ASOPRS 2020 Virtual Spring Scientific Symposium Friday, June 26 – Sunday, June 28

SYLLABUS GENERAL INFORMATION

Continuing Medical Education

ASOPRS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor the Continuing Medical Education (CME) for physicians. The American Society of Ophthalmic Plastic and Reconstructive Surgery designates this live activity for a maximum of 8.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Self-assessment CME credit may be claimed if the physician completes the self-assessment questionnaire at the end of the online meeting evaluation.

Continuing Medical Education Mission Statement

The purpose of the American Society of Ophthalmic Plastic and Reconstructive Surgery’s Continuing Medical Education (CME) program is to present oculofacial plastic surgeons with the highest quality learning opportunities in the areas of aesthetics, eyelid, lacrimal, and orbital diseases that promote positive change in physician performance or competence, thus enabling such physicians to maintain or improve the knowledge, skills, and professional performance needed to provide the best possible care for their patients. Ongoing assessment of the impact of the CME program is important in determining modifications to existing activities and the development of new activities. Specific expected results include increased knowledge across the ASOPRS community, a desire among practicing ophthalmologists to pursue lifelong learning, the refinement of already employed techniques or skills, and the application of new techniques or skills for the improvement of practice and patient care.

Evaluations/CME Certificates

A link to an evaluation will be provided to attendees after the meeting via email. Please complete the evaluation in its entirety. You will have an opportunity to download a CME certificate once you have completed the evaluation. Your feedback is carefully considered when planning future meetings. Thank you in advance for helping ASOPRS improve our Spring Scientific Symposium.

Abstract Disclaimer

Abstract information is published as submitted.

2 FINANCIAL DISCLOSURES

As an accredited CME provider, ASOPRS is responsible for demonstrating that our CME educational programs are planned and presented independent of commercial influence. In accordance with the guidelines of the Accreditation Council for Continuing Medical Education (ACCME), ASOPRS requires disclosure of relevant financial relationships with commercial interests of Abstract Reviewers (AR), Faculty (F), Moderators (M), Program Committee and CME Subcommittee Members (PC), abstract authors, and all other individuals in control of content. A commercial interest is defined as “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.” The ACCME does not consider providers of clinical service directly to patients to be commercial interests — unless the provider of clinical service is owned or controlled by an ACCME-defined commercial interest. The ASOPRS CME Subcommittee has conducted a conflict of interest (COI) resolution process with anyone determined to have a relevant financial relationship. This process may have included reviewing presentations for indicators of integrity and absence of bias, and an agreement from faculty to keep their presentation free from commercial bias. Moderators have been assigned to sections of the program that are not related to any financial disclosure they have made. Planners with relevant financial disclosures were removed from making any decisions or having any influence over the programmatic content which relates to their financial disclosure. Programmatic recommendations from Executive Committee and other Committee members were not considered if they were related to a relevant financial disclosure of that Committee member. During the CME educational program, the moderators will identify situations in which a presenter does not uphold the agreement above, by bringing the bias to the attention of the audience at the conclusion of the speaker’s presentation. Meeting attendees may also bring their concerns of bias to the microphone during Q&A. ASOPRS is committed to transparency. The CME Subcommittee has determined that financial disclosures deemed to be relevant will be published in this Syllabus. If a financial relationship was deemed relevant, the COI process has been conducted and the conflict resolved. If through observation at the meeting, or meeting evaluations, any faculty is determined to have presented bias, the CME Subcommittee will follow up in writing with the individual and may bar the individual from presenting at future meetings.

Cat N. Burkat PC Horizon Therapeutics – Consultant/Advisor Peter J. Dolman F Immunovant - Consultant/Advisor Don O. Kikkawa F Horizon Therapeutics - Consultant/Advisor Tanuj Nakra Co-Author Global Beauty Science, Inc - Equity Owner Jeremiah P. Tao PC, AR Horizon Therapeutics - Consultant/Advisor All other individuals in control of content have declared that they have no relevant financial disclosures, or, their financial disclosures have not been found relevant to their role(s) in the program.

3 THYROID EYE DISEASE UPDATE Friday, June 26

Program times below are Eastern Daylight Time MAXIMUM 2 CME HOURS FOR FRIDAY (7 – 9 pm EDT, 6 – 8 pm CDT, 5 – 7 pm MDT, 4 – 6 pm PDT)

Moderators: Thomas E. Johnson and Michael T. Yen

7:05 – 7:23 pm Basic Introduction to TED: Pathophysiology, Evaluation, and Clinical Findings

Jonathan J. Dutton University of North Carolina, Durham, North Carolina, United States

The pathophysiology of autoimmune thyroid disease is not completely understood. Antigen presenting cells are attracted to specific thyroid antigens and migrate to the draining lymph nodes where they present thyroid antigens to immunologic cells. Here, they activate B- and T-lymphocytes against several thyroid gland antigens, most commonly the TSH-receptor. In Graves disease, these are typically anti-TSH stimulating antibodies. The primary target of the autoimmune reaction is the TSH-receptor in the thyroid gland, where they initiate the synthesis of thyroid hormone, resulting in the classic symptom of hyperthyroidism.

Graves disease is associated with several manifestations outside the thyroid gland related to the presence of TSH-receptor antigen in other tissues. These most commonly occur in the dermis of the lower leg and the orbit. Pretibial myxedema is a form of mucinous dermopathy occurring in a small proportion of patients with Graves disease. In about 30-50% of Graves patients, the orbit also becomes involved in the immune reaction resulting in orbitopathy referred to as thyroid eye disease (TED). The typical orbital findings include eyelid edema, conjunctival injection, eyelid retraction, proptosis, and restrictive ophthalmoplegia from enlarged and often fibrotic extraocular muscles. Severe secondary manifestations include compression of the optic nerve from enlarged extraocular muscles in the posterior orbit and corneal exposure and ulceration from eyelid retraction with impaired blink reflex.

To date, the most plausible candidate for the primary immunological target in the orbit is the orbital fibroblast. The orbital fibroblasts express TSH- and IGF-1 receptors that interact to help regulate fibroblast function. These receptors are targeted by Graves disease activated T- and B-cells which home to the orbit in GD patients. Some of these cells are capable of undergoing adipocyte differentiation into mature fat cells that contribute to the orbital volume expansion so characteristic of Graves ophthalmopathy.

(continued) 4 Thyroid Eye Disease Update Friday, June 26

(continued) Interactions between fibroblasts and immunocompetent cells are responsible for the pathogenesis of orbital remodeling. The initial insult involves the production of chemokines that attract immune cells to the orbit and cytokines that initiate the synthesis of a variety of chemical pro-inflammatory factors. Inflammatory mediators result in vascular dilatation, increased vascular permeability, tissue edema, glycosaminoglycan (GAG) synthesis, and tissue fibrosis.

The natural history of thyroid eye disease goes through an Active Inflammatory Phase characterized by cytokine secretion and inflammatory activity that typically lasts for about12-36 months. There follows a Chronic Fibrotic Phase where collagen deposition, increased fat deposition, and glycosaminoglycan infiltration of extraocular muscles predominate. Accurate clinical assessment is essential for evaluating patient status and for planning management. This will be discussed by Dr. Dolman.

Management of Thyroid Eye Disease in the Active Phase

The concept of immunomodulation for Thyroid Eye Disease is based on depletion of activated T- and B-cell populations, blockage of TSH- and IGF-1-receptor sites on the orbital fibroblast, prevention of fibroblast activation, reduction of cytokine production, blockage of cytokine action, inhibition of adipogenesis and GAG production, and prevention of connective tissue remodeling. These therapies are only useful during the active phase of the disease. Standard-of-care therapies currently available include glucocorticoid steroids, non- steroidal anti-inflammatory agents, radiotherapy, and targeted immunomodulation.

Glucocorticoid Steroids

Glucocorticoid steroids have an anti-inflammatory effect by modulation of inflammatory gene transcription. They increase the synthesis of anti-inflammatory agents and inhibit the synthesis of pro-inflammatory mediators. Steroids are indicated for moderate to severe congestive TED and early compressive optic neuropathy.

Steroids can be given by periorbital injection, PO, or IV routes with evidence suggesting that IV gives better results with fewer side effects. Studies show improvement in soft tissue swelling, proptosis, diplopia, & optic neuropathy. Potential complications of IV steroids include gastritis, hypertension, glaucoma, tachycardia, diabetes, and liver toxicity.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

The Cox-2 pathway produces a prostaglandin inflammatory mediator. Expression of Cox-2 has been demonstrated in orbital fibroblasts during the active phase of Graves disease so that Cox-2 inhibitors might play a role in decreasing the severity of active inflammation. Our preference is Diclofenac 50 mg bid. This is a selective Cox-2 inhibitor that has minimal effect on the Cox-1 pathway that is important in blood clotting.

(continued) 5 Thyroid Eye Disease Update Friday, June 26

(continued) Orbital Radiotherapy

The mechanism of action of radiotherapy is poorly understood. It has several non-specific anti-inflammatory actions that may include decreased chemokine expression, increased fibroblast DNA damage and reduced DNA repair, and blockage of fibroblast proliferation. Several large meta-analyses have shown that radiotherapy can reduce orbital pain, inflammation, and swelling, and can improve diplopia. The overall response rate is 50%-60%.

Targeted Therapy and Immunomodulation

CD-20 is a surface antigen that regulates B-cell function and differentiation. Rituximab (RTX) binds to the CD-20 antigen-binding site and blocks B-cell function.

TNF-α is a cytokine produced by orbital fibroblast interaction with activated T-cells. It increases GAG production and incites inflammation, both of which contribute to orbital changes in TED. These and other targeted therapies have been useful in some cases of TED and will be discussed by Dr. Kazim.

Newer immunomodulatory agents are under investigation and some have proven to be useful in the management of other autoimmune diseases. Temprotumumab is a monoclonal antibody attenuates signaling between TSH- and IGF-1 receptors, thereby blocking pathologic immune responses in active thyroid eye disease. This will be discussed by Dr. Douglas.

Surgical Management of Thyroid Eye Disease in the Chronic Phase

For patients in the chronic fibrotic phase, immunomodulation will have little or no effect. Although surgical intervention may sometimes be required in the active phase of the disease, especially when visual loss is threatened, as with optic nerve compression or severe corneal exposure, in most cases surgery is deferred until the disease is stable and inactive and surgical reconstructive procedures will depend upon patient symptoms and functional morbidity. These will be discussed by Dr. Kikkawa.

6 Thyroid Eye Disease Update Friday, June 26

7:23 – 7:38 pm Assessment and Management of Dysthyroid Optic Neuropathy

Peter J. Dolman Univ of British Columbia Eye Care Centre, Vancouver, BC, Canada

Thyroid eye disease (TED) is an immune -mediated inflammation often associated with autoimmune thyroid disease that causes enlargement of orbital muscle and fat. The disease severity and activity can be categorized using the VISA classification. Disease severity is graded using four VISA parameters: Vision (DON), Inflammation (congestion), Strabismus (diplopia/restriction) and Appearance (exposure). The disease follows a biphasic course with an active (progressive) phase lasting 6 to 18 months during which VISA grades worsen, followed spontaneously be an inactive (stable) phase.

Dysthyroid optic neuropathy (DON) is a potentially reversible optic nerve dysfunction occurring in about 7% of patients with TED (and 20% of high-risk patients). It most commonly results from compression of the nerve by enlarged muscles in the tight orbital apex, although occasionally optic nerve stretch associated with severe proptosis may be a factor. DON patients tend to be older, more likely male and more commonly diabetic than TED patients without DON. The onset may be insidious and in early cases the diagnosis may be uncertain. Emotional stress, systemic infections, surgery and radioactive iodine may precipitate onset of DON. It typically is diagnosed while the disease is progressive / active.

Clinical features include blurring of central vision and desaturation of colours, both confirmed on visual examination. Colour vision changes are a more sensitive indicator of DON than central acuity. In a review of 73 cases managed by myself, 55% had a relative afferent pupil defect, but only 20% demonstrated disc edema. The latter is not a sensitive marker for DON, but when present is specific. Associated VISA findings include mean congestive/inflammatory scores of 5/10 and mean strabismus scores of 2/3. Appearance changes are not a reliable indicator of DON, as some patients may have minimal proptosis or lid retraction and still have progressive DON.

Common CT findings include apical crowding and distension of the optic nerve sheath; in our series, intracranial fat herniation or straightening of the optic nerve were not reliable indicators of DON. Paracentral visual field defects are identified in 70% of DON patients.

Medical management of DON includes oral or intravenous glucocorticoids, while cyclosporine and rituximab have showed promise in small case reports. In my review, over 90% of patients showed temporary response to medical intervention, but only 7.5% were able to avoid surgical intervention.

(continued) 7 Thyroid Eye Disease Update Friday, June 26

(continued) Radiotherapy (XRT) caused improvement in 96% of cases of DON in a 2002 report by Kazim et al. It may also prevent new onset DON: a review of all my patients over the past 12 years being treated for progressive TED found new onset of DON in 19% of patients who were on steroid therapy alone compared with 0% of patients who received XRT.

Surgery usually consists of bony decompression of the posterior medial wall and floor although lateral wall decompression and fat excision have also been described. A review of my cases found 90% improved vision to 6/12 or better, and that even severe central vision pre-operatively might be improved to excellent vision. Delay to surgery did not necessarily result in a poorer outcome.

8 Thyroid Eye Disease Update Friday, June 26

7:38 – 7:56 pm Has the Age of Targeted Therapy for TED Arrived?

Michael Kazim The Edward S. Harkness Eye Institute, New York, New York, United States

8:09 – 8:24 pm Surgical Management in TED

Don O. Kikkawa Shiley Eye Institute, USCD, La-Jolla, California, United States

8:24 – 8:42 pm Case Presentations with Audience Discussion

Jennifer A. Sivak-Callcott Mon Health Oculofacial Surgery, Morgantown, West Virginia, United States

Cases will be presented for discussion regarding the treatment of thyroid eye disease. This will be following several talks in the symposium regarding pathogenesis and management of thyroid eye disease. These cases will provide a summary for the audience of thyroid eye disease and allow for practical take home points that can be implemented in clinical practice.

9 YASOPRS RAPID FIRE CASES AND PRESENTATIONS Saturday, June 27

Program times below are Eastern Daylight Time MAXIMUM 3 CME HOURS FOR SATURDAY (12 – 3 pm EDT, 11 am – 2 pm CDT, 10 am – 1 pm MDT, 9 am – 12 pm PDT)

Moderators: Sophie D. Liao and M. Reza Vagefi

12:07 – 12:11 pm Romaña Sign: An Uncommon Cause of Periorbital Erythema

Aliza Epstein1, Kristin Mondy2, Frank Hudson2, Natalie Homer1 1TOC Eye and Face, Austin, Texas, United States, 2Division of Infectious Diseases, The University of Texas at Austin Dell Medical School, Austin, Texas, United States

Introduction: Chagas disease is a systemic parasitic infection endemic to areas of Central and South America with increasing incidence in the United States. Chagas disease can initially present with painless periorbital erythema, or Romaña sign, and be mistaken for orbital infection.

Methods: Case Report

Results: A 41-year-old male was transferred to a tertiary care center with one week of progressive left-sided painless periorbital swelling nonresponsive to broad-spectrum treatment with Trimethoprim/Sulfamethoxazole, Vancomycin, Cefepime, Piperacillin/tazobactam, Ampicillin/sulbactam, and Acyclovir. The patient denied any discomfort or vision changes. He had no known past medical history and denied travel outside of the state or recent insect bite. Examination revealed non-tender left periorbital erythema and edema (Figure 1), with associated conjunctival injection (Figure 2), and ipsilateral preauricular lymphadenopathy. He had intact visual acuity, pupillary response and extraocular motility without proptosis or resistance to retropulsion. Magnetic resonance imaging revealed preseptal edema, ipsilateral medial rectus and lacrimal gland enlargement with retrobulbar fat stranding (Figure 3). Despite his significant and persistent eyelid swelling and erythema, he denied pain or other symptoms. He had two recorded fevers during hospitalization. Serum blood counts, angiotensin converting enzyme, antineutrophil cytoplasmic antibodies, and IgG4 were normal. Tests for bartonella, toxoplasmosis, tularemia, HIV, syphilis, and adenovirus were negative. Plasma sent for next generation sequencing (NGS) testing (Karius Laboratory, Redwood, CA) to identify atypical pathogens revealed Trypanosoma cruzi (505 DNA molecules/microliter). Confirmatory PCR testing was performed by the Center for Disease Control (CDC). The patient was initiated on a 60-day course of oral benznidazole with complete resolution of periorbital edema and erythema (Figure 4).

(continued) 10 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

(continued) Conclusions: Chagas disease, also known as American Trypanosomiasis, is caused by the single-celled protozoa Trypanosoma cruzi and transmitted through vectorial spread by infected triatomine insects. Infection is transmitted via trypomastigotes in insect feces deposited near the site of infection1. Reported cases in the United States have been predominantly in immigrants from endemic countries and those with recent travel to affected areas2. Very few cases have been locally acquired3,4. Acute infection can present with fever, lymphadenopathy, and the pathognomonic painless periorbital edema, erythema, and conjunctivitis, termed Romaña sign. The conjunctiva is believed to be the port of entry when this classic finding is present. Potential complications of untreated chronic infection include dilated cardiomyopathy, megacolon, megaesophagus, and stroke. NGS testing may be particularly useful in atypical orbital infections where rare pathogens are considered. Benznidazole, an FDA approved treatment for Chagas disease in patients age 2-12, is often prescribed for children and adults alike. The only other known medication to treat Chagas is nifurtimox, which is available through the CDC.

Ophthalmologists and oculoplastic surgeons should have high suspicion for Chagas disease in patients presenting with periorbital erythema, particularly if they report recent residence or travel to endemic countries, atypical absence of pain, or show resistance to antibacterial and antiviral treatment. Expedient diagnosis of Chagas disease is essential to prevent significant associated morbidity and mortality.

Figure 1 Figure 2 Figure 3 Figure 4

References 1. Perez-Molina J, Molina I. Chagas Disease. The Lancet. 2018;391:82-94 2. Carter YL, Juliano JJ, Montgomery SP, et al. Case Report: Acute Chagas Disease in a Returning Traveler. Am. J. Trop. Med. Hyg. 2012;87(6):1038–1040. 3. Bern C, Kjos S, Yabsley MJ, Montgomery SP. Trypanosoma cruzi and Chagas’ disease in the United States. Clin Microbiol Rev. 2011;24:655–81. 4. Hernandez S, Flores CA, Viana GM, Sanchez DR, Traina MI, Meymandi SK. Autochthonous Transmission of Trypanosoma cruzi in Southern California. Open Forum Infect Dis. 2016;3(4):1-3. 11 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

12:11 – 12:15 pm Microscopic Polyangiitis with Concomitant Orbital Mass and Uveal Effusion Angle Closure

Sanja Cypen, Catherine Sheils, Param Bhatter, Jeremiah Tao Ophthalmic Plastic & Reconstructive Surgery, University of California, Irvine, Irvine, California, United States

Introduction: We present a unique case of a concomitant infiltrative orbital mass and angle closure secondary to uveal effusions.

Methods: A case report.

Results: A 63-year-old Caucasian man with no significant past medical history presented with three weeks of worsening, painless left-sided proptosis, ptosis, and diplopia. On examination, visual acuity was 20/30 and 20/25 in the right and left eyes, respectively. Intraocular pressure was 15 mmHg in both eyes. There was a 1+ afferent pupillary defect in the left eye. Extraocular movements were limited in all directions of gaze in the left eye. The right eye examination was unremarkable. Significant findings on the left included complete ptosis, 6 mm of proptosis by Hertel exophthalmometry, 1+ diffuse conjunctival/scleral injection, and a flat anterior chamber with absence of cell or flare (Figure 1). No angle structures were visible on gonioscopy. Dilation was deferred due to anterior chamber anatomy. Ultrasound biomicroscopy revealed a diffusely shallow anterior chamber with ciliary body effusions and anterior rotation. A B-scan ultrasound revealed flattening and indentation of the superior globe with a hyperechoic retrobulbar lesion. Magnetic resonance imaging of the orbits demonstrated an irregular, enhancing superotemporal mass involving the lacrimal gland, superior rectus/levator muscle complex, and lateral rectus muscle with thickening and enhancement of the posterior globe (Figure 2). The patient was initiated on intravenous methylprednisolone. An orbital biopsy was performed two days after admission and revealed mild dacryoadenitis without associated perivascular infiltrates or granulomatous inflammation. Serum laboratory work-up revealed positive perinuclear ANCA with elevated myeloperoxidase antibodies. The findings were consistent with a diagnosis of microscopic polyangiitis (MPA). The patient was continued on oral prednisone for one week with complete resolution of symptoms and examination findings. He is now tapering prednisone and has been initiated on steroid-sparing therapy (rituximab) without recurrence of disease.

Conclusions: Of the three clinical phenotypes of ANCA-associated vasculitis, granulomatosis with polyangiitis is most commonly associated with intraocular and orbital inflammation, less frequently occurring simultaneously.1 To our knowledge, this is the first reported case of MPA presenting with an orbital mass and appositional angle closure secondary to uveal effusions.

(continued) 12 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

(continued) Figure 1 Figure 2

References 1. Ungprasert P, Crowson CS, Cartin-Ceba R, et al. Clinical characteristics of inflammatory ocular disease in anti-neutrophil cytoplasmic antibody associated vasculitis: a retrospective cohort study. Rheumatol Oxf Engl. 2017;56(10):1763-1770.

13 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

12:15 – 12:19 pm Sinus Pericranii with Orbital Involvement: A Case Report and Review of Literature

Laura Gadzala1, Omar Sadat2, John Nguyen3,4 1Ophthalmology, Devers Eye Institute, Portland, Oregon, United States, 2West Virginia University, Morgantown, West Virginia, United States, 3Ophthalmology, West Virginia University, Morgantown, West Virginia, United States, 4Otolaryngology, West Virginia University, Morgantown, West Virginia, United States

Introduction: Sinus pericranii (SP) is an uncommon venous anomaly involving aberrant transosseus communication between the intracranial and extracranial venous systems usually found in children. While it normally presents as a pulsatile compressible lesion of the midline scalp, rare cases involving the periorbital region may cause unilateral upper lid ptosis. We describe a case of sinus pericranii with orbital involvement causing headache and intermittent diplopia.

Results: A 49-year-old Caucasian female with SP diagnosed at age 12 presented with progressively worsening pressure-type pain of the left eye and head for the past 6 months. Pressure pain and swelling of a varicosity located in her left temple began each morning when she arose from bed and improved after being upright. She also had horizontal diplopia when reclining. Her past surgical history included ligation of varicosities via a bicoronal incision following attempted percutaneous alcohol ablation of the pericranial sinuses.

External examination revealed a 1.5 cm, round, partially compressible nodule with a smaller nearby nodule in the left temporal region that was tender to the touch. The lesion enlarged with reclining; there was no proptosis or resistance to retropulsion. Visual acuity was 20/20 OU; there was no pupillary or motility deficit. Intraocular pressure was 13 mmHg OD and 15 mmHg OS. The remaining examination was unremarkable. Humphrey visual field was full. MRI revealed multiple sinus pericranii along the left frontal and parietal calvarium and scalp with prominent venous communication to the sphenoid wing and lateral orbital wall displacing the lateral rectus with the patient’s head extended and in a dependent position (Figure 1A-C). On digital subtraction angiography, the orbital venous varix communicated with the left superior middle cerebral vein and enlarged with Valsava (Figure 1D). Discussion with interventional radiology raised significant risks of embolization, and the decision was made to observe. The patient’s discomfort was controlled with NSAIDS, with no progression of symptoms at 6 months follow up.

(continued) 14 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

(continued) Conclusions: Periorbital SP is rare with eight cases identified since 1956. Most patients are asymptomatic or have cosmetic concerns, but SP can cause headaches and tinnitus; our patient was unusual in that she presented with diplopia due to posterior orbit involvement. Sinus pericranii most often affects the frontal region near the central and posterior thirds of the superior sagittal sinus. Most cases are congenital and may be associated with other venous anomalies, although post-traumatic cases have been reported in adults. Angiography is critical to distinguish accessory SP from dominant SP, where the anomaly forms the major outflow for intracranial venous drainage. While accessory SP can be treated with surgical or endovascular intervention, dominant SP is best managed conservatively with lifetime surveillance to monitor for complications such as cerebral venous hypertension or hemorrhage due to the significant risk of intraoperative hemorrhage and venous infarction. This case demonstrates the challenges of managing SP, as there are no consensus or guidelines to management, and a multidisciplinary approach is needed to individually tailor a therapeutic plan.

Figure 1

References 1. Akram H, Prezerakos G, Haliasos N, O’Donovan D, Low H. Sinus pericranii: an overview and literature review of a rare cranial venous anomaly (a review of the existing literature with case examples). Neurosurgical Review. 2012;35(1):15–26. doi:10.1007/s10143-011-0325-6. 2. Bollar A, Allut AG, Prieto A, Gelabert M, Becerra E. Sinus pericranii: radiological and etiopathological considerations. case report. Journal of Neurosurgery. 1992;77(3):469–72. 3. Grahovac G, Rajappa P, Vilendecic M, Zic R, Lambasa S, Prgomet S. Sinus pericranii in the left frontal region involving the superior eyelid: a case report. J Neurol Surg a Cent Eur Neurosurg. 2013;74(S 01):169. doi:10.1055/s-0032-1333423. 4. Luker GD, Siegel MJ (1995) Sinus pericranii: sonographic findings. AJR Am J Roentgenol 165:175–176. 5. Mastin WM IV. Venous blood tumors of the vault of the cranium communicating with the superior longitudinal sinus. Continued. Ann Surg. 1885;(1):439–463. 6. Sakai K, Namba K, Meguro T, Mandai S, Gohda Y, Sakurai M, Matsumoto Y Sinus pericranii associated with a cerebellar venous angioma–case report. Neurol Med Chir (Tokyo). 1997;(37):464–467. 7. Osanai T, Houkin K. Adult-onset orbital sinus pericranii with t2 hyperintensity lesion: a case report. Case Reports in Neurology. 2018;10(1):112–117. doi:10.1159/000488477. 8. Ota T, Waga S, Handa H, Nishimura S, Mitani T Sinus pericranii. J Neurosurg. 1975;(42):704–712. doi: 10.3171/jns.1975.42.6.0704.

15 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

12:19 – 12:23 pm Our Experience Repairing Orbital Fractures with a Commercially Available Pre-contoured Hybrid Titanium/Porous Polyethylene Implant

Nathan Blessing1, Andrew Rong2, Brian Tse2, Benjamin Erickson3, Tom Johnson2 1Dean McGee Eye Institute / University of Oklahoma, Oklahoma City, Oklahoma, United States, 2Bascom Palmer Eye Institute / University of Miami, Miami, Florida, United States 3Byers Eye Institute / Stanford University, Palo Alto, California, United States

Introduction: Large orbital floor and medial wall fractures involving the inferomedial strut or posterior bony ledge present reconstructive challenges due to loss of intraoperative orbital anatomical landmarks and adjacent bony support. Reconstructive implant options include titanium mesh, porous polyethylene (PPE) sheeting, hybrid titanium/PPE, silastic sheeting, and bone grafting. Basic, unshaped implants require the surgeon to fashion an appropriately sized and contoured implant intraoperatively or preoperatively using a 3D printed biomodel. Pre-sized and contoured hybrid titanium/PPE implants (Medpor Titan 3D Orbital Floor Implant, Stryker Craniomaxillofacial, Kalamazoo, MI) are designed to re-establish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. These implants only recently became commercially available and this is the first study to report clinical outcomes and experiences with this implant (Figure 1).

Methods: This IRB-approved retrospective case series reviewed clinical data for all patients undergoing orbital fracture repair with a novel implant from January 2016 to June 2018.

