Teprotumumab-Related Adverse Events in Thyroid Eye Disease: A Multicenter Study

PURPOSE

To assess the duration, incidence, reversibility, and severity of adverse events (AEs) in patients with thyroid eye disease (TED) treated with teprotumumab.

DESIGN

Multicenter, retrospective, observational cohort study.

PARTICIPANTS

Patients with TED of all stages and activity levels treated with at least 4 infusions of teprotumumab.

METHODS

Patients were treated with teprotumumab between February 2020 and October 2022 at 6 tertiary centers. Adverse event metrics were recorded at each visit.

MAIN OUTCOME MEASURES

The primary outcomes measure was AE incidence and onset. Secondary outcome measures included AE severity, AE reversibility, AE duration, proptosis response, clinical activity score (CAS) reduction, and Gorman diplopia score improvement.

RESULTS

The study evaluated 131 patients. Proptosis improved by 2 mm or more in 77% of patients (101/131), with average proptosis improvement of 3.0 ± 2.1 mm and average CAS reduction of 3.2 points. Gorman diplopia score improved by at least 1 point for 50% of patients (36/72) with baseline diplopia. Adverse events occurred in 81.7% of patients (107/131). Patients experienced a median of 4 AEs. Most AEs were mild (74.0% [97/131]), 28.2% (37/131) were moderate, and 8.4% (11/131) were severe. Mean interval AE onset was 7.9 weeks after the first infusion. Mean resolved AE duration was 17.6 weeks. Forty-six percent of patients (60/131) demonstrated at least 1 persistent AE at last follow-up. Mean follow-up was 70.2 ± 38.5 weeks after the first infusion. The most common type of AEs was musculoskeletal (58.0% [76/131]), followed by gastrointestinal (38.2% [50/131]), skin (38.2% [50/131]), ear and labyrinth (30.5% [40/131]), nervous system (20.6% [27/131]), metabolic (15.3% [20/131]), and reproductive system (12.2% [16/131]). Sixteen patients (12.2%) discontinued therapy because of AEs, including hearing loss (n = 4), inflammatory bowel disease flare (n = 2), hyperglycemia (n = 1), muscle spasms (n = 1), and multiple AEs (n = 8).

CONCLUSIONS

Adverse events are commonly reported while receiving teprotumumab treatment. Most are mild and reversible; however, serious AEs can occur and may warrant treatment cessation. Treating physicians should inform patients about AE risk, properly screen patients before treatment, monitor patients closely throughout therapy, and understand how to manage AEs should they develop.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

An Analysis of Solicitations from Predatory Journals in Ophthalmology

PURPOSE

To evaluate trends associated with email communication from potentially predatory publishers to faculty in ophthalmology.

DESIGN

Cross sectional study METHODS: Ophthalmologists (n=14) from various subspecialties and institutions were recruited to participate. Participants identified unsolicited emails they had received originating from publishers in May 2021. Information collected included details on email contents and publisher organizations. Trends in communications from predatory publishers were evaluated.

RESULTS

Over a 30-day study period, a total of 1813 emails were received from 383 unique publishers and 696 unique journals with a mean (SD) of 4.73 (2.46) emails received per day per participant. Of the 1813 emails identified, 242 (13%) emails were invitations to conferences, whereas 1440 (80%) were solicitations for article submissions to open-access pay-to-publish journals. A total of 522 (29.0%) emails were related to ophthalmology, and reference to a prior publication of the participant occurred in 262 emails (14%). Of the 696 unique journals identified, 174 (25%) journals were indexed on PubMed and 426 (61%) were listed on Beall's list. When comparing journals listed on PubMed versus those that were not, PubMed indexed journals had a higher impact factor (2.1 vs 1.5, p=0.002), were less likely to use "greetings" (76% vs 91%, p<0.001), had fewer spelling/grammar errors (40% vs 51%, p=0.01), and were less likely to offer rapid publication (16% vs 25%, p=0.02).

CONCLUSION

Unsolicited requests to publish occur frequently and may diminish the quality of the scientific literature. We encourage individuals in ophthalmology to be aware of these trends in predatory publishing.

Association of Ocular Manifestations of Marfan Syndrome With Cardiovascular Complications

PURPOSE

To evaluate associations between ocular manifestations of Marfan syndrome and cardiovascular complications.

DESIGN

Retrospective cohort study.

METHODS

The TriNetX Analytics platform, a federated health research network of aggregated deidentified electronic health record data of more than 119 million patients, was used to identify patients diagnosed with Marfan syndrome. Univariate logistic regression models were used to evaluate the association of ocular manifestations of Marfan syndrome (such as retinal tears/detachment, lens dislocation, and myopia), with cardiovascular comorbidities. Additional sensitivity analyses were performed using propensity matching. Odds ratios and 95% CIs were calculated for incidence of cardiovascular comorbidities (including aortic dissection, valvular disease, and arrhythmias) following diagnosis of Marfan syndrome.

RESULTS

A total of 19,105 patients were identified who were diagnosed with Marfan disease without ocular manifestations, and an additional 3887 Marfan patients with ocular comorbidities. Patients who were diagnosed with ocular disease included 883 with ectopic lens, 417 with retinal tear or detachment, 683 with aphakia, 534 with pseudophakia, and 2465 with myopia. Patients with any ocular manifestations of Marfan were significantly more likely to be diagnosed with all cardiovascular comorbidities modeled including aortic aneurysm and dissection (OR 2.035; P < .0001), mitral valve prolapse (OR 2.725; P < .0001), tricuspid valve disorders (OR 2.142; P < .0001), cardiac arrhythmias (OR 1.836; P < .0001), and all cardiovascular outcomes combined (OR 2.194; P < .0001).

CONCLUSIONS

In a large and diverse cohort of patients with Marfan syndrome, ocular manifestations of the disorder appear strongly associated with cardiovascular comorbidities.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study

PURPOSE

To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM).

METHODS

In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality.

RESULTS

Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality.

CONCLUSIONS

Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Teprotumumab for the Treatment of Recalcitrant Thyroid Eye Disease

PURPOSE

Teprotumumab, an insulin-like growth factor 1 receptor monoclonal antibody, is FDA-approved to treat thyroid eye disease (TED). The initial clinical trials excluded patients with previous orbital irradiation, surgery, glucocorticoid use (cumulative dose >1 gm), or prior biologic treatment. Information on the use of teprotumumab for patients who failed prior therapy is limited. Our purpose is to characterize the efficacy of teprotumumab for the treatment of recalcitrant TED.

METHODS

This is a multicenter retrospective study of all patients treated with teprotumumab for moderate-to-severe TED after failing conventional therapy with corticosteroids, orbital radiation, surgical decompression, biologics, or other steroid-sparing medications. Treatment failure was defined as an incomplete response to or reactivation after previous treatment. Only patients who received at least 4 infusions of teprotumumab were included in the analysis. Primary outcome measures comprised proptosis response (≥2 mm reduction in the study eye without a similar increase in the other eye), clinical activity score (CAS) response (≥2-point reduction in CAS), and diplopia response (≥1 point improvement in Gorman diplopia score in patients with baseline diplopia) following treatment. Adverse events and risk factors for recalcitrant disease were also evaluated.

