Implementation of thyroid eye disease registry in Iran: rationale and research protocol

BACKGROUND

To describe the implementation of a registry system for patients with thyroid eye disease (TED) in Iran to obtain more information about its nature, prevalence, and annual incidence, as well as extend insight into the etiology, pathogenesis, and eventually make an accurate prognosis of different medical or surgical treatment methods.

METHODS

After receiving approval from the Disease Registry Committee of Iran University of Medical Sciences (IUMS) in 2019 and the Ministry of Health and Medical Education (MOHME) in 2020, the protocol was introduced in three consecutive phases at regional, provincial and national levels. The establishment of a registry committee in Rassoul Akram Hospital, one of the medical centers affiliated to IUMS, was the first step to organizing the registry project's main core. The steering committee included six subgroups of required subject fields. The members are experts in developing a guideline, providing a new dataset, drawing an outline for the next steps, and structuring user-friendly software through several panel discussion meetings. The data is collected from clinical and para-clinical/imaging findings, laboratory evaluations, and their selected treatment strategy, retrospectively and prospectively.

RESULTS

The purpose is to broaden our knowledge about the profile of TED; accordingly, data related to patients' demographics, thyroid gland disease (status, duration, treatments, and function tests), general medical and ocular history, along with visual/ocular exams resulting TED status are collected and recorded in a 2- language software. The web-based software system is accessible at https://orc.iums.ac.ir . To maintain data security, prioritized user access was defined for different members. Furthermore, diverse methods, such as employing trained staff and utilizing software validation rules, were implemented to control data quality in every step of data collection, entry, and registration. Medical records of retrospective subjects were also evaluated and entered after accuracy verification.

CONCLUSION

Iran's TED registry provides practitioners with comprehensive data on natural history and phenotype variations in clinical features and outcomes. It facilitates patient recruitment and, consequently, earlier diagnosis on a large scale which helps improve treatment and quality of life for patients.

Long-Term Results of Oral Propranolol Treatment Protocol for Periocular Infantile Hemangioma: Should There Be Any Contraindication?

PURPOSE

The authors report long-term results of the oral propranolol treatment protocol for periocular infantile hemangioma regardless of conventional indications.

METHODS

This is a retrospective study (2008-2018) on children with propranolol treatment protocol for periocular infantile hemangioma and last follow-up (FU) of ≥4 months after treatment and age of >24 months. After systemic evaluation, it was started with 0.5 and increased by 0.5 every 3 days to reach 2 mg/kg/day. If there was no good response, it would be gradually increased up to 3 mg/kg/day. Tapering (0.5 mg/kg/day every 4 weeks) was started when patients were on treatment for ≥6 months and ≥12 months old and there was no change in the infantile hemangioma size for ≥3 months. Rebound growth was based on the parents' report and would be treated by increasing the dose to at least 2 mg/kg/day for 3 months. FU was either in-person or via social media. Change in periocular infantile hemangioma size on the photos was scored by 3 masked observers (visual analog scale) and presented as excellent (≥50% reduction), good (1%-49%), fair (no change), and failure (enlarged).

RESULTS

Forty-three patients were included. Orbital involvement was in 49%, ptosis in 58%, and risk of amblyopia in 63%. Mean treatment, tapering, and FU duration were 37, 13, and 74 months, respectively. Mean age at presentation, start of propranolol treatment protocol, tapering, stop, and last FU were 1.5, 5, 29, 42, and 78 months, respectively. Twenty-seven patients received 2, seven 2.5, and nine 3 mg/kg/day. Mean visual analog scale significantly increased from 43% (FU1) to 92% (last FU) when 97.6% of patients showed an excellent response. The remaining skin lesions were observed in 35%. No side effect was reported.

CONCLUSIONS

Long-term results of the propranolol treatment protocol for periocular infantile hemangioma showed an excellent response in 97.6% of patients with no side effects. A residual skin lesion was observed in 1/3 of the patient.

Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty

BACKGROUND

Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique for preventing postoperative tear trough deformity. Its drawbacks include retraction, limited volume, transcutaneous fixation, and a complex insertion technique. The minced lower eyelid fat graft was introduced to overcome these drawbacks.

OBJECTIVES

The aim of this study was to compare the outcome of preperiosteal pedicle fat flaps with minced free fat graft in TCLB.

METHODS

Participants who underwent the pedicle fat flap procedure from April 2019 to April 2020 (Group A) and the minced free fat graft from May 2020 to May 2021 (Group B) with at least 6 months of follow-up were included. Subjective (pain, infraorbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes, satisfaction (visual analogue scale score) at the last follow-up, and reoperation rates were compared.

RESULTS

There were 142 participants (94% females) with a mean age of 48.4 years (range: 21-71) and a follow-up of 8.2 months (range: 6-36). There were 73 participants in Group A and 69 in Group B, with no significant differences in age (P = .6), sex (P = .7), or follow-up (P = .3). In addition to TCLB, Groups A and B had simultaneous upper eyelid and eyebrow procedures (53% vs 49%, P = .2), lateral canthal plication (77% vs 83%, P = .4), and pinch skin excision (82% vs 88%, P = .3). Groups A and B did not have significant differences in postoperative numbness (6.8% vs 1.4%, P = .2), chemosis (11% vs 10%, P = 1), skin wrinkles (12.3% vs 8.7%, P = .6), hyperpigmentation (1.4% in both groups), bumps (2.7% vs 7.2%, P = .3), tear trough deformity (0.0% in both groups), satisfaction score (97.7% vs 98.1%, P = .4), or reoperation rate (12.3% vs 5.8%, P = .2).

CONCLUSIONS

The desired aim of fat redistribution in TCLB seems to be equally achievable with minced fat graft and pedicle fat flap techniques.

LEVEL OF EVIDENCE: 4

Endoscopic-assisted Orbitotomy for Obliteration of Orbital Arteriovenous Fistula Refractory to Endovascular Techniques

Orbital arteriovenous fistula is a rare acquired disorder. The coincidence of arteriovenous fistula with lymphaticovenous malformation is even rarer. The optimal treatment, thus, is controversial. Surgical approaches vary widely, with associated pros and cons. The purpose of this case report is to describe an orbital arteriovenous fistula in a 25-year-old man with congenital fronto-orbital lymphaticovenous malformation, refractory to endovascular techniques, which was later successfully ablated by a direct endoscopic-assisted orbital approach.

