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

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

Intense Pulsed Light Therapy for Patients with Meibomian Gland Dysfunction and Ocular Demodex Infestation.

To observe the clinical changes of meibomian gland dysfunctipn (MGD) and ocular Demodex infestation after intense pulsed light (IPL) treatment to further examine the mechanism of IPL treating patients with MGD and ocular Demodex infestation. The medical records of 25 patients (49 eyes) with MGD treated with IPL, were retrospectively examined to determine outcomes. Associated ocular-surface parameters (ocular surface disease index, OSDI; lipid layer thickness, LLT; noninvasive first breakup time, NIF-BUT; noninvasive average breakup time, NIAvg-BUT; tear film breakup area, TBUA; Schirmer I Test, SIT; corneal fluorescein staining, CFS), eyelid margin abnormalities, meibum quality and expressibility, MG morphological parameters (macrostructure and microstructure), and the number of Demodex infestation were examined before and after treatment. The MG microstructure and the Demodex infestation were examined via in vivo confocal microscopy (IVCM). The results showed that there were statistically significant differences in associated ocular-surface parameters (all P<0.05) before and after IPL treatment, except SIT (P=0.065). Eyelid margin abnormalities, meibum quality and expressibility obviously improved in upper and lower eyelid after IPL treatment (all P<0.0001). MG macrostructure (MG dropouts) decreased in upper (P=0.002) and lower eyelid (P=0.001) after IPL treatment. The nine parameters of MG microstructure in upper and lower eyelid all distinctly improved after IPL treatment (all P<0.0001). The mean number of Demodex mites on the upper lid margin (6.59±7.16 to 3.12±3.81/9 eyelashes) and lower lid margin (2.55±2.11 to 1.29±1.53/9 eyelashes) significantly reduced after IPL treatment (all P<0.0001). The Demodex eradication rate was 20% (8/40) in upper lid margin and 34.15% (14/41) in lower lid margin. These findings indicate that IPL shows great therapeutic potential for patients of MGD and ocular Demodex infestation.

Further Investigations on the Crosslinking of Tarsal Collagen as a Treatment for Eyelid Laxity: Optimizing the Procedure in Animal Tissue.

PURPOSE: A follow-up experimental study on the exposure of animal tarsal plate to ultraviolet-A radiation aimed at establishing an optimum range for safe irradiation conditions. METHODS: Sheep tarsus specimens were excised postmortem and then subjected to irradiation with ultraviolet-A rays (wavelength 365 nm) at higher irradiances than those reported in an initial study, using a laboratory radiation source. The mechanical properties (tensile strength and Young's modulus) of irradiated and nonirradiated samples were evaluated in a mechanical tester. The test and control specimens were examined histologically with an aim to assess the effects of radiation upon the meibomian glands and tarsal collagen networks, and to establish a safe range for the exposure irradiance level. RESULTS: As expected, irradiation induced both stiffening and strengthening of the tarsal plate specimens. At an irradiance of 50 mW/cm for 3-minute exposure, these effects were at their maximum level, after which a decline in mechanical characteristics were observed. No destruction of the tarsal connective tissue or the meibomian glands were noticed up to an irradiance of 125 mW/cm for 3-minute exposure, corresponding to a fluence of 22.5 J/cm. Histology revealed that the collagen network surrounding the glands were packed more compactly following irradiation. At a fluence of 45 J/cm, massive destruction of periglandular collagen-rich network and meibocytes were demonstrated histologically. CONCLUSIONS: The study indicates that irradiation of tarsal collagen leading to tissue stiffening shall be carried out at levels of fluence between 10 and 15 J/cm, a region that is deemed safe. The exposure time can be adjusted according to the surgeon's decision.Safe irradiation conditions are established for the exposure of ex vivo ovine tarsus to ultraviolet-A radiation as a potentially effective treatment for eyelid laxity in human patients.

CO2 Laser Treatment of Xanthelasma Palpebrarum in Skin Types III-IV: Efficacy and Complications After 9-Month Follow-Up.

