Resolving conjunctival prolapse following severe blepharoptosis correction: A simple sutureless direct excision technique and systematic review.

BACKGROUND: Conjunctival prolapse (CP) is an uncommon but challenging condition following maximal levator resection (MLR) and other extensive periorbital procedures. MLR extending beyond the Whitnall's ligament is frequently performed to address severe blepharoptosis with poor levator function (LF). Patients with CP may encounter symptoms such as ocular discomfort, tearing, vision impairment, persistent conjunctival chemosis, lagophthalmos, or exposure keratopathy. Typically, surgical intervention becomes necessary if conservative measures prove to be ineffective; nevertheless, there is no consensus regarding the optimal treatment approach. OBJECTIVES: This study aimed to propose a simple sutureless direct excision method and explore the surgical advancements in CP correction through a systematic review. METHODS: Patients with recurrent CP after MLR who underwent sutureless direct excision of the conjunctiva using loupe magnifiers at a tertiary hospital were included in this study. The clinical evolution and surgical results were recorded. PubMed, MEDLINE, EMBASE, and Web of Science databases were queried following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. RESULTS: The comprehensive analysis of 1858 articles identified 88 patients from 24 studies, highlighting that blepharoptosis surgery is predominantly associated with CP (36.6%). Surgically treated CP showed a higher resolution rate compared to those managed conservatively (54.8% vs. 45.2%; p = 0.034). No relapse was observed in patients treated with sutureless direct excision of CP in long-term follow-up. CONCLUSION: We proposed a simple sutureless direct excision technique that offers a straightforward and efficient approach in treating CP, which is particularly suitable for cases requiring excision lengths >16 mm during MLR. Furthermore, stitch removal can be obviated after surgery.

Extended frontalis orbicularis oculi muscle flap shortening for treating refractory apraxia of eyelid opening associated with blepharospasm.

BACKGROUND: Refractory apraxia of eyelid opening (AEO) is mostly unresponsive to botulinum toxin (BTx) and inevitably leads to functional blindness. To treat this challenging condition, an innovative surgical technique was proposed. METHODS: The extended frontalis orbicularis oculi muscle (FOOM) flap shortening consisting of frontalis suspension, partial myectomy, and myotomy in situ of eyelid protractors was applied to treat refractory AEO associated with blepharospasm. The postoperative outcomes and patient satisfaction were evaluated. RESULTS: Seven patients (mean ages 64.1 ± 3.9 years) of 14 eyelids in total had an average flap shortening distance of 24.4 ± 1.3 mm. During a mean follow-up of 31.6 ± 11.4 months, the average BTx dosage reduced from 58.6 ± 12. 1 units to 30.0 ± 8.2 units, with a mean injection interval decreasing from 2.3 ± 0.5 months to 4.1 ± 0.9 months (p < 0.05). Palpebral fissure height increased from 1.4 ± 0.5 mm to 7.9 ± 0.7 mm, and the disability scale decreased from 78.8% ± 7.2% to 12.6% ± 7.0% (p < 0.05). The postoperative BTx dosage and frequency were significantly reduced. All patients restored voluntary eyelid opening and reported high postoperative satisfaction (average Likert scale 4.6 ± 0.5). CONCLUSION: Extended FOOM flap shortening is an effective treatment to solve refractory AEO associated with blepharospasm.

Matching intraoperative teaching and learning for medical undergraduates via modified briefing-intraoperative teaching-debriefing (BID) model.

Intraoperative teaching is a challenging task. The briefing-intraoperative teaching-debriefing (BID) model, which is based on guided discovery learning at limited time intervals, has rarely been investigated. This study validated the benefits of the modified BID model on medical clerks. This study involved 37 first-year medical clerks enrolled from September 2019 to May 2020. Every learner scrubbed in one the totally implantable venous access device placement surgery and completed a pre-/posttest survey on surgical procedures and associated anatomy conducted through an intraoperative teaching questionnaire. Of these participants, 15 merely observed throughout the entire procedure (observation group), whereas the remaining 22 performed simple suturing under supervision (suturing group). All participants underwent an objective structured assessment of simple interrupted suturing skills at the end of the observership. Correlations were tested using a two-tailed paired t-test, with a p-value < 0.05 indicating statistical significance. The response rate was 100% and participants could reconfirm the precise venous access, catheter tip location, and suture materials for portal fixation after totally implantable venous access device placement (p < 0.05). Although a relatively higher satisfaction of the intraoperative teaching environment and educator attitude was reported in the suturing group than in the observation group, the difference in scores on the objective structured assessment was not statistically significant (8.7 ± 1.8 vs. 7.2 ± 3.7; p = 0.104). Our findings indicate that the modified BID model with hands-on experience is a practicable module for matching intraoperative teaching and learning via learning perception enhancement for medical undergraduates during totally implantable venous access device placement.

