Combining early lower eyelid surgery with neuromuscular retraining for synkinesis prevention after facial palsy: the role of the eye in aberrant facial nerve regeneration.

Background: Facial synkinesis (FS) is a distressing sequela of facial palsy (FP) characterized by involuntary, simultaneous movements of facial muscles occurring during voluntary facial expressions. Treatment of synkinesis is challenging, and preventive methods are needed. Aim: This study evaluated the efficacy of physical facial nerve rehabilitation (PFNR) therapy alone vs. PNFR with eyelid surgery to correct lagophthalmos and prevent the onset of synkinesis. Methods: Twenty five outpatients were randomized to receive either PFNR alone (neuromuscular retraining and Kabat proprioceptive neuromuscular facilitation) or PNFR and early (90 days after FP onset) eyelid surgery (involving a conservative oculoplastic correction for lagophthalmos with epiphora or ectropion). Comprehensive otolaryngological assessments and Magnetic Resonance Imaging (MRI) were conducted. Synkinesis progression was measured using Another Disease Scale (ADS) at baseline, 3-, 6-, 12-, and 24-months post-treatment. The data were analyzed with ANOVA, τ-test, Chi-Square analyses. Results: Patients undergoing eyelid surgery with PFNR showed faster (p < 0.001) and better recovery of facial movements (p < 0.05) than patients receiving PFNR alone comparing T0 and T12 (p < 0.0001). No synkinesis were observed in the PFNR plus surgery group while 37% of patients in PFNR alone had synkinesis (p = 0.03). At 24 months, none of the patients in the surgery group presented synkinesis. Conclusion: Combining early surgical treatment of paralytic lagophthalmos or epiphora with PFNR accelerated functional recovery and reduced synkinesis in patients with FP compared to facial rehabilitation alone. Further investigations in larger populations with long-term follow-up are needed. Clinical trial registration: https://clinicaltrials.gov/study/NCT06538103, NCT06538103.

Acceptance and willingness of patients with chronic facial nerve palsy for an implantable device that assists with eye closure.

BACKGROUND: Patients with facial nerve palsy often experience lagophthalmos (incomplete eye closure), which can lead to exposure keratitis. The Bionic Lid Implant for Natural Eye Closure (BLINC) is a medical device designed to mimic the more natural blink kinetics than traditional lid loading techniques. AIMS: This study aimed to evaluate potential factors that might influence the design of the BLINC device and willingness of participant to undergo the implant placement surgery. METHODS: Patients attending a multidisciplinary facial nerve clinic were invited to complete a survey addressing patient acceptance of the BLINC device implantation. RESULTS: Seventy-two patients were mailed the survey, of which 50 returned completed surveys (69%). The most important factor identified by participants was the device function (81% ranked as very important) and the least important factor was cost (16% ranked as very important). Median acceptable device function time was 5 years (range 1-10 years). Ten participants (20%) indicated willingness to be the first to trial BLINC. Women were more likely to rate visual appearance as important (OR 3.32, CI 1.14-9.62, p = 0.028), and less likely to rate user friendliness as important (OR 0.16, CI 0.04-0.52, p = 0.0021). Older participants were more likely to rate the length of recovery period as important (OR 1.04, CI 1.01-1.08, p = 0.006). Participants with complete eye closure were less likely to be willing to trial the implant (OR 0.08, CI 0.00-0.53, p = 0.006, whilst patients with eye irritation were more willing to trial the implant (OR 7.20, CI 1.12-142, p = 0.036). CONCLUSION: Certain patient demographics impact patient aesthetic and functional preferences and the willingness to trial the BLINC device.

Through their eyes: Navigating life with limited eyelid closure in patients with Moebius syndrome.

BACKGROUND: Moebius syndrome (MoS), a rare congenital condition caused by the underdevelopment of the sixth and seventh cranial nerves, presents with uni- or bilateral facial paralysis and lateral gaze palsy. Those with MoS often have incomplete eyelid closure (lagophthalmos). This study aimed to investigate the experiences of individuals living with incomplete eyelid closure due to MoS. METHODS: Participants shared their experiences in semi-structured open-ended focus groups during the 2023 MoS Foundation Conference. Data were analyzed thematically using Nvivo. The Terzis and Bruno scoring system was used to grade participant eyelid closure (range: 1 being no eyelid closure with full scleral show to 5 being complete eyelid closure with no scleral show) and blink (from 1 being no blink to 5 being synchronous and complete blink present). Marginal reflex distances 1 and 2 (MRD1 and MRD2) were measured to grade for ptosis and lid retraction, respectively. RESULTS: Fifteen participants participated in two focus groups, comprising adults (n = 12) and adolescents (n = 3). All participants had lagophthalmos with some scleral show, ptosis, and lid retraction. The median eyelid closure score was 3 (incomplete eye closure with 1/3 scleral showing). Five key themes were identified: social stigma and misunderstanding, daily life impacts, seasonal exacerbations, different attitudes toward surgical intervention between adults and adolescents, and a prevailing sense of self-acceptance regarding their condition. CONCLUSION: Incomplete eyelid closure poses significant social challenges for individuals with MoS, especially around social encounters. Our findings show the importance of developing tailored communication tools to support those living with this facial difference.

