Association of Diabetic Retinopathy with Midlife Hepatic Steatosis Diagnosed by Elastography and Hepatic Steatosis Index in Type 2 Diabetes in an Indian Population.

Aims: People with type 2 diabetes mellitus are at increased risk of developing hepatic steatosis. We determined the prevalence of hepatic steatosis in middle-aged patients with and without diabetic retinopathy (DR) in an Indian population. We feel this information is critical, with trends of increasing chronic liver disease-related mortality at younger ages. Method: Institution-based analytical cross-sectional study with 114 middle-aged type 2 diabetes patients; 57 in each group with <15 years of duration of DM and without excessive drinking. Hepatic steatosis was determined by the hepatic steatosis index (HSI), hepatic ultrasonography (USG), and elastography. Result: The HSI in DR (37.9 ± 3.9) was more (P = 0.012) than in without diabetic retinopathy (NODR) (36.3 ± 3.3). There was no difference between two groups in liver span (P = 0.829) or in the prevalence of fatty liver (P = 0.562) as determined by conventional USG. Elastography value (kPa) was more (P = 0.001) in DR (6.51 ± 1.85) than in NODR (5.14 ± 1.60). On elastography, 50.9% in DR had a likelihood ratio (Metavir score for a stiffness value) for stage 2 Metavir score. In DR, 11.8% of those missed by USG had a likelihood ratio for ≥ stage 2 Metavir score on elastography. The presence of DR was independently correlated with kPa value (P < 0.001). Conclusion: A significantly higher prevalence of hepatic steatosis was observed in DR in this population. DR can be a useful biomarker for early hepatic screening in midlife, particularly with hepatic elastography, so that timely diagnosis of hepatic steatosis can be made.

Nested U-Net for Segmentation of Red Lesions in Retinal Fundus Images and Sub-image Classification for Removal of False Positives.

Diabetic retinopathy is a pathological change of the retina that occurs for long-term diabetes. The patients become symptomatic in advanced stages of diabetic retinopathy resulting in severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy stages. There is a need of an automated screening tool for the early detection and treatment of patients with diabetic retinopathy. This paper focuses on the segmentation of red lesions using nested U-Net Zhou et al. (Deep Learning in Medical Image Analysis and Multimodal Learning for Clinical Decision Support, Springer, 2018) followed by removal of false positives based on the sub-image classification method. Different sizes of sub-images were studied for the reduction in false positives in the sub-image classification method. The network could capture semantic features and fine details due to dense convolutional blocks connected via skip connections in between down sampling and up sampling paths. False-negative candidates were very few and the sub-image classification network effectively reduced the falsely detected candidates. The proposed framework achieves a sensitivity of [Formula: see text], precision of [Formula: see text], and F1-Score of [Formula: see text] for the DIARETDB1 data set Kalviainen and Uusutalo (Medical Image Understanding and Analysis, Citeseer, 2007). It outperforms the state-of-the-art networks such as U-Net Ronneberger et al. (International Conference on Medical Image Computing and Computer-Assisted Intervention, Springer, 2015) and attention U-Net Oktay et al. (Attention u-net: Learning where to look for the pancreas, 2018).

Association of mid-life cerebral small vessel disease with diabetic retinopathy in type 2 diabetes in an Indian population.

PURPOSE: Prevalence of cerebral small vessel disease (SVD) in elderly patients with diabetic retinopathy (DR) is higher than in those without DR. We determined the prevalence and severity of SVD in middle-aged patients with DR and compared it with those without DR (NODR) in a subset of the Indian population. We feel this information is critical with evolving trends of an increasing incidence of stroke at younger ages. METHOD: Institution-based analytical cross-sectional study with 88 middle-aged type 2 diabetes patients; 44 in each group with <10 years diabetes duration, <8% HbA1C value, and with no history of cardiovascular disease. The presence and severity of SVD were determined by magnetic resonance imaging (MRI). RESULT: Prevalence of SVD was 59.1% among study participants; 70.5% in DR and 47.7% in NODR (p = .03). Significantly increased SVD score (p = .008), high SVD score (p = .030), and white matter hyperintensity (WMH) load (p = .017) were observed in DR compared to NODR. There was no difference in the load of lacune and microbleed. SVD score did not differ according to the severity of DR (p = .395). The location-wise study of MRI revealed a significantly higher SVD load at the centrum semiovale in DR than in NODR (p = .014). We observed a 2.6 times greater chance of SVD (Odds ratio: 2.6, 95% CI 1.1-6.3) and a 9.6 times greater chance of high SVD score (Odds ratio: 9.6, 95% CI 1.1-80.0) in DR compared to NODR. CONCLUSION: Significantly higher burden of SVD in DR was observed, particularly affecting the centrum semiovale suggesting an association of mid-life SVD with DR in this population.

