Lower Eyelid Margin Research Articles

Corneal Inflammatory Events with Daily Silicone Hydrogel Lens Wear

This study aimed to determine the probability and risk factors for developing a corneal inflammatory event (CIE) during daily wear of lotrafilcon A silicone hydrogel contact lenses. Eligible participants (n = 218) were fit with lotrafilcon A lenses for daily wear and followed up for 12 months. Participants were randomized to either a polyhexamethylene biguanide-preserved multipurpose solution or a one-step peroxide disinfection system. The main exposures of interest were bacterial contamination of lenses, cases, lid margins, and ocular surface. Kaplan-Meier (KM) plots were used to estimate the cumulative unadjusted probability of remaining free from a CIE, and multivariate Cox proportional hazards regression was used to model the hazard of experiencing a CIE. The KM unadjusted cumulative probability of remaining free from a CIE for both lens care groups combined was 92.3% (95% confidence interval [CI], 88.1 to 96.5%). There was one participant with microbial keratitis, five participants with asymptomatic infiltrates, and seven participants with contact lens peripheral ulcers, providing KM survival estimates of 92.8% (95% CI, 88.6 to 96.9%) and 98.1% (95% CI, 95.8 to 100.0%) for remaining free from noninfectious and symptomatic CIEs, respectively. The presence of substantial (>100 colony-forming units) coagulase-negative staphylococci bioburden on lid margins was associated with about a five-fold increased risk for the development of a CIE (p = 0.04). The probability of experiencing a CIE during daily wear of lotrafilcon A contact lenses is low, and symptomatic CIEs are rare. Patient factors, such as high levels of bacterial bioburden on lid margins, contribute to the development of noninfectious CIEs during daily wear of silicone hydrogel lenses.

Clinical Experience of the Modifi ed Transconjunctival Lower Lid Approach for Orbital Fractures with Lateral Peri-Canthal Incision

INTRODUCTION: Optimal repair of orbital fractures requires adequate exposure of the fracture area. The transconjunctival approach with lateral canthotomy has gained increasing popularity. This technique offers arguably improved visualization with lower risk of lid retraction. However, if the lateral canthotomy area is improperly repaired, it may cause lower lid malposition and deformity.1 The authors report the use of a modified transconjunctival incision method with a lateral peri-canthal incision to overcome this problem in the cantholysis. METHODS: Between January 2011 and December 2012, the authors used this technique in 30 patients with orbital fractures. When the transconjunctival approach was performed, an inferolateral incision of the lower eyelid near the lateral canthus including the tarsal plate was added instead of the common lateral canthotomy incision for the cantholysis (Figure 1).Figure 1: Transconjunctival incision with lateral peri-canthal incision.RESULTS: Average follow-up was 6 months. There were no functional complications (no webbing, no ectropion, no entropion, etc) related to the operation. In 28 of 30 cases (93%) they were rated as having an excellent cosmetic outcome; however, there were two cases (7%) with complications. One patient had a subcutaneous preseptal hematoma, which required reoperation to obtain hemostasis. In another patient, there was a notch deformity on the lower eyelid margin, but the patient was satisfied and did not choose to have it revised. CONCLUSION: The authors believe that for orbital fracture repair the modified transconjunctival incision with lateral peri-canthal incision can be easily performed and reliably repaired as opposed to the more traditional lateral canthotomy technique. We believe that there is more anatomical reliability in repairing the tarsal plate rather than the attachment of the lateral canthus. Furthermore, in our experience this modified technique provided more than adequate exposure for fracture repair, with excellent cosmetic and functional result on long-term follow-up.

Keratoconus in a Case of Lipoid Proteinosis

To report a patient of lipoid proteinosis (LP) with bilateral keratoconus. A 16-year-old boy presented to our institution with a complaint of gradual decrease in vision over the past 4 years in both eyes and a contact lens intolerance. He had a hoarse voice and multiple areas of hyperpigmented lesions over the head and neck region. Slit lamp biomicroscopy of the both eyes showed multiple round solid pearly lesions along the upper and lower lid margins and a mild central corneal ectasia in both eyes. Central corneal thickness and the keratometric values were measured by using Scheimpflug imaging (Pentacam), and the results were compatible with keratoconus. The histopathologic examination of the lesions taken from bilateral eyelid margins showed hyalinosis, papillomatosis, and depositions of eosinophilic material around the blood vessels, which were compatible with LP. With this report, we describe a case of LP with keratoconus. As seen in our case, LP and its characteristic eyelid margin lesions in keratoconus patients can be associated with a contact lens intolerance.

