PURPOSE:To develop a globally applicable consensus statement for the assessment and management of thyroid eye disease (TED). METHODS:The World Society of Ophthalmic Plastic Reconstructive and Aesthetic Surgery council selected a 6-member, geographically diverse TED task force to develop a consensus statement on the assessment and management of TED. Consensus was achieved through monthly meetings from January to July 2025, alongside an analysis of the literature in terms of relevance, level of evidence, and global versus local applicability. A draft document was circulated to all World Society of Ophthalmic Plastic Reconstructive and Aesthetic Surgery constituent societies for feedback. Using a modified Delphi approach, the expert panel convened over 6 additional virtual sessions from July 2025 to March 2026 to review the submitted feedback, incorporating comments with agreement from at least 5 of 6 experts. The final statement was approved by both the World Society of Ophthalmic Plastic Reconstructive and Aesthetic Surgery council and the International Thyroid Eye Disease Society board of directors. RESULTS:Consensus was achieved regarding methods, TED definitions, assessment, medical and surgical management, and safety recommendations. The consensus statement delineates acceptable standards, workup, and evaluation time points for basic-, intermediate-, and advanced-level assessment tailored to diverse global contexts, as well as tiered medical and surgical interventions, recommended for the different phases and severities of TED. CONCLUSIONS:The World Society of Ophthalmic Plastic Reconstructive and Aesthetic Surgery-International Thyroid Eye Disease Society consensus statement on TED, developed by oculoplastic and orbital surgeons, provides a global framework for the standardized assessment and management of TED to improve TED care and enhance patient outcomes.
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that may cause rapid tissue destruction when it involves the periocular region. We report a 17-year-old patient with ulcerative colitis who developed progressive upper eyelid ulceration initially treated as preseptal cellulitis and later suspected necrotizing infection. Despite broad-spectrum antibiotics, the lesion worsened. Clinical findings, sterile cultures, associated cutaneous lesions, and a PARACELSUS score of 17 strongly supported the diagnosis of PG, prompting immediate systemic corticosteroid therapy before histopathologic confirmation. Adjunctive wound care included topical hypochlorous acid therapy and ophthalmic antibiotic ointment. Histopathology subsequently confirmed PG. Complete re-epithelialization was achieved within 3 weeks without eyelid malposition, functional sequelae, or recurrence during 8 months of follow-up. This case highlights the value of the PARACELSUS score in facilitating early diagnosis of periocular PG and supports prompt tissue-preserving management to prevent irreversible eyelid damage.
PURPOSE:Approximately 50% of ASOPRS surgeons consider young age to be an indication for imaging in patients with nasolacrimal duct obstruction. This practice is rooted in the assumption that young age confers a higher risk of clinically occult disease. This study examines whether young age is, in fact, associated with clinically occult lacrimal pathology. METHODS:A retrospective multicenter chart review was conducted at the Université de Montréal on consecutive patients with clinically presumed primary acquired nasolacrimal duct obstruction who underwent dacryocystorhinostomy with intraoperative tissue biopsy. RESULTS:A total of 457 sides from 413 patients were analyzed, including 64 sides in patients ≤50 years (group 1) and 393 in patients >50 years (group 2). Expected lacrimal histopathology (nonspecific inflammation) was observed in 90.6% of group 1 and 89.1% of group 2 (p = 0.71). No malignant or potentially malignant pathologies occurred in group 1, compared with 2.8% in group 2 (p = 0.18). On logistic regression, young age was neither a predictor of occult pathology (B = -0.002. p = 0.82) nor occult malignancy/potential malignancy (B = 0.004. p = 0.81). Preoperative imaging was obtained in a subset of 96 dacryocystorhinostomies (34 group 1, 62 group 2) and did not detect a clinically occult pathology in any case; however, 7 patients with normal imaging ultimately had unsuspected pathologies on dacryocystorhinostomy, including 4 malignant/potentially malignant lesions. CONCLUSION:Young age was not associated with an increased likelihood of clinically occult lacrimal pathology in patients presumed to have primary acquired nasolacrimal duct obstruction, and routine imaging failed to detect all clinically silent pathologies. Available evidence therefore does not support the practice of preferentially imaging young patients with clinically presumed primary acquired nasolacrimal duct obstruction.