RESULTS

Sixty-six patients were included in this study, 46 females and 20 males. Average age was 59.3 years (range 29-93). The mean duration of disease from TED diagnosis to first infusion was 57.8 months. The proptosis, CAS, and diplopia responses in this recalcitrant patient population were 85.9%, 93.8%, and 69.1%, respectively. Patients experienced a mean reduction in proptosis of 3.1 ± 2.4 mm and a mean improvement in CAS of 3.8 ± 1.6. Patients who underwent prior decompression surgery experienced a statistically significant decrease in diplopia response (46.7% vs. 77.5%, p = 0.014) and proptosis response (75.0% vs. 90.9%, p = 0.045) when compared with nondecompression patients. Additionally, there were no significant differences in proptosis, CAS, and diplopia responses between patients with acute (defined as disease duration <1 year) versus chronic (disease duration ≥1 year) TED. While most adverse events were mild to moderate, 4 patients reported serious adverse events related to persistent hearing loss.

CONCLUSIONS

Patients with recalcitrant TED demonstrated a significant improvement after teprotumumab in each of the primary study outcomes. The degree of proptosis reduction, diplopia response, and CAS improvement in the recalcitrant group were similar to those of treatment-naïve patients from the pivotal clinical trials. Patients with a prior history of orbital decompression, however, demonstrated poor improvement in diplopia and less reduction in proptosis than surgery naïve patients. These results indicate that teprotumumab is a treatment option for the treatment of patients with TED recalcitrant to prior medical therapies.

Preparing the Ocular Surface for a Boston Keratoprosthesis Type 1 Through En Bloc Minor Salivary Gland Transplantation and Mucous Membrane Grafting in End-Stage Stevens-Johnson Syndrome

PURPOSE

This case describes the successful visual restoration of a patient with end-stage Stevens-Johnson syndrome (SJS) with a severely keratinized ocular surface.

METHODS

This study is a case report.

RESULTS

A 67-year-old man with SJS secondary to allopurinol sought visual rehabilitation options. His ocular surface was severely compromised from sequelae of chronic SJS, leaving him with light perception vision bilaterally. The left eye was completely keratinized with severe ankyloblepharon. The right eye had failed penetrating keratoplasty, limbal stem cell deficiency, and a keratinized ocular surface. The patient declined both a Boston type 2 keratoprosthesis and a modified osteo-odonto keratoprosthesis. Therefore, a staged approach was pursued with (1) systemic methotrexate to control ocular surface inflammation, (2) minor salivary gland transplant to increase ocular surface lubrication, (3) lid margin mucous membrane graft to reduce keratinization, and finally, (4) Boston type 1 keratoprosthesis for visual restoration. After minor salivary gland transplant and mucous membrane graft, the Schirmer score improved from 0 mm to 3 mm with improvement in ocular surface keratinization. This approach successfully restored the vision to 20/60, and the patient has retained the keratoprosthesis for over 2 years.

CONCLUSIONS

Sight restoration options are limited in patients with end-stage SJS with a keratinized ocular surface, aqueous and mucin deficiency, corneal opacification, and limbal stem cell deficiency. This case demonstrates successful ocular surface rehabilitation and vision restoration in such a patient through a multifaceted approach that resulted in successful implantation and retention of a Boston type 1 keratoprosthesis.

Erdheim-Chester disease and vemurafenib: a review of ophthalmic presentations and clinical outcomes

PURPOSE

To provide a comprehensive review of ocular and orbital manifestations of Erdheim-Chester Disease (ECD) and compare clinical outcomes with vemurafenib (INN) to historical treatments (HT). Primary outcomes are ophthalmic findings on presentation, changes in visual acuity, and mortality rate. Secondary outcomes include the progression of ocular findings, systemic involvements, and treatment modalities.

METHODS

All published literature from January 1983 to March 2021 was searched for ophthalmic manifestations of ECD. Clinical outcomes following HT were collected and compared with INN.

RESULTS

Forty-seven patients with ECD and ophthalmic presentations were identified. The mean age was 49.6 years (SD = 15.0). Proptosis (65.6%) and extraocular muscle restrictions (42.5%) were the most common presenting signs. Of 41 (87.2%) patients with orbital masses on radiologic examination, 90.2% were bilateral, and 53.7% were located in the intraconal space. Ophthalmic examination was significant for xanthelasma (27.2%), optic disc edema (34.0%), and subretinal changes (21.3%). Common treatments were systemic steroids (76.6%), interferon-α (17.0%), and cyclophosphamide (14.9%). INN was less commonly used (12.8%). The mean change in logMAR visual acuity declined with HT (29.9%) but improved with INN (79.1%) (p > 0.05). The proportion of eyes with complete vision loss increased after HT (p < 0.05). The overall mortality rate was 27.7% and notably higher in the HT group (29.3%) when compared to the INN group (16.7%) (p > 0.05).

CONCLUSION

ECD presents with many ophthalmic manifestations. Although the intraocular treatments remain controversial, INN should be highly considered in treating orbital ECD patients with BRAF-V600E mutations to prevent and reverse vision loss.

The use of Google Trends and Twitter data as a tool for evaluating public interest in hyaluronic acid eyelid filler

Background

Google Trends and the Twitter Academic Research Product Tract (TARPT) are free, online tools that can be used to evaluate public interest in plastic surgery procedures.

Aim

The aim of the study was to evaluate the correlation between online public interest in hyaluronic acid eyelid filler on two popular web platforms (Google and Twitter) and hyaluronic acid filler procedure volumes in the United States.

Methods

The Google Trends database and the TARPT tool were used to calculate the number of annual Google searches and Twitter tweets, respectively, related to 10 search terms associated with hyaluronic acid eyelid filler injections from January 2010 to December 2020. Annual procedure volumes for hyaluronic acid filler injections were obtained from the American Society of Plastic Surgery (ASPS). Univariate linear regression was used to correlate Google searches to ASPS procedure volumes and Twitter tweet volumes to ASPS procedure volumes.

Results

Significant positive correlations were found between Google Trends data and ASPS procedure volumes for 8/10 search terms and between Twitter tweet volumes and ASPS procedure volumes for 6/10 search terms, respectively. Online public interest in eyelid filler related search terms increased significantly over time according to an exponential model (P < 0.0001).

Conclusions

We observed statistically significant positive associations between public interest related to eyelid filler on two online platforms, Google and Twitter, and hyaluronic acid soft-tissue filler procedure volumes. The Google Trends and TARPT databases represent free information sources for surgeons that may be used to inform marketing and advertising decisions and to anticipate patient inquiries during the patient encounter.

Relevance for Patients

Information provided by the Google Trends and TARPT tools can be used by surgeons to (1) inform marketing and advertising strategies and (2) gain insight into which procedures patients are researching during a given time period, preparing them to best address the evolving needs of patients.

Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab

PURPOSE

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.

METHODS

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.

RESULTS

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, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption.

CONCLUSIONS

Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

Oral Corticosteroids for Teprotumumab-Related Hearing Loss: A Case Report

Teprotumumab is a novel insulin-like growth factor-1 receptor inhibitor approved for the treatment of thyroid eye disease, but growing reports of hearing loss require further investigation. To date, an effective protocol for managing hearing loss in this setting has not been determined. Here, we present the first report of the resolution of teprotumumab-related hearing loss with prompt oral prednisone. A 70-year-old woman on teprotumumab experienced sudden hearing loss and tinnitus after her first infusion. An audiogram demonstrated a mild down-sloping to moderately severe mixed conductive and sensorineural hearing loss that was promptly treated with prednisone 60 mg for 6 days with a 1-week gradual taper. An audiogram 3 weeks later demonstrated return of hearing to normal thresholds, and the whole teprotumumab treatment course was completed without further issue. This case highlights the importance of audiometric monitoring, prompt identification of hearing symptoms, and the potential for oral steroids to reverse teprotumumab-related hearing loss.

#CosmeticsTwitter: Predicting Public Interest in Nonsurgical Cosmetic Procedures Using Twitter Data

BACKGROUND

The utilization of social media in plastic surgery is expanding. The Twitter Academic Research Product Tract (TARPT) database provides plastic surgeons the opportunity to monitor public interest in plastic surgery procedures. Previously, TARPT was shown to be effective in tracking public interest in surgical cosmetic facial and body procedures.

OBJECTIVES

The authors sought to determine the ability of the TARPT tool to track and predict public interest in nonsurgical cosmetic procedures and to examine temporal public interest trends in nonsurgical cosmetic procedures.

METHODS

The authors employed the TARPT tool to calculate the total number of tweets containing keywords related to 15 nonsurgical cosmetic procedures from 2010 to 2020. Annual case volumes were obtained for each of the 15 procedures from annual reports provided by the American Society of Plastic Surgeons. Univariate linear regression was employed to compare tweet volumes and procedure volumes, with P < 0.05 as a threshold for significance.

RESULTS

Univariate linear regression revealed significant positive correlations between tweet volumes and American Society of Plastic Surgeons procedure volumes for 10 search terms representing 6 nonsurgical cosmetic procedures: "xeomin," "microdermabrasion," "facial filler," "fat filler," "fat injections," "fat transfer," "hyaluronic acid filler," "hyaluronic acid injection," "HA filler," and "PRP filler." Thirty-two search terms did not demonstrate a significant relationship.

CONCLUSIONS

The TARPT tool is an informative data source for plastic surgeons with the potential to guide marketing and advertising strategies, and monitor public interest in nonsurgical cosmetic procedures, helping surgeons respond to patients' evolving needs.

Comparison between 7 Tesla and 3 Tesla MRI for characterizing orbital lesions

PURPOSE

Characterizing orbital lesions remains challenging with imaging. The purpose of this study was to compare 3 Tesla (T) to 7 T magnetic resonance imaging (MRI) for characterizing orbital lesions.

MATERIALS AND METHODS

This prospective single-center study enrolled participants presenting with orbital lesions from May to October 2019, who underwent both 7 T and 3 T MRI examinations. Two neuroradiologists, blinded to all data, read both datasets independently and randomly. They assessed general characteristics of each orbital lesion as well as image quality and presence of artifacts. Comparison between both datasets was made using Fisher exact test.

RESULTS

Seven patients (4 women, 3 men) with a median age of 52 years were enrolled. Orbital lesion conspicuity was better scored at 7 T compared to 3 T MRI, with 3/7 lesions (43%) scored as very conspicuous at 7 T compared to 0/7 lesion (0%) at 3 T, although the difference was not significant (P = 0.16). Delineation of lesion margins was better scored at 7 T compared to 3 T with 3/7 lesions (43%) scored as very well delineated on 7 T compared to 0/7 lesions (0%) at 3 T, although the difference was not significant (P = 0.34). Details of internal structure were better assessed at 7 T compared to 3 T, with 4/7 lesions (57%) displaying numerous internal details compared to 0/7 lesions (0%) at 3 T (P = 0.10). Internal microvessels were visible in 3/7 lesions (43%) at 7 T compared to 0/7 lesions (0%) at 3 T (P = 0.19).

CONCLUSION

Although no significant differences were found between 7 T and 3 T MRI, assumably due to a limited number of patients, our study suggests that 7 Tesla MRI might help improve the characterization of orbital lesions. However, further studies with more patients are needed.

Trends in Leadership and Award Recognition Among Women in the American Society of Retina Specialists

Purpose

This work evaluates trends in achievement of women in the retina field, through an analysis of gender representation in the American Society of Retina Specialists (ASRS).

Methods

This retrospective, longitudinal study spans 1983 to 2020. Historical data classified by male or female gender were collected from ASRS's overall membership, board of directors and officers, and recipients of the 4 society awards. The proportion of each benchmark held by women was compared with prior decades since the founding of ASRS using the Fisher's exact test.

Results

Women's representation increased from 11% of ASRS members in 2007 to 19.7% in 2020. From 2010 to 2019, women received a higher proportion of society awards (21.1%) compared with membership prior to the start of that decade. In 2020, women were proportionally well represented in board of director positions (21.9%) and held a significantly higher proportion of board positions than in the period 1983 to 1989 (P = .02). From 1983 to 2020, women held 4.3% (1 of 23) of presidencies.

Conclusions

Although the number of women in retina is increasing, women remain underrepresented in the leadership of ASRS. Interventions to increase exposure to female mentorship and improve childcare benefits are warranted to engage female ophthalmology trainees in retina and ultimately society leadership.

Advances in the Treatment of Thyroid Eye Disease Associated Extraocular Muscle Myopathy and Optic Neuropathy

PURPOSE OF REVIEW

To review emerging treatments for thyroid eye disease (TED) associated extraocular muscle myopathy and dysthyroid optic neuropathy (DON).

RECENT FINDINGS

Emerging targeted biologic therapies may alter the disease course in TED. Teprotumumab, a type I insulin-like growth factor receptor inhibitor, is the most recent addition to the treatments available for TED-associated extraocular muscle myopathy causing diplopia. Small studies also suggest a potential therapeutic benefit for DON. Various recent studies have also expanded our knowledge on conventional TED therapies. The therapeutic landscape of TED and its sequelae has evolved in recent years. New targeted therapies have the potential to reduce the extraocular muscle and orbital volume expansion which can lead to diplopia and vision loss from optic nerve compression. Longer term efficacy and durability data is needed to determine the role biologics, such as teprotumumab, should play in the treatment of TED patients compared to the current standard of care.

#PlasticsTwitter: The Use of Twitter Data as a Tool for Evaluating Public Interest in Cosmetic Surgery Procedures

BACKGROUND

Plastic surgeons are increasingly turning to social media to market their services. The newly released Twitter Academic Research Product Track (TARPT) database provides free, customizable analysis of keywords that are included in tweets on the Twitter platform. The TARPT tool may provide valuable insight into public interest in cosmetic surgery procedures.

