We report a proof-of-concept case demonstrating intraoperative fluorescence of periocular sebaceous carcinoma using 5-aminolevulinic acid (5-ALA). 5-aminolevulinic acid-induced fluorescence has been well established in n...We report a proof-of-concept case demonstrating intraoperative fluorescence of periocular sebaceous carcinoma using 5-aminolevulinic acid (5-ALA). 5-aminolevulinic acid-induced fluorescence has been well established in neurosurgical oncology for high-grade glioma resection and more recently applied to select head and neck malignancies. Given the challenges of visualizing sebaceous carcinoma intraoperatively-particularly due to pagetoid spread and subtle epithelial involvement-we evaluated whether 5-ALA could delineate tumor extent in vivo and correlate with histopathology. An 80-year-old man with a large, biopsy-proven invasive sebaceous carcinoma of the right upper eyelid and conjunctiva underwent planned orbital exenteration with sentinel lymph node biopsy. Preoperative imaging demonstrated extensive periocular disease without retrobulbar invasion or metastatic spread. As part of an investigational protocol, oral 5-ALA (20 mg/kg) was administered 3.5 hours before surgery. Intraoperative blue-light examination revealed distinct fluorescence of the bulbar and tarsal conjunctiva and caruncle that was not appreciable under white light. Histopathologic analysis confirmed sebaceous carcinoma in all fluorescent regions, while nonfluorescent areas were tumor-free. Sentinel lymph nodes did not fluoresce and were negative for metastasis. The patient tolerated 5-ALA without adverse effects. This case demonstrates that 5-ALA fluorescence can identify occult periocular sebaceous carcinoma in vivo and correlate closely with histopathology. These findings support the potential role of 5-ALA as an intraoperative adjunct for tumor mapping and margin assessment in future globe-sparing surgery for periocular malignancies.
PURPOSE: To describe a new diagnostic clinical feature-the "needle head sign" along with histopathology, immunohistochemistry, and electron microscopy of the medial canthal tendon in patients with Centurion syndrome (CS)...PURPOSE: To describe a new diagnostic clinical feature-the "needle head sign" along with histopathology, immunohistochemistry, and electron microscopy of the medial canthal tendon in patients with Centurion syndrome (CS). METHODS: Retrospective review of all cases diagnosed with CS and having external and closed eye photographs in their electronic medical records. Patients with missing or inappropriate photographs or those who had prior surgical interventions were excluded from the analysis. Data collected included demographics, history, presenting complaints, external and ocular examination, lacrimal examination, including the tear meniscus height, fluorescein dye disappearance test, and lacrimal irrigation. Photographs were reviewed for all signs of CS, along with the additionally described "needle head sign" for diagnosis of CS. Medial canthal tendons from patients with CS who underwent surgical intervention and normal tendon from a patient undergoing dacryocystectomy were obtained for histopathological analysis. RESULTS: 28 eyes of 14 patients with complete documentation were included for the analysis. Males (n=13, 92.86%) were more affected and the average age at presentation was 17 years (range= 5-32 years). Epiphora was the universal symptom and was present for an average duration of 43.06 months. Anterior placement of the medial canthal tendon and beak sign were universal (100%), followed by prominent nasal bridge in 92.86% (26 eyes), punctal dystopia in 82.14% (23 eyes) synophrys in 7.14% (2 eyes), epicanthal fold in 7.14% (2 eyes), ptosis in 3.57% (1 eye), lagophthalmos in 7.14% (2 eyes), and punctal agenesis in 1 eye of 1 patient (3.57%). The "needle head sign" was seen in 21 eyes of 14 patients (75%), bilateral in 64.28% (9 patients), unilateral in 21.43% (3 patients) and absent in 7 eyes of 5 patients (25%). The fluorescein dye disappearance test performed showed delay of >5 minutes in 21 eyes of 11 patients (95.45%). Tear meniscus height was raised in 25 eyes of 14 patients (89.29%). Irrigation was patent in all eyes. Histopathology and electron microscopy showed morphological changes in the tendons. CONCLUSION: The "needle head sign" is an additional sign that can be of adjunct value in the diagnosis of CS. The medial canthal tendons of CS demonstrate certain histopathological and ultrastructural changes, which need further evaluation.
