Scanning Electron Microscopic Features of the Inferior Meatal Nasolacrimal Duct Openings

Purpose: The aim of this study was to examine the ultrastructural features of the nasolacrimal duct (NLD) openings in the inferior meatus. Methods: Five openings of the NLD in the inferior meati from 5 sagittal head sections of 3 cadavers were studied. Each of the openings were completely excised with 2 mm margins on all sides and transported to the laboratory in 2.5% glutaraldehyde. The analysis was performed using the standard protocols of scanning electron microscopy. The ends, edges, and surfaces were studied along with the mucosal folds, if any, guarding the edge of the openings. Results: Of the 5 NLD openings studied, 4 were of the sulcus variety and 1 was of the shape of a fissure. The fissure opening had a guarding anterior edge mucosal fold. The luminal surfaces of the openings were mostly smooth with focal defined glandular structures. Occasional heterogenous areas with prominent and extensive well-defined glands lined by ciliated columnar epithelium were noted. There were presence of mucosal folds on the floor of the sulci of the openings giving an appearance of a subsulcus. Conclusions: The luminal surfaces of the NLD openings in the inferior meati shows mucosal folds reflected on themselves and cavernous vessels throughout the expanse of the openings. Tear rheology at the NLD opening and the physiologic role of subsulci need to be investigated further. Accepted for publication July 3, 2018. M.J.A. receives royalties from Springer for his treatises "Principles and Practice of Lacrimal Surgery" and "Atlas of Lacrimal Drainage Disorders." The author has no conflicts of interest to disclose. Address correspondence and reprint requests to Mohammad Javed Ali, F.R.C.S., Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad 500034, Telangana, India. E-mail: drjaved007@gmail.com © 2018 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.

Color Doppler Flow Imaging of Retrobulbar Ocular Blood Flow Changes in Retinal Artery Occlusions Caused by Cosmetic Facial Filler Injections

Purpose: This study aimed to evaluate the effects of retinal artery occlusions caused by cosmetic facial filler injections on the retrobulbar blood flow parameters. Methods: This was a retrospective, noncomparative case series. Ten consecutive patients with fundus artery occlusions caused by facial filler injections were evaluated using color Doppler flow imaging (CDFI). The peak systolic velocity and end diastolic velocity of the ophthalmic artery, central retinal artery, and posterior ciliary arteries were determined. The clinical features, including the filler material, injection site, best-corrected visual acuity, fundus fluorescein angiography, and associated ocular and systemic manifestations were also collected. Results: Injected materials included autologous fat (7 cases) and hyaluronic acid (3 cases). In 6 of the patients with ophthalmic artery occlusions, the CDFI showed no or drastic declines in the retrobulbar blood flow in the ophthalmic artery, central retinal artery, and posterior ciliary arteries. In 3 of the patients with central retinal artery occlusions, the CDFI showed no or a grossly decreased retrobulbar blood flow in the central retinal artery. In one patient with anterior ischemic optic neuropathy, the CDFI showed decreased end diastolic velocities and increased pulsatility and resistance indices in the central retinal artery, posterior ciliary arteries, and ophthalmic artery. During the follow-up period, the retrobulbar blood flow recovered to some degree. Overall, ophthalmic artery occlusion patients receiving autologous fat may have neurologic complications. Conclusions: The results suggest that the retrobulbar ocular blood flows measured with CDFI were distinctly different in the different types of ophthalmic artery occlusion. Color Doppler flow imaging could provide a practicable and convenient method for the diagnosis and follow up of retinal artery occlusions caused by cosmetic facial filler injections. Accepted for publication July 8, 2018. The authors have no financial or conflicts of interest to disclose. Dr Xue had full access to all of the data in the study, taking responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were performed by Dr Xue, A. Liu, P. Huang, and Dr Ren. Acquisition, analysis, or interpretation of the data were carried out by Dr Xue and P. Huang. Drafting of the manuscript was done by P. Huang. Critical revision of the manuscript for important intellectual content was performed by all authors. Statistical analysis was done by P. Huang. Administrative, technical, or material support was given by P. Huang and Dr Ren. Address correspondence and reprint requests to Kang Xue, M.D., Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai 200031, China. E-mail: xuekang@foxmail.com © 2018 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.

