Edward Wladis

Rosacea is a common chronic skin disease affecting mostly people aged 40 and above, with currently no cure. When it affects the eyelids and periocular skin, it leads to dry eye and potentially corneal damage. Research performed over the last decade shed light into the potential mechanisms leading to skin hypersensitivity and provided promising avenues for development of novel, rational therapeutics aimed at reducing the skin inflammatory state. In this review, we discuss the current knowledge on the mechanisms of rosacea in general and of periocular skin-affecting disease in particular, identify key questions that remain to be answered in future research, and offer a disease model that can explain the key characteristics of this disease, with particular emphasis on a potential positive feedback loop that could explain both the acute and chronic features of rosacea.

To identify the efficacy and adverse event rates of balloon dacryoplasty in cases of congenital nasolacrimal duct obstruction in children who fail to respond to an initial nasolacrimal duct probing. A literature search was last performed in September 2017 in the PubMed database to identify all reports of balloon dacryoplasty. All searches up to and including the last search were limited to the English language, and they yielded 104 articles that were assessed for relevancy. Thirty-six articles were selected for full review, and 8 of these were selected for inclusion in this assessment and assigned a quality of evidence rating by the panel methodologist. Three of the 8 studies included in this assessment were rated level II, and 5 were rated level III. Success rates varied from 75% to 100%. Only 2 complications were identified, and these were cases of self-limited postoperative emesis. The 2 studies that compared balloon dacryoplasty with lacrimal stenting reported that outcomes were...

To review the medical literature on the outcomes and complications of various Food and Drug Administration-approved botulinum toxins for benign essential blepharospasm (BEB) and hemifacial spasm (HFS). Literature searches were last conducted in February 2017 in PubMed for articles published in English and in the Cochrane Library database without language limitations; studies published before 2000 were excluded. The combined searches yielded 127 citations. Of these, 13 articles were deemed appropriate for inclusion in this assessment, and the panel methodologist assigned ratings to them according to the level of evidence. A combined total of 1523 patients (1143 with BEB and 380 with HFS) were included in the 13 studies. Five studies provided level I evidence, 2 studies provided level II evidence, and 6 studies provided level III evidence. Pretarsal injections were more efficacious than preseptal injections (96% vs. 86%, respectively). Pretarsal injections also resulted in a higher re...

To report a case in of intravitreal silicone oil migration into the inferior orbit. Silicone oil tamponade is commonly used in retinal detachment repair and extrusion into the orbital tissues is very rare. A 70-year-old male with a remote history of repair of a right ruptured globe and retinal detachment surgery presented with progressive right lower eyelid edema. There was a known history of intravitreal silicone oil instillation and removal. An elective right inferior orbitotomy with excisional biopsy was performed. Histopathology confirmed the presence of silicone oil intermixed with necrotic fat. The patient had excellent cosmetic and functional outcome. The presence of silicone oil within the orbital fat may be a result of increased intraocular pressure and extrusion through presumably water-tight sclerotomy sites.

The programmed death-1 pathway negatively regulates the immune system. Previous reports have indicated worse tumor-related outcomes with increased expression of the ligand for this pathway. This study was undertaken to assess the role of the PD pathway in cutaneous malignancies that invade the orbit. Immunohistochemical staining for the programmed death-1 receptor and ligand was performed on exenteration specimens of invasive cutaneous orbital malignancies (n = 12) and nodular basal cell carcinoma (n = 10). The numbers of positively-staining cells/40× field were counted across 5 consecutive fields, and statistical analyses were performed to compare the differences between the 2 groups. Programmed death-1 receptor positivity was seen in means of 30.9 cells/40× field and 62.4 cells/40× field for nodular basal cell carcinomas and invasive malignancies, respectively (p = 0.0046). A mean of 4.54 cells/40× field stained positively for the programmed death-1 ligand in nodular basal cell carcinoma, whereas a mean of 46.4 cells/40× field stained positively for programmed cell death ligand-1 in orbital invasive cutaneous carcinomas (p = 0.0015). Both of these differences were statistically significant. Both the programmed death-1 receptor and its ligand are enriched in invasive cutaneous malignancies. This finding indicates that negative regulation of the immune system likely prohibits tumor surveillance, and facilitates increasing aggressiveness and invasion of cutaneous malignancies.

