Publications by authors named "Catherine J Hwang"

57 Publications

Direct Browlift.

Clin Plast Surg 2022 Jul;49(3):409-414

Cleveland Clinic Foundation, Cole Eye Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Direct browlifting comprises various techniques to lift the brows using incisions on or around the brows. The classic direct browlift involves removing an ellipse of skin and subcutaneous tissue within or just above the brow cilia. However, the technique can be modified to address only lateral brow ptosis, to place the incision in the midforehead or the eyelid crease, and to place the incisions in different areas during bilateral surgery to attempt to improve symmetry. Careful attention to incision location, closure technique, and use of postoperative therapies can allow for nearly invisible scars in some cases.
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http://dx.doi.org/10.1016/j.cps.2022.03.002DOI Listing
July 2022

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2022 May-Jun 01;38(3):310-312. Epub 2022 May 11.

¶Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1097/IOP.0000000000002201DOI Listing
May 2022

Biplanar-pivoted V-Y Flap for Reconstruction of Medial Canthal Defects.

Ophthalmic Plast Reconstr Surg 2022 May 13. Epub 2022 May 13.

Oculofacial Plastic Surgery, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH, U.S.A.

Purpose: To determine the safety and effectiveness of a biplanar-pivoted V-Y flap design in reconstructing medial canthal defects of all sizes.

Methods: Retrospective review of patients who underwent repair of medial canthal region defects with the biplanar-pivoted V-Y flap from January 2016 to May 2021. Variables collected included age, gender, surgical indication, defect sizes and location, flap(s) and/or graft(s) used, and follow-up time. Outcome measures included complications, patient satisfaction with cosmesis, ability to close the defect with minimal wound tension, and additional surgeries.

Results: Eighteen cases of medial canthal, nasal sidewall, and nasojugal fold area reconstruction were performed using a biplanar-pivoted V-Y flap in 18 patients. The cohort included 7 males and 11 females with a mean age of 72.4 years (range, 52-92 years) and mean follow-up time of 4.4 months (range, 1-14 months). Mean defect size was 2.0 × 1.4 cm (range, 0.5-5.5 cm). Eight patients received concomitant full-thickness skin grafts, five patients underwent simultaneous rotational flap repair, one patient underwent simultaneous nasoglabellar myocutaneous flap repair, and one patient received a simultaneous traditional, nonbiplanar V-Y plasty of the upper eyelid. All defects were closed with no wound tension. No cases of infection, hemorrhage, or wound dehiscence occurred during follow-up. Complications included mild ectropion (2 patients) and mild tip necrosis (1 patient). No patients elected for reoperation. No trapdoor deformity was observed. No patients underwent reoperation for local tumor recurrence.

Conclusions: The extended mobility of the biplanar-pivoted V-Y flap provides excellent closure of defects involving the medial canthal region with minimal surgical complications.
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http://dx.doi.org/10.1097/IOP.0000000000002215DOI Listing
May 2022

Invited Discussion On: "Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy".

Aesthetic Plast Surg 2022 Apr 18. Epub 2022 Apr 18.

Oculofacial Plastic Surgery, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1007/s00266-022-02875-xDOI Listing
April 2022

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2022 Mar-Apr 01;38(2):214-216

Chief Oculofacial Surgery, Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1097/IOP.0000000000002154DOI Listing
March 2022

Invited Discussion on: "Conjoint Fascial Sheath Suspension for Correction of Recurrent Blepharoptosis".

Aesthetic Plast Surg 2022 04 20;46(2):752-753. Epub 2022 Jan 20.

Cleveland Clinic Foundation, Oculofacial Plastic Surgery, Cole Eye Institute, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1007/s00266-021-02697-3DOI Listing
April 2022

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):90-91

Chief Oculofacial Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000002128DOI Listing
January 2022

Invited Discussion on: "Changes in Tear Meniscus Analysis After Ptosis Procedure and Upper Blepharoplasty".

Aesthetic Plast Surg 2022 04 22;46(2):742-743. Epub 2021 Nov 22.

Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1007/s00266-021-02668-8DOI Listing
April 2022

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2021 Nov-Dec 01;37(6):604-606

Chief Oculofacial Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000002101DOI Listing
November 2021

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2021 Sep-Oct 01;37(5):506-508

Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1097/IOP.0000000000002062DOI Listing
September 2021

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3):300-302

Chief Oculofacial Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001973DOI Listing
May 2021

Invited Discussion on: "An Efficacy and Safety Study of Intraarterial Recanalization of Occluded Ophthalmic Arteries in Patients with Monocular Blindness Caused by Injection of Hyaluronic Acid in Facial Tissues".