Early Experience With Nonporous Polyethylene Barrier Sheet in Orbital Fracture Repair

Purpose: The aim of this study was to evaluate the efficacy of the nonporous polyethylene barrier sheet as an alternative for nylon foil (SupraFOIL) implants in repair of orbital fractures. Methods: This is a prospective, case series using the Stryker 0.4-mm-thick nonporous polyethylene barrier sheet in all patients over the age of 18 years presenting with orbital fractures from December 2014 to June 2015. Patient's age, location of fracture, etiology of injury, presence of preoperative restriction and diplopia, and postoperative diplopia and/or enophthalmos was recorded. Institutional review board approval was received, and consent was obtained from all participants. Patients were followed for at least 6 months when possible. Scanning electron microscopy was used to compare the thickness, surface characteristics, and porosity of the nonporous polyethylene barrier and nylon foil implants. Beam deflection testing was also performed to compare the biomechanical properties of each implant. Results: Forty-six patients who underwent repair of orbital fractures with the nonporous polyethylene barrier sheet were included in this series. Average age was 43.3 years (range: 18–84 years). Twenty-six of 46 patients (56.5%) were males, and 20 (43.4%) were females. The most common causes of injuries were assault (38.3%), falls (25.5%), motor vehicle accident (14.9%), and sports related (10.5%). Twenty of 46 patients (43.4%) had isolated orbital floor, and 2 patients (4.3%) had isolated medial wall fractures. Fifteen patients (32.6%) had combined floor and medial wall fractures involving the inferomedial orbital strut, and 9 (19.6%) had floor fractures associated with zygomaticomaxillary complex or lateral wall fractures. Twenty-eight patients (60.9%) had preoperative diplopia. Timing of surgery was between 3 and 55 days, with the median of 11.5 days. Five of 46 patients (10.8%) had residual diplopia at their 1-week postoperative visit, 4 of those patients' diplopia had resolved at 2 months postoperatively. One patient had residual diplopia at 6-month follow up. Electron microscopy showed that the 0.4-mm nonporous polyethylene barrier implant was thinner (0.33 mm) than expected and thinner than 0.4-mm SupraFOIL (0.38 mm). Scanning electron microscopy exhibited that the surface of the nonporous polyethylene barrier was smooth and nonporous. Beam deflection testing showed that for small forces (

Orbital Extension of Conjunctival Pseudoadenomatous Hyperplasia

A 41-year-old woman developed persistent unilateral conjunctivitis following an upper respiratory infection. A white cystic lesion of the inferior fornix was noted on computed tomography scan to extend behind the orbital septum into the anterior portion of the orbit. Following subtotal excision, histopathology showed benign pseudoadenomatous (pseudoglandular) hyperplasia. The case represents the 5th report of this lesion occurring in the conjunctiva and the only instance of its extension into the orbit.

Re: “Can We Improve the Tolerance of an Ocular Prosthesis by Enhancing Its Surface Finish?”

No abstract available

Endonasal Approach to Orbital Pathology

Purpose: Transnasal endoscopic orbital surgery in an emerging surgical field. The surgical field has expanded from orbital decompression to excision of tumours from the medial orbit and over the last 20 years. As instrumentation has improved, the nature, location and size of tumours being excised has changed. Methods: This article discusses the salient surgical considerations when approaching an orbital lesion via a transnasal endoscopic route and reviews the literature. Results: An endonasal approach offers a potential space surgeons can utilise to access the orbit, possibly providing additional exposure, illumination and magnification to the medial and apical aspects of selected lesions. Conclusions: An endonasal approach may be useful as a sole or adjunctive approach in selected cases of orbital tumour excision.

