Percutaneous delivery of liquid tetracycline using a thermal resurfacing drug delivery system for the treatment of festoons.

OBJECTIVES: To examine the effects of percutaneous tetracycline delivery to the malar area using a thermomechanical device (Tixel) in patients suffering from festoons. METHODS: This retrospective study included patients who underwent combination treatment with a thermomechanical device (Tixel) followed by application of topical tetracycline 1% at two private clinics between 2019 and 2023. Demographic and medical data, treatment parameters along with before and after treatment photographs were retrieved retrospectively. All patients were asked to answer a questionnaire, assessing self-reported pre and posttreatment disturbance, patient global impression of change (PGIC) score, overall satisfaction with treatment, and the onset and duration of treatment effect. Finally, three masked reviewers evaluated and graded the severity of before and after treatment photographs. RESULTS: Twenty healthy patients received the combination treatment. The mean age was 59.4 ± 8.2 years (range: 45-72 years), and 90.0% (n = 18) were female. The number of treatment sessions per patient ranged from 2 to 8, mean of 5.0 ± 1.9, performed at 5.4 ± 1.2-week intervals. The masked reviewers' grading scores demonstrated a significant improvement (2.81 ± 1.3 before vs. 1.6 ± 1.1 after, p < 0.001). The self-reported disturbance caused by the festoons improved significantly as well (4.7 ± 0.98 vs. 1.7 ± 1.1, p < 0.001). On the PGIC score, 85% (17/20) reported moderate (grade 5) to significant (grade 7) improvement of symptoms and life quality after treatment. Improvement onset was reported to occur 11.2 ± 6.6 days after the first treatment (range 2-30 days), and 90% (18/20) of the patients reported improvement lasting at least 4 months after completion of the second treatment. CONCLUSIONS: Topical tetracycline application following Tixel treatment induced significant improvement in patient with festoons.

Applied Anatomy of the Lower Eyelid Preseptal Space for Treating Ectropion and Retraction with Soft-Tissue Fillers.

BACKGROUND: Lower eyelid malposition can result from age-related changes, such as ectropion, or postsurgical changes, such as retraction after lower lid blepharoplasty. The current accepted treatment is surgical, but soft-tissue fillers have been used as well, with good outcome. The underlying anatomy, which is incompletely described, would be useful information for practitioners desiring to provide minimally invasive injections of the lower eyelid. The authors describe a minimally invasive injection technique adjusted to the complex anatomy of the lower eyelid for the treatment of ectropion and retraction of the lower eyelid. METHODS: A total of 39 periorbital regions of 31 study participants were retrospectively analyzed using photographs before and after reconstruction of the lower eyelid with soft-tissue fillers. Two independent raters assessed the degree of ectropion and lower eyelid retraction (0 to 4, best to worst) before and after the reconstruction and the overall aesthetic improvement using the Periorbital Aesthetic Improvement Scale. RESULTS: The median degree of ectropion and lower eyelid retraction score improved statistically significantly from 3.00 (SD, 1.5) to 1.00 (SD, 1.0) ( P < 0.001). The mean volume of soft-tissue filler material applied per eyelid was 0.73 cc (SD, 0.5). The median Periorbital Aesthetic Improvement Scale score after the treatment was rated as 4.00 (SD, 0.5), indicating improvement of the periorbital functional and appearance. CONCLUSIONS: Anatomic knowledge of the lower eyelid and of the preseptal space is of clinical relevance when reconstructing the lower eyelid with soft-tissue fillers. The targeted space provides optimal lifting capacities for improved aesthetic and functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Management of Severe Botulinum-Induced Eyelid Ptosis With Pretarsal Botulinum Toxin and Oxymetazoline Hydrochloride 0.1.

