Digital image processing measurement of the upper eyelid contour in Graves disease and congenital blepharoptosis

Quantitative analysis of the eyelid curvature in patients with blepharoptosis

BACKGROUND

The aim of this study was to evaluate the ability of two novel eyelid curvature measurements to distinguish between normal eyes and different severities of blepharoptosis.

METHODS

A comparative cross-sectional analysis of upper eyelid curvature was performed for different severities of patients with unilateral blepharoptosis (congenital and aponeurotic) and normal controls. Mean upper lid contour index (ULCI) and area circularity index (ACI) were calculated for each group by dividing the intercanthal distance by upper eyelid margin length (ULCI) and dividing the interpalpebral area by the area of a circle enclosing the eye (ACI). The ratio of each index for the study and fellow normal eye of each patient was also calculated and compared between groups.

RESULTS

A total of 106 eyes including 30 eyes in the control group and 25, 27, and 24 eyes in the mild, moderate, and severe ptosis groups were enrolled in the study. ULCI and ACI showed a statistically significant difference between the groups (p < 0.001, p < 0.001). The inter-eye ratio (ULCI-ratio and ACI-ratio) of indices was also significantly different between groups (p = 0.002, p < 0.001). Pairwise comparisons revealed that ACI and ACI-ratio were significantly different between all pairs of study groups.

CONCLUSION

The results of our study showed that ACI based on area measurements may distinguish blepharoptosis patients from normal controls and from each other. Including the data from the fellow normal eyes in the form of ratio indices may improve the differentiating power. These results can be useful in designing the optimal eyelid curvature measurements.

Sector area index: a novel supporting marker for blepharoptosis screening and grading

PURPOSE

To introduce a new supporting marker for discriminating different grades of ptosis called Sector Area Index (SAI) and a semi-automated technique to calculate it.

METHODS

In this cross-sectional comparative case series, a circle enclosing the intercanthal distance was automatically drawn after choosing two points as the medial and lateral canthus and manually selecting the palpebral fissure region. Finally, 15-degree apart sectors are applied to the enclosed circle. SAI was measured automatically by dividing the area of each 15-degree sector marked with the upper eyelid contour by the total area of the sector marked with the edge of the surrounding circle. SAI values and inter-eye SAI differences were compared between patients with different grades of ptosis as well as normal patients.

RESULTS

In the current study, 106 eyes were recruited (30, 25, 27, and 24 in the control, mild, moderate, and severe ptosis groups, respectively). Mean values of SAI in all sectors showed a decreasing trend from normal individuals toward patients with severe ptosis. The mean difference values of SAI between study eyes and fellow eyes in all four groups of patients showed a statistically significant difference (p < 0.05). In a pairwise comparison between groups, mean values of SAI in all nasal sectors from 15° to 60° showed a statistically significant difference between all groups (p < 0.05).

CONCLUSION

The mean difference of SAI between study eyes and fellow eyes, including eyelid curvature, especially in 15°-60° and 120°-165° sectors, can demonstrate differentiating performance for detecting and discriminating varying grades of ptosis.

Cross-species Blink Characterisation Tool for the Analysis of Emerging Interventions for Overcoming Facial Paralysis

The loss of the ability to blink is considered the most severe consequence of facial nerve paralysis. Surgical techniques and implantable technologies continue to be developed to reanimate the eye; however, few analyse the full movement of blink when evaluating success. Here, we describe a method of taking high-quality, and high-speed video recordings of the eye, to non-invasively extract meaningful data about the dynamic movement of blinking. This can then be used to assess the effectiveness of a new technology in mimicking the natural movement. The tool was validated on humans (N=2, authors) before testing on an ovine recording (N=1), to confirm the cross-species utility of the tool, for use during preclinical development of technologies. It was found to be accurate and comprehensive, able to give insights on blinking in both human and ovine cases.

The Arched Rainbow Brow in Thyroid Eye Disease

PURPOSE

To morphologically describe and mathematically quantify a novel clinical feature of thyroid eye disease (TED).

METHODS

A retrospective study was conducted of TED patients and age-sex-matched normal controls. The arched Rainbow Brow appearance in TED patients was determined by unanimous agreement of 3 oculoplastic surgeons. Eyebrow curvature was assessed by plotting 15 points along the eyebrow in ImageJ. The fourth-degree polynomial ( y = ax4 + bx3 + cx2 + dx + e ) was fitted to each eyebrow.

RESULTS

Two hundred seventy-one eyes were analyzed (200 TED and 71 age-sex-matched normal controls). A Rainbow Brow was identified in 42% of TED patients. A unilateral Rainbow Brow was seen in 15% of patients. The fourth-degree polynomial coefficients yielded significant differences between Rainbow Brow patients and age-sex-matched normal controls for the coefficients a, b, c , and d . Similar analysis of TED patients with and without a Rainbow Brow showed differences in coefficients a and b . Age >50 years ( p = 0.009) and the presence of brow fat expansion ( p < 0.001) were associated with the presence of a Rainbow Brow. Proptosis >24 mm showed a trend toward association with the presence of a Rainbow Brow ( p = 0.057). When considering the contribution of these features in a multivariable analysis, only brow fat expansion was a significant contributing factor ( p = 0.009).

CONCLUSIONS

The Rainbow Brow is a distinct entity in TED and is likely consequent to brow fat pad expansion. Patients with a Rainbow Brow have different eyebrow curvature as compared to both normal age-sex-matched controls and TED patients without a Rainbow Brow.

Mathematical Modeling of Eyebrow Curvature

The aim of the study is to describe a mathematical model for analyzing eyebrow curvature that can be applied broadly to curvilinear facial features. A total of 100 digital images (50 men, 50 women) were obtained from standardized headshots of medical professionals. Images were analyzed in ImageJ by plotting either 8 or 15 points along the inferior-most row of contiguous brow cilia. A best-fit curve was automatically fit to these points in Microsoft Excel. The second derivative of the second-degree polynomial and a fourth-degree polynomial were used to evaluate brow curvature. Both techniques were subsequently compared with each other. A second-degree polynomial and fourth-degree polynomial were fit to all eyebrows. Plotting 15 points yielded greater goodness-of-fit than plotting 8 points along the inferior brow and allowed for more sensitive measurement of curvature across all images. A fourth-degree polynomial function provided a closer fit to the eyebrow than a second-degree polynomial function. This method provides a simple and reliable tool for quantitative analysis of eyebrow curvature from images. Fifteen-point plots and a fourth-degree polynomial curve provide a greater goodness-of-fit. The authors believe the described technique can be applied to other curvilinear facial features and will facilitate the analysis of standardized images.

