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Background Static eyelid reconstruction surgery, such as ptosis repair or brow lift, is widely performed for patients with facial paralysis. Complications include exposure keratitis and possible vision loss mainly due to eyelid closure impairment in spontaneous blinking. However, no quantitative evaluation data has been available regarding postoperative closure deterioration. Methods To elucidate factors associated with postoperative eyelid closure impairment, a retrospective study was performed for 51 patients who underwent an initial static eyelid reconstruction surgery from October 2017 to August 2020. A static eyelid reconstruction surgery consisted of either 1 or more of the following: (1) levator advancement, (2) brow lift, and (3) orbicularis oculi myectomy. Eyelid closure ratios (0% for complete closure impairment and 100% for perfect closure) at spontaneous blinks were measured on 6 occasions: before operation and at postoperative 1, 3, 6, 9, and 12 months. Comparison was made between preoperative and postoperative values by using mixed-effects model. Results Overall, average closure ratio was significantly increased. However, 10 patients had >10% closure ratio decreases at at least 1 postoperative measurement point, and all those patients had undergone brow lift procedures. Conclusions Although eyelid closure at spontaneous blinks may, contrary to assumptions, generally be improved after static eyelid reconstruction surgery, brow lift was suggested to be associated with eyelid closure impairment.

In this article the indications and surgical treatment options for patients with facial nerve palsy are discussed. A distinction is made between static and dynamic surgical procedures. Static reconstructions for example are used to restore the eyelid closure function. For smile reconstruction, which is important for the psychosocial life of the patient, dynamic procedures are used. Depending on the duration of the facial nerve paralysis, there are several possibilities to restore the smile. In this work the masseteric branch transposition to the buccal branch, the hypoglossal-facial nerve anastomosis, the Labbe procedure and the gracilis flap as a free muscle transplant are discussed. The surgical procedures are compared and the advantages and disadvantages of the intervention are presented. A spontaneous smile is aimed, this cannot always be achieved. With the masseteric branch transposition to the buccal branch and the Labbe procedure the smile is initially triggered by chewing. A spontaneous smile is possible through cortical adaptation. With the gracilis flap, however, a nerve anastomosis with the contralateral 'healthy' facial nerve is possible, either directly or via a so-called cross facial nerve grafting, whereby a spontaneous smile can be achieved.

Individual differences (IDs) may reduce the detection-accuracy of drowsiness-driving by influencing measurements’ drowsiness-detection performance (MDDP). The purpose of this paper is to propose a model that can quantify the effects of IDs on MDDP and find measurements with less impact by IDs to build drowsiness-detection models. Through field experiments, drivers’ naturalistic driving data and subjective-drowsiness levels were collected, and drowsiness-related measurements were calculated using the double-layer sliding time window. In the model, MDDP was represented by |Z-statistics| of the Wilcoxon-test. First, the individual driver’s measurements were analysed by Wilcoxon-test. Next, drivers were combined in pairs, measurements of paired-driver combinations were analysed by Wilcoxon-test, and measurement’s IDs of paired-driver combinations were calculated. Finally, linear regression was used to fit the measurements’ IDs and changes of MDDP that equalled the individual driver’s |Z-statistics| minus the paired-driver combination’s |Z-statistics|, and the slope’s absolute value (|k|) indicated the effects of ID on the MDDP. As a result, |k| of the mean of the percentage of eyelid closure (MPECL) is the lowest (4.95), which illustrates MPECL is the least affected by IDs. The results contribute to the measurement selection of drowsiness-detection models considering IDs.

We consider the Pavlovian eyeblink conditioning (EBC) via repeated presentation of paired conditioned stimulus (tone) and unconditioned stimulus (airpuff). The influence of various temporal recoding of granule cells on the EBC is investigated in a cerebellar network where the connection probability $p_c$ from Golgi to granule cells is changed. In an optimal case of $p_c^*~(=0.029)$, individual granule cells show various well- and ill-matched firing patterns relative to the unconditioned stimulus. Then, these variously-recoded signals are fed into the Purkinje cells (PCs) through parallel-fibers (PFs). In the case of well-matched PF-PC synapses, their synaptic weights are strongly depressed through strong long-term depression (LTD). On the other hand, practically no LTD occurs for the ill-matched PF-PC synapses. This type of "effective" depression at the PF-PC synapses coordinates firings of PCs effectively, which then make effective inhibitory coordination on cerebellar nucleus neuron [which elicits conditioned response (CR; eyeblink)]. When the learning trial passes a threshold, acquisition of CR begins. In this case, the timing degree ${\cal T}_d$ of CR becomes good due to presence of the ill-matched firing group which plays a role of protection barrier for the timing. With further increase in the trial, strength $\cal S$ of CR (corresponding to the amplitude of eyelid closure) increases due to strong LTD in the well-matched firing group. Thus, with increasing the learning trial, the (overall) learning efficiency degree ${\cal L}_e$ (taking into consideration both timing and strength of CR) for the CR is increased, and eventually it becomes saturated. By changing $p_c$ from $p_c^*$, we also investigate the influence of various temporal recoding on the EBC. It is thus found that, the more various in temporal recoding, the more effective in learning for the Pavlovian EBC., Comment: arXiv admin note: substantial text overlap with arXiv:2003.11325