PURPOSE:To prospectively evaluate changes in blink dynamics following unilateral ptosis surgery and to assess their relationship with ocular surface parameters. METHODS:Sixteen patients (10 female, 6 male; mean age 56.0 ± 13.2 years) undergoing unilateral levator aponeurosis advancement were enrolled. Incomplete blink percentage and blink rate were assessed using slow-motion smartphone videography. Noninvasive tear break-up time, meibomian gland area loss, palpebral fissure height, and margin reflex distance 1 were measured bilaterally at baseline and at a postoperative visit between day 45 and 60. Ocular surface symptoms were assessed with the Ocular Surface Disease Index. RESULTS:Incomplete blink percentage increased markedly in the operated eye following surgery (12.0% [0.0-50.8] vs. 67.5% [49.0-90.0], p = 0.001), with patients demonstrating ≥50% incomplete blink rates rising from 37.5% to 75.0%. Meibomian gland area loss also increased significantly (29.2% [17.9-42.1] vs. 36.9% [24.9-47.0], p = 0.016). Blink rate, noninvasive tear break-up time, and Ocular Surface Disease Index did not change significantly. No eye-specific parameter changed in the contralateral eye. A negative correlation was found between preoperative incomplete blink percentage and magnitude of postoperative change (r = -0.606, p = 0.013). CONCLUSIONS:Levator aponeurosis advancement produces a marked and selective increase in incomplete blink percentage accompanied by increased meibomian gland area loss, without affecting blink rate or the contralateral eye. Blink incompleteness may represent a clinically underrecognized consequence of ptosis surgery with long-term ocular surface implications.
PURPOSE:Facial feminization surgery includes craniofacial and soft-tissue procedures intended to soften traditionally masculine features. Although upper and midface skeletal changes are often emphasized, the periocular region plays a central role in gender perception. Few studies have examined which eyelid or canthal characteristics are most consistently perceived as feminine, limiting alignment between surgical techniques and patient-driven priorities. METHODS:A cross-sectional online survey was conducted from January 2023 to September 2025 among individuals in academic, community, and private practice settings. A total of 763 participants completed the survey, including 75 transgender or nonbinary respondents. Participants viewed paired, digitally modified periocular images that differed by a single feature (eyelid crease height, tarsal platform show, superior sulcus depth, lateral canthal tilt, or brow contour) and selected the more feminine-appearing image. RESULTS:Preferences for eyelid crease height and superior sulcus depth varied. Thirty-six point two percent preferred a higher crease, whereas 63.8% felt a fuller upper eyelid was more important; 66.5% of cisgender patients preferred a deeper sulcus, versus almost all transgender respondents who favored a fuller eyelid. An upward lateral canthal tilt was endorsed almost unanimously. Brow contour preferences were mixed. Free-text descriptors most commonly referenced long eyelashes, an arched brow, and an upward outer canthus. Transgender women consistently preferred a fuller upper eyelid and smoother brow contour more often than cisgender respondents. CONCLUSIONS:An upward lateral canthal tilt was a strong determinant of perceived femininity, whereas other periocular preferences varied by gender identity. These differences suggest that cis-derived aesthetic norms may not reflect the goals of transgender and nonbinary patients. Integrating identity-specific perspectives may enhance periocular planning in gender-affirming care.
A 72-year-old female required bilateral socket reconstruction with dermis fat grafting for exposed implants after undergoing staged enucleations with insertion of porous polyethylene implants with suturing platforms (EZYPOR) 18 months previously. Patient factors, surgical technique, and implant design may have contributed to the exposures. Additional clinical studies with long-term follow-up are needed to determine if this style of implant is predisposed to complications.
