Publications by authors named "Guy Ben Simon"

108 Publications

The Effect of Upper Eyelid Muller Muscle Conjunctival Resection Surgery on Lower Eyelid Position.

Curr Eye Res 2021 Mar 12:1-5. Epub 2021 Mar 12.

Sheba Medical Center, Goldschleger Eye Institute, Ramat Gan, Israel.

: To examine whether Müller's-muscle-conjunctival-resection (MMCR) changes the position of the lower eyelid.: Retrospective controlled-cohort study. All patients who underwent MMCR (study group) or blepharoplasty (control group) between January 2016 and September 2018 were recruited. The data retrieved from the patients' medical records included demographics, visual-acuity, eyelid parameters and dry-eye parameters before and 3 months after surgery. Frontal photographs of the patient's eyes in primary position were taken preoperatively and at 3 months postoperatively. The margin-reflex-distance 1 (MRD1) and MRD2 were evaluated. The preoperative and 3 months postoperative MRD1, MRD2,and dry-eye signs and symptoms were compared.: Sixty-nine patients underwent MMCR and 54 patients underwent blepharoplasty during the study period. There were significant changes in MRD2 after MMCR surgery compared to preoperative values ( < .01, paired t-test), but no significant changes in MRD2 after blepharoplasty surgery ( = .091, paired t-test). The mean changes in MRD2 (delta MRD2) were 0.51 in the MMCR group versus (-0.10) in the blepharoplasty group ( = .04, t-test).: The position of the lower eyelid was altered significantly in patients that underwent MMCR surgery. This sequela should be discussed with the patients before surgery and should be considered by physicians when planning ptosis surgery.
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http://dx.doi.org/10.1080/02713683.2020.1853780DOI Listing
March 2021

Kelly Punch Punctoplasty and Simple Punctal Dilatation Are Equally Effective for Punctal Stenosis: A Prospective Study.

Ophthalmic Plast Reconstr Surg 2021 Feb 11. Epub 2021 Feb 11.

Goldschleger Eye Institute Institute of Pathology, Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: To examine the clinical, imaging, and histopathologic differences between Kelly punch punctoplasty and punctal dilatation, both with mini Monoka stent insertion.

Methods: This is a prospective, comparative clinical study. Patients with bilateral punctal stenosis and for whom surgery was advised participated in the study. The right eye underwent Kelly punch punctoplasty and the left eye simple punctal dilatation, both with mini Monoka stents were participated. Data were collected and analyzed before and 3 months following the procedure and included the degree of epiphora (Munk score) and punctal size as measured by anterior segment optical coherence tomography (AC- OCT). All specimens removed by the Kelly punch punctoplasty were sent for histopathologic evaluation, including Masson's trichome muscle staining.

Results: The study included 46 eyes of 23 patients (4 males and 19 females) whose mean age at presentation was 60.43 ± 14.81 years (range 19-84 years). There was a significant decrease in the Munk score after both punctoplasties compared with baseline values (P < 0.01, matched pairs). There were no significant differences between groups in the delta Munk score. There was a significant increase in punctal size after both procedures compared with baseline values as measured by AS-OCT. Horner-Duverney's muscle was visible in only 3 of the 23 (13.04%) specimens from patients who underwent the Kelly punch punctoplasty.

Conclusions: The Kelly punch punctoplasty and the simple dilator punctoplasty, both with stents, are equally effective treatments for epiphora due to acquired punctal stenosis. Only a few specimens removed during the Kelly punch method show muscle fibers.
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http://dx.doi.org/10.1097/IOP.0000000000001940DOI Listing
February 2021

Quality of life of patients with thyroid eye disease: 3-year follow-up in a multidisciplinary clinic in Israel.

Graefes Arch Clin Exp Ophthalmol 2021 Feb 2. Epub 2021 Feb 2.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Background: Changes in the quality of life (QOL) of patients with thyroid eye disease (TED) were examined during a 3-year follow-up in a multidisciplinary eye clinic, and factors that may improve QOL were identified.

Methods: A retrospective review of medical records of all patients who attended the TED clinic at Sheba Medical Center, Israel, from May 2016 to May 2019 was performed. The retrieved data included demographics, comprehensive ophthalmic examination findings, clinical activity scores (CAS), laboratory test results, and QOL assessments by the Graves' Orbitopathy QOL (GO-QOL) questionnaire.

Results: One hundred thirty-two TED clinic patients were examined. Thirty patients (22.72%) received medical treatment consisting of steroids according to the European Group on Graves' Orbitopathy (EUGOGO) protocol, high-dose steroids, or immunosuppressive drugs. Twenty-eight patients (21.21%) underwent surgical rehabilitation (decompression, strabismus, or eyelid surgery). There was a significant increase in total QOL score after steroid treatment according to the EUGOGO protocol, after decompression surgery, and after strabismus surgery compared to pre-treatment total QOL (p=0.04, p=0.021, and p=0.042, respectively, matched pairs). In addition, there were significant positive correlations between the changes in the total QOL score and the change in thyroid-stimulating immunoglobulin (TSI) as well as the change in CAS among the patients who underwent medical and surgical interventions.

Conclusions: QOL improved significantly after medical/surgical treatments. A change in the CAS and in the TSI may also correlate with change in QOL. Periodic evaluation of TED patients' QOL is recommended for enhanced and more comprehensive management.
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http://dx.doi.org/10.1007/s00417-021-05103-5DOI Listing
February 2021

Minimally Invasive Surgery of Orbital Apex.

Isr Med Assoc J 2020 Dec;22(12):800

Department of Otorhinolaryngology-Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel.

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December 2020

Gender differences in clinical presentation and prognosis of thyroid eye disease.

Eur J Ophthalmol 2020 Nov 6:1120672120964112. Epub 2020 Nov 6.

Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel.

Objective: To examine the clinical differences in manifestation, treatment, and prognosis of thyroid-eye-disease (TED) between men and women.

Methods: This is a longitudinal cohort study. Men and women, who diagnosed with TED and treated at a multidisciplinary TED clinic, were compared regarding differences in demographics, eye examination, disease activity, and quality of life evaluation.