Purpose To analyze the tear dynamics during blinking by measuring the inner pressure of the upper lacrimal drainage system. Methods This observational study involved 11 healthy bi- or tricenarian volunteers. Direct manometry was performed using a fiber optic pressure sensor inserted into the conjunctival sac, upper/lower canaliculus (5 mm from punctum), and inferior lacrimal sac (15 mm from punctum) during both involuntary and intentional tight blinking. Pressure was measured 200 times/second during 3 separate blinks and then chronologically analyzed. Results In all subjects of all locations during both types of blinking, the inner pressures during the stationary eyelid closing/opening were positive/approximately zero, while a positive/negative pressure spike was observed during the eyelid closing/opening movement. The averages of the maximum pressure in the spike during the intentional tight blinking (tPmax: mm Hg) in the conjunctival sac, upper/lower canaliculus, and lacrimal sac were 8.00, 12.39/12.93, and 10.59, respectively, while for the minimum (tPmin: mm Hg), the pressures were -3.18, -3.91/-3.43, and -3.31, respectively. The tPmax and tPmin in the lacrimal duct were positively correlated with that of the conjunctival sac, which suggested synchronism of the drainage system. However, the tPmax in the canaliculus was significantly higher than that of the conjunctival sac, which suggested that tears do not flow from the conjunctival sac into the lacrimal duct during eyelid closure. Conclusions The upper lacrimal drainage system functions as one united lumen in the lacrimal pump. The positive /negative pressure spike is essential for the lacrimal pump to efficiently eject/aspirate the tear from the lacrimal/conjunctival sac.

Blepharospasm is an act of involuntary blinking. In most of the cases, symptoms last for few days then disappear without any intervention. However in few cases, disease becomes chronic with symptoms of persistent blinking and the person will be able to open his eyes only with a great effort which could eventually lead to a functional blindness. Most of the times it is associated with ALO (Apraxia of lid opening). ALO is an inability to initiate voluntary eyelid opening following a period of eyelid closure. Manual lifting of the eyelid often resolves the problem and lid is able to stay open for a while thereafter. Botulinum toxin injections are the treatment of choice for both Blepharospasm and ALO, which is too expensive and at the same time have only a temporary improvement. In Ayurveda such condition is comparable with Kruchronmeelana which is postulated to be resultant of vata vitiation. Netrakalpana is the therapy of choice to treat above conditions. A single case study done at our department has shown significant improvement both in pain, blinking after the patient was subjected to Netraseka. Before Netraseka the same patient was treated with Aksitarpana which was done with triphala ghrita for seven days, but which hasn't produced much difference neither in pain nor in blinking. Netraseka was given with a specific kashaya for a period of 14 days following Tarpana therapy.

Purpose Marin-Amat syndrome is an acquired facial synkinesis manifesting as involuntary eyelid closure on jaw movement. The authors investigate the clinical features, especially the quantitative changes in eyelid parameters of patients with Marin-Amat syndrome. Methods Patients with Marin-Amat syndrome between 2015 and 2017 in a medical center were collected. Clinical features and the change of eyelid parameters, including margin reflex distance 1 (MRD-1), margin reflex distance 2 (MRD-2), and palpebral fissure height, were evaluated. Results There were 5 men and 3 women with a mean age of 76 years. All had a history of facial palsy. The mean time to onset of Marin-Amat syndrome was 4.4 years after facial palsy. Seven patients (87.5%) developed subsequent ipsilateral facial spasm after facial palsy. Most patient complaints were ptosis (62.5%) and ptosis on eating (37.5%). The mean palpebral fissure height of involved eyes decreased from 5.88 to 2 mm on jaw opening (p = 0.011), which resulted from decrease in MRD-1 (from 2.06 to 0.06 mm, p = 0.012) and MRD-2 (from 3.81 to 1.94 mm; p = 0.012). Botulinum toxin A (Botox) injection into the periorbital orbicularis muscle in 6 patients significantly relieved the change of palpebral fissure height on jaw opening compared with that before injection (9.9% vs. 68.6 %, p = 0.027). Conclusions Most patients with Marin-Amat syndrome present with ptosis and might be overlooked or underestimated. The reduction in palpebral fissure height in our patients with Marin-Amat syndrome was due to involuntary orbicularis oculi muscle contraction, resulting in decrease of both the MRD-1 and MRD-2 on jaw opening.

