Publications by authors named "Mohsen Bahmani Kashkouli"

111 Publications

A Systematic Review on the Role of Antioxidants in Thyroid Eye Disease.

J Curr Ophthalmol 2022 Jan-Mar;34(1):16-24. Epub 2022 Apr 16.

Eye Research Center, The Five Senses Institute, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To systematically review the role of antioxidants in management of patients with thyroid eye disease (TED).

Methods: A literature search of the electronic databases was performed without restrictions on the date of publication till the end of March 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical trials, case-control studies, cohorts, case series, case reports, and experimental (including ) studies in the English language were included. The primary outcome in human studies was improvement in severity, activity scores, and/or quality of life scores. There was a decrease in the level of HO-dependent oxidative stress, Hyaluronic acid release, reactive oxygen species, cell proliferation, or antifibrotic/antiproliferative actions in the studies.

Results: Out of 374 initially screened articles, 157 studies were selected, the full texts of 82 were reviewed, and 14 papers were finally included. There were 4 clinical and 10 studies from 1993 to 2018. While β-carotene, retinol, Vitamin E, Vitamin C, melatonin, resveratrol, N-acetyl-l-cysteine, and quercetin showed some efficacy in studies; allopurinol, nicotinamide, pentoxifylline, and selenium (Se) were effective in both clinical and experimental reports. Se was the only recommended antioxidant based on one high-level randomized controlled trial.

Conclusion: While different antioxidants could potentially be effective in the management of TED, no strong recommendation for any or combination of antioxidants could be made to be implemented in the daily practice.
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http://dx.doi.org/10.4103/joco.joco_266_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9128423PMC
April 2022

Diagnostic value of lacrimal scintigraphy in the evaluation of lacrimal drainage system obstruction: a systematic review and meta-analysis.

Nucl Med Commun 2022 Aug 4;43(8):860-868. Epub 2022 May 4.

Research Center for Nuclear Medicine, Dr. Shariati Hospital, Tehran University of Medical Sciences.

Purpose: A systematic review and meta-analysis to evaluate the diagnostic performance of lacrimal scintigraphy (LS) versus anatomical methods in the evaluation of the nasolacrimal duct obstruction (NLDO).

Materials And Methods: A systematic search was performed using electronic bibliographic databases until the end of May 2021. Inclusion criteria: (a) used LS as a diagnostic method to evaluate NLDO; (b) used anatomical studies [including syringing, irrigation, probing, and dacryocystography (DCG)] as reference tests; and (c) provided adequate crude data. A hierarchical method was used to pool the sensitivity and specificity. The hierarchical summary receiver-operating characteristic model was performed. Additionally, the studies' heterogeneity and publication bias were analyzed. All analyses were conducted by the 'Midas' module of STATA 16.

Results: Twelve articles (with 14 separate populations) were considered eligible to enter the meta-analysis. They were divided into two groups based on the reference standard method, called irrigation and DCG groups. In the irrigation group, the pooled sensitivity and specificity were 89% [95% confidence interval (CI), 72-96%] and 25% (95% CI, 8-56%), respectively. In DCG group, the pooled sensitivity and specificity were 97% (95% CI, 85-100%) and 27% (95% CI, 0.12-0.49), in turn.

Conclusion: LS is a sensitive modality to evaluate the anatomical obstruction of NLD. In contrast, it shows low pooled specificity compared with anatomical methods. Thus, LS can be used as the first noninvasive modality for the evaluation of epiphora. However, in case of any abnormality, confirmatory procedures are required.
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http://dx.doi.org/10.1097/MNM.0000000000001578DOI Listing
August 2022

Targeted chemotherapy in retinoblastoma: A step forward from patient survival to globe survival.

Eur J Ophthalmol 2022 Apr 13:11206721221093018. Epub 2022 Apr 13.

MAHAK Hematology Oncology Research Center (MAHAK-HORC), MAHAK Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background/ Objectives: Despite being the most common intraocular malignancy in childhood, there is a substantial disparity between developing and developed countries in terms of patient and globe survival in retinoblastoma (Rb). The current study intends to determine patient and globe survival before and after the introduction of the new targeted treatment modalities in a developing country.

Methods: Medical records of 350 patients (516 eyes) with retinoblastoma referred to a tertiary referral center for Rb in Tehran, Iran, were reviewed. In order to compare patient and globe survival before and after the availability of the new treatment modalities, including intra-arterial and intravitreal chemotherapy, the patients were divided into group 1 (2001-2007) and group 2 (2008-2018) based on the calendar period of diagnosis.

Results: Two-hundred-twenty-three eyes of 149 patients and 293 eyes of 201 patients were categorized into groups 1 and 2, respectively. The 5-year patient survival was 97% across the current survey, and the overall survival rate was 96% in group 1 and 99% in group 2 (P = 0.08). Overall, 50% of eyes with retinoblastoma underwent enucleation, which was the primary in 63% (116/184) of the unilateral and 30% (99/322) of the bilateral cases. Primary enucleation was significantly lower in group 2 (35%) in contrast to group 1 (50%) (P < 0.001). In addition, globe survival improved significantly in the International Classification of Retinoblastoma Groups D (17% in group 1 vs. 66% in group 2, P < 0.001) and E (1% in group 1 vs. 23% in group 2 P < 0.001) during the two timelines. In enucleated eyes, despite the increased rate of prelaminar involvement in group 2 (13% vs. 2% in group 1, P = 0.003), the rate of high-risk histopathologic findings was similar between the two groups.