The Lid Wiper – a specialized structure at the inner eyelid margin for distribution of the tear film

AbstractPurpose The lid wiper is an epithelial structure at the inner eyelid border that distributes the thin precorneal tear film during the up‐phase of the blink. Clinically it is the first area of the ocular surface that shows epithelial alterations in dry eye disease.Methods A literature review on the posterior lid margin and lid wiper is discussed together with own data and considerations of the relevance of the lid wiper region in ocular surface physiology and pathology.Results The posterior side of the inner lid border has an epithelium of conjunctival morphology with goblet cells. It forms an elevation of about 100µm (10‐12 cell layers) thickness immediately at the crest of the inner border with a slope towards the subtarsal fold. The lid wiper hence forms a distinct epithelial lip that is the only region of the upper lid in contact with the globe as verified by functional tests. It extends along the upper and lower eyelid margins, has a width of typically about 1mm, narrower in the middle and wider to the temporal and nasal sides. The lid wiper of the upper lid appears as a suitable device to distribute the thin precorneal tear film during the blink as supported by the finding that in conditions with increased friction, such as dry eye disease and contact lens wear, the lid wiper is the first zone of the ocular surface that shows a pathological vital staining indicating epithelial destruction.Conclusion The lid wiper is of underestimated importance for tear film distribution and ocular surface integrity as well as a sensitive early indicator of dry eye disease. Integration and scoring of lid wiper epitheliopathy in dry eye diagnosis and therapy schemes could be a valuable addition to clinical practice. Support DFG KN317/11

Congenital Orbital Encephalocele, Orbital Dystopia, and Exophthalmos

We present here an exceedingly rare variant of a nonmidline basal encephalocele of the spheno-orbital type, and this was accompanied with orbital dystopia in a 56-year-old man. On examination, his left eye was located more inferolaterally than his right eye, and the patient said this had been this way since his birth. The protrusion of his left eye was aggravated when he is tired. His naked visual acuity was 0.7/0.3, and the ocular pressure was 14/12 mm Hg. The exophthalmometry was 10/14 to 16 mm. His eyeball motion was not restricted, yet diplopia was present in all directions. The distance from the midline to the medial canthus was 20/15 mm. The distance from the midline to the midpupillary line was 35/22 mm. The vertical dimension of the palpebral fissure was 12/9 mm. The height difference of the upper eyelid margin was 11 mm, and the height difference of the lower eyelid margin was 8 mm. Facial computed tomography and magnetic resonance imaging showed left sphenoid wing hypoplasia and herniation of the left anterior temporal pole and dura mater into the orbit, and this resulted into left exophthalmos and encephalomalacia in the left anterior temporal pole. To the best of our knowledge, our case is the second case of basal encephalocele and orbital dystopia.

Horner’s Muscle Contribution to Lacrimal Sac Drainage

This study was designed to examine the anatomical relationship between Horner's muscle and the lacrimal sac at 3 representative levels of the lacrimal sac and to verify the contribution of Horner's muscle to lacrimal sac drainage. Seven ocular specimens from 7 elderly Japanese cadavers, fixed in 10% buffered formalin, were analyzed. Axial sections were made parallel to the eyelid margin at 1 mm above the upper eyelid margin, 1 mm below the lower eyelid margin, and 3 mm below the lower eyelid margin. The vertical common fascial length, length of the lateral lacrimal sac wall, and the proportion between the 2 were measured for each specimen at the 3 levels. The vertical common fascial length and its proportion to the length of the lateral lacrimal sac wall were statistically the same at all 3 levels of the lacrimal sac. Based on the present anatomical findings, the activity of Horner's muscle may be the same for all sac levels, although this hypothesis should be examined by further experimental research, such as manometric studies of the sac at different levels along its length.

