Xiaodong Zheng, Tomoko Goto, Atsushi Shiraishi & Yumi Nakaoka
Purpose: To report a new method to analyze sagittal images of the upper eyelid by anterior segment optical coherence tomography (AS-OCT).
Methods: Ninety subjects equally divided into young (20–39 years), middle age (40–59 years), and elderly (60–79 years) group were studied. A sagittal image of the upper eyelid was obtained by AS-OCT (CASIA2, Tomey, Japan) and the following parameters were determined: upper eyelid thickness (UET), the distance between two parallel lines tangential to the apexes of the cornea and the upper eyelid; the upper eyelid angle (UEA) was the angle formed by a line running tangential to the apex of the cornea and a line passing from the apex of the cornea to the apex of the upper eyelid; and the cross-sectional area (CSA), the area from the edge of the eyelid to a point 6 mm above the corneal apex. All parameters were compared among groups and correlation analyses were studied between age and eyelid parameters.
Results: The UET was 2.09 ± 0.58 mm, 2.63 ± 1.04 mm and 2.83 ± 0.83 mm in the young, middle age and elderly group, respectively. The difference between the young and the elderly group was significant (P = 0.014). The elderly group had a significantly larger UEA than that of young group (P = 0.022). The elderly group also had significantly larger CSA than the other two groups (all P < 0.01). The age was significantly correlated with all eyelid parameters.
Conclusions: AS-OCT can be used as a non-invasive and quantitative method of evaluating sagittal images of the upper eyelid.
Vahdani, Kaveh; Rose, Geoffrey E.
Over a 2-year period, a 68-year-old woman suffered multiple recurrences of left giant fornix syndrome during the repeated tailing of intensive topical steroids and antibiotics; she had also undergone surgery to reduce the left upper fornix. After a further recurrence during tailing of topical therapy for bilateral disease, treatment with 4 times daily preservative-free povidone-iodine 5% eyedrops was started—with a marked improvement of symptoms and signs within a week. The patient is maintained, symptom-free, on once-daily povidone-iodine drops and dexamethasone 0.1% drops. The dramatic improvement on topical povidone-iodine therapy might suggest that, as an initial therapy, this might be more effective than the previously-recommended regime of hourly potent topical steroids and antibiotics.
Charles, Norman C.; Belinsky, Irina
A 37-year-old woman underwent excision of a congenital melanocytic nevus of the right lower eyelid margin for cosmetic reasons. She suffered from a severe dry eye syndrome which was partially alleviated with various topical eye drops. Histopathology of the excised tissue displayed flecks of calcium that were present within the immediate subepithelial conjunctival fibrous tissue but not the nevocytes or the cutaneous surface. Unlike calcinosis cutis, wherein calcium is deposited within the cutaneous dermis, calcification of the conjunctival substantia propria is rare and may be related to the dry eye state.
Parvizi, Sahar; Ong, Juling; Abou Rayyah, Yassir; Dunaway, David
Purpose: There are different techniques for medial canthoplasty in blepharophimosis syndrome where individuals have epicanthus inversus and telecanthus leading to typical facial appearances. These methods have potential problems with scarring, epistaxis, and extrusion of metal plates.
Methods: The authors describe a novel technique of medial canthal reconstruction using titanium microplates with microscrew fixation to the anterior lacrimal crest, with effective, safe, and reproducible results.
Results: Seven children with blepharophimosis syndrome underwent medial canthus reconstruction surgery at a single center with the collaboration of a pediatric oculoplastic surgeon and craniofacial plastic surgeon to improve eye opening through correction of the lid contours and telecanthus.
Conclusions: This is a safe, effective, and reproducible technique, with minimal morbidity and rapid postoperative recovery in children. It produces cosmetically acceptable scars and a strong stable reconstruction of the medial canthal insertion.
Bernardini, Francesco P.
The video (see Video, Supplemental Digital Content 1, available at https://drive.google.com/open?id=10uuVCNADWhLRWo_EE8gx5GK2nqz5mATW) demonstrates the technique previously described in the report by Cruz et al. for correction of poor levator function (<4 mm) congenital ptosis.1 Supramaximal levator resection refers to resection of the muscle above the Whitnall ligament. The amount of resection is based on the severity of the ptosis and the measured levator function: the more severe the ptosis and poorer the levator function, the more muscle resection required. The end-point of the surgery is to have the eyelid margin rest 1 to 2 mm below the super limbus with the patient under general anesthesia. In the author’s practice, supra-maximal levator resection has become the procedure of choice for unilateral, poor levator function congenital ptosis.
Blandford, Alexander D.; Bachour, Salam P.; Chen, Rachel; Xu, Lucy T.; Hwang, Catherine J.; Perry, Julian D.