Conclusion: Similar to developed countries, the application of new targeted treatment modalities, including intra-arterial and intravitreal chemotherapy, has been associated with significantly improved globe survival in Rb patients. However, it should be noted that even with the availability of these novel treatment options, the decision for on-time enucleation should not be deferred.
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http://dx.doi.org/10.1177/11206721221093018DOI Listing
April 2022

Prevalence of Masked versus Unmasked Blepharoptosis in Subjects Seeking for Blepharoplasty and or Eyebrow Lift.

Semin Ophthalmol 2022 Jul 22;37(5):651-656. Epub 2022 Mar 22.

Eye and Skull Base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Science, Tehran, Iran.

Purpose: To report the prevalence of unmasked versus masked in subjects seeking for eyelid and eyebrow rejuvenation.

Methods: This retrospective study included subjects (>18 years) who were seeking for blepharoplasty and/or eyebrow lift procedures in the year 2020. They were either having (complaining of simultaneous droopy eyelid, which was confirmed on examination), or (not complaining of simultaneous droopy eyelid, but its presence was revealed on the examination). Margin reflex distance 1 (MRD1) and levator function (LF) were recorded. Associated ptosis was defined as MRD1 of ≤3 mm and regarded as mild (3 and 2.5 mm), moderate (2 and 1.5 mm), and severe (≤1 mm).

Results: Included were 1401 subjects with a mean age of 47.2 years. The prevalence of masked and unmasked ptosis was 31% (90% unilateral) and 15.6% (59% bilateral), respectively. A significantly younger mean age (45.6 vs. 59.7 years), higher MRD1 (2.6 vs. 1.9 mm), and better LF (13.3 vs. 11.3 mm) were observed in the masked vs. unmasked ptosis group. More than 80% of the subjects with masked ptosis presented with indirect signs. A majority of both groups (68.8% of masked and 63.5% of unmasked ptosis) were mild to moderate.

Conclusion: Almost half of the subjects seeking for eyelid and eyebrow rejuvenation had either (2/3) or (1/3) associated ptosis. Masked ptosis was mostly unilateral and presenting with indirect signs of ptosis.
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http://dx.doi.org/10.1080/08820538.2022.2053727DOI Listing
July 2022

Postoperative Blepharoptosis after Trabeculectomy versus Ahmed Glaucoma Valve Implantation.

J Curr Ophthalmol 2021 Oct-Dec;33(4):388-393. Epub 2022 Jan 6.

Skull Base Research Center, The Five Senses Health Institute, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To investigate the frequency of persistent postoperative ptosis (PP) following trabeculectomy or Ahmed glaucoma valve (AGV) implantation and to analyze the associated factors.

Methods: It is a prospective observational study on glaucoma patients who underwent trabeculectomy or AGV implantation from October 2015 to June 2017 in a tertiary center. Margin reflex distance 1 and 2 (MRD1 and 2) and levator function were measured before and at least 6 months, postoperatively. Clinically significant ptosis was defined as ≥2 mm drop of MRD1.

Results: One hundred and fourteen patients (124 eyelids) including 76 patients (87 eyelids) with trabeculectomy and 35 patients (37 eyelids) with AGV implantation were included. The mean age was 55.50 (standard deviation = 17.54) years. Most of the surgeries were performed under general anesthesia (87.9%, 109/124) between 30 and 60 min (53.2%, 66/124) by residents (39.5%, 49/124). Trabeculectomy and AGV groups did not differ in terms of pre, intra, and postoperative variables (0.1≤ ≤0.9) except duration of surgery ( = 0.01) and sex ( = 0.04). Clinically significant persistent PP was observed in 12.9% (16/124) in total, 13.7% (12/87) in the trabeculectomy group, and 10.8% (4/37) in the AGV group ( = 0.6). Male gender (ß coefficient = 2.56, 95% confidence interval (CI) = 4.76-0.36, = 0.02) and a higher preoperative MRD1 (ß coefficient = 1.24, 95% CI = 0.52-1.95, = 0.001) were the only factors affecting the frequency of clinically significant PP.

Conclusions: Postoperative blepharoptosis occurred in 12.9% of eyes after glaucoma procedures. Male gender and higher preoperative MRD1 were significantly associated with a higher frequency of postglaucoma surgery blepharoptosis.
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http://dx.doi.org/10.4103/joco.joco_120_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8772497PMC
January 2022

Optic Nerve Head Vessel Density Changes from Graves' Disease without TED to TED Dysthyroid Optic Neuropathy: Does Optic Nerve Head Ischemia Play a Role?

Ophthalmic Plast Reconstr Surg 2022 May-Jun 01;38(3):250-257. Epub 2021 Sep 28.

Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences.

Purpose: To compare the retinal peripapillary capillary (RPC) vessel density (VD) between 5 groups of patients on the spectrum of thyroid eye disease (TED).

Method: This is a prospective comparative study looking at 5 groups of patients who were consecutively included from January 2018 to March 2021. They were composed of: Healthy volunteers (39 eyes and 20 subjects), patients with Graves' disease without TED (26 eyes and 13 patients), mild TED (28 eyes and 14 patients), moderate-severe TED (30 eyes and 17 patients), and TED with dysthyroid optic neuropathy (DON) (21 eyes and 12 patients). Ocular and periocular examination, visual field indices, RPC-VD (with optical coherence tomography angiography), and retinal nerve fiber layer, and macular ganglion cell complex thickness were recorded.

