Intense Pulsed Light Therapy for Patients with Meibomian Gland Dysfunction and Ocular Demodex Infestation.

To observe the clinical changes of meibomian gland dysfunctipn (MGD) and ocular Demodex infestation after intense pulsed light (IPL) treatment to further examine the mechanism of IPL treating patients with MGD and ocular Demodex infestation. The medical records of 25 patients (49 eyes) with MGD treated with IPL, were retrospectively examined to determine outcomes. Associated ocular-surface parameters (ocular surface disease index, OSDI; lipid layer thickness, LLT; noninvasive first breakup time, NIF-BUT; noninvasive average breakup time, NIAvg-BUT; tear film breakup area, TBUA; Schirmer I Test, SIT; corneal fluorescein staining, CFS), eyelid margin abnormalities, meibum quality and expressibility, MG morphological parameters (macrostructure and microstructure), and the number of Demodex infestation were examined before and after treatment. The MG microstructure and the Demodex infestation were examined via in vivo confocal microscopy (IVCM). The results showed that there were statistically significant differences in associated ocular-surface parameters (all P<0.05) before and after IPL treatment, except SIT (P=0.065). Eyelid margin abnormalities, meibum quality and expressibility obviously improved in upper and lower eyelid after IPL treatment (all P<0.0001). MG macrostructure (MG dropouts) decreased in upper (P=0.002) and lower eyelid (P=0.001) after IPL treatment. The nine parameters of MG microstructure in upper and lower eyelid all distinctly improved after IPL treatment (all P<0.0001). The mean number of Demodex mites on the upper lid margin (6.59±7.16 to 3.12±3.81/9 eyelashes) and lower lid margin (2.55±2.11 to 1.29±1.53/9 eyelashes) significantly reduced after IPL treatment (all P<0.0001). The Demodex eradication rate was 20% (8/40) in upper lid margin and 34.15% (14/41) in lower lid margin. These findings indicate that IPL shows great therapeutic potential for patients of MGD and ocular Demodex infestation.

Treatment of refractory conjunctivitis associated to dupilumab with topical pimecrolimus applied to the eyelid skin.

Patients with atopic dermatitis commonly experience ophthalmic complications, and a higher incidence of conjunctivitis has been observed during treatment with dupilumab. We present the case of a 49-year-old woman with persistent severe atopic dermatitis who complained of refractory conjunctivitis associated with dupilumab. Ocular examination showed features of atopic conjunctivitis for which an external topical application to the eyelids of pimecrolimus 10 mg/g cream was prescribed. The patient showed substantial clinical remission after only 12 days. This case was remarkable as the medication applied externally to the eyelid skin was effective in treating the conjunctival involvement possibly due to penetration of pimecrolimus through the eyelid layers. Further studies are needed to support the use of this drug for dupilumab-related conjunctivitis.

Historical Data: Histopathology Lesions Observed in the Eyes of Control Rabbits in Topical Ocular Administration and Contact Lens Studies.

Information on background changes in the ocular tissues of rabbits ( Oryctolagus cuniculus), a common species employed in ophthalmic toxicology studies, is sparse. This complicates interpretation of changes in light of small sample sizes on any single study. The purpose of this publication is to document the interstudy incidence of spontaneous or iatrogenic changes occurring in eyes of control rabbits. Photomicrographs of select lesions are provided. The data set was derived from a total of 54 studies conducted over an eleven-year period at Alcon Research Ltd., a Novartis Division, which featured topical ocular and contact lens routes of administration. It includes a total of 1,222 pigmented and albino New Zealand rabbits and a total of 2,084 eyes which were either untreated or treated with innocuous control articles. There were no noteworthy differences across routes of administration. Changes in anterior segment ocular and adnexal tissues were more common than in posterior segment ocular tissues. Overall, mononuclear cell infiltration was the most common finding. The retina was the posterior tissue most commonly observed with spontaneous changes, with folds and rosettes being the most common retinal finding. Retinal changes were more common in albino as compared to pigmented rabbits. Understanding the incidence and characteristics of spontaneous ocular lesions facilitates accurate and consistent diagnosis and data interpretation.

Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

OBJECTIVE: To evaluate the use of perforated punctal plugs with adjuvant application of mitomycin-C in the management of acquired external punctal stenosis grades 0 and 1. METHODS: This is a prospective interventional case series including 30 eyes of 30 patients with acquired external punctal stenosis of the lower punctum of grades 0 and 1 presenting with epiphora. They were examined to exclude other causes of lacrimation and epiphora: Slit-lamp assessment of the stenosed punctum and grading was done, probing was done to exclude associated canalicular stenosis, and syringing was done to exclude nasolacrimal duct obstruction. For all cases, dilatation was done, followed by application of mitomycin-C, and perforated punctal plugs were then inserted. Plugs were removed after 6 months, and anatomical and functional success were assessed and followed during and for 6 months after removal of the plugs. RESULTS: The study included 30 patients with acquired external punctal stenosis: 9 males (30%) and 21 females (70%) with a mean age of 62.83 ± 8.3 years. Punctal stenosis grade 0 (no punctum) occurred in 9 cases (30%), and grade 1 (the punctum is covered by a membrane) occurred in 21 cases (70%). Six months after removal of the plugs, epiphora improved in 93.3% of patients, and fluorescein dye disappearance test results improved in 90% of patients; 6.7% of cases had early extrusion of the plug, and 3.3% had granuloma formation. CONCLUSIONS: Application of perforated punctal plugs combined with mitomycin-C is a simple and efficient technique in the management of tight acquired external punctal stenosis.

Xanthelasma-Like Reaction to Filler Injection.

PURPOSE: The purpose of this study is to describe a new complication of a xanthelasma-like reaction which appeared after dermal filler injection in the lower eyelid region. METHODS: A retrospective case analysis was performed on 7 patients presenting with xanthelasma-like reaction after filler injection to the lower eyelids. RESULTS: Seven female subjects with no history of xanthelasma presented with xanthelasma-like reaction in the lower eyelids post filler injection. Fillers included hyaluronic acid (2 patients), synthetic calcium hydroxyapatite (4 patients), and polycaprolactone microspheres (one patient). Average time interval between filler injection and development of xanthelasma-like reaction was 12 months (range: 6-18 months). Treatment included steroid injections, 5FU injections, ablative or fractionated CO2 laser, and direct excision. Pathology confirmed the lesion was a true xanthelasma in one patient. In treated patients, there was subtotal resolution after laser. Xanthelasma-like reaction resolved completely after direct excision. Three patients elected to have no treatment. CONCLUSIONS: Previously there has been one reported case of xanthelasma after filler injection. This case series is the largest to date. Furthermore, this series is notable because xanthelasma-like reactions appeared after injection with 3 different types of fillers. None of the patients had evidence of xanthelasma prefiller injection. The precise mechanism by which filler injection can lead to the formation of xanthelasma-like reaction is unclear. A possible mechanism may be related to binding of low-density lipoprotein and internalization by macrophages. Further investigation is required. Nevertheless, physicians performing filler injections should be aware of this new complication and treatment options.

Hybrid facial image feature extraction and recognition for non-invasive chronic fatigue syndrome diagnosis.

Due to an absence of reliable biochemical markers, the diagnosis of chronic fatigue syndrome (CFS) mainly relies on the clinical symptoms, and the experience and skill of the doctors currently. To improve objectivity and reduce work intensity, a hybrid facial feature is proposed. First, several kinds of appearance features are identified in different facial regions according to clinical observations of traditional Chinese medicine experts, including vertical striped wrinkles on the forehead, puffiness of the lower eyelid, the skin colour of the cheeks, nose and lips, and the shape of the mouth corner. Afterwards, such features are extracted and systematically combined to form a hybrid feature. We divide the face into several regions based on twelve active appearance model (AAM) feature points, and ten straight lines across them. Then, Gabor wavelet filtering, CIELab color components, threshold-based segmentation and curve fitting are applied to extract features, and Gabor features are reduced by a manifold preserving projection method. Finally, an AdaBoost based score level fusion of multi-modal features is performed after classification of each feature. Despite that the subjects involved in this trial are exclusively Chinese, the method achieves an average accuracy of 89.04% on the training set and 88.32% on the testing set based on the K-fold cross-validation. In addition, the method also possesses desirable sensitivity and specificity on CFS prediction.

