Causes of Punctal Plug Loss in Sjögren’s Syndrome

Purpose@#To evaluate the long-term maintenance rate and associated factors of silicone punctal plugs in patients with Sjögren’s syndrome (SS). @*Materials and Methods@#We retrospectively reviewed the medical records of 163 patients with SS who underwent silicone punctal plug insertion between December 2013 and July 2021 at Severance Hospital. The status of punctal plug insertions was classified into the following three categories by the clinician: maintenance, spontaneous loss, and intended removal. Cox proportional hazards model was used to evaluate the risk factors for spontaneous loss. @*Results@#The mean maintenance period was 12.8±15.3 (median 7.07) months. The rate of spontaneous loss was 58%, and the rate of punctal plug removal by the clinician was 14%. The number of prior plug insertions was a risk factor for spontaneous loss [hazard ratio (HR) 1.055, p=0.035]. The upper eyelid punctum was at a higher risk than the lower one (p=0.042). Small-sized plugs showed a significantly higher risk for spontaneous loss than large-sized ones (HR 1.287, p=0.035). Flow-controller type plugs were more vulnerable to spontaneous loss than complete occluders [Micro FlowTM vs. EagleFlex® (HR 2.707, p=0.008) and Micro FlowTM vs. UltraplugTM (HR 3.402, p=0.005)]. The most common reason for removal was tear overflow (5.6%). @*Conclusion@#In repeated insertion, characteristics of the punctal plug, including the type and size, and location of plug insertion, influenced the spontaneous loss of plugs. The management of punctal plugs, including insertion, maintenance, and removal, requires personalized strategies for versatile situations.

Effect and Safety of Pressure Sensor-equipped Handpiece in Phacoemulsification System

Purpose@#To evaluate the effect of the Active Sentry handpiece of the Centurion Vision System compared to the Centurion Ozil handpiece for phacoemulsification in cataract surgery. @*Methods@#A retrospective study was conducted on 281 patients (449 eyes) who underwent cataract surgery between August 2020 and June 2021. Preoperative measurements, intraoperative parameters, complication rate, and postoperative outcomes were compared between the Active Sentry handpiece and the Centurion Ozil handpiece groups. Additionally, the parameters were compared in different cataract severity groups and multiple predictive factors for the number of active surge mitigation (ASM) actuations were assessed with the Active Sentry handpiece. @*Results@#There were 198 eyes in the Active Sentry group and 251 eyes in the Centurion Ozil group. There were no statistically significant differences between the two groups, as the cumulative dissipated energy in the Active Sentry and Centurion Ozil groups were 8.32 ± 7.74 and 7.87 ± 9.25 μJ, respectively (p = 0.576). Total surgery time, ultrasound usage time, aspiration time, amount of fluid aspirated, postoperative corrected distant visual acuity, and postoperative decrease in corneal endothelial cell density were comparable between the two groups. The significant contributors to the number of ASM actuations were age, preoperative corrected distant visual acuity, axial length, and total ultrasound time. @*Conclusions@#There was no clear advantage of the Active Sentry handpiece compared to the Centurion Ozil handpiece. ASM actuation increases with age, poor visual acuity before surgery, short axial length, and prolonged ultrasound usage time. It is expected that in more severe and high-risk cataract surgery, the Active Sentry handpiece functions more effectively, possibly affecting the safety and prognosis.

Mini-Review: Clinical Features and Management of Granular Corneal Dystrophy Type 2

Granular corneal dystrophy type 2 (GCD2) is an autosomal dominant corneal stromal dystrophy that is caused by p.Arg124His mutation of transforming growth factor β induced (TGFBI) gene. It is characterized by well demarcated granular shaped opacities in central anterior stroma and as the disease progresses, extrusion of the deposits results in ocular pain due to corneal epithelial erosion. Also, diffuse corneal haze which appears late, causes decrease in visual acuity. The prevalence of GCD2 is high in East Asia including Korea. Homozygous patients show a severe phenotype from an early age, and the heterozygote phenotype varies among patients, depending on several types of compound heterozygous TGFBI mutations. In the initial stage, conservative treatments such as artificial tears, antibiotic eye drops, and bandage contact lenses are used to treat corneal erosion. Different surgical methods are used depending on the depth and extent of the stromal deposits. Phototherapeutic keratectomy removes anterior opacities and is advantageous in terms of its applicability and repeatability. For deeper lesions, deep anterior lamellar keratoplasty can be used as the endothelial layer is not always affected. Recurrence following these treatments are reported within a wide range of rates in different studies due to varying definition of recurrence and follow-up period. In patients who have undergone corneal laser vision-correction surgeries such as photorefractive keratectomy, LASEK, or LASIK including SMILE surgery, corneal opacity exacerbates rapidly with severe deterioration of visual acuity. Further investigations on new treatments of GCD2 are necessary.

