to the neoplasm. The
absence of the eye however, may have allowed for a more rapid and direct intracranial spread of the tumor compared to the cases
with intact globe. In addition, the exposure of the orbital implant with violated conjunctival and Tenon’s barriers likely contributed to an
accelerated disease progression. More studies are needed to further understand the clinical course and optimal management of this
type of tumor.
References: 1. Tumours of the Salivary Glands. In: Pathology and Genetics of Head and Neck Tumours, Barnes L, Eveson JW,
Reichart P, Sidransky D. (Eds), World Health Organization, Lyon 2005. p.209.
2. Guzzo M, Locati LD, Prott FJ, et al. Major and minor salivary gland tumors. Crit Rev Oncol Hematol 2010; 74:134.
3. Chawla B, Kashyap S, Sen S, Bajaj MS, et al. Clinicopathologic review of epithelial tumors of the lacrimal gland.Ophthal Plast
Reconstr Surg. 2013 Nov-Dec;29(6):440-5.
4. Zhang H, Yan J, Li Y, Zhang P.Mucoepidermoid carcinoma of the eyelid: a case report and review of the literature. Yan Ke Xue Bao.
2005 Sep;21(3):152-7.
POSTERS
F22
Mucoepidermoid Carcinoma Arising in the Anophthalmic Socket, continued
POSTERS
F23
Aneurysmal Bone Cysts of the Orbit: Unusual Presentations of a Rare Lesion
Sophie Liao, Thomas Johnson. Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, United States
Introduction: Aneurysmal bone cysts are benign fibro-osseus lesions of unknown etiology. Orbital lesions are extremely rare, with
fewer than 30 cases reported in the literature and only 3 cases in children under 3 years of age. They may mimic malignant tumors
on presentation, and require imaging for diagnosis1-5. We review the literature regarding aneurysmal bone cysts of the orbit and
describe the presentation and management of two patients with unusual features.
Methods: Retrospective case series
Results: Case 1: A 2-year-old female presented with one month of progressive proptosis, pain, and chemosis of the right eye and
no light perception vision. Neuroimaging demonstrated a large heterogeneously enhancing orbital mass with extensive bony erosion
of the orbital roof and intracranial extension. Intraoperative frozen section biopsies revealed a spindle cell mass that could not rule
out rhabdomyosarcoma. Subsequent review of the permanent sections showed spindle cell proliferation, multinucleated giant cells,
and vascular spaces without malignant features that were consistent with a diagnosis of aneurysmal bone cyst. The right eye was
found to be necrotic and was enucleated, and the tumor was subsequently excised in conjunction with a neurosurgeon. Case 2: A
6-month-old male presented with ten days of right orbital proptosis and severe chemosis. CT scans showed a large, circumscribed,
heterogeneously enhancing intraorbital lesion with erosion into the ethmoid and maxillary sinuses. Surgical excision of the lesion was
undertaken and the mass was confirmed on histopathology as an aneurysmal bone cyst. This patient is the youngest case reported in
the literature.
Conclusions: Aneurysmal bone cysts are highly uncommon lesions of the orbit that mimic malignant orbital tumors on presentation.
The rapid onset of symptoms and presentation in a predominantly pediatric population requires differentiation from malignant orbital
rhabdomyosarcoma. Timely radiographic and clinical evaluation must be performed, with surgical biopsy to confirm the diagnosis
in atypical cases. Definitive therapy requires complete surgical excision as lesions may recur. A systemic workup must rule out
associated disorders such as fibrous dysplasia and neurofibromatosis type 1. Practicing ophthalmologists must be aware of this
disease and include it in the differential diagnosis of any rapidly expanding orbital mass in a child.
References: 1. Menon J, Brosnahan DM, Jellinek DA. Aneurysmal bone cyst of the orbit: a case report and review of literature. Eye.
Dec 1999;13 ( Pt 6):764-768.
2. Johnson TE, Bergin DJ, McCord CD. Aneurysmal bone cyst of the orbit. Ophthalmology. Jan 1988;95(1):86-89.
3. Senol U, Karaali K, Akyuz M, Gelen T, Tuncer R, Luleci E. Aneurysmal bone cyst of the orbit. AJNR. American journal of
neuroradiology. Feb 2002;23(2):319-321.
4. Yazici B, Yazici Z, Yalcinkaya U. Aneurysmal bone cyst secondary to ossifying fibroma in the orbit. Ophthalmic plastic and
reconstructive surgery. Jul-Aug 2011;27(4):e84-85.
5. Yu JW, Kim KU, Kim SJ, Choi S. Aneurysmal bone cyst of the orbit : a case report with literature review. Journal of Korean
Neurosurgical Society. Feb 2012;51(2):113-116.
POSTERS
F24
Frontoethmoidal Sinus Mucocele Associated with Osteoma —
Clinical Features of 3 Cases
Reshma Mehendale1, Tanuj Nakra2, Roman Shinder1,2. 1Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY,
United States, 2Texas Oculoplastics Consultants, Austin, TX, United States
Introduction: Frontoethmoidal sinus mucocele may lead to significant proptosis, globe dystopia, & neurological sequelae from
bony erosion with resultant intracranial extension. Sinus osteoma is the most common benign neoplasm of the sinuses & may
cause recurrent headache or sinusitis. However, a rare association of frontoethmoidal sinus mucocele and osteoma has not yet
been reported in the ophthalmic literature and may reflect more aggressive lesions with intracranial extension warranting
neurosurgical evaluation.
Methods: Records of 3 patients with frontoethmoidal sinus mucocele and associated osteoma were reviewed.
Results: The first patient is a 79-year-old man who presented with a draining right frontoethmoidal mucopyocele (Fig 1A).
The second patient is a 21-year-old man with a history of bilateral frontal and nasal bone fractures who presented with 3 months
of diplopia. In both cases, ophthalmic exam revealed right proptosis and inferotemporal globe dystopia. CT orbits of both patients
demonstrated a frontoethmoidal mucocele and adjacent osteoma with orbital extension and intracranial expansion (Fig 1B, C, 2A, B).
Both patients underwent endoscopic mucocele drainage and restoration of proper sinus outflow tracts. The third patient, a 14-yr-old
boy with Gardner Syndrome and history of multiple head and neck osteomas, presented with right orbital cellulitis. CT orbits revealed
a right frontothemoidal sinus mucocele as well as ethmoid and maxillary sinus osteomas (Fig 3). The patient was successfully treated
with IV antibiotics and was referred for outpatient otolaryngology evaluation for possible surgical intervention.
Conclusions: Frontoethmoidal sinus mucocele may arise as a complication of sinus osteoma, in the setting of trauma or
inflammation with expansion leading to proptosis, globe dystopia, and potentially dramatic neurological sequelae from intracranial
extension, such as headache, seizure, or intracranial abscess. It appears that mucocele with associated osteoma may correlate
with increased incidence of intracranial expansion and communication. This association has been reported in few case reports in
the neurosurgical literature but has not been cited in the ophthalmic literature. Prompt recognition of this association may warrant
neurosurgical evaluation and intervention prior to development of neurological symptoms given the potential for future sequelae.
References: 1. Jurlina M, Janjanin S, Melada A, et al. Large intracranial intradural mucocele as a complication of frontal sinus
osteoma. J Craniofac Surg. 2010(4):1126-9.
2. Gutenberg A, Larsen J, Rohde V. Frontal sinus osteoma complicated by extended intracranial mucocele and cerebral abscess:
neurosurgical strategy of a rare clinical entity. Cen Eur Neurosurg. 2009(2):95-7.
3. Akay KM, Ongürü O, Sirin S, et al. Association of paranasal sinus osteoma and intracranial mucocele-two case reports.
Neurol Med Chir (Tokyo). 2004(4):201-4.
POSTERS
F25
Does Eyebrow Soft Tissue Expansion in Thyroid Eye Disease Improve
over Time?
Grant Moore, Amir Yeganeh, Daniel Rootman, Robert Goldberg. Ophthalmology, University of California, Los Angeles, Los Angeles,
CA, United States
Introduction: Lateral eyebrow soft tissue commonly expands in thyroid eye disease (TED) (1,2), but the long term behavior of
periorbital myxedema has not been assessed. The purpose of the current study is to evaluate the long-term transformation of lateral
eyebrow soft tissue in a group of patients with known thyroid eye disease.
Methods: In this retrospective cohort study, a chart review was completed to find all patients with a known diagnosis of TED who
had clinical photos available from both their initial diagnosis visit and at least 7 years following their initial visit. History of orbital
and eyelid surgery was noted, as was history of treatment with radioactive iodine, steroids, and external beam radiation. In addition
to surgical and medical treatment status, baseline variables included age at diagnosis and sex. A grading key for the level of tissue
expansion was produced for front views of each of the four grades, which ranged from 0 to 3 (2). The area between the upper
eyebrow and upper eyelid crease was then evaluated in standardized clinical photographs by a panel of four expert, independent,
masked observers.