BACKGROUND: Eyelid ptosis following periocular onabotulinumtoxinA (BoNT-A) treatment is a known complication that can be frustrating for both patients and practitioners. Iatrogenic blepharoptosis occurs due to local spread of the BoNT-A from the periocular region into the levator palpebrae superioris muscle. Although injectors should have a thorough understanding of the relevant anatomy in order to prevent it, BoNT-A induced ptosis can occur even in the most experienced hands. OBJECTIVES: The aim of this study was to describe a case series of patients treated effectively with topical oxymetazoline HCl 0.1% and pretarsal BoNT-A injections in the setting of botox-induced ptosis. METHODS: The study group consisted of 8 patients who had undergone recent cosmetic BoNT-A treatment preceding the sudden onset of unilateral upper eyelid ptosis. RESULTS: A diagnosis of severe ptosis (>3 mm) was made in all the cases in this series. Pretarsal BoNT-A injections alone or in association with topical administration of Upneeq eyedrops (Upneeq, Osmotica Pharmaceuticals, Marietta, GA) significantly reversed the ptosis in all treated cases. CONCLUSIONS: This is the first documented case series of patients treated effectively with topical oxymetazoline HCl 0.1% and pretarsal BoNT-A injections in the setting of botox-induced ptosis. This treatment combination is a safe and effective option in these cases.

The effect of thermo-mechanical device (Tixel) treatment on evaporative dry eye disease - A pilot prospective clinical trial.

PURPOSE: To examine the effects of treatment with a thermomechanical skin device to the eyelid area on the clinical signs and symptoms of patients who suffer from dry eye disease (DED) secondary to meibomian gland dysfunction (MGD). METHODS: Forty patients aged 45 years or older with DED due to MGD were recruited. Both eyes (n = 80) of each patient received three treatments with the Tixel device (Novoxel®, Israel), with each treatment separated by a 2-week period. Treatment was applied across the upper and lower eyelids, with the same intensity, tip protrusion distance, and contact duration. Two additional follow-up visits were performed at 2-week intervals after treatment cessation. DED status was evaluated during each visit via SPEED II questionnaire, tear break-up time (TBUT), corneal staining score (CSS), MGD score, and frequency of lubricant use. Visual acuity (VA) was recorded during first and last visits. RESULTS: Mean age was 64.3 ± 12.4 years and 72.5 % (n = 29) were female. 45 % (n = 18) had a history of blepharitis, 12.5 % (n = 5) had chalazia, and 17.5 % (n = 7) suffered from allergic conjunctivitis. Mean follow-up time was 2.1 ± 0.6 months. Comparing the first and last visits, all parameters showed significant improvement after Tixel treatment: mean SPEED II scores (16.5 ± 5.9 to 11.8 ± 6.7, p < 0.001), CSS (2.0 ± 1.3 to 0.5 ± 0.9, p < 0.001), TBUT (2.7 ± 0.8 s to 6.5 ± 2.2 s, p < 0.001), MGD score (2.7 ± 0.5 to 1.2 ± 0.4, p < 0.001), and rate of lubricant use (3.4 ± 2.4 per day to 1.9 ± 2.0, p < 0.001). VA also improved (0.10 ± 0.11 logMAR to 0.08 ± 0.10 logMAR, p < 0.05). No major side effects were observed. CONCLUSIONS: In this pilot study Tixel treatment induced significant improvement of signs and symptoms among patients with DED due to MGD. Benefits persisted for at least one month. Further randomized controlled double-blinded studies are needed.

Routine use of non-absorbable sutures in bi-medial rectus recession as a measure to reduce the incidence of consecutive exotropia.

OBJECTIVE: To evaluate the incidence of consecutive exotropia following bilateral medial rectus muscle recession surgery (BMR) for esotropia using non-absorbable compared with absorbable sutures in children undergoing strabismus surgery. METHODS: A retrospective cohort study of all children with esotropia who underwent BMR by a single surgeon in a tertiary public hospital. As of February 2018, only non-absorbable sutures were used. The primary outcome was the incidence of consecutive exotropia. RESULTS: A total of 121 children were included in the analysis, 3.66 ± 2.62 years, 53% were male. In 80 children (66%) non-absorbable sutures were used (non-absorbable group) and in 41 children (34%) absorbable sutures were used (absorbable group). Consecutive exotropia (≥ 8 prism dioptres) occurred in ten children (24%) in the absorbable group and in three children (4%) in the non-absorbable group (OR = 8.28, 95% CI = 2.13-32.13; P = 0.002). This difference between groups remained significant after adjustment for potential confounders and follow-up time (HR = 4.98, 95% CI = 1.30-19.05, P = 0.019). Mean follow-up time was 22 and 12 months in the absorbable and non-absorbable groups, respectively (P < 0.001). Two children in the non-absorbable group had pyogenic granuloma that resolved after 3 months of topical steroidal therapy. CONCLUSION: Routine use of non-absorbable sutures in BMR surgery for esotropia may be a preferable alternative to absorbable sutures for the prevention of consecutive exotropia.

