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Purpose: To compare the efficacy and safety of combination therapy with orbital irradiation and systemic steroids versus steroid monotherapy in the management of active Graves' orbitopathy (GO)., Methods: The clinical charts of 127 patients with active inflammation due to GO who received intravenous steroid pulse therapy as a first-line treatment with or without orbital radiotherapy between 2010 and 2014 were reviewed. Patients were divided into two treatment groups: 1) combined orbital radiotherapy and steroid pulse therapy (SRT group) and 2) steroid pulse therapy only (ST group). Primary outcome measures included clinical activity score (CAS); NOSPECS classification; ocular motility impairment; and exophthalmos at 1, 3, 6, and 12 months after treatment. The secondary outcome measure was the change in orbital, extraocular muscle (EOM), and fat volume after treatment measured by orbit computed tomography., Results: Sixty-eight patients were included in the SRT group, and 59 patients were in the ST group. In both treatments, CAS and NOSPECS were significantly reduced. In the comparison of the degree of change from baseline between the groups, the SRT group demonstrated more improvement in NOSPECS and scores of ocular motility. Orbital, EOM, and fat volume significantly decreased in the SRT group; however, only fat volume was reduced in the ST group. Compressive optic neuropathy after treatment developed in 0 % of the SRT group and 3.4 % (2/59) of the ST group. Reactivation of inflammation occurred in 11.8 % (8/68) of the SRT group and 28.8 % (17/59) of the ST group., Conclusions: Orbital radiotherapy in combination with steroid treatment significantly improved ocular motility by reducing EOM volume in patients with active GO.