Results: A total of 33 patients and 34 orbits were identified (mean age 43 +/- 16 years, 70% male). All patients were treated by an ASOPRS-trained oculoplastic surgeon via a transconjunctival incision with or without (79%) a swinging eyelid approach. Common traumatic mechanisms included assault (36%), falls (18%), and motor vehicle accidents (21%). Other patients were post-cancer resection, suicide attempt, mucocele repair, and silent sinus syndrome. All patients had large orbital floor deformities and 76% had defects of the medial wall/orbital strut. Symptomatic diplopia (73%) and enophthalmos (94%, mean of 3.7 +/- 2.1mm) were common preoperative findings. A large number of cases were revisions (42%) (Figure 2). Most orbits (82%) received size “large” implants. The medial wing was modified in 59% of implants. Post-operatively, mean follow-up was 7.8 +/- 6.7 months. All patients had improved globe positioning, enophthalmos (mean post-op relative enophthalmos of 0.9 +/- 1.4mm), and hypoglobus. Seven patients had persistent post-operative diplopia; 6 responded to prism therapy and one required strabismus surgery. One patient required revision surgery at post-op week 2 due to a delayed retrobulbar hemorrhage from Valsalva and one patient required implant explantation due to persistent infection following erosion of the maxillary sinus mucosa (history of adjuvant radiation following cancer resection involving the orbital floor).

(continued) 16 YASOPRS Rapid Fire Cases and Presentations Saturday, June 27

(continued) Conclusions: This study demonstrates that a novel pre-contoured hybrid titanium/PPE implant in orbital fracture repair can achieve functional improvement in diplopia, enophthalmos, and extraocular motility with a low incidence of post-operative complications or revisional surgery. This implant is well-suited for combined floor and medial wall fractures, large floor fractures without adequate posterior bony support, patients with complex anatomical defects due to resection of malignancies or sinonasal pathology, and revisional surgery requiring explantation of a previously placed implant. Theoretical advantages of this implant include reduced operative time, reduced surgeon error in implant sizing and contouring, titanium rigid fixation with PPE resistance to cicatricial tethering, and anatomic orbital reconstruction. Although the “small” size implant is easier to insert, the authors believe that the anterior-posterior dimension of the “large” implant may be an advantage in cases with a minimal posterior bony support and have developed a unique technique to insert the larger implant.

Figure 1 Figure 2

References 1. Zimmerer RM et al. A prospective multicenter study to compare the precision of posttraumatic internal orbital reconstruction with standard preformed and individualized orbital implants. J Craniomaxillofac Surg. 2016 Sep;44(9):1485-97. 2. Peng MY et al. Orbital fracture repair outcomes with preformed titanium mesh implants and comparison to porous polyethylene coated titanium sheets. J Craniomaxillofac Surg. 2017 Feb;45(2):271-274. 3. Strong EB et al. Preformed vs intraoperative bending of titanium mesh for orbital reconstruction. Otolaryngol Head Neck Surg. 2013 Jul;149(1):60-6. 4. Lee GH, Ho SY. Orbital Adherence Syndrome following the Use of Titanium Precontoured Orbital Mesh for the Reconstruction of Posttraumatic Orbital Floor Defects. Craniomaxillofac Trauma Reconstr. 2017 Mar;10(1):77-83.

17 ONCOLOGY SESSION Saturday, June 27

12:33 – 12:38 pm Hedgehog Pathway Inhibitors for Orbital and Periorbital Basal Cell Carcinoma: Long Term Analysis of Clinical Response and Recurrence

Andrea Kossler1, Arthika Chandramohan1, Amee Azad2 1Ophthalmology, Stanford School of Medicine, Palo Alto, California, United States, 2Stanford School of Medicine, Palo Alto, California, United States

Introduction: Hedgehog pathway inhibitors (HPI) have been used effectively as neoaduvant and monotherapy for orbital and periorbital basal cell carcinoma (BCC). Our purpose is to characterize clinical response, resistance, and recurrence rates of neoadjuvant, adjuvant and monotherapy for orbital and periorobital BCC.

Methods: A retrospective interventional case series of all patients treated with HPIs for biopsy-proven locally advanced periorbital or orbital BCC between 01/2010 and 11/2018. Patients received HPIs as intended mono, adjuvant, or neoadjuvant therapy. Clinical charts and imaging databases were mined for patient data. Primary outcomes included rates of and time to clinical response, total treatment time, and rates of resistance and recurrence. Side effect data was also collected.

Results: Twenty-two patients were included, averaging 67 years of age, and 36% female. Nineteen patients received neoadjuvant or monotherapy while three underwent adjuvant treatment. Median treatment length was 10 months and followed for a median of 36.5 (range 8-123) months. Seventeen (81%) had a complete or partial response and most patients (86%) were able to avoid exenteration. Twelve patients (55%) demonstrated secondary resistance, or progressive disease after initial response to the drug. Of the 15 patients treated with an HPI as monotherapy, 46% showed complete response an average of 22 months on the medication however 53% had biopsy proven recurrences 8.5 months (median) after stopping the drug. Of the 13 patients treated with monotherapy or neoadjuvantly who underwent surgical excision (planned or for resistance or recurrence), three (23%) developed recurrent disease following surgical excision (median 30 months following surgery).

Conclusions: HPIs are effective neoadjuvant treatments for orbital or periorbital BCC that can avoid exenteration in the majority of cases. While most patients demonstrated early clinical response, resistance or late recurrence off of the drug occurred in many patients treated with only an HPI, and in some after surgical excision. Surgeons should consider globe salvaging surgical excision of the tumor bed in patients with complete or partial response to therapy or counsel patients on possible secondary resistance or late recurrence that may occur with monotherapy, as these patients need close long term observation.

(continued) 18 Oncology Session Saturday, June 27

(continued) Figure 1 Treatment timelines plotted for individual Figure 2 Treatment response in one patient with neoadjuvant therapy patients demonstrating periorbital CT and exam findings (A & C) prior to treatment, and complete radiographic and clinical response of the tumor after 12 months of treatment (B & D).

Figure 3 Kaplan Meier Survival Curve of Recurrence at Table 1: Number of months in patients with stable, partial, or complete number of months following cessation of vismodegib1 response following either cessation of vismodegib to recurrence or recurrence following excision if continued on vismodegib through surgery. Patients were excluded from analysis if <= 4 weeks of follow up after vismodegib cessation or continued use of vismodegib (n=14).

(continued) 19 Oncology Session Saturday, June 27

(continued) References 1. Papastefanou, Vasilios P., and Cornelius René. “Secondary resistance to vismodegib after initial successful treatment of extensive recurrent periocular basal cell carcinoma with orbital invasion.” Ophthal Plast Reconstr Surg 33.3S Suppl 1 (2015): S68-S70. 2. Ozgur, Omar K., et al. “Hedgehog pathway inhibition for locally advanced periocular basal cell carcinoma and basal cell nevus syndrome.” American journal of ophthalmology 160.2 (2015): 220-227. 3. Chang, Anne Lynn S., et al. “Expanded access study of patients with advanced basal cell carcinoma treated with the Hedgehog pathway inhibitor, vismodegib.” Journal of the American Academy of Dermatology 70.1 (2014): 60-69. 4. Tang, Nikki, and Desiree Ratner. «Implementation of systemic hedgehog inhibitors in daily practice as neoadjuvant therapy.» Journal of the National Comprehensive Cancer Network 15.4 (2017): 537-543. 5. Atwood, Scott X., et al. «Smoothened variants explain the majority of drug resistance in basal cell carcinoma.» Cancer cell 27.3 (2015): 342-353. 6. Eiger-Moscovich M, Reich E, Tauber G et al. Efficacy of Vismodegib for the Treatment of Orbital and Advanced Periocular Basal Cell Carcinoma. Am J Ophthal (2019): 207:62-70.

20 Oncology Session Saturday, June 27

12:38 – 12:43 pm Proton Beam Therapy for Granular Cell Tumor of the Orbit

Nahyoung Grace Lee, Paula Cortes Barrantes Ophthalmic Pathology, Massachusetts Eye and Ear, Boston, Massachusetts, United States

Introduction: Granular cell tumors (GCT) are rare lesions in the ocular adnexa and orbit. They are thought to be derived from Schwann cells and they are most frequently found near the inferior rectus muscle. Although they are generally benign tumors, they can cause significant morbidity in the confined space of the orbit, which may warrant further treatment. Our case was unique in that it is the first reported case of GCT adjacent to the lateral rectus muscle (the other case was metastatic GCT to the lateral rectus). Furthermore, this is the first case, to our knowledge, of apical granular cell tumor treated with proton beam radiation (PBRT).

Methods: A 32 year-old man was referred to our institution for a mass in the left orbit. He had undergone lateral orbitotomy with attempted biopsy by another surgeon who was unable to obtain a biopsy of the mass. He presented to us with left retrobulbar pain and anisocoria. On exam, he had visual acuity of 20/25 in both eyes. His right pupil measured 3mm and his left measured 5mm with a relative afferent pupillary defect (RAPD) and limited abduction of the left eye. Magnetic resonance imaging (MRI) revealed a fusiform, intraconal mass between the optic nerve and lateral rectus muscle measuring 21mm x 6mm x 9mm which was isointense with muscle (Figure 1A).

Results: A lateral orbitotomy with biopsy was pursued and the retrobulbar mass was encountered, which was firm and white in appearance, similar in characteristics to a schwannoma. Histopathologic and immunohistochemical evaluation characterized the lesion as a granular cell tumor. Due to the RAPD, changes in his visual field, and inferior retinal nerve fiber layer thinning, a decision was made to pursue treatment. Complete resection was not deemed to be possible without an intracranial approach. A discussion with radiation oncology resulted in a decision to proceed with PBRT of a total dose of 54Gy (Figure 2: planning CT- red line demarcates mass). Although this led to moderate shrinkage of the tumor (Figure 1B) and improvement of the optic neuropathy, it unexpectedly resulted in radiation retinopathy approximately 1 year later.

Conclusions: Granular cell tumor of the orbit is rare and is most commonly treated with complete resection. However, when it involves the orbital apex, PBRT could be an alternative option to reduce tumor load and morbidity from optic nerve compression. Although benign tumors are generally not considered for radiation treatment, it is important to discuss with radiation oncologists the validity of attempting radiation on ones that inflict compressive damage to vital structures in the orbital apex.

(continued) 21 Oncology Session Saturday, June 27

(continued) Figure 1 Figure 2

References 1. Ribeiro SF, Chabud F, Cruz AA. Oculomotor disturbances due to granular cell tumor. Ophthal Plast Reconstr Surg. 0212 Jan-Feb;28(1):e23-7. 2. Yang D, McLaren S, Van Vliet C, deSousa JL, Gajdatsy A. Progressive orbital granular cell tumour associated with medial rectus. Orbit. 2017 Oct;36(5):356-358.

22 Oncology Session Saturday, June 27

12:43 – 12:48 pm Acute Post-Partum Vision Loss due to Pilocytic Astrocystoma

Natalie Homer1, Aliza Epstein1, Gowtham Jonna2, Vikram Durairaj1,3, Marie Somogyi1,3 1TOC Eye and Face, Austin, Texas, United States, 2Retina Consultants of Austin, Austin, Texas, United States, 3Wong Eye Institute, Dell Medical School, University of Texas at Austin, Austin, Texas, United States

Introduction: Optic pathway gliomas (OPG) most commonly present in the pediatric patient population with painless proptosis, slowly progressive vision loss, and clinical findings of chronic optic neuropathy.1 Acute presentations of this disease in adulthood are rare.

Methods: We report a case of a thirty-three-year-old woman who presented with acute unilateral vision loss following pregnancy and was ultimately found to have a pilocytic astrocystoma.

Results: A thirty-three-year-old previously healthy female presented with unilateral vision loss that began one month prior following Caesarean section. Her post-operative course was complicated by an intestinal ileus, requiring endoscopy and nasogastric tube placement under anesthesia. Upon awakening, the patient noted left eye vision loss. Examination revealed count-fingers visual acuity, a brisk left afferent pupillary defect and 2 mm of relative left globe proptosis (Figure 1A-B). Upon dilated examination, she was found to have diffuse optic nerve head edema, subretinal fluid and choroidal folds (Figure 2A). B-scan ultrasound revealed a large intraconal mass with posterior globe flattening (Figure 2B). MRI confirmed a large left optic nerve lesion with homogenous enhancement, and canalicular and prechiasmatic T2 hyperintensity and atrophy (Figure 3). Her history did not include any stigmata of Neurofibromatosis, and oral steroid therapy was initiated with minimal visual improvement. Incisional biopsy was pursued via a medial lid crease orbitotomy. A grossly enlarged optic nerve was encountered with hypervascular nerve sheath (Figure 4A). The optic nerve sheath was incised revealing underlying gelatinous material without organized hemorrhage (Figure 4B). Pathologic evaluation was consistent with a diagnosis of pilocytic astrocytoma, WHO grade 1 (Figure 5A-B).

The patient was continued on oral prednisone post-operatively. One-month post-biopsy, she reported subjective improvement in color vision, and was found to have a Snellen visual acuity of 20/100 with resolution of optic disc edema. Further management options, including potentially curative globe enucleation, were discussed in detail. The patient opted for globe-sparing therapy and was managed with close observation and serial imaging.

(continued) 23 Oncology Session Saturday, June 27

(continued) Conclusions: Optic pathway gliomas are low-grade neoplasms that primarily affect children, with fewer than 10% presenting after the second decade of life.2 OPGs affect the intraorbital optic nerve in 25% of cases.1 Lesions may be associated with systemic neurofibromatosis type 1, but also occur sporadically, with higher rate of chiasmal progression.1 These lesions typically induce painless axial globe proptosis, progressive vision loss and clinical stigmata of compressive optic neuropathy. The patient herein instead presented with sudden vision change, an edematous optic nerve with adjacent subretinal fluid, and posterior globe flattening, inferring an acute pathology. However, MRI revealed evidence of atrophy suggestive long-standing compression and previous records indicated 20/40 visual acuity 6 months prior.

A single case report of acute presentation of optic pathway glioma during pregnancy suggested intralesional hemorrhage and hypercoagulability as inciting factors.3 Although non-optic pathway gliomas of WHO grade II-IV have been found to commonly progress during gestation, there has been no previous report of progression in a WHO grade I lesion.4-6

Traditional management options include observation, chemotherapy and targeted radiation. More recently, targeted therapy with Mitogen-activated protein kinase pathway inhibitors and systemic anti-VEGF have been successfully trialed.1 Surgical enucleation is often reserved for intracranial or intracanalicular involvement, or for painful and/or disfiguring proptosis in low-vision eyes.

Figure 1 Figure 2 Figure 3

(continued) 24 Oncology Session Saturday, June 27

(continued) Figure 4 Figure 5

References 1. Farazdaghi MK, Katowitz WR, Avery RA. Current treatment of optic nerve gliomas. Curr Opin Ophthalmol. 2019 Sep;30(5):356-363. 2. Dutton JJ. Gliomas of the anterior visual pathway. Surv Ophthalmol. 1994;38:427-452. 3. Yokoyama S, Takayama K, Sueda M, Ishikawa Y, Hirano H. Optic nerve glioma manifesting as intratumoral hemorrhage in a pregnant woman--case report. Neurol Med Chir (Tokyo). 2003 Nov;43(11):559-62. 4. Peeters S, Pagès M, Gauchotte G, et al. Interactions between glioma and pregnancy: insight from a 52-case multicenter series. J Neurosurg. 2017;128:3-13. 5. Pallud J, Mandonnet E, Deroulers C, et al. Pregnancy increases the growth rates of world health organization grade II gliomas. Ann Neurol. 2010;67: 398-404. 6. Yust-Katz S, de Groot JF, Liu D, et al. Pregnancy and glial brain tumors. Neuro Oncol. 2014;16: 1289-1294. 7. Bayley VJC, Goethe EA, Srinivasan VM, Klisch TJ, Mandel JJ, Patel AJ. Newly Diagnosed Optic Pathway Glioma During Pregnancy. World Neurosurg. 2019 Jul;127:58-62.

25 ASOPRS FOUNDATION RALPH E. WESLEY, MD LECTURE Saturday, June 27

1 – 1:05 pm Introduction of Lecture and Dr. Kahana

Jan Kronish, ASOPRS Foundation Board Chair

1:05 pm – 1:25 pm ASOPRS Foundation Ralph E. Wesley, MD Lecture: Setting Up an Investigator Trial for a Drug or a Device: Lessons Learned

Alon Kahana Consultants in Ophthalmic & Facial Plastic Surgery, Ann Arbor, Michigan, United States

26 ORBIT SESSION Saturday, June 27

1:34 – 1:39 pm Contributing Factors to Outcome of Optic Nerve Sheath Fenestration in Patients with Idiopathic Intracranial Hypertension

Farzad Pakdel, Askar Ghorbani, Samira Yadegari, Razieh Mahmoudzadeh, Mostafa Soltan Sanjari, Mehdi Moghadasi, Mohamad Rohani Department of Oculo-Facial Plastic Surgery, Farabi Hospital, Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of

Introduction: Optic nerve sheath fenestration (ONSF) has gained attention as surgical method of choice in patients with idiopathic intracranial hypertension (IIH) and progressive visual loss despite medical treatments. However, effect of different factors on visual outcome has remained elusive. In this study we aimed to investigate the effect of different factors on outcome in patients with IIH that underwent ONSF.

Methods: this was a prospective interventional study on patients with IIH that were referred to Oculo-Facial clinic of one senior oculofacial surgeon (F.P.) and underwent ONSF from May 2013 to March 2019. All patients with established diagnosis of IIH based on modified Dandy criteria that showed papilledema and progressive optic neuropathy or acute/subacute profound visual loss were enrolled. Comprehensive ophthalmology exam including best corrected visual acuity, extra-ocular movements, fundus exam and assessment of papilledema based on Frisen grading, OCT, visual field perimetry, and also neurology evaluations including exam, brain MRI and measurement of intra-cranial pressure (ICP) were performed before and after ONSF.

Results: Twenty-five eligible patients were enrolled. Mean age was 32.8(SD=13.62) year. Sixteen (64%) were female. Mean BCVA improved after ONSF (p=0.027). Papilledema in operated (p=0.0001) and opposite eye improved after ONSF(p=0.005). Nineteen cases underwent unilateral ONSF. Among unilateral cases BCVA, optic disc swelling showed significant improvement. The ICP significantly reduced after ONSF from baseline of 42.15 (SD=14.55) to 18 (SD=4.85) (p= 0.005). Multivariate analysis showed that the period between initiation of visual symptoms and ONSF was the independent factor that showed negative and significant correlation with the visual outcome. Patients’ sex, age, BMI and initial visual acuity did not show any effect on outcome. No remarkable complication was observed.

Conclusions: ONSF was effective and safe in treatment of patients with IIH papilledema and progressive visual loss. ONSF can be associated with decrease in ICP. Earlier ONSF was associated with better visual outcome.

(continued) 27 Orbit Session Saturday, June 27

(continued) Figure 1 Figure 2 Figure 3

References 1. Biousse V, Bruce BB, Newman NJ. Update on the pathophysiology and management of idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry 2012;83(5):488–494. 2. Corbett JJ, Savino PJ, Thompson HS, Kansu T, Schatz NJ, Orr LS, Hopson D. Visual loss in pseudotumor cerebri. Follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss.Arch Neurol 1982; 39:461–474. 3. Carta, A., Bertuzzi, F., Cologno, D., Giorgi, C., Montanari, E. and Tedesco, S. Idiopathic intracranial hypertension (pseudotumor cerebri): descriptive epidemiology, clinical features, and visual outcome in Parma, Italy, 1990 to 1999. Eur J Ophthalmol 2004;14: 48–54. 4. Brazis PW. Clinical review. The surgical treatment of idiopathic pseudotumour cerebri (idiopathic intracranial hypertension).Cephalalgia 2008; 28:1361–1373. 5. Galgano MA, Deshaies EM. An update on the management of pseudotumor cerebri. Clin Neurol Neurosurg 2013; 115:252–25. 6. Wall M. Idiopathic intracranial hypertension. Neurol Clin 2010; 28:593– 617. 7. Fields JD, Javedani PP, Falardeau J, et al. Dural venous sinus angioplasty and stenting for the treatment of idiopathic intracranial hypertension. J.Neurointerv.Surg 2013; 5(1):62-8. 8. Tsai JC, Petrovich MS, Sadun AA. Histopathological and ultrastructural examination of optic nerve sheath decompression. Br J Ophthalmol 1995; 79:182–5. 9. Seiff SR, Shah L. A model for the mechanism of optic nerve sheath fenestration. Arch Ophthalmol 1990; 108:1326–9. 10. Frisén L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry 1982; Jan;45(1):13-8. 11. Ball AK, Clarke CE .Idiopathic intracranial hypertension.Lancet Neurol 2006;5(5):433–442 12. Bruce BB, Kedar S, Van Stavern GP, et al. Idiopathic intracranial hypertension in men. Neurology 2009; 72(4):304-9. 13. Chen J, Wall M. Epidemiology and risk factors for idiopathic intracranial hypertension. Int Ophthalmol Clin 2014; 54:1–11. 14. Alsuhaibani A, Carter K, Nerad J, et al. Effect of optic nerve sheath fenestration on papilledema of the operated and the contralateral nonoperated eyes in idiopathic intracranial hypertension. Ophthalmology 2011; 118:412–414.

(continued) 28 Orbit Session Saturday, June 27

(continued) 15. Pineles SL, Volpe NJ. Long-Term Results of Optic Nerve Sheath Fenestration for Idiopathic Intracranial Hypertension Earlier Intervention Favours Improved Outcomes. Neuroophthalmology 2013; Jan 29;37(1):12-19. 16. Sergott RC, Savino PJ, Bosley TM. Modified optic nerve sheath decompression provides long-term visual improvement for pseudotumor cerebri. Arch Ophthalmol 1988; 106:1384–90. 17. Wall M, Kupersmith MJ, Thurtell MJ, Moss HE, Moss EA, Auinger P; NORDIC Idiopathic Intracranial Hypertension Study Group. The Longitudinal Idiopathic Intracranial Hypertension Trial: Outcomes From Months 6-12. Am J Ophthalmol. 2017 Apr;176:102-107. doi: 10.1016/j.ajo.2017.01.004. Epub 2017 Jan 17. 18. Kattah JC, Pula JH, Mejico LJ, McDermott MP, Kupersmith MJ, Wall M. CSF pressure, papilledema grade, and response to acetazolamide in the Idiopathic Intracranial Hypertension Treatment Trial. J Neurol. 2015 Oct;262(10):2271-4. doi: 10.1007/s00415-015-7838-9. Epub 2015 Jul 10.

29 Orbit Session Saturday, June 27

1:39 – 1:44 pm T-cell Prolymphocytic Leukemia Masquerading as Thyroid Associated Orbitopathy

Evan Kalin-Hajdu, Victoria Leung Ophthalmology, University of Montreal, Montreal, Quebec, Canada

Introduction: Thyroid associated orbitopathy (TAO) is a relatively common disease with stereotypical clinical and radiographic features; deviation from these features warrants work-up for alternate causes of extraocular muscle (EOM) enlargement.

Methods: This case report describes a 64-year-old female referred for orbital decompression due to proptosis presumed secondary to TAO. She had a 6-month history of progressive bilateral proptosis and conjunctival erythema. Her past medical history included primary hypothyroidism and indolent-phase T-cell prolymphocytic leukemia.

Ophthalmologic examination confirmed 27mm of bilateral proptosis, conjunctival injection, chemosis, and lower lid retraction (Fig. 1). Visual acuity, color vision, pupillary responses, and extraocular motility were normal. Von Graefe’s sign and lagophthalmos were absent. Slit lamp examination and dilated fundus examination were normal.

Orbital CT scans revealed marked bilateral enlargement of all EOMs with sparing of anterior tendinous insertions. Notably, the lateral rectii were especially enlarged, and the anterior third of both lateral rectus muscle bellies appeared normal (Fig. 2). Thyroid stimulating hormone, thyroid stimulating immunoglobulin, and thyroid peroxidase antibody levels were normal.

Diagnostic uncertainty led to a muscle biopsy of the enlarged left lateral rectus, which revealed skeletal muscle densely infiltrated by CD4+/CD8- T-cell lymphocytes. This finding was incompatible with a diagnosis of TAO, but suggestive of infiltration by T-cell PLL. Following the diagnosis of EOM T-cell PLL, the patient was started on cyclosporine and demonstrated dramatic clinical and radiologic improvement within three days (Fig. 3, 4).

Results: TAO is the most common pathology of the orbit. Patients who present with TAO are most likely to be female in their 4th or 6th decade of life.1 Although 90% of patients with TAO are hyperthyroid, the remaining 10% can be euthyroid or hypothyroid.1 Despite our patient exhibiting epidemiologic and clinical features of TAO, three subtle radiographic observations raised suspicion of non- thyroid pathology.

(continued) 30 Orbit Session Saturday, June 27

(continued) First, patients with TAO demonstrate EOM enlargement and associated clinical restriction affecting the inferior, medial, superior, and lateral rectus in decreasing order of severity and frequency.2 Pronounced lateral rectus enlargement in our patient was atypical of TAO. Second, fusiform enlargement of EOMs in TAO typically involves the entire muscle belly and spares the tendinous insertions. Additional sparing of the anterior one-third of the muscle belly may be suggestive of EOM infiltration by hematologic malignancy.3 Third, despite our patient’s enlarged EOM diameters exceeding 7mm, she had free ductions, which is inconsistent with TAO. In TAO, when maximum EOM diameter exceeds 7mm, the affected EOM invariably demonstrates a degree of motility restriction.2

T-PLL represents less than 2% of lymphoid leukemias in adults and is generally an aggressive and fatal malignancy.4 A subset of patients (10-15%) may present asymptomatically with an indolent phase that can persist for years.4 Periorbital and conjunctival edema are frequently observed in T-PLL.4 However, to the authors’ knowledge, not a single case of biopsy-proven orbital T-PLL has been reported.

Conclusions: Even in the presence of clinical signs typical of TAO, examination and radiographic findings inconsistent with TAO warrant further work-up. After the diagnosis of EOM T-cell PLL, our patient started cyclosporine and demonstrated a dramatic response within days.

Figure 1 Figure 2 Figure 3 Figure 4

References 1. Bartley G. The epidemiologic characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Trans Am Ophthalmol Soc. 1994;92:477-588. 2. Dagi LR, Zoumalan CI, Konrad H, et al. Correlation between extraocular muscle size and motility restriction in thyroid eye disease. Ophthal Plast Reconstr Surg. 2011; 27:102-110. 3. Rose G. Personal correspondence. Mon Nov 12, 2018, 6:00 pm. 4. Staber P, Herling M, Bellido M et al. Consensus criteria for diagnosis, staging, and treatment response assessment of T-cell prolymphocytic leukemia. Blood. 2019;134(14):1132-1143. 31 Orbit Session Saturday, June 27

1:44 – 1:49 pm Orbital Langerhans Cell Histiocytosis: 10-year Experience and Literature Review

Suzanne van Landingham, Cat Burkat, Mark Lucarelli Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States

Introduction: This series describes the cases of orbital Langerhans cell histiocytosis (LCH) cared for at a single institution over the past 10 years and reviews the relevant literature.

Methods: An electronic search was performed to identify medical records containing CPT codes applicable to orbital biopsy (67400, 67412, 67420, 67450, 61330, 61332) and ICD10 or ICD9 codes applicable to LCH (ICD9 202.9, ICD 10 C96.0, C96.5, and C96.6) from 2009-2019. These charts were reviewed to confirm a diagnosis of orbital Langerhans cell histiocytosis and for patient and disease characteristics. An IRB exemption was granted for this study.

