Clinicopathologic Characteristics Associated with Prognosis in Ocular Extranodal Marginal Zone B Cell Lymphoma.

Background and Objectives: Extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) type is the most common subtype of the ocular adnexal lymphoma. Despite its excellent prognosis, some patients experience partial remission or progressive disease. We aimed to evaluate clinicopathologic differences in the treatment responder group by comparing complete remission (CR) and non-complete remission (non-CR). Materials and Methods: This study retrospectively reviewed 48 patients who were diagnosed with ocular adnexal MALT lymphoma at Ulsan University Hospital between March 2002 and August 2018. Patients who were followed up for less than 6 months were excluded. Histologic and clinical features were analyzed. The patients were divided into two groups: CR and non-CR. Results: Among the 48 patients, 33 achieved CR and 15 achieved non-CR during the median follow-up period of 40.00 months (range, 7-109 months). In univariable analysis, more patients tend to undergo treatment in the CR group, and post-radiotherapy (post-RT) SUVmax, PET and serum lactate dehydrogenase (LDH) levels were higher in the non-CR group (p = 0.043, p = 0.016, and p = 0.042, respectively). In a multivariable analysis, only application of treatment, including radiotherapy or chemotherapy with immunotherapy, was related to CR (odd ratio 7.301, 95% confidence interval 1.273-41.862, p = 0.026). In subgroup analysis according to the site of involvement, none of the variables were significant except for the post-RT SUVmax of PET and level of serum LDH in the non-conjunctiva group (p = 0.026, and p = 0.037, respectively). Seven (14.6%) patients had a recurrence, and those with a recurring site other than the primary site had a higher Ki-67 labeling index, although it was not statistically significant (9.56% vs. 18.00%, p = 0.095). Conclusions: Although belonging to the early stages, the non-CR rate was high in patients with high serum LDH levels, and recurred patients had higher Ki-67. Thus, considering active treatment is recommended in this group of patients.

Revision Surgery for Undercorrected Blepharoptosis After Frontalis Sling Operation Using Autogenous Fascia Lata.

PURPOSE: Undercorrected blepharoptosis can be encountered after frontalis sling operation. Revision surgery for undercorrection has commonly involved introducing a new sling material. We describe and evaluate a simple surgical technique to correct undercorrection by adjusting preexisting fascia. METHODS: This is a retrospective interventional case series of patients undergoing sling revision between February 2010 and February 2017. Skin incision was made on the previous incision line. Careful dissection was performed superiorly to identify a preexisting fascia, and the dissected fascia was reattached to the tarsal plate using nonabsorbable sutures with adjustments for eyelid height and contour. The success of the procedure was defined as less than 1 mm of difference in the marginal reflex distance 1 of both eyes without any contour deformity. RESULTS: Twenty-one eyelids in 18 patients were included with a mean follow-up of 17.5 months (range 6-48) and a mean age of 14.7 years (range 5-57). All patients had undergone frontalis sling with autogenous fascia lata for congenital ptosis. Undercorrection due to recurrent ptosis was found in 12 eyelids, and contour deformity such as temporal ptosis was found in 9 eyelids. The mean time interval between previous frontalis sling operation and sling revision was 6.8 years. Nineteen patients (90.5%) achieved surgical success and a cosmetically acceptable appearance. CONCLUSION: Sling revision is a simple and effective method with low perioperative morbidity for cases of undercorrection or contour deformity following frontalis sling operation using autogenous fascia lata, even long after the primary procedure.

Modified Epiblepharon Repair Preserving Orbicularis Oculi Muscle.

Methods: A retrospective review of was conducted of patients who received modified epiblepharon repair preserving orbicularis oculi muscle from April 2016 to October 2018. Removal of the orbicularis oculi muscle was minimally performed with eyelash rotating sutures and epicanthal weakening procedure. The preoperative severity of epiblepharon was classified according to skin fold height and cilia-corneal touch. Main postoperative outcomes were evaluated by functional success and cosmetic satisfaction. Results: A total of 208 eyelids of 104 patients were evaluated. The mean age was 7.2 ± 4.2 years with a mean follow-up time of 5.6 ± 4.6 months. Functional success was obtained in 206 eyelids (99.0%). Only two cases that had a total epiblepharon score of 7 showed a recurrence of mild cilia-corneal touch, but reoperation was not required. The cosmetic satisfaction score was 8.7 ± 1.8 (range, 1-10). The excellent cosmesis group with a cosmetic score of 9 or higher had significantly higher skin fold height (p=0.027). Conclusions: Modified epiblepharon repair preserving orbicularis oculi muscle can be effective in the treatment of lower epiblepharon regardless of its severity. Excellent outcomes were obtained functionally and cosmetically without debulking of the orbicularis oculi muscle.