Purpose: To quantify the complete dimensions of the retro-orbicularis oculi fat (ROOF) pad and to determine its relationship to other fat compartments of the forehead.
Methods: The entire forehead of 14 hemifaces of seven fresh frozen human cadavers (four female, three male) was dissected in the subcutaneous and submuscular planes. For each plane, a ruler was placed at the facial midline, and images of the dissection plane were taken at 90° and 45°. Images were analyzed for vertical height, horizontal length, the distance to midline from the point of maximal height, and area for each hemiface of the ROOF and for the entire fat compartment contiguous with the ROOF. A two-tailed t test was conducted between ROOF and ROOF plus the extended fat plane across all measurements. A Wilcoxon nonparametric signed rank test was performed to determine equivalent fat distribution of the extended fat plane over each cadaver’s respective eye.
Results: The deep fat originating from the ROOF consistently extended laterally and superiorly in each specimen, distinctly separated via septae from the deep central, deep lateral, and the deep temporal fat compartments. The color, composition, and distribution of this contiguous deep fat did not differ phenotypically from the traditional ROOF. The extended deep fat plane possessed an average vertical height of 3.09 ± 0.68 cm, average distance to midline from point of maximal height of 3.56 ± 0.53 cm, an average horizontal length of 5.37 ± 0.82 cm, and an average area of 13.40 ± 2.69 cm2. The extended deep fat demonstrated a statistically significant increase in maximal height, length, and total area compared with the ROOF. A Wilcoxon nonparametric signed rank test was nonsignificant (α = 0.01) across all measurements, demonstrating that the extended fat plane was similarly distributed over each eye.
Conclusions: A layer of deep fat originating from the traditionally defined ROOF extends superiorly and laterally beneath the frontalis muscle, separate from the deep lateral, deep central, and deep temporal fat pads. This is the first study to clearly demonstrate a contiguous superficial musculoaponeurotic system layer of fat extending under both the orbicularis oculi and frontalis muscles. This plane of fat is more appropriately described as the retro-orbicularis oculi and frontalis fat.
Maeng, Michelle M.; De Moraes, Carlos Gustavo; Winn, Bryan J.; Glass, Lora R. Dagi
Purpose: To study the effect of periocular steroid use on intraocular pressure (IOP).
Methods: Charts of adult patients with atopic dermatitis or eczema treated with topical periocular steroid creams and ointments from January 1st, 2007 to October 1st, 2017 were reviewed. Patients with the following were excluded: glaucoma, ocular hypertension, known systemic/topical/injectable steroid history, and lack of documented IOP prior to or during treatment with periocular steroid ointment. Patient data were collected regarding gender, treatment regimen, as well as IOP prior to and during treatment. Steroid responders were identified. Statistical analysis was performed using linear mixed effects models adjusting for follow-up time to test the relationship between pre and posttreatment IOP change adjusting for intereye correlations.
Results: Thirty-one patients were identified. Twenty-one were treated bilaterally and 10 unilaterally. Five patients were glaucoma suspects. The mean treatment period was 14.2 weeks with a range of 0.1–83.9 weeks. Patients were treated with fluorometholone (42%), loteprednol etabonate (23%), dexamethasone-neomycin-polymyxin B (13%), hydrocortisone 1% or 2.5% (3%), and tobramycin-dexamethasone (19%). In the combined sample, there was no significant IOP change even after adjusting for follow-up time (mean change: +0.44 mm Hg, p = 0.126). However, eyes with baseline IOP ≥ 14 mm Hg had a significant increase (+0.73 mm Hg/year, p = 0.032). Individual steroid responses included the following: 1 intermediate and 30 low responders, of which 19 patients had an IOP change of <1 mm Hg. One patient had a clinically significant intermediate steroid response of 7 mm Hg.
Conclusions: Periocular steroid treatment causes a statistically significant rise in IOP in eyes with higher baseline IOP measurements, the risk of which increases with follow up. While this change is not always correlated with a clinically significant rise in IOP, clinicians should monitor more closely patients at greatest risk of steroid response.
Heisel, Curtis J.; Heider, Amer; Stewart, Krista J.; Andrews, Christopher A.; Kahana, Alon
Purpose: Congenital ptosis can threaten visual function and is usually treated with surgical correction. This study tests the hypothesis that congenital ptosis involves not only the levator muscle but also the orbital septum, which may tether the eyelid in the primary position.
Methods: A retrospective chart review was performed on 30 patients (41 eyelids) with congenital ptosis who underwent surgical correction that included partial septum excision. Histologic analysis was performed by a masked pediatric pathologist, with grading of septal tissue disorganization and fibrosis based on standard histologic criteria. An independent comparison of histologic grading with clinical ptosis measures was then performed.
