Prostaglandin-associated periorbitopathy in latanoprost users

Lower eyelid position before and after blepharoptosis repair

PURPOSE

This study aimed to examine the changes in lower eyelid position after blepharoptosis surgery and the factors that influence the outcome.

METHODS

We conducted a retrospective study of 155 eyes of 89 patients who underwent blepharoptosis surgery between June 2019 and October 2022. The margin reflex distance (MRD)-1 and MRD-2 were examined preoperatively and 3 months postoperatively in two groups: one with lower scleral show (LSS) (n = 37) and one without LSS (n = 118). The clinical characteristics of the two groups were compared.

RESULTS

Both the LSS and non-LSS groups showed significant postoperative improvement in MRD-1 scores (p < .01, p < .01, respectively). MRD-2 was significantly reduced in the LSS group, while it remained unchanged in the non-LSS group (p < .01, p = .27, respectively). There were no significant differences between the two groups in age, sex, history of hard contact lens use, preoperative levator function, use of topical steroids, history of endophthalmic surgery, or history of filtration surgery; however, the LSS group significantly used prostaglandin analogs (PGAs) (p = .03). Postoperatively, MRD-2 decreased in 13 eyes (35.1%) and was maintained in 24 eyes (64.9%) in the LSS group and was maintained in all eyes in the non-LSS group. In the LSS group, we also examined the association between postoperative MRD-2 reduction and the use of PGAs and found that more patients with MRD-2 reduction used PGAs (p = .02).

CONCLUSION

Lower scleral show in PGAs-associated blepharoptosis is expected to improve after blepharoptosis surgery.

Improvement of Prostaglandin-Associated Periorbitopathy after Discontinuing Treatment

Objectives

To report that the periorbital changes induced by prostaglandin analogue (PGA) eye drops are partially reversible after discontinuing treatment.

Materials and Methods

Nine patients with prostaglandin-associated periorbitopathy seen in a referral oculoplastic practice were included in this study, eight with unilateral glaucoma and one with bilateral open-angle glaucoma. All of them had been treated with topical PGA for at least one year, before the treatment was discontinued for cosmetic reasons.

Results

In all cases, there were evident periocular differences between the treated eye and the fellow eye, consisting mainly of deepening of the upper eyelid sulcus and eyelid fat pad reduction. One year after discontinuing the PGA eye drops, improvement of these features was observed.

Conclusion

Clinicians and patients should be aware of the side effects of topical PGA therapy on periorbital tissues, and that these side effects can partially regress after discontinuation of the medication.

Facial Fat Fitness: A New Paradigm to Understand Facial Aging and Aesthetics

Traditionally, facial adipose tissue has been perceived and treated as a homogenous volume-occupying subcutaneous depot. However, recent research from across disciplines is converging to reveal a far more anatomically organized and functionally dynamic role of facial adipose tissue. In this narrative review, we will discuss new insights into adipocyte function and facial adipose anatomy that have far-reaching implications for the practice of aesthetic facial plastic surgery. These concepts are synthesized into a "facial fat fitness" model which can be used to explain clinical observations in facial aging and aesthetic surgery. Fat fitness relates to the quality of facial adipose tissue, as opposed to quantity, and describes whether adipose tissue is in a predominantly healthy hyperplastic or unhealthy hypertrophic state. Fat fitness is modulated by lifestyle factors, and may be impacted positively or negatively by facial aesthetic treatments. 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 .

Orbital Fat Volume After Treatment with Topical Prostaglandin Agonists

Purpose

Topical prostaglandin analogs (PGAs) are common treatment for primary open-angle glaucoma (POAG) but reportedly may cause adnexal fat atrophy. We asked if patients with POAG treated with PGAs have abnormalities in orbital fat volume (OFV).

Methods

We studied 23 subjects with POAG who had never experienced intraocular pressure (IOP) exceeding 21 mm Hg and were treated long term with PGAs, in comparison with 21 age-matched controls. Orbital volume, non-fat orbital tissue volume, and OFV were measured using high-resolution magnetic resonance imaging.

Results

Subjects with POAG had been treated with PGAs for 39 ± 19 months (SD) and were all treated within the 4 months preceding study. In the region from trochlea to orbital apex, OFV in POAG was significantly less at 9.8 ± 1.9 mL than in the control subjects at 11.1 ± 1.3 mL (P = 0.019). However, between the globe-optic nerve junction (GONJ) and trochlea, OFV was similar in both groups. Width and cross sectional area of the bony orbit were significantly smaller in POAG than in controls (P < 0.0001). Posterior to the GONJ, the average orbital cross-sectional area was 68.2 mm² smaller, and the orbital width averaged 1.5 mm smaller throughout the orbit, in patients with POAG than in controls.

