ABSTRACT Purpose To analyze Tocilizumab (TCZ, an interleukin 6 inhibitor) as a second-line treatment for thyroid-associated ophthalmopathy (TAO). Methods In this retrospective observational study, the charts of patients with moderately severe to severe TAO who received intravenous Tocilizumab as a second-line treatment 2020-2023 were reviewed. Results Twenty-three patients were enrolled in the study. At the follow-up visit 24 weeks after the initiation of treatment, 14 out of 22 patients (63.6%, one missing data) had a reduction of proptosis of 2 mm or more. The mean proptosis decreased from 21.07 (±3.23) to 19.18 (±2.52) mm in the right eye (RE) and from 20.61 (±3.12) to 19.95 (±2.81) mm in the left eye (LE). Twenty patients (87%) also showed a reduction of the clinical activity score (CAS) of at least two points with a mean decrease from 5.22 (±1.53) pre-treatment to 2.09 (±1.38) post-treatment points. The median patient total follow-up time after treatment was ten (range 6–26) months. The comparisons reached strong significance between pre-treatment and 24 weeks, as well as pre-treatment and final visit assessments for both proptosis and clinical activity scores. Serum TRAb levels also dropped significantly, and only two patients needed re-treatment with TCZ. Improvement of diplopia did not reach statistical significance. Conclusions Intravenous Tocilizumab as a second-line treatment for TAO led to a significant improvement of proptosis and CAS at 24 weeks follow-up, with a sustained effect over time.

ABSTRACT Pleomorphic adenoma of the lacrimal gland (PALG) is a benign neoplasm typically presenting with gradual, painless globe displacement and/or lid swelling. We report an atypical case of PALG in a 53-year old male presenting acutely, mimicking orbital cellulitis. Imaging demonstrated an extraconal rim-enhancing soft-tissue lesion medial to the left lacrimal gland, involving superior rectus and levator palpebrae superioris. Surgical excision and histopathology revealed PALG with central infarction, necrosis, and chronic and acute pseudocapsular arteriolar occlusion. These findings correlated with the fluctuating symptoms and suggested a multifactorial mechanism involving both underlying vasculopathy, thrombosis, and tumor growth. Infarction in PALG may occur iatrogenically or from spontaneous tumor infarction, and can cause an acute inflammatory presentation. We discuss unique histopathologic features of necrotic PALG and mechanisms of infarction. Recognition of these features and the varied presentations of PALG is crucial for proper diagnosis. Complete resection is necessary to prevent recurrence or malignant transformation.

ABSTRACT Purpose To determine the risk factors impacting the surgical success of endonasal dacryocystorhinostomy (eDCR) in pediatric patients. Methods This is a retrospective interventional case series of patients 18 years and younger treated over a 16-year period via eDCR for nasolacrimal duct obstruction (NLDO). Data were extracted on surgical outcomes, follow-up duration, and comorbidities (i.e. punctal agenesis, trisomy 21, dacryocystitis). Functional success was defined as the resolution of NLDO symptoms postoperatively. Results Of 356 cases in 281 patients (median age: 3.32 years), 78.9% of cases in 79.0% of patients achieved functional success after initial eDCR. The median follow-up duration without tearing symptoms as observed by an ophthalmologist and non-ophthalmology trained clinician was 11.0 months and 62.1 months, respectively. Patients with punctal agenesis and those requiring bilateral surgery had significantly higher rates of failure (p = .01; p < .001, respectively). Age at operation was not significantly associated with failure (p = .30). Excluding cases of trisomy 21 and punctal agenesis, functional success was achieved in 82.7% of 295 cases. Conclusions Endonasal DCR is effective in resolving NLDO symptoms in pediatric patients, with success rates comparable to the adult population and to an external approach. Despite a higher reoperation rate in patients with trisomy 21 and punctal agenesis, trisomy 21 and age at operation were not significant risk factors for failure.

The challenge of training in ophthalmic plastic surgery in Europe – the role of the European Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS). Our subspecialty has grown, a rapid evolution is in progress, new therapies are a reality, several studies are underway, and we are capable of blending artistry with science to provide exceptional patient care. As for now, the EBO-ESOPRS exam certifies the European title of subspe cialist in oculoplastic surgery. Are we ready to go further and transform our subspecialty in a surgical specialty in its own right in the near future?

ABSTRACT Leprosy, also known as Hansen disease, is an airborne spread disease caused by Mycobacterium leprae (M. leprae) which commonly presents with skin lesions, peripheral neuropathy, and ocular involvement. This report describes a patient who presented with epiphora secondary to chronic nasolacrimal duct obstruction four years after completing antimicrobial treatment for tuberculoid leprosy. At the time of endoscopic dacryocystorhinostomy (DCR), the lacrimal sac demonstrated chronic dacryocystitis with granulomatous inflammation and a Fite positive staining bacterial rod-like structure. Pathological examination of the surgical specimen demonstrated numerous non-necrotizing granulomas in a perivascular and neural distribution, compatible with sequelae of previously treated M. leprae infection. The patient has remained symptom free six months after surgery.