Visual Function after Multifocal Intraocular Lens Insertion in a Heterozygous Granular Corneal Dystrophy Type 2 Patient: Case Report

Purpose@#A patient with heterozygous granular corneal dystrophy type 2 (GCD2) underwent phacoemulsification with multifocal intraocular lens insertion, and complained of visual discomfort. We investigated the cause of the discomfort and visual function in this case.Case summary: A 59-year-old woman with granular opacity had slit lamp photographs taken 5 years earlier. Two years later, she underwent phacoemulsification with multifocal intraocular lens (Trifocal AT Lisa tri toric 839MP®, Carl Zeiss Meditec AG, Inc., Jena, Germany) insertion in both eyes at a local clinic. She felt very uncomfortable after the surgery, but the granular and lattice opacities due to GCD2 of her corneas remained stationary for 5 years. Her visual acuity decreased from preoperatively (preoperative: right 0.5, left 0.6; last visit: right 0.3, left 0.4). Her contrast sensitivity was also decreased and the total higher order aberration was increased (right 1.590 μm, left 1.194 μm), compared to normal range. @*Conclusions@#Multifocal intraocular lens insertion in cataract surgery can lead to severe declines in contrast sensitivity and visual acuity and increased higher-order aberration in a GCD2 patient. It may not be advisable to use multifocal intraocular lenses in a GCD2 patient.

Anterior Ocular Biometrics Using Placido-scanning-slit System, Rotating Scheimpflug Tomography, and Swept-source Optical Coherence Tomography

Purpose@#To compare anterior biometry measurements using placido-scanning-slit topography, rotating Scheimpflug tomography, and swept-source optical coherence tomography. @*Methods@#A retrospective review consisted of 80 eyes of 49 participants who underwent anterior chamber depth (ACD), central corneal thickness (CCT), and keratometry examination on the same day. We used placido-scanning-slit topography (ORBscan II), rotating Scheimpflug tomography (Pentacam HR), and swept-source optical coherence tomography (CASIA SS1000). The intraclass correlation coefficients and Bland-Altman plots were used to evaluate the agreement and differences between measurements. @*Results@#The mean ACD values were 2.88 ± 0.43, 2.82 ± 0.50, and 2.68 ± 0.44 mm; and the mean CCT values were 536.96 ± 31.19, 543.79 ± 31.04, and 561.41 ± 32.60 μm; and the mean keratometry (Km) were 43.81 ± 1.69, 43.81 ± 1.77, and 44.65 ± 1.95 diopters; as measured by CASIA SS-1000, Pentacam HR, and ORBscan II, respectively. Among the three devices, ACD was deepest to shallowest in the order of CASIA SS-1000, Pentacam HR, and ORBscan II (p < 0.05). The CCT was thickest to thinnest in the order of ORBscan II, Pentacam HR, and CASIA SS-1000 (p < 0.05). No significant differences in Km values were examined between CASIA SS-1000 and Pentacam HR, whereas ORBscan II overestimated Km with a statistically significant difference compared to the other two devices. @*Conclusions@#High level of agreement was found between CASIA SS-1000 and Pentacam HR for anterior parameters, including ACD, CCT, and Km, suggesting interchangeability. However, ORBscan II measurements differed considerably with the measurements obtained from the other two devices; therefore, it should not be used interchangeably. However, further studies with repeatability test should be considered in order to elucidate the reliability of each device.

