Periocular Area Research Articles

Reliability of Stereophotogrammetry for Area Measurement in the Periocular Region

Three-dimensional (3D) stereophotography area measurements are essential for describing morphology in the periocular region. However, its reliability has not yet been sufficiently validated. The objective of this study was to evaluate the reliability of 3D stereophotogrammetric area measurements in the periocular region. Forty healthy volunteers had five flat paper objects placed at each of the seven periocular positions including the endocanthion and the upper medial, upper middle, upper lateral, lower medial, lower middle, and the lower lateral eyelid. Two series of photographic images were captured twice by the same investigator. Each image of the first series was measured twice by the same rater, while images of both series were measured once by a second rater. Differences between these measurements were calculated, and the intrarater, interrater, and intramethod reliability was evaluated for intraclass correlation coefficients (ICCs), mean absolute differences (MADs), technical errors of measurements (TEMs), relative errors of measurements (REMs), and relative TEM (rTEM). Our results showed that 21.2% of all ICCs were considered as excellent, 45.5% were good, 27.3% were moderate, and 6.1% were poor. The interrater ICC for the endocanthion location was 0.4% on a low level. MAD values for all objects were less than 0.3 mm2, all TEM were less than 1 mm2, the REM and rTEM were less than 2% for all objects, showing high reliability. 3D stereophotogrammetry is a highly reliable system for periocular area measurements and may be used in the clinical routine for planning oculoplastic surgeries and for evaluating changes in periocular morphology.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Face Masks and Bacterial Dispersion Toward the Periocular Area

Taping the superior aspect of patient masks qualitatively decreases air flow and bacterial dispersion towards the ocular surface while inappropriately worn masks both qualitatively and quantitatively increase bacterial dispersion towards the ocular surface.

Bullous Pemphigoid in a Dog

Background: In dogs, bullous pemphigoid (BP) is a subepithelial autoimmune disease, a rare dermatopathy in the clinical routine. BP is characterized by formation of vesicles and subepidermal blisters that result from dissolution of the dermal-epithelial junction. Clinical signs of BP usually include severe dermatological alterations with a variable prognosis. The aim of this work is to report a case of BP in a dog to contribute information for diagnosis, and to present clinical and pathological aspects that emerge during development of BP.Case: An adult male mongrel dog exhibited hyperemic, exudative, crusty lesions on the lip commissure and periocular areas. Results from laboratory tests were normal. Results from parasitological and mycological tests on skin scrapings were negative. Imprint cytology of the crusts revealed presence of gram-positive cocci bacteria. In the histopathological analysis of punch biopsy material, the epidermis was detached from the dermis, leading to formation of vesicles. There were inflammatory infiltrates containing neutrophils, eosinophils, and high amounts of fibrin, and areas of multifocal orthokeratotic hyperkeratosis. Multifocal infiltrates containing lymphocytes, histiocytes, and plasma cells were observed on the superficial portions of the dermis, which indicated a diagnosis of BP. After the definitive clinical diagnosis, the animal was treated with enrofloxacin (Baytril Flavour®; 5 mg/kg once a day for 10 days), and prednisolone (Prediderm®; 2 mg/kg once a day until further instructions). On the follow-up visit, 15 days later, the clinical picture had improved, and the lesions had decreased. Continuity of the treatment was prescribed, along with a gradual decrease in the corticoid dose. The dose of prednisolone was initially reduced to 1 mg/kg once a day, and later to 0.5 mg/kg until improvement of the clinical status of the patient. Remission of the lesions was observed 13 weeks later.Discussion: The diagnosis of BP was established after identification of the clinical cutaneous lesions and observation of microscopic findings on punch biopsy material obtained from the ocular and lip regions. BP does not exhibit breed or sex predisposition, and affects adult dogs. The clinical signs of BP are characteristic of autoimmune diseases that affect the dermoepidermal junction, and consist of erythematous, ulcerated, crusty, and painful lesions on the nose, dorsal area of the muzzle, and periorbital region. However, these lesions must be differentiated, by histological analysis, from several other conditions with a similar clinical presentation. Diseases that must be considered in the differential diagnosis comprise other variants of the pemphigus complex, lupus erythematosus, drug eruption, erythema multiforme, toxic epidermal necrolysis, epitheliotropic lymphoma, inherited bullous epidermolysis, mucous membrane pemphigoid, and lymphoreticular neoplasia. The clinicopathological findings indicated that the lesions were compatible with BP. The occurrence of necrotic and erythematous lesions is due to production of antibodies accompanied by a strong response of neutrophils, which results in loss of cell adhesion and epidermal necrosis. The presence of detachment of the epidermis from the dermis, inflammation in the superficial portion of the dermis, and infiltrates containing lymphocytes, histiocytes and plasma cells observed at the histopathological examination indicated the occurrence of BP. The skin histopathological examination warranted establishment of a diagnosis and therapeutic success. The lack of recurrence of clinical manifestations 43 weeks after the end of the glucocorticoid treatment demonstrated that the therapeutic approach and the cooperation of the owner are essential for success of the treatment.

