Lower Eyelid Margin Research Articles

Palpebral Fissure Changes in Early Childhood

To describe palpebral fissure changes during early childhood. Digital imaging was used to analyze the monocular palpebral fissure images of 185 children and 35 adults. Six variables were quantified for each eye: the distance between the pupil center and the upper and lower eyelid margin, the palpebral fissure area, and the obliquity and length of the fissure. The lower eyelid crease pattern also was evaluated qualitatively. The upper eyelid was at its lowest position after birth, and the lower eyelid margin was close to the pupil center. Between ages 3 and 6 months, the position of the upper eyelid reached its maximum and then declined linearly. At the same time, the distance between the pupil center and the lower eyelid margin increased linearly until age 18 months when its position stabilized. Both the horizontal palpebral fissure length and the fissure area followed a logarithmic pattern of growth and were strongly correlated. The obliquity of the fissure was evident at an early age and did not change until adulthood. At birth, the most common pattern of the lower eyelid crease was a single crease. The number of individuals showing a double crease increased with age, and at approximately age 36 months, a double crease became the most common pattern. The palpebral fissure undergoes complex changes during infancy. An accurate knowledge of these changes is important for evaluating eyelid disorders in children.

The Geometrical Basis of the Eyelid Contour

To derive a two-dimensional, frontal-view model of eyelid contour. Observational study. Palpebral fissure images of 110 normal subjects were acquired with a charge-coupled device camera and processed with National Institutes of Health Image software on a Macintosh computer. Monocular frontal-view images of the palpebral fissures were recorded and second-degree polynomial functions were fitted to both upper and lower eyelid contours for two areas: the whole eyelid margin (ciliated and inner canthal portions) and the ciliated portion alone. In addition, frontal and lateral palpebral fissure images were obtained. From the frontal view, the upper and lower ciliated contours were fitted with quadratic functions. From the lateral view, the upper and lower lateral angles, formed by the upper and lower eyelid margins and the axial axis, were measured. Exclusion of the inner canthal portion of the eyelid contour led to a much better quadratic fit for the contours. The sine (sin) of the upper lateral angle was strongly correlated with the parameter A of the quadratic function fitted to the upper eyelid (the parameter A determines the curvature of the function around its extremum point). For the lower eyelid, this correlation was not significant. The parabolic shape of the upper ciliated contour seen in two-dimensional images can be justified geometrically in a simple way, allowing a precise quantification of its shape. The same was not true for the lower eyelid. The parabolic shape of the upper eyelid can be demonstrated, using the Taylor series, to be a close approximation of the arc of a circle.

Topographic anatomy of the eyelids, and the effects of sex and age

AIMSTo describe the effects of sex and age on eyeball, eyelid, and eyebrow position.METHODSA cross sectional cohort study was performed in which both eyes of 320 normal subjects aged between...

Eyeball position in Graves orbitopathy and its significance for eyelid surgery.

The goal of this article is to investigate the effect of Graves orbitopathy and orbital decompression on the position of the eyeball, and to relate this to a straight upper eyelid contour, observed in several patients after correction of upper eyelid retraction. The positions of the pupil center and the upper and lower eyelid margin were measured in relation to a reference line through the medial canthi, on slides obtained from 120 eyelids before and after correction of upper eyelid retraction, and on similar slides obtained from 90 control eyelids. In control subjects, the distance between the reference line and the pupil center was, on average, 4.5 mm (SD 1.2 mm). In decompressed patients, the pupil center was, on average, 2.2 mm lower (SD 1.3 mm), and in nondecompressed patients it was, on average 1.0 mm lower (SD 1.2 mm). A relatively straight upper eyelid contour after otherwise satisfactory correction of upper eyelid retraction was observed in 14 eyelids of 8 patients. All cases occurred in decompressed patients with a distance between the pupil center and the reference line of 2 mm or less. No significant difference was found in the position of the lateral canthal angle between the three groups. Many patients with Graves orbitopathy show a downward shift of the pupil center in relation to a reference line through the medial canthi. This is partially caused by orbital decompression, but also by other factors discussed by the authors. If the distance between this reference line and the pupil center is 2 mm or less, otherwise satisfactory correction of upper eyelid retraction may cause visible straightening of the upper eyelid contour.