Evaluation of Blepharoptosis in Patients With Refractory Blepharospasm by VISA-Video Recordings, Idiosyncratic Expressions, Sensory Tricks, and Ancillary Procedures.

BACKGROUND: How to evaluate blepharoptosis concomitantly presented with refractory and uncontrollable blepharospasm? To date, there is a paucity of publications on the ideal evaluation methods. An innovative method-video recordings, idiosyncratic facial expressions, sensory tricks, and ancillary procedures (VISA)-is developed for preoperative evaluation, and the surgical outcomes are demonstrated. METHODS: A retrospective study using VISA for blepharoptosis evaluation was conducted on 51 patients with refractory blepharospasm. Based on the evaluation, patients underwent blepharoptosis correction simultaneously besides the selective myectomy and myotomy in situ of the eyelid protractors for blepharospasm. Preoperative and postoperative palpebral fissure height, margin reflex distance 1, ptosis severity, and levator function were assessed to identify the effectiveness of VISA. All the procedures were performed by the senior author C.-S.L. RESULTS: There were 42 patients diagnosed with essential blepharospasm and 9 patients with Meige syndrome. Forty-one patients (82/102 eyelids [80.4%]) had concomitant blepharoptosis and blepharospasm. Ptosis severity was mild in 21 eyelids (25.6%), moderate in 12 eyelids (14.6%), and severe in 49 eyelids (59.8%). Preoperative/postoperative (6 months) values of palpebral fissure height, margin reflex distance 1, and levator function were 4.70 ± 2.45 mm/8.35 ± 1.33 mm (P < 0.05), -0.30 ± 3.19 mm/3.73 ± 1.05 mm (P < 0.05), and 13.07 ± 2.56 mm/13.68 ± 2.34 mm (P < 0.05), respectively. Undercorrection and revision rate reported 9.8% and 3.7%, individually. CONCLUSIONS: VISA approach overcomes the difficulty of blepharoptosis assessment in patients with refractory blepharospasm. It provides useful preoperative information required for adequate blepharoptosis correction in blepharospasm surgery and yielded desirable outcomes.

Selective Myectomy and Myotomy In Situ for the Management of Refractory Blepharospasm in Meige Syndrome.

BACKGROUND: Meige syndrome is characterized by involuntary blepharospasm and varied subphenotypes of oromandibular tonic-clonic muscle contraction. Despite botulinum toxin (BTx) being the mainstay of treatment for Meige syndrome, a small subset of patients remain refractory to its effects because the disease is a form of functional blindness. An integrative surgical procedure combining selective myectomy and myotomy in situ of eyelid protractors, blepharoptosis correction, and tightening of the lower eyelid laxity was first applied to treat refractory blepharospasm in patients with Meige syndrome. MATERIALS AND METHODS: This study is a retrospective review conducted on 24 patients with refractory Meige syndrome between 2013 and 2020. Besides selective myectomy and myotomy in situ of eyelid protractors, levator plication and lateral tarsoplasty or canthopexy was performed for blepharoptosis correction and lower eyelid tightening, respectively. Patient demographics, associated diseases, medical treatment history, associated surgical procedures, final aesthetic outcomes, and therapeutic effects as reflected by changes in function disability score and Botox (BTx) treatment were thoroughly recorded and analyzed. RESULTS: The mean age of the patients was 65.2 ± 8.9 years. Twenty-one patients (87.5%) received blepharoptosis correction by levator plication with an average of 11.2 ± 2.9 mm in length. Lateral tarsoplasty was performed in 16 patients (66.7%) by pentagonal tarsal resection with an average of 3.9 ± 0.8 mm in width. Five patients (20.8%) received lateral canthopexy. Among the total of 96 operated eyelids, scar revision with fat graft was performed in 3 eyelids (3.1%). The average amount of BTx treatment decreased from 49.2 ± 12.8 U once every 2.7 ± 0.8 months before surgery to 35.4 ± 7.8 U once every 3.8 ± 0.7 months after surgery. Function disability score improved from 76.7 ± 17.5% preoperatively to 15.6 ± 9.9% postoperatively ( P < 0.001). Only 3 upper eyelids (3.1%) received scar revision and fat grafting due to minor postoperative contour depression. All patients expressed high satisfaction with both functional and aesthetic outcomes (Likert scale 4.5 ± 0.5). CONCLUSIONS: Selective myectomy and myotomy in situ of eyelid protractors combining blepharoplasty correction and lower eyelid tightening can produce long-lasting functional and aesthetic results with minimal complication in patients with refractory Meige syndrome.

