Mehmet Goksel Ulas

Aims: To evaluate long-term clinical outcomes and factors associated with recurrence after nasolacrimal drainage procedures with bicanalicular silicone intubation. Methods: This retrospective cohort included 1576 patients (2094 eyes) treated between 2008 and 2025 at a tertiary referral center. All tubes underwent square-knot fixation without additional intranasal fixation; no comparator group was available. Success required a Munk score of 0–1 and patent irrigation at final follow-up, coinciding with tube removal for eyes followed for only three months. Generalized estimating equation (GEE) logistic regression accounted for bilateral eye correlation. Sensitivity analyses compared pediatric and adult patients, repeated multivariable GEE in adults, and stratified follow-up (3–12, 13–24, and >24 months). Results: Recurrence occurred in 5.9% of eyes (123/2094), ranging from 5.5% after external dacryocystorhinostomy to 13.2% after probing with intubation (p=0.016). External dacryocystorhinostomy comprised over 90% of procedures, limiting comparisons. Epiphora, postoperative complications, and tube exposure occurred in 6.7%, 11.0%, and 5.3%, respectively; exposure was not significantly associated with recurrence. Multivariable GEE identified associatio with probing [odds ratio (OR) 2.79, 95% confidence interval (CI) 1.22–6.37; p=0.015], increasing age (OR 1.01, 95% CI 1.00–1.03; p=0.048), and attending-surgeon procedures (OR 1.69, 95% CI 1.07–2.69; p=0.026). Recurrence was higher with longer documented follow-up. Conclusion: Standardized square-knot fixation was accompanied by 5.9% recurrence and 11.0% postoperative complications. Associations are descriptive and hypothesis-generating given subgroup imbalance, incomplete covariate information, variable follow-up, and residual confounding. The attending-surgeon association may reflect case selection or other unmeasured factors. These findings do not establish causality, fixation superiority, comparative effectiveness, or surgeon performance.

Objective: To evaluate the effect of Müller Muscle–Conjunctival Resection (MMCR) on pupil diameter under different lighting conditions and to evaluate whether MMCR is associated with measurable postoperative changes in pupil diameter under different lighting conditions in patients with blepharoptosis.Material and Methods: This retrospective clinical study included 34 eyes of 34 patients who underwent MMCR for mild-to-moderate ptosis with good levator function and a positive phenylephrine test. All surgeries were performed by a single experienced surgeon. Preoperative and postoperative (1 and 3 months) assessments included margin reflex distance-1 (MRD-1), comprehensive ophthalmic examination, and static pupillometry using an infrared-based device. Scotopic (0.04 lux), mesopic (4.0 lux), and photopic (40.0 lux) pupil diameters were recorded under standardized environmental conditions. Repeated measurements were analyzed using the Friedman test with Bonferroni-corrected post hoc comparisons. A p value < 0.05 was considered statistically significant.Results: The present study comprised 34 eyes from 34 patients, predominantly female (59%), with 20 (59%) of the patients undergoing right eyelid surgery and 14 (41%) undergoing left eyelid surgery. The etiology of ptosis was categorized as follows: congenital ptosis, 28 patients (82%); involutional ptosis, 4 patients (12%); and neurogenic ptosis, 2 patients (6%). The mean patient age was 30.82 ± 11.92 years. Mean levator function was 16.05 ± 2.32 mm. MRD-1 increased significantly from 2.35 ± 0.19 mm preoperatively to 3.52 ± 0.17 mm at 1 month and 3.82 ± 0.15 mm at 3 months postoperatively (p < 0.001). In contrast, no statistically significant differences were observed between preoperative and postoperative scotopic, mesopic, or photopic pupil diameters at any time point (all p> 0.05). No clinically relevant pupillary abnormalities or ocular surface complications were detected. One eyelid with inadequate correction underwent subsequent levator surgery. Conclusions: MMCR significantly improved eyelid height without detectable statistically significant changes in pupil diameter under varying lighting conditions. These findings may have implications for the surgical outcomes of refractive and ptosis surgeries. However, further prospective studies with larger patient populations are required to confirm these observations.

