Eyelid Motility Research Articles

Reducing tension step by step in epicanthus and lower eyelid incision for treating cilial entropion in children: A case series analysis

ObjectiveTo evaluate the surgical outcomes of a modified technique for treating congenital cilial entropion in children, which involves reducing tension step by step in the epicanthus and lower eyelid incision. MethodsThe observational group consisted of 153 pediatric patients (81 males and 72 females) who were treated using the modified technique, whereas the control group included 124 patients (68 males and 56 females) who were treated using the rotating suture surgery. All the participants were bilateral. Surgical outcomes were classified as good, fair, or poor, and the recurrence rate, scar condition, inferior eyelid position, and patient satisfaction were also assessed. ResultsThe mean follow-up period was 9.13 ± 3.50 months (range: 3–14 months) for the observational group and 6.93 ± 4.51 months (range: 3–14 months) for the control group. In the observational group, surgical success with "good" outcomes was achieved in 300 eyes (98.04%), compared to 224 eyes (90.32%) in the control group. No recurrence occurred in the observational group, whereas the recurrence rate in the control group was 4.43%. Postoperative scar formation was mild in the observational group. The average scar score was 1.27 ± 0.96 in the observational group and 2.70 ± 0.99 in the control group, with a statistically significant difference (P < 0.001). Neither overcorrection nor postoperative ectropion was observed in both groups. ConclusionThe modified technique effectively corrected medial entropion and trichiasis in the lower eyelid, resulting in stable postoperative outcomes, mild scar formation, quick recovery, flexible eyelid motility, and stable ocular surface. Therefore, it can be widely applied to children with congenital entropion and trichiasis.

Clinical Report: Clinician Feedback on the Magnetic Levator Prosthesis.

Stakeholder engagement has been identified by national health organizations as a crucial step to successful translation of new healthcare treatments. In this clinical report, clinician-stakeholder feedback is presented for the Magnetic Levator Prosthesis (MLP), a promising non-invasive spectacle device which restores eyelid motility with magnetic force. To evaluate MLP clinical need and translational barriers. Ten vision rehabilitation optometrists who attended an educational presentation on the MLP and participated in a hands-on workshop in the fitting of a patient were invited to complete an anonymous online survey. Ten multiple-choice items gathered data on estimated patient need, current approaches, main barriers for MLP, temporary versus chronic use, cost barriers, and need for insurance coverage. Open fields allowed for additional comments. Nine of 10 specialists completed the survey. Of those, 7 answered that they could potentially see at least 1-5 patients for ptosis management within a year. The most common ptosis management options reported were the ptosis crutch, taping the eyelid open, and Oxymetazoline drops, all with 6 responses each. Seven clinicians indicated that cost was a main concern. If cost-to-patient was not a barrier, all indicated they would be at least somewhat likely to try the MLP for: 1) temporary management of ptosis, 2) as a pre-surgical trial, and 3) for long term management of ptosis, with more selecting extremely likely and very likely than somewhat likely. Main comments were expressing enthusiasm for the technology and that it would be more appealing for patients if covered by insurance. This clinical report suggests the main barriers to clinical success of the MLP may be cost and insurance coverage, appearance of the device, and self-application. Possible solutions are cost-benefit analysis research, engineering efforts to reduce spectacle magnet size and improve the ease of eyelid magnet application.

Modified levator muscle complex suspension on treating pediatric blepharoptosis with poor Bell’s phenomenon

To evaluate the surgical outcomes of pediatric congenital blepharoptosis with poor Bell's phenomenon (BP) treated with modified levator muscle complex suspension. Forty-two pediatric congenital blepharoptosis patients with poor BP were treated with modified levator muscle complex suspension, and their major surgical outcomes such as marginal reflex distance1 (MRD1), palpebral fissure height (PFH), and postoperative lagophthalmos were retrospectively reviewed. The mean follow-up was 10.28 ± 9.89months (range 3-32 Months). Surgical success was achieved in 54 (87.1%) of 62 eyelids at the final visit, including excellent results in 46 (74.2%) eyelids, good results in 8 (12.9%) eyelids, and poor results in 8 (12.9%) eyelids, respectively. The postoperative PFH of affected eyes (7.97 ± 1.47mm) was significantly improved compared with that before surgery (3.58 ± 1.31mm). The mean MRD1 was improved from - 1.48 ± 1.36mm before surgery to 2.94 ± 1.46mm after surgery. The postoperative MRD1 was ≥ 3mm in 46 eyelids and < 3mm in 16 eyelids. The mean lagophthalmos was 1.42 ± 1.20mm 3months after surgery. All of the patients presented complete blink postoperatively. Postoperative complications were rarely observed during follow-up. No patient had exposure keratitis, but blepharoptosis recurred in 6 patients (8 eyelids). All patients had satisfactory eyelid symmetry and contour. No complications were observed until the last visit. The modified method results complete blink, mild, and quick recovery of lagophthalmos, flexible eyelid motility, stable ocular surface, and it is simple to perform with few complications and a low recurrence rate at 12.9%, which is worth to wide application on poor Bell's phenomenon blepharoptosis.

