A Review of Diagnostic and Therapeutic Dacryoendoscopy Purpose: To provide a systematic review of the literature on diagnostic and therapeutic indications, techniques, utility, and complications of dacryoendoscopy (DEN). Methods: The authors performed a PubMed search of articles published in English/German/Japanese/Chinese on DEN. Data captured include evolution and techniques, diagnostic utility, therapeutic interventions, outcomes, and limitations. Specific emphasis was laid on addressing the current practice patterns and existing lacunae. Results: Diagnostic DEN has enabled the exact localization and differentiation of mucosal edema, stenosis, strictures, and obstructions throughout the lacrimal drainage system (LDS). Guided expansion of the stenosis, laser dacryoplasty (LDP) for strictures and microdrill removal of dacryoliths (microdrill dacryoplasty [MDP]) are some of the therapeutic uses of DEN. Successful outcomes of up to 60%–70% were achieved with stenosis anywhere along the LDS with a restenosis rate of 20%. Longer segment of stenosis (>2 mm), presence of enlarged lacrimal sac, history of dacryocystitis, postsaccal stenosis, and complete obstruction were associated with poorer outcomes. Microendoscopic procedures like LDP or MDP achieve canalicular and NLD recanalization with optimal results. DEN guided-probing demonstrated high success rates in cases with an earlier failed probing. Available dacryoendoscopes allow high-quality image capture (15,000 pixels) with multiple ports for additional instrumentation and irrigation. Conclusions: Dacryoendoscopic examination of canaliculus and nasolacrimal duct plays a significant role in the diagnosis and management of lacrimal disorders. Further improvements in microendoscopic techniques and instrumentation will expand its clinical usage and give impetus to minimally invasive lacrimal surgeries. Dacryoendoscopy examinations are increasingly playing a significant role in the diagnosis and therapies of lacrimal drainage disorders.

Myopathic Blepharoptoses: A New Classification System Purpose: Myopathic blepharoptoses (ptoses) is a complex group of disorders. To date, no formal categorization scheme has been developed based on associated ocular and systemic findings, genetic fingerprint, treatment, and prognosis for each ptosis in this group. We report a new classification scheme for myopathic ptoses. Methods: Literature review and classification development. Results: A new classification scheme of myopathic ptoses includes isolated static myopathic ptosis (congenital ptosis), static myopathic ptosis associated with aberrant innervation and those associated with periocular abnormalities, and progressive myopathic ptoses that affect the levator muscle and other muscle groups in childhood and adulthood. Conclusions: Making the distinction of myopathic ptosis type early will maximize patient outcomes by optimizing surgical and systemic management and facilitating the recruitment of subspecialists to care for patients with these challenging conditions. The authors present a comprehensive and effective myopathic ptosis classification scheme to optimize surgical management and facilitate subspecialty care.

