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.

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.

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.

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.

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.

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.

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.

Merkel cell carcinoma in the orbitopalpebral region

Trabecular carcinoma is a rare cutaneous neuroendocrine carcinoma that probably originates from the Merkel cells that are usually found in the basal layer of the epidermis. The treatment of Merkel cell carcinoma is controversial and there is no specific therapeutic protocol because of the small number of cases that have been published. The procedures used to treat Merkel cell carcinoma must be tailored to minimise morbidity while maximising survival. Because the condition is so rare and difficult to diagnose and treat, we report three cases of orbitopalpebral tumours that confirm the local and regional aggressiveness and the high metastatic potential of this tumour.

Shrinking upper and lower eyelid skin with a novel radiofrequency tip

BACKGROUND

Many subjects wish to have tightening of eyelid skin but are reluctant to undergo aesthetic blepharoplasty surgery. We wanted to perform a small pilot study to test the efficacy and safety of a 0.25-cm(2) monopolar radiofrequency tip in a prospective noncomparative study as a novel nonsurgical method to safely tighten upper and lower eyelid skin in subjects of differing ethnicity and sex.

METHODS

Twenty adult subjects were enrolled in this prospective pilot study. All received symmetrical monopolar radiofrequency treatments in multiple passes to the pretarsal, preseptal, and lateral orbital skin. All subjects wore a protective plastic haptic contact lens to protect their vision during the radiofrequency treatment. (Haptic contact lenses fit over the entire anterior surface of the globe from superior to inferior and medial to lateral fornix. The purpose of using such a large contact lens was to protect the globe itself from radiofrequency energy.) Standardized color digital photography with eyes both open and closed was taken on each visit. Treatment efficacy was evaluated by both the expert observer and the subject at each visit. RESULTS At 6-month follow-up, according to the expert observer, 26 upper lids (87%) showed 25% or more tightening. Twenty lower lids (67%) showed 25% or more tightening. Two subjects (3.33%) had 51% to 75% upper lid tightening at 6 months. There were no adverse events beyond one subject with minimal corneal epithelial punctate defects on the treatment day. These resolved over several hours.

CONCLUSIONS

The use of this new tip was shown to be safe. Effectiveness at shrinking eyelid skin was at best mild to moderate.

Monopolar radiofrequency treatment of the eyelids: a safety evaluation

BACKGROUND

Monopolar radiofrequency (RF) energy has been used to successfully accomplish noninvasive skin tightening of the face, abdomen, and extremities. Owing to concerns about injury to the eye itself, monopolar RF treatment of the eyelids has not been feasible.

OBJECTIVE

The objective was to evaluate the safety of a novel 0.25-cm(2)"shallow" treatment tip for noninvasive tightening of eyelid skin.

METHODS AND MATERIALS

This was a tripartite study that began with an animal model to evaluate soft tissue effects and temperature change at the ocular surface. Findings were then extrapolated to ex vivo evaluation of human eyelids and ultimately to an in vivo human eyelid safety study.

RESULTS

The animal studies demonstrated that the 0.25-cm(2) treatment tip could be used safely on eyelids in conjunction with appropriate ocular protection. The ex vivo human eyelid studies confirmed that, at typical treatment settings, the shallow treatment tip did not produce frank eyelid injury. The in vivo human studies confirmed that, at the tested settings, the novel treatment tip did not injure the eyelids or eyes.

CONCLUSION

If used properly, the 0.25-cm(2) treatment tip can be safely used on human eyelids.

Anterior Lamella Actinic Changes as a Factor in Involutional Eyelid Malposition

PURPOSE

We conducted a noncomparative, retrospective chart review of 45 patients and 51 eyelids with the diagnosis of involutional entropion or ectropion that underwent full-thickness lower eyelid shortening between June 2001 and February 2004, in whom the severity of actinic damage was analyzed in relation to the eyelid position. Patients with any different surgical approach or other primary causes of abnormal eyelid position, such as paralytic, congenital, or mechanical factors, were excluded.

METHODS

After excision, all eyelid specimens were examined by a single anatomic pathologist, who was masked to the type of eyelid malposition. The extent of dermal actinic change was evaluated under light microscopy, according to a previously validated grading system.

RESULTS

Fifty-one eyelids from 26 male and 19 female patients were analyzed. The mean age at the surgery was 76 +/- 10 years (range, 52 to 92 years), affecting one side in 39 cases and both sides in 6 cases. The most frequent eyelid malposition was ectropion, which affected two thirds of the cases (35 eyelids). Half of the patients presented with mild actinic skin changes; however, the severity of the histologic skin actinic changes was significantly worse in patients with ectropion in comparison to those with entropion (p < 0.0001).

CONCLUSIONS

Actinic damage affecting the anterior lamella of the lower eyelid contributes as an additional factor in final eyelid position in patients with involutional eyelid changes. More severe and extensive actinic changes were present in eyelids with ectropion.

