Jeremiah P. Tao

Effects of age and dysfunction on human meibomian glands.

OBJECTIVE To identify age-related changes in human meibomian glands that may be associated with meibomian gland dysfunction (MGD). METHODS Excess eyelid tissue from 36 patients (age range, 18-95 years, 19 female, 17 male) who underwent canthoplasty procedures were used. Dermatologic history, age, and presence of MGD were recorded. Samples were frozen, sectioned, and stained with specific antibodies against peroxisome proliferator-activated receptor γ (PPARγ) to identify meibocyte differentiation, Ki67 nuclear antigen to identify cycling cells, and CD45 to identify inflammatory cell infiltration. RESULTS Staining for PPARγ showed cytoplasmic and nuclear localization in the 2 youngest subjects (ages, 18 and 44 years). Older individuals (>60 years) showed predominantly nuclear staining, with cytoplasmic staining limited to the basal acinar cells in 17 of 31 subjects. The number of Ki67 positively stained basal cells were significantly elevated in the younger compared with older subjects based on linear regression analysis (r(2) = 0.35; P < .001). There was also a significant correlation between MG expression grade and CD45 cell infiltration (r = 0.414; P = .05). CONCLUSIONS These results indicate that aging human meibomian glands show decreased meibocyte differentiation and cell cycling that is associated with the development of MGD. Findings also suggest that altered PPARγ signaling may lead to acinar atrophy and development of an age-related hyposecretory MGD. CLINICAL RELEVANCE Meibomian gland dysfunction and evaporative dry eye are common age-related eyelid disorders. Understanding the underlying mechanism of MGD may lead to the development of novel therapeutic strategies to treat this disease.

Nylon foil "wraparound" repair of combined orbital floor and medial wall fractures.

Purpose: To evaluate a technique of implanting a single 0.4-mm–thick nylon foil (Supramid) continuously across combined medial wall and floor fractures within weeks of orbital trauma. Methods: This retrospective, interventional case series includes patients with combined medial wall and floor fractures with or without external orbital and facial fractures, without prior surgery, and who were in the early posttrauma phase. One hundred two orbits in 98 consecutive patients were treated with a “wraparound” technique. The surgical technique is provided in detail. Comatose patients, those with cranial nerve palsies, severe globe injury, anophthalmia, or previous repair of the same fractures were excluded. Patients underwent surgery from 5 to 21 days after trauma. Postoperatively (average, 6.2 months), patients were evaluated for enophthalmos, extraocular motility, and diplopia. Results: In 101 of 102 orbits, normal globe position, and full extraocular motility without diplopia was accomplished. One orbit had persistent enophthalmos, requiring a second procedure. This same patient had ipsilateral restriction in extreme upgaze, but no diplopia symptoms. This orbit had complete loss of inferomedial strut support. Overall, strut loss was not a risk factor for subsequent enophthalmos. No other patient had globe malposition, restrictive myopathy, or diplopia. Implant migration, hemorrhage, fistula, or infection was not observed. The transconjunctival and canthal wounds were hidden and tolerated by all patients with no eyelid cicatrization, webbing, or malposition. Conclusions: The “wraparound” technique for 0.4-mm nylon foil implantation continuously across orbital floor and medial wall fractures was associated with almost no enophthalmos and diplopia in this series.

Efficacy of fentanyl or alfentanil in suppressing reflex sneezing after propofol sedation and periocular injection.

Purpose: A sneeze reflex may occur after propofol sedation and during periocular injections. Unexpected movement from sneezing can result in needle injury to the globe or optic nerve, or hematoma. We investigate the efficacy of concomitant fentanyl or alfentanil in reducing sneezing following propofol and during periocular injections. Methods: Our prospective, randomized study included 81 adult patients undergoing conscious sedation prior to periocular injection of local anesthesia. All patients received propofol and were randomized to propofol only (25 patients), propofol plus midazolam (14 patients), propofol plus opioid (31 patients), propofol plus midazolam and opioid (11 patients). Periocular injection of local anesthetic was given in the usual manner. The main outcome measure was sneezing. Patients were also assessed for cardiorespiratory parameters, analgesia, and adverse side effects of sedatives. Results: Of the patients who received no opioid, 17 of 39 (43.6%) sneezed. Of the patients who received an opioid, 0 of 42 sneezed (p < 0.0001 by Fisher exact two-tailed test). Among subjects receiving no opioids, midazolam was associated with a higher incidence of the sneeze reflex, but this was not quite statistically significant (p = 0.09). No adverse cardiorespiratory events were noted and analgesia was universally adequate. Conclusions: Fentanyl or alfentanil suppressed sneezing after propofol sedation and eyelid anesthetic injection. These medications may prevent needle injury.