Fractures of the orbital floor are common yet repaired by various techniques, including open periorbital, transantral endoscopic, and endoscopic endonasal approaches. To date, endoscopic endonasal repair of an orbital floor fracture using an alloplastic implant has not been described. We aim to determine the technique and limitations of completely endoscopic endonasal orbital floor repair using an alloplastic implant. Cadaveric anatomic study and retrospective case series. Cadaveric study of 12 sides with endoscopic sinonasal dissection followed by the creation and repair of an isolated orbital floor fracture using an alloplastic implant. Four representative patient cases are presented in which the techniques developed in the cadaveric study were employed. Patients were selected for this technique based on the results of the cadaveric study. Cadaveric study demonstrated feasibility of access and repair for fractures that did not extend lateral to the infraorbital canal or anterior t...

Rosacea-related cutaneous inflammation is a common cause of ocular surface disease. Currently, there are no specific pharmacologic therapies to treat ocular rosacea. Here, we aimed at determining the differences in intracellular signaling activity in eyelid skin from patients with and without ocular rosacea. This was an observational, comparative case series including 21 patients undergoing lower lid ectropion surgery at one practice during 2013 and 2014 (18 patients with rosacea, 13 control patients), and 24 paraffin-embedded archival samples from Albany Medical Center, selected randomly (12 patients with rosacea, 12 control patients). Cutaneous biopsies resulting from elective lower lid ectropion surgery were analyzed by Proteome Profiler Human Phospho-Kinase Array, Western blot, and/or immunohistochemistry. Samples derived from ocular rosacea patients showed increased levels of phosphorylated (active) p38 and Erk kinases. Phosphoproteins were mainly localized to the epidermis of ...

Dacryocystitis-related orbital cellulitis is a relatively rare condition, and large case series of this clinical entity have been reported. This study was undertaken to identify a larger cohort of patients with this ailment, with the intent of defining its clinical and microbiologic features. Case logs from four institutions were reviewed to identify patients that suffered from dacryocystitis-related orbital cellulitis. A retrospective chart review was then performed to identify clinical features, management strategies, microbiologic features, and outcomes. A dedicated statistical software package was utilized to identify correlations between these variables. 13 patients (7 females, 6 males; mean age = 57.2 years, range = 7-89 years) were identified. One patient carried a diagnosis of immunosuppressive disease. All patients underwent emergent surgical drainage and received intravenous antibiotics. Primary acquired nasolacrimal duct obstruction was found to be the underlying etiology...

To review the existing medical literature on the role of oral antibiotics in the management of ocular surface disease (OSD) that arises from disorders of the meibomian glands and to assess the efficacy of oral antibiotics in the management of this common ocular disease. A literature search was last conducted on August 12, 2015, in the PubMed and Cochrane databases for English-language original research investigations that evaluated the role of doxycycline, minocycline, and azithromycin in OSD among adult patients. The searches identified 87 articles, and 8 studies ultimately met the criteria outlined for this assessment. The 8 studies identified in the search documented an improvement in meibomian gland-related OSD after treatment with these agents, although side effects were common. This search identified only 1 randomized, controlled trial to assess the efficacy of these medications. Although oral antibiotics are used commonly in the management of OSD, there is no level I evidence...

Ocular rosacea is an incurable disease that affects millions of Americans annually. While multiple therapeutic strategies have been devised to address this disorder (including topical and oral medications, laser and light-based treatments, and surgical interventions), our current interventions are largely nonspecific and often ineffective. Nonetheless, ocular rosacea remains a source of intense research, and newer treatments offer tremendous promise for improved outcomes. In this review, we discuss the current and emerging treatment modalities for ocular rosacea and analyze novel basic science findings that will hopefully lead to highly targeted medications to treat this potentially blinding illness with greater specificity and fewer side effects.

