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A scanning electron microscope study of fetal eyelid closure accelerated by cortisone in SWV/Bc mice.

Eyelid closure occurs earlier in SWV/Bc and CBA/J mouse fetuses whose mothers were treated with cortisone on day 14 of gestation than it does in fetuses from untreated mothers. Similar treatment prevents the open-eyes defect of lidgap-Miller mutant mice, but examination by scanning electron microscope (SEM) has shown differences in the periderm of the closing eyelids of the cortisone-treated mutant compared with those of untreated genetically normal fetuses. (Untreated mutant eyelids remain wide open and very abnormal). The present study has examined at the SEM level the accelerated eyelid closure of cortisone-treated normal strain, SWV/Bc, fetuses to investigate whether the differences from normal in the eyelids of treated lidgap-Miller fetuses are part of the mechanism of the cortisone "cure." At the SEM level, cortisone-accelerated eyelid closure of SWV/Bc fetuses is indistinguishable from that in untreated fetuses. This suggests that the early eyelid closure induced by cortisone in normal strain fetuses represents acceleration of the normal coordinated sequence of events that leads to closure, rather than an abnormality that fortuitously leads to closure. The data also indicate that the cellular abnormalities seen previously in treated lidgap-Miller mutant fetuses are a combination of 1) abnormalities due to the mutation that are not completely reversed by cortisone and 2) normal developmental stages that have become concurrent with the cortisone-induced late closure in lidgap-Miller mutant fetuses.

Animals↗

[Eyelid injuries: epidemiological aspects].

PURPOSE: To present epidemiological data on eyelid trauma which appear rarely in the literature. PATIENTS AND METHODS: Medical records of 180 patients given surgical treatment for eyelid injuries at the ophthalmology department of LMU Munich between 1997 and 1999 were evaluated. Clinical findings of eyelids and eyeballs, surgical procedures and complications during wound healing were considered. RESULTS: Out of 180 patients, 140 suffered blunt trauma of which 66 were due to manual work, 38 to sudden falls, 23 to violence, 7 to motor vehicle accidents and 6 to sports. From 26 cutting injuries caused by glass, 12 were caused by broken spectacles, 8 were caused by sudden falls, 4 by violence and only 2 by car accidents. Clinically 85 patients showed injuries of the upper eyelid, 55 of the lower and 40 of both lids. The lid margin was affected in 43 patients and the lacrimal drainage system in 28. Wound contamination occurred in 34 patients, 19 had foreign bodies and 13 loss of tissue. Accompanying injuries of the face was noticed in 16 patients and of the eyeball in 79 patients of which 31 were superficial, 36 were eyeball contusions of varying severity, 12 were perforations or ruptures and 4 patients additionally had orbital bone fractures. The average time from injury to surgery was 3.3 h. A total of 100 patients needed simple skin suturing, 26 sutures to the skin and subcutaneous tissue including the orbicularis and levator muscle, 43 needed readaption of the lid margin and 24 repair of the canalicular system. Post-operatively only one patient developed a necrosis and one an infection. CONCLUSIONS: In eyelid trauma, the lid margin is affected in 24% and the lacrimal drainage system in 16% of all injuries. Our data also showed a high association (44%) of eyelid injuries with trauma to the eyeball. This emphasises the necessity for eyelid injuries to be treated primarily by an ophthalmic surgeon, although difficult primary reconstruction and early complications in particular, are relatively rare.

Accidental Falls↗

Epidemiology of basal cell carcinoma of the eyelid in south-western Finland.

BACKGROUND: Basal cell carcinoma (BCC) is the most common malignant tumour of the skin in Caucasians. It often appears on the eyelids but there are no population-based studies on the incidence of BCC of the eyelid in Nordic countries. METHODS: The mean annual incidence rates of BCC of the eyelid in the region of South-Western Finland from 1977 to 1997 were calculated. RESULTS: The mean annual incidence (per 100,000 population) of BCC of the eyelid showed a statistically significant increase from 0.82 (in 1977-1979) to 2.88 (in 1995-1997). The incidence of BCC of the eyelid was 0.8 in the age group of 30-49 years and rose significantly with age (P < 0.0005) to the maximum of 17.2 in the age group of 80-89 years. There were no statistically significant differences in the incidence rates of BCC of eyelid between males and females or between urban, semi-urban and rural populations. CONCLUSION: In South-Western Finland the incidence of BCC of the eyelids more than tripled during the years from 1977 to 1997. This may be due to the increase of the elderly population, because the incidence showed a significant increase with age.