Association of sleep disturbance with diabetic retinopathy.

PURPOSE: Diabetes mellitus (DM) patients are more likely to experience sleep disturbances than normal. Sleep disturbances may contribute to the development of diabetic retinopathy (DR) by higher inflammatory markers in circulation. We investigated the association between sleep quality and DR. METHODS: Institutional case control study with type 2 DM patients of <10 years duration and HbA1c ⩽8%; 70 cases with DR and 70 controls without DR (NODR) (power 0.8). Sleep quality was assessed by Pittsburg sleep quality index (PSQI) questionnaire and compared. RESULTS: Cronbach's alpha was 0.777 with high internal homogeneity. Global PSQI score in DR (7.44 ± 3.99; 95%CI 6.88, 9.42) was more than in NODR (4.30 ± 3.26; 95%CI 3.87, 6.45) (p < 0.001). All sleep disturbance scores were more in DR except sleep duration. Poor sleep (PSQI score>5) was more prevalent in DR (p = 0.000) and associated with increasing DR severity (p = 0.026). Normal sleep latency was recorded in 78.57% and 42.85% patients in NODR and DR respectively (p < 0.001). Severe difficulty in subjective sleep quality (p = 0.024), sleep latency (p = 0.002) and daytime dysfunction (p < 0.001) was seen more in DR. Elevated daytime dysfunction was observed with increasing DR severity (p = 0.008). The optimal cut-off for global PSQI score and sleep latency for DR was 5.5 (OR: 5.97; 95%CI 2.86, 12.47) and 25 min(OR: 4.89; 95%CI 2.32, 10.26) respectively. CONCLUSION: Sleep disturbance is positively associated with DR. Our study identifies cut off value for DR of a modifiable parameter like sleep latency. It emphasizes the need of sleep quality assessment for risk assessment of DR.

Spectropathologic endorsement of ocular carotenoids for early detection of diabetic retinopathy.

Diabetic retinopathy (DR) is a common health concern. Unfortunately, the metabolic pathway causing DR is yet to be understood. The carotenoid level in the human body is known to protect the health of the eyes. In this work, resonance Raman spectroscopy and multivariate analysis of the spectral data of human serum are reported as next-generation spectropathologic tools to detect retinal degeneration efficiently. The proposed technique shows promise by endorsing ocular carotenoids as a critical biomarker for such pathosis. Furthermore, the multivariate analysis of the spectral data distinguishes between two different stages of the disease. The machine learning algorithm is used to estimate a significant accuracy of 94% of the proposed model for the classification. As the carotenoid level can be controlled by dietary intake, we believe that the reported results also indicate a therapeutic role of the same in DR.

Compassionate use of delamanid in adults and children for drug-resistant tuberculosis: 5-year update.

BACKGROUND: Although delamanid has been approved for the treatment of multidrug-resistant TB (MDR-TB) in numerous regions, in areas where it is not yet registered it can be accessed as part of salvage therapy (in particular for those patients with limited treatment options) via the Otsuka compassionate use programme. Here we present the analysis of interim treatment outcomes by 24 weeks of more than 200 MDR-TB patients globally who received delamanid under this programme. METHODS: We evaluated treatment efficacy with respect to culture negativity at 24 weeks, as well as the safety profile of delamanid, in an MDR-TB patient cohort treated under compassionate use between 2014 and 2019. RESULTS: Among patients who received delamanid as part of a multidrug regimen, 123 (61%) out of 202 had extensively drug-resistant TB (XDR-TB), 66 (33%) out of 202 had HIV co-infection and 34 (17%) out of 202 were children aged between 6 and 17 years. Of those patients who were culture positive at delamanid treatment initiation and who completed 24 weeks of delamanid treatment in combination with other anti-tuberculosis (TB) drugs, culture negativity was achieved in 116 (79%) out of 147 cases. The corresponding rates of culture negativity for patients with XDR-TB and HIV co-infection, as well as the paediatric subgroup were 69 (77%) out of 90, 44 (92%) out of 48 and 20 (80%) out of 25, respectively. QT interval prolongation was the most frequently observed serious adverse event and was reported in 8% of patients receiving delamanid. Overall, treatment safety outcomes did not reveal any new or unidentified risks. CONCLUSIONS: The use of delamanid combined with other active drugs has the potential to achieve high rates of culture negativity in difficult-to-treat drug-resistant TB cases, with a favourable safety profile.

