Introduction La sensibilité au contraste peut être diminuée chez les patients aux antécédents de névrite optique. Nous rapportons ici un cas de phénomène d’Uhthoff inaugural avec une sensibilité au contraste diminuée. Observation Une danseuse professionnelle sans antécédents consulte pour des troubles de la vision qu’elle décrit comme brouillée et assombrie, lorsqu’elle danse, en particulier lors des efforts intenses. Les examens ophtalmologiques et neurologiques standards, y compris l’IRM cérébrale et orbitaires, sont interprétés comme normaux, et les symptômes sont considérés comme fonctionnels. Sa fonction visuelle est secondairement évaluée par oculométrie (eye-tracking) avec BulbiCAM®, permettant entre autres de mesurer la sensibilité au contraste dans des conditions contrôlées. Les mesures de base au repos sont légèrement diminuées aux deux yeux (équivalent≤1,23 log contrast Pelli–Robson). Cependant, lors d’un nouveau test effectué immédiatement après un effort (monter et descendre des escaliers), la sensibilité au contraste diminue nettement, passant à 0,77 pour l’œil gauche et 0,54 pour l’œil droit, avant de revenir à la valeur de base après une période de repos. L’objectivation d’une diminution réversible de la fonction visuelle liée à l’effort a fait évoquer le diagnostic de phénomène d’Uhthoff. La relecture des IRM, à la lumière de cette hypothèse, a révélé de subtiles anomalies pouvant évoquer une démyélinisation (Figure 1, Figure 2). Discussion Ce cas illustre la difficulté d’objectiver des anomalies sur les explorations standard lors de symptômes transitoires, notamment visuels. L’intérêt de répéter les tests après effort pour démasquer les symptômes a été démontré, notamment via les PEV, mais la réalisation de ceux-ci reste longue et nécessite un personnel qualifié. La sensibilité au contraste n’est habituellement pas pratiquée en routine en ophtalmologie. Conclusion L’accessibilité grandissante de l’oculométrie peut permettre de réaliser des examens répétés, standardisés et rapides facilitant le diagnostic de manifestations neuro-ophtalmologiques transitoires ou atypiques.

Thyroid eye disease (TED) is a heterogenous autoimmune disease and the main extra-thyroidal manifestation of Graves’ disease. There are limitations with the current disease classification of TED that may mislead the underlying pathophysiology and treatment choices of the disease. Phenotype is how the disease looks, which is secondary to the interaction between the patient tissue and its response to the disease. It is crucial to classify the phenotype of TED as not everyone follows the classic disease course of active inflammatory followed by inactive, “burnt-out” TED phases with associated signs. TED patients are usually classified as active if they have the signs of inflammation as suggested by the clinical activity score (CAS)—eyelid oedema/redness, conjunctival redness, caruncular swelling and limitation of the eye movements. However, patients can present with a low CAS score but have progressive or severe disease. Patients can have a “white eye” and optic neuropathy or white eye with limitation of the eye movements. We describe six different phenotypes: (1) Congestive, (2) White eye expansion, (3) White eye apex, (4) Hydraulic apex, (5) Cicatricial active and (6) Cicatricial passive. Classifying these phenotypes of TED in addition to the traditional active-inactive classification, directs the clinician to considering the different pathophysiologies in order to provide the best tailored treatment for the patient.

Thyroid eye disease (TED) is an autoimmune condition that is classically divided into active (inflammatory) and inactive (“burnt-out”) disease. Hydraulic or meta-active TED is driven by specific “mechanical” factors at the posterior orbit resulting in a characteristic increased orbital tension, congestion and venous obstruction. It is associated with posterior orbital muscle expansion and crowding. It may be present with or without a significant concurrent inflammatory component. Hydraulic apex TED manifests during or following the active (inflammatory) phase. This can be misinterpreted as active inflammation only, leading to over-treatment with, or poor response to immunosuppression. Patients with hydraulic phenotype TED have severe disease. They typically have limited moderate proptosis, firm orbits to retropulsion and deep dilated conjunctival vessels throughout. Optic neuropathy or visual obscurations when changing posture or eye movements may be present. They may suffer from double vision with limitation in their eye movements. Posterior and apical extraocular muscle enlargement is characteristic. They respond poorly to immunosuppression but well to posterior apical orbital decompression surgery. Therefore, it is essential to identify these patients and distinguish from the other phenotypes of TED in order to tailor treatment choices and avoid unnecessary immunosuppression.