Two-Stage Reconstruction for Eyelid Deformities in Partial Cryptophthalmos

Cryptophthalmos was first described in 1872 as a rare syndrome consisting of congenital upper eyelid and eyebrow coloboma and a rudimentary ocular bulb. Later, Fraser described it as being part of a complex syndrome with multiple anomalies. Many cases have been described since then, but very few surgical techniques have been proposed for its correction. In this paper, the authors present a surgical procedure for correction of the upper eyelid and ocular bulb anomalies in cryptophthalmos. Five patients with Fraser syndrome were seen from 1993 to 2008. They were in the age group of 18 months to 24 years. Of these, 4 patients underwent reconstruction of the upper eyelid. The large upper eyelid coloboma and the cutaneous pterygium were treated with a 2-stage procedure, with good results obtained with the adoption of Mustardé's technique. The complexity of the surgical treatment increases when there is no possibility of rudimentary eye bulb preservation. In upper eyelid reconstruction, the authors adopted Mustardé's technique with fixation of the lower eyelid transposed flap to the levator muscle, leading this way to relatively good upper eyelid motility. The authors consider imperative that the upper fornix be reconstructed with adequate depth to allow perfect positioning of an aesthetic prosthesis, in this way improving the final aesthetic and functional results.

The Significance of Intraoperative Measurements in Acquired Ptosis Surgery

During a series of 101 levator procedures to correct acquired ptosis we measured the motility of the aponeurosis, the necessary advancement of the aponeurosis to adjust the eyelid height and the motility of Whitnall's ligament.We compared these intraoperative data with the data of the preoperative examination and did not find any correlation.The necessary amount of advancement of the aponeurosis to adjust the height of the eyelid was not related to the motility of the aponeurosis, the levator function or the amount of ptosis.However, we did find that the motility of Whitnall's ligament is closely related to the motility of the aponeurosis. Therefore connecting both structures is useful in ptosis adjustment without risking limited eyelid motility.

Blink Recovery in Patients with Bell’s Palsy: A Neurophysiological and Behavioral Longitudinal Study

To examine the recovery process of blinking in a longitudinal study of nine patients severely affected by Bell's palsy. Kinematics of bilateral eyelid and eye movements and concomitant orbicularis oculi activity during voluntary blinking and air-puff- and acoustic-click-induced reflex blinking were determined by using the magnetic search coil technique and electromyographic recording of the orbicularis oculi muscle (OO-EMG). In the first 3 months of absence of OO-EMG activity, reduced eyelid and eye movement of the palsied eyelid were observed during all types of blinking. First OO-EMG activity was determined 3 months after onset of the affliction. After 1 year, OO-EMG activity was normalized and showed values similar to those on the nonpalsied side. Clinically, eyelid movements were normal after 1 year, although corresponding maximum amplitudes and corresponding velocities were two times smaller, expressed in reduced eyelid motility. Directions of eye movement during reflex blinking were normal after 1 year, although maximum amplitudes were smaller on the palsied side. Eye movements during voluntary blinking remained impaired. A simultaneous horizontal upward shift of both eyes in the same direction was recorded throughout the study. Although OO-EMG activity on the palsied side was normalized 1 year after onset of the affliction, the accompanying eyelid movements and their maximum amplitudes and velocities remained smaller throughout the study. The consistent impairment of eye movements in voluntary blinking during the study and reduced motility of eyelid movements indicates that higher brain structures, which modify eyelid and eye movement control during blinking, may be altered by the affliction.

