Natalie Anne Homer, MD

All Publications

• 5-Fluorouracil With Microneedling Modulates Wound Healing in a Murine Model: An Immunohistochemical Analysis of Mechanism and Dose Efficacy. Ophthalmic plastic and reconstructive surgery Homer, N. A., Hanafy, M. S., Baer, S. C., Watson, A. H., Somogyi, M., Shore, J. W., Blaydon, S., Durairaj, V. D., Cui, Z., Nakra, T. 2022; 38 (6): 596-601

  Abstract

  The purpose of this study is to assess the dose-dependent immunohistopathological effects of intradermal microneedle-delivered 5-fluorouracil (5-FU) for postincisional wound healing in a murine model.A prospective experimental study was performed. Twelve hairless mice were randomized into 4 treatment groups for postincisional wound treatment: microneedling with topical saline, or microneeding with topically-applied 5-FU at concentrations of 25 mg/ml, 50 mg/ml, or 100 mg/ml. Two surgical wounds were created on each animal. Combination wound treatments were performed on postoperative days 14 and 28, and cutaneous biopsies were obtained on day 56. Specimens were analyzed by a dermatopathologist, blinded to the treatment group, for collagen thickness, lymphocytic infiltration, histiocytic response, sub-epidermal basement membrane zone thickness, and myofibroblast density.Histopathologic evaluation showed increased collagen thickness, lymphocyte infiltration, and granuloma density in the groups undergoing microneedling treatment with 5-FU, compared to saline. Immunohistochemical analysis revealed a trend toward thicker basement membranes with higher concentrations of 5-FU used, reaching statistical significance between controls and those treated with 100 mg/ml 5-FU ( p = 0.0493). A trend toward decreasing myofibroblast density with increasing doses of 5-FU was noted. No postincisional or treatment complications were observed.Our results demonstrate that microneedling is an effective topical subepithelial drug delivery system, and further suggest a beneficial dose-dependent immunomodulatory effect of 5-FU on intermediate wound healing when used in combination with microneedling. We recommend a 5-FU dose at the mid-range 50 mg/ml concentration to simultaneously maximize efficacy and minimize complication risk.

  View details for DOI 10.1097/IOP.0000000000002227

  View details for PubMedID 35604385

• Autologous Fat Transfer Harvest-site Complications: Incidence, Risk Factors, and Management OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY Homer, N. A., Patel, A. S., Epstein, A., Durairaj, V. D., Nakra, T. 2022; 38 (1): 65-67

  Abstract

  Autologous fat transfer is an effective tool for volume restoration to the aging face. Although numerous reports exist regarding injection site complications, there is limited data on donor-site morbidity in the cosmetic surgery literature.This study is a large-scale retrospective review to determine incidence of fat harvest-site complications, identify risk factors, and describe management strategies. Records of all patients who underwent autologous fat harvesting and facial grafting at a single oculofacial plastic surgery practice from 2010 to 2019 were reviewed. Patient demographics and clinical data were collected and assessed. A statistical analysis was performed using a two-tailed T-test with p values of <0.05 considered significant.Four-hundred sixteen patients were followed for an average of 6.2 months postoperatively. There was an overall 5.5% harvest-site complication rate. There was no correlation of harvest-site complications with gender (p = 0.249) or age (p = 0.881). Harvest location did not significantly correlate with complication rate. The most common complications were contour irregularities, prolonged induration, and prolonged erythema. Low body mass index was associated with higher complication rate (p = 0.003), even when excluding those patients with contour irregularities (p = 0.001). Various treatment modalities were used to manage donor-site morbidity with consistent improvement.Autologous fat transfer used for facial volume augmentation has low donor-site morbidity. Minor harvest-site complications occur more commonly in patients with low body mass index, irrespective of age, gender, or fat source.

  View details for DOI 10.1097/IOP.0000000000001989

  View details for Web of Science ID 000738050900024

  View details for PubMedID 33927171

• Safety of laser skin resurfacing in immunocompromised and diabetic patients EUROPEAN JOURNAL OF PLASTIC SURGERY Campagna, G. A., Homer, N. A., Artymowicz, A., Epstein, A., Durairaj, V. D., Nakra, T. 2022; 45 (1): 117-131

  View details for DOI 10.1007/s00238-021-01847-9

  View details for Web of Science ID 000674205600002

• Oculoplastic fellow education during the COVID-19 crisis ORBIT-THE INTERNATIONAL JOURNAL ON ORBITAL DISORDERS-OCULOPLASTIC AND LACRIMAL SURGERY Homer, N. A., Epstein, A., Somogyi, M., Shore, J. W. 2022; 41 (1): 79-83

  Abstract

  In March 2020, the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) advised the suspension of all non-emergent oculofacial patient care, imparting unprecedented interruptions in fellowship training.ASOPRS fellows and program directors were asked to complete an anonymous survey regarding their perceived impact of the COVID-19 crisis.Forty ASOPRS fellows (70.2%) participated, including 20 first-year and 20 second-year trainees, from all country regions. During the social distancing restrictions, 100% of fellows continued to participate in surgical procedures, including orbital biopsy (77.5%), abscess drainage (55.0%), fracture repair (45.6%), eyelid lesion excision (70.0%) and temporal artery biopsy (57.5%). ASOPRS fellows evaluated patients, including in emergency room (84.6%) and inpatient hospital (76.9%) settings, wearing surgical (85.0%) or N-95 (40.0%) masks, gloves (80.0%) and eye protection (62.5%).Most ASOPRS fellows (87.5%) participated in virtual interinstitutional education sessions and indicated a desire to continue this curriculum. Fellows also used available time for research (85.0%), independent study (77.5%), personal health (70.0%) and social interaction (60.0%).ASOPRS fellows reported COVID-19 restrictions to have a mild (72.5%) to moderate (27.5%) impact on their overall training, and most (75.0%) felt their surgical confidence to decline. Fellowship program directors also asserted a mild (72.2%), moderate (19.4%) or significant (5.6%) impact on subspecialty training, and 94.4% predict adverse effects on graduation case logs.During the COVID-19 restrictions most ASOPRS fellows participated in emergent clinical activities and novel telemedicine curriculum. Most fellows and program directors expressed concern regarding a negative impact on overall subspecialty education and surgical confidence.