OBJECTIVES

The aim of this study was to determine TARPT's utility in tracking and predicting public interest in cosmetic surgery procedures and to examine temporal trends in tweets related to cosmetic facial and body procedures.

METHODS

The TARPT tool was used to calculate the total number of tweets containing keywords related to 10 facial cosmetic procedures and 7 cosmetic body procedures from 2010 to 2020. Annual volumes for respective procedures were obtained from annual statistics reports of The Aesthetic Society from 2010 to 2020. Tweet volumes and procedure volumes were compared by univariate linear regression, taking P < 0.05 as the cutoff for significance.

RESULTS

Variations in tweet volume were observed. Univariate linear regression analysis demonstrated statistically significant positive correlations between tweet volumes and procedure volumes for 7 search terms: "eyelid lift," "facelift," "lip injections," "mastopexy," "butt lift," "butt implants," and "liposuction." Many procedure-related keywords were not significant, demonstrating the importance of careful selection of Twitter search terms.

CONCLUSIONS

The TARPT database represents a promising novel source of information for plastic surgeons, with the potential to inform marketing and advertising decisions for emerging trends in plastic surgery interest before these patterns become apparent in surgical or clinical volumes.

Ocular, Orbital, and Adnexal Toxicity With High-dose Volumetric Modulated Arc Radiation Therapy for Orbital Malignancies

PURPOSE

Conventional modalities of external-beam radiation therapy (EBRT) are associated with high incidences of severe vision-threatening ocular and orbital toxicities when used to treat orbital malignancies. We investigate toxicities associated with high-dose volumetric modulated arc therapy (VMAT), a commonly used contemporary treatment modality for these tumors.

METHODS

Retrospective analysis of malignant orbital tumors managed with adjuvant high-dose VMAT preceded by globe-salvaging surgical therapy (GST) or exenteration. Dosimetric quantitation of target volumes and critical structures was performed. Incidence and severity of ocular, orbital, and adnexal toxicities were evaluated and assessed with regard to conventional EBRT toxicities for orbital malignancies described in the literature.

RESULTS

Eighty-four subjects (mean age = 65.9 ± 9.7 years) were included (N = 48 and N = 36 in GST and exenteration subgroups, respectively). Mean dose was 64.8 ± 2.1 Gy to the planning target volume. Dosing to critical structures typically did not surpass known tissue tolerance limits. Median follow up was 18.3 months. Visual acuity in the GST subgroup was not significantly different after VMAT (0.25 ± 0.06) compared with baseline (0.23 ± 0.02; P = 0.302). Whereas severe toxicities reported by major systematic analyses in the literature with older EBRT modalities were relatively common-for example, retinopathy (16-40%), optic neuropathy (16%), and corneal perforation (13%)-toxicities with VMAT were typically mild and less common. The most common toxicities with VMAT were mild dry eye (81.3%; 39/48), cataract (21.1%; 8/38 phakic eyes), and periocular dermatitis (15.5%; 13/84). Vision-threatening toxicities, including severe corneal pathologies, retinopathy, or optic neuropathy, were rare. There were no contralateral ocular or adnexal toxicities.

CONCLUSIONS

High-dose VMAT for orbital malignancies demonstrated low incidence and severity of eye-related toxicity, in contradistinction to adverse events reported from conventional forms of radiotherapy.

A Paradigm Shift in the Management of Thyroid Eye Disease How Teprotumumab Has Changed the Therapeutic Interface

BACKGROUND

Teprotumumab, a monoclonal antibody that blocks the insulin-like growth factor-1 receptor, has recently been approved by the US Food and Drug Administration (FDA) for the treatment of thyroid eye disease (TED). Since its approval, aside from data on the safety and clinical efficacy of teprotumumab from Phase-2 and Phase-3 trials, only a handful of reports have been published regarding its use in the wider population. In this review, we briefly describe the mechanism of action of teprotumumab and review the literature to provide an overview of published clinical experience. This information was used to provide recommendations for patient selection, management of patient expectations, infusion details and site options, tips to optimize the authorization process, and how to monitor and mitigate side effects.

EVIDENCE ACQUISITION

A systemic review of the literature was performed regarding teprotumumab, focusing on its mechanisms of action and published reports on its use on patients with TED. A review of Embase, Medline (PubMed), Web of Science, and Google Scholar was conducted.

RESULTS

Clinical experience following the approval of teprotumumab has confirmed its efficacy in reducing inflammation and proptosis in patients with acute TED (<2 years). The reduction in proptosis occurs due to a reduction in orbital fat and muscle volume. Furthermore, there is evidence for its use in patients with compressive optic neuropathy. There are also reports that show its efficacy in reducing proptosis, inflammation, and diplopia in patients with chronic TED (>2 years). Teprotumumab was associated with side effects, such as muscle spasm, hearing loss, and hyperglycemia. To date, 2 case reports have shown a possible association with flares of inflammatory bowel disease.

CONCLUSIONS

Teprotumumab is a powerful therapeutic option for the treatment of TED. Clinical experience following FDA approval has demonstrated efficacy in treating patients with acute and chronic TED. It is the only therapeutic option that has been shown to reduce orbital soft tissue expansion in TED. However, it is expensive, and sometimes, obtaining insurance authorization can be time consuming and difficult. Further work will reveal its full side effect profile and help to establish its role in the armamentarium used to treat TED.

Genome Sequencing and Apoptotic Markers to Assess Treatment Response of Lacrimal Gland Adenoid Cystic Carcinoma to Intra-Arterial Cytoreductive Chemotherapy

Adenoid cystic carcinoma of the lacrimal gland is an aggressive, malignant epithelial neoplasm. We report the case of a 30-year-old male with lacrimal gland adenoid cystic carcinoma treated with neoadjuvant intra-arterial chemotherapy through the internal carotid artery, followed by orbital exenteration and chemoradiation. Treatment response was evaluated using a novel combination of pre- and posttreatment genome sequencing coupled with immunohistochemical evaluation, which showed diffuse tumor apoptosis. A posttreatment decrease in variant allele frequency of the NOTCH1 mutation, and robust tumor cytoreduction on imaging, supports exploration of NOTCH1 analysis as a potential marker of cisplatin sensitivity. The use of genome sequencing and immunohistochemical evaluation could provide a more targeted therapeutic assessment of neoadjuvant intra-arterial chemotherapy in the management of lacrimal gland adenoid cystic carcinoma.

Hearing Dysfunction After Treatment With Teprotumumab for Thyroid Eye Disease

PURPOSE

To characterize the frequency, severity, and resolution of hearing dysfunction in patients treated with teprotumumab for thyroid eye disease (TED).

DESIGN

Prospective observational case series.