A case presentation of hypersensitivity to 2.5-diaminotoluene sulfate/permanent hair dye

The anamnesis in the allergist’s office has always been a challenge for the clinician, and in the midst of the pandemic, in many instances, has made this investigative process more difficult. We present a case of hypersensitivity to hair dye that was applied only along the length of the hair, avoiding the root and skin area, a reaction clinically presented in the form of contact dermatitis with emphasis on the periocular area.

Dramatic invasion of the orbit by periocular cutaneous squamous cell carcinoma

The periocular skin is susceptible to numerous benign and malignant neoplasms. Malignant skin tumors of the periocular area are very particular; they can present differently, are rapidly aggressive and pose a real therapeutic challenge. Aggressive forms occur mostly in immunocompromised individuals. A complete destruction of the orbit is rare and the initial seat is most often the eyelid. We report the case of an immunocompetent 70-year-old patient with destruction of the entire orbital region including the eyeball secondary to the extension of squamous cell carcinoma of the internal canthus.

15620 Paederus dermatitis involving the periocular area: An observational study from Nepal

Background: Paederus dermatitis involving the periocular area, also known as Nairobi ey,e is characterized by erythematous vesiculobullous linear patch or plaque with itching, stinging, or burning sensation. It commonly occurs during rainy season and near to the agricultural fields.

A Potential Novel Organ at Risk: Vitreous Humour

Radiation therapy for the ocular and periocular areas can cause vision-threatening complications. There is no data in the literature about the possible contribution of the vitreous in the emergence of radiation-induced orbital complications. For this purpose, an experimental animal model was developed to reveal ionizing radiation-induced changes in the vitreous humour. Six white New Zealand rabbits were used in this experimental study. High dose (60 Gy in 3 fractions) ionizing radiation was delivered to the right globe of all rabbits. Left globes were the control group. Animals were kept alive for 12 weeks after radiation exposure. During the 12 weeks period, the animals and their eyes were examined weekly (including fundus examination). At the end of 12 weeks, animals were sacrificed, eyes were enucleated, and vitrectomy was performed. Collected vitreous fluids were assayed for viscosity, type II, V/XI, IX collagen levels, and its metabolomic profile. In the weekly examinations, no changes were observed in the retina of the animals. Compared to the control group (left eyes of each animal), collagen type 2 levels of the study group were found to be significantly decreased (P<0.05). No significant difference was determined between groups in terms of collagen type 5,9 and 11 content. In 4 animals, the viscosity of the samples was found to be decreased by the effect of radiation. As the number of animals included in the study is limited, this difference could not be confirmed by statistical analysis. Comparative metabolomic analysis of vitreous humour samples from rabbits was carried out based on the GC-MS metabolomic profiling. After deconvolution and aligned of the chromatograms, 401 mass spectral features have been detected, and 126 of them were annotated using retention index libraries. These identified metabolites belong to the Krebs cycle, amino acid, and fatty acid metabolism. The multivariate analysis shows a clear separation between control and irritated vitreous humour samples. At metabolomics level, phosphocolamine, N-ethylglycine, cholic acid, and citric acid level were significantly altered (p<0.05, paired test, n = 6). To our knowledge, this is the first study to demonstrate that ionizing radiation affects vitreous humour and significantly changes its viscosity, type II collagen levels, and metabolomics content. Serious pathologies such as retinal detachment may occur as a result of changes in the vitreous humor with aging. Changes in the vitreous that occur with aging are similar to the radiotherapy effect. In this experiment, the changes in the vitreous without any change in retina suggest that the pathologies which occur in the retina may be secondary to the pathologies in the vitreous.

