Inferior Mesenteric Artery Injury in Post-lumbar Microdiscectomy: A Case Report.

Iatrogenic vascular injury during lumbar microdiscectomy is a rather rare complication, but it can have fatal consequences. Here, we report a patient who underwent an L5-S1 microdiscectomy, which was complicated by inferior mesenteric artery injury. The patient presented in the recovery room with symptoms of hypotension and tachycardia after the operation which was successfully managed by endovascular embolization. The patient was positioned in a prone position, which may have contributed to the development of vascular injury. To prevent potential complications, we advised using the Jackson table rather than a standard surgical table and thoroughly inspecting the abdomen and pelvis prior to the operation.

Waste cooking oil processing over cobalt aluminate nanoparticles for liquid biofuel hydrocarbons production.

The catalytic conversion of waste cooking oil (WCO) was carried out over a synthetic nano catalyst of cobalt aluminate (CoAl2O4) to produce biofuel range fractions. A precipitation method was used to create a nanoparticle catalyst, which was then examined using field-emission scanning electron microscopy, X-ray diffraction, energy dispersive X-ray, nitrogen adsorption measurements, high-resolution transmission electron Microscopy (HRTEM), infrared spectroscopy, while a gas chromatography-mass spectrometer (GC-MS) was used to analyze the chemical construction of the liquid biofuel. A range of experimental temperatures was looked at including 350, 375, 400, 425, and 450 °C; hydrogen pressure of 50, 2.5, and 5.0 MPa; and liquid hour space velocity (LHSV) of 1, 2.5, and 5 h-1. As temperature, pressure, and liquid hourly space velocity increased, the amount of bio-jet and biodiesel fractional products decreased, while liquid light fraction hydrocarbons increased. 93% optimum conversion of waste cooking oil over CoAl2O4 nano-particles was achieved at 400 °C, 50 bar, and 1 h-1 (LHSV) as 20% yield of bio-jet range,16% gasoline, and 53% biodiesel. According to the product analysis, catalytic hydrocracking of WCO resulted in fuels with chemical and physical characteristics that were on par with those required for fuels derived from petroleum. The study's findings demonstrated the nano cobalt aluminate catalyst's high performance in a catalytic cracking process, which resulted in a WCO to biofuel conversion ratio that was greater than 90%. In this study, we looked at cobalt aluminate nanoparticles as a less complex and expensive alternative to traditional zeolite catalysts for the catalytic cracking process used to produce biofuel and thus can be manufactured locally, which saves the cost of imports for us as a developing country.

Apparent Association of Insulin With Interleukin-6 (IL-6) in Severe COVID-19 Patients Having Chronic Disease Comorbidities.

Background The severe acute respiratory syndrome caused by the novel coronavirus (COVID-19), due to its fast spread, is a disease with global health, social and economic burden. This is complicated by its high morbidity and mortality among those with medical comorbidities and older adults. During the outbreak in Libya, intensive care facilities were overwhelmed by the number of patients requiring special care. Admission to such facilities was reserved for severe cases showing low blood oxygen levels. Due to the inflammatory process in COVID-19, we believed it was essential to evaluate the outcome of inflammation reflected in the changes in interleukin-6 (IL-6) and insulin. Objective To study the changes in IL-6 and insulin during the course of the disease, if an association between them exists, and whether this association changes following seven days of treatment. Method We analyzed the data of 60 patients diagnosed with COVID-19 and admitted to the hospitals' Intensive Care Units (ICU) in the eastern part of Libya. The study was initiated on January 18th and concluded on March 22, 2021. Samples for the analysis were collected on the first day of admission and after seven days of hospitalization for patients who survived till the selected day. The collected samples were used to analyze IL-6 as an indicator of change in inflammation and insulin as a potential anti-inflammatory modulator. In addition, the association of insulin with IL-6 was statistically tested. Results Diabetes and hypertension, the most commonly observed chronic diseases in Libya, were found to represent the highest comorbidities among the ICU patients included in this study. Nonetheless, other diseases affected a smaller proportion of them, ranging from two patients for malignancy to 10 patients for cardiovascular disease. In addition, both age and gender showed differences in the number of ICU hospitalized patients and the death tally among them. The study showed that the IL-6 level was on the rise during the course of COVID-19, whereas that of insulin was on the decrease. The two variables showed an association for admission day samples as well as for samples after seven days of ICU hospitalization. Conclusion Although, IL-6 appears to play a predictive role in the development and outcome of severe COVID-19, along with other biochemical and clinical findings it could serve as an indicator of the disease outcome. On the other hand, the role of insulin as a complementary factor for alleviating inflammation remains to be fully understood and requires further research. There is a pressing necessity for establishing the mechanism through which insulin is associated with inflammation modulatory pathways, in particular through the pathways involving IL-6.

