PURPOSE:To compare the reimbursements associated with posterior blepharoptosis, ectropion, entropion, pterygium, and chelation for band keratopathy surgeries performed in an operating room versus an office procedure room and assess the potential benefit of incentivizing the use of the more cost-effective option. DESIGN:Economic analysis. METHODS:The 2022 Centers for Medicare and Medicaid Services database was used to determine the reimbursement for each procedure when performed in the operating room and office procedure room. Total services for each procedure were aggregated and used to estimate the total cost to the healthcare system based on location.Overhead costs for office procedures were calculated by examining the 3 main costs associated with these office procedures: disposables, human resources, and physical facilities.An incentive analysis was performed, which involved calculations examining the change in annual cost to Medicare if the reimbursement for the study procedures were increased to include overhead costs and various incentive payment percentages. RESULTS:Procedures performed in the operating room cost an average of $2200 more than office procedures. The average overhead cost for office procedures was $150. The total cost of the study procedures in 2022 was $177 million, with >90% of procedures performed in the operating room. Increasing reimbursement by 150% the cost of overhead, when 50% of procedures are performed in the office, saves the healthcare system $52 million. CONCLUSIONS:Increasing office reimbursement to cover overhead costs and provide a small incentive to perform procedures in the office could save the healthcare system millions of dollars.

PURPOSE:Cutaneous squamous cell carcinoma has a propensity for perineural invasion. Treating perineural spread has involved surgery and adjuvant chemoradiation, and more recently, immune checkpoint inhibitors. This study aims to evaluate motor and sensory functional outcomes in patients with cranial neuropathies from perineural spread of squamous cell carcinoma, particularly those undergoing immunotherapy. METHODS:This was a multicenter case series and literature review. RESULTS:Eighteen patients with cranial neuropathies from perineural spread had a mean age of 72.5 ± 9.7 years. Cranial nerves V and VII were most often involved. Treatments included radiotherapy (8/18; 44.4%), chemotherapy (7/18; 38.9%), and/or immunotherapy (11/18; 61.1%), with many receiving a combination of modalities (8/18; 44.4%). Of those receiving immunotherapy, 72.7% (8/11) demonstrated at least partial clinical and/or radiologic tumor response. Among those with functional outcomes documented, half had improvement in sensory/motor nerve function following immunotherapy (4/8; 50%). A literature review identified 55 articles describing 449 patients total with cranial neuropathies from squamous cell carcinoma perineural spread. Combinations of surgery, chemotherapy, and/or radiotherapy were employed, with immunotherapy used in 16 patients. From 5 patients on immunotherapy with documented functional outcomes, all demonstrated at least some improvement. CONCLUSION:Immunotherapy plays an evolving role in managing advanced squamous cell carcinoma. Functional improvements in cranial neuropathy were demonstrated in 50% of patients receiving treatment with immunotherapy at a mean of 32.6 months of follow-up. This may hold important implications for the timing of surgical intervention, particularly in the case of cranial nerves V and VII palsies.

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssuePrevious IssuesPublished Ahead-of-Print CMECollectionsVideosFor Authors Submit a ManuscriptInformation for AuthorsInformation for ReviewersLanguage Editing ServicesAuthor Permissions Journal Info About the JournalEditorial BoardAdvertisingOpen AccessSubscription ServicesReprintsRights and Permissions All Articles Images Videos Podcasts Blogs Advanced Search

PURPOSE:Patients with facial nerve paralysis (FNP) can have corneal decompensation resulting in poor visual outcomes. Here, we measure the associations between clinical parameters and corneal epitheliopathy in FNP. METHODS:In this cross-sectional cohort study, FNP patients from a 6-year period were reviewed. Etiology of FNP, visual acuity, grade of corneal epitheliopathy, and corneal sensation were recorded. Multivariate analysis was completed to assess the association between severe epitheliopathy and 4 ocular protective mechanisms: corneal innervation, House-Brackmann orbicularis score, Bell's phenomenon, and lagophthalmos. RESULTS:Forty patients (mean age 58.7 years) were included: 38% had an underlying central etiology, while 22% had peripheral causes and 40% Bell's palsy. Mean logMAR visual acuity on the ipsilateral side of FNP was 0.49. Severe epitheliopathy was identified in 18%. However, 35% of patients had decreased corneal sensation. Best corrected visual acuity was worse in patients with severe corneal epitheliopathy (p = 0.0003), and the rate of decreased corneal sensation was 4 times higher than in patients with normal corneas (p = 0.001). Multivariable analysis demonstrated a significant association between severe epitheliopathy and decreased corneal sensation (odds ratio [OR] = 14.97; p = 0.04), but not with House-Brackmann grading (OR = 1.86; p = 0.31), poor Bell's phenomenon (OR = 7.19; p = 0.13), or lagophthalmos (OR = 0.99; p = 0.95). Compared with patients with normal corneal sensation, those with reduced sensation had worse best corrected visual acuity and degree of corneal epitheliopathy (p = 0.005, p = 0.0003). CONCLUSIONS:Reduced corneal sensation was the most significant independent predictor of severe corneal epitheliopathy. Corneal sensitivity can affect visual outcomes and is an important variable to measure in patients with FNP.

