Cirurgia da Tricomatose Tricomatosa, Terceira Edição

A terceira edição do manual sobre intervenção de rotação tarsal bilamelar para o tratamento do entrópio devido à triquíase tracomatosa, publicado pela Organização Mundial da Saúde (OMS), apresenta várias atualizações e melhorias. Desde sua primeira edição em 1993 e a segunda em 2015, esta nova versão amplia o conteúdo inicial, incorpora avanços acordados na quarta Reunião Científica Mundial sobre Tracoma em 2018 e melhora significativamente a estrutura e apresentação do manual. Descrições detalhadas sobre o exame do entrópio foram adicionadas, listas de instrumentos cirúrgicos necessários foram otimizadas e orientações sobre cuidados pós-operatórios foram aprimoradas. Além disso, ilustrações atualizadas foram incluídas e conteúdo redundante foi removido, tornando o manual mais acessível e útil. O manual foi desenvolvido principalmente para instrutores encarregados de treinar cirurgiões na técnica de rotação tarsal bilamelar. Está dividido em duas partes: a primeira centra-se nas competências necessárias para a formação dos cirurgiões e serve como documento de referência, incluindo objetivos pedagógicos específicos e exercícios práticos. A segunda parte destina-se exclusivamente a formadores, abordando a seleção e avaliação final dos alunos. Este recurso integral não apenas detalha o conhecimento teórico, mas também as habilidades práticas essenciais que precisam ser desenvolvidas e avaliadas durante o treinamento cirúrgico.

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.

A preliminary study of cutaneous wound healing on the upper eyelid in a small Brazilian population using Rhizophora mangle-based cream.

Plants used in traditional medicine offer an affordable new alternative in tissue repair therapy. This study aimed to evaluate the effectiveness of the 5% Rhizophora mangle cream compared to the 5% dexpanthenol cream in healing open surgical wounds on the upper eyelid. A total of 18 patients were submitted to the experiment and divided into 2 groups with 9 patients each who used topically and daily 5% dexpanthenol cream (control group) or 5% R.mangle cream (intervention group) for 7 days. Clinical, morphometric and histomorphometric analyses of wounds and surgical procedures for skin removal were performed. In the morphometric analysis, all wounds treated with R.mangle and dexpanthenol creams showed complete macroscopic scars, without inflammatory signs and infection free. The skin hydration values in pre and post application periods of the cream were 43.82 ± 43.93 and 62.12 ± 67.40 respectively. The histomorphometric study showed lower values of epithelium distance in R. mangle group and higher in dexpanthenol group with significant difference between groups (p < 0.05). The R.mangle 5% cream proved to be effective in healing wounds of human upper eyelid skin with a significant improvement in epithelization compared to dexpanthenol 5% cream.

The Dysmorphic Concern Questionnaire: Is It Possible to Predict a Satisfactory Result After Cosmetic Eyelid Surgery?

PURPOSE: As oculofacial surgeons performing esthetic surgery, the most valuable result is a satisfied patient. It can be extremely frustrating to have an unhappy patient with, what we believe is, a satisfactory result. Therefore, the ability to predict satisfaction is of extreme importance. We studied our cosmetic eyelid surgery patients to try to find factors that can predict satisfaction. METHODS: We retrospectively studied 454 consecutive patients, who underwent any combination of 7 cosmetic surgical procedures. Patients answered the Dysmorphic Concern Questionnaire (DCQ) before surgery. We studied age, gender, type and number of procedures performed, DCQ score, presence of complications, and history of previous fillers. At the 3-month follow-up visit, patients were given an outcome report survey to graduate their surgical results on a scale from 1 to 5. Results were evaluated using a model of binary logistic regression in which the outcome variable was divided into 2 groups. RESULTS: Three hundred eighty-six patients (85%) were female and the median age was 54.8 years old. The median for the number of procedures was 2 (range, 1-5). Two hundred two of the 454 patients (44.5%) had a history of fillers. Twenty-five patients had complications. DCQ score was significantly lower in the satisfied group (median score, 3) versus the unsatisfied group (median, 6), p = 0.007. In the multiple binary logistical model, the variables age, male gender, DCQ, presence of complications, and upper eyelid blepharoplasty resulted as significant. CONCLUSIONS: We found a significant positive association with upper lid blepharoplasty and a negative association with increasing age, male gender, occurrence of complications, and DCQ score, as predictors of patient satisfaction. We routinely administer the DCQ to all cosmetic patients: It is a brief, sensitive, and specific screening instrument for body dysmorphic disorder.

