Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Case Reports
FIG. 3. A, Low-power photomicrograph (hematoxylin-eosin, ×200) showing irregular distribution of spindle cell areas between mature adipose tissue. B, Photomicrograph showing a hypocellular spindle cell component; the spindle cells are cytologically bland with oval to elongated nuclei and bipolar cytoplasmic processes (hematoxylin-eosin, ×400). C, Diffuse CD34 positivity is evident for the spindle cells (×400). D, S-100 positivity is evident for the adipose tissue with sparing of the spindle cell component (×400).
Psychogenic Unilateral Pseudoptosis Abbas Bagheri, M.D., Ehsan Abbasnia, M.D., Mohammad Pakravan, M.D., Maryam Roshani, M.D., and Mehdi Tavakoli, M.D., F.I.C.O. Abstract: Conversion disorders are among common psychological problems. Pseudoptosis is an uncommon presentation of this category of disorders. Herein, the authors report 2 cases of psychogenic pseudoptosis. The first case is a 21-year-old man who presented with sudden onset of ptosis in his OS 2 weeks previous. The patient reported episodes of left upper eyelid drooping during the last 7 months. The second case is a 10-year-old girl with ptosis onset 6 months previously, after a viral conjunctivitis. In both patients, specific presentations in favor of nonorganic ptosis were observed; all neurological and paraclinical evaluations were normal, and considerable familial or social stressors were found. Both patients received psychological treatment, and no recurrence was observed afterward.
Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Accepted for publication October 20, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Mehdi Tavakoli, M.D.,F.I.C.O., #23, Paydarifard St., Pasdaran Avenue, Tehran 16666, Iran. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000069
C
onversion disorder is defined by DSM-IV as a deficit of sensory or motor function that cannot be explained by a medical condition and where psychological factors are judged to be associated with the deficit because symptoms are preceded by conflicts or other stressors.1 The most common signs of conversion disorder in ophthalmology and neuro-ophthalmology are blindness, diplopia, and gaze palsies. Herein, they report 2 patients with pseudoptosis as a rare manifestation of conversion disorder.2,3 Furthermore, they have discussed about signs and symptoms associated with psychogenic pseudoptosis that help differentiate it from true ptosis.
CASE REPORT The first case was a 21-year-old man who presented with unilateral ptosis. The patient was a worker. He was in low socioeconomic state and married about 8 months ago. There was no history of head or face surgery or trauma. Family history was negative for similar disease. He had sudden-onset ptosis on the left side 2 weeks before presentation. There was no history of fever, trauma, unusual fatigue or weakness of limbs, slurring of speech, voice disorder, or symptoms suggestive of raised intracranial pressure. The history revealed frequent episodes of headache with exacerbation after struggling in family. He remembered periods of ptosis in his left upper eyelid with simultaneous recovery in last 7 months. The amount of ptosis was stable during the daytime. On presentation, examination revealed complete ptosis of the left upper eyelid (Fig. 1A) with no evidence of
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Case Reports
deeper than usual. When the examiner elevated the ptotic left upper eyelid, the patient’s eye moved downward and inward as shown in Figure 2C (Reverse Bell’s phenomenon). Ocular movements were normal in all directions. Slit-lamp examination revealed subepithelial opacities due to previous epidemic keratoconjunctivitis. Corneal sensation, intraocular pressure, and fundus examination were unremarkable in OU. Serum anti-acetylcholine receptor antibody was negative. Orbital and brain CT scan and electromyography of facial muscles were reported normal as well. For the possibility of the psychogenic disorder, placebo intravenous saline injection test was performed, and consequently, her symptoms almost completely disappeared, confirming the diagnosis of psychogenic disorder (Fig. 2D). A few hours later, ptosis recurred. The patient was referred to a pediatric psychologist and treated as conversion disorder. Two months later, complete recovery was seen without any recurrences after 2 years.
DISCUSSION Ptosis is a rare manifestation of conversion disorder, especially in children.2–5 To our knowledge, only 1 case of psychogenic pseudoptosis has been reported in a child.3 Misdiagnosis can impose adverse outcomes including unnecessary diagnostic and therapeutic measures, which are both costly and time-consuming. Furthermore, delayed diagnosis may affects prognosis of improvement in such patients.3,4 There are some diagnostic clues that differentiate psychogenic pseudoptosis from other causes of eyelid drooping:
FIG. 1. A, Drooping of the left eyebrow and higher position of the right eyebrow is seen. Note obvious frontal skin folds on the right side that is due to frontalis muscle action. Prominent skin folds of the left upper eyelid are due to orbicularis oculi muscle spasm. B, The patient uses the frontalis muscle for opening his eyelid fissure. With obstruction of frontalis muscle action, complete bilateral ptosis is seen, and drooping of left eyebrow is resolved. C, Complete resolution of eyelid drooping after treatment.