Invasive Fungal Sinusitis: Risk Factors for Visual Acuity Outcomes and Mortality Purpose: Invasive fungal sinusitis is a rare but potentially lethal disease that primarily affects immunocompromised patients. The purpose of this study was to review an academic medical center’s experience in the presentation, diagnosis, and treatment of invasive fungal sinusitis. Methods: A retrospective chart review was performed at a single institution over a 17-year period. Medical records, radiographic imaging, and operative reports were analyzed. Bivariate and multivariable analyses were performed to determine factors that affected visual acuity outcomes and mortality. Results: Fifty-five patients with histopathologically confirmed invasive fungal sinusitis were included. The average duration of follow up was 1.8 ± 2.6 years (range: 1 week to 10 years). The most common causes of immunosuppression were hematologic malignancy (45%), diabetes (31%), and organ transplantation (9%). At presentation, 35% of individuals were neutropenic (absolute neutrophil count < 500/μl). All patients received systemic antifungal treatment. A surgical intervention was performed on 50 patients (91%), and all but one had functional endoscopic sinus surgery. Nine (16%) patients underwent orbital exenteration. Multivariable analysis of visual acuity outcomes demonstrated that individuals infected with Zygomycota had 6–7 lines worse vision than those infected with Ascomycota (mean difference in logMAR 0.66, 95% confidence interval 0.27 to 1.06, p = 0.001). Patients who had functional endoscopic sinus surgery had 7–8 lines better visual acuity than those without functional endoscopic sinus surgery (mean difference in logMAR −0.76, 95% confidence interval −1.13 to −0.38, p < 0.001). The overall death rate due to infection was 24%. Bivariate models demonstrated no difference in mortality in patients receiving exenteration versus those who did not (p = 0.14). Multivariable analysis of mortality demonstrated that neutropenia increased mortality (adjusted odds ratio 10.05, 95% confidence interval 1.49 to 67.67, p = 0.02). Having a greater number of surgeries was associated with an increased rate of survival (adjusted odds ratio 0.39, 95% confidence interval 0.15 to 0.96, p = 0.04). Conclusions: Invasive fungal sinusitis is an aggressive disease with significant mortality. Patients with neutropenia had a lower rate of survival, and infection with Zygomycota was associated with worse visual acuity outcomes. Those having functional endoscopic sinus surgery had better final visual acuity, and an increased number of surgeries was associated with a decreased chance of death. Exenteration yielded no observed survival benefit. Endoscopic sinus debridement portends better visual acuity outcomes in patients with invasive fungal sinusitis, whereas exenteration yields no difference in survival benefit.

Microbial Keratitis in Thyroid Eye Disease: Clinical Features, Microbiological Profile, and Treatment Outcome Purpose: To report the incidence, clinical features, microbiologic profile, and risk indicators in the development of microbial keratitis in Thyroid Eye Disease (TED). Methods: All patients who were diagnosed to have TED and developed microbial keratitis between the years 2009 to 2017 at the Ophthalmic Plastic Surgery service, LV Prasad Eye Institute were included in this retrospective interventional study. The clinical features, microbiological profile, and treatment outcome of the infection were studied. Possible risk factors leading to the development of microbial keratitis were studied. Results: A total of 1,000 patients of TED were evaluated in the 10-year period. Of the 1,000, 13 patients (14 eyes, 1.4%) were diagnosed with microbial keratitis. The average age at presentation was 44 years (range 1969 years). Of the 13 patients, 10 (77%) were men, 12 (92%) were hyperthyroid, and 12 (92%) were active (average clinical activity score 3) at presentation. Average exophthalmometry value in the involved eye was 24.75mm, and severe eyelid retraction (>2mm scleral show) was noted in 13 of 14 eyes. None of the patients had optic nerve compression. Moderate motility restriction (2 in all gazes) was noted in 6 eyes, and severe motility restriction (4 in all gazes) in 8 eyes. At presentation, 11 (85%) had visual acuity of counting fingers at 1 meter or less, The mean follow up from the time of presentation was 18.3 months (range 566 months). Majority of the eyes (8/14) presented with severe infection (panophthalmitis with microbial keratits = 1, total corneal infiltrate with/without melt = 4, severe thinning/perforation = 4). Microbiological work up of 14 eyes revealed presence of gram-negative bacteria in 5 eyes which included Escherichia coli, Pseudomonas sp., and Acinetobacter sp., and gram-positive bacteria in 4 eyes including Streptococcus pneumoniae, Corynebacterium sp., and Staphylococcus sp. Three eyes revealed a mixed infection of E. coli with Alternaria sp, and E. coli with Corynebacterioum amycolatum while 1 had Corynebacterium pseudodiptheriticum, and S. pneumoniae. Two eyes of the bilateral case showed no growth. Antibiotic susceptibility revealed 6 of the 7 gram-negative isolates were multidrug resistant, whereas the gram-positive isolates were susceptible to most drugs tested. Surgical procedures required were tarsorrhaphy in 7 eyes, tissue adhesive with bandage contact lens in 4, evisceration in 4, levator recession in 2, 3-wall orbital decompression in 2, and penetrating keratoplasty in 1 eye. The visual acuity at presentation was counting fingers or worse in 10/14 eyes. Posttreatment, 10 eyes achieved resolution of infiltrate (with visual improvement in 2), and 4 required evisceration. Conclusions: In the authors large series of TED, microbial keratitis was noted in 1.3% of patients presenting to a tertiary eye center. Majority presented with advanced diseases and ended with a poor outcome. Gram-negative isolates showed multidrug resistance. An association with early phase of active TED (CAS 3 or more), severe eyelid retraction, and moderate-severe motility restriction is suggested. Microbial Keratitis occurs in 1.3% cases of Thyroid Eye Disease. It is more common in men, and in active disease. The microbiological spectrum and possible clinical risk factors are presented.

