Lora R. Dagi Glass

Orbital fat decompression for thyroid eye disease: retrospective case review and criteria for optimal case selection.

Purpose: The purpose of this study is to identify the subgroups of thyroid eye disease (TED) patients most likely to benefit from orbital fat decompression. Methods: This retrospective study reviews 217 orbits of 109 patients who underwent orbital fat decompression for proptosis secondary to thyroid eye disease. Charts were reviewed for demographic, radiographic, clinical, and surgical data. Three groups of patients were defined for the purposes of statistical analysis: those with proptosis secondary to expansion of the fat compartment (group I), those with proptosis secondary to enlargement of the extraocular muscles (group II), and those with proptosis secondary to enlargement of both fat and muscle (group III). Results: Groups I and II, and those patients with greater preoperative proptosis and those with a history of radiation therapy were most likely to benefit from orbital fat decompression. However, even those in group III or with lesser proptosis appreciated significant benefit. Conclusions: While orbital fat decompression can and, at times, should be combined with bone decompression to treat proptosis resulting from thyroid eye disease, orbital fat decompression alone is associated with lower rates of surgical morbidity, and is especially effective for group I and II patients, those with greater preoperative proptosis, and those with a history of radiation.

Accuracy of MRI in defining tumor-free margin in optic nerve glioma surgery.

Purpose:To determine the value of preoperative MRI in predicting the histopathologic margin of optic nerve glioma undergoing surgical resection. Methods:Retrospective, noncomparative, multicenter case series of patients diagnosed with prechiasmal optic nerve glioma, using MRI, who underwent surgical resection. Clinical data were abstracted from patient medical records at 6 medical centers through a survey vehicle. Preoperative MRI findings were compared with intraoperative findings and postoperative histopathologic interpretations of the posterior margins of 13 surgically resected optic nerve gliomas. Results:A total of 13 patient submissions qualified for study entry based on preoperative MRI having identified a unilateral optic glioma anterior to the optic chiasm. Of these, 2 cases (15%) demonstrated an abnormal macroscopic appearance of the chiasm intraoperatively and were surgically debulked rather than resected as planned preoperatively. The remaining 11 patients underwent resection posterior to the margins indicated by preoperative MRI. Of these, 3 (27%) demonstrated evidence of microscopically positive margins on histopathologic examination. Follow up ranged from 3 months to 21 years. One patient with involvement of the chiasm manifested tumor growth; no other recurrences or evidence of growth occurred in the remaining patients, including 1 other case with involvement of the chiasm and 3 cases with positive surgical margins. Conclusions:Unilateral optic nerve gliomas limited to the prechiasmatic nerve on MRI not infrequently extend beyond the MRI borders. This finding is of significance when considering management options, particularly surgical resection.

Reactivation of thyroid eye disease following extraocular muscle surgery.

A 60-year-old man with stable bilateral thyroid eye disease (TED) underwent unilateral strabismus surgery. Within 1 month, he developed TED reactivation in only the contralateral orbit. At a later date, again after 6 months of inactive TED, he underwent bilateral strabismus surgery. Within 1 month of surgery, he developed bilateral TED reactivation. Surgical manipulation of orbital tissues may, in rare cases, provoke reactivation of TED.

Optic nerve glioma: case series with review of clinical, radiologic, molecular, and histopathologic characteristics.

Purpose: This study was designed to better understand the biologic nature of optic nerve gliomas (ONGs) and to investigate staining techniques that might improve the pathologic interpretation of surgical margins. Methods: In this retrospective case series, clinical data on patient presentation, MRI, surgical visualization, and initial pathologic interpretation were gathered. Specimens were then reexamined using analysis of p53, isocitrate dehydrogenase 1 (IDH1), MIB-1, and B-rapidly accelerated fibrosarcoma (BRAF) duplication. Results: Six patients were studied. All were diagnosed with World Health Organization grade 1 ONGs on original pathology. On reexamination, BRAF tandem duplication was found in 2 patients with neurofibromatosis Type 1 association. P53 immunoreactivity was noted in a third case. No cases had IDH1 immunoreactivity. Focal elevations of MIB-1 up to 7.5% were noted in 2 cases. Conclusions: ONGs are neoplasms with variable degrees of aggressiveness. As more is understood regarding their varied genetic underpinnings, improved pathologic classification and individualized treatment regimens may be achieved. The authors hope that this study helps guide the oculoplastic community toward a multi-institutional, prospective study of ONG genomic sequencing.

Mullers Muscle Conjunctival Resection for Treatment of Contact Lens-Associated Ptosis.

Purpose: The aim of this study was to look at the surgical outcomes of posterior approach Mullers muscle conjunctival resection surgery for contact lens-related ptosis. Methods: This was a retrospective, comparative interventional case series. All patients and controls underwent phenylephrine 10% testing and had a positive response prior to surgical intervention. Results: Thirty-one eyelids with ptosis were identified in 20 contact lens wearing patients, which were matched with 27 eyelids in 15 controls. The contact lens wearing patients wore contact lenses for a mean of 20.6 ± 12.1 years. More than half (60%) wore soft contact lenses, as opposed to rigid gas-permeable contact lenses. Preoperative margin-to-reflex distance-1 was lower in patients who wore rigid contact lenses (0.8 ± 0.7 mm) as compared with patients with soft contact lenses (1.7 ± 1.1 mm) (p = 0.01). Surgical success, as defined by margin-to-reflex distance-1 ≥3 mm or symmetry of upper eyelid height (within 1 mm), was achieved in 93.5% in the contact lens group and 92.6% of controls. Postoperative margin-to-reflex distance-1 was significantly higher in the contact lens wearers (3.9 ± 1.3 mm) compared with the controls (3.2 ± 1.1 mm; p = 0.01). There was a significant correlation between the amount of tissue resected intraoperatively and the improvement in margin-to-reflex distance-1 (Pearsons correlation coefficient, r =0.36; p = 0.006). There were no surgical complications of any patients in the study. Conclusion: Mullers muscle conjunctival resection surgery is an effective surgical correction for contact lens-associated ptosis. Patients can achieve excellent results with minimal risk of residual ptosis or asymmetry.