PURPOSE:This study aimed to compare the effectiveness of 3 artificial intelligence language models-GPT-3.5, GPT-4o, and Gemini, in delivering patient-centered information about thyroid eye disease (TED). The authors evaluated their performance based on the accuracy and comprehensiveness of their responses to common patient inquiries regarding TED. The study did not assess the repeatability of artificial intelligence responses, focusing on single-session evaluations per model. METHODS:Five experienced oculoplastic surgeons assessed the responses generated by the artificial intelligence models to 12 key questions frequently asked by TED patients. These questions addressed TED pathophysiology, risk factors, clinical presentation, diagnostic testing, and treatment options. Each response was rated for correctness and reliability on a 7-point Likert scale, where 1 indicated incorrect or unreliable information and 7 indicated highly accurate and reliable information. Correctness referred to factual accuracy, while reliability assessed trustworthiness for patient use. The evaluations were anonymized, and the final scores were averaged across the surgeons to facilitate model comparisons. RESULTS:GPT-3.5 emerged as the top performer, achieving an average correctness score of 5.75 and a reliability score of 5.68, excelling in delivering detailed information on complex topics such as TED treatment and surgical interventions. GPT-4o followed with scores of 5.32 for correctness and 5.25 for reliability, generally providing accurate but less detailed information. Gemini trailed with scores of 5.10 for correctness and 4.70 for reliability, often providing sufficient responses for simpler questions but lacking detail in complex areas like second-line immunosuppressive treatments. Statistical analysis using the Friedman test showed significant differences between models ( p < 0.05) for key topics, with GPT-3.5 consistently leading. CONCLUSIONS:GPT-3.5 was the most effective model for delivering reliable and comprehensive patient information, particularly for complex treatment and surgical topics. GPT-4o provided reliable general information but lacked the necessary depth for specialized topics, while Gemini was suitable for addressing basic patient inquiries but insufficient for detailed medical information. This study highlights the role of artificial intelligence in patient education, suggesting that models like GPT-3.5 can be valuable tools for clinicians in enhancing patient understanding of TED.

PURPOSE:Robotic surgical techniques have transformed many surgical specialties however robotic techniques and applications have been much more limited in ophthalmology. This study aims to evaluate the feasibility of robotic assisted orbital surgery using a single-port novel robotic platform, the da Vinci SP. METHODS:A series of orbital procedures were performed in cadaveric specimens utilizing the da Vinci SP robotic system. The procedures performed included lacrimal gland dissection and biopsy, medial and lateral orbital wall dissections, enucleation, and lid-sparing orbital exenteration. Successful completion of each procedure was defined by the operating surgeon and was considered the primary outcome and marker of feasibility. RESULTS:Seven cadaveric procedures were performed in 3 cadaveric specimens. All 7 procedures were completed successfully without complication. Setup optimization occurred throughout the study and setup and operative times were acceptable. Three instrument arms and 1 endoscope were utilized throughout the study allowing 3 arm operating and dynamic retraction. Instrument size was found to limit surgical access and precision particular at the orbital apex. CONCLUSIONS:This preclinical study demonstrates that the da Vinci SP can be utilized within the orbit and is feasible for several applications. Robotic surgical systems offer significant advantages over conventional techniques and should be embraced. However, current commercially available robotic platforms are not optimized for the orbit and have their limitations although they may be suitable for some clinical applications.

