Periocular rejuvenation involves surgical removal of excess skin, fat debulking, or transfer, and optionally includes eyelid ptosis repair or lateral canthal resuspension. Periocular injectables have revolutionized these esthetic treatments, sometimes replacing surgery. We describe our experience with current treatment approaches for periocular rejuvenation of upper and lower eyelids. We extracted data on treatment types and outcomes of all patients treated for periocular rejuvenation of upper and lower eyelids between 2015 and 2020. All patients were treated by a single surgeon (GBS) at three medical centers. Outcome measures included demographic trends, procedural frequencies, age and gender distribution, as well as age-stratified preferences for surgical versus injectable treatments. In total, 1923 patients (mean age 64 years, 1340 females [70 www.springer.com/00266 .

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.

IntroductionOcular surface squamous neoplasia (OSSN) encompasses a spectrum of epithelial malignancies of the conjunctiva and cornea that, untreated, may invade intraocularly or into the orbit. Clinical examination alone may fail to define true depth of invasion, risking under- or overtreatment. Advanced anterior segment imaging provides objective structural information that complements slit-lamp assessment.MethodsThis review summarizes the complementary roles of anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) in assessing OSSN depth through a targeted literature review and illustrates their practical applications through representative cases from a single tertiary center.ResultsAS-OCT offers non-contact, high-resolution imaging of the epithelium and stromal interface, facilitating detection of invasive change. UBM, with deeper penetration, visualizes the sclera, ciliary body, angle, and iris, detecting deep or clinically occult extension. The cases demonstrate how each imaging modality contributes to refining diagnosis, guiding treatment selection, and supporting long-term surveillance.DiscussionApplying AS-OCT for superficial disease and UBM for suspected deep extension enhances diagnostic confidence and supports personalized, globe-preserving management. Integrating both modalities into a stepwise imaging workflow can improve staging accuracy and align treatment intensity with true disease extent.

BACKGROUND:While episcleral brachytherapy is an effective treatment for uveal melanoma, its long-term complications have primarily focused on intraocular structures. Eyelid disorders following brachytherapy are rarely reported despite potential complications related to the plaque surgery. This retrospective study aimed to assess the prevalence, characteristics, and risk factors for acquired ipsilateral eyelid disorders (IEDs) after ocular brachytherapy. DESIGN:A retrospective clinical cohort study was conducted on patients who underwent episcleral brachytherapy at a single tertiary center between 2009 and 2023. METHODS:Medical records were reviewed. Data collected included demographic variables, tumor characteristics, plaque type, surgical details, and presence of postoperative IEDs. The primary outcome was the association between brachytherapy and acquired IEDs. RESULTS:A total of 191 patients were included, 101 females (52.9%) mean age 63.4±14.2 years. All tumors were malignant melanoma: choroidal (n = 156, 81.7%), ciliary body (n = 27, 14.1%), iris (n = 7, 3.7%), and anterior segment (n = 1, 0.5%). Isotopes used included Iodine-125 (n = 150, 78.5%) and Ruthenium-106 (n = 41, 21.5%). IEDs developed in 40 cases (20.9%), predominantly affecting the upper eyelid. Ptosis was the most common finding (n = 35, 87.5%), followed by trichiasis (n = 1, 2.5%), ectropion (n = 1, 2.5%), and benign eyelid lesions (n = 3, 7.5%). Ptosis was significantly associated with anterior tumor location (p = 0.03), iodine isotope (p = 0.01), and female gender (p = 0.04). On multivariate logistic regression analysis, iodine-125 use (OR 5.38, 95% CI 1.21-23.88; p = 0.027) and anterior tumor location (OR 2.40, 95% CI 1.01-5.71; p = 0.048) remained independently associated with postoperative ptosis, whereas female gender did not retain statistical significance. No association was found with age, plaque diameter, radiation dose, laterality, muscle manipulation, or tarsorrhaphy. CONCLUSION:Acquired eyelid disorders, particularly upper eyelid ptosis, are a relatively common and underrecognized complication following episcleral brachytherapy. Increased awareness of these potential sequelae and timely referral to oculoplastic specialists are advised.