Results: One-hundred-and-five patients met inclusion criteria. Fifteen participants were male, and 90 were female. The mean patient
age was 50.1 years, and the mean follow up duration was 10.0 years (+/- 2.3 years). In a paired samples T-test, including initial and
follow-up photo grades for all patients, the appearance of eyebrow soft tissue improved by 0.23 points over time (p<0.001) (Figure
1). This effect was independent of age, sex, orbital decompression, functional eyelid surgery, strabismus surgery, and blepharoplasty.
Patients were also evaluated based on the severity of their presentation. Patients with an average initial photo grade that was greater
than one (i.e. more severe involvement) showed significantly more improvement in the appearance of their eyebrow soft tissue in later
photos than those patients with presenting grades less than one (i.e. less severe disease) (p<0.001) (Figure 2).
Conclusions: Overall, the current study found that the pathologic expansion of eyebrow soft tissue improves over time in patients
with thyroid eye disease. This change was not affected by age, sex, orbital decompression, strabismus surgery, functional eyelid
surgery, or blepharoplasty. Patients who presented with more severe eyebrow soft tissue expansion experienced a significantly larger
improvement than patients who presented with less severe disease.
References:
1) Papageorgiou KI, Hwang CJ, Chang SH, et al. Thyroid-associated periorbitopathy:eyebrow fat and soft tissue expansion in patients
with thyroid-associated orbitopathy. Arch Ophthalmol. 2012;130(3):319-328.
2) Savar LM, Menghani RM, Chong KK, et al. Eyebrow Tissue Expansion: An Underappreciated Entity in Thyroid-Associated
Orbitopathy. Arch Ophthalmol. 2012; 130(12): 1566-1569.
POSTERS
F25
Does Eyebrow Soft Tissue Expansion in Thyroid Eye Disease improve over Time?, continued
Figure 1: Average Baseline and Follow Up Brow Tissue Appearance Score
Figure 2: Change in Brow Fat Appearance According to Severity of Initial Presentation
Figure 3: Baseline and Follow Up Photo Series
POSTERS
F26
The Ophthalmologic Findings in Acute Orbital Wall Fractures
Leslie Neems, MD, Elisa Chiang, MD PhD, Lilly Saadat, BS, Jared Spitz, BS, Paul Bryar, MD, Christopher Chambers, MD.
Ophthalmology, Northwestern University, Chicago, IL, United States
Introduction: This study evaluates the clinical features of 243 patients with orbital wall fracture who were assessed by
ophthalmology at Northwestern Memorial Hospital January 2005- October 2012
Methods: The Enterprise Database Warehouse (EDW) was used to identify patient records from Northwestern Memorial Hospital
electronic medical records using ICD9 codes for facial fractures and CPT codes for orbital fracture repair between 1/1/2001 and
10/15/2012. Patients evaluated by Ophthalmology in the Emergency Room, inpatient wards, or outpatient clinics were selected.
The ophthalmologic history and physical exam from such patients were reviewed for findings associated with orbital wall fracture.
Results: Two hundred and forty three patients had complete ophthalmologic consults. The initial visual acuity was reported in
222 patients. One hundred forty three patients (64.4%) had good acuity in the affected eye at 20/20 - 20/30. In 57 (25.7%)
patients, reported acuity range was 20/40 - 20/100. Lastly, 22 patients (9.9%) had poor vision with initial acuity of 20/120 to NLP.
To evaluate visual loss, vision in the affected eye was compared to the fellow uninvolved eye. Significant vision loss was set as worse
acuity of greater than 2 lines on the Snellen chart. Forty-one patients (18.5%) had significant vision loss when compared to the fellow
eye, with an average of 3.8 lines lost. This included visually devastating outcomes in 2 patients with ruptured globes and 2 with large
choroidal ruptures.
Analysis of intraocular pressure revealed 171 patients (79.5%) with normal IOP <21 mm Hg in the affected eye. IOP greater than
30 mm Hg was found in 9 patients (4.2%). In this group, marked periorbital edema and ecchymosis were noted on exam. This group
included 2 patients that had a fixed pupil and retrobulbar hemorrhage on CT. One patient was NLP and required emergent lateral
canthotomy and cantholysis.
On bedside exam, the most common exam finding was periorbital edema and ecchymosis affecting 207 patients (85.2%),
followed by subconjunctival hemorrhage in 148 patients (60.9%). Fifty-nine patients (26.6%) complained of diplopia, with only
16 (7.2%) symptomatic in primary gaze. Motility was restricted in 84 patients (37.8%), mostly on upgaze relating to eyelid edema.
Enophthalmos was noted in 12 patients (4.9%), and 8 patients (3.9%) were proptotic. On slit lamp exam, 23 patients (9.5%) had
traumatic iritis, with hyphema in 14 patients (5.8%). Commotio was appreciated on 30 (12.3%) retinal exams.
Conclusions: The majority of patients (64.4%) had good initial visual acuity in the affected eye. Vision loss was appreciated in
18.5% of patients when compared to the fellow eye. The most common ophthalmologic findings were periorbital edema and
ecchymosis (85.2%) and subconjunctival hemorrhage (60.9%). Diplopia was noted in 26.6%, but only a small portion (7.2%) in
primary gaze. Devastating injuries were rare but included ruptured globe in 2 patients and 2 patients with choroidal ruptures.
Such devastating injuries lead to poor visual outcomes.
POSTERS
F27
Epidemiology and Clinical Characteristics of Pediatric Eyelid Retraction
Jessica Olayanju1, Gregory Griepentrog2, David Hodge1, Brian Mohney3. 1Mayo Medical School, Rochester, MN,
United States, 22Division of Oculofacial and Orbital Surgery, Department of Ophthalmology, Medical College of Wisconsin,
Milwaukee, WI, United States, 3Department of Ophthalmology, Mayo Clinic, Rochester, MN, United States
Introduction: To describe the baseline epidemiology and clinical characteristics of upper and lower eyelid retraction in children.
Methods: The medical records of all pediatric patients (<19 years) diagnosed with eyelid retraction from January 1, 1976,
through December 31, 2010, at Olmsted Medical Group and Mayo Clinic were retrospectively reviewed.
Results: A total of 62 children were diagnosed with eyelid retraction during the 35-year period with a median age of diagnosis of
yielding 11.50 years (range 1 day to 18.72 years). There was a preponderance of female (39; 62%) patients. Upper eyelid retraction
was documented in 35 (56%) patients, lower eyelid retraction in 18 (29%) patients, and both upper and lower eyelid retraction
in 9 (15%) patients. The most common cause of eyelid retraction was thyroid eye disease (40%), followed by trauma (15%) and
congenital idiopathic eyelid retraction (10%). Symptomatic tearing, ocular surface irritation and photophobia were noted in 24 (38%)
patients. Other ocular abnormalities including eyelid lag, lagophthalmos, enophthalmos, proptosis and exposure keratitis were noted
in 42 (68%) patients. There were no documented cases of visual impairment secondary to eyelid retraction. Of the 62 patients,
17 (27%) underwent surgical intervention through various combinations of conjunctival mullerectomy, levator recession, lamellar
spacer grafts, lateral tarsal strip and tarsorrhaphy, with 16 (94%) patients experiencing improvement postoperatively.
Conclusions: The differential diagnosis of eyelid retraction is extensive and well-documented. In this population-controlled study
of 35-years, nearly two-thirds of cases diagnosed in children were due solely to three diagnoses: thryroid eye disease, trauma,
or congenital idiopathic eyelid retraction. While tear film disturbances from ocular surface exposure commonly results in visual
disturbance in adults, there were no documented cases of visual impairment in this childhood cohort. A minority of children required
surgical intervention, and post-operative improvement was experienced in the vast-majority of these cases through widely-ranging
surgical correction techniques.
References: 1. Bartley GB. The differential diagnosis and classification of eyelid retraction. Ophthalmology 1996;103(1): 168-76.
2. Stout AU, Borchert M. Etiology of eyelid retraction in children: a retrospective study. J Pediatr Ophthalmol Strabismus 1993;
30(2): 96-9.
3. Katowitz WR, Katowitz JA. Congenital and developmental eyelid abnormalities. Plast Reconstr Surg 2009;124(1 Suppl): 93e-105e.
4. Rocca WA, Yawn BP, St Sauver JL, Gr ssardt BR, Melton LJ, 3rd. History of the Rochester Epidemiology Project: half a century of
medical records linkage in a US population. Mayo Clin Proc 2012;87(12): 1202-13.
5. Bartley GB, et al. Clinical features of Graves’ ophthalmopathy in an incidence cohort. Am J Ophthalmol 1996; 121: 284-90.
POSTERS
F28
Reconstruction of Medial Upper Eyelid Defects Following Excision of Large
Xanthelasma Palpebrarum with Blepharoplasty Island Rotation Flaps
Gamze Ozturk Karabulut1, Pelin Kaynak1, Can Ozturker1, Korhan Fazil1, Altug Cetinkaya2, Ahmet Demirok1, Omer Faruk Yilmaz1. 1OPRS,
Beyoglu Eye Research And Training Hospital, Istanbul, Turkey, 2OPRS, Dunyagoz Ankara Hospital, Istanbul, Turkey
Introduction: Xanthelasma palpebrarum is a benign disorder manifesting as yellowish cholesterol laden plaques on the eyelids.