Aims: To investigate the effect of silicone stent intubation (SI) on the quality of life of patients diagnosed with nasolacrimal duct stenosis and dry eye syndrome., Methods: This study is a prospective, interventional case series. Consecutive 30 patients diagnosed with nasolacrimal duct stenosis and reflex tearing due to dry eye syndrome were included. Eligible subjects underwent SI and were asked to complete the Glasgow Benefit Inventory (GBI) questionnaire. Surgical outcomes and GBI scores were investigated 6 months postoperatively., Results: The surgical success rate determined by the patients' subjective symptoms was 76.7% (23/30). Mean total GBI score was +17.19 (95% CI 8.34 to 26.03). The general subscale score was +20.36 (95% CI 10.19 to 30.54), the social support scale score was +21.54 (95% CI 11.37 to 31.71) and the physical health score was -0.56 (95% CI -8.92 to 7.80)., Conclusions: SI could be an effective treatment option for reflex tearing in patients diagnosed with dry eye syndrome and nasolacrimal duct stenosis., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: To investigate leptin expression and distribution in the tissue of lacrimal gland epithelial tumours, and leptin concentration in the tears secreted by these tumours., Methods: Clinical records and microscopic slides of six pleomorphic adenoma (PA), three adenoid cystic carcinoma (ACC), and one chronic sclerosing dacryoadenitis (CSD) cases were reviewed. Normal-appearing gland tissue adjacent to tumours from patients with PA served as controls. Tissue leptin expression and distribution were assessed using leptin immunohistochemistry staining. Preoperative and postoperative leptin concentrations in tears were measured in the tumour-affected eye in two patients with PA, two with ACC and one with CSD, and in the contralateral eye in one patient with ACC and one with CSD., Results: Moderate cytoplasmic staining was observed in all tumour-adjacent morphologically normal tissue, PA, ACC and CSD tissues. ACC tissues revealed moderate nuclear staining in tumour cells, whereas other tissues did not reveal leptin nuclear staining (p=0.012). Leptin in tears was not detected in the eyes of patients with PA preoperatively and postoperatively. However, leptin was detected in tears of patients with ACC and CSD preoperatively, and its concentration markedly decreased at 1 month postoperatively. Leptin was not detected in any sample from the contralateral eyes of patients for which such samples were available., Conclusions: The leptin concentration in tears was greater in patients with ACC than in those with PA. Leptin nuclear staining was only observed in the ACC tissue. Further investigations should be conducted to identify the cause and significance of these findings., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To examine morphologic changes in the meibomian glands associated with patients with Graves' orbitopathy (GO) using a novel meibography imaging system, and to evaluate its correlation with GO clinical manifestations., Design: Retrospective, observational case series., Participants: Fifty-one GO patients and 31 normal control participants., Methods: This retrospective study examined 51 GO patients and 31 normal control participants. The structure of the meibomian gland was assessed using the meibography imaging system. All of the participants completed the Ocular Surface Disease Index (OSDI) questionnaire. The tear film break-up time (BUT) was measured. The palpebral fissure height, exophthalmos, and eyelid retraction were also assessed., Results: The meibography score, tear film BUT, and OSDI indicated statistically significant differences between the GO and normal groups: The tear film BUT was shorter and the OSDI and meibography score were higher in the GO patient group. There was a significant negative correlation between the meibography score and the tear film BUT in GO patients (r = -.503 and p < .001). In the multivariable linear regression analysis, the meibography score of the GO patients had a positive association with exophthalmos and palpebral fissure height., Conclusions: Compared with the normal control participants, GO patients had more unstable tear films and severe symptoms of dry eye. Using the meibography system, the authors found that GO patients had a higher prevalence of obstructive type meibomian gland dysfunction and changes in meibomian glands increased, with proptosis and lid fissure widening., (Copyright © 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the expression and the clinical implications of metabolism-related proteins in lacrimal gland adenoid cystic carcinoma (ACC) in comparison with salivary gland ACC., Methods: Human tissue samples of lacrimal gland ACC (n = 11) and salivary gland ACC (n = 64) were analyzed. Immunochemistry was used to measure expression of proteins related to glycolysis (glucose transporter 1, hexokinase II, carbonic anhydrase IX, and monocarboxylate transporter 4 [MCT4]), glutaminolysis (glutaminase 1 [GLS1], glutamate dehydrogenase [GDH], and amino acid transporter 2 [ASCT2]), mitochondria (adenosine triphosphate [ATP] synthase, succinate dehydrogenase A [SDHA], and succinate dehydrogenase B), and glycolytic intermediate metabolism (phosphoserine phosphatase [PSPH], serine hydroxymethyl transferase 1 [SHMT1])., Results: GLS1 and ASCT2 were more highly expressed, and GDH, ATP synthase, and SDHA were expressed to a lesser degree in lacrimal gland ACC than in salivary gland ACC (P < .05). Lacrimal gland ACC showed less of a mitochondrial phenotype than did salivary gland ACC (P = .001). Positivity of MCT4 and PSPH was related to shorter disease-free survival, and SHMT1 was related to shorter overall survival (P < .05)., Conclusions: Lacrimal gland ACC exhibited higher expression of GLS1 and ASCT2, compared with salivary gland ACC. Overexpression of MCT4, PSPH, and SHMT1 was associated with poorer prognosis., (Copyright© by the American Society for Clinical Pathology.)

