Long-Term Results of Oral Propranolol Treatment Protocol for Periocular Infantile Hemangioma: Should There Be Any Contraindication?

PURPOSE: The authors report long-term results of the oral propranolol treatment protocol for periocular infantile hemangioma regardless of conventional indications. METHODS: This is a retrospective study (2008-2018) on children with propranolol treatment protocol for periocular infantile hemangioma and last follow-up (FU) of ≥4 months after treatment and age of >24 months. After systemic evaluation, it was started with 0.5 and increased by 0.5 every 3 days to reach 2 mg/kg/day. If there was no good response, it would be gradually increased up to 3 mg/kg/day. Tapering (0.5 mg/kg/day every 4 weeks) was started when patients were on treatment for ≥6 months and ≥12 months old and there was no change in the infantile hemangioma size for ≥3 months. Rebound growth was based on the parents' report and would be treated by increasing the dose to at least 2 mg/kg/day for 3 months. FU was either in-person or via social media. Change in periocular infantile hemangioma size on the photos was scored by 3 masked observers (visual analog scale) and presented as excellent (≥50% reduction), good (1%-49%), fair (no change), and failure (enlarged). RESULTS: Forty-three patients were included. Orbital involvement was in 49%, ptosis in 58%, and risk of amblyopia in 63%. Mean treatment, tapering, and FU duration were 37, 13, and 74 months, respectively. Mean age at presentation, start of propranolol treatment protocol, tapering, stop, and last FU were 1.5, 5, 29, 42, and 78 months, respectively. Twenty-seven patients received 2, seven 2.5, and nine 3 mg/kg/day. Mean visual analog scale significantly increased from 43% (FU1) to 92% (last FU) when 97.6% of patients showed an excellent response. The remaining skin lesions were observed in 35%. No side effect was reported. CONCLUSIONS: Long-term results of the propranolol treatment protocol for periocular infantile hemangioma showed an excellent response in 97.6% of patients with no side effects. A residual skin lesion was observed in 1/3 of the patient.

Endoscopic-assisted Orbitotomy for Obliteration of Orbital Arteriovenous Fistula Refractory to Endovascular Techniques.

Orbital arteriovenous fistula is a rare acquired disorder. The coincidence of arteriovenous fistula with lymphaticovenous malformation is even rarer. The optimal treatment, thus, is controversial. Surgical approaches vary widely, with associated pros and cons. The purpose of this case report is to describe an orbital arteriovenous fistula in a 25-year-old man with congenital fronto-orbital lymphaticovenous malformation, refractory to endovascular techniques, which was later successfully ablated by a direct endoscopic-assisted orbital approach.

Minced Free Fat Graft Versus Pedicle Fat Flap to Efface Orbital Rim Hollow in Lower Blepharoplasty.

BACKGROUND: Lower eyelid fat flap repositioning during transconjunctival lower blepharoplasty (TCLB) is a widely accepted technique for preventing postoperative tear trough deformity. Its drawbacks include retraction, limited volume, transcutaneous fixation, and a complex insertion technique. The minced lower eyelid fat graft was introduced to overcome these drawbacks. OBJECTIVES: The aim of this study was to compare the outcome of preperiosteal pedicle fat flaps with minced free fat graft in TCLB. METHODS: Participants who underwent the pedicle fat flap procedure from April 2019 to April 2020 (Group A) and the minced free fat graft from May 2020 to May 2021 (Group B) with at least 6 months of follow-up were included. Subjective (pain, infraorbital numbness) and objective (chemosis, residual skin wrinkles, hyperpigmentation, tear trough deformity, bumps) postoperative outcomes, satisfaction (visual analogue scale score) at the last follow-up, and reoperation rates were compared. RESULTS: There were 142 participants (94% females) with a mean age of 48.4 years (range: 21-71) and a follow-up of 8.2 months (range: 6-36). There were 73 participants in Group A and 69 in Group B, with no significant differences in age (P = .6), sex (P = .7), or follow-up (P = .3). In addition to TCLB, Groups A and B had simultaneous upper eyelid and eyebrow procedures (53% vs 49%, P = .2), lateral canthal plication (77% vs 83%, P = .4), and pinch skin excision (82% vs 88%, P = .3). Groups A and B did not have significant differences in postoperative numbness (6.8% vs 1.4%, P = .2), chemosis (11% vs 10%, P = 1), skin wrinkles (12.3% vs 8.7%, P = .6), hyperpigmentation (1.4% in both groups), bumps (2.7% vs 7.2%, P = .3), tear trough deformity (0.0% in both groups), satisfaction score (97.7% vs 98.1%, P = .4), or reoperation rate (12.3% vs 5.8%, P = .2). CONCLUSIONS: The desired aim of fat redistribution in TCLB seems to be equally achievable with minced fat graft and pedicle fat flap techniques.

