Incidence and Risk Factors for the Ptosis after Trabeculectomy

Purpose@#To investigate the incidence and risk factors for the ptosis after trabeculectomy. @*Methods@#We retrospectively analyzed the medical records of 94 patients who underwent trabeculectomy by a single surgeon. Patients with previous eyelid surgery and ophthalmic surgery, as well as those with systemic disease affecting the eyelid, were excluded from the study. Ptosis was defined as higher eyelid crease compared with contralateral eyelid or a ≥2 mm reduction of margin reflex distance-1 after the surgery. Age, sex, bleb location, conjunctival incision site, mitomycin C concentration, range of mitomycin C contact area, and soaking time were analyzed. @*Results@#The incidence of ptosis was 19.1% (18/94) at 6 months after trabeculectomy. There were no statistically significant relationships between postoperative ptosis and the following factors: age, sex, surgical site, bleb site, and conjunctival incision site. The incidence of ptosis was significantly higher in the 0.04% mitomycin C group than in the 0.02% mitomycin C group (40.0% vs 11.6%, p = 0.002). The incidence of ptosis was significantly higher in eyes with a large contact area of mitomycin C to the posterior part of the eye, compared to eyes with a smaller contact area (44.4% vs 9.0%, p < 0.001). Logistic regression analysis showed that the range of mitomycin C contact area remained statistically significant. @*Conclusions@#The large contact area of mitomycin C to the posterior part of the eye during trabeculectomy was found to be a risk factor for postoperative ptosis.

Using Computed Tomography: Predictive Factors for Recovery Time in Patients with Orbital Fracture with Diplopia

PURPOSE: To identify predictive factors for recovery time in patients with orbital fracture with diplopia through analysis of preoperative and postoperative computed tomography (CT) images and postoperative recovery time. METHODS: We retrospectively analyzed CT findings-preoperative: fracture size, type of fracture, fracture site, extraocular muscle (EOM) swelling, EOM and soft tissue injury, and the amount of soft tissue herniation; post-operative: degree of enophthalmos, and diplopia recovery period in 379 patients who underwent surgical treatment for orbital fracture between March 2006 and December 2015. RESULTS: The average postoperative follow-up period was 556.2 ± 59.5 days, and the mean duration of recovery was 23.9 ± 42.5 (range, 3–186) days. The recovery time of diplopia was significantly increased with the following preoperative CT findings: fracture size (small and medium < large) (p = 0.049), type of fracture (linear < hinge < comminuted, trap-door) (p < 0.01), fracture site (inferior < medial and both) (p < 0.01), EOM and soft tissue injury (prolapse and torsion, muscle entrapment, kinked muscle) (p < 0.01), and the amount of soft tissue herniation (small and medium < large) (p < 0.001). The mechanism of injury, sex, age, and the degree of enophthalmos were not related to the length of the diplopia recovery period. CONCLUSIONS: The length of diplopia recovery could be predicted by CT findings.

Endogenous Endophthalmitis Due to Klebsiella ozaenae

PURPOSE: To report a case of endogenous endophthalmitis due to Klebsiella ozaenae, which is a rare causative organism of endophthalmitis. CASE SUMMARY: A 61-year-old male who was undergoing chemotherapy for hepatocellular carcinoma complained of sudden visual loss and ocular pain in his left eye for 2 days. On the first examination, the patient's visual acuity was counting fingers at 10 cm and the intraocular pressure was elevated to 29 mm Hg. Partial scleral rupture and choroidal prolapse were observed. Subretinal abscess was detected with increased echogenicity using ultrasonography. The patient complained of burning sensation on voiding and urinary frequency; subsequent urinalysis showed pyuria and bacteriuria. Intravitreal and systemic antibiotics were administered under the impression of endogenous endophthalmitis caused by urinary tract infection. Despite treatment, visual acuity decreased to no light perception in 4 days and intraocular pressure and pain was uncontrollable. Enucleation was performed and pus culture from the eye during surgery revealed Klebsiella ozaenae. CONCLUSIONS: Klebsiella ozaenae is a rare causative organism of endophthalmitis and shows a rapid progress and poor prognosis. Endogenous endophthalmitis must be highly suspected in patients with urinary tract infection as well as pyogenic liver abscess.

