PURPOSE: Acquired punctal stenosis (APS) represents a common cause of epiphora and a reason for attendance at oculoplastic clinics. The three-snip punctoplasty is the mainstay of APS treatment, although perforated puncta...PURPOSE: Acquired punctal stenosis (APS) represents a common cause of epiphora and a reason for attendance at oculoplastic clinics. The three-snip punctoplasty is the mainstay of APS treatment, although perforated punctal plugs (PPPs) represent an alternative, offering reversibility and less burden on minor-operation lists. This study aimed to identify if PPPs are an acceptable alternative to the three-snip punctoplasty through comparison of functional, anatomical, and quality of life outcomes. METHODS: Participants with APS were randomized to receive either a three-snip punctoplasty or PPP in this assessor-masked study. Participants were followed up for 1 to 2 years, with a total of 3 follow-up visits. Data collected included patient demographics, slit-lamp examination findings, punctum dimensions on punctal optical coherence tomography, and results of Watery Eye Quality of Life questionnaire assessment. RESULTS: Forty-seven patients were recruited, with 25 attending the first postoperative visit and 32 providing final follow-up data via a telephone questionnaire. Both groups had significant reductions in weekly eye watering episodes and total Watery Eye Quality of Life scores, with no significant difference between groups. Only the three-snip group had a significant improvement in their simple 1 to 10 quality-of-life rating, with a significantly greater improvement than the PPP group. Following the intervention, three-snip had wider punctal optical coherence tomography and Kashkouli grade. CONCLUSIONS: Both punctoplasty and PPPs are effective APS interventions. Despite greater enlargement to punctal anatomy following three-snip punctoplasty, PPPs, and three-snip punctoplasty both improve epiphora, although three-snip punctoplasty may provide a greater improvement to quality of life.
Orbital cellulitis (OC) is a rare diagnosis in infants, with limited numbers of cases reported in the literature to date. We report a 34‑day‑old female who presented with severe left-sided periorbital swelling and propto...Orbital cellulitis (OC) is a rare diagnosis in infants, with limited numbers of cases reported in the literature to date. We report a 34‑day‑old female who presented with severe left-sided periorbital swelling and proptosis. Imaging confirmed a large orbital abscess with associated ethmoid sinusitis, and she underwent urgent exploration and drainage and initiation of broad‑spectrum intravenous antibiotics. Cultures grew methicillin‑sensitive Staphylococcus aureus. Postoperatively, she developed leukocytosis, eosinophilia, and recurrent skin abscesses, prompting immunologic evaluation. Genetic testing identified a novel STAT3 mutation in the SH2 domain consistent with Hyper‑IgE syndrome. This case highlights both the importance of prompt surgical and medical intervention in infantile orbital cellulitis and the need to consider underlying immune dysregulation when atypical clinical or laboratory findings are present. To our knowledge, this is the first reported case of infantile orbital cellulitis associated with Hyper-IgE syndrome, and the first report of this specific STAT3 variant causing hyper‑IgE syndrome.
PURPOSE: The authors describe a novel modification to the direct brow lift technique that targets the descent of the retro-orbicularis oculi fat (ROOF). Dissection and repositioning of the ROOF superiorly directly addres...PURPOSE: The authors describe a novel modification to the direct brow lift technique that targets the descent of the retro-orbicularis oculi fat (ROOF). Dissection and repositioning of the ROOF superiorly directly addresses the underlying etiology of brow ptosis-related hooding, fullness of the superior sulcus, and heaviness on the eyelids. Superior placement of the ROOF may help restore youthful volume to the brow. METHODS: A case series of 9 male patients with age-related brow ptosis underwent bilateral direct brow lift with the described ROOF mobilization technique. RESULTS: Mean preoperative brow-reflex distance improved from 5.17 to 11.76 mm postoperatively. The temporal ROOF was elevated above the orbital rim, which improved temporal hooding in all patients. All patients reported resolution of brow heaviness, improved visual function, and high satisfaction without the need for revision. No cases of frontalis paresis or neural compromise were observed. CONCLUSIONS: This technique leverages the anatomical and functional role of the ROOF to enhance the outcomes of functional direct brow lifting in mature male patients by restoring volume and reducing heaviness while preserving natural brow mobility.
