Wendy W. Lee

Ocular damage secondary to intense pulse light therapy to the face.

Purpose: To promote awareness and prevention of ocular damage that can occur during Intense Pulsed Light (IPL) treatments of the periocular areas. Methods: A retrospective chart review was conducted of 2 cases involving ocular damage following IPL procedures that were treated at Bascom Palmer Eye Institute for ocular complications. Routine data were collected during ophthalmic examinations. Results: Case 1: A 36-year-old female presented with eye pain, marked pupillary constriction, and anterior uveitis an hour after receiving IPL treatment to the face. Within 1 month, the damage had progressed to posterior synechiae and iris transillumination defects. She continues to have pain and severe photophobia due to permanent iris atrophy and transillumination that have persisted for years. Case 2: A 27-year-old female presented with severe eye pain, vision disturbances, pupillary defects, and anterior uveitis 3 days after IPL of an eyelid freckle. At 2 months follow up, the iris and pupillary defects remain permanent. The patient continues to suffer from photophobia and pain. Conclusions: The pigmented iris absorbs light in the same wavelength range of IPL, thus remaining vulnerable to IPL exposure, especially when applied to the periocular area. The fact that IPL is not a laser may give people a false sense of security regarding damage to the eye. The cases presented give evidence that periorbital IPL treatment may permanently affect pigmented intraocular structures. It is imperative for treating physicians to be aware of these hazards and to use appropriate eye protection to prevent ocular damage.

Efficacy of fresh versus refrigerated botulinum toxin in the treatment of lateral periorbital rhytids.

Purpose: To determine if there is a difference in the efficacy of refrigerated (previously reconstituted) versus freshly reconstituted botulinum toxin (Botox Cosmetic, Allergan, Irvine, CA, U.S.A.) in the treatment of lateral periorbital rhytids. Methods: This is a randomized, double-blind, controlled, prospective study. Participants included individuals who were interested in the treatment of their lateral periorbital rhytids (crow’s feet) and responded to signs posted in ophthalmology clinics at our institution. Patients were randomized to receive fresh botulinum toxin on 1 side and refrigerated (reconstituted 2 weeks prior) botulinum toxin on the other. Photographs were taken at the pretreatment visit and at the 2-week, 6-week, and 3-month post-treatment visits. Patients were asked to describe any improvement in the appearance of the rhytids at the 2-week visit, the appearance of the rhytids at the 6-week visit, the appearance of the rhytids at the 3-month visit, and finally, the duration of effect at the 3-month visit as well as whether any intervening loss of efficacy had been noted subjectively. The subjective information was recorded by 1 investigator (JIH) at each of the follow-up visits. At the conclusion of the study, the photographs were shown to an ophthalmic plastic and reconstructive surgery fellow, who did not participate in the interventional portion of the study, to determine the response to treatment. This physician was masked to the study protocol and purpose and looked at each photograph without knowledge of treatment arm or timeline. The physician used the Wrinkle Assessment Scale developed by Lemperle et al. to grade the lateral periorbital rhytids on a 0 to 5 scale. Results: Forty-five patients were included in the final analysis. One patient felt there was a difference in the time of onset with the refrigerated toxin taking effect on day 3 versus day 4 for the fresh toxin. Unmasking revealed the following: 5 patients felt there was a greater effect on the freshly reconstituted side while 6 patients felt there was a greater effect on the refrigerated side. The independent physician evaluator determined there was a difference in effect between sides in 4 patients with the greater effect on the fresh side in 2 patients and the refrigerated side in 2 patients. Conclusions: This study demonstrates that 2 weeks of refrigeration does not appear to significantly affect the time of onset or efficacy of botulinum toxin in the treatment of lateral periorbital rhytids.

Three-Snip Punctoplasty Outcome Rates and Follow-Up Treatments

ABSTRACT Purpose: To demonstrate the success rate of three-snip punctoplasty (TSP) for the treatment of punctual stenosis and to evaluate the need for additional treatment after TSP. Methods: A retrospective chart review was conducted of all patients undergoing TSP by a single surgeon at Bascom Palmer Eye Institute from January 1, 2006 to January 1, 2010. Outcome measures include the persistence of symptomatic epiphora, the need for additional surgical interventions, and postoperative time required until complete resolution of symptoms achieved. Results: Primary TSP resulted in an 86% success rate with resolution of symptomatic epiphora without further surgical intervention. Seven eyes (14%) required secondary TSP with or without stent placement. All 6 eyes with TSP with stent placement achieved functional success within an average of 6.8 months (stdev 6.83) from the first TSP. The one eye that was not stented during secondary TSP required a tertiary TSP with stenting and achieved functional success within the 1 month of the final procedure. Conclusion: Primary TSP showed an 86% success rate with the resolution of tearing by an average of 1.2 months post-operatively. Membrane formation or scarring over the surgical site required an additional TSP with stenting in 14% of patients. All 50 eyes eventually achieved functional success. TSP alone as a primary procedure is a safe, relatively simple, and effective treatment of epiphora caused by punctual stenosis. Stenting should be explored as an adjunct to this procedure if primary TSP alone does not produce resolution of symptoms.

