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Lu JE, Wolkow N, Lee NG, Lefebvre DR, Freitag SK, Yoon MK. Perceived change in age after functional upper blepharoplasty. Orbit 2024; 43:165-167. [PMID: 37224403 DOI: 10.1080/01676830.2023.2214940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/10/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE To evaluate the perceived age of patients before and after functional upper blepharoplasty. METHODS Retrospective chart review of patients who underwent upper blepharoplasty by a single surgeon at an academic center. The inclusion criterion was having external photographs before and after blepharoplasty. Exclusion criteria included any other concurrent eyelid or facial surgery. Primary endpoint: perceived change in age after surgery as judged by the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) surgeons. RESULTS Sixty-seven patients (14 men, 53 women) were included. Mean pre-operative age was 66.9 years (range 37.8-89.4) and mean post-operative age was 67.4 years (range 38.6-89). The mean perceived age pre-operatively was 68.9 years, and the mean perceived age post-operatively was 67.1 years, a change of 1.8 years (p = 0.0001 by two-tailed paired T-test). Inter-rater reliability of the observers was measured by intraclass correlation coefficient of 0.77 for pre-operative and 0.75 for post-operative photos. The decreased perceived age was 1.9 years for women, 1.4 years for men, 0.3 years for Asians, 1.2 years for Hispanics, and 2.1 years for whites. DISCUSSION Functional upper blepharoplasty by an experienced ASOPRS surgeon was shown to reduce the perceived age of a patient by an average of 1.8 years.
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Affiliation(s)
- Jonathan E Lu
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Natalie Wolkow
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - N Grace Lee
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Daniel R Lefebvre
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Michael K Yoon
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
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2
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Feng Y, Chiou CA, Stagner AM, Chang YS, Freitag SK. Distinguishing spheno-orbital metastatic prostate cancer mimicking a meningioma using novel 18F-PSMA PET/CT imaging. Orbit 2024:1-6. [PMID: 38526143 DOI: 10.1080/01676830.2024.2318769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/07/2024] [Indexed: 03/26/2024]
Abstract
A 78-year-old man presented with acute-onset left temporal pain, eyelid swelling, and double vision. Computed tomography (CT) demonstrated a left sphenoid wing mass with extra-osseous intra-orbital and intracranial extension, thought to be a typical sphenoid wing meningioma by the primary team. The patient was admitted for an urgent craniotomy, which was planned for the following day. However, upon consultation with ophthalmic plastic surgery, concern was raised for an alternative diagnosis given the atypical timeline, inflammatory changes, and uncharacteristic imaging findings of mixed lytic and sclerotic bony changes without hyperostosis on CT and extensive peri-lesional dural thickening and enhancement on magnetic resonance imaging. A serum prostate-specific antigen was elevated to 206 ng/mL. Subsequent positron emission tomography (PET)/CT using 18F-fluorodeoxyglucose radiotracer was negative for metastatic disease. A prostate-specific membrane antigen (PSMA) PET/CT was then obtained and demonstrated extensive metastases. An orbital biopsy revealed poorly differentiated prostatic adenocarcinoma. The significant incongruence between the standard PET/CT and PSMA PET/CT highlights the value of this novel advanced radiographic modality in narrowing the differential diagnosis and determining the extent of disease. Findings of widespread metastasis on the PSMA PET/CT ultimately helped to avoid a large, morbid neurosurgical intervention in this patient, allowing for a minimally invasive orbital biopsy to characterize the tumor for therapeutic targeting.
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Affiliation(s)
- Yilin Feng
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina A Chiou
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna M Stagner
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Yuh-Shin Chang
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Suzanne K Freitag
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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Rosenblatt TR, Chiou CA, Yoon MK, Lee NG, Wolkow N, Freitag SK. Change in upper eyelid position after teprotumumab treatment for thyroid eye disease. Orbit 2024:1-7. [PMID: 38466206 DOI: 10.1080/01676830.2024.2323543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/20/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE Despite the high prevalence, treatment challenges, and significant impact of eyelid retraction on vision and quality of life among patients with thyroid eye disease, the effects of teprotumumab on eyelid retraction are not fully understood. This study evaluated change in upper eyelid position after teprotumumab. METHODS A retrospective study of all patients who completed eight teprotumumab infusions at one institution from January 1 2020 to December 31 2022. Primary outcome was change in upper eyelid position immediately after treatment and at most recent follow-up compared to pre-treatment. RESULTS Among 234 eyes of 118 patients, average margin reflex distance-1 (MRD1) pre-treatment was 5.25 mm (range 0-10.0, SD 1.75), 4.66 mm (1.0-9.0, SD 1.32) immediately post-treatment (p < 0.001), and 4.50 mm (0-10.0, SD 1.52) at most recent follow-up (mean follow-up duration 10.60 months). In total, 136 (58.12%) eyes of 88 patients had MRD1 reduction immediately post-treatment, averaging 1.49 mm (0.5-5.0 mm, SD 0.97). Every 1-mm increase in pre-treatment MRD1 increased the odds of MRD1 reduction by 15.03% (CI 10.52-19.72, p < 0.001) and increased the reduction amount by 0.48 mm (CI 0.39-0.57, p < 0.001). Of 154 eyes of 78 patients with most recent follow-up, 107 (69.48%) eyes had stable or further improved retraction at most recent follow-up compared to immediately post-treatment. CONCLUSIONS This study found a modest but significant reduction in MRD1 in approximately 60% of eyes, independent of proptosis change, which was sustained by most patients over longer-term follow-up. Higher pre-treatment MRD1 corresponded with greater improvement. These results suggest an overall mild benefit of teprotumumab for upper eyelid retraction.
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Affiliation(s)
- Tatiana R Rosenblatt
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina A Chiou
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Yoon
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Nahyoung Grace Lee
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalie Wolkow
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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Robinette ML, Weeks LD, Kramer RJ, Agrawal M, Gibson CJ, Yu Z, Sekar A, Mehta A, Niroula A, Brown JT, McDermott GC, Reshef ER, Lu JE, Liou VD, Chiou CA, Natarajan P, Freitag SK, Rao DA, Ebert BL. Association of Somatic TET2 Mutations With Giant Cell Arteritis. Arthritis Rheumatol 2024; 76:438-443. [PMID: 37909388 PMCID: PMC10922498 DOI: 10.1002/art.42738] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/07/2023] [Accepted: 10/23/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Giant cell arteritis (GCA) is an age-related vasculitis. Prior studies have identified an association between GCA and hematologic malignancies (HMs). How the presence of somatic mutations that drive the development of HMs, or clonal hematopoiesis (CH), may influence clinical outcomes in GCA is not well understood. METHODS To examine an association between CH and GCA, we analyzed sequenced exomes of 470,960 UK Biobank (UKB) participants for the presence of CH and used multivariable Cox regression. To examine the clinical phenotype of GCA in patients with and without somatic mutations across the spectrum of CH to HM, we performed targeted sequencing of blood samples and electronic health record review on 114 patients with GCA seen at our institution. We then examined associations between specific clonal mutations and GCA disease manifestations. RESULTS UKB participants with CH had a 1.48-fold increased risk of incident GCA compared to UKB participants without CH. GCA risk was highest among individuals with cytopenia (hazard ratio [HR] 2.98, P = 0.00178) and with TET2 mutation (HR 2.02, P = 0.00116). Mutations were detected in 27.2% of our institutional GCA cohort, three of whom had HM at GCA diagnosis. TET2 mutations were associated with vision loss in patients with GCA (odds ratio 4.33, P = 0.047). CONCLUSIONS CH increases risk for development of GCA in a genotype-specific manner, with the greatest risk being conferred by the presence of mutations in TET2. Somatic TET2 mutations likewise increase the risk of GCA-associated vision loss. Integration of somatic genetic testing in GCA diagnostics may be warranted in the future.
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Affiliation(s)
- Michelle L. Robinette
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lachelle D. Weeks
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Center for Leukemia and Center for Prevention of Progression, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ryan J. Kramer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Mridul Agrawal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Zhi Yu
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Aswin Sekar
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Arnav Mehta
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Abhishek Niroula
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Jared T. Brown
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Gregory C. McDermott
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edith R. Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Boston Children’s Hospital, Boston MA, USA
| | - Jonathan E. Lu
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Victor D. Liou
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
- Current address: The Permanente Medical Group, Kaiser Permanente Northern California, San Rafael, CA, USA
| | - Carolina A. Chiou
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Pradeep Natarajan
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne K. Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Deepak A. Rao
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Benjamin L. Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- The Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Howard Hughes Medical Institute, Dana-Farber Cancer Institute, Boston, MA, USA
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Rosenblatt TR, Chiou CA, Yoon MK, Wolkow N, Lee NG, Freitag SK. Proptosis Regression After Teprotumumab Treatment for Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:187-191. [PMID: 37791840 DOI: 10.1097/iop.0000000000002531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
PURPOSE This study analyzed the degree and timing of proptosis regression after teprotumumab therapy. METHODS A retrospective study of all patients who completed 8 teprotumumab infusions at 1 institution from January 1, 2020 to December 31, 2022. Change in proptosis was assessed in millimeters and percentages compared with immediate post-treatment and pretreatment proptosis. RESULTS Of 119 patients with post-treatment data (mean follow-up 10.56 months, range: 3.05-25.08), 208 (87.39%) eyes of 110 patients had initial proptosis improvement. Of the 78 patients with multiple follow-up visits, 102 (65.38%) eyes of 59 patients had proptosis regression averaging 12.78% (range: 1.85-58.82%) compared with immediately post-treatment or 2.43 mm (0.5-10.0 mm). Eight (7.84%) eyes had initial documentation of regression more than 1 year after treatment, 40 (39.22%) between 6 months and 1 year, and 54 (52.94%) eyes within 6 months with 25 (46.30%) of these continuing to worsen at subsequent follow-up. Forty (25.64%) eyes of 24 patients had more proptosis at most recent follow-up than before teprotumumab, with an average regression of 1.53 mm (0.5-4.0 mm) or 7.74% (1.85-20.69%) of pretreatment proptosis. In comparison, 99 (63.46%) eyes of 54 patients maintained improvement, with reduction averaging 3.13 mm (0.5-11.0 mm) or 13.19% (1.92-41.67%) of pretreatment proptosis ( p < 0.001). CONCLUSIONS Two-thirds of eyes had regression despite initial teprotumumab response, typically within 1 year of treatment, with ongoing worsening over time. Most patients maintained some proptosis reduction compared with before treatment despite regression, although 25% were worse than pretreatment. The occurrence of regression was independent of the pretreatment duration of clinical thyroid eye disease. Overall, compared with preteprotumumab, there was a greater amount of improvement than regression at most recent follow-up.
