Publications by authors named "Erin M Shriver"

68 Publications

Update on thyroid eye disease: Regional variations in prevalence, diagnosis, and management.

Indian J Ophthalmol 2022 Jul;70(7):2335-2345

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

Thyroid eye disease (TED) is a rare disease that can lead to decreased quality of life, permanent disfigurement, and vision loss. Clinically, TED presents with exophthalmos, periorbital edema, extraocular muscle dysfunction, and eyelid retraction, and can lead to vision-threatening complications such as exposure to keratopathy and dysthyroid optic neuropathy (DON). Over the last several years, significant advancements have been made in the understanding of its pathophysiology as well as optimal management. Ethnic variations in the prevalence, clinical presentation, and risk of vision-threatening complications of TED are summarized, and risk factors associated with TED are discussed. Additionally, significant advances have been made in the management of TED. The management of TED traditionally included anti-inflammatory medications, orbital radiation therapy, orbital surgical decompression, and biologic therapies. Most recently, targeted therapies such as teprotumumab, an insulin-like growth factor-1 receptor antagonist, have been studied in the context of TED, with promising initial data. In this review, updates in the understanding and management of TED are presented with a focus on the international variations in presentation and management.
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http://dx.doi.org/10.4103/ijo.IJO_3217_21DOI Listing
July 2022

Misdiagnosis of fungal infections of the orbit.

Can J Ophthalmol 2022 May 4. Epub 2022 May 4.

From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Electronic address:

Objective: To evaluate the accuracy of the initial diagnosis in the case of fungal infections of the orbit and identify factors that may influence patient outcomes.

Methods: An institutional review board-approved retrospective chart review was conducted across 2 large academic centres to identify cases of fungal infections involving the orbit from January 1, 1998, to November 15, 2019. Data collected included patient demographics, past medical history, examination findings, diagnosis, treatment, imaging, and outcomes.

Results: Fifty cases of fungal infection involving the orbit were identified. Of these, 33 (66.0%) were initially misdiagnosed as nonfungal diagnoses. Sixteen patients (32.0%) received multiple initial diagnoses. The most common diagnoses on presentation were bacterial cellulitis (n = 12 of 50; 24.0%) and bacterial sinusitis (n = 12 of 50; 24.0%). These were followed by vascular and orbital inflammatory conditions (n = 9 of 50; 18.0%): 5 patients (10.0%) were clinically diagnosed with giant cell arteritis, 3 (6.0%) with nonspecific orbital inflammation, and 1 (2.0%) with optic neuritis. In this subset of patients, 77.8% (n = 7 of 9) were treated initially with systemic steroids. Additional initial diagnoses included neoplastic mass lesions, mucocele, dacryocystitis, cavernous sinus thrombosis, hemorrhage, tick-borne illness, allergic rhinitis, and allergic conjunctivitis. Misdiagnosis was significantly correlated with involvement of the masticator space on imaging (p = 0.04).

Conclusion: Fungal infections of the orbit are misdiagnosed in 2 of 3 cases. Nearly 15% of patients who are later diagnosed with fungal disease of the orbit were initially treated with systemic steroids. Misdiagnosis is more frequent when the masticator space is involved.
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http://dx.doi.org/10.1016/j.jcjo.2022.04.007DOI Listing
May 2022

The Effect of Teprotumumab on Eyelid Position in Patients with Thyroid Eye Disease.

Plast Reconstr Surg Glob Open 2022 Apr 22;10(4):e4287. Epub 2022 Apr 22.

Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Teprotumumab has been shown to improve proptosis and clinical activity scores (CAS) in patients with thyroid eye disease, but little has been published regarding its effects on eyelid retraction. The purpose of this work was to evaluate changes in eyelid position in thyroid eye disease patients after teprotumumab. Eight patients completed eight cycles of teprotumumab. Data collected included exophthalmometry; clinical activity scores; margin reflex distance (MRD) 1; MRD2; and pre-, during, and posttreatment photographs. ImageJ analysis was also used to evaluate eyelid position in photographs. Proptosis significantly improved in 15 of 16 orbits [mean 4.75 ± 2.07 mm reduction ( = 0.0001) in study orbits and mean 3.00 ± 2.14 mm reduction ( = 0.0048) in nonstudy orbits]. CAS was significantly reduced (pretreatment mean 4.88 mm and posttreatment mean 1.88 mm, 0.006). MRD1 decreased in 11 of 16 orbits and increased in five orbits ( 0.18 in study orbits and 0.22 in nonstudy orbits). MRD2 decreased in six of 16 orbits and increased in eight orbits ( 0.49 in study orbits and 0.43 in nonstudy orbits). Patients exhibited variable changes in eyelid position with teprotumumab. There was a statistically insignificant decrease in MRD1 after teprotumumab. Proptosis reduction led to unpredictable changes in MRD1 and MRD2. Severity of eyelid retraction did not correlate with clinical activity score response to teprotumumab. There are inherent difficulties in evaluating eyelid position in thyroid eye disease, which may necessitate a paradigm shift in how patients are examined, measured, and photographed.
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http://dx.doi.org/10.1097/GOX.0000000000004287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9029877PMC
April 2022

Peripheral Trigeminal Nerve Blocks for Chronic Orbital Pain: Clinical Features and Outcomes.

