Evaluation of ocular psoriasis with meibography

Abstract Background: Previous studies has shown that dry eye test abnormalities, meibomian gland dysfunction (MGD), may occur in psoriasis. Objectives: The authors aimed to evaluate the dry eye disease (DED), MGD, in psoriasis patients with meibography which is a current, objective, noninvasive method for patients with meibomian gland diseases, to investigate the relationship between disease severity and ocular involvement. Methods: This study included 50 participants with psoriasis and 50 healthy individuals. All subjects were examined by the same dermatologist and referred for ophthalmological examination including meibomian gland obstruction, lid margin alterations assessment, ocular surface disease index assessment, tear film break-up time test, Schirmer test, corneal conjunctival fluorescein staining assessment. Additionally, upper and lower lids were evaluated for meibomian gland loss with meibography. Results: MGD (28%), meibomian gland loss (MGL) (29.5%), upper meiboscore (0.61 ± 0.81), lower meiboscore (0.46 ± 0.61), DED (22%) were significantly higher in the psoriasis group compared with the control group (p = 0.008, p < 0.001, p = 0.027, p = 0.041, p = 0.044, respectively). There was a significant relationship between MGD and psoriasis area severity index (PASI) (p = 0.015, Odds Ratio = 1.211). There was a significant positive relationship between MGL with PASI (p < 0.001, r = 608) and psoriasis duration (p < 0.001, r = 0.547). Study limitations: Smaller study group and inability to detect quality changes of meibum with meibography were limitations of the study. Conclusions: Psoriasis may affect the meibomian gland morphology, may cause structural changes in meibomian glands, and as a result of these may cause MGD and DED. Therefore, ophthalmologists and dermatologists should be aware of this situation and co-evaluate the patients in this respect.

Intra- and interobserver reliability of a modified distraction test based on digital images to assess lower eyelid horizontal tension / Confiabilidade intra e interobservador do teste de tração modificado para avaliar a tensão da pálpebra inferior baseado em imagens digitais

ABSTRACT Purpose: Inferior eyelid laxity is classically evaluated using "snap-back" and "distraction" tests. This study aimed to assess the reproducibility of the technique used to indirectly quantify the horizontal tension in the lower eyelids using digital image processing. Methods: This longitudinal study was conducted to assess the reproducibility of a new technique that quantifies the horizontal tension in the lower eyelid. The study was conducted at the Hospital das Clínicas of Porto Alegre. The protocol was established by two trained ophthalmologist examiners, allowing intra- and interobserver agreement analyses. Image acquisition was done in two stages: the first image was captured with the eyelid in primary gaze position and the second with the eyelid in traction position. All images and measurements were processed using Image J 1.33m software from the National Institute of Health. The Bland-Altman method, intraclass correlation coefficients, concordance correlation coefficients, and technical measurement error were used to evaluate reproducibility. Results: The study participants comprised healthy individuals with no ophthalmologic pathologies. The measurements obtained in the neutral position showed a slightly higher agreement than those obtained in the traction position. The mean difference between the measurements performed in the traction position was 0.028 ± 0.7 mm and 0.014 ± 0.9 mm in the intra- and interobserver analyses, respectively. The Bland-Altman method demonstrated adequate confidence limits for both measurements. Correlation coefficients for measurements varied between 0.87 [95% confidence interval (CI) 0.68-0.95] and 0.91 (95% CI 0.77-0.97) in the neutral position and between 0.72 (95% CI 0.37-0.89) and 0.76 (95% CI 0.4-0.91) in the traction position. Conclusion: A high intra- and interobserver concordance was observed in the studied method to quantify lower eyelid tension. The proposed method is simple and easily reproducible, and to the best our knowledge, this is the first method that quantifies lower eyelid horizontal tension on the basis of digital image processing. This modified distraction test might be useful in studies quantifying lower eyelid horizontal tension.

RESUMO Objetivo: A frouxidão palpebral inferior é avaliada classicamente por meio de testes de "snap-back" e "distraction test". O objetivo deste estudo foi avaliar a reprodutibilidade da técnica utilizada para quantificar indiretamente a tensão horizontal nas pálpebras inferiores através do processamento digital de imagens. Métodos: Este estudo longitudinal foi realizado para avaliar a reprodutibilidade de uma nova técnica que quantifica a tensão horizontal na pálpebra inferior. O estudo foi realizado no Hospital das Clínicas de Porto Alegre. O protocolo foi estabelecido por dois examinadores oftalmologistas treinados, permitindo análises de concordância intra e interavaliador. A aquisição de imagens foi feita em duas etapas: a primeira imagem foi capturada com a pálpebra na posição primária do olhar e a segunda com pálpebra tracionada. Todas as imagens e medições foram processadas usando o software Image J 1.33m do National Institute of Health. O método de Bland-Altman, os coeficientes de correlação intraclasses, os coeficientes de correlação de concordância e o erro técnico da medida foram utilizados para avaliar a reprodutibilidade. Resultados: Os participantes do estudo foram indivíduos saudáveis e sem patologias oftalmológicas. As medidas obtidas na posição neutra mostraram concordância levemente maior do que as obtidas na posição tracionada. A diferença média entre as medidas realizadas na posição tracionada foi de 0,028 ± 0,7mm e 0,014 ± 0,9mm nas análises intra e interobservadores, respectivamente. O método de Bland-Altman demonstrou limites de confiança adequados para ambas as medidas. Os coeficientes de correlação para as medidas variaram entre 0,87 [intervalo de confiança de 95% (IC) 0,68-0,95) e 0,91 (IC 95% 0,77-0,97) na posição neutra e entre 0,72 (IC 95% 0,37-0,89) e 0,76 (IC 95% 0,46-0,91) na posição tracionada. Conclusão: Observou-se elevada concordância intra e interobservador no método estudado para quantificar a tensão palpebral inferior. O método proposto é simples e facilmente reproduzível, e, do melhor modo possível, este é o primeiro método que quantifica a tensão horizontal da pálpebra inferior com base no processamento digital de imagens. Este teste de distração modificado pode ser útil em estudos que quantifiquem a tensão horizontal da pálpebra inferior.