The Rare and Atypical Diabetes Network (RADIANT) Study: Design and Early Results

OBJECTIVE

The Rare and Atypical Diabetes Network (RADIANT) will perform a study of individuals and, if deemed informative, a study of their family members with uncharacterized forms of diabetes.

RESEARCH DESIGN AND METHODS

The protocol includes genomic (whole-genome [WGS], RNA, and mitochondrial sequencing), phenotypic (vital signs, biometric measurements, questionnaires, and photography), metabolomics, and metabolic assessments.

RESULTS

Among 122 with WGS results of 878 enrolled individuals, a likely pathogenic variant in a known diabetes monogenic gene was found in 3 (2.5%), and six new monogenic variants have been identified in the SMAD5, PTPMT1, INS, NFKB1, IGF1R, and PAX6 genes. Frequent phenotypic clusters are lean type 2 diabetes, autoantibody-negative and insulin-deficient diabetes, lipodystrophic diabetes, and new forms of possible monogenic or oligogenic diabetes.

CONCLUSIONS

The analyses will lead to improved means of atypical diabetes identification. Genetic sequencing can identify new variants, and metabolomics and transcriptomics analysis can identify novel mechanisms and biomarkers for atypical disease.

Targeted chemotherapy in retinoblastoma: A step forward from patient survival to globe survival

BACKGROUND/ OBJECTIVES

Despite being the most common intraocular malignancy in childhood, there is a substantial disparity between developing and developed countries in terms of patient and globe survival in retinoblastoma (Rb). The current study intends to determine patient and globe survival before and after the introduction of the new targeted treatment modalities in a developing country.

METHODS

Medical records of 350 patients (516 eyes) with retinoblastoma referred to a tertiary referral center for Rb in Tehran, Iran, were reviewed. In order to compare patient and globe survival before and after the availability of the new treatment modalities, including intra-arterial and intravitreal chemotherapy, the patients were divided into group 1 (2001-2007) and group 2 (2008-2018) based on the calendar period of diagnosis.

RESULTS

Two-hundred-twenty-three eyes of 149 patients and 293 eyes of 201 patients were categorized into groups 1 and 2, respectively. The 5-year patient survival was 97% across the current survey, and the overall survival rate was 96% in group 1 and 99% in group 2 (P = 0.08). Overall, 50% of eyes with retinoblastoma underwent enucleation, which was the primary in 63% (116/184) of the unilateral and 30% (99/322) of the bilateral cases. Primary enucleation was significantly lower in group 2 (35%) in contrast to group 1 (50%) (P < 0.001). In addition, globe survival improved significantly in the International Classification of Retinoblastoma Groups D (17% in group 1 vs. 66% in group 2, P < 0.001) and E (1% in group 1 vs. 23% in group 2 P < 0.001) during the two timelines. In enucleated eyes, despite the increased rate of prelaminar involvement in group 2 (13% vs. 2% in group 1, P = 0.003), the rate of high-risk histopathologic findings was similar between the two groups.

CONCLUSION

Similar to developed countries, the application of new targeted treatment modalities, including intra-arterial and intravitreal chemotherapy, has been associated with significantly improved globe survival in Rb patients. However, it should be noted that even with the availability of these novel treatment options, the decision for on-time enucleation should not be deferred.

Lacrimal Canalicular Bypass Surgery with Autologous Superficial Temporal Artery Graft

Purpose

To describe superficial temporal artery graft as a new autologous tissue to reconstruct the upper lacrimal drainage system.

Methods

We explain the history of a 30-year-old female with upper lacrimal drainage system obstruction, in whom conjunctivodacryocystorhinostomy (CDCR) failed to resolve epiphora. A superficial temporal artery graft was harvested, intubated with Masterka tube, and implanted between the conjunctiva and nasal cavity. Masterka was replaced with a thicker dummy tube 12 weeks postoperatively. The adequacy of the graft was checked with irrigation tests in follow-up visits from 1 to 26 months after the procedure.

Results

Superficial temporal artery autograft successfully eliminated epiphora of the patient in whom (CDCR) with Jones tube failed to make her symptom free.

Conclusion

Superficial temporal artery autograft as an autogenous tissue with adequate characteristics can be considered in selective patients of upper lacrimal obstruction to reconstruct the lacrimal drainage system.

Diagnostic value of lacrimal scintigraphy in the evaluation of lacrimal drainage system obstruction: a systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis to evaluate the diagnostic performance of lacrimal scintigraphy (LS) versus anatomical methods in the evaluation of the nasolacrimal duct obstruction (NLDO).

MATERIALS AND METHODS

A systematic search was performed using electronic bibliographic databases until the end of May 2021. Inclusion criteria: (a) used LS as a diagnostic method to evaluate NLDO; (b) used anatomical studies [including syringing, irrigation, probing, and dacryocystography (DCG)] as reference tests; and (c) provided adequate crude data. A hierarchical method was used to pool the sensitivity and specificity. The hierarchical summary receiver-operating characteristic model was performed. Additionally, the studies' heterogeneity and publication bias were analyzed. All analyses were conducted by the 'Midas' module of STATA 16.

RESULTS

Twelve articles (with 14 separate populations) were considered eligible to enter the meta-analysis. They were divided into two groups based on the reference standard method, called irrigation and DCG groups. In the irrigation group, the pooled sensitivity and specificity were 89% [95% confidence interval (CI), 72-96%] and 25% (95% CI, 8-56%), respectively. In DCG group, the pooled sensitivity and specificity were 97% (95% CI, 85-100%) and 27% (95% CI, 0.12-0.49), in turn.

CONCLUSION

LS is a sensitive modality to evaluate the anatomical obstruction of NLD. In contrast, it shows low pooled specificity compared with anatomical methods. Thus, LS can be used as the first noninvasive modality for the evaluation of epiphora. However, in case of any abnormality, confirmatory procedures are required.

Optic Nerve Head Vessel Density Changes from Graves' Disease without TED to TED Dysthyroid Optic Neuropathy: Does Optic Nerve Head Ischemia Play a Role?

