Examining treatment strategies for xanthelasma palpebrarum: a comprehensive literature review of contemporary modalities.

Xanthelasma palpebrarum (XP) is the predominant form of cutaneous xanthoma, as it accounts for greater than 95% of cases. It is characterized by the presence of foam cell clusters containing a large amount of low-density lipoprotein (LDL), which are located in the connective tissue of skin, tendons, and fascia. XP lesions commonly present as distinctive yellow-orange macules, papules, or nodules, and are primarily on the upper eyelids as well as the inner canthus. Women are affected twice as often as men, with lesions typically emerging between the ages of 35 and 55. The pathophysiology of XP involves abnormal lipid metabolism and is often associated with hyperlipidemic states like Type II and IV hyperlipidemia, hypothyroidism, weight gain, and fatty diet. Despite the availability of various treatment methods, current XP management lacks standardization, particularly due to limited comparative research. To address this gap, we conducted an extensive literature review of 45 studies published between 2012 to 2023, which provides an updated overview of current XP treatment modalities. This comprehensive analysis will inform researchers and clinicians on the evolving landscape of XP management.

[LOWER EYELID BLEPHAROPLASTY].

INTRODUCTION: Eyelid blepharoplasty, including lower eyelid blepharoplasty, are among the most common aesthetic surgeries recently performed. In contrast to upper eyelid blepharoplasty, lower eyelid blepharoplasty is a surgery with mostly an aesthetic indication, in which patients bear all associated costs, and their expectations rise accordingly. Nevertheless, the complexity of the anatomy, the differences in the aging processes of the face and eyelids between patients, the diversity of surgical methods, and the expectations gap make the surgery more challenging in comparison to upper eyelid blepharoplasty. A comprehensive understanding of the eyelid anatomy and the surrounding tissues, as well as matching expectations alongside with thorough preoperative evaluation, are all essential for providing a more personal adjustment of the surgical method and avoiding complications and mental distress for both patients and surgeons. This article briefly reviews the anatomy and aging processes of the lower eyelids, the main surgical approaches, and their common complications. Moreover, we present a framework for how such complications can be avoided.

A Magnetic Actuator Device for Fully Automated Blinking in Total Bidirectional Eyelid Paralysis: First Proof of Concept in a Human Participant.

Purpose: Currently, no solution exists to restore natural eyelid kinematics for patients with complete eyelid paralysis due to loss of function of both the levator palpebrae superioris and orbicularis oculi. These rare cases are prone to complications of chronic exposure keratopathy which may lead to corneal blindness. We hypothesized that magnetic force could be used to fully automate eyelid movement in these cases through the use of eyelid-attached magnets and a spectacle-mounted magnet driven by a programmable motor (motorized magnetic levator prosthesis [MMLP]). Methods: To test this hypothesis and establish proof of concept, we performed a finite element analysis (FEA) for a prototype MMLP to check the eyelid-opening force generated by the device and verified the results with experimental measurements in a volunteer with total bidirectional eyelid paralysis. The subject was then fitted with a prototype to check the performance of the device and its success. Results: With MMLP, eye opening was restored to near normal, and blinking was fully automated in close synchrony with the motor-driven polarity reversal, with full closure on the blink. The device was well tolerated, and the participant was pleased with the comfort and performance. Conclusions: FEA simulation results conformed to the experimentally observed trend, further supporting the proof of concept and design parameters. This is the first viable approach in human patients with proof of concept for complete reanimation of a bidirectionally paretic eyelid. Further study is warranted to refine the prototype and determine the feasibility and safety of prolonged use. Translational Relevance: This is first proof of concept for our device for total bidirectional eyelid paralysis.

Blink Lagophthalmos in Graves Orbitopathy.