PURPOSE: To describe a single academic institutional experience with ophthalmic Rosai-Dorfman disease (RDD) and to review the literature incorporating the revised 2016 classification of histiocytoses. METHODS: The author...PURPOSE: To describe a single academic institutional experience with ophthalmic Rosai-Dorfman disease (RDD) and to review the literature incorporating the revised 2016 classification of histiocytoses. METHODS: The authors review all cases of RDD at a single institution over a 10-year period, extracting those with ophthalmic findings. In addition, they provide an exhaustive review of previously published ophthalmic RDD patients and utilize the revised 2016 histiocytosis classification system to categorize both groups. RESULTS: Forty-eight patients with RDD were identified, of whom 12 had ophthalmic findings, with a mix of cutaneous, nodal, and extranodal forms. Twenty-one previously published case series and 105 case reports were analyzed, showing a diverse range of presentation and RDD categories. CONCLUSIONS: Rosai-Dorfman disease is a rare benign disorder characterized by proliferation of histiocytes, often with emperipolesis. While commonly presenting with cervical lymphadenopathy, extranodal involvement, including the orbit and ocular structures, can occur. Initially described as a pseudolymphomatous entity, RDD has recently been reclassified to reflect increased understanding of cellular origins, molecular pathology, and clinical spectrum. In this study, we utilize the new classification system to describe 12 patients with RDD and orbital/ocular involvement identified at a single institution-the largest single institution series of orbital RDD in the United States to date. We also review existing published examples of ophthalmic RDD, regrouping them to reflect the revised categorization. Diagnosis continues to be challenging, and further studies are needed to improve pre-biopsy diagnostic accuracy.
PURPOSE: The purpose of this study was to evaluate reimbursement trends for the surgical management of chalazion for the years 2000 to 2023 based on Centers for Medicare & Medicaid Services values. METHODS: Reimbursement...PURPOSE: The purpose of this study was to evaluate reimbursement trends for the surgical management of chalazion for the years 2000 to 2023 based on Centers for Medicare & Medicaid Services values. METHODS: Reimbursement rates for eyelid abscess blepharotomy and chalazion incision and drainage (Current Procedural Terminology codes 67700 and 67800) were queried from the Physician Fee Schedule Look-Up Tool for the years 2000 to 2023. The average reimbursement, the percent change, and the compound annual growth rate were calculated after adjusting for inflation using the consumer price index. Results were compared with reported reimbursement for other ophthalmic and general procedures. RESULTS: Reimbursement for facility and nonfacility fees for Current Procedural Terminology code 67700 was $130.84 and $328.41, respectively, in 2023. This corresponded to 9.23% and 11.76% percent changes in facility and nonfacility fees since 2000, adjusted for inflation. Reimbursement for facility and nonfacility fees for Current Procedural Terminology code 67800 was $104.87 and $133.95 in 2023. This corresponded to-20.48% and -57.95% percent changes since 2000, adjusted for inflation. The adjusted compound annual growth rates for code 67700 facility and nonfacility fees were 0.38% and 0.48%. The adjusted compound annual growth rates for code 67800 facility and nonfacility fees were -3.60% and -3.70%. CONCLUSIONS: While both procedure codes have decreased reimbursement over the last decade, code 67700 reimbursement has demonstrated growth above inflation from 2000 to 2023. This observed decrease in reimbursement can be attributed to Medicare budget policy changes in 2013, emphasizing the importance of Medicare reduction limits on the financial stability of certain procedures.