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Affiliation(s)
- Tatiana R Rosenblatt
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
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Taketani Y, Dehghani S, Sinha S, Freitag SK, Papaliodis G, Foster S, Dohlman TH, Dana R. Concurrence of Ocular Cicatricial Pemphigoid in Chronic Ocular Graft-Versus-Host Disease. Cornea 2024; 43:387-390. [PMID: 38128104 DOI: 10.1097/ico.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/04/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE The aim of this study was to report a series of 3 patients with ocular graft-versus-host disease (oGVHD) with progressive cicatricial conjunctival changes who were diagnosed with ocular cicatricial pemphigoid (OCP) after conjunctival biopsy. METHODS This study was a retrospective case series. RESULTS Three patients who received hematopoietic stem cell transplantation for hematologic malignancies developed oGVHD and subsequently were diagnosed with OCP. Case 1 was a 73-year-old woman with oGVHD who developed symblepharon and showed positive IgA, IgG, and C3 staining of the basement membrane zone (BMZ) on conjunctival biopsy, consistent with OCP. She was systemically treated with tacrolimus and prednisone with resolution of conjunctival inflammation. Case 2 was a 68-year-old man with oGVHD who developed symblepharon, severe dry eye, and corneal epithelial defect. An initial conjunctival biopsy was negative, but a repeat biopsy performed 10 years later showed positive BMZ IgA and IgG staining. Healing of the epithelial defect was achieved after treatment with high-dose systemic cyclosporine. Case 3 was a 75-year-old woman with oGVHD who had a nonhealing corneal epithelial defect and symblepharon with positive IgA BMZ staining on conjunctival biopsy, consistent with OCP. The patient responded well to methotrexate with healing of the epithelial defect. CONCLUSIONS Although low-grade conjunctival fibrotic changes may be observed in chronic oGVHD, development of severe and progressive cicatricial changes, including symblepharon formation, should prompt consideration of biopsy to rule out concurrent OCP, the management of which differs from that of oGVHD.
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Affiliation(s)
- Yukako Taketani
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Shima Dehghani
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Shruti Sinha
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - George Papaliodis
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Stephen Foster
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
- Massachusetts Eye Research and Surgery Institution, Waltham, MA
| | - Thomas H Dohlman
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - Reza Dana
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA; and
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Oke I, Elze T, Miller JW, Lorch AC, Hunter DG, Freitag SK, Dagi LR. The Incidence of Strabismus After Upper and Lower Blepharoplasty in the United States. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00345. [PMID: 38346431 DOI: 10.1097/iop.0000000000002617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE To compare the incidence of strabismus after upper and lower blepharoplasty in the United States. METHODS Retrospective cohort study of adults (age ≥18 years) in the IRIS Registry (Intelligent Research in Sight) who underwent blepharoplasty between January 1, 2013 and December 31, 2020. The primary outcome was the Kaplan-Meier estimated cumulative incidence of strabismus diagnosis and surgery within 3 years of blepharoplasty. Multivariable Cox regression was used to determine the association of blepharoplasty type with strabismus diagnosis and surgery, adjusting for patient age, sex, and geographic region. RESULTS Blepharoplasty was performed in 368,623 patients (median [interquartile range] age, 69 [63-75] years, and 69% female). Compared with those undergoing upper eyelid blepharoplasty, patients treated with lower eyelid blepharoplasty were slightly younger (median age, 66 vs. 69 years; p < 0.001) and more likely to be female (71% vs. 69%; p < 0.001). There was a greater 3-year incidence of strabismus diagnosis (2.0% vs. 1.5%; p < 0.001) and a greater 3-year incidence of strabismus surgery (0.15% vs. 0.06%; p = 0.003) for individuals undergoing lower vs. upper blepharoplasty. After adjusting for age, sex, and geographic region, lower blepharoplasty was associated with a higher 3-year risk of strabismus diagnosis (HR, 1.49; 95% CI, 1.23-1.81; p < 0.001) and surgery (HR, 2.53; 95% CI, 1.27-5.03; p = 0.008). CONCLUSIONS This registry-based analysis found that individuals undergoing lower eyelid blepharoplasty were at higher risk of strabismus compared with those undergoing upper eyelid blepharoplasty. Using large databases to understand the incidence of complications of frequently performed procedures may improve ophthalmologists' ability to provide data-driven counseling on surgical risks prior to intervention.
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Affiliation(s)
- Isdin Oke
- Department of Ophthalmology, Boston Children's Hospital
| | - Tobias Elze
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, U.S.A
| | - Joan W Miller
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, U.S.A
| | - Alice C Lorch
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, U.S.A
| | | | | | - Linda R Dagi
- Department of Ophthalmology, Boston Children's Hospital
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Azad AD, Chiou CA, Stagner AM, Freitag SK. Slate Grey Eyelid Pigmentation in a Patient With Hemochromatosis and Prior Hydroxychloroquine Use. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00337. [PMID: 38319174 DOI: 10.1097/iop.0000000000002609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Affiliation(s)
- Amee D Azad
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Carolina A Chiou
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Anna M Stagner
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
- Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
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Neerukonda VK, Freitag SK, Wolkow N. Histopathologic alterations in the eyelid after Hughes tarsoconjunctival flap: loss of Meibomian glands with preservation of accessory lacrimal glands. Orbit 2024; 43:115-118. [PMID: 35619561 DOI: 10.1080/01676830.2022.2080232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
A 71-year-old female with invasive squamous cell carcinoma of the lower eyelid involving the ocular surface underwent surgical excision with negative margins and a subsequent reconstruction. The posterior lamellar defect was reconstructed with a Hughes tarsoconjunctival flap, and the anterior lamellar defect was reconstructed by advancing the lower eyelid skin. Three years later, the patient presented with signs suspicious for recurrence involving the tarsoconjunctival graft: a nodule along the mucocutaneus junction, symblepharon, and forniceal shortening. Repeat scouting biopsies showed variable degrees of moderate to severe squamous dysplasia so the patient underwent a staged full thickness excision of the lower eyelid and involved conjunctiva followed by reconstruction. Direct immunofluorescence was not diagnostic for ocular cicatrcial pemphigoid. Permanent histopathologic sections did not show any carcinoma, but the full thickness excisions involving the prior Hughes tarsoconjunctival flap highlighted two notable alterations: the Meibomian glands were absent and the accessory lacrimal glands of Wolfring were transposed to the mucocutaneous junction of the reconstructed lower eyelid.
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Affiliation(s)
- Vamsee K Neerukonda
- Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology Massachusetts Eye and Ear, Harvard Medical SchoolDavid G. , Boston, Massachusetts, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalie Wolkow
- Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology Massachusetts Eye and Ear, Harvard Medical SchoolDavid G. , Boston, Massachusetts, USA
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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10
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Tao JP, Shen JF, Aakalu VK, Foster JA, Freitag SK, McCulley TJ, Vagefi MR, Kim SJ, Wladis EJ. Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology. Ophthalmology 2023; 130:1336-1341. [PMID: 37642619 DOI: 10.1016/j.ophtha.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE To review the literature to determine the efficacy and safety of thermal pulsation technologies in improving signs or symptoms of meibomian gland dysfunction (MGD) and dry eye compared with no therapy or with conventional warm compress therapy or eyelid hygiene. METHODS A literature search was conducted in the PubMed database in June 2022 and again in March 2023 to identify all studies in the English language on the use of thermal pulsation to treat MGD or dry eye. The search yielded 59 citations, and 11 articles met all of the inclusion criteria. The panel methodologist then assigned a level of evidence rating for each study; 8 studies were rated level I evidence and 3 studies were rated level II evidence. RESULTS All included studies evaluated a single 12-minute session using the LipiFlow automated thermal pulsation system (TearScience, Inc, or Johnson & Johnson). Improvements were detected in subjective and objective metrics of MGD or dry eye in patients within 1 to 12 months of thermal pulsation treatment compared with nontreatment. Most of the studies (9/11) reported greater efficacy with thermal pulsation than with standard warm compress therapy and eyelid hygiene. Four of these studies showed relevant industry conflicts of interest. Two of the 4 level I studies without direct industry participation concluded that thermal pulsation treatment was not significantly different from conventional hygiene or warm compress therapy control treatments (in symptoms in one of the studies and in objective findings in the second study). No serious adverse events were reported in any of the 11 studies. CONCLUSIONS According to the current literature, a single thermal pulsation session may improve subjective or objective parameters of MGD and dry eye safely. However, industry support and participation were present in 4 of the 8 level I studies. The durability beyond several months and cost efficacy remain uncertain. Because the inclusion parameters of this assessment captured only the LipiFlow system, the conclusions are limited to that product. High-quality independent studies are needed to assess the long-term benefits of this intervention. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | | | - Vinay K Aakalu
- Department of Ophthalmology and Visual Sciences University of Michigan, Ann Arbor, Michigan
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Timothy J McCulley
- Department of Ophthalmology, John P. McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - M Reza Vagefi
- Tufts University School of Medicine, Boston, Massachusetts
| | - Stephen J Kim
- Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
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Freitag SK, Aakalu VK, Foster JA, McCulley TJ, Tao JP, Vagefi MR, Yen MT, Kim SJ, Wladis EJ. Use of Mitomycin C in Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology. Ophthalmology 2023; 130:1212-1220. [PMID: 37656088 DOI: 10.1016/j.ophtha.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/02/2023] Open
Abstract
PURPOSE To review the literature on the adjuvant use of mitomycin C (MMC) during dacryocystorhinostomy (DCR) in adults with primary nasolacrimal duct obstructions (NLDOs) to determine the efficacy in improving functional and anatomic outcomes with an acceptable level of risk. METHODS A literature search conducted in November 2020 and updated in November 2022 yielded 137 articles. Twenty-four articles met the inclusion criteria and were rated for level of evidence by the panel methodologist. Inclusion criteria required controlled studies on the effect of MMC on outcomes of external, endoscopic endonasal, or diode laser-assisted transcanalicular DCR in adults with primary acquired nasolacrimal obstruction with 6 months minimum follow-up and at least 10 participants. RESULTS Six of the 24 articles were rated level I evidence, 15 level II , and 3 level III. In primary external DCR, MMC significantly improved functional outcomes in 3 of 9 series. In primary endoscopic endonasal DCR, MMC significantly improved functional outcomes in 1 of 9 series. In revision endoscopic endonasal DCR, MMC significantly improved functional success in 1 of 3 series. The use of MMC did not improve outcomes statistically in any diode laser-assisted transcanalicular DCR studies. Concentrations of MMC ranged from 0.05 to 1 mg/ml, with 0.2 mg/ml used most frequently in 12 series, with duration of application ranging from 2 to 30 minutes. Ostium size was significantly larger in MMC groups than in control groups at 6 months after surgery in 4 of 5 reporting studies. However, these larger ostia did not confer higher functional success rates. Reporting of adverse events related to MMC were rare, with delayed cutaneous wound healing reported in 1 of 750 patients. CONCLUSIONS Intraoperative use of MMC in external and endoscopic endonasal DCR has been shown to improve functional and anatomic outcomes compared with controls in some series, but there is no agreement on the recommended concentration or application time for MMC in DCR. The data support that MMC use can result in a larger ostium size, decreased granulation tissue formation, and a decreased number of postoperative nasal debridements compared with controls, but this does not translate into improved functional success. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Suzanne K Freitag
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Vinay K Aakalu
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Timothy J McCulley
- Department of Ophthalmology, John P. McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - M Reza Vagefi
- Tufts University School of Medicine, Boston, Massachusetts
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
| | - Stephen J Kim
- Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
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12
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Jafari A, Adappa ND, Anagnos VJ, Campbell RG, Castelnuovo P, Chalian A, Chambers CB, Chitguppi C, Dallan I, El Rassi E, Freitag SK, Fernandez Miranda JC, Ferreira M, Gardner PA, Gudis DA, Harvey RJ, Huang Q, Humphreys IM, Kennedy DW, Lee JYK, Lehmann AE, Locatelli D, McKinney KA, Moreau A, Nyquist G, Palmer JN, Prepageran N, Pribitkin EA, Rabinowitz MR, Rosen MR, Sacks R, Sharma D, Snyderman CH, Tonya Stefko S, Stokken JK, Wang EW, Workman AD, Wu AW, Yu JY, Zhang MM, Zhou B, Bleier BS. Orbital resection by intranasal technique (ORBIT): A new classification system for reporting endoscopically resectable primary benign orbital tumors. Int Forum Allergy Rhinol 2023; 13:1852-1863. [PMID: 36808854 DOI: 10.1002/alr.23141] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 02/05/2023] [Accepted: 02/07/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs. METHODS Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi-squared or Fisher's exact tests. The Cochrane-Armitage test for trend was used to analyze outcomes by class. RESULTS Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p < 0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate postoperative cranial nerve palsy (p < 0.05). CONCLUSION Endoscopic treatment of PBOTs is an effective approach, with favorable short-term and long-term postoperative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic-based framework that effectively facilitates high-quality outcomes reporting for all PBOTs.