Objective: Ultrapulse CO2 laser has been used for several decades for removal of xanthelasma lesions. However, most studies to date have focused on Caucasian patients (skin types I-II). We sought to assess the efficacy and complications of CO2 laser therapy for xanthelasma palpebrarum (XP) in Chinese patients (skin types III-IV). Methods: Data of 38 patients with xanthelasma who received CO2 laser treatment between December 2013 and January 2016 at our hospital were retrospectively analyzed. Patients were followed up for 9 months. Results: Recurrence occurred in 19/38 (50%) patients. Recurrence was significantly more common in patients with multiple lesions (15/24; 62.5%) than in patients with single lesions (4/14; 28.6%). At 3 months after treatment, the complication rate was 63.16%. The complications included hypopigmentation (23/24; 95.8%) and scarring (1/24; 4.2%). In all patients, the hypopigmentation had disappeared by end of the 9-month follow-up. Conclusions: Ultrapulse CO2 laser appears to be capable of completely removing XP in patients with medium skin type III-IV. The most common complication is hypopigmentation, but this resolves with time.

Photochemically Induced Crosslinking of Tarsal Collagen as a Treatment for Eyelid Laxity: Assessing Potentiality in Animal Tissue.

PURPOSE: An experimental study to demonstrate in animal eyelids that the controlled exposure of excised tarsal plate to ultraviolet-A radiation can induce a rigidification effect due to photochemical crosslinking of the constitutive collagen. METHODS: Excised strips of sheep tarsus were irradiated with ultraviolet-A rays (wavelength 365 nm) at low and high irradiances, in the presence of riboflavin as a photosensitizer, using radiation sources available for corneal collagen crosslinking procedure. The tensile strength and Young's modulus (stiffness) of irradiated and control samples were measured in a mechanical tester and analyzed statistically. Histologic examination of the specimens was carried out to evaluate the effect of radiation on the meibomian glands and collagen organization. RESULTS: Mechanical evaluation showed that irradiation induced both stiffening and strengthening of the tarsal plate specimens, and this effect was enhanced at the higher levels of irradiance. The changes in mechanical properties can be attributed to a process of photochemically induced crosslinking of tarsal collagen. Histology revealed no changes in the meibomian glands or in the fibrous collagen system of the tarsus. CONCLUSIONS: These findings indicate that irradiation of tarsal collagen leading to tissue stiffening could be a safe procedure for treating lax eyelid conditions in human patients.

UV imaging reveals facial areas that are prone to skin cancer are disproportionately missed during sunscreen application.

Application of sunscreen is a widely used mechanism for protecting skin from the harmful effects of UV light. However, protection can only be achieved through effective application, and areas that are routinely missed are likely at increased risk of UV damage. Here we sought to determine if specific areas of the face are missed during routine sunscreen application, and whether provision of public health information is sufficient to improve coverage. To investigate this, 57 participants were imaged with a UV sensitive camera before and after sunscreen application: first visit; minimal pre-instruction, second visit; provided with a public health information statement. Images were scored using a custom automated image analysis process designed to identify areas of high UV reflectance, i.e. missed during sunscreen application, and analysed for 5% significance. Analyses revealed eyelid and periorbital regions to be disproportionately missed during routine sunscreen application (median 14% missed in eyelid region vs 7% in rest of face, p<0.01). Provision of health information caused a significant improvement in coverage to eyelid areas in general however, the medial canthal area was still frequently missed. These data reveal that a public health announcement-type intervention could be effective at improving coverage of high risk areas of the face, however high risk areas are likely to remain unprotected therefore other mechanisms of sun protection should be widely promoted such as UV blocking sunglasses.

Detailed modeling of palpebral fissure and its influence on SAR and temperature rise in human eye under GHz exposures.

This article investigates variations in specific absorption rate and temperature rise in human eye caused by changes in palpebral fissure, the extent of opening between eyelids, under GHz plane-wave electromagnetic (EM) exposures. Detailed human head models with different palpebral fissure features were developed with a refined spatial resolution of 0.25 mm. These head models were then incorporated into both EM and bio-heat simulations, but using finite-difference time-domain method and finite-difference method, respectively. Maximum temperature rise in lens was found to be 0.8°C under EM exposure at 100 W/m(2). Results reveal that changes in palpebral fissure would produce a 0.23°C variation in maximum temperature rise in lens.

Local Recurrence and Ocular Adnexal Complications Following Electronic Surface Brachytherapy for Basal Cell Carcinoma of the Lower Eyelid.