Preoperative ocular characteristics predicting the development of intraoperative floppy iris syndrome regardless of alpha-antagonist exposure status.

PURPOSE: To assess structural risk factors for intraoperative floppy iris syndrome (IFIS) available on preoperative examination before cataract surgery. METHODS: In this retrospective study, medical records of patients who underwent cataract surgery in Shamir Medical Center, between July and September 2019, were reviewed. Patients younger than 50 years, with preexisting ocular conditions affecting the pupillary size or anterior chamber depth (ACD), and combined procedures were excluded. Association of IFIS with preoperative ocular parameters was tested using uni- and multivariant analyses. RESULTS: Overall, 394 eyes of 394 patients were included. The mean age was 72.48 ± 8.63 years, and 58.4% were female. IFIS occurred in 18 eyes (4.6%), seven (38.89%) of which had been previously treated with alpha-antagonists. Patients in the IFIS group were significantly older compared with those in the non-IFIS group (78.1 ± 6.7 vs. 72.2 ± 8.6 years, P = 0.005), with no significant gender difference. The mydriatic pupil diameter was significantly smaller in the IFIS group (5.73 ± 1.16 vs. 6.97 ± 1.03 mm, P < 0.001), and the lens thickness (LT) was larger (4.93 ± 0.42 vs. 4.49 ± 0.42 mm, P = 0.001). ACD was inversely correlated with LT (r = - 0.613, P < 0.001) and positively correlated with pupil diameter (r = 0.252, P < 0.001). On univariate analysis, ACD was significantly shallower in the IFIS group (2.88 ± 0.49 vs. 3.14 ± 0.39 mm, P = 0.008). In multivariant analysis controlling for alpha-antagonist use, both LT and mydriatic pupil diameter remained significantly predictive of IFIS (LT: OR 9.9, 95%CI 1.9-49, P = 0.005; pupil diameter OR 0.427, 95%CI 0.26-0.69, P < 0.001). CONCLUSIONS: Increased LT and decreased mydriatic pupil diameter were associated with increased IFIS risk regardless of alpha-antagonist treatment status.

Inverted Papilloma of the Orbit and Nasolacrimal System.

PURPOSE: Periocular inverted papilloma (IP) is a rare, locally aggressive tumor with a propensity for recurrence and malignant transformation. Historically treated via wide excision, this study examines the characteristics and management of periocular IP, comparing those confined to the nasolacrimal system with those invading the orbit. METHODS: An Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective, comparative case series was conducted in patients with IP of the orbit or nasolacrimal system across 15 clinical sites. RESULTS: Of 25 patients, 22 met inclusion criteria with 9 limited to the nasolacrimal system and 13 invading the orbit. Mean age was 60.4 years, 55% were women, all were unilateral. Mean follow-up was 48 months. Rates of smoking, dust and/or aerosol exposure, human papillomavirus (HPV) status, and inflammatory polyps were elevated compared to rates in the general population (45%, 18%, 18%, and 14%, respectively). Bony erosion on computed tomography scans was statistically significantly associated with orbit-invading IP (p = 0.002). Treatment involved all confined IP undergoing surgery alone while 39% of orbit-invading IP also received radiation therapy and/or chemotherapy (p = 0.054). Orbit-invading IP was more likely to be excised with wide margins than IP confined to the nasolacrimal system (85% vs. 22%, p = 0.007). Overall rates of malignancy, recurrence, and patient mortality from IP were found to be 27%, 23%, and 9%, respectively. CONCLUSIONS: IP invading the orbit typically requires aggressive therapy, while IP confined to the nasolacrimal system may be treated more conservatively. Using risk factors, characteristics, and outcomes, a treatment algorithm was created to guide management.

Late-Onset Upper Eyelid and Brow Edema as a Long-Term Complication of Hyaluronic Acid Filler Injection.