ABSTRACT Purpose Assessment of the frontalis muscle flap eyelid reanimation surgical technique for adults with severe ptosis and apraxia of eyelid opening. Methods A retrospective case series of 30 eyes with severe ptosis or apraxia of eyelid opening. Outcomes were assessed for margin to reflex distance 1 (MRD1), lagophthalmos, complications, and need for subsequent surgical intervention. A paired t-test was used to compare preoperative and postoperative scores of a quality-of-life questionnaire. Results Thirty eyes of 19 patients underwent surgery, 16 (53%) with combined frontalis + levator-Muller muscle flap and 14 (46%) with frontalis muscle flap alone. There were 14 female and 5 male patients, with an average age of 55 years (range, 18–76). Mean preoperative MRD1 was −0.6 mm (range, −5 to 2) with mean levator excursion of 7.1 mm. Seventeen eyes had a myogenic etiology, five had a paralytic etiology, six had blepharospasm with apraxia of lid opening, and two had a neurodegenerative etiology. Nineteen eyes (63%) had previously undergone ptosis repair. Mean postoperative MRD1 was 2.5 mm (range, 0.5 to 5) at mean follow-up of 63.3 days. There were no serious surgical complications; minor complications included ocular surface keratopathy and one patient who required surgical revision. Results of the QOL questionnaire indicated significant improvement in vision-related symptoms postoperatively (p = 0.02). Conclusions Use of the frontalis muscle flap eyelid reanimation technique, with or without a levator-Muller retractor muscle flap, was very effective in this case series and provided good upper eyelid position with acceptable corneal protection and high patient satisfaction.

ABSTRACT Pyomyositis is a bacterial infection of skeletal muscle leading to abscess formation. Younger males are predominantly involved, but pyomyositis may occur in all ages and sexes. Underlying systemic disease or accompanying immunocompromised states may increase the risk of pyomyositis. This is a report of a 72-year-old, male, with uncontrolled diabetes mellitus, presenting initially as a case of orbital cellulitis. Magnetic resonance imaging confirmed the presence of an abscess in the left lateral rectus. Antibiotic therapy was promptly initiated, and drainage of the abscess was performed via a transconjunctival approach. Pyomyositis resolved post-surgery and medical therapy. Residual exotropia was noted at the eighth month of follow-up necessitating subsequent strabismus surgery. Nine months post-treatment, left lateral rectus pyomyositis did not recur.

ABSTRACT Purpose To assess the management of patients with congenital nasolacrimal duct obstruction (CNLDO) in a paediatric population and review the long-term outcomes over a 5-year interval, with particular emphasis on the difference between patients with trisomy 21 and those without trisomy 21. Methods This single-centre, retrospective, cross-sectional, case review study included patients suffering from CNLDO at Alder Hey Children’s Hospital NHS foundation Trust. Patients were divided into two groups: Non-trisomy 21 and trisomy 21. Patients were followed-up for a 60-month interval. Patients aged <12 months at the time of surgery, patients with <60 months of follow-up data and patients with acquired nasolacrimal duct obstruction were excluded. The main outcome measures were discharge rates in patients undertaking primary intervention with syringe and probe (S&P), number of patients requiring further treatment with lacrimal intubation or dacryocystorhinostomy (DCR) and overall symptom-free periods post-treatment. Results Ninety-three patients (142 eyes) were included. The mean number of surgical interventions was 1.53 ± 0.65. The mean interval between the 1st and 2nd intervention was 15.54 ± 16.33 months. There was a trend towards greater success rates non-trisomy 21 patients versus patients with trisomy 21 (p = 0.1352). The average symptom-free period after the final intervention was 44.31 ± 20.68 months, significantly longer in the non-trisomy 21 group compared to the trisomy 21 group (p = 0.0074). Conclusions The overall success rate after primary S&P was 55.9%. Our results suggest that in trisomy 21 patients suffering from CNLDO, a one-stage intervention with primary monocanalicular intubation should be considered instead of sequential approach.

ABSTRACT Valsalva-associated orbital compartment syndrome in the setting of orbital cellulitis, mucocele, or subperiosteal abscess has not been previously reported. A previously healthy girl presented with orbital cellulitis complicated by a subperiosteal abscess and frontoethmoidal mucocele. On the day of her planned orbitotomy and endoscopic sinus surgery, she developed a Valsalva-associated retrobulbar hemorrhage and elevated intraocular pressure after crying during a blood glucose fingerstick. An urgent canthotomy and cantholysis in addition to the planned endoscopic sinus procedure was performed. She did well post-operatively with normal vision at follow-up. Based on these experiences, there should be a consideration to implement heightened vigilance to prevent or minimize Valsalva maneuvers in orbital cellulitis patients with subperiosteal abscesses or mucoceles extending into the orbit. While it remains unclear whether and to what degree these patients may be at an increased risk of developing retrobulbar hemorrhage leading to orbital compartment syndrome, we hope that this novel report aids in providing another consideration with the goal of preventing vision loss.

ABSTRACT Purpose The purpose of this study is to determine the public’s perception of the scope of practice for oculofacial plastic and reconstructive surgeons (OFPRS). Methods A 49-question survey was distributed by QualtricsⓇ to a panel similar to the US demographic composition. Responses collected underwent bivariate statistical analysis. Result A total of 530 responses were obtained, with most respondents being white, female, over the age of 35, from the Midwest, and with at least a college education or above. Most respondents did not think ophthalmologists or optometrists were surgeons, and only 158 people (29.8%) knew the primary specialty of OFPRS was ophthalmology. Board certification was preferred by 98.87% of respondents, and 95.28% preferred ASOPRS-trained OFPRS. Conclusions Our study highlights the gap in knowledge about OFPRS as a field, the qualifications and training required, and the scope of practice. Notably, even for OFPRS-specific procedures, PRS remained the leading subspecialist chosen for interventions such as orbital decompression (58.5% vs. 71.5%), orbital reconstruction (57.9% vs. 74.2%), enucleation/evisceration (48.1% vs. 53.4%), optic nerve-related surgery (39.8% vs. 43.4%), orbital cancer resection (42.8% vs. 46.8%), and tear duct surgery (41.9% vs. 52.5%). Additionally, most respondents did not feel that facial fillers, laser skin resurfacing, eyelid cancer removal, or cataract surgery were within the OFPRS scope of practice.