Publications by authors named "Ayelet Priel"

32 Publications

Kelly Punch Punctoplasty and Simple Punctal Dilatation Are Equally Effective for Punctal Stenosis: A Prospective Study.

Ophthalmic Plast Reconstr Surg 2021 Feb 11. Epub 2021 Feb 11.

Goldschleger Eye Institute Institute of Pathology, Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: To examine the clinical, imaging, and histopathologic differences between Kelly punch punctoplasty and punctal dilatation, both with mini Monoka stent insertion.

Methods: This is a prospective, comparative clinical study. Patients with bilateral punctal stenosis and for whom surgery was advised participated in the study. The right eye underwent Kelly punch punctoplasty and the left eye simple punctal dilatation, both with mini Monoka stents were participated. Data were collected and analyzed before and 3 months following the procedure and included the degree of epiphora (Munk score) and punctal size as measured by anterior segment optical coherence tomography (AC- OCT). All specimens removed by the Kelly punch punctoplasty were sent for histopathologic evaluation, including Masson's trichome muscle staining.

Results: The study included 46 eyes of 23 patients (4 males and 19 females) whose mean age at presentation was 60.43 ± 14.81 years (range 19-84 years). There was a significant decrease in the Munk score after both punctoplasties compared with baseline values (P < 0.01, matched pairs). There were no significant differences between groups in the delta Munk score. There was a significant increase in punctal size after both procedures compared with baseline values as measured by AS-OCT. Horner-Duverney's muscle was visible in only 3 of the 23 (13.04%) specimens from patients who underwent the Kelly punch punctoplasty.

Conclusions: The Kelly punch punctoplasty and the simple dilator punctoplasty, both with stents, are equally effective treatments for epiphora due to acquired punctal stenosis. Only a few specimens removed during the Kelly punch method show muscle fibers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IOP.0000000000001940DOI Listing
February 2021

Quality of life of patients with thyroid eye disease: 3-year follow-up in a multidisciplinary clinic in Israel.

Graefes Arch Clin Exp Ophthalmol 2021 Feb 2. Epub 2021 Feb 2.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Background: Changes in the quality of life (QOL) of patients with thyroid eye disease (TED) were examined during a 3-year follow-up in a multidisciplinary eye clinic, and factors that may improve QOL were identified.

Methods: A retrospective review of medical records of all patients who attended the TED clinic at Sheba Medical Center, Israel, from May 2016 to May 2019 was performed. The retrieved data included demographics, comprehensive ophthalmic examination findings, clinical activity scores (CAS), laboratory test results, and QOL assessments by the Graves' Orbitopathy QOL (GO-QOL) questionnaire.

Results: One hundred thirty-two TED clinic patients were examined. Thirty patients (22.72%) received medical treatment consisting of steroids according to the European Group on Graves' Orbitopathy (EUGOGO) protocol, high-dose steroids, or immunosuppressive drugs. Twenty-eight patients (21.21%) underwent surgical rehabilitation (decompression, strabismus, or eyelid surgery). There was a significant increase in total QOL score after steroid treatment according to the EUGOGO protocol, after decompression surgery, and after strabismus surgery compared to pre-treatment total QOL (p=0.04, p=0.021, and p=0.042, respectively, matched pairs). In addition, there were significant positive correlations between the changes in the total QOL score and the change in thyroid-stimulating immunoglobulin (TSI) as well as the change in CAS among the patients who underwent medical and surgical interventions.

Conclusions: QOL improved significantly after medical/surgical treatments. A change in the CAS and in the TSI may also correlate with change in QOL. Periodic evaluation of TED patients' QOL is recommended for enhanced and more comprehensive management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00417-021-05103-5DOI Listing
February 2021

Gender differences in clinical presentation and prognosis of thyroid eye disease.

Eur J Ophthalmol 2020 Nov 6:1120672120964112. Epub 2020 Nov 6.

Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.

Objective: To examine the clinical differences in manifestation, treatment, and prognosis of thyroid-eye-disease (TED) between men and women.

Methods: This is a longitudinal cohort study. Men and women, who diagnosed with TED and treated at a multidisciplinary TED clinic, were compared regarding differences in demographics, eye examination, disease activity, and quality of life evaluation.

Results: TED was diagnosed in 132 patients during the study period, and they included 38 men (28.78%) and 94 women (71.21%). There were six men and 20 women with active disease (Clinical-Activity-Score (CAS) ⩾ 3) during the entire follow-up period ( < 0.01). The mean time from TED diagnosis to CAS ⩾ 3 was 4.50 years for men and 2.35 years for women ( = 0.05). There were no significant differences in mean total Graves' Orbitopathy-Quality-of-Life questionnaire (GO-QOL) score. However, mean GO-QOL subtotal score of external appearance of women was significantly lower compare to men in the first and last visit ( = 0.04, 0.03, respectively).