Elevated Matrix Metalloproteinase in Aqueous Humor in Patients with Open-Angle Glaucoma

PURPOSE: To compare the aqueous concentrations of cytokines in glaucomatous eyes with those of normal controls and to characterize the clinical factors associated with aqueous cytokine concentration. METHODS: In this cross-sectional study, aqueous humor samples were collected from 54 eyes of 54 patients (34 medically treated primary open angle glaucoma and 20 normal controls) during cataract surgery from January 2014 to January 2015. Glaucoma patients were divided into two groups: patients using prostaglandin analogue for more than 6 months (prostaglandin F2α analogue [PGA] user) and patients with no experience of PGA use (PGA non-user). The levels of cytokines (matrix metalloproteinase [MMP]1, MMP9, MMP3, vascular endothelial growth factor, interleukin [IL]-1, IL-8, tumor necrosis factor [TNF]-α) in the aqueous of glaucoma and control subjects were quantified using a multiplex cytokine analysis. RESULTS: Aqueous humor collected from the glaucoma patients exhibited significantly increased concentrations of MMP1 (p = 0.002) and MMP9 (p = 0.026). Among glaucoma patients, PGA users showed significantly higher level of MMP 9 compared with PGA non-users (p = 0.003). In the univariate and multivariate linear regression analyses, PGA use (β = 0.351, p = 0.027) and vertical cup-to disc ratio (β = -0.401, p = 0.013) were the significant risk factors associated with the level of MMP9. CONCLUSIONS: Primary open-angle glaucoma showed increased aqueous levels of MMP1 and MMP9. Especially, PGA use for longer than 6 months was associated with increased level of MMP9.

Elevated Matrix Metalloproteinase in Aqueous Humor in Patients with Open-Angle Glaucoma

PURPOSE: To compare the aqueous concentrations of cytokines in glaucomatous eyes with those of normal controls and to characterize the clinical factors associated with aqueous cytokine concentration. METHODS: In this cross-sectional study, aqueous humor samples were collected from 54 eyes of 54 patients (34 medically treated primary open angle glaucoma and 20 normal controls) during cataract surgery from January 2014 to January 2015. Glaucoma patients were divided into two groups: patients using prostaglandin analogue for more than 6 months (prostaglandin F2α analogue [PGA] user) and patients with no experience of PGA use (PGA non-user). The levels of cytokines (matrix metalloproteinase [MMP]1, MMP9, MMP3, vascular endothelial growth factor, interleukin [IL]-1, IL-8, tumor necrosis factor [TNF]-α) in the aqueous of glaucoma and control subjects were quantified using a multiplex cytokine analysis. RESULTS: Aqueous humor collected from the glaucoma patients exhibited significantly increased concentrations of MMP1 (p = 0.002) and MMP9 (p = 0.026). Among glaucoma patients, PGA users showed significantly higher level of MMP 9 compared with PGA non-users (p = 0.003). In the univariate and multivariate linear regression analyses, PGA use (β = 0.351, p = 0.027) and vertical cup-to disc ratio (β = -0.401, p = 0.013) were the significant risk factors associated with the level of MMP9. CONCLUSIONS: Primary open-angle glaucoma showed increased aqueous levels of MMP1 and MMP9. Especially, PGA use for longer than 6 months was associated with increased level of MMP9.

Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide

PURPOSE: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. METHODS: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. RESULTS: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were 23.62 ± 0.45 cm3 and 21.95 ± 1.01 cm3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were 21.65 ± 0.91 cm3 and 21.78 ± 0.83 cm3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were 21.84 ± 0.93 cm3 and 21.81 ± 0.91 cm3, respectively (p = 0.889). CONCLUSIONS: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications.

Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide

PURPOSE: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. METHODS: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. RESULTS: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were 23.62 ± 0.45 cm3 and 21.95 ± 1.01 cm3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were 21.65 ± 0.91 cm3 and 21.78 ± 0.83 cm3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were 21.84 ± 0.93 cm3 and 21.81 ± 0.91 cm3, respectively (p = 0.889). CONCLUSIONS: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications.