Palpebral position interdependence in blepharoptosis: comparison of the effect of instillation of 10% phenylephrine drop and digital lifting / Interdependência na posição palpebral em ptose palpebral: comparação do efeito de instilação de colírio de fenilefrina 10% e o teste de elevação digital da pálpebra

Purpose: To quantify and compare the effects of instillation with 10% phenylephrine and digital lifting on the contralateral upper eyelid of patients with involutional bilateral blepharoptosis. Methods: The present prospective clinical study involved patients with involutional bilateral blepharoptosis who underwent two tests: 1) digital lifting of the more ptotic eyelid and observation of the effect on the contralateral eyelid and 2) instillation of two drops of 10% phenylephrine in the more ptotic eye and observation of the effect on the contralateral eyelid. Patients were filmed before and 5, 10, and 15 min after instillation, and the resulting images were analyzed to obtain eyelid measurements. The results were tested using a linear mixed-effects model. Results: A total of 27 patients, ranging from 52 to 82 years of age (mean age 68.51 ± 8.21 years), 24 (88.88%) of whom were women, were included in the present study. In eyes that received instillation, the marginal distance reflex-1 (MDR1) values increased from baseline (1.21 ± 0.60 mm) until 10 min after instillation, then remained statistically unchanged until 15 min after instillation (2.42 ± 0.90 mm). Significant differences were observed in the contralateral eye of the group that underwent digital lifting (1.51 ± 0.53 mm - 1.63 ± 0.56 mm) and in the contralateral eye of the group that underwent 10% phenylephrine instillation (1.38 ± 0.54 mm - 1.63 ± 0.56 mm); p=0.02 and p<0.01, respectively. Conclusion: In all eyes, 10% phenylephrine elevated the upper eyelid, with improved eyelid height at 10 min after instillation. Significant differences were observed in the height of the contralateral eyelid when compared before and after each intervention in each group; however, this difference was very small and nearly undetectable by conventional clinical evaluation in the digital lifting group. However, the 10% phenylephrine eye-drop test resulted in substantial changes in MDR1 values ...

Objetivo: Quantificar e comparar o efeito da instilação do colírio de fenilefrina 10% com o levantamento manual da pálpebra superior contralateral de pacientes com ptose palpebral bilateral involucional. Métodos: Estudo clínico e prospectivo de pacientes com ptose palpebral bilateral involucional submetidos a dois testes: 1) elevação manual da pálpebra mais ptótica e observação do efeito da intervenção na pálpebra contralateral; e 2) a instilação de duas gotas de colírio de fenilefrina 10% no olho mais ptótico e observação do efeito da intervenção na pálpebra contralateral. Os pacientes foram filmados antes e 5, 10 e 15 minutos após a instilação. Os resultados foram analisados estatisticamente com o modelo linear de efeitos mistos. Resultados: O estudo incluiu 27 pacientes com idade entre 52-82 anos (68,51 ± 8,21), 24 dos quais eram do sexo feminino (88,88%). Em olhos submetidos a instilação do colírio, os valores da DMR1 (distância marginal reflexo) aumentaram da linha de base (1,21 ± 0,60 mm) até os 10 min, em seguida, manteve-se estatisticamente estável até 15 min (2,42 ± 0,90 mm). Diferenças significativas foram observadas nos olhos contralaterais, independentemente do levantamento manual da pálpebra (1,51 ± 0,53 mm - 1,63 ± 0,56 milímetros) e da instilação do colírio de fenilefrina 10% (1,38 ± 0,54 mm - 1,63 ± 0,56 mm), p=0,02 e p<0,01 respectivamente. Conclusões: Em todos os olhos, a instilação do colírio de fenilefrina 10% mostrou um aumento gradual do valor de distância marginal reflexo até os 10 min. Nos olhos contralaterais houve diminuição do valor de distância marginal reflexo, independentemente do teste realizado, porém as mudanças que ocorrem na posição da pálpebra contralateral, durante o teste da elevação manual, são muito pequenas e difíceis de serem detectadas no exame clínico convencional. Enquanto isso, o teste de colírio de fenilefrina 10% produziu mudanças substanciais nos valores distância marginal reflexo nos ...

Efficacy of porcine placental extract on wrinkle widths below the eye in climacteric women.

OBJECTIVE: Injections of human placental extract, which is known to play a role in skin regulation, have long been used for the treatment of skin wrinkles and non-healing wounds. Porcine placental extract (PPE), an oral supplement, was recently developed for this purpose. The aim of this study was to assess whether PPE has a positive effect on the improvement of fine wrinkles below the eye in climacteric women. METHODS: We first non-invasively measured wrinkle widths with a skin analyzer in a cross-section of 185 healthy adult Japanese women. Next, 44 climacteric women with mild or few climacteric symptoms were enrolled into an open-label, randomized, controlled study of the effect of PPE on wrinkle widths. A retrospective comparison of wrinkle widths in 123 climacteric women with climacteric symptoms with or without PPE treatment was also performed. RESULTS: Wrinkle widths below the eye in women ≥ 30 years of age were significantly higher than in women 20-29 years of age. Treatment with three capsules of PPE per day was significantly (p < 0.05) effective in reducing wrinkle widths at 24 weeks compared with control subjects. Retrospective analysis showed that subjects treated with three (p < 0.05) and six (p < 0.01) capsules of PPE per day observed a significant reduction in wrinkle widths compared with untreated subjects. CONCLUSION: Oral PPE treatment is a possible option for improving the appearance of fine wrinkles below the eye in climacteric women.

