Eyelid Tension Research Articles

Assessment of Laser Parameters to Improve Lid Tension-A Proof of Concept towards Lasercanthoplasty.

Preliminary clinical work indicates that increasing eyelid tension improves the function of the meibomian glands. The aim of this study was to optimize laser parameters for a minimally invasive laser treatment to increase eyelid tension by coagulation of the lateral tarsal plate and canthus. Experiments were performed on a total of 24 porcine lower lids post mortem, with six lids in each group. Three groups were irradiated with an infrared B radiation laser. Laser-induced lower eyelid shortening was measured and the increase in eyelid tension was assessed with a force sensor. A histology was performed to evaluate coagulation size and laser-induced tissue damage. In all three groups, a significant shortening of the eyelids after irradiation was noticed (p < 0.0001). The strongest effect was seen with 1940 nm/1 W/5 s, showing -15.1 ± 3.7% and -2.5 ± 0.6 mm lid shortening. The largest significant increase in eyelid tension was seen after placing the third coagulation. Laser coagulation leads to lower eyelid shortening and an increase in lower eyelid tension. The strongest effect with the least tissue damage was shown for laser parameters of 1470 nm/2.5 W/2 s. In vivo studies of this effect have to confirm the efficacy of this concept prior to clinical application.

A modified 3D stereophotogrammetry-based distraction test for assessing lower eyelid tension.

To investigate the reliability of a modified three-dimensional distraction test (3D-DT) and three-dimensional pinch test (3D-PT) for assessing lower eyelid tension (LET). A cross-sectional study was conducted among 97 volunteers including 97 eyelids with no history of trauma, tumor, or reconstructive surgeries. Six three-dimensional photographs were acquired for each participant, including two photographs obtained in a neutral position (NP), two using a modified 3D-DT with a 15.9-grammes stainless steel eyelid hook performed, and two using 3D-PT. The mean absolute differences between NP, 3D-DT, and 3D-PT measurements varied between 0.07 and 7.42, 0.10 and 13.10, and 0.07 and 15.97, respectively; technical error of measurement varied between 0.05 and 7.81, 0.09 and 10.19, and 0.07 and 12.47, respectively; and relative error measurements varied between 0.10% and 11.50%, 0.16% and 30.51%, and 0.11% and 38.75%, respectively. For intra-rater reliability, the intraclass correlation coefficients (ICCs) were more than 0.80 in seven out of eight measurements obtained in the NP and 3D-DT, whereas those obtained in the 3D-PT were as low as less than 0.30 by rater 1; the ICCs of all the measurements obtained in all the positions (NP, 3D-DT, and 3D-PT) were more than 0.80 by rater 2. For inter-rater reliability six out of eight NP and 3D-DT measurements had an ICC greater than 0.80, whereas those of 3D-PT measurements were less than 0.30. For intra-method reliability, the ICCs of all the NP measurements were more than 0.87, whereas those of the six 3D-DT measurements and four 3D-PT measurements were more than 0.80. Our study results prove that the modified 3D-DT, which involves the use of an eyelid hook, can be a highly reliable method for evaluating LET. Furthermore, this novel and simple method may be utilized as the basis for further investigation and routine pre- and postoperative clinical evaluation.

Outcomes of surgery for epiblepharon accompanied with lower eyelid retraction secondary to buphthalmos in children.

