Meibography-Guided Electroepilation for Congenital Distichiasis: A Novel Surgical Technique.

PURPOSE: Congenital distichiasis is managed either by ablation, using laser, cryotherapy, or electroepilation, or by surgical excision with mucous membrane grafting. Ablative procedures are usually blind as the exact depth of distichiatic eyelashes is unknown. The described surgical technique utilizes meibography for imaging the root and depth of distichiatic eyelashes that aided in performing electroepilation. METHODS: Six patients (n = 24 eyelids; mean age 15.5 ± 12.2 years) underwent infrared meibography (Oculus Keratograph 5 M) and noninvasive tear breakup time prospectively. Eyelashes were electroepilated using a premarked needle inserted at a depth based on meibography findings in 4 patients. Surgical success was defined as no distichiatic eyelash regrowth and functional success was defined as the resolution of symptoms at a minimum of 3 months of follow-up. RESULTS: All 6 patients had all 4 eyelids involved to varying degrees, with a total of 230 distichiatic eyelashes. The median number of distichiatic eyelashes was 9 in the upper eyelids and 4.5 in the lower eyelids. Meibography revealed visible distichiatic eyelash roots in 70% of eyelashes in the upper eyelid and 87.8% in the lower eyelid, respectively. The median eyelash root depth was 2.7 mm (mean 2.9 mm, range 1.8-5.4 mm). The mean noninvasive tear breakup time was 12.2 seconds despite absent or rudimentary meibomian gland segments seen on meibography. The anatomical success was 75% (12/16 eyelids), and functional success was 87.5% (7/8 eyes) at a median follow-up of 5.5 months. CONCLUSION: Preoperative infrared meibography in eyelids with congenital distichiasis helps estimate the eyelash depth and can be used to guide eyelash ablation procedures.

[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.

Lid-wiper keratopathy and mucous membrane grafting.

BACKGROUND: A healthy lid-wiper is an important component of a healthy ocular surface. Any abnormality or irregularity of the lid wiper can potentially damage a relatively healthy ocular surface. Stevens-Johnson syndrome, toxic epidermal necrolysis, and ocular cicatricial pemphigoid are some of the examples that can result in lid-margin keratinization during the course of the disease. These permanent changes at the lid margin mechanically abrade the corneal surface and facilitate corneal neovascularization. The corneal clarity is lost over time, and the patients have corneal blindness. PURPOSE: This video discusses the role of a healthy lid-wiper, conditions causing lid-margin keratinization and subsequent lid-wiper keratopathy, and surgical technique in mucous membrane grafting. SYNOPSIS: The video demonstrates the technique of restoration of a healthy lid margin by doing a mucous membrane graft for lid-margin keratinization and its role in the prevention of corneal blindness. HIGHLIGHTS: Lid-margin keratinization is essentially a chronic sequela and is often ignored till irreversible corneal changes develop. Early intervention in the form of mucous membrane grafting can prevent corneal vascularization and loss of corneal clarity. VIDEO LINK: https://youtu.be/NGMlqUp_qLU.

Head rotation and the perception of eyelid height and contour.

PURPOSE: Effective visual perceptual processing is one of the many components of surgical competence. Human face identification is most efficient when viewed upright. However, it is not yet clear how this perception sensitivity impacts eyelid symmetry. This study investigates surgeons' and laypeople's accuracy and efficiency in perceiving eyelid asymmetry from different spatial perspectives. METHODS: A prospective psychometric experiment was conducted where oculoplastic surgeons were recruited from the American Society of Ophthalmic Plastic and Reconstructive Surgery and the Brazilian Oculoplastic Surgery Society, and control participants were recruited via crowdsourcing (Amazon's Mechanical Turk). Standard illustrations of the human face with varying degrees of eyelid abnormality, laterality, gender and rotation were presented to participants who were asked to judge whether the eyelids were symmetric or asymmetric. RESULTS: The survey was completed by 75 oculoplastic surgeons (49.33% male; mean age of 46.9±10.7) and 192 lay individuals (54.6% male; mean age 34.6±11.3 years). Among oculoplastic surgeons, deviation from upright was significantly associated with increased reaction time and decreased proportion correct (OR per 45° for peak 0.68, 95% CI 0.60 to 0.77, p<0.001; OR per 45° for ptosis 0.52, 95% CI 0.32 to 0.87, p=0.012; OR per 180° for aggregate responses 0.56, 95% CI 0.51 to 0.61, p<0.001). Oculoplastic surgeons demonstrated increasing accuracy and decreasing reaction time with additional trials for both peak and ptosis. CONCLUSION: Oculoplastic surgeons perceive eyelid asymmetries more accurately and can better compensate for inverted sensory information. However, accuracy increases and reaction time decreases with additional trials, suggesting trainability and potential for improvement in inversion disability.

