Publications by authors named "Jeremiah Tao"

77 Publications

Blindness Secondary to Odontogenic Orbital Cellulitis During the COVID-19 Dental Shutdown.

Ophthalmic Plast Reconstr Surg 2021 Jul 15. Epub 2021 Jul 15.

Gavin Herbert Eye Institute; University of California, Irvine, California, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000002020DOI Listing
July 2021

Homeopathic Agents or Vitamins in Reducing Ecchymosis after Oculofacial Surgery: A Report by the American Academy of Ophthalmology.

Ophthalmology 2021 Jun 24. Epub 2021 Jun 24.

Cullen Eye Institute, Baylor College of Medicine, Houston, Texas.

Purpose: To review the published literature to determine the efficacy and safety of homeopathic agents or vitamins in reducing ecchymosis after oculofacial surgery or laser surgery.

Methods: A literature search was conducted in the PubMed database initially in December 2019 and updated in March 2020 to identify all studies in the English language literature on the use of homeopathic agents or vitamins in oculofacial procedures, including laser surgery. The search yielded 124 citations, and 11 articles met all inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study. Eleven studies met inclusion criteria; 9 were rated level I, and 2 were rated level III.

Results: The agents studied in the articles identified included oral or topical Arnica montana (AM), oral Melilotus extract, topical vitamin K oxide, and topical AM combined with Rhododendron tomentosum. Metrics to describe ecchymosis varied. In 7 controlled studies, perioperative AM provided no or negligible benefit versus placebo. In 2 studies, vitamin K cream was equivalent to placebo. One study of oral Melilotus extract had less ecchymosis compared with controls in paranasal and eyelid ecchymosis at postoperative day (POD) 7, but not at PODs 1 and 4. A lone cohort study of combined topical AM and R. tomentosum lacked objective metrics and adequate controls. No serious side effects from administration of homeopathic agents or vitamins were identified.

Conclusions: The current literature does not support the use of AM, vitamin K oxide, R. tomentosum, or Melilotus extract for reducing ecchymosis after oculofacial surgery or pulsed dye laser surgery.
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http://dx.doi.org/10.1016/j.ophtha.2021.05.018DOI Listing
June 2021

A Prospective Randomized Study of Lateral Brow-Eyelid Complex Volume after Internal Browpexy Using Three-Dimensional Stereophotogrammetry.

Facial Plast Surg Aesthet Med 2021 Jun 24. Epub 2021 Jun 24.

Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, USA.

A full lateral brow-eyelid complex may help rejuvenate and feminize the face. To compare periorbital volume change of patients as measured by three-dimensional (3D) stereophotogrammetry before and after blepharoplasty with or without internal browpexy sutures. This is a prospective randomized controlled study of 124 eyelids of 62 adult female patients who underwent cosmetic upper eyelid blepharoplasty by a single surgeon. Subjects were randomized to blepharoplasty alone (control) or blepharoplasty with an adjunctive "brassiere suture" internal browpexy (intervention). An observer masked to the intervention measured the brow-eyelid volume using standardized images obtained with a 3D camera, before and after surgery. The minimum follow-up was 6 months postoperatively. Sixty eyelids (30 patients) were treated with upper blepharoplasty alone and 64 eyelids (32 patients) had blepharoplasty plus internal browpexy. The mean volume gain was 0.85 mL in the internal browpexy intervention group and 0.19 mL in the control group. The volume increased in all patients receiving browpexy and this change was greater than after blepharoplasty alone ( < 0.05). The mean follow-up time was 16.8 months (range 6-24 months). Adjunctive internal browpexy during blepharoplasty was associated with increased volume of the lateral brow-eyelid complex.
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http://dx.doi.org/10.1089/fpsam.2020.0586DOI Listing
June 2021

Carotid-Cavernous Sinus Fistula Masquerading as Thyroid Eye Disease.

Cureus 2021 Apr 2;13(4):e14261. Epub 2021 Apr 2.

Department of Ophthalmology, Division of Oculofacial Plastic & Orbital Surgery, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, USA.

A 29-year-old man with a medical and social history notable for smoking presented with progressive orbital congestion, conjunctival injection, and extraocular muscle enlargement consistent with thyroid eye disease (TED). On ophthalmologic examination, tortuous episcleral vessels and blood in Schlemm's canal on gonioscopy clued an alternative diagnosis. Cavernous sinus enhancement on computed tomography also suggested a retro-orbital process. Digital subtraction angiography confirmed a low-flow indirect carotid-cavernous fistula (CCF). He subsequently underwent endovascular embolization treatment. Ocular symptoms resolved by seven weeks, and he remained ocular symptom free at six months. Eye redness and proptosis frequently cause patients to seek medical attention. In the absence of a mass or signs of infection, TED is high on the differential, especially with a smoking history and even with normal thyroid parameters. However, CCF may lurk; the authors describe key diagnostic features and management.
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http://dx.doi.org/10.7759/cureus.14261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093110PMC
April 2021

A Digital Microscreen for the Enhanced Appearance of Ocular Prosthetic Motility (an American Ophthalmological Society Thesis).