PURPOSE

To compare the retinal peripapillary capillary (RPC) vessel density (VD) between 5 groups of patients on the spectrum of thyroid eye disease (TED).

METHOD

This is a prospective comparative study looking at 5 groups of patients who were consecutively included from January 2018 to March 2021. They were composed of: Healthy volunteers (39 eyes and 20 subjects), patients with Graves' disease without TED (26 eyes and 13 patients), mild TED (28 eyes and 14 patients), moderate-severe TED (30 eyes and 17 patients), and TED with dysthyroid optic neuropathy (DON) (21 eyes and 12 patients). Ocular and periocular examination, visual field indices, RPC-VD (with optical coherence tomography angiography), and retinal nerve fiber layer, and macular ganglion cell complex thickness were recorded.

RESULT

An initial insignificant (0.5 < p < 0.9) rise in the peripapillary-VD (pp-VD) and whole image-VD (wi-VD) from the healthy subject to the Graves' disease without TED was followed by a significant (p = 0.001) fall in RPC-VD in different severity grades of the TED. Paired comparison between the 5 groups showed that the statistically significant fall from the Graves' disease group occurred in the moderate-severe and DON groups (0.001 ≤ p ≤ 0.04). No variable significantly affected the VD (0.08 ≤ p ≤ 0.9). A lower wi-VD and pp-VD were significantly (0.001 ≤ p ≤ 0.009) correlated with the impaired optic nerve functional and structural tests. The sensitivity and specificity of wi-VD (81% and 76%) and pp-VD (69% and 71%) for detecting the DON were statistically significant (p < 0.001).

CONCLUSION

Despite an insignificant rise in the wi- and pp-VD from the healthy volunteers to the patients with Graves' disease without TED, VD showed a declining trend in the course of patients with TED, which was statistically significant in the moderate-severe TED and DON groups.

Prevalence of Masked versus Unmasked Blepharoptosis in Subjects Seeking for Blepharoplasty and or Eyebrow Lift

PURPOSE

To report the prevalence of unmasked versus masked in subjects seeking for eyelid and eyebrow rejuvenation.

METHODS

This retrospective study included subjects (>18 years) who were seeking for blepharoplasty and/or eyebrow lift procedures in the year 2020. They were either having No ptosis, Unmasked or Exposed ptosis (complaining of simultaneous droopy eyelid, which was confirmed on examination), or Masked or Hidden ptosis (not complaining of simultaneous droopy eyelid, but its presence was revealed on the examination). Margin reflex distance 1 (MRD1) and levator function (LF) were recorded. Associated ptosis was defined as MRD1 of ≤3 mm and regarded as mild (3 and 2.5 mm), moderate (2 and 1.5 mm), and severe (≤1 mm).

RESULTS

Included were 1401 subjects with a mean age of 47.2 years. The prevalence of masked and unmasked ptosis was 31% (90% unilateral) and 15.6% (59% bilateral), respectively. A significantly younger mean age (45.6 vs. 59.7 years), higher MRD1 (2.6 vs. 1.9 mm), and better LF (13.3 vs. 11.3 mm) were observed in the masked vs. unmasked ptosis group. More than 80% of the subjects with masked ptosis presented with indirect signs. A majority of both groups (68.8% of masked and 63.5% of unmasked ptosis) were mild to moderate.

CONCLUSION

Almost half of the subjects seeking for eyelid and eyebrow rejuvenation had either masked (2/3) or unmasked (1/3) associated ptosis. Masked ptosis was mostly unilateral and presenting with indirect signs of ptosis.

Short- and Long-term Patient Satisfaction and Complications in 650 Endoscopic Forehead Lift Procedures

PURPOSE

The aims are to compare short- versus long-term patient satisfaction and report temporary versus permanent complications in 650 patients with endoscopic forehead lift procedure (EFL).

METHODS

This is a retrospective study on all of the consecutive patients with EFL. Patients with previous trauma and surgery and less than 2 years follow up were excluded. Short- (6 months) and long-term (≥2 years) patient satisfaction (visual analog score [VAS], 0-100) were recorded. Patients' perspectives on temporary versus permanent complications were also documented.

RESULTS

Mean age and follow up were 46.4 and 7.1 (2-13) years, respectively. Long-term satisfaction (79.9) was significantly lower than the short term (96.6). The long-term satisfaction decreased in 95.7%, increased in 2.7%, and remained the same in 1.6% of the patients. Intraoperative skin laceration occurred in 3 patients (0.5%). Mean time of forehead numbness recovery was 2.3 months. Temporary complications were itching (13.7%), headache (6.3%), unilateral facial nerve palsy (5.8%), acne (3.2%), and remained staples (1.7%). Permanent complications included undercorrection (7.1%), alopecia (4.2%), forehead irregularities (2.3%), surprised look (2.2%), incision site complications (2%), and glabellar depression (0.9%). Reoperation (1.2%) was performed for undercorrection and alopecia. While short-term satisfaction was significantly lower in patients with temporary facial nerve paresis, long-term satisfaction was lower in patients with undercorrection and reoperation.

CONCLUSION

A high satisfaction scores of 96.6 and 80 were observed in the short- and long-term follow up after the EFL. Frequency of temporary and permanent postoperative complications was 30.3% and 15.8%. Reoperation rate was 1.2%.

Conversion Rate of Web-based Versus Non-web-based Patient Referral Sources in a Facial Plastic Surgery Practice

PURPOSE

To compare the conversion rate (number of procedures/referrals) of web-based and non-web-based referrals to a facial plastic surgery practice (2012-2019).

METHOD

Data on demographics, referral source, patient's concern, and their facial procedures were recorded. Web-based referral sources include website and Instagram. Non-web-based counterparts were the word-of-mouth, medical professionals, and others (TV, radio, printed media). Patient concerns were either cosmetic or noncosmetic (functional). Patients who underwent facial cosmetic surgery and injections (botulinum toxin A, filler, fat) were categorized in the cosmetic procedure group. Patients with functional procedures with or without facial injections were categorized in the noncosmetic procedure group. The conversion rate was defined as the ratio of the number of referrals with different facial procedures to the total number of referrals.