Result: An initial insignificant (0.5 < p < 0.9) rise in the peripapillary-VD (pp-VD) and whole image-VD (wi-VD) from the healthy subject to the Graves' disease without TED was followed by a significant (p = 0.001) fall in RPC-VD in different severity grades of the TED. Paired comparison between the 5 groups showed that the statistically significant fall from the Graves' disease group occurred in the moderate-severe and DON groups (0.001 ≤ p ≤ 0.04). No variable significantly affected the VD (0.08 ≤ p ≤ 0.9). A lower wi-VD and pp-VD were significantly (0.001 ≤ p ≤ 0.009) correlated with the impaired optic nerve functional and structural tests. The sensitivity and specificity of wi-VD (81% and 76%) and pp-VD (69% and 71%) for detecting the DON were statistically significant (p < 0.001).

Conclusion: Despite an insignificant rise in the wi- and pp-VD from the healthy volunteers to the patients with Graves' disease without TED, VD showed a declining trend in the course of patients with TED, which was statistically significant in the moderate-severe TED and DON groups.
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http://dx.doi.org/10.1097/IOP.0000000000002046DOI Listing
May 2022

Normal Exophthalmometry Values in Iranian Population: A Meta-analysis.

J Ophthalmic Vis Res 2021 Jul-Sep;16(3):470-477. Epub 2021 Jul 29.

Ophthalmic Plastic and Reconstructive Surgery Unit, Rasoul-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

There are limited studies on the normal values of eye protrusion in Iran. Systematic efforts to provide acceptable normal exophthalmometry values for Iranian population are required for a proper approach to orbital diseases.English and Farsi language publications in PubMed, the ISI Web of Knowledge database, Iranian SID, and Iran Medex were searched using the following keywords: "proptosis", "eye protrusion", "exophthalmous", "Hertel exophthalmometer" and "Iran". Four articles from 1995 to 2010 were found and included in the meta-analysis. Statistical analysis was performed using the Metan command within Stata 15.0 software.It included 3,696 subjects in whom the average eye protrusion was 16.5 mm (95% CI: 15.1-17.8) in men and 16.2 mm (95% CI: 14.6-17.7) in women ( = 0.5). Mean left and right eye protrusion were 16.3 (95% CI: 14.7-18.1) and 16.4 mm (95% CI: 14.8-17.7), ( = 0.3), respectively. While Iranian teenagers (13-19 years old) showed a mean value of 17.1 mm (95% CI: 15.0-19.1), older age group ( 20 years) showed a lower mean eye protrusion of 16.3 mm (95% CI: 14.8-17.7). Considering the two standard deviations, the highest normal value of eye protrusion in Iranian population is 20.1 mm.In conclusion,Iranian normal eye protrusion values were higher than Asians and lower than Caucasians.
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http://dx.doi.org/10.18502/jovr.v16i3.9441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8358757PMC
July 2021

Long-term Results of Palpebral Fissure Transfer With No Lower Eyelid Spacer in Chronic Progressive External Ophthalmoplegia.

Am J Ophthalmol 2022 02 30;234:99-107. Epub 2021 Jul 30.

Skull Base Research Center, Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To evaluate the long-term outcomes of the palpebral fissure transfer (PFT) technique without lower eyelid spacer in patients with chronic progressive external ophthalmoplegia (CPEO).

Design: Retrospective interventional case series.

Methods: Consecutive patients with CPEO with PFT surgery (2006-2017) and a minimum follow-up of 24 months were included. The PFT included simultaneous levator resection or frontalis sling (based on the levator function and Bell's phenomenon) and lower eyelid retractor recession without spacer. Primary outcome measures included the change in margin reflex distance 1 (MRD-1), MRD-2, and palpebral fissure height (PFH) in the course of time. Potential predictors of keratopathy were also explored.

Results: There were 32 patients (64 eyelids) with the mean age and follow-up of 34.1 years (range 15-56 years) and 37.9 months (range 24-72 months), respectively. Mean MRD-1 significantly increased from -0.9 mm to 3.4 mm in postoperative weeks 1 and 2 and 1.8 mm at the last follow-up. Mean MRD-2 significantly decreased from 5.6 mm to 3.7 mm in postoperative weeks 1 and 2 and 5 mm at the last follow-up. Eyes with frank lower eyelid retraction (MRD-2 >5 mm) gained more reduction in MRD-2 compared with those with no sclera show (-0.9 mm vs -0.3 mm, P < .001). Reoperation was performed in 9 eyelids for under- (n = 5) and overcorrection (n = 4). Persistent keratopathy was observed in 3 eyes (4.5%).

Conclusion: Lower eyelid retractor recession without spacer yields significant protective corneal coverage at the critical early postoperative period when the risk of keratopathy is highest.
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http://dx.doi.org/10.1016/j.ajo.2021.07.027DOI Listing
February 2022

Re: A Modified Procedure for Single-Eyelid Asian Females with Lacrimal Gland Prolapse: Lacrimal Gland Reposition Combined with Fat Transposition in Double-Eyelid Operation.

Aesthetic Plast Surg 2021 Jul 20. Epub 2021 Jul 20.

Eye and skull base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Sattarkhan Niayesh St., 1455364, Tehran, Iran.

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http://dx.doi.org/10.1007/s00266-021-02476-0DOI Listing
July 2021

Short- and Long-term Patient Satisfaction and Complications in 650 Endoscopic Forehead Lift Procedures.

Ophthalmic Plast Reconstr Surg 2022 Mar-Apr 01;38(2):138-145

Eye and Skull Base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Science, Tehran, Iran.