Aesthetic Plast Surg 2021 08 28;45(4):1579-1580. Epub 2021 Apr 28.

Oculofacial Plastic Surgery, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1007/s00266-021-02285-5DOI Listing
August 2021

Blindness After Filler Injection: Mechanism and Treatment.

Facial Plast Surg Clin North Am 2021 May 24;29(2):359-367. Epub 2021 Apr 24.

Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

Dermal fillers remain popular for facial rejuvenation but with its increasing use, the potential for more complications including blindness is present. This article focuses on the mechanism of filler-associated blindness, possible treatments, and future directions. Unfortunately, to date there is no proven treatment to reverse filler-induced blindness or visual compromise. It is essential for all injectors to discuss the potential ocular risks including blindness with their patients and obtain informed consent before filler injection.
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http://dx.doi.org/10.1016/j.fsc.2021.02.002DOI Listing
May 2021

Treatment Options for Lower Eyelid Festoons.

Facial Plast Surg Clin North Am 2021 May 24;29(2):301-309. Epub 2021 Apr 24.

Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Electronic address:

Festoons represent a combination of fluid accumulation and soft tissue laxity in the superolateral cheek. They remain a difficult entity to treat. The ideal treatment for festoons would possess minimal invasiveness and recovery time, and predictably improve the condition. No nonsurgical treatment currently meets these criteria, and surgical treatments have significant limitations. Fortunately, a variety of treatment options exist that can benefit each patient and be tailored to their specific needs. Knowledge of the underlying anatomy, clinical characteristics, and clinical evaluation will better equip the treating physician to manage festoons.
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http://dx.doi.org/10.1016/j.fsc.2021.02.005DOI Listing
May 2021

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2021 Mar-Apr 01;37(2):194-196

Chief Oculofacial Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001954DOI Listing
March 2021

Bilateral dysthyroid compressive optic neuropathy responsive to teprotumumab.

Eur J Ophthalmol 2022 May 1;32(3):NP46-NP49. Epub 2021 Feb 1.

Cleveland Clinic Foundation, Cole Eye Institute, Cleveland, OH, USA.

Thyroid eye disease is an auto-immune mediated orbitopathy which can cause dysthyroid compressive optic neuropathy. Traditional management of active thyroid eye disease includes temporizing high-dose steroids, orbital radiation and surgical decompression, which each possess significant limitations and/or side effects. Teprotumumab is an IGF-IR inhibitor recently FDA-approved for active thyroid eye disease. The authors report reversal of bilateral dysthyroid compressive optic neuropathy managed medically utilizing teprotumumab.
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http://dx.doi.org/10.1177/1120672121991042DOI Listing
May 2022

Aesthetic Abstracts.

Ophthalmic Plast Reconstr Surg 2021 Jan-Feb 01;37(1):99-101

Chief Oculofacial Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001907DOI Listing
January 2021

Dimensions, Function and Applications of the Auricular Muscle in Facial Plastic Surgery.

Aesthetic Plast Surg 2021 02 30;45(1):309-314. Epub 2020 Nov 30.

Cleveland Clinic Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk i-132, Cleveland, OH, 44195, USA.

Purpose: To determine the dimensions and function of the auricular muscle and to consider applications of this muscle in facial plastic surgery.

Methods: Nonpreserved fresh frozen human cadaver dissections from the (HOSPITAL-Blinded) Body Donation program were dissected. The length and width of the superior auricular muscle were measured. One surgeon performed all dissections and measurements.

Results: A total of seven left and five right hemifaces were studied. The average central height of the superior auricular muscle was 4.7 cm, and an average width was 5.0 cm. There was no significant difference between the average values of the left versus the right hemiface measurements. The muscle originated in the fibers of the galea and temporal fascia and inserted into the conchal cartilage in each specimen. Engaging the muscle in its line of action yielded slight elevation of the forehead and prevented movement of the galea along the vertex of the scalp.

Conclusions: The auricular muscle acts as an occipitofrontalis stabilizer and a weak brow elevator.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors - www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-020-02045-xDOI Listing
February 2021

Long-Term Patient Experience with Tetracycline Injections for Festoons.