Optical Coherence Tomography Findings in Patients of Parkinson's Disease: An Indian Perspective.

BACKGROUND: Parkinson's disease (PD) is one of the most common neurodegenerative movement disorders and its incidence is increasing worldwide along with population aging. Previous clinical and histologic studies suggest that the neurodegenerative process, which affects the brain, may also affect the retina of PD patients. OBJECTIVE: The objective of this study was to determine the thickness changes of retina nerve fibers and macular volume with optical coherence tomography (OCT) in PD patients. MATERIALS AND METHODS: The spectral domain OCT was used to assess the thickness of retinal nerve fiber layer (RNFL) and macular volume from 34 PD patients and 50 healthy age-matched controls. RESULTS: Compared with healthy age-matched controls, the RNFL thickness of PD patients was much thinner (P < 0.05) in all retinal quadrants, with temporal thinning being more than nasal thinning. Macular volumes were diminished in both perifoveal and outer macular regions in all sectors (P < 0.05) with preserved foveal volume. The degree of tissue loss corroborated with the severity of disease as objectively assessed by standardized rating scales (UPDRS). CONCLUSION: There is generalized retinal nerve degeneration in patients of PD and the degree of loss correlated with the severity and duration of disease.

Spectropathology-corroborated multimodal quantitative imaging biomarkers for neuroretinal degeneration in diabetic retinopathy.

INTRODUCTION: Image-based early detection for diabetic retinopathy (DR) needs value addition due to lack of well-defined disease-specific quantitative imaging biomarkers (QIBs) for neuroretinal degeneration and spectropathological information at the systemic level. Retinal neurodegeneration is an early event in the pathogenesis of DR. Therefore, development of an integrated assessment method for detecting neuroretinal degeneration using spectropathology and QIBs is necessary for the early diagnosis of DR. METHODS: The present work explored the efficacy of intensity and textural features extracted from optical coherence tomography (OCT) images after selecting a specific subset of features for the precise classification of retinal layers using variants of support vector machine (SVM). Fourier transform infrared (FTIR) spectroscopy and nuclear magnetic resonance (NMR) spectroscopy were also performed to confirm the spectropathological attributes of serum for further value addition to the OCT, fundoscopy, and fluorescein angiography (FA) findings. The serum metabolomic findings were also incorporated for characterizing retinal layer thickness alterations and vascular asymmetries. RESULTS: Results suggested that OCT features could differentiate the retinal lesions indicating retinal neurodegeneration with high sensitivity and specificity. OCT, fundoscopy, and FA provided geometrical as well as optical features. NMR revealed elevated levels of ribitol, glycerophosphocholine, and uridine diphosphate N-acetyl glucosamine, while the FTIR of serum samples confirmed the higher expressions of lipids and ß-sheet-containing proteins responsible for neoangiogenesis, vascular fragility, vascular asymmetry, and subsequent neuroretinal degeneration in DR. CONCLUSION: Our data indicated that disease-specific spectropathological alterations could be the major phenomena behind the vascular attenuations observed through fundoscopy and FA, as well as the variations in the intensity and textural features observed in OCT images. Finally, we propose a model that uses spectropathology corroborated with specific QIBs for detecting neuroretinal degeneration in early diagnosis of DR.

Quantitative Analysis of Segmented Fluorescein Angiography Images for the Follow-up of Choroidal Neovascular Membrane.