Asian upper lid blepharoplasty: an update on indications and technique.

This article (1) briefly reviews the topographical and surgical anatomy of the Asian upper eyelid, (2) provides guidelines for preoperative assessment and postoperative management for upper Asian blepharoplasty, (3) describes the senior author's surgical technique for external incisional approach to upper eyelid crease formation, and (4) discusses potential pitfalls and complications.

Anatomical position of hyaluronic Acid gel following injection to the infraorbital hollows.

PURPOSE: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens. METHODS: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains. RESULTS: Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel. CONCLUSIONS: In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.

Ocular surface discomfort and Demodex: effect of tea tree oil eyelid scrub in Demodex blepharitis.

The purpose of this study was to evaluate the relation between ocular discomfort and ocular Demodex infestation, and therapeutic effects of tea tree oil (TTO) in Demodex blepharitis patients. Three hundred and thirty-five patients with ocular discomfort were evaluated for ocular Demodex infestation and subjective symptoms with ocular surface discomfort index (OSDI) score. Among them, Demodex-infested patients were randomized to receive either eyelid scrubbing with TTO (TTO group,106 patients) or without TTO (Control group, 54 patients) for 1 month. Demodex were found in 84% of patients with ocular discomfort. The number of Demodex was significantly correlated with age (P = 0.04) and OSDI score (P = 0.024). After eyelid scrub treatment, Demodex count was reduced from 4.0 ± 2.5 to 3.2 ± 2.3 in the TTO group (P = 0.004) and from 4.3 ± 2.7 to 4.2 ± 2.5 in the control group (P = 0.27). Also, OSDI score was reduced from 34.5 ± 10.7 to 24.1 ± 11.9 in the TTO group (P = 0.001) and from 35.3 ± 11.6 to 27.5 ± 12.8 in the control group (P = 0.04). In conclusion, Demodex number showed a significant positive correlation with age and subjective ocular discomfort. The tea tree oil eyelid scrub treatment is effective for eliminating ocular Demodex and improving subjective ocular symptoms.

Treatment of infraorbital dark circles using a low-fluence Q-switched 1,064-nm laser.

OBJECTIVE: To evaluate the efficacy and safety of the low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminium garnet (QSNY) laser in treating infraorbital dark circles. PARTICIPANTS AND METHODS: Thirty women with infraorbital dark circles (predominant color dark brown) participated in this open-label study. Participants underwent eight sessions of low-fluence QSNY laser treatment at 4.2 J/cm(2) at 3- to 4-day intervals. A spot size of 3.5 mm was used, with a pulse duration of 8 ns. The melanin deposition in the lesional skin was observed in vivo using reflectance confocal microscopy (RCM). Morphologic changes were evaluated using a global evaluation, an overall self-assessment, a narrow-band reflectance spectrophotometer, and a skin hydration measurement instrument. RESULTS: Twenty-six of 30 patients showed global improvement that they rated as excellent or good. Twenty-eight rated their overall satisfaction as excellent or good. The melanin index indicated a substantial decrease, from 225.84 at baseline to 182.65 (p < .05). RCM results showed a dramatic decrease of melanin deposition in the upper dermis. Adverse effects were minimal. CONCLUSIONS: The characteristic finding for dark-brown infraorbital dark circles is melanin deposition in the upper dermis. Treatment of infraorbital dark circles using low-fluence 1,064-nm QSNY laser is safe and effective. The authors have indicated no significant interest with commercial supporters.

Digital image analysis to characterize the upper lid marginal peak after levator aponeurosis repair.

