Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy.

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Do Prostaglandin Analogue Lash Lengtheners Cause Eyelid Fat and Volume Loss?

BACKGROUND: Prostaglandin analogues (PGAs; a first-line antiglaucoma treatment) have been remarketed as popular eyelash-lengthening serums due to their lash-lengthening and lash-thickening side effects. Periorbital volume loss is now a well-established side effect of topical PGAs used to treat glaucoma (prostaglandin-associated periorbitopathy) but has not, to date, been listed as a potential side effect of lash-lengthening serums containing PGAs. OBJECTIVES: The aim of this study was to identify whether periorbital fat/volume loss is seen in users of PGA lash lengtheners. METHODS: This investigation comprised a case report and an informal randomized controlled study comparing "before-and-after" color photographs displayed on the websites of manufacturers of PGA-containing lash lengtheners (PGALLs) (ie, containing bimatoprost, norbimatoprost, isopropyl cloprostenate, dechloro-dihydroxy-difluoro-ethylcloprostenolamide, or methylamido-dihydro-noralfaprostal) vs 2 control groups: non-PGALLs (NPGALL) and false eyelashes (FLs). Expert and layperson blinded graders used a purpose-designed grading system to identify subtle signs of periorbital fat/volume loss over time. RESULTS: A 35-year-old female developed thin, wrinkled, darker skin, and periorbital hollowing after 10 months of treatment with Lash Boost (Rodan & Fields, San Francisco, CA), containing isopropyl cloprostenate, which reversed 6 months after discontinuation. Fifteen "before-and-after" pairs of photographs (PGALL, n = 10; NPGALL, n = 3; FL, n = 2) were graded by 5 graders (3 expert, 2 layperson). Mean grading score was 8.2 (of 19) in the PGALL group, 2.3 in the NPGALL group, and 3.2 in the FL group. PGALL scores were significantly higher than scores in the NPGALL (P < 0.001) and FL (P = 0.017) groups. CONCLUSIONS: Review of commercial "before-and-after" photographs suggests that PGALL users develop changes compatible with prostaglandin-associated periorbitopathy. Consumers must be aware of the possibility of periorbital volume loss prior to commencing treatment with PGALLs. Often the customer-facing product ingredient list contains no mention of PGAs.

The UK National Artificial Eye Questionnaire Study: comparisons between cosmetic shell and artificial eye users. Part 2: maintenance, management and quality of life.

AIMS: To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear. METHODS: In this observational, cross-sectional study, the National Artificial Eye Questionnaire was employed nationwide within the National Health Service England. This second part of the study assesses daily management and care experiences, as well as visual function and quality of life aspects. RESULTS: Overall, 951 respondents wore an AE, while 238 wore a CS. Both AE and CS respondents rated a relatively high score for a beneficial effect of prosthesis polishing, with an average score of 80.08±0.87 versus 77.17±1.73 (p=0.13, respectively). CS respondents removed and cleaned their prosthesis more frequently than AE respondents (p<0.0001, p=0.002, respectively). CS respondents instilled lubrication more frequently than AE respondents (p=0.022) with 33.3% versus 43.7% of AE and CS wearers, respectively, lubricating on at least a daily basis. The overall QOL composite score was similar in both AE and CS groups (approximately 77%, p=0.74). Social functioning was similar, and relatively high in both groups (approximately 86%, p=0.77). CONCLUSIONS: This study characterises unique aspects of CSs versus AEs in a large national cohort. The results should provide reinforcement to the gain in popularity of CSs.

Rates of diabetic retinopathy screening in pregnant patients with type 1 and type 2 diabetes in a predominantly Indigenous Central Australian population.

