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Vogt AZ, Vrcek IM. Use of oxymetazoline hydrochloride ophthalmic solution, 0.1% for improved lid symmetry in Graves' disease. Orbit 2024:1-5. [PMID: 39158466 DOI: 10.1080/01676830.2024.2389303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 08/01/2024] [Indexed: 08/20/2024]
Abstract
PURPOSE The purpose of this study is to evaluate the usage of oxymetazoline hydrochloride ophthalmic solution, 0.1% in the treatment of Graves' disease to improve lid symmetry. METHODS Fourteen patients were identified with unilateral upper eyelid retraction, secondary to Graves' disease. A phenylephrine test was performed to evaluate whether treating the unaffected (non-retracted) side would result in improved symmetry using Hering's law. Patients were prescribed oxymetazoline hydrochloride ophthalmic solution, 0.1% to instill into the unaffected eye. Marginal reflex distance 1 (MRD1) measurements were taken pre- and post-treatment and patient satisfaction surveys were completed. RESULTS The average pre-treatment MRD1 difference between the right eye (OD) and the left eye (OS) was 2.46 [range 1.50-4.00]. The average post-treatment MRD1 difference between OD and OS was 0.39 [range 0.00-1.00]. One hundred percent of patients were satisfied or very satisfied with the improvement in symmetry. CONCLUSIONS Oxymetazoline hydrochloride ophthalmic solution, 0.1% is a potential method to improve symmetry in patients with Graves' disease and unilateral upper eyelid retraction via Hering's law, especially for non-surgical candidates or those who prefer non-surgical treatment. Our results indicate improved MRD1 differences between fellow eyes and patient satisfaction regarding the symmetry of the upper eyelids.
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Affiliation(s)
- Ashtyn Z Vogt
- Department of Ophthalmology, Dean McGee Eye Institute, Oklahoma City, Oklahoma, USA
| | - Ivan M Vrcek
- Ophthalmology, Texas Ophthalmic Plastic, Reconstructive & Orbital Surgery Associates, Dallas, Texas, USA
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2
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Ducker LG, Halbach CS, Piazza AN, Rajjoub RD, Kamboj A, Harrison AR, Mokhtarzadeh A. "Blue Scrub Lid Retraction": Changes in Eyelid Position on the Day of Surgery. Ophthalmic Plast Reconstr Surg 2024; 40:388-391. [PMID: 38967564 DOI: 10.1097/iop.0000000000002587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE The aim of this study is to test the hypothesis that margin-reflex distance 1 (MRD1) on the day of surgery will be higher than the MRD1 measured at the in-clinic consult visit among patients undergoing blepharoptosis repair due to an increased sympathetic drive. METHODS Patients evaluated for involutional blepharoptosis repair were prospectively enrolled over a 12-month period in this single-center, self-controlled study. Three investigators independently determined MRD1 using cropped photos taken of patients at the in-clinic consult visit and on the day of surgery. A difference in height was tested for by using the 2-tailed Wilcoxon signed rank test. RESULTS Evaluated in this study were 76 eyelids from 38 patients. Over 3-quarters of study participants had a higher MRD1 in the right and OSs on the day of surgery than at their in-clinic consultation visit (p < 0.001). The mean increase in MRD1 for the right eyelid and left eyelid was 1.0 mm (range: 0-3.15 mm) and 1.1 mm (range: 0-2.7 mm), respectively. CONCLUSIONS In patients with involutional blepharoptosis, we conclude that MRD1 is higher on the day of surgery as compared with the in-clinic consult visit. This may be secondary to the stress of surgery and an associated increase in sympathetic drive. In some cases, this change in eyelid position led to resolution of apparent involutional ptosis altogether. Caution should be used when considering deferral of ptosis repair on the basis of exam findings present on the day of surgery.
