Eyelid Position Research Articles

What is a blink? Classifying and characterizing blinks in eye openness signals

Blinks, the closing and opening of the eyelids, are used in a wide array of fields where human function and behavior are studied. In data from video-based eye trackers, blink rate and duration are often estimated from the pupil-size signal. However, blinks and their parameters can be estimated only indirectly from this signal, since it does not explicitly contain information about the eyelid position. We ask whether blinks detected from an eye openness signal that estimates the distance between the eyelids (EO blinks) are comparable to blinks detected with a traditional algorithm using the pupil-size signal (PS blinks) and how robust blink detection is when data quality is low. In terms of rate, there was an almost-perfect overlap between EO and PS blink (F1 score: 0.98) when the head was in the center of the eye tracker’s tracking range where data quality was high and a high overlap (F1 score 0.94) when the head was at the edge of the tracking range where data quality was worse. When there was a difference in blink rate between EO and PS blinks, it was mainly due to data loss in the pupil-size signal. Blink durations were about 60 ms longer in EO blinks compared to PS blinks. Moreover, the dynamics of EO blinks was similar to results from previous literature. We conclude that the eye openness signal together with our proposed blink detection algorithm provides an advantageous method to detect and describe blinks in greater detail.

Reconstruction of Full-Thickness Eyelid Defects Following Tumor Resection: The Bucket Handle Modification.

To describe a modified approach for full-thickness lower eyelid defect reconstruction. This is a retrospective review of 5 patients with large full-thickness lower eyelid defects after tumor resection requiring reconstruction. For these lower eyelid defects, a lateral-based or superior-based tarsoconjunctival pedicle flap from the upper eyelid was used to rebuild the posterior lamella. In all cases, the anterior lamella was supplied from an adjacent myocutaneous flap in a bucket handle configuration. Data collection included tumor type and location, size of eyelid defect, presence of canalicular involvement, postoperative eyelid position, patient satisfaction, and complication rates. Five eyelids of 5 patients underwent Mohs micrographic excision of basal cell carcinoma followed by reconstruction with a bucket handle flap. Age range was 68 to 96 years old (mean of 81y). Five patients presented with lower eyelid involvement. The defect size ranged from 80% to 100% of the eyelid. Three patients had canalicular involvement and required bicanalicular nasolacrimal stent placement. After reconstruction, all patients showed good eyelid apposition to the globe with excellent esthetic outcome. No revision procedures were done. Average follow-up time was 13 months (range of 8 to 21mo). The bucket handle flap for full-thickness eyelid reconstruction is a simple technique that allows for preservation of all anatomical layers of the anterior lamella. This technique shows promising functional and esthetic outcomes.

Levator Resection in Neurogenic Ptosis Oculi Sinistra et causa Third Nerve Paresis + Type II Diabetes: A Case Report

Introduction : Neurogenic ptosis is abnormal position of the upper eyelid caused by dysfunction or damage to the oculomotor or sympathetic nerves supplying the eyelids. Third nerve palsy (35.7%) is the most common cause among others. We report a case of neurogenic ptosis managed surgically by levator resection.
 Case Illustration : A 67-year-old male complained of drooping left upper eyelid, getting worse in 7 months. He had history of falling off motorcycle 6 months ago. Clinical histories of hypertension and diabetes mellitus were found. Right and left eyelids measurements in millimeter showed horizontal palpebral fissure (HPF) 28/26, vertical palpebral fissure (VPF) 6/3, margin reflex distance 1 (MRD1) 2/-2, margin reflex distance 2 (MRD2) 6/5, margin limbal distance (MLD) 8/4, and levator function (LF) 8/3. Bell’s phenomenon was negative in both eyes. Ice pack test was negative. There were ocular movement restriction in his left eye. Patient underwent a maximum levator resection and had better levator function after 3 weeks follow up.
 Discussion : Neurogenic ptosis caused by third nerve injury is associated with microvascular ischemia such as diabetes mellitus and hypertension. Operative management is carried out after 3 to 6 months observation. Evaluation of levator function allows the clinician to correctly classify the degree and type of ptosis. Maximal levator resection is the treatment of choice for ptosis with poor levator function.
 Conclusion : Although various surgical techniques have been developed, ptosis correction should be performed according to the indications and clinical condition of the patient.

