Publications by authors named "Bobby S Korn"

112 Publications

Lateral Wall Implant as an Adjunct to Lateral Wall Orbital Decompression in Severe Thyroid Eye Disease.

Ophthalmic Plast Reconstr Surg 2021 Jul 21. Epub 2021 Jul 21.

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, La Jolla, California Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California, U.S.A.

Purpose: To describe the use of a lateral wall implant as an adjunct in lateral orbital wall decompression in severe thyroid eye disease.

Methods: This study is a retrospective review of 6 patients who underwent prior orbital decompression but had persistent proptosis. These patients underwent lateral wall decompression with adjunct lateral wall implant placement with a manually vaulted 0.6-mm polyethylene-coated titanium mesh implant. Data collection included: visual acuity, intraocular pressure, exophthalmometry, ocular motility, eyelid position, and complication rates.

Results: Eight orbits in 6 patients underwent maximal lateral wall decompression and reconstruction using the polyethylene-coated titanium implant. Four males and 2 females were included with ages ranging from 25 to 73 years. Visual acuity improved an average of 2.4 lines (range 0-5 lines). Intraocular pressure improved an average of 7.5 mm Hg (2-13 mm Hg). There was reduction of proptosis by 3.4 mm on average (1-7 mm). Upper eyelid retraction improved on average by 1.8 mm (0-5 mm). Horizontal eye movements improved by 11% on average (-3.1% to +25%). Excellent cosmesis was achieved with no visible temple deformity, trismus, conjunctival scarring, orbital hemorrhage, or vision loss.

Conclusions: The amount of volume created in lateral wall decompression is limited by the amount of native bone present and the temporalis muscle. In severe or recalcitrant cases, the authors propose the placement of a lateral wall implant as an adjunct to laterally displace the temporalis muscle and create additional volume. This technique accomplishes further reduction of proptosis in patients who have undergone prior orbital decompression.
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http://dx.doi.org/10.1097/IOP.0000000000002007DOI Listing
July 2021

Giant Deep Orbital Dermoid Cyst Presenting in Infancy.

J Craniofac Surg 2021 Jul 7. Epub 2021 Jul 7.

Viterbi Family Department of Ophthalmology, UC San Diego, San Diego Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, La Jolla Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, CA.

Abstract: Orbital dermoid cysts are benign choristomas that are very common in children and occur most often as a lateral or medial mass associated with the frontozygomatic or frontoethmoidal suture line. The authors present an unusual case of an occult giant deep orbital dermoid cyst in infancy that initially presented with a small, benign appearance and central upper eyelid location on clinical exam. Orbitotomy with complete excision prevented further ocular sequelae in this 11-month-old.
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http://dx.doi.org/10.1097/SCS.0000000000007860DOI Listing
July 2021

Eyelid and Periorbital Soft Tissue Trauma.

Oral Maxillofac Surg Clin North Am 2021 Aug;33(3):317-328

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, 9415 Campus Point Drive, La Jolla, CA 92093, USA; Division of Plastic Surgery, UC San Diego Department of Surgery, 9500 Gilman Drive, La Jolla, CA 92093, USA. Electronic address:

Facial trauma often involves injuries to the eyelid and periorbital region. Management of these injuries can be challenging due to the involvement of multiple complex anatomic structures that are in close proximity. Restoration of normal anatomic relationships of the eyelids and periocular structures is essential for optimum functional and aesthetic outcome after trauma. This review provides an overview of the current literature involving soft tissue trauma of the eyelid and periorbital tissue, and highlights key steps in patient evaluation and management with various types of injuries.
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http://dx.doi.org/10.1016/j.coms.2021.04.004DOI Listing
August 2021

Outcomes of Single Suture Mueller's Muscle Conjunctival Resection: Ethnic Considerations.

Ophthalmic Plast Reconstr Surg 2021 Jun 4. Epub 2021 Jun 4.

Department of Ophthalmology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel Department of Ophthalmology, Dongguk University Ilsan Hospital, Goyang, Gyeonggido, Korea Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, UC San Diego Shiley Eye Institute, La Jolla, California, U.S.A. Division of Plastic Surgery, UC San Diego, La Jolla, California, U.S.A.

Purpose: To compare outcomes of Mueller's Muscle Conjunctival Resection (MMCR) between 2 groups of patients with different anatomy due to ethnic heritage.

Methods: The medical records of patients who underwent MMCR between 2013 and 2018 were retrospectively reviewed. Patients who underwent additional procedures, such as upper blepharoplasty and browplasty, were excluded from the study. Patients were divided in 2 groups based on self-identified ethnic groups (Asian and Caucasian). Image J software was used to calculate MRD1 from digital images. The improvement of MRD1 (net MRD1) after surgery was evaluated and compared between 2 groups.

