The caretaker-reversible Tarsorrhaphy.

PURPOSE: To present a modification of the reversible tarsorrhaphy that can be opened and reclosed as necessary by caretakers and the patient. METHODS: Retrospective case series of patients who underwent the reversible tarsorrhaphy. Materials included intravenous (IV) tubing as bolsters and 4-0 polypropylene suture. The 4-0 suture is first passed through and through one end of IV tubing approximately 20 mm in length. Starting on the lateral upper lid and approximately 4 mm above the lash line, the suture is placed through the skin and into the tarsus. The suture exits through the eyelid gray line. These steps through the eyelid are repeated in the opposite direction. An air knot is tied above the upper eyelid near the base of IV tubing. A second air knot can be tied higher to provide a handle easily allowing the caretaker to close the eyelid. RESULTS: Included were 13 patients (ages 21-95-yeas), indications included lagophthalmos secondary to cicatricial changes from burns (2), keratouveitis (1), neurogenic palsy (3), neurotrophic ulcer (6), and cicatricial changes from skin cancer (1). There were no reported difficulties in maintaining the tarsorrhaphy by either family members or healthcare providers. The first tarsorrhaphy for each patient lasted between 3-19 weeks, with an average of 8 weeks. All were well tolerated. CONCLUSIONS: The caretaker-reversible tarsorrhaphy can be used as a temporizing measure. The technique balances the need for ocular protection with the need for examination/treatment by health care professionals and, equally importantly, the patients and caretakers.

The impact of modified incision height and surgical procedure on trichiasis surgery outcomes: Results of the maximizing trichiasis surgery success (MTSS) randomized trial.

BACKGROUND: Poor surgical outcomes remain a problem in trachoma-endemic countries working to reach elimination thresholds. Methods to improve outcomes could positively impact programmatic success. METHODS: This parallel, three-armed clinical trial conducted in Ethiopia randomized individuals with previously unoperated trachomatous trichiasis (TT) to receive surgery utilizing one of three approaches: bilamellar tarsal rotation with a 3 mm incision height (BLTR-3), BLTR with 5 mm incision height (BLTR-5) and posterior lamellar tarsal rotation (PLTR). We followed participants for one year. The primary outcome was post-operative trichiasis (PTT). Secondary outcomes were eyelid contour abnormalities (ECA) and pyogenic granulomata. FINDINGS: We randomized and operated on 4,914 individuals with previously unoperated TT (6,940 eyes). Primary analyses include 6,815 eyes with follow-up. Overall, 1,149 (16.9%) eyes developed PTT. The risk difference for PTT was minimal comparing BLTR-3 and PLTR (adjusted risk difference [aRD] 1.8% (98.3%CI: -0.5-4.2%)), but significantly higher for BLTR-5 surgeries compared to BLTR-3 (aRD: 6.7% (3.9-9.4%)) and PLTR (aRD: 8.6% (5.9-11.3%)). BLTR-5 had the lowest ECA (6.1% versus 9.6% BLTR-3, 11.2% PLTR) and granuloma rates (5.2% versus 6.5% BLTR-3 and 7.5% PLTR). One eyelid operated with PLTR experienced an eyelid margin division; four BLTR-3 and eight BLTR-5 eyelids experienced excessive bleeding. INTERPRETATION: We do not recommend modifying the BLTR incision height of 3 mm. Overall, we did not find a significant difference in PTT between BLTR-3 and PLTR in terms of PTT or ECA. TRIAL REGISTRATION: Registration number: NCT03100747; ClinicalTrials.gov Full study protocol available at (https://doi.org/10.15139/S3/QHZXWD).

Effect of upper eyelid blepharoplasty surgery on cornea biomechanics and ocular surface.