Plast Reconstr Surg 2020 12;146(6):737e-743e

From the Cole Eye Institute, Cleveland Clinic Foundation.

Background: The purpose of this study was to evaluate the long-term patient experience with tetracycline injections for treatment of festoons.

Methods: Charts of all patients undergoing tetracycline injection for treatment of lower eyelid festoons at the Cole Eye Institute, Cleveland Clinic, between 2008 and 2018 were identified using billing records. Patients were invited to participate in a questionnaire based on the FACE-Q checklist, a previously validated questionnaire for studying cosmetic procedure outcomes. Data from the questionnaire were summarized with size, mean, and frequency.

Results: One hundred two patients who received tetracycline injection during the study period were identified and 61 responses were obtained. The average follow-up time after injection was 3.6 years. Of 61 respondents, 36 (59 percent) noted improvement in their festoons after treatment, and 27 of 33 (82 percent) noted that improvement occurred within 2 months of treatment. Overall, 40 of 60 respondents (67 percent) would consider repeating tetracycline treatment. The most common adverse effects included discomfort (18 percent), swelling (15 percent), and bruising (13 percent). There was no statistically significant difference in questionnaire responses between men and women, except that men were more likely to consider repeated injection (92 percent versus 58 percent; p = 0.005).

Conclusion: Tetracycline injection appears to improve festoons in a majority of patients, with an acceptable side-effect profile, although more data are needed to determine the optimal dose and frequency and to identify possible rare and/or significant side effects.
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http://dx.doi.org/10.1097/PRS.0000000000007334DOI Listing
December 2020

Unilateral Ptosis, Proptosis, and Orbital Myositis After Shingles Vaccination.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3):e100-e103

Department of Ophthalmology, Cleveland Clinic Cole Eye Institute, Cleveland, Ohio, U.S.A.

Vaccinations for shingles are recommended for most adults over 60 years of age and are typically well tolerated. The present case describes acute onset of unilateral ptosis, proptosis, and orbital myositis developing within days after administration of shingles vaccination. The episode resolved to baseline after 1 week of treatment with steroids. To the authors' knowledge, this is first reported case of orbital inflammation following shingles vaccination. Given the temporal relationship and rapid response to treatment, this may represent an autoimmune reaction to the shingles vaccine.
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http://dx.doi.org/10.1097/IOP.0000000000001847DOI Listing
May 2021

Invited Discussion on: Revisiting Anchor Epicanthoplasty in Mild to Moderate Asian Epicanthal Folds: A Clinicopathological Study.

Aesthetic Plast Surg 2021 02 11;45(1):191-192. Epub 2020 Sep 11.

Cleveland Clinic Foundation, Cole Eye Institute, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1007/s00266-020-01942-5DOI Listing
February 2021

Effectiveness of Retrobulbar Hyaluronidase Injection in an Iatrogenic Blindness Rabbit Model Using Hyaluronic Acid Filler Injection.

Plast Reconstr Surg 2020 03;145(3):658e-660e

Division of Oculofacial Plastic Surgery, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

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http://dx.doi.org/10.1097/PRS.0000000000006583DOI Listing
March 2020

Invited Discussion on: The Effect of Two Different Frontalis Sling Approaches on Postoperative Eyelid Contour: A Comparative Study.

Aesthetic Plast Surg 2020 04 13;44(2):390-391. Epub 2020 Feb 13.

Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1007/s00266-020-01634-0DOI Listing
April 2020

Longitudinal Changes in Adult Bony Orbital Volume.

Ophthalmic Plast Reconstr Surg 2020 May/Jun;36(3):243-246

Cole Eye Institute, Cleveland Clinic, Department of Ophthalmology.

Purpose: To our knowledge, no prior study has measured bony orbital volume in a group of subjects over time. This study evaluates longitudinal changes in bony orbital volume with age.

Methods: A search was created for patients with digitized CT imaging studies of the orbit at least 8 years apart. Charts with a history of prior head trauma, head and neck tumors, sinus disease, head surgery, elevated intracranial pressure, thyroid eye disease, or conditions that could affect bone metabolism were excluded. Three outcome measures were used: orbital volume, medial orbital wall length, and lateral orbital wall length. Categorical data were summarized with frequency (%); normally distributed continuous data are summarized with mean (standard deviation), and non-normally distributed data were summarized with median. Normality was verified with Shapiro-Wilk Test. Paired t-tests were used to analyze the differences in the 3 outcome variables.