ABSTRACTImportanceIn cases of epiblepharon with lower eyelid retraction secondary to glaucoma, correcting epiblepharon alone is ineffective. Combined surgery should be performed to obtain satisfactory outcomes.ObjectiveTo investigate outcomes after surgery to correct epiblepharon with lower eyelid retraction secondary to buphthalmos in children.MethodsA retrospective analysis of six eyes in four patients was performed included lower lid retractor recession combined with marginal rotation with tarsal fixation. The margin reflex distance‐2, lagophthalmus, resolution of clinical symptoms, and complications were assessed during 6 to 12 months of follow‐up.ResultsIn all cases, epiblepharon and lagophthalmus were corrected, symptoms of photophobia and epiphora were relieved, and the corneal epithelium was repaired. The margin reflex distance‐2 decreased and remained normal during the follow‐up period, but slightly regressed within 6 months postoperatively.InterpretationEpiblepharon caused by buphthalmos in children is often associated with lower eyelid retraction. Lower lid retractor recession combined with marginal rotation with tarsal fixation fundamentally solves the problems of high eyelid tension, lower eyelid retraction, and epiblepharon and reduces the recurrence rate.

A novel standardized distraction test to evaluate lower eyelid tension using three-dimensional stereophotogrammetry.

Standardized pre-operative assessment of the lower eyelid tension is essential to determine the optimal surgical technique. However, quantitative analysis using the conventional distraction test is inaccurate and user-dependent. Our purpose was to introduce a novel, standardized three-dimensional distraction test for measuring lower eyelid tension and to determine its standard values in a Caucasian population. In 94 participants (50 men and 44 women; age 21-85 years), a 15.9-g weighted eyelid hook was used to pull down the lower eyelid. Two three-dimensional images were acquired with a VECTRA M3 stereophotogrammetry device-one in the neutral position without a hook and the other in the distracted position with the eyelid hook. The images of all participants in both positions were measured twice by a single observer. There was no clinical (>1 mm) or statistically significant difference between the two repeated measurements of all the inter-landmark linear distances in both positions (P≥0.05, respectively). The mean distracted displacement between the neutral and distracted position for margin reflex distance was 5.50±1.53 mm, without any age-specific difference (P=0.08); however, a significant gender-specific difference was observed as men had significantly greater displacement than women (P<0.001). Our proposed standardized three-dimensional distraction test for assessing lower eyelid tension using an eyelid hook and a simple landmark-based system seems to provide high reliability. This novel and simple method might be helpful for the preoperative planning of eyelid surgeries.

Association of blepharoptosis with refractive error in the Korean general population.

We investigated the effect of blepharoptosis on refractive errors across different age groups in Korean population. This cross-sectional study was performed with data obtained in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2012. A total of 33,103 participants were enroled in our study. Blepharoptosis was defined as a marginal reflex distance 1 (MRD1) less than 2 mm, and was diagnosed in 3,305 (9.98%) participants. Ophthalmic examinations were performed, including measurements of MRD1, spherical equivalent, and degree of astigmatism. The age range was divided into three groups: less than 20 years old; more than 20 years and less than 60 years old; and more than 60 years old. The mean spherical equivalent were -0.28 ± 2.23 D in the ptotic eyelids and -1.13 ± 2.30 D in the non-ptotic eyelids (p < 0.001, 95% CI: -0.93, -0.77). The mean cylinder dioptre were -1.03 ± 0.87 D and -0.80 ± 0.77 D respectively (p < 0.001, 95% CI: 0.20, 0.26). The association with the eyelid position and refractive error significantly differed according to the age group and body mass index. Increased positive spherical change and increased astigmatism were prominent among ptotic participants aged less than 60 years. A decrease in MRD1 was associated with a hyperopic shift and higher astigmatism. Mechanical compression of the ptotic eyelid may affect ocular biometry, with the effect being particularly prominent in younger participants who had greater eyelid tension.

Lower Eyelid Horizontal Tightening in Prostaglandin Associated Periorbitopathy.