Examining timing of periorbital interventions in patients with upper division facial paralysis.

BACKGROUND: Facial paralysis is a life-altering condition that may arise from various etiologies, ranging from trauma to malignancy. Permanent facial paralysis may occur secondary to facial nerve sacrifice or irreversible damage to the nerve. In these particularly devastating cases, protection and maintaining function of the eye is paramount. There are many effective lagophthalmos corrective surgical procedures available for these patients. While placement of eyelid weights and lid tightening surgeries are the cornerstone of eyelid rehabilitation, limited information exists on whether the timing of eyelid interventions in the setting of permanent facial paralysis impact outcomes, including need for revision surgery. METHODS: A single-center retrospective chart review was performed for patients with irreversible facial paralysis treated with an upper eyelid weight between 2013 to 2022. Electronic health records were acquired to obtain facial paralysis etiology, associated clinical characteristics, the type of intervention, and the timing of intervention. Patients were classified as immediate if the eyelid weight operation occurred within 29 days of the initial facial paralysis and delayed if the surgery occurred 30 days or more after initial presentation. Outcomes were assessed in terms of revision procedures and surgical complications. RESULTS: There were 70 patients in total, with 35 patients in the immediate category and 35 patients in the delayed category. The most common etiology related to parotid gland pathology, and 58.6% of patients had facial paralysis from cancer-related surgeries. There were no significant differences in revision rates (p < 0.208) or in the types of procedures (p = 0.077) between the two groups. The complication rates also did not differ significantly between groups; however, there were only complications in the delayed intervention group. CONCLUSIONS: These findings suggest there is no difference in postoperative complications between groups, including the need for revision surgeries when comparing groups with immediate or delayed intervention. Thus, treatment plans should be customized based on patient and provider preferences.

Superior rectus/levator complex in acquired anophthalmic socket repaired with spheric implant-a computed tomography scan and topographic study.

AIM: To determine whether the levator palpebrae superioris (LPS)/superior rectus (SR) muscle complex, can influence the position of the upper lid and fornix in acquired anophthalmic sockets. METHODS: This comparative non-randomized and non-interventional study included retrospective data of 21 patients with unilateral acquired anophthalmic sockets repaired with spheric implants. High-resolution computed tomography (CT) measurements of the LPM/SR muscle complex and clinical topographic position of the upper lid, superior and inferior fornix depth in primary gaze position were evaluated. Demographic data were presented as frequency and percentage proportions and quantitative variables comparing the socket measurements with the normal contralateral orbit was statistically analyzed using non-parametric tests considering P<0.05. RESULTS: The anophthalmic orbits had a significantly shorter LPS length (P=0.01) and significantly thicker SR (P=0.02) than the normal orbit. Lagophthalmos was present in anophthalmic sockets but not in normal orbits (P=0.002), while levator function was normal in both (P>0.05, all comparisons). The superior fornix depth was similar in the anophthalmic socket and the contralateral normal orbit (P=0.192) as well the inferior fornix depth (P=0.351). CONCLUSION: Acquired anophthalmic sockets repaired with spheric implants have shorter LPS, thicker SR, and more lagophthalmos than normal orbits. The relationship of the LPS and SR with other orbital structures, associated with passive or active forces acting in the final position of the lids and external ocular prosthesis should be further investigated.

[Clinical and morphological aspects of the use of palpebral implants made of noble metals]. / Kliniko-morfologicheskie aspekty primeneniya pal'pebral'nykh implantatov iz blagorodnykh metallov.

Loading of the upper eyelid with palpebral implants made of noble metals is the modern standard of surgical treatment for paralytic lagophthalmos, and is aimed at increasing the mobility of the upper eyelid and normalizing involuntary blinking movements. This review presents the results of morphological studies, including immunohistochemical studies, reflecting the features of biointegration of palpebral implants in uncomplicated and complicated course of the postoperative period, and describes the modern understanding of the causes and immunopathological processes underlying the development of nonspecific inflammatory response, which is one of the most serious complications that often becomes an indication for implant removal.

