Reply on Lee et al., Tight orbit syndrome: a previously unrecognized cause of open-angle glaucoma

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Editor, W e read with interest the article ‘Tight orbit syndrome: a previously unrecognized cause of openangle glaucoma,’ by Lee et al. (2010). The authors have described their observation with some patients characterized by the tight eyelids pressing firmly against the globe, limiting globe exposure during tonometry, gonioscopy and surgery, and intractable glaucoma with a poor visual prognosis, and defined as tight orbit syndrome. We appreciate the effect of eyelid on intraocular pressure (IOP) when the eyelid is squeezed by the patient or it is pressed against the globe by examiner. The authors reported six patients (two Asian, four Caucasian) with tight eyelid and intractable glaucoma, but they demonstrated the normalization of the IOP after canthotomy and decompression surgery following Ahmed implant surgery in only one case of them. They also measured the orbital volume in three cases, but the measurements were not conclusive. Therefore, we don’t think they defined ‘tight orbital syndrome’ precisely. We propose racial and individual variability of eyelid tension considered to define ‘tight orbital syndrome’. Yuzuriha et al. (2000) reported that a robust ligamentous structure was observed in 46% of Japanese and it determined puffier eyelids and a narrower palpebral fissure in the Asian eye. We also observe many Asian patients who have very narrow palpebral fissure and thick eyelid, and it makes us feel difficulty to measure IOP in clinics. Because most of them are not related to high IOP, the term ‘tight eyelid’ should be defined more clearly. We also suggest the orbital measurements, such as exophthalmometry and axial length of globes, should be included to explain the eyelid tension. Because the orbital volume in this study was estimated for bony orbit, it doesn’t reflect the relationship between the globe and the eyelid. Exophthalmometry would be the one of most important measurements for explaining the relationship. We believe thoughtful consideration for racial and individual variability of eyelid tension, orbital examination measures affecting eyelid tension, and the evidence suggesting the normalization of IOP by reducing the eyelid tension by surgery are needed to define the new disease entity.