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Purpose To evaluate the effectiveness of incobotulinumtoxinA (Xeomin ® ) in treating upper eyelid retraction in patients with Graves orbitopathy (GO) initially scheduled for surgery via two different application sites. Methods This is a comparative, prospective study, conducted at the Department of Ophthalmology, Medical School, University Hospital Centre Zagreb, EUGOGO site (EUropean Group On Graves' Orbitopathy) in Croatia from January 2020 till January of 2021 in accordance with national health headquarter recommendations. All patients were classified as inactive with marked eyelid retraction and randomly divided into groups according to application sites. Group A underwent transconjunctival application (18 eyes) and group B transcutaneous application (20 eyes) of incobotulinumtoxinA. The primary end point of this study was lowering the eyelid, to alleviate anterior eye segment symptoms and achieve acceptable aesthetic appearance until surgery becomes available. Results There were no nonresponders and we found no statistically significant difference in the degree of lowering the eyelid between the two application sites. Following rules for avoiding spread of SARS-CoV-19, none of the patients included in this study were infected. Moreover, participants reported diminishing of anterior eye segment irritation and improved aesthetics. Conclusion Treatment of inactive GO patients with incobotulinumtoxinA for upper eyelid retraction is efficient and safe and can be used as an adjuvant treatment while patients wait for surgery, by alleviating symptoms and improving the level of aesthetic satisfaction without causing a threat to anterior eye segment and visual function. The study showed that effect of treatment was the same, whether we applied the toxin transconjunctivaly or transcutaneously.

To evaluate the therapeutic effect of combining subconjunctival botulinum toxin A (BTX-A) with periorbital triamcinolone acetonide (TA) injections in treating upper eyelid retraction (UER) due to thyroid-associated ophthalmopathy (TAO). Fifty eyes with TAO-related UER were randomized into two groups. Group 1 received TA alone, while group 2 received BTX-A plus TA. Marginal reflex distance (MRD1) and graine sign (GS) were measured at baseline and post-injection intervals. Elevated intraocular pressure incidence was monitored. Group 1 showed significant MRD1 reductions at 1, 3, and 6 months ( P  < 0.05) and a GS increase at 3 months ( P  < 0.05). Group 2 exhibited quicker MRD1 reductions at 1 week, 1, 3, and 6 months ( P  < 0.05) and earlier GS improvements at 1 week, 1, and 3 months ( P  < 0.05). Group 2 had lower MRD1 and higher GS values one week post-initial injection ( P  < 0.001 and P  = 0.013, respectively) and a lower incidence of elevated intraocular pressure compared to group 1 ( P  < 0.05). In a six-month study, patients treated with BTX-A and TA for TAO-related UER experienced a faster therapeutic onset and sustained efficacy with reduce the total dose of multiple local TA injections and fewer side effects like elevated intraocular pressure.The trial registration number is ChiCTR2300077958, with the date of registration being 24/11/2023 (retrospectively registered).

Natural eyelid conformation is essential for normal function and health of the ocular surface. However, many modern dog types are deliberately bred for abnormal eyelid conformation associated with severe health and welfare issues. This study aimed to report the prevalence, demographic risk factors and clinical management under primary veterinary care for conformational eyelid disorders in dogs. The study explored the anonymised clinical records of all dogs under UK primary veterinary care within the VetCompass Programme during 2019. Risk factor analysis used multivariable logistic regression modelling. From 2,250,417 dogs under primary veterinary care in 2019, the analysis included a random sample of 3,029 confirmed conformational eyelid disorder cases that included 2,752 (90.86%) entropion and 344 (11.36%) ectropion cases. After accounting for the subsampling process, the annual prevalence for overall conformational eyelid disorder in dogs was 0.36% (95% CI: 0.35-0.37). The annual prevalence for entropion in dogs overall was 0.33% (95% CI: 0.32-0.34). Breeds with highest annual prevalence for entropion were Shar-Pei (15.41%, 95% CI 14.00-16.91), Chow Chow (9.28%, 95% CI 7.64-11.14) and Neapolitan Mastiff (6.88%, 95% CI 3.02-13.14). The estimated annual prevalence for ectropion in dogs overall was 0.04% (95% CI: 0.04-0.05). Breeds with the highest annual prevalence for ectropion were Neapolitan Mastiff (4.30%, 95% CI 1.41-9.77), Saint Bernard (1.72%, 95% CI 0.86-3.05) and Basset Hound (1.59%, 95% CI 0.94-2.49). Surgical management was carried out for 414/2275 (18.20%) of the incident (2019) entropion cases and 12/305 (3.93%) of the incident (2019) ectropion cases. Normalisation of conformation-related health issues in certain high profile dog breeds have been discussed as a canine welfare priority for over half a century. The current results suggest that substantial work remains to be done to ensure good innate health for all dogs.