PURPOSE: The aim of this study was to evaluate choroidal neovascular (CNV) lesions with fluorescein angiography (FA) and to identify quantitative parameters and correlate these parameters to treatment outcomes. SUBJECTS AND METHODS: This institution based cross-sectional study evaluated 30 eyes with active sub-foveal predominantly classic CNV treated with bevacizumab. Pre- and post-injection segmented FA images were analyzed. Lesion area and CNV lesion were manually delineated. Outcome measure was the change 1-month after each injection in different intensity values (0-255 divided in eight regions A [lowest intensity] to H [highest intensity] on a linear scale) in lesion area, perimeter, greatest linear dimension (GLD), area, visual acuity (VA) and central macular thickness (CMT). RESULTS: At month 3, statistically significant changes from baseline occurred in VA, CMT, lesion area, GLD and perimeter (P < 0.05 all comparisons). Change in CMT from baseline to 3 months postinjection was correlated with change in VA (P = 0.009, r = 0.469) and intensity regions B (P = 0.001, r = -0.565), D (P = 0.001, r = 0.560), E (P = 0.035, r = 0.386). At month 3, change in intensity values 0-63 (A + B) was negatively correlated with CMT (P = 0.001, r = -0.575) and lesion area (P = 0.019, r = -0.427); change in intensity values 64-223 (C-G) was positively correlated with CMT (P = 0.000, r = 0.636) and lesion area (P = 0.002, r = 0.551). CONCLUSIONS: Decrease in area, GLD, perimeter and area with intensity ≥ 64 on segmented FA were associated with a favorable outcome of treatment. These parameters may be useful adjuncts to existing evaluation techniques during follow-up of CNV.

Hyperhomocysteinemia, a biochemical tool for differentiating ischemic and nonischemic central retinal vein occlusion during the early acute phase.

PURPOSE: The purpose of the study was to differentiate ischemic central retinal vein occlusion (CRVO) from nonischemic CRVO during the early acute phase using plasma homocysteine as a biochemical marker. METHODS: Fasting plasma homocysteine, serum vitamin B12, and folate levels were measured in 108 consecutive unilateral elderly adult (age >50 years) ischemic CRVO patients in the absence of local and systemic disease and compared with a total of 144 age and sex matched nonischemic CRVO patients and 120 age and sex matched healthy control subjects. RESULTS: Homocysteine level was significantly increased in the patients with ischemic CRVO in comparison with nonischemic CRVO patients (p = 0.009) and also in comparison with control subjects (p < 0.001). Analysis also showed that hyperhomocysteinemia was associated with increased incidence of ischemic CRVO (odds ratio, 18) than that for nonischemic CRVO (odds ratio, 4.5). Serum vitamin B12 and folate levels were significantly lower (p < 0.001) in CRVO patients compared to the control but were not significantly different between nonischemic and ischemic CRVO patients (p > 0.1). CONCLUSIONS: Hyperhomocysteinemia can be regarded as useful in differentiating nonischemic and ischemic CRVO during the early acute phase in absence of local and systemic disease in the elderly adult (age >50 years) population.

Characteristic OCT Pattern in Waldenstrom Macroglobulinemia.

PURPOSE: To report characteristic optical coherence tomography (OCT) patterns as a guide in diagnosis of Waldenstrom macroglobulinemia in a patient presenting with bilateral vision loss. CASE REPORT: A 60-year-old male patient presented with bilateral sudden-onset vision loss and low-grade fever. The patient had bilateral exudative retinal detachment involving the macula. Spectral domain OCT revealed neurosensory detachment along with a very regular and harmonious cystoid change in the outer retina as well as deposits around photoreceptors. The patient had lymphadenopathy and hepatosplenomegaly. Serum protein electrophoresis showed the presence of M band in the gamma globulin region, which, on immune fixation, showed a monoclonal band at the "IgM and K" region. Infiltration by lymphoplasmacytic proliferative cells with secondary myelofibrosis was seen in the bone marrow biopsy specimen. The immunophenotype scattergram of lymphoplasmacytic proliferative cells of bone marrow showed no light-chain expression, and the cells were brightly positive for CD19, CD5, and CD20. Quantitative assay of immunoglobulin M was 10,057 mg/dL. CONCLUSIONS: Spectral domain OCT showing a harmonious and regular cystoid pattern and deposits around photoreceptors was a guide in our diagnosis of this case of Waldenstrom macroglobulinemia presenting with retinal detachment and retinal deposits.

Correlation of C-reactive protein and body mass index with diabetic retinopathy in Indian population.