Spontaneous Blinking Kinematics After Frontalis Muscle Flap Advancement.

PURPOSE: To measure the spontaneous blinking metrics after blepharoptosis correction with frontalis muscle flap advancement. METHODS: A video system was employed to measure the amplitude and velocity of spontaneous blinking of 24 eyelids after the frontalis muscle flap surgery for blepharoptosis correction. A control group with no eyelid disorders was also measured. The data of 13 eyelids who had frontalis slings with autogenous fascia, which were previously collected with the same method in another study, were used for comparison. Digital images were used to measure the superior margin reflex distance and the presence of lagophthalmos during a gentle closure of the palpebral fissure. Superficial keratitis was assessed by corneal biomicroscopy. RESULTS: The mean amplitude of spontaneous blinking was 6.3 mm in controls, 2.6 mm in the frontalis flap patients, and 2.1 mm in the fascia sling group. The mean blink velocity was 133.8 mm/second in controls, 39.0 mm/second (3.7 standard error) after the frontalis flap, and 36.3 mm/second in patients with frontalis sling with fascia. For these 2 parameters, there was no statistical difference between the surgical groups, but a significant reduction when compared with the control group. No significant association was found between lagophthalmos and keratitis and the surgical procedure. CONCLUSIONS: There is no difference between the blinking metrics of eyelids operated using the frontalis muscle flap advancement technique or frontalis sling with autogenous fascia. The presence of lagophthalmos and keratitis also does not differ between the 2 procedures.

A novel hybrid BonT-A and hyaluronic acid cannula-based technique for eyelid ptosis and periorbital rejuvenation.

BACKGROUND: Eyelid ptosis is characterized by an inferior displacement of the upper eyelid when the eye assumes its primary position. Besides its aesthetic implications, ptosis can also adversely affect visual acuity. OBJECTIVE: This study aimed to evaluate the simultaneous administration of IncobotulinumtoxinA (IncoBonTA) and hyaluronic acid effect in eyelid ptosis and ocular rejuvenation. METHODS: A novel, non-surgical technique for eyelid ptosis management involving IncoBonTA and hyaluronic acid the co-administration within a single syringe, and applied using a cannula. RESULTS: The dual action of IncoBonTA and hyaluronic acid in conjunction with the exact injection sites approaches improves overall aesthetic outcomes but also optimizes the restoration of eyelid functionality in palpebral ptosis. CONCLUSIONS: The functional balance achieved among the contributory muscles-primarily the orbicularis oculi (OO) and its antagonists, the frontal muscle and levator palpebrae superioris (LPS), yields to both, cosmetic and functional.

Eye and lid involvement as an uncommon feature of pemphigus foliaceus in a pediatric patient.

Pemphigus foliaceus (PF) is an autoimmune blistering disorder which affects the superficial layers of the epidermis with rare mucosal involvement. We present the case of a 12-year-old girl with PF involving the eyes and eyelids. A literature review of pediatric nonendemic PF revealed another two cases with ocular manifestations. Eyelid involvement is an uncommon feature of PF that should be properly identified and treated.

Digital analysis of unilateral ptosis repair: external levator advancement vs. Müller's muscle conjunctival resection.

PURPOSE: Evaluation of lid contour and marginal peak point changes to compare outcomes of external levator advancement and Miiller's muscle conjunctival resection surgery in unilateral ptosis. METHODS: We reviewed the charts of unilateral ptosis patients who underwent external levator advancement or Miiller's muscle conjunctival resection. Eyelid contour analysis was conducted on preoperative and 6-month postoperative digital images. This was performed with the multiple margin reflex distances technique, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. The marginal peak point changes were analyzed digitally using the coordinates of the peak point according to the pupil center. Each position's mean distance was compared preoperatively, postoperatively, and with the fellow eyelid. RESULTS: Sixteen patients underwent external levator advancement and 16 patients had Miiller's muscle conjunctival resection. The mean margin reflex distance was improved by both techniques (1.46 vs. 2.43 mm and 1.12 vs. 2.25 mm, p=0.008 and p=0.0001 respectively) and approached that of the fellow eyelid (2.43 vs. 2.88 and 2.25 vs. 2.58 mm, p=0.23 and p=0.19, respectively). However, statistically significant lid margin elevation was limited to between the N6 and T6 points in the external levator advancement group. Whereas, significant elevation was achieved along the whole lid margin in the Miiller's muscle conjunctival resection group. The marginal peak point was shifted slightly laterally in the external levator advancement group (p=0.11). CONCLUSIONS: Both techniques provide effective lid elevation, however, the external levator advancement's effect lessens toward the canthi while Müller's muscle conjunctival resection provides more uniform elevation across the lid margin. The margin reflex distance alone is not sufficient to reflect contour changes.

