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.

Impact of COVID-19 on cataract surgical competency of ophthalmology residents.

CONTEXT: Coronavirus disease 2019 (COVID-19) pandemic led to a decrease in elective surgeries. PURPOSE: To compare the performance of postgraduate year 4 prepandemic (2018-2019) and pandemic (2021-2022) ophthalmology residents. SETTINGS AND DESIGN: This was an observational comparative study conducted at a university-based hospital. METHODS: Ophthalmology residents of postgraduate year 4 during prepandemic (2018-2019) and pandemic (2021-2022) time periods were included. The performances of residents in phacoemulsification were scored by a single faculty assessor using the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric for phacoemulsification (ICO-OSCAR: phaco). The scores were compared between the two groups. STATISTICAL ANALYSIS USED: The comparisons between the pre- and post-pandemic groups were performed using the Chi-square and Mann-Whitney U test. RESULTS: Seventy-one surgeries were rated in each group. All task-specific and global scores of the pandemic group were lower than those of the prepandemic group (all P values < 0.001). The maximum intergroup difference was in capsulorrhexis circular completion (difference of 1.21 score, P < 0.001) and tissue handling (difference of 1.21 score, P < 0.001) among task-specific and global scores, respectively. The residents of the two groups had the highest similarity in irrigation and aspiration (difference of 0.61 score, P < 0.001) from task-specific scores and central eye position from global scores (difference of 0.93 score, P < 0.001). CONCLUSION: The COVID-19 pandemic has negatively affected the surgical competency of ophthalmology residents in phacoemulsification.

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.

Comparison of the effect of tea tree oil eye gel with standard treatment in patients with anterior blepharitis: An open-label clinical trial.

Purpose: Daily cleansing of eyelids is very important to carry out a successful blepharitis treatment. However, there are no therapeutic guidelines for blepharitis. The aim was to compare the symptomatic relief of anterior blepharitis using Blephamed eye gel, a cosmetic product, versus standard treatment. Methods: The study was a prospective, interventional open label clinical trial at a university-based hospital. The test population was subjects aged 18-65 years who presented with mild to moderate anterior blepharitis. Eyelid hygiene was applied twice a day. At each visit, a detailed assessment of symptomatology was carried out. A two-way repeated measure mixed model ANOVA was used to compare two groups by time. Results: In total, 61 patients with mean age of 60.08 ± 16.69 years were enrolled in the study including 30 patients in standard group and 31 patients in Blephamed group. Two groups did not differ in terms of age (P = 0.31) and eye laterality (P = 0.50). The baseline scores of erythema, edema, debris, and symptoms as well as total score were similar between two groups (all P values >0.50). Two groups became different for all these parameters at day 45 (all P values <0.001). Significant interaction was detected between time and intervention groups for all severity parameters of blepharitis as well as total score (all P values <0.001). Conclusion: Eyelid hygiene with Blephamed more significantly decreased symptoms of anterior blepharitis compared to standard treatment.

Corneal Allograft Endothelial Rejection after Sinopharm COVID-19 Vaccination; Report of Six Cases.

AIM: To report the clinical characteristics of six patients with corneal allograft endothelial rejection after COVID-19 vaccination with Sinopharm and to review the literature. METHODS: This is a prospective case series describing corneal allograft rejection among subjects having received Sinopharm (BBIBP-CorV) vaccine, coming to cornea clinic at a university-based hospital (Rassoul Akram Hospital, Tehran, Iran) from September 2021 to March 2022 for regular follow-up examinations. Data on demographics, vaccination (based on vaccine card), and graft condition (based on recent examination and previous medical documents) were recorded. RESULTS: Out of 54 eyes (46 patients), 6 eyes (6 patients) had corneal allograft endothelial rejection after 3 to 117 days, post-vaccination. Three out of six rejections occurred within two weeks following vaccination. All of them were male with the mean age of 53.00 ± 19.66 years. The graft type of all patients was penetrating keratoplasty (PKP). The adverse event developed on average at 40.67 ± 34.33 months after surgery. Four patients were under maintenance treatment by topical steroid at the time of vaccination. One also received systemic immunomodulatory medication. Four grafts ended up with partial or complete graft failure. One case had received two doses of vaccine before undergoing the second corneal graft transplantation. CONCLUSION: COVID-19 vaccination with Sinopharm may trigger corneal allograft endothelial rejection even in individuals with low-risk graft and under maintenance topical and/or systemic immunomodulatory medications.