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Affiliation(s)
- Aria Jafari
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vincent J Anagnos
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raewyn G Campbell
- Faculty of Medicine and Health Science, Macquarie University, Sydney, New South Wales, Australia
- Department of Otorhinolaryngology, Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Ara Chalian
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Chandala Chitguppi
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Iacopo Dallan
- Ear, Nose, Throat (ENT) Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Edward El Rassi
- Department of Otolaryngology-Head & Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Manuel Ferreira
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David A Gudis
- Department of Otolaryngology-Head & Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Richard J Harvey
- Faculty of Medicine and Health Science, Macquarie University, Sydney, New South Wales, Australia
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Qian Huang
- Department of Otolaryngology-Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology-Head & Neck Surgery, Ministry of Education, Beijing, China
| | - Ian M Humphreys
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - David W Kennedy
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashton E Lehmann
- Department of Otolaryngology-Head & Neck Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, Ospedale Di Circolo E Fondazione Macchi, University of Insubria, Varese, Italy
| | - Kibwei A McKinney
- Department of Otolaryngology-Head & Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Annie Moreau
- Department of Ophthalmology, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Gurston Nyquist
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Narayanan Prepageran
- Department of Otorhinolaryngology, Faculty of Medicine, Universiti Malaya, Jalan Universiti, Wilayah Persekutuan, Kuala Lumpur, Malaysia
| | - Edmund A Pribitkin
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - Mindy R Rabinowitz
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - Marc R Rosen
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - Raymond Sacks
- Faculty of Medicine and Health Science, Macquarie University, Sydney, New South Wales, Australia
- Department of Otolaryngology-Head & Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
| | - Dhruv Sharma
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - S Tonya Stefko
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Janalee K Stokken
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alan D Workman
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Arthur W Wu
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jen Y Yu
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew M Zhang
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | - Bing Zhou
- Department of Otolaryngology-Head & Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology-Head & Neck Surgery, Ministry of Education, Beijing, China
| | - Benjamin S Bleier
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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Reshef ER, Marsiglia M, Bouhadjer K, Chiou CA, O'Brien-Coon D, Reinshagen KL, Freitag SK. Reduction in Extraocular Muscle Cross-sectional Area and Correlation With Extraocular Motility and Diplopia Following Teprotumumab for Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2023; 39:433-439. [PMID: 36852831 DOI: 10.1097/iop.0000000000002337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
PURPOSE To quantify changes in extraocular muscle (EOM) cross-sectional areas (CSA) on orbital imaging in patients with thyroid eye disease before and after teprotumumab treatment, and assess for correlation with clinical outcomes. METHODS This retrospective study included thyroid eye disease patients treated with teprotumumab who had pre- and post-treatment CT imaging. Reformatted oblique coronal images were created for each orbit in a plane perpendicular to the optic nerve. EOM CSA measurements were performed by 2 radiographic reviewers and averaged. Primary outcomes included change in ratio of total EOM to orbit CSA, and of each individual muscle group to orbit CSA, before and after treatment. Secondary outcomes included subanalysis based on age (≥40, <40 years) and Clinical Activity Score (CAS) (≥4, <4), and comparison with clinical outcomes including CAS, Hertel exophthalmometry, Gorman diplopia score, and extraocular motility. RESULTS Forty-eight orbits of 24 patients (16 female, mean age 57.9 years) were included. There was a significant reduction in the total EOM to orbit CSA ratio ( p < 0.01) and for each individual rectus muscle to orbit CSA ratio ( p < 0.01 for all groups). Total EOM to orbit CSA ratios were reduced for 21 patients (87.5%); this was statistically significant in 13 patients (54.2%). There was significant improvement in CAS, proptosis, diplopia, and EOM motility ( p < 0.01 for all categories). There was a significant correlation between reduction of EOM CSA, and reduction of diplopia ( p < 0.01) and EOM motility ( p < 0.01). CONCLUSIONS EOM CSA is significantly reduced following treatment with teprotumumab, and correlates with clinical findings including improvement in extraocular motility and diplopia.
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Affiliation(s)
- Edith R Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Marcela Marsiglia
- Department of Radiology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Karim Bouhadjer
- Department of Radiology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Carolina A Chiou
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Devin O'Brien-Coon
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | | | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
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14
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Reshef ER, Marsiglia M, Bouhadjer K, Chiou CA, O'Brien-Coon D, Reinshagen KL, Freitag SK. Reply Re: "Reduction in Extraocular Muscle Cross-sectional Area and Correlation With Extraocular Motility and Diplopia Following Teprotumumab for Thyroid Eye Disease". Ophthalmic Plast Reconstr Surg 2023; 39:397. [PMID: 37413682 DOI: 10.1097/iop.0000000000002455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
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15
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Lin LY, Stagner AM, Freitag SK. Minocycline-induced Conjunctival Hyperpigmentation. Ophthalmic Plast Reconstr Surg 2023; 39:e133. [PMID: 36700850 DOI: 10.1097/iop.0000000000002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Lisa Y Lin
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School
| | - Anna M Stagner
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School
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16
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Chiou CA, Vickery TW, Reshef ER, Bleier BS, Freitag SK. Endonasal Endoscopic Approach to Orbital Tumors. Int Ophthalmol Clin 2023; 63:249-262. [PMID: 37439622 DOI: 10.1097/iio.0000000000000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
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17
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Oke I, Reshef ER, Elze T, Miller JW, Lorch AC, Hunter DG, Freitag SK. Smoking Is Associated With a Higher Risk of Surgical Intervention for Thyroid Eye Disease in the IRIS Registry. Am J Ophthalmol 2023; 249:174-182. [PMID: 36690290 PMCID: PMC10767645 DOI: 10.1016/j.ajo.2023.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To describe the association of smoking status with surgical intervention for thyroid eye disease (TED) at the population-level. DESIGN Retrospective cohort study. METHODS This study included all adults (aged ≥18 years) with Graves disease in the Intelligent Research in Sight (IRIS) Registry (January 1, 2013, to December 31, 2020). The primary outcome was surgical intervention for TED, stratified into orbital decompression, strabismus surgery, and eyelid recession surgery. The Kaplan-Meier estimated 5-year cumulative probability for each surgical intervention was calculated. Multivariable Cox regression was used to evaluate the association between smoking status and each surgical intervention, adjusting for age, sex, race, ethnicity, and geographic region. RESULTS This study included 87,774 patients. Median age was 59 years (IQR, 48-68 years); 81% were female patients. Current smokers had a greater 5-year cumulative probability of orbital decompression (3.7% vs 1.9%; P < .001), strabismus surgery (4.6% vs 2.2%; P < .001), and eyelid recession (4.1% vs 2.6%; P < .001) compared to never smokers. After adjusting for demographic factors, current smokers were at greater risk for orbital decompression (hazard ratio [HR], 2.1; 95% CI, 1.8-2.4; P < .001), strabismus surgery (HR, 2.0; 95% CI, 1.8-2.3; P < .001), and eyelid recession (HR, 1.7; 95% CI, 1.5-1.9; P < .001) than never smokers. Former smokers were at higher risk for each type of surgery for TED, albeit at lower levels than current smokers. CONCLUSIONS Smoking was associated with increased risk of surgical intervention for TED in the IRIS Registry. Former smokers were at a lower risk than current smokers, supporting the role of smoking cessation on lowering the burden of surgical disease at the population-level.
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Affiliation(s)
- Isdin Oke
- From the Department of Ophthalmology (I.O., E.R.R., D.G.H., S.K.F.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Ophthalmology (I.O., E.R.R., T.E., J.W.M., A.C.L., D.G.H., S.K.F.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.
| | - Edith R Reshef
- From the Department of Ophthalmology (I.O., E.R.R., D.G.H., S.K.F.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Ophthalmology (I.O., E.R.R., T.E., J.W.M., A.C.L., D.G.H., S.K.F.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Tobias Elze
- Department of Ophthalmology (I.O., E.R.R., T.E., J.W.M., A.C.L., D.G.H., S.K.F.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Joan W Miller
- Department of Ophthalmology (I.O., E.R.R., T.E., J.W.M., A.C.L., D.G.H., S.K.F.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Alice C Lorch
- Department of Ophthalmology (I.O., E.R.R., T.E., J.W.M., A.C.L., D.G.H., S.K.F.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - David G Hunter
- From the Department of Ophthalmology (I.O., E.R.R., D.G.H., S.K.F.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne K Freitag
- From the Department of Ophthalmology (I.O., E.R.R., D.G.H., S.K.F.), Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Ophthalmology (I.O., E.R.R., T.E., J.W.M., A.C.L., D.G.H., S.K.F.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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18
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Ho TC, Maamari RN, Kossler AL, Sears CM, Freitag SK, Reshef ER, Shinder R, Rootman DB, Diniz SB, Kahana A, Schlachter D, Do TH, Kally P, Turner S, Mokhtarzadeh A, Harrison AR, Hwang CJ, Kim HJ, Avila SA, Thomas DA, Magazin M, Wester ST, Lee WW, Clauss KD, Holds JB, Sniegowski M, Compton CJ, Briggs C, Malik AI, Lucarelli MJ, Burkat CN, Patel LG, Couch SM. Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab. Ophthalmic Plast Reconstr Surg 2023; 39:150-155. [PMID: 36095848 PMCID: PMC10771969 DOI: 10.1097/iop.0000000000002267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen. METHODS This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events. RESULTS The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption. CONCLUSIONS Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.
