Modification of the Suprachoroidal Buckling Technique for the Treatment of Rhegmatogenous Retinal Detachment.

PURPOSE: To describe modification of the suprachoroidal buckling technique for the treatment of rhegmatogenous retinal detachment (RRD), which may improve the safety profile. METHODS: A single-surgeon foot-pedal-controlled automated suprachoroidal injection (SCI) of sodium hyaluronate 1%, namely ProVisc (Alcon Laboratories, Fort Worth, TX) was used for the treatment of RRD. MicroDose Injection Kit (MedOne Surgical, Sarasota, FL) including a connector and a 1-mL syringe, designed for subretinal injection, was used to adapt Constellation Vision System (Alcon Laboratories) console for SCI of ProVisc from the 1-mL syringe. RESULTS: This approach enables better surgeon control during SCI. Three highly myopic eyes of three patients with primary macula-on RRD and single superior peripheral retinal break were treated. Complete retinal reattachment was achieved in all eyes without complications. CONCLUSION: Injecting ProVisc under foot-pedal control provides a more precise and potentially safer suprachoroidal buckling technique compared with the manual technique with more variable injection speed and pressure.

RPE65 c.353G>A, p.(Arg118Lys): A Novel Point Mutation Associated with Retinitis Pigmentosa and Macular Atrophy

Precise genetic diagnosis in RPE65-mediated retinitis pigmentosa (RP) is necessary to establish eligibility for genetic treatment with voretigene neparvovec: a recombinant adeno-associated viral vector providing a functional RPE65 gene. This case report aims to report a novel RP-related point mutation RPE65 c.353G>A, p.(Arg118Lys), a variant of uncertain significance associated with a severe clinical presentation and the striking phenotypic feature of complete macular atrophy. We report the case of a 40-year-old male with inherited retinal dystrophy, all features typical for the RPE65-associated RP, and marked macular atrophy. Genetic testing identified that the patient was a compound heterozygote in trans form with two heterozygous variants: RPE65 c.499G>T, p.(Asp167Tyr) and RPE65 c.353G>A, p.(Arg118Lys). Furthermore, short-wavelength and near-infrared autofluorescence patterns exhibited deficiencies specific to mutations in the visual cycle genes. To the best of our knowledge, RPE65 c.353G>A, p.(Arg118Lys) is the first described point mutation on this locus, among all other reported insertional mutations, currently classified as likely benign and of uncertain significance. We concluded that this variant contributed to the pathological phenotype, demonstrating its significance clearly to be reclassified as likely pathogenic. This being the case, patients with this specific variant in homozygous or compound heterozygous form would be likely candidates for genetic treatment with voretigene neparvovec.

COMBINED TREATMENT WITH BEVACIZUMAB AND TRIAMCINOLONE ACETONIDE FOR MACULAR EDEMA DUE TO RETINAL VEIN OCCLUSION.

The purpose of this study was to determine the efficacy of combined intravitreal bevacizumab and triamcinolone in the treatment of macular edema due to retinal vein occlusion. A prospective randomized trial was conducted in the Department of Ophthalmology, Osijek University Hospital Centre in Osijek including 51 patients divided into three groups depending on the drug received. The first group received 1.25 mg intravitreal bevacizumab, the second group received 1 mg intravitreal triamcinolone, and the third group received a combination of 1.25 mg bevacizumab and 1 mg intravitreal triamcinolone on the same day. Changes in the central macular thickness, intraocular pressure and visual acuity were monitored during the follow up period. The retinal perfusion status was evaluated by fluorescein angiography. The group that received combined treatment had better outcome in terms of reduction of macular thickness. There was no statistically significant intraocular pressure elevation among the three treatment groups or within each group of patients. A positive trend regarding visual improvement was observed in the group receiving combined treatment in spite of the lowest initial visual acuity, highest value of macular thickness and longest mean duration of symptoms. In conclusion, combined treatment with bevacizumab and triamcinolone for the treatment of retinal vein occlusion is more potent, safe, efficient and cost-effective. It can also be recommended because fewer injections are needed in patients undergoing treatment for macular edema.

SPECIFIC CHARACTERISTICS OF OCULAR BIOMETRIC FACTORS IN GLAUCOMATOUS PATIENTS WITH PSEUDOEXFOLIATIVE SYNDROME AS MEASURED BY OPTICAL LOW-COHERENCE REFLECTOMETRY.