Ophthalmic Plast Reconstr Surg 2022 Jul-Aug 01;38(4):369-376. Epub 2022 Jan 13.

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

Purpose: To characterize chronic orbital pain in patients who benefitted from peripheral trigeminal nerve blocks and to explore the relationship between pain etiologies and phenotypes, injection attributes, and positive response to treatment.

Methods: In this single-center retrospective descriptive study, patients who underwent peripheral trigeminal nerve blocks for chronic orbital pain from November 2016 to May 2021 were selected. Data reviewed included inciting factors, neuropathic symptoms of orbital pain, injection composition (anesthetic alone versus anesthetic + dexamethasone), and corneal epitheliopathy grades. Primary outcomes assessed were response to injection, duration of injection effectiveness, and overall treatment efficacy. Associations between subgroups of chronic orbital pain, injection attributes, and treatment outcomes were examined.

Results: Nineteen patients who underwent a total of 94 peripheral trigeminal nerve blocks for chronic orbital pain were included. During a mean follow-up period of 2.4 years after initial injection (range 7 days-4.6 years), 16 (84.2%) patients achieved either partial or complete improvement. Ocular versus nonocular origin of orbital pain or the presence of neuropathic sensory characteristics was not associated with a treatment outcome. Injections containing dexamethasone had a lower positive efficacy (relative risk, 0.88; 95% CI, 0.81-0.97) and no statistically significant association with prolonged effect. Twenty-nine (50.9%) of the 57 injections for which effect duration was recorded produced a response lasting greater than 6 weeks.

Conclusions: Modulation of trigeminal afferent nerve activity with peripheral trigeminal nerve blocks containing anesthetic with or without dexamethasone may be a promising treatment strategy for chronic orbital pain of diverse etiologies and phenotypes.
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http://dx.doi.org/10.1097/IOP.0000000000002120DOI Listing
July 2022

The role of teprotumumab in chronic, clinically active thyroid eye disease.

Eye (Lond) 2022 Jul 4;36(7):1500-1501. Epub 2022 Jan 4.

University of Iowa Hospital and Clinics, Department of Ophthalmology and Visual Sciences, Iowa City, IA, 52240, USA.

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http://dx.doi.org/10.1038/s41433-021-01904-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9232635PMC
July 2022

Trends in horizontal periocular asymmetry.

Can J Ophthalmol 2021 Dec 16. Epub 2021 Dec 16.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa. Electronic address:

Objective: To determine whether there is laterality predominance in the horizontal dimensions of the periocular region.

Design: Retrospective study.

Participants: Patients >18 years of age who presented to a single academic ophthalmology department. Exclusion criteria included history of facial trauma or surgery, aesthetic injections, or other periocular-altering processes.

Methods: Standardized digital photographs were obtained, and periocular structures were measured with Image J software. The midline was defined as the midpoint between the medial canthi, and the distances measured include midline to medial canthus, pupil centre, lateral canthus, and lateral zygoma. The palpebral fissure width was calculated as the distance between the lateral canthus and medial canthus. Data analysis was done for the full cohort and subsequently according to patient-identified gender.

Results: Periocular structures were measured in 83 patients (50 female and 33 male) with a mean age of 57.0 ± 16.2 years (range, 22-84 years). Right-sided predominance was found to be increasingly significant for the following variables: midline to pupil centre (31.34 mm vs 31.08 mm, p < 0.01), midline to lateral canthus (42.57 mm vs 42.23 mm, p < 0.005), and midline to lateral zygoma (65.70 mm vs 64.01 mm, p < 0.001).

Conclusions: Photographic analysis of adults with no periocular-altering history demonstrates that there is a right-sided predominance in the horizontal dimension of the midline to the pupil, lateral canthus, and zygoma with increasing significance. Asymmetry of horizontal periocular measurements was more prevalent in males.
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http://dx.doi.org/10.1016/j.jcjo.2021.11.004DOI Listing
December 2021

The roles of sex and gender in women's eye health disparities in the United States.

Biol Sex Differ 2021 10 20;12(1):57. Epub 2021 Oct 20.

Office of Research on Women's Health, National Institute of Health, Bethesda, MD, USA.

