Lid Fissure Research Articles

Análise morfométrica da fenda palpebral de pacientes com retração palpebral na fase aguda da orbitopatia distireoidiana submetidos à injeção palpebral de toxina botulínica tipo A

To compare morphometric data of eyelid fissure using computerized image analysis before and after application of botulinum toxin type A in patients with eyelid retraction caused by dysthyroid orbitopathy in acute stage. This was a prospective study with 12 individuals that received transcutaneous 5 UI/0.1 ml injection of botulinum toxin in the upper eyelid. They were examined periodically for 6 months. Clinical eyelid examination was performed and recorded using a video camera connected to a microcomputer. Vertical eyelid fissure, upper eyelid margin to reflex distance and the eyelid area showed reduction in the treated eye. A decrease in the levator function of the upper eyelid was observed, and also, a reduction in the difference between the lateral and medial areas. The lower eyelid margin reflex distance did not show any significant differences after the application. Measurements of the contralateral eye increased up to 2 weeks after the application. These results showed a reduction in eyelid retraction and improving the upper eyelid contour, without changes in the lower eyelid position.

Das freie autologe Tarsustransplantat als Spacer zur Behandlung der Unterlidretraktion bei Endokriner Orbitopathie

Lower lid retraction in dysthyroid orbitopathy is of less functional concern than optic neuropathy or diplopia in central positions of gaze. However, it may lead to incomplete lid closure resulting in corneal exposure. Patients often suffer from aesthetic impairment. A retrospective analysis of 13 consecutive patients treated for lower lid retraction due to Grave's Disease between 2005 and 2007 was undertaken. In spite of regular ophthalmological examinations, specific attention was directed to measurement of the lid fissure width and scleral show for quantification of lower lid retraction. OPERATION: The lower lid is everted and the conjunctiva is opened horizontally underneath the tarsal edge. Lower lid retractors are disinserted and dissected until the lower lid might be elevated in symmetry to the fellow eye. This procedure is continued until 1 mm overcorrection is gained. A free tarsal transplant is harvested from the ipsilateral upper lid tarsus. At least 4 mm vertical tarsus have to be left. Tarsus is sutured with absorbable material. In the 13 patients operated upon (9 women, 4 men) aged 23 - 67 years, scleral show was preoperative 2.7 mm (mean) and postoperative 0.1 mm. Lid fissure width was preoperative 13 mm (10 - 16 mm) and immediately postoperative 10.3 mm (7 - 13). 6 months postoperative the lid-elevating effect was reduced by 0.5 mm in maximum in the 9 patients available for control. The lid closure deficit, which was present in 7 patients before, could be corrected completely in 5 and diminished to 1 mm in 2 patients. Using this particular technique, functional and aesthetical satisfying results are obtained. The main advantages are renunciation of allogen, xenogeny or synthetic material with its possible risks of slow-virus infection and/or extrusion. Further studies are necessary to evaluate long-term results.

Retrospective outcome analysis of temporalis muscle transfer for the treatment of paralytic lagophthalmos

Temporalis muscle transfer for paralytic lagophthalmos, which was first proposed by Gillies and later developed by Andersen, has been one of the most common treatment modalities for paralytic lagophthalmos. However, there have been no scientific reports statistically analysing the efficacy of temporalis muscle transfer. We, therefore, retrospectively analysed the functional and aesthetic results of temporalis muscle transfer. Between 1994 and 2006, we carried out temporalis muscle transfer (the so-called Gillies-Andersen method) on 95 established facial paralysis patients. We sent a postal questionnaire to these patients and 47 of them responded. The functional and aesthetic results were analysed based on the patients' replies together with clinical records and photographs, and unfavourable factors of this procedure were investigated. After surgery, most ocular symptoms (mechanical irritation, dry eye, soreness, and discharge) improved significantly. Achievement rate of complete eye closure was 78.7%. A morphometric study revealed that possible unfavourable factors (old age, intracranial disease, use of dentures, etc.) did not affect the achievement rates of complete eye closure. Deformity of eyelid fissure due to undue tension of the temporal fascia fixation was found in nine patients (19.1%) and six of these patients underwent secondary revision. Unlike lid loading with a gold implant, the results of temporalis muscle transfer depend greatly on the surgeon's skill. However, if this procedure is performed properly, strong eye closure can be obtained. We, therefore, recommend temporalis muscle transfer as the preferred option for reconstruction of paralytic lagophthalmos.

