Telemedicine for Musculoskeletal Rehabilitation and Orthopedic Postoperative Rehabilitation.

Telehealth visits result in high-quality care, with high patient and provider satisfaction. Strong evidence suggests that virtual physical therapy is noninferior to conventional face-to-face physical therapy for a variety of musculoskeletal disorders. Postoperative telerehabilitation has a strong positive effect on clinical outcomes, and the increased intensity telerehabilitation programs offer is a promising option for patients. Studies demonstrate effective virtual postoperative management. The novel coronavirus disease 2019 pandemic has led to improved reimbursement for telehealth visits and accelerated widespread implementation of telemedicine. This article establishes experience and evidence-based practice guidelines for conducting telemedicine visits, with emphasis on the virtual physical examination.

The effect of eyebrow stenting on the measurement of levator excursion in normal and ptotic eyelids.

Introduction: Levator function is classically estimated by measuring upper eyelid excursion (ULE) with digital brow stenting. The purpose of this study is to compare ULE with and without brow stenting in normal and ptotic eyelids. Methods: In this prospective observational study, normal and ptotic eyelids were recruited. Subjects were photographed with and without digital brow stenting in primary position, downgaze, and upgaze. Measurements were conducted on digital photographs. The primary outcome measure was ULE (distance travelled by the eyelid margin between downgaze and upgaze). Normal and ptosis (MRD1 ≤ 2.5 mm or asymmetry ≥ 1 mm) subgroups were defined. Independent one-way ANOVA and independent samples t-tests were performed. This study was powered to detect a 1 mm difference in the primary outcome measure, assuming SD = 1 mm, with alpha = 0.05 and beta-error = 0.95. Results: Twenty-eight normal eyelids of 22 subjects and 28 ptotic eyes of 18 subjects were included. Stenting significantly (p < 0.01) increased ULE in the overall sample (+0.9 mm) and in controls (+1.2 mm), but not (p > 0.05) in ptotic eyelids (+0.5 mm). Post hoc analysis revealed a beta-error of 0.08 in the latter. Conclusion: ULE was significantly higher with brow stenting in normal eyelids (approximately +1.2 mm) but not in ptotic eyelids, possibly due to increased levator tone secondary to increased effort in the coupled frontalis.

The Relationship Between Eyebrow and Eyelid Position in Patients With Ptosis, Dermatochalasis and Controls.

PURPOSE: The purpose of this study is to explore mechanical and co-innervational factors involved in both voluntary and involuntary brow elevation among people affected by ptosis and dermatochalasis. METHODS: In this prospective cohort study of normal controls and eyelids with ptosis or dermatochalasis, marginal reflex distance (MRD1) and brow height were measured under the following conditions: neutral position, involuntary mechanical brow elevation, voluntary brow elevation, and maximal eyelid opening. The primary outcome measure was change in MRD1. Secondary outcome measures included brow height and coupling (mm brow height change per mm MRD1 change). Analysis of variance and t tests were performed for intra- and intercondition comparisons, respectively. RESULTS: Mechanical (involuntary) brow elevation significantly raised MRD1 in control eyelids and eyelids with dermatochalasis, but not in eyelids with ptosis. Voluntary brow elevation produced significantly greater brow height than maximal eyelid opening in controls and eyelids with dermatochalasis, but not in eyelids with ptosis. Maximal eyelid opening increased MRD1 greater than voluntary brow elevation significantly in control eyelids, but not in eyelids with dermatochalasis or ptosis. Coupling of the brow and eyelid margin during maximal eyelid opening was significantly greater in eyelids with ptosis relative to controls. CONCLUSIONS: In eyelids with ptosis, mechanical brow elevation does not change eyelid position; however, voluntary brow elevation raises eyelid position to a similar position as maximal eyelid opening. These results argue against the contention that the brow is elevated to mechanically lift the eyelid in ptosis and instead suggest that the brow elevation is driven by efforts to raise the eyelid, possibly via co-innervation.

Predictors of Success Following Müller's Muscle-Conjunctival Resection.

