Hyperostosis associated with orbital vascular malformation

A previously healthy adult male presented with a slowly enlarging orbital mass associated with 5 mm of non-pulsatile proptosis. On imaging, a soft tissue lesion with avid contrast enhancement and associated bony hyperostosis was noted. The lesion and hyperostotic bone were surgically debulked, and significant arterial bleeding was noted intraoperatively consistent with an arteriovenous malformation. Histopathologic analysis revealed a vascular malformation with enhanced microvasculature infiltrating the periosteum. While vascular lesions elsewhere in the body can be associated with skeletal changes, bony hyperostosis is a rare feature of orbital vascular malformations.

Visual Outcomes Following Surgical Debulking in Exophytic Optic Nerve Sheath Meningiomas

PURPOSE

To report a case of a globular primary optic nerve sheath meningioma managed surgically with improvement in vision and review the literature for outcomes of purely intraorbital exophytic-globular primary optic nerve sheath meningiomas managed surgically.

METHODS

A literature review was conducted using Google Scholar and PubMed with the search terms "primary optic nerve sheath meningioma," "surgery," "exophytic," and "globular." Articles were included if they were available in English. Individual cases from the reviewed articles were included if the tumor was purely intraorbital with a globular or exophytic morphology, was managed with total or subtotal surgical excision, and visual outcomes were reported. Cases were excluded if the tumor extended intracanalicularly or intracranially, tumor morphology was unknown, or surgical management consisted of biopsy, optic nerve sheath decompression, or optic canal decompression rather than tumor debulking.

RESULTS

A total of 28 patients with intraorbital globular-exophytic primary optic nerve sheath meningiomas managed surgically have been reported in the literature. Vision improved in 29% (n = 8/28) and remained stable in 43% (n = 12/28) of patients. Furthermore, patients with good (Snellen notation ≥ 0.5) vision (n = 10) typically retained good vision postoperatively and at follow-up, with 1 patient experiencing a decline to poor (Snellen ≤0.1) vision at the last follow-up (92 months postoperatively). Similarly, patients with fair (Snellen notation >0.1 and <0.5) vision (n = 5) often improved to good vision (n = 3) or stayed at fair vision (n = 1), with 1 declining to poor vision at postoperative hospital discharge.

CONCLUSIONS

Surgical management of exophytic or globular optic nerve meningiomas does not universally lead to vision loss and may be appropriate in select patients.

Transorbital Endoscopic Approach to the Pterygopalatine Fossa: A Less Invasive Alternative to Traditional Access

PURPOSE

The purpose of this article and accompanying video is to demonstrate a transorbital endoscopic approach for accessing the pterygopalatine fossa (PPF). This technique does not require a skin incision, avoids dissection of critical neurovascular structures, and utilizes a comparatively small osteotomy. The 2 cases presented in this article highlight the utility of a transorbital endoscopic approach for accessing an anatomic region that has traditionally required more invasive techniques to reach.

METHODS

Description of surgical technique with 2 illustrative clinical cases and accompanying surgical video.

RESULTS

Surgical technique: A trans-conjunctival approach is taken to the inferior orbital rim, and a subperiosteal dissection is propagated posteriorly. The bone of the posterior orbital floor is then deroofed, and the superior portion of the posterior wall of the maxillary sinus is removed, allowing access to the PPF for an incisional biopsy.

CASE

A 76-year-old male with a history of left cheek squamous cell carcinoma presented with progressive V2 paresthesia and an abnormally enhancing lesion in the left PPF on MRI.

CASE

A 58-year-old male with no significant medical history presented with left facial numbness (V1-V3), ptosis, an abduction deficit, and decreased hearing. Contrast-enhanced MRI demonstrated an abnormally enhanced lesion in the left PPF extending to Meckel's cave.The transorbital approach described was used to successfully obtain a diagnostic biopsy in both cases.

CONCLUSIONS

These cases highlight the utility of a transorbital endoscopic approach to the PPF as a less morbid alternative to traditional access. Patient selection is key to identifying appropriate cases.

Dedifferentiated liposarcoma of the orbit

Purpose

To present a rare case of dedifferentiated liposarcoma of the orbit.

Observations

A 61-year-old male complained of left-sided proptosis, diplopia, and limited ocular motility for two years. Biopsy results at that time were suggestive of an atypical lipomatous neoplasm. Ten years later, he presented with increase in size of the mass and worsening of his symptoms. Imaging showed a multi-lobulated mass in the left orbit involving the intraconal, medial, and anterior orbit. Decompression and orbitotomy with biopsy were performed to debulk the mass. Pathology showed a low-grade well-differentiated liposarcoma and the patient was monitored thereafter annually. Eight years later, he complained of persistent proptosis and mass effect from the tumor resulting in ptosis and diplopia and underwent orbital exenteration. Histopathological analysis of the exenterated orbit revealed a focal area of dedifferentiated liposarcoma.

Conclusions and importance

Dedifferentiation of an orbital mass can occur as a late complication years after the diagnosis of well-differentiated liposarcoma. Compared to the previously published cases of orbital liposarcoma, this presentation shows a prolonged timeline prior to dedifferentiation (18 years after initial diagnosis). Symptoms of growth or invasive features could indicate dedifferentiation and should warrant a biopsy.

Radiologic Features of Well-circumscribed Orbital Tumors With Histopathologic Correlation: A Multi-center Study

PURPOSE

To delineate specific imaging characteristics of solitary fibrous tumors, schwannomas, cavernous venous malformations, and well-circumscribed orbital lymphoma.

METHODS

Patients undergoing excisional biopsy of solitary fibrous tumor, schwannomas, cavernous venous malformations, or well-circumscribed orbital lymphoma with preoperative MRIs available for review were identified at 3 academic centers in the United States and Australia. An exploratory statistical analysis was performed to identify important radiologic features, which were subsequently included in a random forest model. Histopathologic correlates were evaluated in representative cases.