Comparison of Anterior Segment Measurements with a New Multifunctional Unit and Five Other Devices

Purpose@#To evaluate the clinical availability of a multifunctional ocular biometric unit, MR-6000, for simultaneous keratometry, tonometry, topography, and pachymetry evaluation, and compare anterior segment measurements with five other devices: autokeratometer (KR-1), Scheimpflug camera (Pentacam HR), swept-source optical coherence tomography (IOLMaster 700), Placido disk scanning-slit topography (Orbscan II), and noncontact tonometry (FT-1000). @*Methods@#Thirty eyes from thirty patients who visited Severance Hospital for cataract surgery were examined using MR6000 and the other devices. The mean keratometry, central corneal thickness (CCT), white-to-white (WTW) distance, and intraocular pressure (IOP) values were compared. Repeated measures analysis of variance, Wilcoxon signed-rank test, intraclass correlation coefficient (ICC), and Bland-Altman plot were used to assess the correlation and agreement between devices. @*Results@#Thirty eyes of thirty patients were evaluated. Statistically significant differences in mean keratometry between MR6000, KR-1, Pentacam HR, and IOLMaster 700 were not observed (p > 0.05). All five devices, including Orbscan II, had almost perfect agreement in measuring keratometry (ICC > 0.80, p 0.60, p < 0.05). The WTW distance measured by MR-6000 was not significantly different from that measured by IOLMaster 700 but was different from that measured by Orbscan II. IOP measured by MR-6000 was not correlated with FT-1000. @*Conclusions@#Keratometric values obtained through MR-6000 can be used interchangeably with other devices based on good correlation and agreement. However, the CCT, WTW, and IOP values were not interchangeable with a single multifunctional unit for cataract surgery preoperative examination.

Clinical Results of Cataract Surgery Using the ARTIS ® PL E Intraocular Lens

Purpose@#To compare the clinical outcomes of cataract surgery using the ARTIS ® PL E (Cristalens Industrie, Lannion, France) intraocular lens (IOL) and conventional Tecnis ® ZCB00 (Johnson & Johnson Vision, Santa Ana, CA, USA) IOL. @*Methods@#This retrospective study examined patients who underwent in-the-bag implantation of either an ARTIS ® PL E (33 eyes, group A) or Tecnis ® ZCB00 (45 eyes, group B) IOL after phacoemulsification performed by a single surgeon. Best-corrected visual acuity (BCVA), spherical equivalent, and higher-order aberrations (HOA) were measured 1 and 3 months after cataract surgery. @*Results@#Preoperative BCVA did not differ significantly in groups A and B. Postoperative BCVA at 1 and 3 months improved significantly (p < 0.001) in both groups compared to preoperative baseline BCVA. At 1 and 3 months postoperatively, total HOA, spherical aberration, and coma were significantly lower compared to the preoperative baseline HOA (p < 0.05) in both groups. However, there were no significant differences in the trefoil values 1 and 3 months postoperatively compared to the preoperative baseline in both groups. The absolute refractive error 3 months postoperatively was 0.27 ± 0.20 (group A) and 0.28 ± 0.20 (group B), both within ± 0.50 diopters of the targeted goal diopter; there were no significant differences in the accuracy or predictability of the IOL power calculation in both groups (p = 0.390, p = 0.959). The absolute refractive error 1 and 3 months postoperatively did not differ significantly; there were no significant differences in the stability of both IOLs (p = 0.482, p = 0.372). @*Conclusions@#Conventional cataract surgery using the ARTIS ® PL E IOL significantly increased the BCVA, while obtaining comparable clinical results to the verified Tecnis ® ZCB00 IOL in postoperative visual acuity and HOA.

Effect of 0.15% Preservative-free Sodium Hyaluronate on Dry Eye Disease after Femtosecond Laser-assisted Cataract Surgery

Purpose@#The efficacy of using preservative-free 0.15% sodium hyaluronate eyedrops for dry eye disease after femtosecond laser- assisted cataract surgery (FLACS) was evaluated. @*Methods@#This prospective randomized study was conducted on patients with dry eye who were scheduled for FLACS among those with Tear Film & Ocular Surface Society Dry Eye Workshop II Dry Eye Levels 1 and 2. In total, 37 eyes scheduled for FLACS were randomized to the treatment group (n = 19) or control group (n = 18). Corneal and conjunctival fluorescein staining (CFS), tear breakup time (TBUT), Schirmer I test (SIT) value, ocular surface disease index (OSDI), meibomian gland evaluation result, and lipid layer thickness were evaluated for all patients, preoperatively and at 1 and 3 months postoperatively. @*Results@#In the treatment group, the OSDI and CFS scores were significantly lower at 3 months postoperatively than at baseline, but the TBUT and SIT values were significantly increased. In the control group, TBUT was significantly shorter at 3 months postoperatively than at baseline, SIT values were significantly decreased at 1 and 3 months postoperatively compared with the baseline, and meibum quality was significantly aggravated at 1 month postoperatively compared with the baseline. In the treatment group, OSDI improved significantly from baseline at 1 and 3 months. TBUT increased significantly in the treatment group at postoperative 3 months. Meibomian gland quality showed clinically better results in the treatment group than in the control group at postoperative 3 months. There were no significant differences in corneal and CFS, lipid layer thickness, and other dry eye disease parameters between the treatment and control groups. @*Conclusions@#Preservative-free 0.15% sodium hyaluronate eyedrops were effective for improving dry eye symptoms and tear film stability after FLACS.