METHODS

Ophthalmic examination and adverse event assessment, including otologic symptoms, were performed at baseline, after infusions 2, 4, and 8, and at 6-month follow-up in consecutive patients who received at least 4 teprotumumab infusions. Laboratory test results were collected at baseline and during treatment. Audiometry, patulous eustachian tube (PET) testing, and otolaryngology evaluation were obtained for patients with new or worsening otologic symptoms, with a subset obtaining baseline and posttreatment testing.

RESULTS

Twenty-seven patients were analyzed (24 females, 3 males, average 56.3 years old). Twenty-two patients (81.5%) developed new subjective otologic symptoms, after a mean of 3.8 infusions (SD 1.8). At 39.2-week average follow-up after the last infusion, most patients with tinnitus (100%), ear plugging/fullness (90.9%), and autophony (83.3%) experienced symptom resolution, whereas only 45.5% (5 of 11) of patients with subjective hearing loss/decreased word comprehension experienced resolution. Six patients underwent baseline and posttreatment audiometry, 5 of whom developed teprotumumab-related sensorineural hearing loss (SNHL) and 1 patient also developed PET. Three of the 5 patients with teprotumumab-related SNHL had persistent subjective hearing loss at last follow-up. A prior history of hearing loss was discovered as a risk factor for teprotumumab-related SNHL (P = .008).

CONCLUSIONS

Hearing loss is a concerning adverse event of teprotumumab, and its mechanism and reversibility should be further studied. Until risk factors for hearing loss are better understood, we recommend baseline audiometry with PET testing and repeat testing if new otologic symptoms develop. Screening, monitoring, and prevention guidelines are needed.

Modified Gundersen Flap Using Inferior Palpebral-Bulbar Conjunctiva

PURPOSE

The purpose of this article was to describe a modification to the traditional Gundersen flap technique that expands eligible eyes to include those with severe conjunctival scarring and to report results from a clinical case.

METHODS

A 68-year-old woman with a history of herpes simplex keratitis, multiple failed penetrating keratoplasties, lagophthalmos, persistent epithelial defect, and low visual potential in the left eye presented for the evaluation of a Gundersen flap. Severe superior bulbar conjunctival scarring precluded a traditional approach. A modified Gundersen flap technique using a contiguous flap of inferior palpebral-bulbar conjunctiva extending from the inferior tarsal border to the limbus was devised and performed.

RESULTS

The modified Gundersen flap technique successfully stabilized the ocular surface, obviating the need for a cosmetically disfiguring permanent tarsorrhaphy or an evisceration.

CONCLUSIONS

This modified Gundersen flap technique expands the indications to eyes with severe conjunctival scarring and can be offered in eyes with previous trabeculectomies, glaucoma drainage implants, and scleral buckles, which were previously excluded from the globe-preserving option.

Stimulating Tear Production: Spotlight on Neurostimulation

Dry eye disease (DED) affects up to one-third of the global population. Traditional therapies, including topical lubricants, have been employed with variable success in the treatment of DED. Recently, neurostimulation of the lacrimal functional unit (LFU) has emerged as a promising alternative therapy for DED. In this review, we describe the neuroanatomical and pathophysiological considerations of DED and the LFU that make neurostimulation a viable therapeutic alternative. We further detail the various neurostimulatory approaches taken thus far—from implanted stimulators to external devices to chemical neurostimulation. Existing studies reveal the strengths of the neurostimulatory approach in increasing tear volume and improving dry eye symptoms, but further studies are needed to elucidate its true potential in treatment of DED.

New Indicator of Children's Excessive Electronic Screen Use and Factors in Meibomian Gland Atrophy

PURPOSE

To evaluate the association of children's daily electronic screen use with severe meibomian gland atrophy (MGA).

DESIGN

Retrospective cross-sectional study.

METHODS

Children (aged 6-17years) presenting at clinical practice December 2016 - October 2017 were evaluated for ≥grade 2 MGA vs age-matched controls with insignificant atrophy (<grade 1 atrophy). Questionnaires assessed dry eye symptoms, daily electronic screen use hours, diet, and outdoor time. Meibography imaging assessed for severe meibomian gland atrophy (≥grade 2 atrophy; ≥1 eyelid on validated, 4-point, ImageJ scale: 0 [normal] - 3 [severe]). Autoimmune disease biomarker positivity was assessed in 16 severe meibomian gland atrophy cases after being found relevant in firstcase.

RESULTS

A total of 172 children were evaluated. Patients with known meibomian gland atrophy causes or poor-quality meibographies were excluded. Forty-one met inclusion criteria (mean age, 11 years; 49% female): 17 cases had severe meibomian gland atrophy; 24 controls had insignificant gland atrophy. All severe meibomian gland atrophy cases had ocular symptoms/signs of dry eye disease including corneal neovascularization (29%), best-corrected visual acuity loss (41%), and central corneal neovascularization (14%). No controls had significant dry eye symptoms/signs. Controls had lower/"better" meibogrades vs cases (P < .01). In severe meibomian gland atrophy cases, 86% reported ≥4 hours of daily electronic screen use; 50% reported ≥8 hours. No controls exceeded 2 hours. Increased electronic screen use was positively associated with increased/"worse" meibogrades (odds ratio: 2.74; 95% confidence interval, 1.39-5.41). In 16 severe meibomian gland atrophy cases, 62.5% tested positive for autoimmune biomarker(s), though none had systemic symptoms: 18.8% rheumatoid factor; 6.25% SS-A/SS-B; 31.3% early Sjögren syndrome biomarkers; 6.25% ANA-positive/RF-negative. Autoimmune disease biomarker positivity was not significantly associated with severe meibomian gland atrophy vs controls (P = .34, right-eye; P = .71, left-eye).

CONCLUSIONS

Children's excessive electronic screen use is associated with severe meibomian gland atrophy. Further research is needed to establish formal electronic screen use limits based on meibography grade and evaluate correlation of autoimmune disease biomarker positivity in children with severe meibomian gland-atrophy.

Perioperative Management of Antithrombotic Medications: An Investigation into Current U. S. Ophthalmologic Recommendations

Purpose:

To investigate the availability and content of educational statements or recommendations disseminated by U. S. ophthalmologic organizations regarding perioperative management of antithrombotic agents for ophthalmic and orbital surgery, given the highly variable management of these agents by U. S. ophthalmologists and limited consensus recommendations in the literature.

Methods:

National U. S. ophthalmic surgical organization websites were systematically examined for educational statements, which were reviewed for discussion of perioperative management of antithrombotic agents including antiplatelet and anticoagulant medications. A “statement” was defined as either: (a) a guideline directed toward ophthalmologists or (b) a surgical/clinical educational posting directed toward ophthalmologists or patients.

Results:

Fourteen surgical organizations were identified, with eight of these publishing clinical/surgical educational statements. A total of 3408 organizational statements were identified, with 252 (7.4%) and 3156 (92.6%) statements directed toward physicians and patients, respectively. In total, 0.3% (9/3408) of statements discussed perioperative management of antithrombotics. These accounted for 0.8% (2/252) of ophthalmologist-directed statements and 0.2% (7/3156) of patient-directed statements. The majority of patient-directed statements (57.1%, 4/7) recommended that patients discuss antithrombotic cessation with their ophthalmologists, though ophthalmologist-directed information regarding these medications was scant or absent.