Association of blepharoptosis with refractive error in the Korean general population.

BACKGROUND/OBJECTIVES: We investigated the effect of blepharoptosis on refractive errors across different age groups in Korean population. SUBJECTS/METHODS: This cross-sectional study was performed with data obtained in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2012. A total of 33,103 participants were enroled in our study. Blepharoptosis was defined as a marginal reflex distance 1 (MRD1) less than 2 mm, and was diagnosed in 3,305 (9.98%) participants. Ophthalmic examinations were performed, including measurements of MRD1, spherical equivalent, and degree of astigmatism. The age range was divided into three groups: less than 20 years old; more than 20 years and less than 60 years old; and more than 60 years old. RESULTS: The mean spherical equivalent were -0.28 ± 2.23 D in the ptotic eyelids and -1.13 ± 2.30 D in the non-ptotic eyelids (p < 0.001, 95% CI: -0.93, -0.77). The mean cylinder dioptre were -1.03 ± 0.87 D and -0.80 ± 0.77 D respectively (p < 0.001, 95% CI: 0.20, 0.26). The association with the eyelid position and refractive error significantly differed according to the age group and body mass index. Increased positive spherical change and increased astigmatism were prominent among ptotic participants aged less than 60 years. CONCLUSIONS: A decrease in MRD1 was associated with a hyperopic shift and higher astigmatism. Mechanical compression of the ptotic eyelid may affect ocular biometry, with the effect being particularly prominent in younger participants who had greater eyelid tension.

Astigmatism Associated with Allergic Conjunctivitis in Urban School Children.

INTRODUCTION: We first examined the association of an ocular refractive error with allergic conjunctivitis in school children and then examined this association in children attending a suburban school and an urban school. METHODS: We enrolled 426 children attending a primary school in a suburban area and 550 children attending a primary school in an urban area which had a higher level of air pollution. Allergic conjunctivitis was defined as the diagnosis of this condition at any time during a child's life. The ophthalmic examinations included measurements of visual acuity and refraction, and a slit lamp examination. Skin prick tests were also performed at each school during 2018. The significance of associations was determined by the calculation of odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Astigmatism (increase of 1 cylindrical diopter) was associated with allergic conjunctivitis in children overall (OR = 1.287, 95% CI = 1.010 to 1.642) and in children attending the urban school (OR = 1.408, 95% CI = 1.029 to 1.926), but not in children attending the suburban school (OR = 1.040, 95% CI = 0.672 to 1.610). Allergic conjunctivitis also had a higher prevalence among children attending the urban school. The urban school had higher levels of air pollutants than the suburban school. Skin prick tests indicated that the major allergens in children with allergic conjunctivitis were house dust mites and various types of pollen. CONCLUSION: Astigmatism is associated with allergic conjunctivitis in children attending an urban school.

Surgical treatment of unilateral severe simple congenital ptosis.

Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.

Maximal levator resection in unilateral congenital ptosis with poor levator function.

BACKGROUND/AIMS: Surgical treatments for the correction of congenital ptosis with poor levator function, including frontalis suspension or maximal levator resection, remain controversial. We evaluated the postoperative surgical and cosmetic outcomes after maximal levator resection for unilateral congenital ptosis with poor levator function. METHODS: A retrospective, interventional case series was performed. A total of 243 patients with 243 eyelids (210 unilateral and 33 bilateral asymmetric ptosis) who underwent unilateral maximal levator resection were included. The surgical results were graded as excellent, good and poor and postoperative complications were documented. RESULTS: The mean age at the time of surgery was 8.8±9.7 years (range, 2-58 years) with mean follow-up time of 40.9±38.9 months (range, 3 months to 18.9 years). Satisfactory results (excellent or good result) were obtained in 93.0% of the patients. Patients were divided into two groups based on levator function as follows: 0-2 mm (80 cases) and 2.5-4.0 mm (163 cases). Factors such as preoperative levator function, margin reflex distance-1 and levator dehiscence were not correlated with postoperative surgical outcomes. Complications included exposure keratopathy (11.1%), lid crease asymmetry (8.2%), entropion (8.2%), overcorrection (3.3%), eyelash ptosis (3.7%), temporal eyelid droop (3.3%), suture abscess (0.8%) and conjunctival prolapse (0.8%). CONCLUSIONS: Maximal levator resection is an effective procedure for congenital ptosis even in patients with poor levator function, which provides improved cosmesis, a more natural lid contour, and avoids brow scars.