This study presents the treatment and outcomes of large xanthelasma palpebrarum defects in patients whose lesions could not
be closed primarily.
Methods: A retrospective review of 8 patients who received surgery for large xanthelasma palpebrarum between 2012 and
2014 was conducted. All lesions were located in the medial canthus of the upper eyelid. After excision of xanthelasma palpebrarum,
blepharoplasty skin flap is created with a classical skin crease and lateral blepharoplasty incision and hinged blebharoplasty island
flap was rotated to cover the bare area. Excess skin was removed and the flap was sutured without tension into the defect in a
conventional manner. Antibiotics were prescribed postoperatively and sutures were removed on the tenth day. The main outcome
criterae were preservation of upper eyelid aesthetics and functions.
Results: Follow-up ranged from 6 months to 24 months. No flap necrosis or infection occurred after the operation. In the long term
follow-up lesion recurrence, lagophthalmos, hypertrophic scar, or bulky appearance were not observed.
Conclusions: Good aesthetic outcome and high patient satisfaction without functional compromise was achieved in all patients at
the last follow-up visit without postoperative complications and need for revisionary surgery. This simple technique can be used for
the reconstruction of medial skin defects after treatment of xanthelasma palpebrarum that are not amenable to direct closure.
References: 1) ) Lee HY, Jin US, Minn KW, Park Y. Outcomes of surgical management of xsanthelasma palpebrarum. Arch Plast
Surg 2013;40:380-386.
2) Bergman R. The pathogenesis and clinical significance of xanthelasma palpebrarum. J Am Acad Dermatol 1994;30: 236-42.
3) Mendelson BC, Masson JK. Xanthelasma: follow-up on results after surgical excision. PlasReconstr Surg 1976;58: 535-8.
4) Raulin C, Schoenermark MP, Werner S, et al. Xanthelasma palpebrarum: treatment with the ultrapulsed CO2 laser. Lasers Surg
Med 1999;24:122-7.
5) Borelli C, Kaudewitz P. Xanthelasma palpebrarum: treatment with the erbium:YAG laser. Lasers Surg Med 2001;29: 260-4.
6) Cannon PS, Ajit R, Leatherbarrow B. Efficacy of trichloroacetic acid (95%) in the management of xanthelasma palpebrarum.
Clin Exp Dermatol 2010;35:845-8.
7) Fusade T. Treatment of xanthelasma palpebrarum by 1064- nm Q-switched Nd:YAG laser: a study of 11 cases. Br J Dermatol
2008;158:84-7.
8) Kose R. Treatment of large xanthelasma palpebrarums with full-thickness skin grafts obtained by blepharoplasty. J Cutan Med
Surg. 2013 May-Jun;17(3):197-200.
9)Yang Y, Sun J, Xiong L, Li O. Treatment of xsanthelasma palpebrarum by upper eyelid skin flap incorporating blepharoplasty.
Aesthetic Plast Surg. 2013 Oct;37(5):882-6
10) Then SY, Malhotra R. Superiorly hinged blepharoplasty flap for reconstruction of medial upper eyelid defects following excision
of xanthelasma palpebrum. Clin. Experiment. Ophthalmol. Jul 2008; 36(5); 410-14.
POSTERS
F28
Reconstruction of Medial Upper Eyelid Defects Following Excision of Large Xanthelasma
Palpebrarum with Blepharoplasty Island Rotation Flaps, continued
POSTERS
F29
Obesity as a Potential Risk Factor for Blepharoptosis: The Korea National Health
and Nutrition Examination Survey 2008-2010
Ji-Sun Paik1, Su-Kyung Jung2, Won-Kyung Cho3, Suk-Woo Yang1. 1Ophthalmology and visual science, Seoul St. Mary’s Hospital,
The Catholic University of Korea, Seoul, South Korea, 2Ophthalmology and visual science, Bucheon St. Mary’s Hospital, The Catholic
University of Korea, Seoul, South Korea, 3Ophthalmology and visual science, Dae-Jeon St. Mary’s Hospital, The Catholic University of
Korea, Seoul, South Korea
Introduction: To examine obesity parameters as potential risk factors associated with age-related blepharoptosis in a
representative Korean population.
Methods: We analyzed the Korea National Health and Nutrition Examination Survey (KNHANES), conducted between 2008 and
2010. 10,285 Korean adults (4,441 men and 5,844 women) aged 40 years or older was enrolled. We compared body mass index
(BMI), waist circumference (WC) and percentage body fat (BF), according to the severity of blepharoptosis. Multiple logistic regression
analysis was conducted to examine the associations of each obesity parameter with blepharoptosis.
Results: The overall prevalence of age-related blepharoptosis was 14.8 % in South Korea. There were significant and graded
associations between increasing blepharoptosis severity and the mean value of obesity parameters (P for trend <0.05). As marginal
reflex distance 1 (MRD1) decreased, the prevalence of general obesity and overweight status increased (P for trend=0.121 in men
and <0.001 in women); the prevalence of abdominal obesity increased (P for trend <0.001 for both genders); the prevalence of
highest quartile of percentage BF increased (P for trend ≤0.001 for both genders). After adjusting, blepharoptosis was significantly
associated with general obesity in women (adjusted odds ratio (aOR), 2.17; 95% confidence intervals (CI), 1.35-3.44); and with the
highest quartile of percentage BF in men (aOR, 2.08; 95% CI, 1.42-3.03) and in women (aOR, 1.63; 95% CI, 1.16-2.33).
Conclusions: The etiology of age-related blepharoptosis may be multifactorial and is unclear. Our results suggest that obesity
parameters such as BMI, WC and percentage BF might be potential risk factors for age-related blepharoptosis in a representative
Korean population.
References: 1. Shore JW, McCord CD Jr. Anatomic changes in involutional blepharoptosis. Am J Ophthalmol 1984;98:21-27.2.
Cahill KV, Buerger Jr GF, Johnson BL. Ptosis associated with fatty infiltration of Műller muscle and levator muscle. Ophthal Plast
Reconstr Surg 1986;2:213-217.3. Netland PA, Sugrue SP, Albert DM, Shore JW. Histopathologic features of the floppy eyelid
syndrome. Involvement of tarsal elastin. Ophthalmology 1994;101:174-181.4. Shirado M. Dyslipidemia and age-related
involutional blepharoptosis. J Plast Reconstr Aesthet Surg 2012;65:e146-150.5. Yoon KC, Mun GH, Kim SD, et al. Prevalence
of eye diseases in South Korea: data from Korean National Health and Nutrition Examination Survey 2008-2009. Korean
J Ophthalmol 2011;25:421-433.
POSTERS
F30
Primary Renal Carcinoid Metastatic to the Orbit
Deep Parikh1, Reshma Mehendale1, Tanuj Nakra2, Roman Shinder1,2. 1Department of Ophthalmology, SUNY Downstate Medical Center,
Brooklyn, NY, United States, 2Texas Oculoplastic Consultants, Austin, TX, United States
Introduction: Carcinoid tumors are rare neoplasms derived from enterochromaffin cells primarily found in the gastrointestinal
tract and bronchial tree. They comprise only 0.5% of all human malignancies. Rarely, they may develop in the ovaries, testis,
thymus, breast, or kidney. The most common site of carcinoid metastasis is the liver which can lead to the classic signs of
carcinoid syndrome: flushing, diarrhea, tachycardia, and wheezing. Orbital metastasis is exceedingly rare1. One past report has
described orbital metastasis from renal carcinoid2. We herein describe only the second reported case of primary renal carcinoid
metastasizing to the orbit.
Methods: The medical record of a patient with metastatic carcinoid to the orbit was reviewed.
Results: A 70-year-old man presented with a several month history of asymptomatic left globe proptosis (Fig 1, 2). Less than a
year earlier, a left renal carcinoid was discovered. It was proven to be a renal primary carcinoid through extensive systemic workup
and the patient underwent a left nephrectomy. Upon presentation the patient had developed known metastatic disease involving the
retroperitoneal lymph nodes, lungs, and vertebrae, for which he was being treated with octreotide and everolimus chemotherapy.
Pertinent exam findings included 2 mm of left axial globe proptosis with full ductions, no diplopia, and stable 20/30 visiual acuity
without visual field defect. MRI showed a 2 x 1.4 x 1.2 cm well circumscribed, homogeneous, enhancing mass in the left lateral
rectus muscle (Fig. 3, 4). A biopsy was not performed due to classic clinical and radiographic evidence of metastatic disease.
The patient remains asymptomatic on chemotherapy with stable proptosis and radiographic findings at last follow up 6 months
following presentation.