Tear film osmolarity in patients with thyroid ophthalmopathy

To compare tear film osmolarity between patients with thyroid ophthalmopathy and normal healthy subjects. The tear film osmolarity in 15 normal subjects (15 eyes) (control group) and 21 patients (21 eyes) with thyroid ophthalmopathy was evaluated. Tear film osmolarity in milliosmole (mOsm) was determined by using an auto-osmometer. The palpebral fissure width, degree of proptosis, and tear break-up time (BUT) were also determined. The results for the two groups were compared statistically. The mean palpebral fissure width was 9.13 +/- 0.74 mm in the healthy subjects and 13.33 +/- 1.55 mm in the thyroid ophthalmopathy patients. This difference was statistically significant (P = 0.0001). The mean proptosis was 15.33 +/- 1.39 Hertel units in the healthy subjects and 20.71 +/- 0.95 Hertel units in the patients. This difference was also statistically significant (P = 0.0001). The mean tear BUT was 6.35 +/- 1.56 s in the patients and 18.27 +/- 1.53 s in the healthy subjects, and this difference was also statistically significant (P = 0.0005). The mean tear film osmolarity was 290.80 +/- 13.58 mOsm in the healthy subjects and 340.38 +/- 18.74 mOsm in the patients. There was a statistically significant difference between the groups (P = 0.0001). The significantly higher tear film osmolarity in patients with thyroid ophthalmopathy was most likely due to the increased proptosis and lid fissure width. These conditions may lead to injury of the ocular surface.

Comparative study of Botox® injection treatment for upper eyelid retraction with 6-month follow-up in patients with thyroid eye disease in the congestive or fibrotic stage

To compare morphometric data of the eyelid fissure and the levator muscle function (LF) before and up to 6 months after transcutaneous injection with five units of Botox in patients with upper lid retraction (ULR) from congestive or fibrotic thyroid eye disease (TED). Twenty-four patients with ULR from TED were submitted to transcutaneous injection of 5 units (0.1 ml) of Botox in one eye only. Patients were divided into two groups: 12 with congestive-stage TED (CG), and 12 with fibrotic-stage TED (FG). Bilateral lid fissure measurements using digital imaging and computer-aided analysis were taken at baseline and at regular intervals 2 weeks, 1 month, 3 months and 6 months after unilateral Botox injection. Mean values taken at different follow-up points were compared for the two groups. Most patients experienced marked improvement in ULR, with a mean reduction of 3.81 mm in FG and 3.05 mm in CG. The upper eyelid margin reflex distance, fissure height and total area of exposed interpalpebral fissure were significantly smaller during 1 month in CG and during 3 months in FG. Reduction in LF and in the difference between lateral and medial lid fissure measurements was observed in both groups. The treatment lasted significantly longer in FG than in CG. A single 5-unit Botox injection improved ULR, reduced LF and produced an adequate lid contour in patients with congestive or fibrotic TED. The effect lasts longer in patients with fibrotic orbitopathy than in patients with congestive orbitopathy.

A new conformer design to expand the horizontal lid fissure in severely microphthalmic eyes

Effective treatment of severe microphthalmos requires early placement of conformers to increase the size of the conjunctival sac and to increase orbital dimensions. This process may be confounded by inadequate horizontal lid length and microblepharon. Lateral canthotomy can be used to facilitate early placement of serial conformers, but this procedure is often avoided due to frequent peripalpebral scarring and recurrent phimosis. Conformers currently in use do not separate the lateral lid margins enough to prevent such scarring after lateral canthotomy. We describe a child with severe microphthalmos and microblepharon in whom a novel conformer was used to prevent scarring following lateral canthotomy. Use of this conformer design may make lateral canthotomy a viable option to expand the horizontal lid fissure and facilitate early orbital expansion in patients with severe microphthalmos.

