INTRODUCTION: Orbital lymphatic malformations (OLMs) are a unique subset of head and neck low flow vascular malformations, located either in the periorbital region or in the closed orbital cavity. We discuss our experience of minimally invasive strategies of treatment using advanced imaging and Bleomycin sclerotherapy to effectively treat these malformations. MATERIALS AND METHODS: Between 2008 and 2013, we have treated 54 cases of orbital low flow vascular malformations including 22 cases of OLMs of which 16 were treated using Bleomycin. This retrospective analysis was performed from patient charts, operative reports, operative images, pre-operative, and post-operative MR imaging. Bleomycin was used for sclerotherapy in all the cases with a maximum dose per session of treatment limited to 15 mgs. DIRECT PUNCTURE SCLEROTHERAPY TECHNIQUE: OLMs target was determined using pre-procedure MR imaging and direct puncture either per-cutaneous or per-conjunctival was achieved using ultrasound or i-guide guidance. In most lymphatic fluid was drained else the position confirmed with constrast injection under fluoroscopy. Bleomycin was used either undiluted or in various concentrations mixed with saline, or contrast material and recently we favor the use of Bleofoam mixed with 25% Human albumin and air. Microcystic LMs, were treated using gravity technique, the needle track was sealed with Surgiflo or Floseal. In cases of intra cystic or intra ocular haemorrhage with elevated orbital pressure, lateral canthotomy was performed to prevent permanent damage to vision and the contents of the orbit. Postoperatively, the patients recover in ICU and monitored for vision and orbital swelling. Bleomycin skin precautions were followed for 72 h in order to avoid skin hyperpigmentation. Optimal results were obtained at 6 to 8 weeks and assessed using follow-up MRI and ophthalmologic evaluation. RESULTS: The patient's age ranged from 1 to 45 years, with equal male to female ratio. Most cases (13/16) (80%) presented non acutely while three patients (20%) presented acutely with proptosis, visual disturbance and double vision due to haemorrhage within the malformation. Treatment completed in 14, one lost to follow up and the other is yet to be followed. The follow up period ranged from 6weeks to 6 months. 65% (9/14) needed less than three procedures while the remaining five patients needed between 3-5 procedures. All patients had improvement in proptosis; vision either remained stable or improved; volume reduction of more than 80% was noted in 57% (8/14), while the remaining patients 43% had volume reduction of 50-79%. One patient had transient mydriasis post procedure that completely recovered at three months. Another developed haemorrhage within the malformation immediate post sclerotherapy requiring lateral canthotomy, drainage and redo sclerotherapy. None of our patients developed skin pigmentation or pulmonary complication related to bleomycin usage. CONCLUSION: Bleomycin sclerotherapy combined with appropriate image guidance for precise target localization is an effective and safe treatment for OLMs. Bleomycin is a preferred sclerosant as it induces minimal inflammation and post procedure swelling. Standard precautions must be instituted to prevent cutaneous pigmentation and pulmonary fibrosis. DISCLOSURES: S. Paramasivam: None. A. Fay: None. J. Fifi: None. A. Berenstein: None.

The maintenance of mydriasis and the control of postoperative pain and inflammation are critical to the safety and success of cataract and intraocular lens replacement surgery. Appropriate mydriasis is usually achieved by topical and/or intracameral administration of anticholinergic agents, sympathomimetic agents, or both, with the most commonly used being cyclopentolate, tropicamide, and phenylephrine. Ocular inflammation is common after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drugs are widely used because they have been proved effective to control postsurgical inflammation and decrease pain. Topical nonsteroidal anti-inflammatory drugs have also been shown to help maintain dilation. However, use of multiple preoperative drops for pupil dilation, inflammation, and pain control have been shown to be time consuming, resulting in delays to the operating room, and they cause dissatisfaction among perioperative personnel; their use can also be associated with systemic side effects. Therefore, ophthalmologists have been in search of new options to streamline this process. This article will review the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control. In addition, a new combination of ketorolac, an anti-inflammatory agent, and phenylephrine, a mydriatic agent has recently been designed to maintain intraoperative mydriasis and to reduce postoperative pain and irritation from intraocular lens replacement surgery. Two Phase III clinical trials evaluating this combination have demonstrated statistically significant differences when compared to placebo in maintaining intraoperative mydriasis (P<0.00001) and in reducing pain in the early postoperative period (P=0.0002). This medication may be of benefit for use in cataract and lens replacement surgery in the near future.