Results: TED was diagnosed in 132 patients during the study period, and they included 38 men (28.78%) and 94 women (71.21%). There were six men and 20 women with active disease (Clinical-Activity-Score (CAS) ⩾ 3) during the entire follow-up period ( < 0.01). The mean time from TED diagnosis to CAS ⩾ 3 was 4.50 years for men and 2.35 years for women ( = 0.05). There were no significant differences in mean total Graves' Orbitopathy-Quality-of-Life questionnaire (GO-QOL) score. However, mean GO-QOL subtotal score of external appearance of women was significantly lower compare to men in the first and last visit ( = 0.04, 0.03, respectively).

Conclusion: Active disease was more common in women and the time-from-diagnosis of TED to CAS ⩾ 3 was shorter among women. Moreover, the appearance QOL score of women was poorer. These findings should be taken into consideration when planning the timing of treatment and when choosing the best treatment for TED patients.
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http://dx.doi.org/10.1177/1120672120964112DOI Listing
November 2020

Low-dose Bleomycin Injections for Orbital Lymphatic and Lymphatic-Venous Malformations: A Multicentric Case Series Study.

Ophthalmic Plast Reconstr Surg 2020 Nov 5. Epub 2020 Nov 5.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: Orbital lymphatic malformations (LM) are associated with ocular morbidity and facial disfigurement. Surgery is challenging and may not be effective. We describe the outcome of bleomycin injections for venous LM and lymphatic-venous malformation (LVM) malformations of the orbit in 5 tertiary referral centers between January 2010 and December 2018.

Methods: Multicenter retrospective case series, 5 oculoplastic referral centers: Sheba and Rabin Medical Centers, Israel; Mulago Hospital, Uganda; Sri Sankaradeva Nethralaya, India; and Clinique Ophtalmologique de Tunis, Tunisia. All patients diagnosed with orbital LM/LVM were assigned to successive (range 1-6) intralesional 5 international units bleomycin injections. They all underwent complete ophthalmic and orbital evaluations, orbital imaging, and ancillary testing as needed. Clinical photographs were assessed pre- and posttreatment along with objective assessments of clinical improvement. Additional injections were provided in cases of incomplete response.

Results: A total of 21 patients (17 women, mean ± standard deviation age 18 ± 13 years, range 2-48 years) underwent bleomycin injections. The mean injection dose was 12 ± 10 international units in 1-3 injections. There was a dramatic improvement in lesion size, appearance, proptosis, and ocular motility in 20/21 patients (95%) after a mean follow-up of 18 months. Visual acuity slightly improved after treatment (20/50-20/30; P = 0.076). No side effects were noted after bleomycin injections.

Conclusions: Bleomycin injections for LM/LVM of the orbit are effective; local or systemic side effects were not seen in this series. To the best of our knowledge, this is the largest reported series of this treatment.
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http://dx.doi.org/10.1097/IOP.0000000000001870DOI Listing
November 2020

New insight into the physiologic function of Müller's muscle.

Exp Eye Res 2021 01 30;202:108336. Epub 2020 Oct 30.

The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Purpose: Müller's muscle is a sympathetically innervated smooth muscle which serves as an accessory upper eyelid retractor. Its physiologic function and purpose have not yet been clearly defined. We hypothesize that sympathetic innervation to Müller's muscle serves to adjust the upper eyelid's position to variations in pupil size in response to changes in light intensity.

Methods: This is a single center cross-sectional study. Healthy volunteers were asked to fixate on a distant non-accommodative target, and a video scan of the anterior segment was performed for each subject's right eye using the Heidelberg Spectralis® optical coherence tomography scanner in infrared mode. The video was taken both in photopic and scotopic conditions, recording the resultant transition of the pupil and eyelids. The pupil diameter (PD), upper eyelid margin-to-reflex distance (MRD1), lower eyelid margin-to-reflex distance (MRD2), and vertical palpebral fissure height (PFH) were measured.

Results: Thirty-three healthy volunteers (19 women, 57.6%) with a median age of 40 years (range 30-58) were included. The mean PD under photopic conditions increased significantly under scotopic conditions, from 3483 ± 521 μm to 6135 ± 703 μm, respectively (P < 0.0001). An increase in MRD1 was observed following transition from light to dark, with a mean change of 348 ± 311 μm (P < 0.0001). There was no significant change in MRD2.

Conclusions: Upper eyelid retraction occurs after transition from photopic to scotopic conditions. This movement suggests the existence of an "eyelid-light reflex" involving Müller's muscle that adjusts the position of the eyelids as the pupil dilates under scotopic conditions.
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http://dx.doi.org/10.1016/j.exer.2020.108336DOI Listing
January 2021

Ocular injuries incurred by Israeli defense forces during low-intensity conflicts.

Injury 2021 Feb 18;52(2):292-298. Epub 2020 Sep 18.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Background: To describe ocular injuries sustained by Israeli Defense Forces (IDF) soldiers during low-intensity conflicts from 1998 to 2017, and to evaluate the use of protective eyewear.

Methods: Retrospective analysis of data retrieved from two tertiary Israeli medical centers and the military trauma registry. The analysis included all IDF soldiers with ocular injuries who were referred to these centers between 1998 and 2017. Data on injury type, the use of protective eyewear, and interventions were retrieved and analyzed. Additional data regarding the use of protective eyewear and ocular injuries in 108 patients with head and neck injuries in one operation was analyzed.