BACKGROUND: Pregnancy is a risk factor for the progression of diabetic retinopathy (DR) in women with pre-gestational diabetes. Australian screening guidelines recommend DR screening in the first trimester of pregnancy. The rates of DR screening in pregnant patients with pre-gestational diabetes are unknown in Australia. AIM: To determine the rates of DR screening in pregnant women with pre-gestational diabetes at Alice Springs Hospital Diabetes Antenatal Care and Education (DANCE) clinic. MATERIALS AND METHODS: Retrospective review of women with pre-gestational diabetes who attended the DANCE clinic between July 2016 and June 2020. RESULTS: There were 146 pregnancies in 144 individual women included in this review. There were 93% (n = 134) who identified as Aboriginal but not Torres Strait Islander. DR screening was performed in 23 (16%) pregnancies, in which DR was present in six (26%) and no retinal abnormality was found in 17 (74%). Of seven (5%) women who had a history of DR, only three had a screen during the pregnancy period. The location of the DR screen included Alice Springs Hospital (17%, n = 4), Alice Springs general practice clinics (35%, n = 8) and remote NT community clinics outside of Alice Springs (39%, n = 9). The trimesters in which women received their DR screens were: trimester 1, 45%, n = 10; trimester 2, 39%, n = 9; trimester 3, 17%, n = 4. CONCLUSION: The minority of pregnant women who attend the DANCE clinic at Alice Springs Hospital received DR screening in adherence with national guidelines.

Recognising meibomian gland inversion in patients with facial palsy to improve the ocular surface.

Background: Facial nerve palsy (FNP) is known to worsen Meibomian gland dysfunction on the affected side. Chronic Meibomian gland dysfunction leads to a variant of upper eyelid marginal entropion associated with excessive tarsal curling, termed Meibomian gland inversion (MGI). Surgical correction with grey line split, tarsoplasty and anterior lamellar repositioning (GLS surgery) appears to further improve the ocular surface in these patients who have previously undergone upper eyelid loading. Methods: Retrospective, 3 year, non-comparative, single-centre study of patients with FNP identified as having MGI and treated by GLS surgery under the supervision of a single surgeon. We present specific examination findings and a useful test (cotton tip test) to determine suitability for GLS surgery. We assessed changes in symptoms and CADS (Cornea, static Asymmetry, Dynamic function and Synkinesis) score, along with cosmetic grading of lash loss and contour and report complications. Results: 23 patients with acquired FNP underwent GLS surgery for MGI with or without lash ptosis. 17 out of the 23 patients (74%) demonstrated an improvement in their CADS score after GLS surgery. Seven patients had insufficient records with scores missing and no conclusion could be reached for this group. Improvement of corneal staining, static and dynamic symmetry were all statistically significant. No patient worsened. The cosmetic outcome including lashes, lid contour and lid margin appearance is acceptable. Whilst it is possible to achieve minimal difference between the operated and unoperated eyelids, many patients will have a small difference. Conclusion: We report outcomes of MGI treatment and useful diagnostic features.

Does lagophthalmos change on lying supine after upper eyelid platinum segment chain loading?

BACKGROUND: Facial nerve palsy (FNP) often significantly affects blink. Platinum segment chains (PSC) improve lagophthalmos, however, debate exists as to the effectiveness of weights when the patient lies supine. METHODS: Prospective case series of patients with FNP following PSC insertion. Lagophthalmos on blink, gentle and forced closure was observed in the seated position, lying flat supine at 0 degrees, lying supine with one pillow underneath the head and lying on the side, with the non-facial palsy side to the pillow. This side was chosen to account for the effect that the pillow may have on lagophthalmos. RESULTS: Twenty eyes with PSC for facial palsy related lagophthalmos were assessed in 19 patients. Clinically, 12 out of the 20 eyes had no change in lagophthalmos on gentle closure when sitting up compared to supine (no pillow). The remaining 8 eyes had an increase of lagophthalmos of mean 2.3 mm (range 1-6 mm) when supine. There was no statistical difference in the amount of lagophthalmos between sitting up and lying flat with no pillow on gentle closure (P value = .0804) and blink (P value = .1567). About 50% of patients have ongoing requirements for evening lubricating ointment application but only one patient in our cohort experienced morning ocular symptoms. No patient was taping their eyelids. CONCLUSION: In our study, the prevalence of lagophthalmos increasing on gentle closure when supine is 40%. Statistically, there is no difference between gentle closure in the sitting and supine position.

UK National Artificial Eye Questionnaire study: comparisons between cosmetic shell and artificial eye users. Part 1: demographics, comfort and satisfaction.