Results: One hundred and eighty-two subjects, 91 males and 91 females, were included. The median time between CT scans was 9.4 years. Orbital volume was significantly larger at the second scan than the first (p < 0.001). The average difference in orbital volume was 0.91 ml, an increase of 4.1%. Lateral orbital length was significantly shorter in the second scan than in the first (p = 0.046) though the difference was only 0.4 mm. There was no statistically significant change in medial orbital wall length.

Conclusions: Bony orbital volume increases in individuals with age. This increase in orbital volume occurs in the context of soft tissue changes to contribute to the aging appearance of the periorbital region.
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http://dx.doi.org/10.1097/IOP.0000000000001519DOI Listing
March 2021

Temporal Fat Pad Volume in Patients With Thyroid Eye Disease.

Ophthalmic Plast Reconstr Surg 2020 Mar/Apr;36(2):194-197

Cole Eye Institute, Cleveland Clinic Foundation.

Purpose: To determine whether thyroid eye disease (TED) is associated with a change in temporal fossa soft tissue volume.

Methods: CT imaging studies were selected from patients with TED considering orbital decompression surgery and from an age-matched group of controls presenting to the Emergency Department for nontraumatic conditions requiring CT imaging. Measurements of the temporal fossa fat pad and soft tissue thickness were used as a proxy for volume and were performed using the zygomaticotemporal suture as a reference point. Categorical variables were described using frequencies and percentages, while continuous variables were described using medians and standard deviations. Chi-square tests were used to assess the relationship between gender and age group, while t-tests were used to examine the relationship between continuous variables and age group.

Results: A total of 56 CT scans were evaluated, including scans from 28 patients with TED and 28 controls. The following measurements were found to be significantly larger in the TED population: left fat pad measured 5 mm above the zygomaticotemporal suture (p = 0.012), right fat pad measured 15 mm above the suture (p = 0.005), right soft tissue measured 15 mm above the suture (p = 0.026), left fat pad measured 15 mm above the suture (p = 0.006), and the left soft tissue measure 15 mm above the suture (p = 0.032).

Conclusions: Thyroid eye disease is associated with an increase in temporal fossa fat pad and soft tissue volume. These findings suggest that TED disease may produce pan-facial changes rather than changes confined to the peri-orbital region.
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http://dx.doi.org/10.1097/IOP.0000000000001511DOI Listing
March 2021

Comparison of Orbital Volume in Young Versus Senescent Human Skulls.

Ophthalmic Plast Reconstr Surg 2020 Mar/Apr;36(2):139-143

Cole Eye Institute, Cleveland Clinic Foundation.

Purpose: To compare bony orbital volumes in young skulls with those of older skulls to elucidate aging-associated changes of the orbit.

Methods: One hundred Caucasian male skulls from the Hamann-Todd collection of the Cleveland Museum of Natural History were studied. There were 50 young skulls (age range, 19-33 years) and 50 senescent skulls (age range, 79-96 years). Volcanic sand was used to fill each orbit in an identical fashion and weighed as a proxy for volume. Digital calipers were used to perform linear measurements of the orbit. The relationship between orbit measures and skull size was assessed using Pearson's correlations and 95% CI, and statistical models to compare age groups adjusted for skull size.

Results: The volume of the orbits (P < 0.001), the horizontal diameter of the orbit (P = 0.015), and the orbital depth (P < 0.001) were significantly larger in the senescent group of skulls after adjusting for skull surface area. No significant differences were found in the vertical diameters of the orbit between the 2 groups. Skull size did not statistically differ between the age groups.

Conclusions: Increases in the depth and horizontal dimensions of the orbit lead to increasing bony orbital volume with increasing age. These changes in size and shape of the orbit with age may contribute to phenotypic changes of aging and may affect disease processes and management.
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http://dx.doi.org/10.1097/IOP.0000000000001492DOI Listing
March 2021

Dimensions and Morphologic Variability of the Retro-Orbicularis Oculi and Frontalis Muscle Fat Pad.

Ophthalmic Plast Reconstr Surg 2019 Sep/Oct;35(5):447-450

Cleveland Clinic Cole Eye Institute.

Purpose: To quantify the complete dimensions of the retro-orbicularis oculi fat (ROOF) pad and to determine its relationship to other fat compartments of the forehead.

