Eyelid Asymmetry Research Articles

Determining the Degree of Perceptible Static Eyelid Asymmetry and Effect of Face Inversion: A Cross-sectional Pilot Study.

To determine the degree of static eyelid asymmetry required to be perceptible and whether this is affected by image inversion. Images of 3 volunteers were digitally manipulated to have eyelid asymmetry of 0.5 mm, 1 mm, or 1.5 mm of 3 different types, upper lid ptosis, upper lid retraction, and lower lid retraction. Forty-nine laypersons stated whether the images were symmetrical or asymmetrical. A separate inversion survey, completed by 29 clinicians, consisted of symmetrical images and 1 mm asymmetrical images, with half being inverted. Upper lid ptosis, upper lid retraction, and lower lid retraction were not detected by most laypeople at 0.5 mm of severity (18.9%, 6.7%, 18.9% detection, respectively) but all 3 were detected by the majority of participants once asymmetry reached 1 mm severity (65.7%, 61.8%, 51.0% detection, respectively) and rose to over 70% identification at 1.5 mm (92.2%, 73.5%, 73.5% detection, respectively). Inversion of the images led to 19.7% lower rates of correct identification of asymmetrical faces compared with images presented in the correct orientation (80.7% asymmetry identified in normal images, 61.0% inverted, p < 0.001). All asymmetries were detectable by a majority of laypersons at a severity of 1 mm. Image inversion decreases a clinician's ability to detect a 1 mm asymmetry, indicating an impaired asymmetry perception in the intraoperative view. This study provides research to counsel patients with varying degrees of eyelid asymmetry.

Head rotation and the perception of eyelid height and contour

PurposeEffective visual perceptual processing is one of the many components of surgical competence. Human face identification is most efficient when viewed upright. However, it is not yet clear how this...

Silicone sling frontalis suspension for congenital ptosis: Outcome of 174 consecutive cases.

Frontalis suspension (FS) is the treatment of choice in congenital ptosis with poor levator function. We report the surgical outcome of FS using a double triangle configuration of silicone slings in children. A retrospective cohort study of all paediatric patients with simple myogenic congenital ptosis repaired with FS over a 12-year period (2009-2020). Each silicone sling was secured by simple knots. Pre- and post-operative margin reflex distance (MRD1 ) measurements were determined from clinical photographs using ImageJ Software. Main outcome measures were improvement in eyelid height, eyelid asymmetry, reoperation rate and timing. One hundred and thirty nine patients (174 eyes) were included, with 35 (25%) having bilateral surgery. Mean (±SD) age was 1.4 ± 1.9 years. Mean follow up time was 32 ± 20.5months. Sixteen patients (11%) had a history of previous ptosis repair surgery. Mean MRD1 improved by an average of 1.5 mm. The final MRD1 in the group of patients who did not have a second procedure was a mean of 2.1 mm. The MRD1 difference between both eyes in all unilateral cases improved from 2.5 mm preoperatively to 1.2 mm at final visit (p < 0.001). In the 123 cases without a history of previous ptosis surgery, repeat ptosis repair was performed in 37 (30%) patients, 34.9 ± 19.9months after the initial procedure. Overall, repeat repair was performed in 47 patients (34%). Double triangle silicone sling frontalis suspension has a favourable outcome in two-thirds of paediatric patients with simple myogenic congenital ptosis. Failed cases can be addressed with a second repair, using either autogenous fascia lata or a second silicone sling.