Purpose: The aims are to compare short- versus long-term patient satisfaction and report temporary versus permanent complications in 650 patients with endoscopic forehead lift procedure (EFL).

Methods: This is a retrospective study on all of the consecutive patients with EFL. Patients with previous trauma and surgery and less than 2 years follow up were excluded. Short- (6 months) and long-term (≥2 years) patient satisfaction (visual analog score [VAS], 0-100) were recorded. Patients' perspectives on temporary versus permanent complications were also documented.

Results: Mean age and follow up were 46.4 and 7.1 (2-13) years, respectively. Long-term satisfaction (79.9) was significantly lower than the short term (96.6). The long-term satisfaction decreased in 95.7%, increased in 2.7%, and remained the same in 1.6% of the patients. Intraoperative skin laceration occurred in 3 patients (0.5%). Mean time of forehead numbness recovery was 2.3 months. Temporary complications were itching (13.7%), headache (6.3%), unilateral facial nerve palsy (5.8%), acne (3.2%), and remained staples (1.7%). Permanent complications included undercorrection (7.1%), alopecia (4.2%), forehead irregularities (2.3%), surprised look (2.2%), incision site complications (2%), and glabellar depression (0.9%). Reoperation (1.2%) was performed for undercorrection and alopecia. While short-term satisfaction was significantly lower in patients with temporary facial nerve paresis, long-term satisfaction was lower in patients with undercorrection and reoperation.

Conclusion: A high satisfaction scores of 96.6 and 80 were observed in the short- and long-term follow up after the EFL. Frequency of temporary and permanent postoperative complications was 30.3% and 15.8%. Reoperation rate was 1.2%.
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http://dx.doi.org/10.1097/IOP.0000000000002003DOI Listing
April 2022

Conversion Rate of Web-based Versus Non-web-based Patient Referral Sources in a Facial Plastic Surgery Practice.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):59-64

Eye and Skull Base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Science, Tehran, Iran.

Purpose: To compare the conversion rate (number of procedures/referrals) of web-based and non-web-based referrals to a facial plastic surgery practice (2012-2019).

Method: Data on demographics, referral source, patient's concern, and their facial procedures were recorded. Web-based referral sources include website and Instagram. Non-web-based counterparts were the word-of-mouth, medical professionals, and others (TV, radio, printed media). Patient concerns were either cosmetic or noncosmetic (functional). Patients who underwent facial cosmetic surgery and injections (botulinum toxin A, filler, fat) were categorized in the cosmetic procedure group. Patients with functional procedures with or without facial injections were categorized in the noncosmetic procedure group. The conversion rate was defined as the ratio of the number of referrals with different facial procedures to the total number of referrals.

Results: Included were 19,965 patients, majority of whom (63.3%) had cosmetic concern. Total, cosmetic, and noncosmetic conversion rates were 30.1%, 27.7%, and 2.4% for the web-based and 24.1%, 19.8%, and 4.3% for the non-web-based referrals, respectively (0.3 < p < 0.4). Cosmetic conversion rate grew from 6.7% in referrals ≤20 to more than 23% in >20 years of age (p = 0.03). It was also significantly (p < 0.001) higher in the referrals with cosmetic (28.3%) than noncosmetic (12.1%) concern. Gender and year of practice did not have a significant effect on the conversion rates.

Conclusion: Conversion rates were not significantly different between the web-based and non-web-based referrals. A significantly higher cosmetic conversion rate was observed for the referrals with cosmetic concern and older than 20 years.
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http://dx.doi.org/10.1097/IOP.0000000000001988DOI Listing
January 2022

Dermatochalasis Through Decades: A Histopathologic Study.

Ann Plast Surg 2021 03;86(3):340-344

Eye Research Center, The Five Senses Institute.

Objectives: Three prior studies (2008, 2011, 2018) histopathologically compared the eyelid specimens of patients with dermatochalasis (DC, undergoing blepharoplasty) with a control group and proposed that DC may begin with subclinical inflammation leading to elastolysis and lymphostasis. With growing number of younger patients consulting for blepharoplasty, the unanswered question is whether histopathologic changes of DC differ between the younger and the older.

Patients And Methods: In this prospective case series, 20 right upper eyelid skin of 20 nonsmoker, class 3 Fitzpatrik skin type women (30-68 years old) were histopathologically examined. Patients were divided into 2 age groups of 50 years or older and older than 50 years. Upper eyelid skin was preoperatively marked, intraoperatively removed, postoperatively divided into 3 sections: lateral (lateral limbus to lateral canthus), central (between medial and lateral limbi), and medial (medial limbus to medial canthus), and separately (totally 60 specimens) sent for histopathological examination. A masked pathologist recorded skin thickness in all specimens (60) as well as lymphatic vessels diameter and density, elastic fiber density, macrophage number, collagen intrafibril edema, and depth of collagen stromal bed in central sections (20 specimens).

Results: There were 10 patients at each age group. Histopathological measurements were not significantly different between the 2 age groups except mean lymphatic vessel diameter (P = 0.034) that was larger in the second group (>50 years). A significant positive correlation was also observed between the age and lymphatic vessel diameter (rs = 0.3, P = 0.009).

Conclusions: Lymphangiectasia progresses significantly by age. Histopathological characteristics of DC are the same in the 2 age groups.
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http://dx.doi.org/10.1097/SAP.0000000000002489DOI Listing
March 2021

Web-Based Versus Non-Web-Based Patient Referral Patterns and Factors Affecting Them.

Ophthalmic Plast Reconstr Surg 2021 Sep-Oct 01;37(5):470-475

Eye and Skull Base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Science, Tehran, Iran.