Targeted chemotherapy in retinoblastoma: A step forward from patient survival to globe survival.

BACKGROUND/ OBJECTIVES: Despite being the most common intraocular malignancy in childhood, there is a substantial disparity between developing and developed countries in terms of patient and globe survival in retinoblastoma (Rb). The current study intends to determine patient and globe survival before and after the introduction of the new targeted treatment modalities in a developing country. METHODS: Medical records of 350 patients (516 eyes) with retinoblastoma referred to a tertiary referral center for Rb in Tehran, Iran, were reviewed. In order to compare patient and globe survival before and after the availability of the new treatment modalities, including intra-arterial and intravitreal chemotherapy, the patients were divided into group 1 (2001-2007) and group 2 (2008-2018) based on the calendar period of diagnosis. RESULTS: Two-hundred-twenty-three eyes of 149 patients and 293 eyes of 201 patients were categorized into groups 1 and 2, respectively. The 5-year patient survival was 97% across the current survey, and the overall survival rate was 96% in group 1 and 99% in group 2 (P = 0.08). Overall, 50% of eyes with retinoblastoma underwent enucleation, which was the primary in 63% (116/184) of the unilateral and 30% (99/322) of the bilateral cases. Primary enucleation was significantly lower in group 2 (35%) in contrast to group 1 (50%) (P < 0.001). In addition, globe survival improved significantly in the International Classification of Retinoblastoma Groups D (17% in group 1 vs. 66% in group 2, P < 0.001) and E (1% in group 1 vs. 23% in group 2 P < 0.001) during the two timelines. In enucleated eyes, despite the increased rate of prelaminar involvement in group 2 (13% vs. 2% in group 1, P = 0.003), the rate of high-risk histopathologic findings was similar between the two groups. CONCLUSION: Similar to developed countries, the application of new targeted treatment modalities, including intra-arterial and intravitreal chemotherapy, has been associated with significantly improved globe survival in Rb patients. However, it should be noted that even with the availability of these novel treatment options, the decision for on-time enucleation should not be deferred.

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.

Prevalence of uncorrected distance refractive errors and associated risk factors in employees of an academic centre.

BACKGROUND: Uncorrected refractive error (RE) may affect the work performance of adults in the workplace. The aim of current study was to determine the prevalence of corrected and uncorrected RE, and the determinants of uncorrected RE in adult employees of a university. METHODS: This was a cross-sectional study of Tehran University Medical Sciences' staff. Besides demographic and some specific questionnaires, ophthalmic examinations including the measurement of uncorrected visual acuity (UCVA), best spectacles corrected visual acuity (BCVA), and presenting visual acuity were performed for all participants. The need for spectacles was defined as UCVA worse than 6/12 in the better eye that could be corrected to better than 6/12 with spectacles based on subjective refraction. RESULTS: In total, 4460 individuals with mean age of 42.32 ± 8.80 were included in the study. The VA of the better eye was 0.01 ± 0.05 logMAR for BCVA, 0.13 ± 0.26 for UCVA, and 0.05 ± 0.12 for presenting VA. Prevalence of RE was 15.7%, including uncorrected RE of 5% and spectacles coverage (corrected RE) of 10.7%. The proportion of individuals with elementary education and poor-fair status of general health were 1.62 times higher in the uncorrected group. In the univariate analysis, type of occupation (office versus non-office workers), socioeconomic status, and insurance of employees were not related to uncorrected RE (all P > 0.4). Myopia was the only factor associated with uncorrected RE in logistic regression analysis (odds ratio = 2.73, 95%CI = 1.02-7.31, P = 0.04). CONCLUSION: The prevalence of uncorrected RE and spectacle coverage were 5% and 10.7%, respectively. Myopia was almost three times more likely to be associated among employees with uncorrected RE.