PURPOSE: To investigate the relationship between the kinematics of spontaneous blinks and the anterior area of the levator palpebrae superioris muscle in patients with Graves orbitopathy (GO). METHODS: This is a case-control study. The authors measured the margin reflex distance of the upper eyelid (margin reflex distance 1), the kinematics of spontaneous blinks, and the anterior area of levator palpebrae superioris muscle in CT coronal scans of patients with Graves upper eyelid retraction (GO) and a control group. The eye with the greatest margin reflex distance 1 was selected for analysis in each group. RESULTS: A total of 68 participants were included, with 36 in the GO group and 32 in the control group. In the GO group, the mean margin reflex distance 1 measured 6.5 mm, while in the control group, it was 3.9 mm. Almost all parameters related to the closing phase of spontaneous blinking activity, including amplitude, velocity, blinking rate, and interblink time, did not differ between the two groups. However, the effectiveness of the blink's amplitude (ratio of blink amplitude to margin reflex distance 1) and the main sequence (relationship between amplitude and velocity) were significantly reduced in the GO group compared with the control group. The area of the levator palpebrae superioris muscle was significantly larger in GO than in controls, with 71.4% of patients' muscles outside of the maximum range of the controls. CONCLUSIONS: In patients with GO, there is a reduction in blinking effectiveness, also known as blink lagophthalmos, which is a factor in the common occurrence of ocular surface symptoms. The increase in velocity with amplitude is also reduced in GO.

Combining the Tunnel Orbicularis Oculi Muscle Flap Technique With Skin Grafting for Enhanced Adhesion in Burn-Induced Ectropion Repair.

PURPOSE: Scar contracture of the eyelid following facial burns often has adverse consequences. Total cicatricial contracture often makes adjustment flap translation challenging to implement. Previously used upper and lower eyelid adhesion methods are ineffective for patients with severe cicatricial contracture, and ectropion can easily recur. This study aimed to retrospectively examine upper and lower eyelid adhesions using an orbicularis oculi muscle flap and verify its stability. METHODS: In patients with ectropion caused by severe scar contracture following head and face burns, we employed a tunnel orbicularis oculi muscle flap technique, which involved creating a tunnel between the skin and the tarsal plate of the eyelid, mobilizing the orbicularis oculi muscle, and rotating it into this tunnel to provide stable adhesion of the upper and lower eyelids. Full-thickness skin grafting was then performed. The eyelids were examined postoperatively to determine whether reoperation was necessary and to monitor for any potential complications. RESULTS: This study included 26 patients and 46 eyes. No accidental disconnection occurred after eyelid adhesion, which lasted for an average of 21.87 ± 10.08 months before the eyelid adhesion was cut open. No complications or adverse reactions occurred, and the adhesions did not break unexpectedly. CONCLUSIONS: Repairing eyelid ectropion with the tunnel orbicularis oculi muscle flap is a simple procedure that immediately creates tension against upper and lower eyelid contractures, providing long-term stable adhesion. This method avoids structural disorders, such as eyelid margin scarring, minimally influences surrounding tissues, and has few postoperative complications. It holds great value for repairing eyelid tissue defects and warrants further study.

Surgical Management of Overgrowth Syndrome With Bilateral Vision-Threatening Ptosis.

We describe the first case reported in ophthalmological literature of the surgical management of a 17-month-old boy with bilateral vision-threatening ptosis, tarsomegaly, ectropion, and euryblepharon secondary to suspected overgrowth syndrome. We elaborate on the major challenges associated with surgical management including the natural and asymmetric growth of oversized tissue, the high likelihood of scarring and formation of disorganized tissue, and risks of frequent intubation in these patients who may have lesions that compromise critical structures such as the airway. Ultimately, surgical intervention is encouraged primarily if vision or ocular health is threatened and secondarily to achieve good cosmesis.

"Demodicosis" Mimicking PreSeptal Cellulitis: Severe Periocular and Facial Inflammation Caused by "Normal" Skin Flora.

Due to their relatively high prevalence and commensalism, the pathogenicity of Demodex mites has been debated. Recent data, however, show Demodex to be associated with skin and ocular surface diseases such as rosacea, blepharitis, and keratitis. Here the authors report the first known case, to the best of the their knowledge, of Demodex infestation mimicking preseptal cellulitis in an adult human. A 29-year-old male bilaterally blind from advanced retinopathy of prematurity presented with a 2-month history of right-greater-than-left upper eyelid and periocular/cheek swelling, redness, and ocular discharge that did not resolve with oral antibiotics or oral steroids. Based on MRI findings, biopsies of the right lacrimal gland, right orbital fat, and right upper eyelid preseptal skin were obtained which revealed marked intrafollicular Demodex mite density and budding yeasts in the upper eyelid skin. This case serves to alert clinicians to this entity that may not otherwise be usually considered in ophthalmic clinical practice.

Orbital fat graft retroseptal transconjunctival blepharoplasty for treatment of groove in the infraorbital region.