RESULTS

Included were 19,965 patients, majority of whom (63.3%) had cosmetic concern. Total, cosmetic, and noncosmetic conversion rates were 30.1%, 27.7%, and 2.4% for the web-based and 24.1%, 19.8%, and 4.3% for the non-web-based referrals, respectively (0.3 < p < 0.4). Cosmetic conversion rate grew from 6.7% in referrals ≤20 to more than 23% in >20 years of age (p = 0.03). It was also significantly (p < 0.001) higher in the referrals with cosmetic (28.3%) than noncosmetic (12.1%) concern. Gender and year of practice did not have a significant effect on the conversion rates.

CONCLUSION

Conversion rates were not significantly different between the web-based and non-web-based referrals. A significantly higher cosmetic conversion rate was observed for the referrals with cosmetic concern and older than 20 years.

A Systematic Review on the Role of Antioxidants in Thyroid Eye Disease

Purpose

To systematically review the role of antioxidants in management of patients with thyroid eye disease (TED).

Methods

A literature search of the electronic databases was performed without restrictions on the date of publication till the end of March 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical trials, case-control studies, cohorts, case series, case reports, and experimental (including in vitro) studies in the English language were included. The primary outcome in human studies was improvement in severity, activity scores, and/or quality of life scores. There was a decrease in the level of H2O2-dependent oxidative stress, Hyaluronic acid release, reactive oxygen species, cell proliferation, or antifibrotic/antiproliferative actions in the in vitro studies.

Results

Out of 374 initially screened articles, 157 studies were selected, the full texts of 82 were reviewed, and 14 papers were finally included. There were 4 clinical and 10 in vitro studies from 1993 to 2018. While β-carotene, retinol, Vitamin E, Vitamin C, melatonin, resveratrol, N-acetyl-l-cysteine, and quercetin showed some efficacy in in vitro studies; allopurinol, nicotinamide, pentoxifylline, and selenium (Se) were effective in both clinical and experimental reports. Se was the only recommended antioxidant based on one high-level randomized controlled trial.

Conclusion

While different antioxidants could potentially be effective in the management of TED, no strong recommendation for any or combination of antioxidants could be made to be implemented in the daily practice.

Normal Exophthalmometry Values in Iranian Population: A Meta-analysis

There are limited studies on the normal values of eye protrusion in Iran. Systematic efforts to provide acceptable normal exophthalmometry values for Iranian population are required for a proper approach to orbital diseases.English and Farsi language publications in PubMed, the ISI Web of Knowledge database, Iranian SID, and Iran Medex were searched using the following keywords: “proptosis”, “eye protrusion”, “exophthalmous”, “Hertel exophthalmometer” and “Iran”. Four articles from 1995 to 2010 were found and included in the meta-analysis. Statistical analysis was performed using the Metan command within Stata 15.0 software.It included 3,696 subjects in whom the average eye protrusion was 16.5 mm (95% CI: 15.1–17.8) in men and 16.2 mm (95% CI: 14.6–17.7) in women (P = 0.5). Mean left and right eye protrusion were 16.3 (95% CI: 14.7–18.1) and 16.4 mm (95% CI: 14.8–17.7), (P = 0.3), respectively. While Iranian teenagers (13–19 years old) showed a mean value of 17.1 mm (95% CI: 15.0–19.1), older age group (≥20 years) showed a lower mean eye protrusion of 16.3 mm (95% CI: 14.8–17.7). Considering the two standard deviations, the highest normal value of eye protrusion in Iranian population is 20.1 mm.In conclusion,Iranian normal eye protrusion values were higher than Asians and lower than Caucasians.

Dermatochalasis Through Decades: A Histopathologic Study

OBJECTIVES

Three prior studies (2008, 2011, 2018) histopathologically compared the eyelid specimens of patients with dermatochalasis (DC, undergoing blepharoplasty) with a control group and proposed that DC may begin with subclinical inflammation leading to elastolysis and lymphostasis. With growing number of younger patients consulting for blepharoplasty, the unanswered question is whether histopathologic changes of DC differ between the younger and the older.

PATIENTS AND METHODS

In this prospective case series, 20 right upper eyelid skin of 20 nonsmoker, class 3 Fitzpatrik skin type women (30-68 years old) were histopathologically examined. Patients were divided into 2 age groups of 50 years or older and older than 50 years. Upper eyelid skin was preoperatively marked, intraoperatively removed, postoperatively divided into 3 sections: lateral (lateral limbus to lateral canthus), central (between medial and lateral limbi), and medial (medial limbus to medial canthus), and separately (totally 60 specimens) sent for histopathological examination. A masked pathologist recorded skin thickness in all specimens (60) as well as lymphatic vessels diameter and density, elastic fiber density, macrophage number, collagen intrafibril edema, and depth of collagen stromal bed in central sections (20 specimens).

RESULTS

There were 10 patients at each age group. Histopathological measurements were not significantly different between the 2 age groups except mean lymphatic vessel diameter (P = 0.034) that was larger in the second group (>50 years). A significant positive correlation was also observed between the age and lymphatic vessel diameter (rs = 0.3, P = 0.009).

CONCLUSIONS

Lymphangiectasia progresses significantly by age. Histopathological characteristics of DC are the same in the 2 age groups.

Revisiting Anchor Epicanthoplasty in Mild to Moderate Asian Epicanthal Folds: A Clinicopathological Study

BACKGROUND

To assess the epicanthal fold (EF), eyelid, eyebrow, scar, and patients' satisfaction after anchor epicanthoplasty and upper blepharoplasty and histopathologically compare Asian epicanthal fold skin with non-Asian counterpart.

METHODS

Asian Iranians with grade 2 and 3 EF were included. Photographs were taken before and at least 12 months after the surgery. Photoanalysis included EF grade, inter-canthal distance (ICD), margin reflex distance 1 (MRD1), tarsal plate show (TPS), brow fat span (BFS), and eyebrow height. Manchester scar scale score (5-28) and patients' satisfaction score (0-100) were documented. The most medial skin of 5 Asian and 5 non-Asian subjects was histologically compared for the thickness and elastic fiber density and morphology.