The impact of COVID-19 on the occupational health of oncologists: a descriptive analysis of occupational safety, perceived burnout and social support among practicing oncologists in Alexandria, Egypt.

BACKGROUND: Healthcare workers, including oncologists, face a higher potential risk of contracting coronavirus disease 2019 (COVID-19) while managing patients. Moreover, the uncertainty that came with COVID-19 and its associated social stigma may worsen what was already a crisis (burnout) among oncologists. Data are scarce on the impact of COVID-19 on the occupational health and safety of oncologists in low and middle-income countries. METHODS: We conducted a cross-sectional survey in February 2021 to evaluate the impact of COVID-19 on practicing oncologists in Alexandria governorate, Egypt. An anonymised self-reporting questionnaire was electronically distributed to 88 participants to collect information on occupational safety at work, the prevalence of COVID-19 among respondents and the impact of COVID-19 on their wellbeing, including perceived burnout and family support. RESULTS: Out of the 88 contacted oncologists, 75% completed the survey. The mean age of participants was 34.79 years (SD ± 10.42), of which 45% were residents, 36% were specialists and 18% were consultants. Most of the oncologists (58% of 66) felt they were not adequately protected against COVID-19. The majority (78% of 66) have managed COVID-19 infected cancer patients, and 76% (out of 66) had experienced COVID-19 like symptoms. A third (n = 21) of the respondents were confirmed COVID-19 infected: 62% of the latter thought they were infected at the workplace, either by a patient or a colleague. The majority of the oncologists (78%) perceived being more overwhelmed or burned out than in the pre-COVID-19 era. Nearly half of the participants (48%) reported their family members and friends had reduced contact with them despite being COVID-19 negative, in fear of being infected. The burnout was significantly higher in those lacking family support than those who had, 52% versus 28% respectively (p = 0.038). CONCLUSIONS: One-third of practicing oncologists were diagnosed with COVID-19, and most thought they were infected at the hospital. Occupational safety measures, including mental health programs, need to be improved with special emphasis on the role of family support in mitigating perceived burnout among practicing oncologists.

Anti-inflammatory effects of diet and caloric restriction in metabolic syndrome.

BACKGROUND: Weight loss in patients with metabolic syndrome has positive effects on cardiovascular and type 2 diabetes risks, but its effects on peripheral cytokines and lipid profiles in patients are still unclear. AIM: To determine the effects of diet-induced weight loss on metabolic parameters, lipids and cytokine profiles. METHODS: Eighteen adult males with metabolic syndrome (defined according to IDF 2009) and Body Mass Index (BMI) between 25 and 35 kg/m2 were subjected to a balanced hypocaloric diet for 6 months to reach at least a 5% body weight loss. RESULTS: After weight loss, a significant improvement in BMI, waist circumference, insulin, fasting blood glucose and HOMA-IR (homeostasis model assessment of insulin resistance) was observed. The analysis of LDL (low-density lipoprotein cholesterol) and HDL (high-density lipoprotein cholesterol) lipoproteins showed a change in their composition with a massive transfer of triacylglycerols from HDL to LDL. This was associated with a significant reduction in peripheral pro-inflammatory cytokines such as IL-6, TNF-α, IL-8 and MIP-1ß, leading to an overall decreased inflammatory score. An interesting positive correlation was also observed among peripheral cytokines levels after diet and peripheral levels of CETP (cholesteryl ester transfer protein), an enzyme with a key role in lipid change. CONCLUSION: Weight loss through caloric restriction is associated with an improvement in peripheral lipid and cytokine profiles that may play a major role in improving cardiovascular risk.

Application of a hybrid method for efficiency calibration of a NaI detector.

A previously proposed hybrid analytical-numerical method for efficiency calibration of a NaI detector for a point γ-source is extended and applied for other shapes of sources. The shapes include line, disk, and cylindrical sources of various dimensions and locations with respect to the right circular cylindrical NaI detector. The results obtained by this method have been evaluated through comparison with Monte Carlo (MC) calculations. A relative maximum difference of 3.5% is found between the two methods.

