Catherine J. Choi

Intraocular pressure fluctuation and glaucoma progression: what do we know?

While mean intraocular pressure (IOP) has long been known to correlate with glaucomatous damage, the role of IOP fluctuation is less clearly defined. There is extensive evidence in the literature for and against the value of short-term and long-term IOP fluctuation in the evaluation and prognosis of patients with glaucoma. We present here the arguments made by both sides, as well as a discussion of the pitfalls of prior research and potential directions for future studies. Until a reliable method is developed that allows for constant IOP monitoring, many variables will continue to hinder us from drawing adequate conclusions regarding the significance of IOP variation.

Full-Thickness Skin Graft as an Independent or Adjunctive Technique for Repair of Cicatricial Lower Eyelid Ectropion Secondary to Actinic Skin Changes.

Purpose: To retrospectively review and describe full-thickness skin graft repair of lower eyelid cicatricial ectropion secondary to actinic skin. Methods: A retrospective, noncomparative chart review of all patients who underwent lower eyelid ectropion repair with placement of a full-thickness skin graft between June 2004 and March 2014 was conducted with IRB approval. The etiology of lower eyelid ectropion, demographics including age, gender, ethnicity, laterality, graft donor site, additional surgical procedures, graft viability, surgical success rate, complications, and clinical exam findings were summarized. Results: Twenty-nine eyelids in 24 patients underwent skin grafting for repair of cicatricial ectropion secondary to actinic skin changes. Ninety six percent of patients were male and 96% were Caucasian. Donor sites for skin grafts included upper eyelid (9, 31%), supraclavicular skin (9, 31%), postauricular skin (7, 24%), inner brachial skin (2, 7%), axilla (1, 3.5%), and preauricular skin (1, 3.5%). Twenty-four of 29 eyelids in the series underwent 1 or more additional procedures at the time of full-thickness skin grafting, including lateral tarsal strip (9 eyelids, 37.5%), punctoplasty (8, 33%), canthoplasty (7, 29%), excision of keratinized conjunctiva (2, 8%), transverse tarsotomy (1, 4%), ipsilateral external dacryocystorhinostomy (3, 12.5%), and lesion removal (1, 4%). There was 100% viability of the skin grafts. Overall surgical success rate was 76%, with asymptomatic recurrence rate of 17% and symptomatic recurrence rate of 7%. Conclusion: Repair of cicatricial lower eyelid ectropion secondary to actinic skin changes may be accomplished with full-thickness skin grafting, and is often performed in conjunction with additional procedures to fully address anatomic abnormalities.

Margin Reflex Distance: Differences Based on Camera and Flash Positions.

Purpose: To evaluate the effect of camera flash position on the measurement of photographic margin reflex distances (MRD). Methods: Subjects without any ophthalmic disease were prospectively enrolled after institutional review board approval. Clinical measurements of MRD1 and interpalpebral fissure were obtained. Photographs were then taken with a digital single lens reflex with built-in pop-up flash (dSLR-pop), a dSLR with lens-mounted ring flash (dSLR-ring), a point-and-shoot camera, and a smartphone, each in 4 positions: with the camera upright, rotated 90°, 180°, and 270°. The images were analyzed using ImageJ software to measure MRD1, interpalpebral fissure, horizontal white-to-white, and distance from nasal limbus to the corneal light reflex. Results: Thirty-two eyes of 16 subjects were included (ages 27–65). When using the dSLR-ring, point-and-shoot, and smartphone, the difference between clinical and photographic MRD1 did not reach statistical significance. There was, however, a statistically significant difference in the upright position with dSLR-pop (mean difference 0.703 mm, &sgr; = 0.984 mm, p = 0.0008). For dSLR-pop, photographic MRD1 in upright versus inverted position differed significantly (mean difference -0.562 mm, &sgr; =0.348 mm, p < 0.0001). Photographic MRD1 between dSLR-pop and dSLR-ring showed significant difference in upright position (mean difference -0.572 mm, &sgr; = 0.701 mm, p = 0.0002). There were no statistically significant differences between clinical and photographic interpalpebral fissure, and among white-to-white and nasal limbus to light reflex measurements in any position in all 4 cameras. Conclusions: When using photographs for measurement of MRD1, cameras with a near-coaxial light source and aperture have values that are most similar to clinical measurements.