inflammation. Pupils were equal and reactive to light, with normal accommodation reflex and no relative afferent pupillary defect. Full range of conjugate eye movements was present. Left upper eyelid ptosis coexisted with palpebral skin folds (orbicularis oculi spasm), which was more prominent in upward gaze. Frontal creases were asymmetric and more prominent on right side that shows frontalis muscle contraction, and with its inhibition, eyelid drooping occurred on the right side too (Fig. 1B). The patient was referred to a psychiatrist and was treated as an outpatient in the department of psychology. His symptoms spontaneously disappeared, and there have not been any recurrences after 3 years (Fig. 1C). The second case was a 10-year-old girl with left upper eyelid ptosis since 6 months ago. The patient had a history of bilateral viral conjunctivitis accompanied by inflammation and discharge. Following improvement of conjunctivitis, she developed left upper eyelid ptosis for which she was scheduled for levator resection surgery in another center. Several psychological stress factors including school problems were identified during interview with the patient. On examination, complete drooping of left upper eyelid with prominent palpebral skin folds was present (Fig. 2A). On upward gaze, reverse ptosis was apparent, that is, the location of left lower eyelid was more elevated than right lower eyelid (Fig. 2B). Left palpebral sulcus was normal and was not
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a. Conversion symptoms are clearly associated with psychological problems and environmental stresses; therefore, attending social, economic, and psychological history of the patients is mandatory. Often, there is a close temporal relationship between symptoms and an intense stress or emotion. Environmental factors such as stresses at home and school, poor intrafamilial communications, unresolved grief from child abuse, and other psychological trauma and feelings of parental rejection predispose to the development of a conversion disorder.6–8 b. On clinical examination, no neurologic finding is present. Some atypical findings are helpful in the diagnosis of conversional pseudoptosis including: 1. Eyebrow position: on the ptotic side, there is some eyebrow ptosis, and on the other side, the eyebrow position is slightly more elevated than normal.2–4 This is due to frontalis muscle overactivity that occurs to compensate decreased levator muscle activity on the same side. This was observed in the first case. 2. Eyelid position and Hering’s law; the Hering’s law is working in pseudoptosis too. The law proposes that muscles of OU responsible for each eye’s movements are innervated equally.2 In conversional pseudoptosis, the innervation for levator muscle on the side of ptosis is subconsciously suppressed; so on the other side, there would be some ptosis too. The opposite is true in real ptosis; due to ptosis on 1 side and increased innervation to the weak levator muscle on the ptosis side, the levator muscle on the opposite side is influenced, and there would be an eyelid retraction on the opposite side of ptosis. 3. Skin folds in upper and lower eyelids are due to orbicularis oculi muscle overcontraction, especially in upward gaze or when the patient is requested to forcefully close and then open his eyes.3–5 In true ptosis, the skin of involved eyelid is smooth due to its lower muscle tonicity. This finding was noted in both cases.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Case Reports
FIG 2. A, Prominent skin folds of the left eyelids are due to orbicularis muscle spasm. B, Higher position of left lower eyelid (reverse ptosis) that is more prominent in upper gaze. C, Reverse Bell’s phenomenon. In this patient, the OS has moved downwardly and inwardly. D, Normal eyelid fissures following intravenous placebo injection.
4. Reverse ptosis on the same side defined as the elevation of the lower eyelid position compared with the other side.3,4 Reverse ptosis is accentuated in upper gaze in which, a little rising of the upper eyelid causes compensatory rising of the lower eyelid. This was seen in the second case. 5. Normally, when an attempt is made to forcefully open the closed eyes, an upward and outward movement of the eyes is noticeable; Bell’s phenomenon. If the movement is downward and inward, it is called reverse Bell’s phenomenon (Fig. 2C).2 In conversional pseudoptosis, there is an involuntary attempt for closing the eye, so when the examiner tries to open the eye on the ptotic side, Bell’s or Reverse Bell’s phenomenon would be seen. This finding is not present in true ptosis. This was also seen in the second case. 6. Both in conversional blindness and conversional pseudoptosis, the patient avoids looking directly at the examiner’s eyes. 7. In true unilateral or bilateral ptosis, patients try to open their eyes with their fingers or by chin elevation even temporarily. Both of these patients did not do this 8. In most of reported cases of psychogenic pseudoptosis, ptosis was on the left side.3–5 Conversional disorders are more common on the left side.3 This is an unexplained finding, which was also seen in both of these cases. Various combination approaches such as behavior therapy and psychotherapy program linked to a reward system have been reported to be of benefit.6–8 In conclusion, an attempt to identify the underlying primary reason for the manifestation of the conversion disorder should be made, and once this is identified, further appropriate therapeutic measures should be instituted.