Results: 4 cases of orbital LCH were identified. The mean age at presentation was 7.3 years (median 6.7 years, range 11 months to 15 years). 3/4 patients were male. Presenting symptoms for definite cases included eyelid swelling (4/4) and mild discomfort (3/4). Median time from symptom onset to diagnosis was 3 weeks (range 1 day to 6 weeks). 2 patients were initially misdiagnosed with allergies and preseptal cellulitis, respectively. 3/4 definite lesions were in the superolateral orbit. All 4 cases had erosion of the orbital roof, 2 involved the dura, and 1 extended into the brain parenchyma. The lesions were heterogeneously enhancing on MRI in each case. Definitive diagnosis was made by biopsy in all 4 cases – 3 via anterior orbitotomy and 1 via craniotomy. Lesions contained friable tissue. Tissue color was inconsistent. Further imaging revealed no systemic involvement. 2 cases were treated with curettage +/- intralesional steroid, the other 2 were treated with systemic chemotherapy. No cases have had recurrences. Median follow-up time following biopsy was 13 months (range 8-13 months).

Conclusions: In the past decade, our service has treated 4 cases of isolated orbital LCH. The 4 isolated cases adhered to typical characteristics: pediatric male patients, superolateral location, heterogenous enhancement and lytic destruction of bone on MRI, intraoperative findings of encapsulated, friable tissue, and good response to therapy. Treatment of isolated orbital LCH is controversial: many oncologists favor systemic chemotherapy due to perceived risk of CNS involvement and many oculoplastic surgeons favor local therapy.

(continued) 32 Orbit Session Saturday, June 27

(continued) Figure 1 Figure 2 Figure 3 Figure 4

References 1. Esmaili N, Harris GJ. Langerhans Cell Histiocytosis of the Orbit: Spectrum of Disease and Risk of Central Nervous System Sequelae in Unifocal Cases. ORPS 2016;32:28–34. 2. Margo CE, Goldman DR. Langerhans cell histiocytosis. Surv Ophthalmol 2008;53:332–58.

33 Orbit Session Saturday, June 27

2:01 – 2:06 pm Radioactive Iodine and the Development of Thyroid Eye Disease

Dianne Schlachter1,2, Robert Beaulieu1,2, Olivia Cheng2 1Consultants in Ophthalmic and Facial Plastic Surgery, Southfield, Michigan, United States,2 Beaumont Eye Institute, Royal Oak, Michigan, United States

Introduction: This is a retrospective study to determine the association between radioactive iodine treatment (RAI) and the development of thyroid eye disease (TED) in a private practice oculoplastics clinic in the Midwest.

Methods: The development of TED in patients with thyroid dysfunction is estimated to be as high as 50%.1 Worsening of or de novo onset of TED in patients with thyroid dysfunction who receive RAI is a controversial topic.2 Some studies estimate that 20-30% of patients who receive RAI develop or have progression of TED while other refute the role of RAI in TED.3,4 Our study investigated the rate of new patients who presented for care in our oculoplastics clinic that had been treated with RAI and the temporal association of symptom development. A chart review was performed of all patients who presented to the corresponding author (DS) for initial evaluation for suspected TED diagnosis. Patients who presented between January 2016 and March 2019 were included in the study. Age, gender, ethnicity, smoking history, type of thyroid disease, type of treatment received, and TED signs and symptoms were documented for each subject. For patients who received RAI, histories were reviewed to determine onset of TED symptoms and temporal relationship to RAI.

Results: 132 patients were included in the study. Of these, 105 (79.4%) were female and 27 (20.5%) were male. 95 (72.0%) were Caucasian, 36 (27.3%) were black, and 1 (0.8%) was Asian. 51 (38.6%) had been treated with RAI at some point in time and 81 (61.4%) had not. Among the patients who had undergone RAI treatment, RAI preceded development of TED signs or symptoms in 40 (78.4%) patients as compared to 11 (21.6%) patients in whom TED preceded RAI.

Conclusions: Among TED patients who had received RAI treatment, RAI preceded development of TED in the large majority (78.4%). This finding supports the idea that RAI is a considerable risk factor in the development of TED. Additionally, this subset of patients represents a substantial portion of TED patients in our practice (30%). Improved communication between endocrinology, nuclear medicine, and ophthalmology concerning the risks of RAI may help reduce the risk of TED progression or development in some patients.

References 1. Bartalena L. The dilemma of how to manage Graves’ hyperthyroidism in patients with associated orbitopathy. J Clin Endocrinol Metab. 2011;96(3):592-9. 2. Choi, Catherine J., Aubrey L. Gilbert, and Nahyoung G. Lee. “Radioactive Iodine Therapy and Thyroid Eye Disease From an Ophthalmologist’s Perspective.” International ophthalmology clinics 55.4 (2015): 63-72. 3. Li, H. X., et al. “Relation between therapy options for Graves’ disease and the course of Graves’ ophthalmopathy: a systematic review and meta-analysis.” Journal of endocrinological investigation 39.11 (2016): 1225-1233. 4. El-Kaissi S, Bowden J, Henry MJ, et al. Association between radioiodine therapy for Graves’ hyperthyroidism and thyroid-associated ophthalmopathy. Int Ophthalmol. 2010;30:397–405. 34 Orbit Session Saturday, June 27

2:06 – 2:11 pm Efficacy of Anti-TNF-alpha Agents in Active Thyroid Eye Disease

Farzad Pakdel1, Niloofar Pirmarzdashti2, Annousheh Haghighi3 1Department of Oculo-Facial Plastic Surgery, Farabi Hospital, Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of, 2Eye Research Center Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of, 3Department of Rheumatology, Tehran, Iran, Islamic Republic Of

Introduction: The key role of tissue necrosis factor alpha has been shown in the pathophysiology of thyroid eye disease. In addition, few reports showed that anti-TNF-alpha agents could decrease orbital inflammation in idiopathic orbital inflammatory disease. In few limited reports anti-TNF alpha agents were used as steroid sparing agents. However, no reliable consistent effect was found. In this study we aimed to report the effect of anti-TNF alpha agents in treatment of patients with active thyroid eye disease (TED) who could not either take or showed resistance to corticosteroids.

Methods: Data of all patients with active TED from January 2014 to December 2018, that received anti-TNF alpha agents because they could not either take or showed resistance to corticosteroids were reviewed. Data included visual acuity, clinical, activity score (CAS), extra-ocular motility, eyelid swelling and erythema, conjunctival injection and chemosis, carancular congestion, proptosis, eyelid retraction, keratopathy and dysthyroid optic neuropathy. Those with follow-up less than 9 months were excluded.

Results: Data of eight eligible patients were analyzed. Mean age was 54.6 (SD= 7.08, range=42-65) years. Five were male. The reason for abandonment from corticosteroid included: gastrointestinal bleeding (n=1), congestive heart failure (n=1), diabetic hyperosmolar state (n=1), non- or inadequate response to corticosteroid regimen (n=5). Patients received one anti-TNF alpha agent as single main treatment including infliximab (n=3), etanercept (n=3), adalimumab (n=2). CAS score decreased from baseline 5.5 (SD= 1.69) to 0.5 (SD= 0.75) (p=0.0001). Proptosis value showed decreased from baseline 24.12 mm (SD= 2.23) to 22.12 (SD=1.88) after treatment (p=0.037). Two showed recurrence of orbital inflammation one with infliximab and another with etanercept. Both were controlled by re-starting the same agent. Notably the two patients that received adalimumab showed resolution of diplopia and decrease in proptosis in contrast to none of the other six patients. Mean follow up time was 27.75 (range: 15-46, SD= 10.30) months. Four (50%) patients were current smokers. We did not observe any complication associated with the use of anti-TNF alpha agents.

Conclusions: This study supports the efficacy of anti-TNF alpha agents in active TED. Further they may be considered in patients that cannot take corticosteroids or are resistant to steroid therapy. Results of this study justify future comparative studies to verify efficacy of this modality of treatment in patients with active TED.

(continued) 35 Orbit Session Saturday, June 27

(continued) Figure 1

References 1. Durrani OM, Reuser TQ, Murray PI.Infliximab: A Novel Treatment for Sight-Threatening Thyroid Associated Ophthalmopathy. Orbit. 2005 Jun;24(2):117-9. 2. Ayabe R, Rootman DB, Hwang CJ, Ben-Artzi A, Goldberg R. Adalimumab as steroid-sparing treatment of inflammatory-stage thyroid eye disease.Ophthalmic Plast Reconstr Surg. 2014 Sep-Oct;30(5):415-9. 3. Laban-Guceva, Bogoev, Antova, Serum concentrations of interleukin (IL-)1alpha, 1beta, 6 and tumor necrosis factor (TNF-) alpha in patients with thyroid eye disease (TED), Med Arh, 61, 203-6, 2007. 4. Interruption of autoimmunity for thyroid eye disease: B-cell and T-cell strategy. 5. Strianese D, Rossi F. 6. Paridaens D, van den Bosch WA, van der Loos TL, Krenning EP, van Hagen PM. The effect of etanercept on Graves’ ophthalmopathy: a pilot study. Eye. 2005;19:1286–1289.

36 Orbit Session Saturday, June 27

2:11 – 2:16 pm Artificial Intelligence for Thyroid-Associated Ophthalmopathy Development in Patients with Graves Disease or Hashimoto’s Thyroiditis: Deep Neural Network Prognostic Risk Assessment

Emily Sarah Charlson, Albert Y. Wu Byers Eye Institute, Stanford University, Palo Alto, California, United States

Introduction: Traditional risk assessment of thyroid-associated ophthalmopathy (TAO) among patients with Graves disease (GD) is based on a limited set of clinical findings, and largely unknown in Hashimoto’s thyroiditis (HT). Here, we use artificial intelligence to identify factors for TAO development from thousands of clinical features in patients with newly diagnosed GD or HT and build models for ophthalmopathy disease prediction.

Methods: In this longitudinal cohort study, GD and HT patients who subsequently developed TAO were identified via International Classification of Disease, Ninth and Tenth Revision (ICD 9 and ICD 10) billing codes from the Stanford STARR Tahoe database 2000- 2017. Features included demographics, family history, allergies, medications, laboratory values, procedures, and diagnoses. After cohort selection, a grid search of 10 machine learning models was preformed to identify the model with optimal performance. Pearson correlation coefficients of each clinical feature to TAO development were calculated. A subset of important features positively correlated with TAO were selected based off of univariate ANOVA as well as multivariate Recursive Feature Elimination and Random Forest analysis. This smaller subset of features was then used to re-train a neural network to predict TAO. Analysis was coded in Python with TensorFlow and Scikit-learn packages.

Results: n this cohort, 10.6% (260/2,460) of those with GD and 5.2% (108/20638) of those with HT were subsequently diagnosed with TAO. Using 7,531 individual features, the neural network predicted TAO development from GD with f1 score 0.91 (range 0.88-0.95), precision 0.93 (0.89-0.96), recall 0.87 (0.83-0.96), and Area Under the Curve (AUC) 0.90 (0.88-0.92). A re-trained model with only 17 features was able to predict TAO from GD with f1 0.78 (0.76-0.80), precision 0.83 (0.77-0.91), recall 0.74 (0.70-0.80), and AUC 0.78 (0.75-0.81). These features include older age at diagnosis, elevated BMI, dry eye, diplopia, myopia, cataract, use of ophthalmic antibiotics, chronic sinusitis, latex allergy, joint pain, myalgia/myositis, vitamin D deficiency, osteoporosis, diarrhea, esophageal reflux, edema, and having undergone cardiovascular surgery. A similar analysis of HT using 7,150 features predicted TAO with f1 0.82 (0.77- 0.86), precision 0.84 (0.77-0.96), recall 0.80 (0.72-0.90), and AUC 0.83 (0.77-0.87). When re-trained with 18 select features, the network predicted TAO from HT with f1 0.76 (0.72-0.79), precision 0.81 (0.73-0.92), recall 0.72 (0.63-0.76), and AUC 0.78 (0.76- 0.81). These features include dry eye, joint pain, vitamin D deficiency, osteoporosis, anemia, abdominal pain, hyperlipidemia, taking

(continued) 37 Orbit Session Saturday, June 27

(continued) acetylsalicylic acid, taking smoking deterrents, cough, personal history of immunity disorders, penicillin allergy, visiting an allergist, allergic rhinitis, contact dermatitis, urinary tract infection, obstructive sleep apnea and insomnia.

Conclusions: Artificial intelligence deep neural networks were able to predict TAO development in those with GD and HT with high precision, recall and accuracy. Clinical features important for predicting TAO development from GD and HT identified here include both known (e.g. smoking) and lesser known factors (e.g. obstructive sleep apnea). These data could provide guidelines to assess probability of TAO development feasible for clinical use among newly diagnosed GD and HT. Validation of these results in other big data cohorts and from prospective trials is warranted.

References 1. Li Z, Cestari DM, Fortin E. Thyroid eye disease: what is new to know? Curr Opin Ophthalmol. 2018;29(6):528-534. 2. Stein JD, Childers D, Gupta S, et al. Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves disease. JAMA Ophthalmol. 2015;133(3):290-296. 3. Sabini E, Mazzi B, Profilo MA, et al. High serum cholesterol is a novel risk factor for graves’ orbitopathy: results of a cross-sectional study.Thyroid . 2018;28(3):386-394. 4. Habib LA, Godfrey KJ, Mathews P, De Rojas J, Kazim M. Association of Risk of Obstructive Sleep Apnea With Thyroid Eye Disease: Compressive Optic Neuropathy. Ophthalmic Plast Reconstr Surg. 2019;35(3):232-234. 5. Kharrazian D, Herbert M, Vojdani A. Immunological reactivity using monoclonal and polyclonal antibodies of autoimmune thyroid target sites with dietary proteins. J Thyroid Res. 2017;2017. 6. Kashkouli MB, Pakdel F, Kiavash V, Heidari I, Heirati A, Jam S. Hyperthyroid vs hypothyroid eye disease: the same severity and activity. Eye. 2011;25(11):1442-1446.

38 PEDIATRIC/LACRIMAL SESSION Saturday, June 27

2:28 – 2:33 pm Pediatric Conjunctiva-Sparing Posterior Ptosis Surgery

Aliza Epstein1, Natalie Homer1, Phillip Tenzel2, Harini Suresh2, Ivan Vrcek3, Ronald Mancini2, Tanuj Nakra4, Marie Somogyi1 1Oculofacial Plastic Surgery, TOC Eye and Face, Austin, Texas, United States, 2Ophthalmology, UT Southwestern Medical Center, Dallas, Texas, United States, 3Oculofacial Plastic Surgery, Texas Eye Plastics, Dallas, Texas, United States, 4TOC Eye and Face, Oculofacial Plastic Surgery, Austin, Texas, United States

Introduction: Pediatric ptosis results from varying degrees of eyelid retractor abnormalities and portends a risk of sensory-derivational amblyopia. A variety of surgical interventions have been employed in the treatment of congenital ptosis that are often directed by the levator function, including various techniques involving the levator palpebrae superioris, Müller’s muscle, and frontalis suspension.1-5 Conjunctiva-sparing posterior ptosis surgery is a recently described modification to the original Müller's muscle conjunctiva resection, with advantages of tissue conservation and more robust eyelid lift.6 The goal of our study was to investigate the utility of conjunctiva- sparing posterior ptosis repair for pediatric patients.

Methods: A retrospective review of all patients with congenital ptosis who underwent conjunctiva-sparing posterior ptosis surgery at a private practice and university-based practice from 2015-2019 was performed. Baseline and post-operative marginal reflex distance 1 (MRD1) and baseline levator function (LF) measurements were recorded. Data was analyzed using a paired sample t-test with p value <0.05 considered significant.

The surgical technique was identical to that described by Vrcek et al.6 A conjunctival incision is made at the superior border of the tarsus followed by creation of a window pane conjunctival flap that is reflected inferiorly to expose Müller's muscle. A Putterman ptosis clamp is used to grasp the desired amount of Müller's muscle. A 6-0 plain gut suture is passed in a serpentine fashion along the base of the clamp and anchored externally to the medial and lateral eyelid. The clamped Mullers muscle is excised. The conjunctival flap is repositioned anatomically.

Results: We analyzed eleven eyelids in ten patients who underwent conjunctiva-sparing posterior ptosis repair. The patients’ age ranged from 1.5 to 17.0 years of age (mean 7.6 years). Follow up ranged from 1.0 to 6.0 months (mean 3.2 months). Levator function ranged from 5.5 to 14 mm (mean 11.6 mm). Baseline MRD1 ranged from -0.5 to 1.5 mm (mean 0.3 mm). Post-operative MRD1 ranged from 0.5 to 4 mm (mean 2.7 mm). The average change in MRD1 was 2.1 ± 1.1 mm, p<0.0001. All patients achieved improvement in MRD1, clearance of the visual axis, and improved symmetry between the eyelids at final follow up (Figure 1 and 2). One patient underwent frontalis sling for persistent ptosis.

(continued) 39 Pediatric/Lacrimal Session Saturday, June 27

(continued) Conclusions: The primary goal of congenital ptosis repair is to clear the visual axis to allow for proper visual development. Conjunctiva- sparing posterior ptosis surgery is an ideal modification for use in the pediatric population due to its preservation of natural eyelid contour and palpebral conjunctiva. Furthermore, this technique offers additional advantages over traditional posterior ptosis correction through the conservation of goblet cells and conjunctiva, as well as reduction of suture-related keratitis. As shown in our patients, this minimally invasive technique is an excellent option in the management of congenital ptosis with fair to good levator function and can prevent or delay the need for more invasive and consequential surgical interventions, including levator resection and frontalis sling procedures. Additional advantages include the shortened surgical time and technical ease with learning and performing this procedure.

Figure 1 Figure 2

References 1. Beard C. Ptosis. New York, NY: C. V. Mosby Co, 1976:120. 2. Beard C. The surgical treatment of blepharoptosis: a quantitative approach. Trans Am Ophthalmol Soc 1966;64:401–87. 3. Mauriello JA, Wagner RS, Caputo AR, et al. Treatment of congenital ptosis by maximal levator resection. Ophthalmology1986;93:466–9. 4. Mazow ML, Shulkin ZA. Mueller’s Muscle-Conjunctival Resection in the Treatment of Congenital Ptosis. Ophthal Plast Reconstr Surg 2011;27:311–312. 5. Gazit I, Gildener-Leapman J, Or L, et al. Muller’s Muscle-conjunctival Resection Combined With Tarsectomy for Treatment of Congenital Ptosis. Ophthalmic Plast Reconstr Surg 2019;35:619–622. 6. Vrcek I, Hogan R, Rossen J, et al. Conjunctiva-Sparing Posterior Ptosis Surgery: A Novel Approach. Ophthal Plast Reconstr Surg 2016;32:366–370.

40 Pediatric/Lacrimal Session Saturday, June 27

2:33 – 2:38 pm Restrictive Strabismus as a Presenting Sign of Jones Tube associated Atypical Mycobacterial Infection

Ali Mokhtarzadeh, Andrew Harrison Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, United States

Introduction: Restrictive strabismus is an infrequently reported complication of conjunctivodacryocystorhinostomy (CDCR) with placement of Jones tube. Atypical mycobacterial infections of the orbit is also an uncommon complication of periocular surgery and implants. We present a case of slowly progressive restrictive strabismus following CDCR, initially managed with removal of the tube. Despite removal of the Jones tube, the strabismus gradually worsened and ultimately the process declared itself over months as a mass, and later an inflammatory infectious process. Biopsy and cultures were consistent with a very resistant strain of mycobacterium abscessus. She ultimately required aggressive orbital debridement in addition to long term amikacin, tigecycline, and linezolid.

Methods: Retrospective chart review

Results: Strabismus has stabilized, and orbital inflammatory signs have resolved five months following the most recent orbitotomy and debridement, along with long term treatment with amikacin, tigecycline, and linezolid.

Conclusions: Restrictive strabismus has previously been reported and attributed to posterior placement and angulation through medial orbital tissue or irritation of the nasal globe and fibrosis of the nasal conjunctiva and medial rectus. We present a case of progressive strabismus which was eventually found to be associated with, and likely secondary to atypical mycobacterial infection. Management ultimately required debridement and long term antibiotic treatment.

(continued) 41 Pediatric/Lacrimal Session Saturday, June 27

(continued) Figure 1 Figure 2 Figure 3

References 1. Ashenhurst M, Hill VE, Keyhani K. Restrictive strabismus following Jones tube insertion: a case series of 8 patients. Can J Ophthalmol 2007;42:613. 2. Rose GE, Welham R. Jones’ lacrimal canalicular bypass tubes: Twenty-five years’ experience. Eye 1991; (5): 13-19. 3. Sjov CMB, Mazow M. Diplopia following Jones tube placement. Ophthalmic Surg 1984; 15:932-933. 4. Klapper SR, Patrinely JR, Kaplan SL, Font RL. Atypical mycobacterial infection of the orbit. Ophthalmol 1995; 102(10):1536-41.

42 Pediatric/Lacrimal Session Saturday, June 27

2:38 – 2:43 pm The Superficial Temporal Artery as ‘Biologic Jones Tube’: A Cadaveric Proof of Concept

Benjamin Erickson1, Andrea Kossler1, Nathan Blessing2, Katie Topping3, Audrey Ko4, Wendy Lee5, Thomas Johnson5 1Stanford Ophthalmology, Byers Eye Institute, Palo Alto, California, United States, 2University of Oklahoma Ophthalmology, Dean McGee Eye Institute, Oklahoma City, Oklahoma, United States, 3US Navy Ophthalmology, San Diego Naval Medical Center, San Diego, California, United States, 4University of Iowa Ophthalmology, University of Iowa, Iowa City, Iowa, United States, 5University of Miami Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, United States

Introduction: In cases of canalicular sacrifice or dense stenosis resulting in symptomatic epiphora, Jones tubes offer the only practical means of restoring nasolacrial drainage. Despite their efficacy, they confer significant disadvantages. As foreign bodies, they are prone to migration, blockage, and infection. Attempts to ‘bypass’ the Jones tube by creating neo-canaliculi with mucosa wrapped stents invariably end in re-stenosis, while canalicular transplantation potentially compromises lacrimal drainage on the healthy side. We present an alternate method of canalicular reconstruction, using the superficial temporal artery (STA).

Methods: Cadaveric heads were obtained. Proximal portions of the STA, measuring 1.5 cm were isolated and harvested. A modified DCR incision was then created, and dissection performed to identify the nasolacrimal sac mucosa beneath the medial canthal tendon (MCT). A paracentesis blade was used separate the anterior and posterior eyelid lamella in the desired location of the neo-punctum (Figure 1A). A medium colarette monocanalicular stent was then modified by removing the internal flange with sharp Westcott scissors, and the previously harvested STA was advanced over the attached probe. An 8-0 suture ligature was placed to anchor the distal end of the STA to the underlying stent (Figure 1B). A bent 18-gauge spinal needle was then used to tunnel in the sub-orbicularis plane, emerging through the nasal eyelid margin within the previously constructed incision (Figure 1C). The probe was introduced into the tunnel via the spinal needle, which was subsequently removed (Figure 1D, 2A/B). An aperture was then created in the lacrimal sac beneath the MCT with a Von Graefe blade, and the probe was passed and retrieved beneath the inferior turbinate (Figure 2C). Once fully advanced, the external flanges of the monocanalicular stent were anchored to the lid margin using interrupted 8-0 polyglactin (Figure 2D). The previously placed ligature was removed, and the STA was trimmed to the appropriate length and anastomosed to the lacrimal sac using additional 8-0 sutures. The DCR incision was then closed, the probe removed, and the stent anchored within the nasal vestibule.

Results: The superficial temporal artery bypass graft concept for nasolacrimal drainage was successfully executed in a cadaveric model.

(continued) 43 Pediatric/Lacrimal Session Saturday, June 27

(continued) Conclusions: The STA is currently used to create bypass grafts for ischemic cerebrovascular disease, and techniques for cannulation and suturing are well established. As needed, vessel suitability can be assessed pre-operatively using CT angiography, as for neurosurgical applications. The indwelling stent would keep the lumen patent during healing, while permitting tear drainage. Antibiotic/steroid drops and serum tears (to provide growth factors to the endothelial lining) could be applied. With vessels of this diameter (that lack vasa vasorum), diffusion provides adequate oxygen and nutrients to promote growth, and transplanted vessels (including the endothelium) could likely survive and undergo metaplasia. Unlike tubes formed from mucosal grafts, the STA has a muscular tunica media to help resist collapse and re-stenosis, theoretically increasing the likelihood of survival and function. Unlike a Jones tube, the STA graft would also permit function of the underlying lacrimal pump mechanism, resulting in active siphoning of tears.

Figure 1 Figure 2

References 1. Meltzer MA, Zatezalo CC, Zoltan S. Lacrimal canalicular transplantation with composite eyelid graft. Ophthal Plast Reconstr Surg. 2010 Jan-Feb;26(1):23-5. 2. Steele EA. Conjunctivodacryocystorhinostomy with Jones tube: a history and update. Curr Opin Ophthalmol. 2016 Sep;27(5):439-42. 3. Kakizaki H, Zako M, Miyaishi O, Nakano T, Asamoto K, Iwaki M. Overview of the lacrimal canaliculus in microscopic cross-section. Orbit. 2007 Dec;26(4):237-9. 4. Kim BS, Jung YJ, Chang CH, Choi BY. The anatomy of the superficial temporal artery in adult koreans using 3-dimensional computed tomographic angiogram: clinical research. J Cerebrovasc Endovasc Neurosurg. 2013 Sep;15(3):145-51.

44 Pediatric/Lacrimal Session Saturday, June 27

2:43 – 2:48 pm Solitary Fibrous Tumor of the Lacrimal Sac in a Pediatric Patient

Zvi Gur, Danielle Ozzello, Catherine Liu, Don Kikkawa, Bobby Korn Shiley Eye Institute, UCSD, La Jolla, California, United States

Introduction: To report the clinical features, radiographic studies and histopathology of a solitary fibrous tumor of the lacrimal sac in a pediatric patient with local recurrence.

Methods: Case report of a pediatric patient with solitary fibrous tumor. Data studied included: clinical history, radiographic studies, histopathology and genetic analysis.

Results: This 16-year-old female presented with tearing and a progressively enlarging mass along the right medial canthus over the past 5 years. On examination, a large inferomedial mass was noted on to displace the right globe superolaterally (Figure 1A). MR imaging of the orbit showed a 3.4 x 3.3 x 2.6 cm mass arising from the lacrimal sac with a smaller secondary lobe extending superiorly with rapid contrast washout (Figure 1B). An orbitotomy was performed to remove the lesion with its capsule. Histopathology demonstrated bland spindle cell neoplasm consistent with solitary fibrous tumor and the superior extent of the excision positive for tumor cells at resection margin. DNA microarray analysis showed that the tumor was positive for the NAB2-STAT6 gene fusion. Owing to the potential for malignant degeneration, the residual focus of tumor was excised with negative margins. At 6 months surveillance imaging, there is no residual tumor.

Conclusions: Solitary fibrous tumor (SFT) is a rare neoplasm in the pediatric population. SFT can present in any location in the orbit and may causing epiphora when involving the lacrimal system. Although considered benign, incomplete SFT excision can result in malignant degeneration, necessitating margin clearance and long term surveillance. Lacrimal bypass surgery should be delayed by at least 1 year to ensure no tumor recurrence.

Figure 1

(continued) 45 Pediatric/Lacrimal Session Saturday, June 27

(continued) References 1. Solitary Fibrous Tumors of the Lacrimal Drainage System With Variable Orbital and Sinonasal Extensions: Combined External and Endoscopic Surgical Approach. Morawala A, Bothra N, Dendukuri G, Ali MJ. Ophthalmic Plast Reconstr Surg. 2020 Jan 23. 2. Malignant transformation of orbital solitary fibrous tumor. Wang X, Qian J, Bi Y, Ping B, Zhang R.Int Ophthalmol. 2013 Jun;33(3):299-303. doi: 10.1007/s10792-012-9637-y. Epub 2013 Mar 23. 3. Solitary fibrous tumor of the orbit: CT and MR imaging findings. Kim HJ, Kim HJ, Kim YD, Yim YJ, Kim ST, Jeon P, Kim KH, Byun HS, Song HJ. AJNR Am J Neuroradiol. 2008 May;29(5):857-62. doi: 10.3174/ajnr.A0961. Epub 2008 Feb 13.