Purpose: To analyze the 8-year (2012-2019) change in the patient referral source trends to a plastic surgery practice and the factors affecting them.

Methods: Data on demographics, referral source, and patient's concern were recorded. The web-based referral sources were website and Instagram and non-web-based included other patients (word-of-mouth), medical professionals (physician, nurse, and optometrist), and others (printed media, TV, and radio). Patients' concerns were divided into cosmetic and noncosmetic. The first (2012-2015) and second (2016-2019) half of the study period were also compared.

Results: Included patients were 19,965. The 8-year referral sources, in order of frequency, were medical professionals (34%), other patients (32.7%), web-based sources (32.5%), and the others (0.7%). The web-based sources significantly increased by 2.4 times in the second half. While they had a third rank after the medical professionals and other patients in the first half of the study period, they became the first in the second half. The non-web-based source showed a decline during the study period. Type of referral sources was not significantly different between the 2 genders. A significantly higher percentage of the patients between 21 and 50 years of age were referred through web-based sources than the other age groups. Patients with cosmetic concerns were 2 times more likely to be referred through web-based sources.

Conclusion: The web-based referral sources have significantly grown from the third rank in the beginning to the first one from 2015 till the end of study.
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http://dx.doi.org/10.1097/IOP.0000000000001918DOI Listing
October 2021

Postoperative Blepharoptosis After Pars Plana Vitrectomy Procedure.

Ophthalmic Plast Reconstr Surg 2021 Sep-Oct 01;37(5):431-434

Eye and Skull Base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To describe the frequency of blepharoptosis and factors affecting it after the pars plana vitrectomy (PPV) procedure.

Methods: In a prospective study, patients were recruited consecutively from October 2016 to June 2018. Upper eyelid margin reflex distance 1 and 2 (MRD1 and 2), upper eyelid crease height, and levator function were measured before, 1 and at least 6 months after surgery by the same investigator. Clinical and Clinically significant ptosis were defined as ≥0.5 and ≥2 mm drop of MRD1.

Result: There were 60 eyes from 57 patients. The majority of surgeries were performed by the fellows (63.3%, 38/60) and under general anesthesia (95.0%, 57/60). Clinical and clinically significant ptosis following PPV were 47.2% (25/53) and 11.3% (6/53) at the last follow up (at least 6 months), respectively. MRD2 (p = 0.389) and eyelid crease height (p = 0.057) did not significantly change. Surgeons' level, time of the procedure and other variables were not significantly impacting the frequencies.

Conclusion: Persistent clinically significant ptosis was observed in 11% of patients undergoing PPV. No variable was significantly associated with persistent postoperative ptosis after PPV.
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http://dx.doi.org/10.1097/IOP.0000000000001890DOI Listing
October 2021

Revisiting Anchor Epicanthoplasty in Mild to Moderate Asian Epicanthal Folds: A Clinicopathological Study.

Aesthetic Plast Surg 2021 02 6;45(1):181-190. Epub 2020 Aug 6.

Eye and Skull Base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Science, Sattarkhan Niayesh St, 1455364, Tehran, Iran.

Background: To assess the epicanthal fold (EF), eyelid, eyebrow, scar, and patients' satisfaction after anchor epicanthoplasty and upper blepharoplasty and histopathologically compare Asian epicanthal fold skin with non-Asian counterpart.

Methods: Asian Iranians with grade 2 and 3 EF were included. Photographs were taken before and at least 12 months after the surgery. Photoanalysis included EF grade, inter-canthal distance (ICD), margin reflex distance 1 (MRD1), tarsal plate show (TPS), brow fat span (BFS), and eyebrow height. Manchester scar scale score (5-28) and patients' satisfaction score (0-100) were documented. The most medial skin of 5 Asian and 5 non-Asian subjects was histologically compared for the thickness and elastic fiber density and morphology.

Results: Included were 89 patients (178 eyelids) with a mean age of 31.6 years and follow-up of 13.1 months. Mean ICD significantly decreased by 3.5 mm (shortening ratio of 9.7%). All grade 2 and almost half of the grade 3 EF disappeared. Significant postoperative increase in mean MRD1 (0.3 mm) and TPS (1.1-1.4 mm) and decrease in BFS (3.3-3.6 mm) and eyebrow height (1.7-3.4 mm) were observed. Revision rate of epicanthoplasty was 7.3%. Mean satisfaction and scar scores were 97.1 and 5.4, respectively. Histopathologically, Asian and non-Asian medial upper eyelid skin was not significantly different.

Conclusion: Anchor epicanthoplasty eliminated grade 2 and improved grade 3 EF with a high satisfaction and negligible scar. Simultaneous upper blepharoplasty significantly increased MRD1 and TPS and decreased eyebrow height. EF skin was not histologically different from non-Asians.

Level Of Evidence Iv: 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 .
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http://dx.doi.org/10.1007/s00266-020-01901-0DOI Listing
February 2021

Corneal endothelial assessment in xeroderma pigmentosum: a case-control study.

Int Ophthalmol 2020 Sep 5;40(9):2179-2183. Epub 2020 May 5.

Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Sattarkhan-11 Niayesh St., Tehran, 14455-364, Iran.

Purpose: To analyze and compare corneal endothelial mosaic in terms of endothelial cell population, morphology and irregularity in patients with xeroderma pigmentosum (XP) with clear corneas with normal age and sex matched subjects using specular microscopy.

