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.

Addressing Disparities in Acute Stroke Management and Prognosis.

There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.

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.

Rundle's Curve: A Useful Construct That Does Not Fit All.

PURPOSE: The purpose of this study was to analyze Rundle's original data and subsequent articles on Graves orbitopathy (GO) natural history. METHODS: Rundle's texts were analyzed qualitatively and quantitatively. Serial measurements were plotted and fitted with different functions. Subsequent articles in the English literature on the natural history of GO were also analyzed. RESULTS: Different functions such as simple linear regressions, parabolic, saturating exponential growth, and exponential decay functions were well fitted for Rundle's data on measurements of proptosis and supraduction along time. The few quantitative data of the same variables post-Rundle were also well-fitted with various functions. CONCLUSION: Rundle described in his articles, from 1945 to 1957, 2 phases of ocular changes in GO: dynamic and static. However, he did not mention the pathophysiology of these phases nor used the terms inflammatory and cicatricial. Actually, most of his observations and the subsequent data in the literature on proptosis and supraduction did not obey the biphasic pattern of the so-called Rundle's curve.

Revisiting the orbital complications of acute rhinosinusitis

Abstract Objective: The present study revisited three classification systems of orbital complications of acute rhinosinusitis (ARS) (Chandler, Mortimore & Wormald, and Velasco e Cruz & Anselmo-Lima) and observed which of them presented the best clinical applicability. Methods: Clinical data and CT scan findings of patients with orbital infection were retrospectively collected. To compare the three classification systems, we revised and graded all CT images accordingly, and divided the patients into four groups: Eyelid cellulitis (EC), orbital cellulitis (OC), subperiosteal abscess (SA), and orbital abscess (OA). The groups were compared regarding the presence of sinus opacification, the need for hospitalization and/or surgical treatment, and the presence of further complications/sequelae. Results: 143 patients were included. The median number of sinuses involved in patients in the OC, SA, and OA groups was 2.0. ARS was rarely associated with signs of EC (present in both Chandler's and Mortimore & Wormald's classifications. The hospitalization rate was significantly lower in the EC group compared to the other three groups. Surgery was performed in all cases in the OA group, in 58.1% in the SA group, 19.4% in the OC group, and 12.5% in the EC group (p-value < 0.0001 ). Complications were present at higher rates in the OA group compared to the other three groups. Conclusions: ARS was rarely associated with Eyelid Cellulitis. The stratification in the other three groups showed to be clinically relevant. Velasco e Cruz & Anselmo-Lima's classification system proved valid, simple, and effective for categorizing orbital complications of ARS. Level of evidence: 3.

Revisiting the orbital complications of acute rhinosinusitis.

OBJECTIVE: The present study revisited three classification systems of orbital complications of acute rhinosinusitis (ARS) (Chandler, Mortimore & Wormald, and Velasco e Cruz & Anselmo-Lima) and observed which of them presented the best clinical applicability. METHODS: Clinical data and CT scan findings of patients with orbital infection were retrospectively collected. To compare the three classification systems, we revised and graded all CT images accordingly, and divided the patients into four groups: Eyelid cellulitis (EC), orbital cellulitis (OC), subperiosteal abscess (SA), and orbital abscess (OA). The groups were compared regarding the presence of sinus opacification, the need for hospitalization and/or surgical treatment, and the presence of further complications/sequelae. RESULTS: 143 patients were included. The median number of sinuses involved in patients in the OC, SA, and OA groups was 2.0. ARS was rarely associated with signs of EC (present in both Chandler's and Mortimore & Wormald's classifications. The hospitalization rate was significantly lower in the EC group compared to the other three groups. Surgery was performed in all cases in the OA group, in 58.1% in the SA group, 19.4% in the OC group, and 12.5% in the EC group (p-value < 0.0001). Complications were present at higher rates in the OA group compared to the other three groups. CONCLUSIONS: ARS was rarely associated with Eyelid Cellulitis. The stratification in the other three groups showed to be clinically relevant. Velasco e Cruz & Anselmo-Lima's classification system proved valid, simple, and effective for categorizing orbital complications of ARS.

The effect of rim-off deep lateral orbital decompression on the lateral rectus shape and oculomotor balance.