Cyst Excision and Globe Preservation in a Case of Microphthalmos With a Large Orbital Cyst and Visual Potential

Congenital microphthalmos belongs to a spectrum of diseases ranging from true anophthalmos to congenital clinical anophthalmos to microphthalmos. These conditions are frequently associated with an orbitopalpebral cyst, and pathologically, this represents a failure in the closure of the embryonic fissure at the 7–14 mm stage of gestation. The cyst develops as an outpouching from the eyeball and is generally helpful as it provides a stimulus for the orbit to expand. The general management guideline is to retain the cyst till it provides a stimulus for the orbit to expand and then to consider aspiration and sclerotherapy once orbital expansion is achieved. However, in eyes that have visual potential, sclerotherapy is contraindicated. The authors present an unusual case of a mildly microphthalmic eye with visual potential and a communicating cyst that was excised with a good result. The challenges faced in the excision of the communicating cyst with a wide pedicle and the management of the case are highlighted.

Paracanthal “One-Snip” Decompression in a Cadaver Model of Retrobulbar Hemorrhage

Purpose: The authors assess the effectiveness of a modified paracanthal or "one-snip" procedure compared with the traditional lateral canthotomy and inferior cantholysis in the reduction of intraocular pressure (IOP) and proptosis in a human cadaveric model of retrobulbar hemorrhage. Methods: This study comprised a comparative interventional study in a cadaveric model of retrobulbar hemorrhage. Six orbits of 3 fresh cadavers were included in the study. Baseline measurements of IOP and proptosis were recorded for all 6 orbits before and after simulation of retrobulbar hemorrhage as previously described. Right orbits (n = 3) underwent traditional lateral canthotomy and inferior cantholysis. Left orbits (n = 3) underwent modified paracanthal or "one-snip" procedure. The primary outcome measures were reduction in IOP and proptosis between the 2 techniques. Results: Following lateral canthotomy and inferior cantholysis of each right orbit, the average IOP dropped to 14 mm Hg (range of 11–18 mm Hg), corresponding to a mean decrease of 32 mm Hg. Following the "one-snip" procedure of each left orbit, the average IOP dropped to 19 mm Hg with a range of 16 to 23 mm Hg, corresponding to a mean decrease of 22 mm Hg. There was no statistically significant difference in IOP reduction (p = 0.36) or proptosis reduction (p = 0.23) between the 2 treatment groups. Conclusions: Compared with traditional lateral canthotomy xand inferior cantholysis, the modified paracanthal or "one-snip" procedure is effective for IOP reduction and led to mild improvement of proptosis in a cadaveric model of retrobulbar hemorrhage. The authors hope this study helps improve orbital compartment syndrome outcomes by providing an option that more providers will feel comfortable performing and therefore decreasing time to surgical decompression.

Mild Complications or Unusual Persistence of Porcine Collagen and Hyaluronic Acid Gel Following Periocular Filler Injections

The purpose of this study was to describe the histopathologic appearance of dermal eyelid fillers that were unexpectedly encountered in ophthalmic plastic surgery samples from patients with mild eyelid disfigurements, and to review eyelid cases with complications that had previously been described in the literature. A retrospective histopathologic study with Alcian blue, elastic, and Masson trichrome stains of 2 cases that were submitted to the Ocular Pathology Department was conducted, and a critical review of previously published cases of the histopathologic characteristics of dermal filler material in the periocular region was also conducted. Two periocular tissue samples were found to contain dermal filler material. In one case, porcine collagen appeared as amorphous or indistinctly microfibrillar aggregates that stained light blue with the Masson trichrome method. In the other case, hyaluronic acid gel appeared as vivid blue amorphous pools of material in extracellular locules after staining with the Alcian blue method. An inflammatory response was not observed in either case. Patients who undergo facial filler procedures may, at a later time, require a surgical excisional procedure from which a specimen is generated. Previously injected dermal filler that the patient neglected to mention may be present in the pathologic sample, potentially perplexing the unsuspecting pathologist. Both ophthalmic plastic surgeons and ocular pathologists should be aware of the histopathologic features of dermal fillers. It is helpful if a surgeon who submits a specimen to the pathology service makes note of any known prior use of facial filler material or is alert to its possible presence when unfamiliar foreign material is discovered in the dermis of the eyelids.