IntroductionOrbital vascular anomalies (OVAs) encompass a heterogeneous group of lesions requiring precise imaging to guide diagnosis and treatment. Multiple imaging modalities offer distinct strengths and limitations, with the choice guided by the balance between spatial and temporal resolution. This review aligns imaging modalities with specific OVM subtypes to optimize diagnostic accuracy and procedural planning, while highlighting advanced and evolving imaging techniques that may further enhance clinical decision-making.MethodsA narrative review was conducted on studies describing imaging characteristics, diagnostic performance, and clinical utility in OVAs, supplemented with imaging from patients presenting with a wide range of lesions. All patient data were collected and reviewed in compliance with HIPAA regulations and international ethical standards.ResultsAlthough ultrasound provides dynamic assessment of vascular flow and superficial morphology, its role is limited in modern practice due to poor spatial resolution and depth penetration. CT offers superior spatial resolution for osseous and calcified lesions, while MRI provides excellent soft tissue characterization and evaluation of complex low-flow malformations. MR and CT angiography deliver detailed vascular mapping critical for pre-embolization planning, yet their static nature limits evaluation of dynamic changes. Dynamic techniques, such as Time-Resolved Imaging of Contrast KineticS (TRICKS) MRI angiography and dynamic CT angiography, enable real-time assessment of flow and venous distensibility, improving procedural planning. Conventional digital subtraction angiography remains the standard for complex lesions in critical locations, combining high-temporal-resolution diagnosis with therapeutic intervention. Given the heterogeneity of OVAs, a multimodal approach is often necessary to address diagnostic, planning, and treatment needs comprehensively.ConclusionOptimal imaging of OVAs requires tailoring modality selection to lesion type and clinical context. Incorporating advanced and emerging imaging approaches into clinical practice may further improve diagnostic precision, procedural planning, and patient outcomes.

Importance Advances in the understanding of the pathophysiology of thyroid eye disease (TED) provide an opportunity to use novel, targeted therapeutic agents. However, our capacity to assess the efficacy and indications for the new agents is potentially limited by the clinical metrics used in recent research trials, which fail to adequately capture the clinical complexity and diversity of TED. Objectives To review the features of TED that make it atypical among autoimmune diseases, review the limitations of the currently available metrics, and introduce the Innovate TED Initiative to develop new outcome metrics. Conclusions and Relevance To best evaluate and use potential new therapeutic agents for TED, physicians with expertise in the field perceive the need for a novel set of metrics. The outlined Innovate TED Initiative can, through the design and execution of prospective validation studies, develop the requisite metrics for the mutual benefit of physicians, regulatory bodies, the pharmaceutical industry, and patients with TED.