  View details for DOI 10.1080/01676830.2020.1839919

  View details for Web of Science ID 000590741300001

  View details for PubMedID 33121312

• Wound Dehiscence Following Upper Blepharoplasty: A Review of 2,376 Cases. Ophthalmic plastic and reconstructive surgery Homer, N. A., Zhou, S., Watson, A. H., Durairaj, V. D., Nakra, T. 2020; 37 (3S): S66-S69

  Abstract

  There have been limited studies evaluating specifically the incidence of wound dehiscence following isolated upper blepharoplasty. This is a large-scale upper blepharoplasty review to evaluate the rate of wound dehiscence, to assess risk factors, and to analyze management outcomes.A retrospective review was performed of all patients who underwent upper blepharoplasty at a single surgery center. All incisions were closed using either 6-0 fast-absorbing plain gut or polypropylene suture in a running fashion, with an additional interrupted suture near the lateral wound edge. Incidence of wound dehiscence was determined and further assessed by patient age (≤67 or >67 years), gender, preexisting medical conditions, smoking history, and suture type.A total of 1,190 patients (2,376 eyelids) met inclusion criteria. In total, there were 34 instances (1.4%) of wound dehiscence in 32 patients at an average 9 days (range, 0-30 days) following surgery. Evaluation of wound dehiscence rates by demographic factors revealed male gender to be a significant predictor of wound dehiscence (p = 0.0062). Age, hypertension, heart disease, and diabetes were not predictors of wound dehiscence. Lifetime smoking history increased risk for wound dehiscence (p < 0.0001). Use of fast-absorbing plain gut suture was also significantly associated with dehiscence, when compared with polypropylene (p = 0.0025). Multivariate analysis revealed male gender and fast-absorbing plain gut suture to be independent risk factors for wound dehiscence. Seventeen eyelids with wound separation were observed for second-intention healing, 1 underwent delayed scar revision. Fourteen eyelids were repaired primarily using suture and 3 with cyanoacrylate surgical skin adhesive. All patients reported satisfaction with their final outcome, and objective final healing was deemed satisfactory.Wound dehiscence following isolated upper blepharoplasty is rare and associated with male gender and fast-absorbing plain gut suture. Patients with wound separation may be successfully managed with individualized care.

  View details for DOI 10.1097/IOP.0000000000001816

  View details for PubMedID 32852369

• Consideration of Nasal Contour in Endoscopic Forehead Rejuvenation FACIAL PLASTIC SURGERY & AESTHETIC MEDICINE Homer, N. A., Elwood, K., Watson, A. H., Somogyi, M., Nakra, T., Blaydon, S. 2021; 23 (2): 98-102

  Abstract

  Purpose: Preliminary studies have suggested an improvement in nasal aesthetics after endoscopic forehead lifting. We aimed to assess subjective and objective changes in nasal contour after minimally invasive forehead rejuvenation. Methods: We performed a retrospective review of patients who underwent endoscopic forehead lifting by four surgeons at a single surgery center from 2004 to 2018. All patients had subperiosteal blunt release of soft tissues overlying the radix. Changes in nasal contour were assessed on pre- and postoperative patient photos by four independent judges using the Global Aesthetic Improvement Scale. Objective changes in nasal length and length-to-base ratio were measured on patient photographs using ImageJ software. Measurements were further compared by demographic variables of age and gender. Results: In total, 326 patients met inclusion criteria. Summative judging results revealed 79.4% of patients with clinical improvement in nasal contour (11.1% very much improved, 25.6% much improved, and 42.6% improved), 20.1% with no change and 0.6% with worsening. There was a statistically significant increase in average nasal length (2.17 mm, p < 0.0001) and length-to-base ratio (0.03, p < 0.0001) postoperatively. Stratification of patients by age and gender did not reveal a significant difference in degree of nasal proportion change. Conclusions: There is a noteworthy subjective and quantitative improvement in nasal contour and length after endoscopic forehead lifting. This change restores ideal facial proportions and may serve as a useful counseling point when offering this surgery to patients.

  View details for DOI 10.1089/fpsam.2020.0142

  View details for Web of Science ID 000549575800001

  View details for PubMedID 32654507

• Uncovered Undulations. JAMA ophthalmology Homer, N., Nakra, T., Wong, R. W. 2019; 137 (10): 1207-1208

  View details for DOI 10.1001/jamaophthalmol.2019.3090

  View details for PubMedID 31465108

• Contemporary management of orbital blowout fractures. Current opinion in otolaryngology & head and neck surgery Homer, N., Huggins, A., Durairaj, V. D. 2019; 27 (4): 310-316

  Abstract

  Orbital floor blowout fractures may lead to significant morbidity, including debilitating double vision and globe malposition. Thorough evaluation and timely surgical intervention may prevent long-term sequelae.New studies have demonstrated certain patients with orbital floor fractures to do well when managed conservatively. In those necessitating operative repair, precise surgical dissection and adequate fracture reduction are essential to restoring orbital anatomy and function. Novel surgical techniques and orbital floor reconstruction materials, described in this review, will further optimize patient outcomes.A knowledgeable evaluation, thoughtful management strategy and modernized surgical technique can prevent long-term disability in patients with orbital floor blowout fractures.

  View details for DOI 10.1097/MOO.0000000000000550

  View details for PubMedID 31219830

• Management of Long-Standing Flaccid Facial Palsy: Periocular Considerations. Otolaryngologic clinics of North America Homer, N., Fay, A. 2018; 51 (6): 1107-1118

  Abstract

  Ineffective eyelid closure can pose a serious risk of injury to the ocular surface and eye. In cases of eyelid paresis, systematic examination of the eye and ocular adnexa will direct appropriate interventions. Specifically, 4 distinct periorbital regions should be independently assessed: eyebrow, upper eyelid, ocular surface, and lower eyelid. Corneal exposure can lead to dehydration, thinning, scarring, infection, perforation, and blindness. Long-term sequelae following facial nerve palsy may also include epiphora, gustatory lacrimation, and synkinesis.