A Case of Primary Tuberculosis of the Lacrimal Sac Presenting as Epiphora

Extra-pulmonary tuberculosis usually progresses as a secondary infection from pulmonary tuberculosis, and tuberculosis of the head and neck region. Tuberculosis of ocular and periocular areas, however, is a rare disease. Among ocular tuberculosis involving the adnexal structures, a few lacrimal sac tuberculosis has been reported. We recently experienced a case of lacrimal sac tuberculosis presenting as epiphora. Examination revealed bilateral nasolacrimal duct obstruction and the patient underwent endoscopic endonasal dacryocystorhinostomy. During the operation, a biopsy taken from the unhealthy looking lacrimal sac filled with caseous necrotic tissue was suggestive of tuberculosis. Histopathological features and further systemic evaluation confirmed tuberculosis. She was treated medically with anti-tubercular agents. The new opening of the lacrimal sac was patent and epiphora was resolved successfully at a year follow up. This report highlights the requirement of high suspicion of tuberculosis, even in the nasolacrimal drainage system.

Reperfusion of Free Full-Thickness Skin Grafts in Periocular Reconstructive Surgery Monitored Using Laser Speckle Contrast Imaging.

Free skin grafts are frequently used in reconstructive surgery. However, little is known about the course of reperfusion due to the previous lack of reliable perfusion monitoring techniques. The aim of this study was to use state-of-the-art laser speckle contrast imaging to monitor free skin grafts in the periocular area. Seven patients needing surgery due to tumor removal or cicatricial ectropion in the periocular region underwent reconstructive surgery using free skin grafts from either the contralateral upper eyelid or the upper inner arm. The free skin grafts measured 10-30 mm horizontally and 9-30 mm vertically. Blood perfusion was monitored using laser speckle contrast imaging immediately postoperatively (0 weeks) and at follow-up after 1, 3, and 7 weeks. All grafts were reperfused gradually during healing, the median value being 46% in the central part of the graft after 1 week and 79% after 3 weeks. The grafts were completely reperfused after 7 weeks. No difference was observed in the rate of reperfusion between the center and periphery of the grafts (p = not significant). The cosmetic and functional outcome was excellent in all but 1 patient, who developed ectropion that had to be surgically corrected. Skin grafts in the periorbital area are fully reperfused after 7 weeks. The periocular area is known to be well-vascularized and thus forgiving to reconstructive surgery. Future investigations of the reperfusion of free skin grafts in other parts of the body or in higher-risk populations should be carried out.

Consensus report on the use of PN‐HPT™ (polynucleotides highly purified technology) in aesthetic medicine

BackgroundInjective procedures using polynucleotides‐based products to promote dermal rejuvenation and revitalization are steadily evolving, yet no structured protocols are available that discuss and provide guidance in aesthetic treatments with highly purified polynucleotides. The goal of this document was to provide consensus‐based recommendations for the safe and effective use of Polynucleotides Highly Purified Technology™ (PN‐HPT™) devices for skin rejuvenation.Patients/MethodsA team of eight experts with extensive experience in treatments for skin rejuvenation and revitalization integrated the best available evidence and clinical judgment and devised a series of practical guidance to support dermatologists, plastic surgeons, and aesthetic physician in the use of PN‐HPT™ products, alone and in combination, in aesthetic medicine.ResultsFor most items, the expert group achieved a majority consensus. “Recommendations” (consensus >80%) were reached for the face, periocular area, décolleté and neck, hands, scalp, and stretch marks. Recommendations include details of techniques, information on dosage, volumes to be injected, and the ideal number of required treatment sessions, as well as time intervals between them for different areas of face and body. A lower agreement level of 60% was reached on but one item related to the initial treatment cycle for the face, leading to a “Consensus statement” for that area instead of a full “Recommendation.”ConclusionThe expert consensus illustrates the value of natural‐origin, highly purified polynucleotides (PN‐HPT™) as biostimulatory booster strategy for skin priming and revitalization of face and body and provides a detailed guide for the use.

