Accuracy and replicability of identifying eyelid tremor as an indicator of recent cannabis smoking.

INTRODUCTION: Cannabis intoxication may increase the risk of motor vehicle crashes. However, reliable methods of assessing cannabis intoxication are limited. The presence of eyelid tremors is among the signs of cannabis use identified under the Drug Evaluation and Classification Program of the International Association of Chiefs of Police. Our objectives were to assess the accuracy and replicability of identifying eyelid tremor as an indicator of recent cannabis smoking using a blinded, controlled study design. METHODS: Adult subjects (N = 103) were recruited into three groups based on their cannabis use history: daily, occasional, and no current cannabis use. Participants' closed eyelids were video recorded for 30 seconds by infrared videography goggles before and at a mean ± standard deviation time of 71.4 ± 4.6 minutes after the onset of a 15-minute interval of ad libitum cannabis flower smoking or vaping. Three observers with expertise in neuro-ophthalmology and medical toxicology were trained on exemplar videos of eyelids to reach a consensus on how to grade eyelid tremor. Without knowledge of subjects' cannabis use history or time point (pre- or post-smoking), observers reviewed each video for eyelid tremor graded as absent, slight, moderate, or severe. During subsequent data analysis, this score was further dichotomized as a consensus score of absent (absent/slight) or present (moderate/severe). RESULTS: Kappa and intraclass correlation coefficient statistics demonstrated moderate agreement among the coders, which ranged from 0.44-0.45 and 0.58-0.61, respectively. There was no significant association between recent cannabis use and the observers' consensus assessment that eyelid tremor was present, and cannabis users were less likely to have tremors (odds ratio: 0.75; 95 percent confidence interval: 0.25, 2.40). The assessment of eyelid tremor as an indicator of recent cannabis smoking had a sensitivity of 0.86, specificity of 0.18, and accuracy of 0.64. DISCUSSION: Eyelid tremor has fair sensitivity but poor specificity and accuracy for identification of recent cannabis use. Inter-rater reliability for assessment of eyelid tremor was moderate for the presence and degree of tremor. The weak association between recent cannabis use and eyelid tremor does not support its utility in identifying recent cannabis use. LIMITATIONS: Videos were recorded at only one time point after cannabis use. Adherence to abstinence could not be strictly supervised. Due to regulatory restrictions, we were unable to control the cannabis product used or administer a fixed Δ9-tetrahydrocannabinol dose. Participants were predominately non-Hispanic and White. CONCLUSIONS: In a cohort of participants with a range of cannabis use histories, acute cannabis smoking was not associated with the presence of eyelid tremor, regardless of cannabis use history, at 70 minutes post-smoking. Additional research is needed to identify the presence of eyelid tremor accurately, determine the relationship between cannabis dose and timeline in relation to last cannabis use to eyelid tremor, and determine how it should be, if at all, utilized for cannabis Drug Recognition Evaluator examinations.

The Rise and Fall of the Pale Puffy Lower Eyelid Pillow.

This case series demonstrates an exaggerated form of the clinical presentation of a known distressing late complication of retained hyaluronic acid filler – the “pale puffy pillow.” This presentation is often, unfortunately for the patient, misdiagnosed as festoons. However, the correction with liberal hyaluronidase is simple. Additionally, we have demonstrated that ablative fractional carbon dioxide laser resurfacing is an excellent tool that may be utilized after hyaluronidase to correct the residual skin laxity.J Drugs Dermatol. 20(4):475-476. doi:10.36849/JDD.5509.

