Correlation of Levator Palpebrae Superioris and Dry Eye Disease

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Methods: 168 eyes of 84 patients (group 1= levator function ≤9 mm, 78 eyes; group 2= levator function >9 mm, 90 eyes) who have been diagnosed with ptosis were retrospectively enrolled. Levator function test, Ocular Surface Disease Index Questionnaire (OSDI), Schirmer I test, noninvasive tear break up time (NItBUT), corneal staining score, meibography, meibum quality and expressibility scores, tear meniscus height, and partial blinking rate (PBR) were examined. Results: PBR and NItBUT in group 2 (9.29 ± 4.01 and 4.76 ± 2.39, respectively) were significantly worse than those in group 1 (5.88 ± 3.99 and 5.78 ± 2.94, respectively) (P<0.05). There was a significantly positive correlation between levator function and partial blinking rate (R=0.4114, P=0.0002). Meibum expressibility and lipid thickness in group 2 (0.48 ± 0.70 and 1.12 ± 0.33, respectively) were significantly better than those in group 1 (1.29 ± 0.65 and 1.39 ± 0.45, respectively) (P<0.05) (Figure 3). There was a significantly negative correlation between levator function and meibum expressibility grade (R=0.4114, P=0.0002) (Figure 2). Conclusion: The eyes with good levator function showed shorter tear break-up time due to a higher partial blinking rate, but showed better lipid thickness due to better meibum expressibility compared with the eyes with fair levator function. Levator palpebrae superioris Dry eye disease Tear break-up time Meibum expressibility Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The dry eye disease (DED) is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms. [ 1 ] Ptosis refers to a condition in which the upper eyelid droops and the gap between the upper eyelid and lower eyelid is small because the force of the levator palpebral muscle to open the eyes is weak. [ 2 , 3 ] Depending on the time of occurrence, there are congenital ptosis that occurs from birth and acquired ptosis that occurs with age. Acquired ptosis is mainly when the function of the levator palpebral muscle weakens with age or there is a problem in the attachment site with the eyelid, causing the eyelid to droop downward. [ 4 – 6 ] The normal position is for the upper eyelid to slightly cover the upper part of the pupil when the eyes are opened, but in patients with ptosis, the upper eyelid droops down, covering more pupils than the normal position, and in severe cases, it can even cover the pupil. A dry eye disease could be a possible cause of aponeurogenic blepharoptosis. [ 2 ] Although the degree of ptosis surgery varies, in most cases, since the eyes close less than before the surgery, dry eye symptoms may occur. [ 7 – 9 ] However, in most cases, the discomfort diminishes over time. [ 10 ] Frontalis sling surgery is the primary option for patients with weak levator action (less than 4mm). [ 11 ] Bell’s phenomenon reduces tear film instability and ocular surface damage in eyes with lagophthalmos caused by frontalis suspension surgery. [ 12 ] Compared to upper blepharoplasty, Muller muscle-conjunctival resection surgery can increase both the symptom and signs in dry eye. [ 9 , 13 ] These differences result from the increase in ocular surface and corneal exposure, which produces an increase in evaporative and aqueous tear-deficient dry eye because of the loss of meibomian glands after Muller muscle-conjunctival resection surgery. [ 13 ] There are many studies on dry eye and changes in tears that occur after ptosis surgery. However, to date, there has been no report on whether ptosis itself is related to the function of the meibomian glands or the severity of dry eyes. Recently, studies on dermatochalasis, dry eye, and meibomian gland function have been reported. In the study, it was reported that the degree of dermatochalasis showed a significant association with meibomian gland expression (MGE) and meiboscale grade. Schirmer test, tBUT and SPK did not show a significant difference. [ 14 ] Therefore, the authors conducted a study to determine the degree of dry eye and meibomian gland function according to the function of the levator palpebral muscle. Methods Study Design and Patients This retrospective study was performed in Seoul St. Mary’s Hospital at the Catholic University of Korea in Seoul, Korea. We retrospectively reviewed the medical records of 84 patients with ptosis. The data provided to us excluded all personal identifiers. This study was performed in accordance with the tenets of the Declaration of Helsinki. The Institutional Review Board (IRB)/Ethics Committee of Seoul St. Mary Hospital approved this study protocol (XC16MIMV0056H) and waived the informed consent because of the retrospective nature of the study. Those with a history of previous orbital surgery, blepharoplasty, or ocular trauma were excluded from the study. Clinical Assessment All patients completed a full ophthalmological examination and eyelid function test, including a slit-lamp examination. The grading of levator action consists of four cathegories (less than 4 mm – poor, 5 to 9 mm – fair, 9 to 11 mm – good, greater than 12 mm – excellent). [ 15 ] We divided patients into two groups according to fair or good levator function grades (group 1 = levator function ≤ 9 mm in more than one eye, 40 patients, or group 2 = levator function > 9 mm in both eyes, 44 patients) (Table 1 ). And we divided the eyes into two groups according to fair or good levator function grades (group 1 = levator function ≤ 9 mm, 78 eyes; group 2 = levator function > 9 mm, 90 eyes) (Table 2 ). Schirmer I tested without topical anesthetic and stained the cornea with fluorescein strips (fluorescein paper; Haag-Streit AG, Köniz, Switzerland). The corneal staining score was assigned a value ranging from zero to five points using the Sicca scoring. The noninvasive tear break up time (NItBUT) test, Ocular Surface Disease Index (OSDI) score, and tear-meniscus height were measured. Partial blinking rate was also examined by LipiView. Table 1 Patients’s parameters according to the levator function Parameter Group 1 (Levator function ≤ 9) Group 2 (Levator function > 9) Number of eyes 40 44 F:M 30:10 28:12 Age, years (range) 73.45 ± 8.15 (55–81) 73.33 ± 6.44 (66–82) OSDI score (range) 10.98 ± 9.36 (4–35) 7.28 ± 6.86 (2–25) Tear Height, mm (range) 0.26 ± 0.21 (0.08–0.44) 0.29 ± 0.13 (0.12–0.44) Schirmer I, mm (range) 11.02 ± 6.95 (5–30) 10.90 ± 5.75 (4–20) NItBUT, sec (range) 5.68 ± 2.99 (1.5-11.85) 4.73 ± 2.27 (2.29–11.47) Corneal Stain (range) 0.45 ± 0.76 (0–3) 0.58 ± 0.76 (0–3) Meibomian gland dropout (range) 1.27 ± 0.62 (0–3) 1.11 ± 0.69 (0–3) Meibum expressibility (range) 1.29 ± 0.65 (0–3) *0.48 ± 0.70 (0–2) Meibum quality (range) 1.26 ± 0.79 (0–3) 1.10 ± 0.79 (0–3) Lid inflammation (range) 1.21 ± 0.78 (0–3) 1.10 ± 0.75 (0–3) Lipid layer thickness (range) 1.39 ± 0.64 (0–2) 1.31 ± 0.77 (0–3) Partial blinking rate (%) (range) 5.88 ± 8.99 (0–27) 9.29 ± 10.01 (0–38) Meibum expressibility in group 2 was significantly better than that of group 1 (p < 0.05). Group 1: Levator function < 9 in more than one eye Group 2: Levator function ≥ 9 in both eye OSDI: Ocular Surface Disease Index Questionnaire NItBUT: Noninvasive tear break up time Values are presented as mean ± SD. D; diopter Table 2 Parameters of eyes according to the levator function Parameter Group 1 (Levator function ≤ 9) Group 2 (Levator function > 9) Number of eyes 78 90 Tear Height, mm (range) 0.26 ± 0.11 (0.09–0.50) 0.29 ± 0.13 (0.12–0.45) Schirmer I, mm (range) 11.02 ± 6.95 (5–30) 10.90 ± 5.75 (5–26) Corneal Stain (range) 0.45 ± 0.76 (0–3) 0.58 ± 0.77 (0–3) Meibomian gland dropout (range) 1.27 ± 0.75 (0–3) 1.30 ± 0.77 (0–3) Meibum quality (range) 1.18 ± 0.79 (0–3) 1.15 ± 0.81 (0–3) Lid inflammation (range) 1.14 ± 0.77 (0–3) 1.15 ± 0.76 (0–2) There was no statistical difference between the two groups (p > 0.05). Group 1: Levator function < 9 in more than one eye Group 2: Levator function ≥ 9 in both eye Values are presented as mean ± SD. D; diopter Measurement of the meibomian gland A Lipiview (Johnson & Johnson Vision, Irvine, CA, USA) was used to measure meibomian gland grade and lipid layer thickness. Meibomian gland dropout was examined using infrared pictures of the upper and lower lid meibomian glands. Meibomian gland dropout was graded from 0 to 3, as reported earlier. [ 16 ] Meibum expression score (MES) and meibum quality score (MQS) were also examined, as reported earlier. [ 17 ] Lipid layer thickness was captured by Keratograph 5M, which was graded from 0 to 3, as follows: 0, severely decreased lipid layer; 1, mildly to moderately decreased lipid layer; 2, normal lipid layer; and 3, hypersecretary lipid layer (Fig. 1 ). Statistical Analysis All statistical analyses were carried out using SPSS for Windows (version 21.0.1; SPSS Inc., Chicago, IL). The Wilcoxon signed rank test was used to compare the data before and after treatment. Comparisons among three groups were performed with one-way analysis of variance (ANOVA) with a Bonferroni post hoc comparison. The chi-square test was used for the comparison between groups of different proportions. P values < 0.05 were considered statistically significant. P values < 0.05 were considered statistically significant. Results Patients’s parameters We divided the patients into two groups according to fair or good levator function grades (group 1 = levator function ≤ 9 in more than one eye, 40 patients with 80 eyes, or group 2 = levator function > 9 mm in both eyes, 44 patients with 88 eyes). The meibum expressibility grade in group 2 (0.48 ± 0.70) was significantly better than that in groups 1 (1.29 ± 0.65) and 2 (P < 0.05). There were no statistically significant differences between the two groups according to age, OSDI, tear height, Schirmer I, NItBUT, corneal stain, meibomian gland scores, lid inflammation grade, or lipid layer thickness grade, or partial blinking rate (P > 0.05) (Table 1 ). Parameters of the eyes We divided the eyes into two groups according to fair or good levator function grades (group 1 = levator function ≤ 9 mm, 78 eyes; group 2 = levator function > 9 mm, 90 eyes). The partial blinking rate (%) and NItBUT (seconds) in group 2 (9.29 ± 4.01 and 4.76 ± 2.39, respectively) were significantly worse than those in group 1 (5.88 ± 3.99 and 5.78 ± 2.94, respectively) (P < 0.05) (Fig. 2 ). There was a statistically significant positive correlation between levator function and partial blinking rate (R = 0.4114, P = 0.0002) (n = 168 eyes) (Fig. 3 ). The meibum expressibility grade and lipid thickness grade in group 2 (0.48 ± 0.70 and 1.12 ± 0.33, respectively) were significantly better than those in group 1 (1.29 ± 0.65 and 1.39 ± 0.45, respectively) (P < 0.05) (Fig. 4 ). There was a statistically significant negative correlation between levator function and meibum expressibility grade (R = 0.4114, P = 0.0002) (n = 168 eyes) (Fig. 5 ). A lower grade of meibum expressibility is better expressible. There was no statistically significant difference between the two groups according to tear height, Schirmer I, corneal stain, meibomian gland dropout grade, meibum quality, or lid inflammation grade (P > 0.05) (Table 2 ). Discussion Dry eye disease can be simply classified as an evaporative or aqueous-deficient type. Both inflammation and apoptosis play an important role in dry eye pathogenesis. [ 18 ] Treatment of DED is complicated because it is caused by a vicious cycle of tear film instability, hyperosmolarity, and ocular surface inflammation. [ 19 ] Acquired aponeurogenic blepharoptosis can be induced by disinsertion or dehiscence of the levator aponeurosis. [ 4 ] Aponeurogenic ptosis can be caused by aging, continuous use of hard contact lens, intraocular surgery, or trauma. [ 20 , 21 ] Moesen, I. et al. reported that increased eyelid friction, orbicularis tonus, and inflammation in the dry eye patient, may promote disinsertion of the levator aponeurosis after a prolonged period of time. [ 2 ] Patients with acquired aponeurogenic blepharoptosis were reported to have decreased aqueous tear production more often. Although low tear production may play a part in the etiology of acquired blepharoptosis, it could also be explained by a weakened reflex in blepharoptosis patients. [ 2 ] In our result, there was no statistically significant difference between the two groups according to tear height and Schirmer I. But those of group 2 (levator function > 9) were insignificantly increased compared with group 1 (P > 0.05) (Table 2 ). The reason why the tear production of both groups was not significantly different is that both groups had mild blepharoptosis (one group had fair and the other had good levator function in our result). There were no changes in dry eye tests after blepharoplasty in patients without dry eye symptoms. [ 7 ] However, changes were prominent after ptosis surgery, especially Muller’s muscle-conjunctival resection (MMCR). [ 7 , 8 , 22 ] Zloto O. et al. also reported that MMCR leads to an increase both the symptom and signs of dry eye disease. [ 13 ] In patients with initial high tear volume, tear volume can decrease after the blepharoptosis surgery. [ 22 ] On the other hand, some physicians reported that the MMCR after upper eyelid blepharoplasty did not aggravate ocular surface scores or dry eye symptoms. [ 9 , 23 ] Age and mental activity influence spontaneous blinking, which complicatedly interacts with the ocular surface. [ 24 ] PBR and meibomian gland dropout rates measured with IDRA were reported to have a significant correlation with dry eye symptoms. [ 25 ] In our study, PBR and NItBUT in group 2 (9.29 ± 4.01 and 4.76 ± 2.39, respectively) were significantly worse than those in group 1 (5.88 ± 3.99 and 5.78 ± 2.94, respectively) (P < 0.05). There was a significantly positive correlation between levator function and partial blinking rate (R = 0.4114, P = 0.0002). Meibum expressibility and lipid thickness in group 2 (0.48 ± 0.70 and 1.12 ± 0.33, respectively) were significantly better than those in group 1 (1.29 ± 0.65 and 1.39 ± 0.45, respectively) (P < 0.05) (Fig. 3 ). There was a significantly negative correlation between levator function and meibum expressibility grade (R = 0.4114, P = 0.0002) (Fig. 2 ). The reason why PBR in group 2 was higher than that in group 1 may be that the lid height of group 2 is higher than that of group 1. So we think NItBUT in group 2 was shorter than that in group 1 because evaporation increased due to higher PBR in group 2. Incomplete blinking is associated with decreased tBUT. [ 26 ] Patients with dry eye disease spent 4.5% of a minute with their eyes closed, while normal subjects spent 0.7% of a minute. [ 27 ] And we also think the meibum expressibility in group 2 was better than that in group 1 because the lid closing pressure in group 2 may be higher than that in group 1 because of the higher gravity force of group 2 compared with that of group 1. So we think lipid thickness in group 2 was significantly better than that in group 1 because meibum expressibility in group 2 was better than that in group 1. The levator palpebrae superioris and orbicularis oculi are antagonistic muscles in eyelid motion. But motoneurons innervating the levator and orbicularis muscles were controlled by retrograde transport of WGA/HRP and HRP. [ 28 ] So we think that good levator function may have a correlation with good orbicularis muscle function. To the best of our knowledge, there was no study about the levator palpebrae superioris function in patients with dry eye disease In our study, there was a limitation that a multicenter clinical trial with a larger sample size and a longer follow-up period was required to observe the long-term study of levator palpebrae superioris function in patients with dry eye disease. In conclusion, the eyes with good levator function showed shorter tear break-up time due to a higher partial blinking rate, but showed better lipid thickness due to better meibum expressibility compared with the eyes with fair levator function. Abbreviations MES Meibum expression score MQS meibum quality score MMCR Muller’s muscle-conjunctival resection Declarations Ethics approval and consent to participate This study was approved by the institutional review board at Seoul St. Mary’s Hospital (XC16MIMV0056H); the informed consent was waived. All clinical investigations have been conducted according to the principles expressed in the Declaration of Helsinki. Consent for publication Not applicable. Competing interests None Funding This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2022R1F1A1069218). The funding offered support in the design of the study and collection, analysis, interpretation of data, and publication fee. Author Contribution ECK was involved in analysis and interpretation of data and drafting the manuscript. ECK, HS, SEK, SY made contribution to acquisition of data and drafting. SY contributed to conception and design, analysis and interpretation of data, drafting and revising the manuscript. All authors read and approved the final manuscript. Acknowledgements None. Availability of data and materials The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. References Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276–83. Moesen I, van den Bosch W, Wubbels R, Paridaens D. Is dry eye associated with acquired aponeurogenic blepharoptosis? Orbit 2014, 33(3):173–177. Lee YG, Son BJ, Lee KH, Lee SY, Kim CY. Clinical and Demographic Characteristics of Blepharoptosis in Korea: A 24-year Experience including 2,328 Patients. Korean J Ophthalmol. 2018;32(4):249–56. Fujiwara T, Matsuo K, Kondoh S, Yuzuriha S. Etiology and pathogenesis of aponeurotic blepharoptosis. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4005099","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276686939,"identity":"f438f704-a3b1-4bb1-ab52-a72f26106bcf","order_by":0,"name":"Eun Chul Kim","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Eun","middleName":"Chul","lastName":"Kim","suffix":""},{"id":276686940,"identity":"18424bcd-952b-4700-9a6a-7182777b4c07","order_by":1,"name":"Ha-Rim So","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Ha-Rim","middleName":"","lastName":"So","suffix":""},{"id":276686941,"identity":"962a06b6-000c-46d9-bee6-34cca3caf81f","order_by":2,"name":"Sung Eun Kim","email":"","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":false,"prefix":"","firstName":"Sung","middleName":"Eun","lastName":"Kim","suffix":""},{"id":276686942,"identity":"67e5dc24-b777-4a32-86b9-2ec64fa1e18f","order_by":3,"name":"Suk-Woo Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYLACxgabBDAjoYB4LWlQLQZAgo04LYchWhiI0WJw/ozh48Id5/P4Z3cnfnhgwJDHL99AQMuNHGPjmWduF0vcObtZAuiwYsk2Qrbc4N0mzdt2O7HhRu4GkJbEDccIOuwsSMu5xPk3cjf/AGnZT1DLgVyQlgOJG27kboPYQsj7kjfyPxvPbEtO3AjUYpFgIJE441gCfi18548lPi5ss0ucB3TYzR8VNon9zQfwa1EAyjMj8SUIuAoIQJHATFDVKBgFo2AUjGwAAL6fSyxq8SN/AAAAAElFTkSuQmCC","orcid":"","institution":"The Catholic University of Korea","correspondingAuthor":true,"prefix":"","firstName":"Suk-Woo","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-03-02 01:45:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4005099/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4005099/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52191201,"identity":"b3fc306b-20a9-4921-8416-1b7f78e48bde","added_by":"auto","created_at":"2024-03-07 19:28:07","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":178388,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLipid layer thickness was captured using the Keratograph 5M\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLipid layer thickness was graded from 0 to 3, as follows: 0, severely decreased lipid layer; 1, mildly to moderately decreased lipid layer; 2, normal lipid layer; and 3, hypersecretary lipid layer.