The aim of the study was to assess biometric factor aberrations and differences among groups of eyes with cataract and pseudoexfoliative syndrome, cataract and pseudoexfoliative glaucoma, and cataract and primary open-angle glaucoma (POAG), and to determine biometric factors of the eye specific for the group of glaucomatous patients with pseudoexfoliative syndrome by use of optical low-coherence reflectometry. This retrospective study included 72 patients, and the study sample of 102 eyes was divided into the following three groups according to diagnosis: 29 eyes with pseudoexfoliative syndrome and cataract; 36 eyes with POAG and cataract; and 37 eyes with pseudoexfoliative glaucoma and cataract. Data on biometric measurements (central corneal thickness, pupillary diameter, anterior chamber depth, lens thickness, axial length, retinal thickness, astigmatism and white-to-white) obtained by use of optical low-coherence reflectometry on a Lenstar LS 900® (Haag-Streit International) were collected and analyzed by thorough survey of medical documentation of patients scheduled for cataract surgery at Department of Ophthalmology, Sveti Duh University Hospital in Zagreb, Croatia. Comparative analysis of the groups yielded statistically significant differences in central corneal thickness (F2/99=7.066; p=0.001) and lens thickness (F2/96=5.133; p=0.008). The group of eyes diagnosed with pseudoexfoliative glaucoma and cataract had a significantly thinner cornea as compared with the other two groups and a significantly thicker lens as compared with the group of eyes with POAG and cataract. In conclusion, optical low-coherence reflectometry revealed differences in biometric factors among the three groups of eyes, with a statistically significantly thinner cornea and thicker lens in the group of glaucomatous patients with pseudoexfoliative syndrome.

Cystoid macular lesions are resistant to topical dorzolamide treatment in enhanced S-cone syndrome child.

PURPOSE: To evaluate whether cystoid macular lesions respond to treatment with dorzolamide 2% drops in the enhanced S-cone syndrome (ESCS) child, as several case reports document favorable efficacy in adults. METHODS: Seven-year-old boy with ESCS and cystoid macular lesions was treated with dorzolamide 2% in both eyes three times a day for a period of 7 months. The efficacy of treatment was analyzed by visual acuity assessment (ETDRS), multifocal electroretinography and SD-OCT central foveal thickness (CFT) measurement. RESULTS: Baseline RE CFT was 540 and 453 µm in the LE, with amplitude of P1-wave density 39.8 and 50.4 nV/deg(2), respectively. Best corrected visual acuity (BCVA) was 0.3 logMAR RE and 0.3 logMAR LE at distance. At 7-month follow-up examination, CFT showed no reduction in thickness (RE 599 µm, LE 521 µm). P1-wave density increased (RE 49.1 nV/deg(2), LE 84.9 nV/deg(2)), with BCVA 0.3 logMAR RE and 0.2 logMAR LE. CONCLUSIONS: To the best of our knowledge, this is the youngest ESCS patient treated with dorzolamide drops and the first report recording that cystoid macular lesions are resistant to topical dorzolamide treatment. Furthermore, these data are in favor of the hypothesis that microcystoid changes in ESCS appear due to defects in cell-to-cell adhesion rather than the disintegration of the retinal barrier. The marked differences in treatment response to carbonic anhydrase inhibitors between the adults and the child here presented suggest that the breakdown of the blood-retinal barrier may play a more important role later in life.

Zagreb Amblyopia Preschool Screening Study: near and distance visual acuity testing increase the diagnostic accuracy of screening for amblyopia.

AIM: To present and evaluate a new screening protocol for amblyopia in preschool children. METHODS: Zagreb Amblyopia Preschool Screening (ZAPS) study protocol performed screening for amblyopia by near and distance visual acuity (VA) testing of 15 648 children aged 48-54 months attending kindergartens in the City of Zagreb County between September 2011 and June 2014 using Lea Symbols in lines test. If VA in either eye was >0.1 logMAR, the child was re-tested, if failed at re-test, the child was referred to comprehensive eye examination at the Eye Clinic. RESULTS: 78.04% of children passed the screening test. Estimated prevalence of amblyopia was 8.08%. Testability, sensitivity, and specificity of the ZAPS study protocol were 99.19%, 100.00%, and 96.68% respectively. CONCLUSION: The ZAPS study used the most discriminative VA test with optotypes in line as they do not underestimate amblyopia. The estimated prevalence of amblyopia was considerably higher than reported elsewhere. To the best of our knowledge, the ZAPS study protocol reached the highest sensitivity and specificity when evaluating diagnostic accuracy of VA tests for screening. The pass level defined at ≤0.1 logMAR for 4-year-old children, using Lea Symbols in lines missed no amblyopia cases, advocating that both near and distance VA testing should be performed when screening for amblyopia.