Conclusion: Active disease was more common in women and the time-from-diagnosis of TED to CAS ⩾ 3 was shorter among women. Moreover, the appearance QOL score of women was poorer. These findings should be taken into consideration when planning the timing of treatment and when choosing the best treatment for TED patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1120672120964112DOI Listing
November 2020

New insight into the physiologic function of Müller's muscle.

Exp Eye Res 2021 01 30;202:108336. Epub 2020 Oct 30.

The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Purpose: Müller's muscle is a sympathetically innervated smooth muscle which serves as an accessory upper eyelid retractor. Its physiologic function and purpose have not yet been clearly defined. We hypothesize that sympathetic innervation to Müller's muscle serves to adjust the upper eyelid's position to variations in pupil size in response to changes in light intensity.

Methods: This is a single center cross-sectional study. Healthy volunteers were asked to fixate on a distant non-accommodative target, and a video scan of the anterior segment was performed for each subject's right eye using the Heidelberg Spectralis® optical coherence tomography scanner in infrared mode. The video was taken both in photopic and scotopic conditions, recording the resultant transition of the pupil and eyelids. The pupil diameter (PD), upper eyelid margin-to-reflex distance (MRD1), lower eyelid margin-to-reflex distance (MRD2), and vertical palpebral fissure height (PFH) were measured.

Results: Thirty-three healthy volunteers (19 women, 57.6%) with a median age of 40 years (range 30-58) were included. The mean PD under photopic conditions increased significantly under scotopic conditions, from 3483 ± 521 μm to 6135 ± 703 μm, respectively (P < 0.0001). An increase in MRD1 was observed following transition from light to dark, with a mean change of 348 ± 311 μm (P < 0.0001). There was no significant change in MRD2.

Conclusions: Upper eyelid retraction occurs after transition from photopic to scotopic conditions. This movement suggests the existence of an "eyelid-light reflex" involving Müller's muscle that adjusts the position of the eyelids as the pupil dilates under scotopic conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.exer.2020.108336DOI Listing
January 2021

Kelly punch punctoplasty vs. simple punctal dilation, both with mini-monoka silicone stent intubation, for punctal stenosis related epiphora.

Eye (Lond) 2021 Feb 21;35(2):532-535. Epub 2020 Apr 21.

Sheba Medical Center, Goldschleger Eye Institute, Tel Hashomer, Israel.

Objectives: To compare the outcomes of stenotic punctal dilation by means of a punctal dilator alone vs. a Kelly punch punctoplasty, both followed by insertion of a mini-monoka stent, for treatment of symptomatic punctal stenosis.

Methods: A retrospective, comparative study. The participants were patients with punctal stenosis related epiphora treated at the Goldschleger Eye Institute, Sheba Medical Center. All patients were treated either by simple punctal dilation (group 1) or Kelly punch-assisted punctoplasty (group 2), both followed by mini-monoka stent insertion. Symptoms relief and subjective epiphora scoring (Munk score) were compared and analysed.

Results: Fifty patients were included in the study; Mean age (+SD) of the participants was 60 years (±12, range 30-86 years). Baseline characteristics (age, gender distribution, and visual acuity) were similar in both groups. The mini-monoka stent was placed for an average period of 2 weeks, and all patients received postoperative steroids and antibiotic treatment for 1 week. The Munk score decreased significantly in both groups following the procedure, dropping from 4.9 to 1.9 in group 1 and from 4.3 to 1.2 in group 2 (P < 0.005 for both groups). There was no difference in the delta Munk score between the two groups.

Conclusions: Simple punctal dilation followed by insertion of a mini-monoka stent is effective in alleviating the symptoms of punctal stenosis-related epiphora. There was no added benefit when the more invasive Kelly punch-assisted punctoplasty was used, raising some doubt about its justification in these cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41433-020-0891-3DOI Listing
February 2021

Naevus of Ota: clinical characteristics and proposal for a new ocular classification and grading system.

Br J Ophthalmol 2021 Jan 30;105(1):42-47. Epub 2020 Mar 30.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.

Introduction: Naevus of Ota is a congenital condition that may involve the skin, eyeball and even intracranial structures usually in the distribution of the ophthalmic and maxillary divisions of the trigeminal cranial nerve. The purpose of this study was to summarise our experience with the ocular clinical presentation, imaging, outcome, treatment of complications and to offer a new classification of patients with naevus of Ota.

Methods: We retrospectively reviewed the patients' medical records and the following parameters were retrieved and analysed: demographics, clinical presentation complications and treatment of complications. Imaging characteristics of patients with naevus of Ota were compared with images from the same period of time of 57 age-matched and gender-matched patients without naevus of Ota (control group).

Results: The series was composed of 40 patients (18 males, 22 females) whose mean age at diagnosis was 35.27 years (range 0.5-77 years). Thirty-three patients (82.5%) were type I naevus of Ota according to the Tanino classification, three patients (7.5%) were type II, one patient (2.5%) was type III and three patient (7.5%) were type IV (bilateral naevus of Ota). We further classified all cases in according to the ocular involvement extent. Three patients developed malignant transformation to choroidal melanoma and four patients developed glaucoma.