REFERENCES 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994. Available at: http://www.psychiatryonline.com/DSMPDF/dsm-iv.pdf 2. Miller NR. Neuro-ophthalmologic manifestations of nonorganic disease. In: Miller NR, Newman NJ, eds. Walsh & Hoyt’s Clinical
Neuro-Ophthalmology. Philadelphia, PA: Lippincott Williams & Wilkins, 2006:1332–3 3. Peer Mohamed BA, Patil SG. Psychogenic unilateral pseudoptosis. Pediatr Neurol 2009;41:364–6. 4. Hop JW, Frijns CJ, van Gijn J. Psychogenic pseudoptosis. J Neurol 1997;244:623–4. 5. Matsumoto H, Shimizu T, Igeta Y, et al. Psychogenic unilateral ptosis with ipsilateral muscle spasm of orbicular oculi. Acta Med Indones 2012;44:243–5. 6. Zeharia A, Mukamel M, Carel C, et al. Conversion reaction: management by the paediatrician. Eur J Pediatr 1999;158:160–4. 7. Goodyer I. Hysterical conversion reactions in childhood. J Child Psychol Psychiatry 1981;22:179–88. 8. Leary PM. Conversion disorder in childhood–diagnosed too late, investigated too much? J R Soc Med 2003;96:436–8.
Nasal Glioma Presenting With Strabismus Saime Irkoren, M.D., Heval Selman Ozkan, M.D., and Huray Karaca, M.D. Abstract: Congenital midline nasal masses are rare anomalies that occur in about 1 in 20,000 to 40,000 live births. Nasal gliomas are thought to be collections of heterotopic tissue of neurogenic origin, which have lost their intracranial connection.1 It rarely cause ocular distortion and deformity in the medial orbital wall. We describe here a case of a 12-month-old baby girl diagnosed as extranasal glioma at the lateral nasal wall and medial orbital wall Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. Accepted for publication October 25, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Heval Selman Ozkan, M.D., Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000071
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e57
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Case Reports
FIG. 3. A, Low-power photomicrograph (hematoxylin-eosin, ×200) showing irregular distribution of spindle cell areas between mature adipose tissue. B, Photomicrograph showing a hypocellular spindle cell component; the spindle cells are cytologically bland with oval to elongated nuclei and bipolar cytoplasmic processes (hematoxylin-eosin, ×400). C, Diffuse CD34 positivity is evident for the spindle cells (×400). D, S-100 positivity is evident for the adipose tissue with sparing of the spindle cell component (×400).
Psychogenic Unilateral Pseudoptosis Abbas Bagheri, M.D., Ehsan Abbasnia, M.D., Mohammad Pakravan, M.D., Maryam Roshani, M.D., and Mehdi Tavakoli, M.D., F.I.C.O. Abstract: Conversion disorders are among common psychological problems. Pseudoptosis is an uncommon presentation of this category of disorders. Herein, the authors report 2 cases of psychogenic pseudoptosis. The first case is a 21-year-old man who presented with sudden onset of ptosis in his OS 2 weeks previous. The patient reported episodes of left upper eyelid drooping during the last 7 months. The second case is a 10-year-old girl with ptosis onset 6 months previously, after a viral conjunctivitis. In both patients, specific presentations in favor of nonorganic ptosis were observed; all neurological and paraclinical evaluations were normal, and considerable familial or social stressors were found. Both patients received psychological treatment, and no recurrence was observed afterward.
Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Accepted for publication October 20, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Mehdi Tavakoli, M.D.,F.I.C.O., #23, Paydarifard St., Pasdaran Avenue, Tehran 16666, Iran. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000069
C
onversion disorder is defined by DSM-IV as a deficit of sensory or motor function that cannot be explained by a medical condition and where psychological factors are judged to be associated with the deficit because symptoms are preceded by conflicts or other stressors.1 The most common signs of conversion disorder in ophthalmology and neuro-ophthalmology are blindness, diplopia, and gaze palsies. Herein, they report 2 patients with pseudoptosis as a rare manifestation of conversion disorder.2,3 Furthermore, they have discussed about signs and symptoms associated with psychogenic pseudoptosis that help differentiate it from true ptosis.