Objective: To investigate the effect of previous incisional double-fold surgery on spontaneous resolution of eyelid retraction caused by Graves orbitopathy (GO) in Asian individuals., Design: Retrospective review of medical records., Participants: Patients (N = 30; 39 eyes) with eyelid retraction associated with GO with symptom duration of less than 6 months., Methods: Patients who visited the Ophthalmology Department of Severance Hospital, Yonsei University, between January 2010 and December 2011, followed up for more than 6 months and in a euthyroid state with antithyroid drug treatment were included. Patients treated with steroids or who underwent surgery during follow-up were excluded. Upper scleral show was measured as the distance between the central upper lid margin and limbus at initial presentation and after 6 months. Comparative analysis was performed between the 2 groups delineated by history (n = 12; 16 eyes), or lack thereof (n = 18; 23 eyes), of incisional double-fold surgery before onset of GO symptoms and signs., Results: Patient demographics and initial upper scleral show were not significantly different between groups. In both groups, upper scleral show significantly decreased at 6 months of follow-up (p < 0.001 in both groups); however, improvement of upper scleral show was significantly reduced in patients who had undergone previous double-fold surgery (0.8 ± 0.5 mm) than in nonsurgical patients (1.8 ± 0.5 mm; p < 0.001)., Conclusions: Graves eyelid retraction resolves spontaneously over time, albeit not completely. Previous double-fold surgery hinders the degree of spontaneous resolution, probably because of the fibrosis and cicatrization between the skin, the subcutaneous layer, and the levator complex., (Copyright © 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Levator resection surgery is commonly performed to correct ptosis, and a large number of postoperative complications are well known. This report presents a previously unreported complication of marginal ectropion after levator resection surgery for congenital ptosis., Methods: The three patients with upper eyelid marginal ectropion in this observational case series previously had undergone levator resection surgery for congenital ptosis. The patients' medical records and clinical photographs were reviewed retrospectively. The patients underwent reoperations for ectropion correction. Unusual tissues identified during the surgery were excised and processed for histopathologic analysis., Results: The patients presented with upper eyelid marginal ectropion and had a history of levator resection surgery for congenital ptosis on the same eye. Ingrown tissues were observed during the second operations for ectropion correction in all three patients. Histopathologic analysis was performed for two of the patients, confirming that the tissue consisted of mucosa. The ectropions were corrected after surgical removal of the ingrown tissues., Conclusions: Marginal ectropion can occur after levator resection surgery. In this study, the ectropion was attributed to mucosal ingrowth, a complication not previously reported. To improve the surgical outcomes, surgeons should be aware of this complication., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: This study reports the surgical technique of modified medial tarsorrhaphy using tarsoconjunctival advancement flap for treatment of exposure keratitis secondary to incomplete lid closure combined with ocular dysmotility or decreased corneal sensation., Methods: Three patients suffered from intractable exposure keratitis due to incomplete lid closure with ocular motility limitation or decreased corneal sensation, even after the lateral tightening procedure. Because they did not want a cosmetically unacceptable appearance by permanent tarsorrhaphy, modified medial tarsorrhaphy using tarsoconjunctival advancement flap was performed. Clinical manifestation and surgical outcome were investigated through retrospective chart review., Results: The minimum follow-up period was 10 months. All patients showed successful surgical results. Ocular symptoms were satisfactorily treated, corneal re-epithelialization was achieved and maintained during the follow-up period, lagophthalmos improved, and all patients were satisfied with their appearance., Conclusions: We describe modified medial tarsorrhaphy with tarsoconjunctival advancement flap which was effective in treatment of severe exposure keratitis with incomplete lid closure in patients who elected not to have cosmetically problematic, permanent corrective surgery.

Purpose: To determine whether meibomian gland dysfunction (MGD) is a possible cause of ocular discomfort in patients wearing an ocular prosthesis, with the paired normal eye used as a control., Methods: Thirty consecutive patients with a unilateral ocular prosthesis completed a questionnaire designed to identify MGD-related ocular symptoms. Both eyelids of each patient underwent slit lamp examination, meibography imaging, and Fourier-domain (FD) optical coherence tomography (OCT) scanning. Intra-individual comparison of main outcome measures between the eyelids of a prosthetic eye and paired normal eyelids was performed using Wilcoxon signed-rank test. A linear mixed model was used to investigate an association between ocular symptoms and condition of meibomian gland/tear parameters., Results: The eyelids with an ocular prosthesis exhibited significantly higher scores for ocular symptoms, lid margin abnormality, meibomian gland expression, and meibography compared to the normal eyelids (p<0.01 for all scores). Tear parameters in the eyelid of a prosthetic eye, assessed with FD OCT, were significantly lower than those of the normal eyelid (p<0.01 for all scores except tear meniscus angle). The ocular symptom score was significantly positively correlated with the meibography score and negatively correlated with tear parameters (p<0.01 for all parameters, linear mixed model)., Conclusions: Compared to paired normal eyelids, the eyelids with an ocular prosthesis exhibited significant signs of MGD. These results indicate that clinical assessment and management recommendations for MGD may benefit patients with prosthetic eyes, especially those with ocular discomfort.