Conclusions: In this study, a new clinical classification based on the involved ocular component and extent of the involvement (in quadrants) of the globe is suggested first. Further studies are needed to assess whether our clinical ocular classification can assist in identifying patients at risk for developing glaucoma and malignant transformation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bjophthalmol-2019-313984DOI Listing
January 2021

Changes in Refraction and Visual Acuity after Upper Eyelid Blepharoplasty versus Posterior Approach Ptosis Procedures.

Ophthalmic Res 2020 5;63(6):588-592. Epub 2020 Mar 5.

Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel,

Purpose: To evaluate surgically induced refractive changes (SIRC) and visual acuity (VA) changes after blepharoplasty combined with posterior approach ptosis surgery (Müller's muscle-conjunctival resection [MMCR]) versus upper eyelid blepharoplasty alone.

Methods: In this prospective, comparative, clinical study on patients undergoing MMCR and blepharoplasty, comprehensive ophthalmic examinations were performed preoperatively and 3 months postoperatively. SIRC were calculated with the 10-step Holladay method.

Results: Fifty-six patients participated in the study, 31 in the blepharoplasty group and 25 in the ptosis group. logMAR VA improved significantly after surgery in both groups (p < 0.001). In both groups, most patients showed significant changes in SIRC sphere and spherical equivalent of >0.5 D (blepharoplasty group: 61.29 and 67.74%; ptosis group: 72.72 and 72.72%, respectively). Patients undergoing combined blepharoplasty ptosis surgery showed the greatest SIRC cylinder.

Conclusions: Upper eyelid blepharoplasty with or without MMCR is associated with significant SIRC 3 months postoperatively. This may affect decision-making for all patients, especially for those who intend to seek refractive correction in addition to the index upper eyelid surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000506951DOI Listing
March 2020

The clinical and histopathological characteristics of Kelly punch punctoplasty.

Eye (Lond) 2020 12 17;34(12):2295-2299. Epub 2020 Feb 17.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: To examine the clinical presentation, histopathological characteristics and surgical success of patients that underwent Kelly punch punctoplasty.

Methods: A retrospective consecutive case series of all patients diagnosed with punctal stenosis and referred to Kelly punch punctoplasty and mini-monoka insertion between January 2017 and December 2017. The demographic, clinical and prognosis parameters were retrieved and analyzed. Moreover, a histopathological examination was performed on the tissue retrieved from the Kelly punch at the end of the procedure in order to evaluate the presence of muscle in the tissue, as well as chronic inflammation.

Results: The series was composed of 44 eyes of 28 patients. All patients' complaints prior to surgery were epiphora: 18 patients had bilateral epiphora, 5 presented with right-eye epiphora and 5 with left-eye epiphora. The average Munk degree of epiphora before surgery was 3 and at least 3 months after surgery 1.04 (matched pairs, p < 0.0001). Two patients underwent the second punctoplasty. In haematoxylin and eosin staining, the Riolan muscle was not visible in the mucosal layer in 40 specimens. In four specimens, the muscle was observed. A Masson's trichrome staining ensured that the Riolan muscle existed only in those four specimens.

Discussion: Kelly punch punctoplasty is a simple and minimally invasive procedure for punctal dilation with high functional success rate. Moreover, in histopathological specimens, in all but four of the cases there was no muscle indicated. Intact Riolan muscle enables the punctum to stay in the right circular shape and position, and the lacrimal pump to maintain its pressure gradient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41433-020-0813-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784900PMC
December 2020

Endoscopic dacryocystorhinostomy with and without mucosal flap-is there any difference?

Eye (Lond) 2020 08 25;34(8):1449-1453. Epub 2019 Nov 25.

Goldschleger Eye Institute, The Chaim Sheba Medical Center, Tel Hashomer, Israel.

Background: The nasal mucosa is sacrificed in conventional endoscopic dacryocystorhinostomies (EDCRs). Some surgeons, however, modify the technique by elevating a mucosal flap prior to creating the osteotomy with the aim of preserving the mucosa. To our knowledge, no clear-cut benefit of a mucosal flap has been established. The aim of this study is to examine the differences in surgical techniques and success rates of EDCRs with and without mucosal flap preservation.

Methods: We carried out a medical record review of all patients who underwent primary EDCR at the Goldschleger Eye Institute from October 2009 to October 2017. The following data were retrieved from the medical database and analyzed: patient demographics (age at diagnosis and gender), medical history, examination findings, surgical details, postoperative success, complications, and follow-up.

Results: A total of 107 patients who underwent 117 EDCRs participated in the study. Fifty-one patients comprised the group without a mucosal flap and 56 patients comprised the group with mucosal flap preservation. The medical history, presenting complaints, and preoperative examination findings were similar for both groups. The surgical success rate was not significantly different between the groups (82.1% without flap vs. 86.8% with flap, P = 0.478, Chi-square).