Relation of the aged gels microstructure on the zeolite a particulate properties.

The microstructure of the starting hydrogel has extremely important role in the synthesis of the microporous materials. Due to the fact that very limited number of experimental methods (techniques) can be used for gel analysis, there are still a lot of missing informations about the processes on molecular level, which occur before and during the nuclei formation. In this paper, various methods were used in characterization of pretreated (aged) hydrogel before the process of its hydrothermal transformation to zeolite A. Results show the changes in chemical composition and in microstructure of the solid phase (FTIR, PALS, BET, DTG), indicating that the structure of the ordered phase (potential nuclei) within gel matrix (completely amorphous according to PXRD patterns) is rather of different structural units typical for FAU and SOD (or their mixture) than the final product (LTA) only!

Vitreous hyper-reflective dots and the macular thickness after cataract surgery.

PURPOSE: To assess the association between vitreous hyper-reflective dots (VHD) and the macular thickness changes following uneventful phacoemulsification. METHODS: In this prospective cohort study optical coherence tomography (OCT) examinations were performed preoperatively and 1 week, 1 month and 3 months postoperatively in patients undergoing cataract surgery. OCT images were analyzed for retinal central subfield thickness (CST) and preretinal VHDs. Surgeries were recorded for the assessment of lens fragments in the space of Berger. RESULTS: 111 eyes of 97 patient were enrolled of whom 69 (62.2%) were female. VHDs were seen in 25 eyes (22.5%) at week 1; in 21 eyes (18.9%) at month 1 and in 3 eyes (2.7%) at month 3. In all eyes with VHDs retro-capsular lens fragments were visible immediately after phacoemulsification. The number of VHDs significantly decreased over the postoperative period. There was a moderate correlation between the number of VHDs and CST at 1 month (r = 0.426, p<0.001). In eyes with VHD the CST averaged 238.8±17.6 µm (214-266) at 1 week; 276.1±63.5 µm (231-481) at 1 month and 285.1±122.3 µm (227-785) at 3 months. In eyes with no detectable VHDs CST averaged 235.9±23.3 µm (192-311) at 1 week; 240.1±21.6 µm (200-288) at 1 month and 242.2±21.3 µm (205-289) at 3 months. Although the differences among the assessment points were relatively low, there was a significant difference in general (p<0.001, Friedman test). CONCLUSION: In conclusion, VHDs seem to cause macular thickening throughout the postoperative course. The origin of VHDs is still unknown; however, they presumably represent lens fragments that provoke subclinical inflammation.

Pathogenicity reclassification of the RPE65 c.1580A>G (p.His527Arg) - a case report.

BACKGROUND: It is of utmost importance to define the molecular diagnosis of patients with retinitis pigmentosa (RP) due to existing targeted therapeutic option: voretigene neparvovec.We provide clinical evidence for pathogenicity reclassification of variants of uncertain significance (VUSs) RPE65 c.1580A>G (p.His527Arg). MATERIALS AND METHODS: A case report of a 10-year-old boy with progressive vision loss. The patient manifested disease highly suggestive of RPE65 retinal dystrophy: nyctalopia, fairly good central vision, severely depressed full-field electroretinography responses and complete loss of peripheral fundus aut ofluorescence. RESULTS: Invitae Inherited Retinal Disorders Panel identified likely pathogenic mutation RPE65 c.499G>T (p.Asp167Tyr) and RPE65 c.1580A>G (p.His527Arg), variant of uncertain significance. Segregation analysis confirmed that these variants are in trans. CONCLUSIONS: We conclude that the variant RPE65 c.1580A>G (p.His527Arg) has contributed to the pathologic phenotype, demonstrating its significance clearly in the case presented, and should be reclassified according to the criteria of evidence as pathogenic. Therefore, patients with this specific variant in homozygous or compound heterozygous form would likely benefit from genetic treatment based on recombinant adeno-associated virus vector, providing a working RPE65 gene to act in place of a mutated RPE65 gene.

Optical low-coherence reflectometry enables preoperative detection of zonular weakness in pseudoexfoliation syndrome.