Corneal Ulcer in a Sheep - Treatment with Third Eyelid Flap

Background: Corneal ulcers are frequently reported in the literature in several species, however, the treatment of traumatic lesions on the corneal surface of ruminants is still poorly described. The use of the third eyelid flap is questioned when applied to deep ulcers, since the technique prevents the evolutionary follow-up of corneal healing and compromises care. However, several authors report its successful use for the treatment of superficial and deep corneal ulcers. This technique protects the ocular surface and prevents the occurrence of new lesions or their aggravation. The aim of this study was to report the treatment of corneal ulcers in sheep through the third eyelid flap associated with the use of topical antibiotics.Case: A 2-year-old Dorper sheep, with ocular discomfort, conjunctival hyperemia and mucopurulent secretion in the left eye, was assisted in a private rural property in the West region of Bahia, Brazil. The owner reported that before seeking veterinary help he used a spray based on oxytetracycline and hydrocortisone, which worsened the animal's condition. Upon inspection, it was observed eyelid asymmetry, slight lateralization of the head to the left, periorbital alopecia on the left face, intense blepharospasm in the left eye, with projection of the third eyelid occurring at times. The ophthalmic examination was performed after application of anesthetic eye drops based on proxymetacaine to reduce eye discomfort. A corneal stromal lesion, edema and fibrovascular tissue in the left eye were identified, but the cause of the lesion was not defined, with lagophthalmia, entropion, dystychiasis or ectopic cilia being ruled out. So, it was suggested that the lesion had occurred by a foreign body, such as dust or feed fiber. The contralateral eye showed no changes, Schirmer 15 mm, no changes in sensory and sensory reflexes and negative fluorescein. No signal clinical disease. Due to the severity of the lesion, it was performed a third eyelid flap associated with drug treatment with ciprofloxacin eye drops, every 8 h for 21 days. The animal was placed in the right lateral decubitus position and palpebral akinesia was achieved with the application of 2 mL lidocaine without vasoconstrictor in the region of the auriculopalpebral nerve. This was followed by the routine performance of the third eyelid flap.Discussion: The delay in seeking veterinary care and the application of spray based on oxytetracycline and hydrocortisone aggravated the lesion, since the corticosteroid delays corneal healing and favors the aggravation of the lesion. After desensitization of the cornea, the animal allowed eye manipulation and it was possible to observe the lesion and choose the best treatment, with option for the third eyelid flap because it is a simple and fast technique, does not require special equipment or materials, ideal for performed in the field and is widely used in the treatment of injuries involving the cornea and, besides that, helps to contain corneal perforation and protect the ocular surface. Corneal debridement was also performed to remove necrotic debris and improve drug action, in addition to using broad-spectrum antibiotic eye drops until complete regeneration of the lesion. Twenty-one days after the surgical procedure, the patient had no ocular discomfort, the flap was removed and no changes in the corneal surface were observed. The treatment was considered satisfactory for the healing of the corneal ulcer, guaranteed the esthetics and visual function of the sheep.Keywords: keratitis, surgery, ciprofloxacin, ocular, ruminant.

Optimization of Diagnosis and Surgical Treatment of Involutional Entropion of the Lower Eyelid

Background: Rolling inwards of the lid margin is called entropion, and is produced by a disparity in length and tone between the anterior skin muscle, and posterior tarso-conjunctival laminae of the eyelid. Involutional, cicatricial, spastic, or congenital are some of the classifications involutional entropion there is general instability of the lid structures with age .A weakness of the posterior retractors of the lid occurs, together with a laxity of the medial and lateral canthal ligaments, accompanied by a loss of posterior support ,as atrophy of the orbital fat leads to enophthalmos. The current treatment modalities for this condition are surgical in nature, although non-surgical temporary medical treatment are also used. It's a commonest types of eyelid asymmetry. Corneal and conjunctival damage may lead to abrasions, scarring, corneal thinning, or corneal neovascularization due to this misalignment. Unilateral or bilateral entropion is possible. Involutional entropion of lower eyelids are common, but cicatricial upper eyelids are common. Entropion of lower eyelid is a much more prevalent than entropion of the upper eyelid.&#x0D; Objective: The purpose is to review the scientific literature on diagnosis and surgical management of involutional entropion of the lower eyelid.&#x0D; Methodology: The data were collected from the various electronic data bases like google scholar, PubMed and various books.&#x0D; Conclusion: After reviewing the articles, we come to the conclusion that the signs and symptoms of involutional entropion are easily manageable by given treatment.

