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To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques.We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX).A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3-156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective.This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.

PURPOSE To demonstrate the utility of an ultrasonic aspirator (Sonopet, Stryker Corporation; Kalamazoo, MI) for debulking firm, soft tissue masses of the orbit. METHODS Case series. The ultrasonic aspirator was used to debulk firm, soft tissue masses in 3 cases. The initial patient had a large orbitofacial mass extending to the inferior and lateral orbital apex secondary to IgG4 disease. The second patient had a lacrimal sac adenocarcinoma extending to the medial orbital apex. The third patient had a large orbital mass extending to the apex secondary to granulomatosis with polyangiitis. RESULTS The ultrasonic aspirator facilitated debulking of infiltrative firm soft tissue masses of the orbit. The device's ability to emulsify, irrigate, and aspirate, along with its small footprint, facilitated precise sculpting and debulking to an extent which would have been difficult otherwise due to location. CONCLUSIONS The ultrasonic aspirator allows precise sculpting of infiltrative firm soft tissue masses in the orbit and is particularly useful in cases with challenging anatomical access.

The authors report the case of a 75-year-old man with preexisting glaucoma and recurrent retinal detachment who underwent intraocular silicone oil placement OD resulting in subsequent retrolaminar silicone oil migration to the optic chiasm and vision loss OS. MRI showed silicone oil tracking posteriorly along the right optic nerve to the chiasm. He was placed on high-dose corticosteroids and underwent a successful optic nerve sheath fenestration with improvement of vision in the contralateral eye. Clinicians should be cognizant of the potential for translaminar posterior migration of intraocular silicone oil, as well as the utility of optic nerve sheath fenestration to decompress the anterior visual pathways and restore vision.

To determine effect of upper eyelid surgery on headache symptoms. Consecutive adults undergoing upper eyelid surgery for obscuration of superior visual field, who also reported headache symptoms for greater than 1 year completed a pre- and postoperative Headache Impact Test-6 quality of life questionnaire (study group). A cohort of patients undergoing other oculoplastic procedures with headaches also completed the questionnaire pre- and postoperatively (control group). The study was conducted over a 2-year period. Neither the patients nor the study investigators were masked. Twenty-eight patients met criteria for the study group, and 19 patients in the control group. Mean age was 58.7 and 60.7 years, respectively. There was no statistically significant difference in preoperative location of headaches. There was no significant difference in mean Headache Impact Test-6 scores preoperatively, 57.7 study group, 58.1 control group, p = 0.86. Mean postoperative scores were lower (improved) in the study arm, 45.3, as compared with the control arm, 58.6, p < 0.05. There was no statistically significant difference between individual preoperative survey questions between the study arm and control group, while every Headache Impact Test-6 question significantly improved in the study arm compared with the control arm. Mean Headache Impact Test-6 score improved 12.4 points in the study arm after surgery (p < 0.05), while the mean postoperative score worsened by 5 points in the control arm, but this was not significant (p = 0.48). Subjectively, 25 of 28 study patients, and 4 of 19 control patients noticed at least some improvement in headache symptoms after surgery. Correction of visually significant upper eyelid position may improve chronic headache symptoms.

A 64-year-old woman with relapsed acute myelogenous leukemia (AML) undergoing salvage chemotherapy developed rapid onset of right-sided ophthalmoplegia, proptosis, optic neuropathy, and vision loss from 20/30 to hand motions over a 3-hour period on day 4 of her treatment. CT scan of her orbits revealed a superolateral orbital mass and periocular edema. She underwent immediate canthotomy and cantholysis, and lateral orbitotomy with debulking of the mass later the same day. The histopathology was consistent with aggregates of myeloid blasts. Her vision recovered to 20/20 on postoperative day 1. 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.

A 40-year-old white woman presented to her general ophthalmologist for swelling of the left upper eyelid that began approximately 6 months before. CT scan of the orbits with and without contrast demonstrated homogenous enhancement of the left lacrimal gland. Examination was notable for left hypoglobus and proptosis. The patient underwent left lateral orbitotomy with biopsy of the mass and frozen section analysis showed lymphoid infiltrates. Subsequent histopathologic diagnosis was consistent with nodular lymphocyte predominant Hodgkin lymphoma, a rare subtype of Hodgkin lymphoma that has only once been previously reported in the orbit. The authors review the case and the relevant literature.