Proper eyelid closure and a normal blink reflex are essential to maintain a stable tear film and a healthy corneal surface. We present a simple technique to apply moisture chamber eyeglasses after oculoplastic surgery. The Opti-Gard® protective eyewear is faster, easily applicable and well performing. It can be used with different face shape, and it does not require any additional trimming or modification. This technical note explains a very simple, economical and less time-consuming method to prevent a postoperative dry keratoconjunctivitis. It may be applied to all procedures within the field of ophthalmic surgery, including oculoplastic surgery. Level of Evidence V 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 .

International audience; Facial nerve damage can lead to partial or total facial nerve palsy. Photobiomodulation has been reported to improve and accelerate functional recovery following peripheral nerve lesion, depending on the type of lesion and the light exposure parameters used. The aim of this study was to investigate the effects of infrared exposure on functional and axonal regeneration after section-suture of the distal branches of the facial nerve: the buccal and marginal mandibular branches and the distal pes. The animals underwent surgery and were irradiated with infrared light at 850 nm twice daily from day 1 to day 16. The recovery of facial function was then studied at both the behavioral and morphological levels. Behavioral analyses were performed by videoscoring with a high-speed camera and using various devices to assess the recovery of whisker movement on the lesioned side from day 1 to day 30. We also assessed nasal deviation toward the intact side and the ability to close the ipsilateral eyelid completely from day 1 to day 38 and from day 1 to day 50, respectively. For morphological analyses, we assessed the re-establishment of facial motoneuron labeling with Fluorogold®, an immunofluorescent retrograde marker of axonal transport injected into the vibrissae, on D10, D14 and D30. We found that whisker movements recovery was significantly faster in treated than in control mice. A complete disappearance of nasal deviation was observed at 2 weeks in infrared-treated lesioned mice and at 5 weeks in controls. Complete eyelid closure was observed 3 weeks after surgery in treated animals and 6 weeks after surgery in controls. Finally, normal fluorogold labeling of the facial nuclei complex was restored 30 days after surgery in the treated animals, but no such restoration was ever observed in control animals. In conclusion, our data show that IR treatment at a distal site has a significant positive effect on facial nerve recovery. These findings pave the way for the clinical use of infrared photobiomodulation in patients with nerve lesions.

Background: Brow-lift-induced eyelid closure impairment is commonly discussed in patients with facial paralysis but has not been well quantified. Objective: To measure the limitation of eyelid closure in patients with facial paralysis using simulated brow-lift with tape. Design, Setting, and Participants: For 50 facial paralysis patients with brow ptosis who visited our institution from October 2017 to December 2020, brow-lift was simulated by elevating the paralyzed-side brow using surgical tape, and closed palpebral fissure heights in spontaneous blinking were measured using high-speed videography. The effect of several factors on the change in closed palpebral fissure height was evaluated by multiple linear regression analysis. Results: Greater patient age (p = 0.021), single eyelids (p = 0.003), higher value of closed palpebral fissure height before simulation (p = 0.004), and higher value of brow elevation (p = 0.013) were significant for the increase of closed palpebral fissure height. Conclusions: Brow elevation to the degree that achieves symmetrical brow height could be detrimental to eyelid closure in patients with facial paralysis, especially who are elderly, have single eyelids, or present with preoperative decreased lid-closure function. UMIN Clinical Trials (UMIN Registry No. 000042974).

To assess spontaneous blinking and anomalous eyelid movements in patients with hemifacial spasm with an emphasis on interocular differences. Spontaneous eyelid movements were registered bilaterally for 3 min using a high-speed video camera in 28 patients with hemifacial spasm (HFS) who had not been treated with botulinum toxin injections for at least 5 months. The degree of blink conjugacy, maximum velocity, and amplitude of the closing phase of the blinks were determined for the affected and non-affected sides. Out of the 28 subjects, 23 (82%) presented with abnormal nonconjugate spasms that were similar to blinks, and in 17 (61%), high-frequency eyelid twitches were detected between blinks on the affected eye. The rate of nonconjugate blink-like spasms ranged from 0.3 to 24.7 movements/min. With regard for conjugate blinks, there was no significant interocular difference in amplitudes or eyelid closure velocities. The amplitude and velocity were significantly lower for nonconjugate movements than for spontaneous blinks. HFS is a unique condition in which complex patterns of eyelid movements, including both conjugate and nonconjugate movements, are present. Conjugate movements correspond to spontaneous blinking, and the same metrics were observed in affected and non-affected eyes. Nonconjugate movements correspond to anomalous nonconjugate blink-like spasms and high-frequency eyelid twitches in the affected eye, both of which were characterized by lower amplitudes and velocities than were observed in conjugate movements.

