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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.

In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen.This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events.The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS (P0.01) and reduction in ocular motility restriction (P0.01) were maintained during interruption.Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

Background Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of active Thyroid eye disease (TED). The current study reviews its efficacy in chronic TED. Methods In this retrospective review, consecutive patients with chronic stable TED (>2 years), who had received ≥3 infusions of teprotumumab were included. All patients had measurements of proptosis, and calculation of the CAS and diplopia scores before and after therapy. Five-point strabismus scores were also calculated. Patients who had imaging within 4 months prior to therapy and 6 weeks post therapy underwent orbital 3D volumetric analysis. Results Thirty-one patients met the inclusion criteria. The mean (SD) duration of TED was 81 months (56) and the mean (SD) number of infusions received by each patient was 7 (2). Mean (SD) reduction in proptosis for each study orbit was 3.5 mm (0.4) and 3 mm (0.3) for the fellow orbit. The CAS response was 90% for the study orbit and 87% for the fellow orbit. Of the 15 patients who had diplopia at baseline, 67% had a clinically significant response, while 47% had complete resolution following treatment. Following teprotumumab, mean (SD) reduction of muscle tissue was 2011 mm3 (1847) in the study orbit and 1620 mm3 (1759) in the fellow orbit. The mean (SD) reduction of fat volume was 2101 mm3 (1681) in the study orbit and 1370 mm3 (1181) in the fellow orbit. Conclusion Teprotumumab significantly reduces proptosis, inflammation, diplopia, strabismus and orbital soft tissue volume in patients with chronic TED.

Orbital penetrating injuries from pencils are rare. This report describes a case of penetrating orbital injury in a young child with a retained blue-colored pencil core foreign body, which led to rapid onset of orbital abscess requiring surgical drainage. Intraoperatively, orbital tissues were stained a bright-blue color. Histopathological study of specimen also highlighted bright blue aggregates of foreign material infiltrating the orbital tissues. Cultures grew Streptococcus mitis and Exophiala jeanselmei , which are rare causes of orbital abscess. Unique properties of retained colored pencil core as compared to graphite pencil core are herein discussed. Due to differences in composition, colored pencil core foreign bodies may require more timely surgical intervention compared to noncolored graphite pencil core.

A 65-year-old male presented with headaches and painless episodes of unilateral vision loss. He had a history of renal cell carcinoma, in remission following surgery and immunotherapy with ipilimumab and nivolumab, discontinued 2 years and 3 months before presentation, respectively. MRI revealed an optic nerve sheath mass and perineuritis. After 1 month of corticosteroid therapy, there was a robust clinical and radiographic response, which relapsed dramatically following cessation. An optic nerve sheath biopsy showed chronic mild inflammation, and extensive work-up for alternative etiologies of orbital inflammation was negative. Following a prolonged taper of corticosteroids, he demonstrated complete response. In the setting of ocular immune privilege, ophthalmic immune-related adverse events (irAE) are rare, although multifarious. While on-treatment irAE are well-characterized, posttreatment irAE have become increasingly recognized across multiple organ systems. We report a case of a delayed-onset inflammatory optic nerve sheath mass and perineuritis after cessation of immunotherapy.

Lacrimal sac squamous cell carcinoma is a rare but life-threatening disease that is often a delayed diagnosis secondary to difficulty in differentiating from other causes of dacrocystitis and acquired nasolacrimal duct obstruction. Chronic inflammation, including that of an underlying autoimmune disease, prior instrumentation, and poor wound healing, may be risk factors in the development to lacrimal sac squamous cell carcinoma. The authors present the first case of lacrimal sac squamous cell carcinoma associated with antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4 positivity. Rather than an overlap syndrome between antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4-related disease, high immunoglobulin G4 positivity may be considered an inflammatory marker of disease severity in the setting of antineutrophil cytoplasmic antibody-associated vasculitis and underlying malignancy. Inflammation-mediated tumorangiogenesis should be considered in the development of malignancy and red flags of chronic uncontrolled inflammation should warrant a lower threshold for further workup.

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.