IMPORTANCE: Various treatment options exist for nonmelanoma skin cancer (NMSC), including topical agents, surgery, or definitive or adjuvant radiation therapy. Recently, electronic surface brachytherapy (ESB) has been described as a noninvasive option for NMSC. We report a case of local recurrence of basal cell carcinoma (BCC) and ocular complications following ESB to the lower eyelid. OBSERVATIONS: A man in his 60s presented with a recurrent BCC within the radiation field 10 months after undergoing ESB for a biopsy-proven BCC. In addition to the recurrence, he had contracture of the conjunctiva in the socket of his previously enucleated eye, as well as lower eyelid ectropion, resulting in displacement and loss of retention of his ocular prosthesis. CONCLUSIONS AND RELEVANCE: Electronic surface brachytherapy should be used with caution, particularly in the periocular region because the late effects of hypofractionated radiation may cause ocular and orbital complications. To our knowledge, this is the first reported case of ocular complications with this modality. This case highlights a local recurrence following use of this new treatment modality, suggesting further investigation is warranted to determine the safety and efficacy of ESB.

Tumor evolution. High burden and pervasive positive selection of somatic mutations in normal human skin.

How somatic mutations accumulate in normal cells is central to understanding cancer development but is poorly understood. We performed ultradeep sequencing of 74 cancer genes in small (0.8 to 4.7 square millimeters) biopsies of normal skin. Across 234 biopsies of sun-exposed eyelid epidermis from four individuals, the burden of somatic mutations averaged two to six mutations per megabase per cell, similar to that seen in many cancers, and exhibited characteristic signatures of exposure to ultraviolet light. Remarkably, multiple cancer genes are under strong positive selection even in physiologically normal skin, including most of the key drivers of cutaneous squamous cell carcinomas. Positively selected mutations were found in 18 to 32% of normal skin cells at a density of ~140 driver mutations per square centimeter. We observed variability in the driver landscape among individuals and variability in the sizes of clonal expansions across genes. Thus, aged sun-exposed skin is a patchwork of thousands of evolving clones with over a quarter of cells carrying cancer-causing mutations while maintaining the physiological functions of epidermis.

Treatment of periorbital wrinkles with a novel fractional radiofrequency microneedle system in dark-skinned patients.

BACKGROUND: Periorbital wrinkles as a result of photoaging are a frequent cosmetic concern. Recently, the fractional radiofrequency microneedle system was introduced as a new device for facial rejuvenation, and it has received much recognition for its unique "deep dermal heating with epidermal sparing" feature. OBJECTIVE: The purpose of this study was to examine the clinical efficacy and safety of the system for the treatment of periorbital wrinkles in Korean patients. MATERIALS AND METHODS: Twenty Korean patients (Fitzpatrick skin Type IV-V) with varying degrees of periorbital wrinkles were enrolled in this study. The patients were treated 3 times at 4-week intervals with the system. Changes in periorbital wrinkling were evaluated by 2 independent experts with digital images of the subjects' faces using a 5-point Wrinkle Assessment Scale. At the end of the study, the patients rated their satisfaction with the overall treatment outcome on a numerical scale. RESULTS: All patients completed the treatment regimen and were satisfied with the treatment. Most patients improved according to clinical and photographic assessments performed 6 months after the treatment. Two patients (10%) reported mild hyperpigmentation. CONCLUSION: The system may be an effective and safe treatment option for periorbital wrinkles in dark-skinned Korean patients.

Transpalpebral proton beam radiotherapy of choroidal melanoma.

BACKGROUND: Collateral damage to upper eyelid margin during proton beam radiotherapy (PBR) for choroidal melanoma may cause squamous metaplasia of the tarsal conjunctiva with keratinisation, corneal irritation, discomfort and, rarely, corneal perforation. We evaluated transpalpebral PBR as a means of avoiding collateral damage to the upper eyelid margin without increasing the risk of failure of local tumour control. METHODS: Retrospective study of consecutive patients who underwent PBR for choroidal melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. RESULTS: Sixty-three patients were included in this study. Mean basal tumour diameter and tumour thickness were 11.8 mm and 3.6 mm, respectively. PBR mean beam range and modulation were 26.5 mm and 16.9 mm respectively. The eyelid margin was included in the radiation field in 15 (24%) eyes. The median follow-up was 2.5 years. Local tumour recurrence developed in 2 (3.2%) patients. In these two cases that developed tumour recurrence the transpalpebral treatment did not involve the eyelid margin. Six (9.5%) patients died of metastatic disease. No eyelid or ocular surface problems developed in any of the 48 patients who were treated without eyelid rim involvement, while 7 of the 15 patients with unavoidable irradiation of the eyelid rim developed some degree of madarosis. These seven patients all received more than 26.55 proton Gy to the eyelid margin. Symptoms, such as grittiness occurred in 12% of 48 patients without eyelid margin irradiation as compared with 53% of 15 patients whose lid margin was irradiated. CONCLUSIONS: Transpalpebral PBR of choroidal melanoma avoids eyelid and ocular surface complications without increasing failure of local tumour control.