Conclusions

Patients with POAG who have been treated with PGAs have lower overall OFV than controls, but OFV in the anterior orbit is similar in both groups. Lower overall OFV in POAG may be a primary association of this disorder with a horizontally narrower bony orbit, which may be a risk factor for POAG at nonelevated IOPs.

Changes in Prostaglandin-associated Periorbital Syndrome After Switch from Conventional Prostaglandin F2α Treatment to Omidenepag Isopropyl in 11 Consecutive Patients

PURPOSE

We evaluated the recovery of patients with PAPS for whom the treatment regimen switched from conventional prostaglandin F2α analogues to a new selective prostaglandin-EP2 agonist: omidenepag isopropyl.

PATIENTS AND METHODS

From November 2018 to July 2019, we prospectively evaluated 11 patients who had been using conventional PGF2α drugs. Digital photographs of the patients were taken before the start of omidenepag isopropyl therapy and ~3 and 6 months after. Three independent observers used the photographs to judged recovery according to the 5 signs of PAPS: deepening of the upper eyelid sulcus (DUES), flattening of the lower eyelid bags, upper eyelid ptosis, ciliary hypertrichosis, and periorbital skin hyperpigmentation.

RESULTS

The mean age of patients was 61, and 7 patients were female. The original PGF2α drugs were bimatoprost, latanoprost, travoprost, and tafluprost. The mean duration of PGF2α treatment was 65 months. PAPS signs were evaluated in 10 patients after 3 months and in all 11 patients after 6 months: After 3 and 6 months, DUES improved in 3 and 3 patients, respectively; flattening of the lower eyelid bags improved in 1 and 2 patients, respectively; upper eyelid ptosis did not improve in any patients; ciliary hypertrichosis improved in 0 and 2 patients, respectively; and eyelid pigmentation improved in 2 and 8 patients, respectively. The 3 patients who showed improvement in DUES at 6 months had all previously used bimatoprost.

CONCLUSIONS

Some PAPS signs improved after patients started taking omidenepag isopropyl. Our findings will be useful for patients taking antiglaucoma eye drops.

One-Year Follow-Up Study of Changes in Prostaglandin-Associated Periorbital Syndrome After Switch From Conventional Prostaglandin F2alfa to Omidenepag Isopropyl

Background

Cosmetic problems induced by conventional prostaglandin F2α (PGF2α) analogs are common. We prospectively evaluated the improvement of patients with prostaglandin-associated periorbital syndrome (PAPS) for whom the treatment regimen was switched from conventional PGF2α analogs to a new selective prostaglandin-EP2 agonist (i.e., omidenepag isopropyl).

Methods

We finally evaluated 12 patients with follow-up for one year who changed the therapy from conventional PGF2α drugs to omidenepag isopropyl. Digital facial images of the patients were captured prior to the initiation of therapy with omidenepag isopropyl and after approximately three, six, and 12 months. Three independent observers judged the recovery according to the five signs of PAPS - deepening of the upper eyelid sulcus (DUES), flattening of the lower eyelid bags, upper eyelid ptosis, ciliary hypertrichosis, and periorbital skin hyperpigmentation - by comparing images at baseline and each month.

Results

The mean age of patients (eight females; four males) was 61 years. The original PGF2α drugs were bimatoprost (N = 7), latanoprost (N = 3), travoprost (N = 1), and tafluprost (N = 1). The mean duration of treatment with PGF2α was 61 months. PAPS signs were evaluated in 11 patients after three months and in all 12 patients after six and 12 months. After three, six, and 12 months, DUES improved in five, six, and six patients, respectively; flattening of the lower eyelid bags improved in two, two, and three patients, respectively; upper eyelid ptosis improved in zero, one, and two patients, respectively; ciliary hypertrichosis improved in zero, one, and zero patients, respectively; and eyelid pigmentation improved in one, five, and three patients, respectively. Recovery of DUES was the most observed sign at ≤50%, whereas the recovery of ciliary hypertrichosis was the least sign at ≤8% at 12 months. All patients with improved DUES at one year had been receiving bimatoprost or travoprost.

Conclusions

Some PAPS signs improved after the administration of omidenepag isopropyl for one year. Our findings are useful for patients suffering from cosmetic problems induced by conventional PGF2α analogs.

Distribution of 14C-Latanoprost Following a Single Intracameral Administration Versus Repeated Topical Administration

Purpose

To qualitatively evaluate the ocular and periocular distribution of ¹⁴C-latanoprost following a single intracameral administration or repeated topical ocular administration in beagle dogs and cynomolgus monkeys.