RESULTS

A total of 91 cases were included with a mean age of 52.9 ± 17.2 years. Nearly all solitary fibrous tumors were located in the anterior or mid orbit (87.5%) and they more commonly demonstrated intralesional heterogeneity on T2-weighted imaging (45.5%) (p < 0.01). Compared with the other tumors, schwannomas tended to be intraconal (66.7%) and were often in the mid or posterior orbit (83.4%) (p < 0.01). Cavernous venous malformations characteristically demonstrated progressive contrast enhancement (93.9%; p < 0.01). Most lesions in all 4 groups were hypointense on T1-weighted imaging (80%-100%; p = 0.14) and only well-circumscribed orbital lymphoma tended to also be hypointense on T2 (81.8%) (p < 0.01). Finally, cases of lymphoma had significantly lower apparent diffusion coefficient ratios (0.9 ± 0.2) (p < 0.001), while the other 3 groups were not significantly different from one another (cavernous venous malformations: 1.8 ± 0.4; schwannomas: 1.8 ± 0.5; and solitary fibrous tumor: 1.6 ± 0.6) (p = 0.739).

CONCLUSIONS

Key features that aid in the differentiation of these 4 tumors from one another include T2 intensity and homogeneity, early contrast-enhancement pattern, and ADC ratio.

Orbital Decompression: Conceptual Approach for Orbital Volume Expansion

PURPOSE

To review the advances in the surgical techniques of orbital decompression.

METHODS

A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression.

RESULTS

In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed.

CONCLUSION

A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms.

Teprotumumab and Orbital Decompression for the Management of Proptosis in Patients With Thyroid Eye Disease

PURPOSE

To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence.

METHODS

Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects.

RESULTS

One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up (p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone.

CONCLUSIONS

Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone.

External carotid artery to ophthalmic artery flow associated with internal carotid artery stenosis

PURPOSE

One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease.

METHODS

In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved.

RESULTS

The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) (p < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow (p < .001).

CONCLUSIONS

ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.

Orbital Involvement in Acute Adult Leukemias: Case Series and Review of Literature

Orbital involvement in acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) is well-described in children but is uncommon in adults. This series reports 2 adult patients with orbital leukemic involvement and summarizes the existing literature. A 37-year-old male with recently diagnosed AML underwent induction therapy and subsequently developed a tan-pink colored sub-conjunctival lesion in the left eye. Incisional biopsy confirmed AML. A 35-year-old male with history of ALL presented with left-sided orbital mass. Fine needle aspiration biopsy confirmed ALL. Literature review of adult-onset orbital leukemia yielded 29 cases of AML and 3 cases of ALL. Orbital involvement of acute adult-onset leukemia tends to be unilateral, presents in the extraconal space and can occur at any point during systemic leukemic disease. Chemotherapy is the mainstay of treatment, often in combination with radiation and/or hematopoietic stem cell transplant.

Banking Autologous Tarsus: A Simple Technique for Maximizing Preservation of Healthy Tissue

A 28-year-old female with congenital left-sided ptosis presented after 3 prior surgeries elsewhere. Although centrally her margin to reflex distance1 was 3 mm, persistent ptosis was noted laterally. In an effort to improve the symmetry of her eyelid contour, a lateral tarsectomy was performed. As the authors worried this might worsen her dryness, the decision was made to bank the excised tarso-conjunctival tissue in case additional revision surgery is required at a later date. To accomplish this, a conjunctival incision was created at the inferior tarsal margin in the ipsilateral lower lateral eyelid and the excised upper eyelid tarso-conjunctival tissue was secured in this pocket. Four months postoperatively, the banked tissue appeared healthy and the upper eyelid contour was improved. This technique may be most helpful in multi-operated situations, where the chance of future revision is not insignificant.

Extrascleral extension of choroidal melanoma after iodine-125 brachytherapy treatment: a case series

BACKGROUND/OBJECTIVES

The purpose of this study is to report cases of choroidal melanoma that developed extrascleral tumour recurrence after treatment with iodine-125 brachytherapy.

SUBJECTS/METHODS

In this single-institution retrospective observational case series, all instances of biopsy-confirmed orbital melanoma after known intraocular melanoma were reviewed. Tumour characteristics, clinical course, time to recurrence, cytogenetics of initial tumour and recurrence, and presence of intraocular recurrence were documented.

RESULTS

Five cases of orbital melanoma following treatment with plaque radiotherapy are described. Tumour staging was Ia (1), IIa (2), and IIb (2). The primary lesion in four of the five appeared to have undergone complete regression for an average of 2 years, with the orbital melanoma developing after this interval. Recurrence of the intraocular tumour was seen in conjunction with an extrascleral component in two cases. Four cases ultimately underwent enucleation or exenteration; three had evidence of direct extension of tumour through the sclera. Four cases in this series had molecular characteristics associated with high metastatic risk (three patients with monosomy 3, one with BAP1 mutation).

CONCLUSIONS

High-risk tumour biology may predispose to late appearance of extrascleral melanoma despite optimal treatment and adequate control of the intraocular tumour. Extended follow-up with detailed orbital examination and imaging is recommended for this population.

Unhealed Pressure Ulcers Among Nursing Home Residents with Diabetes

INTRODUCTION

Nearly a third of US nursing home residents have diabetes mellitus. These residents have an increased risk of pressure ulcer (PU) development and progression; however, little is known about the characteristics of their PUs or the role of other risk factors. This study estimates the prevalence of PUs, describes characteristics of PUs, and quantifies associations between risk factors and PUs in nursing home residents with diabetes.

METHODS

We conducted a cross-sectional study of nursing home residents aged ≥50 years with diabetes mellitus using national 2016 Minimum Data Set 3.0 data. Pressure ulcers were defined as the presence of any stage PU and by subgroups of stage and tissue type. Prevalence estimates of PUs were calculated overall and by covariate subgroups. Unadjusted and adjusted odds ratios were calculated using logistic regression.

RESULTS

The prevalence of any unhealed PU was 8.1%. Of those with a PU, 19.4% had at least two ulcers and the most common subtypes were identified as unstageable and stage 2 ulcers. These were most often treated by pressure reducing devices. In our fully adjusted model, risk factors that were strongly associated with PUs were related to mobility, nutrition, incontinence, and infections.

CONCLUSION

We observed that the prevalence of PUs remains high in nursing home residents with diabetes and that higher stage ulcers were common in this population. Our adjusted model highlights the importance of suspected risk factors in the development of PUs. Further research is needed to understand the unique needs of nursing home residents with diabetes.

Optimizing Management of Asymmetric Ptosis: A Comparison of Three Posterior Approach Resection Algorithms

PURPOSE

The purpose of this study was to compare the efficacy of 3 resection algorithms in the management of patients with asymmetric ptosis.