PURPOSE: To evaluate optical ocular components in patients with pseudoexfoliation syndrome using optical low-coherence reflectometry. METHODS: A prospective cohort study of 224 eyes of patients planned for cataract surgery was conducted in the period from January 2009 until July 2009. Patients were divided in two groups: the first group of 47 eyes with cataract complicated with pseudoexfoliation syndrome and the control group of 177 eyes with uncomplicated cataract. Each group was further divided into two subgroups based on its refractive state: emmetropes and hypermetropes. The optical low-coherence reflectometry biometer LENSTAR LS 900 was used to define ocular optical components. RESULTS: A statistically significant difference of ocular optical components was established between the two groups of patients and its matching subgroups: AL (t = 2.25; p < 0.05) and ACD (t = 2.24; p < 0.05) were significantly higher in the control group, PD was significantly higher in the control group hypermetropes than the PEX group hypermetropes (t = 2.21; p < 0.05) while LT (t = 3.01; p < 0.001), AST (t = 2.13; p < 0.05) and IOL (t = 3.06; p < 0.001) were higher in the PEX group of patients than in the control group. CONCLUSIONS: The optical low-coherence reflectometry enabled preoperative detection of zonular weakness and subsequent lens instability documented as a significantly shallower anterior chamber, thicker lens, and smaller pupillary diameter in the pseudoexfoliation syndrome group in the studied population.

Early satellite metastatic uveal melanoma to the lower eyelid--the first report.

PURPOSE: To present a unique case of an early satellite metastatic uveal melanoma to the ipsilateral lower eyelid. METHODS: Retrospective review of the medical records of a single patient. RESULTS: A 71-year-old white male developed a fast growing, painless, solitary, subcutaneous, nodular mass in the medial half of his right lower eyelid 13 months after enucleation of the right eye for inferonasally located uveal melanoma of the spindle cell type. Microscopically excised eyelid tumor proved to be malignant melanoma of the epitheloid type. The patient underwent complete systemic examination including positron emission tomography that ruled out the primary cutaneous or visceral melanoma. CONCLUSION: The paper is, according to our knowledge, the first documented case of an early satellite metastatic uveal melanoma to the lower eyelid in the patient with no evidence of further metastases.

Modified operative technique for involutional lower lid entropion.

The paper presents a modified operative technique for involutional lower lid entropion. The prospective noncomparative study of 101 lower eyelids of 88 patients undergoing surgery for involutional lower lid entropion was conducted in period from September 2005 until March 2012. Indication for the surgery was entropion, previously untreated, with moderate to severe horizontal lid laxity and no clinically relevant medial and lateral canthal tendon laxity. The operative technique is our modification of Quickert and Jones procedures. Photo was taken preoperatively and one month after surgery. Clinical follow-up was at 7th postoperative day, one month and six months after surgery and in case of the recurrence. Long-term follow-up was obtained via telephone interviews. There were 44 male (50%) and 44 female (50%) patients included in the study. The age of patients was in average 73.27 +/- 8.1 years (range 53-90 years). Early postoperative complication was localized lid swelling found in two patients starting 4-6 weeks postoperatively at the area of absorbable suture. It resolved spontaneously in two and three weeks respectively. There was recurrence of entropion in 11 eyelids (10.89%) of 10 patients. The mean interval between primary surgery and the recurrence was 17.45 +/- 14.84 months (range 4-48 months). In these eyelids Jones procedure was performed. However in four eyelids of four patients from the recurrent group an additional surgery needed to be performed after 6, 12, 12 and 17 months respectively. Our modification of surgical treatment for involutional lower lid entropion was effective in 89.11% of eyelids. Complications of the procedure were scarce.

RPE65 c.393T>A, p.(Asn131Lys): Novel Sequence Variant Detected.

Background: Leber congenital amaurosis (LCA) is a monogenic, but genetically heterogenous disease, and at least 27 genes are implicated. This case report is aimed at providing evidence to link the novel variant RPE65 c.393T>A, p.(Asn131Lys), variant of uncertain significance (VUS), to clinical phenotype and to set the ground for objective assignment of pathogenicity confidence. Case Presentation. A case report of a female patient with LCA who manifested with nystagmus, night blindness, profound visual deficiency, and peripheral involvement of the retina consistent with RPE65 dystrophy. A thorough clinical examination, diagnostic evaluation, and genetic testing were performed. The patient was a compound heterozygote in trans form: RPE65 c.304G>T, p.(Glu102∗) pathogenic, and RPE65 c.393T>A, p.(Asn131Lys), VUS. The latter variant is absent in healthy controls and is considered harmful on in silico prediction. Conclusions: We conclude that RPE65 c.393T>A, p.(Asn131Lys) contributed to the pathologic phenotype, demonstrating its significance clearly in the case presented, and should be reclassified according to the criteria of evidence as likely pathogenic. This being the case, patients with this specific variant are likely candidates for genetic treatment.