Objective assessment of eyelid position and tear meniscus in facial nerve palsy

ABSTRACT Purpose To evaluate lower lid position and tear meniscus in peripheral idiopathic facial nerve palsy (FNP). Methods A prospective study enrolled patients with peripheral idiopathic FNP and epiphora. Data were collected on patient demographics,House-Brackmann (HB) scale, digital photographs of the face, and tear meniscusat the 1st, 30, and 90 day after onset of FNP. Marginal reflex distance to theupper (MRD1) and lower eyelid (MRD2) were evaluated using ImageJ software.Anterior segment optical coherence tomography(OCT) was performed to measure the tear menis- cus. P< .05 was consideredstatistically significant. Results Sixteen patients were evaluated. The HB scale at presentation was grade III in six patients (37.5%). At 90 day, nine patients(56.25%) were grade I-normal. Three (18.7%) had upper lid retraction, three(18.7%) upper eyelid asymmetry and 7 (43.75%), lower eyelid retraction. Thedifference between MRD2-FNP with MRD2-healthy side was 0.51 ± 1.9 mm at the 1stvisit, decreasing to 0.09 ± 1.47 mm at 90 days (P= .877). Tear meniscusmeasurements were significantly higher in FNP at the 1st visit (P= .001). Thedecrease in MRD2 was statistically correlated with the reduction of the tearmeniscus area (TMA) (r = 0.67; P= .007) at 90 days. No correlation was foundbetween HB and TMA. There is a difference in TMA between age groups at the 1stday(p= .009). Eldest group had higher HB scales. Conclusion Quantitative evaluation of eyelid position and tear meniscus are effective to document the evolution of FNP and can serve as aclue of orbicularis recovery.

Silent sinus syndrome: potentially misleading features that should be recognized

ObjectiveSilent sinus syndrome (SSS) usually manifests clinically as hypoglobus and enophthalmos. Patients may experience different symptoms and may present to an assortment of specialties and delay diagnosis and management. The objective of this article was to describe the different and sometimes misleading signs and symptoms of SSS to improve the level of suspicion and reduce time to diagnosis. MethodsA retrospective consecutive audit of the records of all patients diagnosed with SSS between 2015 and 2019 in the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust. Demographic and clinical data including presentation, diagnosis, and symptoms were obtained from the patients’ medical files. ResultsTen patients were included; mean age was 42.5 ± 11.5 years (range, 16–56 years). Four patients were initially referred to an ophthalmologist with globe asymmetry, diplopia, eyelid asymmetry, or retraction. Three patients were initially referred to an ear, nose, and throat specialist with facial asymmetry or infraorbital paraesthesia. Two patients were referred from the maxillofacial department with an incidental finding, and the last patient was seen initially by the neurology team with headaches. ConclusionSSS has a variable presentation. Patients may have common or misleading signs. Patients may attend different clinics and subspecialties, and physicians should be aware of the broad range of presenting signs in this condition to prevent delay in diagnosis and further morbidity.

The Effect of Sleep Position Preference on Eyelid and Eyebrow Symmetry.

To investigate the relationship between sleep position preference and eyebrow and eyelid position and degree of upper eyelid dermatochalasis. A prospective study evaluating the impact of sleep position on facial asymmetry was conducted at an academic ophthalmology department. Eligibility criteria included the absence of periocular-altering trauma or surgery, contact lens use, or other periorbital disease processes. Patients reported their sleep position preference on a questionnaire. Standardized digital photographs of patients were obtained, and Image J software was used for measurements and converted into millimeters based on a standard corneal limbus-to-limbus ratio. Upper and lower eyelid position, upper eyelid dermatochalasis, and eyebrow position were assessed by the following image-derived measurements: marginal reflex distance 1 (iMRD1), marginal reflex distance 2 (iMRD2), tarsal platform show (iTPS), and central brow position (iBP). These results were compared with the patient reported sleep position preference to determine correlation. Seventy-one patients were enrolled and reported the following sleep position preferences: 28 (right), 24 (left), 13 (both), and 6 (supine). Patients with a right- or left-sided preference demonstrated lower iMRD1 measurements for the preferred sleep side (p < 0.0004) with no other significant difference in periorbital measurements. A larger degree of upper eyelid height (iMRD1) asymmetry was observed among patients with a sleep side preference. Patients with a predominant sleep side preference demonstrate a significant increase in ipsilateral upper eyelid asymmetry and an inferior upper eyelid position on the sleep side. There were no differences noted in lower eyelid position, central eyebrow position, or amount of upper eyelid dermatochalasis.

Efficacy of the Müller Muscle-Conjunctival Resection for the Correction of Unilateral Ptosis following External Levator Operations in Patients with Bilateral Involutional Ptosis.