Methods: Nine patients with XP without corneal involvement were evaluated in the study. An age and sex matched group of nine healthy subjects participated as control group. Evaluation of corneal endothelial layer was performed using specular microscopy.

Results: Each study group consisted of five males and four females with total mean age of 28 ± 11.3 years (12-46 years). Endothelial cell density was significantly lower in patients with XP in comparison with controls (P < 0.002). Maximum and minimum cell areas were significantly higher in XP group (P < 0.016 and P < 0.029, respectively). Although central corneal thickness was higher in controls, the difference was not statistically significant (P = 0.106). Furthermore, our study showed that the patients with XP had no difference with controls in terms of coefficient of variation of cell areas.

Conclusions: This study showed that endothelial cell population can decrease in patients with XP, although other specular microscopic variables such as coefficient of variation and central corneal thickness may remain within normal values.
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http://dx.doi.org/10.1007/s10792-020-01398-1DOI Listing
September 2020

Techniques of Eyebrow Lifting: A Narrative Review.

J Ophthalmic Vis Res 2020 Apr-Jun;15(2):218-235. Epub 2020 Apr 6.

Eye and Skull Base Research Centers, The Five Senses Institute, Iran University of Medical Sciences, Tehran, Iran.

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms "eyebrow lift", "forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).
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http://dx.doi.org/10.18502/jovr.v15i2.6740DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151508PMC
April 2020

Endoscopic-Assisted Lateral Orbitotomy for Large Orbital Roof Dermoid Cysts With Dural Invasion.

Ophthalmic Plast Reconstr Surg 2020 Sep/Oct;36(5):508-511

Eye Department, Eye and Skull Base Research Center, The Five Senses Institute, Iran University of Medical Science, Tehran, Iran.

Purpose: To demonstrate the technique and report the results of endoscopic-assisted lateral orbitotomy for 6 patients with huge intraorbital dermoid cyst causing orbital roof bone erosion and dural invasion.

Methods: Patients had unilateral cystic tumor with proptosis and hypoglobus for more than 6 months. There was no compressive optic neuropathy. Lateral orbitotomy procedure was performed from 2004 to 2016 by 1 surgeon. Cysts were dissected, and fluid content was aspirated to reduce the size. Solid contents were then suctioned, its cavity was repeatedly irrigated, and orbital part of epithelial lining was removed. The remained epithelial lining and keratinized content at the orbital roof (abutting the dura) were removed using the rigid endoscope lenses (4 mm, 0° and 30°) and curettage. Orbital tissue was pulled away from the roof (inferior) by an assistant surgeon to make a space for introducing the lens and curette. The surgical field was frequently irrigated. No orbital drain was used, and all the patients were discharged on the same day after 8-10 hours of observation. Skin sutures were removed 1 week later.

Results: They were 4 men and 2 women with age range of 19-48 years. A large superolateral orbital tumor with roof erosion and dural invasion was observed on imaging. Procedures were performed uneventfully. Dermoid was the pathological diagnosis. While one patient lost to follow up after 1 week, others had 6-18 months follow-up time with no recurrence.

Conclusions: Endoscopic-assisted lateral orbitotomy approach provided a good field of view, illumination, and magnification to totally remove all the content and epithelial lining of very large orbital roof dermoid cysts with dural invasion.
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http://dx.doi.org/10.1097/IOP.0000000000001661DOI Listing
March 2021

Diabetic versus non-diabetic rhino-orbito-cerebral mucormycosis.

Mycoses 2020 Jun 18;63(6):573-578. Epub 2020 Apr 18.

Eye and skull base Research Centers, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Objective: To compare the characteristics and outcomes of rhino-orbito-cerebral mucormycosis (ROCM) in diabetic versus non-diabetic patients.

Method: It is a retrospective comparative case series on consecutive patients with biopsy-proven ROCM. Systemic and ophthalmic manifestations, imaging, management and final outcomes were compared between diabetic versus non-diabetic ROCMs referred the eye clinic of a university-based hospital (2008-2016).

Results: Forty-three diabetics (55 eyes) with mean age of 54.6 (SD:12.5) years and 20 non-diabetics (24 eyes) with mean age of 57.5 (SD:13.8) years were enrolled. Patients' survival was observed in 51% of diabetics and 70% of non-diabetics (P = .1). The mortality rate was 7.4 times (CI95%: 1.85-29.96) higher in diabetic ROCM treated with non-liposomal amphotericin (P = .01). Exenteration did not significantly change the mortality rate in either group. Globe survival was 40% and 50% in diabetics and non-diabetics (P = 1), respectively. Vision survival was observed in 20% of diabetics and 37% of non-diabetics (P = .2).

Conclusion: Patients', globe and vision survivals were not different between diabetic and non-diabetic patients with ROCM. They were 51%, 40% and 20% in diabetic and 70%, 50% and 37% in non-diabetic ROCM.
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http://dx.doi.org/10.1111/myc.13078DOI Listing
June 2020

Pressure ulcer following circumferential head dressing.

Orbit 2020 Oct 30;39(5):350-356. Epub 2020 Jan 30.

Eye Research Center, The Five Senses Institute, Iran University of Medical Sciences , Tehran, Iran.

Purpose: To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.

Methods: Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.

Results: Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.

Conclusion: Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.
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http://dx.doi.org/10.1080/01676830.2020.1719521DOI Listing
October 2020

Postoperative Blepharoptosis After Modern Phacoemulsification Procedure.

Am J Ophthalmol 2020 05 9;213:17-23. Epub 2020 Jan 9.

Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To investigate the frequency of transient (1 month) and persistent (at least 6 months) postoperative ptosis following clear corneal sutureless phacoemulsification and to analyze the factors affecting them.

