Clinical Features and Risk Factors for Uveitis in Patients with Ankylosing Spondylitis: A Survey-Based Study

Purpose@#We investigated the clinical features and risk factors associated with the onset of uveitis in patients with ankylosing spondylitis. @*Methods@#A survey was conducted targeting patients with ankylosing spondylitis who have experienced uveitis. The questionnaire collected information on demographic characteristics, clinical features, and lifestyle-related risk factors for uveitis including stress, sleep quality, rest periods, eating habits, and intake of caffeine, alcohol, and tobacco. Respondents were asked to recall their condition at the time of their most recent uveitis flare-up and rate it on a 5-point scale (1 = good to 5 = bad). @*Results@#The study included 47 patients with ankylosing spondylitis; the average age was 40.0 years, 68.1% were male, and 89.4% tested positive for human leukocyte antigen (HLA)-B27. The average treatment duration for uveitis was 5.2 weeks, with an average recurrence rate of 4.5 times. The most common symptom at the time of uveitis was eye redness (87.2%). The average scores for the surveyed risk factors were as follows: stress, 4.1 points; sleep, 3.1 points; rest, 3.4 points; eating habits, 2.9 points; caffeine intake, 3.3 points; alcohol intake, 2.4 points; and smoking, 2.5 points. No significant correlation was found between age, uveitis treatment duration, number of recurrences, and any of the surveyed scores. @*Conclusions@#Patients with ankylosing spondylitis appeared to experience higher levels of stress during episodes of uveitis; however, further investigation is needed.

Fluorescein Angiographic Findings and Recurrence of Human Leukocyte Antigen-B27-Associated Anterior Uveitis

Purpose@#To evaluate the associations of fluorescein angiographic findings with recurrence of human leukocyte antigen (HLA)-B27-associated anterior uveitis. @*Methods@#Medical records of 56 eyes of 56 patients with first-onset, treatment-naive HLA-B27-associated anterior uveitis who performed fluorescein angiography was analyzed. We recorded the fluorescein angiographic findings of optic disc and peripheral vascular leakage and anterior chamber inflammation at the first visit. The 1-year recurrences and times to the first recurrences and the associations between them were investigated. @*Results@#Fluorescein angiography revealed optic disc leakage in 23 patients (41.1%) and peripheral vascular leakage in 36 (64.3%). We found no significant association between the anterior chamber inflammation grade and either optic disc (p = 0.841) or peripheral vascular (p = 0.775) leakage. The 1-year recurrence rate in the optic disc leakage-positive group was significantly higher than in the leakage-negative group (14 patients, 60.9% vs. 11 patients, 33.3%) (p = 0.041), but peripheral vascular leakage status did not significantly affect the recurrence rate (19 leakage-positive patients, 52.8% vs. 8 leakage-negative patients, 40.0%) (p = 0.602). The time to first recurrence was not significantly associated with age (p = 0.772), anterior chamber inflammation (p = 0.841), optic disc leakage (p = 0.108), or systemic corticosteroid use (p = 0.321). @*Conclusions@#We sought correlations between angiographic leakage in patients with HLA-B27-associated anterior uveitis, and the 1-year recurrence rate and the time to first recurrence. Careful follow-up for at least 1 year after initial diagnosis is essential to monitor possible recurrence in patients with optic disc leakage.

Hydroxychloroquine Retinopathy Update

Hydroxychloroquine (HCQ) has been used widely for the treatment of several rheumatologic and dermatologic conditions, including systemic lupus erythematosus and rheumatoid arthritis. Its toxic effects on the retina, HCQ retinopathy, is not uncommon among long-term users, and produces characteristic irreversible and progressive outer retinal damage. Recent studies of Asian populations showed different patterns of retinopathy according to ethnicity; for example, a pericentral pattern is more common in Asian populations, whereas the parafoveal type is more prevalent in Caucasian patients. The pericentral pattern, which is common in Asian patients, is likely to lead to a late diagnosis with conventional imaging modalities, thereby necessitating increased attention to the screening of Asian patients. The most recent American Academy of Ophthalmology guidelines suggest optical coherence tomography and a visual field examination as the primary screening tests, and multifocal electroretinogram and fundus autofluorescence as other recommended objective screening tests. The optimal timing and frequency of annual screening depend on the systemic and ocular risk factors. Annual screening should begin from 5 years of drug use in cases without any known risk factors, but patients with major risk factors require earlier regular screening. After a diagnosis of HCQ retinopathy, a decision regarding whether to stop the drug should be made in consultation with the prescribing physician, and the progression of retinopathy should be monitored carefully because the retinopathy can progress even after drug cessation.