Nontechnical skills for the surgery clerkship in the operating room based on adult learning principles in Taiwan.

Medical education has traditionally been rooted in the teaching of medical knowledge and surgical technique in the operating room, with little attention to the nontechnical skills (NTS) that include situational awareness, decision-making, teamwork and communication, and leadership. Under the guidance of adult learning principles, the aim of this study is to evaluate the learning outcomes of the NTS program for the surgery clerkship in the operation room in Taiwan. Self-directed learning principles were practiced during this 2-week subspecialty rotation. The learners were randomly divided into two groups: the control group (the learners and teachers deciding together what should be learnt) and the intervention group (the same as the control group and the formal NTS program implemented during the second week). A 12-item quantitative questionnaire including both the 6-item Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and the 6-item adult learning characteristics was completed twice: before and after rotation. From Oct 2020 to May 2021, 16 medical students received NTS training and 16 were training-naïve. For those undergoing NTS training, six core competencies significantly improved on a 6-point scale. Moreover, total score differences (post-training - pre-training) in core competency had significant correlations to the differences in adult learning characteristics (r = 0.648, p = 0.007). The NTS program could be feasibly integrated into core objectives of the basic surgical clerkships, with the improvement in adult learning motivation in the learners helping to facilitate NTS training under the competency-based surgical training program.

Treatment algorithm for Kimura's disease: A systematic review and meta-analysis of treatment modalities and prognostic predictors.

BACKGROUND: Kimura's disease is a rare, chronic inflammatory condition that usually manifests as highly recurrent head and neck tumors. OBJECTIVE: Systematic review of recurrence predictors following surgical excision. MATERIALS AND METHODS: The pathologically confirmed cases at the tertiary medical center were reviewed. PubMed, Medline, the Cochrane Library, Web of Science, Airiti Library containing grey literature were searched through August 31st, 2019. RESULTS: A total of 31 articles were included for meta-analysis which revealed that surgical excision resulted in a lower recurrence rate (pooled odds ratio [POR] = 3.15, 95% confidence interval [CI] = 1.12-8.82; p = 0.03) than conservative measures. Surgery was an effective single treatment modality for patients with tumors smaller than 3 cm (POR = 2.89, 95% CI: 1.20-6.95; p = 0.02), symptom duration shorter than 5 years (POR = 3.11, 95% CI, 1.03-9.38; p = 0.04), peripheral blood eosinophilia less than 20% (POR = 4.49, 95% CI: 1.46-13.84; p = 0.009) or serum IgE level less than 10000 IU/ml (POR = 8.30, 95% CI: 1.05-65.34; p = 0.04). CONCLUSIONS: Directing patients with Kimura's disease through the treatment algorithm will reduce the recurrence rate. Combination adjuvant therapy with surgery is recommended for the following conditions -- a tumor greater than or equal to 3 cm in size, symptom duration longer than or equal to 5 years, peripheral blood eosinophilia greater than or equal to 20%, or serum IgE greater than or equal to 10000 IU/ml to achieve the optimal therapeutic outcome. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020173258 (http://www.crd.york.ac.uk/PROSPERO).

Lateral Tarsoplasty for Managing Ectropion and Laxity of the Lower Eyelid.