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Affiliation(s)
- Laurence G Ducker
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Caroline S Halbach
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Amber N Piazza
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Raneem D Rajjoub
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Alisha Kamboj
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Andrew R Harrison
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, U.S.A
- Department of Otolaryngology and Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Ali Mokhtarzadeh
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, U.S.A
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3
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Zhao H, Ren Y, Yang Z, Wang Y, Zhang J. Progressively worsening ptosis in a woman: A case report. Clin Case Rep 2024; 12:e9005. [PMID: 38855088 PMCID: PMC11157416 DOI: 10.1002/ccr3.9005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/31/2024] [Accepted: 05/12/2024] [Indexed: 06/11/2024] Open
Abstract
Key Clinical Message Filler injections into the upper eyelid may cause levator aponeurosis fibrosis and ptosis. This risk must be considered. When ptosis appears, treatment might be difficult. Understanding the upper eyelid anatomy and procedures is essential to prevent eyelid damage. Abstract Ptosis is a prevalent condition in cosmetic surgery that occurs due to malfunction of the levator palpebrae superioris or insufficient Müller muscle action. It is characterized by the upper eyelid edge appearing lower than usual when seen at eye level. Ptosis may be categorized into congenital and acquired forms. The primary cause of congenital ptosis is attributed to abnormalities of the levator palpebrae superioris muscle or the motor nerve innervation that controls it. The condition arises from atypical development and malfunction of the oculomotor system. Acquired ptosis may be classified into many categories including traumatic, neurogenic, myogenic, senile, mechanical, and fake ptosis. Currently, there is little documentation of ptosis resulting from the degeneration of the aponeurosis of the muscle in the upper eyelid. We received a case of ptosis caused by fibrosis of the levator palpebrae superioris aponeurotic membrane. We used the technique of levator palpebrae superioris great advancement. The levator palpebrae superioris-Müller muscle was folded to create a stable composite construction via the levator palpebrae superioris high progress.
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Affiliation(s)
- Hongqing Zhao
- Department of Plastic Surgery, Daping HospitalArmy Medical UniversityChongqingChina
- Nanbu County People's HospitalNanchongSichuan ProvinceChina
| | - Yuan Ren
- Department of Plastic Surgery, Daping HospitalArmy Medical UniversityChongqingChina
| | | | - Yuanyuan Wang
- Department of Plastic Surgery, Daping HospitalArmy Medical UniversityChongqingChina
| | - Junbo Zhang
- Department of Plastic Surgery, Daping HospitalArmy Medical UniversityChongqingChina
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4
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Aloyan T, Shilleh N, Sharma A, Barsamian B, Sovory L. A Breath of Relief: Oxymetazoline and Flunisolide Nasal Spray in the Management of Myasthenia Gravis Ptosis. Cureus 2024; 16:e58812. [PMID: 38784340 PMCID: PMC11112969 DOI: 10.7759/cureus.58812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
The current pharmaceutical management of myasthenia gravis (MG) is widely accepted to be pyridostigmine and prednisone, both known to cause adverse effects and incur significant costs. This treatment may be particularly burdensome for patients primarily complaining of localized ocular MG, and little is known about the management of MG ptosis with topical medications. Oxymetazoline hydrochloride 0.1% ophthalmic solution has recently been approved by the FDA for the treatment of ptosis, but there have been limited studies in MG ptosis and no report to date of symptomatic improvement with the intranasal formulation. This case report discusses a 71-year-old female whose newly diagnosed MG ptosis resolved after three days of intranasal oxymetazoline hydrochloride 0.05%, followed by three days of intranasal flunisolide. Our patient's rapid resolution of symptoms, along with the favorable side effect profile and over-the-counter availability, highlights the promising indication for the use of intranasal oxymetazoline and flunisolide as potential alternatives or adjuncts in MG management. Further research in larger cohorts is necessary to confirm the efficacy of these nasal sprays in treating MG ptosis.
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Affiliation(s)
- Toni Aloyan
- Neurology, Arrowhead Regional Medical Center, Colton, USA
- School of Medicine, California University of Science and Medicine, Colton, USA
| | - Najla Shilleh
- Neurology, Arrowhead Regional Medical Center, Colton, USA
- School of Medicine, California University of Science and Medicine, Colton, USA
| | - Arjun Sharma
- Neurology, Arrowhead Regional Medical Center, Colton, USA
- School of Medicine, California University of Science and Medicine, Colton, USA
| | - Barsam Barsamian
- Internal Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Lisa Sovory
- Neurology, Arrowhead Regional Medical Center, Colton, USA
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5
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Matossian C. The Prevalence and Severity of Acquired Blepharoptosis in US Eye Care Clinic Patients and Their Receptivity to Treatment. Clin Ophthalmol 2024; 18:79-83. [PMID: 38223816 PMCID: PMC10788066 DOI: 10.2147/opth.s441505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Purpose To assess the presence and severity of acquired blepharoptosis (ptosis) among patients visiting an eye care clinic and the receptivity of eligible patients to pharmacologic treatment with oxymetazoline 0.1% ophthalmic solution. Patients and Methods Patients aged 50 years or older who had a scheduled clinic appointment for any reason (eg, dry eye, cataract surgery consultation) were asked to respond to written questions about lid position and select whether their upper lid position most closely matched one of 4 images shown to them corresponding to no, mild, moderate, or severe ptosis. Patients selecting any of the mild, moderate, or severe ptosis were offered treatment with oxymetazoline 0.1% ophthalmic solution, barring any medical contraindications. The outcome measures were the proportion of patients with each self-reported lid position level (none to severe ptosis), the proportion of patients with asymmetric ptosis, and the proportion of patients willing to accept the treatment. Results Data for 188 eyes of 94 patients were analyzed. Overall, 73.4% of patients had ptosis in at least one eye, and 25.5% had an asymmetric upper eyelid presentation. The proportions of patients with self-reported mild, moderate, or severe ptosis in at least one eye were 41.5%, 25.5%, and 6.4%, respectively. Among those patients eligible for treatment, 19.7% were willing to accept the treatment. Conclusion Based on patients' self-assessment of lid position, this study suggests a higher prevalence of ptosis than reported previously. Evaluation of the eyelids should be a standard part of the comprehensive eye examination.