Adult↗

Interactions of eyelids and tears in corneal wetting and the dynamics of the normal human eyeblink.

We used a high-speed camera system to study in detail the eyelid motion dynamics of the human eyeblink. Films were made from a hidden location through a one-way mirror. In this manner, normal, unforced blinks were recorded. The descent of the upper eyelid reached its maximum speed at about the time that it crossed the visual axis, generally in the range of 17 to 20 cm/sec, but occasionally reaching a speed of over 40 cm/sec. The motion of the lower eyelid was mostly horizontal, in a nasally directed movement, with a total displacement in the range of 20 to 5 min. A distinction must be made between normal, unforced blinks, and voluntary, forced eyelid motion. In a normal blink, no appreciable upward rotation of the globe is observed. A forced blink or a restraint of motion of the upper eyelid results in a significant demonstration of Bell's movement. The globe moves posteriorly up to 1 to 6 mm as the upper eyelid descends, probably caused by eyelid pressure during the closing phase of the blink.

Adult↗

Histological studies on eyelid opening in normal male mice and hemizygotes for the mutant gene Tabby (Ta) with and without epidermal growth factor treatment.

Previous work has shown that mice hemizygous or homozygous for the mutant gene Tabby have delayed eyelid opening, as compared to unaffected, wildtype littermate controls; exogenous treatment with epidermal growth factor reverses this delay. We performed histological studies to explore the mechanisms of action of the Tabby gene and of epidermal growth factor in these processes. These show that eyelid opening is associated with keratinization of the fusion junction and conjunctival sac formation. Both these processes occur earlier in normal male mice (days 4 and 7 respectively) than in Tabby hemizygotes (days 7 and 10, respectively). After epidermal growth factor injection, keratinization and conjunctival sac formation are both observed on postnatal day 1 in all control and mutant pups. Thus epidermal growth factor appears to accelerate eyelid opening by stimulating these morphological processes and the Tabby gene appears to delay eyelid opening by impairing them. It is possible that deficiency of epidermal growth factor at the tissue level may be involved in the development of some of the traits seen in Tabby mutants. In addition to analysing the effects of the Tabby gene and of epidermal growth factor on eyelid opening in the mouse, this study appears to be the first detailed histological description of normal eyelid opening. The findings have potential clinical significance; firstly, because the Tabby gene shows genetic homology to the human gene for hypohidrotic ectodermal dysplasia, and disturbed eyelid opening is a trait of some forms of human ectodermal dysplasia, and secondly, because the gene for epidermal growth factor receptor is an oncogene.

Animals↗

Patterns of regional and distant metastasis in patients with eyelid and periocular squamous cell carcinoma.

PURPOSE: To determine the frequency and location of regional lymph node metastasis in patients with squamous cell carcinoma (SCC) of the eyelid and periocular skin. Patterns of distant metastasis were also investigated. DESIGN: Retrospective case series. PATIENTS: One hundred eleven patients treated at The University of Texas M. D. Anderson Cancer Center for SCC of the eyelid and periocular skin between 1952 and 2000. METHODS: The clinical records of the 111 patients were retrospectively reviewed. The clinical characteristics analyzed included age, gender, location of lesion, treatment modalities, patterns of regional nodal and distant metastasis, and perineural invasion. Follow-up time ranged from 6 to 484 months (median, 76.6). MAIN OUTCOME MEASURE: Incidence of regional lymph node metastasis. RESULTS: The most common sites of SCC were the lower eyelid (54 patients [48.6%]), the medial canthus (40 patients [36.0%]), and the upper eyelid (25 patients [22.5%]). Local treatment of SCC consisted of wide local excision with frozen section analysis to ensure negative margins in 96 patients (86.4%), radiotherapy (without surgery) in 7 patients, and primary exenteration because of extensive tumor in 7 patients. Local recurrence occurred in 41 patients (36.9%). Twenty-seven patients (24.3%) had regional nodal metastasis during the study period. Sixteen of these patients had regional lymph node metastasis at the time of the initial presentation to M. D. Anderson Cancer Center. Eleven developed regional nodal disease later. Seven patients (6.2%) had distant metastasis during the study period. Nine patients (8.1%) had perineural invasion. CONCLUSION: This study indicates that the overall rate of regional lymph node metastasis in patients with SCC of the eyelid or periocular skin may be as high as 24%. Thus, careful surveillance of the regional lymph nodes is an important aspect of the initial management of eyelid or periocular skin SCC. Consideration could be given to studying sentinel lymph node biopsy as a technique to stage SCC of the eyelid or periocular skin more accurately, especially in patients with recurrent, large, or highly invasive lesions or with perineural invasion.