Efficacy and safety study of an eyelid gel after repeated nocturnal application in healthy contact lens users and non-users

PURPOSE: To evaluate skin biocompatibility of a nighttime hydrating eyelid gel and possible ocular surface effects in contact lens users (CLU) and non-contact lens users (NCLU). The formulation is registered as a medical device as Tridocosahexaenoine-AOX(R) (TDHA-AOX) (a concentrated DHA triglyceride), containing also hyaluronic acid (HA). METHODS: A prospective, randomized, masked clinical trial was performed with 62 participants of both sexes, aged 20-70 years, split into: (1) CLU (n = 30) and (2) NCLU (n = 32). All participants were instructed to apply a single dose of the moisturizing gel (containing TDHA-AOX and HA) nightly to the upper and inner eyelids of their right eye (RE) only, and during 2 consecutive weeks. Personal interviews, questionnaires, ophthalmic examinations and reflex tear collection were performed. Ophthalmological parameters included ocular surface response and contact lens status. Levels of satisfaction/adverse events were also recorded. Biochemical parameters included basal and final determination of pro-inflammatory mediator molecules in tear samples by multiplex analyses. Statistics were done by the SPSS 24.0 program. RESULTS: The CLU group had higher OS dysfunction than NCLU, but overall clinical parameters (corneal staining, and Schirmer/FBUT tests) and OSDI scores showed significant improvement in CLU individuals as compared to the NCLU participants, at the end of study. CLDEQ-8 scores pinpointed significant amelioration in initial risk of developing DEs by applying eyelid gel. Multiplex analyses demonstrated significantly lower VEGF expression levels (p < 0,05) in tears among the CLU compared to NCLU after nightly application of eyelid gel. CONCLUSIONS: Eyelid gel appeared to safely and efficiently provide hydration and decongestion of the skin and amelioration of the ocular surface during sleep

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Comparison of preseptal and pretarsal onabotulinum toxin an injection in patients with hemifacial spasm.

AIM: The aim of the present study was to evaluate the effects of different doses of onabotulinum toxin A on the amplitude and latency values of the blink reflex and facial nerve in the pretarsal and preseptal portions of the orbicularis oculi muscle in patients with hemifacial spasm. MATERIALS AND METHODS: Thirty patients with hemifacial spasm were assigned in two equal groups: Pretarsal Group: Five units of onabotulinum toxin A were injected into each of 2 points of the pretarsal portion; Preseptal Group: Five units of onabotulinum toxin A was injected into 4 points of the preseptal portion. We compared the electromyographic features of the patients before and 5 weeks after botulinum toxin (BTX) injection. RESULTS: In comparison of pre- and post-treatment measurements of blink reflex amplitude responses, the decreases in R1 (p = 0.003), R2 (p < 0.001), and R2C amplitudes (p = 0.031) were found to be significant in the BTX injected side in the pretarsal group. In the comparison of pre- and post-treatment measurements of facial nerve compound action potential amplitude changes, decreases in the amplitudes of the BTX injected (ipsilateral), and uninjected (contralateral) side in the pretarsal group were found to be significant (p < 0.001 for both groups). Decreases in the amplitudes of the BTX injected, and uninjected side in the preseptal group were found to be significant (p < 0.001, and p = 0.008, respectively). CONCLUSION: According to our hypothesis, the smaller amount of BTX applied to the pretarsal portion was found to be more effective than higher amount of BTX injected into the preseptal portion of the orbicularis oculi muscle.

Topical application of Zanthoxylum piperitum extract improves lateral canthal rhytides by inhibiting muscle contractions.