46 YASOPRS RAPID FIRE CASES AND PRESENTATIONS Sunday, June 28

Program times below are Eastern Daylight Time MAXIMUM 3.5 CME HOURS FOR SUNDAY (12 – 3:30 pm EDT, 11 am – 2:30 pm CDT, 10 am – 1:30 pm MDT, 9 am – 12:30 pm PDT)

Moderators: Michael T. Yen and Natalie Stanciu

12:01 – 12:05 pm Eyelid Ecthyma gangrenosum in an Immunocompromised Patient

Natalie Homer1, Aliza Epstein1, Paul Hoesly2 1TOC Eye and Face, Austin, Texas, United States, 2Dermatology, Austin Regional Clinic, Austin, Texas, United States

Introduction: Ecthyma gangrenosum is a rare cause of periorbital skin necrosis that most commonly affects immunocompromised patients with pseudomonal sepsis.

Methods: Case report of extensive right lower eyelid necrosis from ecthyma gangrenosum in an immunocompromised patient with Pseudomonas bacteremia.

Results: An 87-year-old man with a recent diagnosis of blastic plasmacytoid dendritic cell neoplasm managed with decitabine, venetoclax and filgrastim presented for evaluation of a right lower eyelid lesion. He was hospitalized one month prior for Pseudomonas aeruginosa bacteremia, at which time a hemorrhagic bulla developed on the right lower eyelid that was believed to be a hematoma. He was treated with intravenous cefepime followed by a course of oral levofloxacin, which he did not complete. Physical exam revealed a dusky-colored scaly patch with focal crusted ulceration involving the right lower eyelid (Figure 1A). Extensive debridement of the ulceration was performed, and intraoperative exam showed full-thickness necrosis of the lower eyelid margin (Figure 1B). Right endonasal evaluation revealed a necrotic plaque, which was bluntly debrided (Figure 1C). Intranasal tissue cultures grew scant Exserohilum species, consistent with chronic rhinosinusitis. Right lower eyelid and right cheek tissue cultures both grew Pseudomonas aeruginosa, confirming a diagnosis of ecthyma gangrenosum. The patient was treated with ciprofloxacin and showed spontaneous granulation of the right lower eyelid over several weeks (Figure 2).

Ecthyma gangrenosum is a rare cutaneous infection characterized by gangrenous ulcerations of the skin. Most cases occur in immunocompromised patients with Pseudomonas bacteremia, but children and immunocompetent patients may also be affected.1-3 Lesions may affect the face in 6% of cases, and initially appear as painless red macules that progress to bullae and eventual gangrenous ulcerations. Treatment includes surgical debridement and systemic antibiotic therapy. Following bacterial eradication, ulcerations may be allowed to heal by granulation1,3-5 or be managed with delayed reconstruction.2

(continued) 47 YASOPRS Rapid Fire Cases and Presentations Sunday, June 28

(continued) Conclusions: Ecthyma gangrenosum should be considered in cases of periorbital cutaneous necrosis, particularly in immunocompromised patients with pseudomonal sepsis. Herein we present the fifth reported case of ecthyma gangrenosum to arise in the periorbital area. Systemic anti-pseudomonal therapy and surgical debridement with escharectomy are typically indicated, followed by secondary intention healing or delayed reconstruction.

Figure 1 Figure 2

References 1. Martin-Lozano G, Canivell-Zabaleta M, Torres-Carranza E, Cabrera-Perez R, Infante-Cossio P. Ecthyma Gangrenosum in the Eyelid. J Craniofac Surg. 2018 Mar;29(2):531-532 2. Kumar SP, Kumar KP, Kaliaperumal S, Ashokan A. Nonpseudomonal ecthyma gangrenosum of the upper lid treated with lid reconstruction. Indian J Ophthalmol 2015;63:798-800. 3. Sarkar S, Patra AK, Mondal M. Ecthyma gangrenosum in the periorbital region in a previously healthy immunocompetent woman with bacteremia. Indian Dermatol Online J. 2016 Jan-Feb;7(1):36-9. 4. Lin Q, Hu B, Shi J, Shi W, Cao W, Li L. Eyelid and periorbital ecthyma gangrenosum due to Pseudomonas aeruginosa in an infant. Pediatric Investigation. 2017 Dec;1:47-49 5. Habal MB. The Journal of Craniofacial Surgery. 2018 March;29(2):531

48 YASOPRS Rapid Fire Cases and Presentations Sunday, June 28

12:05 – 12:09 pm Rectus Muscle Mass in the Setting of Long-standing Langerhans Cell Histiocytosis and Dabrafenib Treatment

Suzanne van Landingham1, Diane Puccetti2, Heather Potter1, David Gamm1,3, Mark Lucarelli1 1Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States, 2Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, United States, 3McPherson Eye Research Institute and Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, United States Introduction: An 18-year old man with history of neurodegenerative Langerhans cell histiocytosis, recently started on the B-raf inhibitor dabrafenib, presented with right eye pain. Methods: Case report Results: Magnetic resonance imaging (MRI) of the orbits revealed a lateral rectus muscle mass. Dabrafenib was stopped, and the patient underwent incisional biopsy of the mass. Biopsy findings were concerning for sarcoma. The mass was absent on post-operative MRI, so no further treatment was pursued. Re-examination of the pathologic specimen revealed findings more consistent with necrotizing myositis. The mass did not recur, nor did the patient develop other signs or symptoms concerning for myositis over a 24-month follow- up period. Conclusions: Necrotizing myositis has not previously been described in a rectus muscle or with B-Raf inhibitor use, though myalgias and secondary malignancies are established side effects. Necrotizing myositis may masquerade as sarcoma, and should be on the differential diagnosis for a new mass in the setting of dabrafenib therapy.

Figure 1 Figure 2

49 INVITED ASOPRS SPEAKER Sunday, June 28

12:14 – 12:26 pm Columbus Discovered the LPS!

David M. Reifler (Retired) Michigan State University, College of Human Medicine, Grand Rapids, Michigan, United States

Introduction: Matteo Realdo Colombo [Realdus Columbus] (1516–1559) published the first written description of the musculus levator palpebrae superioris (LPS) in his sole (posthumously published) literary work, De re anatomica (1559).

Methods: Portions of De re anatomica were translated into English and compared to anatomical writings of several contemporaries of Colombo: Andreas Vesalius (1514–1564); Gabriele Falloppio (1523–1562); and Michael Servetus (1509 or 1511–1553). Attention was given to anatomical structures of great importance to ophthalmology and oculofacial plastic and reconstructive surgery, especially descriptions of the eyelids and orbit. The lives of these Renaissance anatomists and authors were also studied to critically assess their literary contributions in the following contexts: their intersecting careers and interpersonal relationships; Renaissance politics, patronage, and academic censorship; and the judgments of medical historians over the ensuing centuries.

Results: Colombo was the first to correctly describe the LPS which he termed “musculus palpebrae aperiens.” He recognized the LPS as a retractor (opening muscle) of the upper eyelid and the musculus orbicularis oculi as its protractor (closing muscle). In his book, Colombo brusquely criticized errors in the monumental De humani corporis fabrica (1543 and 1555) by Vesalius. Following Galen (129–199 or 216), Vesalius had failed to identify the LPS, had erroneously described the orbicularis oculi as the eyelid retractor, and had erroneously described the musculus retractor bulbi as existing in humans. In 1546, Vesalius responded to the criticisms of his use a bovine eye in public dissections and its representation among the illustrations of the Fabrica, but in the second edition of this work, he did not replace the illustration nor did he retract the assertion of this “seventh eye muscle” in the human orbit. A description of the “musculus parvus et tenuis et palpebram attolens” (LPS) by Falloppio appeared in his sole literary work, Observationes anatomicae (1561). In 1734, Bernhard Siegfried Albinus (1697–1770) correctly assigned priority for the description of the LPS to Columbo ahead of Falloppio and other later anatomists and Albinus coined the now familiar term, musculus levator palpebrae superioris. Over time, priority for the description of the LPS became obfuscated or forgotten and Colombo’s character came into question with unsubstantiated claims of plagiarism of a prior description of the pulmonary circulation that had appeared in a theological work by Servetus. Because Servetus had been burned at the stake for heresy and almost all copies of this book were destroyed, the work may not have been available to Colombo. It is also possible that, as a high-profile protégé of Pope Paul IV, Colombo may have simply avoided citing the unfortunate heretic. In reviewing the medical literature, Colombo’s name was found to be conspicuously absent from histories of ophthalmology while, in recent years, the discovery of the LPS has been incorrectly attributed to Falloppio.

(continued) 50 Invited ASOPRS Speaker Sunday, June 28

(continued) Conclusions: Colombo discovered the LPS and he was the first to accurately describe retractors and protractors of the eyelid. These documented contributions of oculofacial plastic surgical importance should be added to other ongoing reappraisals of Colombo by medical historians.

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

(continued) 51 Invited ASOPRS Speaker Sunday, June 28

(continued) References 1. Albert DM and DD Edwards (eds), The History of Ophthalmology. Cambridge, MA: Blackwell Science, 1996, Chapter 4, pp 48–49 & 236. 2. Ball JM. Realdus Columbus. Tri-State Medical Journal 1897;4(September):447–450. 3. Bartley GB. Origins of oculoplastic surgery. Presented at the 50th Annual ASOPRS Fall Scientific Symposium, San Francisco, CA, October 10, 2019. 4. Boisliniere LC. Realdus Columbus of Cremona and Book XIIII (concerning vivisection) of his Treatise on Anatomy A.D. 1559. St. Louis Medical Review 1906;54(October 20):357–362. 5. Colombo R. De re anatomica libri XV. Venetiis: Ex Typographia Nicolai Beuilacquae, 1559, Book 5, Chapters 8-9, pp 122-124. See https://play.google.com/books/ reader?id=VcuFx_WLHhgC&pg=GBS.PP6 6. Duke-Elder S & Wybar KC. The history of the anatomy of the eye. In System of Ophthalmology, Vol 2. The Anatomy of the Visual System. London: Henry Kimpton, 1961, 1–72. 7. Falloppio G. Observationes anatomicæ. Venetiis: M. A. Ulmum, 1561, See https://play.google.com/books/reader?id=m2QBqi7aHcQC&hl=en&pg=GBS.PP1 8. Galen, C. Claudii Galeni Opera Omnia. Translations by Karl Gottlob Kühn in twenty volumes: Leipzig: Carl Knobloch, 1821–1833, De Usu Partium, Vol 3, pp 792 (line 12ff), & 804 (line 11ff), published 1822; and De Locis Affectis Libri VI, Vol 8, p 220 (line 14ff), published 1824. See https://www.textkit.com/greek-latin-forum/viewtopic. php?t=65078. 9. Garrison FH. An Introduction to the History of Medicine, 4th ed. Philadelphia: W.B. Saunders, 1929, pp 222–223. 10. Goldstone L and Goldstone N. Out of the Flames: The Remarkable Story of a Fearless Scholar, a Fatal Heresy, and One of the Rarest Books in the World. New York: Broadway Books, 2002, pp 197–199 containig digitized images from Servetus M. Christianismi Restituto. Vienne, 1553, :pp 170–171. 11. Musil V, Suchomel Z, Malinova P, Stingl J, Vlcek M, Vacha M. The history of Latin terminology of human skeletal muscles (from Vesalius to the present). Surgical Radiology and Anatomy 2015;37: 33–41. 12. Norman JM (ed). Morton’s Medical Bibliography: An Annotated Check-List of Texts Illustrating the History of Medicine, 5th ed. Aldershot, England: Scolar Press, 1991, p 75. 13. O’Malley, CD. Andreas Vesalius of Brussels 1514–1564. Berkeley: University of California Press, 1965. 14. Vesalius A. The Fabric of the Human Body: An Annotated Translation of the 1543 and 1555 Editions of ‘De humani corporis fabrica libri septem.’ Translated and edited by Daniel H. Garrison and Malcolm H. Hast. Basel: Karger Publishers, 2014, Volume 1 (Book 2, Chapters 10, 11, & 11-appendix), pp 484–490. 15. Vesalius A. The China Root Epistle. A New Translation and Critical Edition [Epistola, rationem modumque propinandi radices Chynae decocti]. Edited and translated by Daniel H. Garrison. New York: Cambridge University Press, 2015, pp 185–188. 16. Whitnall SE. An instance of the retractor bulbi muscle in man. Journal of Anatomy and Physiology 1911 Oct; 46(Pt 1): 36–40. 17. Whitnall SE. The Anatomy of the Human Orbit and Accessory Organs of Vision. London: Henry Frowde and Hodder & Stoughton, 1921.

52 EYELID SESSION Sunday, June 28

12:32 – 12:37 pm Rates of Ptosis and Success of Ptosis Repair following Ophthalmic Surgery

Katherine Williams, Adam Sweeney, Christopher Dermarkarian, Richard Allen, Michael Yen Baylor College of Medicine, Houston, Texas, United States

Introduction: Post-operative blepharoptosis has been observed following routine intraocular surgery; changing surgical technology and techniques have led to advances in ophthalmic surgery which may have changed the rates of development of ptosis and surgical success in repair.

Methods: A retrospective chart review of all patients who underwent ptosis repair between 2012 and 2019 by four surgeons at a tertiary referral center was performed. Inclusion criteria were patients who underwent external levator advancement or resection (ELR) or Muller muscle conjunctival resection (MMCR), patients age 18 or older, and patients with a minimum of three months of follow up. Surgical failure was defined as patient-reported or physician-reported dissatisfaction with eyelid eye or a postoperative upper eyelid margin reflex distance (MRD1) of less than 2 mm.

Results: A total of 407 eyelids met inclusion criteria. Mean presenting MRD1 was 0.54 mm. One-hundred ninety-three eyes (49.8%) had previously undergone intraocular surgery. The presenting MRD1 was 0.52 mm and 0.58 mm in eyes with and without a history of intraocular surgery, respectively (p = 0.51). The mean presenting MRD1 of patients with history of cataract surgery was 0.60 mm (N = 124) and 0.36 mm in patients with history of other types of intraocular surgery (N = 69; p = 0.08; figure 1). In comparison to no prior intraocular surgery, the average MRD1 for prior PKP was 0.67 mm (p = 0.804), prior retina surgery was -0.75 mm (p = 0.107), prior glaucoma surgery was 0.29 mm (p = 0.09). Compared to eyes without prior intraocular surgery, eyes with prior intraocular surgery were more likely to fail ptosis repair (p = 0.0088; figure 2). When evaluating failure of ptosis repair based on the type of prior surgery, those patients which had multiple surgeries were most likely to fail followed by those patients with prior retinal surgery or prior penetrating keratoplasty (p < 0.001; regression coefficient = 1.47; figure 3).

Conclusions: Our study found patients with prior intraocular surgery were more likely to fail ptosis repair in comparison to eyes without a history of prior intraocular surgery. Eyes with prior retina surgery or with multiple prior surgeries may be at highest risk of early ptosis recurrence following ptosis repair. There are certainly numerous perioperative factors influencing the eyelids in patients undergoing ptosis repair, however, we speculate the duration and frequency of eyelid speculum use to be a potential cause of ptosis and ptosis repair failure. This study was limited by variable follow up between different types of prior ophthalmic surgery.

(continued) 53 Eyelid Session Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3

54 Eyelid Session Sunday, June 28

12:37 – 12:42 pm Acute Reconstruction of Partial-thickness Periocular Burns with Simultaneous Epidermal/Dermal Autografting and Amniotic Membrane Grafting

Donovan Reed1, Andrew Plaster1, Aditya Mehta2, Marshall Hill1, Tatiana Zanganeh1, Timothy Soeken1, Sheri DeMartelaere3, Brett Davies1 1Ophthalmology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, United States, 2Ophthalmology, William Beaumont, El Paso, Texas, United States, 3San Antonio Uniformed Services Health Education Consortium, Ophthalmology, San Antonio, Texas, United States

Introduction: The authors present a novel technique for the acute reconstruction of partial-thickness periocular burns with simultaneous epidermal/dermal autografting and amniotic membrane grafting.

Methods: A retrospective review of four cases utilizing this novel technique was performed. The operative and post-surgical outcomes were evaluated. The technique examined involves preparation of the involved eyelids, followed by debridement of necrotic eyelid and periorbital tissue. Amniotic membrane grafting is subsequently performed over the debrided region, and the amniotic membrane graft secured to uninvolved tissue with cyanoacrylate tissue adhesive. Periclavicular skin is procured for autografting. Approximately 2mm by 2mm strips of periclavicular epidermal/dermal tissue is evenly distributed over the amniotic graft. A second amniotic membrane graft is then laid over the autografts, and secured to healthy surrounding skin with cyanoacrylate tissue adhesive. The autograft site is then gently covered with antibiotic ointment and moisture chambers, and a bolstered suture tarsorrhaphy is performed to minimize tissue trauma throughout the healing process.

Results: All autografts examined demonstrated clinical viability during the initial post-operative period. The successful autograft sites demonstrated appropriate skin coverage and healthy granulation tissue over the previously necrotic areas. No evidence of cicatricial changes or lagophthalmos were noted during post-operative evaluations. One autograft did ultimately fail requiring re-grafting after initial healing secondary to mechanical trauma and resultant ischemia to the autograft site from adjacent compressive wound dressings. Additionally, one case demonstrated multiple peripheral small squamous papillomas at the post-operative month one evaluation, which were not bothersome to the patient.

Conclusions: This analysis demonstrates the viability of simultaneous epidermal/dermal autografting and amniotic membrane grafting for the acute reconstruction of periocular partial-thickness burns. The post-operative outcomes demonstrated excellent functionality and cosmesis. By providing acute reconstruction, the risk of ophthalmic damage and vision loss secondary to cicatricial eyelid changes may be avoided. Additionally, vital skin is preserved by utilizing only a minimal amount of epidermal/dermal tissue for reconstruction.

(continued) 55 Eyelid Session Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

References 1. Malhotra R, Sheikh I, and Dheansa B. The Management of Eyelid Burns. Survey of Ophthalmology. 2009(3):356. 2. Fitzgerald O’Connor E, et al. Periorbital burns – A 6 year review of management and outcome. Burns, 2015. 41(3):616-623. 3. Mandrekas AD, et al. Treatment of bilateral severe eyelid burns with skin grafts: an odyssey. Burns. 2002. 28(1):80-86. 4. Kevin MK, et al. Acute surgical vs non-surgical management for ocular and peri-ocular burns: a systematic review and meta-analysis. Burns & Trauma. 2019(1):1. 5. Bin X, et al. Early management of eyelid burns with full-thickness skin grafts prevents eye injury. Burns: Journal Of The International Society For Burn Injuries. 2012. 38(6):947-948. 6. Barrow RE, Jeschke MG, and Herndon DN. Early release of third-degree eyelid burns prevents eye injury. 2000. 860-863. 7. Amescua G, et al. Modified Simple Limbal Epithelial Transplantation Using Cryopreserved Amniotic Membrane for Unilateral Limbal Stem Cell Deficiency. American Journal of Ophthalmology, 2014. 158(3):469-475.

56 Eyelid Session Sunday, June 28

12:42 – 12:47 pm Outcomes after Müller Muscle Conjunctival Resection versus External Levator Advancement in Severe Involutional Blepharoptosis

Adam Sweeney, Christopher Dermarkarian, Katherine Williams, Richard Allen, Michael Yen Baylor College of Medicine, Houston, Texas, United States

Introduction: To compare outcomes between Müller muscle conjunctival resection (MMCR) ptosis repair and external levator advancement/resection (ELR) in patients presenting with severe involutional blepharoptosis.

Methods: A retrospective chart review was performed of all patients who underwent ptosis repair between 2012 and 2019 by 4 surgeons at a tertiary referral center. Inclusion criteria were patients who underwent MMCR or ELR ptosis repair, patients with complete documentation of preoperative eyelid measurements, and patients with documentation of postoperative outcome. Patients were excluded if they were less than 18 years of age, underwent frontalis suspension, or did not have at least 3 months postoperative follow-up. Surgical failure was defined as patient-reported or physician-reported dissatisfaction with postoperative eyelid height or postoperative upper eyelid margin reflex distance (MRD1) of less than 2 mm. Severe ptosis was described as eyelids bisecting the pupil— an MRD1 of 0 or worse. Comparative statistical analyses were performed amongst patient groups before and after ptosis repair.

Results: A total of 231 patients (372 eyelids) met the study criteria, of which 142 eyelids had severe ptosis. Of eyelids with severe ptosis, 36 underwent MMCR and 106 underwent ELR. Of patients with severe ptosis, mean preoperative MRD1 was -0.11 mm (SD 0.32; range -1 to 0) and -0.28 mm (SD 0.64; range -3 to 0) for patients who underwent MMCR vs ELR, respectively (p = 0.14). Levator function averaged 10.0 mm for both patients who underwent MMCR and ELR (p = 1.00). Comparing outcomes of MMCR vs. ELR in patients with severe ptosis, there was a statistically significant higher rate of success following MMCR (p = 0.0143). The rate of ptosis repair success in eyelids that underwent MMCR was 97.2% in eyelids with severe ptosis, and 90.9% in patients with mild to moderate ptosis (p = 0.42). In eyelids that underwent ELR, the rate of ptosis repair success was 77.4 % in eyelids with severe ptosis, and 85% in eyelids with mild to moderate ptosis (p = 0.15).

Conclusions: MMCR ptosis repair is an effective approach in treating patients with severe ptosis, and may offer superior outcomes to ELR in this patient setting. In patients with good responses to phenylephrine, MMCR may offer an efficient and highly efficacious surgery regardless of presenting MRD1.

(continued) 57 Eyelid Session Sunday, June 28

(continued) Figure 1 Figure 2

58 Eyelid Session Sunday, June 28

12:47 – 12:52 pm Concurrent Tumors: Sebaceous Gland Carcinoma and Squamous Cell Carcinoma

Farzad Pakdel1, Fatemeh Heidary2, Fahimeh Asadi Amoli3, Zohre Nozarian3, Farhad Sameie4, Mehran Zarei Ghanavati5, Mohamad Keramatipour6 1Department of Oculo-Facial Plastic Surgery, Farabi Hospital, Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of, 2Tehran, Iran, Islamic Republic Of, 3Department of Pathology, Farabi Hospital, Tehran University of Medical Sciences, Tehran, Iran., Tehran, Iran, Islamic Republic Of, 4Department of Oncology-Radiotherapy, Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of, 5Department of Cornea, Farabi Hospital, Eye Research Center, Tehran University of Medical Sciences, Tehran, Alabama Iran, Islamic Republic Of, 6Tehran University of Medical Sciences, Department of Genetics, Tehran, Iran, Islamic Republic Of

Introduction: Sebaceous gland carcinoma (SGC) and squamous cell carcinoma (SCC) are malignant tumors with different clinical, histopathology, prognosis and management plans. There are reports of co-existence of SCC with merkel cell or basal cell carcinoma. However, concurrent SGC and SCC is an extremely rare and interesting entity. We aim to describe clinical features, diagnostic and treatment strategy of this interesting entity.

Methods: Demographic, clinical, histopathology, immunohistochemical features were recorded. Molecular profiling using next -generation sequencing (NGS) were done. Surgical resection of the tumors and adjuvant treatments were performed.

Results: We reported a 58-year-old healthy man with one year history of dry eye symptoms. We noticed a yellow lesion the posterior upper eyelid margin and palpebral conjunctiva of the right eye. Histopathologic and immunohistochemical studies could rule out the rare variant of SCC with sebaceous differentiation and also pagetoid spread of SGC to conjunctiva. Extensive evaluations confirmed two separate tumor entities in this patient. Our patients had a stage T2b SGC and conjunctival SCC diagnosed simultaneously.

He underwent extensive tumor resection with microscopic margin control. Sebaceous cell carcinoma of the eyelids were resected with microscopic margin control and map biopsy. Near total upper eyelid resection was performed followed by reconstruction. Conjunctival SCC was resected, and ocular surface was covered by amniotic membrane graft. Adjuvant external beam radiotherapy. The patient showed no recurrence at twenty-six months after tumor resection and saved the functional eye despite severe dry eye.

Conclusions: To the best of our knowledge this is the first report of concurrent SGC and SCC in a same patient. Careful clinical, histopathology and molecular evaluations are critical for correct diagnosis and formulating appropriate treatment plan. Our patient was successfully managed with surgical resection, reconstructive surgeries and adjuvant fractionated external beam radiotherapy.

(continued) 59 Eyelid Session Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3 Figure 4

References 1. Wali UK, Al-Mujaini A. Sebaceous gland carcinoma of the eyelid. Oman J Ophthalmol 2010;3(3):117-21. 2. Izumi M, Mukai K, Nagai T, et al. Sebaceous carcinoma of the eyelids: thirty cases from Japan. PatholInt2008;58(8):483-8. 3. Milman T, Schear MJ, Eagle RC Jr. Diagnostic utility of adipophilin immunostain in periocular carcinomas. Ophthalmology 2014;121(4):964-71. 4. Plaza JA, Mackinnon A, Carrillo L, et al. Role of immunohistochemistry in the diagnosis of sebaceous carcinoma: a clinicopathologic and immunohistochemical study. Am J Dermatopathol 2015;37(11):809-21. 5. Plaza JA, Ortega PF, Stockman DL, et al. Value of p63 and podoplanin (D2-40) immunoreactivity in the distinction between primary cutaneous tumors and adenocarcinomas metastatic to the skin: a clinicopathologic and immunohistochemical study of 79 cases. J CutanPathol 2010;37(4):403-10. 6. Asadi-Amoli F, Khoshnevis F, Haeri H, Jahanzad I, Pazira R, Shahsiah R. Comparative examination of androgen receptor reactivity for differential diagnosis of sebaceous carcinoma from squamous cell and basal cell carcinoma. Am J Clin Pathol. 2010 Jul;134(1):22-6. 7. Amoli FA, Heidari AB. Survey of 447 patients with conjunctival neoplastic lesions in Farabi Eye Hospital, Tehran, Iran. Ophthalmic Epidemiol. 2006 Aug;13(4):275-9. 8. Jacinto FA, Margo CE. Clinically Occult Squamous Cell Carcinoma of Conjunctiva After Topical Immunotherapy for Ocular Surface Squamous Neoplasia. Can J Ophthalmol 2017;52(4):e152-e153. 9. Lee GA, Hirst LW. Ocular surface squamous neoplasia. SurvOphthalmol 1995;39(6):429-50. 10. Muthusamy K, Halbert G, Roberts F. Immunohistochemical staining for adipophilin, perilipin and TIP47. J ClinPathol 2006;59(11):1166-70. 11. Tanahashi J, Kashima K, Daa T, et al. Merkel cell carcinoma co-existent with sebaceous carcinoma of the eyelid. J CutanPathol 2009;36(9):983-6. 12. Cicinelli MV, Kaliki S. Ocular sebaceous gland carcinoma: an update of the literature. IntOphthalmol 2018 Apr 25. 13. Jakobiec FA, Zimmerman LE, La Piana F, Hornblass A, Breffeilh RA, Lackey JK. Unusual eyelid tumors with sebaceous differentiation in the Muir-Torre syndrome. Rapid clinical regrowth and frank squamous transformation after biopsy. Ophthalmology. 1988 Nov;95(11):1543-8. 14. Kashkouli MB, Heirati A, Pakdel F, Kiavash V, Naseripour M, Aghamohammadi F. Long-term follow-up of invasive ocular surface squamous cell carcinoma treated with excision, cryotherapy, and topical mitomycin C. Graefes Arch Clin Exp Ophthalmol. 2012 Feb 3.

60 Eyelid Session Sunday, June 28

12:52 – 12:57 pm Intense Pulse Light as a New Treatment For Distichiasis and Trichiasis

Sara Plazola Oculoplastic, Centro Medico Nacional 20De Noviembre, Mexico City, Mexico

Introduction: Trichiasis and districuiasis are conditions that cause constant trauma to the ocular surface. This alteration can affect the entire eyelid or be located in a small area. Within the proposed treatments this is a pathology with high incidence of recurrence.