Design: Cohort study.

Methods: Patients who underwent phacoemulsification cataract surgery from October 2016 to June 2018 in a tertiary center were enrolled. Margin reflex distance 1 (MRD1), MRD2, and levator function were measured and facial photography was taken before, 1 month, and at least 6 months after the surgery. Clinical ptosis was defined as any postoperative drop of MRD1 and clinically significant ptosis as MRD1 drop of ≥2 mm. Photo-based ptosis was assessed by a masked oculofacial plastic surgeon at the end of the study.

Results: A total of 234 patients (313 eyelids) were included. The majority of surgeries were performed by senior residents (65.5%, 205/313) and under topical anesthesia (78.0%, 244/313). Persistent clinical, clinically significant, and photo-based ptosis were 25.4% (71/279), 3.2% (9/279), and 3.3% (9/276). Eyelids with persistent postoperative ptosis showed a significantly (P = .03) lower preoperative levator function (13.9 vs 15.8 mm). No other factor was significantly different between the eyelids with and without postoperative ptosis.

Conclusion: Persistent clinically significant ptosis was observed in more than 3% of patients undergoing clear corneal sutureless phacoemulsification cataract surgery. It should be counseled preoperatively. Lower preoperative levator function was significantly associated with a higher frequency of postoperative ptosis. Duration of surgery, level of surgeons, and other variables did not have any significant effect on the frequency of postoperative ptosis.
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http://dx.doi.org/10.1016/j.ajo.2019.12.023DOI Listing
May 2020

Visual Outcomes of Adding Erythropoietin to Methylprednisolone for Treatment of Retrobulbar Optic Neuritis.

J Ophthalmic Vis Res 2019 Jul-Sep;14(3):299-305. Epub 2019 Jul 18.

Ophthalmology Department, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To compare the short-term visual function results and safety of erythropoietin as an add-on to the standard corticosteroid therapy in retrobulbar optic neuritis (RON).

Methods: In this prospective pilot study, adult patients with isolated RON with less than 10 days of onset were enrolled. Patients were consecutively assigned to standard intravenous methylprednisolone treatment either in combination with intravenous erythropoietin (20,000 units/day for three days) (group-1) or intravenous methylprednisolone alone (group-2). Primary outcome measure was best-corrected visual acuity (BCVA), which was assessed up to 120 days from the day the treatment was begun. Systemic evaluations were performed during and after treatment.

Results: Sixty-two patients with RON (mean age = 26.6 5.77 years; range = 18-40 years) were enrolled into the study (group-1, = 35; group-2, = 27). BCVA three months after the treatment was 0.19 0.55 logMAR and 0.11 0.32 logMAR in group-1 and group-2, respectively (95% CI: 0.61 0.16; = 0.62). Change in BCVA after three months was 2.84 3.49 logMAR in group-1 and 2.46 1.40 logMAR in group-2 (95% CI: 0.93 1.91; = 0.57). Pace of recovery was not significantly different between the groups. No complications were detected among patients.

Conclusion: Intravenous erythropoietin as an add-on did not significantly improve the visual outcome in terms of visual acuity, visual field, and contrast sensitivity compared to traditional intravenous corticosteroid. This pilot study supports the safety profile of intravenous human recombinant erythropoietin, and it may help formulate future investigations with a larger sample size.
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http://dx.doi.org/10.18502/jovr.v14i3.4786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815326PMC
July 2019

Change in Lower Eyelid Position After Ptosis Repair in Patients With Unilateral Myogenic Versus Aponeurotic Blepharoptosis.

Ophthalmic Plast Reconstr Surg 2019 Jul/Aug;35(4):383-386

Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To compare preoperative and postoperative lower eyelid scleral show in patients with unilateral myogenic (MP) and aponeurotic (AP) ptosis, analyze the factors correlated with them, and assess the rate of postoperative lower eyelid symmetry in both groups.

Methods: Patients (older than 5 years old) with unilateral MP (58) and AP (20) were included from June 2015 to April 2017. Excluded were patients with previous eyelid surgery, strabismus, levator function of ≤3, and associated procedures. Margin reflex distance (MRD) 1 and 2 and levator function were measured by the same observer before and at least 6 months after the ptosis repair.

Results: Lower scleral show was observed in 56.8% and 80% of MP and AP, respectively. Margin reflex distance 2 was significantly (r = -0.37, p = 0.002) associated with MRD1 in the MP group (multiple regression analysis). Both groups showed a significant improvement of MRD2, postoperatively resulting in symmetric MRD2 in 91.4% of MP and 80% of AP group. It was not changed in 43% of MP and 25% of AP group. Multiple regression analysis showed that preoperative MRD2 was the only significant factor associated with postoperative improvement of scleral show in the MP group.

Conclusions: Lower scleral show was significantly improved after ptosis repair in both MP and AP. The more severe MP was significantly associated with more severe preoperative scleral show. Preoperative MRD2 was the only factor predicting postoperative improvement of scleral show in the MP. No factor was significantly associated with MRD2 in the AP group.
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http://dx.doi.org/10.1097/IOP.0000000000001287DOI Listing
December 2019

Postoperative levator function change in patients with unilateral myogenic versus aponeurotic blepharoptosis.

J Plast Reconstr Aesthet Surg 2019 Oct 27;72(10):1675-1681. Epub 2019 Jun 27.

Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Sattarkhan Niayesh St., Tehran 1455364, Iran.