PURPOSE: This study aims to describe Müller's muscle-conjunctival resection surgery in terms of outcomes and potential factors that may predict final positions. METHODS: This cross-sectional cohort study included patients undergoing Müller's muscle-conjunctival resection surgery for involutional ptosis over a 15-year period. Success was defined in 2 ways: 1) final marginal reflex distance 1 (MRD1) ≥2.5 mm (MRD1 success) and 2) final difference in MRD1 ≤1 mm between eyelids (symmetry success). Percentages of patients achieving both outcomes were calculated. Predictors of outcome were assessed using bivariate analysis and multivariate models. RESULTS: The final sample included 315 eyes in 192 patients. The mean age (standard deviation) was 67.9 (11.9) years, and 60.0% were female. MRD1 ≥2.5 mm was achieved in 65.7% of the sample. Symmetry within 1 mm was achieved in 82.9% of the sample. Significant (p < 0.05) predictors of MRD1 success were female sex, concurrent lower eyelid blepharoplasty, and higher preoperative MRD1 in bivariate analysis; preoperative MRD1 and female sex in the multivariate model; and preoperative MRD1 in the a priori model. Significant (p < 0.05) predictors of symmetry success were female sex, previous lower eyelid blepharoplasty, concurrent lateral canthoplasty, preoperative symmetry, and older age in bivariate analysis; only female sex in the multivariate model. DISCUSSION: Müller's muscle-conjunctival resection is effective for elevating the eyelid in ptosis and may be more effective for achieving symmetry than absolute elevation over 2.5 mm. The results remain difficult to predict based clinical, surgical, or demographic factors.

Change in Eyelid Position Following Muller's Muscle Conjunctival Resection With a Standard Versus Variable Resection Length.

PURPOSE: This study compares the use of a standard 7 mm resection length to a variable 4:1 ratio of resection length to desired elevation nomogram when performing Muller's muscle conjunctival resection surgery. METHODS: In this cross-sectional case control study, 2 groups were defined. The first underwent Muller's muscle conjunctival resection surgery with a standard 7 mm resection length and the second underwent the same surgery with a variable resection length determined by a 4:1 ratio of resection length to desired elevation nomogram. Groups were matched for age (within 5 years) and sex. Pre- and postoperative photographs were measured digitally. Change in upper marginal reflex distance 1 (MRD1) and final MRD1 were the primary outcome measures. The study was powered to detect a 1 mm difference in MRD1 to a beta error of 0.95. RESULTS: No significant preoperative differences between the groups were noted. No significant difference in final MRD1 (0.1 mm; p = 0.74) or change in MRD1 (0.2 mm; p = 0.52) was noted. Mean resection length to elevation ratios were 3.9:1 for standard group and 4.3:1 for the variable group (p = 0.54). CONCLUSION: The authors were not able to detect a significant difference in final MRD1 or change in MRD1 for patients undergoing Muller's muscle conjunctival resection surgery with standard or variable resection lengths. These results tend to argue against a purely mechanical mechanism for Muller's muscle conjunctival resection surgery.

Assessing the Accuracy of Eyelid Measurements Utilizing the Volk Eye Check System and Clinical Measurements.

PURPOSE: The purpose of this study was to validate the accuracy of marginal reflex distance 1 (MRD1) measurements obtained by the Volk Eye Check system, a modified smartphone that measures MRD1 automatically, relative to clinical and digital measurements. METHODS: In this prospective observational study of adults with normal eyelids and ptosis, MRD1 was measured clinically, digitally, and automatically with the Volk device. Eyes were divided into successful versus unsuccessful Volk trial groups; successful eyes were then subdivided into control and ptosis subgroups. The primary outcome measures were mean MRD1 obtained by the 3 modalities. Secondary outcome measures included the success rate of the device and the prevalence of ptosis within the successful and unsuccessful groups. RESULTS: In the overall sample of 88 eyes, clinical and digital MRD1 were not significantly different. Among eyes with successful Volk trials, significant differences in MRD1 measured by the 3 modalities were as follows: in the successful group, Volk MRD1 (3.05 mm) was significantly (p < 0.01) higher than digital MRD1 (2.68 mm); in the ptosis subgroup, Volk MRD1 (2.47 mm) was significantly higher than clinical (2.05 mm; p < 0.05) and digital MRD1 (1.91 mm; p < 0.01). Eyes in the successful group (66% of attempted collections) demonstrated significantly higher MRD1 (mean difference, 1.21 mm; p < 0.01) and were significantly less likely to demonstrate ptosis (2.7×; p < 0.05) than those in the unsuccessful group. CONCLUSIONS: The Volk device measures MRD1 well in normal patients but overestimates MRD1 in patients with ptosis. It may be most appropriate in assessing patients with normal or elevated eyelid position. Clinical and digital MRD1 measurements were not different than each other.