Results: Fifteen eyelids demonstrated significant septal fibrosis, 19 were mild, and 7 were not fibrotic. Thirty-six eyelids demonstrated histologic disorganization. Mildly fibrotic eyelids were found to have reduced preoperative levator function than those that were not fibrotic (2.84 ± 1.92 vs. 9.57 ± 4.76 mm; p < 0.0001). Samples that demonstrated significant fibrosis were also found to have reduced preoperative levator function (4.67 ± 2.12 vs. 9.57 ± 4.76 mm; p = 0.0007). Histologically disorganized samples were also found to have a lower preoperative levator function (9.50 ± 6.04 vs. 3.99 ± 2.49; p = 0.0052).
Conclusions: Orbital septae in patients with congenital ptosis demonstrate histologic disorganization and fibrosis. When decreased levator function is observed clinically, septal fibrosis and/or disorganization is likely present. These observations suggest that debulking the fibrotic septum during congenital ptosis surgery may improve outcomes by releasing the eyelid from its congenitally tethered position, improving eyelid elasticity.
Godfrey, Kyle J.; Kally, Peter; Dunbar, Kristen E.; Campbell, Ashley A.; Callahan, Alison B.; Lo, Christopher; Freund, Robert; Lisman, Richard D.
Purpose: To investigate the safety and efficacy of direct, intralesional doxycycline hyclate injection for improving the appearance of cosmetically significant lower eyelid festoons and malar edema.
Methods: An Institutional Review Board approved, retrospective review was performed of 15 consecutive patients with malar edema and/or festoons injected with doxycycline hyclate at a concentration of 10 mg/ml. Pre- and postinjection photographs were reviewed and graded on a scale of 0 to 3 (0: no festoon; 1: small festoon; 2: medium festoon; 3: large festoon) by 2 masked physician observers. Patients were excluded from the final analysis if they received an alternate dose concentration, had incomplete photographic records, or did not follow up. Student t test was used for statistical analysis.
Results: Twenty consecutive treatment areas of 11 patients were included in the analysis. Final follow up ranged from 3 to 104 weeks, with a mean follow up of 22.5 weeks. The average (standard deviation) initial festoon grade of 2.5 (0.58) decreased to 0.9 (0.82) with a p value of <0.001. The average number of injections performed per side was 1.4 (range: 1–2). The mean volume per injection was 0.72 ml (range: 0.15–2.0 ml). Commonly documented subjective complaints were burning sensation with injection, pain, bruising, and erythema. There were no other dermatologic or visual complications following treatment.
Conclusions: These preliminary results suggest that intralesional injections of doxycycline hyclate at a concentration of 10 mg/ml may be an effective treatment option for cosmetically significant lower eyelid festoons and malar edema. Future prospective studies with increased patient numbers, increasing concentrations, combination therapies with local anesthetic or regional nerve blocks, and longer follow up are needed to validate these results and determine optimal injection technique.
DeAngelis, Kendra D.; Rider, Alex; Potter, Whitney; Jensen, Jason; Fowler, Brian T.; Fleming, James C.
Purpose: To analyze the spontaneous eyelid blink and sphincter closure activity of the orbicularis oculi by measuring the horizontal eyelid movement.
Methods: Individuals 18+ years of age, any ethnicity, and gender were recruited. Participants completed a questionnaire to determine eligibility. Exclusion criteria included the following: history of facial trauma, nerve palsy, surgery, use of periorbital neuromodulators or filler within the past year, thyroid eye disease, and eyelid or ocular surface disease. Data were collected from participants by decade. Eyelid blinks were recorded using the FPS 1000HD. The motions of 3 spontaneous blinks in primary gaze were recorded. All blinks were reviewed and one chosen for most accurate analysis. Horizontal palpebral fissure width and its changes of open and closed eye measurements were taken using National Institute of Health ImageJ software version 2.0. The data were subjected to SAS version 9.4 analysis using paired t test, t test, and linear models.
Results: One hundred thirty-six patients were recruited. Fourteen patients were excluded; 122 patients were used in analysis. Ages ranged from 22 to 90 years. Participants were divided into 6 groups according to age (20–29, 30–39, 40–49, 50–59, 60–69, and 70+ years of age). The average horizontal fissure length across all ages was 24.23 mm. Average change in horizontal fissure length decreased 1.42 mm among all ages. There was a statistically significant difference comparing age 20–29 decade to age 70+ decade.
Conclusions: Horizontal fissure length changes with eyelid blink and defines 1 component of the eyelid sphincter.