PURPOSE:Nasolacrimal duct obstruction (NLDO) is a common cause of chronic epiphora and visual disturbance. This project aims to evaluate the association between NLDO and a spectrum of mental health conditions in a racially and socioeconomically diverse national cohort. METHODS:A retrospective cohort study with cross-sectional and time-to-event analyses was conducted with data from January 1, 2007, to January 1, 2022. The population-based cohort was derived from the National Institutes of Health All of Us Research Program, a multicenter national research initiative in the United States that compiles deidentified patient health record data. Adults with a coded diagnosis of NLDO (n = 420) were identified and compared with 1,260 adults without NLDO selected through 1:3 propensity score matching on age, sex, race, ethnicity, income, education, and insurance status. Psychiatric diagnoses, including depression, anxiety, and bipolar disorder, were ascertained from Systematized Nomenclature of Medicine diagnostic codes extracted from linked electronic health records available within the All of Us Research Program platform. Adjusted odds ratios (ORs) were estimated using multivariable logistic regression, and hazard ratios (HRs) for incident psychiatric diagnoses were estimated using Cox proportional hazards models. RESULTS:NLDO was associated with higher prevalences of anxiety (32.1% vs. 12.5%), depression (34.3% vs. 11.2%), and bipolar disorder (4.8% vs. 1.7%). After adjustment, NLDO remained significantly associated with anxiety (OR 3.60), depression (OR 4.79), and bipolar disorder (OR 3.37) (all p < 0.01). In time-to-event analyses, NLDO was linked to increased hazards of depression (HR 3.98), anxiety (HR 8.30), and bipolar disorder (HR 6.97). CONCLUSION:In this large, ethnically diverse national cohort, NLDO was associated with significantly increased prevalence and risk of mood and anxiety disorders. These findings suggest that NLDO carries a meaningful psychosocial burden and support consideration of mental health screening and integrated care in affected patients.
PURPOSE:The objective of this study is to investigate whether checkpoint inhibitor proteins, including programed death protein-1, programmed death-1-pathway ligand, cytotoxic T-lymphocyte associated protein-4, lymphocyte activation gene-3, and CD73, are implicated in orbitally invasive sinonasal undifferentiated carcinomas (SNUCs). METHODS:Patients with orbitally invasive SNUC presenting to a single institution between 2020 and 2024 were identified. Age and gender match controls were identified. Immunohistochemical staining was performed for each of the checkpoint inhibitors. Using light microscopy, the number of positively staining cells per 40× field was recorded across 5 consecutive fields and averaged. The differences in expression between the 2 were compared via a Mann-Whitney analysis. RESULTS:Six patients with orbitally invasive SNUC and 11 sinus mucosal controls were identified. Immunohistochemical analysis of these tumors demonstrated positivity in both SNUC specimen and normal sinus mucosa for all biomarkers tested (CD73, lymphocyte activation gene-3, cytotoxic T-lymphocyte associated protein-4, programmed death-1-pathway ligand, programed death protein-1). Expression of CD73 and programmed death-1-pathway ligand was statistically significantly higher in SNUC specimens compared with normal sinus controls (p = 0.0003 and p = 0.0111, respectively). CONCLUSION:Specimens from patients with sinonasal undifferentiated carcinoma express increased levels of programmed death-1-pathway ligand and CD73 compared with sinus controls. The results discovered in this investigation represent a significant proof of principle that immunotherapy may be a promising approach to address a potentially devastating disease.
PURPOSE:To describe an anterior scleral capping technique using human donor sclera or preserved pericardium during ocular evisceration to enable the placement of larger orbital implants. METHODS:Retrospective interventional case series. Six consecutive patients underwent evisceration for blind, painful eyes without infection or suspected intraocular malignancy. Following standard evisceration, the largest possible spherical implant was inserted. A human donor scleral button (5 cases) or preserved pericardium (1 case) was sutured to the anterior scleral surface as a cap over the implant. Main outcome measures were graft integrity, implant size, successful prosthesis fitting, and postoperative complications. RESULTS:Six patients (mean age 67 years) were included. The mean implant size was 18 mm. Five patients underwent scleral capping, and 1 received a pericardial graft. Five of 6 patients had an uncomplicated postoperative course, with intact grafts and successful prosthesis fitting. One patient developed partial graft dehiscence requiring implant exchange with a smaller implant. No implant exposures were observed over a mean follow-up of 12 months. CONCLUSIONS:Anterior scleral capping during evisceration is a simple technique that allows for the placement of larger orbital implants without additional scleral incisions. Early results demonstrate good graft integration and favorable short-term outcomes. Larger studies with longer follow-up are needed to evaluate long-term safety and potential impact on post-enucleation socket syndrome.