Classification of Color-Coded Scheimpflug Camera Corneal Tomography Images Using Deep Learning.

Purpose: To assess the use of deep learning for high-performance image classification of color-coded corneal maps obtained using a Scheimpflug camera. Methods: We used a domain-specific convolutional neural network (CNN) to implement deep learning. CNN performance was assessed using standard metrics and detailed error analyses, including network activation maps. Results: The CNN classified four map-selectable display images with average accuracies of 0.983 and 0.958 for the training and test sets, respectively. Network activation maps revealed that the model was heavily influenced by clinically relevant spatial regions. Conclusions: Deep learning using color-coded Scheimpflug images achieved high diagnostic performance with regard to discriminating keratoconus, subclinical keratoconus, and normal corneal images at levels that may be useful in clinical practice when screening refractive surgery candidates. Translational Relevance: Deep learning can assist human graders in keratoconus detection in Scheimpflug camera color-coded corneal tomography maps.

Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report.

We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.

Evaluation of radiation-induced cardiac toxicity in breast cancer patients treated with Trastuzumab-based chemotherapy.

PURPOSE: Patients with Her2-positive breast cancer treated with trastuzumab have higher rates of cardiotoxicity (CT). Left-breast radiation might increase the risk for CT from cardiac exposure to radiation. The goal of our study is to evaluate the contribution of radiotherapy (RT) in the development of CT in breast cancer patients receiving trastuzumab. METHODS: Two hundred and two patients were treated with RT and trastuzumab from 2000 to 2014. The RT plans for left-side disease were recalled from archives. The heart, each chamber, and left anterior descending artery (LAD) were independently contoured. New dose-volume histograms (DVH) were generated. Their serial left-ventricular ejection fractions (LVEF) were studied. CT for left and right side were compared using Fisher's exact test. The DVH data were correlated with the predefined cardiac events using actuarial Cox regression analysis. RESULTS: Compared to the right sided, the left-side cases showed statistically significant development of arrhythmia (14.2%) versus (< 1%) (p < 0.001). Cardiac ischemia was found in 10 patients in left and one patient in right side (p = 0.011). The equivalent uniform dose (EUD) to the left ventricle (LV), right ventricle (RV), and LAD was significantly associated with decrease in LVEF by > 10% (p = 0.037, p = 0.023 and p = 0.049, respectively). CONCLUSIONS: Among patients treated for left-sided lesions, there were no significant differences in EF decline. However, there was a higher rate of ischemia and arrhythmia compared to those with right-sided disease. The EUD index of LV, RV, and LAD could be considered as a parameter to describe the risk of radiation-induced CT.

Comparison between Ologen implant and different concentrations of Mitomycin C as an adjuvant to trabeculectomy surgery.

CONTEXT: Trabeculectomy is the most common surgical procedure for treatment of glaucoma. To improve success rates, adjuvants were utilized as Mitomycin C (MMC) and Ologen implant. AIMS: This study aims to establish efficacy and safety of Ologen implant versus MMC in trabeculectomy. SETTING AND DESIGN: A prospective, comparative clinical study was conducted at the Department of Ophthalmology, Assiut University, between December 2014 and April 2016. SUBJECTS AND METHODS: Patients with primary open-angle glaucoma (OAG), primary narrow-angle glaucoma and secondary OAG were assigned equally to trabeculectomy with Ologen, 0.4 mg/mL or 0.2 mg/mL MMC. The study outcome measures were reduction in intra-ocular pressure (IOP), success rates, survival analysis, and rate of complications. STATISTICAL ANALYSIS USED: SPSS software Version 17.0 (SPSS, Inc., IL, USA) was utilized. RESULTS: Thirty eyes were included in the study. Mean baseline IOP in Ologen, MMC 0.4 and MMC 0.2 groups were 27.43 ± 2.97, 28.4 ± 3.24, and 27.56 ± 2.69 mmHg, respectively. At week 24 follow-up, mean IOP in Ologen, MMC 0.4 and MMC 0.2 groups were 18.55 ± 3.18, 16.2 ± 3.22, and 16.93 ± 3.04 mmHg, respectively. No significant inter-group difference was noticed at any visits. Complete success was achieved in 10%, 40%, and 30%, whereas incomplete success in 70%, 50%, and 60%, respectively in Ologen, MMC 0.4 and MMC 0.2 groups. No treatment group difference was reported by Kaplan-Meier analysis. Shallow anterior chamber occurred more in Ologen and MMC 0.4 groups. A single case of serous choroidal effusion had occurred in MMC 0.4 group. CONCLUSION: Ologen implant is a promising alternative to MMC for improving the success rate of trabeculectomy.