Background: In the United States, women are at a higher risk of developing vision impairment or a serious eye disease (such as age-related macular degeneration, thyroid eye disease, or chronic dry eye disease) than men. Disparities in eye diseases due to biology widen even further when considering factors such as social determinants of health; gaps in research data, literature, and policy; insufficient provider and patient education; and limitations in screening and treatment options. Sex and gender disparities in eye health are clinically under-addressed and burdensome on both patient quality of life and the health care and economic systems, resulting in a pressing population health issue that negatively impacts women.

Design: The Society for Women's Health Research convened a working group of expert clinicians, researchers, and patient advocates to review the current state of science regarding sex and gender disparities in women's eye health, identify knowledge gaps and unmet needs, and explore better means to advance research, improve patient care, and raise awareness of key issues.

Discussion: The SWHR Women's Eye Health Working Group identified priority areas in research, clinical care, and education to reduce disparities and improve patient care in women's eye health. The working group recommends using a systems approach that incorporates a comprehensive research framework with a sex and gender lens to guide future work and that increases health care provider and public education, as well as engagement by expanding partnerships among ophthalmologic providers, researchers, and non-vision stakeholders.
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http://dx.doi.org/10.1186/s13293-021-00401-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8527306PMC
October 2021

The Effect of Sleep Position Preference on Eyelid and Eyebrow Symmetry.

Ophthalmic Plast Reconstr Surg 2022 May-Jun 01;38(3):266-269. Epub 2021 Oct 13.

Department of Ophthalmology and Visual Sciences, University of Iowa Health Care, Iowa City, Iowa, U.S.A.

Purpose: To investigate the relationship between sleep position preference and eyebrow and eyelid position and degree of upper eyelid dermatochalasis.

Methods: A prospective study evaluating the impact of sleep position on facial asymmetry was conducted at an academic ophthalmology department. Eligibility criteria included the absence of periocular-altering trauma or surgery, contact lens use, or other periorbital disease processes. Patients reported their sleep position preference on a questionnaire. Standardized digital photographs of patients were obtained, and Image J software was used for measurements and converted into millimeters based on a standard corneal limbus-to-limbus ratio. Upper and lower eyelid position, upper eyelid dermatochalasis, and eyebrow position were assessed by the following image-derived measurements: marginal reflex distance 1 (iMRD1), marginal reflex distance 2 (iMRD2), tarsal platform show (iTPS), and central brow position (iBP). These results were compared with the patient reported sleep position preference to determine correlation.

Results: Seventy-one patients were enrolled and reported the following sleep position preferences: 28 (right), 24 (left), 13 (both), and 6 (supine). Patients with a right- or left-sided preference demonstrated lower iMRD1 measurements for the preferred sleep side (p < 0.0004) with no other significant difference in periorbital measurements. A larger degree of upper eyelid height (iMRD1) asymmetry was observed among patients with a sleep side preference.

Conclusion: Patients with a predominant sleep side preference demonstrate a significant increase in ipsilateral upper eyelid asymmetry and an inferior upper eyelid position on the sleep side. There were no differences noted in lower eyelid position, central eyebrow position, or amount of upper eyelid dermatochalasis.
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http://dx.doi.org/10.1097/IOP.0000000000002066DOI Listing
May 2022

Echographic Assessment of Extraocular Muscle Response to Teprotumumab.

Ophthalmic Plast Reconstr Surg 2022 Jul-Aug 01;38(4):336-339. Epub 2022 Oct 13.

Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: To evaluate extraocular muscle response to teprotumumab using orbital echography in thyroid eye disease.

Methods: This retrospective study included adult thyroid eye disease patients with pre- and post-teprotumumab orbital echography. Data collected included: age, Hertel measurements, clinical activity score, Gorman diplopia scores, ocular motility, and recti muscle diameters measured by echography. The patient's more proptotic eye before treatment initiation was designated as the study orbit. Ocular motility was assessed by totaling the ductions in all 4 cardinal directions. Orbital echography was obtained pre- and post-treatment to assess response of extraocular muscle diameters.

Results: Six patients with a mean age of 67 years were included. There was a mean improvement in proptosis of 4.3 mm in the study eye with 11/12 orbits showing improvement in globe position ( p < 0.05). All patients had a decrease in clinical activity score with a mean reduction of 2.5. Four patients had an improvement in Gorman diplopia score. Ocular motility in the study orbits improved by a total mean of 26.9° ( p < 0.05). Mean total extraocular muscle diameter was reduced from 27.4 to 23.4 mm ( p < 0.001). On average, superior recti were largest pre- and post-treatment, followed by inferior, medial, then lateral recti. However, inferior recti showed the greatest reduction of 23% ( p < 0.02).

Conclusions: Orbital echography demonstrated extraocular muscle reduction in all patients after teprotumumab, correlating with improved clinical activity score, ocular motility, and proptosis. Orbital echography is a safe and cost-effective imaging alternative to monitor therapeutic response to teprotumumab.
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http://dx.doi.org/10.1097/IOP.0000000000002072DOI Listing
July 2022

Audiology findings in patients with teprotumumab associated otologic symptoms.