Lid Restraint Evokes Two Types of Motor Adaptation

Unilateral reduction in eyelid motility produced two modes of blink adaptation in humans. The first adaptive modification affected both eyelids. Stimulation of the supraorbital branch of the trigeminal nerve (SO) ipsilateral to the upper eyelid with reduced motility evoked bilateral, hyperexcitable reflex blinks, whereas contralateral SO stimulation elicited normally excitable blinks bilaterally. The probability of blink oscillations evoked by stimulation of the ipsilateral SO also increased with a reduction in lid motility. The increased probability of blink oscillations correlated with the enhanced trigeminal reflex blink excitability. Thus, the trigeminal complex ipsilateral to the restrained eyelid coordinated an increase in excitability and blink oscillations independent of the eyelid experiencing reduced motility. The second type of modification appeared only in the eyelid experiencing reduced motility. When tested immediately after removing lid restraint, blink amplitude increased in this eyelid relative to the normal eyelid regardless of the stimulated SO. A patient with seventh nerve palsy exhibited the same two patterns of blink adaptation. These results were consistent with two forms of adaptation, presumably because unilateral lid restraint produced two error signals. The corneal irritation caused by reduced blink amplitude generated abnormal corneal inputs. The difference between proprioceptive feedback from the blink and expected blink magnitude signaled an error in blink amplitude. The corneal irritation appeared to drive an adaptive process organized through the trigeminal complex, whereas the proprioceptive error signal drove an adaptive process involving just the motoneurons controlling the restrained eyelid.

Penetrating orbital injury with organic foreign bodies

ObjectiveThe authors reviewed the clinical features, diagnostic workup, and management of patients of penetrating orbital injuries with retained organic foreign bodies. DesignRetrospective, noncomparative case series. ParticipantsNineteen patients (15 males, 4 females) with penetrating orbital injuries due to organic foreign bodies. ResultsThe series included 15 (78.9%) males and 4 (21.1%) females who ranged in age from 6 months to 40 years (mean = 14.6 years); 12 (63.2%) patients were younger than 12 years of age. Twelve (63.2%) right and 7 (36.8%) left orbits were involved. Time between injury and presentation varied from a few hours to 9 months. Most common injury site was the superior orbit in 11 (57.9%) patients leading to abnormal extraocular motility (84.2%), proptosis (68.4%), and upper lid ptosis (47.4%). Associated pathologies also included acute cellulitis in 11, orbitocutaneous fistula in 5, and osteomyelitis in 2 patients. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) identified the foreign bodies in 42% and 57% of the patients, respectively. ConclusionPreoperative identification of the foreign material in the orbit was found to be very helpful for patient management but was only possible in approximately 50% of our cases with the use of CT and MRI. The vision in our patients usually improved shortly after treatment; the long-term complications more often included extraocular muscle and eyelid motility problems and periorbital scarring.

Trigeminal disynaptic circuit mediating corneal afferent input to M. depressor palpebrae inferioris motoneurons in the pigeon (Columba livia).

Corneal afferent projections to the trigeminal brainstem nuclear complex (TBNC) and associated structures, as determined by transganglionic transport of various tracers, were found to be predominantly concentrated in two distinct patches in the dorsolateral medulla at periobex levels. One was in the external cuneate nucleus, and the other was in the ventralmost part of the ophthalmic division of the TBNC. The projections of putative second-order neurons in these regions, as determined by injections of wheat germ agglutinin conjugated to horseradish peroxidase into the dorsolateral medulla, were found to include the dorsal trigeminal motor nucleus (Vd), which innervates the M. depressor palpebrae inferioris. Electrical stimulation of Vd, which elicited lower eyelid movements, was then used to guide injections of tracer into Vd, which retrogradely labeled clusters of neurons in the corneal afferent recipient regions of the dorsolateral medulla. The lower eyelid of pigeons, unlike the nictitating membrane and upper lid, does not appear to be appreciably involved in either reflex blinking in response to relatively mild stimulation of the cornea (e.g., air puff), or in eye closure during the saccade-like head movements associated with walking, or in eye closure during pecking; but in response to a stimulus that makes corneal contact, an upward movement of the lower lid follows descent of the nictitating membrane and upper lid as part of a defensive eye-closing mechanism. The anatomical results thus appear to define a dedicated disynaptic trigeminal sensorimotor circuit for the control of lower eyelid motility in response to mechanical or noxious stimuli of the cornea. Injections of tracers into the lower and upper eyelids labeled palpebral sensory afferents that terminated predominantly in maxillary and ophthalmic portions, respectively, of the dorsal horn of upper cervical spinal segments. These terminal fields were therefore largely separate from those of corneal afferents. There were no specific corneal afferent projections upon accessory abducens motoneurons that innervate the two muscles controlling the nictitating membrane.

Distinctive abnormalities of facial reflexes in patients with progressive supranuclear palsy.