Effect of 0.15% Preservative-free Sodium Hyaluronate on Dry Eye Disease after Femtosecond Laser-assisted Cataract Surgery

Purpose@#The efficacy of using preservative-free 0.15% sodium hyaluronate eyedrops for dry eye disease after femtosecond laser- assisted cataract surgery (FLACS) was evaluated. @*Methods@#This prospective randomized study was conducted on patients with dry eye who were scheduled for FLACS among those with Tear Film & Ocular Surface Society Dry Eye Workshop II Dry Eye Levels 1 and 2. In total, 37 eyes scheduled for FLACS were randomized to the treatment group (n = 19) or control group (n = 18). Corneal and conjunctival fluorescein staining (CFS), tear breakup time (TBUT), Schirmer I test (SIT) value, ocular surface disease index (OSDI), meibomian gland evaluation result, and lipid layer thickness were evaluated for all patients, preoperatively and at 1 and 3 months postoperatively. @*Results@#In the treatment group, the OSDI and CFS scores were significantly lower at 3 months postoperatively than at baseline, but the TBUT and SIT values were significantly increased. In the control group, TBUT was significantly shorter at 3 months postoperatively than at baseline, SIT values were significantly decreased at 1 and 3 months postoperatively compared with the baseline, and meibum quality was significantly aggravated at 1 month postoperatively compared with the baseline. In the treatment group, OSDI improved significantly from baseline at 1 and 3 months. TBUT increased significantly in the treatment group at postoperative 3 months. Meibomian gland quality showed clinically better results in the treatment group than in the control group at postoperative 3 months. There were no significant differences in corneal and CFS, lipid layer thickness, and other dry eye disease parameters between the treatment and control groups. @*Conclusions@#Preservative-free 0.15% sodium hyaluronate eyedrops were effective for improving dry eye symptoms and tear film stability after FLACS.

Accuracy of the Kane Formula for Intraocular Lens Power Calculation in Comparison with Existing Formulas: A Retrospective Review

Purpose@#To evaluate the accuracy of the Kane formula for intraocular lens (IOL) power calculation in comparison with existing formulas by incorporating optional variables into calculation. @*Materials and Methods@#This retrospective review consisted of 78 eyes of patients who had undergone uneventful phacoemulsification with intraocular implantation at Severance Hospital in Seoul, Korea between February 2020 and January 2021. The Kane formula was compared with six of the existing IOL formulas (SRK/T, Hoffer-Q, Haigis, Holladay1, Holladay2, Barrett Universal II) based on the mean absolute error (MAE), median absolute error (MedAE), and the percentages of eyes within prediction errors of ±0.25D, ±0.50D, and ±1.00D. @*Results@#The Barrett Universal II formula demonstrated the lowest MAEs (0.26±0.17D), MedAEs (0.28D), and percentage of eyes within prediction errors of ±0.25D, ± 0.50D, and ±1.00D, although there was no statistically significant difference between Barrett Universal II-SRK/T (p=0.06), and Barrett Universal II-Kane formula (p<0.51). Following the Barrett Universal II formula, the Kane formula demonstrated the second most accurate formula with MAEs (0.30±0.19D) and MedAEs (0.28D). However, no statistical difference was shown between Kane-Barrett Universal II (p=0.51) and Kane-SRK/T (p=0.14). @*Conclusion@#Although slightly better refractory outcome was noted in the Barrett Universal II formula, the performance of the Kane formula in refractive prediction was comparable in IOL power calculation, marking its superiority over many conventional IOL formulas, such as HofferQ, Haigis, Holladay1, and Holladay2.