Analysis of association of risk factors for age-related macular degeneration.

PURPOSE: To evaluate the significance of risk factors and analyze their interrelationship in developing age-related macular degeneration (AMD). MATERIALS AND DESIGN: This is a multicenter, cross-sectional study conducted in eight ophthalmology centers in Europe. The STARS (Simplified Thea AMD Risk-Assessment Scale) questionnaire was used to assess 12 risk factors grouped in four major categories. We used Welch's t-test/F ratios to determine statistically significant changes. The principal component analysis was done to investigate the association between risk factors. RESULTS: There were 3297 participants included in our data analysis. Nineteen percent of patients had a high risk of developing AMD, whilst 45.92% and 34.85% had moderate and small risk, respectively. Atherosclerosis appeared as the most relevant risk indicator for AMD development (Cohen's d = 0.861). Tukey's post hoc analysis of the smoking variable showed that ex-smokers (p < 0.001) have a significantly high risk of developing AMD. The Welch's t-test showed pseudophakic patients have a higher risk of developing AMD than phakic ones. Then, we conducted the principal component analysis, which revealed a significant connection between smoking and male gender and between smoking and atherosclerosis. Pseudophakic patients were generally older and had more often myocardial infarction as compared to phakic patients. We showed that higher BMI, history of arterial hypertension, hypercholesterolemia, and atherosclerosis tend to occur together as risk factors for AMD. CONCLUSION: Risk factors evaluated in our study should be considered for the development of AMD.

Comparison of optical low-coherence reflectometry and applanation ultrasound biometry on intraocular lens power calculation.

BACKGROUND: The aim of the study was to determine whether the innovative non-contact optical low-coherence reflectometry method utilized by the Lenstar LS 900® agrees sufficiently with applanation ultrasound A-scan technique in routine biometric measurement and intraocular lens power calculation to replace it. METHODS: Twenty-two patients hospitalized at our eye clinic undergoing cataract surgery were assigned to have five consecutive measurements of axial length by two examiners in a single session using applanation ultrasound and the Lenstar. The applanation ultrasound intraocular lens power calculation was based on automated keratometry and applanation ultrasound axial length measurements. The Lenstar intraocular lens power calculation was based on its measurement of keratometry and axial length. Bland-Altman analysis was used to assess interobserver repeatability of applanation ultrasound and the Lenstar as well as agreement between the Lenstar and applanation ultrasound for axial length measurement and intraocular lens power calculation. RESULTS: Thirty-two eyes of 22 patients were analyzed. In 95% of the observations, predicted refractive error corresponded to -0.26 ± 0.62 D and 0.01 ± 0.20 D obtained with applanation ultrasound and the Lenstar, respectively. CONCLUSIONS: Based on excellent repeatability of the Lenstar and acceptable repeatability of applanation ultrasound, two techniques may be used interchangeably. The predicted refractive error of ± 0.20 D in 95% of the observations has never been achieved. Optical low-coherence reflectometry might become a new standard method for biometric measurement needed for intraocular lens-power calculation in patients with cataract.

Intraobserver and interobserver repeatability of ocular components measurement in cataract eyes using a new optical low coherence reflectometer.

BACKGROUND: The purpose of the study was to assess intraobserver and interobserver repeatability of eight ocular components measurement in cataract eyes using the optical low-coherence reflectometer Lenstar LS 900®. METHODS: Five consecutive measurements of ocular components were taken by two examiners using the Lenstar. Components analyzed were: central corneal thickness, lens thickness, anterior chamber depth, axial length, retinal thickness, keratometry, white-to-white distance, and pupillometry. Within-subject standard deviation and the coefficient of variation were calculated for evaluation of intraobserver repeatability. Bland-Altman analysis was used for assessment of interobserver repeatability. RESULTS: Thirty-two eyes of 22 patients were included. For both observers, the smallest intraobserver coefficient of variation was obtained for axial length, while the largest was found for corneal steepest meridian position. Interobserver repeatability demonstrated less repeatable results for white-to-white distance and corneal steepest meridian position. Considering axial length and anterior chamber depth values, predicted refractive error was 0 ± 0.05 D and 0.02 ± 0.19 D respectively in 95% of observations. CONCLUSION: The Lenstar LS 900® evidenced excellent repeatability and observers´ independent results of all components analyzed except white-to-white distance and corneal steepest meridian position measurements. To the best of our knowledge, this is the first study on interobserver repeatability of optical low-coherence reflectometry in cataract eyes.