Facial wrinkles are the predominant phenotypes of skin aging. To date, one of the most effective ways to improve wrinkles is botulinum toxin type A (BoNT/A) injection, which inhibits muscle contractions by reducing acetylcholine release from neurons. However, since BoNT/A is a hazardous neurotoxin, the injection can only be performed by medical doctors and the procedure is only possible through invasive injection, causing inconveniences such as pain. To overcome these inconveniences, we tried to find a way to reduce wrinkles non-invasively via mechanisms similar to BoNT/A. We first designed in vitro assays to test BoNT/A-like muscle contraction inhibition in two different model systems. By using the assays, we identified Zanthoxylum piperitum (Z. piperitum) fruit extract as a BoNT-like reagent (27.7% decrease of muscle contraction rates by 1000 ppm of Z. piperitum extract treatment). Next, we determined mechanisms of how Z. piperitum extract decreases muscle contraction rates and found that the extract treatment inhibits electrical signal transduction in neurons. We also showed that among known components of Z. piperitum extract, quercitrin is responsible for muscle contraction inhibition. We further identified that Z. piperitum extract has synergistic effects with acetyl hexapeptide-8 and BoNT/A light chain, which are well-known BoNT-like peptides. Finally, we showed that topical treatment of the Z. piperitum extract indeed decreases facial wrinkles and treatment of Z. piperitum extract with acetyl hexapeptide-8 has a tendency to improve wrinkles synergistically (14.5% improvement on average). The synergistic effect of the combination is expected to improve wrinkles effectively by implementing the BoNT/A mechanisms in a non-invasive way.

Time-dependent Response of Eyelid Height with a Single Drop of 2.5% Phenylephrine in Korean Ptotic Patients.

PURPOSE: We sought to investigate the temporal changes of eyelid height after phenylephrine instillation in Korean patients with and without ptosis to determine the time points of the first and maximum reactions. METHODS: The phenylephrine test was performed on 16 eyes of 12 ptotic patients (group I) and 24 eyes of 12 normal control subjects (group II) in our hospital between September 2017 and March 2018. One drop of 2.5% phenylephrine was instilled and the marginal reflex distance 1 (MRD1) was measured at 15 seconds before instillation and the following time points after instillation: at 15-second intervals for the initial 5 minutes and at 5-minute intervals until a total of 20 minutes was reached (i.e., at 10, 15, and 20 minutes). RESULTS: In group I patients, the first reaction appeared at 5 minutes (p = 0.034), while the maximum eyelid height after the first reaction was reached at 15 minutes (p = 0.025) and was maintained until 20 minutes. In group II subjects, the first reaction appeared at 5 minutes (p = 0.034), while the maximum eyelid height was reached at 10 minutes (p = 0.015) and was maintained until 20 minutes. There was no significant difference in the response of eyelid height based on time (p = 0.122) between the two groups. CONCLUSIONS: Our analysis of phenylephrine test results in Korean ptotic patients revealed a significant increase occurred in the eyelid height after 5 minutes; meanwhile, the maximum eyelid height was reached at 15 minutes and was maintained until 20 minutes after instillation.

Effect of topical Phenylephrine on the upper eyelid crease position.

PURPOSE: To investigate the effect of Phenylephrine test on the upper eyelid crease position. MATERIAL AND METHODS: This study follows a prospective and analytical design and included patients with unilateral acquired involutional ptosis recruited between January 2015 and January 2018. In the Phenylephrine test, 1 drop of Phenylephrine 10% was instilled on the inferior fornix of the ptotic eye and the eyelid crease position was evaluated 10 min after. RESULTS: A total of 60 patients were included in the final sample. The mean Margin-to-reflex distance 1 (MRD1) of the ptotic eye was 2.1 ± 1.0 and 3.8 ± 0.6 mm before and 10 min after the instillation of Phenylephrine, respectively. The difference between the means was statistically significant (p < 0.001). Ninety-five per cent of the eyes had a positive Phenylephrine test result. Of this, 100% showed a decrease in the height of eyelid crease after the drop. There was a statistically significant decrease in the height of eyelid crease from 10.3 ± 2.5 to 7.8 ± 2.0 mm (p < 0.001). CONCLUSION: Phenylephrine test not only affects the eyelid position but also the eyelid crease height. We show a significative decrease in eyelid crease height to a symmetrical level with the contralateral lid in all patients that had a positive Phenylephrine test result. This effect is probably due to a posterior lamella shortening secondary to Müller's muscle contraction and suggests that the eyelid crease is not only determined by the projections of levator aponeurosis, but also by the entire force vector of the upper eyelid retractors.

Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl.