Conclusion: The findings of this comparison of EDCRs with and without mucosal flap preservation in a large patient population revealed no differences in surgical success or complications rates between the two procedures and, therefore, no benefit for adding flap preservation to conventional EDCRs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41433-019-0716-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468247PMC
August 2020

No impact of nasal septoplasty on the outcome of endoscopic dacryocystorhinostomy.

Eye (Lond) 2020 08 25;34(8):1454-1458. Epub 2019 Nov 25.

Goldschleger Eye Institute, Sheba Medical Center, Ramat Gan, Israel.

Objective: To compare the outcomes of combined endoscopic dacryocystorhinostomy (endoDCR) with nasal septoplasty for deviation of the nasal septum to endoDCR alone in cases of nasolacrimal duct obstruction (NLDO).

Methods: A retrospective cohort study that included 107 consecutive patients with NLDO, who underwent endoDCR with or without concomitant nasal septoplasty in our institution between October 2009 and October 2017.

Results: A total of 117 operations were performed (107 patients, 80.4% females; mean age ± SD 51.1 ± 19.5 years). Twenty-five (21.4%) endoscopic surgeries were combined with septoplasty (the endoDCR + septoplasty group), and 92 (78.6%) comprised endoDCR alone (the endoDCR group). There was no difference in anatomical success and functional success rates between the two groups (P = 0.76 and P = 0.18, respectively). There were no complications attributed to the septoplasty component of the surgical procedure.

Conclusion: Considerable numbers of patients undergoing endoDCR also require a septoplasty. Combining an additional procedure (septoplasty), that was not performed for its original indication but rather for facilitating the main surgical intervention (endoDCR), yields surgical success and associated complications equivalent to those of endoDCR alone.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41433-019-0696-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376107PMC
August 2020

Efficacy of Vismodegib for the Treatment of Orbital and Advanced Periocular Basal Cell Carcinoma.

Am J Ophthalmol 2019 11 9;207:62-70. Epub 2019 May 9.

Department of Ophthalmology, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel.

Purpose: To evaluate the effectiveness of vismodegib, a Hedgehog pathway inhibitor, in treating orbital and advanced periocular basal cell carcinoma (BCC) in Israeli multidisciplinary medical centers.

Design: Retrospective case series.

Methods: Background, treatment, and outcome data were retrospectively collected from the medical records of all patients with locally advanced and metastatic orbital or periocular BCC treated with vismodegib in 2012-2017 at 2 tertiary medical centers.

Results: The cohort included 21 patients (16 male) of median age 76 years with periocular (n=6) or orbital (n=15) BCC. Median duration of treatment was 9 months, with follow-up of 26 months (range 9-60 months) overall and 17 months after treatment cessation. Clinical response was complete in 10 patients, partial in 10 patients, and stable in 1 patient. Among the complete responders, 5 maintained a complete response at 16 months, and 3 who stopped treatment had a recurrence 8 months later. Almost all treatment-related adverse reactions were graded 1 or 2 (low-grade). The most common grade 1 or 2 complications were muscle spasm (76%), followed by dysgeusia (57%), alopecia (47%), weight loss (47%) and decreased appetite (19%). The only grade 3 or 4 adverse event was hepatotoxicity (10%). Eight patients discontinued treatment because of side effects. Five patients died, most from reasons unrelated to vismodegib therapy, except for 1 patient who died from possibly treatment-related sepsis (grade 5 adverse event).

Conclusions: To our knowledge, this is the only study generated outside the United States and Europe, and it represents the largest study to date on vismodegib therapy for locally advanced periocular BCC. Treatment according to an individualized maximally tolerated dose may achieve a comparable response to the ERIVANCE protocol. Longer-term studies are needed to assess prognosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajo.2019.04.013DOI Listing
November 2019

Challenging Management of Double Vision After Functional Endoscopic Sinus Surgery-A Series of 6 Cases.

Am J Ophthalmol 2018 06 29;190:134-141. Epub 2018 Mar 29.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS).

Design: Retrospective observational case series.

Methods: The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes.

Study Population: All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included.

Main Outcome Measures: The presence and extent of strabismus and double vision at the end of follow-up.

Results: Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1-5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only.

Conclusions: Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajo.2018.03.030DOI Listing
June 2018

The Epidemiological, Clinical, and Histopathological Characteristics of Lacrimal Gland Biopsies in a Tertiary Care Center in Israel.

Isr Med Assoc J 2018 Feb;20(2):104-108

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: The distribution of pathology and clinical characteristics of lacrimal gland diseases are different in different areas of the world.

Objectives: To evaluate the incidence rate, patient characteristics, and indications for surgical intervention of lacrimal gland lesions in a tertiary care center in Israel.

Methods: All biopsied or surgically removed lacrimal gland lesions at the Goldschleger Eye Institute from 2009 to 2015 were identified. The following data were collected: age, gender, indications for surgical intervention, diagnosis, treatment, and prognosis.