Patients with syndromic craniosynostosis, including Crouzon and Pfeiffer syndromes, may develop lower-eyelid malposition, including retraction and secondary entropion, associated with complex midfacial and orbital anatomical abnormalities. Progressive midface hypoplasia, shallow orbits, and postoperative anatomical changes following craniofacial surgery may contribute to imbalance between the anterior and posterior lamellae, relative posterior lamellar insufficiency, and persistent eyelash-corneal contact. We report a retrospective case series of 3 patients who underwent posterior lamellar lengthening using autologous auricular cartilage grafts via a transconjunctival approach. The harvested cartilage was secured to the tarsal plate to increase posterior lamellar height and correct lower-eyelid entropion. All patients experienced improvement in cilia-corneal touch and symptomatic relief, with satisfactory functional and aesthetic outcomes. No recurrence or major complications were observed during follow-up. Auricular cartilage grafting may represent a useful surgical option for selected patients with lower-eyelid entropion associated with syndromic craniosynostosis, particularly in patients with severe midface hypoplasia or previous midface advancement procedures.
PURPOSE:This study's purpose was to investigate the outcomes of immune checkpoint inhibitor (ICI) treatment of periocular cutaneous squamous cell carcinoma with orbital invasion. METHODS:A retrospective review was performed of 19 patients with biopsy-confirmed, advanced periocular cutaneous squamous cell carcinoma with orbital invasion treated with ICIs at a single institution. Tumors of conjunctival, sinonasal, lacrimal sac, or indeterminate origin were excluded. Demographic and clinical features at presentation, duration (number of cycles) of ICI, and treatment response were analyzed. RESULTS:Nineteen patients with periocular cutaneous squamous cell carcinoma with orbital invasion treated with ICI were identified. The median age at diagnosis was 74 (interquartile range, 67-78) years. Most patients were non-Hispanic White (95%, n=18) and male (68%, n=13). Eight patients (42%) had AJCC T4 disease. Median presenting logMAR visual acuity in the affected eye was 0.3 (0.2-0.8). Eighteen patients (95%) had orbital involvement, and 14 (74%) had perineural involvement. Thirteen (68%) were treated with cemiplimab and 5 (26%) with pembrolizumab, and 1 was transitioned to cemiplimab after progression on pembrolizumab. Patients received a median of 9 (interquartile range, 6-15) cycles. Nine patients (47%) had complete response, 6 (32%) had a partial response, 3 (16%) remained stable, and only 1 (6%) progressed on ICIs. No tumors recurred nor required exenteration by the end of the study period. The median follow-up time was 35 (interquartile range, 19-53) months. CONCLUSIONS:Immunotherapy demonstrated excellent, sustained clinical outcomes in periocular cutaneous squamous cell carcinoma with orbital invasion with low morbidity and mortality. A disease control rate of over 90% was achieved and sustained at a median follow-up of almost 3 years.