Conclusions:

Educational material from U. S. ophthalmologic organizations regarding perioperative management of antithrombotics is notably lacking despite the fact that ophthalmic and orbital surgeries carry unique vision-threatening hemorrhagic risks. Given these risks, as well as the medicolegal consequences of hemorrhagic complications in ophthalmic surgery, increased dissemination of educational material, and consensus statements by ophthalmic surgical organizations on the perioperative management of antithrombotics may be justified.

Early efficacy of teprotumumab for the treatment of dysthyroid optic neuropathy: A multicenter study

Purpose

To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) treated with teprotumumab.

Observations

In this multicenter observational Case series, patients with DON were treated with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with acute and chronic thyroid eye disease (TED) with DON who had failed conventional therapies and were not candidates for surgical decompression. Data collected included best corrected visual acuity (BCVA), color vision, RAPD when present, and orbital CT or MRI. Proptosis, clinical activity score (CAS), Gorman diplopia score (GDS), and Humphrey visual fields (HVF) were also evaluated.

Ten patients (6 women, 4 men) with an average age 64 years old were included in this study. Mean follow up after completion of infusions was 15 weeks. Baseline visual acuity (VA) impairment ranged from hand motion (HM) to 20/25 in affected eyes. All patients had pre-treatment orbital CT or MRI that confirmed orbital apex compression. Seventy percent of patients had objective improvement in DON after 2 infusions of teprotumumab measured as significant improvement in visual acuity, resolution of RAPD, or both. After completion of treatment, affected eyes had a mean BCVA improvement of 0.87 logMAR (p=0.0207), proptosis reduction of 4.7 mm (p<0.00001), CAS improvement of 5.25 points (p<0.00001), and GDS improvement of 0.75 points (p=0.160). All 6 patients who presented with an RAPD had resolution or improvement of RAPD. All 7 patients who presented with color vision deficits had normalization or improvement of color vision.

Conclusions and Importance

Teprotumumab infusions resulted in medical decompression and objective resolution or improvement of dysthyroid optic neuropathy. Most patients had rapid improvement of visual acuity and reversal of RAPD. Post-infusion imaging demonstrated reduction in extraocular muscle size that correlated with improvement in visual dysfunction. However, patients who presented with longstanding severe visual loss had limited improvement. There was no recurrence of DON after completion of teprotumumab in our cohort.

•

Teprotumumab is effective for the treatment of dysthyroid optic neuropathy.

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Most patients demonstrated rapid objective improvement after 2 infusions.

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Visual acuity improved and relative afferent pupillary defect resolved after treatment.

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Orbital imaging showed improvement of orbital apex crowding after treatment.

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Patients with longstanding severe vision loss had limited improvement in visual acuity.

The Efficacy of Teprotumumab for Chronic, Progressive Thyroid Eye Disease Greater Than 9 Months

Purpose: To evaluate the efficacy of teprotumumab for the treatment of patients with chronic, progressive Thyroid Eye Disease (TED) who do not meet the inclusion and exclusion criteria used in prior clinical trials. Methods: This is a prospective case series of patients with chronic, progressive TED, defined as ocular symptoms of more than 9 months prior to treatment initiation with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with a Clinical Activity Score (CAS) greater than or equal to 4. Data collected included patients’ age, sex, race, baseline thyroid status, thyroid stimulating immunoglobulin, CAS, smoking status, best corrected visual acuity, intraocular pressure, Schirmer’s, pupil exam, extraocular motility, Gorman diplopia score, and exophthalmometer measurements. Pre-infusion and post-infusion external photos in all 9 gazes, orbital imaging (CT or MRI), Humphrey visual fields and optical coherence tomography were obtained when possible.

Results: Ten patients with chronic TED were treated with teprotumumab either as a primary treatment or following other interventions including oral prednisone, intravenous methylprednisolone, orbital radiation, orbital decompression and/or eyelid surgery. The age range was 55 to 79, with 5 female patients and 5 male patients. Four of the patients were African American and 6 of the patients were White/Non-Hispanic. The number of years the patients had been diagnosed with Graves’ disease ranged from 4 to 33 years, with ocular involvement spanning 4 to 15 years. Patients had CT scans of the orbits to document muscle size prior to initiation, and external photos were taken at each visit. All patients improved subjectively after the first infusion and objectively by the fourth infusion. We will report the long-term follow-up after 8 infusions at ENDO2021.

Discussion: Teprotumumab is a fully human monoclonal IgG1 antibody that blocks the IGF-1 receptor, disrupting the cell-to-cell signaling of the immunologic cascade and is independent of the duration or severity of TED. At this time, FDA approval for teprotumumab is for the treatment of TED without any specific restrictions. However, our teprotumumab-treated patients included those who would have been excluded in the phase 2 and 3 clinical trials due to: (1) poor thyroid control, (2) previous orbital surgery, (3) previous therapeutic interventions including steroids and radiation, (4) visual loss due to compressive optic neuropathy or exposure keratopathy and (5) chronic TED greater than 9 months. In our series, we found that teprotumumab was as effective in a wider population of chronic TED patients than included in the clinical trials.

Progress Towards Parity: Female Representation in the American Society of Ophthalmic Plastic and Reconstructive Surgery

PURPOSE

To report female representation within the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) at all levels of career achievement over 50 years.

METHODS

Data were extrapolated from published ASOPRS directories and the 50th anniversary booklet. Fellowship, membership, leadership, and awards data were evaluated over 5 decades. Comparisons were made between the first and second 25 years, proportions of early and late career achievements, and time to career progression between males and females.

RESULTS

During the first decade, 5.6% of ASOPRS fellows were female (n = 2), which rose to 6.6% (n = 8), 17.6% (n = 32), 22.4% (n = 35), and 39.4% (n = 97) in the second, third, fourth, and fifth decades, respectively. These patterns were echoed in ASOPRS membership. When comparing the first half (1969-1994) to the second half (1995-2018), fellowship (10.5% vs. 30.0%, p < 0.001), membership (8.0% vs. 30.3%, p < 0.001), early career awards (5.6% vs. 28.9%, p = 0.047), program directorship (0.0% vs. 15.7%, p = 0.017), and executive committee female representation (4.5% vs. 16.8%, p < 0.001) increased significantly. However, females were proportionally underrepresented as program directors (p = 0.003), late career award winners (p = 0.001), executive committee members (p < 0.001), and presidents (p = 0.020). Among those reaching leadership positions, females took longer than males to become program directors by a median of 4 years (p = 0.025).

CONCLUSIONS

There has been a steady increase in female representation in ASOPRS fellowship training and membership. While significant progress has been made, growth in female leadership and award recognition is still needed.