Background: To investigate the changes of epiblepharon by evaluating the severity of epiblepharon before and after induction of general anesthesia., Methods: Sixty-three pediatric patients (126 eyes) underwent surgery for epiblepharon between April 2008 and September 2008 (35 females, 28 males; average age: 4.74 years). The severity of epiblepharon in each eye was scored according to skin-fold height (scored 1-4) and area of ciliocorneal touch (scored 1-3) while the patient was in upright and supine positions before induction of general anesthesia and in supine position after induction of anesthesia., Results: The severity of epiblepharon was significantly reduced by a positional change to supine position and induction of general anesthesia. Skin-fold height scores decreased when patients were moved from upright (estimated mean ± standard error [SE]; 2.98 ± 0.08) to supine position (2.63 ± 0.09) (P < 0.001) prior to induction of anesthesia, and decreased further after induction of general anesthesia (2.12 ± 0.08) (P < 0.001). Ciliocorneal touch scores also decreased after patients were moved to supine position and after induction of general anesthesia (upright: 2.17 ± 0.05; supine: 1.95 ± 0.06; general anesthesia: 1.64 ± 0.07, P < 0.001)., Conclusions: Our study demonstrates that positional changes and general anesthesia using muscle relaxants affect the degree of epiblepharon. Surgeons should be aware of these variations for operative planning of epiblepharon.

Cigarette smoking is known to aggravate Graves' orbitopathy (GO) severity by enhancing adipogenesis. We investigated the effect of quercetin, an antioxidant, on adipocyte differentiation induced by cigarette smoke extract (CSE) in primary cultured orbital fibroblasts (OFs) from GO patients. Freshly prepared CSE was added to the cells and H(2)O(2) was used as a positive control. Intracellular reactive oxygen species (ROS) generation and adipogenesis were measured. The expressions of proteins peroxisome proliferator-activated receptor (PPAR) γ, CCAAT-enhancer-binding proteins (C/EBP) α and β, and heme oxygenase-1 (HO-1), an antioxidant enzyme, were examined during adipogenic differentiation. In result, CSE and H(2)O(2) dose-dependently stimulated intracellular ROS production in normal and Graves' OFs. The effect of 2% CSE was similar to that of 10 μM H(2)O(2); both concentrations were noncytotoxic and were used throughout the experiment. Quercetin pretreatment reduced the ROS generation stimulated by either CSE or H(2)O(2) in preadipocyte OFs. CSE and H(2)O(2) stimulated adipocyte differentiation in cultured OFs. The addition of quercetin (50 or 100 μM) suppressed adipogenesis. Quercetin also suppressed ROS generation in differentiating OFs during adipogenesis stimulated by CSE and H(2)O(2). Additionally, the expressions of PPARγ, C/EBPα, and C/EBPβ proteins were reduced in the quercetin-treated OFs. Quercetin also reduced the CSE- and H(2)O(2)-induced upregulation of ROS and HO-1 protein in differentiated OFs and preadipocyte OFs. As shown in this study, quercetin inhibited adipogenesis by reducing ROS in vitro, supporting the use of quercetin in the treatment of GO.