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6
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Razavi CR, Byrne PJ. Intellectual Property in Facial Plastic and Reconstructive Surgery: The Importance and Process of Obtaining Intellectual Property Rights. Facial Plast Surg 2023; 39:460-465. [PMID: 37196666 DOI: 10.1055/a-2095-6367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
Understanding the purpose and process of obtaining intellectual property rights (IPR) is fundamental to health care innovation. Facial plastic and reconstructive surgeons are natural innovators; however, knowledge deficit in this space may hinder the ability to move ideas from the "bench to bedside." Here we provide an overview of IPR, outlining the steps necessary to obtain intellectual property protection in an academic setting while highlighting recent U.S. Food and Drug Administration (FDA) approvals pertaining to facial plastic and reconstructive surgery.
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Affiliation(s)
- Christopher R Razavi
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Patrick J Byrne
- Section of Facial Plastic and Microvascular Surgery, Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio
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7
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Johnson AJ, Chen DS. Office-based facial plastics procedures: Neuromodulators. World J Otorhinolaryngol Head Neck Surg 2023; 9:220-226. [PMID: 37780669 PMCID: PMC10541165 DOI: 10.1002/wjo2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 10/03/2023] Open
Abstract
Botulinum toxin is a potent neuromodulator commonly used for cosmetic applications in the clinic. In this article, we reviewed the various formulations of botulinum toxin type A commercially available in the United States, as well as clinical pearls for preprocedural planning, common in-office injections, and management of complications.
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Affiliation(s)
- Andrew J. Johnson
- Department of Otolaryngology ‐ Head & Neck SurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - David S. Chen
- Department of Otolaryngology ‐ Head & Neck SurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
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8
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Taha M, Li Y, Morren J. Oxymetazoline Hydrochloride Eye-Drops as Treatment for Myasthenia Gravis-Related Ptosis: A Description of Two Cases. Cureus 2023; 15:e36351. [PMID: 37082493 PMCID: PMC10111874 DOI: 10.7759/cureus.36351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 03/21/2023] Open
Abstract
In this article, we described two patients with myasthenia gravis-related ptosis who experienced sustained improvement with the use of oxymetazoline hydrochloride ophthalmic solution 0.1%. Despite the commonly used treatments for ptosis in myasthenia gravis (MG), such as acetylcholinesterase inhibitors and corticosteroids, complete remission of ptosis is not always achieved, and these treatments are often accompanied by systemic side effects. Our case report suggests the long-term efficacy of daily use of oxymetazoline eye drops in improving ptosis, providing a potential alternative or adjunctive treatment option without significant adverse effects. Further research is necessary to confirm these observations across larger cohorts of MG patients and establish the effectiveness of oxymetazoline eye drops in MG-related ptosis.