Conclusions: Carcinoids comprise 4-5% of orbital metastasis with a 5-year survival of 72%. Neuroendocrine cells do not typically
exist in renal tissue and thus primary renal carcinoids are rare with only 81 reported cases in the English literature. Metastatic
renal carcinoid to the orbit has only been described in a single past case report. Somatostatin analogs have been shown to
provide symptomatic relief in patients
with carcinoid disease, as well as have
antiproliferative effects shown to stabilize
tumor growth. Regression of the tumor,
however, is rare. Our case displays the
propensity of orbital metastasis, including
carcinoid, to invade the highly vascular
recti muscles. A focal fusiform mass
involving an extraocular muscle should
always alert the clinician to the possibility
of metastatic disease, and if clinical data
support this suspicion, some patients may
avoid orbitotomy and biopsy. Clinicians
should be aware that carcinoid metastasis
to the orbit, although rare, can spread from
primary disease of any anatomic location.
References: 1. Mehta JS, Abou-Rayyah Y, Rose GE. Orbital Carcinoid Metastases. Ophthalmology. 2006113(3)466-72.
2. Khaw P, Ball D, Duchesne G. Carcinoid tumour of the orbital muscles: A rare occurrence. Australasian Radiology.
200145(2)179-81.
POSTERS
F31
Endonasal vs. External Dacryocystorhinostomy: A Meta-Analysis
W. Jordan Piluek, Timothy McCulley. Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School
Introduction: Controversy continues to surround the optimal dacryocystorhinostomy (DCR) technique. Endonasal DCR (EN-DCR)
avoids an external excision and resultant scar. It is also alleged to be associated with less morbidity and a shorter recovery time.
Proponents of external DCR (EX-DCR) tout a higher success rate. This study is designed to assess and compare success rates of
endonasal and external DCR.
Methods: A comprehensive literature search was conducted in PubMed to identify potentially relevant clinical studies. 1964
publications were identified. Of those, 375 addressed endonasal techniques, with 25 providing a direct comparison to external
techniques. All cases from these 25 studies were pooled and compared for success rates (chi-square). Differences in success rate
were plotted against year of publication, and a trend was assessed (Pearson’s coefficient). Prospectively and retrospectively
collected data were pooled and weighted similarly. Definitions for success were as determined by the original authors.
Results: The results of 2651 surgeries were included. The overall success rate of EX-DCR (87.5%, n=1301) was greater than
EN-DCR (82.4%, n=1350). This difference was statistically significant, p<0.01. In earlier reports, the difference between success
rates was greater than in more recent years. This trend was statistically significant (r=0.5, p=0.01).
Conclusions: Based on a meta-analysis of published data, external DCR has a statistically significant higher success rate than
endonasal DCR (87.5% vs 82.4%, p<0.01). However, the gap is closing with the success rate of endonasal approaching that of
external techniques in more recent years. This likely relates to improved endonasal techniques, possibly moving away from the use
of lasers and with the preservation of mucosal flaps.
References: 1. Zaidi FH, Symanski S, Olver JM. A clinical trial of endoscopic vs external dacryocystorhinostomy for partial
nasolacrimal duct obstruction. Eye (Lond). 2011 Sep;25(9):1219-24.
2. Walker RA, Al-Ghoul A, Conlon MR. Comparison of nonlaser nonendoscopic endonasal dacryocystorhinostomy with external
dacryocystorhinostomy. Can J Ophthalmol. 2011 Apr;46(2):191-5.
3. Leong SC, Karkos PD, Burgess P, Halliwell M, Hampal S. A comparison of outcomes between nonlaser endoscopic endonasal and
external dacryocystorhinostomy: single-center experience and a review of British trends. Am J Otolaryngol. 2010 Jan-Feb;31(1):32-7.
4. Feretis M, Newton JR, Ram B, Green F. Comparison of external and endonasal dacryocystorhinostomy. J Laryngol Otol. 2009
Mar;123(3):315-9.
5. Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhinostomy for
acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology. 2005 Aug;112(8):1463-8.
6. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal
Plast Reconstr Surg. 2004 Jan;20(1):50-6.
7. Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology. 2003
Jan;110(1):78-84.
8. Cokkeser Y, Evereklioglu C, Er H. Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130
eyes). Otolaryngol Head Neck Surg. 2000 Oct;123(4):488-91.
9. Hartikainen J, Antila J, Varpula M, Puukka P, Seppä H, Grénman R. Prospective randomized comparison of endonasal endoscopic
dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope. 1998 Dec;108(12):1861-6.
POSTERS
F32
The Role of Prophylactic Antibiotic Use in Orbital Fractures
Lamise Rajjoub, Benjamin Reiss, Craig Geist, Tamer Mansour. Ophthalmology, The George Washington University, Washington, DC,
United States
Introduction: The purpose of this study is to evaluate the role of prophylactic antibiotic use in patients with orbital fractures.
Methods: A retrospective chart review of all patients diagnosed with an orbital fracture at The George Washington University Hospital
(GWUH) and clinics between January 1, 2008 and March 1, 2014. Inclusion criteria consisted of having an orbital fracture diagnosed
by Computerized Tomography (CT) imaging at the GWUH Emergency Department or at a different emergency department if adequate
scanned records were present and at least one follow up examination by an Ophthalmologist and/or Otolaryngologist. Subjects were
excluded from the study if they had co-morbid conditions necessitating the use of therapeutic antibiotics not solely for the purpose of
orbital infection prophylaxis.
Results: 174 patients with orbital fractures met our inclusion and exclusion criteria. Of those, 19 patients (10%) received
no prophylactic antibiotics, 3 received a single dose of antibiotics in the operating room, 137 received oral antibiotics, and
13 received IV antibiotics. Sixty patients (34%) received two or more different antibiotics. Twenty-nine patients (14%) received at
least one dose of IV antibiotics (excluding cefazolin) within the first week solely for prophylaxis. By 3-month follow-up, no orbital
infections were documented.
Conclusions: The use of prophylactic antibiotics in patients with orbital fractures is widely used and found to be nearly universal
in our university hospital system. To our knowledge, our study is the first to assess for any evidence of benefit of such practice.
In a 3-month follow up period our study revealed no orbital infections in patients who did or did not receive antibiotic prophylaxis.
A larger study population, including the pediatric population, is underway to further assess evidence of benefit for prophylactic
antibiotics in orbital fractures.
References: 1. Martin B, Ghosh A. Antibiotics in orbital floor fractures. Emerg Med J. 2003 Jan;20(1):66. Review
2. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg. 2000
Oct;38(5):496-504
3. Brink, Susan. 2014 “Fatal Superbugs: Antibiotics Losing Effectiveness, WHO Say” National Geographic. http://news.
nationalgeographic.com/news/2014/05/140501-superbugs-antibiotics-resistance-disease-medicine/?sf2792698=1 (May 19, 2014)
4. Westfall CT, Shore JW. Isolated fractures of the orbital floor: risk of infection and the role of antibiotic prophylaxis.Ophthalmic Surg.
1991 Jul;22(7):409-11
POSTERS
F33
Dynamic Analysis of Muller’s Muscle Response to Phenylephrine
Sathyadeepak Ramesh, Ronald Mancini. Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, United States
Introduction: To characterize in vivo response of Muller’s muscle to phenylephrine with respect to time and diurnal variation.
Methods: A nonrandomized trial of healthy adults (n=20, 40 eyes) with measurement of marginal reflex distance-1 (MRD1) at 15
second intervals for 5 minutes with standard frontal plane full face photography (Figure 1) after instillation of topical phenylephrine,
once in the AM (6-10am) and once in the PM (6-10pm). Mean MRD1 was plotted over time, and AM and PM MRD1 were compared
with Spearman’s correlation coefficient (r) and paired t-test.
Results: Regardless of time of day, subjects had maximal response to phenylephrine within 120 seconds (Figures 2, 3).
Figure 4 shows mean MRD1 prior to instillation of phenylephrine in AM, PM, and total groups (3.87 ± 0.15mm, 3.96 ± 0.16mm,
and 3.92 ± 0.12mm respectively, p=0.20), at maximal response time (4.57 ± 0.19mm, 4.76 ± 0.14mm, and 4.62 ± 0.13mm
respectively, p=0.81), and mean change in MRD1 (0.53 ± 0.17mm, 0.76 ± 0.16, and 0.65 ± 0.12mm respectively, p=0.88).
There was no statistically significant difference in increase of MRD1 between AM or PM groups (p = 0.88), with excellent correlation
between AM and PM curves (Spearman’s r = 0.92).
Conclusions: Classical teaching suggests that the ptosis surgeon wait 5 minutes before measuring elevation in MRD1. Our study
demonstrates that maximal response to phenylephrine occurs within 120 seconds of instillation; there appears to be no diurnal
variation in phenylephrine testing.
POSTERS
F33
Dynamic Analysis of Muller’s Muscle Response to Phenylephrine, continued
References: 1. Bang YH, Park SH, Kim JH, Cho JH, Lee CJ, Roh TS. The role of Muller’s muscle reconsidered. Plast Reconstr Surg
1998;101(5):1200-4.
