Idowu, Oluwatobi O.; Ashraf, Davin C.; Vagefi, M. Reza; Kersten, Robert C.; Winn, Bryan J.
Purpose of review To summarize the ocular and systemic associations of floppy eyelid syndrome (FES) as well as provide an up-to-date review on the pathogenesis and treatment strategies.
Recent findings Virtually all patients with FES have obstructive sleep apnea (OSA). However, a significantly lower proportion of patients with OSA have FES. Although some studies demonstrate no association between OSA and FES, almost all show at least an association with increased eyelid laxity, which may be a less severe form of FES. FES has also been associated with keratoconus (KCN) and glaucoma. Decreased corneal hysteresis has been found in FES, KCN, glaucoma, and OSA and may be related to matrix metalloproteinase (MMP) upregulation. Hypoxia–reperfusion injury, leptin resistance, and mechanical forces all may lead to increased MMP activity, contributing to elastin breakdown in the tarsus and other tissues throughout the body. Management of FES begins with investigation for OSA. Treating OSA with continuous positive airway pressure (CPAP) or surgical uvulopalatoplasty may improve FES. Surgical treatments for FES should reduce horizontal eyelid laxity while maximizing the stability of the tarsus. Collagen crosslinking may prove a helpful modality for stabilizing the tarsus in the future.
Summary FES is associated with OSA, glaucoma, and KCN. MMP upregulation and lower corneal hysteresis have been found in these conditions, pointing toward a potential common pathogenesis.
Price, Jade M.; Boparai, Ranjodh S.; Wasserman, Barry N.
Purpose of review Congenital fibrosis of the extraocular muscles (CFEOM) is caused by abnormal development of the innervation of extraocular muscles. We update the recent literature regarding the clinical, anatomic, genetic, and molecular characteristics of CFEOM. Surgical considerations are addressed.
Recent findings CFEOM is broken down into three main subtypes, CFEOM1, CFEOM2, and CFEOM3. Several recent reports of individuals, as well as family pedigrees, highlight the phenotypic heterogeneity of CFEOM. Intracranial and intraorbital radiologic findings have enhanced our understanding of the disease pathophysiology. Molecular genetics research has increased our understanding of the development of extraocular muscles and their innervation as well as pathophysiology of CFEOM.
Summary Our understanding of the pathophysiology of CFEOM has increased with the recent contributions from neuroimaging, molecular genetics, and pedigree analysis. Surgical management of patients with CFEOM continues to be challenging.
Al-Haddad, Christiane; El Salloukh, Nasrine Anais; El Moussawi, Zeinab
Purpose of review To evaluate the medical literature on the use of β-blockers, through different routes, for the treatment of periorbital infantile hemangiomas and to summarize the recommendations available on dosage and monitoring.
Recent findings β-blockers for the treatment of infantile hemangioma are now considered to be first-line treatment. Growing literature on the role of oral propranolol confirmed its efficacy but also presented its multiple side-effects including hypotension, bradycardia, hypoglycemia, and bronchospasm. No universal guidelines exist concerning pretreatment evaluation, dosage, monitoring, and duration of treatment but different protocols have been created.
In the aim of minimizing side-effects, other routes of administration and more selective β-blockers have emerged. Many studies showed promising results for topical timolol especially in the treatment of superficial hemangiomas. Few studies evaluated intralesional propranolol. Limited data exist on the use of more selective β-blockers promising similar results to propranolol with fewer side-effects.
Summary Oral β-blockers are now the mainstay of treatment for periorbital hemangiomas but still with no consensus on their administration and monitoring. The topical form or more selective β-blockers may be the solution to minimize side-effects.
Williams, Katherine J.; Allen, Richard C.
Purpose of review This study is a review of recent literature in the diagnosis and management of preseptal cellulitis, orbital cellulitis and dacryocystitis, including causative organisms, diagnosis and medical or surgical therapy and potential complications.
Recent findings Advances in vaccination against Haemophilus influenzae B have resulted in a shift in the most common causative organisms of preseptal and orbital cellulitis. Management of orbital cellulitis has been advanced by adjuvant corticosteroids, and subperiosteal abscess volumes of more than 1250 ml has been shown as predictive for requiring potential surgical intervention.
Summary Periorbital infections require prompt evaluation and management. Although the infectious organisms in both preseptal and orbital cellulitis include Staphylococcus/Streptococcus species, management may differ significantly on the basis of the nidus of infection, presenting signs and symptoms, and response to initial medical management.
Farazdaghi, Marybeth K.; Katowitz, William R.; Avery, Robert A.
Purpose of review Optic pathway gliomas are low-grade neoplasms that affect the precortical visual pathway of children and adolescents. They can affect the optic nerve, optic chiasm, optic tracts and radiations and can either be sporadic or associated with neurofibromatosis type one. Gliomas isolated to the optic nerve (ONG) represent a subgroup of optic pathway gliomas, and their treatment remains controversial. New developments in ONG treatment have emerged in recent years, and it is necessary for clinicians to have a current understanding of available therapies.