Incidence and Clinical Features of Neovascularization of the Iris following Acute Central Retinal Artery Occlusion

PURPOSE: To investigate the incidence of neovascularization of the iris (NVI) and clinical features of patients with NVI following acute central retinal artery occlusion (CRAO). METHODS: A retrospective review of 214 consecutive CRAO patients who visited one tertiary hospital between January 2009 and January 2015 was conducted. In total, 110 patients were eligible for this study after excluding patients with arteritic CRAO, a lack of follow-up, iatrogenic CRAO secondary to cosmetic filler injection, or NVI detected before CRAO attack. Fluorescein angiography (FA) was applied until retinal arterial reperfusion was achieved, typically within 1 to 3 months. RESULTS: The incidence of NVI was 10.9% (12 out of 110 patients). Neovascular glaucoma was found in seven patients (6.4%). The mean time to NVI diagnosis after CRAO events was 3.0 months (range, 1 week to 15 months). The cumulative incidence was 5.5% at 3 months, 7.3% at 6 months, and 10.9% at 15 months. Severely narrowed ipsilateral carotid arteries were observed in only three patients (27.3%). The other nine patients (75.0%) showed no predisposing conditions for NVI, such as proliferative diabetic retinopathy or central retinal vein occlusion. Reperfusion rate and prevalence of diabetes were significantly different between patients with NVI and patients without NVI (reperfusion: 0% [NVI] vs. 94.7% [no NVI], p < 0.001; diabetes: 50.0% [NVI] vs. 17.3% [no NVI], p = 0.017). CONCLUSIONS: CRAO may lead to NVI and neovascular glaucoma caused by chronic retinal ischemia from reperfusion failure. Our results indicate that follow-up fluorescein angiography is important to evaluate retinal artery reperfusion after acute CRAO events, and that prophylactic treatment such as panretinal photocoagulation should be considered if retinal arterial perfusion is not recovered.

Diagnostic Value of the Serum Anti-Toxocara IgG Titer for Ocular Toxocariasis in Patients with Uveitis at a Tertiary Hospital in Korea

PURPOSE: This study evaluated the prevalence of ocular toxocariasis (OT) in patients with uveitis of unknown etiology who visited a tertiary hospital in South Korea and assessed the success of serum anti-Toxocara immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) as a diagnostic test for OT. METHODS: The records of consecutive patients with intraocular inflammation of unknown etiology were reviewed. All participants underwent clinical and laboratory investigations, including ELISA for serum anti-Toxocara IgG. OT was diagnosed based on typical clinical findings. Clinical characteristics, seropositivity, and IgG titers were compared between patients diagnosed with OT and non-OT uveitis. The seropositivity and the diagnostic value of anti-Toxocara IgG was investigated among patients with different types of uveitis. RESULTS: Of 238 patients with uveitis of unknown etiology, 71 (29.8%) were diagnosed with OT, and 80 (33.6%) had positive ELISA results for serum anti-Toxocara IgG. The sensitivity and specificity of the ELISA test were 91.5% (65 / 71) and 91.0% (152 / 167), respectively. The positive predictive value of the serum anti-Toxocara IgG assay was 81.3%. Among patients with anterior, intermediate, posterior, and panuveitis, the prevalence rates of OT were 8.3%, 47.1%, 44.8%, and 7.1%, respectively; the seropositivity percentages were 18.1%, 47.1%, 43.7%, and 17.9%; and the positive predictive values were 38.5%, 95.8%, 92.1%, and 40.0%. The serum anti-Toxocara IgG titer also significantly decreased following albendazole treatment. CONCLUSIONS: OT is a common cause of intraocular inflammation in the tertiary hospital setting. Considering that OT is more prevalent in intermediate and posterior uveitis, and that the positive predictive value of the anti-Toxocara IgG assay is high, a routine test for anti-Toxocara IgG might be necessary for Korean patients with intermediate and posterior uveitis.