Comparing the symmetry of upper eyelid following unilateral ptosis correction

Background

Margin Reflex Distance 1(MRD 1) only describes the central height of upper eyelid and relies on the examiner’s experience and disregards eyelid contour abnormalities. Therefore MRD 1 may not be sufficient for an acceptable result to evaluate the outcomes of ptosis surgery. The primary purpose of this study was to assess outcomes of unilateral ptosis correction based on parameters including degree of symmetry, MRD 1, peak height of the upper lid, temporal and nasal ocular surface area, and temporal/nasal area ratio with an objective, quantitative, and repeatable method.

Methods

This study was designed as a retrospective non-randomized case-control study. Medical records of the patients with unilateral ptosis between October 2015 and December 2020 were reviewed. Patients with unilateral ptosis who underwent surgical correction and levator function of 5 mm or greater were included in the study. Two groups were defined; ptotic eye was case group and contralateral eye was control group. Data analysis was performed Image J and Matlab softwares.

Results

Thirty-four patients were included in the study. Mean age of patients was 58.8 ± 12.7 years (range 15–75 years). Mean follow-up time was 19.5 ± 7.3 months (range 8–40 months). Four patients were diagnosed with congenital ptosis and 30 patients aponeurotic ptosis. Mean preoperative degree of symmetry for overall eyelid contour was 36.6 ± 27.5% (range 1–92%). Mean postoperative degree of symmetry for overall eyelid contour was 72.4 ± 16.5% (range 55–92%). Temporal/Nasal (T/N) area ratios for contralateral normal eye was 1.19 pre-postoperative, and it was 1.11 preoperatively, 1.15 postoperatively for operated ptotic eye.

Conclusions

This study primarily demonstrated a quantitative, objective, and repeatable method to investigate the degree of symmetry after eyelid surgeries. Secondly, this study suggested that T/N ratio may not be a reliable parameter to evaluate the eyelid symmetry.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02208-7.

Standardized Three-Dimensional Lateral Distraction Test: Its Reliability to Assess Medial Canthal Tendon Laxity

Background

Assessment of MCT laxity is critical to the surgery options. Our study aimed to analyze the reliability of measuring medial canthal tendon (MCT) laxity by using a novel standardized three-dimensional lateral distraction test (3D-LDT).

Methods

Forty-eight Caucasian volunteers (25 males and 23 females, 96 eyes) between 22 and 84 years of age (55.6 ± 18.6 years old) were included in our study. From a neutral position, the lower eyelid was gently pulled laterally along a horizontal line to define the most distracted position of the lower punctum. Both in the neutral and distracted position, standardized 3D images were acquired for each subject by two observers, and each image were measured twice by two raters. Four landmarks and six corresponding linear measurements were evaluated for intra-rater, inter-rater, and inter-method reliability.

Results

Intra-rater, inter-rater and inter-method reliability analyses of 3D-LDT revealed an intraclass correlation of more than 95%, a mean absolute difference of less than 1 mm, and a technical error of measurement of less than 1 mm. Measurements of relative error (2.59–12.04%) and relative technical error (1.83–16.05%) for the inter-landmarks distance from pupil center to the lower punctum were higher than those from limbus nasal center to the lower punctum (6.13–30.39 and 4.34–26.85%, respectively).

Conclusions

This study provided high reliability of the three-dimensional lateral distraction test (3D-LDT) for assessing medial canthal tendon (MCT) laxity, which were never evaluated by digital imaging system.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Muller muscle conjunctival resection or external levator advancement; a quantitative comparison of symmetry in unilateral ptosis

PURPOSE

To compare muller muscle conjunctival resection (MMCR) and external levator advancement (ELA) in terms of objective and subjective symmetry in unilateral ptosis.

METHODS

The patients who underwent unilateral MMCR (group1, n = 25) and ELA (group2, n = 25) were reviewed retrospectively. With the written algorithm, margin reflex distance-1 (MRD1), localization of the contour peak, and the percentage of overlapping curvatures (POC) of both upper eyelid curves were calculated. Semi-automated measurements were compared with the manual measurements. The correlation between objective and subjective symmetry was evaluated.

RESULTS

Preoperative levator functions were similar in both groups (13.93 ± 3.25 mm and 13.3 ± 2.86 mm, respectively). We found strong correlations between manual and semi-automated measurements (ICC: 0.942, 95% CI = 0.924-0.956, p < 0.001). Preoperative MRD1 (2.15 ± 0.90 vs 1.51 ± 1.01, p = 0.022) and POC was lower in group 2 (66% vs 47.2%, p = 0.01). In the postoperative period, the increase in MRD1 and POC were similar in both groups (p = 0.2 and p = 0.7 respectively), and the contour peak displaced temporally (p < 0.01) providing a symmetric peak in both groups. Subjective symmetry increased as the difference in MRD1 between two eyes decreased (r = -0.456, p = 0.001), and POC increased (r = 0.396, p = 0.004).

CONCLUSIONS

Besides subjective symmetry, MMCR and ELA are equally effective in ensuring symmetry objectively, as measured with MRD1 and contour peak symmetry and POC in unilateral ptosis. POC may be used as a criterion of symmetry in the evaluation of ptosis.