Results: A total of 126 soldiers, all males, mean age 22 (SD 5.3) years, sustained ocular injuries during low-intensity conflicts and treated at one of the two participating medical centers. Blast was the most common type of injury (n = 70/126, 56%), followed by shrapnel (n = 37/126, 29%) and gunshot wound (n = 12/126, 9%). The Birmingham Eye Trauma Terminology System (BETTS) injury pattern disclosed lamellar laceration (n = 34/126, 27%), intraocular foreign body (n = 27/126, 21%), penetrating (n = 10/126, 8%), and perforating (n = 7/126, 6%) injuries. Average VA improved from 20/140 at presentation to 20/60 after surgical or conservative intervention, the median VA improved from 20/40 to 20/30 (P < 0.001). Forty-nine patients (49/126, 39%) had poor visual outcome. The mean follow-up lasted 22 (SD 31) months. The use of protective eyewear was correlated with better initial VA(20/30 vs 20/217, P = 0.07). Among 108 patients with head and neck injuries, there was a higher rate of ocular injuries in the group of patients who did not use protective eyewear (n = 26/73, 36% vs n = 4/35, 11%, P = 0.016).

Conclusions: Ocular injuries are common occurrences in low-intensity conflicts. The use of protective eyewear significantly reduces these injuries and should be mandatory.

Level Of Evidence: III, prognostic.
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http://dx.doi.org/10.1016/j.injury.2020.09.041DOI Listing
February 2021

Outcomes of Vismodegib for Periocular Locally Advanced Basal Cell Carcinoma From an Open-label Trial.

JAMA Ophthalmol 2020 07;138(7):749-755

Department of Ophthalmology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.

Importance: The outcomes of vismodegib treatment in a relatively large cohort of study participants with periocular locally advanced basal cell carcinoma (POLA-BCC) may guide physicians when considering this treatment.

Objective: To report the outcomes of vismodegib treatment in patients with POLA-BCC in the Safety Events in Vismodegib (STEVIE) study.

Design, Setting, And Participants: This post hoc subgroup analysis from the STEVIE single-arm, multicenter, open-label cohort study screened all 1215 participants for ocular or periocular involvement and identified 244 participants with POLA-BCC or metastatic BCC. Data for the first STEVIE trial were collected from 167 treatment locations in 36 countries from June 30, 2011, to June 14, 2017. This post hoc analysis was performed from April 1 to August 31, 2019.

Main Outcomes And Measures: Response to treatment and adverse events.

Results: Ocular or periocular involvement was found in 244 of 1215 STEVIE participants (20.1%), who constituted the analytic sample. The median age of the study participants was 72.0 (interquartile range [IQR], 60.0-82.0]) years, and they included 143 men (58.6%). Locally advanced BCC was diagnosed in 238 of the 244 participants (97.5%) and metastatic BCC, in 6 (2.5%). The median duration of exposure to vismodegib was 40.0 (IQR, 20.0-78.0) weeks, specifically 39.7 (IQR, 19.9-76.0) weeks for POLA-BCC and 92.4 (IQR, 53.2-163.0) weeks for metastatic BCC. Sixty-nine participants (28.3%) sustained serious adverse events (alopecia, muscle spasms, dysgeusia, weight loss, decreased appetite, asthenia, ageusia, nausea, fatigue, and diarrhea). Two hundred thirty-two study participants (95.1%) sustained more than 1 adverse effect. The overall mean (SD) number of drug-related adverse effects per study participant by first adverse event, regardless of the severity, was 5.48 (3.84). Discontinuation of vismodegib treatment owing to an adverse event was recorded in 58 participants (23.8%). During the study, 22 participants (9.0%) died, 70 (28.7%) achieved complete response, and 94 (38.5%) achieved partial response.

Conclusions And Relevance: Vismodegib was well tolerated by the study participants with POLA-BCC. The safety of vismodegib treatment according to the STEVIE trial findings is consistent with that reported in previous studies. These data may be helpful when considering vismodegib for patients with POLA-BCC.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.1539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226292PMC
July 2020

Kelly punch punctoplasty vs. simple punctal dilation, both with mini-monoka silicone stent intubation, for punctal stenosis related epiphora.

Eye (Lond) 2021 Feb 21;35(2):532-535. Epub 2020 Apr 21.

Sheba Medical Center, Goldschleger Eye Institute, Tel Hashomer, Israel.

Objectives: To compare the outcomes of stenotic punctal dilation by means of a punctal dilator alone vs. a Kelly punch punctoplasty, both followed by insertion of a mini-monoka stent, for treatment of symptomatic punctal stenosis.

Methods: A retrospective, comparative study. The participants were patients with punctal stenosis related epiphora treated at the Goldschleger Eye Institute, Sheba Medical Center. All patients were treated either by simple punctal dilation (group 1) or Kelly punch-assisted punctoplasty (group 2), both followed by mini-monoka stent insertion. Symptoms relief and subjective epiphora scoring (Munk score) were compared and analysed.

Results: Fifty patients were included in the study; Mean age (+SD) of the participants was 60 years (±12, range 30-86 years). Baseline characteristics (age, gender distribution, and visual acuity) were similar in both groups. The mini-monoka stent was placed for an average period of 2 weeks, and all patients received postoperative steroids and antibiotic treatment for 1 week. The Munk score decreased significantly in both groups following the procedure, dropping from 4.9 to 1.9 in group 1 and from 4.3 to 1.2 in group 2 (P < 0.005 for both groups). There was no difference in the delta Munk score between the two groups.

Conclusions: Simple punctal dilation followed by insertion of a mini-monoka stent is effective in alleviating the symptoms of punctal stenosis-related epiphora. There was no added benefit when the more invasive Kelly punch-assisted punctoplasty was used, raising some doubt about its justification in these cases.
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http://dx.doi.org/10.1038/s41433-020-0891-3DOI Listing
February 2021

Naevus of Ota: clinical characteristics and proposal for a new ocular classification and grading system.

Br J Ophthalmol 2021 Jan 30;105(1):42-47. Epub 2020 Mar 30.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.

Introduction: Naevus of Ota is a congenital condition that may involve the skin, eyeball and even intracranial structures usually in the distribution of the ophthalmic and maxillary divisions of the trigeminal cranial nerve. The purpose of this study was to summarise our experience with the ocular clinical presentation, imaging, outcome, treatment of complications and to offer a new classification of patients with naevus of Ota.