Taeniectomy pouch as neorectum after low rectal resection.

Background and purpose The functional outcomes of incontinence and high stool frequency resulting from restorative surgery are often criticised. The aim of this study was to assess the taeniectomy pouch in comparison with other pouches described in the literature. Material and methods This was a prospective cohort study. All patients who were candidate for low rectal resection presenting to the colorectal unit at Cairo University hospitals during the period February 2013 to February 2015 were included in the study (90 patients). Safety and feasibility of the new technique were assessed, including operative time, leakage, postoperative urgency, incontinence, number of daily motions and difficulty in evacuation. These parameters were assessed clinically, by means of defecography and anorectal manometry. Results The mean age of patients was 49.6 years. Percentages of postoperative mortality and leakage were 2.2% and 3.4%, respectively. Mean operative time was 117 minutes. Mean numbers of daily motions were 3.04 and 1.52 at 3 and 12 months, respectively. Mean Wexner score for continence at 3 and 12 months were 3.21 and 1.32, respectively. Mean resting pressure was 51.63 mmHg, squeeze pressure was 130.42 mmHg and mean threshold volume was 118.68 ml. Conclusions Taeniectomy is a novel technique for pouch formation after low rectal resection, which can be used as an alternative to other pouches, especially the widely used transverse coloplasty.

Excessive iodine intake, water chemicals and endemic goitre in a Sudanese coastal area.

OBJECTIVE: To study the associations between intakes of iodine and water chemicals and the thyroid gland status of schoolchildren living in the coastal city of Port Sudan. DESIGN: In our previous nationwide study on goitre, it was observed that the prevalence of goitre was high in Port Sudan city despite high urinary iodine excretion. A cross-sectional study including schoolchildren aged 6­12 years was designed. Measurements determined the prevalence of goitre, urinary iodine concentration and thiocyanate secretion in casual urine samples, serum levels of thyroxine, triiodothyronine, thyroid-stimulating hormone and thyroglobulin, as well as the levels of Cl⁻, F⁻, Ca²âº, Mg²âº and total hardness of drinking water. SUBJECTS: Schoolchildren (n 654) aged 6­12 years. SETTING: Port Sudan city is located at the western bank of the Red Sea. The city is surrounded by a mountainous area known as the Red Sea Hills. It is the main sea port in the Sudan, inhabited by ethnically and socio-economically heterogeneous populations. RESULTS: The prevalence of goitre in Port Sudan was 34.86% while the median urinary iodine concentration was 46,4µg/dl. Out of thirty-one pupils from Port Sudan, twenty-four (77.42 %) were found to have urinary iodine concentration greater than 30µg/dl and twelve (38.71 %) had different degrees of biochemical hypothyroidism. Excessive concentrations of Cl⁻, Ca²âº, Mg²âº and water hardness (369.2, 116.48, 60.21 and 539.0mg/l, respectively) were detected in drinking water samples collected from Port Sudan that exceeded levels permitted by the WHO. CONCLUSIONS: The coastal city of Port Sudan is a goitre-endemic area. In contrast to other Sudanese cities in which endemic goitre is related to iodine deficiency, goitre in Port Sudan is associated with iodine excess. Water chemicals seemed to have no effects on thyroid status.

Association of tumour necrosis factor-alpha -308 G/A promoter polymorphism with susceptibility and disease profile of rheumatoid arthritis.

