Ophthalmic Plastic and Reconstructive Surgery最新文献

Purpose: To compare clinical characteristics of patients with and without a known systemic malignancy at the time of diagnosis of orbital metastases.

Methods: Retrospective case note and imaging review for patients with orbital metastases presenting between 1980 and 2022. Patients were classified as having known malignancy at orbital presentation (group I) or without known malignancy (group II).

Results: Of 159 patients with orbital metastases, breast cancer was the commonest (77/159; 48%), followed by neuroendocrine tumors (10%), melanoma (7%), and lung or prostate cancers (5% of each); cancers with unknown primary site comprised 11%. There were 105/159 (66%) group I patients with known primary tumor, their having more females (79% group I vs. 61% group II; p = 0.02), breast cancers (58% vs.30%; p = 0.0004), and melanomas (10% vs. 0%; p = 0.02). Compared with group II, group I had a lower rate of globe dystopia (21% vs. 38%; p = 0.03) and fewer extraconal lesions (33% vs. 50%; p = 0.05), but more involvement of the posterior third of the orbit (21% vs. 6%; p = 0.03). Imaging revealed a distinct orbital mass in 74%, with breast cancer often presenting as ill-defined or infiltrative lesions (29%).

Conclusion: Most orbital metastases originate from breast, neuroendocrine tumors, or melanoma, with about a third presenting before a primary systemic malignancy is detected. Those from breast and melanoma were more frequent in patients with a known primary tumor. Symptoms and signs were similar in patients with or without known systemic tumor at the time of orbital presentation, and most presented with features due to a mass effect.

Purpose: To review evidence supporting proposed anatomic etiologies of involutional entropion and propose additional potential contributing factors.

Methods: A literature review was performed to identify publications describing possible etiologies of involutional entropion. The author's clinical observations and information supporting new proposed causes are presented.

Results: The frequency of perceived anatomic causes of entropion listed in modern publications include retractor dehiscence (97%), horizontal eyelid laxity (89%), orbicularis override (89%), enophthalmos (33%), tarsal atrophy (16%), and fat prolapse (10%). Evidence suggests attenuation of the retractors is a predominant factor in most patients. Tarsal atrophy, enophthalmos, and fat prolapse likely play a role in some individuals. The eyelid distraction test often shows horizontal margin laxity, although the eyelids typically are not elongated. Poor deep fixation and increased inferior mobility of the lateral canthus may contribute to marginal laxity and predispose patients to entropion. Lateral rectus capsulopalpebral fascia attenuation could lead to this canthal instability and reduced horizontal stability of the tarsal base.

Conclusions: Various age-related anatomic changes predispose patients to involutional entropion. Findings may vary among individuals. Tarsal atrophy and relative enophthalmos reduce appositional tension between the eyelid and globe. Lower eyelid retractor dehiscence causes poor anterior lamellar fixation and rotary instability of the tarsal base. Orbital fat prolapse may displace the tarsal base and alter orbicularis mechanics. Dysfunction of the lateral rectus capsulopalpebral fascia may contribute to both canthal instability and reduced horizontal tension near the tarsal base. Each patient's findings should be considered when individualizing surgical repair.

In this case report, the authors demonstrate a rare co-occurrence of multiple eyelid apocrine hidrocystomas with a prolactinoma.

We report the youngest case of solitary fibrous tumor (SFT) with extensive involvement of the nasolacrimal duct system and discuss current literature regarding this tumor type. A 12-year-old female presented with a 6-month history of an enlarging right medial orbit mass. CT orbits revealed a well-circumscribed, enhancing lesion adjacent to the right nasolacrimal system. Pathology confirmed SFT (1.2 × 1.1 × 1.1 cm) with spindle cell morphology and a mitotic rate of 5 per 10 high power fields. Immunohistochemistry (IHC) was positive for CD-34 and signal transducer and activator of transcription 6 and negative for S-100, consistent with SFT. Next-generation sequencing confirmed NGFI-A-binding protein 2::signal transducer and activator of transcription 6 gene fusion. To our knowledge, only 17 cases of SFT involving the lacrimal sac have been reported, of which, the average age was 43.5 years. Notably, SFTs with a high mitotic rate carry a heightened risk of malignant transformation. Given our patient's mitotic rate of 5 per 10 high power fields, positive surgical margins, and young age, close follow-up is imperative.