AIMS: To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear. METHODS: In this observational, cross-sectional study, the National Artificial Eye Questionnaire (NAEQ) was employed nationwide within the National Health Service England. The proportions or mean values of the aetiology of sight or eye loss, demographics, length of prosthesis wear, reported adjustment time to the prosthesis, comfort, discharge and satisfaction of appearance were compared between AE and CS respondents. RESULTS: Overall, 951 respondents wore an AE, while 238 wore a CS. In both, trauma was the leading cause for the prosthesis (47.6% and 44.1%, respectively); however, these groups differed in the proportions of the other aetiologies (p<0.0001). AE respondents were generally older (p=0.002) and had longer overall prosthesis wear (p<0.0001) compared with CS respondents. The overall comfort score was similarly, relatively high in both AE and CS respondents (80.4±0.73 vs 81.41±1.45; p=0.51). The discharge-related patient satisfaction ranking was relatively low, in both groups, with a small trend towards worse discharge scores among AE wearers (59.41±0.76 vs 62.26±1.52, p=0.094). Self-reported length of time that has taken to adjust to wearing the prosthesis was not significantly different (p=0.17). Appearance of the eye (p=0.032) and motility of the prosthesis (p<0.0001) were ranked superior by CS respondents compared with AE. CONCLUSIONS: This study characterises unique aspects of CS versus AE in a large national cohort. The results should provide reinforcement to the gain in popularity of CS.

Submental and Anterior Neck Originated Full-Thickness Skin Grafts for Periocular Procedures.

PURPOSE: The submental and neck regions share cutaneous features with the face and are suitable donor sites for facial full-thickness skin grafts (FTSGs). Age-related laxity and skin redundancy in the cervicomental region may be an additional motivator to use its skin. We aim to describe, raise awareness, and remind surgeons of the utilization of submental and anterior neck as sources of FTSG for the periocular region, particularly when traditional donor sites are unavailable. METHODS: Retrospective case series of 5 patients who underwent periocular FTSG from anterior neck and submental regions between January 2017 and January 2019. All patients had contraindications to the usually preferred graft donor sites. Main outcome measures were surgical functional results and cosmesis. RESULTS: Five patients (all female) received FTSGs using anterior neck and submental regions as donor sites. Two patients required skin grafts due to eyelid retraction and anterior lamella shortening; one due to previous multiple basal cell carcinoma excisions with FTSG reconstructions and the other due to chronic Bell's palsy. Three patients required skin grafts for Hughes flap reconstruction after excision of lower eyelid basal cell carcinoma. In all patients, conventional skin donor sites were unavailable or unsuitable due to previous skin grafting, actinic changes, postauricular situated hearing aids or patient's preference. All patients achieved good cosmesis and functional results. None of the patients experienced donor site morbidities. CONCLUSIONS: Submental and anterior neck regions are useful FTSG donor sites for periocular procedures, particularly in elderly female patients with submental fullness and neck skin redundancy.

Long-Term Outcomes of Upper Eyelid Loading with Platinum Segment Chains for Lagophthalmos: An Adjustable Approach.

PURPOSE: This article reports the outcomes of a 5-year series of individually sutured platinum segment chains for upper eyelid loading. DESIGN: Consecutive case series. METHODS: Platinum segments of 0.4 and 0.2 g were assembled to create the desired weight and were placed in a supratarsal location after levator aponeurosis recession. Primary outcome measures included lagophthalmos on blink, gentle and forced eyelid closure, upper eyelid margin-to-reflex distance (MRD1), corneal staining, static and dynamic validated scoring for facial palsy patients, and complications. Secondary outcome measures were visual acuity, occurrence of induced ptosis, need for further surgery, cosmesis, and quality of life evaluation. RESULTS: During 2013-2018, a total of 122 upper eyelids of 117 patients received platinum segment chains (mean weight, 1.2 ± 0.2 g; range, 0.8-1.6 g) for lagophthalmos. Median follow-up was 17.4 months. All grades of lagophthalmos were reduced (P < 0.001), with mean reductions of 3.6, 2.5, and 1.5 mm on blink, gentle, and forced closures, respectively. Mean MRD1 was reduced by 1.4 mm (P < 0.001). Overall, 36 eyelids (29.5%) underwent revision surgery at 9.1 ± 9.2 months after implantation. Of those, 6 eyelids (5.0%) required 2 or more procedures. No platinum allergy occurred. The chain was graded as having no prominence in 77.5% of eyelids; the eyelids were graded as having a normal contour in 70.8% of cases. CONCLUSIONS: Platinum segments are US Food and Drug Administration approved and provide benefits of platinum chains with the additional advantages of allowing postoperative adjustability, reduced health care costs, and less likelihood of inducing allergy than gold. Platinum segments are an ideal first-line loading implant for lagophthalmos.