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis.

Abstract Purpose: Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss. Methods: All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed. Results: Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (−2.5 ± 1.2 vs. −0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm3 vs. 0.7 ± 0.5 mm3, p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology. Conclusions: Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

Optic nerve sheath fenestration for the treatment of papilledema secondary to cerebral venous thrombosis

A 16-year-old adolescent girl with multiple risk factors for thrombosis presented with acute onset of headache, decreased vision, and papilledema. Evaluation demonstrated cerebral venous thrombosis (CVT) involving the left transverse and sigmoid sinuses and left internal jugular vein. Following bilateral optic nerve sheath fenestration (ONSF), she experienced improvement in vision and resolution of papilledema. In selected cases, ONSF is an effective surgical option for the treatment of papilledema due to CVT after medical treatment has failed.

Assessing the Effectiveness of Arnica montana and Rhododendron tomentosum (Ledum palustre) in the Reduction of Ecchymosis and Edema After Oculofacial Surgery: Preliminary Results.

PURPOSE The purpose of this study was to provide preliminary data on the potential effectiveness of the combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) in reducing postoperative ecchymosis and edema in a select population of healthy volunteers after oculofacial surgery. METHODS This retrospective review examined the postoperative course of healthy volunteers using topical Arnica and Ledum after undergoing common oculofacial procedures, including blepharoplasty, browpexy, and rhinoplasty, in the hands of 4 surgeons at tertiary referral centers from July 1, 2012 to December 31, 2012 using medical records review. Each patient included had used topical hydrogel pads (OcuMend, Cearna Inc., Chicago, IL) containing Arnica 50 M (10) 50% and Ledum 50 M (10). The pads were applied bilaterally after surgery through postoperative day 6. At each postoperative visit, the patients were evaluated by their respective surgeons and assigned a subjective physician-patient rating score comparing each patients observed healing compared with expected healing if not using Arnica/Ledum. Photographs of patients undergoing equivalent procedures, but not using Arnica/Ledum were used as controls for comparison. Physician-patient rating scores were categorical: markedly accelerated healing defined as approximately 7 days ahead of expected, accelerated healing, defined as <7 days ahead of expected, and no appreciable difference from expected. The proportion of patients with each physician-patient rating score was calculated for postoperative days 1 to 2, 3 to 5, 6 to 8, and overall. Difference of proportions was calculated with 95% confidence intervals using Newcombe unpaired difference comparison of proportions. Photographs documenting the clinical progression of selected patients are provided. RESULTS A total of 27 patients (16 females, 11 males) were included in the study. Age range was 18 to 70 years. The majority of patients were white (52.9%), and underwent blepharoplasty (78.9%). The median duration of follow-up was 7 days, range 1 to 14 days. The proportions of patients with markedly accelerated healing were 38.5% (5 of 13), 85.7% (6 of 7), 60.0% (12 of 20), and 51.9% (14 of 27) at POD 1 to 2, 3 to 5, 6 to 8, and overall, respectively. The proportions of patients with accelerated healing at the same time points were 15.4% (2 of 13), 14.3% (1 of 7), 30.0% (6 of 20), and 37.0% (10 of 27), respectively. The proportions of patients with no appreciable difference at the same time points were 46.2% (6 of 13), 0% (0 of 7), 10.0% (2 of 20), and 11.1% (3 of 27) of patients, respectively. The proportion of patients using Arnica/Ledum with markedly accelerated healing was significantly more than the proportion of those demonstrating no appreciable difference from expected at POD 3 to 5 (85.7% vs. 0%, p = 0.05), POD 6 to 8 (60.0% vs. 10.0%), and overall (51.9% vs. 11.1%, p = 0.05). No adverse effects were reported. CONCLUSIONS The preliminary results from this study demonstrate that the combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) may be effective in reducing postoperative ecchymosis and edema after oculofacial surgery.The purpose of this study was to provide preliminary data on the potential effectiveness of the combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) in reducing postoperative ecchymosis and edema in a select population of healthy volunteers after oculofacial surgery. This retrospective review examined the postoperative course of healthy volunteers using topical Arnica and Ledum after undergoing common oculofacial procedures, including blepharoplasty, browpexy, and rhinoplasty, in the hands of 4 surgeons at tertiary referral centers from July 1, 2012 to December 31, 2012 using medical records review. Each patient included had used topical hydrogel pads (OcuMend, Cearna Inc., Chicago, IL) containing Arnica 50 M (10−100,000) 50% and Ledum 50 M (10−100,000). The pads were applied bilaterally after surgery through postoperative day 6. At each postoperative visit, the patients were evaluated by their respective surgeons and assigned a subjective physician–patient rating score comparing each patient’s observed healing compared with expected healing if not using Arnica/Ledum. Photographs of patients undergoing equivalent procedures, but not using Arnica/Ledum were used as controls for comparison. Physician–patient rating scores were categorical: markedly accelerated healing defined as approximately 7 days ahead of expected, accelerated healing, defined as <7 days ahead of expected, and no appreciable difference from expected. The proportion of patients with each physician–patient rating score was calculated for postoperative days 1 to 2, 3 to 5, 6 to 8, and overall. Difference of proportions was calculated with 95% confidence intervals using Newcombe unpaired difference comparison of proportions. Photographs documenting the clinical progression of selected patients are provided. A total of 27 patients (16 females, 11 males) were included in the study. Age range was 18 to 70 years. The majority of patients were white (52.9%), and underwent blepharoplasty (78.9%). The median duration of follow-up was 7 days, range 1 to 14 days. The proportions of patients with markedly accelerated healing were 38.5% (5 of 13), 85.7% (6 of 7), 60.0% (12 of 20), and 51.9% (14 of 27) at POD 1 to 2, 3 to 5, 6 to 8, and overall, respectively. The proportions of patients with accelerated healing at the same time points were 15.4% (2 of 13), 14.3% (1 of 7), 30.0% (6 of 20), and 37.0% (10 of 27), respectively. The proportions of patients with no appreciable difference at the same time points were 46.2% (6 of 13), 0% (0 of 7), 10.0% (2 of 20), and 11.1% (3 of 27) of patients, respectively. The proportion of patients using Arnica/Ledum with markedly accelerated healing was significantly more than the proportion of those demonstrating no appreciable difference from expected at POD 3 to 5 (85.7% vs. 0%, p = 0.05), POD 6 to 8 (60.0% vs. 10.0%), and overall (51.9% vs. 11.1%, p = 0.05). No adverse effects were reported. The preliminary results from this study demonstrate that the combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) may be effective in reducing postoperative ecchymosis and edema after oculofacial surgery.