Methods: We retrospectively reviewed the patients' medical records and the following parameters were retrieved and analysed: demographics, clinical presentation complications and treatment of complications. Imaging characteristics of patients with naevus of Ota were compared with images from the same period of time of 57 age-matched and gender-matched patients without naevus of Ota (control group).

Results: The series was composed of 40 patients (18 males, 22 females) whose mean age at diagnosis was 35.27 years (range 0.5-77 years). Thirty-three patients (82.5%) were type I naevus of Ota according to the Tanino classification, three patients (7.5%) were type II, one patient (2.5%) was type III and three patient (7.5%) were type IV (bilateral naevus of Ota). We further classified all cases in according to the ocular involvement extent. Three patients developed malignant transformation to choroidal melanoma and four patients developed glaucoma.

Conclusions: In this study, a new clinical classification based on the involved ocular component and extent of the involvement (in quadrants) of the globe is suggested first. Further studies are needed to assess whether our clinical ocular classification can assist in identifying patients at risk for developing glaucoma and malignant transformation.
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http://dx.doi.org/10.1136/bjophthalmol-2019-313984DOI Listing
January 2021

Changes in Refraction and Visual Acuity after Upper Eyelid Blepharoplasty versus Posterior Approach Ptosis Procedures.

Ophthalmic Res 2020 5;63(6):588-592. Epub 2020 Mar 5.

Goldschleger Eye Institute, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel,

Purpose: To evaluate surgically induced refractive changes (SIRC) and visual acuity (VA) changes after blepharoplasty combined with posterior approach ptosis surgery (Müller's muscle-conjunctival resection [MMCR]) versus upper eyelid blepharoplasty alone.

Methods: In this prospective, comparative, clinical study on patients undergoing MMCR and blepharoplasty, comprehensive ophthalmic examinations were performed preoperatively and 3 months postoperatively. SIRC were calculated with the 10-step Holladay method.

Results: Fifty-six patients participated in the study, 31 in the blepharoplasty group and 25 in the ptosis group. logMAR VA improved significantly after surgery in both groups (p < 0.001). In both groups, most patients showed significant changes in SIRC sphere and spherical equivalent of >0.5 D (blepharoplasty group: 61.29 and 67.74%; ptosis group: 72.72 and 72.72%, respectively). Patients undergoing combined blepharoplasty ptosis surgery showed the greatest SIRC cylinder.

Conclusions: Upper eyelid blepharoplasty with or without MMCR is associated with significant SIRC 3 months postoperatively. This may affect decision-making for all patients, especially for those who intend to seek refractive correction in addition to the index upper eyelid surgery.
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http://dx.doi.org/10.1159/000506951DOI Listing
March 2020

The clinical and histopathological characteristics of Kelly punch punctoplasty.

Eye (Lond) 2020 12 17;34(12):2295-2299. Epub 2020 Feb 17.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: To examine the clinical presentation, histopathological characteristics and surgical success of patients that underwent Kelly punch punctoplasty.

Methods: A retrospective consecutive case series of all patients diagnosed with punctal stenosis and referred to Kelly punch punctoplasty and mini-monoka insertion between January 2017 and December 2017. The demographic, clinical and prognosis parameters were retrieved and analyzed. Moreover, a histopathological examination was performed on the tissue retrieved from the Kelly punch at the end of the procedure in order to evaluate the presence of muscle in the tissue, as well as chronic inflammation.

Results: The series was composed of 44 eyes of 28 patients. All patients' complaints prior to surgery were epiphora: 18 patients had bilateral epiphora, 5 presented with right-eye epiphora and 5 with left-eye epiphora. The average Munk degree of epiphora before surgery was 3 and at least 3 months after surgery 1.04 (matched pairs, p < 0.0001). Two patients underwent the second punctoplasty. In haematoxylin and eosin staining, the Riolan muscle was not visible in the mucosal layer in 40 specimens. In four specimens, the muscle was observed. A Masson's trichrome staining ensured that the Riolan muscle existed only in those four specimens.

Discussion: Kelly punch punctoplasty is a simple and minimally invasive procedure for punctal dilation with high functional success rate. Moreover, in histopathological specimens, in all but four of the cases there was no muscle indicated. Intact Riolan muscle enables the punctum to stay in the right circular shape and position, and the lacrimal pump to maintain its pressure gradient.
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http://dx.doi.org/10.1038/s41433-020-0813-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784900PMC
December 2020

The Effect of a Ptosis Procedure Compared to an Upper Blepharoplasty on Dry Eye Syndrome.

Am J Ophthalmol 2020 04 23;212:1-6. Epub 2019 Nov 23.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Purpose: To examine the effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty on dry eye syndrome.

Design: Prospective, comparative clinical study.

Methods: This is prospective, comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients with dermatochalasis and the ptosis group consisted of adult patients with dermatochalasis and ptosis that showed significant improvement after phenylephrine 10% instillation. The following parameters were compared for all patients before the procedure (baseline) and on postoperative day 90: MRD1, Ocular-Surface-Disease-Index (OSDI), Schirmer test 2, tear break-up time (TBUT), fluorescein staining, Lissamine-green staining (LG).

Results: Fifty-four patients participated in this study (blepharoplasty group: 23 patients, ptosis group 31 patients). There were significant increases in the postoperative LG scores and in fluorescein staining post ptosis surgery compared with the preoperative values (paired t test, P = .05 and P = .02, respectively). The postoperative OSDI score was significantly higher post ptosis surgery compared with the preoperative score (25.38 vs 17.24, respectively, paired t test, P < .01). There were no significant differences, in the blepharoplasty group, between the postoperative and preoperative objective and subjective dry eye tests.

Conclusions: MMCR surgery causes an increase in the subjective feeling of dry eye as well as an increase of signs of dry eye. This increase was not noticed after blepharoplasty surgery. Physicians should be aware of the risk of dry eye after ptosis surgery and discuss dry eye as a complication of MMCR surgery with their patients before surgery. Those patients should be examined carefully and treated for dry eye during follow-up.
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http://dx.doi.org/10.1016/j.ajo.2019.11.021DOI Listing
April 2020

Endoscopic dacryocystorhinostomy with and without mucosal flap-is there any difference?