2. Skibell BC, Harvey JH, Oestreicher JH, Howarth D, Gibbs A, Wegrynowski T, Wing T, DeAngelis DD. Adrenergic Receptors in
the Ptotic Human Eyelid: Correlation With Phenylephrine Testing and Surgical Success in Ptosis Repair. Ophthalmic Plastic &
Reconstructive Surgery 2007;23(5):367-371 10.1097/IOP.0b013e3181462a2e.
3. Panza JA, Epstein SE, Quyyumi AA. Circadian variation in vascular tone and its relation to alpha-sympathetic vasoconstrictor
activity. N Engl J Med 1991;325(14):986-90.
4. Ayala E, Galvez C, Gonzalez-Candial M, Medel R. Predictability of conjunctival-Muellerectomy for blepharoptosis repair. Orbit
2007;26(4):217-21.
5. Baldwin HC, Bhagey J, Khooshabeh R. Open sky Muller muscle-conjunctival resection in phenylephrine test-negative
blepharoptosis patients. Ophthal Plast Reconstr Surg 2005;21(4):276-80.
POSTERS
F34
Chronic Anophthalmic Socket Pain Treated by Implant Removal and
Dermis Fat Graft
Pari Shams1, Meredith Baker1, Eva dafgard-kopp2, Elin Bohman 2, Richard Allen1. 1Department of Ophthalmology and Visual Sciences,
University of Iowa Hospitals and Clinics, Iowa City, IA, United States, 2Oculoplastic and Orbital services, St. Erik Eye Hospital,
Stockholm, Sweden
Introduction: The clinical management of chronic anophthalmic socket pain (ASP) can be challenging. The outcome of surgical
intervention, in patients in whom all detectable causes of pain had been ruled out and medical management had failed, is reported.
Methods: Retrospective, multicenter review of chronic ASP identified from a database of consecutive cases undergoing implant
removal and dermis fat graft implantation 2007-2013. Inclusion criteria included: 1) chronic ASP greater than 2 years and
unresponsive to treatment, 2) detailed socket examination and orbital imaging ruling out pathologic disease including prosthesis
related problems, lacrimal insufficiency, inflammation, infection, implant exposure and neoplasm, 3) surgical treatment by removal of
the orbital implant and placement of a dermis fat graft, 4) minimum 12-month post-operative follow-up.
Results: Six patients, 3 male, with intractable ASP were identified. Four cases underwent enucleation, and 2 were eviscerated at
an average age of 45 years (range 3-79). The incidence of ASP among enucleations at one center (UIHC) over a 7-year period was
0.7%. Indications for enucleation and evisceration included malignant melanoma, optic-nerve-glioma, blind-painful eyes due to
congenital and rubeotic glaucoma and trauma. ASP had been present for an average of 11 years (range 3-34) and persisted despite
medical management: anticonvulsants, antidepressants, opioids, antibiotics, orbital injections of local anesthetic and alcohol. All
patients were free of pain within 3 months of implant removal and dermis fat graft placement and remained pain free at an average
24 months (range 16-38) post-surgical follow-up.
Conclusions: Orbital implant removal and dermis fat graft was effective at relieving chronic ASP within 3-months of surgery, and
pain resolution was sustained in all cases at 2-years on average. This surgical intervention may be a useful management option for
patients in whom all detectable causes of pain have been excluded and have failed medical pain management.
References: 1. Bohman E, Rassmusen MLR, Dafgård Kopp D. Pain and discomfort in the anophthalmic socket. Curr Opin
Ophthalmol. 2014; In press.
2. Glatt HJ, Googe PB, Powers T, Apple DJ. Anophthalmic socket pain. Am J Ophthalmol. 1993; 116(3): 357-62.
3. Rasmussen ML, Prause JU, Toft PB. Phantom pain after eye amputation. Acta Ophthalmol. 2011; 89(1): 10-6.
4. Blodi FC. Amputation neuroma in the orbit. Am J Ophthalmol. 1949; 32(7): 929-32.
5. Borchers AT, Gershwin ME. Complex regional pain syndrome: a comprehensive and critical review. Autoimmun Rev. 2014;
13(3): 242-65.
POSTERS
F35
A Case of Dual Organism Canaliculitis
Janhavi Shirali, Alan Friedman, Albert Wu. Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
Introduction: Canaliculitis is an inflammation or infection of the canalicular portion of the lacrimal drainage system that may present
with epiphora, discharge from the punctum, unilateral conjunctivitis, and a swollen “pouting” punctum. It is often misdiagnosed
as chronic conjunctivitis, chalazion or dacryocystitis and accounts for only 2% of all patients with lacrimal disease. i Some case
series report actinomyces as the most common microbe ii, versus others, which identify streptococcus as the most commonly
cultured organism iii. We present a case of unilateral canaliculitis positive for both streptococcus and actinomyces in a patient with a
complicated ocular history whose symptoms resolved after biopsy and exploration of the canaliculus.
Methods: Case report: Case 1: Patient with unilateral canaliculitis diagnosed by canaliculotomy and examination of histopathology
and culture. A literature review was performed on PubMed with keywords “canaliculitis”, “actinomyces” and “streptococcus”.
Results: The patient is a 74-year-old female with a history of hypertension, diabetes, rheumatoid arthritis, and corneal perforation
after two penetrating keratoplasty operations in the right eye for corneal melt from rheumatoid arthritis who presented with mild
right eye pain, discharge and irritation for one year (Figure 1). Lacrimal irrigation and antibiotics did not resolve her symptoms. Her
symptoms resolved after canaliculotomy and biopsy followed by a course of antibiotics. Histopathology of the biopsy showed gram
positive filamentous organisms identified as actinomyces and gram positive cocci along with sulfur granules (Figure 2: H&E, Figure
3: Gram Stain). The culture was positive for group viridans streptococci. One month after the procedure the patient reported reduced
discharge, lacrimation and irritation.
Conclusions: We present an unusual case of unilateral canaliculitis that showed histopathology positive for both actinomyces and
streptococcus. Prior case series report either actinomyces or streptococcus as the most commonly identified organism.
Sulfur granules on histopathology are suggestive of actinomyces, but gram positive bacteria can also produce such granules. Hence,
culture is an important diagnostic tool along with histopathology as is evident from our case.
Our case report supports surgical management as the definitive treatment of canaliculitis. Initial conservative treatment with
oral antibiotics and the initial gram stain of secretions did not show positive microbiology or improve the patient’s symptoms.
Canaliculotomy is regarded as the definitive treatment of choice for primary canaliculitis.i In our patient as well, canaliculotomy
provided adequate material for culture and diagnosis and resulted in the resolution of the patient’s symptoms.
References: [i] Primary canaliculitis: clinical features, microbiology profile and management outcome. Kaliki S, Ali M, Honavar S,
Chandrashekar G, Naik M. Ophthal Plast Reconstr Surg. 2012(28):355-360
[ii] Primary and Secondary Lacrimal Canaliculitis: A Review of Literature. Freedman J, Markert M, Cohen A. Survey of Ophthalmology.
2011 July-Aug(56): 336-346
[iii] Clinical features and bacteriology of lacrimal canaliculitis in patients presenting to a tertiary eye care center in the Middle East.
Gogandy M, Al-Sheikh O, Chaudhry I. Saudi J Ophthalmol. 2014 Jan(28):31-5
POSTERS
F36
Outcomes of Strabismus Surgery in Thyroid Eye Disease Using the Technique
of Tenon Recession
Gregory Stein, Carisa Petris, Michael Kazim. Ophthalmology, Columbia University Medical Center, New York, NY, United States
Introduction: The goal of surgery for Thyroid Eye Disease-strabismus(TED-S) is to produce single binocular vision in primary and
reading gaze with or without <10 D prismatic correction. Due to the incomitance of the strabismus, eccentric gaze diplopia is
routinely accepted, as is the high rate of reoperation due to residual diplopia. We believe that the addition of tenon recession to the
standard muscle recession improves the success of surgery in primary gaze and eccentric binocular fusion. We examined the change
in deviation in primary and eccentric gaze in patients undergoing strabismus surgery with tenon recession for TED-S.
Methods: An institutional-review-board-approved, retrospective study was conducted of 19 patients with thyroid eye disease who
underwent only horizontal strabismus surgery with tenon recession. The surgical technique was previously described by Zoumalan
et al. 2011.1 Formal orthoptic measurements were obtained in all patients before and after surgery. The ocular deviations were
measured in Diopters (D). The mean of the total deviations in primary gaze as well as in eccentric gaze was calculated separately
for both the horizontal and vertical measurements. A Student’s paired t-Test with a two-tailed distribution was used to determine
the statistical significance of a difference in horizontal and vertical deviations in each field of gaze before and after surgery.
Data regarding postoperative double vision, prism use, fusion/binocularity and re-operation was also collected and analyzed.
