Horizontal Palpebral Aperture Research Articles

Artificial intelligence to automate assessment of ocular and periocular measurements.

To develop and validate a deep learning facial landmark detection network to automate the assessment of periocular anthropometric measurements. Patients presenting to the ophthalmology clinic were prospectively enrolled and had their images taken using a standardised protocol. Facial landmarks were segmented on the images to enable calculation of marginal reflex distance (MRD) 1 and 2, palpebral fissure height (PFH), inner intercanthal distance (IICD), outer intercanthal distance (OICD), interpupillary distance (IPD) and horizontal palpebral aperture (HPA). These manual segmentations were used to train a machine learning algorithm to automatically detect facial landmarks and calculate these measurements. The main outcomes were the mean absolute error and intraclass correlation coefficient. A total of 958 eyes from 479 participants were included. The testing set consisted of 290 eyes from 145 patients. The AI algorithm demonstrated close agreement with human measurements, with mean absolute errors ranging from 0.22 mm for IPD to 0.88 mm for IICD. The intraclass correlation coefficients indicated excellent reliability (ICC > 0.90) for MRD1, MRD2, PFH, OICD, IICD, and IPD, while HPA showed good reliability (ICC 0.84). The landmark detection model was highly accurate and achieved a mean error rate of 0.51% and failure rate at 0.1 of 0%. The automated facial landmark detection network provided accurate and reliable periocular measurements. This may help increase the objectivity of periocular measurements in the clinic and may facilitate remote assessment of patients with tele-health.

Restoration of the Lateral Canthus and Stabilization of the Lower Eyelid After Failed Esthetic Lateral Canthoplasty.

An improper procedure of esthetic lateral canthoplasty can lead to lateral canthal deformity with other complications. To ensure proper canthal contour and eyelid function, the lateral canthus must be restored and the lower eyelid must be stabilized. This was a retrospective study that included a group of consecutive patients who had failed esthetical lateral canthoplasty between 2020 and 2022. All patients underwent the modified lateral tarsal strip procedure to restore the normal anatomy of the lateral canthus and stabilize the lower eyelid. Clinical data (age, sex, laterality, follow-up, ocular symptoms, previous medical history, and lateral canthal deformity) were collected. Preoperative and postoperative photographs were analyzed for cosmetic outcomes. Among the 15 female patients, 25 eyelids were treated, including both eyes in 10 patients and only the left eye in 5 others. The mean age was 32.6 years. The mean follow-up was 13.34 months. All the patients had undergone esthetic lateral canthoplasty with other esthetic surgeries. Lateral canthus deformities include canthal webbing, rounding canthus, eyelid margin defect, remnant raw surface, mucosal exposure, lower eyelid retraction, sclera show, ectropion, symblepharon, and lagophthalmos. All the patients exhibited esthetically satisfactory results with improved ocular symptoms. In statistical analysis, horizontal palpebral aperture, vertical palpebral aperture, MRD2, and lateral canthus angle were statistically different pre to postprocedure (paired t test, P < 0.001). Restoration of the lateral canthus and stabilization of the lower eyelid using the modified lateral tarsal strip procedure showed good functional and cosmetic outcomes in patients who had failed lateral canthoplasty.

Normal periocular anthropometric measurements in an Australian population

PurposeTo report the normative ocular and periocular anthropometric measurements in an Australian cohort and investigate how these may be affected age, gender, and ethnicity.MethodsProspective study of patients presenting to the Royal Adelaide Hospital. Patient with orbital or eyelid disease, previous surgery, craniofacial abnormalities, pupil abnormalities, strabismus, and poor image quality was excluded. Standardised photographs were taken in a well-illuminated room. A green dot with a diameter of 24 mm was placed on the participant’s foreheads for calibration between pixels and millimetres. Ocular and periocular landmarks were segmented to calculate the periorbital measurements. Independent sample t test was used to compare male and female subjects, Pearson’s correlation was used to correlate periocular dimensions with age, and ANOVA with Bonferroni was used to compare periocular dimension between ethnic groups.ResultsSeven hundred and sixty eyes from 380 participants (215 female, mean age 58 ± 18 years) were included. The mean marginal reflex distance (MRD) 1 was 3.5 mm and decreased with increasing age (r = − 0.09, p = 0.01) and MRD 2 was 5.2 mm. Compared to Caucasians, African subjects had a significantly larger interpupillary distance and outer intercanthal distance, whereas East Asians had a significantly larger inner intercanthal distance (p < 0.05). The values of marginal reflex distance 2, palpebral fissure height, horizontal palpebral aperture, inner intercanthal distance, interpupillary distance and outer intercanthal distance were significantly higher in male subjects than female subjects (p < 0.05).ConclusionsNormative periocular dimensions may vary according to age, gender, and ethnicity. An understanding of normal periocular dimensions is important in the evaluation of orbital disease across different ethnic groups and may serve as reference points for oculoplastic surgery and industry.