METHODS

Patients undergoing bilateral Muller's muscle-conjunctival resection (MMCR) were identified. Standardized preoperative clinical photographs were examined and margin reflex distance 1 (MRD1) was measured using ImageJ. Patients presenting with ≥1 mm of asymmetry in MRD1 were included. Three groups were identified: variable (4:1 ratio, with the lower side receiving a greater resection), fixed (7 mm resection bilaterally), and tarsectomy (7 mm bilaterally + 1 mm of tarsus resected on the lower preoperative side). Postoperative MRD1 was measured from photographs obtained 3 months after surgery. The primary outcome was postoperative asymmetry.

RESULTS

A total of 95 patients with a mean age of 71.0 ± 11.0 years were included. There was no significant difference in age ( p = 0.277) or length of follow-up ( p = 0.782) between the groups. Although the fixed tarsectomy group had significantly greater preoperative asymmetry ( p = 0.001), there was no significant difference in postoperative asymmetry ( p = 0.166). On multivariate analysis, preoperative asymmetry was the only significant predictor of postoperative asymmetry ( p < 0.001). Specifically, the surgical group was not a predictor of the primary outcome ( p = 0.723).

CONCLUSIONS

Resection amount and technique did not predict postoperative outcomes in cases of asymmetric ptosis. This may support the hypothesis that changes in eyelid position and symmetry following MMCR is due to a dynamic system, rather than as a result of purely mechanical forces.

Endoscopic endonasal approach for resection of a recurrent spheno-orbital meningioma resulting in complete resolution of visual symptoms: A case report and review of literature

PURPOSE

Spheno-orbital meningiomas are rare tumors, accounting for up to 9% of all intracranial meningiomas. Patients commonly present with proptosis, and visual deficits. These slow growing tumors are hard to resect due to extension into several anatomical compartments, resulting in recurrence rates as high as 35-50%. Although open surgical approaches have been historically used for resection, a handful of endoscopic approaches have been reported in recent years. We aimed to review the literature and describe a case of spheno-orbital meningioma with severe vision loss which was resected with an endoscopic endonasal approach achieving complete resolution of visual symptoms.

METHODS

A systematic review of literature was conducted in accordance with the PRISMA guidelines. PubMed, Cochrane, and Web of Science databases were queried for spheno-orbital meningiomas resected via an endoscopic endonasal approach. Furthermore, the presentation, surgical management, and post-operative outcomes of a 53-year-old female with a recurrent spheno-orbital meningioma are described.

RESULTS

The search yielded 26 articles, of which 8 were included, yielding 19 cases. Average age at presentation was 60.5 years (range: 44-82), and 68.4% of patients were female. More than half of the cases achieved subtotal resection. Common complications associated with endoscopic endonasal surgery included CN V2 or CN V2/V3 hypoesthesia. Following surgical intervention, visual acuity and visual field remained stable or improved in the majority of the patients.

CONCLUSION

Endoscopic approaches are slowly gaining momentum for treatment of spheno-orbital meningiomas. Further studies on the clinical benefits of this approach on patient outcomes and post-operative complications is warranted.

Orbital vascular malformations: determining outflow with Valsalva CT angiography

Distensible orbital vascular malformations with direct outflow to the cavernous sinus tend to show a disproportionate increase in ipsilateral superior ophthalmic vein size on Valsalva CTA and are often located closer to the apex.

Recurrence of Distensible Orbital Venous-dominant Venolymphatic Malformations After Sclerotherapy Versus Embolization With Excision

PURPOSE

Treatment for orbital venolymphatic malformations (VLMs) commonly includes 3 major options: sclerotherapy, surgery, and embolization followed by surgical excision. Each has certain advantages, although it is not clear whether all are effective. The authors characterize the clinical course for a series of patients with distensible orbital venous-dominant VLM treated with sclerotherapy and/or embolization with excision.

METHODS

In this cross-sectional cohort study, patients affected by distensible orbital venous-dominant VLM presenting to the orbital and ophthalmic plastic surgery service from 2014 to 2020 were identified. Patients were included if they presented with a moderate-flow, distensible venous-dominant malformation associated with Valsalva-related symptoms (e.g., pain, proptosis, and diplopia).

RESULTS

Six cases were treated with sclerotherapy. Four underwent multiple treatments, with a mean ± SD of 3.5 ± 2.3 (range 1-7). All patients in this group failed to improve or experienced recurrence of symptoms after sclerotherapy. Twelve cases were treated with embolization and excision. Resolution of symptoms in all 12 cases was noted and maintained for a mean of 3.4 ± 2.1 years. There have been no cases of recurrence. Patients treated with sclerotherapy were more likely to experience recurrence of symptoms compared to those treated with embolization and excision (p < 0.001).

CONCLUSIONS

Treatment of distensible venous-dominant moderate-flow orbital VLM with sclerotherapy may provide temporary improvement in some cases. However, in the medium to long term, recurrence was universal in this series. Embolization with excision appears to provide more definitive management, avoiding recurrence in all cases for a mean follow-up of 3 years.

Lid Flare Measurement with Lateral Midpupil Distances

PURPOSE

To assess the sensitivity and specificity of lateral midpupil lid distances for the detection of upper lid lateral flare.

METHODS

Lateral lid flare was determined by unanimous agreement among six experienced oculoplastic surgeons in the grading of photographs obtained for patients with Graves orbitopathy (GO). Bézier lines were employed to extract the upper eyelid contours of the patients and a control group of age and sex matched subjects. Custom software was employed to determine 5 lateral midpupil eyelid distances. The sensitivity and specificity of each measurement in detecting lateral flare were estimated from receiver operating characteristic curves. The non-parametric Kruskal-Wallis one-way analysis of variance (ANOVA) with Dunn's posthoc test was used to compare the median values of the contour parameters between groups.

RESULTS

The degree of agreement between judges evaluated with the Fleiss' Kappa test was relatively high (K = 0.69, z = 16.6, p < .0001). The raters classified 12 lids with lateral lid flare (LLF) and 7 without LLF in patients with GO. There was no agreement on the presence or absence of LLF in 11 lids. In all eyes, lateral midpupil lid distances diminished from the center of the eyelid towards the lateral canthus. Receiver operating characteristic analysis for the midpupil distances revealed that the fourth distance from the center demonstrated high sensitivity and specificity in detecting flare. At this location (2.5 mm medial to the lateral canthus) a midpupil distance equal to or greater than 60% of the margin reflex distance (MRD₁) indicated the presence of flare.