Anatomical Relationship of Horner's Muscle Origin and Posterior Lacrimal Crest

This study was designed to examine the distance from the posterior lacrimal crest to the posterior margin of the Horner's muscle origin (the PLC-HMO distance), considering their complex anatomical relationship. Eight macroscopic specimens from 8 Japanese cadavers and 7 microscopic specimens from 7 Japanese cadavers, fixed in 10% buffered formalin, were analyzed. Macroscopically, the PLC-HMO distance was measured at 2 mm superior to the most posterior point of the muscle origin (Group A), directly at the most posterior point (Group B) and 2 mm inferior to the most posterior point (Group C). Microscopically, the PLC-HMO distance was measured in axial sections at 1 mm above the upper eyelid margin (Group 1), 1 mm below the lower eyelid margin (Group 2), and 3 mm below the lower eyelid margin (Group 3). In the macroscopic study, the average PLC-HMO distance was 2.94, 2.57, and 2.05 mm for Groups A, B and C, respectively. The distance for Group C was significantly smaller than that of Group A (p = 0.006). In the microscopic study, the average PLC-HMO distance was 3.62, 3.74, and 3.14 mm for Groups 1, 2 and 3, respectively (no significant difference). The PLC-HMO distance was approximately 2-4 mm with some specimens showing a smaller distance inferiorly.

A Case of Syringocystadenoma Papilliferum of the Eyelid

Case summary: A 37-year-old woman presented with a mass around the punctum in the right lower eyelid margin, which had developed several years earlier and was increasing in size. The mass was a light pinkish nodule consisting of a few smooth-surface papillary lobules. The pathologic findings of the specimen obtained from a shaving biopsy showed a papil- lary projection which was covered with epithelium and communication with duct-like structures showing glandular config- uration in the deep portion of the lesion. EMA-positive cells were found at the invaginated epithelium, implying a glandular epithelial origin. GCDFP-15-positive cells were found in the deep portion of the lesion, implying apocrine differentiation. The findings were compatible with syringocystadenoma papilliferum. Conclusions: Syringocystadenoma papilliferum should be considered as a differential diagnosis of a solitary eyelid tumor. J Korean Ophthalmol Soc 2012;53(7):1023-1026

Anatomy of medial canthal tendon in Caucasians

To analyse the anatomy of the medial canthal tendon in Caucasians and to clarify the true anatomical nature of its posterior limb. This was an experimental anatomic study. Seven Caucasian cadavers (11 eyelids; age range: 78-101years at death). Anatomical dissection and histological examination of cadaveric eyelids fixed in 10% buffered formalin was performed. The axial sections were made in parallel with the eyelid margin at 1mm superior or inferior to the upper or lower eyelid margins, respectively. The histological specimens were first dehydrated and embedded in paraffin and then divided into 7µm thickness sections and stained with Masson's trichrome. Microscopic photographs were taken with a digital camera system attached to the microscope. The posterior limb of the medial canthal tendon was not detected in any of the specimens. The medial check ligament supported the posterior aspect of Horner's muscle and inserted into the medial orbital wall through the periosteum. The lacrimal diaphragm around the posterior lacrimal crest ran almost parallel to Horner's muscle and was usually difficult to distinguish from the tendon of Horner's muscle. The posterior limb of the medial canthal tendon was not detected in any of the studied specimens. This anatomical structure appears to be Horner's muscle, and the lacrimal diaphragm.