BACKGROUND: Association of C-reactive protein (CRP) and body mass index (BMI) with diabetic retinopathy (DR) has conflicting reports. METHOD: Sixty diabetes patients each with DR (Group A), no DR (Group B) and 60 healthy volunteers (control, group C) were studied. CRP was measured. BMI was calculated. RESULT: Significant difference in CRP was observed between groups A & B (p=0.000) and A & C (p=0.007). No significant difference in BMI was observed. Central macular thickness correlated positively with CRP and negatively with BMI. CONCLUSION: We observed strong association of CRP with DR and no significant relationship between DR and BMI.

Deep neural network and random forest hybrid architecture for learning to detect retinal vessels in fundus images.

Vision impairment due to pathological damage of the retina can largely be prevented through periodic screening using fundus color imaging. However the challenge with large-scale screening is the inability to exhaustively detect fine blood vessels crucial to disease diagnosis. In this work we present a computational imaging framework using deep and ensemble learning based hybrid architecture for reliable detection of blood vessels in fundus color images. A deep neural network (DNN) is used for unsupervised learning of vesselness dictionaries using sparse trained denoising auto-encoders (DAE), followed by supervised learning of the DNN response using a random forest for detecting vessels in color fundus images. In experimental evaluation with the DRIVE database, we achieve the objective of vessel detection with max. avg. accuracy of 0.9327 and area under ROC curve of 0.9195.

Correlation of morphological pattern of optical coherence tomography in diabetic macular edema with systemic risk factors in middle aged males.

To study correlation of different optical coherence tomography (OCT) patterns of diabetic macular edema (DME) with systemic risk factors. Institutional cross-sectional double-masked non-interventional study with 330 eyes of middle-aged male type 2 diabetes patients with DME. Various systemic parameters were measured. Diffuse retinal thickening (DRT), cystoid and serous patterns of DME were identified on OCT. Comparison between DRT versus non-DRT and serous versus non-serous eyes was done in respect to systemic parameters. Correlation of serous and DRT pattern was tested with systemic parameters above and below specified values. Mean age was 54.4 ± 7.1 years. Mean duration of diabetes was 8.7 ± 4.2 years. Mean serum globulin level was significantly higher (p = 0.018) in serous compared to non-serous group. Prevalence of serous DME was significantly high in those with serum globulin level >3.5 gm/dl (prevalence ratio = 3.01, p = 0.040). Significant correlation of central macular thickness was observed with duration of diabetes (p = 0.002, r = 0.440).Visual acuity (logMAR) was correlated significantly with HbA1C (p = 0.031, r = 0.305). Increased serum globulin, a positive phase reactant of inflammation, was found significant independent risk factor for development of serous DME. This study did not identify any modifiable systemic factor for any of the OCT patterns in DME.

Change in tear protein profile in diabetic retinopathy with duration of diabetes.

AIMS: To study change in tear protein profile with duration of diabetes and severity of diabetic retinopathy (DR) in type 2 diabetes patients. MATERIALS AND METHODS: Tear protein profile was ascertained by SDS PAGE method in 30 patients with DR (group A) and 37 patients without DR (group B). RESULTS: Six distinct bands of proteins were identified; these proteins are as follows: 91kDa (P1), 66kDa (P2), 60kDa (P3), 30kDa (P4), 18.4kDa (P5) and 14.4kDa (P6). Prevalence of P3 was significant (p=0.036) in group A, especially in cases with diabetes ≤8 years compared with diabetes >8 years (p=0.0107). In group B, P2 was significantly prevalent (p<0.0013) in cases with diabetes ≤8 years compared to diabetes >8 years. Considering the changes in terms of duration of diabetes in general, patients with diabetes of ≤8 years, P3 was significantly prevalent in group A compared to group B (p=0.004); and when the duration of diabetes is >8 years, P2 was found significantly more in group A compared to group B (p=0.01). No significant difference in P3 (p=0.025), P4 (p=0.2877), P5 (p=0.4801), P6 (p=0.0985) was observed in mild to moderate NPDR group compared to severe NPDR to PDR group. P1 and P2 were present only in severe NPDR and PDR. CONCLUSION: Variable protein expression was observed with duration of diabetes and severity of diabetic retinopathy.

Huge congenital teratoma containing tooth in a three-day-old neonate.

Congenital teratoma is a rare cause of congenital proptosis. A full term three-day-old male child was presented with massive unilateral swelling in the left orbit, which was noted since birth. Diagnosis of orbital teratoma without intracranial extension was made based on clinical examination and imaging. Lid-sparing exenteration of the left orbit was done. Histopathological examination confirmed the diagnosis of cystic teratoma. Congenital orbital teratoma with a tooth and mature elements of all the three germ cell layers is reported due to its extreme rarity.