Autologous fat transfer for orbital volume augmentation in sockets with small nonseeing eyes

End-stage ocular diseases usually end up with atrophic bulbi or phthisis bulbi leading to orbital volume loss which needs to be addressed. We studied the use of autologous fat for volume augmentation of the orbit because it is minimally invasive and allows early rehabilitation with the use of an artificial eye. It was a prospective, interventional study. A total of 14 eyes of 14 patients with atrophic bulbi with shrinkage or phthisis bulbi with no perception of light (PL) and aged older than 18 years were included for the study purpose. Painful or inflamed eyes or suspected intraocular tumors were excluded. An autologous fat graft was obtained from the lower abdomen or buttocks and injected into the retrobulbar space using a 20-gauge cannula after adequate peribulbar anesthesia. Outcomes measures were patient satisfaction, change in Hertel's exophthalmometry, vertical and horizontal palpebral aperture, and socket volume. Hertel exophthalmometry showed a significant improvement both with and without an artificial eye from 14.92±2.3mm to 16.71±1.94mm (p-value 0.003 without an artificial eye). The vertical palpebral aperture also showed a significant improvement from 5±1.70mm to 6.71±1.58mm (p-value<0.001). There was a significant reduction in the socket volume from 1.22ml to 0.39ml (p-value<0.001). No local or donor site complications were seen. Autologous fat transfer is a minimally invasive, safe, and effective procedure for orbital volume augmentation in small, nonseeing eyes. The short-term outcome of our study was good in most patients and can be considered for such patients.

The effect of lower eyelid malposition repair on palpebral fissure size changes

Objectives:The aim of the study was to evaluate the effect of changes in the horizontal and vertical palpebral fissure dimensions on surgical success performed due to entropion and ectropion of the lower eyelid.Methods:The present research was conducted as a retrospective and interventional case series who had undergone involutional lower eyelid malposition repair with a lateral tarsal strip (LTS) alone, LTS with a medial spindle, and LTS with the advancement of the lower eyelid retractors. The subjects’ medical records, including demographic and clinic characteristics, pre-operative assessment of horizontal eyelid laxity, and surgical outcomes, were reviewed. The distance between the pupillary light reflex and the lower-eyelid margin marginal reflex distance 2 (MRD-2) and the horizontal palpebral aperture (HPA) width were measured using the Image J program in the pre-operative and post-operative 6-month follow-up. The correlation between surgical success, changes in pre-operative and post-operative MRD-2, and HPA width was assessed by the Spearman rank correlation test.Results:A total of 66 eyelids of 48 patients were included in the study. This cohort comprised of 41 males (86.4%) and 7 females (13.6%), 18 of whom underwent bilateral surgery. The pre-operative mean MRD-2 was 7.13 ± 1.98 mm, and the post-operative 6-month mean MRD-2 was 6.21±1.19 mm (p<0.01). The mean post-operative HPA width was statistically significantly higher in comparison with the mean pre-operative HPA width (27.35±2.41, 26.89±2.39, p=0.02, respectively). There was no correlation between success rate and changes in horizontal and vertical palpebral fissure dimensions.Conclusion:LTS surgery is a method that turns the shortened HPA width to normal and enables the successful correction of the lower eyelid malpositions.

Long-Term Follow-Up of Lateral Canthal Resuspension.