Is Alacrima So Prevalent in Patients With Early-Onset Achalasia?: Author's reply

TO THE EDITOR: The Schirmer (Shirmer) I test is one of the old tests available for dry eye diagnosis and is a test to measure reflex tear secretion.1 It is performed on unanesthetised eyes. A standard filter paper is placed with its notched tip bent around the lower lid margin at the junction of the middle and outer third. With the eyes closed for 5 minutes, the Schirmer paper is measured from the notch to the leading wetted edge. It is interpreted as dry eye when the wetted part of the filter paper is 10 mm.2,3 The diagnostic criteria of dry eye by the Schirmer I test are known to vary from less than 5 mm/5 min, narrow criterion, and to less than 10 mm/5 min, broad criterion.3-5 In our article, we chose a broad cut-off value of less than 10 mm/5 min which is used widely, because we wanted to enroll as many patients as possible for our study.6,7 With the narrow cut-off value of less than 5 mm/5 min, the prevalence of alacrima was 26.3% (5 out of 19 enrolled patients), lower than that in our original article. By the way, all the 5 patients revealed 0 mm of paper length in at least one eye. The relatively low reproducibility and varying diagnostic yield of the Schirmer I test might be one of the limitations of our study.4 The previous study of Verma et al8 reported the 20% prevalence of alacrima with the Schirmer II test using the 5 mm/5 min cut-off value regardless of the onset of achalasia. When we used the more strict cut-off value in Schirmer I test (less than 5 mm/5 min), 26.3% of early-onset achalasia showed alacrima. However, the other 3 patients in 19 patients, who could be regarded as alacrima with a broad cut-off value of less than 10 mm/5min, showed somewhere between 6 and 7 mm/5 min and a total of 8 patients (41.5%) were analyzed as an alacrima. Because of the relatively small numbers of achalasia patients enrolled in our article, further studies based on more numbers of achalasia patients might be needed to define the association between achalasia and alacrima.

Primary Eyelid Leiomyoma

A 10-year-old white male presented with a recurrent painful nodule of the left lateral lower eyelid margin with associated madarosis. The initial pathologic diagnosis at an outside institution was reported as chalazion. The lesion was re-excised, and histopathologic examination with immunohistochemical evaluation confirmed the diagnosis of leiomyoma. This is the first reported case of primary leiomyoma originating in the eyelid.

The lid wiper and muco-cutaneous junction anatomy of the human eyelid margins: an in vivo confocal and histological study

The inner border of the eyelid margin is critically important for ocular surface integrity because it guarantees the thin spread of the tear film. Its exact morphology in the human is still insufficiently known. The histology in serial sections of upper and lower lid margins in whole-mount specimens from 10 human body donors was compared to in vivo confocal microscopy of eight eyes with a Heidelberg retina-tomograph (HRT II) and attached Rostock cornea module. Behind the posterior margin of the Meibomian orifices, the cornified epidermis stopped abruptly and was replaced by a continuous layer of para-keratinized (pk) cells followed by discontinuous pk cells. The pk cells covered the muco-cutaneous junction (MCJ), the surface of which corresponded to the line of Marx (0.2-0.3 mm wide). Then a stratified epithelium with a conjunctival structure of cuboidal cells, some pk cells, and goblet cells formed an epithelial elevation of typically about 100 μm initial thickness (lid wiper). This continued for 0.3-1.5 mm and formed a slope. The MCJ and lid wiper extended all along the lid margin from nasal to temporal positions in the upper and lower lids. Details of the epithelium and connective tissue were also detectable using the Rostock cornea module. The human inner lid border has distinct zones. Due to its location and morphology, the epithelial lip of the lid wiper appears a suitable structure to spread the tear film and is distinct from the MCJ/line of Marx. Better knowledge of the lid margin appears important for understanding dry eye disease and its morphology can be analysed clinically by in vivo confocal microscopy.

Anthropometry of the Eyelid and Palpebral Fissure in an Indian Population

The shapes of the eyebrow and upper eyelid are distinctive facial landmarks. In cosmetic and reconstructive procedures, maintenance of the anatomical relations of these landmarks ensures a pleasing postoperative appearance. The authors establish normal values for eyelid anthropometry in an Indian population. This prospective study included 216 patients between the ages of 16 and 60 years, divided into three groups by age (Groups A to C: 16 to 30 years, 31 to 45 years, 46 to 60 years, respectively) and sex. All patients were photographed from a frontal view, with measurements taken from these photographs. Parameters included the distance between the medial canthus and the lateral canthus (ie, the width of the palpebral fissure), the distance between the open upper eyelid margin and the lower eyelid margin, (ie, the vertical dimension of the palpebral fissure), the intercanthal distance, the interpupillary distance, and the height of the open upper lid. All measured values were analyzed by independent t-test. There was a significant increase in palpebral fissure from Group B to Group C. A significant increase was also observed in intercanthal distance as age progressed beyond 45 years. There was a significant decrease in the interpupillary distance as age increased-from Group A to Group B and from Group B to Group C-and a similar increase in eyelid height in that age progression. The anatomy of the Indian population is distinct in that the palpebral fissure in men is less than that in women. It appears that changes in the eye become more pronounced after 45 years, including an increase in palpebral fissure, intercanthal distance, and height of the upper lid, along with a decrease in interpupillary distance.