Imaging in orbital trauma

Orbital trauma is one of the most common reasons for ophthalmology specialty consultation in the emergency department setting. We survey the literature from 1990 to present to describe the role of computed tomography (CT), magnetic resonance imaging (MRI) and their associated angiography in some of the most commonly encountered orbital trauma conditions. CT orbit can often detect certain types of foreign bodies, lens dislocation, ruptured globe, choroidal or retinal detachments, or cavernous sinus thrombosis and thus complement a bedside ophthalmic exam that can sometimes be limited in the setting of trauma. CT remains the workhorse for acute orbital trauma owing to its rapidity and ability to delineate bony abnormalities; however MRI remains an important modality in special circumstances such as soft tissue assessment or with organic foreign bodies.

Inferolateral migration of hydrogel orbital implants in microphthalmia

Purpose: Hydrogel spheres may be useful in treating orbital hypoplasia associated with congenital microphthalmia. The authors describe migration associated with the use of these devices. Methods: The authors retrospectively reviewed 5 cases in which a hydrogel orbital expander (Osmed) was implanted to treat orbital hypoplasia in pediatric patients with congenital microphthalmia (with or without previous surgery). Results: In all 5 cases, a lateral orbitotomy, conjunctiva-sparing approach was used to insert the hydrogel spheres. Two cases involved previously unoperated orbits; 3 patients had prior orbit or socket surgery. Inferolateral movement outside the desired central, deep orbital position occurred in all 5 cases. Four of 5 cases required further procedures to achieve an adequate orbital implant position. Conclusions: Inferolateral migration may occur with hydrogel spheres implanted via a lateral orbitotomy approach in microphthalmia.

A Multicenter Analysis of the Ophthalmic Knowledge Assessment Program and American Board of Ophthalmology Written Qualifying Examination Performance

OBJECTIVE To compare the performance on the American Board of Ophthalmology Written Qualifying Examination (WQE) with the performance on step 1 of the United States Medical Licensing Examination (USMLE) and the Ophthalmic Knowledge Assessment Program (OKAP) examination for residents in multiple residency programs. DESIGN Comparative case series. PARTICIPANTS Fifteen residency programs with 339 total residents participated in this study. The data were extracted from the 5-year American Board of Ophthalmology report to each participating program in 2009 and included residency graduating classes from 2003 through 2007. Residents were included if data were available for the USMLE, OKAP examination in ophthalmology years 1 through 3, and the WQE score. Residents were excluded if one or more of the test scores were not available. METHODS Two-sample t tests, logistic regression analysis, and receiver operating characteristic (ROC) curves were used to examine the association of the various tests (USMLE, OKAP examination year 1, OKAP examination year 2, OKAP examination year 3, and maximum OKAP examination score) as a predictor for a passing or failing grade on the WQE. MAIN OUTCOME MEASURES The primary outcome measure of this study was first time pass rate for the WQE. RESULTS Using ROC analysis, the OKAP examination taken at the third year of ophthalmology residency best predicted performance on the WQE. For the OKAP examination taken during the third year of residency, the probability of passing the WQE was at least 80% for a score of 35 or higher and at least 95% for a score of 72 or higher. CONCLUSIONS The OKAP examination, especially in the third year of residency, can be useful to residents to predict the likelihood of success on the high-stakes WQE examination.

Buccal mucous membrane graft-assisted lacrimal drainage surgery.

Purpose: Dacryocystorhinostomy (DCR) success may depend on mucous membrane alignment across the osteotomy and entire surgical lacrimal outflow conduit. Scar tissue, obliteration of the lacrimal sac, and obstruction at the level of the common canaliculus may result from prior surgery or may occur as an isolated problem. We describe and evaluate the efficacy of a technique of grafting autologous buccal mucous membrane during external DCR in cases complicated by scarring and/or common canalicular obstruction. Methods: We retrospectively reviewed 11 nasolacrimal outflow system obstructions (in 9 patients) treated with a buccal mucous membrane graft–assisted DCR. The surgical technique is described in detail. Results: All cases presented with insufficient nasolacrimal outflow. Ten tear ducts failed prior DCR procedures, while one case had isolated common canalicular obstruction, resistant to multiple probing and intubation and was previously recommended a Jones tube procedure. Three tear outflow systems (in 2 patients) exhibited common canalicular obstruction; the rest were obstructed at the level of the lacrimal sac. Two patients had bilateral obstruction. Ten eyes had symptomatic epiphora. One eye had dacryocystitis alone, and 2 eyes had dacryocystitis and epiphora. Six tear ducts had more than one previous DCR procedure. Four tear ducts had prior endonasal DCR procedures, while 6 had a previous external DCR. All eyes with epiphora preoperatively had complete relief of tearing. All cases of dacryocystitis resolved with no recurrences. Nine tear ducts were patent to irrigation testing postoperatively (2 were not tested). Conclusions: Buccal mucous membrane grafting may improve the success of DCR in cases complicated by scarring, mucosal shortage, and/or common canalicular obstruction.