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9
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Shoji MK, Markatia Z, Ameli K, Bayaraa M, Clauss KD, Ugradar S, Lee WW. The Effect of Topical Oxymetazoline on Eyelid Position, Eye Redness, and Patient-Reported Eye Appearance: A Randomized Controlled Trial. J Plast Reconstr Aesthet Surg 2023; 80:66-74. [PMID: 36996503 DOI: 10.1016/j.bjps.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE This study assesses the effects of topical oxymetazoline 0.1% on eyelid position, eye redness, and patient-perceived eye appearance in patients without severe ptosis. METHODS This is a randomized double-blinded controlled trial conducted at a single institute. Patients aged 18-100 years were randomized to receive one drop of oxymetazoline hydrochloride 0.1% or placebo bilaterally. Marginal reflex distance (MRD) 1 and 2, palpebral fissure height, eye redness, and patient-perceived eye appearance were assessed at baseline and two hours after drop instillation. Primary outcome measures included the change in MRD1, MRD2, and palpebral fissure height. Secondary outcome measures included changes in eye redness and patient-perceived eye appearance after drop instillation. RESULTS In total, 114 patients were included, 57 treatment patients (mean age 36.4 ± 12.7 years, 31.6% male) and 57 controls (mean age 31.3 ± 10.1 years, 33.3% male). Baseline mean MRD1, MRD2, and palpebral fissure were similar between groups (p = 0.24, 0.45, and 0.23, respectively). Changes in MRD1 and eye redness in the treatment group were significantly greater than those in the control group (0.9 ± 0.9 mm vs. - 0.3 ± 0.4 mm, p < 0.001; - 2.6 ± 4.4 vs. - 0.5 ± 2.3, p = 0.002, respectively). Patient-perceived eye appearance was significantly improved in the treatment group compared to the controls (p = 0.002), with more treatment group patients also reporting increased eye size and decreased eye redness (p = 0.008, p = 0.003, respectively). There were 9 treatment-emergent adverse events (TEAEs) in 7 treatment group patients and 5 TEAEs in 5 control patients (p = 0.25), all of which were mild in severity. CONCLUSIONS Topical oxymetazoline 0.1% increases MRD1 and palpebral fissure height, decreases eye redness, and improves patient-perceived eye appearance.
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Affiliation(s)
- Marissa K Shoji
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | - Zahra Markatia
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | - Kambiz Ameli
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | - Mandah Bayaraa
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | - Kevin D Clauss
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | - Shoaib Ugradar
- Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Wendy W Lee
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America.
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10
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Pacella SJ. Commentary on: Is It Worth Using Botulinum Toxin Injections for the Management of Mild to Moderate Blepharoptosis? Aesthet Surg J 2022; 42:1382-1384. [PMID: 35723540 DOI: 10.1093/asj/sjac161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Indexed: 12/30/2022] Open
Affiliation(s)
- Salvatore J Pacella
- Division of Plastic and Reconstructive Surgery, Scripps MD Anderson Cancer Center, La Jolla, CA, USA
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11
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Sung J, Song A, Song M, Song J. Oxymetazoline hydrochloride ophthalmic solution, 0.1%, boosts the effects of botulinum toxin on blepharospasm: a case series. J Med Case Rep 2022; 16:299. [PMID: 35927744 PMCID: PMC9354271 DOI: 10.1186/s13256-022-03493-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 06/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Oxymetazoline hydrochloride ophthalmic solution (0.1%) is a medication used to treat blepharoptosis. Patients who suffer from blepharoptosis have low-lying eyelids that can hinder their vision. Oxymetazoline hydrochloride ophthalmic solution (0.1%) is prescribed to patients to improve their vision by lifting the upper eyelids. Blepharospasm consists of involuntary, bilateral orbicularis oculi muscle movements that result in twitching and eyelid closure. Botulinum toxin is a treatment used to treat blepharospasm by preventing muscle contraction; but it is not always effective. Case presentation The effects of treatment with both oxymetazoline hydrochloride ophthalmic solution (0.1%) and botulinum toxin are assessed in three patients: (1) Patient A, a 58-year-old Filipina woman; (2) patient B, a 62-year-old Korean woman; and (3) patient C, A 57-year-old Vietnamese woman. All patients had been diagnosed with blepharoptosis as well as blepharospasm. Each patient was given an opportunity to complete an optional survey to assess not only the efficacy of oxymetazoline hydrochloride ophthalmic solution (0.1%) together with botulinum toxin but also their perceived stress during the past month. Conclusions Administering botulinum toxin for the treatment of blepharospasm in patients A and B yielded the expected results; adding oxymetazoline hydrochloride ophthalmic solution (0.1%), a medical treatment for ptosis, to the treatment regimen yielded an unexpected reduction of blepharospasm. We propose that botulinum toxin and oxymetazoline hydrochloride ophthalmic solution (0.1%) can have a synergistic effect on reducing blepharospasm when used concomitantly. We present three cases in which combined use of botulinum toxin with oxymetazoline hydrochloride ophthalmic solution (0.1%) reduced blepharospasm, and propose possible reasons for such effects. We also discuss previous literature in agreement with the results of our cases.