Purpose Orbital surgery benefits from well-designed instrumentation that offers gentle tissue manipulation, high manoeuvrability and control. Nevertheless, in confined spaces, tissue manipulation must be accomplished with exceptionally high accuracy and precision. This is where robotic surgery offers an advantage. We aimed to evaluate a robotic-assisted surgical system’s feasibility, safety and outcome in assisting tumour clearance. Patients and methods A case series of patients with advanced periocular tumours undergoing robotic-assisted globe-sparing resection was performed using the DaVinci XI system (Intuitive Surgical, Inc). Institutional ethics and multidisciplinary approval were sought in all cases. Results Four patients with advanced periocular tumours underwent robotic-assisted orbital surgery at a mean age of 63 years (range 42–86). Two patients were diagnosed with squamous cell carcinoma, and two had basal cell carcinoma. One patient was found to have positive lymph nodes at the time of surgery and underwent simultaneous parotidectomy and lymph node clearance. Clear resection of the primary tumour was achieved in all patients; three patients underwent further resection due to narrow margins prior to reconstruction. Patients were follow-up for at least one year, and three remained disease-free. One patient with pre-existing extra-orbital disease developed metastatic disease four months post-op. All patients preserved vision peri-operatively, with no complaints of diplopia. Moderate ocular surface disease was noted in two patients. Conclusion Our series highlights the potential advantage of three-dimensional optics, multi-directional instrumentation and motion scaling technology to achieve globe-sparing tumour resection in advanced periocular tumours. However, further robotic instrumentation development is required for orbital surgery.

OBJECTIVE:To describe the clinical, imaging characteristics, and treatment of pediatric orbital Langerhans cell histiocytosis (LCH). DESIGN:Retrospective case series. PARTICIPANTS:Children with orbital LCH. METHODS:Children with orbital LCH who presented to 4 different centres over the past 10 years. Demographic details, presenting features, imaging, histopathology, immunohistochemistry, and management outcomes were analyzed. RESULTS:Sixteen patients were reviewed. The mean age of presentation was 6.56 ± 4.38 years (range, 1-18 years). Eyelid swelling was the most common presenting feature (13, 81%), followed by proptosis (1, 5%), eyebrow swelling (1,5%), and temple swelling (1, 5%). Imaging revealed superior orbital lesions with osteolytic defects of the orbital roof in 13 (72.2%) patients. Frontal and zygomatic bones were the most commonly affected. All the orbital lesions were extraconal. All patients in the study were diagnosed with LCH from orbital tissue biopsy. Three patients also demonstrated extra-orbital involvement. Two patients (12.5%) had intraoperative steroid injection with curettage, and 1 patient (6.25%) underwent curettage only. The remainder of the patients (n = 13, 81.25%) received systemic steroids and chemotherapy after undergoing biopsy. All patients had complete remission of disease without any signs of recurrence, except for 1 case of refractory LCH. CONCLUSIONS:LCH is a rare disorder of the orbit and should be considered in the differential diagnosis for osteolytic lesions involving the superior orbit among the pediatric age group. Histopathologic confirmation is mandatory. Although optimal treatment remains controversial, complete removal of unifocal orbital LCH is recommended and may be achieved through excision and curettage.

Background Patients with benign eyelid lesions make up a large proportion of referrals to the oculoplastic service and lend themselves well to telemedicine with assessments heavily reliant on history, observation-based examination and photographs to enable management decision-making. Our tertiary unit set up tele-oculoplastics clinics for all new patients referred for benign eyelid lesions comprising tele-consultation with antecedent patient photograph: Benign Eyelid Lesion Pathway (BELP). One year on, we describe a retrospective analysis of 974 patients looking at distinct parameters of effectiveness. Methods We retrospectively collected data from electronic patient records (EPR) for BELP patients from July 2020 to August 2021 ( n = 974). We analysed time efficiency (referral time to treatment plan, consultation duration in minutes, average waiting times, number of patients seen per clinician and DNA rate), accessibility, safety (via video surveillance clinic) and theatre utilisation. Results 57.3% ( n = 558) were listed for a surgical procedure direct from tele-consultation with 94.9% ( n = 513) of these proceeding to surgery; 22.8% ( n = 222) were discharged, 10.7% ( n = 104) had further video follow-up and 6.7% ( n = 65) required face-to-face follow-up. Our results showed efficient referral-to-treatment times, waiting times, consultation times and non-attendance rate. There was only a 2.57% non-attendance rate. There was no missed diagnosis of a malignancy of a presumed benign lesion. Conclusion Tele-oculoplastics provides a streamlined, safe, effective, and logistically convenient way to review benign eyelid lesions. With the increased waiting times for referral to biopsy of eyelid lesions, this clinic shows it is imperative to provide digital accessibility for patient assessment and booking to operating theatre.