Am J Ophthalmol Case Rep 2021 Dec 16;24:101202. Epub 2021 Sep 16.

Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, USA.

Purpose: To report a case series of subjective and objective hearing function changes associated with teprotumumab treatment for thyroid eye disease.

Observations: A 74-year-old female with a history of Graves' disease with thyroid eye disease was treated with teprotumumab. She had a history of bilateral tinnitus and noticed a subjective improvement in her tinnitus after the second infusion. Audiology testing obtained before, during, and after completion of infusions showed symmetric and rapidly progressive worsening of the patient's sensorineural hearing loss. In contrast, a 42-year-old male with a history of Grave's disease endorsed worsening intermittent tinnitus and low-pitched hearing loss after initiation of teprotumumab. Audiology testing before, during, and after completion of infusions showed stable and normal hearing function bilaterally.

Conclusion And Importance: This case series highlights the importance of objective testing in patients prior to and after teprotumumab initiation as subjective hearing changes may not accurately reflect objective hearing function. In addition, this report suggests that teprotumumab may play a role in potentiating sensorineural hearing loss.
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http://dx.doi.org/10.1016/j.ajoc.2021.101202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8452766PMC
December 2021

Scleral Contact Lens as Initial Management in a Neonate With a Large Upper Eyelid Coloboma.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):e10-e13

From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.

A neonate presented with a large full-thickness upper eyelid coloboma with near-complete exposure of the cornea. After failing lubrication and a moisture chamber, he was fit with a customized scleral contact lens that protected the ocular surface. It was tolerated well, and ocular surface health was maintained for 13 months to permit the growth of eyelid tissue for future oculoplastic surgery. Delaying reconstruction by using scleral contact lenses as management for large eyelid colobomas has not been previously described. A temporizing measure such as this could be considered for large eyelid colobomas in neonates.
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http://dx.doi.org/10.1097/IOP.0000000000002057DOI Listing
January 2022

Aesthetic Eyelid Measurements of "Beautiful People": Gender Differences and Application for Thyroid Eye Disease Patients.

Plast Reconstr Surg Glob Open 2021 Jul 6;9(7):e3666. Epub 2021 Jul 6.

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

There remains a paucity of studies investigating measurements of periocular structures of people popularly seen as "beautiful." Such measurements may be helpful in establishing postoperative goals and measuring aesthetic outcomes. This study (1) identifies aesthetic measurements of the periocular structures in idealized celebrities, (2) determines gender differences in such measurements, and (3) compares these measurements to patients who underwent surgical repair of upper eyelid retraction associated with thyroid eye disease.

Methods: Digital analysis of 38 celebrity photographs in 's "Most Beautiful People" and "Sexiest Man Alive" was performed to measure image-derived (denoted with an "i") margin reflex distance (iMRD1), tarsal platform show (iTPS), brow fat span (iBFS), and iTPS:iBFS ratio. The same analysis was used for 35 women who underwent surgical repair for thyroid eye disease-related upper eyelid retraction.

Results: Significant gender differences ( < 0.05) were observed in celebrity metrics, with women having higher upper eyelids (longer iMRD1) (3.30 mm versus 2.50 mm), longer iTPS measurements (3.90 mm versus 2.50 mm), and larger iTPS:iBFS values (0.31 versus 0.20). Postoperative thyroid eye disease patients had significantly higher upper eyelids (longer iMRD1s) (4.80 mm versus 3.30 mm), longer iTPS (5.10 mm versus 3.90 mm), and larger iTPS:iBFS (0.37 versus 0.31) than celebrities.

Conclusions: There are significant gender differences in the periocular metrics of "beautiful people." Optimal aesthetic outcomes may be more effectively obtained by achieving a preferred range of ratios than by relying on independent measurements. Although aesthetic outcomes are multi-factorial, measurements of "beautiful" people provide helpful guidelines to gauge aesthetic outcomes.
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http://dx.doi.org/10.1097/GOX.0000000000003666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8376344PMC
July 2021

An Eye on Gender Equality: A Review of the Evolving Role and Representation of Women in Ophthalmology.

Am J Ophthalmol 2022 04 17;236:232-240. Epub 2021 Jul 17.

From the Department of Ophthalmology, the University of Auckland, Auckland, New Zealand (H.G., R.L.N., H.V.D.-M.). Electronic address:

Purpose: In recent decades, women have achieved greater representation in ophthalmology. Globally, women now constitute approximately 25%-30% of ophthalmologists and 35%-45% of trainees. Nevertheless, women remain under-represented in key areas, including positions of professional and academic leadership and ophthalmic surgical subspecialization. Furthermore, there is evidence that women in ophthalmology encounter more bias and discrimination across multiple domains than men, including a gender-pay gap that is wider than in many other surgical subspecialties. Women ophthalmologists and trainees report sharply differing training experiences from male peers, including fewer opportunities to operate, more bullying and harassment, less access to mentorship, and contrasting expectations around contributions to family life.