BACKGROUND: The most challenging complication associated with lower blepharoplasty is ectropion, and the traditional lateral canthopexy or canthoplasty procedure may carry the risk of eyelid malposition or subsequent chemosis. We propose lateral tarsoplasty with a detailed description of the techniques to treat and even prevent ectropion by not involving the medial or lateral canthal ligament so as to avoid complications. MATERIALS AND METHODS: Lower eyelid laxity was analyzed with the snap-back test and distraction test before surgery. Approximately 5 mm medial to the lateral canthus, lateral tarsoplasty is performed through a full-thickness pentagonal tarsal-conjunctival resection according to the "overlapping test" for an accurate measurement of the amount of the tarsus to be resected. Seventy-two eyelids that received either ectropion correction or prevention with lateral tarsoplasty over an 8-year period at a single institution were collected and analyzed for this retrospective review. RESULTS: Lateral tarsoplasty was performed in 39 patients with a mean age of 63.8 years. Thirteen patients with 20 eyelids presented for ectropion correction, in whom 5 to 10 mm of tarsus was resected, 6.0 mm in average. The other 26 patients with 52 eyelids presented for ectropion prevention, in whom 3 to 7 mm of tarsus was resected, 4.1 mm in average. Apart from temporary mild chemosis, all patients experienced highly satisfactory results without any ectropion or malposition of the involved lower eyelids after a follow-up of 8.1 months in average. CONCLUSIONS: For patients with moderate and severe laxity of lower eyelids, lateral tarsoplasty without involvement of the lateral canthal ligament proves to be an effective way to treat and prevent lower eyelid ectropion.

Learning outcomes of structured perioperative teaching based on adult learning.

BACKGROUND: Self-directed learning is the cornerstone of adult learning. The aim of the study was to investigate the improvement of core competency and increase interest to be a surgeon among medical students after a perioperative training through a structured learning with written record model. The mediating role of adult learning pattern on core competency was also examined. METHODS: A 2-week training protocol was based on a structural learning model which included a structured written record by the learner for postoperative immediate feedback. An adult learning questionnaire (ALQ) was developed to assess learners' adult learning pattern and a clinical core competency questionnaire (CCCQ) was developed to assess learning outcomes. A two-way repeated measured of ANCOVA would be used to analyze the interaction effect of adult learning pattern and learning effect on learning outcomes. RESULTS: From Jan 2017 to Dec 2019, 412 medical students were enrolled in the study. The increase scores of CCCQ and a significant numbers of increase interest to be a surgeon were shown after the perioperative training. Two-way repeated measure ANOVA revealed that there were significant differences in change between pre- and post-CCCQ across four levels of ALQ (interaction effect F = 13.0, p <0.001). The more adult learning patterns medical students own, the more they will benefit from the training. CONCLUSIONS: The structural learning with written record model provides an effective perioperative training represented with clinical core competency and increase the interest to be a surgeon in the future. Medical students with tendency of adult learning pattern would learn better.

The Function-Preserving Frontalis Orbicularis Oculi Muscle Flap for the Correction of Severe Blepharoptosis With Poor Levator Function.

BACKGROUND: Severe blepharoptosis with poor levator function (LF) has traditionally been managed with exogenous frontalis suspension but complications such as lagophthalmos, infection, and rejection are often reported. OBJECTIVES: The aim of this study was to design a function-preserving frontalis orbicularis oculi muscle (FOOM) flap to correct severe blepharoptosis with poor LF. The long-term surgical outcome of the technique was assessed. METHODS: This retrospective study included only adult patients with severe blepharoptosis and poor LF, all of whom had their surgery performed by the senior surgeon over a 6-year period. Clinical assessment of LF, palpebral fissure height (PFH), marginal reflex distance 1 (MRD1), duration of follow-up, and postoperative complications were recorded. RESULTS: A total of 34 patients and 59 eyelids were recorded during a mean follow-up period of 17.7 months. Postoperative evaluation yielded mean [standard deviation] improvements of PFH gain of 5.62 [1.61] mm (P < 0.001), and MRD1 and PFH increases of 4.03 [0.82] mm (P < 0.001) and 8.94 [0.81] mm (P < 0.001), respectively. All patients demonstrated normalization of orbicularis function: no lagophthalmos was observed at the 8-month postoperative follow-up. Recurrence of ptosis was recorded in 4 eyelids (6.78%). Revisions were performed in 2 eyelids (3.39%). No infection or granuloma was noted. CONCLUSIONS: The function-preserving FOOM flap is a useful vector for frontalis suspension. Not only does it effectively address lagophthalmos as well as other complications, but it provides aesthetically pleasing outcomes in patients with severe blepharoptosis and poor LF.

Personal Approach to Optimizing Inframammary Fold Incision for Asian Augmentation Mammoplasty.