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Affiliation(s)
- Tiffany C Ho
- John F. Hardesty, MD, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Robi N Maamari
- John F. Hardesty, MD, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Palo Alto, California, U.S.A
| | - Connie M Sears
- Department of Ophthalmology, Byers Eye Institute, Palo Alto, California, U.S.A
| | - Suzanne K Freitag
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Edith R Reshef
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, New York, U.S.A
| | - Daniel B Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, University of California, Los Angeles, California, U.S.A
| | - Stefania B Diniz
- Division of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, University of California, Los Angeles, California, U.S.A
| | - Alon Kahana
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan, U.S.A
- Kahana Oculoplastic & Orbital Surgery, Rochester, Michigan, U.S.A
| | - Dianne Schlachter
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan, U.S.A
| | - Thai H Do
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan, U.S.A
| | - Peter Kally
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, Rochester, Michigan, U.S.A
| | - Sara Turner
- Kahana Oculoplastic & Orbital Surgery, Rochester, Michigan, U.S.A
| | - Ali Mokhtarzadeh
- Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Andrew R Harrison
- Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Christopher J Hwang
- Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Hee Joon Kim
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Sarah A Avila
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Dilip A Thomas
- Department of Ophthalmology, Georgia Regents University, Augusta, Georgia, U.S.A
| | - Maja Magazin
- Department of Ophthalmology, Georgia Regents University, Augusta, Georgia, U.S.A
| | - Sara T Wester
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - Wendy W Lee
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - Kevin D Clauss
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - John B Holds
- Ophthalmic Plastic and Cosmetic Surgery Inc., Des Peres, Missouri, U.S.A
- Departments of Ophthalmology and Otolaryngology-Head and Neck Surgery, Saint Louis University, St. Louis, Missouri, U.S.A
| | - Matthew Sniegowski
- Department of Ophthalmology, University of Missouri Kansas City, Kansas City, Missouri, U.S.A
| | - Christopher J Compton
- Department of Ophthalmology and Visual Sciences, University of Louisville, Louisville, Kentucky, U.S.A
| | - Christian Briggs
- Department of Ophthalmology and Visual Sciences, University of Louisville, Louisville, Kentucky, U.S.A
| | - Amina I Malik
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Mark J Lucarelli
- Oculoplastic, Facial Cosmetic & Orbital Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Cat N Burkat
- Oculoplastic, Facial Cosmetic & Orbital Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Luv G Patel
- Retina Center of Texas, Dallas, Texas, U.S.A
| | - Steven M Couch
- John F. Hardesty, MD, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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Lin LY, Armstrong GW, Gardiner M, Lorch A, Freitag SK, Yadav P. Dedicated Chalazion Clinic as a Tool for Early Surgical Education in Ophthalmology Residency. J Acad Ophthalmol (2017) 2023; 15:e36-e40. [PMID: 38737156 PMCID: PMC10804763 DOI: 10.1055/s-0043-1761275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/14/2022] [Indexed: 01/30/2023]
Abstract
Objective Ophthalmology residency programs aim to improve resident surgical teaching through increased surgical exposure over a 4-year period. Resident-centric surgical clinics across various surgical specialties have been established to help develop surgical autonomy and experience. We present the first demonstration of a resident-centric chalazion incision and drainage clinic (chalazion clinic) in an ophthalmology residency with the goal of increasing early surgical exposure to residents. Design The chalazion clinic was founded in July 2019. It is a once weekly procedure clinic conducted by an ophthalmology resident and supervised by an ophthalmology attending. Patients with chalazia were referred directly to this clinic for evaluation and management, rather than the oculoplastics clinic as they were in the past. Retrospective review of Accreditation Council for Graduate Medical Education (ACGME) case logs of all residents per academic year before and after establishment of the chalazion clinic was performed in order to assess the impact on residents' chalazion procedures numbers per academic year. Setting The study involved a single academic ophthalmology department. Participants Ophthalmology residents of all years were present. Results A resident of any year performed an average of 3.0 chalazion procedures per year in the 2018 to 2019 academic year, 3.8 in 2019 to 2020, and 8.4 in the 2020 to 2021, which represents a 180% increase in procedure numbers per resident. Among post-graduate-year 2s (PGY)2s, the average number of chalazion procedures increased from 2.1 procedure per year to 22.3 per year (961.9% increase). Conclusion To the best of our knowledge, this is the first description of a dedicated resident-centric chalazion clinic in an ophthalmology residency program. PGY2s demonstrated the largest increase in procedural numbers. While chalazion incision and drainage is a minor procedure, increased exposure to surgical procedures early in training could help improve residents' skills and confidence. This clinic provides a proof of concept of a dedicated minor procedure clinic for ophthalmology residents to increase early procedural volume.
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Affiliation(s)
- Lisa Y. Lin
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Grayson W. Armstrong
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Matthew Gardiner
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Alice Lorch
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Suzanne K. Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Prashant Yadav
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
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Guzman Aparicio MA, Liebman DL, Chodosh J, Freitag SK, Kazlas M, Mai DD, Marando CM, Mukai S, Wu AM, Chen TC. Two pediatric cases of reticular corneal epithelial edema associated with netarsudil. Am J Ophthalmol Case Rep 2022; 27:101638. [PMID: 35813588 PMCID: PMC9259473 DOI: 10.1016/j.ajoc.2022.101638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To report two pediatric cases of reticular corneal epithelial edema associated with the use of netarsudil ophthalmic solution 0.02%. Observations In Case 1, a six-year-old male with glaucoma following cataract surgery was treated with netarsudil for thirteen months and developed diffuse reticular corneal epithelial edema on post-operative day one after undergoing transscleral diode cyclophotocoagulation for persistently elevated intraocular pressures. In Case 2, a three-month-old male with bilateral ocular hypertension developed unilateral inferior reticular corneal epithelial edema five weeks after initiation of netarsudil, which had been discontinued in the fellow eye two weeks prior. In both cases, the reticular epithelial edema resolved following cessation of netarsudil. Conclusions and Importance Netarsudil-associated reticular corneal epithelial edema can occur in infants and young children.
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Affiliation(s)
- Maria A. Guzman Aparicio
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Glaucoma Service, Boston, MA, USA
| | - Daniel L. Liebman
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
| | - James Chodosh
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Cornea Service, Boston, MA, USA
| | - Suzanne K. Freitag
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Ophthalmic Plastic Surgery Service, Boston, MA, USA
| | - Melanie Kazlas
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Pediatric Ophthalmology Service, Boston, MA, USA
| | - Derek D. Mai
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Glaucoma Service, Boston, MA, USA
| | - Catherine M. Marando
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Glaucoma Service, Boston, MA, USA
| | - Shizuo Mukai
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Retina Service, Boston, MA, USA
| | - Annie M. Wu
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Glaucoma Service, Boston, MA, USA
| | - Teresa C. Chen
- Harvard Medical School, Department of Ophthalmology, Boston, MA, USA
- Massachusetts Eye and Ear, Glaucoma Service, Boston, MA, USA
- Corresponding author. Massachusetts Eye and Ear Infirmary, Glaucoma Service, 243 Charles Street, Boston, MA, 02114, USA.
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21
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Abstract
BACKGROUND AND AIMS This review aims to summarize current and emerging therapies for treatment of thyroid eye disease (TED), in the light of novel understanding of pathogenetic mechanisms, leading to new treatment options and clinical trials. METHODS We reviewed and analyzed peer-reviewed literature reporting recent translational studies and clinical trials in the treatment of TED. Searches were made at www.pubmed.gov with keywords "thyroid eye disease," "Graves' ophthalmopathy," "thyroid orbitopathy," and "Graves' orbitopathy." RESULTS Surgery is reserved for rehabilitation in chronic TED or for emergent compressive optic neuropathy. Oral and intravenous glucocorticoid therapy has been used for decades with variable efficacy in acute TED, but results may be temporary and side effects significant. Nonsteroidal oral immunosuppressive agents offer modest benefit in TED. Several immunomodulatory monoclonal antibodies, including rituximab and tocilizumab, have shown efficacy for inactivating TED. Recently, teprotumumab, an insulin-like growth factor 1 receptor (IGF-1R) inhibitor, has demonstrated significant improvement in proptosis, clinical activity score, diplopia, and quality of life in patients with active TED, with good tolerability. Newly proposed TED therapies, currently in preclinical and clinical trial phases, include thyroid-stimulating hormone (TSH) receptor inhibitory drugs, RVT-1401, local anti-vascular endothelial growth factor therapy, IGF-1R drugs delivered subcutaneously and orally, and desensitization to the TSH receptor with modified TSH receptor peptides. CONCLUSION New, albeit incomplete, understanding of the molecular mechanisms of TED has led to new promising therapies and offered improved outcomes in TED patients. Their full role and their relationship to classical immune suppression should be clarified over the next few years.
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Affiliation(s)
- Giuseppe Barbesino
- Correspondence: Giuseppe Barbesino, MD, Thyroid Unit, Massachusetts General Hospital, Harvard Medical School, WACC730S, 15 Parkman St, Boston, MA 02114, USA.
| | - Mario Salvi
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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22
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Dave TV, Nair AG, Joseph J, Freitag SK. Immunopathology of COVID-19 and its implications in the development of rhino-orbital-cerebral mucormycosis: a major review. Orbit 2022; 41:670-679. [PMID: 35856238 DOI: 10.1080/01676830.2022.2099428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To present a literature review on various immunopathologic dysfunctions following COVID-19 infection and their potential implications in development of rhino-orbital-cerebral mucormycosis (ROCM). METHODS A literature search was performed via Google Scholar and PubMed with subsequent review of the accompanying references. Analogies were drawn between the immune and physiologic deviations caused by COVID-19 and the tendency of the same to predispose to ROCM. RESULTS Sixty-two articles were reviewed. SARS-CoV-2 virus infection leads to disruption of epithelial integrity in the respiratory passages, which may be a potential entry point for the ubiquitous Mucorales to become invasive. COVID-19 related GRP78 protein upregulation may aid in spore germination and hyphal invasion by Mucorales. COVID-19 causes interference in macrophage functioning by direct infection, a tendency for hyperglycemia, and creation of neutrophil extracellular traps. This affects innate immunity against Mucorales. Thrombocytopenia and reduction in the number of natural killer (NK) cells and infected dendritic cells is seen in COVID-19. This reduces the host immune response to pathogenic invasion by Mucorales. Cytokines released in COVID-19 cause mitochondrial dysfunction and accumulation of reactive oxygen species, which cause oxidative damage to the leucocytes. Hyperferritinemia also occurs in COVID-19 resulting in suppression of the hematopoietic proliferation of B- and T-lymphocytes. CONCLUSIONS COVID-19 has a role in the occurrence of ROCM due to its effects at the entry point of the fungus in the respiratory mucosa, effects of the innate immune system, creation of an environment of iron overload, propagation of hyperglycemia, and effects on the adaptive immune system.
