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Objective: To compare the indications, surgical techniques and outcomes for revision orbital decompression surgery for thyroid eye disease in open, endoscopic, and combined open and endoscopic approaches., Methods: A retrospective review of all revision orbital decompression procedures for thyroid eye disease from a single large academic institution over a 17-year period (01/01/2004-01/01/2021) was performed. Patient demographics, as well as indications and types of surgery were reviewed. Outcome measures included changes in proptosis, intraocular pressure, visual acuity and diplopia., Results: Thirty procedures were performed on 21 patients. There was a median of 9.4 months between primary orbital decompression and revision decompression surgery. There were 6 bilateral procedures, and 2 of these patients underwent additional revision surgeries due to decreased visual acuity with concern for persistent orbital apex compression or sight-threatening ocular surface exposure in the setting of proptosis. Twenty-five procedures were performed as open surgeries with 5 endoscopic/combined cases. Combined Ophthalmology/Otolaryngology surgery via combined open/endoscopic approaches was favoured for persistent orbital apex disease. Visual acuity remained preserved in all patients. The overall median reduction in proptosis was 2 mm and intraocular pressure change was 1 mmHg regardless of surgical approach. The overall rate of new onset diplopia after surgery was 15%. These patients had open approaches. All endoscopic/combined approach patients had pre-existing diplopia. There were no statistically significant differences between the open and endoscopic/combined groups in regard to change in visual acuity, reduction in proptosis or intraocular pressure., Conclusion: Revision orbital decompression is an uncommon procedure indicated for those patients with progressive symptoms despite previous surgery and intensive medical management. Both endoscopic and non-endoscopic techniques offer favourable outcomes with respect to visual acuity, decrease in intraocular pressure, and improvement in proptosis and overall lead to a low incidence of new onset diplopia., Level of Evidence: Level IV., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This article compares the perception of health and beauty of patients after exenteration reconstruction with free flap, eyelid-sparing, split-thickness skin graft, or with a prosthesis. Cross-sectional evaluation was performed through a survey sent to all students enrolled at the University of Iowa Carver College of Medicine. The survey included inquiries about observer comfort, perceived patient health, difficulty of social interactions, and which patient appearance was least bothersome. Responses were scored from 0 to 4 for each method of reconstruction and an orbital prosthesis. A Friedman test was used to compare responses among each method of repair and the orbital prosthesis for 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. One hundred and thirty two students responded to the survey and 125 completed all four questions. Favorable response for all questions was highest for the orbital prosthesis and lowest for the split-thickness skin graft. Patient appearance with an orbital prosthesis had significantly higher scores compared to patient appearance with each of the other methods for all questions (p value < 0.0001). Second highest scores were for the free flap, which were higher than eyelid-sparing and significantly higher compared to split-thickness skin grafting (p value: Question 1: < 0.0001; Question 2: 0.0005; Question 3: 0.006; and Question 4: 0.019). The orbital prosthesis was the preferred post-operative appearance for the exenterated socket for each question. Free flap was the preferred appearance for reconstruction without an orbital prosthesis. Split-thickness skin graft was least preferred for all questions.

Purpose: Optic nerve sheath fenestration (ONSF) has evolved since its inception in 1872. Surgical approaches include a lateral orbitotomy, a medial orbitotomy, or a superomedial lid crease. The actual fenestration can be done with slits or a window excision with biopsy. Each variation has its advantages and disadvantages. We describe the current preferences in surgical approach and biopsy for ONSF and examine the value of biopsy in patients who have undergone ONSF., Design: Eight-question survey and retrospective, noncomparative case review., Subjects: All American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) members are invited to participate in a survey and ONSFs from 1998 to 2013 at the University of Iowa Hospital and Clinics., Methods: Data from the survey was analyzed and patient records were reviewed., Main Outcome Measures: Preferred surgical approach, type of fenestration, and biopsy results., Results: Sixty-four percent of responding ASOPRS members (150/236) have not performed an ONSF in the last year. One third of that group has performed an ONSF in the last 5 years. Fifty-nine percent perform a medial; 10%, a lateral and 31%, a superomedial approach. Seventy-three percent perform a window fenestration, and about half of those surgeons send the specimen for pathologic evaluation. Anecdotally, some biopsies from surgeons who were surveyed have revealed new diagnoses. In a chart review of 90 cases of ONSF, no biopsy gave an unexpected result., Conclusion: The medial approach for ONSF is most common in our respondents; however, the superomedial lid crease incision is gaining popularity for its efficiency and elegance. Three quarters of surgeons remove a window and a quarter fenestrate with slits. Optic nerve sheath biopsy has limited diagnostic value. In the absence of any evidence to suggest a diagnosis other than idiopathic intracranial hypertension, the usefulness of biopsy during fenestration is low.