PATIENTS WEARING FACE MASKS DURING INTRAVITREAL INJECTIONS MAY BE AT A HIGHER RISK OF ENDOPHTHALMITIS

To investigate the safety of face masks worn by patients during intravitreal injections. A prospective, qualitative, interventional study performed in a tertiary university hospital. Healthy volunteers were asked to wear three different professional surgical face masks while air leaks around the eyes were monitored. Three types of masks were investigated as follows: 1) surgical face mask with four tying strips, 2) surgical face mask with elastic ear loops and 3) 2200 N95 tuberculosis particulate face mask. For each session the periocular area was inspected for air leak during normal respiration, speech, and deep respiration. Detection of air leak was performed using the following two professional thermal cameras: FLIR A310-thermal camera and EyeCGas 2.0-super sensitive infrared camera used for detection of minute fugitive emissions of industrial gases. Ten healthy volunteers were enrolled in this study. The experiment was repeated 45 times for each camera; 3 times for each of 3 mask types, on 5 volunteers, for a total of 90 trials. Air jets were detected originating from the superior edges of the masks radiating toward the eyes in 81% (73/90) of cases in total; 71% (32/45) with the FLIR camera and 91% (41/45) with the OPGAL camera. Air leaks were detected with all investigated mask types. Patients wearing face masks during intravitreal injections may be at a higher risk of endophthalmitis. Until further data are available, we recommend verifying proper face mask fitting and either taping the upper edges of the face masks with a medical adhesive tape or using an adhesive surgical drape around the injected eye.

Combination Approach to Tear Trough Deformities and Under Eye Appearance Using Microfocused Ultrasound With Visualization and Hyaluronic Acid Filler

Filler for tear trough deformities and improved under eye appearance has become a well-accepted procedure to treat fine lines, wrinkles, shadowing, darkness, and hollowness. Microfocused ultrasound with visualization–induced skin tightening can be a powerful modality to treat periocular laxity on its own. There is also considerable rationale for combining these 2 modalities for synergistic rejuvenation of the entire periocular area. This case series recruited participants with mild-to-moderate skin laxity in the periocular area and tear trough deformities. Participants received microfocused ultrasound with visualization therapy followed 3 months later by injection with Cohesive Polydensified Matrix hyaluronic acid gel. Photographs were taken at baseline, 3 months after microfocused ultrasound with visualization therapy, and 1 month after Cohesive Polydensified Matrix hyaluronic acid injection for rating by physicians and participants using the Global Aesthetic Improvement Scale. All participants also completed a satisfaction questionnaire. This pilot study enrolled 10 participants ranging in age from 35 to 55 years. After microfocused ultrasound with visualization alone, physicians rated 4 participants “much improved,” 5 “improved,” and 1 with “no change.” After participants had received both treatment modalities, physicians rated 9 participants as “very much improved” and 1 as “much improved.” Participant satisfaction was high with microfocused ultrasound with visualization alone and even higher with the combined treatment approach with all 10 participants reporting their periocular appearance “very much improved” at the end of the study. No treatment complications were observed. In conclusion, microfocused ultrasound with visualization in combination with Cohesive Polydensified Matrix hyaluronic acid gel was effective at improving appearance of the eye area in participants with periocular skin laxity and tear trough deformities.

Clinical characteristics and pathological depths of syringomas in 94 Korean patients.

Syringoma is a common benign tumor with eccrine origin that typically occurs on the face of middle-aged women. Laser ablation with CO2 laser or Er:YAG laser has been widely used in the clinical field, often leading to scars due to its deep location. This study aimed to investigate clinical characteristics and pathological depths of the lesions in syringoma patients. Syringoma patients, pathologically confirmed at Samsung medical center (Seoul, Korea) from January 1996 to March 2019, were analyzed. Clinical characteristics such as the location of lesion, age, and sex, and pathological depths of the lesions were investigated, and univariable and multivariable analyses were done for these factors. Of total 94 syringomas, 17.0% were located on periocular area, 10.6% on forehead, 34.0% on head and neck areas excluding periocular area and forehead, and 38.3% on trunk and extremities. The mean depth of syringoma from the surface including stratum corneum to the deepest stromal location was 1174.14±1142.95μm for periocular area, 1055.93±247.76μm for forehead, 1488.06±1217.36μm for other areas of head and neck including scalp, and 1169.53±349.2 for the lesions located at trunk and extremities including external genitalia. No significant correlation was observed from univariable analysis and multivariable analysis by age, sex, and site of lesion. Our findings offer valuable information of the mean depth of syringoma at different sites, which can be taken into consideration for successful treatment without adverse events such as scarring.