Ocular toxocariasis: clinical features, diagnosis, treatment, and prevention

Despite being one of the most common zoonotic infections worldwide, human toxocariasis has been one of the neglected tropical diseases. Although most human infections are asymptomatic, two main syndromes of human toxocariasis are classically recognized: systemic toxocariasis, which encompasses diseases in major organs; and ocular toxocariasis (OT), disease in the eye or optic nerve, caused by the migration of Toxocara larvae into the eye. OT is usually a unilateral disease, which typically presents as retinal granuloma, a yellowish or whitish inflammatory mass, in the posterior pole or peripheral retina. Granuloma itself or other comorbid conditions such as epiretinal membrane, macular edema, and retinal detachment can lead to permanent retinal damage and visual loss in eyes with OT. OT is diagnosed clinically by identification of clinical signs on ophthalmologic examination. Serological tests, such as enzyme-linked immunosorbent assay (ELISA) for detection of serum antibody against the Toxocara larvae, can confirm the diagnosis. In addition, serum immunoglobulin E and detection of ocular fluid antitoxocara antibody by ELISA may give additional aid to the diagnosis. Standard treatment of OT is corticosteroid in patients with active intraocular inflammation. Although the role of anthelmintic therapy is unclear, favorable outcome has been reported by combined corticosteroid and albendazole therapy in eyes with active inflammation. Prevention, by increasing public awareness and reducing the risk of infection, is also important. Recently, the association between ingestion of uncooked meat or liver and toxocariasis was reported, especially in adult patients. Future research on the potential source of infection, diagnosis, and treatment should be performed.

The Usefulness of Interferon-gamma Release Assay for Diagnosis of Tuberculosis-related Uveitis in Korea

PURPOSE: To evaluate the usefulness of the interferon-gamma release assay (IGRA) for diagnosing tuberculosis (TB)-related uveitis (TRU). METHODS: Records from 181 patients with ocular signs and symptoms suggestive of TRU and intraocular inflammation of unknown etiology were reviewed. All subjects underwent clinical and laboratory testing, including IGRA, to rule out presence of underlying disease. A diagnosis of presumed TRU was made based on an internist's TB diagnosis and a patient's response to anti-TB therapy. Sensitivity, specificity, and positive predictive values of IGRA for TRU diagnosis were calculated. Clinical characteristics were compared between patients with positive and negative IGRA results. RESULTS: The sensitivity and specificity of IGRA for TRU were 100% and 72.0%, respectively. Mean age, percentage of patients with retinal vasculitis, and the anatomic type of uveitis were significantly different between patients with positive and negative IGRA results (all p < or = 0.001). Positive IGRA rates and false-positive rates were significantly different between age and anatomic type groups (both p = 0.001). The positive predictive value of the IGRA among patients with intraocular inflammation was high (70%) when all of younger age (< or =40 years), posterior uveitis, and retinal vasculitis were present. CONCLUSIONS: The IGRA is useful for diagnosing TRU in the Korean population, especially when it is used as a screening test. Clinical characteristics, including younger age (< or =40 years), posterior uveitis, and retinal vasculitis in IGRA-positive patients, increase the likelihood of the patient having TRU.

Capillary-free Vascularized Retina in Patients with Aggressive Posterior Retinopathy of Prematurity and Late Retinal Capillary Formation

PURPOSE: To report the clinical features, clinical course, and treatment outcomes after laser photocoagulation in infants with aggressive posterior retinopathy of prematurity (APROP) and capillary-free zones in vascularized retina. METHODS: Six patients (12 eyes) with APROP and capillary-free zones in vascularized retina were retrospectively reviewed. Twelve eyes of six infants were included and were treated with laser photocoagulation for avascular retina and for capillary-free zones in vascularized retina, except for the posterior pole, and fundus findings were photographically-documented in sequence. In addition, anatomic and visual outcomes were evaluated with complications of APROP. RESULTS: Among all of the consecutive infants with APROP, capillary-free zones in vascularized retina were demonstrated in 24% of the infants. All of the infants were >27 weeks of gestation age and had birth weights >1,000 g. After laser treatment, 7 eyes (58.3%) had favorable outcomes, and late capillary filling in capillary-free zones of vascularized retina were noted, however 4 eyes (33.3%) progressed to retinal detachment and 1 eye (8.3%) was complicated by a retinal fold-distorting posterior pole. The visual outcomes were associated with anatomic outcomes. CONCLUSIONS: The anatomic outcomes in infants with APROP who had capillary-free zones were comparable to previously reported infants with APROP. The late capillary filling of capillary-free zones in vascularized retina was noted, and angiogenesis was considered to be involved. This process toward normal capillary formation or neovascularization in APROP, might determine its outcome.

