John D. Ng

IgG4 Immunostaining and Its Implications in Orbital Inflammatory Disease

Objective IgG4-related disease is an emerging clinical entity which frequently involves tissue within the orbit. In order to appreciate the implications of IgG4 immunostaining, we analyzed gene expression and the prevalence of IgG4- immunostaining among subjects with orbital inflammatory diseases. Methods We organized an international consortium to collect orbital biopsies from 108 subjects including 22 with no known orbital disease, 42 with nonspecific orbital inflammatory disease (NSOI), 26 with thyroid eye disease (TED), 12 with sarcoidosis, and 6 with granulomatosis with polyangiitis (GPA). Lacrimal gland and orbital adipose tissue biopsies were immunostained for IgG4 or IgG secreting plasma cells. RNA transcripts were quantified by Affymetrix arrays. Results None of the healthy controls or subjects with TED had substantial IgG4 staining. Among the 63 others, the prevalence of significant IgG4-immunostaining ranged from 11 to 39% depending on the definition for significant. IgG4 staining was detectable in the majority of tissues from subjects with GPA and less commonly in tissue from subjects with sarcoidosis or NSOI. The detection of IgG4+ cells correlated with inflammation in the lacrimal gland based on histology. IgG4 staining tissue expressed an increase in transcripts associated with inflammation, especially B cell-related genes. Functional annotation analysis confirmed this. Conclusion IgG4+ plasma cells are common in orbital tissue from patients with sarcoidosis, GPA, or NSOI. Even using the low threshold of 10 IgG4+ cells/high powered field, IgG4 staining correlates with increased inflammation in the lacrimal gland based on histology and gene expression.

Facial skin rejuvenation

Purpose of review In recent years, many new products and techniques have arisen that are useful in the rejuvenation of facial skin. Most of the therapies are directed at improving the results of photoaging. These cutaneous changes occur from chronic exposure to ultraviolet B light (290 to 320 nm) associated with sunburn, and ultraviolet AII light (320 to 340 nm), and ultraviolet AI light (340 to 400 nm) associated with photoaging. Clinically chronic photoaging may result in fine wrinkles, texture abnormalities, pigment dyschromias, and actinic keratoses. Recent findings Many methods of patient assessment are available, but the most useful include the Fitzpatrick skin type classification and the Glogau photoaging scale. Although many therapies are available to reduce or even reverse many of these aging changes, patient education regarding lifestyle changes (especially smoking cessation) and sun avoidance need to be a critical foundation of treatment. Indeed, patient participation in their own skin care regimen is important for any program to be effective. Topical therapy including tretinoins, hydroxy acids, bleaching agents, and sunscreens are discussed herein. Summary The physician has an important role in understanding which treatment options are appropriate for mild, moderate, and severe photoaging, and in educating patients on the risks and benefits of each. This includes resurfacing modalities with microdermabrasion, chemical peels, and laser skin resurfacing.

The porous polyethylene/bioglass spherical orbital implant: a retrospective study of 170 cases.

Purpose: To report patient outcomes after placement of porous polyethylene (PPE)/bioglass (BG) orbital implants for primary enucleation or secondary implantation. Design: Retrospective chart review in one surgeons practice (J.D.N.). Methods: A chart review of all patients who underwent placement of PPE/BG orbital implants was performed. Data included patients age, gender, surgical indication, prior ocular surgery, medical history, procedure performed, implant size, and postoperative complications. Results: PPE/BG implants were placed in 170 sockets. Seventy-seven patients were women, and 85 were men. One hundred forty patients underwent primary enucleation and placement of an implant, and 22 patients underwent secondary implantation. One hundred sixty-one patients did well after orbital implantation with a comfortable socket, quiet conjunctiva, and motility. Complications occurred in 9 patients (5.3%). Excessive discharge alone occurred in 2 patients (1.2%). Seven sockets undergoing primary enucleation and implant placement had implant exposure. One patient had an early exposure, and 6 had late exposures. All exposures were successfully treated with antibiotics or additional surgery. Secondary surgeries were required by some patients, but not due to implant complications, included ectropion repair in 5 patients (2.9%) and volume augmentation in 3 patients (1.7%). Conclusions: The PPE/BG orbital implant may be a useful implant for orbital reconstruction after primary enucleation or as a secondary implant.

Complications of bioabsorbable orbital implants and fixation plates.

After orbital floor and trimalar fracture repair with the use of a bioabsorbable maxillofacial implant, a patient had eyelid retraction with a thickened, immobile eyelid. We observed a dense, fibrous scar and encapsulation at the implantation site.

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.

Comparison of injection pain of articaine and lidocaine in eyelid surgery

Purpose: To compare the pain induced by tissue infiltration of lidocaine 2% with epinephrine 1:100,000 versus articaine 4% with epinephrine 1:100,000 for eyelid surgery. Methods: Thirty patients undergoing bilateral eyelid surgery were enrolled in a prospective, randomized, double-masked study. Each subject received injections of lidocaine 2% with epinephrine 1:100,000 (Xylocaine) on one side and articaine 4% with epinephrine 1:100,000 (Septocaine) on the other for surgical anesthesia. The patients rated the pain of infiltration using a 100-mm visual analogue scale immediately after receiving each injection. The pain scores were compared using the paired t test. Results: Twenty-two of the 30 patients (73.3%) rated the articaine injection as less painful than the lidocaine injection. The mean pain score for lidocaine was 42.60 ± 24.74 and the pain score for articaine was 31.85 ± 20.28 (p = 0.011). Conclusions: In this study, infiltration of articaine was less painful than lidocaine for eyelid surgery, making articaine an attractive alternative for local anesthesia.