Isolated primary amyloidosis of the inferior rectus muscle mimicking Graves’ orbitopathy / Amiloidose primária isolada do músculo reto inferior simulando orbitopatia de Graves

ABSTRACT The diagnosis of Graves’ orbitopathy is usually straightforward. However, orbital diseases that mimick some clinical signs of Graves’ orbitopathy may cause diagnostic confusion, particularly when associated to some form of thyroid dysfunction. This report describes the rare occurrence of localized inferior rectus muscle amyloidosis in a patient with autoimmune hypothyroidism, who was misdiagnosed as Graves’ orbitopathy. A 48-year-old man complained of painless progressive proptosis on the left side and intermittent vertical diplopia for 6 months. The diagnosis of Graves’ orbitopathy was entertained after magnetic resonance imaging revealing a markedly enlarged, tendon-sparing inferior rectus enlargement on the left side, and an autoimmune hypothyroidism was disclosed on systemic medical workup. After no clinical improvement with treatment, the patient was referred to an ophthalmologist and further investigation was performed. The presence of calcification in the inferior rectus muscle on computed tomography, associated with the clinical findings led to a diagnostic biopsy, which revealed amyloid deposition. This report emphasizes that a careful evaluation of atypical forms of Graves’ orbitopathy may be crucial and should include, yet with rare occurrence, amyloidosis in its differential diagnosis.

RESUMO O diagnóstico de orbitopatia de Graves usualmente é fácil de ser estabelecido. No entanto, doenças da órbita que simulam alguns sinais clínicos da orbitopatia de Graves podem levar à confusão diagnóstica, particularmente quando associada à alguma forma de disfunção tireoidiana. Relatamos a ocorrência rara de amiloidose localizada no músculo reto inferior em paciente com hipotireoidismo autoimune, que recebeu inicialmente o diagnóstico errôneo de orbitopatia de Graves. Paciente masculino, 48 anos, com queixa de proptose progressiva e indolor do lado esquerdo e diplopia vertical intermitente há 6 meses. O diagnóstico de orbitopatia de Graves foi considerado após a realização de ressonância magnética, que revelou aumento importante do músculo reto inferior esquerdo, sem acometimento do tendão, e uma propedêutica sistêmica detectou hipotireoidismo autoimune. Como não houve melhora com o tratamento clínico, o paciente foi encaminhado a um oftalmologista, que realizou nova investigação. A presença de calcificação no músculo reto inferior na tomografia computadorizada, associada aos achados clínicos, levou a uma biópsia da lesão, que demonstrou a deposição de material amiloide. Este relato enfatiza como uma avaliação minuciosa das formas atípicas de orbitopatia de Graves é essencial e deve incluir a ocorrência, embora rara, de amiloidose no diagnóstico diferencial da orbitopatia de Graves.

Periorbital Lipogranuloma after Facial Autologous Fat Injection and Its Treatment Outcomes

PURPOSE: To investigate periorbital lipogranuloma cases that developed after autologous fat injection and to determine various treatment outcomes from these cases. METHODS: This retrospective study involved 27 patients who presented with periocular mass (final diagnosis of lipogranuloma) and had history of facial autologous fat injection. The collected data included information on patient sex, age, clinical presentation, number and site of fat injections, interval between injections, duration from injection to symptom onset, fat harvesting site, use of cryopreservation, and treatment outcome. RESULTS: The most common presenting symptom was palpable mass (92.6%), followed by blepharoptosis and eyelid edema. The mean time from injection to symptom onset was 13.6 +/- 29.2 months (range, 2 to 153 months). Patients were managed by intralesional triamcinolone injection (six patients) and surgical excision (three patients); 18 patients were followed without treatment. Among the six patients who underwent intralesional triamcinolone injection, five showed complete resolution, and one showed partial resolution. Among the 18 patients who were followed without management, three showed spontaneous resolution over a 5-month follow-up period. CONCLUSIONS: Lipogranuloma can develop in the eyelid after autologous fat injection into the face. Both surgical excision and intralesional triamcinolone injection yield relatively good outcomes. Simple observation can be a good option because spontaneous resolution can occur in a subset of patients.