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ObjectiveTo investigate whether functional upper eyelid malposition is associated with unrecognized deficits in automated perimetry among glaucoma patients by examining patients undergoing eyelid surgery who had not been identified as requiring eyelid taping during glaucoma field testing.MethodsIn this retrospective pre-post study, an automated database search followed by manual chart review was used to identify eligible patients from January 2012 to March 2020. Included patients had reliable visual field testing within two years before and after functional upper blepharoplasty or ptosis repair and no comorbid ocular diagnoses. As part of routine practice, glaucoma visual field technicians taped patients with pupil-obstructing eyelid malposition; taped examinations were excluded from analysis. Clinical and demographic characteristics, mean deviation, and pattern standard deviation were evaluated within a two year period before and after eyelid surgery.ResultsThe final analysis included 60 eyes of 38 patients. Change in visual field parameters after eyelid surgery did not reach statistical significance in crude or adjusted analyses. Among patients with ptosis, the margin reflex distance-1 was not associated with change in mean deviation after surgery (Pearson R2 ​= ​0.0061; P ​= ​0.700). Five of 17 eyes excluded from analysis due to unreliable pre-operative visual fields demonstrated substantial improvement after surgery.ConclusionsFunctional upper eyelid malposition does not appear to cause spurious visual field abnormalities among glaucoma patients with reliable visual fields who were determined not to require eyelid taping at the time of their visual fields. Unreliable visual fields could be a sign of eyelid interference in this population.

Purpose: To determine the pre-operative, peri-operative, or post-operative risk factors that contribute to pediatric frontalis sling infection or exposure. Methods: Retrospective study of 193 eyelids that underwent silicone-rod frontalis sling surgery at a single institution between 2014 and 2019. Results: A total of 222 eyelids were originally identified. Of the 222 eyelids that underwent frontalis sling surgery, 193 (86.9%) received silicone-rod slings (SRS), 24 (10.8%) received autologous fascia lata sling (AFS), and 5 (2.3%) received Gore-Tex slings (GS). The 193 eyelids that received SRS met inclusion criteria and underwent further statistical analysis. Patients with SRS who did not receive intra-operative antibiotics had a higher risk of infection or exposure compared to patients with SRS that did receive intraoperative antibiotics (P = 0.03). There was no association between SRS exposure and the other studied risk factors (all P-values > 0.41). Conclusions: Intraoperative antibiotics should be considered in silicone-rod frontalis suspension surgery, as it associated with a decreased risk of exposure or infection. [ABSTRACT FROM AUTHOR]

After developing job-exposure matrices (JEMs) for screen and sedentary time, we aimed to assess the associations between the JEM-derived exposures and various ocular diseases. We collected data from patients hospitalized from 2005 to 2021. JEMs were developed from 41,718 patients with occupational information and screen and sedentary times. The adjusted means of screen and sedentary time were calculated for 143 occupational groups and categorized into three classes based on the tertiles. The associations between ocular diseases and these JEM-derived exposures were examined using multivariable conditional logistic regression for 727,589 patients. The odds ratios of the class with highest screen time were 1.05 (95% confidence interval, 1.01–1.09) for cataract, 1.24 (1.06–1.45) for primary open-angle glaucoma (POAG), 1.26 (1.06–1.49) for rhegmatogenous retinal detachment (RRD), 1.49 (1.26–1.76) for ptosis, and 0.39 (0.27–0.57) for pterygium. The odds ratios of the class with highest sedentary time were 1.05 (1.01–1.09) for cataract, 1.24 (1.05–1.46) for RRD, 1.68 (1.42–1.99) for ptosis, and 0.60 (0.42–0.84) for pterygium. Both screen and sedentary time were positively associated with cataract, RRD and ptosis. Interestingly, POAG had a positive association with only screen time. Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary."I have confirmed that the content is correct. No amendments are necessary.Please check article title if captured correctly."?>"I have confirmed that the content is correct. No amendments are necessary. [ABSTRACT FROM AUTHOR]

Background: Hemifacial spasm (HFS) is a neuromuscular disorder characterized by unilateral facial muscle spasms, negatively impacts quality of life due to social embarrassment. Botulinum Neurotoxin (BoNT) injections have emerged as a viable therapeutic approach. This systematic review evaluated the efficacy and safety of BoNT injections for HFS management, along with effects on patients' quality of life and mental health. Materials and methods: A systematic search for studies on BoNT treatment for HFS published between January 1, 2000, and May 1, 2024, was performed across major databases. Study quality was evaluated using Cochrane and Joanna Briggs Institute (JBI) tools, with data management handled by EndNote X9 and statistical analyses conducted via Review Manager (RevMan 5.4) and STATA 14.0. Results: Thirty-five studies met the inclusion criteria: 2 RCTs comprising 83 HFS patients compared the efficacy of perioral injections of botulinum toxin and placebo, while 33 single-arm studies reported outcomes for 2786 patients post-BoNT injection. The selection of 17 single-arm studies focused on the effectiveness rate as the key outcome metric. Pooled estimate signified a remarkably high effectiveness (ES: 0.882, 95% CI: 0.830, 0.926, P < 0.001). Analysis of depression scale (SMD: -0.85, 95% CI: -1.34, -0.35, P < 0.001), anxiety scale (SMD: -1.50, 95% CI: -2.19, -0.80, P < 0.001) and total scale of quality of life (SMD: -0.64, 95% CI: -0.87, -0.41, P = 0.766) showed that BoNT therapy worked well especially in improving mental state and quality of life. Ptosis was considered as the most common adverse reaction during BoNT injections (OR: 0.30, 95% CI: 0.11, 0.81, P = 0.843). Conclusion: BoNT injection showed validity and clinical safety in the treatment of HFS, particular for depression relief. Injections around the mouth were only effective for HFS cases with severe symptoms. A standardized strategy for BoNT injections in managing HFS, detailing parameters such as injection sites, doses, and frequencies, remained elusive. Additional RCTs are necessary to further elucidate the interplay between efficacy and these components. [ABSTRACT FROM AUTHOR]