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Affiliation(s)
- Jonathan Sung
- Southern California Eye Physicians & Surgeons, 1111 S. Fair Oaks Ave, Pasadena, CA, 91105, USA
| | - Alice Song
- Center for Oculofacial & Orbital Surgery, 10861 Cherry Street #208, Los Alamitos, CA, 90720, USA
| | - Michael Song
- Center for Oculofacial & Orbital Surgery, 10861 Cherry Street #208, Los Alamitos, CA, 90720, USA
| | - Julia Song
- Southern California Eye Physicians & Surgeons, 1111 S. Fair Oaks Ave, Pasadena, CA, 91105, USA.
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12
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Ugradar S, Kim JS, Trost N, Parunakian E, Zimmerman E, Ameli K, Shoji MK, Lee WW. Changes to Eye Whiteness and Eyelid/Brow Position With Topical Oxymetazoline in Aesthetic Patients. Aesthet Surg J 2022; 42:582-589. [PMID: 34962512 DOI: 10.1093/asj/sjab400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Oxymetazoline hydrochloride 0.1% ophthalmic solution has recently been approved in the United States for the treatment of ptosis. OBJECTIVES The aim of this study was to assess the upper and lower eyelid position as well as the brow position and the color of the sclera following the ophthalmic administration of oxymetazoline hydrochloride 0.1%. METHODS In this prospective cohort study, consecutive patients presenting with ptosis received topical oxymetazoline 0.1%. The primary outcome was measurement of the upper eyelid height (margin-to-reflex distance 1 [MRD1]) and lower eyelid height (MRD2) relative to the center of pupil, along with assessment of brow height, measured on photographs at baseline and 2 hours after instillation of oxymetazoline. The secondary outcome was the assessment of the color of the sclera (eye whiteness) before and after treatment with a novel color space algorithm. RESULTS Twenty-nine patients participated in the study. The mean [SD] MRD1 at baseline was 2.3 [0.6] mm. At 2 hours following oxymetazoline treatment, the mean MRD1 significantly increased to 4.2 [0.9] mm (P < 0.01). The mean MRD2 also significantly increased from 5.3 [0.9] mm to 5.7 [1.0] mm (P < 0.01). Brow position did not change with treatment (P = 0.4). Following treatment, the eye sclera became significantly whiter, with a mean ΔEab (color change) of 9.7 [3.9], with 57 out of 58 eyes experiencing a significant change in color. A change of ΔEab ≥2 is considered visually perceptible to the human eye. CONCLUSIONS Within 2 hours of use, oxymetazoline significantly improves the size of the palpebral aperture (MRD1 + MRD2) and also makes the eye appear significantly whiter. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Shoaib Ugradar
- The Jules Stein Eye Institute, UCLA, Los Angeles, CA, USA
| | - Jane S Kim
- Kellog Eye Center, University of Michigan, Ann Arbor, MI, USA
| | - Noelle Trost
- The Jules Stein Eye Institute, UCLA, Los Angeles, CA, USA
| | | | - Erin Zimmerman
- The Jules Stein Eye Institute, UCLA, Los Angeles, CA, USA
| | - Kambiz Ameli
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Marissa K Shoji
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Wendy W Lee
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
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13
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Nichols KK, Malloy KA, Karpecki PM, Bacharach J, Douglas RS, Foster S, Gromacki SJ, Whitley WO. Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis. Optom Vis Sci 2022; 99:230-240. [PMID: 35058403 DOI: 10.1097/opx.0000000000001868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
SIGNIFICANCE Acquired ptosis is a condition of the upper eyelid that has negative cosmetic and functional effects but is likely underdiagnosed and undertreated. Given the evolving understanding of the condition and expanding therapeutic options, this review reappraised published evidence and clinical experience regarding diagnosis and treatment of acquired ptosis.The authors met over two structured virtual working sessions to review current evidence and develop timely recommendations for acquired ptosis identification, differential diagnosis, characterization, and treatment selection. Diagnostic algorithms, plus management and referral guidelines, are presented. Eyelid evaluation and, when needed, ptosis diagnostic workup are essential in the comprehensive eye examination. Acquired ptosis can be efficiently identified via patient questionnaire, history, and photograph review combined with assessment of eyelid position and symmetry using established methods. When ptosis is present, it is essential to evaluate onset, symptoms, pupil diameter, and extraocular muscle function to identify or rule out serious underlying conditions. If signs of serious underlying etiology are present, immediate referral/follow-up testing is required. After ruling out serious underlying causes, masquerade conditions, and pseudoptosis, pharmacologic or surgical treatment should be selected based on the clinical evidence. Effectively managing acquired ptosis requires practice-wide commitment to thorough eyelid evaluation, accurate diagnosis, and adoption of new treatment modalities. Aided by evolving pharmacologic therapeutic options, shifting from a "detect and refer" to a "diagnose and manage" approach can support identification and treatment of more patients with acquired ptosis, particularly mild-to-moderate cases.