Results: The average age of the subjects was 64 years. 11 female and 8 male patients were included. Primary gaze mean
horizontal ocular deviation (±standard deviation) was 32D±16(preop) and 3.8D±4.9(postop)(p<0.0001). In dextroversion deviation
was 32D±17(preop) and 6.8D±6.9 (postop)(p<0.0001), in levoversion 34D±17(preop) and 4.5D±3.4 (postop)(p<0.0001), in
supraduction 28D±21(preop) and 3.7D±4.6(postop) (p<0.0001) and in infraduction 32D±17(preop) and 4.3D±5.0(postop)
(p<0.0001). The difference between preoperative and postoperative vertical mean deviations was not clinically or statistically
significant in any field of gaze. At last postoperative measurement 89% of patients enjoyed single binocular fusion with or without
prisms (14 patients did not require prism or surgery, 3 patients required prism), and 2 patients required additional muscle surgery.
Conclusions: The addition of tenon recession in strabismus surgery for TED-S produces superior surgical outcomes in both primary
and perhaps of greater mechanistic interest in eccentric gaze.
References: 1. Zoumalan CI, Lelli GJ, Kazim M. Tenon Recession: A Novel Adjunct to Improve Outcome in the Treatment of
Large-Angle Strabismus in Thyroid Eye Disease. Ophthal Plast Reconstr Surg 2011; 27:287-29
POSTERS
F37
Retinoblastoma: A Surveillance, Epidemiology, and End Results Dataset
Evaluation for Treatment Patterns, Second Malignant Neoplasms, and
Overall Survival
Diana Tamboli1, Alan Topham2, Nakul Singh3, Vivek Patel4, Julian Perry5, Arun Singh5. 1Ophthalmology, Loyola University
Chicago Stritch School of Medicine, Chicago, IL, United States, 2Coalition of Cancer Cooperative Groups, Philadelphia, PA,
United States, 3Biostatistics, Harvard School of Public Health, Boston, MA, United States, 4Vanderbilt University, Nashville, TN,
United States, 5Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
Introduction: To characterize treatment patterns, overall survival, and risk of second malignant tumors in patients with
retinoblastoma (RB) using the SEER dataset.
Methods: The SEER dataset was used to identify cases of RB using ICD-03 histology codes. Special permission was granted by
the SEER administration to release chemotherapy information for this study (information which is not available in the standard
SEER dataset). Treatment of RB for patients with locoregional disease was characterized as surgical therapy, radiation therapy,
chemotherapy or any form thereof across 4 time periods from 1975-2010. Main outcome measures: Treatment trends over time,
observed-to-expected (O/E) ratios for second malignant neoplasms, and overall survival.
Results: There were 1452 cases of RB identified from 1975-2010 with 48% of patients being male and 30% presenting with
bilateral disease. Treatment patterns over time of 1220 (84%) patients with localized disease showed an increase in chemotherapy
(+/- any treatment) from 16.5% to 50.2% and a decrease in surgery (+/- any treatment) from 96.2% to 88.5% and decrease
in radiation from 15.2% to 4.9% from the 1975-1979 time period to the 2000-2010 time period, Figure 1. Risk of SMN was
highest among patients treated with radiotherapy with O/E ratio of 43 compared to 30 and 5 for chemotherapy and surgery alone,
respectively. The 10 year overall survival was 93.7%, 93.7%, 97.5%, and 97% for time periods (1975-1979, 1980-1989,
1990-1999, 2000-2010 respectively (p=0.029), Figure 2.
Conclusions: Treatment trends for RB show an increase in chemotherapy utilization with a decreased use of radiation therapy from
1975-2010. Second malignant neoplasms occurred mainly in patients treated with radiation therapy. To our knowledge, for the
first time, our series demonstrates improvement in survival in contemporary time periods, which parallels a shift in therapy towards
chemotherapy with a decline in radiation therapy.
References: Broaddus E, Topham A and Singh AD: Incidence of retinoblastoma in the USA: 1975-2004. British Journal of
Ophthalmology 2008; 93: 21-23.
Shinohara ET, Dewees T and Perkins SM: Subsequent malignancies and their effect on survival in patients with retinoblastoma.
Pediatr Blood Cancer 2013.
Paulino AC: Trilateral retinoblastoma. Cancer 1999; 86: 135-141.
Wong FL, Boice JD, Abramson DH, et al: Cancer incidence after retinoblastoma. Radiation dose and sarcoma risk. JAMA:
The Journal of the American Medical Association 1997; 278: 1262-1267.
Shields CL, Shields JA, Needle M, et al: Combined chemoreduction and adjuvant treatment for intraocular retinoblastoma.
Ophthalmology 1997; 104: 2101-2111.
Shields CL and De Potter P: Chemoreduction in the initial management of intraocular retinoblastoma. … of ophthalmology 1996.
Shields CL and Shields JA: Retinoblastoma management: advances in enucleation, intravenous chemoreduction, and intra-arterial
chemotherapy. Current Opinion in Ophthalmology 2010; 21: 203-212.
Broaddus E, Topham A and Singh AD: Survival with retinoblastoma in the USA: 1975-2004. British Journal of Ophthalmology
2008; 93: 24-27.
POSTERS
F37
Retinoblastoma: A Surveillance, Epidemiology, and End Results Dataset Evaluation for
Treatment Patterns, Second Malignant Neoplasms, and Overall Survival , continued
POSTERS
F38
Acquired Socket Contracture. The Role of the Yofibroblast Revisited
Hatem Tawfik1, Yousef Fouad2, Wesam Osman3, Hazem Rashed1, Mohamed Abdulhafez1, Sameh Abdelrahman1. 1Ophthalmology, Ain
Shams University, Cairo, Egypt, 2Medical Student, Ain Shams University, Cairo, Egypt, 3Pathology, Ain Shams University, Cairo, Egypt
Introduction: Conjunctival scarring is detrimental in causing acquired socket contracture. Prevention and modulation of conjunctival
wound healing could favorably impact the management of socket contracture. A previous pioneering study has demonstrated the
abundance of myofibroblasts in healing contracting and non-conracting sockets. 1
Methods: One eye from 15 skeletally mature white rabbits was eviscerated and the rabbits were divided into 5 groups. Each group
of 3 rabbits received a subconjunctival injection of a different agent.
Group I : Bevacizumab 25 mg/mL.
Group II : Triamcinolone 40 mg/mL.
Group III: 5 FU 50 mg/mL.
Group IV: MMC 0.4 mg/mL.
Group V: Control group with no injection given.
The animals were sacrificed 2 weeks after evisceration and conjunctival samples were submitted for histopathological examination.
Monoclonal anti alpha smooth muscle antibody was applied and the mean of 5 readings of the number of myofibroblasts was
recorded in each slide.
Results: The mean count of myofibroblasts was highest for the control group and all groups achieved statistically significant
reduction in myofibroblast count compared with the control group. Sorting the means showed that Group IV (MMC) achieved
the lowest mean value followed by group II (triamcinolone), while group I (bevacizumab) achieved the least reduction in
myofibroblast count.
Conclusions: Until newer anti-myofibroblast medications and antibodies are commercially available, a single injection of
MMC or triamcinolone could help improve the outcome of contracted socket surgery.
References: 1. Kaltreider SA, Wallow IH, Gonnering RS, Dortzbach RK. The anatomy and histology of the anophthalmic socket—
is the myofibroblast present? Ophthal Plast Reconstr Surg. 1987;3(4):207-30.
POSTERS
F39
Congenital Ptosis with Poor Levator Function: The Role of ConjunctivalMüllerectomy Repair
Leslie Wei, MD, Cathy Burkat, MD FACS. Department of Ophthalmology, Oculoplastic, Facial Cosmetic and Orbital Surgery Service,
University of Wisconsin – Madison, Madison, WI, United States
Introduction: Traditional surgical management of congenital ptosis with poor levator muscle function is a frontalis sling,
while conjunctival-Müllerectomy is generally reserved for patients with good levator function. We report a small series of pediatric
patients with congenital ptosis and poor levator function who underwent conjunctival-Müllerectomy.
Methods: Retrospective case series from the University of Wisconsin - Madison. Patients with congenital ptosis and levator function
<7 mm with no prior history of eyelid surgery who underwent conjunctival-Mülllerectomy ptosis repair were identified from the senior
author’s practice. All patients were seen postoperatively at 1-2 weeks, 2 months, and 6 months. Data on patient age, sex, pre and
postoperative margin reflex distance (MRD), levator function, pre and postoperative lagophthalmos, exposure keratopathy, visual
acuity, amblyopia, complications, and reoperations were collected and analyzed. T-test was used to compare pre and postoperative
MRD. Descriptive statistics were computed for all other recorded variables.
Results: Five patients (seven lids) with congenital ptosis and levator function <7 mm had a conjunctival-Müllerectomy ptosis repair
between 2006 and 2014. Four were female, one male. Ages ranged from 13 months to 18 years (average 6.2 years). Three were
unilateral, two bilateral. Preoperative levator function ranged from 3-6 mm, MRD 1-2 mm, and lagophthalmos 1-2 mm. Reasons for
pursuing this type of repair instead of a frontalis sling were parental wish for minimally invasive surgery with no permanent foreign
body, and concern for poor aesthetic outcome such as scarring or visible/palpable sling material. All patients had a conjunctivalMüller’s muscle resection of 9-10 mm. Postoperatively, the average MRD after at least 6 months of follow-up of operated eyelids
was 3.5 mm (range 3-4.5 mm). There was a significant increase in postoperative MRD compared to preoperative MRD (p <0.0001).