Comparing Pentacam HR Screening Indices in Different Normal Corneal Thicknesses among Refractive Surgery Candidates.

Purpose: To compare Pentacam indices in normal eyes with different corneal thicknesses. Methods: It is a retrospective observational study. Ninety-six normal eyes of 96 patients who were referred for refractive surgery in a tertiary university-based hospital from October 2015 to April 2019 were recruited consecutively. Corneal keratometry as well as Pentacam's software Belin-Ambrósio Enhanced Ectasia Display (BAD) parameters including pachymetry progression indices (PPIs), maximum Ambrosio's relational thickness (ART-max), corneal elevations, normalized deviations, BAD total deviation value (BAD-D), and anterior surface indices were measured by Pentacam HR (Type 70900). The included were classified as thin (26 eyes), average (45 eyes), and thick (25 eyes) corneas with the thinnest point thickness of ≤496 µm, 497-595 µm, and ≥596 µm, respectively. The specificities of all parameters were calculated based on routine cut-off values. Results: The refraction, keratometry, and elevations were not different (P > 0.05). All PPIs (minimum, average, and maximum) of thick corneas were significantly lower than average and thin corneas (P < 0.001). ART-max increased by thickening of the cornea (P < 0.001). BAD-D score and normalized indices of pachymetric parameters decreased with the increase of thickness (P < 0.001), while specificities of all indices increased with corneal thickening. More than 96% of thick corneas were classified as normal PPI-max (24/25), ART-max (25/25), and BAD-D (25/25), while nearly <54% of thin corneas (14/26 for PPI-max, 9/26 for ART-max, and 12/26 for BAD-D) were normal. Conclusions: The pachymetry-related indices and BAD-D were different among normal corneas with various thicknesses. The specificities of PPIs, ART-max, and BAD-D of thin corneas were lower than in thick corneas.

Early Macular Thickness Changes after Trabeculectomy and Combined Phaco-Trabeculectomy.

Purpose: To assess postoperative changes in central retinal thickness (RT) following trabeculectomy and combined phaco-trabeculectomy using spectral domain-optical coherence tomography. Methods: In a prospective interventional comparative study, 64 consecutive glaucoma patients who underwent trabeculectomy (32 eyes) or phaco-trabeculectomy (32 eyes) were included. A macular thickness map using the Early Treatment Diabetic Retinopathy Study circles of 1 mm, 3 mm, and 6 mm was the standard to evaluate the 9-subfield thickness preoperatively and again at 1 and 3 months after surgery. Four subfields in each of the 3 mm and 6 mm rings were considered parafoveal and perifoveal regions, respectively. Results: Preoperative measurements were similar in the two groups, except patients in the combined group which were older (P = 0.002). The mean RT in the combined phaco-trabeculectomy group at month 1 was significantly higher than baseline measurements at central subfield retinal thickness (CSRT) (P = 0.01), temporal (P = 0.001), and inferior (P = 0.04) parafoveal and temporal (P = 0.01), superior (P = 0.02), and nasal (P < 0.001) perifoveal quadrants; however, RT changes in the trabeculectomy-only group were not statistically significant at months 1 and 3 (P > 0.05). The increase in the temporal perifoveal RT of the combined phaco-trabeculectomy group persisted at month 3 (P = 0.01), while the RT in other sectors returned to preoperative values. The two treatment groups did not differ in terms of changes in the CSRT over time (P = 0.37). In addition, no difference was observed between the treatment groups regarding the parafoveal RTs at each time points (0.06 ≤ P ≤ 0.29). Conclusions: There was no significant difference in the pattern of changes of CSRT and parafoveal RT between trabeculectomy and combined phaco-trabeculectomy treatment groups up to 3 months after surgery. Some detectable increase in RT in the combined phaco-trabeculectomy will reverse to baseline values 3 months after surgery, except in the temporal perifoveal region.