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Affiliation(s)
| | - Kelly A Malloy
- The Eye Institute of the Pennsylvania College of Optometry, Salus University, Philadelphia, Pennsylvania
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14
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Price FW, Hom M, Moshirfar M, Evans D, Liu H, Penzner J, Robinson MR, Lee S, Wirta DL. Combinations of Pilocarpine and Oxymetazoline for the Pharmacological Treatment of Presbyopia. OPHTHALMOLOGY SCIENCE 2021; 1:100065. [PMID: 36246939 PMCID: PMC9562347 DOI: 10.1016/j.xops.2021.100065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 11/04/2022]
Abstract
Purpose To determine the safety, efficacy, and tolerability of combinations of pilocarpine (Pilo) and oxymetazoline (Oxy) ocular drops dosed once daily and identify the optimal concentration of each for the pharmacologic treatment of presbyopia. Design Two concurrent Phase 2, multicenter, double-masked, randomized, vehicle-controlled studies, 1 short-term and 1 extended study. Participants Emmetropic individuals affected by presbyopia and in good general health. Methods Uncorrected near visual acuity (UNVA) was measured throughout both studies with various concentrations and combinations of Pilo (0%, 0.5% 1.0%, and 1.5%) and Oxy (0%, 0.0125%, 0.05%, and 0.125%). For safety, uncorrected distance visual acuity (UDVA) was measured, treatment-emergent adverse events (TEAEs) were recorded, and a temporal/supraorbital headache assessment was completed. Main Outcome Measures The primary efficacy end point was mean change from baseline in UNVA. Results In the short-term study, Pilo was shown to produce a significant dose response in the average increase of letters (P < 0.001), whereas Oxy did not have a significant impact (P = 0.4797). The addition or increase in concentration of Oxy did not reduce incidence or severity of headaches when compared with Pilo alone. Efficacy results from the extended study supported the results from the short-term study. As early as 15 minutes postadministration, a dose response could be seen, with peak effect at 1 hour. Peak improvement increased from day 1 to day 14 and was maintained up to day 28. The most common TEAE was headache. There was no clinically significant reduction in UDVA. A polynomial regression model was developed and determined that the optimal concentration range of Pilo is between 1.16% and 1.32%. Conclusions On the basis of the results of the 2 Phase 2 studies, AGN-190584, a reading drop containing an optimized concentration of pilocarpine HCl (1.25%) delivered using a proprietary formulation, was developed and is currently under investigation in Phase 3 studies.
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Cooper J, Yang D. Case Report: Treatment of Myasthenic Ptosis with Topical Ocular Oxymetazoline. Optom Vis Sci 2021; 98:1317-1320. [PMID: 34510144 DOI: 10.1097/opx.0000000000001800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Ptosis is often the hallmark finding in ocular and general myasthenia gravis. Reduction of ptosis has been achieved with oral and topical ocular medications. However, these medications can result in systemic and ocular adverse effects. A novel eye drop seems to be effective in reducing ptosis while minimizing adverse effects. PURPOSE This case report aimed to demonstrate the efficacy of topical oxymetazoline hydrochloride 0.1%, an α-adrenergic agonist, in temporary elimination of ptosis associated with myasthenia gravis. CASE REPORT A 68-year-old woman with a history of myasthenia gravis and long-standing ptosis in the right eye presented to improve the asymmetrical appearance of her eyelids. One drop of oxymetazoline hydrochloride 0.1% was instilled in the right eye of the patient. Within 2 hours, the ptosis was eliminated, the margin-reflex distance 1 increased by 2.0 mm, and the superior visual field measured by a superior 36-point screening test increased by 15 points. The effect lasted for at least 7 hours. Of note, there was a decrease in elevation of the contralateral nonptotic eyelid that did not receive a drop of oxymetazoline, which might occur only in myasthenia gravis. Further evaluation is warranted. CONCLUSIONS Oxymetazoline 0.1% is effective in reducing and potentially eliminating ptosis related to ocular myasthenia gravis for up to 7 hours.