RESULTS

Included were 89 patients (178 eyelids) with a mean age of 31.6 years and follow-up of 13.1 months. Mean ICD significantly decreased by 3.5 mm (shortening ratio of 9.7%). All grade 2 and almost half of the grade 3 EF disappeared. Significant postoperative increase in mean MRD1 (0.3 mm) and TPS (1.1-1.4 mm) and decrease in BFS (3.3-3.6 mm) and eyebrow height (1.7-3.4 mm) were observed. Revision rate of epicanthoplasty was 7.3%. Mean satisfaction and scar scores were 97.1 and 5.4, respectively. Histopathologically, Asian and non-Asian medial upper eyelid skin was not significantly different.

CONCLUSION

Anchor epicanthoplasty eliminated grade 2 and improved grade 3 EF with a high satisfaction and negligible scar. Simultaneous upper blepharoplasty significantly increased MRD1 and TPS and decreased eyebrow height. EF skin was not histologically different from non-Asians.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postoperative Blepharoptosis After Modern Phacoemulsification Procedure

PURPOSE

To investigate the frequency of transient (1 month) and persistent (at least 6 months) postoperative ptosis following clear corneal sutureless phacoemulsification and to analyze the factors affecting them.

DESIGN

Cohort study.

METHODS

Patients who underwent phacoemulsification cataract surgery from October 2016 to June 2018 in a tertiary center were enrolled. Margin reflex distance 1 (MRD1), MRD2, and levator function were measured and facial photography was taken before, 1 month, and at least 6 months after the surgery. Clinical ptosis was defined as any postoperative drop of MRD1 and clinically significant ptosis as MRD1 drop of ≥2 mm. Photo-based ptosis was assessed by a masked oculofacial plastic surgeon at the end of the study.

RESULTS

A total of 234 patients (313 eyelids) were included. The majority of surgeries were performed by senior residents (65.5%, 205/313) and under topical anesthesia (78.0%, 244/313). Persistent clinical, clinically significant, and photo-based ptosis were 25.4% (71/279), 3.2% (9/279), and 3.3% (9/276). Eyelids with persistent postoperative ptosis showed a significantly (P = .03) lower preoperative levator function (13.9 vs 15.8 mm). No other factor was significantly different between the eyelids with and without postoperative ptosis.

CONCLUSION

Persistent clinically significant ptosis was observed in more than 3% of patients undergoing clear corneal sutureless phacoemulsification cataract surgery. It should be counseled preoperatively. Lower preoperative levator function was significantly associated with a higher frequency of postoperative ptosis. Duration of surgery, level of surgeons, and other variables did not have any significant effect on the frequency of postoperative ptosis.

Techniques of Eyebrow Lifting: A Narrative Review

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms “eyebrow lift", “forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).

Pressure ulcer following circumferential head dressing

PURPOSE

To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.

METHODS

Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.

RESULTS

Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.

CONCLUSION

Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.

Visual Outcomes of Adding Erythropoietin to Methylprednisolone for Treatment of Retrobulbar Optic Neuritis

Purpose

To compare the short-term visual function results and safety of erythropoietin as an add-on to the standard corticosteroid therapy in retrobulbar optic neuritis (RON).

Methods

In this prospective pilot study, adult patients with isolated RON with less than 10 days of onset were enrolled. Patients were consecutively assigned to standard intravenous methylprednisolone treatment either in combination with intravenous erythropoietin (20,000 units/day for three days) (group-1) or intravenous methylprednisolone alone (group-2). Primary outcome measure was best-corrected visual acuity (BCVA), which was assessed up to 120 days from the day the treatment was begun. Systemic evaluations were performed during and after treatment.

Results

Sixty-two patients with RON (mean age = 26.6 ± 5.77 years; range = 18–40 years) were enrolled into the study (group-1, n = 35; group-2, n = 27). BCVA three months after the treatment was 0.19 ± 0.55 logMAR and 0.11 ± 0.32 logMAR in group-1 and group-2, respectively (95% CI: -0.61 - 0.16; P = 0.62). Change in BCVA after three months was 2.84 ± 3.49 logMAR in group-1 and 2.46 ± 1.40 logMAR in group-2 (95% CI: -0.93-1.91; P = 0.57). Pace of recovery was not significantly different between the groups. No complications were detected among patients.

Conclusion

Intravenous erythropoietin as an add-on did not significantly improve the visual outcome in terms of visual acuity, visual field, and contrast sensitivity compared to traditional intravenous corticosteroid. This pilot study supports the safety profile of intravenous human recombinant erythropoietin, and it may help formulate future investigations with a larger sample size.

Postoperative levator function change in patients with unilateral myogenic versus aponeurotic blepharoptosis

PURPOSE

To compare the change in levator function (LF) after levator resection in patients with unilateral myogenic (MP) and aponeurotic ptosis (AP).

METHODS

In a prospective study, patients of >5 years old were included from June 2015 to April 2017. Other types of ptosis, associated strabismus and previous eyelid surgery were excluded. Eyelid examination and photography were performed before and at least 6 months after surgery. Success was defined as Margin reflex distance 1 (MRD1) of within 0.5 mm of the unoperated side. All procedures (levator resection) were performed by or under supervision of one surgeon.

RESULTS

There were 58 patients in the MP (mean age: 19.2 years) and 20 in the AP (mean age: 49.5) group with median follow up of 10 months. LF was significantly improved from 5.8 to 7.3 mm in the MP and from 11.8 to 13.6 mm in the AP group. LF improvement was not observed in 17.2% of MP and 25% of AP group (P = 0.5). Mean preoperative LF was significantly (Odd ratio = 1.8) higher in patients with than without LF improvement in the MP group. It was significantly reverse in the AP group (Odd ratio = 0.38). A significantly positive (r = 0.30) and negative (r = -0.72) correlations were observed between preoperative LF and LF improvement in the MP and AP groups, respectively. Success was observed in 90% of AP and 84.5% of MP group. In order of frequency, undercorrection, overcorrection, and contour abnormality were the reasons for failure. No variable significantly affected the success rate in either group.

CONCLUSION

Majority of MP and AP showed postoperative LF improvement. While higher preoperative LF was significantly correlated with LF improvement in the MP, it was reverse in the AP group. Success rate was not significantly different between the groups and no factor significantly affected the success in either group.