Do Gender, Age, Body Mass and Height Influence Eye Biometrical Properties in Young Adults? A Pilot Study.

BACKGROUND: Do gender, age, body mass and height influence eye biometrical properties in young adults? METHODS: A total of 155 eyes (92 female, 63 male) of healthy subjects between the ages of 18 and 39 years were included in the study. The subjects' gender and age were recorded, and their body mass, height and biometrical properties of the eyes were measured. RESULTS: The male subjects had significantly thicker and flatter corneas and lower minimal rim-to-disk ratios than the female subjects did. In both genders, age showed strong, negative correlations with anterior chamber depth and pupil diameter and a positive correlation with lens thickness. We also found significant, negative correlations between body height and mass with keratometry measurements, negative correlations between body height and optic disk rim area and rim volume, and positive correlations between body mass and axial length in both genders. CONCLUSIONS: Biometric eye parameters differ among people. In addition to age and gender, which are usually taken into consideration when interpreting ocular biometry findings, we strongly suggest that body height and mass should be also routinely considered when interpreting eye biometry data, as these factors have an impact on ocular biometry.

Our experience with dermofat graft in reconstruction of anophthalmic socket.

PURPOSE: To present our experience with dermofat graft in reconstruction of anophthalmic socket. MATERIAL AND METHODS: In period from September 2005 until June 2009, eight patients have undergone orbital surgery of transplantation of dermofat graft. In six patients the dermofat graft was used as the secondary orbital implant after extrusion of hydroxyapatite orbital implant with major defect of bulbar conjunctiva. The other indication for the dermofat graft was correction of deep superior sulcus of the upper lid in anophthalmic socket in two patients. The graft was harvested from the left side of the belly. The size of the graft purposely exceeded the size of the defect to account for the expected tissue resorption. RESULTS: We experienced no major complication. Approximately 20-40% of dermofat graft reduction was noticed in 3-months period postoperatively. It took 6-8 weeks for the graft to fully epithelize from the conjunctival edge. Silicone conformer was introduced for that period of time. Subsequently, in two out of six patients with dermofat graft as the secondary implant, fornix had to be reconstructed later on with oral mucosa graft. CONCLUSION: Dermofat graft is a valuable material in orbital reconstruction especially in anophthalmic socket.

Microincision aponeurotic ptosis surgery of upper lid.

The paper is a prospective study of 23 lids of 20 patients with upper lid aponeurotic ptosis operated using microincision technique in period 2005-2008. There were 7 males and 13 females. Age of the patients was 28-83 years (y), average 61 +/- 17 y, for female 63 +/- 13.4 y and for male 61 +/- 19 y. Inclusion criteria were: aponeurotic upper lid ptosis more than 2 mm, no other lid abnormalities, minimal dermatochalasis, no previous or concomitant lid surgery. The procedure was performed in local anesthesia through 10 mm cut. Aponeurosis was fixated to the tarsal plate with two sutures. Success was considered if operated lid height differed up to 0.5 mm of the other eye and margin-to-reflex distance was 2-4 mm in primary position. Postoperative results regarding contour, skin crease and lash position were good in all patients. Regarding height, 19/23 (83%) met criteria of 0.5 mm of the other eye and MRD 2-4 mm. In one bilateral procedure there was an asymmetry of 1 mm. Three patients with unilateral procedure had at least 1mm asymmetry comparing to the other eye. Reoperation was neccessary in two bilateral cases. Lid fold was symmetrical only in 7 patients (35%). The rest had slight to grose lid fold asymmetry. Complications were scarce, in early postoperative period there was hematoma in two patients lasting up to three weeks. Late failure was noticed in two cases 6 and 8 months postoperatively. Advantages are: less anesthetic results in less decreased levator function and more accurate assessment of eyelid position intraoperatively, less distortion of the lid due to less bleeding and edema, shorter operation time, less scarring and shortened recovery time. However it can be used only in selective cases.