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Ptosis surgery outcomes are measured by one-dimensional metrics like Marginal Reflex Distance (MRD) and Palpebral Fissure Height (PFH) using ImageJ. However, these methods are insufficient to capture the full range of changes post-surgery. Eyeball Exposure Rate (EER) offers a more comprehensive two-dimensional perspective as metric. This study compares AI-based EER measurements with conventional ImageJ methods for assessing outcome of ptosis surgery. Methods: Images from 50 patients (total 100 eyes) taken before and after surgery were analyzed using manual ImageJ and the AI-tool \"Anigma-View\". Statistical tests assessed the accuracy and consistency of both methods, using intraclass correlation coefficients (ICCs) and Bland-Altman plots for comparison. EER measured by the AI-tool at pre- and post-operation were 58.85% and 75.36%, respectively. Similarly, manual measurements using ImageJ showed an increase from 58.22% to 75.27%. The Intraclass Correlation Coefficients (ICCs) between the AI-tool and manual measurements ranged from 0.984 to 0.994, indicating excellent agreement, with the repeated AI-tool demonstrating high reproducibility (ICC =  1). Bland-Altman plots showed excellent agreement between the two methods and reproducibility of AI-based measurements. Additionally, EER improvement was more prominent in the moderate to severe ptosis group with a 45.94% increase, compared to the mild group with 14.39% increase. The findings revealed no significant differences between AI-tool and manual methods, suggesting that AI-tool is just as reliable. AI-tool to automate measurements offers efficiency and objectivity, making it a valuable method in clinical fields. AI-based EER analysis is accurate and efficient, providing comparable results to manual methods. Its ability to simplify surgical outcome assessments makes it a promising addition to clinical practice. Further exploration of AI in evaluating three-dimensional changes in ptosis surgery could enhance future surgical assessments and outcomes.

Background The aim of this study was to evaluate the ability of two novel eyelid curvature measurements to distinguish between normal eyes and different severities of blepharoptosis. Methods A comparative cross-sectional analysis of upper eyelid curvature was performed for different severities of patients with unilateral blepharoptosis (congenital and aponeurotic) and normal controls. Mean upper lid contour index (ULCI) and area circularity index (ACI) were calculated for each group by dividing the intercanthal distance by upper eyelid margin length (ULCI) and dividing the interpalpebral area by the area of a circle enclosing the eye (ACI). The ratio of each index for the study and fellow normal eye of each patient was also calculated and compared between groups. Results A total of 106 eyes including 30 eyes in the control group and 25, 27, and 24 eyes in the mild, moderate, and severe ptosis groups were enrolled in the study. ULCI and ACI showed a statistically significant difference between the groups ( p  < 0.001, p  < 0.001). The inter-eye ratio (ULCI-ratio and ACI-ratio) of indices was also significantly different between groups ( p  = 0.002, p  < 0.001). Pairwise comparisons revealed that ACI and ACI-ratio were significantly different between all pairs of study groups. Conclusion The results of our study showed that ACI based on area measurements may distinguish blepharoptosis patients from normal controls and from each other. Including the data from the fellow normal eyes in the form of ratio indices may improve the differentiating power. These results can be useful in designing the optimal eyelid curvature measurements.

Purpose: To study the features of upper eyelid in healthy individual and different types of congenital ptosis in the Indian population using ultrasound biomicroscopy (UBM). Methods: This was a prospective observational study at a tertiary care center. Eyelid structure of healthy individuals with no eyelid abnormalities (n = 19); simple congenital ptosis (n = 33) cases; Marcus Gunn jaw-winking ptosis (MGJWP, n = 7) cases, and blepharophimosis-ptosis-epicanthus inversus syndrome (BPES, n = 20) cases were studied on a vertical UBM scan using 50-MHz probe. Lid-thickness, tarsal-thickness, orbicularis oculi and levator-Muller-orbital septum-conjunctival (LMSC) complex were measured in primary gaze. Comparison was made between four groups and results were statistically analyzed using ANOVA test. In normal individuals, LMSC measurements were repeated in down-gaze imaging. Results: Skin with subcutaneous tissue, LMSC complex and pre-aponeurotic fat-pad appeared echodense while orbicularis oculi and tarsus appeared echolucent. In primary gaze, mean thickness (± standard deviation) of the eyelid, tarsus, orbicularis oculi and LMSC, respectively, were: 1.612 ± 0.205, 0.907 ± 0.098, 0.336 ± 0.083, and 0.785 ± 0.135 mm in normal individual. LMSC showed 46.64% increase in thickness on down-gaze. The mean eyelid thickness and LMSC were thicker in MGJWP and BPES as compared to normal. In different types of congenital ptosis cases, various patterns of UBM imaging were observed. Conclusion: UBM allows noninvasive imaging of eyelid structures with good anatomical correspondence in normal eyelids and study the structural alterations of eyelids in different types of congenital ptosis. UBM can be used to highlight the anatomical difference in normal eyelids that may help modify the surgery for better cosmetic outcomes. Furthermore, it has the potential to be used in preoperative evaluation and operative planning in certain types of acquired ptosis, which needs to be evaluated.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of upper and lower motor neurons that usually spare the oculomotor nerves. Here, we describe a case of two siblings with a familial bulbar-onset ALS both with ptosis manifested at the onset of the disease.