Background: Myopathies encompass a wide range of diseases with diverse etiologies, courses, and prognoses, and can be either genetic or acquired in nature. One of the rare causes of acquired myopathies in children is hyperthyroidism. Ocular manifestations of hyperthyroidism include proptosis (exophthalmos) and widening of the palpebral fissure. Conversely, ptosis may indicate co-existing myasthenia or primary or secondary myopathy. Methods: This study presents a case of a 2-year-old child exhibiting both ocular disorders—each in one eye—along with features of proximal myopathy associated with undiagnosed thyrotoxicosis. Results: To our knowledge, this unique presentation of thyrotoxicosis in a young child has not been previously reported. After appropriate treatment for thyrotoxicosis, the child's ocular and muscular symptoms showed improvement. Conclusions: Given that thyroid disorders can be a rare cause of both myopathy and ocular disorders in children, it is recommended that any child presenting with such symptoms undergo thyroid function screening tests. [ABSTRACT FROM AUTHOR]

PurposeMethodsResultsConclusionsTo identify and evaluate the risk factors for ptosis repair failure.Retrospective, case-controlled study evaluating adult patients with ptosis who underwent ptosis surgery by external levator advancement/resection (ELR) or Müller muscle conjunctival resection (MMCR) with at least 3 months postoperative follow-up. Regression analyses were performed of ptosis repair outcomes comparing preoperative and perioperative risk factors for failure.A total of 240 patients (404 eyelids) met the inclusion criteria for the study. Surgical outcomes were measured categorically by success rate and measured quantitively over time using Kaplan–Meier survival analysis. Success was categorically achieved in 101/112 (90%) eyelids after MMCR and 231/292 (79%) eyelids after ELR (p = .0088). Success as measured over 5 years of follow-up was significantly better in eyelids following MMCR compared to ELR (p = .0469). In terms of surgical failure, the following variables were found to be predictive in order of decreasing risk: chronic topical prostaglandin use, chronic topical corticosteroid use, surgical approach, lower preoperative margin reflex distance 1, prior intraocular surgery, age, lower preoperative levator function, concomitant blepharoplasty, presence of a glaucoma filtering bleb, and female gender.Ptosis repair surgery is a complex and challenging procedure. This study provides the largest comparative analysis of ELR versus MMCR to date with findings suggesting MMCR to be more a successful surgery than ELR. Topical prostaglandin analogue use appears to be the highest known risk factor for MMCR and ELR ptosis repair failure. [ABSTRACT FROM AUTHOR]

Physical features that are desired by the opposite sex may drive competition between members of the same sex to gain access to potential mates. Women's breasts are considered sexually attractive to men, and it has been shown that women may engage in competitive tactics to compete with or derogate women with ideal physical traits (i.e., physically attractive features). In the current online study, we investigated Hispanic women's (n = 114) perceptions of breast stimuli that had been manipulated to display four levels of breast size (A-, B-, C-, and D-cup) and three levels of ptosis (i.e., levels of sagginess: non, low, and high) and their likelihood of engaging in rival derogation tactics, such as verbal and indirect aggression. The findings demonstrated that women were more likely to engage in rival derogation towards women with larger breast sizes. Women's dispositional level of intrasexual competition did not play a role in rival derogation tactics. The results are in line with previous research suggesting that women's rival derogation tactics are likely to be targeted towards women with attractive features that are desired by men. [ABSTRACT FROM AUTHOR]

Telemedicine is now being used more frequently to evaluate patients with myasthenia gravis (MG). Assessing this condition involves clinical outcome measures, such as the standardized MG-ADL scale or the more complex MG-CE score obtained during clinical exams. However, human subjectivity limits the reliability of these examinations. We propose a set of AI-powered digital tools to improve scoring efficiency and quality using computer vision, deep learning, and natural language processing. This paper focuses on automating a standard telemedicine video by segmenting it into clips corresponding to the MG-CE assessment. This AI-powered solution offers a quantitative assessment of neurological deficits, improving upon subjective evaluations prone to examiner variability. It has the potential to enhance efficiency, patient participation in MG clinical trials, and broader applicability to various neurological diseases. [ABSTRACT FROM AUTHOR]

