Faculty Bibliography

BACKGROUND:Repair of margin-involving eyelid lacerations is a challenge for beginning ophthalmology residents, yet no commercially-available simulation models exist for learning this skill. The objective of the study was to modify a mannequin-based surgical simulator originally developed for trachomatous trichiasis surgery training to teach margin-involving eyelid laceration repair and to evaluate its success within a residency wet-lab environment. METHODS:We modified a previously developed mannequin-based training system for trachomatous trichiasis surgery into a simulator for margin-involving eyelid laceration repair. Six ophthalmology residents from a tertiary care academic institution performed at least one simulated margin-involving eyelid laceration repair using the surgical simulator between September 2019 and March 2020. Each session was video recorded. Two oculoplastic surgeons reviewed the videos in a blinded fashion to assess surgical proficiency using a standardized grading system. Participants were surveyed on their comfort level with eyelid laceration repair pre- and post-completion of simulation. They were also queried on their perceived usefulness of the surgical simulator compared to past methods and experiences. RESULTS:Six residents completed 11 simulation surgeries. For three residents who completed more than one session, a slight increase in their skills assessment score and a decrease in operative time over two to three simulation sessions were found. Self-reported comfort level with margin-involving eyelid laceration repairs was significantly higher post-simulation compared to pre-simulation (p = 0.02). Residents ranked the usefulness of our surgical simulator higher than past methods such as fruit peels, surgical skill boards, gloves, and pig feet (p = 0.03) but lower than operating room experience (p = 0.02). Residents perceived the surgical simulator to be as useful as cadaver head and emergency department/consult experience. CONCLUSIONS:We developed a surgical simulator for teaching eyelid laceration repair and showed its utility in developing trainees' surgical skills. Our surgical simulator was rated to be as useful as a cadaver head but is more readily available and cost effective.

We present a case of vision loss secondary to neurosarcoidosis, which initially presented with severe bilateral vision loss, temporal headaches, and elevated erythrocyte sedimentation rate, concerning for giant cell arteritis. However, temporal artery biopsy was negative. Initial neuroimaging features were misinterpreted to represent a meningioma that did not account for his clinical presentation. Clinical course, including atypically rapid enlargement of presumed meningioma, development of skin lesions, appearance of optic nerve enhancement on MRI, and steroid response, strongly increased suspicion for sarcoidosis. Biopsy of a skin lesion demonstrated noncaseating granulomatous inflammation, consistent with sarcoidosis.

Late-onset orbital hemorrhage is a rare complication of alloplastic implant use in orbital wall reconstruction following trauma. The authors report 3 patients with chocolate cysts presenting 3 to 9 years after orbital fracture repair with porous polyethylene implants. All patients were managed by implant removal and evacuation of cyst contents. Complete excision of the cyst was performed in 1 patient, while partial excision of the capsule was performed in 2 patients. Improvement of symptoms associated with the mass effects of the cyst was noted after surgical intervention. The authors also report the first case of orbital volume expansion from a chocolate cyst associated with a nonbarriered porous polyethylene implant. Delayed hemorrhage with capsule formation, although extremely rare, is a possible complication following orbital fracture repair with porous polyethylene implants.

The coronavirus disease 2019 pandemic has led to widespread change as public health strategies for containment have emphasized social distancing and remaining at home. These policies have led to downscaled clinic volumes, cancellation of elective procedures, enhanced personal protective strategies in the clinic, and adoption of telemedicine encounters. We describe the evidence-based practical approach taken in our ophthalmology department to continue delivering eye care during the pandemic by rescheduling visits, enhancing clinic safety, and adopting virtual video encounters.

INTRODUCTION/BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic has led to rapid adoption of teleophthalmology to deliver eyecare remotely. The purpose of our study was to assess the implementation and patient acceptability of video consultation for outpatient ophthalmic care at our institution. METHODS:We conducted a retrospective, cross-sectional analysis and patient survey of adult patients who completed a virtual video visit at our institution from 18 March 18 through to 27 April 2020. All video visit encounters were assessed for patient characteristics, diagnoses, management, and follow-up outcomes. Patients were surveyed for their feedback on acceptability and utility of their virtual video consultation. RESULTS:A total of 219 patients (mean age 55 years; range 21-89 years) completed 231 video visit encounters at our department over a 6-week period, of whom 118 were women (54%). About half of these encounters were acute visits (102 visits, 47%). The most common diagnosis of these visits was postoperative state (20 visits, 9% of the total), followed by conjunctivitis (16 visits, 7%), and keratitis (14 visits, 6%). The most common management decisions were medication prescription (102 visits, 46%) or reassurance (86 visits, 39%), while 17 video visit patients (8%) were escalated to an urgent, in-person evaluation. Ninety-two patients completed a follow-up survey (42% response rate), of whom 45 (49%) indicated that they might have delayed seeking care during this pandemic in the absence of a virtual video option. Seventy-two (78%) reported that they would consider participating in a video visit as an alternative to an office-based encounter in the future, and the overall video visit experience was rated highly, with a weighted mean Likert scale rating of 4.3 out of 5 (Cronbach's α = 0.88). CONCLUSION/CONCLUSIONS:Virtual video visits may be used to manage a range of ophthalmic complaints. Patients participating in this survey found such video visits acceptable and timesaving, and the majority would consider using video consultations for future eyecare encounters.