Eye (Lond) 2020 08 25;34(8):1449-1453. Epub 2019 Nov 25.

Goldschleger Eye Institute, The Chaim Sheba Medical Center, Tel Hashomer, Israel.

Background: The nasal mucosa is sacrificed in conventional endoscopic dacryocystorhinostomies (EDCRs). Some surgeons, however, modify the technique by elevating a mucosal flap prior to creating the osteotomy with the aim of preserving the mucosa. To our knowledge, no clear-cut benefit of a mucosal flap has been established. The aim of this study is to examine the differences in surgical techniques and success rates of EDCRs with and without mucosal flap preservation.

Methods: We carried out a medical record review of all patients who underwent primary EDCR at the Goldschleger Eye Institute from October 2009 to October 2017. The following data were retrieved from the medical database and analyzed: patient demographics (age at diagnosis and gender), medical history, examination findings, surgical details, postoperative success, complications, and follow-up.

Results: A total of 107 patients who underwent 117 EDCRs participated in the study. Fifty-one patients comprised the group without a mucosal flap and 56 patients comprised the group with mucosal flap preservation. The medical history, presenting complaints, and preoperative examination findings were similar for both groups. The surgical success rate was not significantly different between the groups (82.1% without flap vs. 86.8% with flap, P = 0.478, Chi-square).

Conclusion: The findings of this comparison of EDCRs with and without mucosal flap preservation in a large patient population revealed no differences in surgical success or complications rates between the two procedures and, therefore, no benefit for adding flap preservation to conventional EDCRs.
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http://dx.doi.org/10.1038/s41433-019-0716-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468247PMC
August 2020

No impact of nasal septoplasty on the outcome of endoscopic dacryocystorhinostomy.

Eye (Lond) 2020 08 25;34(8):1454-1458. Epub 2019 Nov 25.

Goldschleger Eye Institute, Sheba Medical Center, Ramat Gan, Israel.

Objective: To compare the outcomes of combined endoscopic dacryocystorhinostomy (endoDCR) with nasal septoplasty for deviation of the nasal septum to endoDCR alone in cases of nasolacrimal duct obstruction (NLDO).

Methods: A retrospective cohort study that included 107 consecutive patients with NLDO, who underwent endoDCR with or without concomitant nasal septoplasty in our institution between October 2009 and October 2017.

Results: A total of 117 operations were performed (107 patients, 80.4% females; mean age ± SD 51.1 ± 19.5 years). Twenty-five (21.4%) endoscopic surgeries were combined with septoplasty (the endoDCR + septoplasty group), and 92 (78.6%) comprised endoDCR alone (the endoDCR group). There was no difference in anatomical success and functional success rates between the two groups (P = 0.76 and P = 0.18, respectively). There were no complications attributed to the septoplasty component of the surgical procedure.

Conclusion: Considerable numbers of patients undergoing endoDCR also require a septoplasty. Combining an additional procedure (septoplasty), that was not performed for its original indication but rather for facilitating the main surgical intervention (endoDCR), yields surgical success and associated complications equivalent to those of endoDCR alone.
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http://dx.doi.org/10.1038/s41433-019-0696-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376107PMC
August 2020

Repetitive magnetic stimulation protects corneal epithelium in a rabbit model of short-term exposure keratopathy.

Ocul Surf 2020 01 28;18(1):64-73. Epub 2019 Sep 28.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel. Electronic address:

Purpose: To investigate the effect of repetitive magnetic stimulation (RMS) on corneal epithelial permeability in a rabbit model of exposure keratopathy.

Methods: 61 female New Zealand White (NZW) rabbits were treated on one eye with repetitive magnetic stimulation (RMS) at a frequency of 20 Hz for 15 min. The other eye was untreated. Rabbit eyes were kept open for 2 h to induce acute corneal desiccation. The extent of fluorescein corneal staining was evaluated using EpiView software and the concentration of fluorescein in the anterior chamber was determined by a fluorometer. Safety was evaluated by electroretinogram, spectral domain optical coherence tomography (SD-OCT) and histopathology. Expression pattern of corneal cell markers was determined by immunofluorescence.

Results: A significant decrease in fluorescein concentration in the anterior chamber (54 ± 8.4 ng/ml vs. 146.5 ± 18.6 ng/ml, p = 0.000001) and in corneal surface fluorescein staining score (1.7 ± 0.2 vs. 4.6 ± 0.6, p = 0.00001) was obtained in RMS-treated eyes compared with control eyes, respectively. RMS treatment reduced by nearly 4 fold the percentage of corneal area with epithelial erosions by anterior segment SD-OCT. The therapeutic effect was maintained for at least 3 months. Increased expression of epithelial tight junction protein Zo-1 was observed in treated eyes. SD-OCT and histopathology analysis revealed no pathological changes in the treated or non-treated eyes.

Conclusions: RMS treatment decreases epithelial corneal erosions in a rabbit model of exposure keratopathy, with no indication of pathological changes. RMS may present a novel treatment for protection of corneal epithelium from desiccation.
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http://dx.doi.org/10.1016/j.jtos.2019.09.009DOI Listing
January 2020

Efficacy of Vismodegib for the Treatment of Orbital and Advanced Periocular Basal Cell Carcinoma.

Am J Ophthalmol 2019 11 9;207:62-70. Epub 2019 May 9.

Department of Ophthalmology, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel.

Purpose: To evaluate the effectiveness of vismodegib, a Hedgehog pathway inhibitor, in treating orbital and advanced periocular basal cell carcinoma (BCC) in Israeli multidisciplinary medical centers.

Design: Retrospective case series.

Methods: Background, treatment, and outcome data were retrospectively collected from the medical records of all patients with locally advanced and metastatic orbital or periocular BCC treated with vismodegib in 2012-2017 at 2 tertiary medical centers.

