Cho, Raymond I.
Purpose: To describe a novel technique to correct cicatricial lower lid entropion and retraction using a transverse lower lid tarsotomy with an interposed tarsoconjunctival flap posterior lamellar spacer.
Methods: Technique description and retrospective interventional case series.
Results: Four patients underwent the procedure—two with complications following treatment of sinonasal carcinoma and two with complications following orbital fracture repair. All patients had failed prior posterior lamellar spacer grafts, including donor sclera, dermis-fat graft, and hard palate mucosa. Average time to flap takedown was 20 (11–28) days, with an average follow-up interval of 8.4 (6.2–11.5) months. All patients had resolution of lower lid entropion and significant improvement of lower lid retraction with an average of 2.8 mm (2.0–4.3) of elevation. There were no serious complications, and all patients reported significant improvement in ocular surface symptoms.
Conclusions: Transverse tarsotomy combined with a tarsoconjunctival flap is effective for the correction of cicatricial lower lid retraction and entropion in eyelids that have failed surgery with traditional posterior lamellar spacer grafts.
Wolkow, Natalie; Weinberg, David A.; Bersani, Thomas A.; Yoon, Michael K.; Lefebvre, Daniel R.; Lee, Nahyoung Grace; Sutula, Francis C.; Mandeville, John T.; Hatton, Mark P.; Freitag, Suzanne K.
Purpose: The centenarian population is growing and ophthalmic plastic surgeons are providing care to an increasing number of elderly patients. Outcomes of centenarians have not been previously studied in the ophthalmic plastic surgery literature. The goal of the current review was to examine the baseline characteristics, surgical problems, and outcomes of this select group of patients.
Methods: A retrospective chart review was performed. Patients who underwent ophthalmic plastic surgery at age 100 or older between January 2000 and June 2016 by a member of the New England Oculoplastics Society were included in the study.
Results: Fifteen patients met inclusion criteria. The majority (66%) were female. More than half (60%) presented with a surgical problem of an urgent nature. Most disorders involved the lacrimal system or eyelids, and many were the result of trauma or infection. There were no cases of orbital tumor or thyroid eye disease. There were no surgical or anesthesia-related complications. Most patients (80%) had no documented history of dementia, and only 1 was diabetic. Notably, 33% of patients presented with no light perception vision in at least 1 eye.
Conclusions: Ophthalmic plastic surgery can be performed safely in select patients 100 years of age and older. Formal prospective studies are needed to improve surgical care in this group.
Jaksha, Alexandria F.; Justin, Grant A.; Davies, Brett W.; Ryan, Denise S.; Weichel, Eric D.; Colyer, Marcus H.
Purpose: To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma.
Methods: Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery.
Results: Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0–65 was noted in 14 (38.9%) and 66–100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth.
Conclusions: The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.
Charlson, Emily S.; Tsai, Lester; Yonkers, Marc A.; Tao, Jeremiah P.
Purpose: To assess the epidemiology of women and underrepresented minorities (URMs; Hispanic, African American, and Native American) in the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS).
Methods: An observational retrospective study of living ASOPRS members was identified through the ASOPRS member directory, search engine-driven informatics, and direct communication. Members were profiled for gender, race, geographic location, and academic rank (or not). The percentage of women and URMs in the society over time was also assessed.
Results: The authors identified 617 living ASOPRS members as of June 2017. Of these, 109 (17.7%) were female and 58 (9.4%) were URMs. Surgeons completed fellowships from 1961 (male) or 1973 (female) until 2015. Women members significantly increased from 7 (4.9% of the total) before 1986 to 24 (30.4%) between 2011 and 2015 (last 5 years). URMs significantly increased over time, with 0 female and 5 (3.4%) male minorities before 1985 to 5 (6.3%) females and 13 (16.5%) males within the last 5 years (p < 0.05). With only 1 female and 3 male members, African American representation was sparse. ASOPRS members were not found in 5 states and were most represented in California, New York, Florida, and Texas. Among ASOPRS members in full-time academic positions, women tended to have lower rank compared to men; however, after controlling for number of years post-fellowship, this finding was narrowly not statistically significant (p = 0.0624). There were no academic differences with URMs and nonminority groups.