CONCLUSIONS

- A single measurement of a lateral midpupil eyelid distance 2.5 mm medial to the lateral canthus is a sensitive and specific measurement for the diagnosis of the LLF.

Orbital anatomical parameters affecting outcome of deep lateral orbital wall decompression

PURPOSE

To determine orbital anatomical parameters that affect surgical outcome of deep lateral orbital wall decompression.

METHODS

Twenty orbits of 20 patients with moderate proptosis (maximum 25 mm) due to thyroid eye disease who were stable for at least 6 months were included in this prospective cohort study. Four parameters including lateral orbital wall distance (LOWD), removable surface area (RSA), removable surface length (RSL), and sphenoid door jamb thickness (SDJ) were evaluated by computed tomography (CT) scan prior to surgery in these patients. Deep lateral orbital wall decompression without fat removal was done in all patients. Relationship between all these factors and proptosis reduction, 6 months after surgery was assessed.

RESULTS

Mean proptosis before decompression surgery (mean ± SD) was 23.22 ± 1.19 mm and reduction in Hertel exophthalmometry (mean ± SD) was -3.27 ± 1.03 mm (p = 0.006). Pearson correlation showed that LOWD, RSL, and SDJ had statistically significant correlation with proptosis reduction (p = 0.017, 0.002, and 0.001, respectively.). Linear multivariate regression analysis showed SDJ as the only independent factor in predicting surgical outcome.

CONCLUSION

several orbital anatomical factors have significant role in predicting surgical outcome following deep lateral wall orbital decompression. Among these parameters, SDJ is an independent factor, whereas LOWD and RSL are dependent factors. Preoperative assessment of the bony sphenoid anatomy may be helpful in predicting the amount of potential decompression.

A novel variation of the suture suspension facelift

BACKGROUND

We propose a technical variation of the minimally invasive suture suspension facelift.

METHODS

A novel variation of the minimally invasive facelift is proposed. The technique consists of two components. The anterior component addresses aging of the midface by anchoring the SMAS on to the sturdy retroauricular supra-helical deep temporal fascia using approximately 6-8 passes of a 4/0 Mersilene suture. The posterior component addresses cervical aging by securing the posterior edge of the platysma onto the sturdy mastoid fascia, using multiple loops of a 4/0 Mersilene suture. This technique was performed on 100 consecutive patients between 2005 and 2010.

RESULTS

The technique was found to be safe due to the plane of dissection remaining superficial to the parotid gland in the anterior component. There were no instances of facial nerve injury or sensory disturbance. None of the patients required a secondary procedure within the first 18 months following the procedure.

CONCLUSIONS

This technique offers a safe and effective option for patients who seek a facelift, especially in combination with other procedures. It is envisaged that the use of multiple loops of suture to anchor mobile tissue onto fixed sturdy fascia will contribute to the longevity of the results. The limited skin undermining also makes this procedure a better choice for smokers.

In Vivo Measurement of the Human Vitreous Chamber Volume Using Computed Tomography Imaging of 100 Eyes

Purpose

To accurately measure the vitreous chamber volume (VCV) in humans using high-resolution computed tomography (CT) scanning techniques combined with three-dimensional analysis software. Potential relationships between age, axial length, and VCVs were also explored.

Methods

In this retrospective study, the eyes of 100 healthy individuals were studied. Scans were acquired during clinical care and did not show any signs of orbital pathology. Exclusion criteria included any ocular history. CT scans were acquired with a slice thickness of 0.7 mm, and volumetric analysis was carried out using the MIMICS image analysis software version 19.0 (Materialise, Leuven, Belgium).

Results

The final sample included 100 eyes from 50 patients (30 women, 20 men). The mean age was 48.67 ± 20.72 years, and the age range was 18 to 91 years. The mean VCV was 4.649.99 ± 0.426.54 mm³ for women and 4.969.0 ± 0.465.20 mm³ for men. We found a significant correlation between age and VCV (P < 0.001), axial length and VCV (P < 0.001), and age and axial length (P < 0.005).

Conclusions

The VCV appears to be greater than the current consensus suggests. This work also suggests that the VCV is associated with age and axial length, indicating that it is dynamic and may change throughout adulthood.

Translational Relevance

This information regarding the volume of the vitreous chamber is useful for our understanding of proper dosage and behavior of agents we commonly insert into the vitreous chamber.

Biomechanical and Morphologic Effects of Collagen Cross-Linking in Human Tarsus

Purpose

To investigate the feasibility of increasing the stiffness of human tarsal tissue following treatment with riboflavin and ultraviolet A (UVA) to induce cross-linking of collagen fibers.

Methods

In this case control study, 18 right and left upper eyelids were excised en bloc from 18 fresh-frozen cadavers. One side served as the control while the samples from the opposite side were cross-linked. Four 2 × 6-mm vertical strips of central tarsus were cut from the superior to inferior border of each tarsal plate. Sample tissue was irradiated with UVA at 6 mW/cm² for 18 minutes. A microtensile load cell and an optical coherence tomography scanner allowed calculation of stiffness (Young's modulus). Six cross-linked samples and corresponding controls were stained with hematoxylin and eosin (H&E) and Masson trichrome stains. Four controls and four cross-linked samples were also reviewed with a transmission electron microscope.

Results

Mean Young's modulus in the linear region for controls was 28 ± 9 MPa and was much higher at 138 ± 8 MPa for cross-linked samples (P < 0.001), yielding a 493% mean stiffness increase. Staining with H&E and Masson did not reveal any histologic changes. Transmission electron microscopy showed a decrease in average diameter of 50 randomly selected collagen fibers from 47.2 ± 1.9 nm prior to cross-linking to 34.2 ± 1.1 nm post cross-linking (P < 0.001). Qualitatively, the collagen fibers appeared more closely packed following cross-linking.

Conclusions

The findings of this study suggest that collagen cross-linking is a viable and effective modality for increasing the stiffness of human tarsal plates.

Translational Relevance

This work provides proof that collagen cross-linking produces stiffening of the human tarsal plate and may be used in disorders that cause eyelid laxity.

Objective Comparison of Nasojugal Fold Depth and Lower Eyelid Length After Fat Excision Versus Fat Transpositional Lower Blepharoplasty

BACKGROUND

Lower blepharoplasty is one of the most commonly performed aesthetic surgeries in the world. However, there are no studies to directly compare patients who had fat excision vs fat transposition.