To determine the effect of chronic topical use of prostaglandin analogs for glaucoma on lower eyelid tension. A prospective case-control study was performed. Lower eyelid tension was measured in a group of glaucoma patients (73 eyelids) using prostaglandin analogs and a paired control group (87 eyelids). Seven glaucoma patients with unilateral use of prostaglandin analogs had the lower eyelid tension of the exposed side compared with the contralateral eyelid. Eyelid tension was digitally measured in photographs in neutral position and after manual downward traction in the center of the eyelid (modified distraction test). Duration of drug exposition, age, use of other topical medication and other prostaglandin-associated periorbitopathy signs as long eyelashes, eyelid hyperemia, eyelid pigmentation, and deepening of upper eyelid sulcus were recorded for analysis. Mean lower eyelid tension in prostaglandin group was significantly higher than in control group: distraction 5.26 mm (SD 1.52) versus 6.80 mm (SD 1.29) (p < 0.001). On the unilateral prostaglandin use intragroup comparison, mean lower eyelid distraction in prostaglandin side was 4.24 mm (SD 1.80) and in control side was 6.79 mm (SD 1.63) (p < 0.012). Beta blocker and carbonic anhydrase inhibitor concomitant use was associated with lower eyelid tension measures in prostaglandin users. Presence of long eyelashes was associated with higher eyelid tension. All other measured variables did not demonstrate interaction with eyelid tension. Chronic topical use of prostaglandin analogs for glaucoma is associated with lower eyelid tightening.

Lateral Canthal Sling Procedure for Meibomian Gland Dysfunction? Results of a Pilot Study

ABSTRACT Background: Involutional changes of lid structures often induce horizontal lid laxity; this can result in a reduction of Meibomian gland expression, potentially leading to symptoms of dry eye. The aim of this study was to evaluate the effect of tightening the lower eyelid via a lateral canthal sling (LCS) procedure on dry eye parameters. Methods: Patients with Meibomian Gland Dysfunction (MGD), lower lid laxity (positive Snap-back Test and positive Pinch Test) and no previous lid surgery were evaluated before and 3 months after LCS procedure for symptoms by OSDI. The fellow eye without surgery functioned as a control group. MGD parameters included lipid layer thickness (LLT), non-invasive breakup time (NIBUT), tear meniscus height, loss of Meibomian glands, lid margin parallel conjunctival folds (LIPCOFs), Schirmer’s test, the number of expressible Meibomian glands as well as quality of Meibum. Results: Fourteen patients (8 men and 6 women; 79.2 ± 4.0 years) were enrolled in this prospective clinical study. After 3 months, the OSDI showed a significant reduction (preop 42.9 ± 24.7; postop 23.8 ± 21.6; p = .002); NIBUT (5.5 ± 2.6 s to 9.9 ± 6.8 s p = .08) and LLT (64.3 ± 30.4 to 74.1 ± 27.8; p = .025) improved, while Schirmer Test (15.3 ± 4.7 mm to 11.9 ± 2.9 mm; p = .03) and tear meniscus height were reduced (0.8 ± 0.3 to 0.6 ± 0.2; p = .05). Meibomian gland loss scored by the meiboscale slightly increased postoperatively (1.2 ± 0.9 to 1.4 ± 0.9; p = .18). The number of expressible Meibomian glands improved (4.4 ± 2.6 to 6.8 ± 2.1, p = .002) as well as the quality of Meibum (0.9 ± 1.0 to 0.5 ± 0.8, p = .04). Snap back test as well the pinch test were negative in all patients postoperatively. Conclusion: Addressing lower lid laxity with an LCS procedure simultaneously enhances tear drainage, reduces tear film volume parameters and increases tear film stability results with an improvement of dry eye symptoms. It is likely that increased lower eyelid tension and thus excretory pressure on the Meibomian glands is responsible for these alterations.