Results: We evaluated 28 lacrimal gland biopsies from 26 patients (11 men, 15 women). Mean age at biopsy was 47.5 years old. The most common presenting symptoms were: eyelid swollenness (57.14%), ptosis (32.14%), and proptosis (10.71%). All patients underwent computed tomography and magnetic resonance imaging. In 28 cases, infiltrations of the lacrimal gland were found. In nine cases infiltration of muscles or orbital extension were found. The most common pathologies were non-specified inflammation (44.82%), lymphoma (20.68%), and immunoglobulin G4-related disease (10.34%). The treatment was diverse according to the patient diagnosis. Prognosis of lacrimal gland disease was good; however, in five patients the systemic disease progressed.

Conclusions: Lesions of the lacrimal gland comprise a wide variety of pathological findings that require different treatment strategies. Lacrimal gland biopsies enable physicians to precisely recognize the pathology; therefore, it is important to consider this surgical method in any patient with lesions in the lacrimal gland.
View Article and Find Full Text PDF

Download full-text PDF

Source
February 2018

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury.

Ophthalmic Plast Reconstr Surg 2016 Jul-Aug;32(4):296-301

*Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Shiley Eye Institute, University of California San Diego, La Jolla, California, U.S.A.; †Oculoplastic Service, Singapore National Eye Center, Singapore, Singapore; ‡Division of Orbital, Ophthalmic Plastic and Reconstructive Surgery, Clinica de Oftalmología de Cali, Universidad del Valle, Cali, Colombia; and §Department of Ophthalmology, Goldschleger Eye Institute, Sheba Medical Center at Tel Hashomer, Tel Aviv, Israel.

Purpose: Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described.

Methods: This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded.

Results: Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25-80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1-5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively.

Conclusion: Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IOP.0000000000000511DOI Listing
February 2017

Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation.

Ophthalmic Plast Reconstr Surg 2014 Jan-Feb;30(1):24-7

*Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, Department of Ophthalmology, University of California, San Diego; †Department of Ophthalmology, Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora; and ‡Fante Eye and Face Center, Denver, Colorado, U.S.A.

Purpose: Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed.

Methods: The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation.

Results: A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases.

Conclusions: Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IOP.0b013e3182a7502eDOI Listing
June 2014

[Congenital orbital teratoma].

Harefuah 2013 Jun;152(6):323-5, 369

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer Hospital.

Congenital orbital teratoma is a rare benign tumor, composed of all three germ cell layers. The Lesion presents clinically as uniLateral proptosis in the newborn. In order to diagnose the tumor correctly a multidisciplinary approach is needed, including ophthalmologists, neurosurgeons, pediatrics, radiologists, and pathologists to eventually diagnose the lesion. Early detection and treatment is needed in order to prevent mechanical destruction of adjacent tissues, and blindness from mechanical pressure on the optic nerve. Surgical excision is the treatment of choice. We present a case report of a newborn, diagnosed with congenital orbital teratoma, and discuss the clinical and histological characteristics of the tumor.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2013

Reduction of orbital inflammation following decompression for thyroid-related orbitopathy.

Biomed Res Int 2013 18;2013:794984. Epub 2013 Jun 18.

Division of Oculofacial Plastic and Reconstructive Surgery, UCSD Department of Ophthalmology, CA, USA.

Purpose: Thyroid-related orbitopathy (TRO) is associated with inflammation, expansion of orbital fat, enlargement of extraocular muscles, and optic neuropathy (ON). We examined the effects of orbital decompression on the inflammatory and congestive signs of TRO in patients who underwent emergent orbital decompression.

Methods: This retrospective, consecutive study included patients with ON from TRO who underwent orbital decompression. Pre- and postoperative orbital inflammatory signs in the operated and nonoperated, contralateral eyes were graded with the 10-item clinical activity score (CAS).

Results: Thirty-one orbits were included. Postoperatively, 22 patients and 29 orbits had resolution of ON while the remaining 2 patients had improvement in visual acuity. Mean preoperative CAS was 9.5 ± 0.4. At 12 months, postoperative CAS was 2.1 ± 0.6 (P < 0.01) in the operated eye and 3.2 ± 0.5 (P < 0.05) in the nonoperated, contralateral eye.

Conclusion: In our series, 94% of orbits had resolution of ON. There was also a statistically significant postoperative reduction in the CAS in both the operated and nonoperated, contralateral eyes. This phenomenon may be due to lowered venous congestion, decreased intraorbital pressure, and diminution in inflammatory factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2013/794984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3703426PMC
February 2014

Use of antimetabolites in the reconstruction of severe anophthalmic socket contraction.

Ophthalmic Plast Reconstr Surg 2012 Nov-Dec;28(6):409-12

UCSD Department of Ophthalmology, Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Center, La Jolla, California 92093-0946, USA.

Purpose: The use of antimetabolites is well established in ophthalmology with expanded uses still being defined. We describe our experience of antimetabolite use in the reconstruction of severe anophthalmic socket contraction.