Implantation of a Newly Designed Supratarsal Gold Weight versus the Traditional Pretarsal Model for the Correction of Long-standing Paralytic Lagophthalmos: A Retrospective Cohort Study.

Background The study determined to compare the clinical outcomes of traditional gold weight implantation for the correction of paralytic lagophthalmos with those of a newly designed model. Methods In this retrospective cohort study, we enrolled 30 patients (76% females; average age 60.8 ± 12 years) with facial palsy who underwent implantation of either the traditional pretarsal gold weight (PT group; n = 15) or a new supratarsal model (ST group; n = 15) from May 2014 to April 2019. The main outcome measures were the 12-month postoperative weight prominence, weight migration, improvement of lagophthalmos, upper eyelid contour, and upper eyelid ptosis. The secondary outcome was long-term (24 months) reoperative rate. Results The new model group had significantly better eyelid contour (risk ratio [RR] 3.16, 95% confidence interval [CI] 1.62-6.15, p = 0.001), less weight prominence (RR 1.74, 95% CI 1.13-2.70, p = 0.013), less weight migration (RR 1.31, 95% CI 1.12-1.54, p = 0.001), and less eyelid ptosis (RR 2.36, 95% CI 1.21-4.59, p = 0.011) than the traditional model group. Improvement of lagophthalmos was not statistically significant between the two groups (RR 1.44, 95% CI 0.72-2.91, p = 0.303). The 24-month reoperative rate was 53.3% in the PT group versus 13.3% in the ST group (RR 2.00, 95% CI 1.15-3.49, p = 0.015). Conclusion The newly designed supratarsal gold weight showed superior postoperative outcomes than the standard traditional model.

Scleral Contact Lens to Preserve a Corneal Graft in Chronic Lagophthalmos.

Facial burns involving the periorbital region may lead to cicatricial ectropion and lagophthalmos, causing severe exposure keratopathy and eventually blindness if uncorrected. In these patients, it is critical to provide aesthetic and functional surgical correction to protect the ocular surface from chronic desiccation in addition to visual rehabilitation. Conventional methods may not be sufficient to provide visual rehabilitation in complex cases. Scleral lenses can be a multipurpose alternative for these patients. Herein, we present the challenging case of a patient who developed cicatricial lagophthalmos and exposure keratopathy after facial transplantation due to gasoline burns and received a scleral contact lens for visual rehabilitation.

Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy.

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Evaluating the Correlation between Ptosis Improvement and Immediate Postoperative Lagophthalmos following Blepharoptosis Surgery under General Anesthesia in Pediatric Patients.

Background: The objective of this study is to establish a potential correlation between postoperative improvement in upper eyelid ptosis, measured by the marginal reflex distance 1 (MRD1), and the immediate postoperative degrees of lagophthalmos (IPDL). The established correlation is then used to assess whether IPDL can be used as a reliable indicator of successful treatment of eyelid ptosis. Methods: This retrospective study involved 19 patients, aged 1 to 11, with a total of 28 eyes affected by ptosis, who underwent surgery under general anesthesia at Seoul National University Bundang Hospital from January 2018 to December 2022. We monitored the MRD1 of the patients for over six months postoperatively and measured the IPDL. Results: After ptosis correction surgery, no statistically significant correlation was observed between the improvement in MRD1 and IPDL. Furthermore, the degree of postoperative eyelid ptosis improvement was found to vary and was not consistently sustained, attributable to a range of factors. Conclusions: Our study did not establish a statistically significant correlation between IPDL and ptosis improvement as measured by MRD1. Further research is needed to draw definitive conclusions about their correlation.

Congenital ectropion in Noonan syndrome.

Ten-year-old female patient, with facial dysmorphia, scoliosis, short stature, muscular hypotonia, patent foramen ovale and maturational delay, presented for correction of bilateral congenital ectropion. Ophthalmological examination revealed bilateral lower eyelid ectropion, euryblepharon and lagophthalmos, with a positive Bell's phenomenon. She was treated with full-thickness autologous skin grafts on the lower eyelids with bilateral lateral canthoplasty, resolving the ectropion and improving eyelid occlusion. Subsequently, a genetic study was performed that revealed a mutation in the PTPN11 gene and allowed, together with the clinical picture, to make the diagnosis of Noonan syndrome. Noonan syndrome is a multisystem genetic disorder with a wide variety of phenotypes, which usually presents with ocular and periocular disorders. Eyelid ectropion, a distinctive feature of this patient, is a rare ophthalmological manifestation of this syndrome that can be corrected with full-thickness skin graft and lateral canthoplasty.