OBJECTIVES

The authors sought to compare and contrast aesthetic results of fat excisional and fat transpositional lower blepharoplasty.

METHODS

A retrospective review was conducted of 60 patients (120 eyelids) who underwent transconjunctival lower blepharoplasty, either with fat excision or fat transposition into a preperiosteal plane. Marginal reflex distance-2, lower eyelid length, nasojugal fold depth, and pretarsal orbicularis definition were measured.

RESULTS

Mean follow-up was 5.6 months. Mean marginal reflex distance-2 did not significantly differ after either fat excision or fat transposition. Mean lower lid length decreased after fat excision only (P < 0.001), and postoperative fat excision patients had a shorter lower eyelid length than patients who underwent fat transposition (13.5 ± 2.1 mm vs 16.1 ± 1.9 mm, P < 0.0001). Pretarsal orbicularis definition increased after both surgeries (P < 0.001), and the groups did not differ (1.0 ± 0.8 vs 1.1 ± 0.9, not significant). Mean nasojugal fold depth was effaced after surgery in both groups (P < 0.001), although the nasojugal fold was significantly more effaced after fat transposition (1.5 ± 0.7 vs 0.48 ± 0.6, P < 0.001).

CONCLUSIONS

In lower blepharoplasty, fat excision resulted in a shorter lower eyelid, and fat transposition resulted in a more effaced lid-cheek junction. Surgeons should be able to balance both techniques to deliver a customized aesthetic result.

Level of Evidence: 3.

Orbital granulomatosis with polyangiitis masquerading as invasive fungal sinusitis

A 55-year-old man presented with unilateral orbital inflammation and no light perception vision. Imaging revealed infiltrative enhancement of the optic nerve, orbit, and intracranial tissue. The case was suspicious for invasive fungal disease, but ultimate workup and orbital biopsy revealed granulomatosis with polyangiitis. The patient's inflammation resolved with corticosteroid and rituximab therapy. Granulomatosis with polyangiitis is a systemic vasculitis that can mimic a number of orbital pathologies.

Abducens nerve palsy after orbital decompression

INTRODUCTION

Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED.

AIM

We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery.

RESULTS

Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring.

DISCUSSION

Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.

Mikulicz's Disease: A New Perspective and Literature Review

PURPOSE

To report the clinical and pathophysiologic features of two patients with Mikulicz's disease and to further characterize recommendations for diagnosis and management with a review of the literature.

METHODS

Retrospective nonrandomized consecutive case series, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA.

RESULTS

Mikulicz's disease is characterized by symmetric lacrimal, parotid, and submandibular gland enlargement with associated lymphocytic infiltrations. The authors noted two cases of Mikulicz's disease. The diagnosis of Mikulicz's disease was based on the following criteria: 1) symmetric and persistent swelling of the lacrimal glands and either or both of the major salivary glands (parotid and submandibular); and 2) the exclusion of other diseases that may mimic this presentation, such as sarcoidosis, viral infection, or lymphoproliferative disorders.

CONCLUSIONS

Mikulicz's disease is a condition in which there is bilateral lacrimal and salivary gland swelling that is not associated with other systemic conditions. The condition is self-limiting and most often, the diagnosis is a clinical one. Previously, Mikulicz's disease was often considered as a subtype of Sjögren's syndrome (SS). Clinical and immunologic differences between Mikulicz's disease and SS may warrant further consideration of Mikulicz's disease as a specific autoimmune phenomenon separate from SS, and Mikulicz's disease may be amenable to different treatment modalities than those employed in patients with SS.

Ultrasonographic motion analysis of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy

Purpose

To present the qualitative and quantitative ultrasonographic findings of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy (TAO) compared to normal subjects.

Methods

In a prospective study, dynamic and static ultrasonographic investigation, applying high resolution (15 MHz) ultrasound was performed to assess the lower eyelid, in 15 TAO patients that were in chronic phase and 10 normal subjects. The thickness and echogenisity of dermis, orbicular oculi muscle, lower eyelid retractor muscle, lower eyelid fat pads, and their qualitative relationships during vertical excursion of the globe were evaluated in static and dynamic investigation. Correlation of ultrasonic and clinical findings was evaluated.

Results

The mean age of the patients was 41.82 ± 7.4 years, and the controls were age-matched (mean age, 42.8 ± 5.6 years). Mean proptosis of the involved eyes was 3.3 mm, and mean lower lid retraction was 2.4 mm in chronic TAO group. Pattern of fat motion was blocky in chronic TAO patients compared to normal jelly motion of the fat in normal cases. In analyzing the range of motion, the difference was significant in the motion of both superficial and deep fat pockets between the two groups (P < 0.001). Limitation of fat motion correlated both with proptosis and lower eyelid retraction (Pearson correlation coefficient = −0.77 vs −0.43, P < 0.001). Fibrotic changes of lower lid fat pads appear in the tissue around the septum on observation. Considering the ultrasound findings, a new staging method is proposed in this study that starts with the appearance of echodense points, getting worse in fine bands, progresses to thick bands and ends in cord formation in the lower lid fat pocket that determines total fibrosis.

Conclusion

Development of a series of static and dynamic changes in ultrasound is related to the clinical findings in chronic phase of TAO. The limitation of motion and fibrotic changes of lower eyelid fat pads were more detectable in cases with a more severe proptosis and lower lid retraction. It is considered that ultrasound findings can be a representative of the severity of involvement in the chronic phase of the TAO.

Teprotumumab for Thyroid-Associated Ophthalmopathy

BACKGROUND

Thyroid-associated ophthalmopathy, a condition commonly associated with Graves' disease, remains inadequately treated. Current medical therapies, which primarily consist of glucocorticoids, have limited efficacy and present safety concerns. Inhibition of the insulin-like growth factor I receptor (IGF-IR) is a new therapeutic strategy to attenuate the underlying autoimmune pathogenesis of ophthalmopathy.

METHODS

We conducted a multicenter, double-masked, randomized, placebo-controlled trial to determine the efficacy and safety of teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, in patients with active, moderate-to-severe ophthalmopathy. A total of 88 patients were randomly assigned to receive placebo or active drug administered intravenously once every 3 weeks for a total of eight infusions. The primary end point was the response in the study eye. This response was defined as a reduction of 2 points or more in the Clinical Activity Score (scores range from 0 to 7, with a score of ≥3 indicating active thyroid-associated ophthalmopathy) and a reduction of 2 mm or more in proptosis at week 24. Secondary end points, measured as continuous variables, included proptosis, the Clinical Activity Score, and results on the Graves' ophthalmopathy-specific quality-of-life questionnaire. Adverse events were assessed.