Herpes zoster ophthalmicus (HZO) is a neuro-oculo-dermic infection caused by reactivation of latent varicella zoster virus in the dorsal root ganglia of the ophthalmic division of the trigeminal nerve. Although a rare diagnosis in an otherwise healthy, vaccinated pediatric patient, this entity may occur with increasing frequency among those with preceding trauma, particularly in the month prior to presentation. Herein, we highlight a case of HZO in a vaccinated, immunocompetent adolescent in the setting of recent facial trauma.

Background: Giant disfiguring cranial tumors are exceptionally rare and develop over the course of many years, typically in patients who lack access to medical care. Here, we describe four patients who were flown to our center for treatment by a multidisciplinary surgical team, who had previously been turned down for treatment at multiple international centers in Africa, Europe, and the United States (US) due to complexity and financial concerns. The case series describes socioeconomic implications and the feasibility of offering such care to patients from outside the US. Case Descriptions: Four patients with giant skull disfiguring tumors were flown internationally and treated by a surgical team consisting of a complex cranial neurosurgeon, a craniofacial reconstructive plastic surgeon, and an oculoplastic surgeon. All patients underwent aggressive surgical therapy with the aim of complete tumor removal and simultaneous cranial reconstruction. A patient with osteogenic sarcoma underwent two additional resections in 3 years, with delayed reconstruction. They returned home but ultimately succumbed to the disease. A patient with ossifying fibroma required two follow-up procedures for cosmetic reconstruction and sought asylum in the US, where they remain today. Two additional patients, one with a giant plexiform neurofibroma and one with a cerebellopontine angle meningioma, achieved good results and returned to Africa 1 month and 3 weeks after surgery, respectively. Conclusion: Resection of giant disfiguring cranial tumors and reconstruction of the impacted region requires an experienced multidisciplinary team. These cases can be managed by transporting such patients from areas without access to medical care to specialized centers able to provide excellent care.

Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact quality of life. While there are several known forms of congenital ptosis, acquired ptosis (appearing later in life, due to a variety of causes) is the predominant form of the condition. This review summarises the prevalence, causes, identification, differential diagnosis, and treatment of acquired ptosis. Particular attention is paid to the differential diagnosis of acquired ptosis and emerging treatment options, including surgical and pharmacologic approaches.摘要: 上睑下垂是视光学和眼科临床中最常见的上睑疾病之一。以上睑下垂为特征的单侧或双侧上睑下垂会影响外观和视觉功能, 这两种情况都会对生活质量产生负面影响。目前已知有几种先天性的上睑下垂, 但获得性上睑下垂 (由各种原因所导致并出现在其后的生活中) 是该病的主要形式。本文就获得性上睑下垂的发病率、病因、鉴别诊断及治疗作一综述。并特别研究获得性上睑下垂的鉴别诊断以及新的治疗方法, 包括手术和药理治疗途径。.

Purpose: If not recognized and treated promptly, nontraumatic orbital subperiosteal hemorrhage (NTSOH) can have serious sequelae including compressive optic neuropathy and permanent vision loss. The following case establishes erotic asphyxiation as a cause of NTSOH. Observations: A 29 year-old patient presented with diplopia and periorbital edema and ecchymosis. Complete ophthalmologic exam showed no optic neuropathy. Computed tomography of the orbits revealed a subperiosteal fluid collection in the right orbit. The patient had no risk factors for NTSOH, but after detailed questioning she admitted to participating in erotic asphyxiation prior to the onset of her symptoms. She was observed and subsequently lost to follow up. Conclusions and Importance: To the authors' knowledge, erotic asphyxiation as a cause of orbital subperiosteal hematoma has not been previously reported. Lack of knowledge about erotic asphyxiation amongst healthcare providers may contribute to hesitance to directly question patients about the practice. Clinicians should be aware of erotic asphyxiation as a potential cause of orbital subperiosteal hemorrhage. Keywords: Erotic asphyxiation, Nontraumatic orbital subperiosteal hemorrhage, Orbital hematoma

A 48-year-old man presented with a longstanding left upper eyelid mass that increased in size when bending forward. The mass was associated with enophthalmos and slowly increased in size with Valsalva maneuver. Magnetic resonance imaging and arteriography demonstrated a vascular malformation without an abnormal arterial component. Because of his increasing pain, the vascular malformation was excised in a multidisciplinary approach involving intraoperative fluoroscopic mapping, cyanoacrylate embolization, and surgical excision. Histopathology was consistent with a benign vascular malformation. Clinically, this was a low-flow, distensible venous malformation—or orbital varix.