Am J Ophthalmol 2021 Apr 11;228:35-46. Epub 2021 Apr 11.

Department of Computer Science, University of California, Irvine, California, USA.

Purpose: This study aims to improve the apparent motility of ocular prosthetic devices using technology. Prevailing ocular prostheses are acrylic shells with a static eye image rendered on the convex surface. A limited range of ocular prosthetic movement and lack of natural saccadic movements commonly causes the appearance of eye misalignment that may be disfiguring. Digital screens and computational systems may obviate current limitations in eye prosthetic motility and help prosthetic wearers feel less self-conscious about their appearance.

Methods: We applied convoluted neural networks (CNNs) to track pupil location in various conditions. These algorithms were coupled to a microscreen digital prosthetic eye (DPE) prototype to assess the ability of the system to capture full ocular ductions and saccadic movements in a miniaturized, portable, and wearable system.

Results: The CNNs captured pupil location with high accuracy. Pupil location data were transmitted to a miniature screen ocular prosthetic prototype that displayed a dynamic contralateral eye image. The transmission achieved a full range of ocular ductions and with grossly undetectable latency. Lack of iris and sclera color and detail, as well as constraints in luminosity, dimensionality and image stability limited the real eye appearance. Yet, the digitally rendered eye moved in the same amplitude and velocity as the native, tracked eye.

Conclusions: Real-time image processing using CNNs coupled to microcameras and a miniscreen DPE may offer improvements in amplitude and velocity of apparent prosthetic eye movement. These developments, along with ocular image precision, may offer a next-generation eye prosthesis.
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http://dx.doi.org/10.1016/j.ajo.2021.03.025DOI Listing
April 2021

Oculofacial plastic surgery-related online search trends including the impact of the COVID-19 pandemic.

Orbit 2021 Feb 14;40(1):44-50. Epub 2020 Dec 14.

Division of Oculofacial Plastic & Orbital Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California , Irvine, California, USA.

: The authors aim to characterize oculofacial plastic surgery-related online interest that may be useful in forecasting demand and in designing patient-directed online resources. : The authors queried Google Trends for over 100 oculofacial plastic surgery terms. The main outcome measure was the top 50 oculofacial plastic surgery-related search terms from 2004 to 2020. Secondary outcomes were trends, including seasonality, and search volume changes during the COVID-19 lockdown (March-May 2020) compared to 2018-2019. Terms were analyzed individually and in thematic categories; controlled against generic search terms to account for general internet traffic. : Between 2004 and 2020, searches for oculofacial plastic surgery altogether increased, surpassing the rate of internet traffic growth. One thematic category - eyelid malpositions - decreased month-over-month. The top five terms were "face lift," "Bell's palsy," "puffy eyes," "dark circles under eyes," and "chalazion." Eyelid neoplasms searches peaked in summer (  = 0.880) whereas cosmetic (  = 0.862), symptoms (  = 0.907), and surgeries (  = 0.140) peaked in winter. Overall, oculofacial-related searches decreased during the COVID-19 lockdown, although thyroid eye disease interest increased compared to 2018 or 2019 (+68.6%; adj. = .005). Oculofacial plastic surgery interest in 2020 was inversely correlated to "COVID-19" searches (r = -0.76, < .001). : Oculofacial plastic surgery searches increased since 2004 at a pace greater than that ascribed to internet traffic growth. The most searched terms were "face lift," "Bell's palsy," "puffy eyes," "dark circles under eyes," and "chalazion." Almost all oculofacial-related searches decreased during the COVID-19 lockdown.
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http://dx.doi.org/10.1080/01676830.2020.1852264DOI Listing
February 2021

Pharmaceutical and Supply Waste in Oculofacial Plastic Surgery at a Hospital-Based Outpatient Surgery Center.

Ophthalmic Plast Reconstr Surg 2020 Nov 19. Epub 2020 Nov 19.

Division of Oculofacial Plastic and Orbital Surgery, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, U.S.A.

Purpose: To investigate the financial and environmental waste burden of unused disposable surgical supplies and pharmaceutical products in oculofacial plastic surgery at a hospital-based outpatient surgery center.

Methods: This descriptive study was performed at a single academic hospital-based outpatient surgery center. Unused pharmaceuticals and disposable surgical materials were recorded for each of 34 consecutive oculofacial plastic surgeries performed by the same surgical team. Pharmaceutical products were grouped as local anesthetic (tetracaine, bupivacaine, lidocaine, and sodium bicarbonate), intraoperative (basic saline solution, methylene blue, and oxymetazoline hydrochloride), or antiseptic/antimicrobial (erythromycin ointment and hydrogen peroxide). Percentage of unused pharmaceutical product and disposable surgical material were calculated and extrapolated to direct costs to the institution and greenhouse gas emissions.