Methods: Nonrandomized, retrospective case series. The medical records and clinical photographs of 5 patients with severe socket contraction were reviewed. Either 5-Fluorouracil (5-FU) (50 mg/ml) or Mitomycin C (MMC) (0.4 mg/ml) was used during the course of the surgery via direct injection into the operative bed in the area of scarring. In addition, in 3 cases, 5-FU was also applied after surgery, in the clinic setting. Variables examined included: number of previous socket operations; preoperative ability to retain a prosthesis; type of socket reconstruction; type, amount, and location of antimetabolite injected; number of postoperative injections; average follow-up; and the postoperative ability to retain a prosthesis.

Results: All 5 patients had multiple operations previously. After surgery, all 5 were able to retain an ocular prosthesis. We did not observe any delay in wound healing, implant exposure, or extrusion, and no significant side effects were noted.

Conclusion: The use of adjunct antimetabolite in severe anophthalmic socket reconstruction is an effective option that is well tolerated with minimal side effects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IOP.0b013e3182627e86DOI Listing
March 2013

Avastin treatment reduces retinal neovascularization in a mouse model of retinopathy of prematurity.

Curr Eye Res 2012 Jul 11;37(7):624-9. Epub 2012 May 11.

Goldschleger Eye Institute, Tel-Aviv University , Tel-Aviv, Israel.

Purpose: This study was designed to evaluate the effect of one intraperitoneal (IP) injection of bevacizumab (Avastin) on the severity of oxygen-induced retinopathy (OIR) in a mouse model.

Materials And Methods: Twenty-eight eyes of 14 mice with OIR were studied. There were nine mice in the bevacizumab-treated group (study group) and five mice in the saline-treated group (controls). The mouse OIR model consisted of a 5-day exposure to 75% oxygen. On postnatal day 12 (P12), Avastin 2.5 mg/kg was administered IP to the study group and 2.5 mg/kg normal saline was administered IP to the controls. All 14 mice underwent fluorescein angiography of the retinal vasculature on P17 and the following parameters were scored (Modified Retinopathy Scoring System, MRSS): blood vessel growth, formation of blood vessel tufts, extraretinal neovascularization, degree of central constriction, and tortuosity of vessels. In addition, the neovascular vessels were quantified on the hematoxylin and eosin (H&S)-stained paraffin sections of the eyes in a masked fashion.

Results: The MRSS score in the Avastin-treated mice was significantly lower than that of the saline-treated mice (3.06 ± 1.63 versus 7.1 ± 2.01, respectively, p = 0.0021). The neovascularization count was also significantly lower in the study group (3.44 ± 1.81 versus 9.34 ± 3.23 for the controls, p = 0.0013).

Conclusions: IP Avastin treatment reduced the extent of oxygen-induced retinopathy in a mouse model of retinopathy of prematurity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3109/02713683.2012.669003DOI Listing
July 2012

Medial canthal degloving injuries: the triad of telecanthus, ptosis, and lacrimal trauma.

Plast Reconstr Surg 2011 Oct;128(4):300e-305e

La Jolla, Calif. From the Shiley Eye Center, Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, University of California, San Diego.

Background: Medial canthal degloving injury causes a spectrum of damage to the soft tissues of the nasoorbitoethmoid complex. The authors present a case series of medial canthal degloving injuries and discuss clinical findings and treatment options.

Methods: The medical records of nine patients who presented to the University of California, San Diego Ophthalmic Plastic Service with medial canthal degloving injuries between 1999 and 2010 were reviewed retrospectively. Data collected included type and duration of injury, clinical findings, surgical procedures, and duration of follow-up.

Results: Nine patients (seven males and two females) were examined and treated from 1999 to 2010. Average age at the time of presentation was 33.3 years (range, 12 to 68 years). Causes of injury included motor vehicle accident (six patients), bicycle accident (one patient), dog bite (one patient), and bear attack (one patient). Average duration of injury before presentation to the authors' clinic was 4.4 years (range, 2 months to 20 years). Average follow-up was 32 months (range, 6 to 110 months). Common findings in these patients included a laceration extending from the forehead or eyebrow region across the medial canthus, telecanthus, eyelid ptosis, and canalicular injury.

Conclusions: Medial canthal degloving injuries typically result in characteristic findings of vertically oriented laceration traversing the medial canthus, telecanthus, ptosis, and injury to the lacrimal outflow system. Reconstruction should be performed in a staged fashion, first addressing telecanthus and lacrimal system repair. Ptosis repair is performed as a second-stage procedure. Adherence to specific surgical principles leads to satisfactory functional and cosmetic results.

Clinical Question/level Of Evidence: Therapeutic, V.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0b013e3182268b67DOI Listing
October 2011

Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy.

J Cataract Refract Surg 2011 Aug 17;37(8):1434-8. Epub 2011 Jun 17.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.

Purpose: To assess the safety of phacoemulsification cataract extraction in patients on combined anticoagulant and antiplatelet treatment.

