Edward J. Wladis

Intraductal meibomian gland probing in the management of ocular rosacea.

Purpose: Rosacea is a significant cause of ocular surface disease, and our current therapeutic armamentarium is often ineffective. Intraductal meibomian gland probing is a novel technique to address dry eye syndrome, although its use has not been described in the management of ocular surface disease from rosacea. Methods: Patients with ocular rosacea, meibomian gland dysfunction, and surface disease, which was refractory to conventional management, underwent intraductal meibomian gland probing. Each patient completed the Ocular Surface Disease Index (OSDI) questionnaire before the procedure and at the 1- and 6-month postoperative visits. Results: Forty eyelids of 10 patients (5 men, 5 women; mean age = 42.1 years) underwent intraductal meibomian gland probing. All patients reported subjective improvement in their symptoms of discomfort, tearing, and blurred vision. The mean preoperative, 1-month, and 6-month OSDI scores were 78.11 (standard deviation [SD] = 5.33), 37.54 (SD = 7.25), and 43.00 (SD = 5.49), respectively. The differences between the preoperative and one- and six-month scores were statistically significant (p < 0.05). Nine of the ten patients in this study were able to discontinue their doxycycline use after surgery, and 10 out of 10 patients reported decreased frequency of artificial tear use. No complications were identified in the 6-month follow-up period. Conclusions: Intraductal meibomian gland probing is a safe, effective technique to address the ocular surface disease, tearing, and discomfort associated with ocular rosacea, and this intervention results in a dramatic improvement in these symptoms. This study provides the first documentation of these findings and represents the first quantitative demonstration of the use of intraductal meibomian gland probing in the peer-reviewed literature.

Role for surgery as adjuvant therapy in optic nerve sheath meningioma.

Purpose: To describe a role for optic nerve decompression as adjuvant surgical therapy in the management of optic nerve sheath meningioma in patients with severe, progressive visual loss and optic disc edema before or after radiation therapy. Methods: Interventional case report. Results: Two patients with unilateral optic nerve sheath meningioma had progressive visual loss (20/200 and no light perception) and disc edema. The first had previously undergone fractionated stereotactic radiotherapy and the second subsequently was treated with fractionated stereotactic radiotherapy after decompression surgery. After excision of a dural window and biopsy of the tumor from the nerve sheath, visual acuity improved to 20/25 and 20/200, respectively, both coinciding with resolution of disc edema. Conclusions: In patients with optic nerve sheath meningioma with severe disc edema and rapid vision loss, surgery may serve an important but restricted, adjuvant role to radiation therapy under special conditions.

Histologic Assessment of Dermatochalasis: Elastolysis and Lymphostasis Are Fundamental and Interrelated Findings

OBJECTIVE To determine the presence, degree, and extent of lymphatic, elastic, and collagen fiber alterations in dermatochalasis (DC) specimens. DESIGN Case control study of patients with DC compared with age-, gender-, and site-matched controls. PARTICIPANTS A total of 25 eyelid specimens were studied; 15 of these were blepharoplasty specimens (experimental) and 10 were entropion/ectropion specimens of patients without DC (controls). METHODS The number and maximal dilation of lymphangiectasia was measured by light microscopy, immunohistochemistry with lymphatic marker D2-40, and elastic tissue content by Verhoeff-van Gieson histochemistry. The number of macrophages was compared between patients with DC and controls in CD68 immunostained specimens. MAIN OUTCOME MEASURES Lymphatic density, edema, and inflammation. RESULTS Dermatochalasis eyelid specimens showed increased lymphangiectasia density (5.6 vs. 2.4 lymphatics/high power field; P<0.05), maximal lymphatic dilation (127 vs. 51.5 μm; P<0.05), loss of elastic fibers (2.2 vs. 8.9 fibers/high power field; P<0.05), and greater disruption of collagen networks and edema compared with controls (increased stromal collagen bed of 752 vs. 269 μm; P<0.05; increased intercollagen space of 32.5 vs. 11.8 μm; P<0.05). Macrophages were present in greater quantities in DC specimens (28.6 vs. 11.9 macrophages/high power field; P<0.05). CONCLUSIONS Patients with DC show an increase in number and maximal dilation of lymphatic vessels in conjunction with widely spaced collagen bundles. This finding coexists with loss of elastic fibers, components known to be essential to the structure and function of the lymphatic system. Governed by macrophages, the pathogenesis of DC may begin with subclinical inflammation leading to elastolysis and secondary lymphostasis. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Orbital cellulitis with subperiosteal abscess: demographics and management outcomes.