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Affiliation(s)
- Tarjani Vivek Dave
- Ophthalmic Plastic Surgery Service, LV Prasad Eye Institute, Hyderabad, India
| | - Akshay Gopinathan Nair
- Aditya Jyot Eye Hospital, Mumbai, India.,Advanced Eye hospital and Institute, Navi Mumbai, India
| | - Joveeta Joseph
- Jhaveri Microbiology Centre, Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, India
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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Habib LA, North VS, Freitag SK, Yoon MK, Lefebvre DR, Grace Lee N. Medical comorbidities and orbital implant exposure. Acta Ophthalmol 2022; 100:e813-e819. [PMID: 34233090 DOI: 10.1111/aos.14973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate medical conditions and systemic therapies associated with orbital implant exposure in patients with anophthalmic sockets. METHODS Retrospective review of patients who underwent enucleation or evisceration at a single centre between January 1, 2008 and March 1, 2018. Medical comorbidities, including peripheral or coronary artery disease, rheumatologic conditions, diabetes, malignancy and history of smoking were recorded. Use of immunomodulatory and anticoagulation therapy at the time of eye removal was noted. Patients were divided into two groups-those with implant exposure and those without. Univariate and multivariate analysis was used to compare groups. RESULTS Two hundred and twenty-nine patients underwent eye removal surgery over a ten-year period. Implant exposure was seen in 20 (8.7%) patients. Univariate analysis revealed a statistically significant difference between groups in rates of smoking, malignancy, and immunomodulatory therapy at the time of surgery. A history of smoking (HR = 11.72; 95% CI: 2.95, 46.53; p = 0.0001) and immunomodulatory therapy (HR = 8.02; 95% CI: 1.96, 32.87; p = 0.004) were independent predictors of exposure. The probability of exposure was 81.2% when all three risk factors were present versus 4.4% when none were present (c-index = 0.737, 95% CI: 0.608, 0.865; p < 0.001). The model was a good fit to the data (Hosmer-Lemeshow goodness-of-fit test p = 0.475). CONCLUSIONS Smoking and immunomodulatory therapy were associated with orbital implant exposure in patients with anophthalmic sockets. This is the first report examining medical comorbidities in patients with orbital implant exposure. Understanding the pathophysiology of implant exposure is crucial to preoperative planning and postoperative care.
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Affiliation(s)
- Larissa A. Habib
- Oculoplastic and Reconstructive Surgery Division Department of Ophthalmology Yale Medical School New Haven CT USA
| | - Victoria S. North
- Oculoplastic and Orbital Surgery Edward S. Harkness Eye Institute Columbia University Irving Medical Center New York‐Presbyterian Hospital New York NY USA
| | - Suzanne K. Freitag
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
| | - Michael K. Yoon
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
| | - Daniel R. Lefebvre
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
| | - Nahyoung Grace Lee
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
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Abstract
Three patients presented with periorbital swelling, pain with extraocular movements, and binocular diplopia 1-4 days after receiving an mRNA Coronavirus Infectious Disease-19 (COVID-19) vaccine (BNT162b2, Pfizer/BioNTech; mRNA-1273, Moderna). All patients had a normal afferent function, unilateral limitation of extraocular motility, proptosis, and periorbital inflammation. Neuroimaging of the orbits with contrast revealed inflammation and enlargement of extraocular muscles in 2 cases and the lacrimal gland in 1 case. In all 3 cases, an extensive infectious and inflammatory laboratory work-up was unremarkable and signs and symptoms of orbital inflammation rapidly improved to complete resolution after treatment with high-dose oral prednisone. This is the first reported series of orbital inflammation occurring shortly after administration of the COVID-19 vaccine. Clinicians may consider an inflammatory postvaccine etiology as an alternative to presumed idiopathic diagnosis in such cases.
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Affiliation(s)
- Edith R. Reshef
- Department of Ophthalmology, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Suzanne K. Freitag
- Department of Ophthalmology, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Nahyoung Grace Lee
- Department of Ophthalmology, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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25
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Sobel RK, Aakalu VK, Vagefi MR, Foster JA, Tao JP, Freitag SK, Wladis EJ, McCulley TJ, Yen MT. Orbital Radiation for Thyroid Eye Disease: A Report by the American Academy of Ophthalmology. Ophthalmology 2021; 129:450-455. [PMID: 34895729 DOI: 10.1016/j.ophtha.2021.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To review the current literature on the safety and efficacy of orbital radiation for the management of thyroid eye disease (TED). METHODS A literature search was conducted last in February 2021 of the PubMed database to identify all articles published in the English language on original research that assessed the effect of orbital radiation on TED. The search identified 55 articles, and 18 met the inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study, and all of them were rated level III. RESULTS Two large retrospective studies demonstrated the efficacy of radiation treatment, with or without corticosteroid use, in preventing or treating compressive optic neuropathy (CON). Three studies highlighted the role of orbital radiation therapy (RT) to facilitate the tapering of corticosteroids. Several other studies showed a possible role for RT to improve diplopia and soft tissue signs. CONCLUSIONS Although no level I or level II evidence exists, the best available evidence suggests that orbital radiation, used with or without corticosteroids, is efficacious in preventing CON, improving motility restriction, and decreasing clinical activity in TED. Orbital radiation also may facilitate a corticosteroid taper. Together, these studies show that RT seems to modify the active phase of TED. Short-term risks of orbital radiation are minor, but long-term outcome data are lacking.
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Affiliation(s)
- Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - M Reza Vagefi
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Timothy J McCulley
- Ruiz Department of Ophthalmology and Visual Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
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26
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Pennington JD, Bleier BS, Freitag SK. Endoscopic endonasal resection of orbital schwannoma assisted with small-incision medial orbitotomy: case series and surgical technique. Orbit 2021; 40:536-542. [PMID: 33045896 DOI: 10.1080/01676830.2020.1832123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE To describe a surgical approach for the resection of schwannomas occurring in the medial aspect of the orbit and to review a series of patients who underwent this novel technique. METHODS This retrospective, non-comparative case series presents the surgical technique and outcomes of patients who underwent removal of a medial orbital schwannoma via an endoscopic endonasal approach combined with a small-incision medial orbitotomy by a team of two surgeons (BSB and SKF). Patient demographics, pre- and post-operative clinical examination findings, visual field testing, and radiographic studies were reviewed. Operative reports were reviewed for technical details and complications. RESULTS The patients included a 12 year-old male, 73 year-old female and 8 year-old male. Indications for surgery included: decreased visual acuity, diplopia, proptosis and Humphrey visual field (HVF) deficit, in the presence of a medial orbital biopsy-proven schwannoma. The surgical approach in all three patients was primarily endoscopic endonasal. Additionally, two had transcaruncular orbitotomies and one had a small-incision medial lid crease orbitotomy to assist with lateral tumor dissection. Tumor resection was complete in one case and near-total in two cases. There were no intra-operative surgical complications. Average resected specimen volume was 3.41 cm3 ± 2.20. All patients had post-operative improvement in visual acuity (VA) and proptosis. Post-operative follow-up intervals were 27.5 months, 12.3 months and 3.5 months, respectively. CONCLUSION Resection of orbital schwannomas using an endoscopic endonasal approach with small-incision medial transorbital assistance is a safe and effective option for a multidisciplinary surgical team.
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Affiliation(s)
- Justin D Pennington
- Department of Ophthalmology, Rhode Island Hospital, the Warren Alpert School of Medicine, Brown University, Providence, USA
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
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Tao JP, Aakalu VK, Freitag SK, Sobel RK, Foster JA, Wladis EJ, McCulley TJ, Yen MT. Homeopathic Agents or Vitamins in Reducing Ecchymosis after Oculofacial Surgery: A Report by the American Academy of Ophthalmology. Ophthalmology 2021; 129:220-226. [PMID: 34176651 DOI: 10.1016/j.ophtha.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To review the published literature to determine the efficacy and safety of homeopathic agents or vitamins in reducing ecchymosis after oculofacial surgery or laser surgery. METHODS A literature search was conducted in the PubMed database initially in December 2019 and updated in March 2020 to identify all studies in the English language literature on the use of homeopathic agents or vitamins in oculofacial procedures, including laser surgery. The search yielded 124 citations, and 11 articles met all inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study. Eleven studies met inclusion criteria; 9 were rated level I, and 2 were rated level III. RESULTS The agents studied in the articles identified included oral or topical Arnica montana (AM), oral Melilotus extract, topical vitamin K oxide, and topical AM combined with Rhododendron tomentosum. Metrics to describe ecchymosis varied. In 7 controlled studies, perioperative AM provided no or negligible benefit versus placebo. In 2 studies, vitamin K cream was equivalent to placebo. One study of oral Melilotus extract had less ecchymosis compared with controls in paranasal and eyelid ecchymosis at postoperative day (POD) 7, but not at PODs 1 and 4. A lone cohort study of combined topical AM and R. tomentosum lacked objective metrics and adequate controls. No serious side effects from administration of homeopathic agents or vitamins were identified. CONCLUSIONS The current literature does not support the use of AM, vitamin K oxide, R. tomentosum, or Melilotus extract for reducing ecchymosis after oculofacial surgery or pulsed dye laser surgery.