Results: Eighty-three eyes of 68 patients were included in this study. The Asian group consisted of 41 eyelids from 28 patients. The Caucasian group consisted of 42 eyelids from 40 patients. The average age was 52.18 (SD 20.176) in the Asian group compared with the 66.45 years (SD 9.22, p< 0.005) in the Caucasian group. The mean improvement of MRD1 was 1.96 ± 0.75 mm in Asian group and 2.05 ± 0.72 mm in Caucasian group, which was not statistically significant (p = 0.62). The incidence of ptosis overcorrection and undercorrection between the groups was also not statistically significant.

Conclusions: There was no statistically significant difference in the surgical outcomes among the 2 study groups. Despite differences in the anatomy of Caucasian and Asian eyelids, MMCR is a successful procedure in patients self-identified from both ethnic groups.
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http://dx.doi.org/10.1097/IOP.0000000000001980DOI Listing
June 2021

Minimal Dissection Direct Frontalis Muscle Advancement Flap for Congenital Ptosis Repair.

J Craniofac Surg 2021 May 28. Epub 2021 May 28.

Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology School of Medicine, University of California San Diego, Division of Plastic and Reconstructive Surgery, University of California San Diego Department of Surgery, La Jolla, CA.

Background: Frontalis flap advancement is an alternative means of congenital ptosis repair from frontalis suspension utilizing autologous fascia or allogenic implants. Variations in technique, including flap division, location and number of skin incisions, and dissection planes, are described in the literature.

Materials And Methods: A retrospective case series of patients with congenital myogenic ptosis treated with simplified, minimal dissection frontalis flap advancement involving a single upper eyelid crease incision with dissection in the preseptal and subcutaneous planes without division to mobilize the frontalis flap. Inclusion criteria: pediatric patients age < 18 years with either primary or recurrent congenital ptosis following previous surgical repair. Exclusion criteria: ptosis of neurogenic etiology or postoperative follow-up < 3 months. Primary outcome measures were postoperative margin-reflex distance 1 (MRD1), the difference in MRD1 between surgical and nonsurgical eyelids in unilateral ptosis, and lagophthalmos. Secondary outcome measures included recurrence and complications.

Results: Twenty-six patients met inclusion criteria, 24 males and 2 females. Mean postoperative MRD1 at last follow-up was 2.9 ± 1.2 mm and the mean difference in MRD1 between surgical and nonsurgical eyelids at last follow-up was 1.1 ± 1.0 mm. Average lagophthalmos at postoperative month 2 to 5 was 0.6 ± 0.7 mm. One patient demonstrated postoperative lid retraction that required re-operation. Four of 31 eyelids (12.9%) demonstrated ptosis recurrence at 5, 12, or 24 months.

Conclusions: In this retrospective series, the authors report clinically and statistically significant surgical eyelid height improvement and symmetry between nonsurgical and surgical eyelids in congenital ptosis patients treated with minimal dissection direct frontalis flap advancement.
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http://dx.doi.org/10.1097/SCS.0000000000007761DOI Listing
May 2021

Secondary infection with rhino-orbital cerebral mucormycosis associated with COVID-19.

Orbit 2021 Mar 23:1-4. Epub 2021 Mar 23.

Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, UC San Diego Shiley Eye Institute, La Jolla, California, USA.

We report two fatal cases of rhino-orbital-cerebral mucormycosis associated with COVID-19 infection. Both patients had pre-existing diabetes mellitus type 2, were treated with corticosteroids, and developed ketoacidosis. Both patients rapidly declined owing to rapid extension of the infection into the intracranial cavity. We postulate that additional risk factors for opportunistic fungal infection exist in COVID-19 patients including mechanical ventilation and Sars-CoV-2 induced immunosuppression. The ophthalmologist's role is particularly important in the early diagnosis of mucormycosis associated with COVID-19.
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http://dx.doi.org/10.1080/01676830.2021.1903044DOI Listing
March 2021

Enrichment of IGF-1R and PPARγ signalling pathways in orbital inflammatory diseases: steps toward understanding pathogenesis.

Br J Ophthalmol 2021 Feb 26. Epub 2021 Feb 26.

Casey Eye Institute, Oregon Health & Science University Casey Eye Institute, Portland, Oregon, USA

Background: Orbital inflammatory disease (OID) encompasses a wide range of pathology including thyroid-associated orbitopathy (TAO), granulomatosis with polyangiitis (GPA), sarcoidosis and non-specific orbital inflammation (NSOI), accounting for up to 6% of orbital diseases. Understanding the underlying pathophysiology of OID can improve diagnosis and help target therapy.