Postoperative lagophthalmos ranged from 1-5 mm, with most patients having 1-2 mm worsening of lagophthalmos compared to
preoperatively. There was no exposure keratopathy in any patients pre or postoperatively. One patient’s lid remained undercorrected
at 2 year follow-up, although still improved from baseline. There were no surgical complications or reoperations.
Conclusions: Conjunctival-Müllerectomy can be used successfully for congenital ptosis repair in patients with poor levator function
who cannot undergo frontalis sling for other reasons. In our series there were no cases of postoperative exposure keratopathy or
corneal abrasion despite increased lagophthalmos. A larger series is needed to further study the potential patient population that
could benefit from this procedure.
References: 1) Mazow ML, Shulkin ZA. Mueller’s muscle conjunctival resection in the treatment of congenital ptosis. Ophthal Plast
Reconstr Surg 2011;27:311-2.
2) Patel SM, Linberg JV, Sivak-Calcott JA, et al. Modified tarsal resection operation for congenital ptosis with fair levator function.
POSTERS
F40
Traumatic Orbital Encephalocele: Presentation and Imaging
Leslie Wei, MD1, Tabassum Kennedy, MD2, Sean Paul, MD3, Greg Griepentrog, MD3, Timothy Wells, MD3, Mark Lucarelli, MD 1.
1
Department of Ophthalmology, Oculoplastic, Facial Cosmetic and Orbital Surgery Service, University of Wisconsin – Madison,
Madison, WI, United States, 2Department of Radiology, University of Wisconsin – Madison, Madison, WI, United States, 3Division of
Oculofacial and Orbital Surgery, Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, WI, United States
Introduction: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe three cases
of orbital encephalocele due to trauma in children.
Methods: Retrospective case series from the University of Wisconsin – Madison and Medical College of Wisconsin. Traumatic orbital
encephaloceles were identified from the clinical practices of two authors (MJL and TSW). Data on patient age, gender, intracranial
pressure, and ophthalmic exam were collected and analyzed. Fracture size, orbital mass size, and concomitant facial fractures were
also measured from available imaging.
Results: Three cases of traumatic orbital encephalocele in pediatric patients were found. Two were female, one male. Ages ranged
from 3 to 17 years. Mechanism of injury was motor vehicle accident in two patients and accidental self-inflicted gunshot wound in
one patient. All three patients sustained orbital roof fractures (4 mm to 19 mm in width), frontal lobe contusions, intraparenchymal
brain hemorrhages, high intracranial pressure, and multiple facial and skull fractures. A key finding in all 3 cases was progression
of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage
adjacent to the roof fractures, with subsequent enlargement of the mass over several days to two weeks and eventual diagnosis of
encephalocele. Fracture fragment diastasis remained stable in two patients, but showed enlargement in one. All patients underwent
encephalocele repair by neurosurgery.
Conclusions: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital
encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial
hematoma, which can be difficult to distinguish from herniated brain tissue. An MRI of the orbits and brain with contrast should
be obtained for additional characterization, as high resolution T1 and T2-weighted sequences on MRI are optimal for diagnosis
and tissue characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging
heterogeneous orbital mass in conjunction with a roof fracture ≥ 4 mm in width and /or widening fracture segments.
References: 1) Cayli SR, Kocak R, Alkan A, et al. Intraorbital encephalocele: an important complication of orbital roof fractures in
pediatric patients. Pediatr Neurosurg. 2003;39:240-5.
2) Giuffrida M, Cultrera M, Antonelli V, et al. Growing fracture of the orbital roof with post-traumatic encephalocele in an adult patient.
Case report. J Neurosurg Sci. 2002;46:131-4.
3) Antonelli V, Cremonini AM, Campobassi A, et al. Traumatic encephalocele related to orbital roof fractures: report of 6 cases and
literature review. Surg Neurol. 2002;57:117-25.
4) Manfre L, Nicoletti G, Lombardo M, et al. Orbital “blow-in” fracture: MRI. Neuroradiology. 1993;35:612-3.
Videos
Point of view (POV) Video Surgical Training: The use of Consumer
Electronics to Record and Teach Oculoplastic Surgery Procedures from
the Surgeon’s Perspective
Jonathan Hurst, Paul Huang, Vladimir Kratky. Ophthalmology, Queen’s University, Kingston, ON, Canada
Introduction: While video has to been demonstrated to benefit the teaching of surgical skills, there have until recently been
financial and technical barriers to the creation of high quality digital recordings for oculoplastics training. Traditional ‘over-theshoulder’ (OTS) filming is fraught with a number of technical problems including: obstruction of camera view by the surgeon
or assistant, difficulty adjusting and maintaining focus, poor view of small ‘keyhole’ surgical fields (eg. external-DCR), bulky
equipment (eg. tripods), and necessary compensatory maneuvers by the surgeon to maintain an adequate view for the camera.
For these reasons and the resource cost associated with older technologies, video production for oculoplastics residency training
has not kept pace with other surgical specialties.
Methods: We describe an inexpensive and simple method to create surgical teaching videos from the unobscured, direct
perspective of the oculoplastics surgeon using readily available consumer electronics. A GoPro Hero3 camera on a head-mount
accessory was used in conjunction with an iPhone 5S and the GoPro iOS application to capture high definition video with a clear
view not offered by (OTS) video capture systems. An Apple computer and proprietary video-editing software were used to edit and
export videos for teaching purposes.
Results: We created the first surgical video library of high-definition digital videos taken from the true viewpoint of an ASOPRS
surgeon for the purpose of resident teaching. Our videos are free of the pitfalls of traditional OTS viewpoint and required fewer
resources to produce.
Conclusions: POV surgical teaching videos for Oculoplastics resident training are superior to traditional OTS recording techniques
and can be created with minimal cost and/or technical expertise using accessible consumer electronics.
References: Ruiz, Jorge G., et. al. “The impact of e-learning in medical education.” Academic medicine 81.3 (2006): 207-212.
Satava, Richard M. “Emerging technologies for surgery in the 21st century.” Archives of Surgery 134.11 (1999): 1197-1202.
Reznick, Richard K., and Helen MacRae. “Teaching surgical skills—changes in the wind.” New England Journal of Medicine
355.25 (2006): 2664-2669.
Wurnig, P. N., et al. “A new method for digital video documentation in surgical procedures and minimally invasive surgery.”
Surgical Endoscopy And Other Interventional Techniques 17.2 (2003): 232-235.
Nakayama, Hisashi, et al. “Recording of surgery with two crane-type tripods and video cameras.” International surgery 89.4
(2003): 217-220.
Martin, Edwin, and P. M. L. Martin. “The reactions of patients to a video camera in the consulting room.” JR Coll Gen Pract 34.268
(1984): 607-610.
Nousiainen, Markku, et al. “Comparison of expert instruction and computer-based video training in teaching fundamental surgical
skills to medical students.” Surgery 143.4 (2008): 539-544.
Xeroulis, George J., et al. “Teaching suturing and knot-tying skills to medical students: a randomized controlled study comparing
computer-based video instruction and (concurrent and summary) expert feedback.” Surgery 141.4 (2007): 442-449.
Videos
Permanent Punctal Closure for Dry Eye Disease with the Slit-lamp
532nm Diode Laser
Charles Rice1,2. 1Lansing Ophthalmology, East Lansing, MI, United States, 2Ophthalmology, Michigan State University,
East Lansing, MI, United States
Introduction: The slit-lamp 532nm laser is a precise, effective, and reproducible method for permanent punctal closure in
patients with moderate to severe dry eye disease.
Methods: Twenty-four patients with moderate to severe dry eye disease who were unable to tolerate previously placed punctal plugs
or had spontaneous extrusion of previous plugs were selected for the study. Treatments were performed over a two year period.
A 532nm continuous wave millisecond pulsed laser with slit-lamp adaptor was used with 500 microns spot size, 800mWatts power,
and 0.2 seconds duration. The punctum was marked with gentian violet and cauterized at 1.5 mm width and 1mm depth with
30 to 50 pulses.
Results: Of 54 treated puncta, 49 ( 90%) were successfully closed with complete closure or pinpoint opening. The interval from
laser treatment to last follow-up exam ranged from 4 to 30 months with an average of 15 months. There were no complications or
cases of epiphora. Punctal closure correlated with lessening of dry eye symptoms in the majority of cases.
Conclusions: The consequences of moderate to severe dry eye disease have a profound effect on the quality of life. 1 Unless
adequately treated prior to ocular or eyelid surgery, worsening of dry eye disease can have a significant impact on comfort and vision.