Purpose: To evaluate the effect of optic nerve sheath fenestration (ONSF) on papilledema grade in the operated eyes and the contralateral nonoperated fellow eyes in patients with idiopathic intracranial hypertension (IIH)., Design: Retrospective review., Participants: A total of 78 patients underwent ONSF, and 20 patients served as controls., Methods: Charts of patients with IIH who had ONSF at the University of Iowa Hospital and Clinics were reviewed for age, gender, body mass index, and clinical findings. Optic disc photographs were graded by a masked observer using the Frisén papilledema grading scale at preoperative baseline and postoperatively at 2 weeks, 3 months, 6 months, and 12 months follow-up. Wilcoxon signed-rank test was used to examine the change in papilledema grade in both operated and nonoperated eyes at each time point., Main Outcome Measures: Grade of papilledema., Results: Sixty-two patients (52 women and 10 men) with a mean age of 32 years (range, 13-57 years) underwent unilateral ONSF. The median grade of papilledema for operated and nonoperated eyes was 3 and 2, respectively, at preoperative baseline. Postoperatively the grade was 2 in each eye at 2 weeks (P<0.0001 and <0.0002 for operated and nonoperated eyes, respectively), 1 in each eye at 3 months (P<0.0001 for both operated and nonoperated eyes), 1 in each eye at 6 months (P<0.0001 for both operated and nonoperated eyes), and 0.5 and 1 for operated and nonoperated eyes, respectively, at 12 months follow-up (P<0.0001 for both operated and nonoperated eyes). There was no significant difference in grade of disc edema or reduction of disc edema on the basis of age, gender, or body mass index., Conclusions: Unilateral ONSF significantly decreases the grade of papilledema in both ipsilateral (operated) and contralateral (unoperated) eyes. The reduction of the papilledema and the stability of visual field in the contralateral (nonoperated) eyes suggest that bilateral ONSF may not always be necessary in patients with bilateral visual loss and papilledema due to IIH., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Large upper eyelid defects are typically repaired by the two-stage Cutler-Beard procedure. Replacing the tarsal plate is integral in reconstructing the upper eyelid. Currently, autogenous cartilage is the most frequently used tarsal substitute. We propose using donor Achilles tendon as an alternative for increased stability of the upper eyelid when repairing large defects by the Cutler-Beard procedure., Methods: We present a retrospectively reviewed case series of four patients with large upper eyelid defects. Each had the traditional Cutler-Beard procedure with the variation of using donor Achilles tendon as the tarsal replacement. Patients were examined and photographed in follow-up ranging from 6 months to 4 years., Results: All cases were successful in recreating the upper eyelid without complication. The tendon graft supplied structure, motility, and cosmesis throughout follow-up. The human Achilles tendon was investigated by literature review and compared with currently available posterior lamellar substitutes., Conclusions: The replacement of upper eyelid tarsus with Achilles tendon as part of the Cutler-Beard procedure was successful in repairing large upper eyelid defects in four patients. The tendon graft is easily placed and incorporated in the normal eyelid anatomy. It is pliable and mobile yet stable. Repair is not limited by the size of the defect, as the tissue is readily available. The modification produced excellent functional and cosmetic results.