PURPOSE: To evaluate the changes in corneal biomechanical properties and tear film layer analysis after upper eyelid blepharoplasty surgery. METHOD: Sixty eyes of 30 patients were included in our prospective study. Corneal hysteresis (CH), corneal resistance factor (CRF), corneal compensated intraocular pressure (IOPcc) and Goldmann intraocular pressure (IOPg) measurements were taken with the Ocular Response Analyzer (ORA) device at the preoperative, postoperative 1st and 3rd months. The ocular surface was evaluated with tear breakup time (TBUT) and Ocular Surface Disease Index (OSDI) scores. Lid crease (LC), margin-to-reflex distance 1 (MRD1), and palpebral fissure height (PFH) were evaluated at each visit. RESULTS: In the ORA analysis, in the 1st month CH value was found to be significantly lower than the preoperative value (preoperative 13.39 ± 6.08 mmHg; 1st month 10.74 ± 1.94 mmHg, p = 0.011). In addition, there was a statistically significant decrease in the 3rd month value compared to the preoperative values (10.46 ± 1.69 mmHg, p = 0.021). However CRF decreased postoperatively, no statistical difference was detected (preop 12.59 ± 3.84; 1st month 11.94 ± 3.04; 3rd month 9.78 ± 1.74; p = 0.149). While there was a decrease in IOPcc and IOPg in the postoperative period, no statistical difference was detected (respectively p = 0.96, p = 0.71). In the postoperative 1st month, TBUT increased significantly (p = 0.024). When those with a TBUT value below 10 were considered dry eye, significant decrease was observed in the percentage of dry eye in the first postoperative month (p = 0.027). Although the dry eye percentage decreased in the 3rd month compared to the preoperative percentage, no statistical difference was detected (p = 0.125). There was a significant decrease in the number of those with an OSDI score above 13 in the first month (p = 0.004). CONCLUSION: In our study, a decrease in ORA values was observed after blepharoplasty, with only CH being statistically significant. Reducing the load on the cornea after surgery may change the corneal biomechanics. These changes should be taken into consideration after eyelid surgery, especially in patients who may require glaucoma follow-ups.

Enhancing aesthetic outcomes: The role of biomechanics in periorbital and eyelid cosmetic surgery.

Cosmetic periorbital and eyelid surgery is a commonly performed procedure in facial plastic surgery. Understanding the biomechanics of periorbital anatomy and its role in aesthetic surgery is essential for achieving optimal outcomes. This review explores the biomechanical processes involved in periorbital age changes and analyzes the impact of cosmetic surgery approaches on these processes. By maintaining the initial mechanical equilibrium of the brows, eyelids, septal fat, and blepharoplasty folds, periorbital and eyelid cosmetic surgery can effectively rejuvenate the appearance. Disruption of this equilibrium can lead to the migration of anatomic components, resulting in signs of aging. Surgeons, by applying biomechanical concepts, can tailor the forces exerted upon the different structures to manifest the patient's aesthetic aspirations. The key to success in periorbital and eyelid cosmetic surgery lies in re-establishing a dynamic mechanical equilibrium within the periorbital framework.

Posterior lamellar wedge resection of lower eyelid margin lesions.

PURPOSE: Removal of clinically benign eyelid margin lesions is frequently desired for cosmetic concerns. Although surgical excision remains the standard therapy for such lesions, it carries the risk of unfavorable outcomes. Hence, this study aimed to evaluate a more aesthetic technique entailing a posterior lamellar wedge resection of lower eyelid margin lesions through an infraciliary incision. METHODS: A retrospective review of patients who underwent posterior lamellar wedge resection for benign lower eyelid margin lesions between May 2017 and June 2022 was performed. Patient satisfaction using the visual analog score (VAS) and cosmetic outcomes using the Strasser score. RESULTS: Forty-two patients met the inclusion criteria (61.9% female, mean age: 46.8 years). Nevus was the most frequent histologic diagnosis (57.1%). Furthermore, 66.7% of lesions extended to the back of the lid margin. The mean defect size was 5.8 mm (range: 3.5-8 mm). The mean follow-up interval was 24.1 months (range: 6-60 months). Thirty-two (76.2%) eyelids had scores indicating an excellent result, and 10 (23.8%) patients had a good result. The mean patient satisfaction VAS score for the eyelid appearance was 96 (range: 70-100). There were no cases of recurrence of resected lesions. No further surgery was performed on the operated eyelid for any reason during the follow-up period. CONCLUSION: Posterior lamellar wedge resection for lower eyelid margin lesions was associated with excellent cosmetic outcomes, high patient satisfaction, and minimal adverse events.

Silicone sling surgery for congenital ptosis: Tarsal tunnel technique.

This was a prospective, interventional, comparative study conducted on patients with congenital simple severe ptosis. A novel method of silicone rod fixation to the tarsus (tarsal tunnel technique, group 1) was done compared with a conventional technique of silicone rod fixation (suture fixation technique, group 2) in frontalis suspension surgery. A total of 30 patients were randomized into two groups of 15 patients each. Postoperatively, MRD1, vertical palpebral aperture, and eyelid fold height were comparable in both groups till the last follow-up with stability in eyelid position. Patient satisfaction scores showed similar results with good-fair satisfaction grading in 13 patients in group 1 and 11 patients in group 2 at 6 months follow-up. No significant complications occurred in either group. Tarsal tunnel fixation of silicone rods is a novel method in sling surgery with optimal cosmetic and function outcomes. Further long-term studies are needed to validate the results of the technique.