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.

Cheeklift With and Without Posterior Lamellar Spacer Grafts for Treatment of Lower Eyelid Retraction.

BACKGROUND: To compare outcomes of lower eyelid retraction repair using a subperiosteal midface lifting technique with and without posterior lamellar grafts. METHODS: Charts of patients undergoing a sub-periosteal midface lift for treatment of lower eyelid retraction using 4 techniques for posterior lamellar reconstruction were reviewed. Thirty patients were included in each of the groups: midface with hard palate graft (HPG), midface lift with acellular cadaveric graft (ADG), midface lift with retractor disinsertion (RD) and midface lift alone (NG). Measurements of distance from pupil center to lower lid margin (MRD2) and from lateral limbus to lower lid margin (MRD2limbus) were taken from pre- and postoperative photographs and compared. Secondary outcomes included rates of reoperation, major and minor complications, resolution of symptoms and keratopathy. RESULTS: One hundred twenty operations were assessed (n = 30 for each surgical group). The average follow-up time was 20 weeks. The median MRD2 elevation was 0.95 mm (NG), 0.85 mm (HPG), 1.59 mm (ADG) and 1.02 mm (RD). The median MRD2limbus elevation was 1.06 mm (NG), 0.92 mm (HPG), 1.45 mm (ADG) and 1.12 mm (RD). There were no significant differences in MRD2 or MRD2limbus between the 4 groups (p = 0.06 and 0.29, respectively). Reoperation rates were highest with in the hard palate graft group (33%) compared to other techniques (p = 0.0006). CONCLUSIONS: Similar degrees of lower eyelid elevation were achieved with all the midface lifting techniques, and complication rates did not significantly differ between techniques. However, the higher reoperation rates with the use of spacer grafts suggest that a no-graft technique may be preferable. LEVEL OF EVIDENCE III: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association of FGF4L1 Retrogene Insertion with Prolapsed Gland of the Nictitans (Cherry Eye) in Dogs.

Cherry eye is the common name for prolapse of the nictitans gland, a tear-producing gland situated under the third eyelid of dogs. Cherry eye is characterized by a red fleshy protuberance in the corner of the eye, resembling a cherry. This protrusion is a displacement of the normal gland of the third eyelid, thought to be caused by a defect in the connective tissue that secures the gland in place. Options for treatment may include anti-inflammatory medications in mild cases, but surgical replacement of the gland is usually indicated. Cherry eye is most often seen in dogs under the age of two years, with certain breeds having a higher incidence, suggesting a potential genetic association. Integration of panel genetic testing into routine clinical practice allows for the generation of large numbers of genotyped individuals paired with clinical records and enables the investigation of common disorders using a genome-wide association study (GWAS) approach at scale. In this investigation, several thousand cases and controls for cherry eye in both purebred dogs and mixed breeds are used for a large-scale GWAS, revealing a single peak of genome-wide significance on canine chromosome 18, directly at the location of the previously identified FGF4 insertion known to cause chondrodysplasia in several breeds.

Reconstruction of an Eyelid Defect Associated with Congenital Coloboma in a 7-Month-Old Male Infant Using an Acellular Dermal Allograft.

BACKGROUND Congenital eyelid coloboma in children often faces complications such as keratitis, symblepharon, and amblyopia. Repairing defects involving at least 50% of the eyelid margin can be challenging. Acellular dermal allograft (ADA) has achieved excellent results as a substitute in adult eye plastic surgery, with minimal morbidity. This report describes a case of reconstruction of an eyelid defect in a 7-month-old male infant using an ADA. CASE REPORT A 7-month-old male infant was referred due to congenital eyelid coloboma in the left eye, which affected nearly one-half of the upper and lower eyelids medially, with more than 9 mm of lagophthalmos and lacrimal duct malformation inducing dacryocystitis. Under general anesthesia, A U-shaped silicone drainage tube was inserted in the nasolacrimal duct to ensure an unobstructed lacrimal duct. The symblepharon release, pseudopterygium excision, and medial canthus reconstruction were performed sequentially. Then, the upper eyelid defect was repaired through the advancement of the lateral segment of the eyelid, following lateral cantholysis. A trimmed ADA was placed as a substitute for the tarsal plate in the lower eyelid defect area and sutured with the free edge of the retractor. Finally, the lower and lateral skin orbicular muscle flap was advanced to cover the acellular dermis composite graft. The postoperative eyelid morphology was satisfactory. At 6 months after surgery, lower eyelid retraction gradually appeared. CONCLUSIONS ADA is presented as an effective solution for reconstructing significant eyelid defects of infants. However, the potential of postoperative eyelid retraction still deserves future research and refinement in surgical techniques.