Acute invasive fungal rhinosinusitis (AIFRS) is a rare, aggressive disease process with an estimated mortality rate of 50.3% [1]. The rates of orbital invasion in AIFRS range from 40% to 60% [1, 2], and management of rhino-orbital disease remains controversial, with options ranging from orbital exenteration to tissue debridement to, more recently, transcutaneous retrobulbar amphotericin (TRAM-B) [3, 4]. In 2019, our institution began to treat rhino-orbital AIFRS primarily via TRAM-B. The objective of this study is to detail our experience with TRAM-B in the management of AIFRS and analyze patient outcomes. IRB-approved retrospective review of patients with tissue-confirmed sinonasal AIFRS at a tertiary center from 2010 to 2024. Demographic, medical, and surgical history, imaging, and laboratory information were obtained. Patient MRIs were reviewed, and orbital involvement was defined as the presence of abnormal contrast enhancement or loss of contrast enhancement attributed to invasive fungal disease within the orbital tissues [3]. Descriptive statistics, as appropriate, were reported. Bivariate and multivariate analyses were evaluated using independent two-tailed t-testing or ANOVA for parametric data. A binary logistic regression using alive and deceased as outcomes was performed to determine the impact of various treatment-related factors on patient mortality. All tests used a significance level of ≤0.05. Patients with orbital AIFRS underwent retrobulbar injection of 1 mL of 3.5 mg/mL liposomal amphotericin B compounded by the inpatient pharmacy. TRAM-B is an off-label application that is not approved by the Food and Drug Administration. The procedure was performed in conjunction with sinonasal debridement in the operating room or the inpatient wards. The globe is manually displaced laterally with direct instillation of amphotericin B into the retrobulbar space. Postinjection, manual pressure was applied to the globe, and the patient was monitored for orbital compartment syndrome. Initially, injections were performed daily for a total of three injections, but injections were transitioned to every other day intervals, due to orbital chemosis seen with daily injections. Ninety-five patients were included: 50 (52.6%) patients with nonorbital AIFRS, 32 orbital AIFRS patients (33.7%) received TRAM-B, 10 (10.5%) patients underwent orbital exenteration, and three (3.2%) patients received at least one dose of TRAM-B followed by exenteration. Among patients receiving TRAM-B followed by exenteration, one patient received a single injection of TRAM-B for postseptal orbital changes on MRI but developed same-day eyelid and facial soft tissue necrosis, necessitating exenteration and local debridement. Two patients received three TRAM-B injections followed by exenteration. One patient progressed to complete ophthalmoplegia and proptosis concerning clinical disease progression, and another developed complete ophthalmoplegia and proptosis with continued progression on MRI with loss of enhancement involving the optic nerve, remaining extraocular muscles, and extending toward the inferior orbital fissure. Demographic and disease-related characteristics are in Table 1. Patients with orbital AIFRS had higher hemoglobin A1C than nonorbital AIFRS (p = 0.003), were more likely to be transferred from an outside hospital (p = 0.027), and had Rhizopus/mucor as the underlying fungal pathogen (p = 0.003). There were no differences between the TRAM-B groups or orbital exenteration groups in any demographic, comorbidity, or presenting symptoms/extent of disease. The mortality rate for the total cohort was 50.1% (n = 48) with six (6.3%) patients lost to follow-up after discharge: 46% in the nonorbital AIFRS group, 53.1% in the TRAM-B, 70% in the orbital exenteration group, and 33.3% in patients receiving TRAM-B and exenteration. These rates were not significantly different. Binary logistic regression found no difference in odds of survival between nonorbital AIFRS, TRAM-B, or orbital exenteration patients when accounting for the severity of DM2, causative fungal organism, or transfer status (Table 2). There was no difference in mortality between patients undergoing orbital exenteration, TRAM-B, or nonorbital AIFRS. Other studies have examined patients with rhino-orbital AIFRS and noted a decrease in exenteration rate from 36–54% to 9–12% in patients managed with TRAM-B without differences in mortality [3, 4], which is comparable to our population where 8.6% (3 of 35 patients) receiving at least one injection of TRAM-B required exenteration. A recent meta-analysis examining the role of TRAM-B in AIFRS noted that no studies were sufficiently powered to substantiate differences in mortality, and there may be a role for TRAM-B in decreasing exenteration rates, but direct comparative studies remain limited [5]. There is a paucity of literature examining the role of orbital exenteration in survival outcomes in AIFRS patients. Turner et al. [1], in a systematic review of 807 patients, found that 20% of patients underwent exenteration without any impact on survival outcomes. Hargrove et al. [6] examined 224 cases of orbital AIFRS and found that exenteration only improved survival in patients with fevers but could identify no other prognostic factors associated with exenteration, emphasizing that alternatives to exenteration should be considered in the management of orbital AIFRS. Our data adds to the literature supporting TRAM-B as an alternative management approach to patients with AIFRS and demonstrates that these patients have no worse mortality than those undergoing exenteration. There were three patients in our cohort that had progressive orbital AIFRS despite TRAM-B, requiring exenteration. Orbital symptoms in each patient progressed rapidly and developed progression during the course of their TRAM-B or within 24 h of completion of their treatment course. Monitoring for disease progression via clinical and/or imaging examination is necessary to ensure that treatment failures are captured early enough to determine if additional surgical intervention is required. There are multiple limitations to this study, including the small sample size for the cohort undergoing orbital exenteration, which limits the ability to perform robust multivariate analyses. TRAM-B is a more recent treatment, and the study design may not fully account for advances in medical and anti-fungal therapy that may impact mortality. Multi-institutional studies with larger population sizes would be beneficial to evaluate these associations. The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Department of Defense, the Department of the Air Force, the Uniformed Services University of the Health Sciences, or any other agency of the U.S. Government. The authors declare no conflicts of interest.

