Comparing the symmetry of upper eyelid following unilateral ptosis correction

Chasing the objective upper eyelid symmetry formula; R2, RMSE, POC, MAE, and MSE

PURPOSE

Investigate the most appropriate mathematical formula to objectively express upper eyelid contour symmetry.

METHODS

62 eyes of 31 patients were included in the study. The upper eyelid contour symmetry of the patients was classified subjectively (independent of MRD1) as poor, acceptable, and good by three oculoplastic specialists (senior, expert, and junior surgeon). Bézier curves of the upper lid contour were drawn with ImageJ software (NIH, Bethesda, MA, USA). Using the algorithms created by Author SKC in Spyder (Python 3.7.9.), the symmetry of the Bézier curves of the left eyelids were obtained according to the y-axis, and the mid-pupils of both eyes were superimposed. The lower curve moved vertically to the equal height of the other curve to equalize MRD1's. R2 (Coefficient of determination), RMSE (Root-mean-square error), MSE (Mean squared error), POC (Percentage of co-efficiency), and MAE (Mean absolute error) were calculated. We evaluated the correlation between these objective formulas and the subjective grading of three surgeons using Spearman's rho (ρ).

RESULTS

The correlation coefficient of RMSE and MSE were the same for all surgeons grading. There was a strong correlation between the senior surgeon's subjective scoring (N; poor = 8, acceptable = 16, good = 8) and R2, RMSE, POC, MAE (ρ = 0.643, p < 0.001, ρ = -0.607, p < 0.001, ρ = 0.562, p < 0.001, ρ = -0.517, p < 0.001, respectively). We found a strong relationship between the expert surgeon's subjective scoring (N; poor = 9, acceptable = 13, good:10) and R2 (ρ = 0.611, p < 0.001), RMSE (ρ = -0.549, p < 0.001), POC (ρ = 0.511, p < 0.001), and MAE (ρ = -0.450, p < 0.05). We found a strong correlation between junior surgeon's subjective scoring (N; poor = 6, acceptable = 18, good = 8) and R2, RMSE, and POC (ρ: -0.517, p < 0.001; ρ: -0.470, p < 0.001; ρ: 0.521, p < 0.001; respectively) and moderate correlation between MAE (ρ:-0.394, p < 0.05). The highest correlation is observed with R2.

CONCLUSIONS

RMSE, MSE, POC, MAE, and especially R2, may quantitatively express upper eyelid contour symmetry, comparable with the oculoplastic surgeon. The highest correlation was observed between the senior surgeon and R2, and decreases with the experience of the surgeon.

Symmetry of upper eyelid after unilateral blepharoptosis repair with minimally invasive conjoint fascial sheath suspension technique

AIM

To investigate the symmetry of upper eyelid in patients with unilateral mild and moderate blepharoptosis who underwent unilateral minimally invasive combined fascia sheath (CFS) suspension.

METHODS

A retrospective study of patients who underwent unilateral minimally invasive CFS suspension surgery between January 2018 and December 2021. Inclusion criteria included unilateral mild and moderate ptosis, good levator muscle function (>9 mm) and follow-up of at least 6mo. Pre- and post-operative symmetry was graded subjectively for marginal reflex distance 1 (MRD1), tarsal platform show (TPS) and eyebrow fat span (BFS). A t-test was used to evaluate MRD1, TPS and BFS asymmetry by calculating delta values. The Bézier curve tool of the Image J software was used to extract the upper eyelid contours, where the symmetry was measured by the percentage of overlapping curvatures (POC).

RESULTS

Totally 105 patients (105 eyelids) were included (mild group, n=84; moderate group, n=21). Postoperatively, all patients increased MRD1 and decreased TPS in the ptotic eye while maintaining unchanged BFS. The asymmetric delta value for MRD1 was measured to be 1.48±0.86 preoperatively, and it decreased to 0.58±0.67 postoperatively in all cases (P=0.0004). In patients with mild ptosis, the asymmetry value of TPS fell significantly from 1.15±0.62 to 0.68±0.38 (P=0.0187). The symmetry of the upper eyelid contour increased in all subgroups of patients, with a POC of 59.39%±13.45% preoperatively and POC of 78.29%±13.80% postoperatively.

CONCLUSION

Minimally invasive CFS suspension is proved to be an effective means of improving the symmetry of unilateral ptosis in terms of MRD1 (all subgroups), POC (all subgroups) and TPS (only mild group), whereas BFS is unaffected.

