Dynamic and quantitative evaluation of eyelid motion using image analysis

Evaluation of facial movement, especially eyelid movement, has depended on the subjective judgment of trained clinicians. Recently, a few objective methods have been reported, but they required uncomfortable markers to be attached to the eyelids and a special-purpose, high-speed video camera. This study had two aims: one was to develop a new device for measuring eyelid motion dynamically and quantitatively, without eyelid markers or a high-speed camera; the other was to devise feasible parameters for eyelid motion. The system consisted of a personal computer with a general-purpose multimedia board and a software program that the authors named blepharokymography. A sequence of blinking eyes was recorded with a video camera. After the capturing process of the video, kymograms were produced from the movie file. Kymograms were converted to binary images by threshold filtering. The lower margin of the upper eyelid was traced, and displacement and velocity curves were obtained. Some parameters were devised and verified in preliminary clinical data. The analysis revealed that the displacement (8 mm in normal compared with 5.2 mm in paralysis), average closing velocity (74 mm s(-1) in normal compared with 30.6 mm s(-1) in paralysis) and peak closing velocity (154 mm s(-1) in normal against 63.4 mm s(-1) in paralysis) were useful parameters for differentiating the normal and facial-paralysis states.

[A case of spinocerebellar ataxia type 2 presenting with lid retraction with prominent eyes and pyramidal signs]

We herein report a case of a 45-year-old man who was diagnosed with spinocerebellar ataxia type 2 (SCA 2) by genomic testing and whose grandmother, father, and uncle were also affected by the same disease. The patient had noted difficulty in walking and dysarthria since the age of 43. Neurological examination revealed lid retraction with prominent eyes, cerebellar ataxia and pyramidal signs including spasticity, ankle clonus, and hyperreflexia with pathological reflexes. MRI showed atrophy of the cerebellum, brain stem, and spinal cord. This case report suggests that the lid retraction with prominent eyes and pyramidal signs are sometimes major features in SCA2.

Eyelid tremor in a patient with a unilateral paramedian thalamic lesion

A patient with a circumscribed infarction of the right paramedian thalamus developed a tremor of both eyelids on voluntary eye closure. Co-registration of the magnetic resonance image to a stereotactic atlas of the human thalamus revealed that the lesion was confined to a small subgroup of paramedian nuclei, including the parvocellular part of the mediodorsal nucleus. It is concluded that this region provides inhibitory input to cortical and/or subcortical regions controlling eyelid movements. Voluntary eye closure may involve direct cortico-nuclear connections and indirect pathways through the paramedian thalamus, most probably through the mediodorsal nucleus.

Relationship between the axis and degree of high astigmatism and obliquity of palpebral fissure

PURPOSE

To investigate a possible relationship between the slanting of palpebral fissures and the magnitude and axis of astigmatism in children with astigmatism.

METHODS

Cross-sectional study at a referral center of 53 children with astigmatism of more than +1.50 D in at least 1 eye. Visual acuity testing, cycloplegic refraction, slit-lamp biomicroscopy, and ophthalmoscopy were done on every patient. Corneal topography was obtained in 40 cooperative patients. External photographs of the midface were taken in 45 children. The degree of slanting of the palpebral fissures was evaluated based on the photographs. The statistical analysis tool used was repeated measures analysis of variance. Patients in whom photographic analysis was not available were excluded from the part of the statistical analysis dealing with eyelid slant.

RESULTS

Palpebral fissure slant (P =.013) and gender (P =.0005) were highly correlated with the obliquity of cylinder axis. There was a possible correlation between gender and eyelid slant (P =.0594), with females having slightly larger degrees of upward palpebral fissure slanting and male more downward slanting of their fissures compared to published angles in an age-matched population. We found a statistically significant correlation between the degree of total astigmatism and a larger abnormal slant (P =.0192) and between the axis and magnitude of corneal astigmatism and abnormal slant (P =.0092). Higher degrees of eyelid slant (> 8 degrees or < -4 degrees ) increased the risk of high cylinder magnitude (> 3.00 D) by an odds ratio of 4.17 (95% CI: 1.03, 19.95).