Results: The mean percentage of disposable surgical supply waste per case was 11.6% ($29.32). The mean percentage of pharmaceutical waste was 96.1% ($271.84) for local anesthetic, 71.0% ($163.47) for intraoperative medications, and 26.7% ($2.19) for antiseptic medication. The mean emissions per surgical case for unused disposable surgical equipment and unused pharmaceutical product were 10 and 103 kg of carbon equivalent gases (kg CO2-e), respectively.

Conclusions: Surgical supply waste was nominal, but pharmaceutical waste was considerable in this single hospital-based outpatient surgery center study. There may exist opportunities for quality improvement in waste, especially pharmacologic burden, in oculofacial plastic surgery.
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http://dx.doi.org/10.1097/IOP.0000000000001891DOI Listing
November 2020

Antibiotic Ointment after Oculofacial Plastic Surgery: Does It Make a Difference?

Authors:
Jeremiah P Tao

Ophthalmology 2020 12;127(12):1755-1756

Irvine, California. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2020.07.057DOI Listing
December 2020

Interventions for Indirect Traumatic Optic Neuropathy: A Report by the American Academy of Ophthalmology.

Ophthalmology 2021 Jun 6;128(6):928-937. Epub 2020 Nov 6.

Cullen Eye Institute, Baylor College of Medicine, Houston, Texas.

Purpose: To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head.

Methods: A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis.

Results: No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.

Conclusions: Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.
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http://dx.doi.org/10.1016/j.ophtha.2020.10.038DOI Listing
June 2021

Opioid Use After Orbital, Eyelid, or Lacrimal Surgery.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3S):S62-S65

Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine.

Purpose: Opioids may be indicated to mitigate pain after oculofacial surgery. The opioid crisis prompted attention to how these medications are dispensed and disposed. This study aims to characterize opioid usage and handling of patients undergoing oculofacial plastic surgery.

Methods: Eighty-nine adult patients were surveyed on their opioid usage after undergoing orbital, lacrimal, or eyelid (including esthetic) surgery at a tertiary oculofacial plastic surgery practice. Each patient was prescribed 10 tablets of hydrocodone/acetaminophen 5 mg/325 mg; one tablet taken orally as needed every 6 hours for pain not relieved by acetaminophen. Subset analysis was performed for type of surgery, age, and gender.

Results: Patients consumed an average of 3 ± 0.4 tablets. In the subsets, the averages were 2.1 ± 0.5 (n = 38) tablets after eyelid surgery, 1.6 ± 0.6 (n = 24) after lacrimal surgery, and 5.6 ± 0.9 (n = 27) after orbital surgery. Greater opioid usage was observed after orbital versus eyelid surgery (p = 0.0007) and orbital versus lacrimal surgery (p = 0.0005) but not eyelid versus lacrimal surgery (p = 0.8604). Forty-six patients (51.7%) used no opioids. Over half (57.3%; n = 51) filled their prescription. Thirty-three patients (37.1%) had unused medications, of which 21 patients did not properly dispose of their medications. The mean age of patients who used opioids was less than the mean age of those who needed no opioids (p = 0.024). There were no gender differences in opioid usage use versus not (p = 0.62).

Conclusions: Opioid needs after oculofacial plastic surgeries, especially eyelid and lacrimal, were minimal in this cohort. For most patients, the prescription exceeded needs. Younger age but not gender was associated with opioid use versus not. Most did not properly discard these medications. Quality improvement in both the dispensing and disposal of opioids in oculofacial surgical practice may be warranted.
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http://dx.doi.org/10.1097/IOP.0000000000001813DOI Listing
May 2021

Sentinel Lymph Node Biopsy for Eyelid and Conjunctival Malignancy: A Report by the American Academy of Ophthalmology.

Ophthalmology 2020 12 19;127(12):1757-1765. Epub 2020 Jul 19.

Cullen Eye Institute, Baylor College of Medicine, Houston, Texas.

Purpose: To determine the efficacy and safety of sentinel lymph node biopsy (SLNB) in the management of eyelid and conjunctival malignancy.

Methods: A literature search was performed in August 2019 and January 2020 for articles published in English in the PubMed and Cochrane Library databases. This search yielded 151 articles that were reviewed for relevancy, of which 27 were deemed to have met the inclusion criteria for this assessment. The data from these articles were abstracted and the articles were rated for strength of evidence by the panel methodologist.