The Experience in Lower Eyelid Blepharoplasty: Improvement of Surgical Procedures Based on Anatomical Basis.

OBJECTIVE: This study characterizes the appearance changes associated with aging of the human lower eyelid, grounded in its anatomical basis. Tailored approaches to lower eyelid bag are performed by these anatomical manifestations. METHODS: From January 2017 to January 2023, lower eyelid blepharoplasty was performed on 137 patients, aged 20 to 60 years. These patients were divided into 3 groups according to the periorbital aging appearance, primarily characterized by the presence and location of the "bag" bulge of the lower eyelid. We analyzed the corresponding changes in anatomical structures for each type, which included a weakened fibrous orbital support system, reduced muscle tone, and increased orbital fat. Patients were treated with tailored blepharoplasty techniques according to their classification. All patients in this study ranged in follow-up from 1 to 12 months. With patients' permit, photographs and clinical information were taken to evaluate the preoperative and postoperative outcome. RESULTS: Our study identified 3 morphologies of the lower eyelid. Type 1 presents a "bubble bag" in the medial and inferior aspect of the lower eyelid. Type 2 features a double convexity contour, with separate fat pad herniations demarcated by fibrous connective tissue. Type 3 exhibits a single convexity with a uniform herniation of fat pads across the entire lower eyelid. We have delineated the anatomical changes associated with each morphology type. With an approach grounded in "remodeling" and "recovery," the surgical treatment targets the fibrous support tissue to improve the outcomes of lower eyelid rejuvenation. No complications occurred. All postoperative results reached both surgeon's and patient's expectations. CONCLUSIONS: Surgeons must recognize the pivotal role of fibrous connective tissues-including the arcuate expansion, fascia of the inferior oblique muscle, and the orbicularis retaining ligament-and endeavor to preserve or reinforce these structures during surgical procedures. An anatomically based surgical approach would more effectively and safely to resist the facial aging process.

Complications of Fat Grafting and Repositioning for Correction of Lower Eyelid Pouch With Tear Trough Deformity or Lid-Cheek Junction: A Systematic Review.

BACKGROUND: Fat grafting and repositioning may serve as a convenient, economical, and effective surgical method for correcting lower eyelid pouch with a tear trough deformity or lid-cheek junction. However, comprehensive systematic reviews and meta-analyses investigating the complications associated with this technique are lacking. OBJECTIVE: This study aimed to summarize and gather data on complications related to fat grafting and repositioning for the correction of tear trough deformity or lid-cheek junction in lower eyelid blepharoplasty. METHODS: A thorough search was performed across multiple databases including PubMed, Cochrane, Embase, ProQuest, Ovid, Scopus, and Web of Science. Specific inclusion and exclusion criteria were applied to screen the articles. The occurrence of complications was analyzed using a random-effects model. RESULTS: A total of 33 studies involving 4671 patients met the criteria for systematic evaluation and were included in this meta-analysis. The overall complication rates were 0.112 (95% confidence interval [CI]: 0.060-0.177) for total complications, 0.062 (95% CI: 0.003-0.172) for unsatisfactory correction or contour irregularity, 0.062 (95% CI: 0.009-0.151) for hematoma, swelling (not specified as bulbar conjunctiva), ecchymosis, or oozing of blood, and 0.024 (95% CI: 0.013-0.038) for reoperation. CONCLUSIONS: Fat grafting and repositioning for correcting a lower eyelid pouch with tear trough deformity or lid-cheek junction was associated with high rates of complications. Therefore, it is crucial to closely monitor the rates of unsatisfactory correction or contour irregularity, hematoma, swelling (not specified as bulbar conjunctiva), ecchymosis, or oozing of blood, and reoperation. In addition, effective communication with patients should be prioritized.

Artificial intelligence-assisted grading for tear trough deformity.