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.

Congenital nasolacrimal duct obstruction most often resolves spontaneously or following nasolacrimal probing with or without silicone intubation. If probing and intubation fail to resolve tearing in children with nasolacrimal duct obstruction, dacryocystorhinostomy is indicated. This may be performed either externally or endonasally. An endonasal approach has the advantages of no external scarring, shorter recovery time, and preservation of the lacrimal pump with a comparable success rate to external dacryocystorhinostomy. Unique anatomical considerations when performing endonasal dacryocystorhinostomy in children include the lower insertion of the cribriform plate and smaller overall dimensions of the nasal passages. Complications of endonasal DCR include extrusion of the silicone intubation tube, synechiae or granuloma formation, and nasal vestibule abrasion.

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.

The management issues associated with pediatric ptosis begin with determining the etiology of the ptosis, and considering how the eyelid position affects the child's visual and psychosocial development. These ultimately determine if and when surgical management should be undertaken. Surgical challenges include the lack of intraoperative feedback regarding the dynamic eyelid height and contour under general anesthesia. When the eyelid elevators do not function or if there is little drive to lift the involved eyelid, obtaining good surgical outcomes can be extremely challenging. A plethora of surgical techniques and materials have been developed, each with their own benefits and drawbacks. Careful preoperative evaluation, planning and counseling can usually result in satisfactory surgical results with happy parents and patients. Families should always be aware that the child will need to be followed long term for visual development, ocular health, and they need to be counseled regarding the possibility of revision surgery.

To compare the outcomes of coaxial microincision cataract surgery (MICS) performed with 3 phacoemulsification techniques (phaco-chop, divide-and-conquer, and stop-and-chop) according to cataract density.Bucheon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea.Prospective randomized clinical trial.Eyes with nuclear density from grade 2 to 4 were randomly subdivided into 3 groups (phaco-chop, divide-and-conquer, and stop-and-chop). Intraoperative measurements included ultrasound time (UST), mean cumulative dissipated energy (CDE), and balanced salt solution use. Clinical measurements included preoperative and 1 day, 1 month, and 2 month postoperative corrected distance visual acuity, central corneal thickness, and endothelial cell count.Intraoperative measurements showed significantly less UST, CDE, and balanced salt solution use with the phaco-chop technique than with the divide-and-conquer and stop-and-chop techniques in the grade 4 cataract density group (P.05). The percentage of endothelial cell loss was significantly lower in the phaco-chop group than in the divide-and-conquer and stop-and-chop groups in the grade 4 cataract density group 2 months after cataract surgery (P.05).All 3 techniques may be effective for coaxial MICS in mild and moderate cataracts. However, in eyes with hard cataract having coaxial MICS, the phaco-chop technique can be more effective for lens removal, with less corneal endothelial damage, than the divide-and-conquer and stop-and-chop techniques.No author has a financial or proprietary interest in any material or method mentioned.

Background The risk of optic disc haemorrhages on visual outcome in idiopathic intracranial hypertension (IIH) is unknown. We report the type and frequency of optic disc haemorrhages and other funduscopic abnormalities at baseline in the study eye of the 133 subjects enrolled in the Idiopathic Intracranial Hypertension Treatment Trial completing 6 months of follow-up. Methods We reviewed optic disc photographs to tabulate the frequency and type of optic disc haemorrhages, other funduscopic abnormalities and papilloedema grades of the study eye at baseline and analyse if their presence is associated with a poor visual outcome. Results 27.2% of subjects had nerve fibre layer haemorrhages in at least one eye. Five of seven, 71% of subjects that met criteria for treatment failure, had nerve fibre layer haemorrhages in at least one eye (Fisher9s exact test: p=0.02). There was a good correlation between presence of nerve fibre layer haemorrhages and Frisen grade (Spearman9s correlation, p=0.002; r=0.271). Subjects with nerve fibre layer haemorrhages had a higher cerebrospinal fluid pressure (40.0 mm water, p=0.04). There was poor correlation between nerve fibre layer haemorrhages at baseline and the perimetric mean deviation change at 6 months. Cotton wool spots were present in 4% of subjects, exudates in 3% and pseudodrusen in 4%. Conclusions Nerve fibre layer haemorrhages are common in patients with IIH with mild visual loss and correlate with the severity of the papilloedema. They occur more frequently in treatment failure subjects and therefore may be associated with poor visual outcomes. Trial registration number NCT01003639, Post-results.