Color Doppler imaging of orbital vasculature before and after orbital decompression in thyroid eye disease

Purpose: To measure alterations in orbital blood flow parameters using color Doppler imaging (CDI) before and after orbital decompression in patients with moderate to severe thyroid eye disease (TED). Methods: Resistance index (RI) and maximum and minimum velocity of ophthalmic artery (OA), superior ophthalmic vein (SOV), and central retinal artery (CRA) of 24 eyes (14 patients) with TED were measured before and at least 3 months after cosmetic orbital decompression procedure (single or double walls) using CDI. Complete eye examination was performed to define the severity (EUGOGO classification) and activity (clinical activity score) of TED. Results: Median OA (p = 0.003) and CRA (p = 0.001) resistance indices were significantly reduced postoperatively. Significant differences were found in maximum (p = 0.001) and minimum (p = 0.014) velocity of SOV before and after surgery. While a significant decrease in exophthalmometry was observed after the orbital decompression (p = 0.031), intraocular pressure changes were not significant (p = 0.182). Conclusion: Orbital decompression procedure led to a significant reduction of RI in both CRA and OA in patients with TED.

How reliable is the lacrimal scintigraphy report? An inter-observer agreement and reliability study

AIM

To assess the inter-observer agreement and reliability as well as intra-observer repeatability for lacrimal scintigraphy (LS) reports with and without considering the irrigation test results.

METHODS

A prospective, observational, cross sectional study. Two masked clinicians (lacrimal surgeon and nuclear medicine specialist) independently reported 100 LS images (50 patients of >6 years of age with unilateral anophthalmic socket) in a university hospital. The lacrimal surgeon performed a diagnostic irrigation test and repeated the report of the same LS images 2y after the first report (intra-observer agreement). A weighted Kappa analysis was performed to determine inter-observer agreement and reliability as well as intra-observer repeatability for the type (normal, partial and complete obstruction) and location (presac, preduct, and intraduct) of the obstruction. Subgroup analysis was also performed with consideration of irrigation test results.

RESULTS

A significantly moderate agreement was found between lacrimal surgeon and nuclear medicine specialist for both the type (Kappa=0.55) and location (Kappa=0.48) of obstruction. Agreement values were higher for the type (Kappa=0.61 vs 0.41) and location (Kappa=0.56 vs 0.31) of obstruction in cases with normal than abnormal irrigation test. Strong and significant intra-observer (lacrimal surgeon) repeatability was found for both the type (Kappa=0.66) and location (Kappa=0.69) of obstruction. LS showed no to slight reliability based on irrigation test.

CONCLUSION

A moderate agreement is found between lacrimal surgeon and nuclear medicine specialist regarding the interpretation of LS suggesting the importance of consensus groups among nuclear medicine specialists and lacrimal surgeons to create a common language for interpretation of LS. Intra-observer repeatability is strong for the lacrimal surgeon.

Outcomes and factors affecting them in patients with rhino-orbito-cerebral mucormycosis

Aim

To report the frequency and factors affecting patients’, globe and vision survivals in rhino-orbito-cerebral mucormycosis (ROCM).

Methods

This is a retrospective study of 63 patients (79 eyes) with biopsy-proven ROCM at a university hospital 2008–2016. Systemic and ophthalmic manifestations, imaging, management and final outcomes were recorded. Globe survival was defined as no exenteration and vision survival as final visual acuity of light perception and more.

Results

Mean age was 55.5 (SD 12.9) years with no gender preference. Diabetes was the most common underlying disease (68.3%). Patient survival was observed in 57.1 % (36/63). Presence of frozen eye (OR 4.6), nasal mucosal involvement (OR 7.3) and shorter duration of antifungal therapy (OR 1.03) were significantly associated with lower patient survival. Exenteration did not significantly change the survival. Globe survival was detected in 43% (34/79). Higher white blood cell (WBC) count was associated with a lower globe survival (p=0.02). Vision survival was observed in 25.3% (20/79) in whom younger age was significantly associated with a worse vision survival.

Conclusion

Patient, globe and vision survivals were 57%, 43% and 25%, respectively. Exenteration did not affect the patients’ survival. While frozen eye and nasal mucosal involvement were significantly associated with a lower survival, higher WBC count significantly increased the risk of exenteration.

Is primary optic nerve sheath schwannoma a misnomer? Report of two cases and literature review

Aims: To report clinicopathological characteristics of two patients with optic nerve sheath schwannoma (ONSS) and review the literature. Method: The first patient (22-year-old man) presented with left eye proptosis and decreased vision in 2012 whose orbital imaging showed a large cystic lesion around the optic nerve. The second patient (52-year-old man) presented with decreased vision in the left eye (without proptosis) in the 2006. His imaging showed a small orbital apex lesion between the medial rectus and optic nerve. Both lesions were histopathologically consistent with ONSS. ONSS has previously been reported in 12 patients. Results: Orbital biopsy and subsequently external beam radiotherapy were performed for the first patient who showed a temporary improvement of vision. However, his proptosis progressed and vision decreased to light perception (LP) a few months after radiotherapy when the lesion was resected in April 2013. Second patient declined any procedure until his vision gradually decreased to LP in October 2007. It was then removed through a combined medial and lateral orbitotomy procedure. Both patients ended up with visual acuity of no LP and no recurrence in their last follow up visits in April 2018. No histopathological evidence was found to show that optic nerve sheath could be the origin for presenting and previously reported cases in the literature. Conclusion: Presenting cases and literature review imply that ONSS is a misnomer and all the lesions are different types of orbital schwannomas with optic nerve sheath attachment.

Inadvertent inferior oblique extirpation during orbital decompression

PURPOSE

To report a case of inadvertent inferior oblique extirpation during orbital decompression, its management, and postoperative result.

METHODS

A 38-year-old female with thyroid eye disease underwent cosmetic right orbital decompression during whichinferior oblique extirpation was noticed.

RESULT

The muscle was repaired on the same session (illustrated in the article) with no postoperative diplopia at 3-month follow-up.

CONCLUSION

Inferior oblique injury should be considered among the uncommon yet important complications of orbital decompression. It can be easily found and repaired in the same session as demonstrated in this case report.