Results: The cohort included 21 patients (16 male) of median age 76 years with periocular (n=6) or orbital (n=15) BCC. Median duration of treatment was 9 months, with follow-up of 26 months (range 9-60 months) overall and 17 months after treatment cessation. Clinical response was complete in 10 patients, partial in 10 patients, and stable in 1 patient. Among the complete responders, 5 maintained a complete response at 16 months, and 3 who stopped treatment had a recurrence 8 months later. Almost all treatment-related adverse reactions were graded 1 or 2 (low-grade). The most common grade 1 or 2 complications were muscle spasm (76%), followed by dysgeusia (57%), alopecia (47%), weight loss (47%) and decreased appetite (19%). The only grade 3 or 4 adverse event was hepatotoxicity (10%). Eight patients discontinued treatment because of side effects. Five patients died, most from reasons unrelated to vismodegib therapy, except for 1 patient who died from possibly treatment-related sepsis (grade 5 adverse event).

Conclusions: To our knowledge, this is the only study generated outside the United States and Europe, and it represents the largest study to date on vismodegib therapy for locally advanced periocular BCC. Treatment according to an individualized maximally tolerated dose may achieve a comparable response to the ERIVANCE protocol. Longer-term studies are needed to assess prognosis.
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http://dx.doi.org/10.1016/j.ajo.2019.04.013DOI Listing
November 2019

Multimodal Assessment of Corneal Erosions Using Optical Coherence Tomography and Automated Grading of Fluorescein Staining in a Rabbit Dry Eye Model.

Transl Vis Sci Technol 2019 Jan 28;8(1):27. Epub 2019 Feb 28.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: To evaluate the potential use of anterior segment spectral domain optical coherence tomography (AS-SD-OCT) combined with an automated grading of fluorescein staining for assessment of corneal erosions in a rabbit short-term dry eye model.

Methods: Twenty-one New Zealand white rabbits were anesthetized and eyes were kept open for 140 minutes to induce acute corneal desiccation. Rectangular scans of the cornea were performed using Spectralis AS-SD-OCT. Total corneal thickness, corneal epithelial thickness, and the percentage of epithelial erosion area (PEEA) were evaluated. Corneas were stained with fluorescein and graded automatically using EpiView and semi-automatically using ImageJ. Spearman's rank-order correlations were calculated to compare the AS-SD-OCT PEEA and the two corneal staining scores.

Results: Eye desiccation resulted in corneal epithelium erosions that covered 0.67% to 14.2% of the central cornea (mean ± SD: 3.95% ± 3.2%) by AS-SD-OCT. The percentage of corneal area positively stained with fluorescein ranged from 0.24% to 38.01% (mean ± SD: 12.24% ± 9.7%) by using ImageJ, correlating with the AS-SD-OCT PEEA (Spearman's ρ, 0.574; = 0.007). The EpiView score ranged from 0.5 to 10.17 and was better correlated with the AS-SD-OCT PEEA score (Spearman's ρ, 0.795; = 0.000017).

Conclusions: Our study suggests that multimodal analysis of AS-SD-OCT and grading of fluorescein staining using EpiView software may enable quantitative assessment of corneal epithelial erosions in a rabbit short-term dry eye model.

Translational Relevance: This multimodal imaging analysis may be applied for evaluation of superficial punctate keratitis associated with dry eye.
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http://dx.doi.org/10.1167/tvst.8.1.27DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396684PMC
January 2019

Subcutaneous tranexamic acid in upper eyelid blepharoplasty: a prospective randomized pilot study.

Can J Ophthalmol 2018 12 27;53(6):600-604. Epub 2018 Mar 27.

Mohs Unit, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Objective: Postoperative ecchymoses or hematomas can prolong healing from surgery, and a search for locally administered agents that decrease bleeding is warranted. The objective of this study is to evaluate whether preoperative subcutaneous injection of tranexamic acid (TXA) reduces intra- and postoperative bleeding or ecchymoses in skin-only upper eyelid blepharoplasty surgery.

Design: This is a prospective randomized, double-blind, controlled study.

Participants: We included 34 consecutive patients who were referred to an upper eyelid blepharoplasty surgery in our institution.

Methods: The patients were equally randomized to a preoperative local injection of lidocaine mixed with either TXA or normal saline. All patients stopped antiaggregates 1 week before surgery. All surgeries were performed by a single surgeon who was unaware of group assignment. Total surgical time, cumulative time of cautery use, blood loss, the surgeon's assessment of bleeding extent, pain level reported by the patient, periocular ecchymoses during the first postoperative week, and time for patient's return to normal daily activity were recorded.

Results: There was a trend toward smaller ecchymoses in the TXA group compared with the placebo group on the seventh day (p = 0.072). There were no group differences in total surgery time, cumulative cautery time, net blood weight in surgical pads, patient-reported pain level, surgeon's assessment of hemostasis, or periocular ecchymosis size on the first postoperative day.

Conclusions: Subcutaneous TXA was associated with similar intra- and postoperative hemorrhage in upper eyelid blepharoplasty compared with placebo. The effect of TXA in patients who did not stop antiaggregate use before surgery warrants further study.
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http://dx.doi.org/10.1016/j.jcjo.2018.01.006DOI Listing
December 2018

Therapeutic contact lenses vs. tight bandage patching and pain following pterygium excision: a prospective randomized controlled study.

Graefes Arch Clin Exp Ophthalmol 2018 Nov 1;256(11):2143-2148. Epub 2018 Sep 1.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel.

Purpose: The immediate postoperative management of patients undergoing pterygium excision usually includes eye patching in order to alleviate pain and prevent accidental tissue damage. Commonly applied tight patching with gauze bandages results in decreased field of monocular vision and discomfort. The aim of this study was to evaluate the patient-centered outcome of pterygium surgery when therapeutic contact lenses (TCL) are used instead of tight bandage patching in the first 24 postoperative hours.

Methods: Prospective randomized controlled study. Sixty patients with primary pterygium who underwent pterygium surgery consisting of conjunctival autografting with 10-0 Vicryl sutures were randomized into two groups, bandaged with TCLs and tight bandage patching.