Design: Perspective.

Methods: An extensive literature search was undertaken to compile and review papers published with a focus on gender equity across ophthalmology, surgery, and medicine.

Results: We identified 8 broad domains that were widely discussed: leadership, research and academics, income, surgical exposure and subspecialization, harassment, career satisfaction, mentorship, and family and marital differences. We have summarized the current research across each of these areas, and discussed possible solutions to reduce the inequities reported.

Conclusions: This review draws on current research published around representation and experiences of women in ophthalmology and suggests that there are opportunities to improve gender inequity.
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http://dx.doi.org/10.1016/j.ajo.2021.07.006DOI Listing
April 2022

Association of Age-adjusted Charlson Comorbidity Index With Orbital Fungal Disease Outcomes.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):53-58

Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Purpose: To determine whether the age-adjusted Charlson comorbidity index (age-CCI) in sino-orbital fungal disease patients correlates with disease-specific mortality.

Methods: Hospital billing systems at 2 academic institutions were queried for patients with ICD-9, ICD-10, and CPT codes used in fungal disease who also had orbital disease and significant visual loss. Thirty-two patients at Institution A and 18 patients at Institution B met the inclusion criteria of microbiologic or pathologic confirmation of fungal infection and completion of inpatient ophthalmology evaluation. Patients without radiographic abnormality in the sinus or orbit were excluded. Demographic, diagnostic, treatment, and outcome variables were recorded. Our primary outcome was death due to fungal disease.

Results: Of the 50 medical records examined, 44 patients met the criteria for fungal-related death outcome on multivariate analysis. The regression coefficient for age-CCI and fungal-related mortality was 0.242 (95% CI, 0.012-0.779) with a p value of 0.038.

Conclusions: Age-CCI is significantly associated with fungal-related mortality. This relationship remains significant when controlling for 5 covariates of fungal organism phylum, presence or absence of CNS disease, exenteration, local treatment use, and presence or absence of an immunosuppressive diagnosis. Age-CCI shows promise as a clinical and research tool in the evaluation of invasive fungal disease involving the orbit.
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http://dx.doi.org/10.1097/IOP.0000000000001987DOI Listing
January 2022

Challenging the current treatment of residual postoperative ptosis: safety and efficacy of repeat Müller's muscle conjunctival resection.

Can J Ophthalmol 2022 08 29;57(4):247-252. Epub 2021 May 29.

Department of Ophthalmology and Visual Sciences, University of Iowa, Carver College of Medicine, Iowa City, Iowa. Electronic address:

Objective: To determine if repeat Müller's muscle conjunctival resection (MMCR) is a viable approach in the treatment of recurrent or residual eyelid ptosis.

Methods: A retrospective review of patients who underwent repeat MMCR was performed using external photos obtained preoperatively, postoperatively, and at last follow-up. The marginal reflex distances (MRD1 and MRD2), brow position (BP), and tarsal platform show (TPS) were evaluated with digital image analysis. The change in upper eyelid height (MRD1) and TPS following repeat ptosis repair were the outcome measures.

Results: Repeat MMCR was performed on 12 eyelids of 11 patients. Mean MRD1 elevation after initial MMCR was 1.6 mm (standard deviation [SD] = 1.0mm, p < 0.00001). Mean decrease in TPS was 1.9 mm (p = 0.04). There was no significant change in MRD2 (p = 0.36) or BP (p = 0.33) with initial MMCR. Mean interval between procedures was 12.8 months (range 2.3-48.0) and follow-up after repeat MMCR was 2.3 months. Total average follow-up after initial MMCR was 15.1 months. Mean elevation in MRD1 after repeat MMCR was 1.0 mm (SD = 0.8 mm, p < 0.002). Mean decrease in TPS was 1.0 mm (p = 0.03). There was no difference in MRD2 (p = 0.90) or BP (p = 0.53). There were no complications of repeat MMCR noted clinically or spontaneously reported, including no entropion, fornix foreshortening, or development of dry eye signs or symptoms.

Conclusion: Repeat MMCR significantly improves recurrent or residual ptosis after initial MMCR without significant adverse consequences. The degree of elevation with repeat MMCR was diminished when compared with initial MMCR.
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http://dx.doi.org/10.1016/j.jcjo.2021.04.021DOI Listing
August 2022

Detection and Referral of Orbital and Ocular Injuries Associated With Intimate Partner Violence Following an Educational and Screening Initiative in an Emergency Department.

JAMA Ophthalmol 2021 Jul;139(7):785-789

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

Importance: Intimate partner violence (IPV) is a substantial cause of morbidity and mortality in the US. Previous studies indicate gaps in identifying and referring female patients with IPV-associated orbital and ocular injuries to ancillary services.