Methods

In the dog study, three animals received an intracameral dose of ¹⁴C-latanoprost bilaterally and were euthanized at 1, 2, and 4 h post dose; three control animals received topical ¹⁴C-latanoprost bilaterally once daily for 5 days and were euthanized at 1, 4, and 24 h post final dose. Sagittal 40-µm sections of eyes with surrounding tissues were collected and processed for autoradiography. Methods in the monkey study were similar; two animals received a unilateral intracameral dose of ¹⁴C-latanoprost.

Results

After intracameral dosing in dogs, radioactivity was concentrated in the cornea, iris, ciliary body, and anterior chamber with no radioactivity detected in the eyelids or other periorbital tissues. After topical dosing, radioactivity was distributed in the bulbar conjunctiva, cornea, anterior chamber, iris, ciliary body, upper and lower eyelids, and periorbital tissues (fat/muscle). After intracameral dosing in monkeys, radioactivity was concentrated in the anterior chamber, cornea, iris, ciliary body, and posteriorly along the uveoscleral outflow pathway; there was no radioactivity in the eyelids or periorbital tissues aside from signal in the nasolacrimal duct, likely from reflux of ¹⁴C-latanoprost into the tear film.

Conclusions

Intracameral delivery resulted in more selective target tissue drug exposure. Intracameral drug delivery has potential to reduce ocular surface and periocular adverse effects associated with topical administration of prostaglandin analogues, such as eyelash growth and periorbital fat atrophy.

Electronic supplementary material

The online version of this article (10.1007/s40123-020-00285-3) contains supplementary material, which is available to authorized users.

Time course of conjunctival hyperemia induced by omidenepag isopropyl ophthalmic solution 0.002%: a pilot, comparative study versus ripasudil 0.4

Objective

We investigated the detailed time course of conjunctival hyperemia induced by omidenepag isopropyl ophthalmic solution 0.002% (omidenepag), a selective prostaglandin E2 receptor 2 agonist.

Methods and analysis

We recruited 34 healthy subjects and administered omidenepag in the right eye and ripasudil 0.4% in the left eye. We evaluated conjunctival hyperemia using slit-lamp photography at baseline and after 15, 30, 60, 120, 180 and 360 min. The conjunctival hyperemia score was graded by three independent observers using a scale from 0 (none) to 3 (severe). We also evaluated conjunctival hyperemia by the pixel coverage of conjunctival blood vessels (per cent coverage) determined using a conjunctival hyperemia-analysing software.

Results

In omidenepag, the conjunctival hyperemia score and per cent coverage peaked at both 30 min (mean score±SD: 1.57±0.67 and 11.90%±3.66%, respectively) and then gradually decreased at 60 min (10.79%±3.32%) and 120 min (1.10±0.52) when they reached a level that was not significantly different from the baseline values. For ripasudil 0.4%, the peak time of the conjunctival hyperemia score and per cent coverage were both at 15 min (score: 2.42±0.54 and 15.26%±3.38%). The degree of conjunctival hyperemia was significantly higher for ripasudil 0.4% than that for omidenepag from 15 to 30 min in both the conjunctival hyperemia score and per cent coverage (p<0.007 by Bonferroni correction).

Conclusion

Conjunctival hyperemia induced by omidenepag gradually peaks to moderate severity, though weaker compared with that induced by ripasudil 0.4%, and subsides relatively quickly.

Effects of the Selective EP2 Receptor Agonist Omidenepag on Adipocyte Differentiation in 3T3-L1 Cells

Purpose: We aimed at comparing the effects of omidenepag (OMD) with those of prostaglandin F (FP) receptor agonists (FP agonists) on adipogenesis in mouse 3T3-L1 cells. Methods: To evaluate the agonistic activities of OMD against the mouse EP2 (mEP2) receptor, we determined cAMP contents in mEP2 receptor-expressing CHO cells by using radioimmunoassays. Overall, 3T3-L1 cells were cultured in differentiation medium for 10 days and adipocyte differentiation was assessed according to Oil Red O-stained cell areas. Changes in expression levels of the adipogenic transcription factors Pparg, Cebpa, and Cebpb were determined by using real-time polymerase chain reaction (PCR). OMD at 0.1, 1, 10, and 40 μmol/L, latanoprost free acid (LAT-A) at 0.1 μmol/L, or prostaglandin F_2α (PGF_2α), at 0.1 μmol/L were added to cell culture media during adipogenesis. Oil Red O-stained areas and expression patterns of transcription factor targets of OMD or FP agonists were compared with those of untreated controls. Results: The 50% effective concentration (EC₅₀) of OMD against the mEP2 receptor was 3.9 nmol/L. Accumulations of Oil Red O-stained lipid droplets were observed inside control cells on day 10. LAT-A and PGF_2α significantly inhibited the accumulation of lipid droplets; however, OMD had no effect on this process even at concentrations up to 40 μmol/L. LAT-A and PGF_2α significantly suppressed Pparg, Cebpa, and Cebpb gene expression levels during adipocyte differentiation. Conversely, OMD had no obvious effects on the expression levels of these genes. Conclusions: A selective EP2 receptor agonist, OMD, did not affect the adipocyte differentiation in 3T3-L1 cells, whereas FP agonists significantly inhibited this process.