To describe severe lymphedema of the eyelids, known as Morbihan disease, a previously characterized but infrequently reported and poorly understood entity related to rosacea that features solid mid-facial and eyelid lymphedema. Retrospective chart review, histopathologic and immunohistochemical analysis, and pertinent literature consideration. Five cases of Morbihan disease were identified. Histopathologic examination revealed pleomorphic perivascular and perilymphatic inflammation with profound lymphangiectasis and lymph stasis, thus suggesting elements of both rosacea and localized, chronic lymphedema. Multiple therapeutic interventions were performed including systemic anti-inflammatory therapy, surgical debulking, and corticosteroid injection. Extreme eyelid edema associated with characteristic skin changes and histopathologic findings represents an entity known as Morbihan disease which is rare and difficult to treat. While multiple modalities have been employed with variable r...

Pediatric idiopathic orbital inflammation (IOI) is a rare entity with little known about the clinical presentation and natural history. The authors report the demographics, clinical presentations, radiographic and histopathologic characteristics, and treatment outcome of 30 children with IOI. Retrospective chart review of 30 patients 18 years and younger diagnosed with IOI and statistical analysis using analysis of variance and Fisher's exact test. This study was reviewed and approved by the Institutional Review Board of SUNY Downstate Medical Center. There were 9 males (30%) and 21 females (70%) with pediatric IOI who presented at a median age of 11 years (range 2-18 years). Primary IOI was found in 19 patients (63%) and recurrent IOI in 11 patients (37%). Overall, 26 patients (87%) had unilateral IOI while 4 patients (13%) had bilateral disease at presentation. There were 12 patients (40%) with systemic constitutional signs. The most common ophthalmic findings included periorbital edema (n = 20, 67%) and blepharoptosis (n = 17, 57%). All patients had orbital radiography with common findings of dacryoadenitis (n = 12, 40%), orbital mass (n = 12, 40%), or myositis (n=10, 33%). The presence of a radiographic orbital mass was significantly related to the clinical presence of blepharoptosis (p = 0.03). The most common treatment was oral glucocorticoids in 24 patients (80%). Over mean follow up of 19 months (range 6-64 months), females were more likely to display recurrent disease (p = 0.01). Idiopathic orbital inflammation is an uncommon but important cause of acute orbital syndrome in children, manifesting as a bilateral condition in 13% and with constitutional symptoms in 40%. Posttreatment recurrence is found in 37% of cases.

To assess the role of intravenous acetaminophen (IVA) in orbital surgery. Fifty control patients underwent orbital surgery without IVA. Fifty patients received 1 g of IVA within 30 minutes of surgery, and 50 patients received 1 g of IVA immediately preoperatively. Postoperative requirements for analgesic and anti-emetic medications and standardized pain scores were recorded. 44 patients (88%) in the control group and 57 patients (57%) that received IVA preoperatively required analgesic medications (p = 0.0023). 31 patients (62%) that received the medication within 30 minutes of surgery and 26 patients (52%) that received IVA immediately preoperatively required analgesic medications (p = 0.77). The control group had a greater requirement for analgesic medications than patients that received IVA within 30 minutes of orbital surgery (p = 0.0076) and those that received IVA immediately preoperatively (p = 0.032). Twelve patients in the control group (24%) and 4 patients (4%) in the grou...

To describe a modified wound closure technique in cases of necrotizing fasciitis and to describe its efficacy and usefulness. The clinical characteristics of patients that underwent extensive debridement and modified wound closure were recorded and documented. Seven patients (5 males, 2 females; mean age = 40.9 years, standard deviation = 25.3 years) underwent debridement and modified wound closure. At discharge from the hospital, 6 patients (84.7%) achieved vision of 20/25 of better, although 1 patient lost all vision in the affected eye. Six patients (84.7%) experienced improvement in their visual acuity between admission to and discharge from the hospital. After a mean follow-up interval of 6.3 months, 5 patients (71.4%) did not require additional reconstructive interventions. In cases of periorbital necrotizing fasciitis, extensive debridement with a modified wound closure is a technically feasible intervention and produced excellent clinical, functional, and aesthetic results.

To describe the clinical features associated with periorbital necrotizing fasciitis and to correlate these features with clinical outcomes. The case logs of 3 surgeons were used to identify cases of necrotizing fasciitis. Chart reviews were performed to characterize clinical metrics, and statistical analyses were performed. Seventeen patients (9 males, 8 females; mean age = 48.1 years, standard deviation = 22.6 years) were identified with periorbital necrotizing fasciitis. Of these patients, 52.9% did not have immunodeficiencies, and 52.9% did not have antecedent trauma or infected facial lesions. One patient died from necrotizing fasciitis. A history of immunosuppression correlated with the requirement for exenteration, but did not correlate visual acuity of worse than 20/40 upon discharge from the hospital. Most of the patients (68.75%) were discharged with visual acuity of better than 20/40 in the affected eye. This study represents the largest case series of patients with perior...