Conjunctival Melanoma Responsive to Combined Systemic BRAF/MEK Inhibitors.

This report demonstrates a unique case of conjunctival melanoma harboring a BRAF V600E mutation responsive to systemic therapy with BRAF and MEK inhibitors. While systemic therapy would not be appropriate in patients with local disease alone, it may act therapeutically in cases of higher stage ocular surface and eyelid melanoma.

The lateral brow: position in relation to age, gender, and ethnicity.

Purpose: Despite multiple studies regarding modes of eyebrow measurement and movement over time, the lateral aspect of the brow has been relatively ignored in the literature. Therefore, we arranged a study of the most lateral aspect of the eyebrow; in doing so, we hoped to ascertain the most practical line or angle of measurement. Methods: In this cross-sectional study, adults age 18 years and older with no history of congenital or acquired periorbital or orbital pathology or surgery, brow tattooing or heavy plucking, phthisis, or strabismus were measured using a combination of in-office metrics and computer analysis. Subjects were asked to identify their ethnicity and country of origin. Models of age, gender, and ethnicity were created. Results: One thousand twenty-four subjects were included (1,944 eyes). Measurements of nasal ala to lateral brow (NALB), lateral brow plumb line (LBPL; the vertical line between the tail of the brow and a horizontal line extending from the lateral canthus), and angle from the midbrow to the lateral brow tail showed statistically significant decline over time. The angle and LBPL varied mostly by ethnicity. The angle narrowed approximately 3° per 20 years, while the LBPL fell approximately 2.5 mm per 20 years. The NALB varied most by age and fell approximately 3 mm per 20 years. Conclusions: The lateral tail of the brow descends with age. Measurements of its location and rate of change vary between genders and within ethnic groups. Two easily measured values—NALB and LBPL—can be used for preoperative planning and postoperative documentation.

Non-glaucoma periocular allergic, atopic, and irritant dermatitis at an academic institution: A retrospective review

ABSTRACT Purpose: To better understand the nature of periocular dermatitis (PD) patient presentation, treatment, time-to-cure, and referral pattern for allergy testing in an ophthalmic academic center. Methods: A retrospective chart review of 344 patients diagnosed with PD between January 1, 2000 and November 30, 2016 at the Edward S. Harkness Eye Institute was performed. Eighty patients were eligible for the study. The primary endpoint was the time-to-cure. Cox proportional hazards regression was performed to assess if there was a significant difference between time-to-cure in patients treated with: 1) combination topical steroid/antibiotic (n = 6) vs. topical steroid alone (n = 40) and 2) combination topical steroid and oral antihistamine (n = 5) vs. topical steroid alone (n = 40). Results: The median age of eligible patients was 57.69 years old, 66.25% of patients were female, and 41.25% had a history of atopy. Seven patients in total were referred for allergy testing. A significant difference was found in likelihood of cure when comparing combination topical steroid and oral antihistamine versus topical steroid alone, adjusting for age and gender (aHR = 3.97, 95% CI: 1.40–11.25). No significance was found when comparing combination topical steroid/antibiotic versus topical steroid alone (aHR = 1.96, 95% CI: 0.72–5.27). Conclusion: Patients treated with topical steroid and oral antihistamine were approximately 4 times more likely to experience cure in comparison to patients treated with topical steroids alone. While the majority of patients were not referred for formal allergy testing, this would likely be of benefit.

Reply re: "Reactivation of thyroid eye disease following extraocular muscle surgery".

To the Editor: We read with interest the results of a recent article by Petris and Holds describing the results of medial conjunctivoplasty for the surgical treatment of symptomatic patients with conjunctivochalasis (CCh). We congratulate the authors for quantifying the severity of epiphora to judge the success of their intervention in this population. Their results reveal that the majority (80%) of CCh cases benefit from a medial conjunctival procedure and support the role of punctal occlusion in the development of epiphora in CCh. In our previous report published in Cornea, we were able to demonstrate that among 75 patients with different severity of CCh, 47 (63%) patients had punctal occlusion, 54 (72%) had delayed fluorescein clearance test (FCT), and 56 (75%) had epiphora. Furthermore, epiphora and delayed FCT were more frequently observed with increasing grades of CCh and were strongly correlated (r = 0.797, p < 0.001). Thus, targeting the medial conjunctiva appears to be a logical strategy for the treatment of symptomatic CCh and is a less invasive procedure compared with the resection of an entire inferior conjunctival wedge as advocated in previous reports. Nonetheless, the observation that certain eyes did not benefit from the medial conjunctival procedure lends support to the notion that punctal occlusion is not the only mechanism causing epiphora and unstable tear film also plays an important role in this disorder. We recommend grading the extent of CCh as advocated by Meller and Tseng in future studies to better understand the effects of different surgical approaches to treat the redundant conjunctiva in this disorder.