PeriorbitAI: Artificial Intelligence Automation of Eyelid and Periorbital Measurements

PURPOSE

To develop a deep learning semantic segmentation network to automate the assessment of 8 periorbital measurements DESIGN: Development and validation of an artificial intelligence (AI) segmentation algorithm METHODS: A total of 418 photographs of periorbital areas were used to train a deep learning semantic segmentation model to segment iris, aperture, and brow areas. These data were used to develop a post-processing algorithm that measured margin reflex distance (MRD) 1 and 2, medial canthal height (MCH), lateral canthal height (LCH), medial brow height (MBH), lateral brow height (LBH), medial intercanthal distance (MID), and lateral intercanthal distance (LID). The algorithm validity was evaluated on a prospective hold-out test set against 3 graders. The main outcome measures were dice coefficient, mean absolute difference, intraclass correlation coefficient, and Bland-Altman analysis. A smartphone video was also segmented and evaluated as proof of concept.

RESULTS

The AI algorithm performed in close agreement with all human graders, with a mean absolute difference of 0.5 mm for MRD1, MRD2, LCH, and MCH. The mean absolute difference between graders is approximately 1.5-2 mm for LBH and MBH and approximately 2-4 mm for MID and LID. The 95% confidence intervals for all graders overlapped in most cases, demonstrating that the algorithm performs similarly to human graders. The segmentation of a smartphone video demonstrated that MRD1 can be dynamically measured.

CONCLUSIONS

We present, to our knowledge, the first open-sourced, artificial intelligence system capable of automating static and dynamic periorbital measurements. A fully automated tool stands to transform the delivery of clinical care and quantification of surgical outcomes.

Aesthetic Eyelid Measurements of "Beautiful People": Gender Differences and Application for Thyroid Eye Disease Patients

There remains a paucity of studies investigating measurements of periocular structures of people popularly seen as “beautiful.” Such measurements may be helpful in establishing postoperative goals and measuring aesthetic outcomes. This study (1) identifies aesthetic measurements of the periocular structures in idealized celebrities, (2) determines gender differences in such measurements, and (3) compares these measurements to patients who underwent surgical repair of upper eyelid retraction associated with thyroid eye disease.

Analysis of surgical outcome after upper eyelid surgery by computer vision algorithm using face and facial landmark detection

PURPOSE

To evaluate the postoperative changes with a computer vision algorithm for anterior full-face photographs of patients who have undergone upper eyelid blepharoplasty surgery with, or without, a Müller's muscle-conjunctival resection (MMCR).

METHODS

All patients who underwent upper eyelid blepharoplasty surgery (Group I), or upper eyelid blepharoplasty with MMCR (Group II) were included. Both preoperative and 6-month postoperative anterior full-face photographs of 55 patients were analyzed. Computer vision and image processing technologies were used to measure the palpebral distance (PD), eye-opening area (EA), and average eyebrow height (AEBH) for both eyes. Preoperative and postoperative measurements were calculated and compared between the two groups.

RESULTS

In Group II, change in postoperative Right PD, Left PD, Right EA, Left EA was significantly higher than in Group I (p = 0.004 for REPD; p = 0.001 for LEPD; p = 0.004 for REA; p = 0.002 for LEA, p < 0.05). In Group II, the postoperative change in Right AEBH, Left AEBH was significantly higher than in Group I (p = 0.001 for RABH and LABH, p < 0.05).

CONCLUSION

Eyelid surgery for esthetic purposes requires artistic judgment and objective evaluation. Because of the slight differences in photograph sizes and dynamic factors of the face due to head movements and facial expressions, it is hard to compare and make a truly objective evaluation of the eyelid operations. With a computer vision algorithm, using the face and facial landmark detection system, the photographs are normalized and calibrated. This system offers a simple, standardized, objective, and repeatable method of patient assessment. This can be the first step of Artificial Intelligence algorithm to evaluate the patients who had undergone eyelid operations.

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.

An Artificial Intelligence Approach to the Assessment of Abnormal Lid Position

New artificial intelligence (AI) approaches to facial analysis show promise in the clinical evaluation of abnormal lid position. This could allow more naturalistic, quantitative, and automated assessment of lid position. The aim of this article was to determine whether OpenFace, an AI approach to real-time facial landmarking and analysis, can extract clinically useful measurements from images of patients before and after ptosis correction. Manual and AI-automated approaches to vertical palpebral aperture measurement of 128 eyes in pre- and postoperative full-face images of ptosis patients were compared in this study. Agreement in interpupillary distance to vertical palpebral aperture ratio between clinicians and an AI-based system was assessed. Image quality varied highly with interpupillary distance defined by a mean of 143.4 pixels (min = 60, max = 328, SD = 80.3 pixels). A Bland-Altman analysis suggests a good agreement between manual and AI analysis of vertical palpebral aperture (94.4% of measurements falling within 2 SDs of the mean). Correlation between the 2 methods yielded a Pearson's r(126) = 0.87 (P < 0.01) and r2 = 0.76. This feasibility study suggests that existing, open-source approaches to facial analysis can be applied to the clinical assessment of patients with abnormal lid position. The approach could be extended to further quantify clinical assessment of oculoplastic conditions.

The Effect of Two Different Frontalis Sling Approaches on Postoperative Eyelid Contour: A Comparative Study

PURPOSE

To compare two different frontalis sling approaches, tarsal fixation and orbicular muscle fixation, using silicone rod (FCI Ophthalmics, Marshfield Hills, MA, USA) in terms of postoperative upper eyelid contour in patients with poor levator muscle function.

DESIGN

Retrospective, comparative, case series.

METHODS

Ten eyes of seven patients who received frontalis sling surgery with orbicularis muscle fixation (group 1), eight eyes of seven patients who received frontalis sling surgery with tarsal fixation (group 2) and 30 eyes of 15 age and sex-matched healthy controls (control group) were included. Postoperative photographs of all the participants were taken in the primary gaze, and each photograph was viewed on a computer. The distance between the upper lid margin and pupillary center (MCD), nasal limbus (MND), and temporal limbus (MTD) was measured, respectively, using the ruler in Microsoft Paint Software and compared with each other for each participant.

RESULTS

Both nasal, central and temporal margin distance values in group 1 and group 2 were significantly lower than those of the control group (p < 0.05 for all values). The ratio of MTD/MCD in the control group was significantly higher than group 1 (p = 0.04) besides the ratio of MND/MTD in the control group was significantly lower than group 1 (p = 0.01).