Lateral Canthopexy in Lower Blepharoplasty: A Review Literature

Background: Lower eyelid malposition is a known complication of lower (lid) blepharoplasty surgery.The prevention of this complication is easier than its treatment. Over the past 10 years lot of patients havehad lower blepharoplasties with a canthopexy procedure and in some cases a tarsal strip canthoplasty. Thecriterion for a lateral tarsal strip canthoplasty was a lid distraction distance greater than or equal to 10 mm.Lid distraction distance is the distance the eyelid can be pulled away from the globe after the initial skinincision has been made and measured with calipers. If the eyelid can be pulled away from the globe less than10 mm, then a canthopexy is performed, which occurred in 98% of cases. Patients had lateral canthopexiesregardless of age or preoperative assessment. Herein, we describe a simple method of canthopexy that canbe performed on most patients having a lower blepharoplasty, to not only achieve a cosmetically superiorresult but also to prevent eyelid malposition or ectropion.Conclusion: We have described a simple prophylactic canthopexy suturing technique that all surgeonsperforming lower blepharoplasty can do to prevent rounding or ectropion. Naturally, the more cases that aredone, the more accurate will be the eyelid position and adequacy of eyelid tension achieved. Lateral tarsalstrip canthoplasty is also used in more advanced cases of lid laxity.

Intra- and interobserver reliability of a modified distraction test based on digital images to assess lower eyelid horizontal tension.

Inferior eyelid laxity is classically evaluated using "snap-back" and "distraction" tests. This study aimed to assess the reproducibility of the technique used to indirectly quantify the horizontal tension in the lower eyelids using digital image processing. This longitudinal study was conducted to assess the reproducibility of a new technique that quantifies the horizontal tension in the lower eyelid. The study was conducted at the Hospital das Clínicas of Porto Alegre. The protocol was established by two trained ophthalmologist examiners, allowing intra- and interobserver agreement analyses. Image acquisition was done in two stages: the first image was captured with the eyelid in primary gaze position and the second with the eyelid in traction position. All images and measurements were processed using Image J 1.33m software from the National Institute of Health. The Bland-Altman method, intraclass correlation coefficients, concordance correlation coefficients, and technical measurement error were used to evaluate reproducibility. The study participants comprised healthy individuals with no ophthalmologic pathologies. The measurements obtained in the neutral position showed a slightly higher agreement than those obtained in the traction position. The mean difference between the measurements performed in the traction position was 0.028 ± 0.7 mm and 0.014 ± 0.9 mm in the intra- and interobserver analyses, respectively. The Bland-Altman method demonstrated adequate confidence limits for both measurements. Correlation coefficients for measurements varied between 0.87 [95% confidence interval (CI) 0.68-0.95] and 0.91 (95% CI 0.77-0.97) in the neutral position and between 0.72 (95% CI 0.37-0.89) and 0.76 (95% CI 0.4-0.91) in the traction position. A high intra- and interobserver concordance was observed in the studied method to quantify lower eyelid tension. The proposed method is simple and easily reproducible, and to the best our knowledge, this is the first method that quantifies lower eyelid horizontal tension on the basis of digital image processing. This modified distraction test might be useful in studies quantifying lower eyelid horizontal tension.

Treatment Effects of Botulinum Toxin Injection and Acupuncture on Blepharospasm Assessed by the Change in Lower Eyelid Tension

ABSTRACTObjective: To investigate the treatment effects of botulinum toxin-A (BTA) injection and acupuncture on blepharospasm (BP) evaluated by the change in lower eyelid tension (LET).Methods: A series of 30 patients (male: 8, female: 22) aged between 37 and 83 years (63.80 ± 10.96 yrs) who met the eligibility criteria of BP were recruited in this study, who were randomly assigned to BTA injection group (BTA group, n = 15) and acupuncture treatment group (Acupuncture group, n = 15). BTA injections were administered to the patients in BTA group while patients in acupuncture group received the acupuncture treatment. The LET was measured by a tensiometer in both groups at baseline and at post-treatment.Results: A significant decrease in LETs over 8 weeks was found in acupuncture group (812.76 ± 193.95 Pa at baseline, 549.69 ± 150.04 Pa at 4 weeks, and 510.96 ± 150.66 Pa at 8weeks, respectively; F = 31.127, p << 0.001). There was a significant decrease in LET from 858.61 ± 190.54 Pa at baseline to 414.45 ± 63.38 Pa at 2 weeks after treatment (Z = −4.542, p << 0.01) in BTA group. At the endpoint of the study, a significant difference in LET was found between the acupuncture group (301.80 ± 181.77 Pa) and the BTA group (444.16 ± 193.44 Pa) (t = −2.077, p = 0.047).Conclusions: BP patients have an increased LET. Both BTA and acupuncture are effective in decreasing the LET. Close monitoring of LET holds promise in planning the treatment strategy for Blepharospasm.