Background: To evaluate the efficacy of subconjunctival triamcinolone injection for treating upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO)., Methods: Prospective single blind randomized clinical trial. Patients diagnosed with TAO-associated eyelid retraction and/or swelling <6 months before study onset were randomly assigned to triamcinolone-injected (group I; 55 patients, 75 eyes) or observation-only (group II; 40 patients, 59 eyes) populations. Group I received 1-3 injections of 20 mg triamcinolone acetate into the subconjunctival eyelid, between the conjunctiva and Muller's muscle, at 3-week intervals. Group I was followed up at 3, 6, 9, and 24 weeks post-injection, and group II was evaluated at 9 and 24 weeks after initial visit. Eyelid swelling and retraction were each graded on a 0-3 scale. Treatment was stopped after 1-2 injections if both swelling and retraction resolved completely or if retraction and swelling scored 0/1 or 1/0 without functional or cosmetic patient concerns. Treatment success was defined at 9 and 24 weeks post-injection if eyelids were normal or when treatment was terminated because of early clinical resolution. We compared baseline clinical data between success and failure group evaluated at 9 and 24 weeks in group I, and investigated short-term and long-term success prognostic factor using multiple logistic regression analysis in each group I and II., Results: Swelling and retraction decreased significantly more in group I than in group II. Significantly more eyes had severe swelling (≥ grade 2) in group I (67 %) than in group II (34 %) upon initial evaluation (p < 0.01); this difference disappeared at 9 and 24 weeks. Fewer severely retracted eyes were observed in group I than in group II at 9 and 24 weeks (p < 0.01). Significantly more eyes in group I achieved success at both 9 and 24 weeks (59 %, 75 %) than in group II (39 %, 57 %) (p = 0.03, p = 0.04 respectively). Higher initial retraction grades (2-3) predicted a higher chance of post-injection failure versus the reference group (grade 0-1) at 9 and 24 weeks in group I, with adjusted odds ratios (aOR) 45.4 (95 % CI = 5.9-351.1, p < 0.01) and aOR 11.6 (95 % CI = 2.3-58.5, p < 0.01) respectively. Similarly in group II, initial retraction grade was associated with the failure at 9 and 24 weeks, with aOR 10.3 (95 % CI = 1.8-59.6, p < 0.01) and aOR 5.9 (95 % CI = 1.3-25.9, p < 0.05) respectively. Transient intraocular pressure elevation was observed in three eyes of two patients, although all ocular pressures were normalized within 1 month using anti-glaucoma medication., Conclusions: Subconjunctival triamcinolone injections were very effective in resolving eyelid swelling and retraction in recent-onset TAO. However, the symptom-reducing effect of triamcinolone was modest and less effective in patients initially presenting with severe retraction grades. As intraocular pressure may rise after steroid injection at upper eyelid, the treatment should be avoided in patients suspected to have glaucoma.

Background: Interleukin (IL)-17 and T helper 17 (Th17) cells are reported to be involved in many autoimmune diseases. The aim of this study is to investigate the involvement of IL-17 in the pathogenesis and disease activity of Graves' ophthalmopathy (GO)., Methods: Sixty-two GO patients and 19 healthy controls were recruited. Serum concentrations of cytokines, IL-17, IL-6, IL-23, and IL-16, were measured using multiplexed microsphere-based flow cytometric immunoassays. GO hormonal parameters, clinical activity score (CAS), exophthalmometry, and extraocular muscle involvement were evaluated, and relationships with cytokine concentrations were analyzed., Results: The concentration and positive detection rates of serum IL-17 were significantly higher in patients with GO than in controls. The serum levels of IL-17 in active GO patients were higher than that of inactive GO patients. Serum IL-17 concentration had significant correlation with CAS (p < 0.001)., Conclusion: The increased serum level of IL-17 and related cytokines in GO patients and the correlation of IL-17 concentration with the clinical activity scores suggest that IL-17 may play a pathophysiological role in GO.