DISCUSSION

Frontalis sling approach with tarsal fixation using silicone rod might provide improved cosmetic results including more symmetrical upper eyelid contour compared with orbicularis muscle fixation approach. Moreover, the novel measuring technique presented in the current study provides a simple and effective assessment of the upper lid contour in daily practice setting.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Impact of Canthal Height on Horizontal Upper Eyelid Peak Position: A Guide for Blepharoptosis Surgery

This study was aimed at examining the relationship between the horizontal upper eyelid peak position (Δpeak-pupil) and the difference between the medial and lateral canthal heights (Δcanthi) in Japanese individuals. Images of the left eyelid of 71 participants without eyelid disease were acquired with a camera with a slit-lamp microscope. Multivariate linear regression analysis was performed to determine the influence of age, sex, distance from the pupil center to the upper eyelid margin (margin reflex distance-1), Δcanthi, and palpebral fissure width on Δpeak-pupil. In addition, Δpeak-pupil distribution in participants with Δcanthi <3 (Group A), 3 to 6 (Group B), and >6 mm (Group C) was calculated as the average±2x the standard deviation. The mean Δpeak-pupil was 1.12 ± 1.29 mm (range: -1.44 to 6.12) and the mean Δcanthi was 4.50 ± 1.71 mm (1.02-7.96). Δcanthi was a significant determinant factor of Δpeak-pupil (P < 0.0001), whereas age (P = 0.62), sex (P = 0.88), margin reflex distance-1 (P = 0.29), and the horizontal palpebral fissure width (P = 0.65) were not related to Δpeak-pupil. The normal Δpeak-pupil ranges were -1.47 to 1.52, -0.95 to 3.22, and -0.84 to 4.73 mm in Groups A, B, and C, respectively. There was a statistically significant difference between the Group A and B ranges and between the Group A and C ranges (Kruskal-Wallis test, P < 0.01). It was concluded that the normal eyelid peak position differs according to medial-to-lateral canthal positional difference. This finding may help intraoperative determination of the upper eyelid peak position in blepharoptosis surgery.

Orbicularis Oculi Morphological Alterations in Affected and Nonaffected Sides in Hemifacial Spasm

BACKGROUND

Although the nonaffected side appears to be clinically normal in hemifacial spasm (HFS), it is not known whether this side can be considered normal regarding histopathological findings. The purpose of this study was to objectively evaluate and compare orbicularis oculi samples of patients with HFS (not previously treated with botulinum toxin) and control patients undergoing cosmetic upper eyelid blepharoplasty.

METHODS

Orbicularis oculi samples from 22 eyelids were evaluated. There were 7 samples from the affected and 7 samples from the nonaffected sides of patients with HFS who had not been previously treated with botulinum toxin, and 8 samples from normal control patients. Muscle samples were prepared using hematoxylin and eosin staining, and a digital image analysis software was used for objective analyses.

RESULTS

When compared with normal controls, endomysial and perimysial connective tissue areas were significantly increased (P = 0.015) on the affected side in HFS, suggesting that this disorder is associated with chronic alterations that lead to muscle degeneration. Cell density was significantly reduced on the affected (P = 0.028) and also on the nonaffected sides in HFS (P = 0.003) compared with normal controls. This was observed, although, clinically, there were no signs or symptoms of increased muscular contraction on the nonaffected sides in any of the patients with HFS studied.

CONCLUSIONS

Significant morphological differences in the orbicularis oculi muscle in patients with HFS were observed on both the affected and nonaffected sides. Our findings suggest a potential role for muscle homeostasis disturbances on both sides for patients with HFS. Affected sides in patients with HFS did, however, demonstrate muscle degeneration that was not present on the nonaffected sides.

Symmetry of Upper Eyelid Contour After Unilateral Blepharoptosis Repair With a Single-strip Frontalis Suspension Technique

PURPOSE

To analyze the upper eyelid contour of patients with unilateral congenital ptosis who underwent single-strip frontalis suspension.

METHODS

The authors compared the upper eyelid shape of the right and left eyes of 10 patients who underwent unilateral frontalis suspension with a single strip of autogenous fascia. At a mean postoperative time of 10.1 ± 4.01 months, the image J software was used to measure the ratio between the nasal and temporal areas of the upper half of the palpebral fissure. The midpupil upper eyelid distance (MRD1) was also measured on the photos with the same software. The nonparametric Wilcoxon signed-rank test was used to compare the data.

RESULTS

Postoperative MRD1 ranged from 2.5 to 4.7 mm (median = 3.8) on the affected side. The MRD1 for nonoperated eyelid ranged from 1.8 to 5.0 mm (median = 3.5). On the operated side, the temporal areas ranged from 50.3 to 85.7 mm (median 65.2) and nasal areas ranged from 41.5 to 72.3 (the median was 60.1). In the contralateral, nonoperated palpebral fissures, the temporal areas ranged from 42.7 to 94.3 mm (median = 54.5) and the nasal areas ranged from 36.8 to 86.1 mm (median 52.3). The T/N ratio distributions were almost identical between groups, ranging from 0.9 to 1.2 (median = 1.1) in the operated eyes and from 0.9 to 1.3 (median = 1.1) in the fellow eyes.

CONCLUSIONS

In autogenous fascia frontalis suspension procedures, the upper eyelid contour of the ptotic eyelids can be adequately normalized with a single area of traction on the tarsal plate.

Efficacy of Gaze Photographs in Diagnosing Ocular Myasthenia Gravis

Background and Purpose

The various tests that are routinely used to diagnose generalized myasthenia gravis, such as the edrophonium test, serum anti-acetylcholine-receptor antibodies (AChR-Ab), and repetitive nerve stimulation (RNS) tests, have lower diagnostic sensitivity in ocular myasthenia gravis (OMG). Diagnosing OMG becomes even more difficult when the clinical symptoms are subtle. There is no gold-standard diagnostic test available for OMG patients, and so this study compared the diagnostic sensitivity of gaze photographs with conventional tests in OMG.