PurposeLax eyelid condition (LEC) and floppy eyelid syndrome (FES) represent two distinct conditions which have been associated with several ocular and systemic comorbidities. The main aim of this systematic review and meta-analysis is to explore the available literature to estimate the prevalence rate of LEC and FES in obstructive sleep apnea (OSA).MethodsThe protocol of this systematic review and meta-analysis has been registered in PROSPERO. Four electronic databases (PubMed/MEDLINE, Google Scholar, Cochrane Library, Web of Science) were searched from inception to December 24, 2021. A random intercept logistic regression model was carried out for the analysis of overall proportions. Odds ratio and mean difference were reported as measures of the effect size in the presence of binary and continuous outcomes, respectively. The estimated numbers of LEC/FES patients in OSA were calculated by multiplying the prevalence rate determined by our random-effects model and the corresponding Benjafield et al.’s population prospect.ResultsWe included 11 studies comprising 1225 OSA patients of whom 431 and 153 affected by LEC and FES, respectively. Our model estimated a pooled prevalence rate for LEC and FES in OSA patients of 40.2% (95%CI: 28.6–53.1%) and of 22.4% (95%CI: 13.8–34.2%), respectively. The number of LEC/FES affected individuals among OSA patients is expected to peak up to 376 and to 210 million, respectively. OSA patients appeared to have a 3.4 (95%CI: 2.2–5.2) and a 3.0 (95%CI: 1.7–5.5) increased risk of developing LEC and FES than the healthy counterpart.ConclusionPrevalence of LEC and FES is higher in OSA-affected patients compared to controls. More studies are warranted to investigate the mechanisms leading to the development of LEC and/or FES in OSA patients, as well as the feasibility of the adoption of these clinical findings as screening tools for OSA.

Background To evaluate the efficacy of subconjunctival triamcinolone injection for treating upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO). Methods Prospective single blind randomized clinical trial. Patients diagnosed with TAO-associated eyelid retraction and/or swelling <6 months before study onset were randomly assigned to triamcinolone-injected (group I; 55 patients, 75 eyes) or observation-only (group II; 40 patients, 59 eyes) populations. Group I received 1–3 injections of 20 mg triamcinolone acetate into the subconjunctival eyelid, between the conjunctiva and Muller’s muscle, at 3-week intervals. Group I was followed up at 3, 6, 9, and 24 weeks post-injection, and group II was evaluated at 9 and 24 weeks after initial visit. Eyelid swelling and retraction were each graded on a 0-3 scale. Treatment was stopped after 1–2 injections if both swelling and retraction resolved completely or if retraction and swelling scored 0/1 or 1/0 without functional or cosmetic patient concerns. Treatment success was defined at 9 and 24 weeks post-injection if eyelids were normal or when treatment was terminated because of early clinical resolution. We compared baseline clinical data between success and failure group evaluated at 9 and 24 weeks in group I, and investigated short-term and long-term success prognostic factor using multiple logistic regression analysis in each group I and II. Results Swelling and retraction decreased significantly more in group I than in group II. Significantly more eyes had severe swelling (≥ grade 2) in group I (67 %) than in group II (34 %) upon initial evaluation ( p  < 0.01); this difference disappeared at 9 and 24 weeks. Fewer severely retracted eyes were observed in group I than in group II at 9 and 24 weeks ( p  < 0.01). Significantly more eyes in group I achieved success at both 9 and 24 weeks (59 %, 75 %) than in group II (39 %, 57 %) ( p  = 0.03, p  = 0.04 respectively). Higher initial retraction grades (2–3) predicted a higher chance of post-injection failure versus the reference group (grade 0–1) at 9 and 24 weeks in group I, with adjusted odds ratios (aOR) 45.4 (95 % CI = 5.9–351.1, p  < 0.01) and aOR 11.6 (95 % CI = 2.3–58.5, p  < 0.01) respectively. Similarly in group II, initial retraction grade was associated with the failure at 9 and 24 weeks, with aOR 10.3 (95 % CI = 1.8–59.6, p  < 0.01) and aOR 5.9 (95 % CI = 1.3–25.9, p  < 0.05) respectively. Transient intraocular pressure elevation was observed in three eyes of two patients, although all ocular pressures were normalized within 1 month using anti-glaucoma medication. Conclusions Subconjunctival triamcinolone injections were very effective in resolving eyelid swelling and retraction in recent-onset TAO. However, the symptom-reducing effect of triamcinolone was modest and less effective in patients initially presenting with severe retraction grades. As intraocular pressure may rise after steroid injection at upper eyelid, the treatment should be avoided in patients suspected to have glaucoma.