To document the use of a transconjunctival approach to lower eyelid epiblepharon repair. Retrospective chart review of all patients who underwent transconjunctival lower eyelid epiblepharon repair. Nine patients underwent repair via this approach. All patients experienced the resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval, and no patient developed a postoperative complication. Furthermore, no patient developed cutaneous scarring. Conventional approaches to lower eyelid epiblepharon repair have necessitated the creation of a skin and muscle flap, thus risking the development of scarring and a cosmetically unacceptable eyelid crease. This report documents the use of a transconjunctival approach for the management of this condition that avoids external incisions and provides excellent outcomes without scarring of the anterior lamella of the eyelid.

Infectious orbital cellulitis represents a serious threat to vision and, if untreated, poses significant morbidity risk. In this study, the authors attempt to further characterize the features of orbital cellulitis with subperiosteal abscess (SPA) and determine outcomes based on the type of surgical intervention employed. Data were obtained by retrospective chart review of all inpatient admissions for orbital inflammation/cellulitis from Sept 2005 to April 2010. Charts were reviewed for demographic information, radiographic and clinic evidence of orbital cellulitis, presence of SPA (defined by radiographic criteria), interventions taken (surgical and nonsurgical), presence of concurrent sinusitis, types of microbes present, and duration of hospital admission. Statistical analysis was performed using chi-square tests. A total of 97 patients were admitted with a diagnosis of orbital inflammation/cellulitis, of whom 49 patients had clinical and/or radiographic evidence of orbital cellu...

To identify the cytokines that are expressed in elevated concentrations in idiopathic orbital inflammation (IOI). Experimental study. Biopsy specimens from 8 patients with biopsy-proven IOI and negative serologic and radiographic examinations, versus orbital biopsy samples taken from 8 control patients without clinical evidence or subjective complaint of orbital inflammation. Quantitative cytokine assays were performed to assess the levels of 9 different molecules for IOI and control patients. Statistical analyses were performed to compare the cytokine concentrations between the 2 groups. Cytokine concentrations. Six cytokines were statistically significantly elevated in IOI (interleukin-2, -8, -10, -12, gamma interferon, and tumor necrosis factor alpha) (p < 0.05). Gamma interferon and interleukin-12 were expressed at concentrations greater than 10 times higher in patients with IOI. IOI involves discrete elevations of specific cytokines, and individual molecules are clearly impl...

An 88-year-old man developed recurrent bouts of dacryocystitis and underwent dacryocystorhinostomy. Cultures from the lacrimal sac demonstrated Stenotrophomonas maltophilia. This uncommon bacterium is highly antibiotic resistant, and clinicians should consider it in atypical cases of infection and should guide antibiotic therapy appropriately.

To determine the presence, degree, and extent of lymphatic, elastic, and collagen fiber alterations in dermatochalasis (DC) specimens. Case control study of patients with DC compared with age-, gender-, and site-matched controls. A total of 25 eyelid specimens were studied; 15 of these were blepharoplasty specimens (experimental) and 10 were entropion/ectropion specimens of patients without DC (controls). The number and maximal dilation of lymphangiectasia was measured by light microscopy, immunohistochemistry with lymphatic marker D2-40, and elastic tissue content by Verhoeff-van Gieson histochemistry. The number of macrophages was compared between patients with DC and controls in CD68 immunostained specimens. Lymphatic density, edema, and inflammation. Dermatochalasis eyelid specimens showed increased lymphangiectasia density (5.6 vs. 2.4 lymphatics/high power field; P<0.05), maximal lymphatic dilation (127 vs. 51.5 μm; P<0.05), loss of elastic fibers (2.2 vs. 8.9 fibers/high power field; P<0.05), and greater disruption of collagen networks and edema compared with controls (increased stromal collagen bed of 752 vs. 269 μm; P<0.05; increased intercollagen space of 32.5 vs. 11.8 μm; P<0.05). Macrophages were present in greater quantities in DC specimens (28.6 vs. 11.9 macrophages/high power field; P<0.05). Patients with DC show an increase in number and maximal dilation of lymphatic vessels in conjunction with widely spaced collagen bundles. This finding coexists with loss of elastic fibers, components known to be essential to the structure and function of the lymphatic system. Governed by macrophages, the pathogenesis of DC may begin with subclinical inflammation leading to elastolysis and secondary lymphostasis. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. Case series. Ninety-seven patients with bilateral LG disease. Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis…