BACKGROUND: Late-onset upper eyelid edema is an uncommonly recognized complication of hyaluronic acid (HA)-based filler injection to the supraorbital area. OBJECTIVES: The authors sought to report their experience in diagnosing and managing late-onset upper eyelid edema. METHODS: This was a noncomparative, retrospective study of a series of 17 consecutive patients who presented with upper eyelid edema 6 to 24 months after uneventful HA filler injection in the supraorbital area. RESULTS: The study group included 17 female patients. The average time of presentation was 13.9 months. Thirteen patients (76.4%) were satisfied after hyaluronidase and requested no further treatment (observation only); 4 patients (23.5%) elected to receive HA filler re-treatment, with satisfactory results. All patients were followed-up for at least 6 months after the re-treatment. CONCLUSIONS: The incidence of late-onset upper eyelid edema is likely to increase as the number of patients undergoing HA filler injection to the supraorbital area increases. Our study emphasizes the importance of recognizing this condition and suggests a suitable noninvasive treatment with satisfying results for both the patient and the physician.

Balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction.

PURPOSE: The aim of this study is to report the outcome of balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction in children of all ages. METHODS: A 10-year retrospective study of 148 children (270 eyes), aged 9 to 159 months (mean age: 29.6 ± 17.7 months), who previously had not undergone a nasolacrimal surgical procedure and who presented with clinical signs of nasolacrimal duct obstruction, was conducted. All children underwent balloon catheter dilation of the nasolacrimal duct. RESULTS: Treatment success, defined as complete resolution of nasolacrimal duct obstruction symptoms present at follow-up visits at 1 week and up to 6 months after surgery, was 87% (234 of 270 eyes). Partial success was defined as occasional tearing which was acceptable to parents and present in 3% (nine eyes). Only 10% of the children underwent a second procedure due to complete failure. In a sub-analysis by age groups-under 18 months, between 18 and 36 months, and above 36 months-complete resolution rates were 85%, 93%, and 77%, and partial success rates were 3%, 3%, and 4%, respectively. There was a statistically significant difference between the age groups (p = .007). CONCLUSION: In this large cohort of patients with nasolacrimal duct obstruction, balloon catheter dilation was successful as a primary treatment for congenital nasolacrimal duct obstruction, particularly under the age of 36 months.

Inferiorly Based Preauricular Flap for Anterior Ear Reconstruction.

BACKGROUND: The anterior aspect of the auricle is a complex 3-dimensional structure. Each anatomical component in this region has an essential role in the aesthetic appearance of the ear and face. The reconstruction of defects in this region is challenging because of the lack of mobile, excess skin for primary closure, and the inability to skin graft overexposed cartilage. OBJECTIVE: The aim of the study was to present the planning and surgical technique of a simple, reproducible, 1-stage flap, for the reconstruction of the anterior aspect of the auricle. PATIENTS AND METHODS: A series of 11 patients, who underwent reconstruction of the anterior aspect of the auricle with 1-stage, inferiorly based, preauricular, cutaneous flap. All reconstructions were conducted under local anesthesia, and the defects were mainly due to tumor resections or skin necrosis after otoplasty. The average defect size was 1.5 cm. The flap was applied to different sites of the anterior auricle. RESULTS: All flaps survived except one, where there was partial flap loss. The aesthetic results were excellent, with no auricular deformity. CONCLUSIONS: The inferiorly based, preauricular flap is a versatile flap for a safe, simple, and reproducible, 1-stage reconstruction for almost every region of anterior ear defect, with excellent aesthetic results.

Investigation of the Longevity of the Endoscopic Midface Lift.