Characterizing Congenital Double Punctum Anomalies: Clinical, Endoscopic, and Imaging Findings Purpose: To characterize the anatomical anomaly of congenital double puncta, identify factors contributing to epiphora and its treatment. Methods: Retrospective review of patients presenting with epiphora and a double lacrimal punctum over a 6-month period. Results: Five consecutive patients (3 female) were identified. The median age was 50 years (range 34–76). Investigations included punctum optical coherence tomography, dacryocystography, and canalicular endoscopy. The medial punctum was more morphologically abnormal when compared with healthy puncta, with optical coherence tomography showing no vertical canalicular component in 80% (4/5) of patients, and a more superficial than usual horizontal canaliculus in 80% (4/5). Dacryocystography and canalicular endoscopy showed the junction of the 2 inferior canaliculi, which was very proximal in 1, mid canalicular in 2, and at the level of the common canaliculus in 2. In 1 patient, the only abnormality identified was the double lower punctum, with a high tear meniscus and delayed fluorescence dye disappearance test. They underwent endonasal dacryocystorhinostomy with improvement of epiphora. In the other 4 patients, causes of epiphora were nasolacrimal duct stenosis with mucocoele, punctal stenosis, common canalicular stenosis with nasolacrimal duct stenosis, upper canaliculitis, and blepharitis. Their treatments included endonasal dacryocystorhinostomy, punctoplasty, canaliculotomy, and blepharitis treatment. All had improvement of epiphora following treatment. Conclusions: These findings suggest that the underlying canalicular anomalies are varied and that the clinical manifestation is also heterogenous. Optical coherence tomography imaging suggests that the medial of the 2 puncta is the more morphologically abnormal one, with dacryocystography and canalicular endoscopy demonstrating different accessory canaliculi lengths. Double puncta coexist with a range of other nasolacrimal pathologies. OCT suggests that the medial of the 2 double puncta is the abnormal one, with DCG and endoscopy demonstrating a range of accessory canaliculus lengths.

Altered Surfactant Protein Expression in Primary Acquired Nasolacrimal Duct Obstruction Purpose: To investigate the presence and distribution patterns of 6 surfactant proteins in lacrimal drainage tissues of patients with primary acquired nasolacrimal duct (NLD) obstruction. Methods: The presence and distribution of surfactant proteins (SP)-G and SP-H was first assessed in normal cadaveric lacrimal systems. The study was then performed in 10 samples of lacrimal sac and the respective NLDs obtained from patients suffering from primary acquired NLD obstruction who underwent either a dacryocystorhinostomy or a dacryocystectomy. The lacrimal sac samples were further divided into fundus and body, soon after their removal. Immunohistochemical labeling was performed for assessing the presence and distribution of SPs: SP-A, SP-B, SP-C, SP-D, SP-G/SFTA2, and SP-H/SFTA3. The results were then scored as positive or negative and the distribution pattern, if any, within the lacrimal sac and NLDs was assessed. Human lung tissues were used as controls. Results: SP-H was demonstrated in the lining epithelia of the normal lacrimal drainage systems, whereas SP-G was uniformly negative. Immunohistochemical labeling revealed wide variations in the staining patterns of different SPs in different regions of the lacrimal sac and the NLD. SP-D and SP-G revealed uniformly negative immunoreactivity. Variable staining patterns were also noted between the superficial and basal layers of the lining epithelia. However, the goblet cells and intraepithelial mucous glands did not express any of the SPs. Conclusions: This study provides a proof of principle for the presence of SP-H and absence of SP-G in the normal lacrimal drainage systems. In cases of primary acquired nasolacrimal duct obstruction, there were alterations or loss of SP expression in the lining epithelia of the lacrimal sac and NLDs, reflecting their possible role in the etiopathogenesis of primary acquired nasolacrimal duct obstruction. In cases of primary-acquired nasolacrimal duct obstruction, the expression of multiple surfactant proteins was either deranged or lost in the lining epithelium of the lacrimal sac and nasolacrimal ducts.