  View details for DOI 10.1016/j.otc.2018.07.007

  View details for PubMedID 30170698

• Assessment of Infraorbital Hypesthesia Following Orbital Floor and Zygomaticomaxillary Complex Fractures Using a Novel Sensory Grading System. Ophthalmic plastic and reconstructive surgery Homer, N., Glass, L. R., Lee, N. G., Lefebvre, D. R., Sutula, F. C., Freitag, S. K., Yoon, M. K. 2018; 35 (1): 53-55

  Abstract

  Introduction of a novel sensory grading system to assess the incidence and long-term recovery of infraorbital hypesthesia following orbital floor and inferior orbital rim fractures.Patients who presented for evaluation of orbital floor and/or zygomaticomaxillary complex (ZMC) fractures between January 2015 and April 2016 were analyzed. Two-point subjective infraorbital sensory grading in 5 discrete anatomic areas was performed. Fractures were repaired based on traditional criteria; hypesthesia was not an indication for surgery. The sensory grading system was repeated a mean 21.7 months (range 18-28) after initial fracture.Sixty-two patients (mean 41.8 years) participated in the initial symptom grading, and 42 patients (67.7%) completed the 2-year follow-up. Overall, 20 of 42 patients (47.6%) had some infraorbital hypesthesia. There were fewer with isolated orbital floor fractures versus ZMC fractures (31.8% vs. 68.4%; p = 0.019). Two years postinjury, 9.1% and 40.0% with isolated floor and ZMC fractures, respectively, had persistent sensory disturbance (p = 0.0188). Of patients with sensory disturbance on presentation, 71.4% with isolated floor fractures and 38.5% with ZMC fractures experienced complete sensory recovery (p = 0.1596). Patients with isolated floor fractures had improved recovery after surgery (100% vs. 33.3% recovery; p = 0.0410). Patients with ZMC fractures showed no difference in sensory prognosis between those repaired and observed.In this pilot study, isolated orbital floor fractures carried a good infraorbital sensory prognosis, further improved by surgical repair. Zygomaticomaxillary complex fractures portended a worse long-term sensory outcome, unaffected by management strategy. This study validates the novel sensory grading system in post-fracture analysis.

  View details for DOI 10.1097/IOP.0000000000001162

  View details for PubMedID 29975327

• Evaluation of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) Fellowship Program Website Content and Quality. Ophthalmic plastic and reconstructive surgery Homer, N., Yoon, M. K. 2017; 33 (6): 471-473

  Abstract

  The qualities that applicants value in the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) fellowship programs have been studied, but the availability of this information on program websites has not yet been reviewed. The authors evaluated the availability of resident-valued ASOPRS fellowship program information on the Internet.The authors performed an Internet search of the 53 ASOPRS fellowship program websites and evaluated websites for 20 characteristics of interest to ASOPRS fellowship applicants such as teaching faculty, program description, rotation schedule, operative cases, and interview information.Of the 53 ASOPRS fellowship programs, 43 (81.1%) had a fellowship program-dedicated website. The fellowship websites contained a mean 7.6 characteristics (38.1%, range 0-15). Faculty listing, program description, and case diversity were the most commonly included data (74.4%, 72.1%, and 69.8%, respectively). Fellow selection process, interview information, and graduate job placement were least commonly included (7.0%, 2.3%, and 0.0%, respectively). There was no significant difference in website inclusiveness based on fellowship region or faculty number. Programs affiliated with an ophthalmology residency were more complete than those that were not (40.3% vs. 20.0%, p = 0.0098).This review found that most programs had websites and contained a reasonable number of characteristics. However, applicant-valued information regarding surgical volume, procedure variety, application information, and postgraduate employment history were often missing. American Society of Ophthalmic Plastic and Reconstructive Surgery fellowship programs may improve match outcomes by providing and enhancing program websites with details that their applicants seek.

  View details for DOI 10.1097/IOP.0000000000000830

  View details for PubMedID 27997464

• Periocular breast carcinoma metastases: correlation of clinical, radiologic and histopathologic features. Clinical & experimental ophthalmology Homer, N., Jakobiec, F. A., Stagner, A., Cunnane, M. E., Freitag, S. K., Fay, A., Yoon, M. K. 2017; 45 (6): 606-612

  Abstract

  To describe presenting patterns of breast cancer metastases to the orbit and eyelids.To provide clinical, radiographic and pathologic correlations of breast metastases to the orbit or eyelids and evaluate radiographic volumetric orbital changes.Retrospective review in an academic centre.Ten female patients with periocular metastatic breast carcinoma who were seen at the Massachusetts Eye and Ear Infirmary Oculoplastics Clinic.Retrospective review of patient records, imaging and pathology findings.Presenting clinical characteristics, radiographic findings and histopathological features were assessed and correlated to discover distinctive presenting patterns. Volumetric measurements of the tumours and orbital soft tissue structures were made on magnetic resonance imaging studies.The breast cancer metastases included eleven orbital lesions and one eyelid lesion. Two distinct clinical presentations were observed. The first consisted of seven patients who had either enophthalmos or euphthalmos, a radiographically indistinct intraconal lesion and a histologically classic invasive lobular breast carcinoma with a prominent fibrotic stroma. The second group consisted of two proptotic patients with discrete mass lesions on imaging and an atypical invasive lobular breast carcinoma pathological subtype (pleomorphic or alveolar). One patient had diffusely indurated eyelid fullness. Volumetric analyses demonstrated variable tumour sizes with an inconsistent impact on the orbital volume and fat.This correlative study provides the clinical-radiographic-histopathologic basis for separating two overarching phenotypic presentations of metastatic breast carcinoma to the orbit. Previously postulated mechanisms for the distinctive finding of tumour-induced enophthalmos are re-examined in the light of the foregoing conclusions.