Acute Management of Central Retinal Artery Occlusion.

Central retinal artery occlusion (CRAO) has been likened to ischemic cerebral stroke as the same atherosclerotic risk factors can contribute to both processes. Hypertension, diabetes, carotid and coronary artery disease, and smoking tobacco have all been associated with nonarteritic CRAO. Although there are clear evidence-based protocols widely in use for the management of cerebral stroke, there continues to be debate concerning the acute management of CRAO. Many clinicians feel that the available treatment options are ineffective and that the inherent risks outweigh the potential benefits. The goal of this paper is to provide the most updated summary of the current literature on this topic. CRAO can have devastating visual consequences. First described by Von Graefe in 1859, the estimated annual incidence rate is 1 in 100,000 and it leaves most patients with profound permanent visual impairment. The loss of vision affects quality of life, especially in the older population, the group in which CRAO is the most common. In addition, the disorder can result in increased health care costs due to falls and other associated complications. Given the severity of outcomes, an effective treatment for CRAO has long been sought and a wide variety of treatments have been attempted. In 1881, the use of inhaled amyl nitrite to dislodge a presumed embolus through vasodilation was reported by Samelsohn. Seven years later, Mules described a patient who had a central embolus pass into a smaller more peripheral vessel after anterior chamber paracentesis. In 1926, Oppenheimer boldly recommended temporary detachment of the inferior rectus to gain access for direct massage of the optic nerve to attempt to displace an embolus. Other proposed and attempted

Orbital Angiogenesis and Lymphangiogenesis in Thyroid Eye Disease: An Analysis of Vascular Growth Factors with Clinical Correlation

PURPOSE The human orbit is an environment that is vulnerable to inflammation and edema in the setting of autoimmune thyroid disease. Our study investigated the tenet that orbital adipose tissue lacks lymphatic vessels and analyzed the clinicopathologic differences between patients with acute and chronic thyroid eye disease (TED). The underlying molecular mediators of blood and lymphatic vessel formation within the orbital fat also were evaluated. DESIGN Retrospective cohort study. PARTICIPANTS The study included fat specimens from 26 orbits of 15 patients with TED undergoing orbital decompression. Orbital fat specimens from patients without TED as well as cadaveric orbital fat served as controls. METHODS Tissue specimens were processed as formalin-fixed, paraffin-embedded sections or frozen cryosections for immunohistochemistry. Total RNA was extracted and analyzed via quantitative (real-time) reverse-transcription polymerase chain reaction. Clinicopathologic correlation was made by determining the clinical activity score (CAS) of each patient with TED. MAIN OUTCOME MEASURES Samples were examined for vascular and lymphatic markers including podoplanin, lymphatic vessel endothelial hyaluronan receptor 1 (LYVE-1), and cluster of differentiation 31 (CD31) by immunohistochemistry, as well as for mRNA levels of vascular endothelial growth factor (VEGF), VEGF receptors, semaphorin 3F, neuropilin 1, neuropilin 2, podoplanin, and LYVE-1 by quantitative (real-time) reverse-transcription polymerase chain reaction. RESULTS Clinicopathologic correlation revealed increased staining of CD31-positive blood vessels in patients with acute TED with a CAS more than 4, as well as rare staining of podoplanin-positive lymphatic vessels within acutely inflamed orbital fat tissue. Additionally, quantitative (real-time) reverse-transcription polymerase chain reaction analysis demonstrated increased expression of VEGF receptor (VEGFR) 2 as well as VEGF signaling molecules VEGF-A, VEGF-C, and VEGF-D. CONCLUSIONS In acute TED, compared with chronic TED and control orbital fat, there is increased blood vessel density, suggesting neovascularization and rare lymphatic vessels suggestive of limited lymphangiogenesis. This proangiogenic and prolymphangiogenic microenvironment is likely the result of the increased expression of VEGFR-2, VEGF-A, VEGF-C, and VEGF-D. These findings imply that orbital edema in acute TED may be mediated, in part, by both the formation of new, immature blood vessels and the formation of lymphatic capillaries that are functionally incapable of draining interstitial fluid.