Adult↗

Incidence of eyelid cancers in Taiwan: a 21-year review.

PURPOSE: To describe the epidemiologic characteristics and incidence trends of primary eyelid cancers in the Chinese population in Taiwan between 1979 and 1999. DESIGN: Retrospective population-based cancer registry data review. PARTICIPANTS: A total of 1166 primary eyelid cancers coded to International Classification of Diseases 8 or 9, site 172.1 (malignant melanoma of eyelid) and 173.1 (other malignant neoplasm of eyelid) were retrieved from the Taiwan National Cancer Registry between January 1979 and December 1999. Of these, 1121 (96.1%) were histopathologically verified and were used for analysis. METHODS: Age- and gender-specific incidence rates were calculated and were age-adjusted to the 2000 world standard population. Trends in incidence rates were estimated by calculating the annual percentage change. We further examined the effects of age, period of diagnosis, and birth cohort on incidence trends using age-period-cohort analysis. MAIN OUTCOME MEASURE: Age-standardized incidence rate. RESULTS: The mean age at diagnosis of eyelid cancers was 62.6+/-14.1 years. The average annual age-standardized incidence rate was 3.2 per million during the study period. There was an overall increase of incidence rates from 1.5 per million in 1979 to 5.1 per million in 1999, with an annual percentage change of 4.63% (P<0.001). The most common eyelid malignancy was basal cell carcinoma (BCC; 65.1%), followed by squamous cell carcinoma (12.6%), and sebaceous cell carcinoma (7.9%). The increasing rates were mainly driven by an increase in the incidence of BCC. Cohort effects were found to play a major role in terms of model fit for the incidence trends of BCC. CONCLUSIONS: These national data reveal a rapidly increasing incidence of eyelid cancers from 1979 to 1999 in Taiwan. Basal cell carcinoma dominates the incidence trends, and the significant cohort effects give a warning of increasing risk of BCC in younger birth cohorts.

Adenocarcinoma, Sebaceous↗

Topical tacrolimus treatment of atopic eyelid disease.

PURPOSE: To describe the effects of topical tacrolimus treatment of severe atopic eyelid disease. DESIGN: Interventional consecutive case series. METHODS: A description of clinical findings and therapeutic response for five consecutive adult patients (mean age, 56.2 years; range 44-62) treated with topical tacrolimus for severe atopic eyelid disease at one institution. RESULTS: Five patients with bilateral atopic eyelid disease that was refractory to treatment with topical corticosteroids were treated with tacrolimus 0.03% ointment, applied to the affected eyelid skin of both eyes twice daily. Eyelid induration, erythema, and eczematous changes were substantially improved within 1 to 3 weeks after initiation of topical tacrolimus treatment in all patients. There was an associated decrease in ocular surface irritation and inflammatory signs in each of four patients who also had atopic keratoconjunctivitis. No adverse effect associated with tacrolimus treatment was noted during continued treatment for 5 to 14 months. All patients were able to discontinue longstanding use of topical corticosteroid drugs. CONCLUSIONS: Application of topical tacrolimus on eyelid skin may be effective for treatment of severe atopic dermatitis of the eyelids, and may have secondary benefits for atopic keratoconjunctivitis. Topical tacrolimus may be used for at least 1 year without apparent adverse reaction in some patients, although the rate of adverse reaction cannot be determined from this small series.

Administration, Topical↗

Eyelid abnormalities in lamellar ichthyoses.