Hyaluronic Acid Gel Biodegradation After Intrapalpebral and Intraorbital Injection in Experimental Study Purpose: Amid the increasing clinical application of hyaluronic acid (HA) fillers in the ocular adnexa is a paucity of histological data concerning the fate of the injected material. The current study documents the in vivo biodegradation of HA deposited in the eyelid and orbit. Methods: The study included 22 chinchilla rabbits. The right upper eyelid of 12 rabbits received a single 0.2 ml Restylane (Galderma, Uppsala, Sweden) subcutaneous injection. In 10 different rabbits, the right orbit was injected with 1.0 ml Restylane SubQ (Galderma, Uppsala, Sweden) in the extraconal space. The rabbits in the eyelid group were euthanized at 2 weeks, 1 month, 2, 4, 6, and 9 months, while the rabbits in the orbit group were euthanized at 1 month, 3, 6, 12, and 18 months. Histological analysis was performed on the harvested samples. Results: In the eyelid, the HA assumed a sponge-like structure that diminished gradually over time. At 9 months, the injected HA partially persisted, mainly in the peripheral areas of injection. A similar histologic pattern was observed in the injected orbits, with slow changes persisting at the eighteenth month. In both cohorts, clear signs of collagen deposition and pseudocapsule formation were observed around HA droplets, with no signs inflammation. Conclusions: HA injected subcutaneously into the eyelid and orbit of rabbits undergoes slow and gradual biodegradation, with HA persisting to no less than 9 months in the eyelid and 18 months in orbit. Neocollagen synthesis and lack of hyaluronidase activity could explain the unexpectedly prolonged HA persistence.

Immunohistochemical Analysis of the Lacrimal Sac Mucopeptide Concretions Purpose: To investigate the presence and distribution patterns of proteins in the lacrimal sac mucopeptide concretions. Methods: The study was performed on 10 mucopeptide concretions obtained from the lacrimal sac during an endoscopic dacryocystorhinostomy. Immunohistochemical labeling was performed for assessing the presence and distribution of von Willebrand factor, fibronectin, collagen I, collagen III, human beta-defensin 2, beta-defensin 3, lysozyme, prolactin, cytokeratin (CK)—CK4, CK7, CK18, immunoglobulin M (IgM), immunoglobulin G (IgG), psoriasin (S100-A7), and migration inhibitory factor-related protein (MRP14/S100-A9). The results were then scored as positive or negative and the distribution pattern, if any, within the sectioned concretions was assessed. Results: Immunohistochemical labeling was strongly positive for von Willebrand factor and fibronectin in the core areas of the concretions. Collagen I was widely dispersed both in the peripheral and core areas whereas collagen III was mostly limited to only few areas of the core. Strong immunoreactivity was noted for lysozyme, which was abundantly distributed, whereas prolactin receptors were positive on the surface and also the dispersed cells within the concretion matrices. Very few peripheral areas of concretions showed MRP14 or S100-A9 positivity in a noncontiguous fashion. Immunoreactivity was uniformly negative for CK-18, IgM, IgG, and psoriasin. Conclusions: The presence of fibronectin and von Willebrand factor in the core of the concretions strengthens the earlier hypothesis that blood components may act as a nidus for subsequent mucopeptide deposition. The study also provides possible clues to the lacrimal defenses mounted during dacryolithiasis. Fibronectin and vWF are present in the core of the dacryoliths. Blood components may act as a nidus in the evolution of lacrimal sac mucopeptide concretions.