Orbital Trauma Caused by Bicycle Hand Brakes

Purpose This report aims to increase awareness of an unusual mechanism of orbital injury sustained by bicycle riders. Methods In this retrospective small case series, we describe two cases of orbital injury caused by upper eyelid penetration. A 5-year-old boy (patient 1) and a 6-year-old boy (patient 2) presented to our service within a 2-week period. Both had been injured by similarly styled, handlebar-mounted bicycle hand brake levers. Patient 1 had an orbital roof fracture and penetrating brain injury and underwent repair of a left upper eyelid laceration, craniotomy for pseudoencephalocele, and ptosis repair. Patient 2 had orbital hemorrhage and underwent repair of left upper eyelid laceration. Results In both cases, a handlebar-mounted bicycle hand brake lever perforated the left eyelid when the rider fell onto it. Neither patient was wearing protective headwear or eyewear. Two months after surgery, patient 1 had 20/25 visual acuity OU and excellent cosmetic appearance. Patient 2 had baseline amblyopic vision 2 days after surgery but moved from town and was lost to follow-up. Conclusions Orbit injuries from bicycle brake levers are rare, and helmets or protective eyewear probably would not have prevented these injuries. However, a change in the design and/or mounting location of handlebar-mounted brake levers might help prevent further injuries of this type.

The Endoscopic Browlift for Forehead Rejuvenation

Since its initial description by Vasconez et al in 1992, the endoscopic browlift has evolved into a popular method for addressing brow ptosis and forehead rejuvenation. The advantages of fewer incisions, less postoperative swelling, alopecia and prolonged scalp anesthesia, and more rapid rehabilitation have provided greater patient acceptance than the traditional coronal approach. Unlike the coronal browlift where the amount of elevation is determined by the amount of skin excised, the elevation in the endoscopic browlift is determined by periosteal release at the arcus marginalis and forehead flap fixation. Though equipment costs are greater and a learning curve exists, the endoscopic browlift offers the oculoplastic surgeon additional beneficial options in the management of brow ptosis.

Review of Alloderm Acellular Human Dermis Regenerative Tissue Matrix in Multiple Types of Oculofacial Plastic and Reconstructive Surgery

Purpose: AlloDerm acellular human dermis is used for repair or replacement of damaged or inadequate skin tissue. It has been used successfully in multiple types of surgeries, including abdominal wall reconstruction, breast reconstruction, and head and neck reconstruction. Its application to ophthalmic plastic and reconstructive surgery is less well described. This study seeks to evaluate the efficacy and factors influencing surgical outcomes using Alloderm in multiple types of oculofacial plastic surgery. Methods: Institutional Review Board-approved retrospective review of 84 patients who underwent surgical procedures using Alloderm. Preoperative demographic data, comorbidities, smoking, clinical etiology, surgical methods, Alloderm type, and outcome (cosmetic and functional) were evaluated. Results: This study included 84 patients, accounting for a total of 98 procedures. Mean age was 52.5 years (3–93 years). Etiologies necessitating surgery included malignancy in 26 patients (31.0%), trauma in 19 patients (22.6%), congenital lesions in 15 patients (17.9%), and senile change in 11 patients (13.1%). Surgical procedures included lower eyelid posterior lamella elongation, socket and fornix reconstruction, scar repair, patch grafts, and filler. Mean duration of follow up was 530 days. Overall, 92.8% of patients had favorable outcomes. Factors associated with significantly worse outcomes included smoking, congenital anomaly etiologies, and previous graft/flaps in the same area (p = 0.03, p = 0.029, and p = 0.007, respectively). Conclusions: This study suggests that Alloderm acellular human dermis can be used safely and effectively in multiple types of oculofacial procedures. Smoking, congenital anomaly etiologies, and previous graft/flap were associated with poor cosmetic and functional outcomes.

Orbital pseudotumor can be a localized form of granulomatosis with polyangiitis as revealed by gene expression profiling.

Biopsies and ANCA testing for limited forms of granulomatosis with polyangiitis (GPA) are frequently non-diagnostic. We characterized gene expression in GPA and other causes of orbital inflammation. We tested the hypothesis that a sub-set of patients with non-specific orbital inflammation (NSOI, also known as pseudotumor) mimics a limited form of GPA. Formalin-fixed, paraffin-embedded orbital biopsies were obtained from controls (n=20) and patients with GPA (n=6), NSOI (n=25), sarcoidosis (n=7), or thyroid eye disease (TED) (n=20) and were divided into discovery and validation sets. Transcripts in the tissues were quantified using Affymetrix U133 Plus 2.0 microarrays. Distinct gene expression profiles for controls and subjects with GPA, TED, or sarcoidosis were evident by principal coordinate analyses. Compared with healthy controls, 285 probe sets had elevated signals in subjects with GPA and 1472 were decreased (>1.5-fold difference, false discovery rate adjusted p<0.05). The immunoglobulin family of genes had the most dramatic increase in expression. Although gene expression in GPA could be readily distinguished from gene expression in TED, sarcoidosis, or controls, a comparison of gene expression in GPA versus NSOI found no statistically significant differences. Thus, forms of orbital inflammation can be distinguished based on gene expression. NSOI/pseudotumor is heterogeneous but often may be an unrecognized, localized form of GPA.