Methods

Records of gaze photographs were available for 25 of 31 consecutive patients diagnosed with OMG. Each patient underwent a neuro-ophthalmologic examination, serum AChR-Ab, RNS, edrophonium test, ice tests, and the acquisition of gaze photographs. The margin reflex distance 1 (MRD1) was measured on each of the gaze photographs, with MRD1 <2 mm or an interlid MRD1 difference of ≥2 mm on any of the gaze photographs defined as a positive sign of OMG. The diagnostic sensitivities of the tests were assessed.

Results

The mean age at onset was 38.5 years (range, 2–76 years), and 13 patients (52%) were men. The diagnostic sensitivities of the RNS test, AChR-Ab test, gaze photographs, and ice test were 56%, 64%, 80%, and 73%, respectively.

Conclusions

The diagnostic sensitivity was higher for gaze photographs than for the other tests applied to OMG patients.

A novel technique for the measurement of eyelid contour to compare outcomes following Muller's muscle-conjunctival resection and external levator resection surgery

BACKGROUND

Both external levator resection (ELR) and Müller's muscle-conjunctival resection (MMCR) are procedures well known to improve marginal reflex distance (MRD1) in patients with ptosis. This study aims to understand differential post-operative changes in eyelid contour for MMCR and ELR surgery.

METHODS

In this cross-sectional cohort study, patients affected by involutional ptosis were randomized into two groups: those who underwent ELR or MMCR surgery. Pre-operative and late post-operative photographs were obtained. Digital analysis of the lid contour was performed by measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. Mean distance at each position was compared pre- and post-operatively between the groups.

RESULTS

The final sample included 60 eyes from 39 patients, 30 eyes per group. At each time point there was significant variation in height across the eyelid (p < 0.05). A significant (p < 0.05) group difference in vertical height was noted only at the 2 and 4 mm temporal positions in the post-operative analysis, with the ELR group being slightly higher. There were no significant differences in MRD1, pre- or post-operatively, between the ELR and MMCR groups.

CONCLUSIONS

Both ELR and MMCR are effective at elevating the eyelid in multiple positions across the length of the eyelid. Although they do not produce significantly different MRD1 results, ELR was associated with a greater eyelid height at the 2 and 4 mm temporal positions.

Topographic analysis of eyelid position using digital image processing software

PURPOSE

To propose a novel analysis technique for objective quantification of topographic eyelid position with an algorithmatically calculated scheme and to determine its feasibility.

METHODS

One hundred normal eyelids from 100 patients were segmented using a graph cut algorithm, and 11 shape features of eyelids were semi-automatically quantified using in-house software. To evaluate the intra- and inter-examiner reliability of this software, intra-class correlation coefficients (ICCs) were used. To evaluate the diagnostic value of this scheme, the correlations between semi-automatic and manual measurements of margin reflex distance 1 (MRD1) and margin reflex distance 2 (MRD2) were analysed using a Bland-Altman analysis. To determine the degree of agreement according to manual MRD length, the relationship between the variance of semi-automatic measurements and the manual measurements was evaluated using linear regression.

RESULTS

Intra- and inter-examiner reliability were excellent, with ICCs ranging from 0.913 to 0.980 in 11 shape features including MRD1, MRD2, palpebral fissure, lid perimeter, upper and lower lid lengths, roundness, total area, and medial, central, and lateral areas. The correlations between semi-automatic and manual MRDs were also excellent, with better correlation in MRD1 than in MRD2 (R = 0.893 and 0.823, respectively). In addition, significant positive relationships were observed between the variance and the length of MRD1 and 2; the longer the MRD length, the more the variance.

CONCLUSION

The proposed novel optimized integrative scheme, which is shown to have high repeatability and reproducibility, is useful for topographic analysis of eyelid position.

Differences in interpalpebral fissure measurement in patients with unilateral enophthalmos resulting from orbital wall fractures

PURPOSE

To determine the correlation between the degree of enophthalmos and interpalpebral fissure (IPF) measurements in a group of patients with unilateral orbital wall fractures.

MATERIALS AND METHODS

The medical charts of 45 patients diagnosed with unilateral enophthalmos resulting from an orbital wall fracture were reviewed. Demographic characteristics were investigated, including patient age, sex, medical history, and type of orbital wall fracture. The correlation between the degree of enophthalmos and IPF was determined, adjusting for confounding demographic factors.

RESULTS

In the group with orbital wall fractures, the correlation between the degree of enophthalmos and the IPF measurements was positive and significant (R = 0.299, p = 0.046, Pearson's correlation). The correlation coefficient increased after adjusting for age, sex, medical history, and type of orbital wall fracture (R = 0.316, p = 0.044).

CONCLUSION

The patient group with more severe enophthalmos tended to have lower IPF values.

Contour Symmetry of the Upper Eyelid Following Bilateral Conjunctival-Müller's Muscle Resection

Background

Conjunctiva-Müller muscle resection (CMMR) is a simple, effective, and predictable procedure for internal treatment of ptosis.

Objectives

The authors determined contour symmetry of the upper eyelid following bilateral CMMR.

Methods

Thirty control participants (ie, without ptosis) and 44 patients with acquired bilateral blepharoptosis who underwent CMMR were evaluated in a prospective study. To assess symmetry of lid contour, distances from midpupil to the upper eyelid (ie, MPLDs) were determined radially at intervals of 15° (total, 180°) along the palpebral fissure, and MPLDs at each angle were compared for right and left eyes.

Results

For control participants, the mean marginal reflex distance (MRD1; ie, MPLD at 90°) ± standard error (SE) was 4.05 mm ± 0.75 mm, and small contour asymmetries (<10%) were measured for all angles. Medial (9.4% ± 4.7%) and lateral (8.1% ± 4.9 %) asymmetries were not significantly different for these participants. For patients with ptosis, the mean preoperative MRD1 was 2.56 ± 0.1 mm, and mean medial and lateral lid asymmetries (14.3% ± 8.4% and 16.7% ± 9.7%, respectively) were significantly higher than those of controls. Medial and lateral asymmetries correlated significantly with the extent of ptosis and were more pronounced laterally than medially. One month after CMMR, the lateral-medial discrepancy in lid asymmetry was resolved, and mean medial and lateral MPLDs (9.9% ± 7.5% and 8.5% ± 5.3%, respectively) were similar to those of controls.