Patients with aponeurotic blepharoptosis who are treated with external levator advancement may experience complications such as upper eyelid height asymmetry and often require revision surgery. The authors assessed the efficacy of Müller muscle-conjunctival resection in cases with upper eyelid height asymmetry following bilateral external levator advancement. The authors used retrospective analysis of 11 cases between September of 2016 and October of 2018 with eyelid asymmetry following bilateral external levator advancement. Following a positive phenylephrine test, these patients underwent unilateral Müller muscle-conjunctival resection revision surgery to treat the undercorrected eyelid. Preoperative and postoperative marginal reflex distance 1, symmetry outcomes, and clinical outcomes of patients were evaluated after the Müller muscle-conjunctival resection. The average patient age was 54.81 ± 3.95 years (range, 37 to 69 years; median, 56 years); seven patients (63.6 percent) were women. Hering dependency was seen in all patients before the external levator advancement. A total of three patients underwent bilateral external levator advancement simultaneously, and eight patients underwent bilateral external levator advancement sequentially. The phenylephrine test was positive in all patients before the Müller muscle-conjunctival resection. Symmetry outcomes were assessed after the revision surgery as perfect (<0.5 mm), good (≥0.5 to <1 mm), or fair (≥1 mm) in four patients, six patients, and one patient, respectively. An optimal correction was noted in 13 of the 22 eyelids after the revision surgery, whereas eight of the 22 eyelids had minimal undercorrection, and one eyelid had minimal overcorrection. Müller muscle-conjunctival resection revision surgery for treatment of the ptotic eyelid following bilateral external levator advancement is viable and may represent a new alternative among the limited revision techniques. Therapeutic, IV.

Evaluation of upper blepharoplasty outcome-objective measurements and patients` satisfaction

Background/Aim. Upper blepharoplasty is one of the most often performed aesthetic operations and is indicated for periorbital rejuvenation or correction of some functional problems. The aim of the study was to evaluate the outcome of this procedure and to assess patients? satisfaction and possibilities of objective measurement of operative results. Methods. A two-year prospective observational study was conducted among female patients who had upper blepharoplasty done by the same surgeon. Data were collected from medical documentation, questionnaire, and objective measurements conducted via standardized digital photographs taken before and two months after surgery. Tarsal platform show (TPS) and brow fat span (BFS) were measured at three points (P1, P2, P3) before and two months after the surgery. A questionnaire conducted before surgery and two months after it included general complaints considering upper eyelids (visual field narrowing, fallen eyelids, the sensation of heavy eyelids, raising head backward in order to enhance vision, headache), patients? assessment of eyelid asymmetry and an additional questionnaire after surgery included questions for the surgeon and patients concerning satisfaction with treatment outcome. Results. This study involved 50 female patients aged be-tween 33 and 67 years (49.98 ? 8.6 years). There was a statistically significant difference in all points for TPS and BFS measurements before and after the operation. No significant asymmetries were noticed between eyes neither before nor after surgery. There was a statistically significant difference in operation success among 3 age categories in TPS-P1 (?2 = 13.089, df = 2, p = 0.001) and TPS-P2 (?2 = 8.386, df = 2, p = 0.015) with best results achieved in older patients (&gt; 55 years). There was strong positive, statistically significant correlation between patient?s and surgeon?s satisfaction (r= 0.704, p = 0.002), as well as between patients? satisfaction and their age (r = 0.704, p = 0.002). Conclusion. Realistic expectations, adequate information about the surgery and possible complications, are essential to satisfied patients. Objective measurements correlate with patients? satisfaction and together with photographs can be a useful tool in communication with them.

Treatment of Congenital Ptosis in Infants With Associated Amblyopia Using a Frontalis Muscle Flap Eyelid Reanimation Technique.

To determine the efficacy of a frontalis muscle flap eyelid reanimation technique for correction of severe congenital ptosis and associated amblyopia in infants. The authors performed a retrospective chart review of patients 12 months of age or younger with unilateral or bilateral congenital ptosis and associated amblyopia or deemed at high risk for amblyopia due to visual deprivation. Following ptosis repair via a frontalis muscle flap technique, primary outcomes of postoperative eyelid position and amblyopia reversal were assessed. Seventeen eyes of 12 participants were included for study. Seven of these patients had simple congenital ptosis, and the remainder had ptosis as part of a syndrome. Nine were diagnosed with amblyopia preoperatively, and the remaining 3 were too young for acuity testing but had occlusion of the visual axis by the ptotic eyelid in primary gaze. Postoperatively, the mean margin-to-reflex distance 1 was 2.4 mm (range: 0.0-4.0), and 9 patients (75%) demonstrated no evidence of amblyopia. Only 2 patients had eyelid asymmetry greater than 2 mm, which in both cases was due to lack of frontalis activation by the patient secondary to ongoing visual impairment. The most common complication was lagophthalmos in 6 eyes (35.3%), with no significant associated surface keratopathy. The frontalis muscle flap technique may offer a new and effective approach to treating infants with severe congenital ptosis causing poor eyelid excursion and associated amblyopia while avoiding use of an implant.