Orbital masses include a diverse spectrum of benign, malignant, inflammatory, and vascular lesions in pediatric and adult patients. Accurately diagnosing the type of lesion is critical, as management strategies differ significantly. Advanced imaging is therefore essential, and computed tomography (CT) is central to orbital evaluation. We reviewed the literature to synthesize evidence on CT features across common orbital pathologies and correlated imaging with clinical presentation to emphasize diagnostic relevance. CT characteristics are summarized for vascular lesions (cavernous venous malformation, lymphatic malformation), inflammatory conditions (orbital myositis, dacryoadenitis), benign lesions (dermoid cyst, pleomorphic adenoma), and malignant lesions (lacrimal gland lymphoma, adenoid cystic carcinoma, rhabdomyosarcoma). We present characteristic patterns of location, morphology, enhancement, and bone change, with practical discriminators and common pitfalls to aid differentiation. When used alongside clinical context, CT remains a preferred modality in many clinical settings due to its rapid acquisition, wide availability, and reliable depiction of bone and calcifications. It supports accurate diagnosis and informed management decisions in time-critical settings. This review provides a structured reference for interpreting CT findings across a wide range of orbital disease.

PurposeBlepharitis and lower eyelid ectropion are highly prevalent ocular conditions occurring in 37%-46% and 2-3% of the general adult population, respectively. Blepharitis has multifactorial origins and involves anterior and posterior types of eyelid inflammation. Lower eyelid ectropion results in ocular surface exposure, epiphora and chronic conjunctivitis. This study aims to investigate any possible association between both conditions. MethodsMedical records of 37,692 consecutive patients examined at a single medical screening center between 2001-2020 were retrospectively analyzed. Main Outcome MeasuresThe prevalence of lower eyelid ectropion and of blepharitis, a possible association between the two, and the relation of each to age and sex. ResultsA total of 35,670 patients were included. Ectropion was diagnosed in 69 patients (0.2%), and blepharitis in 4725 patients (13.2%). Male sex was more prevalent for each pathology (88.4% ectropion, and 85% blepharitis, p < .001). Older age was associated with each diagnosis (77.3 years for ectropion patients vs. 52.2 years for the general screened population and 60.5 years for blepharitis patients vs 52.2 years for the general screened population p < .001). The prevalence of ectropion was significantly higher in patients with coexisting blepharitis compared to those without (0.8% vs. 0.1%, respectively, p < .001). ConclusionsEctropion was significantly more prevalent in patients with blepharitis. Both conditions were associated with older age and male sex. This coexistence can aid in decision making of early surgical intervention of lower eyelid ectropion as well as the approach to medical treatment of blepharitis.

Pregnancy induces significant physiological changes in women, impacting various bodily systems. These alterations can influence ocular health and visual function. Ophthalmologists at our center noted an apparent increase in reports of transient binocular visual disturbances among pregnant women presenting to the Ophthalmic Emergency Room (OER), with no ophthalmic findings. This study aims to examine the rate of Transient Visual Disturbances with Normal Ocular Examination (TraViNo) in pregnant vs. non-pregnant women of childbearing age. A cross-sectional study was conducted at Sheba Medical Center, analyzing data from 562 females between 18 and 50 years of age who presented to the OER during January-March 2019. Data retrieved from the participants’ medical records included demographics, medical history, symptoms, comprehensive ophthalmological evaluation findings, and final diagnoses recorded at the OER. Included were 562 females (mean age 31.2 ± 9.0 years), among whom 69 (12.0%) were pregnant (mean pregnancy week 25 ± 11). The mean age was similar for both groups ( P = 0.2). Presenting symptoms varied between the groups ( P < 0.001), with the most common being visual disturbances in the pregnant group (PG) (58%). TraViNo was the final diagnosis in 86 (15%) study women and significantly more common in the PG (48% vs. 11%, respectively, P < 0.001). Most cases (74%) were bilateral. The additional workup included neurologic examinations in 45 (66%) cases, brain/orbital imaging in 28 (33%), and visual field testing in 8 (12%). Obstetric evaluations performed in the PG were normal except for 2 cases of hypertension. TraViNo is more common during pregnancy. Further research is warranted to identify underlying causes and long-term implications.