Impact of COVID-19 on the patient referral pattern and conversion rate in the university versus private facial plastic surgery centers.

PURPOSE: To compare the number of referrals and conversion rate between the pandemic and pre-pandemic period. METHODS: The number of referrals and conversion rate between the 10-month pandemic (March-December 2020) and pre-pandemic (March-December 2019) were evaluated in the two university (mainly non-cosmetic) and private (mainly cosmetic) facial plastic surgery centers. Demographics and monthly number and type (cosmetic and non-cosmetic) of the referrals and surgeries were recorded from the both and cosmetic facial injections (botulinum toxin and filler) and the source of referrals (web- and non-web-based) from the private center. The conversion rate was a ratio of the number of the surgeries to the number of referrals. RESULTS: The number of referrals declined by 7.7% in the private center which was significantly higher for the non-cosmetic (26%) than the cosmetic (0.5%) referrals. It was 32% in the university center. The private center conversion rate significantly (P < 0.001) decreased for both the cosmetic (60%) and non-cosmetic (82%) procedures. It was not significantly different between the cosmetic (65%) and non-cosmetic (58%) procedures in the university center. However, the number of cosmetic facial injections (11%) and the web-based referral source (4%) increased. The recovery was better for the number of referrals (better in the private center) than the conversion rate. CONCLUSION: The fall in the conversion rate was statistically significant in the private center. While the number of referrals recovered to almost the pre-pandemic level, the conversion rates, despite recovery, remained at a lower level at the end.

Short- and Long-term Patient Satisfaction and Complications in 650 Endoscopic Forehead Lift Procedures.

PURPOSE: The aims are to compare short- versus long-term patient satisfaction and report temporary versus permanent complications in 650 patients with endoscopic forehead lift procedure (EFL). METHODS: This is a retrospective study on all of the consecutive patients with EFL. Patients with previous trauma and surgery and less than 2 years follow up were excluded. Short- (6 months) and long-term (≥2 years) patient satisfaction (visual analog score [VAS], 0-100) were recorded. Patients' perspectives on temporary versus permanent complications were also documented. RESULTS: Mean age and follow up were 46.4 and 7.1 (2-13) years, respectively. Long-term satisfaction (79.9) was significantly lower than the short term (96.6). The long-term satisfaction decreased in 95.7%, increased in 2.7%, and remained the same in 1.6% of the patients. Intraoperative skin laceration occurred in 3 patients (0.5%). Mean time of forehead numbness recovery was 2.3 months. Temporary complications were itching (13.7%), headache (6.3%), unilateral facial nerve palsy (5.8%), acne (3.2%), and remained staples (1.7%). Permanent complications included undercorrection (7.1%), alopecia (4.2%), forehead irregularities (2.3%), surprised look (2.2%), incision site complications (2%), and glabellar depression (0.9%). Reoperation (1.2%) was performed for undercorrection and alopecia. While short-term satisfaction was significantly lower in patients with temporary facial nerve paresis, long-term satisfaction was lower in patients with undercorrection and reoperation. CONCLUSION: A high satisfaction scores of 96.6 and 80 were observed in the short- and long-term follow up after the EFL. Frequency of temporary and permanent postoperative complications was 30.3% and 15.8%. Reoperation rate was 1.2%.

Conversion Rate of Web-based Versus Non-web-based Patient Referral Sources in a Facial Plastic Surgery Practice.