Physiologic Anisocoria: A Manifestation of a Physiologic Sympathetic Asymmetry

Forty-two consecutive subjects identified clinically by other clinicians as having anisocoria were evaluated by the author in a blinded fashion with the friction sweat test. The presence and side of any ptosis or lid fissure narrowing was also noted. Thirty-three of 42 (79%) had an associated decrease in sweating on the same side as the smaller pupil. Three (7%) had decreased sweating contralateral to the miosis and in 6 (14%) no significant asymmetry could be detected. Fifteen had an associated ptosis and narrowed lid fissure, all but one ipsilateral to the miosis. These findings strongly suggest that physiologic anisocoria is a manifestation of a physiologic asymmetry of resting sympathetic tone.

A Randomized Clinical Trial of Two Methods of Fascia Lata Suspension in Congenital Ptosis

To compare the results of 2 methods of upper eyelid sling placement with autogenous fascia lata in the treatment of congenital ptosis. In a randomized clinical trial, patients with congenital upper eyelid ptosis and poor levator function (<4 mm) were randomly assigned to either of 2 methods of upper eyelid sling placement: group A, bitriangular fascia sling (modified Crawford method), and group B, monotriangular fascia sling (modified Fox method). This study included 30 upper eyelids (15 eyelids in each surgical group) of 19 patients (8 unilateral and 11 bilateral cases) with congenital ptosis. Mean increase in eyelid fissure height was 2.7 +/- 2.3 mm in group A and 3.4 +/- 2.2 mm in group B. Change in eyelid fissure in both groups was significant (p < 0.001, paired t test) but the intergroup difference was not (p = 0.4, independent sample t test). Early complications such as corneal epithelial defects and entropion and late complications such as undercorrection were comparable in the 2 groups. No patient experienced recurrent ptosis requiring reoperation in either group. The monotriangular method of upper eyelid fascia sling placement can be used instead of the more popular bitriangular method. Advantages include less need for fascial tissue, less periocular scar formation, and a shorter period of anesthesia.

Surgical treament of 13 cases of blepharophimosisptosis-epicanthus inversus syndrome

目的 讨小睑裂综合征的联合手术方法.方法 小睑裂综合征13例26眼,采用三联手术,即上睑提肌缩短术、上睑提肌缩短加横韧带悬吊术、额肌腱膜悬吊术或额肌悬吊术治疗上睑下垂;Spaeth双Z成形术和Y-V成形术治疗内眦赘皮;并进行外眦开大术以扩大睑裂,3项手术一次完成.结果 术后外观有明显改善,睑裂长度和高度显著增加,内眦间距显著缩短.术前睑裂长度19～24 mm,平均(21.0±1.4)mm,睑裂高度:1～4mm,平均(2.3±1.1)mm,内眦间距35～40 mm,平均(37.0±1.6)mm,术后睑裂长度25～30 mm,平均(27.4±1.3)mm.睑裂高度:5～8 mm,平均(6.2±0.9)mm.内眦间距30～35 mm,平均(32.7±1.3)mm,各相应组两两比较差异均有统计学意义(P=0.000).结论 三联手术治疗小睑裂综合征取得良好效果。

Randomized, Double-Blind, Placebo-Controlled Trial of Long-Acting Release Octreotide for Treatment of Graves’ Ophthalmopathy