Purpose: To describe a developmental concept for congenital eyelid anomalies by integrating embryologic evidence and recent molecular data with descriptive anatomy of some of the more common congenital eyelid anomalies. Attention is directed to the importance of developmental stages in which anomalies arise as stage-dependent disturbances along a continuous embryologic timeline, and where minor differences in molecular signaling timing result in graded phenotypic variations. Methods: Embryologic literature was reviewed and combined with descriptive anatomic, molecular, and genetic studies of eyelid development. Phenotypic variations in congenital eyelid anomalies were evaluated to identify relationships to gestational stages and to identify transitional and overlapping anatomic features. Results: Molecular data show that disruptions in specific genetic regulators and signaling pathways acting at defined eyelid developmental stages can cause phenotypic anomalies. Minor temporal, spatial, and environmental differences in these disruptions result in graded phenotypic expressions within clinically defined anomalies, resulting in transitional and overlapping variants. Conclusion: The concept of stage-specific disturbances along the eyelid developmental continuum resulting in graded phenotypic variations helps to clarify the etiology of, and phenotypic relationships among, congenital eyelid abnormalities.
PURPOSE:To evaluate the efficacy of pembrolizumab, a programmed death-protein 1 (PD-1) immune checkpoint inhibitor, in the management of advanced ocular sebaceous carcinoma with pagetoid conjunctival spread, as well as in recalcitrant, recurrent, and metastatic disease. METHODS:Five patients with ocular sebaceous carcinoma were included in the study. Three patients had advanced disease with diffuse eyelid involvement and pagetoid conjunctival spread, 1 had recalcitrant recurrent eyelid disease, and 1 had orbital recurrence with regional lymph node metastasis. All patients were treated with pembrolizumab (200 mg intravenous every 3 weeks). RESULTS:Three cases with diffuse upper eyelid involvement and pagetoid spread on the bulbar conjunctiva showed no response after receiving an average of 7 cycles of pembrolizumab therapy, and they underwent surgical excision. One case, who presented with orbital recurrence and lymph node metastasis after the excision of the right upper eyelid involvement with pagetoid spread, underwent surgical excision of the orbital mass with positive margins and neck lymph node dissection. After 8 cycles of pembrolizumab therapy, there was no recurrence or new metastatic lesion at 60 months of follow-up. Another case with diffuse left upper eyelid involvement, who had been treated with multiple surgeries and external beam radiotherapy, developed recurrent sebaceous carcinoma and received 9 cycles of pembrolizumab therapy. At 48 months of follow-up, there was no recurrence or new metastasis. Tumor mutation burden was ≤7.6 Mut/Mb in all 5 patients. CONCLUSION:Pembrolizumab, a PD-1 immune checkpoint inhibitor, does not appear to be effective as a first-line treatment for advanced sebaceous carcinoma with pagetoid spread. However, there might be a place for pembrolizumab in the treatment of recurrent and metastatic cases.
Orbital fat transposition, used to manage tear trough deformity, involves mobilizing orbital fat over the inferior orbital rim to smooth the lid-cheek junction. We report 2 cases of unilateral orbicularis paresis after lower blepharoplasty with supraperiosteal fat transposition. Videos recorded 2 weeks postoperatively showed that the median amplitude of 3 consecutive blinks was markedly reduced in the affected eye of each patient (patient 1: OD = 3.14 mm, OS = 8.43 mm; patient 2: OD = 4.33 mm, OS = 8.50 mm). At 6 months postoperatively, blink amplitude was symmetrical, and symptoms related to ocular exposure had resolved. Motor nerve fibers innervating the pretarsal upper and lower orbicularis oculi muscles follow a sub- and intramuscular course in the medial portion of the lower eyelid. Surgical procedures in this region may therefore injure these nerves, resulting in orbicularis paresis. A subperiosteal approach to orbital fat transposition may help avoid this complication.
Lacrimal sac epithelial tumors are rare and often present with subtle symptoms. We report 2 cases managed with combined external dacryocystectomy and endoscopic endonasal resection. Case 1 involved a 59-year-old female with lacrimal sac inverted papilloma extending into the nasolacrimal duct and inferior meatus. Case 2 involved a 79-year-old male with a chronically draining medial canthal wound and progressive induration after prior cyst excision, ultimately diagnosed as lacrimal sac oncocytoma. In both cases, preoperative imaging and clinical features demonstrated nasolacrimal duct involvement and adjacent anatomic distortion, prompting combined surgery for direct visualization and controlled resection of the lacrimal sac and ductal components. The combined approach allowed safe excision despite ductal expansion and adjacent tissue involvement. A small localized recurrence in case 1 at 11 months was successfully managed with in-office resection. These cases support case-selected multidisciplinary external-endonasal surgery for lacrimal sac tumors with nasolacrimal duct involvement.