Conclusions

For patients with involutional ptosis, CMMR enables elevation of the lid margin and correction of contour anomalies.

Periorbital Biometric Measurements using ImageJ Software: Standardisation of Technique and Assessment Of Intra- and Interobserver Variability

Purpose:

To assess the reliability and repeatability of periorbital biometric measurements using ImageJ software and to assess if the horizontal visible iris diameter (HVID) serves as a reliable scale for facial measurements.

Methods:

This study was a prospective, single-blind, comparative study. Two clinicians performed 12 periorbital measurements on 100 standardised face photographs. Each individual’s HVID was determined by Orbscan IIz and used as a scale for measurements using ImageJ software. All measurements were repeated using the ‘average’ HVID of the study population as a measurement scale. Intraclass correlation coefficient (ICC) and Pearson product-moment coefficient were used as statistical tests to analyse the data.

Results:

The range of ICC for intra- and interobserver variability was 0.79–0.99 and 0.86–0.99, respectively. Test-retest reliability ranged from 0.66–1.0 to 0.77–0.98, respectively. When average HVID of the study population was used as scale, ICC ranged from 0.83 to 0.99, and the test-retest reliability ranged from 0.83 to 0.96 and the measurements correlated well with recordings done with individual Orbscan HVID measurements.

Conclusion:

Periorbital biometric measurements using ImageJ software are reproducible and repeatable. Average HVID of the population as measured by Orbscan is a reliable scale for facial measurements.

Digital Analysis of Eyelid Features and Eyebrow Position Following CO2 Laser-assisted Blepharoptosis Surgery

Background:

To compare the margin reflex distance of the upper (MRD-1) and lower (MRD-2) eyelids and the eyebrow height (EBH) in patients with involutional and hard contact lens wear--induced blepharoptosis before and after ptosis surgery.

Methods:

Sixty patients with acquired blepharoptosis were studied. Group 1 consisted of 30 patients with involutional ptosis (age, 75.8 ± 6.4 years), and group 2 consisted of 30 patients with hard contact lens wear–induced ptosis (age, 50.2 ± 7.1 years). All patients underwent bilateral, CO₂ laser–assisted levator aponeurosis advancement surgery. A digital image was taken in the primary position before and 2 months after the surgery. The image was analyzed by the ImageJ (NIH, Bethesda, Md.) software. Parameters included MRD-1, MRD-2, EBH, and ocular surface area (OSA).

Results:

After surgery, all patients had a significant increase in the MRD-1 and OSA and a decrease in the EBH (all P < 0.001). The increase in MRD-1 was significantly larger in group 1 than in group 2 (P = 0.028). The decrease of EBH was significantly greater in group 1 than in group 2 (P = 0.007). Group 1 had a slight decrease in the MRD-2, but group 2 had a significant increase after surgery (P = 0.026). The change in the OSA was not significantly different between the 2 groups.

Conclusions:

Digital image analyses can be used for precise measurements of the eyelid features. The disparity in the changes of eyelid and eyebrow features between the 2 groups may suggest different responses of the external eyelid muscles to surgery between cases of different etiology.

Validation of the facial assessment by computer evaluation (FACE) program for software-aided eyelid measurements

The aim of this article is to validate the accuracy of Facial Assessment by Computer Evaluation (FACE) program in eyelid measurements. Sixteen subjects between the ages of 27 and 65 were included with IRB approval. Clinical measurements of upper eyelid margin reflex distance (MRD1) and inter-palpebral fissure (IPF) were obtained. Photographs were then taken with a digital single lens reflex camera with built-in pop-up flash (dSLR-pop) and a dSLR with lens-mounted ring flash (dSLR-ring) with the cameras upright, rotated 90, 180, and 270 degrees. The images were analyzed using both the FACE and ImageJ software to measure MRD1 and IPF.Thirty-two eyes of sixteen subjects were included. Comparison of clinical measurement of MRD1 and IPF with FACE measurements of photos in upright position showed no statistically significant differences for dSLR-pop (MRD1: p = 0.0912, IPF: p = 0.334) and for dSLR-ring (MRD1: p = 0.105, IPF: p = 0.538). One-to-one comparison of MRD1 and IPF measurements in four positions obtained with FACE versus ImageJ for dSLR-pop showed moderate to substantial agreement for MRD1 (intraclass correlation coefficient = 0.534 upright, 0.731 in 90 degree rotation, 0.627 in 180 degree rotation, 0.477 in 270 degree rotation) and substantial to excellent agreement in IPF (ICC = 0.740, 0.859, 0.849, 0.805). In photos taken with dSLR-ring, there was excellent agreement of all MRD1 (ICC = 0.916, 0.932, 0.845, 0.812) and IPF (ICC = 0.937, 0.938, 0.917, 0.888) values. The FACE program is a valid method for measuring margin reflex distance and inter-palpebral fissure.

Influence of involuntary eyelid spasms on corneal topographic and eyelid morphometric changes in patients with hemifacial spasm

BACKGROUND/AIMS

In patients with hemifacial spasm (HFS), treatment relieves eyelid spasms on the affected side, thus changes in corneal topography and eyelid morphometry may be observed after treatment. We aimed to evaluate these parameters during a 4-month period in patients with HFS treated with botulinum toxin A (BTX-A).

METHODS

This prospective study evaluated eyelid morphometric and corneal topographic changes in patients with HFS before onabotulinum toxin A application, and after 15 days and 2, 3 and 4 months.