OBJECTIVE: The use of tissue adhesives has become a popular option for closure of wounds in the ED. There have been a growing number of reports of inadvertent tissue adhesive injuries including closure of the eyelids. We aim to identify and compare various removal methods of tissue adhesives described in the literature in an exploratory trial. METHODS: A review was first conducted to establish all published methods for the removal of medical-grade tissue adhesives as well as commercial cyanoacrylates. This search was conducted on PubMed, Google Scholar and Google. All articles that reported attempts at removal of cyanoacrylate glues were included. These methods were then tested on a porcine model in an exploratory trial. Incisions were made on pigskin and closed with Histoacryl, a tissue adhesive. Three removal methods were tested-gentle rubbing with test compound after 45 or 90 s, as well as soaking in test compound. Removal methods that were successful underwent repeat testing. RESULTS: A total of 37 sources were reviewed with 13 different removal methods suggested. Based on the information, we tested 24 different compounds. Soaking of Histoacryl-closed wounds in Polydexa ear/eye drops displayed consistent success in achieving complete separation of incision edges after 2 hours. Several other soapy substances and antibiotic ointments showed potential but were not as consistent. CONCLUSION: In conclusion, in our trial of removal methods of Histoacryl, soaking in Polydexa antibiotic drops consistently facilitated removal after 2 hours. This approach can be attempted after inadvertent Histoacryl injury.

Concealing of under eye orbital fat pads with hyaluronic acid filler: A case report.

Under eyelid bags and tear troughs are the two most common concerns for the patients coming to an aesthetic center, and specially their correction without undergoing a surgery. Efficacy of hyaluronic acid fillers has been proven successfully in correction of periorbital volume loss but no reports have been published for their role in concealing infraorbital fat pads. Hence, the effectiveness and safety of hyaluronic acid filler in treatment and correction of tear troughs thereby concealing under eyelid bags are being reported in this article. A 43-year-old woman who presented with grade 3 tear troughs and bulged out infraorbital fat pads underwent a single treatment session with 1ml 15mg/mL cross-linked hyaluronic acid filler (Juvederm Volbella®). Assessment of the periorbital area was done immediately after the procedure and after 3 days. Hyaluronic acid filler injection not only showed significant improvement in periorbital hollowness but also concealed the bulge of infraorbital fat pads remarkably. Correction of tear troughs is known to be done with the help of hyaluronic acid but it can also become an excellent alternative to surgery for concealing under eye orbital fat pads without any formation of lumps and irregularity.

Comparison of topical antiaging creams in the management of lateral canthal lines.

OBJECTIVE: This study compared an antiaging treatment with two currently marketed cosmetic antiaging products for the treatment of lateral canthal lines ("crow's feet"). METHODS: Healthy female volunteers (72) aged of 54.6 years (mean) having fine-to-moderate wrinkles in the lateral canthal areas were randomized to one of three treatments applied daily over 28 days: Group A (Purgenesis™ Day Cream, Purgenesis™ Eye Cream, and Purgenesis™ Night Cream); Group B (Prevage® Eye Lotion, Prevage® Day Cream, and Prevage® Night Cream); or Group C (La Mer® Eye Balm, Crème de La Mer® , and La Mer® Night Cream). The effects on anti-wrinkle properties and for sensory attributes and general performance were evaluated on Days 1, 7, and 28. RESULTS: Skin hydration improved significantly at all time points in Groups A and B, and at Day 28 in Group C. Group A patients experienced significant improvements in measured skin elasticity parameters at Day 28; extensibility and maximum amplitude were significantly better at Day 28 in Groups B and C. Benefits were also seen in profilometric parameters with statistical significance only in Group A Volunteer tolerance was good with all three treatments, although moderate and high levels of adverse events were numerically higher in Group B than in Groups A or C, and levels of slight discomfort were significantly more prevalent in Group B. CONCLUSION: The Purgenesis™ antiaging treatment significantly improved skin hydration, elasticity, and profilometry parameters during a 28-day study. This therapy was found to be well tolerated and effective in countering the cutaneous signs of aging.