BACKGROUND To assess pointwise corneal elevation changes after forced eyelid closure test (FECT) in the eyes of healthy subjects and in eyes with keratoconus. METHODS Twenty-nine subjects with keratoconus and 31 healthy volunteers were evaluated. Patients with keratoconus who had corneal hydrops, apical scarring, corneal thickness ≤ 400 μm, ocular surface disease, contact lens wear on the examination day and a history of corneal cross-linking were excluded. Exclusion criteria for healthy participants were spherical error > +3.00 D and 1.50 D, corneal curvature > 47 D, ocular allergy, clinical findings and family history of keratoconus. Pentacam was performed before and after 20 seconds of FECT and raw data were extracted from the built-in software. Pointwise anterior and posterior elevation changes in the central 8 mm cornea were assessed using paired samples t-test and heat maps were constructed to reflect mean changes and statistically significant data points. Statistical significance was assumed at p

Author(s): van den Bosch, Jacqueline JON; Pennisi, Vincenzo; Invernizzi, Azzurra; Mansouri, Kaweh; Weinreb, Robert N; Thieme, Hagen; Hoffmann, Michael B; Choritz, Lars | Abstract: PurposeTo explore the effect of gaze direction and eyelid closure on intraocular pressure (IOP).MethodsEleven patients with primary open-angle glaucoma previously implanted with a telemetric IOP sensor were instructed to view eight equally-spaced fixation targets each at three eccentricities (10°, 20°, and 25°). Nine patients also performed eyelid closure. IOP was recorded via an external antenna placed around the study eye. Differences of mean IOP between consecutive gaze positions were calculated. Furthermore, the effect of eyelid closure on gaze-dependent IOP was assessed.ResultsThe maximum IOP increase was observed at 25° superior gaze (mean ± SD: 4.4 ± 4.9 mmnHg) and maximum decrease at 25° inferonasal gaze (-1.6 ± 0.8 mmnHg). There was a significant interaction between gaze direction and eccentricity (P = 0.003). Post-hoc tests confirmed significant decreases inferonasally for all eccentricities (mean ± SEM: 10°: -0.7 ± 0.2, P = 0.007; 20°: -1.1 ± 0.2, P = 0.006; and 25°: -1.6 ± 0.2, P = 0.006). Eight of 11 eyes showed significant IOP differences between superior and inferonasal gaze at 25°. IOP decreased during eyelid closure, which was significantly lower than downgaze at 25° (mean ± SEM: -2.1 ± 0.3 mmnHg vs. -0.7 ± 0.2 mmnHg, P = 0.014).ConclusionsOur data suggest that IOP varies reproducibly with gaze direction, albeit with patient variability. IOP generally increased in upgaze but decreased in inferonasal gaze and on eyelid closure. Future studies should investigate the patient variability and IOP dynamics.

The use of face video information for driver fatigue detection has received extensive attention because of its low cost and non-invasiveness. However, the current vehicle-mounted embedded device has insufficient memory and limited computing power, which cannot complete the real-time detection of driver fatigue based on deep learning. Therefore, this paper designs a lightweight neural network model to solve this problem. The model includes object detection and fatigue detection. First, a lightweight object detection network is designed, which can quickly identify the opening and closing states of the driver’s eyes and mouth in the time series video. Secondly, the EYE-MOUTH (EM) driver fatigue detection model is designed, which encodes the driver’s eye and mouth opening and closing state, and calculates the driver’s PERCLOS (Percentage of Eyelid Closure over the Pupil) and FOM (Frequency of Open Mouth) according to the coding sequence. Finally, the multi-feature fusion judgment algorithm is used to realize the judgment of the driver’s fatigue state. The experimental results show that our method has an accuracy rate of 98.30% for drowsiness and yawning behaviors in a real vehicle environment, and a detection speed of 27FPS, which is better than other advanced methods and meets the requirements of real-time detection.

One of the most common factors of road accidents is the drowsiness of drivers. The project's key purpose is to define the strategies for detecting and alerting driver somnolence, thus growing transportation safety. Via uses several physiological variables, such as pulse rate, EEG, ECG, eyelid closure, skin conductance. This scenario indicates that the driver is not in reasonable driving shape. EOG signals are used in this suggested framework. The Electrooculogram (EOG) is an electrical activity indicator related to eye motions. Other signal origins, called objects, may contaminate the electrooculography signal. Eye wink is one of the key causes of disturbance in the EOG signals among the various artefact sources. Blink attributes are determined from these signals, and they are evaluated using Fuzzy logic.

