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Background Despite traditional facelift and transtemporal endoscopic facelift techniques are used in treatment of mid face ptosis, they do not have a big impact on the midface area. Lower blepharoplasty techniques are effective to provide rejuvenation on nasojugal area, midface ptosis and tear trough deformity. Additionally, it is also possible to correct the lower face area and jowls with lower blepharoplasty. Objectives To define effect of vertical space lift in tear-trough, midcheek groove, midface, and lower face. Methods A retrospective study was carried out on 23 patients who had surgeries between January 2018 and January 2021. The buccal fat is suspended and anchored to the medial infra orbital rim with a superomedial vector and the midface flap anchored to the lower and lateral orbital rim with a superomedial and superolateral vector. The average follow-up period was 12 months. Results A high degree of satisfaction has been achieved in the feedback of questionnaires. Results showed that there is a significant improvement in nasojugal deformity, malar ptosis, mid-cheek grove, and jowls. Conclusions While transcutaneous lower blepharoplasty provides an opportunity for rejuvenation of the lower eyelid and midface area, vertical space lift allows the surgeon to work on the midface, lower face, and jowls area except the neck. Choosing appropriate technique according to area that needs to be corrected increases success rate. Level of Evidence: 4

Dry eye disease (DED) affects up to one-third of the global population. Traditional therapies, including topical lubricants, have been employed with variable success in the treatment of DED. Recently, neurostimulation of the lacrimal functional unit (LFU) has emerged as a promising alternative therapy for DED. In this review, we describe the neuroanatomical and pathophysiological considerations of DED and the LFU that make neurostimulation a viable therapeutic alternative. We further detail the various neurostimulatory approaches taken thus far-from implanted stimulators to external devices to chemical neurostimulation. Existing studies reveal the strengths of the neurostimulatory approach in increasing tear volume and improving dry eye symptoms, but further studies are needed to elucidate its true potential in treatment of DED.

Purpose To assess whether oculoplastic surgeries can be performed without any topical and systemic antibiotics, in a “100% antibiotic free” fashion. Method We conducted a multicenter retrospective study between November 2017 and December 2022. Patients who underwent an oculoplastic procedure were screened. Patients who received preoperative or postoperative systemic antibiotics were excluded. Intraoperative IV antibiotics were allowed. Patients were divided into two groups: those who were treated with local antibiotics ointments (LATB group) and those who were treated without local antibiotics ointments (LATB free group) postoperatively. The primary outcome was the incidence of surgical site infections (SSI). The relationship between the use of local antibiotics and the occurrence of SSI was assessed using Fisher’s exact test. The alpha risk was set to 5% and two-tailed tests were used. Results Among the 947 procedures included, 617 were included in the LATB group and 330 in the LATB free group. 853 and 80 procedures were classified Altemeier class 1 (clean) and class 2 (clean-contaminated) surgeries, respectively. Overall, 310 (32.73%) procedures were performed without any systemic nor topical antibiotics (100% antibiotic free fashion). SSI occured in four (4/617; 0.65%) and five (5/330; 1.52%) procedures in the LATB and LATB free group respectively, without any statistical difference between the groups ( p  = 0.290). A subgroup analysis was carried out by excluding the procedures performed under prophylactic intraoperative intravenous antibiotics and did not reveal any statistical difference between the two groups ( p  = 0.144). All SSI patients were treated with systemic antibiotics with favorable outcomes. Postoperative wound dehiscence was the only risk factor associated with postoperative SSI ( p  = 0.002). Conclusion This study suggests that performing a “100% antibiotic free” oculoplastic surgery without systemic and topical antibiotics is reasonable in Altemeier class 1 and class 2 procedures.

BackgroundGraves’ orbitopathy (GO) is subject to epidemiological and care-related changes. Aim of the survey was to identify trends in presentation of GO to the European Group On Graves’ Orbitopathy (EUGOGO) tertiary referral centres and initial management over time.MethodsProspective observational multicentre study. All new referrals with diagnosis of GO within September–December 2019 were included. Clinical and demographic characteristics, referral timelines and initial therapeutic decisions were recorded. Data were compared with a similar EUGOGO survey performed in 2012.ResultsBesides age (mean age: 50.5±13 years vs 47.7±14 years; p 0.007), demographic characteristics of 432 patients studied in 2019 were similar to those in 2012. In 2019, there was a decrease of severe cases (9.8% vs 14.9; p<0.001), but no significant change in proportion of active cases (41.3% vs 36.6%; p 0.217). After first diagnosis of GO, median referral time to an EUGOGO tertiary centre was shorter (2 (0–350) vs 6 (0–552) months; p<0.001) in 2019. At the time of first visit, more patients were already on antithyroid medications (80.2% vs 45.0%; p<0.001) or selenium (22.3% vs 3.0%; p<0.001). In 2019, the initial management plans for GO were similar to 2012, except for lid surgery (2.4% vs 13.9%; p<0.001) and prescription of selenium (28.5% vs 21.0%; p 0.027).ConclusionGO patients are referred to tertiary EUGOGO centres in a less severe stage of the disease than before. We speculate that this might be linked to a broader awareness of the disease and faster and adequate delivered treatment.