Botulism is a rare cause of bulbar and oculomotor syndromes. A late diagnosis and, therefore, late initiation of specific therapy may lead to multiple life-threatening complications. Epidemiological history and clinical findings are key to the correct diagnosis, but if these data are not available due to atypical clinical findings, botulism identification is challenging. In our clinical case, a 31-year-old man was admitted to the hospital with double vision, impaired eye movements, and difficulty swallowing rapidly developing for 2 days. Ocular motility dysfunction included disturbed conjugate eye movements. In young patients, this is most often caused by demyelinating disease with medial (posterior) longitudinal fasciculus damage and symmetrical bilateral ptosis. The patient denied eating foods that could cause botulism and did not have any gastrointestinal symptoms. Differential diagnoses included demyelinating disease onset and Miller–Fisher syndrome. The next morning, completely identical clinical signs appeared in the patient’s mother who had eaten canned mushrooms, so botulism was suspected. Over the next few hours, despite the administration of anti-botulinum serum, acute respiratory failure developed, and the patient was placed on a ventilator for 28 days. The patient and his mother were discharged in a satisfactory condition, and their symptoms completely resolved within a few months. The diagnosis of botulism was confirmed by toxicological examination.

Abstract Accurate segmentation of pupil light reflexes is essential for the reliable assessment of ptosis severity, a condition characterized by the drooping of the upper eyelid. This study introduces a novel encoder-decoder network specialized in reflex segmentation by focusing on addressing issues related to very small regions of interest from an architectural perspective. Specifically, the proposed network is designed to exploit low-level features effectively by integrating a multi-level skip connection and a 1 × 1 convolution-enhanced initial encoding stage. Assessed using a photograph image dataset from Chung-Ang University Hospital, which includes 87 healthy subjects, 64 with ptosis, and 257 with Graves’ orbitopathy (collected between January 2010 and February 2023), the proposed network outperforms five conventional encoder-decoders. Over 30 trials, the proposed network achieved a mean Dice coefficient of 0.767 and an Intersection over Union of 0.653, indicating a statistically significant improvement in the segmentation of reflex. Our findings show that an elaborate design based on the lowest-level skip connection and 1 × 1 convolution at initial stage enhances the segmentation of pupil light reflexes. The source code of the proposed network is available at https://github.com/tkdgur658/ReflexNet .

Abstract Background Hemifacial spasm (HFS) is a neuromuscular disorder characterized by unilateral facial muscle spasms, negatively impacts quality of life due to social embarrassment. Botulinum Neurotoxin (BoNT) injections have emerged as a viable therapeutic approach. This systematic review evaluated the efficacy and safety of BoNT injections for HFS management, along with effects on patients’ quality of life and mental health. Materials and methods A systematic search for studies on BoNT treatment for HFS published between January 1, 2000, and May 1, 2024, was performed across major databases. Study quality was evaluated using Cochrane and Joanna Briggs Institute (JBI) tools, with data management handled by EndNote X9 and statistical analyses conducted via Review Manager (RevMan 5.4) and STATA 14.0. Results Thirty-five studies met the inclusion criteria: 2 RCTs comprising 83 HFS patients compared the efficacy of perioral injections of botulinum toxin and placebo, while 33 single-arm studies reported outcomes for 2786 patients post-BoNT injection. The selection of 17 single-arm studies focused on the effectiveness rate as the key outcome metric. Pooled estimate signified a remarkably high effectiveness (ES: 0.882, 95% CI: 0.830, 0.926, P

AIM: To examine the effects of blepharoplasty on the ocular surface and refractive state.METHODS:Retrospective study. A total of 70 patients(108 eyes)who underwent blepharoplasty in our ophthalmology department from January 2022 to June 2023 were selected, among which 40 cases(48 eyes)diagnosed with ptosis received levator muscle shortness, and 30(60 eyes)diagnosed with eyelid laxity/single eyelids received blepharoplasty. The ocular surface disease index(OSDI), tear meniscus height(TMH), Schirmer Ⅰ test(SⅠt), tear film break-up time(BUT), corneal fluorescein staining(FL), cylindrical(Cyl), surface regularity index(SRI), surface asymmetry index(SAI), keratometry(Km), and cylindrical(C).RESULTS:There were statistical differences in preoperative and postoperative OSDI, BUT, SⅠt, and FL of patients who received levator resection(all P0.05). At 1 mo postoperatively, OSDI, BUT, SⅠt, and FL were significantly different compared to preoperative values(all P0.05). No significant differences were found in Cyl, SRI, SAI, Km, or C in either group before and after surgery(all P>0.05).CONCLUSION:The levator resection has an early impact on the ocular surface of patients with ptosis, and corneal protection measures should be taken early. There was no significant impact on patients undergoing blepharoplasty; there was no significant effect on the refractive status of all patients.