Lichen sclerosus is a chronic, debilitating, and recurring disease that is most commonly seen affecting the anogenital region. Extragenital locations of lichen sclerosus has been well documented, frequently seen in the shoulders, neck, trunk, breasts, and arms, however, infrequently of the face. Specifically, extragenital lichen sclerosus has been reported in several cases to be involving the infraorbital region, but to our knowledge it has never been found affecting the adnexa of the eye. To our understanding, this is the first documented report of a patient with extragenital lichen sclerosus of an eyelid.

If giant cell arteritis is suspected as a cause of visual loss, emergent management is necessary. Clinical suspicion should prompt the practitioner to obtain laboratory studies and initiate treatment prior to establishing the diagnosis. The evaluation includes immediate erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC). Treatment begins with high-dose intravenous corticosteroids. We recommend intravenous methylprednisolone (250 mg every 6 h) for 3 to 5 days. During that time, a temporal artery biopsy should be performed for pathologic diagnosis. We also begin daily adjunctive aspirin orally. After the initial bolus of intravenous corticosteroids, therapy transitions to oral prednisone administered at 1 mg/kg per day until the activity of the disease process attenuates, as demonstrated by improvement in systemic symptoms and normalization of both ESR and CRP. This change usually occurs in the first 3 to 4 weeks. The patient should be followed closely, with therapy tapered as guided by systemic symptoms, ESR, and CRP. To maximize the use of remaining vision, appropriate patients should be referred to specialists for help with low-vision therapies, assistive devices, and precautions to protect the better-seeing eye.

Ocular pain is most commonly associated with redness and inflammation; however, eye pain can also occur in the absence of grossly visible pathology. Pain in the quiet eye can be the first sign of a number of threatening conditions. Many of these conditions such as intermittent angle closure glaucoma, carotid artery dissection, idiopathic intracranial hypertension, and giant cell arteritis can lead to permanent vision loss or blindness. In this review, ocular history and examination techniques are summarized. The article also reviews pertinent ocular, orbital, referred, and other causes of eye pain in the quiet eye. The neurologist and headache specialist should recognize when consultation with an ophthalmologist is necessary.

PURPOSE OF REVIEW The purpose of this review is to describe the results from published clinical studies evaluating the efficacy of two types of dacryocystorhinostomy, namely external and endonasal. RECENT FINDINGS Many studies report high success rates with either procedure in alleviating the consequences of nasolacrimal duct obstruction. However, only a few studies have compared the two approaches in a prospective, randomized fashion. SUMMARY Both types of procedure achieve excellent outcomes, and there is no definitive evidence from published, large-scale studies that one approach is superior to the other.

A 52-year-old man with chronic hepatitis C presented with painless, bilateral, simultaneous non-arteritic anterior ischemic optic neuropathy (NAION) and peripheral neuropathy. Symptoms began 19 weeks after starting peginterferon alpha-2a. The peripheral neuropathy and vision of the right eye improved, but the vision of the left eye worsened after stopping interferon. We identified 23 additional cases of NAION during interferon alpha therapy. At least 12 of these patients suffered bilateral NAION. Patients lost vision 1–40 weeks after initiating therapy. Of 21 eyes that had documented initial and follow-up acuities, 8 improved, 1 worsened, and the rest remained stable. One patient had a painful peripheral neuropathy. Treatment with interferon alpha may result in NAION. Discontinuation of therapy deserves consideration after weighing individual risks and benefits.