Aims: To test the hypothesis that shared signalling pathways are activated in different forms of OID.

Methods: In this secondary analysis, pathway analysis was performed on the previously reported differentially expressed genes from orbital adipose tissue using patients with OID and healthy controls who were characterised by microarray. For the original publications, tissue specimens were collected from oculoplastic surgeons at 10 international centres representing four countries (USA, Canada, Australia and Saudi Arabia). Diagnoses were independently confirmed by two masked ocular pathologists (DJW, HEG). Gene expression profiling analysis was performed at the Oregon Health & Science University. Eighty-three participants were included: 25 with TAO, 6 with orbital GPA, 7 with orbital sarcoidosis, 25 with NSOI and 20 healthy controls.

Results: Among the 83 subjects (mean (SD) age, 52.8 (18.3) years; 70% (n=58) female), those with OID demonstrated perturbation of the downstream gene expressions of the IGF-1R (MAPK/RAS/RAF/MEK/ERK and PI3K/Akt/mTOR pathways), peroxisome proliferator-activated receptor-γ (PPARγ), adipocytokine and AMPK signalling pathways compared with healthy controls. Specifically, GPA samples differed from controls in gene expression within the insulin-like growth factor-1 receptor (IGF-1R, PI3K-Akt (p=0.001), RAS (p=0.005)), PPARγ (p=0.002), adipocytokine (p=0.004) or AMPK (p=<0.001) pathways. TAO, sarcoidosis and NSOI samples were also found to have statistically significant differential gene expression in these pathways.

Conclusions: Although OID includes a heterogenous group of pathologies, TAO, GPA, sarcoidosis and NSOI share enrichment of common gene signalling pathways, namely IGF-1R, PPARγ, adipocytokine and AMPK. Pathway analyses of gene expression suggest that other forms of orbital inflammation in addition to TAO may benefit from blockade of IGF-1R signalling pathways.
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http://dx.doi.org/10.1136/bjophthalmol-2020-318330DOI Listing
February 2021

The Effect of Photographic Visual Aids in Preoperative Patient Counseling in Oculoplastic Surgery.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3S):S70-S75

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa.

Purpose: To investigate the effect of visual supplementation and its mode of delivery in preoperative counseling of patients undergoing oculoplastic surgery.

Methods: A prospective randomized controlled trial of consecutive patients undergoing oculoplastic eyebrow and eyelid surgery was conducted. Patients were randomized to an "oral only" group receiving routine preoperative oral counseling or an "oral and visual" group receiving identical counseling visually supplemented with photographs demonstrating common postoperative physical findings. Patients in the "oral and visual" group were further randomized to receive education from the medical team in person versus prerecorded video. Patient emotions and expectations regarding postoperative healing were assessed preoperatively and at 1 week and 2 months postoperatively.

Results: 103 patients were included: 32 received in-person oral education, 33 received in-person oral education with photographs, and 38 received education with photographs via video. There were no significant differences in demographics or preoperative patient fear, anxiety, or preparedness. The "oral and visual" group expected more severe postsurgical discomfort and physical findings at postoperative day 1 and week 1. There were no significant differences between groups in surgery signup, cancellation, or triage call rates; patient expectations of postoperative months 2 and 4; or in anxiety, preparedness, or satisfaction.

Conclusions: Visual supplementation in preoperative counseling increases patient expectations of postoperative physical findings without escalating fear or anxiety, and has no significant impact on patient emotions, triage call rates, and satisfaction throughout their surgical experience. Preoperative education via video is perceived by patients to be equivalent to counseling in person by the surgeon.
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http://dx.doi.org/10.1097/IOP.0000000000001817DOI Listing
May 2021

A case of mistaken identity: of the orbit.

Orbit 2020 Aug 30:1-4. Epub 2020 Aug 30.

Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, UC San Diego, La Jolla, CA, USA.

The authors describe a rare presentation of invasive fungal rhino-orbital cellulitis caused by in an immunocompetent child. The patient was initially diagnosed and treated as , which has a high mortality rate and is primarily seen in immunocompromised patients. Though of the same order, Mucorales, the families and , may be difficult to differentiate on histologic examination and must be distinguished by fungal culture and speciation. Our patient responded well to sino-orbital debridement and systemic treatment with amphotericin and posaconazole.
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http://dx.doi.org/10.1080/01676830.2020.1814354DOI Listing
August 2020

Colorectal carcinoma presenting in the orbit: mass effect from an uncommon cause.