Anatomical and ultrasound-based injections for sunken upper eyelid correction.

BACKGROUND: A needle or a cannula can be safely used during filler injection procedures to correct a sunken upper eyelid. To date, there are no precise injection points recommended that are based on an anatomical study. OBJECTIVE: This study systematically investigated the vascular pattern and depth of forehead arteries at the periorbital area of upper eyelid. METHODS: Twenty cadavers were dissected in this study. Additional data were obtained from 30 healthy volunteers using Doppler ultrasound imaging with high-frequency probe. RESULTS: The ophthalmic artery divided into two opposite primary branches: the superior and inferior orbitoglabellar arteries running along the orbital rim. After the supratrochlear artery arose from the superior orbitoglabellar artery at the medial eyebrow, the supraorbital artery either divided from this artery near the supraorbital foramen or emerged as an individual artery from the supraorbital notch. The inferior orbitoglabellar artery gave off the radix artery superior to the medial canthal tendon. The radix artery divided into two opposite branches: the dorsal nasal artery going to the nose and the paracentral artery going to the glabella. Ultrasound imaging revealed a subcorrugator space that a cannula can safely pass through. At the supraorbital foramen/notch, the supraorbital artery traveled very close to the bone. Based on the anatomical data collected, the following injection points for a needle and a cannula technique are recommended. CONCLUSION: Correction of a sunken upper eyelid is a dangerous procedure which should be performed only by experienced physicians. However, with precise anatomical knowledge and correct techniques, optimal outcomes can be safely achieved.

DermaTOP Blue and Antera 3D as methods to assess cosmetic solutions targeting eyelid sagging.

BACKGROUND: As the eye contour ages, the skin on the lid becomes lax often causing a voluminous protrusion where the superior palpebral sulcus begins to sag onto the upper eyelid. This sagging feature may present a novel anti-ageing target for cosmetic products when treating the eye area. A quantitative method to evaluate the volume of this sagging feature has not been previously established. We investigate the use of the DermaTOP fringe projector and Antera 3D Camera to this end. METHODS: Eyelid topographic measurements were collected on 20 female volunteers aged 50-75 years with the DermaTOP and Antera 3D. The DermaTOP and Antera 3D measurements were assessed for reproducibility and product effect detection capabilities. RESULTS: The DermaTOP and Antera 3D successfully measured sagging feature volume, demonstrated reproducibility of measurement and furthermore were suitably sensitive to allow for detection of sagging feature volume reduction after a single application of aqueous tightening serum. DermaTOP parameters were found to moderately correlated with the Antera 3D parameters. CONCLUSION: Both the DermaTOP and Antera 3D allow for quantitative measurement of eyelid sagging feature volume and in-turn permit evaluation of anti-ageing cosmetic preparations targeting the eyelid.

Chronic eyelid edema and xerophthalmia secondary to periorbital hyaluronic acid filler injection.

BACKGROUND: Hyaluronic acid (HA) is a popular, nonsurgical, temporary technique that is commonly used in the periocular region to restore volume in areas that have undergone volume loss, as well as adjusting the height and contour of the eyebrow. AIMS: Due to the location of glands, nerves, and vasculature, the facial anatomy should be well understood to avoid injections into areas that may result in complications. PATIENT/METHODS: A 54-year-old woman presented for a cosmetic consultation to address "puffy eyelids". She states she had HA filler injected along the orbital ridge inferior to the eyebrow and medially at the glabellar crease two years prior. Two months after her injection, she began to notice upper eyelid edema, xerophthalmia, and dryness of her nasal mucous membranes. Extensive evaluation and imaging were done by physicians of different specialties with a negative workup. RESULTS: A total of 60 units of hyaluronidase were injected into the areas of previous filler placement over a three-week period. This resulted in complete resolution of the patient's presenting symptoms. CONCLUSION: Familiarity with potential adverse events is arguably the most important aspect of treating patients with HA filler. The anatomy of the orbit and lacrimal system are important to keep in mind when evaluating symptoms related to possible long-term complications of retained filler injections. Reporting this case should raise awareness about this potential adverse event and further explain the delicate anatomy of the periorbital area.