Monopolar radiofrequency treatment of human eyelids: A prospective, multicenter, efficacy trial

BACKGROUND/OBJECTIVE

To evaluate the efficacy of a novel 0.25 cm(2) monopolar radiofrequency (RF) treatment tip for aesthetic rejuvenation of the eyelids.

STUDY DESIGN/MATERIALS AND METHODS

This was a prospective, multicenter trial in which the eyelids of 72 patients were treated. Patients underwent a single treatment session and were then followed on a serial basis for 6 months. Cutaneous anesthesia was not required to perform the treatments. Assessments were made by the treating physician, the subjects, and by masked physician observers evaluating photographs taken at each data point.

RESULTS

Upper eyelid tightening and reduction of hooding was noted in 88 and 86% of subjects, respectively. Lower eyelid tightening was noted in 71-74% of subjects. The majority of patients treated achieved at least up to 25% improvement while a smaller percentage achieved more dramatic results. There was no correlation between the amount of energy applied to the eyelids and the clinical outcome. There were no serious adverse sequelae.

CONCLUSION

Human eyelids can be safely treated with monopolar RF energy delivered via a novel 0.25 cm(2) treatment tip. Using this technology non-invasive eyelid rejuvenation was achieved in the majority of subjects treated. The factors differentiating those patients who achieve the most impressive changes from others remain unclear. Further development and testing of this technology is warranted.

The use of alert behaving mice in the study of learning and memory processes

The availability of transgenic mice that mimic human neurodegenerative processes has made it necessary to develop new recording and stimulating techniques capable of being applied in this species. We have studied here the motor learning and memory capabilities of wild-type and transgenic mice with deficits in cognitive functions, using classical conditioning procedures. We have developed an electrical shock/SHOCK paradigm corresponding to a trace classical conditioning; that is, a learning task involving the cerebral cortex, including the hippocampus. The conditioning procedure is a modification of the air-puff/AIR-PUFF conditioning (Gruart et al., J. Neurophysiol. 74:226, 1995). Animals were implanted with stimulating electrodes in the supraorbitary branch of the trigeminal nerve and with recording electrodes in the orbicularis oculi muscle. Computer programs were developed to quantify the appearance and evolution of eyelid conditioned responses. According to the present results, the classical conditioning of eyelid responses appears to be a suitable (associative) learning procedure to study learning capabilities in genetically-modified mice.

Eyelid and scleral necrosis following bare iridium-192 seed for retinoblastoma

A 2 1/2-year-old girl with a history of bilateral retinoblastoma underwent primary enucleation of the right eye and was referred for further management of persistent tumor in the fellow eye. Previous treatment of the left eye included external beam radiotherapy, systemic chemotherapy, laser photocoagulation, cryotherapy, and direct scleral application of a bare iridium-192 radioactive seed. Examination revealed focal full-thickness necrosis of the left upper and lower eyelid and a large inferonasal viable retinoblastoma tumor with overlying retinal detachment. Systemic chemotherapy and direct laser photocoagulation were administered. Four months after presentation, the patient developed focal scleral necrosis with 360 degrees hemorrhagic choroidal detachment. Enucleation was performed and histopathologic examination demonstrated full-thickness scleral necrosis with adjacent viable retinoblastoma tumor cells. Follow-up examinations showed no evidence of recurrent or metastatic tumor. This case is the first report of scleral necrosis following combined modality treatment of retinoblastoma.

No melatonin suppression by illumination of popliteal fossae or eyelids

A recent report that popliteal illumination shifted the circadian rhythms of body temperature and melatonin challenged the longstanding belief that light phase-shifting the circadian system in mammals is mediated only through the retina. The authors tested effects of popliteal illumination and illumination provided through the eyelids on melatonin suppression. In randomized, counterbalanced orders, healthy volunteers received three treatments from midnight until 2:00 AM, one on each of three visits to the laboratory. Treatments included (1) no illumination from light pads applied to the popliteal fossae, with light mask maintained at < 3 lux (control); (2) light mask illuminated at 1700 lux, with popliteal light pads extinguished; and (3) popliteal light pads illuminated (13,000 lux) and light mask at < 3 lux (control). Saliva specimens were sampled at midnight, at 1:00 AM, and at 2:00 AM. Mean salivary melatonin concentrations rose from an average of 30.8 (3.9) pg/ml at midnight (baseline), to 33.2 (4.0) pg/ml at 1:00 AM, and to 37.2 (3.8) pg/ml at 2:00 AM in all three conditions, but no statistical differences were found using repeated-measures ANOVA. No evidence of melatonin suppression by either popliteal or closed eyelid light stimulation was found. These data suggest that bright retinal illumination is necessary for suppression of melatonin mediated through the suprachiasmatic nuclei.