PURPOSE: To characterize and compare the clinical features, timing, and duration of thyroid eye disease relapse after teprotumumab in patients treated during the active versus stable phases of the disease. METHODS: A ret...PURPOSE: To characterize and compare the clinical features, timing, and duration of thyroid eye disease relapse after teprotumumab in patients treated during the active versus stable phases of the disease. METHODS: A retrospective case series was conducted of 26 adult patients who experienced a return of thyroid eye disease symptoms after completing teprotumumab therapy between July 2021 and July 2024 at 2 academic centers. Patients were stratified by thyroid eye disease phase at treatment initiation (active vs. stable). Data included clinical history, treatment details, and relapse characteristics. Relapse was defined by worsening of proptosis or extraocular motility deficits after completion of treatment. Statistical comparisons were made using t tests and Fisher's exact test. RESULTS: Of 26 patients, 20 were treated during the active phase and 6 during the stable phase. Active phase patients relapsed sooner (mean 8.2 vs. 12.3 months) and experienced significantly longer relapse duration (mean 11.1 vs. 4.2 months, p = 0.000035). In the active phase group, relapse was associated with progression of clinical signs beyond pretreatment levels, including 1 case of new-onset optic neuropathy. In contrast, stable phase patients uniformly returned to pretreatment clinical baselines without further progression. Both groups had similar rates of adverse events. CONCLUSIONS: Thyroid eye disease relapse after teprotumumab differs by disease phase at initiation. Active phase patients experience earlier, more prolonged, and more severe relapses, suggesting teprotumumab acts as a disease modulator. Stable phase patients exhibit shorter, nonprogressive symptom return, which we would term "rebound"-suggesting a distinct mechanism. These findings underscore the need for phase-specific counseling, monitoring, and further investigation into potentially disparate mechanisms of action of teprotumumab in the acute and stable phases.
We present an SWItch/Sucrose NonFermentable (SWI/SNF) complex-deficient carcinoma centered in the lacrimal drainage system and orbit of a 76-year-old male. The patient presented with nasolacrimal duct obstruction, which...We present an SWItch/Sucrose NonFermentable (SWI/SNF) complex-deficient carcinoma centered in the lacrimal drainage system and orbit of a 76-year-old male. The patient presented with nasolacrimal duct obstruction, which persisted after dacryocystorhinostomy. Imaging and surgical exploration showed a 3-cm orbital mass centered around the lacrimal sac with involvement of the nasolacrimal duct and orbit. Microscopic examination revealed sheets, nests, and strands of poorly differentiated tumor cells. Some had enlarged hyperchromatic nuclei and eosinophilic cytoplasm, and others had round to oval, somewhat vesicular nuclei with paler cytoplasm. In situ carcinoma was present in the lacrimal sac lining, with invasion into adjacent structures. Immunohistochemical analysis showed loss of INI1 protein in the neoplastic cells, with retained expression in non-neoplastic stroma. While a few SWI/SNF complex-deficient sinonasal carcinomas have been shown to invade into the orbit, this case highlights the need to consider this rare entity in the differential diagnosis of tumors arising in the lacrimal drainage system.
With this report, the authors describe a patient with locally advanced cutaneous angiosarcoma that presented with periorbital induration and recommend a systematic approach to the diagnostic workup of chronic, nonspecifi...With this report, the authors describe a patient with locally advanced cutaneous angiosarcoma that presented with periorbital induration and recommend a systematic approach to the diagnostic workup of chronic, nonspecific facial edema. A 69-year-old man presented with progressive, asymmetric periorbital edema over 12 months. He had a comprehensive evaluation across multiple specialties with extensive imaging, laboratory studies, and empiric treatments with glucocorticoids and antibiotics. Punch biopsy of the involved skin revealed cutaneous angiosarcoma. Positron-emission tomography-CT identified increased metabolic activity in the left periorbital region and lymph nodes. The tumor was deemed locally advanced and inoperable. Pembrolizumab was initiated after initial treatment with taxol was not tolerated. Facial edema that progresses despite comprehensive workup and empiric treatment warrants a broad, structured diagnostic approach, including advanced imaging and dermal punch biopsy. This case exemplifies the utility of this approach and reinforces the importance of timely diagnosis in investigating elusive causes of periorbital edema.