Capillary-free Vascularized Retina in Patients with Aggressive Posterior Retinopathy of Prematurity and Late Retinal Capillary Formation

PURPOSE: To report the clinical features, clinical course, and treatment outcomes after laser photocoagulation in infants with aggressive posterior retinopathy of prematurity (APROP) and capillary-free zones in vascularized retina. METHODS: Six patients (12 eyes) with APROP and capillary-free zones in vascularized retina were retrospectively reviewed. Twelve eyes of six infants were included and were treated with laser photocoagulation for avascular retina and for capillary-free zones in vascularized retina, except for the posterior pole, and fundus findings were photographically-documented in sequence. In addition, anatomic and visual outcomes were evaluated with complications of APROP. RESULTS: Among all of the consecutive infants with APROP, capillary-free zones in vascularized retina were demonstrated in 24% of the infants. All of the infants were >27 weeks of gestation age and had birth weights >1,000 g. After laser treatment, 7 eyes (58.3%) had favorable outcomes, and late capillary filling in capillary-free zones of vascularized retina were noted, however 4 eyes (33.3%) progressed to retinal detachment and 1 eye (8.3%) was complicated by a retinal fold-distorting posterior pole. The visual outcomes were associated with anatomic outcomes. CONCLUSIONS: The anatomic outcomes in infants with APROP who had capillary-free zones were comparable to previously reported infants with APROP. The late capillary filling of capillary-free zones in vascularized retina was noted, and angiogenesis was considered to be involved. This process toward normal capillary formation or neovascularization in APROP, might determine its outcome.

Topographic Progression of Keratoconus in the Korean Population

PURPOSE: To develop a criterion for determining the topographic progression of keratoconus and to analyze the prognostic factors of progression. METHODS: Medical records of 211 eyes of 128 patients who had been followed up for more than 2 years on three or more occasions were retrospectively reviewed. Topographic parameters, including simulated K, corneal astigmatism, irregular astigmatism at 3 and 5 mm, thinnest-point pachymetry, anterior and posterior elevation, and inferior minus superior index, were used to determine topographic progression. Topographic progression was determined by the greatest kappa value associated with progression to corneal graft surgery. Eyes were separated into progressed and non-progressed groups on the basis of topographic progression. The association of clinical factors with topographic progression, including demographic factors, contact lens use, corneal erosion, and atopic history at the time of diagnosis, was assessed by logistic regression. RESULTS: When topographic progression was defined as five or more progressed topographic parameters, the greatest kappa value (0.354) was obtained. Ninety-four of the 211 keratoconic eyes (44.5%) were identified as topographically progressed. Age at diagnosis was significantly different between the progressed and non-progressed groups (22.2 vs. 24.7 years, p = 0.014). Logistic regression revealed that younger age at diagnosis was a risk factor for topographic progression (odds ratio, 0.948; 95% confidence interval, 0.907 to 0.991; p = 0.010). CONCLUSIONS: We developed a criterion for evaluating topographic progression of keratoconus using diverse topographic indices. Younger age at diagnosis was associated with topographic progression of keratoconus.

Superior Rectus Muscle Recession for Residual Head Tilt after Inferior Oblique Muscle Weakening in Superior Oblique Palsy

PURPOSE: Residual head tilt has been reported in patients with superior oblique muscle palsy (SOP) after surgery to weaken the inferior oblique (IO) muscle. The treatments for these patients have not received appropriate attention. In this study, we evaluated the superior rectus (SR) muscle recession as a surgical treatment. METHODS: The medical records of 12 patients with SOP were retrospectively reviewed. Each of these patients had unilateral SR muscle recession for residual head tilt after IO muscle weakening due to SOP. The residual torticollis was classified into three groups on the basis of severity: mild, moderate, or severe. Both IO muscle overaction and vertical deviation, features of SOP, were evaluated in all patients. The severity of the preoperative and postoperative torticollis and vertical deviation were compared using a paired t-test and Fisher's exact test. RESULTS: The torticollis improved in nine of 12 (75%) patients after SR muscle recession. The difference between the preoperative and postoperative severity of torticollis was statistically significant (p = 0.0008). After surgery, the mean vertical deviation was significantly reduced from 12.4 prism diopters to 1.3 prism diopters (p = 0.0003). CONCLUSIONS: Unilateral SR muscle recession is an effective method to correct residual head tilt after IO muscle weakening in patients with SOP. This surgical procedure is believed to decrease head tilt by reducing the vertical deviation and thereby the compensatory head tilt.