BACKGROUND: The rates of aesthetic breast augmentation have risen substantially in Asia. Outcomes of various breast augmentation approaches in Asia have not been comprehensively studied. In the past, the inframammary approach to breast augmentation was not popular because of conspicuous scarring. In this article, the authors review academic articles related to the use of an inframammary incision for breast augmentation in Asian women and present our recommendations for the available techniques. METHODS: A literature search was performed for articles published after 2015 on Asian women with augmentation mammoplasty describing techniques, incision sites, outcomes, and complications. The search was performed using the MEDLINE, Embase, and Cochrane databases. We also included our own technique to demonstrate the outcome of augmentation mammoplasty through inframammary incision. RESULTS: Eight articles satisfied our inclusion criteria. Evidence indicates that with proper preoperative design and surgical techniques, scarring resulting from the inframammary approach is not inferior to that resulting from the transaxillary approach in Asian patients. Long-term satisfaction with the inframammary approach to breast augmentation is high in Asian patients.Eight articles reported the outcomes of 1168 women receiving breast augmentation. Inframammary incisions were used in 45.29% of patients (529 patients). After the 2015 publication of Zelken's review paper on Asian breast augmentation, the rate of inframammary incisions increased from 3.1% to 45.29%. CONCLUSIONS: With precise design of the new inframammary fold, accurate wound suture fixation, and postoperative scar care, the inframammary approach to breast augmentation offers optimal operative visualization, reduced pain, fewer complications, and desirable esthetic outcomes even in Asian patients. This study demonstrates that the percentage of inframammary fold approach of Asian esthetic mammoplasty grows rapidly after 2015.

Cilostazol Ameliorates Peripheral Neuropathic Pain in Streptozotocin-Induced Type I Diabetic Rats.

Background: Cilostazol is an antiplatelet agent with vasodilating, endothelial function restoration, and anti-inflammatory effects. This study aims to investigate the efficacy of oral cilostazol for preventing the development of diabetic peripheral neuropathy (DPN). Materials and Methods: Ninety adult male Sprague-Dawley rats were divided into five groups: 1) naïve (control); 2) diabetic (DM); 3) DM receiving 10 mg/kg cilostazol (cilo-10); 4) DM receiving 30 mg/kg cilostazol (cilo-30); and 5) DM receiving 100 mg/kg cilostazol (cilo-100). Hindpaw responses to thermal and mechanical stimuli were measured. Activation of microglia and astrocytes in the spinal dorsal horn (SDH) and expression of NaVs in the dorsal root ganglia (DRG) were examined with Western blots and immunofluorescence. Results: DM rats displayed decreased withdrawal thresholds to mechanical stimuli (mechanical allodynia) and blunted responses to thermal stimuli. In addition, the expression of microglia increased, but astrocytes were reduced in the SDH. Upregulation of Nav -1.1, 1.2, -1.3, -1.6, and -1.7 and downregulation of Nav-1.8 were observed in the DRG. The DM rats receiving cilostazol all returned DM-induced decrease in withdrawal threshold to mechanical stimuli and attenuated neuropathic pain. Additionally, all cilostazol treatments suppressed the level of activated microglial cells and ameliorated the DM-induced decline in astrocyte expression levels in the SDH. However, only the rats treated with cilo-100 demonstrated significant improvements to the aberrant NaV expression in the DRG. Conclusion: Oral cilostazol can blunt the responses of mechanical allodynia and has the potential to treat diabetic neuropathy by attenuating NaV and glial cell dysregulation.

Disparity of perspectives between teachers and learners on perioperative teaching and learning.