Orbit 2021 Aug 9;40(4):338-341. Epub 2020 Jul 9.

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, California, USA.

An 84-year-old male with previously documented poor medical follow-up presented with progressive painless proptosis of the right eye. Right upper eyelid ptosis, limited motility, proptosis, and inferomedial displacement of the right globe were noted on the exam. Computed tomography (CT) imaging revealed a right retrobulbar extraconal heterogenous mass with ill-defined borders. Biopsy revealed a malignant adenocarcinoma with tumor markers suggestive of a colorectal primary. A rectal mass was identified during a systemic workup. After biopsy, the patient was diagnosed with stage IV metastatic rectal adenocarcinoma. He began palliative radiation therapy shortly following diagnosis.
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http://dx.doi.org/10.1080/01676830.2020.1787466DOI Listing
August 2021

Early experience with teprotumumab for chronic thyroid eye disease.

Am J Ophthalmol Case Rep 2020 Sep 15;19:100744. Epub 2020 May 15.

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, La Jolla, CA, USA.

Purpose: To report the first case of a patient with chronic thyroid eye disease (TED) treated with teprotumumab.

Observations: A 50-year-old female with a 3-year history of Graves' disease presented with bilateral exophthalmos greatest on the left side. She was followed for 2 years with stable proptosis measurements (23mm OD, 28mm OS). Her clinical activity score (CAS) was 1 and there were no examination findings reflective of active inflammation. The patient underwent systemic treatment with teprotumumab and despite chronic TED and low CAS, she had notable improvement in proptosis (18mm OD, 22mm OS) and decrease in extraocular muscle volume as noted on orbital imaging.

Conclusion And Importance: This case report suggests that teprotumumab may be used in patients with chronic TED and low CAS. Improvement in the proptosis and reduction in extraocular muscle volume suggest that teprotumumab may alter disease course even in patients with inactive or quiescent TED.
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http://dx.doi.org/10.1016/j.ajoc.2020.100744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7243051PMC
September 2020

Canalicular laceration repair using a self-retaining, bicanalicular, hydrophilic nasolacrimal stent.

Orbit 2021 Jun 20;40(3):239-242. Epub 2020 May 20.

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, La Jolla, CA, USA.

: To evaluate outcomes of primary eyelid and canalicular laceration repair using a self-retaining bicanalicular hydrophilic nasolacrimal stent.: This study is a retrospective review of seven patients with canalicular laceration primarily repaired with a self-retaining bicanalicular nasolacrimal stent within 72 hours of initial injury. After lacrimal intubation, repair was performed by reapproximation of the lacerated tissues. Data collection included ophthalmic examination, mechanism of injury, involvement of upper/lower/common canaliculi, symptoms of epiphora, operative time, stent extrusion and canalicular irrigation.: Seven patients with monocanalicular laceration were repaired using the self-retaining bicanalicular nasolacrimal stent. The stent was left in place an average of 5 months. The average operative time was 29.3 minutes. None of the stents extruded prior to removal. After 5 months, the stent was removed successfully without difficulty. All patients reported subjective improvement in epiphora, with complete resolution of symptoms. Anatomic success was confirmed with irrigation in all cases. There were no complications associated with usage of the self-retaining bicanalicular nasolacrimal stent.: Primary repair of canalicular lacerations can be successfully performed with a self-retaining bicanalicular nasolacrimal stent. This stent has several advantages, including potentially faster operative times, no need for intranasal fixation or retrieval, easier intubation in the lacrimal system, and improved anatomic reapproximation of lacerated tissues.
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http://dx.doi.org/10.1080/01676830.2020.1768559DOI Listing
June 2021

Characterization of Facial Trauma Associated with Standing Electric Scooter Injuries.

Ophthalmology 2020 07 14;127(7):988-990. Epub 2020 Feb 14.

Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California; Division of Oculofacial Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, California; Division of Plastic Surgery, University of California, San Diego, La Jolla, California. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2020.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703691PMC
July 2020

Newly Designed Universal Trans-punctal Rigid Lacrimal Microendoscope.

Ophthalmic Plast Reconstr Surg 2020 Nov/Dec;36(6):579-581

Department of Ophthalmology, Osaka Medical College, Takatsuki City, Osaka, Japan.

Purpose: To report the development and clinical findings of a universal trans-punctal lacrimal microendoscope design.