To evaluate the long-term results of lateral canthal resuspension over time. A cohort study of adults (n = 25, 45 eyelids) undergoing lateral canthal resuspension. Marginal reflex distance 2 (MRD2), inferior scleral show, lateral canthal height, lateral canthal angle, horizontal palpebral aperture, and lateral scleral triangle area were measured preoperatively and at postoperative week 1, month 3, and the final follow-up visit. Minimum follow-up time was 6 months (mean, 15.1 months). At the final follow-up visit, MRD2 decreased by 0.41 ± 0.14 mm, inferior scleral show decreased by 0.27 ± 0.05 mm, and lateral canthal height increased by 0.81 ± 0.15 mm. The overall function of time was found to be significant for change in MRD2 (P < 0.01). In multiple comparisons, all time point values were significantly different from one another (Bonferroni corrected, P < 0.05), except for 3 months and the final position, which were not. Similarly, the overall effect of time on lateral canthus position was also significant (P < 0.01). All time points were significantly different from one another (Bonferroni corrected, P < 0.05). The overall effect of time on inferior scleral show was also significant (P < 0.01). Differences were significant from preoperative to final postoperative position, although the other time points were not significant (Bonferroni corrected, P < 0.05). No complications were noted. Minimally invasive lateral canthal resuspension provides durable, albeit modest, improvements in MRD2, inferior scleral show, and lateral canthal height without significantly changing lateral canthal angle, horizontal palpebral aperture, or lateral scleral triangle area.

Periorbital Soft Tissue Anthropometric Analysis of Young Adults.

The authors aim to determine the periorbital soft tissue anthropometric norms for Turkish young adults for right and left eyes using a noninvasive two-dimensional photogrammetric analysis. Anthropometric measurements of the periorbital soft tissue were taken from 172 female and 56 male Turkish adults aged between 18 and 24 years. The periorbital soft tissue profiles (ocular and palpebral) for males and females were digitally analyzed using linear measurements made with standardized photographic records, taken in a natural head position. Statistically significant differences were found for ocular soft tissue measurements according to gender except inner intercanthal distance (P = 0.125) and right horizontal palpebral aperture (P = 0.240). Statistically significant differences were found for palpebral soft tissue measurements according to gender except right pretarsal skin height (P = 0.112) and left pretarsal skin height (P = 0.056). Results were compared with other ethnic groups. Normal periorbital soft tissue measurements are fundamental anatomical parameters utilized in ophthalmology, optometry, ophthalmic industry, oculoplastic surgery, clinical genetics, dermatocosmetology. Further, normal anthropometric measurements generate reference data for studies in craniofacial dysmorphology, oculoplastic surgery, dermatocosmetology, and comparative physical anthropology.

Lateral Canthal Position Following Lateral Orbitotomy and the Influence of Ocular Proptosis.

Anecdotal evidence suggests that detachment of the lateral canthal tendon during lateral orbitotomy results in shortening of the horizontal palpebral aperture (HPA) and rounding of the lateral canthal angle (LCA). This study investigated the change in HPA and LCA following lateral orbitotomy and the effect of proptosis on the HPA. Retrospective, single surgeon, review of all cases undergoing lateral orbitotomy, comprising of a canthotomy and cantholysis and reconstruction of the lateral canthus using a single suture. The HPA and lateral canthal height (LCH) were measured on pre- and postoperative photographs using ImageJ software. Changes in the LCA and degree of proptosis were also investigated. Exclusion criteria included previous eyelid surgery, acute trauma, and less than 6 months' follow up. There were 41 cases of lateral orbitotomy in 27 patients, 67% female, average age 51 years. Twenty patients had thyroid eye disease of which 14 underwent bilateral surgery; the other 7 patients had a variety of orbital pathologies. Thirteen patients underwent unilateral orbitotomy with the contralateral eye serving as a control. Average follow up was 23 months. Overall, the HPA and proptosis were reduced by 0.6 mm (p = 0.143) and 3.4 mm (p < 0.001), respectively. A 0.2-mm reduction in HPA was observed for every 1-mm reduction in proptosis. A difference in post-orbitotomy HPA was observed between cases and their matched controls (p = 0.016). No rounding of the LCA or significant change in LCH was observed following lateral orbitotomy. The described technique of lateral orbitotomy and simple reconstruction do not appear to cause lateral canthal drift or rounding. There was no significant change in HPA or LCH. The degree of change of proptosis does appear to influence the change of HPA.