Involutional Entropion of The Upper Eyelid: A Rare Case Report

Introduction : Entropion is a condition in which the eyelid folds inward or the edge of the eyelid folds inward, causing the eyelashes, eyelid margin, and skin to touch the eyeball. The most common entropion is involutional which caused by the aging process, but reports of cases of involutional entropion in the upper eyelid are rare.
 Case Illustration : A 66-years-old woman presented with redness, foreign body sensation and teary on both eyes. No history of trauma or foreign body exposure. She had a history with similar complaint 2 years ago. Upper eyelid turn inward, dermatochalasis, and corneal abrasion of both eyes were found in ophtalmic examination. Patient was diagnosed with involutional entropion of the left upper eyelid and treated with anterior lamellar repositioning (ALR). A week after the ALR procedure, on examination it was found that the position of the left eye's upper eyelid was good, there was still minimal swelling, with intact sutures.
 Discussion : Involutional entropion generally occurs in elderly patients over 60 years old and is more common in women. Progressive senile changes in the structure of the eyelid cause the occurrence of involusional entropion. Involutional entropion in the upper eyelid is associated with dermatochalasis. One management option for involutional entropion is ALR, which aims to pull the folded-in eyelid margin outward.
 Conclusion : This case shows that involutional entropion on the upper eyelid can still occur, albeit very rarely. ALR can be a simple and safe surgical option for patients with involutional entropion on the upper eyelid.

"Blue Scrub Lid Retraction": Changes in Eyelid Position on the Day of Surgery.

The aim of this study is to test the hypothesis that margin-reflex distance 1 (MRD1) on the day of surgery will be higher than the MRD1 measured at the in-clinic consult visit among patients undergoing blepharoptosis repair due to an increased sympathetic drive. Patients evaluated for involutional blepharoptosis repair were prospectively enrolled over a 12-month period in this single-center, self-controlled study. Three investigators independently determined MRD1 using cropped photos taken of patients at the in-clinic consult visit and on the day of surgery. A difference in height was tested for by using the 2-tailed Wilcoxon signed rank test. Evaluated in this study were 76 eyelids from 38 patients. Over 3-quarters of study participants had a higher MRD1 in the right and OSs on the day of surgery than at their in-clinic consultation visit (p < 0.001). The mean increase in MRD1 for the right eyelid and left eyelid was 1.0 mm (range: 0-3.15 mm) and 1.1 mm (range: 0-2.7 mm), respectively. In patients with involutional blepharoptosis, we conclude that MRD1 is higher on the day of surgery as compared with the in-clinic consult visit. This may be secondary to the stress of surgery and an associated increase in sympathetic drive. In some cases, this change in eyelid position led to resolution of apparent involutional ptosis altogether. Caution should be used when considering deferral of ptosis repair on the basis of exam findings present on the day of surgery.

The Prevalence and Severity of Acquired Blepharoptosis in US Eye Care Clinic Patients and Their Receptivity to Treatment.

To assess the presence and severity of acquired blepharoptosis (ptosis) among patients visiting an eye care clinic and the receptivity of eligible patients to pharmacologic treatment with oxymetazoline 0.1% ophthalmic solution. Patients aged 50 years or older who had a scheduled clinic appointment for any reason (eg, dry eye, cataract surgery consultation) were asked to respond to written questions about lid position and select whether their upper lid position most closely matched one of 4 images shown to them corresponding to no, mild, moderate, or severe ptosis. Patients selecting any of the mild, moderate, or severe ptosis were offered treatment with oxymetazoline 0.1% ophthalmic solution, barring any medical contraindications. The outcome measures were the proportion of patients with each self-reported lid position level (none to severe ptosis), the proportion of patients with asymmetric ptosis, and the proportion of patients willing to accept the treatment. Data for 188 eyes of 94 patients were analyzed. Overall, 73.4% of patients had ptosis in at least one eye, and 25.5% had an asymmetric upper eyelid presentation. The proportions of patients with self-reported mild, moderate, or severe ptosis in at least one eye were 41.5%, 25.5%, and 6.4%, respectively. Among those patients eligible for treatment, 19.7% were willing to accept the treatment. Based on patients' self-assessment of lid position, this study suggests a higher prevalence of ptosis than reported previously. Evaluation of the eyelids should be a standard part of the comprehensive eye examination.