Significance of Early Postoperative Eyelid Position on Late Postoperative Result in Mueller’s Muscle Conjunctival Resection and External Levator Advancement Surgery

Purpose: The purpose of this study was to determine whether advancement of the levator aponeurosis in external levator resection surgery or Mueller's muscle and conjunctiva in Mueller's muscle conjunctival resection (MMCR) surgery has a differential effect on variation in eyelid position during the postoperative period. Methods: In this retrospective observational cohort study, 2 groups of patients were defined. The first underwent MMCR surgery without tarsectomy by surgeon 1. The second underwent external levator resection without dissection posterior to the levator aponeurosis by surgeon 2. Marginal reflex distance (MRD1) was calculated based on digital photographs at baseline, 1 week postoperatively and at 3-month follow up. The primary outcome measure was change in MRD1 over time. The secondary outcome was defined as the proportion of patients with minimal early postoperative change (change of MRD1 less than 0.5 mm at 1 week postoperatively). Repeated measures analysis of variance, t test, and chi-square analyses were performed. Results: Of the 114 eyes in the sample, there were 68 in the MMCR group and 46 in the external levator resection group. A significant interaction between group and time was noted (p 1 mm from the early postoperative to the late postoperative time points. Conclusions: Both external levator resection and MMCR can effectively elevate the eyelid in cases of primary involutional ptosis, and have similar late postoperative results. The authors found that MMCR cases undergo greater change between the early and late postoperative period, suggesting the process of eyelid elevation after MMCR may be dynamic, involving postoperative physiologic modification.

Sino-Orbital Fungal Infection by Tilletiopsis minor, a Rare Human Pathogen, Diagnosed by Internal Transcribed Spacer Sequencing

Orbital infection can be caused by numerous pathogens, and accurate diagnosis informs appropriate therapy. The authors report a case of a 78-year-old man with well-controlled diabetes mellitus and recurrent sino-orbital infection following multiple surgical procedures with negative microbiologic results. This case presented a diagnostic and treatment challenge and was aided by the use of internal transcribed spacer sequencing for pathogen identification. The fungal pathogen, Tilletiopsis minor, has not previously been described as a human pathogen in the sinus and orbit. This report describes a novel orbital pathogen and highlights the importance of diagnostic diligence and utilizing internal transcribed spacer sequencing in the workup of atypical orbital infection.

Symmetry of Upper Eyelid Contour After Unilateral Blepharoptosis Repair With a Single-strip Frontalis Suspension Technique

Purpose: To analyze the upper eyelid contour of patients with unilateral congenital ptosis who underwent single-strip frontalis suspension. Methods: The authors compared the upper eyelid shape of the right and left eyes of 10 patients who underwent unilateral frontalis suspension with a single strip of autogenous fascia. At a mean postoperative time of 10.1 ± 4.01 months, the image J software was used to measure the ratio between the nasal and temporal areas of the upper half of the palpebral fissure. The midpupil upper eyelid distance (MRD1) was also measured on the photos with the same software. The nonparametric Wilcoxon signed-rank test was used to compare the data. Results: Postoperative MRD1 ranged from 2.5 to 4.7 mm (median = 3.8) on the affected side. The MRD1 for nonoperated eyelid ranged from 1.8 to 5.0 mm (median = 3.5). On the operated side, the temporal areas ranged from 50.3 to 85.7 mm2 (median 65.2) and nasal areas ranged from 41.5 to 72.3 (the median was 60.1). In the contralateral, nonoperated palpebral fissures, the temporal areas ranged from 42.7 to 94.3 mm2 (median = 54.5) and the nasal areas ranged from 36.8 to 86.1 mm2 (median 52.3). The T/N ratio distributions were almost identical between groups, ranging from 0.9 to 1.2 (median = 1.1) in the operated eyes and from 0.9 to 1.3 (median = 1.1) in the fellow eyes. Conclusions: In autogenous fascia frontalis suspension procedures, the upper eyelid contour of the ptotic eyelids can be adequately normalized with a single area of traction on the tarsal plate.