소프트콘택트렌즈 피팅과 관련된 가시홍채직경 및 검열크기에 대한 상관관계

목적: 초등학생에서 일반인을 대상으로 가시홍채직경(수평, 수직) 및 검열의 폭과 길이를 측정하여 이들의 상관관계 및 소프트콘택트렌즈 크기의 연령별 적합성을 알아보고자 하였다. 방법: 안질환이 없고 외형적으로 미용을 포함한 눈 수술을 하지 않은 초등학생에서 일반인 총 514명(1028안)을 대상으로 가시홍채직경(수평, 수직)과 검열의 폭과 길이를 측정하고 분석하였다. 결과: 가시홍채수평직경과 수직직경은 연령별 남녀 간의 유의한 차이는 없었으나, 중학생과 대학생의 검열의 길이와 고등학생의 검열의 폭은 남학생과 여학생 간 유의한 차이가 있었다(p<0.05). 또한, 남녀 모두 가시홍채수평직경, 가시홍채수직직경, 검열의 길이 그리고 검열의 폭에서 연령별로 유의한 차이를 보였다. 가시홍채직경과 검열의 크기는 문헌에 기준한 정상범위 근사치보다 검열의 폭은 남녀를 포함한 전체 대상자의 27.9%, 가시홍채직경은 36.0%가 작은 것으로 나타났다. 결론: 가시홍채직경과 검열의 크기는 소프트콘택트렌즈의 직경 결정에 영향을 미치며, 특히 렌즈 삽입시 피검자의 불편함을 덜어주기 위해서 좀 더 세심하게 고려되어야 할 사항이라고 사료된다. Purpose: In order to find suitable size of soft contact lens for different ages group of elementary student to adults, visible iris diameter(horizontal, vertical) and palpebral aperture size were measured. Methods: Visible iris diameter (horizontal, vertical) and palpebral aperture size were measured in different age groups of total 514 subjects (1028 eyes) who have no eye disease and none history of surgery included cosmetic purpose. Results: No significant difference was found in iris diameter of both horizontal and vertical direction for different groups of age and sex but horizontal direction of palpebral aperture size in middle school students and university students groups and vertical direction of palpebral aperture size in high school student group shows significant difference (p<0.05) by sex. Horizontal visible iris diameter, vertical visible iris diameter, horizontal palpebral aperture size and vertical palpebral aperture size shows significant difference in difference age and sex. Conclusions: Visible iris diameter and palpebral aperture size are affective factor for soft contact lens diameter decision, especially it should considered more intensive for removing uncomfortable feeling of lens wearer.

Surgical preferences for lateral canthoplasty and canthopexy.

To describe the currently used techniques of lateral canthal tightening and their indications. The treatment of involutional ectropion involves horizontal tightening of the lower eyelid via a lateral canthal resuspension procedure, which can be either a canthopexy or a canthoplasty. The lateral tarsal strip, one of the most common canthoplasty procedures performed today, is a powerful technique, very useful in cases of profound eyelid laxity or ectropion in which horizontal eyelid shortening is necessary to achieve adequate eyelid tightening.For less-severe eyelid laxity, a canthopexy can be performed through either an upper or a lower eyelid incision, in which the suture is passed through the eyelid incision without externalization at the lateral canthal angle. We recently described the lateral canthal resuspension sine canthotomy technique that was slightly more effective than the lateral tarsal strip at decreasing the MRD-2 and lengthened the horizontal palpebral aperture without significantly changing the lateral canthal height. Although the lateral canthal resuspension sine canthotomy technique has advantages for tightening loose lower eyelids in both cosmetic and functional cases, the lateral tarsal strip remains the procedure of choice for severe lid laxity or ectropion.

Lateral Canthal Resuspension Sine Canthotomy

The purpose of this study is to describe a novel canthopexy technique-the lateral canthal resuspension sine canthotomy (LCR-SC)-performed via an upper-eyelid incision and to compare it with the lateral tarsal strip procedure (LTS). This is a retrospective study in which the pre- and postoperative photographs of 20 patients per group who had LCR-SC, LCR-SC + midface lift (LCR-SC+ML), or LTS were analyzed by using the Image-J 1.40 software. Parameters measured were as follows: the horizontal palpebral aperture margin-reflex distance 2 (MRD-2) and the height of lateral canthus. LCR-SC was performed through an upper-eyelid incision, by using a 4.0 Prolene suture. For the LCR-SC+ML, a large myocutaneous flap was created first and anchored to the orbital-rim periosteum. The surgical technique is described. Two-way ANOVA was used for analysis. The horizontal palpebral aperture was significantly increased by LCR-SC and LCR-SC+ML when compared with LTS (1.61 ± 0.22 mm and 1.56 ± 0.14 vs. 0.04 ± 0.12 mm; p < 0.01). LCR-SC and LCR-SC+ML decreased the MRD-2 more than the LTS (1.06 ± 0.26 and 1.50 ± 0.23 mm vs. 0.86 ± 0.1 mm; p < 0.01). All 3 procedures increased the lateral canthal height by less than 0.5 mm. LCR-SC is a safe and effective procedure for tightening the lower eyelids. It tightens both the upper and the lower cruri of the lateral canthal tendon, avoiding imbrication of the eyelids. LCR-SC obviates the need for a lateral canthal incision and widens the horizontal palpebral aperture. LCR-SC is more effective than LTS at decreasing the MRD-2. Concomitant midface elevation (LCR-SC+ML) further decreases MRD-2.