Kathleen T Berg, Andrew R Harrison, Michael S LeeDepartment of Ophthalmology, University of Minnesota, Minneapolis, MN, USAAbstract: Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.Keywords: perioperative, postoperative, vision loss, ocular surgery, nonocular surgery

A 12-year-old boy presented with a weight of 136 kg and a history of progressive vision loss associated with unremitting pseudotumor cerebri requiring bilateral optic nerve sheath decompression. He underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) without complication. At 36 months post-RYGBP, he has grown 5 cm since the time of surgery, his weight is 6.8 kg above his postoperative nadir weight of 68.2 kg, and his visual acuity has improved with OD 20/100 (preoperative, 20/200) and OS 20/70 (preoperative, 20/100). This case suggests that RYGBP can be performed safely and without stopping linear growth in carefully selected children.

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 To evaluate the change in upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome. Design Prospective, noncomparative, interventional case series. Participants Eighteen patients with a clinical diagnosis of floppy eyelid syndrome. Methods Horizontal surgical tightening of the upper eyelid was performed by full-thickness wedge resection in 24 eyelids of 18 patients with floppy eyelid syndrome. Preoperative and postoperative upper eyelid position as measured by the margin reflex distance (MRD) was assessed. Student's paired t test then was used to analyze the change in upper eyelid position after horizontal tightening alone of floppy upper eyelids. Main Outcome Measures Change in upper eyelid MRD after surgery. Results Preoperative MRD ranged from −0.5 to 4.0 mm, with a mean of 1.9 mm (±1.3 mm, standard deviation [SD]). Postoperative MRD ranged from 0.5 to 6.0 mm, with a mean of 3.2 mm (±1.4 mm, SD). The change in MRD ranged from −0.5 to 2.5 mm, with a mean of 1.3 mm (±0.7 mm, SD; P Conclusions Horizontal upper eyelid tightening alone generally results in secondary improvement of the ptosis associated with floppy eyelid syndrome.

Commercially available preparations of botulinum toxin have been used for a wide variety of diseases. In many instances, it has supplanted other therapeutic modalities to become the first line of therapy. We review the pharmacologic properties of botulinum toxin, the indications for use in ophthalmic plastic and reconstructive surgery, the potential adverse effects associated with the use of the toxin and the future of therapy directed at chemodenervation.

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.

In summary, this project proposes to explore the feasibility of a new temporary implant and surgical technique to improve the DCR procedure. This is a significant improvement over current DCR practice for the following primary reasons: (1) it eliminates the risk of injury to both the eye and upper lacrimal system; (2) it permits tear flow into the nose immediately following surgery, potentially 6 months earlier than current practice and procedure, which frequently does not re-establish normal tear flow until stents are removed. Plans have been made to implant stents of different sizes and proportions into cadavers in order to test implantation and removal of the stent via external and intranasal approaches.

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.

OBJECTIVE AND IMPORTANCE Painful oculomotor palsy can result from enlargement or rupture of intracranial aneurysms. The IIIrd cranial nerve dysfunction in this setting, whether partial or complete, is usually fixed or progressive and is sometimes reversible with surgery. We report an unusual oculomotor manifestation of a posterior carotid artery wall aneurysm, which mimicked ocular myasthenia gravis. CLINICAL PRESENTATION A 47-year-old woman developed painless, intermittent, partial IIIrd cranial nerve palsy. She presented with isolated episodic left-sided ptosis, which initially suggested a metabolic or neuromuscular disorder. However, digital subtraction angiography revealed a left posterior carotid artery wall aneurysm, just proximal to the origin of the posterior communicating artery. INTERVENTION The aneurysm was successfully clipped via a pterional craniotomy. During surgery, the aneurysm was observed to be compressing the oculomotor nerve. The patient's symptoms resolved after the operation. CONCLUSION The variability of incomplete IIIrd cranial nerve deficits can present a diagnostic challenge, and the approach for patients with isolated IIIrd cranial nerve palsies remains controversial. Although intracranial aneurysms compressing the oculomotor nerve classically produce fixed or progressive IIIrd cranial nerve palsies with pupillary involvement, anatomic variations may result in atypical presentations. With the exception of patients who present with pupil-sparing but otherwise complete IIIrd cranial nerve palsy, clinicians should always consider an intracranial aneurysm when confronted with even subtle dysfunction of the oculomotor nerve.