[Clinico-radiometric studies of the eye in radioactive contamination]

The aim of the study was assessment of local and remote effects of radioactive substances on ocular media and development of measures to remove radionuclides from the eye. Radioactive substances getting into the eye in the form of aerosols, dust, or gaseous mixtures are unevenly distributed in it. The highest radioactivity was found on the skin of the eyelids and orbit, particularly so on the eyelashes and eyebrows, the least one on the cornea and in the conjunctival cavity. A follow-up of 8 to 17 years showed that timely removal of radionuclides from ocular surface prevented the development of specific symptoms and trophic changes of ocular media, of radiation cataracts among other things. The suggested method for washing the skin of the eyelids and orbital area from radioactive contaminants did not induce skin irritation, maceration, sense of discomfort, and is recommended for practice.

Present status of eyelid phototherapy. Clinical efficacy and transmittance of ultraviolet and visible radiation through human eyelids

BACKGROUND

Phototherapy for the eyelid has not previously been recognized as a safe and effective treatment of photoresponsive dermatoses of the eyelid, such as atopic dermatitis, vitiligo, psoriasis, lymphomatoid papulosis, and parapsoriasis.

OBJECTIVE

The purpose of this study was to demonstrate the efficacy and safety of this treatment.

METHODS

Two cases are presented to demonstrate clinical efficacy. In addition, a retrospective eye evaluation of seven patients receiving a combined total of greater than 1300 eyelid phototherapy treatments was performed. To determine whether potentially harmful UV radiation is significantly transmitted through eyelid skin, an in vitro study was conducted to measure the percentage transmittance of ultraviolet-visible radiation through five excised eyelids.

RESULTS

In the two cases presented, remarkable improvement occurred without adverse side effects, suggesting that it is possible to deliver incremental UV dosages to eyelid skin to achieve clearing of skin disease. Retrospective analysis of patients' records revealed no ocular disease from the phototherapy. In vitro eyelid examination produced data that indicated negligible quantities of UV radiation were transmitted through eyelid skin compared with the visible spectrum, in which up to 77% of the radiation was transmitted through the tissue.

CONCLUSION

The combined clinical experience and transmittance data suggest that eyelid phototherapy is a safe and effective treatment in selected patients.

Linear pemphigus vulgaris after X-ray irradiation

The authors report the case of a 64-year-old female with a pemphigus vulgaris that relapsed on her left cheek following X-irradiation. The lesion developed not only on the irradiated area but also along a linear streak. Blaschko lines seem to represent the linear systematization pattern more likely to account for this unusual distribution.

Effects of XeCl excimer laser on the eyelid and anterior segment structures

We evaluated the in vitro and in vivo effects of an XeCl excimer laser on the eyelid and anterior segments of the eye. The wavelength of this laser was successfully transmitted through a quartz fiberoptic system. The action of the XeCl excimer laser through our system was more photocoagulative than photoablative.

Alterations to eye structures in hairless mice by long-term ultraviolet irradiation. A histopathological study

The eyes of 75 Hr/Hr hairless mice were irradiated with one minimal erythema dose/day of UV light for a period of 12 months, and then observed for a further 6 months. The mice were divide into 3 subgroups, - one without protectans, - one protected by the sun protection lotion Sea and Ski, factor 5, - and one by Piz Buin, Factor 6. The eyes of 75 non-irradiated mice of the same type, subdivided into 3 comparable groups, served as controls. Animals which died during the test period were examined immediately. After the 18 months period, eyes and adnexa of the surviving animals were examined macroscopically and by light microscopy. The lifespan of unprotected, irradiated mice was significantly shorter than the protected groups. The eyelids of irradiated mice presented hyperplasia, actinic keratosis and invasive carcinoma, the latter in 20%. No melanotic tumours were recorded. Since the sun lotion protected animals had a significantly longer lifespan they showed a higher number of palpebral tumours. No irradiation lesions could be demonstrated in the lens, the vitreous or the retina.

[Roentgen soft radiotherapy of eyelid basaliomas]

Reported are the results of soft X-ray therapy of 237 patients with 245 basal cell carcinomas of the eye lids. The medial angle of the eye and the lower eye lid were mostly affected. Histologically in 62% solid basal cell carcinomas and in 14% sclerodermiform basal cell carcinomas could be diagnostized. By soft X-ray therapy 92% of all basal cell carcinomas could be healed. All recurrences were observed in the first 2 years following radiotherapy. They were relatively more frequent at the lateral angle of the eye. Recurrences occurred in 4.9% of female patients, and in 13.0% of male patients. In two thirds they may be due to elected conditions of radiotherapy; in one third the cause of recurrences are not known. The cosmetic result was good or excellent in 95% of patients during the first 2 years following radiotherapy. After more than 5 years this rate declined to 65%. A good functional result could be obtained in 88% of the patients.

Late functional and cosmetic results of treatment of eyelid tumours

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