Validation of the facial assessment by computer evaluation (FACE) program for software-aided eyelid measurements

ABSTRACT The aim of this article is to validate the accuracy of Facial Assessment by Computer Evaluation (FACE) program in eyelid measurements. Sixteen subjects between the ages of 27 and 65 were included with IRB approval. Clinical measurements of upper eyelid margin reflex distance (MRD1) and inter-palpebral fissure (IPF) were obtained. Photographs were then taken with a digital single lens reflex camera with built-in pop-up flash (dSLR-pop) and a dSLR with lens-mounted ring flash (dSLR-ring) with the cameras upright, rotated 90, 180, and 270 degrees. The images were analyzed using both the FACE and ImageJ software to measure MRD1 and IPF.Thirty-two eyes of sixteen subjects were included. Comparison of clinical measurement of MRD1 and IPF with FACE measurements of photos in upright position showed no statistically significant differences for dSLR-pop (MRD1: p = 0.0912, IPF: p = 0.334) and for dSLR-ring (MRD1: p = 0.105, IPF: p = 0.538). One-to-one comparison of MRD1 and IPF measurements in four positions obtained with FACE versus ImageJ for dSLR-pop showed moderate to substantial agreement for MRD1 (intraclass correlation coefficient = 0.534 upright, 0.731 in 90 degree rotation, 0.627 in 180 degree rotation, 0.477 in 270 degree rotation) and substantial to excellent agreement in IPF (ICC = 0.740, 0.859, 0.849, 0.805). In photos taken with dSLR-ring, there was excellent agreement of all MRD1 (ICC = 0.916, 0.932, 0.845, 0.812) and IPF (ICC = 0.937, 0.938, 0.917, 0.888) values. The FACE program is a valid method for measuring margin reflex distance and inter-palpebral fissure.

Loose anchoring suture to secure a free flap after laser in situ keratomileusis

UNLABELLED We describe the use of a single loose anchoring suture to secure a free flap with good outcomes. We believe this simple, safe technique combines the advantages of previously reported methods, including stability and minimal invasiveness. FINANCIAL DISCLOSURE Neither author has a financial or proprietary interest in any material or method mentioned.

Orbital Complication Following Calcium Hydroxylapatite Filler Injection.

Cosmetic facial fillers have gained immense popularity in recent years. Although some patients opt to undergo an injection over surgery in light of the risks of an operation, there have been numerous reports of complications from these injections, including blindness. It is thought that filler particles can migrate within an artery and become emboli within small vessels. This case of focal orbital inflammation and dysmotility as a consequence of calcium hydroxylapatite filler injection in the face has not yet been documented in the literature.

Limbal Mantle Cell Lymphoma of the Conjunctiva

Limbal Mantle Cell Lymphoma of the Conjunctiva A 56-year-old woman presented with a 5-month history of a painless subconjunctival nodule without evidence of intraocular extension (Fig 1). Excisional biopsy was consistent with mantle cell lymphoma with a diffuse monotonous infiltrate of small, densely packed lymphoid cells with slightly irregular nuclei, finely dispersed chromatin, scant cytoplasm, and positive cyclin D1 staining (Fig 2, 400 magnification, inset 600 ). Peripheral blood flow cytometry demonstrated a clonal population of CD5-positive cells with 11:14 translocation. Mantle cell lymphoma constitutes 3% of all conjunctival lymphomas, with systemic involvement in 50% of patients and 1-year progression rate of 15%. Treatment of choice is systemic chemotherapy.

Atypical location of primary orbital conjunctival epithelial cysts: a case series.

Primary orbital conjunctival epithelial cysts are congenital lesions that are lined by non-keratinizing epithelium with goblet cells. They can be very anteriorly located and readily visible, or deep within the orbit with mass effect and ocular motility disturbance mimicking any number of orbital masses. They can manifest at any age and are most commonly found in the superonasal, followed by the superotemporal orbit, and sometimes associated with the superior rectus–levator complex. The authors report three cases of primary orbital conjunctival cysts occurring in the inferior orbit.