Semi-adjustable posterior approach for congenital ptosis repair- outcomes of local and general anesthesia.

BACKGROUND: To report a single center experience with semi-adjustable posterior approach levator plication ('levatorpexy') in patients with congenital ptosis. MATERIALS AND METHODS: A retrospective study. All cases who underwent posterior approach levatorpexy for congenital ptosis between the years 2016 to 2022 were included. The primary outcome measures were margin-to-reflex distance 1 (MRD1) before and after surgery, upper eyelid contour, symmetry of upper eyelid height, complications, and surgical success. Surgery was successful if all the following criteria were met: A postoperative MRD1 of ≥2 mm and ≤4.5 mm, a satisfactory eyelid contour in the operated eyelid, and an inter-eyelid MRD1 asymmetry of ≤1 mm. Postoperative modifications in semi-adjustable techniques were considered in all cases. RESULTS: Twenty-three eyelids of 21 patients were included, 11 were performed under general anesthesia, and 12 were performed under local anesthesia. The mean age of all patients was 24.1 years (8-47 years). The mean levator function was 11.2 (±2.11). Mean preoperative MRD1 was 1.05 mm and 1.41 for general and local anesthesia, respectively. Mean postoperative MRD1 was 3.33 mm and 3.37 mm for general and local anesthesia, respectively. Eighteen patients (85%) achieved the desired eyelid height and fulfilled our criteria for success. There were no complications reported in any of the groups. CONCLUSION: Posterior approach levatorpexy is a safe and effective procedure for repairing congenital ptosis in patients with good levator function. This technique is suitable for young patients and those unable to undergo surgery under local anesthesia. This technique offers post-operative modification due to its semi-adjustable nature.

Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience.

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

Ocular injuries associated with motor vehicle accidents: long term effects on quality of life.

PURPOSE: To describe the prevalence and outcome of motor vehicle accidents-associated ocular injuries. METHODS: A survey of patients who presented to the emergency room at a level 1 trauma center with motor vehicle accidents-associated ocular injuries. A patient questionnaire and review of clinical notes were conducted for all patients. RESULTS: Of 274 motor vehicle accident victims with ocular injuries who presented to the emergency room, 40 (15%) responded to the survey. Over half of them were driving a vehicle, and most reported wearing a seat belt or a helmet. Most ocular injuries were mild. The most common injuries were bone fractures, subconjunctival hemorrhage, eyelid involvement and corneal injury. Most respondents had no change in vision and perceived their ocular involvement as a minor part of their injury. Most respondents returned to work and to driving within a year. CONCLUSION: Our study sheds light on the details and extent of ocular involvement and the visual ability to perform daily activities following motor vehicle accidents.

Long-Term outcomes of pediatric dacryocystorhinostomy in a single medical center- a retrospective study.

PURPOSE: To examine the long-term success rate of pediatric endoscopic DCR surgery via telephone questionnaires, as determined by patients and their parents. METHODS: This is a retrospective cohort study of all patients who underwent DCR surgery at the Schneider Children's Medical Center of Israel between 2010 and 2020. We performed long-term follow-ups to assess the quality of life, surgical complications, and satisfaction with surgical outcomes. RESULTS: Our study includes seventy-nine patients with a total of 108 eyes. The mean age at the time of DCR was 7.05 years (Std = 4, min = 0.3, max = 17.7) Mean follow-up time was 5.7 years (Std =2.5, min = 1.4, max = 11.1). Tubes were inserted for a mean of 129 days (Std = 101). Fifty-seven patients (72%) declared they had no complications after surgery, three patients (4%) reported pain after surgery, and 14 patients (17.7%) reported tube extrusion, which occurred 7-21 days after surgery. Forty-four patients (56%) reported no recurrence of symptoms, 29 (37%) complained of mild epiphora, and 18 (23%) reported some ocular discharge. Sixty-eight patients (86%) stated that they did not undergo additional surgery, while the remaining 11 (14%) reported undergoing a revision operation for symptom control. Satisfaction rate (1-7) mean score reported was 6.15 (Std = 1.6). Sixty-two (78%) reported improved quality of life, while 17 (22%) reported no improvement. Our questionnaire results have been compared with the TEARS scores with similar findings. CONCLUSION: Regardless of its etiology, endoscopic DCR surgery in the pediatric population is safe and efficient, with a high long-term patient satisfaction rate, as reported via a telephone questionnaire.