Main Outcome Measures: Degree of pain on an 0-10 scale, use of pain killers, level of patient discomfort, sleep quality, and visual acuity (VA).

Results: Sixty patients were studied. The pain level and pain duration during the first postoperative day was significantly lower in the tight bandage patching group compared with the TCL group (P = 0.034, P = 0.04 respectively). Sleep quality was significantly poorer in the TCL group (P = 0.004). The VA on the first postoperative day was similar for the two groups.

Conclusions: The application of TCL in the first 24 h after pterygium surgery resulted in more discomfort and pain and decreased quality of sleep compared with tight bandage patching. Despite the limitation in monocular vision and the inconvenience of gauze bandages, they are preferred over TCL for alleviating pain following pterygium surgery.
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http://dx.doi.org/10.1007/s00417-018-4118-2DOI Listing
November 2018

Challenging Management of Double Vision After Functional Endoscopic Sinus Surgery-A Series of 6 Cases.

Am J Ophthalmol 2018 06 29;190:134-141. Epub 2018 Mar 29.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS).

Design: Retrospective observational case series.

Methods: The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes.

Study Population: All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included.

Main Outcome Measures: The presence and extent of strabismus and double vision at the end of follow-up.

Results: Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1-5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only.

Conclusions: Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.
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http://dx.doi.org/10.1016/j.ajo.2018.03.030DOI Listing
June 2018

The Epidemiological, Clinical, and Histopathological Characteristics of Lacrimal Gland Biopsies in a Tertiary Care Center in Israel.

Isr Med Assoc J 2018 Feb;20(2):104-108

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: The distribution of pathology and clinical characteristics of lacrimal gland diseases are different in different areas of the world.

Objectives: To evaluate the incidence rate, patient characteristics, and indications for surgical intervention of lacrimal gland lesions in a tertiary care center in Israel.

Methods: All biopsied or surgically removed lacrimal gland lesions at the Goldschleger Eye Institute from 2009 to 2015 were identified. The following data were collected: age, gender, indications for surgical intervention, diagnosis, treatment, and prognosis.

Results: We evaluated 28 lacrimal gland biopsies from 26 patients (11 men, 15 women). Mean age at biopsy was 47.5 years old. The most common presenting symptoms were: eyelid swollenness (57.14%), ptosis (32.14%), and proptosis (10.71%). All patients underwent computed tomography and magnetic resonance imaging. In 28 cases, infiltrations of the lacrimal gland were found. In nine cases infiltration of muscles or orbital extension were found. The most common pathologies were non-specified inflammation (44.82%), lymphoma (20.68%), and immunoglobulin G4-related disease (10.34%). The treatment was diverse according to the patient diagnosis. Prognosis of lacrimal gland disease was good; however, in five patients the systemic disease progressed.

Conclusions: Lesions of the lacrimal gland comprise a wide variety of pathological findings that require different treatment strategies. Lacrimal gland biopsies enable physicians to precisely recognize the pathology; therefore, it is important to consider this surgical method in any patient with lesions in the lacrimal gland.
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February 2018

The impact of IgG-4-ROD on the diagnosis of orbital tumors: A retrospective analysis.

Orbit 2017 Dec 22;36(6):359-364. Epub 2017 Aug 22.

b Sheba Medical Center , Tel Hashomer , Israel.

This study was to determine the prevalence of immunoglobulin G4 (IgG4)-related orbital disease (IgG4-ROD) among patients who have previously undergone biopsy and were diagnosed to have idiopathic orbital inflammatory disease (IOID) or orbital lymphoproliferative disease (OLD), namely, lymphoma and benign reactive lymphoid hyperplasia (BRLH). This is a retrospective cross-sectional study. The charts and slides of all patients who underwent biopsies and were histopathologically diagnosed to have either IOID or OLD were reviewed. Demographics, clinical features, initial histopathological diagnoses, treatment received, and final outcome were noted. Using the diagnostic criteria for diagnosis for IgG4 disease, those cases that would classify as "possible IgG4-related disease (IgG4-RD)" were reviewed, reclassified, and reassigned a diagnosis of IgG4-ROD. We reviewed 105 patients' clinical charts. Of these 105 patients, upon reviewing the histopathology, 18 (17.15%) patients were found to fit the diagnostic criteria for possible IgG4-ROD. Of these 18 patients who were now reassigned the diagnosis of IgG4-ROD, the most common previous histopathological diagnosis was found to be IOID, for eight patients (44%), then BRLH, which was noted in five patients (27.8%), followed by lymphoma, which was noted in two patients (11.1%). Previously diagnosed cases of IOID and OLD were found to fulfill the criteria for IgG4-ROD. Given the advent of recent diagnostic and histopathological techniques, all cases of suspected IOID and OLD should be screened for IgG4-ROD and all previously diagnosed cases must be closely followed up, given the systemic implication of IgG4-RD. Histopathological reassessment of previously diagnosed cases may be considered.
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http://dx.doi.org/10.1080/01676830.2017.1337192DOI Listing
December 2017

Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease.

Can J Ophthalmol 2017 Jun 13;52(3):264-268. Epub 2017 Jan 13.

Goldschleger Eye Institute, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED).

Methods: Data on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests.

Results: 145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ test, p = 0.004).

Conclusions: To the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients' characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.
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http://dx.doi.org/10.1016/j.jcjo.2016.11.006DOI Listing
June 2017

Evicel versus Tisseel versus Sutures for Attaching Conjunctival Autograft in Pterygium Surgery: A Prospective Comparative Clinical Study.

Ophthalmology 2017 01 3;124(1):61-65. Epub 2016 Nov 3.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Purpose: To evaluate the outcome of pterygium surgery with conjunctival autograft using Vicryl sutures (Ethicon, NJ), Evicel fibrin glue (Omrix Biopharmaceuticals Ltd, Ramat-Gan, Israel), or Tisseel fibrin glue (Baxter Corp., Deerfield, IL).

Design: Prospective, randomized study.

Participants: Eighty-nine adult patients with primary pterygium.