Objective: To determine the number of IPV-associated orbital floor fractures, zygomaticomaxillary complex (ZMC) fractures, and ruptured globes referred to ancillary services in adult female patients following an educational and screening intervention to health care professionals.

Design, Setting, And Participants: This single-center retrospective quality improvement analysis examined electronic medical records of adult female patients seen in a single level 1 trauma center emergency department and ophthalmology clinic between January 2015 and February 2019, after the initiative began. Female adults who sustained orbital floor fractures, ZMC fractures, or ruptured globes were included. Preinitiative data were previously collected between January 1995 and January 2015 on adult female patients and published. Data analysis for this study occurred from May 2020 to September 2020.

Interventions: A 2-part, ongoing initiative began January 2015. First, enhancement of IPV screening protocols in the emergency department was conducted. Second, an educational campaign on IPV injury patterns was presented to residents and faculty in ophthalmology, emergency, otolaryngology, and trauma departments.

Main Outcomes And Measures: Comparison of ancillary service involvement preinitiative (January 1995 to January 2015) and postinitiative (January 2015 to February 2019).

Results: A total of 216 adult female patients (mean [SD] age, 55.0 [22.7] years; age range, 18-99 years) sustained orbital floor or ZMC fractures postinitiative. A total of 22 of 216 (10.2%) sustained fractures from IPV compared with 31 of 405 (7.6%) preinitiative (95% CI, -2.2% to 7.3%; P = .28). Documented social work referrals (11 of 31 preinitiative vs 20 of 22 postinitiative; difference, 55% [95% CI, 35%-76%]; P < .001), homegoing safety assessments (1 of 31 preinitiative vs 18 of 22 postinitiative; difference, 79% [95% CI, 61%-96%]; P < .001), and law enforcement involvement (7 of 21 preinitiative vs 16 of 22 postinitiative; difference, 50% [95% CI, 26%-74%]; P < .001) were higher in patients who presented after the initiative with orbital floor and ZMC fractures. A total of 51 adult female patients (mean [SD] age, 57.7 [20.8] years; age range 20-93 years) sustained ruptured globes postinitiative. A total of 5 of 51 patients (9.8%) sustained injury due to IPV postinitiative, compared with 5 of 141 (3.5%) preinitiative (95% patients, -2.5% to 15.0%; P = .08).

Conclusions And Relevance: Following the start of the initiative, referral patterns of adult female patients with IPV-associated orbital fractures improved. Targeted IPV screening of patients with orbital and ocular injuries is essential for effective intervention.
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http://dx.doi.org/10.1001/jamaophthalmol.2021.1546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8160912PMC
July 2021

A direct transcutaneous approach to infraorbital nerve biopsy.

Orbit 2022 Feb 6;41(1):130-137. Epub 2021 May 6.

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

Purpose: To describe a novel transcutaneous infraorbital nerve biopsy technique which can be performed to aid in the diagnosis of perineural invasion (PNI) of facial cutaneous squamous cell carcinoma (SCC).

Methods: A single-center retrospective chart review was performed. Patients diagnosed with SCC with PNI via an infraorbital nerve biopsy between February 2019 and February 2020 were included. Data collected consisted of patient demographics, medical history, clinical presentation and exam, histologic and radiographic findings, treatment, and outcomes.

Results: Four patients (3 male, 1 female) met inclusion criteria. The mean age at diagnosis was 79.5 years (range 66-85 years). Three of the four patients had a history of facial skin lesions, including actinic keratosis and SCC, involving the nose, cheek, or ear. One patient had no history of cutaneous malignancy. All patients presented with cranial neuropathies, including total V2 hypoesthesia. The most common presenting symptom was facial pain, followed by diplopia, unilateral facial weakness, and hypoesthesia in the V1 and/or V2 distribution. Transcutaneous infraorbital nerve biopsy in all patients revealed squamous cell carcinoma with no biopsy complications.

Conclusion: Definitive diagnosis of PNI can be challenging but is important to minimize tumor-related morbidity. Infraorbital nerve biopsy can establish this diagnosis, especially in the context of negative or indeterminate imaging findings. This work comprises the first description of a transcutaneous approach to infraorbital nerve biopsy, which is a minimally invasive technique that can be performed in an outpatient procedure suite with limited to no sedation.
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http://dx.doi.org/10.1080/01676830.2021.1920041DOI Listing
February 2022

Biliary obstruction-induced coagulopathy with subperiosteal orbital hemorrhage after endoscopic retrograde cholangiopancreatography.

Can J Ophthalmol 2021 12 1;56(6):e179-e180. Epub 2021 May 1.

Carver College of Medicine, University of Iowa, Iowa City, Iowa. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2021.03.010DOI Listing
December 2021

Responding to Patient-Initiated Verbal Sexual Harassment: Outcomes of a Pilot Training for Ophthalmologists.