A Case of Steatocystoma Simplex of the Orbit

PURPOSE: Steatocystoma is a cyst that originates embryologically from hair follicles and usually occurs on the face, chest, back and axillae as multiple lesions and rarely occurs as a solitary lesion. We experienced a case of steatocystoma simplex that developed in the orbit and present our case with a brief review of the literature. CASE SUMMARY: A 44-year-old male presented with a history of palpable mass in the right inferomedial periorbital area that had been slowly growing for a few months. Physical examination revealed a non-tender, soft and round mass. Magnetic resonance imaging of the orbit showed 2.0 x 2.0 x 2.0 cm-sized mass in the right inferomedial orbit. We performed excisional biopsy of the orbital mass using transconjunctival approach. The pathological diagnosis was steatocystoma. There was no local recurrence during the postoperative follow-up. CONCLUSIONS: We experienced a rare case of steatocystoma simplex that developed in the orbit. Base on our results, steatocystoma simplex should be considered when diagnosing an orbital mass.

Orbital Emphysema Causing Eye Movement Restriction Without Orbital Fractures Due to Compressed Air Injury

PURPOSE: The authors experienced a case of orbital emphysema causing eye movement disorder following conjunctival tear without any orbital wall fractures after exposure to compressed air. CASE SUMMARY: A 28-year-old man's left periorbital area was injured while working with compressed air. There was marked lid swelling on the left side with palpable crepitus. The patient had an exotropia and hypertropia of the left eye. In addition, the extraocular movement of the left eye was restricted on upgaze without nausea and vomiting. On slit-lamp examination, conjunctival partial laceration and subconjunctival air bubbles adjacent to the conjunctival laceration could be seen. Orbital computed tomography showed air in the periorbital and retrobulbar region of the left eye and no evidence of orbital fracture. On examination 4 days after the primary repair of the conjunctival laceration, the patient completely recovered without any complication. CONCLUSIONS: Orbital emphysema following a conjunctival laceration caused by compressed air without any orbital wall fractures can cause restriction of eye movement.

A Case of IgG4-Related Sclerosing Disease Involving the Eyelid in an Idiopathic Sclerosing Myositis Patient

PURPOSE: To report a case of IgG4-related sclerosing disease involving the eyelid in an idiopathic sclerosing myositis patient. CASE SUMMARY: A 51-year-old woman presented with swelling, redness, and tenderness of the left lower eyelid of 1 month duration had taken an immunosuppressant for idiopathic sclerosing myositis. Eye movements showed limitation all directions but there was no exophthalmos. A palpable mass was noted in the left lower eyelid. The left extraocular muscles were hypertrophied but the lacrimal gland was normal on orbital magnetic resonance imaging. IgG4-related sclerosing disease was confirmed by immunostained biopsy from the left lower eyelid, showing infiltration of IgG4-positive lymphoplasmacytic cells. The patient was given oral steroids and an immunosuppressant and the symptoms did not recur for at least 7 months. CONCLUSIONS: IgG4-related sclerosing disease involving ocular adnexa usually consists of bilateral lacrimal gland involvement. Additionally, the orbital soft tissue involvement without dacryoadenitis is rare. The authors of the present study report a case of IgG4-related sclerosing disease involving the left lower eyelid in an idiopathic sclerosing myositis patient and should be considered in the differential diagnosis of eyelid masses.

Prevalence and Risk Factors of Dry Eye Syndrome in the Incheon Area

PURPOSE: To investigate the prevalence, clinical manifestations, and risk factors of dry eye syndrome (DES) among people over 50 years old in the Incheon area. METHODS: A cross-sectional prevalence study was performed on 462 people over 50 years old in Dong-gu, Incheon. DES was defined as the constant or frequent presence of symptoms of both dryness and irritation. Symptoms and past medical history were assessed by a survey. Eye examination included slit lamp examination, Schirmer test, and tear break-up time (T-BUT). Age, sex, living habits, systemic and eye diseases were also analyzed to determine the risk factors of DES. RESULTS: The prevalence of DES was 26.2%. The major symptoms were as follows in descending order: dryness (77.9%), tearing (75.2%), and sandiness (72.7%). An average of 12.1 +/- 6.0 mm in the Schirmer test and 6.7 +/- 2.4 seconds in the T-BUT were significantly different in the DES group from the normal group (p < 0.001). Variables such as age, sex, living habits, and eye diseases were not related to the diagnosis of DES, whereas diabetes was the only risk factor of DES with statistical significance (p = 0.03). CONCLUSIONS: In the present study, the prevalence of DES among people over 50 years old in the Incheon area was 26.2%. Schirmer test and T-BUT were considered to be helpful tools for the diagnosis of DES, and diabetes was a significant risk factor of DES.