Methods: Patients undergoing pterygium surgery with conjunctival autografting were randomized into groups receiving 10-0 Vicryl sutures, Evicel fibrin glue, or Tisseel fibrin glue.

Main Outcome Measures: Duration of surgery, level of patient discomfort, visual acuity (VA), surgically induced refractive change (SIRC), complications, and pterygium recurrence.

Results: Eighty-nine patients participated: 25 in the Vicryl group, 29 in the Evicel group, and 35 in the Tisseel group. The patients' preoperative characteristics were similar in all groups. Fashioning and repositioning of the conjunctival autograft (flap time) was significantly shorter in the fibrin glue groups compared with the Vicryl group: 5.46 minutes for Evicel, 3.6 minutes for Tisseel, and 16.72 minutes for sutures (P < 0.0001). The patient discomfort level during the first postoperative day was significantly lower in the fibrin glue groups compared with the suture group (P = 0.047). There were no significant group differences in the change in logarithm of the minimum angle of resolution VA before surgery and 3 months after surgery (P = 0.7). There were also no significant group differences in the SIRC (P = 0.108). The recurrence rate was 17.24% in the sutures group, 4.17% in the Evicel group, and 0% in the Tisseel group (P = 0.027 sutures vs. fibrin glue groups). Complications included 5 cases of conjunctival graft dislocation in the Evicel group, 1 case of pyogenic granuloma in the Tisseel group, and no complications in the sutures group (P = 0.019 sutures vs. fibrin glue groups).

Conclusions: Tisseel fibrin glue for the repositioning of conjunctival autografts in pterygium surgery was associated with a similar functional outcome as that of Vicryl sutures in terms of VA and SIRC. Pterygium recurrence, patient discomfort level, and surgery time were reduced markedly, as were flap dislocation and pterygium recurrence with Tisseel fibrin glue compared with Evicel fibrin glue.
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http://dx.doi.org/10.1016/j.ophtha.2016.09.010DOI Listing
January 2017

Ptosis Shmosis.

Surv Ophthalmol 2017 Mar - Apr;62(2):237-240. Epub 2016 Feb 26.

Dean McGhee Eye Institute, Department of Ophthalmology, University of Oklahoma, Oklahoma City, Oklahoma, USA.

A 10-year-old girl presented with painless unilateral left upper lid ptosis. A nontender hard mass was palpated in the left upper lid. Blood smear was compatible with the diagnosis of leukemia. The cause of ptosis was now thought to be a mass composed of myeloid blast cells (myeloid sarcoma).
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http://dx.doi.org/10.1016/j.survophthal.2016.02.004DOI Listing
May 2017

Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease.

Graefes Arch Clin Exp Ophthalmol 2016 Apr 19;254(4):791-6. Epub 2015 Dec 19.

The Royal Victorian Eye and Ear Hospital, Melbourne, Australia.

Purpose: Rim-off lateral wall decompression may be associated with functional and cosmetic deficit. Our objective, therefore, was to describe the functional and cosmetic results of deep lateral orbital decompression with and without anterior rim repositioning for thyroid eye disease.

Methods: In this retrospective comparative case series all consecutive thyroid eye disease patients who underwent deep lateral wall decompression at the Royal Victorian Eye and Ear Hospital between 1990-2007 and the Goldschleger Eye Institute, Sheba Medical Center between 2008-2011 were included. Patients were divided into two groups: the "rim-on" group in which the anterior lateral orbital rim was repositioned and the "rim-off" group in which it was left off. Main outcome measures were: proptosis reduction, postoperative oscillopsia and diplopia, presence of visible or palpable lateral orbit depression.

Results: One hundred and twelve patients who underwent 186 orbital decompressions were included in the final analysis. The average proptosis reduction for two- and three-wall decompressions ranged between 4.6-4.9 mm in the rim-on and 4.6-5.7 mm in the rim-off group respectively. The prevalence of postoperative oscillopsia was similar in both groups. The preoperative diplopia worsened in 17 patients (32.1 %) in the rim-on group and in seven patients (12.3 %) in the rim-off group (P = .02, chi-square test). None of the patients developed visible or palpable lateral orbit depression.

Conclusions: Deep lateral orbital decompression without anterior rim repositioning may be an effective approach to enhance functional and cosmetic outcomes in thyroid eye disease patients without increasing the risk of lateral wall depression or postoperative oscillopsia.
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http://dx.doi.org/10.1007/s00417-015-3237-2DOI Listing
April 2016

Age differences in clinical manifestation and prognosis of thyroid eye disease.

Graefes Arch Clin Exp Ophthalmol 2015 Dec 7;253(12):2301-8. Epub 2015 Sep 7.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.

Purpose: To examine the clinical differences in manifestation, course, treatment, and prognosis of thyroid eye disease (TED) in patients younger than 40 years of age at diagnosis compared to older patients.

Methods: Medical record review of 131 TED patients was performed. The patients were divided into two age groups, Group 1 ≤ 40 years (23 patients) and Group 2 > 40 years (108 patients).

Results: Younger patients had more eyelid retraction and proptosis at initial presentation, whereas older patients were more likely to have diplopia (P = 0.001). Acute inflammatory signs were more common in the Group 2 patients (P = 0.04). Corrected visual acuity was 20/20 and 20/25 in both groups. Optic neuropathy was diagnosed only in Group 2 patients (n = 12; 11 %), and it resolved after steroids or orbital decompression surgery in all cases. The mean follow-up time was 36 months (36 ± 7.7; 59.3 ± 5.8). Systemic steroid use, orbital surgery, and strabismus surgery were more common in Group 2 (P < 0.0001, P < 0.05 respectively).

Conclusions: TED under the age of 40 years has different clinical features. In our group of younger patients, the clinical presentation was milder than in the older group with a higher rate of lid retraction and proptosis and lower rate of restrictive myopathy and optic neuropathy. Their disease course was less severe and required less aggressive medical treatment and less surgical procedures.
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http://dx.doi.org/10.1007/s00417-015-3156-2DOI Listing
December 2015