PURPOSE: To describe eyelid abnormalities in lamellar ichthyoses (LI). DESIGN: Retrospective observational case series. PARTICIPANTS: Eight patients with classic LI and two patients with congenital ichthyosiform erythroderma. METHODS: Results of eyelid and corneal examinations of 10 patients with LI were reviewed and analyzed with emphasis on the relationship between eyelid ectropion and corneal damage. RESULTS: All patients presented with cicatricial lagophthalmos. Of the eight patients with classic LI, five had ectropion of the four eyelids, one had only lower ectropion, and two had no degree of ectropion. Two patients with congenital ichthyosiform erythroderma had distinct eyelid abnormalities, including madarosis and eyelash retraction. Loss of vision caused by corneal damage was found in three patients with classic LI. Of these three patients, two did not have upper eyelid ectropion. CONCLUSIONS: Severe corneal damage can occur in LI even if there is no upper or lower eyelid ectropion.

Adolescent↗

Lower eyelid medial canthal tendon laxity grading: an interobserver study of normal subjects.

OBJECTIVE: To describe a simple grading system for medial canthal tendon (MCT) laxity and measure its reproducibility. STUDY DESIGN: Observational case series and interobserver variability study. PARTICIPANTS: Fifty subjects (100 lower eyelids) without eyelid disease. The age range was 19 to 98 years. METHODS: Subjects without eyelid pathology or previous surgery were selected. Two ophthalmologists assessed the position of the inferior punctum in relation to the cornea with the patient in primary gaze. Two measurements were made, the first with the lower eyelid at rest and then with the lateral distraction test. Both observers were masked to the other observer's measurements. MAIN OUTCOME MEASURES: Kappa statistics to show the strength of agreement between the two observers for the resting and lateral distraction eyelid positions. RESULTS: High kappa values were found for resting position (agreement in 92 of 100 eyelids) and for lateral distraction testing (agreement in 85 of 100 eyelids). The range of resting positions was from position -1 to position 1. The range of laterally distracted positions was from position 0 to position 5. Overall, a very high level of agreement was achieved between observers. CONCLUSIONS: This grading system for MCT laxity is simple, easy to learn and reproducible, easier than measuring in millimeters, and has an advantage over merely saying the tendon is "lax" or "not lax." We propose this standardized grading system in the evaluation of patients with entropion and ectropion to identify those patients who may benefit from MCT stabilization/plication.

Adult↗

Minimally invasive lower eyelid blepharoplasty.

BACKGROUND: Transconjunctival lower eyelid blepharoplasty can significantly reduce the incidence of postoperative eyelid retraction and ectropion encountered with the traditional transcutaneous approach. These complications rarely are encountered because no scarring is induced at the level of the orbital septum and post-orbicularis facia. METHODS: A modification of the transconjunctival blepharoplasty procedure is described in which two small buttonhole incisions are used for fat removal. This procedure was performed in 148 eyelids. RESULTS: All patients had a subjective improvement of eyelid puffiness after the procedure. Lower eyelid retraction or ectropion did not develop in any of the patients. Two patients were concerned with residual eyelid puffiness and redundant eyelid skin. CONCLUSION: The primary advantages of the minimally invasive transconjunctival blepharoplasty are the ease in performing the procedure and the reduction of disruption of the conjunctival surface.

Adipose Tissue↗

The effect of phenylephrine on Müller muscle. A blepharogram study of eyelid motion.

PURPOSE: The blepharogram technique is used to study the effect of a drug on blinking. The authors show that ocular instillation of phenylephrine, a stimulant of Müller muscle of the eyelid, accelerates the up phase of the blink. METHODS: Motion of a tiny search coil glued to the eyelid moving in a weak magnetic field modifies an induced alternating current which is amplified and used to display the position of the upper eyelid in degrees on the ordinate of a graph with time in milliseconds on the abscissa. The graph is called a blepharogram. Blepharogram studies and individual blink analysis show the effect of phenylephrine on eyelid motion (blinking). RESULTS: Instillation of phenylephrine accelerated the up phase of the blink in all ten experimental subjects. In 65% of subjects, phenylephrine also produced or increased newly described N and M blepharogram patterns. CONCLUSION: This is the first instrumental detection of the effect of a pharmacologic agent on eyelid motion. The blepharogram technique provides insight into eyelid physiology and can be used to study any neuromuscular condition that affects eyelid motion.

Adult↗

[Prevention of amblyopia in acute eyelid closure--a new method for keeping the optical axis open by insertion of a small tube].