Brain Abscess Formation Accompanied by Improvement of Orbital Cellulitis

PURPOSE: To present a case of brain abscess formation accompanied by improvement of orbital cellulitis. CASE SUMMARY: A 54-year-old male came to our clinic complaining of swelling and pain of the left periorbital area and decreased visual acuity (VA) of the left eye. Initial best-corrected visual acuity (BCVA) was 0.3 and intraocular pressure was 27 mmHg in the left eye. Eye movement in all directions was restricted and 4 mm of proptosis was observed in the left eye. An orbital CT scan demonstrated pansinusitis and orbital cellulitis of the left eye. The patient underwent endoscopic sinus surgery and was treated with systemic antibiotics. However, periorbital swelling was aggravated and another orbital CT scan was performed and analyzed. The CT scan showed localized periorbital abscess of the left eye, and the authors performed an incision and drainage (I&D) of abscess procedure. After the operation, BCVA of the left eye was recovered to 0.8 and eye movement improved and periorbital swelling decreased. However, 15 days after the I&D, the patient complained of a severe headache. Brain magnetic resonance imaging (MRI) was performed and showed an abscess of the left frontal lobe of the brain. The authors consulted with a neurosurgeon, and the patient received intravenous antibiotics and mannitol. The headache steadily decreased, and three months after the first visit, a follow-up brain MRI was performed. The MRI showed almost complete disappearance of the abscess and six months after the first visit, BCVA was recovered to 1.0 and eye movement was full in all directions. CONCLUSIONS: Although orbital cellulitis is improved by treatment of antibiotics and surgery, if the patient complains of neurologic symptoms such as headache, other complications such as brain abscess formation should be considered.

Fundus Examination Rate in Diabetics and the Public Health Factors Associated With Fundus Examination Rate

PURPOSE: To investigate the fundus examination rate in diabetic patients and the public health factors associated with the fundus examination rate. METHODS: We analyzed the results of the third Korean National Health and Nutrition Examination Survey. We investigated the fundus examination rate in patients who had diabetes mellitus for more than 3 months during the previous year and determined the relationship of public health factors with the fundus examination rate. RESULTS: In all 547 patients (38.1%) received the fundus examination out of 1,437 total patients with diabetes mellitus. We found that many public health factors influenced the higher fundus examination rate, including patients who were residents in urban areas, women, office workers, university graduates, patients with a higher family income or more than 5 years duration of diabetes mellitus, patients with current insulin treatment, treatment of diabetes mellitus, education about diabetes mellitus, subjective visual problems or subjective health problems. However, age, marital status, health insurance and residential district did not influence the fundus examination rate. CONCLUSIONS: The Korean National Health and Nutrition Examination Survey is the largest health survey in Korea. This study is meaningful as a population-based study, not a clinic-based cross-sectional study and it suggests the basic data for improving the fundus examination rate in diabetes mellitus patients.

A Case of Atypical Miller Fisher Sndrome

PURPOSE: To report one case of atypical Miller Fisher syndrome with spontaneous recovery. METHODS: A 44-year-old woman was visited our clinic complaining of diplopia for 2 days. She has irregular medication history for thyroid dysfunction, and there was no antecedent respiratory or gastrointestinal infection. The best corrected visual acuity of both eyes was 20/20. She showed bilateral proptosis and limitation of abduction and supraduction, mild blepharoptosis of left eye and esotropia of 30 prism diopter (PD). RESULTS: Thyroid fuction test, orbital CT and electromyography were normal. Cerebrospinal fluid (CSF) analysis revealed albuminocytologic dissociation. Steroid pulse therapy was started promptly, but there was no improvement. Extraocular movement and diplopia gradually improved after 4 weeks of onset. and spontaneously recovered completely after 2 months. CONCLUSIONS: We reported a case of atypical Miller Fisher syndrome that completely and spontaneously recovered within 2 months., and represented normal findings by every examination such as orbital CT, thyroid function test, electromyography and CSF analysis.