Histoplasmosis Presenting as a Cutaneous Malignancy of the Eyelid

Cutaneous histoplasmosis is an uncommon infection and can occur as a primary infection. A manifestation imitating a cutaneous neoplasm is rare, and eyelid involvement is rarer still. The authors report a case of histoplasmosis that presented as an ulcerated lesion on the lower eyelid margin that clinically resembled a basal cell carcinoma. Given its worldwide distribution, it is important to include this disease in the differential diagnosis of nonhealing eyelid lesions. Biopsy and tissue culture are paramount to establishing the diagnosis. This case describes a rare presentation of histoplasmosis on the eyelid and highlights the importance of histopathologic evaluation.

Surgical Correction of Lid Retraction with a Silicone Sponge in Congenital Fibrosis of the Extraocular Muscles

A 5-year-old boy who was diagnosed with congenital fibrosis of the extraocular muscles (CFEOM) presented with bilateral lower eyelid retraction after strabismus surgery. To correct the lower eyelid retraction, a silicone sponge was used as a spacer; it was sutured to the inferior border of the tarsus and the lower eyelid retractor. At the 3-month postoperative visit, both lower eyelid margins were at the inferior corneal limbus. No complications or recurrence was noted at 1 year after surgery. The silicone sponge served as a good spacer for correction of lower lid retraction after strabismus surgery in a child with CFEOM.

Examination of Staphylococcus aureus on the Ocular Surface of Patients With Catarrhal Ulcers

The purpose of this study was to investigate the role of Staphylococcus aureus in the onset of ocular catarrhal ulcers. We examined the colonization by S. aureus of the ocular surface (conjunctival sac, upper and lower lid margins) of 3 patients with catarrhal ulcers and analyzed the S. aureus isolates by pulsed-field gel electrophoresis. S. aureus organisms were found on the lid margin of all eyes affected by catarrhal ulcers. The contralateral eye without ulcers harbored S. aureus exhibiting a pulsed-field gel electrophoresis pattern identical to that of the affected eye. Although S. aureus on the lid margin plays an important role in the onset of catarrhal ulcers, its presence is one among several risk factors.

Zonal differentiation of the epithelium including the lid wiper at the human lid margin

Abstract Purpose The lid margin represent the “other end” of the tear film and appear critically important for ocular surface integrity, in addition to the glandular structures that produce the tears. It guarantees the thin expansion of the tear film with every blink and prevents the leakage of tears over the lid border. However, the differentiation of the lid margin zones is insufficiently known as yet. Methods The upper and lower lid margin in human whole‐mount specimens from ten body donors was investigated in serial section histology and compared to the image by in‐vivo confocal microscopy in four eyes with a Heidelberg retina tomograph and Rostock cornea module (RLSM). Results At the inner lid border, following the keratinised epidermis of the free lid margin, a narrow zone (100‐150µm) of para‐keratinised squamous epithelium represented the muco‐cutaneous junction (MCJ) corresponding to the line of Marx. This was followed by a much broader zone of epithelial thickening (50‐100µm) that formed a kind of cushion, reclined sharply at the inner lid border and represented the so called lid wiper which extended for about 1mm and finally transformed into the epithelium of the sub‐tarsal fold. MCJ and lid wiper extended all along the lid margin from nasal to temporal in upper and lower lid. Details of the epithelial structure as well as the underlying dermal papillae in these zones were also detectable by RLSM. Conclusion Due to its location and structure, the lid wiper appears as the structure that actually spreads the tear film and is distinct from the MCJ/line of Marx. Better knowledge of the lid margin structure and its different zones appears important for the understanding of ocular surface disease, in particular the dry eye disease.