Setting: Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Design: Prospective interventional case series.

Methods: Consecutive patients with simple cataract on combined anticoagulant (warfarin) and antiplatelet (aspirin or clopidogrel) treatment who were unable to discontinue the treatment because of a high risk for thromboembolic events were included. Patients had cataract extraction under topical anesthesia with a clear corneal incision (CCI), phacoemulsification, and implantation of a foldable posterior chamber intraocular lens. Prothrombin time-international normalized ratio and platelet functions were evaluated immediately before surgery. Patients were also examined 1 day and 7 days postoperatively. Intraoperative and postoperative ocular bleeding and other related complications were assessed.

Results: Forty patients (51 eyes) with a mean age of 72 years (range 51 to 90 years) had phacoemulsification. Hemorrhagic complications were not observed at surgery or during the 1-week follow-up. Surgical complications included 1 rupture of the capsulorhexis and 1 implantation of a capsular tension ring due to partial zonulysis. No patient had a thromboembolic event.

Conclusions: In patients with uncomplicated cataract at high risk for thromboembolic events, phacoemulsification cataract surgery using a CCI under topical needle-free anesthesia was safely performed without discontinuing systemic anticoagulant and antiplatelet treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcrs.2011.02.035DOI Listing
August 2011

Analysis of eyelid fat pad changes with aging.

Ophthalmic Plast Reconstr Surg 2011 Sep-Oct;27(5):348-51

UCSD Department of Ophthalmology, Shiley Eye Center, La Jolla, CA, USA.

Purpose: Few studies have focused on the aging changes in the upper eyelid. This study evaluated the differential changes in the nasal and central fat pads of the upper eyelid associated with aging.

Methods: In this retrospective, consecutive series, the medical records and photographs of 77 patients were reviewed. The patients were grouped in 7 categories according to decade of life. Using a standardized scale, the volume grade of the nasal and central fat pads was graded from 0 to 3. Statistical evaluation correlating age with central and nasal fat pad change was performed.

Results: With aging, the central fat pad volume appeared to diminish, with relative sparing of the nasal fat pad. There was a positive correlation of the volume grade of the nasal fat pad with age and a negative correlation of the central fat pad with age. In addition, there was a statistically significant difference between the volume grades of the nasal and central fat pads in the groups 70 years and older.

Conclusions: With aging, there appears to be a pattern of differential fat pad alteration. This study shows that in the upper eyelids of patients >70 years of age, the medial fat pad becomes prominent whereas the central fat pad atrophies. Teleologically, the relative preservation of nasal fat may be due to its higher abundance of neural-crest progenitor cells. Clinically, this finding has implications in esthetic and functional upper eyelid blepharoplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IOP.0b013e3182141c37DOI Listing
November 2011

Rituximab for thyroid eye disease.

Ophthalmology 2011 Apr;118(4):792; author reply 792-3

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ophtha.2011.01.012DOI Listing
April 2011

Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers.

Plast Reconstr Surg 2011 Feb;127(2):844-849

La Jolla, Calif.; Seoul, Korea; and Singapore From the Division of Ophthalmic Plastic and Reconstructive Surgery, University of California, San Diego Department of Ophthalmology, Shiley Eye Center; the Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Kim's Eye Hospital; and the Singapore National Eye Center.

Background: Preliminary experience with the use of hyaluronic acid fillers as a nonsurgical alternative in the management of upper eyelid crease asymmetry and superior sulcus hollowing in Asian patients has proven promising.

Methods: This retrospective, interventional case series included seven patients (11 eyes) of various Asian ancestries. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. Upper eyelid crease asymmetry and hollowing of the superior sulcus were assessed before and after treatment. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juvéderm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Pretreatment and posttreatment photographs were taken. Outcomes were assessed by the total volume injected; masked, independent assessment using preoperative and postoperative photographs; and the subjective assessment of results by the patient.

Results: The average age was 43.1 years. The average volume of hyaluronic acid filler injected was 0.61 cc per eye. All seven patients were satisfied with the cosmetic improvement after hyaluronic acid filler injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 18 months.

Conclusions: Hyaluronic acid filler injections into the upper eyelid and superior sulcus are effective in providing volume to recreate the fullness natively present in the Asian upper eyelid. Furthermore, this fullness lowers the surgically created eyelid crease in those patients with eyelid asymmetry following cosmetic blepharoplasty. It should be considered in Asian patients presenting with upper eyelid hollowing or asymmetric eyelid creases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0b013e3181fed6cbDOI Listing
February 2011

Applied anatomy for the aesthetic surgeon.

Curr Opin Ophthalmol 2010 Sep;21(5):404-10

Division of Oculofacial Plastic and Reconstructive Surgery, UCSD Department of Ophthalmology, Shiley Eye Center, La Jolla, California 92093-0946, USA.

Purpose Of Review: With the expanding view of the oculofacial surgeon as experts in the realm of aesthetic surgery, familiarity with facial anatomy is essential. The purpose of this review is to present an update on the relevant facial anatomy and its application on rejuvenation.