CT and MRI findings of tongue ptosis and atrophy should alert radiologists to potential pathology along the course of the hypoglossal nerve (cranial nerve XII), a purely motor cranial nerve which supplies the intrinsic and extrinsic muscles of the tongue. While relatively specific for hypoglossal nerve pathology, these findings do not accurately localize the site or cause of denervation. A detailed understanding of the anatomic extent of the nerve, which crosses multiple anatomic spaces, is essential to identify possible underlying pathology, which ranges from benign postoperative changes to life-threatening medical emergencies. This review will describe key imaging findings of tongue denervation, segmental anatomy of the hypoglossal nerve, imaging optimization, and comprehensive imaging examples of diverse pathology which may affect the hypoglossal nerve. Armed with this knowledge, radiologists will increase their sensitivity for detection of pathology and provide clinically relevant differential diagnoses when faced with findings of tongue ptosis and denervation.

AbstractEpithelial carcinoma of the nasopharynx originates from the mucosal lining of this region. The etiology of the disease involves a complex interplay of environmental factors, genetic predisposition, and infection with the Epstein Barr virus. In this article, we present a case of nasopharyngeal carcinoma (NPC) that presented with right orbital proptosis and ocular symptoms, without any of the typical signs of nasopharyngeal carcinoma. However, imaging studies revealed subtle findings of NPC. Isolated neuro-ophthalmologic symptoms are not a common manifestation in NPC patients. Proptosis is a rarer finding among ophthalmologic symptoms, usually associated with tumor invasion into the orbit. However, in the presented case, unilateral proptosis was observed without orbital tumor invasion.

Pituitary apoplexy (PA) is a rare, potentially life-threatening condition primarily associated with pituitary adenomas. It presents with sudden, severe symptoms due to inadequate blood supply, bleeding, or tissue death in the pituitary gland. This case report describes a case of PA in a 40-year-old female, and reviews the recent literature surrounding the subject. The patient presented with complete bilateral third nerve palsy and dilated non-reactive pupils. Her initial symptoms included retroorbital headache, fever, and double vision, which rapidly progressed to oculomotor nerve palsy. MRI revealed hemorrhagic PA. High-dose steroids were initiated, leading to the resolution of ptosis. Additionally, surgical intervention was performed. PA typically affects older males with known adenomas, making this case unusual due to the patient's age, gender, and absence of prior adenoma history. Differentiating PA from other intracranial pathologies is crucial, and MRI plays a pivotal role in accurate diagnosis.

Introduction: Pituitary apoplexy is a rare endocrine emergency that is occasionally life-threatening, most often involving pituitary macroadenomas. Most pituitary macroadenomas are nonsecretory and are diagnosed in the late stages. They remain undiagnosed until they cause compression of the surrounding vital structures and lead to subsequent symptoms. The clinical feature depends on the size of the tumor and the direction of the spread. There are two approaches for surgery. The less invasive endoscopic transnasal transsphenoidal approach is favored more than the transcranial approach. Case Report: 46-year-old female patient presented to the outpatient department (OPD) with complaints of headache and drooping of the right eyelid for 1.5 months. On neurological examination, right severe ptosis was present and extraocular movements of the right eye are restricted for the muscles supplied by the third nerve. Pupils were reactive to light. On perimetry, the left eye showed temporal hemianopia. Right eye perimetry was not done due to ptosis. MRI Brain gave differential diagnosis as pituitary macroadenoma with hemorrhage or necrosis and pituitary apoplexy without macroadenoma. Endoscopic transnasal transsphenoidal excision of the tumor under general anesthesia was performed. Conclusion: MRI brain is the preferred imaging for cases with high suspicion of pituitary apoplexy. Endoscopic transnasal transsphenoidal excision of the tumor is an excellent choice for surgical resection of pituitary adenomas, with improved rates of complete tumor removal and reduced incidence of complication.

Physical features that are desired by the opposite sex may drive competition between members of the same sex to gain access to potential mates. Women’s breasts are considered sexually attractive to men, and it has been shown that women may engage in competitive tactics to compete with or derogate women with ideal physical traits (i.e., physically attractive features). In the current online study, we investigated Hispanic women’s (n = 114) perceptions of breast stimuli that had been manipulated to display four levels of breast size (A-, B-, C-, and D-cup) and three levels of ptosis (i.e., levels of sagginess: non, low, and high) and their likelihood of engaging in rival derogation tactics, such as verbal and indirect aggression. The findings demonstrated that women were more likely to engage in rival derogation towards women with larger breast sizes. Women’s dispositional level of intrasexual competition did not play a role in rival derogation tactics. The results are in line with previous research suggesting that women’s rival derogation tactics are likely to be targeted towards women with attractive features that are desired by men.