Methods: The entire forehead of 14 hemifaces of seven fresh frozen human cadavers (four female, three male) was dissected in the subcutaneous and submuscular planes. For each plane, a ruler was placed at the facial midline, and images of the dissection plane were taken at 90° and 45°. Images were analyzed for vertical height, horizontal length, the distance to midline from the point of maximal height, and area for each hemiface of the ROOF and for the entire fat compartment contiguous with the ROOF. A two-tailed t test was conducted between ROOF and ROOF plus the extended fat plane across all measurements. A Wilcoxon nonparametric signed rank test was performed to determine equivalent fat distribution of the extended fat plane over each cadaver's respective eye.

Results: The deep fat originating from the ROOF consistently extended laterally and superiorly in each specimen, distinctly separated via septae from the deep central, deep lateral, and the deep temporal fat compartments. The color, composition, and distribution of this contiguous deep fat did not differ phenotypically from the traditional ROOF. The extended deep fat plane possessed an average vertical height of 3.09 ± 0.68 cm, average distance to midline from point of maximal height of 3.56 ± 0.53 cm, an average horizontal length of 5.37 ± 0.82 cm, and an average area of 13.40 ± 2.69 cm. The extended deep fat demonstrated a statistically significant increase in maximal height, length, and total area compared with the ROOF. A Wilcoxon nonparametric signed rank test was nonsignificant (α = 0.01) across all measurements, demonstrating that the extended fat plane was similarly distributed over each eye.

Conclusions: A layer of deep fat originating from the traditionally defined ROOF extends superiorly and laterally beneath the frontalis muscle, separate from the deep lateral, deep central, and deep temporal fat pads. This is the first study to clearly demonstrate a contiguous superficial musculoaponeurotic system layer of fat extending under both the orbicularis oculi and frontalis muscles. This plane of fat is more appropriately described as the retro-orbicularis oculi and frontalis fat.
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http://dx.doi.org/10.1097/IOP.0000000000001314DOI Listing
January 2020

Collagenoma of the Eyelid.

Ophthalmic Plast Reconstr Surg 2019 Mar/Apr;35(2):e29-e30

Cole Eye Institute, Cleveland Clinic.

The rare case of an eyelid lesion comprised of hamartomatous dermal collagen, known as a collagenoma, is presented. Collagenomas may be sporadically acquired, or inherited as part of numerous autosomal dominant syndromes. In the appropriate clinical context, their diagnosis should prompt a thorough review of systems, systemic examination, and inquiry into family history, to assess for underlying autosomal dominant syndromes. Recognition of collagenomas may thus allow diagnosis of inherited syndromes, allowing patients to obtain appropriate genetic counseling, as well as screening and treatment of associated systemic pathology.
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http://dx.doi.org/10.1097/IOP.0000000000001298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411431PMC
December 2019

Age-related Changes in Globe Position.

Ophthalmic Plast Reconstr Surg 2019 Mar/Apr;35(2):155-158

Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Purpose: To longitudinally evaluate for changes in globe position as part of the natural aging process.

Methods: A Cleveland Clinic Foundation imaging database of all head imaging scans performed from 1995 to 2017 was used to identify adults with normal orbits undergoing imaging studies at least 20 years apart. A total of 100 patients (200 globes) who had CT or MRI scans were studied. Globe position was determined by measuring the distance from the anterior aspect of the cornea to the zygomaticofrontal processes baseline. Clinically significant changes in globe position were defined as changes of ≥2 mm posteriorly (enophthalmos) or anteriorly (exophthalmos).

Results: On average, globe projection decreased by 0.25 ± 2.3 and 0.26 ± 2.2 mm in the right and left eyes, respectively. Clinically significant enophthalmos with age was measured in 55 (27.5%) globes in 35 (35%) individuals, while clinically significant exophthalmos with age was measured in 43 (21.5%) globes in 26 (26%) individuals. The proportion of cases that developed enophthalmos, exophthalmos, or experienced no change were not significantly different from each other (p = 0.26). No patients developed clinically significant enophthalmos in one eye and exophthalmos in the other.

Conclusions: Adults may develop clinically significant enophthalmos, exophthalmos, or no change in globe position over a 20-year period. This lack of uniform change in globe position with age impacts surgical considerations for treatment of the aging periocular region.
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http://dx.doi.org/10.1097/IOP.0000000000001193DOI Listing
December 2019
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