Conjunctival Dirofilariasis Causing Symptoms for 1 Day

No abstract available

Continuous Positive Airway Pressure Thresholds for Nasolacrimal Air Regurgitation in a Cadaveric Model

Purpose: To elucidate the mechanisms underlying nasolacrimal air regurgitation (AR) in the setting of continuous positive airway pressure therapy. Methods: Twelve nasolacrimal systems of 6 fresh female human cadavers were evaluated individually for AR using continuous positive airway pressure therapy before any nasolacrimal procedure. Cadavers were then randomly assigned to undergo nasolacrimal duct probing or endoscopic dacryocystorhinostomy and then each hemisystem was again evaluated for AR. The pressure where AR was first observed (discovery pressure) or maximum possible pressure in systems without AR was recorded. In systems that demonstrated AR, the pressure was then gradually decreased to the lowest pressure where regurgitation persisted. This pressure was recorded as the secondary threshold pressure. Results: None of the 12 unoperated nasolacrimal systems or the 6 systems that underwent nasolacrimal duct probing demonstrated AR through the maximum continuous positive airway pressure therapy (30 cm H2O). After endoscopic dacryocystorhinostomy, all 6 nasolacrimal systems demonstrated AR. The mean discovery pressure was 16.0 cm H2O (range, 14.0–18.0 cm H2O) and mean secondary threshold pressure was 7.25 cm H2O (range, 6.5–8.0 cm H2O). Conclusions: Air regurgitation during continuous positive airway pressure therapy in the setting of prior endoscopic dacryocystorhinostomy can be replicated in a cadaver model. The secondary threshold pressures required for AR in this model were similar to AR pressures reported clinically. Prior to dacryocystorhinostomy, patients using continuous positive airway pressure therapy should be counseled on AR, and physicians should consider this phenomenon when evaluating ophthalmic complaints in postoperative patients on positive airway pressure therapy.

Aesthetic Abstracts and Citations

No abstract available

Orbital Extranodal Marginal Zone Lymphoma Following Radiotherapy: A Report of 2 Cases

Purpose: To present 2 patients in whom orbital radiation preceded the development of periorbital extranodal marginal zone lymphoma by more than a decade and to investigate the likelihood of this representing irradiation-induced malignancy. Methods: Retrospective chart review and histopathologic study with immunohistochemistry of 2 cases. Results: The first patient was a 58-year-old woman who developed an orbital mass within the vicinity of the lateral rectus muscle 17 years after external beam proton radiation therapy for an inferotemporal choroidal melanoma. The second patient was a 32-year-old woman who developed a mass in the right lacrimal gland 12 years after external beam photon radiation therapy for chronic inflammatory dacryoadenitis. Histopathologic and immunohistochemical studies confirmed orbital extranodal marginal zone lymphoma in both cases. Retrospective review of older histopathologic slides from the second patient revealed underlying immunoglobulin G4–related disease. Discussion: The unusual sequence of events in these 2 cases raises the question of whether orbital radiation may in rare instances promote the development of orbital extranodal marginal zone lymphoma. The literature pertaining to irradiation-induced secondary malignancy in the orbit is reviewed. Conclusions: Clinicians should consider the possibility of a secondary malignancy when evaluating a patient with an orbital mass and a history of prior local radiation exposure.

Carboplatin and Pembrolizumab Chemoimmunotherapy Achieves Remission in Recurrent, Metastatic Sebaceous Carcinoma

A 72-year-old Caucasian woman who had recurrent sebaceous carcinoma of the right orbit with bilateral cervical lymph node involvement 24 months after orbital exenteration was treated with carboplatin (area under the curve of 5) and pembrolizumab (2 mg/kg) for 6 cycles, followed by maintenance pembrolizumab. She obtained a complete pathological remission and remains free of local, regional, and systemic disease at 15 months.