PURPOSE/OBJECTIVE:To examine the incidence of intracapsular hemorrhage in orbital fracture repair with non-fixated nylon sheet implants. METHODS:A retrospective chart review of 227 patients presenting from January 2013 to December 2016 for orbital fracture repair with nylon sheet implants. RESULTS:Of the 331 orbital fractures repaired over 4 years, a total of 227 met inclusion criteria. The average implant thickness was 0.38 mm and no implants were fixated. Four total implants (1.8%) were removed due to complications; one each secondary to exploration for ongoing postoperative diplopia, immediate post-operative orbital hemorrhage, a cystic mass anterior to the implant, and pain. There were no cases of intracapsular hemorrhage nor infection for any of the 227 patients over 4 years. CONCLUSIONS:To the authors knowledge, this represents the largest case series to date to assess the rate of intracapsular hemorrhage in non-fixated nylon sheet orbital implants. In the 227 cases reviewed over a 4-year period, there were no cases of intracapsular hemorrhage. This suggests a much lower complication rate than previously reported. PRéCIS: A case series of 227 patients who underwent orbital fracture repair with non-fixated nylon sheet implants.

To assess the practice patterns of current members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) in the treatment of medically refractive endophthalmitis (MRE). A 17-question survey included the procedure of choice for MRE, the preferred type of orbital implant, the timing of implant placement, and the incidence of postoperative complications. 107 ASOPRS members participated in the study. In the setting of MRE, 72% preferred evisceration versus 28% who preferred enucleation. Fifty-nine percent of responders preferred enucleation if the MRE extended to orbital tissues versus 27% who would eviscerate. Among those that would place an orbital implant at the initial surgery, 65% would do so during an enucleation and 58% would do so during an evisceration. If an orbital implant was placed at the initial surgery, 52% of responders preferred a silicone implant, while 17% preferred hydroxyapatite implant. A minority of responders (6%) reported "yes" to ever having infectious complications after primary enucleation, compared to 10% after primary evisceration. Overall, 12% of responders noted more frequent complications (other than infectious) when an enucleation was performed compared to 5% for eviscerations. Current opinions on the surgical management of MRE show a trend toward evisceration, with 65% of ASOPRS respondents placing an orbital implant at the time of an enucleation and 58% at the time of an evisceration. Enucleation was preferred when involvement of orbital tissues was apparent. Both evisceration and enucleation remain a viable treatment option for MRE. The most appropriate initial approach is best determined by careful patient selection and informed decision-making by the patient.

PURPOSE:To review physician-based clinical surveys published in Ophthalmic Plastic and Reconstructive Surgery. METHODS:Complementary Ovid and PubMed searches of Ophthalmic Plastic and Reconstructive Surgery journal content were performed for the term "survey." Results were narrowed to studies that specifically addressed physicians' clinical practices. This search resulted in 162 articles, and after dual-investigator independent screening, 13 surveys met inclusion criteria. RESULTS:Of the 13 surveys published from 2007 to January 2017, 6 were published since 2015, showing an increased trend in survey-based publications. Topics included assessing practice patterns regarding eyelid disorders, thyroid eye disease, optic nerve sheath fenestration, anophthalmic socket, and diagnosing lacrimal disorders. Average response rate was 38.7% (range 17.5-60%), with 201 average number of replies (range 72-310). Nine out of 13 surveys included some form of statistical analysis with the remainder presenting data in percentages. CONCLUSIONS:There has been an increased rate of survey-type publications in Ophthalmic Plastic and Reconstructive Surgery over the past 10 years. The low response rate and frequent lack of statistical analysis raise concerns regarding the validity and usefulness of such studies. The authors believe that survey studies can be improved through better standardization and the use of author guidelines. They have made specific recommendations to improve the impact of survey papers in the future.

PURPOSE/OBJECTIVE:To present the results of treating combined lower eyelid laxity, retraction and midface descent secondary to facial nerve weakness with a hybrid surgical procedure. MATERIALS AND METHODS/METHODS:A retrospective analysis of patients from January 2015 to January 2017 who underwent a hybrid surgical technique for the treatment of corneal exposure secondary to facial nerve paresis with a single surgeon was performed. Age, gender, and presence of exposure symptoms were recorded pre-operatively. Outcomes assessed included improvement of lower eyelid laxity and position, operative complications, and post-operative symptomatic relief. RESULTS:A total of 11 patients underwent unilateral eyelid surgery. All patients had symptomatic relief and good functional outcomes defined as improvement in eyelid laxity, lower eyelid position, and objective corneal exposure. No cases required reoperation during an average follow up of 174.5 days. CONCLUSIONS:Combining portions of a tarsorrhaphy and lateral wedge resection technique is a simple and effective procedure to improve lower eyelid position and limit corneal exposure secondary to facial nerve paresis.