Methods: In this study, we examined a unique and original "2-bend" (i.e., double-angle) rigid lacrimal microendoscope designed for universal applications for anatomical variations. The shape of endoscope was initially evaluated in 6 lacrimal systems of cadavers (4 Caucasian-cadaver lacrimal systems and 2 Asian-cadaver lacrimal systems). Second, a prospective clinical study involving 45 consecutive cases of nasolacrimal duct obstruction in Japanese patients was conducted to compare the facility and ease of use between the conventional single-bend type and our original 2-bend type trans-punctal lacrimal microendoscope for examination of the lacrimal drainage system.

Results: The findings in the cadaver study revealed that original 2-bend lacrimal microendoscope, which was designed double-angled 20°-30° at 10 and 30 mm from the tip of the scope, could more easily used to insert and image all lacrimal systems, while the conventional single-bent lacrimal microendoscope was difficult to insert in subset of patients with a prominent nasal process of the frontal bone. In the clinical trial, our findings showed that 26.7% of lacrimal systems could not be passed using the conventional single-bend design, while using the 2-bend design, all cases could successfully be investigated.

Conclusions: The original 2-bend-design microendoscope was found to be effective and valuable for universal use in examination and evaluation of the lacrimal passage.
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http://dx.doi.org/10.1097/IOP.0000000000001653DOI Listing
March 2021

Promoting Quality Face-to-Face Communication during Ophthalmology Encounters in the Electronic Health Record Era.

Appl Clin Inform 2020 01 19;11(1):130-141. Epub 2020 Feb 19.

Health Sciences Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States.

Objective: To evaluate informatics-enabled quality improvement (QI) strategies for promoting time spent on face-to-face communication between ophthalmologists and patients.

Methods: This prospective study involved deploying QI strategies during implementation of an enterprise-wide vendor electronic health record (EHR) in an outpatient academic ophthalmology department. Strategies included developing single sign-on capabilities, activating mobile- and tablet-based applications, EHR personalization training, creating novel workflows for team-based orders, and promoting problem-based charting to reduce documentation burden. Timing data were collected during 648 outpatient encounters. Outcomes included total time spent by the attending ophthalmologist on the patient, time spent on documentation, time spent on examination, and time spent talking with the patient. Metrics related to documentation efficiency, use of personalization features, use of team-based orders, and note length were also measured from the EHR efficiency portal and compared with averages for ophthalmologists nationwide using the same EHR.

Results: Time spent on exclusive face-to-face communication with patients initially decreased with EHR implementation (2.9 to 2.3 minutes,  = 0.005) but returned to the paper baseline by 6 months (2.8 minutes,  = 0.99). Observed participants outperformed national averages of ophthalmologists using the same vendor system on documentation time per appointment, number of customized note templates, number of customized order lists, utilization of team-based orders, note length, and time spent after-hours on EHR use.

Conclusion: Informatics-enabled QI interventions can promote patient-centeredness and face-to-face communication in high-volume outpatient ophthalmology encounters. By employing an array of interventions, time spent exclusively talking with the patient returned to levels equivalent to paper charts by 6 months after EHR implementation. This was achieved without requiring EHR redesign, use of scribes, or excessive after-hours work. Documentation efficiency can be achieved using interventions promoting personalization and team-based workflows. Given their efficacy in preserving face-to-face physician-patient interactions, these strategies may help alleviate risk of physician burnout.
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http://dx.doi.org/10.1055/s-0040-1701255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7030957PMC
January 2020

PREVALENCE OF MISMATCH REPAIR GENE MUTATIONS IN UVEAL MELANOMA.

Retina 2020 Nov;40(11):2216-2220

Departments of Ophthalmology, and.

Purpose: Uveal melanomas are associated with characteristic genetic changes. Germline mutations in mismatch repair (MMR) genes and microsatellite instability have been implicated in the development of numerous malignant neoplasms such as colon and ovarian cancers. The frequency of MMR defects in uveal melanomas has yet to be determined.

Methods: Here, we analyzed the frequency of MMR gene mutations in uveal melanoma specimens from the University of California, San Diego (UCSD), The Cancer Genome Atlas (TGCA), and the Catalogue of Somatic Mutations in Cancer (COSMIC).

Results: We identified only two mutations in a MMR gene: one premature stop codon in the PMS gene within the UCSD cohort (0.5% frequency) and one in-frame deletion in MSH3 within the COSMIC database (0.8% frequency). We report copy number variation of MLH1 in monosomy 3 and show decreased mRNA expression of MLH1 in uveal melanoma specimens with monosomy 3. Expression levels of MLH1 were not found to correlate with the observed number of total mutations.