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Affiliation(s)
- Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Suzanne K Freitag
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Timothy J McCulley
- Department of Ophthalmology, McGovern Medical School at University of Texas Health Science Center, Houston, Texas
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
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28
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Chiou C, Wolkow N, Freitag SK. Eyelid Keratoacanthoma in an 86-Year-Old Man: Clinical and Histopathologic Features. Ophthalmic Plast Reconstr Surg 2021; 37:S166. [PMID: 32732539 DOI: 10.1097/iop.0000000000001721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Carolina Chiou
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology and
| | - Natalie Wolkow
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology and
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
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Yoon MK, Kelly HR, Freitag SK, Marneros AG, Barshak MB, Brackett DG. Case 12-2021: A 78-Year-Old Man with a Rash on the Scalp and Face. N Engl J Med 2021; 384:1553-1562. [PMID: 33882209 DOI: 10.1056/nejmcpc2100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael K Yoon
- From the Departments of Ophthalmology (M.K.Y., S.K.F.) and Radiology (H.R.K.), Massachusetts Eye and Ear, the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Massachusetts General Hospital, and the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Harvard Medical School - all in Boston
| | - Hillary R Kelly
- From the Departments of Ophthalmology (M.K.Y., S.K.F.) and Radiology (H.R.K.), Massachusetts Eye and Ear, the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Massachusetts General Hospital, and the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Harvard Medical School - all in Boston
| | - Suzanne K Freitag
- From the Departments of Ophthalmology (M.K.Y., S.K.F.) and Radiology (H.R.K.), Massachusetts Eye and Ear, the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Massachusetts General Hospital, and the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Harvard Medical School - all in Boston
| | - Alexander G Marneros
- From the Departments of Ophthalmology (M.K.Y., S.K.F.) and Radiology (H.R.K.), Massachusetts Eye and Ear, the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Massachusetts General Hospital, and the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Harvard Medical School - all in Boston
| | - Miriam B Barshak
- From the Departments of Ophthalmology (M.K.Y., S.K.F.) and Radiology (H.R.K.), Massachusetts Eye and Ear, the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Massachusetts General Hospital, and the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Harvard Medical School - all in Boston
| | - Diane G Brackett
- From the Departments of Ophthalmology (M.K.Y., S.K.F.) and Radiology (H.R.K.), Massachusetts Eye and Ear, the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Massachusetts General Hospital, and the Departments of Radiology (H.R.K.), Dermatology (A.G.M.), Medicine (M.B.B.), and Pathology (D.G.B.), Harvard Medical School - all in Boston
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30
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Abstract
Historically, surgical access to orbital tumors has required a transcutaneous, transconjunctival or transcranial approach. Resection of orbital tumors is notoriously challenging due to the surrounding dense network of critical structures in a confined bony cavity. Advances in endoscopic endonasal surgery, initially used for sinonasal and skull base conditions, have allowed for expansion of its applications beyond the sinorbital interface. In the past decade, the evolution of techniques has enabled a purely endoscopic, minimally invasive approach to medially located orbital pathology with good outcomes. With experience and multidisciplinary collaboration between orbit and rhinologic surgeons, this has expanded to allow for a safe and effective transnasal approach to nearly all regions of the orbit with or without assistance from the orbital side. This review summarizes the relevant anatomy, variations of surgical approaches, and literature regarding outcomes of the endoscopic endonasal approach to orbital tumors.
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Affiliation(s)
- Edith R Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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Chiou CA, Reshef ER, Freitag SK. Teprotumumab for the treatment of mild compressive optic neuropathy in thyroid eye disease: A report of two cases. Am J Ophthalmol Case Rep 2021; 22:101075. [PMID: 33889787 PMCID: PMC8050009 DOI: 10.1016/j.ajoc.2021.101075] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose To report two cases of thyroid eye disease (TED) associated compressive optic neuropathy (CON) that resolved after treatment with teprotumumab. Observation Two patients presented with active TED resulting in mild CON with the typical corresponding visual field (VF) defects. Both patients were initiated on intravenous (IV) corticosteroid therapy but despite treatment had persistent VF defects. Both patients were then treated with teprotumumab and demonstrated marked clinical improvement and complete resolution of TED-CON VF defects early in their infusion course. Conclusions and importance These cases suggest that teprotumumab can be a rapid and effective treatment for TED-CON, and raises the question of whether it may be superior to IV corticosteroid therapy.
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Affiliation(s)
- Carolina A Chiou
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Edith R Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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Freitag SK, Yen MT. Reply. Ophthalmology 2021; 128:e29-e30. [PMID: 33583571 DOI: 10.1016/j.ophtha.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Michael T Yen
- Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
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Abstract
Purpose: To compare the incidence of lower eyelid malposition following repair of isolated orbital floor fractures with that of complex orbitofacial fractures (defined as multi-wall fractures or prior orbital fracture repairs requiring revision) by oculofacial plastic surgeons via a transconjunctival or swinging eyelid approach.Methods: Retrospective review of 175 patients who underwent surgical repair of orbital fractures at our institution. The primary outcomes were the occurrence of lower eyelid malposition (ectropion, entropion, and eyelid retraction) and the need for subsequent surgical correction.Results: Of 95 patients with isolated orbital floor fractures, 4 developed eyelid malposition (4.2%), 1 of which required surgical repair (1.1%). Of 80 patients with complex orbitofacial fractures (48 multi-wall fractures, 32 secondary revisions), 10 had pre-operative eyelid malposition and were excluded from further analysis. Fourteen of the remaining 70 patients developed postoperative eyelid malposition (20%), 3 of which required surgical repair (4.3%). The difference in the occurrence of eyelid malposition between groups was statistically significant (p = .001), but the difference in rates of those requiring subsequent repair was not (p = .182). There was no statistically significant difference in the occurrence of eyelid malposition when considering other surgical factors including lateral canthotomy, conjunctival closure, implant material, or anterior rim screws.Conclusions: The incidence of lower eyelid malposition following orbital fracture repair via a fornix-based approach was significantly higher for the repair of complex orbitofacial fractures than for isolated floor fractures. However, very few patients in either group required surgical repair for eyelid malposition. Surgical factors including implant material did not affect outcomes.
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Affiliation(s)
- Victoria S North
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Edith R Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Nahyoung Grace Lee
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Daniel R Lefebvre
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Michael K Yoon
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Jafari A, von Sneidern M, Lehmann AE, Shen SA, Shishido S, Freitag SK, Bleier BS. Exclusively endoscopic endonasal resection of benign orbital tumors: a systematic review and meta-analysis. Int Forum Allergy Rhinol 2020; 11:924-934. [PMID: 33350602 DOI: 10.1002/alr.22745] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) classification system was developed to standardize prospective outcome analysis following orbital cavernous hemangioma (OCH) resection. The goal of this study was to retroactively apply the CHEER system to all prior existing reports of endoscopic resection of primary benign orbital tumors (BOTs) to: (1) compare patient presentations, perioperative characteristics, and outcomes between OCH and other BOTs; and (2) determine whether the CHEER categorization regime could be expanded to other BOTs. METHODS A systematic review of studies reporting exclusively endoscopic resections of OCH and other BOTs (eg, solitary fibrous tumor, schwannoma, and meningioma) was performed. Patient, tumor characteristics, and operative outcomes were recorded. All tumors with adequate reporting were retrospectively assigned a CHEER stage. Outcomes were compared using chi-square or Fisher's exact tests. RESULTS Ninety-three studies met inclusion criteria, and sufficient data were available in 36 studies, comprising 105 tumors (n = 87 OCHs; n = 18 other BOTs). Baseline patient and tumor characteristics, as well as intraoperative and short-term postoperative outcomes were not significantly different between OCHs and other BOTs. Long-term outcomes (eg, visual deficits, diplopia, eye position, and recurrence) also did not differ when controlling for CHEER stage. CONCLUSION This review represents the largest collection of outcomes data following exclusively endoscopic endonasal resection of BOTs. Short-term and long-term outcomes appear similar between OCHs and other BOTs. These results suggest that exclusively endoscopic resection of orbital tumors may be effective in a range of benign pathologies. Furthermore, these results support a broader application of the CHEER system to other benign primary orbital tumors.
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Affiliation(s)
- Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA
| | | | - Ashton E Lehmann
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
| | - Sarek A Shen
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD
| | - Sachie Shishido
- Faculty of Arts and Sciences, Fung Library, Harvard University, Cambridge, MA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
| | - Benjamin S Bleier
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
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35
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Wladis EJ, Aakalu VK, Sobel RK, McCulley TJ, Foster JA, Tao JP, Freitag SK, Yen MT. Interventions for Indirect Traumatic Optic Neuropathy: A Report by the American Academy of Ophthalmology. Ophthalmology 2020; 128:928-937. [PMID: 33161071 DOI: 10.1016/j.ophtha.2020.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head. METHODS A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis. RESULTS No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage. CONCLUSIONS Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.
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Affiliation(s)
- Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy J McCulley
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Suzanne K Freitag
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
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Abstract
PURPOSE OF REVIEW Orbital disease represents a diverse spectrum of pathology and can result in a variety of neuro-ophthalmic manifestations. The aim of this review is to provide updates on recent advances in our understanding of orbital disease secondary to thyroid eye disease, myositis, IgG4-related disease, sarcoidosis, granulomatosis with polyangiitis and various tumours. RECENT FINDINGS With regards to thyroid eye disease, there have been recent advances in the development of steroid-sparing therapies, new modalities for objectively monitoring disease activity and increased understanding of the role of environmental risk factors. There has been interest in characterizing the clinical course and underlying mechanism of optic nerve disease secondary to orbital disorders, which has led to advances in how we monitor for and prevent permanent vision loss. Increased knowledge of orbital tumour subtype histopathology and the development of novel classification systems has had prognostic value and aided medical decision-making. SUMMARY Orbital disease occurs secondary to a wide variety of diseases and can lead to neuro-ophthalmic manifestations with significant morbidity. Advances in our understanding of different subtypes of orbital disease have improved our ability to treat these potentially debilitating conditions.
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Affiliation(s)
| | | | - Suzanne K Freitag
- Department of Ophthalmology
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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37
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Abstract
Transcaruncular and transconjunctival approaches are commonly used by ophthalmic plastic surgeons to access various orbital compartments. These approaches are versatile and may be combined with transnasal or transcranial approaches to the orbit to gain optimal access to challenging locations. A major advantage of the transcaruncular and transconjunctival approaches is the lack of a visible skin incision with excellent postoperative cosmesis. As with all orbital surgery, an in-depth knowledge of orbital anatomy and physiology, as well as meticulous hemostasis, is needed to prevent complications including globe injury, permanent vision loss, diplopia, and retrobulbar hemorrhage. This article reviews the surgical steps of these approaches. The indications for each approach and case examples are illustrated.