Despite a strong rationale for trials of somatostatin analogs in the treatment of Graves' ophthalmopathy (GO), recent studies have provided conflicting results. The objective of the study was to determine whether octreotide long-acting release (LAR) is effective treatment for active GO. This was a prospective, randomized, double-blind, placebo-controlled study. The setting was a single tertiary referral center. Twenty-nine consecutive euthyroid patients with active GO [clinical activity score (CAS) >or= 3] were enrolled; 25 completed the study. Patients received four monthly doses of either octreotide LAR (20 mg) or saline by im injections. Primary measure was a change in CAS; the secondary measure was changes in retrobulbar tissue volume, proptosis, lid fissure width, range of motion, and diplopia fields. Median (range) CAS change was 2.5 (1, 5) in the treatment and 1.0 (0, 7) in the placebo group (P = 0.02). Median lid fissure width improved in the treatment group, (decreased 1 mm on the right and 0.5 mm on the left), compared with the placebo group (no change on the right, P < 0.01; increased 1 mm on the left, P < 0.01). No other significant differences between groups were identified. CAS improved to a greater extent in octreotide-LAR-treated patients than the control group. However, this finding may not represent clinical benefit because patients with higher baseline CAS were overrepresented in the treatment group, and the control group was small. In contrast, treatment-related improvement in eyelid fissure width was noted, suggesting that octreotide LAR may be useful in the treatment of a subgroup of active GO patients with significant lid retraction.

A New Z-Epicanthoplasty and a Concomitant Double Eyelidplasty in Chinese Eyelids

Patients with no double eyelid folds and with a mild or moderate medial epicanthus are most typically Asians. After only receiving double eyelidplasty, they often complain that their eyes look round and their eyelid fissures are shorter because their medial epicanthi still exist. In this article, according to the authors' surgical findings, it is reasoned that the malpositioned portion of the orbicularis oculi muscle fibers is the main cause of congenital medial epicanthus. Several design principles for performing the Z-epicanthoplasty concomitant with a double eyelidplasty were advanced: (1) removal of the main deformity-formed cause, (2) correcting the pretarsal skin shortage in the medial upper eyelid, (3) preventing the prominent scarring in the medial canthal area, and (4) achieving other advantages (i.e., easy design and operation, precision of performance with a concomitant double eyelidplasty, and excellent and reproducible results). Epicanthoplasty only was performed in six patients. An epicanthoplasty concomitant with a double eyelidplasty was performed in 230 cases with congenital or traumatic medial epicanthi. Sixty-seven cases in this series were followed up for 4 to 23 months (average, 7 months). The contours of the double eyelids were natural. Mild scar proliferation was observed in all of the patients in the early postoperative period and then would diminish and become a gray-white line. Some skin wrinkles and skin shadow on the B flap could be seen. The indications for this procedure are all types of medial epicanthi but the inversus type. Older age is a relative contraindication.

Changes of the Lid Fissure After Surgery on Horizontal Extraocular Muscles

To evaluate the effect of isolated medial and lateral rectus muscle surgery on eye lid position. Prospective, interventional case series. We recruited 36 patients with strabismus with surgery performed on one horizontal extraocular muscle only. The width of the lid fissure and the position of the upper and lower lids in relation to the pupil center were measured before and 3 months after surgery. Regression analysis was used to evaluate the surgical effect. Recessions induced a widening of and resections a narrowing of the lid fissure, mainly because of changes of the lower lid position. The effect was statistically significant (change in lid fissure width, = 0.13 x surgical dose in millimeters; r(2) = .35; P = .0001). Patients should be informed about changes in lid fissure width after operations on horizontal extraocular muscles. If adequately integrated into the surgical plan, this side effect may alleviate pre-existing interocular differences in lid configuration.

An Improved Water Bath for Ultrasound Biomicroscopy

A beveled, oval-shaped eyecup molded from a medical-grade polymer with a round fluid reservoir fused to the top of it has been designed for use with the ultrasound biomicroscope. This new design addresses the problem of saline leaking out from under the water bath, improves comfort for patients with various lid fissures, and increases room for oscillations of the ultrasound probe.

Randomized, Single Blind Trial of IntravenousversusOral Steroid Monotherapy in Graves’ Orbitopathy