PURPOSE: Primary acquired nasolacrimal duct obstruction is predominantly observed in postmenopausal women, indicating a potential hormonal etiology in the maintenance of the lacrimal drainage system. This study aims to e...PURPOSE: Primary acquired nasolacrimal duct obstruction is predominantly observed in postmenopausal women, indicating a potential hormonal etiology in the maintenance of the lacrimal drainage system. This study aims to explore the association between menopausal status, hormone replacement therapy (HRT), and epiphora symptoms in a nationally representative sample of US women. METHODS: A cross-sectional analysis was conducted using data from the National Health and Nutrition Examination Survey 2005-2008. Women aged ≥40 years with complete reproductive health and ocular symptom data were identified as the study sample. Menopausal status was categorized as premenopausal, perimenopausal, and postmenopausal. HRT use was classified as never, past, and current users. The primary outcome was self-reported epiphora symptoms. Weighted logistic regression models were employed with adjustments for age, race, body mass index, poverty income ratio, smoking, diabetes, and hypertension. RESULTS: A total of 3,842 women were included in the analysis. The weighted prevalence of epiphora was significantly higher in postmenopausal women compared with pre-menopausal women (p < 0.001). In the fully adjusted models, postmenopausal status was independently associated with higher odds of epiphora (odds ratio 1.62, 95% confidence interval 1.24-2.11, p=0.002). Among postmenopausal women, current HRT use was significantly associated with reduced odds of epiphora compared with never users (odds ratio 0.68, 95% confidence interval 0.49-0.94, p=0.021), whereas past use showed no significant protection. Furthermore, subgroup analysis indicated the protective effect of HRT was most pronounced in the 40-60 age group. CONCLUSIONS: Menopause is an independent risk factor for epiphora, while current HRT use appears to offer a protective effect against symptom development. These findings provide supporting evidence for the hypothesis that estrogen deficiency contributes to lacrimal drainage dysfunction, possibly via mucosal atrophy and fibrosis. Endocrine status should also be considered in the comprehensive management of epiphora in older women.
PURPOSE: To determine the clinical utility of the assessment of preoperative orbital compliance in predicting the amount of postoperative proptosis reduction in patients with stable-phase thyroid eye disease who undergo...PURPOSE: To determine the clinical utility of the assessment of preoperative orbital compliance in predicting the amount of postoperative proptosis reduction in patients with stable-phase thyroid eye disease who undergo orbital fat decompression surgery. METHODS: A retrospective chart review was conducted of stable-phase thyroid eye disease patients who underwent orbital fat decompression by a single surgeon. Orbital compliance was measured preoperatively as axial globe displacement (in millimeters) using a Hertel exophthalmometer. Displacement ≥2.5 mm was classified as high compliance and <2.5 mm as low compliance. Radiographic thyroid eye disease type, preoperative proptosis, and intraoperative fat volume removed were recorded. Linear regression analysis determined whether orbital compliance independently predicted postoperative proptosis reduction. Levene's test assessed variability between groups. RESULTS: Forty-six orbits from 24 patients were included, 15 orbits with low compliance and 31 with high orbital compliance. Patients with high orbital compliance had a mean postoperative proptosis reduction of 3.19 mm (range 0.5-6.0 mm) while patients with low orbital compliance had a mean proptosis reduction of 2.67 mm (range 2.0-3.5 mm). On average, higher preoperative orbital compliance led to 0.959 mm greater proptosis reduction compared with low orbital compliance, when accounting for radiographic thyroid eye disease type and volume of fat removed intraoperatively (p = 0.048). Variability in proptosis reduction was higher among the high orbital compliance group (p = 0.00085). CONCLUSIONS: Higher preoperative orbital compliance results in greater proptosis reduction. However, patients with high orbital compliance have greater variability in proptosis reduction, suggesting that surgical outcomes are less predictable among these patients.