  View details for DOI 10.1111/ceo.12926

  View details for PubMedID 28181367

• Post-Operative Endonasal Debridement May Improve Outcomes of Endoscopic Dacryocystorhinostomy. Ear, nose, & throat journal Homer, N. A., Watson, A. H., Nakra, T. 2023: 1455613231195144

  Abstract

  Background: Endoscopic dacryocystorhinostomy (endoDCR) has proven to be an effective minimally invasive surgical procedure for treatment of nasolacrimal duct obstruction. Post-surgical endonasal debridement has not yet been independently assessed for its impact on functional success. Methods: A retrospective review was performed of all patients who underwent endoDCR by an experienced oculofacial plastic surgeon over 7 years (2012-2019). Post-operative intranasal debridement was not routinely performed from March 2012 to February 2016. From March 2016 to June 2019, all patients underwent routine ipsilateral intranasal debridement at post-operative week 2. Surgical success was determined based upon subjective assessment of epiphora resolution at the patient's final post-operative visit. Results: A total of 69 patients (88 surgeries) were included. Thirty-five patients had standard post-operative follow-up without debridement, whereas 34 underwent endonasal debridement at post-operative week 2. Demographics and follow-up were similar between the 2 groups. Functional success was achieved in 84.1% of patients without debridement, and in 97.7% with debridement (P = .058). Conclusion: This review demonstrates a trend toward improvement in the rate of surgical success of endoDCR when routine endonasal debridement was instituted 2 weeks following surgery. We believe that removal of nasal crusts, clots, and residual absorbable gelatin sponge at the osteotomy site improves tear outflow and reduces cicatricial healing enhancing patency of the surgically derived lacrimal-nasal fistula. We advocate for postoperative debridement in the perioperative management of endoDCR patients to optimize successful outcomes.

  View details for DOI 10.1177/01455613231195144

  View details for PubMedID 37650255

• Fungal Endophthalmitis Masquerading as Sympathetic Ophthalmia. Retinal cases & brief reports Hang, A., Ruiz, J., Park, S. S., Homer, N. A., Kim, E., Moussa, K. 2023

  Abstract

  PURPOSE: To describe the ocular pathology of a patient with fungal endophthalmitis with features mimicking sympathetic ophthalmia.METHODS: Review of medical records and histopathology of a single patient.RESULTS: A 72-year-old male who sustained penetrating injury to the left eye with an agave plant presented to our clinic 16 months after the initial injury. Prior to presentation, the patient had developed endophthalmitis and had undergone anterior chamber washout, vitrectomy, and intravitreal steroids, antibiotics, antifungals, and anti-vascular endothelial growth factor (VEGF) therapy. At presentation, the patient had a blind, painful eye and subsequently underwent enucleation. Histopathology demonstrated granulomatous inflammation with multinucleated giant cells in the iris and Dalen Fuchs nodules with CD68 positive epithelioid histiocytes associated with the retinal pigment epithelium (RPE) sparing the choriocapillaris. These findings were initially attributed to sympathetic ophthalmia. The fellow eye did not have any signs of inflammation, and additional fungal PAS stains were positive for filamentous fungal elements, leading to a diagnosis of fungal endophthalmitis.CONCLUSIONS: Fungal endophthalmitis may develop histopathologic features that are similar to those seen in sympathetic ophthalmia. Recognition of the overlap between the histopathologic features of these diseases may reduce the possibility of misdiagnosis and unnecessary treatment of the fellow eye.

  View details for DOI 10.1097/ICB.0000000000001454

  View details for PubMedID 37463471

• Primary Cranio-Orbital Presentation of Multiple Myeloma. Ophthalmic plastic and reconstructive surgery Homer, N. A., Epstein, A., Kemper, C., Somogyi, M. 2023

  View details for DOI 10.1097/IOP.0000000000002439

  View details for PubMedID 37351854

• Rare Intraosseous Cavernous Hemangioma of the Orbit. Ophthalmology Soetikno, B. T., Charoenkijkajorn, C., Homer, N. A. 2023

  View details for DOI 10.1016/j.ophtha.2023.05.019

  View details for PubMedID 37278677

• Adnexal squamous cell carcinoma: incidence of eyelid margin involvement. Orbit (Amsterdam, Netherlands) Watson, A. H., Akbani, S., Homer, N., Somogyi, M., Durairaj, V. 2023; 42 (3): 269-272

  Abstract

  We aimed to perform a review of facial and periorbital squamous cell carcinoma (SCC) cases to assess the relative incidence of eyelid margin involvement.This is a retrospective review of all patients with biopsy-proven SCC who were evaluated at a single oculoplastic surgery practice from 2007 to 2019. The charts were reviewed for the anatomical location of the malignancy, and those involving the eyelid were further divided into marginal and non-marginal lesions. Statistical analysis was performed using a one proportion z-test.A total of 76 patients with a diagnosis of biopsy-proven periorbital and facial SCC were identified, 67 involved the ocular adnexa. Thirty-nine (58.2%) patients had lesions located on the eyelid. Of these, 33 (84.6% p < 0.0001, 95% CI 69.45-94.13) had lesions located at the margin, six of the 39 lesions were non-marginal. The remaining lesions were present within the brow (n = 10, 14.9%), medial canthus (n = 10, 14.9%), palpebral conjunctiva (n = 1, 1.5%), or orbit (n = 1, 1.5%). In six patients (8.9%) lesions involved multiple anatomic subunits.We present our investigation of the incidence of SCC of the marginal vs. non-marginal eyelid, revealing a statistically significant increased involvement of the eyelid margin. Future investigations are necessary to further elucidate the vulnerability of the eyelid margin to the development of SCC in particular in regards to the role of the unique genetic expression profile of eyelash follicular stem cells.

  View details for DOI 10.1080/01676830.2022.2092156

  View details for PubMedID 35766103

• Giant Lacrimal Gland Cyst in a Pediatric Patient: Case Report and Review of the Literature. Ophthalmic plastic and reconstructive surgery Luthra, S., Kim, E., Homer, N. A. 2023

  Abstract

  Lacrimal gland cysts are rare clinical entities in the pediatric population. Herein is described a 6-year-old male patient presenting with progressive left upper lid ptosis, found to have a large ipsilateral superotemporal orbital mass. Diagnosis of a giant lacrimal gland cyst was confirmed excisional biopsy. Despite the resolution of mechanical blepharoptosis, the patient maintained visual acuity limitation due to suspected deprivation amblyopia. The pathophysiology and clinical manifestations of lacrimal gland cysts in the pediatric population are reviewed to emphasize the importance of expedited identification and management in this patient cohort.