The Use of a Dynamic Scheimpflug Analyzer to Measure Changes of Post-keratoplasty Corneal Biomechanical Properties

Purpose@#To evaluate the biomechanical properties of corneas using a dynamic Scheimpflug analyzer (Corvis ST) after penetrating keratoplasty (PKP) and Descemet’s membrane stripping keratoplasty (DSEK). @*Methods@#The medical records of 11 eyes that had undergone PKP (PKP group) and 11 eyes that had undergone DSEK (DSEK group) from March 2017 to March 2018 and the results were compared with 20 eyes of the control group. All patients’ corneal biomechanical properties, including a deformation amplitude ratio of 2.0 mm (DA ratio 2.0 mm), integrated inverse radius (IntInvRad), stiffness parameter at first applanation (SP-A1), and Ambrosio relational thickness through the horizon meridian (ARTh) were measured and compared with those of the normal control group. In addition, biomechanically corrected intraocular pressure (bIOP) measured by the Corvis ST was compared with intraocular pressure measured by a Tono-Pen Applanation Tonometer (IOP-Tono-Pen). @*Results@#In the PKP group, the biomechanical properties using the Corvis ST showed a significantly lower DA ratio 2.0 mm, SP-A1, ARTh, and IntInvRad, compared with those of the control group. However, in the DSEK group, only ARTh was significantly lower than that of the control group. @*Conclusions@#Corvis ST can be used to measure the change of corneal biomechanical properties after corneal transplantation.

Clinical Efficacy of Microblepharoexfoliation in Meibomian Gland Dysfunction Patients

Purpose@#To assess the clinical efficacy of microblepharoexfolication using BlephEx™ (Scope Ophthalmics, London, UK) in meibomian gland dysfunction (MGD) patients. @*Methods@#We performed a prospective study involving 48 eyes of 24 patients who were diagnosed with MGD. All patients were treated with BlephEx™ for 8-10 minutes, and the ocular surface disease index (OSDI), tear break-up time (TBUT), Schirmer’s I test, corneal staining score, lid margin abnormality, MGD score, and lipid thickness layer using the Lipiview II (TearScience, Morrisville, NC, USA) were assessed before treatment and after one month. @*Results@#Significant changes were observed after microblepharoexfoliation using BlephEx™. The TBUT improved from 2.65 ± 1.16 to 3.77 ± 1.80 after 1 month (p < 0.001) and the OSDI improved from 38.83 ± 17.13 to 18.67 ± 15.01 after 1 month (p < 0.001). Before and after 1 month of treatment, the lid margin abnormalities were 2.98 ± 1.16 and 2.50 ± 1.01 (p < 0.001) and the MGD scores were 21.60 ± 6.95 and 18.02 ± 6.68 (p = 0.001), respectively. @*Conclusions@#BlephEx™ improved the patients’ ocular surface symptoms, MGD score, and TBUT. Using steroid eye drops, there was a synergistic effect in improvement. Therefore, using BlephEx™ may be suggested as a treatment option for MGD patients.

Clinical Reliability of the Topolyzer Vario Instrument for Measurement of Corneal Refractive Power

Purpose@#To evaluate the clinical reliability of the Topolyzer Vario (Wavelight-Alcon, Erlangen, Germany), we compared threedifferent corneal topographers in terms of corneal refractive power. @*Methods@#The medical records of patients who visited Severance Hospital for corneal refractive surgery were retrospectivelyreviewed. Keratometric data of patients who underwent evaluations using the Pentacam HR (Oculus, Wetzlar, Germany),ORBscan II (Bausch & Lomb, Rochester, NY, USA), and Topolyzer Vario instruments on the same day were obtained. Flat keratometry(Kf), steep keratometry (Ks), mean keratometry (Km), astigmatism keratometry (Kastig), Cartesian astigmatism (J0), andoblique astigmatism (J45) values were calculated. The measurement values of the three devices were subjected to Pearson’scorrelation analysis and repeated measures analysis of variance (with Bonferroni correction); a Bland-Altman plot was alsocreated. @*Results@#The keratometric data of 80 eyes were included in the analysis and all of the keratometric measurements obtained bythe three devices showed significant correlations, i.e., good agreement. The Kf and Km measurements of the Pentacam HR wereflatter than those of the ORBscan II, and the Kf, Km, Ks, and J45 measurements were flatter than those of the Topolyzer Vario.However, there was no significant difference in keratometric values between the ORBscan II and Topolyzer Vario. Furthermore,the difference in corneal refractive power between the Pentacam HR and Topolyzer Vario was not clinically significant. @*Conclusions@#When measuring the corneal refractive power of patients without any history of corneal disorder or ocular surgery,the Topolyzer Vario is a clinically reliable device that shows similar performance to the ORBscan II and Pentacam HR.