Surgical Predictors of Reduced Marginal Reflex Distance After Upper Blepharoplasty Purpose: Ptosis may occur in certain cases after upper blepharoplasty. The authors aim to characterize the incidence of postoperative marginal reflex distance (MRD1) reduction after upper blepharoplasty and surgical variables that may predict this occurrence. Methods: In this cross-sectional study, patients > 18 years old undergoing upper blepharoplasty were screened. Patients were excluded if they had any history of ptosis and brow surgery. Data regarding the excision of skin, muscle, fat, and brow fat as well as crease formation were documented. The distance in millimeter from the center of the pupil to the upper eyelid margin in the midpupillary line (MRD1) was measured digitally. The primary outcome measure was a postoperative reduction in MRD1 of >1 mm. Secondary outcome was overall mean change in MRD1 and the incidence of ptosis as defined by a final MRD1 ≤ 2.5 mm. Results: The final sample consisted of 100 patients (200 eyelids) and the mean age was 55.8 years. There were 65 patients with orbicularis muscle removal, 52 patients with postseptal fat removed, and 9 patients with crease formation. Overall 15 patients developed MRD1 decrease of greater than 1 mm (5 bilaterally and 10 unilaterally) with 7 eyes demonstrating a final MRD1 of ≤ 2.5 mm. In multivariate modeling, muscle removal was found to be the only variable with significant impact on the development of MRD1 reduction > 1 mm after upper blepharoplasty (p < 0.05, odds ratio = 8.2). The other variables did not significantly contribute. The overall mean (SD) MRD1 was 3.43 mm (1.1) preoperatively and 3.62 mm (1.1) postoperatively (p < 0.01). Conclusions: Fifteen percent of patients demonstrated a reduction in MRD1 > 1 mm after upper eyelid blepharoplasty, and those with orbicularis resection were more likely to experience this change. The authors’ study demonstrates a 15% incidence of postoperative MRD1 reduction after upper eyelid blepharoplasty. Orbicularis oculi muscle removal was significantly associated with this occurrence.

The Flip-Back Myocutaneous Advancement Flap for Periocular Reconstruction Purpose: To present a novel myocutaneous flap for anterior lamellar reconstruction. Methods: Retrospective interventional case series of consecutive patients who underwent Mohs reconstruction using the flip-back flap. Operations were performed by a single surgeon (DTT) between January 2012 and May 2016. For lower eyelid defects, an extended subciliary incision was made and a skin-muscle flap developed and suspended in the manner of lower eyelid blepharoplasty. A back-cut was used to develop a pedicle from the overlapping tissue, which was then rotated 180 degrees into the defect. A similar method was employed in an inverted manner for upper eyelid defects. Postoperative eyelid function, cosmesis, complications, and need for further interventions were assessed. Results: Ten patients—8 with lower and 2 with upper eyelid defects—were reconstructed using this method. Mean follow up was 18.3 ± 15.5 months with a minimum interval of 4 months. Despite the 180-degree rotation of a relatively narrow pedicle, none of the patients experienced flap necrosis. Postoperative function and cosmesis was satisfactory, with no tissue puckering, notching, or symptomatic retraction. No antimetabolite/steroid injection or surgical revision was required. Conclusions: The flip-back flap expands the armamentarium of the periocular reconstructive surgeon. Its particular forte is in addressing broad and relatively shallow anterior lamellar defects where sufficient tissues are not available for transposition via a uni- or bipedicle flap. By leveraging the robust periocular vascular plexus and defying traditional guidelines governing pedicle formation and rotation, it permits creation of a local flap in cases where skin grafts or extensive Mustarde-style flaps might otherwise be required. The flip-back myocutaneous flap offers a novel alternative to skin grafting or more extensive cheek rotational flaps for reconstruction of challenging anterior lamellar defects involving the eyelids and adjacent periocular tissues.