BACKGROUND: Complete eyelid closure by capillary eyelid hemangioma or ptosis in the first months of life is an indication for acute measures to prevent amblyopia. Since it is sometimes not possible to hold up the affected upper eyelids with adhesive tape (mechanical obstacle, danger of skin maceration in involvement of the forehead) or not sufficiently (intense divergence), an alternative method will be presented for emergency treatment of blockade of the optical axis. METHODS: The eyelids are kept open mechanically with a cylindrical tube of perspex (scleral immersion shell), which is normally used for echography of the anterior segment and for biometry (immersion technique). After surface anesthesia, it can be readily inserted. Its area of contact to the sclera has the form of a scleral shell. A drop of lubricant is applied into the tube at intervals of about five minutes. PATIENTS AND RESULTS: In a six-week-old girl with complete eyelid closure owing to a facial hemangioma, adequate eyelid opening could only be achieved by insertion of the scleral immersion shell. In an eleven-months-old boy with complete ptosis and divergence as well as vertical deviation, the optical axis could only be kept open by insertion of the scleral immersion shell and by simultaneous displacement to the temporal side (adhesive tape). The uncomplicated performance for up to two hours daily was initially carried out in the hospital and later by the parents, and could be terminated after five and three and a half weeks, respectively, thanks to improvement due to therapy or spontaneous improvement. CONCLUSIONS: Mechanical eyelid opening by insertion of a scleral immersion shell serves to bridge over the time interval to the onset of spontaneous improvement or the success of a causal therapy. The advantages consist in the good handling, also for parents, the low danger of injury and the ubiquitous and rapid availability (basic equipment of an ophthalmological ultrasonography unit).

Amblyopia↗

Modified temporalis muscle transfer for paralytic eyelids.

The major problems in paralytic eyelids are the inability to close the eye, lower lid sagging, and epiphora. The upper eyelid is responsible for most of the opening and closing of the eye, whereas a lower eyelid positioned properly against the globe is necessary for collection and flow of the tear fluid. Modification of temporalis muscle transfer, a classic technique, was planned to restore these functions selectively in paralytic eyelids. Twelve unilateral and one bilateral irreversible facial paralysis patients with different degrees of lagophthalmos and ectropion were included. Twice as much muscle mass (in thickness) to the upper eyelid than the lower was taken and passed submuscularly 5 to 6 mm away from the limbus for stronger motion of the upper eyelid, and a thinner muscle mass was passed subcutaneously beneath the lower cilia for longevity of the correction of ectropion and epiphora. Fixation of these strips was performed to the medial canthal ligament and 3 to 4 mm above it. The average duration of follow-up was 35.5 months. Excellent eyelid closure and correction of ectropion and epiphora were achieved with one procedure in all patients without creating a cosmetic deformity.

Adolescent↗

Histopathologic changes of the eyelid skin following trichloroacetic acid chemical peel.

The use of trichloroacetic acid (TCA) as a periorbital and eyelid peel for skin rejuvenation is gaining significant acceptance among oculoplastic surgeons, dermatologists, and other surgery groups. In spite of the current enthusiasm, there remain potentially serious complications resulting from any periorbital peel. Cases of cicatricial ectropion have been reported in phenol-peeled patients, and lower eyelid ectropion has reportedly occurred in patients undergoing deep eyelid peel in conjunction with a blepharoplasty (1,2). To avoid this complication, it is necessary to better understand the depth of the wound produced by different strengths and combinations of peeling agents applied to living eyelid tissue and, more important, to determine the concentrations of TCA that are likely to lead to cicatricial ectropion when applied in a consistent fashion. We chose upper-eyelid skin because it is easier to obtain for histopathologic study than lower-eyelid skin and, in our experience, is more sensitive to hypertrophic changes after chemical peeling or carbon dioxide laser resurfacing. We applied TCA to the preseptal skin of 10 patients 48 h before standard upper-eyelid blepharoplasty. The acid was applied to produce a "frost," using varying concentrations of acid, ranging from 20 to 50%. The treated skin removed at the time of blepharoplasty was reviewed in a masked fashion by a dermatopathologist to determine the depth of necrosis. We found that superficial peels with necrosis involving 30% of the epidermis were produced by the lowest-concentration combination of TCA applied (20% followed by 0%). As the strength increased, so did the depth of peel. The combination of 50% followed by a second application of 50% produced the deepest peel, with necrosis into the papillary dermis. This finding would indicate that the chance of developing cicatricial ectropion with any of the tested combinations of TCA should be very remote.