Key Clinical Message: Ptosis associated with rhinosinusitis may indicate orbital or cavernous sinus involvement, typically accompanied by various other symptoms. However, isolated ptosis is a rare occurrence. This explains the diverse treatment approaches found in this literature review, ranging from conservative management to surgery. Imaging plays a crucial role in diagnosis and treatment planning. Isolated upper lid ptosis is a rare manifestation of acute rhinosinusitis, typically occurring without other neuro‐ophthalmological or orbital signs. This report presents a case of unilateral isolated ptosis in an adult male with acute rhinosinusitis. A 30‐year‐old male with asthma and bipolar disorder, and recent intranasal drug use, presented with nasal congestion, facial pressure, headache, and left eye droopiness. Neurological examination found left ptosis as the only abnormality. Lab results were normal, and COVID‐19 PCR was negative. Imaging showed pansinusitis without complications. The patient received IV antibiotics and steroids, followed by oral antibiotics and steroids. Ptosis resolved within 3 days and did not recur at three‐month follow‐up. Only seven cases of isolated ptosis with rhinosinusitis have been reported, all in males, most recovering with medical therapy alone. This is the first case treated with high‐dose steroids in addition to antibiotics. Isolated ptosis may be due to inflammation of the oculomotor nerve's distal branch or related muscular structures. Isolated ptosis in rhinosinusitis has a favorable prognosis. Imaging is crucial to exclude severe complications. The role of steroids needs further evaluation, and the timing for considering surgery remains to be defined. [ABSTRACT FROM AUTHOR]

Background: Postherpetic neuralgia (PHN) and postherpetic pruritus (PHP) are common complications of shingles that affect patients' quality of life. PHN and PHP can be managed using various medications and interventional procedures; however, complications persisting for at least six months may hamper recovery. Subcutaneous injections of botulinum toxin type A (BTX-A) can control persistent PHN and PHP. Case presentation: A 71-year-old man presented at our hospital with itching and pain. He had been diagnosed with shingles in the ophthalmic branch of the trigeminal nerve one year previously. As the pain and itching persisted despite medication, a supraorbital nerve block, Gasserian ganglion block, epidural nerve block, and radiofrequency thermocoagulation were performed. A subcutaneous injection of BTX-A was administered into the ophthalmic area of the trigeminal nerve three years after the initial presentation. A decrease of >80% in pain and itching was reported after the injection; however, the left eyelid drooped and the eyeball shifted downward and outward immediately after the injection. No deterioration in vision or pupil dilation was observed, and almost complete resolution of these symptoms occurred spontaneously three months after the injection. Pain and itching continued to improve without further side-effects until six months after the injection. Conclusions: The subcutaneous injection of BTX-A may be an alternative treatment option for chronic and refractory neurological diseases such as PHN and PHP, which persist for four years and are resistant to conventional treatments. Nevertheless, care must be taken to minimize the risk of ptosis. [ABSTRACT FROM AUTHOR]

PurposeMethodsResultsConclusionsAssessment of the frontalis muscle flap eyelid reanimation surgical technique for adults with severe ptosis and apraxia of eyelid opening.A retrospective case series of 30 eyes with severe ptosis or apraxia of eyelid opening. Outcomes were assessed for margin to reflex distance 1 (MRD1), lagophthalmos, complications, and need for subsequent surgical intervention. A paired t-test was used to compare preoperative and postoperative scores of a quality-of-life questionnaire.Thirty eyes of 19 patients underwent surgery, 16 (53%) with combined frontalis + levator-Muller muscle flap and 14 (46%) with frontalis muscle flap alone. There were 14 female and 5 male patients, with an average age of 55 years (range, 18–76). Mean preoperative MRD1 was −0.6 mm (range, −5 to 2) with mean levator excursion of 7.1 mm. Seventeen eyes had a myogenic etiology, five had a paralytic etiology, six had blepharospasm with apraxia of lid opening, and two had a neurodegenerative etiology. Nineteen eyes (63%) had previously undergone ptosis repair. Mean postoperative MRD1 was 2.5 mm (range, 0.5 to 5) at mean follow-up of 63.3 days. There were no serious surgical complications; minor complications included ocular surface keratopathy and one patient who required surgical revision. Results of the QOL questionnaire indicated significant improvement in vision-related symptoms postoperatively (p = 0.02).Use of the frontalis muscle flap eyelid reanimation technique, with or without a levator-Muller retractor muscle flap, was very effective in this case series and provided good upper eyelid position with acceptable corneal protection and high patient satisfaction. [ABSTRACT FROM AUTHOR]

Introduction: Pituitary apoplexy is a rare endocrine emergency that is occasionally life-threatening, most often involving pituitary macroadenomas. Most pituitary macroadenomas are nonsecretory and are diagnosed in the late stages. They remain undiagnosed until they cause compression of the surrounding vital structures and lead to subsequent symptoms. The clinical feature depends on the size of the tumor and the direction of the spread. There are two approaches for surgery. The less invasive endoscopic transnasal transsphenoidal approach is favored more than the transcranial approach. Case Report: 46-year-old female patient presented to the outpatient department (OPD) with complaints of headache and drooping of the right eyelid for 1.5 months. On neurological examination, right severe ptosis was present and extraocular movements of the right eye are restricted for the muscles supplied by the third nerve. Pupils were reactive to light. On perimetry, the left eye showed temporal hemianopia. Right eye perimetry was not done due to ptosis. MRI Brain gave differential diagnosis as pituitary macroadenoma with hemorrhage or necrosis and pituitary apoplexy without macroadenoma. Endoscopic transnasal transsphenoidal excision of the tumor under general anesthesia was performed. Conclusion: MRI brain is the preferred imaging for cases with high suspicion of pituitary apoplexy. Endoscopic transnasal transsphenoidal excision of the tumor is an excellent choice for surgical resection of pituitary adenomas, with improved rates of complete tumor removal and reduced incidence of complication. [ABSTRACT FROM AUTHOR]