J Acad Ophthalmol 2020 Jul 10;12(2):e175-e180. Epub 2020 Oct 10.

Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.

Background: Sexual harassment of physicians by patients is highly prevalent and rarely reported. Little is known on how to prepare physicians to handle verbal sexual harassment that detracts from their ability to provide care but does not meet the threshold for reporting.

Purpose: To assess the impact of a sexual harassment workshop and toolkit for ophthalmologists and ophthalmology trainees on responding to patient-initiated verbal sexual harassment.

Methods: A survey study of ophthalmology faculty, fellows, and residents who participated in workshops on responding to patient-initiated verbal sexual harassment was performed at an academic center. A toolkit of strategies for response was distributed. Volunteer participants completed a retrospective pretest-posttest evaluation at the conclusion of the workshop and follow-up survey 3 weeks after the workshops on whether they experienced harassment and intervened. The pretest-posttest surveys assessed the workshop's effect on ophthalmologists' perceptions of and preparedness to respond to sexual harassment in the moment using a 5-point Likert scale, including bystander intervention. Participants described their responses observing and/or experiencing patient-initiated sexual harassment in the 3 weeks following the workshop and whether they had intervened toward the harassment.

Results: Ophthalmologists (n=31) felt significantly more prepared to respond to patient-initiated sexual harassment directed towards themselves or a trainee in the moment after participating in the workshop (4.5 ± 1.63,) than before (3.0 ± 1.3) with a mean change of -1.6 (95% CI -2.2 to -.98, p<0.001). After the workshop 86.3% of participants felt mostly or completely prepared to respond to comments about their age, gender, marital status, appearance, attractiveness, a specific body part, and sexual or inappropriate jokes. Most participants (83.9%) said that they had not previously received training on techniques for responding to patient-initiated sexual harassment. Two-thirds (66.7%) of participants who experienced (n=8) or observed (n=13) harassment (n=15) following the workshop intervened. All participants who intervened toward patient-initiated harassment behavior after the workshop (n=10) found the Sexual Harassment Toolkit helpful in addressing harassment in the moment.

Conclusion: Participation in a brief skills-based workshop significantly improved ophthalmologists' preparedness to respond to verbal sexual harassment by patients.
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http://dx.doi.org/10.1055/s-0040-1717062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011573PMC
July 2020

Tools for Responding to Patient-Initiated Verbal Sexual Harassment: A Workshop for Trainees and Faculty.

MedEdPORTAL 2021 02 11;17:11096. Epub 2021 Feb 11.

Clinical Professor, Department of Ophthalmology and Visual Sciences, University of Iowa Roy J. and Lucille A. Carver College of Medicine.

Introduction: Patients are the most common source of gender-based harassment of resident physicians, yet residents receive little training on how to handle it. Few resources exist for residents wishing to address patient-initiated verbal sexual harassment themselves.

Methods: We developed, taught, and evaluated a 50-minute workshop to prepare residents and faculty to respond to patient-initiated verbal sexual harassment toward themselves and others. The workshop used an interactive lecture and role-play scenarios to teach a tool kit of communication strategies for responding to harassment. Participants completed retrospective pre-post surveys on their ability to meet the learning objectives and their preparedness to respond.

Results: Ninety-one participants (57 trainees, 34 faculty) completed surveys at one of five workshop sessions across multiple departments. Before the workshop, two-thirds (67%) had experienced patient-initiated sexual harassment, and only 28 out of 59 (48%) had ever addressed it. Seventy-five percent of participants had never received training on responding to patient-initiated sexual harassment. After the workshop, participants reported significant improvement in their preparedness to recognize and respond to all forms of patient-initiated verbal sexual harassment ( < .01), with the greatest improvements noted in responding to mild forms of verbal sexual harassment, such as comments on appearance or attractiveness or inappropriate jokes ( < .01).

Discussion: This workshop fills a void by preparing residents and faculty to respond to verbal sexual harassment from patients that is not directly observed. Role-play and rehearsal of an individualized response script significantly improved participants' preparedness to respond to harassment toward themselves and others.
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http://dx.doi.org/10.15766/mep_2374-8265.11096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880260PMC
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

Medial Canthal Fistula in Chronic Canaliculitis.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3S):S169

Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, Iowa, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001750DOI Listing
May 2021

Closure Technique and Antibiotics in Frontalis Sling Infection and Exposure.

Ophthalmology 2021 03 16;128(3):480-482. Epub 2020 Jul 16.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2020.06.066DOI Listing
March 2021

Thyroid eye disease with choroidal folds.

Orbit 2021 Jun 23;40(3):206-214. Epub 2020 Apr 23.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED).: A multi-center retrospective case series of patients with TED who developed CRF.: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF ( = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF.: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.
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http://dx.doi.org/10.1080/01676830.2020.1756347DOI Listing
June 2021

Preserving Vision: Rethinking Burn Patient Monitoring to Prevent Orbital Compartment Syndrome.