BACKGROUND: Various classification systems for tear trough deformity (TTD) have been published; however, their complexity can pose challenges in clinical use, especially for less experienced surgeons. It is believed that artificial intelligence (AI) technology can address some of these challenges by reducing inadvertent errors and improving the accuracy of medical practice. In this study, we aimed to establish a reliable and precise digital image grading model for TTD using smartphone-based photography enhanced using AI deep learning technology. This model is designed to aid and guide surgeons, particularly those who are less experienced or from younger generations, during clinical examinations and in making decisions regarding further surgical interventions. MATERIALS AND METHODS: A total of 504 patients and 983 photos were included in the study. We adopted the Barton's grading system for TTD. All photos were taken using the same smartphone and processed and analyzed using the medical AI assistant (MAIA™) software. The photos were then randomly divided into two groups to establish training and testing models. RESULTS: The confusion matrix for the training model demonstrated a sensitivity of 56%, specificity of 87.3%, F1 score of 0.57, and an area under the curve (AUROC) of 0.85. For the testing group, the sensitivity was 49.3%, specificity was 85%, F1 score was 0.49, and AUROC was 0.83. Representative heatmaps were also generated. CONCLUSION: Our study is the first to demonstrate that tear trough deformities can be easily categorized using a built-in smartphone camera in conjunction with an AI deep learning program. This approach can reduce errors during clinical patient evaluations, particularly for less experienced practitioners.

Lower eyelid retraction repair using autologous auricular scapha cartilage.

PURPOSE: To assess the efficacy of lower eyelid retraction surgery utilizing autologous auricular scapha cartilage (located within the anterior surface groove between the helix and anti-helix) and to present the surgical outcomes in a patient cohort. METHODS: Medical records of 21 patients who underwent lower eyelid retraction surgery with scapha cartilage were retrospectively reviewed. Retractions, present for an extended duration (6 months to 20 years), exhibited 1 mm or more inferior scleral show, attributed to prior lower eyelid blepharoplasty, facial palsy, or as a normal anatomical variation. Surgical interventions included lateral canthotomy, cantholysis, incision of the subtarsal conjunctiva-lower eyelid retractors, lower eyelid retractor lysis, cartilage graft suturing to the defect area without conjunctival cover, and tightening of the lateral canthal corner in all patients. RESULTS: A total of 29 eyelids in 21 patients underwent surgery without intraoperative complications. Over a mean follow-up period of 11 months (range: 6-30 months), lower lid retraction improved in 96.5% of eyelids. Postoperative margin-to-reflex distance measurements (MRD2) significantly decreased compared to preoperative values (p = 0.001; p < 0.01). Average improvements in MRD2-a (midpupil to lower lid) and MRD2-b (lateral limbus to lower lid) were 1.77 ± 0.80 and 2.04 ± 0.81, respectively (p = 0.001; p < 0.01). Four eyelids (4/29) required revision due to canthal corner loosening, with correction necessitating periosteal flaps. All four patients had previously undergone two or more repairs elsewhere. The graft was visible in two lids but did not require further revision. One patient experienced mild helix deformity at the donor site, which did not warrant additional intervention. CONCLUSION: In cases of lower lid retraction associated with middle/posterior lamellar shortening, utilizing an autologous auricular scapha cartilage spacer graft offers notable benefits. These advantages comprise straightforward harvesting with minimal donor site complications, stability without experiencing shrinkage, a softer texture in comparison to posterior cartilage, a concave shape that facilitates proper fitting on the globe, and its autologous nature.

"Blue Scrub Lid Retraction": Changes in Eyelid Position on the Day of Surgery.

PURPOSE: The aim of this study is to test the hypothesis that margin-reflex distance 1 (MRD1) on the day of surgery will be higher than the MRD1 measured at the in-clinic consult visit among patients undergoing blepharoptosis repair due to an increased sympathetic drive. METHODS: Patients evaluated for involutional blepharoptosis repair were prospectively enrolled over a 12-month period in this single-center, self-controlled study. Three investigators independently determined MRD1 using cropped photos taken of patients at the in-clinic consult visit and on the day of surgery. A difference in height was tested for by using the 2-tailed Wilcoxon signed rank test. RESULTS: Evaluated in this study were 76 eyelids from 38 patients. Over 3-quarters of study participants had a higher MRD1 in the right and OSs on the day of surgery than at their in-clinic consultation visit (p < 0.001). The mean increase in MRD1 for the right eyelid and left eyelid was 1.0 mm (range: 0-3.15 mm) and 1.1 mm (range: 0-2.7 mm), respectively. CONCLUSIONS: In patients with involutional blepharoptosis, we conclude that MRD1 is higher on the day of surgery as compared with the in-clinic consult visit. This may be secondary to the stress of surgery and an associated increase in sympathetic drive. In some cases, this change in eyelid position led to resolution of apparent involutional ptosis altogether. Caution should be used when considering deferral of ptosis repair on the basis of exam findings present on the day of surgery.