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4005099/v1/62d7a9e6edb14e0a5c7df50c.jpg"},{"id":52191204,"identity":"5059f7da-6a35-4227-8264-fabf862857fe","added_by":"auto","created_at":"2024-03-07 19:28:07","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41869,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePartial blinking rate and NItBUT in both groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe partial blinking rate (%) and NItBUT (seconds) in group 2 (9.29 ± 4.01 and 4.76 ± 2.39, respectively) were significantly worse than those in group 1 (5.88 ± 3.99 and 5.78 ± 2.94, respectively) (P\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eNItBUT: Noninvasive tear break up time\u003c/p\u003e\n\u003cp\u003eGroup 1 = levator function ≤9 mm, 78 eyes\u003c/p\u003e\n\u003cp\u003eGroup 2 = levator function \u0026gt;9 mm, 90 eyes\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4005099/v1/69e29fd35cf8c76bbbe42ed4.jpg"},{"id":52193389,"identity":"90bd0bc5-a368-4d98-88b9-d843846475e7","added_by":"auto","created_at":"2024-03-07 19:36:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":50350,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between levator function and partial blinking rate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a statistically significant positive correlation between levator function and partial blinking rate (%) (R=0.4114, P=0.0002) (n=168 eyes).\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4005099/v1/706ea58fca88e48f09574047.jpg"},{"id":52193390,"identity":"fa5d2c91-24ac-468d-9a82-316ddee095eb","added_by":"auto","created_at":"2024-03-07 19:36:08","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":48349,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMeibum expressibility grade and lipid thickness grade in both groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe meibum expressibility grade and lipid thickness grade in group 2 (0.48 ± 0.70 and 1.12 ± 0.33, respectively) were significantly better than those in group 1 (1.29 ± 0.65 and 1.39 ± 0.45, respectively) (P\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eGroup 1 = levator function ≤9 mm, 78 eyes\u003c/p\u003e\n\u003cp\u003eGroup 2 = levator function \u0026gt;9 mm, 90 eyes\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4005099/v1/2cde7f4090bb9c24191f13b8.jpg"},{"id":52191205,"identity":"eeeb2858-edd7-49cb-ab32-b7ca871fd014","added_by":"auto","created_at":"2024-03-07 19:28:07","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":40074,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between levator function and meibum expressibility grade.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a statistically significant negative correlation between levator function and meibum expressibility grade (R=0.4114, P=0.0002) (n=168 eyes). A lower grade of meibum expressibility is better expressible.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4005099/v1/3a73ac9a3c094e464ea34441.jpg"},{"id":52879399,"identity":"46b3b6f4-6b5d-4250-a54f-a6f10efcde2b","added_by":"auto","created_at":"2024-03-18 09:06:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":571164,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4005099/v1/c70efd1f-4469-49e5-aa65-ce9b873f20b9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlation of Levator Palpebrae Superioris and Dry Eye Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe dry eye disease (DED) is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Ptosis refers to a condition in which the upper eyelid droops and the gap between the upper eyelid and lower eyelid is small because the force of the levator palpebral muscle to open the eyes is weak. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Depending on the time of occurrence, there are congenital ptosis that occurs from birth and acquired ptosis that occurs with age. Acquired ptosis is mainly when the function of the levator palpebral muscle weakens with age or there is a problem in the attachment site with the eyelid, causing the eyelid to droop downward. [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] The normal position is for the upper eyelid to slightly cover the upper part of the pupil when the eyes are opened, but in patients with ptosis, the upper eyelid droops down, covering more pupils than the normal position, and in severe cases, it can even cover the pupil. A dry eye disease could be a possible cause of aponeurogenic blepharoptosis. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAlthough the degree of ptosis surgery varies, in most cases, since the eyes close less than before the surgery, dry eye symptoms may occur. [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] However, in most cases, the discomfort diminishes over time. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Frontalis sling surgery is the primary option for patients with weak levator action (less than 4mm). [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Bell’s phenomenon reduces tear film instability and ocular surface damage in eyes with lagophthalmos caused by frontalis suspension surgery. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Compared to upper blepharoplasty, Muller muscle-conjunctival resection surgery can increase both the symptom and signs in dry eye. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] These differences result from the increase in ocular surface and corneal exposure, which produces an increase in evaporative and aqueous tear-deficient dry eye because of the loss of meibomian glands after Muller muscle-conjunctival resection surgery. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere are many studies on dry eye and changes in tears that occur after ptosis surgery. However, to date, there has been no report on whether ptosis itself is related to the function of the meibomian glands or the severity of dry eyes. Recently, studies on dermatochalasis, dry eye, and meibomian gland function have been reported. In the study, it was reported that the degree of dermatochalasis showed a significant association with meibomian gland expression (MGE) and meiboscale grade. Schirmer test, tBUT and SPK did not show a significant difference. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTherefore, the authors conducted a study to determine the degree of dry eye and meibomian gland function according to the function of the levator palpebral muscle.\u003c/p\u003e \n\n "},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy Design and Patients\u003c/b\u003e \u003c/p\u003e\u003cp\u003eThis retrospective study was performed in Seoul St. Mary’s Hospital at the Catholic University of Korea in Seoul, Korea. We retrospectively reviewed the medical records of 84 patients with ptosis. The data provided to us excluded all personal identifiers. This study was performed in accordance with the tenets of the Declaration of Helsinki. The Institutional Review Board (IRB)/Ethics Committee of Seoul St. Mary Hospital approved this study protocol (XC16MIMV0056H) and waived the informed consent because of the retrospective nature of the study. Those with a history of previous orbital surgery, blepharoplasty, or ocular trauma were excluded from the study.