Comparison of 2 moxifloxacin regimens for preoperative prophylaxis: Prospective randomized triple-masked trial: Part 2: Residual conjunctival flora

To determine whether a regimen of topical moxifloxacin hydrochloride ophthalmic solution 0.5% (Vigamox) administered on the day of cataract surgery reduces conjunctival bacterial flora. Iladevi Cataract & IOL Research Centre, Ahmedabad, India. Seventy-four patients were prospectively randomized to receive Vigamox 4 times 1 day before surgery plus 1 drop 2 hours preoperatively (Group 1) and 74 patients, to receive Vigamox 2 hours before surgery and every 15 minutes in the first hour only (Group 2). Conjunctival swabs from the upper and lower lid margins and lower fornix were taken before and after Vigamox instillation. Aliquots were spread on chocolate blood, anaerobic basal, and nutrient agars. The number of bacterial colony-forming units (CFU) on the plates was counted with a grid technique and expressed as log values. The total number of CFU per eye and mean percentage reduction in CFU after instillation were calculated. Bacterial species were identified using biochemical and biophysical reactions. Wilcoxon signed ranked and Mann-Whitney tests and multiple linear regression were applied. In Group 1, the median colony count decreased from 1284.00 CFU +/- 643.18 (SD) before Vigamox instillation to 65.00 +/- 72.61 CFU after instillation (93.12% reduction) (P<.001) and in Group 2, from 1634.00 +/- 769.27 CFU to 75.00 +/- 81.23 CFU (93.28% reduction) (P<.001). The percentage reduction after instillation was similar between the 2 groups (P = .09). Both Vigamox regimens reduced the number of CFU of conjunctival flora, indicating that instillation beginning on the day of surgery is effective.

Fornix Fat Prolapse as a Sign for Involutional Entropion

To compare horizontal and vertical laxity of lower eyelids in patients with unilateral lower eyelid involutional entropion, introduce a reliable and common finding in involutional entropion, and review the literature. Prospective, comparative observational case series. Eighty patients with unilateral involutional entropion. Horizontal laxity was measured by recording the distance between the globe and the lower eyelid margin when pulled anteriorly with the eye in primary position (digital subtraction test). Vertical laxity was gauged by recording lower lid excursion between extreme up- and downgaze. Forniceal preaponeurotic fat prolapse was assessed by pulling the lower lid margin to the level of the inferior orbital rim and comparing the meniscus of protruding fat in each fornix. Forniceal fat pad height of <2 mm was graded as grade 1, and that of >or=2 mm as grade 2. Fornix fat prolapse. There were 43 males and 37 females, with a mean age of 77.70 years (range, 57-93 years) (standard deviation, 7.79). There were 47 patients with right-sided and 33 with left-sided entropion. The range of horizontal lid laxity was between 7.5 and 11 mm. The amount of vertical laxity assessed by lower lid excursion between extreme up- and downgaze ranged from 2 to 5 mm. Comparison between the affected and nonaffected sides failed to show a statistical difference in horizontal or vertical laxity (0.19<P<0.49). However, grade 2 forniceal fat height was observed to be significantly more on the affected than unaffected side (P = 0.000). Increased forniceal fat height is associated with lower lid entropion. Forniceal fat height represents a more accurate assessment tool for either lower lid retractor laxity or disinsertion than the lid excursion test.

Microscopic Findings of Lateral Tarsal Fixation in Asians

To identify microscopically lateral tarsal fixation in Asians. Specimens from 19 postmortem lateral eyelids and orbits of 11 Asians (11 right, 8 left; aged 45-96 years at death) were used. Samples damaged on sectioning and samples without tarsal plates were excluded. The samples were fixed in 10% buffered formalin and examined under a microscope. Two levels of tarsus were observed in the upper and lower eyelids, suggesting the possibility of different means of fixation. The first and second sections, which were incised parallel to the eyelid margin, were obtained at 1 mm and 5 mm from the upper eyelid margin, and at 1 mm and 3 mm from the lower eyelid margin. The sections were stained with Masson trichrome. The first sections of all upper eyelids and those of the lower eyelids except one showed tarsal fixation by both the lateral rectus capsulopalpebral fascia (lr-CPF) and the tendon-ligament complex of the lateral canthal tendon (LCT), which in several cases received the muscle of Riolan. The second sections of all upper eyelids showed fixation by the lr-CPF and the ligamentous part of the LCT. The second sections of the lower eyelids were mostly similar to the second sections of upper eyelids, though some showed only ligamentous fixation. The lr-CPF in all cases included a small amount of smooth muscle fibers. The lateral aspect of the tarsus is supported by the lr-CPF and the LCT, which in some cases includes the muscle of Riolan.