RESULTS

24 patients were treated with BTX-A. On the normal side, the mean palpebral fissure height (PF), interpalpebral surface area (ISA), steep K and astigmatism values were 8.7±1.98 mm, 122.09±39.37 mm², 44.99±1.45 D and 0.9±0.64 D, respectively, before treatment. A statistically significant difference was not observed in these parameters after treatment (p>0.05). On the affected side, the mean PF, ISA, steep K and astigmatism were 5.5±1.77 mm, 67.68±28.49 mm², 46.91±3.57 D and 2.63±2.46 D, respectively, before treatment. We observed a statistically significant (p<0.05) increase in the mean PF and ISA on the affected side 15 days (8.36±1.91 mm and 115.92±34.44 mm², respectively), 2 months (8.18±1.80 mm and 112.22±33.57 mm², respectively) and 3 months (7.27±1.65 mm and 95.48±27.80 mm², respectively) after treatment. A statistically significant decrease in steep K and astigmatism was observed at 2 months (45.14±1.20 D and 1.01±0.58 D, respectively) and 3 months (45.64±1.77 D and 1.36±1.31 D, respectively) after treatment.

CONCLUSIONS

The results suggest that treatment with BTX-A in patients with HFS leads to eyelid and corneal changes on the affected eye that are significant during the known period of action of the toxin. Thus, caution should be taken when performing ophthalmological examination in patients with HFS, since it may vary according to BTX-A period of action.

Quantitative Comparison of the Effect of 10% Phenylephrine Instillation and Manual Elevation in Patients with Involutional Blepharoptosis

OBJECTIVE

To compare the effect of 10% phenylephrine (PE) instillation and manual elevation (ME) on the upper eyelid position of the tested eye and the contralateral eye in patients with involutional blepharoptosis (IB).

METHODS

IB patients were submitted to two tests followed by observation of the effect on the contralateral eyelid: (1) ME of the more ptotic eyelid; and (2) instillation of two drops of 10% PE (phenylephrine test) in the more ptotic eye. The patients were filmed before and 5, 10, and 15 minutes after instillation. The upper eyelid margin reflex distance (MRD1) was measured using the software Image J, and the results were analyzed with the linear mixed-effects model.

RESULTS

The study included 70 patients aged 44-86 years, 64 of whom were female (91.43%), divided into three groups: subjects with unilateral IB, subjects with bilateral IB, and controls. The eye submitted to instillation with 10% PE displayed significant elevation during the first 10 min: from 1.33 ± 0.66 mm to 2.06 ± 0.89 mm (unilateral group), from 1.26 ± 0.63 mm to 2.29 ± 0.86 mm (bilateral group), and from 3.12 ± 0.68 mm to 4.06 ± 0.92 mm (control group). MRD1 decreased in the contralateral eye in IB patients, significantly more so after the phenylephrine test: PE vs. ME = 18.9% versus 17.2% reduction in the unilateral group, and 13.6% versus 10.7% reduction in the bilateral group. The outcome was not influenced by IB severity and the concurrence of IB and eye dominance.

CONCLUSION

Both ME and 10% PE affected the contralateral upper eyelid, but the response was significantly better with the latter.

Lateral and medial upper eyelid contour abnormalities in graves orbitopathy: the influence of the degree of retraction

PURPOSE

To determine the location of contour abnormalities in Graves upper eyelid retraction.

METHODS

Multiple midpupil angular eyelid distances of 75 upper eyelids of 55 patients (mean age = 41.7 ± 13.3 SD years) in the inactive phase of Graves orbitopathy were measured with a recently developed custom-made software. Sixty eyelids of 60 normal subjects were also measured as a control group. A contour peak was defined by the highest midpupil angular eyelid distance normalized (divided) by the superior limit of normality (mean + 2SD).

RESULTS

In 45 eyelids (60%), the peaks were lateral between 120° and 150°. For high levels of retraction, the peaks tended to be centrally located with a substantial number of medial deformities (30 eyelids). Although the lateral and medial peaks were not affected by exophthalmometry, there was a statistically significant increase of medial peaks when midpupil eyelid distance was greater than 6.75 mm (χ = 5.20, p = 0.02).

CONCLUSIONS

Lateral contour abnormalities are more frequent than medial deformities. With minor degrees of retraction, there is a predominance of lateral peaks. With higher degrees of retraction, the number of medial abnormalities is similar to the lateral ones.

Assessment of eyebrow position before and after upper eyelid blepharoplasty

OBJECTIVE

Assess the occurrence of secondary brow ptosis after upper lid blepharoplasty.

METHODS

Forty-five individuals (n = 90 brows) submitted to upper lid blepharoplasty, were assessed by means of a comparative analysis using pre- and post-operatively digital photographs, in the primary position of the eye. The images were processed using ImageJ "software", transferred to a computer, to an electronic Microsoft Excel 2002(®) worksheet. Angular measurements were used, taking the lateral canthal angle of the brow, the most medial point of the brow, the medial canthal angle and the lateral canthal angle of the lid as anatomical reference points. When the outer angles were reduced or the inner angles increased after surgery this was considered a brow ptosis. Individuals who had undergone lid surgery associated with the eyebrow, previous eyebrow surgery and those with eyelid ptosis were excluded. The difference between the pre-operative and post-operative measurements were analyzed statistically using the Student's t-test for paired samples and the angular variation was compared with their corresponding contralateral sample using Wilcoxon's non-parametric test.

RESULTS

The measurements obtained after the blepharoplasty show significant variations from those before the surgery, indicating that the correction of redundant tissues in the brow accentuates the tendency of the eyebrow to move down. The alterations are more important in the lateral portion of the eyebrow and they occur bilaterally.

CONCLUSION

The assessment of angular measurements obtained pre- and post-operatively showed that there are secondary changes in the position of the eyebrow as a result of upper eyelid blepharoplasty.

Multiple radial midpupil lid distances: a simple method for lid contour analysis

PURPOSE

To describe a new computerized method for the analysis of lid contour based on the measurement of multiple radial midpupil lid distances.

DESIGN

Evaluation of diagnostic technology.

PARTICIPANTS AND CONTROLS

Monocular palpebral fissure images of 35 patients with Graves' upper eyelid retraction and of 30 normal subjects.