Cerclage sling technique using temporalis muscle fascia to manage paralytic lagophthalmos: A preliminary study.

PURPOSE: Despite various existing surgical techniques, treatment of facial nerve palsy remains difficult. The purpose of this report is to present the cerclage sling technique using temporalis fascia to manage paralytic lagophthalmos. METHODS: A series of six patients underwent a cerclage sling technique using temporalis muscle fascia to treat paralytic lagophthalmos. The technique is presented in detail. Symptoms, palpebral fissures, and lagophthalmos were assessed pre- and postoperatively. Data were submitted for statistical analysis. RESULTS: After surgery, all patients achieved a reduction in clinical symptoms. The upper eyelids had lowered, and the inferior eyelids had elevated, reducing ocular exposure even if mild residual lagophthalmos was present. CONCLUSION: Cerclage using the temporalis muscle fascia sling technique is a safe and effective procedure to treat facial nerve paralytic lagophthalmos. A reduction in ocular exposure and lagophthalmos provides improvement in clinical symptoms and eyelid function.

Tape Eyelid Closure: An Effective Solution for Nocturnal Lagophthalmos in Patients with Ptosis and Poor Bell's Phenomenon.

BACKGROUND: Poor Bell's phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell's phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell's phenomenon in ptosis surgery and the management of nocturnal lagophthalmos. METHODS: We conducted a retrospective case series of 23 patients with ptosis and poor Bell's phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell's phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes. RESULTS: Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment. CONCLUSION: We conclude that poor Bell's phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell's phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The effect of various muscle transfer procedures on eye closure and blinking in longstanding facial palsy patients.

BACKGROUND: Facial palsy causes paralytic lagophthalmos, which remarkably deteriorates a patient's quality of life. In cases where denervation time is over 18-24 months (longstanding facial palsy), a free or pedicled muscle transfer is needed to replace the denervated orbicularis oculi muscle. PURPOSE: The purpose of this systematic review is to investigate the effect of various eye sphincter substitution procedures (free or pedicled muscle transfers) in longstanding facial palsy patients on eye closure and blink. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the Embase, Medline, Web of Science and Cochrane Library databases and Google Scholar. Our literature search yielded 4322 articles. Following a full-text review, 4 retrospective cohort studies and 21 case series were selected for this review. Meta-analyses using R package meta (version 6.5-0) were conducted. MAIN FINDINGS: All free and pedicled muscle transfers in this review showed an improvement in the scores and measurements on eye closure and blink. The pedicled temporalis muscle transfer was the procedure most commonly performed as eye reanimation surgery and showed consistent good results. Using the random effects model, the pooled effect of mean difference in lagophthalmos after gentle eye closure post-operatively versus pre-operatively (mm) in patients who received a pedicled (temporalis) muscle transfer was -6.19 (I2 = 85%, 95% CI: -7.89; -4.49) whereas it was -4.11 (I2 = 85%, 95% CI: -7.26; -0.95) for free (gracilis or platysma) muscle transfers. The pooled proportion of patients with complete eye closure after surgery was 0.69 (I2 = 49%, 95% CI: 0.54; 0.82) in patients who received a pedicled (temporalis) muscle transfer and 0.40 (I2 = 74%, 95% CI: 0.13; 0.74) in patients who received a free (platysma) muscle transfer. CONCLUSIONS: Unlike smile reanimation, dynamic eye closure and blink restoration are rather neglected topics in facial reanimation. The pedicled temporalis muscle transfer is often recommended as the first treatment of choice for eye reanimation in longstanding facial palsy patients since it is a reliable, straightforward procedure, that does not require complex microsurgery. However, with the advancements in the field of microsurgery, free muscle transfers are promising therapies, which may regenerate voluntary and spontaneous blinking.

Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review.

The purpose of this review was to study the evaluation, diagnosis, and management of ophthalmic complications associated with facial nerve palsy and to discuss the current and future interventions. The ophthalmic complications of facial paralysis include lagophthalmos, ectropion, exposure keratopathy, ocular synkinesis, and crocodile tears. Evaluation by an ophthalmologist skilled in recognizing and managing complications of facial paralysis shortly after its initial diagnosis can help identify and prevent long-term complications. Several types of grading scales are used to evaluate, measure the severity, and track surgical and patient-reported treatment outcomes. Lagophthalmos or ectropion are managed using temporary measures aimed at lubricating and covering the eye, including scleral lenses; however, these measures can be expensive and challenging to acquire and maintain. Temporary surgical interventions include lateral tarsorrhaphy, weighted eyelid implants, lateral canthoplasty, and other procedures that tighten or lift the eyelid or surrounding tissues. Management of flaccid facial paralysis due to iatrogenic injury or neoplasm requires neurorrhaphy or graft repair. The most common techniques for dynamic reconstruction in chronic facial paralysis are regional and free muscle flap transfer. Future directions for the management of ophthalmic complications aim to induce blinking and eye closure by developing systems that can detect blinking in the normal eye and transmit the signal to the paralyzed eye using mechanisms that would stimulate the muscles to induce eyelid closure. Blink detection technology has been developed, and a study demonstrated that blinking can be stimulated using electrodes on the zygomatic branch of the facial nerve. Further studies are needed to develop a system that will automate blinking and synchronize it with that of the normal eye.