  View details for DOI 10.1097/IOP.0000000000002327

  View details for PubMedID 36735325

• Potent Periorbital Fractionated CO 2 Laser Resurfacing. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] Watson, A. H., Van Brummen, A., Somogyi, M. B., Homer, N., Nakra, T. 2022; 48 (10): 1089-1091

  Abstract

  The aged face results from a culmination of skin changes, gravitational descent, and volume loss. Surgical interventions in the periorbital region are beneficial for addressing these 3 factors. Despite this, studies describing CO2 laser safety settings are lacking.There is no present consensus on ideal periorbital CO2 laser; therefore, this study evaluates the safety of periorbital laser resurfacing as an adjunct to lower blepharoplasty using robust settings.A retrospective review was performed of all patients who underwent bilateral lower blepharoplasty with adjunctive periorbital (upper and lower eyelid) fractionated CO2 laser resurfacing from 2013 to 2018 performed by a single oculoplastic surgeon.Fifty-nine patients were included. Six patients experienced side effects including postinflammatory hyperpigmentation, (3/59, 5.1%), prolonged superficial excoriations (1/59, 1.7%), prolonged hyperemia (1/59, 1.7%), and lower eyelid retraction requiring lower eyelid recession (1/59, 1.7%). None of the patients developed postoperative infection. All patient expressed satisfaction at their final postoperative visit.CO2 laser resurfacing, even with robust settings, is a safe and effective adjunct to lower blepharoplasty.

  View details for DOI 10.1097/DSS.0000000000003533

  View details for PubMedID 35947796

• Traumatic intrachoroidal nail implantation. Proceedings (Baylor University. Medical Center) Epstein, A., Homer, N., Reed, D., Young, R., Durairaj, V. D. 2022; 35 (1): 106-107

  Abstract

  Penetrating globe injury can lead to serious vision loss and even loss of the eye. Intraocular foreign bodies (IOFBs) are a major cause of traumatic globe injury commonly seen in work-related accidents. We present a unique case of a large IOFB that was fully embedded within the choroid, where enucleation was pursued due to inability to safely remove the IOFB.

  View details for DOI 10.1080/08998280.2021.1974261

  View details for PubMedID 34970054

  View details for PubMedCentralID PMC8682831

• Middle-aged Woman With Atypical Upper Eyelid Retraction JAMA OPHTHALMOLOGY Homer, N. A., Darrow, M. 2022; 140 (9): 902-903

  View details for DOI 10.1001/jamaophthalmol.2022.1532

  View details for Web of Science ID 000812370800003

  View details for PubMedID 35708672

• Metastatic melanoma regression on targeted therapy ORBIT-THE INTERNATIONAL JOURNAL ON ORBITAL DISORDERS-OCULOPLASTIC AND LACRIMAL SURGERY Copparam, S., Kim, E., Homer, N. A. 2022: 1

  View details for DOI 10.1080/01676830.2022.2074050

  View details for Web of Science ID 000802932400001

  View details for PubMedID 35635141

• Cutaneous angiosarcoma presenting as bilateral periorbital edema. Orbit (Amsterdam, Netherlands) West, B. A., Hoesly, P. M., LeBoit, P. E., Homer, N. A. 2022: 1-3

  Abstract

  A 66-year-old man presented with chronic bilateral periorbital edema with associated yellowish hue, scattered violaceous smooth macules and contracture of the forehead. He had undergone dental surgery 3 months prior to symptom onset. Laboratory workup for common causes of eyelid edema was unremarkable and MRI of the orbits was unrevealing. The patient did not respond to oral corticosteroids or antibiotics. Punch biopsies were obtained which revealed atypical lymphatic endothelial cells consistent with a diagnosis of cutaneous angiosarcoma.The patient was deemed not to be a surgical candidate and underwent 3 cycles of immunotherapy with limited response. He declined further treatment and transitioned to hospice care. Although cutaneous angiosarcoma uncommonly involves the periorbital region, it should be considered in the differential diagnosis of eyelid edema as early recognition and treatment are critical to prevent rapid intradermal spread and metastases.

  View details for DOI 10.1080/01676830.2022.2056901

  View details for PubMedID 35467482

• Unilateral Favre-Racouchot of the Eyelid ORBIT-THE INTERNATIONAL JOURNAL ON ORBITAL DISORDERS-OCULOPLASTIC AND LACRIMAL SURGERY Watson, A. H., Homer, N., El-Hadad, C., Durairaj, V. 2022: 1

  View details for DOI 10.1080/01676830.2022.2025857

  View details for Web of Science ID 000803510600001

  View details for PubMedID 35612527

• Devastating injury from blunt airbag trauma. Journal of the American College of Emergency Physicians open Malhotra, K., Rose, J., Homer, N. 2022; 3 (1): e12676

  View details for DOI 10.1002/emp2.12676

  View details for PubMedID 35224549

  View details for PubMedCentralID PMC8847708

• Acute retrobulbar hemorrhage after tooth extraction: Case report and treatment of a rare condition SPECIAL CARE IN DENTISTRY Gupta, N., Epstein, A., Reed, D., Homer, N., Blaydon, S., Alford, J., Nakra, T. 2022; 42 (3): 304-307

  Abstract

  Retrobulbar hemorrhage (RBH) refers to hemorrhage within the bony orbital cavity and most commonly results from periorbital surgery or trauma. RBH following tooth extraction is a rare occurrence. Patients with RBH will endorse symptoms of periorbital pain, double vision, or vision loss, and present with evidence of proptosis, chemosis, or subconjunctival hemorrhage. Irreversible vision loss may occur if orbital compartment syndrome (OCS) results in the setting of RBH and is not expediently treated. Herein we present a case of a 72-year-old female who developed a RBH and OCS immediately after routine molar tooth extraction. Emergent treatment by the oral surgeon with a lateral canthotomy and inferior cantholysis led to full visual recovery. Dentists and oral surgeons should be aware of this potential rare vision-threatening complication of atraumatic tooth extraction and educated on the technique of decompressive lateral canthotomy and cantholysis.