The purpose was to ascertain if any relation exists between the elevated intraocular pressure (IOP) in patients with thyroid-associated orbitopathy (TAO) in active stage and the severity of extraocular muscle involvement and the extent of exophthalmos.MethodsA total of 96 eyes and orbits of 48 adult patients with active TAO were investigated. All patients underwent magnetic resonance imaging of the orbit and measurement of all extraocular recti muscles (EOM). The obtained data was divided into two groups according to the IOP value: normal IOP ≤ 21 mmHg; n = 47 and elevated IOP with IOP > 21 mmHg; n = 49, and analyszed.ResultsA significant difference was found in the short diameter of medial rectus and inferior rectus muscles and in the sum of short parameters of all EOM. All these parameters were significantly higher in the elevated IOP group. Motility restriction in at least one gaze direction was also significantly more frequent (p < 0.0001) in the elevated IOP group. A positive moderate correlation was found between IOP and the sum of short parameters of EOM (r = 0.496). No correlation was found between the IOP and exophthalmos values (r = 0.267). During the follow-up, the frequency of strabismus surgery and orbital decompression was significantly higher in the elevated IOP group (p = 0.003; p = 0.002).ConclusionElevated IOP in the active TAO stage particularly correlates with extraocular muscle involvement. These patients are also more likely to require orbital decompression and strabismus surgery.

Purpose To present a modification of the reversible tarsorrhaphy that can be opened and reclosed as necessary by caretakers and the patient. Methods Retrospective case series of patients who underwent the reversible tarsorrhaphy. Materials included intravenous (IV) tubing as bolsters and 4–0 polypropylene suture. The 4–0 suture is first passed through and through one end of IV tubing approximately 20 mm in length. Starting on the lateral upper lid and approximately 4 mm above the lash line, the suture is placed through the skin and into the tarsus. The suture exits through the eyelid gray line. These steps through the eyelid are repeated in the opposite direction. An air knot is tied above the upper eyelid near the base of IV tubing. A second air knot can be tied higher to provide a handle easily allowing the caretaker to close the eyelid. Results Included were 13 patients (ages 21–95-yeas), indications included lagophthalmos secondary to cicatricial changes from burns (2), keratouveitis (1), neurogenic palsy (3), neurotrophic ulcer (6), and cicatricial changes from skin cancer (1). There were no reported difficulties in maintaining the tarsorrhaphy by either family members or healthcare providers. The first tarsorrhaphy for each patient lasted between 3–19 weeks, with an average of 8 weeks. All were well tolerated. Conclusions The caretaker-reversible tarsorrhaphy can be used as a temporizing measure. The technique balances the need for ocular protection with the need for examination/treatment by health care professionals and, equally importantly, the patients and caretakers.

Background Ocular trauma is an important cause of visual loss worldwide. Improvements in our knowledge of the pathophysiology and management of ocular trauma during the past 30 years, in conjunction with advances in the instrumentation and techniques of ocular surgery, have improved the efficacy of vitreoretinal surgery in injured eyes. The aim of the current study was to determine the visual outcomes and prognostic factors of open-globe injuries in the Japanese population. Methods Retrospective study of 59 eyes of 59 patients presented with open globe injuries between September 2008 and March 2014 at Nagasaki University Hospital was conducted. Demographic factors including age, gender, and clinical data such as cause of injury, presenting visual acuity (VA), location of injury, type of injury, lens status, presence of intraocular foreign body, types of required surgeries, and final VA were recorded. According to the classification of Ocular Trauma Classification Group, wound location was classified into three zones. Chi-square test was used to compare presented data. Results Out of the 59 patients, 46 were placed in the Light Perception (LP) group, and 13 were placed in the No Light Perception (NLP) group. Work-related trauma was the most common cause (27 eyes) followed by falls (19eyes). Work-related trauma was common in males ( P  = 0.004), while falls was significantly common in females ( P  = 0.00001). Zone III injuries had statistically significantly poor prognostic factor compared to other zones ( P  = 0.04). All cases of NLP group (100%) presented with rupture globe. Poor VA at first visit ( P  = 0.00001), rupture globe ( P  = 0.026), history of penetrating keratoplasty (PK) ( P  = 0.017), retinal detachment (RD) ( P  = 0.0001), vitreous hemorrhage (VH) ( P  = 0.044), and dislocation of crystalline lens ( P  = 0.0003) were considered as poor prognostic factors. Conclusion Poor VA at first visit, rupture globe, zone III injuries, history of penetrating keratoplasty, RD, VH, and dislocation of crystalline lens were found to be poor prognostic factors. PPV had a good prognostic value in open globe injuries associated with posterior segment involvement.