Fibroblast growth factor (FGF10)-mediated signals are essential for embryonic eyelid closure in mammals. Systemic SOX11-deficient mice are born with unclosed eyelids, suggesting a possible role of SOX11 in eyelid closure. However, the underlying mechanisms of this process remain unclear. In this study, we show that epithelial deficiency of SOX11 causes a defect in the extension of the leading edge of the eyelid, leading to failure of embryonic eyelid closure. c-Jun in the eyelid is a transcription factor downstream of FGF10 required for the extension of the leading edge of the eyelid, and c-Jun level was decreased in epithelial SOX11-deficient embryos. These results suggest that epithelial SOX11 plays an important role in embryonic eyelid closure.

SUMMARY Blepharospasm is an idiopathic condition characterized by involuntary eyelid closure mainly caused by bilateral tonic-clonic contractions of the orbicularis oculi muscle. It results in patient inability to open their eyes, thus significantly impairing their ability to perform activities of daily living. First-line treatment for blepharospasm are primarily botulinum toxin type A injections. However, surgical procedure as a treatment option can also be taken in consideration. In this overview, we present a case of a 75-year-old female patient who received surgical treatment as per Anderson’s method after being treated with botulinum toxin type A for 3 years. This form of therapy proved to be an extremely successful permanent solution in the treatment of severe cases of refractory blepharospasm, without any long-term complications, especially ectropion and lagophthalmos.

We present a new dataset with annotated eye movements. The dataset consists of over 800,000 gaze points recorded during a car ride in the real world and in the simulator. In total, the eye movements of 19 subjects were annotated. In this dataset there are several data sources such as the eyelid closure, the pupil center, the optical vector, and a vector into the pupil center starting from the center of the eye corners. These different data sources are analyzed and evaluated individually as well as in combination with respect to their goodness of fit for eye movement classification. These results will help developers of real-time systems and algorithms to find the best data sources for their application. Also, new algorithms can be trained and evaluated on this data set. The data and the Matlab code can be downloaded here https://atreus.informatik.uni-tuebingen.de/seafile/d/8e2ab8c3fdd444e1a135/?p=%2FA%20Multimodal%20Eye%20Movement%20Dataset%20and%20...&mode=list

The cerebellum is crucial for various associative sensorimotor behaviors. Delay eyeblink conditioning (DEC) depends on the simplex lobule-interposed nucleus (IN) pathway, yet it is unclear how other cerebellar modules cooperate during this task. Here, we demonstrate the contribution of the vermis-fastigial nucleus (FN) pathway in controlling DEC. We found that task-related modulations in vermal Purkinje cells and FN neurons predict conditioned responses (CRs). Coactivation of the FN and the IN allows for the generation of proper motor commands for CRs, but only FN output fine-tunes unconditioned responses. The vermis-FN pathway launches its signal via the contralateral ventral medullary reticular nucleus, which converges with the command from the simplex-IN pathway onto facial motor neurons. We propose that the IN pathway specifically drives CRs, whereas the FN pathway modulates the amplitudes of eyelid closure during DEC. Thus, associative sensorimotor task optimization requires synergistic modulation of different olivocerebellar modules each provide unique contributions., Delay eyeblink conditioning depends on the simplex lobule-interposed nucleus pathway in the cerebellum. Here, the authors show that the vermis-fastigial nucleus-medullary reticular nucleus pathway modulates the conditioned and unconditioned eyelid closure during delay eyeblink conditioning.

Driving fatigue is a physiological phenomenon that often occurs during driving. When the driver enters a fatigue state, they will become distracted and unresponsive, which can easily lead to traffic accidents. The driving fatigue detection method based on a single information source has poor stability in a specific driving environment and has great limitations. This work helps with being able to judge the fatigue state of the driver more comprehensively and achieving a higher accuracy rate of driving fatigue detection. This work mainly introduces research into different signal fusion methods to detect fatigue drive. This work will take the normal driver’s breathing signal, eye signals, and steering wheel signal as research objects and collect and isolate the characteristics of the fatigue detection signal. Research was then conducted on different signal fusion methods for the detected depth of breath. Change of steering angle, eyelid closure, and blinking marks and the fatigue driving experiment was designed to evaluate the results of different data fusion methods. Experimental results show that the detection accuracy of the heterogeneous signal fusion method in fatigue detection is as high as 80%.