PURPOSE: Lid contour is important for eyelid symmetry, but clinical quantification can be difficult. The marginal peak is a major determinant of upper eyelid contour, and its horizontal position, relative to the mid-pupillary line, may be used as a measure of symmetry after surgery. This study used digital image analysis to assess the peak position in patients who had undergone levator aponeurosis repair. METHODS: An unselected group of patients underwent anterior-approach levator aponeurosis repair, performed under local anesthesia by a single surgeon, using 3 6/0 Vicryl sutures to reattach the levator aponeurosis to the upper tarsus. Both before and 2-3 weeks after ptosis repair, digital photographs were taken in a fixed format and the images analyzed using NIH imaging software to assess the position of the upper eyelid peak. Comparisons were made between the pre- and postoperative measurements in the operated eye and between the operated eye and its fellow eye. RESULTS: Twenty people (8 male; 40%) underwent unilateral levator muscle resection (9 right eyes; 45%). In eyes before ptosis surgery, the peak was significantly more medially placed (median +0.17 mm) as compared with that of fellow eyes (median +0.80 mm) (p = 0.023). There was a significant temporal shift of the median peak after surgery, from +0.17 mm to +0.92 mm (p = 0.029). Although there was a minor nasal shift of peak in the unoperated eyes after contralateral surgery (median +0.80 mm to +0.64 mm), the peak positions for the 2 eyes were not significantly different at 2-3 weeks after aponeurosis repair (p = 0.22). CONCLUSIONS: Digital image analysis allows an objective assessment of the upper eyelid marginal contour after ptosis repair. A nasal shift in the upper eyelid marginal peak has been identified in ptotic eyes (as compared with the contralateral side) and, after successful ptosis repair, there is a significant temporal shift to match the unoperated fellow eye.

Effects of a Brazilian herbal compound as a cosmetic eyecare for periorbital hyperchromia ("dark circles").

BACKGROUND: Evidence suggests that periorbital hyperchromia (dark circles) occurs mainly as a consequence of postinflammatory hemodynamic congestion producing a typical bruising aspect on the lower eyelids. AIMS: To evaluate the clinical effects of Pfaffia paniculata/Ptychopetalum olacoides B./Lilium candidum L.-associated compound (PPLAC) on periorbital hyperchromia and to study in vitro its underlying anti-inflammatory and antioxidant mechanisms. METHODS: Twenty-one volunteers presenting with periorbital hyperchromia received a serum sample containing 5.0% PPLAC, which was applied topically in the periorbital area twice a day for 28 days. Skin color was measured using variations in the individual typological angle (DeltaITA(0)) and skin luminance (DeltaL*) calculated in the area around the eyes and in the adjacent area. Colorimetric readings were taken at the onset and end of the 28-day treatment. Volunteers were also asked to fill out a questionnaire concerning the improvement in "dark circles." The anti-inflammatory and antioxidant effects of PPLAC were measured by quantification of prostaglandin E(2), leukotriene B(4), histamine, and superoxide dismutase levels using an in vitro model of human skin culture. RESULTS: Topical application of PPLAC led to a significant improvement in skin luminance and tone in the periorbital area, which was demonstrated by increased values of ITA(0) and L* in about 90% of volunteers. In addition, subjects reported reduced intensity and improved appearance of "dark circles." A dose-dependent decreased production of inflammatory mediators, concomitant to increased antioxidant enzyme levels, was observed in our in vitro studies, under basal and lipopolysaccharide-stimulated conditions. CONCLUSIONS: Although the precise mechanisms related to PPLAC remain to be clarified, our results indicate that the reduction in the inflammatory process as well as the antioxidant protection against deleterious elements may be considered as an integral approach to preserve the integrity of vascular endothelium, preventing the hemodynamic congestion that culminates in the formation of "dark circles" around the eyes.

Venous malformation of the eyelid treated with pulsed-dye-1064-nm neodymium yttrium aluminum garnet sequential laser: an effective and safe treatment.

Venous malformations of the skin and subcutaneous tissue are compressible, blue-purple tumors that are present at birth. According to the location and symptoms caused, venous malformations can be treated with surgery, sclerotherapy, or a combination of both. Laser therapy can also be used, especially when surgery is contraindicated. We report the case of a 24-year-old man who presented with a venous malformation on the upper and lower left eyelids, which provoked a mechanical ptosis. Treatment with sequential pulsed-dye neodymium yttrium aluminum garnet (PDL-Nd:YAG) laser was performed. After 2 treatments, a marked reduction of volume and blanching of the venous malformation was observed, with satisfactory cosmetic results. The sequential PDL-Nd:YAG laser seems to be an effective and safe therapy for the treatment of cutaneous venous malformations. It penetrates deeper than pulsed-dye laser alone, and because it allows the use of lower fluencies than Nd:YAG laser alone, it reduces the risk of adverse effects.

Recurrent allergic contact dermatitis due to allergen transfer by sunglasses.

Tea tree oil (Melaleuca oil) is an essential oil, distilled predominantly from the leaves of the Australian plant, Melaleuca alternifolia. This species is unique to Australia and native to New South Wales. Allergic contact dermatitis to tea tree oil is well recognized and is becoming increasingly common in Australia (1, 2).