Dermatochalasis Aggravates Meibomian Gland Dysfunction Related Dry Eyes

Upper Blepharoplasty for Dermatochalasis With or Without Resection of the Orbicularis Oculi Muscle, Preaponeurotic and Nasal Fat Pads: A Comparative Study

OBJECTIVE

Upper blepharoplasty is the gold standard procedure for upper eyelid dermatochalasis. Upper blepharoplasties procedures include removing the skin, orbicularis oculi muscle, preaponeurotic, or nasal fat pad. The purpose of this study is to report surgical outcomes and compare them to the most common techniques.

MATERIAL AND METHODS

A retrospective review of 386 consecutive patients who underwent upper blepharoplasty at Turku University Hospital from January 1st, 2015 to June 30th, 2017 was conducted. Data collected include patient demographics, surgical details, and details regarding the type and frequency of complications.

RESULTS

During the study period, 51 upper blepharoplasties with orbicularis oculi muscle excision, skin, preaponeurotic and nasal fat pads removal (study group) and 335 upper blepharoplasties with skin only removal (control group) were performed. Non-parametric tests showed that operative time (M=60.2min; SD=11.7min) and return to work (M=8.0days; SD=3.1days) were significantly shorter in the control group. No significant differences in the total amount of complications were detected (7.8% vs 2.4%, p=0.075). Subjective patients' satisfaction was significantly higher in the study group (from 0-10, mean 8.3 vs 7.0, p=0.034).

CONCLUSIONS

When compared to skin-only blepharoplasty, upper blepharoplasty with orbicularis oculi muscle excision, removal of skin, preaponeurotic and nasal fat pad appears to be a safe surgery with improved patient satisfaction and without carrying on additional complications.

LEVEL OF EVIDENCE III

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A comparative study on the lipid layer thickness analysis of medical staff before and after work

Background & Aims

To study the change of the lipid layer thickness analysis in medical staff (MS) before and after work, and to explore the significance of measuring lipid layer thickness (LLT) respectively in four quadrants.

Methods

Ocular Surface Disease Index (OSDI) questionnaire and video display terminal using time for 55 MS were collected (the informed consent was obtained from all patients). Noninvasive tear break-up time, LLT, tear meniscus height (TMH), meibomian glands (MG) dropout, and blink pattern before and after work (worked for more than 4 h) of 110 eyes were measured by Gaush iDea Ocular surface analyzer. Lid margin abnormalities were evaluated by the slit-lamp microscopy.

Results

The average OSDI score of 55 MS was 25.68 ± 14.91. The average LLT of 110 eyes after work (65.12 ± 3.63 nm) was significantly reduced compared to before work (66.54 ± 4.16 nm), p < 0.05. The LLT in the superior quadrant was significantly thinner than that in the other three quadrants, p < 0.01. The average LLT was positively correlated with the LLT in the inferior (r = 0.822, p < 0.001), nasal (r = 0.261, p < 0.001), and temporal quadrant (r = 0.372, p < 0.001), while was negatively correlated with the MG dropout in lower lid (r = -0.209, p = 0.002). There was a significant correlation between the LLT in the inferior quadrant and the VDTt (r = -0.173, p = 0.01). The LLT of inferior quadrant were positively related to the TMH (r = 0.149, p = 0.027) and negatively related to MG dropout in lower lid (r = -0.162, p = 0.017).

Conclusion

The LLT significantly decreases after work in MS. The distribution of the lipid layer on the ocular surface is uneven. It is unreasonable for current detection instruments to measure the inferior quadrant LLT alone to represent average LLT.

Safety and Efficacy of Dry Eye Intelligent Therapeutic Device in the Treatment of Meibomian Gland Dysfunction in Rabbits

PURPOSE

To assess the safety and efficacy of the dry eye intelligent therapeutic device in rabbits with meibomian gland dysfunction.

METHODS

The meibomian gland dysfunction-afflicted rabbits were subjected to treatment using the dry eye intelligent therapeutic device. Various parameters, including eyelid margin, meibomian gland opening, redness, meibomian gland area, keratoconjunctival fluorescence staining, and intraocular pressure, were examined and analyzed using an ocular surface comprehensive examination instrument, slit lamp, and tonometer at corresponding times points. Hematoxylin and eosin staining was performed to examine the mucosal epithelium and meibomian gland.