Glucocorticoids are effective for severe Graves' orbitopathy (GO), which causes substantial morbidity. The question at issue is how best to use them. The objective of this study was to optimize glucocorticoid application in GO. The study design was a randomized trial over 12 wk with 6-month follow-up. The study was performed at university joint thyroid and ophthalmic clinics. Seventy euthyroid out-patients with untreated, active, and severe GO were studied. Patients received either once weekly iv methylprednisolone (0.5 g, then 0.25 g, 6 wk each) or oral prednisolone starting with 0.1 g/d, then tapering the dose by 0.01 g/wk. At 3 months, the primary end point was a composite of improvements in proptosis, lid fissure width, and rate of diplopia in primary gaze, visual acuity, eye muscle thickness, and patient's quality of life. Intravenous glucocorticoid therapy resulted in rapid, significant, and sustained improvement. At 3 months, 27 of 35 patients (77%) in the iv group had a treatment response compared with 18 of 35 (51%) in the oral group (P < 0.01). Improvements over baseline values for disease severity (e.g. visual acuity; P = 0.01) and activity (e.g. chemosis; P < 0.01) and for quality of life (P < 0.001) were greater in the iv group. TSH receptor antibody titers decreased during iv steroid administration (P < 0.001), and smoking had a strong impact on the therapy response (P < 0.001). Additional treatment was required less frequently in the iv group. Intravenous steroids were safe, with different rates of adverse events between the two groups (P < 0.001). In patients with active and severe GO, iv glucocorticoids were more effective and better tolerated than oral steroids.

Alterações palpebrais após a idade de 50 anos

To quantify the palpebral alterations occurring in subjects after the age of 50 years. An observational study was done with 325 subjects older than 50 years. The data comprised measurements of intercantal distance, palpebral fissure length and height, external and internal eyelid angles, margin reflex distance (MRD) and total palpebral fissure area. Digital images were obtained with a Sony Lithium movie camera at the frontal view in ocular primary position, with the object of observation being located at the height of the pupil. The images were saved on tape, transferred to a McIntosh G4 computer and processed with the NIH 1.58 program. The data were submitted to statistical analysis. The subjects presented dermochalasis (96.5%), eyebrow ptosis (60.8%), orbital fat prolapse (50.0%) or eyelid ptosis (39.1%). The alterations were bilateral in 68.8% of the subjects. The intercantal distance was higher with age; the eyelid fissure length, the margin reflex distance and the external angle decreased in the elderly. The differences were more important on evaluating each eye separately. Intercantal distance increase and palpebral fissure length, margin reflex distance and total eyelid area decrease with age.

Congenital Oculomotor Nerve Synkinesis Associated Wwith Fetal Retinoid Syndrome

Isotretinoin (RA), used for the treatment of cystic acne, is a powerful teratogen, causing craniofacial dysmorphisms and neural tube defects. We present two patients with RA embryopathy and oculomotor nerve synkinesis. Retrospective review of patient records. Two patients presented with third nerve synkinesis and fetal RA exposure. Both had marked elevation of the upper eyelids on adduction such that the lid fissures alternately opened and closed on gaze from side to side. Both patients showed typical dysmorphisms of RA embryopathy. The first patient had complete agenesis of the cerebellar vermix and died at 2 years. The second patient had restricted extraocular muscles in one eye and was exotropic and hypotropic. Both patients demonstrated simultaneous innervation of the medial rectus and levator palpebrae muscles causing coincident lid elevation in adduction. This evidence of oculomotor nerve synkinesis is consistent with animal studies showing abnormalities in the formation of cranial nerve ganglia following fetal RA exposure. RA is a powerful teratogen. These patients provide additional clinical evidence of its influence on neural migration during early development.

Induced Videokeratography Alterations in Patients With Excessive Meibomian Secretions

To describe lipid-induced specific videokeratographic (VKG) corneal changes and subsequent resolution after eyelid washing. VKG was performed with C-Scan corneal topography. In all patients an excessive meibomian gland lipid secretion was found with or without coexistent chronic posterior blepharitis. After the initial VKG, a meticulous cleaning of the lids with a mild alkali shampoo (10% Johnson's baby shampoo in sterile water) was done, first by gently scrubbing the closed eyelid fissure with the solution to mobilize and emulsify any Meibomian gland secretions followed by cleaning of the upper and lower margins individually, using Q-tip applicators soaked in the detergent. Three patients with tear film lipid layer excess (TFLE), which correlated with the presence of a superior or central corneal steepening in VKG, were studied. In two of the subjects, careful lid washing reversed either completely or partially this VKG effect, whereas in the last patient the VKG changes after artificially increasing the tear film lipid content is described. Meibomian gland lipid secretions may induce mainly superior and occasionally central VKG corneal steepening that is not correlated with any slit-lamp pathologic findings. Computerized corneal topography can help detect such corneal abnormalities, and their reversibility may distinguish them from other pathologic conditions (such as contact lens-induced warpage, eccentric ablations, irregular astigmatism, superior keratoconus).