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Copyright of Acibadem Saglik Bilimleri Dergisi is the property of Acibadem University Medical School and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: The pattern of extraocular muscle involvement in ocular myasthenia gravis varies across different reports, diverging from our own observations. Thus, we employed two novel tools to discern this pattern. Methods: A retrospective analysis was conducted to collect and organize clinical data from 43 patients diagnosed with ocular myasthenia gravis. Each patient underwent both the computerized diplopia test and the Ocular Motor Nerve Palsy Scale assessment to evaluate the involvement of extraocular muscles. Results: Among the patients, there were 30 male and 13 female individuals, with a total of 113 affected extraocular muscles identified. Among all the affected extraocular muscles, the involvement of the levator palpebrae superioris muscle accounted for 35.40%, medial rectus muscle 7.7%, lateral rectus muscle 16.81%, superior rectus muscle 13.27%, inferior rectus muscle 12.39%, superior oblique muscle 1.77%, and inferior oblique muscle 2.65% of the total affected extraocular muscles. The positivity rates of the Neostigmine test were 89.19%, AChR antibody detection was 59.38%, and repetitive nerve stimulation was 34.38%. The AChR antibody positive rate among patients with only diplopia was 100%; among those with only ptosis, it was 80%; and among those with both diplopia and ptosis, it was 86.67%. Conclusion: The involvement of the extraocular muscles is not uniform. The levator palpebrae superioris exhibits the highest incidence rate, followed by the four rectus muscles and two oblique muscles. The inferior oblique involvement typically occurs when four or more EOMs are affected. Moreover, the levator palpebrae superioris and medial rectus show a higher tendency for bilateral involvement compared with other extraocular muscles. [ABSTRACT FROM AUTHOR]

Botulinum toxin (BoNT) has been known for over 50 years. It has conquered many areas of medicine and has become indispensable in contemporary medicine. Now, BoNT is used to treat at least 26 conditions in six medical specialties. Although the use of BoNT began in strabology, it became the gold standard for many ophthalmologic pathologies. The present review of the literature focuses on the use of BoNT in ophthalmology and treatment of the following conditions: blepharospasm, facial hemispasm, facial palsy, spastic entropion, strabismus, endocrine orbitopathy, convergence spasm, and facial trauma. We conclude that nearly half a century of experience in utilizing BoNT in ophthalmology ensured a satisfactory level of effectiveness and safety for patients with many pathologies. Areas of future research include the application of BoNT in new selected indications, the development of the route of application without injections, and the development of long‑acting BoNT forms for patients who require repeated long‑term treatment. [ABSTRACT FROM AUTHOR]

This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE). This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized. Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period. An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Filler injections into the upper eyelid may cause levator aponeurosis fibrosis and ptosis. This risk must be considered. When ptosis appears, treatment might be difficult. Understanding the upper eyelid anatomy and procedures is essential to prevent eyelid damage. Ptosis is a prevalent condition in cosmetic surgery that occurs due to malfunction of the levator palpebrae superioris or insufficient Müller muscle action. It is characterized by the upper eyelid edge appearing lower than usual when seen at eye level. Ptosis may be categorized into congenital and acquired forms. The primary cause of congenital ptosis is attributed to abnormalities of the levator palpebrae superioris muscle or the motor nerve innervation that controls it. The condition arises from atypical development and malfunction of the oculomotor system. Acquired ptosis may be classified into many categories including traumatic, neurogenic, myogenic, senile, mechanical, and fake ptosis. Currently, there is little documentation of ptosis resulting from the degeneration of the aponeurosis of the muscle in the upper eyelid. We received a case of ptosis caused by fibrosis of the levator palpebrae superioris aponeurotic membrane. We used the technique of levator palpebrae superioris great advancement. The levator palpebrae superioris—Müller muscle was folded to create a stable composite construction via the levator palpebrae superioris high progress. [ABSTRACT FROM AUTHOR]

KEY CLINICAL MESSAGE: Prompt diagnosis and treatment of GCA are crucial to preserve vision. Because of this, new-onset ptosis or diplopia in elderly patients should warrant consideration of GCA, even in the absence of classic features, systemic symptoms or elevated inflammatory markers. ABSTRACT: Giant cell arteritis (GCA) is a vision-threatening, ophthalmic emergency that classically presents with new-onset headaches, scalp tenderness, systemic symptoms, visual disturbances, and elevated inflammatory markers. We describe an atypical presentation of GCA in an 87-year-old patient with fatigable ptosis and diplopia, with subsequent anterior ischemic optic neuropathy and choroidal infarction.

Metastasis to the skull base is a rare but serious complication of various malignancies. This case report discusses a 50-year-old woman with a history of advanced endometrialadenocarcinoma who presented with progressive headache, left-eye blindness, and ptosis. Imaging revealed a mass along the left optic nerve, raising suspicions of mucormycosis, but biopsy confirmed metastatic endometrial adenocarcinoma. Despite undergoing skull base radiotherapy, the patient’s vision did not improve. This case underscores the importance of considering metastatic endometrial adenocarcinoma in differential diagnoses for skull base lesions, particularly when other conditions are ruled out. Accurate diagnosis requires careful integration of clinical, radiological, and histopathological data.