IMPORTANCE: To our knowledge, until now, the efficacy and durability of the transtemporal endoscopic preperiosteal midface lift has not been reported in the literature. OBJECTIVE: To determine the efficacy and longevity of the endoscopic preperiosteal midface lift using objective measurements and validated aesthetic scales. DESIGN, SETTING, AND PARTICIPANTS: This retrospective review included patients 18 years or older who were treated for aging midface by endoscopic midface lift by the senior author (A.E.W.) between June 2000 and August 2016. Patients were categorized based on length of follow-up into 3 groups: (1) short-term (1-3 years), (2) intermediate-term (3-5 years), and (3) long-term (>5 years). INTERVENTIONS OR EXPOSURES: Endoscopic preperiosteal midface lift. MAIN OUTCOMES AND MEASURES: (1) Objective measurements of midfacial height (the width of the interzygomatic distance of the midface to the medial canthus [WIZDOM-MC]), (2) validated regional aesthetic scales, and (3) global aesthetic scoring systems measured preoperatively, 3 to 6 months postoperatively, and at the most recent follow-up visit. RESULTS: Adult patients 18 years or older (median [range] age, 59 [31-79] years) who were treated for aging midface by undergoing an endoscopic midface lift were included in this study. The medical records of 143 patients were reviewed (135 women and 8 men). The endoscopic midface lift resulted in objective improvement in midfacial height. The median WIZDOM-MC decreased by 3.4 mm after the endoscopic midface lift (interquartile range [IQR], 2.3-4.4 mm; P < .001), thus shortening the elongated lower eyelid. At 5 to 15 years after surgery, there was a sustained decrease in median WIZDOM-MC of 2.1 mm (IQR, 0.8-3.1 mm; P < .001). Improvement in the infraorbital hollow was also sustained in patients at more than 5 years' follow-up (IQR, 0-1.0; P < .001). Improvements in upper cheek fullness and lower cheek fullness were maintained at 3 to 5 years and tended to be at baseline at more than 5 years. Global aesthetic improvement scores remained significantly improved at 5 to 15 years' follow-up. CONCLUSIONS AND RELEVANCE: There is a significant, objective improvement in midfacial height after the endoscopic midface lift that persists for up to 15 years. Validated midfacial scales and global aesthetic scoring systems demonstrate sustained improvement in midface appearance over time. Surgery that minimally disrupts the zygomatic and orbicularis retaining ligaments can provide long-lasting aesthetic improvements. LEVEL OF EVIDENCE: 4.

Müller's Muscle-conjunctival Resection Combined With Tarsectomy for Treatment of Congenital Ptosis.

PURPOSE: To evaluate the efficacy of Müller's muscle-conjunctival resection combined with tarsectomy for the treatment of congenital ptosis. METHODS: A retrospective, noncomparative case series was performed on 38 eyes of 36 patients who underwent Müller's muscle-conjunctival resection combined with tarsectomy for the treatment of congenital ptosis. Age range was 2-25 years (mean: 7.86 years). Follow-up measurements taken up to 4 years after procedure were compared with baseline values. RESULTS: Thirty-six patients presenting with congenital ptosis underwent Müller's muscle-conjunctival resection combined with tarsectomy. All patients had fair-to-good levator function of 5-10 mm. A mean improvement in the margin reflex distance-1 of 2.79 mm (p value < 0.0001) was noted. All cases except one achieved excellent lid height and postoperative symmetry of the eyelids. CONCLUSIONS: Müller's muscle-conjunctival resection combined with tarsectomy is a safe and effective procedure in the treatment of congenital ptosis in patients with moderate-to-good levator function. The surgery is rapid with quick recovery time. No complications were noted.The authors describe a retrospective case analysis of patients who underwent Müller's muscle-conjunctival resection combined with tarsectomy, for the treatment of congenital ptosis with moderate-to-good levator function, demonstrates excellent results.

The Sutureless Mullerectomy.

PURPOSE: Müller's muscle-conjunctival resection (MMCR) is a well-known approach for ptosis repair. In its standard fashion, it involves resection of Müller's muscle and conjunctiva, followed by suturing of the conjunctiva and Müller's muscle to the tarsus with absorbable or nonabsorbable sutures. The authors herein present their experience in performing MMCR without sutures. METHODS: The study was conducted as a retrospective review of 19 patients (34 eyelids) undergoing sutureless MMCR. Thirty-three eyelids had acquired ptosis and 1 eyelid had congenital ptosis. Surgery consisted of a standard approach and placement of a Putterman clamp. Following excision of the clamped tissues, no internal sutures were placed. Preoperative and postoperative upper margin-to-reflex distances were measured and patients were evaluated for symmetry within 1 mm and the incidence of any complications. RESULTS: Nineteen patients underwent 34 sutureless MMCR procedures. Of these, 13 patients had bilateral ptosis repair. Thirty-three of 34 eyelids (97%) showed improvement in margin-to-reflex distances, with an average improvement of 1.4 mm (range, 0-3.5 mm, SD = 0.64) among all patients. Eighteen of the 19 patients (94.7%) showed postoperative symmetry of margin-to-reflex distances within 1 mm (p < 0.001, χ test). One patient who underwent unilateral surgery demonstrated a Herring's response postoperatively, leading to the single case of asymmetry. There was 1 case of corneal abrasion seen postoperatively. CONCLUSIONS: The sutureless technique is a rapid and effective method for performing MMCR. This technique is especially useful as an adjunct to blepharoplasty where mild ptosis exists for an added rejuvenating effect. It is low-risk and potentially corneoprotective when compared to the standard suture technique. Further studies could determine if a modified algorithm needs to be applied.