CONCLUSIONS

Children with astigmatism with large degrees of slanting of their palpebral fissures are at higher risk for high astigmatism (> 3.00 D). The axis of the astigmatism is highly correlated with the slanting of the palpebral fissure.

Complications of deep brain stimulation surgery

Although technological advances have reduced device-related complications, DBS surgery still carries a significant risk of transient and permanent complications. We report our experience in 86 patients and 149 DBS implants. Patients with Parkinson's disease, essential tremor and dystonia were treated. There were 8 perioperative, 8 postoperative, 9 hardware-related complications and 4 stimulation-induced side effects. Only 5 patients (6%) sustained some persistent neurological sequelae, however, 26 of the 86 patients undergoing 149 DBS implants in this series experienced some untoward event with the procedure. Although there were no fatalities or permanent severe disabilities encountered, it is important to extend the informed consent to include all potential complications.

A modified temporalis transfer in facial reanimation

A modified surgical procedure for temporalis transfer in facial reanimation of five consecutive cases is presented. Instead of the traditional stripping of the temporalis from its origin, its attachment at the coronoid removed, and to its end, the harvested fascia lata graft was sutured to lengthen the muscle's action. These fibres were then passed to the Orbicularis Oculi and Oris to aid in reanimation and to improve their tone. The procedure is less extensive, provides a direct line of pull with good functional results, no muscle atropy since vascularity and innervation is maintained. No complaints of paresthesia, hyposthesia or scar on donor leg was noticed. None of the patients required a revision of surgery for unacceptable contour or asymmetry. This simple procedure has helped reconstruction of natural symmetrical smile with highly successful results.

Cross-facial and functional microvascular muscle transplantation for longstanding facial paralysis

Functional results continue to improve with advancing microsurgical techniques and monitoring to detect and correct problems within minutes [47]. However, failures do occur, even when one can project a 98% survival for the transplant. Figs. 9 and 10 show two of our early cases that were fortunately salvaged with a second microvascular transplant. Evaluation of the result is a continuing challenge--anatomically, physiologically, and psychologically [37]. If one can remove the stigma or stigmata of facial paralysis in the patient's mind. success has been achieved (Fig. II) [48].

Aesthetic considerations in facial reanimation

The treatment results of facial paralysis have improved within the last two decades with the introduction of new techniques for neuromuscular reconstruction. However, many patients still complain of aesthetic imbalance impairment after treatment. This article presents some complementary procedures that can be used to improve the appearance of the face either isolated in incomplete palsies, or after the completion of reconstructive procedures in complete paralysis. The procedures are divided according to anatomical areas--forehead, eyelids, middle third of the face, and the lower lip.

Isolated unilateral neurogenic blepharoptosis secondary to eyelid trauma

PURPOSE

To describe eyelid trauma as a cause of isolated neurogenic blepharoptosis.

DESIGN

Observational case series.

METHODS

Three previously healthy patients (two male and one female; aged 29 to 39 years) were evaluated for unilateral blepharoptosis following forceful anterior displacement of the upper eyelid. Two injuries occurred during domestic altercations and one while the patient was playing basketball.

RESULTS

All three patients had complete unilateral upper eyelid ptosis with no levator palpebrae superioris function, consistent with loss of innervation. Additional findings included minimal eyelid ecchymosis, eyelid edema, and subconjunctival hemorrhage in two cases. The remainder of the examinations was unremarkable with full ocular motility and no anisocoria. Without treatment, within 2 weeks, all three patients recovered completely with normal symmetric lid height and levator function.

CONCLUSIONS

Isolated neurogenic blepharoptosis may result from traumatic anterior upper eyelid displacement. Resolution is likely within 2 weeks.