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Affiliation(s)
| | - Danica Yang
- Cooper Panariello Eye Institute, Brooklyn, New York
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16
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Wirta DL, Korenfeld MS, Foster S, Smyth-Medina R, Bacharach J, Kannarr SR, Jaros MJ, Slonim CB. Safety of Once-Daily Oxymetazoline HCl Ophthalmic Solution, 0.1% in Patients with Acquired Blepharoptosis: Results from Four Randomized, Double-Masked Clinical Trials. Clin Ophthalmol 2021; 15:4035-4048. [PMID: 34675472 PMCID: PMC8517985 DOI: 10.2147/opth.s322326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/13/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose An oxymetazoline 0.1% ophthalmic solution was recently approved for treatment of acquired blepharoptosis in adults. This study's objective was to evaluate the safety profile of oxymetazoline 0.1% when administered once daily for 14-84 days. Patients and Methods Pooled analysis examined safety outcomes from four randomized, double-masked, placebo-controlled clinical trials conducted at 6, 16, 27, and 35 sites, respectively, in the United States. In total, 568 participants with acquired blepharoptosis were evaluated. Median age was 66 years and 74.8% of participants were female. Overall, 375 participants self-administered oxymetazoline 0.1% to both eyes once/day and 193 self-administered placebo (vehicle) daily. Treatment-emergent adverse event (TEAE) rates, severity, and causality were evaluated in the overall population and within participant subgroups defined based on age, race, and ethnicity. Vital signs and ophthalmic findings were evaluated at predefined study visits. Patient-reported treatment tolerability was recorded at study end. Results TEAE incidence was similar among participants using oxymetazoline 0.1% (31.2%) or vehicle (30.6%). Nearly all TEAEs were mild-to-moderate, and most were not suspected of being treatment related. Serious TEAEs occurred in four participants receiving oxymetazoline 0.1% and one participant receiving vehicle. Nine and two participants in the oxymetazoline 0.1% and vehicle groups, respectively, discontinued due to a TEAE. Ocular TEAEs occurring in ≥2% of participants receiving oxymetazoline 0.1% were punctate keratitis, conjunctival hyperemia, dry eye, blurred vision, instillation site pain, and corneal vital dye staining, with none occurring in >3.5% of participants. TEAE rates were similar across subgroups based on age, race, and ethnicity. No clinically significant mean changes in vital signs or ophthalmologic findings occurred, and >98% of participants rated oxymetazoline 0.1% as causing no/mild discomfort. Conclusion Once-daily oxymetazoline 0.1% was safe and well tolerated in participants with acquired blepharoptosis when used for 14-84 days. Safety did not appear to differ based on age, race, or ethnicity.
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Affiliation(s)
- David L Wirta
- Aesthetic Eye Care Institute & Eye Research Foundation, Newport Beach, CA, USA
| | | | | | | | | | | | | | - Charles B Slonim
- Department of Ophthalmology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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17
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Nestor MS, Han H, Gade A, Fischer D, Saban Y, Polselli R. Botulinum toxin-induced blepharoptosis: Anatomy, etiology, prevention, and therapeutic options. J Cosmet Dermatol 2021; 20:3133-3146. [PMID: 34378298 PMCID: PMC9290925 DOI: 10.1111/jocd.14361] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
Background Botulinum toxin A (BoNT‐A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate‐to‐severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT‐A which, although rare, more frequently occurs among inexperienced practitioners. Objectives The purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT‐A administration including new anatomic pathways for BoNT‐A spread from the brow area to the levator palpebrae superioris muscle. Methods A literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT‐A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations. Results Blepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3–14 days after injection and eventually self‐resolves after the paralytic effect of BoNT‐A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT‐A injections to the pre‐tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle. Conclusion Providers should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT‐A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into “danger zones,” which increase the risk of eyelid ptosis.