A simple method of noninvasive canthopexy during routine lower blepharoplasty

Lower blepharoplasty treats one of the most delicate and sensitive areas in plastic surgery. Often slight weakness, redundancy, or shortness of the lower eyelid will produce unsightly results and an unhappy patient. I tackled this problem about 18 years ago with a split skin-skin muscle flap technique with lateral suspension.1 This technique, in most cases, is adequate in firming the lower lid laxity, which is often preexisting and is worsened by blepharoplasty. For lack of better terminology, this laxity could be called “presenile ectropion” (Figure 1). Figure 1. Typical appearance of presenile ectropion. In some cases, however, laxity will still occur. During the last 10 years, I have tried a variety of techniques of canthopexy. I have found the techniques presented in this article to be the least invasive; they provide a very effective means of firming up the lower lid margin, not only in its inferior-superior dimension, but also in the anterior-posterior direction, resulting in close contact of eyelid to eyeball. Basically, the preseptal part of the orbicularis muscle is sutured to an area under the lateral palpebral ligament at the lateral orbital rim (Figure 2). Thus, while tightening the lower lid, it helps to reduce the nasojugal and zygomatic fold of the lower lid with conservative lift of the cheek and nasolabial fold. The higher point of insertion permits lateral orbital rim structures, orbicularis muscle, and lateral tarsal ligament to be detoured to a higher point without detaching and resuturing all these structures (Figure 3). In effect, it shortens and firms up the lid margin and lifts the lateral canthal angle upward. This method (procedure 1) is adequate in most cases. Figure 2. Direction of vector of pull of preseptal part of orbicularis muscle under lateral canthal ligaments. Figure 3. The goal of surgery—to shift the whole lateral eyelid higher without shortening …

A Measurable Subjective Patient Response to the Dry Eye

Patients with "dry eyes" are often poor prospects for successful contact lens wear. Screening out these patients could improve contact lens practice. Currently used diagnostic tests, such as the Schirmer strip test or the time for tear film breakup, are not very effective in identifying the dry eye patient who may have trouble wearing a contact lens. A new test is described here that asks the patient to report the time to disappearance of the pillar-like flare image seen above a disk light source. A flare image is created by the tear prism in the lower lid margin. This test, when it was applied to a small group composed of young, middle-aged, and elderly adults, was able to correlate rapid disappearance of the flare image with the presence of typical dry eye syndrome complaints in two subjects.

Single Tarsoconjunctival Flap (Lower Eyelid) for Upper Eyelid Reconstruction ("Reverse" Modified Hughes Procedure)

We present a two-stage reconstruction of partial or total full-thickness upper eyelid defects. In the first stage, a single tarsoconjunctival flap from the donor lower eyelid reconstitutes the posterior lamella, and a full-thickness skin graft reconstructs the anterior lamella. In the second stage, 5 to 8 weeks later, the skin tarsoconjunctival flap is severed. The single tarsoconjunctival flap we describe is analogous to the modified Hughes reconstruction for full-thickness lower eyelid defects and thus may be termed a "reverse" modified Hughes procedure. In the lid-sharing Cutler-Beard procedure, the popular alternative, the full-thickness lower lid is advanced into the upper eyelid defect. Our procedure provides greater stability due to the increased amount of vertical tarsus in the reconstructed eyelid. Also, in our procedure, the tarsoconjunctival flap is incised 1.5 to 2 mm from the lower eyelid margin rather than the 4 to 6 mm necessary to preserve the marginal artery in the Cutler-Beard procedure. With a follow up ranging from at least 6 months to over 2 years, the only complications among the 10 patients in our series were pyogenic granuloma at the edge of the donor lower eyelid, and mild, medial upper eyelid blepharoptosis. There were no cases of cicatricial entropion of the upper eyelid, a known complication of the Cutler-Beard procedure.

Physiology of the Lower Eyelid Retractors

Although the histologic anatomy of the lower eyelid retractors is well defined, the physiology of the lower retractors has been determined only by interference based on anatomic and clinical findings. In this study, in five normal subjects we investigated the physiology of the lower eyelid retractors utilizing dynamic high resolution magnetic resonance imaging (MRI) with a custom designed surface coil. Measurements of the excursion of the cornea, lower eyelid margin, and anterior edge of the inferior oblique muscle were made from scans taken in upgaze and downgaze. We found that the corneal movement was substantially greater than the movement of the eyelid margin, a finding that can readily be made clinically. A more important result was that the movement of the eyelid margin and the movement of the inferior oblique margin were similar in all cases. Thus, the length of the anterior capsulopalpebral fascia between the tarsus and inferior oblique muscle remains constant in downgaze, and the source of the stretch in the lower eyelid retractors lies in the posterior capsulopalpebral system, at the capsulopalpebral head. High resolution eyelid MR has great potential to allow investigation of essential aspects of normal and pathologic eyelid anatomy and physiology.