RESULTS

In the intention-to-treat population, 29 of 42 patients who received teprotumumab (69%), as compared with 9 of 45 patients who received placebo (20%), had a response at week 24 (P<0.001). Therapeutic effects were rapid; at week 6, a total of 18 of 42 patients in the teprotumumab group (43%) and 2 of 45 patients in the placebo group (4%) had a response (P<0.001). Differences between the groups increased at subsequent time points. The only drug-related adverse event was hyperglycemia in patients with diabetes; this event was controlled by adjusting medication for diabetes.

CONCLUSIONS

In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. (Funded by River Vision Development and others; ClinicalTrials.gov number, NCT01868997 .).

Association of Eyelid Position and Facial Nerve Palsy With Unresolved Weakness

IMPORTANCE

Understanding the prevalence and clinical features of eyelid malpositions in facial nerve palsy (FNP) may inform proper management of patients with FNP and supplement our knowledge of eyelid physiology.

OBJECTIVE

To describe eyelid malposition in FNP.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, patients with FNP seen at the Center for Advanced Facial Plastic Surgery and Jules Stein Eye Institute between January 1, 1999, and June 1, 2014, were reviewed for study inclusion. Data collection was performed between June 1, 2014, to August 1, 2014, and data analysis was performed between June 15, 2014, to September 1, 2015. The distances from the center of the pupil to the upper eyelid margin (marginal reflex distance 1 [MRD1]) and to the lower eyelid margin (marginal reflex distance 2 [MRD2]) were measured on photographs of patients in the primary position and with full smile. Eyelid asymmetry, retraction, ptosis, synkinesis, and severity and duration of FNP were assessed. Eligible participants were adults with FNP at a private tertiary care clinic with primary position photographs. Exclusion criteria included prior history of procedures or medical conditions that could alter eyelid position.

RESULTS

The 52 included patients were predominantly female (38 [73%]), with a mean (SD) age of 44.1 (13.8) years. Of this group, 34 patients (65%) were white, 8 (15%) were Asian, 8 (15%) were Hispanic, and 2 (4%) were African American. Retraction (MRD1, >5.0 mm) was present in 8 patients (15%), 3 of whom had eyelid asymmetry (MRD1, >1.0 mm). Overall, total asymmetry of greater than 1.0 mm was present in 14 patients (27%), with the FNP side higher in 12 (23%). Compared with those without asymmetry, patients with eyelid asymmetry were significantly more likely to have contralateral ptosis (42% vs 2.5%, P < .001) but did not have a significantly shorter duration of FNP (12.3 months vs 13.8 months, P = .82). Ptosis was noted in 4 patients and was also unrelated to duration of FNP (9.6 months in patients with ptosis vs 13.6 months in those without, P = .60). Synkinesis was found in 24 patients (46%), but none had concomitant ptosis. Severe FNP (House-Brackmann score, ≥4) was present in 28 patients (54%), and these patients were 20 times more likely to have asymmetry greater than 1.0 mm, often with the FNP side higher.

CONCLUSIONS AND RELEVANCE

Upper eyelid asymmetry is common in FNP. In most of the patients in this study, the FNP side was higher without demonstrating retraction, and the contralateral side was ptotic. Thus, contralateral ptosis surgery may benefit these patients. Furthermore, patients with severe facial weakness were more likely to have eyelid asymmetry, suggesting that the ability of the eyelid position maintenance system to adapt to weakness of eyelid protractors may be limited by the severity of this weakness.

LEVEL OF EVIDENCE

3.

The effect of upper eyelid blepharoplasty on eyelid and brow position

This article evaluates the effect of upper eyelid blepharoplasty on eyelid margin position and brow height. This study is a retrospective analysis of patients who underwent upper eyelid blepharoplasty without concurrent blepharoptosis repair or brow surgery. The medical records of the participants were retrospectively reviewed and an established image analysis software was used to quantify the upper margin reflex distance (MRD1) as well as brow height using high quality standardized clinical photographs. A total of 19 patients (38 eyelids and brows) met the inclusion criteria. The mean preoperative MRD1 was 2.8 mm, and the mean post-operative MRD1 was 3.5 mm, revealing an increase of MRD1 from upper blepharoplasty alone of 0.7 mm (p = 0.0001). The mean preoperative brow position was 17.5 mm above the pupil, and the mean post-operative position was 17.4 mm, for an average change of position of -0.2 mm (p = 0.39) following upper eyelid blepharoplasty. Upper eyelid blepharoplasty without ptosis surgery results in a statistically significant increase in MRD1. Brow position does not demonstrate a statistically significant change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.

The success rate of TED upper eyelid retraction reoperations

Although reoperation rates for upper lid retraction surgery for thyroid eye disease (TED) typically range between 8% and 23%, there is little literature describing the outcomes of these second operations. In this retrospective observational cohort study, all patients that underwent surgery for upper eyelid retraction over a 14-year period at a single institution were included. Cases were included if a second eyelid retraction surgery was performed during the study period. Success of surgery was defined as a marginal reflex distance (MRD1) of 2.5 to 4.5 mm in each eye and less than 1 mm difference in MRD1 between the eyes. Overcorrection and undercorrection were defined as above and below these bounds, respectively. 72 eyes in 49 patients were included in the study. The mean age was 56.6 (±11.5) years. By definition, all patients had at least 1 lid lengthening surgery for upper eyelid retraction, and at least 1 subsequent surgery. For this second surgery, 61 eyes (85%) underwent retraction surgery and 11 eyes (15%) underwent ptosis surgery. After this second operation, 31% were undercorrected and 33% were overcorrected. A third surgery was performed in 19 eyes (25%), 12 had surgery for residual retraction and 7 for ptosis. After the third operation 10% of eyes were under corrected and 11% were over corrected. Four patients underwent a fourth surgery: one for retraction and three for ptosis. Success was noted in 35% after the second surgery and 44% after the third. Surgical success in eyelid retraction surgery increases from a second to a third consecutive surgery, and residual asymmetry was roughly equally distributed between over- and undercorrection.