A Review of Periocular Botulinum Neurotoxin on the Tear Film Homeostasis and the Ocular Surface Change.

Clinical usage of botulinum neurotoxin (BoNT) in ophthalmology has dramatically increased since the 1980s and has become one of the most widely used agents for treating facial movement disorders, autonomic dysfunction and aesthetic wrinkles. Despite its high efficacy, there are some complications with periocular BoNT injections due to its chemodenervation effect. Among these, there is still controversy over the BoNT effect on tear film homeostasis and the ocular surface. A periocular BoNT injection could dry the eye by reducing tear production of the lacrimal gland and increase tear evaporation due to potential eyelid malposition and abnormal blinks. On the contrary, the injection of BoNT in the medial eyelids could treat dry eye disease by impairing lacrimal drainage. Regarding the ocular surface change, corneal astigmatism and high-order aberrations may decrease due to less eyelid tension. In conclusion, the entire awareness of the effect of BoNT and the patients’ ocular condition is crucial for successful and safe results.

Lower eyelid tension balance reconstruction: A new procedure for the repair of congenital epiblepharon with epicanthus

Congenital epiblepharon with epicanthus (CEE) is a common eyelid malposition in Asian children, which generally involves the lower eyelid. The induced cilial entropion may cause constant ocular irritation that requires surgical repair. The purpose of this study is to report the outcomes and surgical details of a novel procedure, lower eyelid tension balance reconstruction (LETBR), for the correction of CEE. Patients diagnosed with CEE underwent LETBR, which consists of modified half Z epicanthoplasty, and fixation between marginal orbicularis oculi muscle and lower eyelid retractor was reviewed retrospectively. The outcomes were classified as 'good' with no cilia-ocular surface contact, 'fair' with 5 or fewer asymptomatic cilia-ocular surface points of contact and 'poor' with most of the eyelashes remaining in contact with the eyeball. The surgical outcomes (good, fair or poor), recurrence and complications were evaluated. One hundred and forty-nine eyelids of 78 patients (43 females and 35 males; mean age 6.6 ± 2.4 years, range 4-17 years) were evaluated in this study. The mean follow-up time was 14 months (range 9-24 months). At the last follow-up time, 144 of 149 eyelids were judged as 'good' (96.6%), the other 5 eyelids were judged as 'fair' (3.4%) and no eyelid was assessed with a 'poor' outcome. There were no significant complications or complaints about scarring on eyelids from patients or their parents. LETBR is effective, safe and stable for patients with CEE.

Objective Assessment of Ocular Surface Response to Contact Lens Wear in Presbyopic Contact Lens Wearers of Asian Descent.