  View details for DOI 10.1111/scd.12673

  View details for Web of Science ID 000714421000001

  View details for PubMedID 34735030

• Acute Chagas Disease Manifesting as Orbital Cellulitis, Texas, USA. Emerging infectious diseases Hudson, F. P., Homer, N., Epstein, A., Mondy, K. 2021; 27 (11): 2937-2939

  Abstract

  We report a case of acute, vectorborne Chagas disease, acquired locally in central Texas, USA, manifesting as Romaña's sign, which was initially mistaken for orbital cellulitis. After the infection failed to respond to antibiotics, DNA-based next generation sequencing on plasma yielded high levels of Trypanasoma cruzi; results were confirmed by PCR.

  View details for DOI 10.3201/eid2711.203698

  View details for PubMedID 34670654

  View details for PubMedCentralID PMC8544979

• Black bone disease of the skull incidentally discovered during endoscopic brow lifting EUROPEAN JOURNAL OF PLASTIC SURGERY Vaswani, Z. G., Homer, N. A., Epstein, A., Nakra, T. 2022; 45 (1): 183-186

  View details for DOI 10.1007/s00238-021-01824-2

  View details for Web of Science ID 000652982500001

• Ecthyma gangrenosum of the eyelid in an immunocompromised patient. Orbit (Amsterdam, Netherlands) Homer, N. A., Epstein, A., Hoesly, P. M. 2021; 40 (2): 172

  View details for DOI 10.1080/01676830.2020.1760315

  View details for PubMedID 32354244

• Simultaneous presentation of orbital mantle cell lymphoma and endocrine mucin-producing sweat gland carcinoma ORBIT-THE INTERNATIONAL JOURNAL ON ORBITAL DISORDERS-OCULOPLASTIC AND LACRIMAL SURGERY Shah, D. S., Homer, N. A., Epstein, A., Durairaj, V. D. 2022; 41 (4): 509-513

  Abstract

  Mantle cell lymphoma is a rare malignancy to present in the orbit, comprising only 1-5% adnexal lymphomas. Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is an equally uncommon adnexal tumor of sweat gland origin that may present on the eyelid. Herein we present a case of a 77-year old man with no previous cancer history who presented with painless progressive left globe proptosis and an enlarging left upper lid margin lesion, ultimately determined upon biopsy to be simultaneous orbital mantle cell lymphoma with systemic involvement and isolated eyelid EMPSGC. The pathogenesis, clinical manifestation, and management for each rare disease entity are reviewed and concept of collision tumors is discussed.

  View details for DOI 10.1080/01676830.2021.1894583

  View details for Web of Science ID 000625516900001

  View details for PubMedID 33657963

• Atypical presentation of an endocrine mucin-producing sweat gland carcinoma of the eyelid. Orbit (Amsterdam, Netherlands) Homer, N. A., Hoesly, P. M., Durairaj, V. D. 2021; 40 (1): 81-82

  View details for DOI 10.1080/01676830.2020.1735454

  View details for PubMedID 32116079

• Acute post-partum vision loss due to pilocytic astrocytoma. American journal of ophthalmology case reports Homer, N. A., Epstein, A., Durairaj, V. D., Wang, M., Jonna, G., Somogyi, M. 2020; 20: 100897

  Abstract

  We report an unusual case of a thirty-three-year-old woman who presented with acute unilateral vision loss following pregnancy and was ultimately discovered to have a pilocytic astrocytoma of the optic nerve.A thirty-three-year-old previously healthy female presented one month following Caesarean section with unilateral vision loss. She was found to have significantly decreased visual acuity, an afferent pupil deficit, proptosis, optic nerve edema and choroidal folds. Imaging revealed a large lesion of the optic nerve. Biopsy was performed and pathologic analysis revealed a pilocytic astrocytoma, WHO grade 1. The patient opted for close observation without further management and demonstrated mild improvement in visual function.Optic pathway gliomas (OPG) most commonly present in the pediatric patient population with painless proptosis, slowly progressive vision loss, and clinical findings of chronic optic neuropathy.( Farazdaghi et al., 2019 Sep) 1 Acute presentations of this disease in adulthood are rare. This case demonstrates a rare case of acute optic nerve glioma presentation during the post-partum period.

  View details for DOI 10.1016/j.ajoc.2020.100897

  View details for PubMedID 32875164

  View details for PubMedCentralID PMC7452090

• Atypical acute presentation of an optic nerve sheath meningioma. American journal of ophthalmology case reports Holan, C., Homer, N. A., Epstein, A., Durairaj, V. D. 2020; 20: 100951

  Abstract

  Primary optic nerve sheath meningiomas (ONSM) are benign lesions that typically present with findings of painless proptosis (59%), optic nerve pallor (55%), and decreased peripheral vision (35%). Herein we share an atypical case of a patient who presented acutely with periorbital pain and optic nerve head edema, and was ultimately determined to have a low-grade optic nerve meningioma.A 36-year-old healthy woman presented with acute onset of left periorbital discomfort. She was found to have intact visual acuity, full peripheral vision, and ipsilateral optic nerve edema. MRI imaging revealed a large intraconal mass partially encircling the left optic nerve. Incisional biopsy revealed a diagnosis of meningioma, WHO grade 1.Low-grade optic nerve sheath meningiomas may uncommonly present with acute pain and optic nerve head swelling, and absence of classic disease features.