Refinements of the Tarsal Strip Procedure

We present several refinements in technique that simplify the tarsal strip procedure and enhance its results. Among these refinements are: electrosurgical deepithelialization of conjunctiva and lid margin, use of a V-shaped needle, direct needle passage about the lateral orbital tubercle, and the parallel placement of a buried absorbable suture to unite the upper and lower lid margins and to maintain a long-lasting sharp canthal angle. We have used these maneuvers in 45 patients with few complications; patient acceptance has been high. Also, we have found that using these maneuvers is helpful in teaching the procedure to residents.

Surgical Treatment of Thyrotoxic Exophthalmos

Conservative treatment of thyrotoxic exophthalmos has not given satisfactory results. Our observations, modifications of the standard surgical technique, and the results of orbital decompression for this condition are presented. Through a transverse incision close to the lower eyelid margin, the floor and the lateral orbital wall are explored. The posterior part of the orbital floor and the zygomatic part of the lateral orbital wall, as well as the periorbital fat, are removed. Through an incision made over the medial margin of the orbit, the medial orbital wall is explored and its ethmoidal part is removed. By the same approach, further retrobulbar fat is removed. Through an upper eyelid incision, fat is removed from the eyelid region and the levator aponeurosis is divided. This produces satisfactory symmetrical decompression of the orbit with good correction of exophthalmos and a significant decrease in the signs and symptoms of this condition.

An operation for senile entropion

The factors are important in the aetiology of senile entropion—rotation of the tarsal plate and loss of attachment of skin and orbicularis to the deeper tissues. they can be corrected by excising a full-thickness triangle, apex up, from the central part of the lower lid. the operation is simple and successful. Its main disadvantage is a temporary pucker in the lower lid margin, which disappears in a few weeks.

Morpheic Plaque of the Lower Eyelid

REPORT OF A CASE A 77-year-old retired businessman noted an asymptomatic lesion on his right lower eyelid. He was an avid golfer and had been treated for numerous actinic keratoses and a basal cell carcinoma of the right nasolabial fold in the past. His medical history also included treated pulmonary tuberculosis, carcinoma of the prostate treated with radioactive iodine in 1978, and multifocal transitional cell carcinoma of the bladder, which led to a radical cystectomy in 1981. Examination showed a morpheic plaque on the right lower eyelid margin, extending onto the skin of the eyelid (Fig 1). A skin biopsy specimen showed a normal epidermis with nests of epithelial cells filling the dermis and extending into the underlying muscle of the eyelid (Fig 2). Nuclear atypia was present, and occasional mitotic figures were seen. Some of the nests showed cells with foamy vacuolated cytoplasm (Fig 3). What is your diagnosis?

The Board Case

I considered it a fortunate coincidence that he came to see me in the first place. I was in the infancy of my plastic surgery practice, at a time when any truly challenging patient is considered a windfall, an act of God, perhaps even a board case. Everett was 24 and handsome, with a large, deep malignant melanoma on his lower eyelid margin—a prognostic, anatomic, and cosmetic disaster. His understandably frantic mother took him from the dermatologist who had performed the original biopsy to another, perhaps in the hope of obtaining a better diagnosis. The dermatologist referred them both to a plastic surgeon, who was on his way out of town, and thus they were directed to me. Everett seemed much less concerned than his mother or, as a matter of fact, than I about the seriousness of his problem. I presented everything as optimistically as I could. They told

Epidermal and papillary dermal characteristics of the bowhead whale (Balaena mysticetus).

Skin samples from most body regions of the bowhead whale were examined. The epidermis is 2.7 to 50 times thicker than that reported in other cetaceans with both regional and individual variations in thickness. The thinnest areas examined (1 mm) occur on the eyelid margins and the thickest (25 mm) occur on the lower jaw. A distinctive parakeratotic stratum corneum with a thick underlying stratum spinosum (without a stratum granulosum) extends over the entire body surface. From a few dozen to several hundred epidermal lesions are present on all whales studied. A typical stratum basale of germinative keratinocytes (with melanocytes in pigmented areas) rests upon a well-defined basal lamina. Epidermal rod arrays arise from the basal keratinocytes which cover highly elongated dermal papillae and extend to the epidermal surface through the distal stratum spinosum and the stratum corneum. At least four diatom genera occur on and in the stratum corneum and lesion areas of different whales. The superficial dermis consists of a papillary layer with long (up to 13 mm) dermal papillae interdigitating with the epidermis from a basal area that is 2-4 mm in thickness. The number of dermal papillae per mm2 varies inversely with the thickness of the epidermis. Large diameter, sensory papillae packed with tortuous, highly elongated, encapsulated nerve end organs also interdigitate with the thin epidermal areas of the ventral surface of the rostrum, the upper and lower lip margins, and the upper and lower eyelid margins. Scattered, single, stiff hairs emerge from the skin only in specific, pigmented regions of the head.