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

The authors report seven patients from six neuro-ophthalmology referral centers who developed pseudo-tumor cerebri during treatment with doxycycline. All four female patients and one of three male patients were obese. Vision was minimally affected in most patients, but two had substantial visual acuity or visual field loss at presentation. Discontinuation of doxycycline, with or without additional intracranial pressure-lowering agents, yielded improvement, but permanent visual acuity or visual field loss occurred in five patients.

PURPOSE Detection of differences in disease characteristics between male and female patients with benign essential blepharospasm (BEB). METHODS We retrospectively reviewed charts of 32 male and 61 female BEB patients, comparing the time interval between treatments with botulinum toxin A. We prospectively compared BEB-related questionnaire results between 36 female and 15 male patients. RESULTS The mean interval between treatment in weeks was 16.69 for men and 17.31 for women (p = 0.19). The questionnaire results showed a higher degree of symptom severity and frequency in women over men. (p = 0.008), but similar responses for disease-related handicap in daily activities. CONCLUSIONS Aside from greater symptom severity and frequency among women, we found no significant differences between male and female patients with BEB.

PURPOSE The normal distribution of exophthalmometry measurements in a U.S. pediatric population was determined as a reference for clinical practice. METHODS This was a cross-sectional study, in which 673 normal subjects, between 1 and 17 years of age, randomly selected from patients presenting to our institution, were measured with an exophthalmometer. Normal volunteers also participated at a booth at the annual state fair. Subjects were excluded for a prior history of orbital tumor, craniofacial anomaly, thyroid disease, orbital trauma, or inability to tolerate the measurement. RESULTS A total of 673 subjects (52% female) with a mean age of 9.6 years were studied. There was no difference in exophthalmometric measurements between male and female subjects. Mean exophthalmometric measurements increased with age: less than 4 years old (13.2 mm), 5-8 years old (14.4 mm), 9-12 years old (15.2 mm), and 13-17 years old (16.2 mm). Asymmetric measurements occurred in 100 (14.9%) subjects, with a 2-mm maximal difference in 2 subjects. CONCLUSION Exophthalmometric measurements vary with age among the pediatric population. Reference data are presented for each age group in a U.S. cohort.

Even though conventional botulinum neurotoxin (BoNT) products have shown successful treatment results in patients with benign blepharospasm (BEB), the main, potential long-term side effect of BoNT use is the development of immunologic resistance due to the production of neutralizing antibody to the neurotoxin after repeated injections. Xeomin(®) (incobotulinumtoxinA), a unique botulinum neurotoxin type A (BoNT/A) drug free of complexing proteins otherwise contained in all conventional BoNT/A drugs, was recently approved by US Food and Drug Administration for the treatment of cervical dystonia or blepharospasm in adults. The newly approved BoNT/A drug may overcome this limitation of previous conventional products, since it contains pure neurotoxin (150 kDa) through a manufacturing process that separates it from complexing proteins such as hemagglutinins produced by fermentation of Clostridium botulinum. Many studies have also shown that Xeomin(®) has the same efficacy and safety profile as complexing protein-containing products such as Botox(®) and is exchangeable with Botox(®) using a simple 1:1 conversion ratio. Xeomin(®) represents a new treatment option for the repeated treatment of patients with blepharospasm in that it may reduce antibody-induced therapy failure. But, long-term comparative trials in naive patients between Xeomin(®) and conventional BoNT/A drugs are required to confirm the low immunogenicity of Xeomin(®).

OBJECTIVE To determine whether early surgical excision of complicated periorbital hemangiomas (CPHs) reversed refractive errors and prevented further visual complications; CPHs can cause visual complications including astigmatism, strabismus, and occlusion of the visual axis with resultant amblyopia. DESIGN Retrospective review of patient series from a tertiary care pediatric referral center. Nine patients with CPHs were managed by otolaryngology and ophthalmology services with complete surgical excision. Preoperative eye examination findings were compared with postoperative findings. RESULTS Comparison of preoperative and postoperative refraction measurements and/or eye examination findings indicated reduction of astigmatism and substantial improvement in vision as measured by refractive changes and reduction of pupillary occlusion. CONCLUSIONS Total excision of CPHs is a safe and effective approach. When completed early, excision provides definitive therapy, reduces or eliminates astigmatism, and can prevent amblyopia in pediatric patients when pupillary occlusion is present.