Decreased orbital fat and enophthalmos due to bimatoprost: Quantitative analysis using magnetic resonance imaging

We quantitatively determined the relation between the decrease in orbital fat and enophthalmos due to bimatoprost using magnetic resonance imaging (MRI). Nine orbits in nine patients were treated unilaterally with bimatoprost for glaucoma or ocular hypertension. The contralateral orbits were used as controls. The volumes of the orbital tissues and the enophthalmos were measured using MRI. The mean volumes on the treated and untreated sides were, respectively, 14.6 ± 2.1 and 17.0 ± 4.3 cm³ for orbital fat (P = 0.04) and 3.4 ± 0.5 and 3.3 ± 0.5 cm³ for total extraocular muscles (P = 0.85). The mean enophthalmos values were 14.7 ± 2.5 and 16.0 ± 2.3 mm on the treated and untreated sides, respectively (P = 0.002). The data acquired by quantitatively measuring the volumes of orbital fat and enophthalmos on MRI showed that each might be reduced by bimatoprost administration. The enophthalmos could be caused by the bimatoprost-induced decrease in orbital fat.

Treatment with bimatoprost for exophthalmos in patients with inactive thyroid-associated ophthalmopathy

Purpose

This study was performed to observe changes prospectively in exophthalmos and orbital fat in patients with inactive thyroid-associated ophthalmopathy (TAO) treated with bimatoprost.

Methods

In this 12-month single-treatment pilot observational study, 13 patients with inactive-phase TAO were administered bimatoprost to treat exophthalmos due to TAO. Exophthalmos values and orbital tissue volumes were measured on MRI by technicians in a masked fashion.

Results

Nine orbits of nine patients (eight women, one man) were treated with bimatoprost for 12 months. Mean exophthalmos values before and after treatment were 21.7±2.2 and 21.7±2.0 mm, respectively. The mean value after 12 months of treatment was not significantly different from before treatment (P=0.82). Mean orbital fat volume before and after 12 months of treatment was 17.2±2.5 and 17.0±3.0 cm³, respectively. The corresponding total extraocular muscle volume was 4.0±0.7 and 3.8±0.9 cm³, respectively. Mean volume in each tissue type after 12 months of treatment was not significantly different from before treatment (orbital fat, P=0.70; extraocular muscles, P=0.32).

Conclusion

Topical bimatoprost treatment did not reduce exophthalmos or orbital fat in this cohort of patients with inactive TAO.

Intracameral Sustained-Release Bimatoprost Implant Delivers Bimatoprost to Target Tissues with Reduced Drug Exposure to Off-Target Tissues

Purpose: To explore the ocular distribution of bimatoprost after intracameral administration of a biodegradable sustained-release bimatoprost implant (Bimatoprost SR) versus repeated topical administration of bimatoprost 0.03% ophthalmic solution in dogs. Bimatoprost SR and topical bimatoprost 0.03% previously were shown to have similar intraocular pressure-lowering effects in humans in a phase 1/2 clinical trial.

Methods: Twenty-four beagle dogs received either once-daily topical bimatoprost 0.03% for 7 days or a bilateral intracameral administration of Bimatoprost SR (15 μg). At predetermined time points, ocular tissues were collected and concentrations of bimatoprost and bimatoprost acid were quantified using liquid chromatography–tandem mass spectrometry.

Results: Bimatoprost SR administration enhanced delivery of study drug to a site of action [iris–ciliary body (ICB)] compared with topical bimatoprost (C_max [bimatoprost+bimatoprost acid] = 18,200 and 4.13 ng/g, respectively). However, distribution of drug to tissues associated with prostaglandin analog (PGA)-related side effects (i.e., bulbar conjunctiva, eyelid margins, and periorbital fat) was limited following Bimatoprost SR administration (C_max [bimatoprost+bimatoprost acid] = BLQ [beneath the limit of quantitation] to 0.354 ng/g) compared with topical dosing (C_max [bimatoprost+bimatoprost acid] = 36.6–2,110 ng/g).