Purpose: To compare the change in levator function (LF) after levator resection in patients with unilateral myogenic (MP) and aponeurotic ptosis (AP).

Methods: In a prospective study, patients of >5 years old were included from June 2015 to April 2017. Other types of ptosis, associated strabismus and previous eyelid surgery were excluded. Eyelid examination and photography were performed before and at least 6 months after surgery. Success was defined as Margin reflex distance 1 (MRD1) of within 0.5 mm of the unoperated side. All procedures (levator resection) were performed by or under supervision of one surgeon.

Results: There were 58 patients in the MP (mean age: 19.2 years) and 20 in the AP (mean age: 49.5) group with median follow up of 10 months. LF was significantly improved from 5.8 to 7.3 mm in the MP and from 11.8 to 13.6 mm in the AP group. LF improvement was not observed in 17.2% of MP and 25% of AP group (P = 0.5). Mean preoperative LF was significantly (Odd ratio = 1.8) higher in patients with than without LF improvement in the MP group. It was significantly reverse in the AP group (Odd ratio = 0.38). A significantly positive (r = 0.30) and negative (r = -0.72) correlations were observed between preoperative LF and LF improvement in the MP and AP groups, respectively. Success was observed in 90% of AP and 84.5% of MP group. In order of frequency, undercorrection, overcorrection, and contour abnormality were the reasons for failure. No variable significantly affected the success rate in either group.

Conclusion: Majority of MP and AP showed postoperative LF improvement. While higher preoperative LF was significantly correlated with LF improvement in the MP, it was reverse in the AP group. Success rate was not significantly different between the groups and no factor significantly affected the success in either group.
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http://dx.doi.org/10.1016/j.bjps.2019.06.005DOI Listing
October 2019

Supine Test: A New Test for Detecting Lacrimal Gland Prolapse Before Upper Blepharoplasty.

Ophthalmic Plast Reconstr Surg 2019 Nov/Dec;35(6):581-585

Eye Department, Eye Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Purpose: To introduce a new (Supine) test and assess the values of lateral eyelid bulging for diagnosis of lacrimal gland (LG) prolapse before upper blepharoplasty.

Methods: In a prospective case series (2011-2017), lateral eyelid bulging and Supine Test were recorded, preoperatively. Lacrimal gland prolapse was graded as mild (<4 mm), moderate (4-7 mm), and severe (>7 mm). A few spots of cautery on LG capsule was performed in patients with bilateral mild and suture repositioning in unilateral or bilateral moderate and severe LG prolapse. Patients with asymmetric LG prolapse were treated based on more severe grade, bilaterally.

Results: Included were 1,207 patients. Frequency of positive Supine Test (11.8%, 142/1,207) increased from almost 10% in patients less than 41 years of age to 15% in more than 60 years of age. Their mean age was significantly older, and 53.2% showed asymmetric LG prolapse. Septum was just opened in patients with positive Supine Test, and all had LG prolapse of ≥3 mm (mean: 5.6 mm, range: 3-14 mm). Mild LG prolapse, moderate LG prolapse, and severe LG prolapse were observed in 22.5%, 62.6%, and 14.7% of the patients, respectively. Mean follow-up time was 22 months (12-60 months). Recurrence was observed in 1 patient (bilateral) after suture repositioning. Lateral eyelid bulging had a high negative (96.2%) and low positive (30.6%) predictive value when compared with the Supine Test.

Conclusions: Positive Supine Test means LG prolapse of ≥3 mm (100% positive predictive value). Negative lateral eyelid bulging was highly predictive of no LG prolapse.
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http://dx.doi.org/10.1097/IOP.0000000000001397DOI Listing
January 2020

How reliable is the lacrimal scintigraphy report? An inter-observer agreement and reliability study.

Int J Ophthalmol 2019 18;12(3):401-406. Epub 2019 Mar 18.

Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran 14455-364, Iran.

Aim: To assess the inter-observer agreement and reliability as well as intra-observer repeatability for lacrimal scintigraphy (LS) reports with and without considering the irrigation test results.

Methods: A prospective, observational, cross sectional study. Two masked clinicians (lacrimal surgeon and nuclear medicine specialist) independently reported 100 LS images (50 patients of >6 years of age with unilateral anophthalmic socket) in a university hospital. The lacrimal surgeon performed a diagnostic irrigation test and repeated the report of the same LS images 2y after the first report (intra-observer agreement). A weighted Kappa analysis was performed to determine inter-observer agreement and reliability as well as intra-observer repeatability for the type (normal, partial and complete obstruction) and location (presac, preduct, and intraduct) of the obstruction. Subgroup analysis was also performed with consideration of irrigation test results.

Results: A significantly moderate agreement was found between lacrimal surgeon and nuclear medicine specialist for both the type (Kappa=0.55) and location (Kappa=0.48) of obstruction. Agreement values were higher for the type (Kappa=0.61 0.41) and location (Kappa=0.56 0.31) of obstruction in cases with normal than abnormal irrigation test. Strong and significant intra-observer (lacrimal surgeon) repeatability was found for both the type (Kappa=0.66) and location (Kappa=0.69) of obstruction. LS showed no to slight reliability based on irrigation test.

Conclusion: A moderate agreement is found between lacrimal surgeon and nuclear medicine specialist regarding the interpretation of LS suggesting the importance of consensus groups among nuclear medicine specialists and lacrimal surgeons to create a common language for interpretation of LS. Intra-observer repeatability is strong for the lacrimal surgeon.
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http://dx.doi.org/10.18240/ijo.2019.03.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6423397PMC
March 2019
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