Phosphaturic mesenchymal tumors (PMTs) are rare benign neoplasms that are often associated with tumor-induced osteomalacia. The authors present a rare case of a PMT with primary origin in the orbit. A 53-year-old female presented with diffuse bone pain and deficiency fractures throughout the body on x-ray imaging. Antinuclear antibody, immunoglobulin G4, and parathyroid hormone were elevated at that time. An incidental apical orbital mass with medial rectus and superior oblique involvement was found on MRI of the brain. Histologic examination confirmed fibroblast growth factor 23 positivity following biopsy. At postoperative week 6, bone pain and double vision resolved. Patient chose to undergo curative treatment with external beam radiation treatment with close follow up by oculoplastic surgery, endocrinology, and radiation oncology. At postoperative month 6, the ophthalmologic examination was within normal limits and repeat MRI demonstrated significant reduction in tumor size relative to post biopsy scans. PET scan did not demonstrate further lesions systemically. The prognosis for PMTs is favorable with adequate treatment. For patients with diffuse nonspecific skeletal pain and concurrent ocular symptomatology, this rare condition should remain on the differential diagnosis.

PURPOSE:Phenylephrine testing prior to Müller muscle conjunctival resection has traditionally been used to predict postoperative outcomes. The purpose of this study is to determine if preoperative phenylephrine testing impacts postoperative changes in eyelid position. METHODS:In this multicenter cross-sectional cohort study, 270 eyelids of participants with involutional ptosis and levator function >12 mm who underwent Müller muscle conjunctival resection were divided into 2 comparison groups. Participants who had preoperative phenylephrine testing served as the control group and those who did not were the study group. The primary outcome measure was postoperative marginal reflex distance from the upper eyelid margin (marginal reflex distance 1 [MRD1]) at the latest follow-up visit. Secondary outcomes included change in MRD1, reoperation rate, and predictive capacity of preoperative phenylephrine testing. RESULTS:Of the 270 eyelids that underwent Müller muscle conjunctival resection, 116 eyelids served as controls and 154 were in the study group. Mean age of participants was 62.6 years. Levator function, resection length, preoperative MRD1, change in MRD1, and latest postoperative MRD1 measures when compared in the control and study groups demonstrated no significance (p > 0.05) via 2-tailed t-test. Postoperative MRD1 was correctly predicted within 1 mm for 60.2% of eyelids that underwent preoperative phenylephrine testing. CONCLUSIONS:Preoperative phenylephrine testing does not significantly predict postoperative eyelid elevation following Müller muscle conjunctival resection. Surgeons may thereby reassess the utility of preoperative phenylephrine testing given the lack of influence on surgical outcomes.

BackgroundBlepharoptosis repair is a common eyelid surgery worldwide, however technique and outcome measurements vary widely.ObjectiveThis study aims to determine a consensus on pre- and postoperative factors important to oculoplastic surgeons in the evaluation of ptosis.MethodsOculoplastic surgeons were queried to describe 10 or more variables important for pre- and postoperative evaluation of ptosis and subsequently rate them on a 5-point Likert scale. A nominal group meeting determined a consensus on the 10 most important pre- and postoperative factors based on the previous survey responses. Mean and standard deviation for Likert score responses were compared using a student’s t-test.ResultsOne hundred and sixty-three respondents contributed a total of 1,909 open-ended responses. The two most cited factors were levator function (91.4%) and upper marginal reflex distance (87.7%). Known secondary causes of ptosis (75.5%), health of cornea and tear film (58.9%) and brow elevation/compensation (55.2%) were reported as important by over 50% of the respondents. The final variables were categorized into four groups: Causes of Ptosis, Surgical Planning, Anatomy and Symmetry, and Ptosis-Related Quality of Life.ConclusionA cohort of ASOPRS oculoplastic surgeons reached a consensus on a critical set of variables important for ptosis evaluation.