Conclusion: Overall, we show that mutations in MMR genes in uveal melanoma specimens are exceedingly rare, and although one copy of MLH1 is lost in monosomy 3, it does not seem to have pathologic consequences in uveal melanoma pathogenesis.
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http://dx.doi.org/10.1097/IAE.0000000000002732DOI Listing
November 2020

Evaluation of Electronic Health Record Implementation in an Academic Oculoplastics Practice.

Ophthalmic Plast Reconstr Surg 2020 May/Jun;36(3):277-283

UC San Diego Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute and Viterbi Family Department of Ophthalmology.

Purpose: Despite increasing electronic health record (EHR) adoption, perceptions of EHRs are negative among ophthalmologists due to concerns about productivity, costs, and documentation. The authors evaluated the effects of EHR adoption in an oculoplastics practice, which had not been previously studied.

Methods: Clinical volume, documentation time, time spent with patients, reimbursement, relative value units, and patient satisfaction were examined for 2 academic oculoplastics attendings between April 2018 and April 2019, with EHR implementation in September 2018.

Results: The mean number of patients seen in a half-day clinic was 31.8 versus 27.7 (p = 0.018) pre- and post-EHR implementation, respectively. EHR implementation had no effect on total monthly reimbursement (p = 0.88) or total monthly relative value units (p = 0.54). Average reimbursement (p = 0.004) and relative value units (p = 0.001) per patient encounter were significantly greater with EHR use. Patient satisfaction scores improved (p = 0.018). Mean physician time per patient increased from 6.4 to 9.0 minutes (p < 0.001). Mean documentation time per patient increased from 1.7 to 3.6 minutes (p < 0.001). Average patient wait times decreased by 9 minutes (p = 0.03) with EHR use. No scribes were used.

Conclusions: EHR implementation was associated with decreased patient volume without significant differences in total reimbursement. Although EHR adoption was associated with increased physician time devoted to patients and greater time expenditure on documentation, patients experienced decreased wait times. This suggests that EHR use streamlined the overall clinic flow without sacrificing physicians' time with the patient. The author's findings suggest that EHR implementation can be accomplished in an academic oculoplastics setting without negative impact on patient experience or reimbursement considerations.
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http://dx.doi.org/10.1097/IOP.0000000000001531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210068PMC
March 2021

Surgical Intervention of Periocular Infantile Hemangiomas in the Era of β-Blockers.

Ophthalmic Plast Reconstr Surg 2020 Jan/Feb;36(1):70-73

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, La Jolla, CA.

Purpose: To examine the role of adjuvant surgical resection of infantile hemangiomas after systemic β-blocker therapy.

Methods: This is a multicentered retrospective study. Standard protocol for oral propranolol was employed by the referring physicians. Ocular indications for surgery included ptosis obstructing the visual axis, high degrees of astigmatism causing amblyopia, or disfigurement from residual tumor. Patients underwent complete excision or debulking.

Results: Eleven girls and 4 boys were surgically treated with mean operative age of 34.4 months. Patients were followed for a mean of 19.6 months after surgery. Four patients required surgical treatment due to an inability to tolerate medical therapy secondary to drug-related side effects (including bradycardia). The other 11 patients proceeded to surgery due to residual eyelid and orbital lesions despite medical treatment. All 15 patients underwent orbitotomy for residual hemangioma excision. Four patients also underwent simultaneous levator advancement at the time of excision. In all cases, there was resolution of ptosis with clearing of the visual axis. No complications were incurred during the surgical treatment and there were no hemangioma recurrences.

Conclusions: This is the first study to report surgical management of periocular infantile hemangiomas recalcitrant to standard therapy in the β-blocker era. In patients with infantile hemangioma who have failed medical therapy, adjuvant surgical treatment still plays an important role. For patients with persistent tumor causing ocular sequelae, surgical intervention aimed at soft tissue debulking and ptosis repair can be successful in achieving excellent functional and aesthetic outcomes with minimal side effects.For patients with periocular infantile hemangiomas with residual soft tissue deformity following propranolol therapy, surgical treatment plays an important role in improving functional and cosmetic outcomes with minimal side effects.
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http://dx.doi.org/10.1097/IOP.0000000000001466DOI Listing
March 2021

Does Intraoperative Ketorolac Increase Bleeding in Oculoplastic Surgery?

Ophthalmic Plast Reconstr Surg 2020 Jul/Aug;36(4):355-358

Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, UC San Diego School of Medicine, La Jolla, California, U.S.A.

Purpose: To report adverse hemorrhagic outcomes in patients who received intravenous (IV) ketorolac during oculofacial plastic surgical procedures.