Background: Juvenile myasthenia gravis (MG) is a rare autoimmune neuromuscular disorder and has a varied presentation in childhood making it a diagnostic challenge. Clinical Description: An 8-year-old girl presented to the pediatric emergency with multiple episodes of falling, drooling of saliva, dysphagia, and bilateral ptosis. Within a few hours of admission, she had acute deterioration, developed respiratory failure, and was put on ventilatory support. Management and Outcome: A myasthenic crisis was suspected and a neostigmine challenge test was done. She was managed in the emergency with atropine, neostigmine, intravenous immunoglobulin, and supportive care. Subsequently, she achieved complete remission with steroids, physostigmine, and oral mycophenolate mofetil over the next 6 weeks. Conclusion: Juvenile MG may rarely be the cause of generalized muscular weakness. A strong suspicion of myasthenic crisis must be kept in case of sudden deterioration involving bulbar and respiratory muscles, in a patient with neurologic weakness. Early intervention in this rare condition can be lifesaving.

Abstract 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

Abstract Background Uraemia causes a generalised encephalopathy as its most common neurological complication. Isolated brainstem uraemic encephalopathy is rare. We report a case of fatigable ptosis and complex ophthalmoplegia in brainstem uraemic encephalopathy. Case presentation A 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain. Conclusions Uraemia may rarely cause an isolated brainstem encephalopathy mimicking ocular myasthenia, which resolves with correction of the uraemia.

Kearns–Sayre syndrome (KSS) is a rare mitochondrial disease that affects young adults, due to a deletion of mitochondrial DNA and characterized by the triad: age of onset lower than 20 years, chronic progressive external ophthalmoplegia, and an atypical pigmentary retinopathy. It is also characterized by other endocrine, neurological, and especially cardiac impairment with a very high risk of cardiac complications during surgical procedures under all types of anesthesia.

There are a number of diseases that can compromise with the vision of an individual. For example, there are diseases that directly affect the movement of eyelids, in turn, affecting vision. Ptosis is one such disease that affects the functionality of the muscles that control the movement of the eyelids or their nerve supply. Consequently, an upper eyelid of the individual naturally droops or falls hindering the vision of the individual.

Background: The simultaneous occurrence of Parkinson's disease (PD)--a progressive neurodegenerative disorder marked by the loss of monoaminergic neurons in the substantia nigra--and Myasthenia gravis (MG)--a neuromuscular junction disease--is exceptionally rare. Although these conditions have different pathophysiological foundations, literature reports at least 29 cases of individuals diagnosed with both disorders. Case Report: We present the case of a 66-year-old patient treated for Parkinson's disease for four years before being diagnosed with MG, following the onset of dysphagia and bilateral ptosis. Apomorphine infusion, an advanced treatment option, was safely initiated. Conclusion: This case highlights the coexistence of PD and MG and illustrates the potential benefits of apomorphine infusion therapy. Apomorphine was effective in reducing symptoms, improving motor function, and enhancing the patient's quality of life. [ABSTRACT FROM AUTHOR]

To examine the long-term effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty procedure on dry eye syndrome. This is a Prospective comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients that underwent blepharoplasty at least 3 years earlier and the ptosis group consisting of adult patients that underwent MMCR with blepharoplasty at least 3 years earlier. The parameters that were compared for all patients before the procedure, on postoperative day 90, and at the long-term follow-up were: Schirmer-test 2, tear break-up time (TBUT), fluorescein staining, and lissamine green (LG) staining. The participants included 25 post-MMCR patients with a mean follow-up of 4.94 ± 0.64 years and 15 post-blepharoplasty patients with a mean follow-up of 4.22 ± 0.32 years. There was a significant increase in the postoperative LG and fluorescein staining scores compared to the preoperative scores in the ptosis group (p <.01 and p <.01, respectively) as well as a decrease in postoperative TBUT compared to the preoperative values (p =.044). Those parameters were not significant in the blepharoplasty group. Patients who underwent MMCR, but not those following upper blepharoplasty, showed signs of dry eye compared to the preoperative status after long-term follow-up. Dry eye signs should be examined before MMCR surgery, and patients should be aware of the high risk of developing dry eye and the need for long-term treatment. Surgeons should carefully consider performing MMCR for patients with severe dry eye. [ABSTRACT FROM AUTHOR]