BACKGROUND: To build a consensus about learning objectives in the operating room, the aim of the study was to evaluate both surgical teacher and learner perspectives on perioperative teaching and learning in Taiwan. METHODS: Twelve main technical and non-technical learning objectives in the operating room were evaluated by learners and surgical teachers in Kaohsiung Medical University Hospital. The learners included postgraduate year (PGY) 1-3 residents (junior learner, JL) and PGY 4-7 residents (senior learner, SL). The definition of learning preferences were recommended learning objectives, and learning load was defined as demands of learning preferences. During the survey, surgical teachers evaluated the learning preferences for the learner, and learners evaluated their learning preferences. The learners also evaluated the learning preferences that the surgical teachers should teach. RESULTS: Response rate of the questionnaire was 65.4%. A total of 31 learners and 39 surgical teachers completed the survey. The consensus was that the need to increase the learning loads and ethical issues were the learning preferences for SL, and indications, details of procedure, and teamwork were important to both JL and SL. The teachers intended to set specific learning objectives for different learner levels, including (i) indications, details of procedure, teamwork, and postoperative care for both JL and SL; (ii) preoperative preparation, surgical anatomy, and instrument handling for JL (P = 0.022, 0.021 and 0.006); and (iii) surgical technique, independent practice, clinical reasoning, complications, and ethical issues for SL (P = 0.010, < 0.001, < 0.001, 0.001, 0.011). Resident perspective on learning objectives differed between JL and SL, and there was discrepancy between resident's learning as perceived by teachers, particularly in the JL. CONCLUSIONS: Our study revealed significant disparity of perspectives between teachers and learners on perioperative teaching and learning. Surgical teachers should set specific learning objectives for different learner levels, since junior and senior residents have different learning preferences even though both scrub in the same case. Effective communication between teachers and learners has the potential to improve learning experience and create a positive environment in the operating room.

Myotomy In Situ for Essential Blepharospasm Refractory to Botulinum Toxin.

BACKGROUND: Full myectomy is recommended for benign essential blepharospasm (BEB) refractory to botulinum toxin (BT) treatment, but long-term swelling, scar contracture, hollow appearance, and unnatural contour of the eyelids are common postoperative complications. We present myotomy in situ to minimize these adverse outcomes. METHODS: The redundant eyelid skin with its underlying muscle is resected first, and myotomy in situ is performed by completely cutting the residual orbicularis oculi muscles into multiple cubes and down to the subcutaneous layer, and then cutting the procerus and corrugator muscles down to the periosteum. Patient demographics, medical treatment history, BT injection history, blepharoptosis correction techniques, associated surgical procedures, and aesthetic outcomes were analyzed. Preoperative and postoperative BT injection dosage and frequency, as well as modified disability scores, were compared using paired Student t tests. RESULTS: Twenty-five patients underwent this technique. Their average ± SD age was 64.4 ± 8.9 years, with average postoperative follow-up occurring 17.0 ± 8.0 months. Associated diseases included blepharoptosis (88%) and apraxia of lid opening (44%). There were no postoperative hematoma, seroma, scar contracture, and depressed hollow eyelid contours. Preoperative to postoperative assessments revealed improvements in mean BT injection interval (10.4 ± 2.1 to 14.6 ± 2.9 weeks, P < 0.001), BT injection dosage (44.4 ± 13.3 to 28.1 ± 6.7 units, P < 0.001), and modified disability score (15.3 ± 3.0 to 2.8 ± 2.2, P < 0.001). All patients were highly satisfied with functional and aesthetic surgical outcomes (4.5 ± 0.6 on Likert scale). CONCLUSIONS: Myotomy in situ is effective for patients with BEB who are refractory to BT treatment, with therapeutic benefits similar to that of full myectomy with the ability to maintain favorable cosmetic results. Relative high incidence of blepharoptosis and apraxia of lid opening in patients with refractory BEB was reported. Simultaneous correction of the ptosis can further optimize outcomes.

Severe Ocular Complications After Blepharoptosis Correction in the Oculopharyngeal Muscular Dystrophy Patient: Literature Review and Case Presentation.

BACKGROUND: Blepharoptosis correction in oculopharyngeal muscular dystrophy (OPMD) patients may result in severe ocular complications owing to lagophthalmos and ophthalmoplegia. Managing the acute episode to prevent further aggravation of the keratopathy or blindness is of paramount importance. METHODS: A review of the literature for severe chemosis, keratopathy, and corneal ulceration in the patient population was performed using the PubMed database, with key words including ptosis surgery, ptosis correction, ptosis repair, and oculopharyngeal muscular dystrophy. A retrospective review of all patients with blepharoptosis from a single surgeon from September 2009 and May 2017 was performed, selecting those with OPMD who underwent blepharoptosis correction. RESULTS: Our literature review revealed a total of 15 articles after excluding repeated articles and selecting those meeting our inclusion criteria. A total of 232 OPMD patients underwent blepharoptosis correction. Severe ocular complications were noted in 7 patients, with treatment unspecified. For 9 years, 2 OPMD patients at our institute underwent blepharoptosis correction, with one developing severe acute keratitis, chemosis, and corneal ulceration due to lagophthalmos and ophthalmoplegia. Use of the temporary drawstring tarsorrhaphy and topical eye drop treatment for 2 weeks led to resolution of corneal ulcerations without necessitating further intervention. CONCLUSIONS: Severe ocular complications may occur after blepharoptosis correction in OPMD patients, potentially owing to lagophthalmos and ophthalmoplegia. Temporary drawstring tarsorrhaphy is an effective option to treat these adverse outcomes.