To report the rate of all-cause returns to the operating room (OR) after surgery for rhegmatogenous retinal detachment (RRD). This was a retrospective consecutive case series; 1278 eyes underwent RRD repair from 1/1/2014 to 12/31/2016 at a tertiary care center. A total of 507 eyes returned to the OR. Surgical indication, procedure, number of reoperations, and final vision were recorded. At least one secondary procedure was performed in 24.9% at 6 months, 34.7% at 1 year, and 39.7% as of last follow-up. The most common indications for reoperation were cataract (43.9%) and recurrent RRD (12.8%). Cornea, glaucoma, and oculoplastic issues were rare (each <1.1%). There was no association between final visual outcome and number of reoperations (p > 0.05). SB/PPV had the highest rate of return to OR (p < 0.001) but lowest rate of recurrent RRD (p = 0.007). To our knowledge, there are no other large studies that examine all-cause returns to the OR after primary RRD repair. This study provides important risk-benefit and prognostic information to patients undergoing RRD repair.

PurposeTo assess the characteristics and long-term outcomes of adult patients with dysthyroid optic neuropathy (DON) who underwent orbital decompression surgery and/or received intravenous (IV) methylprednisolone.MethodsRetrospective chart review of 98 eyes of 49 patients who were diagnosed and treated with bilateral DON between 2007 and 2018 at the Department of Ophthalmology and Optometry and Oral and Maxillofacial Surgery of the Medical University of Vienna.ResultsThe mean follow-up period was 4.1 ± 2.7 years. The most common presenting symptoms were eyelid and periorbital swelling (45%) representing active inflammation. Upgaze restriction was the most common clinical finding (73%). At time of diagnosis, the mean clinical activity score was 4 ± 1/4 ± 1 (right/left eye, respectively). Sixty-three percent (31/49) of the patients were treated both with IV methylprednisolone and underwent orbital decompression surgery, 22% (11/49) were treated with IV methylprednisolone alone and 14% (7/49) underwent surgical decompression only. Seventy-one percent (30/42) of the patients underwent 3-wall decompression. The mean reduction of proptosis in patients treated with both IV methylprednisolone and orbital decompression surgery was 4/5 mm. Mean of reduction in proptosis in patients receiving IV methylprednisolone only was 1/0 mm and in patients with surgical decompression only was 5/5 mm. Mean VA was 0.1 ± 0.5/0.1 ± 0.5 logMAR at baseline and 0.05 ± 0.7/0.05 ± 0.7 at final follow-up. In 92% (45/49), VA was preserved or improved at final follow-up.ConclusionsThe majority of patients with DON were treated both with IV corticosteroids and 3-wall decompression surgery. Vision could be successfully preserved in most cases and reduction of proptosis was achieved, especially after orbital decompression surgery.

PurposeTo evaluate the postoperative changes with a computer vision algorithm for anterior full-face photographs of patients who have undergone upper eyelid blepharoplasty surgery with, or without, a Müller’s muscle-conjunctival resection (MMCR).MethodsAll patients who underwent upper eyelid blepharoplasty surgery (Group I), or upper eyelid blepharoplasty with MMCR (Group II) were included. Both preoperative and 6-month postoperative anterior full-face photographs of 55 patients were analyzed. Computer vision and image processing technologies were used to measure the palpebral distance (PD), eye-opening area (EA), and average eyebrow height (AEBH) for both eyes. Preoperative and postoperative measurements were calculated and compared between the two groups.ResultsIn Group II, change in postoperative Right PD, Left PD, Right EA, Left EA was significantly higher than in Group I (p = 0.004 for REPD; p = 0.001 for LEPD; p = 0.004 for REA; p = 0.002 for LEA, p < 0.05). In Group II, the postoperative change in Right AEBH, Left AEBH was significantly higher than in Group I (p = 0.001 for RABH and LABH, p < 0.05).ConclusionEyelid surgery for esthetic purposes requires artistic judgment and objective evaluation. Because of the slight differences in photograph sizes and dynamic factors of the face due to head movements and facial expressions, it is hard to compare and make a truly objective evaluation of the eyelid operations. With a computer vision algorithm, using the face and facial landmark detection system, the photographs are normalized and calibrated. This system offers a simple, standardized, objective, and repeatable method of patient assessment. This can be the first step of Artificial Intelligence algorithm to evaluate the patients who had undergone eyelid operations.