Background Blood-stained tears can indicate occult malignancy of the lacrimal drainage apparatus. This study reviews data on patients presenting with blood in their tears and the underlying cause for this rare symptom. Methods Patients presenting with blood in their tears, identified over a 20-year period, were retrospectively collected from a single tertiary ophthalmic hospital's database and analysed. Results 51 patients were identified, the majority female (58%) with a mean age of 55 years. Most cases were unilateral (96%) with blood originating from the nasolacrimal drainage system in 53%. The most common diagnosis for blood-stained tears was a lacrimal sac mucocele (n = 16) followed by a conjunctival vascular lesion (n = 4). Three patients had systemic haematological disorders. The rate of malignancy was 8% (n = 4), with 2 patients having lacrimal sac transitional cell carcinomas, one with a lacrimal sac plasmacytoma and the other with chronic lymphocytic leukaemia and bilateral orbital infiltration (with bilateral bloody tears). One patient had a lacrimal sac inverted papilloma, a premalignant lesion. Four patients had benign papillomas (of the lacrimal sac, conjunctiva and caruncle). Conclusion Haemolacria was a red flag for malignancy in 8% of patients (and tumours in 18% of patients). A thorough clinical examination including lid eversion identified a conjunctival, caruncle, eyelid or canalicular cause in 27% of cases.

Background: Graves' orbitopathy (GO) has a profound negative impact on quality of life. Surgery is undertaken to preserve vision, correct diplopia, and improve aesthetics. We sought to quantify the effect of different surgical approaches on quality of life.Methods: Electronic databases Ovid-MEDLINE and EMBASE were used from inception until March 22, 2021, to identify studies assessing quality of life pre- and postsurgical intervention for GO. Two reviewers independently extracted data and performed quality assessments. Random-effects and Bayesian models for meta-analyses were utilized.Results: Ten articles comprising 632 patients with a mean age of 48.4 years (range 16-85 years) were included. All used the Graves' Ophthalmopathy Quality of Life (GO-QOL) questionnaire. For GO-QOL appearance, the pooled standardized mean improvement for patients after surgery was +0.72 (95% confidence interval [CI 0.50-0.94]), I-2 = 69% [CI 52-80%]. For GO-QOL visual functioning, the pooled standardized mean difference (SMD) for patients after surgery was +0.41 [CI 0.25-0.58], I-2 = 60% [CI 36-74%]. For visual appearance, orbital decompression yielded the greatest improvement (SMD +0.84 [CI 0.54-1.13]) followed by eyelid surgery (SMD +0.38 [CI 0.05-0.70]), while strabismus correction had no significant effect (SMD +0.94 [CI -0.10 to 1.99]). Conversely strabismus correction was associated with the greatest improvement (SMD +1.25 [CI 0.29-2.21]) in visual functioning, outperforming orbital decompression (SMD +0.29 [CI 0.15-0.43]) and eyelid surgery (SMD +0.12 [CI -0.18 to 0.41]). A mean improvement in GO-QOL of greater than 10 points after orbital decompression surgery was achieved in 12/14 (86%) patient groups for appearance and 5/14 (36%) patient groups for visual functioning. A mean improvement of greater than 6 points was achieved in 5 of 6 (83%) patient groups for strabismus surgery for both appearance and visual functioning. A mean improvement of greater than 6 points after eyelid surgery was achieved in 2/3 (67%) patient groups and 0/3 patient groups for visual appearance and functioning, respectively.Conclusion: Ophthalmic surgery results in substantial improvements in quality of life in patients with GO, with greater perceived effects on appearance than visual function. Orbital decompression has particular impact on visual appearance; strabismus surgery may benefit both visual appearance and function equally, whereas eyelid surgery benefits appearance alone.