Traumatic penetrating injuries to the orbit from pencils, while uncommon, have a plethora of presentations, both acute and delayed. With the most incidents occurring in the pediatric population where obtaining a detailed history is difficult, the ability to effectively evaluate and diagnose these injuries is cumbersome, yet important. The authors report a patient who presented with optic neuropathy, blepharoptosis, and strabismus 10 months after an orbital injury with pencil graphite.

Purpose: We hypothesized that patients with benign essential blepharospasm and hemifacial spasm experience relief of headache and eye pain after botulinum toxin injections. Methods: A retrospective chart review of 85 patients who had received botulinum toxin injections at the University of Minnesota for treatment of benign essential blepharospasm and hemifacial spasm was conducted. A prospective telephone questionnaire was used to ascertain details regarding improvement of headache and eye pain. Results: Of the 85 patients (34 men, 51 women), 20 patients (23.5%) had headaches and 29 (34.1%) had eye pain. Ten of 20 (50.0%) headache-positive patients and 24 of 29 patients (82.8%) with eye pain had reduction in their pain after botulinum toxin injections. Conclusion: The findings of this study support the use of botulinum toxin for headache and eye pain relief in patients with benign essential blepharospasm and hemifacial pain. In addition, with the expanding uses of botulinum toxin, the results support its antinociceptive effects. Further investigation should continue in the mechanism of botulinum toxin's effects on pain.

PURPOSE The authors recently demonstrated that a single injection of the immunotoxin ricin-mAb35 has potent and long-lasting myotoxic effects in extraocular muscles. The myotoxicity of injected ricin-mAb35 was tested in the eyelids of rabbits to determine its potential for use in the treatment of benign essential blepharospasm and other dystonias. METHODS The immunotoxin ricin-mAb35 was injected in one eyelid of adult rabbits. After 1 week, 1 month, or 6 months, the rabbits were euthanized, and the eyelids were prepared for histologic examination of inflammatory cell infiltrate with immunohistochemical localization of cd11b and myosin heavy chain isoform expression. Muscle loss was quantified by analysis of muscle fiber cross-sectional area and total myofiber number. RESULTS Within the first week after a single injection of ricin-mAb35, some edema developed, which resolved by the second week. Otherwise, the eyelids were normal in appearance. A short-lived inflammatory response was seen at 1 week, but this resolved 1 month after treatment. One week after injection, there was a significant decrease in the total number of orbicularis oculi myofibers in the ricin-mAb35-treated eyelids. This myofiber loss remained significant 1 month later and was maintained 6 months after the initial injection. CONCLUSIONS Direct injection of the immunotoxin ricin-mAb35 resulted in significant, acute muscle loss in the orbicularis oculi of rabbits that was maintained for up to 6 months. Physiologic studies are needed to demonstrate concomitant loss of muscle strength, but these results suggest that ricin-mAb35 injection holds promise as a muscle-weakening agent in the eyelid.

Objective: To characterize and evaluate treatment options for medial rectus muscle (MR) injury associated with functional endoscopic sinus surgery (FESS). Design: Retrospective interventional case series Participants: A total of 30 cases were gathered from 10 centers. Methods: Cases of orbital MR injury associated with FESS surgery were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) through an e-mail discussion group. Main Outcome Measures: Variables assessed included patient demographics, computerized tomography and operative findings, extent of MR injury and entrapment, secondary orbital/ocular injuries, initial and final ocular alignment and ductions, and interventions. Results: A spectrum of MR injury ranging from simple contusion to complete MR transection, with and without entrapment, was observed. Four general patterns of presentation and corresponding injury were categorized. Conclusions: Medial rectus muscle injury as a complication of FESS can vary markedly. Proper characterization and treatment are important, particularly with reference to the degree of direct MR injury (muscle tissue loss) and entrapment. Patients with severe MR disruption can benefit from intervention but continue to show persistent limitation of ocular motility and functional impairment. Prevention and early recognition and treatment of these injuries are emphasized.