Conclusions: Bimatoprost SR administration in dogs selectively delivered drug to the ICB with low or undetectable drug levels in ocular surface and extraocular tissues. Use of Bimatoprost SR for glaucoma treatment may reduce the incidence of adverse events typically associated with topical PGAs by targeting bimatoprost delivery to the key site of action of the PGA class and reducing exposure to off-target tissues.

The eyelash follicle features and anomalies: A review

The primary role of eyelashes is to protect and maintain the health of the lid margin. However, the mechanisms to fulfill this role are not fully understood. Unraveling these mechanisms will stand to greatly improve the efficiency of eye care professionals' interventions in anomalies of the eyelashes. The aim of this article is to provide a review on eyelashes including highlights and new avenues for research; the biology of both the lash and its follicle; the pathophysiology and management of lash anomalies by eye care professionals; and the effect of iatrogenic factors on lashes. Using the database of Ovid MEDLINE, we reviewed studies specifically directed on human/mammalian eyelashes and key articles on current trends in scalp hair methodologies that can be applicable to lash research. The eyelash morphology, pigmentation and growth rate have been documented using techniques ranging from lash imaging to follicle immunohistochemistry. Furthermore, studies have demonstrated that the lash follicle is sensitive to many factors of the external environment, a variety of systemic/topical medications and cosmetics. Recently, aerodynamic studies using a mammalian eye model confirmed that an optimal lash length was needed so that eyelashes serve a protective role in reducing the number of particles that can reach the eye. Despite recent advances in lash research, studies are still scarce, due to the limited availability of the human lid for sampling. This review brings awareness that further research is needed with respect to eyelashes and will hopefully reduce the gap with scalp hair research.

The effect of air pulse-driven whole eye motion on the association between corneal hysteresis and glaucomatous visual field progression

Corneal hysteresis (CH) measured with Ocular Response Analyzer (Reichert: ORA) has been reported to be closely related to the glaucomatous visual field (VF) progression. The air pulse applied to an eye not only induces corneal deformation, but also whole eye motion (WEM), which may result in an inaccurate measurement of CH. Here we investigated the influence of air pulse-driven WEM measured with the Corivs ST (CST^®, OCULUS) on the relationship between CH and VF progression in primary open angle-glaucoma patients. Using the CST parameters of the maximal WEM displacement (WEM-d) and the time to reach that displacement (WEM-t), the eyes were classified into subgroups (WEM-d low- and high-group, and WEM-t short- and long-group). For the whole population and all subgroups, the optimal linear mixed model to describe mean of total deviation (mTD) progression rate with eight reliable VFs was selected from all combinations of seven parameters including CH. As a result, optimal models for the mTD progression rate included CH in the whole population, the WEM-d low- group and the WEM-t short-group, but not in the WEM-d high-group and the WEM-t long-group. Our findings indicated association between CH and glaucomatous progression can be weakened because of large WEM.

Periorbital changes associated with prostaglandin analogs in Korean patients

Background

Prostaglandin analogs (PGAs) are commonly used to treat glaucoma because of their powerful intraocular pressure lowering effect. However, various periorbital changes associated with the use of PGAs have been reported. We investigated the incidence of periorbital changes in Korean patients who were treated with PGAs, and analyzed clinical factors associated with superior sulcus deepening.

Methods

This study included 58 glaucoma patients who were treated with latanoprost, travoprost, or bimatoprost unilaterally. Face photographs were collected, and periorbital changes such as superior sulcus deepening, eyelid pigmentation, ptosis, lid retraction, dermatochalasis, and redness were evaluated by two oculoplastic specialists. For each patient, the contralateral eye served as a control. The frequency of ptosis, dermatochalasis, pigmentation, erythema, and superior sulcus deepening were analyzed. Demographic and ocular factors were compared between patients who showed superior sulcus deepening and those who did not.

Results

Thirty-one patients (53.4%) showed one or more periorbital changes associated with PGAs. The most common change was superior sulcus deepening (24.1%), followed by eyelid pigmentation (19.0%), eyelid erythema (19.0%), dermatochalasis (10.3%), eyelid retraction (5.2%), and ptosis (3.4%). The age of the patient and the duration of PGA administration was significantly correlated with superior sulcus deepening (p = 0.007, p = 0.002, respectively).

Conclusions

Periorbital changes are frequently seen in patients who use PGAs, and superior sulcus deepening is the most common change in Korean patients. Long-term use of PGAs and old age were associated with superior sulcus deepening.