The objective was to analyze the possible involvement of tumour necrosis factor-alpha (TNF-α) -308 G/A promoter polymorphism in the susceptibility and/or the disease profile of rheumatoid arthritis (RA) in Egyptian patients. TNF-α-308 G/promoter polymorphism detection by amplification refractory mutation system (ARMS) technique was carried out for 122 RA patients and 120 healthy controls. TNF-α-308 G allele/GG homozygous genotype were higher in patients with rheumatoid arthritis than those in control group (P < 0.001, respectively). A statistically significant association was found between the frequency of the A allele and presence of erosion (OR = 3.42, P = 0.015). No associations were found between the distribution of TNF-α-308 G/A alleles/genotypes and age of patients, disease duration, absence of remission, presence of deformity, clinical manifestations of the disease and presence or absence of rheumatoid factor. The positivity of rheumatoid factor was associated with occurrence of erosion (OR = 25.0, P < 0.001). The results of this study demonstrate the association of the TNF-α-308 G allele and GG homozygous genotype with susceptibility to RA and the A allele with the presence of erosion in the Egyptian patients.

Endemic goitre in the Sudan despite long-standing programmes for the control of iodine deficiency disorders.

OBJECTIVE: To describe the status of iodine deficiency disorders (IDDs) in the Sudan more than 25 years after the initiation of IDD control programmes and to explore the causes of endemic goitre in the country. METHODS: Testing for IDDs was carried out in 6083 schoolchildren 6 to 12 years of age from the capital cities of nine states in different areas of the country using the three indicators recommended by the World Health Organization: the prevalence of goitre, laboratory measurements of urinary iodine concentration in casual urine samples and serum thyroglobulin (Tg) levels. Serum levels of thyroxine (T4), triiodothyronine (T3) and thyroid-stimulating hormone (TSH), as well as urinary secretion of thiocyanate, which can affect the transport of iodine into thyrocytes, were also measured. FINDINGS: The prevalence of goitre in the different samples ranged from 12.2% to 77.7% and was 38.8% overall. The overall median urinary iodine concentration was 6.55 µg/dl, with the lowest median value having been found in Kosti city (2.7 µg/dl), situated in the centre of the country, and the highest (46.4 µg/dl) in Port Sudan, on the Red Sea coast. The highest mean serum Tg level (66.98 ng/ml) was found in Kosti city, which also had the highest prevalence of goitre. CONCLUSION: IDDs still constitute a public health problem throughout urban areas in the Sudan and iodine deficiency appears to be the main etiological factor involved.

Optical time division multiplexer on silicon chip.

In this work, we experimentally demonstrate a novel broadband optical time division multiplexer (OTDM) on a silicon chip. The fabricated devices generate 20 Gb/s and 40 Gb/s signals starting from a 5 Gb/s input signal. The proposed design has a small footprint of 1mm x 1mm. The system is inherently broadband with a bandwidth of over 100nm making it suitable for high-speed optical networks on chip.

ELISPOT assays provide reproducible results among different laboratories for T-cell immune monitoring--even in hands of ELISPOT-inexperienced investigators.

Measurements of antibodies in bodily fluids (e.g., by ELISA) have provided robust and reproducible results for decades and such assays have been validated for monitoring of B-cell immunity. In contrast, measuring T-cell immunity has proven to be a challenge due to the need to test live cells in functional assays ex vivo. Several previous efforts looking into the reproducibility of ex vivo T-cell assays between different laboratories, or even within the same laboratory, have provided rather discouraging results. The hypothesis we tested in this study is that those poor results are due to the lack of assay and data analysis standardization, rather than the inherent complexity of T-cell assays. In this study, 11 laboratories across Europe and the United States were provided identical reagents and were asked to follow the same protocol while testing aliquots of the same three cryopreserved peripheral blood mononuclear cells (PBMC) in an interferon-gamma (IFNgamma) ELISPOT assay measuring the antigen-specific T-cell response to a CMV peptide. All individuals performing the assays were ELISPOT novices. At their first attempt, while three of these individuals failed with the basic logistics of the trial, eight detected the peptide-specific CD8+ T-cells in frequencies approximating the values established by the Reference Laboratory. The data show that ELISPOT assays provide reproducible results among different laboratories when the assay procedure and data analysis is standardized. Since ELISPOT assays have been qualified and validated for regulated studies, they are ideal candidates for robust and reproducible monitoring of T-cell activity in vivo.

Genetic diversity in Egyptian and Italian goat breeds measured with microsatellite polymorphism.