PURPOSE: To determine the incidence of severe ocular injury in visually asymptomatic patients with orbital fractures. METHODS: Retrospective review of 241 cases of orbital fracture, of which 126 cases had ophthalmic evaluation within 1 week of injury and were included in our analysis. Fracture type, associated symptoms, and injuries were evaluated. Injuries were categorized into severe (requiring immediate evaluation), moderate (requiring evaluation within the next several days), and mild (may not require evaluation). The presence of symptoms and associated visual acuity and severity of injury were analyzed for statistical significance. RESULTS: Forty-six of 126 patients with orbital fractures were visually asymptomatic. Of these patients, none had severe injuries, 15 had moderate injuries, 23 had mild injuries, and 8 had no injuries. Of those with symptoms, 15 had severe injuries, 27 had moderate injuries, 35 had mild injuries, and 3 had no injuries. Using Fisher exact test analysis, asymptomatic patients were unlikely to have severe ocular injury in the setting of orbital fracture (p = 0.0009). In addition, visual acuity did not accurately predict the presence of severe ocular injury. CONCLUSION: Visually asymptomatic patients with orbital fractures do not have ocular injury requiring emergent evaluation. Language: en

Purpose: To present a patient with congenital entropion of the upper eyelid caused by levator aponeurosis disinsertion. Methods: Case report. Results: Surgical correction of the levator aponeurosis disinsertion corrected the upper eyelid entropion. Conclusions: Congenital upper eyelid entropion may be caused by levator aponeurosis disinsertion and treated effectively by repairing the anatomic defect.

Purpose To determine whether a 32-gauge needle can reduce the pain associated with periocular injections of botulinum toxin type A compared with 30-gauge needles. Methods In this prospective, randomized, masked study, 30 patients received bilateral periocular injections of botulinum toxin type A for benign essential blepharospasm. For each patient, a 30-gauge needle was used on one side of the face, and a 32-gauge needle was used on the other side. Equal number of injections and equal amounts of botulinum toxin type A at each injection site were administered on each side of the face. Patients were then asked to rate their pain level on each side of the face, using a standardized 11-point visual analogue pain scale. Results The average pain score was 4.38 +/- 2.02 for 30-gauge needles and 3.98 +/- 1.65 for 32-gauge needles. Statistical analysis via Mann-Whitney U test confirmed the null hypothesis that no statistical difference in pain level existed between the 2 needle sizes. Conclusions There is no difference in perceived pain when comparing periocular botulinum toxin type A injections with 30- and 32-gauge needles. In addition, smaller gauge needles require special order and result in greater cost. The authors recommend continued use of 30-gauge needles for botulinum toxin injection in the office setting.

Purpose The authors used the database of eyelid surgeries performed at the Phillips Eye Institute in Minneapolis, MN, to help determine the infection rate in outpatient eyelid surgery. Methods The authors retrospectively reviewed the reported cases of infections after all eyelid surgeries performed between January 1, 1999 and December 31, 2004 at the Phillips Eye Institute in Minneapolis, MN. Results Of a total of 2,227 patients who underwent oculoplastic procedures, there was only one reported infection (0.04%). Conclusions The infection rate in outpatient eyelid surgery is extremely low.

A 53-year-old woman with left periorbital swelling 4 days after botulinum toxin injection in the lateral canthal area presented after noticing left eye prominence. Physical examination demonstrated proptosis and eyelid retraction. Computed tomography of the orbits confirmed extraocular muscle enlargement consistent with thyroid eye disease. In this case, the patient had development of proptosis after receiving botulinum toxin injections. Although the proptosis may represent progression of the patients’ thyroid eye disease, it is worthwhile to consider incitation by botulinum toxin as a possible cause given its widespread use.

A 44-year-old woman presented with a 1-month history of right-sided tearing, redness, and chronic headache. Clinical examination was notable for 4-mm proptosis and decreased visual acuity OD. Orbital CT demonstrated isolated enlargement of the right lateral rectus. Surgical biopsy was undertaken after an unsuccessful trial of oral steroids. Histopathology and immunophenotyping demonstrated a lymphoplasmacytic lymphoma. External beam radiation induced regression of the lymphoma with decreased proptosis and improved visual acuity.