Recent findings The current review of the literature covers the background of and recent developments in ONG treatment, with a focus on standard chemotherapy, new molecularly targeted therapies, radiation therapy and surgical resection and debulking.
Summary Although standard chemotherapy remains the mainstay of ONG treatment, newer molecularly targeted therapies such as mitogen-activated protein kinase kinase inhibitors and bevacizumab represent a promising new treatment modality, and clinical studies are ongoing.
Kashkouli, Mohsen B.; Karimi, Nasser; Khademi, Behzad
Purpose of review After failed conservative management, most clinicians treat congenital nasolacrimal duct obstruction (CNLDO) in a conventional stepwise fashion: starting with probing, then repeat probing, next silicone intubation and/or balloon dilatation, and finally dacryocystorhinostomy. This approach is based on the patient’s age and previously failed procedures and recruits ‘one procedure for all’ CNLDO. A newly introduced approach is based on the type of obstruction and recruits ‘all procedures for one’ CNLDO. The aim of this review is to examine the best available evidence regarding CNLDO management.
Recent findings Recent articles support the concept that through intraoperative evaluation of obstruction in CNLDO, clinicians may predict probing failure and instantaneously employ more appropriate treatment modalities. This review addresses whether an age-based approach should be changed into a one-stage obstruction-based approach.
Summary An age-based approach treats CNLDO as a homogeneous disease and thus treats all patients with one predetermined procedure. A one-stage obstruction-based approach, however, considers CNLDO to be a heterogeneous disease, and therefore allows recruitment of all procedures simultaneously and selects the best intraoperatively. It may allow replacement of the conventional stepwise approach to CNLDO treatment provided that randomized trials verify its efficacy, safety, and cost-effectiveness.
Ruiters, Sébastien; Mombaerts, Ilse
Purpose of review To comprehensively review the applications of advanced three-dimensional printing technology in the management of orbital abnormalities.
Recent findings Three-dimensional printing has added value in the preoperative planning and manufacturing of patient-specific implants and surgical guides in the reconstruction of orbital trauma, congenital defects and tumor resection. In view of the costs and time, it is reserved as strategy for large and complex craniofacial cases, in particular those including the bony contour. There is anecdotal evidence of a benefit of three-dimensional printing in the manufacturing of prostheses for the exenterated and anophthalmic socket, and in the fabrication of patient-specific boluses, applicators and shielding devices for orbital radiation therapy. In addition, three-dimensional printed healthy and diseased orbits as phantom tangible models may augment the teaching and learning process of orbital surgery.
Summary Three-dimensional printing allows precision treatment tailored to the unique orbital anatomy of the patient. Advancement in technology and further research are required to support its wider use in orbital clinical practice.
Lam, Stacey C.; Yuen, Hunter K.L.
Purpose of review Currently, there is no ideal management for orbital lymphatic malformations. Significant advances have been made since the discovery of new agents in the treatment. The purpose of this manuscript is to review the recent evidence on new sclerotherapy agents and systemic medications.
Recent findings Traditional sclerosants are OK-432, sodium tetradecyl sulphate and ethanol. More recent developments are the use of doxycycline, bleomycin, and pingyangmycin. Sirolimus as a systemic medication has revolutionized the medical management of lymphatic malformations. Other oral drugs such as propranolol and sildenafil are controversial. Future treatment involves targeting lymphangiogenic pathways including inhibition of vascular endothelial growth factors and the phosphatidylinositol 4,5-bisphosphate 3-kinase catalytic subunit.
Summary The development of new agents allows multimodal management either as monotherapy or combined therapy to achieve better outcomes in this difficult to manage disease.
Murthy, Rachna; Roos, Jonathan C.P.; Goldberg, Robert A.
Purpose of review The use of dermal filler in the periocular area is increasing – both for functional and aesthetic indications. Hyaluronic acid fillers dominate the market; these treatments offer an alternative to some surgical procedures with the advantage of instant results, minimal healing time and low complication rates. However, success depends on judicious selection of patients, products and procedures to achieve favourable outcomes. This article reviews current understanding of the principal complications in the periocular area and their management.
Recent findings Hyaluronic acid is a ubiquitous, biodegradable, nonspecies-specific molecular substrate with limited potential for immunogenic reactions. However, in the periocular area, such products can migrate and last significantly longer than the expected filler lifespan. Contamination or subsequent immune stimulation can trigger delayed-onset inflammatory reactions. Though minor vascular occlusions are not uncommon, cases of blindness secondary to facial filler injections are thought to be rare. Timely enzymatic degradation with injectable hyaluronidase can be effective in the treatment of some such complications. But recent studies demonstrate lack of penetration through arterial walls and optic nerve sheath, casting doubt on the role of retrobulbar hyaluronidase in the management of vision loss because of embolism with hyaluronic acid filler.
Summary Hyaluronic acid fillers represent an emerging and important addition to the armamentarium of the oculofacial plastic surgeon with their use in the aesthetic field also expected continue to rise. The oculoplastic facial surgeon, armed with a thorough knowledge of facial anatomy, safe injection planes and the means of minimizing and treating complications is in the best position to lead clinically in the use of this well tolerated and effective treatment modality.