Predictors for surgical intervention in orbital complications of pediatric rhinosinusitis.

OBJECTIVES: Orbital complications are the most common complication of acute rhinosinusitis, especially among pediatric patients. While most cases are treated with antibiotics alone, severe presentation may demand surgical intervention. Our goal was to determine which factors predict the need for surgery and to investigate the role of computerized tomography in the decision process. METHODS: A retrospective review of all children hospitalized between 2001-2018 with orbital complications of acute rhinosinusitis in a university-affiliated children's hospital. RESULTS: A total of 156 children were included. Mean age was 7.9 years (1-18 years). Twenty-three children (14.7%) were surgically treated, and the rest were conservatively treated. High fever, ophthalmoplegia and diplopia in association with minimal or no response to conservative treatment were predictive for surgical intervention, as well as higher inflammatory indices. Eighty-nine children (57%) underwent imaging during hospitalization. Presence of a subperiosteal abscess, as well as its size and its location were not found to be predictors for surgery. CONCLUSION: Clinical and laboratory findings in association with minimal or no response to conservative treatment predict the need for surgical intervention in cases of orbital complications of acute rhinosinusitis. As Computerized Tomography scans can have long-term implications in the pediatric population, caution and patience should be practiced when deciding on the timing of imaging in this population. Thus, close clinical and laboratory monitoring should lead the decision-making process in these cases and imaging should be reserved for when the decision for surgery has been made.

In Vivo Effects of Prostaglandin Analogues Application by Topical Drops or Retrobulbar Injections on the Orbital Fat of a Rat Model.

PURPOSE: To assess the in vivo effects of bimatoprost 0.03% (Lumigan®) on the orbital fat in a rat model. METHODS: Twenty rats were randomly divided into two groups: bimatoprost was administrated to the right eye by topical drops (group 1) or retrobulbar injection (group 2), and saline was administrated to the left eye by similar administration routes (controls). Four weeks later, all rats were sedated and euthanized, both orbits exenterated, and thin sections through the intraconal orbital fat were obtained. RESULTS: Average adipocyte cell count was significantly lower in the bimatoprost treated orbits (drops or retrobulbar injection, 29.5 vs. 67.5 cells per slide in the control globes, p=0.046). Fat cells were not detected in 9/20 (45%) bimatoprost treated orbits     . CONCLUSIONS: Orbits treated with bimatoprost by drops or retrobulbar injection demonstrated significant decrease in adipocytes cell count compared with controls. Bimatoprost could be an effective treatment for inactive thyroid eye disease.

Medical cannabis oil for benign essential blepharospasm: a prospective, randomized controlled pilot study.

OBJECTIVE: To examine the efficacy and safety of medical cannabis in benign essential blepharospasm (BEB). METHODS: This is a prospective, double-blind, placebo-controlled study. All consecutive adult BEB patients who had been treated with BTX-A injections without success between 3/2019 and 2/2020 were recruited. The study patients were randomly allocated into a treatment and a control (placebo) group in a 1:1 ratio. The treatment group used cannabis drops and the control group used cannabis oil drops during the first 6 weeks of the study, and both groups were treated with the medical cannabis drops during the second 6 weeks. The cannabis dose was gradually increased for each patient depending upon effect and tolerability. RESULTS: Three patients were included in each group (treatment and control groups). The mean duration of spasm attack during the first 6 weeks was 4.29 min in the treatment group and 73.9 min in the placebo group (P < 0.01). During the last 6 weeks, the treatment group used an average of 6.27 drops and the placebo group used an average of 5.36 drops (P = 0.478). There were 61 spasm events in the treatment group and 94 spasm events in the placebo group (P = 0.05). The mean duration of spasm attack was 1.77 and 8.96 min, respectively (P < 0.01). The side effects were mild, and they included general fatigue, dry mouth, and insomnia. CONCLUSIONS: Medical cannabis can be an effective and safe treatment for BEB as a second line after BTX-A injections when used for 3 months. No significant ocular or systemic side effects was associated with the treatment.