PURPOSE:Blepharitis is a prevalent ocular condition, associated with significant discomfort and linked to other ocular and systemic pathologies such as dermatological conditions. The pathophysiology of blepharitis is multifactorial, and the potential correlation with systemic conditions including blood test abnormalities is still not fully known. We aimed to identify systemic conditions and routine laboratory abnormalities independently associated with blepharitis in a large screening-clinic cohort. METHODS:This case-control study analyzed electronic medical records from adults who underwent routine ophthalmic and systemic evaluations at a single Medical Screening Institute between 2001 and 2020. Patients with blepharitis were compared with controls after accounting for age and sex differences via inverse probability weighting. The outcome measures were systemic conditions and blood tests results. P values were adjusted for multiple testing using the false discovery rate (q-values). RESULTS:Overall, 35,678 individuals were included in the study. Among them, 4797 (13.4%) were diagnosed with blepharitis. Blepharitis cases were characterized by a higher rate of dermatological conditions (15.7% vs. 12.2%, q < 0.001), and neurological disorders (7.2% vs. 5.7%, q = 0.013) compared with controls. No significant correlations were observed between blepharitis blood test abnormalities, including complete blood count and chemistry. CONCLUSIONS:This study supports the association between blepharitis and dermatological conditions and highlights a possible link with neurological disorders.

Teprotumumab is the only FDA-approved medication for thyroid eye disease (TED), showing benefits in reducing proptosis, diplopia, clinical activity score (CAS), and improving quality of life. This study describes the clinical outcomes of TED patients treated with Teprotumumab across 5 medical centers in Israel and evaluates time-to-improvement. A retrospective cohort study of electronic medical records for Israeli patients treated with Teprotumumab between 2021 and 2024 in five medical centers. The main outcome included changes in proptosis and diplopia. Thirty-two TED patients (mean age 53.3, 19 females) received partial or complete treatment with Teprotumumab. All had previously failed IV glucocorticoids, and some also failed other biologics. Four patients had decompression surgery prior; 3 with optic neuropathy and 1 with proptosis improved after 1–7 doses. Proptosis decreased by 2.4mm (right) and 2.0mm (left) (p < 0.001, p = 0.002, paired sample t-test), with significant reductions in primary gaze diplopia (p = 0.015, chi-square test). Four patients (12.5

A 47-year-old woman developed left eyelid drop, proptosis, ophthalmoplegia, and conjunctival injection (A) 6 days after endovascular mechanical thrombectomy of a left internal carotid artery occlusion. On examination, visual acuity was intact with no pupillary defect, whereas vascular studies demonstrated normal ophthalmic arterial flow (B), ruling out orbital infarction syndrome. C, Computed topography angiography excluded a carotid cavernous fistula, while magnetic resonance imaging demonstrated extraocular muscle enlargement and intraconal fat straining. The patient was diagnosed with transient orbital inflammatory syndrome prompted by the thrombectomy procedure. D, Rapid improvement was demonstrated after intravenous glucocorticoids treatment, with complete resolution 1 week later. (Magnified version of Figure A-D is available online at www.aaojournal.org).

Sympathetic overstimulation of Müller’s muscle is a suggested mechanism underlying upper eyelid retraction in thyroid eye disease (TED). We examined the effect of tamsulosin, an alpha-1 antagonist, on eyelid retraction in patients with TED. A single-centre prospective study. Patients with TED and associated eyelid retraction were treated with oral 0.4 mg/day tamsulosin for 3 months. Upper eyelid margins-to-reflex distance (MRD1), vertical palpebral fissure height (PFH), subjective improvement, signs and symptoms of dry eye, and lubricants use were assessed at baseline and at each subsequent visit. Eleven suitable patients (mean age 47.5 ± 9.68, 8 females) enrolled in the study. Three patients discontinued the drug due to mild adverse effects (dizziness, bradycardia, nausea, and gastrointestinal distress), which resolved immediately upon stopping treatment. The other eight patients tolerated the drug well and reported no side effects. Five patients experienced an objective improvement in eyelid position and subjective improvement in eye discomfort. The mean MRD1 decreased by −1.04 ± 0.81 mm (P = 0.015), and mean PFH decreased by −1.46 ± 1.33 mm (P = 0.039). Mean duration of tamsulosin treatment was 84.63 ± 71.9 days. Patients discontinued the drug due to no improvement in MRD1 (n = 3), referral for eyelid surgery with stable inactive TED (n = 2), treatment with intravenous methylprednisolone due to worsening active TED (n = 2), and patient choice after 5 months of treatment with spontaneous resolution of symptoms (n = 1). Tamsulosin is a safe potential treatment for eyelid retraction in TED and can be used as a temporary alternative therapeutic approach for patients unsuitable for surgery.