Methods: The medical records of 111 consecutive patients who underwent lacrimal or orbital surgery, between the years 2016 and 2018, performed by a single surgeon under general anesthesia were retrospectively reviewed. Patients were excluded if they had history of a bleeding coagulopathy, anticoagulant use prior to surgery, or insufficient follow up. Patients were divided into 2 groups based on whether they received intravenous ketorolac. The primary outcome measure was the occurrence of a major postoperative bleeding event, and the secondary outcome measures were the evaluation of postoperative ecchymosis graded at 1 week after surgery and the incidence of persistent ecchymosis beyond 4 weeks.

Results: A total of 111 patients were analyzed further, including 31 patients who received intraoperative IV ketorolac and 80 control patients who did not. The demographic characteristics between the 2 groups were similar. No major bleeding events occurred in either group. And there was no statistically significant difference between the 2 groups in terms of ecchymosis grade and the incidence of development of persistent ecchymosis. Comparing the subgroups of lacrimal and orbital cases, there was also no significance difference between these groups.

Conclusions: This study suggests that intraoperative ketorolac use does not increase the risk of postoperative bleeding complications in oculofacial procedures. This alternative to opioids may assist with pain control and lessen the narcotic burden.
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http://dx.doi.org/10.1097/IOP.0000000000001549DOI Listing
March 2021

Precision in Oculofacial Surgery: Made-To-Specification Cast-Molded Implants in Orbital Reconstruction.

Ophthalmic Plast Reconstr Surg 2020 May/Jun;36(3):268-271

UC San Diego Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute and Viterbi Family Department of Ophthalmology, La Jolla, California.

Purpose: To describe the utilization of customized made-to-specification porous polyethylene implants and to evaluate clinical characteristics and outcomes of patients who received these implants for unilateral orbital defects.

Methods: A retrospective review of 9 patients was performed. Three-dimensional surface models were generated from high-resolution computed tomography scans. Orbital constructs were modeled after the normal, contralateral orbits and mirrored across the vertical midline to generate the target orbital implant. Measured outcomes included globe position, extraocular motility, facial symmetry, and diplopia.

Results: Patients ranged 25-56 years old (mean: 37) and included 6 males and 3 females. Cases consisted of 6 orbital floor fractures due to trauma, 1 lateral wall defect after neurofibroma resection, 1 floor/medial wall defect after myxoma resection, and 1 superior orbital rim defect after intraosseous hemangioma resection. Seven patients had ≥1 prior repair. All patients had previous hard and soft tissue defects and varying degrees of restrictive globe motility. Patients exhibited improved ductions after implant placement and improved facial appearance and symmetry. Post-operatively, 1 patient was found to have a small orbital hematoma between the implant and orbital floor, resolving within weeks.

Conclusions: Precision, personalized oculofacial surgery is the next wave in tailoring surgical care to the individual patient. Customizable implants are manufactured to specifically mold to an individual patient's unique bony architecture, which can lead to superior outcomes in reconstructing orbital and craniofacial bony defects. This technique is particularly useful in patients with prior unsuccessful repair.
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http://dx.doi.org/10.1097/IOP.0000000000001529DOI Listing
March 2021

Exposed Scleral Buckle Causing Atypical Mycobacterial Infection.

Ophthalmic Plast Reconstr Surg 2020 May/Jun;36(3):e83

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology.

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http://dx.doi.org/10.1097/IOP.0000000000001458DOI Listing
March 2021

Endoscopic Evaluation of Lacrimal Mucosa With Indigo Carmine Stain.

Ophthalmic Plast Reconstr Surg 2020 Jan/Feb;36(1):49-54

Department of Ophthalmology, Osaka Medical College, Takatsuki City, Osaka, Japan.

Purpose: Histological investigation in the use of indigo carmine for detection of mucosal pathology in lacrimal microendoscopy. To investigate the histopathological correlation of staining found on lacrimal microendoscopy.

Methods: A prospective case series was conducted in patients with a history of nasolacrimal duct obstruction and dacryocystitis requiring treatment with dacryocystorhinostomy or dacryocystectomy. Prior to lacrimal surgery, all patients underwent endolacrimal evaluation using transpunctal lacrimal microendoscopy. Indigo carmine dye (0.2 mg/0.5 ml) was injected into the lacrimal system via the irrigation channel of the endoscope, and after copious irrigation, the differential mucosal staining was recorded. Histopathologic analysis of tissue samples of positively and negatively stained lacrimal sac mucosa collected after surgery was performed to investigate the correlation with the results of each endoscopic evaluation.