Conclusions: Women and URMs have increased steadily in ASOPRS, especially in recent years. Similar to the rest of ophthalmology and general medicine, there remain opportunities for ASOPRS to increase diversity.
Zhang, Kevin R.; Blandford, Alexander D.; Hwang, Catherine J.; Perry, Julian D.
Purpose: The infraorbital foramen (IOF) represents a highly conserved structure but demonstrates morphologic variability. The purpose of this study is to describe the IOF location, size, and supernumerary foramina in an African American population and compare it with a Caucasian population.
Methods: Sixty African American and 60 Caucasian skulls from the Hamann-Todd collection of the Cleveland Museum of Natural History were studied. The primary outcome was the number of accessory IOF and measurements of the location, size, shape, and direction of each foramen. Pearson chi-square, t tests, Fisher exact test, and Wilcoxon rank sum tests were used to analyze the data.
Results: The African American population had a smaller vertical IOF diameter (mean = 2.81 mm) compared with the Caucasian population (mean = 3.08 mm) on the right side (p < 0.01). The distance from the IOF to the anterior nasal spine on the left side was greater in the African American population (mean = 33.93 mm) compared with the Caucasian population (Caucasian mean = 32.84 mm, p = 0.03). The distance from the IOF to the zygomaticomaxillary suture was significantly shorter in the African American population (mean = 11.85 mm) compared with the Caucasian population (mean = 13.21 mm) on the left side (p = 0.01). Accessory foramina were found in 13 Caucasian skulls (21.7%) and 6 African American skulls (10%; p = 0.08). Two distinct types of IOF existed in each population, one close to the main foramen and one within the sutura notha.
Conclusions: The IOF is smaller and exits more laterally, with a lower proportion of accessory foramina in an African American population compared with a Caucasian population. Both groups exhibit 2 distinct types of IOF. These morphologic differences should be noted during surgeries and anesthetic planning to avoid neurovascular complications.
M. Mazhar Çelikoyar
I have read the letter titled “Viability of a modified GoPro for professional surgical videography”1 by Zoltie and Ho, and felt the need to share our experience and emphasize several aspects of the video-recording a surgical procedure. The authors Zolttie and Ho have stressed the difficulties associated with such recordings, i.e. cost, positioning, focusing; yet there remains one more issue: lighting, as surgery is done under intense lighting. This is of utmost importance in order to obtain a decent recording, as most surgeries are being done with surgeon’s headlight in addition to external lighting; yet the surgeon’s headlight brings an intermittent further lighting to the field during his/her work and darkening while he/she looks elsewhere.
Yijie Wang, Lixia Lou, Zhifang Liu, Juan Ye
We conducted a systematic review and meta-analysis to evaluate the incidence and risk factors of ptosis following ocular surgery.
PubMed, Embase, and Cochrane Library were searched for articles that assessed the incidence or risk factors of ptosis following ocular surgery up to October 2017. We used a fixed effects model to calculate a pooled estimate of incidence, with subgroup analyses to evaluate the effect of different variables. The relative risks (RRs) or odds ratios (ORs) and 95% confidence intervals (CIs) for all available factors were calculated using the fixed effects models.
A total of 16 studies on 2856 eyes were analyzed, including 3 randomized controlled trials (RCTs) and 13 cohort studies. The overall incidence of ptosis following ocular surgery was 11.4% (95% CI 10.1–12.8%). Subgroup analyses showed that the region and the surgery type were significantly associated with the incidence of postoperative ptosis. Men were less likely to get postoperative ptosis than women (OR 0.62; 95% CI 0.43–0.89). However, age (OR 0.77; 95% CI 0.48–1.23), side (OR 1.37; 95% CI 0.84–2.25), type of anesthesia (OR 0.57; 95% CI 0.16–2.05), prior surgery (OR 1.09; 95% CI 0.64–1.83), bridle suture (OR 2.04; 95% CI 0.94–4.42), or combined surgery (OR 0.95; 95% CI 0.58–1.57) did not significantly change the risk of ptosis following ocular surgery.
More than one in ten patients who undergo ocular surgery will develop ptosis. Different regions and surgery types may influence the occurrence of this abnormality. Female gender is a risk factor for development of postoperative ptosis.