Purpose: The authors previously reported that quercetin significantly inhibits interleukin (IL)-1β-induced increases of proinflammatory cytokines in cultured primary orbital fibroblasts from Graves' orbitopathy (GO). This study investigated the inhibitory effect of quercetin on inflammation in cultured whole orbital tissue., Methods: Orbital fat tissues from GO and normal samples were cultured with or without non-toxic concentrations of quercetin. Lactate dehydrogenase (LDH) release was used to identify non-toxic concentrations of quercetin. IL-6, IL-8, IL-1α, IL-1β and tumour necrosis factor alpha (TNFα) proteins were measured in tissue culture supernatants by ELISA, and gene transcript levels were determined using quantitative PCR, expressed as relative fold changes of threshold cycle value relative to the control group., Results: The maximal non-cytotoxic treatment of quercetin was 100 μM for 72 h, based on the considerably low LDH release with these conditions. IL-1β, IL-6 and TNFα protein levels corrected for tissue weight were significantly higher in supernatants of GO samples than normal controls (p<0.05). Quercetin reduced IL-6, IL-8 and TNFα protein production in supernatants of all GO samples (n=4) in a dose-dependent manner; however, only the reduction in IL-6 was statistically significant (p<0.05). Quercetin had a significant suppression of tissue IL-6, IL-8, IL-1β and TNFα mRNA expression in cultured orbital tissues from three GO samples relative to untreated control tissue (p<0.05)., Conclusions: Inhibition of proinflammatory cytokines by the natural product quercetin in both primary orbital fibroblasts and tissue culture provides the basis for its potential use as an anti-inflammatory agent in the treatment of GO.

Purpose: To evaluate the sociodemographic factors of myopia and the care of myopia in Korean children., Methods: We acquired data from 8,633 children who had completed the Health Interview Survey portion of the third Korea National Health and Nutrition Examination Survey. We assessed the prevalence of eye problems in subjects younger than 19. Sociodemographic factors that affect myopia and myopia care were identified by multivariate logistic regression analysis., Results: The prevalence of child myopia in Korea was 22.6%. The results indicated a significant association between increasing age and myopia. There was a relation between the prevalence of myopia and income level. Participants living in homes owned by their parents or in urban areas as well as those with disabilities were more likely to have myopia. In terms of myopia care, age and monthly household income were significant factors., Conclusions: Public education and strategies such as a national vision screening programs are needed for appropriate vision care as children get older, and more effort needs to be made in assisting disabled persons with vision care.

Purpose: To determine the rate of mortality for uveal melanoma in the Korean population and assess whether it correlates with cytogenetic data, and clinical and histopathological factors., Methods: A retrospective review of medical files from 33 uveal melanoma patients who underwent enucleation at Yonsei University, Seoul, Korea, between January, 1994 and December, 2009 was performed. Dual-colour fluorescence in situ hybridization was performed using centromeric probes for chromosome 3 and 8 in archived patient tissues., Results: The mean age of patients was 53.2 years (range; 29-78), and the mean largest basal diameter was 11.8 mm (range; 6.0-18.1). Of the 20 tissue blocks with available cytogenetic data, there was monosomy 3 in seven (35%) and polysomy 8 in four (20%). The presence of monosomy 3 (p < 0.001), polysomy 8 (p < 0.001), ciliary body involvement (p < 0.001), a mitotic rate ≥5/40 high-power fields (p = 0.006), closed extravascular matrix loop (p = 0.025), large basal tumour diameter (p = 0.029) and epithelioid cellularity (p = 0.038) predicted melanoma-related mortality. The median time from enucleation to liver metastasis was 16 months (range; 10-70), and the median survival after metastasis was 5 months (range; 1-9). The Kaplan--Meier survival curve estimated the metastatic death rate to be 22% for 5 years and 30% for 10 years., Conclusions: Korean patients with uveal melanoma are younger and appear to exhibit no worse prognosis than Caucasian. Cytogenetic abnormality of chromosome 3 and 8 highly predicted metastatic death., (© 2011 The Authors. Acta Ophthalmologica © 2011 Acta Ophthalmologica Scandinavica Foundation.)