A Systematic Review on the Role of Antioxidants in Thyroid Eye Disease.

Purpose: To systematically review the role of antioxidants in management of patients with thyroid eye disease (TED). Methods: A literature search of the electronic databases was performed without restrictions on the date of publication till the end of March 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical trials, case-control studies, cohorts, case series, case reports, and experimental (including in vitro) studies in the English language were included. The primary outcome in human studies was improvement in severity, activity scores, and/or quality of life scores. There was a decrease in the level of H2O2-dependent oxidative stress, Hyaluronic acid release, reactive oxygen species, cell proliferation, or antifibrotic/antiproliferative actions in the in vitro studies. Results: Out of 374 initially screened articles, 157 studies were selected, the full texts of 82 were reviewed, and 14 papers were finally included. There were 4 clinical and 10 in vitro studies from 1993 to 2018. While ß-carotene, retinol, Vitamin E, Vitamin C, melatonin, resveratrol, N-acetyl-l-cysteine, and quercetin showed some efficacy in in vitro studies; allopurinol, nicotinamide, pentoxifylline, and selenium (Se) were effective in both clinical and experimental reports. Se was the only recommended antioxidant based on one high-level randomized controlled trial. Conclusion: While different antioxidants could potentially be effective in the management of TED, no strong recommendation for any or combination of antioxidants could be made to be implemented in the daily practice.

Outcomes of a Single-Segment Intrastromal Corneal Ring in Early Keratoconus and Early Pellucid Marginal Degeneration.

PURPOSE: To determine the effect of a single-segment intrastromal corneal ring segment (ICRS; Intacs SK) on early keratoconus (KCN) and pellucid marginal degeneration (PMD). METHODS: It is a prospective interventional study. One hundred twenty-four eyes (99 patients) with KCN and 36 eyes (26 patients) with PMD at early stage (the maximum keratometric reading less than 55 diopters) were included to ICRS implantation using femtosecond laser at a tertiary university-based hospital and a private outpatient center. The uncorrected distance and spectacle-corrected visual acuity (UDVA and SCDVA), manifest spherical and cylindrical refractions, and keratometry indices were measured preoperatively and postoperatively, 1 week, 2 and 6 months. RESULTS: One week after surgery, significant improvements were observed in UDVA, SCDVA, cylinder and keratometry readings of both KCN and PMD groups (all P < 0.05) with no significant changes afterward. No significant change occurred in the sphere refraction of PMD group (P = 0.10) in contrast to KCN group (P < 0.001). Corneal irregularity of KCN group in central 3 and 5 mm zones increased at 1 week (both P < 0.001) and then started to decrease up to 6 months. However, the corneal irregularity of PMD group had significant reduction only at 1 week in 5-mm zone (P = 0.02) and 2 months in 3-mm zone (P = 0.01) postoperatively. The final efficacy indexes were 1.44 ± 0.71 and 0.87 ± 0.40 in KCN and PMD groups, respectively. CONCLUSION: Visual acuity, refractive errors and keratometry values have been improved after one-segment Intacs SK implantation in early KCN and PMD patients.

Correlation between global prevalence of vision impairment and depressive disorders.