Driver’s drowsiness is one of the major causes of traffic accidents worldwide. An early detection of episodes of sleepiness becomes of fundamental importance for safety purposes. Several studies demonstrated that PERCLOS, that is the percentage of eyelid closure over the pupil across time, is one of the most accurate parameters for drowsiness state assessment. However, since PERCLOS is typically computed from the visible video of the subjects, its evaluation is strictly dependent on the lighting conditions and it is not accessible if the driver wears sunglasses. The objective of this study is to overcome these limitations, evaluating drowsy states using a low-cost and high-resolution thermal infrared technology. Ten sleep-deprived subjects were recruited for the experiment, consisting in one-hour driving task on a driving static simulator. During the experiment, facial skin temperature was recorded by means of the thermal camera Device Alab SmartIr640, together with facial visible videos of the subjects. Relevant thermal features were estimated from facial regions of interest (i.e., nose tip, glabella) whereas PERCLOS was performed on visible videos. Features were extracted over a time window of 30 seconds. A data-driven multivariate machine learning approach based on a three-level Support Vector Classification of the drowsy state (AWAKE class: PERCLOS 0.15) was employed. The average classification accuracy was 0.65±0.09 (mean ± standard deviation). Although preliminary, these results indicate the possibility to assess driver's drowsiness based on facial thermal features, overcoming the limitation related to lighting condition and eyes detection, typical of standard methods.

Fatigue and distraction are the two critical causes which account for the majority of the road accidents leading to innumerable fatalities. There is a need for real-time fatigue and activity detection while the vehicle is in motion. This paper presents an overview of fatigue and distraction analysis using two machine learning algorithms, KNN and CNN. Fatigue symptoms like eyelid closure and yawning are computed by eye and mouth aspect ratios through facial landmarks mapping on a live video to obtain high throughput with alarm generation for different states. Fatigue states are classified using KNN which unlike other algorithms provides a very simplistic approach with adequate accuracy. Distraction types are classified using CNN implemented on a data set containing different driving activities comprising of specific actions performed by a driver inside the vehicle. Images are trained and classified followed by test prediction. VGG16 transferred learning has been applied to CNN to increase the accuracy. Thus, the system is able to efficiently predict and classify driver states based on input feeds through a camera and also drive activities from a model leading to a robust driving-based analysis.

BackgroundDaytime sleepiness is a common symptom of multiple sclerosis (MS) that may jeopardize safe driving. The aim of this study was to compare daytime sleepiness, recorded in real-time through eyelid tracking, in a simulated drive between individuals with MS (iwMS) and healthy controls.MethodsFifteen iwMS (age = median (Q1 – Q3), 55 (50 – 55); EDSS = 2.5 (2 – 3.5); 12 (80%) female) were matched for age, sex, education, and cognitive status with 15 controls. All participants completed self-reported fatigue and sleepiness scales including the Modified Fatigue Impact Scale (MFIS), Pittsburg Sleep Quality Inventory (PSQI), and Epworth Sleepiness Scale (ESS). Percentage of eyelid closure (PERCLOS) was extracted from a remote eye tracker while completing a simulated drive of 25 minutes.ResultsAlthough iwMS reported more symptoms of fatigue (MFIS, p =0.003) and poorer sleep quality (PSQI, p = 0.008), they did not report more daytime sleepiness (ESS, p = 0.45). Likewise, there were no differences between groups in real-time daytime sleepiness, indexed by PERCLOS (p = 0.82). Both groups exhibited more real-time daytime sleepiness as they progressed through the drive (time effect, p< 0.0001). The interaction effect of group*time (p = 0.05) demonstrated exacerbated symptoms of daytime sleepiness towards the end of the drive in iwMS compared to controls.PERCLOS correlated strongly (Spearman ρ = 0.76, p = 0.001) with distance out of lane in iwMS.ConclusionIwMS show exacerbated symptoms of daytime sleepiness during monotonous, simulate drive. Future studies are warranted to investigate the effect of MS on daytime sleepiness during real-world driving.

Vehicular accidents caused by driver drowsiness involve about 7,000 people/year in Brazil, only on federal highways, and cause psychic damage and traumatic stresses for both the victims involved and their families. Drowsiness is characterized by reduced level of vigilance and concentration, which are essential during driving activity. Due to this adversity, many applications of drowsiness detection had been continuously developed through electrical body signals to alert the driver at the time when sleepiness is identified, such as heart rate variability (HRV) and electroencephalogram (EEG). Although these methods work, the use of electrodes in the driver’s body is highly invasive. Therefore, we propose a drowsiness detection system based on driver’s real time video capture, by estimating the percentage of eyelid closure over a period, without any contact device. Since the use of smartphones has been growing in the last decade, the system has been implemented in a mobile phone even with memory and processing limitations. Processing reduction procedures were developed to improve the application performance, such as the reduction of the region of interest and the limitation of the search window, which increased by 93.09% the number of frames per second and allowed the application to operate smoothly.