Changes in the eyelids and conjunctiva caused by ultraviolet radiation.

The aim of this study was to show the frequency, sex and age distribution of eyelids skin tumor changes and degen erative changes of the conjunctiva for the period of three years (2011-2013) at the Department of Ophthalmology in Split. We analyzed the eyelids skin lesions in biopsy material at the Department of Pathology and the same were compared with the profession of the patients. In this period there were found 131 tumor changes of the eyelids. The most common tumor was the basal cell carcinoma (118) with the higher frequency in women. There were 10 squamous cell carcinomas with the equal representation among sexes and three melanomas. There were 79 female and 52 male patients. There were 299 pterygiums operated with the higher frequency in women (68.2%). Exposure to UV radiation, particulary UVB radiatiori is the most common causative factor for genetic abnormalities in cells and provoked factor in oncogenesis of skin tumors. In our research we found a correlation between changes in the eyelids and conjunctiva caused by UV radiation with the professional interest of the respondents. Due to high incidence of eyelids skin tumor changes in the population professionally exposed to UV radiation, medical professionals should be aware of the importance of the public education on the etiology of these tumors and the importance of the UVprotection.

Numerical analysis of specific absorption rate in the human head due to a 13.56 MHz RFID-based intra-ocular pressure measurement system.

A modern wireless intra-ocular pressure monitoring system, based on 13.56 MHz inductively coupled data transmission, was dosimetrically analyzed with respect to the specific absorption rate (SAR) induced inside the head and the eye due to the electromagnetic field exposure caused by the reader antenna of the transmission system. The analysis was based on numerical finite difference time domain computations using a high resolution anatomical eye model integrated in a modern commercially available anatomical model of a male head. Three different reader antenna configurations, a 7-turn elliptic (30 mm × 50 mm) antenna at 12 mm distance from the eye, a flexible circular antenna (60 mm diameter, 8 turns on 2 mm substrate) directly attached to the skin, and a circular 7-turn antenna (30 mm diameter at 12 mm distance to the eye) were analyzed, respectively. Possible influences of the eye-lid status (closed or opened) and the transponder antenna contained in a contact lens directly attached to the eye were taken into account. The results clearly demonstrated that for typical reader antenna currents required for proper data transmission, the SAR values remain far below the limits for localized exposure of the head, as defined by the International Commission for Non-Ionizing Radiation Protection. Particularly the induced SAR inside the eye was found to be substantially (orders of magnitudes for typical reader antenna currents in the order of 1 A turn) below values which have been reported to be critical with respect to thermally induced adverse health effects in eye tissues.

Fractionated microneedle radiofrequency for the treatment of periorbital wrinkles.

Non-ablative bipolar and monopolar radiofrequency devices have been shown to be effective for the treatment of facial wrinkles. Recently, novel fractionated microneedle radiofrequency (FMRF) devices have been introduced. The aim of this study was to evaluate the clinical effectiveness and safety of FMRF for the treatment of periorbital wrinkles. Eleven women, aged 34-59 years, with periorbital wrinkles underwent three sessions of FMRF at 3-week intervals with a follow-up period of 3 months after treatment. Clinical improvement was evaluated using the Fitzpatrick Wrinkle Classification System (FWCS) and subjective satisfaction on a visual analog scale (VAS). The FWCS scores demonstrated significant improvement in periorbital wrinkles after treatment (P < 0.001). A satisfaction VAS score of more than 5, indicating high satisfaction, was obtained from 10 of 11 patients (91%) 3 months after treatment, and the mean satisfaction VAS score (n = 11) was 6.7. Patients undergoing treatment reported minimal pain, and neither long-lasting side-effects nor significant downtime was noted. This clinical study suggests that FMRF is a safe and tolerable method for successful treatment of periorbital wrinkles.

Efficacy of low dose radiotherapy for primary orbital marginal zone lymphoma.