Macular Choroidal Thickness and Volume Measured by Swept-source Optical Coherence Tomography in Healthy Korean Children.

PURPOSE: To evaluate the thickness and volume of the choroid in healthy Korean children using swept-source optical coherence tomography. METHODS: We examined 80 eyes of 40 healthy children and teenagers (<18 years) using swept-source optical coherence tomography with a tunable long-wavelength laser source. A volumetric macular scan protocol using the Early Treatment Diabetic Retinopathy Study grid was used to construct a choroidal thickness map. We also examined 44 eyes of 35 healthy adult volunteers (≥18 years) and compared adult measurements with the findings in children. RESULTS: The mean age of the children and teenagers was 9.47 ± 3.80 (4 to 17) vs. 55.04 ± 12.63 years (36 to 70 years) in the adult group (p < 0.001, Student's t-test). Regarding the Early Treatment Diabetic Retinopathy Study subfields, the inner temporal subfield was the thickest (247.96 µm). The inner and outer nasal choroid were thinner (p = 0.004, p = 0.002, respectively) than the surrounding areas. The mean choroidal volumes of the inner and outer nasal areas were smaller (p = 0.004, p = 0.003, respectively) than those of all the other areas in each circle. Among the nine subfields, all areas in the children, except the outer nasal subfield, were thicker than those in adults (p < 0.05). Regression analysis showed that age, axial length, and refractive error correlated with subfoveal choroidal thickness (p < 0.05). CONCLUSIONS: Overall macular choroidal thickness and volume in children and teenagers were significantly greater than in adults. The nasal choroid was significantly thinner than the surrounding areas. The pediatric subfoveal choroid is prone to thinning with increasing age, axial length, and refractive error. These differences should be considered when choroidal thickness is evaluated in children with chorioretinal diseases.

A clinical study on the trocar-guided mesh repair system for pelvic organ prolapse surgery.

OBJECTIVE: To evaluate the complication and recurrence rates in patients undergoing trocar-guided mesh implant for pelvic organ prolapse (POP) treatment. METHODS: A retrospective study was performed based on the medical records of patients who had undergone mesh implant by one surgeon from May 2006 to August 2013 at the Presbyterian Medical Center in Korea. We evaluated perioperative complications such as bladder injury, mesh exposure, urinary symptoms, infections, and chronic pelvic pain. Recurrence was defined as a POP-quantification system stage ≥II or any symptomatic prolapse. RESULTS: Sixty-seven patients were evaluated, and the mean age of patients was 65.4±7.2 years. Stage ≥III POP-quantification Ba was noted in 61 patients (91%). Intraoperative complications included three cases of bladder injury (4.5%). The mean follow-up period was 44.1±7.9 months. Postoperative complications occurred in seven women (10.5%): four cases of urinary symptoms (6%), two cases of infections (3%), and one case of chronic pelvic pain (1.5%). Mesh exposure did not occur (0%). Prolapse recurrence was reported in five patients (7.5%). CONCLUSION: Based on our operational result, the trocar-guided mesh implant seems to provide safe and effective outcomes.

Preaponeurotic fat advancement in levator recession for treatment of upper eyelid retraction.

BACKGROUND: Postoperative cosmetic deformities can be encountered after surgical treatments for upper eyelid retraction. The authors described a preaponeurotic fat advancement technique and investigated the effectiveness in patients who underwent levator recession for upper lid retraction. METHODS: This retrospective comparative case series included 44 patients (57 eyelids) who underwent levator recession surgery with (flap group, n = 31) or without (no-flap group, n = 26) the preaponeurotic fat advancement flap procedure. Comparisons of the marginal reflex distance 1, palpebral fissure, upper palpebral fissure area, pretarsal show, eyelid asymmetry, and cosmetic complications were made between the two groups. Lid position outcomes (good, fair, and poor), which were grouped according to eyelid asymmetry, marginal reflex distance 1, and the position of upper eyelid margin, and cosmetic complications were assessed. RESULTS: In the flap group, lid position outcomes were graded as good in 16 patients (72.7 percent), fair in four patients (18.2 percent), and poor in two patients (9.1 percent). In the no-flap group, lid position outcomes were good in 15 patients (68.2 percent), fair in five patients (22.7 percent), and poor in two patients (9.1 percent). There were no differences between the two groups in achieving acceptable eyelid lowering and eyelid symmetry (90.9 percent in both groups). However, cosmetic outcomes demonstrated some differences. There were no multiple lid creases in the fat advancement group, compared with six eyes (23.1 percent) without fat advancement. CONCLUSION: Preaponeurotic fat advancement flap is an effective method with which to prevent unintended multiple lid creases and provide satisfactory cosmetic outcomes in levator recession.