METHODS

Custom software was used to measure the conventional midpupil upper lid distance (MPLD) and 12 oblique MPLDs on each 15° across the temporal (105°, 120°, 135°, 150°, 165°, and 180°) and nasal (75°, 60°, 45°, 30°, 15°, and 0°) sectors of the lid fissure.

MAIN OUTCOME MEASURES

Mean, standard deviation, 5th and 95th percentiles of the oblique MPLDs obtained for patients and controls. Temporal/nasal MPLD ratios of the same angles with respect to the midline.

RESULTS

The MPLDs increased from the vertical midline in both nasal and temporal sectors of the fissure. In the control group the differences between the mean central MPLD (90°) and those up to 30° in the nasal (75° and 60°) and temporal sectors (105° and 120°) were not significant. For greater eccentricities, all temporal and nasal mean MPLDs increased significantly. When the MPLDs of the same angles were compared between groups, the mean values of the Graves' patients differed from control at all angles (F = 4192; P<0.0001). The greatest temporal/nasal asymmetry occurred 60° from the vertical midline.

CONCLUSIONS

The measurement of radial MPLD is a simple and effective way to characterize lid contour abnormalities. In patients with Graves' upper eyelid retraction, the method demonstrated that the maximum amplitude of the lateral lid flare sign occurred at 60° from the vertical midline.

Comparative evaluation of oculometric variables in Graves' ophthalmopathy

OBJECTIVES

To estimate oculometric parameters of Graves' ophthalmopathy in comparison to healthy eyes using digital photography and digital image analysis.

INTRODUCTION

Graves' ophthalmopathy is the main cause of eye proptosis. Because these protrusions cause clinically perceived distortions in orbital architecture, digital photographs can be used to detect and quantify these changes.

METHODS

We carried out a cross-sectional study comprising 12 healthy volunteers and 15 Graves' ophthalmopathy patients with the purpose of evaluating the use of simple, non-invasive digital photography to estimate oculometric parameters of Graves' ophthalmopathy and compare them with the parameters of unaffected eyes. Facial photographs of cases and controls were taken in a standardized manner. Oculometric parameters were compared between the groups and then correlated to proptometer measures.

RESULTS

All estimated oculometric variables showed significant differences between the groups, in particular with regard to mediopupilar aperture, lateral height, distance from the iris edge to the lateral boundary of the palpebral fissure, and distance from the higher point of the iris to the lateral limit of the palpebral fissure. The product of medial aperture and horizontal palpebral fissure also revealed greater discrepancy between the groups. Proptometer measures showed significant linear correlation between the distance from the iris edge to the lateral boundary of the palpebral fissure and between the distance from the higher point of the iris to the lateral limit of palpebral fissure (p<0.05).

CONCLUSIONS

Comparative analysis of oculometric parameters in Graves' ophthalmopathy suggests that eye proptosis is related to an asymmetric increase in lateral oculometric measures. Standardized digital photographs can be used in clinical practice to objectively estimate oculometric parameters of Graves' ophthalmopathy patients.

Extraocular muscle quantification using mathematical morphology: A semi-automatic method for analyzing muscle enlargement in orbital diseases

Mathematical morphology was used to quantify the dimensions of the human extraocular muscles in computed tomography orbital scans. Coronal images of 28 patients with Graves orbitopathy and 5 controls (218 orbital scans) were analyzed with an algorithm for extraocular muscle segmentation. The results showed that measurements of extraocular muscle area obtained with semi-automatic segmentation are highly correlated with manual tracing and provides a simple method to quantify orbital structures including the extraocular muscles.

[Morphometric analysis of the palpebral fissure in patients with thyroid-related disfunction before and after application of botulinum toxin]

INTRODUCTION

Botulinum toxin is an alternative treatment for retraction of ocular thyroid related dysfunction. The aim of this study was to evaluate the effects of this medication on upper lid position, levator palpebrae superioris muscle function and corneal exposure.

METHODS

Seven patients were enrolled into the study. The palpebral fissure images were acquired by a digital camera and transferred to a computer video edition program in order to be processed and analyzed. The levator palpebrae superioris muscle function and lacrimal film tests were also studied.

RESULTS

The distance between upper eyelid superior margin and light reflection on the center of the cornea had a significantly reduction in its measurements after toxin injection. The muscle function was diminished and there were improvement in corneal exposure after treatment.

DISCUSSION

Botulinum toxin injection could be an alternative treatment for upper eyelid retraction; it may relieve symptoms and improve eye appearance.

The Morphology of the Palpebral Fissure in Different Directions of Vertical Gaze

PURPOSE

The purpose of this study is to investigate the normative morphology of the palpebral fissure by measuring a range of biometric eye dimensions for a population of young subjects through analysis of digital images in primary gaze and two typical angles of downward vertical gaze. Palpebral fissure characteristics are clinically important in areas such as contact lens practice.

METHODS

High-resolution digital images were taken of 76 young subjects with a range of refractive errors in primary gaze and 20 degrees and 40 degrees downward gaze. The digital images were analyzed to ascertain a range of biometric measures of the palpebral fissure for each subject in each angle of gaze. Repeated-measures analysis of variance was used to investigate changes occurring in the palpebral fissure dimensions with vertical angle of gaze.

RESULTS

Highly significant changes were found to occur in the horizontal and vertical palpebral fissure dimensions, the palpebral fissure angle, and the eyelid contour as a function of angle of gaze. The palpebral fissure narrows in the vertical dimension (from an average vertical palpebral aperture width for white subjects in primary gaze of 9.7+/-1.2 mm to an average width of 6.4+/-1.1 mm in 40 degrees downgaze), shortens in the horizontal dimension (from average horizontal palpebral aperture width of 27.1+/-1.5 mm in primary gaze to an average of 25.6+/-1.8 mm in 40 degrees downgaze), and becomes more "down-slanted" with increasing downward gaze.

CONCLUSIONS

Highly significant changes to the palpebral fissure dimensions occur in downward vertical gaze. These changes are important because many visual tasks are performed in downward gaze. These findings have implications for the management of lid anomalies and for contact lens fitting and design.