Loss of Malar Bags in Lower Eyelid in Orbital Blow Out Fracture Reconstruction Following Pre- or Retro-Septal Transconjunctival Incision.

An isolated orbital blow out fracture may require surgical correction by accessing the infraorbital rim through a transconjunctival incision and inserting an orbital plate. The risk for aesthetic complications due to the incision has previously been well described. Sixty patients surgically treated using pre- or retro-septal transconjunctival incisions for isolated orbital blow out fractures were recruited and examined with regards to lower eyelid asymmetry. Forty-seven controls with conservative treatment were recruited and underwent a similar examination. A grading system for malar bags in the lower eyelids was set up to compare the 2 groups. All patients with moderate or severe malar bags on the nonoperated eyelid lost the malar bags on the operated side and developed asymmetry in the lower eyelids. No difference was found between the pre- and retro-septal approach. In this study we describe a new complication related to the transconjunctival incision and highlight the importance of informing patients in need of reconstruction of the orbital walls about the risk of postoperative asymmetry in the lower eyelids.

Classification for treatment urgency for the microphthalmia/anophthalmia spectrum using clinical and biometrical characteristics.

PurposeCurrent clinical classifications do not distinguish between the severity of the MICrophthalmia/Anophthalmia (MICA) spectrum with regard to treatment urgency. We aim to provide parameters for distinguishing mild, moderate and severe MICA using clinical and biometrical characteristics.MethodsWe performed a single‐centre, cross‐sectional analysis of prospective cohort of 58 MICA children from September 2013 to February 2018 seen at the Amsterdam University Medical Center, The Netherlands. All patients with a visible underdeveloped globe were included. We performed full ophthalmic evaluation including horizontal palpebral fissure length, axial length by ultrasound and/or MRI measurements, paediatric and genetic evaluation. Cases were subdivided based on clinical characteristics. Biometrical data were used to calculate the relative axial length (rAL) and the relative horizontal palpebral fissure length (rHPF) compared with the healthy contralateral eye for unilateral cases.ResultsIn previously untreated patients, a strong correlation exists between rAL and rHPF, distinguishing between severe, moderate and mild subjects using rAL of 0–45%, 45–75% and 75%–100%, respectively. Clinical subgroups were randomly dispersed throughout the scatterplot.ConclusionCurrent classifications lack clinical implications for MICA patients. We suggest measuring eyelid length and axial length to classify the severity and determine treatment strategy. The ‘severe’ group has obvious asymmetry and abnormal socket configuration for which therapy should quickly be initiated; the ‘moderately’ affected group has normal socket anatomy with a microphthalmic eye with disturbing asymmetry for which treatment should be initiated within months of development; the ‘mild’ group has a slightly smaller axial length or less obvious eyelid asymmetry for which reconstructive correction is possible, but expansive conformer treatment is unnecessary.

Brow height asymmetry before and after eyelid ptosis surgery

In the setting of upper eyelid ptosis, asymmetric eyebrow position may be observed and may contribute to overall facial asymmetry. In this study, the authors aim to elucidate the prevalence and predictors of brow height asymmetry in the setting of ptosis and to determine the effect of eyelid surgery on brow height asymmetry to guide preoperative evaluation and informed consent. In this cohort study, patients undergoing posterior approach ptosis surgery, unilateral or bilateral, with or without blepharoplasty, were included. Exclusion criteria included heterotropia, history of brow surgery, and history of previous ptosis surgery. Clinically significant eyelid asymmetry was defined as a difference greater than or equal to 1 mm between right and left margin reflex distance 1 (MRD1) values. Brow asymmetry was defined as difference in pupil-to-brow (PTB) distance of greater than or equal to 3.5 mm. The sample included 228 patients. Preoperative brow asymmetry was found in 17.1% of the sample. Notably, half of the patients with preoperative brow asymmetry were found to have postoperative brow asymmetry. Logistic regression indicated that preoperative brow asymmetry was a predictor of postoperative brow asymmetry (odds ratio=17.03, p<0.01). In subgroup analysis of those with preoperative brow asymmetry, postoperative eyelid asymmetry was a predictor of postoperative brow asymmetry (odds ratio=5.58, p<0.01). No variables in the current investigation were found to predict brow symmetry in those with preoperative brow asymmetry. Understanding the limitations of ptosis surgery in altering brow symmetry helps manage patient expectations, prepare informed consent, and guide surgical and postsurgical planning.