J Burn Care Res 2020 09;41(5):1104-1110

Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics.

Burn patients receiving aggressive fluid resuscitation are at risk of developing orbital compartment syndrome (OCS). This condition results in elevated orbital pressures and can lead to rapid permanent vision loss. Risk factors and monitoring frequency for OCS remain largely unknown. A retrospective review was therefore conducted of admitted burn patients evaluated by the ophthalmology service at an American Burn Association verified Burn Treatment Center. Demographic, burn, examination, and fluid resuscitation data were compared using two-sided t-tests, Fisher's exact tests, and linear regression. Risk factors for elevated intraocular pressures (IOPs; a surrogate for intraorbital pressure) in patients resuscitated via the Parkland formula were found to be total body surface area (% TBSA) burned, resuscitation above the Ivy Index (>250 ml/kg), and Parkland formula calculated volume. Maximum IOP and actual fluid resuscitation volume were linearly related. Analysis of all patients with elevated IOP found multiple patients with significant IOP increases after initial evaluation resulting in OCS within the first 24 hours postinjury. While %TBSA, Ivy Index, and resuscitation calculated volume are OCS risk factors in burn patients, two patients with facial burns developed OCS (25% of all patients with OCS) despite not requiring resuscitation. Orbital congestion can develop within the first 24 hours of admission when resuscitation volumes are the greatest. In addition to earlier and more frequent IOP checks in susceptible burn patients during the first day, the associated risk factors will help identify those most at risk for OCS and vision loss.
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http://dx.doi.org/10.1093/jbcr/iraa053DOI Listing
September 2020

Orbital Actinomyces Masquerading as Meningioma.

Ophthalmic Plast Reconstr Surg 2020 Sep/Oct;36(5):e124-e126

Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa.

Orbital actinomyces is a rare diagnosis with only a few cases reported in the literature. It can be difficult to diagnose due to its slow, indolent course, and nonspecific findings on imaging and clinical examination, and frequently it can masquerade as other pathologies such as neoplasm and inflammatory disease. The authors present a case of actinomyces masquerading as meningioma with findings of hyperostosis and a superior orbital roof interosseous tract on imaging.
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http://dx.doi.org/10.1097/IOP.0000000000001626DOI Listing
March 2021

A multidisciplinary educational curriculum for the management of orbital compartment syndrome.

Am J Emerg Med 2020 06 9;38(6):1278-1280. Epub 2019 Dec 9.

Department of Ophthalmology and Visual Sciences, University of Iowa, Carver College of Medicine, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2019.12.002DOI Listing
June 2020

A U.S. Survey of Sexual Harassment in Ophthalmology Training Using a Novel Standardized Scale.

J Acad Ophthalmol 2020 Jan;12(1):e27-e35

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

Objective: This study aimed to assess the frequency and severity of sexual harassment toward ophthalmology trainees.

Design: Present study is an anonymous retrospective online survey.

Participants: U.S. ophthalmology residents and fellows participated in this study.

Methods: Sexual harassment comments directed toward University of Iowa ophthalmology trainees and faculty members were compiled. Statements were ranked by severity to develop the Iowa Verbal Sexual Harassment Scale. A brief, anonymous online survey incorporating the scale was sent to all United States ophthalmology residency program directors to distribute among trainees. Participants rated the prevalence, severity, and frequency of verbal and physical sexual harassment during training.

Main Outcome Measures: Response to the survey questions on the prevalence, severity, and frequency of reporting of verbal and physical sexual harassment in ophthalmology training.

Results: Among 112 respondents (59 men and 53 women), 72 (64.3%) experienced sexual harassment in the workplace from patients (86.8% of women vs. 44.1% of men; <0.0001, 95% confidence interval [CI]: 1.48-2.74). Trainees rarely experienced harassment by colleagues (10.7%) or supervisors (8.9%). Women experienced more severe and frequent sexual harassment compared with men, with 54.7% women and 30.5% men experiencing sexual harassment weekly ( = 0.013, 95% CI: 1.29-5.71). Unwanted touching was the most common physical harassment type. The trainees' threshold for reporting sexual harassment was higher than their worst actual experience (< 0.0001, F(2,282) = 67.59). Few trainees formally reported verbal (6.3%) or physical sexual harassment (1.8%). Trainees most commonly responded to harassment by redirecting the harasser (67.9%). Only 33.9% of trainees rated their institution's sexual harassment training as helpful preparation for addressing harassment.

Conclusion: Most ophthalmology trainees experienced sexual harassment with almost all harassment coming from patients. Female trainees reported substantially greater severity and frequency of sexual harassment. There remains an unmet need for targeted response training in ophthalmology training programs.
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http://dx.doi.org/10.1055/s-0040-1705092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136612PMC
January 2020
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