PURPOSE: To investigate the efficacy of the retroseptal transconjunctival blepharoplasty together with tear trough ligament (TTL) and Orbicularis retaining ligament (ORL) release with orbital fat graft in the management of groove in the infraorbital region (GIR). METHODS: A prospective study of 80 eyes of 40 patients that underwent retroseptal transconjunctival lower blepharoplasty together with TTL and ORL release and resected orbital fat grafting. An ophthalmic examination includes lower eyelid evaluation and Barton's Tear trough deformity grading was done at baseline, 2 weeks, 3 months, and 6 months after the surgery. Patient satisfaction was evaluated using Global aesthetic improvement scale (GAIS) and Blepharoplasty outcomes evaluation (BOE). RESULTS: Baseline tear trough defects were graded into grade 1, 2, and 3 in 12 (15%), 39 (48.75%) and 29 (36.25%) eyes, respectively. While at 6 months follow-up, grade 0 was recorded in 63 (78.75%) eyes, and grade 1 was recorded in 17 (21.25%) eyes. The amount of fat removed was 0.52 ± 0.04 mL per eye, whereas the amount of injected fat graft was 0.24 ± 0.04. The mean operative time was 33.2 ± 4.1 min per eye. GAIS showed degree 1, 2, and 3 in 8 (20%), 29 (72.5%), and 3 (7.5%) patients at 6 months follow-up, respectively. The mean baseline BOE increased significantly from 36.5 ± 5.9 to 86.9 ± 5.5 at 6 months follow-up. CONCLUSIONS: Our cohort highlights the beneficial effects of TTD/ORL release with resected orbital fat grafting in the management of GIR and infraorbital hollow.

Comparing Neuromuscular Blockade Measurement Between Upper Arm (TOF Cuff®) and Eyelid (TOF Scan®) Using Mivacurium during General Anesthesia.

BACKGROUND Mivacurium is a non-depolarizing neuromuscular blocking agent. TOF-Cuff® is a device that monitors intraoperative neuromuscular blockade and blood pressure. TOF-Scan® measures muscle relaxation status of an anaesthetized patient. This study included 36 patients aged 18 to 75 years presenting for elective surgery, to compare neuromuscular blockade measured using the TOF-Cuff of the upper arm and the TOF-Scan of the facial corrugator supercilii muscle during general anesthesia and following administration of mivacurium. MATERIAL AND METHODS Train-of-four (TOF) values were obtained every 30 s before intubation and successively every 5 min until extubation. RESULTS The median onset time for TOF-Cuff was longer than for TOF-Scan (210 s vs 90 s, P<0.00001). Multiplying the time to relaxation (according to TOF-Scan) by 1 to 8, respectively, provided concordance with the TOF-Cuff result for the following cumulative percentages of patients: 5.5%, 38.9%, 58.3%, 77.8%, 83.3%, 86.1%, 88.9%, and 91.7%. Analogue values for time to recovery from the last dose were 11.1%, 63.9%, 83.3%, 86.1%, 86.1%, 88.9%, 88.9%, and 91.7%. The proportion of patients who still had TOFratio=0 in the assessment performed at min 15 did not differ significantly between these 2 methods (P=0.088). Both TOF-Scan and TOF-Cuff showed a false-negative result in patients with clinical symptoms of preterm recovery; the numerical difference favored TOF-Cuff (1.6% vs 2.1%) but without statistical significance (P=0.2235). CONCLUSIONS When measurement on the limb is not possible, TOF-Scan on the eyelid can be an alternative for TOF-Cuff on the upper arm, if the time to relaxation is multiplied by at least 8, which is enough for 90% of patients.

[Laser Doppler flowmetry in the diagnosis of chronic mixed blepharitis]. / Lazernaya dopplerovskaya floumetriya v diagnostike khronicheskogo smeshannogo blefarita.