Purpose: Infectious orbital cellulitis represents a serious threat to vision and, if untreated, poses significant morbidity risk. In this study, the authors attempt to further characterize the features of orbital cellulitis with subperiosteal abscess (SPA) and determine outcomes based on the type of surgical intervention employed. Methods: Data were obtained by retrospective chart review of all inpatient admissions for orbital inflammation/cellulitis from Sept 2005 to April 2010. Charts were reviewed for demographic information, radiographic and clinic evidence of orbital cellulitis, presence of SPA (defined by radiographic criteria), interventions taken (surgical and nonsurgical), presence of concurrent sinusitis, types of microbes present, and duration of hospital admission. Statistical analysis was performed using chi-square tests. Results: A total of 97 patients were admitted with a diagnosis of orbital inflammation/cellulitis, of whom 49 patients had clinical and/or radiographic evidence of orbital cellulitis. Twenty-four patients had radiographic evidence of SPA. All patients with SPA had concurrent sinusitis, and 16 patients underwent initial surgical intervention. Nine patients had external transcaruncular/transcutaneous SPA drainage only, 6 had combined SPA and sinus drainage, and one had sinus drainage alone. Of those that underwent SPA-only drainage, 5 had SPA reaccumulation, while no reaccumulation occurred with combined SPA and sinus drainage. No reaccumulation occurred if the SPA was less than 2 cm in its greatest diameter. Conclusion: In this study, for those abscesses larger than 2 cm, combined sinus and SPA drainage was associated with improved treatment outcome, demonstrated by absence of abscess reaccumulation and shorter hospital stay. SPA-only drainage was more frequently associated with SPA reaccumulation.

Bilateral Lacrimal Gland Disease: Clinical Features of 97 Cases

OBJECTIVE Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. DESIGN Case series. PARTICIPANTS Ninety-seven patients with bilateral LG disease. METHODS Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. MAIN OUTCOME MEASURES Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. RESULTS Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease. CONCLUSIONS The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%.

Oral Antibiotics for Meibomian Gland-Related Ocular Surface Disease: A Report by the American Academy of Ophthalmology

OBJECTIVE To review the existing medical literature on the role of oral antibiotics in the management of ocular surface disease (OSD) that arises from disorders of the meibomian glands and to assess the efficacy of oral antibiotics in the management of this common ocular disease. METHODS A literature search was last conducted on August 12, 2015, in the PubMed and Cochrane databases for English-language original research investigations that evaluated the role of doxycycline, minocycline, and azithromycin in OSD among adult patients. The searches identified 87 articles, and 8 studies ultimately met the criteria outlined for this assessment. RESULTS The 8 studies identified in the search documented an improvement in meibomian gland-related OSD after treatment with these agents, although side effects were common. This search identified only 1 randomized, controlled trial to assess the efficacy of these medications. CONCLUSIONS Although oral antibiotics are used commonly in the management of OSD, there is no level I evidence to support their use. There are only a few studies that have assessed the efficacy of oral antibiotics in clinically meaningful ways in the management of OSD that arises from disorders of the meibomian glands. The current level of evidence is insufficient to conclude that antibiotics are useful in managing OSD arising from disorders of the meibomian glands. The few existing studies on the topic indicate that oral antibiotics may be an effective treatment for OSD that results from meibomian gland disease.

Transient descent of the contralateral eyelid in unilateral ptosis surgery.

Purpose: To report novel findings regarding contralateral eyelid height (i.e., intraoperative descent, followed by postoperative elevation) during unilateral ptosis surgery and to comment on their relevance in surgical planning. Methods: Twelve adults with unilateral ptosis underwent levator advancement surgery. During surgery, eyelid height was set to the contralateral preoperative margin reflex distance value, rather than intraoperative level. The margin reflex distance of both eyes was measured before, during, and after surgery. Results: The mean preoperative margin reflex distance on the ptotic side was 0.63 mm versus 3.83 mm contralaterally. No patient demonstrated a Hering phenomenon preoperatively. In each case, the goal was to elevate the ptotic eyelid to the contralateral preoperative height. For the ptotic eyelid, this resulted in a mean intraoperative margin reflex distance of 4 mm. Simultaneously, the contralateral side was noted to drop in each case, to a mean margin reflex distance of 1.67 mm. Postoperatively, at a mean follow up of 1.25 weeks, the mean margin reflex distance values were 3.88 mm and 3.83 mm for the operated and unoperated sides, respectively (Pearson correlation coefficient = 0.88, p < 0.05). At a mean follow-up of 4.35 months, the mean margin reflex distance values were 3.80 mm and 3.83 mm for the operated and unoperated sides, respectively (Pearson correlation coefficient = 0.96, p < 0.05). No patient had greater than 0.5 mm of asymmetry, and no patient requested postoperative adjustment. Had intraoperative symmetry been obtained with a postoperative contralateral return to preoperative height, a mean 42.1% of postoperative height asymmetry would have resulted between the 2 eyelids. Conclusions: During unilateral levator advancement surgery, the authors noted that the contralateral eyelid temporarily droops, and this Hering-like effect reverses postoperatively. The authors recommend that by raising the operated eyelid to the height of the contralateral side’s preoperative (rather than intraoperative) height, excellent postoperative eyelid height and symmetry can be obtained.