Deep Orbital Sub-Q Hyaluronic Acid Filler Injection for Enophthalmic Sighted Eyes in Parry–Romberg Syndrome

Purpose: The authors present a consecutive series of deep orbital Sub-Q injections to treat enophthalmic sighted eyes in Parry–Romberg syndrome patients. Methods: Retrospective, interventional case series in 2 centers. Data were collected on patient demographics, Parry–Romberg syndrome onset age, previous orbital and eyelid surgeries, diplopia, ocular movement restriction before and after the injection, number of injections, interval between injections, indication for any top-up or dissolution of filler, and any other complications. In all cases, the hyaluronic acid gel used was Restylane Sub-Q + Lidocaine. Results: A total of 8 injections on 3 patients with Parry–Romberg syndrome, and significant enophthalmos is reported. All injections were with deep orbital Sub-Q filler. All patients were females, aged 32, 24, and 52 years old while their symptoms started at 15, 16, and 30 years old, respectively. None had orbital surgery prior to the injection. Follow up period was 2, 7, and 5 years respectively. All presented a significant enophthalmos of 4 mm which reduced to 1 mm after the injection, and duration effect was 18, 24, and 20 months, respectively. We observed a significant improvement in enophthalmos, lagophthalmos, exposure keratopathy, and even ocular motility. Lagophthalmos improved from 1, 4, and 7 mm to 0, 1, and 2 mm post injection. Ocular motility improved with no onset of new limitation or diplopia. Lower eyelid retraction increased in 1 patient after orbital injection. No other complications occurred. Conclusions: Deep orbital Sub-Q hyaluronic injection for treatment of enophthalmos in Parry–Romberg syndrome is an useful option in sighted eyes.

Epithelial–Myoepithelial Carcinoma Presenting as a Pseudo Veno-Lymphatic Malformation

A 41-year-old woman presented with several days of right eye pain and blurred vision. Examination and radiologic workup were consistent with a veno-lymphatic malformation, including demonstration of cystic fluid–fluid levels on imaging. Histopathology supported the presence of cystic spaces but revealed the final diagnosis of lacrimal epithelial–myoepithelial carcinoma, a rare neoplasm typically associated with the salivary gland. This represents the first reported case of lacrimal epithelial–myoepithelial carcinoma presenting with pain and evidence of intralesional cysts on radiographic and histopathologic evaluation. Better characterization will enable recognition, complete surgical excision, and potential adjuvant radiation therapy.

Gelatin-Based Hemostatic Agents: Histopathologic Differences

Purpose: To delineate the histopathologic appearance of gelatin-based hemostatic agents, Surgiflo, Gelfoam, and Floseal, which are used by ophthalmic plastic surgeons, and which may incidentally be found as foreign materials in histopathologic tissue samples. Methods: Histopathologic analysis was performed with hematoxylin-eosin, periodic acid-Schiff, Masson trichrome, and elastin staining on tissue samples in which gelatin-based agents were found. To better characterize these materials, similar analyses were performed on in vitro samples of commonly used gelatin-based hemostatic agents. Results: Surgiflo and Gelfoam are composed of small stellate pieces of gelatin with a smooth, homogeneous quality. In tissues, they are faintly positive with periodic acid-Schiff staining, amphophilic with Masson trichrome staining, and ink-black with elastin staining. Floseal has a distinctly different morphology of large rectangular sheets, yet almost identical in vitro staining properties. Discussion: While the morphology of the gelatin-based hemostatic agents is consistent under various conditions, the staining properties of these materials differ based on whether they have been in contact with human tissue. Conclusions: Gelatin-derived hemostatic agents are best identified based on their morphologic characteristics. Elastin staining highlights these materials prominently within tissue samples and may be helpful in distinguishing them from other foreign materials.