The authors report the clinicopathological features of crystal-storing histiocytosis (CSH) that involved the orbit and conjunctiva and review published cases of CSH. Cases of histologically proven CSH were identified from archives at the Institute of Ophthalmology, London, and a retrospective review of clinical details and pathology was performed for cases between 1997 and 2017. Four cases of CSH were identified: 1 might have arisen from an inflammatory reaction to a silicone retinal buckle and 3 others occurred with localized B-cell lymphomas. Two patients presented with a conjunctival mass, and 2 had an orbital mass causing proptosis and hypoglobus. One case was associated with amyloid deposition and another had an earlier diagnosis of IgG4-related disease. In the patient without underlying lymphoma, the condition settled with removal of the explant and orbital mass, and the 3 with lymphoma underwent orbital radiotherapy with cessation of disease progression. All patients retained good vision. Ocular CSH is rare, can present in several ways, and should prompt investigation for an underlying lymphoproliferative disorder.

Thyroid eye disease (TED) is a potentially sight-threatening and cosmetically disfiguring condition arising in 25-50% of patients with Graves' hyperthyroidism. CIRTED is the first study to evaluate the long-term role of radiotherapy and prolonged immunosuppression with azathioprine in treating TED, one aim of which was to validate the use of the English version of GO-QOL in an UK population with TED. In a three stage design over a 48 week period, the GO-QOL was tested and compared to a general measure of quality of life (WHOQOL-Bref). In stage 1 utilising a standard 14 day test-retest design both GO-QOL subscales achieved Cronbach's alphas demonstrating excellent validity and internal reliability (Visual Function 0.929 and 0.931; Appearance 0.888 and 0.906). In stage 2, Repeated Measures ANOVA demonstrated longitudinal validity, with both subscales of the GO-QOL showing significant change over time (Visual Function, eta(2) = 0.114, p < .001; Appearance, eta(2) = 0.069, p < .002). In stage 3 the GO-QOL showed discriminant validity at the week 48 time point, with the visual function subscale being able to detect changes in groups identified by clinicians (using BCCOM ratings of improvement or deterioration), while both subscales could detect group differences when based on participants' subjective ratings of TED noticeability and severity. The results of this project provide support for the English translation of the GO-QOL as an outcome measure for patients with moderately severe active Graves' orbitopathy/TED.

Background Multiple disease processes may arise within the orbit and imaging plays a vital role in the evaluation of such lesions. The anterior orbital contents are readily amenable to evaluation by ultrasonography. Furthermore, the modality can be used to guide tissue sampling (fine needle aspiration or core biopsy) and may obviate the requirement for invasive surgical biopsy. Methods We carried out a retrospective review of ultrasound-guided fine needle aspirations/core biopsies of extra-ocular orbital lesions undertaken at our institution. The anatomical locations, sonographic appearances and sampling techniques were analysed. Results There were 7 fine needle aspirations and 1 core biopsy carried out during the period analysed. Multimodality imaging was available in all cases. The majority of lesions were located in the region of the lacrimal gland. All procedures were well-tolerated and there were no post-procedure complications. Conclusion Many extra-ocular, orbital neoplasms are amenable to ultrasound-guided tissue sampling and the procedure is well tolerated. However, a clear understanding of orbital anatomy, differential diagnosis and technique is required to enable safe sampling. Furthermore, a collaborative, multimodality approach is imperative for optimal patient management.