Intense Pulsed Light system (IPL) is the emission of incoherent polychromatic high intensity light pulsed, was commercialized in 1994. The IPL is similar to the laser in its basic principle, in the absorption of endogenous and exogenous photons and chromophores of the skin, transferring the energy to these chromophores; this transfer generates heat with the subsequent destruction of the follicles. In addition, it is used for photorejuvenation, against acne and permanent hair removal with excellent results.

The purpose of this study was to evaluate the outcome of IPL in the thermodestruction of eyelashes follicles as a new treatment of trichiasis and districhiasis in patients.

Methods: Prospective, interventional study in 12 patients in 21 eyelids, 6 females and 6 males. The etiology of missdirectional eyelashes was trauma (5), Stevens Johnson syndrome (2), prostaglandin analogs users (2), chronic idiopatic blepharitis (2), eyelid herpes (1). We included all skin types. The energy used in the IPL was between 28 and 32 J/cm2 and 10 to 12 aplications, the mean was 6 sesions in total and the follow up was monthly.

Results: All the patients had a good result. These was found evaluating the remain eyelashes of the patients treated with IPL had significantly decrease of the missdirectional eyelashes in 90%. No inflamatory signs where found nether in conjuntiva or eyelid.

Conclusions: In conclusion we can observe a clinical reduction of the eyelashes and improvement in the signs and symptoms in these patients without major secondary effects. IPL is a new technology in which thermodestruction is used to inhibit this growth; which can be considered as a new and definitive alternative in the treatment of these pathologies.

(continued) 61 Eyelid Session Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

References 1. B A O’Donnell , J R Collin. Distichiasis: management with cryotherapy to the posterior lamella. Br J Ophthalmol. 1993 May; 77(5): 289–292. 2. S Zandi, H Lui. Long-Term Removal of Unwanted Hair Using Light. Dermatol Clin 31 (2013) 179–191 3. A. Bdour, A.Till. Argon laser: a modality of treatment for trichiasis. Int J Biomed Sci. 2007 Mar;3(1):56-9. 4. S Jo, J Kim, J Ban, Y Lee, O Kwon, W Koh, Efficacy and Safety of Hair Removal with a Long-Pulsed Diode Laser Depending on the Spot Size: A Randomized, Evaluators- Blinded, Left-Right Study. Ann Dermatol. 2015 Oct; 27(5): 517–522. 5. Buddhadev RM. Standard guidelines of care: Laser and IPL hair reduction. Indian J Dermatol Venereol Leprol 2008;74, Suppl S1:68-74 (2) 6. Ruby Medina Murillo. Luz pulsada intensa: aplicaciones en dermatología. Rev Hosp Jua Mex 2011; 78(4): 240-243 7. P. Serrano-Grau, A. Campo-Voegeli, D. Romer. Fotodepilación. Actas Dermosifiliogr 2009;100:351-61 - Vol. 100 Núm.5 DOI: 10.1016/S0001-7310(09)71254-2 8. M.H. Gold,M.W. Bell,T.D. Foster,S. Street. Long-term epilation using the Epilight broad band, intense pulsed light hair removal system. Dermatol Surg, 23 (1997), pp. 909-913 (continued) 62 Eyelid Session Sunday, June 28

(continued) 9. R.A. Weiss,M.A. Weis,S. Marwaha,A.C. Harrington. Hair removal with a non-coherent filtered flashlamp intense pulsed light source. Lasers Surg Med, 24 (1999), pp. 128-132 10. N.S. Sadick,R.A. Weiss,C.R. Shea,H. Nagel,J. Nicholson,V.G. Prieto. Long-term photoepilation using a broad-spectrum intense pulsed light source. Arch Dermatol, 136 (2000), pp. 1336-1340 11. Sánchez-Carpintero I., Mihm M.C., Waner M.. Láser y luz pulsada intensa en el tratamiento de hemangiomas infantiles y malformaciones vasculares. Anales Sis San Navarra. 2004 [citado 2017 Mayo 02] ; 27( Suppl 1 ): 103-115. 12. N AlNomair, R Nazarian. E Marmur. Complications in Lasers, Lights, and Radiofrequency Devices. Facial Plast Surg 2012;28:340–346 13. E-Light Manual de Instrucciones. Equipos portables. Aesthetics Brokers. Beijing V- GO science and technology. 2008 14. Lee, J Murdock, T. Albini, T. O’Brien, M. Levine. Ocular Damage Secondary to Intense Pulse Light Therapy to the Face. Ophthal Plast Reconstr Surg, Vol. 27, No. 4, 2011 15. W K. Greveling, E.P. Prens, L. Liu, M.B.A van Doorn. Non-invasive anaesthetic methods for dermatological laser procedures a systematic review running head. Department of Dermatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. 2017 16. P Manning, D Ringler. Rabbit Anesthesia & Analgesia Guidelines. University of Michigan, 2009

63 INVITED ASOPRS SPEAKER Sunday, June 28

1:08 – 1:18 pm Periocular Laser, Lights, Injectables, and Surgery for Scar Therapy

Chad Zatezelo The Zatezalo Group, North Bethesda, Maryland, United States

64 AESTHETICS SESSION Sunday, June 28

1:25 – 1:30 pm Autologous Fat Transfer Harvest Site Complications: Incidence, Risk Factors and Management

Natalie Homer1, Anika Patel2, Aliza Epstein1, Vikram Durairaj1,3, Tanuj Nakra1,3 1TOC Eye and Face, Austin, Texas, United States, 2Medicine, University of California Los Angeles, Los Angeles, California, United States, 3Wong Eye Institute, Dell Medical School, University of Texas at Austin, Austin, Texas, United States

Introduction: Autologous fat transfer is an effective tool to restore volume to the aging face. Although numerous reports exist regarding injection site complications,1,2 there is limited data on donor site morbidity in the facial cosmetic surgery literature.3,4 This study is a large-scale retrospective review to determine incidence of harvest site complications, identify risk factors and describe management strategies.

Methods: We reviewed records of all patients who underwent autologous fat harvesting at a single oculoplastic practice from 2010 to 2019. We collected and assessed patient demographic and clinical data. Statistical analysis was performed via two-tailed T-test with p-values of < 0.05 considered significant.

Results: In total, 416 patients met inclusion criteria. Patients were 94.4% female and average age 55.9 years. Patients were followed for an average 6.2 months (range 1.0 month – 38.0 months, median 5.0 months) post-operatively. Two-hundred eighty patients (67.3%) had fat harvest from the abdomen only, 99 (23.8%) from the abdomen, medial knees and thighs, and 31 (7.4%) from elsewhere. Six patients did not have harvest site location specified.

There was an overall 5.5% harvest site complication rate. Six (1.4%) patients complained of contour irregularities (Figure 1), 5 (1.2%) had harvest site induration, and 4 (0.9%) showed prolonged erythema. Two patients (0.5%) developed donor site infection, one with a discrete abscess and one with periumbilical erythema consistent with early cellulitis. Two patients (0.5%) had persistent tenderness, one patient (0.2%) developed a small self-resolving donor site hematoma, one (0.2%) had post-inflammatory hyperpigmentation (PIH), and one (0.2%) had an allergic reaction to bacitracin ointment.

There was no correlation of harvest site complications with gender (p = 0.249) or age (p = 0.881). Harvest location did not significantly correlate with complication rate. Contour irregularities occurred more commonly in patients with a lower average Body Mass Index (BMI) (18.94 vs. 23.58, p = 0.003). Interestingly, low BMI was associated with higher complication rate, even when excluding those patients with contour irregularities (p = 0.001).

(continued) 65 Aesthetics Session Sunday, June 28

(continued) Of patients with contour irregularities, two were treated non-surgically with a combination of deoxycholic acid and poly-L lactic acid. Two were managed with additional liposuction and directed fat transfer. Persistent hyperemia was managed with intense pulsed light therapy and PIH with topical hydroquinone. One patient had persistent abdominal pain, successfully treated conservatively with non- steroidal anti-inflammatory medication and an abdominal binder. All treated patients showed improvement of their post-operative donor site morbidities.

Conclusions: Autologous fat transfer, used for face volumization, has low donor site morbidity. Minor harvest site complications occur more commonly in patients with low BMI, irrespective of age, gender or fat source. Surgeons should maintain high vigilance post- operatively and directed management initiated quickly when indicated.

Figure 1

References 1. Gornitsky J, Viezel-Mathieu A, Alnaif N, Azzi A, Gilardino MS. A systemic review of the effectiveness and complications of fat grafting in the facial region.Journal of Plastic Reconstructive and Aesthetic Surgery. 2019 March;19:87-97. 2. Simonacci F, Bertozzi N, Grieco MP, Grignaffini E, Raposio E. Procedure, applications, and outcomes of autologous fat grafting. Ann Med Surg (Lond). 2017;20:49–60. 3. Groen J, Negenborn VL, Twisk JWR, Ket JCF, Mullender MG, Smit JM. Autologous Fat Grafting in Cosmetic Breast Augmentation: A Systematic Review on Radiological Safety, Complications, Volume Retention, and Patient/Surgeon Satisfaction, Aesthetic Surgery Journal. 2016 Oct. 36(9): 993–1007. 4. Yoshimura K, Coleman SR. Complications of Fat Grafting. How They Occur and How to Find, Avoid and Treat Them. Clinc Plastic Surg. 2015(42):383-388

66 Aesthetics Session Sunday, June 28

1:30 – 1:35 pm Evaluating the Response of Expired Fillers to Hyaluronidase and Bacterial Culture

Sandy Zhang-Nunes MD, Zalea Nunes USC Roski Eye Institute, Los Angeles, California, United States

Introduction: Most hyaluronic acid (HA) gel fillers have a shelf life of about 24 months after they are manufactured. Not much is known about what happens when HA gel fillers expire, but they are not recommended for use since they have not been tested for safety and efficacy beyond an expiration date. Some practitioners use expired fillers on themselves for practice. We sought to evaluate some expired fillersex vivo to aid us in understanding what happens when they expire. We looked at their change in form on a slide over 3 hours, their response to hyaluronidase, and cultured them for bacterial growth.

Methods: Three different types of HA gel fillers with 3 different expiration dates each were evaluated: Restylane Refyne (4/30/2019, 9/30/2019, 4/30/2020), Belotero Balance (10/27/2018, 1/27/2019, 10/5/2020), and Juvederm Ultra (3/29/2016, 11/7/2019, 3/17/2020). The testing was performed in 12/2019 for all of these fillers making two of them expired, and one of them unexpired for each product. For each product, a 0.2 mL aliquot was placed on two separate glass slides, one for control, and one injected with 20 units of hyaluronidase (Hylenex) in the center with a 25 gauge needle. A standard method was used to measure height and take photos to evaluate their texture at the following time points: right after gels placed on slides, then 1 minute after hyaluronidase injection, and 15 minutes, 30 minutes, 1 hour, 2 hours and 3 hours after.

Results: Juvederm Ultra showed a difference both in height and texture between the filler expired for three years and the unexpired filler. (Fig. 1). Belotero, a naturally softer filler flattened by itself, but the filler that was most expired (10-27-2018, over 1 year expired) and had hyaluronidase added to it, flattened even faster (Fig. 2). The most expired Belotero filler also had a difference in texture (more liquified) compared to the unexpired one, which may signify that the filler breaks down faster than the unexpired filler. Restylane Refyne showed no significant difference between the unexpired and expired fillers, which may be due to the fact that the expired fillers were all less than one year expired (Fig. 3). In addition, none of the fillers, unexpired and expired, showed any sign of bacterial growth when grown on Luria Broth plates (Fig. 4).

Conclusions: The fillers that were more than one year expired flattened more quickly or responded more readily to hyaluronidase when compared to unexpired fillers. Fillers less than one year expired did not show any significant difference from unexpired fillers. All fillers tested, which were expired less than four years, did not grow any bacteria.

(continued) 67 Aesthetics Session Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3 Figure 4

68 Aesthetics Session Sunday, June 28

1:35 – 1:40 pm Reconstructive Fat Transfer to the Orbit and Periocular Region

Bradford Lee Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, United States

Introduction: Autologous fat transfer has become a popular procedure for facial rejuvenation. However, less is known about its potential applications for various other orbital, periocular, and facial reconstructive indications. Fat transfer can volumize the soft tissues of the orbit and face without the use of alloplastic materials and without incisional surgery. The author will discuss his experience with using autologous fat transfer to improve facial symmetry and to correct soft tissue and bony structural deficits in patients with post-traumatic facial deformities, thyroid eye disease, anophthalmic socket syndrome, and post-maxillectomy facial deformities.

Methods: Retrospective case series.

Results: All patients underwent autologous fat transfer via manual liposuction from the periumbilical and flank regions. Fat was washed and purified using a closed filtration system and injected into the orbit, periocular region, and throughout various regions of the face. All patients noted significant volumization and long-term fat graft survival with improved facial symmetry. There were no complications, and no patients went on to have subsequent reconstructive surgery.

Conclusions: Autologous fat transfer is a useful technique that can be applied to correct soft tissue or bony structural abnormalities resulting from various diseases, trauma, or surgeries. Long-term graft survival and volumization can improve facial symmetry and avoid the need for further reconstructive surgeries.

Figure 1 Figure 2

69 DIFFICULT CASES Sunday, June 28

1:52 – 1:57 pm An Unusual Occult Orbital Foreign Body

Michael Migliori, Yash Vaishnav Ophthalmology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States

Introduction: A high index of suspicion and an interdisciplinary approach is often required to recognize the presence of an occult orbital wooden foreign bodies in the trauma setting when the patient’s history and clinical findings do not reconcile.

Methods: The authors present a case of an occult orbital foreign body in a 66-year-old male who presented to the hospital emergency department four days after a syncopal episode while bending down to pick something up off the floor. He struck his head on a hope chest as he fell. His initial examination was significant for hand motion vision on the left with left proptosis and ophthalmoplegia. His CT scan was initially read as as left medial wall fracture with a possible orbital foreign body or air in the orbit, but the patient denied being hit with anything. There were conflicting opinions about diagnosis and the patient was discharged for outpatient follow up.

Results: The radiology attending and the orbital surgeon reviewed and reformatted the CT the following day, confirming there was a relatively radiolucent orbital foreign body, which was subsequently removed surgically with return of normal vision and motility. The foreign body was determined to be the tip of a wooden pole of a toy flag.

Conclusions: Ophthalmologists should maintain a high index of suspicion when there is a question of an orbital foreign body on imaging regardless of the history, and a low threshold to consult radiology colleagues in the diagnostic evaluation, especially with unusual radiologic findings. Junior residents should not be afraid to escalate their concerns to more senior members of the treatment team, including other services, if they do not agree with diagnostic or treatment decisions.

(continued) 70 Difficult Cases Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3 Figure 4

References 1. Hamilton A, Meena M, Lawlor M, Kourt G. An unusual case of intraorbital foreign body and its management. Int Ophthalmol. 2014;34:337–9. 2. Bartkowski SB, Kurek M, Stypulkowska J, et al. Foreign bodies in the orbit. Review of 20 cases. J Maxillofac Surg. 1984 Jun; 12(3):97-102. 3. Kim YH, Kim H, Yoon ES. Unrecognized intraorbital wooden foreign body. Arch Craniofac Surg. 2018;19:300–3. 4. Shelsta HN, Bilyk JR, Rubin PA, et al. Wooden intraorbital foreign body injuries: Clinical characteristics and outcomes of 23 patients. Ophthalmic Plast Reconstr Surg. 2010;26:238–44.

71 Difficult Cases Sunday, June 28

1:57 – 2:02 pm Orbital Reconstruction following Resection of Sinonasal Malignancy

Raymond Cho Department of Ophthalmology and Visual Science, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

Introduction: A 43-year-old man with a history of squamous cell carcinoma of the right maxillary sinus (T4N0M0) underwent complete orbit-sparing maxillectomy and reconstruction of the maxilla with a fibular free flap and reconstruction of the orbital floor with titanium mesh. Postoperatively, the fibular free flap failed and was replaced with a scapular tip flap, which also failed. The patient underwent adjuvant radiation and subsequently developed hypoglobus, hypotropia, mechanical lower lid retraction and ectropion, cicatncial lower lid entropion, and lagophthalmos.

Methods: Difficult case presentation

Results: Six months after the initial surgery, the patient was taken to the OR for attempted reconstruction, but coded on the table, and the surgery was aborted. One month later, the patient returned to the OR for removal of the orbital floor implant and secondary reconstruction of the inferior orbital rim with a customized polyetheretherketone implant and the orbital floor with a customized titanium implant. The maxillary and midface defect was reconstructed with a radial forearm free flap. The lower lid entropion was treated with a tarsotomy and nasal septal mucosal graft. The globe malposition, diplopia, and lagophthalmos resolved postoperatively with a stable reconstruction at three months follow up.

Conclusions: This case demonstrates several complications that can arise in patients who undergo radical resection of sinonasal tumors with subsequent reconstruction and postoperative radiation. Multiple customized implants and surgical techniques were employed to successfully address the patient’s deficit.

(continued) 72 Difficult Cases Sunday, June 28

(continued) Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

73 PRACTICE MANAGEMENT SESSION Sunday, June 28

2:12 – 2:17 pm The Impact of Social Media, Internet Searches, and a Practice’s Website on an Oculoplastics Practice: Economic Patterns of Self-referred Patients

Robert Beaulieu, Evan Black Consultants in Ophthalmic and Facial Plastic Surgery, Southfield, Michigan, United States

Introduction: Creating and maintaining an online presence for physicians has become an increasingly important topic as social media platforms have become ubiquitous in daily life. Patients have numerous avenues to find providers, review ratings, and judge results to seek out the right physician or surgeon.1 There are many articles encouraging physicians to establish a social media, internet, and marketing presence while others explain strategies to build the best profile and how to market to potential patients outside of the traditional physician referral networks. However, there is a relative lack of evidence showing how these investments translate into economic benefits for a practice.

Methods: A retrospective analysis of information collected from a single-specialty oculoplastics private practice management database was conducted for all patient appointments scheduled over a two-year period (January 1, 2018-December 31, 2019). Patient referral source, insurance type, chief complaint, completion of consultation, follow up visit, and surgical procedures completed were all documented. Referral source percentage for all patient visits were calculated. For self-referred patients (designated as “Website”, “Internet Search”, “Magazine”, or “Self”), no-show rate, insurance type, chief complaint, and surgical procedures completed, and follow up visits completed were calculated.

Results: There were 146 patients seen were self-referred, which accounted for 1.6% of all patients seen in the practice (8957 total patients seen). The show-rate for these patients was 68% compared to 86% for the overall patient show rate. From the 146 patients that were seen, 76 (52%) did not have surgery (either not recommended or the patient cancelled the recommended procedure). 38 (26%) patients had a functional surgery, 10 (7%) had a functional surgery with a cosmetic procedure added on, and 11 (8%) had a purely cosmetic surgery. Nine (6%) patients had an in-office procedure, such as chemodenervation, filler, or hyaluronidase injection. 25% of the patients who were self-referred had a purely cosmetic complaint. Of the purely cosmetic complaint patients, 30% had surgery.

(continued) 74 Practice Management Session Sunday, June 28

(continued) Conclusions: In the world of plastic surgery, taking advantage of new internet-based avenues to educate, showcase results, and attract new patients is perceived as an increasing requirement. Studies over the last decade have reported the perceived role internet-based marketing is having on plastic surgeons, especially those in an aesthetic marketplace.2 Despite the idea that patients who use the internet or social media are aesthetically focused, approximately 75% of the patients that presented to our practice as a self-referral had a functional complaint. Of the 146 patients who presented to our clinics over the 2-year period, roughly 40% underwent surgical correction. Moreover, the majority of procedures performed on these patients were covered by insurance. Self-referred patients had a higher no-show rate compared to the traditional methods of physician and friend referrals. This subtype of patient also made up a very small portion of our total patient population (<2%). This study challenges the belief that self-referred patients are a key cosmetic demographic.

References 1. Dorfman RG, Mahmood E, Ren A, et al. Google Ranking of Plastic Surgeons Values Social Media Presence Over Academic Pedigree and Experience. Aesthet Surg J. 2019;39(4):447-451. 2. Wheeler CK, Said H, Prucz R, Rodrich RJ, Mathes DW. Social media in plastic surgery practices: emerging trends in North America. Aesthet Surg J. 2011;31(4):435-41.

75 Practice Management Session Sunday, June 28

2:17 – 2:22 pm Building your Brand: Analysis of Successful Oculoplastic Surgeons on Social Media

Anne Barmettler1, Sally Park2, Jee Young Moon3 1Ophthalmology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, United States,2 Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, United States, 3Statistics, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, United States

Introduction: Many physicians use social media not only as a means to educate the public, but also to collaborate with colleagues, to attract prospective patients, and to build professional recognition, otherwise known as “building one’s brand.”1,2 As the influence of social media grows, studies have examined the impact of social media on healthcare and the content of health care professional’s social media.3-5 However, to date, no study has examined real, physician-held accounts to determine what types of content and other factors result in the most public engagement.

This study examines thousands of posts by oculoplastic surgeon social media accounts for levels of public engagement. Instagram (Menlo Park, California) was chosen for this study for its popularity and focus on images, which is helpful as a teaching platform, as well as for aesthetic providers and users.

Methods: This study analyzed successful Instagram accounts (defined by >500 followers as of May 2019) held by American Society of Ophthalmic Plastic Reconstruction Surgery (ASOPRS) members. Each account’s 20 most and 20 least successful posts (based on number of likes) were characterized by the post’s subject, location, media type, and tag usage. Posts were then analyzed using a web- based application that calculates the engagement level of Instagram users with the selected post.

Results: A total of 4,812 posts were analyzed from 37 Instagram accounts. Of these ASOPRS members, the majority were men (67.6%, n=25) in private practice solely (70.3%, n=26). Numerous post characteristics, like content, location, and media type, impacted success in a statistically significant manner; for example, public engagement rose when featuring the posting doctor, especially when smiling and wearing a white coat. Meanwhile, posts featuring an office procedure had a negative effect. Formatting was also found to contribute to success. For example, photographs were preferred over videos, while multiple images were best presented sequentially as a carousel (with the viewer swiping through the series) rather than in a large collage. Use of tags (hashtags, accounts, and locations) were associated with increased engagement.

(continued) 76 Practice Management Session Sunday, June 28

(continued) Conclusions: Social media is an important communication and marketing tool, especially in aesthetic fields like oculoplastics. Guidelines for success are presented in this study; content, location, subject, media type, and tags statistically significantly impact public engagement.

References 1. Gould DJ, Grant Stevens W, Nazarian S. A Primer on Social Media for Plastic Surgeons: What Do I Need to Know About Social Media and How Can It Help My Practice? Aesthet Surg J. 2017;37(5):614-619. 2. DeBord LC, Patel V, Braun TL, Dao H, Jr. Social media in dermatology: clinical relevance, academic value, and trends across platforms. J Dermatolog Treat. 2019;30(5):511-518. 3. Smailhodzic E, Hooijsma W, Boonstra A, Langley DJ. Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals. BMC Health Serv Res. 2016;16:442. 4. Surani Z, Hirani R, Elias A, et al. Social media usage among health care providers. BMC Res Notes. 2017;10(1):654. 5. Haeberle HS, Egger AC, Navarro SM, et al. Social Media and Pediatric Scoliosis: An Analysis of Patient and Surgeon Use. Surg Technol Int. 2017;31:189-196.

77 PRACTICE MANAGEMENT PANEL Sunday, June 28

2:30 – 2:36 pm Lean Principles in the Office – One Team’s Journey

Mark J. Lucarelli Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States

Acknowledgements Overview

Lean Consultant Clinical Team Team Journey Lean Principles in the office – • Aneesh Suneja, MBA • Laura Becker • Core principles one Team’s journey • Kaitlin Houghton • Process Oculofacial Colleagues • Linda Jorgensen Favorite Lean Lessons Mark J. Lucarelli, MD, FACS • Cat Burkat, MD • Beth Pelar • Dr. Suzanne van Landingham, MD Examples of Change Results / Data Team Culture Change

Team Journey Our Core Principles Our Process

• First meeting Jan 25, 2019 Focus: Improve Patient experience 1. Team brainstorming à Action item • 5 Follow up meetings (approx. q 6 weeks; x 90 min) 2. Point person to take the lead • 3/8; 4/26,7/8; 9/3; 11/5 • Minimize patient’s steps / travel • Lean basicsà more advanced concepts 3. If Service-wide impact: Oculofacial attendings discuss off line • Minimize wasted time for the patient 4. Communicate implementation consensus to Point person • Meeting structure • Minimize “over-processing” • Aneesh Suneja, MBA facilitating • Every member of our team adding value 5. Set up Trial Exam Room for the change 1. Use the room for a week and make observations • EVERYONE contributing • Working more effectively as a TEAM • Relaxed, supportive, egalitarian 2. Gather feedback from various stakeholders • Follow up: general progress and action items 6. Scrap the idea vs Modify/Try again vs Move Ahead • New action items / specific next steps 7. Move Aheadà Roll out and Standardize the change • Tremendous progress over 10 months GOAL: Put patient at center of a caring, efficient, high- • From folding paper airplanes to actual culture change performance TEAM

(continued) 78 Practice Management Panel Sunday, June 28

(continued)

Lean Lesson: Areas of Clinical Waste Lean Lessons: Value stream mapping the patient experience Favorite Lean Lessons WAIT / WALK WAIT WAIT/WALK ROOMED SIGN VISUAL BY TRAINEE FIELDS IN TECH PT: 2 MIN WT: 3 MIN PT: 8 MIN WT: 5 MIN PT: 14 MIN WT: 12 MIN PT: 12 MIN

WAIT / WALK

Value-added Vs Waste WT: 20 MIN

WAIT / WALK WAIT / WALK

CHECK TECH ROOM / OUT WRAP-UP MD

PT: 3 MIN PT: 4 MIN WT: 4 MIN PT: 12 MIN

Image credit: aLeanJourney.com Image Credit: GoLeanSixSigma.com Modified from Aneesh Suneja

Favorite Lean Lessons Favorite Lean Changes 5 S’s - Illustrative Example Minimizing patient steps and travels • Action item from Team brainstorming • 5 S’s • Point person to take the lead • Sort • Oculoplastics attendings discuss the idea and details Examples: • Set in Order • Communicate implementation consensus to Point person • Shine • Set up Trial Room for the change • Phenylephrine test • Standardize • Use the room for a week and make observations Gather feedback • Sustain • • Scrap the idea vs Modify/try again vs Move ahead • Basic photography • Roll out and Standardize the change • Ptosis visual fields PRIOR to the consult

Manual; Oculoplastics Techs’

Lean Changes Favorite Lean Changes Favorite Lean Lessons

• Minimizing patient steps and travels • Culture Change: “Good idea! Let’s try it…” • Culture Change: “Good idea! Let’s try it…”

Photography (work in progress) Examples • More examples

Leanmanufacturingtools.org Pre-Lean: Patient goes upstairs to Ophthalmic Photo for all photos • Logical and standard organization of exam room instruments • Increasing Photography in lower level • Standardization of the patient education handouts • Oculoplastics dry erase board for projects/ brainstorming àSelected photos by MD via Image Mover then Haiku • Patient flow monitor in Provider work room • Oculoplastics Techs’ Binder àTrial of Techs using MD iphone / iPod • Mini clipboards outside patient exam rooms à Laura developing a written guide for Tech use à Attendings discussing / working toward consensus à Cat Burkat spearheading training efforts à Standardization for Oculoplastic Service

(continued) 79 Practice Management Panel Sunday, June 28

(continued)

Favorite Lean Lessons End of visit overlap /Grab a clipboard… Remote Scribing

• Culture Change: “Good idea! Let’s try it…” • Benefits: • Complete Game changer • Continuity / Familiarity with Tech who roomed patient • More examples • Fewer red lights • Less provider time wasted waiting for help • Previsit ”microhuddle” / handoff • Techs more informed on the patient’s situation and needs • Work flow overlap (esp Tech overlapping with Attending at end of visit) • Concierge-like • Improved communication of next steps for the patient • Techs engaged at higher lever in the patient’s care • Patient experiences efficiency, coordination, and teamwork

Micro 80 70.5 Lean Lessons: Value stream mapping the patient experience - huddle 68.1 70

WAIT WAIT/WALK WAIT / WALK WAIT WAIT/WALK 60 55.6 54.93 53.43 54.07 ROOMED VISUAL WALK ROOMED VISUAL 52.38 SIGN SIGN TRAINEE BY TRAINEE BY FIELDS 47.5 IN FIELDS IN 50 45.86 44.8 TECH TECH PT: 2 MIN WT: 3 MIN PT: 8 MIN WT: 5 MIN PT: 14 MIN WT: 12 MIN PT: 12 MIN Remote scribing 40 WAIT / WALK WAIT / 30 WALK Value-added Vs Waste 20 10 Vs WT: 20 MIN Value-added Waste WAIT ATTEND 0 WAIT / WALK WALK MD WAIT / WALK CHECK TECH Dec -Pre Mar April May June July Aug Se pt. Oct. Nov OUT WRAP-UP CHECK TECH ROOM / OUT WRAP-UP MD Overlap PT: 3 MIN PT: 4 MIN WT: 4 MIN PT: 12 MIN Congratulations *Photos with Haiku Modified from Aneesh Suneja Image credit: Artplusmarketing.com

Lean Final Thoughts

• Very positive journey for our team Change is the law of life. And those who look only to the past or present are certain to miss the future. • Our care of patients is improving John F. Kennedy • Our work is more creative and more enjoyable • Our mindset as a team has changed Image credit: Artplusmarketing.com • “Good idea…Let’s try it” • Performing at a higher level has made all of us hungry to keep improving Thank You! • “Wish we could have started this 20+ years ago!”