PURPOSE:The purpose of this study is to evaluate the association between the blepharospasm disability index (BSDI) and botulinum neurotoxin (BTX) dosage for patients affected by either benign essential blepharospasm or hemifacial spasm. METHODS:Cross-sectional cohort study evaluating adult patients diagnosed with benign essential blepharospasm or hemifacial spasm who completed a BSDI evaluation prior to receiving same-day therapeutic BTX injections. Primary outcome measures included BSDI score and number of BTX units. Simple and multivariable linear regression analyses were utilized to assess the relationship between BSDI score and BTX dosage. RESULTS:For patients with benign essential blepharospasm, BTX dosage was significantly and positively correlated to BSDI score (R2=0.16, β=1.15, p=0.007). This relationship remained robust when controlling for age, sex, disease duration, interval since previous BTX injection, and injecting provider (β=1.11, p=0.010). No significant correlation was identified between BSDI score and BTX dosage for patients affected by hemifacial spasm (R2=0.05, β=0.39, p=0.379). CONCLUSIONS:This study demonstrates that BTX dosage is significantly and positively correlated to BSDI score for patients affected by benign essential blepharospasm, but not for those affected by hemifacial spasm. Incorporating BSDI score may support more individualized and efficient clinical management of benign essential blepharospasm.

BackgroundAcute invasive fungal rhinosinusitis (AIFRS) is an aggressive and often fatal disease process that principally impacts immunocompromised patients. Maxillary dental trauma and infections have been associated with the development of maxillary sinus fungal balls, but the role of dental procedures/trauma in the pathogenesis of AIFRS remains poorly defined.ObjectiveThis study seeks to review a single-institutional experience with AIFRS and examine the association between dental events and AIFRS severity and outcomes.MethodsRetrospective review of 95 consecutive patients with biopsy-proven AIFRS treated at a tertiary institution between 2010 and 2024. Demographic information, comorbidities, disease course and outcomes were evaluated. The primary objective was to evaluate the impact of antecedent dental events on AIFRS morbidity and mortality. Secondary objectives included evaluating variability in demographic factors, comorbidities, and extent of disease.ResultsEleven patients with an antecedent dental event within 2 weeks of AIFRS diagnosis were identified for a rate of 11.6%. Dental AIFRS patients were more likely to be African American (P = .003) and more likely to have diabetes mellitus as their underlying immunodeficiency (P = .03) than non-dental AIFRS patients. Patients with dental-related AIFRS were more likely to present with invasion of the orbit (OR 6.0, 95% CI 1.2-29.5) and nasal floor (OR 4.2, 95% CI 1.1-17.1) than non-dental AIFRS patients. There was no difference in mortality between dental and non-dental AIFRS (36.4% vs 52.4%, P = .31).ConclusionMore investigation is necessary to further evaluate the association between dental events and the development of AIFRS. In our cohort, 11.6% of patients experienced AIFRS within 2 weeks of a dental event and these patients tended to present with higher rates of orbital involvement without a resultant increase in mortality.

BackgroundMinimally invasive techniques for the resection of sinonasal masses have become increasingly important over the past few decades. Sinonasal disease involving the lamina papyracea remains difficult to manage given the risk of injury to critical orbital structures and hemorrhage from nearby vessels.ObjectiveDetail the transcaruncular approach with orbital protection for the resection of benign and malignant sinonasal pathologies.MethodsDescription of surgical technique and presentation of 2 representative cases that were successfully managed with this surgical technique.ResultsThe transcaruncular approach involves incising the lateral 1/3 of the caruncle in a vertical plane between the upper and lower puncta. Dissection is then carried through the retrocaruncular fascia posterior to Horner's muscle to the posterior lacrimal crest along the medial orbital wall. Dissection can then be performed in a subperiosteal or supraperiosteal plane with subsequent ligation of the anterior ethmoidal artery. Once dissected, a nylon sheet used for orbital reconstruction and colored orbital shield can then be placed to aid in protection and visualization or orbital contents during endonasal tumor resection.ConclusionThe transcaruncular approach with orbital protection provides intraoperative protection of the orbital contents, allowing for safer removal of the mass irrespective of integrity of the lamina papyracea.