  View details for DOI 10.1016/j.ajoc.2020.100951

  View details for PubMedID 33073056

  View details for PubMedCentralID PMC7549060

• Benign Meningioma With Rare Osteolytic Behavior. Ophthalmic plastic and reconstructive surgery Homer, N. A., Huggins, A. B., Durairaj, V. D. 2020; 36 (3): e81

  View details for DOI 10.1097/IOP.0000000000001439

  View details for PubMedID 31574040

• Varicella-Zoster Virus of the Eyelid. JAMA ophthalmology Watson, A. H., Homer, N. A., Somogyi, M. B. 2020; 138 (7): 795-796

  View details for DOI 10.1001/jamaophthalmol.2020.0575

  View details for PubMedID 32437495

• Bilobed Dermoid Cyst in Unique Location. Ophthalmic plastic and reconstructive surgery Artymowicz, A., Homer, N., Bratton, E. 2020; 37 (2): e82

  View details for DOI 10.1097/IOP.0000000000001668

  View details for PubMedID 32282645

• Pedicled Buccal Fat Flap: An Underutilized Source of Vascularized Periorbital Volume. Facial plastic surgery & aesthetic medicine Watson, A. H., Homer, N., Somogyi, M., Shore, J., Nakra, T. 2020; 22 (1): 61-63

  Abstract

  Pedicled buccal fat flaps have demonstrated great utility for oral reconstructions. We present a retrospective case description detailing the utility of the buccal fat pad (BFP) as an anterior maxillary flap for midfacial and lower eyelid volumization and reconstruction. A 64-year-old healthy female had undergone bilateral lower blepharoplasty with silicone tear tough implantation, complicated by infection of the right tear trough implant. Delayed implant removal resulted in chronic infection and inflammation producing significant right lower eyelid retraction, and full-thickness scarring to the orbital rim. Reconstruction was performed, featuring the creation of a midfacial subperiosteal pocket and to access the BFP, which was mobilized and secured to the inferior orbital rim. Long-term follow-up confirms ongoing viability of the surgical intervention. Herein, the BFP is shown to be a source of vascularized volume in reconstructive periorbital surgery.

  View details for DOI 10.1089/fpsam.2019.29003.nak

  View details for PubMedID 32053422

• Clinicopathologic and Magnetic Resonance Imaging Analysis of a Multifocal Orbital Lymphoid Tumor. Ocular oncology and pathology Jakobiec, F. A., Homer, N., Zakka, F. R., Curtin, H. D., Fay, A. 2018; 4 (2): 82-89

  Abstract

  To distinguish between a multifocal orbital lymphoid tumor and a major simulator represented by a diffuse lymphaticovenous malformation.We performed a comparison of clinical and radiographic (magnetic resonance imaging [MRI]) findings of these two disparate entities and demonstrated how a misdiagnosis can be prevented.Orbital lymphoid tumors develop in adults at around 60 years of age, whereas extensive lymphaticovenous malformations are generally detected in the first decade. Despite these differences, this is the first description of clinical confusion between them. MRI with gadolinium injection in the current lymphoid tumor displayed a low signal on T2-weighted images, rapid and uniform enhancement, and reduced diffusion. Lymphaticovenous malformations are heterogeneous, display poor or only focal perfusion, and fail to exhibit diminished diffusion. Newer techniques such as diffusion-weighted imaging and dynamic contrast-enhanced imaging may be able to provide additional differential diagnostic information. The final pathologic diagnosis was an extranodal marginal zone lymphoma.Despite the obvious distinctions between orbital lymphoid tumors and lymphaticovenous malformations, several clinical radiologic specialists misdiagnosed the present orbital lesion as a vascular lesion. A combined clinicoradiographic analysis should obviate such errors and facilitate the correct diagnosis in the future.

  View details for DOI 10.1159/000478731

  View details for PubMedID 30320086

  View details for PubMedCentralID PMC6167658

• Bilateral Periorbital Impetigo Inducing Significant Dermatitis and Cicatricial Eyelid Changes in an Adult. Ophthalmology Homer, N., Habib, L., Lee, N. G. 2018; 125 (6): 798

  View details for DOI 10.1016/j.ophtha.2018.02.021

  View details for PubMedID 29784090

• Facial Pyoderma Gangrenosum Presenting With Cranial Nerve VII Palsy and Cicatricial Ectropion. Ophthalmic plastic and reconstructive surgery Homer, N., Freitag, S. K. 2017; 33 (6): e170

  View details for DOI 10.1097/IOP.0000000000000832

  View details for PubMedID 27893584

• Lymphatic malformation with acquired Horner syndrome in an infant. BMJ case reports Spors, B., Seemann, J., Homer, N., Fay, A. 2017; 2017

  Abstract

  An infantpresented with right upper eyelid ptosis and was subsequently diagnosed with acquired Horner syndrome. Further evaluation revealed a right-sided cervicothoracic lymphatic malformation. At 13 weeks of age, the child underwent percutaneous intracystic sclerotherapy with a mixture of sodium tetradecyl sulphate and ethanol. Twenty-one weeks after initial treatment, ophthalmic examination showed complete resolution of the blepharoptosis and pupillary miosis. Percutaneous sclerotherapy not only effectively treated the space-occupying lymphatic malformation but also reversed the Horner syndrome that was presumably induced by neural tension (more likely) or compression.

  View details for DOI 10.1136/bcr-2017-013315

  View details for PubMedID 29066632

  View details for PubMedCentralID PMC5665238

• Periocular Breast Carcinoma Metastases: Predominant Origin From the Lobular Variant. Ophthalmic plastic and reconstructive surgery Jakobiec, F. A., Stagner, A. M., Homer, N., Yoon, M. K. 2017; 33 (5): 361-366