PURPOSE: Orbital infectious processes, including necrotizing fasciitis (NF) and orbital cellulitis (OC), often present similarly, although clinical management is individualized for each etiology. Therefore, rapid diagnos...PURPOSE: Orbital infectious processes, including necrotizing fasciitis (NF) and orbital cellulitis (OC), often present similarly, although clinical management is individualized for each etiology. Therefore, rapid diagnosis is critical for appropriate therapy and to avoid possible complications. This study was undertaken to compare the efficacy of the Laboratory Risk Indicator for NF score and other established biomarkers in differentiating NF and OC. METHODS: Using laboratory results obtained from the first blood draw at the time of presentation to the emergency department, Laboratory Risk Indicator for NF scores, derived neutrophil-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, and neutrophil-to-platelet ratio were calculated. Mann-Whitney and the area under the receiver operating characteristic curve were used for statistical analysis. RESULTS: The authors' cohort included 21 patients with NF and 21 patients with OC. The Laboratory Risk Indicator for NF scores ( p value = 0.3400, AUC = 0.5862), monocyte-to-lymphocyte ratio ( p value = 0.2204, AUC = 0.6164), and platelet-to-lymphocyte ratio ( p value = 0.5489, AUC = 0.5582) were not statistically significantly different in OC and NF. Neutrophil-to-lymphocyte ratio ( p value = 0.0051, AUC = 0.7593), derived neutrophil-to-lymphocyte ratio ( p value = 0.0358, AUC = 0.69), and neutrophil-to-platelet ratio ( p value = 0.0002, AUC = 0.8254) were statistically significantly higher in NF, as compared to OC. CONCLUSIONS: This study employed the largest dataset of patients with NF and OC to compare the efficacy of different biomarkers at distinguishing between these conditions. While the Laboratory Risk Indicator for NF score failed to distinguish orbital NF from OC, other biomarkers, including the derived neutrophil-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, and neutrophil-to-platelet ratio, accurately differentiated between these conditions. Given that these biomarkers are readily available, they could be implemented as auxiliary diagnostic tools.
PURPOSE: To describe the use of an acellular fish skin (AFS) xenograft as a biologic scaffold for eyelid reconstruction in patients with scarring and tissue loss due to trauma, necrotizing fasciitis, and thermal burns. M...PURPOSE: To describe the use of an acellular fish skin (AFS) xenograft as a biologic scaffold for eyelid reconstruction in patients with scarring and tissue loss due to trauma, necrotizing fasciitis, and thermal burns. METHODS: The authors present a novel technique for eyelid reconstruction in 4 patients using AFS following severe eyelid injuries from diverse etiologies: thermal burns (n = 2), necrotizing fasciitis (n = 1), and trauma (n = 1). Patients experienced cicatricial retraction and/or periorbital tissue loss necessitating reconstruction. AFS grafts were applied as dermal substitutes for eyelid defects. RESULTS: In all cases, AFS was well tolerated with no evidence of graft rejection, infection, or significant inflammation. Functional outcomes, including eyelid closure and ocular surface protection, were preserved or improved in all patients. Some patients required multiple applications of AFS to address ongoing tissue contraction and cicatricial changes that occurred during the healing process. CONCLUSIONS: AFS is a safe and effective dermal substitute in eyelid reconstruction for cicatricial changes and tissue loss due to burns, infections, or trauma. Its biocompatibility and capacity to support neovascularization make it a promising option in cases where active inflammation or devitalized tissue is present. Larger studies are warranted to further define its role in facial and periocular reconstructive surgery.