CASE REPORT The first case was a 21-year-old man who presented with unilateral ptosis. The patient was a worker. He was in low socioeconomic state and married about 8 months ago. There was no history of head or face surgery or trauma. Family history was negative for similar disease. He had sudden-onset ptosis on the left side 2 weeks before presentation. There was no history of fever, trauma, unusual fatigue or weakness of limbs, slurring of speech, voice disorder, or symptoms suggestive of raised intracranial pressure. The history revealed frequent episodes of headache with exacerbation after struggling in family. He remembered periods of ptosis in his left upper eyelid with simultaneous recovery in last 7 months. The amount of ptosis was stable during the daytime. On presentation, examination revealed complete ptosis of the left upper eyelid (Fig. 1A) with no evidence of
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e55
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Case Reports
deeper than usual. When the examiner elevated the ptotic left upper eyelid, the patient’s eye moved downward and inward as shown in Figure 2C (Reverse Bell’s phenomenon). Ocular movements were normal in all directions. Slit-lamp examination revealed subepithelial opacities due to previous epidemic keratoconjunctivitis. Corneal sensation, intraocular pressure, and fundus examination were unremarkable in OU. Serum anti-acetylcholine receptor antibody was negative. Orbital and brain CT scan and electromyography of facial muscles were reported normal as well. For the possibility of the psychogenic disorder, placebo intravenous saline injection test was performed, and consequently, her symptoms almost completely disappeared, confirming the diagnosis of psychogenic disorder (Fig. 2D). A few hours later, ptosis recurred. The patient was referred to a pediatric psychologist and treated as conversion disorder. Two months later, complete recovery was seen without any recurrences after 2 years.
DISCUSSION Ptosis is a rare manifestation of conversion disorder, especially in children.2–5 To our knowledge, only 1 case of psychogenic pseudoptosis has been reported in a child.3 Misdiagnosis can impose adverse outcomes including unnecessary diagnostic and therapeutic measures, which are both costly and time-consuming. Furthermore, delayed diagnosis may affects prognosis of improvement in such patients.3,4 There are some diagnostic clues that differentiate psychogenic pseudoptosis from other causes of eyelid drooping:
FIG. 1. A, Drooping of the left eyebrow and higher position of the right eyebrow is seen. Note obvious frontal skin folds on the right side that is due to frontalis muscle action. Prominent skin folds of the left upper eyelid are due to orbicularis oculi muscle spasm. B, The patient uses the frontalis muscle for opening his eyelid fissure. With obstruction of frontalis muscle action, complete bilateral ptosis is seen, and drooping of left eyebrow is resolved. C, Complete resolution of eyelid drooping after treatment.
inflammation. Pupils were equal and reactive to light, with normal accommodation reflex and no relative afferent pupillary defect. Full range of conjugate eye movements was present. Left upper eyelid ptosis coexisted with palpebral skin folds (orbicularis oculi spasm), which was more prominent in upward gaze. Frontal creases were asymmetric and more prominent on right side that shows frontalis muscle contraction, and with its inhibition, eyelid drooping occurred on the right side too (Fig. 1B). The patient was referred to a psychiatrist and was treated as an outpatient in the department of psychology. His symptoms spontaneously disappeared, and there have not been any recurrences after 3 years (Fig. 1C). The second case was a 10-year-old girl with left upper eyelid ptosis since 6 months ago. The patient had a history of bilateral viral conjunctivitis accompanied by inflammation and discharge. Following improvement of conjunctivitis, she developed left upper eyelid ptosis for which she was scheduled for levator resection surgery in another center. Several psychological stress factors including school problems were identified during interview with the patient. On examination, complete drooping of left upper eyelid with prominent palpebral skin folds was present (Fig. 2A). On upward gaze, reverse ptosis was apparent, that is, the location of left lower eyelid was more elevated than right lower eyelid (Fig. 2B). Left palpebral sulcus was normal and was not
e56
a. Conversion symptoms are clearly associated with psychological problems and environmental stresses; therefore, attending social, economic, and psychological history of the patients is mandatory. Often, there is a close temporal relationship between symptoms and an intense stress or emotion. Environmental factors such as stresses at home and school, poor intrafamilial communications, unresolved grief from child abuse, and other psychological trauma and feelings of parental rejection predispose to the development of a conversion disorder.6–8 b. On clinical examination, no neurologic finding is present. Some atypical findings are helpful in the diagnosis of conversional pseudoptosis including: 1. Eyebrow position: on the ptotic side, there is some eyebrow ptosis, and on the other side, the eyebrow position is slightly more elevated than normal.2–4 This is due to frontalis muscle overactivity that occurs to compensate decreased levator muscle activity on the same side. This was observed in the first case. 2. Eyelid position and Hering’s law; the Hering’s law is working in pseudoptosis too. The law proposes that muscles of OU responsible for each eye’s movements are innervated equally.2 In conversional pseudoptosis, the innervation for levator muscle on the side of ptosis is subconsciously suppressed; so on the other side, there would be some ptosis too. The opposite is true in real ptosis; due to ptosis on 1 side and increased innervation to the weak levator muscle on the ptosis side, the levator muscle on the opposite side is influenced, and there would be an eyelid retraction on the opposite side of ptosis. 3. Skin folds in upper and lower eyelids are due to orbicularis oculi muscle overcontraction, especially in upward gaze or when the patient is requested to forcefully close and then open his eyes.3–5 In true ptosis, the skin of involved eyelid is smooth due to its lower muscle tonicity. This finding was noted in both cases.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Case Reports
FIG 2. A, Prominent skin folds of the left eyelids are due to orbicularis muscle spasm. B, Higher position of left lower eyelid (reverse ptosis) that is more prominent in upper gaze. C, Reverse Bell’s phenomenon. In this patient, the OS has moved downwardly and inwardly. D, Normal eyelid fissures following intravenous placebo injection.