A Case of Chondroid Syringoma Involving the Eyelid Margin

PURPOSE: To report a case of chondroid syringoma that involved the eyelid margin, was accompanied by cilia loss, and required differential diagnosis with other malignant eyelid masses. CASE SUMMARY: A 46-year-old woman presented with a recurrent mass in the right lower eyelid margin, which was observed 10 years earlier, where incision and curettage had already been performed twice. The mass was neither tender nor ulcerated, was brighter in color than the neighboring skin, and had a smooth surface with cilia loss. The pathologic findings obtained from an incisional biopsy were compatible with a dermoid cyst. Full-thickness excision of the eyelid mass and direct closure were subsequently performed. The pathologic diagnosis after excisional biopsy was chondroid syringoma because cystic structures in the chondroid stroma were observed.

Clinical Features, Predisposing Factors, and Treatment Outcomes of Scleritis in the Korean Population

PURPOSE: To evaluate the clinical features, associated factors, and treatment outcomes of scleritis in the Korean population. METHODS: Medical records were retrospectively reviewed for 94 eyes of 76 patients with scleritis. Clinical features of scleritis, including systemic disease, presence of microorganisms, serologic markers, history of previous ocular surgery, and use of immunosuppressants were investigated and compared amongst the subtypes of scleritis. Treatment outcomes were evaluated using best corrected visual acuity (BCVA) and time to scleritis remission. RESULTS: Nodular scleritis was the most common form observed, followed by necrotizing scleritis with inflammation, diffuse scleritis, and necrotizing scleritis without inflammation, respectively. A total of 16 of 76 patients (21.1%) had connective tissue diseases. Eleven cases (14.5%) had infectious scleritis, of which bacteria (54.5%) and fungi (45.5%) were the causative microorganisms. Thirty-three patients (43.4%) had previous ocular surgery, mostly pterygium excision. Notably, a history of pterygium excision was significantly associated with development of necrotizing and infectious scleritis (odds ratio [OR], 399 and 10.1; p < 0.001 and 0.002, respectively). In addition, patients with necrotizing scleritis were more likely to have infectious scleritis (OR, 11.7; p = 0.001). BCVA after treatment and time to remission also showed significant differences among the different scleritis subtypes. Systemic immunosuppression was required in addition to steroids for treating diffuse and necrotizing scleritis. CONCLUSIONS: Careful taking of patient history including previous pterygium excision should be performed, especially in patients with necrotizing and infectious scleritis. In addition, evaluation of microbiological infection can be crucial for patients with necrotizing scleritis and history of pterygium excision.

Clinical Features of Nevus of Ota in Korean Population

PURPOSE: To investigate the clinical features of the nevus of Ota in the Korean population. METHODS: A retrospective chart review of the medical records from 94 patients (100 eyes), diagnosed to have a nevus of Ota from September 2005 to February 2010, was performed. RESULTS: The mean age of detection of a nevus of Ota was 8 months, and the mean extent of the nevus was 253 degrees, which covered more than 2 quadrants in most cases. The patients with a faint nevus tended to be younger. Pigmentation did not reach the fornix, but the limbus was mostly pigmented. Combined conjunctival pigmentation was observed in 61.7% of cases. The pigmentation was significantly associated with a greater extent of the nevus. Iris pigmentation was demonstrated in 98.7% of cases. CONCLUSIONS: The clinical features of nevi of Ota were diverse regarding the location, extent, and color of the lesion. Conjunctival pigmentation was associated with the extent of the nevus. Iris pigmentation was revealed in almost all cases; therefore, this feature had the diagnostic value for a nevus of Ota. Young patients with a nevus of Ota may mimic osteogenesis imperfecta, which necessitates careful consideration upon differential diagnosis.