\u003c/p\u003e\u003cp\u003e \u003cb\u003eClinical Assessment\u003c/b\u003e \u003c/p\u003e\u003cp\u003eAll patients completed a full ophthalmological examination and eyelid function test, including a slit-lamp examination. The grading of levator action consists of four cathegories (less than 4 mm – poor, 5 to 9 mm – fair, 9 to 11 mm – good, greater than 12 mm – excellent). [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] We divided patients into two groups according to fair or good levator function grades (group 1 = levator function ≤ 9 mm in more than one eye, 40 patients, or group 2 = levator function \u0026gt; 9 mm in both eyes, 44 patients) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). And we divided the eyes into two groups according to fair or good levator function grades (group 1 = levator function ≤ 9 mm, 78 eyes; group 2 = levator function \u0026gt; 9 mm, 90 eyes) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Schirmer I tested without topical anesthetic and stained the cornea with fluorescein strips (fluorescein paper; Haag-Streit AG, Köniz, Switzerland). The corneal staining score was assigned a value ranging from zero to five points using the Sicca scoring. The noninvasive tear break up time (NItBUT) test, Ocular Surface Disease Index (OSDI) score, and tear-meniscus height were measured. Partial blinking rate was also examined by LipiView.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients’s parameters according to the levator function\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1 (Levator function ≤ 9)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 2 (Levator function \u0026gt; 9)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of eyes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e40\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e44\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF:M\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30:10\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28:12\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.45 ± 8.15 (55–81)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.33 ± 6.44 (66–82)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSDI score (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.98 ± 9.36 (4–35)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.28 ± 6.86 (2–25)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTear Height, mm (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.26 ± 0.21 (0.08–0.44)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.29 ± 0.13 (0.12–0.44)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchirmer I, mm (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.02 ± 6.95 (5–30)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.90 ± 5.75 (4–20)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNItBUT, sec (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.68 ± 2.99 (1.5-11.85)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.73 ± 2.27 (2.29–11.47)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorneal Stain (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.45 ± 0.76 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58 ± 0.76 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibomian gland dropout (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.27 ± 0.62 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11 ± 0.69 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum expressibility (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.29 ± 0.65 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e*0.48 ± 0.70 (0–2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum quality (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.26 ± 0.79 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.10 ± 0.79 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLid inflammation (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.21 ± 0.78 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.10 ± 0.75 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLipid layer thickness (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39 ± 0.64 (0–2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.31 ± 0.77 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial blinking rate (%) (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.88 ± 8.99 (0–27)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.29 ± 10.01 (0–38)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eMeibum expressibility in group 2 was significantly better than that of group 1 (p \u0026lt; 0.05).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eGroup 1: Levator function \u0026lt; 9 in more than one eye\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eGroup 2: Levator function ≥ 9 in both eye\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eOSDI: Ocular Surface Disease Index Questionnaire\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNItBUT: Noninvasive tear break up time\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eValues are presented as mean ± SD. D; diopter\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters of eyes according to the levator function\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1 (Levator function ≤ 9)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 2 (Levator function \u0026gt; 9)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of eyes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e78\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e90\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTear Height, mm (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.26 ± 0.11 (0.09–0.50)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.29 ± 0.13 (0.12–0.45)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchirmer I, mm (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.02 ± 6.95 (5–30)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.90 ± 5.75 (5–26)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorneal Stain (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.45 ± 0.76 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58 ± 0.77 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibomian gland dropout (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.27 ± 0.75 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.30 ± 0.77 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum quality (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.18 ± 0.79 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.15 ± 0.81 (0–3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLid inflammation (range)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.14 ± 0.77 (0–3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.15 ± 0.76 (0–2)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eThere was no statistical difference between the two groups (p \u0026gt; 0.05).