One-stage bone strip reconstruction technique with balloon sinus dilatation surgery for chronic maxillary atelectasis

PURPOSE

Chronic maxillary atelectasis is characterized by unilateral spontaneous enophthalmos and hypoglobus due to increased orbital volume secondary to maxillary sinus inward deformation. Reformation of the sinus architecture and reconstruction of the orbit are key to a successful outcome. Here, we introduce a one-staged surgery that addresses both these goals.

PATIENTS AND METHODS

We retrospectively reviewed 11 patients treated with one-stage orbital and sinus surgery. A transconjunctival subperiosteal approach was used to create slats in the thinned orbital floor. A nasal endoscopic approach was utilized to access the maxillary sinus and place a modified Foley catheter balloon through the enlarged maxillary ostium. A bridge graft of nasal septal, ear cartilage, or LactSorb was placed on the reconstructed and balloon-supported orbital floor. The balloon was deflated and removed at 10-14 days. All patients underwent complete ophthalmic and orbital evaluation, including standardized photography and radiologic imaging.

RESULTS

Eleven patients, mean age 39.5 years, presented with diplopia in upgaze, superior sulcus deformity, and at least 2 mm of relative enophthalmos. After initial overcorrection, enophthalmos improved in all cases. Symmetry within 1 mm was accomplished in 10 of 11 cases. Follow-up time was 259±320 days. Full motility was recovered in all patients.

CONCLUSION

We describe a one-staged surgery consisting of cutting slats in the orbital floor, dilating the maxillary sinus with a balloon, and stabilizing the orbital floor with a cartilage graft placement. Our anecdotal experience suggests that this surgical approach can safely achieve normalization of the pathologic sinus outflow and restoration of the orbit anatomy. The balloon ensures orbital floor stability during the healing process, and it may act to stent open the sinus ostium during early mucosal healing.

Engorgement of the Angular and Temporal Veins Following Periorbital Hyaluronic Acid Gel Injection

PURPOSE

To study angular and temporal vein engorgement following periorbital hyaluronic acid gel (HAG) injection.

METHODS

In this retrospective study, the authors reviewed the photographs of 805 patients who had periorbital HAG injection at Jules Stein Eye Institute Oculoplastic Clinic between January 2004 and January 2014. HAG injections were used to fill the orbital hollow, zygomatic hollow, septal confluence hollow, and cheek. The inclusion criteria were patients who had at least 1 pre-, immediate post-, and late postinjection photographs. Immediate postinjection photographs were taken right after HAG injection, and late postinjection photographs were taken at the following visit before any injection. The exclusion criteria were patients with any previous ocular surgery 6 months before filler injection, patients with orbital diseases, and patients who had HAG injections for functional purposes. The photographs were evaluated for the presence of angular and temporal vein engorgement at any of the injections during the follow-up visits. The photographs of eyes with vein engorgement were graded on a scale of 0 (no engorgement), 1 (mild engorgement), 2 (moderate engorgement), and 3 (severe engorgement).

RESULTS

There were 78 eligible patients (156 orbits; 68 females and 10 males) with average age of 59.4 ± 13.4 years. The authors found 18 orbits of 12 patients (15.4%; 6 unilateral and 6 bilateral) with angular vein engorgement at least 1 time after HAG injection during the follow-up visits. The frequency of temporal vein engorgement was 9.1%. The mean ± SD of angular vein grading for engorgement increased from 0.72 ± 0.51 on preinjection photographs to 1.45 ± 0.88 on immediate postinjection photographs (p = 0.0001) and 0.89 ± 0.50 on late postinjection photographs (p = 0.04). The mean ± SD of angular vein grading for engorgement was 0.67 ± 0.55 on the first preinjection photographs, which increased to 1.10 ± 0.50 on the last late postinjection photographs. The difference was statistically significant (p = 0.001).

CONCLUSIONS

Angular and temporal vein engorgement occurred following HAG injection in the periorbital region. The engorgement occurred immediately after injections and decreased considerably but not completely in the following visit.

Compartmental Innervation of the Superior Oblique Muscle in Mammals

PURPOSE

Intramuscular innervation of mammalian horizontal rectus extraocular muscles (EOMs) is compartmental. We sought evidence of similar compartmental innervation of the superior oblique (SO) muscle.

METHODS

Three fresh bovine orbits and one human orbit were dissected to trace continuity of SO muscle and tendon fibers to the scleral insertions. Whole orbits were also obtained from four humans (two adults, a 17-month-old child, and a 33-week stillborn fetus), two rhesus monkeys, one rabbit, and one cow. Orbits were formalin fixed, embedded whole in paraffin, serially sectioned in the coronal plane at 10-μm thickness, and stained with Masson trichrome. Extraocular muscle fibers and branches of the trochlear nerve (CN4) were traced in serial sections and reconstructed in three dimensions.

RESULTS

In the human, the lateral SO belly is in continuity with tendon fibers inserting more posteriorly on the sclera for infraducting mechanical advantage, while the medial belly is continuous with anteriorly inserting fibers having mechanical advantage for incycloduction. Fibers in the monkey superior SO insert more posteriorly on the sclera to favor infraduction, while the inferior portion inserts more anteriorly to favor incycloduction. In all species, CN4 bifurcates prior to penetrating the SO belly. Each branch innervates a nonoverlapping compartment of EOM fibers, consisting of medial and lateral compartments in humans and monkeys, and superior and inferior compartments in cows and rabbits.

CONCLUSIONS

The SO muscle of humans and other mammals is compartmentally innervated in a manner that could permit separate CN4 branches to selectively influence vertical versus torsional action.

Transorbital approach without craniotomy to orbital tumors with extradural intracranial extension

PURPOSE

To review indications and clinical outcomes in a series of orbitocranial tumors treated surgically through a transorbital extradural approach without craniotomy.

METHODS

In this retrospective case series, all patients who underwent surgery through a transorbital extradural approach without craniotomy for benign orbitocranial tumors involving the dura or extending into the anterior or middle cranial fossae were analyzed.