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.

Outcome Comparison of Transconjunctival Müller's Muscle Recession With Levator Disinsertion (TMRLD) to Gold Weight Implantation in the Treatment of Paralytic Lagophthalmos.

PURPOSE: To compare clinical outcomes of transconjunctival Müller's muscle recession with levator disinsertion (TMRLD) to the traditional gold weight implantation in patients with paralytic lagophthalmos. METHODS: A retrospective nonrandomized comparative review of patients who had gold weight implantation and TMRLD surgeries for paralytic lagophthalmos from January 2016 to January 2023 was performed. The main outcome comparisons were measurement changes in lagophthalmos, marginal reflex distance 1, visual acuity, and corneal examination. Complication and reoperation rates were also compared. RESULTS: Twenty-six cases of gold weight implantation and 20 cases of TMRLD surgeries were identified. The changes in logMAR visual acuity between gold weight implantation and TMRLD groups were not statistically significant (-0.10 ± 0.48 vs. +0.05 ± 0.14, p > 0.05). The percent improvement in lagophthalmos (62.2% ± 51.8% vs. 58.4% ± 21.1%) and final marginal reflex distance 1 (2.22 ± 1.42 vs. 2.25 ± 1.41 mm) were also comparable between groups ( p > 0.05). Both groups showed similar changes in marginal reflex distance 1 (1.75 ± 1.31 vs. 2.83 ± 1.37 mm) and lagophthalmos (3.77 ± 3.92 vs. 3.36 ± 1.36 mm) ( p > 0.05). The overall complication (15.4% vs. 15.0%) and reoperation rates (15.4% vs. 15.0%) were comparable over the follow-up duration (291.6 ± 437.3 vs. 121.0 ± 177.8 days) ( p > 0.05). CONCLUSION: TMRLD is as safe and effective as the gold weight implantation in addressing paralytic lagophthalmos in patients with facial nerve palsy.

Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

Restoration of function following traumatic superior eyelid avulsion in a horse treated with advancement flap blepharoplasty (H-plasty) and subdermal hyaluronic acid filler.

OBJECTIVE: To describe the successful restoration of superior eyelid function in a horse following traumatic avulsion using an advancement flap blepharoplasty and subdermal hyaluronic acid filler. ANIMAL STUDIED: A 21-year-old American Paint Horse stallion who was attacked by a fellow stallion resulting in numerous traumatic injuries including avulsion of approximately 75% of the left superior eyelid. PROCEDURES: With standing sedation and locoregional anesthesia, the superior eyelid wound was debrided and an advancement flap blepharoplasty (H-plasty) and temporary tarsorrhaphy were performed. Routine healing of the surgical site occurred over the subsequent weeks, though lagophthalmos persisted. At 2 and 4 weeks post-operatively, 2.4% cross-linked hyaluronic acid was injected subdermally into the superior eyelid to attempt to improve corneal coverage. At 8 weeks post-operatively, a complete blink was restored and the cosmetic outcome was good. CONCLUSIONS: Injection of subdermal hyaluronic acid filler following eyelid injuries or blepharoplastic procedures that result in lagophthalmos can improve corneal coverage by the eyelids and allow for maintenance of a comfortable and visual eye.

Surgical Correction of Cicatricial Lower Eyelid Retraction: A Systematic Review.

BACKGROUND: Cicatricial lower eyelid retraction is a challenging condition. It involves scarring of the lower eyelid, which causes it to retract and expose the sclera. This can lead to complications such as dry eye syndrome and corneal melting. It can be caused by trauma, burns, or previous eyelid surgery. Detailed assessment and understanding of eyelid anatomy and retraction are critical for successful surgical planning. Dynamic and static examinations of the eyelid including measurements of the lower eyelid margin reflex distance (MRD2) and scleral show are also essential to determine the appropriate treatment approach. METHODS: A systematic review was conducted using Medline, Scopus, and Cochrane databases with keywords related to cicatricial lower eyelid retraction. The publication language was limited to English after 2000. A total of 29 articles were included for data extraction and analysis. RESULTS: The main surgical techniques include tarsoconjunctival grafts, spacers, midface lift, and lateral canthal tendon suspension, although no single procedure has been universally recognized as the gold standard. New innovations such as synthetic grafts and xenografts are being explored for their potential in eyelid reconstruction. Severe cases, defined as those with inferior scleral show greater than 2 mm, may require a combination of reconstruction methods. CONCLUSIONS: Correcting cicatricial lower eyelid retraction is a major challenge in oculoplastic reconstruction. The surgical approach should be individualized, considering the pathologies and etiologies of lid retraction. In-depth knowledge and careful surgical planning are essential for best outcomes. There is no gold standard technique, and postoperative outcomes, complications, and management vary depending on the surgical approach used.