Unexpected effect of upper eyelid blepharoplasty on lid position

Unexpected effect of upper eyelid blepharoplasty on lid position

Safety and Efficacy of Mucograft Porcine Collagen Bioengineered Acellular Dermal Matrix as a Spacer Graft in Lower Eyelid Elevation Surgery.

Recent regulatory changes have limited the access to a widely used commercially available bioengineered acellular dermal matrix (BADM) product as a spacer graft in the surgical correction of lower eyelid retraction. We report our off-label usage of Mucograft, a porcine BADM, as an alternative BADM. A retrospective review was conducted of patients undergoing bilateral lower lid surgery with Mucograft (12 eyes) at a single institution. For the six patients, there was a mean lower lid elevation of 1.93 mm, without any serious complications. There was greater elevation of the lower lid position for the Mucograft group compared with four septo-retractor control patients (1.93 versus 0.94mm, P = 0.008). Mucograft performed satisfactorily, and further investigation is warranted regarding its longer-term safety and efficacy.

Анализ эффективности дозированной хирургической резекции леватора верхнего века при лечении врожденного блефароптоза у детей

Purpose. Analysis of the clinical efficacy of dosed resection of the upper eyelid’s levator in congenital blepharoptosis in children. Material and methods. 54 children with congenital blepharoptosis (54 eyes) from 4 to 14 years old. It was diagnosed mild form in 4 eyes, moderate form in 11 eyes, and severe form in 29 eyes. In 47 children, blepharoptosis was complicated by obscurative amblyopia of various degrees (87%), in 21 children it was combined with concomitant monolateral strabismus: from +10° to +25° Hirschberg. Method of surgical resection of the upper eyelid’s levator with preservation of Whitnall’s ligament: linear skin incision along the orbito-palpebral fold, followed by isolation of the levator and it’s cutting off from the place of attachment to the tarsal plate by 5–18 mm (depending on the degree of ptosis). Three U-shaped sutures were placed through the levator with their subsequent fixation to the tarsal plate, with resection of the levator and two interrupted sutures on the skin with the capture of the underlying tissues in the areas of the outer and inner corners of the eye. All surgeries went as planned with no complications. Results. On the 10th day, 51 children had the correct position of the upper eyelid, in both eyes it became symmetrical. The palpebral fold was well contoured, it also became symmetrical in both eyes. The excursion of the upper eyelids in this group of children corresponded to that in paired eyes. In two children, the width of the palpebral fissure in the operated eyes turned out to be 1–2 mm less than in the healthy ones, in one child hyper effect of the operation was noted, he underwent reoperation. After 3 years, the initially achieved effect of the operation was preserved in 52 children (96.3%). Conclusion. The use of the technique of surgical resection of the upper eyelid’s levator in the treatment of blepharoptosis of various degrees of severity in children showed high clinical efficacy – 96.3% after 3 years of observation. Key words: congenital blepharoptosis in children, ptosis of upper eyelid, dosed resection of upper eyelid’s levator

Lower eyelid position before and after blepharoptosis repair

ABSTRACT Purpose This study aimed to examine the changes in lower eyelid position after blepharoptosis surgery and the factors that influence the outcome. Methods We conducted a retrospective study of 155 eyes of 89 patients who underwent blepharoptosis surgery between June 2019 and October 2022. The margin reflex distance (MRD)-1 and MRD-2 were examined preoperatively and 3 months postoperatively in two groups: one with lower scleral show (LSS) (n = 37) and one without LSS (n = 118). The clinical characteristics of the two groups were compared. Results Both the LSS and non-LSS groups showed significant postoperative improvement in MRD-1 scores (p < .01, p < .01, respectively). MRD-2 was significantly reduced in the LSS group, while it remained unchanged in the non-LSS group (p < .01, p = .27, respectively). There were no significant differences between the two groups in age, sex, history of hard contact lens use, preoperative levator function, use of topical steroids, history of endophthalmic surgery, or history of filtration surgery; however, the LSS group significantly used prostaglandin analogs (PGAs) (p = .03). Postoperatively, MRD-2 decreased in 13 eyes (35.1%) and was maintained in 24 eyes (64.9%) in the LSS group and was maintained in all eyes in the non-LSS group. In the LSS group, we also examined the association between postoperative MRD-2 reduction and the use of PGAs and found that more patients with MRD-2 reduction used PGAs (p = .02). Conclusion Lower scleral show in PGAs-associated blepharoptosis is expected to improve after blepharoptosis surgery.