Evaluation of Meibomian gland dysfunction using meibography in patients with xeroderma pigmentosum.

PURPOSE: To assess Meibomian gland dysfunction using meibography in patients with xeroderma pigmentosum and correlate with ocular surface changes. METHODS: This cross-sectional study evaluated patients with xeroderma pigmentosum. All patients underwent a comprehensive and standardized interview. The best-corrected visual acuity of each eye was determined. Detailed ophthalmic examination was conducted, including biomicroscopy examination of the ocular surface, Schirmer test type I, and meibography, and fundus examination was also performed when possible. Meibomian gland dysfunction was assessed by non-contact meibography using Oculus Keratograph® 5M (OCULUS Inc., Arlington, WA, USA). Saliva samples were collected using the Oragene DNA Self-collection kit (DNA Genotek Inc., Ottawa, Canada), and DNA was extracted as recommended by the manufacturer. Factors associated with abnormal meiboscores were assessed using generalized estimating equation models. RESULTS: A total of 42 participants were enrolled, and 27 patients underwent meibography. The meiboscore was abnormal in the upper eyelid in 8 (29.6%) patients and in the lower eyelid in 17 (62.9%). The likelihood of having abnormal meiboscores in the lower eyelid was 16.3 times greater than that in the upper eyelid. In the final multivariate model, age (p=0.001), mutation profile (p=0.006), and presence of ocular surface malignant tumor (OSMT) (p=0.014) remained significant for abnormal meiboscores. For a 1-year increase in age, the likelihood of abnormal meiboscores increased by 12%. Eyes with OSMT were 58.8 times more likely to have abnormal meiboscores than eyes without ocular surface malignant tumor. CONCLUSION: In the final model, age, xeroderma pigmentosum profile, previous cancer, and clinical alterations on the eyelid correlated with a meiboscore of ≥2. Meibomian gland dysfunction was common in patients with xeroderma pigmentosum, mainly in the lower eyelid. The severity of Meibomian gland dysfunction increases with age and is associated with severe eyelid changes.

Objective demonstration of eyelid spasm relief with smartphone and custom software in hemifacial spasm patients.

PURPOSE: To objectively demonstrate eyelid spasms relief in hemifacial spasm (HFS) patients using a smartphone and a custom-made software. METHODS: Nineteen patients with HFS had standardized videos recorded with a smartphone (iPhone 6S, Apple) camera before and 15 days after receiving onabotulinumtoxinA injections. Nineteen age-matched control subjects were also assessed. The Eye Aspect Ratio (EAR) is an algorithm previously described to determine whether the eye is opened or closed. When the eye is closed, EAR tends to be closer to zero. Analogously, if the eye is wide open, values are greater. A custom-made software using the EAR concept was developed and pre- and post-treatment EARs were analyzed to assess HFS patients. RESULTS: Botulinum toxin (BoNT) injections led to a significant increase in the average EAR of the affected side: + 10.4% (p = 0.0175) of HFS patients, compared to baseline. Mean EAR before BoNT applications were significantly lower (16.2%) on the affected side (0.25 ± 0.05) of HFS patients when compared to controls (0.30 ± 0.05, p = 0.004). After BoNT injections, no statistically significant difference was observed for the average EAR between the affected side of HFS patients (0.27 ± 0.04) and controls (p = 0.20). CONCLUSIONS: Use of a smartphone and custom-made software objectively demonstrated eyelid spasm relief in patients with HFS. Additional refinement of this system could permit more accurate assessments of treatment response rates for each patient, making it possible to be used in clinical practice.

Effect of upper eyelid blepharoplasty on the ocular surface, tear film, and corneal microstructure.