PURPOSE: The purpose of the study was to measure the effect of rim-off deep lateral decompression for Graves orbitopathy on the lateral rectus muscle path and oculomotor balance. METHODS: Retrospective analysis of the medical records and pre- and postoperative computed tomography scans of 34 orbits of 23 patients who underwent deep lateral decompression alone. The oculomotor balance of these 23 patients was measured with the alternate cover test and prisms before and after surgery. Bezier functions were used to measure the postoperative path of the lateral rectus in all decompressed orbits. RESULTS: Deep lateral decompression induced a curvilinear deformation of the lateral rectus. There was no significant correlation between the position of the point of maximum muscle displacement and the size of the residual lateral wall. The changes in the lateral rectus path had no adverse effects on the oculomotor balance of the patients. CONCLUSIONS: The location of the curvilinear deformation of the lateral rectus does not depend on the residual segment of the lateral wall. The changes of the lateral rectus path have no deleterious effect on the oculomotor balance.

Blinking Parameters Do Not Normalize After Botulinum Toxin Therapy in Blepharospasm and Hemifacial Spasm Patients.

BACKGROUND: Little is known regarding changes induced by botulinum toxin injections on blinking parameters in blepharospasm (BSP) and hemifacial spasm (HFS) patients. The purpose of this study was to investigate objective changes induced by botulinum toxin (BoNT) injections on blinking parameters in BSP and HFS patients. METHODS: Thirty-seven patients with BSP and HFS were evaluated before and 30 days after receiving onabotulinumtoxinA injections. Twelve age-matched control subjects were also assessed. Pretreatment and post-treatment parameters were assessed and compared with normal controls. A high-speed camera and microlight-emitting diodes were used to register the blinking in patients and control groups. Outcomes were blinking frequency, amplitude, and maximum velocity of eyelid closure. RESULTS: BoNT injections led to a significant reduction in all parameters, compared with baseline, in BSP and on the affected side in HFS, respectively: 22% ( P < 0.001) and 20% ( P = 0.015) in amplitude; 21% ( P = 0.04) and 39% in frequency ( P = 0.002); and 41% ( P < 0.001) and 26% ( P = 0.005) in maximum closing velocity. Blinking amplitude ( P = 0.017 and P = 0.019) and velocity ( P < 0.001 for both groups) were significantly lower at 30 days on BSP and on the affected HFS side, when compared with controls. BSP and HFS patients presented a significantly lower velocity of eyelid closure, even before BoNT, compared with controls ( P = 0.004. and P < 0.001, respectively). CONCLUSIONS: Although blinking frequency became close to normal, amplitude and velocity after BoNT applications were significantly lower in BSP and on the affected side of HFS patients when compared with age-matched normal controls, demonstrating that blinking parameters do not normalize after treatment. The velocity of eyelid closure was shown to be significantly lower, even before BoNT treatment, when compared with control subjects.

Investigation of chemical partitioning of 7Be, 210Pb and 137Cs and novel dating of road sediment by 210Po:210Pb disequilibrium method.

A suite of road sediment and soil samples from a post-industrial city (Detroit, MI) were collected and analyzed for atmospherically-delivered 210Pb, 210Po, 7Be along with 226Ra and 137Cs in the bulk and size-fractionated solid samples. From the measured atmospheric depositional fluxes of 7Be, 210Po, and 210Pb, the initial 210Po/210Pb activity ratio was quantified. In all samples, there is disequilibrium between 210Po and 210Pb, with a 210Po/210Pb activity ratio (AR) of <1.0, which is reported for the first time. Using the measured 210Po/210Pb AR, the average 'apparent age' of road sediment was found to be 146 ± 62 days. Using numerical modeling, it is predicted that the (210Po/210Pb) excess activity ratio will reach a 'dynamic equilibrium' value of ~0.59 over a period of >1 year. Results from a subset of samples that were sequentially extracted for exchangeable, carbonate, Fe-Mn oxide, organic and residual phases indicate the Fe-Mn oxide fraction was found to contain the largest fraction of 7Be and 210Pb; however, the largest fraction of 210Pb was associated with the residual phase and is attributed to complexation of 210Pb with recalcitrant organic matter. This study shows that the natural tagging of 7Be and 210Po-210Pb pair via precipitation provides insights on the time scale of their mobility and adds a new dimension of time information on the pollutant-laden road sediment.

New, fast, and precise method of COVID-19 detection in nasopharyngeal and tracheal aspirate samples combining optical spectroscopy and machine learning.