Purpose: To measure tear nerve growth factor (NGF) concentrations in cases of active thyroid-associated ophthalmopathy (TAO) before and after glucocorticoid treatment, and to correlate NGF levels with disease inflammatory activity and thyroid autoantibody concentration., Methods: The study involved 20 patients with active TAO and 20 age- and gender-matched controls. Tear break-up time (BUT) was obtained, the Schirmer test was performed, and tear NGF/total protein ratio was measured in control subjects and patients with active TAO before, and 2 and 4 weeks after, steroid treatment., Results: Tear BUT and Schirmer values significantly increased after 2 and 4 weeks of steroid treatment (p < 0.001 and p = 0.004 respectively). Baseline tear NGF/total protein ratio was higher in patients with active TAO than in control subjects, and the ratio significantly decreased after 2 and 4 weeks of steroid treatment (p < 0.001). Tear NGF/total protein ratio did not correlate with inflammatory activity score, exophthalmos value and thyroid binding inhibiting immunoglobulin (TBII) level (p > 0.05)., Conclusions: Tear NGF may have a specific role in ocular surface inflammation, which protects against ocular surface damage in patients with active TAO. Anti-inflammatory treatment significantly reduced the level of NGF in tears, increased tear film stability and production, and decreased congestive symptoms.

Purpose: To report postoperative results and effectiveness using autogenous sclera as a wrapping material for hydroxyapatite orbital implant., Methods: A chart review of 78 patients (78 eyes) undergoing primary enucleation or a secondary procedure using autogenous sclera as a wrapping material from March 1997 to October 2004 was undertaken. Primary enucleation was performed in 54 eyes and secondary implantation in 24. In severely constricted eyes or eviscerated eyes with small implants, the sclera was unfolded and used for wrapping only on the anterior surface of the implant., Results: The average size of implants was 19.7 mm in diameter, and all the 78 implants were over 18 mm. During an average postoperative follow-up of 18 months, complications such as implant exposure, infection or extrusion did not occur in any case., Conclusion: This study shows that autogenous sclera is a safe, effective wrapping material for hydroxyapatite orbital implants with no serious complications., (Copyright 2008 S. Karger AG, Basel.)

Purpose: To assess alterations in the tear film and ocular surface after frontalis suspension repair in patients with pediatric congenital ptosis with either intact or poor Bell's phenomenon., Methods: The study involved 15 patients (23 eyes) with poor Bell's phenomenon (group 1) and 21 patients (33 eyes) with intact Bell's phenomenon (group 2) who underwent frontalis suspension surgery using autogenous fascia lata. The control group comprised 15 age-matched subjects (30 eyes) (group 3). Corneal esthesiometry, tear film break-up time (BUT) measurement, Schirmer II tests, and vital staining were performed prospectively before surgery and 1, 3, and 6 months postoperatively., Results: Group 1 had a lower mean BUT at all postoperative follow-up time points compared to group 2. Group 1 had a greater mean fluorescein staining score (FSS) at 6 months postoperatively compared to group 2. The degree of lagophthalmos strongly correlated with BUT and FSS at 6 months postoperatively in group 1, but not in group 2. In group 1, mean lagophthalmos (5.2 mm) and amount of eyelid elevation (5.8 mm) were higher in abnormal FSS eyes (n=17) than in normal FSS eyes (n=6) (3.3 and 3.9 mm, respectively)., Conclusion: Bell's phenomenon prevents tear film instability and ocular surface damage in eyes with lagophthalmos induced by frontalis suspension surgery. In patients with poor Bell's phenomenon, ptosis correction of more than 5.5 mm or lagophthalmos of more than 5.0 mm could increase the risk of exposure keratopathy, necessitating careful postoperative monitoring.