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Affiliation(s)
- Natalie Wolkow
- Department of Ophthalmology, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, United States
| | - Suzanne K Freitag
- Department of Ophthalmology, Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, United States
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Amarnani D, Sanchez AV, Wong LL, Duffy BV, Ramos L, Freitag SK, Bielenberg DR, Kim LA, Lee NG. Characterization of a Murine Model of Oxazolone-Induced Orbital Inflammation. Transl Vis Sci Technol 2020; 9:26. [PMID: 32855872 PMCID: PMC7422768 DOI: 10.1167/tvst.9.8.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 05/04/2020] [Indexed: 01/15/2023] Open
Abstract
Purpose Acute orbital inflammation can lead to irreversible vision loss in serious cases. Treatment thus far has been limited to systemic steroids or surgical decompression of the orbit. An animal model that mimics the characteristic features of acute orbital inflammation as found in thyroid eye disease can be used to explore novel treatment modalities. Methods We developed a murine model of orbital inflammation by injecting oxazolone into the mouse orbit. The mice underwent magnetic resonance imaging (MRI) and were euthanized at various time points for histologic examination. Immunofluorescence studies of specific inflammatory cells and cytokine arrays were performed. Results We found clinical and radiographic congruity between the murine model and human disease. After 72 hours, sensitized mice exhibited periorbital dermatitis and inflammation in the eyelids of the injected side. By one week, increased proptosis in the injected eye with significant eyelid edema was appreciated. By four weeks, inflammation and proptosis were decreased. At all three time points, the mice demonstrated exophthalmos and periorbital edema. Histopathologically, populations of inflammatory cells including T cells, macrophages, and neutrophils shared similarities with patient samples in thyroid eye disease. Proteomic changes in the levels of inflammatory and angiogenic markers correlated to the expected angiogenic, inflammatory, and fibrotic responses observed in patients with thyroid eye disease. Conclusions A murine model of orbital inflammation created using oxazolone recapitulates some of the clinical features of thyroid eye disease and potentially other nonspecific orbital inflammation, typified by inflammatory cell infiltration, orbital tissue expansion and remodeling, and subsequent fibrosis. Translational Relevance This animal model could serve as a viable platform with which to understand the underlying mechanisms of acute orbital inflammation and to investigate potential new, targeted treatments.
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Affiliation(s)
- Dhanesh Amarnani
- Schepens Eye Research Institute/Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Angie V Sanchez
- Schepens Eye Research Institute/Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lindsay L Wong
- Schepens Eye Research Institute/Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | | | | | - Suzanne K Freitag
- Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Diane R Bielenberg
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Leo A Kim
- Schepens Eye Research Institute/Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.,Retina Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Nahyoung Grace Lee
- Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Singer MC, Marchal F, Angelos P, Bernet V, Boucai L, Buchholzer S, Burkey B, Eisele D, Erkul E, Faure F, Freitag SK, Gillespie MB, Harrell RM, Hartl D, Haymart M, Leffert J, Mandel S, Miller BS, Morris J, Pearce EN, Rahmati R, Ryan WR, Schaitkin B, Schlumberger M, Stack BC, Van Nostrand D, Wong KK, Randolph G. Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology. Head Neck 2020; 42:3446-3459. [PMID: 32812307 DOI: 10.1002/hed.26417] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/03/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement. METHODS A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations. RESULTS Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management. CONCLUSION Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.
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Affiliation(s)
- Michael C Singer
- Department of Otolaryngology - Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Francis Marchal
- Department of Otolaryngology - Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Peter Angelos
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Vic Bernet
- Department of Endocrinology, Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - Laura Boucai
- Department of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Samanta Buchholzer
- Maxillofacial Surgery and Oral Medicine and Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Brian Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Eisele
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evren Erkul
- Department of Otorhinolaryngology, Gulhane Medical School, University of Health Sciences, Istanbul, Turkey
| | - Frederic Faure
- Department of Otolaryngology - Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Marion Boyd Gillespie
- Department of Otolaryngology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Richard Mack Harrell
- Memorial Center for Integrative Endocrine Surgery, Memorial Healthcare System, Hollywood, Florida, USA
| | - Dana Hartl
- Department of Head and Neck Oncology, Institut de Cancerologie Gustave Roussy, Villejuif, France
| | - Megan Haymart
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Susan Mandel
- Department of Endocrinology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Barbra S Miller
- Division of Endocrine Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - John Morris
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth N Pearce
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rahmatullah Rahmati
- Division of Otolaryngology, Yale School of Medicine, New Haven, Connecticut, USA
| | - William R Ryan
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Barry Schaitkin
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Martin Schlumberger
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and University Paris-Saclay, Villejuif, France
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Doug Van Nostrand
- Division of Nuclear Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Ka Kit Wong
- Department of Radiology, Division of Nuclear Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Gregory Randolph
- Department of Otolaryngology - Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Freitag SK, Tanking T. A Nomenclature to Describe the Sequence of Visual Field Defects in Progressive Thyroid Eye Disease-Compressive Optic Neuropathy (An American Ophthalmological Society Thesis). Am J Ophthalmol 2020; 213:293-305. [PMID: 31843473 DOI: 10.1016/j.ajo.2019.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 01/28/2023]
Abstract
PURPOSE To create a novel nomenclature to characterize the longitudinal sequence of visual field (VF) defects in patients with progression of thyroid eye disease-compressive optic neuropathy (TED-CON). METHODS A retrospective review of records from 1 institution identified patients with progressive Humphrey VF defects secondary to TED-CON. The VF defects were analyzed by 2 independent reviewers and classified into 1 of 10 categories, divided into 3 stages that reflect the observed progression pattern, plus a miscellaneous category (stage X). Stage 1 VF defects are the earliest detectable and involve the inferior visual field with 3 levels of severity. Stage 2 VF defects include 2 distinguishable levels of severity and occur as the inferior defects advance above the horizontal midline to involve the superior VF. Stage 3 involves progression of stage 2 VF defects to complete loss of inferior and superior hemifields. RESULTS Of 234 VFs in 37 eyes of 23 subjects, inferior defects were most common, including stage 1a (small inferior paracentral defect) in 22 of 234 VFs (9.4%), stage 1b (large inferior paracentral defect) in 112 of 234 VFs (47.9%), and stage 1c (inferior altitudinal defect) in 11 of 234 VFs (4.7%). Stage 2a (inferior altitudinal with superior advancement above the horizontal meridian) occurred in 41 of 234 VFs (17.5%), stage 2b (inferior altitudinal with superior arcuate) occurred in 6 of 234 VFs (2.6%), and stage 3 (total loss) occurred in 5 of 234 VFs (2.1%). The longitudinal sequence of VF defects from the 37 eyes of 23 patients was analyzed. Thirty-one of 37 eyes (83.8%) demonstrated a predictable progression pattern from least to more severe: stage 1a, stage 1b, stage 1c, stage 2a, stage 2b, and stage 3. A reverse order of VF defect progression was noted in 15 eyes with improving TED-CON. A minority of progression patterns (16.2%) originated from stage X (central/paracentral, enlarged blind spot, and scatter). CONCLUSIONS Humphrey VF defects resulting from TED-CON are most often inferior, often have a predictable pattern of progression, and can be categorized into a novel descriptive nomenclature system. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Wladis EJ, Aakalu VK, Foster JA, Freitag SK, Sobel RK, Tao JP, Yen MT. Intense Pulsed Light for Meibomian Gland Disease: A Report by the American Academy of Ophthalmology. Ophthalmology 2020; 127:1227-1233. [PMID: 32327256 DOI: 10.1016/j.ophtha.2020.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To review the literature on the efficacy of intense pulsed light (IPL) on the eyelids in the management of meibomian gland disease (MGD) and meibomian gland-related ocular surface disease. METHODS A literature search was last conducted on May 15, 2019, in the PubMed and Cochrane Library databases for English-language original research that assessed the effect of IPL on MGD in adult patients. Thirty-three articles were identified, and 12 studies were determined to be relevant to the criteria outlined for assessment. The panel methodologist (V.K.A.) assigned a level of evidence rating to each study; 4 studies were rated level II, and 8 studies were rated level III. Five studies had potential conflicts of interest and design limitations that affected interpretation of results. RESULTS All studies documented improvement in clinically meaningful metrics, including tear breakup time (TBUT), corneal staining and eyelid margin measurements, meibum quality, meibomian gland expressability, ocular surface disease index (OSDI), and standard patient evaluation of eye dryness (SPEED) questionnaire scores. Side effects were relatively uncommon but included discomfort, cutaneous erythema, blistering, eyelash loss, and floaters; these were uniformly self-limited. CONCLUSIONS Although methodological limitations and potential conflicts of interest in some studies raised concern, the existing body of literature demonstrates improvements in the signs and symptoms of MGD after IPL therapy.
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Affiliation(s)
- Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Ohio State University, Columbus, Ohio
| | - Suzanne K Freitag
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
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42
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Starks VS, Reinshagen KL, Lee NG, Freitag SK. Visual field and orbital computed tomography correlation in dysthyroid optic neuropathy due to thyroid eye disease. Orbit 2020; 39:77-83. [PMID: 31057005 DOI: 10.1080/01676830.2019.1600150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/22/2019] [Indexed: 06/09/2023]
Abstract
Purpose: The pathogenesis of dysthyroid optic neuropathy (DON) in thyroid eye disease (TED) is thought to be compression of the apical optic nerve by hypertrophied extraocular muscles. We correlated worsening DON to the area occupied by extraocular muscles.Methods: Records of adults with TED DON evaluated from 1/1/2013 to 1/1/2018 were retrospectively reviewed. Each patient's visual field with the worst mean deviation (MD) was selected. Orbit CT scans were reviewed. Reformatted oblique coronal images were created perpendicular to the optic nerve. The cross-sectional area (CSA) of the orbit and each muscle group was measured and expressed as ratios of the CSA of the orbital apex. Univariate and multivariate analysis was performed for predictors of HVF MD.Results: 34 orbits with TED DON were analyzed. On orbital CT, the superior muscle complex occupied 15% of the apex (range 6-26%), inferior 18% (range 6-33%), lateral 10% (range 4-18%), medial 17% (range 8-27%), and all combined 61% (range 28-80%). Increasing total muscle area and superior complex area correlated with worsening MD. In multivariate linear regression, the superior muscle complex remained a significant predictor of MD (p = 0.01) over total muscle area (p = 0.25).Conclusions: Enlargement of extraocular muscles is common in TED, but DON occurs in only 6%. Our findings demonstrate that as DON worsens, as quantified by visual field MD, the superior muscle complex crowds the apex. This is consistent with the typical inferior visual field findings seen in TED DON. Hypertrophy of the superior rectus and levator palpabrae superioris complex may be predictive of worsening DON.
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Affiliation(s)
- Victoria S Starks
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | | | - Nahyoung G Lee
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Reshef ER, Habib LA, Rao R, Modjtahedi BS, Eliott D, Freitag SK, Reinshagen KL, Lee NG. Clinical and radiographic features of hydrolyzed MIRAgel scleral buckles: A comparative analysis. Clin Imaging 2019; 60:10-15. [PMID: 31864194 DOI: 10.1016/j.clinimag.2019.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/04/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
Abstract
The MIRAgel (hydrogel) scleral buckle, introduced in the 1980s, was a novel material to repair retinal detachments. It was later discontinued due to the frequency of long-term complications related to buckle hydrolysis and expansion. These complications included pain, limited extraocular motility, and more serious complications such as infection or scleral perforation, which ultimately necessitated surgical extraction as late as 20-30 years after placement. Prompt and proper diagnosis and treatment is often delayed as these buckle-associated complications frequently mimic other orbital pathologies such as tumors or infections. The hydrolyzed MIRAgel buckle exhibits distinct radiographic features that are helpful in arriving at the correct diagnosis, particularly in cases of ambiguous clinical presentation or history. Here, we expand on the previously described radiographic features of hydrolyzed MIRAgel and compare them to features of common, mimicking orbital pathology.