Fast, precise, and low-cost diagnostic testing to identify persons infected with SARS-CoV-2 virus is pivotal to control the global pandemic of COVID-19 that began in late 2019. The gold standard method of diagnostic recommended is the RT-qPCR test. However, this method is not universally available, and is time-consuming and requires specialized personnel, as well as sophisticated laboratories. Currently, machine learning is a useful predictive tool for biomedical applications, being able to classify data from diverse nature. Relying on the artificial intelligence learning process, spectroscopic data from nasopharyngeal swab and tracheal aspirate samples can be used to leverage characteristic patterns and nuances in healthy and infected body fluids, which allows to identify infection regardless of symptoms or any other clinical or laboratorial tests. Hence, when new measurements are performed on samples of unknown status and the corresponding data is submitted to such an algorithm, it will be possible to predict whether the source individual is infected or not. This work presents a new methodology for rapid and precise label-free diagnosing of SARS-CoV-2 infection in clinical samples, which combines spectroscopic data acquisition and analysis via artificial intelligence algorithms. Our results show an accuracy of 85% for detection of SARS-CoV-2 in nasopharyngeal swab samples collected from asymptomatic patients or with mild symptoms, as well as an accuracy of 97% in tracheal aspirate samples collected from critically ill COVID-19 patients under mechanical ventilation. Moreover, the acquisition and processing of the information is fast, simple, and cheaper than traditional approaches, suggesting this methodology as a promising tool for biomedical diagnosis vis-à-vis the emerging and re-emerging viral SARS-CoV-2 variant threats in the future.

Medial Oblique Eyelid Split Orbitotomy.

PURPOSE: The authors describe their experience with a variant of the split orbitotomy with a small medial oblique transmarginal incision for approaching a variety of lesions involving the superonasal aspect of the orbit. METHODS: Retrospective review of medical records and clinical photographs of all patients who underwent an unilateral medial oblique incision to access various intraconal lesions abutting the superomedial quadrant of the orbit. The curvature of the medial contour of the operated and contralateral eyelids were expressed with Bézier functions and compared using the R-squared coefficient of determination (R 2 ). RESULTS: Twenty-three patients were submitted to this surgical technique for approaching various unilateral lesions on the superonasal quadrant of the orbit. Excellent cosmesis was achieved in all eyelids, with almost imperceptible scars, and no ptosis or retraction. There was no significant difference between the postoperative medial contour of the operated and the contralateral eyelid, with R 2 ranging from 0.896 to 0.999, mean 0.971. CONCLUSIONS: The authors' results show that the modified eyelid split approach provides a wide exposure of the superonasal quadrant of the orbit with no risk of eyelid dysfunctions or significant scars.

New, fast, and precise method of COVID-19 detection in nasopharyngeal and tracheal aspirate samples combining optical spectroscopy and machine learning

Fast, precise, and low-cost diagnostic testing to identify persons infected with SARS- CoV-2 virus is pivotal to control the global pandemic of COVID-19 that began in late 2019. The gold standard method of diagnostic recommended is the RT-qPCR test. However, this method is not universally available, and is time-consuming and requires specialized personnel, as well as sophisticated laboratories. Currently, machine learning is a useful predictive tool for biomedical applications, being able to classify data from diverse nature. Relying on the artificial intelligence learning process, spectroscopic data from nasopharyngeal swab and tracheal aspirate samples can be used to leverage characteristic patterns and nuances in healthy and infected body fluids, which allows to identify infection regardless of symptoms or any other clinical or laboratorial tests. Hence, when new measurements are performed on samples of unknown status and the corresponding data is submitted to such an algorithm, it will be possible to predict whether the source individual is infected or not. This work presents a new methodology for rapid and precise label-free diagnosing of SARS-CoV-2 infection in clinical samples, which combines spectroscopic data acquisition and analysis via artificial intelligence algorithms. Our results show an accuracy of 85% for detection of SARS-CoV-2 in nasopharyngeal swab samples collected from asymptomatic patients or with mild symptoms, as well as an accuracy of 97% in tracheal aspirate samples collected from critically ill COVID-19 patients under mechanical ventilation. Moreover, the acquisition and processing of the information is fast, simple, and cheaper than traditional approaches, suggesting this methodology as a promising tool for biomedical diagnosis vis-a-vis the emerging and re-emerging viral SARS-CoV-2 variant threats in the future.

Bivalves maintain repair when faced with chronically repeated mechanical stress.