Introduction:Contact lens wearers of Asian descent may be predisposed to experience microtrauma of the ocular surface as a result a thinner post-lens tear film and higher eyelid tension, and these effects would be anticipated to be most marked in an older population. The objective of this study was to quantify the mechanical effects of the study contact lenses on the ocular surface in a population of presbyopic contact lens wearers of Asian descent.Methods:Twenty established presbyopic contact lens wearers (hydrogel n=5, none habitual wearers of etafilcon A lenses; silicone hydrogel n=15) of Asian descent were refitted with etafilcon A multifocal daily disposable contact lenses (1-DAY ACUVUE MOIST MULTIFOCAL) for a period of 1 month of daily lens wear. The habitual modalities of wear were 45% daily disposable and 55% planned replacement. Digital photographs of the upper lid margins, nasal and temporal conjunctiva, and superior cornea were taken after 6 hr of wear of the participants' habitual contact lenses, after 1 day without contact lens wear, and after 6 hr of wear of the study contact lenses at the end of the 1-month period. The photographs were masked according to study visit and the staining extent measured using proprietary software.Results:Lid margin staining was significantly lower with the study contact lenses (2.0±1.0 mm2) than with the participants' own contact lenses (3.2±3.0 mm2) after 6 hr of wear, representing a mean staining decrease of 38% (P=0.010). Lid margin staining after 6 hr of wear of the study contact lenses was not different from that measured after 1 day without contact lenses (P=0.507). Limbal staining was also significantly less with the study contact lenses than with the participants' own contact lenses after 6 hr of wear (P=0.009). There was minimal upper corneal staining, and the degree was similar with the study and habitual lenses.Conclusions:Etafilcon A material, worn under a daily disposable modality, was shown to reduce upper lid margin and limbal staining in presbyopic contact lens wearers of Asian descent compared with the wearers' own contact lenses. Because of the high preponderance of dry eye amongst presbyopes, material selection is of importance and consideration should be given to the lens–ocular surface interaction.

Blepharoptosis following ocular surgery: identifying risk factors.

To evaluate the incidence of blepharoptosis following ocular surgical procedures, to elucidate mechanisms for its cause, and to identify potential risk factors for ocular surgeons to avoid. Postoperative blepharoptosis has been a poorly understood concept. In the search for a definitive cause, various technical components of surgery have been implicated. Recent research highlights the importance of individual anatomy and proposes new mechanisms for postoperative ptosis, including excessive eyelid tension from specula, topical prostaglandin analogue use, and direct trauma at the level of the tarsal plate. Blepharoptosis is common following ocular surgery and can occur through multiple mechanisms. Certain individuals are at a higher risk for postoperative blepharoptosis, but all surgeons and patients undergoing ocular surgery should understand this risk when providing informed consent. Operative techniques can be adjusted to decrease rates of postoperative blepharoptosis.

Lower Eyelid Tension in Young Adults Determined by a Simple Lid Tensiometer

Eyelid tension seems to be related to corneal astigmatism and to affect the ocular surface. The aim of this study is to determine the lower eyelid tension in young adults with a simple lid tensiometer. A commercially available precision digital pressure gauge that was connected to a pressure-guided tube full of water with a sensor at its end being placed between the lower eyelid and ocular surface was used as the lid tensiometer to measure the lower eyelid pressure at the central lid in 8 male and 12 female subjects aged between 20 and 39 years with normal healthy eyes. Measurements were respectively performed by 2 operators under the same conditions to test possible interoperator variation. The lower eyelid pressures of the 20 subjects measured by 2 operators at the central lid were 445.28 ± 121.17 and 458.65 ± 127.15 Pa, respectively. The test of interoperator variation demonstrated that there was good agreement between 2 operators (intraclass correlation coefficient = 0.965, F = 56.09, P < 0.001). Our simple lid tensiometer is a viable option for measuring eyelid pressure with good repeatability.

The Comparison of Astigmatic Outcomes after Cataract Surgery of Inferior versus Superior Clear Corneal Incision