Endoscopically assisted Balloon Dacryocystoplasty and Silicone Intubation versus Silicone Intubation Alone in Adults with Incomplete Nasolacrimal Duct Obstruction

PURPOSE

To compare the success rate of endoscopically assisted balloon dacryocystoplasty (DCP) and silicone intubation (DCP-SI) with endoscopically assisted silicone intubation alone (SI) in adults with incomplete nasolacrimal duct (NLD) obstruction. METHODS. In a retrospective nonrandomized comparative case series, 62 eyes of 55 adult patients with incomplete NLD obstruction underwent endoscopic probing and either SI (n=39 eyes) or DCP-SI (n=23 eyes) under general anesthesia. The last follow-up examination included diagnostic probing and irrigation if there was not success. Success was defined as disappearance of the symptoms and failure as partial improvement or absence of improvement at last follow-up.

RESULTS

Patients ranged from 20 to 85 years of age (mean: 60.93, SD: 15.60). Tubes were removed between 6 and 20 weeks (mean: 7.49, SD: 2.25) postoperatively. Follow-up ranged from 6 to 63 months (mean: 14.60, SD: 10.33). Success rate of the eyes with SI (21/39, 53.84%) and DCP-SI (14/23, 60.86%) were not statistically different (p=0.60). Complications included slight nasal and canalicular bleeding in almost all eyes in both groups which was easily controlled, slit punctum in four eyes with bicanalicular intubation (4/50, 8%), and monocanalicular tube lost in three eyes prematurely.

CONCLUSIONS

Success rate of endoscopic DCP-SI had no statistically significant difference from silicone intubation alone in treatment of incomplete NLD obstruction in adults.

Acute primary angle closure after periorbital facial procedures report of four cases and literature review

AIMS

To report four cases of acute primary angle closure (PAC) after blepharoplasty and forehead lifting procedures and review the previous reported cases in the literature.

METHODS

Four female subjects with age range of 50-67 years developed PAC 2-5 days after blepharoplasty and endoscopic forehead lifting procedures. All presented with pain, nausea, blurred vision, red eye, and eyelid swelling. Diagnosis was delayed in the first subject because of considering the signs and symptoms as usual postoperative ones. Presumed risk factors for the PAC were female gender (all), advanced age (all), pupillary dilation (all), and hyperopia (case 2).

RESULTS

Medical treatment controlled the pressure which was followed by bilateral YAG Laser iridotomy. They fully recovered with no optic neuropathy in their last follow-up examination 10 months to 10 years after the procedures.

CONCLUSION

Risk of PAC should be investigated preoperatively and its presentation should be considered in the postoperative follow-up of subjects with periorbital facial procedures.

Traumatic optic neuropathy treatment trial (TONTT): open label, phase 3, multicenter, semi-experimental trial

PURPOSE

Intravenously administered erythropoietin (EPO) was firstly commenced (phase 1) in patients with indirect traumatic optic neuropathy (TON) by this group in 2011. It was re-tested by another group (phase 2) in 2014. This multicenter clinical trial was designed to compare its effect with intravenous steroid and observation.

METHODS

Included were TON patients ≥5 years of age and with trauma-treatment interval of ≤3 weeks. Follow-up visits were set at 1, 2, 3, 7, 14, 30, and at least 90 days after treatment. EPO and methylprednisolone were infused intravenously every day for three consecutive days. Primary outcome measure was change in the best corrected visual acuity (BCVA). Secondary outcomes included change in color vision and relative afferent pupillary defect (RAPD), side effects, and factors affecting the final visual improvement.

RESULTS

Out of 120 patients, 100 (EPO: 69, steroid: 15, observation: 16) were finally included. All three groups showed a significant improvement of BCVA which was not significantly different between the groups (adjusted for pretreatment BCVA). Color vision was significantly improved in the EPO group. Late treatment (>3 days) (odds ratio = 2.53) and initial BCVA of NLP (odds ratio = 5.74) significantly worsened visual recovery. No side effect was observed in any group.

CONCLUSION

EPO, steroid, and observation showed a significant improvement of BCVA in patients with TON. Initial BCVA of NLP and late treatment (>3 days) were significant risk factors for visual improvement.

Periorbital facial rejuvenation; applied anatomy and pre-operative assessment

PURPOSE

Since different subspecialties are currently performing a variety of upper facial rejuvenation procedures, and the level of knowledge on the ocular and periocular anatomy and physiology is different, this review aims to highlight the most important preoperative examinations and tests with special attention to the eye and periocular adnexal structures for general ophthalmologist and specialties other than oculo-facial surgeons in order to inform them about the fine and important points that should be considered before surgery to have both cosmetic and functional improvement.

METHODS

English literature review was performed using PubMed with the different keywords of "periorbital rejuvenation", "blepharoptosis", "eyebrow ptosis", "blepharoplasty", "eyelid examination", "facial assessment", and "lifting". Initial screening was performed by the senior author to include the most pertinent articles. The full text of the selected articles was reviewed, and some articles were added based upon the references of the initial articles. Included articles were then reviewed with special attention to the preoperative assessment of the periorbital facial rejuvenation procedures.

RESULTS

There were 254 articles in the initial screening from which 84 articles were found to be mostly related to the topic of this review. The number finally increased to 112 articles after adding the pertinent references of the initial articles.

CONCLUSION

Static and dynamic aging changes of the periorbital area should be assessed as an eyelid-eyebrow unit paying more attention to the anthropometric landmarks. Assessing the facial asymmetry, performing comprehensive and detailed ocular examination, and asking about patients' expectation are three key elements in this regard. Furthermore, taking standard facial pictures, obtaining special consent form, and finally getting feedback are also indispensable tools toward a better outcome.

Measurement Properties of the Persian Translated Version of Graves Orbitopathy Quality of Life Questionnaire: A Validation Study

PURPOSE

To determine the measurement properties of the Persian language version of the Graves orbitopathy quality of life questionnaire (GO-QOL).