Urticarial reaction following endovascular embolization of an orbital arteriovenous malformation (AVM) with n-butyl cyanoacrylate (nBCA) glue.

Orbital arteriovenous malformations (AVMs) are rare vascular lesions that may be managed with endovascular embolization followed by surgical resection. Embolization is often accomplished with n-butyl-2-cyanoacrylate (nBCA), which is considered to be a safe and effective liquid occlusive agent. Localized vascular inflammation has been associated with endovascular nBCA use in histopathologic studies, but reports of systemic hypersensitivity reactions following endovascular embolization with nBCA are rare. We present a case of a 26-year-old male who developed an intermittent systemic urticarial reaction without cardiopulmonary compromise beginning four weeks after nBCA embolization of an orbital AVM. Subsequent skin allergy testing performed by an allergist confirmed hypersensitivity to nBCA glue and the patient has since been successfully managed with daily oral antihistamines. Awareness of this rare potential complication of endovascular embolization with nBCA will aid in the counseling and management of patients with AVMs.

Association of Eyelid Position and Facial Nerve Palsy With Unresolved Weakness.

IMPORTANCE: Understanding the prevalence and clinical features of eyelid malpositions in facial nerve palsy (FNP) may inform proper management of patients with FNP and supplement our knowledge of eyelid physiology. OBJECTIVE: To describe eyelid malposition in FNP. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, patients with FNP seen at the Center for Advanced Facial Plastic Surgery and Jules Stein Eye Institute between January 1, 1999, and June 1, 2014, were reviewed for study inclusion. Data collection was performed between June 1, 2014, to August 1, 2014, and data analysis was performed between June 15, 2014, to September 1, 2015. The distances from the center of the pupil to the upper eyelid margin (marginal reflex distance 1 [MRD1]) and to the lower eyelid margin (marginal reflex distance 2 [MRD2]) were measured on photographs of patients in the primary position and with full smile. Eyelid asymmetry, retraction, ptosis, synkinesis, and severity and duration of FNP were assessed. Eligible participants were adults with FNP at a private tertiary care clinic with primary position photographs. Exclusion criteria included prior history of procedures or medical conditions that could alter eyelid position. RESULTS: The 52 included patients were predominantly female (38 [73%]), with a mean (SD) age of 44.1 (13.8) years. Of this group, 34 patients (65%) were white, 8 (15%) were Asian, 8 (15%) were Hispanic, and 2 (4%) were African American. Retraction (MRD1, >5.0 mm) was present in 8 patients (15%), 3 of whom had eyelid asymmetry (MRD1, >1.0 mm). Overall, total asymmetry of greater than 1.0 mm was present in 14 patients (27%), with the FNP side higher in 12 (23%). Compared with those without asymmetry, patients with eyelid asymmetry were significantly more likely to have contralateral ptosis (42% vs 2.5%, P < .001) but did not have a significantly shorter duration of FNP (12.3 months vs 13.8 months, P = .82). Ptosis was noted in 4 patients and was also unrelated to duration of FNP (9.6 months in patients with ptosis vs 13.6 months in those without, P = .60). Synkinesis was found in 24 patients (46%), but none had concomitant ptosis. Severe FNP (House-Brackmann score, ≥4) was present in 28 patients (54%), and these patients were 20 times more likely to have asymmetry greater than 1.0 mm, often with the FNP side higher. CONCLUSIONS AND RELEVANCE: Upper eyelid asymmetry is common in FNP. In most of the patients in this study, the FNP side was higher without demonstrating retraction, and the contralateral side was ptotic. Thus, contralateral ptosis surgery may benefit these patients. Furthermore, patients with severe facial weakness were more likely to have eyelid asymmetry, suggesting that the ability of the eyelid position maintenance system to adapt to weakness of eyelid protractors may be limited by the severity of this weakness. LEVEL OF EVIDENCE: 3.