Purpose: To analyze the difference in astigmatism and the mean change in total astigmatism between inferior clear corneal incision and superior clear corneal incision following cataract surgery in surgically-induced astigmatism (SIA). Methods: Fifty-five eyes of 55 patients with with-the-rule astigmatism >0.5 diopters were evaluated. Patients were divided into two groups according to incision location (Group 1, 26 eyes with an inferior incision; Group 2, 29 eyes with a superior incision). Patients were evaluatied one month postoperatively. Uncorrected visual acuity (UCVA, log MAR), best-corrected visual acuity (BCVA, log MAR), SIA and mean change in corneal astigmatism were measured in both groups. Results: One month postoperatively, mean UCVA was 0.15 ± 0.17 log MAR in Group 1 and 0.23 ± 0.24 log MAR in Group 2 (p = 0.253). Mean BCVA was 0.08 ± 0.13 and 0.08 ± 0.12 log MAR in Groups 1 and 2, respectively (p = 0.926). The SIA was 0.50 ± 0.17 diopter and 0.57 ± 0.34 diopter (p = 0.253) and mean change in total astigmatism was 0.50 ± 0.96 diopter and 0.38 ± 0.86 diopter in Groups 1 and 2, respectively (p = 0.426). Conclusions: There was no statistically significant difference between the two groups. Thus, corneal incision on the inferior side in patients of with-the-rule astigmatism can reduce the SIA and mean change in corneal astigmatism for patients with glaucoma, hard upper eyelid tension or sunken eye. J Korean Ophthalmol Soc 2014;55(10):1470-1475

Corneal epithelial permeability: Ethnic differences between Asians and non-Asians

To ascertain whether a difference in the permeability of the corneal epithelium to fluorescein (Pdc) exists between Asians and non-Asians. From a multi-study database we extracted 632 records of baseline, open-eye Pdc measurements taken on both eyes of 176 subjects. Subjects were awake for a minimum of 4h before measurement, and were free of ocular disease and central corneal staining. Pdc was transformed by natural logarithm to better approximate normality for statistical tests. The mean ln(Pdc) in the Asian group was significantly greater than in the non-Asian group [-2.34 ln(nm/s) vs. -2.58 ln(nm/s); p<0.001]. Compared with non-Asians, Asians exhibited a less negative ln(Pdc), which translates to a higher Pdc and a more permeable corneal epithelium. We speculate that this may be related to anatomic differences responsible for greater eyelid tension in Asians.

Concepts in Eyelid Biomechanics With Clinical Implications

The inner canthal orbicularis drives spontaneous blinking of the eyelids and is richly innervated by a branching network of twigs based largely on the buccal branch of the facial nerve. This segment of the orbicularis is relatively resistant to denervation from subciliary incisional approaches. Combined with proper eyelid tension, contraction of this segment of orbicularis results in the normal physiologic blink mechanism. The authors discuss how to achieve proper eyelid tension and position intraoperatively during the treatment of patients with a range of orbital morphologies.

Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy

External dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. The lower eyelid crease approach has been seldom reported. The purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. Prospective, interventional case series. Twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± SD= 44.84 ± 23.67) were included in the study. All patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. The inner canthus was photographed with a Nikon D70S digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. The resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). The surgery was easily performed in all patients with a 90.48% success. Three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. One patient had a hypometric blink which spontaneously recovered within one month. The mean score for scar visibility was 2.19 (1(st) mo), 1.65 (3(th) mo) and 1.44 (6(th) mo). The eyelid crease approach is an excellent option for external dacryocystorhinostomy. It leaves an unapparent scar since the first month after surgery, even in younger patients. The functional results are excellent and comparable to other techniques. Care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.

Tight orbit syndrome: a previously unrecognized cause of open-angle glaucoma: authors reply

hank you for your interest inour article ‘Tight orbit syn-drome: a previously unrecognizedcause of open-angle glaucoma’ (Leeet al. 2010a). We agree it is difficult toprecisely define the mechanism of thissyndrome (Lee et al. 2010b); however,we feel it is related to both eyelid and -orbital factors. Unfortunately, reliev-ing eyelid tension alone is not‘curative’ in these patients. In termsof exophthalmometry, most of thepatients in this series had deeply setglobes, rather than bulging orbits. Theattempt at imaging three of thesepatients did not reveal any consistentrelationship such as a greater axiallength⁄globe volume in a relativelysmall orbital volume. As you suggest,there is much racial variation with nowidely accepted ‘normal’ parameters.We hope that this initial descriptionwill stimulate further case descriptionsand further elucidate this uncommon,but blinding syndrome.