Passive task-related (TR) fatigue caused by monotonous driving can negatively affect driving safety by impairing driver alertness and performance. This study aims to evaluate the effectiveness of a motion seat system on the driver&rsquo, s passive TR fatigue in terms of driving performance, physiological response, and subjective fatigue by using automotive and physiological sensors those applicable to on-road driving environment. Twenty drivers (5 females and 15 males, age = 38.5 &plusmn, 12.2) with more than two years of driving experience participated in an on-road experiment with two driving conditions: driving in the static seat condition during the first half of the driving session and then in the static (static&ndash, static, SS) or motion seat (static&ndash, motion, SM) condition during the second half. The SM condition showed significantly lower passive TR fatigue by 4.4~56.5% compared to the SS condition in terms of the standard deviation of velocity, percentage of eyelid closure rate (PERCLOS), and the ratio of low- to high-frequency power (LF/HF) of electrocardiography signals. The drivers rated significantly lower subjective state changes of overall fatigue, mental fatigue, passive TR fatigue, drowsiness, and decreased concentration in the SM condition than those in the SS condition. The findings of the study support the use of a motion seat system can be an effective countermeasure to reduce passive TR fatigue.

We present a facial wearable robot to support eyelid movement for patients with hemifacial paralysis. People with facial paralysis are not able to blink, which leads to dry eyes and could cause permanent damage to the cornea. To address this issue, we developed a robotic system to support eyelid movement on the paralyzed side based on voluntary eyelid movement on the healthy side. The robot has a novel mechanism for supporting eyelid movement and is made from soft material, which we call the eyelid gating mechanism (ELGM). We defined the requirements for eyelid manipulation. Then, we introduced design rules for the ELGM based on this definition, and conducted a deformation analysis. As a result, we could control deformation so that it is tailored to eyelid movement with simple rotational input at two hinged ends. This system provides appropriate support for eyelid movement in a non-invasive and gentle manner, based on voluntary eyelid movement on the healthy side. In this paper, we present a performance evaluation of the developed ELGM and the wearable facial robot. We confirm that ELGM could aid eyelid closure in 8 out of 10 patients. Further, we find that the time lag between eyelid closure detection and completion was $$236.9 \pm 19.4$$ ms.

Introduction For treatment of lagophthalmos, metallic weight implants can be inserted in the upper eyelid to aid eyelid closure. Rigid and flexible implants are available. The objective of this study was to investigate the effect of implant type and patient variables on the survival of lid load implants. Materials and methods Forty-four patients with lagophthalmos were recruited to undergo upper-eyelid weight implantation. The predictor variable was type of implant inserted (rigid or flexible). The outcome variable was survival of the inserted implant (survival or extrusion). Other study variables were demographic data (age, gender), implant features (material, weight), and other conditions, such as history of radiation. An NMLE test was used to compare implant survival, depending on implant type (flexible versus rigid). Other variables were analysed by use of a χ2 test. Results Forty-four participants were recruited, 29 female (65.9%) and 15 male (34.1%). Forty-six implants (23 rigid implants, 50.0%; 23 flexible implants, 50.0%) were inserted (bilateral implantation in two patients). The average weight of implants used was 1.76 g (range 1.4–2.2 g). One to two years after surgery, average vertical aperture (eyelid gap) for the closed eye was 0.65 mm (range 0–4 mm). Incidence of extrusion was 15.2% (one in the rigid implant group, 2.2%; six in the flexible implant group, 13.0%). Incidence of extrusion was significantly higher for flexible implants than for rigid implants (p = 0.0273). Conclusions The study results suggest that flexible implants are more likely to perforate the skin. The assumed advantages of the expensive chain lid weight must, therefore, be re-evaluated.

Background PERCLOS is a metric that has been primarily studied in the domain of driver fatigue to predict performance decrements, but there is comparatively less research applying it to aviation, where hypoxia is a safety concern. Hypoxic exposure was expected to increase blink activity, possibly by means of impairing blink inhibition behavior, thereby leading to increased eyelid closure time. Methods PERCLOS, blink rate, and blink duration were measured using head-mounted eye-tracking on pilots using a flight simulator inside a hypobaric chamber. Pilot subjects were tasked with programming the autopilot of a G-1000 console according to instructions from a simulated air traffic controller. Data was collected at 5% decrements in blood oxygen saturation (Spo2) through progressive decreases in hypobaric pressure to model slow-onset hypoxia. Results PERCLOS, blink rate, and blink duration increased significantly and linearly as a function of decreasing Spo2, and largely recovered in the posthypoxia normoxia condition. The greatest change in PERCLOS relative to the prehypoxia baseline occurred in the 80% Spo2 condition, whereas the greatest change in blink rate and duration occurred at 75% Spo2. As Spo2 decreased, a higher frequency of long blink durations was observed. Discussion The increase in blink rate and duration in the absence of task demand manipulation could suggest hypoxia-induced sympathetic excitation and impairment of adaptive blink inhibition behavior. The effect of hypoxia on oculomotor features is also likely task-specific. In consideration of the extensive demand made upon the visual modality in flight, increased PERCLOS may further tax visual information processing.Thropp JE, Scallon JFV, Buza P. PERCLOS as an indicator of slow-onset hypoxia in aviation. Aerosp Med Hum Perform. 2018; 89(8):700-707.