Purpose: Thyroid eye disease-related retraction and strabismus treatment is complicated by the activity level of the disease. Botulinum toxin injection can provide relief of symptoms in lieu of, or while waiting for surgery, radiation, or alternative medications. This study reviews techniques, outcomes, and effectiveness of botulinum toxin usage in thyroid eye disease.

Methods: A systematic review was conducted using PubMed, Embase, Web of Science, and Cochrane to identify research investigating botulinum toxin treatment of thyroid eye disease through May 2024. A meta-analysis was performed on change in marginal reflex distance in retraction patients, resolution of diplopia in strabismus patients, necessity of further strabismus surgery, and side effects.

Results: Of 157 studies screened by 2 reviewers, 30 underwent analysis. In 19 upper eyelid retraction studies (299 patients), 1.5 to 15 U Botox (onabotulinum toxin A) or 10 to 40 U Dysport (abobotulinum toxin A) was administered to the superior tarsal border, with an 84% success rate and an average decrease in marginal reflex distance of 2.42 mm lasting 1 to 6 months. In 10 strabismus studies (205 patients), 5 to 20 U Botox or 25 U Dysport was administered in extraocular muscles; 24% achieved resolution of diplopia lasting 2 to 6 months, while 58% required further surgical management. In upper eyelid retraction studies, side effects included ptosis (13%) and diplopia (2%). In strabismus studies, side effects included ptosis (2%).

Conclusions: This systematic review and meta-analysis confirmed that botulinum toxin is an effective treatment for thyroid eye disease-related lid retraction and strabismus. Randomized controlled studies are warranted to optimize botulinum toxin administration.

Purpose: To investigate the association between blepharoptosis (ptosis) and psychosocial stress levels, depression, and anxiety in a diverse population of American adults.

Methods: Utilizing data from the National Institutes of Health's All of Us Research Program, we analyzed responses from 104,456 participants who completed psychosocial assessments. Participants with a history of a ptosis diagnosis were 1:3 matched with controls using propensity score calculated based on demographics and comorbidities. Univariate and multivariable regression models were used to evaluate associations.

Results: Among 1,032 participants (mean age: 70.0 years, 33.6% male) with ptosis, the prevalence of depression and anxiety (15.3% vs. 5.2%; p < 0.001) was significantly higher (43.7% vs. 18.2%; p < 0.001) compared to 3,096 matched controls. Multivariable analysis revealed increased odds of depression (OR: 3.25; 95% CI: 2.78-3.80; p < 0.001) and anxiety (OR: 3.13; 95% CI: 2.47-3.96; p < 0.001) among those with ptosis. Female participants with ptosis had greater odds of depression (OR: 3.44 vs. 2.90) and anxiety (OR: 3.13 vs. 3.04) compared with males. In univariate analysis, participants with ptosis had greater scores in the University of California Los Angeles Loneliness Scale (18.53 vs. 18.23; p = 0.03) and Everyday Discrimination Scale (0.62 vs. 0.57; p = 0.02) than controls. However, these associations were not significant in the multivariate analysis. In multivariate analysis, female participants with ptosis had greater Everyday Discrimination Scale scores than matched controls (1.10 vs. 1.02; p = 0.004).

Conclusions: Ptosis is significantly associated with higher rates of depression and anxiety, particularly in females. This underscores the need for comprehensive treatment approaches that address both aesthetic and psychological needs.