Objective Outcomes in Upper Blepharoplasty

GOALS/PURPOSE: The availability of objective outcome measures for facial reconstructive surgery remains lacking. Evaluations submitted by external raters or by patient self-report may be influenced by expert knowledge, emotional antecedent, or implicit attitude. Visual markers that lead to differential perception of patients before and after upper blepharoplasty were explored. By examining the early stages of visual processing that occur when an observer encounters images of affected individuals, we intended to reveal the focus of impression formation, thereby helping surgeons and their patients pinpoint the facial features that are most salient to viewers. METHODS/TECHNIQUE: Eighty images for 13 patients who underwent upper blepharoplasty, with and without lower blepharoplasty and brow lifts, were collected. Photographs were obtained before and after surgical correction (>3 months postoperative). Twenty lookzone regions were mapped onto each facial image, reflecting the esthetic units of the face. Eighty observers examined the images while an infrared eye tracking camera continuously recorded their eye movements. The observers were then asked to rate the image for character attributes (Attractiveness, Trustworthiness, Sociability, Healthy, and Capability, 17 scale). Factorial analysis of variance and Student’s t test analysis were performed to determine significance of differences between groups. Outcomes measured were the total number of eye fixations within different lookzone regions. Eye tracking data of pre- and postoperative images were analyzed and compared. RESULTS/COMPLICATIONS: Thirteen blepharoplasty patients were identified. (1) The surgical intervention was found to increase observers’ attention to the upper eyelid and periorbital area, and to decrease attention to the forehead, lower eyelid, and midcheek areas. (2) The surgical intervention was found to significantly increase the character ratings for all 5 attributes compared to preoperative controls: Sociable 3.66–4.01, Trustworthy 3.91–4.24, Attractive 3.39–3.75, Healthy 4.26–4.66, Capable 4.27–4.56; (P < 0.05) except for Attractive (P = 0.059). (3) For those preoperative images of brow and upper eyelid ptosis that resulted in clinical eyelid asymmetry, observers’ attention was overwhelming drawn to the area of disproportion. (4) Our eye tracking methodology clearly reflects a trend toward normalization of gaze attention following surgical intervention. This finding was associated with the improvement in character assessment of the images in the postoperative cohort of images. CONCLUSION: We provide data illustrating a novel and objective technique to evaluate the effect of reconstructive intervention for the upper eyelid and/or the brow. This information may be used to inform patients about how these areas of facial difference are perceived, and the potential effect that surgical intervention may have on others’ perception of them. This work may assist patients and their surgeons to more meaningfully focus their surgical decision-making priorities.

Levator Pull-Out Suture Technique for Immediate Postoperative Correction of Eyelid Asymmetry After Ptosis Surgery in Asians.

Postoperative eyelid asymmetry is the most common complaint of patients after undergoing blepharoplasty and ptosis correction surgery. Calibrating eyelid asymmetry during ptosis correction surgery is still difficult for surgeons despite the development of innovative procedures. Our levator pull-out suture technique for correcting postoperative eyelid asymmetry after ptosis surgery is introduced. A total of 330 patients who underwent ptosis correction surgery with upper blepharoplasty from 2016 to 2017 were enrolled in our study. All surgeries were performed using the levator pull-out suture technique, and the postoperative eyelid asymmetry was corrected in the outpatient clinic at 2-3days after the operation. Patient satisfaction was evaluated preoperatively and at 1week and 2months postoperatively using a questionnaire. Visual acuity, marginal reflex distance 1 (MRD1), and vertical palpebral fissure length asymmetry were measured preoperatively and compared to values taken postoperatively. Patient satisfaction regarding asymmetry increased from 2.7/5 (preoperatively) to 4.1/5 points (postoperatively). MRD1 and vertical palpebral fissure length increased from 1.1/1.2 and 6.8/6.8mm (preoperatively), respectively, to 2.8/2.9 and 8.5/8.6mm (postoperatively), respectively. The asymmetry of MRD1 and vertical palpebral fissure length before and after surgery were corrected from 0.45/1.81 to 0.01/0.19mm (p < 0.01). Our innovative surgical method of using the levator pull-out suture technique is relatively simple and allows for finer suture adjustments postoperatively to effectively correct eyelid asymmetry, with satisfactory results. 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 .