Triamcinolone Acetonide Suppresses Keloid Formation Through Enhancing Apoptosis in a Nude Mouse Model.

BACKGROUND: Current understanding of steroid treatments for keloids is in regards to modulation of inflammation, proliferation, and apoptosis, with no in vivo study on the latter. Using a nude mouse model, we investigated whether triamcinolone acetonide (TA) injections induce keloids regression through enhancing apoptosis. MATERIALS AND METHODS: Thirty-six keloid specimens (1 × 1 cm) were harvested from 6 patients and separated into sets of 2 from the same patient: no treatment and intralesional TA injection (0.4 mg/mL/kg) at 8 weeks of postimplantation. One set was implanted in each of 18 randomly selected nude mice, which were separated into 3 groups based on time of keloid harvesting after treatment: group A, 2 weeks; group B, 8 weeks; and group C, 14 weeks. Each group had 1 set of specimen from each patient. Histological staining was performed with hematoxylin and eosin stain. Immunohistochemistry staining was performed for human-prolyl 4-hydroxylase (hPH4) and caspase 3 protein, along with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. RESULTS: All keloid specimens survived, with no noted overgrowth. Hematoxylin and eosin staining revealed dense extracellular matrix and viable fibroblasts, and hPH4 immunohistochemistry revealed strong expression, demonstrating keloid viability. Caspase 3 protein and TUNEL expressions were significantly increased in the treatment versus control groups, demonstrating that TA injections induced apoptosis. CONCLUSIONS: Triamcinolone acetonide intralesional injections significantly increased apoptosis in keloids, represented by increased caspase 3 protein and TUNEL expressions, supporting that steroids suppress keloids in part owing to enhancement of apoptosis.

Fluorescent Nanodiamonds Enable Long-Term Detection of Human Adipose-Derived Stem/Stromal Cells in an In Vivo Chondrogenesis Model Using Decellularized Extracellular Matrices and Fibrin Glue Polymer.

Clinically available materials, including allogeneic irradiated costal cartilage and fibrin glue polymer, were used as scaffolds for in vivo chondrogenic differentiation of human adipose-derived stem/stromal cells (hASCs) in the attempt to develop a more efficient treatment over current methods. Current studies include the use of growth-factor stimulation, tissue engineering, and biocompatible materials; however, most methods involve complicated processes and pose clinical limitations. In this report, the xenografts in the experimental group composed of a diced decellularized cartilage extracellular matrix (ECM), hASCs, and fibrin glue polymer were implanted into the subcutaneous layer of nude mice, and the results were compared with two groups of controls; one control group received implantation of decellularized cartilage ECM and fibrin glue polymer, and the other control group received implantation of hASCs mixed with fibrin glue polymer. To evaluate whether hASCs had in vivo chondrogenesis in the xenografts, hASCs were labeled with fluorescent nanodiamonds (FNDs), a biocompatible and photostable nanomaterial, to allow for long-term detection and histological analysis. Increased cellularity, glycosaminoglycan, and collagen deposition were found by the histological examination in the experimental group compared with control groups. With the background-free detection technique and time-gated fluorescence imaging, the numbers and locations of the FND-labeled hASCs could be detected by confocal microscopy. The chondrocyte-specific markers, such as aggrecan and type II collagen, were colocalized with cells containing signals of FNDs which indicated in vivo chondrogenesis of hASCs. Taken together, functional in vivo chondrogenesis of the hASCs could be achieved by clinically available decellularized cartilage ECM and fibrin glue polymer in the nude mice model without in vitro chondrogenic induction. The fluorescent signals of FNDs in hASCs can be detected in histological analysis, such as hematoxylin and eosin staining (H&E staining) without the interference of the autofluorescence. Our study may warrant future clinical applications of the combination of decellular cartilage ECM, fibrin glue polymer, and hASCs for cartilage repair.