Frequency of apraxia of eyelid opening in the general population and in patients with extrapyramidal disorders

We ascertained the prevalence of apraxia of eyelid opening (AEO) in a community located in Puglia, a region of southern Italy. The crude prevalence rate was 59 per million (95% confidence interval, 24-173). AEO coexisted with adult onset blepharospasm in 75% of cases, with atypical parkinsonism in 25% of cases. Among the overall patient population seen at our movement disorders clinic from 1987 to 1997, AEO was isolated in 10 otherwise healthy individuals, associated with adult-onset dystonia in 13 cases, and associated with a parkinsonian syndrome in 9 cases. The frequency of AEO was 10.8% in the dystonia group, and 2.1% in the overall parkinsonian group (Parkinson's disease, 0.7%; progressive supranuclear palsy, 33.3%). In two patients with possible progressive supranuclear palsy, AEO worsened after increasing levodopa dosage or acute apomorphine challenge and disappeared following levodopa discontinuation. AEO developing in the setting of a parkinsonian syndrome may be either disease- or drug-related.

Pulmonary low-grade MALT-lymphoma associated with localized pulmonary amyloidosis. A case report

We report on a female patient, who, at the age of 63 years, was found to suffer from low-grade MALT-lymphoma localized at her right upper eyelid. At the time of initial diagnosis, clinical staging showed no further organ involvement. Within the following two months, nodular infiltrates occurred in both lungs. Histopathological investigation of the pulmonary lesions showed pulmonary involvement by the low-grade MALT-lymphoma associated with large globular amyloid deposits of lambda-light chain origin. Since the tumor cells of the MALT-lymphoma showed restriction to lambda-light chain the amyloid deposits in this case were interpreted as being related to the MALT-lymphoma.

Effect of hyperthyroidism on the orbicularis oculi muscle in rabbits

PURPOSE

To determine the effect of hyperthyroidism on both myofiber number and myosin heavy-chain isoform composition within the palpebral orbicularis oculi muscle in rabbits.

METHODS

Four New Zealand White rabbits were made hyperthyroid by injection of 3,3,3'-triiodothyroinine intraperitoneally every other day for 1 month. Four rabbits were used as control animals. After 1 month the rabbits were euthanized, and the eyelids were excised and sectioned in a cryostat. The sections were immunostained to determine the presence of fast, slow, and neonatal myosin heavy-chain isoforms. To determine alterations in myofiber number, differential counts of myofiber number and the cross-sectional areas of the muscle fibers were performed with the use of computerized morphometry.

RESULTS

The orbicularis oculi muscle in the palpebral portion of the eyelids from hyperthyroid rabbits had significantly fewer myofibers compared with control eyelids, predominantly as the result of a loss of myofibers in the preseptal region. The remaining fibers showed continued expression of fast myosin but upregulated coexpression of slow myosin isoform.

CONCLUSIONS

Hyperthyroidism led to reduced orbicularis oculi muscle in the rabbit model and an alteration in the myosin heavy-chain isoform composition. This finding may help explain the clinical finding of eyelid retraction in patients with Graves orbitopathy.

Drooping eyelids due to aging

Aging is a normal sequence of life. When one's eyelids start to age many changes can occur, and these changes may affect one's life activities and appearance. Nurses can help the elderly to accept some of life's changes gracefully and at the same time make them aware that some visual changes are correctable.

[Clinical and etiological considerations about the symptomatic epileptic syndromes with occipital paroxism blocked when the eyes open]

The syndrome of idiopathic partial epilepsy with occipital paroxysms in the EEG shows a considerable clinical heterogeneity. The present paper investigated the significance of electrophysiologic and clinical characteristics in eight patients with occipital paroxysms blocked by the eye opening. All patients were submitted to radiological exams including brain MRI and/or CT. There was agreement between EEG findings and type of seizures in 5 patients and between anatomical abnormalities in the MRI or CT and EEG focal abnormalities in 7 patients. Our results confirm that the unusual pattern comes from eletrographic multifactors origins.

Stretching of the Mueller muscle results in involuntary contraction of the levator muscle

PURPOSE

Since the levator muscle involuntarily and tonically contracts against the weight and elastic resistance of the upper eyelid to maintain an adequate visual field, a mechanoreceptor such as a muscle spindle or a periodontal mechanoreceptor is thought to be essential for its functioning. It was surmised that the Mueller muscle might act as a serial kind of muscle spindle of the levator muscle.

METHODS

The response of the bilateral levator muscles evoked by stretching the Mueller muscle of each eyelid of 87 patients with dermatochalasis or aponeurotic blepharoptosis was electromyographically and photographically recorded.