Frontalis sling surgery (FSS) is the standard treatment for congenital blepharoptosis with poor levator function; however, long-term failure and material-related complications are common, particularly with silicone slings. Evidence regarding optimal revision strategies after failed silicone FSS remains limited. This study evaluated the anatomical outcomes, ocular surface safety, and patient satisfaction following maximal levator resection surgery (MLRS) performed after silicone frontalis sling removal. This retrospective study included 20 eyes of 17 patients who underwent MLRS following silicone frontalis sling removal between 2019 and 2023. Preoperative and postoperative assessments included best-corrected visual acuity, margin reflex distance-1 (MRD-1), levator function, lagophthalmos, corneal fluorescein staining, punctate epithelial keratopathy, and patient satisfaction. Postoperative evaluations were performed at 1 week, 1 month, 3 months, and 6 months. Statistical analyses were conducted using paired and repeated-measures tests, with a significance level set at p < 0.05. The mean age at the time of MLRS was 11.05 ± 5.94 years, and the mean preoperative levator function was 4.85 ± 2.49 mm. Revision surgery was indicated for undercorrection in 18 eyes (90%) and conjunctival complications in 2 eyes (10%). Mean MRD-1 increased significantly from 0.25 ± 0.85 mm preoperatively to 2.55 ± 0.60 mm at 6 months postoperatively (p < 0.001), with stable values across follow-up visits. Lagophthalmos increased slightly postoperatively but did not differ significantly from preoperative measurements (p > 0.05). Mild corneal surface changes were observed in the early postoperative period and were successfully managed with medical treatment. Additional revision surgery was required in 2 eyes (10%). Most patients and their parents reported high satisfaction, with dissatisfaction primarily related to insufficient postoperative eyelid elevation. MLRS following silicone frontalis sling removal is associated with significant and stable improvement in eyelid position, with acceptable ocular surface safety and high patient satisfaction in selected patients across a range of levator function values. However, given the retrospective design, small sample size, and lack of a comparative control group, these findings should be interpreted with caution. MLRS may be considered as a potential revision option rather than a definitive or superior approach.

Background/Objectives: To evaluate margin reflex distance-1 (MRD-1), inter-eyelid symmetry, functional visual parameters, and cosmetic outcomes following Müller Muscle–Conjunctival Resection (MMCR) in selected pediatric patients with mild-to-moderate blepharoptosis, good levator function, and a positive 2.5% phenylephrine test. Methods: This retrospective observational study included pediatric patients (p < 0.05 considered statistically significant. Results: Fifty patients (55 eyes; mean age 13.16 ± 4.04 years) were included. Mean preoperative MRD-1 increased significantly from 1.83 ± 0.89 mm to 2.97 ± 0.83 mm at 6 months (p < 0.001). Postoperative MRD-1 at 6 months showed a significant correlation with the phenylephrine response. In unilateral cases, excellent or satisfactory postoperative symmetry was achieved in 83.6% of eyes. Bilateral cases demonstrated comparable MRD-1 elevation with satisfactory contour and high patient/parent satisfaction. Transient lagophthalmos improved over time. No overcorrection, exposure keratopathy, or significant ocular surface complications were observed. Revision surgery was required in 8.9% of unilateral cases. Conclusions: MMCR is a safe and effective option for appropriately selected pediatric patients, providing predictable eyelid elevation, good symmetry, and low complication rates when functional indications are present.

To evaluate the anatomical, functional, and aesthetic outcomes of phenylephrine-guided bilateral Müller muscle-conjunctival resection (MMCR) using a standardized resection algorithm designed to optimize eyelid symmetry by preoperatively accounting for Hering's phenomenon in patients with mild-to-moderate ptosis METHODS: This retrospective clinical study included patients with good levator function and a positive phenylephrine test who underwent simultaneous bilateral MMCR planned according to a phenylephrine-based resection algorithm. The protocol aimed to simulate postoperative eyelid position and unmask contralateral ptosis related to Hering's law, thereby enabling individualized bilateral surgical planning in a single session. Preoperative and postoperative best-corrected visual acuity (BCVA), margin reflex distance1 (MRD-1) and upper eyelid symmetry were evaluated at postoperative months 1 and 3 RESULTS: A total of 118 eyes from 59 patients (31 females, 28 males) were included. The mean preoperative MRD-1 was 1.24 ± 0.95 mm in the right eye and 1.32 ± 0.84 mm in the left eye. At postoperative month 3, the mean MRD-1 increased to 2.68 ± 0.91 and 2.61 ± 0.78, respectively. Comparison of preoperative and postoperative MRD-1 values demonstrated demonstrated a statistically significant improvement in both eyes at months 1 and 3 (p < 0.001 for each eye). Postoperative MRD-1 outcomes were not significantly different when stratified by the magnitude of the preoperative phenylephrine response (p = 0.32 for right eye, p = 0.06 for left eye). Excellent eyelid symmetry was achieved in 44 patients (74.6%), satisfactory symmetry in 12 (20.3%), and poor symmetry in 3 patients (5.0%). Revision surgery was required in 5 patients (8.4%) during follow-up CONCLUSION: Phenylephrine-guided bilateral MMCR using a standardized resection algorithm is a safe, effective, and highly predictable surgical approach for achieving optimal eyelid symmetry in patients with mild-to-moderate ptosis. Preoperative simulation of postoperative eyelid position by accounting for Hering's phenomenon allows accurate bilateral surgical planning in a single session and may reduce the need for secondary procedures, making this technique a strong first-line alternative to more invasive ptosis repair methods.