Min Gyu Choi, Joon Hyung Yeo, Jeong Woo Kang, Yeoun Sook ChunJeong Kyu LeeJae Chan Kim
To determine the effects of botulinum toxin type A (BTX-A) injection on dry eye signs, symptoms, and tear cytokine levels in patients with intractable dry eye disease (DED).
In this prospective study, patients with intractable DED were randomized to a BTX-A (group A) or control group (group B). Patients were injected with BTX-A or normal saline in the medial part of the upper and lower eyelids. Before and at 2 weeks, 1 month, 2 months, and 4 months after injection, dry eye signs; tear film break-up time (TBUT), Schirmer I test, corneal fluorescein staining (CFS), and symptoms; ocular surface disease index (OSDI); and frequency of lubricants were assessed. The tear levels of matrix metalloproteinase (MMP)-9 and serotonin were measured before and at 1 month after injection.
Fifty-two eyes from 26 patients (mean age, 57.7 years) were included. The TBUT was higher at 2 weeks and at 1 month in group A. The Schirmer I test and OSDI scores were also better in group A for up to 2 months. The CFS grades in group A were significantly lower until 4 months. Repeated measures analysis of variance (RMANOVA) demonstrated significant differences between the two groups over time for the Schirmer I test (p = 0.002), CFS (p = 0.025), OSDI (p = 0.020), and frequency of lubricants (p = 0.029). The MMP-9 conversion rate of group A (76.92%) was significantly higher than that of group B (38.46%, p = 0.005). The tear serotonin level in group A was reduced from 2.76 ± 0.34 to 1.73 ± 0.14 ng/mL (p < 0.001). No complications were observed during the study.
BTX-A injection into the medial part of eyelid improves dry eye signs and symptoms and reduces tear cytokine levels. BTX-A is thus a potential treatment option for patients with intractable DED.
Jennifer S. N. Verhoekx Sanne E. Detiger Gerlof Muizebelt Rene J. Wubbels Dion Paridaens
Prolonged hard contact lens wear is known to be a risk factor of acquired, aponeurotic blepharoptosis (van den Bosch & Lemij 1992), while only a few studies suggest that there is a relation between soft contact lens wear and acquired blepharoptosis. Following our earlier report (Bleyen et al. 2011), the purpose of this study is to acquire further evidence to support the hypothesis that the use of soft contact lens may cause aponeurotic blepharoptosis….
Andrzej Grzybowski, Piotr Kanclerz
In recent years, there have been many attempts to rationalise medicine through verification of different practice patterns as well as the identification and elimination of unnecessary procedures. For example, The Choosing Wisely Campaign named the use of topical antibiotics in intravitreal injections and employment of topical antibiotics in adenovirus conjunctivitis as nonbeneficial and disadvised (Parke et al. 2013). The problem is not trivial as the impact of unnecessary tests and procedures in the United States was estimated to be as high as 30% of all healthcare spending. Moreover, rationing and waste avoidance are complementary, and elimination of wasteful, nonbeneficial interventions was proposed to be ethically mandated (Brody 2012).
Cataract surgery is the most common surgical procedure worldwide, with about three million procedures performed in the United States every year. In a recent article by Thiel et al. (2017), it was concluded that the Aravind Eye Care System generated significantly less solid waste and CO2‐equivalent greenhouse gases compared to that of the methods used in the United Kingdom. Surgical gloves and gowns were not changed between procedures. Gloves were sterilized between cataract surgeries using an antiseptic gel and disposed of via the biomedical waste stream after approximately 10 cases. The efficacy of reduction in bacterial load on surgical gloves with antiseptic scrubs has already been demonstrated previously by authors from Aravind Eye Care (Nirmalan et al. 2004). Intriguingly, this practice pattern was not related with increased risk to the patient. Aravind Eye Care employed the same procedure in previous studies, and the endophthalmitis rate was 0.03% without intracameral antibiotics (Ravindran et al. 2009) and 0.01% with intracameral antibiotics (Haripriya et al. 2017).
In intravitreal injections studies, the utility of sterile gloves, and even no gloves at all, has not been shown to reduce the risk of endophthalmitis; thus, the use of sterile gloves was not included in US guidelines of an expert panel (Avery et al. 2014).
We believe that the presented data justifies to start a discussion, and possibly a prospective randomized study to verify if the use of disposable and sterilized gloves and gowns are necessary in cataract surgery.