Recent Findings: Numerous studies have redefined facial morphology and variations in facial features, which are important when treating all aesthetic patients. This particularly becomes valuable when patients of differing ethnic origins present for evaluation. Enhanced surgical options are now available that have expounded on previous work on skeletal and fascial attachments of the face that occur with aging. Additionally, an improved understanding of facial anatomy has led to safer and more effective surgical procedures to anatomically restore youth to the aging face.

Conclusion: Anatomic and anthropomorphic knowledge is constantly improving in the realm of oculofacial plastic surgery. Newer insights into the treatment of facial aging have resulted from the application of an ever-expanding understanding of facial anatomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ICU.0b013e32833ce990DOI Listing
September 2010

The trans-septal approach to the orbital apex via the contralateral exenterated orbit.

Orbit 2010 Oct 23;29(5):284-5. Epub 2010 Jun 23.

Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Shiley Eye Center, University of California, San Diego, CA 92093-0946, USA.

Purpose: To report a unique approach to the orbital apex through the contralateral orbit.

Methods: A 65-year-old male presented with right compressive optic neuropathy due to nasopharyngeal carcinoma spread. Clinical evaluation and imaging showed a right orbital apex mass. Surgery included apical orbital tumor debulking, and orbital decompression performed via the contralateral exenterated side. Postoperatively, symptoms were relieved.

Conclusions: Orbitotomy via the contralateral exenterated orbit should be considered as a surgical option in these unique patients requiring direct access to the orbital apex.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3109/01676831003664335DOI Listing
October 2010

Cryo-assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases.

Acta Ophthalmol 2010 Sep;88(6):675-80

The Goldschleger Eye Institute, Sackler Faculty of Medicine, Tel-Aviv University, Sheba Medical Centre, Tel-Hashomer, Israel.

Purpose:   To describe and evaluate a cryo-assisted, minimally invasive, anterior approach for orbital tumour surgery.

Methods:   Retrospective, non-comparative, consecutive, interventional case series of 103 patients who were operated on by the same surgeon for retroocular orbital tumours over the last 16 years.

Results:   A cryo-assisted, minimally invasive, anterior approach was employed in 63 out of the 103 patients (61.2%). In 37 patients (35.9%), anterior orbitotomy without the use of cryoprobe was employed for biopsy or excision of small, anteriorly located lesions. Lateral orbitotomy was used in three patients (2.9%). In a subgroup of 61 patients with circumscribed lesions (mainly cavernous haemangiomas and schwannomas), cryoextraction was used in 51 (83.6%). None of the procedures required conversion to lateral orbitotomy and there were no intraoperative complications.

Conclusion:   In contrast to other reports on the treatment of orbital lesions, in the current case series surgery of most solid tumours and many other cystic or infiltrative lesions was achieved here via an anterior, cryo-assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favourable consideration because the combination of the anterior approach with the use of cryoprobe and surgical microscope can yield successful results, even in patients with large or deeply located tumours - obviating in most of them the need for lateral or transcranial orbitotomies with bone flaps.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1755-3768.2009.01515.xDOI Listing
September 2010

Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematologic risk assessment.

Am J Ophthalmol 2007 Nov 17;144(5):719-723. Epub 2007 Sep 17.

Goldschleger Eye Institute, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.

Purpose: To assess the risks of intra- and postoperative bleeding tendency associated with uncomplicated cataract surgery by phacoemulsification in patients receiving Coumadin treatment.

Design: Prospective, nonrandomized, interventional, consecutive case series.

Methods: Sixty-three consecutive patients underwent cataract extraction with lens implantation in 75 eyes. All patients were receiving Coumadin therapy at the time of surgery, and nine patients (14.3%) were also taking antiaggregants. The operations were performed by phacoemulsification technique under topical anesthesia. All patients underwent a hemostatic work-up before intervention. Structured questionnaires were completed by the surgeon immediately after the operation. In 18 (24%) eyes, the surgery was videotaped, and the tapes were reviewed subsequently for any bleedings by an independent observer.

Results: Twelve patients (19%) underwent surgery in both eyes, not simultaneously. The mean prothrombin time international normalized ratio (INR) was 2.03 at the time of the surgery. No significant intraoperative bleeding occurred. Four (6.3%) patients had minor postoperative ocular bleeding. A microscopic hyphema and a dot retinal hemorrhage were each seen in one eye on the first postoperative day, and small iris hemorrhages were identified in two additional eyes at the one-week visit. All bleedings disappeared within one week without affecting the visual acuity. The mean INR of the four patients with minor bleedings was 2.1.

Conclusions: Cataract surgery by phacoemulsification in uncomplicated eyes can be performed safely in patients receiving Coumadin treatment. However, a large clinical trial is required to assess the safety of continuous Coumadin treatment associated with phacoemulsification in eyes with complicated cataract.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajo.2007.07.029DOI Listing
November 2007