PURPOSE: To compare the conversion rate (number of procedures/referrals) of web-based and non-web-based referrals to a facial plastic surgery practice (2012-2019). METHOD: Data on demographics, referral source, patient's concern, and their facial procedures were recorded. Web-based referral sources include website and Instagram. Non-web-based counterparts were the word-of-mouth, medical professionals, and others (TV, radio, printed media). Patient concerns were either cosmetic or noncosmetic (functional). Patients who underwent facial cosmetic surgery and injections (botulinum toxin A, filler, fat) were categorized in the cosmetic procedure group. Patients with functional procedures with or without facial injections were categorized in the noncosmetic procedure group. The conversion rate was defined as the ratio of the number of referrals with different facial procedures to the total number of referrals. RESULTS: Included were 19,965 patients, majority of whom (63.3%) had cosmetic concern. Total, cosmetic, and noncosmetic conversion rates were 30.1%, 27.7%, and 2.4% for the web-based and 24.1%, 19.8%, and 4.3% for the non-web-based referrals, respectively (0.3 < p < 0.4). Cosmetic conversion rate grew from 6.7% in referrals ≤20 to more than 23% in >20 years of age (p = 0.03). It was also significantly (p < 0.001) higher in the referrals with cosmetic (28.3%) than noncosmetic (12.1%) concern. Gender and year of practice did not have a significant effect on the conversion rates. CONCLUSION: Conversion rates were not significantly different between the web-based and non-web-based referrals. A significantly higher cosmetic conversion rate was observed for the referrals with cosmetic concern and older than 20 years.

Optic Nerve Head Vessel Density Changes from Graves' Disease without TED to TED Dysthyroid Optic Neuropathy: Does Optic Nerve Head Ischemia Play a Role?

PURPOSE: To compare the retinal peripapillary capillary (RPC) vessel density (VD) between 5 groups of patients on the spectrum of thyroid eye disease (TED). METHOD: This is a prospective comparative study looking at 5 groups of patients who were consecutively included from January 2018 to March 2021. They were composed of: Healthy volunteers (39 eyes and 20 subjects), patients with Graves' disease without TED (26 eyes and 13 patients), mild TED (28 eyes and 14 patients), moderate-severe TED (30 eyes and 17 patients), and TED with dysthyroid optic neuropathy (DON) (21 eyes and 12 patients). Ocular and periocular examination, visual field indices, RPC-VD (with optical coherence tomography angiography), and retinal nerve fiber layer, and macular ganglion cell complex thickness were recorded. RESULT: An initial insignificant (0.5 < p < 0.9) rise in the peripapillary-VD (pp-VD) and whole image-VD (wi-VD) from the healthy subject to the Graves' disease without TED was followed by a significant (p = 0.001) fall in RPC-VD in different severity grades of the TED. Paired comparison between the 5 groups showed that the statistically significant fall from the Graves' disease group occurred in the moderate-severe and DON groups (0.001 ≤ p ≤ 0.04). No variable significantly affected the VD (0.08 ≤ p ≤ 0.9). A lower wi-VD and pp-VD were significantly (0.001 ≤ p ≤ 0.009) correlated with the impaired optic nerve functional and structural tests. The sensitivity and specificity of wi-VD (81% and 76%) and pp-VD (69% and 71%) for detecting the DON were statistically significant (p < 0.001). CONCLUSION: Despite an insignificant rise in the wi- and pp-VD from the healthy volunteers to the patients with Graves' disease without TED, VD showed a declining trend in the course of patients with TED, which was statistically significant in the moderate-severe TED and DON groups.

Dermatochalasis Through Decades: A Histopathologic Study.

OBJECTIVES: Three prior studies (2008, 2011, 2018) histopathologically compared the eyelid specimens of patients with dermatochalasis (DC, undergoing blepharoplasty) with a control group and proposed that DC may begin with subclinical inflammation leading to elastolysis and lymphostasis. With growing number of younger patients consulting for blepharoplasty, the unanswered question is whether histopathologic changes of DC differ between the younger and the older. PATIENTS AND METHODS: In this prospective case series, 20 right upper eyelid skin of 20 nonsmoker, class 3 Fitzpatrik skin type women (30-68 years old) were histopathologically examined. Patients were divided into 2 age groups of 50 years or older and older than 50 years. Upper eyelid skin was preoperatively marked, intraoperatively removed, postoperatively divided into 3 sections: lateral (lateral limbus to lateral canthus), central (between medial and lateral limbi), and medial (medial limbus to medial canthus), and separately (totally 60 specimens) sent for histopathological examination. A masked pathologist recorded skin thickness in all specimens (60) as well as lymphatic vessels diameter and density, elastic fiber density, macrophage number, collagen intrafibril edema, and depth of collagen stromal bed in central sections (20 specimens). RESULTS: There were 10 patients at each age group. Histopathological measurements were not significantly different between the 2 age groups except mean lymphatic vessel diameter (P = 0.034) that was larger in the second group (>50 years). A significant positive correlation was also observed between the age and lymphatic vessel diameter (rs = 0.3, P = 0.009). CONCLUSIONS: Lymphangiectasia progresses significantly by age. Histopathological characteristics of DC are the same in the 2 age groups.