Lower eyelid position after ptosis repair in patients with blepharoptosis.

To determine the changes in the lower eyelid position, following ptosis surgery of the upper eyelid of the same eye in blepharoptosis patients. This prospective interventional before and after study included patients aged more than 5 years with blepharoptosis. Margin reflex distance one (MRD-1), MRD two (MRD-2), and levator function were measured before and the 6 months after the surgery. Sixty patients with blepharoptosis (33 congenital and 27 acquired) were recruited. The mean age was 21.61 ± 10.82 and 59.8 ± 13.73 years in congenital and acquired groups, respectively. The mean MRD-1 improved from 1.95 ± 0.99 before treatment to 4.47 ± 0.47 after treatment (p < 0.001). The mean MRD-2 improved from 5.57 ± 0.63 before treatment to 4.95 ± 0.51 after treatment (p < 0.001). There was no statistically significant difference in MRD-1 and MRD-2 changes between the two groups (p > 0.05) There was no statistically significant correlation between MRD-2 changes and LF (r = -0.03. p = 0.83). Present study showed a significant improvement in the condition of the lower eyelid improved after upper eyelid ptosis surgery.

Efficacy and Safety of Processed Amniotic Fluid (pAF) Drops for the Treatment of Ocular Chronic Graft-Versus-Host Disease

Background: Ocular graft-versus-host disease (GVHD) affects more than 50% of patients with chronic GVHD and can lead to debilitating dry or painful eyes, impaired activities of daily living and poor quality of life. Management is mainly supportive, through control of surface inflammation, lubrication, and control of drainage and evaporation. Amniotic fluid (AF) is a rich source of nutrients, cytokines, and growth factors that has antimicrobial and immunomodulatory activities and may have reparative and regenerative roles in human disease. Investigators at the University of Utah developed protocols to collect AF from full-term pregnant women, process and sterile filter AF to separate cytokines and growth factors from residual cells and debris contained in the no-cellular fraction of AF, and treat patients with different conditions. We report the treatment effects and safety of processed AF (pAF) for the treatment of ocular GVHD. Methods: In this randomized, double-blinded, placebo-controlled phase II trial (NCT# 03298815), patients age ≥ 18 years diagnosed within 5 years after allogeneic hematopoietic transplant with ocular GVHD causing dry eye symptoms requiring lubricant drops &amp;gt;3x/day, punctal plugs, thermally cauterized puncta or special eyewear to relieve pain; or inability to work because of ocular symptoms; or loss of vision due to keratoconjunctivitis sicca were enrolled. Patients with any other chronic GVHD treated with &amp;gt;3 lines of therapy beyond corticosteroids with or without calcineurin inhibitors or sirolimus; or had a difference in dryness between both eyes of &amp;gt;2 points by the International Dry Eye WorkShop (DEWS) 2007 report; or were not willing to discontinue the use of medicated lubricant eye drops prior to randomization were excluded. Randomization was performed within participants, with one eye receiving one drop of pAF and the other eye saline treatment (placebo) twice daily for 30 days. In patients wearing scleral lenses, the eye drops were applied prior to lens insertion in the morning and after removal at night. Patients were allowed to resume their medicated eye drops after the 30-day treatment period. The primary objectives were to determine the day 30 overall response (complete and partial response) and safety of pAF. Response type to treatment is defined in Table 1. Key secondary objectives included longitudinal changes in visual acuity and the corneal surface, and patient-reported outcomes. Results: All fifteen patients' eyes were randomized to either pAF or saline treatment. The median age was 61 years (range, 35-72). At enrollment, six patients wore scleral lenses. The median baseline FACT-G score was 88 (range, 58-104). Baseline eye characteristics by treatment are shown in Table 2. Baseline NIH CC eye scores were similar between pAF and saline-treated eyes. The saline-treated group had more eyes with DEWS score 3 (n=7) compared to the pAF group (n=2). All 15 patients completed treatment. The overall response at day 30 in the pAF and saline-treated groups was 25% and 50%, respectively, p=0.38. All responding eyes had a partial response. No treatment-related serious ocular adverse events were observed. Two minor events occurred in the pAF treated eye group, including a change in eyelid position (n=1) and stinging after study drop application (n=1). There was no significant change in visual acuity and corneal surface staining between treatment groups at 30, 60, and 100 days. There was no significant change in the FACT-G score at 30, 60, and 100 days, and there was no significant difference in patient reported eye pain between pAF vs. saline-treated eyes over time (p=0.21). Conclusion: In this study, the primary endpoint of safety was met as there were few adverse events. One quarter of pAF-treated eyes responded. These findings justify evaluating pAF for ocular GVHD in a larger study. Limitations of this study included restricting patients to pAF application to twice a day and the study design of randomizing eyes within each subject as several patients had mild asymmetric disease between the two eyes. Other challenges included having delayed ocular assessments and/or altered perceptions of quality of life due to the COVID19 pandemic.