PURPOSE: To investigate whether cataract surgery is a risk factor for developing new-onset thyroid eye disease in patients with preexisting thyroid disorders using a large, population-level database. METHODS: The study u...PURPOSE: To investigate whether cataract surgery is a risk factor for developing new-onset thyroid eye disease in patients with preexisting thyroid disorders using a large, population-level database. METHODS: The study utilized a large database of deidentified electronic health records. Patients who underwent cataract extraction were divided into 2 cohorts and were balanced using propensity score matching for demographic factors and comorbidities, including age, sex, race, diabetes mellitus, hyperlipidemia, and nicotine dependence. The incidence of thyroid eye disease-related outcomes was assessed at 3-time intervals following the surgery date: up to 3 months, 3-6 months, and 6-12 months. The need for orbital decompression surgery was also assessed. A secondary sensitivity analysis was conducted for patients with hyperthyroidism. RESULTS: After propensity score matching, 87,179 pairs were analyzed. Patients with thyroid disease had a significantly higher risk for the composite thyroid eye disease outcome at all time intervals: 0-3 months (risk ratio [RR]: 1.30, 95% confidence interval [CI]: 1.12-1.51), 3-6 months (RR: 1.30, 95% CI: 1.12-1.51), and 6-12 months (RR: 1.51, 95% CI: 1.33-1.71). The risk was even more pronounced in the hyperthyroid subgroup (n = 8,381), reaching a 103% increased risk at 6-12 months (RR: 2.03, 95% CI: 1.39-2.95). While no significant difference was observed for orbital decompression surgery in the immediate postoperative period, a significantly increased risk emerged at the 6-12-month interval (RR: 1.59, 95% CI: 1.13-2.24). CONCLUSIONS: Cataract surgery is associated with a significantly increased risk of developing thyroid eye disease-related outcomes in patients with underlying thyroid disease. While the overall incidence may be low, the potential consequences can be serious, highlighting the importance of clinical awareness, patient counseling, and close postoperative monitoring for this at-risk population.
PURPOSE: This study aims to compare the efficacy of phenylephrine 2.5% ophthalmic solution versus traditional upper eyelid taping in evaluating surgical need and insurance reimbursement eligibility for patients with visu...PURPOSE: This study aims to compare the efficacy of phenylephrine 2.5% ophthalmic solution versus traditional upper eyelid taping in evaluating surgical need and insurance reimbursement eligibility for patients with visually significant ptosis. METHODS: This single-arm, sequential study included 27 eyes with ptosis. Eyes were evaluated under 3 testing conditions: at baseline, after manual eyelid taping, and post phenylephrine instillation. The outcome measures were change in margin reflex distance 1 and superior visual field, assessed using tangent screen VF testing. Participants completed a poststudy questionnaire evaluating their experience. RESULTS: Margin reflex distance 1 increased from a mean baseline of 0.83 mm to 2.17 mm after phenylephrine (mean improvement 1.33 mm, 95% confidence interval: 1.09-1.57 mm, p < 0.001). Mean VF improved from 6.85° to 21.77° with taping and to 22.56° with phenylephrine. The insurance criterion (≥12° increase) was met in 88.8% of eyes with taping and 92.5% of eyes with phenylephrine, with no significant difference in the proportion of eyes meeting criteria ( p = 1.000). Margin reflex distance 1 and VF changes after phenylephrine instillation showed no positive correlation (rs = 0.13, p > 0.05). Patient satisfaction scores were higher with phenylephrine (4.26 ± 0.81) compared with manual taping (3.67 ± 0.48 (mean difference 0.59, p < 0.001). CONCLUSIONS: Phenylephrine 2.5% ophthalmic solution provides comparable visual field improvements and significantly higher patient satisfaction compared with manual upper eyelid taping for preoperative VF testing in the context of insurance reimbursement eligibility for patients with ptosis. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05890027.