Results: All 27 studies were rated level III, and a total of 197 SLNBs were reported. Diagnoses included conjunctival and eyelid cutaneous melanoma (85 and 42 patients, respectively), sebaceous gland carcinoma (35 patients), squamous cell carcinoma (26 patients), Merkel cell carcinoma (6 patients), pigmented epithelioid melanocytoid tumor (1 patient), mucoepidermoid carcinoma (1 patient), and signet ring carcinoma (1 patient). Tracer was found in regional lymph nodes in 100% of patients in 21 of 27 articles and in 191 of 197 patients overall. The number of lymph nodes removed ranged from 1 to 16, with most ranging from 1 to 5. Tumor-positive lymph nodes were found in 33 of 197 patients (16.8%), prompting recommendations for adjuvant treatments. Survival data were reported for 16 of these patients, with follow-up periods ranging from 3 to 36 months (average, 12.7 months). Fourteen of 16 patients received adjuvant treatments. Nine were alive and well, 1 was alive with metastases, and 6 had died of metastatic disease (including 2 patients who declined additional treatment). False-negative SLNB results were reported in 5 articles involving 9 of 197 procedures (4.6%). Complications were documented in 7 of 27 articles and included transient facial nerve weakness, persistent blue dye staining of the conjunctiva, neck hematoma, and suture abscess.

Conclusions: Sentinel lymph node biopsy is a promising procedure in patients with eyelid and conjunctival malignancy, and it is useful in identifying sentinel lymph nodes. However, at present, insufficient evidence exists showing that SLNB improves patient outcomes and survival. Recognition of microscopic metastatic disease may prove beneficial in staging and guiding adjuvant therapy.
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http://dx.doi.org/10.1016/j.ophtha.2020.07.031DOI Listing
December 2020

Broken Needle Retrieval Following Periorbital Soft-Tissue Filler Injection.

Ophthalmic Plast Reconstr Surg 2020 Jul/Aug;36(4):e108

Division of Oculoplastic and Orbital Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, School of Medicine, Irvine, California, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001495DOI Listing
March 2021

Orbital Microscopic Polyangiitis With Secondary Angle Closure Due to Uveal Effusion.

Ophthalmic Plast Reconstr Surg 2021 Jan-Feb 01;37(1):e33-e35

Division of Oculofacial Plastic & Orbital Surgery, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, U.S.A.

A 63 year-old man presented with 3 weeks of worsening, painless left-sided proptosis, ptosis, and diplopia. Examination of the affected eye revealed normal visual acuity, normal intraocular pressure in the presence of a shallow anterior chamber, grade 1 relative afferent pupillary defect, restricted motility in all directions of gaze, and 6 mm of proptosis. Ultrasound biomicroscopy revealed uveal effusions with anterior rotation of the ciliary body causing appositional angle closure. B-scan ultrasonography and MRI demonstrated enhancement of the posterior globe and an infiltrative mass involving the lacrimal gland and multiple extraocular muscles. Laboratory studies revealed positive perinuclear antineutrophil cytoplasmic antibody with elevated myeloperoxidase antibodies, consistent with a diagnosis of microscopic polyangiitis. Biopsy showed nonspecific dacryoadenitis. Intravenous and oral corticosteroids were associated with rapid improvement of all examination findings. The patient was later switched to rituximab steroid-sparing therapy and has shown no recurrence of disease at 3-months follow-up.
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http://dx.doi.org/10.1097/IOP.0000000000001725DOI Listing
April 2021

Lateral Tarsoconjunctival Flap Suspension Treatment of Post Blepharoplasty Lower Eyelid Retraction.

Ophthalmic Plast Reconstr Surg 2020 Nov/Dec;36(6):613-616

Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, U.S.A.

Purpose: To describe and evaluate the use of a lateral tarsoconjunctival suspension flap (TCSF) for the management of post blepharoplasty lower eyelid retraction.

Methods: Two-center, retrospective chart review of patients who received a lateral TCSF between 2010 and 2018 for correction of post blepharoplasty lower eyelid retraction. The postoperative follow-up was a minimum of 3 months. Pre- and postoperative lower eyelid position (margin reflex distance 2 on standard photographs), degree of ocular surface disease, symptoms, complications, and need for further intervention were recorded. Pre- and postoperative photographs were scored using an objective grading system for cosmetic surgical results (MDACS).

Results: Forty-eight eyelids from 30 patients met inclusion criteria for this study. Twenty (67%) of the patients were female. Age ranged from 55 to 89 (mean, 73.2). After the TCSF, ocular surface exposure improved in all cases. Lower eyelid retraction (average margin reflex distance 2 pre- vs. postintervention) improved in 98% of cases. Objective scoring of appearance improved; the mean MDACS score was 8 pre- and 3 post-TCSFs (p < 0.0001). One patient required midface lift and lateral canthoplasty 7 months later for undercorrected eyelid retraction. Another case required partial resection due to visibility of the flap in the interpalpebral zone. Postoperative pyogenic granulomas were noted in 8% (4/48) of eyelids.