Medial canthal open nasal fracture repair.

Purpose: Open repair of facial fractures may offer better outcomes than closed approaches. Advantages are inherent with direct visualization and the use of fixation devices. Yet, closed approaches are commonly favored for nasal fractures for simplicity, the avoidance of a facial scar, and because exposure to the nasal bones through traditional approaches is limited. Inadequate nasal repair, however, may result in collapsed or crooked noses caused by failure to adequately reduce and fixate fractures. We describe a medial canthal approach that provides optimal bony nasal exposure, minimizes facial incisions, and provides excellent open reduction and direct fixation of nasal fractures. Methods: We retrospectively reviewed 21 consecutive patients with nasal bony fractures surgically treated with open reduction and internal fixation, using a small, medial canthus incision. The surgical technique is described in detail. Results: In all 21 patients, the entire fractured nasal bridge was visualized. The fractures were reduced and then fixated to the normal anatomic position using a microfixation system (1.0 mm module). The scars were well hidden and tolerated by all patients. At follow-up of 6 to 18 months, 1 patient underwent scar revision for a depressed scar. Another patient required hardware removal secondary to tenderness associated with the microplate. Otherwise, there were no complications such as saddle nose, canthal dystopia, canthal webbing, or nasolacrimal outflow obstruction. No patient needed or desired revision rhinoplasty. Conclusions: The medial canthal approach was effective in permitting wide exposure and microplate fixation of nasal fractures.

Imaging of eyelid lymphatic drainage

PURPOSE Traditional descriptions of lymphatic drainage show eyelids emptying into the submandibular or preauricular basin. However recent studies based on in vivo lymphatic imaging show a possible predilection for the preauricular basin. We describe lymphoscintigraphy and report findings in patients with eyelid malignancies undergoing sentinel lymph node biopsy (SLNB). METHODS Retrospective chart review of 15 consecutive patients at a single institution with eyelid carcinoma undergoing SLNB. The primary outcome measure was primary facial lymphatic drainage site from the eyelid as determined by lymphoscintigraphy. RESULTS The preauricular basin was the site of focal radioactive uptake in all 15 patients. The location of the primary tumor was as follows: medial upper eyelid (1), medial canthus (3), medial lower eyelid (3), lateral upper eyelid (3), and lateral lower eyelid (5). The types of tumor were: invasive squamous cell carcinoma (7), malignant melanoma (3), and sebaceous cell carcinoma (2), Merkel cell carcinoma (2), and conjunctival spindle cell carcinoma (1). CONCLUSIONS Lymphoscintigraphy is increasingly used in the context of SLNB for periocular malignancy. The recent literature suggests that the preauricular lymph node basin may be the primary site of eyelid lymphatic drainage and this is corroborated by our series. Further data will elucidate the biology of eyelid lymphatic channels in humans but the preauricular basin may be the prime lymphatic metastastic site in eyelid malignancies.

Bilateral Upper and Lower Eyelid Severe Psoriasiform Blepharitis: Case Report and Review of Literature

The purpose of the present study is to describe a case of severe, psoriasiform blepharitis by means of a case report and literature review. A 44-year-old man developed chronic blepharitis and tearing months after bilateral cataract surgery. Exam showed diffuse quad-eyelid erythema, discharge, edema, madarosis, and scale. He also had insufficient tear drainage due to bilateral upper eyelid cicatricial punctal atresia with bilateral lower eyelid punctal stenosis. Biopsy of the lower eyelids exhibited psoriasiform hyperplasia. Topical 0.1% tacrolimus achieved improvement but caused some subjective eye irritation. Psoriasiform dermatitis manifesting on the eyelids is rare, may be associated with insufficient tear drainage, and may respond favorably to 0.1% tacrolimus.