A Case of Horizontal Gaze Palsy with Ipsilateral Esotropia due to Pontine Hemorrhage

PURPOSE: We describe a patient with a horizontal pontine gaze palsy and a concurrent esotropia and discuss the etiology and surgical management of this condition. METHODS: A 42-years-old male visited the hospital with dipopia and left ocular pain. He had a history of pontine hemorrhage a year ago. Because of left ficial palsy, lagophthalmos was noted on the left eye and slit-lamp examination showed filament keraititis and superficial punctate keratitis. Left face turn was noted and a left horizontal gaze palsy with inability to abduct the left eye and to adduct the right eye past the midline was also noted. By Krimsky estimation, 40 prism diopter (PD) left esotropia was present in the primary position. Brain magnetic resonance imaging carried a yeas ago showed a large lobulated hyperdense lesion and the central lesion is on the left dorsal portion of pons. RESULTS: The patient underwent a right lateral rectus muscle recession of 5 mm, a left medial rectus muscle recession of 6 mm and a parial tendon transfer of the left superior and inferior rectus muscles th the left lateral rectus muscle insertion (modified Hummelsheim operation with augmentation). A lateral tarsorrhaphy was also performed. 3 months after operation, he didn't complain diplopia and orthotropia was noted in the primary position by Hirshberg test. His head posture was also right. The lagophthalmos and keratitis was markely improved and ocular pain was not complained. CONCLUSIONS: The lesion in this patient caused by potine hemorrhage may be involve the left PPRF, the left sixth nerve nucleus and the left facial nerve fascicles. Strabismus surgery on the patient improved diplopia and face turn.

A Case of Plexiform Neurofibroma with Severe Ptosis and Proptosis

PURPOSE: We present a case of plexiform neurofibroma that extensively invaded cranial and temporal bone, eyelid, orbit and uveal tissues, showing signs of severe ptosis and proptosis and symptoms of headache and ocular pain. METHODS: A 24-year old woman visited our clinic with pain and progressive proptosis, which had persisted for 2 weeks. She had a history of congenital neurofibromatosis. There were multiple Cafe-au-lait spots on her extremities, trunk, and face. Also, she had severe ptosis in her upper left eyelid, proptosis, and a distorted and asymmetric facial form. The cornea was markedly edematous. An enhanced computed tomography scan revealed an uncertain circumscribed soft tissue mass with enlargement of the eyeball and orbit, coupled with sphenoid wing dysplasia and herniation of the dura mater into the orbit due to expansion and bony destruction of the superior orbital wall. Under general anesthesia, the patient underwent excision and histopathologic biopsy of intraocular neurofibroma through evisceration. RESULTS: The tumor had black-colored multilobular nodules whose dimensions were 1.5x1.2x0.4 cm. After a histopathologic examination, the tumor was determined to be a pigmentary hamartoma of the uvea. Based on the clinical and histologic findings, we diagnosed the patient with plexiform neurofibroma with type I neurofibromatosis.

The Effect of Transconjunctival Lower Blepharoplasty Combined with Pinch Skin Excision Technique

PURPOSE: The aim of this study was to analyze the effects of transconjunctival lower blepharoplasty combined with the pinch skin excision technique. METHODS: This study followed 15 patients over a six-month period who had undergone transconjunctival lower blepharoplasty combined with the pinch skin excision technique. The follow-up period exceeded 6 months. After subconjunctival injection of local anesthetic, incisions of the conjunctiva and lower lid retractors were made. The exposed fat pads were excised by clamping, excising, and cauterizing the base of the pad. The conjunctiva was closed with a continuous 6-0 Vicryl suture. If there was mild skin excess, a pinch skin excision technique was used. RESULTS: There were no complications (i.e., lower eyelid retraction, ectropion, etc.). All 15 patients were satisfied with the final result. CONCLUSIONS: The transconjunctival lower blepharoplasty combined with the pinch skin excision technique in middle-aged patients with prominent lower eyelid fat and skin excess had lower complication rates and higher patient satisfaction than the transcutaneous approach.