Administration, Topical↗

The effect of upper blepharoplasty on eyelid position when performed concomitantly with Müller muscle-conjunctival resection.

PURPOSE: To determine the effect on eyelid elevation of excising excess skin, orbicularis oculi muscle, and herniated orbital fat and reconstructing the upper eyelid crease (blepharoplasty) concomitant with a Müller muscle-conjunctival resection. METHODS: The charts of 202 patients who had undergone Müller muscle-conjunctival resection during an 8-year interval were reviewed. Three hundred forty-five eyelids were divided into two groups. Group 1 (n = 162) underwent a Müller muscle-conjunctival resection only, and group 2 (n = 183) had this procedure combined with excision of skin, orbicularis muscle, and herniated orbital fat with upper eyelid crease reconstruction. Each group was divided into three subgroups based on the amount of Müller muscle-conjunctival resection. Subgroup A had resection less than 7.75 mm; subgroup B, resection of 7.75 to 8.75 mm; and subgroup C, resection greater than 8.75 mm. The change in margin reflex distance-1 (MRD1) measurements of the upper eyelid levels (postoperative MRD1 minus preoperative MRD1) were calculated and compared between groups. RESULTS: The mean (+/- standard deviation) change in MRD1 was, respectively, 2.3 +/-1.0 mm and 1.9+/-1.0 mm for groups 1A and 2A; 3.1+/-1.3 mm and 2.1+/-1.2 mm for groups 1B and 2B; and 3.4+/-1.2 mm and 2.8+/-1.3 for groups 1C and 2C. CONCLUSIONS: Blepharoplasty performed concomitant with a Müller muscle-conjunctival resection reduced the anticipated postoperative eyelid elevation by as much as 1 mm. Surgeons who perform these procedures together should be aware that a larger Müller muscle-conjunctival resection may be required to obtain the desired increase in eyelid height postoperatively.

Blepharoplasty↗

Supernumerary orbital muscle in congenital eyelid retraction.

PURPOSE: Although several reports of supernumerary orbital muscles related to the levator palpebrae superioris have been published, no case has been associated with congenital eyelid retraction. This report describes an apparent causal relationship between an accessory levator muscle slip and congenital eyelid retraction. METHODS: Case report and literature review. RESULTS: Release of the anomalous muscle's attachment from the superior tarsal border alone resulted in resolution of the eyelid retraction. CONCLUSIONS: Eyelid muscle anomalies may be a cause of congenital eyelid retraction. Ophthalmologists who treat eyelid disorders should be aware of this possibility when evaluating and operating on patients with congenital eyelid retraction.

Child, Preschool↗

Congenital upper eyelid coloboma and cryptophthalmos.

PURPOSE: To discuss the relation between congenital upper eyelid coloboma and cryptophthalmos and to present a new grading for both conditions. METHODS: Observational case series study. Twenty-six children (age range, one day after birth to 15 years old) were included in the study: 19 with upper eyelid coloboma, 4 with classic cryptophthalmos, and 3 with both eyelid coloboma and cryptophthalmos. RESULTS: Of the 19 cases of upper eyelid coloboma, 5 occurred in isolation, 11 were associated with facial deformities, and 3 were part of a first arch syndrome (according to the Mustardé classification). All cases of classic cryptophthalmos were sporadic and nonsyndromic. All patients with coloboma with facial deformities, cryptophthalmos, and both eyelid coloboma and cryptophthalmos had similar associated facial abnormalities. CONCLUSION: Upper eyelid colobomas with facial deformities and cryptophthalmos can be considered as one anomaly. A new grading for this anomaly has been suggested. Grade 1: Coloboma without cryptophthalmos. Grade 2: Coloboma with abortive cryptophthalmos. Grade 3: Coloboma with complete cryptophthalmos. Grade 4: Classic cryptophthalmos (absence of all eyelid structures and the eye is completely covered with skin). Grade 5: Severe cryptophthalmos (with severe deformity of the nose and ectropion of the upper lip).

Adolescent↗