PURPOSE: To assess the correlation of the worldwide prevalence of visual impairment and depressive disorders. METHODS: This is an ecologic study on Global Burden of Disease 2019 data. Global and national prevalence numbers and rates of vision impairment (VI) and depressive disorders were obtained from database. The human development index (HDI) and socio-demographic index (SDI) were derived from international open databases. Main outcome measures were the correlation of the VI and depressive disorders in total and different age, sex, and socioeconomic subgroups. RESULTS: In 2019, the worldwide prevalence of total VI and total depressive disorders were 9.6% (95% Uncertainty Interval (UI): 8.0-11.3) and 3.8% (95% UI: 3.4-4.2), respectively. The prevalence rates of total VI (r = 0.38, P < 0.001) as well as cataract (r = 0.43, P < 0.001), age-related macular degeneration (AMD) (r = 0.32, P < 0.001), refractive disorders (r = 0.19, P < 0.001) and near vision loss (r = 0.33, P < 0.001) correlated, positively, with dysthymia. In addition, the prevalence rates of glaucoma (r for total depressive disorders = 0.37, P < 0.001 and r for major depressive disorders (MDD) = 0.38, P < 0.001) and AMD (r for total depressive disorders = 0.37, P < 0.001 and r for MDD = 0.28, P < 0.001) had a positive correlation with MDD and total depressive disorders. The correlations remained significant in sociodemographic subgroups. CONCLUSION: There was a significant correlation between national prevalence rates of VI and ocular disabilities with depressive disorders, worldwide.

Role of Different Types of Contact Lenses in Epithelial Thickness.

OBJECTIVE: To evaluate the potential role of different types of contact lenses, such as soft (SCL), hard (HCL), and mini scleral (SCCL), in corneal epithelial thickness with anterior segment optical coherence tomography (AS-OCT). METHODS: In this cross-sectional study, patients who used contact lens at recent 6 months were recruited consecutively from September 2019 to October 2019, and the epithelial thicknesses of the cornea were obtained by AS-OCT and compared with control subjects who did not use contact lens. RESULTS: In total, 184 eyes (115 subjects) were included; of them, 75 eyes were keratoconic (KCN) and 109 eyes were nonkeratoconic (non-KCN). Twenty eyes in KCN and 79 eyes of non-KCN group had no history of contact lens use and were included for comparison with KCN and non-KCN contact lens users, respectively. Mean duration of contact lens wearing was 75.63±50.42 months. The epithelial thickness of non-KCN SCL group was thinner than that of non-KCN control subjects all over the cornea, whereas the epithelium of non-KCN HCL was thinner at central site as well as nasal and temporal paracentral and midperipheral areas. Epithelial thickness of the KCN HCL group was not different from the KCN control subjects in all sectors. The KCN SCCL group had thinner epithelium at nearly all peripheral sectors as well as inferior, inferotemporal, inferonasal, and nasal midperipheral sectors compared with KCN control subjects. CONCLUSION: The corneal epithelium was thinner at the peripheral zones in KCN SCCL users; at both peripheral and central zones in non-KCN SCL users and in central zones in non-KCN HCL users.

Prevalence of Masked versus Unmasked Blepharoptosis in Subjects Seeking for Blepharoplasty and or Eyebrow Lift.

PURPOSE: To report the prevalence of unmasked versus masked in subjects seeking for eyelid and eyebrow rejuvenation. METHODS: This retrospective study included subjects (>18 years) who were seeking for blepharoplasty and/or eyebrow lift procedures in the year 2020. They were either having No ptosis, Unmasked or Exposed ptosis (complaining of simultaneous droopy eyelid, which was confirmed on examination), or Masked or Hidden ptosis (not complaining of simultaneous droopy eyelid, but its presence was revealed on the examination). Margin reflex distance 1 (MRD1) and levator function (LF) were recorded. Associated ptosis was defined as MRD1 of ≤3 mm and regarded as mild (3 and 2.5 mm), moderate (2 and 1.5 mm), and severe (≤1 mm). RESULTS: Included were 1401 subjects with a mean age of 47.2 years. The prevalence of masked and unmasked ptosis was 31% (90% unilateral) and 15.6% (59% bilateral), respectively. A significantly younger mean age (45.6 vs. 59.7 years), higher MRD1 (2.6 vs. 1.9 mm), and better LF (13.3 vs. 11.3 mm) were observed in the masked vs. unmasked ptosis group. More than 80% of the subjects with masked ptosis presented with indirect signs. A majority of both groups (68.8% of masked and 63.5% of unmasked ptosis) were mild to moderate. CONCLUSION: Almost half of the subjects seeking for eyelid and eyebrow rejuvenation had either masked (2/3) or unmasked (1/3) associated ptosis. Masked ptosis was mostly unilateral and presenting with indirect signs of ptosis.