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eGroup 1: Levator function \u0026lt; 9 in more than one eye\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eGroup 2: Levator function ≥ 9 in both eye\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eValues are presented as mean ± SD. D; diopter\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch3\u003eMeasurement of the meibomian gland\u003c/h3\u003e\u003cp\u003eA Lipiview (Johnson \u0026amp; Johnson Vision, Irvine, CA, USA) was used to measure meibomian gland grade and lipid layer thickness. Meibomian gland dropout was examined using infrared pictures of the upper and lower lid meibomian glands. Meibomian gland dropout was graded from 0 to 3, as reported earlier. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Meibum expression score (MES) and meibum quality score (MQS) were also examined, as reported earlier. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eLipid layer thickness was captured by Keratograph 5M, which was graded from 0 to 3, as follows: 0, severely decreased lipid layer; 1, mildly to moderately decreased lipid layer; 2, normal lipid layer; and 3, hypersecretary lipid layer (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were carried out using SPSS for Windows (version 21.0.1; SPSS Inc., Chicago, IL). The Wilcoxon signed rank test was used to compare the data before and after treatment. Comparisons among three groups were performed with one-way analysis of variance (ANOVA) with a Bonferroni post hoc comparison. The chi-square test was used for the comparison between groups of different proportions. P values \u0026lt; 0.05 were considered statistically significant. \u003cem\u003eP\u003c/em\u003e values \u0026lt; 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003ePatients\u0026rsquo;s parameters\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe divided the patients into two groups according to fair or good levator function grades (group 1\u0026thinsp;=\u0026thinsp;levator function\u0026thinsp;\u0026le;\u0026thinsp;9 in more than one eye, 40 patients with 80 eyes, or group 2\u0026thinsp;=\u0026thinsp;levator function\u0026thinsp;\u0026gt;\u0026thinsp;9 mm in both eyes, 44 patients with 88 eyes).\u003c/p\u003e \u003cp\u003eThe meibum expressibility grade in group 2 (0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70) was significantly better than that in groups 1 (1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65) and 2 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no statistically significant differences between the two groups according to age, OSDI, tear height, Schirmer I, NItBUT, corneal stain, meibomian gland scores, lid inflammation grade, or lipid layer thickness grade, or partial blinking rate (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eParameters of the eyes\u003c/h3\u003e\n\u003cp\u003eWe divided the eyes into two groups according to fair or good levator function grades (group 1\u0026thinsp;=\u0026thinsp;levator function\u0026thinsp;\u0026le;\u0026thinsp;9 mm, 78 eyes; group 2\u0026thinsp;=\u0026thinsp;levator function\u0026thinsp;\u0026gt;\u0026thinsp;9 mm, 90 eyes).\u003c/p\u003e \u003cp\u003eThe partial blinking rate (%) and NItBUT (seconds) in group 2 (9.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01 and 4.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39, respectively) were significantly worse than those in group 1 (5.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99 and 5.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94, respectively) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a statistically significant positive correlation between levator function and partial blinking rate (R\u0026thinsp;=\u0026thinsp;0.4114, P\u0026thinsp;=\u0026thinsp;0.0002) (n\u0026thinsp;=\u0026thinsp;168 eyes) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe meibum expressibility grade and lipid thickness grade in group 2 (0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70 and 1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33, respectively) were significantly better than those in group 1 (1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65 and 1.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45, respectively) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). There was a statistically significant negative correlation between levator function and meibum expressibility grade (R\u0026thinsp;=\u0026thinsp;0.4114, P\u0026thinsp;=\u0026thinsp;0.0002) (n\u0026thinsp;=\u0026thinsp;168 eyes) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). A lower grade of meibum expressibility is better expressible.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere was no statistically significant difference between the two groups according to tear height, Schirmer I, corneal stain, meibomian gland dropout grade, meibum quality, or lid inflammation grade (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDry eye disease can be simply classified as an evaporative or aqueous-deficient type. Both inflammation and apoptosis play an important role in dry eye pathogenesis. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Treatment of DED is complicated because it is caused by a vicious cycle of tear film instability, hyperosmolarity, and ocular surface inflammation. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAcquired aponeurogenic blepharoptosis can be induced by disinsertion or dehiscence of the levator aponeurosis. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Aponeurogenic ptosis can be caused by aging, continuous use of hard contact lens, intraocular surgery, or trauma. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Moesen, I. et al. reported that increased eyelid friction, orbicularis tonus, and inflammation in the dry eye patient, may promote disinsertion of the levator aponeurosis after a prolonged period of time. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Patients with acquired aponeurogenic blepharoptosis were reported to have decreased aqueous tear production more often. Although low tear production may play a part in the etiology of acquired blepharoptosis, it could also be explained by a weakened reflex in blepharoptosis patients. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In our result, there was no statistically significant difference between the two groups according to tear height and Schirmer I. But those of group 2 (levator function\u0026thinsp;\u0026gt;\u0026thinsp;9) were insignificantly increased compared with group 1 (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The reason why the tear production of both groups was not significantly different is that both groups had mild blepharoptosis (one group had fair and the other had good levator function in our result).\u003c/p\u003e \u003cp\u003eThere were no changes in dry eye tests after blepharoplasty in patients without dry eye symptoms. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] However, changes were prominent after ptosis surgery, especially Muller\u0026rsquo;s muscle-conjunctival resection (MMCR). [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Zloto O. et al. also reported that MMCR leads to an increase both the symptom and signs of dry eye disease. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] In patients with initial high tear volume, tear volume can decrease after the blepharoptosis surgery. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] On the other hand, some physicians reported that the MMCR after upper eyelid blepharoplasty did not aggravate ocular surface scores or dry eye symptoms. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAge and mental activity influence spontaneous blinking, which complicatedly interacts with the ocular surface. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] PBR and meibomian gland dropout rates measured with IDRA were reported to have a significant correlation with dry eye symptoms. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] In our study, PBR and NItBUT in group 2 (9.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01 and 4.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39, respectively) were significantly worse than those in group 1 (5.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99 and 5.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94, respectively) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was a significantly positive correlation between levator function and partial blinking rate (R\u0026thinsp;=\u0026thinsp;0.4114, P\u0026thinsp;=\u0026thinsp;0.0002). Meibum expressibility and lipid thickness in group 2 (0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70 and 1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33, respectively) were significantly better than those in group 1 (1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65 and 1.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45, respectively) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). There was a significantly negative correlation between levator function and meibum expressibility grade (R\u0026thinsp;=\u0026thinsp;0.4114, P\u0026thinsp;=\u0026thinsp;0.0002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe reason why PBR in group 2 was higher than that in group 1 may be that the lid height of group 2 is higher than that of group 1. So we think NItBUT in group 2 was shorter than that in group 1 because evaporation increased due to higher PBR in group 2. Incomplete blinking is associated with decreased tBUT. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Patients with dry eye disease spent 4.5% of a minute with their eyes closed, while normal subjects spent 0.7% of a minute. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAnd we also think the meibum expressibility in group 2 was better than that in group 1 because the lid closing pressure in group 2 may be higher than that in group 1 because of the higher gravity force of group 2 compared with that of group 1. So we think lipid thickness in group 2 was significantly better than that in group 1 because meibum expressibility in group 2 was better than that in group 1. The levator palpebrae superioris and orbicularis oculi are antagonistic muscles in eyelid motion. But motoneurons innervating the levator and orbicularis muscles were controlled by retrograde transport of WGA/HRP and HRP. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] So we think that good levator function may have a correlation with good orbicularis muscle function.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, there was no study about the levator palpebrae superioris function in patients with dry eye disease\u003c/p\u003e \u003cp\u003eIn our study, there was a limitation that a multicenter clinical trial with a larger sample size and a longer follow-up period was required to observe the long-term study of levator palpebrae superioris function in patients with dry eye disease.\u003c/p\u003e \u003cp\u003eIn conclusion, the eyes with good levator function showed shorter tear break-up time due to a higher partial blinking rate, but showed better lipid thickness due to better meibum expressibility compared with the eyes with fair levator function.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMeibum expression score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMQS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emeibum quality score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMuller\u0026rsquo;s muscle-conjunctival resection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was approved by the institutional review board at Seoul St. Mary\u0026rsquo;s Hospital (XC16MIMV0056H); the informed consent was waived. All clinical investigations have been conducted according to the principles expressed in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2022R1F1A1069218). The funding offered support in the design of the study and collection, analysis, interpretation of data, and publication fee.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eECK was involved in analysis and interpretation of data and drafting the manuscript. ECK, HS, SEK, SY made contribution to acquisition of data and drafting. SY contributed to conception and design, analysis and interpretation of data, drafting and revising the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCraig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoesen I, van den Bosch W, Wubbels R, Paridaens D. Is dry eye associated with acquired aponeurogenic blepharoptosis? \u003cem\u003eOrbit\u003c/em\u003e 2014, 33(3):173\u0026ndash;177.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee YG, Son BJ, Lee KH, Lee SY, Kim CY. Clinical and Demographic Characteristics of Blepharoptosis in Korea: A 24-year Experience including 2,328 Patients. Korean J Ophthalmol. 2018;32(4):249\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFujiwara T, Matsuo K, Kondoh S, Yuzuriha S. Etiology and pathogenesis of aponeurotic blepharoptosis. Ann Plast Surg. 2001;46(1):29\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButtanri IB, Serin D. Levator Resection in the Management of Myopathic Ptosis. Korean J Ophthalmol. 2014;28(6):431\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrishami A, Bagheri A, Salour H, Aletaha M, Yazdani S. Outcomes of Levator Resection at Tertiary Eye Care Center in Iran: A 10-Year Experience. Korean J Ophthalmol. 2012;26(1):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAydemir E, Aksoy Aydemir G. Changes in Tear Meniscus Analysis After Ptosis Procedure and Upper Blepharoplasty. Aesthetic Plast Surg. 2022;46(2):732\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorge JL, Tercero ME, Angio\u0026iuml;-Duprez K, Maalouf T. Risk of dry eye after mullerectomy via the posterior conjunctival approach for thyroid-related upper eyelid retraction. Orbit. 