Mini-monoka stenting for patients with perennial allergic conjunctivitis.

Purpose: To assess the effectiveness of mini-monoka (MM) stenting in treating patients with perennial allergic conjunctivitis (PAC) and punctal stenosis. Methods: A retrospective case analysis was performed on 20 patients (40 eyes) who suffered from PAC with punctal stenosis who underwent MM (FCI Ophthalmics, Pembroke, MA, USA) stenting. Results: Nineteen patients (95%) were females, with an age range of 19-66 years (average 40.6 ± 25.4 years). All 20 patients (100% of eyes) had signs of PAC and punctal stenosis. All 20 patients (40 eyes) had received previous topical treatment including steroids. Nineteen patients (95% of eyes) had significant improvement in their allergy symptoms (tearing and conjunctival inflammation) following MM stenting. Conclusions: Stenosis of the punctum may play a role in the relapsing symptoms in PAC. MM stenting is a simple, safe, effective, and relatively non-invasive treatment option for the management of PAC in the presence of punctal stenosis.

Phi, Fat, and the Mathematics of a Beautiful Midface.

PURPOSE: The Golden ratio, or Phi, has been used to explain the substrates of two-dimensional beauty utilizing the faces of models. A "Phi point" has been identified at the apex of the cheek mound that can be targeted in filler injections. The authors report herein how they have applied this algorithm for surgical shaping of the "beautiful" cheek as a routine part of their lower blepharoplasty procedure. The authors present their technique and results with patients undergoing lower blepharoplasty along with the adjunct of liposculpture to areas of volume deficiency in the midface with a particular goal of enhancing the Phi point. METHODS: This study was retrospective, consecutive, nonrandomized, interventional case series. The authors reviewed the medical records of 113 consecutive patients who underwent lower blepharoplasty with autologous fat transfer to the Phi point. The aesthetic outcome, patient satisfaction, and complication/revisions were evaluated. RESULTS: One hundred two out of 113 patients achieved excellent lower lid position and cheek enhancement as assessed by both patient and surgeon. In these 102 patients, there was significant improvement in lower lid appearance, contour, transition to the cheek, and cheek projection as observed by the surgeon. Three patients required revision to achieve sufficient volume. Eight patients were satisfied with the outcome, nevertheless, requested additional filler injection to optimize. CONCLUSIONS: Lower blepharoplasty combined with autologous fat transfer to reshape the Phi point is a safe and reliable technique and another step further in our quest for recreating the beautiful face.

Orbicularis Retaining Ligament Release in Lower Blepharoplasty: Assessing Efficacy and Complications.

PURPOSE: Release of the orbicularis retaining ligament (ORL) has been advocated as a technique to address tear trough deformities. This study sought to compare the effectiveness and morbidity of lower blepharoplasty with and without ORL release. METHODS: Retrospective chart review of 53 lower blepharoplasty patients. Twenty-six patients had ORL release and 27 patients did not. Three independent masked experienced cosmetic surgeons reviewed preoperative and postoperative photographs to assess degree of swelling, ecchymosis, change in steatoblepharon and tear trough deformity, and overall aesthetic result. RESULTS: There were no significant differences in overall aesthetic result, change in steatoblepharon or tear trough deformity, and postoperative ecchymosis in patients who had ORL release compared with those who did not. Patients who had ORL release had postoperative swelling and chemosis of significantly longer duration and a higher likelihood of developing postoperative ectropion. CONCLUSIONS: Orbicularis retaining ligament release does not appear to result in additional aesthetic benefit in lower blepharoplasty patients and may increase morbidity in the form of ectropion and prolonged swelling and chemosis.