PURPOSE: This study aimed to investigate the effect of upper eyelid blepharoplasty with the removal of the skin and a strip of orbicularis oculi muscle on the ocular surface, tear film, and dry eye-related symptoms. METHODS: Twenty-two eyes of 22 consecutive patients operated by a single surgeon (21 females; mean age, 61 years; age range, 41-75 years) were included. All subjects completed the Ocular Surface Disease Index questionnaire, underwent in vivo confocal microscopy, tear film breakup time measurements, the Schirmer test with anesthesia, and fluorescein and lissamine green staining measurements before, 1 month, and 6 months after upper blepharoplasty alone with preseptal orbicularis excision. RESULTS: A significant increase in Ocular Surface Disease Index, and corneal fluorescein and lissamine green staining and a significant decrease in tear film breakup time were observed after 1 month (p=0.003, p=0.004, p=0.029, and p=0.024 respectively) and 6 months (p=0.001 for all findings). No significant difference in the Schirmer test score was observed during the follow-up. None of the in vivo confocal microscopy parameters showed significant changes during the study. CONCLUSIONS: An increase in dry eye symptoms and a decrease in tear film stability along with ocular surface staining were observed in patients undergoing upper eyelid blepharoplasty.

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.

Shih-Tzu dogs show alterations in ocular surface homeostasis despite adequate aqueous tear production.

BACKGROUND: Shih-Tzu dogs are frequently affected by ocular surface disorders such as corneal ulceration and dry eye disease (DED). The aim of this study was to evaluate ocular surface homeostasis in Shih-Tzu dogs that have adequate aqueous production. Twenty-eight dogs were subjected to eyelid blink counting, Schirmer tear test (STT-1), ophthalmic evaluation, tear film break-up time (TBUT), fluorescein test and Masmali tear ferning (TF) grading scale. RESULTS: Of the 28 animals evaluated, the median value of incomplete eyelid blinks/min (median = 15.0 blinks/min; Interquartil interval - IQR = 8.7 blinks/min - 19.5 blinks/min) was higher than the complete blinks/min (median = 2.5 blinks/min; IQR = 1.6 blinks/min - 4.3 blinks/min), with statistically significant difference. The Schirmer tear test had a median value of 25.0 mm/min (IQR = 22.7 mm/min - 27.5 mm/min), considered within the normal range for the species. On ophthalmic examination, all dogs had trichiasis of the caruncle and medial lower eyelid entropion. Lagophthalmos was the third most common alteration observed (71.4%; 20/28). The median of TBUT was 4.0 s; (IQR = 3.0 - 6.0 s). All the animals were negative to the fluorescein test and the TFT indicated that the majority of the eyes (51.8%; 29/56) were classified in abnormal grades 3 and 4 according to the Masmali tear ferning (TF) grading scale. CONCLUSIONS: Although the Shith-Tzu dogs had STT-1 values within the normal range for the species there was high prevalence of abnormal TFT grades and low TBUT in all dogs, showing that despite adequate aqueous production, these dogs have poor precorneal tear film quality. In addition, the dogs showed few complete eyelid blinks and ophthalmic alterations, promoting poor tear film diffusion. All these findings, isolated or together, can result in DED.

Ophthalmic Manifestations of Monkeypox Virus Infection: A Cases Series.

This retrospective case series aims to describe the ophthalmic manifestations of the Monkeypox virus infection in seven patients evaluated in two countries of South America (Colombia and Brazil). Two had skin lesions in the eyelid, and five had conjunctivitis. None had intraocular involvement. Three of seven patients had a history of Human Immunodeficiency Virus infection, and all patients had lesions in the genital region, suggesting sexual-contact transmission. In 6 of 7 cases, conjunctival RT-PCR was positive for the Monkeypox virus, including one case without conjunctival vesicles. In all cases, lesions resolved without complications, and just two required antiviral treatment. All patients demonstrated improvement without complications. RT-PCR positivity in conjunctiva demonstrated the presence of the Monkeypox virus, suggesting that ocular-mediated transmission could be plausible. Ophthalmologists should be aware of this ophthalmic manifestation.

Cirugía de la triquiasis tracomatosa. Tercera edición

En esta tercera edición se actualiza la definición de la triquiasis tracomatosa según lo acordado en la cuarta Reunión Científica Mundial sobre el Tracoma (Ginebra, del 27 al 29 de noviembre del 2018), se agrega una descripción sobre cómo examinar el entropión, se mejoran las listas de instrumentos y material fungible necesarios para la cirugía, se amplía y se mejora la orientación sobre los cuidados posoperatorios, se incluyen ilustraciones actualizadas, se mejora la presentación en todo el libro, y se elimina el contenido redundante.

Definition and Diagnostic Criteria for Pediatric Blepharokeratoconjunctivitis.