PURPOSE:Transorbital neuroendoscopic surgery (TONES) is an emerging minimally invasive skull-base approach. The addition of an orbitotomy may increase the size of the surgical corridor, but this measurement has not previously been quantified. METHODOLOGY:Six fresh-frozen cadaveric specimens (11 orbits) underwent bilateral superior eyelid crease incisions and periorbital dissection to the meningo-orbital band and superior orbital fissure. This was followed by bilateral sphenoidotomy to expose the trigeminal ganglion and temporal dura. A custom surgical probe with an Augmented Reality, University of Cordoba tracker at its base was then positioned with its tip at the foramen ovale, and freedom of instrument articulation was quantified by maneuvering the probe throughout the limits of the exposure. Repeated measurements were taken following lateral (L-TONES) and superolateral (SL-TONES) orbital rim osteotomy. RESULTS:Both approaches demonstrated statistically significant increases in surgical exposure area when calculated using both convex-hull and simple elliptical area (p < 0.001). SL-TONES achieved the greatest area of 93.78 cm2 (SD, 22.3 cm2), which was 125% greater than standard TONES, which had a mean convex-hull area of 41.6 cm2 (SD: 11.8 cm2). L-TONES provided 70.38 cm2 of exposure when using the convex hull. CONCLUSIONS:This study presents a novel, inexpensive method of quantifying surgical exposure and demonstrates increased instrument freedom through the successive addition of lateral and superior orbitotomies during TONES dissection.
A 56-year-old man with a history of hereditary multiple exostoses and secondary low-grade chondrosarcomas was diagnosed with a pigmented mass in his left eye involving the inferonasal ciliary body and peripheral choroid following a superotemporal visual field defect. The intraocular mass continued to grow following brachytherapy, prompting enucleation that revealed a low-grade chondrosarcoma (CHS), similar in appearance to his prior skeletal neoplasms. There are 3 reports of CHS metastatic to the eye, and all 3 individuals had metastases to the lungs and other body sites before or at the time of ocular metastasis. Our patient had no pulmonary or other metastases identified radiographically at the time his intraocular tumor was diagnosed, presenting a conundrum: was the intraocular tumor a metastasis or did it arise de novo in a patient with hereditary multiple exostoses? The intraocular CHS in our patient resembles that reported rarely in other mammals, suggesting that it was a primary neoplasm arising from induced chondrogenic differentiation of uveal mesenchymal stromal cells in a patient with hereditary multiple exostoses and a predilection for developing low-grade chondrosarcomas.
This case report describes a 52-year-old male who developed testosterone dysregulation and erectile dysfunction while receiving teprotumumab infusions. He presented with active thyroid eye disease with proptosis, orbital pain, and edema. His clinical activity score was 4/10, and thyroid-stimulating immunoglobulin was elevated. He was started on the first course of teprotumumab, and after 5 infusions, he developed erectile dysfunction and low libido. Testosterone levels were found to be low during treatment and normalized by 4 months after completion of therapy, along with symptom resolution. Nine months later, his thyroid eye disease symptoms recurred, and a second course of teprotumumab was initiated. Erectile dysfunction and low testosterone levels returned. He was started on testosterone replacement therapy, which improved hypogonadal symptoms and testosterone levels. Testosterone levels returned to normal 8 months after completion of the second course of teprotumumab. At this time, thyroid eye disease symptoms recurred, and a third course of teprotumumab was initiated. One week after the second dose, erectile dysfunction returned and low testosterone levels were confirmed serologically. He was started on testosterone replacement therapy again, which improved hypogonadal symptoms and testosterone levels. This case shows a likely association between teprotumumab infusions and reversible testosterone dysregulation.