Microbiology and Biofilm Trends of Silicone Lacrimal Implants: Comparing Infected Versus Routinely Removed Stents

Purpose: To investigate the pathogens and biofilms responsible for clinically significant infection of silicone stents implanted within the lacrimal system. Methods: Retrospective review of culture results and patient demographics for all silicone lacrimal stents removed early for clinically significant infection and sent to the Bascom Palmer Microbiology Laboratory through the end of year 2010. As a control, routinely removed, clinically noninfected stents from the same institution were prospectively sent for culture over a 6-month period. Four clinically infected and 6 clinically noninfected stents showing mucus within the lumen at removal were sent for scanning electron microscopy. Images were randomized and graded by a microbiologist for the presence of organisms, matrix deposits, organisms within matrix, and overall impression of significant biofilm formation. Results: Nineteen stents were included in the study; 100% of clinically infected (n = 10) and noninfected (n = 9) stents were culture positive. Culture positivity for nontuberculous mycobacterium was found in 90% of infected stents and none of the noninfected stents (p < 0.001). Of infected stents, 50% grew Gram-positive organisms compared with 89% of noninfected stents (p = 0.07). Fifty percent of infected versus 67% of noninfected stents were culture positive for Gram-negative organisms (p = 0.46). Electron microscopy of stents revealed organisms consistent with culture results (size, shape) in planktonic and biofilm form. Masked observer image grading revealed a statistically significant higher amount of organism and biofilm on infected versus noninfected specimen. Conclusion: Nontuberculous mycobacteria comprise the primary pathogens responsible for clinically significant infection of silicone stents in the lacrimal system in South Florida. Robust biofilm production by this organism likely plays a role in pathogenesis. Further research into biofilm-related lacrimal implant infection may aid in the development of useful prevention and treatment strategies.

Adenoid cystic carcinoma of the lacrimal gland in a 14-year-old male

ABSTRACT Adenoid cystic carcinoma (ACC) of the lacrimal gland is an aggressive, malignant epithelial neoplasm. This tumor is rarely seen in adults and even less commonly seen in children and adolescents; thus, there have been no large studies to date describing the optimal treatment of this malignancy in the pediatric population. Here, we report a case of lacrimal gland ACC in a 14-year-old male treated with neoadjuvant intra-arterial chemotherapy followed by globe-sparing tumor resection and chemoradiation. At 2-year follow-up, he remains disease free without evidence of tumor recurrence.

Novel Pigtail Cannula for a Canalicular-Involving Eyelid Laceration.

An 89-year-old woman presented with a canalicular-involving laceration/avulsion of the right lower eyelid after a fall. The inferior canaliculus was severed deep within the wound, and the ends were difficult to identify. Novel pigtail cannulas, designed by the authors, were used for lacrimal system intubation and suture passage. Satisfactory cosmetic and functional results were achieved. These cannulas facilitate repair by integrating multiple functionalities in a single instrument. Once a cannula has been inserted and rotated, the location of fluid egress provides important clues. If injected saline appears in the nasopharynx but not in the wound, absence of a common canaliculus can be suspected. Injection of viscoelastic, air or fluorescein-impregnated saline also permits easier identification of the cut end of the canaliculus within the wound and facilitates appropriate rotation of the pigtail.

Split face evaluation of long‐pulsed non‐ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars

To investigate 1,064 nm long‐pulse Nd:YAG laser for postoperative treatment of direct browplasty scars.