Effects of alcohol concentration and temperature on the dynamics and stability of mutant Staphylococcal lipase

The stability and activity of lipase in organic media are important parameters in determining how quickly biocatalysis proceeds. This study aimed to examine the effects of two commonly used alcohols in industrial applications, methanol (MtOH) and ethanol (EtOH) on the conformational stability and catalytic activity of G210C lipase, a laboratory-evolved mutant of Staphylococcus epidermidis AT2 lipase. Simulation studies were performed using an open-form predicted structure under 30, 40 and 50% of MtOH and EtOH at 25 °C and 45 °C. The overall enzyme structure becomes more flexible with increasing concentration of MtOH and exhibited the highest flexibility in 40% EtOH. In EtOH, the movement of the lid was found to be temperature-dependent with a noticeable shift in the lid position at 45 °C. Lid opening was evidenced at 50% of MtOH and EtOH which was supported by the increase in SASA of hydrophobic residues of the lid and catalytic triad. The active site remained mostly intact. An open-closed lid transition was observed when the structure was re-simulated in water. Experimental evaluation of the lipase stability showed that the half-life reduced when the enzyme was treated with 40% (v/v) and 50% (v/v) of EtOH and MtOH respectively. The finding implies that a high concentration of alcohol and elevated temperature can induce the lid opening of lipase which could be essential for the activation of the enzyme, provided that the catalytic performance in the active site is not compromised. Communicated by Ramaswamy H. Sarma

U-type soft tissue lifting: A new composited technique for reversing lower eyelid and midfacial aging.

Facial rejuvenation is becoming more and more popular, particularly among middle-aged persons. There are currently many techniques for improving the aforementioned situations, but each has its drawbacks. Our study aimed to discuss the treatment effect of a composited technique for reversing both lower eyelid and midface aging. The patient's face was designed and measured before surgery. During surgery, a traditional lower blepharoplasty incision was made. The layer between the orbital septum and the orbicularis oculi muscle was separated to approximately 4-5mm below the infraorbital, then the orbital septum and orbicularis retaining ligament were found to be released. A self-made suspension curving needle subconsciously passed through the brim of the superficial cheek fat pad via the "U-type" path and raised them to the proper location. Then sutured them to the infraorbital rim periosteum, as well as the suborbicularis oculi fat (SOOF) and the orbital septum fat. Secured the outside canthus to keep the lower lid position stable. From February 2020 to November 2022, 106 patients underwent the new surgical procedure and were successfully followed up for 20±6.5 months postoperatively. The mean GAIS score was 2.42±0.78, patient satisfaction rate was 95%. All of the Barton grades were decreased. The nasal base level suspension points were elevated to a level of 5±2mm. 3D measurement data revealed significant improvements. The composited technique is a safe and effective way to reverse the aging of the lower eyelid and midface.

Клинический случай комплексного лечения пациентки с паралитическим лагофтальмом, ассоциированным с нейротрофической кератопатией

Introduction. Combined leisure of facial and trigeminal nerves causes paralytic lagophthalmos and severe neurotrophic keratopathy that can lead to significant loss of vision. Material and methods. This article describes a clinical case of step-by-step complex surgical treatment in paralytic lagophthalmos accompanied by neuropathic keratopathy complicated by fistula of corneal graft. Results. The performed three stepped surgeries to improve lagophthalmos and corneal nerve supply resulted in subcompensation of lagophthalmos and restoration of corneal sensitivity up to the low limit. This was accompanied by heeling of long lasting corneal fistula. Conclusion. Pathogenetic treatment of combined paralytic changes, that includes correction of eyelid position and direct corneal neurotization, provides medical and social rehabilitation of patients with paralytic lagophthalmos complicated by neurotrophic keratopathy. Keywords: facial nerve, trigeminal nerve, neuropathic keratopathy, corneal neurotization, corneal fistula

Effects of pupil size in video head-impulse tests.