Conclusions: The lateral TCSF was safe and effective in improving both functional and esthetic parameters in this series of post blepharoplasty eyelid retraction patients.
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http://dx.doi.org/10.1097/IOP.0000000000001699DOI Listing
March 2021

Intense Pulsed Light for Meibomian Gland Disease: A Report by the American Academy of Ophthalmology.

Ophthalmology 2020 09 21;127(9):1227-1233. Epub 2020 Apr 21.

Cullen Eye Institute, Baylor College of Medicine, Houston, Texas.

Purpose: To review the literature on the efficacy of intense pulsed light (IPL) on the eyelids in the management of meibomian gland disease (MGD) and meibomian gland-related ocular surface disease.

Methods: A literature search was last conducted on May 15, 2019, in the PubMed and Cochrane Library databases for English-language original research that assessed the effect of IPL on MGD in adult patients. Thirty-three articles were identified, and 12 studies were determined to be relevant to the criteria outlined for assessment. The panel methodologist (V.K.A.) assigned a level of evidence rating to each study; 4 studies were rated level II, and 8 studies were rated level III. Five studies had potential conflicts of interest and design limitations that affected interpretation of results.

Results: All studies documented improvement in clinically meaningful metrics, including tear breakup time (TBUT), corneal staining and eyelid margin measurements, meibum quality, meibomian gland expressability, ocular surface disease index (OSDI), and standard patient evaluation of eye dryness (SPEED) questionnaire scores. Side effects were relatively uncommon but included discomfort, cutaneous erythema, blistering, eyelash loss, and floaters; these were uniformly self-limited.

Conclusions: Although methodological limitations and potential conflicts of interest in some studies raised concern, the existing body of literature demonstrates improvements in the signs and symptoms of MGD after IPL therapy.
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http://dx.doi.org/10.1016/j.ophtha.2020.03.009DOI Listing
September 2020

Massive Silicone-Induced Orbital Granuloma.

Ocul Oncol Pathol 2020 Mar 9;6(2):145-150. Epub 2019 Aug 9.

Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, USA.

We report a large subconjunctival-orbital granuloma in a 51-year-old male presenting with a blind painful right eye and marked chemosis 15 months after undergoing vitrectomy and silicone oil retinal tamponade for retinal detachment with no reported intraoperative complications. Gross and histopathologic examination of the enucleated eye and episcleral tumor revealed a bosselated mass measuring 17 × 10 × 5 mm containing prominent vacuoles with surrounding epithelioid histiocytes and foreign body multinucleated giant cells. Such a large silicone-induced orbital granuloma following uncomplicated retinal surgery in a grossly intact eye has not been previously reported to the authors' knowledge. High intraocular pressure and emulsification of oil may facilitate silicone extravasation through scleral wounds after retinal surgery.
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http://dx.doi.org/10.1159/000501295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7109432PMC
March 2020

The American Oculofacial Plastic Surgery Family Tree.

Ophthalmic Plast Reconstr Surg 2020 Nov/Dec;36(6):e159

Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001576DOI Listing
March 2021

5-Fluorouracil Management of Oculofacial Scars: A Systematic Literature Review.

Ophthalmic Plast Reconstr Surg 2020 May/Jun;36(3):222-230

Gavin Herbert Eye Institute, Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, Irvine School of Medicine, Irvine, California, U.S.A.

Purpose: To review the literature for the safety and efficacy of intralesional 5-fluorouracil (5-FU) in the management of oculofacial scars.

Methods: A literature search was performed in July 2019 in the PubMed database to identify reports of the use of 5-FU injections for modulating oculofacial cutaneous scars. The search yielded 152 articles, of which 15 met criteria outlined for assessment. Data were abstracted from these 15 relevant articles.

Results: While there were no high-level prospective randomized controlled trials, 8 were lower-quality randomized controlled trial, 3 were retrospective cohort studies, and 4 were case series. Most studies pooled results of facial and nonfacial cutaneous applications. Three studies focused solely on oculofacial applications, and these were all lower-level evidence studies. The study outcomes included scar dimension reduction, erythema, patient satisfaction score, observer assessment of scar improvement, and recurrence rates. 5-Fluorouracil was administered as monotherapy or as part of multimodality treatment with other agents (usually corticosteroids) or with CO2 laser, radiotherapy, or pulsed dye laser. 5-Fluorouracil was usually given as an intralesional injection, but in some studies, it was applied topically after micropuncture of the skin. The number and timing of treatments varied between studies. Overall, the level of safety of 5-FU was high. Pain with injection was the most common reported side effect. Other common adverse side effects included pruritus, telangiectasias, changes in pigmentation, and purpura, and 2 studies noted more serious events, such as ulceration, superficial necrosis, and local infection. There were no severe side effects such as anaphylaxis, immune suppression, secondary malignancy, systemic infection, blindness, or death. In all studies, 5-FU was associated with prophylaxis of oculofacial scars or improvement of keloids or hypertrophic scars in terms of reducing size, erythema, and pruritus. 5-Fluorouracil application was associated with favorable patient satisfaction and observer assessment scores especially compared with corticosteroid injections alone.