An 84-year-old male with uncontrolled intraocular pressure (IOP), despite maximum topical medications including prostaglandin F2α analog, had bilateral prostaglandin-associated periorbitopathy-related tight upper eyelids. One day after trabeculectomy of the left eyelid, IOP was 24 mm Hg, with a flat bleb. Daily ocular massage failed to maintain bleb filtration. IOP was reduced to 4 mm Hg after lifting the left upper eyelid; hence, ocular compression from a tight upper eyelid was the suspected cause preventing flow from the scleral flap. A lateral cantholysis was performed to release the eyelid pressure. On the first postoperative day, the bleb was documented to be large and diffuse, with subsequent IOP reduction to 10 mm Hg. At the third month of follow-up, the IOP was 8 mm Hg in the left eyelid, with a well-formed bleb.

A 66-year-old woman status post bony lateral orbital decompression for thyroid eye disease presented with recurrent episodes of left lateral canthal edema and erythema, despite repeated courses of oral antibiotics, titanium hardware removal, and repeated exploratory orbitotomies with debridement and curettage. MRI later revealed an intraosseous fluid collection in the left greater sphenoid wing. Another exploratory orbitotomy was performed and an intraosseous abscess was identified. The purulent fluid was sent for culture, and the area was debrided and irrigated thoroughly with bacitracin solution. Cultures grew Staphylococcus epidermidis. The patient was treated with a 6-week course of intravenous antibiotics and has remained symptom free for 3 years.

Purpose: To examine the anatomy of the orbital septum posterior to the medial canthal tendon area.

Materials and methods: We performed 3 anatomical dissections in the present study. The first one was a microscopic study in which exenterated specimens from 6 Japanese cadavers (age from 77 to 93 years at death) were cut inferno-horizontally, including the Müller muscle, medial rectus pulley, and lateral rectus pulley, and stained with Masson's trichrome. The second one was also a microscopic study in which the exenterated specimens from 5 Japanese cadavers (age from 73 to 87 years at death) were cut horizontally, 1 mm superior to the upper eyelid margin and 1 mm inferior to the lower eyelid margin, and stained with Masson's trichrome. The third one was a macroscopic study in which exenterated specimens from 5 Japanese cadavers (age from 73 to 91 years at death) were cut horizontally at the medial palpebral commissure.

Results: In the first study, all the specimens showed the orbital septa with close vicinity to the orbicularis oculi muscle in the medial area. The second and third studies both demonstrated the double lamellar structure of the medial canthal tendon area. The anterior one was the fibrous tissue corresponding to the white medial canthal tendon. The posterior one referred to the preseptal orbicularis oculi muscle. The orbital septum was located directly posterior to this muscular structure.

Conclusion: The orbital septum posteriorly lined the preseptal orbicularis oculi muscle, the muscular part of the medial canthal tendon.

Purpose: The purpose of this study was to evaluate the clinical features, surgical treatments, and outcomes of pediatric post-traumatic nasolacrimal duct obstructions and predictors for surgical outcomes.

Methods: A retrospective chart review was performed of patients under the age of 18 years with the diagnosis of traumatic nasolacrimal duct obstructions during an 11-year period from a tertiary referral center. The clinical data were reviewed and analyzed. A binary logistic regression was performed to establish a predictive model for surgical failure after treatment.

Results: Eighty-three eyes of 80 consecutive patients were included in the study. Anterior displacement of the lacrimal sac was noted in 71.1% (59/83) cases. Medial canthus deformities were observed in 79.5% (63/83) cases. External dacryocystorhinostomy and endoscopic dacryocystorhinostomy were performed on 65 and 18 cases, respectively. At a mean follow-up of 28 months following stent removal, anatomical and functional success rate was noted in 83.1% (69/83). The presence of orbital fractures involving the rim, gross skin scaring, lacrimal sac displacement, and fracture fragments in the vicinity of the lacrimal sac were found to be significant predictors for surgical failure. The area under the raw current curves of the predictive model was 0.888.

Conclusion: This large series of post-traumatic pediatric nasolacrimal duct obstructions showed that sac-duct junction was the most common site of obstruction and anterior displacement of the lacrimal sac and bony fragments in the lacrimal sac area were significant predictors of failures. Medial canthal deformities can be addressed simultaneously with good outcomes.