Sebaceous Carcinoma: A Rare Extraocular Presentation of the Cheek

Sebaceous carcinoma is a rare and aggressive malignant cutaneous cancer that arises from the sebaceous gland epithelium. This type of cancer typically presents in the periocular area and is rarely expressed in the extraocular space. The estimated overall incidence rate is one to two per million people per year. Sebaceous carcinoma tends to carry a delay in diagnosis as its variability in presentation of histologic growth patterns and diverse clinical presentation causes it to frequently be mistaken for common benign entities. Here, the authors report a case of a rare extraocular sebaceous carcinoma presenting on the cheek of a 78-year-old Caucasian male and discuss commonly mistaken differential diagnoses and the standard approach to properly diagnose and manage this rare tumour. Dermatologic literature has limited reference to sebaceous carcinoma, because this is rarely seen in an extraocular location, thus this case report provides a primary dermatologic perspective on this rare and aggressive skin cancer.

Eye trauma in falls presenting to the emergency department from 2006 through 2015

AimsTo characterise the epidemiology of eye trauma in the event of falls presenting to the emergency departments (ED) in the USA.MethodRetrospective cohort study. Nationwide Emergency Department Sample was used to...

Bacterial etiology of ocular and periocular infections, antimicrobial susceptibility profile and associated factors among patients attending eye unit of Shashemene comprehensive specialized hospital, Shashemene, Ethiopia

BackgroundEye infection is a public health problem in developing countries including Ethiopia. Bacteria are major causative agents of eye infections that can lead to loss of vision. The objective of this study was to determine bacterial etiology of ocular and periocular infections, antimicrobial susceptibility profile and associated factors among patients who visited the eye unit of Shashamane Comprehensive Specialized Hospital (SCSH).MethodA hospital-based cross-sectional study was conducted at SCSH from September 1, 2018, to March 30, 2019. Specimens from the ocular and periocular areas were collected from a total of 332 patients who visited the eye unit. Specimens were inoculated on blood agar, chocolate agar, MacConkey agar, and mannitol salt agar. Isolated bacteria were identified by a series of biochemical tests using the standard bacteriological method. Antimicrobial susceptibility test was performed according to the Clinical and Laboratory Standard Institute by disk diffusion method. Factors that could be associated with ocular and periocular infection were collected by using structured questionnaire. Data analysis was done using SPSS version 22.0 software package. A P value less than 0.05 was considered statistically significant.ResultOut of the total 332 study participants with ocular and periocular infections, 198(60%) were culture positive. The proportion of Gram-positive and Gram-negative bacteria were 135(68.2%) and 63(31.8%) respectively. Among Gram-positive bacteria, Staphylococcus aureus were predominant. Among Gram-negative bacteria, Escherichia coli were predominant. Most S. aureus were resistant to penicillin.ConclusionMajority of ocular and periocular infections in this study were caused by bacteria; Gram-positive bacteria were responsible for most cases.

What do men want? A gender-specific approach to male facial rejuvenation

Men are a small, but growing, segment of the non-surgical facial rejuvenation patient population. Men seek treatment for a variety of reasons, including seeking a more youthful and masculine appearance, and, most often, seek treatments to improve their hairline, periocular area and jawline. Sexual dimorphism in the human face dictates a different approach to male facial rejuvenation and revolumisation. Approaches to the upper, mid and lower face with neurotoxins and dermal fillers are discussed, with an emphasis on masculising and not feminising the male patient.

An Alternative Periorbital Treatment Option Using Calcium Hydroxyapatite for Hyperpigmentation Associated with the Tear Trough Deformity.