The Vascular Pattern In Vicinity Of Chorioretinal Coloboma: An Optical Coherence Tomography Angiography Study.

BACKGROUND: Chorioretinal coloboma is a congenital anomaly which can be present in a clinical spectrum with a possibility of significant influence on visual acuity. Optical coherence tomography (OCT) has been frequently used for the study of chorioretinal coloboma. OCT angiography (OCTA), as a non-invasive method of taking high-resolution images of chorioretinal vessels, can improve our understanding of developmental aspects of this anomaly. MATERIALS AND METHODS: This observational case series evaluated patients with chorioretinal coloboma, who were referred to the eye clinic of a university-based hospital between March 2018 and October 2019. All patients underwent comprehensive ocular examination, OCT, and OCTA using AngioVue technologies from the colobomatous sites. RESULTS: This study included OCTA imaging of five patients (six eyes) with chorioretinal coloboma lesions. Large retinal vessels, which were intact in all eyes, coursed through the coloboma in four cases and around the margin of the involved area in one case. Attenuation of the microvasculature in the vicinity of coloboma with various extents from nearly normal to severe attenuation was evident in OCTA. Five eyes of four patients had disorganized superficial vessel plexus. Also corkscrew vessels were found in one eye. CONCLUSIONS: This is the first study assessing the vascular pattern in the vicinity of chorioretinal coloboma using OCTA. OCTA revealed nearly normal to severely attenuated retinal microvasculature. At the same time, intact large retinal vessels at the level of superficial vessel plexus coursed across or around the coloboma. OCTA imaging adds new insights about vascular characteristics in the vicinity of these lesions.

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.

Long-term Results of Palpebral Fissure Transfer With No Lower Eyelid Spacer in Chronic Progressive External Ophthalmoplegia.

PURPOSE: To evaluate the long-term outcomes of the palpebral fissure transfer (PFT) technique without lower eyelid spacer in patients with chronic progressive external ophthalmoplegia (CPEO). DESIGN: Retrospective interventional case series. METHODS: Consecutive patients with CPEO with PFT surgery (2006-2017) and a minimum follow-up of 24 months were included. The PFT included simultaneous levator resection or frontalis sling (based on the levator function and Bell's phenomenon) and lower eyelid retractor recession without spacer. Primary outcome measures included the change in margin reflex distance 1 (MRD-1), MRD-2, and palpebral fissure height (PFH) in the course of time. Potential predictors of keratopathy were also explored. RESULTS: There were 32 patients (64 eyelids) with the mean age and follow-up of 34.1 years (range 15-56 years) and 37.9 months (range 24-72 months), respectively. Mean MRD-1 significantly increased from -0.9 mm to 3.4 mm in postoperative weeks 1 and 2 and 1.8 mm at the last follow-up. Mean MRD-2 significantly decreased from 5.6 mm to 3.7 mm in postoperative weeks 1 and 2 and 5 mm at the last follow-up. Eyes with frank lower eyelid retraction (MRD-2 >5 mm) gained more reduction in MRD-2 compared with those with no sclera show (-0.9 mm vs -0.3 mm, P < .001). Reoperation was performed in 9 eyelids for under- (n = 5) and overcorrection (n = 4). Persistent keratopathy was observed in 3 eyes (4.5%). CONCLUSION: Lower eyelid retractor recession without spacer yields significant protective corneal coverage at the critical early postoperative period when the risk of keratopathy is highest.

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%.