Determining the Degree of Perceptible Static Eyelid Asymmetry and Effect of Face Inversion: A Cross-sectional Pilot Study.

PURPOSE: To determine the degree of static eyelid asymmetry required to be perceptible and whether this is affected by image inversion. METHODS: Images of 3 volunteers were digitally manipulated to have eyelid asymmetry of 0.5 mm, 1 mm, or 1.5 mm of 3 different types, upper lid ptosis, upper lid retraction, and lower lid retraction. Forty-nine laypersons stated whether the images were symmetrical or asymmetrical. A separate inversion survey, completed by 29 clinicians, consisted of symmetrical images and 1 mm asymmetrical images, with half being inverted. RESULTS: Upper lid ptosis, upper lid retraction, and lower lid retraction were not detected by most laypeople at 0.5 mm of severity (18.9%, 6.7%, 18.9% detection, respectively) but all 3 were detected by the majority of participants once asymmetry reached 1 mm severity (65.7%, 61.8%, 51.0% detection, respectively) and rose to over 70% identification at 1.5 mm (92.2%, 73.5%, 73.5% detection, respectively). Inversion of the images led to 19.7% lower rates of correct identification of asymmetrical faces compared with images presented in the correct orientation (80.7% asymmetry identified in normal images, 61.0% inverted, p < 0.001). CONCLUSIONS: All asymmetries were detectable by a majority of laypersons at a severity of 1 mm. Image inversion decreases a clinician's ability to detect a 1 mm asymmetry, indicating an impaired asymmetry perception in the intraoperative view. This study provides research to counsel patients with varying degrees of eyelid asymmetry.

Vertical Lid Split to Aid Excision and Reconstruction of Conjunctival Tumors Involving the Fornices.

PURPOSE: To describe how a vertical lid split helps excision and reconstruction of conjunctival tumors. METHODS: All patients with a limited view of conjunctival tumors involving the fornices underwent a vertical lid split procedure to improve access during resection and reconstruction. RESULTS: There were 11 cases where vertical lid splits were performed to assist excision and reconstruction of conjunctival tumors on patients between 2015 and 2019. There were 4 male and 7 female patients, 50-85 years of age, mean age 67.2 years. Four patients had invasive malignant melanoma, 2 melanoma in situ, 3 invasive squamous cell carcinoma, and 2 squamous cell carcinoma in situ. The authors have had no local reoccurrences in 9 patients (follow-up 8-54 months, mean 18 months). One patient's deep margins were involved and proceeded to exenteration, and 1 patient died from liver metastases. CONCLUSIONS: A vertical lid split incision of either or both eyelids, well away from the visible tumor edge splays the lid open allowing the whole conjunctival surface to be stretched out and viewed as a single flat sheet. This aids excision and reconstruction of the tumor, potentially reducing the risk of seeding and simplifying the reconstruction.

Diplopia Following the Insertion of a Canalicular Bypass Tube: Etiology, Risk Factors, Management, and Outcomes.

PURPOSE: To report the etiology, management, and possible risk factors for diplopia after canalicular bypass surgery. METHODS: A multicenter retrospective, noncomparative case series of patients who developed diplopia following canalicular bypass surgery were assessed. RESULTS: Twenty-four cases of diplopia were identified across 12 institutions. Tubes were inserted as a primary procedure with external dacryocystorhinostomy (DCR) (1; 4%) or without DCR (10; 42%) or as a secondary procedure after external (8; 33%) or endonasal (5; 21%) DCR. Factors predisposing to local damage were noted in 17 (71%): these factors included preexisting autoimmune/inflammatory condition (7 cases), medial canthal tumor resection (5 cases), preoperative radiotherapy (2 cases), 2 drug treatments (topical and systemic), and 1 local surgery. Horizontal diplopia was due to restriction of abduction and first noted at a median of 3.5 months (mean: 17.8 months, range: 1 day to 112 months) and persisted in 23 (96%) cases with a mean restriction of -2, affecting primary gaze in 4 patients and activities of daily living in 13 (42%). Seventeen patients received various treatments: 10 were operated on resulting in cure in 1 and improvement in 9. A stable degree of diplopia persisted in all but one patient. CONCLUSIONS: Restriction of abduction causing horizontal diplopia is a rare complication with canalicular bypass surgery and a notably high proportion occurred after tube placement without DCR; carunculectomy was not ubiquitous. Although in some the diplopia may be improved with intervention, the chance of cure is low. This complication should probably be included during informed consent for canalicular bypass tubes.

Application of SPF moisturisers is inferior to sunscreens in coverage of facial and eyelid regions.

Many moisturisers contain sun protection factors (SPF) equivalent to those found in sunscreens. However, there is a lack of research into how SPF moisturiser application compares to sunscreens in terms of coverage achieved and protection afforded. Previously we demonstrated that users incompletely covered their eyelid regions during routine sunscreen application. Here, we aimed to determine if SPF moisturiser users also displayed these tendencies. A study population of 84 participants (22 males, 62 females, age 18-57) were exposed to UV radiation and photographed using a tripod mounted UV sensitive DSLR camera on two separate visits. At visit one, images were acquired before and after applying either SPF30 sunscreen or moisturiser, then at visit two the study was repeated with the other formulation. Images were processed for facial landmark identification followed by segmentation mapping of hue saturation values to identify areas of the face that were/were not covered. Analyses revealed that application of moisturiser was significantly worse than sunscreen in terms area of the whole face missed (11.1% missed with sunscreen compared to 16.6% for SPF moisturiser p<0.001 paired t-test). This difference was primarily due to decreased coverage of the eyelid regions (14.0% missed with sunscreen, 20.9% moisturiser, p<0.001). Analysis of a post-study questionnaire revealed participants to be unaware of their incomplete coverage. Secondary analyses revealed improved coverage in males (p = 0.05), and, with moisturiser only, in participants with darker skin tones (p = 0.02). Together these data indicate that, despite potential advantages in terms of increased frequency of application of moisturiser, the areas of the face that are at higher cancer risk are likely not being protected, and that participants are unaware that they are at risk. As such, alternative sun-protection strategies should be promoted.

UV imaging reveals facial areas that are prone to skin cancer are disproportionately missed during sunscreen application.

Application of sunscreen is a widely used mechanism for protecting skin from the harmful effects of UV light. However, protection can only be achieved through effective application, and areas that are routinely missed are likely at increased risk of UV damage. Here we sought to determine if specific areas of the face are missed during routine sunscreen application, and whether provision of public health information is sufficient to improve coverage. To investigate this, 57 participants were imaged with a UV sensitive camera before and after sunscreen application: first visit; minimal pre-instruction, second visit; provided with a public health information statement. Images were scored using a custom automated image analysis process designed to identify areas of high UV reflectance, i.e. missed during sunscreen application, and analysed for 5% significance. Analyses revealed eyelid and periorbital regions to be disproportionately missed during routine sunscreen application (median 14% missed in eyelid region vs 7% in rest of face, p<0.01). Provision of health information caused a significant improvement in coverage to eyelid areas in general however, the medial canthal area was still frequently missed. These data reveal that a public health announcement-type intervention could be effective at improving coverage of high risk areas of the face, however high risk areas are likely to remain unprotected therefore other mechanisms of sun protection should be widely promoted such as UV blocking sunglasses.