The nasojugal groove or tear trough (TT) area deformity produces visible, pigmented, difficult-to-treat hollows. Hyaluronic acid (HA) filler-based correction yields variable results and complications. We developed an alternative, minimally invasive treatment for this area. Patients with significant, visible TT area pigmentation, and/or those requiring corrections for TT filler removal, were given lignocaine-diluted calcium hydroxyapatite (CaHA) fillers. CaHA boluses were placed deep on the bone, under the origin of the orbicularis retaining ligament, and under the sub-orbicularis oculi fat. Diluted CaHA was used as a subcutaneous biostimulatory wash. Efficacy and complications were assessed using the Global Aesthetic Improvement Scale and a modified Tear Trough Rating Scale, at 4 and 18 months. Twelve patients, between 25 and 52 years of age, were treated and showed immediate improvements in hyperpigmentation due to light reflection and some visibility of the filler through skin. Lower eyelid swelling and redness occurred a few days postinjection but resolved spontaneously. Over 4 to 6 months, hyperpigmentation and skin tone, thickness, and color improved noticeably. Global Aesthetic Improvement Scale and modified Tear Trough Rating Scale scores indicated that all patients experienced satisfactory improvements. Three prior HA patients required a second CaHA treatment at 4-6 months for a satisfactory correction, one of whom required a third CaHA "wash" at 10 months. Some mild redness was observed for up to 12 weeks in a few patients; however, no differences in the degree of redness were observed between those treated for dark circles or post-HA correction. One patient experienced a persistent, dull erythema for 8 months; another had overt erythema and swelling following a chest infection which resolved with antibiotics and hydrocortisone cream. No nodules developed in any patient. We developed an alternative TT deformity treatment that leverages CaHA unique rheology and neocollagenesis-stimulating ability, which lifted and supported the prolapsing orbicularis retaining ligament, improved skin quality, and rejuvenated the periocular area without direct injections into the TT.

Local Binary Pattern Method (LBP) and Principal Component Analysis (PCA) for Periocular Recognition

Identification of identity through eye is gaining more and more importance. Commonly, the researchers approach the eye from any of three parts, the iris, the circumference around the eye, and the iris and its circumference. This study follows a holistic approach to identity identification by using the iris and whole periocular area and proposes a periocular recognition system (PRS) that has been developed using the Local Binary Pattern (LBP) technique combined with Principal Component Analysis (PCA) at the feature extraction stage and the k-nearest neighbors (k-NN) algorithm as a classifier at the classification stage. This system achieves identity recognition through three steps: pre-processing, feature extraction, and classification. Pre-processing is applied to the images so as to convert them to grayscale. In the feature extraction step, the LBP method is applied to extract the texture feature from the images and use it in PCA to reduce data dimensionality and obtain the relevant data so that only the important features are extracted. These two steps are applied both in the training phase and the testing phase of image processing. On the other hand, the testing data sets are processed using the k-NN classifier. The proposed PRS was tested on data drawn from the PolyU database using more than one basis of system experience. Specifically, the system performance was tested once on all 209 subjects present in the database and once on 140 subjects. This database also contains images taken in the visible (VIS) and near-infrared (NIR) regions of the electromagnetic radiation (EMR) spectrum. So, the system was tested on images taken in both regions separately for matching. As well, the proposed PRS benefited from the availability of images for the right and left perioculars. Performance was, therefore, tested on images of each side of the periocular area (the left and right sides) separately, as well as for the combination of the two sides. The identity recognition rates characteristic of the proposed PRS were most often higher than the recognition rates produced by systems reported in the literature. The highest recognition accuracy obtained from the proposed system, which is 98.21%, was associated with the 140-subject data sub-set.

Prostaglandin-associated periorbitopathy: A prospective study in Indian eyes

Context: Prostaglandin analogs (PGAs) are commonly used antiglaucoma medications in the current era. The purpose of this study is to monitor the periorbital changes in patients started on topical PGA. Aim: The aim of this study is to study the periorbital changes in patients on PGA eye drops. Settings and Design: It is a prospective, uncontrolled, nonrandomized study. Subjects and Methods: During the initial visit, periorbital area was assessed by ptosis, proptosis, and lash length measurement. Color photography of periocular area was taken using a well-illuminated background for documentation and comparison. All the clinical assessments and color photography were repeated after 6 months. Statistical Analysis Used: Data were analyzed using the SPSS software version 16.0 and Microsoft Excel 2007. Results: Six eyes (9.5%) in the initial evaluation and 22 eyes (34.9%) in the follow-up visit showed periocular hyperpigmentation. There was a statistically significant increase in periocular hyperpigmentation with a P