Even though mollusks' capacity to repair shell damage is usually studied in response to a single event, their shells have to defend them against predatory and environmental threats throughout their potentially multi-decadal life. We measured whether and how mollusks respond to chronic mechanical stress. Once a week for 7 months, we compressed whole live California mussels (Mytilus californianus) for 15 cycles at ∼55% of their predicted one-time breaking force, a treatment known to cause fatigue damage in shells. We found mussels repaired their shells. Shells of experimentally stressed mussels were just as strong at the end of the experiment as those of control mussels that had not been experimentally loaded, and they were more heavily patched internally. Additionally, stressed shells differed in morphology; they were heavier and thicker at the end of the experiment than control shells but they had increased less in width, resulting in a flatter, less domed shape. Finally, the chronic mechanical stress and repair came at a cost, with stressed mussels having higher mortality and less soft tissue than the control group. Although associated with significant cost, mussels' ability to maintain repair in response to ongoing mechanical stress may be vital to their survival in harsh and predator-filled environments.

Healthcare Worker With Large Vessel Acute Ischemic Stroke Likely Related to Mild SARS-CoV-2 Infection.

We report the case of a healthcare worker who presented with a large vessel acute ischemic stroke in setting of a mild SARS-CoV-2 infection and provide a review of the emerging literature on COVID-related stroke. A 43-year-old female presented with right-sided hemiparesis, aphasia and dysarthria. She had a nonproductive of cough for 1 week without fever, fatigue or dyspnea. A CT Head, CT angiography and CT perfusion imaging revealed a M1 segment occlusion of the left middle cerebral artery requiring transfer from a primary to a comprehensive stroke center. A nasopharyngeal swab confirmed SARS-CoV-2 infection prior to arrival at the accepting center. During the thrombectomy a 3 cm thrombus was removed. Thrombus was also evident in the 8 French short sheath during closure device placement so a hypercoagulable state was suspected. Stroke work-up revealed a glycosylated hemoglobin of 8.7%, elevation of inflammatory markers and an indeterminate level of lupus anticoagulant IgM. On discharge home, she had near complete neurological recovery. This case highlights suspected mechanisms of hypercoagulability in SARS-CoV-2 infection and the importance of optimizing stroke care systems during the COVID-19 pandemic.

Upper Eyelid Contour Changes After Orbital Decompression in Graves Orbitopathy.

PURPOSE: To evaluate the effect of orbital decompression on the upper eyelid contour. METHODS: A paired cross-sectional analysis of the upper eyelid contour was performed for 103 eyes of 66 patients who underwent orbital decompression. A control group of 26 normal subjects was also included. The eyelid contour of all participants were measured with Bézier lines adjusted to the eyelid contour and 9 midpupil eyelid margin (MPD) distances from a horizontal line bisecting the pupil. One central, corresponding to the margin reflex distance (MRD 1), and 8 equally distributed medially and laterally at 20% of the interval between the lines. Patients were classified as with flare if the height of the most lateral MPD relative to the MRD 1 was above the upper limit of the controls. RESULTS: Preoperatively 63 of the 103 contours were classified as flare + (F+). After decompression MRD1 showed a mean decrease of 0.4 mm and the location of the contour shifted 0.8 mm medially. These changes were not correlated with proptosis reduction. Orbital decompression decreased the lateral curvature of the contours especially for the F+ lids. In 40% of the F+ eyelids the flare sign disappeared after decompression. CONCLUSIONS: Orbital decompression affects the lateral eyelid contour and diminishes the amount of lateral eyelid retraction surgery necessary to correct the flare sign. In 40% of the patients, the eyelid contour is normalized with proptosis reduction only.

Biological Activity of Sacha Inchi (Plukenetia volubilis Linneo) and Potential Uses in Human Health: A Review.

Sacha inchi (Plukenetia volubilis Linneo) is an ancestral plant originating in the Amazon jungle that has been adopted as a food source due to its high nutritional value, which has gradually been recognized to have potential benefits for human health. Diverse prospective studies have evaluated the effect of consuming components from the plant, derivatives from its seeds, leaves and shell on preventing the risk of cardiovascular disease, chronic inflammatory disease, dermatitis and controlling tumor proliferation, especially given its recognized high content of essential fatty acids, phenolic compounds and vitamin E, showing antioxidant, hypolipidemic, immunomodulation and emollient activity, as well as the capacity to remove heavy metals from aqueous solutions. This review offers a complete description of the existing information on the use and biological activity of P. volubilis L., based on its essential lipid components and evidenced on its use in the field of human health, in prevention, therapeutic and nutritional contexts, along with industrial uses, making it a promising bioresource.

Bivalves rapidly repair shells damaged by fatigue and bolster strength.