Simultaneous bilateral or sequential DCR? What to choose?

BACKGROUND: Dacryocystorhinostomy is used to treat nasolacrimal duct obstruction when conservative measures fail. It may be performed via an external or endoscopic-endonasal approach. The aim of this study was to compare the outcomes of patients with nasolacrimal duct obstruction treated with simultaneous bilateral or unilateral dacryocystorhinostomy. METHODS: The database of a tertiary medical center was retrospectively reviewed for all patients treated for nasolacrimal duct obstruction in 2012-2017. The study sample was divided into six groups by surgery type and approach: adults (>18 years) - external or endoscopic-endonasal sequential unilateral or simultaneous bilateral dacryocystorhinostomy (four subgroups); children (18 years) - endoscopic-endonasal unilateral or simultaneous bilateral dacryocystorhinostomy (two subgroups). Data were collected on patient age and sex, surgery and anesthesia type and duration, and complications. RESULTS: The cohort included 95 adults and 27 children who underwent 111 and 41 surgical procedures, respectively. Among the adults, the durations of anesthesia and surgery were significantly longer in the external bilateral dacryocystorhinostomy group than the others, but no such differences were found between simultaneous bilateral endonasal dacryocystorhinostomy and unilateral dacryocystorhinostomy by either approach. Among the children, there was no significant between-group difference in surgery duration.In neither age population was bilateral endoscopic surgery associated with an excess of intraoperative or postoperative complications of hemorrhage, infection, and epiphora. CONCLUSION: The lack of intergroup differences in clinical, surgical, and outcome parameters suggests that in cases of bilateral nasolacrimal duct obstruction in adults and children, simultaneous bilateral endoscopic-endonasal dacryocystorhinostomy may yield excellent therapeutic results.

Surgical Site Reassessment: An Important Step in Improving Clinical Outcomes Following Pediatric Endoscopic Dacryocystorhinostomy.

PURPOSE: To report the authors' experience with endoscopic unpowered dacryocystorhinostomy in the treatment of pediatric nasolacrimal duct obstruction, and to evaluate whether surgical site reassessment (after the appropriate healing period) affects clinical outcomes. METHODS: This retrospective study included 47 children aged between 1.5 and 17.0 years (mean age: 6.9 years) who underwent endoscopic unpowered dacryocystorhinostomy between 2014 and 2019 at one tertiary care hospital. Twenty-six patients required unilateral and 21 required bilateral endoscopic dacryocystorhinostomy. The main outcome measures were duct patency on lacrimal irrigation ("anatomical success") and resolution of symptoms ("clinical success") over 6 months of postoperative follow-up. RESULTS: Sixty-eight dacryocystorhinostomy procedures were performed. Surgical site reassessment during tube removal was performed in 52 of 68 cases. Five cases (9.6%) required treatment of local pathologies, only after which was symptomatic relief achieved. Overall anatomical success was observed in 49 (94.2%) of the 52 cases in which nasal endoscopy was performed, including the 5 cases treated during reevaluation. Clinical success was observed in 63 (92.6%) cases. CONCLUSIONS: Pediatric endoscopic dacryocystorhinostomy is an effective surgical procedure used to correct nasolacrimal system obstruction resistant to conservative measures. The unpowered endoscopic dacryocystorhinostomy technique is practical and safe in the pediatric population. Surgical site reassessment allows treating local pathologies threatening ostium patency and increases clinical success rates. [J Pediatr Ophthalmol Strabismus. 2021;58(3):168-173.].

Oculoplastic aspects of ocular surface disease and their management.

The normal structure and function of the eyelids, eyelashes, conjunctival fornices, and lacrimal system are essential for the health of the ocular surface, and abnormalities of these structures accompany many cases of ocular surface disease. We describe the role of oculoplastic intervention in the context of ocular surface disease, focusing on blink disorders, lagophthalmos, entropion, lid scarring and keratinization, trichiasis, and punctal and lacrimal sac disease.

Prostaglandin analogue drops for the treatment of soft tissue expansion and exophthalmos in patients with inactive thyroid eye disease.