RESULTS

Stretching of the unilateral Mueller muscle evoked contraction of the ipsilateral levator muscle in 18 and of the bilateral levator muscle in 69 of the 87 patients.

CONCLUSIONS

The Mueller muscle can be thought of as a large, serial kind of muscle spindle, so that stretching by voluntary phasic contraction of the levator muscle for initial eye opening may evoke an afferent impulse to the mesencephalic trigeminal nucleus. Subsequently, this nucleus may stimulate the central caudal nucleus of the oculomotor nuclear complex, leading to involuntary tonic contraction of the ipsilateral or bilateral levator muscles, in the form of a continuous stretch reflex, to maintain an adequate visual field.

Eyelid sensation after supratarsal lid crease incision

PURPOSE

To determine the severity and duration of the loss of eyelid sensation after upper eyelid crease incision.

METHODS

This clinic-based case study was performed by analyzing observational measurements of patients undergoing upper blepharoplasty or ptosis surgery. Eighty-three eyelids of 50 patients were studied. A Cochet-Bonnet filament-type aesthesiometer was used to obtain all measurements. Preoperative and postoperative measurements were recorded at 1 week, 1 month, and final (2-6 months) time periods. Statistical analysis evaluated the degree and duration of the sensory loss and the extent of recovery during the evaluation period. Recovery of sensation was defined as a numerical reading within one point of baseline.

RESULTS

The mean aesthesiometry reading was calculated at the preoperative (3.45), 1-week (1.20), 1-month (1.56), and final postoperative (2.56) periods. Paired t testing showed a decreased but significant difference in sensation measurement at each comparison. Recovery of sensation to within one point occurs at the preoperative to late time period comparison. All but 4 of the 68 eyelids tested at the 1-week postoperative time period had a measured loss of sensation. Of the 44 eyelids tested at the final time period, all but 1 had regained some or all of this sensory loss.

CONCLUSIONS

Loss of skin sensation in the eyelid after upper eyelid crease incision blepharoplasty or blepharoptosis repair occurs in most patients and should be considered an expected outcome of the procedure. Partial to complete recovery of eyelid sensation over 2 to 6 months should also be expected, though in rare instances this does not occur.

Comparison of preseptal and pretarsal injections of botulinum toxin in the treatment of blepharospasm and hemifacial spasm

Although the beneficial effect of subcutaneous injections of botulinum toxin type A (BTX-A) is well known in both blepharospasm and hemifacial spasm, the position of the injection sites around the orbicularis oculi may influence the effectiveness and side effects. Here we report results of preseptal and pretarsal BTX-A injections in 53 patients (25 blepharospasm and 28 hemifacial spasm) in whom we used both injection techniques successively. Pretarsal injections were used in 102 out of 186 treatments in blepharospasm group and in 84 out of 202 treatments in hemifacial spasm group. Pretarsal BTX-A treatment produced significantly higher response rate and longer duration of maximum response in both patient groups. This technique was also associated with a lower frequency of major side effects such asptosis. We concluded that injections of BTX-A into the pretarsal, rather than the preseptal portion of the orbicularis oculiis more effective for treatment of involuntary eyelid closure due to contractions of this muscle.

An unusual case of paroxysmal kinesigenic dyskinesia

Paroxysmal kinesigenic dyskinesia (PKD) is an uncommon neurological disorder characterised by abnormal episodic brief movements induced by sudden movements of the body. The recognition and understanding of this disorder has increased over the past few decades. While most cases are idiopathic, the association of PKD with various disorders, including metabolic abnormalities has also been reported. We report an interesting case of a 52 year old male who presented with PKD manifesting as subtle facio-brachial movements and apraxia of eyelid opening (ALO) secondary toidiopathic hypoparathyroidism.

Blepharoclonus in multiple sclerosis

OBJECTIVE

Keane described 2 patients with gaze-evoked blepharoclonus (BLC), a form of reflex BLC, and multiple sclerosis (MS). A search for common areas of demyelination and focal axonal atrophy (T1 black holes) of the central nervous system (CNS) in 11 patients with MS exhibiting eyelid closure BLC was conducted employing magnetic resonance imaging (MRI). Finding lesions in common CNS locations on these patients can help to elucidate the pathogenesis of this restricted movement disorder.