Non-surgical management of congenital ichthyosis using hyaluronic acid gel injection.

AIM: To test if hyaluronic acid gel injection in the upper eyelid achieves correction of congenital cicatricial ectropion and reduction in lagophthalmos, in preparation for intraocular surgery. METHODS: This case reports the long-term outcome of hyaluronic acid gel injection in the upper eyelid for the correction of ectropion prior to cataract surgery. One millilitre of hyaluronic acid gel was injected in both the upper eyelids of a child with congenital ichthyosis in the suborbicularis plane, prior to cataract surgery. RESULTS: Lagophthalmos reduced by 15 mm in the right eye and 13 mm in the left eye. Subsequently, the child underwent cataract surgery without any complications. CONCLUSION: We demonstrate the long-term outcome of using hyaluronic acid gel injection for successful, non-surgical correction of cicatricial ectropion in ichthyosis.

Association between cannabis and the eyelids: A comprehensive review.

Cannabis is the most consumed illicit drug worldwide. As more countries consider bills that would legalize adult use of cannabis, health care providers, including eye care professionals (ophthalmologists, optometrists), will need to recognize ocular effects of cannabis consumption in patients. There are only 20 studies on the eyelid effects of cannabis usage as a medical treatment or a recreational drug. These include ptosis induction, an "eyelid tremor" appearance and blepharospasm attenuation. Six articles describe how adequately dosed cannabis regimens could be promising medical treatments for blepharospasm induced by psychogenic factors. Fourteen articles report eyelid tremors in intoxicated drivers and ptosis as a secondary effect in cannabinoid animal experimental models. The exact mechanism of cannabinoids connecting cannabis to the eyelids is unclear. Further studies should be conducted to better understand the cannabinoid system in relation to the eyelid and eventually develop new, effective and safe therapeutic targets derived from cannabis.

Ocular surface and tear film changes in workers exposed to organic solvents used in the dry-cleaning industry.

Workers in the dry-cleaning industry are exposed to organic solvents that may cause eye irritation and tear film changes. Objective To quantify changes in the ocular surface and tear film in dry cleaners exposed to organic solvents and associate these changes with ocular irritation as reported in a symptom questionnaire for dry eye diagnosis. Methods This was a case and control study in which the characteristics and eye-irritation symptoms were compared between two groups of 62 participants that were either exposed or not exposed to organic solvents. A general optometric examination and the following test were performed: lipid interferometry, Lissamine Green Stain, tear breakup time, Schirmer I, conjunctival impression cytology and the Donate dry eye symptoms questionnaire. Results Sixty-five percent of exposed workers obtained a higher score than 13 on the Donate dry eye symptoms questionnaire which indicated the presence of more irritation symptoms than those in the non- exposed group. A Chi-square analysis indicated the exposed group reported significantly higher incidences (P <0.005) for eye irritation symptoms of sandy sensation; tearing eyes sensation; foreign body sensation; tearing; dry eye; dryness; eyestrain and heavy eyelids. A Mann Whitney-U indicated greater severity only for symptoms relating to dry eye; sandy sensation; foreign body sensation, tearing; tearing eyes and dryness. There was a statistically significant difference (P <0.05) for Schirmer I; tear break up time; and the ocular surface assessed with Lissamine green staining and conjunctival impression cytology between groups. A reduction in the thickness of the lipid layer in the exposed group compared to the non-exposed group was observed. Surprisingly, clinical test outcomes were not significantly correlated with dry eye symptoms nor years of exposure. Conclusion Workers in the dry-cleaning industry exposed to organic solvents are associated with changes in ocular surface and tear film generating irritation symptoms commonly present in evaporative dry eye.