Rethinking Our Definition of Postoperative Success: A Comparative Analysis of Three Upper Eyelid Retraction Repair Techniques Using Novel Metrics to Capture Functional and Aesthetic Outcomes

The effectiveness and safety of eyelid defect reconstruction after sebaceous carcinoma of the eyelid surgery: A protocol for systematic review and meta-analysis

INTRODUCTION

Sebaceous carcinoma of the eyelid is the third most common eyelid malignancy, after basal cell carcinoma and squamous cell carcinoma. It is highly malignant and potentially aggressive. Surgical excision is currently the best treatment option for this condition. Patients often require reconstruction surgery to repair eyelid defects to achieve normal eyelid function and appearance. However, no comprehensive systematic review has assessed the efficacy and safety of eyelid defect reconstruction. This protocol was developed to conduct a systematic review and meta-analysis to evaluate evidence related to the efficacy and safety of reconstruction.

METHODS

We will systematically search the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure, WanFang Database, and Chinese Biomedical Literature Database from their inception to February 2023 for studies on eyelid defect reconstruction. We will identify other potential studies using multiple methods such as manual searching. The outcomes were eyelid function, eyelid morphology, patient satisfaction, recurrence rate, metastasis rate, tumor-related mortality, and adverse events. Two researchers will independently screen titles and abstracts, identify full-text studies for inclusion, extract data, and appraise the risk of bias in the included studies. A meta-analysis will be conducted using Review Manager 5.4 and R software. The certainty of evidence will be appraised by grading of recommendations, assessment, development, and evaluation system.

RESULTS

This full-text will adhere to the preferred reporting items for systematic reviews and meta-analyses statement to ensure clarity and completeness of reporting in all phases of the systematic review.

DISCUSSION

This study provides evidence of the efficacy and safety of reconstruction methods for sebaceous carcinoma of the eyelid.

The Postsurgical Clavien–Dindo Classification in Minor Surgery Can Improve Perception and Communication (Investigation on Blepharoplasty)

The postsurgical Clavien–Dindo classification in minor surgery can improve perception and communication (Investigation on Blepharoplasty). Background: Minor surgery lacks a standardized postoperative complication classification. This leads to the presentation of inaccurate postsurgical complication rates and makes comparisons challenging, especially for patients seeking information. This study aims to evaluate a standardized five-step complication grading system (Clavien–Dindo Classification, CDC) on the example of blepharoplasty, which is the most performed minor aesthetic surgery worldwide. Methods: A retrospective observational exploratory study of patients (N = 344) who received a bilateral upper eyelid blepharoplasty under local anesthesia from the same surgical staff was performed. Data were retrieved from the electronic patient record: the CDC grading and the surgeon-reported complications (N = 128) at the first follow-up on day 7. In addition, a telephone survey with patients (N = 261) after 6 months was performed, which consisted of 7 complication-related yes/no questions. Results: Based on the CDC, 41.6% of patients were classified as having no complications, and 58.4% had one. Furthermore, 1 patient (0.3%) received a revision under general anesthesia (CDC IIIb), 18 patients (5.2%) were re-operated under local anesthesia (CDC IIIa), 23 patients (6.7%) required pharmacological intervention (CDC II), and 159 patients (46.2%) had a complication from the normal postoperative course and received supportive treatment (CDC I). Moreover, 90.5% of the mentioned complications accounted for Grade I and II; 94% of the patients subjectively experienced no complications; 51% of patients were pleased with the surgery even though a complication occurred according to the CDC; 34% of complications escaped the awareness of the surgeon. Conclusions: Grade I and II complications occurred frequently. Complications escaped the perception of the patients and surgeons. The classification identifies a wide variety of postsurgical complications and allows a standardized comparison in minor surgery objectively. Potential: The CDC in minor procedures can improve the (institutional) preoperative communication with patients regarding potential postoperative expectations. Furthermore, the classification can be a useful tool to detect complication-related costs, identify insurance-related requests, and support evidence in medicolegal disputes. The example of blepharoplasty can be translated to various other and even less invasive procedures.

The Effect of Teprotumumab on Eyelid Position in Patients with Thyroid Eye Disease

Teprotumumab has been shown to improve proptosis and clinical activity scores (CAS) in patients with thyroid eye disease, but little has been published regarding its effects on eyelid retraction. The purpose of this work was to evaluate changes in eyelid position in thyroid eye disease patients after teprotumumab. Eight patients completed eight cycles of teprotumumab. Data collected included exophthalmometry; clinical activity scores; margin reflex distance (MRD) 1; MRD2; and pre-, during, and posttreatment photographs. ImageJ analysis was also used to evaluate eyelid position in photographs. Proptosis significantly improved in 15 of 16 orbits [mean 4.75 ± 2.07 mm reduction (P = 0.0001) in study orbits and mean 3.00 ± 2.14 mm reduction (P = 0.0048) in nonstudy orbits]. CAS was significantly reduced (pretreatment mean 4.88 mm and posttreatment mean 1.88 mm, P = 0.006). MRD1 decreased in 11 of 16 orbits and increased in five orbits (P = 0.18 in study orbits and P = 0.22 in nonstudy orbits). MRD2 decreased in six of 16 orbits and increased in eight orbits (P = 0.49 in study orbits and P = 0.43 in nonstudy orbits). Patients exhibited variable changes in eyelid position with teprotumumab. There was a statistically insignificant decrease in MRD1 after teprotumumab. Proptosis reduction led to unpredictable changes in MRD1 and MRD2. Severity of eyelid retraction did not correlate with clinical activity score response to teprotumumab. There are inherent difficulties in evaluating eyelid position in thyroid eye disease, which may necessitate a paradigm shift in how patients are examined, measured, and photographed.

Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy

BACKGROUND

We present our experience on 153 cases of full-thickness anterior blepharotomy with mullerectomy (FTABM) in the treatment of upper eyelid retraction (UER) related to Graves' ophthalmopathy (GO).

METHODS

We included all the patients who underwent a graded FTABM between 1^st January 2015 and 30^th June 2020 for UER GO-related. The analysis included: pre-/post-operative conjunctival symptoms, epiphora, GO-Quality of Life Questionnaire (QoL), lagophthalmos, marginal reflex distance (MRD-1) index, eyelid symmetry within 1mm. The statistical analysis was designed to detect postoperative improvement in objective and subjective clinical features. Outcomes were analysed through Chi-squared test for dichotomous variables and through Wilcoxon-Mann-Whitney test for continuous variables.

RESULTS

Of the 111 patients, 42 underwent a bilateral procedure, while 69 a monolateral. Conjunctival symptoms were reported in 32% of cases before surgery and in 12.4% after FTABM (p < 0.001). Epiphora was complained by 29.6% of patients preoperatively and in 12.4% postoperatively (p < 0.001). Preoperative lagophthalmos was found in 12.4% (mean value of 0.34 ± 0.76 mm) of eyelids, and in 2.6% (mean value 0.05 ± 0.19 mm) eyelids (p = not significant) postoperatively. Pre-operative GO-QoL was 24.9 ± 4.4 mm; while post-operative GO-QoL was 35.3 ± 5.5 mm (p < 0.001). The MRD-1 varied from 10.12 ± 2.1 mm preoperatively, to 4.3 ± 0.6 mm (p < 0.001) after surgery. Asymmetric palpebral fissure was noted in 94 (84.7%) patients before surgery and in 7 (6.3%) after the procedure (p < 0.001).

CONCLUSION

FTABM is an effective procedure to treat UER GO-related. The technique manages to prevent complications of UER and determine good aesthetics.

LEVEL OF EVIDENCE IV

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

The Effect of Sleep Position Preference on Eyelid and Eyebrow Symmetry

PURPOSE

To investigate the relationship between sleep position preference and eyebrow and eyelid position and degree of upper eyelid dermatochalasis.

METHODS

A prospective study evaluating the impact of sleep position on facial asymmetry was conducted at an academic ophthalmology department. Eligibility criteria included the absence of periocular-altering trauma or surgery, contact lens use, or other periorbital disease processes. Patients reported their sleep position preference on a questionnaire. Standardized digital photographs of patients were obtained, and Image J software was used for measurements and converted into millimeters based on a standard corneal limbus-to-limbus ratio. Upper and lower eyelid position, upper eyelid dermatochalasis, and eyebrow position were assessed by the following image-derived measurements: marginal reflex distance 1 (iMRD1), marginal reflex distance 2 (iMRD2), tarsal platform show (iTPS), and central brow position (iBP). These results were compared with the patient reported sleep position preference to determine correlation.

RESULTS

Seventy-one patients were enrolled and reported the following sleep position preferences: 28 (right), 24 (left), 13 (both), and 6 (supine). Patients with a right- or left-sided preference demonstrated lower iMRD1 measurements for the preferred sleep side (p < 0.0004) with no other significant difference in periorbital measurements. A larger degree of upper eyelid height (iMRD1) asymmetry was observed among patients with a sleep side preference.

CONCLUSION

Patients with a predominant sleep side preference demonstrate a significant increase in ipsilateral upper eyelid asymmetry and an inferior upper eyelid position on the sleep side. There were no differences noted in lower eyelid position, central eyebrow position, or amount of upper eyelid dermatochalasis.

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

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

Validated Outcome Measures and Postsurgical Scar Assessment Instruments in Eyelid Surgery: A Systematic Review

BACKGROUND

Determining which postsurgical scar assessment instruments, if any, cover important eyelid outcome measures can either attest to the strength of one or more instruments or reveal the need for a more comprehensive scale.

OBJECTIVE

To systematically review validated outcome measures after eyelid surgery and postsurgical scar assessment tools to see whether any individual or combination of 2 assessment tools encompass all relevant, validated eyelid outcome measures.

METHODS

Systematic reviews of validated eyelid outcome measures and postsurgical scar assessment tools were conducted using PubMed/MEDLINE and Ovid. Outcome measure papers that met inclusion criteria were sorted into 8 categories: Patient Subjective, Visual Function, Mechanical Function, Daily Activities, Adverse Effects, Aesthetic Quantitative: Clinical Measurements, Aesthetic Qualitative: Global, and Aesthetic Qualitative: Specific. Outcome measure papers were categorized into tiers of evidence support, and assessment tools were evaluated based on which outcome measures each covered.