Conclusions: High-quality randomized controlled trials are currently lacking, and the existing literature is predominately not specific to use of 5-FU on the face. These studies, however, suggest that intralesional 5-FU is safe and probably more effective than other options in the management of cutaneous scars in the oculofacial region. The delivery methods, timing, dosing, and concomitant therapies were highly variable. Further high-quality controlled studies specific to oculofacial scars may be indicated to assess the efficacy of 5-FU and to establish the best protocols for administering this medication.
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http://dx.doi.org/10.1097/IOP.0000000000001532DOI Listing
March 2021

Bioengineered Acellular Dermal Matrix Spacer Grafts for Lower Eyelid Retraction Repair: A Report by the American Academy of Ophthalmology.

Ophthalmology 2020 05 30;127(5):689-695. Epub 2019 Dec 30.

Cullen Eye Institute, Baylor College of Medicine, Houston, Texas.

Purpose: To review the literature on the efficacy and safety of bioengineered acellular dermal matrix (BADM) grafts for lower eyelid retraction repair.

Methods: A literature search was conducted in the PubMed database initially in January 2018 and updated in July 2019 to identify all studies in the English language literature on the use of BADM grafts in eyelid reconstruction. The searches yielded 193 citations, and 15 of the 34 articles selected for full review met all inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study. Two of the 15 studies included were rated level II and 13 were rated level III.

Results: The definition of success varied, but lower eyelid position improvement using lower lid margin-to-pupillary reflex distance was the most common outcome measure. Other end points were the amount of lagophthalmos, cosmesis, exposure, reoperation, or complications, as well as prosthesis retention in anophthalmic socket cases. The surgeon-reported success rate of these outcomes ranged from 75% to 100%. Minor complications included cyst formation, infection, chemosis, pyogenic granuloma, and corneal abrasion. No serious complications such as blindness, anaphylactic reaction, or terminal disease transmission occurred. Of the 526 implants included for assessment in these disparate studies, 27 cases (5%) required reoperation.

Conclusions: No level I evidence was available, and the existing level II and level III studies have variable primary end points, study design limitations, and only short-term follow-up data. The current literature suggests that BADM grafts represent an implantation option for lower eyelid retraction repair. Short-term results are favorable, and the materials used may fill an important gap in care for patients for whom no acceptable alternatives exist, but long-term safety and efficacy remain unknown.
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http://dx.doi.org/10.1016/j.ophtha.2019.11.011DOI Listing
May 2020

Punctal stenosis associated with dupilumab therapy for atopic dermatitis.

J Dermatolog Treat 2020 Jan 7:1-4. Epub 2020 Jan 7.

Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, CA, USA.

In this case series, the authors report three patients with severe atopic dermatitis who presented with epiphora and conjunctivitis while undergoing dupilumab therapy. On clinical examination, all patients were found to have punctal stenosis, with one case having progressed to punctal obstruction. An assortment of strategies was elected, including discontinuation of dupilumab, treatment of conjunctivitis, and surgical intervention with probing, punctoplasty, and silicone intubation. This report spotlights punctal stenosis as an important new side effect of dupilumab and suggests that additional cases of dupilumab-associated lacrimal drainage impairment will continue to emerge.
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http://dx.doi.org/10.1080/09546634.2019.1711010DOI Listing
January 2020

Eccrine Porocarcinoma: A Rare Tumor of the Eyelid With a Novel Histopathological Finding of Free Tumor Cells in the Tear Film.

Ophthalmic Plast Reconstr Surg 2020 Mar/Apr;36(2):e40-e43

Emeritus Professor of Ophthalmology, Clinical Professor of Laboratory Medicine, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, California, U.S.A.

The authors present a case of an eyelid eccrine porocarcinoma, a very rare malignant sweat gland tumor characterized histopathologically by nests of atypical poromatous cells and the presence of duct-like lumina. Histopathologic analysis of this case also exhibited numerous loose tumor cells in the adjacent tear film, a finding that has not been previously described.
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http://dx.doi.org/10.1097/IOP.0000000000001544DOI Listing
March 2021

Orbital Bone Decompression for Non-Thyroid Eye Disease Proptosis.

Ophthalmic Plast Reconstr Surg 2020 Jan/Feb;36(1):13-16

Department of Ophthalmology, University of California, Irvine, California, U.S.A.

Purpose: To report a multicenter large case series of orbital decompression for non-thyroid eye disease proptosis.