OBJECTIVE: Thyroid eye disease (TED) is characterized by an inflammatory response leading to soft tissue expansion within the bony orbit, which may cause exophthalmos. Studies of glaucoma patients reported periorbital fat atrophy after treatment with prostaglandin analogue drops. We hypothesize that owing to this side effect, prostaglandin analogue drops may benefit patients with TED-induced exophthalmos. DESIGN: Interventional prospective pilot study. PARTICIPANTS: Five adults with inactive TED and exophthalmos treated with a single daily drop of bimatoprost to both eyes for 6 months. METHODS: The effect of treatment was evaluated by clinical examinations, Hertel exophthalmometry, marginal reflex distance (MRD), and comparison of digital photographs from before and after treatment by 3 masked oculoplastic surgeons. Patients' subjective satisfaction was recorded as well. RESULTS: Hertel exophthalmometry showed an improvement in exophthalmos after treatment in 3 patients and no change in 2. Both MRD1 and MRD2 increased (for MRD2 p = 0.007). Two observers correctly identified the photograph taken after treatment in 4 patients, and the third observer correctly identified 2 patients and was indecisive about the others. Four patients reported an improvement in their appearance, although additional eyelid retraction was observed. Adverse effects were minimal. CONCLUSION: Topical prostaglandin analogue treatment of TED-associated exophthalmos appears safe. Although this pilot study was statistically underpowered to show positive results, our findings suggest a treatment-related reduction in periorbital fat volume in most cases and a subjective improvement in appearance. These findings have potential implications for the treatment of exophthalmos in the clinical setting, but more research is required.

Resolution of recalcitrant chronic papillary conjunctivitis associated with epiphora following punctoplasty and lacrimal stenting.

OBJECTIVE: To assess the use of lacrimal stenting for chronic papillary conjunctivitis associated with epiphora in young adults with little or no atopic background. METHODS: A retrospective interventional case series of 21 consecutive patients (36 eyes) treated for epiphora and chronic papillary conjunctivitis at a tertiary university-affiliated medical center between January 2014 and August 2015 by the same oculoplastic surgeon (I.A). Data were collected by retrospective file review. Patients with a history of ocular disease were excluded from the study. Treatment modalities included lacrimal stenting, punctoplasty, and conservative topical medication. The main outcome measure was post-treatment presence of epiphora and conjunctivitis. RESULTS: Mean patient age was 40 ± 11 years; 86% of patients were female. Fifteen (72%) had bilateral disease. Mean follow-up time was 3.9 ± 1.7 months. Delayed tear clearance as well as a patent lacrimal apparatus were noted in all eyes. No apparent cause of the symptoms was found in any of the eyes. In 12 of the 13 patients (92%) who underwent tube or stent placement, the conjunctivitis and epiphora resolved. In the remainder, symptoms resolved bilaterally in only 1 of 4 patients (25%) who underwent punctoplasty and in only 1 of 4 patients (25%) treated conservatively. CONCLUSION: Recalcitrant papillary conjunctivitis improves following nasolacrimal stenting. Further studies are needed using a prospective controlled design and longer follow-up time.

Prevention of Exposure Keratopathy in Critically Ill Patients: A Single-Center, Randomized, Pilot Trial Comparing Ocular Lubrication With Bandage Contact Lenses and Punctal Plugs.

OBJECTIVES: To compare the effectiveness of bandage contact lenses and punctal plugs with ocular lubricants in preventing corneal damage in mechanically ventilated and sedated critically ill patients. DESIGN: Single-center, prospective, randomized, pilot study. SETTING: Sixteen-bed, general ICU at a tertiary academic medical center. PATIENTS: Adults admitted to the ICU and anticipated to require mechanical ventilation and continuous sedation for greater than or equal to 4 days. INTERVENTIONS: Patients were randomized to receive eye care with ocular lubricants (n = 38), bandage contact lenses (n = 33), or punctal plugs (n = 33). The bandage contact lenses were changed every 4 days, whereas the punctal plugs remained in situ for the entire study. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the presence or absence of corneal damage as assessed by the grade of keratopathy. Patients were examined by an ophthalmologist blinded to the study group every 4 days and at the time of withdrawal from the study, due to cessation of sedation, discharge from the ICU, or death. The mean duration of the study was 8.6 ± 6.2 days. The grade of keratopathy in the ocular lubricant group increased significantly in both eyes (p = 0.01 for both eyes) while no worsening was noted in either the lens or punctal plugs groups. In a post hoc analysis of patients with an initially abnormal ophthalmic examination, significant healing of keratopathy was noted in the lens group (p = 0.02 and 0.018 for left and right eyes, respectively) and in the right eye of the plugs group (p = 0.005); no improvement was noted in the ocular lubricant group. CONCLUSIONS: Compared with ocular lubrication, bandage contact lenses and punctal plugs were more effective in limiting keratopathy, and their use, particularly of bandage contact lenses, was associated with significant healing of existing lesions.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.