Multi-compartment skull base orbital cavernous venous malformation: A rare presentation of a common orbital mass

Purpose

We present a unique case of an orbital intraconal cavernous venous malformation that extended along the trigeminal nerve to the pterygopalatine and middle cranial fossa. Our aim is to describe an atypical presentation of this common orbital vascular mass.

Observations

A 57-year-old female presented with right eye proptosis. Orbital magnetic resonance imaging demonstrated a lobulated contrast-enhancing mass involving the right intraconal orbital space, pterygopalatine fossa, and right middle cranial fossa, radiographically presumed to be a schwannoma. Intraoperative and histopathologic evaluation confirmed a cavernous venous malformation that extended along the trigeminal nerve. The mass, including its attachments to the cranial nerves and dura, was successfully removed via a combined transorbital and endoscopic endonasal approach. The patient recovered well with 20/20 vision, full extraocular movements, and resolution of proptosis.

Conclusions

This a rare presentation of an orbital cavernous venous malformation not previously described. Cavernous venous malformations typically present as ovoid well-circumscribed lesions; however, they can also extend outside the orbit along the path of cranial nerves, as was observed in this case. These types of lesions should be included in the differential diagnosis of masses arising from or extending along cranial nerves, even when involving the orbit.

Updates on the understanding and management of thyroid eye disease

Thyroid eye disease (TED) is a complex disease associated with myriad clinical presentations, including facial disfigurement, vision loss, and decreased quality of life. Traditionally, steroid therapy and/or radiation therapy were commonly used in the treatment of active TED. While these therapies can help reduce inflammation, they often do not have a sustainable, significant long-term effect on disease outcomes, including proptosis and diplopia. Recent advances in our understanding of the pathophysiology of TED have shifted the focus of treatment toward targeted biologic therapies. Biologics have the advantage of precise immune modulation, which can have better safety profiles and greater efficacy compared to traditional approaches. For instance, the insulin-like growth factor-1 receptor (IGF-1R) has been found to be upregulated in TED patients and to colocalize with the thyroid-stimulating hormone receptor (TSHR), forming a signaling complex. Teprotumumab is an antibody targeted against IGF-1R. By inhibiting the IGF-1R/TSHR signaling pathway, teprotumumab may reduce the production of proinflammatory cytokines, hyaluronan secretion, and orbital fibroblast activation in patients with TED. Due to promising phase II and III clinical trial results, teprotumumab has become the first biologic US Food and Drug Administration (FDA)-approved for the treatment of TED. In addition, there are currently ongoing studies looking at the use of antibodies targeting the neonatal Fc receptor (FcRn) in various autoimmune diseases, including TED. FcRn functions to transport immunoglobulin G (IgG) and prevent their lysosomal degradation. By blocking the recycling of IgG, this approach may dampen the body's immune response, in particular the pathogenic IgG implicated in some autoimmune diseases. Advances in our understanding of the pathophysiology of TED, therefore, are leading to more targeted therapeutic options, and we are entering an exciting new phase in the management of TED. This review will cover recent insights into the understanding of TED pathophysiology and novel treatment options as well as ongoing studies of new potential treatment options for TED.

Outcomes of corneal neurotisation using processed nerve allografts: a multicentre case series

Background

Corneal neurotisation is a rapidly evolving procedure treating neurotrophic keratopathy. The variety of surgical techniques used and corresponding outcomes after corneal neurotisation are not well understood. This study describes the techniques and outcomes in the largest case series of corneal neurotisation using processed nerve allografts to date.

Methods

This is a retrospective case series of patients who underwent corneal neurotisation with human cadaveric processed nerve allografts. All patients had preoperative and postoperative description of best corrected visual acuity and measurement of corneal sensation. Comparative studies after stratification of techniques were performed.

Results

A total of 17 patients were identified. The cause of corneal anaesthesia was prior infection in eight cases, trigeminal nerve palsy in eight cases and ocular trauma in one case. There were no intraoperative or postoperative complications. Following neurotisation surgery, the time to first gain of corneal sensation and maximal gain of sensation occurred at a mean of 3.7 months (range 1–8 months) and 6.6 months (range 3–15 months), respectively. The mean preoperative and postoperative corneal sensation as measured by Cochet-Bonnet aesthesiometry was 0.36 cm (range 0–3.2 cm) and 4.42 cm (range 0–6 cm), respectively (p<0.01). Visual acuity was unchanged after neurotisation. There were no statistical differences in outcomes based on end-to-end versus end-to-side coaptations, donor nerve selection or laterality of donor nerve.

Conclusion

Corneal neurotisation with processed nerve allografts is a safe and effective procedure. This study provides further evidence for the use of processed nerve allografts for corneal neurotisation.

Chronic Electrical Stimulation for Tear Secretion: Lacrimal vs. anterior ethmoid nerve

PURPOSE

To evaluate and compare the effect of lacrimal nerve stimulation (LNS) and anterior ethmoid nerve stimulation (AENS) on aqueous tear secretion, and tissue condition following chronic implantation.

METHODS

A neurostimulator was implanted in rabbits adjacent to the (1) lacrimal nerve, and (2) anterior ethmoid nerve. Tear volume was measured with Schirmer test strips after stimulation (2.3-2.8 mA pulses at 30 Hz for 3-5 min), and scores were compared to sham stimulation. Lacrimal gland and nasal septal tissue were evaluated histologically after chronic stimulation (2 weeks-7 months).

RESULTS

LNS increases tear volume by 32% above sham (p < 0.05, n = 5), compared with 133% for AENS (p ≤ 0.01, n = 6). AENS also significantly increases tear secretion in the fellow, non-stimulated eye (p ≤ 0.01, n = 6), as expected from the tearing reflex pathway. Histologically, chronic LNS is well tolerated by surrounding tissues while chronic AENS results in nasal mucosal fibrosis and implant extrusion within 3 weeks.

CONCLUSIONS

AENS is significantly more effective than LNS at enhancing aqueous tear secretion, including the fellow eye. The lacrimal implant is well tolerated, while the nasal implant requires further design optimization to improve tolerability.

Orbital, eyelid, and nasopharyngeal silicone oil granuloma presenting as ptosis & pseudo-xanthelasma

PURPOSE

To highlight the presentation and management of a patient with eyelid, orbital and nasopharyngeal silicone oil migration through a glaucoma drainage implant presenting as pseudo-xanthelasma and ptosis.

OBSERVATIONS

A 68-year male presented with unilateral ptosis and presumed xanthelasma. He had a history of glaucoma drainage implant surgery, pseudophakia, and multiple retinal detachment repairs with silicone oil. During ptosis repair it was discovered that his presumed xanthelasma was in fact an eyelid silicone granuloma. Additional work up revealed silicone infiltration of the eyelids, orbits, and nasopharynx, resulting from emulsified silicone oil leakage through his glaucoma valve implant.

CONCLUSIONS AND IMPORTANCE

Silicone oil may emulsify with time, with potential egress via a glaucoma filtration device. Clinicians should be alert for eyelid, orbital and sinonasal findings that may indicate occult migration.