Purpose To examine the ophthalmic data from a large database of people attending a general medical survey institute, and to investigate ophthalmic findings of the eye and its adnexa, including differences in age and sex. Methods Retrospective analysis including medical data of all consecutive individuals whose ophthalmic data and the prevalences of ocular pathologies were extracted from a very large database of subjects examined at a single general medical survey institute. Results Data were derived from 184,589 visits of 3676 patients (mean age 52 years, 68% males). The prevalence of the following eye pathologies were extracted. Eyelids: blepharitis (n = 4885, 13.3%), dermatochalasis (n = 4666, 12.7%), ptosis (n = 677, 1.8%), ectropion (n = 73, 0.2%), and xanthelasma (n = 160, 0.4%). Anterior segment: pinguecula (n = 3368, 9.2%), pterygium (n = 852, 2.3%), and cataract or pseudophakia (n = 9381, 27.1%). Cataract type (percentage of all phakic patients): nuclear sclerosis (n = 8908, 24.2%), posterior subcapsular (n = 846, 2.3%), and capsular anterior (n = 781, 2.1%). Pseudophakia was recorded for 697 patients (4.6%), and posterior subcapsular opacification for 229 (0.6%) patients. Optic nerve head (ONH): peripapillary atrophy (n = 4947, 13.5%), tilted disc (n = 3344, 9.1%), temporal slope (n = 410, 1.1%), ONH notch (n = 61, 0.2%), myelinated nerve fiber layer (n = 94, 0.3%), ONH drusen (n = 37, 0.1%), optic pit (n = 3, 0.0%), and ON coloboma (n = 4, 0.0%). Most pathologies were more common in males except for ONH, and most pathologies demonstrated a higher prevalence with increasing age. Conclusions Normal ophthalmic data and the prevalences of ocular pathologies were extracted from a very large database of subjects seen at a single medical survey institute.

Objective: To develop an automated, new framework based on machine learning to diagnose malignant eyelid skin tumors. Methods: This study used eyelid lesion images from Sheba Medical Center, a large tertiary center in Israel. Before model training, we pretrained our models on the International Skin Imaging Collaboration (ISIC) 2019 dataset consisting of 25,332 images. The proprietary eyelid data set was then used for fine-tuning. The data set contained multiple images per patient, aiming to classify malignant lesions in comparison to benign counterparts. Results: The analyzed data set consisted of images representing both benign and malignant eyelid lesions. For the benign category, a total of 373 images were sourced. By comparison, for the malignant category, 186 images were sourced. For the final model, at sensitivity of 93.8% (95% CI 80.0-100.0%), the model has a corresponding specificity of 73.7% (95% CI 60.0-87.1%). To further understand the decision-making process of our model, we employed heatmap visualization techniques, specifically gradient-weighted Class Activation Mapping. Discussion: This study introduces a dependable model-aided diagnostic technology for assessing eyelid skin lesions. The model demonstrated accuracy comparable to human evaluation, effectively determining whether a lesion raises a high suspicion of malignancy or is benign. Such a model has the potential to alleviate the burden on the health care system, particularly benefiting rural areas, and enhancing the efficiency of clinicians and overall health care.

We present two cases of removal of an orbital apex cavernous venous malformation using an endoscopic endonasal trans-septal approach and a CT-guided navigation system. The apex was accessed through endoscopic medial wall orbitotomy. The periorbita was then opened, and the inferior and medial rectus muscles were isolated to enable an approach to the lesion. These surgeries were performed jointly by Oculoplastics and ENT endoscopy teams.