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Affiliation(s)
- Edith R Reshef
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America
| | - Larissa A Habib
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America
| | - Rohini Rao
- Department of Ophthalmology, School of Medicine, Boston University, Boston, MA, United States of America
| | - Bobeck S Modjtahedi
- Department of Ophthalmology, Southern California Permanente Medical Group, Baldwin Park, CA, United States of America
| | - Dean Eliott
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America
| | - Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America
| | - Katherine L Reinshagen
- Department of Radiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America.
| | - Nahyoung G Lee
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America
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Abstract
Introduction Endoscopic orbital surgery requires the acquisition of unique skill set including endoscopic bimanual dissection of intra/extraconal lesions adherent to orbital fat and neurovascular structures. Our goal was to develop a modular cadaveric model used to train surgeons to resect orbital pathology within any desired orbital compartment. Methods Expansile superabsorbent polymer (SAP) beads (2 mm) were soaked in Omnipaque™ (Iohexol) solution for 15 minutes prior to transcaruncular orbital implantation using 10-gauge angiocath. Insertion depth was designed to implant beads in predetermined intraconal compartments corresponding to established orbital tumor stages. Beads were left to expand in situ over a period of 1 to 5 hours. Computed tomography scans were performed using the FUSION image guidance protocol. Model utility and learning curves were assessed by quantifying resection time over 8 sequential attempts. Results All 24 beads were successfully implanted in 8 orbits corresponding to CHEER stage II to IV lesions (n = 3 per orbit). Beads expanded from 2 mm to an average of 5.2 mm within 1 hour. During expansion, the beads interpolated into the adjacent fascia similar to in vivo tumors. Average insertion time was 5:53 minutes per orbit (range, 3:24–10:33 min) and average time to bead identification was 10:47 minutes. Across all beads, dissection times decreased in a nonsignificant manner over 8 consecutive attempts. Conclusion The directed implantation of expansile SAP beads in this cadaveric model accurately replicates the approach, identification, and resection of isolated orbital lesions. This orbital model can assist the endoscopic surgical team to develop further knowledge and technical skill sets to approach orbital lesions. Further ongoing studies to validate this model are currently underway.
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Affiliation(s)
- Catherine Banks
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Qasim Husain
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Raymond Sacks
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Suzanne K. Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Benjamin S. Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
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45
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Affiliation(s)
- Natalie Wolkow
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Larissa A. Habib
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Michael K. Yoon
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Suzanne K. Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
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Abstract
Immunotherapy has significantly advanced the field of oncology in recent decades. Understanding normal immunosurveillance, as well as the ways in which tumor cells have evolved to evade it, has provided the knowledge for development of drugs that allow one's own immune system to target and destroy malignant cells (immunotherapy). Cutaneous malignancies are particularly sensitive to this class of drugs. In a very sensitive anatomic region such as the periocular tissue, where surgical excision may come with significant morbidity, this technology has had a strong impact in the successful treatment of historically challenging tumors.
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Affiliation(s)
- Larissa A Habib
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Natalie Wolkow
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Suzanne K Freitag
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Michael K Yoon
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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Wladis EJ, Aakalu VK, Tao JP, Sobel RK, Freitag SK, Foster JA, Mawn LA. Monocanalicular Stents in Eyelid Lacerations: A Report by the American Academy of Ophthalmology. Ophthalmology 2019; 126:1324-1329. [PMID: 30953742 DOI: 10.1016/j.ophtha.2019.03.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 03/29/2019] [Accepted: 03/29/2019] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To determine the efficacy and complication rates of monocanalicular stents in the setting of canalicular lacerations. METHODS A literature search was performed in May 2018 in the PubMed database to identify all English-language reports of monocanalicular stenting to address canalicular lacerations. Studies that did not include at least 10 patients with at least 3 months of follow-up evaluation after surgery were excluded. Ninety-nine articles were identified, and 15 of these met criteria for data abstraction and were included in this assessment. The panel methodologist (V.K.A.) evaluated the quality of evidence and assigned a level-of-evidence rating to each of these studies. RESULTS All 15 studies were rated as level III evidence. Anatomic and functional success rates after surgery ranged from 68% to 100% and 79% to 100%, respectively. Stents were generally well tolerated, although extrusion rates varied from 0% to 29%. CONCLUSIONS Only level III evidence was available, and studies were not powered to detect differences between groups for rare complications or failure. Monocanalicular stents seem to be efficacious and well tolerated in the management of canalicular lacerations. Potential complications include extrusion (most commonly), tube displacement, granuloma, ectropion, slit punctum, fistula, and infection. Further comparative studies would help to identify the optimal time for device removal and to directly compare monocanalicular with bicanalicular stents.
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Affiliation(s)
- Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | | | - Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Louise A Mawn
- Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee
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Wang JC, Jiménez Pérez JC, Friedmann AM, Louissaint A, Freitag SK. Myeloid sarcoma involving the greater wing of the sphenoid bone and additional skeletal sites presenting with unilateral proptosis and fevers. Orbit 2019; 38:154-157. [PMID: 29557698 DOI: 10.1080/01676830.2018.1449225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/04/2018] [Indexed: 06/08/2023]
Abstract
We report a case of myeloid sarcoma with multifocal skeletal involvement, including the greater wing of the sphenoid bone. A 23-month-old boy presented with left-sided proptosis and fevers, and was found to have an infiltrative mass involving the left sphenoid bone on orbital imaging. Full body imaging further demonstrated multiple bony lesions in the pelvis, thoracic and lumbar vertebrae, bilateral femura, and left humerus, and biopsies of the humerus were consistent with myeloid sarcoma. The patient was started on a standard chemotherapy regimen and is responding well. Myeloid sarcoma presenting with proptosis due to sphenoid bone involvement with simultaneous multifocal skeletal involvement is very uncommon and highlights the importance of biopsy for establishing a definitive diagnosis.
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Affiliation(s)
- Jay C Wang
- a Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Juan C Jiménez Pérez
- a Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Alison M Friedmann
- b Department of Pediatrics , Massachusetts General Hospital Cancer Center , Boston , MA , USA
| | - Abner Louissaint
- c Department of Pathology , Massachusetts General Hospital , Boston , MA , USA
| | - Suzanne K Freitag
- a Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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Gregorio LL, Busaba NY, Miyake MM, Freitag SK, Bleier BS. Expanding the limits of endoscopic intraorbital tumor resection using 3-dimensional reconstruction. Braz J Otorhinolaryngol 2019; 85:157-161. [PMID: 29337012 PMCID: PMC9452230 DOI: 10.1016/j.bjorl.2017.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 11/13/2017] [Indexed: 12/27/2022] Open
Abstract
Introduction Endoscopic orbital surgery is a nascent field and new tools are required to assist with surgical planning and to ascertain the limits of the tumor resectability. Objective We purpose to utilize three-dimensional radiographic reconstruction to define the theoretical lateral limit of endoscopic resectability of primary orbital tumors and to apply these boundary conditions to surgical cases. Methods A three-dimensional orbital model was rendered in 4 representative patients presenting with primary orbital tumors using OsiriX open source imaging software. A 2-Dimensional plane was propagated between the contralateral nare and a line tangential to the long axis of the optic nerve reflecting the trajectory of a trans-septal approach. Any tumor volume falling medial to the optic nerve and/or within the space inferior to this plane of resectability was considered theoretically resectable regardless of how far it extended lateral to the optic nerve as nerve retraction would be unnecessary. Actual tumor volumes were then superimposed over this plan and correlated with surgical outcomes. Results Among the 4 lesions analyzed, two were fully medial to the optic nerve, one extended lateral to the optic nerve but remained inferior to the plane of resectability, and one extended both lateral to the optic nerve and superior to the plane of resectability. As predicted by the three-dimensional modeling, a complete resection was achieved in all lesions except one that transgressed the plane of resectability. No new diplopia or vision loss was observed in any patient. Conclusion Three-dimensional reconstruction enhances preoperative planning for endoscopic orbital surgery. Tumors that extend lateral to the optic nerve may still be candidates for a purely endoscopic resection as long as they do not extend above the plane of resectability described herein.
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El Rassi E, Adappa ND, Battaglia P, Castelnuovo P, Dallan I, Freitag SK, Gardner PA, Lenzi R, Lubbe D, Metson R, Moe KS, Muscatello L, Mustak H, Nogueira JF, Palmer JN, Prepageran N, Ramakirshnan VR, Sacks R, Snyderman CH, Stefko ST, Turri-Zanoni M, Wang EW, Zhou B, Bleier BS. Development of the international orbital Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system. Int Forum Allergy Rhinol 2019; 9:804-812. [PMID: 30809970 DOI: 10.1002/alr.22316] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/15/2018] [Accepted: 01/26/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic-based staging system was developed. METHODS An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed. RESULTS Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty. CONCLUSION Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high-quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH.
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Affiliation(s)
- Edward El Rassi
- Department of Otolaryngology-Head and Neck Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Nithin D Adappa
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Paolo Battaglia
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, Head and Neck Surgery & Forensic Dissection Research Center (HNS & FDRc), University of Insubria, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, Head and Neck Surgery & Forensic Dissection Research Center (HNS & FDRc), University of Insubria, Varese, Italy
| | - Iacopo Dallan
- Ear, Nose, and Throat (ENT), Audiology, and Phoniatrics Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA.,Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ricardo Lenzi
- Unit of Otorhinolaryngology, Azienda Unità Sanitaria Locale Toscana Nord Ovest-Apuane Hospital, Massa, Italy
| | - Darlene Lubbe
- Department of Otolaryngology, University of Cape Town, Cape Town, South Africa
| | - Ralph Metson
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA.,Department of Otolaryngology, Harvard Medical School, Boston, MA
| | - Kris S Moe
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Washington School of Medicine, Seattle, WA.,Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA
| | - Luca Muscatello
- Unit of Otorhinolaryngology, Azienda Unità Sanitaria Locale Toscana Nord Ovest-Apuane Hospital, Massa, Italy
| | - Hamzah Mustak
- Oculoplastics and Orbital Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | | | - James N Palmer
- Division of Rhinology and Skull Base Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Narayanan Prepageran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - Vijay R Ramakirshnan
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO
| | - Raymond Sacks
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO.,Discipline of Otolaryngology, University of Sydney, Sydney, Australia.,Department of Otolaryngology, Macquarie University, Sydney, Australia
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - S Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mario Turri-Zanoni
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, Head and Neck Surgery & Forensic Dissection Research Center (HNS & FDRc), University of Insubria, Varese, Italy
| | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Bing Zhou
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Beijing, China
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA.,Department of Otolaryngology, Harvard Medical School, Boston, MA
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