Difference of Organism and Their Antibiotics Sensitivity from Urine Culture in Symptomatic Urinary Tract Infection of Spinal Cord Injury Patients

OBJECTIVE: To assess the necessity of extra rounds of urine culture when symptom of urinary tract infection (UTI) is developed from asymptomatic bacteriuria in spinal cord injury patients. METHOD: A total of 226 patients who took a urine culture at least twice during their stay and did not show symptoms of UTI at the admission were chosen. We then divided them into two groups: the one with patients who showed symptoms of UTI, and the other with ones who did not. Follow-up urine culture was performed when patients had symptoms of UTI or after one month from admission. RESULTS: 1) Of the 226 patients, 60 patients showed symptoms of UTI, while 166 patients did not. 2) From the UTI group, there were 38 (63.3%) patients whose organism from their urine culture changed. From the non-UTI group, 79 (47.6%) patients saw their organism from their urine culture changed. 3) From the UTI group, there were 31 (56.4%) patients whose organism was more resistant to the antibiotics. From the non-UTI group, there were 80 (68.4%) patients whose organism was more resistant to the antibiotics. CONCLUSION: If UTI occurs in spinal cord injury patients, new organism might be detected in urine culture. Therefore, we should choose the proper antibiotics based on results of follow-up urine culture performed when the patients had symptoms of UTI.

Quantitative and Qualitative Muscular Changes after Selective Neurotomy

Disfigurement of body contour, caused by excessive muscular hypertrophy, can seldom be effectively and safely corrected by lipectomy, liposuction or combined partial myomectomy. This study was conducted to obtain basic knowledge for the development of a safe and effective method of treating patients with excessive and unwelcome muscle hypertrophy. Accordingly, we developed a new experimental rat model, consisting of the peroneal nerve and its target muscles - the anterolateral crural muscle group. After severance of 1/4, 1/2, and 1/1 of the peroneal nerve, functional parameters based on gross movement and electrophysiologic data were monitored. Changes in the external circumference and weight of the anterolateral crural muscle were documented and compared with control sides. Histologic and histomorphometric parameters of the muscle were also documented. Average takeoff latency in 1/4 and 1/2 neurotomy groups was increased to 130% and 154% of the control at 3 months, and 156% and 149% of control at 6months, respectively. Similarly, average peak-to-peak compound action potentials were 72% and 59% of the control at 3months and 57% and 50% of control at 6months. No definite gait disturbances were evident in the partial neurotomy groups. Maximal circumferences of the anterolateral crural muscle group were significantly reduced to 86%, 71% and 66% of the control in the 1/4, 1/2 and 1/1 neurotomy groups at 3 months (p < 0.001), and to 74%, 68% and 64% of the control at 6 months, respectively (p < 0.001). The corresponding weights were 76%, 62%, and 50% of the control sides at 3 months, and 70%, 56%, and 48% at 6 months in 1/4, 1/2 and 1/1 neurotomy groups. Histograms drawn showing the number of muscle fibers per mm2 in cross-sections, showed a total number of 239 +/- 52 in the control group; the size of muscle fibers was mainly medium to large. The more extensive the neurotomy, the greater the was the number of small angulated muscle fibers, up to a total of 1,564 +/- 211. Although more research work and clinical trials are required, we believe that selective neurotomy has the potential of being an effective tool for reducing muscle bulk, and avoiding apparent muscular dysfunction and complications.

CLINICAL EXPERIENCES OF NASAL TIP PLASTY IN ORIENTALS

The nasal tips of Orientals are different from those of caucasians with are characterized by flat nose and bulbous nasal tip appearance because of its thick and tense skin, shory columella, flaring of nostrils, and restriction of nasal tip projection due to underdevelopement of medial crus of alar cartilage. For better nasal tip definition and projection, alar carilage must be realigned and tip might be augmented with autogenous cartilage onlay graft. Furthermore in patient with short columella, strut formation might be performed because the nostril comprises two-thirds of height of nasal tip. If the nasal tip is prjected without lengthening of columella, sometimes we noted unnaturally tented appearance of nasal tip may result. Also for the soft tissue lengthening in columella in proportion to the nasal tip projection, the short columella can be lengthened with columella based V-Y advancement. Surgical approach through alar rim incision or open rhinoplasty incision may be employed depending upon the severity of tip defomity. If flattening is severe to enough require lengthening of the columella, open rhinoplasty incision is the best choice. Through the incision, the alar cartilage is dissected freely from the skin and vestibulsr mucosa. Cartilage grafts are performed using carilage onlay graft or columella strut formation after transdormal fixation suture. This study presents clinical cases of various nasal tips in the view of nasal tip deformity which were corrected with various operative methods using combined technique of approximating the alar cartilage and a multilayered autogenous onlay cartilage graft on the nasal tip harvested from the auricular cartilage, also Silicone implant was used for augmetation of nasal dorsum and columella strut formation with columella base V-Y advancement. The ten years of our experience with nasal tip plasty in over one hundred patient showed excellent result and no complications were observed during post operative follow-up so we are reporting these cases with review of literature.