PURPOSE: To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. METHODS: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. RESULTS: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture. CONCLUSION: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis.

PURPOSE: To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis. METHODS: Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999-2011. RESULTS: We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38-82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30-60 mg tapered within 10 days-8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months). CONCLUSIONS: All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.

Upper-eyelid wick syndrome: association of upper-eyelid dermatochalasis and tearing.

OBJECTIVE: To highlight a case series of patients manifesting epiphora and misdirection of tears laterally or along the upper-eyelid skin crease. This association has been termed upper-eyelid wick syndrome. We describe the clinical features and outcomes of management of these patients. METHODS: A retrospective review of patients referred to 2 oculoplastic centers during a 6-year period for epiphora, who were considered to have misdirection of tears related in some way to upper-eyelid dermatochalasis. RESULTS: Nine patients (7 women and 2 men; mean [SD] age, 61.2 [11.3] years, range, 41-76 years) with bilateral epiphora and lateral spillover (100%), occasionally combined with upper-eyelid wetting (n = 2). All patients had upper-eyelid dermatochalasis. Five patients had upper-eyelid skin obscuring and in contact with the lateral canthus (type 1), and in 4 the lateral canthus was only partially obscured by upper-eyelid skin (type 2). Five patients (56%) had linear excoriation of skin in the lateral canthus. All patients underwent upper-eyelid blepharoplasty, 3 combined with ptosis repair and 3 combined with eyebrow-lift. All patients achieved 80% to 100% improvement in epiphora following surgical intervention to the upper eyelid. The mean (range) follow-up was 2.8 (1-6) years. CONCLUSIONS: We defined upper-eyelid wick syndrome as the misdirection of tears laterally or along the upper-eyelid skin crease causing epiphora, related in some way to upper-eyelid dermatochalasis. In all cases, epiphora improved with treatment of upper-eyelid dermatochalasis. Although recognized among physicians, this has never been formally described in the ophthalmic literature, to our knowledge.

The prevalence of polycystic ovary syndrome in women with idiopathic intracranial hypertension.

Purpose. The purpose of this study is to re-evaluate whether the prevalence of polycystic ovary syndrome (PCOS) amongst women with idiopathic intracranial hypertension (IIH) is higher than in the general population using the NIH criteria. Methods. We included all consecutive women with IIH of child-bearing age seen at a hospital-based neuro-ophthalmology clinic between the years 2000-2005. All consenting women included in this study filled-out a screening questionnaire aimed at identifying women at risk for PCOS. The endocrinologist examined each patient suspect of PCOS as well as their biochemical results and diagnosed PCOS according to NIH criteria. The prevalence of PCOS in these women with IIH was compared with the reported prevalence of PCOS in the general population. Results. Out of 58 women with IIH who completed the study, definite PCOS was diagnosed in nine women (9/58; 15.5%). We found a significantly higher prevalence of PCOS using the NIH criteria among the IHH study group (15.5%, P = 0.001) compared to the general population (8.7%). Conclusions. The prevalence of PCOS is higher among patients with IHH, compared to the general population. We suggest a novel screening questionnaire to aid in the identification of women with IIH at risk for PCOS.

Multiple Conjunctival Papillomas of Eyelid Margins in Pemphigus vulgaris.

Ocular involvement in pemphigus vulgaris (PV) ranges from mild conjuctivits to conjunctival blisters and rarely prominent erosions of the bulbar and palpebral conjunctiva which may be found at the eyelid margin. We report two unusual cases of PV patients presenting with multiple conjunctival papillomatous lesions of the eyelids margins.