RESULTS

In this study, eyelid margin congestion and meibomian gland opening obstruction were significantly improved after 3 weeks and 4 weeks of treatment, respectively (p < .01, p < .05). The treatment group showed a significant increase in tear meniscus height after 2 weeks, 3 weeks and 4 weeks of treatment (p < .001, p < .01, p < .05). No significant changes were noted in meibomian gland area, redness, intraocular pressure, and keratoconjunctival fluorescence staining of rabbits before and after treatment. Hematoxylin and eosin staining revealed a complete structure of mucosal epithelium and meibomian gland in the treatment group and that the expansion of the blocked meibomian gland duct was reduced.

CONCLUSION

The utilization of the dry eye intelligent therapeutic device in treating meibomian gland dysfunction-afflicted rabbits exhibits potential promising safety, efficacy, and overall benefits, thereby offering a novel alternative for managing meibomian gland dysfunction patients in clinical settings.

Is Blepharoplasty Cost-effective? Utility Analysis of Dermatochalasis and Cost-effectiveness Analysis of Upper Eyelid Blepharoplasty

PURPOSE

This cross-sectional prospective study measured utility values of upper eyelid dermatochalasis to quantify its impact on quality of life and assess cost-effectiveness of upper blepharoplasty.

METHODS

Utility of dermatochalasis was assessed using the standard reference gamble and time trade-off methods, with dual anchor points of perfect eye function and perfect health. The utility value obtained was used to create a Markov model and run a cost-effectiveness analysis of blepharoplasty as a treatment for dermatochalasis while utilizing the societal perspective.

RESULTS

One hundred three patients with dermatochalasis recruited from an urban outpatient ophthalmology clinic completed the utility survey. The authors determined utility values for dermatochalasis ranging from 0.74 to 0.92 depending on the measurement method (standard reference gamble/time trade-off) and anchor points. The cost-effectiveness analysis yielded an incremental cost-effectiveness ratio of $3,146 per quality-adjusted life year, well under the conventional willingness-to-pay threshold of $50,000 per quality-adjusted life year. Probabilistic sensitivity analysis with Monte Carlo simulation demonstrated that blepharoplasty would be cost-effective in 88.1% of cases at this willingness-to-pay threshold.

CONCLUSIONS

Dermatochalasis has an impact on quality of life that is significantly associated with level of perceived functional impairment. Rising health care costs have underscored the importance of providing value-based treatment to patients, and the results of this study suggest that blepharoplasty is a cost-effective treatment option for symptomatic bilateral upper eyelid dermatochalasis.

The Effect of Conjunctiva-Müller Muscle Resection on Tear Oxidative Stress Levels in Patients with Blepharoptosis

Objectives

To examine changes in tear oxidative stress levels and tear film functions in patients with blepharoptosis and dermatochalasis following conjunctiva-Müller muscle resection (CMMR) and blepharoplasty surgeries.

Materials and Methods

This prospective study included 32 healthy controls and 62 patients with blepharoptosis or dermatochalasis. CMMR surgery was performed in 20 eyes and upper blepharoplasty was performed in 42 eyes. Tear oxidative stress markers (8-hydroxy-2’-deoxyguanosine [8-OHdG] and 4-hydroxy-2-nonenal [4-HNE]) were quantified by enzyme-linked immunosorbent assay and tear film functions were evaluated preoperatively and at 1 and 6 months postoperatively. The same assessments were performed in the control group at the same time points.

Results

Preoperative tear 8-OHdG and 4-HNE levels were lower in healthy controls (52.8±13.5 ng/mL and 27.8±6.4 ng/mL, respectively) compared to patients with dermatochalasis (86.1±37.2 ng/mL and 29.8±11.1 ng/mL, respectively) and blepharoptosis (90.4±39.3 ng/mL and 43.1±4.2 ng/mL, respectively) (p<0.001). 8-OHdG levels were increased at 1 month after CMMR, while both markers were decreased 1 month postoperatively in the blepharoplasty group (p=0.034). Schirmer 1 and OSDI scores did not change throughout the visits in both patient groups, but a temporary decrease in tear break-up time (TBUT) was observed after CMMR (p=0.017).