Marginal zone lymphoma (MZL) is a radiosensitive tumor, with high local control (LC) rates with moderate dose radiotherapy (RT). This retrospective study, performed at the Peter MacCallum Cancer Centre, evaluated the efficacy and toxicity of patients with orbital MZL treated to 24-25 Gy. Twenty-four patients (27 orbits) were identified, with median follow-up of 41 months. Disease was conjunctival in 16 orbits (59%), lacrimal in seven (26%), in the eyelid in one (4%) and elsewhere in three (11%). All patients attained a complete response. Three patients had treatment failures: one local relapse, one contralateral and one distant relapse. Freedom from local failure, freedom from progression, progression-free survival and overall survival were 100%, 90%, 90% and 100% at 2 years and 92%, 81%, 81% and 100% at 5 years, respectively. Aside from cataractogenesis, there was no significant late toxicity. Our study shows that RT doses of 24-25 Gy provide high rates of LC for orbital MZL with acceptable morbidity.

Radiation therapy for primary carcinoma of the eyelid: tumor control and visual function.

BACKGROUND AND PURPOSE: Surgical excision remains the standard and most reliable curative treatment for eyelid carcinoma, but frequently causes functional and cosmetic impairment of the eyelid. We therefore investigated the efficacy and safety of radiation therapy in eyelid carcinoma. PATIENTS AND METHODS: Twenty-three patients with primary carcinoma of the eyelid underwent radiation therapy. Sebaceous carcinoma was histologically confirmed in 16 patients, squamous cell carcinoma in 6, and basal cell carcinoma in 1. A total dose of 50-66.6 Gy (median, 60 Gy) was delivered to tumor sites in 18-37 fractions (median, 30 fractions). RESULTS: All but 3 of the 23 patients had survived at a median follow-up period of 49 months. The overall survival and local progression-free rates were 87% and 93% at 2 years, and 80% and 93% at 5 years, respectively. Although radiation-induced cataracts developed in 3 patients, visual acuity in the other patients was relatively well preserved. There were no other therapy-related toxicities of grade 3 or greater. CONCLUSION: Radiation therapy is safe and effective for patients with primary carcinoma of the eyelid. It appears to contribute to prolonged survival as a result of good tumor control, and it also facilitates functional and cosmetic preservation of the eyelid.

Decellularized porcine derived membrane (Tarsys®) for correction of lower eyelid retraction.

Retraction of the lower eyelid can be consequence of medical and surgical conditions. Various kinds of allotransplants and biomaterial have been used to correct it; we report on the surgical correction of lower lid retraction with a decellularized porcine derived membrane (Tarsys(®)). A 49-year-old patient with a history of adenoid cystic carcinoma in the pterygo-palatine fossa, requiring extensive surgery and repeated radiotherapy, presented with 6 mm lagophthalmus and exposure keratopathy secondary to facial nerve palsy. The lower lid malposition was corrected with a Tarsys(®) implant. Three months after surgery no lagophthalmos was present and substantial relief of signs and symptoms of ocular surface disease and good symmetry between right and left eye was achieved. If general condition or morbidity in potential donor sites hamper harvesting autologous graft material to support the lower lid, bioengineered xenografts can be used successfully to correct eyelid malpositions such as lower lid retraction.

Treatment of infraorbital dark circles using a low-fluence Q-switched 1,064-nm laser.

OBJECTIVE: To evaluate the efficacy and safety of the low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminium garnet (QSNY) laser in treating infraorbital dark circles. PARTICIPANTS AND METHODS: Thirty women with infraorbital dark circles (predominant color dark brown) participated in this open-label study. Participants underwent eight sessions of low-fluence QSNY laser treatment at 4.2 J/cm(2) at 3- to 4-day intervals. A spot size of 3.5 mm was used, with a pulse duration of 8 ns. The melanin deposition in the lesional skin was observed in vivo using reflectance confocal microscopy (RCM). Morphologic changes were evaluated using a global evaluation, an overall self-assessment, a narrow-band reflectance spectrophotometer, and a skin hydration measurement instrument. RESULTS: Twenty-six of 30 patients showed global improvement that they rated as excellent or good. Twenty-eight rated their overall satisfaction as excellent or good. The melanin index indicated a substantial decrease, from 225.84 at baseline to 182.65 (p < .05). RCM results showed a dramatic decrease of melanin deposition in the upper dermis. Adverse effects were minimal. CONCLUSIONS: The characteristic finding for dark-brown infraorbital dark circles is melanin deposition in the upper dermis. Treatment of infraorbital dark circles using low-fluence 1,064-nm QSNY laser is safe and effective. The authors have indicated no significant interest with commercial supporters.