Purpose: To examine the long-term effect of combined blepharoplasty and Muller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty procedure on dry eye syndrome.Methods: This is a Prospective comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients that underwent blepharoplasty at least 3 years earlier and the ptosis group consisting of adult patients that underwent MMCR with blepharoplasty at least 3 years earlier. The parameters that were compared for all patients before the procedure, on postoperative day 90, and at the long-term follow-up were: Schirmer-test 2, tear break-up time (TBUT), fluorescein staining, and lissamine green (LG) staining.Results: The participants included 25 post-MMCR patients with a mean follow-up of 4.94 +/- 0.64 years and 15 post-blepharoplasty patients with a mean follow-up of 4.22 +/- 0.32 years. There was a significant increase in the postoperative LG and fluorescein staining scores compared to the preoperative scores in the ptosis group (p < .01 and p < .01, respectively) as well as a decrease in postoperative TBUT compared to the preoperative values (p = .044). Those parameters were not significant in the blepharoplasty group.Conclusions: Patients who underwent MMCR, but not those following upper blepharoplasty, showed signs of dry eye compared to the preoperative status after long-term follow-up. Dry eye signs should be examined before MMCR surgery, and patients should be aware of the high risk of developing dry eye and the need for long-term treatment. Surgeons should carefully consider performing MMCR for patients with severe dry eye.

PURPOSE:To determine the role of diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) in differentiating the inflammatory process and malignant lymphoma of the lacrimal gland. METHODS:A retrospective analysis of all subjects who underwent lacrimal gland biopsy and magnetic resonance (MR) imaging with DWI sequences during a 10-year period at the Sheba Medical Center, Israel. The lacrimal glands' ADC values were documented bilaterally by blinded observers and correlated with the final histology verified diagnoses. RESULTS:Twenty-eight patients were included, with 19 females (68%) with a mean ± SD age of 48.1 ± 25.7 years. The right orbit was involved in 14 cases (50%) and the left in 13 (46%); one patient (4%) had bilateral involvement. Seventeen cases (61%) had a final diagnosis of idiopathic inflammation or dacryoadenitis, and six cases (21%) were diagnosed with lymphoma. Additional diagnoses included pleomorphic adenoma in 3 (11%), adenoid cystic carcinoma, and solitary fibrous tumor. Lower mean ADC values were observed in the lymphoma versus inflammatory group (1.03 × 10-3 Vs. 1.45 × 10-3, P = 0.02). CONCLUSION:Restricted diffusion on MR imaging can serve as a diagnostic tool in the differentiation between inflammatory processes of the lacrimal gland and lymphoma.

Objective To determine whether Xanthelasma palpebrarum (XP) is associated with dyslipidemia, cardiovascular disease (CVD) and other systemic conditions in a large population. Design Case-control study conducted at a single tertiary care center. Participants Individuals who were examined at a medical screening institute from 2001 to 2020. Methods Medical records were reviewed to extract data on ophthalmic evaluations, blood tests, and systemic diagnoses. Patients identified with XP in at least one eye comprised the study group. A control group without XP was established matched by age and sex at a 10:1 ratio to allow robust statistical analysis. Main Outcome Measures Associations between XP and dyslipidemia and CVD. Lipid profiles, diagnosis of dyslipidemia and CVD were compared between the case and control groups. Results The database included 35,452 individuals, 24,287 males (69%), mean age 52.2±12.2 years. The study population included 203 XP patients (0.6%) and 2030 matched controls. The prevalence of dyslipidemia diagnosis and the usage rates of statins, fibrates, or other cholesterol-lowering medications was similar between the two groups. Lipid profiles were similar between the groups, including median total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglyceride levels (187 controls vs. 192 XP, 48 controls vs. 47 XP, 120 controls vs. 125 XP, 111 controls vs. 105 XP, respectively, P>0.05 for all). The rate of CVD was similar as well (10% controls vs. 8.9%, XP P=0.56). The prevalences of related conditions, including hypertension, diabetes mellitus, and history of cerebrovascular accident, were similar between groups (24% controls vs. 23% XP, 14% controls vs. 10% XP, 1.3% controls vs. 1% XP, respectively P>0.05). Conclusions XP was not associated with increased rates of dyslipidemia or CVD. This questions the extent to which XP serves as an indicative marker for heightened systemic risk.Introduction

Purpose: Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. Methods: Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. Results: Over a mean follow-up period of 31.3 months (range: 3 months–8 years), mean corneal sensitivity improved from 3.6 mm (range: 0–25 mm) to 25.3 mm (range: 0–57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. Conclusions: Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.