Web-Based Versus Non-Web-Based Patient Referral Patterns and Factors Affecting Them.

PURPOSE: To analyze the 8-year (2012-2019) change in the patient referral source trends to a plastic surgery practice and the factors affecting them. METHODS: Data on demographics, referral source, and patient's concern were recorded. The web-based referral sources were website and Instagram and non-web-based included other patients (word-of-mouth), medical professionals (physician, nurse, and optometrist), and others (printed media, TV, and radio). Patients' concerns were divided into cosmetic and noncosmetic. The first (2012-2015) and second (2016-2019) half of the study period were also compared. RESULTS: Included patients were 19,965. The 8-year referral sources, in order of frequency, were medical professionals (34%), other patients (32.7%), web-based sources (32.5%), and the others (0.7%). The web-based sources significantly increased by 2.4 times in the second half. While they had a third rank after the medical professionals and other patients in the first half of the study period, they became the first in the second half. The non-web-based source showed a decline during the study period. Type of referral sources was not significantly different between the 2 genders. A significantly higher percentage of the patients between 21 and 50 years of age were referred through web-based sources than the other age groups. Patients with cosmetic concerns were 2 times more likely to be referred through web-based sources. CONCLUSION: The web-based referral sources have significantly grown from the third rank in the beginning to the first one from 2015 till the end of study.

Postoperative Blepharoptosis After Pars Plana Vitrectomy Procedure.

PURPOSE: To describe the frequency of blepharoptosis and factors affecting it after the pars plana vitrectomy (PPV) procedure. METHODS: In a prospective study, patients were recruited consecutively from October 2016 to June 2018. Upper eyelid margin reflex distance 1 and 2 (MRD1 and 2), upper eyelid crease height, and levator function were measured before, 1 and at least 6 months after surgery by the same investigator. Clinical and Clinically significant ptosis were defined as ≥0.5 and ≥2 mm drop of MRD1. RESULT: There were 60 eyes from 57 patients. The majority of surgeries were performed by the fellows (63.3%, 38/60) and under general anesthesia (95.0%, 57/60). Clinical and clinically significant ptosis following PPV were 47.2% (25/53) and 11.3% (6/53) at the last follow up (at least 6 months), respectively. MRD2 (p = 0.389) and eyelid crease height (p = 0.057) did not significantly change. Surgeons' level, time of the procedure and other variables were not significantly impacting the frequencies. CONCLUSION: Persistent clinically significant ptosis was observed in 11% of patients undergoing PPV. No variable was significantly associated with persistent postoperative ptosis after PPV.

Revisiting Anchor Epicanthoplasty in Mild to Moderate Asian Epicanthal Folds: A Clinicopathological Study.

BACKGROUND: To assess the epicanthal fold (EF), eyelid, eyebrow, scar, and patients' satisfaction after anchor epicanthoplasty and upper blepharoplasty and histopathologically compare Asian epicanthal fold skin with non-Asian counterpart. METHODS: Asian Iranians with grade 2 and 3 EF were included. Photographs were taken before and at least 12 months after the surgery. Photoanalysis included EF grade, inter-canthal distance (ICD), margin reflex distance 1 (MRD1), tarsal plate show (TPS), brow fat span (BFS), and eyebrow height. Manchester scar scale score (5-28) and patients' satisfaction score (0-100) were documented. The most medial skin of 5 Asian and 5 non-Asian subjects was histologically compared for the thickness and elastic fiber density and morphology. RESULTS: Included were 89 patients (178 eyelids) with a mean age of 31.6 years and follow-up of 13.1 months. Mean ICD significantly decreased by 3.5 mm (shortening ratio of 9.7%). All grade 2 and almost half of the grade 3 EF disappeared. Significant postoperative increase in mean MRD1 (0.3 mm) and TPS (1.1-1.4 mm) and decrease in BFS (3.3-3.6 mm) and eyebrow height (1.7-3.4 mm) were observed. Revision rate of epicanthoplasty was 7.3%. Mean satisfaction and scar scores were 97.1 and 5.4, respectively. Histopathologically, Asian and non-Asian medial upper eyelid skin was not significantly different. CONCLUSION: Anchor epicanthoplasty eliminated grade 2 and improved grade 3 EF with a high satisfaction and negligible scar. Simultaneous upper blepharoplasty significantly increased MRD1 and TPS and decreased eyebrow height. EF skin was not histologically different from non-Asians. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Diabetic versus non-diabetic rhino-orbito-cerebral mucormycosis.