Hard external armors have to defend against a lifetime of threats yet are traditionally understood by their ability to withstand a single attack. Survival of bivalve mollusks thus can depend on the ability to repair shell damage between encounters. We studied the capacity for repair in the intertidal mussel Mytilus californianus by compressing live mussels for 15 cycles at ∼79% of their predicted strength (critically fracturing 46% of shells), then allowing the survivors 0, 1, 2 or 4 weeks to repair. Immediately after fatigue loading, mussel shells were 20% weaker than control shells that had not experienced repetitive loading. However, mussels restored full shell strength within 1 week, and after 4 weeks shells that had experienced greater fatiguing forces were stronger than those repetitively loaded at lower forces. Microscopy supported the hypothesis that crack propagation is a mechanism of fatigue-caused weakening. However, the mechanism of repair was only partially explained, as epifluorescence microscopy of calcein staining for shell deposition showed that only half of the mussels that experienced repetitive loading had initiated direct repair via shell growth around fractures. Our findings document repair weeks to months faster than demonstrated in other mollusks. This rapid repair may be important for the mussels' success contending with predatory and environmental threats in the harsh environment of wave-swept rocky coasts, allowing them to address non-critical but weakening damage and to initiate plastic changes to shell strength. We highlight the significant insight gained by studying biological armors not as static structures but, instead, as dynamic systems that accumulate, repair and respond to damage.

Clinical manifestations and visual outcomes associated with ocular toxoplasmosis in a Brazilian population.

Ocular toxoplasmosis is the leading cause of posterior uveitis worldwide. We conducted an observational study of 262 consecutive individuals (n = 344 eyes) with ocular toxoplasmosis who were followed over a 34-month period. Most subjects were T. gondii IgG + /IgM- (n = 242; 92.4%; 317 eyes), and 140 eyes (40.7%) had active lesions. For eyes in which retinal lesions were active at recruitment and best-corrected visual acuity (BCVA) could be measured (n = 133), 21.0% (n = 28) remained blind (BCVA below 20/400) after inflammation resolved. In these eyes, atypical ocular toxoplasmosis (OR 4.99; 95% CI 1.14-22.85; p = 0.0330), macular lesion (OR 9.95; 95% CI 2.45-47.15; p = 0.0019) and any complication (OR 10.26; 95% CI 3.82-30.67; p < 0.0001) were associated with BCVA below 20/200. For eyes with only inactive lesions at recruitment and BCVA measured (n = 178), 28.1% (n = 50) were blind. In these eyes, having at least one lesion larger than one disc-diameter (OR 6.30; 95% CI 2.28-22.46; p = 0.0013) and macular lesion (OR 5.69; 95% CI 2.53-13.54; p < 0.0001) were associated with BCVA below 20/200. Older age (OR 1.02; 95% CI 1.00-1.05; p = 0.0493) and active disease at presentation (OR 4.74; 95% CI 1.95-12.91; p = 0.0011) were associated with recurrences. Additional clinical attention should be directed towards patients with risk factors for poor visual outcome.

Lid Flare Measurement with Lateral Midpupil Distances.

PURPOSE: To assess the sensitivity and specificity of lateral midpupil lid distances for the detection of upper lid lateral flare. METHODS: Lateral lid flare was determined by unanimous agreement among six experienced oculoplastic surgeons in the grading of photographs obtained for patients with Graves orbitopathy (GO). Bézier lines were employed to extract the upper eyelid contours of the patients and a control group of age and sex matched subjects. Custom software was employed to determine 5 lateral midpupil eyelid distances. The sensitivity and specificity of each measurement in detecting lateral flare were estimated from receiver operating characteristic curves. The non-parametric Kruskal-Wallis one-way analysis of variance (ANOVA) with Dunn's posthoc test was used to compare the median values of the contour parameters between groups. RESULTS: The degree of agreement between judges evaluated with the Fleiss' Kappa test was relatively high (K = 0.69, z = 16.6, p < .0001). The raters classified 12 lids with lateral lid flare (LLF) and 7 without LLF in patients with GO. There was no agreement on the presence or absence of LLF in 11 lids. In all eyes, lateral midpupil lid distances diminished from the center of the eyelid towards the lateral canthus. Receiver operating characteristic analysis for the midpupil distances revealed that the fourth distance from the center demonstrated high sensitivity and specificity in detecting flare. At this location (2.5 mm medial to the lateral canthus) a midpupil distance equal to or greater than 60% of the margin reflex distance (MRD1) indicated the presence of flare. CONCLUSIONS: - A single measurement of a lateral midpupil eyelid distance 2.5 mm medial to the lateral canthus is a sensitive and specific measurement for the diagnosis of the LLF.