Chronic mixed blepharitis accounts for 51.7% of all ophthalmic diseases. The use of laser Doppler flowmetry (LDF) in the diagnosis of this disease can help establish the initial manifestations of the inflammatory process in the eyelids, which is important for the prevention of possible complications - dry eye disease. PURPOSE: This study was conducted to determine the sensitivity and specificity of the LDF method in the diagnosis of chronic mixed blepharitis based on the study of microcirculatory changes in the eyelid skin. MATERIAL AND METHODS: The study included 23 patients with chronic mixed blepharitis (mean age 67±5.8 years) and 18 healthy volunteers (mean age 63±1.1 years). LDF was performed using the LAZMA MC-1 device. ROC analysis was used to determine sensitivity and specificity. RESULTS: A typical disturbance of the eyelid skin microcirculation was revealed in chronic mixed blepharitis - ischemia - with inhibition of the intensity of the functioning of blood flow regulatory systems and moderate activation of the lymph flow. The sensitivity and specificity of the coefficient of variation (reflecting the vasomotor activity of microvessels) of blood flow was 71.43 and 71.43%, lymph flow - 65.71 and 80.00%; myogenic rhythms of blood flow - 83.33 and 85.71%, lymph flow - 66.67 and 71.43%; neurogenic rhythms of blood flow - 75.00 and 78.57%, lymph flow - 91.67 and 78.57%, respectively. CONCLUSION: Laser Doppler flowmetry of the eyelid skin in combination with clinical, functional and instrumental research methods helped reveal with high sensitivity and specificity the eyelid damage in chronic mixed blepharitis. This method allows assessment of the condition of the eyelids in individuals without diseases of the anterior segment of the eye.

[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.

Fourteen-Year Experience in Burn Eyelid Reconstruction and Complications Recurrence: A Retrospective Cohort Study.

BACKGROUND: Loss of vision and other ocular defects are a concern with eyelid burn sequelae. This most commonly progresses from eyelid contracture to cicatricial ectropion and lagophthalmos. When left untreated, these may lead to exposure keratitis, ulceration, infection, perforation, and loss of vision. In the case of full-thickness eyelid burns, release and grafting are required. However, there is a paucity of studies on outcomes in eyelid burn surgery treatment, despite concern for permanent ocular damage or loss of vision. The aim of the study is to describe the complication rates in burn eyelid reconstruction at a single center for 14 years. METHODS: A retrospective cohort study was performed of all patients who had sustained eyelid burns and required reconstruction between April 2009 and February 2023. Medical records were obtained from patients' charts. Collected data include demographics, medical history, type of injury, indication for surgery, procedure performed, and complications. RESULTS: A total of 14 patients and 25 eyelids underwent eyelid reconstruction of the 901 total patients with burn-related injuries requiring plastic surgery reconstruction. These patients underwent 54 eyelid surgeries with a mean follow-up time of 13.1 ± 17.1 months. Patients were 71% men and 29% women, with a mean age of 45.1 ± 15.6 years. In 53.7% (n = 29) of the cases, the simultaneous reconstruction of both the upper and lower eyelids was necessary. The reconstruction of the upper and lower eyelid alone represented a smaller percentage (25.9% and 20.4%, respectively). On average, the patients received 3.9 ± 3.5 eyelid surgeries. The overall complication rate was 53.7% (n = 29). The most common complication was ectropion (42.6%, n = 23). Other complications included eye injury (25.9%, n = 14), lagophthalmos (24.1%, n = 13), local infection (7.4%, n = 4), and graft loss (5.6%, n = 3). CONCLUSION: Periorbital burns represent a major challenge that may require complex surgical intervention. Full-thickness skin graft remains the standard of care for patients with eyelid burns. However, there is a high incidence of ectropion that may require reoperation. Further studies examining the conditions of successful eyelid burn procedures may provide guidance on when patients may benefit from eyelid reconstruction during their burn treatment.

Isolated cavernous venous malformation of the eyelid.

Cavernous hemangioma, currently known as "cavernous venous malformation," is a common, benign, non-infiltrative, slowly progressive vascular malformation of the orbit presenting in adults. We report the case of a 9-year-old girl who presented with a painless palpable mass over the right upper eyelid of 7 years' duration. A computed tomography scan of the orbits revealed a heterogeneously enhancing, well-circumscribed mass in the right upper eyelid with no orbital extension. A transcutaneous excisional biopsy with histopathology disclosed cavernous venous malformation. The majority of cavernous venous malformations are intraconal and present in the fourth to fifth decade of life.

Temozolomide-associated blepharoconjunctivitis: a case report.