80 Practice Management Panel Sunday, June 28

2:36 – 2:48 pm Harnessing the Potential of Physician Extenders in Ophthalmic Plastic Surgery

Alon Kahana1, Julian D. Perry2 1Consultants in Ophthalmic & Facial Plastic Surgery, Ann Arbor, Michigan, United States, 2Cleveland Clinic Cole Eye Institute, Cleveland, Ohio, United States

2:48 – 2:54 pm Surgeon-owned Medical Spa – Lessons Learned over 2 Decades

Vikram Durairaj TOC Eye and Face, Austin, Texas, United States, Wong Eye Institute, Dell Medical School, University of Texas at Austin, Austin, Texas, United States

81 OMIC RISK MANAGEMENT Sunday, June 28

3 – 3:15 pm OMIC Risk Management: Electronic Medical Records Gone Bad: How Auto-Populate can Land You in Court

Ron W. Pelton Colorado Springs, Colorado, United States

Electronic Health Records (EHRs) can improve quality, safety and efficiency and reduces costs… but they often do not.

Learning Objectives:

1. Identify and discuss data entry problems and/or liability issues associated with EHRs.

2. Identify how risk might be introduced into the process with the “copy forward” and “auto-populate” functionality available in an EHR

3. Consider appropriate actions to reduce potential practice risk associated with the EHRs

4. Discuss methods to legally correct errors when discovered in the EHR.

82 POSTERS AND VIDEOS CME NOT AWARDED FOR POSTERS AND VIDEOS

1 A Modified Hughes Flap for Correction of Refractory Cicatricial Lower Lid Retraction with Concomitant Ectropion

Ying Chen1, Zakeya Al-Sadah2, Don O. Kikkawa3, Bradford W. Lee2 1Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, United States, 2Division of Oculofacial Plastic & Reconstructive Surgery, Bascom Palmer Eye Institute, Miami, Florida, United States, 3Division of Oculofacial Plastic & Reconstructive Surgery, Shiley Eye Institute, University of California, San Diego, San Diego, California, United States

Introduction: Correction of lower eyelid retraction commonly involves one or more techniques, including recession of the eyelid retractors, spacer grafts, horizontal lid tightening, and midface lifting.1 However, patients presenting with cicatricial lower lid retraction following prior eyelid surgery often have scarring and concomitant ectropion or entropion that cause unpredictable wound healing, recicatrization, and suboptimal outcomes. The modified Hughes tarsoconjunctival flap is typically used to repair full-thickness eyelid defects. Prior reports describe treating refractory lower lid retraction with a modified Hughes flap placed beneath the tarsus after full-thickness blepharotomy.1,2 We present our experience with a novel surgical technique for treating refractory cicatricial lower lid retraction using a modified Hughes flap above the tarsus after excision of the scarred lid margin.

Methods: Three patients were treated using this technique. The upper edge of the lower eyelid and associated scar tissue are excised. A modified Hughes flap is mobilized and secured above the posterior lamellar remnant. A full-thickness skin graft is placed over the flap. The flap is divided 4-5 weeks later.

Results: This surgical technique was employed in all three cases. All cases were revisional, with two having extensive multi-operative histories with multiple unsuccessful reconstructions and lid retraction repairs. All patients had improvement in cicatricial eyelid retraction, lagophthalmos, exposure keratopathy, and resolution of concomitant cicatricial ectropion. Case 3 required further orbital reconstruction after removing the infected orbital implant.

Conclusions: The technique of using a modified Hughes flap to reconstruct above the tarsus with excision of the scarred lid margin was effective in correcting refractory cicatricial lower lid retraction. This procedure can be considered in multi-operative cases in which traditional techniques for lower lid retraction repair have failed. Reconstructing a new lid margin reduces the risk of recicatrization and suboptimal results.

(continued) 83 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

References 1. Putterman AM. Lower eyelid full-thickness vertical lengthening. Am J Ophthalmol. 1979 Jul;88(1):113-8. PubMed PMID: 380349. 2. Anzeljc AJ, Saunders JA, Wojno TH. A modification to the Hughes tarsoconjunctival flap for a challenging case of recurrent lower eyelid retraction. Ophthalmic Plast Reconstr Surg. 2015 May-Jun;31(3):245-7. PubMed PMID: 25719372.

84 POSTERS AND VIDEOS

2 A Vision Threatening Reaction to Bone Wax After Orbital Decompression

Peter Timoney1, Stephen Ambrose2, Jason Sokol2 1Ophthalmology, University of Kentucky, Lexington, Kentucky, United States, 2Ophthalmology, University of Kansas, Prairie Village, Kansas, United States

Introduction: Bone wax is typically thought of as an inert hemostatic agent; however, we present the first case of a vision threatening reaction to bone wax.

Methods: Case review regarding a foreign body reaction to bone wax and a literature review of cases involving foreign body reactions to bone wax.

Results: A 73 year old male with a complex ocular history of Graves’ ophthalmopathy and secondary glaucoma underwent a bilateral three wall orbital decompression. Four months after decompression of the right side, he began experiencing signs of orbital inflammation and declining vision. A slit lamp examination demonstrated keratic precipitates, dilated episcleral veins, and increased conjunctival injection. The patient was seen four months post-operatively for surgical follow up where he was noted to have declining visual acuity to 20/70 OD. Four days later he was re-evaluated and found to have visual acuity of 20/250. During further work up for his acute vision loss, imaging revealed orbital inflammation predominantly along the deep temporal and supraorbital extraconal orbit. A maxillofacial computed tomography scan showed a small osseous defect at the sphenotemporal buttress containing a hypodense material. In comparison with MR imaging, this same material was noted to be hypointense on the T1-weighted sequence consistent with bone wax. To further confirm, this area was then biopsied. Pathology results from the biopsy revealed an amorphous material within the soft tissue that was birefringent on polarized microscopy suggestive of beeswax. The overall findings were consistent with a foreign body giant cell reaction surrounding the beeswax material used intra-operatively.

Conclusions: This case highlights the potential for reactions to bone wax when used for hemostasis intra-operatively. Typically, bone wax is inert and while most cases do not cause a foreign body reaction, this case demonstrates the possibility of unforeseen negative outcomes. To date, only a handful of cases have been described showing injurious reactions to bone wax. Per the literature review, bone wax has had multiple adverse reactions including granulomatous inflammation in the orbit, chronic non-healing wounds and a nidus source for infection. However, the case presented above is unique in that it not only shows the orbital inflammation but also the potential for vision threatening reactions.

References 1. Adverse effects of bone wax in surgery of the orbit. - PubMed - NCBI. Accessed November 26, 2019. 2. Chronic, Symptomatic Orbital Inflammation Resulting From Retained Bone Wax. Accessed November 26, 2019. 3. Translation of bone wax and its substitutes: History, clinical status and future directions - ScienceDirect. Accessed November 26, 2019.

85 POSTERS AND VIDEOS

3 Changes in Eyelid Beauty through the Centuries

Michael Burnstine1,2 1Ophthalmology, USC Roski Eye Institute, Los Angeles, California, United States, 2Eyesthetica, Los Angeles, California, United States

Introduction: To examine eyelid beauty through the lens of art and time.

Methods: Review art in different civilizations to examine unifying principles of eyelid beauty from early civilizations to our present time. Civilizations examined include: ancient Egypt (3150-31 BC), ancient China (2100-221 BC), Maya/Aztec civilization (2000BC-16th century), Rama empire (10000-2500 BC), ancient Greece (800-146 BC), and Inca civilization (1200-1542 AD).

Results: There are unifying principles of beauty in multiple civilizations. These include mathematical proportions, facial harmony, and facial symmetry.

Conclusions: As oculofacial surgeons, we must be learned in the science of beauty, aware of multicultural influences affecting our patient’s changing perceptions of eyelid beauty, and we must listen to our patients to meet their goals.

Figure 1 Figure 2 Figure 3

(continued) 86 POSTERS AND VIDEOS

(continued) Figure 4 Figure 5

References 1. Etcoff N. Survival of the PRettiest: The Science of Beauty. New York. Doubleday, 1999. 2. Adamson PA, Doud Galli SK> Modern concepts of beauty. Curr Opin Otolaryngol Head Neck Surg 2003; 11:295-300.

87 POSTERS AND VIDEOS

4 Complete Necrosis of a Dermis Fat Graft in an Anophthalmic Socket

Natalie Homer1, Aliza Epstein1, Marie Somogyi1,2 1TOC Eye and Face, Austin, Texas, United States, 2Wong Eye Institute, Dell Medical School, University of Texas at Austin, Austin, Texas, United States

Introduction: Dermis fat grafts are commonly used in anophthalmic socket reconstruction to replace orbital volume with an intrinsic vascular supply. In cases of traumatized, irradiated, and contracted sockets, a paucity of conjunctival tissue and delayed graft epithelialization may limit graft viability.

Methods: We present a patient with extensive post-traumatic periocular scarring, who developed complete dermis fat graft necrosis following enucleation.

Results: A 52-year-old man with a remote history of extensive trauma requiring multiple facial and orbital fracture repairs and a traumatic left globe rupture presented for evaluation of a left blind painful eye and inability to maintain his scleral shell. On examination, he had no-light-perception vision and a phthisical left globe with limited motility, contracted conjunctival fornices and palpable orbital rim hardware (Figure 1).

The patient opted to proceed with enucleation. Intraoperatively, he was found to have extensive conjunctival cicatrization with significant inferior forniceal shortening and scarred extraocular muscles. A dermis fat graft was utilized, and the minimal remaining conjunctiva was secured to the graft dermis with slight overlap using absorbable sutures. One-week post-operatively, the tarsorrhaphy was removed and the patient was found to have appropriate healing. At post-operative month one, the patient was found to have white liquification of the orbital graft (Figure 2A). The necrotic tissue was debrided and cultured. Histopathologic analysis confirmed necrotic fibroadipose tissue with marked acute inflammation and the culture was positive for proteus mirabilis. The patient was placed on oral antibiotic therapy and underwent serial socket debridement, orbital irrigation and iodoform-packing, which progressed to eventual complete graft necrosis (Figure 2B-C). Further reconstructive options were discussed, including split-thickness skin graft and free flap, but the patient declined further treatment. Spontaneous socket granulation ensued with local wound care (Figure 3).

Conclusions: Dermis fat grafts are preferentially utilized following extensive orbital trauma, given the risks of implant extrusion.2-5 While these autologous grafts are ideally suited for the contracted socket, graft necrosis can be seen in up to 17.7% of cases.3 Graft viability can be negatively affected by systemic vascular disease, trauma history, excessive cautery to the graft bed, oversized grafts, and post- operative infection.1,6 Minimizing surgical manipulation of the fatty graft component and avoiding use of conformer and tarsorrhaphy have been proposed to reduce risk of ischemia.6,8,9 A delayed epithelialization of 12-16 weeks, compared to the normal 8-10 weeks, with prolonged dermal surface exposure, is proposed to explain worse graft survival in contracted sockets.1,6 (continued) 88 POSTERS AND VIDEOS

(continued) In our case, complete graft necrosis likely occurred from limited recipient vascular supply, poor conjunctival overlap of the graft, and delayed epithelialization. A conformer and tarsorrhaphy was utilized in our case with the goal of optimizing the fornicies and eventual prosthesis fitting, though may have further exacerbated pressure-induced ischemia.

Management of dermal fat graft necrosis should include complete debridement of necrotic tissue and culture for infection. Infection treatment with antimicrobials should be immediately initiated. Subsequent orbit rehabilitation may involve secondary-intention granulation, split-thickness facial flaps, or free flaps in cases of complete orbital soft tissue necrosis. Our patient declined further treatment and opted for secondary-intention granulation of the socket.

Figure 1 Figure 2

References 1. Shore, J. W., McCord, C. D., Bergin, D. J., Dittmar, S. J., Maiorca, J. P., & Burks, W. R. (1985). Management of Complications Following Dermis-Fat Grafting for Anophthalmic Socket Reconstruction. Ophthalmology, 92(10), 1342–1350. 2. Al-Mujaini A, Ganesh A, Al-Zuhaibi S. Autogenous Dermis-Fat Orbital Implant for Anophthalmic Socket. Sultan Qaboos Univ Med J. 2007 Aug;7(2):145-148 3. Galindo-Ferreiro, Alicia, Khandekar, Rajiv, Hassan, Sultan Al, Al-Hammad, Fatimah, Al-Subaie, Hamad, Artioli Schellini, Silvana. (2018). Dermis-fat graft for anophthalmic socket reconstruction: indications and outcomes. Arquivos Brasileiros de Oftalmologia, 81(5), 366-37 4. Betharia SM, Patil ND. Dermis fat grafting in contracted socket. Indian Journal of Ophthalmology. 1988. 36(3):110-112 5. Dermis fat grafts ideal in complex socket reconstruction. Ophthalmology Times. 2005 March. 6. Bosniak SL. Avoiding Complications Following Primary Dermis-Fat Orbital Implantation. Ophthalmic Plast Reconstr Surg. 1985;1(4):237-241 7. Przybyla VA, La Piana FG, Bergin DJ. Fitting the dermis-fat graft socket. Ophthalmology. 1981;88:904-907 8. Starks, V., Freitag, S. K. (2017). Postoperative Complications of Dermis-Fat Autografts in the Anophthalmic Socket. Seminars in Ophthalmology, 33(1), 112–115

89 POSTERS AND VIDEOS

5 Congenital Cystic Eye with Multiple Dermal Appendages presenting in a Newborn

Krishna Patel, Ted Wojno Ophthalmology, Emory Eye Center, Atlanta, Georgia United States

Introduction: Congenital cystic eye with dermal appendages is an extremely rare diagnosis. An orbital cyst results from failure of the invagination of the optic vesicle during week four of gestation, and dermal appendages are believed to be from failure of normal coalescence of the facial buds during week six of gestation. This diagnosis can be characterized from microphthalmia with cyst, which is an abnormality in closure of the embryonic fissure.1 Diagnosis is made pathologically, as congenital cystic eye has no remnant ocular tissue or ectodermal structures. Patients with congenital cystic eye may have other systemic findings, such as facial clefting, saddle nose, choanal atresia, agenesis of the corpus callosum, and bifid thumb.2 To our knowledge, there are only three previously reported cases of congenital cystic eye with dermal appendages.

Methods: Case report: Case 1: Patient with biopsy proven diagnosis of congenital cystic eye with dermal appendages. Literature review on PubMed was performed with keywords “congenital cystic eye,” “dermal appendages,” and “anophthalmos/microphthalmos with cyst.”

Results: A one day old female was transferred to our facility from an outside hospital with a large orbital mass protruding from the right orbit and several dermal appendages on her face and neck (Fig 1). She was born at 36 weeks gestation to healthy, nonconsanguineous parents. Mother had poor prenatal care.

An MRI was done immediately which showed large multiloculated cystic mass 4.6 x 3.5 x 3.9 cm in size with thinned right optic nerve and decreased volume on the right aspect of the optic chiasm. MRI also showed several cranial findings such as dysplastic features of the right cerebral and cerebellar parenchyma and agenesis of the corpus callosum (Fig 2).

On day 11, patient was taken to the operating room for excision of right orbital mass and dermal appendages. The lesions were sent for pathology, and due to lack of remnant ocular tissue and lack of ectodermal structures, diagnosis of congenital cystic eye with dermal appendages was made (Fig 3, 4).

Conclusions: The diagnosis of congenital cystic eye is made histopathologically by lack of ocular remnants and ectodermal structures seen. Immediate treatment of the cyst is dependent on the age of the child as well as size of the cyst. Aspiration of the cyst has a high risk of recurrence, and the cyst should be removed promptly in cases of rupture or spontaneous hemorrhage. Sclerotherapy can also be considered for treatment of orbital cysts.3 Our patient underwent excision of the mass due to size and anterior prolapse of the cyst as well as risk for infection. The patient is currently being followed with placement of serial conformers by an ocularist.

(continued) 90 POSTERS AND VIDEOS

(continued) To our knowledge, there are fewer than 30 cases of congenital cystic eye reported, and only three previous cases of congenital cystic eye with dermal appendages.

Figure 1 Figure 2 Figure 3 Figure 4

References 1. Pasquale L, et al. “Congenital cystic eye with multiple ocular and intracranial anomalies.” ArchOphthalmol. 1991; 109: 985-87 2. Gupta P, et al. “Congenital cystic eye with multiple dermal appendages: a case report.” BMC Ophthalmology. 2003; 3 3. M.N. Naik, S.G. Honavar, R.K. Murthy, K. Raizada, R. Thomas.”Ethanolamine oleate sclerotherapy versus simple cyst aspiration in the management of orbitopalpebral cyst associated with congenital microphthalmos.” Ophthal Plast Reconstr Surg. 2007; 23: 307-311

91 POSTERS AND VIDEOS

6 Difficult Case: Lower Lid Reconstruction with Combined Tarsoconjunctival and Paramedian Forehead Flaps

Raymond Cho1, Trevor Hodson2 1Department of Ophthalmology and Visual Science, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States, 2The Ohio State University College of Medicine, Columbus, Ohio, United States

Introduction: A 43-year-old woman with a history of adenoid cystic carcinoma of the left maxillary and ethmoid sinuses (stage T4aN0M0) presented with hypotropia and total loss of the left lower lid following tumor resection, adjuvant radiation, and orbital implant infection/extrusion.

Methods: Difficult case presentation

Results: The patient underwent removal and replacement of the infected orbital implant with a customized titanium implant and reconstruction of the lower lid with a temporoparietal fascia flap covered anteriorly with a full-thickness skin graft and posteriorly with a buccal mucous membrane graft. The lid reconstruction failed over 12 months, necessitating another reconstruction with a combined tarsoconjuncitval flap and paramedial forehead flap. The reconstruction was stable at three months postoperatively, but the patient experience recurrence of the adenoid cystic carcinoma with orbital invasion, necessitating subsequent orbital exenteration.

Conclusions: This case demonstrates several complications that can arise in patients who undergo radical resection of sinonasal tumors with subsequent reconstruction and postoperative radiation. Multiple surgical procedures were required to address the patient’s deficit, but ultimately the initial tumor triumphed.

Figure 1 Figure 2 Figure 3 Figure 4

(continued) 92 POSTERS AND VIDEOS

(continued) References 1. Hughes WL. Total lower lid reconstruction: technical details. Tr Am Ophth Soc 1976;74:321-9. 2. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg 1993;91:1017-24 3. Paridaens D, van den Bosch W. Orbicularis Muscle Advancement Flap Combined with Free Posterior and Anterior Lamellar Grafts. Ophthalmology. 2008;115(1):189-194. 4. Elliot D, Britto JA. Tripier’s innervated myocutaneous flap 1889. Br J Plast Surg 2004;57:543-9. 5. Cullen KW, Meyer M. Eyelid reconstruction using temporalis fascia. Ophthal Plast Reconstr Surg 1989;5:271-3. 6. Hallock GG. Reconstruction of a lower eyelid defect using the temporalis muscle. Ann Plast Surg 1984;13:157-62. 7. Price DL, Sherris DA, Bartley GB, Garrity JA. Forehead flap periorbital reconstruction. Arch Facial Plast Surg 2004;6:222-7. 8. Brodland DG. Paramedian forehead flap reconstruction for nasal defects. Dermatol Surg 2005;31:1046-52.

93 POSTERS AND VIDEOS

7 Graded Transantral Orbital Decompression in Stable Thyroid Eye Disease

Michael Burnstine1,2, Jonathan Lu1 1Ophthalmology, USC Roski Eye Institute, Los Angeles, California, United States, 2Eyesthetica, Los Angeles, California, United States

Introduction: To provide outcome data for transantral orbital decompression for functional and aesthetic rehabilitation for exophthalmos in stable thyroid eye disease (TED)

Methods: Retrospective, non-comparative chart review of consecutive TED patients who underwent primary graded transantral orbital decompression for exophthalmos by a single surgeon (MAB) between 2005 and 2018. Additional inclusion criteeria included follow-up greater than 90 days and no prior orbital surgery. Outcome data included millimeters of proptosis reduction, postoperative complications, and patient satisfaction.

Results: A total of 47 orbits in 30 patients were included. Average proptosis reduction was 2.8mm (range 0-9mm). Cosmetic imporvement was reported in 14/14 orbits with relief of orbital achech in 10/10 patients. Patient satisfaction survey score was 8.9/10 (rang 4-10; median: 10)

Conclusions: Graded transantral orbital decompression is a viable option for stable TED patients with orbital ache, exophthalmos, and exposure keratopathy, resulting in a high degree of functional and cosmetic satisfaction in our cohort.

Figure 1 Figure 2

References 1. Walsh TE, Ogura JH (1957). Transantral orbital decompression for malignant exophthalmos. Laryngoscope; 67, no 6. 2. Edirwickrema LS, Korn BS, Kikawa DO (2018). Orbital decompression for thyroid-related orbitopathy during the quiescent phase. OPRS. May 2018. 3. Rootman DR (2018).Orbital decompression for thyroid eye disease. Survey of Ophthalmology 2018; 63: 86-104. 94 POSTERS AND VIDEOS

8 Histopathology of Hydrolyzed Hydrogel Scleral Buckles

Natalie Wolkow1,2, Frederick A. Jakobiec2 1Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear/Harvard Medical School, Boston, Massachusetts, United States, 2David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Mass Eye and Ear/Harvard Medical School, Boston, Massachusetts, United States

Introduction: Previous studies of explanted hydrolyzed hydrogel scleral buckles have focused on the capsules surrounding the implants rather than on the implant material; the goal of this study was to histopathologically characterize hydrolyzed hydrogel scleral buckles to assist in distinguishing them from other orbital and periorbital foreign materials.

Methods: The study was submitted to the Partners IRB and was exempt from review. Explanted fragments from 3 hydrolyzed hydrogel scleral buckles that had been submitted to the Mass Eye and Ear Ophthalmic Pathology laboratory between 2017 and 2019 for gross examination were processed and embedded in paraffin. Five micron sections were stained with the hematoxylin and eosin, Alcian blue, periodic acid-Schiff, Masson trichrome and elastic stains. Corresponding clinical charts and radiographs were reviewed.

Results: Fragments from 3 scleral buckles were examined. Two had been explanted after 24 years, and one had been explanted after 35 years; all had significantly enlarged and were causing orbital mass effect and pain (Figure, A). With hematoxylin and eosin staining, some areas displayed an amphiphilic well-organized honeycomb array (Figure, B), while other areas were more amorphous and lacked definition (Figure, C). The centers and walls of the honeycomb arrays were strongly positive with the periodic acid-Schiff stain (Figure, D) and the walls of the honeycomb arrays prominently stained with the Alcian blue stain (Figure, E). No inflammatory cells were seen within the hydrolyzed implants.

Conclusions: Earlier studies have focused on capsules surrounding hydrogel implants, which often display a foreign-body giant cell reaction; however, the implants themselves had not been well characterized. hydrogel scleral buckles have a unique histopathologic appearance, and stain strongly with periodic acid-Schiff and Alcian blue stains, helping to distinguish them from other orbital foreign materials.

(continued) 95 POSTERS AND VIDEOS

(continued) Figure 1

References 1. D’Hermies F, Korobelnik JF, Savoldelli M, Chauvaud D, Pouliquen Y. Miragel versus silastic used as episcleral implants in rabbits. An experimental and histopathologic comparative study. Retina. 1995;15(1):62–67. 2. D’Hermies F, Korobelnik JF, Caputo G, et al. Encapsulation of scleral buckling materials. A study of sixty specimens. Ophthalmology. 1998;105(6):1079–1086. 3. D’Hermies F, Korobelnik JF, Chauvaud D, Pouliquen Y, Parel JM, Renard G. Scleral and episcleral histological changes related to encircling explants in 20 eyes. Acta Ophthalmol Scand. 1999;77(3):279–285. 4. D’Hermies F, Korobelnik JF, Meyer A, Chauvaud D, Pouliquen Y, Renard G. Experimental encircling scleral buckle with silicone and hydrogel: histopathologic and comparative study of 26 rabbit eyes. Retina. 1999;19(2):148–157. 5. Roldan-Pallares M, LLanes-Estrada M, LLanes-Menendez F. MIRAgel: the immunohistochemical expression of CD3, CD34, and CD68 in the surrounding capsule. Eye (Lond). 2016;30(10):1381–1388. 6. Lai YC, Mirani NM, Langer PD, Bhagat N. Infiltration of hydrogel implant into the sclera with calcification: a case report with histologic findings. Can J Ophthalmol. 2016;51(6):e187–e189.

96 POSTERS AND VIDEOS

9 Long-term Outcomes of Porcine Acellular Dermal Matrix Grafts for Eyelid Retraction

Sanja Cypen, Andrea Tham, Kayla White, Jeremiah Tao Ophthalmic Plastic & Reconstructive Surgery, University of California, Irvine, Irvine, California, United States

Introduction: Porcine acellular dermal matrix (PADM) grafts are an option in eyelid reconstruction and obviate second surgical site morbidity with autologous grafts, such as hard palate or ear cartilage.1 Several studies have reported short term success with the use of PADM grafts in eyelid surgery.2 Here, we report for the first time, long-term outcomes and characteristics of PADMs implanted to the eyelids.

Methods: We performed a retrospective chart review of patients treated with PADM grafts for repair of eyelid retraction at a single institution between May 2009 and November 2019. Only patients with a minimum of 6 months follow-up were included. The primary outcome was improvement in lower eyelid position. Secondary outcomes were need for further surgical intervention, subjective improvement in symptoms, and complications such as implant rejection or resorption.

Results: We identified 64 eyelids in 38 patients who were treated for eyelid retraction. The average age of patients was 70.6 years. Fourteen of the 38 patients (36.8%) were male. The mean follow-up time was 19.2 months. The primary etiology of eyelid retraction included: thyroid eye disease in 20 (31.2%) eyelids, involutional in 18 (28.1%), cicatricial in 16 (25%), post-traumatic in 1 (1.6%), and post- blepharoplasty in 1 (1.6%). The etiology was not documented in 8 (12.5%) eyelids. Successful retraction repair was achieved in 43 (67.2%) eyelids. Additional surgery was required in 21 (32.8%) eyelids, including further eyelid reconstruction with canthoplasty, hard palate graft or both. In these cases, resorption of the graft was evident clinically. Two eyelids (3.1%) required removal of the spacer graft due to chronic swelling in one case and scarring of the lower eyelid making the graft obsolete in the second case.