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Affiliation(s)
- Mark S Nestor
- Center for Clinical and Cosmetic Research, Aventura, Florida, USA.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,Division of Plastic Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Haowei Han
- Center for Clinical and Cosmetic Research, Aventura, Florida, USA
| | - Anita Gade
- Center for Clinical and Cosmetic Research, Aventura, Florida, USA
| | - Daniel Fischer
- Center for Clinical and Cosmetic Research, Aventura, Florida, USA
| | - Yves Saban
- Facial Plastic and Maxillofacial Surgery, Facial Anatomist, Nice, France.,European Academy of Facial Plastic Surgery (EAFPS), Lübeck, France.,Rhinoplasty Focus Group, Chennai, India
| | - Roberto Polselli
- Ear Nose Throat, Facial Plastic Surgery, Private Practice in Marina di Carrara, Marina di Carrara, Italy
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Bacharach J, Wirta DL, Smyth-Medina R, Korenfeld MS, Kannarr SR, Foster S, J Jaros M, Slonim CB. Rapid and Sustained Eyelid Elevation in Acquired Blepharoptosis with Oxymetazoline 0.1%: Randomized Phase 3 Trial Results. Clin Ophthalmol 2021; 15:2743-2751. [PMID: 34211263 PMCID: PMC8240850 DOI: 10.2147/opth.s306155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/27/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Oxymetazoline 0.1% is a novel ophthalmic agent for the treatment of acquired blepharoptosis in adults that has been shown to improve upper eyelid elevation and superior visual field deficits. This analysis characterized the rapid onset of upper eyelid elevation with once-daily oxymetazoline 0.1% and durability of this effect over 42 days. Materials and Methods Pooling data from two prospective, randomized, placebo-controlled, phase 3 studies, change in marginal reflex distance 1 (MRD-1) was evaluated at a range of post-instillation time points on treatment days 1, 14, and 42. Onset of effect was assessed beginning at 5 minutes post-administration (one study) and through 6 hours at the first two visits (both studies). Overall, 203 subjects received oxymetazoline 0.1% and 101 received vehicle. Results Oxymetazoline 0.1% demonstrated a rapid onset of action on all days evaluated. Mean changes from baseline 5 and 15 minutes post-oxymetazoline 0.1% instillation on day 1 were 0.59 ± 0.72 mm and 0.93 ± 0.81 mm, respectively (vs 0.20 ± 0.57 mm and 0.32 ± 0.64 mm with vehicle; both p<0.001). On day 14, mean changes from baseline 5 and 15 minutes post-oxymetazoline 0.1% instillation were 0.77 ± 0.85 mm and 1.11 ± 0.92 mm, respectively (vs 0.42 ± 0.78 mm and 0.41 ± 0.83 mm with vehicle; both p<0.05). This effect was also observed immediately post-instillation on day 42, where mean increases 5 and 15 minutes post-oxymetazoline 0.1% instillation were 0.86 ± 0.85 mm and 1.04 ± 0.91 mm, respectively (vs 0.42 ± 0.80 mm and 0.47 ± 0.93 mm with vehicle; both p<0.005). Significant improvements vs vehicle (p<0.001) were also observed at 2–6 hours on days 1 and 14. At all time points, the proportion of subjects showing a positive response to treatment (>0% MRD-1 increase) was >15% greater in the oxymetazoline 0.1% group (range 16.6–36.1% more responders vs vehicle), with the largest differences observed 2 and 6 hours post-instillation. Conclusion Oxymetazoline 0.1% provided rapid and sustained upper eyelid elevation. Together with data demonstrating superior visual field improvement and a favorable safety profile, this analysis supports oxymetazoline 0.1% as an effective non-surgical treatment for acquired ptosis.
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Affiliation(s)
| | - David L Wirta
- Aesthetic Eye Care Institute & Eye Research Foundation, Newport Beach, CA, USA
| | | | | | | | | | | | - Charles B Slonim
- Department of Ophthalmology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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19
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Bacharach J, Lee WW, Harrison AR, Freddo TF. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye (Lond) 2021; 35:2468-2481. [PMID: 33927356 PMCID: PMC8376882 DOI: 10.1038/s41433-021-01547-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/15/2021] [Accepted: 04/07/2021] [Indexed: 11/25/2022] Open
Abstract
Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact quality of life. While there are several known forms of congenital ptosis, acquired ptosis (appearing later in life, due to a variety of causes) is the predominant form of the condition. This review summarises the prevalence, causes, identification, differential diagnosis, and treatment of acquired ptosis. Particular attention is paid to the differential diagnosis of acquired ptosis and emerging treatment options, including surgical and pharmacologic approaches.
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Affiliation(s)
| | - Wendy W Lee
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Andrew R Harrison
- Department of Ophthalmology and Visual Neurosciences, Department of Otolaryngology, University of Minnesota, Minneapolis, MN, USA
| | - Thomas F Freddo
- Massachusetts College of Pharmacy and Health Sciences, Worcester, MA, USA
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