Orbital and chorioretinal manifestations of Erdheim-Chester disease treated with vemurafenib

Purpose

We report a patient with severe multi-organ dysfunction of unknown origin who presented with bilateral orbital and chorioretinal manifestations that led to the diagnosis of Erdheim-Chester Disease (ECD).

Observations

ECD is a rare, histiocytic, proliferative disorder characterized by multi-systemic organ involvement that has historically lacked effective therapy. Our patient underwent genetic testing that was positive for the BRAF V600E mutation; therefore, the patient was treated with vemurafenib.

Conclusions and importance

This case demonstrates the rare orbital and intraocular manifestations of ECD and the unfortunate impact of a delayed diagnosis, the importance of early gene therapy testing for management decisions, and the utilization of targeted directed therapy to improve visual outcomes and quality of life.

Disseminated silicone granulomatosis in the face and orbit

Purpose

To report a case of disseminated silicone granulomatosis presenting with ptosis, proptosis and vision loss.

Observations

A 56-year-old female presented with ptosis, proptosis, and vision loss and was noted to have palpable, erythematous masses involving the orbit, face, trunk, and body. She had a history of bilateral silicone breast implants and cosmetic facial filler injections. Orbital biopsy demonstrated non-caseating granulomas with foreign-body giant cells and vacuoles containing material consistent with silicone. Removal of the patient's breast implants and systemic immunosuppression led to dramatic granuloma regression.

Conclusions

Silicone can induce a severe, systemic inflammatory response and should be considered in the differential for facial and periorbital granulomas in patients with a history of silicone breast implants. Management of disseminated silicone granulomatosis is challenging and requires multimodal treatment with silicone removal and systemic immunomodulation.

Enhanced Tearing by Electrical Stimulation of the Anterior Ethmoid Nerve

Purpose

Electrical neurostimulation enhances tear secretion, and can be applied to treatment of dry eye disease. Using a chronic implant, we evaluate the effects of stimulating the anterior ethmoid nerve on the aqueous, lipid, and protein content of secreted tears.

Methods

Neurostimulators were implanted beneath the nasal mucosa in 13 New Zealand white rabbits. Stimulations (2.3–2.8 mA pulses of 75–875 μs in duration repeated at 30–100 Hz for 3 minutes) were performed daily, for 3 weeks to measure changes in tear volume (Schirmer test), osmolarity (TearLab osmometer), lipid (Oil-Red-O staining), and protein (BCA assay, mass spectrometry).

Results

Stimulation of the anterior ethmoid nerve in the frequency range of 30 to 90 Hz increased tear volume by 92% to 133% (P ≤ 0.01). Modulating the treatment with 50% duty cycle (3 seconds of stimulation repeated every 6 seconds) increased tear secretion an additional 23% above continuous stimulation (P ≤ 0.01). Tear secretion returned to baseline levels within 7 minutes after stimulation ended. Tear film osmolarity decreased by 7 mOsmol/L, tear lipid increased by 24% to 36% and protein concentration increased by 48% (P ≤ 0.05). Relative abundance of the lacrimal gland proteins remained the same, while several serum and corneal proteins decreased with stimulation (P ≤ 0.05).

Conclusions

Electrical stimulation of the anterior ethmoid nerve increased aqueous tear volume, reduced tear osmolarity, added lipid, and increased the concentration of normal tear proteins. Human studies with an intranasal stimulator should verify these effects in patients with aqueous- and lipid-deficient forms of dry eye disease.

Neurostimulation of the lacrimal nerve for enhanced tear production

PURPOSE

To design a proof-of-concept study to assess the effect of lacrimal nerve stimulation (LNS) with an implantable pulse generator (IPG) to increase aqueous tear production.

METHODS

Experimental animal study design of 6 Dutch Belted rabbits. Ultra high-resolution optical coherence tomography (UHR-OCT) quantified tear production by measuring the baseline tear volume of each rabbit's OD and OS. A neurostimulator was implanted adjacent to the right lacrimal nerve. After 2 minutes of LNS (100 μs, 1.6 mA, 20 Hz, 5-8 V), the tear volumes were measured with UHR-OCT. The change in tear volume was quantified and compared with the nonstimulated OS. Three rabbits underwent chronic LNS (100 μs, 1.6 mA, 10 Hz, 2 V) and their lacrimal glands were harvested for histopathologic analysis.

RESULTS

The UHR-OCT imaging of the OD tear volume showed a 441% average increase in tear production after LNS as a percent of baseline. After stimulation, OD had statistically significant greater increase in tear volumes than OS (p = 0.028, Wilcoxon test). Poststimulation OD tear volumes were significantly greater compared with baseline (p = 0.028, Wilcoxon test). Histopathologic examination of the lacrimal glands showed no discernible tissue damage from chronic neurostimulation. In addition, there were no gross adverse effects on the general well-being of the animals due to chronic stimulation.

CONCLUSIONS

LNS with an IPG appears to increase aqueous tear production. Chronic LNS showed no histopathologic lacrimal gland damage. This study suggests that LNS is a promising new treatment strategy to increase aqueous tear production.

Long-term outcomes of neoadjuvant intra-arterial cytoreductive chemotherapy for lacrimal gland adenoid cystic carcinoma

PURPOSE

To compare the long-term outcomes after intra-arterial cytoreductive chemotherapy (IACC) with conventional treatment for lacrimal gland adenoid cystic carcinoma (ACC).

DESIGN

Retrospective case series.

PARTICIPANTS

Nineteen consecutive patients treated with IACC, followed by orbital exenteration, chemoradiotherapy, and intravenous chemotherapy.

INTERVENTIONS

Analyses of the histologic characteristics of biopsy specimens, extent of disease at the time of diagnosis, diagnostic surgical procedures, incidence of locoregional recurrences or distant metastases, disease-free survival time, response to IACC, tumor margins at definitive surgery, and toxicity and complications.

MAIN OUTCOME MEASURES

Disease relapse, disease-free survival, and chemotherapeutic complications.

RESULTS

Eight patients with an intact lacrimal artery had significantly better outcomes for survival (100% vs. 28.6% at 10 years), cause-specific mortality, and recurrences (all P = 0.002, log-rank test) than conventionally treated patients from the University of Miami Miller School of Medicine. These 8 patients (group 1) had cumulative 10-year disease-free survival of 100% compared with 50% for 11 patients (group 2) who had an absence of the lacrimal artery or deviated from the treatment protocol (P = 0.035) and 14.3% for conventionally treated patients (P<0.001). Likewise, group 2 was associated with lower cause-specific mortality than the institutional comparator group (P = 0.038). Prior tumor resection with lateral wall osteotomy, delay in IACC implementation or exenteration, and failure to adhere to protocol are risk factors for suboptimal outcomes.

CONCLUSIONS

Neoadjuvant IACC seems to improve overall survival and decrease disease recurrence. An intact lacrimal artery, no disruption of bone barrier or tumor manipulation other than incisional biopsy, and protocol compliance are factors responsible for favorable outcomes. The chemotoxicity complication rate is limited and manageable.