Conclusions: PADM grafts were safe and well-tolerated in this retrospective series with long-term follow-up data. Several eyelids had regression of retraction repair effect and graft resorption was evident in several cases. Explantation for inflammatory reaction was a rare adverse event.

References 1. Symbas, J, McCord, C, Nahai, F. Acellular Dermal Matrix in Eyelid Surgery. Aesthet Surg J. 2011;31(7 S):101S-107S. 2. Tao, JP, et al. Bioengineered Acellular Dermal Matrix Spacer Grafts for Lower Eyelid Retraction Repair. A Report by the American Academy of Ophthalmology. Ophthalmology. 2019 Dec 30. Epub ahead of print.

97 POSTERS AND VIDEOS

10 Ocular Sarcoidosis presenting as Isolated Chalazion

Peter Timoney, Eric Peterson Department of Ophthalmology and Visual Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, United States

Introduction: To illustrate a case of ocular sarcoidosis initially presenting clinically as a chalazion, with pathology ultimately returning as non-necrotizing granulomatous inflammation consistent with sarcoidosis.

Methods: We report a case of a 62-year-old African American male referred to our oculoplastic service for a single right lower eyelid nodule. The patient reported acute onset 3 months prior to arrival. Clinical course was marked by swelling and inflammation, consistent with a chalazion. Given the size, a recommendation for excisional biopsy in the operating room was made.

Results: Histology returned with non-necrotizing granulomatous inflammation, consistent with sarcoidosis in light of negative infectious studies. Thus far, the patient is healing appropriately. The patient has been referred for a systemic sarcoidosis investigation

Conclusions: Sarcoidosis is a multisystem disease of granulomatous inflammation well-known for its dramatic variability in both initial and subsequent manifestations. Despite such dramatic variability, to our knowledge, this is the first reported case of ocular sarcoidosis presenting as a chalazion, and among few presenting as isolated eyelid lesions. Although ocular and cutaneous manifestations of systemic sarcoidosis are common sites of extrapulmonary involvement, eyelid involvement is rare. A few cases of sarcoidosis presenting as isolated eyelid lesions were found, however none exhibited signs or symptoms concerning for a chalazion. This case report seeks to add yet another layer of possibility to the increasingly complex nature of this systemic disease. While clinical decisions should not be unduly affected by a single report, this case should encourage appropriate consideration of a diagnosis of sarcoidosis in the right clinical setting.

(continued) 98 POSTERS AND VIDEOS

(continued) Figure 1

References 1. Rajput R, et al. Periocular cutaneous sarcoid: case series and review of the literature. Eye (Lond). 2019;33(10):1590–1595. doi:10.1038/s41433-019-0448-5 2. Hall JG, Cohen KL. Sarcoidosis of the Eyelid Skin. Am J Ophthalmol. Volume 119, Issue 1, January 1995, Pages 100-101 3. Cacciatori M, McLaren KM, Kearns PP. Sarcoidosis presenting as a cutaneous eyelid mass. Br J Ophthalmol. 1997;81(4):329–330. doi:10.1136/bjo.81.4.329a 4. Jabs DA, Johns CJ. Ocular involvement in chronic sarcoidosis. Am J Ophthalmol. 1986 Sep 15; 102(3):297-301. 5. Ungprasert P, Tooley AA, Crowson CS, Matteson EL, Smith WM. Clinical Characteristics of Ocular Sarcoidosis: A Population-Based Study 1976-2013. Ocul Immunol Inflamm. 2019;27(3):389–395. doi:10.1080/09273948.2017.1386791. 6. Judson MA, Boan AD, Lackland DT. The clinical course of sarcoidosis: presentation, diagnosis, and treatment in a large white and black cohort in the United States. Sarcoidosis Vasc Diffuse Lung Dis. 2012;29(2):119–127.

99 POSTERS AND VIDEOS

11 Orbital Complication Secondary to Vitreoretinal Surgery

Guillermo Salcedo1,2, Ariel Ceriotto3, Ana Bety Enriquez4 1Orbit and Oculoplastics Department, Asociacion Para Evitar la Ceguera en Mexico Hospital, Mexico, Mexico, 2Orbit and Oculoplastics, Clinica de Ojos ondesa, Mexico, Mexico, 3Asociacion Para Evitar la Ceguera en Mexico Hospital, Mexico, Mexico, 4Retina, Asociacion Para Evitar la Ceguera en Mexico Hospital, Mexico, Mexico

Introduction: orbital emphysema is frequently associated with trauma, orbital or sinonasal surgery. The loss of continuity of one or more orbital bones enables the communication between the sinus and orbit. The presence of orbital enphysema without an associated orbital fracture has ben described.

In this study we describe the findings of a retrospective review of medical records of patients who underwent vitreoretinal surgery and developed secondary orbital enphysema as a complication.

Methods: Patients diagnosed with orbital emphysema due to vitreoretinal surgery that were followed and treated between January 2006 and October 2018 at tertiary cara ophthalmological referral center in Mexico City were identified using lectronical medical records.

Inclusion critria encompassed clinical diagnosis of orbital emphysema and orbital computed tomography. Minimum follow-up of 3 months was required.

Results: In the period comprised between January 2006 and October 2018, 21441 vitreoretinal surgeries were performed in our institution. sixten patients resented orbital emphysema and fulfilled the inclusion criteria. The incidence of orbital emphysema secondary to vitreoretinal surgery corresponded to 0.074%.

Fiffty percent of patients (8) were female nine eyes presentes the complication in the left eye. Two patients developed emphyema in the single functional eye, and none of the patients presented the complkcation bilaterally.

Twenty-five percent (4 patients) had a history of previous ocular trauma, and 43.75% (7 patients) had undergone previous ocular surgeries. twenty five percent of cases (4 patients ) underwent pars plana vitrectomy, 50% (8 patients) encircling escleral buckling + PPV. All the patients that received scleral buckles had solid silicone bands. In 56.25% of surgeries (9 patients) perfluorocarbon liquid was required. Sixty two percent of cases (10 patients) received silicone oil as a endotamponade, 12.5% (2 patients) C3F8 gas, 6.25% (1 patient) SF6 gas, 6.25% (1 patient) air, 6.26% (1 patient) an unespecified gas.

(continued) 100 POSTERS AND VIDEOS

(continued) Only 25% of cases (4 patients) showed resolution of orbital emphysema, with a mean duration of 202 days. 12.5% (2 patients) had a significant improvement in VA, and 18.75% (3 patients) ended up with no light perception.

Conclusions: There are several hypotheses that attempt to explain the pathophysiology of the presence of air whitin the orbital cavity after vitreoretinal surgery. The evolution of our cases compared to previously described reports is different and took more time to resolve.

Most of the patients that were included in this study showed an adverse evolution despite the multiple treatment alternatives offered.

Figure 1 Figure 2 Figure 3 Figure 4

References 1. Moon H, Kim Y, Wi JM, Chi M. Morphological characteristics and clinical manifestations of orbital emphysema caused by isolated medial orbital wall fractures. Eye. Apr 2016;30(4):582-587. 2. Zimmer-Galler IE, Bartley GB. Orbital emphysema case report and review of the literature. Mayo Clinic proceedings. Feb 1994; 69(2):115-121. 3. Rodriguez-Cabrera L, Rodriguez-Loaiza JL, Tovilla-Canales JL, Zuazo F. Orbital Emphysema as a Rare Complication of Retina Surgery. Ophthalmic plastic and reconstructive rurgery. Nov/Dic 2017;33(6): e141-e142.

101 POSTERS AND VIDEOS

12 Out of Sight Out of Mind: Masquerading Recurrent Unilateral Aponeurotic Ptosis

Daniel Ozzello, Zvi Gur, Catherine Liu, Bobby Korn, Don Kikkawa Department of Oculofacial Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, California, United States

Introduction: To describe the case of a patient with unilateral ptosis recurrent after multiple surgical repairs who was eventually found to have an alternative diagnosis.

Methods: A 64-year-old male with history of hypertension presented to the oculoplastics clinic with a chief complaint of left upper eyelid ptosis. Four years prior, he had undergone uncomplicated bilateral upper eyelid blepharoplasty. He noticed the slow development of left upper eyelid ptosis blocking his vision, but he was also bothered by bilateral brow ptosis. He underwent bilateral endoscopic brow ptosis repair, repeat bilateral upper eyelid blepharoplasty, and left upper eyelid ptosis repair by internal levator advancement. He was initially happy with his post-operative result, but by post-operative week six he had re-developed left upper eyelid ptosis. He was referred to another provider who performed an uncomplicated external levator advancement on the left. However, eyelid height worsened post- operatively. The patient was then referred to our service.

Results: The patient was evaluated. Vision was 20/30 and 20/20, extraocular motility was full, pupillary exam revealed no anisocoria or relative afferent defect, and intraocular pressures were normal. Anterior segment evaluation was unremarkable. He was noted to have ptosis on the left with an MRD1 of 1mm, compared to 5mm on the right. Levator function was normal and symmetric at 12mm bilaterally. He was found to have slight fullness of the superior orbit on the left with 1.5mm of proptosis relative to the right side. Magnetic resonance imaging showed no definite orbital masses or extraocular muscle enlargement. He was taken to the operating room for left orbital exploration. Intraoperatively, he was noted to have a mass deep to the levator muscle, which was biopsied. An external levator advancement was also performed. Histopathologic examination of the mass revealed an infiltrative mass. Repeat imaging during the post-operative period revealed moderate enlargement of the left levator palpebrae muscle consistent with infiltration. He was referred for systemic workup.

Conclusions: Isolated unilateral ptosis is a rare presentation of orbital or ocular adnexal infiltrative process. Alternative diagnoses should be considered when apparent aponeurotic ptosis recurs after uncomplicated surgery.

(continued) 102 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3

References 1. Abalo-Lojo JM, Baleato-Gonzalez S, Abdulkader I, Gonzalez F. Extraocular muscle involvement in MALT lymphomas. Orbit. 2011;30(4):186-188. 2. Ben Salah R, Kammoun S, Frikha F, et al. Disseminated lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy. Eur J Ophthalmol. 2019:1120672119873275. 3. Eade EL, Hardy TG, McKelvie PA, McNab AA. Clinicopathological Features and Outcomes in Lymphoma of Extraocular Muscles. Ophthalmic Plast Reconstr Surg. 2019;35(6):615-618. 4. Gupta V, Kumar M, Gupta SK. Ptosis: a rare presentation of Hodgkin lymphoma. J Pediatr Hematol Oncol. 2014;36(2):163-165. 5. Hsu MW, Chung CH, Chang CH, Hu PS, Hsu SL. Ptosis as an initial manifestation of orbital lymphoma: a case report. Kaohsiung J Med Sci. 2006;22(4):194-198. 6. Izambart C, Robert PY, Petellat F, et al. Extraocular muscle involvement in marginal zone B-cell lymphomas of the orbit. Orbit. 2008;27(5):345-349. 7. Latting MW, Huggins AB, Marx DP, Giacometti JN. Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions. Semin Plast Surg. 2017;31(1):5-16. 8. Lueangarun S, Auewarakul CU. Diffuse large B cell lymphoma presenting as Horner’s syndrome in a patient diagnosed with neurofibromatosis type 1: a case report and review of the literature. J Med Case Rep. 2012;6:8.

103 POSTERS AND VIDEOS

13 Polytetrafluoroethylene Frontalis Suspension in Blepharospasm with Eyelid Apraxia

Adam Sweeney, Christopher Dermarkarian, Katherine Williams, Richard Allen, Michael Yen Baylor College of Medicine, Houston, Texas, United States

Introduction: The purpose of this study is to report on the efficacy of polytetrafluoroethylene (PTFE) frontalis suspension for blepharospasm with eyelid apraxia and postoperative botulinum toxin requirements.

Methods: Retrospective chart review of patients with blepharospasm and eyelid apraxia who underwent frontalis suspension. Patients less than 18 years of age, without postoperative follow-up, and with other conditions responsible for ptosis (i.e. congenital ptosis, nerve palsy, trauma, etc.) were excluded from the study. The primary outcome was surgical success, defined by surgeon and patient reported success in postoperative eyelid opening. Comparative statistical analyses of botulinum toxin dosage and treatment intervals were performed amongst patients before and after frontalis suspension ptosis repair.

Results: Five patients (10 eyelids) met the study criteria, of which 40% were female. Mean age was 63.2 years. All patients had successful surgical outcomes based on physician reported and patient reported satisfaction with the postoperative eyelid opening. Average follow- up was 14 months amongst study subjects. Preoperative botulinum toxin treatments averaged 80.4 units (range 32-110, SD 33.2) to the periocular region over an average of 9.6 week intervals. Postoperative botulinum toxin treatments averaged 61.4 units (range 24-110, SD 34.7) to the periocular region over an overage of 9.8 week intervals. No patients experienced postoperative exposure keratopathy, extrusion of the sling, or postoperative infection around the PTFE suture.

Conclusions: Frontalis suspension using PTFE suture in the setting of blepharospasm with eyelid apraxia is a safe and effective procedure. Frontalis suspension in this population is not a substitute for botulinum toxin treatment, but may allow for reduced treatment dosage. Frontalis suspension increases patient functionality with improved eyelid opening in patients with severe blepharospasm with eyelid apraxia.

104 POSTERS AND VIDEOS

14 Quantitative Assessment of Orbital Compliance and Soft Tissue Restriction: The Third Generation STORM Device

Benjamin Erickson1, Henry Bair2, David Tse3, Thomas Johnson4 1S, Byers Eye Institue, Palo Alto, California, United States, 2Stanford University School of Medicine, Palo Alto, California, United States, 3University of Miami Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, United States, 4University of Miami Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, United States

Introduction: We present design updates for a portable device and descriptive system permitting automated, quantitative assessment of orbital compliance and soft tissue restriction with emphasis on cadaveric models of orbital restrictive disease.

Methods: The previously described second-generation prototype had the capacity to map soft tissue resistance and range of motion via automated scanning of each orbit clock hour, with a color coded ‘heat map’ as output. It consisted of stacked piezoelectric motor stages — one rotational and one translational — coupled to a force sensing load cell via a 3D printed rail and shuttle system to generate an appropriate vector for reproducible globe manipulation. Ocular surface interface was via vacuum assisted suction, obviating the need for potentially traumatic grasping of conjunctiva/Tenon’s fascia. Despite promising early results, this platform permitted too many remaining degrees of freedom to deliver fully reproducible results. The third-generation device has been updated with a locking gooseneck swing arm, retaining rapid intraoperative positioning while eliminating potential user movement and neutralizing recoil force. It contains an additional force sensing element and third stage to provide full standardization of vertical pressures on the globe and orbital soft tissues. Device excursion was also increased in order to permit analysis of conditions impacting extremes of gaze. This updated device was tested in a cadaveric model of simulated iatrogenic entrapment with a bare titanium implant as well as with manipulations of the rectus muscles (suture plication and transection) to simulate intramuscular fibrosis and other traumatic conditions.

Results: The third-generation prototype was created and force versus excursion curves and 360 degree ‘heat map’ scans were produced with cadaveric simulation of iatrogenic entrapment and after resolution. Similar outputs were produced for the described rectus muscle manipulations.

Conclusions: The third-generation STORM (Soft Tissue of the Orbit Range of Motion analysis) device overcomes shortcomings of its predecessor with key design modifications to neutralize external forces and extend range of motion. The authors believe that this novel automated device and the accompanying 360 degree orbital compliance and soft tissue restriction ‘heat map’ is now ready for intraoperative testing and will be able to enhance the clinical management of fractures and other restrictive orbital disease, especially once normative data and deep learning algorithms have been integrated, as with core ophthalmic technologies such as optical coherence tomography.

105 POSTERS AND VIDEOS

15 Rapidly Progressive Adolescent Orbital Osteomas Change in Surgical Paradigm

Ann Tran1, Sefy Paulose2, Andrea Tooley1, Kyle Godfrey3, Michael Kazim1 1Oculoplastics and Reconstructive Surgery, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, New York, United States, 2Oculoplastics and Reconstructive Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States, 3Oculoplastics and Reconstructive Surgery, Weill Cornell Medical Center, New York, New York, United States

Introduction: Osteomas are the most common benign neoplasm of the paranasal sinuses and rarely extend to the orbit. The majority of osteomas are slow growing and asymptomatic requiring no further treatment. However, a small subset progress to rapidly produce functional deficits requiring surgical excision. The surgical approach to remove these lesions depends on size and location. With advancement in endoscopic skull base surgery, newer techniques serve as an alternative to open procedures to minimize surgical morbidity.

Methods: Retrospective case series of rapidly progressive osteomas in adolescent and young adult patients over 20 years describing their clinical presentation and surgical management.

Results: Three cases of orbital adolescent osteomas were identified. The mean age at presentation was 17.0 ± 2.6 years old, predominantly female (66%). The initial presenting symptoms included proptosis (100%), headaches (33%), epiphora (66%), upper eyelid ptosis (33%), diplopia (33% and acute dacryocystitis (33%). The lesions arose from both the ethmoid and frontal sinuses with extension into the orbit. Indications for surgical repair included signs of compressive optic neuropathy (66%), rapidly progressive growth (100%) and symptomatic diplopia (33%). A bifrontal craniotomy with complete resection was used in one of the cases, while the other two cases were removed with a multidisciplinary approach using endoscopic transnasal orbitotomy with either an additional lateral or medial orbitotomy. No postoperative complications occurred. All of the patients’ vision remained 20/20 without signs of recurrence six month to 4 years post-operatively.

Conclusions: While most osteomas are indolent in nature, a small subset, often in younger or adolescent patients, may be rapidly progressive. As the surgical techniques of advanced skull base surgery continues to evolve, a multidisciplinary approach should be considered for these challenging rapidly progressive lesions.

106 POSTERS AND VIDEOS

16 Recurrent Hyposphagma as Presenting Signs of Primary Localized Orbital Amyloidosis with Lateral Rectus Involvement

Jamie Schaefer1, Justin Harvey2, Jeffrey Voss3, John Nguyen2,4 1Ophthalmology, Brown University, Providence, Rhode Island, United States, 2Ophthalmology, West Virginia University, Morgantown, West Virginia, United States, 3Pathology, West Virginia University, Morgantown, West Virginia, United States, 4Otolaryngology, West Virginia University, Morgantown, West Virginia, United States

Introduction: Primary localized orbital amyloidosis is rare, with isolated involvement of extraocular muscle being even less common. We here in described a case of orbital amyloidosis involving the lateral rectus presenting with recurrent hyposphagma.

Methods: Results: A 77 year-old Caucasian woman presented with left eye irritation and recurrent subconjunctival hemorrhage for 2-3 years following cataract surgery (Figure 1A). She had no pain with eye movement or diplopia and denied having any trauma or Valsava maneuver associated with episodes of hemorrhages. The past medical history was significant for hypothyroidism, osteoarthritis, hypertension and allergic rhinitis, and osteopenia for which she controlled with medications. The vision was 20/25 OD and 20/20 OS, and there was no proptosis, motility restriction or pupillary abnormality. The slit lamp examination showed a 10x5mm patch of pink conjunctival mass overlying the lateral rectus insertion along with well position PCIOL, and the dilated fundus examination was unremarkable (Figure 1B). An orbital CT showed thickening of the left lateral rectus muscle with tendinous involvement and calcification (Figure 1C,D). An anterior orbitotomy with biopsy was performed to remove a pink gelatinous mass infiltrating the anterior portion of the lateral rectus. Histopathology revealed diffuse eosinophilic amorphous material that was highlighted by Congo red stain and had apple-green birefringence on polarized microscopy (Figure E-G). The patient had increased serum free Kappa/Lambda light chain ratio consistent with AL amyloidosis. A hematology evaluation included EKG, bone marrow biopsy, abdominal fat pad biopsy, and skeletal survey which were all unremarkable. The patient was treated with preservative-free artificial tears for surface lubrication and elected to manage via observation.

Conclusions: Very few cases of orbital amyloidosis affecting extraocular muscle have been described since the 1st description in 1987 by Gerd Holmstrom and Karl Nyman. While lacrimal gland is most commonly described, only 3.8% have been reported in isolated rectus involvement. Palpable mass, proptosis, diplopia, ocular displacement, and ptosis are common presenting symptoms of orbital cases, recurrent hyposphagma is commonly associated conjunctival involvement. Isolated involvement of the lateral rectus in amyloidosis is rare and should be considered in the differential of any extraocular muscle mass.

(continued) 107 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2

References 1. Holmstrom GE, Nyman KG. Primary orbital amyloidosis localised to an extraocular muscle. Br J Ophthalmol. 1987;71(1):32-33. doi:10.1136/bjo.71.1.32. 2. Erie J, Garrity J, Norman M. Orbital amyloidosis involving the extraocular muscles. Arch Op. 1989;107:1428-1429. 3. Ceviker N, Baykaner K, Akata F, Keskil S, Uluoglu O. Primary amyloidosis of an extraocular muscle. Neuro-ophthalmology. 1997;18(3):147-148. 4. Okamoto K, Ito J, Emura I, et al. Focal orbital amyloidosis presenting as rectus muscle enlargement: CT and MR findings. Am J Neuroradiol. 1998;19(9):1799-1801. 5. Banerjee S, Bogman J, Reuser TTQ. Amyloid deposition in the extraocular muscles. Orbit. 1999;18(2):105-106. doi:10.1076/orbi.18.2.105.2715. 6. Yıldız A, Yalçınoglu O, Cinel L, et al. Primary Localized Orbital Amyloidosis of an Extraocular Muscle: CT and MRI Findings. Clin Radiol Extra. 2002;57(10):37-39. doi:10.1053/crae.2002.0013. 7. Hamidi Asl K, Liepnieks JJ, Nunery WR, Yazaki M, Benson MD. Kappa III immunoglobulin light chain origin of localized orbital amyloidosis. Amyloid. 2004;11(3):179-183. doi:10.1080/1350-6120400000707. 8. Teoh SCB, Liew GC, Yap WM. Incidental hypoglobus: Primary amyloidosis of the superior rectus. Singapore Med J. 2006;47(1):65-67. 9. Paula J, Paula S, Cruz A, Chahud F. Superior Oblique Muscle Amyloidosis Mimicking Myositis. Ophthal Plast Reconstr Surg. 2008;24(1):77-79. doi:10.1097/ IOP.0b013e31815c9053. 10. Khaira M, Mutamba A, Meligonis G, Rose GE, Plowman PN, O’Donnell H. The use of radiotherapy for the treatment of localized orbital amyloidosis. Orbit. 2008;27(6):432- 437. doi:10.1080/01676830802350216. 11. Jeon CY, Jin SY, Jang JW, Kim US. A case of isolated primary amyloidosis in the medial rectus muscle. Graefe’s Arch Clin Exp Ophthalmol. 2013;251(1):395-396. doi:10.1007/s00417-011-1867-6. 12. Mora-Horna ER, Rojas-Padilla R, López VG, Guzmán MJ, Ceriotto A, Salcedo G. Ocular adnexal and orbital amyloidosis: a case series and literature review. Int Ophthalmol. 2016;36(2):281-298. doi:10.1007/s10792-015-0138-7. 13. Murchison AP, Bilyk JR, Savino PJ. Orbital amyloidosis masquerading as metastatic breast carcinoma. Ophthal Plast Reconstr Surg. 2014;30(6):e147-e149. doi:10.1097/ IOP.0b013e3182a74f62. 14. Monteiro MLR, Gonçalves ACP, Bezerra AMPS. Isolated primary amyloidosis of the inferior rectus muscle mimicking Graves’ orbitopathy. Einstein. 2016;14(4):553-556. doi:10.1590/S1679-45082016RC3744.

108 POSTERS AND VIDEOS

17 Recurrent Sebaceous Carcinoma with Multifocal, Diffuse Intra-epithelial Disease

Sandy Zhang-Nunes1, Eric Hamill1,2 1Ophthalmology, Roski Eye Institute, University of Southern California, Los Angeles, California, United States, 2Eyesthetica, Los Angeles, California, United States

Introduction: Sebaceous carcinoma is a rare, potentially lethal tumor of sebaceous glands. It is notable for its tendency to spread within the epithelium, making local excision difficult. Herein we report a case of sebacous carcicnoma with two recurrences over a four year period. The patient now has diffuse and multifocal areas of intraepithelial sebaceous carcinoma without evidence of invasive disease. Management options are discussed.

Methods: Case study.

Results: A fifty nine-year old female presented to an outside hospital with a left lower eyelid lesion of three years’ duration. Biopsy at that time showed squamous cell carcinoma of the left lower eyelid with pagetoid spread. She was referred to a tertiary care center. Her vision was 20/20 in both eyes. Her left lower eyelid was notable for a diffuse, erythematous lesion along the lid margin with madarosis (Figure 1). The remainder of the exam was within normal limits. The patient underwent excision by Mohs micrographic surgery, which required five stages to clear margins. Pathology at time of Mohs excision showed invasive squamous cell carcinoma arising in squamous cell carcinoma in situ. The resultant defect involved the majority of the left lower lid (Figure 2). Reconstruction was performed with a tarsoconjunctival flap. Two-and-a-half years later, the patient developed a red, ulcerated lesion on her left lower eyelid suspicious for tumor recurrence (Figure 3). A biopsy was performed which showed sebaceous carcinoma with pagetoid spread. Given the new diagnosis, the patient was taken to the operating room for lesion excision with conjunctival map biopsies. Histological examination of the lesion’s margins were reportedly clear but limited by crush artifact; the map biopsies were negative for tumor. A PET scan and sentinel lymph node biopsy were also performed, both of which were negative. Two years later, the patient again showed an area of erythema and ulceration at the left lateral canthus (Figure 4). Biopsy in clinic showed intra-epithelial sebaceous carcinoma without invasive disease. The patient was again taken to the operating room for lesion excision with conjunctival map biopsies. Pathology from the lesion showed intra-epithelial sebaceous carcinoma only; the majority of map biopsies on the lateral bulbar, forniceal, and palpebral conjunctiva of both the left upper and lower eyelids were positive for intra-epithelial sebaceous carcinoma without evidence of invasive disease. The patient’s vision remains 20/20 in both eyes.

Conclusions: Recurrent sebacous carcinoma is difficult to treat. Herein the authors discuss treatment options.

(continued) 109 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3 Figure 4

References 1. Shields CL, Naseripour M, Sheilds JA, et al. Topical mitomycin-C for pagetoid invasion of the conjunctiva by eyelid sebaceous gland carcinoma. Ophthalmology 2002;109:2129-2133. 2. Rudkin AK, Muecke JS. Mitomycin-C as adjuvant therapy in the treatment of sebaceous gland carcinoma in high-risk locations. Clin and Exp Ophthalmol 2009;37:352-356. 3. Khong JJ, Muecke J. Complications of mitomycin-C therapy in 100 eyes with ocular surface neoplasia. Br J Ophthalmol 2006;90:819-822.

110 POSTERS AND VIDEOS

18 Removal of a Large Apical Cavernous Hemangioma combining a Transcaruncular Approach and a Lateral Bone Flap with Endoscopic Transethmoidal Visualization

Seanna Grob1, Kenneth Krantz2, Kenneth Feldman2 1Ophthalmology, University of California, San Francisco, San Francisco, California, United States, 2Ophthalmology, Southern California Permanente Group, Santa Ana, California, United States

Introduction: Many techniques have been reported for removal of orbital tumors. Reports of endoscopic removal of orbital tumors has increased in the last decade.1-7 However, few reports discuss combined orbital and endoscopic transethmoidal approaches to orbital tumors,6-7 and no other reports specifically describe utilizing both a medial and lateral orbitotomy combined with sinus endoscopy. Herein, we present a unique case of the largest reported cavernous hemangioma removed using a combined orbital-sinus endoscopic approach.

Methods: Report of a case and surgical approach for tumor removal.