Pharmacologic inhibition of tumor necrosis factor-alpha (TNF-α) has been used in the management of a variety of inflammatory conditions. Recently, reports on the development of sarcoid-like granulomatous disease at multiple systemic sites after treatment with TNF-α inhibitors have emerged, although, to the authors' knowledge, orbital manifestations of this problem have not been previously described. A 48-year-old woman who received injections of adalimumab for the treatment of psoriatic arthritis developed right-sided orbital pain and inflammation. Orbital biopsy of a focal lesion demonstrated sarcoid-like granulomatosis, and a workup for other causes of this problem was noncontributory. This report represents the first documented case of this phenomenon in the orbit, and possible mechanisms are discussed in this presentation. Given the expanding role of TNF-α inhibitors and the increased frequency of their use, clinicians should be aware of this possible side effect.

Pemetrexed is an antimetabolite agent that inhibits multiple folate-requiring enzymes and is used in the treatment of mesothelioma and non-small-cell lung cancer. One of its toxicities is isolated cutaneous swelling affecting the eyelids and/or orbit. The pathologic assessment or its management has not been addressed to date. Herein, the authors report a case of a 77-year-old woman treated with pemetrexed for non-small-cell lung adenocarcinoma who developed persistent, severe bilateral lower eyelid swelling for several months, despite compresses and oral diphenhydramine. Elective excision was performed with good results and no recurrence after 6 months' follow up. Histopathologically, the excised tissue showed changes typical of dermatochalasis with dissolution of collagen and elastic bundles and marked dilation of lymphatic vessels. The combination of pre-existing, localized lymphatic failure and capillary leakage secondary to pemetrexed therapy can explain the onset and worsening swelling with successive rounds of chemotherapy.

Previous investigations have explored molecular differences between proliferative vitreoretinopathy and primary retinal detachment. An exploration of a greater number of molecules might provide novel insight into the biology of this disorder and identify potential therapeutic targets. Vitreous specimens were obtained from patients with epiretinal membranes or macular puckers (n = 15), patients with a primary retinal detachment without proliferative vitreoretinopathy (n = 15), and patients with retinal detachments and proliferative vitreoretinopathy (n = 15). A multiplex assay was performed to calculate the concentrations of 48 different cytokines and chemokines, and statistical analyses were performed to identify differences between the groups. Of the 48 molecules that were studied, we identified 10 that were statistically significantly different in cases of proliferative vitreoretinopathy, including interleukins 4, 5, 6, and 15; granulocyte-macrophage colony-stimulating factors; stem cell factor; stem cell growth factor; macrophage inflammatory protein 1α; and interferon γ-induced protein 10. Proliferative vitreoretinopathy represents a highly ordered molecular process that involves discrete changes in the concentrations of specific cytokines and chemokines. These molecules may represent novel therapeutic targets.

To report the nature of periorbital trauma after pit bull attacks. While these attacks have been well-characterized in the popular media, no case series has documented the ophthalmic manifestations of this trauma. We retrospectively reviewed all cases of pit bull terrier attacks that presented to the oculoplastic and orbital surgery service at Albany Medical Center between 2008 and 2011. The age, gender, extent of the injuries, care provided, follow up interval, and complication rate were evaluated for each patient. Seven patients were identified, with a mean age of 17.2 years. Six of the seven patients were in the pediatric age group. All patients suffered eyelid lacerations, and only one patient had additional injuries. Four patients (57.2%) suffered a canalicular laceration. Despite the lack of post-operative oral antibiotic use, no patient developed a wound infection. In the ophthalmic setting, pit bull terrier attacks most frequently involve children and result in eyelid lacerations. Canalicular injuries are common after these attacks.