Conclusion

Dermatochalasis and blepharoptosis were associated with higher tear oxidative stress levels. CMMR surgery caused a temporary decrease in TBUT scores and an increase in oxidative stress in the first postoperative month.

Effects of cyclosporine on steroid-refractory dry eyes

PURPOSE

The purpose is to compare the effects of cyclosporine (CsA) on the steroid-refractory mixed-type dry eye (MTDE) and aqueous deficient dry eye (ADDE).

MATERIALS AND METHODS

We retrospectively enrolled 71 patients with levels 3 and 4 dry eye that were refractory to artificial tears and topical steroids. The effects were analyzed using the ocular surface disease index (OSDI) and standard patient evaluation of eye dryness (SPEED) questionnaires, Schirmer test II, blink patterns, lipid layer thickness (LLT), meibomian gland expressibility (MGE) and extent of meibomian gland (MG) dropout (meiboscale).

RESULTS

MTDE patients (LLT ≤60 nm, n = 38) were younger than those in ADDE (LLT >60 nm, n = 33). Before CsA treatment, they had higher Schirmer scores, less MGE, and a thinner LLT. There was no statistically significant difference in OSDI/SPEED scores between groups. CsA improved the OSDI in the ADDE group but not in the MTDE group. CsA treatment decreased the severity of superficial punctate keratitis (SPK) in both groups, but it significantly decreased partial blinks, total blinks, and partial blink rates in the ADDE group only. CsA did not increase the Schirmer score, LLT, MGE, or meiboscale grade in both groups. CsA could significantly improve subjective symptoms, SPK, and blink patterns in dry eyes refractory to topical steroids, which were more pronounced in ADDE than in MTDE.

CONCLUSION

In MTDE cases, concurrent MG treatment modalities, such as intense pulse light and/or thermal pulsation, could be considered to maximize the effects of CsA treatment.

Association between Dry Eye Parameters Depends on Tear Components

How tear components contribute to dry-eye symptoms/signs remains less well-defined. This observational cross-sectional study enrolled 4817 (F/M = 3590/1227) patients. Subjective symptoms were evaluated with the SPEED and OSDI questionnaires. Fluorescein tear breakup time (FTBUT), superficial punctate keratitis (SPK) grading, Schirmer scores, number of expressible meibomian glands (MGE), lipid layer thickness (LLT), blink/partial blink rates and meibography were recorded. Patients were divided into 4 types according to their Schirmer scores and LLT, i.e., Type 1 (N = 1494): Schirmer > 5 mm, LLT > 60 nm; Type 2 (N = 698): Schirmer > 5 mm, LLT ≤ 60 nm; Type 3 (N = 1160): Schirmer ≤ 5 mm, LLT ≤ 60 nm; Type 4 (N = 1465): Schirmer ≤ 5 mm, LLT > 60 nm. Lipid deficiency (LLT ≤ 60 nm) and aqueous deficiency (Schirmer score ≤ 5 mm) were found in 38.6% and 54.5% of patients, respectively. The majority (62.4%) of lipid-deficient patients were also aqueous deficient, while 44.2% of aqueous-deficient patients were also lipid-deficient. Type 3 patients (mixed type) had the highest symptom scores (p = 0.008 and 0.007 for SPEED and OSDI, respectively), more total blinks (p < 0.001) and the shortest FTBUT (p < 0.001). Stepwise multiple regression demonstrated that LLT and Schirmer score were significant contributors to FTBUT in all 4 types. The FTBUT correlated with SPK severity in all 4 types, with Schirmer score in types 1 and 4, and with LLT in type 3 patients. SPK correlated with LLT and MGE in types 1 and 4. Age correlated with dry eye parameters more significantly than sex. Subtyping by aqueous and lipid components facilitates the understanding of dry eye pathophysiology.