PURPOSE: To describe a novel technique of tragal cartilage contouring during facelift surgery and evaluate its effectiveness in preserving tragal contour and preventing postoperative tragal deformities. METHODS: A retros...PURPOSE: To describe a novel technique of tragal cartilage contouring during facelift surgery and evaluate its effectiveness in preserving tragal contour and preventing postoperative tragal deformities. METHODS: A retrospective chart review was performed of patients who underwent rhytidectomy with tragal cartilage contouring between January 2022 and December 2023 by a single surgeon. Following flap elevation and repositioning, the cephalic tragal rim was trimmed, vertically scored, then contoured with a horizontal mattress suture to support a convex surface postoperatively. Overlying soft tissue was anchored to the superficial musculoaponeurotic system to reduce tension. Standardized pre- and postoperative photographs were evaluated by 3 independent, blinded, oculoplastic surgeons using a 4-point Likert scale to assess tragal contour, peritragal contour, scar visibility, and overall aesthetic result. Patients also provided subjective ratings of their aesthetic outcome. RESULTS: Twenty-eight patients (24 women, 4 men; mean age 62 years, range 51-74) were included, with a mean follow-up of 8 months (range, 4-12). Independent reviewers rated all tragal contour outcomes as "good" or "excellent," with no cases rated "fair" or "poor." All patients rated their aesthetic outcome as "excellent." No complications or secondary interventions occurred. CONCLUSIONS: Tragal cartilage contouring is an effective technique that can be performed during rhytidectomy. By addressing cartilage shape and tension distribution, this method preserves tragal contour and prevents common postoperative deformities, supporting consistently favorable aesthetic results.
Anaphylactic shock is a rare but life-threatening perioperative emergency characterized by bronchospasm, hypoxia, and hypotension. A 56-year-old woman underwent elective oculofacial plastic surgery and developed anaphyla...Anaphylactic shock is a rare but life-threatening perioperative emergency characterized by bronchospasm, hypoxia, and hypotension. A 56-year-old woman underwent elective oculofacial plastic surgery and developed anaphylactic shock shortly after exposure to tetracaine eye drops; intravenous sedation with midazolam and propofol; and a local anesthetic mixture of lidocaine, bupivacaine, and epinephrine. Initial signs included facial flushing, hypotension, and oxygen desaturation. Intubation, epinephrine, steroid, and intensive care unit transfer were required. Blood tryptase drawn 2.5 hours after the onset of symptoms was within normal range, but subsequent allergy testing revealed positive reactions to both midazolam and tetracaine. The patient fully recovered and was discharged the following day. She underwent successful surgery 6 months later under general anesthesia. This case underscores the importance of early recognition of anaphylactic shock and the necessity of procedure rooms being well equipped to intervene. Vigilance is necessary even with agents not commonly associated with anaphylactic shock.
PURPOSE: To evaluate the clinical outcomes of endoscopic conjunctivodacryocystorhinostomy with Jones tube placement and to identify patient- and surgery-related risk factors for postoperative complications. METHODS: This...PURPOSE: To evaluate the clinical outcomes of endoscopic conjunctivodacryocystorhinostomy with Jones tube placement and to identify patient- and surgery-related risk factors for postoperative complications. METHODS: This single-center, retrospective case series analyzed 42 consecutive patients (42 eyes) who underwent endoscopic conjunctivodacryocystorhinostomy. Data were collected on patient demographics, comorbidities, and surgical variables, including Jones tube diameter (3.5 vs. 4.0 mm). Primary outcomes were anatomical and functional success. The primary endpoint for risk factor analysis was the occurrence of any postoperative complication. Univariate and multivariable logistic regression analyses were performed to identify significant predictors of adverse outcomes. RESULTS: Over a mean follow-up of 4.6 years, the anatomical success rate was 83.3%, while the functional success rate was 66.7%. Tube displacement was a common complication, occurring in 23.8% of cases. In multivariable analysis, the use of a larger 4.0-mm tube was significantly protective against complications (adjusted odds ratio: 0.35, p = 0.007), whereas a diagnosis of preoperative dry eye disease significantly increased the risk (adjusted odds ratio: 1.71, p = 0.028). The benefit of the larger tube was primarily driven by a statistically significant reduction in the rate of tube displacement compared with the 3.5-mm tube (5.3% vs. 27.3%, p = 0.03). CONCLUSION: Larger-diameter (4.0 mm) Jones tube significantly reduces complications in endoscopic conjunctivodacryocystorhinostomy (particularly tube displacement), whereas preexisting dry eye symptoms were found to be associated with increased postoperative complications.