Methods: Retrospective chart review of cases of orbital decompression performed by 9 experienced orbital surgeons from different countries from 2014 to 2017 for non-thyroid eye disease proptosis. Patients were divided into 3 groups: 1) negative vector (high axial length or shallow orbit), 2) inflammatory, and 3) tumor. Types of orbital decompression and Hertel exophthalmometry (preoperative and minimum 6 months postoperative) were recorded. Charts were also assessed for serious complications. The amount of exophthalmometry improvement was recorded according to the above groups.

Results: The analysis included 41 orbits of 29 patients (14 women and 15 men) with a mean age of 38.9 years (ranging from 9 to 74; standard deviation (SD) 15.66). There were 17 orbits of 11 patients in the negative vector group, 16 orbits of 10 patients in the inflammatory group, and 8 orbits of 8 patients in the tumor group. The mean reduction of proptosis was 2.95 mm in the negative vector group, 2.54 mm in the inflammatory group, and 5.75 mm in the tumor group. There were no serious complications.

Conclusions: Orbital decompression was safe and effective in reducing proptosis for non-thyroid eye disease indications in this series. The amount of exophthalmometry improvement was less in the inflammatory orbitopathy group compared with other proptosis etiology groups.Orbital decompression may have a role in improving proptosis in non-thyroid eye disease entities.
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http://dx.doi.org/10.1097/IOP.0000000000001435DOI Listing
March 2021

Gender Differences in Case Volume Among Ophthalmology Residents.

JAMA Ophthalmol 2019 Sep;137(9):1015-1020

Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, New York.

Importance: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear.

Objective: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency.

Design, Setting, Participants: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018.

Main Outcomes And Measures: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status.

Results: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, -15.0 [95% CI, -22.2 to -7.8]; P < .001); men performed a mean (SD) of 509.4 (208.6) total procedures and women performed a mean (SD) of 451.3 (158.8) (mean difference, -58.1 [95% CI, -80.2 to -36.0]; P < .001). Eighty-five of 815 male residents (10.4%) and 71 of 456 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean of 27.5 (95% CI, 13.3 to 41.6; P < .001) more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave (mean difference, -2.0 [95% CI, -18.0 to 14.0]; P = .81). From 2005 to 2017, each additional year was associated with a 5.5 (95% CI, 4.4 to 6.7; P < .001) increase in cataract volume and 24.4 (95% CI, 20.9 to 27.8; P < .001) increase in total procedural volume. This increase was not different between genders for cataract procedure volume (β = -1.6 [95% CI, -3.7 to 0.4]; P = .11) but was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women (β = -8.0 [95% CI, -14.0 to -2.1]; P = .008).

Conclusions And Relevance: Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017, a finding that warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. However, this study included a limited number of programs (24 of 119 [20.2%]). Future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.2427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646997PMC
September 2019

Monocanalicular Stents in Eyelid Lacerations: A Report by the American Academy of Ophthalmology.

Ophthalmology 2019 09 4;126(9):1324-1329. Epub 2019 Apr 4.

Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee.

Purpose: To determine the efficacy and complication rates of monocanalicular stents in the setting of canalicular lacerations.

Methods: A literature search was performed in May 2018 in the PubMed database to identify all English-language reports of monocanalicular stenting to address canalicular lacerations. Studies that did not include at least 10 patients with at least 3 months of follow-up evaluation after surgery were excluded. Ninety-nine articles were identified, and 15 of these met criteria for data abstraction and were included in this assessment. The panel methodologist (V.K.A.) evaluated the quality of evidence and assigned a level-of-evidence rating to each of these studies.

Results: All 15 studies were rated as level III evidence. Anatomic and functional success rates after surgery ranged from 68% to 100% and 79% to 100%, respectively. Stents were generally well tolerated, although extrusion rates varied from 0% to 29%.

Conclusions: Only level III evidence was available, and studies were not powered to detect differences between groups for rare complications or failure. Monocanalicular stents seem to be efficacious and well tolerated in the management of canalicular lacerations. Potential complications include extrusion (most commonly), tube displacement, granuloma, ectropion, slit punctum, fistula, and infection. Further comparative studies would help to identify the optimal time for device removal and to directly compare monocanalicular with bicanalicular stents.
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http://dx.doi.org/10.1016/j.ophtha.2019.03.045DOI Listing
September 2019

Massive Periocular Squamous Cell Carcinoma With Response to Pembrolizumab (Keytruda).

Ophthalmic Plast Reconstr Surg 2019 Sep/Oct;35(5):e127

Oculofacial Plastic and Orbital Surgery, Gavin Herbert Eye Institute University of California, Irvine, California, U.S.A.

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http://dx.doi.org/10.1097/IOP.0000000000001351DOI Listing
January 2020

Orbital Roof Reconstruction Using Nylon Foil Implants.