Objective: By comparing the position of the fusion point between the oriental orbital septum and the levator aponeurosis of the upper eyelid in Asian without and with mild ptosis, this study explores the relationship between the fusion point and mild ptosis, providing scientific basis for better utilizing the orbital septum to correct mild ptosis. Methods: In this study, the outpatients who underwent double eyelid blepharoplasty with incision method in the plastic laser cosmetology department of Hunan Provincial People's Hospital from October 2018 to April 2019 were divided into the normal group and the mild ptosis group. The position of the fusion part of the orbital septum and the aponeurosis of the levator palpebrae superioris was observed in the two groups. There are three types of this position: the height of the fusion part is greater than the width of the tarsal plate, the height of the fusion part is equal to the width of the tarsal plate, and the height of the fusion part is less than the width of the tarsal plate. After the fusion part was exposed during the operation, the width of tarsal plate and the height of fusion part were measured with a scale. The difference of the location of fusion part between the two groups was analyzed. Results: The tarsal plate width was 11.061 ± 0.635 mm in the normal group and 11.062 ± 0.675 mm in the mild ptosis group. There was no significant difference in tarsal plate width between normal group and mild ptosis group (t = 0.645, p = 0.16). The height of the fusion part was 11.032 ± 0.646 mm in the normal group and 11.645 ± 0.429 mm in the mild ptosis group. The fusion position of mild ptosis group was higher than that of normal group (t = 3.769, P < 0.05). There was significant difference in the distribution of fusion site between the two groups (x2 =38.00, P < 0.0001). Conclusion: The height of aponeurosis fusion of orbital septum and levator palpebrae superioris in mild ptosis group was higher than that in normal group, which may be the cause of mild ptosis. It is suggested that the appropriate treatment of orbital septum in clinical operation may be effective in the treatment of mild blepharoptosis. Level of Evidence III: 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 https://www.springer.com/00266. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Uraemia causes a generalised encephalopathy as its most common neurological complication. Isolated brainstem uraemic encephalopathy is rare. We report a case of fatigable ptosis and complex ophthalmoplegia in brainstem uraemic encephalopathy. Case presentation: A 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain. Conclusions: Uraemia may rarely cause an isolated brainstem encephalopathy mimicking ocular myasthenia, which resolves with correction of the uraemia. [ABSTRACT FROM AUTHOR]

Currently, there is no universally accepted standard treatment for ocular myasthenia gravis (OMG) in children. We aimed to investigate the possible proper regimens and timing of treatment for pediatric OMG cases based on the clinical manifestations: OMG with ptosis only and OMG with other features. One hundred and forty two OMG cases attended at the Department of Pediatrics, Xiangya Hospital, Central South University, from 2010 to 2019 were included, and information from medical records was reviewed and recorded. Comparisons of clinical characteristics between patients with OMG with ptosis only and patients with OMG with other features as well as between patients treated with glucocorticoid (GC) within or after six months from disease onset were performed. OMG with other features constituted about 54.9% of the cases, and 66.2% of the patients achieved optimal outcome. Patients with OMG with ptosis only responded to pyridostigmine alone more than patients with OMG with other features who required several therapies (P < 0.001). Patients with OMG with ptosis only had a larger proportion of optimal outcome than the patients with OMG with other features (P = 0.002), and the difference remained significant even when the individual outcome groups were compared (P < 0.001). Patients who received GC within six months had a greater proportion of optimal outcome than those who received it after six months (P < 0.001). Although OMG with other features is a more common subtype of OMG, it is also more severe than OMG with ptosis only. An earlier addition of GC leads to optimal outcome. [ABSTRACT FROM AUTHOR]

We present here a 12-year-old child who presented with complaints of blurring of vision and drooping of the left upper eyelid for the past 4 years, which started 1 month after he encountered blunt trauma to the left-sided orbital region. History, examination and pharmacological (neostigmine test) tests were suggestive of ocular myasthenia gravis, however anti-acetylcholine receptor antibodies and anti-musk antibodies were negative. Repetitive nerve stimulation tests and electromyography were also unremarkable. The patient was labelled as a case of trauma-induced double-Seronegative Ocular Myasthenia Gravis and was started on oral Pyridostigmine. The patient reported a drastic improvement in both diplopia and ptosis that he initially presented with. Ocular Myasthenia Gravis can be a diagnostic challenge as its initial presentation can vary to a great degree. Thorough history and examination remain of prime importance which can provide adequate clues to lead us to the diagnosis of ocular myasthenia gravis. Trauma should also be recognized as a triggering factor for myasthenia gravis and more attention needs to be given to understand the pathophysiology of this interesting association. [ABSTRACT FROM AUTHOR]

Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures. [ABSTRACT FROM AUTHOR]

Noonan syndrome (NS) is a rare genetic disorder and may present with extraocular findings such as ptosis, telecanthus, and downward-slanting palpebral fissures, as well as ocular signs including refractive errors, amblyopia, nystagmus, and optic atrophy. We present, a 7- year-old patient diagnosed with NS a year ago who was referred for ophthalmological evaluation. The patient had ptosis, nystagmus, esotropia, myopia, astigmatism and optic nerve hypoplasia. The best-corrected visual acuity, was 0.8 in the right eye and 0.1 in the left eye. He was prescribed spectacles and advised occlusion therapy for the right eye for 3 hours per day. At the one-year follow-up, the visual acuity in the right eye remained unchanged, whereas the visual acuity in the left eye improved to 0.2. Factors contributing to vision impairment in NS include ptosis, anisometropic amblyopia, and cataract. Early ophthalmological assessment is crucial for NS; because intervention for these conditions during childhood can lead to improvements in visual acuity. [ABSTRACT FROM AUTHOR]