Self-irrigating piezoelectric device in orbital surgery.

Purpose: Orbital osteotomy risks injury to the eyeball and orbit soft tissues. Used extensively in oral and maxillofacial surgery, piezoelectric technology offers a greater margin of safety than traditional bone cutting instruments. The authors describe the novel use of this system in a variety of orbital surgeries. Methods: This interventional case series was performed in accordance with institutional review board regulations. The medical records of all patients who had undergone orbital surgery using the piezoelectric blade at 3 institutions were reviewed. Indication for surgery, gender, age, duration of follow up, intraoperative complications, surgical result, and postoperative course was recorded. Results: Sixteen patients underwent surgery on 18 orbits using the piezoelectric system between August 2011 and June 2012. Surgeries performed included orbital decompression (8), lateral orbitotomy (5), cranio-orbitotomy (4), and external dacryocystorhinostomy (1). Eight were female and 8 were male patients. Mean age was 55 years old (standard deviation 15 years). Mean follow up was 82 days. The osteotomy created by the blade was narrow and smooth in every case. The surgeons uniformly appreciated the precision and safety of the instrument compared with traditional electric saw blades. There were no soft tissue lacerations or intraoperative complications and reconstructions were uniformly uneventful. Postoperative healing was rapid with no unexpected inflammation, and no palpable bony defects were appreciated in the reconstructed cases. Conclusions: Because it does not cut soft tissue and cuts a narrow trough, the self-irrigating piezoelectric saw blade appears safer and more precise than traditional electric saw blades in and around the orbit.

Molecular biologic assessment of cutaneous specimens of ocular rosacea.

Purpose: To characterize the molecular biologic environment of pathological skin in ocular rosacea and to differentiate the levels of inflammatory molecules in ocular rosacea from those of normal skin. Methods: The concentrations of 48 molecules were assayed in cutaneous biopsies taken from patients with ocular rosacea and from normal controls. Results: There were very few molecular differences between the 2 groups, and 43 of the 48 molecules that were measured in this study were not significantly different between the 2 groups. The concentrations of 5 molecules (interleukin-1&bgr;, interleukin-16, stem cell factor, monocyte chemotactic protein-1, and monokine induced by &ggr;-interferon) were significantly enriched in ocular rosacea. Conclusions: Ocular rosacea is a highly ordered molecular process and involves elevations in the concentrations of specific molecules. The particular pattern of enrichment supports the notion that ocular rosacea represents a disorder of innate immunity. Furthermore, these molecules may represent novel therapeutic targets in the future management of this disorder.

Characterization of the molecular biologic milieu of idiopathic orbital inflammation.

Purpose: To identify the cytokines that are expressed in elevated concentrations in idiopathic orbital inflammation (IOI). Design: Experimental study. Participants and Controls: Biopsy specimens from 8 patients with biopsy-proven IOI and negative serologic and radiographic examinations, versus orbital biopsy samples taken from 8 control patients without clinical evidence or subjective complaint of orbital inflammation. Methods: Quantitative cytokine assays were performed to assess the levels of 9 different molecules for IOI and control patients. Statistical analyses were performed to compare the cytokine concentrations between the 2 groups. Main Outcome Measures: Cytokine concentrations. Results: Six cytokines were statistically significantly elevated in IOI (interleukin-2, -8, -10, -12, gamma interferon, and tumor necrosis factor alpha) (p < 0.05). Gamma interferon and interleukin-12 were expressed at concentrations greater than 10 times higher in patients with IOI. Conclusions: IOI involves discrete elevations of specific cytokines, and individual molecules are clearly implicated in the pathogenesis of this disease. Specifically, gamma interferon and interleukin-12 concentrations are markedly elevated in IOI. These cytokines represent novel therapeutic targets in the management of this inflammatory process. Agents that affect these molecules could be used as potential therapies to control this disease in a more effective fashion with fewer side effects.