OBJECTIVE: To compare the characteristics and outcomes of rhino-orbito-cerebral mucormycosis (ROCM) in diabetic versus non-diabetic patients. METHOD: It is a retrospective comparative case series on consecutive patients with biopsy-proven ROCM. Systemic and ophthalmic manifestations, imaging, management and final outcomes were compared between diabetic versus non-diabetic ROCMs referred the eye clinic of a university-based hospital (2008-2016). RESULTS: Forty-three diabetics (55 eyes) with mean age of 54.6 (SD:12.5) years and 20 non-diabetics (24 eyes) with mean age of 57.5 (SD:13.8) years were enrolled. Patients' survival was observed in 51% of diabetics and 70% of non-diabetics (P = .1). The mortality rate was 7.4 times (CI95%: 1.85-29.96) higher in diabetic ROCM treated with non-liposomal amphotericin (P = .01). Exenteration did not significantly change the mortality rate in either group. Globe survival was 40% and 50% in diabetics and non-diabetics (P = 1), respectively. Vision survival was observed in 20% of diabetics and 37% of non-diabetics (P = .2). CONCLUSION: Patients', globe and vision survivals were not different between diabetic and non-diabetic patients with ROCM. They were 51%, 40% and 20% in diabetic and 70%, 50% and 37% in non-diabetic ROCM.

Endoscopic-Assisted Lateral Orbitotomy for Large Orbital Roof Dermoid Cysts With Dural Invasion.

PURPOSE: To demonstrate the technique and report the results of endoscopic-assisted lateral orbitotomy for 6 patients with huge intraorbital dermoid cyst causing orbital roof bone erosion and dural invasion. METHODS: Patients had unilateral cystic tumor with proptosis and hypoglobus for more than 6 months. There was no compressive optic neuropathy. Lateral orbitotomy procedure was performed from 2004 to 2016 by 1 surgeon. Cysts were dissected, and fluid content was aspirated to reduce the size. Solid contents were then suctioned, its cavity was repeatedly irrigated, and orbital part of epithelial lining was removed. The remained epithelial lining and keratinized content at the orbital roof (abutting the dura) were removed using the rigid endoscope lenses (4 mm, 0° and 30°) and curettage. Orbital tissue was pulled away from the roof (inferior) by an assistant surgeon to make a space for introducing the lens and curette. The surgical field was frequently irrigated. No orbital drain was used, and all the patients were discharged on the same day after 8-10 hours of observation. Skin sutures were removed 1 week later. RESULTS: They were 4 men and 2 women with age range of 19-48 years. A large superolateral orbital tumor with roof erosion and dural invasion was observed on imaging. Procedures were performed uneventfully. Dermoid was the pathological diagnosis. While one patient lost to follow up after 1 week, others had 6-18 months follow-up time with no recurrence. CONCLUSIONS: Endoscopic-assisted lateral orbitotomy approach provided a good field of view, illumination, and magnification to totally remove all the content and epithelial lining of very large orbital roof dermoid cysts with dural invasion.

Pressure ulcer following circumferential head dressing.

PURPOSE: To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature. METHODS: Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination. RESULTS: Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU. CONCLUSION: Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.

Corneal endothelial assessment in xeroderma pigmentosum: a case-control study.

PURPOSE: To analyze and compare corneal endothelial mosaic in terms of endothelial cell population, morphology and irregularity in patients with xeroderma pigmentosum (XP) with clear corneas with normal age and sex matched subjects using specular microscopy. METHODS: Nine patients with XP without corneal involvement were evaluated in the study. An age and sex matched group of nine healthy subjects participated as control group. Evaluation of corneal endothelial layer was performed using specular microscopy. RESULTS: Each study group consisted of five males and four females with total mean age of 28 ± 11.3 years (12-46 years). Endothelial cell density was significantly lower in patients with XP in comparison with controls (P < 0.002). Maximum and minimum cell areas were significantly higher in XP group (P < 0.016 and P < 0.029, respectively). Although central corneal thickness was higher in controls, the difference was not statistically significant (P = 0.106). Furthermore, our study showed that the patients with XP had no difference with controls in terms of coefficient of variation of cell areas. CONCLUSIONS: This study showed that endothelial cell population can decrease in patients with XP, although other specular microscopic variables such as coefficient of variation and central corneal thickness may remain within normal values.

Supine Test: A New Test for Detecting Lacrimal Gland Prolapse Before Upper Blepharoplasty.