Spontaneous and voluntary eyelid motility is often abnormal in patients with progressive supranuclear palsy. In contrast, their eyelid reflex responses are relatively preserved, and only those generated by an acoustic startle have been found absent or severely reduced. We hypothesized that, because of their relevant brainstem pathology, patients with progressive supranuclear palsy might have other brainstem reflex abnormalities which, on detection, could help with their neurophysiological characterization. In this study, we examined facial reflex responses in 14 patients with progressive supranuclear palsy, 12 patients with multisystem atrophy, 10 patients with Parkinson's disease, six patients with corticobasal ganglionic degeneration, 11 patients with various non-parkinsonian neurological illnesses and 10 normal subjects. EMG activity was simultaneously recorded from the orbicularis oculi and mentalis muscles following electrical stimulation of the median nerve at the wrist. Mentalis responses were obtained in two normal subjects and in all patients except one with Parkinson's disease, one with progressive supranuclear palsy and one with corticobasal ganglionic degeneration; there were no differences between groups of subjects regarding latency or peak amplitude. Orbicularis oculi responses were always present in control subjects and patients who exhibited mentalis responses, with the significant exception of patients with progressive supranuclear palsy, in whom only the response of mentalis was obtained. Blink-reflex responses to supraorbital nerve electrical stimuli were present at a normal latency and amplitude in all patients. An abnormally enhanced blink-reflex excitability recovery curve to paired stimuli was found in a similar percentage of patients with progressive supranuclear palsy, multisystem atrophy and Parkinson's disease, but in only two patients with corticobasal ganglionic degeneration. Patients with progressive supranuclear palsy have a functional involvement of circuits mediating orbicularis oculi responses to median nerve electrical stimuli, that is a distinctive feature with respect to other parkinsonian syndromes.

Botulinum toxin treatment of apraxia of eyelid opening in progressive supranuclear palsy: Report of two cases

We report two patients, with postural instability and dystonic parkinsonism whose adjunctive disabling feature was blindness due to an inability to reopen the eyes after voluntary closure of the eyelids, as in apraxia of lid opening (ALO). Supranuclear downgaze paresis permitted the diagnosis of progressive supranuclear palsy (PSP) in one case. Electromyographic studies showed a loss of normal reciprocal inhibition between the levator palpebrae and the pretarsal portion of the orbicularis oculi, with a cocontraction of these two antagonist muscles. The evoked blink reflex, tested with the paired shock technique, showed enhanced recovery of R2 response. Botulinum toxin A injections directed toward the junction of the preseptal and pretarsal parts of the palpebral orbicularis oculi muscle improved eyelid motility in both patients. Successive static and dynamic balance training and development of compensatory strategies for visual scanning deficits reduced gait imbalance, the number of falls, and the disability level as measured on the Northwestern University Disability Scale.

Eyelid motor abnormalities in progressive supranuclear palsy.

Eyelid motor abnormalities found in progressive supranuclear palsy are reviewed. Electrophysiological correlates of blepharospasm, levator inhibition (blepharokolysis) and supranuclear paralysis of lid closure are presented. Disorders of eyelid motility are not uncommon in progressive supranuclear palsy (PSP). They may be found in about one third of patients with this syndrome (Jackson et al., 1983; Golbe et al., 1989). This is not surprising since ocular and eyelid movements are highly coordinated, mainly in the vertical plane (Gordon, 1951; Kennard and Smith, 1963; Kennard and Glaser, 1964), and a supranuclear ophthalmoplegia with down gaze impairment is a cardinal feature of PSP (Steele et al., 1964). The spectrum of eyelid motor disorders described in PSP includes blinking abnormalities, lid retraction, blepharospasm, levator inhibition and supranuclear palsy of eye closure.

Orbicularis Muscle Mobilization in Eyelid Reconstruction

Mobilization of the orbicularis oculi muscle into recipient skin-graft beds was performed in seven patients. Following tumor resection, five eyelids were reconstructed using the Hughes procedure. Two eyelids had orbicularis muscle mobilization in preparation for the recipient graft site for correction of cicatricial ectropion following trauma. All skin grafts were viable and eyelid motility was enhanced. No complications were encountered.

Orbicularis Muscle Mobilization in Eyelid Reconstruction

• Mobilization of the orbicularis oculi muscle into recipient skin-graft beds was performed in seven patients. Following tumor resection, five eyelids were reconstructed using the Hughes procedure. Two eyelids had orbicularis muscle mobilization in preparation for the recipient graft site for correction of cicatricial ectropion following trauma. All skin grafts were viable and eyelid motility was enhanced. No complications were encountered.