Acute bilateral ptosis can be a hallmark of several serious neurological conditions. We present the first case of acute bilateral near-complete ptosis secondary to neuromyelitis optica spectrum disorder. We suggest that clinicians should consider this disorder among the differential diagnosis of acute bilateral ptosis, especially if there are other brainstem signs.

An infant presented with right upper eyelid ptosis and was subsequently diagnosed with acquired Horner syndrome. Further evaluation revealed a right-sided cervicothoracic lymphatic malformation. At 13 weeks of age, the child underwent percutaneous intracystic sclerotherapy with a mixture of sodium tetradecyl sulphate and ethanol. Twenty-one weeks after initial treatment, ophthalmic examination showed complete resolution of the blepharoptosis and pupillary miosis. Percutaneous sclerotherapy not only effectively treated the space-occupying lymphatic malformation but also reversed the Horner syndrome that was presumably induced by neural tension (more likely) or compression.

Raeder syndrome (paratrigeminal oculosympathetic syndrome) is a rare clinical entity characterized by ipsilateral trigeminal sensory deficits, ptosis, and miosis, with an absence of anhidrosis secondary to interruption of the postganglionic oculosympathetic pathway. Going back to its original description, this constellation of physical examination findings has historically been associated with intracranial pathology involving the middle cranial fossa. Understanding this pathway is important in distinguishing Raeder syndrome from Horner syndrome, as the presentation of the former is now recognized to accompany a number of other disease entities in the head and neck region. We present an unusual case of Raeder syndrome associated with bacterial sinusitis, and we discuss its management and review the literature.

Orbital subcutaneous emphysema develops when air enters the surrounding soft tissue. This occurs as a result facial bone trauma, iatrogenic dental and otolaryngeal procedures, and gas-producing infectious microorganisms. Case reports regarding this phenomenon after sneezing are very uncommon. Although orbital subcutaneous emphysema is not a true emergency, it can be distressful to patients. This case serves to bring awareness to emergency department physicians regarding the possibility of a nontraumatic orbital subcutaneous emphysema and its related complications.

Background Systemic lupus erythematosus (SLE) is an autoimmune disease with diverse manifestations, including rare neuro-ophthalmic complications. Isolated unilateral ptosis as a presenting sign of SLE is uncommon and diagnostic uncertainty often exists. Case presentation A 30-year-old woman with a 16-year history of SLE presented with acute right-sided ptosis without other neurological deficits while on stable maintenance immunosuppressive therapy. MRI of the brain and orbits, along with other relevant investigations, excluded common structural causes and showed no abnormalities. Serological testing indicated moderately active SLE, supporting an autoimmune flare as the likely mechanism. Myasthenia gravis–specific testing was not performed, a recognized limitation, but was considered clinically unnecessary given the absence of fatigability, diurnal variation, or generalized weakness. The ptosis resolved completely within 24 h of initiating high-dose systemic corticosteroid therapy. Conclusions Isolated unilateral ptosis may represent a rare neuro-ophthalmic manifestation of SLE, though alternative diagnoses cannot be definitively excluded. The rapid steroid response may suggest an inflammatory or autoimmune mechanism, underscoring the importance of considering such etiologies and initiating timely immunosuppressive therapy when appropriate.

A middle-aged woman with diabetes presented with left-sided facial pain, complete ptosis and fever of short duration. On presentation, she had hyperglycaemia without ketosis. There was total ophthalmoplegia of the left eye with a visual acuity of 6/36. She incidentally tested positive for COVID-19. CT paranasal sinus and MRI brain revealed left-sided pansinusitis with acute infarct in the left parieto-occipital region without angioinvasion. An emergency functional endoscopic sinus procedure was done, which confirmed mucormycosis on histopathological examination. After 1 week of conventional amphotericin B and antibiotics, repeat CT brain showed improvement in mucosal thickening and sinusitis. This case is a rare presentation of mucormycosis associated with rapid progression to orbital apex syndrome with brain infarction in a patient with non-ketotic diabetes and COVID-19. Early diagnosis and treatment are essential to prevent further end-organ damage. It is also interesting that there was no angioinvasion and transient periarterial inflammation was attributed to brain infarction.