Results: Four patients underwent dacryocystorhinostomy and 2 patients underwent dacryocystectomy. Histopathology of positive-stained lacrimal sac mucosa corresponded to areas of the advanced fibrous stage of mucosal changes resulting from dacryocystitis, which showed atrophy of epithelium associated with the loss of goblet cells and subepithelium fibrous scarring. In contrast, areas of lacrimal mucosa that did not stain with indigo carmine were still in an active inflammatory stage of dacryocystitis preserving columnar epithelium with goblet cells.

Conclusions: This study suggests that indigo carmine staining is a useful adjunct in lacrimal microendoscopy for accurately detecting areas of highly damaged fibrous lacrimal mucosa, as it allows for direct visualization of lacrimal mucosal pathology and can provide prognostic insight and guidance in regard to treatment options for patients with lacrimal drainage obstruction.Use of indigo carmine dye as an in vivo adjunct in lacrimal microendoscopy is useful for accurately detecting areas of highly damaged lacrimal mucosa.
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http://dx.doi.org/10.1097/IOP.0000000000001457DOI Listing
March 2021

Analysis of Periorbital Soft Tissue in Thyroid Eye Disease.

Ophthalmic Plast Reconstr Surg 2020 Jan/Feb;36(1):30-33

Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, University of California San Diego, Shiley Eye Institute, La Jolla, California, U.S.A.

Purpose: To investigate periorbital tissue enlargement in thyroid eye disease (TED) by 3-dimensional CT volumetric analysis.

Methods: Twenty-four adult subjects, 16 with TED and 8 controls, were studied. Three-dimensional volumetric calculations were performed on CT imaging of the orbit and face, focusing on the retroorbicularis oculi fat, suborbicularis oculi fat, facial muscles in periorbital region, orbital fat, extraocular muscles, and orbital volume. Analysis was performed using JMP version 12 software. Each measure was compared between the TED and control groups using Wilcoxon rank sum test. Correlations were investigated between periorbital and orbital tissue using the Spearman's correlation coefficient method.

Results: A statistically significant increase in volume was measured in TED patients in the superior and inferior periorbital fat tissue (p = 0.0044, p = 0.047), including the retroorbicularis oculi fat (p = 0.0011), suborbicularis oculi fat (p = 0.0093), and a decrease in facial muscle of superior periorbital region (p = 0.035). Strong positive correlation was noted between the muscles of superior and inferior periorbital region (rs = 0.65; p = 0.0006), and between the suborbicularis oculi fat and retroorbicularis oculi fat (rs = 0.50; p = 0.013). No correlation was observed between orbital and periorbital tissue, except between the orbital fat and the inferior periorbital fat tissue (p = 0.047).

Conclusions: Facial fat in the periorbital region is enlarged in TED, with the superior component correlating with orbital fat tissue expansion. These findings may assist in the clinical evaluation and management of disfigurement in TED patients.Superior and inferior periorbital fat is enlarged in thyroid eye disease with the superior periorbital fat expansion correlating with orbital fat expansion.
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http://dx.doi.org/10.1097/IOP.0000000000001450DOI Listing
March 2021

Development of Poliosis Following Checkpoint Inhibitor Treatment for Cutaneous Melanoma.

Ophthalmic Plast Reconstr Surg 2019 Sep/Oct;35(5):e121-e122

Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute.

The authors describe a clinical case whereby a patient with metastatic cutaneous melanoma developed eyelash poliosis after undergoing treatment with combination immunotherapy with ipilimumab and nivolumab.
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http://dx.doi.org/10.1097/IOP.0000000000001451DOI Listing
January 2020

Impact of Electronic Health Record Implementation on Ophthalmology Trainee Time Expenditures.

J Acad Ophthalmol 2019 Jul;11(2):e65-e72

UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California.

Objective: Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation.

Design: Prospective, manual time-motion observations of ophthalmology trainees in 2018.

Participants: Eleven ophthalmology residents and fellows observed during 156 patient encounters.

Methods: Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models.

Main Outcome Measures: Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients.

Results: Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; = 0.011).

Conclusion: Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout.
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http://dx.doi.org/10.1055/s-0039-3401986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8095731PMC
July 2019

A modified technique for bedside amniotic membrane application to the eyelid margins for Stevens-Johnson syndrome.

Can J Ophthalmol 2019 06 28;54(3):e118-e120. Epub 2018 Nov 28.

Division of Oculofacial Plastic and Reconstructive Surgery; Division of Plastic Surgery, UC San Diego Department of Surgery, La Jolla, Calif.. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2018.08.020DOI Listing
June 2019
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