The results of video head impulse tests (video-HITs) may be confounded by data artifacts of various origins, including pupil size and eyelid obstruction of the pupil. This study aimed to determine the effect of these factors on the results of video-HITs. We simulated ptosis by adopting pharmacological dilatation of the pupil in 21 healthy participants (11 women; age 24-58years). Each participant underwent video-HITs before and after pupillary dilatation using 0.5% tropicamide. We assessed the changes in the vestibulo-ocular reflex (VOR) gain, corrective saccade amplitude, and frequency of eyelid flicks. After pupillary dilatation, the VOR gain decreased for both right (RAC; 1.12 [Formula: see text] 0.12 vs. 1.01 [Formula: see text] 0.16, p = 0.011) and left anterior canals (LACs; 1.15 [Formula: see text] 0.13 vs. 0.96 [Formula: see text] 0.14, p < 0.001), and right posterior canal (RPC, 1.10 [Formula: see text] 0.13 vs. 0.98 [Formula: see text] 0.09, p = 0.001). The corrective saccade amplitudes also decreased significantly for all four vertical canals. The frequency of eyelid flicks, however, did not change. The changes of VOR gain were positively correlated with the lid excursion in RPC (r = 0.629, p = 0.002) and LPC (r = 0.549, p = 0.010). Our study indicates that eyelid position and pupil size should be considered when interpreting the results of video-HITs, especially for the vertical canals. Pupils should be shrunk in a very well-lit room, and artifacts should be prevented by taping or lifting the eyelids as required during video-HITs.

Evaluation of eyebrow position and upper eyelid laxity after endolift laser treatment.

The periorbital area is one of the most sensitive areas in the face, and many techniques are used to change the eyelid laxity and position of the eyebrows. Recently the use of noninvasive or minimally invasive techniques is developed so, the amount of surgical procedures has decreased. In the present study. We evaluate the effect of Endolift laser as a non-invasive method on upper eyelid laxity and eyebrow position. Nine patients underwent Endolift laser and evaluated for eyelid laxity and change in eyebrow position. Two blinded physicians assessed the cosmetic outcome of improvement in upper eyelid tightening via photography 6 months post-treatment. The physicians evaluated the patient's improvement degree using the photographs by two clinical factors: skin laxity and total cosmetic result. Also, eyebrow height from the center of the pupil (CPEBH), Central eyebrow height (CEBH), Lateral eyebrow height (LEBH), Medial eyebrow height (MEBH) were measured by ImagJ before and 6 months post Endolift laser treatment. Our results showed eyelid laxity and eyebrow height were significantly changed after treatment.

Objective Diplopia Outcomes for Patients Treated With Teprotumumab for Thyroid Eye Disease.

Thyroid eye disease (TED) is a condition caused by inflammatory damage to the periocular tissue that often leads to double vision. Teprotumumab is an insulin-like growth factor 1 receptor antibody that was FDA approved for the management of TED in 2020, although much is yet to be elucidated regarding its effects on diplopia outcomes among patients with TED. Diplopia is a significant and life-altering effect of TED. Previous studies have reported the effect of teprotumumab on double vision subjectively using the Gorman diplopia score. However, there is a gap in the literature addressing the effect of teprotumumab treatment on objective ocular alignment measures. The purpose of our study was to address this gap. We performed a retrospective review of patients who were diagnosed with TED, presented with diplopia, and treated with teprotumumab in a single-center academic ophthalmology practice. The primary outcome was change in ocular alignment in primary gaze position at 6 months (completion of teprotumumab treatment). Secondary outcomes included change in ocular alignment in other gaze positions, proptosis, eyelid position, and clinical activity score (CAS) at 6 months compared with baseline. To determine what factors may predict ocular alignment response to teprotumumab, we analyzed baseline characteristics among 3 groups, divided based on whether ocular alignment was worsened, stable, or improved at 6 months. Seventeen patients met inclusion criteria, 3 (18%) worsened, 10 (59%) were stable, and 4 (24%) improved. CAS ( P = 0.02) was significantly different among the groups and was higher in those who worsened and those who improved compared with those who remained stable. Right gaze horizontal prism deviation ( P = 0.01) and left gaze horizontal prism deviation ( P = 0.03) were significantly different among the groups, with a greater degree of left gaze horizontal prism deviation in the worse group than the stable group ( P = 0.04). Our study demonstrated that most patients remained stable after teprotumumab treatment regarding ocular alignment in primary gaze and the number of patients who improved was slightly higher than the number of patients who worsened after teprotumumab treatment. There are some baseline measures, such as CAS and right and left gaze horizontal prism deviation that can help better predict how a patient will respond to teprotumumab treatment. Our results can better inform physicians of how to counsel patients with TED when considering teprotumumab therapy.