Clinical Outcomes of Small Incision Lenticule Extraction in Myopia: Study of Vector Parameters and Corneal Aberrations

Clinical Outcomes after Use of Fibrin Glue Using a Modified Mini-flap Technique for Pterygium Surgery

PURPOSE: To analyze the long-term clinical outcomes after use of fibrin glue using a modified mini-flap technique for pterygium surgery. METHODS: This study is a retrospective, clinical outcome study of 148 subjects that underwent the modified mini-flap technique with fibrin glue from January 2014 to August 2015. We analyzed the recurrence rate and surgical time of modified mini-flap surgery with fibrin glue. We also analyzed associating factors between the recurrence group and non-recurrence group who underwent the same surgery technique. RESULTS: Mean age was 60.2 ± 1.1 (ranging from 29 to 86) years, and mean surgical time was 11.8 ± 5.8 (ranging from 5 to 36) minutes. The recurrence rate of pterygium patients who underwent the fibrin glue using a modified mini-flap technique was 4.0% (6/148), and the re-operation rate was 0.6% (1/148). From the comparison of associating factors between recurred and non-recurred groups, the recurred group was younger, had more severe disease, and had a higher rate of bilaterality than the non-recurred group (p < 0.05). CONCLUSIONS: The new approach using fibrin glue with a modified mini-flap technique shows a low recurrence rate compared to the other type of pterygium surgery. The use of fibrin glue shortened operation time and decreased patient discomfort due to fewer remnant sutures. Fibrin glue use in a modified mini-flap technique can be considered as a feasible surgical option for pterygium patients.

Comparison of Nd:YAG Capsulotomy Rates between Spherical and Aspheric Intraocular Lenses

PURPOSE: The purpose of the present study is to compare Nd:YAG capsulotomy rates between spherical and aspheric intraocular lenses. METHODS: The present retrospective study enrolled patients who received cataract surgery by a single surgeon between March 1, 2006 and October 31, 2009. Patients included in the study were implanted with SA60AT spherical intraocular lenses (Alcon, Fort Worth, TX, USA, 66 eyes), SN60AT spherical intraocular lenses (Alcon, 48 eyes; a total of 114 eyes), or SN60WF aspheric intraocular lenses (Alcon, 187 eyes). The Nd:YAG capsulotomy rates were compared between the two groups 6 months after the operation. Ten patients who were implanted with a spherical intraocular lens in one eye and an aspheric intraocular lens in the contralateral eye were analyzed separately. RESULTS: Nd:YAG capsulotomy was performed in 2 of 114 eyes (1.8%) in the spherical intraocular lens group and 7 of 187 eyes (3.2%) in the aspheric intraocular lens group; no significant difference was found (p = 0.359). Among the 10 patients who were implanted with 2 different intraocular lenses, Nd:YAG capsulotomy was performed in only 1 eye in the aspheric intraocular lens group; no significant difference was found (p = 0.500). CONCLUSIONS: The design of the intraocular lens, especially the shape of the posterior optic, does not influence the rate of Nd:YAG capsulotomy.

Calcinosis Cutis at the Tarsus of the Upper Eyelid

Calcinosis cutis involves the inappropriate deposition of calcium within the dermis layer of the skin, and is often associated with rheumatoid disease. A 42-year-old woman presented for evaluation of a hard palpable mass on the left upper eyelid. After everting the eyelid, a large papillomatous mass with a broad base was identified on the superior area of the tarsus. The lesion was partially excised posteriorly under local anesthesia, and pathologists identified the mass as calcinosis cutis. The patient had no systemic or trauma history, and the serum levels of calcium and phosphorous were normal. Idiopathic calcinosis cutis should be included in the differential diagnosis for a protruding papillomatous mass of the tarsal plate, and surgical debulking could be a viable option for large protruding lesions, although more follow-up is necessary to monitor regrowth.