Maintaining Quality of Life: Electrochemotherapy for Palliative Periorbital Malignancy.

Electrochemotherapy has been used successfully for treatment of recurrent head and neck skin cancers and skin metastasis. It combines both electroporation and chemotherapy. The authors report 4 patients, who all had metastatic periorbital malignancy. These patients were palliative with widespread metastatic malignancy. All patients had either already had multiple procedures or declined surgical resection and preferred less involved measures. The authors report technique and outcomes. Patient 1: 83-year-old man with recurrent malignant melanoma (MM) nodules (BRAF negative) in the left medial orbit and medial canthal area after rhinectomy and previous resections. Patient 2: 72-year-old man with metastatic MM who developed painful and unsightly metastatic nodules on the right and left forehead and the left medial canthus. Patient 3: 93-year-old man with background of widespread multiple myeloma, considered palliative. He developed a left forehead SCC, apparent as a fungating ulcer, which caused significant pain due to perineural invasion. Patient 4: 91-year-old woman with recurrent metastatic sebaceous cell carcinoma of the left lower eyelid obstructing her vision. All patients experienced an improvement in their pain and quality of life. None of the patients developed any significant periorbital inflammation or adverse complications. Electrochemotherapy may be a useful palliative treatment for periorbital tumors. It improves pain and reduces tumor volume. It can be considered for tumors where palliative radiotherapy may be contraindicated.Electrochemotherapy is a useful palliative treatment for metastases to the periorbital area, improving pain and size of the tumors.

How far we have come: A review of the evolution of posterior approach ptosis surgery.

We revisit the evolution of posterior approach ptosis surgery. We address the early attempts at ptosis surgery, assess the more modern approach by de Blaskovics, followed by the division into "open sky" and "closed" techniques. The simultaneous developments occurring in America and Europe are described, along with refinement of surgical approaches such as conjunctival-sparing posterior approach ptosis surgery.

Ibopamine challenge testing becomes negative following successful trabeculectomy surgery.

BACKGROUND: The ibopamine challenge test correlates well with a patient's peak diurnal intraocular pressure (IOP) measurement. We aimed to investigate the effect that a functioning trabeculectomy has on the ibopamine challenge test. DESIGN: Non-randomized prospective clinical trial evaluating a diagnostic test. PARTICIPANTS: Thirteen patients were recruited through glaucoma clinics at the Flinders Medical Centre. Of these, seven required surgical management with trabeculectomy surgery, whilst the remainder were managed medically. METHODS: Patients underwent IOP measurement, and then two drops of Ibopamine 2% solution were instilled into the study eye of each patient. After 45 min, IOP was reassesed. A positive challenge test was considered to be a rise in IOP of greater than 3 mmHg. Changes from baseline were determined and compared between groups. Twelve months later, this test was then repeated in all patients. MAIN OUTCOME MEASURE: Change in IOP after ibopamine challenge. RESULTS: Following the ibopamine challenge, IOP increased by 9.2 mmHg (SD 2.8) (100% positive) for medically managed patients and 7.2 mmHg (SD 2.0) (100% positive) for surgically managed patients (P = 0.18). The surgically managed group then underwent trabeculectomy surgery. Twelve months later, the ibopamine challenge was repeated. Following the repeat ibopamine challenge, IOP increased by 7.2 mmHg (SD 2.3) for medically managed patients and 0.3 mmHg (SD 1.3) for surgically managed patients (P < 0.0001). The medically managed group remained 100% positive, whilst the surgically manage group became 0% positive (Fisher Exact P = 0.044). CONCLUSIONS: A glaucoma patient with a positive ibopamine challenge will show a negative challenge result when re-tested following trabeculectomy surgery.

Ibopamine challenge testing differentiates glaucoma suspect, stable glaucoma and progressive glaucoma cases.