Ophthalmic Plast Reconstr Surg 2019 May/Jun;35(3):286-289

Division of Oculoplastic and Orbital Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, School of Medicine.

Purpose: To describe a surgical technique of orbital roof reconstruction with a thin nylon foil implant.

Methods: This study is a description of a surgical technique with a retrospective chart review of 3 consecutive patients treated with a nylon foil implant for a complete superior orbital defect after meningioma resection via craniotomy approach.

Results: The nylon foil reconstruction achieved an anatomically stable orbit without globe dystopia, pulsatile proptosis, cerebrospinal fluid leak, or other serious cranio-orbital problems, in all cases. Postoperative visual acuity, pain, extraocular motility, proptosis, and globe position remained stable or improved in each case. There were no complications related to the orbital roof reconstruction.

Conclusions: Nylon foil implantation was an effective and inexpensive surgical technique for orbital roof reconstruction after tumor resection in this small series.
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http://dx.doi.org/10.1097/IOP.0000000000001299DOI Listing
January 2020

Opioid Prescribing Patterns Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members in the Medicare Part D Database.

Ophthalmic Plast Reconstr Surg 2019 Jul/Aug;35(4):360-364

Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California.

Purpose: To assess opioid prescribing patterns among American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members.

Methods: An observational, retrospective, cohort study of ASOPRS members' prescribing patterns in the 2013-2016 Medicare Part D Prescriber database. These prescribers were stratified by years in practice, sex, and geography. The ASOPRS member cohort was compared with all ophthalmologists, as a group, and other surgeons.

Results: The authors identified 617 surgeons in the 2017 ASOPRS directory. Members wrote an average of 45 opioid prescriptions/year. Almost half (45%) wrote <10 prescriptions. Those with >10 prescriptions averaged 78 annually. A minority wrote >100 prescriptions per year (14.8%). Overall, opioids comprised 16.5% of all prescriptions written by ASOPRS members. Despite seeing a similar number of beneficiaries (p = 0.20), male members prescribed a greater number (p < 0.05) and a higher rate (p < 0.05) of opioids than female members. Older members had a lower opioid prescription rate (p < 0.0001). Many heavy opioid prescribers practiced in states with high opioid overdose deaths.

Conclusions: American Society of Ophthalmic Plastic and Reconstructive Surgery members prescribe moderate amounts of opioids at a rate (16.5%) higher than all of ophthalmology (4%), above the national mean (6.8%), but lower than other surgical services (36.5%). Male gender, younger age, and practice in states with high opioid-related deaths were correlated to number of prescriptions. Prescribing patterns may naturally relate to the type of surgical intervention and population. Further research is warranted to understand opioid prescriptions and their role in the opioid epidemic.
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http://dx.doi.org/10.1097/IOP.0000000000001266DOI Listing
December 2019

Characterization of expressed human meibum using hyperspectral stimulated Raman scattering microscopy.

Ocul Surf 2019 01 11;17(1):151-159. Epub 2018 Oct 11.

Department of Biomedical Engineering, University of California, Irvine, CA, USA; Gavin Herbert Eye Institute, University of California, Irvine, CA, USA.

Purpose: This study examined whether hyperspectral stimulated Raman scattering (hsSRS) microscopy can detect differences in meibum lipid to protein composition of normal and evaporative dry eye subjects with meibomian gland dysfunction.

Methods: Subjects were evaluated for tear breakup time (TBUT), staining, meibum expression and gland dropout. Expressed meibum was analyzed using SRS vibrational signatures in the CH stretching region (2800-3050 cm). Vertex component analysis and K-means clustering were used to group the spectral signatures into four fractions containing high lipid (G1) to high protein (G4).

Results: Thirty-three subjects could be statistically analyzed using pooled meibum (13 with stable tear films (TBUTs > 10 s) and 20 with unstable tear films (TBUTs ≤ 10 s). Significant differences in meibum from subjects with unstable vs. stable TBUTs were found for the G1 fraction (medians 0.164 and 0.020, respectively; p = 0.012) and the G2 fraction (medians 0.244 and 0.272, respectively; p = 0.045). No differences were observed for the G3 and G4 fractions. Single orifice samples were not significantly different vs. pooled samples from the fellow eye, and eyelid sector samples (nasal, central and temporal) G2:G3 fractional components were not significantly different (p = 0.449). Spearman analysis suggested a significant inverse correlation between G1 fraction and TBUT (R = -0.351; p = 0.045).

Conclusions: hsSRS microscopy allows compositional analysis of expressed meibum from humans which correlated to changes in TBUT. These findings support the hypothesis that hsSRS may be useful in classifying meibum quality and evaluating the effects of therapy.
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http://dx.doi.org/10.1016/j.jtos.2018.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340754PMC
January 2019
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