The distinguishing anthropometric features of the Saudi Arabian eyes

Purpose Identifying the peri-ocular anthropometric measurements characteristic of Saudi Arabian eyes. Methods A prospective, cohort, hospital-based study. Results Measurements were made on 668 subjects (mean age 33.8 years; 58.7% female). The horizontal palpebral aperture was 30.1 ± 2.9 mm (mean ± SD), vertical palpebral aperture was 10.1 ± 0.85 mm, upper lid skin fold height was 3.6 ± 1.9 mm, upper lid crease height was 9.6 ± 0.8 mm, eyebrow height was 10.2 ± 2.7 mm, and intercanthal distance was 32 ± 2.7 mm. There was a statistically significant correlation between gender and eyebrow height ( P = 0.001) and gender and horizontal palpebral aperture ( P = 0.016), but no significant correlations were noted between any measurement and age. Conclusions Saudi Arabian eyes are unique in exhibiting a higher upper lid skin fold, higher lid crease.

The Morphology of the Palpebral Fissure in Different Directions of Vertical Gaze

The purpose of this study is to investigate the normative morphology of the palpebral fissure by measuring a range of biometric eye dimensions for a population of young subjects through analysis of digital images in primary gaze and two typical angles of downward vertical gaze. Palpebral fissure characteristics are clinically important in areas such as contact lens practice. High-resolution digital images were taken of 76 young subjects with a range of refractive errors in primary gaze and 20 degrees and 40 degrees downward gaze. The digital images were analyzed to ascertain a range of biometric measures of the palpebral fissure for each subject in each angle of gaze. Repeated-measures analysis of variance was used to investigate changes occurring in the palpebral fissure dimensions with vertical angle of gaze. Highly significant changes were found to occur in the horizontal and vertical palpebral fissure dimensions, the palpebral fissure angle, and the eyelid contour as a function of angle of gaze. The palpebral fissure narrows in the vertical dimension (from an average vertical palpebral aperture width for white subjects in primary gaze of 9.7+/-1.2 mm to an average width of 6.4+/-1.1 mm in 40 degrees downgaze), shortens in the horizontal dimension (from average horizontal palpebral aperture width of 27.1+/-1.5 mm in primary gaze to an average of 25.6+/-1.8 mm in 40 degrees downgaze), and becomes more "down-slanted" with increasing downward gaze. Highly significant changes to the palpebral fissure dimensions occur in downward vertical gaze. These changes are important because many visual tasks are performed in downward gaze. These findings have implications for the management of lid anomalies and for contact lens fitting and design.

Reconstruction of the horizontal palpebral aperture after failed ectropion surgery with temporal migration of punctum.

Involutional ectropion of the lower lid is the result of progressive stretching and elongation of the lid margin and medial and lateral canthal tendons. The relative laxities of the components of the lower lid-canthal tendon complex will determine the location and extent of the ectropion. Whereas inadequate canthal tightening or horizontal lid shortening will result in recurrent ectropion, overzealous lid shortening without tendon plication will result in a noticeably narrower horizontal palpebral fissure, a persistent ectropion, or temporal migration of the punctum. We used lateral cantholysis, medial canthal tendon plication, and punctal rotation to return the punctum to its normal position and temporalis muscle to support the lower lid in eight cases in which previous procedures had failed to correct the lid malposition. In all eight cases there was improvement of the lid position. In one case of severe medial ectropion, the punctal eversion was not completely corrected. This technique is not recommended as an initial procedure for ectropion repair. It is only used to manage previous surgical failures. It is a new application and combination of well-accepted techniques.