Importance: Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic, sight-threatening inflammatory ocular surface disease. Due to the lack of unified terminology and diagnostic criteria, nonspecific symptoms and signs, and the challenge of differentiation from similar ocular surface disorders, PBKC may be frequently unrecognized or diagnosed late. Objective: To establish a consensus on the nomenclature, definition, and diagnostic criteria of PBKC. Design, Setting, and Participants: This quality improvement study used expert panel and agreement applying the non-RAND modified Delphi method and open discussions to identify unified nomenclature, definition, and definitive diagnostic criteria for PBKC. The study was conducted between September 1, 2021, and August 14, 2022. Consensus activities were carried out through electronic surveys via email and online virtual meetings. Results: Of 16 expert international panelists (pediatric ophthalmologists or cornea and external diseases specialists) chosen by specific inclusion criteria, including their contribution to scientific leadership and research in PBKC, 14 (87.5%) participated in the consensus. The name proposed was "pediatric blepharokeratoconjunctivitis," and the agreed-on definition was "Pediatric blepharokeratoconjunctivitis is a frequently underdiagnosed, sight-threatening, chronic, and recurrent inflammatory eyelid margin disease associated with ocular surface involvement affecting children and adolescents. Its clinical spectrum includes chronic blepharitis, meibomitis, conjunctivitis, and corneal involvement ranging from superficial punctate keratitis to corneal infiltrates with vascularization and scarring." The diagnostic criteria included 1 or more suggestive symptoms accompanied by clinical signs from 3 anatomical regions: the eyelid margin, conjunctiva, and cornea. For PBKC suspect, the same criteria were included except for corneal involvement. Conclusions and Relevance: The agreements on the name, definition, and proposed diagnostic criteria of PBKC may help ophthalmologists avoid diagnostic confusion and recognize the disease early to establish adequate therapy and avoid sight-threatening complications. The diagnostic criteria rely on published evidence, analysis of simulated clinical cases, and the expert panel's clinical experience, requiring further validation with real patient data analysis.

Anquilobléfaro filiforme congênito / Ankyloblepharon filiforme adnatum

RESUMO O anquiloblefáro filiforme congênito é uma rara anomalia congênita, caracterizada por uma fusão palpebral, parcial ou completa, cuja incidência é de 4,4 por 100 mil recém-nascidos. Normalmente, o anquiloblefáro filiforme congênito constitui uma malformação solitária, de ocorrência esporádica, no entanto, pode estar associado a outras malformações. O pediatra possui papel imprescindível para observar as alterações clínicas do recém-nascido e dar orientação para o tratamento adequado. O objetivo deste estudo foi relatar o caso de recém-nascido de termo que teve diagnóstico precoce de anquiloblefáro filiforme congênito associado a outras malformações congênitas, tendo desfeito as aderências em procedimento cirúrgico oportuno, evitando-se a evolução para futuras complicações visuais do paciente.

ABSTRACT Ankyloblepharon filiforme adnatum is a rare congenital anomaly, characterized by partial or complete palpebral fusion, with an incidence of 4.4 per 100,000 newborns. Normally, ankyloblepharon filiforme adnatum constitutes a solitary malformation, with sporadic occurrence, however, it can be associated with other malformations. Pediatricians play an essential role in observing clinical changes in newborns and providing guidance on appropriate treatment. The this study aims to report the case of a full-term newborn who had an early diagnosis of ankyloblepharon filiforme adnatum associated with other congenital malformations.

Treatments of palpebral congenital melanocytic nevus: a systematic review.

PURPOSE: Palpebral congenital melanocytic nevi (PCMN) is a rare congenital skin lesion affecting the eyelids that can lead to cosmetic and psychological concerns and potential health risks such as malignancy. Several authors have analyzed therapeutical strategies to treat PCMN. However, there was no consensus in the literature. This systematic review aimed to evaluate the effectiveness, safety, and success of treatments of PCMN. METHODS: We conducted a systematic review following PRISMA guidelines from October 2022 to April 2023. We included all types of study designs that described or compared PCMN treatments and interventions, as well as histology, recurrence, adverse events, patient satisfaction, and malignant transformation. The search strategy was based on specific search words through the following databases: PubMed, Embase, Latin American and Caribbean Health Sciences Literature (Lilacs), Web of Science, and Scopus. Ongoing studies and gray literature studies were included. RESULTS: We analyzed 25 case reports with 148 participants. The effectiveness, success, and satisfaction with various treatments for PCMN depend on the specific treatment method and the individual patient's case. CONCLUSIONS: Most of the studies showed that surgical procedures (exeresis) are able to treat PCMN in the eyelid. The variability in outcomes emphasizes the importance of further research to better understand the most effective and safe approaches for treating congenital melanocytic nevi.