Results: A 69-year-old male presented with proptosis on the left. Clinical examination showed decreased visual acuity to 20/50, an afferent pupillary defect, decreased color vision, and 4-mm of exophthalmos without a bruit or change with Valsalva maneuvers on the left. MRI orbits showed a 3.0 x 2.1 cm intraconal mass inferomedially displacing the optic nerve and inferior rectus muscle superiorly and extending to the orbital apex, but not into the canal. (Figure 1) Diagnostic angiography was completed to rule out a solitary fibrous tumor or other highly vascular tumor. Findings were consistent with a cavernous hemangioma. Due to the size and location of the lesion, the tumor was removed using a combined approach — transcaruncular with a lateral orbitotomy bone flap as well as an endoscopic transethmoidal approach to visualize the dissection of the tumor at the orbital apex. (Figure 2-4) The tumor was then removed through the sinus (Figure 5) and the medial orbital wall was reconstructed with a nylon foil implant. On 6 month follow up, the patient remained stable with a mild improvement in visual acuity to 20/40.

Conclusions: A transcaruncular dissection with release of the lateral orbital wall combined with an endoscopic transethmoidal approach is a specialized technique for removal of large medial apical orbital masses. This surgical approach allows for improved exposure of the tumor as well as visualization of the apex for safe dissection away from critical structures such as extraocular muscles and the optic nerve. The orbital tumor can be rotated into the sinus for improved visualization of the attachments at the orbital apex, which can be carefully dissected free to allow for tumor removal through the orbit or the sinus. In our case, this allowed for complete excision without complications.

(continued) 111 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

References 1. Bleier BS, Castelnuovo P, Battaglia P, et al. Endoscopic endonasal orbital cavernous hemangioma resection: global experience in techniques and outcomes. Int Forum Allergy Rhinol. 2016 Feb;6(2):156-61. doi: 10.1002/alr.21645. Epub 2015 Dec 1. 2. Zoli M, Sollini G, Milanese L, et al. Endoscopic approaches to orbital lesions: case series and systematic literature review. J Neurosurg. 2020 Jan 3:1-13. doi: 10.3171/2019.10. JNS192138. [Epub ahead of print] 3. Ma J, Zhou B, Qian H, et al. Transnasal endoscopic resection of orbital cavernous hemangiomas: our experience with 23 cases. Int Forum Allergy Rhinol. 2019 Nov;9(11):1374-1380. doi: 10.1002/alr.22383. Epub 2019 Aug 23. 4. Curragh DS, Halliday L, Selva D. Endonasal approach to orbital pathology. Ophthalmic plast reconstr surg. 2018 Sep/Oct;34(5):422-427. doi: 10.1097/ IOP.0000000000001180. 5. Yao WC, Bleier BS. Endoscopic management of orbital tumors. Curr Opin Otolaryngol Head Neck Surg. 2016 Feb;24(1):57-62. doi: 10.1097/MOO.0000000000000215. 6. Wu W, Selva D, Jiang F, et al. Endoscopic transethmoidal approach with and without medial rectus detachment for orbital apical cavernous hemangiomas. Am J Ophthalmol.2013 Sep; 156(3):593-599. 7. Rimmer RA, Graf AE, Fastenberg JH, et al. Management of orbital masses: outcomes of endoscopic and combined approaches with no orbital reconstruction. Allergy Rhinol (Providence). 2020 Jan 14; 11:2152656719899922.doi: 10.1177/2152656719899922. eCollection 2020 Jan-Dec. 112 POSTERS AND VIDEOS

19 Safety of Laser Skin Resurfacing in Immunocompromised and Diabetic Patients

Natalie Homer1, Giovanni Campagna2, Anna Artymowicz3, Aliza Epstein1, Vikram Durairaj1,4, Tanuj Nakra1,4 1TOC Eye and Face, Austin, Texas, United States, 2Transitional Year Internship Program, Dell Medical School, University of Texas at Austin, Austin, Texas, United States, 3Preliminary Internal Medicine Internship, Dell Medical School, University of Texas at Austin, Austin, Texas, United States, 4Wong Eye Institute, Dell Medical School, University of Texas at Austin, Austin, Texas, United States

Introduction: Previous studies have reported anecdotal safety of facial laser resurfacing in the immunocompromised patient population, but this has yet to be scientifically assessed.1-3 We aimed to perform a large-scale review of patients who underwent full- face and periorbital laser skin resurfacing to evaluate for differences in adverse events among immunocompromised patients and diabetic patients.

Methods: A retrospective review of all patients who underwent laser skin resurfacing at a two outpatient surgery centers between 2010 and 2019 was performed. Treatment was administered using the fractional CO4 or with fractional Erbium laser (1-2 J), adjusted by patient Fitzpatrick skin type. All patients received perioperative antiviral medication. Prophylactic antibiotics were not administered. Infectious and other adverse complications within the first 3 months after surgery were recorded and compared between 3 patient groups: immunocompetent, immunocompromised, and diabetic. Patients were considered immunocompromised if they were on immunomodulatory medication, undergoing chemotherapy, or had history of splenectomy. Diabetes was determined by self-report. Infection was defined as any clinical sign of infection and a decision by the clinician to prescribe systemic antimicrobials. Other adverse events accessed included prolonged erythema, post-inflammatory hyperpigmentation, and scarring. Descriptive statistics were performed to compare patient groups.

Results: A total of 525 patient cases were identified, including 22 immunocompromised patients (Table 1), 21 diabetic patients, and 482 immunocompetent patients. Demographics compared similarly between the groups (Table 2). Post-laser infections were found in 1 (4.5%) immunocompromised patient, 1 (4.8%) diabetic patient, and 13 (2.7%) immunocompetent patients (Table 3). Patients were followed for a minimum three months post-laser. No significant difference in rate of infection was observed between the groups (P=0.35). Fourteen infections (93.3%) occurred within the first 2 weeks of laser resurfacing. Of those patients with infection, 6 (40.0%) had full-face treatment, 4 (26.7%) had periorbital and perioral treatment, 4 (26.7%) had periorbital treatment only, and 1 (6.7%) had perioral treatment only. Only 3 patients (20.0%) with suspected infection underwent wound culture, one of which was positive for Staphylococcus aureus (Table 3, Patient #9). This patient developed painful periorbital and perioral crusting and erythema and responded well to antibiotics (Figure 1). Another immunocompetent patient developed painful perioral erythema and papular eruption, treated successfully with oral clindamycin (Table 3, Patient #11; Figure 2). Rates of other adverse events, including prolonged erythema post-inflammatory hyperpigmentation and scarring was similar among the three patient groups (P=1, 0.21, 1, respectively). (continued) 113 POSTERS AND VIDEOS

(continued) Conclusions: This is the first study to statistically determine a lack of significant difference in infection risk or other common adverse events following laser skin resurfacing in immunocompromised and diabetic patients. Our results suggest that the compromised immunologic defense mechanisms and wound healing capabilities these patient groups do not directly infer worse laser-related complications. Laser skin resurfacing can be safely performed on these unique patient groups with adequate peri-operative antiviral prophylaxis and close post-operative monitoring.

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

(continued) 114 POSTERS AND VIDEOS

(continued) References 1. Sriprachya-Anunt S, Fitzpatrick RE, Goldman MP, et al. Infections complicating pulsed carbon dioxide laser resurfacing for photoaged facial skin. Dermatol Surg 1997;23(7):527-536.

2. Walia S, Alster TS. Cutaneous CO2 laser resurfacing infection rate with and without prophylactic antibiotics. Dermatol Surg 1999;25(11):857-861. 3. Metelitsa AI, Alster TS. Fractionated Laser Skin Resurfacing Treatment Complications: A Review. Dermatologic Surgery. 2010 March;36(3):299-306. 4. Ramsdell WM. Fractional carbon dioxide laser resurfacing. Semin Plast Surg. 2012;26(3):125–130.

115 POSTERS AND VIDEOS

20 The Center of the Tarsus (COT), an Alternate Location to Consider for Suture Placement during External Ptosis Repair

Norberto Mancera, Timothy Wells Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States

Introduction: To describe an alternative surgical approach to the external levator advancement procedure to improve upper eyelid contour outcomes.

Methods: Observational surgical outcomes.

Results: We found that a tarsus centered external ptosis repair may result in improved efficiency in obtaining a good eyelid height and contour. We also found that medial horizontal fixation of the levator aponeurosis, shifting it nasally, may be helpful in some cases.

Conclusions: Suture placement is critical for the ideal contour. This method might avoid the need for full thickness wedge resection or horizontal tightening in some settings. There are multiple approaches to address repair of blepharoptosis, with no single best answer.

Figure 1

(continued) 116 POSTERS AND VIDEOS

(continued) References 1. Thomas GN, Chan J, Sundar G, Amrith S. Outcomes of levator advancement and Müller muscle-conjunctiva resection for the repair of upper eyelid ptosis. Orbit. 2017 Feb;36(1):39-42. doi: 10.1080/01676830.2017.1279650. Epub 2017 Jan 27. PubMed [citation] PMID: 28129025. 2. Golbert M, Pereira FJ, Garcia DM, Cruz AAV. Contour Symmetry of the Upper Eyelid Following Bilateral Conjunctival-Müller’s Muscle Resection. Aesthet Surg J. 2017 Mar 1;37(3):269-275. doi: 10.1093/asj/sjw242. PubMed [citation] PMID: 28011464. 3. Ahn S, Lee H, Lee J, Park J, Park M, Baek S. Analysis of Surgical Outcome After Levator Advancement by Assessing Changes in Eyelid Contour. J Craniofac Surg. 2016 Jul;27(5):1147-50. doi: 10.1097/SCS.0000000000002694. PubMed [citation] PMID: 27258709. 4. Lee H, Lee JS, Chang M, Park M, Baek S. Analysis of lid contour change with aging in Asians by measuring midpupil lid distance. Plast Reconstr Surg. 2014 Oct;134(4):521e-9e. doi: 10.1097/PRS.0000000000000579. PubMed [citation] PMID: 25357046. 5. Kim CY, Son BJ, Lee SY. Functional centre of the upper eyelid: the optimal point for eyelid lifting in ptosis surgery. Br J Ophthalmol. 2015 Mar;99(3):346-9. doi: 10.1136/ bjophthalmol-2014-305101. Epub 2014 Sep 23. PubMed [citation] PMID: 25249613. 6. Goldberg RA, Lew H. Cosmetic outcome of posterior approach ptosis surgery (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2011 Dec;109:157-67. PubMed [citation] PMID: 22253486, PMCID: PMC3259674. 7. Lucarelli MJ, Lemke BN. Small incision external levator repair: technique and early results. Am J Ophthalmol. 1999 Jun;127(6):637-44. PubMed [citation] PMID: 10372872. 8. Harvey JT, Anderson RL. The aponeurotic approach to eyelid retraction. Ophthalmology. 1981 Jun;88(6):513-24. PubMed [citation] PMID: 6894973. 9. Baylis HI, Shorr N. Anterior tarsectomy reoperation for upper eyelid blepharoptosis or contour abnormalities. Am J Ophthalmol. 1977 Jul;84(1):67-71. PubMed [citation] PMID: 900219.

117 POSTERS AND VIDEOS

21 Three Year Retained Orbital Plant Material

Kathryn Winkler Ophthalmology, DuPage Medical Group, Downers Grove, Illinois, United States

Introduction: This is a case of a retained intraorbital organic material which presented with symptoms 3 years after the initial injury.

Methods: The details of the case were obtained from the patient chart.

Results: A 65 year old Caucasian female presented with a 3-4 week history of increasing inflammation of a lesion of her left upper lid just inferior to her brow. The lesion had been present for about 1.5 years but only recently had become inflamed (Fig. 1). There was a 1.5cm x 1 cm mobile, non tender lesion with mild purulent drainage. She was started on oral clindamycin. She returned several days later, indicating the inflammation was increasing and excision was planned. Once the skin was incised, the underlying tissue of the lesion appearing significantly abnormal and was noted to be extending into the anterior superior orbit. During dissection, a 1 cm length green plant stem emerged from what appeared to be a tract in the superior orbit. The tract was removed partially, as the remaining tract was invested near the trochlea. The patient indicated she had no recent trauma, but 3 years earlier she had fallen, hitting the left superior orbital rim. She did note a small abrasion just superior to her left brow which healed without intervention. Following the injury, she presented to another provider due to binocular diplopia. An MRI at that time demonstrated an extraconal soft tissue lesion in the superomedial quadrant of the left orbit between the superior oblique and the superior rectus, though to be a hematoma (Fig. 2). The diplopia resolved after 2 months and she had no further symptoms until 3 years later. After removal of the plant, the patient did well and did not develop any further symptoms (Fig. 3).

Conclusions: Organic intraorbital foreign bodies most commonly present acutely with significant inflammatory or infectious sequalae.1 Acute presentations of an organic foreign body may result in purulent inflammation, abscess formation, gangrene or tetanus.1 Delayed or chronic presentation, while less common, may result in granulomatous tissue reaction, fistula formation, and osteomyelitis.1 Those delayed presentations described in the literature, typically present within months of the injury.1-3 MRI is more sensitive to detecting organic foreign bodies but can still be misinterpreted without a high degree of suspicion.4 This case is unique in that the patient initially did present with symptoms which then resolved and then she presented years later with different symptoms, leading to the discovery of the foreign body.

(continued) 118 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3

References 1. Nasr AM, Haik BG, Fleming JC, Al-Hussain HM, Karcioglu ZA. Penetrating orbital injury with organic foreign bodies. Ophthalmology 1999;106(3):523-532. 2. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109(3):494-500. 3. Bullock JD, Warwar RE, Bartley GB, et al. Unusual orbital foreign bodies. Ophthalmic Plast Reconstr Surg 1999;15:44– 51. 4. Smely C, Orszagh M. Intracranial transorbital injury by a wooden foreign body: re-evaluation of CT and MRI findings. Br J Neurosurg. 1999;13(2):206-211.

119 POSTERS AND VIDEOS

22 Thyroid Eye Disease Plus IgG4 Related Disease

Farzad Pakdel, Fahimeh Asadi-Amoli, Zohre Nozarian, Niloofar Pirmarzdashti, Annousheh Haghighi Department of Oculo-Facial Plastic Surgery, Farabi Hospital, Eye Research Center Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of

Introduction: Thyroid eye disease has been reported to be associated with a variety of other autoimmune diseases. Here we report an interesting patient with long history of thyroid eye disease that showed atypical features was found to be associated with IgG4 related disease (IgG4 RD). We aim to show clinical imaging clues, histopathology findings and management of the patient.

Methods: Patient’s demographic data were recorded. Comprehensive ophthalmology, orbital and systemic exams were performed. Clinical, Serology hormone tests for thyroid and a variety of autoimmune conditions were evaluated. Orbital computerized scan and magnetic resonance imaging were performed. Orbitotomy and biopsy of abnormal tissues was done. Histopathology, immunohistochemical studies were performed.

Results: We reported a 55-year-old woman, a known case of thyroid eye disease that was referred to us for severe progressive proptosis. The patient had history of twelve years hyperthyroidism, ten years rheumatoid arthritis. She had developed dry eye sensation and progressive proptosis, pain and diplopia from two years before admission. She had received radioactive iodine, oral prednisolone and underwent four times orbital decompression in both eyes, and currently use levothyroxine. Decreased visual acuity, defective color vision and scotoma in visual fields were compatible with bilateral optic neuropathy. CT scan (Fig 2) and MRI (Fig 3) studies showed enlargement of all recti muscles with huge enlargement of left inferior rectus muscle. (Fig 1) Laboratory evaluations showed, low TSH (0.04 mlu/L), high T4 (11.56 mcg/dl). She underwent orbitotomy and biopsy of inferior rectus muscle, lacrimal gland intraconal fat, and also deep lateral orbitotomy. Histology and immunohistochemical studies were compatible (IgG4 positive cells ratio was 40%) with IgG4 ophthalmic disease (IgG4-ROD). (Fig 3) We prescribed rituximab. She improved pain, stabilized proptosis and recovered her visual acuity until last follow up, two years after starting rituximab.

Conclusions: To the best of our knowledge this is the first report of confirmed concurrent IgG4-ROD and thyroid eye disease. Atypical enlargement of exra-ocular muscles, non-smooth, lumpy and huge enlargement may be an imaging denominator for IgG4-ROD.

(continued) 120 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3

References 1. Aileen Sy and Rona Z Silkiss. Serum total IgG and IgG4 levels in thyroid eye disease. Int Med Case Rep J. 2016; 9: 325–328. 2. Annamaria Erdei, Zita Steiber, Csaba Molnar, et al. Exophthalmos in a young woman with no graves’ disease – a case report of IgG4-related orbitopathy. BMC Ophthalmol. 2018; 18: 5. 3. Alan A McNab, Penny McKelvie. IgG4-Related Ophthalmic Disease. Part I: Background and Pathology. Ophthalmic Plast Reconstr Surg. 2015 Mar-Apr;31(2):83-8. 4. McNab AA, McKelvie P. IgG4-Related Ophthalmic Disease. Part II: Clinical Aspects. Ophthalmic Plast Reconstr Surg. 2015 May-Jun;31(2):167-78. 5. Kim, N., Yang, H.K., Kim, J.H. et al. IgG4-related ophthalmic disease involving extraocular muscles: case series. BMC Ophthalmol 18, 162 (2018). 6. Erdei, A., Steiber, Z., Molnar, C. et al. Exophthalmos in a young woman with no Graves’ disease – a case report of IgG4-related orbitopathy. BMC Ophthalmol 18, 5 (2018).

121 POSTERS AND VIDEOS

23 Topical Corticosteroid Use associated with Increased Degree of Ptosis and Rate of Ptosis Repair Failure

Adam Sweeney, Christopher Dermarkarian, Katherine Williams, Richard Allen, Michael Yen Baylor College of Medicine, Houston, Texas, United States

Introduction: To compare the degree of ptosis and the risk of ptosis repair failure among patients with and without a history of topical corticosteroid use.

Methods: A retrospective chart review was performed of all patients who underwent ptosis repair between 2012 and 2019 by 4 surgeons at a tertiary referral center. Inclusion criteria were patients who underwent ptosis surgery by external levator advancement/resection (ELR) or Müller muscle conjunctival resection (MMCR), patients with documentation of the presence or absence of topical corticosteroid use, and patients with documentation of postoperative outcome with at least 3 months postoperative follow-up. Comparative statistical analyses of surgical outcomes were performed amongst patients with and without history of topical corticosteroid use.

Results: A total of 240 patients (407 eyelids) met study criteria, of which 30 patients (44 eyelids) had history of topical corticosteroid use. Mean preoperative marginal reflex distance (MRD1) was 0.20 mm and 0.58 mm for topical corticosteroid and non-corticosteroids users, respectively (P = 0.01). Mean preoperative levator function was 9.78 mm and 10.38 mm for topical corticosteroid and non- corticosteroid users, respectively (P = 0.02). The rate of ptosis repair failure was 30% and 16% in patients with and without a history of topical corticosteroid use, respectively (odds ratio 2.25, 95% confidence interval (CI) 1.11 – 4.56; P = 0.02). When performing Kaplan Meier analysis, time until ptosis recurrence occurred significantly earlier and overall survival was significantly lower at earlier time points among topical corticosteroid users. There was no significant difference in ptosis failure rates when comparing specific corticosteroid agents (F(4,4) = 6.39, p = 0.17). The rate of recurrence per surgical type in eyelids with and without history of topical corticosteroid use was: ELR 11/27 (41%) and 48/267 (18%) (OR = 3.14, CI 1.37 – 7.18 0; P = 0.01); MMCR 2/17 (12%) and 9/96 (9%) (OR 1.29, CI 0.25 – 6.56; P = 0.76), respectively.

Conclusions: Topical corticosteroid use is associated with more severe presenting ptosis and increased rates of ptosis repair failure. Compared to MMCR, there is significantly higher rate ptosis repair failure in patients undergoing ELR. Ptosis failure is not associated with any specific corticosteroid agent. Preoperative counseling of the increased rate of ptosis repair failure is needed in patients with history of topical corticosteroid use.

(continued) 122 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2

123 POSTERS AND VIDEOS

24 Trigeminal Trophic Syndrome with Extensive Ulceration: A Rare Complication of Herpes Zoster

Jamie Schaefer1, Kara Jones2, Jean-Paul Abboud3, Zachary Zinn4, John Nguyen5,6 1Ophthalmology, Brown University, Providence, Rhode Island, United States, 2West Virginia University, Charleston, West Virginia, United States, 3Oculofacial Surgical Arts, Del Mar, California, United States, 4Dermatology, West Virginia University, Morgantown, West Virginia, United States, 5Ophthalmology, West Virginia University, Morgantown, West Virginia, United States, 6Otolaryngology, West Virginia University, Morgantown, West Virginia, United States

Introduction: Trigeminal Trophic Syndrome (TTS) is rare condition characterized by unilateral facial anesthesia, paresthesia, and soft tissue ulceration due to injury to the ipsilateral trigeminal nerve. We describe a severe case of TTS following herpes zoster ophthalmicus, causing ulceration of the right upper eyelid, forehead, and cornea.

Results: A 53-year-old, otherwise healthy, African-American male presents with a three-month history of an exudative, necrotic, sharply demarcated ulceration involving the right trigeminal V1 hemi-dermatome (Figure 1A). The ulceration slowly progressed due to an uncontrollable urge to scratch the affected areas. Associated symptoms included blurry vision and photophobia. Three months prior to onset of symptoms, the patient was treated with oral acyclovir for severe herpes zoster ophthalmicus.

Visual acuity testing revealed hand motion vision in the right eye and 20/25 in the left eye. There was no pupillary abnormality or motility deficit. There was a cicatricial ectropion of the right upper eyelid, with madarosis and a 3-mm lagophthalmos. The anterior segment exam showed moderate conjunctival injection with diffuse corneal haze and an infratemporal desmatocele (Figure 2A). Corneal sensation in the right eye was diminished. Wound culture was positive for methicillin-sensitive Staphylococcus aureus. Wound swab PCR was negative for varicella zoster virus. The patient was treated with a two-week course of IV Acyclovir for herpes zoster ophthalmicus resulting in TTS. After placement of a temporary tarsorraphy, he underwent eyelid reconstruction with skin graft placement and permanent tarsorrhaphy. He was also prescribed doxepin for pruritis.

At one month follow up, corneal disease improved with a remnant scar with minimal residual lagophthalmos. He was continued on wet- to-dry dressings for the forehead wound for 6 months (Figure 1B). Over the course of three years, he underwent two additional skin grafting procedures due to recurrence of ectropion and exposure from keloid formation. At five years follow up, he had count finger visual acuity in the right eye from a stable corneal scar without lagophthalmos (Figure 1C & 2B).

(continued) 124 POSTERS AND VIDEOS

(continued) Conclusions: TTS is most often due to an iatrogenic, ischemic, or ablative process resulting in damage to the trigeminal nerve.1 It is commonly seen in females during the 5th decade of life. Of the approximately 200 cases of TTS described since the early 20th century,2 the ala nasi is involved in >70% of cases, compared to 16% with eyelid involvement, contributing to corneal pathology. Our case is unique because of significant degree of corneal involvement. Neurotrophic ulcerations may manifest weeks to 20 years after nerve damage. Treatment involves a multi-disciplinary approach. Initial management typically includes behavioral modification with neuromodulatory medications to decrease self-inflicted disfigurement of the skin, and wound care including thermoplastic dressings and negative pressure wound therapy. Significant ocular involvement typically requires surgical intervention with skin grafts and flaps, although post- surgical recurrence is common.3,4 This report describes severe eyelid and corneal involvement in TTS, and highlights the combined surgical and pharmacological interventions necessary to treat this disease.

Figure 1 Figure 2

References 1. Rashid RM, Khachemoune A. Trigeminal trophic syndrome. J Eur Acad Dermatol Venereol 2007; 21: 725–731. 2. Sadeghi P, Papay FA, Vidimos AT. Trigeminal trophic syndrome – report of four cases and review of the literature. Dermatol Surg 2004; 30: 807–812. 3. Kovacs KD, Ehrlich MS. Cicatricial eyelid paralysis secondary to trigeminal trophic syndrome. Ophthal Plast Reconstr Surg 2017;33: e78. 4. Sawada T, Asai J, Nomiyama T, et al. Trigeminal trophic syndrome: report of a case and a review of the published work. J Dermatol 2014; 41: 525–528.

125 POSTERS AND VIDEOS

25 Unwanted Events after Orbital Volumization with Autologus Microfat in Patients with Enophthalmos

Farzad Pakdel1, Niloofar Pirmarzdashti2 1Department of Oculo-Facial Plastic Surgery, Farabi Hospital, Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of, 2Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic Of

Introduction: Restoring orbital volume with autologous macro-fat has been considered an effective method to address volume loss after enucleation. Recent advances in autologous microfat grafting injection have opened a new opportunity for orbital volumization, attracting interest among multiple specialties. Potential advantages of autologous microfat grafting technique include short surgical time, outpatient procedure, it is inexpensive, titratable, and repeatable. However, adverse technique-related events can limit the success of the procedure. The aim of this study was to report the efficacy of the procedure, and to characterize intervention-associated adverse events after orbital microfat injection in non-seeing eye patients with enophthalmos. The technique of injection, and techniques for managing complications, will be demonstrated using video.

Methods: Data of patients with non-seeing eye enophthalmos from March 2011 to September 2018, that underwent orbital volumization with autologous microfat injection, were collected. Fat harvest, processing and injection for all this cohort of patients was based on Coleman’s method. Those patients that received enhancers, changed prosthesis during follow up time or had follow-up less than 6 months were excluded. Data including etiology of enophthalmos, past interventions to correct enophthalmos, Hertel exophthalmometry value with prosthesis in place, superior sulcus depth, extra-ocular motility, and patient satisfaction visual analogue score (VAS)(0-100) were recorded. Any intervention-related adverse event was recorded.

Results: Data of 24 eligible patients were analyzed. Mean age was 32 (SD= 8.7, range=18-46) years. Fifteen patients (63%) were male. Etiology of enophthalmos included post-enucleation/evisceration syndrome (PESS) (n=10, 42%), zygomaticofacial fractures (n=10, 42%), phthisis bulbi (n=2, 8%), congenital hemifacial atrophy (n=1, 4%), and congenital microphthalmia (n=1, 4%). Mean change of enophthalmos was 2.4 (SD= 1.1, range 1-4) mm. Mean satisfaction by VAS was 87 (SD=16, range 50-100). Three patients showed lower eyelid puffiness (Figure 1,2). Two underwent surgical resection of nodular masses that caused bumps. One patient showed worsening of pre-existing lower eyelid cicatricial retraction. No major adverse event was observed.

Conclusions: This study supports the efficacy of orbital volumization by autologous microfat injection, in follow-up of at least 6 months. However, lower eyelid bumps may occur, or pre-existing lower puffiness may be worsened after injection, especially in patients with tough orbital tissue secondary to past trauma and decreased orbital tissue resilience.

(continued) 126 POSTERS AND VIDEOS

(continued) Figure 1 Figure 2 Figure 3

References 1. Pakdel F, Pirmarzdashti N. Re: “Autologous Fat Graft for the Treatment of Sighted Posttraumatic Enophthalmos and SunkenUpper Eyelid”. Ophthalmic Plast Reconstr Surg. 2018 Nov/Dec;34(6):603-604. 2. Chen H, Zhang Q, Qiu Q, Yang Z. Autologous Fat Graft for the Treatment of Sighted Posttraumatic Enophthalmos and SunkenUpper Eyelid. 3. Ophthalmic Plast Reconstr Surg. 2018 Jul/Aug;34(4):381-386. 4. Hunter PD, Baker SS.The treatment of enophthalmos by orbital injection of fat autograft. Arch Otolaryngol Head Neck Surg. 1994 Aug;120(8):835-9. 5. Spinelli G, Arcuri F, Lazzeri D, Salvagni L, Agostini T. Retroseptal structural fat grafting to correct paediatric post-traumatic enophthalmos. Annals of Oral & Maxillofacial Surgery 2014 Jan 18;2(1):2. 6. Avelar RL, Göelzer JG, Azambuja FG,et al. Use of autologous fat graft for correction of facial asymmetry stemming from Parry-Romberg syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Feb;109(2):e20-5.

127