PURPOSE: To introduce a new (Supine) test and assess the values of lateral eyelid bulging for diagnosis of lacrimal gland (LG) prolapse before upper blepharoplasty. METHODS: In a prospective case series (2011-2017), lateral eyelid bulging and Supine Test were recorded, preoperatively. Lacrimal gland prolapse was graded as mild (<4 mm), moderate (4-7 mm), and severe (>7 mm). A few spots of cautery on LG capsule was performed in patients with bilateral mild and suture repositioning in unilateral or bilateral moderate and severe LG prolapse. Patients with asymmetric LG prolapse were treated based on more severe grade, bilaterally. RESULTS: Included were 1,207 patients. Frequency of positive Supine Test (11.8%, 142/1,207) increased from almost 10% in patients less than 41 years of age to 15% in more than 60 years of age. Their mean age was significantly older, and 53.2% showed asymmetric LG prolapse. Septum was just opened in patients with positive Supine Test, and all had LG prolapse of ≥3 mm (mean: 5.6 mm, range: 3-14 mm). Mild LG prolapse, moderate LG prolapse, and severe LG prolapse were observed in 22.5%, 62.6%, and 14.7% of the patients, respectively. Mean follow-up time was 22 months (12-60 months). Recurrence was observed in 1 patient (bilateral) after suture repositioning. Lateral eyelid bulging had a high negative (96.2%) and low positive (30.6%) predictive value when compared with the Supine Test. CONCLUSIONS: Positive Supine Test means LG prolapse of ≥3 mm (100% positive predictive value). Negative lateral eyelid bulging was highly predictive of no LG prolapse.

Change in Lower Eyelid Position After Ptosis Repair in Patients With Unilateral Myogenic Versus Aponeurotic Blepharoptosis.

PURPOSE: To compare preoperative and postoperative lower eyelid scleral show in patients with unilateral myogenic (MP) and aponeurotic (AP) ptosis, analyze the factors correlated with them, and assess the rate of postoperative lower eyelid symmetry in both groups. METHODS: Patients (older than 5 years old) with unilateral MP (58) and AP (20) were included from June 2015 to April 2017. Excluded were patients with previous eyelid surgery, strabismus, levator function of ≤3, and associated procedures. Margin reflex distance (MRD) 1 and 2 and levator function were measured by the same observer before and at least 6 months after the ptosis repair. RESULTS: Lower scleral show was observed in 56.8% and 80% of MP and AP, respectively. Margin reflex distance 2 was significantly (r = -0.37, p = 0.002) associated with MRD1 in the MP group (multiple regression analysis). Both groups showed a significant improvement of MRD2, postoperatively resulting in symmetric MRD2 in 91.4% of MP and 80% of AP group. It was not changed in 43% of MP and 25% of AP group. Multiple regression analysis showed that preoperative MRD2 was the only significant factor associated with postoperative improvement of scleral show in the MP group. CONCLUSIONS: Lower scleral show was significantly improved after ptosis repair in both MP and AP. The more severe MP was significantly associated with more severe preoperative scleral show. Preoperative MRD2 was the only factor predicting postoperative improvement of scleral show in the MP. No factor was significantly associated with MRD2 in the AP group.

Is primary optic nerve sheath schwannoma a misnomer? Report of two cases and literature review.

Aims: To report clinicopathological characteristics of two patients with optic nerve sheath schwannoma (ONSS) and review the literature. Method: The first patient (22-year-old man) presented with left eye proptosis and decreased vision in 2012 whose orbital imaging showed a large cystic lesion around the optic nerve. The second patient (52-year-old man) presented with decreased vision in the left eye (without proptosis) in the 2006. His imaging showed a small orbital apex lesion between the medial rectus and optic nerve. Both lesions were histopathologically consistent with ONSS. ONSS has previously been reported in 12 patients. Results: Orbital biopsy and subsequently external beam radiotherapy were performed for the first patient who showed a temporary improvement of vision. However, his proptosis progressed and vision decreased to light perception (LP) a few months after radiotherapy when the lesion was resected in April 2013. Second patient declined any procedure until his vision gradually decreased to LP in October 2007. It was then removed through a combined medial and lateral orbitotomy procedure. Both patients ended up with visual acuity of no LP and no recurrence in their last follow up visits in April 2018. No histopathological evidence was found to show that optic nerve sheath could be the origin for presenting and previously reported cases in the literature. Conclusion: Presenting cases and literature review imply that ONSS is a misnomer and all the lesions are different types of orbital schwannomas with optic nerve sheath attachment.