Temporary Management of Upper Lid Ptosis, Lid Malposition, and Eyelid Fissure Asymmetry with Botulinum Toxin Type A

During the past 10 years the primary focus for the aesthetic use of botulinum toxin has been directed to the treatment of dynamic facial lines. This agent has been shown to be very effective for the improvement of facial shape. The use of botulinum toxin type A for the correction of a variety of presentations of facial asymmetry has also been well established. The general principles regarding the counter-effects of facial muscle protagonists and antagonists and their potential effects on the position of facial soft-tissue regions apply here as well. Twenty-two patients received botulinum toxin type A for the temporary treatment of mild to moderate unilateral upper eyelid ptosis and aesthetic improvement of lower eyelid position, with favorable results. Although commonly related to a rare yet feared adverse consequence from the inappropriate application of botulinum toxin, its application for the treatment of upper eyelid ptosis, eyelid position, and other lid fissure asymmetries for aesthetic improvement is presented.

Eyelid position measurement in Graves' ophthalmopathy: Reliability of a photographic technique and comparison with a clinical technique

Purpose To evaluate intraobserver reliability and interobserver reliability of a computer-based digital image measurement of eyelid position in Graves' ophthalmopathy and to compare digital image measurement with clinical measurement. Design Cross-sectional study. Participants Eighty-four eyes of 42 patients with mild to moderate bilateral Graves' ophthalmopathy. Methods Digital images were created from 35-mm color slides of both eyes of participants and projected onto a 15-inch flat-screen computer monitor. Three observers (2 oculoplastic surgeons and 1 ophthalmology resident) independently recorded eyelid fissure height, margin–reflex distance, and inferior scleral show for each eye. Main outcome measures Intraobserver reliability and interobserver reliability of eyelid parameter measurements, as described by the intraclass correlation coefficient (ICC) and Bland–Altman plots. Agreement between digital image measurements of the investigators and clinical measurements taken on the same day as the photographs also was assessed. Results Excellent intraobserver agreement was found for the measurement of all eyelid parameters for all 3 investigators (ICC range, 0.93–0.99). Interobserver agreement for all eyelid parameters was also excellent for all investigators (ICC, 0.86–0.97). Agreement between the photographic and clinical measurements for eyelid parameters was fair to moderate (ICC range, 0.38–0.62). Conclusion Measurement of several eyelid parameters in Graves' ophthalmopathy patients from computer-based digital images is reliable. Associations between photographic and clinical measurements for all parameters are weaker. Relative to clinical measurements, the photographic technique offers the advantages of potential for masking and ease of transmission that might be useful in clinical trials.

Quantificação da ação do músculo frontal

OBJETIVO: Quantificar a ação do músculo frontal. MÉTODOS: A ação do músculo frontal foi quantificada por meio da medida da mobilidade do supercílio em 81 sujeitos normais, divididos, segundo a faixa etária, em três grupos: crianças com idades entre 6 e 12 anos (n = 20), adultos com idades entre 20 e 38 anos (n = 33) e idosos com idades entre 60 e 80 anos (n = 28). As medidas foram realizadas com o processamento digital de imagem. Obteve-se uma imagem da face do sujeito com o frontal em repouso e outra com contração voluntária da fronte. Como índice de ação frontal foi tomada a excursão do supercílio na parte média da fenda palpebral. RESULTADOS: Os valores médios da excursão superior do supercílio variaram, de acordo com o grupo etário, de 7,57 a 9,02 mm. Apesar de nítida tendência de aumento da mobilidade com a idade, as diferenças entre os três grupos não foram significativas. CONCLUSÕES: A magnitude da excursão da porção central do supercílio independe da idade.