This study aims to elucidate the effect of thyroid eye disease on perceived facial aging. In this cross-sectional cohort study, an artificial intelligence (AI) model (previously trained to infer patient age from facial photographs) was used to analyze facial aging changes in 2 groups: (1) TED patients and (2) age-matched controls. Standardized photos were analyzed from initial and final visits of patients with more than 5 years of clinic follow-up. The performance of the AI model was compared to that of an expert group composed of oculoplastic surgeons. Chronological, AI-inferred, and expert-estimated ages were compared. AI initially estimated TED subjects to be 4.3 years older than their actual age, compared to 0.63 years older in control subjects (P=0.005). At the final timepoint, TED patients were estimated to be 5.0 years younger than their actual age, compared to 1.4 years younger in controls (P=0.004). The mean difference between actual and AI-inferred change in age was 9.3 years for TED patients and 2.0 years for controls (P<0.001). Human experts tended to underestimate age across all groups and time points. The AI model was significantly more accurate than human experts in estimating the age of controls at the final time point. AI estimated that TED patients were older than their chronological age initially and younger than their chronological age at the final follow-up. This may be due to initial pathologic soft tissue volume expansion in TED, which may compensate for age-related soft tissue deflation.

Lemierre syndrome is a rare, life-threatening condition characterized by internal jugular vein thrombophlebitis and septic embolization. Ophthalmic complications are uncommon but clinically significant. This report describes a case of Lemierre syndrome presenting with ophthalmic vein thrombosis, abducens nerve palsy, and Horner syndrome. A 19-year-old man initially misdiagnosed with immune thrombocytopenic purpura developed neurological deficits, including aphasia and diplopia. Imaging revealed internal carotid artery dissection, cavernous sinus thrombosis, and superior ophthalmic vein occlusion. Ophthalmologic evaluation showed right ptosis, anisocoria, and an abduction deficit, consistent with Horner syndrome and abducens nerve palsy. Microbial cell-free DNA testing detected Fusobcaterium necrophorum , confirming Lemierre syndrome. Targeted antibiotic therapy and anticoagulation led to clinical stabilization, with mild residual ptosis at 6 months. This case highlights the importance of recognizing ophthalmic complications in Lemierre syndrome. Early diagnosis, targeted antimicrobial therapy, and a multidisciplinary approach are essential for optimal management.

A rare case of a 78-year-old male with posterior orbital amyloidosis and cavernous sinus involvement is reported. He presented with 1 year of worsening binocular diplopia with left eye motility restriction in all directions except abduction. Magnetic resonance imaging of the brain demonstrated a well-defined mass in the posterior medial orbit extending into the left optic canal and cavernous sinus, with low T1 and high T2 signaling and minimal contrast enhancement. Given his worsening diplopia, the patient underwent surgery to decompress the left orbital apex and confirm the diagnosis. Histopathology exhibited red-green dichroism under polarization microscopy with Congo red dye, suggesting amyloidosis. Orbital amyloidosis should be considered in patients presenting with apex lesions with posterior extension. An approach to biopsy and decompression of the apex may be facilitated with a combined trans-orbital and endonasal endoscopic approach, but complete surgical excision may not be feasible. Adjunctive radiation can help stabilize disease and prevent progression in cases of orbital amyloidosis with cavernous sinus involvement.

Intro: Endoscopic transorbital resection for spheno-orbital meningioma presents a less invasive alternative to craniotomy with reduced risk of post operative cosmetic deformity, with some studies citing equal or superior rates of gross total resection (GTR) than open approaches. When the primary goal of surgery is orbital decompression, with intracranial tumor resection as a secondary aim, transorbital endoscopic surgery may be a superior approach.

The eyelid performs critical functions to protect the eye and preserve functional vision. These functions are driven by contraction of the orbicularis oculi (OO), which is a unique skeletal muscle with a circular geometry and diffuse innervation. It is thought that this distributed innervation may allow for differential segmental activation and contraction, but it is not currently understood how sequenced activation patterns relate to differential muscle contraction, nor how segmental contraction creates the kinematics that drive the eyelid's critical functions. In fact, motion of the eyelid has predominantly been modeled in only a single dimension (open-close). Here, we show that eyelid motion has important two-dimensional features that vary between eyelid behaviors. Using distributed intramuscular electromyography, we further show that activation differs segmentally across the OO, and that patterns of activation change to produce different behavior-specific eyelid kinematics. Our results demonstrate the role of segmental activation in eyelid motion, highlighting the importance of precise neural control in producing natural eyelid behavior. We anticipate that this research is a starting point for robust mechanistic models of eyelid function. This knowledge has critical implications for diagnosis and treatment of eyelid paralysis.