BACKGROUND: An ibopamine challenge is a novel technique for assessing glaucoma using ibopamine, a topical drug which temporarily increases aqueous production. We aimed to determine whether change in intraocular pressure (IOP) and/or optic cup volume (OCV) during the test differentiated between glaucoma patients at different stages of disease; namely, glaucoma suspects (GS), glaucoma patients who are stable (SG) and glaucoma patients who have demonstrated rapid progression (PG). DESIGN: Non-randomized clinical trial evaluating a diagnostic test. PARTICIPANTS: Sixty-one patients were recruited through glaucoma clinics at the Flinders Medical Centre (24 GS, 24 SG and 13 PG). METHODS: Patients underwent IOP measurement and OCV assessment using optical coherence tomography. Two drops of ibopamine 2% solution were instilled into the study eye of each patient. After 45 min, IOP and OCV were reassessed. Changes from baseline were compared between groups. MAIN OUTCOME MEASURE: Change in IOP and OCV after ibopamine challenge. RESULTS: Following the ibopamine challenge, IOP increased by 1.8 mmHg for GS patients, 4.5 mmHg for SG patients (P = 0.003) and 8.1 mmHg for PG patients (P < 0.0001). OCV increased by 0.2% for GS patients, 0.6% for SG patients and 5.5% for PG patients. This was not significantly different between GS patients and SG patients; however, it was significantly different between GS patients and PG patients (P < 0.0001), and between SG and PG patients (P = 0.001). CONCLUSION: GS patients may be differentiated from those with SG or PG by their IOP response, and SG may be differentiated from PG patients by their change in OCV following an ibopamine challenge.

A longitudinal assessment of early childhood education with integrated speech therapy for children with significant language impairment in Germany.

BACKGROUND: In Lower Saxony, Germany, pre-school children with language- and speech-deficits have the opportunity to access kindergartens with integrated language-/speech therapy prior to attending primary school, both regular or with integrated speech therapy. It is unknown whether these early childhood education treatments are helpful and effective. AIMS: To determine the value of early language-/speech therapy treatment in combination with support of personality traits during the pre-school and primary school period on the long-term social and academic development of children with significant language-/speech delay. METHODS & PROCEDURES: We conducted prospective longitudinal case series, following the academic progress of 71 children after they had been discharged from a speech therapy kindergarten (STK) up to 19 years previously. Data collection included details on language/speech impairment, socio-economic factors, psycho-social skills and intelligence quotient. RESULTS & IMPLICATIONS: At the end of the follow-up period, 58 children were attending secondary schools: 44 (76%) children attended a regular secondary school, whereas 14 (24%) children were enrolled in a school with special needs education. The results suggest that self-awareness and intelligence quotient in this study cohort correlated with later academic achievements. CONCLUSION & IMPLICATIONS: Kindergartens and primary schools which support curriculum-integrated language-/speech therapy and allow for different personality traits appear to improve longterm development and academic outcome of children with language-/speech impairment or delay.

Ibopamine challenge test can be used to differentiate glaucoma suspects from glaucoma patients.

BACKGROUND: Many countries face the challenge of a rising number of patients with or at risk of developing glaucoma. A test to differentiate between people who are unlikely to develop glaucoma and those at risk for the disease could be clinically useful. Ibopamine, when administered topically, temporarily increases aqueous production. Normal eyes with healthy trabecular meshwork show no significant change in intraocular pressure (IOP) following an ibopamine challenge; however, those with glaucoma demonstrate elevated IOP. DESIGN: The study was designed as a prospective case-control study in a tertiary hospital. PARTICIPANTS: Patients were recruited consecutively as they presented to glaucoma clinics at Flinders Medical Centre (n = 39); the sample included 18 glaucoma suspects and 21 patients with glaucoma. All patients had open anterior chamber angles and no evidence of secondary glaucoma. METHODS: Patients underwent IOP measurements followed by instillation of ibopamine 2% solution and subsequent repeated IOP assessment. The difference between the baseline measurement and that taken at 45 min was determined and compared between groups. MAIN OUTCOME MEASURE: The outcome measure was the positivity of the ibopamine challenge test, defined by an increase in IOP > 3 mmHg. RESULTS: We observed a mean increase in IOP of 1.9 ± 1.6 mmHg or 12.5 ± 10.3%) for glaucoma suspects and 7.4 ± 4 mmHg or 52.4 ± 26.5% for glaucoma patients (P < 0.0001). Four glaucoma suspects (22%) and 19 glaucoma patients (90%) tested positive (P < 0.0001). CONCLUSION: This study demonstrates that ibopamine has potential as a test to differentiate glaucoma suspects from patients with glaucoma.