Floppy eyelid, an under-diagnosed syndrome: a review of demographics, pathogenesis, and treatment

Floppy eyelid syndrome (FES) is a frequent eyelid disorder characterized by eyelid laxity that determines a spontaneous eyelid eversion during sleep associated with chronic papillary conjunctivitis and systemic diseases. FES is an under-diagnosed syndrome for the inaccuracy of definition and the lack of diagnostic criteria. Eyelid laxity can result from a number of involutional, local, and systemic diseases. Thus, it is pivotal to use the right terminology. When the increased distractibility of the upper or lower eyelid is an isolated condition, it is defined as 'lax eyelid condition' (LAC). When laxity is associated with ocular surface disorder such as papillary conjunctivitis and dry eyes, it can be referred to as 'lax eyelid syndrome' (LES). However, FES is characterized by the finding of a very loose upper eyelid which everts very easily and papillary tarsal conjunctivitis affecting a specific population of patients, typically male, of middle age and overweight. Obesity in middle-aged male is also recognized as the strongest risk factor in obstructive sleep apnea-hypopnea syndrome, (OSAHS). FES has been reported as the most frequent ocular disorder associated with OSAHS. Patients with FES often complain of non-pathognomonic ocular signs and symptoms such as pain, foreign body sensation, redness, photophobia, and lacrimation. Due to these clinical features, FES is often misdiagnosed while an early recognition might be important to avoid its chronic, distressing course and the associated morbidities. This review provides an updated overview on FES by describing the epidemiology, proposed pathogenesis, clinical manifestations, related ocular, and systemic diseases, and treatment options

El dintel 3 del templo IV de Tikal :\ua0análisis iconográfico y simbólico de la representación /

\ua0tesis que para obtener el grado de Doctorado en Historia, presenta Simonetta Morselli Barbieri ; tutores principales de tesis Manuel Hermann Lejarazú, Ma. Teresa Uriarte Castañeda, Gerardo Bustos Trejo. 275 páginas :\ua0ilustraciones. Doctorado en Historia\ua0Universidad Nacional Autónoma de México,\ua02013\ua0Programa de Posgrado en Histori

Minimally invasive combined glaucoma and cataract surgery: clinical results of the smallest ab interno gel stent

PURPOSE: To verify the efficacy in intraocular pressure (IOP) reduction and safety of the smallest gel stent (XEN 45 Gel Stent) microincisional glaucoma surgery combined with microincisional cataract surgery (MICS). METHODS: Nonrandomized prospective clinical study. Forty-one eyes of 33 patients with open-angle glaucoma underwent a XEN 45 Gel Stent implantation combined with MICS. Treatment outcomes analyzed included: IOP, medication use, intra- and postoperative complications. At the end of the follow-up, we evaluated the complete success, defined as a postoperative IOP 65 6 and 6417 mmHg without glaucoma medications and the qualified success defined as a postoperative IOP 65 6 and 6417 mmHg, with glaucoma medications. RESULTS: The mean preoperative IOP was 22.5 \ub1 3.7 mmHg on 2.5 \ub1 0.9 medication classes. After 12 months, the mean postoperative IOP was 13.1 \ub1 2.4 mmHg (mean IOP reduction of 41.82%) with a mean of 0.4 \ub1 0.8 medication classes (P < 0.05 for IOP and medications). The complete success rate was achieved in 80.4% and a qualified success in 97.5%. There were no major intra- and postoperative complications during the first year of follow-up. CONCLUSIONS: This study demonstrated that the smaller diameter XEN 45 gel implant is statistically effective in reducing IOP and medications in glaucoma patients with a low rate of complications

Theoretic scientific rationale of double XEN 45 Gel Stent implant in severe glaucomatous ocular hypertension