Although silicone plugs are used commonly for long term punctal closure, their effectiveness is limited by spontaneous extrusion,
ocular irritation, and bacterial adherence. 2-3 Indwelling canalicular plugs such as the Medinnium® plugs result in a high rate of
infection with eventual surgical removal. Methods for permanent punctal closure include high temperature battery cautery, argon
laser, or surgical closure. 4 Battery cautery is low cost and effective but lacks precision and consistent reproducibility. The argon
laser is expensive and ineffective due to inability to cauterize the canalicular ring. Surgery is also effective but more time consuming.
The 532nm diode laser is a portable, low maintenance, and reliable laser used in treating retinal disease and available in many
ophthalmic practices. The precision and magnification of the slit lamp laser coupled with successful cauterization achieved using
gentian violet as an artificial chromophore makes this a viable option for permanent punctal closure.
References: 1. Friedman NJ. Impact of dry eye disease on quality of life. Curr. Opin. Ophthalmol. 2010; 21(4):310-6
2. Tai MC, Cosar CB, Cohen EJ. The clinical efficacy of silicone plug therapy. Cornea 2002; 21:135-9.
3. Balarum, M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye
symdrome. Am J Ophthalmol. 2001;131(1):30-6.
4. Vrabec MP, Elsing SH, Aitken PA. A prospective, randomized comparison of thermal cautery and argon laser for permanent punctal
occlusion. Am J Opthalmol. 1993; 116:469-71
Videos
Recurrent Bone Formation in a Complex Grade III Choristoma of the
Anterior Segment
Jeremy Tan1, P. Lloyd Hildebrand1, Annie Moreau1, Hans Grossniklaus2. 1Ophthalmology, Dean McGee Eye Institute, Oklahoma City, OK,
United States, 2Ophthalmology, Emory Eye Center, Atlanta, GA, United States
Introduction: Pediatric case presentation of an unusual progressive course of a complex anterior segment choristoma.
Methods: This is a single case report with history and photographs beginning as an infant in China through present day age 8.
Our direct involvement began at age 5 with clinical evaluation, pre-surgical photographs, CT scan, surgical management, postsurgical photographs, and pathologic assessment. Intermediate follow-up was carried out by an outside ophthalmologist due to
distance from our center. Our involvement was again called for at age 8 with a repeat clinical evaluation, pre-surgical photographs,
CT scan, surgical management, post-surgical photographs, and pathologic assessment for comparison and analysis.
Results: A 5-year old girl adopted from China presented with proptosis of disorganized contents from the left orbit. Sequential
photographs show an anterior cystic epithelialized mass which auto-amputated in early childhood leaving an area of keratinized
epithelium, no definitive cornea, and shortened fornices. CT scan showed a microphthalmic globe with a large anterior cystic
structure containing tissue of similar density to bone. Limited surgical debulking of the calcified tissue provided relief of proptosis.
To provide volume for normal development of the bony orbit, soft tissues were left in place with avoidance of uveal exposure. The
specimen had a tooth-like structure, but following decalcification, histology showed well differentiated cortical bone without evidence
of malignancy. Three years later she presents with recurrent proptosis of the orbital contents preventing lid closure. CT Imaging
revealed a new calcified mass. An exploratory anterior orbitotomy with “en-bloc” resection of the large cystic mass with enucleation
of the microphthalmic globe was performed. A 12 mm silicone sphere orbital implant was placed in the orbit, the conjunctiva closed
and a small conformer placed to maintain fornices for prosthesis fitting. Gross evaluation revealed a new tooth-like growth within a
keratinized cystic structure extending from the anterior segment of a microphthalmic globe. Pathologic evaluation revealed skin,
hair, and bony formation with lack of endodermal tissue consistent with complex choristoma of the anterior segment.
Conclusions: Although subtotal resection of a choristoma
for preservation of tissue volume for stimulation of bony orbit
development is described in the literature¹,² targeted debulking
may result in recurrence of bone formation as described in our
case. Definitive “en bloc” resection of the microphthalmic eye
and the choristoma³ allowed for a good cosmetic outcome with
prosthetic eye placement.
References: 1) Hou ZJ, Korn BS, Ding JW, Li DM.
Management of Extensive Epibulbar Choristoma Associated
With Microphthalmos. JAMA Ophthalmol. Published online
April 03, 2014.
2) Huang TY, Tsai YJ, Tan HY, Ma L. Managing epibulbar choristoma
with microphthalmos. J Pediatr Ophthalmol Strabismus. 2008
May-Jun;45(3):172-3.
3) Oakman JH, Lambert SR, Grossniklaus HE. Corneal Dermoid:
Case Report and Review of Classification. J Pediatr Ophthalmol
Strabismus. 1993;30:388-391.
Videos
Trans-nasal, Trans-caruncular Orbitotomy for Inferomedial Tumors of the
Orbital Apex
Grant Moore, Alexander Nobori, Daniel Rootman, Robert Goldberg. Ophthalmology, University of California, Los Angeles,
Introduction: We describe and demonstrate via video the use of combined trans-nasal endoscopic and trans-caruncular approach
orbitotomy for the excision of inferomedial apical orbital masses.
Methods: Cases of combined trans-nasal endoscopic, trans-caruncular approach orbitotomy were reviewed. To maximize
visualization and assist in approach to the orbit, an initial trans-caruncular incision followed by dissection of the medial orbit was
performed prior to endoscopy. The anterior ethmoidal neurovascular bundle was identified and cauterized. The lamina papyracea
of the posterior ethmoid was then opened from the orbital side.
The endoscopic dissection involved medicalization of the turbinate, excision of the ethmoid bullae cell and removal of the
anterior-posterior waslls of the ethoid air cells exposing the anterior border of the sphenoid sinus. Of note, the anterior wall
of the sphenoid can also be removed at this time if the lesion extends posteriorly on pre-operative imaging.
The periorbita was incised with an arthroscopy blade endoscopically, and the annulus of Zinn was opened if necessary.
When needed, the optic strut was removed for further visualization and nerve decompression. Tumors were removed either
trans-nasally with takahashi forceps or trans-caruncularly with an Olympic grasp (Figure 1).
Post-operative data was reviewed for visual acuity, tumor recurrence, and other pertinent exam data.
Results: Four orbits in 4 patients were included with mean follow-up of 4 months. The lesions excised included 3 cavernous
hemangiomas and 1 metastatic carcinoid tumor. The masses were successfully accessed and removed in all cases. One patient who
had undergone previous orbitotomy for removal of the same apical orbital cavernous hemangioma experienced NLP vision postoperatively that did not improve. Of note, the patient had optic nerve head pallor and atropy on MRI prior to surgery.
Conclusions: Combined trans-nasal endoscopic, trans-caruncular approach orbitotomy is an effective method for excision of lesions
in the inferomedial orbital apex. Advantages of this approach include increased visualization and magnification of the orbital apex for
incising the annulus, identification of mass lesions, and dissection. The combined approach also creates space posteriorly to allow for
medial prolapse of the lesion with transorbital dissection on the lateral side of the lesion. Additionally, the opportunity for transnasal
grasping creates counter traction for orbital and endonasal dissection. Apical cavernous lesions with optic nerve atrophy may be at
elevated risk of visual sequelae, and the endo-nasal approach is not immune to these complications. When considered as a whole,
the endonasal anatomy and combined technique can be mastered by, and are within the scope of, the oculofacial surgeon.
Figure 1: Hemangioma removal via trans-nasal endoscopic aspect of combined approach.
American Society of Ophthalmic Plastic & Reconstructive Surgery
The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) was
founded in 1969 to establish a qualified body of surgeons who have training and experience
in the highly specialized field of oculofacial plastic surgery. ASOPRS has achieved this through
their commitment to the advancement of education, research and the quality of clinical practice
in the fields of aesthetic and reconstructive surgery specializing in the eyelids, orbits, lacrimal
system and face. Today, the Society has over 600 national and international members.
To meet our mission, ASOPRS accredits and oversees post-graduate fellowships across the
United States, training well qualified physicians in the field of oculofacial plastic surgery.
ASOPRS presents an annual Fall Scientific Symposium prior to the AAO Subspecialty Day,
as well as a Spring Meeting available to members only.
ASOPRS is an honorary society, with entry requirements including a 2-year Society-sponsored
oculoplastics fellowship, oral and written examinations and approval of an original thesis.
Other pathways to membership are available to those who did not complete an
ASOPRS-accredited fellowship, and for international oculoplastics surgeons.
www.asoprs.org
ASOPRS 46 TH ANNUAL FALL SCIENTIFIC SYMPOSIUM
NOVEMBER 12-13, 2015
Caesars Palace, Las Vegas, NV

Symposium - American Society of Ophthalmic Plastic and

Transcription

Similar documents

Postcard FINAL 7-23-14 - MD Anderson Cancer Center

LaStalla Night

- Gazprom Space Systems

Feline Orbital Pseudotumor - University of Wisconsin School of

LightMat®

MFI Employee Benefits

Final Program

Dr. Tim Bassett Dr. Bryan King