BACKGROUND: Temozolomide (TMZ) is an effective oral alkylating agent used in treating glioblastoma multiforme (GBM) and high-grade gliomas. It works by introducing methyl groups into DNA, inhibiting cell division. A case of blepharoconjunctivitis linked to the administration of TMZ is detailed in this report. CASE PRESENTATION: We present a case of a 58-year-old African-American man diagnosed with GBM. Following adjuvant TMZ treatment, he developed blepharoconjunctivitis, characterized by eyelid and conjunctival inflammation. Symptoms included eyelid swelling, crusting, and conjunctival discharge, which were promptly resolved with topical steroid cream and eye drops. CONCLUSIONS: Reports specifically linking TMZ to blepharoconjunctivitis are limited. The exact mechanism remains unclear but may involve inflammation extending from blepharitis to the conjunctiva. Healthcare providers must recognize and manage ophthalmic complications promptly. This case report highlights blepharoconjunctivitis associated with TMZ use in a GBM patient. While TMZ is an effective treatment, ophthalmic side effects can occur.

Electrical stimulation of the lower eyelid orbicularis oculi muscle improves periocular dark circles.

BACKGROUND: We developed and tested the safety and efficacy of a cosmetic device to improve dark circles using electrical muscle stimulation of the orbicularis oculi muscle. METHODS: Overall, 18 participants (36 eyes) were studied. The following five items were evaluated before and after the intervention:(1) the Clinical Dark Circle Score using clinical findings and photographs, (2) transcutaneous oxygen partial pressure (TcPO2) on the lower eyelid, (3) thermography, (4) two-dimensional laser blood flowmetry, and (5) spectrophotometry. RESULTS: The mean score at baseline was 2.0 ± 0.90 (mean ± standard deviation), and that at the end of the study was 1.2 ± 1.0 (Wilcoxon signed-rank sum test, p < 0.0001), indicating a significant reduction. The spectrophotometer showed a significant decrease in a* and L* values before and after use (Wilcoxon signed-rank sum test, p < 0.0001). There was also a weak negative correlation between the change in score and the change in blood flow and TcPO2 measured using a laser perfusion device (Spearman's rank correlation coefficient, r = -0.32 and -0.39, respectively). Stratified analysis of the baseline score showed a strong negative correlation between the change in score and the change in spectrophotometric a* in the subjects/group with mild periocular dark circles (Spearman's rank correlation coefficient, r = -0.46). Contrastingly, no correlation was observed for any of the measurements in the subjects/group with severe periocular dark circles. After 1 month, no device-related ophthalmic adverse events were observed in any of the participants. CONCLUSION: Electrical muscle stimulation could improve periocular dark circles, especially in the subjects/group with mild periocular dark circles, and was safe.

Clinical characteristics and surgical outcomes of transcutaneous versus transconjunctival excision of Wolfring gland ductal cysts.

PURPOSE: To analyze the clinicopathological characteristics and surgical outcomes of patients with Wolfring gland ductal cysts (WGDCs). METHODS: A retrospective, consecutive, interventional comparative case series was performed over a period of 7 years. Data on demographic and clinical characteristics, pathological findings and outcomes of surgically excised cysts were collected. A comparison between the transconjunctival and transcutaneous approaches was also assessed. RESULTS: Forty-eight patients (48 eyelids) were included in the final analysis. The most common presenting symptom was painless eyelid swelling (81.3%). The median symptom duration was 11.5 months (IQR, 18.25). The upper eyelid was involved in 31 (64.6%) patients, 29/31 of whom had cysts in a medial or centromedial location. Forty-five (93.8%) cysts were bluish gray and transilluminable with clear contents on lid eversion and a median largest dimension of 22 mm (IQR, 8). A transverse conjunctival fibrotic band was observed along the proximal tarsal border in the cyst area in all patients. Signs of chronic trachoma were noted in 38 (79.2%) patients. Preoperative significant ptosis was present in 28/31 (90.3%) of the upper eyelid cysts. Thirty cysts (62.5%) were excised through the skin, and 18 cysts (37.5%) were excised transconjunctivally. Intraoperative cyst rupture, the need for conjunctival grafting and postoperative residual upper lid ptosis were significantly greater in the transconjunctival group (p = 0.009, p < 0.001, and p = 0.016, respectively). CONCLUSION: The present study highlights the clinicopathological characteristics of a relatively large series of surgically excised WGDCs. Transcutaneous excision of WGDCs has proven to be an effective treatment with fewer adverse sequelae than the transconjunctival approach.