Purpose: To investigate the theoretical hydrodynamic effects of a single or a double XEN 45 Gel Stent (XEN45) implant in glaucomatous eyes. Methods: A prospective non-randomized clinical study on 63 glaucomatous eyes of 63 patients. The preoperative intraocular pressure (IOP) values after 14 days of medical therapy washout was correlated to the postoperative IOP values 7 and 45 days after the implant of a XEN45. A mathematical model based on the Hagen-Poiseuille law was designed to assess the residual aqueous humor outflow (AHO) facility in glaucomatous eyes in function of the postoperative IOP reduction. Using XEN45 as unit of measurement, we transformed through equations the residual preoperative AHO in XEN45 equivalent in order to establish theoretical number of stents needed to reach the target IOP. Results: The mean preoperative washout IOP was 28.9 ± 5.4 mmHg, after 7 and 45 days the mean postoperative IOP was 12.6 ± 4.3 and 15.3 ± 4.4 mmHg, respectively (p &lt; 0.001). A significant positive correlation was found between preoperative and postoperative IOP values. We obtained a mathematical relationship to estimate the theoretical number of XEN45 stents needed to reach the target IOP. Conclusion: The basal IOP (after medical therapy washout) is a predictive factor for the surgical success after a XEN45 implant. Establishing the residual preoperative AHO it is possible to predict the theoretical number of stents to implant. A double XEN45 implant could be considered a possible further tool to reach the target IOP in patients with severe AHO deficiency

Safety and efficacy of multiple cyclocoagulation of ciliary bodies by high-intensity focused ultrasound in patients with glaucoma

PURPOSE: To evaluate long-term efficacy and safety of repeated ultrasonic circular cyclocoagulation (UCCC) in patients with uncontrolled glaucoma. METHODS: Forty eyes of 40 patients affected by primary or secondary uncontrolled glaucoma under maximal tolerated medical therapy were enrolled in this prospective non-comparative case series study. A complete ophthalmic examination was performed before and after each month for 1 year. The UCCC treatment was repeated at 4 months if the intraocular pressure (IOP) was > 21 mmHg without major complications. Complete success was defined as a final IOP > 5 mmHg and 64 21 mmHg without hypotensive medication adjunction and no major or vision-threatening complications. RESULTS: The mean preoperative IOP was 32.5 \ub1 9.9 mmHg. Four months after the first UCCC treatment the overall IOP reduction was 27.8%. Twenty-two of the treated eyes did not achieve the complete success and a second treatment was performed in 20 of these eyes. Four months after the second UCCC procedure, the IOP reduction was 20.3% from preoperative values and 34.7% from baseline. Twelve of the retreated eyes needed a third treatment. Four months after the third UCCC treatment, the overall IOP reduction was 34% and 52.6% from baseline. No major complications occurred during or after any of the procedures. At 12 months, complete success was achieved in 85% (34/40) of treated eyes, with a maximum of three procedures and a significant medication reduction. CONCLUSIONS: Multiple UCCC treatments are safe, and additional treatments increase the overall procedure efficacy

Floppy eyelid syndrome and ectropion improvement after 1 month of 0.03% Bimatoprost topical therapy

Purpose: To report the clinical improvement observed in a glaucomatous patient affected by floppy eyelid syndrome and ectropion after treatment with Bimatoprost 0.03%. Methods: Retrospective observational case report of a single glaucomatous patient (caucasian, 82 years old) affected by floppy eyelid syndrome with marked eyelid laxity and ectropion after 1 month of once a day 0.03% Bimatoprost ocular drop administration. Results: We observed a reduction of intraocular pressure (36% in the right eye and 37.5% in the left eye) and an unexpected improvement of eyelid laxity and inferior ectropion after 1 month of therapy with topical 0.03% Bimatoprost. Secondary outcomes were the improvement of the related ocular surface diseases and the decrease of the upper eyelid dermatochalasis. No side effect in terms of conjunctival inflammation and eyelashes growth was observed. Conclusions and importance: The first observational clinical case of a possible prostaglandin therapeutic effect on periocular tissue improving the laxity and malposition of the eyelids in a patient with floppy eyelid syndrome associated with inferior eyelid ectropion