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.

Upper Eyelid Response to Topical 0.5% Apraclonidine.

To describe the change in upper eyelid position in a self-reportedly normal population after the administration of topical 0.5% apraclonidine in each eye. One hundred self-reportedly normal subjects received a 1-time administration of topical 0.5% apraclonidine in each eye. Digital photographs were taken at baseline and then 30 and 45 minutes following apraclonidine instillation. Marginal reflex distance 1 was determined via image analysis of acquired digital photographs (image-derived measurements are given the prefix "i" in this study). The horizontal corneal diameter was used as a constant measurement scale in each photograph. The mean increase in i-marginal reflex distance 1 post-administration of 0.5% apraclonidine was +0.70 ± 0.60 mm (range, -0.94 to +2.66 mm) after 30 minutes and +0.68 ± 0.59 mm (range, -0.69 to +2.54 mm) after 45 minutes. Of the 200 total eyelids in 100 subjects, 181 (90.5%) had an increase in i-marginal reflex distance 1 at 30 minutes. Of the 100 subjects, 85 (85%) had a bilateral increase in i-marginal reflex distance 1, 4 (4%) had a bilateral decrease, and 11 (11%) had a unilateral increase with a contralateral decrease. Given its predominant small-amplitude upper eyelid elevating effect, topical apraclonidine may be a useful off-label alternative treatment for mild upper eyelid ptosis and in eyelid asymmetry due to eyelid retraction through use in the contralateral eye.

Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma.

Sinonasal inverting papilloma (IP) is a benign but locally aggressive mucosal neoplasm with a high recurrence rate. Extension into the frontal sinus presents surgical challenges for endonasal resection. This study presents an orbitofrontal approach for managing extensive IP. Case series. Four patients seen between 2012 and 2016 with biopsy-proven IP with lateral frontal sinus extension underwent a combined endonasal and transpalpebral approach for tumor resection. Patient demographic data, preoperative characteristics, imaging, and follow-up data were compiled through retrospective chart review. Patients were selected for this approach when the tumor extended to the posterior frontal sinus wall, lateral frontal sinus recess, and orbit. Tumors were first approached endonasally until the frontal recess was reached. A Draf IIB or Draf III procedure was then performed to gain better exposure. Orbitofrontal exposure was achieved through an upper eyelid incision. Miniorbitofrontal craniotomy window was designed based on tumor location. Resection of the frontal and orbital extension was enhanced by endoscopic-assisted dissection through the orbitofrontal window. The transpalpebral approach provided access to all walls of the ipsilateral frontal sinus, the intersinus septum, and the medial aspect of the contralateral sinus. Complete tumor resection was achieved in all patients. There were no orbital complications, no visible eyelid asymmetry or scarring, and all patients had preserved forehead sensation. There were no recurrences on follow-up. Combining a transpalpebral orbitofrontal craniotomy with the endonasal approach allows complete resection of invasive IP with extension into the frontal sinus. This is achieved with great cosmetic results. 4. Laryngoscope, 128:3-9, 2018.

Symmetric tarsal show is crucial in creating upper eyelid symmetry

PurposeTo illustrate different causes of upper eyelid asymmetry and to stress that detection of any asymmetry is important in avoiding an unhappy patient.MethodsPatients want an ‘upper eyelid correction’ and do not know the real cause of the asymmetry, or even did not notice any asymmetry. Different kind of asymmetric appearances of the upper eyelids will be shown and analyzed.ResultsThe upper eyelid has several landmarks. Besides the palpebral aperture, the margin pupil distance and lid crease height, also the margin fold distance/tarsal show, the lid fullness and braw distance needs to be described. An asymmetric tarsal show is often perceived as ptosis. Also bony orbit, eye position, orbital fat and braw position are all important factors influencing the final upper eyelid shape. In some conditions a perfect upper eyelid symmetry is very difficult to achieve or sometimes impossible.ConclusionsGood preoperative assessment is crucial in eyelid surgery, both in primary surgery and in correcting postoperative asymmetry. Good patient counseling is important to create realistic expectations.