Background/aims To assess the efficacy and safety of oral azithromycin compared with oral doxycycline in patients with meibomian gland dysfunction (MGD) who had failed to respond to prior conservative management. Methods 110 patients (>12 years old) with MGD were randomly assigned to receive either oral 5-day azithromycin (500 mg on day 1 and then 250 mg/day) or 1-month doxycycline (200 mg/day). They also continued eyelid warming/cleaning and artificial tears. A score comprising five symptoms and seven signs (primary outcome) was recorded prior to treatment and at 1 week, and 1 and 2 months after treatment. Total score was the sum of both scores at each follow-up. Side effects were recorded and overall clinical improvement was categorised as excellent, good, fair or poor based on the percentage of change in the total score. Results Symptoms and signs improved significantly in both groups (p=0.001). While improvement of symptoms was not different between the groups, bulbar conjunctival redness (p=0.004) and ocular surface staining (p=0.01) were significantly better in the azithromycin group. The azithromycin group showed a significantly better overall clinical response (p=0.01). Mild gastrointestinal side effects were not significantly different between the groups except for the second visit, when the doxycycline group had significantly more side effects (p=0.002). Conclusions Although both oral azithromycin and doxycycline improved the symptoms of MGD, 5-day oral azithromycin is recommended for its better effect on improving the signs, better overall clinical response and shorter duration of treatment. Trial registration number NCT01783860.

Purpose Dermatochalasis is a common disorder of the elderly, often requiring upper blepharoplasty. Although it is mainly accepted as a process of aging, its clinical and histological findings vary among patients. The aim of this study was to classify types of dermatochalasis based on their clinical and histological findings. Methods This retrospective study included patients with dermatochalasis who had undergone senile blepharoplasty at a single center. Clinical parameters such as margin-to-reflex distance 1 (MRD1), eyelid contour, visual field, and pre-existing medical conditions were assessed. Histological analysis was conducted of eyelid tissues stained with hematoxylin and eosin (H&E) and D2-40 to evaluate dermal edema, inflammation, lymphatic changes, and stromal depth. Results This study included 67 eyes of 35 patients. The mean age of the patients was 69.0 ± 8.3 years, and the average MRD1 was 1.8 ± 1.3 mm. In correlation analysis, two distinct types of dermatochalasis based on the histological findings were identified: lymphangiectasia-dominant and stromal edema-dominant types. The difference between nasal and temporal side MRD1(NT-MRD1) showed the area under the ROC curve of 0.718 of for distinguishing the two histological types of dermatochalasis was 0.718. Conclusion Our novel classification of senile dermatochalasis based on morphological and histological analysis provides insights into the underlying pathology and may help to predict surgical outcomes and complications.

Purpose: To compare the efficacy of physiological, non-detergent eyelid wipes with conventional lid hygiene in patients with meibomian gland dysfunction (MGD). Methods: Fifty participants with MGD were recruited and randomized into two groups. Participants in group I used Evolve Pure™ Eyewipes twice a day to clean the eyelid debris along with standard therapy (antibiotic and lubricants) and participants in group II followed lid hygiene with warm compresses along with standard therapy. Symptoms, ocular surface assessment (lipid layer thickness, tear meniscus height, non-invasive tear film breakup time, and meibography), slit-lamp biomicroscopy (eyelash contamination, meibomian gland blockage, meibomian gland secretion, and meibomian gland telangiectasia) and tear film osmolarity were noted at baseline and 90 days after therapy. Results: Significant improvement in symptoms and signs of MGD was observed in both groups after treatment (P < 0.001); however, the clinical improvement was better with the use of eyelid wipes. Lipid layer thickness increased significantly in group I (P = 0.0006) and group II (P = 0.0002), which was maintained even after adjusting for sociodemographic variables such as age, sex, and severity score of symptoms and signs. Conclusion: Lipid layer thickness of the tear film is a sensitive marker in monitoring response to treatment in patients with MGD. The use of physiological detergent-free eyelid wipes is non-inferior to lid hygiene and warm compresses, which remains the mainstay for treatment of MGD; the clinical improvement with eyelid wipes was noted to be better.

Background/aimsTo validate the predictive value of the American Joint Committee on Cancer (AJCC) 8th-edition classification for local recurrence, metastasis and survival in patients with eyelid sebaceous carcinoma.MethodsWe performed a retrospective review of 100 consecutive patients with eyelid sebaceous carcinoma. Eyelid carcinomas were staged according to the AJCC 7th-edition and 8th-edition criteria. Associations between T and N categories and disease-related outcomes including local recurrence, lymph node metastasis, distant metastasis and survival were evaluated.Results60 women and 40 men had a median age of 67 years (range, 41–94 years). The proportions of patients who experienced local recurrence, lymph node metastasis, distant metastasis and death from disease were 6%, 21%, 7% and 6%, respectively. Two-year and 5-year disease-specific survival (DSS) rates were 93.8% and 92.0%, respectively. There were significant correlations between (1) T2c or worse category and lymph node metastasis (p=0.04) and distant metastasis (p=0.01), (2) T3b or worse category and local recurrence (p=0.01) and death from disease (p=0.01) and (3) N1 category at presentation and distant metastasis (p<0.01) and death from disease (p<0.01). The AJCC 8th-edition classification showed a better homogeneity of the T-category distribution (p<0.01) and a slightly higher discrimination ability for lymph node metastasis (C=0.734 vs C=0.728) than the 7th-edition.ConclusionsT and N categories per AJCC 8th-edition classification are predictive of local recurrence, metastasis and DSS outcomes for eyelid sebaceous carcinoma. Surgeons should perform strict surveillance testing for nodal and systemic metastases in patients with T2c or worse T category and/or N1 disease at presentation.