METHODS

Following a systematic translation and cultural adaptation process, 141 consecutive unselected thyroid eye disease (TED) patients answered the Persian GO-QOL and underwent complete ophthalmic examination. The questionnaire was again completed by 60 patients on the second visit, 2-4 weeks later. Construct validity (cross-cultural validity, structural validity and hypotheses testing), reliability (internal consistency and test-retest reliability), and floor and ceiling effects of the Persian version of the GO-QOL were evaluated. Furthermore, Rasch analysis was used to assess its psychometric properties.

RESULTS

Cross-cultural validity was established by back-translation techniques, committee review and pretesting techniques. Bi-dimensionality of the questionnaire was confirmed by factor analysis. Construct validity was also supported through confirmation of 6 out of 8 predefined hypotheses. Cronbach's α and intraclass correlation coefficient (ICC) were 0.650 and 0.859 for visual functioning and 0.875 and 0.896 for appearance subscale, respectively. Mean quality of life (QOL) scores for visual functioning and appearance were 78.18 (standard deviation, SD, 21.57) and 56.25 (SD 26.87), respectively. Person reliabilities from the Rasch rating scale model for both visual functioning and appearance revealed an acceptable internal consistency for the Persian GO-QOL.

CONCLUSION

The Persian GO-QOL questionnaire is a valid and reliable tool with good psychometric properties in evaluation of Persian-speaking patients with TED. Applying Rasch analysis to future versions of the GO-QOL is recommended in order to perform tests for linearity between the estimated item measures in different versions.

Combined external and endonasal approach to fronto-ethmoidal mucocele involving the orbit

Purpose

To present a technique to improve the surgical treatment of frontal sinus mucocele and its recurrence.

Methods

Nine procedures performed on eight patients by a team of ENT and Ophthalmic orbital surgeons. Data collected included patient demographics, surgical details, pathological findings and complications. The surgical technique involved an external approach via the upper eyelid skin crease combined with an internal approach with a rigid 4 mm endoscope described below. Following evacuation of the mucocele the sinus was anastomosed to nasal cavity with insertion of silicon stent. All patients had preoperative and postoperative CT scans of the orbit and paranasal sinuses.

Result

There were nine operations on eight patients (six males, two female patients, mean age of 57.25: range, 15–71). Two patients had inverted papillomas. All patients presented with non-axial proptosis and diplopia. The mean follow up period was 38.7 months (range 11–99). The only intraoperative complication noted was a cerebrospinal fluid (CSF) leak in a patient with a post traumatic mucocele. Post-operative complications included lid scarring in 2 patients. One of the patients had a fistula overlying the affected sinus at presentation. Both patients underwent dermis fat grafting as a second stage procedure and responded well. One patient presented with asymptomatic superior oblique weakness that could be attributed to trauma to the superior oblique intra operatively. There was no case of recurrence of mucocele in our series. One of the inverted papillomas had an early recurrence (within 6 months) that required repeat surgery.

Conclusion

Fronto nasal anastomosis restores the anatomy and reduces the chance of recurrence in our experience. The final cosmetic result is excellent and the patient's satisfaction is high.

Upper Blepharoplasty and Lateral Wound Dehiscence

Purpose:

To report the frequency of lateral wound dehiscence (LWD) after upper blepharoplasty (UB), a technique and its outcome to prevent LWD.

Materials and Methods:

A retrospective review was performed for cases of LWD after UB presenting between 2003 and 2009, and then a prospective comparative study was performed between February 2009 and March 2013. For the comparison, subjects were divided into two groups based on intraoperative assessment of lateral wound tension (same technique and surgeon). Group 1 received 1-3 orbicularis/subcutaneous buried sutures (6-0 polyglactin) before interrupted 6-0 nylon skin closure. Group 2 underwent skin closure only. Subjects, who had re-operation, skin healing disorders, and incomplete follow-up (<6 months), were excluded. P < 0.05 was considered as statistically significant.

Results:

There were 14 (14/678, 2%) cases with LWD with a mean age of 36.2 years in the audit (2003–2009). The prospective study included 68 subjects (68/293, 23.2%) in Group 1 and 225 in Group 2. Gender and simultaneous forehead and eyebrow procedures were similar between groups (P = 0.3 and P = 0.4 respectively). Group 1 was statistically significantly younger at mean age of 41.4 years, compared to Group 2 at 56.1 years (P = 0.000). The frequency of LWD significantly (P = 0.04) decreased to 0.3% (1/293).

Conclusion:

In the presence of wound tension on skin closure (intraoperative assessment), tension relieving buried orbicularis/subcutaneous 6-0 polyglactin suturing of the lateral UB incision could prevent LWD.

Tear Film, Lacrimal Drainage System, and Eyelid Findings in Subjects With Anophthalmic Socket Discharge

PURPOSE

To compare the results of tear film and lacrimal drainage system tests between anophthalmic socket and normal eye and assess discharge characteristics and frequency of prosthesis removal (questionnaire), eyelid function, and meibomian glad dysfunction (MGD).

DESIGN

Prospective masked case control.

METHODS

Subjects (≥6 years and ≥6 months of wearing prosthesis) with unilateral acquired anophthalmic socket discharge were included. Excluded was ocular adnexal abnormality of any reason and incomplete tests. The subjective questionnaire was completed. Blinking rate, lagophthalmos, eyelid laxity, MGD, Schirmer test, tear meniscus height, and dye disappearance test were assessed by a masked examiner. Another masked examiner performed an irrigation test 1 week later and interpreted the scintigraphy images at the end of the study.

RESULTS

Included were 50 subjects (mean age: 31.3 years, mean prosthesis wear: 96.1 months). Discharge was frequent or very frequent in 85%, mucoid or mucopurulent in 90%, and moderate to severe in 86% of the subjects. MGD in 58%, lagophthalmos in 80%, and eyelid laxity in 46% were observed. Anophthalmic socket sides showed a significantly lower tear production and higher tear drainage obstruction. Subjects with frequent prosthesis removal had a significantly (P = .02) greater lagophthalmos and blinking rate (P = .04). The blinking rate was also significantly greater in subjects with higher frequency of discharge (P = .04).

CONCLUSION

Tear film impairment (aqueous and lipid) and lacrimal drainage obstruction should be considered in subjects with anophthalmic socket discharge. A significantly higher blinking rate and lagophthalmos were found in subjects with higher frequency of prosthesis removal.