Natural fat in external eye. Vital-stained by Sudan III powder.

Examination of 113 eyes vital-stained by Sudan powder revealed that fat on the skin of outer canthus may pass onto the precorneal film (in 68%), and that the most reliable staining is obtained by application on the bulbar conjunctiva below the limbus corneae at 6 o'clock. In 41%, the precorneal film had stained drops or foam, with a tendency towards an increase among pathological cases (infectious conjunctivitis and blepharitis). An increased amount of fat was found in the mucous thread of eyes affected with infectious conjunctivitis and lagophthalmos. In a small number of pathological cases fat was also detected on cornea, bulbar conjunctiva, and inferior fornix. The fatty layer on the lower lid margin was stained more frequently and more intensely than that on the superior. The secretion of the meibomian glands was stained in no more than a scant one half of the glands (on an average 44%), independently of age, sex, site, and diagnosis.

CONJUNCTIVAL SENSITIVITY IN PATHOLOGICAL CASES

A total of 209 pathological eyes each had 17 localities tested for sensitivity (cornea, caruncle, upper and lower lid margins (centrally, medially and laterally), and corresponding localities on the palpebral conjunctiva, and upper and lower halves of the bulbar conjunctiva). Reduced conjunctival sensitivity is seen in pemphigoid (excluding the lid margin) in contact lens wearers, at sites of nerves transected during operation and in rare cases of infectious conjunctivitis. Isolated corneal hypaesthesia is seen in bacterial or fungal keratitis. In herpes, the hypaesthesia extends over the bulbar conjunctiva, in zoster, over wider areas (including the lid margin). The sensitivity is normal in keratoconjunctivitis sicca and chronic conjunctivitis. In neurological diseases the hyposensitivity could include the cornea, conjunctiva and lid margin. The conclusion is drawn that a study of the conjunctivo-corneal sensitivity can give differential diagnostic information, provided the normal sensitivity range is known. This has been set out in a Table in 10-year age groups.

Ankyloblepharon filiforme adnatum affecting identical twins.

In this rare congenital abnormality, first described by Hasner (I88i), single or multiple fine strands of tissue join together parts of the upper and lower eyelid margins. These bands arise from the 'grey line', posterior to the cilia but in front of the orifices of the meibomian glands; this is in contradistinction to other forms of developmental ankyloblepharon, in which sheets of tissue that are continuous with the eyelid skin form broad adhesions between the lids. This communication gives the first description of this developmental defect affecting identical twins, and includes a brief note on the spontaneous regression and final resolution of the adhesions which occurred during the first few months of life.

Restoration of lid function in facial palsy with permanent magnets

A method is presented to restore dynamic eyelid function in facial palsy with the implantation of 2 permanent magnets near the upper and lower eyelid margin. The attractive force characteristics of the double magnet system closely simulate the action of the paralyzed orbicularis sphincter. Normal lid opening is accomplished by the intact levators. The width and contour of the palpebral fissure remains undisturbed and is comparable to that of the normal side. The magnetic material used is characterized by a high energy product and coercivity permitting a tiny volume, weight, and size. The siliconized magnets are well tolerated.

A new tarsorrhaphy suture.

Suture of the upper and lower lid margins—with or without surgical fusion—is an important fundamental ophthalmic technique. It splints the lids and reduces their movement to a minimum, thus aiding the healing process after lid repairs, reconstructions, skin grafting, and similar procedures. It provides an anatomic patch in cases of serious corneal pathology. It is also valuable in protecting the globe after orbital surgery and in all cases where prolonged pressure must be applied. Under optimal conditions intermarginal sutures may be kept in anywhere from 10 to 20 days before reaction or infection sets in. This provides an adequate period for the healing together of the margins when a tarsorrhaphy has been created or gives valuable aid where lid splinting by suture alone is needed for a relatively short time. Unfortunately, some intermarginal sutures have a disconcerting way of loosening or pulling out long before their function is fully