PURPOSE: To analyze the safety of oxymetazoline hydrochloride ophthalmic solution 0.1% for blepharoptosis using real-world Food and Drug Administration Adverse Event Reporting System data. METHODS: This retrospective pha...PURPOSE: To analyze the safety of oxymetazoline hydrochloride ophthalmic solution 0.1% for blepharoptosis using real-world Food and Drug Administration Adverse Event Reporting System data. METHODS: This retrospective pharmacovigilance study queried the Food and Drug Administration Adverse Event Reporting System database utilizing OpenVigil 2.1 for oxymetazoline eye drop adverse drug events (ADEs) from Food and Drug Administration approval on January 7, 2020, through April 30, 2025. Disproportionality analysis employed standard methodologies, including reporting odds ratios (RORs) and chi-squared analyses. RESULTS: Three hundred six patients with 658 ADEs from oxymetazoline eye drop were analyzed, revealing 30 significant safety signals. All ADEs on the drug label were identified in this cohort (multiple RORs, all p < 0.001): ocular surface disease (N = 129, 34.5%), conjunctival hyperemia (N = 43, 11.5%), temporary visual blurring (N = 33, 8.8%), instillation site pain (N = 27, 7.2%), headache (N = 32, 8.6%). Novel ADEs (not on the drug label) were vitreoretinal complications (N = 12, 3.2%, multiple RORs, all p < 0.001)-retinal detachment (N = 3, 0.8%), vitreous detachment (N = 3, 0.8%), vitreous floaters (N = 3, 0.8%), and vitreous hemorrhage (N = 3, 0.8%)-mydriasis (N = 21, 5.6%, ROR 175.4 [112.4-273.7], p < 0.001), hypertension (N = 6, 1.6%, ROR 3.2 [1.4-7.2], p = 0.009), and tachyphylaxis (N = 5, 1.3%, ROR 5.1 [2.1-12.4], p < 0.001). CONCLUSIONS: This Food and Drug Administration Adverse Event Reporting System analysis of oxymetazoline eye drops corroborated prior ADEs, including ocular surface disease, conjunctival hyperemia, transient blurred vision, instillation site pain, and headache. The study revealed new safety signals for vitreoretinal complications, hypertension, mydriasis, and tachyphylaxis. Further studies are warranted to confirm these associations and describe mechanisms such as vitreoretinal traction.
PURPOSE: To evaluate whether glucagon-like peptide-1 receptor agonists (GLP-1RA) are associated with an altered risk of thyroid eye disease (TED) compared with other non-GLP-1RA glucose-lowering medications in patients w...PURPOSE: To evaluate whether glucagon-like peptide-1 receptor agonists (GLP-1RA) are associated with an altered risk of thyroid eye disease (TED) compared with other non-GLP-1RA glucose-lowering medications in patients with thyroid disease. METHODS: This retrospective, population-based cohort study utilized the TriNetX U.S. Collaborative Network to identify patients with thyroid disease initiating a GLP-1RA or a non-GLP-1RA active control medication. After 1:1 propensity score matching, 2 balanced cohorts of 173,618 patients each were analyzed. Matching variables included demographics, comorbidities, hemoglobin A1c, body mass index, concomitant diabetes medications, radioactive iodine therapy, thyroid-specific laboratory values, and diabetes complication severity. Outcomes included TED-related diagnoses, surgical interventions, and systemic steroid use. Time-to-event analyses were performed using Cox proportional hazards models. RESULTS: GLP-1RA use was associated with a significantly lower risk of TED compared with the active control group. The risk of a composite TED-related diagnosis was lower at 1 year (hazard ratio [HR] 0.82; 95% confidence interval [CI], 0.76-0.88), 2 years (HR 0.86; 95% CI, 0.81-0.91), and 3 years (HR 0.90; 95% CI, 0.86-0.95). Marked reductions were observed for TED-related surgical interventions (1-year HR 0.42, 95% CI 0.36-0.49; 3-year HR 0.54, 95% CI 0.48-0.61) and systemic steroid use. Subgroup analyses of patients with hyperthyroidism and individual agents demonstrated consistent protective associations. CONCLUSIONS: In a large, rigorously matched cohort, GLP-1RA therapy was associated with a reduced risk of TED diagnoses, surgeries, and systemic steroid use compared to other glucose-lowering medications. These findings suggest a potential protective role for GLP-1 signaling in modulating orbital inflammation, though prospective trials are required for confirmation.