Sector area index: a novel supporting marker for blepharoptosis screening and grading

PURPOSE

To introduce a new supporting marker for discriminating different grades of ptosis called Sector Area Index (SAI) and a semi-automated technique to calculate it.

METHODS

In this cross-sectional comparative case series, a circle enclosing the intercanthal distance was automatically drawn after choosing two points as the medial and lateral canthus and manually selecting the palpebral fissure region. Finally, 15-degree apart sectors are applied to the enclosed circle. SAI was measured automatically by dividing the area of each 15-degree sector marked with the upper eyelid contour by the total area of the sector marked with the edge of the surrounding circle. SAI values and inter-eye SAI differences were compared between patients with different grades of ptosis as well as normal patients.

RESULTS

In the current study, 106 eyes were recruited (30, 25, 27, and 24 in the control, mild, moderate, and severe ptosis groups, respectively). Mean values of SAI in all sectors showed a decreasing trend from normal individuals toward patients with severe ptosis. The mean difference values of SAI between study eyes and fellow eyes in all four groups of patients showed a statistically significant difference (p < 0.05). In a pairwise comparison between groups, mean values of SAI in all nasal sectors from 15° to 60° showed a statistically significant difference between all groups (p < 0.05).

CONCLUSION

The mean difference of SAI between study eyes and fellow eyes, including eyelid curvature, especially in 15°-60° and 120°-165° sectors, can demonstrate differentiating performance for detecting and discriminating varying grades of ptosis.

Analysis of Facial Features of Patients With Sagging Eye Syndrome and Intermittent Exotropia Compared to Controls

PURPOSE

To compare the facial features of patients with sagging eye syndrome (SES) and other ophthalmic diseases, and to evaluate the diagnostic usefulness of facial features for SES.

DESIGN

Retrospective cross-section study.

METHODS

We evaluated frontal facial photographs of patients >60 years of age with SES and intermittent exotropia (IXT), and control patients who visited the ophthalmology outpatient clinics of 2 institutions between June 2020 and December 2021. Three ophthalmologists evaluated each eye for sunken upper eyelid, blepharoptosis, and baggy lower eyelid, using a scoring scale. The average scores for each parameter among the 3 groups were analyzed. Patients with glaucoma, visual acuity <16/20, SES with a vertical strabismus angle of ≥6 Δ, IXT that could not be maintained in the phoria position during photography, a history of previous oculoplastic or ophthalmic surgery, and use prostaglandin analogs for cosmetic purposes were excluded.

RESULTS

A total of 86 patients were included: 23 with SES, 28 with IXT, and 35 in the control group. All were Japanese. In all, 45 patients were male and 41 were female. The mean age was 72.7 ± 7.4 years. The sunken upper eyelid scores were significantly higher in the SES group than in the control and IXT groups (P < .001), whereas the baggy lower eyelid scores were significantly higher in the IXT group than in the control group (P < .05).

CONCLUSIONS

Age-related orbital connective tissue degeneration may manifest as SES in the upper eyelid and as IXT in the lower eyelid.

Combined levator and frontalis muscle advancement flaps for recurrent severe congenital ptosis

BACKGROUND

To evaluate the outcomes of combined levator resection and frontalis muscle advancement for surgical management of recurrent severe congenital ptosis.

DESIGN

Retrospective, nonrandomized interventional case series.

METHODS

A retrospective review was performed of patients who underwent combined levator resection and frontalis muscle advancement for recurrent congenital ptosis between 2017 and 2020. Inclusion criteria were levator function of 4 mm or less and margin reflex distance 1 (MRD1) of 0 mm or less. Main outcome measures were postoperative MRD 1, lagophthalmos, lash angle, and grades of eyelid contour and crease. The outcomes were assessed by reviewing medical charts and photographs.

RESULTS

Thirty-one patients (35 eyelids) met the inclusion criteria. The mean preoperative MRD1 was -1.14 ± 1.56 mm, which improved to 3.93 ± 0.52 mm with an average lagophthalmos of 0.91 ± 0.74 mm at the last follow-up. A total of 91.4% of eyelids had excellent eyelid contour, crease, and eyelash angle at the final follow-up. One eyelid required revision surgery. There were no other significant complications.

CONCLUSIONS

For poor function recurrent congenital ptosis, combining levator resection and frontalis muscle advancement is an effective method that results in long-term correction with cosmetically pleasing outcomes and minimal complications.