Rotating suture technique combined with lid margin split and lower eyelid retractor disinsertion for epiblepharon.

Epiblepharon is an eyelid disease affecting 46-52.5% of Asian children. The Hotz procedure was commonly used for the treatment. However, the currently preferred technique is the rotating suture technique. This study aimed to report the recurrence rate and the complications of using the rotating suture technique combined with lid margin split and lower eyelid retractor (LER) disinsertion of epiblepharon. This was a retrospective study of the procedures performed between January 2017 and December 2020. This study included 64 eyelids of 37 patients who underwent the consecutive rotating suture technique, lid margin split, and LER disinsertion simultaneously for lower eyelid epiblepharon and were followed up for at least 6 months. The mean age of the patients who underwent surgery was 9.5 (5-28) years. The mean observation period was 8.3 (6-27) months. Recurrence was observed in one eyelid (1.6%). The complications included an ectopic eyelash on one eyelid (1.6%). LER disinsertion performed in this study had two advantages. First, the imbalance between the anterior and posterior lamellae was corrected. Disinserting the LER, the tarsal plate could be repositioned cranially, effectively addressing this imbalance. Second, LER disinsertion ensured direct exposure of the lower margin of the tarsal plate, facilitating the implementation of a reliable rotating suture. In conclusion, promising results were achieved by combining the rotating suture technique with LER disinsertion and lid margin splitting.

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.

Efficacy of allogenous fascia lata grafts in the management of lower eyelid retraction.

PURPOSE: To report on the use of allogenous fascia lata (FL) grafts in patients with lower eyelid retraction (LER). METHODS: In this retrospective study, a consecutive series of 27 patients (39 eyes) with LER who underwent lower eyelid elevation with FL was included. Examinations including measurement of the palpebral fissure vertical height (PFVH), the inferior scleral show distance, the margin reflex distance 2 (MRD 2), and the evaluation of conjunctival hyperemia were conducted at baseline and after a mean postoperative time of 25.9 ± 25.5 (5.0-81.0, median 13.0, last follow-up) months in all patients. RESULTS: At the last follow-up, a significant reduction of the PFVH (11.3 ± 1.7 versus 12.8 ± 2.1 at baseline, p < 0.001), the inferior scleral show distance (0.7 ± 1.0 mm versus 2.1 ± 1.1 at baseline, p < 0.001), and the MRD 2 (6.4 ± 0.9 versus 7.8 ± 1.3 at baseline, p < 0.001) occurred. The conjunctival hyperemia grading score (McMonnies) was significantly reduced (1.8 ± 0.7) at the last follow-up compared to baseline (2.6 ± 0.6, p < 0.001). No case of ectropion or entropion was observed at the last follow-up visit. CONCLUSION: In this case series, lower eyelid elevation with FL grafts as a spacer led to a significant reduction of the PFVH, MRD 2, inferior scleral show distance, and conjunctival hyperemia. No severe surgery-related complications occurred.

The Use of the Pericranial Periosteal Flap in Children for Treating Severe Lower Eyelid Retraction.

PURPOSE: To describe a surgical technique that can achieve significant lower eyelid elevation in severe retraction in children using a pericranial periosteal flap with skin graft. METHODS: A retrospective, single-center, case series of 3 consecutive pediatric cases are performed where a pericranial periosteal flap was used with a skin graft to manage severe lower eyelid retraction. Outcome measures include the extent of lower eyelid elevation (mm) and complications in the follow-up visits. RESULTS: Three children with severe lower eyelid retraction underwent the surgery. There were 2 boys and 1 girl with the mean age of 6.7 years (range, 5-8 years). The improvement of lower eyelid retraction was 3, 3, and 7 mm at 28, 24, and 6 months, respectively. No perioperative or postoperative complications occurred. CONCLUSIONS: Children with severe lower eyelid retraction often have a complex craniofacial and surgical history, and its surgical correction can be challenging. This case series present the successful use of pericranial flaps in treating severe lower eyelid retraction in children. The authors recommend this flap in children where traditional options have either failed or are not applicable.