IgG4-related disease in idiopathic sclerosing orbital inflammation.

AIMS: To investigate the frequency of IgG4-related disease (IgG4-RD) among patients previously diagnosed with idiopathic sclerosing orbital inflammation (ISOI), and to compare the clinical features and treatment outcomes of patients with ISOI associated with IgG4-RD and those without IgG4. METHODS: Retrospective clinicopathological series of 24 patients with ISOI diagnosed between June 2001 and June 2010. Biopsy specimens were immunostained for IgG-expressing and IgG4-expressing cells. Clinical data of patients with IgG4-RD and ISOI unrelated to IgG4 were obtained from patient records. RESULTS: Of 24 patients, 11 patients (45.8%) were identified with IgG4-RD. 10 patients (10/11, 90.9%) presented with bilateral lacrimal gland enlargement, and seven of those also had submadibular gland enlargement. One patient (1/11, 9.1%) presented with a superior orbital mass. All patients were successfully treated with steroids and/or radiotherapy or had an indolent clinical course. 13 patients (54.2%) were identified with ISOI unrelated to IgG4. Eight patients (8/13, 61.5%) showed unilateral orbital involvement, and nine patients (9/13, 69.2%) had orbital lesions not involving the lacrimal glands. Treatment modalities for ISOI unrelated to IgG4 were varied and less effective: eight patients (61.5%) relapsed following initial treatment with steroids or radiation, and additional therapies were required to enter remission. CONCLUSIONS: IgG4-RD may be identified frequently in patients with ISOI, and distinguishing features may be bilateral lacrimal gland enlargement with associated submandibular gland enlargement. Patients with IgG4-RD may have better treatment outcomes with less aggressive treatment modalities than those with ISOI unrelated to IgG4. An additional workup for IgG4-RD should be considered in all histopathological biopsy specimens suspicious of ISOI.

The effect of pattern scan laser photocoagulation on peripapillary retinal nerve fiber layer thickness and optic nerve morphology in diabetic retinopathy.

PURPOSE: To evaluate the effect of pattern scan laser (PASCAL) photocoagulation on peripapillary retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), and optic nerve morphology in patients with diabetic retinopathy. METHODS: Subjects included 35 eyes for the PASCAL group and 49 eyes for a control group. Peripapillary RNFL thickness, cup-disc area ratio and CMT were measured before PASCAL photocoagulation and at 2 and 6 months after PASCAL photocoagulation in the PASCAL or control groups. RESULTS: The average RNFL thickness had increased by 0.84 µm two months after and decreased by 0.4 µm six months after PASCAL photocoagulation compared to baseline, but these changes were not significant (p = 0.83, 0.39). The cup-disc area ratio was unchanged after PASCAL photocoagulation. CMT increased by 18.11 µm (p = 0.048) at two months compared to baseline thickness, and partially recovered to 11.82 µm (p = 0.11) at six months in the PASCAL group. CONCLUSIONS: PASCAL photocoagulation may not cause significant change in the peripapillary RNFL thickness, CMT, and optic nerve morphology in patients with diabetic retinopathy.

Trichilemmal carcinoma of the upper eyelid: a case report.

We report a very rare case of trichilemmal carcinoma (TLC) involving the upper eyelid. To the best of our knowledge, this is the first report of trichilemmal carcinoma of the upper eyelid in Korea. A 51-year-old man presented to our hospital complaining of a bloody discharge from his left upper eyelid. He had a soft and lobulated mass on the palpebral conjunctiva. An incisional biopsy revealed trabecular growth of tumor cells with clear cytoplasm, prominent nucleoli, frequent mitoses, and foci of trichilemmal keratinization. Immunohistochemically, the lesion was positive for p53 and negative for CD 34. A diagnosis of TLC was made, and total excision of the mass and reconstruction of the eyelid were performed. Trichilemmal carcinoma is a rare malignant tumor, though it appears to be an indolent neoplasm with no metastatic potential. The treatment of choice for trichilemmal carcinoma of the eyelid is complete excision with tumor-free margins due to the locally invasive nature of the lesion.