MATERIALS AND METHODS

Eleven adult patients with relapsing-remitting, primary or secondary progressive MS were studied. MRI views were completed employing a 1.5-tesla scanner. Contrast Axial T1 imaging was obtained in 9 patients.

RESULTS

TL blackholes were not identified. Ten patients had multiple, scattered periventricular (PV) areas of demyelination. Four patients exhibited brainstem lesions of diverse but inconsistent locations including midbrain, cerebellar peduncle, pons and medulla. In 2 of the patients the brainstem lesions were transient but BLC persisted after the lesions regressed.

CONCLUSION

No common areas of CNS demyelination or focal axonal atrophy were identified on these patients with MS and BLC. The pathogenesis and clinical significance of BLC in MS remains to be elucidated.

Weight measurement of upper eyelid gold implants for lagophthalmos in facial paralysis

The use of the gold weight is an established procedure in the treatment of lagophthalmos and usually produces successful results. The critical technical issues are the firm suture fixation to the tarsal plate and the high location of the weight on this plate. However, the estimated weight of the implant from the trials on the skin of the upper lid fails to obtain the expected eye closure outcomes after surgical implantation on the tarsal plate. One of the main reasons could be the different curvature on the skin and on the tarsal plate of the upper eyelid. In this study, the angles between the vertical line and the surface of the outer (skin) and inner (tarsal plate) part of the upper eyelid have been analyzed when the eye is opened and closed. The results show that an addition of 0.2 g to the gold weight estimated in the trial is required to achieve a similar closure of the eye by means of the gold implant on the tarsal plate.

Three silent periods in the orbiculari oculi muscles of man: normal findings and some clinical vignettes

PURPOSE

To investigate how many true silent periods could be found in the orbiculari oculi muscles of man.

MATERIAL AND METHODS

10 subjects, clinically healthy (5 male, 5 female), with a mean age of 34 years-old (range: 23 to 48) were evaluated by mean of the blink reflex at resting and during contraction of the orbiculari oculi reflex according to protocols validated internationally.

RESULTS

Three responses called R1, R2 and R3 were obtained in the orbicular oculi muscle at resting state which had latencies and amplitudes within normal limits. What was new was to obtain three silent periods when the subjects were evaluated during muscle contraction. The duration of the first silent period was statistically longer than the second one (p < 0.004) and shorter than the third silent period (p < 0.0001). In addition, this test was found useful in detecting more specific findings in patients with hemifacial spasm and Meigge syndrome.

CONCLUSION

This is by the first time that three silent periods in the orbicular oculi muscles are consistently demonstrated. The refractoriness of the alpha motoneurons and the action of gamma-collateral activity seem to be the main conditions leasing to display the first two periods of muscle suppression. The modification of gamma motoneurons firing as well as a pause of muscle spindles in facial muscles due to the action of nociceptive stimuli traveling unmyelinated C fibers of the supraorbital nerve might be the most important mechanisms involved in the production of the third silent period. These results enables further clinical application of this test.

Tissue glue aided lid repositioning in temporary management of involutional entropion

PURPOSE

To evaluate the efficacy of the use of tissue glue in temporary management of involutional entropion.

METHODS

Ten consecutive patients aged 68-74 years presenting senile entropion were included in the study. Lid repositioning as to achieve a slight ectropion was done by application of cyanoacrylate glue in the lower lid crease using a 20-G cannula. Patients were followed at 1 day, 7 days and finally at 14 days. Assessment of correction and, if absent, duration of correction was recorded. Any other ocular or dermatological complications of the application were also recorded.

RESULTS

All the patients had successful correction at day 1. In two patients adhesions broke at day 6, in one patient at day 7, in 3 at day 9 and 2 at day 11. Two patients maintained correction at 2 weeks. No ocular or dermatological reactions were noted.

CONCLUSIONS

Tissue glue aided lid repositioning is an effective method for temporary management of involutional entropion.