4. Reverse ptosis on the same side defined as the elevation of the lower eyelid position compared with the other side.3,4 Reverse ptosis is accentuated in upper gaze in which, a little rising of the upper eyelid causes compensatory rising of the lower eyelid. This was seen in the second case. 5. Normally, when an attempt is made to forcefully open the closed eyes, an upward and outward movement of the eyes is noticeable; Bell’s phenomenon. If the movement is downward and inward, it is called reverse Bell’s phenomenon (Fig. 2C).2 In conversional pseudoptosis, there is an involuntary attempt for closing the eye, so when the examiner tries to open the eye on the ptotic side, Bell’s or Reverse Bell’s phenomenon would be seen. This finding is not present in true ptosis. This was also seen in the second case. 6. Both in conversional blindness and conversional pseudoptosis, the patient avoids looking directly at the examiner’s eyes. 7. In true unilateral or bilateral ptosis, patients try to open their eyes with their fingers or by chin elevation even temporarily. Both of these patients did not do this 8. In most of reported cases of psychogenic pseudoptosis, ptosis was on the left side.3–5 Conversional disorders are more common on the left side.3 This is an unexplained finding, which was also seen in both of these cases. Various combination approaches such as behavior therapy and psychotherapy program linked to a reward system have been reported to be of benefit.6–8 In conclusion, an attempt to identify the underlying primary reason for the manifestation of the conversion disorder should be made, and once this is identified, further appropriate therapeutic measures should be instituted.
REFERENCES 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994. Available at: http://www.psychiatryonline.com/DSMPDF/dsm-iv.pdf 2. Miller NR. Neuro-ophthalmologic manifestations of nonorganic disease. In: Miller NR, Newman NJ, eds. Walsh & Hoyt’s Clinical
Neuro-Ophthalmology. Philadelphia, PA: Lippincott Williams & Wilkins, 2006:1332–3 3. Peer Mohamed BA, Patil SG. Psychogenic unilateral pseudoptosis. Pediatr Neurol 2009;41:364–6. 4. Hop JW, Frijns CJ, van Gijn J. Psychogenic pseudoptosis. J Neurol 1997;244:623–4. 5. Matsumoto H, Shimizu T, Igeta Y, et al. Psychogenic unilateral ptosis with ipsilateral muscle spasm of orbicular oculi. Acta Med Indones 2012;44:243–5. 6. Zeharia A, Mukamel M, Carel C, et al. Conversion reaction: management by the paediatrician. Eur J Pediatr 1999;158:160–4. 7. Goodyer I. Hysterical conversion reactions in childhood. J Child Psychol Psychiatry 1981;22:179–88. 8. Leary PM. Conversion disorder in childhood–diagnosed too late, investigated too much? J R Soc Med 2003;96:436–8.
Nasal Glioma Presenting With Strabismus Saime Irkoren, M.D., Heval Selman Ozkan, M.D., and Huray Karaca, M.D. Abstract: Congenital midline nasal masses are rare anomalies that occur in about 1 in 20,000 to 40,000 live births. Nasal gliomas are thought to be collections of heterotopic tissue of neurogenic origin, which have lost their intracranial connection.1 It rarely cause ocular distortion and deformity in the medial orbital wall. We describe here a case of a 12-month-old baby girl diagnosed as extranasal glioma at the lateral nasal wall and medial orbital wall Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. Accepted for publication October 25, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Heval Selman Ozkan, M.D., Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000071
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