Reconstruction of Orbital Wall Fracture with Resorbable Copolymer Mesh

PURPOSE: BioSorbFX(R)(BIONX Implant Inc.) and Macropore(R)(Medtronics Inc.) are mesh-type resorbable copolymer plate. This report presents a new model necessary for orbital wall reconstruction, accoding to the operative outcomes of orbital fracture with its use. METHODS: A follow-up on 11 patients was performed to ascertain the operative effects of the mesh-type resorbable material for 6 months. RESULTS: The patients were 7 males and 4 females. The patients' average age was 29.7 years and the mean follow-up period was 8.1 months. The most common site of fracture was inferior wall. In these cases, simultaneous fracture of the medial wall and floor was frequently observed. One case showed limitation of ocular movement, diplopias and enophthalmos simultaneously; 3 cases, enophthalmos and diplopia; 5 cases showed limitation of ocular movement and diplopia; and 2 cases, considerable possibility or the presence of enophthalmos due to extended fracture size. The cases improved remarkably after being operated and none were observed to have worsened. Moreover, serious complications, such as visual loss, the infection of implants, dislocation, exposure, etc., were not observed. CONCLUSIONS: Altogether, it is considered that the mesh-type resorbable copolymer plate may be safely used in orbital wall reconstruction without conspicuous complication.

The Effect of Nonincisional Double Fold Formation Using Three Small Incisions, Two-stitch Method

PURPOSE: The aim of this study was to analyze the effects of using the nonincisional, double fold formation method with three small incisions and two-stitches. METHODS: This study included 39 patients who underwent double eyelid operation by a nonincisional technique and who were followed up for more than 6 months. On the desired double eyelid line, three points 6 mm apart were marked and three stab incisions made. A small amount of subcutaneous tissue was removed through the incisions, and orbital fat was removed through the lateral wound site-if necessary. Using double-armed 7-0 nylon or prolene, two buried sutures of 6 mm width were made. Sixteen patients also underwent surgery for epiblepharon, and three patients with unilateral double eyelid due to trauma had a contralateral eyelid operation for asymmetry correction. Five patients also had epicanthoplasty. RESULTS: Two patients lost their folds completely and reoperations were performed. Two patients showed cysts due to suture material and so the suture knots were removed; the double fold remained afterwards, so no other procedures were needed. In one case, the suture was seen subcutaneously, so suture removal and reoperation were performed. CONCLUSIONS: To minimize double fold loss, which is a disadvantage of the nonincisional double fold formation technique, we removed a portion of pretarsal tissue, muscle, and/or orbital fat and made two wide slings. Also, we corrected asymmetry due to traumatic unilateral double eyelid and epicanthal fold. In conclusion, we expect that our method could extend the applicability of nonincisional double fold formation.

The Effect of Nonincisional Double Fold Formation Using Three Small Incisions, Two-stitch Method

PURPOSE: The aim of this study was to analyze the effects of using the nonincisional, double fold formation method with three small incisions and two-stitches. METHODS: This study included 39 patients who underwent double eyelid operation by a nonincisional technique and who were followed up for more than 6 months. On the desired double eyelid line, three points 6 mm apart were marked and three stab incisions made. A small amount of subcutaneous tissue was removed through the incisions, and orbital fat was removed through the lateral wound site-if necessary. Using double-armed 7-0 nylon or prolene, two buried sutures of 6 mm width were made. Sixteen patients also underwent surgery for epiblepharon, and three patients with unilateral double eyelid due to trauma had a contralateral eyelid operation for asymmetry correction. Five patients also had epicanthoplasty. RESULTS: Two patients lost their folds completely and reoperations were performed. Two patients showed cysts due to suture material and so the suture knots were removed; the double fold remained afterwards, so no other procedures were needed. In one case, the suture was seen subcutaneously, so suture removal and reoperation were performed. CONCLUSIONS: To minimize double fold loss, which is a disadvantage of the nonincisional double fold formation technique, we removed a portion of pretarsal tissue, muscle, and/or orbital fat and made two wide slings. Also, we corrected asymmetry due to traumatic unilateral double eyelid and epicanthal fold. In conclusion, we expect that our method could extend the applicability of nonincisional double fold formation.