Retrospective observational study of penetrating keratoplasty in the management of non-responsive microbial keratitis.

Microbial keratitis tops the list of the diseases leading to corneal blindness. Corneal transplant, either partial or full thickness, is the most helpful technique for infective keratitis that remains non- responsive, even with the most suitable medical treatment. Aims of this study are to evaluate the success of therapeutic penetrating keratoplasty in non-responsive microbial keratitis in eradication of infection, restoration of anatomical integrity of the globe and prevention of complication that influence the visual prognosis in a positive way. Result of the retrospective study of 60 patients who underwent therapeutic penetrating keratoplasty, following infected keratitis showed restoration of anatomical integrity in 51 cases (85%). Success rate of penetrating keratoplasty was higher in non- perforated (92%) than in perforated group (74.28%) and in non-mycotic than in mycotic group. Penetrating keratoplasty in non-responsive infected keratitis is thus helpful.

Visual impairment in urban school children of low-income families in Kolkata, India.

To evaluate pattern of visual impairment in school children from low-income families in Kolkata, India, an institutional cross-sectional study was conducted among 2570 children of 10 primary schools. Ocular examination including refraction was done and pattern of visual impairment and refractive error was studied. The age range was 6-14 years. Refractive error was seen in 14.7%. Only 4 children were already wearing correction. Myopia and hypermetropia was present in 307 (11.9%) and 65 (2.5%) children, respectively. Visual acuity of less than 6/12 in better eye was present in 109 (4.2%) and 5 (0.2%) children pre- and post-correction, respectively. Eighteen children had amblyopia. Although prevalence of refractive error in this group is less compared to school children of all income categories reported from other cities of India, it is more compared to school children of all income categories from the same city. Refractive error mostly remains uncorrected in this group.

Correlation of macular thickness and posterior hyaloid change following bevacizumab and triamcinolone in diffuse diabetic macular edema in middle-aged patients.

UNLABELLED: To compare changes in posterior vitreous detachment (PVD) following intravitreal injection of bevacizumab and triamcinolone in diffuse diabetic macular edema in middle-aged type 2 diabetes patients and to correlate this change with change in central macular thickness (CMT). DESIGN: cross sectional study. Fifteen consecutive patients treated by intravitreal bevacizumab (group A) and ten patients treated by intravitreal triamcinolone (group B). Institutional study carried out by retrospective analysis of patient registers including serial optical coherence tomography (OCT) images at baseline, and after 1 and 4 months. A central macular thickness (CMT) and vitreomacular relationship was noted on OCT. PVD was graded on a linear scale (0-4). Change in grade of PVD was correlated with change in CMT at each follow-up. At month 4, the decrease in mean CMT from baseline was 51.2 µ (P = 0.000) and 45 µ (P = 0.022) in group A and group B, respectively, with no significant difference between the two groups (P = 0.874). A change in grades of PVD from baseline to month 4 was significant in both group A (P = 0.001) and group B (P = 0.004) with no significant difference between the two groups (P = 0.906). A significant correlation between change in PVD and reduction of CMT was observed in group A (P = 0.011) but not in group B (P = 0.315). Both bevacizumab and triamcinolone caused a significant reduction in macular thickness and a significant change in grade of PVD. Change in PVD played an influential role in the reduction of macular thickness following bevacizumab.

Inadvertent intracorneal injection of local anesthetic during lid surgery.

PURPOSE: To report a case of inadvertent intracorneal injection of anesthetic agents during lid anesthesia and corneal penetration without full-thickness perforation. METHOD: Case report. RESULTS: Corneal edema with acute loss of vision was noted. The patient was treated with topical, antibiotic, cycloplegic, hyperosmotic agent and lubricant. While the edema slowly subsided, a loss in endothelial cell count was noted. CONCLUSIONS: The effects of intracorneal injection of lignocaine, bupivacaine, and its preservatives have not previously been reported in the literature. A lower postinjection endothelial cell count and associated clinical features in our case indicate that endothelial toxicity occurred. This potential complication should be kept in mind with necessary precautions taken during injection of the eyelid, particularly in cases with preexisting lid laxity.