The Nictavi Tarsus Patch: A New Device for Achieving Temporary Eyelid Closure in Lagophthalmos.

Purpose: To evaluate the effectiveness, tolerability, and safety of the Nictavi Tarsus Patch™ (NTP) in inducing temporary eyelid closure for the management of lagophthalmos in the pediatric and young adult population. Methods: We prospectively enrolled 20 patients <21 years of age who had previously been managed for lagophthalmos to trial the NTP in clinic. Inter-palpebral fissure distance (IPFD) was compared before and after the placement of the NTP in the eyes-closed position using paired t-tests. Subjects then underwent a 3-night home trial with the NTP, and parent and subject perceptions of effectiveness, comfort, and complications with the patch were analyzed using Likert scale survey questions. Results: Twenty subjects ages 2-20 years with paralytic (65%) and non-paralytic (35%) lagophthalmos were enrolled. The NTP improved lagophthalmos from a mean pre-placement IPFD of 3.3 mm to post-placement IPFD of 0.4 mm (p < 0.01). Overall, 80% of subjects achieved successful eyelid closure defined as ≤1 mm of post-placement IPFD. When stratified by subtype, 100% of subjects with paralytic lagophthalmos achieved successful eyelid closure compared to 71% of subjects with non-paralytic lagophthalmos. On a scale of 1 (worst) to 5 (best), parents rated the NTP at 4.3±0.7 for comfort while wearing, 4.3±1.0 for comfort in removing, 4.6±0.7 for ease of use, and 4.3±0.9 for effectiveness. Ninety-three percent of parents reported preferring NTP to other eyelid closure methods previously tried and indicated that they would use it again. Conclusion: The NTP is an effective, tolerable, and safe method of eyelid closure for children and young adults.

[Modern opportunities of lagophthalmos correction]. / Sovremennye vozmozhnosti korrektsii lagoftal'ma.

The main goal in the treatment of lagophthalmos is prevention of serious corneal complications. Based on the results of 2453 surgeries performed in patients with lagophthalmos, a detailed analysis of modern surgical techniques was carried out highlighting their advantages and disadvantages. The article describes in detail the most effective methods of static correction of lagophthalmos, their features and indications, and presents the results of using an original palpebral weight implant.

Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series.

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.

Ocular Surface Changes in Treatment-Naive Thyroid Eye Disease.

OBJECTIVE: To investigate the association of meibomian gland dysfunction (MGD) and ocular surface exposure with tear film instability in untreated thyroid eye disease (TED) patients. METHODS: A cross-sectional study of TED patients from September 2020 to September 2022 was conducted. Ocular surface parameters included ocular surface disease index (OSDI), tear meniscus height (TMH), non-invasive tear break-up time (NITBUT), partial blinking rate, lipid layer thickness (LLT), meibomian gland dropout (meiboscore), Schirmer's test, and corneal punctate epithelial erosions (PEE). Ocular surface exposure was assessed by the margin reflex distances of the upper and lower eyelid (MRD1 and MRD2), the amount of exophthalmos, lateral flare, and lagophthalmos. RESULTS: In total, 152 eyes from 76 TED patients (64 females and 12 males, age 42.99 ± 12.28 years) and 93 eyes from 61 healthy controls (51 females and 10 males, age 43.52 ± 17.93 years) were examined. Compared with control eyes, TED eyes had higher OSDI, TMH, LLT, and PEE; shorter NITBUT; and worse meiboscore (all p < 0.05). They also had larger amounts of exophthalmos, longer MRD1, more lateral flare, and lagophthalmos. Multivariate analysis identified an association of the tear film instability with lagophthalmos (ß = -1.13, 95%CI: -2.08, -0.18) and severe MGD in the lower eyelid (ß = -5.01, 95%CI = -7.59, -2.43). CONCLUSIONS: Dry eye in TED is mainly manifested as evaporative dry eye disease. Severe lower eyelid MGD and worse lagophthalmos were significantly associated with tear film instability in treatment-naive TED patients.