  Abstract

  To further define the histopathologic features of breast carcinoma conducive to orbital metastasis.Ten new female patients with orbital or eyelid breast cancer metastases encountered between 2011 and 2016 had their medical records reviewed for determining their clinical characteristics. Microscopic glass slides from biopsies and immunohistochemical test results were also analyzed. Biomarkers studied included cytokeratin 7, nuclear estrogen and progesterone receptors, HER2, and E-cadherin.All orbital metastatic lesions were lobular (nonductal) carcinomas that could arise as late as 24 years after the diagnosis of the primary breast tumors. The average age of patients at the time or orbital presentation was 64 years. Metastases were composed of small tumor cells with round, orthochromatic nuclei, and a small amount of cytoplasm. The cells were disposed in a variably fibrotic tumor-associated stroma. Two lesions were variants of lobular carcinoma-namely, alveolar and pleomorphic (the latter displaying cellular crowding, with some degree of nuclear atypia and less stroma). Three of the 9 orbital metastases presented with enophthalmos and 2 displayed euphthalmos despite variably sized orbital masses. In 2 cases, synchronous bilateral orbital metastases prevented any relative difference in globe position. Estrogen and progesterone receptors were usually detectable whereas E-cadherin could not be demonstrated.Breast pathologists no longer refer to primary breast carcinomas and their orbital metastases as "scirrhous." It has been determined that the majority of orbital breast metastases are lobular carcinomas. This may be due to their lack of intercellular cohesiveness and the absence of E-cadherin which normally is expressed in many neoplastic cell types including ductal breast carcinomas, limiting their dispersion. In contrast, the majority of primary breast carcinomas are ductal. The ubiquitous collagenous matrix in breast metastases retracts, partially accounting for enophthalmos. The presence of euphthalmos despite an orbital mass additionally suggests some retraction of fibrous tissue (with or without fat atrophy) that suppresses relative proptosis. Metastatic lobular breast carcinoma is further implicated if there is a concomitant limitation in extraocular motility or vision decline.

  View details for DOI 10.1097/IOP.0000000000000793

  View details for PubMedID 27749621

• Response to: 'Comment on Transitioning to intravitreal aflibercept following a previous treat-and-extend dosing regimen in neovascular age-related macular degeneration: 24-month results'. Eye (London, England) Homer, N., Grewal, D. S., Mirza, R. G., Lyon, A. T., Gill, M. K. 2015; 29 (12): 1630-1

  View details for DOI 10.1038/eye.2015.191

  View details for PubMedID 26449193

  View details for PubMedCentralID PMC5129812

• Transitioning to intravitreal aflibercept following a previous treat-and-extend dosing regimen in neovascular age-related macular degeneration: 24-month results. Eye (London, England) Homer, N., Grewal, D. S., Mirza, R. G., Lyon, A. T., Gill, M. K. 2015; 29 (9): 1152-5

  Abstract

  To evaluate frequency of injections, visual and anatomical outcomes of neovascular age-related macular degeneration (nAMD) patients transitioned to intravitreal aflibercept after failure to extend treatment interval beyond 8 weeks with prior intravitreal bevacizumab or ranibizumab.Retrospective review of patients with nAMD switched to aflibercept following ≥ 6 prior intravitreal ranibizumab or bevacizumab injections at 4-8-week intervals. Three monthly aflibercept injections were given followed by a treat-and-extend dosing regimen.Twenty-one eyes of 18 patients who had received a mean of 23.8 ± 18.8 (mean ± SD; range 6-62) prior ranibizumab or bevacizumab injections were included. Over a mean follow-up of 24 months after the transition, 9.2 ± 2.9 (range 4-21) aflibercept injections were required. Interval between aflibercept injections increased to 57.3 days (range 35-133 days), as compared with 37 ± 6.1 days (range 29-54 days) with the prior agents (P = 0.01). Mean best-corrected visual acuity was preserved (0.42 ± 0.31 vs 0.42 ± 0.23 logMAR; P = 0.2). Mean OCT central subfoveal thickness (292.1 ± 83.2 μm to 283.6 ± 78.6 μm; P = 0.4) and mean macular volume (7.9 ± 0.95 mm(3) to 7.67 ± 0.94 mm(3); P = 0.16) remained stable.Patients requiring treatment more frequently than every 8 weeks with ranibizumab and bevacizumab were transitioned to > 8-week treatment interval with aflibercept while maintaining the anatomic and visual gains.

  View details for DOI 10.1038/eye.2015.87

  View details for PubMedID 26021870

  View details for PubMedCentralID PMC4565952

• Early readmission for congestive heart failure predicts late mortality after cardiac surgery. The Journal of thoracic and cardiovascular surgery Lee, R., Homer, N., Andrei, A. C., McGee, E. C., Malaisrie, S. C., Kansal, P., McCarthy, P. M. 2012; 144 (3): 671-6

  Abstract

  Early readmission in patients hospitalized for medical congestive heart failure is common, expensive, and associated with a worse late survival. Our objective was to compare late survival in patients' readmission for congestive heart failure with readmission for other causes in patients undergoing cardiac surgery.Of 3654 consecutive patients undergoing cardiac surgery at a single institution between April 2004 and June 2010, 3492 (96%) were discharged from the hospital before 30 days and analyzed. Survival curves by readmission reason were compared using the log-rank test. Multivariable analyses adjusted for patient demographics, known preoperative cardiac risk factors, and surgical characteristics.The readmission rate at 30 days was 13% (465/3492): 23% for arrhythmias/heart block, 12% for congestive heart failure, 40% for surgery related causes, 14% for infection, and 11% for noncardiac causes. Independent risk factors for readmission include age, gender, congestive heart failure, and cardiopulmonary bypass time. Eight percent (268/3492) of discharged patients died within the 6-year study: 14% in the readmission group versus 7% in the nonreadmission group (P < .01). Patients who had been readmitted for congestive heart failure had worse late survivals compared with all patients who had been readmitted for causes related to their surgery.Readmission within 30 days after cardiac surgery for congestive heart failure predicts late mortality. Targeted postoperative management may be warranted in patients with surgical congestive heart failure.

  View details for DOI 10.1016/j.jtcvs.2012.05.031

  View details for PubMedID 22713305

• Idiopathic massive left ventricular thrombus in HIV patient. Journal of cardiothoracic surgery Homer, N., Sheen, L., Lee, R. 2012; 7: 65

  Abstract

  A 47-year old man with HIV presented with a stroke. Imaging revealed a large mobile left-ventricular thrombus. The mass was resected using a small ventriculotomy with good early postoperative prognosis. Thrombus etiology is likely related to HIV pathology.

  View details for DOI 10.1186/1749-8090-7-65

  View details for PubMedID 22762280

  View details for PubMedCentralID PMC3484021