Seven microsatellite markers were used to study genetic diversity of three Egyptian (Egyptian Baladi, Barki and Zaraibi) and two Italian (Maltese and Montefalcone) goat breeds. The microsatellites showed a high polymorphic information content (PIC) of more than 0.5 in most of the locus-breed combinations and indicated that the loci were useful in assessing within- and between-breed variability of domestic goat (Capra hircus). The expected heterozygosity of the breeds varied from 0.670 to 0.792. In the geographically wider distributed Egyptian Baladi breed there were indications for deviations from random breeding. Analysis of genetic distances and population structure grouped the three Egyptian goat breeds together, and separated them from the two Italian breeds. The studied Mediterranean breeds sampled from African and European populations seem to have differentiated from each other with only little genetic exchange between the geographically isolated populations.

Drusen in age-related macular degeneration: pathogenesis, natural course, and laser photocoagulation-induced regression.

Drusen are subretinal pigment epithelial deposits that are characteristic of but not uniquely associated with age-related macular degeneration (AMD). Age-related macular degeneration is associated with two types of drusen that have different clinical appearances and different prognoses. Hard drusen appear as small, punctate, yellow nodules and can precede the development of atrophic AMD. Areolar atrophy of the retinal pigment epithelium (RPE), choriocapillaris, and outer retina develop as the drusen disappear, but drusen can regress without evidence of atrophy. Soft drusen appear as large (usually larger than 63 microm in diameter), pale yellow or grayish-white, dome-shaped elevations that can resemble localized serous RPE detachments. They tend to precede the development of clinically evident RPE detachments and choroidal neovascularization. Drusen characteristics correlated with progression to exudative maculopathy include drusen number (five or more), drusen size (larger than 63 microm in diameter), and confluence of drusen. Focal hyperpigmentation in the macula and systemic hypertension also are associated with an increased risk of developing choroidal new vessels (CNVs). Large drusen are usually a sign of diffuse thickening of Bruch's membrane with basal linear deposit, a vesicular material that probably arises from the RPE, constitutes a diffusion barrier to water-soluble constituents in the plasma, results in lipidization of Bruch's membrane, and creates a potential cleavage plane between the RPE basement membrane and the inner collagenous layer of Bruch's membrane through which CNVs can grow. Disappearance of drusen spontaneously and in areas adjacent to laser photocoagulation scars was first noted by Gass (Gass JD: Arch Ophthalmol 90:206-217, 1973; Trans Am Acad Ophthalmol Otolaryngol 75:580-608, 1971). Subsequent reports have confirmed these observations. Photocoagulation-induced drusen regression might prevent patients with drusen from developing exudative maculopathy. The mechanism for spontaneous drusen regression probably involves RPE atrophy. The mechanism for photocoagulation-induced drusen regression is unknown. If photocoagulation-induced drusen regression is anatomically similar to atrophy-associated drusen regression, then the former will be associated with dissolution of basal linear deposit and a residuum of basal laminar deposit. Sarks and coworkers (Sarks JP, Sarks SH, Killingsworth MC: Eye 11:515-522, 1997) proposed that this in turn will eliminate the potential cleavage plane between the RPE basement membrane and inner collagenous layer of Bruch's membrane through which CNVs grow, thus retarding the growth of CNVs.

Modified levator aponeurotic advancement with delayed postoperative office revision.

The results of a "modified" levator aponeurotic advancement were reviewed to determine the appropriate indications and optimum timing for office revision after blepharoptosis repair. The levator advancement was modified as follows: 1) elimination of epinephrine from the local anesthetic so as not to stimulate the Müller muscle, 2) use of a 6-0 silk rather than a monofilament nonabsorbable suture to secure the advanced levator to avoid possible cheese-wiring and late recurrence, and 3) excision of a strip of preseptal orbicularis muscle just above the tarsal border to create surgically apposed "raw" surfaces for a firm attachment of the "advanced" levator. Office adjustments were delayed for at least 8 days after surgery and were performed as late as 14 days after surgery. Of the 122 consecutive aponeurotic advancements in 110 patients (12 bilateral cases), five (4.1%) patients were candidates for revision in that the operated eyelid was greater than 1 mm from desired height. All such eyelids were undercorrected by 2.0 mm to 2.5 mm. Four of the five underwent revision at 8, 11, and 14 days (two patients) after surgery. The fifth patient did not undergo revision. Four patients with overcorrections from 2.0 mm to 2.5 mm resolved with eyelid massage. It is concluded that the number of office revisions may be reduced if delayed for at least 8 days after surgery. This delay allows for resolution of postoperative edema and objective prediction of final eyelid position. The advantages of this "modified" levator advancement procedure are discussed.