Efficacy of Combined Conjoint Fascial Sheath and Levator Muscle Composite Flap Suspension for Congenital Severe Ptosis.

Conjoint fascial sheath (CFS) suspension has been gradually recognized and accepted for the treatment of congenital severe blepharoptosis in recent years. To address the problem of postoperative upper eyelid position regression of only CFS suspension, the authors designed and implemented a CFS combined levator muscle (LM) complex flap, and analyzed the surgical efficacy of CFS with LM (CFS+LM) compared with frontalis myofascial flap (FMF) suspension surgery. Patients diagnosed with congenital severe ptosis and LM function of 4 mm or less were enrolled. The patients were assigned to either the CFS+LM group or the FMF group, to compare and statistically analyze the postoperative effects of CFS+LM versus FMF suspension. Data from 182 patients (220 eyes) were collected in this study, including 89 patients (103 eyes) in the CFS+LM group and 93 patients (117 eyes) in the FMF group. The full correction rate, patient satisfaction, postoperative upper eyelid excursion, and lagophthalmos in the CFS+LM group were significantly better than those in the FMF group. The eyelid retraction rate was significantly higher in the FMF group than in the CFS+LM group. The complication rate in the CFS+LM group was significantly lower than that in the FMF group. CFS+LM suspension had better outcomes than FMF suspension. Considering that the CFS tissue could be weak in patients younger than 5 years and have poor muscle elasticity in patients with LM function less than or equal to 1 mm, FMF suspension is recommended first. For patients older than 5 years with severe ptosis, CFS+LM suspension is recommended. Therapeutic, III.

Reconstruction of Large Full-Thickness Lower Eyelid Defects With Remnant Eyelid Rotation, Semicircular Skin and Muscle Flap, and Lateral Tarsoconjunctival Flap.

To describe and assess the results of reconstruction of large, full-thickness defects of the central or medial lower eyelid using a semicircular skin flap, rotation of the remnant lateral eyelid, and a lateral tarsoconjunctival flap. The surgical approach is described, and the authors performed a retrospective chart review of consecutive patients between 2017 and 2023 reconstructed with this technique. Outcomes were assessed for size of eyelid defect, vision, subjective symptoms, facial and palpebral aperture symmetry, eyelid position and closure, corneal examination, surgical complications, and need for subsequent surgical intervention. Postoperative appearance was graded on malposition, distortion, asymmetry, contour deformity, and scarring (MDACS). Charts of 45 patients were identified. The average size of the lower eyelid defect was 18 mm (ranging from 12 to 26 mm). Facial and palpebral aperture symmetry were acceptable and all patients had preserved visual acuity and eyelid position and closure. The MDACS cosmetic score was perfect (0) in 15.6% (7/45) of eyelids, good (1-4) in 80.0% (36/45) of eyelids, and mediocre (5-14) in 4.4% (2/45) of eyelids. Second stage reconstruction was not necessary in 32 (71.1%) cases. There were no serious surgical complications, but minor complications included redness of the eyelid margin and pyogenic granulomas. Medial rotation of the remnant lower eyelid with a lateral semicircular skin and muscle flap over a lateral tarsoconjunctival flap was very effective in this series. Benefits include scarring within the facial skin tension lines, maintained vision throughout the recovery period, no eyelid retraction, and often single stage reconstruction.