To evaluate the surgical outcomes of blepharoptosis in patients with no light perception (NLP) who used prostheses and to assess eyelid symmetry and functional improvement following appropriate surgical management. This retrospective study included 15 patients with prosthesis-related ptosis treated between 2020 and 2024. Demographic characteristics, prosthesis type and duration of use, type of ptosis, preoperative levator function, and surgical technique were recorded. Margin reflex distance 1 (MRD-1) was measured preoperatively and at postoperative 1 week, 1 month, 3 months and 6 months, using standardized digital photographs. Eyelid symmetry, complications, and need for revision surgery were evaluated. Repeated measurements were analyzed using the Friedman test with Wilcoxon signed-rank post hoc comparisons. The mean age was 40.13±17.41 years (range 15–70 years); 10 patients were female and 5 were male. The mean preoperative levator function was 11.80±3.52. Regarding the underlying causes of eye loss/prosthesis use, 9 (60.0%) were due to trauma, 1 (6.7%) was due to infection, 2 (13.3%) were due to glaucoma, and 3 (20.0%) were due to other causes. 12 patients had evisceration, and 3 patients used a prosthesis over a phthisis bulbi eye. 13 patients underwent Müller Muscle-Conjunctival Resection (MMCR) and 2 patients underwent levator surgery. MRD-1 increased significantly from 1.20±0.94 mm preoperatively to 3.27±0.70 mm at 6 months. Further analysis to determine the source of the difference revealed statistically significant differences between preoperative MRD-1 and postoperative MRD1 at 1 week, 1 month, 3 months, and 6 months. The Friedman test showed a significant improvement over time (p<0.001). Technique comparisons were exploratory due to the small levator subgroup. No significant difference was found between the duration of eye prosthesis use and preoperative MRD-1 (p=0.761). MRD-1 improved from 1.20±0.94 mm preoperatively to 3.27±0.70 mm at 6 months, and eyelid symmetry (≤1 mm) was achieved in 86.6% of patients, demonstrating that ptosis of the upper eyelid in ocular prosthesis patients can be effectively corrected with appropriately selected surgical techniques based on levator function.

Purpose: To assess the retinal and choroidal microvascular changes in patients with benign essential blepharospasm (BEB) and to investigate the factors that may be effective on microvascularity. Methods: This study included patients with BEB and healthy controls. All participants underwent a comprehensive examination followed by optical coherence tomography angiography (OCTA). Macular vascular perfusion density (VPD), foveal avascular zone (FAZ), and subfoveal choroidal thickness (CT) were measured. The clinical findings of the BEB group and the administration of botulinum toxin A (BTx-A) prior to OCTA imaging were recorded retrospectively from the medical records. Results: A total of 16 patients with BEB and 20 healthy controls were included in this study. VPD values in all quadrants of the superficial and deep macular capillary plexus were significantly different in the BEB group compared to the control group (each p-value <0.05). In the choriocapillaris layer, VPD was significantly higher in the superior, nasal, and temporal quadrants compared to the control group (each p-value <0.05). The BEB group exhibited significantly smaller superficial and deep FAZ values compared to the control group, consistent with the observed increase in vascular density (each p-value 0.05) Conclusion: Benign essential blepharospasm may be associated with increased retinal vascular density in the superficial and deep capillary plexus and decreased FAZ area.