RESULTS

Twenty-seven patients (20 females and 7 males) were included. Median age was 47.0 years (range: 6-74 years) and median follow-up time was 43.5 months (range: 3-148 months). The median preoperative best-corrected visual acuity (logMAR) was improved from 0.35 (range: 0-2.6) to 0.1 (range: 0-2.6) at the last follow-up (p < 0.03). The mean ± SD preoperative exophthalmos significantly decreased from 20.4 ± 3.4 mm to 13.1 ± 3.5 mm at the last follow-up visit (p < 0.01). Four postoperative complications were noted and included one case each of ptosis, numbness, diplopia (transient for 6 months), and cranial nerve VI palsy (transient for 4 months).

CONCLUSIONS

The transorbital extradural approach provides access to the deep orbit and adjacent extradural cranial spaces. Benign orbital tumors that have eroded through the orbital roof, are located in the orbital apex abutting the anterior cavernous sinus and tumors requiring debulking are all processes that can be potentially approached through the transorbital extradural route. Compared to open craniotomy, the incision is smaller, the access more direct and specific risks of open craniotomy are reduced.

Methicillin-resistant Staphylococcus aureus dacryoadenitis

IMPORTANCE

Although classically thought to be primarily a nosocomial infection, the incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is rising. In this series we report 3 cases of community-acquired MRSA acute dacryoadenitis in adults presenting within a 3-week period.

OBSERVATIONS

All cases presented with pain and periocular erythema increasing over approximately 1 week. An S-shaped lid deformity was evident, and 2 of the 3 cases demonstrated multiple pustules/abscesses in the region of the lacrimal gland that were expressing purulent fluid into the superior fornix. Eye cultures yielded MRSA. Each case had complete clinical resolution with 2 to 4 days of intravenous vancomycin followed by 1 week of oral trimethoprim-sulfamethoxazole combination therapy.

CONCLUSIONS AND RELEVANCE

These cases underscore the changing profile of MRSA infections, especially in the community-based setting. MRSA dacryoadenitis can be difficult to treat with standard therapeutic approaches and may progress to orbital cellulitis. We recommend a short admission for intravenous antibiotic therapy while bacterial sensitivities are being determined before transitioning to a dual-targeted oral antibiotic regimen.

Hyaluronic acid gel distribution pattern in periocular area with high-resolution ultrasound imaging

BACKGROUND

High-resolution ultrasound (HRUS) is a useful tool in defining anatomic and dynamic soft tissue relationships in the periocular area. It also allows visualization of hyaluronic acid (HA) gel within the soft tissue.

OBJECTIVES

The authors investigate the difference in the distribution pattern between 2 HA fillers in the periocular tissue using HRUS.

METHODS

The charts of 10 patients who underwent periocular injection using HA gel filler and were subsequently examined with HRUS were reviewed. Half of the patients (n = 5) were treated with Restylane-L (Medicis Aesthetics, Inc, Scottsdale, Arizona) and the remaining 5 with Belotero Balance (Merz Aesthetics, Inc, San Mateo, California). Ultrasonographic evaluation (Logiq p6; GE Healthcare, Waukesha, Washington) was performed before and immediately after HA filler injection.

RESULTS

The HA appears as a hypoechoic image within the soft tissue plane on HRUS. Restylane-L filler formed a localized hypoechoic image within the tissue, with some spread into bubbles or pearl-like configuration. Belotero Balance spread more widely into the tissue plane and diffused into an elongated or spindle-shaped hypoechoic image.

CONCLUSIONS

Our preliminary data suggest that HA gel fillers with differing production technologies show distinct spread and distribution patterns in the periocular tissues on HRUS examination.

Dynamic high-resolution ultrasound in vivo imaging of hyaluronic acid filler injection

BACKGROUND

High-resolution ultrasound (HRU) imaging is a useful tool to study hyaluronic acid (HA) filler injected in the face.

OBJECTIVE

To observe real-time injection of HA using HRU and describe behavior of the gel injection in various anatomic layers and the effect of massage.

METHODS

Deep (preperiosteal), intermediate (subdermal), and superficial (dermal) injections of HA were performed in the supraclavicular area under ultrasonography visualization on a healthy volunteer. Videos were obtained during injection and static images at several time points, including during injection, immediately after injection, 5 minutes after massage of the treated area, and at 2 weeks after injection.

RESULTS

During injection, dermally injected HA stayed within the dermis, increasing its echogenicity; subdermally injected HA formed multiple anechoic pearls; and preperiosteal HA produced a single anechoic bubble with diffuse margins. No vertical transection of the planes was observed during injection or after massage. Two-week postinjection imaging showed persistence of the varying HA morphology in each plane.

CONCLUSIONS

High-resolution ultrasound allows in vivo study of HA injection behavior. HA adopts different morphology within the tissue depending on the density and compliance of the tissues in the plane of injection.

High-resolution ultrasound as an effective and practical tool to analyze eyebrow profile expansion in thyroid-associated periorbitopathy

PURPOSE

Clinical, radiographic, and molecular studies have shown that patients with thyroid-associated orbitopathy exhibit volumetric expansion of eyebrow tissues. This clinicopathologic entity has been termed thyroid-associated periorbitopathy. The goal of this study was to determine whether high-resolution ultrasonography could be used to reliably quantify thyroid-associated periorbitopathy.

METHODS

Institutional review board approval was obtained. The internal case-control study consisted of 12 subjects with unilateral-asymmetric thyroid-associated orbitopathy. High-resolution ultrasonography using a 15-MHz probe (Logiq p6) was performed by a single operator. Measurements were obtained 0.5 cm cephalad to the superior orbital rim at the midpupillary sagittal level. For each subject and tissue layer thickness (total tissue, dermis fat, retro-orbicularis oculi fat), the measured values on the less affected side were subtracted from those on the more severely diseased side. Summary statistics were used to analyze results.

RESULTS

High-resolution ultrasonography effectively demonstrated asymmetric expansion of total eyebrow tissue (p < 0.0001) and retro-orbicularis oculi fat (p = 0.0003). No significant difference in dermis fat thickness was found between the 2 sides (p = 0.2). Hertel exophthalmometry measurements were statistically different between the 2 sides (p = 0.002).

CONCLUSIONS

This study demonstrates that high-resolution ultrasonography independently confirms previously published studies of retro-orbicularis oculi fat expansion in patients with thyroid-associated orbitopathy. Compared with CT, MRI, and tissue biopsy, high-resolution ultrasonography is a more practical and cost-effective way to quantify and track thyroid-associated periorbitopathy over time. With its potential for real-time tissue assessment, high-resolution ultrasonography may be best suited for future studies of the dynamic relationship between globe and periorbital structures.