Background: Surgical excision of orbital lymphangiomas is difficult, and almost always incomplete due to the diffusely infiltrative pattern of these tumors. The present report describes the successful use of intralesional OK-432 administration to treat two patients with intractable hemorrhagic proptosis due to orbital lymphangiomas., Methods: A 3-year-old girl (case 1) presented with aggressive proptosis and ptosis, and a 1-year-old boy (case 2) presented with massive proptosis and exposure keratopathy, associated with recurrent intracystic bleeding of an orbital lymphangioma. In case 1, 0.02 mg OK-432 was intracystically injected in a volume of 2 ml of physiologic saline. Due to a lack of therapeutic response, a second injection of 0.05 mg OK-432 in 1 ml was administered. In case 2, a single dose of 0.05 mg OK-432 in 1 ml was administered., Results: In both cases, intracystic administration of 0.05 mg of OK-432 in a 1-ml volume resulted in a successful outcome. The adverse effects were minor (mild transient fever and lid swelling), and rebleeding and intraocular pressure elevation did not occur. Proptosis and eyelid swelling gradually improved over 1 month, and completely resolved within 3 months of treatment., Conclusions: Intralesional administration of 0.05 mg/ml OK-432 (delivered in 1 ml) resulted in the successful treatment of two cases of orbital lymphangioma. Although this drug concentration is higher than in previous reports, there were no major adverse effects.

Purpose: Excessive scarring in subconjunctival tissues after filtering surgery seems to be characterized by aberrant extracellular matrix (ECM) production, and tissue transglutaminase (tTgase) plays an important role in this process. In the present study, the effects of transforming growth factor (TGF)-beta2 on the expression of tTgase, its activity in subconjunctival fibroblasts and whether the effects of TGF-beta are mediated by prosurvival signaling pathways were examined., Methods: Primary subconjunctival fibroblasts treated with TGF-beta2 were examined for the expression of tTgase with Western blot analysis. The modulation of extracellular tTgase activity by TGF-beta2 was measured by both the formation of fibronectin polymers and the ECM protein incorporation of fluorescein cadaverine. The expression of tTgase was analyzed by immunofluorescence staining and Western blot analysis of subconjunctival fibroblasts that were transiently transfected with an Akt dominant negative mutant gene or were treated with an Akt inhibitor or tTgase siRNA., Results: Treatment of subconjunctival fibroblasts with TGF-beta2 caused an increase in activation and expression of tTgase. The effects of TGF-beta stimulation of subconjunctival fibroblasts were twofold, causing both rapid activation of the ERK pathway within minutes of treatment and a more delayed activation of the phosphatidylinositol3-kinase-protein kinase B (PKB)/Akt pathway; however, only Akt activation was necessary for TGF-beta-induced tTgase expression. Transient transfection of subconjunctival fibroblasts with an Akt dominant negative mutant gene, or treatment with an Akt inhibitor (but not with an ERK inhibitor) or tTgase siRNA led to decreased activation and expression of tTgase., Conclusions: TGF-beta2 activated the PI3K-Akt pathway, and this activation was essential for the expression and activity of tTgase in subconjunctival fibroblasts. The results indicate a novel biological function of the PI3K-Akt pathway in subconjunctival fibroblasts. Elevated expression and activity of tTgase may play an important role in the pathogenesis of diseases related to wound healing and fibrogenic reactions in subconjunctival fibroblasts.

Purpose: Some patients complain of a foreign body sensation, a burning sensation, or dryness after strabismus surgery. We prospectively investigated the changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery., Patients and Methods: Corneal and conjunctival sensitivity were assessed with an esthesiometer, tear film breakup time was measured, and the Schirmer test was performed prospectively (preoperatively and 1 week, 1 month, and 3 months postoperatively) in 83 patients (124 eyes) who underwent strabismus surgery at our institution., Results: There were no significant changes in corneal sensitivity, tear film stability, or tear secretion after strabismus surgery (P > .05). Conjunctival sensitivity decreased significantly after strabismus surgery (P < .05)., Conclusion: Discomfort and dryness after strabismus surgery do not seem to be related to changes in corneal sensitivity, tear film stability, or tear secretion.