2002;21(1):19\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRymer BL, Marinho DR, Cagliari C, Marafon SB, Procianoy F. Effects of Muller's muscle-conjunctival resection for ptosis on ocular surface scores and dry eye symptoms. Orbit. 2017;36(1):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe A, Kakizaki H, Selva D, Ohmae M, Yokoi N, Wakimasu K, Kimura N, Kinoshita S. Short-term changes in tear volume after blepharoptosis repair. Cornea. 2014;33(1):14\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoka K, Patel BC. Ptosis Correction. In: \u003cem\u003eStatPearls.\u003c/em\u003e edn. Treasure Island (FL): StatPearls Publishing Copyright \u0026copy; 2023, StatPearls Publishing LLC.; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoon JS, Lew H, Lee SY. Bell's phenomenon protects the tear film and ocular surface after frontalis suspension surgery for congenital ptosis. J Pediatr Ophthalmol Strabismus. 2008;45(6):350\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZloto O, Matani A, Prat D, Leshno A, Ben Simon G. The Effect of a Ptosis Procedure Compared to an Upper Blepharoplasty on Dry Eye Syndrome. Am J Ophthalmol. 2020;212:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu WL, Chang SW. Dermatochalasis Aggravates Meibomian Gland Dysfunction Related Dry Eyes. J Clin Med 2022, 11(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97(6):1123\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrinivasan S, Menzies K, Sorbara L, Jones L. Infrared imaging of meibomian gland structure using a novel keratograph. Optom Vis Sci. 2012;89(5):788\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan HH: Is the peripheral retina an important site for myopic development? [Liu, Wildsoet Y. C (2011) The effectof two-zone concentric bifocal spectacle lenses on refractive error development and eye growth in young chicks. Invest Ophthalmol Vis Sci 52(2):1078\u0026ndash;1086]. \u003cem\u003eGraefes Arch Clin Exp Ophthalmol\u003c/em\u003e 2011, 249(7):955\u0026ndash;956.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. (2007). \u003cem\u003eOcul Surf\u003c/em\u003e 2007, 5(2):75\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaudouin C, Aragona P, Messmer EM, Tomlinson A, Calonge M, Boboridis KG, Akova YA, Geerling G, Labetoulle M, Rolando M. Role of hyperosmolarity in the pathogenesis and management of dry eye disease: proceedings of the OCEAN group meeting. \u003cem\u003eOcul Surf\u003c/em\u003e 2013, 11(4):246\u0026ndash;258.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrueh BR. The mechanistic classification of ptosis. Ophthalmology. 1980;87(10):1019\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParis GL, Quickert MH. Disinsertion of the aponeurosis of the levator palpebrae superioris muscle after cataract extraction. Am J Ophthalmol. 1976;81(3):337\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe A, Selva D, Kakizaki H, Oka Y, Yokoi N, Wakimasu K, Kimura N, Kinoshita S. Long-term tear volume changes after blepharoptosis surgery and blepharoplasty. Invest Ophthalmol Vis Sci. 2014;56(1):54\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamed Azzam S, Nama A, Hartstein M, Habib HJ, Mukari A. The Effect of Ptosis Surgery on Meibomian Glands and Dry Eye Syndrome. Ophthalmic Plast Reconstr Surg; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu Y, Liang Q, Su G, Wang N, Baudouin C, Labb\u0026eacute; A. Spontaneous Eye Blink Patterns in Dry Eye: Clinical Correlations. Invest Ophthalmol Vis Sci. 2018;59(12):5149\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeon YJ, Song MY, Kim KY, Hwang KY, Kwon YA, Koh K. Relationship between the partial blink rate and ocular surface parameters. Int Ophthalmol. 2021;41(7):2601\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJie Y, Sella R, Feng J, Gomez ML, Afshari NA. Evaluation of incomplete blinking as a measurement of dry eye disease. Ocul Surf. 2019;17(3):440\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOusler GW 3rd, Abelson MB, Johnston PR, Rodriguez J, Lane K, Smith LM. Blink patterns and lid-contact times in dry-eye and normal subjects. Clin Ophthalmol. 2014;8:869\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorter JD, Burns LA, May PJ. Morphological substrate for eyelid movements: innervation and structure of primate levator palpebrae superioris and orbicularis oculi muscles. J Comp Neurol. 1989;287(1):64\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Levator palpebrae superioris, Dry eye disease, Tear break-up time, Meibum expressibility","lastPublishedDoi":"10.21203/rs.3.rs-4005099/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4005099/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To evaluate the effect of levator palpebrae superioris in patients with dry eye disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 168 eyes of 84 patients (group 1= levator function ≤9 mm, 78 eyes; group 2= levator function \u0026gt;9 mm, 90 eyes) who have been diagnosed with ptosis were retrospectively enrolled. Levator function test, Ocular Surface Disease Index Questionnaire (OSDI), Schirmer I test, noninvasive tear break up time (NItBUT), corneal staining score, meibography, meibum quality and expressibility scores, tear meniscus height, and partial blinking rate (PBR) were examined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ePBR and NItBUT in group 2 (9.29 ± 4.01 and 4.76 ± 2.39, respectively) were significantly worse than those in group 1 (5.88 ± 3.99 and 5.78 ± 2.94, respectively) (P\u0026lt;0.05). There was a significantly positive correlation between levator function and partial blinking rate (R=0.4114, P=0.0002). Meibum expressibility and lipid thickness in group 2 (0.48 ± 0.70 and 1.12 ± 0.33, respectively) were significantly better than those in group 1 (1.29 ± 0.65 and 1.39 ± 0.45, respectively) (P\u0026lt;0.05) (Figure 3). There was a significantly negative correlation between levator function and meibum expressibility grade (R=0.4114, P=0.0002) (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe eyes with good levator function showed shorter tear break-up time due to a higher partial blinking rate, but showed better lipid thickness due to better meibum expressibility compared with the eyes with fair levator function.\u003c/p\u003e","manuscriptTitle":"Correlation of Levator Palpebrae Superioris and Dry Eye Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-07 19:28:03","doi":"10.21203/rs.3.rs-4005099/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d40a1687-1cea-4fef-a49b-5de2634935d2","owner":[],"postedDate":"March 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-18T08:58:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-07 19:28:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4005099","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4005099","identity":"rs-4005099","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}