Introduction Inverse Bell's phenomenon is a rare ophthalmic phenomenon where downward instead of upward movement of the eyeball occurs during eyelid closure. It may be associated with peripheral facial nerve palsy, conjunctival scarring, and ptosis surgery. Case report A 9-year-old male patient with right upper-lid congenital ptosis developed inverse Bell's phenomenon 2 days after frontalis sling-suspension ptosis surgery. At the 3-week postoperative visit, there had been spontaneous resolution of the inversion of Bell's phenomenon without any corneal complication. Conclusion Inverse Bell's phenomenon, more often reported to be associated with levator-resection surgery, may develop following frontalis sling-suspension ptosis surgery. Close monitoring and frequent instillation of topical lubricants are necessary to prevent exposure keratopathy until the resolution of inverse Bell's phenomenon in patients with lagophthalmos after ptosis surgery.

A patient with severe eyelid defects caused by a car accident was admitted to the Plastic Surgery Department of the First Hospital of Jilin University. The lower eyelid was first reconstructed with autogenous palatal mucosa and a temporal musculocutaneous flap, which provided adequate tissue volume. Postoperatively, eyelid closure was good. After long-term follow-up, the reconstructed lower eyelid showed laxity and downward movement. The eyelid could not close completely and lagophthalmos occurred. Then, the lower eyelid was suspended by the fascia lata. The suture at the point of fixation became loose again after the operation. Incomplete eyelid closure recurred. Finally, palmaris longus tendon graft suspension combined with screw fixation was used to obtain a satisfactory therapeutic effect. In summary, rigid suspension and fixation can provide adequate lateral tension to resist lower reconstructed eyelid shifting and lagophthalmos, which is important for the maintenance of lasting effects.

Purpose: The aim of the study was to present the level of knowledge and practice patterns regarding exposure keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU) nurses in Chhattisgarh state. Methods: A previously validated semi-structured questionnaire was administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014–2015. Demography included age, gender, level of education, and months of working in ICU. Most of the questions dealt with frequency of eyelid closure assessment, frequency of cleaning of eyes with saline gauze, using a protocol-based approach for eye care, and documentation of ophthalmic complications. Common barriers to delivery of eye care such as shortage of time and too much writing tasks were also inquired. Results: Our study included 120 nurses. They worked for mean 22.9 ± 17.8 months in ICU. Knowledge about high risk of exposure keratopathy in ventilated patient was present in 93% (78%; 95% confidence interval [CI]) nurses. Only six nurses (5%) followed a strict protocol for eye care, 52 nurses (43%) checked for eyelid closure in the ventilated patients, and 58 (48%) cleaned the eyes frequently. Those who were aware of exposure keratopathy checked eyelid closure (73% vs. 48%) and cleaned eyes with saline gauze more frequently (24% vs. 4%). Nurses in cardiac ICU were significantly lesser aware of exposure complications compared to medical ICU nurses (40% reduction in awareness, 95% CI = 0.37–0.98, P = 0.04). Conclusion: Although there is high awareness, practice patterns of ICU nurses were less than desired. Educational initiatives should focus on weaknesses in knowledge and practice noted to improve eye care of patients in ICU.

Synkinetic movements are common among patients with incomplete recovery from facial palsy, with reported rates ranging from 9.1% to almost 100%. The authors propose the separation of the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex to treat eyelid closure/smiling synkinesis. This technique, associated with an anastomosis between the masseteric nerve and a central branch of the facial nerve, as well as with the use of a cross-facial nerve graft, resolves most of the spasms of the midface musculature, leading to a more relaxed tone when the mimic muscle is at rest and enhancing muscle excursion during voluntary and spontaneous smiling. Between 2011 and 2016, 18 patients affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital (Milan, Italy). Of these patients, 72.22% of cases with hypertone obtained partial to complete relaxation. Synkinesis was completely resolved in 83.33% of cases, and a significant improvement in facial movement was achieved in all patients. Neurorrhaphy of the masseteric nerve and the central branch of the facial nerve appears to produce favorable results. These initial data should be confirmed by further studies.