RESULTS

No one or combination of 2 assessment tools covered all selected eyelid outcome measures. Although measures related to the subjective patient experience were included in several of the assessment scales, none covered measures of visual function or eyelid-specific clinical measurements.

CONCLUSION

There is currently no existing postsurgical scar assessment instrument that covers all important eyelid-specific outcome measures.

Challenging the current treatment of residual postoperative ptosis: safety and efficacy of repeat Müller's muscle conjunctival resection

OBJECTIVE

To determine if repeat Müller's muscle conjunctival resection (MMCR) is a viable approach in the treatment of recurrent or residual eyelid ptosis.

METHODS

A retrospective review of patients who underwent repeat MMCR was performed using external photos obtained preoperatively, postoperatively, and at last follow-up. The marginal reflex distances (MRD1 and MRD2), brow position (BP), and tarsal platform show (TPS) were evaluated with digital image analysis. The change in upper eyelid height (MRD1) and TPS following repeat ptosis repair were the outcome measures.

RESULTS

Repeat MMCR was performed on 12 eyelids of 11 patients. Mean MRD1 elevation after initial MMCR was 1.6 mm (standard deviation [SD] = 1.0mm, p < 0.00001). Mean decrease in TPS was 1.9 mm (p = 0.04). There was no significant change in MRD2 (p = 0.36) or BP (p = 0.33) with initial MMCR. Mean interval between procedures was 12.8 months (range 2.3-48.0) and follow-up after repeat MMCR was 2.3 months. Total average follow-up after initial MMCR was 15.1 months. Mean elevation in MRD1 after repeat MMCR was 1.0 mm (SD = 0.8 mm, p < 0.002). Mean decrease in TPS was 1.0 mm (p = 0.03). There was no difference in MRD2 (p = 0.90) or BP (p = 0.53). There were no complications of repeat MMCR noted clinically or spontaneously reported, including no entropion, fornix foreshortening, or development of dry eye signs or symptoms.

CONCLUSION

Repeat MMCR significantly improves recurrent or residual ptosis after initial MMCR without significant adverse consequences. The degree of elevation with repeat MMCR was diminished when compared with initial MMCR.

Treatment of Graves' ophthalmopathy

Graves' ophthalmopathy is an inflammatory disease with primary involvement of the extraocular muscles and the orbit. It encompasses the most common extra-thyroid manifestation in patients with Graves-Basedow disease. The underlying cause is molecular mimicry with the TSH receptor in ocular fibroblasts, leading to an immuno-mediated pathogenesis. Glucocorticoids at high doses are the cornerstone in moderate-severe cases. However, some patients are corticorresistant or intolerant. In recent years, therapeutic novelties have been described in terms of the dosage of the immunosuppressive treatments used, as well as the emergence of biological therapy in this field. The objective of this review is to update the treatment of Graves' ophthalmopathy, as well as to present alternative options in patients resistant or intolerant to glucocorticoids.

Simultaneous Aesthetic Eyelid Surgery and Orbital Decompression for Rehabilitation of Thyroid Eye Disease: The One-Stage Approach

BACKGROUND

Aesthetic rehabilitation of thyroid orbitopathy includes orbital decompression, correction of eyelid retraction, and aesthetic blepharoplasty, performed traditionally in separate stages.

OBJECTIVES

To report the results of orbital decompression surgery associated with aesthetic eyelid surgery in one stage for aesthetic rehabilitation of patients affected by thyroid eye disease.

METHODS

Retrospective, multicentric study including 40 consecutive patients, who underwent orbital decompression surgery associated with aesthetic eyelid surgery in two centers: Genova (group 1) + Buenos Aires (group 2). Surgical techniques are described in detail.

RESULTS

Mean patient age in the study group was 41.2, 85% of the patients were female, and minimum follow-up time was 12 months, with average follow up of 27 months. All patients underwent orbital decompression; at the same time, 26 patients (65%) underwent bilateral upper blepharoplasty and 32 patients (80%) underwent transconjunctival lower blepharoplasty. Associated upper eyelid procedures included 23 patients (58%) undergoing upper eyelid retraction repair, 9 patients (23%) undergoing associated inferior retractor recession, and 12 patients (30%) closed transcanthal lateral canthopexy. Seven patients (17%) needed strabismus surgery for the treatment of new-onset diplopia and none required further revision eyelid surgery.

CONCLUSIONS

Shorr and Seiff suggested 4 stages of surgical rehabilitation: (1) orbital decompression; (2) eye muscle surgery; (3) correction of eyelid retraction; and (4) removal of excess fat and skin. This is the first study to suggest single-stage aesthetic rehabilitation consisting of combined orbital decompression and aesthetic eyelid surgery. This approach has high patient satisfaction and significant reduction in direct and indirect healthcare costs.

LEVEL OF EVIDENCE 4