Congenital upper eyelid entropion is rare but can rapidly cause severe corneal morbidity in neonates if left untreated. In extremely low-birth-weight infants with multisystem anomalies, surgical intervention carries subs...Congenital upper eyelid entropion is rare but can rapidly cause severe corneal morbidity in neonates if left untreated. In extremely low-birth-weight infants with multisystem anomalies, surgical intervention carries substantial risks, creating a balance between life-preserving caution and vision-preserving urgency. We report a case of early surgical correction in a late preterm neonate weighing 900g who presented with bilateral congenital upper eyelid entropion and right corneal ulceration. Surgical correction involved transposing the pretarsal orbicularis and levator aponeurosis complex, fixing it to the superior tarsal border to restore lamellar balance. Immediate postoperative bilateral eyelid eversion was achieved, resolving ocular irritation. At 4 months postoperatively, the eyelid position was stable without recurrence. Early surgical correction can safely restore lamellar balance and prevent irreversible corneal sequelae in fragile neonates.
This case report describes a rare presentation of orbital cellular myofibroma in a 30-year-old female who initially presented with right proptosis and conjunctival injection. Endovascular embolization followed by surgica...This case report describes a rare presentation of orbital cellular myofibroma in a 30-year-old female who initially presented with right proptosis and conjunctival injection. Endovascular embolization followed by surgical resection revealed an unencapsulated, vascular tumor with histopathologic and molecular findings consistent with cellular myofibroma harboring an SRF::RELA gene fusion. This case highlights the diagnostic challenges associated with orbital tumors and the importance of considering myofibroma in the differential diagnosis. The report also underscores the role of multidisciplinary management in optimizing outcomes for patients with rare orbital neoplasms.
PURPOSE: To describe a transorbital approach to the pterygopalatine fossa following total exenteration. METHODS: Cadaveric dissection study where 5 head specimens (10 orbits) were dissected. The technique involved (1) in...PURPOSE: To describe a transorbital approach to the pterygopalatine fossa following total exenteration. METHODS: Cadaveric dissection study where 5 head specimens (10 orbits) were dissected. The technique involved (1) infraorbital nerve identification, (2) creation of a posterior osteotomy around the orbitomaxillary segment of the infraorbital nerve, and (3) removal of the posterior maxillary sinus wall. The pterygopalatine segment of V2 (pV2) and the third segment of the internal maxillary artery were visualized. RESULTS: The orbital floor defect approximated a parallelogram, with its lateral, medial, anterior, and posterior borders measuring 13.2 mm × 13.5 mm × 7.9 mm × 8.3 mm, respectively. To access pV2, the posterior maxillary wall defect was 10.6 mm (height) × 11.4 mm (width), respectively. To access the internal maxillary artery, this bony defect increased to 17.1 mm (height) × 12.2 mm (width), respectively. CONCLUSIONS: Transorbital approaches to the pterygopalatine fossa following exenteration are feasible. Indications include orbital tumors with extension to the apex and pterygopalatine fossa, such as squamous cell carcinoma.